Gastroesophageal reflux disease (GERD) is defined on the clinical symptoms and pathophysiology of the disease. Therefore, endoscopic study has a subsidiary role in the diagnosis of GERD. The information obtained by endoscopic study, however, is pivotal for finding other disease than GERD that may cause reflux-like symptoms, for understanding pathophysiology of reflux disease by grading esophageal mucosal lesions, and for identifying Barrett's esophagus and assessing the therapeutic effect on it after the endoscopic or medical treatment. Therefore, the purpose of the endscopic study should be well recognized by all the endoscopists before doing study on each patient with different problems. Gastroenterological Endoscopy

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A 46-year-old woman was followed the submucosal tumor of the middle esophagus since 1995. It had been growing and happened to appear the sense of discomfort in swallowing in March 2005. The tumor was diagnosed as the submucosal origin. We excised it in the way of the endoscopic submucosal dissection with the hook-knife. The resected specimen was 3.2× 2.3× 1.7cm in size and had clear boundary. It was diagnosed as the leiomyoma immunohisto-chemistrically. In the anal side, however, the resected margin was positive. Some repors say that the indication for endoscopic resection of the esophageal submucosal tumor is the tumor occupies the submucosal layer. In the case of the large tumor, we think that it is necessary to take care of the anal margin of the tumor.

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We reported a case of early gastric cancer consisting with well-differentiated adenocarcinoma diagnosed by endoscopic mucosal resection (EMR) after a 7-years follow-up as a submucosal tumor (SMT). A 59-year-old man who was recommended a further examination of stomach in a medical checkup underwent upper gastrointestinal endoscopy. There was a SMT-like elevation about 1 cm in diameter covered with intact mucosa without depression or erosion on the anterior wall of the middle body. The endoscopic findings of the lesion followed -up every year did not change until 7 years later, when it increased in size to 2 cm in diameter accompanying erosion on its top. The biopsy specimen from the erosion was pathologically suggestive of well-differentiated adenocarcinoma and the subsequent diagnostic EMR revealed a tumor consisted of a solid proliferation of well-differentiated adenocarcinoma mainly in the submucosal layer. The mucin histochemical staining indicated that the carcinoma showed gastric phenotype and the cancer cells in the surface mucosa resembled foveolar epithelial cells, which made difficult in identifying the margin of the carcinoma. The tumor invaded deeper than 6000μ m from the mucosal muscle layer (sm2 or deeper invasion), suggesting the need of additional gastrectomy. The pathologic study after distal gastrectomy performed a month later demonstrated no cancer cells remained in both the resected stomach and lymph nodes, and there was no evidence of accompanying SMT. Although this case is rare, even such a small SMT-like elevation seems necessary to be under careful follow-up.

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A 67-year-old female presented at our hospital with nausea . Endoscopic examination revealed a granular lesion with erosion on the anterior duodenal wall . We diagnosed this lesion as mucosa-associated lymphoid tissue (MALT) lymphoma by endoscopic biopsy . Endoscopic ultrasound (EUS) showed that the invasion was limited to the superficial submucosa (sm). Eradication of Helicobacter pylori (HP) with antibiotics induced spontaneous remission of the lesion. No evidence of recurrence has been observed for 12 months after the antibiotic treatment. In Japan, based on the findings of the case reports on primary MALT lymphoma of the duodenum, bulbar lesions should be treated with antibiotics because they may be relared to HP infection. These reports suggested that the lesions distal to the descending duodenum were related to other mechanisms.

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An 86-year-old woman was admitted for anorexia and diarrhea (sometimes bloody diarrhea). Colonoscopy revealed proctitis associated with both a huge fistula, through which a scope was easily inserted into the vagina, and a huge deep one adjacent to the urinary bladder, 2 cm and 8 cm from the anus respectively. Histological examination of biopsy specimens from the fistula revealed intranuclear inclusion bodies, and positive immunostaining for cytomegalovirus (CMV) antigen. Serum levels of anti-CMV antibody IgG and IgM were elevated but no serum antigen of CMV was detected. She was diagnosed as having CMV proctitis with fistulae. Serum assay of anti-HIV antibody was negative and serum level of CD4/8 ratio was normal. Three weeks after admission she complained of fecaluria. Colonoscopy revealed 2 orifices, through which a lumen of the urinary bladder was observed, in the base of the huge fistula 8 cm from the anus. Transurethral cystography showed that contrast media in the bladder flowed out through a f istulous tract (2.5 cm in diameter and 4 cm in length) into the rectum and then from the rectum into the vagina. She was treated with ganciclovir for 2 weeks and received transverse colostomy. Two months later cystography, showed that no contrast media in the bladder leaked. Three months later colonoscopy showed that the rectovaginal fistula decreased in size and the rectovesical one diminished. To our knowledge three cases of a rectovaginal fistula due to CMV infection and no case of a rectovesical fistula due to CMV infection have been reported from 1983. This was a rare immunocompetent case of CMV proctitis with both rectovaginal and rectovesical fistulae.

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We herein report a case of small pancreatic cancer without dilatation of the pancreatic duct in which the histological diagnosis was confirmed preoperatively by transpapillary approach. A 75-year-old man presented with a solid hypoechoic mass, 12 mm in diameter, in the pancreatic body detected by abdominal ultrasonographic screening. Endoscopic retrograde pancreatography (ERP) revealed a tiny defect in the main pancreatic duct. Transpapillary pancreatic duct biopsy and cytology of the pancreatic juice indicated the possibility of malignancy. Distal pancreatectomy was performed. Histological examination verified a welldifferentiated adenocarcinoma measuring 15× 15× 13 mm in size without invasion of the pancreatic capsule, retroperitoneum, bile duct, duodenum, portal vein, or major arteries.

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A 43-year old woman was referred to our hospital because of epigastralgia. On abdominal examination, gallbladder adenomyomatosis was suspected with marked wall thickneing. We found high confluence of pancreaticobiliary ducts at FRCP, and it showed high amylase levels of the bile in the gallbladder and in the bile duct. Pathological examination revealed that it was adenomyomatosis with hyperplasia of endemic epithelium. The Ki-67L1 was increased to 39.4%. It is suggested that the gallbladder with high confluence of pancreaticobiliary ducts has a high potential of carcinoma.

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The most critical point in endoscopic papillectomy is the assessment of its indication. Adenoma of the duodenal papilla without extension into the bile or pancreatic duct is an accepted indication. Cancer in adenoma without invasion of the muscularis propria of the duodenum, pancreas, or extension along the bile or pancreatic duct is also a possible candidate for this treatment. On some occasions, endoscopic papillectomy may be indicated as a total biopsy.
The procedure is similar to that in polypectomy of the digestive tract. Following insertion of a duodenoscope into the descending portion of the duodenum, a tumor at the papilla of Vater is caught in a snare loop which is delivered via the cannel of the scope, as deep as possible. To achieve this, the tip of the snare should first be put on the top of the oral protrusion as a fulcrum. Then, the entire tumor is trapped in the snare, and the snare is tightened so that it can grasp the bile duct and the pancreatic duct terminals adjacent to the base of the tumor. We apply the 'cut' current for electrocautery to avoid infiltration of the energy to the pancreatic parenchyma. After resection of the tumor, a stent is placed in the pancreatic duct, which will prevent obstruction of the outlet of pancreatic juice that leads to acute pancreatitis.
Detailed histological examination is mandatory for the evaluation of the quality of the resection. It is ideal to obtain cut margins, including the bile duct and pancreatic duct terminals, be free of neoplastic cells. Sometimes it is not possible to confirm such free margins due to burn of the tissue. In such occasions, follow-up in a short term is required and when a remnant tumor is recognized, surgical resection or ablation should be added based on the depth of invasion of tumor. Further accumulation of the data on follow-up is necessary to justify this procedure as a treatment of choice for the tumors mentioned here.

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