In the provinces of Suoh and Nagato of the Mohri clan during the Edo period, medical education was individually developed in the principal clan at Hagi and 4 branch clans. Acceptance of the western medicine in this province was stimulated probably due to the closer situation to Nagasaki and to the cross-road position of Shimonoseki. Historically, Igakukan at the Tokuyama clan and Kengakudo, a private school in the same district were the old medical schools. Koseido(Koseikan)that was founded in the principal clan at Hagi during the Tempo era was the first full-scale medical school covering both the oriental medicine and the western medicine. Entering into the Meiji era, medical schools at Akamagaseki and Mitajiri started, but they were short-lived. The real modern medical education did not start until the Yamaguchi Prefectural Medical School was founded in 1944 in this district.

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The inter-domain interaction between N-terminal(1-600)and central domains(2000-2500)of the ryanodine receptor(RyR)plays a critical role in channel gating in both skeletal(RyR1)and cardiac(RyR2)muscle RyR-s. We previously reported that dantrolene, a therapeutic agent for malignant hyperthermia(MH),prevented abnormal Ca2+ leak by correction of the defective inter-domain interaction between N-terminal and central domains in MH-type RyR. The amino acid sequence of the putative dantrolene binding site of cardiac RyR2 is identical with the RyR1(Leu590-Cys609).Here, we investigated the molecular mechanism and the in-vivo therapeutic effect of dantrolene against heart failure as well as lethal arrhythmia, in tachycardia-induced heart failure canine model and catecholaminergic polymorphic ventricular tachycardia(CPVT)-associated RyR2R2474S/+ knock-in(KI)mice model. Dantrolene specifically bound to the corresponding domain 601-620 in RyR2 by using a quartz crystal microbalance technique(a highly sensitive mass-measuring technique).Dantrolene was also found to correct defective inter-domain interactions within RyR2 in the both models, inhibited diastolic Ca2+ leak, in turn improved cardiomyocyte function in failing hearts and prevented bidirectional VT induced by injection of epinephrine or exercise in CPVT. Thus, dantrolene may have a potential to treat heart failure and lethal arrhythmia, specifically targeting RyR2.

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A 41-year-old woman was admitted to our hospital for an abdominal ultrasonography, which revealed a hypoechoic liver tumor. She had no past medical history and no risk factors for liver disease. Dynamic computed tomography and MRI revealed a protrusive increasing liver tumor about 4cm in maximal diameter arising from segment I. These examinations using contrast medium showed enhancement in the early phase and washout in the delay phase. The T1-weighted MR image showed a low intensity, and the T2-weighted image showed a little high intensity. Hepatic angiography showed a hypervascular tumor. Liver function tests were normal, and levels of serum tumor markers, including Alfa-fetoprotein and protein induced by vitamin K absence or antagonist II, were within normal ranges. Laparoscopic operation was indicated for the purpose of diagnosis and treatment. The extrahepatic growing soft tumor originating in the caudate process was confirmed, and laparoscopy-assisted partial hepatectomy was performed. The operation time was 299 minutes, and the blood loss was 270ml. Postoperative course was uneventful. Histology showed a myomatous angiomyolipoma of the liver.Laparoscopy-assisted liver resection is useful for a tumor with difficult diagnosis.

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A-60-year-old man was referred to our hospital for further examination and treatment for a longitudinal elevation from the upper to lower esophagus and a short segment Barrett's esophagus in the esophagogastric junction. Histlogical examination of the biopsy specimen from the elevated lesion showed adenocarcinoma. Upper gastrointestinal series showed the same findings as EGD, and trapezoid deformity in the lower esophagus.Sub-total esophagectomy was performed. Histopathological examination revealed Barrett's esophagus and adenocarcinoma with massive lymphovascular invasion.Based on these findings, we thought that this tumor was esophageal adenocarcinoma arising from Barrett's esophagus and forming a longitudinal elevation.

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The patient was a 31-year-old woman who had been diagnosed with Crohn's disease at age 18 years. Enteral nutrition and medical treatment were given, but their effect was insufficient. Gastrointestinal complications worsened, and ileocecal resection was performed three times. The remaining small intestine was 280 cm. But, her symptoms were unstable. Thus long-term fasting and central venous nutrition were adopted. At 31 years old, she was hospitalized with cognitive dysfunction and decreased activity. CT scan showed liver cirrhosis(LC),and hepatic dysfunction and an elevated ammonia level were seen on blood tests. Therefore, she was diagnosed as hepatic encephalopathy from decompensated LC. Blood tests were negative for HBV and HCV infections, she had no history of drinking alcohol, fatty liver had been presented for some time, and elevated transaminase were seen. This led to a diagnosis of LC resulting from non-alcoholic steatohepatitis(NASH).Liver transplantation was considered, but there was no appropriate donor, and the patient did not desire. Therefore, symptomatic therapy was continued. She was repeatedly hospitalized and finally died from liver failure. We report that the rare case in which NASH occurred due to multiple factors during the course of severe Crohn's disease and progressed to decompensated LC.

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We report a rare case of multiple duodenal diverticula associated with ulcer accompanied by melena. A 70-year-old level woman undergone treatment for Hodgkin disease. Anemia was revealed by blood examination, but focus of gastrointestinal hemorrhage was not revealed by esophagogastroduodenoscopy and colonoscopy.However, melena was continued and small intestinal hemorrhage was suspected. Extravasation of contrast medium was not seen, but a diverticulum of the jejunum was found on enhanced-CT. Single-balloon endoscopy introduced orally revealed multiple ulcers in the duodenum, jejunum, and ileum and a diverticulum in the jejunum proximal to the ligament of Treitz. Ulcers and ulcer scars were found in the diverticula. Diclofenac sodium was taken habitually and bowel mucosal damage respected to NSAIDs was suspected. Bowel residues retain easily in diverticula and high concentration NSAIDs grew stagnant. That was thought of as cause of wide ulcer. Therefore we have to administer NSAIDs to a case of small-intestine diverticulum.

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Brunner's gland hyperplasia, a benign disease occurring mainly in the duodenal bulb, also causes hemorrhage or gastrointestinal obstruction. We report a case of Brunner's gland hyperplasia followed with endoscopy over 5 years, resulting in surgery due to hemorrhage. A man in his 50's was referred to us after his medical checkup indicated a submucosal tumor-like protruding lesion with a diameter of approximately 15 mm in the duodenal bulb. Biopsy indicated the low possibility of a neoplastic lesion, and he was followed with esophagogastroduodenoscopy(EGD)annually. However, lesion size had increased year by year to 30 mm, and the patient was admitted to our department for further examination. Melena was observed from 2 to 3 days before admission; therefore, we performed EGD, which revealed the presence of erosion and hemorrhage on the lesion surface. We thought the lesion would tend to grow and that hemorrhage would likely recur, and we judged that the patient met the criteria for resection. Because endoscopic resection was difficult, we resected the lesion by partial duodenectomy. The histopathologic diagnosis was Brunner's gland hyperplasia. This case was valuable because morphological changes leading to hemorrhage in this case of Brunner's gland hyperplasia could be observed chronologically.

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A-70-year-old man complained of fever and upper abdominal pain. Computed tomography and ultrasonography of the abdomen revealed a solitary liver abscess in the anterior segment of liver. He was referred to our hospital. Abdominal MRI showed liver abscess and tumorous lesion of the stomach. Administration of antibiotics and percutaneous drainage of liver abscess was performed; then, the size of the abscess decreased. Cytology of the abscess revealed no malignant cells and Streptococcus milleri was cultured from the abscess. After the abscess diminished, we performed esophagogastroduodenoscopy and found a type 2 gastric carcinoma on the anterior wall of the angular part; therefore, distal gastrectomy was performed. Several investigators reported the association between liver abscess and colon cancer. It is thought that bacteria are transportally transferred to the liver from the mucosal injury caused by colon cancer. It might be possible that liver abscess occurs in patients with gastric cancer. In conclusion, to identify the cause of liver abscess, examinations of gastrointestinal tract should be performed.

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We have reported a rare case in which long-term oral administration of a magnesium oxide caused the development of multiple enteroliths inside the colon. The patient was a 70-year-old woman. She became confined to the bed after developing a cerebral infarction while being hospitalized for a compression fracture and a urinary infection. She had experienced abdominal distension 3 years after starting a treatment using a magnesium oxide for constipation. Abdominal computed tomography revealed the presence of multiple structured objects inside the colon. Lower gastrointestinal endoscopy showed the presence of multiple enteroliths. On the basis of analytical test results, the enteroliths were suspected to be composed of magnesium carbonate. The administration of the magnesium oxide was discontinued, and defecation control was performed;Computed tomography performed 2 weeks later showed that the enteroliths had disappeared. Most cases of true enterolith reported in Japan have been found to be associated with organic factors such as stenosis or diverticula of the colon. However, our patient showed no apparent organic factors. Instead, the stagnation was believed to have been caused by factors such as bowel distention and decreased intestinal movements due to bed confinement, and this might have contributed to the formation of the enteroliths.

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We report a case of spontaneously hemostatic ruptured hepatocellular carcinoma(HCC)resected laparoscopically. A 61-year-old previously healthy woman was admitted to our hospital with complaint of mild pain related to the tumor in the upper abdomen. She had no viral infection. Abdominal ultrasound, computed tomography, and MRI revealed a protrusive liver tumor arising from segment Ⅲ about 5.7cm in maximal diameter, which was increasing. Alfa-fetoprotein and protein induced by vitamin K absence or antagonist Ⅱ were extremely high and increasing rapidly. HCC was suspected and laparoscopic left lateral segmentectomy was performed. A little bloody ascites was present and ruptured HCC was suspected. The tumor was covered with a part of lesser omentum and pancreas, and the bleeding site had been sealed off. We could finish the laparoscopic operation safely because vital signs were stable. Postoperative course was uneventful. A few cases with ruptured HCC have been seen treated by laparoscopic hepatectomy alone in the literature. When the tumor bleeding is completely controlled and general conditions are stable, one-stage laparoscopic liver resection is one of the options.

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