Gastroesophageal reflux occurs mainly during the daytime in patients with Los Angeles (LA) grade A esophagitis, but predominantly during the night in patients with grade C and D esophagitis. When we investigated whether the difference in the pattern of gastroesophageal reflux influences the circumferential localization of erosions in the esophageal wall, longitudinal mucosal breaks tended to be located most frequently in the 2 o'clock position in patients with low grade reflux esophagitis, including LA grades A and B. The longitudinal mucosal breaks in patients with LA grade B were located more dorsally than those in patients with LA grade A. In contrast, in patients with grade C esophagitis, mucosal breaks were located mainly on the most dorsal side of the esophageal wall in approximately the 6 o'clock position. Since the localization of mucosal breaks in patients with LA grade A and B could not be explained by the gravitational position of lower esophagus, the pathogenesis and significance should be investigated in future study.

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Twenty-eight of 95 patients who had undergone allogeneic stem cell transplantation in our hospital between August 2000 and December 2006 developed lower intestinal graft-versus-host disease (GVHD). The endoscopic findings and clinical features of the 20 patients, who did not have viral enteritis were analyzed. There were 13 males and 7 females. Their median age was 49.9 years ; all patients were diagnosed as having hematological malignancy. Intestinal GVHD was diagnosed based on the presence of specific pathological findings including the presence of apoptotic bodies. All patients developed watery diarrhea. On endoscopicy ; redness and/or edema were seen in 18 patients, irregular mucosa in 6, erosion in 15, ulcer in 4, and atrophy or disappearance of microvilli in 14. Compared intestinal stage 1 or 2 patients with stage 3 or 4 GVHD patients had lower gastrointestinal lesions that were more extensive and more severe.
The clinical manifestations of intestinal GVHD were correlated with endoscopic findings and the extent of intestinal lesions.

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We experienced a rare case of esophageal involvement by crohn's disease, which showed various upper gastrointestinal endoscopic findings and successfully treated with steroid. A 49-year-old woman who had been treated for crohn's disease visited our hospital because of dysphagia. Upper gastrointestinal endoscopy shows aphthous erosions and punched-out ulcers in the esophagus, bamboo joint-like appearance in the stomach, and multiple nodular lesions in the duodenum. She was treated with proton pump inhibitor and steroid. Aphthous erosions and punched out ulcers in the esophagus improved, but bamboo joint-like appearance in the stomach, and multiple nodular lesions in the duodenum showed no significant changes.

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The patient was a 60-year-old male. The upper esophago-gastro-duodenoscopy was performed for screening purposes. At the esophagogastric junction, a depressed erythematous lesion was found with a diameter of 15 mm. The histopathological diagnosis by biopsy was well-differentiated adenocarcinoma taken with all examination, we valuated the depth of invasion was in the mucosal layer, therefore, ESD was performed. With consideration for esophageal intramucosal invasion, we performed resection with an approximately more than 6 mm margin around the lesion. The histopathological diagnosis indicated that the lesion had subepithelial spread at the oral side of the esophagus. The oral surgical margin was positive and submucosal invasion was observed. Thus, additional resection was performed. Superficial Barrett's adenocarcinoma often spreads submucosal layer, and it is often difficult to diagnose its extent. We report here a case of Barrett's adenocarcinoma with intramucosal spread extending beyond 1 cm.

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A 80-year-old woman was admitted to our hospital with the complaint of hematochezia. Although colonoscopic examination was planned, she showed fever up and felt sick during preparation for colonoscopy, so the examination had been put off. Two days later, colonoscopy showed ulcers spreading widely and annularly in the descending colon, therefore we diagnosed her as severe ischemic colitis caused by preparation of colonoscopy. Her symptoms as for diarrhea and fever up had continued during total parenteral nutrition. Colonoscopy performed after one month' conservative therapy showed little healing tendency of the ulcers and the biopsy specimen from the bed of ulcers showed inclusion bodies in the cell nuclei. Under the diagnosis of cytomegalovirus infection followed by severe ischemic colitis, we administered ganciclovir to her. After the treatment, her symptoms have improved and she has got to be able to inject meal orally.

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A 28 year-old female complained of fever, arthralgia, diarrhea, and painful erythema nodosum on the lower legs. Although an atypical shallow, longitudinal ulcer was found on colonoscopy, the histological findings did not suggest Crohn's disease. Nevertheless, on skin biopsy, multinucleated giant-cell granulomas were noted in the subcutaneous tissue. Therefore, Crohn's disease with isolated colonic involvement and extra-intestinal cutaneous manifestations was diagnosed. A skin biopsy should be done in the early phase if Crohn's disease with skin lesions is suspected, since it is useful for making the diagnosis.

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A case of a 68-year-old male, who had been treated for diabetes mellitus. Abdominal CT scan revealed a slight contrast-enhancing mass of 38 mm in size in the pancreatic body, accompanied by a solid tumor that contained a microcyst. It also disclosed a dilatation of pancreatic duct of 60 mm in size at caudally. With ERP of the main pancreatic duct, obstruction in the pancreatic head were obtained. Although serous cystadenoma of the pancreas was strongly suggested suspected because of obstruction of the main pancreatic duct, a malignant tumor was also. Distal pancreatectomy with splenectomy was done based on a possibility of pancreatic malignant tumor. Histopathological findings of resected specimen was serous cystadenoma of the pancreas.

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We developed a new technique for sequentially enlarging a fistula so as to allow the reinsertion of a percutaneous endoscopic gastrostomy (PEG) tube. The distinctive feature of this technique is the use of a pair of Griggs guidewire dilating forceps to do a blunt, one-step dilation of the narrow gastric fistula after the insertion of the guide wire. This technique was performed in 5 patients who required a larger-size PEG tube and in 3 patients in whom the PEG tube was accidentally removed ; there were no complications. It is advantageous that the forceps can be sterilized and then reused. Furthermore, all guidewire introduced gastrostomy tubes may be reinserted using this technique. Thus, this technique is safe, efficacious, and cost-effective.

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Endoscopic drainage for pancreatic pseudocysts are inferior to surgical drainage with regard to its success rate and the recurrence rate of the disease following the procedure; however, its results in lower morbidity compared to surgical and percutaneous procedures. In Japan, endoscopic drainage is now gaining popularity as it is less invasive than surgical drainage. It is accomplished via a transpapillary approach with endoscopic retrograde cholangiopancreatography or a transmural approach across the stomach or duodenal wall guided by endoscopic ultrasonography. The use of transpapillary drainage is indicated in cases in which the pseudocyst communicate with the main pancreatic duct structures and/or when impacted stones obstruct the main pancreatic duct. These cases correspond to type-II or type-III, respectively, according to D'Egidio's classification. An endoscopic nasopancreatic drainage (ENPD) tube was inserted and left in place for the first time and subsequently replaced with a pancreatic stent, if required. The ENPD tube should be inserted into the cyst cavity and left in places, if possible, or into the pancreatic duct with the tip as close as possible to the cyst beyond the structured segment. If transpapillary drainage is unsuccessful or ineffective, transmural drainage or surgical drainage should be performed immediately.

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Background and Aim : In order to reduce gastric cancer death, mass screening for gastric cancer has been established in Japan for several decades. Only photofluorography is considered to be an acceptable screening method so far, but recent evidence may show the usefulness of serum pepsinogen (PG) measurement for gastric cancer screening. The aim of the present study was to elucidate the feasibility of measuring serum PG levels for detection of gastric cancers.
Methods : Serum PG levels (PGI/PGII) were measured in asymptomatic middle-aged Japanese between 1991 and 2005. Those with a PG I≤70 ng/mL and PG I/PGII≤3 were defined as having a positive PG test. According to the obtained results of serum PG levels and previous individual records, those with a positive PG test and those with a negative PG test took gastroendoscopy every 2 and 5 years, respectively.
Results : The total number of participating individuals was 101 892 (mean age of 48.7 years). In a total of 21 178 planned gastroendoscopies (20.8%), 13 789 (65.1%) underwent gastroendoscopy and 125 gastric cancers were detected, which corresponded to 0.12% of all participants and to 0.91% of those with gastroendoscopy. Early-stage cancers and intestinal-type intramucosal cancers accounted for 80% and 39% of all the detected cancers, respectively.
Conclusions : Serum PG measurement for mass screening of gastric cancer enabled us to achieve high recruitment for gastroendoscopy in intended individuals, a favorable detection rate of gastric cancer and, in particular, an extremely high proportion of early-stage gastric cancer in all the detected cancers.

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