We have reviewed recent studies of image processing and image analysis for endoscopic diagnosis in gastrointestinal diseases. Correct assessment of gastrointestinalmucosal color is extremely important in the endoscopic diagnosis of gastrointestinaldiseases. However, currently available endoseopes have not met clinical requirements. A new endoscopic spectroscopic system(ESS)has been recently developed for the examination of the spectral characteristics of tissue, especially the reflectance of various lesions in the gastrointestinal tract. we suggest that the ESS will become a useful modality for obtaining spectrum data in the gastrointestinal tract and for clarifying the spectral characteristics of malignant lesions in comparison with any other benign lesions. We have stated practical usefulness of adaptive enhancement by image processing, IHb color enhancement, and infrared ray electronic endoscopy. Adaptive enhancement by image processing, which has been widely used, is especially effective fog diagnosis of erypt pattern of colonic tumors, extent of cancerous invasion in early gastric cancer and ulcer staglng. Cancer and precancerous lesions in many organs generate attenuated autofluorescencein green spectrum band compared to that from normal tissue when irradiated by blue light. Using Light Induced Fluorescent Endoscopy(LIFE), the clinical value of this system is now being studied in gastrointestinal malignancy. Computer analysis of the fine mucosal network pattern by magnifying endoscopy, imaging system using fluorescent labeling substances excited by near-infrared ray, and three-dimentional measuring with an electronic endoseope have been reported. Although further studies are necessary to evaluatetheir clinical usefulness, there is much expectation of success in electronic endoscopy.Furthermore, it is very important to develop image processing and image analysis forimproving the quality of endoscopic diagnosis and for making objective aid quantitativediagnosis.

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A'hoed calibration method'has been developed for quantitative ebservation andimage analysis of regenerative mucosal pattern of gastric ulcer under a magnifying videeendoscepe. Using this method, we measured the size of regenerative mueosal patternat the margin of ulcers and compared with their healing processes. At the healing stage, palisade-or spindle-shaped regenerative mucosal pattern with a larger area appeared tobe well correlated to the healing of gastric ulcer. When ulcer healing was apparently rapid, the maximum length rather than the area of spindle shaped regenerative mucesal patternwas found to be more closely associated with the healing gastric ulcers. On the other hand, in cobblestone-shaped regenerative mucosal pattern, which corresponds to more matureregenerative tissues, the maximum length and their area were not correlated, with thehealing of gastric ulccr at alb stages. Similarly, at the scaring stags, namcly, at a maturcstage of healing, the sire of regenerative mucosal pattern was considered to he unrelatedwith the healing speed of ulcers or the incidence of ulcer recurrence.

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During the period from 1985 to March 1998, we experienced 164 submucosal invadingcancers which were classified the submucosal extension of early cancer according to the vertical and horizontal levels of invasion. The depth of vertical invasion in the submucosal layer was measured by micrometer. In the investigation of submucosal invading cancers, vessel invasion occurred in smlhcancers and lymph node metastasis (LM) occurred in sm2 or sm3 cancers. From theviewpoint of the length of vertical invasion, vessel invasion occurred in lesions with thedepth of invasion more than 450μm. The rates of vessel invasion in the depth of 450-500μm, 501-1000μm, 1001-1500μm, 1501-2000μm, 2001μm or over were 5%, 29.4%β1.3%, 24.1%, 41.8%respectively. Lymph node metastasis occurred in lesions with the depth ofinvasion rnore than 1700μm. The mean depths in the LM positive and negative groups were2880±852(SD)μm and 2278±1789(SD)μm(P=0.0797)respectively.As to the comparisonof relative classification and measurement of suhmucosal invasion, the moan depths in sm1a, sm1b, sm1c, sm2, sm3 groups were 302±179(SD)μm, 403±86(SD)μm, 596±452(SD)μm, 2559±157(SD)μm, 3205±1599(SD)μm respectively.With respect to the form ofinvasion, the rates of vessel invasion in the groups of expanding growth and infiltratinggrowth were 7% and 54.7%respectively (p<0.0001). The rates of LM in the groups of expanding growth and infiltrating growth were 0% and 8.3% respectively. There was a statistically significance in the relationship between relative classificationand measurement of submucasal invasion. The rates of vessel invasion and LM were lowerin the group of expanding growth than the group of infiltrating growth.

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The accessory pancreatic duct(APD)shows two different patterns in pancreatograms;long and short type. The APD of the long type forms a straight line and joins the mainpancreatic duct(MPD)at the neck of the pancreas. The APD of the short type conveys tothe MPD near its first inferior branch. We examined 161 endoscopic retrograde pancreatograms on the inferior branches from the APD. Long inferior branches over 20mm in lengthwere demonstrated in 74.6% of 118 APD of the long type, significantly more frequent than30.2% of 43 APD of the short type(P<0.01). Short inferior branches between 10mm and19mm in length were seen in 51.7% of APD of the long type and 60.5% of APD of the shorttype. There were no differences in the regions of inferior branches arising from the APD. It was suggested that a part of the APD of the short type might be the inferior branchfrom the main duct of the dorsal pancreatic primordiurn embryologically, because the caseswith bong inferior branches were zess frequent.

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A 58-year-old man was admitted to Iwate Prefectural Senmaya Hospital for Mamushibite. Despite the minor swelling at the site of bite, he had gone into shock, while vomitingfood residue and coffee-grounds liquid, he were underwent upper gastrointestinal endoscopy. Endoscopic findings showed:1)large and small blood blister-like protrusions on theentire esophageal mucosa, 2)redness on the entire gastric mucosa, and 3)duodenal ulcer.Those peculiar lesions were found soon after the patient experienced the bite, suggestingthat these symptoms were caused directly by the Mamushi toxin.

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A 48-year-old woman was found to have cholecystolithiasis by ultrasonography(US) on mass examination for adult diseases. The patient visited to our hospital for furtherexamination. US showed cholecystolithiasis and peripancreatic mass lesion. ALTS revealedagastric submucasal tumor, which derived from proper muscle layer. EUS else showed aheterogeneous high echo pattern with internal low echo area. Bariun meal study showedasemi-spherical elevated lesien en the side of greater curvature at the antrum.Thepreoperaive diagnosis obtained by EUS-FNA was made as gastric glomus tumor. Partialresction of the tumor was performed. Final pathological diagnosis was the same as FLTS-FNA.

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A-73-year old man was admitted to our hospital because of sudden onset of right upperquadrant abdominal pawn. Abdominal ultrasonography and computed tomography resealedan expanded gall bladder with slightly thickened wall and stone. Though antibaatzc therapywas performed, tarry stools and dyspnea appeared on the fifth day. Upper gastrointestinalendoscapy revealed a PTP sticking in the duodenal bulb. There was a large ulcer withblood coagula in the bulb and second portion of the duodenum. The PTP was removed byusing a colonoscopic stiffening tube as an overtube. After endoscopic removal of the PTP, his symptoms disappeared rapidly. Therefore, it was considered that the PTP caused thesymptoms. The patient was not aware of ingesting PTP. In mast cases, an ingested PTPis located in the esophagus, and this was a rare case of PTP found in the duodenum.

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We report a case of colonic mucosa-associated-lymphoid-tissue(MALT)lymphomaorganized granular mucosa. A 76-year-old man, an elevated serum level of CEA underwent colonoscopy. Itrevealed a granular lesion with erosions in the cecum and ascending colon, and the biopsyspecimens suggested malignant lymphoma. To confirm the diagnosis, endoscopic mucosalresection was perforrned for this lesion and histological and molecular biological analysisrevealed MALT lymphoma. The classification of colonic MALT lymphoma based on endoscopic observation is notavailable so far. fn cases appearing granular pattern as shown in our case, it xnay be difficult to reach a correct diagnosis by endoscopic examination or even by histological study using the colonic biopsy specimen. Therefore, previous case reports of coionic MALT lymphoma in Japan were reviewed to clarify the morphological features of this disease and we concluded that granular mucosa may be one of the important features of this disease in its early stage.

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A 22-year-old female who had been suffering from ulcerative colitis(UC)from age 20 was adrnitted to our hospital due to frequent bloody stools 5 months after delivery. Although general condition had tended to improve by intensive intravenous steroid therapy and steroid pulse therapy, it gat worse again in the course of tapering steroid. At the 44th hospital day, copious bloody stools developed and hypovolemic shock ensued. Urgent colonoscopy revealed local bleeding from the ulcer with an exposed vessel in the ascendingcolon, which was treated by endoscopic injection of absolu.te ethanol and 1% polidocanol. Rebleeding had not been seen and remission state has continued during the subsequent 4 years and 6 months. In case of UC with massive bleeding, urgent eolonoscopy and endoscapic hemostasis should be attempted considering the possibility of local bleeding before undertaking urgent surgical therapy.

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A 50-year-old female. who had attended this our outpatient department since 1974, was initially diagnosed to have ulcerative colitis. Colonoscopy in 1988 revealed a flatelevated lesion m the rectum and a diagnosis of tubuloviilous adenoma was made accordingto the results of the biopsy. Colonoscopy in February 1997 established a tendency for thelesion to increase in size and per anum resection of the tumor was performed. The resectedspecimen was histelogicaily examined and a diagntisis of dysplasia was made. Patientswith chronic ulcerative colitis are at high risk of colorectal cancer and the involvement of dysplasia in oncogenesis is indicated. Such a suggestive case as this patient who, after a 10-years observation under the diagnosis of adenorna, was finally diagnosed withadenexnateus dysplasia, has rarely been reperted in the literature.

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A 74-year-old man was admitted to our hospital because of a positive fecal occultblood test. Colonoscopy revealed a IIa+IIc type lesion in the hepatic flexure, with a Isplike lesion in the ascending colon. Right hemicolectomy with extensive lymph nodedissection(D₂)was performed. The histology of the IIa+IIc lesion was poorly differentiat-ed adenocarcinoma with the depth sm₂ (invading the middle of the submucosa), measuring 14×7mm in size. Another lesion was mutinous carcinoma including moderately differentiated adenocarcinama, of depth mp (invading the muscularis propria). Molecularbiological examination of two lesions revealed any abnormalities neither in the p53 nor inthe K-ras. However analysing by loss of heterozygosity and replication error, in 2p, 3p, 17p and 18q, various abnormalities were observed between of these lesions.

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Successive use of bath anterior and lateral view endoscopes is preferable to reduce theoversights of lesions in the upPer digestive tract. In order to use routinely both types ofendoscope successively on an occasion, it is necessary to establish a manual technique thatenables anyone to insert the gastric endoscope easily, rapidly and safely without causingpain to the patients. The author has devised the following manual technique:At first, the patient is instructed to lie with his left side down and bend sharply his head and neck forward, thenstick out his lower jaw forward. In this posture, an endoscope is inserted while keepingright and left, up and down angle knobs fixed and holding the site of insertion in such a wayas to farm a straight line. The theoretical base and reasonableness of this technique were clarified by X-ray films and MRI images. with this technique, an endoscape can beinserted into the esophagus smoothy in 3 to 5 seconds without causing pain to the patienteven when a prior treatment such as pharyngeal anesthesia or administration of diazepamis not given. In a questionnairing about 100 insertions in 50 patients using neither anesthesia nor sedatives, 92%of the respondents said they felt quite all right on insertion of the endoscope. The author encountered no accident in some 54, 000 insertions by this technxque.

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