Seventy-four cases with pigment gallstones were attempted to divide into two groups according to the classification criteria of gallstones advocated by the Japanese Society of Gastroenterology, calcium bilirubinate stones and black stones. On the basis of macroscopic findings,29 cases were defined as calcium bilirubinate stones (Group A),30 cases were black stones (Group C). However, there were remained 15 cases that were equivocal (Group B). Analysis with infrared absorption spectroscopic study were carried out to these three types of stones to measure the concentrations of calcium bilirubinate, black pigment, calcium palmitate and cholesterol. In Group A, the mean concentrations of calcium bilirubinate and calcium palmitate were both significantly higher than those of Group B and C (p<0.001). With respect to the concentration of black pigment, Group B showed a significant increase compared with Group A (p<0.001), as well as marked elevation in Group C. No statistical difference was observed among these three groups in the mean concentration of cholesterol. Based upon these results, it is suggested that pigment gallstones are not feasible to be classified definitely into two categories.

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From July 1995 to October 1996, MRCP was performed in 403 patients with suspected pancreatobiliary disease. Male to female was 216: 187, with an average age of 59 years. MRCP was performed using a 1.5T scanner (TOSHIBA VISART). Single shot heavily T2 weighted images were obtained in breath-hold of 3 seconds using Fast Asymmetric Spin Echo Technique (FASE). Bile duct stenosis and filling defect was detected in 70 patients with accuracy rate of 98% and 92%, respectively. Twelve bile duct carcinomas and 6 carcinomas of the papilla of Vater were diagnosed. Six patients were without jaundice and 1 patient was without bile duct dilatation. In 11 patients tumor was resectable. Histology showed 1 tumor was limited to the mucosa,1 tumor limited to the muscle of Oddi, and 1 tumor limited to the adventitia fibrosa. Curative resection based on histological findings was achieved in 6 patients. In 4 patients anomalous union of the pancreatobiliary ducts was detected with accuracy rate of 97%, and gallbladder carcinoma limited to the mucosa was detected in one of these patients.
In conclusion MRCP is useful and accurate in the diagnosis of biliary tract carcinoma at an early stage and will improve post operative survival rates.

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The reticuloendothelial system (RES) function of obstructive jaundiced rat (1 day,7,14 and 21days after ligation of the common bile duct) was investigated in vivo and in vitro, using chondroitin sulfate Fe (CSFe) as phagocytic material.
Phagocytic index K value measured by CSFe clearance test decreased at day 1 and recovered at day 7, but decreased again at day 21 after ligation.
It was found that the uptake of CS⁵⁹ Fe by the liver was similar to the K value as mentioned above. On the other hand, the uptake by the lung increased significantly at day 21 after ligation. There was no significant difference in the uptake rate of CS⁵⁹ Fe by isolated and cultured Kupffer cells, which were incubated with CS⁵⁹ Fe for 24 hours and calculated by γ-counter, between post-ligation and pre-ligation of the common bile duct.
Opsonic activity was measured as the uptake rate of CS⁵⁹ Fe by Kupffer cells isolated from normal rat liver in which the icteric plasma was added in 10 or 30% concentration into the culture system. This activity increased to depend on the concentration of added plasma, and showed significant difference in 30% concentration of plasma in compared with non-icteric plasma.
It was suggested that the reason for RES dysfunction of obstructive jaundiced rat was neither due to the primary dysfunction of Kupffer cells, nor the decrease of opsonic factors in the icteric plasma.

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Diagnosis and treatment for non-dilated pancreaticobiliary maljunction were examined.
Of 65 patients with pancreaticobiliary maljunction,8 patients exhibited non-dilated pancreaticobiliary maljunction in which the maximum diameter of the bile duct in cholangiography was 10 mm or smaller and subjected to further examination.
The subjects consisted of one male and seven female with a mean age of 52 years.
Seven patients complained of abdominal pain, but one had no symptoms. Before operation, all patients were diagnosed as pancreaticobiliary maljunction by ERCP. The confluence type of the pancreatic and biliary ducts was II a in 6 patients and III c1 in 2 patients according to the new Komi′s classification.
Complication in the gallbladder was observed in 7 of the 8 patients, and consisted of gallbladder cancer in 3 patients, cholecystolithiasis in one patient, adenomyomatosis in one patient, cholesterosis in one patient, and polyp in one patient.
Resection of the extrahepatic bile duct and reconstruction of the biliary duct were performed in 4 patients, pancreatoduodenectomy in one patient, chelecystectomy with lymphadenectomy in one patient, cholecystectomy, partial hepatectomy with lymphadenectomy and partial resection of transverse colon and duodenum in one patient, and no resection in one patient. Proliferating cell nuclear antigen labelling index (PCNA L. I. ) was 13.8% in the gallbladder and 5.9% in the bile duct of patients with pancreaticobiliary maljunction. Those values were higher than those of patients without pancreaticobiliary maljuntion. Thus, most patients with non-dilated pancreaticobiliary maljunction have complicated lesions in the gallbladder, which may facilitate diagnosis.
For their treatment an operation for extrahepatic bile duct resection and biliary reconstruction is required since PCNA L. I. is increase in the gallbladder and bile duct.

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A case of cholelithiasis with extremely high value of DUPAN-2 in serum, which were normalized following biliary drainage and surgery, was reported. A 64-year-old woman who developed jaundice due to impacted common bile duct stone, was hospitalized. Serum levels of CA19-9 and CEA were normal, but the DUPAN-2 level was high at 170,000 U/ml. Abdominal ultrasonography, computed tomography, endoscopic retrograde pancreatography and percutaneous transhepatic cholangiography revealed cholecysto-and choledocholithiasis, showed no pancreatic tumor. After the patient's jaundice subsided, the DUPAN-2 level decreased up to 2,800 U/ml. Cholecystectomy and choledocholithotomy were performed. The gallbladder was atrophic and there was marked inflammatory thickness of the hepatoduodenal ligament with the normal pancreas. On immunohistochemical staining of the mucosal epithelium of the resected gallbladder, strongly positivity for DUPAN-2 was obtained, but CA19-9 positivity was week. From the clinical course and this staining pattern, it seems that DUPAN-2 produced by the gallbladder mucosal epithelium leaked into the blood in situation of cholecystitis and the elevated intrabiliary pressure.

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A case of cholecystolithiasis associated with aberrant bile duct and anomalous cystic duct in a 46-year-old woman is reported. The front view of endoscopic retrograde cholangiography revealed that the right posterior segment bile duct (aberrant bile duct) joined the cystic duct revolving around the posterior wall of the bile duct arrived to the left side of intrapancreatic bile duct. The lateral view revealed the aberrant bile duct was ventral to the cystic duct near the junction of the two. Open normograde cholecystectomy was performed under the diagnosis of cholecystolithiasis associated with aberrant bile duct (V type) and anomalous cystic duct (C type). The cystic duct was ligated just before the junction of the aberrant bile duct and cystic duct after confirmation of relationship of the two by operative cholangiography. This case suggests that the period of formation of the cystic duct or hepatic duct is prior to that of twisting of bile duct embryologically. Moreover reversal of the position of the aberrant bile duct and cystic duct is suspected to be owing to twisting of bile duct.

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It is very rarely reported that the biliary duct at the hilar region is compressed by right hepatic artery. We present a rare case of obstructive jaundice due to the compression of the biliary duct at the hilar region by right hepatic artery.
A 34-year-old-japanese man was admitted to the other hospital in Feburary 1994 with jaundice. An ERC was performed and demonstrated a stricture of the biliary duct at the hilar region, dilatation of the intrahepatic duct, and swelling of the Gallbladder. Accordingly, PTGBD was performed. The patient was admitted to our hospital in March 1994 with the object of close examination. PTCS was performed and demontrated pulsation at the wall of the biliary duct at the hilar region, however, there was no stone, and no malignancy. IDUS was described right hepatic artery at the level of the stricture. Celiac angiography was superimposed on the PTC, demonstrated that the stricture of the biliary duct corresponded to the crossing site of the right hepatic artery.
The patient was not jaundice after removing drainage tube, accordingly operation was not performed. He was discharged on the 34 months with normalized liver function.

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A case of gallbladder carcinoma in situ of which cytodiagnosis of the bile via the percutanous transhepatic gallbladder drainage (PTGBD) rout was effective to preoperative diagnosis is reported. A 64-year-old woman was admitted in our hospital with a chief complaint of right hypochondric pain. Abdominal ultrasonography and computed tomography revealed thickened gallbladder wall at the peritoneal side of the body with cholecystolithiasis. Endoscopic retrograde cholangiography revealed 3 cm irregularity at the same lesion of the wall. These findings suggested the gallbladder carcinoma with subserosal invasion. But cytodiagnosis of the gallbladder bile was class II and angiography revealed no significant findings. Irrigation cytodiagnosis via the PTGBD route was class IV. Pathological findings of the resected gallbladder found benign lesions with severe dysplasia in most lesion, but revealed carcinoma in situ in a limited lesion.

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A 25 year-old-woman was admitted to our hospital complaining of right upper abdominal pain, high fever and jaundice at the 28th gestational week. She was diagnosed as congenital bile duct dilatation (CBD) with acute cholangitis. She delivered a baby, weighting 1,192 g by Caesarean operation. Endoscopic retrograde cholangio pancreatography (ERCP) demonstrated a prominent cystic of common bile duct and pancreatico-biliary maljunction. Abdominal CT showed dilatation of intrapancreatic bile duct. Pyrolus preserving pancreato duodenectomy was performed. Through reference to 57 cases of CBD in pregnancy in Japanese literature, abdominal US is most useful to diagnose and manage for CBD in pregnant woman.

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We report a patients with an extremely large common bile duct stone which was successfully treated by extracorporeal shockwave lithotripsy (ESWL) after endoscopic insertion of a nasobiliary tube. The patient was a 79-year-old woman who presented with fever, epigastric pain, and jaundice. She was in a state of shock on admission. Endoscopic sphincterotomy had been performed for common bile duct stones 7 years ago. Abdominal ultrasonography revealed a large stone in the common bile duct, so she was diagnosed as having acute obstructive suppurative cholangitis. ERG was performed immediately and a nasobiliary drainage tube was inserted subsequently. The tube cholangiography showed a huge common bile duct stone more than 4×7 cm in diameter. Endoscopic treatment such as mechanical lithotripsy and removal was considered impossible, so ESWL was performed. The stone was fragmented after 8 sessions, as shown by tube cholangiography, and the fragments were cleared completely without complications. This case demonstrates that even huge stones that are difficult to treat by any other method may be handled comparatively easily and safely by ESWL.

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