It is widely known that gastric lesions, for example, erosive gastritis or gastric ulcer, frequently co-exist with duodenal ulcer. The mucosal border of the stomach and characteristics of the gastric lesions co-existing with duodenal ulcer were discussed. In 91 patients with active duodenal ulcer, 90 (99%) showed the mucosal border of the closed type. On the other hand, 88% of patients with duodenal ulcer scar showed the closed type, and 12%, the open type. In duodenal ulcer patients, about 50% had gastric ulcer, erosive gastritis and/ or comb-like redness. A co-existance rate of gastric lesion was high in patients over 40, compared with those under 40. In the co-existing gastric ulcers, 80% were observed from the angle to the pyloric region. Thirty eight percent of patients with duodenal ulcer had erosive gastritis, multiple red patches or comb-like redness, especially in patients over 40. The recurrence rate of duodenal ulcer without gastric lesion was higher than the ulcer with one.

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It seemed difficult to diagnose the depth invasion of gastric carcinoma . 41 cases of depressed type advanced carcinoma grossly resembling early gastric carcinoma (EGC resembling type) were experienced at our clinic from 1967 to 1981. In this paper, the macroscopical types, metastasis to lymph nodes, histological patterns and endoscopic findings of EGC resembling types were compared with those of depressed type early gastric carcinoma (EGC) in 121 cases. The following results were obtained . Macroscopically, frequency of IIc+III and IIa+IIc types in EGC resembling types was higher than in EGC types, especially about half number of IIa + IIc type were under 2cm diameter in size. Histopathological findings of EGC resembling types revealed low differentiated patterns than those of EGC group. The incidences of metastasis to regional lymph nodes of the stomach was 51.2% in EGC resembling group and only 13.2% in EGC group. In the endoscopic findings, clubbing and fusion of conversing mucosal folds and RC sign of depressed lesions were observed in EGC resembling group significantly higher in incidence than EGC group. These results may be useful to diagnose preoperatively the depth invasion of EGC resembling type.

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The purpose of this study was to investigate an association between intraluminal pressure and colonic blood flow, which might be involved strongly as the genesis of ischemic colitis. Using rabbit, we studied on the blood flow in the segmented large intestine by ligation after insertion of intraluminal catheter into the colon. The mucosal blood flow in both sites of taenia and non-taenia coli was measured simulataneously while segmented intestine was inflated following stepwise increments of intraluminal pressures of 0, 10, 30 mmHg and was deflated thereafter. As the results, the changes of mucosal blood flow measured in several condition inflated with intraluminal pressures of 0, 10, 30 mmHg and following decompression were as follows ; (1) at the site of taenia coli : 97.5, 105.9, 10.3, 99.5 ml/min/100 g respectively, and (2) at the site of non-taenia coli : 83.4, 94.8, 32.9, 89.1 ml/min/100 g respectively. With the pressure of 30 mmHg, the blood flow in both sites was reduced, but especially the reduction at the site of taenia coli was markedly. Colonic mucosal blood flow was clearly influenced by the change of intraluminal pressure, showing that particularly the blood flow of the site of taenia coli decreased much more by the high pressure, this may be one of the reasons why longitudinal ulcer is seen frequently at the site of taenia coli. In conclusion, it is stronly considered that the high intraluminal pressure might be involved into the etiological factor of ischemic colitis.

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With an advancement of technique of percutaneous transhepatic biliary drainage (PTCD) and dilatation of PTCD fistula, percutaneous transhepatic cholecystoscopy (PTCCS) or cholangioscopy (PTCS) by way of the fistula has been clinically performed in several institutions. Moreover, it has been recognized that PTCCS and PTCS are established as a safe method with an improvement of choledochof iberscope. PTCS and PTCCS have been carried out in 5 cases with cholangioma and 3 cases with gallbladder carcinoma respectively for the last one year. These endoscopic techniques allow biopsy to obtain a correct diagnosis under direct visual control and made the laser beam applicable for crushing the stones or for treatment of non-resectable tumor. Furthermore, they are very useful for the insertion of the tube for endoprosthesis into the biliary tract across the site of tumor to obtain a good biliary drainage. In this paper, the methodology, the indication, problems and limitations of PTCD and PTCCS are discussed based on the experiences with these techniques.

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From October 1979 to July 1980, a comparative study was made between 124 cases using Anesoxyin-30 (a permixed gas containing 30% nitrous oxide and 70% oxygen) inhala-tion, and 127 cases using anticholinergic, analgesic and sedative drugs before and during upper gastrointestinal endoscopy. Results were as follows ; 1. Indications of the inhalation were cases with cardiovascular diseses, prostate hypertrophy, glaucoma etc., in which anticholinergics are contraindicated. (Table 12) 2. Anesoxyin-30 may keep the patients co-operation in upper GI endoscopy. (Table 3, 8) 3. Effects of Anesoxyin-30 appeared 3 min. after inhalation, for 8 to 101/min, and disappeared 10 to 20 min. after the inhalation had stopped. (Table 5 ) 4. As clinical effects, anxiety about endoscopy disappeared in approximately 70% and analgesia was noted in approximately 80% of the cases. (Table 4 ) 5. It was clear that a continuous inhalation increases analgesic effects but decreased the level of consciousness. (Table 13) 6. The combination of Anseoxyin-30 with anticholinergics showed reduction of peristalsis and increase of analgesic effects. (Table 11) 7. Examiners suggested that the inhalation made examinations in upper GI endoscopy easier. (Table 7, 9, 10) 8. It may be suggested that these methods are useful and safe without increasing blood pressure or pulse rate, and have no side effects or complications. (Figure 1, Table 6)

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Inhalation anesthesia with 30% nitrous oxide-70% oxygen pre-mixed gas was admini-stered to 88 patients subjected to peritoneoscopy. The anesthetic gas was inhaled through a face mask at a flow rate of 7.8 ± 0.21 per minute for 50.7 ± 24.4 minutes. The clinical efficacy of this inhalation anesthesia was compared with 47 patients not receiving the anesthetic as controls. The results are summarized as follows. Preanesthetic medication was the same in the two groups. 1) The proportion of patients who remained calm without any signs of excitement during operation was significantly greater in the group with the inhalation anesthesia (P < 0.05). 2) Pain felt at the time of puncturing with a syringe needle and of injecting a local anesthetic agent was relieved to a significantly greater extent in the group receiving the inhalation anesthesia (P<0.05). However, there was no significant difference between the two groups in respect of pain produced by manipulation of the endoscope. 3) The proportion of patients who were reported that they felt well during and after endoscopic examination or that endoscopy was performed without discomfort was signifi-cantly larger in the group with the inhalation anesthesia (P <0.01). 4) The physician's overall evaluation of clinical effect was good in a significantly greater proportion of cases in the group with the inhalation anesthesia (P <0.05). 5) No striking difference was observed between the two groups in the incidence of attendant symptoms. There was no evidence of adverse effect on the respiratory and circulatory systems as well as on liver function. 6) The premedication which proved to be nonemetic was a combination of a sedative and analgesic agents. These results led to the conclusion that inhalation of 30% nitrous oxide-70% oxygen pre-mixed gas is a useful anesthetic procedure providing a sedative-analgesic action adequate for peritoneoscopic purposes.

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Effect of premixed gas on colonoscopic examination. There still remains a serious problem as a distress of the patient during endoscopic examination. For the purpose of relieving the patients from anxiety, fear and pain at colonoscopy, 30 nitrous oxide and 70% oxygen premixed gas (Anesoxin 30) has been used in 165 cases of colonoscopy collected from $ hospitals in Japan. By comparing the inhalation group of 100 cases with non-inhalated group of 65 cases, it was confirmed that premixed gas effect helped in performing colonoscopy. A study on clinical effect of premixed gas was performed and several useful results were reported including a few side effects. This method showed rapid effectiveness in the start of colonoscopy and good recovery from analgetic condition after the examination.

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Schönlein-Henoch purpura is a disease characterized by purpura, joint pain and abdominal pain. Abdominal lesions in this disease have been rarely described. This report is the presentation of a case of Schonlein-Henoch purpura accompained by a peculiar lesion in the large bowel. The patient was 48-year-old female who suddenly developed dull pain in the lower abdomen associated with diarrhea. X-ray and colonof iberscopic examinations revealed multiple, deep ulcers in the transverse colon and descending colon, respectively. Narrowing of the involved lumen which was initially prominent recovered to normal. Gastrointestinal lesions of 135 cases of adult Schonlein-Henoch purpura described in the literature were briefly reviewed.

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24-year-old man visited our clinic with a complaint of epigastric pain. X-ray study by double contrast method disclosed a depressed lesion with abrrupt interruption and swelling of the folds on the posterior wall and by compression method an elavated lesion on the greater curvature of the antrum. Endoscopic examination revealed a typical IIc+III, spreading from the antrum to the anglus, and a small elavated lesion with a central pit was also found on the greater curvature which was diagnosed as an aberrant pancreas. Biopsy specimens from these two lesions were both diagnosed as group-V. The surgically resected specimen showed IIc+III, 5 × 4cm in diameter in the antrum, and on the greater curvature a submucosal tumor with a small IIc, 2 × 2cm. Histopatholo-gically, IIc+III was diagnosed as signet-ring cell carcinoma (m), and an aberrant pancreas Heinrich I with adenomyosis. The aberrant pancreas showed also signetring cell carci-noma (m) on the mucosal surface without continuity to the IIc+III. The aberrant pancreas and IIc seemed to be co-exisisting tumors.

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A 54-year-old woman suffering from dysphagia occasionally for about ten years was admitted. On admission, physical examination and laboratory findings revealed no abnormalities. Upper gastrointestinal X-ray examination revealed a stenotic lesion in the lower esophagus. There was no hiatal hernia. Esophagoscopic examination revealed a stricture at 40cm distal to the incisors. The lower part of the stricture was lined by a reddish mucosa, and a scarred esophageal ulcer was observed there. The biopsy specimens from the reddish mucosa showed columnar epithelium and inflammatory change. The transition line between columnar and squamous epithelium is irregular. With the diagnosis of Barrett's esophagus she had been treated with antacid for about two years. However, her symptoms became worse, and the stenotic lesion was resected surgically. There was no evidence of malignancy. This case suggests that Barrett's esophagus may be an acquired condition.

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A case of "primary" esophageal candidiasis healing spontaneously without treatment is described. The diagnosis was made on the basis of typical radioglaphic and endoscopic findings. A 78-year-old man was admitted to our hospital with complaints of dysphagia and retrosternal pain on swallowing. Esophagography was performed, demonstrated a margi-nal irregularity and a cobble stone appearance of the mucosa. Endoscopic scraping and biopsy were performed for histological study and culture. Candida albicans was heavily isolated from the culture. Moreover, candidial hyphae and spores were seen histologically in the mucosa with chronic active inflammation. Further investigation was performed to detect underlying diseases, but all was entirely unremarkable. Moreover, the patient showed a gradual improvement of his symtoms without therapy. Two months later, he was asymptomatic which seemed to be spontaneous remission. Esophageal candidiasis without an underlying disease, or "primary" esophageal can-didiasis is a very rare disease. Only several cases have been reported previously. This is the second case of "primary" esophageal candidiasis in Japan.

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The patient, 38-year-old male, was revealed giant duodenal polyp in the duodenal bulb at a mass screening x-ray examination and admitted to our hospital for the purpose of polypectomy. But the poyp was too large to remove by the usual thermoelectrical polypectomy, so we removed it by the technique of artificial ulcer formation by submucosal injection of 95% ethanol into the stalk of the polyp under direct vision successfully, the polyp could not be withdrawn.

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The worm of Echinostoma hortense has never been found in human alimentary canal or feces, although the ova were detected in human feces. It is still not known where the worms inhabit in the human body, though Yoshida et al. found the worms in the upper portion of the small intestine in the dog. In this study, the authors found the worms in the small intestine by using a small intestinal fiberscope ; test model SIF-2c, Olympus (diameter llmm, length 1, 900mm), which was inserted per os with the aid of the ropeway method. Case 1 was a 48 year-old-man presented with upper abdominal pain and watery diarrhea. Case 2 was a 31 year-old-man with persistent epigastralgia and back pain. Both cases had taken raw loaches previously. By endoscopic observation, white worms were found in the upper portion of the jejunum accompanied by multiple erosions on mucous membrane. Following the administration of anthelmintics, 49 of Echinostoma hortense and Echinochasmus japonicus were confirmed in feces of Case 1. To our knowledge, these 2 cases are the first ones in the world, in which Echinostoma hortense were observed in the small intestine by using an endoscope and were obtained in the feces following the antiparasitic therapy.

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A 41-year-old man visited our department because of melena of unknown origin developing six days after the left lower lobectomy and biopsy of the tumor in the right femoral region. Histology showed a liposarcoma of the right femoral region and its metastasis to the left lung. X-ray and endoscopic finding appeared a submucosal tumor with a central depression on the posterior wall of the gastric antrum. Metastatic liposarcoma of the stomach was strongly suspected by biopsy finding, and gastrectomy was performed. Histologically, the lesion was myxoid mixed type of metastatic liposarcoma of the stomach localized within the submucosal layer. Metastatic tumor of the stomach is seldom diagnosed and treated clinically. There has been no previous reports on the metastasis of liposarcoma to the stomach to our knowledge. From the clinical and histological point of view, this case is very interesting regarding the mode of metastasis.

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Ultrasonically guided Percutaneous Transhepatic Cholecystodrainage (PTCCD) through the gall bladder was performed with linear electronic scanning for acute or chronic cholecystitis. For the cases which were suspected as carcinoma, Percutaneous Transhepatic Cholecystoscopy (PTCCS) was performed two to three weeks after PTCCD to make a correct diagnosis. One case was diagnosed as carcinoma of the gall bladder by biopsy under PTCCS and confirmed by operation. Other two cases, which were suspected as carcinoma, were proved to be benign by biopsy at PTCCS and revealed as cholecystitis by operation. Another case was cholecystitis with gall stones. The patient was 82-year-old and rejected operation, the stones were removed at PTCCS using a basket catheter, drill and Nd-YAG LASER. The diagnostic and therapeutic advantages of PTCCS may be expected for gall bladder cancer or cholecystolithiasis of poor risk.

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It has passed seven years since the first report about peroral cholangioscope by Takekoshi and Takagi. Recently, several types of peroral cholangioscope, which had forceps channel for the treatment, has been made. However, the success rate of insertion of these instruments into the common bile duct was less than 50%. Therefore, we made a new scope by courtesy of Fuji Photo Optical Co. Ltd., for the purpose of easy insertion into the common bile duct. This scope is provided with 105° wide view and 7.5° oblique view, 180° up angle and 30° extra up angle, and 2 mm diameter of forceps channel in order to get good orientation in the duodenum, front view and close observation of the duodenal papilla, which makes possible easier insertion into the common bile duct. We have performed peroral cholangioscopy by using this double angle, oblique view scope in 7 cases of bile duct stone, and succeeded in insertion into the common bile duct in 6 cases. It is concluded that this new scope was useful in bascket removal of stone or differential diagnosis between stone and cancer of the biliary tract.

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