Sphincter of Oddi dysfunction (SOD) is one cause of post-cholecystectomy syndrome and biliary pain. It is a diagnostic and therapeutic challenge. The syndrome is often associated with a variety of other gastrointestinal dysmotility disorders. The Milwaukee classification divides patients with biliary pain into three categories. Biliary Type I patients show the entire objective signs of disturbed biliary outflow : elevated liver function tests dilated common bile duct (CBD) and delayed contrast drainage during ERCP. Biliary Type II patients have biliary pain along with one or two of the criteria from Biliary Type I. Biliary Type III patients have only biliary pain, with no other abnormalities. Recently the huge increase of cholecystectomy by Laparoscopy has increased the number of patients with post-cholecystectomy syndrome and possible Sphincter of Oddi dysfunction (SOD). We described eight patients with Biliary Type I SOD treated by endoscopic sphincterotomy (EST) and confirmed that Biliary Type I SOD is actually papillary stenosis. After seeing several patients with sickle cell disease, concomitant papillary stenosis, and common duct stones, we modified the definition of papillary stenosis to include patients with biliary stones. This paper will focus primarily on SOD syndrome, papillary stenosis, and the diagnostic and therapeutic approaches-in particular endoscopic sphincterotomy.

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A 63-year-old man was admitted to our hospital with the complaints of weight-loss and upper abdominal fullness. The upper gastrointestinal endoscopy showed a large ulcer at the gastric angle and a fistula with remnant gastric mucosa at the bottom of the ulcer. Histology of biopsy specimens, which were obtained from ulcer edge and around the fistula, did not show any malignant findings. Since the fistula was connected to a transverse colon, it was diagnosed as a gastro-colic fistula. The conservative treatment by taking a proton pump inhibitor was selected, because the patient refused surgical operation. Although the endoscopy performed at 63 weeks after start of the treatment showed that gastric ulcer was healed, the fistula was still present at the center of the scar. This case is rare and is valuable to report, since the long-term endoscopical observation of the gastro-colic fistula caused by the perforation of benign ulcer was possible.

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The patient was a 54-year-old woman who presented to our hospital with right lower abdominal pain and bloody stools. Colonoscopy revealed an elevated lesion, 10 mm in size, in the terminal ileum, that appeared to be like a submucosal tumor. A diagnosis of carcinoid tumor was made by biopsy. Because of the high incidence of lymph node metastasis by carcinoid tumors of the ileum, laparoscopic ileocecal resection was performed instead of endoscopic removal of the tumor. Postoperative histopathological examination demonstrated like a submucosal tumor without muscle layer invasion (sm), but despite the small size of the tumor, a lymph node metastasis was detected at the base of the ileocolic artery. Intubation of the terminal ileum during colonoscopy enabled detection of the tumor in this patient.

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Depressed-type jejunal adenoma is very rare. This is the first reported case in Japan. A 62-year-old man was hospitalized because of severe nausea and vomiting. An upper gastro-intestinal endoscopy examination revealed a duodenal ulcer. An abdominal CT examination revealed diffuse dilatation of the main pancreatic duct. When ERCP was performed, we happenedly find a depressed lesion, 5 mm in diameter, in the jejunum. A study of biopsy specimen suggested adenoma, therefore we tried to treat by endoscopic mucosal resection. Pathological findings of the resected specimen showed a depressed lesion, 3 mm in diameter. The histology of the depressed lesion revealed tubular adenoma with severe atypia.

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Clinicopathological features of two Japanese patients (25-year-old and 83-year-old men) with an inflammatory cloacogenic polyp (ICP) are described. Both of the patients have been suffered from hemorrhoids and defecation disturbance. Colonoscopic features are character-ized by a solitary sessile hyperemic polypoidal mass (2 and 3 cm in diameter) with partly villous surface located in the anterior wall of the lower rectum, focally covered by stratified squamous epithelium of the anal verge. Histological examinations show hyperplastic crypts and stromal fibromuscular hypertrophy. These findings seem to indicate mucosal prolapse arround the hemorrhoid in polypogenesis of ICP.

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[Aim] We could successfully performe the placement of a percutaneous endoscopic gastros-tomy (PEG) by the transnasal approach (transnasal PEG) in two cases that the oral insertion of an endoscope was difficulty or danger. We described the safety and utility of the transnasal PEG.[Method] A small-diameter endoscope was inserted via the nostril into the esophagus and stomach and a 16Fr gastrostomy tube with a soft retention dome was placed, through the nose, by using the pull technique.[Result] The transnasal PEG was safely performed without the damage of a pharynx and nostril.[Conclusion] We think that transnasal PEG is a useful method in cases that the oral insertion of an endoscope was difficulty or danger.

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Disseminated intra-abdominal malignancies of recurrent or advanced gastric cancer can also cause colonic or rectal obstruction by extrinsic compression. Surgical treatment is usual option to treat malignant bowel obstruction. However, this usually involved emergency surgery on poor-risk and clinically unstable patients with unprepared bowels. In many cases, particu-larly in palliative surgery, the creation of colostomy is inevitable. The self-expandable metallic stent (SEMS) has been found to be effective in relieving colorectal obstruction, both as a palliative treatment for unresectable tumor and as a temporary measure for subsequent surgery. We reported our preliminary experience with the use of endoscopic self-spandable Ultraflex stents as a palliative treatment for colorectal obstruction for peritoneal dissemina-tion of gastric cancer. All SEMS of five patients with colorectal obstruction were enplaced successfully and covered the obstructive lesions satisfactorily. Bowel function returned within 24 hours, and per oral feeding began again after a day. Four patients of them died of the disease 1 to 14 months after placement of SEMS. The complication of other one was dislocation of SEMS, because of progressive response of recurrence gastric cancer with peritoneal dissemina-tion after chemotherapy of S-1. No one complained of abdominal discomfort and incontinence of stool. The use of SEMS can achieve rapid and effective non-surgical means to relieve colorectal obstruction. It provided good palliation for unresectable peritoneal dissemination of gastric cancer that causes colorectal obstruction.

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The key to minimizing papillary hemorrhage is to perform the sphincterotomy in the correct direction, by using suitable electro-surgical current and by maintaining reliable control in the degree of coagulation surrounding the incision line. The cutting direction should be maintained in the 11 to 12-o'clock range with the current of choice as pure cuttig. To control the width of the coagulated area surrounding the incision line, the cut should be extended in a very gradual manner while applying short bursts of current, cutting only 1-2mm at a time. With the first 3 to 5 mm of the incision, however, care should be taken to avoid excessive coagulation of tissue as this causes edema, which increases the risk of pancreatitis. Another serious problem related to papillary hemorrhage is a sudden zipper cut. The sphincterotome should be bent to establish contact between the cutting wire and the papillary roof. To prevent a sudden zipper cut, a responsive beginning of incision should be initiated without excessive bending of the sphineterotome. To achieve a quick start of sphincterotomy, the leak of current from the cutting wire to the scope should initially be avoided. Next, the contact area between the cutting wire and the papillary roof should be as minimal as possible. Finally, counter-traction between the cutting wire and the papillary roof should be maintained.

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