潰瘍病変の止血法として開発されたヒータープローブ（HPU）法のよい適応と考えられる①F0再発食道静脈瘤，②Vascular ectasia（VE）に対してHPU法を施行し，その有用性について検討した。①RCsign陽性のF0再発食道静脈瘤18例にHPU治療を施行。焼灼後F0静脈瘤は瞬時に消失し，治療後の観察期間（5～16ヵ月）中，静脈瘤からの出血はなかった。RC signの再発を3例に認め，再治療を施行した。②胃のVE10例にHPU治療を施行。VEの止血や消失に有効であった。いずれも問題となる合併症はなく，以上のような非潰瘍病変に対してHPU法は安全で有効な治療法であると考えられた。

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　カラードプラー超音波内視鏡（color Doppler endoscopic ultrasonography, CDEUS）により動脈血の関与が強く疑われた食道静脈瘤症例を報告した。左胃静脈に拍動派を検出したのは53例中4例（7.5％）であった。このうち左胃静脈後枝に拍動派を認めたのは2例であった。2例とも食道静脈瘤に対して内視鏡的治療を受けている。症例1は70歳，女性。childB，肝硬変。食道静脈瘤に対して内視鏡治療を行った。左胃静脈の血流は定常流で流速は6.5cm/secであった。治療1ヵ月後の内視鏡検査で静脈瘤はF0RC（－）であった。CDEUSでは左胃静脈，左胃静脈後枝の血流は拍動派で流速はそれぞれ7.2，21.8cm/sec，傍食道静脈は定常流で流速は18.6cm/secと後枝，傍食道静脈で急激に上昇していた。症例2は51歳，男性。childA，原発性胆汁性肝硬変。2年前に食道静脈瘤に対して内視鏡治療が行われている。食道静脈瘤の再発を指摘された。治療前のCDEUSで左胃静脈，左胃静脈後枝に拍動派が検出された。その流速はそれぞれ3.6，9.2cm/secであった。傍食道静脈は定常流で流速は8.9cm/secであった。2症例とも拍動派は左胃静脈後枝で顕著であった。CDEUSを用いて直接動脈血の関与を観察したが，左胃静脈後枝のレベルで動静脈の開大が起こっていると思われた。

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　アルゴンガスを利用した非接触型高周波凝固装置を使用したアルゴンプラズマ凝固法（APC）のpilot studyを食道癌に対して行い，治療の利点と食道癌に対する適応について検討した。1997年1月より98年12月までに当院および関連病院で経験した42例の食道癌症例中APC治療を行った11例を対象とした。APC治療11例中1例は無治療例であり，8例は前治療に効果がなく内視鏡の通過ができない進行食道癌であった。また1例はEMRおよび放射線治療後の局所再発例であり，その他の1例は食道癌術後の難治性瘻孔症例で，APCとメタルステントを挿入し食事が可能となった。平均2.2回のAPC治療後腫瘍は縮小し，進行食道癌10例中9例にステントの挿入ができたが，1例はAPC治療途中で腫瘍の気道浸潤による呼吸不全のためステントの挿入を中止した。8例に3分粥以上の食事摂取ができたが，1例は癌性腹膜炎による大腸狭窄によりできなかった。いずれも重篤な合併症はなかったが，APC後8例に発熱，5例に胸痛・胸やけ，3例に嘔吐を認めた。治療適応はステント挿入後のingrowthやovergrowthした腫瘍の焼灼やEMR後の遺残腫瘍，局所再発あるいは早期食道癌の焼灼などであるが，進行食道癌に対する前治療に効果がない，ステント挿入前の腫瘍のreductionにも有効であり，適応の1つと考えられた。

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　従来，胃癌の治療法は根治性を重視し，広範なリンパ節郭清を伴う画一的な外科治療が選択されてきた。近年，リンパ節郭清を必要としない早期胃癌では，内視鏡的粘膜切除術や腹腔鏡下胃局所切除術が普及してきている。しかし，sm浸潤を認める早期胃癌ではリンパ節転移の危険性があり，その治療方針の選択には細心の注意が必要と考える。今回，われわれは1987年から1997年の当施設における早期胃癌手術標本を病理組織学的に検索し，リンパ節郭清を必要とする早期胃癌に対しての治療法選択について検討した。早期胃癌200例（m癌100例，sm癌100例）を病変の大きさ，組織型，深達度，潰瘍の有無，リンパ節転移の有無について検討した。その結果，sm1であれば潰瘍の有無にかかわらずリンパ節転移はなく，郭清にとらわれない腹腔鏡補助下幽門側胃切除術（D1郭清まで）の適応である。sm²であっても潰瘍非合併例では分化型で4cm，未分化型で1.5cmまでは，同様の術式の適応と考える。それ以外のsm²は腹腔鏡補助下幽門側胃切除術（D₁＋＃7郭清）を行うなど，腹腔鏡補助下手術の適応拡大の可能性が示唆された。sm3では従来どうりの開腹下胃切除術（D₂郭清）の適応と考えている。

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　平成6年7月より平成10年9月までに大腸内視鏡にて粘膜下腫瘍と診断し，腸管囊腫様気腫症（以下PCIと略）であった3例を対象とした。脱気水充満法にて細径超音波プローブを用いてEUSを施行した。また摘出腸管の粘膜下層（以下SMと略），漿膜下層（以下SSと略）に空気を注入しEUS像を検討した。PCIはSMに一致して高エコーの帯状のエコーがあり，それ以深は高エコー下の音響陰影を示し，ガス・エコーと考えられた。摘出腸管に空気注入した実験EUSにおいて，SM注入ではPCI3例と同様のエコー像を呈した。SSに空気を注入した場合には，筋層と漿膜間に高エコーの帯が出現し，エコーの局在診断は容易と考えられた。PCIの確定診断にはEUSを追加すれば有用と考えられた。経過観察した2例においてPCIは自然消失したが，1例においてPCIの局在位置に相当して白斑が残留した。なお，白斑の部のEUSはガス像の消失を示していたが，明かな線維化は指摘できなかった。

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　症例は49歳，女性。23年前からの嚥下困難が増悪したため，近医を受診した。上部内視鏡検査が施行されたが，食道入口部直下の膜様狭窄のため挿入できず，当センターを紹介受診した。血液検査にて鉄欠乏性貧血が，食道造影にて食道webが認められたため，Plummer-Vinson症候群（PVS）と診断された。鉄剤の内服治療が開始されるとともに，食道webに対して内視鏡的バルーン拡張術が施行された。1ヵ月後の上部内視鏡検査で食道狭窄は改善しており，嚥下困難も軽快していた。PVSは鉄欠乏性貧血に嚥下困難，舌炎，匙状爪などを呈する症候群で，高率に食道webを合併する。治療は鉄補充が基本であるが，食道webによる狭窄が高度な場合は，診断後，すみやかに拡張術が施行されることが多い。また，食道癌，後咽頭癌の合併頻度が高く，継続的な上部内視鏡検査が必要とされている。

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　症例は43歳，男性。主訴は下血。本例は肩周囲の痛みに対して近医でDiclofenac sodium（以下，DS）1日75mgを約1カ月間継続内服中，突然の下血を認めたため，他疾患との鑑別によりDSによる病変と診断。緊急内視鏡検査にて回腸・結腸吻合部（昭和63年上行結腸癌にて手術）の回腸側に不整型で打ち抜き状の境界明瞭な小潰瘍が多発し，一部より活動性の出血を確認しクリップにて止血した。治療はDSの中止，中心静脈栄養による腸管の安静により約30日で改善を認めた。NSAIDsによる下部消化管病変の診断基準は現在のところなく，組織学的な診断も困難であるが，NSAIDs潰瘍は大量出血が特徴であり，その他の炎症性腸疾患とは，臨床経過や内視鏡所見，組織所見から鑑別可能と考えた。本症例のごとく，NSAIDs潰瘍に対して，内視鏡的クリッピング術にて止血し得た症例は他に報告例を認めず，貴重な症例と思われ報告した。

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　急性リンパ性白血病のため同種骨髄移植療法を受けた19歳，男性が，移植後100日目より著明な下痢を呈し，再入院となった。大腸鏡検査で，直腸から回腸末端にかけて粘膜の顆粒状変化，発赤がみられ，生検による組織所見から急性graftversus-host diseaseと診断した。Steroidのpulse療法にて，下痢は一時消退したがふたたび増強し，大腸鏡を再検したところ，回盲部に発赤びらんが認められた。生検で核内に封入体を有する巨細胞がみられ，またcytomegalovirus（CMV）抗原血症検査でも陽性細胞の増加を認めたため，CMV腸炎の併発と診断した。その後，Ganciclovirの投与を行い症状の改善が得られたが，本例では治癒判定に際しては，CMV抗原血症検査に比べ内視鏡所見が有用であった。骨髄移植後の腸管病変が内視鏡的に観察され，かつ診断と治療方針の決定に内視鏡検査が不可欠であった興味深い症例と考えられた。

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　症例は54歳，男性。大腸癌検診の精密検査として実施された注腸造影検査で異常を指摘され，当院を受診した。腹部単純X線および腹部CTで右側結腸壁外に石灰化像が，注腸造影検査で盲腸から横行結腸にかけて結腸膨起の消失・壁硬化・一部に拇指圧痕様所見が，大腸内視鏡検査で同部に一致して青銅色を呈する粗造粘膜と散在する類円形の小潰瘍が認められた。潰瘍辺縁部より得られた生検組織では，粘膜固有層および粘膜下層の肥厚した血管壁にアミロイドに類似した硝子様物質の沈着がみられたが，コンゴ・レッド染色陰性であり，沈着物質は膠原線維と考えられた。以上より，静脈硬化症による虚血性病変と診断した。

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　症例は72歳，女性。平成10年1月9日上部消化管造影検査を受けた。胃粘膜の高度萎縮とそれに伴う進展不良以外は異常所見はなかったが，嘔吐反射直後より穹隆部粘膜下にバリウムの貯留が観察された。特に症状はなく，いったん帰宅するも，同日夕刻より発熱と少量の吐血を認め緊急入院となった。腹部理学所見に異常はなく，補液，抗生剤による保存的治療で経過をみた。第3病日には解熱，free airも消失したが，バリウムの貯留は残存した。第10病日の内視鏡検査で，噴門部から穹隆部の後壁よりに数cmにわたる線状の裂傷と，バリウムが透見される粘膜下腫瘍様の隆起を認めた。本症例は発泡剤による胃内圧上昇と，嘔吐反射によるMallory-Weiss症候群と考えられるが，胃粘膜萎縮が強い高齢者に対しては，比較的侵襲の軽いとされている造影検査においても，十分な配慮と注意が必要と考えられた。

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　症例は60歳，男性。平成9年4月より便秘，下痢を主訴に当院を受診した。注腸検査にて，上行結腸に径27mm，表面に凹凸のある隆起性病変を認めた。大腸内視鏡検査では，径20mm以上のⅡa＋Ⅰ型，白色調，表面結節状のポリープであった。生検組織診断では過形成性ポリープ（以下HP）であったが，径が大きくserrated adenomaも否定できなかったため，内視鏡的粘膜切除術を施行した。病理組織診断では，腺管は鋸歯状構造を呈し，典型的なHPであった。Mib-1染色を施行し，増殖細胞帯を検討したところ，標識率は腺底部で21.6％，表層部で0.7％であった。本症例の増殖細胞は，通常のHPと同様腺底部に優位であったが，標識率は低値で，正常粘膜に近似しており，このことが20mm以上の大きい病変にもかかわらず，扁平な形態を呈した一つの要因である可能性が示唆された。

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We have performed a clinical evaluation on the new Olympus endoscopy system for upper digestiv tract, EVIS-CV240 and GIF-Q240. This new system features better insertability and maneuverability, higher resolution and larger monitor size. This system also enables EUS procedures with the use of US miniature probe.
We have selected 10 doctors with 5 years or more experlence in endoscopy, and performed a questionnaire for 67cases pesformed using this system. The questionnaire included comparison of picture quallty in enhance of structure levels 1, 4, and 8 (hereunder ESL) in the esophagus, stomach and duodenum, and comparison to the current CV200 and GIF-XQ230 system.
As for picture quality, the result showed improvement in the new system. In higher enhance of structure levels, clearer observation of the visible vascular pattern, redness of the mucosa, and change in color were possible for all tracts.
Ln comparison to the CV200 and GIF-XQ230 system, overall results showed improvement in the new CV240 and GIF-Q240 system, however, some identified problems in its maneuverability.
Through our evaluation we conclude that the new CV240 and GIF-Q240 system is useful for observation in the upper digestive tract. This may lead not only to a reduction of misdiagnosis, but more importantly, this may lead to a progress in higher level diagnosis with the use of accumulated high quality pictures of minute lesions.

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Rabeprazole (RPZ) concentrations were measured in gastric mucosa from inhibition zones on H. pylori culture medium and calibration curves.
The proton pump inhibitor (PPI) RPZ and H. pylori were used to measure inhibition zone diameters. The methods were prepared according to previously described. RPZ standard dilution solution was used to make drug concentrations of 0.05～100μg/ml. The diameters of inhibition zones were measured with discs method (72 hours, 35℃, in CO2) . The effects of gastric juice on H. pylori were assessed by adding gastric juice obtained during upper gastric endoscopy to the standard dilution solution. Gastric juice was also centrifuged, heat-treated, filtered by dialysis, and dried, and the antibacterial activity evaluated. H. pylori growth was examined using the pre-endoscopy drugs xylocaine spray, xylocaine jelly, gascon drops, and untreated gastric juice.
A linear curve was obtained for drug concentrations of 0.78～100μg/ml, however, marked increases in inhibition zone diameter were seen with gastric juice addition, suggesting the existence of a substance of suppressed H. pylori. The substance seemed to exist for all treatments, with the pre-endoscopic drugs having the greatest inhibitory effect. Untreated gastric juice did not possess the inhibitory effect.
It is hoped that in the future this method can be used directly assay the concentrations of PPIs and other drugs in the gastric mucosa in successful and unsuccesuful H. pylori eradication cases.

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It is well known that there is a chronic active gastritis (CAG) in Helicobacter pylori (H. pylori) infected stomach. A characteristics of CAG between in H. pylori positive gastric ulcer and duodenal ulcer were studied. We found many differences as follows :
1) CAG was stronger in corpus than in antrum in H. pylori positive gastric ulcer. It was remarkable in cases accompany by gastric mucosal atrophy.
2) In H. pylori positive duodenal ulcer, CAG was stronger in antrum than in corpus. There was no relation in atrophic change of gastric mucosa.

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For the past five years (Feb. 1993-Jan. 1998) , 42 handicapped patients with upper gastrointestinal complication underwent endoscopic examination at the institute.
To take a safe measure, at least four staff members were to assist the handicapped patients during the endoscopic examination. The incidence of esophageal hiatus hernia and reflux esophagitis were particularly high (73.7%) in patients associated with severe mentally and physically disorders who are lying in bed and tube feedings.
When performing endoscopic examination on mentally and physically patients, keeping the safety of the patient in mind, consideration while carring out sedation is important.
Therefore it is necessary to have at least four staff members namely the endoscopist, a sedation specialist, a nurse, and care-worker during the examination.

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From January 1993 to August 1998, five cases of lymphangioma of the colon were diagnosed with endoscopic ultrasonography (EUS) . Endoscopically, four cases revealed as the smooth surfaced hemispherical lesion which covered with normal mucosa with transparency. Only one case revealed a slight elevation in the transverse colon.
EUS findings showed monotonous low echoic area in the submucosal layer and 4 cases of hemispherical lesions were accompanied with septum formation. Four cases were diagnosed cytologically (aspiration cytology) and one case of them was diagnosed histologically after endoscopic resection. Remaining one case was diagnosed only by EUS and have been followed up for these 2 years without any remarkable changes, not only endoscopically but in EUS.
In conculusion, EUS findings of lymphangioma was specific and would be the most helpful diagnostic procedure.

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The method of injection hemorrhoidal sclerotherapy via rigid anoscope has not been generally accepted because it is difficult to inject a sufficient amount of sclerosant into the adequate site of the rectal mucosa, and because the effectiveness of this method is unsatisfactory. The first paper of the endoscopic hemorrhoidal sclerotherapy was published in 1991, where the new method was shown to overcome the shortcomings of the former method. Since Jan. of 1995 to Oct. of 1998, we performed endoscopic hemorrhoidal sclerotherapy for 187 patients, of which we were able to follow the 166 cases. The purpose of this study is to analyze the clinical effectiveness of the endoscopic hemorrhoidal sclerotherapy. In 63 cases of anal prolapse, the procedure was effective in 58 cases (92.1%) . In 99 cases of hemorrhoidal bleeding it was effective in 98 cases (99.0%) . All 4 cases of anal pain were effective. Retreatment was needed in 22 cases. And surgical therapy was needed in 6 cases. By using this technique we were able to select the adequate site for injection and were able to inject the sclerosant sufficiently and safely. In conclusion, the endoscopic hemorrhoidal sclerotherapy is an easily-perfomed, safe, and effective modality for the treatment of symptomatic internal hemorrhoids.

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A self-expandable metallic stent (EMS) was implanted in the bile duct in 20 patients with inoperable malignant biliary strictures, and was assessed for utility and problems. Anti-tumor therapy was administered to 9 patients. Of 20 patients, 17 patients (85%) returned home after EMS implantation, of whom 7 patients had to return to hospital because of stent obstruction. The 12-month cumulative rate of post-implantation patency was 48.5% and the 12-month cumulative survival rate was 36.4%. There was no difference in patency rate or survival rate in relation to anti-tumor therapy. Complications of EMS implantation occurred in 11 patients (duodenal ulcer in 4 patients, cholangitis in 5 patients, acute cholecystitis in 2 patients and acute pancreatitis in 2 patients) . Internal fistulation by EMS implantation did much to improve the quality of life of patients with inoperable malignant biliary strictures. It shouled be borne in mind, however, complications may occur depending on the site of EMS implantation or the type of EMS.

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One hundred and twelve polyps (Ip87, Isp23, Is2, mean size1.4cm) were excised using the detachable snare with a two-channell colonoscope. No complication such as bleeding or perforation was found after the polypectomy in 112 lesions. This method enables polypectomy to be easy, secure and certain to conduct.

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The case was a 67-year old male with a past history of gastrectomy due to gastric ulcer. Upper gastrointestinal tract endoscopy for follow up in 1995 showed an erythematous, slightly depressed lesion in the middle thoracic esophagus. Biopsy specimen disclosed dysplasia. Follow up endoscopy in November 1997 showed a round, elevated lesionwith a central erythematous elevation which was not stained by iodine spray. The central elevation had depressed during ultrasonic endoscopic examination after admission, which disclosed poorly-differentiated squamous cell carcinoma with sarcomatous element. No transitional zone was found between squamous cell carcinoma lesion and sarcomatous lesion. Immunohistochemistrical staining disclosed that the sarcomatous component was negative for epithelial membranous antigen and positive for vimentin, which demonstrated the elevated lesion as pseudosarcoma. The patient underwent subtotal thoracic esophagectomy after chemotherapy. Histological examinasion of the resected specimen showed that the remaining tumor invaded the muscularis propria with no metastatic lymph nodes. We have reported a rare case of carcinosarcoma presumably classified as pseudosarcoma.

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A 66-year-old male was seen in Hitachi General Hospital because of dysphagia. Endoscopic examination revealed a 5cm-sized elevated lesion showing grayish and hemorrhagic granular surface at the lower third of the esophagus. Biopsied specimens of the lesion was diagnosed as carcinosarcoma of the esophagus. No distant metastasis was estimated.
Subtotal esophagotomy and proximal gastorectomy were carried out emergently due to hematemesis.
The tumor was histologically diagnosed as malignant melanoma by histpathological and immunohistochemical examination. Histological staging was represented as follows : A₁, N₁, M₀, Pl₀ stageII, ie (－) . Melanoma cells permeated in the lymphatic vessels and small veins (ly₂, v₁) .

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A 63-year-old Japanease male was incidentally pointed out a elevated lesion on the greater curvature of the upper stomach body at a health check. Subsequent endoscopic examinations were followed up periodically for 6 years. The internal echo pattern of elevated lesion, which was resembled to myogenic tumor changed by the Endoscopic ultrasonography (EUS) in February 1998, so he admitted to our hospital for further invastigation and treatment. Endoscopic and upper gastrointestinal double contrast X ray examinations showed the nodular elevated lesion with mucosal bridging fold, which had no ulceration. EUS revealed submucosal tumor, which was the 27mm in diameter and seemed to be originated from 3rd to 4th layers, and showed cystic and solid internal echo pattern. So, we attempted EUS guided fine needle aspiration cytology (FNA) to the elevated lesion, then which was diagnosed gastric abscess. To date, only 16 cases of gastric abscess have been reported in Japan and no cases have been diagnosed by EUS guided FNA cytology. EUS guided FNA cytology will be of help to evaluate gastrointestinal submucosal lesion in the near future. We reported a case of gastric abscess, which resembled to myogenic tumor of the stomach by endoscopic ultrasonography.

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Recently, a new concept of gastrointestinal stromal tumor (GIST) has been advocated to the tumor which is originated in the mesenchymal tissue. We report on two cases of gastric GIST with extraluminal growth.
Case 1 : A 58-year-old male was pointed out a lesion in the upper corpus of the stomach by gastric mass survey in 1997. The lesion was formed with pressure from outside of the gastric wall. The endoscopic examination using an ultrasonic probe showed the hyperechoic mass, 5 cm in diameter, which had the continuity with the fourth layer of the gastric wall. Partial gastrectomy was performed because the malignancy could not be excluded. The lesion was composed of spindleshaped cells and diagnosed as GIST by immunohistochemical study.
Case 2 : A 74-year-old female was pointed out a submucosal tumor, 1.2cm in size, in the upper corpus of the stomach by gastric mass survey in 1998. Endoscopic ultrasonography revealed the homogeneous hypoechoic mass, 5 cm in diameter, which developed to outside of the stomach and had the continuity with the fourth layer of the gastric wall. It was resected and diagnosed as GIST by immunohistochemical study.
We are not aware of any reports of a case of GIST with the extraluminal growth, which was demonstrated by ultrasonic endoscopy.

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A 72-year-old female referred to our hospital because of upper abdominal pain on Septenber 27, 1997. She had been suffered from Rheumatoid arthritis during recent two years, and was treated with NSAIDs, immunosuppresive agents. Endoscopic examination revealed multiple erosions on the lesser curverture aspect of the antrum. Endoscopic ultrasonography revealed small aechoic lesions in the submucosa. After the biopsy of a erosion, a small cyst appeared. In spite of treatment with PPI, her multiple erosions were not cured. On endoscopic examination one month and one year later, the same findings were found on biopsy.
Gastric submucosal cysts are rare disease. Many cases of gastric cyst were diagnosed by operated specimens with gastric cancer. In this case, it seemed that, this gastric cyst was caused by chronic inflammation. Because many inflammatory cells were found in the gastric mucosa and submucosa with thickned muscularis mucosae. We thought that this case was valuable one, because it was dificult to detect gastric submucosal cysts that were diagnosed without operation on literature.

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The relationship between Helicobacter pylori (H. pylori) infection and foveolar hyperplastic polyp has been reported. In our study, 6 cases of foveolar hyperplastic polyp located on antrum or angulus were disappeared and reduced after the eradication of H. pylori.
It is considered that this phenomonen is due to the improvement of H. pylori-induced mucosal inflammation. This result suggests that the H. pylori eradication may be expected as a new treatment of foveolar hyperplastic polyp.

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A gastric elevated lesion of a 47-years-old woman was followed by endoscopy for 4 years from 1994, because histological findings of biopsy specimen showed as hyperplastic polyp. In 1998, 4 years later, biopsies were performed and histological study indicated hyperplastic polyp with severe atypia. The lesion was completely resected by endoscopic polypectomy. Pathohistological findings showed almost 70% of the total area was occupied with adenocarcinoma cells, and the rest was diagnosed as hyperplastic tissue. We reported a case of smooth surface elevated lesion in stomach which was finally diagnosed as carcinoma. These results suggested that biopsies from every part should be performed in order to diagnose gastric smooth surface elevated lesion, and complete resection by endoscopic polypectomy should be done.

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A 89-year-old female was admitted to our hospital recommended endoscopic gastrostomy. Her activity of dairy living was limitted by hemiplegia. It was difficult for her to intake food perorally. Endoscopic gastrostomy was done. But feeding trouble was occured frequently by the elevation of intraabdominal pressure. Then, endoscopic jejunostomy was intended. When jejunal tube guided endoscopically inserted in duodenal bulb, perforation was happened. Peritonitis and secondary pancreatitis were occured. But her accident was recovered by conservative treatment. This case report suggest that when endoscopic procedure was necessary for after-gastrostomized state, careful management was important.

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A 91 year-old female was admitted to our hospital because of hematemesis. Emergency endoscopic examination disclosed an exposed vessel in the large diverticulum of the second part of the duodenum. Clipping of the vessel was performed endoscopically, and no further bleeding took place thereafter. Hemorrhaging from a duodenal diverticulum is a rare condition and only 56 cases have been reported in Japan. Although resection of the diverticulum was the most popular approach for hemostasis formerly, endoscopic procedures such as ethanol injection therapy have recently become more widely used. Clipping was done in 5 cases and failed to stop bleeding in one case. Exposed vessels which are the cause of bleeding from duodenal diverticulum are seen in about a half of the reported cases. Therefore endoscopic clipping procedure, compressing the bleeding vessel directly by metal clip, is thought to be one of the most effective ways of stopping hemorrhaging from duodenal diverticulum.

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A 24-year-old woman came to the hospital for the biennial check-up. She had had iron deficiency anemia since the age of 11 years, and was found to have multiple polyps in the stomach, small bowel and colon (reported at the 44th Endoscopy Congress) . Polyps were pedunculated as well as sessile, and particularly there were more in the jejunum. Laparotomy was carried out and 39 polyps were removed surgically ; anemia improved subsequently. She was followed every 2 years thereafter. In Nov. 1996, she developed mild anemia. Upper GI endoscopy disclosed 2 polyps in the stomach, colonoscopy demonstrated several, and barium study numerous polyps in the small bowel. Polyps in the small bowel were removed under laparotomy. These polyps were hyperplastic histologically. We now report on this patient with recurrent juvenile polyposis with a review of the literature.

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A 26-year-old man with hemophilia A was admitted to the hospital complaining of persistent lower abdominal pain. Ultrasound showed a cystic fluid collection around the rectum. Abdominal CT and MRI revealed a heterogenous mass around the rectum extending to lower sigmoidal colon. Gastrografin enema showed stenosis due to extrinsic mass of the rectum. Colonoscopy showed a disturbance of extension as well as intramural hematoma. Abdominal symptomes were resolved after administration of cryoprecipitate under the diagnosis of intramural rectal hematoma.

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A 66-year-old man visited our hospital complaining of rectal bleeding. Colonoscopic study showed tumor in the transverse colon. Transverse colectomy was performed. Tumor was 1.5×2.5cm in size, diagnosed as endocrine cell carcinoma invading subserosa, with lymphnode metastasis (n3) , but without liver and peritoneal metastasis. Prognosis of such colonic endocrine cell carcinoma has been recognized very poor, recently. It tends to occur in rectum but our reported case, tumor occupied in the transverse colon, relatively rare site.

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A 46 year-old man was pointed out positive test for fecal occult blood wtihout any symptom. Barium enema examination showed rectal polypoid lesion without any mucosal lesion, however, total colonoscopy revealed ulcer lesions localized only in the cecum covered with yellowish coat. Pathological study showed erosive change and PAS-positive round cells phagocyting red blood cells, which suggested trophozytes of Entamoeba histolytica. Serological examination for Entamoeba histolytica was positive and metronidazole 1.5g/day was given for a week. Two months later, there was no ulcer lesion in the cecum. This case suggested the importance of total colonoscopy for anyone with positive fecal occult blood and of thinking amoebic colitis as one of the colonic inflammation in the ileocecal region.

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A 17-year-old girl having no remarkable past history was admitted to our hospital because of abdominal pain, pyrexia and mucosanguinous diarrhea. Blood chemistory findings on admission were all within normal limits exept for incresed CRP level and white blood cell count, indicating an acute inflammatory reaction. A few stool cultures yielded no enteric pathogens. Colonoscopy demonstrated diffuse multiple aphthoid lesions with circumferential redness in the enteric colon and rectum, being compatible with aphthoid colitis proposed by K. Yoshikawa. She was treated by antibiotics and bowel rest, which have been reported to be effective to aphthoid colitis but were not in this case. Her symtoms and the increased inflammatory reactions improved soon after the administration of Sarazosulfapiridine (SASP) , and colonoscopy done 3 weeks later revealed that aphthoid lesions were healed. Since colonic aphthous ulcer can be an early phase paradigm of inflammatory bowel diseased such as Crohn's disease, we need further observation, but no evidence of recurrence has been noticed for 8 months. This case suggests that SASP can be one of therapeutic options to an aggressive case of so-called aphthoid colitis.

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A 58 year-old woman visited our hospital, with slight fever and goiter. She was treated by NSAID as subacute thyroiditis. Clinical symptom disappeared, but erythrocyte sedimentation rate (ESR) remained accelerating. 2 years after the treatment, occult blood test of her feces turned to positive in mass survey for colorectal cancer. Colonoscopy revealed circular stricture with irregular, shallow and ringed ulcers on right sided transeverse colon.
Biopsy specimen showed granulomatous inflamation with caseation necrosis. Chest X ray showed tiny nodules on both upper lobes of the lung.
Anti-tubercular drugs were effective, and ESR normalized.
Mycobacterium tuberculosis was not detected by Ziehl-Neelsen's staining and PCR technique.

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Dilatation with a balloon catheter was successfully performed for a sigmoid stricture which occurred in a patient with ischemic colitis. A 82-year-old male patient presented with diarrhea and lower abdominal pain from the end of January 1998. He was admitted to our hospital in February. Colonofiberscopy showed narrowing of the lumen and ulcer in the sigmoid colon. Barium enema showed a 3.5cm length stenosis and thumb-printing shadow in the sigmoid colon. He was diagnosed as ischemic colitis. As the symptoms disappeared after conservative therapy, he was discharged in March. Because the symptoms recurred from May, he was readmitted in June. Colonofiberscopy showed marked stenosis of the sigmoid colon that could not be passed through by the scope. After the stricture was dilated by balloon dilator, he referred no complains. No crecurrence of the stenosis has occured five month after the procedure. The balloon dilatation technique may be worth trying before surgical treatment in treating ischemic colonic stricture.

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Torsion of the gallbllader is a rare disease which is difficult to diagnose preoperavility, because of its non-specific symptomes Most of patients with this disease are operated on with a diagnosis of acute cholecystitis, peritonitis or appendicitis.
Recently, owing to the development of modern imaging procedures, a few cases in the Japanese literatures were diagnosed preoperavility.
An 82-year-old man complaining of right hypochondriac pain was found to have remarkable abdominal tenderness and defense. Ultrasond examination demonstated a swollen gallbllader with thickened wall and a small amount of ascites. Subsequent computed tomography visualized the constriction at the gallbllader neck. We attempted percutaneous transhepatic cholecystography to obtain further information. The first puncture demonstrated the bird beak sign at the distal part of the constricted portion of the gallbllader. The cystic and common bile duct were visualizedby the second puncture at the proximal part of constriction. Operation was performed one day after the onset, with suspicion of torsion of the gallbllder because of the bird beak sign. At operation, the congestive and swollengallbllader was found to be twisted clockwise by 210° to 240° at the nwck. Pathological features of the resected gallbllader specimen were compatible with diagnosis of gallbllader torsion.
It is anticipated that percutaneous transhepatic cholecystography may yield an increasing number of accurately diagnosed cases of gallbllader torsion before operation. Because of the risks of complications from the puncture procedure, the surgeon should be prepared for prompt operation.

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A 66-year-old man with alcoholic liver cirrhosis was admitted to our hospital for endoscopic injection sclerotherapy (EIS) in December 1997. He was submitted to EIS using 1% aethoxysklerol. After two sessions of EIS, a hyperemic area with marginal irregularity was detected in the posterior wall, 33cm distal from his incisor. It was not stained by iodine, and was diagnosed as squamous cell carcinoma histologically in the biopsied specimen. Because endoscopic ultrasound sonograpy showed that the carcinoma located only in the epithelial layer, we perfoemed endoscopic mucosal resection using EEMR (endoscopic esophageal mucosal resection) -tube.
There have been 20 cases of esophageal carcinoma after EIS reported in Japan. But there was no case of esophageal carcinoma discovered by EIS.

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We report an 78-year-old man reffered toour department for the management of dysphagia. Endoscopy revealed the cardiac gastric carcinoma and a 7cm-long invasion towards the esophagus. The covered self expanding metalic stent (WALLSTENT^R, SCHINEIDER) was inserted.
On the next day, the stent migrated 3cm down. The patient could swallow diet smoothly. 4 days later we started tegafur・uracil 600mg/day therapy and 3 weeks later, cisplatin 75mg drip infusion added. A month later, tumor overgrowth hap-pened to the proximal uncovered part.
The second covered WALLSTENT was inserted at oral side and overlapped 7cm to the first stent. The secondstent was not migrated. 10 days later, the first stent was migrated down and collided to the stomach wall. We could not pull up the first stent by a baloon or forceps. 24 days later, both stents fell down to the stomach and connected with each other.
We put in an overtube through the 2-chnnneled fiberscope, hanged the stent by a forceps, snared it, and put the stent into the overtube. The connection between the two stents aparted when the stent was removed with the overtube.
A week later, the rest stent was removed by the same method. WALLSTENT can removeusing fiberscope. It is rare report that the removal of the WALLSTENT which was fallen into the stomach lumen using fiberscope.

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A 69-year-old woman who has suffered from loss of appetite, constipation and weight loss. She had an experience of dysentery 52 years ago and no history of tuberculosis. Chest X-p showed normal appearance. Barium enema examination showed a narrowing in the rectum and cord like lesions in the hepatic flexure. Total colonoscopy revealed diffuse and multiple ulcer scars and mucosal bridges between normal mucosa in the entire colon. Histological findings were almost normal. It was reported that endoscopic findings dysentery may vary from erythema to marked superficial ulcerations and rarely deep ulcers. In this case, it was suspected that multiple colonic ulcers of dysentery 52 years ago became multiple ulcer scars and mucosal bridges in the entire colon.

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