The metabolism of cholesterol and bile acids in the liver was investigated in hamsters fed with high glucose diet, as the experimental model of cholesterol gallstone often observed in human type IV hyperlipidemia. Glucose feeding induced augmentation of the activities of both hepaic HMG-CoA reductase, a rate limiting enzyme of cholesterol synthesis, and hepatic cholesterol 7α-hydroxylase, a rate limiting enzyme of bile acid synthesis. The activity of hepatic HMG-CoA reductase exceeded by far that of cholesterol 7α-hydroxylase after the second week of glucose feeding. The dissociation between the activities of both the hepatic enzymes seems to induce extreme increment of cholesterol secretion into bile. Total bile acids secretion into bile didn't increase, although the pool size of bile acids increased.
As a result, it is concluded that the bile becomes supersaturated with cholesterol by glucose feeding and cholesterol gallstone is formed.

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The ease and accuracy of real time ultrasound with which gallstones may be shown in the gallbladder has increased the incidence of silent gallstones. This paper describes experience with clinial course and treatment of silent gallstones.
Between 1972 and 1987,493 patients w ith silent gallstones have been studied. In those patients,278 were detected at the Department of Gastroenterology, Juntendo University, and 215were diagosed at ultrasound mass survey performed in Iki and Izena Islands. Incidence of silent gallstones was 12.8% of gallstones detected at Juntendo University, and 62.8% of those diagnosed at mass survey.
Follow -up of silent gallstones showed that 12.9% of the patients had become symptomatic within three years from the time of diagnosis. In those patients surgical intervention was performed without morbidity or mortality. In only one patient (0.4%), association of carcinoma of the gallbladder was occured.
The result of thi s study indicates that in silent gallstones operation is not required untill the patient becomes symptomatic. Incidence of association of carcinoma of the gallbladder is very low in silent stone.

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Perfusion cholangiomanometry by dilute hydrochloric acid stimulation was carried out on 212 patients having benign biliary tract diseases, and the data were analyzed relative to their clinical findings, surgical findings, and distant prognostic results.
The manometric curve patterns appeared to permit proposal of a new classification, offering better clinical usefulness. Type I (normoreacting type) A flat perfusion pressure pattern with high amplitude spikes; Type II (hypertonic type): The perfusion pressure rises steeply; Type 111(hypotonic type): The flat and low perfusion pressure pattern. Additional subclassification was made into II a, II b, JJaf and 11b1 according to the responsiveness to stimulation with dilute hydrochloric acid.11 a seemed to reflect papillary stenosis. Its histopathological findings were those of acute inflammation, and were reversible papillitis. Some 85% of II b were cases of gallstone incarceration in the lower part of choledochus. The histopathological pictures of type, especially E b were characterized by connective tissue proliferation in the papilla. Most of IIIb cases appeared irreversible papillitis.
For the purpose of differentiati o n of their reversibility, observation of the reaction to an i. v. dose of pentazocine seemed appropriate enough. Duodenal papillitis was concluded to proceed from II a through a to III b.

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The purpose of the present study was to evaluate the resectability of the cases of bile duct carcinoma of the hepatic hilus. Among the cases experienced from July,1978 to December,1986, we evaluated 49 cases (34 resectable and 15 non-resectable) by the findings of cholangiography, arteriography and portography.
The results were as follows:
The resectability was mainly determined by the findings of arteriography and portography. Those cases which presented no abnormal arteriographic findings at the proper, right and left hepatic arteries, were all resectable, and 80% of the case, having unilateral tumor-invasive findings at the right or left heptic artery, could be resected. However, when there existed further more encasements at the proper, right and left hepatic arteries, no resection could be performed. By the findings of portography, those cases which had no invasive findings at the main trunk of the portal vein and bilateral portal branches were all resectable. However, if there were tumor-invasive findings at the main trunk of the portal vein, no cases were resectable. Seventythree percent of the cases which had only unilateral invasive findings at the right or left portal branch were resectable.

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Three cases of bile duct perforation in children with anomalous conjugation of the pancreaticobiliary tract were presented. Case 1 was 10 month-old-boy with intraperitoneal abscess. Case 2 and 3 were 1-year-old and 3-year-old girls with panperitonitis. Case 2 and 3 were preoperatively diagnosed by abdominal echogram. and CT scan with drop infusion cholangiography. In all cases, pancreatic ducts were connected with bile ducts, and their typ e s of anomalous conjugation were III a and III b in the classification by Ohi.
In all cases with common channel dilatation, stenosis of duodenal papilla was suspected. Amylase levels in bile were remarkably high in all cases. In pathological findings of bile ducts, mucosa was preserved and slight fibrosis and massive infiltration of neutrophils were observed. We suspected that the cause of perforation was serious acute inflammation of bile duct that was caused by massive reflux of pancreatic juice with acute stenotic change of duodenal papilla.

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Ultrasonically-guided percutaneous transhepatic gallbladder puncture (UG-PTGBP) was carried out in patients with acute cholecystitis in whom antibiotics and anergesic treatment was not effective.
Using this procedure, pain, fever, and other symptoms had remarkably improved in all patients. No serious complication had been encounterd.
Ultrasonicaly-guided percutanoeus transhep a tic gallbladder drainage (PTGBD) was performe in patients with acute obstruction of the common bile duct. In those patients, intrahepatic bile ducts were not dilated. And PTCD was difficult to performe. The procedure was effective in reducing jaundice and infactious bile drainage.

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A 36-year-old man with complaint of right back pain was admitted to our hospital. Ultrahowed multiple cystic lesions occupying 5x3 cm area in posterior segment of right lobe of the liver. Computed tomography (CT) scan revealed multilocular cystic lesion without calcification of the walls. Celiac angiography showed no tumor stain but dislocation of right hepatic artery. CT-angiography was useful to observed the vascular structure of the walls. Biliary cintigraphy demonstrated uptake of ^99mTc-N-pyridoxyl 5-methyl tryptophan (^99mTc-PMT) at a late phase. Under the diagnosis of biliary cystadenoma, sublobular resection was undergone. Histological examination showed high columnar epitherium producing mucin and confirmed the diagnosis of biliary cystadenoma. Diagnostic imaging modarities were done in a case of biliary cystadenoma and the characteristic findings were reported.

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The patient was a 60-year-old woman complaining of jaundice. Cholangiography demonstrated the stenosis of hilar and upper bile duct and percutaneous transhepatic cholangioscopy (PTCS) revealed adenocarcinoma by biopsy.
Operative findings showed the prim ary tumor of the cystic duct involving the right hepatic artery and portal vein, and radical resection of the right hepatic lobe, total caudate lobe, bile duct and portal vein was carreid out. Histological diagnosis was poorly differentiated adenocarcinoma with scirrhous infiltration. It is rare carcinoma of the cystic duct.

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A 54-year-old male complaining of jaundice and right hypochondralgia was admitted to our hospital. Percutaneous transhepatic cholangioscopy (PTCS) was performed on suspicion of intrahepa tic stones.
The stones were found in the right anterior inferior branch (B₅) and left caudate branch (B₁ls). All stones were completely removed by PTCS. Then, cholecystectomy was performed because of gallbladder stones. The analysis of composition revelaed 98% cholesterol in intrahepatic stones, on the other hand,70% cholesterol and 30% calcium carbonate in gallbladder stones. Intrahepatic stones were considered to be primary intrahepatic cholesterol stones by the following reasons. First, the composition between intrahepatic stones and gallbladder stones were different. Second, segmental cylindrical or cystic dilatation of intrahepatic bile ducts were r ecognized. The entrance of B5 was slightly stenotic and cylindrical dilatation of the dust in which the stones existed. Cystic dilatation was seen in B1ls. PTCS was useful for the diagnosis and treatment of intrahepatic stone.

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We experienced a case of postoperative cholangitis due to intraductal stasis of meals after end to side choledochoduodenostomy. The patient was a 69-year-old female who had undergone cholecystectomy and choledocholithotomy respectively. Thirdly, the patient underwent end to side choledochoduodenostomy for the recurrence of choledocholithiasis. And four weeks after the opcration, intermittcnt high fbver over 38°Cappeared without any symptoms. Abdominal CT and endoscopic study revealed the stasis of meals in the bile ducts beyond the choledochoduodenoanastomosis. The intraductal meals were removed endoscopically and her fever was disappeared. This case proved the risks of the reflux and stasis of meals beyond anastomosis in choledochoduodenostomy.

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A case of inflammatory fibroid polyp of the gallbladder in a 46-year-old man is reported herein.
The patient was admitted to the Hamamatsu Medical Center with intermittent abdominal pain and high fever in February 1982. His clinical history revealed that he had laparotomy for liver rupture in 1969, choledochojejunostoy in 1970 and cholecystojejunostomy in 1973 for common duct stones, respectively. Hepaticojejunostomy carried out on March 3,1982. The gallbladder contained a few calcium bilirbuinate stones. The mucosa was congested and relatively preserved. A small pedunculated polyp,3×3×4 mm in size, was incidentally found in the fundus near the site of cholcystojejunostomy. The surface of the polyp appeared smooth and yellowreddish. Histologically, the polyp was composed of young connective tissue with a vascular network and an inflammatory infiltrate. The overlying mucosa was ulcerated. The stalk of the polyp extended into the muscularis mucosae. The gallbladder showed “acute on chronic” cholecystitis.
This case may represent the first reported of inflammatory fibroid polyp in th i s location. This rare polyp of the gallbladder is reported and the nature of the process is discussed with a brief review of the literature.

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A very rare case of carcinoid tumor of the gallbladder was reported. The patient was a forty-two year-old female whose chief complaint was right hypochondralgia. The preoperative endoscopic retrograde cholangiopancreatography revealed anomalous arrangement of the pancreaticobiliary duct and tumor of the gallbladder. Cholecystecomy and removal of the regional lymph nodes and resection of the bile duct and Roux-enY choledochojejunostomy were performed. The tumor was 36 × 23 mm in diameter. Histologically, the tumor showed carcinoid and adenocarcinoma with areas of mucous change. Carcinoid cells were containing argylophil granules, but no argentaffin granules were detected.15 cases of carcinoid of the gallbladdeer have been reported in Japan. In those,6 cases were composite tumor (carcinoid tumor associated with adenocarcinoma). Carcinoid tumor with anomalous arrangement of the pancreaticobiliary duct has not been reported before in the literature.

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A 74-year-old man was admitted to our hospital complaining of fever and slight liver dysfunction. US showed abnormal opacity in the upper bile duct. ERCP showed filling defect of the upper bile duct, suggesting a tumor. A tumor shadow of the same density as liver was seen on CT-cholangiography. PTBD and PTCS were performed to enable histological diagnosis. Injection of contrast medium performed 7 days after PTBD revealed that the tumor was markedly reduced in size. PTCS revealed an irregular and slightly elevated lesion with redness and bleeding. Biopsied specimens from the affected area showed adenocarcinoma. Pathological analysis after the surgery revealed that the remaining part of the tumor, measuring 10×15 mm, was papillary adenocarcinoma located in the mucosal layer. Patient has been in good health for over 2 years since the surgery.

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A 62-year-old woman was hospitalized in our department due to recurrent fever after sphincteroplasty performed for acute cholangitis caused by Lemmel's syndrome 40 days previously at another hospital. Ultrasound, computed tomography and hepatic angiography demonstrated solid focal liver mass in the right lobe, and cholangiocellular carcinoma was suspected. Right lobectomy was performed and resected specimen showed empyema in the locally dilated bile duct in the posterior segment, and multiple small abscesses surrounding the bile duct. The cause of these liver abscesses may be due to stenosis and dilatation of intrahepatic bile duct which was over-looked before initial sphincteroplasty. In some early pyogenic liver abscess, differential diagnosis from solid liver mass is required.

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Forty-eight year-old female was admitted to the hospital with chief complaints of vague epigastric pain and weight loss of 4 kg. At the time of admission, WBC count was 52,500/mm³and eosinophil count was 15,250/mm³ (29%). No morphological abnormality was found in examinaton of the bone marrow. There was no history of allergies, asthma or skin diseases. She had never traveled outside of Japan. Serum Ig-E level was normal and antibodies to parasites were negative. Multiple liver metastasis was found by image diagnosis. Intra-arterial injection of 20 mg of mitomycin C was performed by the route of celiac angiography. Eosinophil didn't decrease in count.
Adenoca r c inoma cells were found in ascites and intraperitoneal administration of 2 mg of mitomycin C was performed, then eosinophil count decreased from 38,500/mm³ to 2,609/mm3. Autopsy revealed that gallbladder cancer showed no eosinophilic infiltration while hyperplasia of eosinophils without chromosomal abnormalities was found in bone marrow. Accordingly, eosinophilia might be caused by stimulator of eosinophil-colony growth released from gallbladder cancer.

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This report of a case describes resectable hepatocellular carcinoma (HCC) with tumor extension into the bile duct. In a 51-year-old male with jaundice direct cholangiography demonstrated filling defect in the upper bile duct. Ultrasound, computed tomography and hepatic angiography showed no evidence of focal liver mass. Operation disclosed HCC measuring 2 cm in the caudate lobe with tumor extension into the bile duct. Tumor was successfully resected.
More than 100 cases of HCC with tumor extension into the bile duct have been reported. Correct diagnosis was established in 39%. Twenty-seven tumors were resected and only 7 tumors were smaller than 2 cm. Mean survival time of unresectable tumors is 166 days, whereas that of resectable tumors is 15 months.

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