Patients with primary biliary cirrhosis (PBC) develop portal hypertension and esophageal varices (EV) even before they become cirrhotic . It is clear that a hemorrhage from EV occasionally occurrs as an initial symptom of PBC. Incidence of esophageal varices increases with progression of the stages of PBC, but some patients show high risk varices with a red color sign even at an early stage. The PBC patients had a higher portal pressure and an earlier recurrence of esophageal varices compared to patients with liver cirrhosis due to viral and alcoholic etiology. The patients with EV had a poorer prognosis than those without EV. It is difficult to treat patients with EV after rupture. If the patients are diagnosed as PBC, the EV should be diagnosed by the upper gastrointestinal endoscopy. The early treatment for EV is necessary for a good prognosis.

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A 64-year-old man was hospitalized because of hematemesis. Emergency endoscopic examination showed an arterial hemorrhagic esophageal cancer of the middle and lower esophagus. The hemorrhage was temporarily treated with Sengstaken-Blakemore tube. After that we treated the hemorrhage with argon plasma coagulator. A case of arterial hemorrhagic esophageal cancer is rare. We had a new understanding that Sengstaken- Blakemore tube was useful for hemostasis.

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This is a case report of a 77-year-old male with giant gastric ulcer, at the bottom of which there was a large exposed vessel with the arterial beat. As a possibility of inducing the bleeding by the endoscopic hemostasis, we performed abdominal angiography. It showed an aneurysm at the parietal branch of left gastric artery and transcatheter arterial embolization (TAE) was carried out and achieved complete hemostasis. Although hemorrhagic gastric ulcers with aneurysm are rare, their hemostasis seemed to be difficult and TAE may prove to be a useful method in the treatment of these ulcers.

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We experienced poorly differentiated adenocarcinoma in gastric hyperplastic polyp in a 74 -year-old woman . Endoscopic examination of the stomach showed pedunculate reddish polyp, about 7 mm in size, on the greater curvature of middle body . This polyp was removed by snare polypectomy. Histologic study showed the polyp contained intramucosal poorly differentiated adenocarcinoma. Most carcinomas found within hyperplastic polyps are reported to be well differentiated adenocarcinoma. In this case, the gastric hyperplastic polyp contained poorly differentiated adenocarcinoma, which is histologically rare type of cancer found in hyperplastic polyp.

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A 48-year-old woman, was diagnosed to have a flat elevated type polyp in the descending part of the duodenum by upper gastrointestinalendoscopy. The lesion, about 15mm in diameter, had two different colors, white and pink. Magnified endoscopy disclosed a foliar pattern in white willi, and a reticular or sulciform pattern in pink villi on the lesion . Endoscopic mucosal resection was performed. Histological examination revealed that the lesion was tubulovillous adenoma in the white villi and tubular adenoma in the pink villi, and indicated that accumulation of absorbed lipids in absorptive cells at the tip of the villi made the villous color whiter . Case reports of flat elevated adenoma of the duodenum are rare . This case would be valuable because of the variation of microscopic mucosal pattern on one lesion, which was observed by magnifying endoscopy.

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We report a case of cavernous hemangioma in the rectosigmiod colon. A 16-year-old male was admitted to our hospital because of melena and severe anemia. Colonoscopic examination showed edematous mucosa, telangiectasia, and wavy vascularization in the rectosigmoid colon. CT scan and MRI examination revealed that the lesional wall was remarkably thickened. The inferior mesenteric arteriograms showed diffuse prolonged stainings in the arteries in the involved intestine. Based on these examination, he was diagnosed as having diffuse hemangioma in the rectosigmoid colon. The hemangioma in the large intestine is rare, and only 19 cases have been reported in our country, including the one presented here.

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A 66-years-old woman underwent endoscopic sphincterotomy because of a common bile duct (CBD) stone. An eight-wire dormia basket catheter was used in order to remove the CBD stone, but the stone and the basket catheter were impacted in the intrapancreatic CBD . Despite the use of an endotoriptor, the wire of impacted basket was broken and the stone removal was not achieved. After endoscopic procedure, hematochezia and shock due to gastrointestinal bleeding occurred. Conservative treatment such as blood transfusion or administration of the catecholamines was not effective to control gastrointestinal bleeding . Therefore, she was transferred to our hospital for the purpose of intensive care . Because abdominal CT revealed retroperitoneal perforation, she did not have endoscopic technique for hemostasis but had transcatheter arterial embolisation (TAE) . The second TAE achieved complete hemostasis and she recovered from shock. The impacted CBD stone and the basket catheter were migrated into the small intestine spontaneously while she had been waiting for surgical operation . She was discharged from our hospital after laparoscopic cholecystectomy . TAE is one of effective therapeutic maneuvers for post EST hemorrhage in case that endoscopic treatment is avoided for some reason or is not effective . It will be worth planning prior to surgical intervention for patients with post EST hemorrhage.

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Bleeding from cutting sites during endoscopic submucosal dissection (ESD) against gastric tumors is inevitable and it is also one of the major complications of ESD. In such cases, detection of bleeding sites and endoscopic hemostasis during ESD could be performed more easily by squirting water. However, conventional endoscopes except from Pentax Co. do not have any water jet system. Therefore, to detect bleeding sites, procedure of squirting water should be performed each time after pulling devices for ESD out of the accessory channel. However, this procedure is very complicated and wastes time. Thus, we developed useful endoscopic hemostatic device during ESD. A probe/irrigation plug was attached to the accessory channel of the endoscope, and water jet system with a foot switch (Water Pik, Water Pik Technologies) was attached to this plug. So that squirting water was able to be performed through the accessory channel even if the needle knife was passed through it. By using this system, it was able to detect bleeding sites and to do endoscopic hemostasis more easily and quickly. Squirting water was also able to be performed even if the hemostatic hothiopsy forceps was passed through it. Accordingly, this system was thought to be useful for endoscopic hemostasis during ESD against gastric tumors.

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We assessed the knack and pitfalls in procedures and techniques of magnifying colonoscopic observation for colorectal neoplasia. The procedure steps in order are lesion detection, lesion washing by water, standard observation, chromoendoscopic observation with indigo carmine dye spraying, and magnification. Lesions with obscure or V type pit pattern need the additional staining method with crystalviolet for magnification in order to obtain correct pit pattern diagnosis. We have to understand that magnification is a part of standard observation which is the basic procedure in colonoscopic diagnosis.

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Background : Endoscopic papillary balloon dilatation (EPBD) is one of the methods to remove bile duct stones. EPBD might preserve the function of the sphincter of Oddi despite the potential risk of acute pancreatitis. There are only a few reports of EPBD reducing the risk of acute pancreatitis and, at same time, preserving the function of the sphincter of Oddi. Methods : We performed EPBD for bile duct stone removal in 60 patients using two balloons with different diameters. Patients were randomized to EPBD with a 6 mm balloon (n=30) or an 8 mm balloon (n=30). In both groups, isosorbide dinitrate (ISDN) was infused in a rate of 5 mg/h while low pressure EPBD were being performed. The pressure of the sphincter of Oddi was observed before and after the EPBD procedures. Also, serum amylase level after EPBD was observed for both groups. Results : Serum amylase level of the 6 mm group was significantly higher than that of the 8 mm group (P <0.05). Acute pancreatitis occurred in two patients (6.7%) in the 6 mm group whereas no case was observed for the 8 mm group. The rates of duct clearance were 93% in the 6 mm group and 100% in the 8 mm group. Stone removals were difficult in seven cases with 6 mm balloon dilatations due to the narrow orifices of the papilla. In the 6 mm group, there was no significant difference between the basal sphincter of Oddi pressure (BSOP) and the phasic sphincter of Oddi pressure (PSOP) before and after EPBD. However in the 8 mm group, the BSOP observed after the EPBD procedure was significantly higher than BSOP before the treatments. Within this group, BSOP values after EPBD wre preserved by approximately 80% of the BSOP values before the treatments. In contrast, there was no significant difference in PSOP before and after the treatments. Regarding the stone numbers, no significant difference was observed in BSOP before and after the treatments for the 6 mm group with less than two stones. Also, as for stone size, no significant difference was observed in BSOP before and after the treatments for the 6 mm group with stones of less than 6 mm in diameter. Conclusion : We are now conducting EPBD with ISDN infusion using a 6 mm balloon for a patient who has less than two stones with size not exceeding 6 mm in diameter. An 8 mm balloon is used for a patient with more than two stones or a stone greater than 6 mm in size.

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