A comparative investigation was done about the regenerated murosal appearance of intractable (I. U.) as well as tractable (T. U.) gastric ulcers. Using GIF-HM (maximal mag nifying rate : thirty five times), the marginal appearance of 73 gastric ulcers of 39 patients were studied. The gross endoscopic stages of the ulcers were classified into active (AT, A2), healing (HI, H2) and scarring (SI, S2) stages according to the Sakita and Miwa's classification. We could classify the patterns of the marginal appearance into palisade-, nodule-, and spindle-like appearances. We simplified those three patterns to mono component type (MI), mixed type 2 (M2: 2 of three patterns), mixed type 3 (M3: all of three patterns). The T. U. were subdivided to primary and reccurent ulcer groups. Histologically, the nodule-like appearance was found to be riped regenerated tissue and others were relatively unriped. The ulcers which showed the nodule-like appearance at the active stage were I. U. and rec-curent ulcer group. In general, M2 type was observed in the T. U., and began to appear at the active stage of them. M3 type was observed from A2 stage of I.U.. Then, we investivated the course of primary ulcers, they had multiple patterns, but most of them were M2 type. As the course, MI type transformed to M2 and M3 type. Changing the types each other, the ulcers healed to scarring. On the contrary, the mucosal appearance of I. U. had nothing to do with the stage, and M3 type was observed, it was continuously kept to the scarring stage. In case of mucosal appearance changed, I. U. took long time. It is concluded that it is possible to estimate whether ulcer will heal easily or not, in the first magnifying endoscopic examination.

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The change of enzyme activity of lactic dehydrogenase (LDH), isocitrate dehydrogenase (ICD), alkaline phosphatase (ALP), acid phosphatase (ACP) and patterns of LDH iso-enzyme were investigated in the mucosa of the margin of ulcer lesion and the periphery in the various stages (active, healing and scarring stages) of paptic ulcer by using endoscopy for biopsy. The mucosa was obtained at the margin of ulcer lesion and the periphery lcm distant from the margin of ulcer lesion. The control of each enzyme activity was taken in 6 parts of cardiac, middle and antral parts of lesser and greater curvature from the mucosa of normal stomach and from the mucosa of stomach with ulceration. The each activity of LDH and ICD in nomal stomach was 63 Wrob. u / mg wet weight and 117 Sigma u / mg wet weight. The activity of LDH and ICD at the margin of gastric ulcer was 55 Wrob u / mg wet weight (P<0.001) and 55 Sigma u / mg wet weight (P<0.001) in active stage, and 77 Wrob. u / mg wet weight (P<0.005) and 105 Sigma u / mg wet weight (P<0.001) in scarring stage, respectively. In the patterns of LDH isoenzyme, type V of LDH was 30% at the margin of ulcer lesion in active stage, whereas it was dramatically decreased to 16% in scarring stage. Type V of LDH was 19% in active stage and 15% in scarring stage at the periphery of ulcer lesion, which was not changed during healing process. Per-centage of H subunit was increased at the margin of ulcer lesion in the healing process. These resf lts might suggest that aerobic glycolysis was enhanced according to the healing process of gastric ulcer. On the other hand, we observed the opposite tendency in the changes of LDH isoenzyme patterns in the duodenal ulcer, which suggested anaerobic glyc-olysis was restored to the metabolism of normal duodenal mucosa. The activity of ALP was decreased at the margin of ulcer lesion and increased at the periphery of the ulcer lesion in the gastric ulcer. The same tendency in the change of ALP activity was observed at the periphery of the ulcer lesion in the duodenal ulcer. The highest activity of ACP was obtained in healing stage at the margin and the periphery of the ulcer lesion both of the gastric and duodenal ulcer.

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Endoscopic papillotomy (EPT) was attempted in 63 patients with stones of the common bile duct (CBD) encountered over afive-year period from February, 1975 to January, 1980. The indications for EPT in the present study include residual or recurrent CBD stones after cholecystectomy (18 patients), CBD stones in patients with stones in the gallbladder (23 patients), and CBD stones with an intact gallbladder (22 patients). The stones of the CBD were removed in 52 out of 63 patients a rate of removal being 82.5%. The stones were discharged spontaneously after EPT in 30 patients, and extracted successfully using the basket catheter in 13 patients. In the remaining 20 patients, both spontaneous passing and active stone extraction were required. The length of the incision of the papilla of Vater has a significant influence on the effect of EPT, particularly in patients with big stones. The bigger the stone in the bile duct the longer the incision will be. In patients with stones more than 40mm in diameter or with more than 10 stones in the bile duct, successful removal of all the stones by EPT may be very difficult. EPT was successfully carried out in 35 particular cases, wich consisted of 27 cases of juxtapapillary diverticulum, 5 cases of parapapillary choledochoduodenal fistula, 3 cases which had undergone gastro-ejunostomy of Billroth II, and one case of Billroth I. Short-term follow-up observations of biochemical findings were carried out. In most patients alkaline phosphatase and γ-GTP activities falled to a normal level after EPT. In some patients there was a transient elevation of transaminase and serum amylase activities only following the procedure, However, they returned to a normal level in a few days. Complications developed in 5 patients. Acute pancreatitis occurred in 3 patients. Cholangitis and retroperitoneal perforation occurred following EPT in one patient, respectively. No death occurred after EPT. A long-term follow-up observation was conducted in 16 patients after EPT. Sixteen patients has shown no evidence of re-stenosis of the papilla of Vater, but recurrent stones in the CBD were found in one patient. In is concluded that EPT was a very useful method for non-surgical treatment of CBD stones, since it could be performed with relatively high safety and without inducing noticeable pain.

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It is already known the gastric biopsy is important for diagnosis of early gastric cancer, especially of minute ont. We experienced 39 cases with 47 lesions of early gastric cancer less than 10mm in diameter. But there were 9 overlooked cases and 2 false negative cases. Therefore, more careful examination including biopsy should be performed. At this time, 342 cases with 374 lesions of early gastric cancer were experienced. Detectabilty of early cancer by biopsy specimens was studied. Relationship between macroscopic calssification and detection rate of early gastric cancer by biopsy was focused. Consequently, the detection rate of type IIa was the highest (92.3%). Following ha, came type I (75.7%) and type IIa+IIc (75.2%). There was a tendency that detection rate of protrudent type was higher than that of depressed type. The detectabilty of cancer in relation to its size was studied. We devided the size into following calsses; less than 10mm in diameter, 11 to 20mm, 21 to 30mm, 31 to 40mm, 41 to 50mm, 51 to 60mm and more than 60mm. The lesions with the size of 21 to 30mm gave the highest detection rate by biopsy. But difference from other groups were not significant. There is no correlation between the size of cancer and detectability of cancer by biopsy. Although every examiner knows the necessity of careful endoscopic examination and cautious biopsy, we have to point out this faxt again.

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The scanning electron microscopic findings of the surface structure of human gastric intestinal metaplasia were classified into 4 types according to the height and the distribution of the microvilli. And we studied the relationship of the morphlogical feature of intestinal metaplasia to its enzyme activity and its grade of methylene blue absorption. Type 1 : The distribution and the height of the microvilli of the intestinal metaplasia is regular, almost resembling normal intestinal mucosa. Type 2 : Parts of cells have difference in the height of the microvilli, but its distribution is regular. Type 3 : Immature cells, of which distribution of the microvilli is scarce, are recognised in some place. Type 4 : Such cells are recognised in many parts. On the relationship between methylene blue absorption and surface strfcture, Typel and Type 2, in which the distribution of the microvilli is regular, have higher capacity of methylene blue absorption comparing with Type 3 and Type 4 in which the distribution of it is scarce. On the other hand, concerning the relationship to the enzyme activity (ALP, LAP), many of Type 1 and Type 2 are classified as complete type of intestinal metaplasia (ALP +, LAP +), and many of Type 3, Type 4 are classified into incomplete type of intestinal metaplasia (ALP -, LAP +). We recognised intimate relationship among the surface structure of human gastric intestinal metaplasia, its capacity of methylene blue absorptin and its enzyme activity.

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We have experienced 20 patients with pernicious anemia (PA) during the last 10 years, and studied endoscopically their gastric mucosal atrophic pattern and complication of gastric cancer. Their family members were also examined when possible. 1) When the mucosa of the whole gastric body was severely atrophic, in contrast to the less severely atrophic antrum, and completely negative of discoloration by the congo-red test, it was defined as "endoscopic reversed atrophic type gastritis". In the cases of this reversed atrophic type gastritis, a border due to difference in severity of atrophy observed endoscopically between the antrum and the gastric body was defined as the reversed atrophic boder. 2) The reversed atrophic type gastritis was observed in 17 (85%) of 20 patients with PA. Reversed atrophic boder was seen in 12 (60%) of 20 PA patients. 3) In 4 of 11 members of the 7 families of patients with PA, a reversed atrophic type gastritis was found. 4) Reversed atrophic type gastritis of PA had relation to the hypergastrinemia, and no relation to the positivity of PCA and IFA. In cases of reversed atrophic gastritis of f ammly members of PA, serum gastrin was elevated as high as in PA, and was related to positivity of PCA and IFA. 5) Gastric cancer was associated in 5 of 20 patients (25%) with PA, including 1 patient with heterochronous double gastric cancer. Lesions were frequently found in the antrum, with a predominance of elevated, differentinated type of carcinomas. 6) A case of gastric cancer was seen in a higher percentage of family members of PA patient than in the families of gastric cancer or peptic ulcer patients.

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Recognition of the range of the visual field on the liver surface is important to diagnose small space-occupying lesions of the liver on peritoneoscopy. Clay models of the liver with the tumor were constructed from serial computed X-ray tomograms and were compared with peritoneoscopic findings. A metal probe was inserted up to the limit on the liver surface under peritoneoscopic observation and was phtographed by X-ray projection. The position of inserted probe was replicated on the clay models, clarifying the limit of the observable field of the liver surface on the models. The models revealed that it was impossible on peritoneoscopy to observe the space-occupying lesions locating at both the back upper and the right lateral sides of the right liver lobe. 60% of the liver surface of the left lobe, 30% of the upper surface of the right lobe, and 240 of the inferior surface of the right lobe were visible by peritoneoscopy.

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Frequent occurrence of pancreatitis has been known in patients with congenital malfusion of the dorsal and ventral pancreatic ducts. Six patients with such congenital malformations were documented by ERCP done for approximately 2, 500 patients with suspected biliary and/or pancreatic diseases. They showed non-fusion or incomplete fusion of two ducts, stenosis at the junction, dilatation of the dorsal duct distal to the junction and changes compatible with chronic pancreatitis. Morphological characteristics of ERCP of these six subjects were classified into following three types: Type I. Non-fusion of two ducts, with the dorsal duct narrowed in the proximal portion and dilated in the distal portion and its branches while the ventral duct intact. Type II. Incomplete fusion of two ducts with the ventral duct stenotic only in the junctional portion. The changes of the dorsal duce were same as in type. I. Type III. Disappearance of the dorsal duct distal to the junction. Stagnation of the dorsal duct and stenosis at the junction. Stagnation of the pancreatic juice was suggested as an etiology of recurrent pancreatitis from the association of chronic recurrent pancreatitis involving the pancreas around the junction and the dorsal portion as well as abovementioned morphological changes. We would like to propose a term "pancreatitis due to pancreatic juice stasis by congenital-malfusion of pancreatic duct" for this condition.

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The clinical significance of common bile duct stenosis was studied in sixty cases of chronic pancreatitis in which cholangiograms were available on ERCP. Common bile duct stenosis was disclosed in 18 cases (30%). The stenosis was seen in 6 (21%) of 29 cases with cholelithiasis. In the remaining 31 cases without cholelithiasis, it was observed in 12 cases (39%). Among them, we classified the common bile duct stenosis into four types: rigid straightening (2 cases), tubular stenosis (8 cases), localized stenosis (3 cases), and rigid tapering (5 cases) . Tubular stenosis type was comparatively characteristic of alcoholic pancreatitis, and rigid tapering type was frequently seen in gall-stone pancreatitis. In the group without cholelithiasis, cases with common bile duct stenosis tended to show impaired pancreatic exocrine function and the obstructive pattern, in results of liver function tests when compared with those without common bile duct stenosis. However, obvious jaundice was seen only in 50% of those cases. Cholangiographic findings were available also for differentiation of chronic pancreatitis from pancreatic cancer. Irregularity of stenotic region and obstruction of common bile duct were characteristic of the latter. There was the common bile duct stenosis in some cases with chronic pancreatitis, though the pancreatograms were regarded as borderline or slightly abnormal. Cholangiographic findings were useful for diagnosis of such cases.

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According to the average daily alcohol intake, 15 patients with alcoholic liver injury were devided into Group A (68-113g alcohol / day) and Group B (over 113g / day). Peritoneoscopical, histological and clinical investigations have been carried out by per-forming peritoneoscopy and liver function test of these patients. Alcoholic liver cirrhosis was found in 3 out of 7 cases of Group A and 6 out of 8 cases of Group B. Peritoneoscopic observation showed fiber proliferation, scar formation and bull edge of the liver in most of patients in Group A and atrophic nodular liver and numerous lympho-vesicles of the edge were often seen in Group B. Histological examination of the liver revealed a high incidence of pericellular fibrosis (100%) and fatty metamorphosis (66%) but scarcely alcoholic hyaline (7%). Characteristic features of biochemical liver functions were transient elevations of serum GOT and GPT and other liver emzymes in acute exacerbation with alcohol abuse, but persistent abnormalities of ICG test, cephalin f loculation test and cholinesterase were found in patients with liver cirrhosis. The above observations suggest that differentiation of alcohol-induced hepatic injuries such as alcoholic liver cirrhosis, acute alcoholic hepatitis and fatty liver from other non-alcoholic liver diseases are quite difficult during the long term abstinence, and therefore early peritoneoscopic and histological examinations of the liver following discontinuation of alcohol intake are essential.

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In order to clarify jejunal lesions of protein-losing enteropathy, the duodenal and jejunal mucosa were assessed endoscopically and histopathologically by small intestinal scopy (Olympus SIF-B type) in 8 patients with protein-losing gastroenteropathy (4 pateints with intestinal lymphangiectasia, 2 patients with protein-losing enteropathy associated with cardiac diseases, one patient with Budd-Chiari syndrome and one patient with erosive gastritis), and the results were as follows : 1) Three characteristic findings of scattered white spots, white villi and chyle-like substances covering the mucosa were observed in patients with protein-losing gastroenteropathy. 2) Distribution and degree of scattered white spots and white villi were varied in each case and they were remarkable in patients with intestinal lymphangiectasia and cardiac protein-losing enteropathy. 3) Electron microscopic study revealed that scattered white spots indicated markedly dilated lymphatic vessels in the lamina propria of intestinal villi, white vllll suggested disturbance of lipid transport from intestinal epithelial cells to intestinal lymphatics, and chyle-like substances covering the mucosa suggested a loss of lipids into the intestinal lumen.

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We reported here a case of pernicious anemia assosiated with an early gastric cancer in the remained stomach. A 67-year-old man with pernicious anemia had undergone gastrectomy for an early gastric cancer of type IIa on the lesser curvature of the middle gastric body in 1970. Microscopic study had cofirmed well differentiated adenocarcinoma and the oral margin of the resected stomach had been free from carcinous infiltration . Then 8 years after the initial operation, he admitted to our hospital again complaining of general fatigue and palpitation in Nov .1978. The diagnosis of the recurrence of pernicious anemia was made by the findings of the lavoratory data . Endoscopic examination revealed IIa like lesion on the lesser curvature near the cardia of the remained stomach, which was subsequently confirmed by biopsy as well differentiated adenocarcinoma . He had second operation in Oct.1979. Histological findings of this resected specimen revealed IIa type early gastric cancer, well differentiated adenocarcinoma similar to the initial cancer. The longitudinal diameter of the second lesion was 9mm. The surrouding mucosa of the second cancer had severer atrophic gastritis with intestinal metaplasia than that of the initial cancer. The second lesion was considered to be an early gastric cancer newly developed in the remained stomach.Detailes of the family history were taken from this patient His elder sister was gastrectmized for gastric cancer (Bor.III) and she had intrinsic factor antibody in serum. She was determined as latent pernicious anemia.This patient therefore a rare case of pernicious anemia associated with nonsimultaneously multiple early gastric cancers and one of his family members was a case of latent pernicious anemia associated with gastric cancer.

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Surperficial exfoliation of esophageal mucosa by endoscopy which is very rare compli-cation was reported in this paper. A 60-year-old female received endoscopic retrograde cholangio-pancreatography for ex-amination of cholelithiasis. Fiberscope (Olympus JF-B₃) was inserted into the duodenum without any difficulty. Long white cord like mass about 30cm in length was found in the duodenum. After removal of endoscope the mass was vomited with a piece of blood clot. The mass was thin tubular cord 2cm in diameter and 30cm in length. Histological examination revealed that the mass was a superficial layer of the esophageal mucosa con-sisting of squamous epithelium with no degenerative changes. It was thought that endo-scopy brought about exfoliation of superficial esophageal mucosa. The patient complained of slight pain on swallowing for few days and the clinical course was uneventful. There has not been any strictures of the esophagus by X-ray examination for one year follow up.

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This report described a case of a 74-year-old male patient with intestinal lymphangiec-tasia of which endoscopic findings of the duodenum using the magnifying endoscope, Olympus GIF-HM (maximal magnifying power x35), were studied. He was admitted to Keio University Hospital because of edema of the legs and hypoalbuminemia (1.8g/dl). Albumin degradation test using ¹³¹I-RISA and ¹³¹I-PVP test disclosed protein-losing gastroenteropathy. Lymphography showed the hypoplasia of the para-aortal lymphducts. Magnifying endoscopic examination revealed the white villi, scattered white spots and reddened villi especially in the upper part of the duodenal second portion. White villi did not exist homogeneously, with zonal distribution in some parts of the duodenum. Scattered white spots were classified according to the way of existence into: 1 Solitary type 2 Grouping type 1) Linear or zonal type 2) Insular type. White villi and scattered white spots showed various degrees of the depth of white colour. Biopsy specimens obtained fom white spots revealed the lymphangiectasia in the lamina propria of the mucosa. Abnormal olive oil tolerance test and ¹³¹I-Triolein test suggested that white villi and scattered white spots might be related to the disturbance of fat absorption.

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A 43-year-old woman was diagnosed to have multiple ulcers in the antrum and at the gastric angulus. 2 months later, the ulcer in the antrum healed with Henning's sign, while the another ulcer at the gastric angulus showed an unusual change as being a whitish protrusion of the ulcer floor. This polypoid lesion was not covered with regenerated epithelia, but characterized by the presence of basophilic materials among the granulation tissues. By histochemical studies, these basophilic materials seemed to be some degenerated nuclear debris of the regenerated epithelia.

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The patient was a 61 years old man with anorexia and emaciation as his chief complaints. At the time of admission, he was found to have anemia, and hypoproteinemia on laboratory studies. Furthermore, stool test was positive for occult bood, and fecal excretion of ¹³¹I-PVP in 4 days was 7.5% of the administrated dose. X-ray examination of gastrointestinal tract revealed multiple radiolucencies, in which some typical "Bull's eye" signs were recognized. In endoscopic examination, many round elevated lesions were found. Some of them had central umbilication. Histological studies, including electron microscopic examination, revealed malignant melanoma. Although careful examination could not find primay lesion, diagnosis of metastatic inteseinal melanoma was made from the presence of "Bull's eye" sign. As ¹³¹I-PVP test was cleary positive, protein losing enteropathy was considered as a main factor of hypoproteinemia in this case.

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In spite of many reports of antibiotic-associated pseudomembranous colitis due to toxin producing Clostridium difficile in Europe and America, we could not find any case reports of this disease in Japan, yet. Recently, we experienced one case of antibiotic-associated pseudomembranous colitis which was first suspected by endoscopic examination, and finally diagnosed by bacteriological studies. This patient was treated by oral Vancomycin therapy and observed by subsequent endoscopy. The patient was 65-year-old woman and she began to complain watery and bloody diarrhea on the 7th day after our appendectomy. Endoscopy was performed and it showed characteristic pseudomembranes with intervening edematous mucosa and bleeding in the entire colon. Clostridium dif f icile was isolated in a count of 10⁶organisms / g of her fresh stool and toxin was positive in 10^-4 dillution by tissue culture assay. She was treated with oral Vancomycin therapy and endoscopic findings showed that pseudomembranes were disappeared on the 2nd day after its administration and normal mucosa was found on the 12th day. Discussion was also made on the diagnosis, treatment and complications of the antibiotic-associated pseudomembranous colitis due to toxin producing Clostridium difficile.

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