Since the discovery of Helicobacter pylori, the concept of diagnosis and treatment of upper gastrointestinal diseases has changed greatly from conventional beliefs. It has been recognized that H. pylori infection affects endoscopy images of gastric mucosa at the same time. It has been shown that development of chronic atrophic gastritis traditionally considered to be ageing phenomenon is noted in only subjects with H. pylori infection, and it has become clear that eradication of H. pylori markedly improved histological gastritis induced by H. pylori infection. It is also known that there is deep association between H. pylori infection and the background gastric mucosa which various disease is easy to develop of upper gastrointestinal diseases like gastric cancer. Since the histological change concerning H. pylori infection is reflected for the endoscope image, it is important to understand the characteristics of endoscopic findings in various infection status. When a risk of the gastric cancer is considered, it becomes important to grasp features of endoscope image in the 4 groups (uninfected, infected at present, infected in a past, and after eradication by treatment).

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[Aims] We compared the efficacy and complications between the percutaneous endoscopic gastrostomy (PEG) with and without gastropexy in two weeks after PEG was performed. We also compared the cost and benefits of PEG between our original low-cost method (Hokushin Method) and standard gastropexy (Funada's method). [Methods] The 149 patients with gastric wall fixation (gastropexy) and 117 patients without gastropexy were involved. In the gastropexy group, 93 patients received our original method and remaining 56 patients had Funada's method. The complications at the regional area surrounding PEG and general clinical problems were retrospectively surveyed in each cases. [Results] Regional PEG site infection was more prevalent in the group of PEG without gastropexy than the group with gastropexy (7.7% vs 2.0%). However, no significant difference was seen in general complications in those two groups. There were no significant differences between our method and Funada's method in terms of efficacy and the incidence of complications. [Conclusions] PEG with gastropexy significantly reduced the risk of regional infection. PEG should be performed with gastropexy and our low-cost original method would contribute to perform gastropexy more widely than Funada's method.

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A 26 year-old man was diagnosed as duodenal ulcer with a complait of epigastralgia. Six months later, he had tarry stool and was found on gastroscopy to have longitudinal ulcers in the duodenum. Diagnosis was made as Crohn's disease localized at duodenum without other lesion. We gave him prednisolone, mesalazine powder, proton pump inhibitor, and enteral nutrition. After the treatment, remission had continued for eleven months. He admitted to our hospital due to loss of appetite and pyrexia. Gastroscopy showed redness in the antrum and narrowing of the second portion of duodenum. However, we could not pass the scope beyond the narrowing. His symptoms and inflammatory sign was improved by complete bowel rest. Crohn's disease localized in the gastroduodenum is rare. Crohn's disease should take into consideration in the diagnosis if benign ulcerative lesions of upper gastroduodenum were noted.

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A 69-year-old man, who received subtotal gastrectomy because of advanced gastric cancer 22 years ago, was admitted to our hospital with further examination of radiological abnormalities. Endoscopy showed a subpedunculated lesion with irregular and nodular surface covered by white exudate, measuring about 20 mm in size, in the anastomosis of the gastric remnant, which was proved to be signet cell carcinoma by endoscopic biopsy. Total gastrectomy was then performed. The resected specimen showed nodular elevated lesion measuring 18 X 14cm in size. Histological examination showed mucinous adenocarcinoma, partly containing tubular adenocarcinorna in the mucosl layer, with invasion to the muscular layer. No lymph node metastasis was seen. Mucin histochemistry revealed completely intestinal type.

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The cases diagnosed as gastric metastasis from lung small cell carcinoma and endoscopically followed up before their death, are very rare and the only 14 cases have been reported as long as we investigated so far. We were able to endoscopically observe the time-course changes of the gastric metastasis from lung small cell carcinoma occurring as blood vomiting. The metastatic lesions showing verrucose gastritis-like appearance at first, turned to an elevated lesion forming a central depression (so-called Bull's eye type) or Borrmann 2 type-tumor. We were able to diagnose gastric metastasis from lung small cell carcinoma by the biopsy obtained from the Borrmann 2 type-tumor, but not from the verrucosa gastritis-like tumor.

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A 57-year-old woman presented with recurrent intestinal obstruction. She had been treated with nonsteroidal anti-inflammatory drugs (NSAID) for rheumatoid arthritis. Radiographic studies showed dilatation of the distal small intestine but no accurate nature of the stenosis. Double-balloon enteroscopy revealed a pinhole-shaped membranous stenosis of the ileum. She underwent intestinal resection, which revealed a diaphragm disease of the ileum caused by NSAID. Utility of double-balloon enteroscopy is discussed.

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A 65-year-old man presented with tarry stools. Gastrointestinal endoscopic examination could not detect apparent lesions causing gastrointestinal bleeding. Then he was referred to our hospital for further examination. Enteroscopy using the double-balloon method could reveal multiple tumors scattering in the small intestine, which were supposed to be hemorrhagic lesions. Simultaneously biopsy specimens were obtained under the enteroscopy to diagnose these tumors as mantle cell lymphoma. Through this procedure, gastrointestinal bleeding was caused by growth of mantle cell lymphoma in the small intestine. The double-balloon enteroscopic examination was proved to be a new useful maneuver to observe the entire small intestine more precisely.

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A 55 years-old woman who had received peritoneal dialysis and hemodialysis for chronic renal failure since 39 years old, presented to our hospital complaining of continuous abdominal fullness and hematemesis. An emergent upper gastrointestinal endoscopy revealed edematous and erosive mucosa in the first to the second portion of the duodenum. In addition, luminal obstruction was identified in the second duodenum. Computed tomography (CT) and abdominal ultrasonography were done after endoscopic examination, and demonstrated hepatic portal venous gas (HPVG). Mucosal changes in the duodenum were considered to reflect the state of non-obstructive mesenteric ischemia based on a long-term dialysis. Moreover, HPVG was completely disappeared on CT examination at the next day. These findings indicated that HPVG was complication of the emergent upper gastrointestinal endoscopy on the basis of erosion and obstruction of duodenum due to non-obstructive mesenteric ischemia.

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A 77-year-old man was admitted for investigation of right upper quadrant abdominal pain and obstructive jaundice. Magnetic resonance cholangiopancreatography suggested a small stone in the common bile duct. Endoscopic retrograde cholangiopancreatography demonstrated mild dilation of the common bile duct with a small filling defect and linear filling defect in the distal bile duct. A diagnosis of choledocholithiasis and foreign body in the common bile duct was made. Endoscopic papillary balloon dilation was performed, and a stone and foreign body were extracted from the bile duct with basket forceps. The component analysis of the foreign body showed mainly calcium and phosphorus, therefore the foreign body seemed to be a fish bone. We reported this case because an ingested foreign body in the common bile duct is rare in patients without any previous operation.

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Morbid obesity is one of major health problems. We have first experienced two patients with treatment-resistant obesity treated by intragastric balloon (BioEnterics(R) Intragastric Balloon System) in Japan. Four hundred milliliters of physiological saline was injected into the intragastric balloon in each patient. Four months or 3 months later, excess weight loss of -33.4% or -19.3% was achieved, respectively, and hypertension and hyperlipidemia were also improved with no specific complications. For patients with treatment-resistant obesity, the intragastric balloon appears to be safe and useful.

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Endoscopic ultrasonographic scope is a endoscope with ultrasound transducer, which produces transactional image around endoscope. The indication of endoscopic ultrasonography (EUS) for upper gastrointestinal tract is local staging of malignant tumor, diagnosis of submucosal tumor, evaluation of varices and gastric ulcer, and evaluation of chemotherapy efficacy. Concerning about type of EUS, conventional EUS should be employed for relative large lesions and ultrasonic thin probe for small and flat lesions and stricturing lesions such as esophageal cancers. Concerning about scanning techniques, de-aerated water filling method is generally used for gastric lesions and balloon contact method, continuous water infusion method, jelly method for esophageal lesions. In order to have clear image, it is important to do stomach lavage with de-aerated water before scanning, change of patient position such as left lateral to prone, control of volume of de-aerated water in the stomach, and prevention of aspiration in the esophagus. However we have never experienced aspiration case with jelly method. EUS guided fine needle aspiration cytology & biopsy for upper gastrointestinal tract is indicated to submucosal tumor, lymph node, stricture unknown origun. Automatic puncturing needle (NA-11J-KB) so called "shot-gun" is good for beginner, and disposable needle should be used after appropriate experience. It is important to fill the minimum volume of water to reveal the target, puncture the center or base side of submucosal tumor, stroke more than 10-20 times in the target, confirm by on-site pathologist, or obtaining thread like tissue, or puncture until 5 times. Then the satisfied sampling rate and diagnostic rate can he obtained.

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