1989年に筆者が考案した留置スネア（オリンパス，結紮装置）は，内視鏡的結紮を目的としている。非通電性のループを用いて消化管内の病巣を結紮し，その場に留置できる。この結紮装置は，大型隆起病変を切除する際の出血予防処置具として有用なだけでなく，種々の出血病巣に対する止血処置具としても極めて利用価値が高い。国立佐倉病院では1989年5月より1994年1月の間に，80症例に結紮装置による内視鏡的結紮を行ったが，そのうち71例が大型隆起病変を切除する際の出血予防，9例が出血性病変の止血のための結紮であった。止血目的で結紮を行った9例の内訳は，5例がポリペクトミー後の断端出血，3例が出血性ポリープ，1例が食道静脈瘤出血であった。結果は9例とも結紮によって直ちに止血し，再出血はなかった。なお80例すべてにおいて偶発症はなかった。

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　内視鏡下に粉末薬剤を消化管内腔へ直接散布する方法について，長年の検討の結果，滑りのよい散布用チューブと強力なポンプ・アルトシュウターを開発した。今回は消化管粘膜保護剤でもあり止血剤でもある，アルギン酸ナトリウム粉末（アルト）を内視鏡検査の際の生検後やポリペクトミー後の小出血に対して，直接散布を試みてよい成績を得たので報告する。今後種々な粉末や顆粒薬剤の直接的噴射の可能性について検討が可能になったものと考える。

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　われわれはこれまで胃腎シャントのみられる孤立性胃静脈瘤に対して，経頸静脈的塞栓術（TJO）を施行してきた。しかし，胃腎シャントのみられない胃静脈瘤に対してはTJOは施行不可能である。一方，Stiegmannの結紮術は食道静脈瘤に対して考案されたので，結紮可能な範囲が胃静脈瘤には十分でない。そこで，われわれは結紮器の内筒の内径を10.3mmに広げ，長さを16mmに伸ばした巨大結紮器を考案した。この巨大結紮器による結紮術を，胃腎シャントの認められない，蛇が横たわったような胃静脈瘤症例2例に対して施行したところ，胃静脈瘤が全例で潰瘍化，瘢痕化して治癒した。また，各症例では治療6ヵ月および4ヵ月後の経過観察にて，胃静脈瘤は瘢痕化しており，再発が認められなかった。そこで，巨大結紮器を用いた結紮術は孤立性胃静脈瘤に対する治療法の1つとなりえると思われた。

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　早期胃癌61例を対象に内視鏡的胃粘膜切除術（EMR）の適応決定のため，ソノプローブSP101ならびにSP501を用い，深達度診断を行った。m癌では正診率95％，sm癌では67％であった。sm癌では粘膜下層のリンパ濾胞や粘膜筋板の肥厚，結核結節などをsm浸潤とover diagnosisする傾向にあった。しかし，内視鏡的には判断できなかった病巣内潰瘍瘢痕の存在を超音波では捉らえられた。EMRの適応をより正確に判断するためには，内視鏡検査所見に加えて，直視下での超音波所見を加味し判断することは有意義であると考えられた。

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　当科では食道，胃の粘膜癌に対する根治を目的とした内視鏡的治療法として，透明プラスチックキャップを用いた内視鏡的粘膜切除術（EMRC）を施行している。EMRC施行にあたって危惧される合併症として穿孔があるが，強圧吸引を利用する本法において，安全性の基礎となっているのは粘膜下層への十分な生理食塩水注入である。20ml以上の生食の粘膜下局注で，粘膜が筋層より十分に分離されるが，時間の経過とともに生食の拡散により分離が不十分となる。粘膜と筋層の分離が不十分な状態で粘膜を吸引すると，筋層まで吸引する危険性がある。ところでEMRC施行中，細径超音波プローブを局注後の粘膜にあてるだけで，病変を含んだ粘膜が筋層より十分に分離されているかどうか容易に確認でき，また粘膜の絞扼後に筋層が巻き込まれていないかどうかの確認も可能である。細径超音波プローブは粘膜切除施行時の安全性の確保に有用であると考えられたので報告する。

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　バルーン・シースを用いた細径超音波プローブによる内視鏡的超音波断層法（以下，EUS）の基礎的および臨床的検討を行った。先端にバルーンが装着された外径3.2mmのシース内にプローブを挿入し，バルーンに脱気水を注入して膨らませた。太径生検チャンネルを有するスコープを用いてEUSを行い，脱気水充満法と対比した。バルーンの短径は注水量8mlで22mmが最大で，それ以上注入しても長軸方向へのみ膨らむことが判明した。厚さ約0.1mmのバルーン自身のエコーが認められたが，注水量にはほとんど影響を受けず，また層構造の描出においてバルーン自身の影響はなかった。さらに上部および下部消化管病変20例に対し臨床的検討を行ったところ，バルーン・シース法は脱気水充満法と同等の描出画像が得られた。特に狭窄性病変や食道疾患に有用であったが，表在性の病変はバルーンの圧排により描出不良であった。

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　細径超音波プローブ（オリンパス光学社製，UM-3R ; 20MHz，UM-2R ; 12MHz，外径2.4mm）を用い，大腸領域における内視鏡的超音波断層法（以下EUS）について基礎的・臨床的検討を行った。脱気水の注水吸引時間はT字管を用いて接続すると長くなるが，プローブ挿入などの操作が容易となることから，検査全体の時間短縮が期待できた。臨床的には1993年5月より本機種にてEUSを施行し，組織学的に対比しえた大腸腫瘍性病変110症例を対象とした。注水吸引操作と貯水に有効な体位変換で，十分な走査条件を得られた。2チャンネルの内視鏡ではより手際よい操作が可能で，プローブを管腔に誘導する大腸鏡の選択が重要であると考えられた。専用機と比較し高い狙撃性を示したが，プローブを病変に正対できないなど走査困難な場合もあり，プローブ先端や把持鉗子で粘膜面を平坦化させ，ひだの影響を除いたり，透明スライディングチューブを用いて屈曲を直線化するなどの工夫により解決した。高周波プローブにより詳細な画像を描出しえても，有効走査範囲は狭く，超音波減衰も大きいため，丈の高い病変や厚みのある病変では描出不良が多く，機種の選択が重要と考えられた。大腸癌深達度正診率は早期癌85％，進行癌97％，全体で92％と良好であった。

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　周波数15MHzの細径超音波プローブを，内視鏡的乳頭括約筋切開術を施行することなく，経乳頭的に膵管内に挿入し，膵小病変および十二指腸乳頭部疾患の新たな画像診断について検討した。膵管内挿入用の工夫として，プローブには先細り状メタルチップが装備されている。対象は膵囊胞性病変4例，膵管癌1例，十二指腸乳頭部癌2例である。正常膵管内超音波像では，プローブに接して膵実質像が描出され，1層あるいは3層の膵管上皮をその内側に認めることもあった。膵実質像は，通常の超音波内視鏡像よりも微細かつ均一な像を呈し，膵辺縁像の描出も可能であった。症例によっては，実質像の外側に膵外の血管像を確認した。膵乳頭腺癌症例では，超音波内視鏡あるいは内視鏡的逆行性膵管造影によって指摘できない主膵管内の乳頭状隆起について高解像度の画像を描出した。その隆起の連続性と不整な形態から悪性病変と診断し，適切に治療しえた。膵管内超音波検査は今後，膵の微細病変の診断に大きな進展をもたらす可能性がある。従来型超音波内視鏡やバルーンカテーテル膵管造影によって確診できない膵囊胞性疾患の壁在結節について膵管内超音波像を検討した。膵管内超音波像では，壁在結節はより鮮明な像として描出された。今後，高解像度の画質を劣化させずにさらにプローブの細径化が実現できれば，この診断法の有用性が高まるであろう。

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　比較的小さく，隆起成分に乏しい大腸腫瘍性病変の拾い上げ診断の向上を目的として画像処理を検討した。表面型癌の画像に対し周波数解析を行ってバンドパスフィルターを設計し，リアルタイム処理を施行したところ，わずかな凹凸や微細構造が強調された。画像の強調処理の有用性は，リアルタイムでの臨床使用で，客観的に評価される必要が指摘されている。そこで当処理を多数例に長期間施行し，処理しない検査と病変診断率に差がないか検討し，処理の客観的な評価を試みた。当科における大腸内視鏡検査2,208回（1989年8月より1992年8月まで，処理群1,052回，対照群1,156回）を対象とし，両群で検査背景をなるべく一致させて比較検討したところ，診断されたポリープ数は，検査1回につき対照群1.48病巣に対し，処理群では1.75と増加した。大きさ，形態でみると，無茎性で5mm以下の病変で有意な増加を認めた。病理組織学的診断が可能であったものでは，どの組織型においても病変診断数の有意な増加を認めた。5mm以下の病変でも，症例の少ない早期癌を除き同様の傾向を認めた。形態では6mm以上10mm以下の扁平病変で，対照群29病巣に対し処理群60と有意差を認めた。以上より，当処理は下部消化管内視鏡検査における小さな表面型病変の拾い上げ診断に有用と考えられた。

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　1990年1月-1993年12月の間に当科において内視鏡的に摘除（ホットバイオプシーを含む）された大腸腫瘍（腺腫癌）1,198病変のうち10mm以下の906病変を対象とし，腫瘍径，内視鏡的形態および組織学的異型度との関係を検討した。腫瘍径分布では3-5mmにピークがみられ，5mm以下の微小腫瘍が69.3％を占めた。隆起型腫瘍（Ⅰp/Ⅰsp型，Ⅰs型）は87.3％を占め，5mm以下ではm・sm癌は認めず，6mm以上ではⅠp/Ⅰsp型腫瘍の6.3％にm癌を，Ⅰs型腫瘍の5.6％にm癌，2.8％にsm癌を認めた。表面型腫瘍は12.8％を占め，Ⅱa型腫瘍の組織学的異型度はⅠp/Ⅰsp・Ⅰs型腫瘍と同様に5mm以下ではm・sm癌を認めなかった。また，Ⅱa＋Ⅱc型腫瘍は頻度は低いが，5mm以下でもm癌1例（20％）を認め，6mm以上ではm癌1例（10％），sm癌2例（20％）を認めた。Ⅱc型腫瘍は5mm以下に1病変みられ，組織学的には中等度異型腺腫であった。以上より，大腸小腫瘍に対する治療方針は，①5mm以下の微小腫瘍は，陥凹成分のある病変は積極的な切除の対象となるが，陥凹成分のない隆起性病変は経過観察でよい，②6mm以上の腫瘍は形態にかかわらず，積極的な切除を行うべきであると考えられた。

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　10mm以下の直腸カルチノイド22病変を対象として，超音波内視鏡（endoscopic ultrasonography，以下EUS）を用いた深達度診断，および内視鏡的ポリペクトミーにおける2チャンネルスコープの有用性について検討した。対象とした直腸カルチノイドの腫瘍径は，5mm以下8病変（36％），6-10mmが14病変（64％）であった。深達度は全例粘膜下層までにとどまり，リンパ節転移や肝転移も認めなかった。EUSによりカルチノイド腫瘍は，内部が低エコーで境界明瞭な腫瘍像として描出され，EUS施行11病変の全例で深達度が正診可能であり，腫瘍近傍のリンパ節腫脹も認めなかった。治療は内視鏡的ポリペクトミーを14病変（64％），局所切除を8病変（36％）に施行した。内視鏡的ポリペクトミー例のうち，8病変は2チャンネルスコープ，6病変は1チャンネルスコープを用いて切除した。切除断端陽性頻度を両機種で比較すると，2チャンネルスコープでは腫瘍径5mm以下が0％，6-10mmは25％（1/4病変）と良好であり，腫瘍組織の遺残も認めなかった。しかし1チャンネルスコープでは，5mm以下および6-10mmともに67％（2/3病変）と不良であり，断端陽性の2病変で腫瘍組織の遺残が確認された。以上の検討より10mm以下の直腸カルチノイドにおいても，EUSの診断成績は良好であった。また内視鏡的ポリペクトミーにおいては，2チャンネルスコープの使用が腫瘍の完全切除に有用と考えられた。

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　直腸粘膜脱症候群（MPS）を経過観察し，その臨床的および内視鏡所見につき検討した。対象は1986年4月より当院でMPSと診断され，内視鏡的に経過観察された8例である。その結果，①男女比は4対4，年齢は18-72歳で，平均年齢は38.1歳であった。②主な臨床症状は，下血・粘血便6例（75％），貧血および肛門痛が各々1例で，排便習慣は便秘4例（50％），頻回便1例（12.5％）。下剤・摘便・浣腸の使用は4例，“いきみ”の習慣は全例に認められた。病悩期間は最低2ヵ月から最高40年と幅があった。内視鏡による経過観察は最長81ヵ月から最短4ヵ月であった。③診断時の内視鏡所見は潰瘍形成4例，潰瘍形成＋ポリープ2例，ポリープ状の隆起2例であり，主に肛門縁より10cm前後の直腸前壁に病変は認められた。④“いきみ”の禁止を主として，緩下剤などで排便習慣を是正した治療を行い，経過観察した8例中7例で潰瘍・びらんの縮小，瘢痕化，ポリープの縮小が内視鏡的に観察された。直腸脱の1例に対してRipstein手術が行われた。以上，MPSの成因の大きな因子である“いきみ”の禁止によって潰瘍，びらんの改善が認められ，この効果は内視鏡による経過観察で確認された。

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　症例は48歳男性で，胸部不快感，嚥下困難にて来院した。食道内視鏡検査にて下部食道に発赤部位を認め，滑脱型ヘルニアも認めた。発赤部位の中に小陥凹域を認め，その部位よりの生検で高分化型管状腺癌の診断を得た。外科的切除標本では，腫瘍の大きさは5×18mmで，癌は粘膜内に留まっていた。癌は種々の程度の異型性を有する腸上皮化生により囲まれていた。以上の組織学的な検討から，最初胃粘膜に置き換えられた食道粘膜が次に腸上皮化生に置き換えられ，最後に腸上皮化生の中に腺癌が発生したと考えられた。本症例においては，胃粘膜組織は萎縮が高度で，腺窩上皮のみ存在し，腺管はほとんど消失していた。Barrett食道に発生する腺癌の発生率は0-47％と著者により様々である。高度異型上皮は癌への変換のハイリスク状態と考えられ，生検による厳重な経過観察が必要である。

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　症例は82歳女性。気管支喘息，高血圧の加療中，消化器症状にて上部消化管造影を施行し，食道癌を疑われた。上部消化管内視鏡にて歯列より約30cm，2時方向に小結節扁平隆起性病変を認め，X線，内視鏡所見，生検より表在隆起型食道癌（中分化型扁平上皮癌）と診断した。内視鏡的切除など各種治療を検討したが，年齢，全身状態などにより未治療のまま経過観察となった。定期的に内視鏡を実施していたところ，約2年後の内視鏡検査において著明な退縮を認めた。悪性腫瘍の自然退縮は極めてまれな現象であり，頻度は悪性腫瘍6万例から10万例に1例とされており，とりわけ消化器癌ではまれとされている。今回，自然退縮した食道癌を内視鏡的に経過観察しえた1例を経験したので報告する。

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　症例は59歳男性。当院の健診胃X線検査で隆起性病変を指摘され，精査加療目的で入院となった。上部内視鏡検査にて表面やや凹凸を伴う隆起性病変を認め，生検を施行した。病理診断はlymphoma study group（LSG）分類の胃悪性リンパ腫non-Hodgkin，B cell，diffuse medium sizedと診断され，手術を施行した。胃切除標本では，表面にやや凹凸を伴う扁平な隆起性病変を認め，深達度はsmに限局されており，リンパ節転移は認められなかった。以上より早期胃悪性リンパ腫と診断した。近年，上部消化管内視鏡および健康診断の普及により早期胃悪性リンパ腫が多く報告されるようになってきたが，一般的には早期胃癌分類のⅡc様を呈する所見が多く認められ，自験例のようなⅡa様を呈する所見は，著者らが検索しえた範囲では，本邦では自験例を含め7例にしかすぎず，比較的まれな症例であると考えられたので，若干の文献的考察を加え報告する。

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　症例は42歳男性。下血を主訴として入院。術前胃・小腸・大腸内視鏡検査および造影にて出血源を同定できず，Tcシンチグラフィー，血管造影にて，回腸から上行結腸に出血を疑わせる所見が認められた。保存的治療無効の大量下血に対して救命的に開腹手術を施行し，術中小腸内視鏡にて2個の多発潰瘍を認め，回盲部切除術を行った。術後切除標本の病理学的検索では，潰瘍はUlⅡの非特異的小腸潰瘍の所見であった。術後12日目に再下血を認めたため行った十二指腸内視鏡にて出血性びらんを認め，腰痛のために以前より使用していた週約100mg程度のインドメタシン坐薬を中止したところ出血も止まった。このことより本症例の原因が薬剤性であることが判明した。以上，少量のインドメタシン坐薬単剤により大量下血を繰り返した小腸潰瘍を経験したので報告した。

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　大腸の過形成性（化生性）ポリープ（以下hyperplastic polyp : HP）の腺腫および癌への移行は極めてまれといわれている。われわれはHP巣内に早期癌が共存した1例を経験したので，文献的考察を加えて報告する。症例は81歳女性。便潜血反応陽性のため，注腸造影検査および大腸内視鏡検査を施行。（A）S状結腸に長径22mm大の弧状変形を有するⅠsp型早期大腸癌，（B）上行結腸に長径29mm大のⅡa＋Ⅱc様の隆起性病変を認め，HPと診断された。（B）はHPにしては大きさ，形態とも特異であり，癌も否定できず，S状結腸切除および上行結腸ポリープ摘除術を施行した。病理検査にて（A）はsm浸潤の早期大腸癌，（B）は局所にm浸潤の早期癌を伴ったHPと判明した。大腸HPに発癌のポテンシャルがあるとはいいがたく，非常にまれな症例と考えられた。しかし比較的大きく，通常の形態と異なるHPは腺腫や癌の発生も報告されており，内視鏡や手術による完全切除を行うべきと考えられた。

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　早期大腸癌の内視鏡的粘膜摘除術（以下EMR）の適応が，最近確立されつつある。われわれは内視鏡的に一括摘除できずに，piecemeal polypectomy（以下PP）を，あるいは異時的にEMRを繰り返すことによって，42症例の深達度mの腺腫内癌あるいは腺腫成分を伴う癌を肉眼的に完全摘除した。分割摘除であるため，病理学的には完全摘除の証拠は得られなかった。異時的EMRでは3ヵ月以内に完全摘除されており，経過中に局所残存が確認された場合は，再度EMRが繰り返した。5年を目標に厳重に経過観察しているが，経過中4症例に外科的追加切除が必要となった。すなわち2期的，3期的にPPを施行したものの，その摘除標本に病理学的にsm浸潤を認めた1例と，PP後の瘢痕が強く残存病変の内視鏡的追加摘除が困難であった3例であり，4例とも外科的完全治癒切除がなされた。側方断端にm癌陰性の病理学的な証拠が得られなくても，脈管侵襲もなく，明らかなsm浸潤の所見も認められず，かつm癌と正確に深達度診断できれば，肉眼的完全摘除を目標に（たとえ複数回に分けてでも）PPは試みる価値があると考えられた。

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　症例は83歳男性。平成5年12月31日にうっ血性心不全で入院。入院中便秘が増強し，腹部単純X線像上イレウスと診断し，直腸ブジー，坐薬など対症療法を施行し好転した。その直後より鮮血下血が出現し，大腸内視鏡を施行した。直腸下部後壁に多発する炎症性憩室と近接して潰瘍が認められ，潰瘍より滲出性の出血を確認し，同部位に対し内視鏡的にHSEを局注，またトロンビンを散布し止血しえた。直腸に多発する炎症性憩室の報告はまれであると考えられるため，文献的考察を加え報告した。

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　von Recklinghausen病（以下VRD）に合併したまれな直腸癌の1例を経験した。症例は67歳男性で，20歳頃より皮膚腫瘤に気づいた。家族歴は次女にVRDの疑いあり。健診での便潜血陽性の精査を主訴に来院。全身に皮膚腫瘤および“café au lait spot”を認め，皮膚生検で神経線維腫を確認した。大腸内視鏡および注腸造影検査でRa領域に径約3.5cmの2型直腸癌を認め，低位前方切除術が施行された。病理所見はn₁s₁p₀h₀（Stage Ⅲ）で，組織学的には中分化型腺癌であった。同時に直腸から横行結腸に6個の多発ポリープを認め，組織学的には腺管腺腫および絨毛腺管腺腫であった。なお，腹腔内には神経線維腫の存在などの異常所見は認めなかった。文献的に検索しえたVRD合併大腸癌17例について検討したところ，非合併大腸癌の臨床像とほぼ類似していたが，大腸神経線維腫併存例が1例に認められた。合併病因はいまだ不明で，今後遺伝子的検索を含めた症例の蓄積が望まれる。

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　症例は64歳女性。1990年6月，近医にて肺サルコイドーシスと診断され，同時にHCV抗体陽性を指摘された。ステロイド療法開始後トランスアミナーゼの上昇を認め，1992年3月，腹腔鏡検査を施行。肝表面は，びまん性の赤色紋理と右葉に約5mm大の軽度に陥凹した黄色斑を1個認めた。生検像は慢性活動性肝炎の所見で，インターフェロン治療により著効を得た。なおインターフェロン開始時，ステロイド療法は中止した。1993年11月経過観察のため，第2回腹腔鏡検査を施行。肝表面の赤色紋理は消失し，樹枝状の白色紋理を認め，生検像では炎症所見の改善を認めた。また両葉に，3-10mm大の軽度に陥凹した黄色斑の増加を認め，同部位の狙撃生検では多核巨細胞を伴う類上皮肉芽腫の集簇を認めた。本例はインターフェロン治療の前後で，肝表面に著明な変化を認めた興味ある症例と考え報告する。

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　67歳女性にみられた転移性膵癌の1例を報告する。1986年肺癌のために，左肺摘出術を受けている。1991年経過観察のために行われたCTにて，膵体部に低吸収性の腫瘤像および主膵管の圧排，閉塞がみられた。術前検査にて，遠隔転移や上腸間膜動脈および上腸間膜静脈周囲の浸潤はみられなかったことから，膵体尾部脾合併切除術が行われた。体部に母指頭大の腫瘤，腸間膜根部リンパ節腫大が認められた。肺からの転移によるpoorly differentiated acinar adenocarcinomaであった。この1例を含み，転移性膵癌の4例とともに，文献報告された転移性膵癌15例を提示した。ERCPを除いて，転移と原発腫瘍を鑑別する特別な症候や臨床的特徴はなかった。

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Forward viewing colonoscope has some limitation in observating the whole colonic area, for example behind a fold or an acute bend. We used forward-lateral viewing changeable colonoscope and evaluated whether it was usefull for dissolving blind area by comparing the ability of the observation using ordinary forward viewing colonoscope.
Sixty two cases were examined by forward-lateral viewing changeable scope (provisional name Olympus XCF-DS200I) , and 123 cases were examined by forward viewing scope (Olympus CF200I) . Insertion rate to the cecum was 95.2% by forward viewing scope whereas 95.1% by forward-lateral viewing scope. Lesions in the left side colon were observed in front by using forward-lateral viewing scope even when they situated behind folds and difficult to be observed by forward viewing scope. To look at lesions infront by forward-lateral viewing scope, maneuvers of twisting the scope is required.
Therefore observation by forward-lateral viewing scope in the right side colon was more difficult than in the left side colon. During the observation by lateral view system, the endoscopic treatment such as biopsy or polypectomy was impossible. If it were reformed that polypectomy snare wire was accessible in both lateral view and forward view system, it would be more useful.

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We develop a new technique for the prolapse and bleeding internal hemorrhoids (Goligher III) such as fiberscopic hemorrhoidal ligation (FHL) . The technique of FHL is as follows. An upper GI tract fiberscope is employed and the scope is retroflexed in the rectum and the hemorrhoids are ligated using Stiegmann-Goff ligator. A one week, 2-3 ml of 1% aethoxysklerol (AS) is injected between every hemorrhoids submucosally.
We performed FHL in total of 15 cases and excellent results (complete disappearance of chief complaints) were obtained in 15 cases (100%) .
We consider that this new technique allows better visualization and less pain compare to conventional treatment and assumed to be useful in non-oprative hemorrhoidal therapy.

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Eighteen men and 23 women outpatints' gastric mucosal pH was measured under endoscopy, in order to know how the site of pH glass electrode influences the result of pH monitoring for 24 hours.
The mucosal pH of antrum was significantly higher than other sites on anterior and posterior wall. It was also higher than that of middle body and fornix on greater curvature (p<0.01) . It had no difference on lessor curvature. The mucosal pH of duodenum was significantly higher than any sites of stomach. It was also higher on middle esophagus than lower esophagus. The pH value of gastric juice was 2.59±2.00, and that of duodenal juice 6.74±0.59.
These results show possibility of a difference of pH value according to the location of the pH glass electrode, when 24 hour pH monitoring is done. And any of the pH value of mucosa in esophagus, stomach, duodenum and juices did not show more than 7.8.

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Miniature probe which can be inserted into gastrointestinal tract through gastrointestinal fiber scope is recently in clinical use. We had reported the usefulness of color Doppler-endoscopic ultrasonography (CD-EUS) for the detection and selection of treatment of gastroesophageal varices, this time, we evaluated the usefulness of miniature probe for the detection of gastroesophageal varices in comparison with CD-EUS.
We examined 12 patients with gastroesophageal varices due to liver cirrhosis (9 cases of viral liver cirrhosis and 3 cases of alcoholic liver cirrhosis) using miniature probe (SSD-550, 15MHz and 20MHz) and CD-EUS (EPE-703FL, SSA-270A, 7.5MHz) , and the both examinations were performed within one month.
The following results were obtained :
1) The detectability of F₁ varices was 100% by miniature probe and 66.7% by CD-EUS.
2) The detectability of F₂-F₃ varices was 100% by both miniature probe and CD-EUS, but the overall feature of the varices could not be observed by miniature probe.
3) Not only extramural blood flow and penetrating vein but also direction of blood flow could be detected by CD-EUS.
4) We must select either miniature probe or CD-EUS for the detection of gastroesophageal varices according to the subjects and the purposes.

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Endoscopic variceal ligation (EVL) and endoscopic sclerotherapy for consolidation (EIS) were employed in 20 patients suffering from liver chirrhosis with esophageal varices (F₁ ; n=5, F₂ ; n=15) . Variceal angles were determined in each patients as follows.
From picture using ultrasonic miniature probe (UMP) each varix was given its own individual angle corresponding to its width on esophageal surface length transversally. Variceal angles were then determined as the sum of each individual variceal angle. The severity of varices were evaluated by variceal angles and cardiac venous dilatation (3 mm or more diameter) , and efficasy of EVL with/without EIS was determined by mucosa and submucosa thickness all of which were obtained from UMP pictures. EVL group was devided to EVL-A group (less than 12 O-rings) and EVL-B group (12 O-rings or more) .
Before treatments variceal angles were greater in F₂ group significantly (p<0.01) than F₁ group, and in cardiac venous dilatation group significantly (p<0.05) greater than those in without dilatation group. After treatments esophageal mucosa and submucosa thickness in EVL-B group as well as EVL with EIS group were greater significantly (p<0.01) than in EVL-A group respectively.
From these results above it was suggested that variceal angles and cardiac venous dilatation were related to the variceal severity, and that more O-rings used rendered a more effective therapy of esophageal varices.

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Sixty-two patients with gastric cancer were examined preoperatively, using a miniature ultrasonic probe (MUP) to diagnose the depth of cancer invasion. In 62 patients, 16 had stenotic lesion and 46 type 0 cancer. We used the two kinds of new technique, namely jelly and soft balloon method, added to the conventional water-filling method. Jelly method is manipulating MUP in the viscous jelly sprinkled on the tumor and soft balloon method is in the soft balloon filled with deaerated water putting on the tip of the scope. We selected the proper method according to the location of tumor.
The results were as follows : (1)Jelly method was useful for the stenotic lesion and the tumor located on the prepylorus, however, it was difficult to make the differential diagnosis between ss and se cancer. (2)Soft balloon method was available for the tumor located close to the esophagogastric junction. (3)The accuracy rates of type 0 cancer were 76% (23/30) in mucosal cancer, 75% (9/12) in submucosal cancer and 100% (4/4) in mp cancer. Overall accuracy was 78% (36/46) . Of 10 patients misdiagnosed, 9 had the ulcerative changes in the lesion.
In conclusion, a proper selection of method seems to be important in performing MUP examination, however, further studies are required as to the lesion with ulcerative changes and ss cancer.

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We studied the usefulness of a jelly infusion method in comparison with the ultrasonography by the traditional water infusion method for colorectal lesions. From October 1993 to May 1994, ultrasonic probes by jelly infusion method (UM-1W 7.5 MHz, MP-PN15-06 15MHz) were performed in 28 cases.
This new method was easy to handle because the jelly stayed in the lesion of the examination, and therefore, the position change of patient was not necessary. Concerning to the diagnostic ability, diagnostic accuracy of depth of the cancer was 69.6% (early cancer 90%, advanced cancer 53.8%) . In conclusion, this method seems to be efficient and useful in ultrasonic diagnosis of colorectal lesions.

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We reported a new preparation for colonoscopy by a new sodium phosphate solution. This new sodium phosphate solution was prepared by adding two kinds of sodium phosphates, namely, 48g Na (PO₄) ₂＋18g NaHPO₄ in 100ml of water. The new preparation was performed as follows :
On the day before examination no diet restriction was required and patient received 45ml of the sodium phosphate solution diluted to 90ml with water at 8 : 00 pm. On the day of examination patients received the same lavage solution again at 6 : 00 am. After taking the lavage solution patients were instructed to drink at least three glasses of water within one hour.
Nineteen patients received the new preparation, the acceptance was that 11 patients felt easy, 8 patients felt tolerable. No one failed to complete this new preparation. Average times of evacuation prior to the examination was 7.6 and it took 5.2 hours on the average for patients to start the first evacuation. Serial measurements of blood tests showed that sodium increased and potassium decreased but both did not exceed normal range. Hyperphosphatemia was noted after taking sodium phosphate but was transient, and no concomitant decrease in calcium was seen.
Consequently, no clinical symptom due to the disturbance of electrolytes was found except that two women complainted of nausea and one of them did not sleep well because of midnight evacuation. We got impression that the cleansing effect of the new preparation was better than that of coventional 2l-PEG preparation.

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Endoscopic and clinicopathological findings in our consecutive 26 patients (19 males and 7 females, average age : 54.7 y.o.) with colorectal submucosal tumor (SMT) treated by endoscopic polypectomy were compared with those in 186 patients in the Japanese literature. In our series, endoscopic ultrasonography (EUS) was carried out as far as possible to evaluate the size, gross appearance, location in the layer structure and ultrasonic characteristics of the tumors. Endoscopic polypectomy was carried out only when the snare-wire loop was tightened within a few mm in diameter.
The final diagnosis of the 26 cases were 12 lipomas, 7 carcinoids, 3 leiomyomas, 2 lymphangiomas, one hemangioma and one mixed tumor. Complication of transient lower intestinal bleeding was observed after polypectomy only in one case of lipoma. Correct preoperative diagnosis was not obtained from 5 patients, and 3 of whom were not carried out of EUS. The average size of SMTs resected were 10.1 mm in our series and from 7.3 to 18.9 mm in 186 in the literature. The semipedunculated or pedunculated appearance of SMTs were seen in 54% in our series and 69% in the cases in literature.
In conclusion, endoscopic polypectomy can be indicated to colorectal SMTs in the following conditions ; 1) the benign SMT less than 20 mm in diameter showing pedunculated of semipedunculated appearance, and 2) carcinoid tumor less than 10 mm in diameter without any metastasis.

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Elevated 4,669 lesions of the colorectum which histological diagnoses were adenomas or early cancers were studied clinicopathologically and endoscopically, in order to clarified which lesions less than 10mm in diameter shoud be resected endoscopically.
The incidence of cancer less than 5mm in diameter was only 1.1%. The incidence of cancer or that of submucosal cancer, more than 5mm and less than 10mm in diameter, was about 11 times or about 8 times respectively in comparison with those less than 5mm in diameter. Out of 4 lesions, IIa+IIc type less than 5mm in diameter, 2 lesions were mucosal cancer or submucosal cancer. Furthermore, minute depression observed by endoscope was important finding in order to diagnose cancer. Especially, the lesions accompanied by depression and expansional configuration obserbed by endoscope had the possibilities of the submucosal cancers.
In conclusion, the lesions more than about 5mm in diameter shoud be resected endoscopically and the lesions less than 5mm in diameter, if those had depression or expansional configuration as endoscopic findings, shoud be resected endoscopically.

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Fifty-seven lesions (16 carcinomas and 41 adenomas) were evaluated for purpose of dignosis and treatment in 48 patients with depressed type lesions classified as type IIc and IIc+IIa (40 males and 8 females with a mean age of 62.2 years) .
The clues to cancer detection that were obtained in endoscopic study were redness, deformity, discoloration, and whitish coat. Redness was the most predominant sign, accounting for as much as 73.7% (43/57) of lesions detected. When the depressed lesions were classified into small depressed lesions of type A, dendritic lesions of type B, asteroid lesions of type C, wide irregular lesions of type D, and cylindroid lesions of type E, 20 lesions of type D were found to include 10 carcinomas, of which 3 were classified as carcinomas with submucosal invasion. On the other hand, 49 lesions were treated by endoscopic mucosal resection (EMR) .
The results suggest that carcinomas may be considered an indication for EMR if void of traits of submucosal invasive carcinomas, such as converging folds.

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We investigated the usefulness of colonoscopy with peroral dye method using 300mg of indigocarmine to detect small neoplastic lesions. These patients were divided into two groups. In group I, patient received the peroral administration of the dye during the preparation with polyethylene glycol-electrolyte lavage solution (n=62) . In group II, patient did not receive the administration of the dye and had the same preparation as that in group I (n=68) .
In group I, most patients showed good contrast effect of the entire colon. The incidence of sessile or flat polyps less than 5mm was 41.9% (26/62) in group I, and 8.8% (6/68) in group II. The difference was statistically significant. In the other series of 419 patients in whom peroral dye method was performed, 391 neoplastic lesions less than 10mm were found, and among those, 67 lesions (17.1%) were superficial type lesions.
These results suggested that the peroral dye method might be useful in detecting small flat lesions.

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With 306 colonic polyps which were resected in the endoscopic polypectomy, we classified colonic polyps into 5 types, A to E. Type A looks nearly round, type B elliptic and type C has a lobulation tendency in type A and B. Type D has apparent lobulation tendency in type B. Type E has irregular shape with apparent lobulation tendency.
We studied a relationship between size and transformation to cancer of polyps by this classification and LDH isoenzyme patterns. In the polyps below 11mm in size, cancers were found in 14.3% of type C, 16.0% of type D and 7.1% of type E. For example, with a combination of lateral views (sessile, subpedunculated and pedunculated) and type E, transformation to cancer rate become 27.8%, 23.5%, and 40.0% respectively. With using only laterl views, transformation to cancer rate was 1.8%, 11.5% and 16.9% respectively.
The fact stated above suggested this classification was useful in diagnosis of colonic polyps. If the level of LDH-M subunit in a polyp tissue was higher than the one of its back ground mucosa, it might be malignant. We would like to conclude that when a polyp looks type C to E and has higher level of LDH-M subunit, it might be malignant.

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We have experienced fifteen cases of a foreign body in the upper digestive tract removed with an endoscope from September 1984 to August 1993. The most common anatomic location was the esophagus (53%) , followed by stomach, and duodenum. The most common foreign body was a PTP medical tablet (60%) . Every case of a foreign body in the esophagus complained of chest pain, sore throat or dysphagia.
In thirteen cases an endoscope and a catching forceps was enough usefull to remove a foreign body. In the other two cases the importance to know more about the shape and kind of a foreign body for removal has come to be seriously felt. Without stomach tube with a magnet attached, we would have fail to remove a mercurial battery. Without gastric lavage and postural change, we would have fail to remove a root canal reamer.
These cases suggested that an endoscope and a catching forceps were not always usefull for the removal. Further studies are needed to establish the improved endoscopic techniques and methods.

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Hemangioma of the esophagus is very rare lesion. We successfully treated hemangioma of the cervical esophagus, 2.5cm in length, by endoscopic injection sclerotherapy (EIS) .
A 42-year-old female was referred for dysphagia. Esophagography showed a filling defect with a sharp margin in the cervical esophagus. Endoscopic examination revealed a soft and red-purple color tumor at 18-20.5cm from the incisor. It was diagnosed as hemangioma of the esophagus and was treated by EIS. After 8ml of 1% polidocanol and 1ml of ethanol was injected into the lesion, it turned dark-red and shrinked. Three days later 3ml of 1% polidocanol were injected additionally. Three weeks later the lesion shrinked to one forth.
EIS is a good method for hemangioma of the esophagus to improve dysphagia and to prevent bleeding.

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A case of 53-year-old female was reported who admitted to our clinic with the chief complaint of epistaxis and melena. She had been treated with pulmonary arteriovenous fistulae and heart failure caused by Rendu-Osler-Weber disease.
Endoscopic observation revealed multiple small elevated lesion of teleangiectasia and one lesion with bleeding on the wall of the stomach. Hemostatic technique using clip was performed and bleeding was stopped. There were no noteworthy complications. No bleeding from other teleangiectasia has occurred after the treatment.
Pulmonary arteriovenous fistulae may involve brain complications such as abscess and embolism, then surgical resection should be performed. Moreover, patients with recurrent hemorrhage from teleangiectasia with anemia should be treated with non-operative manner.
We conclude that endoscopic hemostasis using clip is a safe and effective treatment for bleeding from teleangiectasia of Rendu-Osler-Weber disease.

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A 58-year-old female was admitted diagnosed with gastric adenoma. Endoscopic findings revealed an adenoma with protruding lesion, approximately 15mm in length on the posterior wall of the gastric antrum. A EMR performed without abdominal pain or evidence of bleeding. A resected specimen was revealed Group III. Liquid antacid, thrombin, and ranitidine were prescribed with the patient initially responding well. However, five days after the EMR the patient experienced epigastric discomfort followed by massive tarry stool. Blood pressure indicated pronounced hemorrhagic shock with systoric pressure measuring 70mmHg.
Emergency endoscopic hemostasis was performed using hemoclipping technique, however, aggrevated hemorrhaging resulted from the procedure. A partial gastrectomy was performed with subsequent histological findings revealing a bleeding ulcer (Ul II) .

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A 17-year-old male, complaining epigastralgia, admitted to our hospital due to gastric tumor. No abnormalities were found in the systemic examination. Upper GI series and endoscopic examination revealed a large-sized, smoothsurfaced, and round-shaped submucosal tumor on the posterior wall of the gastric fornix. Endoscopic ultrasonogram demonstrated a homogeneous and hyperechoic mass in the submucosa of the stomach. Abdominal CT showed a giant tumor to be a fat density, growing in the stomach and spreading below the left diaphragma. From these findings, we diagnosed this tumor as a gastric lipoma and the enucleation of tumor was performed. The lesion was 82×73×73 mm in size and histopathologically a lipoma.
The lipoma is rare and occupies 3-5% of all gastric submucosal tumor. It is commonly found in middle age. A case of gastric lipoma in 17-year-old is very rare and reported with a bibliographic discussion.

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Case 1 : A 61-year-old female was admitted to our hospital to evaluate a gastric polyp. Endoscopic examination showed a protruded lesion at the antrum. Endoscopic biopsy specimen showed benign findings. Endoscopic ultrasonography showed homogeneous hypoechoic mass in the second to the third layer of the gastric wall. This tumor was resected endoscopically, and diagnosed as an inflammatory fibroid polyp.
Case 2 : A 70-year-old male was admitted to our hospital to evaluate a gastric cancer and polyp. The cancer was located at the middle body of the stomach, and the polyp was located at the antrum. He had the cancer and polyp resected by surgery, and it was diagnosed as an early gastric cancer and IFP.
Most gastric IFP were located within the antrum (72%) , and most were smaller than 2cm in size (69%) . IFP was demonstrated as a hypoechoic tumor in the third layer of the gastric wall by EUS. Histologically, it was characteristic in the IFP that inflammatory cells containing eosinophils proliferated in the gastric deeper lamina propria mucosae and submucosa in IFP. Reports described eighteen cases of IFP that coexisted with gastric cancer. But there was no relationship between the IFP and the cancer.

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The cases were brothers of 65 and 62 years of age. In their family line, onset gastric cancer were many, therefore, they received X-ray examination of the stomach for a general health care in October 1993. Since in both cases, abnormal findings at the gastric vestibule were noted, endoscopic examination was performed.●改行● In the elder brother, a lesion of IIa was observed at the anterior wall near the greater curvature of the gastric vestibule, and in the younger brother, that of IIc was observed at the same position. Pathologically, both of them were well differentiated adenocarcinoma. Ultrasonic endoscopy showed retention of the 2nd layer and the depth of invasion was diagnosed as m in both cases. Endoscopic mucosal resection was indicated and so the operation was performed.●改行● It is our purpose of the present report that, in such a family that gastric cancer was observed in as many as 9 out of 27, a precise monitoring of condition of facilitate an earlier detection and treatment of cancer is necessary.

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A 76-year-old woman was admitted to our hospital complaints of epigastralgia. Upper gastrointestinal series and endoscopic examinations identified a giant nodular tumor with rough surface extending from anterior wall to greater curvature of the antrum. By using ultrasonography, it was revealed that the serosal side of the proper muscle layer was well preserved and unaffected by the tumor, although the mucosal side of the proper muscle layer was involved. The tumor was diagnosed to be advanced gastric cancer of type I. A subtotal gastrectomy was performed. Pathological findings revealed a well differentiated adenocarcinoma limited within the mucosal layer.

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A 56-year-old man presented himself at the out-patient department complaining of general fatigue. Laboratory data revealed iron deficiency anemia. Upper gastrointesinal examination showed giant pedunculated polypoid gastric cancer on the lesser curvature of the antrum. This tumor have been prolapsing into the duodenal bulb, therefore, we pulled the tumor out of duodenal bulb during endoscopy. However tumor has a stalk, the size of tumor was huge such as extended from lower body to prepylorus. We diagnosed type I early gastric cancer invaded to submucosal layer preoperatively.
Subtotal gastrectomy was performed. There was the pedunculated elevated lesion, 7×3.5×2.5 cm in size, at antrum of the resected stomach. Histological examination of the resected specimen showed papillotubular adenocarcinoma limited within the mucosal layer. Though the size of tumor was very large, depth of invasion is localized mucosal layer. We have reported a rare case of giant type I early gastric cancer (m invasion) prolapsing into the doudenal bulb.

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Changes of the endoscopic findings were studied in three cases of advanced gastric cancer which were resected successfully after neoadjuvant chemotherapy.
Endoscopic and histological effectiveness was found in only one case. In two cases, changes of the endoscopic findings were mild, but metastatic lesions regressed in the image diagnosis. Moreover, histological effectiveness was also recognized in the resected stomachs.
Even when changes in the endoscopic findings are mild, not only an overall judgement with endoscopic changes, but also the image diagnosis by an abdominal CT and etc should be considered for the assessment of the effectiveness of preoperative chemotherapy as well as for the reevaluation of the curative resection after chemotherapy.

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A 35-year-old male associated with IgA nephrophathy was admitted to our hospital with melena and hematoemesis. Urgent upper GI endoscopy revealed angiodysplasia at the descending part of the duodenum with massive spouting bleeding. Laboratory data on admission showed severe anemia. Endoscopic hemoclipping was performed immediately. Following endoscopy performed next day showed no mucosal abnormalities except clip.
No recurrence of bleeding has been observed and parmanent hemostasis was obtained.

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A 53-year-old male swallowed his artificial denture with rice cake. He admmited to our hospital for the purpose of removing foreign body. He was sick of liver cirrhosis with esophageal varices.
We tried endoscopical removal using the guide tube. The clasp of artificial denture stuck into the second portion of duodenal mucosa. We pulled out the clasp from duodenal mucosa using an alligator forceps to the pyloric antrum and grasped the sharp edge of clasp with basket forceps. We draw it into the slot of guide tube and draw out the artificial denture together with guide tube. Variceal bleeding was not seen. Endoscopical removal of gastrointestinal foreign bodies is useful technic with severe complication.

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A 73-year-old man who complained of bloody stool was pointed out to have two polyps of sigmoid colon and admitted to our hospital for further examination and treatment.
On admission, mild anemia (Hb 10.5ｇ/dl) and hypergam maglobulinemia (36.1%) were observed. Serum immunoglobulin G (IgG) value was high (3,872 mg/dl) . In immunological electrophoresis, monoclonal gammopathy of IgG_κ type was observed and Bence-Jones protein in urine was positive. The bone marrow was occupied by atypical plasma cells. After all he was diagnosed multiple myeloma of IgG_κ type.
He had two plypes at the sigmoid colon, one polype was polypectomized under colonoscopy and proved to be a cancer in adenoma ; the other polyp was a cancer invading in proper muscle layer and surgically resected. The upper GI series and endoscopic examination revealed a gastric cancer of Borrman 3 type, about 5 cm in size, in the lesser curvature of gastric cardia.
We reported a rare case of multiple myeloma complicated with both gastric and sigmoid colon cancers.

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We experienced two cases of colo-cutaneous and colovesical fistula, which are confirmed endoscopy.
Case 1 was a 72-year-old woman. She was admitted to the hospital for pus discharge from abdominal skin. Percutaneous fistulogram showed the caecum and ascending colon. By endoscopic examination, there was no remarkable findings exclusive of elevated lesion in caecum. We could find the injected dye flowing out from the elevated lesion. Fistulectomy was done with general anesthesia. The cause of the fistula was unknown.
Case 2 was a 56-year-old woman with radiotherapy after operation for the ovarian cancer. She was admitted with cloudy urin. Endoscopic findings showed a sigmoid-versical fistula and the urinary bladder lumen through the fistula. The fistula suspected to be due to radiation damage. She underwent the operation of transverse colostomy.
These endoscopic findings were useful for operations.

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