[in Japanese]

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Among 25, 824 patients examined by gastroscopy during 14 years (1967-1980), radiologic and endoscopic features of 30 gastric peptic ulcers associated with candida infection which were diagnosed histologically, were studied. Furthermore, the endoscopic and histologic follow-up studies were performed in 23 lesions of 23 patients over a period of 6 months to 12 years.The following results were obtained. 1. The incidence of gastric ulcers associated with candida infection was 30 lesions in 30 patients (0.12%) of 25, 824 gastroscopically examined patients and 13 of them (43%) were found over the 7th decade. 2. Although gastric ulcers associated with candida infection did not show endoscopic and radiologic characteristic features, 16 lesions (54%) measured more than 2 . lcm. in dia-meter, 16 lesions (54%) with Ul-II in depth, 18 lesions (60%) with unclear borders of the ulcers and 9 lesions (30%). bezoarlike images. 3. Eighteen lesions (60%) were found in the upper part of the stomach, and 10 of 30 lesions (33%) were associated with other systemic diseases. 4. Curability of gastric ulcers associated with candida infection was low. Only 6 of 20 lesions (30%) were cured in 6 months or more of follow-up period. However, continuity of candida infection, bleeding or perforation from the ulcer, candi-demia or fatal accident were not encountered without antimycotic treatment.

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Even nowadays, multiple gastric carcinomas still present a lot of diagnostic and path-ological problems. We have experienced 72 cases of multiple gastric carcinomas in the past 1L years, in-cluding 42 of early lesions, 2 of advanced lesions, and 28 of both advanced and early lesions. We recently studied of the diagnosis of carcinoma present orally, in 8 cases of advanced carcinoma of the antrum with orally coexisting ones, and found that the diagnosis was more difficult than the other types of multiple gastric carcinomas.The results were as follows;1. All patients were men, the mean age being 69.2. All had a pyloric stenosis due to Borrmann 2 or 3 type.3. The size of these early carcinomas, most being IIc type, ranged from 0.4 to 1.2cm, and two lesions were under 0.5cm, so-called microcarcinoma.4. The distance between advanced and early lesions was 1.8 to 9.5 cm, the mean being 4.5 cm.5. All lesions were found in the atrophic zone or intermediate zone. It is concluded that more cautious endoscopic observation and knowledge on the extent of the surrounding mucosal atrophy are required for the proper diagnosis of multiple gas-tric carcinomas.

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We previously introduced a new method of endoscopic local injection of hypertonic saline epinephrine (HS-E) solution to arrest hemorrhage from the upper digestive tract. In this paper are described the results of a fundamental research to elucidate the mechanism of arresting hemorrhage by local injection of HS-E solution. A serial HS-E solution was locally injected into the gastric wall of rats and pathohis-tological reactions thereafter at the injected site were carefully examined (Table 1). Among histological reactions, tissue swelling and edema of the injected site were dominant (Table 2 and Figure 7, 8, 9). Increased thickenss and swelling of media and intima as well as fibrinoid degenertion of the arterial well were also observed (Figure 4, 5). When epine-phrine and hypertonic saline solution were employed together, they exerted a synergistic effect resulting in more remarkable histological changes than when either one of the two was singly used (Table 4, 5, 6, 7). Pathological changes in the mucosa brought about by local injection of HS-E solution were well in parallel with those of the arterial wall in-volved (Figure 1, 2, 3 and Table 3). A significant reduction of blood flow in the tissue and prolonged ischemia were also demonstrated at the site of injection (Figure 10). From the standpoint of mucosal injuries or ulceration, it became apparent that HS-E solution has a sufficient safety margin in concentration (Table 8). In conclusion, based on the results mentioned above, hemostatic effect by local injection of HS-E can be explained by primary vasoconstrictive action of epinephrine and by such secondary organic changes due to hypertonic saline solution as tissue swelling, fibrinoid degeneration of the arterial wall and thrombus formation.

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While earlyga stric cancer has been increasingly detected in the past two decades, cancer located in the proximal one third (“ C” area) of the stomach is still infrequently diagnosed in “ early” stage. To know the clinical and technical problems which might contribute to diagnostic delay and lower frequency of early gastric cancer in this area, we have reviewed our experience with 28 cases of early gastric cancer in this area, drawn from 1, 715 cases of curatively resected gastric cancer. The results were as follows; 1) Frequency of early gastric cancer in “ C” area was only 5% of total number of early gastric cancer, and no tendency of increase was observed over the period from 1965 to 1978. 2) None of the cases with early gastric cancer in “ C” area was detected by mass survey, indicating technical difficulties in screening. 3) At the initial work-up after the onset of symptoms, the cancerous lesion was over-looked in 46% and 30% of the cases examined by UGI series and endoscopy respectively. 4) Polypoid type of early gastric cancer, mostly type I, was detected by UGI series with ease. However, in 2 out of 7 cases with type I, cancer was overlooked by UGI series, whose lesion located within 2cm from GE junction. 5) Depressed type of early gastric cancer was frequently overlooked by routine UGI series, and checked by subsequent endoscopy which led to suspicion of malignancy. Because of difficulties in both visualization and identification of early gastric cancer in “ C” area, we recommend combined use of endoscopy particularly when one feels that an optimal UGI series is not achieved.

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An advance in ERCP is taking a place remarkably. Cannulation can be done suc-cessfully in almost all cases except for a few with anatomical abnormalities. Neverthless. ERCP is not always done easily, having a hard time in some cases. In these two years, therefore, trials of the improvement in the fiberduodenoscope have been made for FRCP; that is, 1) a lens with wide view angle of 75° and 105°, 2) 10° backward view-angle, 3) short tip-length of 37mm between the apex and the bend of the scope, 4) rightward bend ing-angle of 110° The purpose of this paper is to ascertain whether each of the improvement is really useuul or not for facilitating easier handling of FRCP. Four new models of fiberduodenoscope, each of which had different improvements as shown in Table 1, were put to the test for ERCP in 217 cases by 6 skilled endoscopists, and the following results were obtaind through a questionnaire. 1) A lens with wide view-angle is essentially useful, not only for looking out the papilla but also for face-on or looking-up observation of the papilla. No opposite replies in questionnaire on this matter. It was thought to be necessary to ascertain what degree of lens view-angle the most useful is. 2) Although no differences in practical usefulness in observation of the papilla was found between the scopes equipped with side-view lens and those with 10- backwardview lens, the later was more useful for looking-up obsergation of the papilla when the scope was approached to the papilla by using “pulling-out” technique. 3) As for the tip-length, the scope with short tip-length is more useful than those with ordinary tip-length. 4) No bad reputation in using the scope equipped with 110° rightward bending-angle in any cases. Summary; It can be said that the fiberscope for ERCP should be equipped with a lens of wide view-angle with 10° backward view-direction, short tip-length and 110° right ward bending-angle.

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Twenty-one patients with unresectable carcinoma of the pancreas were treated by intraoperative irradiation with a large electron dose of 1500-3000 rads and upper gastro-intestinal complications were encountered in five cases. All of those five cases were ca-rcinoma of the pancreatic head, and were seen the gastrointestial tract inguries after intra, opecative irradiation of the duodenum as follows, gastric ulcer in 2 cases, ulcer of the 1st duodenal portion in one case and ulcer with severe stenosis of the 2nd or 3rd duodenal portion in one case, respectively. Endoscopic features of these postirradiation gastrointestinal ulcers were characterized by deep, pounched-out ulcers with grayish bases and sharp margins. Clinically these ulcers and stenosis were very difficflt to treat by medical treatment, so that by-pass operation was performed in two cases resulting in prolonged surgival.

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Colonic polyps of any size and site are being removed by either snear polypectomy or diathermy-biopsy (hot-biopsy) over the past several years. Two hunereds sixty-three polyps in 45 patients were removed by hot-biopsy from 1974 to 1979 in our hospital. Excluding adenomatosis coli, 113 polyps in 37 patients were histologically investigated. Twenty-eight polyps in 21 patients were removed by conven-tional biopsy forceps and these polyps were also investigated. Hot-biopsy cases consisted of 26 men and 11 women. The average age was 57.3 years. Thirty-two polyps were in the sigmoid colon, 28 in the rectum, 22 in the transverse colon, 19 in the descending colon, 10 in the ascending colon and 2 in the cecum. Histologic examination showed that 95 polyps were adenomas with mild dysplasia (84%), 10 were metaplastic polyps, 5 were normal mucosa or hyperalasyic nodules, 2 were inflammatory polyps and a Peutz-Jeghers type polyp in their nature. So far no severe dysplasia (focal carcinoma) was found. Seventy-six out of 85 polyps in the colon were adenomas (89%), while 19 out of 28 polyps were adenomas in the rectum (68%). These polyps were under 10 mm in diameter and most adenomas were between 1 and 4mm in diameter. The shape of the polyps were broad based or sessile. Sixteen of our 37 patients (43%) had multiple polyps up to 20 in number. Ten patients had only adenomas, 4 showed a coexistance of adenomas and non-neoplastic polyps and 2 had metaplastic polyps. In about half of our patients (18 patients), snear polypectomy for larger polyps has been performed at the same time. From our experience it became clear that even tiny polyps under 5 mm in diamter were most likely to be adenomas and therefore it is recommended to remove all tiny polyps of any site by hot-biopsy. Careful follow-up after polypectomy or hot-biopsy is also recommended.

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The purpose of this paper is to call attention to the infrequent occurence of independent cancer of the stomach in individuals with benign duodenal ulcers. Eusterman (1935) reported that the presence of duodenal ulcer was in a certain sense insurance against carcinoma of the stomach. While, Sano (1977) reported the frequency of their coexistence was 2.7 of early gastric cancers. In Japan, gastric cancer coexisting with duodenal ulcers were more often in early stage than in advanced stage. The records of 356 gastric carcinoma patients who were treated surgically in our hospi-tal were reiewed. Among them, six patients (1.7%) had duodenal ulcers. Five of these six cases were in early cancer stage classified as type IIc or IIc+III, and one was an advanced cancer. Carcinomas of the six cases were localized in the rather half of the stomach and in five, in the intermdiate zone between fundic and distal pyloric gland area. Gastric analysis showed hyperacidity in two cases and normoacidity in four cases. Three had signet ring cell carcinomas, two had poorly differentiatedadenocarcinomas and one had well differentiated adenocarcinoma. It is assumed that the carcinomas of the stomach in the cases coexisting with duodenal ulcers with retained high acid secretion may glow slowly and may be limited to the mucosa for a long period showing "malignant cycle".

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The authors experienced three cases of gastric anisakiasis during a 2 month period at an institution in Aichi prefecture where it has been said to be a rare disease. In two of these anisakis larva was removed at endoscopic examination performed immediately after a suspicion of gastric anisakiasis had been raised from the patient's clinical history. Recently gastric anisakiasis has been increasing anywhere with improvement of transportation system. However, clinical awareness of gastric anisakiasis is generally not as prevalent as in epi-demic areas and most patients are thought to be treated inappropriately with a probable diagnosis of food poisoning. It is concluded that taking a detailed history is most important to establish the diagnosis of anisakiasis and endoscopical removal of anisakis should be done immediatly after the diagnosis has been made.

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A rare case of carcinoid of the duodenal bulbus with early gastric cancer and gastric polyp is reported. A 72-year-old male consulted his doctor because of 2kg of weightloss within a month. Upper GI series revealed type III polypoid lesion by Yamada's classification in the duodenal bulbus, small irregular errosion on the lesser curvature just above the gastric angle, and Yamada's type IV polyp on the greater curvature of the lower body of the stomach. Accoring to histological findinigs of biopsy specimens, these lesions were argyro-phil cell carcinoid of the duodenal bulbus, IIc type early gastric cancer (poorly differenciat-ed adenocarcinoma), and inflammatory gastric polyp. Resection of the duodenal bulbus and distal two thirds of the stomach was performed. There was no evidence of metastasis of carcinoid and gastric cancer. Postoperatively the patient is in good health.

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Two cases of splenic venous occlusion due to pancreatic pseudocyst were reported. Case 1, 51-year-old man, and case 2, 38-year-old man, were admitted to our clinic because of massive hematoemsis and of melena of episodic duration, respectively. In both cases, upper GI series revealed marked gastric varices, and selective caeliacoangiogram dem-onstrated splenic venous occlusion. Laparoscopic exami nation revealed a remarkable venous dilatation along the greater curvature of the stomach, but surface of the liver was smooth in both cases. In view of these, two patients were suspected to have bled from the gastric varices which were induced by the splenic venous occlusion. By operation, pancreatic pseudocyst in the pancreatic tail were detected which compressed the splenic vein completely. Chronic pancreatitis was found histologically in both cases.

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Case 1: A 47 year-old female, complained of the venous dilatation of the abdominal wall, showed membranous obstruction of the inferior vena cava (IVC). Case 2: A 33 year-old male, complained of the venous dilatation of the abdominal wall, showed thrombo-tic obstruction of the IVC extend over 4cm. Case 3: A 51 year-old male, complained of the venous dilatation of the abdominal wall and the dull pain of the right hypochondrium, showed thrombotic obstruction of the IVC. Peritoneoscopic findings: In case 1 and case 2, the liver was enlarged, its color was dark brownish-red. The liver surface showed the undulating irregularities. Moreover, innumerable lymph vesicles were seen on the capsule. In case 3, the liver had the irregular spots of a bright reddish color against a light white background. Its surface showed the undulating irregularities. Bluish discoloration of the liver was not observed in our three cases. Splenomegaly under the peritoneosropy was found in case 3 only. However, the enlarged vessels in the round ligament and the peritoneum were observed in all cases. Histological findings of the liver: The slightly fibrous change of the portal areas and the congestion in sinusoids of the centrilobular areas were observed in case 1 and case 2. Micronodular pattern of cicchosis was observed in case 3.

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A 74-year-old male was admitted to our hospital with complaints of jaundice and abdominal pain. Percutaneous transhepatic cholangiography (PTC) showed a filling defect at the distal common bile duct. The localized tumor was observed by percutaneous tran-shepatic cholangioscopy (PTCS), and the reddish and discolored mucosa was observed extensively in the common bile duct, and cholangioscopic biopsy of the bile duct mucosa away from the primary tumor confirmed malignancy. Curative pancreaticoduodenectomy was performed and the common hepatic duct was resected. Histologically, it was diagnosed as papillotubular adenocarcinoma and it was localized in the bile duct wall, and spreaded superficially in the common hepatic duct. The pre-operative PTCS should be used in all cases of obstructive jaundice. The din-ical improvement of their radical resections will be expected by use of this technique.

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With cooperation of Olympus co. we designed and developed a retrograde ileofiberscope consisting of the mother scope and the baby scope. The mother scope to be inserted into Bauhin's valve has the working length 1, 865mm, tip diameter 16mm and a large channel, 5mm in diameter. The baby scope is a direct viewing type with 80°in the angle of view field, 2, 520mm in total length, 4.5mm in diameter of the flexible part, and 3 to 50 mm in depth of observation. The angles of up and down irk the baby scope are both 1500. The baby scope can be inserted 300mm in maximal length further from the mother scope. After introducing the tip of mother scope in the terminal ileum, the baby scope is inserted to the ileum through the forceps opening of mother scope by manipulating the knob of up-down angle of baby scope and by rolling the mother scope. We can well observe the ileal mucosa in a satisfactory extent through the baby scope. This scope seems very useful in detecting the ileal lesion and for the accurate diagnosis. Furthermore this can be applicable to endoscopic observation of the fistula or stenosis of colonic diseases.

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