In order to elucidate the mechanism of iron absorption, stereomicroscopic studies of the duodenal mucosa, and histologic studies on the localization of iron, transferrin and ferritin in the duodenal mucosa using rats fed by iron-free diet in the animal experiments and the cases with iron deficiency anemia in the clinical experiments were performed . The following results were obtained ; 1) Stereo-microscopic findings of duodenal mucosa after administration of iron reflected well histologic findings . Therefore, stereo-microscopic observations were useful to evaluate the absorptive capacity of iron in the duodenal mucosa . 2) Localization of transferrin in the duodenal mucosa before administration of iron was different between controls and cases with iron deficiency anemia both in the animal and clinical experiments. Transferrin was scarcely found only in the capillaries in controls, while transferrin was identified in the absorptive cells as well as stroma and capillaries inthe cases with iron deficiency anemia. From these findings, it was assumed that absorptive cells in the duodenum were prepared to be able to absorb iron promptly in the cases with iron deficiency anemia. 3) In the animal experiments, it was presumed that iron may be absorbed by two steps from the results of movement of localization of iron and transferrin obtained by the change of passage of time. 4) Localization of transferrin was closely consistent with that of iron in the duodenal mucosa. 5) In the animal experiments, time of transfer of iron from intestinal lumen to capillaries through absorptive cells in the rats fed by iron free diet was more shortened than that in the control rats. 6) In the clinical experiments, ferritin was mainly found in the epithelial cells of Lieberkuhn's gland before administration of iron . Ferritin was strongly stained in the epithelial cells at the top of villi and macrophage as well as the epithelial cells of Lieberkuhn's gland after administration of iron. However, localization of ferritin was not different between the controls and the cases with iron deficiency anemia . Therefore, it was interpreted that significance of ferritin on iron absorption was relatively small. From those results mentioned above, it was clarified that transferrin may be closely related to iron absorption in the duodenal mucosa . Therefore, it was suggested that transferrin may play the promotive role as one of the carrier-like substances of iron in the route of transfer of iron from the intestinal lumen to the capillaries through absorptive cells.

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There are many reports concerning the influence of endoscopic examination on cardiovascular system, but no reports seem to have studied on blood biochemistry. The levels of serum cortisol, plasma ACTH, plasma adrenalin, plasma noradrenalin, serum free fatty acid, serum gastrin, serum blood sugar and serum insulin were measured before and after endoscopic procedures. The first blood sample was collected just after injection of anticholinergic agents, and the second sample was collected at 10 minutes after procedures. The levels of serum cortisol, plasma adrenalin and serum free fatty acid were significantly higher in the second sample than in the first. The serum cortisol levels in the peptic ulcer group and the psychically neurotic group showed more significant increase in the second sample than in the first. These facts suggest that gastroscopic examination affects patients by conciderable emotional and/or physical stress. To safely perform endoscopic examination, endoscopists should pay attention to the changes of various vital functions, especially changes in blood biochemistry as well as cardiovascular system.

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An endoscope was inserted into the stomach after degultition and peristalsis of the esophagus was inhibited through general paralysis and local paralysis of the pharynx using diazepam and an intravenous injection of a parasympatholytic agent. First, the gastric juice remaining in the stomach from the time of fasting were suctioned out and discarded. The tip of the endoscope was then advanced into the duodenum, and air was then introduced into the duodenum to prevent regurgitation ofduodenal fluid into the stomach. This was followed by washing of the gastric mucosa with water through a tube within a forceps channel with subsequential sampling of the gastric mucus. The gastric mucus was divided into those that pH was adjusted, and those that protein was deproteinized and each type was concentrated. The former was submitted to immunoelectrophoresis and the latter to mucosubstance electrophoresis. Electrophoresis of mucosubstance was conducted following deproteinization by Sevag method in the 1/10 N HCI on cellulose acetate by Wessler method.

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Immunoelectrophoresis and electrophoresis of mucosubstance were performed on gastric mucus obtained through an endoscope by preventing mixing of saliva and duodenal juice. Indigocarinine and methylene blue were thereafter sprayed via the endoscope to conduct dye endoscopy. After electrophoreisis of mucosubstance the sample was stained with Toluidine blue (pH 2.5 ), Alcian blue (pH 2.5) and standard PAS . Hyaluronic acid (HA), Chondroitin sulfate (Chs-A) and Heparin (Hep) were simultaneously submitted to electrophoresis as the reference standards. An appearence of immunoglobulin was pH-dependent, becoming higher as pH rises. SC (Secretory Component), however, was specifically elevated in intestinal metaplasia and carcinoma. Thus SC appears to be released from the mucosa with organic abnormalities into the mucus. Electrophoresis of mucosubstance revealed a neutral mucosubstance with positive PAS reaction in all patients. Six other fractions were distinguished from near the starting point to Hep (S₁-S₆). S₆ comigrated with Hep, S₅ with Chs-A and S₄ with HA . S₁ and S₂ were shown to be released due to hemorrhage according to experimental and statistical analysis. S3-S6 fractions were frequently associated with intestinal metaplasia. S₆ was commonly associated with acute erosion . Endoscopy revealed methylene blue metachromasia. As to the characteristics of diseases, findings on immunoelectrophoresis and electrophoresis of mucosubstance were parallel in intestinal metaplasia, but no such parallelism was found in carcinoma . An appearence rate of mucopolysaccharide was occasionally low in the presence of SC. In one patient with carcinoma, no mucopolysacchride appeared, and double precipitation lines were seen on Ig-A and S-IgA . Endoscopy revealed metachromasia within the lesion. Follow-up observation in intestinal metaplasia revealed absence of SC in simple intestinal metaplasia. SC appeared only in conditions associated with inflammation, erosion and ulcer.

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Gastrointestinal hemorrhage is a serious and sometimes fatal complication of renal transplantation. When hemorrhage develops, immediate diagnosis and treatment are necessary. In this paper, thirteen transplanted patients with upper gastrointestinal bleeding were investigated. Thireen cases consisted of nine duodenal ulcer, one gastric ulcer andthree unknown cases. Several techniques for the endoscopic control of upper gastrointestinal hemorrhage following renal transplantation were perfomed in three patients . These included endoscopic spraying of thrombin, electrocoagulation and local injection of HSE solution. Hemostasis was readily obtainded in all canes . Our studies have demonstrated that urgent endoscopy was necessary and endoscopic hemostatic method was effective to manage the upper gastrointestinal bleeding following renal transplantation.

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A 44-year old woman visited our clinic because of progressing dysphagia on May 1981. Endoscopic study revealed a broad-based, about 3cm long tumor in the middle esophagus. Four months later, the tumor had grown upto 10cm long with a narrow stalk . Esophagotomy and gastroesophagostomy was done, its histological features resembled those of sarcoma, being not likely to fibrosarcoma, myosarcoma, etc. Metastasis to the regional lymphonodes could not be found, and squamous cell carcinoma (in situ) was seen in the vicinity of the tumor. According to these findings, we diagnosed it as pseudosarcoma of the esophagus, first mentioned by Stout & Lattes (1957). Pseudosarcoma of the esophagus is very rare tumor and only 25 cases have been reported since 1957, when Stout & Lattes proposed this clinical entity. She was well in January 1983 (15months after operation).

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This report described the case of a 47-year-old male patient with early gastric cancer with complicating lymphoid stroma and heterotopic gastric glands. He was admitted to our hospital following complaints of epigastralgia. X-ray and endoscopic examination revealed a submucosal tumor on the posterior wall of the middle gastric body and a IIc type tumor on the greater curvature of the lower gastric body, which was subsequently confirmed by biopsy as a moderately differentiated tubular adenocarcinoma. In the pathological examination of the resected stomach, the IIc type tumor was a moderately differentiated tubular adenocarcinoma involving remarkable lymphoid infiltration in the submucosal layer. This type of gastric carcinoma was designated as gastric carcinoma with lymphoid stroma. A submucosal tumor, measuring 2.0 ? 1.2 cm, was a submucosal cyst which consisted of heterotopic glandular structures, later diagnosed as retention cysts. Heterotopic glandular structures also appeared diffusely in the submucosal layer. We reported here a rare case of early gastric cancer with lymphoid stroma and heterotopic gastric glands.

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Malignant melanoma originating in the esophagus has been found in only 65 patients including those in Japan and the Western countries, according to the report of Kreuser et al. in 1979. The number of the patients to whom operation is applicable is considered to be smaller. A 66-year-old man visited our hospital with a complaint of dysphagia. Fluoroscopic examination of the esophagus revealed a mass shadow with the smooth surface in the upper part of the esophagus and slightly irregular wall of the esophagus on the anal side. Endoscopic examination of the esophagus revealed a main grayish mass with the smooth surface and partially with ulcer 23-26 cm from the incisal line . Also on the anal side, blackish small protuberances were disseminated . This patient was diagnosed as having malignant melanoma from the findings of histopathological examination by biopsy. The size of the main mass was 1.5×1.0 cm. Small protuberances with chromatosis were disseminated in the area 2.0 cm on the anal side. Concerning the histopathological findings, proliferation of tumor on the boundary between the epidermis and the dermis was revealed by H-E staining in the main mass. Images of junctional changes were observed, and melanin granulen were demonstrated by Fontana's staining . Junctional changes were segmentally observed in the elevated lesion disseminated on the anal side, indicating the multifocal pathogenesis of the mass. No reginal lymph nodes were not involved at operation. This patient leads his life uneventfully at present (22 months after operation) .

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The first case in which the neurogenic sarcoma and two adenocarcinomas coexisted in the stomach were reported. A 46-year-old woman, who was found to have abnormal findings in the course of gastric mass survey, came to the Detection Center of Hokkaido Cancer Society for detailed examination of the stomach. X-ray and endoscopic examination revealed early gastric cancer (IIc) on the angle and submucosal tumor with central depression on the antrum. Partial gastrectomy was performed at Sapporo Kosei Hospital. The results of microscopic examination were as follows: 1) There were two carcinomas. One on the angle was moderately differentiated adenocarcinoma which was involved the submucosa. The other on the surface mucosa of submucosal tumor was well differentiated adenocarcinoma. 2) The submucosal tumor was neurogenic sarcoma. Immunohistochemical examination for nervous tissue specific S 100 protein was helpful in identifying the tumor as neurogenic origin.

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Three cases of the flat type of early gastric cancer (IIb) were detected preoperatively and the analysed clues to the detection were reported on 21 cases including 22 lesions of IIb-18 reported in the literature and 4 of our own . The majority of IIb lesions were found by endoscopy followed by biopsy, and it was extremely rare to find it by X ray examination. Abnormal tint of mucosa in endoscopy, redness and discoloration, constituted the chief marks of IIb lesion. The redness was visible in 12 of the 22 lesions, the discoloration in 7 and no change in 3. The redness tended to be observed in differentiated adenocarcinoma and the discoloration in undifferenciated adenocarcinoma. Four lesions of our own were detected by biopsy performed immediately after finding an abnormal tint of mucosa directly through the endoscope. Since the visible features of IIb through the endoscope could not be represented correctly on an endoscopic photograph in our cases, endoscopic observation offered the more important aid for the detection than reading the endoscopic photograph. Consequently, it is concluded that (1) endoscopy is the most preferable examination for the IIb detection, (2) direct observation through the endoscope immediately followed by biopsy serves more effectively as an detecting clue and (3) magnif ing endoscopy with the dyeing seems to be useful as a secondary examination.

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A forty-two year-old man with chronic relapsing pancreatitis presented with severe abdominal pain. Clinical examination such as ultrasonography (US), CT and ERCP revealed pseudocyst in the body of the pancreas. Calcification was not observed in abdominal plain x-ray film or CT, but ERCP revealed filling defect floating in the main pancreatic duct in the head of the pancreas, and the case was diagnosed as non-calcified pancreatolithiasis. While the clinical course was followed up by US, CT and ERCP, pseudocyst disappeared within about a month. After one year, attack of pancreatitis recurred. In order to relieve the intraductal pancreatic pressure and to remove the stone, endoscopic sphincterotomy to the pancreatic duct was performed according to the method of sphincterotomy described by Warren, or to the methods of sphincteroplasty described by Jones et al. or Nardi. After performing the usual endoscopic papillotomy, a papillotome was inserted into the pancreatic orifice and an incision was made in the manner of pulling in the 12° direction. The pancreatic stone was grasped by a basket catheter under fluoroscopy, and removed. His clinical course is presently under obsevation with no complication.

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A 55-year-old female was admitted with complaints of severe epigastric pain and vomiting. Physical examination revealed a palpable mass with tenderness in the epigastrium. Upper GI series and endoscopic examinations revealed a submucosal tumorarising from the upper body of the stomach prolapsed into the duodenum . Resected specimen showed a smooth-surfaced, well-movable tumor, measuring 5.5×5.5×5.0 cm in size and weighing about 50 g. Histologically, it was diagnosed to be a leiomyoma. Nine cases of submucosal tumor including this one, which developed in the upper part of the stomach and prolapsed into the duodenum, have been reported in Japan. Clinical aspects of these cases were discussed in this paper.

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We recently experienced two cases of duodenal varices. A 45-year-old woman who had undergone cholecystectomy and gastrectomy was admitted to the hospital with melena. X-ray examination of upper gastrointestinal series revealed filling defects in the descending part of the duodenum. Endoscopically, large dilated, bluish varices were noted in the second portion of the duodenum. Dilated tortuous veins of the right colon were demonstrated by angiography. The another patient was a 35-year-old woman, who had a history of chronic pancreatitis and chronic cholecystitis. X-ray findings and endoscopic findings had revealed varices in the second portion of the duodenum. Percutaneus transhepatic portogram showed no occulusion of portal vein, but demonstrated esophagogastric varices, duodenal varices and accessory portal vein. These two cases were diagnosed noncirrhotic portal hypertension with duodenal varices by the other examinations. 67 cases have been reported since Alberti described about duodenal varices for the first time in 1931, but this is the first report in Japan.

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A patient with gastro-jejuno-colic fistula developing 11 years after operation for duodenal ulcer was reported. A 53-year-old man was admitted to Gifu Univ. Hosp. because of recurrent diarrhea, emaciation, abdominal pain, and fecal smelling belch. Laboratory data on admission showed hypoproteinemia with hypoalbuminemia. A basal plasma gastrin level was less than 10 pg/ml, and plasma secretin level was high, 445 pg/ml. The peak acidity of gastric juice responded to tetra-gastrin was 82 mEq/l. Barium enema demonstrated a free communication from the mid-transverse colon to the remnant stomach. Two open ulcers were revealed as well as fistula to the colon near the portion of previous gastro-jejunostmyby the endoscopic examination. In the previous operation by Billroth II method, the only one-third of stomach had been resected. The transverse colon lay anterior to the gastrojejunostomy, and they adhered each other. The fistula was found there. Although the f istulectomy was performed on this admission, post operative ulcer was recurrent four months later. No histological evidence of malignancy was noted. In the re-examination of gastrin test, the peak acidity was only 20 mEq/l. So in this case, large remnant stomach and/or some other unknown factors might resulted in incidence of stomal ulceration and the gastro-jejuno-colic fistula.

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