Endoscopic diagnosis using acetic acid is classified under the following four methods ; (1) acetic acid enhanced magnifying endoscopy, (2) acetic acid dynamic chemical endoscopy, and (3) acetic acid indigocarmine method, (4) endoscopic observation using NBI after acetic acid spraying. After spraying acetic acid, a white change in the mucosal color and the structure of epithelium can clearly be observed with magnifying endoscopy. This method is named (1) acetic acid enhanced magnifying endoscopy. Several seconds after acetic acid spraying, the white change disappears in cancerous areas, although non-cancerous areas continue to be whitish. A contrast is thus visible between cancerous and non-cancerous areas. That helps endoscopic diagnosis of the extent of the cancer. This diagnostic approach is named (2) acetic acid dynamic chemical endoscopy. When indigocarmine is added after spraying acetic acid, the indigocarmine disappears quickly from cancerous areas, but continues to be visible in the non-cancerous areas. This contrast is good to diagnose the extent of cancerous areas and as known as the (3) acetic acid indigocarmine method. After having been sprayed with acetic acid, cancerous areas appear brownish in color, whereas non-cancerous areas appear green by using NBI. This contrast to diagnose the extent of the cancerous involvement. This method is referred to as (4) endoscopic observation using NBI after acetic acid spraying.

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Variation exists in the reported incidence of synchronous and metachronous gastric cancer, likely attributable to missed synchronous gastric cancer. The purpose of this study was to determine the status of the incidence of synchronous and metachronous gastric cancer within a year post endoscopic submucosal dissection (ESD) for early gastric cancer. We also retrospectively examined whether metachronous gastric cancer could be confirmed by endoscopic images taken at the preoperative examination. A total of 40 patients were surveyed 3, 6, and 12 months postoperatively by the same surgeon using the same endoscope (Olympus 260H). We detected 2 (5.0%) synchronous and 6 (15.0%) metachronous gastric cancers ; 3 of 6 metachronous gastric cancers were confirmed by endoscopic images. Metachronous gastric cancer detected within a year of ESD is clinically considered synchronous. Based on this definition, we found the incidence of synchronous gastric cancer to be surprisingly high at 20.0%. Our findings also suggest that most metachronous gastric cancers detected within a year of ESD are missed synchronous gastric cancers.

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Patient 1 was a female in her 50's and patient 2 was a male in his 80's. In both cases, submucosal invasion was suspected following conventional endoscopy. Using magnifying endoscopy and endoscopic ultrasonography, the depths of the tumors were diagnosed as T1a-EP and LPM with leiomyoma respectively. These 2 lesions were resected by endoscopic submucosal dissection in an en bloc fashion. Pathological examination of the 2 lesions showed squamous cell carcinoma, depth T1a-EP and LPM, with leimyoma, margin negative. It is essential to use 3 modalities correctly for precise diagnosis of superficial esophageal carcinoma.

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A 59-year-old woman has been undergoing treatment for asymptomatic primary biliary cirrhosis since 2003. She was admitted to our hospital because of further examination and for treatment of a gastric lesion in July, 2009. Endoscopic examination showed a normal and slightly discolored flat lesion and its extra-border was unclear. Besides, examinations had revealed almost no change for two years and three months. Histology of the biopsy specimens revealed a normal gastric mucosa in 2007 and 2008. However, in April 2009 the possibility of gastric carcinoma was suspected based on HE staining and Ki-67 immunohistochemical analysis. ESD was performed in July, 2009. Histopathology of the resected specimen revealed an extremely well differentiated adenocarcinoma [SM1, 0-IIb, ly0, v0]. The surface of mucosa consisted of normal epithelium. The tumor's phenotype was classified as gastric-type. Besides, Pepsinogen-I immunohistochemistry was positive, so this tumor was identified fundic gland type. No recurrence has been seen in our patient for about seventeen months after ESD.

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In Japan, the numbers of HIV infected patients and acquired immunodeficiency syndrome (AIDS) patients are still increasing. In relation to AIDS we sometimes diagnose gastrointestinal Kaposi's sarcoma (KS) and its endoscopic findings are very characteristic and should be known to endoscopists. Diagnosis of intestinal KS can be the opportunity to notice HIV infection and diagnose AIDS.
This is a retrospective study of eight gastrointestinal KS patients related to AIDS and concerning their background, the location of KS and the therapeutic courses in the Osaka National Hospital.
They were all male and the mean CD4 positive T lymphocyte counts was 114.9/ul, when diagnosed. HHV-8 infected cells were proven by immunohistochemistry performed in 5 of 5 cases. Gastrointestinal KS were found in both upper and lower gastrointestinal tracts (upper in 5 cases and lower in 5 cases). In endoscopy we could see the typical protrusion with bright redness in both upper and lower gastrointestinal tracts. We treated the patients with by liposomal doxorubicin and highly active antiretroviral therapy (HAART) in 4 cases, with HAART alone in 3 cases and with liposomal doxorubicin alone in 1 case. All cases are on a good therapeutic course with CR recognized in 2 cases, PR in 5 cases and unknown in 1 case, and are currently alive. We experienced 1 case in whom the diagnosis of gastrointestinal KS had lead to find the HIV infection.
Now most cases of gastrointestinal KS are not directly life-threatening, but it could lead to early diagnosis of HIV infection. We should be familiar with endoscopic characteristics of gastrointestinal KS.

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A 64 year-old woman with melena for over 6 months, had undergone an evaluation including upper gastrointestinal endocopy and totalcolonoscopy that failed to identify the bleeding focus. She then underwent computed tomography, video capsule endoscopy (CE) and double balloon endoscopy (DBE), that revealed a bleeding polypoid lesion in the upper jejunum. A partial resection of the jejunum was performed.
Histopathologic findings revealed the tumor was a lymphangioma.
Lymphangiomas are benign tumors which may cause gastrointestinal bleeding. Recently, new examination modalities for the small bowel such as CE and DBE have become available and widespread, and are expected to contribute to the accurate diagnosis of small intestinal lesions particularly with bleeding like the lymphangioma in this case.

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A 26-year-old woman who complained of abodominal pain and vomiting was treated with noninvasive therapy, and was suspected having an intestinal tumor based on the results of an abdominal CT examination. She underwent double-balloon endoscopic examination, and a white-yellowish submucosal tumor was observed in the upper jejunum. After partial resection of the jejunum, the tumor was iagnosed as an intestinal lymphoangioma. Histological examination revealed that the mucosal membrane was thin, weak and partially ruptured at the site of the tumor. This organic weakness of the mucosal membrane was suggested to be the cause of the lymphoangioma growth and symptoms.

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The patient was a 76-year-old man. Sorafenib was prescribed for treatment of progressive hepatocellular carcinoma (HCC). Six weeks after starting administration of Sorafenib, he was admitted into our hospital on suspicion of gastrointestinal bleeding because melena and anemia were detected. When upper gastrointestinal endoscopy was carried out, multiple ulcers with a parallel tendency were recognized extending from the superior duodenal angle to the descending part of the duodenum. According to Forrest's classification, the ulcers were grade IIc, and consequently administration of Sorafenib was stopped and conservative management was started. After 1-week hospitalization, upper gastrointestinal endoscopy revealed that the multiple ulcers of the descending part of the duodenum tended to improve promptly. On the other hand, the ulcers of the superior duodenal angle did not improve. This was diagnosed as direct invasion of HCC into that part. Computerized tomography (CT) revealed enlargement of the tumor, and the therapeutic effect of Sorafenib was judged as PD. Later, the patient's liver dysfunction got worse, hepatic failure progressed, and finally he died three months after starting treatment.
In addition to the hand-foot syndrome, Sorafenib may induce thrombosis via inhibition of vascular endothelial growth factor. As adverse reactions of low incidence, Sorafenib reportedly causes gastrointestinal bleeding and perforation, but development of gastrointestinal ulcers is rare. In our present case, multiple ulcers with a parallel tendency developed in the descending part of the duodenum after starting Sorafenib administration, while improvement could be achieved following discontinuation of this medicine. We should consider the possibility of development of multiple ulcers consequent to impairment of the blood flow to the duodenum due to Sorafenib administration. We herein report on this case and discuss the relevant literature.

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We explaine herein a technique for biliary tract stone treatment using Percutaneous Transhepatic Cholangioscopy (PTCS).
PTCS is a useful non-surgical approach for common bile duct and intrahepatic stones.
PTCS can be indicated in those cases where treatment with ERCP would be difficult. The scope of PTCS comprises adaptation, the insertion and expansion of Percutaneous Transhepatic Hepatic Biliary Drainage (PTBD), the stone removal, observation by PTCS after the stone removal, the prevention and assessment of the complications.
Also, PTBD is important when performing PTCS, and PTBD must be performed safely.
We can treat biliary tract stones and the other biliary tract diseases with ERCP and PTCS.

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[in Japanese]

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