待機，予防例の食道静脈瘤治療に内視鏡的硬化療法（5％ethanolamine oleate ; EOの血管内注入）と内視鏡的静脈瘤結紮術（EVL）を初回に同時併用したvariceal sclero-ligation（VSL）法34例と，EVLを施行し，後日1％Aethoxysklerol（AS）による硬化療法を追加治療する異時性併用法24例を，当院で従来施行してきたEO・ASを併用する食道静脈瘤硬化療法（two-step EIS法）72例と比較検討した。食道静脈瘤荒廃効果はそれぞれ97.1％，91.7％，84.7％で，VSL法が最も荒廃効果が高く，two-step EIS法との間に統計学的有意差を認めた（p＜0.01）。静脈瘤消失例では累積出血率には差がみられなかった。また，治療に要した回数は差がなかったが，硬化剤（5％EO）の総量はVSL法がtwo-step EIS法に比べ有意に少なかった（p＜0.01）。併存した胃静脈瘤の荒廃効果は64.7％，0％，81.1％で，異時性EVL・EIS併用法では胃静脈瘤への効果はみられなかった。また，合併症の頻度は50.0％，33.3％，75.0％で，two-step EIS法が最も高かった。食道静脈瘤治療に静脈瘤の荒廃効果が高く，合併症の少ないVSL法は今後有用な静脈瘤治療手技となりうる可能性が示唆された。

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　食道表在癌発見のためのヨード染色法の有用性と至適撒布間隔の検討を行った。1980年から1996年までに発見された食道表在癌の中で，初回検査でヨード不染なしと診断されたが，その後の検査でヨード不染が判明し癌と診断された群（A群），初回検査でヨード撒布が行われず，その後の検査でヨード不染が判明し癌と診断された群（B群）の2群（A群6名，B群6名）を抽出し，深達度ならびに検診間隔を比較した。A群の6例をみると，深達度はm₁5例，m₃1例で，A群の平均検診間隔は29カ月（18-36カ月）であった。同様にB群の6例をみると，深達度はm₂1例，m₃以深5例，平均検診間隔は38カ月（14-60カ月）であった。以上より，A群とB群の深達度を比較することにより，ヨード染色法はm₂までの癌の発見に有用であるものと考えられた。また，ヨード染色法により不染がなければ，ヨード撒布を行う検診間隔は，A群のデータから2年程度が適当と思われた。ヨード撒布の検診間隔に関しては，prospectiveに今後検討を加えていく必要性があるものと思われた。

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　症例は55歳，女性。49歳時大動脈炎および異型大動脈縮窄症にて人工血管置換術を受けた。平成9年2月19日昼，突然吐血し来院，再度吐血しショック状態にて入院。上部消化管内視鏡を施行したが，凝血塊が多量で出血点不明であった。第6病日内視鏡にて，噴門部後壁に直径2mm大の陥凹底から白色の粘液流出を認め，穿通潰瘍が疑われたが，胃内に出血，凝血塊なく，腹部単純X線写真にてfree airも認めなかった。第11病日再度ショック状態となり，緊急内視鏡を施行したが出血多量にて出血点は不明で，内視鏡的には止血不可能と判断し，緊急手術を行った。胃噴門部後壁の陥凹底からの出血を認めたが，出血多量にて死亡した。剖検所見では，人工血管分岐部（double velour graft）の大動脈と胃噴門部に穿通孔を認め，出血源と考えられた。内視鏡で診断困難なまれな症例と考え報告する。

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　症例は54歳男性。黒色便を主訴に当科を受診。貧血（Hb6.2g/dl），低蛋白血症（5.7g/dl）を認め，精査治療目的で入院となった。緊急上部消化管内視鏡検査にて，胃体下部大弯に山田Ⅲ型の粘膜下腫瘍を認めた。大きさは約25mmで，凝血塊が付着した潰瘍を伴っていた。また，胃体部には柔らかい皺襞の肥厚と多量の粘液付着がみられた。生検にて腫瘍はカルチノイドと診断されたが，巨大皺襞に悪性所見はみられなかった。胃カルチノイドを合併したメネトリエ病の診断にて，胃全摘術を施行した。切除標本の病理学的検索では，腫瘍は異型の乏しい核を有する細胞が小結節状の配列を示すカルチノイドで，大きさは22×22mm，深達度はsmであった。また，胃底腺領域の粘膜は著明に肥厚し，腺窩上皮の囊状拡張を伴う過形成や固有胃腺の萎縮の所見が認められた。

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　症例は74歳男性。平成8年12月より食欲低下，立ちくらみが出現。半年で15kgの体重減少も認め，平成9年7月当院に来院。血液検査でHgb5.7mg/dlのため入院となった。上部消化管検査では異常なく，注腸検査で上行結腸に全周性の狭窄病変と横行結腸に径2.5cmの腫瘤を認めた。大腸鏡では横行結腸に不整形の腫瘍，上行結腸肝弯曲部にBorrmann3型腫瘍を認め，生検で両病変とも腺癌と診断された。CT，エコー上，肝など他の臓器に転移巣はなく，7月15日外科的手術を施行した。術中，十二指腸Treitz靱帯部にも5cm大の腫瘤が確認され，右半結腸切除，十二指腸切除を施行，病理学的に腫瘍はAFP陽性のhepatoid adenocarcinomaと診断された。本症の上下部消化管での多発症例は極めてまれであり報告する。

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　症例は41歳，男性。1996年11月下旬頃より下痢，次第に鮮血便が出現。12月中旬より症状が増悪したため12月24日当院初診し，貧血強く同日入院となった。翌日の便培養にて病原性大腸菌（O1）が検出された。大腸内視鏡検査で，下部大腸には散在性に小さなびらんを認め，生検組織像では感染性腸炎の所見であった。深部大腸に挿入すると肝弯曲部に立ち上がり急峻な隆起を，口側は管腔の狭小化と白苔を伴った易出血性の粘膜を認め，生検組織は印環細胞癌であった。注腸検査では肝弯曲部より上行結腸にかけて，広範な鉛管状狭窄と肛門側に腫瘤陰影を認めた。骨盤CTでは上行結腸に一致して辺縁不整な腫瘤像があり，周辺への浸潤を疑わせる所見であった。以上より原発性びまん浸潤型大腸癌と診断し，2月3日拡大右半結腸切除術，胃空腸吻合術が施行された。今回感染性腸炎を契機にびまん浸潤型大腸癌を診断しえたので報告する。

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We performed endoscopic study with a thin gastrointestinal fiberscope, GIF-N230 in 19 patients. In 4 of them, GIF-XQ230 or GIF-Q200 couldn't pass through the esophagus or EC junction because of the stenosis or trismus. In these 4 patients, endoscopic study with GIF-N230 was successful. However, the images were less clear, the photographs were too small, and the cardia of the stomach was hard to see closely.
We concluded that GIF-N230 is useful particularly in patients who have the lumen too narrow for conventional endoscopes to pass irrespective of the above mentioned disadvantages.

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The detachable snare effectively allows preventive hemostasis prior to the endoscopic removal of large colonic polyps. The detachable snare, however can not be easily applied to a subpedunculated polyp because the polyp of this type does not have any stalk.
Therefore, we have devised a new technical procedure in which the subpedunculated polyp is easily manipulated by the combined use of a polypectomy snare and a detachable snare with 2-channel colonoscope, so that we can easily change the shape of a subpedunculated polyp to the pedunculated polyp.

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Laparoscopic ultrasound system (LUS) is a useful equipment to prevent the unexpected injury during laparoscopic surgery. We developed a new type LUS (EUP-OL334) with a cooperation of Hitachi Medico Co Ltd.
Probe of our LUS is 10mm in diameter, 424mm in length and a tip of the probe is flexible up to 90 degree. This system equipped a color Doppler with color flow angiography and has dual frequency (5/7.5MHz) . Scanning window is as wide as 40 degree.
Two cases of cholecystolithiasis and two cases of hepatic tumor were examined by EUP-OL334. Gallbladder wall was delineated as 3 layers and cystic duct and common hepatic duct were also visualized. Hepatic tumor was shown as hyperechoic lesion and the blood flow was easily detected by color Doppler and color flow angiography. Pulse Doppler demonstrated two type blood flow such as pulsatile and continuous wave. Laparoscopic microwave coagulation therapy (LMCT) was underwent for these patients and laparoscopic ethanol injection therapy (LEIT) was added in one patient. LMCT was performed under LUS observation and coagulated part of the tumor was changed to bright hyperechoic lesion because of the microbubble occurrence. There were no unexpected injury during this series.
Further improvement, i. e. working channel for biopsy and injection, is required however, we consider that EUP-OL334 guarantee the safer and more accurate treatment during laparoscopic surgery.

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We investigated the records of emergency gastrointestinal endoscopy for gastric bleeding in Keio University Hospital in order to reveal the background, the hemostatic procedure and the effects of each method.
Out of 109 cases of emergency endoscopy from January to December 1996, 62 cases were investigated.
The most common disease which caused gastric bleeding was gastric ulcer : 30 patients (47%) , and the second was AGML : 25 patients (39%) . They were followed by gastric cancer : 4 patients (6%) . As for the hemostatic procedure, clipping : 27 patients (52%) , drug splaying method : 10 patients (20%) and ethanol injection method : 10 patients (20%) were performed. More than 2 different procedures were performed in 18 patients (30%) . Two patients (4%) were treated by interventional radiology (IVR) and no surgical operation for hemostasis was performed.
Among many diseases which cause gastric bleeding, gastric ulcer was the most common. The hemostatic procedure should be selected based on the bleeding situations and it could result in better outcome using multiple methods.

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Chronic active gastritis in Hp positive cases : peptic ulcer and control group, which has no lesion except atrophic gastritis, was studied.
We used 3 specimen taken with endoscope from greater curvature of the lower antrum ((1)) , greater curvature of the upper body ((2)) and lesser curvature of the lower body ((3)) . Activity score of gastric ulcer was stronger in specimen number (2) than in (1) and (3). It was same in control group. Average of histological activity score decreased with aging in both groups. When we observe activity score with distinction of biopsy position, the score decreased in number (1) and (3) as the age grew older. In specimen number (2), activity score was almost same in every age group. On the other hand, activity score of duodenal ulcer was strong in number (1) and (3). It was different from gastric ulcer and control group. Activity score of duodenal ulcer in number (2) was weaker than gastric ulcer and control group in every age group.

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The degree of activity, atrophy, intestinal metaplasia and Helicobacter pylori (Hp) were observed based on the Sydney System in gastric biopsy specimen and their relationship were also estimated.
(1) Observation of histological activity and Hp infection : In biopsy specimen at the greater curvature of lower antrum, Hp infection grade 0 was the most predominat in activity grade 0. Activity score related to Hp was same in the greater curvature of upper body and the lesser curvature of lower body.
(2) Relationship between atrophy and Hp : The degree of atrophic change and Hp were observed in biopsy specimen at the lesser curvature of lower body. Hp grade 3 was the most freguent in atrophy grade 1. We couldn't find a difference on Hp grade in atrophy grade 2 and 3.
(3) Relationship between atrophic change and intestinal metaplasia : Severe intestinal metaplasia cases were low in atrophic grade 1. With the increase of atrophic grade, intestinal metaplasia grade increased gradually.

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Resistance to antibiotics is considered to be one of the main cause of treatment failure of H. pylori infection, although both of high eradication rate and low side effect are almost accomplished by new triple therapy using two antibiotics.
We performed two step therapy to avoid occurrence of resistant H. pylori and to achieve complete eradicaton finally. Lansoplazole (PPI) , amoxicillin (APMC) and mucosal protective drugs (Ecabet sodium or polaprezinc) were administered for 2 weeks as first step and metronidazole (MET) was added to them as second step in unsuccessful cases of the first step. A total of 150 patients with H. pylori positive peptic ulcer were subjected to the first step therapy. The patients were diagnosed by ¹³C-urea breath test, detection of H. pylori DNA in gastric juice by PCR, culture or histology.
Eighteen out of 35 cases, failed to eradicate with first step therapy, were subjected to examine the minimum inhibitory concentration (MIC) of AMPC, MET and clarithromycin (CAM) for H. pylori, which taken from biopsy samples from the antrum, by agar plate dilution method. All of 18 strains were sensitive (MIC≦0.10μg/ml) to both AMPC and CAM, while 3 strains (16.7%) showed MIC of MET ranging from 3.13to 50.0μg/ml.
Two step therapy has excellent merits that it is rare to induce antibiotics resistant H. pylori by the first step therapy. Furthermore drug sensitivity test could be done for the selection of adequate antibiotics before the second step therapy.

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Case 1 : A 60-year-old male with liver cirrhosis was admitted to our hospital for the treatment of esophageal varices. He had been treated by endoscopic injection sclerotherapy (EIS) before 5 years, but varices reccured. His laboratory data revealed marked thrombocytopenia (14,000/μl) and prolonged prothrombin time (43.3%) . At 14 day's after EVL, tarry stool and progression of anemia was observed. Bleeding from EVL ulcer was point out by urgent endoscopy. Hemastasis was achieved with 1% Aethoxysklerol injection successfully.
Case 2 : A 38-year-old female with liver cirrhosis was diagnosed as critical esophageal varices by standard endoscopy, then EVL was done. Laboratory data and clinical course were same as case 1. At 12 day's after EVL, hematemesis and hepatic encephalopathy were occured. Bleeding EVL ulcer was detected. Hemastasis was achieved with the same method of case 1. EVL was established as safe and effective procedure for esophageal varices but our two cases showed the necessity for careful monitering after EVL especially in obvious bleeding tendency.

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The patient was a 50-year-old female complaining of swallowing pain. She had ingested about 50ml of an acid detergent (9.5% hydrochloric acid) with suicide intent. Endoscopy revealed corrosive change through the esophagus to the upper stomach. In spite of conservative treatment under hospitalization, corrosive stricture had been exacerbated in her lower esophagus.
At first, she was treated by a balloon dilator inflated at 30 pounds square inches 2 times a day. After 5th balloon dilatation, recurrent stricture was observed. Endoscopic steroid injection therapy was tried to prevent recurrent stricture. Approximately 0.25ml of 0.4% betamethasone was injected into stenotic lesion at four sites. After four times of steroid injection therapy, a tendency of recurrent stricture declined.
In conclusion, local steroid injection following balloon dilatation would be effective to prevent recurrent stricture of corrosive esophagitis.

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A case of esophageal stricture treated with a dilator is reported.
The patient was a 65-year-old female who complained of difficulty swallowing. Her past history revealed accidental ingestion of acetic acid 45 years before, and esophageal stricture had been diagnosed by another physician. Hard bougie treatment had been performed for 1 year. About 45 years later, her dysphagia became more severe, and she was referred to our clinic. Esophagography and endoscopy revealed two stenotic lesions, one each in the upper and lower esophagus. After being admitted, she was treated with a hard bougie dilator. After the eleventh treatment, the stenosis appeared to be adequately dilated.
Because the stenotic lesion in the upper esophagus was at the introitus of the esophagus and the stenotic lesion in the lower esophagus appeared to have been caused by reflux esophagitis, we tried treating the patient with a dilator.

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A 26-year-old female was admitted to our hospital because of lasting retrosternal burning pain and back pain after taking a doxycycline tablet. It was taken with little water just going to bed 5 days ago.
Esophagoscopy revealed circular ulcers with clot in the lower esophagus in 3cm length (34cm from incisors) . She was diagnosed as doxycycline-induced esophageal ulcers by endoscopic findings and course, and treated with H₂-receptor antagonist under nothing by mouth. On the 15th day after the onset, endoscopy showed marked improvement. The follow-up esophagoscopy performed 3 month later showed disapperance of the ulcers with scars.
There have been several reports of solitary ulcer induced by doxycycline tablet. However very few cases of circular ulcers caused by the tablet have been reported.

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We report a rare case of esophageal retention cyst that could be excised by endoscopic mucosal resection.
A 57-year-old male was admitted to our hospital because of a submucosal esophageal tumor detected on a barium swallow examination. The esophagogram showed a smooth surfaced semi-pedunculated protruding lesion, 2.5×1.2×0.7cm in size, just above the esophagocardial junction. Endoscopic examination of the esophagus showed a submucosal tumor 38cm to 40cm from the incisors. The surface of the tumor was smooth and soft, and it was easily deformed. Endoscopic ultrasonography showed a hypoechoic mass in the submucosal layer.
The tumor was resected by endoscopic mucosal resection for diagnosis and treatment. The submucosal tumor was completely removed. Histologically, the cystic tumor contained exudate and necrotic tissue, and its wall was lined columnar cells. The tumor was diagnosed as“esophageal retention”cyst.

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We report a case of early adenocarcinoma arising in Barrett's esophagus. A 53-year-old man was diagnosed with Barrett's esophagus in August 1995. An esophageal protruding lesion with irregular surface was found out by mass screening X-ray
examination of the upper gastrointestinal tract in August 1996. Endoscopic examination revealed a protruding lesion in erythematous esophageal mucosa that was not stained by iodine spraying. The tumor was diagnosed as adenocarcinoma with biopsy. A subtotal esophagectomy was performed. The histological type of the tumor was well-differentiated adenocarcinoma, with the invasion limited within the submucosa and without lymph node involvement. The esophageal glands were seen in the submucosa under the tumor microscopically.
Five cases, including our case, of esophageal adenocarcinoma arising in followed up Barrett's esophagi were reported in Japan. Cancerous invasion was limited within the submucosa and there were no tumor-invaded lymph nodes in any of the 5 cases. Patients with Barrett's esophagus are recognized as having a risk of development of adenocarcinoma. If patients with Barrett's carcinoma can be identified during prospective follow-up Barrett's esophagus, they are diagnosed at the early stage and offered the possibility of curative therapy.
We think that a long term clinical, endoscopic, and careful histologic surveillance in patients with Barrett's esophagus are very important.

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We report our experience of using an indwelling ultraflex esophageal stent in 3 patients with cardiac stenosis caused by advanced gastric cancer.
Case 1 : A 80-year-old man had Stage IVb, type 2 gastric cancer infiltrating the lower esophagus. Though he could take some solid food, an indwelling stent 15cm in length was placed for fear that stenosis might become severer. He could take some solid food at 2 weeks after stent placement, but the stent dropped off into the stomach at 3 weeks and excreted from the anus with defecation at 4 weeks.
Case 2 : A 66-year-old woman had Stage IVb, type 3 gastric cancer infiltrating the lower esophagus. Because she became unable to take fluid diet after chemotherapy, an indwelling stent 15cm in length was placed after endoscopic bougienage. She could take semisolid food for about 4 weeks from stent placing to cancer death.
Case 3 : A 76-year-old woman had Stage IVb, type 3 gastric cancer infiltrating the lower esophagus. After chemotherapy and endoscopic bougienage, she became unable to take water, so an indwelling stent 10cm in length was placed. She has been able to take normal diet for about 2 months since stent placing.
We believe that use of indwelling self-expanding metallic stent for inoperable cardial gastric cancer is effective for improving QOL of patients with severe stenosis following chemotherapy or endoscopic bougienage.

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A 63-year-old male was refered to our hospital to examine and to treat a tumor of the stomach. An upper gastrointestinal series showed an elevated lesion more than 4cm in size at greater curvature side of gastric body. Endoscopic findings of the lesion revealed a polyp more than 4cm with a stalk of 1cm. Histological examinations of biopsy specimens of the lesion highly suggested a hyperplastic polyp. Since we considered it would be possible to treat the polyp endoscopically in spite of its huge size, endoscopic resection was performed.
In detail, two detachable snares were placed at the stalk of the polyp, an absolute ethanol of 0.2ml was injected into the stalk at a polyp side of the detachable snares and the polyp was resected using bipolar snare. Two clips were placed at the site to close the wound. Microscopic findings of a polypectomized specimen revealed hyperplastic foveolar polyp (group 2) as well as biopsy specimens.
As it has been rarely reported that such a huge hyperplastic polyp of the stomach was resected endoscopically, we think a methodology of our case such as using detachable snare and bipolar snare is unique and is worth reporting.

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A 64-year-old male had been pointed out gastric polypoid lesion since these 25years. After admission on our hospital, he was diagnosed as gastric submucosal tumor (SMT) by endoscope. Endoscopic ultrasonography revealed multiple small and large aechoic area in the third layer of the stomach wall, suggesting that the tumor was different from typical SMT like leiomyoma.
In order to define the diagnosis, polypectomy was done. Histological examination of the polypectomized specimen showed pyloric gland cavities with small and large cystic delatation in the submucosal layer and the interstitium composed of hyperplastic muscule bundle branches and the lesion was diagnosed as a hamartomatous polyp. The cystic dilatations corresponded to aechoic area on endoscopic ultrasonography and this finding was useful for the diagnosis of hamartomatous polyp.

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A 48-year-old man was admitted to our hospital complaining of tarry stool. Laboratory data revealed marked anemia (Hgb 4.7g/dl) . Endoscopic examination revealed diffusely erythematous spots and Oozing hemorrhage at the gastric antrum. Endoscopic biopsy specimen taken from those areas demonstrated dilated vessels with fibrosis in the proper gastric mucosal layer.
A 68-year-old man was admitted to our hospital complaining of general fatigue. Laboratory data revealed marked anemia (Hgb 6.0g/dl) . Endoscopic examination revealed longitudinal stripes, resembling the stripes of a watermelon at the gastric antrum.
Endoscopic laser coagulation was performed for our two cases, under the diagnosis of gastric antral vascular ectasia (GAVE) . After the therapy, the vascular ectasia disappeared, and there was remarkable improvement in anemia.
We consider that the endoscopic laser coagulation is an effective therapeutic method for gastric antral vascular ectasia, and should be the treatment first choice for this disease.

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A 26-year-old man visited us complaining of tarry feces. Emergency endoscopy was conducted as upper GI bleeding was suspected.
An elevated lesion of about 30mm was discovered in the inferior greater curvature in the body of the stomach, but whether it was the source of bleeding was unclear. Colonic endoscopy and small intestinal X-rays also failed to clearly identify the source of bleeding. Ultrasonic endoscopy of the gastric lesion showed that the 3rd layer was mainly elevated.
Endoscopic polypectomy was undertaken under the suspicion that this lesion was the source of bleeding. Histological diagnosis of this lesion was vascular dysplasia with the elevation being mainly attributable to dilatation in the submucosal layer, as well as hyperplasia of serpiginous blood vessels and interstitial connective tissues.
Hemosiderosis was also observed under the superficial epithelium. Bleeding from this lesion was therefore strongly suspected. It is rare that vascular dysplasia shows localized elevation. This report describes our findings with reference to the literature.

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In 1989, a 48-year-old male underwent an endoscopic examination revealing an irregular-shaped depression with both an erosion and an easy-bleeding at the anterior wall of the gastric angle, which was pathologically diagnosed no malignant cell.
In October 1994, based on the diagnosis of Hp positive MALT lymphoma, the eradication was succeeded by both 1500mg amoxicillin (AMPC) and 40mg omeplazole (OPZ) daily for 14 days. The endoscopic findings were improved and no lymphoma cell was found pathologically. In May 1996, ¹³C-urease breath test (UBT) showed Hp-positive and endoscopic findings showed the relapse of the disease. In July 1996, the re-eradication was successfully done with 400mg of clarythromycin daily added to those 2 drugs for 14 days.
A few cases of MALT lymphoma were reported which were relapsed and re-eradicated after having been initially eradicated for Hp. In our case, the re-eradication was effective because it had brought the remission of the disease endoscopically, pathologically, and by ¹³C-UBT results. It is necessary to establish the measures of the regimen for relapsing MALT lymphoma after the initial eradication for Hp.

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A 46-year-old male had had a continuous fever since December 1996. As increased WBC and inflammatory response were observed in blood examination, he was admitted to our hospital. Detailed examination showed that he was suffering from ATL with pneumonia. Chemotherapy with an antibiotic, etc was commenced. As hematemesis and melena developed, endoscopic examination was carried out.
An ulcer of A₁ stage was found together with an exposed vessel in the center of the anterior wall of the stomach body. After hemostatic operation with clips, bleeding was not found. Following treatment with PPI for 8 weeks, treatment with an H₂-blocker was commenced. Periodical examination showed that gastric ulcer was refractory and only improved to H₂ stage after 6 months. ATL cells were not seen in biopsy. Specific staining of cellular inclusion and cytomegalovirus was positive. The gastric ulcer was concluded to be caused by cytomegalovirus infection manifested by opportunistic infection due to ATL. We report this interesting case while reviewing the literature.

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There are extremely few reports of small cell carcinoma of stomach, although small cell carcinoma occurs to a lung a lot. We report a very rare case of small cell carcinoma of stomach.
A 76-year-old woman, chief complaining of an epigastralgia, visitted our hospital. No abnormalities were found in systemic exermination. An endoscopic approach revealed a Borrmann type 2 tumor at the anterior wall of lesser curvature. The lesion was 5.3×3.0cm in size. The histological diagnosis with biopsy was a well-differentiated adenocarcinoma.
Subtotal gastrectomy was performed. Histologically, the tumor consisted of a differentiated adenocarcinoma and an undifferentiated component. The former was characterized by vaying sizes of solid nests composed of relatively uniform, round cells with numerous mitotic figures. The components were negative to Grimelius, PAS and Alcian Blue stain, NSE, CEA, S-100 protein, Chromogranine. Ultrastructurally, core granules were found in the cytoplasm of a majority of the tumor cells, indicating that our case in a small-cell carcinoma in stomach.

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A 67-year-old male patient referred to our department had received X-ray examination for mass screening and had a diagnosis of early gastric cancer type Ilc in the greater curvature opposite to the gastric angle.
Endoscopically it was 8 mm in length with reddening and well-defined margins. Because the biopsy result was well differentiated type of tubular adenocarcinoma (tub₁) histologically and both conventional endoscopy and endoscopic ultrasonography did not suggest any of deeper invasion, the patient underwent endoscopic mucosal resection (EMR) . Unexpectedly, however, minute submucosal invasion of 1500×1000µm in size was detected microscopically from the center of the lesion resected and partial gastrectomy with lymph adenectomy of Dl was added to EMR. No lymph node metastasis and no residual cancer was found in the surgical specimen.
The case presented indicated the difficulty in preoperative diagnosis of minute submucosal invasion, as well as the importance of EMR for providing the definite histological diagnosis. In addition, it should be an urgent need to assess the necessity of additional surgery for those having minute submucosal invasion with a large number of such cases.

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Case 1 : A 86-year-old woman visited us complaining of palpable lower abdominal mass. Serum AFP level was normal (＜10ng/ml) . Gastroscopy showed Borrmann type 2 gastric cancer of the antrum. Histological study of the biopsy specimen showed adenocarcinoma (por₁＋tub₂) . Immunohistochemical examination showed AFP in the cytoplasm of cancer cell. Liver metastasis was not detected by computed tomography and ultrasonography.
Case 2 : A 68-year-old man, serum AFP level was high (＞20,000ng/ml) . Gastroscopy showed Borrmann type 3 gastric cancer of the body. Histological study of the biopsy specimen showed adenocarcinoma (por₁) . Immunohistochemical examination showed AFP in the cancer cell. Computed tomography showed multiple metastasis of gastric cancer in the liver.
Case 1 was so called latent AFP-producing gastric cancer. There was few reports of this type gastric cancer. It was suggested that there was a possibility that case 1 would be a liver metastasis positive AFP-producing gastric cancer. So, care must be taken not to overlook liver metastasis for this type of gastric cancer.

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A 52-year-old female underwent allogeneic bone marrow transplantation because of acute myeloid leukemia. She entered hospital again on suspicion of relapse after 6 months. Prescription of cyclosporin A (cy-A) was ceased to induce graft-versus-leukemia effect.
Therefore graft-versus-host disease (GVHD) of the skin and the liver occured. After a while epigastralgia and nausea appeared. The endoscopic examination revealed candidiasis of the esophagus, diffuse redness in the greater curvature of the stomach and hemorrhagic erosion of the duodenal 2nd portion. The biopsy specimen from stomach and duodenum showed chronic and acute GVHD histologically. Then because the symptom of enteric GVHD was increased, cy-A was prescribed again and later steroid was added to prescribe. As a result the clinical symptom and endoscopic finding of GVHD were improved.
The endoscopic study of enteric GVHD is rare, so we reported this case.

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A 71-year-old women visited our hospital to receive a check up of the upper gastrointestinal tract and we found a small elevated lesion in the duodenal bulb. Endoscopically, it was a submucosal tumor covered by normal mucosa with erythematous depression, approximately 1cm in diameter. Histological examination of the biopsy specimen confirmed the diagnosis of carcinoid tumor. EUS image of the tumor appeared to be limited to the submucosal layer. No metastatic lesion was indicated by US and CT. Laboratory data including endocrinological examinations were within normal limit.
On the basis of these findings, we successfully performed endoscopic mucosal resection (EMR) for the tumor. The resected tumor was limited to the submucosal layer and 9×7mm in size, histologically. The histological feature showed a classical pattern of carcinoid tumor, composing of small uniform with the trabecular structure, by a high magnification view of hematoxylin-eosin staining. In addition, carcinoid cells showed positive staining by the Grimelius method.

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The patient is a 67-year-old male. At a periodic medical examination, a polypoid lesion was discovered in the duodenal bulb by endoscopy. A biopsy of the reddish tinged apex lesion was performed and diagnosed to be a carcinoid tumor. Invasion of the submucosa was confirmed under endoscopic ultrasound. An operation was performed through a laparotomy incision to pertially resected to duodenal bulb area, accompanied by lymph node sampling. Two carcinoid tumors were resected, one was 10mm by 9mm, and the other was 1 mm by 1 mm.
The literature supports practice guidelines of performing endoscopic mucosal resection (EMR) on tumors measuring 1 cm or less. However, in some EMR cases there have been incidences of insufficient tumor margines, which have resulted in lymph node metastasis.
In this case, in order to decrease the risk of lymph node metastasis, an open laparotomy with radical resection of the tumor and lymph node sampling was performed. We conclude that this procedure is appropriate from a curative and quality of life standpoint.

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Case 1 : A 58-year-old female was first seen in our hospital because of abnormality found by gastric checkup study. Endoscopic examination revealed a flat elevation, 12mm in diameter, and whitish in color, at the duodenal bulb. Endoscopic mucosal resection (EMR) of the carcinoma was carried out. Histological examination showed well differentiated adenocarcinoma proliferating within the mucosal layer.
Case 2 : Endoscopic examination of a 67-year-old female was performed because of anemia revealing a flat elevation, 25mm in diameter, at the duodenal bulb. Subtotal gastrectomy and duodenectomy were carried out for curative resection of carcinoma. Histological examination showed well differentiated adenocarcinoma with submucosal invasion at the excavation. Histological staging was represented as follows : p₀, h₀, n₀, sm, Stage I. Carcinoma cells permeated in the lymphatic vessels and small veins (ly₁, v₁) .

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A 23-year-old male visited our hospital with a complaint of abdominal pain. He was treated with antibiotics, but developed abdominal pain, so he was admitted.
The pancreatic enzyme level was elevated gradually. During the hospitalization, he had melena and a rash over his legs. The skin biopsy at purpura showed vasculitis. A diagnosis of pancreatitis complicating Schönlein Henoch purpura was made. Gastroenterological endoscopic examination revealed multiple erosion, enlarged folds, shallow linear ulcer of the duodenum. He was treated prednisolone and intravenous fluids. In cases of this syndrome with abdominal pain, pancreatic enzyme levels should be estimated.

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A 19-year-old female was admitted to our hospital with complaints of abdominal pain. After admission, she complained hematemesis. Endoscopic examination revealed marked ulcer of the second portion of the duodenum and round-shaped hemorrhagic erosion of the stomach. Colonoscopic examination revealed hemorrhagic erosion of the small intestine and round-shaped hemorrhagic erosion of the cecum. Eight days after admission, she noted hemorrhagic spot on hip and femur. The diagnosis of Schönlein-Henoch purpura was confirmed by the biopsy of the skin. The patient was effectively treated with H₂-blocker and prednisolone.
We suggest that when we recognize the endoscopic findings of marked ulcer of the second portion of the duodenum and round-shaped hemorrhagic erosion, we anticipate Schönlein-Henoch purpura and other systemic disease.

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A 22-year-old female patient was diagnosed as Peutz-Jeghers syndrome since 17-year-old.
Colonoscopic polypectomy was performed several times to remove the cause of abdominal pain. Lastly surgical operation was carried out. In the 3rd month after operation, she was hospitalized with abdominal pain and vomiting. Double contrast study of small bowel revealed a ileal polyp 3cm in sized and located at 100cm from Bauhin's valve.
We tried to resect by long type colonoscope (168cm length) using X-ray. Polyp was detected by using contrast media under X-ray, and resected safely. Endoscopic resection for ileal polyp will be considered to avoid laparotomy.

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This report presents a case of Peutz-Jeghers Syndrome.
A 39-year-old male was admitted for further evaluation of the gastrointestinal polyposis. Endoscopic examination, double contrast study of gastrointestinal tract revealed Peutz-Jeghers syndrome. Intestinal evertion method was performed to large polyps. Small polyps were resected endoscopically via intraoperative endoscopy. To privent resection of the small bowel (short bowel syndrome) , intestinal evertion method, transfixation ligation method and intraoperative endoscopic polypectomy were performed.

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The case reported here was a 74-year-old woman who noticed rash in the right shoulder from about 1991 and visited the dermatological department of our hospital in July 1996 because the rash spread over the left shoulder and back. The rash was diagnosed as amyloidosis on skin biopsy. She was referred to a department of internal medicine for systemic examination.
In colonoscopic examination, small and whitish submucosal phyma-like protrusions were sporadically observed from the rectum to the sigmoid colon, and angiectasia from the ascending colon to the cecum. Congo red positive substances were detected in her biopsy specimen of the lesions. Thus the patient was diagnosed as having primary amyloidosis based on the results of all related examinations.
Colorectal amyloidosis shows various endoscopic appearances, including rare cases of phyma formation due to regional deposition of amyloid. We encountered a case with small submucosal phyma-like protrusions identical to skin lesions. Thus we herein report this case in addition to the discussion on the literature.

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A 49-year-old man visited our hospital because he was positive for immunological fecal occult blood. Barium enema revealed pedunculated polyps in the sigmoid and transverse colon, so he underwent colonoscopy and two tubular adenomas were resected, which show severe and moderate atypia.
Two months later, on the second colonoscopic examination, a submucosal tumor like elevated lesion with smooth and reddish surface was detected in the descending colon, about 12mm in size. This polyp was resected by snare polypectomy, and pathological findings revealed dilated, congested vessels in the submucosa, which was compatible with arterio-venous malformaion.
In the Japanese literature, only four cases of AVM which show submucosal tumor-like appearance were reported. We should be careful in treating with such polyps to avoid hemorrhage due to polypectomy.

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A patient was 71-year-old female. She was undergone a colostomy before 3 years ago because of colono-vaginal fistula causing diverticulitis of sigmoidcolon.
She admitted for a closure of a colostomy. A colocolostomy was done using automatic anastomat circular stapler (PCEEA 25) . Ten days after operation, she was suffered from abdominal pain and distension, so diagnosed ileus for a obstruction of anastomosis by barium enema and colonoscopy.
Cecostomy was performed because a ileus tube was not effective. After a dilation of cecostomy, endoscopic treatment for a obstruction of anastomosis was planed. Firstly an endoscopy (XP-10) was inserted from cecotomy. Secondary an endoscopy (200HI) was inserted from anus. Aiming at light of oral side scopy, a center of a obstruction was cut using precutting knife through anal side scope. Following this cutting, anastmosis was dilated by a balloon dilator.
A obstruction of anastomosis after using automatic anastomat circular staplaer is very rare. We can not recognized a same case in the literature.

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A 55-year-old male visited our department for further examination with positive fecal occul blood test results in the mass screening for colorectal cancer. He complained of abdominal pain and diarrhea which had started about 2 months before. Small ulcers and erosions were observed in the ascending colon and cecum at colonoscopy. Biopsied specimen at the erosions showed numerous trophozoites in the mucosa. Many Lamblias were observed under a microscope in residual liquid collected in the ascending colon or cecum. Thus, this patient was diagnosed as amoebic colitis complicated with Giardiasis.
At colonoscopy performed 3 weeks after Metronidazole therapy (1000mg/day) , erosions and ulcers in the ascending colon and cecum disappeared. This patient was thought to be infected with both parasites by taking contaminated foods because he was not homosexual and had no HIV antibody.

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A 52-year-old Japanese man visited our hospital because of loose stool with blood and mucus. He had the past history of syphilis 10 years ago.
Colonoscopic study showed multiple discrete ulcers in the right hemicolon and erosions in the rectum. The biopsy specimen showed no Entamoeba histolytica, however I diagnosed the patient as an amebic colitis. I administered metronidazole orally, 500mg/day for 14days. The therapeutic results were good. Entamoeba histolytica was detected in the biopsy specimen from the erosions in the cecum at the follow-up study by colonoscopy eight months after the first study. I re-treated the patient as an amebic colitis. The patient confessed one month later that he was homosexual and was infected by human immunodeficiency virus (HIV) .
In this report, I stress an amebic colitis associated with HIV in homosexual is still rare in Japan.

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A 59-year old female visited our hospital due to diarrhea and body weight loss and was diagnosed as Crohn's disease by colonoscopy in 1988.
In April 1997, the serum immunoglobulin G (IgG) was found to be increased and the immunoelectrophoresis demonstrated“M-peak”. Bone marrow aspiration was performed to show multiple myeloma. Atypical plasma cells were accounted for 15.8% of all bone marrow cells. Although only 2.5mg of prednisolone daily was administered, the serum IgG didn't increase. This case was recognized to start with benign monoclonal hypergammmopathy and develop multiple myeloma.
Only one case has been reported on the relationship between Crohn's disease and multiple myeloma although some cases have been reported on the relationship between multiple myeloma and benign monoclonal gammopathy. Judging from Kyle's report describing that 25% of benign monoclonal gammopathy developed multiple myeloma, this Crohn's disease case might have complicated with benign monoclonal gammopathy from the beginning which developed multiple myeloma.

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A 58-year-old female visited a hospital due to frequent diarrhea and underwent the barium-enema revealing nothing in 1992. In 1996 colonoscopy was done due to bloody stool and revealed the active stage of ulcerative colitis, total-colitis-type.
Administration of Salicylazosulfapyridine (SASP) and lactic acid bacillus decreased the frequency of diarrhea. In January 1997, the lumbago and the right ankle pain occurred. The monoclonal protein in the serum and abnormal accumulation of the ^99mTc in the bone scintigraphy were clues for multiple myeloma. An immunoelectrophoresis showed the monoclonal protein (IgG κ-type) . Bone marrow aspiration revealed normocellular bone marrow with plasma cell proloferation (10.8%) and consisted with multiple myeloma. The therapy with melphalan and predonisolone was effective to reduce the monoclonal protein peak.
Only 2 cases have been reported on ulcerative colitis complicated by multiple myeloma. Several reports show that the risk is significantly increased for leukemia, non-Hodgkin lymphoma, and Hodgkin lymphoma in ulcerative colitis although the relationship between ulcerative colitis and multiple myeloma is unclear. Recently the number of ulcerative colitis patients has been increased. More attention must be paid for both colorectal and extracolonic malignant disorders in ulcerative colitis.

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A 69-year-old man who had been treated with multiple myeloma (MM) , was reffered to our hospital for further evaluation and therapy of obstructive jaundice.
Abdominal ultrasonography and CT scan demonstrated a mass lesion in the head of the pancreas. Endoscopy showed submucosal tumor (SMT) in the stomach and in the 2nd portion of the duodenum with multiple ulcers on its surface. The histological diagnosis of the biopsy specimen was plasmacytoma indicating the metastasis of MM. After relief of jaundice by PTCD, radiation therapy was performed and the SMT of both the pancreas head and the stomach disappeared on CT scan and endoscopy.
Extrameddulary metastasis of MM is sometimes found in the reticuloendotherial system. However, metastasis of MM to the pancreas is very rare, and there have been no reports of the metastasis from MM to both the pancreas and the stomach in one patient.
In the case of MM, it is nessesary to examine gastrointestinal tract or pancreas with extrameddulary metastasis in mind.

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The case reported here was a 69-year-old man who was admitted by our department on February 1997 because of liver cell carcinoma. He was complicated with chronic subdural hematoma and became bedridden.
Colonoscopy was performed on disease day 22 because of sudden onset of indolent bloody stool. Geographic ulcer with an exposed blood vessel was detected in the lower portion of rectum. Because bleeding gradually increased in amount, despite our attempt at clipping, ethanol and HSE were locally injected on disease day 27. The same hemostatic treatment was performed on disease day 36 because of recurrence of bloody stool. Since then, no bloody stool had occurred, and the ulcer was colonoscopically confirmed to be cicatrized on disease day 72. Because it is rare to endoscopically observe a clinical course of ulcer until cicatrization, we herein report our case.

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Case 1 : A 69-year-old female visited another hospital because of hematochezia. Colonoscopy showed an ascending colon tumor revealed prominent submucosal growth during a month. The tumor invading into the muscularis propria showed a low echoic mass by endoscopic ultrasonography (EUS) . She was admitted to our hospital and underwent right hemicolectomy. The histological findings of the resected specimen demonstrated that mucinous adenocarcinoma was invaded to the subserosa, but no cancer tissue was existed in the lamina propria.
Case 2 : A 43-year-old male visited our hospital with positive for occult blood in stool. Colonoscopy showed the broad based mass covered with red granular mucosa was located in the sigmoid colon. EUS findings represented a low echoic tumor with subserosal invasion. Histologically, mucinous adenocarcinoma invaded into the subserosa was mostly covered with noncancerous mucosa except for the center of the tumor.
Colorectal cancer with prominent submucosal growth is rare. Although it is difficult to distinguish the tumor from submucosal tumor and metastatic cancer, EUS can provide useful information for the differentiation between those tumors, and also for the diagnosis of the depth of cancerous invasion.

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The patient was a 61-year-old female, who underwent upper gastrointestinal endoscopic exammination because of a positive serum pepsinogen test.
Gastric adenoma was detected in lesser curvature of the gastric corpus, and rectal cancer was also diagnosed by colonoscopy, performed to evaluate iron-deficiency anemia. They were excised endoscopically and surgically, respectively. During following 6 years, duodenal adenoma in the second part of the duodenum, and other gastric adenomas, and another rectal cancer were detected. Some genetic abnormality was supposed, but there was no familial tendency to malignant disease.
We also discussed the possibility that high-risk subjects of gastric neoplasm screened by serum pepsinogen test also belong to the high-risk group of colorectal cancer.

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A 33-year-old male entered our hospital complaining of fever. He had a 12-year history of systemic lupus erythematosus for which he was treated with oral prednisolone.
The physical examination gave negative results except for erythematous lesions of the fingertips. Chest X-ray films revealed clear lung fields. Result of an extensive work-up for his fever was negative. Smears of sputum, urine, gastric juice and bone marrow were negative for acid-fast bacilli. Peritoneoscopy was performed because of the ambiguous result of therapeutic trial with antituberculosis drugs. Peritoneoscopy revealed numerous small white spots on the liver surface and biopsy specimen showed many epithelioid granulomas.
These results allowed a definitive diagnosis of miliary tuberculosis when interpreted in conjunction with other clinical features. His clinical symptoms improved rapidly by replacement of antituberculosis drugs. Peritoneoscopy is a useful diagnostic method in prolonged unexplained fevers.

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