Gastric mucosal blood flow (BF) and potential difference (PD) were measured under direct vision by endoscopy in patients in whom no localised lesions were observed. In the body, BF and PD were higher than those in the antrum. But in some cases BF and PD in the body showed not only the same value, but olso a lower value than those in the antrum. Then, BF and PD were measured in the area of fundic gland and pyloric gland which were diagnosed by endoscopic Congo-red method. BF and PD in the area of fundic gland were higher than those in the pyloric gland region. Subscequently, BF and PD were measured in cases in which the lesser curvature of lower body showed fundic gland area or showed pyloric area in which atrophic changes of the gastric mucosa was seen. In cases of pyloric gland, BF and PD decreased in comparison to those in cases of fundic gland. Namely, BF and PD decreased in the gastric mucosa with atrophic gastritis. From these results, it is suggested that attension should be paid on glandular area and the existence of atrophic change in the gastric mucosa at measuring BF and PD. Finally, BF and PD were measured in three points of stomach ; in the area of fundic gland, pyloric gland and atrophic border. BF in atrophic border area showed the lowest value among them. On the other hand, PD in atrophic border area showed the same value as that in pyloric gland area. A decrease of BF in atrophic border area is an interesting finding because gastric ulcer is often found in the area of pyloric gland near by atrophic border.

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Nine patients with hemorrhagic erosion type and 18 patients of ulcerous type of acute gastritis were followed by endoscopy and endoscopic biopsies. Endoscopic findings were as follows : 1) Edema and narrowing of the gastric antrum together with mucosal hemorrhage were present on the first and second days from the onset in both types. 2) On the third day, the erosive area with hemorrhage was demarcated and surround-ed by white coating in both types (Figure 1). 3) In the cases of hemorrhagic erosion type, the lesion appeared to heal on the forth and fifth days, however, the dye-spraying method still demonstrated the depression clearly. On the seventh day, the lesion healed completely (Figure 2). 4) In the cases of ulcerous type, the whitish necrotic coating on the ulcer appeared clearly on the third and forth days. The dye-spraying method demonstrated the shallow depression around the ulcer on fifth and sixth days. Histologic findings of the biopsy specimens were as follows : 1) Mucosal necrosis with hemorrhage and hematin was present together with neutrophilic infiltration and hyperemia in the stroma on the first and second days of both types. 2) Regenerative epithelium appeared at the earliest on the first day in both types. On the fifth day, the regenerative epithelium formed foveola-like structure (Figure 7). 3) In the cases of hemorrhagic erosion type, the mucosal necrosis was generally mild with leaving gastric glands on the first and second days. Regeneration occurred rapidly in these cases. 4) In the cases of ulcerous type, the mucosal necrosis was generally marked without leaving gastric glands on the first and second days. Ulceration occurred because of incomplete regeneration in these areas, while rapid regeneration occurred in the areas showing mild mucosal necrosis.

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In order to investigate the healing process of gastric ulcer, cell proliferation kinetics of the regenerative mucosa over gastric ulcers was studied by ³H-thymidine autoradiography. In addition, the effect of histamine H₂-receptor antagonists on gastric cell kinetics was also studied. The labeling index, which was determined by the ratio of labeled cells to about 500 epithelial cells of gastric mucosa, was significantly higher in cases of endoscopic A₂-H₂ stage ulcer than in cases of the S₂ stage ulcer. Cases of the S₁ stage ulcer showed a higher labeling index than cases of the S₂ stage ulcer, but were not significantly higher. As for histologic findings, the labeling index was significantly higher in cases of the H₂ stage and the H₃ stage ulcers with tufty mucosa than in cases of the H₃ stage ulcer without tufty mucosa (H₂, H₃ ; Yoshii's classification). The cases with intractable ulcers showed a high labeling index. There were no differences in the labeling index between the cases treated with H₂-receptor antagonists and ones without them. These results suggest that gastric ulcers should be considered healed at the endoscopic S₂ stage and histologic H₃ stage without the tufty mucosa. Furthermore, it seemed that H₂ -receptor antagonists did not affect cell proliferation kinetics of the regenerative mucosa over gastric ulcers.

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The changes in the background gastric mucosal blood flow (GMBF) during the healing process of ulcers were investigated in 36 patients with chronic gastric ulcers, including ulcer scars, at the angle (active stage 6, healing stage 13, scar-1 stage 17) and in 26 patients without gastric lesions as normal control. Using the endoscope (Olympus ; GIF-Q10), GMBF was measured by laser-Doppler velocimetry at the antrum, the lower body, and the upper body along the lesser and the greater curvatures. The mucosal blood flow was studied in the normal group. GMBF was higher in the greater curvature than in the lesser curvature, and GMBF at the lower and the upper bodies also had a tendency to be greater than that at the antrum along the lesser and the greater curvatures. GMBF was studied in normal group, active, healing, and scar-1 group at each region. Though GMBF in the scar-1 group at the antrum lesser curvature increased significantly compared to the normal group, there was no difference among the other regions. GMBF in the healing process of ulcers were studied in the initial ulcer and the recurrent ulcer groups. GMBF in the initial ulcer group was significantly higher than that in the normal group and the recurrent ulcer group, at the antrum in the healing stage and at the antrum and the lower body in the scar-1 stage. And, it increased more at the antrum and the lower body from the healing stage to the scar-1 stage. On the other hand, GMBF in the recurrent ulcer group was almost the same as that in the normal group at any region in both of the stages, and had no tendency to increase more from the healing stage to the scar-1 stage. In conclusion, an absence of increase in the background GMBF near the ulcer in the healing and scar-1 stages may be related to the recurrence of gastric ulcers. It seems that the changes in GMBF of the backgroud mucosa as well as the ulcer margin play an important role in the healing process of gastric ulcers.

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The thermal diffusion method for measurement of canine gastric mucosal blood flow (GMBF) at laparotomy has been described previously. In this report, the continuous measurement of GMBF under endoscopic observation by thermal diffusion method was attempted. The authors used newly designed cathether-type probe (Figure 1). Suction pressure applied to the tip of this probe allows good attachment of the probe surface to the gastric mucosa, and stable measurement value was obtainable under endoscopic observation. For the purpose of estimating the reliability of this thermal diffusion method in measuring GMBF, changes of GMBF accompanying the intravenous infusion of AOC tetrapeptide (gastrin), vasopressin, and KCl (140meq) were examined by continuous monitoring of voltage difference, which is measured value of thermal diffusion method. The results obtained, reflected the expected changes of GMBF during these procedure (Figure 6, 7, 9, 11), and this thermal diffusion method correlated well with the electrolytical-ly generated hydrogen gas clearance method (correlation coefficient 0.93 : p 0.01 Figure 12 B).

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Twelve cases of constitutional jaundice including six of Gilbert syndrome (GS), and three of each of Dubin-Johnson syndrome (DJS) and Rotor syndrome (RS) were laparoscopically and histologically studied. The liver surface was smooth except four cases, one of which was histologically diagnosed as chronic hepatitis superimposed on GS. However, most cases revealed some abnormalities on the liver surface such as slight thickness of the edge and capsular turbidity, which corresponded with non-specific changes in the histology. The color of the surface was brownish in three of GS and two of RS, whereas variously black in all three of DJS. The pigment granules in hepatocytes were recognized even in GS or RS as well as DJS, but the nature of those was different each other. The alterations including color or darkness of the surface were not exactly consistent with the histologic changes and the quantity of pigment granules. It was suggested that those findings except the changes in color were not due to own pathology of the diseases, but rather co-existed accidentally. Therefore, the findings on liver surface of the cases studied except one with chronic hepatitis might be permitted to understand as a normal range on laparoscopic examination.

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The relationship between liver disease and digestive canal disease was studied on 1, 201 inpatients in the Digestive Disease Department of Nigon University Itabashi Hospital and on 859 cases of upper GI endoscopy performed for observing mainly on esophagus in the endoscopic suite of the same university hospital in five years from 1980 to 1984. The summary conclusions are as follows. (1) The complication incidence of digestive canal disease in the patients with liver disease was 39.8%, and the complication incidence of liver disease in the patients with digestive canal disease was 21.2%, in the inpatients of the Digestive Disease Department. (2) According to the progress of the liver disease the incidence of complicated gastric and duodenal disease increased. (3) According to the progress of the esophageal varices the incidence of complicated gastric and duodenal disease increased. (4) According to the progress of the esophageal varices the incidence of complicated gastric varices increased. (5) Compared the rate of open ulcer both in normal esophagus and in esophageal varices, the ratio of open ulcer in gastric ulcer is higher than that in duodenal ulcer. (6) The complication incidence of gastric erosions (15.0%) and gastric polyps (9.5%) are high in the patients with esophageal varices. (7) The incidence of gastric erosions (24.7%) and gastric polyps (32.6%) located on the gastric body in esophageal varices cases are somewhat higher than those (19.7%, 28.8%) in normal esophagus cases. (8) According to the progress of esophageal varices the incidence of bleeding from esophageal varices increased. (9) According to the progress of esophageal varices, appearance ratio of R-C sign and incidence of bleeding from R-C sign positive cases increased. (10) The cause of bleeding from upper digestive canal in the case of esophageal varices without R-C sign is gastric or duodenal complication in the most cases.

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Of 140 patients (excluding pediatric patients) from whom Campyrobacter jejuni/coli have been detected in stool culture in this hospital during these 5 years, 27 patients were studied mainly endoscopically. These 27 patients (16 males and 11 females) aged 14 to 74 years, averaging 33.4, and complained of diarrhea (25 cases), bloody stool (18 cases), abdominal pain (21 cases), fever (5 cases) and vomiting (4 cases). Of these 27 cases, 26 showed changes such as redness, bleeding, erosion. In terms of distribution of lesion 7 cases (25.9%), 4 cases (14.8%) and 26 cases showed diffuse type, longitudinal type, and scattering type, respectively ; 5 cases (18.5%) showed aphthoid lesions, and 7 (as high as 77.7%) out of 9 cases observed up to the ileocecal region, showed ulcerative lesions which were all found on Bauhin's valve. Lesions were observed in the rectum and sigmoid colon in 26 of 27 cases, and in the whole colic region in 7 of 9 cases examined for the whole large intestine, respectively. Histological findings in biopsy revealed crypt abscess in 45.8% and high degree of inflammations in 50%. The present Campylobacter colitis, which shows diversified endoscopic pictures, is often undifferentiable from ulcerative colitis and other infectious colitis, and sometimes from drug associated colitis and ischemic colitis. However, ulceration on Bauhin's valve was regarded as symptomatically characteristic of the present colitis.

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N₂ dye laser photodynamic therapy (PDT) with hematoporphyrin derivative (HpD) was performed on 10 patients with early gastric and esophageal cancers. Two of them were operated on soon after PDT but eight of them were inoperable due to high risk. Of two operated cases, the one was a shallow IIc type gastric cancer (4 cm in maximum diameter), and the other was ha type lesion with thick cancer layer (1.5 cm in maximum diameter). Even after PDT, cancer tissue was found in the resected stomach. It was shown that PDT has limitation to a large or thick cancerous lesion. Of eight inoperable cases, one was esophageal cancer and seven were stomach cancers. The lesions disappeared in seven case after PDT, but recurrence was noted in one. The size of therapeutic failures was beyond 3 cm in diameter, and the energy density was under 30 J/cm² of cancer area, which is very low compared with that successfully treated (69.3 J/cm²). Therefore, PDT is not useful for large and/or thick cancers even in the early stage. Moreover, HpD has unavoidable side effects such as photosensitivity. On the other hand, many effective endoscopic methods of therapy for cancer have been developed recently. Thus, PDT with HpD should be performed only in the following cases, 1) relatively small and depressed carcinoma with obscure borders and, 2) residual cancer after therapeutic failure of Nd-YAG laser which is small but has an unclear invading margin.

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Nineteen patients undergoing hemodialysis with chronic renal failure (CRF group) and 16 patients without renal diseases (Control) were studied. The average age was 44.4 years for CRF group and 46.3 years for the control, while the duration of hemodialysis ranged from 1 month to 12 years (averaging 5.8 years). Investigation included serum gastrin assay and f iberscopic gastroduodenoendoscopy with stepwise biopsies. The biopsies were done along the lesser curvature at five points-the duodenum, antrum, angulus, lower body and upper body. We have obtained the following findings : 1. Fiberscopic studies-Erythema or hemorrhagic gastritis was present in 47.8% in CRF group, compared with 18.8% hn the control. 2. Histological studies-Of the biopsied parts, the most conspicuous differences between the 2 groups were noted at the gastric angulus, the fundic gland mucosa being observed in 62.2% in CRF group, compared with 14.3% (p<0.01) in the control. No significant correlation was observed between the frequency of the fundic gland mucosa in the angulus and the duration of dialysis, nor the serum gastrin concentration in CRF group, but the frequency was reduced in cases over 45 years of age compared with the younger generations. 3. These suggest that the border line between the fundic gland mucosa and the antral gland mucosa exists closer to the antral side in CRF group compared with the control.

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Six diminutive carcinoid tumors (5 mm or less in diameter) out of 17 carcinoid tumors have been detected during the last 4 years and removed endoscopically. All lesions were located in the rectum within 6 cm from anal verge. The diameter measured 1 mm in 2 cases, 2 mm in 2 cases, 3 mm in 1 case and 4 mm in 1 case. Diminutive carcinoid tumors have been observed as the small protrusion of submucosal tumor endoscopically. The color of which was the same as surrounding mucosa, yellowish, or reddish. Additional hot biopsy in 5 cases and laser irradiation in 1 case were applied later because of the residual carcinoid tumor. 3 cases were accompanied with benign polyps showing tubular adenoma histologically. In conclusion, even in case of 1 to 2 mm sized diminutive carcinoid tumor, it is able to be recognized moreover not only dignosis but also for treatment endoscopically.

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Although pemphigus vulgaris is a well-known bullous disorder of the skin and oral mucosa, its esophageal involvement has been rarely documented. Recently we experienced two cases of pemphigus vulgaris (PV) in which esophageal ulcers were endoscopically demonstrated and their association with PV was confirmed. The first case is a 54-year-old male with repeated stomatitis. PV was diagnosed by the histological findings of the tongue. Endoscopic examination showed severe esophageal ulcers and erosions, which responded favorably to the steroid therapy. The second case is a 53 Iranian male with necrotizing stomatitis. Histological examination of the skin showed characteristic features of PV. Endoscopic examination of the esophagus revealed irregular ulcers, which improved by the steroid therapy. Direct immunofluorescent study of the esophagus was positive in this case. Only 19 cases of PV with esophageal involvement have been reported inclusive of ours in the world literature. Deposition of IgG was demonstrated in the esophagus in 6 cases. Whereas PV is usually handled by dermatologists and otolaryngologists, gastroenter-ologists should be alerted to this disorder in case of intractable ulcers and erosions of the esophagus.

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Two cases of mucosal bridge secondary to endoscopic injection sclerotherapy (EIS) were reported. Mucosal bridge is sometimes observed in the colon with ulcerative colitis or Crohn's disease. But the mucosal bridge of the esophague after EIS has not been reported in Japan. Case 1 was a 55-year old female who complained of hematemesis. Esophagoscopy demonstrated large, actively bleeding esophageal varices. EIS was performed 6 times. After last procedure, she developed mild retrosternal pain and epigastric discomfort. Esophagoscopy revealed deep esophageal ulcer on the injection site. Three months later, the mucosal bridge and ulcer scar at lower esophagus were demonstrated. Case 2 was a 38-year-old man who complained of easy f atigability and abdominal fullness. Esophagoscopy showed large esophageal varices. Prophylactic EIS was performed 12 times. One month after EIS, varices disappeared and mucosal bridge, multiple ulcer scars and pseudo-polyps were found. In our two cases, mucosal bridge was observed on the area where severe esophageal ulcers developed after EIS. From this results, we suggest that mucosal bridge after EIS is related to the ulceration at the injected site of the esophagus. The mucosal bridge after EIS is thought to be asymptomatic and not troublesome complications.

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A case of gastric lesions associated with acquired syphilis in the secondary period is reported. A 48-year-old man admitted to our hospital because of epigastric pain, anorexia and 3 kg weight loss in the past two weeks. A slightly increased white blood, 7, 000/mm3, with an increased erythrocyte sedimentation rate of 40 mm/hour and hypoproteinemia were found. Blood serological test for syphilis was positive, but no syphilic eruptions were observed on the skin. Roentogenography and gastrofiberscopy revealed four shallow and irregular shaped ulcers on the posterior wall of the lower gastric body (Figure 2, 3 and 6, 7). The margin of the ulcers were clear with redness and the surrounding mucosa was edematous. HE stained histologic specimens biopsied from the margin of the ulcers showed non-specific findings, inf iltrations of lymphocytes, plasma cells and eosinophiles. From the roentgeno-graphic, gastroscopic and histologic findings, the gastric lesions were diagnosed as multiple peptic ulcers and those lesions were healed with cimetidine, pirenzepin and sucralphate (Figure 8). However, pharyngeal pain still continued after healing of the gastric ulcers and a careful examination of the oral cavity revealed syphilitic stomatitis and tonsillitis. Then the biopsied specimens obtained in the endoscopy series were stained by Ohtani's method, which is a kind of silver stains for Treponema pallidum. Many Treponema pallidum were seen in the specimens taken by the first endoscopy after hospitalization (Figure 10). And in the specimen biopsied on the twenty first hospital day, only a few Treponema pallidum were observed in spite of no treatment for syphilis (Figure 11). Finally, the gastric ulcers were healed without treatment for syphilis. Disappearance of the gastric lesions was similar to that of skin eruption usually observed in the secondary period of the disease although an effect of anti-peptic ulcer drugs on the ulcer healing was not disregarded. After healing of the gastric ulcers, penicillin was administered and the blood serological test for syphilis was significantly improved. From these findings, we considered that the gastric lesions of the present case formed during the secondary period of acquired syphilis. And gastric lesions associated with early syphilis might spontaneously disappear without treatment for syphilis.

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A 44-year-old man with liver cirrhosis was admitted for the treatment of his jaundice and ascites. On the 66th hospital day, we treated his high grade esophageal varices with endoscopic injection sclerotherapy. Soon after the sclerotherapy, he became hypotensive with nausea and back pain. Abdominal ultrasonography, CT scan, and angiography revealed massive intraperitoneal hemorrhage from the ruptured splenic varices. He was cured by intensive conservative therapy and discharged. To our knowkedge, this case is very rare, not only, as major complication with sclerotherapy, but also, as rupture of intra-abdominal varices. We could conclude that the splenic vein pressure after the intercept of the gastroesophageal collateral flow increased so rapidly, followed by splenic varices rupture.

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Sarcoidois is a systemic granulomatous disease of unknown etiology and is very rare to have a lesion in the stomach. We report a case of gastric sarcoidosis where the peritoneoscopic examination is a good help in diagnosing this case. This case is a 49 year-old female, who experienced sweating and hunger time epigastralgia in Jul, of 1984. Upper G. I. series and endoscopy disclosed a few submucosal tumor -like elevated lesions in the stomach. The biopsy under endoscopy showed granuloma formation and tuberculosis or sarcoidosis was suspected. Peroral INH 0.3 g per day was started from May and the lesions remained, although they had a tendency of reduction. She was admitted for the further examination to diagnose her gastric disease. Peritoneoscopic examination demonstrated a few white nodules of 0.5-1.0 cm in diameter on the surface of the left lobe of the liver and no adhesions. Biopsy disclosed granuloma formation without caseating necrosis and it was consistent with sarcoidosis. So, the gastric lesions were again diagnosed as sarcoidosis. We see about 50 cases of gastric sarcoidosis reported till now to our knowledge. A submucosal tumor-like lesion like, this case is very rarely seen. The peritoneoscopic examination was a good tool in diagnosing this case giving us a good clinical suggestion, so we report this case here with a bibliographic discussion.

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A 75-year-old female was admitted to our hospital complaining of high fever and general fatigue. On the laboratory findings, marked eosinophilia and liver dysfunction were pointed out. No parasite egg was detected in the duodenal juice and in the feces. Liver scan with 99mTc revealed an irregular isotopic accumlation in the left lobe. Ultrasonography showed the hypoechoic lesion on the ventral side of the left portal vein. Computed tomography disclosed several small low density areas in the left lateral segment of the liver. By the laparoscopy, the thickened liver capsule on the right lobe, solitaly or fused yellowish white nodules on the ventral surface of the left lobe were seen. Liver biopsy was performed from the nodules, and the histological examination showed necrosis of liver tissue, infiltration of eosinophils and the presence of numerous Charcot-Leyden crystals surrounded with granulation. The diagnosis of hepatic fascioliasis was confirmed by positive serological test. She was given Praziquantel (1800 mg/day) for one day, with rapid resolution of clinical symptoms and labolatory findings.

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Gastroenterological endoscopy is the best and essential method to study on gastrointestinal cancer, because of its direct approach to the lesion. The method is composed of observation, sampling and modification. Definition, classification and diagnostics of early gastric cancer were proposed by Prof. S. Tasaka at the 4th Congress of this Society and have prevailed through the world, now. According to the development of gastric biopsy, a gastritis-like type of early gastric cancer has been detected, increasingly. Retro spective study of preceding endoscopic films of detected gastric cancer had clarified the initial feature, growth pattern and velocity. Prospective study with biopsy had proved malignant change from a chronic gastric ulcer, but with a few incidence Electronic endoscope, applying CCD, was inventd, 1983, which has contributed to analysis of endoscopi image of early gastric cancer. Echosonographi endoscopy has made possible image diagnosis of the condition of canerous tissue in the gastric wall and adjacent areas. Analysis of CEA in biopsy specimen and gastric juice has been studied and it has clarified the malignant potential of gastric cancer. Some types of gastric cancer have become possible f to be treated with endoscopy, radically or symptomatically. With endoscopic polypectomy, a y pedunculated, elevated type of early gastric cancer a has been treated, radically. With laser endoscopy, 824 cases of early gastric cancer has been treated, throughout Japan. Out of them, 16 cases have been c alive without recurrence of the carcinoma, and 120 c cases from 3 to 5 years, 316 cases from 1 to 3 years. e Recanalizatiotn of stenosis due to advanced cancer of esophgus, cardia, pylorus etc. were performed with good results in 334 cases with the lesions.

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A concept of the mucosal defensive mechanism is not so previous. Balance theory which were presented by Shay and Sun in 1953, has been widely accepted, and a breach of the balance between an aggressive factor and a defensive factor of mucosa has been considered as an etiology of the peptic ulceration. Acid, pepsin and gastrin as aggressive factors could be measured easily, while defensive factors were difficult to estimate in detail owing to their undevel-oped methodological techniques. Recent advances in functional endoscopy (functional examination by endoscope) contributed new information in the field of patho-physiology of the peptic ulcer. In this report, the results of functional endoscopy will be presented especially concerning with mucosal defensive mechanism. 1) Endoscopic measurement of transmucosal elec-trical potential defference (PD) : Tsuneoka and Matsukawa (1980) and Suyama (1981) developed the technique for measurement of mucosal PD, using endoscope. A decrease of PD shows the drop of mucosal resistance and the mucosal damage, which were pointed out by Donne (1824) and Rhem (1944) as the injury potential. Administration of mucosal barrier braker or decrease of mucous and bicarbonate secretion are closely related with a decrease of PD, which suggest the existence of mucosal cell damages. 2) Mucosal resistance : Function of epithelial cell and synthesis of connective tissue in proper mucosa represent a derect mucosal resistance. Cell kinetics, its regulating factor and the role of basementmembrane, on which proliferation, mobilization, differentiation and restitution of epithelial cell are supported, are included into the mucosal resistance. These factors are observed on the endoscopic biopsy materials by 3H-thymidine autoradiography, electron microscopy and histochemical technique. 3) Endoscopic measurement of mucosal blood flow : Recently, various methods for endoscopic measurement of mucosal blood flow of the stomach and duodenum have been developed (Miyamoto 1981, Murakami 1982, Sato 1977, Miyamoto 1983, Saita 1984, Shimakura 1986). Improvement and maintenance of mucosal microcirculation regarding to "Cytopretoction" prevent a decrease of oxygenic metabolism of all cell and tissue, and serve to remove hydrogen ion and free radicals. Further investigations of the etiology of peptic ulcer are expected in the near future with more advances of the functional endoscopy.

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