Intraductal ultrasonography, which employs a thin, high-frequency ultrasonic probe inserted into the bile duct, produces high-quality cross-sectional images of the bile duct. lntraductalultrasonography is useful in assessing biliary tumor staging including tumor depth infiltration, pancreatic parenchymal invasion, portal vein invasion, and right hepatic artery invasion.However, it has limitations in assessing lymph nodes metastases. The assessment of longitudinal cancer extension along the bile duct is a promising aspect of this area. However, thickening of the bile duct wall is a nonspecific finding that may represent either inflammatory changes that may result from mechanical irritation by a biliary drainage catheter or other factors, or the longitudinal extension of the cancer. ln distinguishing between benign and malignant diseases, a presence of sessile tumor, tumor size greater than 10.0 mm, and interrupted wallstructure on IDUS images were factors that predict malignancy.

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A 61-year-old man was hospitalized because of loss of consciousness. We diagnosed acuteon chronic renal failure. He complained of hematemesis during hemodialysis. Emergencyendoscopic examination showed multiple spontaneous submucosal hematomas of the entireesophagus and multiple ulcers with bleeding of the lower esophagus just above the esophagogastric junction. We performed hemostasis by argon plasma coagulator. Endoscopic examination5 weeks ago showed that esophageal ulcers had scarred. A rare case of spontaneous submucosalhematomas of esophagus complicated with acute on chronic renal failure was reported.

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We reported a case of gastric diffuse large B cell lymphoma treated by eradication forHelicobacter Pylori (H. Pylori). Endoscopy with biopsy was done in this case. Diagnosis ofdiffuse large B cell lymphoma was made on the histological evaluation of the biopsied tissues.EUS and CT scan revealed stage I of diffuse large B cell lymphoma. He was treated byeradication of H. Pylori and this treatment of eradication was successful. The gastric lesionwas healed to gastritis. Then, he was treated distal gastrectomy of Billoth I method. No lymphoma tissue was detected on the operated tissue. We conclude that superficial type of gastric diffuse large B cell lymphoma may be treatedby eradication of H.pylori initially.

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A 60-year-old woman had been admitted to a previous hospital because of fever of unknown origin and had been diagnosed as gastric malignant lymphoma (type unknown). She had been treated by 8 courses of CHOP. However, she had been transferred to our hospital because of a gastric lesion's relapse, after one year of the chemotherapy. She was diagnosed as gastric MALT lymphoma in our department. We treated her with radiation (total 46.6 Gy). Half a year after the radiation, a metastasized right submaxillary gland was found and it was resected. A chromosomal test revealed t(11;18) (q21;q21) translocation in this case. We gave her an additional course of rituximab therapy (375mg/m₂/week×4). She has been complete remission to date (over a year). This case was informative about diagnosis, therapy, relapse and chromosomal translocation of MALT lymphoma.

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A 61-year-old woman came to our hospital with multiple elevated lesions in angular lesser curvature of the stomach in medical upper GI X-ray examination. Multiple elevated lesions sized from 10 mm to 20 mm sized were shaped like bunch of grapes on upper GI endoscopic examination. Pathological findings were poorly differentiated adenocarcinoma. Distal gastor-ectomy (D1+β lymphnode dissection, Billroth I anastomosis) was performed. The tumors were poorly differentiated adenocarcinomas which invaded to mucosa. A case of multiple nodular elevated poorly differentiated adenocarcinoma is an extremely rare case.

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We treated a 67-year-old woman who had a minute T3 colorectal cancer with subserosal invasion. A screening colonoscopic examination revealed a small-depressed lesion at the descending colon and the biopsy specimens showed moderately differentiated adenocarcinoma. Endoscopically, the tumor seemed to invade massively into the submucosal layer or a deeper layer because of positive non-lifting sign. So left hemicolectomy was performed. Resected specimen showed a superficial carcinoma type IIc, measuring 8×7mm in diameter. Microscopi-cally, the tumor was moderately differentiated adenocarcinoma, and which invaded into the subserosal layer without lymph nodes metastasis.

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A 74-year-old female presented with abdominal distention and pain. Abdominal computed tomography revealed a tumor of ascending colon with hepatic metastasis and portal vein thrombosis. On endoscopic examination, the tumor of the ascending colon was as large as occupying the lumen, and an endoscopy could not be introduced to the oralside lumen of the tumor. To relieve the symtoms of stenosis caused by the tumor, we placed an ileus tube per anus. Because the tumor was considered too advanced to be curatively resected, we planned to place an expandable metal stent (EMS) at the stenosis portion of the tumor. An ileus tube was placed per nose while keeping the anal one. After recognizing the nasal tube advanced to ascending colon, we introduced a guide wire through the nasal tube to the anal one. The anal tube was removed as keeping a guide wire, and EMS was placed at the stenosis of the tumor per anus along the guide wire. We could place EMS at the ascending colon with the new method of introducing a guide wire from nose to anus through two ileus tubes per nose and anus.

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A 70-year-old female developed appetite loss. CT scan, ultrasonograpy and gastrographin enema study showed an intussusception of the ileocecal portin to right transverse colon. Colonoscopy revealed the protruding lesion in the hepatic flexure of the colon, which occupied the lumen. Pathological examination of biopsy specimens revealed villous adenoma. Ileocecal resection was performed, when the intussusception dissappeared and a protruding lesion about 3.5 cm long was found in the cecum. The center of the protruding lesion was open, continuing to the appendiceal tip. Histological examination of the surgical specimen revealed the appen-diceal intussusception and the proximal two-thirds of the appendix was covered with tubulovil-lous adenoma. Intussuscepted appendix could be one of the causes of cecocolic intussusception.

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A 71-year-old man whose fecal occult blood test was positive in a routine physical examination underwent colonoscopy by his previous physician, revealing a type 1 tumor of the ascending colon. He was admitted to our hospital. Abdominal ultrasonography and computed tomography showed a tumor in the inferior pole of the right kidney, measuring 8.9cm in diameter, invading the ascending colon and hydronephrosis of the right kidney. We diagnosed a right renal cell carcinoma invading the ascending colon, and performed right nephrectomy and right hemicolectomy. Histologically, the diagnosis was clear cell carcinoma. Renal cell carcinoma with colon invasion is very rare, but occasionally accompanies active bleeding. We have to be careful of direct invasion and metastasis from the other organ to the colon when colonoscopy is done.

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There are 2 ways of endoscopic transpapillary drainage ; nasopancreatic drainage (ENPD) and pancreatic stenting (EPS). ENPD is effective for a short-term drainage in patients with acute papillitis. EPS is effective for the stricture of the main pancreatic duct in patients with chronic pancreatitis. Endoscopic transpapillary drainage is necessary to cannulation for the main pancreatic duct. The complication of ENPD is mainly acute pancreatitis, which recovers quickly after removal of the tube. When the migration of pancreatic stent in EPS occurs, the stent should be exchanged quickly.

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Background: Recently, the usefulness of the oblique transparent cylinder (OTC) in colonoscopy has been reported. In this study, the efficacy of two newly designed OTCs was evaluated. Methods: Colonoscopy performed by six experienced endoscopists in 1, 005 cases and by one inexperienced endoscopist in 177 cases was analyzed. Short (S) and ultra short (US) cylinders, shorter in length than a conventional long (L) cylinder, were used. Results: The use of OTCs in colonoscopy contributed to a significantly faster insertion into the cecum. The average time to reach the cecum for experienced endoscopists were 12.4±0.3 minutes without cylinder, 9.0±0.3 minutes with US cylinder, 8.5 ± 0.4 minutes with S cylinder and 0.9 ± 0.8 minutes with L cylinder respectively. The visual field and handling of the endoscope were more improved with the S cylinder than the conventional L cylinder. On the other hand, with the L cylinder, the success rate of one inexperienced endoscopist for total colonoscopy reached more than 90% and mean insertion time to reach the cecum was 10.4±1.8 minutes seven months later. Both the success rate and average insertion time for the inexperienced endoscopist were satisfactory considering the rather short learning period. Conclusion: OTCs were effective in reducing the insertion time. The use of the S cylinder overcome some of the disadvantages of the L cylinder, however, the L cylinder was helpful for improving the technique of an inexperienced endoscopist.

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Background: This study was performed to evaluate the usefulness of the Memory® 8-wire basket (Wilson Cook Medical, Winston-Salem, N. C., USA) for extracting small common bile duct stones after endoscopic sphincterotomy (EST). Methods: Sixty-one patients with common bile duct stones were underwent EST. In patients with stones with a diameter of 1 cm or more, stones were crushed into fragments with a diameter of less than 1 cm using a mechanical lithotriptor. Stones were extracted using a conventional 4-wire basket and a stone retrieval balloon catheter. After endoscopic and fluoroscopic confirmation of the absence of stones, stone extraction was again attempted using the Memory® 8-wire basket, which consists of a 5 Fr catheter sheath and a helical 8-wire nitinol monofilament basket. After a few days, the presence or absence of residual stones was examined by cholangiography via the ENBD tube. Results: Further extraction of stones was possible using the Memory® 8-wire basket in 47.5% (29/61) of the patients who were underwent extraction of stones by a 4 wire-basket and a stone retrieval balloon catheter. Cholangiography some days after using the Memory® 8-wire basket showed residual stones in only 2 patients (3.3%). Conclusions: The Memory® 8-wire basket was a useful device for the accurate and rapid endoscopic extraction of common bile duct stones with a diameter of less than 1 cm after EST.

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