Gastric mucosal defence mechanism of acute gastric mucosal lesion by means of endoscopical measurment of gastric mucosal blood flow (BF) and gastric mucosal potential difference (PD) was studied. BF measurment by H2 gas clearance method decreased in comparison with control. Especially, BF of the corpus decreased remarkably than that of the antrum. BF was 52.2±2.0 ml/min/100g on the antrum, 37.6±1.7 ml/min/100g on corpus in AGML, and 55.8± 5.3 ml/min/100 g on the antrum, 67.4±4.9 ml/min/100 g on the corpus in control. Therefore, in chronic gastric ulcer BF and PD decreased on the ulcer, but did not decrease on the surrounding mucosa. Relationship between AGML and atrophic pattern by an endoscopic congo-red method was studied in 50 cases of AGML and 455 cases of control and other gastric diseases. The closed type of atrophic pattern was seen 94% of the cases with AGML. Especially, in the cases of AGML C₁ and C₂ due to endoscopic atrophic patterns established by KIMURA & TAKEMOTO were dominantly seen. From those results, it is concluded that it was difference between onset of AGML and that of chronic gastric ulcer.Gastroenterological Endoscopy

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Gastric mucosal defence mechanism of gastric mucosal redness by means of endo-scopical measurment of gastric mucosal blood fiow (BF), gastric mucosal potential differ-ence (PD) and gastric mucosal pH (pH) was studied. Gastric mucosal redness was classified into 3 types: comb-like redness, patch redness and teleangiectasia. Furthermore, patch redness was classified into 3 types: F-type of the fundic gland area, P-type of the pyloric gland area and so called "red spot". Normal pits were observed on the comblike redness and F-type of patch redness by magnifying endoscope, and this could be distinguished from erosion. Relationship between the redness and atrophic pattern classified with endoscopic congo-red method was studied in 219 cases of comb-like redness, 115 cases of patch redness and 455 cases of control. In control an open type increased with aging. But, in redness cases a closed type were dominantly in regardless of age. The closed type of atrophic pattern was seen in 97.7% of the cases with comb-like redness, 81% of the cases with patch redness. It was recognized that BF measured by H₂ gas clearance method decreased on the mucosa with redness as compared with the surrounding mucosa, but there was no difference in PD and pH between the both mucosae. This evidence might be supported by the histological findings of biopsied specimens that edema and hyperemia increased on the redness mucosa, but cellular infiltration did not distinguish the both mucosae. From these results, it is concluded that much attention should be paid to the role of redness in the etiology of erosion and acute gastric mucosal lesion.

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Histological studies had been underwent on the invasive mode of early gastric car-cinoma in views of its location and condition of neighboring mucosa. Materials for studying intramucosal (horizontal) invasion were 38 carcinomas ac-companied by IIb, because IIb might not be affected by peptic action and invaded intramucosa horizontally. And materials of study for submucosal (vertical) invasion included 30 carcinomas of depressed type measuring less than 2 cm in the largest diameter (Table 1).
Neighboring mucosa of gastric carcinoma was divided into three grades according to the severity of mucosal atrophy (+) or (++) and intestinal metaplasia as shown in Table 2. The neighboring mucosa in all of 38 partial IIb showed mucosal atrophy (+) or (++), while only 4 showed mucosal atrophy in 30 carcinomas with deeper invasion. As for the intestinal metaplasia, it was found in all cases of 38 partial IIb and in 24 out of 30 carcinomas with deeper invasion. Sixteen out of those 24 were differentiated adenocarcinoma (Table 3, 4).
The studies on lacation of IIb revealed that partial IIb spread evenly in 17 carcinomas located near or through the lesser curvature, but in contrast 20 partial IIb out of 21 carcinomas located at the posterior or anterior wall spread near to the lesser curvature side in where the mucosa was found to be more atrophic and intestinal metaplastic than other regions of the stomach (Figure 3).
In 18 carcinomas with submucosal invasion accompanied by IIb, 5 out of 9 lacated along the lesser curvature had submucosal invasion at the mid-portion of the carcinoma, however 8 of the rest located at anterior or posterior wall had submucosal invasion near the greater curvature or in fundic gland mucosa with less mucosal atrophy (Figure 4).
Consequently it may be concluded that the modes of intramucosal and submucosal extension of early gastric carcinoma are closely related to the grade of atrophy and intestinal metaplasia of its neighboring mucosa. In other words, carcinoma may spread horizontally when the neighboring mucosa is markedly atrophic, meanwhile carcinoma may spread vertically when neighboring mucosa is essentially within normal limits.

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A prospective study on a causal relationship between digestive endoscopy and HBV infection was investigated at 5 institutions of Japan from October 1977 to April 1979 by the cleaning and disinf ection committee for the endoscope of the Japanese Gastrointestinal Endoscopy Society. HBV negative patients before endoscopy were 189 of 273 patients completely followed up for 6 months. One HBsAg positive and 15 anti-HBs positive patients were found among the 189 patients. The rate of HBV infection was 8.5 percent. In a case with HBsAg positive, HBsAg became positive four months after endoscopy and turned to be negative two months later. However, anti-HBs continued to be negative with normal hepatic function and no symptoms of hepatitis for 3 years after then. A further investigation should be urged to confirm the unexpectedly high rate of HBV infection suggested in this report.

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Examination of HBsAg and anti-HBs was performed in 317 patients who visited outpatient clinic of the Aichi Cancer Center Hospital during a period from May 1982 to April 1983 as a controlled prospective study on transmission of HBV in the procedure of digestive endoscopy. 193 of 317 patients had endoscopy as a endoscopy group and 124 had no endoscopy as a control group after the test. No evidence of HBV infection was confirmed either for the control group or for the endoscopy group. It is concluded that transmission of HBV is not associated with digestive endoscopy by the routine disinfection using activated glutaraldehyde.

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A double-lumen tube, attached an electrode in its tip, was inserted into the stomach through biopsy forceps channel of the endoscope. The tip of the tube was touched with the test points of the mucosa through direct observation by the endoscope. The potential difference (PD) was recorded continuously with perfusion of a test solution through the tube. Half time (t1/2) of PD change associated with the change of NaCl concentration in the t(1/2) perfusate was measured, and the functional unstirred water layer thickness was calculated according to Diamond's formula. This is the first attempt to measure this thickness in the gastric mucosa.
The thickness was measured in 178 points in 95 cases. The results were as follows: They were 205.8±71.9 μm (±SD) and 224.5±73.1 μm in the endoscopically normal gastric mucosa and duodenal mucosa of the bulb, respectively. The thickness of injured points tended to be lower than that of normal points. The thickness in normal gastric mucosa was thicker in duodenal ulcer patients than in gastric ulcer ones. There was the positive correlation between the gastric acid secretion and the thickness.
The clinical significance of this thickness is still unclear. However, it was suggested to become a marker of gastric mucosal defensive mechanism.

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At the time of endoscopic examination the object lens is lavaged by irrigation. The lavage water, however, is not sufficiently removed from the lens, causing blurring of visualisation (Figure 3, 4 and 5), a constant irritation for endoscopists.
The authors developed a modified insufflation-irrigation piston (Figure 1), which allows ejection of air-water mixture from the nozzle (Figure 2) for lavage of the lens. This system for irrigation was named "spray method".
Comparison of the examinations (44 by the spray method and 39 by the conventional, Tables 1 and 2, using GTF-B₃ or GTF-S₄, the side-viewing gastrocamera-incorporated fibrescopes (Olympus Optical Co.) ) showed highly significant (p<0.01) reduction in the incidence of blurring : Blurring occurred in 36% by the spray method in contrast to 55% by the conventional (Table 3).
The spray method irrigation system is effective in improving the quality of endoscopic visualisation and photography.

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The thrombin reacted fibrinogen (fibrin adhesives) was used for 32 cases (Figure 1) for the prevention of hemorrhage after laparoscopic liver biopsy. The fibrin adhesives are prepared by mixing the solutions A (human fibrinogen solution) and B (solution containing human thrombin, CaCl₂, and aprotinin) as shown in Figure 3. Liver biopsy was performed by Tru-Cut biopsy needle, then, outer hollow of the needle was left in the liver. Fibrin adhesives are injected slowly into the biopsy scar through outer hollow of the needle, in the same time, the outer hollow is extracted from the liver before the coagulation period of fibrin adhesives (Figure 4). We confirmed that this method simplified the hemostatic procedure without any complications comparing with other conventional methods which we had reported before. The application of the fibrin adhesives are expected to be useful for the prevention of hemorrhage after laparoscopic liver biopsy in the cases which have higher risks for hemorrhage such as neoplastic liver diseases.

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Out of 23 cases of an anomalous arrangement of pancreatico-biliary duct encountered in our department and the affiliated institutions during the last 8 years, 2 cases (9%) were complicated with acute pancreatitis and 3 cases (13%) with chronic pancreatitis. In view of these findings, the relationship between anomalous arrangement of pancreatico-biliary duct and pancreatitis was clinically investigated from various aspects. The subjects included a total of 23 cases of the anomalous arrangement of pancreatico-biliary duct. They consisted of 3 male cases and 20 female cases. According to Kimura's criteria, the anastomotic pattern was classified as typeI (pancreatic duct anatomotic type) in 11 cases and as type II (bile duct anatomotic type) in 12 cases. All 5 cases with complication of pancreatitis had a congenital biliary dilatation. Two patients who had acute pancreatitis were girls of 5 years and 14 years of age, respectively, and both were diagnosed as having the type I anastomotic pattern. Chronic pancreatitis was seen in 3 patients consisting of a 46-year-old woman, a 49-year-old woman and a 50-year-old man, in all of whom the anastomotic pattern was classified as type II. In these patients, the chronic pancreatitis was considered X-ray-positive pancreatolithiasis, mass forming pancreatitis and alcoholic pancreatitis, respectively. The results in these 5 patients showed that a complication of acute pancreatitis was seen more frequently in younger patients and took a relatively mild course, while chronic pancreatitis is a more frequent complication in patients having the type II anastomotic pattern. These findings suggest the presence of causal relationship between the development of pancreatitis and an anomalous arrangement of pancreaticobiliary duct.

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A 65-year-old Japanese male, who was symptomless except for multiple dark bluish naevi of the skin and oral mucosa, was found to have a submucosal tumour-like mass (Figure 1 to 3), measuring approximately 4 cm in diametre, on the left posterior aspect of the upper oesophagus at the level between 22 and 26 cm from the incisors, or between the lower ends of the 2 nd and of the 4 th thoracic vertebrae, and rapidly developing during a 15 months' interval of periodic general check-up. On endoscopic ultrasonography (Figure 4), the mass was a clearly demarcated oval hypoechoic structure associated with posterior echo enhancement and cyst was thus suspected of, but as it contained multiple internal echoes, parenchymatous tumour such as leiomyosarcoma was not ruled out ; it was confirmed by thoracotomy as thin-walled thoracic duct cyst with several trabecular structures (Figure 5) in the lumen, which were thought to produce internal echoes on ultrasonography. This is the 15 th case of surgically treated thoracic duct cyst and is believed to be the first case that was visualised by endoscopic ultrasonography. Endoscopic ultrasound seemed to be valuable in the diagnosis.

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Diverticula of the stomach are comparatively rare among diverticula of digestive tract. In reviewing several reports, incidence of gsatric diveticula ranged from 0.01% to 0.20%. Most of gastric diveticula occur at the cardia and the lesser curvature toward the posterior wall and diverticula on the greater curvature of the corpus are very rare (2.3% of whole gastric diverticula in Palmer's review). About the size of diverticula, the majority of them measure from 2.1 cm to 3.0 cm and over 5.1 cm are rare (6.9% in Hirota's review). On the wall structure, most of diverticula occuring in the cardia are true. A 48-years-old female was admitted because of heart burn, epigastralgia and loss of appetite. An upper gastrointestinal radiograph showed giant gastric diverticulum in the corpus arising from the greater curvature. Endoscopic examination revealed giant gastric diverticulum at the same position as above. Celiotomy was carried out because symptoms continued resisting to concervative treatment. The diverticulum measured 11.5cm×8.0 cm and it was a pseudodiverticulum.

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Stomach is the most common site of the developement of gastrointestinal lymphoma, however, early detection of primary gastric lymphoma was relatively rare. In this paper, we reported a case of primary malignant lymphoma of the stomach, which was limited to the submucosal layer. A 60-year-old woman without any complaint admitted to our hospital for precise examination of gastric abnormality detected in a mass survey. The X-ray examination of the stomach revealed multiple irregular shaped small ulcers and erosions with irregular gastric area at the antrum. The out-line of this lesion was not sharp. Endoscopic examination revealed various sized granules surrounded by sulcus-like erosions on the anterior wall, grater curvutur, and posterior wall at the antrum. From these roentgenographic and endoscopic features, this case was diagnosed as malignant lymphoma, and histological confirmation was made on the biopsy specimens. Subtotal gastrectomy with extended lymphnode dissection was performed. On the histological examination, the case presented was diagnosed as a diffuse type of poorly differentiated lymphocytic lymphoma. The depth of invasion was limited within submucosal layer, and no lymphnode metastasis was found. This case was so-called early gastric malignant lymphoma, and fortunately she is alive without any sign of recurrence.

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The patient was a 59-year-old housewife, who complained right hypochondralgia on Feb. 1980. She was admitted to our department on Dec. 1980 because of increasing of the pain. On admission, physical examination showed hepatomegaly, but icterus and ascites were not recognized. Abnormality of laboratory findings were elevated LDH titer and hypergammaglobulinemia. Lever scintigram showed a large cold area in the right hepatic lobe and abdominal CT scan revealed a large low density area accompanying with isodensity foci in the right hepatic lobe. Selective celiac angiography showed cotton-wool like tumor stain with avascular area in the right hepatic lobe. Laparoscopic examination presented a yellowish white prominence surrounded by bluish purple spots in the swollen right hepatic lobe. Wedge biopsy disclosed hepatic hemangiosarcoma. She died in twenty months after the onset.

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A rare case was reported which many ova of Schistosoma japonicum were distributed only in the duodenum throughout the digestive tract. The patient was a 69-year-old man with a chief complaint of epigastric pain. The upper panendoscopy revealed a small elevated lesion in the duodenal bulb as like as verruciform erosion of the stomach. Biopsy from that lesion showed many ova of Schistosoma japonicum histopathologically. Repeated biopsy from the stomach, ileum, colon and rectum was negative from the ova. However, slight deformity was seen in the cecum and biopsy from the colon and rectum showed irregular and thickened muscularis mucosae which suggested the possibility of evidence concerning discharged ova. CTscan, radioisotope and ultrasonic examination for involvement to the liver, pancreas and other organs were all negative. Now, Schistosomiasis japonica is reported very seldom, however, many asymptomatic patients are presumed to be present.

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A rare case of ulcerative colitis complicated by antibiotic-indnced peeudomembranous colitis and Basedow's disease was reported. Sixty-six-year-old woman with a history of a subtotal thyroidectomy at the age of forty-six complained of diarrhea of four-months' duration. Since antibiotics were given to the patient three weeks prior to admission and pseudomembranes were seen in the colon, a diagnosis of antibiotic-induced pseudomembranous colitis was made. Despite of administration of metronidazole and vancomycin altogether for nine weeks, colitis did not subsided completely. Thereafter treatment was shifted to Salazopyrin (P. O) and predonisolone enema which were very effective. This case was concluded as ulcerative colitis had been complicated by antibiotic-indnced pseudomembranous colitis because of the following reasons. 1) She had diarrhea and bloody stool and roentgenogram of barium enema was abnormal before antibiotics were given. 2) Vancomycin and metronidazole did not cure her colitis. 3) Remission was obtained by the treatment for ulcerative colitis. The association of ulcerative colitis and Basedow's disease and the meaning of clostridium difficile in ulcerative colitis were reviewed and discussed.

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A rare case of colonic Crohn's disease which occurred rapidly and deteriorated during a short period was reported. A twenty-two years old male who had been completely well developed acute watery diarrhea, lower abdominal pain and high fever followed by pronounced hypoproteinemia and weight loss of 10 kg. He was transferred to our hospital for the further evaluation of colonic lesion which was found by barium enema and colonof iberscopic examination done in another hospital. Stool examinations for parasites and pathogenic bacteria were negative. Both barium enema and colonofiberscopic examination revealed typical longitudinal ulcers and cobble stone appearance in the whole large intestine except for the rectum. Granuloma associated with giant cell was demonstrated in the biopsy specimen taken from the colon. No abnomalities were found in the stomach and small intestine. Diagnosis of Crohn's disease with acute onset was strongly suspected from the clinical course as well as X-ray and endoscopic findings of the colon and confirmed by granuloma in the biopsy specimen of the colon.

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In nine of ten patients with achalasia, passive dilation with Maloney mercury-filled esophageal bougies 50 to 60 French has resulted in satisfactory management of dysphagia over the period of 6 months to 2 years (mean 18 months) of follow-up. Three patients had excellent symptomatic result with a single dilation session with 60 French in two patients and 50 French in one patient. It is noteworthy that a 36 y. o. female who was unable to eat and cahectic was successfully treated by two sessions with 60 French bougie and she has been totally asymptomatic over 6 months with weight gains of 18 kg to the usual body weight before the onset of her disease. The result of the remaining five patients were good, in whom repeat dilations (2 to 6 times) have been needed over the period of 1.4 to 2.6 years of follow-up. In a case of vigorous achalasia, bougienage induced severe substernal pain attack and failed in relief of his dysphagia. Although the role of passive bougienage in achalasia has been deprecated, our experience indicates that bougienage with 60 French is useful with ease and safety, and the relief produced is not transient.

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Questinaires of the complication of peritoneoscopy were sent to the 406 main hospitals in Japan and the answers were got in 283 hospitals (69.7%). It revealed that peritoneoscopy had come into wide use in Japan but its complication had increased more than the increase of peritoneoscopy itself. Among the complications, pneumothorax or various embolisms was observed in 40.7%, hemorrhages was in 25.9%, and injuries of gastrointestinal tracts and shock were in 7.7% respectively. 88.8% of the complications occurred at the basic procedures such as insufflation (46.2%), liver biopsy (34.6%) and insertion of trocar (8.0%). And 63.4% of the complication was done by the operators who experience less than 200 cases. Length of years from the initial experience was not so important as cases experienced. Unskilled operators failed mainly at the time of insufflation. Experts sometimes caused severe complications in the patients with liver cirrhosis or hepatoma by liver biopsy or insertion of trocar. We thought education system and adequate carriculum should be established and conferences concerning complications should be organized for reduction of complication.

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