Endoscopic hemostasis using a distal attachment and short clips against upper gastrointestinal bleeding was performed. Subjects were 66 patients with 80 lesions upper gastrointestinal bleeding. Appropriate endoscopic view using a distal attachment was achieved in all patients. This procedure has been performed against 36 lesions, including 14 of gastric ulcer, 10 of duodenal ulcer, 9 of endoscopic resected lesion against early gastric cancer and gastric adenoma and 3 of Mallory-Weiss syndrome. For tangent view-lesions, this attachment has made endoscopic observation and treatment more easier. In addition, the entire short clip was able to be stored into this attachment, and certainly clamped against a protruded visible vessel. Thirty-four of 36 lesions (94.4%) had temporal hemostasis and thirty-three lesions (91.7%) had permanent hemostasis. One patient with multiple gastric ulcers with advanced hepatocellular carcinoma and bleeding tendency had temporal hemostasis, however he died of rebleeding from the ulcers associated with DIC. The second patient with duodenal ulcer in the superior duodenal flexure underwent interventional radiology, and the third patient with duodenal Dieulafoy's ulcer close to papilla of Vater underwent endoscopic short clip hemostasis using a lateral-viewing endoscope.
Endoscopic hemostasis with a distal attachment and short clips is useful for upper gastrointestinal bleeding.

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For patients whoes oral intake is decreased because of some disorder, naso-gastric tubing has been commonly used for the purpose of enteral feeding. Because of its complications such as pneumonia and getting worse quality of life, percutaneous endoscopical gastrostomy (PEG) became widly used for patients who would need enteral feeding for a long time. It is expected that opportunity for endoscopists to make an enteral feeding route will be increased. PEG will do for many cases, but some patients may have contraindication of PEG. PEG may have little effect on improvement of nuturitional condition for some cases. J-tube insertion and PTEG can be performed and may improve nutritional condition in such cases. Endoscopists should be expert in these treatment, we think, so we illustrate usefulness of J-tube insertion and PTEG with clinical cases.

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Consecutive 165 patients were enrolled in this study. All patients underwent colonoscopic examination with (n＝75) or without UPD (n＝93) .
We investigated patient's 1) SD passage time, 2) insertion time to cecum (min) , 3) colonoscopy completion rate (%) , in order to assess the UPD's usefulness and effectiveness. And, we used Kudo's classification in the level of colonoscope insertion, and classified in five steps of 1 - 5.
And we classified patients difficulty and colonic curve in three steps of the pattern A, B and C. A result that the level 1 group by use of UPD shortend SD passing time in the pattern A, and elevated completion rates in the pattern B. The level 2 group by use of UPD shorted SD passing time in the all pattern, and elevated completion rates in the pattern B. Trainee's leaning curve revealed that time to cecum tended to be shortened when UPD was used. It was suggested that in trainee, UPD system may help to learn accurate colonoscope insertion technique.

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A case infected with Helicobacter pylori (Hp) , which has different sensitivity against amoxicillin (AMPC) , clarithromycin (CAM) and metronidazole (MNZ) according to positions of the stomach, was studied. We performed the susceptibility test by agar plate dilution for Hp in the corpus group, specimen was taken from the greater curvature of the upper corpus, and the corpus-antrum group, specimens were taken from the greater curvature of the upper corpus and the greater curvature of the lower antrum. As a result, 1) There was no case infected with AMPC resistant Hp in both corpus group and corpus-antrum group. 2) The resistance rate for CAM and MNZ was higher in the corpus-antrum group than the corpus group (the corpus-antrum group : 33.3%, the corpus group : 24.2%, respectively) . We found no multidrug resistant Hp. 3) There were different susceptibility for CAM and MNZ between the greater curvature of the lower antrum and the greater curvature of the upper corpus. We found three cases infected with CAM resistant Hp (6.7% out of 45 cases) and two cases infected with MNZ resistant Hp (4.4% out of 45 cases) . 4) These results suggest that the susceptibility test using the biopsy materials taken from the gastric different sites contribute to Hp eradication.

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〈BACKGROUND〉Endoscopic mucosal resection or laparoscopic wedge resection (minimally invasive surgery) have been performed for patients with early mucosal gastric cancer, preserving of gastric function to maintain patients'QOL. It will be important to clarify clinico-pathological risk factors of lymph node (LNs) metastasis, especially in mucosal gastric cancer, in order to keep curability for minimally invasive surgery.〈PURPOSE〉We evaluate clinico-pathological features and LNs metastasis in mucosal gastric cancer retrospectively, to identify critical risk factors of LNs metastasis. In addition, we demonstrate sentinel node navigation surgery (SNNS) for mucosal gastric cancer in our department.〈PATIENTS AND METHODS〉We investigated 476 patients who are pathologically diagnosed as mucosal gastric cancer after gastrectomy with LNs dissection between January, 1992 and December, 2001. Clinico-pathological features (tumor size, macroscopic type, histological type, tumor location, presence of ulcer scar) were evaluated, accoding to existence of LNs metastasis.〈RESULTS〉Ten patients were diagnosed mucosal gastric cancer with LNs metastasis (2.1%) . All 10 cases showed depressed type in macroscopic type and M or L region in tumor location. In histological type, differentiated type, undifferentiated type and squamous cell carcinoma were 2, 7 and 1 cases, respectively. Seven cases were diagnosed as N1 LNs metastasis, and 3 cases as N2. Incidence of LNs metastasis in tumor with ulcer scar (5.3%) is significantly higher than that in tumor without ulcer scar (1.5%) . Thus, undifferentiated type and ul (＋) was determined as critical factors of LNs metastasis in mucosal gastric cancer. On the other hand, we performed SNNS with gastrectomy in 40 cases of mucosal gastric cancer, and only a case showed LNs metastasis (N2) . Six LNs of N1 (4 LNs) and N2 (2 LNs) were detected as SNs, intraoperatively, and the 6 LNs were determined as LNs metastasis by pathological diagnosis.〈CONCLUSION〉We demonstrated critical risk factors of LNs metastasis in mucosal gastric cancer, and undifferentiated type and ul (＋) tumor should be treated with curative surgery with LNs dissection. In addition, clinical usefulness of SNNS for prediction of LNs metastasis in early gastric cancer was shown, evaluating 40 cases of mucosal gastric cancer.

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The total number of colonoscopy and patients who were perfomed with polypectomy, and polyps which were resected were 4,540 and 1,207, and 2,294, repectively. We studied 32 polyps in 32 cases (mean age ; 59.5yrs, men : wemen ratio ; 1 : 0.14) with bleeding and 2,262 polyps in 1,175 cases (mean age ; 64.2yrs, men : wemen ratio ; 1 : 0.3) without bleeding after resection of polyps. The rate of bleeding after resection of polyps which were located at cecum and sigmoid colon was 2.3% and 2.0%, respectively. The rate of bleeding after resection of polyps whose diameter were 11-15mm and over 15mm was 5.9% and 5.4%, respectively. The rate of bleeding after resection of polyps which was flat elevated type and pedunculated type, and sessile and pedunculated type was 3.1% and 2.2%, and 2.0% respectively. The rate of bleeding after endoscopic piecemeal mucosal resection (EPMR) was 8.3%. Most cases that were performed with resection showed bleeding after 6days (mean ; 4.2 days) . The rate of bleeding after resection and clipping was 3.3%, and after resection and detachable snare was 0%, and after resection without clipping or detachable snare was 1.0%. The relatively high rate after bleeding was seen at polyps which were located at cecum and sigmoid colon, whose diameter was over 11mm, whose shape was flat elevated, pedunculated type and sessile and pedunculated and resected by EPMR. A detachable snare is usefull for resection of pedanculated polyps.

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The aim of this study was to evaluate the screening immunological fecal-occult-blood tests (IFOBT) for colorectal lesions, that it will veil early colorectal cancer in false negative group.
We had 4,819 people examined by IFOBT at Cancer Institute Health Center from November in 1997 to January in 2003. There were IFOBT positive in 545 cases, and negative in 4,274 cases. Total colonoscopy was performed among them, for 212 cases with positive test and for 259 cases with negative.
The sensibility and the specificity of IFOBT for invasive carcinoma and advanced cancer were 85% and 56%, the mucosal carcinoma and adenoma with severe atypia, 74% and 56%, adenoma polyps more than 10mm, 64% and 56% respectively.
According to macroscopic type and size of the lesion, there were much Ip types with more than 10mm and IIa types with more than 15mm in IFOBT positive group. However, small polyps (5-10mm in size) were commonly recognized in negative group. In spite of malignant lesions, 2 cases of advanced cancer, 7 cases of adenoma with severe atypia and mucosal carcinoma (8～10mm in size) were recognized in IFOBT negative group. Following polypectomy and mucosal resection, 45 cases with IFOBT positive became negative in 44cases (98%) .
In conclusion, IFOBT has been a useful test to detect advanced colorectal cancer, but it was not enough to detect the early stage of colorectal cancer. We have to consider an endoscopic screening test in addition to IFOBT for the lesions suited to endoscopic treatment.

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When we are going to perform surgical procedure for an advanced colorectal cancer with intestinal stenosis, it is extremely important for determination of the operative method to know the presence of the lesion located oral side intestine of the stenosis. However, the cases in which a colonoscopy can not go through the stenosis, did not have any useful methods to evaluate oral side intestine of the stenosis.
The authors performed virtual endoscopy (VE) for 5 advanced colorectal cancer cases located from the left colon to the rectum, in which a colonoscopy can not go through the stenosis. We had good visualization in the large intestine from the rectum to the stenosis, and from the cecum to the splenic flexure of the colon. All five cases did not have any polyps or tumors.
However, we could not have good visualization from the stenosis to the splenic flexure of the colon because of lack of intestinal expansion by the air. We could not inhibit intestinal spasm from the stenosis to the splenic flexure of the colon without preanesthetic medication such as buscopan.
Though we have to evalute more numbers of cases in the future, the lesion of the oral side intestin of the stenosis will be evaluate sufficiently by using appropriately preparation and preanesthetic medication. Therefore it is conceivable that VE will be extremely useful procedure for advanced colorectal cancer cases with stenosis.

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Fasting breath hydrogen has been measured to evaluate the intestinal bacterial overgrowth. As hydrogen production increases when a small amount of carbohydrate is supplied to colonic bacteria, the measurement of breath hydrogen concentration has been proposed as an indicator of carbohydrate malabsorption.
Fifty consecutive patients (mean age 63.6 years, M : F＝26 : 24) admitted electively to our hospital for diagnostic nonemergency colonoscopy agreed to participate in this study. All patients were allowed to continue their usual diet until the day before the procedure and were not advised to avoid any liquids. After fasting overnight and collecting a 100 ml of breath sample, at 9 : 00 a.m. patients were told to ingest a 200ml of PEG, containing 12g lactulose, 50ml every 5 minutes for 2 hours. During ingestion of PEG, breath samples were taken at 15-min intervals for 240 min. Breath hydrogen concentration was measured using TGA-2000.
Of 50 patients, 10-13 patients (20-26%) had the breath hydrogen level more than 5 ppm until 45 minutes after ingestion. The increased breath hydrogen level at 15 minutes was found in two patients. There was no difference of fasting breath hydrogen levels between patients with and without small intestinal bacterial overgrowth. No patients with high levels of breath hydrogen complained of dyspeptic symptoms.

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A 65-year-old female had undergone endoscopic examination on a regular basis for about 10 years at another clinic due to the diagnosis of liver cirrhosis and esophageal varices. Endoscopic examination had revealed no abnormal findings in the stomach until September 2001. In April 2002, she developed an epigastric pain, and underwent endoscopic examination. It revealed lower esophageal varices and an elevated lesion with deep ulceration at the cardia, and she was referred to our clinic. Endoscopic ultrasonography demonstrated a tumor 6 cm in diameter with an internal heterogeneous echo pattern at the fornix, which seemed to derive from the fourth layer of the gastric wall. Concurrently performed endoscopic biopsy led to the diagnosis of a gastrointestinal stromal tumor (GIST) , and total gastrectomy with splenectomy was done. The tumor was 8×6 cm in size and diagnosed pathohistologically as an uncommitted type GIST. There was no lymphatic metastasis. In summary, this is a case report of a GIST that rapidly grew to 8 cm in diameter with ulceration in six months. This case suggests that even a submucosal tumor may grow rapidly in a shortperiod of time and must be followed-up cautiously.

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A 80-year-old man visited our hospital complaining of epigastric pain and vomiting lasting for a week. The upper gastrointestinal endoscopy revealed a gold bezoar about 5 cm in diameter at the greater curvature of the upper body of the stomach associated with multiple ulcers (H₁ stage) on the lesser curvature of the antrum. We attempted to remove the bezoar endoscopically using a retrieval net (Model 0071182 USE Group, Olympus Ltd. Tokyo) with success. The bezoar was 5×4×3 cm in size and 7.72g in weight. Compornent analysis with infrared absorption spectrum of the sample detected tannic acid, giving a diagnosis of persimmon bezoar.
As gastric bezoar has been reported to be a cause of ulcer due to mechanical stimulation or intestinal obstruction, removal of bezoar should be considered on diagnosis regardless of symptoms. Endoscopic approach using a retrieval net is a safe and effective modality.

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The case was a 68-year-old woman. Jaundice appeared in mid-October 2002 and admitted on November 7th. Ultrasound (US) and CT scan revealed dilatation of the intrahepatic bile ducts, and endoscopic retrograde cholangiography (ERC) was performed.
With diagnosis of bile duct cancer at the porta hepatis, endoscopic nasobiliary drainage (ENBD, 6Fr) was placed in the right intrahepatic bile duct. Since jaundice was scarcely reduced in spite of ENBD, drainage of bile ducts on both sides was also considered necessary, and placement of stents in multiple bile ducts was attempted on November 19th.
Jagwire was placed in the left bile duct with TJF, and endoscopic sphincterotomy (EST) was performed. The bile duct was then dilated by balloon inflation, and jagwire was fixed to RELD (Microvasive^®) . The second jagwire was inserted into the right intrahepatic bile duct, and the first endoscopic retrograde biliary drainage (ERBD, 7Fr/10cm) was inserted and retained. The second ERBD (7Fr/10cm) was subsequently inserted into the left intrahepatic bile duct by the use of jagwire fixed to RELD and retained. Reduction of jaundice proceeded well after that. On December 2nd, hilar bile duct resection was performed. Patient was discharged on day 45 of illness, and under observation currently.
In multiple stents insertion in endoscopic biliary drainage, RELD ensured accurate insertion of the stent by fixing the guidewire and preventing its slippage. RELD was thus considered useful in endoscopic procedures such as one used in the present case.

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A 54-year old man underwent gastro-intestinal endoscopy, which detected carcinoma and varices (F₃ grade) in his esophagus simultaneously. Endoscopic sclerotherapy and band ligation were carried out in the treatment for esophageal varices initially. Since we could not achieve subsequent endoscopic mucosal resection at carcinoma because of mucosal changes after varices treatment, other therapy, such as radiation and chemotherapy, were employed. However, twice recurrences of esophageal cancer within seven months were observed, and we tried a photo dynamic therapy, resulting in two years recurrence free so far. The treatment of esophageal cancer with F₃ grade varices should be further discussed.

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We had two cases of gastrointestinal complications with AIDS (acquired immunodeficiency syndrome) . Case 1 : 70 year-old homosexual male. He admitted our hospital for his dyspnea. He was diagnosed as AIDS and pneumonia of pneumocystis carinii. During his treatment, he complained of epigastralgia, and received gastrointestinal endoscopy. He was diagnosed as Kaposi's sarcoma in the stomach, for an endoscopic finding of several protruded lesions with small red-colored spots on their surfaces in the stomach and immunohistopathological findings. Case 2 : 41 year-old homosexual male. He visited our hospital for candidiasis of the tongue and anal abscess. After admission he was diagnosed as AIDS. During the treatment, he complained of dysphasia, and received gastrointestinal endoscopy. He was diagnosed as CMV esophageal ulcers, for an endoscopic finding of wide deep ulcers in the middle esophagus and an immunohistopathological finding of intracellular inclusion bodies in the biopsy specimens.
We have a chance to encounter AIDS and its complications on practice, getting increased in number. When AIDS patients have complaints of abdominal symptoms, endoscopy is very useful to check them and evaluate the clinical treatment. Even if asymptomatic, it is also very useful to check the malignancies associated with AIDS such as Kaposi's sarcoma.

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Submucosal hematoma of the esophagus is rare disease. We herein report a case of spontaneous submucosal hematoma of the esophagus.
A-74-year old male with vomiting approximately 100ml of blood after vomiting to repeat visited the Metropolitan Bokuto Hospital. Emergent endoscopy revealed a giant hematoma on the wall of the entire esophagus. He was performing the anti-solidification treatment to thrombo-sis, and was considered to be one of the causes of hematoma. An anti-solidification treatment was stopped at the time of hospitalization. Fasting and intravenous hyperalimentation were begun and follow up studies were conducted using endoscopy. In the third endoscopic examination on eight hospital days, the hematoma had disappeared and a deep ulcer was noted. The ulcer became shallow under conservative therapy, and it became scar and there was no constriction of the esophagus in the 4th endoscopic examination on 22 hospital days. From the 34 cases of spontaneous submucosal hematoma inJapan, it was thought that the prognosis of this disease was excellent under conservative therapy also in the patient in an anti-thrombus treatment, or a patient with a bleeding tendency.

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We report a 65-years-old woman of small mucosal gastric cancer with lymph nodes metastasis in N2 region, which is classified by the definitions of the Japanese Research Society for Gastric Cancer. Gastroscopy was performed when the patient complaint of epigastric pain, diagnosing small IIc-typed gastric cancer at the anterior wall of middle stomach. The size of cancer is 8 mm in diameter and cancer invasion was determined as mucosal cancer, preoperatively. As pathological examination revealed signet ring cell carcinoma in the lesion, we performed distal gastrectomy with lymph node dissection (D2) under laparotomy. Pathological diagnosis of the resected specimen showed signet ring cell carcinoma, 9 mm in diameter, pT1 (M) , INFβ, ly0, v0, pN2 lymph node metastasis (14/37［＃3 (6/10) , ＃5 (1/3) , ＃7 (3/4) , ＃9 (4/7) ］) . The frequency of lymph node metastasis of mucosal gastric cancer was reported to be around 2%, and mucosal gastric cancer with N2 metastasis was very rare and was observed in the case with large tumor size. In this case report, we demonstrated a case with small mucosal gastric cancer with N2 lymph node metastasis, suggesting that critical determination of surgical method must be necessary in cases of signet ring cell carcinoma or undifferentiated adenocarcinoma, even in small mucosal gastric cancer.

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A 81-year-old man was admitted to our hospital for detailed evaluation of a gastric cancer. An upper gastrointestinal radiograph and gastrointestinal endoscopy revealed a large, Borrman type II tumor, which was located from the cardia to the upper body. The endoscopic biopsy specimens showed small cells with hyperchromatic nuclei and scant cytoplasm, which showed positive staining for neuron-specific enolase (NSE) and chromogranin A. No squamoid or glandular pattern was observed. The tumor was diagnosed as a primary advanced gastric small cell carcinoma, pure type.
Because of metastatic foci in the liver and lung, chemotherapy composed of irinotecan and cisplatin, which was an effective treatment for metastatic small-cell lung cancer, was performed. But, the patient died four months after admission. We reviewed the clinicopathological aspects of this disease.

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We here report two cases of gastric cancer patients complicated with bleeding. Endoscopic hemostasis using argon plasma coagulation (APC) successfully controlled the bleeding and blood transfusion could be minimized. APC is a safe and beneficial procedure for the bleeding from gastric neoplasia.

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We experienced two early gastric cancers, with over 40 mm in size, resected by a single piece using submucosal dissection EMR.
The first patient was a 61-year-old man with an early gastric cancer (type 0-I) at the greater curvature of the lower body measuring 4 cm in diameter. Biopsy taken from the tumor revealed a papillary adenocarcinoma and endoscopic ultrasonograhy (EUS) demonstrated that the tumor did not invade the submucosa. Submucosal dissection EMR using an electro-surgical snare and a flex knife was performed. The lesion was completely resected with one piece. The size of the resected specimen was 46×45mm. Histological examination showed an early gastric cancer type 0-I (sm², pap, INFβ, ly1, v0) . Additional surgical resection was carried out, but no metastatic lesion was detected in the regional lymph nodes.
The second patient was an 88-year-old woman with an early gastric cancer (type 0-IIa) at the lesser curvature of the lower body, EUS demonstrated that the tumor did not invade the submucosa. Submucosal dissection EMR was performed in the same way as the first case. The resected specimen was 40×35mm and histological findings showed an early gastric cancer type 0-IIa (sm1, tub1＞tub2, INFβ, ly0,v0) . The tumor minimally invaded the submucosa (sm1) with tumor free margins of the resected specimen. Additional surgery was not performed considering her age.
Submucosal dissection EMR makes it possible to remove tumors with one piece regardless of size, which gave us very important pathological findings to determine a complete resection or not.

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A 63-year-old man who suffered from lung MALT lymphoma was administered in University of Tokyo hospital in October, 2001. MALT lymphoma was confirmed by histological findings. He had also paraspinal lymphnode swelling which made spinal compression detected by CT scan. Furthermore, gastric and colonic involvement of MALT lymphoma was found by endoscope and colonic involvement had an unusual macroscopic finding ; a flat elevated lesion, which was about 1 cm in size, was found and it had enlarged mucosal fine-network-pattern. Gastric involvement had little characteristic finding ; there were some gross folds which revealed lymphoma involvement histologically. A combination of chemotherapy and radiotherapy was performed and was succeeded. Not only lung lesion and paraspinal lesion were decreased but also GI lesion was deminished after treatment.

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A 64-year-old man came to our hospital with a chief complaint of epigastralgia and palpitation. Upper gastrointestinal bleeding was presumed to be the cause of severe anemia and tarry stools. By emergent endscopic examination, a large submucosal tumor was revealed at the lesser curvature on the anterior wall of the stomach with a protruding lesion seen on the top, and gastric ulcer was also seen at anal side of submucosal tumor. From CT, US and MRI examination, it was suspected to be a gastric lipoma. But there was not detected such a lesion in endscopic examination at two years ago in our hospital, we could not deny the possibility of malignancy for its rapid growth. It was subsequently resected in open surgery. In operation the protruding lesion had changed to a delle. Histological findings showed that the tumor was a gastric lipoma composed of mature adipose tissue. Sometime, delle is formed on submucosal tumor. But we experienced a rare case of gastric lipoma that formed a protruding lesion on the surface.

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The patient was a 71-year-old female. Although she had been experiencing tarry stools since December 18th, 2002, she had not consulted a doctor. But, considerable exertional dyspnea and dizziness developed and she was admitted to our hospital on December 24th. Gastrointestinal endoscopic findings was a glans-like protruded lesion with an uneven surface accompanied by reddening and ulceration in the anterior wall of the fornix. Biopsies detected no distinct tumor cells, only detecting inflammatory cells. Endoscopic ultrasonography (EUS) showed a clearly bordered high echoic mass of high echo originating from the third layer. Abdominal CT showed a low-absorption region protruding into the gastric cavity. Gastric lipoma was suspected from these findings, the possibility of being any other disease or malignancy could not be denied, the laparoscopic partial gastrectomy was performed. Histopathological examination revealed that the tumor consisted of mature adipose, with partial infiltration from the muscularis mucosae to the lamina propria. Finaly, the lesion was diagnosed as gastric lipoma. Generally, only a few reports are available on pedicled lipoma and in addition, endoscopic findings like this case seems to be rare. Abdominal CT and EUS are useful in the diagnosis of gastric lipoma and less invasive surgery of laparoscopic partial gastrectomy is expected to find further applications in its treatment.

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A recurrent mucosal cancer after endoscopic mucosal resection (EMR) was detected in a 68 year-old man at another hospital and he was informed of the necessity of a gastrectomy because the lesion had severe scarring due to the previous EMR. However, the patient was reluctant to undergo a gastrectomy and referred to our department. Endoscopy revealed other three mucosal tumors in the stomach, but we judged that those lesions could be successfully resected endoscopically, and the submucosal dissection EMR using a flex knife was perfomed all of the tumors without complications. The histological investigation of resected specimens revealed that those tumors were all completely resected, which meant that he did not have an additional gastrectomy. The artificial ulcers formed by EMR were cured within eight weeks without stenosis. This case shows the usefulness of the submucosal dissection EMR using a flex knife, which enables patients with recurrent tumors and multiple tumors like this patient to avoid an unnecessary gastrectomy and provide good quality of live.

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A 63-year-old male visited our hospital with chief complaint of epigastralgia and hematemesis. Emergency upper gastrointestinal endoscopy was performed that revealed giant hemorrhagic gastric ulcer from the lesser curvature of middle body to supra-angular region with mucosal bridge. He was admitted to our hospital and received intravenous injection of proton-pump inhibitor. Six days after admission the gastric ulcer became A2 stage and 13 days after the ulcer became healing stage but the mucosal bridge still remained. Forty-one days after admission, the ulcer became H2 stage and the mucosal bridge was disappeared.
Some cases of mucosal bridge in inflammatory bowel disease and in the esophagus after endoscopic injection sclerotherapy have been reported, but reports of gastric mucosal bridge in Japan are rare. In our case, the patient had experienced gastric ulcers of lesser curvature of middle body and supra-angular region one year before this admission. So we speculated that in this case the mucosal bridge was the result of the penetration of two ulcers of lesser curvature from middle body to supra-angu-lar region.

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A 64-year-old male who had undergone laparoscope-assisted gastrectomy due to early gastric carcinoma on July 9, 2002 was admitted to our hospital on November 27, 2002 with pyrexia and non-productive cough. He had been treated for Helicobacter pylori with clarithromycin, amoxicillin, and lansoprazole for a week and clarithromycin, amoxicillin, and omeprazole for another week after the operation. The laboratory data revealed hypoxemia and the chest radiograms and CT films showed the reticular shadows especially in the right lower lung field. After the cessation of all drugs, his symptoms were disappeared, and the reticular shadows in the chest radiograms also gradually improved Drug-induced lymphocyte stimulation test (DLST) was positive only for amoxicillin. Although the challenge test for amoxicillin was not performed, we diagnosed this case the drug-induced pneumonitis because of these clinical, laboratory findings.

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Foveolar hyperplastic polyps are the most popular polyp of the stomach arise from the mucosa of chronic active gastritis. Recent studies suggested hyperplastic polyp arise from inflammatory process of H.pylori gastritis and disappeared or reduced after H.pylori eradication therapy. We report three cases of foveolar hyperplastic polyps of the stomach, in all cases, foveolar hyperplastic polyps of the stomach disappeared and reduced after H.pylori eradication therapy.
Eradication of H.pylori is considered to be the first choice therapy against hyperplastic polyps with H.pylori gastritis because of its effectiveness and non-invasiveness.

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A 75-year-old man has been conservatively treated for insulinoma since for 5 years ago, and followed-up as the left-sided portal hypertension. He was admitted to our hospital because of anemia. Gastrointestinal endoscopy revealed isolated varices in the fundus of stomach and oozing bleeding from gastric corpus varices. Abdominal CT scan showed the splenic vein completely obstructed by a huge malignant lesion of the pancreas tail. Angiography showed the splenic vein interrupted at the hilum of the spleen, and bloodstream flowed from the short gastric vein to the pericardiophrenic vein, and the most of bloodstream flowed to trunk of the splenic vein intermediated posterior gastric vein. Surgically splenectomy and devascularization were applied. After surgery, varices of the gastric body were disappeared and there was never bleeding thereafter. However, blood flow from the short gastric vein leaked out to the portal system and the pericardiophrenic vein and isolated varices remained.
Left-sided portal hypertension with complicated pancreatic neoplasms is comparatively rare. Splenectomy and devascularization were so effective for the control of bleeding from gastric varices.

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A 45-year-old male visited our hospital with a complaint of epigastralgia. He underwent upper endoscopy for gastric cancer screening before 7 days. At endoscopy, hemorrhagic gastritis was found in the distal stomach. RUT and endoscopic UBT were positive, but conventional UBT kept the negative results for 15 weeks. Since changes of serum pepsinogens, suggesting the inflammation of the gastric mucosa by H. pylori,had been found, eradication therapy was carried out.
A 56-year-old male underwent screening endoscopy and did not have any abnormal findings. After 10 days, he complained of epigastralgia and visited our hospital. Hemorrhagic gastric erosions with evidence of bleeding were seen in the antrum and the duodenal bulb. He had the negative results of UBT, and the UBT result became positive after 5 weeks. From the clinical courses of these two cases, it is suggested that UBT is not sensitive for detection of acute H. pylori infection.

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A 71-year-old man with type C liver cirrhosis was diagnosed as gastric antral vascular ectasia (GAVE) base on pathognostic endoscopic findings of diffuse erythematous spots in the antrum. He showed severe anemia that needed regular blood transfusion. He was administered estrogen-progesterone (E-P) because endoscopic heater probe therapy was unsuccessful. Gastric bleeding stopped after the induction of E-P therapy. Severe anemia, recurring after the discontinuation because of moving, again ameliorated after the re-induction of E-P therapy, in spite of the spread of GAVE to lower gastric body. This case suggests that E-P therapy is effective in the treatment of GAVE.

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We will describe two cases of gastric perforation due to ingestion of foreign body successfully treated by endoscope. Ingestion of tooth pick for octopus cake during drinking caused localized peritonitis with small amount of free-air in the abdominal cavity for 60 years old woman. Ingestion of wire by mentally retarded homeless man with 53 years old caused marked free-air in the abdominal cavity without severe symptom. By endoscopic evaluation to specify the site of perforation, foreign body identified as a toothpick or wire were observed and removal of foreign body were carried out successfully. Though clinical symptom of gastric perforation due to penetrating foreign body is less severe than those due to peptic ulcer, differential diagnosis were difficult. We can conclude that immediate endoscopy were essential for diagnosis and treatment for those condition.

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A 81-year-old man was admitted to the hospital because of abdominal discomfort and vomiting. Marked stenosis in the 3rd portion of duodenum was observed by upper gastrointestinal series. Endoscopy revealed a protruded tumor with retention of foods. Preoperative serum levels of CA19-9 were high (260U/ml) . Operation performed a partial resection of the duodenum. Hisological examination revealed well to moderately differentiated adenocarcinoma with strongly stained to CA19-9 antibody.
We reported a case of primary adenocarcinoma of the horizontal portion of duodenum. This case suggested that CA19-9 might be the marker of the duodenal carcinoma.

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A 81-year-old female complaining with epigastralgia was referred to our hospital. She was recognized a rise of pancreatic enzyme in peripheral blood examination. Abdominal CT and MRI showed the tumor in the second part of the duodenum with mild pancreatitis. Endoscopically the protruding lesion of duodnum was growthed with irregular surface.
Surgicl specimen showed the tumor in papilla of Vater of 2.5×1.5cm in size with shortneck.
Histopathologic diagnosis was adenoma occupying the common channel. Adenoma of the papilla of Vater seems to be responsible for relapsing pancreatitis in this case.

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A 73-year-old and female patient sometimes complaining of nausea and vomiting since June 2002 and 14kg weight reduction for three months. Although the gastroduodenal endoscopy and colonoscopy were performed, the disease was not found.
Also after that, clinical menifestation has not been improved.
So she was admitted our hospital because of detatail examination. Abdominal magnetic resonnance imaging (MRI) showed the solid tumor expanded to the intestinal lumen with dilatation of upper jejunum. Small intestine radiography showed tumor in the jejunum and complete stenosis. Definitive diagnosis was obtained preoperavility with biopsy through the small intestine videoscopy. The histological examination on biopsy specimen revealed well to moderate differentiated adenocarcinoma. Jejunal resection with lymph node dissection was performed in October 2002. Histopathological diagnosis of the lesion was type I appearance and well to moderate differentiated adenocarcinoma with se invasion.

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A 68-year-old male visited our department complaining of abdominal pain. Abdominal CT scan showed an intestinal tumor. Small intestinal fiberscopy showed a tumor at the upper part of jejunum. The tumor was about 3cm in diameter. Immunohistologically, its diagnosis was GIST (positive for CD34, negative for desmin and S-100) . Partial resection of jejunum was performed.
GIST is a common gastrointestinal mesenchymal tumor, but its diagnosis is difficult before operation. If tumor invated near epithelial tissue, magnifying endoscopy can reveal thin epithelium. Its examination will be possible to determine the point of biopsy. Small intestinal fiberscopy, moreover magnifying endoscopy is effective for deagnosis of the small intestinal tumor.

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A 59-year-old man visited to our institution for evaluation of positive fecal occult blood. During his hospitalization, colonoscopy was performed and revealed sanguineous mucus in the cecum. We suspected the bleeding from the upper gastrointestinal tract or small intestine, and performed gastroscopy and small intestinal barium enema. Gastroscopy showed only normal findings, but double-contrast barium enema showed a smooth-surfaced, round mass in the ileum (located about 60cm from terminal ileum) measuring about 20mm in diameter. And then we performed small intestinal endoscopy (push type) from the anal side. In the same location submucosal tumor with erosion at the top of the tumor was revealed. At the same time we tried biopsy for definitive diagnosis, but could not take tumorous component. On the enough informed consent, we performed endoscopic removal. The tumor was carefully removed by snare without bleeding or other serious complications. Pathologic examination showed submucosal mature adipose tissue with a thin fibrous capsule, which was compatible with lipoma. Small intestinal endoscopic examination is not popular yet, because of difficulty of the technique and discomfort of patients. Herein, we report a case of submucosal tumor in the small intestine successfully treated with endoscopic resection.

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A 35-year-old male was admitted to our hospital with anemia. He had been observed almost regularly for the past 20 years under the diagnosis of Peutz-Jeghers Syndrome, and had been operated three times due to the intussusceptions. At the latest operation, after restoration of intussusception of small bowel, the tumor (6cm in diameter) palpated inside the intussusception was resected. Forty-three polyps of small bowel were resected endoscopically, in combination with an apparatus called'Preparation-Set’to prevent the bacterial contamination. The specimens from past operations and other polypectomies show no sign of malignancy.
The Peutz-Jeghers polyps frequently cause the intussusceptions and other abdominal symptoms, but also the malignant alteration of those polyps is known. Careful follow-up intestinal examinations has been performed, though the examination of small bowel still rely on the X-ray radiographies since small bowel enteroscopy is still limited in clinical situations. And also the polypectomy of those polyps often requires laparotomies, which are likely emergency cases due to intussusceptions. However, after several surgical operations, observation of those polyps itself becomes more difficult due to the adhesions. Therefore non-invasive methods are recommended from the first step of diagnosis of this syndrome to reduce hardships in the future.

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A 59-year-old woman with complaint of a right lower abdominal pain and rebound tenderness was admitted to our hospital. Ultrasonography showed a 5 cm-hypoechoic lesion at the ileocecal area, which was shown as a low-density lesion with peripheral enhancement by CT scan.
Even though she had rebound tenderness on admission, by the conservative therapy with Cefmetazone, abdominal sign was disappeared in a few days.
For further investigation, she underwent colonoscopy, which revealed a SMT-like mucosal elevation filled with pus in the cecum apart from the orifice of the appendix. So the pericecal abscess was diagnosed.
Although drainage of pericecal abscesses, usually require the ultrasound, CT guidance or laparotomy, we drained it and washed inside of the cavity colonoscopically using a catheter without complication. Bacterial culture detected Proteus. spp and E. coli from the white pus drained.
After drainage of the abscess, levels of inflammatory markers further declined and colonoscopy detected no particular change in the cecum. For two years after the drainage she had no recurrence of abscesses in the pelvis.
This case shows usefulness of colonoscopy and successive endoscopic abscess drainage before considering of laparotomy as the treatment of the intrapelvic pericecal abscesses.

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A 44-year-old woman came to our hospital because of transient hematochezia in February 2000. She had no particular past history. Total colonoscopy showed multiple scars and pseudopolyps from the cecum to the transverse colon, the ileo-cecal valve showed deformity and the appendix was completely deviated into the lumen. Endoscopically, the diagnosis of old tuberculosis of the intestine and intussusception of the appendix was made. Since, neither diagnosis was likely to be the cause of hematochezia, she was observed without treatment. She remained asymptomatic, and colonoscopy performed in December 2000 and January 2003 showed no remarkable change. Intussusception of the appendix is a rare disease with only about 200 reports in the world. Most patients appear with acute abdominal pain mimicking appendicitis or intussusception of the intestine, or suffer from chronic abdominal pain, whereas there are cases which are incidentally diagnosed from barium enema or colonoscopy as in this case. The presence of both abnormal peristalsis and abnormal anatomy of the appendix is considered to be the cause. Intussusception of the appendix is classified into 5 types according to the grade of intussusception by Langsam. This case was diagnosed as inside-out type. Though the cause was unknown for this case, old tuberculosis of the intestine might have played a role in its pathogenesis.

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We report an extremely rare case of multiple carcinoid tumors of the rectum associated with transverse colon cancer.
Case report : A 54 years-old male was pointed out positive occult blood of stool in a regular medical check up. The patient underwent colonoscopic examination which revealed a surface type tumor in the transverse colon and three elevated type tumors in the rectum, and was referred to our department of surgery. Endoscopic mucosal resections to all lesions were performed. The pathological finding disclosed a well differentiated adenocarcinoma in the transverse colon and two carcinoid tumors in the rectum.
Carcinoid tumor generally occurs as a single lesion in the rectum. Cases of multiple rectal carcinoid tumors have been rarely reported in Japan. Since the rate of multiple carcinoid tumor accompanied with other neoplasms including malignant tumor in the gastrointestinal tract is reported to be high, in the case of multiple colon carcinoid tumors, it was thought that further reference of the whole body should be performed, and also cautious follow-up of these cases is mandatory.

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We experienced a case of multiple vascular ectasias of the rectum who had been effectively treated by argon plasma coaglation (APC) . A 72 year-old man who complained of bloody stool visited our hospital in September, 2002. Colonoscopic examination revealed multiple vascular ectasias of the rectum with oozing. The lesions were treated effectively by APC. At two months after APC treatment, colonoscopic examination showed that these lesions had changed into scars. APC is conceivable to be useful for the treatment of vascular ectasia of the rectum.

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A 66-year-old man was admitted to our hospital because of melena, anemia and high fever. Urgent colonoscopy demonstrated multiple punched-out ulcers of intestines from the terminal ileum through the sigmoid colon. Histological specimens taken from the edge of ulcers revealed non-specific inflammation. He showed oral ulcer and multiple gastric ulcers as well as intestinal involvements. Neither physiological and immunochemical findings for Behçet's criteria, nor pathological bacteria and virus were confirmed. We diagnosed non-specific ulceration. He was treated with total parenteral nutrition and intravenous injection therapy of 50 mg of predonisolon (PSL) per day. This therapy resulted in adequate disease control and was followed by the recurrence afterwards during a dose reduction of PSL. Systemic and gastrointestinal manifestations improved markedly after combination therapy of PSL and azathioprine. This case suggested that combination therapy of PSL and immunosuppressive agent appear to be potentially effective in severely developed non-specific intestinal ulceration.

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The patient was 49-year-old male without any symptom. Because of positive fecal occult blood reaction, total colonoscopy was performed. In that examination, there was a granular LST which measured 4 cm in daimeter close to the anal verge. Although there was gross nodular lesion, 2.8 cm in diameter, in the tumor, EUS examination might suggest, including that region, the whole tumor was intramucosal lesion. So we decided to perform the submucosal dissection EMR for that lesion using a flex-knife, because resection by one piece was preferable to evaluate whether sm invation existed or not strictly and the complete resection of the distal parts of the tumor, near the anal verge was considered to be impossible using the conventional piece-meal EMR.
To make procedure safer and easier, we used some special equipment like a flex-knife, an endoscopy with water jet system and sodium hyaluronate as an injection solution at the submucosal layer. The course of EMR was done without any complication. The tumor was resected by single-step and able to have accurate evaluation. Pathological examination showed tubular adenoma with moderate to severe atypia. Both lateral and vertical margin was negative for adenoma and there was no conponent of carcinoma despite that size.
In conclusion, Single-step EMR makes it possible to gain accurate histologic evaluation and seems to be desirable whenever possible.

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Submucosal dissection EMR using an electro-surgical snare was performed for four cases of an LST.
The age of the patients was ranged from 58 to 69 year-old. The size of the tumors was 20 to 43 mm (mean 34.8mm) in diameter and three tumors were on the colonic fold. Macroscopic type was two granular-type LSTs and two non granular-type LSTs. Submucosal dissection EMR was performed for these cases. Because strip biopsy was associated with a high risk of piece-meal resection due to the size and the location of the tumors. The tumors were successfully resected by a single piece. Histological examination showed one focal cancer in tubulovillous adenoma (m, ly0, v0) , three tubular adenoma with moderate to severe atypia. The margins of the specimens were free of tumor invasion along their circumferences. Thus the pathological findings fulfilled the criteria for curative EMR. This procedure seems to be useful for a single piece resection of relatively large mucosal colorectal tumors, even when they are located on the colonic fold.

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We report on a case of intraductal papillary mucinous tumor (IPMT) with extrahepatic cholangiocarcinoma. A 50-year old man was admitted to our hospital with obstructive jaundice. Ultrasonography and computed tomography (CT) of the abdomen revealed a tumor in the common bile duct, which caused dilation of the upstream bile duct, and a cystic lesion in the head of the pancreas. Endoscopic retrograde cholangiopancreatography (ERCP) was performed. The papilla resembled a“fish-eye”, with mucus extruding from the orifice. A filling defect in the common bile duct and a segmentally dilated pancreatic duct in the pancreatic head were seen. He underwent pancreaticoduodenectomy. Histological testing of the specimen revealed cholangiocarcinoma of the common bile duct and IPMT in the head of the pancreas. IPMT is a rare cystic neoplasm of the pancreas. The majority of patients with IPMT do not have invasive cancer, and usually have a prolonged course without the development of cancer. However, concomitant malignancies of other organs occur in association with IPMT. Careful follow-up is necessary for patients with IPMT.

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A 53-year-old lady was admitted to the hospital because of high fever and epigastritis persisting for three weeks. The patient had a history of hypertension since at age 47, and also she was diagnosed as cholelithiasis at age 49, which was left alone without any treatment.
The patient had a pain in the right hypochondrium and the bulbar conjunctivae were icteric.
Increase of bilirubin, transaminases, CRP and leukocytes were observed in blood test. Abdominal roentgenogram and CT showed pneumobilia, wall thickening of the gallbladder and the gallstone like calcification. We suspected internal biliary fistulae and performed gastroendoscopic study. At the center of the ulcer lesion, a small pit was found suggesting the fistula. Endoscopic retrograde cholangiography (ERC) and contrast examination of the upper gastrointestinal tract were performed and the fistula formation between gallbladder and the antrum of the stomach was confirmed with the contrast medium flow. Thus, surgical operation was performed with a diagnosis of cholecystogastric fistula.
Cholecystogastric fistula is very rare among the spontaneous internal biliary fistula, and difficult to make a preoperative diagnosis. Our case shows the importance of the image examinations, not only the contrast medium flowing through the fistula found by ERC and contrast examination of the upper gastrointestinal tract, but also abdominal roentgenogram and CT showing pneumobilia, direct observation of the fistula with gastroendoscopic study.

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A 79-year-old male was admitted to our hospital because of upper abdominal pain. He was diagnosed to have acute cholangitis due to choledocholithiasis, according to the results of blood tests, ultrasonography and abdominal CT. Endoscopic examination showed 2 separated papillae which had individual orifices, and a duodenal diverticulum was identified close to the oral side of the papillae. Endoscopic retrograde cholangiopancreatography (ERCP) revealed separated openings of common bile duct (CBD) and main pancreatic duct (MPD) . The opening of CBD was located on the oral side of that of MPD. According to these findings, he was also diagnosed as having the completely separated orifices of CBD and MPD, which could be differentiated from choledochoduodenal fistula. Endoscopic retrograde cholangiography (ERC) revealed several stones, 11 mm maximum in diameter, in the CBD. EST was performed safely, and CBD stones were thoroughly removed by means of endoscopic mechanical lithotripsy (EML) . No complications occurred after the removal of stones by EST and EML. The orifice of CBD separated from that of the pancreatic duct is seldom encountered, and was reported to exist with a frequency of fewer than 4% in Japan. Differentiation of the condition from choledochoduodenal fistula is necessary because the incision range during EST is basically different between these two conditions. The present experience indicates that EST is useful and safe for the treatment of CBD stones in the patients with the complete separated orifices of CBD and MPD, if it is possible to be differentiated from choledochoduodenal fistula and the orifice of CBD is not located inside the diverticulum.

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A 74-year-old female was admitted to our hospital because of obstructive jaundice. Biliary metallic expandable stent (MES) was inserted for treatment of biliary obstruction because of pancreas head cancer before 11 months. Percutaneous transhepatic biliary drainage was performed and the puncture tract was dilated to 20 Fr which was necessary for percutaneous transhepatic cholangiography. And than, percutaneous cholangioscopy (2.3mm flexible endoscope) was performed. We used the guidewire to keep the lumen. Permanent irrigation with saline was applied via the scope's working channel. At the first, cholangingraphic findings were bile debris and sludge filled in MES. Bile debris adherent to MES was removed using endoscopy as possible. At the last, cholangiography showed the sooth inner surface of MES and free metallic surface without granulation. In summary, this case was that percutaneous transhepatic cholangiography for stent occlusion was useful and the inner surface of the stent after removed bile debris was regular and smooth without granulation.

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