In Japan, the incidence of bed -ridden old persons is growing with age which is 10.0% for ages between 80 and 84 and 20.5% for ages over 85. Of these, persons with dysphagia, pertutaneous endoscopic gastrostomy (PEG) is used to support nutrition. In 2001, a total of 140, 000 PEG kits was on the market in Japan, although only 6, 500 kits were sold in 1993. Decompression PEG for patients with peritoneal carcinomatosis is newly applied instead of ileus tube. In the technical point, a use of a fixing tool for abdominal and gastric walls is increasing for prevention of complications. Management, at the time of early phase post operation and exchanging of PEG catheter is extremely important because of high incidence of complications.In a long-term nuturitional management, lack of trace-elements causes serious condition. Administration of erythromycin or viscosity increasing additives is useful for patient with gastroesophageal ref lux and hiatus hernia. The complication rate ranges from 5.9% to 37.2% and that of serious condition is approvimately 1%. The rate is on the decrease along with the increase of cases and widespreading of the management.

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Acute hemorrhagic rectal ulcer (AHRU) occurs suddenly with painless idorent massive hematochezia in aged patients suffering from serious primary diseases and bed ridden condition. Patients using analgic suppository and having constipated difficulties show similar occurrences. We assessed clinical features, endoscopic findings and treatments in 18 patients with AHRU seen at our hospital in the past three years. The subjects consisted of 8 men and 10 women with average age of 74.8. The primary diseases on admission were mostly orthpedic diseases. Endoscopic examination revealed that ulcers were nearly round in the lower rectum. In this study, however, numbers and locations of AHRU had no clear trend. In addition, this study suggests that injection treatments of ulcers in the lower rectum were more useful and effective than clipping.

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A 55-year-old man, who had submucosal tumor in the stomach, was transferred to our hospital for the further examination. Endoscopic examination showed a submucosal tumor with central erosion on the posterior wall of the lower body of the stomach. Since endoscopic ultrasonography revealed homogeneous low echoic nodule measuring 12 mm in diameter restricted to the submucosa, this tumor had been suspected of carcinoid. Biopsy specimen from the central erosion did not contain tumor tissue. Endoscopic mucosal resection was performed for total biopsy. Histological examination showed circular or polygonal tumor cell with small nuclei and many fine granules in the cytoplasm. S-100 protein immunostaining showed yellow colored granules. The tumor was histologically confirmed as granular cell tumor of the stomach and completely resected endoscopically. Granular cell tumors are uncommon in the stomach and only 29 cases have been reported in Japan. Homogenous low echoic tumors in the submucosal layer of the stomach are highly suspected of carcinoid or granular cell tumor, which both requires some treatment. If it can not be diagnosed by endoscopic biopsy, endoscopic resection is necessary for total biopsy.

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A 41-year-old man was admitted to our hospital with liver dysfunction. Serological tests revealed positive IgM and IgG antibodies to cytomegalovirus (CMV), and CMV antigenemia was positive. Nine days after admission, he began to complain of an epigastric pain. Gastroscopy revealed friable gastric mucosa and multiple erosions in the antrum and on the lesser curvature of the gastric body, and large rugal folds on the greater curvature of the gastric body. A large amount of gelatinous material was adherent to the mucosa. Biopsy specimen showed the presence of intranuclear inclusion bodies and CMV was demonstrated in the affected tissue by immunocytochemistry using monoclonal antibody against CMV immediate early antigen. Treatment with proton pump inhibitor mitigated epigastric pain and gastroscopy performed 4 months after the onset of symptoms showed normal mucosa. Laboratory studies showed transient hypoproteinemia parallel to endoscopic findings. It was suggested that protein loss was due to gastropathy induced by CMV infection. In children a Menetrier's disease-like disorder was emphasized as being associated with acute CMV infection. A few cases of CMV infection associated protein-losing gastropathy have been also described in adults. Protein-losing gastropathy induced by CMV infection should be considered in adults as well as in children.

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A 72-year-old female visited our hospital with abdominal pain, and the total colonoscopy was performed as a farther examination. Colonoscopy procedure arrived at the cecum within twenty minites with no trouble. A red colored elevated lesion was found in the cecum and hot biopsy was performed. After examination, the patient had a rest for 2 hours and went back to her home without any complaints. On the next morning, abdominal pain and vomiting were occurred and the patient visited our hospital again. The retro-peritoneal emphysema was diagnosed with a abdominal plain X-ray and CT examination. After admission, a conservative theraphy was performed and she recovered. The retroperitoneal emphysema was a rare complication after colonoscopic examination, nevertheless a careful following of the patient is necessary after colonoscopy.

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A 82-year-old man was hospitalized because of the massive anal bleeding. Colonoscopy revealed Dieulaf oy's ulcer in the posterior wall of the rectum and erosive mucosa in the anterior wall of the rectum. A diagnosis of acute hemorrhage rectal ulcer was made. We successfully treated the Dieulaf oy's ulcer using a ligating device of endoscopic variceal ligation (EVL). Permanent hemostasis was obtained with only one procedure. EVL was useful for a lesion of Dieulaf oy's ulcer.

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A sixty-three year old woman, who had a complaint of hematochezia, was diagnosed as primary AL-type amyloidosis. She was treated with colchicine, which promoted the significant improvement of general conditions. Colchicine may be available to recover colonic mucosal injury caused by this type of amyloidosis.

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We reported a case of hepatic nodular regenerative hyperplasia (NRH). The patient was a 49-year-old woman. She had been treated for diabetes mellitus for 2 years and was admitted for pretibial edema and ascites. Abdominal CT showed ascites, mild liver atrophy and splenomegaly. Endoscopic examination showed esophageal varices. On laparoscopic examina-tion, the liver surface was finely uneven. Most of slightly protruded areas were whitish and slightly concaved areas had reddish brown ones. The whitish areas were stained greenly 10-15 minutes after intravenous injection of indocyanine green (ICG) of a dose of 2.5 mg/kg, and color contrast were prominent. The reddish brown areas were stained gradually 30-40 minutes later and a whole of the liver surface was stained greenly. Liver biopsy specimen was diagnosed as NRH. Three years aftet the first admission abdominal CT showed marked liver atrophy and massive ascites, and she died of esophageal variceal bleeding, hepatic failure and renal failure. The reddish brown areas on the liver surface were stained later because of atrophic areas of NRH and without fibrosis. The above laparoscopic findings of NRH were distinguishable from those of liver cirrhosis with fibrosis. In 65 NRH cases reported in the Japanese literature from 1991 to 2000 including ours, the sex ratio (male : female) was 1:1.8. The mean ages were 44.9, 60.6 and 53.5 in cases of percutaneous liver biopsy or surgically resected specimen, in autopsy cases and in all cases, respectively. Portal hypertension was associated in 83.3%, 54.3% and 67.7% in the above groups, respectively.

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‹Background and aim of the Study› To review postoperative complications related to percutaneous endoscopic gastrostomy (PEG). ‹Methods›; We divided complications related to PEG into two categories depending on time after PEG placement, and examined difference of types of complications and their frequencies. ‹Results› Early complications, which was defined as ones occurred within three weeks after the PEG placement, were found in 195 cases out of 651 cases examined (30.0%), whilst late complications, which occurred later than three weeks, were observed in 66 cases (10.1%). ‹Conclusions› It would be crucial to recognize types of complications predicted to occur in different periods after PEG placement.

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Percutaneus endoscopic gastrostomy (PEG) is becoming a commonly used method of enteral feeding for neurological patients with swallowing disturbance. Surgery for head and neck tumors are likely to cause swallowing problems. Therefore, PEG was performed for preoperative patients with head and neck tumors. For these patients PEG is a safer and more beneficial method, because such patients have no dementia and can walk soon after curative surgery. A PEG tube can be an useful route for enteral feeding and has no influence on the surgical wound, allowing the patient to undergo swallowing training easily. We recommend preoperative PEG as a very useful method for patients with head and neck tumors.

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Various kinds of classification have been postulated, however, there remains no plausible classification until now. The Research Society for Gastritis performed a pilot study to establish the endoscopic classification under consideration of the factors such as (1) easy-to-use, (2) permitting the common image, (3) presence of pathological evidence. Eight basic endoscopic and histologic patterns of gastritis (superficial, hemorrhagic, erosive, verrucous, atrophic, metaplastic, hyperplastic and special types) were defined, respectively. One hundred and fifty-five patients were enrolled and underwent gastroendoscopy. Presence of 8 items with 13 findings was endoscopically assessed and endoscopic diagnosis of gastritis was made according to the definition of endoscopic types of gastritis More than 5 biopsy specimens were obtained from the lesser and greater curvatures of the antrum and the corpus, and histologic findings of gastritis and Helicobacter pylori infection were assessed. The histologic diagnosis of gastritis was made according to the definition of histologic types of gastritis in a blind fashion for endoscopic diagnosis. Then comparison of the endoscopic diagnosis to the histologic diagnosis was performed. As the results, in diagnosis of erosive, verrucous and atrophic gastritis, the consistency rates between endoscopic and histologic diagnosis were 40 to 86%, and sensitivity, specificity and accuracy were 62 to 98%. Regarding superficial gastritis, the consistency ratio and sesnsitivity in the corpus were 50% and %, but 6% and 8% in the antrum, respectively. Intestinal metaplasia and hyperplastic gastritis were only correctly diagnosed in severe cases. These results suggest that stipulation of 5 basic patterns including superficial, erosive, verrucous, atrophic and special types is reasonable. Exclusion of metaplastic and hyperplastic types from the basic endoscopic classification is appropriate. New definition of gastritis in the antrum accompanied with redness still remains to be investigated.

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