Swallowable wireless capsule endoscopy (CE) is a new diagnostic tool for the examination of gastrointestinal (GI) tract. PillCam^TMSB (GIVEN Imaging, Israel) is the most popular tool at the present time and its most suitable indication is obscure GI bleeding. The other indications currently accepted are investigation of Crohn's disease, evaluation of the side effects of nonsteroidal anti-inflammatory drugs and surveillance of hereditary polyposis syndrome. PillCam TMSB is widely used in the world but Japanese government does not allow it yet. Recently, a new CE for esophagus (PillCam^TMSB) is developed and allowed in USA and Europe. CE for colon is under development and clinical trial of Japanese CE for small intestine has just started. Various type of CE will be developed and endoscopic diagnosis and treatment could be dramatically changed in the near future.

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A 56-year-old male was admitted to our hospital because of hematemesis and tarry stool with a shock condition. Urgent endoscopy revealed an exposed vessel in the lesser curvature of the gastric cardia without evident abnormal findings in the surrounding mucosa, such as Dieulafoy's ulcer. Endoscopic hemostasis was achieved with two clips. Endoscopy a week after admission revealed mucosal erosion oral to the clips, and a biopsy specimen showed moderately differentiated adenocarcinoma. Follow-up endoscopy revealed the lesion had become a type OIIa+IIc carcinoma three weeks after the first endoscopy. A proximal gastrectomy was performed. Histological examination revealed a moderately differentiated adenocarcinoma invading the muscular layer without lymph node involvement. A large-caliber artery was seen in the submucosal layer and was ruptured at the shallow ulcer of the carcinoma. In most reported cases of gastric cancer associated with Dieulafoy's ulcer-like finding, the first endoscopic examination failed to detect the carcinoma. Follow-up endoscopy and biopsy are recommended in cases of Dieulafoy's ulcer treated by endoscopic procedure.

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We reported two cases of inflammatory fibroid polyp (IFP) of the stomach which could be observed endoscopically for a long time. Case 1: A 64-year-old woman was underwent upper gastrointestinal endoscopy for screening. A hemispheric protruding lesion, 8mm in diameter, was found in the antrum and followed by endoscopy for 9 years. The lesion increased in size up to 25mm and changed to a pedunculated polyp with ulceration. Case 2: A 59-year-old man had a hemispheric elevated lesion, 10mm in diameter, in the antrum which was diagnosed as a submucosal tumor and followed for 8 years. The lesion changed to a tumor with central depression and enlarged to 15mm in diameter. Both lesions were resected endoscopically and led to a histological diagnosis of IFP.

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A 76-year-old woman was diagnosed to have a type 4 advanced gastric cancer with antral stenosis which was judged to be unresectable. To relieve the antral stenosis due to gastric tumor and enable to administer an oral TS-1, we introduced an expandable metallic stent (EMS) successfully into the stenosis. Food intake was improved and a good quality of life (QOL) was maintained on her after the stenting. Then, she received a combined systemic chemotherapy with TS-1 and CDDP. The tumor responded to the chemotherapy remarkably and the EMS escaped from the stenosis and became free in the stomach. Since EMS was migrated into the ileum and caused intestinal obstruction 10 months after placement, we removed it surgically. EMS can achieve the maintenance of a good QOL. However, the migration of EMS is an attentive complication in cases with remarkable response to chemotherapy. To avoid such complication, further efforts would be required to establish the policy for disuse of EMS and the method of removing EMS including the development of retrievable stent.

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A 68 year-old female was admitted to our hospital because of hematemesis and melena. Emergency endoscopic examination revealed an exposed vessel in the diverticulum of the second part of the duodenum. Endoscopic clipping of the vessel was performed, which caused localized peritonitis next day. There were 16 case-reports of endoscopic hemostasis using clip for hemorrhage from duodenal diverticulum in Japan, such a case accompanying localized peritonitis had not been reported.

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A 64-year-old man visited his home doctor because of right low abdominal pain in January, 2002. Barium enema study revealed an irregular protruding lesions at the sigmoid colon and caecum. He was introduced to our hospital for further examination and treatment of tumor of the colon. Colonoscopy revealed a Is type polyp protruding from the appendix, and a sigmoid tumor of approximately about 4.0cm in size with ulcer formation. Ileocecal resection and sigmoidstomy were performed. Histological findings of the resected specimen revealed serrated adenoma of the appendix and well differentiated adenocarcinoma of the sigmoid colon. An appendiceal serrated adenoma is the rare report in Japan.

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A 54-year-old woman had undergone total gastrectomy and partial resection of transverse colon for stage IV gastric cancer (signet-ring cell carcinoma) at the age of 50. She admitted to our hospital because of anal bleeding and abdominal fullness. Barium enema and colonoscopy were done to confirm the diagnosis for Schnitzler's metastasis. It revealed the stenosis, approximately 17cm in length from the sigmoid colon to rectum. The histopathology of biopsy specimen from the rectum demonstrated signet-ring cell carcinoma. Thus, we diagnosed the cob-rectal stenosis caused by Schnitzler's metastasis. After placement of expandable metallic stent (EMS) at the stenotic lesion, the patient was able to maintain bowel activity for 5 months. It is suggested that EMS placement is a useful therapy in patients with malignant cob-rectal stenosis caused by Schnitzler's metastasis.

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A 57-year-old female underwent ERCP for the preoperative examination of anomalous pancreaticobiliary ductal junction and congenital biliary dilatation. Severe acute pancreatitis was caused by FRCP. We performed continuous celiac arterial infusion of Imipenem/Cilastatin sodium (IPM/CS) and naf amostat mesilate (FUT) for 7 days . Consecutively, we performed intravenous infusion of IPM/CS and intravenous continuous infusion of FUT for 7 days. Thereafter, nephrogenic diabetes insipidus and sodium-losing nephropathy were developed. Intravenous continuous infusion of antidiuretic hormone was effective for the control of urine volume.

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Massive hemorrhage from gastric varices (GV) can often be fatal and requires immediate attention. Prediction of GV hemorrhage is difficult. However, aggressive treatment should be undertaken to prevent possible hemorrhage, i. e., large varices of F2 or F3, or GV with erosion and/or red color sign. It is widely accepted that infusion of a tissue adhesive (a -cyanoacrylate monomer (CA) or Histoacryl) should be the first-line treatment for gastric variceal bleeding. However, since the risk of re-bleeding is high due to the complex portal hemodynamics of GV, elective treatment after the bleeding has been stopped is very important. The combined method using CA and ethanolamine oleate (EO) is effective for this purpose. Moreover, CA-EO combined method followed by mucosa-f ibrosing using argon plasma coagulation is more effective to prevent re -bleeding from GV. Pre-treatment assessment of portal vein hemodynamics by endoscopic ultrasonography and multi-detector-row CT, and post-treatment assessment of the effect of treatment are important for safe and effective treatment using these methods.

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The level of inflammation in the gastric mucosa after the eradication of Helicobacter pylori was examined using biopsy samples obtained from patients with gastric ulcers. Gastric mucosal specimens were endoscopically obtained, before and after H. pylori-eradication therapy, from 39 patients with gastric ulcers and a positive H. pylori-infection status. The level of neutrophil-derived oxidants was then measured in each sample using a luminol-dependent chemilumines-cence (ChL) assay. ChL activity in the ulcer portion and the background gastric mucosa (antrum and corpus) was significantly reduced 3 months after successful therapy (n=32). The ChL activity was further decreased 9 months after successful therapy, but the activity in the ulcer portion remained unchanged. In patients who did not respond to the H. pylori-eradication therapy (n=7), the ChL activities were not altered in any mucosal portion after the therapy. Before the H. pylori-eradication therapy, a higher ChL activity was observed in open ulcer tissue than in scarred tissue. The ChL activity in the scarred tissue was reduced 3 months after the successful eradication of H, pylori, however, the ChL activity in the red scars was signifi-cantly higher than that in the white scars. The ChL level in the white scars was almost equivalent to that in the background mucosa 9 months after the completion of the H. pylori-eradication therapy. In conclusion, the eradication of H. pylori may reduce the level of oxidant production in gastric ulcers, promoting the prevention of ulcer recurrence. Furthermore, the presence of a red scar may indicate unstable healing, even after the successful eradication of H. pylori.

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