Pyloric expansion of atrpohic gastritis has been proved by endoscopic biopsy and resected specimens. Carciac expansion of atrophic gastritis has been studied by an endoscopic congo red method. In this report, the biopsy is perf omed according to ring wise way around esophago gastric junction (EGJ) and stepwise way from the upper portion to the antrum along the lesser curvature. The ring biopsy is carried out from 2 concentric circles, one of which is close to EGJ as a inner circle and the other is 3 cm apart from the inner circle as a outercircle. The biopsy speciments are taken from the lesser, the greater, the anterior, and the posterior portion of each circles, and so the total biopsy specimens are 8 different points. According to the histological analysis of the biopsy specimens of each circle 3types of atrophic pattern are classified, type I shows normal mucosa at the both circles, type II showds atrophy only at the inner circle, type III shows atrophy at the both circles. The type I is seen in 31%, type II in 49% and type III in 20%, so that, atrophic change of the inner circlei is revealed in 69% of all cases. A frecuency of atrophic gastritis is increased according with the age of the patients. Atrophic gastritis in the upper portion of stomach was remarkable at the lesser curvature, and incidence is decreased at the posterior wall, anterior wall, and the greater curvature in order. From these results a bilateral expansion of the atrophic gastritis is shown in the most of the patients but an unilateral expansion is a part of patients.

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At the upper portion of the stomach, gastritis has been classified to some patterns by the congo-red method. In this paper, the congo-red method was examined in 44 cases of gastritis with ulcer in the upper portion of the stomach. On the other hand, the location and age distribution were examined by resected specemens in 62 cases of ulcer. The location of ulcers is most frequently (61%) on the posterior wall in the upper portion of the stomach. The cases above 60 year-old is seen in 47% of 106 patients. In these 44 cases, the congo.red pattern was classified into 5 types. Most cases showed type IV, according to the classification of S. Suzuki, M.D. But, the type IV should be devided into 2 sub-types; type IV-a, and IV-b. Discolored area of the type IV-a occupied the greater curvature from the fornix and the angulus, and the type IV-b occupied only the f ornix or no area. The type IV-a was recognized in 12 cases, and the type IV-b in 22 cases. As for congo-red pattern, discolored area is decreased following to the advancing age. The location and age distribution of ulcers in the upper portion of the stomach are closely related to the congored pattern. According to the age distribution of the congored pattern in relation with biopsy analysis, a bilateral expansion of gastritis may be considered as much as an unilateral expansion.

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We have been engaged in making a proper fiber-intestinoscope. The point of our aim is to carry out the intestinoscopy with simple and easy preparation an in gastroscopy or duodenoscopy . So, we adopted the push method, introducing the f iberscope actively from the mouth. Recently we have succeeded in making a fiber-jejunoscope, which could be applied for clinical use with satisfactory results.1) Our fiber-jejunoscope could be inserted distal of the duodenojunal flexure in 25 cases out of 33 and could observe the jejunal mucosa well, but observance of the small lesions and villi was not very satisfactory. It was easy to do aiming biopsy from a large lesion but was difficult from a small target.2) We established the technique of passing the duodenojejunal flexure by using a rigid outer sheath and proved its advantage.3) We consider that the greatest roll of fiber-intestinoscopy is to diagnose enteritis under direct vision with help of biopsy and to make an endoscopic approach to the mechanism of digestion and absorption of the small intestine. For this purpose we would like to improve our technique and instruments further.

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Multiple ulcers of the antrum frequently produce characteristics which may be confused with those of early gastric cancer types IIc, IIa+IIc and ha. Many of these ulcer cases are cured within a short period of time and the differentiation between benign and malignant ulcer generally is not very difficult. In some cases, however, the ulcer scar may become elevated . This findings makes it quite difficult to differentiate from early gastic cancer type ha by a short-term f ollowiup. We had 8 cases elevated type of the gastric ulcer scar which underwent X-ray and endscopic follow-up, biopsy and, in some of the cases, macroscopic examination of the resected stomach. Based on this findings of these studies, we propose to categorize such scar formations as elevated type of the gastric ulcer scar . This type of the gastric ulcer scar morphologically is characterized by the presence of a convergence of mucosal folds, a picture that is often seen with a malignant tumor . In our cases, histopathological findings were those of an ulcer scar type Ul-II maked by the rupture of the muscularis mucosae and fibrosis with the elevated part of the scar consisting of hyperplastic pyloric glands undergoing cystic dilation. The following points give important clues to the diagnosis of the elevated type of the gastric ulcer scar. (i) An elevation of the gastric mucosa with converging mucosal folds is seen on X-ray and gastroscopy. (ii) There is definite evidence that an ulcer was present at the same site previously. (iii) No malignant cells are detected by biopsy of materials taken from the elevated scar and its surrounding tissue. Pathologic conditions that should be considered in making the diagnosis of the condition in question include early gastic cancer of type I and ha, polyps, atypical epithelial lining, and verruciform gastritis.

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Even with precautions such as operative cholangiography or meticulous technics in exploring the common bile duct, retained biliary stones were still occasionary found within the tract after surgery. On the bassis of experiences of 274 operative and post-operative choledochoscopies in 86 cases including 23 cases with retained biliary stones and 9 cases with intrahepatic stones, retrospective studies on the findings of operative and T-tube cholangiographies performed in 120 cases were carried out to prevent retained stones.In conclusions;1) To overcome the pitfalls of conventional cholangiography, observation and selective cholangiography in conjunction with choledochoscopy seem the most reasonable approarch as a diagnostic test, because cholangiography alone is always inconclusive. And the results obtained in this series indicate that two procedures of choledochoscopy and cholangiography complement one another in avoiding the retained stones.2) Common duct exploration and endoscopic examination should be indicated when the diameter of the common bile duct is more than 1.1 cm to prevent retained biliary stones.3) Difficulties sometimes encountered is that a tortous and a narrow T-tube fistula can not negotiated by choledochof iberscope. To overcome this problem, T-tube which has an adequate diameter should be inserted into the common bile duct at right angles, without a tortous tract in the peritoneal cavity to accomplish observation of whole biliary trees.4) Operative and post-operative choledochoscopies are safe and simple procedures and its routine use is advocated whenever duct exploration is performed.

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The endoscopic papillotomy was performed to remove common bile duct stones. After the endoscopic papillotomy, the long catheter was inserted from the incized papilla into the common bile duct, and then, only the duodenof iberscope was pulled out to outside the body. By this procedure, this catheter has been able to retained in the common bile duct. The indwelling catheter method after endoscopic papillotomy was studied on this paper. This procedure could be successfully performed in 3 of the 4 patients. The retaining catheter method appears to be of value in the diagnosis and treatment of the biliary tract, and has many advantages as follows. 1) The ensuing cholangiography to observe whether the stone was delivered or not can be taken by this indwelling catheter. So there is no necessity to use duodenof iberscope. This method lightens a patients burder and prevent the damage of f iberscope from X ray. 2) Through this catheter, liquid lotion can be injected into the biliary tract to syringe it. This injection is useful to wash out the small stone from the biliary tract to the duodenum. 3) The antibiotics can be also given the bile duct through this catheter in the case of the biliary infection. 4) A solution for the stone can be poured into the bile duct through this catheter. 5) Insertion of the catheter into the bile duct is also useful method to prevent the complete stenosis of the incized papilla.

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Disinf ection of the endoscope was imperative to prevent infection especially in retrograde cholangiopancreatography. Although gas sterilization with ethylene oxide was desirable, it was not practical because it took a long time to process and moreover because many patients could not be examined with a limited number of scopes. Then a quick method of disinfection has been developed for a routine work and its effectiveness was bacteriologically evaluated. Our method was as followed. The flexible portion of the scope and the channel for biopsy were washed under running tap water or with an oral hygiene appliance and brushed gently. And then the cord and the channel were disinfected with 0.5% (W/V) chlorhexidine solution for at least three minutes and rinsed with water. Droplets on the exterior were wiped off and the channel was dried with compressor. This process took less than 15 minutes. Our quick method using 0.5% (W/V) chlorhexidine solution proved effective for disinf ection of daily examinatinns.

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A case of pharyngoesophageal diverticulum (Zenker's diverticulum) is presented with special reference to endoscopic findings, and the care of endoscopic examination is discussed. The authors also discussed the error of the triangular of Laimer as location of Zenker's diverticula. The authors point out that many other authors mistook the Lannier-Hackerman spatium from which the Zenker's diverticulum arises, for triangular of Laimer.

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Here is presented a case of erosive gastritis with marked hypoproteinemia, with special consideration on the effect of antiplasmin treatment for about 7 months. A 26-year-old male was admitted to our institute on 10 th Feb., 1975, with chief complaint of diarrhea, which continued preceeding several days. Physical examination was nothing contributory, but radiological and endoscopic examination of the stomach revealed numerous gastric erosions in different size and stages. On biochemical examination, the most remarkable finding was hypoproteinemia, as low as 4.5g/dl. But there was not anemia nor electrolyte imbalance. ¹³¹I-PVP test revealed recovery of 3.7% of injected material, which confirmed the proteinlosing process in the G-I tract. Gastric juice analysis showed unusual high level of protein content. The measurement of f ibrinolytic activity of the gastric mucosa was carried out according to the method of Astrup(The value of this examination was firstly reported by Kondo et al. in 1974.). The f ibrinolytic activity was high in this patient. While, the results of radiological and functional examination of the small intestine was not suggestive of the enteropathy. All of these results indicated at least the diagnosis of protein-losing gastropathy. As the treatment, t-AMCHA 3g daily was given to this patient as was recommended by Kondo et al., but even after 7 months with this treatment, serum protein did not return to normal level. All through the period, serum protein showed fluctuation from 4.5 to 5.5g/dl, without any significant correlation to wax and wane of the erosive gastritis.

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Complaining of anorexia for the last one month, patient, 51-year-old, female, admitted to our hospital. Two large tumors, typed Borrmann II, were found on the anterior wall of the antrum and the posterior wall of the angulus by X-ray and endoscopical examination. Both tumor consisted of sharply defined and ringshaped embankment, covered with smooth and grossy mucosa, and sharply margined ulcer. The ulcer of the angulus was covered with cream-like yellow coat. Degenerated malignant lymphomatoid cells were found from biopsy materials of the tumor of the antrum and no cancer cell was found from both tumors. From these result, we diagnosed preoperatively as two malignant lymphomas of the stomach. Histologically, these tumors were not connected on the epithelial layer, however, were connected partially within the subserosal layer. Consequently, it was diagnosed as single primary reticulum cell sarcoma of the stomach. In re-evaluating X-ray and endoscopical films, we found enlarged folds of submucosal tumor type between both tumors. This finding of submucosal tumor could be important for the preoperative diagnosis of gastric sarcomatous lesion. This patient was on chemotherapy post operatively (oncobin 3.8mg, endoxan 19600mg, 6MP 1400mg, predonin 1020mg) and was well during 20 months after operation.

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A case of a 61-year-old man with a bizarre leiomyoblastoma of the stomach is i eported . He was examined because of abnormality of the antrum in mass survey for a gastric disease. Our fluoroscopic examination revealed a smooth defect on the greater curvature of the antrum with the shadow of calcification. Endoscopy showed a broad-based, hemispheric tumor with a bridging folds, suggesting a submucosa .l tumor. There was no ulcer, nor bleeding on the surface. Partial gastrectomy with gastrojejunostomy was performed. Gross findings of the resected stomach showed a extraluminally growing, 4.0×3.6×1.8cm tumor on the greater curvature of the antrum. Microscopically, the tumor was composed of spindle or polygonal or round cells, and the most of round cells had a perinuclear clear space, which has been regarded as one of characteristic features of bizarre leiomyoblastoma. Case reports of bizarre leiomyoblastoma of the stomach have been increasing recently. Our case is the 36th in Japan, as the case with calcification, is the second one as far as we can refer.

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This report concerns a case of spontaneous cholecystduodenal fistula with interesting endoscopic findings and clinical course. The patient, 62 years old man, visited our out patient department with chief complaints of hematemesis and right upper abdominal pain. Endoscopic examination which was promptly performed with Olympus GIF-D2 in order to spot the site of bleeding revealed a small amount of hemarrhage in the duodenal bulb and a large dark brown gall stone just coming out of a large orifice of the cholecystduodenal fistula at the anterior wall of the duodenal bulb. An attempt at an endoscopic removal of the gall stone was unsuccessful due to it's huge size. The patient was admitted for a close observation of the clinical course because the possibility of a developement of complications such as gall stone ileus and massive hemorrhage was considered. A flat film of the abdomen revealed a large amount of air in the duodenal bulb communicating with the gall bladder and intrahepatic and extrahepatic bile duct. Symptoms suggestive of gall stone ileus developed on 4th hospital day and an operation was performed on 5th day. A large bullet-shaped stone, 22×24×40mm in size, was removed from the ileum, 30cm proximal to the ileocoecal junction. Remaining of other gall stones was considered from the facet formation seen at one end of the removed stone, but surgical intervention to the biliary tract was abandoned because of acute inflammatory changes of the region and the patient's general condition. No other stones were palpable, however, in the gastrointestinal tract. The postoperative course had been uneventful until 9th day, when symptoms suggestive of gall stone ileus recurred. Medical treatment resulted a passage of a large stone, ctimes;2122mm in size, in the stool on 17th day. The second endoscopic examination performed cn 30th day revealed complete healing and closure of the fistula orifice resulting in a scar formation at the anterior wall of the duodenal bulb. Endoscopic retrograde cholangiography showed moderate dilatation of the bile duct and deformity of the gall bladder without any residual gall stones or an abnormal communication between the biliary tract and the duodenum. Outflow of the contrast material through the Vaterian bile duct was normal. No air was shown in the biliary tract. The third endoscopic examination performed 4 months later showed similar findings. Clinical course of the patient has been uneventful. This case indicates an importance of a flat film of the abdomen and suggests that a spontaneous internal biliary fistula can heal to close completely in a short period in a case in which a couse of obstruction of the biliary tract distal to the fistula is removed.

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This paper is to present two cases with intrahepatic calculi, of which calculi were all successfully removed post-operatively under the guidance of choledochoscopy. Forty-two trials for first case, a 34-year-old female, and eleven trials for second case, a 47-year-old female, had been carried out until all intrahepatic calculi were successfully removed. Both patients remain well with no further symptom. The authers suggest that successive efforts in endoscopic approach will contribute to lessen the need for subsequent surgical intervention. Moreover, it is emphasized that choledochoscopy and selective cholangiography are also extremely helpful for the diagnosis of intrahepatic calculi.

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