Through the middle ages and early modern times, the actual clinical entity of the ulcer was not identified, but the symptoms associated with ulcer, namely epigastralgia and hematemesis, were well known. The ulcer therapy in those times meant a treatment of such symptoms, and folk medicines and incantation were mainly used. In Japan, Kampo (Chinese medicine) was also the main form of therapy, but it is doubtful whether correct medical treatments were provided.
In more recent times, autopsy findings finally identified the ulcer as a clinical manifestation. However, due to the fact that pathognomy was in its infancy at that time, the correct diagnosis of ulcers was not possible, and all ulcers were believed to be accompanied with hematemesis. Also, there was no concept of differential diagnosis, so any case of bleeding was considered as having an ulcer as the origin, and all such patients were candidates for ulcer treatment. In the late Meiji period, antacids were used as the primary treatment regimes. However, X-ray and endoscopy had not then been developed, and doubtful diagnosis or a variety of uncertain ulcer treatments were provided. In 1957, the flexible gastroscope was reported in Germany, and the importance of gastroscopy was realized. However, there were few facilities where gastroscopy could be performed, so diagnosis with gastroscopy was mostly an ideal, but unfulfillable, plan. The practical application of X-ray diagnosis lagged far behind. In Japan, X-ray screening for ulcers was finally put to practical use in the postwar period around 1955, though the accuracy of diagnosis was less than sufficient. It is therefore safe to say that the correct treatment being performed on the basis of clinical diagnosis had little possibility. Although gastroscopy was started on a trial basis in a very few facilities, full-scale application of endoscopy was only realized after the practical use of the gastrocamera become common around 1958. As to anti-ulcer agents, anticholinergic medication emerged long after the end of World War II, and then various types of anticholinergic agents were developed one after another. As a result, the combination of an anticholinergic agent and antacid became common and more mucosal protection drugs began to be developed. However, the significance of these steps has faded and they have lost their meaning in today's ulcer treatment regimens. The H₂ receptor antagonist and then PPI have appeared in recent years, and the correct medical care of ulcers began to be performed based on the correct diagnosis, though the problem of recurrence was left unsolved. Therafter, the problem seemed to be solved with the emergence eradication therapy for Helicobacter pylori, however, another problem of esophagitis after eradication has cropped up. In this paper, the author mainly discuss the progress in ulcer therapy and its relation with endoscopy.

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Based on published clinical trials of colon capsule endoscopy (CCE) conducted mainly in Europe, the current situation and problems of CCE were reviewed and summarized. Colon cleansing preparation has a significant influence on the accuracy of CCE. The quality of colon cleansing preparation for CCE has been classified on a 4-level scale specialized for CCE. However, it may also be rational to simplify the scale to a 2-level (adequate and inadequate) scale. Based on the results of 11 original articles with high evidence levels, it is estimated that the excretion rate within the battery-effective hours (about 10 hrs) is in the range of 75 to 94%. The diagnostic ability, sensitivity and specificity of the clinical study were (63, 83%), (58, 85%), and (86, 71%) for Overall (PillCam COLON 1+2), Overall (PillCam COLON 1), and Overall (PillCam COLON 2), respectively. Thus, the clinical study appears to show an excellent diagnostic ability for PillCam COLON 2. Although the usefulness, accuracy and safety of CCE suggest that it may serve as an appropriate modality for screening examinations, further studies examining in particular its usefulness in screening will be needed. The cost of CCE remains a problem, however, the cost-effectiveness of screening with CCE may be high if the patient's adherence can be improved.

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The appropriate therapy for Crohn's disease (CD) cannot be achieved until the extent of disease and its anatomical importance are taken into consideration. Therefore, information from imaging tests is essential to establish a diagnosis. A single gold standard for the diagnosis of CD is not available. The diagnosis should be made by clinical evaluation and a combination of endoscopic, histological, radiological, and/or biochemical investigations. In the case of patients with suspected CD in whom stenosis is not confirmed, if ileocolonoscopy and radiological examination/cross-sectional imaging show no lesion or they are difficult to conduct, small bowel capsule endoscopy is applicable. Radiological examination, especially, double-contrast imaging of the small intestine is one of the best tools for the evaluation of mucosal and transmural lesions and this technique is thought to be necessary to understand the past and present disease status. Double balloon enteroscopy should be reserved for specific situations in which biopsy samples from suspected involved areas are important for diagnosis or in which a dilatation of stricture is reasonable.

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[Purpose] The aim of this study was to determine the relationship between reflux esophagitis of residual esophagus (RE-re), columnar-lined esophagus of residual esophagus (CLE-re) and the acidity of the gastric tube after esophagectomy and gastric tube reconstruction for thoracic esophageal carcinoma. [Methods] RE-re was graded according to the Los Angeles classification System (LA grade). CLE-re was graded according to three grades (non CLE-re, CLE-re of a partial area (mild), CLE-re of the entire area (severe)). We performed postoperative endoscopy and measured the pH of the gastric tube under direct vision through an endoscope using a micro-pH glass electrode. [Result]The more serious the LA grade, the lower the pH value. In a similar manner, progressively lower pH values were seen with progressively serious CLE-re grade. CLE-re increased so that the LA classification was aggravated. Particularly notable was that CLE-re accounted for 66.7% of LA grade D cases. [Conclusions] The results suggested that acid in the gastric tube was related to the development of RE-re and CLE-re.

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Esophageal submucosal tumors (SMTs) are almost all benign in nature, and a malignant SMT is rare. Endoscopic ultrasound (EUS) can give useful information about the differentiation between benign and malignant SMTs, but it is sometimes difficult and occasionally impossible. Treatment policies for SMTs differ depending on the histological type, therefore diagnosis of an SMT requires histological and immunohistochemical confirmation. EUS-guided fine needle aspiration biopsy (EUS-FNAB) is an effective technique to obtain tissue samples of an SMT with minimal risk. We report on a case of an esophageal SMT diagnosed from a direct-observation biopsy by mucosal cutting. We think this method may be tried in convex type EUS-free facilities and, if not enough tissue could be collected with EUS-FNAB.

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A 65-year-old woman underwent screening employing upper gastrointestinal endoscopy at a local hospital, and was found to have a depressed lesion in the greater curvature of the gastric antrum, suggestive of an undifferentiated carcinoma. Multiple biopsy specimens were taken during endoscopic examination on two occasions, but a diagnosis could not be made from them. She was referred to our hospital for further evaluation. NBI magnifying endoscopy of the posterior wall away from the depression that was detected on standard endoscopy, showed a shiny area with a tendency to lose the mucosal microstructure at a mucosal site where no abnormalities were previously detected on ordinary observation and dye spraying, and had a tree-like appearance (TLA), which refers to images of abnormal blood vessels looking like branches from the trunk of a tree. Targeted biopsies were performed in this site under NBI magnifying observation, leading to a diagnosis of MALT lymphoma. Thus, the TLA observed by NBI magnifying endoscopy may be a finding suggestive of the infiltration of MALT lymphoma cells in the mucosa. The results in this case suggest that recognition of this finding provides useful information for the selection of optimal biopsy sites.

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A 76-year-old woman with sudden epigastric pain and vomiting was admitted to our hospital. Gastrointestinal endoscopy revealed that a cord like mucosa involving several streaks in the gastric fornix was incarcerated in the duodenal bulb. Abdominal computed tomography scans visualized a tumor 5 cm in diameter in the duodenal bulb. The tumor was diagnosed as a gastrointestinal stromal tumor (GIST) arising from the gastric fornix after preoperative manually-assisted endoscopic reduction of the impaction was successful. A partial gastrectomy was performed via a small incision. Pathologically, the 5-cm-diameter tumor was a GIST and immunostaining revealed it was positive for KIT and CD34, and negative for desmin and S100 protein. The patient's postoperative course was uneventful. She has shown no signs of recurrence up till the time of writing. We report herein on a case of GIST of the gastric fornix presenting with ball valve syndrome.

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A 60-year-old woman was examined, and screened with upper gastrointestinal endoscopy. The endoscopic findings showed multiple epithelial tumor lesions, each measuring around 0.5 to 2 cm in diameter, located in the second portion of the patient's duodenum. A single-balloon enteroscopy was performed to search for other lesions in the small intestine, revealing a small, centrally depressed epithelial tumor lesion, measuring about 1 cm in diameter, in the jejunum. Although these epithelial tumor lesions were pathologically diagnosed as adenoma by each biopsy specimen, a pancreatoduodenectomy and a partial jejunectomy were performed for these duodenal and jejunal tumor lesions. Pathologically, the jejunal lesion was a well differentiated tubular adenocarcinoma, measuring 6 mm long and 5 mm in diameter, and remained in the jejunal mucosal layer. This case seemed to be notable because, so far, cases of jejunal carcinoma with a diameter smaller than 10 mm have almost never been reported in Japan.

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Cases of colorectal cancer resembling a submucosal tumor are rare and among them, tumors of less than 1 cm in diameter occur very rarely. We report on a case of advanced transverse colon cancer 7 mm in diameter resembling a submucosal tumor with reference to the tumor's clinicopathological features, development and progression. A woman in her 60's was referred to our hospital because of a positive fecal occult blood test. Colonoscopy showed a cancerous lesion resembling a submucosal tumor of the transverse colon. Laparoscopic right hemicolectomy with dissection of group 3 lymph node was performed. The histological diagnosis and pathological stage was moderately differentiated adenocarcinoma, 7×6mm in diameter, pSS, pN0(0/19), sP0, sH0, cM0, and fStage II.

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A 70-year-old man was referred to our hospital because of multiple nodules in both lungs. Colonoscopy revealed multiple lymphomatous polyposis (MLP) and submucosal tumor-like elevation of the appendiceal orifice. Based on the histopathological findings, fluorescence in situ hybridization (FISH), whole body computed tomography (CT), fluorodeoxyglucose-positron emission tomography (FDG-PET), and bone marrow examination he was diagnosed as having mantle cell lymphoma (Ann Arbor StageIVA). Complete remission was achieved after 4 courses of rituximab plus chemotherapy. The patient remained disease-free at 6 months after treatment.

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Endoscopic balloon dilation (EBD) is usually applied once or twice each week during the early post endoscopic submucosal dissection (ESD) stage after esophageal semicircumferential or circumferential ESD to prevent postoperative stricture formation. However, the long duration before being freed from esophageal strictures imposes a heavy burden on patients. Moreover, perforation of a fibrous stricture is a risk associated with EBD. To overcome these problems, we started to inject a steroid (triamcinolone acetonide ; Kenacort^®-A, Bristol-Myers Squibb, USA) into an artificial ulcer base after ESD in June 2008. Two or three days after ESD, the steroid (0.2 mL) is injected into the remaining submucosal layer of the post ESD ulcer base, which is then injected with the steroid two to four more times (twice weekly). The steroid must not be injected into the deeper layer of the ulcer base to avoid delayed perforation. Additional EBD was unnecessary in about 80% of the semicircumferential ESD. Less additional EBD was required for circumferential ESD than for EBD alone. Steroid injection therapy is considered to be very effective in preventing postoperative stricture after esophageal ESD.

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