The causative relation of bile acid contained in the gastric juice to gastric mucosal lesions was studied. The levels and subfractions of bile acid in the fluid were measured using high performance liquid chromatography. Gastric atrophy was endoscopically determined, according to the Kimura & Takemoto classification, and the presence of intestinal metaplasia in the antrum was evaluated by the methylene blue staining method. Grades were divided into 5 subgroups based on the area of methylene blue absorbtion. In this study 69 + 26 subjects were examined. Our findings showed that the redness of the prepylorus in 5 cases that had high levels of bile acid (especially primary glycine conjugated bile acid in the gastric juice) and the redness of the stoma in 18 out of 26 post operative cases, was attributed to goblet cell metaplasia- like tissue through muco-histological study using PAS Alician Blue staining. The area of intestinal metaplasia extended from I to V and correlated with the elevation of bile acid levels in the gastric juice. Of special interest, we found that these levels of taurine conjugated bile acids which contain taurocholic acid were significantly increased in the grade V group in comparison to that of the grade I group. In considering gastric mucosal lesions, it was found that bile acid levels in the ulcer patient were higher than those in the patient with gastric erosion.by methylene blue of the prepylorus of the case of the highly bile acid concentration and post operative 3 years case.

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The relationships of bile acid in the gastric juice and the area of methylene blue absorbtion in the antrum to the generative zone and microvilli of the surface of the intestinal metaplasia were studied. The generative zone was determined by means of autoradiography using ³H-thymidine. The microvilli of the surface of the intestinal metaplasia was observed by scanning electron microscope and its findings were classified into 5 grades according to its maturity based on its height and distribution. The levels and subfractions of bile acid in the fluid were measured using high performance liquid chromatography. As a result, due to the extention of the intestinal metaplasia, the generative zone was shorter and located at the lower portion of the gastric pit, and the microvilli of the surface was more mature. Further, bile acid, especially primary taurine conjugated bile acid in the gastric juice, effected the G-zone and made it shorter in the lower portion of the pit. As a result, the microvilli of the surface was more mature.

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In order to make clear the incipient phase of advanced carcinomas, 1, 221 lesions of gastric carcinomas of depressed type, except for Borrmann IV, were clinicopathologically examined. Five hundred Seventy Six lesions of early carcinomas were divided into two groups from the point of view that peptic ulceration (Ul) in the area of intramucosal carcinoma exist (Ul (+)) or not (Ul (-)). Ul (-) early carcinomas over 15 mm in diameter decreased suddenly in number (Figure 1) and the rate of submucosal invasion becomes very high (Figure 2). The number of advanced gastric carcinomas of Borrmann 2, 3 type increased remarkably over 20 mm in diameter (Figure 3). On the other hand, histopathological studies have given us the following inf ormations, 1) The intramucosal growth pattern of early invasive carcinomas reveals carcinoma cells occupying the entire mucosa with compression of surrounding non-carcinomatous glands. 2) Such a growth pattern is seen more often in Ul(-)carcinomas than in Ul(+)carcinomas (Table 3). 3) In the submucosal layer, Ul(-)carcinomas demonstrate nodularly with high tendency of vascular infiltration (Table 4). The above mentioned findings have led us to consider that advanced carcinomas of Borrmann 2, 3 type develop rapidly from small Ul(-) early carcinomas.

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Portal collateral pathways were evaluated on the clearly opacified endoscopic varicer-ograms (EV), obtained in the endoscopic embolization on 126 patients with esophageal varices from October 1981 to September 1985. Examinations of EV identified the blood supply route to esophageal varices through the left gastric vein, the fundic venous plexus and the short gastric vein, and the blood outlet route besides esophageal varices (the extraesophageal shunt). Frequency of visualization for each collateral pathway was 52.4% for the left gastric vein, 47.6% for the fundic venous plexus, 8.7% for the short gastric vein, and 14.3% for the extraesophageal shunt. According to our results, we believe that in the endoscopic embolization, a necessary injection dose must be established according to the volume of these visualized blood routes.

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We classified endoscopically and histologically 36 cases of gastritis in teenager into three groups; 16 cases of gooseflesh-like gastritis (G-gastritis), 13 cases of verrucous gastritis, and 7 cases of superficial gastritis. Numerous small elevation in G-gastritis being 2-3 mm in size were observed in the pyloric gland area. Histology of all biopsy specimens obtained from the top of the elevation contained lymphf ollicles. Vital staining of direct dye spraying method (0.5% methylene blue) showed small intestinal metaplasia on the elevation in 6 cases of G-gastritis. A few metaplastic glands were found histologically over the lymphfollicles in 4 cases of G-gastritis. Cytoplasmic immunoglobuline (CIg) of lymphocytes and plasma cells in the propria mucosae were dominantly IgA in almost gastritis. IgA and secretory component were located in metaplastic epithelium. In G-gastritis lymphocytes with CIg M, G and A mixed in lymphf ollicles, and lymphocytes with CIg G were dominant in one case. IgA could not be proved in metaplastic epithelium of G-gastritis. Intestinal epithelium over the lymphfollicle of G-gastritis was thought to be immature or in developing stage of immune defence system in gut associated lymphoid tissue.

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Introduction : Since 1984, we have been studying the experimental studies of endos-copic local hyperthermia (laserthermia) with low power (less than 5 watts) Nd-YAG laser irradiation by using frosted probe (wide divergent ceramic contact probe). In this paper, the experimental data and the possibility of applying the endoscopic laserthermia were discussed. Materials and Methods : During the thermal control within the therapeutic level about 43.0°C the thermal distribution on serosal surface of the canine stomach was also measured with thermocamera under laparotomy (Figure 4). Histological studies : Correlations between the distance of thermal control and his-tological effects in the canine stomach were studied. One week after laserthermia, the stomach was removed and studied histologically by hematoxylin and eosin staining (H&E). Results : (1) Thermal distribution (Figure 7, 8); Tissue temperature was controlled to be nearly 43.0°C within an area from 10 mm in diameter at about 6 mm of the control distance. (2) Histological findings in the canine stomach ; One week after laserthermia, wider mucosal damages, submucosal fibrosis and intravascular thrombosis were recog-nized (Figure 10, 11, 12). Conclusions : It is enough and safe to the low power Nd-YAG laser under 3 watts for laserthermia. Effects of laserthermia were wider than those of the conventional laser irradiation, and may be considered as the results of thermal necrosis and intravascular thrombosis. Laserthermia can be applied to the endoscopic therapy of gastrointestinal neoplasms.

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The effect of increased portal blood flow by intravenous glucagon injection on endoscopic findings of the esophageal varices was studied in patients with liver cirrhosis. In 22 patients with liver cirrhosis complicated with esophageal varices, endoscopy was performed after overnight fasting. Soon after routine observation of the esophagus, 1USP unit of glucagon was injected intravenously. Endoscopic findings of the esophagus were continuously observed and photographed before, during and after intravenous glucagon adminis-tration. In 11 patients, repeated examination was performed after endoscopic injection sclerotherapy of the varices. After glucagon administration, some variceal veins were engorged (Figure 1, 2), and reddish hue was increased (Figure 3, 4). Mucosal fine vascular networks were accentuated (Figure 2, 3). Cherry red spots were enlarged, and increased in number (Figure 5, 6). Red wale marking also showed similar change (Figure 5). Diffuse redness was increased in color after glucagon administration (Figure 7). A bleeding from a hematocystic spot was noted after glucagon administration in one case (Figure 8). Engorgement of varices was observed in 15 patients (68%), and increase in variceal redness was seen in 7 (32%). Fine vascular network was increased after injection in 11 patients (50%), and red color sign was accentuated in 7 (32%). In cases with successful endoscopic injection sclerotherapy, no change in figure or color of collapsed variceal veins was noted after glucagon injection. On the other hand, an engorgement of varices was observed after glucagon administration in some cases, suggesting patent lumen of the varices. Endoscopic observation of change in esophageal varices after intravenous administration of glucagon is useful to evaluate the participation of portal blood flow to the formation of varices. It is also applicable to evaluate the effectiveness of endoscopic injection sclerotherapy.

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It was defined that the fornix is a region above the watershed which was recognized by endoscopic examination. We studied on the location and macroscopic findings of excavated lesions in the fornix. Sixteen benign ulcers including one with two lesions and 15 gastric cancers located in the fornix were discussed. Most of the benign ulcers and gastric cancers were located on the posterior wall of the fornix, especially most of the benign ulcers being distributed near the watershed and blind alley of the f ornix. Benign ulcers in the vicinity of the watershed were almost round or oval shaped, and the diameters of those ulcers were more than 15 mm. In the blind alley, benign ulcers were usually shallow and their diameters were less than 11 mm. There were 5 early cancers out of 15 gastric cancers in the fornix. Most of those early cancers were excavated. Four of those early cancers were small in size and without converging folds.

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Total 340 endoscopic examinations were performed in 226 pediatric patients and 32cases of peptic ulcer were found. Of these 32 cases, three had gastric ulcer and 29 hadduodenal ulcer. In regard to sex of these 32 cases, male was predominant in patients over12 years old, and male to female ratio was 3 to 1. On the contrary, there was no significantdifference among distribution in cases below 11 years old. Twenty-seven out of 32 caseshad primary ulcers consisting of 24 duodenal ulcers and 3 gastric ulcers. Eighteen caseswith primary duodenal ulcer had been followed up for more than 6 months. In 9 out of these18 cases, duodenal ulcer probably recurred in 2 years, in terms of clinical symptom.Moreover, this recurrence was confirmed by the endoscopy in 7 of 9 cases. The cumulative recurrence rate was 6%, 22% and 55% at 6 month, 12 month and 24 month, respectively.This rate was similar to that of adults. On the other hand, five out of 32 cases had secondary ulcers. None of these secondary duodenal ulcers recurred. There were 538 patients, including children and adults, with duodenal ulcer for recent seven years at our institution. Of these patients with duodenal ulcer, pediatric patients were only about 3 per cent. However, in all cases examined by endoscopy, duodenal ulcer was detected in 18% of children, 2-5% of adults and a little over 1% of geriatric patients. Namely, the detection rate of duodenal ulcer was very high in children. This probably suggests that endoscopy is less commonly performed in pediatric patients, even though the endoscopy is popular today.

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Studies were done in 11 among 28 cases of malfusion of the main pancreatic duct, which had no complications such as biliary disease. Following items were investigated clinical symptoms, serum amylase level, exocrine and endocrine pancreatic function and endoscopic retrograde cholangio-pancreatography. The age of the subjects ranged from 33 to 86 and the mean age was 54.7 years. The male-to-female ratio was 1: 0.8. Although 2 of the 11 cases complained of severe abdominal pain, the remaining 9 cases had only slight abdominal discomfort. Regarding serum amylase level, slight degree abnormality was noted in 5 cases (45%), and higher levels of amylase tended to occur in cases having a history of drinking. Oral glucose tolerance test (50g-OGTT) was perfumed in 4 cases. Two of these cases were classified as diabetic and one as borderline. P-S test in 6 cases revealed abnormality in 4 cases. Of these, 2 cases showed disturbance in 2 factors including maximum bicarbonate concentration, and the other 2 cases showed disturbance in one factor. With ref arence to endoscopic pancreatogram, abnormal appearance of the ventral pancreas was found in 2 among 11 cases (18%). On the hand, dorsal pancreas showed abnormality in 3 among 6 cases (50%), and one of these was pancreatic carcinoma. According to our data, patients with malfusion of the main pancreatic duct had high frequency of abnormal pancreatogram and pancreatic function in spite of their mild symptoms. It is suggested that the pathogenesis of pancreatitis in cases of malfusion is a disturbance of the excretion of pancreatic juice from the dorsal pancreas due to narrowing of the minor duodenal papilla, and this narrowing injuries the morphology and function. Alcohol intake is also an important factor in this disease state. In addition to the causes described above, congenital abnormalities of the pancreas with malfusion of the main pancreatic duct might be an important factor.

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Complications of the gastrointestinal tract in Crohn's disease were studied in 20 patients followed for more than 5 years. Cases consisted of 9 ileocolitis, 9 ileitis and 2 colitis. There were 13 males and 7 females and age ranged from 13 to 40 years on initial examination. The mean follow-up period was 7 years and 6 months (5 to 12 years). There were 8 patients with fistula, l with free perforation, 2 with ileus, 7 with stenosis and mass formation, and 3 with melena. Fistula formation was found 11 times in 8 patients. Of these 11 fistulas, 6 were internal, 3 entero-enteral and 2 enterocutaneous. Conservative management was done for 6 fistulas in 5 patients, of which 4 internal fistulas were cured and 2 entero-enteral fistulas were remitted uneventfully. Because of gastrointestinal tract complications, a total of 9 patients (4 with fistula, 2 with ileus, and 3 with peritonitis including a case of free perforation) were required surgery. Eight of these 9 patients had a relapse of Crohn's disease within 3 years after surgery. When gastrointestinal tract complications, especially fistula formation, in Crohn's disease are encountered, surgical intervention should be considered only after unsuccessful medical management.

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Thirty-seven early colorectal cancers were compared endoscopically with 35 benign adenomas in order to make a diagnosis of malignancy before polypectomy. Sessile early cancers with submucosal involvement had some characteristic findings indicating malignancy, which are a loss of symmetry, depression or flat surface, sandy or rugged surface and solid impression on endoscopy. These endoscopic findings indicating invasive cancer were seen overlapped in each case of early colorectal cancer with submucosal involvement. These characteristic findings of early colorectal cancer with submucosal involvement were observed more distinctly in sessile lesions than in pedunculated lesions. In our histological study, areas of cancer on the surface of the lesion was proved to be more extensive in the sessile lesions than those in the pedunculated lesions. In sessile lesions of early colorectal cancer with submucosal involvement, it seems to be possible endoscopically to make a diagnosis of malignancy and submucosal invasion before polypectomy.

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A 27-year-old male was admitted to our hospital because of watery diarrhea, belching with fecal odor and abdominal pain with relatively sudden onset. Previous history was as follows; Five years prior to the admission, he received subtotal gastrectomy because of perforated duodenal ulcer. Two years prior to the admission, resection of afferent loop, duodenojejunostomy and cholecystostomy were performed for the strangulation of elongated afferent loop constructed by the previous operation. One and half years before the admission, pain in the epigastrium developed and recurrent ulcer was detected proximal to the stoma by endoscopic examination. Laboratory data on admission revealed mild anemia, hypoproteinemia, hypocholester-olemia and hypocalcemia. Mild increase of fecal fat excretion as well as moderate abnormal D-xylose test and Schilling test was demonstrated. The fistula communicating jejunum distal to the stoma and transverse colon was confirmed by both barium enema and endoscopic examination, and diagnosis of gastrojejunocolic fistula was made. Gastrojejunocolic fistula following stomal ulcer is rare complication of gastric surgery and the cases reported in Japan were briefly reveiwed.

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A 54-year-old man who had undergone Billroth II gastrectomy for duodenal ulcer 20 years ago, was admitted because of melena and dizziness. Emergency endoscopy revealed a protruding lesion along the anatomosis of the gastrojejunostomy site and Dieulafoy-like ulcer on the posterior site of the protruding lesion. Dieulafoy-like ulcer was successfully controlled by local injection of absolute ethyl alcohol through endoscope. Partial polypectomy of the protruding lesion was carried out for the purpose of the proper diagnosis after 17 days on admission. Histologically, the specimen was confirmed as Gastritis Cystica Polyposa (GCP) as proposed by Littler et al. On the previous literatures, many reports indicated that some of GCP cases were discovered by GI bleeding, and GCP have been considered to be reconstruction of the gastric mucosa after severe inflammation due to bile reflux from the jejunum to the remnant stomach, including the vascular displasia. Therefore, as our case, it is possible that GCP and Dieulafoy-like ulcer may occur at the same time.

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A 65-year-old woman was admitted to our hospital on November 21, 1985 with a chief complaint of epigastric pain which had started in the beginning of September, 1985. The first endoscopic examination done by a neighbering doctor on October 19, 1985 showed a large white-coated ulcerated lesion on the anterior wall of the angulus which was suggestive of malignancy. Endoscopic examination, performed about 30 days later revealed marked reduction in the size of the ulcerated lesion, which was surrounded by rough and edematous mucosa with a erosive central depression. The lesion was endoscopically suspected of malignant lymphoma and biopsy specimens confirmed it. Operation was performed on December 10, 1985. In the resected stomach a large ulcer with the converging folds was observed on the anterior wall of the angulus, surrounded by two protruded lesions with a central depression, one on the anterior and the other on the posterior wall. Histologically, the lesions were diagnosed as malignant lymphoma (Diffuse lymphoma, Medium-sized cell type) which was limited to the submucosa. The tumor cells were seen only on the part of the two protruted lesions and no tumor cells were seen on the ulcerated lesion. The biopsy specimen obtained from the margin of the ulcer showed lymphoma cell proliferation. However there was no malignancy in the resected stomach. This clinical and histological course suggested the existence of so-called "malignant cycle" of the malignant lymphoma.

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In general, polypectomy has been considered to be a contraindication for patients with bleeding tendency. The present report, however, deals with a successful endoscopic laser therapy performed in 3 patients with hemorrhagic diathesis. Patients treated with laser therapy included Case 1; 71-year-old male patient with chronic lymphocytic leukemia and a gastric polyp (Group III), Case 2 ; 77-year-old male patient with liver cirrhosis, thrombocytopenia and a polyp of the sigmoid colon (Group 4), and Case 3 ; 75-year-old male patient with aplastic anemia and an early gastric cancer of type I. After the therapy the tumorous lesions disappeared in all 3 cases and there was no evidence of tumor residue on endoscopic and histological examinations. In addition, complications such as bleeding or local peritonitis due to coagulation of deep tissues, known to occur accidentally by endoscopic polypectomy, was not encountered during and after laser irradiation. These results seemed that laser therapy is safely indicated for elevated lesions of gastrointestinal tract in patients with hemorrhagic diathesis.

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We report a case of potato liver complicated with peliosis hepatis. This case is a 61 year-old female patient, who had right hypochondralgia in January of 1986, so underwent a health examination in February. She visited our out-patient clinic in Aprill, because she was suspected to have liver tumor. Abdominal ultrasonography and CT scanning revealed suspicious liver tumor. Therefore, she admitted to our hospital for further examination. The peritoneoscopic examination after admission disclosed massive elevations with deep depressions and bluish purple tiny spots on the surface of both lobes of the liver. Histology of the biopsied liver showed a minimal deformity of the lobular structures with dilated portal veins and connecting sinusoids. These findings are consistent with a potato liver complicated with peliosis hepatis. The peritoneoscopic examination was most important to diagnose this case. A case of such a case is not yet reported till now as long as we look for papers, so we report this rare case with a review of cases.

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Macroglobulinemia involving gastrointestinal tract is very rare. We experienced a case of Macroglobulinemia with atypical lymphoid cell infiltration into the stomach and small intestine. This patient was 49-years-old female. Her chief complaints were nausea, vomiting and body weight loss. She was diagnosed as Macroglobulinemia in our hospital in 1981. At that time she had no symptom of disturvance of gastrointestinal tract. In 1985, she complained nausea, vomiting and body weight loss. She received barium meal study of the stomach and small intestine. Barium meal study of the stomach revealed coarse granular mucosa and irregularity of the margine of the folds. Barium meal study of the small intestine revealed stenosis with rough granular elevation. Endoscopic studies revealed that diffuse redness, granular mucosa and erosion located at the upper body to the fornix of the stomach. And stenosis with coarse granular mucosa and converging folds were existed in the small intestine near the Treiz ligament. Biopsy was taken from each part. There were massive infiltration of atypical small lymphocytoid cell. Histological diagnosis was diffuse, medium sized cell typed malignant lymphoma. These lymphocytoid were stained with anti IgM and anti k serum by immunoperoxidase technique (PAP). We report a case of Macroglobulinemia involving the stomach and small intestine.

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A 61-year-old male patient was admitted to the authors' clinic because of marked hepatomegaly. He had past history of enucleation of right eye because of malignant melanoma 11 years ago. Physical examination revealed remarkable hepatomegaly with nodular surface without any sign suggestive of liver cirrhosis. Blood biochemical analysis suggested the recurrence of malignant tumor. Based on the past history, physical examina-tion and blood biochemical analysis, hepatic metastasis of malignant melanoma could be supposed. Scintigraphy, sonography and computed tomography of the liver revealed multiple space occupying lesions in various form and size of the liver, which were sugges-tive of hepatic metastatic neoplasma. For the purpose of clarifying a diagnosis of metastatic malignant melanoma of the liver, laparoscopy is a very reliable diagnostic tool, although in about 25% of the patients with malignant melanoma, amelanotic melanoma occurred. In this patient, laparoscopical examination revealed multiple melanomas in various form and size with black brown hue of the liver. In a few melanomas, central umbilication could be found in the tumor, which characterized malignant tumor of the liver. Macroscopical appearance of a hepatic specimen due to laparoscopy-guided needle biopsy showed black brown hue and histological findings of it revealed metastatic malignant melanoma of the liver. The authors stress the usefulness of laparoscopy to make diagnosis of metastatic malignant melanoma of the liver.

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A 74-year-old female was diagnosed to have a pancreatic body-tail cancer and treated with cancer chemotherapy in 1982. In August 1985 flushing developed and the patient was hospitalized for evaluation. A tumor (about 5.7/2.8 cm) with calcification on the pancre-atic body-tail and multiple tumors on the both lobes of the liver were observed by ultrasound and CT-scan. ERCP proved a stenosis and obstruction of the main pancreatic duct on the pancreatic body-tail. Abdominal angiography proved that the tumors of the pancreas and liver were hypervascular. Laparoscopic biopsy proved nodular and alveolar (tumorous) proliferation of oval cells. Cellular atypia, however, was not remarkable. Grimelius stain proved argyrophilic granules in cytoplasma, which was also proved by electron microscopy. Accordingly, the patient was diagnosed as A-type carcinoid of the pancreas. Subsequent biopsy of metastatic lymph node on the chest wall proved strongly positive serotonin and weakly positive gastrin (PAP stain). It also proved EC cell and G cell-like granules by electron microscopy. Flushing was regarded as a symptom of carcinoid syndrome.

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A case of generalized amyloidosis, secondary to chronic bronchitis, complicating transient ischemic ileitis is presented. A 71-year-old man was admitted because of bronchopneumonia associated with chronic bronchitis (Figure 1). Since the admission, he complained abdominal pain, diarrhea and melena. Ileus was gradually developed. The X-ray examination of small bowel showed mucosal irregularity and tubular narrowing of the distal ileum with thumb printing appearance (Figure 2). The colonof iberscopic examination revealed hemorrhages, erosions and shallow ulcers in the terminal ileum (Figure 3). Microscopic examination of ileal biopsy showed deposition of amyloid in the wall of submucosal vessels (Figure 4). Amyloid deposition was also confirmed in the rectal and renal biopsy. He was treated with restriction of oral intake, gastrointestinal suction and IVH. The symptoms were disappeared within a month (Figure 5). The small bowel X-ray before the discharge showed no abnormality (Figure 6). It is considered that the transient type of ischemic ileitis in this case, based on amyloidosis, may be provoked by some factors, such as systemic circulatory impairment or arteriosclerosis.

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