The anomalous pancreaticobiliary union has been attracted gastroenterologists' attention for its participation with congenital dilatation of the biliary tract or congenital biliary cyst. Recently, the anomalous pancreaticobiliary union was also reported in those without dilatation of the biliary tree. Such anomalous union was discoverd in seven cases among 122 patients whose pancreaticobiliary unions were well visualized on endoscopic retrograde cholangiopancreatography (ERCP). The diameter of the common bile duct in these seven patients varies from five to 32mm, and the mean being 13.4 mm in diameter. Three cases had a dilated common bile duct more than 15mm in diameter. However, no case had association with congenital biliary cyst, except for a case of choledochal diverticulum. The length of the pancreaticobiliary common channel varies from five to 35mm, and the mean being 18.1mm in length. Three cases had a long common channel more than 20mm in length. It should be emphasized that three carcinomata of the gall bladder and a carcinoma of the choledochus were included in these seven patients. It is also impressive that pancreatograms of the five cases out of those seven were abnormal, being suggested the existance of chronic pancreatitis. Furthermore, one case with normal pancreatogram had an episode of acute pancreatitis. When the anomalous pancreaticobiliary union was encounterd, pancreatic disease as well as biliary disorder, especially malignancy, should be considered as probable complications.

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The colonic mucosa were examined endoscopically in 20 patients with chronic renal failure. Mucosal biopsy specimens were obtained in all cases and examined histologically. In 5 cases electron microscopic study were also done. The results were as follows; 1) Endoscopically anemic and thickened mucosa were seen in 70% and this was the most common finding in these patients. Vascular abnormalities, hemorrhagic lesions involving petechial hemorrhage, erosion and ulcer were observed more frequently than in controls. Irregular colonic abnormal mucosal pattern, polyp, and melanosis coli were also seen in high frequency. 2) Histological examination showed dilated and degenerated glands, hyperplastic glands, crypt abscess, localized edema, plasma cell dominant cell infiltration and microscopic melanosis coli with high frequency in these patients. 3) With electron microscope in the cytoplasm of surface epithelial cells, degenerative changes including increased number of vesicles, appearance of mucin-droplet like large vesicles, dilatation of endoplasmic reticulum and swelling of mitochtndria were frequently observed. In degenerated absorptive cells, diminution or disappearance of microvilli were often seen. In lamina propria, infiltration of plasma cells with Russell's body were also seen. 4) In 18 autopsy cases the same histological changes as seen in endoscopy cases were observed frequently.

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The treatment of esophageal varices by injection of a sclerosing solution through an endoscope has been a source of considerable interest to endoscopists. The first work in this field carried out was done by Craf oord C. and Frenckner P. in 1939. From 1978 to 1981 in our clinic, 27 patients with recurrent esophageal varices following direct operation for portal hypertension were treated by injection of sclerosing agents. (Thrombin, Sodum morrhuate, Aethoxysklerol). The instrument used in this study was a GIF type P₃ with inflatable cuff. The cuff be inflated with about 10 ml of air and can be used both to provide stasis in the vein during injection of sclerosing solution and to tamponade the inevitable bleeding from directly injecting a varix. This report demonstrated the feasibility of endoscopic scleroemblization of esophageal recurrent varices following direct operation for portal hypertension.

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During recent 13 years from 1967 through 1980, a total number of 458 cases of gastric carcinoma were resected at Karasawa Icho-Byoin Hospital, Asahikawa, Hokkaido. The patients were divided into age groups according to their age by decade and clinicopathological studies were made to search for whether or not there are any characteristic features present in the age groups. Incidence of juvenile gastric carcinoma in the teens and twenties was 0.9%. Striking feature was recognized in the thirties where incidence of early carcinoma was 51.3% the highest in this series. Since the populations of thirties are excluded from the mass survey in this country, it was strongly suggested from the present study that the thirties should be included in the gastric-mass-survey. Another interesting feature observed in the early gastric carcinomas of the thirties was that excavated type predominated comprising 86.7% as compared to the other age groups. Since the age of thirties can not be considered as less risky generation for gastric carcinoma any more, whenever the patient with epigastric pain or pyrosis, commonest symptoms in this series, comes to seek for medical advice, "on-the-spot endoscopy" and biopsy should be made with particular attention to the excavated lesions.

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Biochemical, gastroscopic, histopathological and lymphangiographic studies were performed in 6 patients with protein-losing gastropathy (4 patients with Ménétrier's disease, one patient with Cronkhite-Canada syndrome and one patient with chronic erosive gastritis) and their results are as follows : 1) Biochemical studies revealed that there was a patient who had not hypoalbuminemia in spite of gastric protein loss and that there were patients who had hypoimmunoglobulinemia and/or lymphocytopenia. 2) Gastroscopic study demonstrated gastric mucosa covered by mucus, giant rugae and stalactite grotto phenomenon which suggested hypersecretion of gastric mucosa in all patients. 3) Histopathological studies on the stomachs removed at operation or at autopsy clarified that ; (i) hyperplasia of gastric surface epithelial cells was markedly observed in all cases. (ii) structures of gastric fundic glands were divided into two types ; one was proportional hyperplasia of each gastric epithelial components composed of chief cells, parietal cells and surface epithelial cells, and the other was metaplasia of the epithelial components with complete replacement of parietal cells by mucin-secreting cells and cystic dilatations of the glands. (iii) there were seen dilated lymphatics in the mucosa and submucosa of some patients. 4) Lymphangiography by the method of Kinmonth showed an increase in number of retroperitoneal lymphatics as appeared like reticular pattern, their bead-like dilatation and back-flow of contrast medium toward digestive tracts in two of 4 patients studied.

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Endoscopic laser hemostasis was attempted in the treatment of unselected upper gastrointestinal hemorrhage of which 34 cases were treated with a Nd-YAG laser and 12 cases with an argon laser. Bleeding continued to stop for over 24 hour in 32 cases (94%) treated by Nd-YAG laser. 26 of the 32 (76%) were in shock and 8 of them had spurting, arterial bleeding. Using the argon laser, the bleeding could be stopped for over 24 hours in 9 cases (75%). Two cases rebled immediately and in one case the bleeding could not be stopped. These 3 cases were bled from exposed blood vessels the diameters of which were over 1.5mm. 11cases (92%) were in shock and 3 cases had spurting, arterial bleeding. From these results, it was concluded that the Nd-YAG laser was more effective to stop gastrointestinal bleeding than the argon laser, especially in severe case and it was difficult to stop bleeding from an exposed blood vessel, over 1.5mm in diameter, with the argon laser.

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In general, it is well known that atrophic gastritis tends to spread from the antrum toward cardiac portion. On the other hand, it is also observed that atrophic gastritis can extend from cardiac area to the anal side. Therefore, in this moment, we studied endoscopically and histologically on atrophic gastritis and intestinal metaplasia, particularly in the cardiac portion. Cardiac atrophic border by endoscopic congo red test was classified into four types (l-lV), according to Suzuki's classification. The extension of atrophic gastritis in the upper portion of stomach is recognized as the red area by congo red test, that is non-discolored area by Okuda. Biopsy specimens were taken from several portions following the red area, metachromatic border and black area adjecent to the metachromatic border under direct vision. Histological findings showed that atrophic gastritis in the cardiac portion became severe in accordance with the extension of red area by congo red test. Although intestinal metaplasia was rare in the closed type of cardiac atrophic pattern, intestinal metaplasia originated from cardiac portion was certainly present. Methylene blue staining method was performed to investigate the distribution of intestinal metaplasia. Consequently, methylene blue absorption was observed in the intestinal metaplastic mucosa in only one case shown closed type. While the distribution of stained area and the degree of methylene blue absorption in the open type of cardiac atrophic pattern increased, according to endoscopic observation. But in the open type, it was difficult to distinguish intestinal metaplasia, originated in the cardiac area, from that in the pyloric gland area. Morphologically, intestinal metaplasia in the cardiac portion revealed flat type. In conclusion, it seems that the intestinal metaplasia, seen in the cardiac area, has Several different properties from that of the antrum.

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A combined work-up of emergency endoscopy and angiography has proved effective both in the diagnosis and treatment of patients with severe gastrointestinal bleeding. Of twenty cases with gastrointestinal bleeding, emergency endoscopy was performed to 18 cases immediately before emergency angiography, detectring hemorrhagic lesions in 13 cases. Other patients were not diagnosed because of massive bleeding. Arterial hemorrhage was diagnosed by emergency angiography for extravasation of contrast medium in 10 of 20 patients and in 18 of 20 patients hemorrhagic lesions were diagnosed in combining angiography with endoscopy. Diagnoses of hemorrhagic erosion in 3, gastric ulcer in 4, gastric cancer in 2, rupture of varix in 10 and colonic ulcer in 1 were finally established. Hemostasis utilising angiography was performed in all cases, and bleeding was successfully controlled in 17 of 20 patients (85%). Bleeding was controlled in 11 of 12 cases given continuous arterial injection of pitressin, and in all of 6 cases in whom percutaneous transhepatic obliteration of varices was performed. However, bleeding relapsed in 2 cases whose left gastric artery were obliterated.

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Nine patients of Crohn's disease were treated by continuous nasogastric infusion with ED-AC (2, 400 Kcal/day) for 29-110 days. N o other food was allowed. Increases of serum protein and body weight were observed in all cases. In 7 of the 9 patients, ESR and CRP became within normal range and CDAI became below 150. The radiological and endos-copic findings after this theatment were as follows : Most of cobblestone appearances changed into pseudopolyps or scarred zone. Most of longitudinal ulcers in ileum changed into scar or reduced. Fissuring ulcers and aphthoid ulcers disappeared. However, only one of 3 cases with internal fistulas showed closure and stenosis were almost unchanged. Four cases have been in remission for 3-12 months after cessation of ED-AC. Consequently, this study suggests that elemental diet leads to marked improvement of radiological and endoscopic findings except fistulas and stenosis, as well as laboratory data and clinical symptoms in patients with Crohn's disease.

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This study was aimed at investigating why the superficial spreading type of gastric cancer, which is mostly signet ring cell carcinome, remains only on the surface without invading into depth and has a good prognosis. Twelve cases of this type of cancer were studied. Two of them did not advance, remaining in the early stage : one for 71 months and the other 27 months. Their cancer was signet ring cell carcinoma. The neoplastic cells of these 12 cases were mostly found in the f oveolar epithelium. The paradoxical concanavalin A staining showed that the mucus of this type of cancer cell was similar to that of the foveolar epithelial cell and was different from that of the glandular mucous cell. It was also observed that the maturity of the mucus of the cancer cell progressed from the generative zone to the superficial stratum. These findings imply that this type of gastric cancer has a very close relationship to the foveolar epithelial cell. This cancer has been classified as undifferentiated cancer since it is pathohistorically not of tuberlar formation, but, embryologically, it is regarded as highly differentiated. For this reason, this kind of cancer does not grow outside of the foveorlar epithelium and has a good prognosis. For about 6 years and 2 years each, no significant increase was observed in canceraffected area of the two cases, and it was suggested that this type of cancer multifocally developed in a wide range.

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The signet ring cell carcinoma in superficial spreading type gastric cancer, which is histologically classified as undifferentiated because of no tubular formation, and which is though embryologically highly differentiated one, is closely related to the characteristic of the foveolar epithelial cells of the stomach. For this reason it does not undermine and has a good prognosis. On the other hand signet ring cell carcinoma of Borrmann lV or lll type of the stomach are ones thet diffusely invade the gastric wall. At the present time there is no attempt to classify these two types of signet ring cell carcinoma histologically. In this paper the cellular DNA contents of these two types were determined from resected specimens. The DNA histograms of early gastric cancer showed a monophasic pattern with a peak at 2C and regular distribution like normal cells while those of advanced cancers showed almost the same pattern as in early cancer but irregular distribution. This is different from the superficial spreading type. In advanced cancer the cellular DNA contents in both superficial and deep layers were of almost the same pattern, thus the canceruos cells do not metamorphose during the course of development, but grow as an invading cancer from the start.

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We evaluated the clinical efficiency of a new type of ultrasonic gastroendoscope for the diagnosis of digestive diseases. The ultrasonic gastroendoscope, which is developed by the cooperation of Toshiba Medical Co. and Machida Endoscope Co., has an ultrasonic probe incorporated inside the tip of a conventional fiberscope. The ultrasonic probe consists of a 3.5 MHZ, 36-element linear array, having a high resolution real time image of 15 frames/second with a view field of 3cm in width. This new method was clinically applied with success in 8 cases (1 gastric cancer, 2 gastric submucosal tumors, 2 hepatic tumors, 1 carcinoma of gallbladder, 1 pancreatic cancer and 1 chronic pancreatitis with stone formation). The most characteristic benefit of the present method is the direct scan from inside, instead of from outside, of the body, excluding possible interference by intraluminal gas. The picture obtained therefore shows better resolution than that of the conventional method. In the present experimental use, the ultrasonic characteristics of the heart valves, aorta, kidneys, liver, IVC, gallbladder, pancreas and gastric mucosa were well defined, which might contribute to the better ultrasonic diagnosis of digestive diseases. The present prototype should be further improved for the practical application in clinical use. It is expected, however, that the ultrasonic endoscope would paly a major role in the diagnosis of digestive diseases.

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We had an opportunity of clinical use of a newly developed ultrasonic laparoscope in 6 cases (hemangioma, cyst of the liver, liver cirrhosis, pancreatic cyst, pancreatitis with stone and gallbladder cancer), thus having evaluated the diagnostic ability of the scope. An ultrasonic probe of 3.5 MHz and 36 element linear array is incorporated inside the tip of the laparoscope, which is flexible 90 degree up and down. We confirmed that especially as to the localized mass lesions of the liver, pancreas and gallbladder, the laparoscopic ultrascan obtained superior visualization with better resolution than that obtainable from outside the body. As to the huge abdominal mass, however, the conventional scan seemed better. The present prototype should be improved for the better diagnosis ability. First of all, the field of vision should be placed at the end of the scope, and the tip flexioned in four directions in order to secure much accurate and easier orientation and manipulation. It is expected, however, that the ultrasonic laparoscope would play a major role in the diagnosis of abdominal diseases.

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Pancreatic duct anomalies such as congenital aplasia of the pancreatic body and tail, and pancreas divisum are the relatively rare conditions found on endoscopic retrograde cholangiopancreatography (ERCP) . It has been thought that the diagnosis of these anomalies should be made by surgical intervention. Because of the lack of therapeutic indication of laparotomy for such cases, it is necessary to establish nonoperative diagnostic criteria for cases with pancreatic duct anomaly. Differences in endoscopic cholangiopancreatograms between pancreatic duct anomaly and pancreatic cancer with a short main pancreatic duct were investigated. Four cases of pancreatic duct anomaly (I cases of congenital aplasia of the pancreatic body and tail, and 3 cases of pancreas divisum) showed neither disruption of the main pancreatic duct nor irregularity of the branch. On the contrary, all of 12 cases with pancreatic carcinoma revealed an obstruction of the main pancreatic duct and irregularity of the branch. No abnormal changes of the common bile duct were observed in cases of pancreatic duct anomaly. Obstruction or narrowing of the choledochus was observed in 11 of 12 cases of pancreatic cancer. Santorini's duct were opacified by cannulating the major duodenal papilla in case of aplasia of the pancreatic body and tail, and 7 of 12 patients with pancreatic carcinoma. Successful opacification of a dorsal pancreatic duct was obtained by cannulating the minor duodenal papilla in all of 3 cases of pancreas divisum. Abdominal angiography and computed tomography demonstrated abscence of the pancreatic body and tail clearly and contributed to the diagnosis in case of congenital aplasia of the pancreatic body and tail. In conclusion, the diagnosis of pancreatic duct anomaly is possible by means of carefull interpretation of ERCP, abdomdnal angiography and computed tomography without surgical intervention.

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During recent 6 and a half years, a successful ERCP was obtained in 32 of 44 attempts in 41 patients. In a few years of the beginning JF-B₂ which is for adults was used, but the development of pediatric duodenofiberscopes such as FGS-PE and X-PJF significantly improved the success rate. Especially in recent 2 years, ERCP was done successfully in all including 1-month-old infant. In 3 patiants with NH 35, 72 and 79 days after birth was cholangiopancreatography shown and in 3 with CBA 46, 65 and 80 days after birth was only the pancreatic duct revealed. It is concluded that the differential diagnosis between CBA and NH can be made by ERCP.

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In 19 cases with transient-type ischemic colitis, 21 lesions were observed in our hospital in the past 4 years. The course of these lesions were classified into 4 groups by the endoscopic observation.a) erosion→healed stage (2 lesions)b) erosion→irregular ulcer→healed stage (6 lesions)c) erosion→irregular ulcer→linear ulcer→healed stage (1 lesion)d) erosion→linear ulcer→healed stage (12 lesions) Irregular ulcer was observed within 2 weeks after the onset. Linear ulcer was observed not only in early times but also in late times and seen most frequently, so it may be a valuable clue to the diagnosis of ischemic colitis. The lesions healed endoscopically within 3 weeks on the average, earliest in 10 days. 5 lesions were found to be hemosiderin-laden in the biopsy specimens.

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Forty-four early gastric cancer cases with gastric ulcer or ulcerscar at the different site (accompanying group) were studied, compared with 223 cases of early gastric cancer without gastric ulcer (control group). Results obtained were as follows ; 1) Peptic ulcer was discernible at the different site of the stomach from the cancerous lesion in 44 (16.5%) of 267 early gastric cancer cases. 2) Mean age of the accompanying group was 56.4±8.3 years of age, while 54.8±12. 7 years of age in the control group. Male/Female ratio was 6.3 in the former, while 2.6 in the latter. 3) Depressed type of early gastric cancer, especially IIc + III type, was dominant in both groups. 4) Concerned with the depth invasion of cancer, mucosal cancer was more freguently found in the accompanying group, and the size of early gastric cancer was also smaller in this group, with a statistical difference to the control group. 5) Histologically, differentiated type of adenocarcinoma was dominant in both groups. 6) With respect to the relationship between early gastric cancer and peptic ulcer in the accompanying group, early cancer was generally located at the anal site from peptic ulcer. In 19 cases, a combination of early gastric cancer at the antrum and peptic ulcer at the angulus was observed. 7) According to CMA classification, early gastric cancer was located in the “A” area in the accompanying group in general, while in the “M” area in the control one. However, the distribution of the surrounding mucosa of early cancer was not different in both groups. 8) The degree of intestinal metaplasia around early gastric cancer was significantly more remarkable in the control group. 9) Maximum acid output by tetragastrin (4r/kg body weight) showed hyperacidity in the accompanying group, especially in the cases with active stage of ulcer.

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A 71-year-old woman was admitted to our hospital because of generalized tuberculosis. Hematemesis occurred and emergency endoscopic examination was performed. A saucerlike ulcer was found in the gastric body (Figure 3). She died of respiratory failure and DIC syndrome. Autopsy findings were as follows; 1) gastric tuberculous ulcer, measuring 46×48mm, was found in the posterior wall of the gastric body (Figure 6). Tuberculous granulomas and caseation necrosis were identified histologically. Tubercle bacilli were disclosed in the deep layer of the ulcer (Figure 8). 2) Ileocecal tuberculosis presented a girdle ulcer of 65×60mm. 3) Active tuberculous lesions were also found in the right kidney and bilateral lungs. Gastric tuberculosis is a rare disease and we reviewed recent case reports in Japan with special reference to their endoscopic findings (Table 2).

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The authors present the case in which the prominent compression by a hemangioma of the liver at the fornix was suspected to be a submucosal tumor of the stomach. A 49-year-old man took a close exmaination because of an abnormal shadow at the f ornix in photof luorograms at gastric mass survey. Then submucosal tumor of the stomach was suspected, but barium meal examination combined with pneumoperitoneography showed the extragastric compression. Operation revealed a hemangioma of the liver which grew extrahepatically from the left lobe of the liver. At the f ornix, it is sometimes difficult to differenciate a submucosal tumor from a protrusion caused by the compression of extragastric mass. The authors reffered to the points for the differenciation and emphasized the availability of barium meal examination combined with pneumoperitoneography for the diagnosis. Cavernous hemangioma of the liver reported in literatures are discussed.

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A 52-year-old woman ate raw fish (Sebastes spp.) caught in the seashores of Hiroo, Tokachi Area, Hokkaido, on June 29, 1979. She ate the fish twice on the day of catch and after placing inside the freezer for about 24 hrs. The patient complained of pain in the right upper abdomen, nausea and vomiting 10 hrs. after the last meal with the fish. The patient consulted 2 neighboring clinics where UGI series and cholecystography were taken. However, the diagnosis was uncertain. When taking the patient history, we also did not ask about eating raw fish so that the diagnosis was delayed. Eventually, the worm was removed on the 17th day after the onset of the disease, by the Olympus Type JF-B3 endoscopically. Parasitological examinations revealed that the worm is probably of the Anisakis I-type larva. At the same time, the temperature of 16 conventional household refrigerators was surveyed. The results showed that only 3 household refrigerators were suitable for use, according to the "Heringverordnung" of Netherlands. No report on anisakis infection in the second portion of the duodenum has been published until the present time. This is considered the first case on such anisakis infection.

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Annular pancreas has been diagnosed by chance at the gastroenterological examination. Recently it has been made possible to elucidate the pathological features of annular pancreas and to determine the therapeutic plan by the progress of diagnostic procedures, especially Endoscopic Retrograde Cholangio-Pancreatography (ERCP). In a few years, three cases of annular pancreas were diagnosed by ERCP in our institute. Case 1. A 47-year-old male complained of left hypochondralgia and back pain. The main pancreatic duct surrouding the second portion of the duodenum was revealed by ERCP. In the course, pancreatic calculi, chronic relapsing pancreatitis, pancreatic cyst and duodenal ulcer were obseved complicated. Case 2. A 76-year old male complained of diarrhea. A branch of the Wirsung's duct surrounding the second portion of the duodenum was revealed by ERCP. The main and annular ducts showed moderate change. Case 3. A 47-year old female suffering from malignant lymphoma complained of left hypochondralgia. The branch of the Wirsung's duct surrounding the second portion of the duodenum was revealed by ERCP, and minimal change of main pancreatic duct was observed.

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