Six consecutive cases of drug-induced esophageal ulcer were presented with special reference to their endoscopic characteristics. Causative drugs were a doxycycline hydrochloride (Vibramycin) capsule in four cases, a Vi-bramycin tablet and a clindamycin hydrochloride (Dalacin) capsule in one case respectively. As to the patient's history, it is very characteristic that they took a capsule or a tablet just before or even after lying in bed, with no or only small amount of water. The symptoms were substernal burning pain and odynophagia. It was common in all cases that the symptoms appeared very soon or within several hours after taking the drug. These drug-induced esophagal ulcers healed very rapidly. The symptoms disappeared completely within 6 to 15 days (8.5 days on an average), and the ulcers healed endoscopically on the 6th to 18th clinlcal day (11th day as a mean). The diagnosis is fairly easy because of the characteristic history and the relationship to the drugs. Actually from the 2nd case in our series, we were able to suspect almost exclusively a diagnosis of drug-induced esophageal ulcer only by hearing the characteristic history mentioned above, and successfully confirmed it by immediately endoscopy. Endoscopy was performed within 4.8±2.0 days and successfully confirmed fresh ulcers in all cases. The ulcers were multiple, shallow and irregular both in shape and size. In cases of Vibramycincapsule, there was a main ulcer, comparatively bigger and deeper one, and the rest of the ulcers were scattered around or distal of it. These features might be closely related to the lodgement of a dissolving capsule and the spreading of the strongly acid content. Endoscopy should be performed as soon as possible. Otherwise the ulcers might not be found because of the fairly rapid healing.

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When ERCP was unsuccessful by the use of JF-B, it was often helpful to substitute a slender, frontal viewing f iberscope (GIF-P₂, Olympus) for the former instrument, Here is described the significance of using GIF-P₂ in ERCP. Out of 15 cases in which ERCP with GIF-P₂ was attempted, the cases of successful cholangiography were 11, and those of pancreato-graphy were 7, thus well supplementing the low rate of cholangiography by the use of a lateral viewing instrument, JF-B. Indications of using GIF-P₂ for ERCP will be following:1) Unsuccessful cannulation into the orifice of papilla by JF-B.2) Unsuccessful case of cholangiography by JF-B.3) ERCP for cases with stenosis of the esophagus, the stomach and the upper duodenum.4) ERCP in gastrectomized cases with Billroth II anastomosis etc.

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Since 1969, the authors have carried out measurements of temperature on the esophageal and the gastric mucosa using a gastrothermometer with an accuracy of 0.01°C. Three hundred cases were studied, which included 31 esophagi, 76 stomachs and 186 lesions. Four cases of atrophic gastritis and three cases with endoscopically normal stomach were regarded as controls, in which an area of 3 X 3cm² in size were studied as the standard of the thermal distribution in the stomach. The detailed method of measurement was previously reported in the 1st Asian-Pacific Congress of Endoscopy, held in 1973. Results: 1. A delicate thermal difference existed on the lesions of the stomach, when measured with a precision of 0.01°C. This may reflect the difference of the blood flow in that part. 2. In general, cancerous lesions had a wide range of thermal distribution. 3. In the active gastric ulcer, temperature of the central depression was low, but that of the margin was high. This thermal gradient tended to disappear in the course of healing, and thermal difference became smaller within the central depression or marginal parts. 4. The chronic ulcers without tendency of healing had relatively larger ranges of thermal differences. 5. The bigger the polyp, the larger the range of thermal difference. 6. The temperature in the gastric polyps were higher at the top than at the root. 7. A consideration of the thermal difference would be of diagnostic value as well as thinking of the shape and size in a protuberant lesion. 8. The range of temperature in the esophagus was from 36.30°C to 37.29°C, and its distribution ranged 36.80±0.09°C. 9. The temperature of the stomach ranged from 36.06°C to 37.97°C and its mean value was 37.10±0.13°C.

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Emergency endoscopy was performed on 120 consecutive patients with bleeding gastric ulcer, and endoscopic findings of ulcer base were correlated with prognosis. According to relative distribution of 'belag' (white or brownish white coat covering ulcer base) and coagula on ulcer base, ulcers were classified into four types, i. e., B (belag type), Bc (belag+coagula type), Cb (coagula + belag type) and C (coagula type). The present series consisted of 38 type B, 46 type Bc, 17 type Cb and 19 type C ulcers. In patients with type B and type Bc ulcers, bleeding recurred in 2 (5.3%) and 7 (15.2%) respectively, but none developed irreversible shock or underwent emergency operation. In type Cb ulcer patients, bleeding recurred in 10 out of 17, and one of them developed irreversible shock, and 3 patients underwent emergency operation. In 19 patients with type C ulcer, an incidence of rebleeding was extremely high (18 out of 19), and irreversible shock was observed in 11. Most of the rebleeders had to be subjected to emergency operation. Thus it is concluded that the present classification of ulcer base at emergency endoscopy may be a useful prognostic factor in bleeding gastric ulcer.

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We studied on recurrence of gastric and duodenal ulcers. There have been many previous reports on this subject and we also reported recurrence of gastric ulcers at the 2nd. Asian Pacific Congress in Singapore in 1976. Since then we have approached to clarify differences in recurrence between gastric and duodenal ulcers. During a seven-year period from 1970 to 1977, we followed up a total of 305 cases of gastric ulcers and 259 cases of duodenal ulcers for more than six months after complete healing on endoscopy. As a result, recurrence was found in 36.7% of the gastric ulcers and in 34.71 of duodenal ulcers. The recurrence rate similar between both groups and was higher in males, at an open stage at the initial examination and in cases of delayed healing. In general we treat peptic ulcers with anti-cholinergic, anti-pepsin and mucosal defensive drugs So and studied relation between the recurrence rate and medical treatment. Recurrence rates of gastric and duodenal ulcers were predominantly higher in cases of discontinued medical treatment. In gastric ulcer, 58 (50.4%) of 115 patients who discontinued medication had recurrences. On the other hand, only 20.9 % recurred in patients who continued medical treatment. A similar tendency was noted in duodenal ulcers. 44.3% of the discontinued medication group had recurrences but only 26% in continued medication group. Regarding the relationship between an accumlated recurrence rate and time interual until recurrence, 50.8 % of patients with gastric ulcers had recurrences within one year after healing of the initial ulcers and 75% had recurrences within two year. In duodenal ulcer, there was a similar tendency in recurrence as in gastric ulcer, 44.5% of patients had recurrences within one year after healing of the initial ulcer and 75.5 % had recurrences within two year. We, therefore, need to observe patients very carefully during the first year after healing of the initial ulcers. With regard to gastric acid secretion, there was no difference between non-recurrent and recurrent groups.

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Trench ulcer, a special type of acute gastric ulcer, is complicated in aged patients over 60 years old, suffering from cardiovascular disease such as arteriosclerosis, hypertension or myocardial infarction. To elucidate the pathogenesis of Trench ulcer, serum gastrin, gastric secretion and gastric mucosal blood flow were measured in three cases. Serum gastrin level, gastric acid and pepsin output did not apppear to play an important role in the causation of Trench ulcer. The patient with severe head injury showed low gastric mucosal blood flow prior to the development of Trench ulcer and a transient increase in healing stage. In tetanus patient which had a marked fluctuation of blood preasure, gastric mucosal blood flow during hypotensive period (70/0 mmHg) showed a decrease by 30% compared with that in hypertensive period (200/120 mmHg). Severe hypoxia continued for several hours in the patient with acute carbon monoxide poisoning, although the gastric mucosal blood flow was not decreased after the development of the ulcer. From these results, it seems that the disturbance of gastric mucosal blood supply followed by mucosal hypoxia is a major cause of the development of Trench ulcer.

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Extragastric compression by pancreatic cancer was studied endoscopically in 34 patients with pancreatic cancer confirmed by operation or autopsy. An extragastric compression was recognized in 5 (36%) of 14 patients with cancer localized in the head of the pancreas, while it was found in 17 (85%) of 20 patients with cancer located in other parts of the pancreas. The compression was noted mainly on the gastric wall anatomically adjacent to the site of the pancreatic tumor. Degree of the extragastric compression was not closely related to the size of pancreatic cancer. It seems to be influenced by the growing site and direction of pancreatic cancer. Regarding the features of extragastric compression, the elevation was generally gentle and the border was obscure. However, some cases of marked compression had a steep elevation and relatively clear border. Finally, the extragastric compression was classified into the following 5 types based on the general features. 1) minimal compression with smooth surface. 2) minical compression with smooth surface, accompanied by partial irregularity on its surface. 3) minimal compression with wholly irregular surface. 4) marked compression with smooth surface. 5) marked compression with smooth surface, accompanied by partial irregularity on its surface.

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During a 12-year period from 1965 to 1977, minute carcinoma of the stomach smaller than lcm in size was found in 19 (3.9%) of 484 patients with early gastric carcinoma operated on at the Aichi Cancer Center Hospital. Three asymptomatic patients were suspected to have a small lesion by gastric mass survey x-ray examination. Three asymptomatic and 6 symptomatic patients came to hospital to take a thorough examination of the upper gastrointestinal tract. Three had a follow-up as having a benign disease (gastric polyp or peptic ulcer.). Two patients developed a second lesion during a follow-up of benign diseases. In the remaining two, a second tumor was incidentally found on the resected stomach operated on for early gastric carcinoma. There were 13 symptomatic and 6 asymptomatic patients. The former included 10 with epigastric pain and 3 with epigastric fullness. X-ray diagnosis was correct in only three (16%), probably benign in 9 (47%) and normal in 7(37%). Endoscopic diagnosis was correct in 6 (32%), suspicious of malignancy in 8 (42 %) and benign in 5 (26%). Biopsy could obtain tumor tissues in 15 of 17 patients on a single examination. A repeat biopsy was required in 2 patients to make a positive diagnosis. Regarding the gross type, II c was seen in 10 (53%), II a in 7 (73%) and II a + II c in 2. As mentioned above, x-ray diagnosis was more difficult than endoscopy which could pick up an abnormality in all the patients. It is, therefore, concluded that a combined use of x-ray and endoscopic examination will be necessary to detect a minute lesion of gastric carcinoma and early performance of biopsy will make a definitive diagnosis.

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Gastric cancer occuring in identical twins are extremely rare. Reviewing the literatures, only 6 cases with gastric cancer in identical twins have been reported. This is the first case reported in Japan. Case 1. A 45-year-old businessman was admitted to the Yamaguchi University Hospital on July 5th in 1978. About a month prior to this admission, he noted hunger pain in epigastric region. After his subjective symptoms subsided, he underwent gastrof iberscopy which revealed a gastric cancer. X-ray examination of the upper G. I. series revealed irregular shaped shallow concavity, 20 × 1.7 cm in size, at the posterior side of the lower corpus. Endoscopic examination revealed a shallow reddish depeessed lesion without white coating and at the top of the converged mucosal folds showed stick-like swelling. The lesion was diagnosed as the II c type like advanced gastric cancer. Biopsy and resected specimen revealed signet ring cell carcinoma and well differentiated adenocarcinoma. Case 2. A 43-year-old businessman, the identical twin of the previously described patient, was accidentally found to have a shallow nishe, 2.0 × 2.0 cm in size, at the gastric angle through an examination of the gastric mass survey on December 18 th in 1975. Endoscopic examination revealed a shallow depressed lesion with central ulceration. Th lesion was considered to be II c + f type early gastric cancer. Biopsy specimen showed moderately and well differentiated adenocarcinoma. Resected specimen showed II c+ III type early gastric cancer.

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An unusual case of early duodenal carcinoma probably arising in the adenoma of the duodenum is presented. A 64 year old female was seen at the First Department of the Internal Medicine, Iwate Medical University, because of anemia and epigastric discomfort, stool examination showed positive occult blood. A barium examination of the duodenum revealed long mucosal folds running through the second portion. The folds began at near the papilla of Vater and reached to the portion of the ligament of Treitz where a mulberry like tumor, 4 cm. in diameter, was seen. Duodenof iberscopy revealed that the tumor was a pedunculated polyp. The head of the polyp was found in the third portion and the base of the stalk was near the papilla of Vater. The polyp showed strawberry like appearance with reddish and nodular surface. Histologically the large part of the polyp consisted of adenoma, whereas carcinomatous change was recognized in the upper part of the tumor. The invasion of the stalk could not be detected. The diagnosis of the early duodenal carcinoma (cancer in adenoma) was made, and malignant change of the adenoma tissue was suspected. There is no evidence of recurrence one year later. This case is considered to be of value on the point that carcinoma originated from adenoma of the duodenum.

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