Diagnostic method for the depth of gastric cancerous invasion using endoscopic ultrasonograhy (EUS) was studied, especially in the cases of differential diagnosis between cancerous invasion and fibrosis of the co-existing ulcer. 65 cases of IIc+III and IIc + (III) type early gastric cancer and depressed type like advanced cancer were analysed histopathologically. Fibrosis of the co-existing ulcer in m-cancer group, the invasion of which is limited to the mucosa, always showed a fanshaped propagation towards the outside of the stomach. Fibrosis of the co-existing ulcer in sm-cancer group, the invasion of which spread to the submucosa, except microinvasion cases, showed irregular arch-shaped propagation. In the depressed type like advanced cancer group that invaded ss-s (subserosa-serosa) layer without ul-III, IV ulceration, thickening of pm (proper muscle) layer and hump of the serosa was observed. In the depressed type like advanced group that invaded pm or ss-s layer with ul-III ulceration, thickening of sm-pm layer and hump of the serosa was observed. Diagnosis on the depth of cancerous invasion using the ultrasonographic pattern analysis was clinically attemped, the correct diagnostic rate for the ulceration-complicated early gastric cancer group was 78.4% (29/37 cases), while that for the non-complicated group was 88.9% (64/72 cases). Moreover, the result of 76.2% (16/21 cases) for the depressed type like advanced gastric cancer group was obtained. However, a poor correct diagnostic rate of 60.0% (9/15 cases) was obtained for the IIc + III sm-cancer group. That is, minute intra- or para-fibrosis invasion was not detected ultrasonographically. The correct diagnostic rates for lesions of the aeterior wall and the angle of the stomach were 70.6% (24/34 cases) and 78.0% (32/ 41 cases), respectively, which were poor when compared to the others. There was a tendency for the results to be poor as the diameter was increased up to 6 cm in diameter. It was found that a large portion of misdiagnosed cases were grouped under 3 × 2 mm or below of microinvasion, which was thought to be the clinical limit at this stage. It is concluded that the diagnosis on the depth of cancerous invasion using the ultrasonographic pattern analysis was useful especially in the case of ulceration-complicated gastric cancer.

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The H₂-blockers have become front line therapy for reflux oesophagitis. However, there are conflicting views regarding the change in the lower oesophageal sphincter pressure (LESP) by H₂-blockers. The effects of three H₂-blockers, cimetidine, ranitidine, and famotidine, on the LESP were studied in 56 normal subjects. Cimetidine, ranitidine and famotidine were administer-ed intravenously at a does of 200 mg, 50 mg, and 20 mg, respectively. The LESP was measured using an open-tip and pull-through method, infused catheter method, every 5-10 minutes, starting before treatment up to 60 minutes after administration. The LESP increased significantly in the famotidine and ranitidine groups at 5-40 minutes and 10-40 minutes after administration, respectively, However, no significant increase was observed in the cimetidine group. It seemed that the effects of H₂-blockers on LESP have relation to strength of inhibition on gastric acid secretion. The effects of famotidine and ranitidine on thce LESP were also assessed in the same manner in four reflux oesophagitis patients. Both drugs seemed to increase the LESP.

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Crohn's disease is recognized as idiopathic inflammatory disease that may involve any part of alimentary tract from mouth to anal region. However, the incidence of gross gastroduodenal involvement was reported to be no more than 4%. Then, we performed a retrospective analysis of gastroduodenal endoscopic findings and the presence of epitheloid cell granulomas in biopsied specimens. Twenty-nine gastrofiberscopy and 26 duodenofiber-scopy were carried out in 27 patients with Crohn's disease. Biopsies were performed from 90 regions. All biopsied specimens were serially sectioned at 41cm, 50 sections per specimen, and were stained with H & E. Biopsied regions were classified into 12 subgroups, as gastric body, antrum, bulbus and 2nd portion according to location and as ulcer, minor lesions (erosion, small polyp, redness, scar, etc.) and normal-appearing mucosa according to endoscopic findings. Granulomas were found in 2 (67%) of 3 gastric ulcers, 10 (38%) of 26 minor lesions in stomach and 4 (19%) of 21 normal-appearing gastric mucosa. In 13 (52%) of 25 patients examined by gastrofiberscopy, granulomas were recognized. As regards duodenal regions, granulomas were found in 1(33%) of 3 ulcers, 5 (29%) of 17 minor lesions and 6 (30%) of 20 normal-appearing duodenal mucosa. Granulomas were demon-strated in 10 (42%) of 24 patients examined by duodenofiberscopy. All ulcers were present in antrum or bulbus and endoscopic differential diagnosis between ulcers or minor lesions in Crohn's disease and similar findings in general patients without Crohn's disease was difficult. There was no significant difference between the incidences of granulomas in each subgroup. Consequently, gross gastroduodenal involvement was rare, but granulomas were observed in about half patients with Crohn's disease. The possibility is suggested that upper G-I tract, like as intestine, may be exposed to etiologic agent (s) of Crohn's disease, but the lesions may remain milder by the effects of luminal environmental factors (pH, digestive enzymen, bacterial flora, etc.).

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The endoscopic findings in 7 patients with refractory gastric ulcers against treatment with H₂-blockers (non-healed group) were compared with those in 6 gastric ulcer patients for whom more than 3 months was required to heal their ulcers (protracted-healed ulcer group). At the initial stage of ulcers in the protracted-healed ulcer group, the smooth edematous protrusion surrounded the ulcers equally. The converging folds smoothly transfused into the protrusions around the ulcers. On the other hand, in the non-healed ulcer group, the edematous protrusion was uneven and irregularly surrounded the ulcers. Many converging folds reached to the margin of the ulcers, however, some folds were interrupted before reaching the ulcer margins. Many cases of the non-healed ulcer group showed obliteration of the converging fold abruptly as seen in early gastric cancer type IIc, at the healing stage. Thus, non-healed ulcers showed some characteristic endoscopic features at the initial and healing stage. These results indicate that refractory gastric ulcers may be predictable by their endoscopic findings.

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A comparison of laparoscopic findings was made between 31 cases of asymptomatic HB virus carrier (group A) and 19 cases of asymptomatic type B chronic liver diseases (group B). Male/female ratio and mean age were 5.2: 1 and 38.5 in group A, while 18: 1 and 33.1 in group B, respectively. Positive rates of eAg was 35% in group A and 79% in group B. Most common laparoscopic diagnosis was white liver (58%) in group A, whereas patchy liver (58%) in group B. Nodular liver was present in 10% of group A, but none of group B. Vascular dilatation and reddish marking were less and nodular formation was more prevalent in group A than in group B. Most common histologic diagnosis was chronic inactive hepatitis (42%) in group A, whereas chronic active hepatitis (69%) in group B. There were 7 cases (23%) of chronic active hepatitis with lobular distortion or liver cirrhosis in group A, 6 of which had a history of liver dysfunction, although only one has positive eAg. Laparoscopic findings were well correlated with histologic findings. However, an assessment with both findings is thought to be important to obtain a correct diagnosis. Measurement of serum adenosine deaminase level is partly useful in differentiation of the stage of diseases. Carrier patients in whom the progression of liver disease was observed besides positive in eAb were presented.

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The authors have developed the color enhancement apparatus which enables hue and saturation enhancement as well as contrast trasformation on real time with the technical aid of Olympus Optical Co.. Applying this apparatus, the authors have studied the clinical importance about the color informations of mucosal surface among the various G. I, tract diseases. It is very important for endoscopic diagnosis to master the fine structure and difference among the colors of the lesion. But it has mostly been dependent on the examiners' experience so far. With applying this apparatus, the difference among the colors are expected to be grasped much clearly in the lesions whose surface appearance are even as well as vessels' appearance whose signal volume is little. Significant results have come out about showing the following lesions ; the border of IIc type of early gastric cancer, the redness around gastric ulcer, appearance and bounds of esophageal & gastric varices, and so on. Fine difference among the colors is expected to be analysed by this scientific procedure in the future.

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Clinicopathological and endoscopical features of myogenic tumors of the stomach were investigated in 24 patients with leiomyoma (25 lesions) and 12 with leiomyosarcoma (12 lesions). The diagnosis of these tumors was histologically made by examining the resected specimens. Sixty-five percent of leiomyomas were less than 5.0 cm in longest diameter, whereas 75% of leiomyosarcomas were more than 5.0 cm in longest diameter. Crater of the tumor was more frequent in leiomyosarcoma than in leiomyoma : 50% of leiomyosarcomas had craters, whereas only 24% of leiomyomas had craters. In 4 patients tumor growth was endoscopically observed by follow-up examinations, and 3 of them were histologically proven to be a leiomyosarcoma. These findings indicate that tumor size, crater formation and tumor growth were useful to differentiate leiomyosarcomas from leiomyomas. We developed a new biopsy procedure, aspiration biopsy under direct vision of gastrofiberscope, using a heparinized fine-needle. By this procedure, correct diagnosis could be cytologically made in 4 out of 5 patients with leiomyosarcoma. This procedure was useful for cytological diagnosis of gastric myogenic tumors.

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Four juvenile patients with gastric hyperplastic polyp were studied. Three cases were classified histologically as the foveolar hyperplastic type and the other one was of the fundic gland type. From the results of gastric acid secretion test, endoscopic examination using dye methods, and histological examination of the gastric mucosa, atrophic gastritis of the fundus was found in 2 of the cases with foveolar hyperplastic polyp, but not in the other 2 cases. It appears that some foveolar hyperplastic polyps develop under the conditions of atrophic gastritis of the fundus, which was found even in these juvenile patients.

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Twenty-four pediatric patients with peptic ulcer were endoscopycally diagnosed at the Japanese Red Cross Nagoya and Shizuoka Saiseikai Hospitals during the period from 1980 to 1987. Of these 24 patients, 4 had gastric ulcer, 19 had duodenal ulcer and 1 had both gastric and duodenal ulcers. The common symptoms of the patients were gastrointestinal bleeding (54%) and abdominal pain (25%), although abdominal pain was less frequent in the patients under 6 years old than in those over 6 years old. Predisposing factors were found in 18 patients, of which 6 had stress of school study and 3 had domestic trouble. Twenty-two patients were successfully treated with antacids and/or H2 blocker, and 2 patients with duodenal ulcer were subjected to surgical operation because of pyloric stenosis. We conclude that pediatric endoscopy should be more actively done for the early diagnosis of peptic ulcer.

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There were 526 early gastric cancers in 453 patients who underwent gastrectomy at our center from 1982 to 1987. Among them, we studied the clinical findings and endoscopic diagnosis of depressed-type early gastric cancers in the cardia. The results were as follows: 1) There were fourteen lesions in thirteen patients with depressed-type early gastric cancers in the cardia, which was equivalent to 2.7% of early gastric cancers. 2) Macroscopically, only one IIc lesion had an ulcer while most of the other IIc lesions were without ulcers or ulcer scars (Table 6). Histologically, ten cases (71.4%) were well or moderately differentiated adenocarcinomas (Table 7). 3) To detect depressed-type early gastric cancers in the cardia, it is important to perform thorough endoscopic examination and biopsy of lesions with erosive change in the cardia (Table 9, 10). 4) When the lesion is on the lesser curvature or on the posterior wall in the cardia, it is suitable to view the lesion from above using a lateral-viewing fiberscope for en face observation. But when the lesion is on the greater curvature or on the anterior wall in the cardia, it is feasible to apply the U-turn or J-turn method using a front-viewing or oblique-viewing fiberscope (Table 12).

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Follow-up examination following endoscopic polypectomy of the colon has been made for the recent 6 years among 394 polypectomized cases, while 20 cases (5.1%) have experienced as the overlooked and 6 cases (1.5%) as the recurrent. The results were as follows; 1) Out of them 13 polyps were 7 to 9 mm, 7 polyps 10 mm or more in diameter. 2) Their polyps showed 10 sessile, 4 subpedunculated, 3 pedunculated and 3 flat in shape. 3) Ten polyps located in the cecum and ascending colon, 3 in the transverse colon, 2 in the descending colon, 5 in the sigmoid colon and one in the rectum. From the location at point of view, the region near to the hepatic fluxure were commonly overlooked in 13 lesions (65%) containing 5 early colonic carcinomas. 4) Local recurrences after endoscopic polypectomy were recognized in 6 cases. Four of them were removed in piecemeal f asion. All recurrent cases showed villous adenoma histopathologically. Therefore, the patients after endoscopic polypectomy should be followed up by repeated colonoscopy to detect cases of “overlooked”, “recurrence” and “newly arising” colonic polyps.

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Endoscopic retrograde cholangiopancreatography (ERCP) is extremely useful for the diagnosis of the diseases of the pancreas and the biliary tract, but direct observation has been desired for the definite diagnosis of some lesions. We examined these ducts by inserting a miniscope with 0.75 mm in diameter through a cannula with 5F (1.7 mm) into the normal papilla of Vater. This examination has been carried out on 16 cases to date clinically. In twelve out of 16 cases (75%) this miniscope conld be inserted to the target point of the ducts and the lumens were observed successfully. In normal cases, the main pancreatic duct was seen as a clear lumen, in which fine capillary pattern of the mucosa and the orifice of the branch duct were also recognized. Irregularily elevated lesions and uneven mucosa inside the lumen were observed in almost cases with pancreatic cancer and chronic pancreatitis. However, sufficient visualization of the entire parts of the pancreatic duct and the biliary tract has not been attained with this miniscope because of the lack of working channel for angulation. We have recently developed the new 1.7 mm-diameter miniscope with a working channel to resolve the above problem. We predict that this new instrument will play a limited but definite role in diagnostic and therapentic cholan-giopancreatoscopy. Improvements of quality, fragility and therapeutic ability of the scope is under investigation.

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We present a 20-year-old female patient with advanced esophageal cancer. The patient visited our hospital with the chief complaints of dysphagia and body weight loss. Roentgenological examination revealed a stenotic lesion at the upper third portion of the esophagus (Iu-Im). The stenosis was also confirmed endoscopically at 25 cm from the foreteeth. The histological diagnosis of endoscopically biopsied specimen was moderately differentiated squamous cell carcinoma. The patient was admitted to the hospital. After pre-operative radiation therapy, total thoracic esophagostomy and partial gastrectomy was performed. The main lesion of the surgically resected specimen was histologically almost scarred and there were moderately differentiated squamous carcinoma cells left in the lamina propria. In addition to the main tumor, another lesion was found at the lower site of the resected esophagus. The second lesion was histologically diagnosed as poorly differentiated squamous cell carcinoma with invasion to the muscularis mucosa. Very few cases of esophageal cancer in patients under the age of 29 have been reported in Japan. To our knowledge, the present case may be the youngest example of the esophageal cancer without any congenital anomalies among the similar cases reported so far in this country.

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A 86-year-old female was admitted with a complaint of dysphagia for two months duration. Ba-swallow revealed a well-defined elevated tumor in the Im and Ei portions of esophagus. On endoscopy examination, polypoid lesion with irregular and partly erosive surface was noted and it occupied the most of esophageal lumen. Under the diagnosis of esophageal sarcoma, operation was performed. The resected specimen showed a polypoid lesion with superficial roughness in various sizes and was 7.0 × 4.0 × 2.2 cm in size. Histologically, the tumor was predominantly composed sarcomotous spindle cells in a bundle crossing each other, and moderately differentiated squamous-cell carcinoma was irregularly arranged in the area adjacent to the base of tumor (mp). Electron microscopically, the sarcomatous spindle cells, characterized by large nucleus and well-developed rough endoplasmic reticulum, were connected to each other, mainly at the border of their prosesses. A few cells possessed poorly defined demosome-like attachments without tonofila-ments, but the cell had no typical epithelial characteristics. Based on these findings, we diagnosed this tumor as carcinosarcoma of the esophagus.

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Many cases of double cancer of the esophagus and the stomach have been reported in Japan. However, double early cancers of the stomach and the esophagus were early reported. This is a case of early gastric cancer of reconstructed stomach tube found during follow-up study after radical operation of early esophageal cancer. A 78-year-old male was pointed out as superficial depressive esophageal cancer on X-ray and endoscopic examinations of the upper GI tract. Total thoracic esophagectomy was performed and pathological diagnosis was squamous cell carcinoma, mm in depth, without lymphnode metastasis. Esophagogastrectomy was performed in the antesternal space. After 17 months, a minute gastric carcinoma of the prepylorus on the stomach tube was noted on the follow-up endoscopic examination. Partial gasterectomy including the cancer lesion was performed. Pathological studies revealed well dif f erenciated adenocarcinoma, m in depth, ly₀ and v₀.

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A 48-year-old woman was admitted because of diabetes mellitus and acute pyelone-phritis. Upper GI series showed an elevated lesion at the lesser curvature of the upper gastric body. Endoscopic examination showed a hemispherical elevation with a central ulcer. Biopsy studies revealed carcinoid tumor. Immediately after curative resection, the diabetes mellitus improved strikingly without specific treatment. Five years after the operation, there are no signs of recurrence. It is strongly suggested that the carcinoid tumor was closely related to the diabetes mellitus in this patient.

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A 67-year-old male who had undergone radical orchiectomy for left testicular seminoma on Aug. 29, 1981, received 4, 350 rad 60Co-irradiation to the retroperitoneal region including the stomach during the period from Sept. 10 to Oct. 16, 1981 (Figure 1). Since the first of Jan. 1982, 3 months later, epigastric discomfort, anorexia, nausea and vomiting appeared and he visited our hospital on Apr. 3, 1982. Roentgenography demonstrated a deep and irregular ulcer with converging folds on the posterior wall of the antrum, as well as deformity of the antrum (Figure 2). Endoscopy revealed the other small irregular ulcer in the prepyloric region and edematous, erosive and bleeding mucosa in the entire antrum (Figure 5). Biopsy specimens showed no evidence of malignancy. Although medical treatment was given, the ulcers did not tend to heal and deformity of the antrum was progressive. Furthermore, a bleeding ulcer was also found (Figure 3, 4 and 6, 7). From these findings, the gastric lesions were diagnosed as gastric injury following radiotherapy, and a subtotal gastrectomy was performed on Aug. 17, 1982. Macroscopically the resected stomach demonstrated multiple irregular ulcers, multiple erosions, a nodular rough-surfaced mucosa and thickening of the antrum wall (Figure 8). Histological findings showed mucosal atrophy, and hypertrophy as well as fibrosis of the submucosa. Thickened wall, decreased caliber of the lumen and clot formation of the vessel were also noted (Figure 9). These histological features, especially that of the vessel, are similar to those reported in previous studies on gastric ulcer following radiotherapy.

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A 47-year-old male patient was diagnosed as having chronic alcoholic pancreatitis with ERCP and other examinations. On the ninth day after ERCP, he developed fever of higher than 39 degrees. Vegetation at the posterior cups of the mitral valve was disclosed by echocardiography, and Streptococcus faecalis grew in the hemoculture, leading to a diagnosis of bacterial endocarditis. He was successfully treated through intravenous administration of Ampicillin (ABPC). This particular case was complicated by the fact that the patient had acquired mitral insufficiency, which seemed to have induced bacter-emia subsequent to ERCP and to have led to bacterial endocarditis. Upon examination of 28 patients for bactemia by hemocultures following ERCP, no bacteria were detected in any cases. In many other reports, bacteremia was considered a transitory condition, or infection was so slight that it rarely developed into a clinical problem. However, patients with congenital heart diseases, acquired valvular diseases, and immunodef iciency as well as those with artif ical valves are subjected to paticular risks of serious bacterial endocarditis and sepsis. Thus, it is suggested that a prophylactic antibi-otic regimen mainly with Ampicillin should be done soon after endoscopic examinations.

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A 78-year-old female was admitted to our hospital because of obstructive jaundice. After percutaneous transhepatic cholangio-drainage, cholangiography and choledocho-scopy revealed choledochal carcinoma causing complete obstruction at the lower end of the common bile duct. Because of her congestive heart failure, we treated her conservatively. To make an internal fistula we performed local laserthermia using Nd : YAG laser via percutaneous transhepatic choledochoscopy with single channel. Immediately after irradi-ation, we could pass the drainage tube into the duodenum through the duodenal papilla without any complications, on the fourth day, cholangiogram showed partial reduction of the tumour. Our experience demonstrated that endoscopic local laserthermia is an effective treatment for choledochal carcinoma.

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A 73-year-old man was admitted to our hospital with complaints of dyspnea and abdominal fullness. On admission, he was found to have aspiration pneumonia at the bilateral middle and lower lung fields and was noted slight abdominal tenderness around the navel. Bowel sounds were decreased and X-ray of the abdomen showed distended air-filled loops of the bowel in the small and large intestines. His pneumonia was cured by antibiotic therapy given over 14 days, but laboratory findings persistently indicated mild inflammatory signs (for examples W BC 6, 100 / mm³., ESR 54 mm / 1 h, CRP2 +). At the same time, colonoscopy was performed for the purpose of determining the cause of paralytic ileus. Colonoscopic study showed a decolorized tumor with a smooth surface in the cecum. White pus flowed out of the cecal tumor after a transcolonoscopic biopsy was performed at the top of the tumor. Four days after the biopsy, colonoscopy revealed that the tumor had disappeared and the outlet of appendix, which was not observed at the previous colonoscopic study, was clearly visualized. Microscopic examination of the bioptic specimen showed colonic mucosa with numurous inflammatory cell infiltrations. Therefore, the lesion was considered to be a submucosal tumor due to appendiceal abscess. This case provided a useful suggestion for colonoscopic differential diagnosis of cecal tumors and indicated that transcolonoscopic drainage might be effective for the treatment of such cases.

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This report discribes non-specific small intestinal multiple ulcers in two patients with leukemia who developed massive intestinal hemorrhage. The first case was a 48-year-old man with acute leukemia. He passed massive hematochezia during the course of hemator-ogical remission. Intraoperative ileoscopy showed four medium-sized ulcers and scattered aphthoid ulcers in the ileum 40 cm proximal to ileocecal valve. The resected specimen showed four oval-shaped ulcers (Ul-III) and many aphthoid ulcers (Ul-II) without infiltra-tion of leukemic cells. The second case was a 49-year-old man with acute transformation of chronic myelocytic leukemia. He developed hematochezia during treatment for leu-kemia. Endoscopic examination showed four large oval-shaped ulcers and scattered aphthoid ulcers in the terminal ileum. The cause of these small intestinal ulcers in these two cases is likely identical because of similar endoscopic findings, but was unable to be established unequivocally.

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Two cases of mucosal prolapse syndrome are reported. Case 1:40-year-old female with complete rectal prolapse were endoscopically diagnosed as submucosal tumor. Barium enema study showed a few elevated lesions which are about 1 cm in size. Histopathological study revealed this case as colitis cystica profunda. Case 2 : 34-year-old male had been complained of difficulty of defecation for many years. He had a habit of straining. Barium enema study showed filling defect, suspected of rectal malignancy. Endoscopic appearance showed enlarged rectal mucosa and ulcera-tion. Epithelial changes of rectal mucosa were not entirely clear. By histopathological study, this case was diagnosed as solitary ulcer of the rectum. In both cases, fibromuscular obliteration in lamina propria was observed. Therefore, we suppose, these two cases can be included in the entity of mucosal prolapse syndrome which were due to obvious rectal prolapse or a habit of straining as occult mucosal prolapse. According to the concept of this syndrome, it is important to confirm mucosal prolapse. But it is difficult to diagnose occult mucosal prolapse, so detailed questioning is necessary on concealed straining habit. Surgical therapy is effective in case of obvious rectal prolapse.

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Two Cases of colonic carcinoma accompanied by ulcerative colitis were reported. Case 1: 43-year-old female had a history of ulcerative colitis for the past seven years. In retrospective review, a protruded lesion was identified in the descending colon on the barium enema film taken 4 weeks after the onset and it had developed to Borrmann 2 type colonic carcinoma 7 years later. Diagnosis of colonic carcinoma without dysplasia of the surrounding colonic mucosa was made. This case was considered as colonic carcinoma incidentally accompanied by ulcerative colitis. Case 2 : 27-year-old male had ten years' history of ulcerative colitis involving total colon. A protruded lesion identified in the descending colon 2 years before had developed to Borrmann 2 type colonic carcinoma one year later. At the same time, another protruded lesion was demonstrated in the sigmoid colon. Subtotal colectomy was performed. Dysplasia was demonstrated in the colonic mucosa surrounding each carcinoma. It was considered that colonic carcinoma had developed from longstanding ulcerative colitis in this case.

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Although the advancement and spread of gastrointestinal endoscopy has been recently remarkable, we should bear in mind the fact that medical accidents and subsequent medical lawsuits have been increasing in number. There are many reasons for the recent increases in medical troubles and lawsuits, but the disappearance or lack of a good relationship between the doctor and the patient is one of the most crucial problems. In the background, there are also the following important factors : the promoted awareness of rights in ordinary people, that is, the development of sharp sense of human rights and claims on the side of patients, the diminishing of ethics on the side of doctors, and biased dealings with medical accidents by the mass media. The examination of many judicial precedents revealed that the most significant points of debate are : (1) whether the doctor's liability to be careful enough was properly performed ; and (2) whether the liability to inform in advance was adequately carried out. As far as the patient trusts the doctor and, in turn, the doctor respects the patient's character and right of decisionmaking, with the principle of informed consent being strictly maintained, medical lawsuits would never occur. I describe the problems related to the patient's right of decision-making, the doctor's liability to inform and its practice, and fundamental ways to cope with medical suits, by demonstrating informative judicial precedents.

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According to their density and distributions the ascending mucosal capillaries (AMC) of stomach can be divided into three distinct zones horizontal to mucosal surface. The first is the zone I with high vascularity where AMC forms dense anastomosing networks encircling the glandular portion of gastric glands. The second is the zone II with reducing vascularity where AMC is reduced in number and in each caliber forming a constriction at the level of the generative cell zone (G-zone). The thied is the zone III with increasing vascularity where AMC is increased in number and in each caliber toward the mucosal surface at the level of foveolae. In chronic gastritis the vascularity at the level of the glandular portion of gastric glands is progressively reduced resulting in a progressive reduction in size of the zone I. Whereas the zone II and III are progressively and somewhat irregularly expanded. These changes are found to be coupled with a progressive loss of proper gastric glandular epithelial cells, appearence of pseudopyloric mucous cells, foveolar hyperplasia and Medicine. appearence of metaplastic intestinal glands. Since intestinalized glands are found not to connect with the gastric glands preserving parietal cells, the total loss of parietal cells in a gland that may due to a loss of stromal support in the form of progressive vanishment of the zone I can be a prerequisite for the development of intestinal metaplasia. Since pseudopyloric glands are found to have less vascular stromal support than proper pyloric glands the defensive mucous secretory capacity is thought to be reduced in the former. This may explain preferencial locus specificity of chronic gastric ulcers in the intermediate mucosa along the lesser curvature. Since irregular expansions of the zone II and III are coupled with irregular expansion of G-zone these changes may constitute predispositions to the development of gastric cacinomas through an increased accessibility of carcinogens to carcinogen target cells, an increased carcinogen target cell mass, altered controls of cellular proliferation and a decreased capacity of atrophic glands to detoxify carcinogens. Further studies on chronic gastritis may make assessment of risks of carcinogenesis possible using biopsied materials. This suggests an emergence of new dimension of gastro-intestinal endoscopy that embraces preventive medical approaches. (These works were in part supported by grant-in aids from Ministry of Education, Science and Culture, Japan.)

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Endoscopic removal of biliary stones was successful in 820 of 862 patients (95.1%) ; 36 of 38 through the postoperative T-tube track, 744 of 780 through the peroral transpapillary route and 40 of 44 by the percutaneous transhepatic approaches. Most cases were performed by the duodenoscopic instrumentation after endoscopic sphincterotomy (EST). The new techniques such as electrohydraulic lithotripsy, laser beam lithotripsy and mechanical basket lithtripsy were very effective for this purpose. The complications were recognized in 45 of 780 patients (5.8%), 3 out of wich were fatal cases (0.4%). Endoscopic therapy is now the major method for the management of cholelithiasis. In the near future, bile duct stones will be completely treated by the combined use of the various nonsurgical methods.

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