オリンパス社の試作した細径電子スコープXGIF-XP-230を，従来型のGIF-XQ-230と交互に用いて，その利点・欠点について検討したので報告する。利点は，患者の苦痛が従来サテライトクリニックにおいて用いられたsedationに換算して，少なくとも1単位以上は軽減されたこと，幽門通過時間が有意に改善されたこと，ファーター乳頭付近の観察可能性が高かったこと，胃角の後壁の正面視が十分に行えることなどである。一方，欠点は吸引時間が長い，処置具のほとんどが使用不可能であることなどである。パンエンドスコープの細径化は，CCDの進歩によって今後さらに進むものと思われるので，すべての処置具の細径化を試みるか，細径スコープは観察生検のみを目的とすることに割り切って，従来型のものは処置用として更に充実していく必要があるものと考えた。

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　今回われわれは，Hp除菌成功例の消化性潰瘍または瘢痕症例42例における除菌後の食道粘膜の変化について，維持療法群（除菌療法後H₂RA投与群）と非維持療法群に分け検討した。42例全例治療前の内視鏡検査にて，ロサンゼルス分類（改）でgrade 0であった。2カ月後の内視鏡検査にて，両群ともgrade 0からgrade Aに悪化した症例が3例，grade Bに悪化した症例が1例の計8例の食道炎を認めた。疾患別では，胃潰瘍，潰瘍瘢痕4例（23.5％），十二指腸潰瘍，潰瘍瘢痕2例（10％），胃・十二指腸潰瘍，潰瘍瘢痕2例（40％）であった。胃潰瘍または胃潰瘍併発している患者で高率なのは，Hpを除菌することで酸分泌能が改善するためである。従って，除菌前の食道粘膜の変化の十分な観察が必要である。少なくとも食道炎の既往または慢性食道炎があれば，H₂RAの維持療法が必要であると思われる。十二指腸潰瘍は，除菌前でgrade 0であるが，全例粘膜の白色肥厚を伴う慢性食道炎を呈していたことから，すでに食道炎が悪化する要因を持っていたと考えられる。このような症例に対しては，除菌前後の食道粘膜の変化を注意深く観察するとともに，H₂RAによる維持療法が必要であると思われる。以上より除菌に際しては，食道粘膜の詳細な観察により，除菌後に維持療法としてH₂RAの投与を行うかどうかの1つの目安となると考えられた。

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　H．pyloriの診断において，¹³C尿素呼気試験（UBT）が非侵襲的検査法として期待されている。今回われわれは，UBTと培養法の一致率および，UBT値と内視鏡的萎縮パターンとの関連について検討した。対象は消化性潰瘍および慢性胃炎患者66例である。内視鏡検査にて内視鏡的萎縮パターン（木村・竹本の分類 : C-3～O-3）に分類した。さらに前庭部大弯，体上部大弯より胃粘膜を採取し，変法スキロー培地に接種し微好気条件にて4-7日培養後，H．pyloriの有無を同定するとともに，生検材料を懸濁した液を10～1000倍に希釈して同様に培養し，H．pyloriの菌量の測定も行った。UBTの測定は尿素100mgを服用し，15分後に呼気を採取し，Δ¹³C（UBT値）を算出した。カットオフ値は5‰とした。UBTと培養法による比較より，感度は94.7％，特異度100％であった。UBTの有用性が確認された。内視鏡的萎縮パターンの拡がりが高度なほど，UBT値の有意な低下を認めた。培養陽性にもかかわらずUBT陰性であった3例は，いずれも萎縮パターンが高度に拡大したO-3であった。さらにUBT値とH．pyloriの菌量の間に有意な相関関係は認められなかった。UBTによりH．pyloriの存在診断をする場合には，内視鏡的萎縮の程度を考慮する必要があると思われた。

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　明らかな露出血管を認めた出血性胃潰瘍143症例を対象に，止血成績と再出血要因を検討した。露出血管が潰瘍辺縁に存在する場合には，クリップ法では100％，ヒータープローブ法（HPU）では93％の止血率であったが，クリップとHPUの併用例では100％の永久止血が得られた。潰瘍底の場合には，クリップ法およびHPUで91％，クリップとHPUの併用例では94％，クリップとHPUおよび純エタノール局注法の併用法では100％の止血が得られた。出血を活動性出血（Forrest Ⅰa，Ⅰb）と非活動性出血（Forrest Ⅱa）に分けて検討すると，活動性出血例ではクリップ法は79％，HPUでは78％であったのに対して，クリップとHPUの併用例では99％，クリップとHPUおよび純エタノール局注法の併用では100％の永久止血が得られた。非活動性出血例では，クリップ法とクリップとHPUの併用法で100％の永久止血であり，HPUでは93％の永久止血率であった。止血効果をまとめると，クリップ法では94％，HPUでは91％，クリップ法とHPUの併用治療例は95％の止血率であった。再出血症例をまとめると，潰瘍底の露出血管例では再出血率が高く，また活動性出血症例に再出血率が高かった。再出血の危険性がある露出血管の形態は，従来いわれている突出した赤色の露出血管以外にも，淡い発赤した平坦な露出血管からの出血も経験した。

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　左側大腸癌は，他の部位の悪性腫瘍と比較して狭窄を起こしやすい。通過障害によってイレウスをきたすだけでなく，術前の前処置に難渋し，汚染手術の危険性や二期的手術を選択せざるを得ない場合が多い。われわれは，1993年11月より通過障害を伴った全周狭窄型左側大腸癌に対しては，透視下および大腸内視鏡下にガイドワイヤを挿入後，メタリックステントを挿入し内瘻化する手技，stent endoprosthesis for colorectal cancer（SECC）を開発し，第一選択としている。これにより狭窄部を拡張し，腫瘍口側の減圧とともに，その後の良好な機械的前処置が可能となる。そのため安全な一期的手術を行うことができ，術後手術成績の向上が期待できる。現在までに26例にSECCを施行し，22例85％に挿入可能であった。挿入可能例の腫瘍占拠部位は直腸，S状結腸であった。ステント挿入から手術までの期間は最長16日間，平均6.1日であった。挿入可能例は，全例良好な術前処置ができた。本法の利点は，狭窄部に金属ステントを挿入することにより狭窄部を拡張し，口側腸管の減圧をはかり，十分な機械的洗浄ができること，また狭窄部が拡張されることにより，バリウムなどを用いた口側腸管の検索が可能となること，またイレウス発症時は待機手術が可能となり，術後手術成績の向上が期待できること，他の減圧処置に比較してtubeなどの留置の必要がないため，運動制限もなく，挿入中のquality of lifeが良好であることである。

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　造影剤を使用せず，非侵襲的に胆道，膵管の画像を得ることができるmagnetic resonance cholangio-pancreatgraphy（MRCP）は，近年臨床において汎用されはじめている。そこで今回われわれはERCPを対照として，MRCPの臨床的描出能，診断能および有用性について検討した。胆膵疾患を疑われ当院に入院した患者で，ERCPおよびMRCPを施行した121例を対象とした。それぞれの症例におけるMRCPの胆道および膵管の描出率を検討した。また，ERCPで得られた所見とMRCPの所見とを比較し，診断能も検討した。使用機種はSigna Horizon Hispeed 1.0Tを使用し，呼吸同期fast spin echo法で施行した。MRCPにおける胆道系の描出能はそれぞれ肝内胆管68.6％，総胆管85.1％，総胆管92.6％，胆囊管76.9％，胆囊92.4％であった。一方，膵管の描出能に関しては，頭部63.7％，体部59.5％，尾部51.2％，サントリーニ管6.6％であり，胆道系に比べ低率であった。また胆道系の診断能は胆石82.8％，胆管癌83.3％，総胆管結石71.4％，胆囊ポリープ66.7％，胆囊癌60.0％，乳頭部癌50.0％，胆囊腺筋症40％であった。膵疾患の診断能は膵囊胞83.3％，膵臓癌57.1％，慢性膵炎50.0％，膵胆管合流異常50.0％と，胆道疾患にくらべ低率であった。MRCPは現時点ではERCPと比較し小病変の診断などに限界はあるが，非侵襲的に胆管膵管の画像が得られる検査であり，胆膵疾患の診断法として今後の発展が期待される。

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　症例は61歳女性。糖尿病にて当院通院中であり，以前より口腔内のびらんを認めていた。平成8年9月から胸やけ，前胸部痛が持続し，平成9年1月吐血を認めたため当院入院。食道内視鏡検査にて，食道入口部から食道胃粘膜接合部にわたり，出血を伴う潰瘍性病変が連続性に認められた。また口腔内には潰瘍，びらん，水疱が多発していた。入院後，絶食，H₂受容体拮抗剤を投与したが食道病変は改善せず，その後体幹や四肢に水疱が出現し，肛囲には多発するびらんを認めた。皮膚生検組織を用いた螢光抗体法直接法で，表皮真皮境界部にIgGとC₃の沈着を認めて類天疱瘡と診断し，ステロイド大量療法を開始した。その後，口腔内病変，皮膚病変はともに改善し，ステロイド投与8週間後の内視鏡検査では，食道粘膜の出血性潰瘍は消失し，上皮化を認めた。類天疱瘡に伴う食道病変は非常にまれであり，文献的考察を加えて報告する。

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　われわれは半導体レーザーを用いた食道静脈瘤治療法を考案し，基礎検討を行ってきた。今回再発食道静脈瘤の1例に対し，臨床応用を試みた。症例は64歳，肝癌合併肝硬変の男性。硬化療法6カ月後にF₂RC（＋）の食道静脈瘤が認められた。再治療初回は静脈瘤結紮術を施行し，血管径の縮小を図った。2回目は残存静脈瘤の周囲の粘膜下にICG溶液を注入した後，半導体レーザー（Olympus，Diomed 25）を用いて，出力10Wにて食道胃接合部から5cm口側まで全周性に照射した。治療1カ月後の内視鏡検査では静脈瘤は消失しており，超音波内視鏡でも粘膜・粘膜下層に血管像は認められなかった。経過中，食道狭窄などの合併症は認められなかった。本法は少ない治療回数で安全かつ確実に治療できる方法であり，臨床応用可能と考えられた。

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　症例は56歳，女性。当院にて過去2回，食道早期癌に対してEMRを施行し，平成8年8月12日新たな食道内異時性多発癌に対して3回目のEMRを施行した。前回のEMR瘢痕部に接する肛門側断端に癌遺残が疑われ，11月18日EMR瘢痕部全域にNd-YAGレーザー照射を追加した。12月5日熱発と湿性咳嗽を自覚し，12月16日内視鏡検査にて膿の排出を伴う小穿孔部が認められ入院となった。胸部X線およびCTにて縦隔炎，右肺S6の膿瘍も認めた。禁飲食，抗生剤投与などの保存的治療を開始し，開胸ドレナージ術も考慮しつつ，内視鏡検査，造影検査，胸部X線，CTなどにて経過を観察した。症状は次第に軽快し，平成9年1月5日造影検査，1月6日内視鏡検査を施行し，穿孔部の閉鎖を確認し，経口摂取を開始した。EMR瘢痕部は組織修復機転が不良であり，追加レーザー照射は慎重を要し，穿孔例でも保存的治療が第一選択であると考えられた。

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　症例は57歳，男性。検診の胃X線検査にて胃隆起性病変を指摘された。内視鏡検査にて体上部小彎に直径約3cmの山田Ⅳ型ポリープを認めた。ポリープの頭部は胃底腺粘膜様で，茎部は萎縮調の粘膜であり，過形成性ポリープを疑った。またポリープの頭部に陥凹部分が認められ，癌化している可能性もあるため，内視鏡的ポリペクトミーを施行した。ポリープは径2.7×3.2×3.0cmで，表面は腺窩上皮で覆われており，粘膜下層には樹枝状に増生する平滑筋束と，囊胞状に拡張した大小不同の腺管構造が認められた。またポリープの所々に腺窩上皮が粘膜下層に反転増殖している像が認められ，本ポリープは極めてまれなhamartomatous inverted polypに一致するものであると診断した。本ポリープはほとんどが単発で存在し，過誤腫性ポリポーシスとは異なり，他の消化管には異常を認めないのが特徴である。

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　症例は54歳，男性。1996年9月より食後の腹部膨満感と嘔気，嘔吐が出現した。以後も同様の症状が断続し，3カ月間で12kgの体重減少を認めたため，同年12月に他院を受診し，腸閉塞の診断で入院となった。小腸造影で，Treitz靱帯より約20cm肛門側の上部空腸にapple core様の全周性の狭窄を伴う腫瘍を認め，当院を紹介され入院となった。小腸内視鏡所見では，管腔の全周を占め，著明な狭窄を伴う腫瘍を認め，生検診断は高～中分化型腺癌であった。1997年1月に空腸部分切除術を施行した。病理組織学的には，大きさが7.2×5.8×3.2cmで，中心に潰瘍形成を伴う2型様腫瘍であった。癌浸潤は漿膜まで及び，リンパ節転移も認められた。小腸癌は消化管悪性腫瘍の中でも頻度が低く，術前診断が困難な場合も少なくない。小腸内視鏡で術前診断された小腸癌の報告は比較的まれであり，文献的考察を加え報告する。

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　症例は59歳，男性。1991年2月に上腹部痛および発熱を認め当院を受診。大腸内視鏡検査で，回盲弁近傍の上行結腸に腸粘膜の限局した発赤と腫脹を認めた。注腸造影でも同部の壁の伸展性が不良で，周囲に憩室が多発していたことより憩室炎と診断した。抗生剤投与により臨床症状は消失した。治療効果判定のために大腸内視鏡を再検したところ，憩室炎の所見は改善していた。しかし，回盲弁近傍の盲腸に広基性腫瘍を認め，生検診断は中分化腺癌であった。同年5月に右半結腸切除術を施行した。病理組織学的には，盲腸の腫瘍は虫垂への直接浸潤を認め，深達度a₂の進行癌であった。初回の大腸内視鏡検査では盲腸への挿入が困難であったこと，注腸造影では上行結腸の憩室炎の存在に目を奪われたことが，癌の見逃しの主たる原因であると考えられた。初回の大腸内視鏡検査が不十分な場合は，経過観察による全大腸の観察が大腸癌の見逃し防止に必要である。

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　症例は78歳男性で，胃と左腎の同時重複癌および直腸に生じた異時重複癌の三重癌を認めた。胃癌についてはポリペクトミーを施行したが，切除断端陽性のためヒートプローブにて焼灼治療を行った。また腎・直腸癌に対しては，根治的手術を施行した。本症例は腎腺腫，腎血管筋脂肪腫，副腎皮質腺腫，耳下腺多形腺腫，甲状腺腺腫と多数の良性腫瘍を合併しており，また胃・左腎・直腸の組み合わせという点でまれな症例と考えられた。多発癌における経配偶子性遺伝子変異の関与も考慮し，リンパ球および腫瘍組織のp53遺伝子の変異を検索したが異常を認めず，家族歴と併せると遺伝的因子の関与は否定的であった。近年，重複癌は増加傾向にあり，原因として癌好発年齢層の広がり，癌発見率の向上，環境の変化，治療による誘発などが指摘されている。われわれは癌患者の診療に際し，常に多重癌の可能性を考慮する必要があると思われた。

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　症例は33歳，男性。1996年5月急性骨髄性白血病に対し末梢血幹細胞移植を施行し，移植後26日目に大量下血を認めた。緊急大腸内視鏡検査では，全大腸にわたりpunched outの出血性潰瘍が多発していたが，介在する粘膜はほぼ正常であった。生検で上皮の核および細胞質内に封入体構造物を認め，特殊染色にてもCytomegalovirus（CMV）が証明され，CMV腸炎と診断した。Ganciclovir投与によりCMV抗原血症検査は低下したが，真菌性髄膜炎で死亡した。CMV感染症は主にimmunocompromised hostにおいて発症し，予後不良とされるが，最近ではGanciclovirの早期投与の有効性が報告されている。剖検例を含めたCMV感染の報告では，標的臓器として大腸の頻度は高い。Immunocompromised hostが消化器症状を呈する場合，積極的な内視鏡検査は早期診断・治療のために有用と考えられた。

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　症例は73歳，男性。突然の大量下血（鮮血）により入院した。下部消化管内視鏡検査にてS状結腸に凝血塊を伴う潰瘍性病変を認め，拍動を伴っていた。病変部は凝血塊のため出血点を確認できず，内視鏡的に止血困難と判断され，IVR目的に腹部血管造影検査を施行した。左内腸骨動脈瘤を認め，そのS状結腸への穿破が強く疑われたため，左内腸骨動脈瘤空置術を施行した。術中，穿破部は肉眼では確認できなかったが，術後下血を認めなかった。その後，一時的人工肛門造設術を施行し，潰瘍は約3カ月で瘢痕化した。本邦での報告は少なく，本症例は内視鏡検査による病変部の経時的変化を観察しえた貴重な症例であり，また下血の鑑別診断の1つとして考慮することも大切であると考えられた。

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　腸管切除術を施行したにもかかわらず，リンパ節再発した大腸sm癌の3例を経験したので報告する。症例1 : 67歳，男性。直腸（Ra）Ⅱa＋Ⅱcに前方切除術（D₂）施行した。病理所見は中分化腺癌，sm₃，n₁（＋），ly₂であった。約5カ月後5cm大のリンパ節腫大を指摘され，Hartmann手術を施行したが，絶対非治癒であった。担癌生存中である。症例2 : 56歳，女性。下行結腸Ⅰsに結腸左半切除術（D₂）施行した。高分化腺癌，sm₃，n₁（＋），ly₂であった。約2年後10cm大のリンパ節腫大を指摘され，左腎，小腸および結腸合併リンパ節摘出術を施行したが，絶対非治癒であった。その約7カ月後永眠した。症例3 : 77歳，女性。直腸（Rs）Ⅰsに前方切除術（D₃）施行した。中分化腺癌，sm₃，n₂（＋），ly₃であった。約11カ月後局所，大動脈周囲リンパ節再発し，約30カ月後永眠した。

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　症例は54歳，男性。便潜血反応陽性を主訴に他院を受診し，大腸ポリープと診断され，本院に紹介となった。大腸内視鏡検査で直腸RSに1型進行癌（RC），上行結腸に大きさ9mmの有茎性ポリープ（PP）と大きさ3cmの結節集簇型病変（NA）を認めた。PPは内視鏡的硬さと，太い茎を有していた。ポリペクトミーを施行したが断端陽性であったため，ポリペクトミー後3週目に上行結腸・回盲部切除，高位前方切除術を行った。最終病理診断は，RCは深達度mpの高分化腺癌，ACは高度異型腺腫であった。PPは腺腫成分のない，深達度mpの中分化腺癌で，先進部は粘液癌の組織像を呈し，1群リンパ節転移が認められた。有茎性の形態を保った進行癌は極めてまれで，文献検索では1例の報告例があるのみであった。大腸癌の発育進展を考えるうえでも貴重な症例と考えられるため報告する。

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　症例は86歳の男性で，S状結腸進行癌に対する術前の大腸内視鏡検査で発見された約5mm大の横行結腸早期癌が，20カ月後に約半周性の2型の進行癌への発育進展を示した。初回内視鏡検査時の生検所見では明らかな間質内浸潤を認めなかったが，Ⅰs型SM癌の内視鏡像を示していた。切除標本では最大腫瘍径23mm，深達度mp，組織型は高分化腺癌で，脈管侵襲やリンパ節転移は認めなかった。注腸造影所見による遡及的検討では，早期癌から進行癌にいたる間のdoubling timeは3.2カ月と，従来の報告例よりもかなり急速な増大傾向を示した。大腸癌の遡及的検討例の多くは注腸造影による追跡であり，内視鏡的に微小癌から進行癌への発育進展過程を観察した報告はきわめて少ない。自験例は大腸癌の自然史，高齢者大腸癌に対する治療方針を検討する上で示唆に富んだ1例と考えられた。

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　体外衝撃波結石破砕療法（ESWL）に経鼻膵管ドレナージ（ENPD）を併用し，良好な治療効果が得られた嚢胞合併膵石症2例を経験した。症例1は54歳，男性。主訴は腹痛。膵頭体部にX線陰性結石を認めた。膵頭部に55mmの嚢胞を認めたためENPDを挿入し嚢胞のドレナージを図りつつ，造影下にフォーカシングしESWLを施行した。ESWL4,000発で結石は破砕され，嚢胞は著明縮小し，腹痛も消失した。症例2は65歳，男性。主訴は腹痛。膵管内にびまん性結石を認め，膵尾部に40mmの嚢胞を認めた。ESWL26,700発施行後，ERPで残石を認めたが，内視鏡的には採石不可であった。ENPDを留置し，造影下にフォーカシングしESWLを4,000発追加したところ，破砕片の流出を認め，症状，結石，嚢胞は消失した。ESWLにおけるENPDの併用は，嚢胞ドレナージ，破砕片のドレナージ，およびフォーカシングの点で有用であった。

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The effect of the detachable snare for patients with polyp of the colon was studied. At Institute of Gastroenterology, Tokyo Women's Medical College, endoscopic ligation of the device was performed on 15 patients with pedunculated (Ip) polyp of the colon from 1994 to 1996. The size of the polyps were from 14mm to 28mm at the maximum diameter (mean 22mm) .
Hemorrhage after removal was prevented in all, but burn of ligation of stalk were occurred in 6 out of 15 patients (40%) by using mono-polar snare. The detachable snare was concluded to be useful instrument for preventing hemorrhage after polypectomy of colon polyp.

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The new three-dimensional endoscopic ultrasonography (3D-EUS) with former processor was developed by Olympus Co in 1994 and the new imaging processor (EU-IP system) was recently reformed.
Method : We have tested the EU-IP system in evaluating gastroenterological diseases. This system is consisted of 3D-imaging processor, monitor, a driving unit, and ultrasonic probes (3R3D : 20MHz，2R3D : 12MHz) . It has two scanning method, that is, conventional radial scanning and mechanical-spiral scanning, in which forty radial images and one linear image can be obtained at the same time. And it has several functions ; high quality monitor, high resolution picture with pixel up, zoom, pseudo-color, multi freeze, measuring of tumor volume, and three-dimensional presentation with surface image of transected lesion.
Results : (1) The image quality of EU-IP is finer and clearer than that of former processor. (2) Using EU-IP, gastroenterological diseases have been evaluated more precisely. (3) The measuring function of tumor volume is consider to be useful for evaluating the efficacy of chemo therapy. (4) The most adequate picture can be selected after examination with multi freeze and zoom function. (5) Findings or lesion can be emphasized by pseudo color function. (6) The 3D-presentation with surface image similar to normal endoscopic view is easy to understand for endoscopist as well as endosonographist.
Conclusion : The new EU-IP system is novel imaging processor which has several convenient functions in evaluating gastoenterological diseases.

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We studied the clinical usefulness of newly developed ultrasonic scope for colorectal lesions (XCF-UMQ200) . This scope was designed to observe precise image of colorectal image for the definite diagnosis of colorectal cancer, submucosal tumor and extramural lesions.
This scope was assembled 2 different types of ultrasonic scanner (frequency : 7.5MHz and 20MHz) in the mechanical radial scanning. Sixteen patients with colorectal lesions were examined with this scope. All lesions could be approached and obtained images taking with each frequency.
Concerning to the shape of the lesion, protruded type was not well visualized in the deeper area using 20MHz high frequency scanner because of echo dumping. In such cases, visualized image was improved after changed the frequency to the 7.5MHz.
Compare to these images obtained by ultrasonic probe, images obtained by ultrasonic scope were almost fine. Newly developed ultrasonic imaging system (EU-IP) was also examined using this ultrasonic scope. This system was able to visualize the image more precisely due to improved resolution of the image. Ultrasonic image using this system was quite helpful to know the details of wall structure.
In conclusion, this newly developed ultrasonic scope equipped with 2 types of scanner was useful for high resolutional imaging of any colorectal lesions.

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Efficacy of one week triple therapy with amoxicillin (1,500mg/day) , clarithromycin (800mg/day) , and lansoprazole (60mg/day) or omeprazole (40mg/day) for 61 patients with Helicobacter pylori infection was investigated. Diagnosis of H pylori infection was based on the result of rapid urease test, and eradication of H pylori was assessed by culture and Giemsa staining of antral as well as corporeal biopsy specimens 6-8 weeks after the cessation of the eradication therapy. Three patients were dropped out from the therapy due to side effects, such as diarrhea or urticaria.
H pylori eradication was observed in 28/36 (78%) in patients with gastric ulcer, 16/17 (94%) with duodenal ulcer, and 5/5 (100%) with chronic gastritis. Overall eradication rate was 49/84 (84%) . Lansoprazole has been reported to be about 4 times stronger against H pylori than omeprazole in vitro, however in the present study eradication rate with lansoprazole and omeprazole were similar (82% vs 89%) . Recurrence of gastric ulcer was observed in a patient after success of eradication of H pylori, and the reasons of ulcer recurrence were smoker and night worker. A week triple therapy with amoxicillin, clarithromycin, and proton pump inhibitor was considered to be promising with good compliance.

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A relation between Helicobacter pylori (H. pylori) infection and chronic active gastritis were studied with distinction of biopsy position. Gastric ulcer (313cases) , duodenal ulcer (187cases) and control group (160cases) , which has no lesion except atrophic gastritis, were used in this study.
1) There were no difference in activity score in H. pylori positive gastric ulcer and control group among biopsy positions ((1), (2) and (3)) . On the other hand, activity score in cases of H. pylori positive duodenal ulcer was higher in specimen number (1) and (3) than number (2). This tendency was different from gastric ulcer and control group.
2) A frequency of pan-gastritis was high in H. pylori positive cases. It was the highest in H. pylori infected duodenal ulcer.
3) We could analyse the relation between H. pylori infection and chronic active gastritis using biopsy specimen.

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This study was designed to characterize the mechanisms available for bicarbonate transport across the apical membrane using duodenal brush border membrane vesicles (BBMVs) , including the morphological findings. BBMVs were purified using a double Mg²⁺ precipitation technique.
Electron microscopy of the final pellet showed 11.7±2.9 fold in Al-p and 12.6±1.8 fold in LAP. The time course of ³⁶Cl uptake into BBMVs demonstrated a good response curve and equilibrated to the intravesicular space over 120 min.
In this present study, these BBMVs were purified and showed a stabilized structure. Therefore, these results suggest that this model was useful for studying HCO₃^- secretion and ulcer etiology.

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Purpose of this study is to evaluate the visualization of endoscopic ultrasonography (EUS) in the ileocecal area using ultrasonic probe. Subjects are 36 lesions in the cecum (18 : aggregated nodular granular lesion (ANGL) , 10 : submucosal tumor, 8 : advanced cancer) and 4 lesions in the terminal ileum (advanced cancer, intestinal Behçet's disease, simple ulcer and benign lymphoid hyperplasia, respectively) . EUS was performed using ultrasonic probe for 3 year and 8 months, from June 1993 to February 1997.
For ANGLs located in the bottom of cecum (3 of 6 lesions) and in the inner side of cecum connected to the ileocecal valve (1 lesion) , their layer structure could not be visualized clearly. On the other hand, for ANGLs located in the opposite side of the ileocecal valve (8 of 10 lesions) and in the superior side of the ileocecal valve (1 lesion) , their clear layer structure could be visualized easily. Submucosal tumors and advanced cancer in the cecum could be diagnosed and visualized the depth of invasion and para colonic lymphnode swelling clearly. For the lesions in the terminal ileum, EUS were also useful for diagnosis.
In conclusion, EUS using ultrasonic probe was useful for diagnosis in the ileocecal area, but the lesions located in the particular part of cecum could not be visualized clearly.

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Seven patients with acute hemorrhagic ulcer of the rectum (AHUR) , who were denied the cerebrovascular disease, were examined during last 9 years in our hospital.
The purpose of this study is to evaluate them conserning background and endscopic findings. They consisted 3 men and 4 women with average age of 70.2 (55-85) . All of them complained sudden hematochezia. They were divided into two groups according to the decrease of hemoglobin (Hb) on laboratory data after each episode ; Group A : ≧3mg/dl, Group B : ＜3mg/dl. In group A, endoscopic findings showed circular and deep ulcer in the distal 1/3, although 2 were multiple and remaining 2 were solitary. Three of them needed endoscopic hemostasis. On the other hand, geographical and shallow ulcers were revealed in group B. None of them needed endoscopic treetment.
In conclusion, the depth of ulcer should be an important factor to have severe hemorrhage and endoscopic treatment is essential.

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In 1987, we reported on a patient who developed corrosive upper alimentary tract inflammation that ensued NaOH ingestion for suicidal purpose, and who recovered following palliative treatment. Ten years later, this woman repeated the same.
On Jan 16, 1997, a 56-year-old woman employed at a cleaning shop, swallowed while working one glass-full of aqueous solution of NaOH used for cleasing in the shop. Her husband realized the incident and consulted with the Psychiatric Department of this hospital four hours later. She was restless, and her lips were swollen.
Emergency endoscopy disclosed corrosion of the oral cavity and esophagus ; the stomach showed a mild corrostion and a scar allegedly of the past corrosion. The upper GI tract was washed with mild followed by administration of antibiotics and an H₂-blocker, and transvenous alimentation while fasting. Starting on the 5th day, 2 mg of dexamethasone was given. She could phonate the next day, and eventually recovered with a conservative therapy ; she was discharged from the hospital one and a half months later. Our report includes review of the literature.

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We report a case of esophageal and gastric damage by food ingestion. A 61-year-old male ate 6 hot-grilled sardines in a hurry. Durling eating, he had laryngeal and post-sternum pain and hematoemesis for 3 times after eating.
An emargency endoscopic examination performed 22 hours after hematoemesis revealed esophagitis from upper to lower part of the esophagus. There was also a A₁ stage ulcer covered with hematoma at gastric fornix. Four days later, esophagitis changed to submucosal hematoma and gastric ulcer was enlarged. We had already started proton-pump-inhibitor and mucosal protecting drugs, and started central venous alimentation from this time.
Eleven days later, esophageal mucosa peeled and linear ulcer appeared. Gastric ulcer was reduced and became H₁ stage. There was no other report that not only esophageal damage but also gastric damage by food. At first, there was no connection between esophageal and gastric damage. We supposed the gastric ulcer was caused by esophageal sliding hernia, gastric mucosa got into esophagogastric junction. 51 cases of esophageal damage caused by food have been reported and we compare our case with others.

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Originally, the intubating a flexible tube method for esophageal cancer had been developed to provide for improvement of QOL of the patients with severe stenosis or esophagobronchial fistula and had been reported to be also useful to close the leakage at the anastomotic site following esophagectomy for an esophageal cancer.
In this report, we describe a successful treatment of accidental perforation of gastric tube following esophagectomy for an esophageal cancer by intubatig a flexible tube.
The case is a 64-year-old male. Accidental perforation of gastric tube arised owing to intubating endotracheal tube into esophagus following esophagectomy for an esophageal cancer at other hospital. The thracic drainage and tracheostomy were performed and hyper-alimentation was carried out. However, those treatment were ineffective to perforated site. We used flexible tube to prevent saliva and gastric juice. After intubation of the tube, perforation site was closed and general condition was getting better.
We experienced a flexible tube intubation was useful to close the perforation of gastric tube in esophagectomy.

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A case of 56-year-old male who suffered from stomach role-pulmonary fistula after esophageal reconstruction was treated by combined endoscopic procedures.
These procedures consisted of endoscopic fibrin glue application, sodium alginate application, endoscopic insertion of double lumen tube for intestinal nutrition and gastric drainage, endoscopic removal of useless staples, and also endoscopic application of N-butyl-2-cyanoacrylate (Histoacryl) .
The stomach role-pulmonary fistula had been completely closed 4 month later since the beginning of endoscopic treatment. These combined endoscopic procedures were considered safe and reliable for the treatment of stomach role-pulmonary fistula.

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A 51-year-old female was pointed out to have a submucosal tumor in the gastric fornix. Endoscopic ultrasonography showed slightly heterogeneous mass in the proper muscle layer, 2.6cm in size.
Follow up study after four months showed that the tumor size enlarged and that the internal echo pattern changed into more heterogeneous one with low echoic area. Partial gastrectomy was performed and the lesion was diagnosed as gastric stromal tumor with low grade malignancy by histopathological and immunohistochemical examination.
Repetitive examination with endosonography is suggested to be useful for the diagnosis of gastric submucosal tumor.

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We experienced 3 patients of liver cirrhosis presenting with bleeding from gastric vascular ectasia. All patients were admitted because of melena or hematemesis. They had had anemia of unknown etiology and been suspected of gastrointestinal bleeding for one to two years.
Endoscopic examination revealed bleeding from gastric vascular ectasia (diffuse, multiple or single) in all patients, which were successfully controlled by heater probe or injection of 100% ethanol. Gastric vascular ectasia should be considered as a cause of gastrointestinal bleeding complicating liver cirrhosis. Heater probe is preferable as a therapy for diffuse type, because of non-invasive procedure.

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A 59-year-old woman underwent a medical check-up. Liver cirrhosis and esophageal varices were diagnosed, and the patient was admitted to our hospital on May 10, 1996. Endoscopic examination showed the presence of esophageal varices (EV) and gastric varices (GV) with red-color signs.
Magnetic resonance (MR) angiography and arterioportography revealed that the EV and GV received blood from the left gastric vein and short gastric vein, respectively. The blood drainage route was not demonstrated by these examinations. EV were eradicated by both EVL and endoscopic injection therapy (EIS) . We performed percutaneous transhepatic portography (PTP) to obtain further information on the GV. PTP showed that the pericardial vein, not the gastrorenal shunt, was the blood drainage route of the GV.
We concluded that EIS is a better technique than transvenous obliteration for the eradication of GV in this case. Cyanoacrylate was injected into the blood drainage route of GV located at the epicardia. Ethanolamine oleate (EO) was administered into the blood supply route of GV. EIS was performed three times, and the eradication of GV was confirmed by MR angiography after 3 months. This case demonstrated that detailed information on GV obtained by PTP permits EIS to be performed safely.

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We presented two cases with ruptured gastric varices (Lg) treated by combination therapy of endoscopic injection sclerotherapy (EIS) and endoscopic variceal ligation (EVL) .●改行● Case 1 : A 50-year-old male admitted to our hospital due to massive hematemesis with shock. Esophageal varices (EV) and Lg with white plug were observed by endoscopy. Rebleeding occurred during EIS from ruptured Lg and was controlled by EVL.●改行● Case 2 : A 19-year-old female suffering with primary sclerosing cholangitis (PSC) and ulcerative colitis admitted to our hospital due to massive hematemesis. Esophago-gastric varices with spurting bleeding from Lg were diagnosed by emergent upper GI endoscopy. Because of decompensated hepatic function, we prefered EVL therapy to EIS. After EVL, hemorrhage occurred again. Clipping treatment was not effective. After all, hemostasis was carried out by endoscopic varicealography during injection sclerotherapy (EVIS) . In these two cases the combination therapy of EIS and EVL was usefull for ruptured gastric verices.

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A 19-year-old woman admitted to our hospital complaining of epigastralgia. She had a habit of eating her own hair. Endoscopy and upper GI X-ray examination showed a giant trichobezoar in the stomach.
Endoscopic therapy was selected because of accompanying with idiopathic thrombocytopenic purpula. Enzyme and sodium bicarbonate were administered to her, then trichobezoar was cut endoscopically. Remaining part of the trichobezoar moved and impacted to the small intestine. Acute pancreatitis occured and treatment for acute pancreatitis was performed. Finally, trichobezoar was removed.
There were only two reported cases of trichobezoar removed by endoscopic therapy. We reported a rare case with giant trichobezoar removed by endoscopic therapy.

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A 6-year-old boy was admitted to our hospital due to edema in the eye lid and both extrimities after a common cold. Laboratory data revealed low serum protein and albumin, 3.1g/dl and 1.9g/dl respectively, despite of the proteinuria.
Ultrasound sonography revealed the gastric wall thckening. The Tc-99m-HSA-D scintigraphy brought the protein execrined to the stomach. Endoscopic examination showed a lot of erosions surrounded by the edematous mucosa in the whole stomach, while the normal appearance in both the esophagus and the duodenum. Biopsy specimen showed hyperplastic change with rich mucus in the gastric epithelial cells. The edema was disappeared by the albumin administration intravenously.
Endoscopic examination was performed to make sure the lesions had been improved dramatically. The serum CMV-IgM was found to be raised temporary. This case was diagnosed as the Ménétrier disease due to the Cytomegalovirus based on the protein-losing gastroenteropathy and the change of CMV-IgM antibody in the course.

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A 37-year-old man visited our hospital with symptoms of vomitting, anorexia and weight loss which had seen in occurrence since early September 1996, and he received a thorough examination. His past history showed that he had never recieved a blood transfusion. General findings on admission included nodular lesions seen on the skin and inside the mouth, and geniutal condyloma, with no evidence of anemia or jaundice. A hematological examination showed slightly decreased while blood cell counts, hypoproteinemia, and elevated ALP and CPK levels. He was positive for HIV antibody, with CD4 cells 10/µl.
Upper digestive tract endoscopy revealed multiple, sharply protuberant lesions with a depression, occasionally assosiated with ulceration, at the top. A biopy specimen from the lesions revealed Kaposi's sarcoma by pathological evaluation. Kaposi's sarcoma develops in submucosal regions, which sometimes makes its detection by means of endoscope-guided biopsy difficult. As patients with HIV infection are increasing in number, Kaposi's sarcoma is one of the diseases we should be directing our attention to.

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This patient was a 32-year-old male. He has infected by HIV because of hemophylia since 1985. In 1996, he visited us because of much melena and anemia.
We performed an emergent endoscopic examination. On this examination, small ulcers were observed in the colon, and a blood vessel with bleeding was observed in the cecum. The bleeding on the cecum had stopped after we held the blood vessel with clips endoscopically. After that the melena disappeared and the anemia improved.
Although we couldn't regard this case as the infection of opportunity because of the number of CD4, we suspected CMV colitis because of strong damage of a blood vessel. But no specific findings were detected in the biopsied specimen and selological test.
MRSA was possitive in the faecal culture test. But no typical symptoms were revealed in this patient. Endoscopically we couldn't deny MRSA colitis.
We experienced a case of colitis with much melena associeted with HIV infection, and we could stop the bleeding endoscopically. So we reported it with some literatures.

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A case of 42-year-old male diagnosed as submucosal tumor with pronounced calcification was encountered. An abnormal shadow was pointed out on the posterior wall of the lower body in the gastric mass screening. Diagnosed as submucosal tumor in terms of upper GI, endscopy, followed by EUS which revealed acoustic shadow suggestive of calcification.
Diagnosed as gastric leiomyoma preoperatively, partial gastrectomy was carried out along with the strong desire of resection from the patient. The tumor clearly deliniated was elastic hard, of which surface was accompained by mucosal congestion and atrophic change, diagnosed as submucosal tumor, 20×15×9mm in size.
Histopathologically, the bulk of the tumor became fibrous and organized accompained by chronic inflammation such as lymph follicle formation. Furthermore, a great number of calcifications were present all over with no evidence of tumor cell components. Because of the evident degeneration, the origin of the tumor was not be concluded. The tumor, however, was deduced to have orginated from leiomyoma.

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A 40-year-old female was admitted for the further evaluation of elevated lesions of the stomach. Endoscopy revealed multiple small elevated lesions of the gastric body.
The biopsy specimen showed carcinoid tumors and endocrine cell micronests (ECM) . Hypergastrinemia was noticed, whereas urine 5-HIAA, serum serotonin and histamine levels were within normal limits.
Total gastrectomy was performed. Histological examination revealed 12 carcinoid tumors and multiple ECM in atrophic fundic gland mucosa consistent with type A gastritis.

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A 55-year-old male was pointed out to have a reddish erosive lesion at the prepylorus and it was diagnosed as signet ring cell carcioma by a biopsyed specimen. So he was reffered to our hospital. We diagnosed that the lesion was within 5mm. EMR was performed. Three weeks later, an ulcer scar was observed at the same region. But four months later a Yamada-III type polypoid lesion was observed there. It was identified as a hyperplastic polyp by histological examination of polypectomied specimen.
The indication of EMR for poorly differentiated carcioma is still contraversial. In our hospital EMR is performed when the lesion diagnosed less than 5mm and located at the antrum in our hospital. A polyp which arise at the scar of EMR cannot be diagnosed correctly with endoscopy, so follow-up with endoscopic biopsy is very important.

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A 59-year-old female had multiple gastric polyps pointed out in the stomach by routine medical check-up. Detailed endoscopic examination and biopsy showed 7 gastric hyperplastic polyps, two of which included carcinomatous foci.
One of the two polyps with cancer (Yamada type IV, ca. 45 mm in length) was diagnosed as hyperplastic polyp on endoscopy, but histological examination revealed a focal poorly differentiated adenocarcinoma in the uppermost part. The other polyp (Yamada type IV, ca. 30 mm in length) had a depressive change on the side and a white coating all over the polyp. The histological examination showed that the hyperplastic foveolar epithelium was almost replaced by poorly differentiated adenocarcinoma with small portions of signetring cell carcinoma and well differentiated adenocarcinoma.
Gastric hyperplastic polyps are known to occasionally undergo malignant trans-formation, mostly into well differentiated adenocarcinoma. It is to be noted that the present patient had double gastric cancers, chiefly poorly differentiated adenocarcinoma, originating from hyperplastic polyps.

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A 46-year-old man who had a gastric polypoid lesion pointed out by gastric mass survey in October 1996, visited a local docter and received upper GI endoscopy. Biopsy specimens from the lesion showed a posssibility of malignancy, so that he was admitted to our department in December 1996.
Endscopic examination founded the semipedunculated lesion with a diameter 5mm in the greater curvature of the upper body, and the lesion was surrounded by the fundic gland mucosa without endoscopic atrophy and intestinal metaplasia. Endoscopic polypectomy was performed. Histological findings of the resected specimen demonstrated very well differentiated tubular adenocarcinoma, and the background fundic gland mucosa had no pathological atrophy and intestinal metaplasia.
Differentiated gastric cancers in fundic gland region without intestinal metaplasia were so rare that their characteristic had not been known very well. We think it may be important to describe the atrophic grade and atrophic border of the stomach, and to use methylene blue when a differentiated gastric cancer is discovered in fundic gland region without atrophy.

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The case was a 72-year-old woman who was admitted because of hematoemesis and melena. The emergent panendoscopic examination revealed a large duodenal ulcer on the anterior and lesser curvature side of the bulbus. A pair of vessels (an artery and a vein) , which size about 3mm in diameter, were exposed on the ulcer base.
Clipping therapy was unsuccessful because of massive bleeding from the exposed artery during the examination. The bleeding was temporally controled by hypertonic saline and epinephrine injection and thrombin spray, but re-bleeding occured about 16 hours later. The emergent angiography disclosed the leakage of radiocontrast agent from a branch of the gastroduodenal artery to the bulbus. TAE for proximal and distal side of the gastroduodenal artery was performed immediately. No bleeding developed after TAE, and the status of ulcer became S₁ stage 3 months later.
Endoscopic therapy is often difficult when the exposed vesel is larger than 2mm in diameter. In this case, successful therapy for arterial bleeding from duodenal ulcer was achieaved without operation. It seemed be important to make a judge about proper indication of endoscopic hemostasis.

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A 80-year-old man was admitted to our hospital because of epigastralgia and tarry stool. Endoscopic findings showed circular ulceration in the anal side of the duodenal bulb and postbulbar region with coagulation accompanied by the multiple ulcers in the descending part of the duodenum. He did not take any medicine such as nonsteroidal anti-inflammatory drug and did not suffer from any stress. He was treated with an H₂-recepter antagonist. Three weeks after admission, ulcers were almost healed. Six weeks later, endoscopic findings showed ulcer scars and mild stricture in the postbulbar region. We observed him during a year and ulcers were not recurred.
Acute multiple duodenal ulcer is sometimes reported, but the circular ulceration is rare. The cause is usually presumable but our case is not. We assume this ulcer is due to ischemia of the duodenal mucosa, because the patient is arteriosclerotic and the circular ulceration is similar to ischemic colitis. But no stricture and occlusion was able to found in the superior and inferior pancreaticoduodenal arteries with our angiographic study. We conclude that we must evaluate microcirculation of mucosa of the alimentary tract when we examine a similar ulceration to our case.

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A 36-year-old male visited Tsuchiura Kyodo General Hospital because of epigastric discomfort. Endoscopic findings revealed a flat elevation with granular appearance in the duodenal bulb just anal to the pyloric ring. After spraying Congo Red, the color turned to black promptly, suggesting avid secretion of acid by the elevated mucosa. Pathological examination showed fully developed fundic mucosa. A diagnosis of ectopic fundic mucosa in the duodenal bulb with acid secretion was made.
Helicobacter pylori was not detected by rapid urease test, culture, or microscopic examination. The IgG anti-Helicobacter pylori antibody was also negative. Additionally, almost whole gastric mucosa was fundic gland type, and had the ability to secrete acid. There have been no report of a case of ectopic acid-secreting gastric mucosa in the duodenal bulb without Helicobacter pylori infection. The lack of pyloric gland in this patient may have inhibited the infection.

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A 79-year-old female was admitted for recurrent melena. She received hemodialysis due to DM nephropathy. Gastroscopy and colonoscopy revealed no abnormal findings. Tc 99 m-labeled red blood cells scintigraphy revealed hot spot around the terminal ileum, but superior mesentric angiography showed negative findings. As melena persisted, an emergency laparotomy with intra-operative endoscopy was performed. Bleeding vascular ectasia was detected in the 80cm oral side of the ileocecal valve and was resected. The lesion was diagnosed histopathologically vascular ectasia.
There were 18 cases of intestinal bleeding in hemodialysis patients. And 10 cases were reported small intestinal bleedings diagnosed by intra-operative endoscopy. So we reported this case and discussed it and some in the literture there 10 years.

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A 57-year-old man, with bladder cancer had undergone cystectomy with construction of a ileal conduit ten years previously. Following blood transfusion, he developed serum hepatitis (type C) . Since two years the patient began having episodes of massive bleeding from the stoma frequently. MR and mesenteric angiogram showed winding of the vessels around ileal conduit, these findings suggested stomal varices.
Endoscopic ultrasonography (EUS : 7.5MHz linear) revealed winding hypoechoic area at the level of mucosal-submucasal layer. Sclerosing therapy (1% Aethoxysklerol) and ligation of some superficial bleeding veins were conducted several times, bleeding ceased for one or two weeks, however strong bleeding continued to occur. The patient was admitted on emergency because of massive bleeding.
The varices was confirmed by EUS. EUS guided puncture of the varices using a 21G PEIT needle and injection sclerotherapy was applied with 50% cyanoacryl (add lipiodol) . After the treatment the patient has no bleeding episode for six months.
Stomal variceal bleeding from ileal conduit in a patients with portal hypertension is not frequent, but difficult to manage. Diagnostic EUS is available procedure for stomal varices, EUS guided sclerosing therapy with cyanoacrylate injection is usefull method of preventing recurrent bleeding.

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