From January, 1973 to July, 1978, emergency endoscopies were performed in 192 pa-tients hospitalized with bleeding gastric ulcer. Operation was needed in 73 patients (emergency operation, 59; elective operation, 14). The cases were classified into three groups according to the character of ulcer base as follows. 1) Group I (blood vessels are clearly observed in the ulcer base). Emergency operation was performed in 70.5% (31 out of 44) and all petients with an ulcer base, over 2 cm in size had an emergency operation. 2) Group II (an ulcer base is covered with fresh or coagulated blood, but blood vessels are not clearly seen). This group was further classified into three groups as follows, Group II-A: an ulcer base is entirely covered with fresh or coagulated blood. Group II-B: coag-ulated or fresh blood is seen as a clot in the ulcer base, Group II-C: coagulated blood is seen scattered in the ulcer base. In patients with Group II-A, Group II-B and Group II-C, emergency operations were performed in 7 (43.6%) of 16, 15 (83.3%) of 18 and 1 (9.1%) of 11 respectively. We found blood vessels on the ulcer base in all resected speci-mens in Group II-B. 3) Group III neither blood vessels nor coagulated blood are found in an ulcer base covered by whithish exudates. In this group, only one (1.8%) of 55 patient underwent an emergency operation. Summarizing our observation, we believe that endoscopic findings of an ulcer base greatly contributed to planning of the treatment and decision of emergency operation. When they belong to Group I or Group II-B on emergency endoscopy, intensive care seems ne-cessary for at least one week.

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A retrospective comparison was made on preceding endoscopic lesions and evolution in depressed types of gastric cancer. Sixty cases of depressed types of gastric cancer with fair photograph on previous endoscopic examination were selected. The observation period was at least 1 year, and the macroscopic types were as follows; early cancer, 33 cases; IIc like advanced cancer, 9 cases and Borrmann 2 or 3 types, 18 cases. A total of 116 endoscopic procedures were performed in the 60 patients and preceding lesions were classified into four groups; (1) ulcerative group-46 procedures (39.7-0), (2) gastritis-like group such as irregular reddening sign, fine granulation and tiny nodular eleva-tion-35 (30.20), (3) group of no abnormality detected-31 (22.7-0) and (4) group of over-looked malignant signs-4 (3.4%). In these four groups, the percentage of advanced cancer was especially high (54.3%) in gastritis-like group compared with other 3 groups (about 25%). This may suggest different growth patterns between early and advanced cancers. In early gastric cancer, preceding lesions commonly showed appearances of peptic ul-ceration. This finding increased in frequency as the interval between endoscopic examination and final diagnosis became shorter (20% over 8 years before final diagnosis, 80% within 3 years). Reddening sign also showed a similar tendency. But in advanced cancer cases, neither ulcerative changes nor reddening sign had any relationship between the incidence and the intervals. Gastritis-like changes were found with considerable frequency (20-60%). These results may suggest that in early stage the gastritis-like changes are underestimated on their malignant features and are not diagnosed until advanced cancer has developed. On the contrary, a lesion in ulcerative group is easily found at a relatively early stage. For the early detection of advanced cancer, a qualitative diagnosis of ulcera-tive lesion as made today seems insufficient according to our studies. In the near future an emphasis must be paid on a qualitative diagnosis in gastritis-like non-ulcerative lesions.

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Three hundred two patients with advanced gastric cancer were examined serially by endoscopy. They were 213 patients who received no preoperative chemotherapy, 51 those who received preoperative chemotherapy and 38 inoperable patients who were treated with chemotherapy alone. The endoscopic changes and the histopathological findings of biopsy specimens or resected stomach were investigated in relation to chemotherapy. It was found that there were several endoscopic features characteristic to chemotherapy, such as flattening of elevated lesion, shallowing of depressed lesion, smoothening of irregularity, amorphous flattening of the base of ulcerative lesion, blunting of demarcation between normal and cancerous lesion, appearance of monotonous redness in and or around depressed lesion and recovery of limited elasticity. Whenever more than 2 of the endoscopic changes mentioned above were observed, the chemotherapy could be regarded as effective even without any association of decrease in tumor size. According to these results, a new endoscopic grading of anticancer chemotherapy for gastric cancer was proposed. It is composed of progressive disease, no change and improvement which is subclassified as Grade I, II, III, and the endoscopic findings reported here were included in Grade I, even though they are not associated with a decrease in tumor size.

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The anomalous pancreaticobiliary ductal union has recently called attentio:l as to the etiology of the common bile duct dilatation. However, our previous report stressed that the anomalous union was not observed in all cases of the common bile duct dilatation. Here were reported a 65-year-old female with the cystic dilatation and a 55-year-old female with the cylindrical dilatation of the common bile duct. In the two cases ERCP disclosed the minor papillae in the duodenal diverticula without the anomalous pancreaticobiliary ductal union. Congenital local fragility of the duodenal and choledochal wall in the first case and the chronic inflammatory changes from the duodenum through the main and minor pancreatic ducts to the choledochus in the second case are suggested as the cause of the common bile duct dilatation. There have been few reports of the minor papilla in the duodenal diverticulum. Investigations into the minor papilla with the technique of FRCP will be essential for the etiological study of the pancreaticobiliary tract.

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The development and improvement of peroral cholangioscope have been made since the technical establishment of endoscopic papillotomy. Our best concern is how to introduce the scope directly into the common bile duct in the papillotomized patients. After several processes of trial and error. We have reached at the Vth stage of devel-opmental process with successful improvement of the cholangioscope itself and satisfactory establishment of methodology, of introduction of the scope into the common bile duct, which is considered as the most efficient method so far. That is a combination use of the main scope and supplemental devices such as balloon-catheter, inner guiding tube and outer guiding tube. The most characteristic point of this method is to detain the outer guiding tube into the common bile duct of the papillotomized patients. This procedure has ensured easy and repeated introduction not only of the main scope cholangioscope, but also other several types of forceps for biopsy or removal of intrahepatic bile stones. With this present pro-cedure, as a matter of fact, we have succeeded in removing intrahepatic bile stones in 3 cases so far. We will introduce the present state of peroral cholangioscope, reporting a clinical case of intrahepatic cholelithiasis which was successfully treated by this procedure.

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To investigate the laparoscopic change of liver surface directory related to the early hepatocellular carcinoma during hepatocarcinogenesis, the liver surface of rat fed with 0.06-0 3'-methyl-4-dimethylaminoazobenzene (3'-Me-DAB) was examined by the smallest diameter fiberscope (MACHIDA ENT-US-30). In the 4th week, the uneveness and localized red spots were appeared. Histological study of the another rat in the same stage showed the hepatic cell necrosis with inflamma-tory cell infiltration. In the 7th week, the red spots seems to be enlarged and the small vessels in the liver wedge increased. There was no necrotic lesion, but the hyperplastic foci which were focused as the ultimate precancerous lesion were seen histologically in this stage. In the stage of 9th to 13th, the red spots became more clear and the liver surface showed the slight irregularity. This appearance was resemble to the so called "patchy liver" in man. These findings showed the possibility that hyperplastic nodule will grow up from these red spots. Also, our technigue in this study is very usefull to reseach the course of precancerous lesion in experimental hepatocarcinogenesis.

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One of the problems with colonofiberscopy is the difficulty in inserting the instrument into the proximal colon. And the stiffness and elasticity of the fiberscope proper seems to play an important role in the ease of its deeper insertion. To solve this difficulty, therefore, the authors manufactured several prototype colono-scopes with various modifications in its stiffness and elasticity. Colonoscopy with these prototypes was performed in 180 cases to evaluate its clinical usefulness. The procedure was done without fluoroscopic control in the majority of the cases and sliding tube was not applied in any cases. The results obtained were as follows; 1) A prototype having three segments of different stiffness, distal 20cm segment of which is particularly pliable, following 20cm less pliable and the rest stiff, was found best for deeper insertion among these prototypes. 2) Even by prototypes with two step change in the stiffness, distal 40cm of which is pliable and the rest stiff, satisfactory results were obtained in the clinical use.

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We studied the relationship between recurrence of duodenal ulcer and endoscopic atrophic pattern in the stomach. The materials were 101 cases diagnosed as duodenal ulcer endoscopically. They were well-known to have the past history of duodonal ulcer, and studied by using the endoscopic Congo red scattering method, gastric biopsy, and measurement of gastric acid secretion. Our conclusions are as follows. 1) In fifty-two cases of following-up for a long term (-5, 5-10, 10-years), the recurrence rate were about 70 percent in every five years. 2) We evaluated the simple endoscopic Congo red scattering method to be effective in duodenal ulcer cases except for the cases with marked mucosal atrophy. 3) In cases with duodenal ulcer, the patients had a more distal atrophic border, and mucosal atrophy in the fundic area was mild. 4) In the recurrent cases, gastric atrophic pattern C-1 and C-2 groups were seen in 90 percent according to Takemoto and Kimura's classification, on the other hand, in non-recurrent group, open-type pattern was 33 percent. 5) In gastric acid analysis, the values of BAO and BAO/MAO in the recurrent group were higher than that in the non-recurrent group with statiscal significance.

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A case of acute gastro-duodenal lesions which were caused by water-immersion stress was presented. The patient is a 33 year-old male was admitted to our hospital with a complaint of se-vere epigastric pain, while working on the sea. X-ray and endoscopic examinations showed acute lesions in the antrum of the stomach, the bulb and postbulbar region of the duodenum. These lesions were improved ten days later. The lesions were different from stress ulcers in rats induced by the restrained water-immersion method. Acute gastric lesions of the antrum were frequently accompanied by acute duodenal lesions. The pathogenesis of these lesions is still unknown. We have to analize each case of acute gastro-duodenal lesions in detail in order to make the pathogenesis clear.

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A 78-years-old-woman with early esophageal cancer was reported. She had general fatigue, but dysphagia or other discomforts of the esophagus. The upper G-I X-ray series revealed slight mural rigidity in the middle esophagus. Fiberscopy showed a protruded lesion on the anterior wall of the esophagus 25cm distal from the upper incissors. By means of biopsy, histological diagnosis of squamous cell carcinoma was made. By iodine staining method, an unstained protruded lesion was distinguished cleary, in contrast to the normal esophageal mucosa which was stained black or brown. This was a case in which the in-vasion of the cancer was limited to the mucosa and metastasis was noted in any lymph node or in the other organs. The cancer was only 4×6mm in diameter.

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A 38-year-old man with mild idiopathic thrombocytopenic purpura, who was endo-scopically revealed to have multiple hemorrhagic lesions in the gastric mucosa, was present-ed. Patient visited our clinic with a chief complaint of epigastric pain. Physical examina-tion revealed no signs of petechial hemorrhage in his skin and oral and nasal mucosae. Laboratory examination revealed a decrease in platelet, 48, 000, in the peripheral blood and an increase in megakaryocyte associated with an increase in platelet in the bone marrow. Endoscopic examination demonstrated marked petechial hemorrhages confined to the f undic region of the gastric mucosa. The hemorrhage was not seen in the antrum of the stomach, esophagus, and duodenum. In the course of the disease, temporal remission of the petechial hemorrhage and thrombocytopenia were noted despite any specific treatments were not given for idiopathic thrombocytopenic purpura.

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Diagnosis of tuberculosis of stomach is quite difficult without histologic examination of the rerected stomach. This study is a case report of tuberculosis of the stomach, of which diagnosis was confirmed by histologic finding of biopsy specimen obtained from the site of ulceration under direct-vision. Patient is a 26-year-old male who had generalized tuberculous lymphadenitis 6 months prior to admission. He was admitted to Osaka Medical College with a chief complaint of upper abdominal pain. Ulceration was found at the cardia of the stomach by both endoscopic and x-ray examinations. Tuberculosis as well as simple gas-tric ulcer and diverticulum was suspected as a cause of ulceration. Histologic finding of biopsied specimen taken at the site of ulceration was compatible with that of tuberculosis. Administration of antituberculous agents such as INAH, KM. and EB resulted in good re-sponse. Two months later, ulcer diminished markedly and 3 months later, ulcer underwent stage of scar (S) . No recurrence of ulcer occurred during following two years endoscopic followup. Discussions were made on the cases with tuberculosis of the stomach reported previously.

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A case which is reported here for gastric carcinoid showing multiple polyps on the body of the stomach is a 58 years old, housewife. She had been treated for cardiomegaly for 8 years and also suffered from epigastric fullness for 4 years. Two years before operation, an X-ray examination at the mass screening for gastric cancer revealed gastric polyposis. Therefore she was ref f erred to Niigata Cancer Center following X-ray exams. Endoscopic examination revealed gastric polyposis on the body and biopsy specimens from polyps show-ed benign polyps. She had been followed up endoscopiccaly every 4 months with a diag-nosis of gastric polyposis. At the third examination, carcinoid tumor was suspected with biopsy specimens taken from one of these polyps. To confirm the diagnosis, endoscopic polypectomy for the largest polyp was performed to show the typical appearance of carci-noid tumor. In this patient biochemical examination for amines in the serum and urine showed nor-mal value including 5-HIAA and serotonine. After confirmation of the histological and biochemical examination, surgical operation was peformed. In the stomach 19 polyps all of which showed submucosal tumor on the body were seen. Carcinoid tumor proliferated mainly in the submucosal layer and formed submucosal tumor. These 19 tumors were connected with invaded carcinoid cells. The diameter of the largest one is 1.0 cm and it is the smallest tumor among the reported cases with the metastasis to the other organs.

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A 68 years old female was admitted to the hospital complaining of an abnormal sen-sation in her abdomen for 6 months. But during this time, she had no loss of appetite, change of bowel habits and no weightloss. Laboratory studies revealed a hemoglobin of 13.6gm/dl, hematocrit 41.5%, red blood cell count 453 million with normal differential. Stool specimens revealed evidence of blood. Upper gastrointestinal x-ray examination revealed a large, protruded tumor with soup bubble appearance in middle portion of the stomach. Endoscopy revealed a large fungating tumor from angle to corpus of the stomach, some erosion was seen in prepyloric antrum. Grossly the tumor measured 11.0×8.5×3.5cm was soft, polypoid with broad papillary projections separated by deep fissures and was attached to the lessure curvature of the stomach. Histological diagnosis of the lesion in prepyloric antrum was IIb+IIc type early signet ring cell carcinoma and its infiltration was limited within mucosal layer, and the polypoid fungating lesion in middle portion of stomach showed a well organized villous pattern. The patient is alive and well 2 years after surgery.

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A 69-year-old man complaining of right hypochondric pain, hematemesis and melena had underwent an emergency endoscopy 24 hrs after admission. No abnormal findings were noted in the esophagus, stomach and the duodenal bulb. But swelling, redness and bleeding were observed on the papilla of Vater. Furthermore, throughout the second portion of the duodenum were seen redness and erosions associated with bleeding. The acute hem-orrhagic erosions of the duodenal second potion were confirmed histopathologically by biopsy. The reported cases of acute hemorrhagic erosions of the duodenal second portion are extremely few, especially of those cases which were diagnosed endoscopically and histo-pathologically at an acute stage like this. The precise inf ormations in the acute stage would be helpful to study the pathogenesis of such hemorrhagic erosions. This case was also associated with renal failure and we discussed its role.

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A 25 year old female, diagnosed as Gardner's syndrome and had received an operation of subtotal colectomy in 1977, was readmitted to our hospital, complaining of right hypo-chondralgia and epigastralgia with elevated serum amylase levels. The endoscopic retrograde cholangiopancreatography showed the filling defect in the distal end of common bile duct. The papilla of Vater was slightly enlarged and a portion of tumor surface was observed through the orifice of common bile duct. The endoscopic papillotomy was performed for preventing the obstruction of the common bile duct due to the growth of the tumor. The endoscopic biopsy study after sphincterotomy succeeded in confirming the adenomatous polyp of common bile duct.

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A case of pneumatosis coli which was alleviated by oxygen therapy was reported. A 67 years old male came to our clinic in August 1978 with the complaint of loose stool admixed with air bubbles, mucus and blood. Plain abdominal film, barium enema study and colonofiberscopy revealed pneumatosis coli restricted to the sigmoid colon. Treat-ment of oxygen breathing was undertaken eight times at the outpatient service. This re-sulted in almost complete disappearance of the gas cysts. This case is the second in success of oxygen therapy for pneumatosis cystoides intes-tinalis in Japan as far as the authors could collected from the literature. The authors emphasized that only clinical awareness of this uncommon and interesting disorder could allow a rational approach to management that was (1) avoidance of unnecessary surgery and (2) conservative therapy including oxygen therapy.

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We reported our experience of using 4 types of wide-viewing duodenofiberscope with different angle and direction of view field: type A, 75°, side viewing; type B, 75°, 10° ret-rograde; type C, 95°, 5° retrograde; type D, 105°, side viewing. Each scope was the desirable one for upper GI endoscopy allowing better viewing and operation than the former duodenofiberscope, type JF-B3. Precise manipulation on cannulation or biopsy was rather troublesome with very wide-viewing scope, (e. g. type C or D), because working distance was too far. Therefore, the desirable scope for ERCP might be the one with 75° to 80° of viewing angle. Regarding the direction of view field, a side-viewing scope was convenient for FRCP. But, if available, the retrograde-viewing scope could be used on ERC with good results. There were no apparent differences in the rate of cannulation among 4 types of scope on ERCP. However, it was better than that reported previously from our institution.

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