Endoscopic injection sclerotherapy has been spreaded for the treatment of esophageal varices. Recently, endoscopic variceal ligation (EVL) has become popular as the easy technique. Clipping was also developed, and recognized the usefulness for hemostasis and marking. EVL and clipping are the new effective treatments for esophageal varices. We discussed the combination therapy of ligation and intra-variceal injection sclerotherapy for the improvement of therapeutic effect and the prevention of recurrence. We performed the combination therapy of clipping and intra-variceal injection sclerotherapy with 5 %ethanolamine oleate iopamidol (5%EO) for the treatment of esophageal varices (Clipping+5%EO therapy). We tried to perform for 18 patients, and achieved the improvement in all patients by clipping with the mean number of 3.3±1.4 sessions and sclerotherapy with the mean injected volume of 21.4±14.6 ml 5%EO in the primary therapeutic effect. We achieved the remission in 13 (72.2%) and the eradication in 7 (38.9%) out of 18 patients 15.5 months after the treatment. We could decrease the therapeutic sessions and the volume of sclerosant, and improve the therapeutic effect by Clipping+5%EO therapy compared with independent sclerotherapy. Clipping is the useful ligation for stopping the variceal blood flow by the clipping apparatus. The form of varices is not changed by clipping. We can keep the good endoscopic view field, and inject the sclerosant into the varices effectively. Clipping is the suitable method for the combination of intra-variceal injection sclerotherapy. We can also demonstrate endoscopic varicealography during injection sclerotherapy, and the incurable varices can be treated by Clipping+5%EO therapy. In conclusion, Clipping+5%EO therapy is the useful combination method for the therapy of esophageal varices.

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To evaluate the efficacy of microscanner (MS) in diagnosing the depth of invasion of early colorectal cancer, 65 lesions were analyzed. Carcinomas which showed involvement of the submucosal layer are divided into two groups according to the degree of submucosal invasion : a group in which the depth of invasion was one third of the submucosal layer or less (sml) and the other in which the tumor involved the submucosa more deeply (sm2, 3). The results were as follows ;1) Evaluation of early colorectal cancer by MS was possible in 84.6% (55/65) of the cases : 64.7% (11/17) in protruding lesions, 92.3% (36/39) in superficial lesions and 88.9% (8/9) in nodule-aggregating lesions.2) Diagnostic accuracy of depth of invasion in early colorectal cancer by MS was 89.1% (49/55): 81.8% (9/11) in protruding lesions, 94.4% (34/36) in superficial lesions and 75% (6/8) in nodule-aggregating lesions.3) Diagnostic accuracy by MS as to the degree of submucosal invasion was 90.9% (20/22) in m cancer, 20.0% (1/5) in sml cancer and 100% (28/28) in sm2, 3 cancer.4) Diagnostic accuracy by MS for the superficial lesions was satisfactory. However, it was difficult to evaluate protruding lesions more than 11mm in height. In such cases, the five-layer structure of the colonic wall was poorly visualized by MS due to the attenuation of ultrasound. Based on our findings, it is concluded that MS is useful for the diagnosis of the depth of invasion in early colorectal cancers. However, the diagnosis of the depth of invasion in protruding lesions requires improvement.

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Peritoneoscopic findings were studied in patients with auto-antibody-positive chronic hepatitis C. The studied population comprised 133 patients with chronic hepatitis C, 55 of chronic hepatitis B and 19 of autoimmune hepatitis. Anti-nuclear antibody (ANA) was studied by means of indirect fluorescent antibody method (IF) and anti-liver/kidney microsome (LKM) -1 antibody was studied by means of IF method and double immunodif-fusion method. ANA was positive in 15% of Type-C patients and in 20% of Type-B patients. No significant difference in positive ratio of ANA was observed between Type-B and Type-C. In comparison to Type-B counterparts, Type-C subjecs had a higher incidence of gutter- or trench-shaped depressions or small depressions on liver surface. Reddish markings in patients with chronic hepatitis C were characterized by multilobular shape, which was typically localized. No significant differrence in peritoneoscopic findigs was observed between ANA-positive and negative cases. Nevertheless, steroid therapy was effective in patients who had high ANA titers and high γ-globulin levels. Anti-LKM-1 antibody positive patients failed to show gutter- or trench-shaped depressions or large elevated lesions of which findings were characteristic of AIH.

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We performed endoscopic variceal ligation (EVL) alone or combined therapy of EVL and endoscopic injection sclerotherapy (EIS) in 30 patients with F2 or F3 and RC positive esophageal varices. In addition, using MR angiogram (MRA), which is relatively noninvasive examination, we investigated the therapeutic results and prognosis. The variceal supply veins tended to persist on MRA after therapy, with EVL alone or EVL combined with EIS by an exravascular injection of 1% Aethoxysklerol. On the contrary, EVL combined with EIS by an intravascular injection of 5% ethanolamine oleate the variceal supply veins tended to disappear. The recurrence rate of varices was higher in patients with persistently supplying veins than those without them. The combined therapy of EVL and EIS was useful in that the volume of sclerosant used could be reduced. From the aspect of the prophylaxis of recurrence, the combination of EVL and EIS by intravascular injection, enabling obliteration of supplying veins, was thought to be particularly useful.

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In order to prevent Helicobacter pylori infection from contaminating endoscopic instruments, several sterilization methods were recently reported. However, more rapid and convenient method is required clinically for disinf ection after individual endoscopic examination. Electrolized strong acid aqueous solution (ESAAS) has strong and rapid bacterocidal effects and is safe for human tissue. In this study, we investigated the effect of ESAAS for endoscopic disinf ection of H. pylori using PCR method. H. pylori was detected in 18 of 21 cases (85.7%) by rapid urease method or culture method. Urease A gene of H, pylori was detected in the washing solutions of 15 cases (83.3%) before cleaning and in those of 8 cases (53.3%) after washing with tap water. After washing with ESAAS, in addition, H. pylori was not detected at all. In conclusion, washing and suction with ESAAS is a rapid, convenient and safer steriliing method for preventing H. pylori transmission via endoscopic instruments.

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We studied whether the decision of the method of the treatment for rectal carcinoma according to the assessment of mural invasion by endoscopic ultrasonography (EUS) was appropriate. We classified 94 cases of rectal carcinoma into three groups according to the depth of invasion assessed by EUS. In the first group (group-I), the depth of carcinomatous invasion on EUS was the mucosal layer or the superficial submucosal layer. In the second group (group-II), the depth of carcinomatous invasion on EUS was either the deep sub-mucosal layer or the proper muscle layer. In the third group (group-III), the depth of carcinomatous invasion on EUS was beyond the proper muscle layer. Because we have the basic policy of deciding the method of surgery based on the depth of invasion, the endoscopic removal or the local resection is performed in the group-I, the complete autonomic nerve preserving operation (ANPO) is performed in the group-II, the partial ANPO or usual radical operation is performed in the group-III. However, if the endoscopic or local resection is difficult due to the size or the location of the tumor in the group-I, the complete ANPO is performed. The accuracy of EUS was 88.2% in the group-I, 78.6% in the group-II, and 79.6% in the group-III. All of the 6 misjudged cases in the group-II showed the minute extramuscular invasion on histology. Four of the 10 misjudged cases in the group-III showed the inflammatory cell infiltration on histology. We considered that it was impossible to distinguish both the minute extramuscular invasion and the inflammatory cell infiltration from carcinoma tissue by EUS. In the cases in which the judgment by EUS influenced the performed method of surgery, the disease free rate was 93.3% in the group-I, 94.4% in the group-II, 77.5% in the group-III, and only two cases in the group-III showed the local recurrence. We concluded that the decision of the method of the treatment for rectal carcinoma according to the assessment of mural invasion by endoscopic ultrasonography (EUS) was appropriate.

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A 44-year-old woman experienced a sudden onset of retrosternal pain following intake of boiled tea. On the following day, she was admitted to the Depart, of Internal Medicine of this hospital because she vomited fresh blood. Endoscopic examination revealed circumferential hemorrhagic erosions and blisters throughout the esophagus. Although the pathogenesis of esophagitis is multif actorial, the direct cause of esophagitis in this patient was probably thermal burn induced by boiled tea. Idiopathic esophagitis may included this kind of food-related esophagitis as seen in this patient. Careful medical interview and endoscopic examination are recommended for identifying the cause of such esophagitis.

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A 26-year-old male was admitted with intermittent abdominal pain. Ultrasound sonography showed multiple concentric signs, hay-fork signs, and a tumor was founded at the end of intussusceptum. Abdominal CT revealed a concentric layering structure in the dilated colon. Barium enema revealed a mass in the ascending colon, and colonoscopy disclosed an irregular-surfaced tumor with intussusception in the transverse colon. Primary malignant lymphoma of the ascending colon was strongly suspected preoperatively. Right hemicolectomy was performed with lymph node dissection. The resected tumor was 7×7cm in size macroscopically. Histological findings showed a non-Hodgkin lymphoma, diffuse pleomorphic type according to Lymphoma Study Group classification, and immunohistological findings demonstrated B-cell lymphoma. Following operation, chemotherapy was administered with VEPA (Vincristine, Endoxan, Predonine, Adriacin, Methotrexate), and the patient has survived for 23 months without recurrence.

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A case of Osler's disease with massive bleeding from gastric telangiectasis is reported. A 77-year-old woman was admitted to our department with a complaint of hematemesis. Endoscopic examination showed a easily bled telangiectasis in the upper part of the gastric body. Bleeding from the telangiectasis was stopped by local injection of pure ethanol, but telangiectasis reappeared 10 days later. Then the lesion was treated with heater probe and became scarred. Other 4 telangiectases found in the stomach were also treated with heater probe. Of these, 3 became scarred, but the remaining one reappeared. Gastric bleeding from telangiectases did not occur after the treatment and anemia was improved.

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A 39-year-old woman with an ovarian cancer underwent a colonoscopy for preoperative evaluation of the colon. Results showed a carcinoid tumor of the lower rectum of which diagnosis was confirmed by the histologic examination of a biopsy specimen. She was admitted to our department eight months after the total hysterectomy and bilateral salpingo-oophorectomy for the above mentioed ovarian cancer. The second colonoscopy revealed the other one more carcinoid tumor near the known one. Both of them were resected with a transsacral rectal wedge resection. The resected specimen had two yellowish, elastic hard, round tumors which were 8×8×5mm and 5×5×1mm in size, respectively. Histologic examination showed that both tumors were carcinoid tumors invading the submucosal layer. The widespread use of colonoscopy has led to many more discoveries of rectal carcinoid tumors. Although a case with multiple carcinoid tumors of the rectum is rare, the incidence of multicentricity in rectal carcinoids ranges from 1.4 to 10% averaging 5.9% in the literature. Therefore, whenever we perform a colonoscopy and operation, we should bear in mind that the rectal carcinoid could be multiple.

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A 56-year-old man with liver dysfunction was admitted to our hospital. Abdominal ultra-sonography and CT showed a dilatation of the left intrahepatic bile duct and thickness of the gall bladder wall. PTC showed a narrowing of the hilar bile duct. Angiography showed encasement of the proper hepatic artery as well as the right and left hepatic arteries. These findings strongly suggested an inoperable intra-hepatic cholangio-carcinoma. PSC could not be ruled out. Elevated ALP and γ-GTP levels gradually decreased. Jaundice was not observed during the clinical course. In 23 weeks after admission, severe ascites became apparent. After treatment with ursodeoxycholic acid and prednisolone, the ascites was markedly reduced. Laparoscopy showed an irregular surface with neo-vascularity of the left lobe, and the histo-logical examination revealed a poorly-differentiated adenocarcinoma. Both laparo-scopy and histological examination are useful for diagnosing cholangiocarcinoma followed by a rare clinical course.

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We have performed endoscopic variceal ligation (EVL) as prophylactive and elective treatment in 60 patients with esophageal varices from July 1992 to December 1994. Bleeding was observed in 4 patients (6.7%) within 10 days after EVL. In all 4 cases, the grade of varices was severe than F₂ and RC++. Endospically, the bleeding occurred from the edges of ligation-induced ulcers or from other varices without ligation. Contact bleeding by oral intake might be one of causes of post-EVL bleeding, because it occurred after meals. To obtain complete hemostasis, endoscopic injection sclerotherapy was necessary in all patients. EVL is a safe procedure because of a low risk of complication. However, we should be aware of severe complications such as bleeding after EVL and must be more careful to perform EVL.

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