The relationship between the development of gastric cancer and the extent of fundal gastritis was investigated by the endoscopic or epidemiologic procedures in 77 healthy subjects and 743 patients with benign gastric diseases. The extent of fundal gastritis was examined by the endoscopic Congo red test at the first examination. The average follow-up period was 7 years and 7 months (2 to 15 years) after the first endoscopic assessment. Results indicate that gastric cancers developed more frequently and more rapidly in patients with severe fundal gastritis. Therefore, patients with severe fundal gastritis should be considered as high risk group for gastric cancer. The relationship between group I pepsinogen (PG ) in the serum and fundal gastritis or early gastric cancer was investigated in 97 patients with benign gastric diseases and 79 patients with early gastric cancers. PG I was measured by PG I radioimmunoassay kit (CIS). Serum PG I levels were significantly lower in patients with severe fundal gastritis than in those without severe fundal gastritis. The sensitivity of measurement of PG I for detection of gastric cancers of differentiated type of adenocarcinoma was 72%, but only 37% for other ones. Therefore, patients with abnormal lower PG I level in the serum should be considered as high risk group for gastric cancer of differentiated type.

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The effects of cigarette smoking on the location, healing and recurrence of gastric ulcers were investigated by endoscopy. The endoscopic Congo red test developed in this clinic revealed a close relationship between the location of gastric ulcers and the extent of the acid-secreting area, and the smoking index. In general, in patients with a high smoking index, gastric ulcers were located more proximally and the acid-secreting area was smaller. These findings indicate that smoking is associated with the development of fundal gastritis and so development of high lying ulcers. Healing of gastric ulcers was significant ly faster, and recurrence was significantly less frequent in patients who stopped smoking or reduced smoking by a half or more after treatment, as compared with those who did not.

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CT examination after ERCP (FRCP-CT) is a new trial for image diagnosis of biliopancreatic disorder and extrapancreatic mass. In Cancer Institute Hospital, ERCP-CT was carried out in 57 cases during the past 2 years and 4 months (Table 1). To obtain clear ERCP-CT image it is necessary to start CT scanning after ERCP as quickly as possible. To prevent artifacts on CT image, some considerations such as use of diluted contrast medium and less air insufflation are also necessary. The efficacy of ERCP-CT for pancreatic cancer and chronic pancreatitis was studied in this paper. ERCP-CT was useful for diagnosis of pancreas disease with following changes. Pancreatic cancer; 1. Those with cystic change around stenosis of main pancreatic duct (Figure 2-a, B) 2. Those with displacement and stenosis of main pancreatic duct (Figure 2-a, C) Chronic pancreatitis ; 1. Those with localized stenosis of main pancreatic duct (Figure 2-b, b) 2. Those with cyst, especially in the pancreas tail (Figure 2-b, c) As a result of evaluating ERCP-CT of pancreatic cancer (larger than 2 cm in diameter) and chronic pancreatitis, we have come to the conclusion that ERCP-CT is useful for diagnosis of small pancreatic cancer.

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In order to evaluate the effect and limitation of endoscopic hemostatic treatments, 422 patients with hemorrhagic gastric and duodenal ulcers admitted to our hospital before (Jan. 1978-Jul. 1981) and after (Aug. 1981-Jun. 1984) adopting these treatments were studied. Endoscopic treatments including bipolar electrocoagulation, local injection of hypertonic saline epinephrine solution and local injection of pure ethanol were applied to 68 patients with arterial bleeding or with exposed vessels. 1) Severe hemorrhage was more frequent in those with exposed vessels than in those without exposed vessels (Figure 1, 2, 3). 2) In hemorrhagic gastric and duodenal ulcers with exposed vessels the effective rates of H₂-receptor antagonist were 51.1% and 75.0%, respectively. Endoscopic treatments were effective in 91.5% and 100%, respectively (Figure 4). 3) In hemorrhagic gastric and duodenal ulcers without exposed vessels the effective rates of H₂-receptor antagonist were 96.7% and 98.5%, respectively. 4) The rates of emergency operation decreased after adopting endoscopic treatments. In hemorrhagic gastric ulcer the rate of emergency operation significantly decreased from 23.7% to 3.7%. In hemorrhagic duodenal ulcer it decreased from 7.4% to 2.4% (Figure 5). 5) Endoscopic treatments were also applied to patients with critical complications who had no operative indication. The re-bleeding rate for these patients was higher than those without serious complications.

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Authors devised a "Guiding Tube" for gastroduodenal endoscopy and used it in 1574 cases since October 1981. Also abrasive sponge cytology was performed as screening method for esophageal cancer at the same time in every cases. 1. Using the guiding tube in endoscopic examination decreased markedly pain and discomfort of patients during the examination and particularly in changing of equipments. 2. Guiding tube is made of Silicone with 17.5 mm of external diameter, 12.5 mm of internal diameter and 22 cm of length. It is locked in a mouth piece. 3. Among 1, 574 cases examined by endoscopy and sponge cytology using the guiding tube, 3 cases of early esophageal cancer were detected. Only one case was shown the lesion and other 2 cases were not revealed the location of the lesion by X-ray examination. One was detected only by the sponge cytology. Another one case of double cancer of esophagus and stomach, in which the esophageal lesion was missed by gastroendoscopy but was detected by the sponge cytology, was included in this series. 4. A fibercamera of type S3 and a f iberscope of type P10 passed easily through this guiding tube and changing of the equipment was very easy. Overflowing of gastric juice and dyeing fluid are smoothly discharged through this tube. 5. The guiding tube was able to use for emergency endoscopic examination of patients with hematoemesis.

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The elevated type of the gastric ulcer scar (EUS) was noted in six of 163 cimetidinetreated ulcer patients (A group). These were compared with 13 cimetidine-untreated patients with EUS (B group), and its etiology was discussed. The incidence of EUS was higher (3.7%) and the avarage age of patients was higher (56.7 years) in the A group than in the B group. It was noted all over the stomach in the A group (gastric body, two ; gastric angle, three ; pyloric antrum, one). The period from the detection of gastric ulcer to the confirmation of EUS averaged one month, and there was no difference between the two groups. No difference was noted in the histologic findings of elevated lesions in both groups. EUS occurred in acute pyloric antral lesions in all patients from the B group and is assumed to have been caused by compensatory hyperplasia, during reparation of ulcer, due to location specificity of the pyloric antrum. In the A group, however, it appears that EUS was induced by rapid tissue regeneration, due to the strong antiulcer effect of cimetidine, in ulcer lesions, because it was noted in the regions where it had previously been considered unlikely to occur.

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We have found 8 cases of the duodenal lymphangiectasia in the last two years. We usually examine the second portion of the duodenum for panendoscopy. Estimated frequency is about 2 percents for 400 panendoscopies. Endoscopic features of the lymphangiectasia are small (2mm10mm), sessile, granular surfaced polyp. Microscopic findings from biopsy specimens are multiple lymphatic channels filled with lymphatic fluids. These findings are diagnosed as lymphangiectasia. These lesions are clinically silent and more frequent than formerly reported. We have to differentiate this lesion from other pathological lesions.

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Antral varices developed after sclerotherapy is extremely rare. To the best of our knowledge, there is no report in the literature that antral occured as the complication of the injection sclerotherapy. A 64-year-old female was brought to our hospital by ambulance because of hematemesis on August 15, 1981. Hemoglobin fell to 10.1 g/dl (Table 1). Esophageal varices were found by urgent endoscopy as the cause of G-I bleeding. And Sengstaken-Blakemore's tube was inserted quickly to control bleeding. CT scan showed atrophy of the right hepatic lobe, hypertrophy of the left lobe and splenomegaly which were compatible with liver cirrhosis (Figure 1). Endoscopy performed in 1978 revealed no abnormality in the stomach (Figure 2). Endoscopic injection sclerotherapy using 5% Ethanolamine-Oleate was performed two times (Figure 3), and ulcer formation was found after the second treatment (Figure 4). She discharged later uneventfully. She was readmitted because of abdominal fullness and pretibial pitting edema two months after discharge. Endoscopic examination showed no varices in the. esophagus (Figure 5). However, X-ray and endoscopic examination revealed multiple polypoid lesions in the antrum which were not found previously (Figure 6, 7). Antral varices at the portion where gastric coronary vein connected to gastroepiploic vein were confirmed by portography (Figure 8). She is now under following-up at our clinic 2 years and 6 months after the treatment.

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Early gastric cancer producing AFP, especially without liver metastasis is extremely rare. The case reported here is worth recording. 9 reported cases of gastric cancer with immunohistochemical localization of AFP in which a preoperative serum AFP level of more than 20 ng/ml became normal after gastrectomy were also reviewed (Table 2). A 48-year-old woman was admitted to our hospital because of complete check up for anemia found on mass survey for geriatric diseases. Hemoglobin fell to 6.4gm./dl and the serum AFP level was elevated to 1480 ng/ml (Table 1). Liver scintigram revealed no space occupying lesions in the liver (Figure 3). X-ray and endoscopic examination (Figure 1, 2) showed a protruded lesion with a short stalk on the posterior wall of the fornix the stomach. Poorly differentiated adenocarcinoma was confirmed by biopsy. Fundectomy was performed. No metastastases were found in any other organs. A preoperative serum AFP level was 2780 ng/ml and it became normal after operation (Figure 7). On the resected specimen a protruded lesion with a short stalk measuring 4.0×3.5×3.0 cm (Figure 4) was located on the posterior wall of the fornix and it was easily movable. Histopath-ological examination disclosed poorly differentiated adenocarcinoma of medullary type involving the submucosal layer without lymph node metastasis (Figure 5, 6). The localiza-tion of AFP with PAP method was immunohistochemically demonstrated in the cytoplasm of gastric cancer cells (Figure 8). No recurrence was observed 3 years and 2 months after operation.

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A case of Crohn's disease of the stomach was reported together with a review of four reported cases of gastroduodenal Crohn's disease in Japan. A twenty-year-old male who had Crohn's disease of the colon scarred by prednisolone complained of persistent vomiting and weight loss for a year. Laboratory studies revealed hypoproteinemia, hypochloremia and low serum iron level. Tuberculin reaction was negative. An upper gastrointestinal tract roentgenological series showed "ram's horn" deformity of antrum with poor distensibility and irregular cobblestone mucosa. Endoscopy showed linear ulcerations and mucosal nodularities, and endoscopic biopsy revealed a granuloma. With the progression of the gastric outlet obstruction, partial gastrectomy with a Billroth II gastrojejunostomy was elected. The microscopic examination of the specimen revealed the typical features of Crohn's desease like transmural inflammation, fissure and epithelioid granuloma with giant cells. At present time, 10 months after surgery, the patient feels well without steroids nor salicylazosulfapyridine and has gained 11 kg.

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Three cases of annular pancreas in adult are described with emphasis on the value of ERCP procedure for the diagnosis and etiological consideration of this anomaly. The first patient is a 47-year-old-male. ERCP revealed a short main pancreatic duct and branches of the duct of Santorini encircling the duodenum near the papilla of Vater. Intrahepatic bile duct stones were also found. The second patient is a 21-year-old female having a history of pancreatitis. The proximal second portion of the duodenum was encircled by branches of the duct of Wirsung on ERCP. She had a small stone in the gallblader. The third patient is a 67-year-old male. ERCP demonstrated that the duct of annular portion was originated from the duct of Wirsung. The demographic and presenting clinical features among welldescribed 93 cases of annular pancreas in adult reported in Japanese literature were as follows ; a ratio of male to female was 7 to 3, the mean age was 44.9 years and abdominal pain or discomfort and nausea were the majar symptoms. The most leading complications reported were pepticulcer and cholelithiasis, each in the frequency of 21.6% and pancreatitis in 14.4%. The etiology of annular pancreas has not been fully clarified. The analysis of type of the opening site for annular pancreatic ducts by ERCP was considered to be useful for elucidating the evolution of annular pancreas. Many of the cases reported in the literature showed connection of annular pancreatic duct to the duct of Wirsung, so that this anomaly was considered to be derived from the ventral pancreas as described by Lecco. In some cases, however, the corresponding duct of annular pancreas originated from the duct of Santorini as observed in our first case. Therefore, the participation of dorsal pancreas or anomalous evolution of duodenum should be taken into consideration in the etiology of annular pancreas. We believe that ERCP can provide a useful procedure not only for the diagnosis but also for the clarification of the evolutional aspects of annular pancreas.

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A rare case of pancreatic pseudocyst that ruptured into the portal vein is reported. The patient was a 47-year-old man with a history of heavy intake of alcohol and an operation for cholelithiasis. He had been diagnosed as chronic relapsing pancreatitis because of rucurring epigastric pain with hyperamylasemia. Endoscopic retrograde pancreatograms showed an irregular pooling of the contrast medium in the head of the pancreas which communicated with the main pancreatic duct. The pooling of contrast medium extended to the liver hilus through the dilated tubular structure which was considered to be the portal vein. These findings suggested spontaneous rupture occured from a pancreatic pseudocyst into the potal vein. The diagnosis was confirmed by ultrasonically guided percutaneous transhepatic portography. Ultrasonography, CT scan and selective abdominal angiography were helpful for the establishment of the diagnosis. Hyperamylasemia and epigastric pain were improved by percutaneous drainage from the tubular cyst formation resulted from the original potal vein communicating to pancreatic pseudocyst.

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A 61-year-old male with liver cirrhosis who was persistently positive for hepatitis B surface antigen (also positive for HBeAg) was found to have a small liver cancer in the right lobe of the liver under peritoneoscopy. No mass was detected by various imaging methods including echogram, computed tomography, scintigram and hepatic arteriography. Intravenous injection of ICG at the dose of 5 mg/kg was administrated for the purpose of clearly observing the tumor and surrounding cirrhotic nodules. 25 minutes after the dye injection, the liver surface were stained green, while the tumor parenchyma and the small blood vessels surrounding the tumor were not stained at all. The partially encapsulated tumor with 9 mm in diameter was enucleated. Histological examination of the specimen revealed highly differentiated tubular adenocarcinoma (Edomondson II) of the liver. A combination of ICG dye administration and guided liver biospy during per-itoneosocpy might help to diagnose a small iver cancer.

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Recently two cases of colitis cystica profunda were experienced, which is difficult to differentiate from cancer of the sigmoid colon. The first case was a 45-year-old female who was admitted to Kanazawa Medical University Hospital because of abdominal distention. A plain X-ray film of the abdomen showed gaseous distention of the small and large bowels. The endoscopic examination of the sigmoid colon revealed two elevated lesions accompanying reddish and edematous mucosa, which narrowed the cavity of the colon. The second case was a 66-year-old male who was admitted to the same hospital because of left lower abdominal pain. A plain X-ray film of the abdomen showed many fluid levels. In the barium enema examination slight stenosis and mucosal irregularity of the sigmoid colon were observed. Endoscopically, a wide-based large elevated lesion with an ulcer was found at the sigmoid colon. Histological findings were those of colitis cystica profunda and no evidence of mucinous adenocarcinoma was obtained in either case.

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The role of ERC (Endoscopic Retrograde Cholangiography) for the diagnosis of bile duct carcinomas (excluded carcinomas of the gall bladder, cystic duct and major papilla) in area of Santa Cruz, Bolivia, was reported. Twenty six patients with bile duct carcinomas were selected for this study among the 304 cases of ERC performed during April 1982 to March 1984. The routine method for ERCP was used in this study. The incidence of bile duct carcinomas in Bolivia was higher with 26 of 304 ERCP studies (8.4%). ERC was succeeded in 21 of 26 cases (81%) tried for cannulation. However, in 2 of 5 unsucceeded cases, the cannulation was disturbed by parasites (adult Ascaris Lumbricoides) which were present in the second portion of the duodenum. We considered the importance of deparasitation before ERCP in endemic area like Bolivia. Although the incidence of bile duct carcinomas by age, sex and location of the tumors and the diagnostic accuracy did not have any differences with the literature, the cases with defect of filling of the contrast medium in the common bile duct was higher with 19.2% of the total. This finding might suggest that polypoid or papillary tumors were more frequent in this area. Unfortunately, there was no patient survived more than 5 years after surgical treatment and the urgent introduction of another imaging methods for diagnosis such as US, body CT, angiography, etc. including ERCP will be necessary for this country.

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