General Lectures-(II

160 Proceedings of the 58th Annual Meeting, 1972--Tokyo--(H)

Tab. 3. Inc idence o f Au-Antigen in Liver Di sease

Examined Au-Antigen % Case No. Positive

Alcoholic Liver Injury 28 2 7.1 Fulminant Hepatitis 11 5 45.4 Subacute Hepatitis 8 2 25.0 Acute Viral Hepatitis 94 30 31.9 Persistent Hepatitis 18 4 22.2 Chronic Hepatitis 61 20 32.8

active Type {30 {1 i [46.7 Inactive Type 15 j 13.3 Biopsy not performed 16 [25.0

Hepatic Cirrhosis 36 11 30.6 Hepatoma 12 7 58.3 Other Hepatobiliary Dis. 150 6 4.0 Non Hepatic Disease 43 1 2.3

present in 28 cases (62.2%) and slight polymor- phonuclear cell infiltration was found in 34 cases (75.6%), except a few cases where moderate to severe infiltration were detected. Type of fibrosis was dominantly pericelluar, characterizing alcoholic liver injury. Cir- rhosis was present in 7 cases. Hemosiderosis, cholestasis and bile duct proliferation were seen in 28 cases (62.2%), 18 cases (40.0%) and 33 cases (73.3%), respectively.

Au-Ag was positive in only two cases (7.1%). In one case of heavy drinker with Au-Ag, marked mononuclear cell infilt-

ration and bile duct proliferation with periportal and central zonal necrosis were observed. In the other case with positive. Au-Ag, besides periportal zonal necrosis and inflammatory changes marked fatty metamorphosis was found. Periportal and/or central zonal necrosis detected in these two specimens from Au positive patients were never found in other cases. Therefore, in Au-Ag positive cases of heavy drinker with zonal necrosis, the hepatic changes are probably due to hepatitis virus and alcohol is considered as an aggravating factor.

- - G E N E R A L L E C T U R E S - - (II)

(113) COMPARATIVE ANALYSIS BETWEEN ENDOSCOPIC AND RADIOLOGIC FINDINGS OF

THE GASTRIC "HEMOR- RHAGIC EROSION"

Y. Karasawa, H. Onuma and H. Suzuki Karasawa Hospital, Asahikawa Hokkaido, Japan

T. Okazaki Okazaki Hospital, Nayoro, Hokkaido, Japan

A. Yasui and T. Murakami Department of Surgery, Juntendo

University School of Medicine, Tokyo ,Japan

We hav often presented endoscopic findings of the gastric "Hemorrhagic Erosion" (H.E.) Now, more than 120 cases of H.E. have been experienced endoscopically during the past 7 years. 93 cases of them, which revealed irregular-shaped, wide-spread blackened lesion were analysed comparatively between endoscopic and radiologic findings.

4 cases were illustrated. Case 1: 22-year-old female, complained of

severe epigastric pain. Case 2: 35-year-old man, complained of

severe epigastric pain. Case 3 : 44-year-old man, complained of

Proceedings of the 58th Annual Meeting, 1972-- Tokyo--( H) 161

severe epigastric pain and hemate- mesis.

Case 4: 30-year-old man, complained of severe epigastric pain.

Endoscopically, in each of illustrated cases

was observed an irreguler-shaped wide-spread blackened lesion, which spread from the an-

gulus over the pyloric antrum. These find-

ings substantiates the endoscopic diagnosis of

H.E. X-ray examination revealed as follows: (1) Barium-filled radiograph in upright posi-

tion showed that the pyloric antrum looked sylinder-like and got stiff in spite of injection

of Buscopan. (2) Double contrast radiograph in supine position showed lacking of ex-

tension of the pyloric an t rum in spite of fullness of the stomach with air, indistinct shade of gas-

tric folds where barium adheres to the mucosal surface in a irregular fashion.

These radiologic findings can suggest the

diagnosis of the gastric H.E. Moreover, their chief complaint and existence of tenderness in

the epigastrium are of great value for the clinical diagnosis of H.E.

6 patients with H.E. , .ere performed gastre-

ctomy, becouse of, frequent severe epigastric pain, ulceration after H.E., or their desire.

Case 4 is such a one. On laparotomy the pyloric antrum of the stomach showed sausage-

like mass by palpation. Macroscopically, a section on the greater curvature of the resected

stomach was edematous. Histology of the resected specimen showed a marked edema in

submucosal and subserosal layer.

In conclusion, sylinder-like and stiff condition of the antrum in spite of Buscopan in-

jection can be established as radiologic feature of the gastric H.E.

(114) A C L I N I C O P A T H O L O G I C A L S T U D Y O N S P E C I F I C TYPE OF

E R O S I V E G A S T R I T I S

K. Furuya

Dept. Surg. Isehara Kyohdoh Hospital Kanagawa Pref.

M. Ohtsuki

Ohtsuki Hospital, Tokyo

The lesion of erosive gastritis (E.G.) is re-

cognized in 43 of 238 resected specimens which were operated upon under the diagnosis of be-

nign peptic ulcer. The incidence of G.E. is 15/ 152 in gastric ulcer, 18/65 in duodenal ulcer

and 10/21 in combined gastroduodenal ulcers.

E.G. could be classified into protruded and depressed types. In this protruded type, three

cases are grossly uneasy to differentiate from the early gastric carcinoma.

All of them are revealed to have hyper- chlorhydria with the gastric juice analysis.

On the gastroendoscopic study, the small

sized protrusion with the central shallow erosion is observed in the prepyloric lesser cur-

vature, and it extremely simulated I I a + I I c

type of early gastric carcinoma. The gross pathology of the resected stomachs shows that

they have all duodenal ulcer and solitary doughnut shaped protrusions in the prepyloric

region. These protrusions are larger in size

than the usual verrucosa lesions which are multiple and observed at the E.G. frequently.

Fixed specimens show these protrusions to re- semble to the small sized t torrmann 2 type of gastric carcinoma.

Histological study reveals that the protrusion consists of hypertrophy of pyloric gland

with central erosion, where the fibrin is recognized. Neither intestinal metaplasis of the

superficial epithelium nor hypertrophic change

of the mucosal lymph follicle is found. Of course there are no evidence of malignancy in the pathological study.

To differentiate these two lesions, specific

type of erosive gastritis and gastric carcinoma, it is necessary to perform endoscopic biopsy.

(115) E R O S I O N T O U L C E R : A

C L I N I C O P A T H O L O G I C A L S T U D Y O N M U L T I P L E U L C E R S IN

G A S T R I C A N T R U M

K. Furuya Dept. Surg. Isehara Kyohdoh Hospital

Kanagawa P @ M. Ohtsuki

Ohtsuki Hospital, Tokyo.

While the usual chronic gastric ulcer is al-

162 Proceedings of-the 5gth.-Am~aL~M.eeting, 1972--Tokyo--(H)

most solitary and located around the gastric

angle, the multiple ulcers can be recognized occasionally in the region of pyloric gland

scatteringly in the antrum. We have ex-

perienced eight cases of these multiple ulcers, which are associated with multiple erosions

(UL-I) . Some clinicopathological study is performed on these cases, with reference to the

ulceration developing from shallow erosion.

The resected stomachs of these cases show to have duodenal ulcer. In the antrum small

ulcers, three to eight in number, are found predominantly along the lesser curvature.

Histologic evaluation reveals that these multiple ulcers are shallow, limiting to submuco-

sal layer (UL-2) and to proper muscular layer

(UL-3), and these erosions are deep enough to reach Tunica Muscularis Mucosae (m.m.),

which have occasionally inflammatory cellular infiltration and remarkable hemorrhage.

The destruction of m.m. is easily supposed to occur following these inflammatory and hemor-

rhagic changes and the ulceration seems to develope more deeply to UL-2 and -3. In

these cases the deep ulcer demolishing the whole layer of proper muscle (UL-4) is located

only around the angle along lesser curvature. These multiple ulcers have extremely lesser fibrosis and scar formation in their ulcer floor

comparing with that of usual solitary chronic ulcers.

The various ulcers, UL-1 to -3, can be found simultaneously in these stomachs, which are

seemed to suggest the deeper ulceration ori- ginated from the shallow erosion. But no

evidence, that the erosion alters into the usual solitary chronic ulcer with marked fibrosis and scar formation, can be found.

It is reasonable to conclude that these mul-

tiple ulcers are different from the usual solitary chronic gastric ulcer in their origin.

(116) S T U D Y ON G A S T R I C

S E C R E T I O N OF G A S T R I T I S W I T H V A R I O L I F O R M

E R O S I O N

H. Sata, T. Kondo, H. Takada,

K. Kawaguchi S. Sai, S. Takeda,

and M. Kitagawa

Medical Association For Early Gastric Cancer Detection

We have already reported as follows; on the standpoint of endoscopic and bioptic follow-

up studies of varioliform erosions of the stomach, mainly characterized by swollen, raised

margins with central depression, they can be

classified into two varieties: the transient type

(gastritis erosiva) and persistent type (gastritis verrucosa). Now, we studied the difference

of the gastric secretory function between those

two types by the standard histalog test (His- talog 1 mg/kg or 50 rag).

I) Compared with transient types and persistent types appeared in the same region of

the stomach, the former shows higher average than the latter in basal secretion (BSVR, 13AO)

and stimulated secretion (SVR, AO). II) Persistent types (gastritis ver rucosa)- -

@ Persistent types localized in pyloric region show higher average than those spreading to

fundic region in both basal secretion and sti-

mulated one. @ Persistent types with central depression show higher level than those

without central depression in basal secretion and stimulated one.

Then we can say as follows; persistent types with central depression is in active stage and those with none is in inactive stage.

I I I ) Transient types (gastritis e ros iva)- -

In the same cases, stimulated secretion at the appearing phase of gastritis erosiva in nearly the same as at the disappearing phase. On

the other hand, basal secretion (BSVR, BAO) at the appearing phase shows remarkably high

level but at the disappearing phase extremely lOW.

So we can guess that transient types are acute phase of gastritis with varioliform erosions from the gastric secretory study. This

fact was confirmed by histological study of gastric mucosa obtained under direct visual biopsy.

Proceedings of the 58th Annual Meeting, 1972 Tokyo--(H) 163

(117) C L I N I C A L S T U D Y ON T H E

G A S T R I C A N I S A K I A S I S W I T H

A C U T E G A S T R I C S Y M P T O M S

T. Morooka, T. Shiraishi, M. Namiki,

H. Kawauchi, and K. Nakagawa

The Third Department of Medicine, Hokkaido University School of

Medicine, Sapporo

Examination by means of the gastrofiber-

scope of the patients, who came to the clinic

due to the so-called food poisoning symptoms such as gastric pain, nausea and vomiting 4

to 6 hours after ingestion of foods with larvae of anisakis, have often revealed the infiltration

of the living larvae i--to the gastric wall. Fur-

ther, we have been able to find the linear figure

of the larva by the X-ray double contrast picture. We have experienced 46 cases as such. The present report described their

clinical findings and discussed the mechanisms

responsible for them.

(118) ON T H E 2 CASES OF T H E I N T E R E S T I N G A.T.P. (ATYPI-

CAL E P I T H E L I U M ) L E S I O N

O F T H E S T O M A C H

H. Kuramata et al.

KANAGA WA SEIJIN-B I10 Center, Department of Radiology

It is very interesting to know the relationship between A.T.P. and carcinoma. Hereby

we present very interesting cases on this point. C a s e 1 : A .T.P . a c c o m p a n y i n g w i t h

g a s t r i t i s v e r r u c o s a . 44y. Female. This case means as follows:

1) There were many elevations (gastritis verrucosa) scattered on the antrum and the pre-pyloric portion. A clinical diagnosis was

gastritis verrucosa by X-ray and endoscopic

examination. 2) Histological findings revealed the same, namely the elevated lesion to be consisted of the proliferation of the pyloric glands and on

their tops or the surroundings no intestinal metaplasia was to be seen. 3) On the surface of this gastritis verrucosa,

an erosion and repair and reconstruction of

the tissue occured repeatedly, and then got

high grade atypism gradually. 4) It is the most interesting point to imagine what a finding like this case will get to develop

the ability to the carcinoma without intestinal

metaplasia.

C a s e 2: A.T.P. s h o w e d IIc t y p e e a r l y g a s t r i c c a n c e r f i g u r e o n the r e s e c t e d s t o m a c h : 52y. Male.

This case showed a lesion on the pre-pyloric

portion as convergent folds and eroded tips on each club-head swollen of them by X-ray ex-

amination (suspicion of I Ic type early gastric cancer). The endoscopic examination could

not reveal it on account of the interruption of

the swollen folds. On the resected stomach, a lesion was revealed with eroded tip ot" the

swollen gathered folds, and it is able to trace

the complete circumference of the edge of the depressed lesion. So it is able to say IIc

type early gastric cancer, from their view point of the macroscopic findings strictly. But the

histological finding was A.T.P. Group I I I - IV consisted of UI - I I ulcer. Recently as we

have experienced of case report several cases like this, so it is a reason what to present this

c a s e .

(119) AN A N A L Y T I C S T U D Y O N

T H E S Y M P T O M S A N D C R I T E R I A OF E A R L Y D U M P I N G

S Y N D R O M E .

Y. Yamaguchi

2rid Department of Surgery, Jikei University School of Medicine

The criteria for early dumping syndrome are widely variable depending on the institute.

Twenty different symptoms were noted to be used in the early dumping syndrome criteria adopted at 9 surgical departments of medical

school which have submitted the data for this analysis. Now, all these 20 symptoms were

used again by each of these 9 departments on their patients (238 in total) and statistically following symptoms were found to be manifes-

tive of early dumping syndrome, namely; as


general symptoms cold sweat, palpitation, sle- epiness, feeling of oppression in the chest; as

abdominal symptoms abdominal pain, diarrhea, and nausea. It was furthermore noted

that some cases of innegligible percent had only one but very representative general symptom,

therefore "one or more" general symptom(s) should be in the criteria for early dumping

syndrome.

(120) O B S E R V A T I O N A T POST- O P E R A T I V E P A T I E N T S OF

G A S T R I C C A N C E R

T. Kabakino, T. Inokuchi, J . Wakisaka Y. Yamauchi , T. Debuchi W. Ogo

C. Yamasaki, M. Sigemori K. Hashimoto, and T. Shirozu

1st Department of Surgery, Kurume University School of Medicine

In the operative gastric cancer, 152 patients of gastrectomy or total gastrectomy was follow

up from postoperated 3 months 3 years. Reflux oesophagitis was recognized 33.3%

of ~ type anastomosis and 2.3% of Rouz Y type anastomosis.

12.9% of resected gastric cancer had diarrhea. They were due to malabsorption of fat

and Vagotomy, but they amount to 30~o in- elusive of the diarrhea after taking milk.

Loss of postoperative weight were recognized 54.3% of resected gastric cancer.

Anemia of patient of gastrectomy was re-

cognized 20.5%. The increase of serum LDH activity at pa-

tient of the gastric cancer was not too eminent. The increase L D H Isoenzyme was not signifi-

cant at the patients of gastric cancer. It was difficult that we aspect recurrence of

the liver by biochemistory of L D H activity

and AL-P. Aldolase. Isoenzyme is desirable rather than Activity

Transition of postoperative globulin had relations with recurrence of the gastric cancer and

Stage classification. Transit ion o f postoperative globulin had

influence liver d i sease . In half number from three to five survivor

globulin was increased.

(121) P O S T O P E R A T I V E L O N G -

T E R M C A N C E R C H E M O - T H E R A P Y (PLCC) F O R

G A S T R I C C A N C E R

N. Kaibara, K. Inokuchi, K. Soejima,

T. Hiyama, and M. Wakita

2nd Department of Surgery, Faculty of Medicine, Kyushu University

It is well accepted that administering a

chemotherapeutic agent in conjunction with

radical surgery is an effective measure to decrease the recurrence rate and enhance survival

of patients with cancer of the stomach. In

our clinic, the intra-operative upper half body infusion of Mitomycin-C (MMC) has been

attempted, which was performed by clamp-

ing the subrenal aorta for about 20 minutes after intravenous administration of the drug

from an anteeubital vein. In euratively operated patients with stage carcinoma, 41.6%

of the patients subjected to the clamping technique had 5-year survival rate, compared to

31.3% of the unclamped control. Of par-

ticular interest is the fact that 2 to 3-year survivals of the clamped group were as much as two times higher than those of the control.

This may be indicative of insufficiency of a

single intra-operative usage of the drug, and consequent increase of late death. To achieve

more increased survival rate, we proposed the necessity of postoperative long-term cancer

chemotherapy (PLCC), in which the patients subjected to the intra-operative adjuvant

chemotherapy should receive 10 mg of M M C intravenously every three months for two years

in the out-patient clinic. PLCC will serve for not only a goal to enhance survival but a purpose to detect and treat the recurrences

as early as possible.

Proceedings of the 58th Annual 2kieeting, 1972--Tokyo--(H) 165

(122) STUDIES ON THE ADMINI- STRATION OF POSTOPERATIVE

A L I M E N T A T I O N IN PATIENTS

W I T H DIGESTIVE DISEASE- CHANGES OF AMINO ACID

PATTERNS, LDH, HBD IN

SERUM AND PYRUVATE

IN BLOOD-

T. Ikemoto, H. Hayasaka, S. Fukui,

T. Takeda, N. Aoyama, Y. Takada, Y. Saheki, Y. Yoshida, K. Minagawa,

T. Okuyama, S. Yamamitsu and

Y. Konishi

1st. D~artment of Surgery, Sapporo Medical College.

We studied the pre and postoperative changes of serum LDH, HBD and pyruvate in

blood in relation to the metabolism of amino acids in patients with gastric cancer.

The results indicate that the changes of S-

LDH, S-HBD and pyruvate after operation are similar to that of amino acids. Therefore,

we can approximately infer the changes of

amino acid patterns from the level of S-LDH, S-HBD and pyruvate.

(123) EXPERIMENTAL PEPTIC

ULCER AND CHANGES OF M I C R O C I R C U L A T I O N

N. Ishimatsu, S. Murai, A. Nukaga,

S. Toyama, Y. Watanabe,

N. Mizushima, and M. Abe

The 4th Department of Internal Medicine (Professor Masakazu Abe,

M.D.) Tokyo Jikeikai University of Medicine

Reserpine ulcer, steroid ulcer, gastrine ulcer, Curling's ulcer were produced in rats and the

following experiments were done. Their stomachs were opened under anesthesia.

Evans blue was injected into the artery. Dur- ing the whole time from the beginning of ap-

pearance of Evans blue into the gastric mucosal surface to its disappearance from the surface observations were made by use of stereomi-

croscope.

Barium was injected into the mucosal ves-

sels through an artery under the same observation, then it was fixed and sliced the thickness

being 200 /1 in order to do super soft X-ray

examination. Acrylic ester was injected from both venous and arterial sides to make micro-

vessel plastics. It was cut at the area of

ulcers to compare the changes in each ulcer.

Results show that, even though they have different degrees of changes, impaired blood

flow from the arterioles to the capillaries, stasis

of the venules, and the arterio-venous shunts in the submucosa play a part in the development of ulcers.

(124) VASCULAR ARCHITEC-

T U R E AND PATHOGENESIS

OF GASTRIC ATROPHY AND GASTRITIS: A MICROAN-

GIOGRAPHIC STUDY

K. Maruyama, K. Yoshino, T.

Suzuki, .K Akisato, M. Kitajima, T. Tabata, M. Hashimoto,

T. Tanaka, Y. Nakagawa, and Y. Ishii

Dept. Surg. Keio Univ.

Pathogenesis of gastric atrophy as well as gastritis are evaluated with our reformed

microangiographic approach, in which the radio -paque medium, solution of barium sul-

fate crystal and/or colloidal solution of silver iodine, is injected into the blood vessels of the

human stomachs resected in surgical operation. In superficial gastritis, it is only recognized

the marked dilatation of mucosal vessel, which

seems to be due to the inflammatory congestion, without remarkable change of the vascular

architecture. Atrophic gastritis could be classified into two groups, glandular atrophy

without the hyperplastic change of foveolar epithelium and the atrophy with hyperplastic change of that (hyperplastic atrophic gastritis).

In the former, the mucosal vessels are shortened and they have abnormal branching like

shrubs and collateral ways. In additin, the vascular network along the muscularis mucosae

shows some disorder. These changes are

166 Proceedings of the 58th Annual Meeting, 1972--Tokyo--(H )

seemed to be due to the diminution of gastric gland and fibrosis of mucosa and submucosa.

In the latter hyperplastic atrophic gastritis,

area gastricae protrudes remarkably owing to the hyperplastic change of foveolar epithe-

lium, from the center of which the vessel rises

up like a fountain. But the vessel is scant at the depressed portion between these protruded areae.

In hypertrophic gastritis, the vascular pat-

tern resembles to that of atrophic hyperplastic gastritis and markedly elongated mucosal

vessel can be recognized in the protruded area.

This vessel, however, seems to rise up not in the shape of a fountain but in parallel in each

other, which is the diffi'ent point from the atrophic hyperplastic gastritis.

Pathogenesis of gastric atrophy have been

debated since long ago and seems to be very difficult subject to clarify, and it remains yet

unknown now. In our microangiographic study, the factor of blood supply seems to play

the great role on this with the change of mucosal lymph follicle. It is observed that

the mucosal vessel around the enlarged lymph follicle is oppressed aside, the surface mucosa

on the top of the follicle shows the circulatory disturbance and it gives way into surface

erosion. I t could be speculated reasonably that these disorder induce the destruction of

gastric gland, which are followed with various kinds of repairing mechanisms, and that various

types of atrophic change of gastric mucosa break out. Although it is very difficult to determine whether the lymph follicle appears

primarily as the result of immunological re- action and other factors like that, or it develops

secondarily due to the surface erosion, we would like to conclude it to be primary change, for the surface erosion, which is not associated with the lymph follicle beneath it, is able to

be found easily and almost all the surface mucosa situated on the top of enlarged follicle seems to have erosive change in various degree.

(125) S T U D I E S O N fi-GLU- C U R O N I D A S E IN G A S T R I C

J U I C E

M. Inoue

Fukuoka University and Kashii Hospital, Fukuoka

1) fi-glucuronidase activity in gastric juice was estimated using p-nitrophenyl glucuro-

nide as substrate. Because of no definite op-

timal pH, on each samples, reactions were performed at the pH of 4.71 5.0, 5.2 and 5.4, and

the highest value was adopted as the activity.

Enzyme assay was made on basal gastric juice as a rule, however, When the pH was below 6.0,

50 ml. of 1% bicarbonate solution was injected intra-gastrically and aspirated 5-10 minutes

later. The latter procedure was repeated on three occasions, and samples with a p H above

6.5 were chosen for analysis. Protein contents

were measured by the method of Lowry, and enzyme activity was expressed as unit per mg of protein per hour.

2) The patients studied include 17 with gastric cancer, 33 with gastric ulcer, 12 with

duodenal ulcer, 25 with dyspepsia and chronic gastritis, and 8 with miscellaneous diseases (polyps, chronic pancreatitis etc.).

3) 16 out of 17 patients with gastric cancer showed the /~- glucuronidase activities above

6.5 units per mg of protein in their gastric juice, on the other hand, 20% of the patients

with peptic ulcer, and 30% of the patients with dyspepsia, chronic gastritis and miscel-

laneous diseases had elevated fl-glucuronidase activities (above 6.5). In total, 24% of 78

non-malignant patients showed false high levels of enzyme activity.

4) pH activity curves offi-glucuronidase in gastric juice could be classified into three types (one with the optimal pH at 4.7, one at 5.0-

5.2, and one at 5.4), however, specific p H activity curve for malignancy was not found.

5) In the patients with benign diseases, relationship between the enzyme activity and

acid output after pentagastrin was observed. In 47 patients wth peak acid output above

5.1 mEq per 30 minutes, 10% had elevated/9- glucuronidase activities, on the other hand,


in 30 patients with PAO below 5.0, even 50% showed high levels of enzyme activities. Per- haps, the presence of atrophic gastritis might

play considerable role in the elevation of fl-

glucuronidase activity in gastric juice. 6) Isozymes of ~-glucuronidase in gastric

juice were studied by means of DEAE cellulose

column chromatography, and eluted at the beginning with 0.005 M acetate buffer pH

5.0. Afterwards elution buffer was continu-

ously mixed with 0.005 M tris phosphate buffer containing 0.13 M sodium chloride. As

the results, a high peak firstly, and secondary a small peak of ~-glucuronidase activities were

identified. It was concluded that at least two

isozymes of b~-glucuronidase are included in

human gastric juice.

(126) ON T H E ANALYSIS OF

L A C T A T E D E H Y D R O G E N A S E BY E L E C T R O F O C U S I N G - -

C O R R E L A T I O N B E T W E E N S E R U M A N D T I S S U E S L D H

PI I S O Z Y M E S - - - -

S. Katayama, Y. Nakano, and M. Fukuda

Department of Medicine, Cancer Research Institute, Sapporo

Medical College (Directed by Pr@ Ichiro Urushizaki)

The method of electrofocusing (E.F.) has already found numerous applications in the

detailed analyses of various enzymes as well as

of other proteins. In a previous report we described pI isozyme patterns of lactate dehy-

drogenase, which was found to be separated

into more than ten discrete fractions and its diagnostic applicability in malignant diseases

of the digestive system. Present report de- scribes comparative studies on L D H pI iso-

enzyme of serum and tissues obtained from res- pective cases.

Resu l t s Due to the fact that tissue L D H pI isozymes

spread widely after the electrolysis, the effect of pH on the enzyme activities was examined.

L D H activities were significantly inactivated

only in the pH region below 4.3. To confirm the validity of the fractionation, the purified

L D H 1 and L D H 5 from beef cardiac and skeletal muscle were analyzed by E.F. L D H

1 was separated into three fractions and L D H

5 into two fractions. Either of the purified enzyme showed single band at LDH 1 or L D H

5 position before and after the E.F. In the animal experiment with Yoshida sarcoma

inoculated rats, serial pI isozyme determina-

tions were carried out by the use of gel electrofocusing. A peculiar L D H subfraction, which

showed acidic pI with L D H 5 mobility, em- erged after the 7th day of inoculation. This

fraction was also found in the zymogram of

tumor cell extract. The marked increase in the total L D H activity observed in tumor bearing

rats, therefore, is postulated as the result of

appearance of tissue enzyme derived from tumor itself. Similar tendencies were noted

in the clinical cases examined and represent-

ative cases were presented. It is expected that

the use of E.F. in L D H analysis might give a more clear understanding of zymogram

changes in malignancy.

(127) T H E Q U A N T I T A T I V E ANALYSIS O F N U C L E A R

DNA C O N T E N T S OF

G A S T R I C C A N C E R CELLS

M. Takaki et al.

Nagasaki University School of Medicine, Under the direction of Dr.

Professor Shiro Osajima (M.D.)

The nuclear DNA contents of gastric can-

cer cells gained by biopsy under direct vision have been estimated using the microspec-

trophotometry method for these five years. It was revealed that the histogram of nuclear

DNA contents on gastric cancer showed broad

and multiple peaks. In the present study, the nuclear DNA con-

tents of gastric cancer cells were determined

in 95 cases, which were later confirmed his-

168 Proceedings of the 58th Annual Meeting, 19 7 2-- Tokyo--( II )

tologically by materials taken at surgical

operations.

Considering the stages, the dep th of involve-

ment , the metastasis to regional lymph nodes,

and celullar or s t ructural atypism, compar ison

of nuclear D N A contents was made a m o n g those

groups divided on histological types such as

Adenocarc inoma tubulare , Adenocarc inoma

papillare, Adenocare inoma mucocellulare and

etc.

The conclusion is this.

In the groups of Adenocarc inoma tubu la re

and Adenoca rc inoma papillare, appea rance

of polyploidy is more common in the later

stages t han in the earlier, and also more fre-

quent ly seen in the cases with metastasis t h a n

wi thout metastasis and higher grade a typism

than lowers.

(128) S T U D I E S O N T H E DIS-

T R I B U T I O N O F DNA C O N T E N T

O F M U C O S A CELLS IN

E A R L Y G A S T R I C

C A N C E R

H. Hyodo, J . Kobayashi , Dr. Sci.,

H. Nishikawa, K. Morimoto,

T. Takagi , and S. Sako,

Department of Medical Radiology, Tokushima University

School of Medicine

Since the in t roduct ion of D N A dis t r ibut ion

in the mucosa of early gastric cancer in 1967,

the study of D N A has been made mostly in

the su r rounding legion of cancer. This s tudy

has examined the relations between the l imit

of pa t t e rn of D N A in adjoining cancerous

legion and the b o u n d of discolor as 24 cases of

early gastric cancer, fur ther as the possibility

of biopsy.

The dis t r ibut ion of DNA content per cell

in mucosa cells of early gastric cancers was as

similar as tha t in the cancers. Polyploid and

aneuploid cells were observed in all cases in

the surroundings of the cancers. These

regions were abou t from 0 to 4 cm. (1 case

from 0 to 2 cm, 1 case to 3 cm, 14 cases to

4 cm, 9 cass to 6 cm.) The region of discolor

was observed from border land of cancerous

legion to 4 cm in almost cases.

The frequency distributions of DNA conten t

per nucleus in early gastric cancers and

some gastric disease sampled by biopsy were

studied by means ofmicrospect rophotometr ica l

method. In the early and advanced gastric

cancers, all cases showed wider d is t r ibut ion

of DNA content per nucleus than in control

distribution. The pat terns of DNA in biopsies

was similar to the general histological sampled

of the sections. I t is possible to s tudy of

DNA in the gastric mucosal cells by endsco-

pie biopsy.

(129) T H E S E R U M P R O T E I N S

IN P A T I E N T S W I T H C A R C I -

N O M A O F T H E S T O M A C H

H. Tomoda , K. Soejima,

M. Furusawa, and K. Inokuchi

2nd Department of Surgery, Faculty of Medicine, Kyushu University, Fukuoka, Japan

It is well known tha t many diseases produce

a marked a l te ra t ion in the level of the serum

protei n . The first report concerns the results

obta ined f rom the electrophoretic evaluat ion

of the serum protein-levels of 397 pat ients wi th

carc inoma of the stomach.

As the stage of carc inoma of the s tomach

progresses, the a lbumin-level is reduced, the

level of the a-globul ins , especially c~2-globulin,

is raised and there is no significant difference

between the f l -and ~'-globulin levels and the

stage of carc inoma of the stomach.

The next report concerns the results ob ta ined

from the measu remen t of subfractions of a -

globulins, a2-Ant i t ryps in , c~-Acidglycoprotein

and Haptoglobin , in 38 patients wi th carci-

noma of the s tomach and immunoglobul ins ,

IgA, IgG and IgM, in 34 patients wi th carci-

noma of the s tomach by single radial i m m u n o -

diffusion method.

As the stage progresses, the level of subfrac-

tions of c~-globulins is raised and there is a

Proceedings of the 58th Annual Meeting, 1972--Tokyo--( H) 169

rise in IgG-level of immunoglobulins. We think that these alterations of serum pro-

teins in patients with carcinoma of the stomach

are clinically interesting, because these changes are associated with the degree of development

of carcinoma of the stomach.

(130) T H E S T U D I E S ON T H E V A R I O U S K I N D S OF F L U O -

R E S C E N T M A T E R I A L S F O R

C A N C E R D E T E C T I O N

R. Sassa, T. Unuma, and T. Iwase

Department of Gastroenterology, The Institute for Adult Disease,

Asahi Life Foundation.

T. Yoshioka and M. Kusakabe

Toshiba Research and Development Center

M. Iio

The 2nd. Dept. of Internal Medicine, Faculty of Medicine, Univ. of Tokyo.

Since 1953 fluorescent materials are applied

for the purpose of diagnosis of malignancy. However still many problems are remained to

be solved before this method is used conven-

tionally. Major problems are divided in two. The one

is the nature of lights to be used for stimulating

fluor~escent materials. And the other is the

method to detect fluorescent light. In the past ultraviolet light and eye or camera detec-

tion were used. In the present study authors have introduced the use of visible light and spectrometry for this purpose. Results ob-

tained were summarized as follows. 1) F l u o r e s c e n t s p e c t r u m : Many fluo-

rescent materials using for cancer detection showed the stronger fluorescence when stimu-

lated by visible light than by U.V. light, except Acridine Yellow. Spectrum of Fluores-

cence of Acriding Orange (AO), F1uorescin (FR), Tetracycline (TC), Vinblastin and

Actinomycin D were successfully observed by fluorescent spectrometer.

2) B lood l eve l o f f l u o r e s c e n t m a t e r i a l : When TC and A O were given to rabbit intra-

venously, the blood level decreased rapidly in the case of TC, but slowly in AO.

3) Shi f t o f s p e c t r u m to blue: When FR was administrated to the dog intravenously,

the fluorescent spectrum of F R in plasma show-

ed the shift to red in a first stage and then shifted towards blue. Finally, it showed shift

to blue. 4) O r g a n d i s t r i b u t i o n o f f l u o r e s c e n t

m a t e r i a l : Organ distribution was studied

for rabbit with the elapse of time. A O was uptaken rapidly, but T C was trapped slowly in-

to the esophagus and stomach. 5) Aff in i ty to t h e cancer : TC or FR

was administered to the patients with gastric cancer before surgery. Then the resected

specimen was i l luminated by U.V. light according to the published procedure, but no

fluorescence was observed. AO was admi-

nistrated to the patients, also. Biopsy specimen of gastric mucosa was emulsified and its

fluorescent spectrum was measured. It revealed the presence of slight peak at 510 m/~

in cancer tissue, but none in the normal gastric mucosa.

(131) A C I D S E C R E T I O N IN

G A S T R I C C A N C E R : GROSS TYPE A N D G A S T R I C

A C I D I T Y

S. Kobayashi, M. Kizu, and

T. Kasugai

Department of Internal Medicine, Aichi Cancer Center Hospital,

Nagoya, Japan

In order to search for the pathogenesis of developing ulceration on the surface of cancerous tissue, a relationship between the gross

type, and gastric acidity and associated gastritis were investigated. Gastric analysis was performed by giving a patient either one of Histalog, 1.0mg/kg IM, Tetragast:in, 4/t/

kg IM or Pentagastrin 6/t/kg IM. Associated

gastritis was interpreted on the basis of gas- troscopic findings of the body mucosa. Free

170 Proceedings of the 58th Annual Meeting, 1972--Tokyo--(II)

hydrochloric acid was present in two of six cases of protruded gastric cancer and mucosal atrophy was seen in all cases. Of 17 benign gastric polyps, 9 did not have hydroch!oric acid, 10 having atrophic mucosa.

All three patients with atypical epithelium (ATP) demonstrated achlorhydria and atrophic mucosa. Regardless of the nature of a lesion, achlorhydria with associated atrophic gastritis predominated in protruded lesion of the stomach.

Conversely, the presence of free hydrochloric acid without associated atrophic gastritis was most common in the group of depressed type of gastric cancer after stimulation. Only case with achlorhydria was noted in 41 with either IIc or IIc § like lesion, which tendency was totally similar to that in benign peptic ulcer diseases.

The fact suggested that ulcerative changes on the mucosal surface of gastric cancer, more frequently in early gastric cancer, were due probably to petpic digestion of gastric juice and could show apparent healing with treatment of antacids and anticholinergics. Prior to stimulation, achlorhydria was demonstrated in 70% of all cases while in 17% after stimulation.

It is concluded that ulcerative changes in malignant lesion would be most likely produced by peptic activity of gastric secretion as in benign peptic ulcer diseases.

(132) CLINICAL STUDIES ON THE PROTEIN IN THE

GASTRIC JUICE

K. Yoshida, T. Kembo, T. Yoshida, Y. Suga, T. Suguro, Y. Kono,

and S. Mitsui

3rd Department of Medicine, Iwate Medical University,

School of Medicine, Morioka

A relation between the change of the gastric mucosa and the protein content in gastric juice was studied. The subjects were 19 patients with peptic ulcer and 27 controls. The gastric juice from both groups were collected

before and after the histamine injection. The protein content in gastric juice were measured by Biuret method and identified with the method of agar immunoelectrophoresis and electrophoresis with cellulose acetate strips. Albumin, IgA and IgG were measured by electroimmunodiffusion. The following results were obtained :

1) The protein content in gastric juice decreased after the histamine injection in both groups.

2) Electrophoretic pattern of the protein by cellulose acetate electrophoresis showed 1 to 5 bands in both groups.

3) Using the method of immunoelectrophoresis, albumin, IgA and IgG were found in the gastric juice of both patients with peptic ulcer and controls.

4) By electroimmunodiffusion IgA and IgG were detectabl even in unconcentrated gastric juice. IgA was detected in the gastric juice in 4 of 13 patients with peptic ulcer and in 5 of 12 controls. IgG was detected in the gastric juice in 7 of 13 patients with peptic ulcer and in 3 of 12 controls. Mean value of IgG/IgA ratio of the gastric juice was 1.2 in 5 cases including 3 patients with peptic ulcer and 2 controls. On the contrary that of the serum was 5.9 in 15 controls.

(133) EFFECT OF DAMAGING VENTROMEDIAL HYPO-

THALAMUS (SATIETY CENTER) ON FASTING GASTRIC

SECRETION

Y. Nagamachi and T. Nakamura

1st Department of Surgery, Gunma University School of Medicine,

Jl,Iaebashi, Japan

Goldthioglucose is capable of damaging the ventromedial hypothalamus (satiety center) and inducing obesity in dogs. Body weight was increased, significantly, in the goldthioglucose-treated dogs during an 8-week period. Daily food intake was also increased, signifi-

Proceedings of the 58th Annum NIeeting, 1972--To.~y)--(H) 171

candy, as high as 20% or more, in C8% of the goldthioglucose-treated dogs.

The sensitivity of the fundic gland in satiety- center damaged dogs is somewhat promoted by vagal impulses during the fasting period.

Fasting gastric secretion, in the satiety-center damaged and vagally innervated dog, was increased momentari ly and it is difficult to maintain, accurately, such a sensitivity in the denervated dogs.

In the fasting period, using the insulin or the decrease in A-glucose levels (arteriovenous glucose difference) as a warning signal, the hypothalamus may send signals automatically to the stomach via a vagal route before feeding, thus, the gastric gland may be stimulated or prepared for future digestion in step with feeding. In contrast to acid secretion, pepsin secretion is independent of the vagus and presumably controlled through humoral or other mechanisms.

(134) T R I T I A T E D T H Y M I D I N E A U T O R A D I O G R A P H I C STUDIES

ON T H E A S T R I C M U C O S A L LESIONS BY U S I N G "PHYS- ICAL P R E S S U R E M E T H O D "

H. Suto, T. Higuchi, J. Kobayashi,

M. Onai, K. Isizuka, A. Takei, M. Simoda, T. Sekiguchi and

K. Shichijo

First Department of Internal Medicine, School of Medicine, Gunma

University

Chronic gastritis, gastric a typical epithe- l ium and gastric cancer were comparatively examined by autoradiography using 3H-thymidine.

Method: Gastric mucosal samples surgically obtained from 20 cases of chronic gastritis, 2 cases of gastric atypical epithelium and 1 case of gastric cancer were examined. "phy- sical pressure method" (in vitro), which wa devised by us, was used in labeling with 8H-s thymidine.

R e s u l t s : 1. C h r o n i c g a s t r i t i s . In superficial gastritis, labeled cells were found

in the foveolae and neck region of the gastric glands. The labeling index was 2.4% on the average. In hyperplastic atrophic gastritis, labeled cells were found in deeper parts of foveolae and neck region of the gastric glands with the average labeling index of 4.2%. In atrophic gastritis, labeled cells were irregularly distributed with the average labeling index of 4.9o/0 . In intestinalized gastric mucosa, the deeper layers were labeled, with the index of 2.9% .

II. A typ ica l e p i t h e l i u m . Labeled cells were compactly found toward the surface, and scarcely seen in deeper layers. The labeling indexes of 2.6 and 3.0% were obtained.

III . G a s t r i c c a n c e r . Labeled cells occurred quite irregularly, with the index of 18.6%.

D i s c u s s i o n : In atypical epithelium, different from cancer, proliferative cells were found in a definite region. The labeling index in these cases were approximately equal to that in chronic gastritis. The labeling index was considerably higher in gastric cancer than atypical epithelium and chronic gastritis.

(135) THE C L I N I C A L STUDY OF U P P E R G A S T R O I N T E S -

T I N A L BLEEDING

Y. Akashi, K. Mori, K. Ogasawara, R. Tanaka, K. Yoshikawa, and

T. Takahashi

Department of Internal Medicine, Kyoto City Hospital

A study was made of 255 cases, hospitalized with upper gastrointestinal bleeding for the past six years at Kyoto City Hosiptal. The frequency of bleeding causes was following; gastric ulcer 35.3%, duodenal ulcer 17.7, stomach cancer 14.9, esophageal varices 8,6, erosive gastritis 4.3, miscellaneous 9, undetermined 10.2

The early gastroscopy was effective in order to determine the bleeding sources and establish diagnosis without major accidents. The incidence of severe group (requiring emergency operation) in patients with gastric ulcer was

172 Proceedings of the 58th Ammal Meeting, 19 7 2-- Tokyo--( H )

higher than that in patients with duodenal ulcer. Respectively the mortality rate of gas-

tric ulcer and duodenal ulcer was 2 ~o. Only those patients with severe complication died

(Pneumonia, subacute hepatitis, chronic mye- loid leukemia). Among all the patients with

gastric ulcer, the ratio of bleeding ulcer is increasing from the age group above fifty and

massive bleeding occurs more frequently in

patients above the age of sixty. Histological studies were made on gastrectomized material

during emergency operations. In one third of them there was acute gastric ulcer, which

occured mainly .in the corpus of the stomach, multiple in number for half of them, round

or linear in shape. In 70% of all the collected

material in emergency cases, there were arteries

opening directly in the base of ulcer. The bleeding was more severe from acute gastric ulcer than from chronic gastric ulcer and early

prophylactic operation for acute gastric ulcer is suggested. In some of the undetermined

cases, bleeding from acute gastritis is supposed to develop.

(136) S C A N N I N G E L E C T R O N M I C R O S C O P I C S T U D Y O N

T H E H U M A N G A S T R I C

M U C O S A

T. Ogata, S. Tanaka, T. Seito, H. Matsuda, T. Imajo, K. Moriyasu

and Y. Takata

Dept. of Surgery, Okayama University Medical School, Okayama

Samples of normal and pathological human

gastric mucosa were fixed in 2.5~ glutaralde- hyde, dehydrated in acetone, dried in air, coated with gold and examined under a scanning electron microscope. The surface struc-

ture of the gastric mucosa was well preserved in this process.

In the pyloric glandular area, the gastric glands had a columnar structure with a deep hole in the center, namely, a "gastric pi t" .

The deep hollows among the columnar strut-

tures were tentatively named "Cleavage or

cleft" in this study. The surface mucous cells were arranged

rather like a bunch of grapes and the microvilli

appeared as tiny processes. Near the top of the

gastric glands, small pores appeared at the

apical surface of the mucous cells. In some cells these holes had fused into one large hole

per cell and mucous granules were secreted

through these holes. In the normal gastric glands, the size and

arrangement of gastric g!ands and gastric pits were usually regular, but in chronic gastritis

they were irregular. And in gastric cancer,

they lose their surface structure of gastric glands, and irregular proeeces or holes had

appeared on the surface.

(137) H I S T O L O G I C A L INVES-

T I G A T I O N O F T H E D I G E S T I V E

M U C O S A BY USE OF I M M U N O F L U O R E S C E N T

T E C H N I Q U E

H. Kamei, H. Murai, T. Takemitsu,

T. Kanemitsu, M. Ishii, M. Imaizumi, and T. Kondo

The 2nd Dept. of Surgery. Nagoya Univ. School of Med.

A histological investigations were made on the digestive organs associated with various

patho!ogical changes by the use of immuno- fluorescent staining with the rabbit antisera against the preparations of the gastric cancer

cells and the mucosa of the stomach and the small intestine, respectively.

Free gastric cancer cells for immunizing

r~bbits were obtained by passing through the mesh with small gage after cutting with scis- sors the cell rich gastric cancer tissue which

were obtained at surgery. The other two preparations were obtained as the supernatants in phosphate buffered solutions after the freeze

thawing of the normal mucous membrane of the stomach and the small intestines, respectively.

When the three kinds of rabbit antisera were

Proceedings of the 58th Annual Meeting, 197 2-- Tokyo--( H) 173

tested by the Ouchterlony and immunoelec-

trophoretic techniques against human whole sera, gastric juice and the antigens used for the immunization, the presence of several preci-

pitin lines which were mostly common in three

antisera against individual tested materials,

and some specific lines which were found between the anti-gastric cancer cells and the

said preparation from gastric cancer tissue

were found. By fluorescent technique, three antisera

stained positively the certain components of the extracellular secrets and the epithelial

cells of the digestive organs. They positively stained the rat digestive epithelial cells, but

extra cellular secrets in slight degree. Partly

different components were apparently stained by these antisera.

I t was greatly impressed that the specific staining pattern was found in the tissue of

the digestive mucosa associated with various

diseases.

(138) E F F E C T S OF E X P E R I -

M E N T A L A D M I N I S T R A T I O N OF P A R I E T A L C E L L ANTI -

BODY A N D I N T R I N S I C F A C T O R A N T I B O D Y ON

R A T G A S T R I C M U C O S A

M. Inada

Department of Geriatrics, Faculty of Medicine, Kyoto University

G. B.J. Glass

Section of Gastroenterology, New York Medical College

Many papers have reported the presence of circulating parietal cell antibody (PCA) and

intrinsic factor antibody (IFA) in patients with chronic gastritis and pernicious anemia.

In this paper, animal experiments were performed to study effects of these antibodies

from patients or rabbits on secretory function of acid, intrinsic factor, and pepsin and on

the morphological changes; mucosal thickness, surface area, and parietal and peptic cell m a s s e s .

Ninety-six female Sprague-Dawley rats

weighing ca. 300 g were divided into 4 groups

of control rats (I no injection, II saline, I I I normal human IgG, IV normal rabbit IgG)

and 4 groups of experimental rats (V PCA-

alone, VI P C A + I F A , V I I rabbit ant i-human IF, V I I rabbit anti-rat IF). Each group

was composed of 12 rats and each rat was in-

jected as IgG (4mg) saline solution into tail vein for 8-12 weeks. IgG was purified from

antibody-containing sera by DEAE-cellulose

column. Rat gastric juice was collected through a small tube every other week to assay

acid, IF, and pepsin followed by calcuIation

of hourly out-puts. Extirpated stomach opened along greater curvature was pinned out to

make no mucosal folds on a card-board and was circumscribed with a pen on it. After

fixation, 6 strips were cut" for preparation of sections followed by staining with toluidine- blue. Glandular thickness was measured and

parietal and peptic cell mass were calculated from numbers of cells exactly counted at 18

selected sites with application to a formula set up in this study.

Hourly outputs of acid, IF, and pepsin in experimental groups were expressed by ~ inhibition rate (H.O. of experimental group

H.O. of control group 100). Inhibition rates of V, VI, VII , and V I I I groups showed 46.4,

53.6, 67.3, and 34.55 in acid secretion, and 27.4, 60.7, 37.8, and 27.85, in IF secretion,

and 54.7, 66.0, 53.7, and 30.1}o in pepsin secretion. On the other hand, ~ decrease

rates in morphological changes w e r e as follows; the range from 49 to 75~o in thickness,

and 59.2, 50.2, 68.1, and 68.4% in parietal cell mass and 67.2, 54.0 69.5, and 62.8% in

peptic cell mass. These results suggested that hypofunction and decrease of numbers of parietal or peptic cells in chronic gastritis and per-

nicious anemia were mainly due to the reactions of these circulating antibodies.


(139) P H A R M A C O R A D I O G R A P H Y

OF T H E C O L O N BY M E T O C L O P R A M I D E

SYRUP

K. Ebata, N. Yamanaka, and S. Watanabe

Department of Radiology, Nihon JlIedical School

Y. Yoshida and H. Mori

Department of Radiology, Izu Teishin Hospital.

In principle, radiographic diagnosis of the colon should be made by the peroral method

for functional changes and by the barium enema method for organic changes. How-

ever, the pharmacoradiographic technique

enables satisfactory diagnosis of organic changes by the peroral method. We tried to

make contrast by introducing Metoclopra- mide syrup orally and obtained excellent

results. In 30 min. after visualizing the stomach, fol-

lowing the routine examination of the small

intestine is performed, 20 ml. of Metoclopra- mide Syrup (Primperan or Eliten syrup) is

orally administered to take pictures of the colon over a period of 60 to 150 min.

The percentage of subjects whose colon was visualized beyond the transverse coIon within

90 min, after dosing varied greatly with the

drug given: 75.5~ for Primperan syrup, 26.7% for syrup containing no metoelopra-

mide, 70.0% for Eliten syrup, 26.7% for syrup containing no metoclopramide, 70.0% for Primperan inj., and only 8o/o, for no medica-

tion at all. In an observation 3 hrs.. The percentage of patients whose colon was visual-

ized to the descending colon or further was 80 ~85~ for the Metoclopramide syrup group and 26% for the non-medicated group.

This peroral method is considered to be ap- plicable not only to mass survey but also to the

screening of subjects for colonic changes.

If air is introduced rectally at the t ime of contrast, the visualization of the colon may

develop into a clear doublecontrast image which is almost comparable to that obtained

by the injection method. Thus this may well be a highly precise screening method.

(140) C O L O N I C X - R A Y EX-

A M I N A T I O N BY MEANS OF P E R O R A L B A R I U M I N T A K E

M E T H O D

S. Tsukasa, H. Sato, Y. Chuman, N. Nakahara, H. Taniguchi,

S. Ehira, M. Hori, T. Irisa,

and H. Yokoyama

Second Department of Internal Medicine, Kagoshima University School

of Medicine

The fully effective method of colonic X - r a y

examination has not yet been established, though it has been improved considerably

these days. We, in the course of examining 1807 cases for four years by peroral barium

intake method, have come to shorten t ime required for the examination and to obtain

better diagnostic accuracy by improving the

examination procedure and technology. The former method has a drawback in taking long

time for the examination. On the other hand,

it has an advantage that stomach, small and large intestines can be examined in succession

in a same day and that normal and physiological barium passage through intestines can be

observed as well. We used Metochlopromide (to be given in-

tramascularly) and D-sorbit for the purpose

of cutting t ime needed for the examination short to obtain better result. In 63% of the

cases examined, the examination was completed within three hours while 93~o was finish-

ed within five hours.

Polyp cases, especially colonic, were studied in connection with diagnostic accuracy. Dou- ble-contrast X - r a y examination of sigmoid

and rectum was performed by infusing barium

into them through anus and, as a result, better diagnostic accuracy was obtained. Thirty-two colonic polyps were found in 22 cases by single

peroral barium intake examination. Ten out of 26 polyp-suspected cases were given de-

finite diagnosis while the other 16 were proved that they had been given false diagnosis by

Proceedings of the 58th Annual Meeting, 1972-- Tokyo--( H ) 175

means of barium enema method and colonic fiberscopy. There were i0 polyps, the sizes

of which were less than 10 mm in diameter,

overlooked in 7 cases. Considering that high

incidence of cancer has been seen in the lesions, the sizes of which are more than 10 mm

in diameter, it may be concluded that colonic

cancer in early stage can be detected by the improved method.

It has been considered, judging from the fact that many polyp patients without being ac-

companied by any subjective signs and sym-

ptoms have been found, that establishment of more accurate and less painful routine X -

ray examination method which will enable us to examine and find many colonic polyp pa-

tients in a short hour is required. "Premedica-

t ion" and barium concentration are the subjects to be investigated further for the purpose

of bettr diagnostic accuracy of the improved method.

(141) ON T H E N O R M A L R O E N T - G E N O G R A P H I C P I C T U R E IN

T H E B A R I U M E N E M A

(ON T H E H I G H P O S I T I O N OF T H E S P L E N I C F L E X U R E )

T. Kunieda and Y. Ogushi

Department of Radiology, School of Medicine, Gifu University

The criteria on the normal roentgenographic picture concerned with the course, the position,

and the angulation of the colon, is not defined.

But Hayashida et al. indicated the criteria on the normal roentgenographic picture of the colon.

We doubted on the category, that is to say the normal position of the splenic flexture is in 5 to 10 centimeter from the diaphragm in

the patient upright and expiratory phase. Therefore, we divided 99 cases into three

groups by using Hayashidas criteria, namely a group of the normal positon of the splenic flexture, a group of the high position of the

splenic flexture, a group of the high position and the abnormal angulation of the splenic

flexture, and investigated them from the subjective symptom.

It was suggested by our study that there was no significant difference amidst three groups.

(142) H I S T O C H E M I C A L S T U D Y OF

T H E T R U E C H O L I N E S T E R A S E

(CHE) A C T I V I T Y IN T H E

C O L O N I C M U C O S A

K. Kawakami, M. Kuroda,

M. Kuroda, D. Sasaki, S. S6ma S. Yanagiya, A. Munakata, and

F. Matsunaga

The 1st Department of Internal Medicine, Hirosaki Universty School of Medicine, Hirosaki,

Japan

The true eholinesterase (ChE) activity of the colon mucosa was histochemically (after Kar-

novsky) assayed in the materials obtained by

biopsy with Colonofiberscope in various colonic diseases.

ChE activity was higher in irritable colon syndrome than in colon organic diseases, such

as cancer of the colon, polyp of the colon, ulcerative colitis and the others.

ChE activity and stoolanomality had no significant correlation to each other.

In irritable colon syndrome almost all cases

with P type (hyposympathicotonia) in mech- olyl test showed a high ChE activity. A half

cases with N type (normal) also showed a high activity.

From the above results it was concluded that measurement of ChE activity in the mucosa was valuable to differenciate functional colon

disease from colon organic disease, and for etiological diagnosis of irritable colon syndrome.

176 Proceedings of the 58th Annual Meeting, 19 7 2-- Tokya--( H )

(143) C L I N I C A L E X P E R I E N C E

O F I N T E S T I N A L

E N D O M E T R I O S I S

M. Abiko

The Second Hospital of Tokyo Women's Medical College, Department of

Internal Medicine

H. Ohuch i

Department of Gynecology

Intes t inal endometriosis is one of the causes

of bowel m o v e m e n t disorders.

But it is not popula r even among the doctors.

I have experienced the 6 cases. T he charac-

teristic symptoms are constipation, rectal or

gluteal pain, dysmenorrhoea and rectal pa in

by coitus. Const ipat ion is noted in 2 of 6

patients, and increased passages are only in

one.

However, in 4 of 6, passages were increased

dur ing the mens t rua l period.

Sterility is no ted only in 2 of 6.

One pa t ien t h a d melena.

X-ray examinat ions were carr ied in 4, and

colonoscopy examinations, in 2.

By the b a r i u m enema study, filling defects

were observed in 3, and niche or adhesive

changes were in 4.

By the colonoscopy, in one of two, submu-

cosal tumors and mueosal bleeding were ob-

served.

(144) I N D I C A T I O N S F O R U R G E N T

S U R G E R Y IN T H E T R E A T M E N T O F

S E V E R E U L C E R A T I V E C O L I T I S ;

S P E C I A L R E F E R E N C E S T O T H E

C R I T I C A L N U M B E R O F T H I S

DISEASE

C. Tai , T. Kawashima, W. Oosawa,

H. Asakura, H. Senba, and

T. H a t a y a m a

Department of Surgery, Okayama University Medical School and

Department of Surgery, Hiroshima Municipal Hospital

In a series of 42 patients with ulcerat ive

colitis seen by us at the 1st surgical d e p a r t m e n t

of O K A Y A M A univrsity hospital and the

munic ipal hospital H I R O S H I M A between

1962 and 1971, abou t 50% came to surgical

t r ea tmen t involving colonic resection, in which

10 pat ients were all with severe at tacks and

their clinical labora tory data showed the criti-

cal number , score 3 or more. To seven pat ients

of them, u rgen t operat ion as an elective

measure was appl ied and true emergency sur-

gery was requi red for the rest of t hem in which

an elder pa t i en t of h igh risk lost his life shortly

after surgery. In the course of conservat ive

t rea tment , two cases showing the score 3 or

more had lost thei r lives as the result of delay

and inadequa te management . The major i ty

of mild or modera te ly severe attacks of ulcera-

tive colitis, which had subsided wi th conserva-

tive managemen t , were retrospectively scored

according to the critical n u m b e r calculat ion

and tu rned out to be the score 2 or less. De-

l iverating upon these data, we have proposed

the critical n u m b e r (score 3) of this disease, in-

dicat ing the urgent operat ion required. A

severe a t tack of ulcerative colitis with the score

3 or more is consequently a medical emergency

and should be t rea ted as urgent surgical con-

dition, ins t i tut ing intensive course of conserva-

tive measure.

(145) O N T U B E R C U L O S I S

O F T H E C O L O N

K. Yukawa, et al.

Yukawa Gastroenterological Hospital, Osaka

Summary (1) Discussions were held on bo th roentgeno-

graphic a n d pathological examinat ions of four

cases of colonic tuberculosis. Among which

three cases were surgically operated.

(2) In two cases of tumor form, the typical

hour-glass shape was not seen in roentgeno-

grams, t ha t is one edge of the focus showed

like an apple-core.

(3) In two cases of ulcerative form, lesions

were roentgenologically mosaic in pa t t e rn and,

were skipping, so t ha t they were, a t first sight

thought to be Crohn ' s disease of the colon. In

Proceedings of the 58th Annual Meeting, 1972-- Tokyo-- (H) 177

making a diagnosis, biopsy was thought to be most important. So, as a next step, a diagnosis

was made from biopsic specimens by using

romanoscopy or fiberscopy. As the result, tuberculous granuloma with central necrosis

was found. And that was taken from ulcer

base and not from multiple pseudopolipoids.

(146) C H A N G E S IN P O R T A L A N D

I N T R A L U M I N A L SERO- T O N I N LEVELS F O L L O W I N G

I N S T I L L A T I O N O F HYPER-

T O N I C G L U C O S E S O L U T I O N IN T H E P R O X I M A L SMALL

I N T E S T I N E

T. Konishi, M. Miyata, H. Shimazu,

T. Kinoshita, K. Nukada, and

T. Yamagishi

First Department of Surgery, School of Medicine, University of Tokyo

It is well known that portal serotonin level increases significantly after instillation of hypr-

tonic glucose solution in the proximal small intestine in experimental animals. However,

the exact mechanism of this augmentation of portal venous serotonin is not necessarily demonstrated. The present study was carried

out to investigate this mechanism in anesthe-

tized dogs. After instillation of 50~o glucose, there was

a prompt increase in portal serotonin concen-

tration which reached the peak at 10 minutes, maintaining the level for 20 minutes, and then

gradually decreased. Similar changes occured after instillation of 8% NaC1 although the magnitude was comparatively small. No

significant alteration of portal serotonin concentration was noted in case of 50% glucose

load following exposure to 2~ lidocaine. Introduction of 50% glucose caused a pro-

gressive increase in intraluminal serotonin

concentration till 60 minutes. Similar changes occured after instillation of 50 ~o glucose follow-

ing exposure to 2% lidocaine although the magnitude was comparatively small. In case

of 8~o NaC1 load, however, intraluminal sero-

tonin concentration reached the peak at 30

minutes but then gradually decreased.

These data failed to show close correlation between portal and intraluminal serotonin

levels. On the other hand, there occured

much greater increase in portal serotonin

level after instillation of serotonin in saline than after that of salin alone.

Our data would suggest that intraluminal serotonin might play in part a role in the mech-

anism of increase in portal serotonin level after intraluminal hypertonic glucose load.

(147) S T U D I E S O N P E N E T R A T I O N OF A C T I V E P O L Y P E P T I D E S T H R O U G H

I N T E S T I N A L M E M B R A N E (V) - - H I S T O - P A T H O L O G I C A L

C H A N G E O F I N T E S T I N A L B R U S H B O R D E R C E L L - -

K. Harada, S. Nakano, T. Yoshioka, and T. Sakai

Department of Physiology, The Jikei University School of Medicine,

Tokyo

In the last 57th General Assembly of Jap- anese Society of Gastroenterology 1971, our

report on penetration phenomena of glucose, insulin and tryptophane through intestinal wall

was presented, the data of which were obtained by use of everted intestine of rats

treated with NaOH, CHsCOCH3, HC1 etc., and analyzed rom the view of patho-physiology.

This time histo-pathological investigation of intestinal brush border cell in relation to above

experiments and further obtained results on penetrating conditions of materials are presented.

When the time length of treatment with

above agents is within 10-60 see or over 10 min, the values obtained are unstable and characteristic features of active transport which

have been confirmed by our own method, are not found. In 2-5 min's treatment with 0.1N NaOH, however, insulin penetration is en-

hanced, and transport of tryptophane and glucose is inhibitory, which might suggest that there must exist synergistic action be-


tween insulin and glucose or between tryp-

tophane and glucose for active transport.

On the contrary, in t reatment with such degenerative agent of cellular lipids structure

as 10% C H 8 COCH3, no characteristic features

of active transport was olzserved. In treat-

ment with 0.1N HCI each transport of insulin, t ryptophane and glucose is inhibitory, which

might suggest that transport mechanism of

intestinal membrane cell could be disturbed. As the results it will be considered that

selective structural change of such the components of intestinal brush border cell

membrane as protein layer, lipid layer, mu-

copolysaccharid covered over cell membrane,

could produce their own features in trans-

port which are different one another, and the present problem will be also of patho-

physiological interest.

(148) E F F E C T S OF H U M A N I N T E S T I N A L F L O R A O N

T H E B I L I R U B I N A N D BILE ACIDS M E T A -

B O L I S M

K. Shindo, K. Fukushima, S. Odagiri ,

K. Tarao, Y. Saito, K. Ohara, and S. Sasaki

The First Department of Internal Medicine, Yokohama City Uni-

versity Medical School

In oder to study the influence of human in-

testinal bacteria on bilirubin and bile acids metabolism, the conversion of bilirubin into the other metabolites and the splitting of con-

jugated bile acids by intestinal microorganisms were investigated by column chromatography and thin layer chromatography.

All to the species tested metabolized bilirubin but not all of their strains. The percentages

of the metabolizing strains in each species differed from 75% to28%. Corynebacterium.

enterococcus, aerobacter and bacteroides had higher percentages. The percentages of the

strains which metabolized to urobilinogen were highest (8%) in enterococcus and aero-

bacter, lower in intermediate coliform bacillus

and Escherichia coli, and none in the other

species. Species of which all of the strains splitted

conjugated bile acids were enterococcus,

bacteroides and corynebacterium, and most

of the strains splitted were staphylococcus

epidermidis and lactobacillus bifidus. Spe- cies of which none of the strains splitted were

Escherichia, lactobacilli except lactobacillus

bifidus, staphylococcus aureus, aerobacter, pseudomonus, candida, and veillonella, and

almost none of the species splitted was inter-

mediate coliform. C o n c l u s i o n : Of all the species tested

various percentages of their strains metabolized

bilirubin in various degrees. All or none, or almost all or none, of the

strains of each species tested splitted conjugated bile acids, and it is probable that the

presence or absence of this ability would be a proper character of each species.

(149) A M I N O A C I D D E C O M -

P O S I T I O N BY L. B I F I D U S A N D L. A C I D O P H I L U S

T. Tomoda, N. Kaneda, H. Yamaguchi, and T. Hayashi

Department of Clinical Pathology, Osaka Medical College

T. Tanaka Pharmaceutical Research Institute

Many experiments on amine production of

aerobic and anaerobic intestinal bacteria have been studied in the previous reports. In this

study, amino acid metabolism of lactobacillus bifidus and lactobacillus acidophilus was ex-

amined. L. bifidus was isolated from not only the

feces of children but also that of adults. But

in each case of the adults, the variation of the quantity was remarkable. Amino acid component of L. bifidus and other intestinal bacteria was compared. Alanine, cystine and

valine were more than the other microorganisms but these differences were not special-

ly, amino acid consumption in filtrate of culture medium which L. bifidus and L. acid.

Proceedings of the 58th Annual Meeting, 1972--Tokyo--(H) 179

have grown, was examined. Many amino acids were consumed in L. bifidus than L.

acid. and was not always in parallel with amino acid decarboxylase activity.

Ornithine, lysine, histidine, glutamic acid,

tyrosine and phenylalanine decarboxylase activity was examined for L. bifidus and L.

acid. The production of some amines such as cadaverine, histamine and tyramine was

recognized in a few strains of these species, but

little quantity. The change of tyrosine decarboxylase activity of L. bifidus by successive

cultivation, was examined. Tyrosine decarboxylase activity decreased by successive cul-

tivation. On the other hand, in other microorganisms (Klebsiella, P. vulgaris and St.

faecalis), the activity did not change. Sen-

sitivity for various antibiotics of L. acid. and L. bifidus showed same pattern, but differed

from other intestinal bacteria.

It was demonstrated that amine production of L. bifidus and L. acid. was rare and un-

stable. From this viewpoint, the existence of these strains will be also useful for body.

L i t e r a t u r e s 1) Tomoda, T and Tanaka T : The Japanese

Journal of Gastroenterology, 67: 4, 1970.

2) Tomoda, T et .al: The Japanese Journal of Gastroenterology, 68: 1167, 1971.

(150) I N T E S T I N A L I O N TRANS-

P O R T IN R A T 1) P O T A S S I U M T R A N S P O R T A T

S O D I U M E Q U I L I B R I U M C O N C E N T R A T I O N

2) E F F E C T OF G L U C O S E AND P I T R E S S I N O N W A T E R ,

S O D I U M A N D P O T A S S I U M T R A N S P O R T

J. Suzuki, Y. Kofune, A. Urase, A. Yamagata, N. Sugino,

M. Hatano, and K. Oshima.

Department of Internal Medicine, Nikon University School of

Medicine, Tokyo, Japan

In an at tempt to clarify ion transport by rat intestine, using stop flow perfusion technique,

potassium transport of isotonic solution in jejunum, ileum and colon of anesthetized rat

at sodium equilibrium concentration were determined and effect of glucose and pitressin

on water, Na and K transport were observed. Male wister rats weighing 200 to 300 g

were anesthetized with Nembutal (5 mg per

100 g). The abdomen was opened with mid- line incision and 15 cm of intestine was isolated

in vivo with care to preserve normal blood supply.

The segment of intestine was cannulated at

both ends with silicon tubes. The composi- tion of perfuson solution was NaC1 120-140,

KCI 5, MgC12 1.5, CaC12 4, NaHCO8 20 m M / L and were kept isotonic by addition of man-

nitol. K efflux was determined from the changes of total radioactivity of 42KC1. Water

efflux was determined from the changes of phenol red concentration. Electrical poten-

tial difference between the mucosal and serosal surface was measured with a pair of Calomel

electrodes using a Keithley Model 610C elec- trometer.

An indirect electrode was placed on the serosal surface.

Mainly, K was absorbed passively in intes-

tine and K absorption was largest in the jejunum and in ileum larger than in colon.

Na absorption and K secretion was, in great part, active component and largest in

the colon and larger in i leum than jejunum.

Water absorption was apparently passive, depending upon Na movement.

(151) A S I G N I F I C A N C E OF S T E N O S I S OF T H E P A P I L L A OF V A T E R IN A

R E L A T I O N S H I P B E T W E E N C H O L E L I T H I A S I S A N D PANCREAS

- - A C L I N I C O P A T H O L O G I C

S T U D Y - -

T. Tanabe, M. Ohto, and

K. Okuda

The First Department of Internal Medicine, Chiba University

School of Medicine

The papilla of Vater is closely related to the biliary tract and the pancreas because of their

180 Proceedin M of the 58th Annual Meeting, 1972--Toky)--(H)

anatomical structure. In this report, the relationship between cholelitiasis and pancrea-

tiffs with or withont stenosis of the papilla is studied from clinical observations of 108 cases

including 48 cases of cholelithiasis and from histological observations of 67 autopsy mater-

ials including 28 cases of cholelithiasis. The

results are as follows: l) Cholangiograms with dilatation above

13 mm of the extrahepatic biliary passages have a stenosis of the papilla. The cases of

cholelithiasis accompanying acute pancretitis frequently show this cholangiographic picture.

2) The ratio of the abnormal cases of

cholelithiasis with stenosis of the papilla by Pancreozymin-Secretin Test shows higher than

those without stenosis of the papilla. 3) A fibrosis and round cell infiltration

were markedly seen at the papilla with cho-

lelithiasis. 4) At the head of the pancreas with cho-

lelithiasis, periductal fibrosis, cell infiltration,

ductal proliferation and the tall hypertrophied

ductal epithelium were observed more frequent than those at the other part of the pan-

creas. 5) The cases who have chronic papillitis

frequently show chronic inflammatory changes at the pancreatic ducts.

On the basis of these observations, it is

supported that stenosis of the papilla has an important role on the pathogenesis of a pan-

creatitis related to cholelithiasis.

(152) T H E C H A N G E S OF T H E D U O D E N A L PAPILLA O N

T H E DISEASES OF T H E N E I G H B O U R I N G O R G A N S

E. Mitani, S. Yamamoto, K. Koba-

yashi, T. Ono, T. Kamata, S. Mohri, H. Makiishi,

A. Kitano, Y. Suga, S. Tatumi, S. Mizuno, and

K. Tsumori

Medicine, Osaka City University Medical School, Osaka,

Japan. Department of Internal

Two hundred and thirty two endoscopic

observations of the duodenal papilla were made from:July, 1970 to February, 1972. W.e have

studied about the changes of the duodenal papilla on the diseases of the biliary tract and

pancreatic diseases. The purposes of this

paper are to discuss the changes of the duodenal

papilla on the various diseases of digestive tract (Diseases of the biliary tract, liver and pancreas, duodenal ulcer.)

The results were as follows:

(I) The size of the duodenal papilla on the diseases of the biliary tract was 17.34-2.9 mm

in longitudinal diameter and 12.14-2.4 mm in transverse diameter. I t became about three

times as large as that of normal one.

(2) In the diseases of the biliary tract the duodenal papilla, which showed type D was

64%. By endoscopic pancreatocholangiography, dilatation of the terminal part of the

common bile duct was observed in the cases which papilla showed type D and D'.

(3) Commonly, the size of the duodenal papilla on the diseases of pancreas did not so

swell, except the case which infiltration of cancer of the pancreas extend to the ampulla

of the duodenal papilla. (4) In the duodenitis (17 cases,) the cases

which anatomical papilla were swelling was 47%. We believed that the inflammatory

stenosis of the terminal part of the common bile duct sometimes occurred due to extension

of the inflammation of the duodenum. (5) In 16 cases on the diseases of the liver, the

size of the duodenal papilla was almost the same as that on normal one.

(6) The swelling duodenal papilla may occur keeping jaundice and high level of A l k - - P and LAP.

(153) C L I N I C A L S T U D Y F O R I N T E S T I N A L P E R F O R A T I O N

T. Shimizu, K. Nomatsu, H. Hiratsuka, and M. Ichinose

Surg., Ohita Red Cross Hospital

During 11 yrs. and 9 months from Jan. 1960

to Sept. 1971, we have experienced of 46 cases


of intestinal perforation (33 cases of duodenal

ulcer, 18 cases of t rauma, 7 cases of ileus, 3 cases of intestinal phlegmon and 3 cases of

foreign bodies). 54 cases were male and 10 cases were female

2 cases were under the age of 20 years, 22 cases the age 21 to 40 years, 27 cases the age

41 to 60 years and 13 cases over the age of 60

years. Operative mortality rate for intestinal per-

forated cases was 25% ( 16 cases out of 64 cases). The causes of death about 9 cases (56.2%)

were uremia and 7 cases (43.8%) were heart

failure.

About the number of deaths 7 cases (43.7%) were over the age of 60 years and 13 cases (81.2o/o) were treated surgically from the onset

of perforation over 24 hours.

The prognosis of the pt. with perforated

duodenal ulcer was favorable (mortality rate was 9%), on the contrary, the prognosis of the

pt. with intestinal perforation caused by ileus was grave (mortality rate was 85.7%).

By our experience the prognosis of the pt. with intestinal perforation is dominated, if

early and suitable surgical treatment (especially, primary gastric resection for the perfora-

tion of duodenal ulcer) is performed.

(154) S T U D Y O N C H O L E R A

E N T E R I T I S - R A D I O L O G I C A L , I M M U N O L O G I C A L AND

BIOPSY F I N D I N G S

H. Asakura, T. Morishita, A. Morita,

S. Matsuzaki, M. Oda, K. Kamegaya, M. Tuchiya,

and K. Sambe

Department of Internal Medicine (Director K. Sambe), School of Medicine, Keio University

Cholera is characterized by severe diarrhea

with fluid and electrolyte depletion. Its prevaIence has been reported in Asia and Afri-

ca. Clinical and pathological studies of cholera were carried out in order to clarify the pathogertesis of voluminous diarrhea.

Methods and Results:

The present studies were performed on the patients of both sexes admitted to San Lazaro

Hospital (Manila). The culture of rectal

swabs of these patients were all positive for Vibrio eholerae. Serum albumin, globulin

and immunoglobulin concentration of four- teen cholera patient was assessed by electro-

phoretic, immunoelectrophoretic and immuno-

diffusion methods and compared with those of seven control individuals. An apparent

elevation of IgG and T-globulin and an decrease in albumin were observed in cholera

patients. Immunoglobul in levels of the small

intestinal fluids were evaluated in cholera patients as well as the control, to reveal a definite

increase in IgA in the former. IgG and IgM were hardly detectable in the cholera cases.

X- r ay findings of the small intestine in cholera patients revealed a marked hypersecretion

and hyperkinetic peristaltsis.

Histologic study of the jejunal biopsy specimens from 5 cholera cases demonstrated

denudation, necrosis and degenerative changes of mucosal epithelium. Abundant mucus was

found in the lumens of the crypts. The intestinal villi were coated with desquamated

epithelium as well as mucus. It is surmised that rice watery stool is due to multiple focal

denudation and necrosis of intestinal epithe-

l ium as well as hypersecretion of epithelial cells and excess production of mucus in the

crypts.

(155) C L I N I C A L S T U D I E S O N I N T E S T I N A L DISEASES

A C C O M P A N I E D BY D I A R R H E A

Y. Murakami, A. Machii, Y. Nitta, Y. Aiso, N. Kitahara, M. Sato,

Y. Yoshizawa, and Y. Hishinuma

Dept. of Int. Med., Tokyo Metropolitan Toshima Hospital

H. Nagasako and Y. Nao Institute of Gastroenterology,

Tokyo Women's Medical College

Out of total of 37,079 patients who visited

our clinic during 1967--1971. 1,421 (3.8%)


had diarrhea as chief complaint. Of them,

patients of acute diarrhea totaled 1,116. 784

cases of them were subjected to stool culture examination and 125 (15.9%) were positive for

pathogens, which included bacillary dysentery 32, Salmonella enteritis 28, pathological col-

ibacillus enteritis 2 and Vibrio enteritis 63.

Non-infectious types consisted of 990 of acute enteritis in which no pathogens were demonst-

rated and one allergic enteritis.

Chronic diarrhea totaled 306, of which 80 were examined by stool culture but none were

found positive for pathogens. One patient

of amebic dysentery was the only infectious

type: S M O N was observed in 5 patients. Others consisted of chronic gastroenteritis

80, ulcerative colitis 29, irritable colon synd- drome 167, intestinal neoplasma 6 and other

diseases such as valvular disease or malabsorp-

tion syndrome 17. Pathgens were demonstrated in higher per-

centage in patients with higher body temperature and mucous stool. However, they

w e r e also found in 5-13.9~ of those with body temperature below 36~ and whose stools

were watery. On endoscopic examination, hyperemia,

bleeding, ulcer and edema were observed in bacillary dysentery, acute enteritis, amebic

dysentery and ulcerative colitis. In addition

to these, pseudopolyp was also observed in ulcerative colitis. In bacillary dysentery, lesion was marked along the area as far as 20 cm

from the anus. Intestinal atrophy was observ-

ed frequently in irritable colon. On biopsy, there were observed hyperemia,

bleeding, ulcer, edema and infiltration of in- f lammatory cells in bacillary dysentery, acute

enteritis and ulcerative colitis. Cryptabscess was found only in one case of ulcerative colitis, which was fewer then in operated or autopsy

c a s e s .

(156) E X P E R I M E N T A L A N D

C L I N I C A L E V A L U A T I O N OF

E N D O S C O P I C P A N C R E A T O - G R A P H Y

H. Harada, K. Mishima, Y. Yama-

gata, M. Mandai , Y. Kondo, and

Y. Uchida,

Okayama Unicersity Medical School

S. Takizawa and S. Kinoshita

Mizushima Daiichi Hospital

Importance of duodenofiberscope and endoscopic pancreatography and cholangiography

for the diagnosis of diseases of the pancreas and

papilla of Vater was evaluated on the basis of the results of 320 cases of duodenofiberscope

and 167 cases of endoscopic pancreatography and cholangiography which has been perform-

ed at our institute. Followings are our results.

(1) Dogs were used to evaluate the effect of volume and infusion pressure of contrast

medium on the pancreatogram. Infusion of 0.5ml of60% Urographin with .0,2 atmospheric

pressure was most suitable to obtain a fine

pancreatogram without artefacts. (2) In man, infusion of 4 4 5 ml of medium

with 0,2 atmospheric pressure was most suitable. Excessive volume or infusion pressure

resulted in artefacts, so that infusion pressure

and volume of contrast medium should be

standardized to evaluate the endoscopic pancreatography. As a base line, we have adopted 5 ml volume and the lowest infusion pressure

which enables instilment of the medium. (3) Our cases include 8 cases of cancer of the

papilla of Vater, 5 cases of the pancreas cancer, 6 cases of chronic pancreatitis with calcifi-

cation and lithiasis, and 12 cases of chronic pancreatitis without calcification and lithiasis.

(4) Endoscopic observation, biopsy and endoscopic pancreatography and cholangiography

have proved indispensable for the diagnosis of cancer of the pancreas and the papilla of

Vater. (5) In chronic pancreatitis with calcification and litiasis, abnormali ty of endoscopic pancreatography was often remarkable (80-

100%), including irregularity of course, caliber and border of the pancreatic ducts

and ductules. In these cases, pancreozymin-

secretin test also showed remarkable abnor- rmality; a decrease of all 3 factors (volume, amylase output, and max. HCOa concentra-

tion).

Proceedings of the 58th Annual Meeting. 1 9 7 ~ Tokyo--(H) 183

(6) In chronic pancreatitis without calcifica-

tion and lithiasis, in contrast, irregularity of border of the pancreatic ducts and irregular opacification of the acinus and parenchyma of

the pancreas were observed in 50% of cases

In these cases, amylase in the serum and urine was elevated and pancreozymin-secretin tests

showed only mild abnormali ty such as a mini-

mal decrease of only one factor; usually a decrease of mzx. H C O j concentration or

amylase output. Thus, chronic pancreatitis should be evaluat-

ed in the basis of clinical findings, other morphological and functional tests as well as endo-

scopic pancreatography.

and obstruction.

Radiologically, the differentiation of these two groups is now difficult. From the varia-

tion of the serum-amylase after the pancreatography, the different pattern was not recog-

nized in these two groups.

According to the above-mentioned data, no correlation of the morphological findings of

the pancreatography with exocrine secretory function of the pancreas was recognized.

In future, the full functional test and the biopsy of the pancreas will be studied, and

it will be desirable to establish the abnormal findings of the pancreatography in the pan-

creas-diseases.

(157) S T U D I E S O N T H E E N D O S C O P I C A L PAN-

C R E A T O G R A P H Y AND

P A N C R E A T I C F U N C T I O N

T. Kurihara, K. Sakumoto,

H. Okamoto, S. Sakurai,

S. Ishitobi, H. Tanaka, and K. Ishihara

2nd Dept. of Internal Medicine, Tottori Univ.

The pancreatic duct would be affected by the pathologic change of the pancreas. Up

to date, endoscopical pancreatography is the best way to know the pathologic findings of the

pancreatic duct. And then, comparison of morphological findings of the pancreatic duct

obtained by the duodenofiberscopy with the pancreozymin-secretin test was studied in this

report. In the normal group of the P-S test, the

diameter of the main pancreatic duct was on

average 3.8 mm at the head, 3.2 mm at the corpus and 1.8 mm at the tail of the pancreas.

On the other hand the prominent acknowledge- ment was not obtained from the view of the diameter of the main pancreatic duct in the abnormal group with the P-S test. The fol-

lowing findings of the pancreatic duct were studied in the above-mentioned two groups. Tha t is, flexion, irregular wall of the duct,

localized change of the diameter of the duct

(158) E N D O S C O P I C PAN-

C R E A T O C H O L A N G I O - G R A P H Y

- - C O M P A R I S O N W I T H O T H E R

C L I N I C A L E X A M I N A T I O N S - -

N. Kuno, T. Kasugai, I. Aoki,

and M. Kizu

1st Department of Internal Medicine, Aichi Cancer Center Hospital

We have succeeded in Endoscopic Pancre- atocholangiography (EPCG) in 240 cases un-

til February, 1972. In this work, EPCG findings were compared

with those of other clinical examinations. 1) Comparison with routine cholangiography:

Eleven cases of gallstone, 2 of gallbladder cancer and 2 of common bile duct cancer, which were not diagnosed by routine examina-

tions, were revealed by EPCG. 2) Comparison with pancreatic function test:

Findings of chronic pancreatitis by the criteria for EPCG diagnosis of chronic pancreatitis, were obtained in 15 of 16 cases, which

were normal by observation of urinary amylase for a week, and in 12 of 13 cases, which were

abnormal. 3) Comparison with pancreatic scintigram:

Sixteen cases of chronic pancreatitis and

one of pancreatic tail cancer were found in 22 cases interpreted as normal by pancreatic

184 Proceedings of the 58th Annual Meeting, 1972--Tokyo--( H)

scintigram.

4) Comparison with UGI X-ray and gastro- scopic examinations :

Two cases of pancreatic head cancer, 3 of tail cancer and 2 of gallbladder cancer were

found on EPCG in 36 cases, in which extra-

gastric pressure was demonstrated by a routine UGI examination.

Two cases of pancreatic head cancer, one of tail cancer and one of gallbladder cancer

with normal hypotonic duodenograms, were

revealed by EPCG. 5) Comparison with duodenoscopic findings

of papillary area : By duodenoscopic examination, inflamma-

tion and swelling of plica longitudinaris

duodeni were twice found in cases of chronic pancreatitis and biliary diseases diagnosed by

EPCG.

6) Good correlation was found between EP- CG and angiography.

(159) STUDIES ON THE COR- R E L A T I O N BETWEEN THE

RESULTS OF ENDOSCOPIC

PANCREATOGRAPHY AND

PANCREOZYMIN SECRETIN TEST

S. Nakano, T. Suzuki, Y. Hori-

guchi, K. Kitamura, M. Miwa,

K. Okada, and T. Takeda

2rid Clinic of Internal Medicine (Department of Gastroenterology)

Ogaki Municipal Hospital Ogaki, Japan

To confirm the abnormal findings in E.P.

C.G. (endoscopic pancreatocholangiography), function test of the exocrine pancreas by pan-

creozymin secretin test was carried out on the same patients and compared with each other.

Methods and Mater ia l s Endoscopic pancreatography was carried

out on 86 patients who have hospitalized for biliary and pancreatic impairment and pan-

creozymin secretin test was also done on 61 of

them.

Resul t s Judging from three parameters (total volume

after secretin administration, maximal bicar-

bonate concentration and total amylase out-

put after pancreozymin administration) in pancreozymin secretin test, the function of the

patients whose diameter of the main pancrea-

tic duct was over 4.0 mm had showed more

abnormalities. As the signs of the pancreatic impairments

Hess, W. pointed out tortuosities and distor-

tions of the pancreatic duct, irregularities of caliber, pseudodiverticula, filling of side

branches and parenchymal reflexes besides

dilatation of the main pancreatic duct. Correlation between these abnormal findings

in the pancreatography and the results of pancreatic function, pancreozymin secretin

test and glucose tolerance test, was analysed and compared. In the cases, observed ab-

normal findings in the pancreatography, abnormal function was detected more often (PS

test 69%, GTT 78%) than another cases (PS

test 42%, GTT 43%). On the other hand, remarkable abnormal

function was observed in some patients whose pancreatography were quite normal. Al-

though there are no straight relationship between both morphologic and function test,

remarkable morphologic changes are apt to accompany abnormal function of the pancreas.

Thus, there are some discrepancy between both tests, non-time consuming pancreato-

graphy should be added for the diagnosis of the pancreatic disorder.

(160) STUDIES ON THE DIAGNO-

SIS OF MALIGNANT PANCREA- TIC T U M O R S BY HYPOTONIC

DUODENOGRAPHY AND DUODENO- FIBERSCOPY

Y. Endo. M. Tatsuta. T. Morii. S. Okuda, and H. Tamura.

Center for Adult Diseases

For these 2 years, 20 cases of pancreatic malignant tumor were diagnosed by hypo-

Proceedings of the 58th Annual Meeting, 19 7 2-- Tokyo--( H ) 185

tonic duodenography (HDG) and duodenofiberscopy (FDS) and proved by operation or necropsy. The radical operations were performed in 9 cases (45%). As this ratio is higher than other reports, to get some crew of earlier and more certain diagnosis, the findings of HDG & FDS in the 20 cases were reviewed in detail. 1) Findings of C-loop by HDG: enlarge- ment, narrowing, non-symmetric findings were seen in about 50%, and abnormal findings of median wall were seen in about 65%. Swelling or deformity Of papilla vateri were in about 85%. 2) By FDS, about half of 12 pancreatic head cancer cases were definitely diagnosed. The findings were coml~ressed form, submucos~ti tumor, ulcerative change and so on. The other half also showed some change in the descending part of duodenum including papilla vateri, but indefinitive to judge malignant. 3) Cytology: Eight positive cases were obtained out of 11 cases in direct absorption cytology from pancreatic duct. This is indispensable for certain diagnosis. 4) Pancreatic ductography: In 13 "~performed cases~ 6 were determined malignant by this method, and at least some abnormal signs were recognized in all of the 13 cases.

(161) CONSTANT SECRETIN IN- FUSION WITH PANCREOZYMIN PRETREATMENT AS THE PAN-

CREATIC FUNCTION TEST

K. Fukuda, K. Sato, K. Koizumi T. Takebe, and S. Yamagata

Prof. S. Yamagata's Department of Int. Med. Tohoku University School of Medicine,

1-1 Seiryomachi Sendai, Japan

The standard single injection secretin test is now accepted as the most reliable test of excretory function of pancreas, however, for large variance coefficient found in both volume and amylase output found in normal control, the method has inherent problem in detection of minor changes of the pancreatic dysfunction. Therefore, an attempt

is made to introduce another method where pancreozymin pretreatment was given.

In normal human control group, constant infusion of secretin (Boots) in dose of 1/50u. /kg/min. was done for 90 minutes after giving pancreozymin (Boots) lu./kg intravenously. Duodenal juice was collected fractionately in each 10 minutes for 90 minutes and volume, bicarbonate concentration and amylase activity were measured in each fraction and following results were obtained.

1) Volume and bicarbonate concentration reached certain plateau after 50 minu -~ tei of infusion probably reflecting the plateau of the effective secretin level in ~this period. The coefficient of variation-of both volume and bicarbonate concentration in this period and total amylase output, showed significant decrease than the results obtained by stafldard method,, although a temporaly increase of amylase concentration and volume was oh-" served shortly after pancreozymin injection.

2) The effect of pancreozymin injectior~ is short lived. Volume output and increase of icterus index of the juice was only Observed in the initial one or two 10 minutes.fractions. Therefore the separation of bile and pancreatic juice is now feasible if samples of fourth and therafter fraction periods were to be analyzed.

It is, therefore, concluded that the new technic will increase the reliability and diagnostic ability of the secretin test.

(162) CHANGES OF SOME ELEC- TROLYTES IN DUODENAL ASPI- RATE, PANCREATIC JUICE AND BILE BY STIMULATION OF PAN-

CREOZYMIN AND SECRETIN

S. Noda, Y. Toda, T. Hayakawa, S. Nakajima, and S. Hitokawa

2nd Department of Internal Medicine, Nagoya University School of Medicine

S. Nakano, T. Suzuki, and T. Takeda 2nd Department of Internal Medicine,

Ogaki Municipal Hospital

Some electrolytes in the duodenal aspirate, pancreatic juice and bile obtained by the stimulation of pancreozymin and secretin

186 Proceedings of the 58th Annual Meeting, 1972-- Tokyo--(H)

were determined on 90 subjects including controls (16 cases), diseases of biliary tract (28 cases) and pancreatic diseases (46 cases).

Results were as follows: 1) The concentration of sodium ion was

elevated just after the stimulation of pancreozymin and maintained almost constant throughout the course of Pancreozyrnin- Secretin Test. The concentration of potassium was decreased after the stimulation of pancreozymin and kept constant thereafter. The lower concentration of sodium and the higher that of potassium before the stimulation were secondary to the contamination of the gastric juice and the bile.

2) In the hepatic bile from the external fistula, the ionic concentration of chloride was extremely higher than that of bicarbonate and decreased gradually after the stimulation of secretin. Changes of these anions in the duodenal aspirate were thought to be considerably influenced by the contamination of the bile.

3) The concentration of calcium was elevated after the stimulation of pancreozy- rain. This was due largely to the contamination of the bile, particularly the cystic bile.

4) The change of calcium concentration was considerably similar to that of amylase concentration in the pancreatic juice, even in the duodenal aspirate, suggesting that pancreatic acinar cells might be the place of calcium secretion. However, it was unknown whether calcium was secreted strictly corresponding to pancreatic amylase.

5) After the stimulation of secretin, the concentration of calcium was significantly higher in patients with pancreatic calcification, gallstone and common bile duct stone than in the control subjects.

(163) AN APPLICATION OF 7sSE- SELENOMETHIONINE TO PAN- CREOZYMIN-SECRETION (PS)

TEST

N. Sawabu, S. Hirose, A. Takada, and J. Takeuchi

The First Department of Internal

Medicine, School of Medicine, Kanazawa University

In order to evaluate the mode of secretion of radioactive methionine into pancreatic juice, total and TCA-precipitable radioactivity in pancreatic juice and bile were measured after i.v. injection of 7sSe-selenomethionine in 5 dogs stimulated by continuous infusion with secretin and pancreozymin. Total and TCA-precipitable radioactivity in pancreatic juice became constant 2 hours after the injection of the radioisotope. The ratio of TCA-precipitable to total gradually increased and reached a plateau (over 90%) 2 hours after the injection. The amount of radioactivity in pancreatic juice became 2 to 3 times higher than that of bile, and the excretion of TCA-precipitable radioactivity into pancreatic juice was 5 to 6 times higher than that into bile. From these results it seems reasonable to carry out PS test 2 hours after the injection of 7~Se-selenomethionine.

Clinically PS test was performed 140 minutes after i.v. injection of 7~Se-selenomethionine (100 pc) in 30 subjects including 14 cases with pancreatic diseases. Con- ventional three parameters, protein content and 7~Se-radioactivity were measured in duodenal juice.,The serial excretion pattern of total and TCA precipitable radioactivity was similar to that of amylase output in control. Both excretions of total and TCA precipitalbe radioactivity were correlated significantly to amylase output. There was a significant correlation between total and TCA precipitable radioactivities. From the excretion pattern of both factors, subjects having abnormality in 3 conventional

parameters could be well differentiated from the control, and subjects with abnormality

of 2 parameters were almost separated from the

control. But there was no difference between group with abnormality in one parameter and control.

These results suggest that change in amylase could be evaluated by measuring radioactivity in duodenal aspirate. Amylase determi- nation could be substituted by measurement


of radioactivity because of superiority of it's

convenience and stability.

(164) S C I N T I G R A P H I C S T U D Y

O F C H R O N I C P A N C R E A T I T I S W I T H SPECIAL R E F E R E N C E S T O ITS

F U N C T I O N A N D E T I O L O G Y

Y. Kuniyasu, H. Kakehi, G. Uchiyama, N. Arimizu, K. Okuda, M. Ohto,

T. Kuroda, H. Saishyo, and T. Tanabe

Dept. of Radiology, and Dept. of 1st Internal Medicine, Chiba University School of Medicine

Scintigrams of chronic pancreatitis were

analyzed with special reference to their func- tions and etiologies. Twenty four patients

with chronic pancreatitis, clinically diagnosed by the biopsy, surgery, or X-ray(calcifi-

cation) were selected for this study.

Scintigrams were classified into 3 types

according to their image appearances. Whole pancreas (type I), a part of pancreas

(type II) and no pancreas (type I I I ) is delineat- ed in each group of scintigram. Eighty three

percent of all patients (type I and II) showed the images of pancreas in scintigrams and

rest of them (type I I I ) showed no delineation of pancreas. The correlation of these scin-

tigraphic patterns with the pancreozymin- secretin test was not proved. As the indicator of the pancreatic function, the 75Se-selenome-

thionine uptake of pancreas relative to that

of liver (P/L ratio) was calculated from the scintigram especially made for that purpose.

The P/L ratio in a control group falls in 20-31% (average 25.7%), and chronic pan-

creatitis in 6-13% (average 8.6~ The chronic pancreatitis could be differentiated

from the normal functioning pancreas by the P/L ratio, even in case the pancreas scinti-

gram appeared normal. Th.e carcinoma of the pancreas showed low P/L ratio as in the chronic

pancreatitis, so that the differentiation of these two was not possible. While the alcoholic pancreatitis includes all types of scintigraphic

patterns (type I - I I I ) , chronic pancreatitis followed by the cholelithiasis showed type I scintigram.

Two cases, the scintigraphic pattern changed from type I and I I to type I I I

within few years were demonstrated.

(165) E F F E C T OF S E C R E T I N

ON S E L E C T I V E P A N C R E A T I C A N G I O G R A P H Y ( S E L E C T I V E

G A S T R O D U O D E N A L

A N G I O G R A P H Y )

T. Takashima and M. Shin

Department of Radiology, School of Medicine Kanazawa University

Selective gastroduodenal angiography

was performed in patients. In a group of control studies, several parameters such as ves-

sel diameter, visualization of pancreatic vas-

cular bed and pancreatogram are tabulated. Similar data are presented following the

intra-arterial injection of secretin and comparison is made with control studies. Al-

though the conventional serial arteriography

constantly has not been successful in demon- strating the evidence of increase in uptake

of contrast material in the pancreas following hormone stimulation, the X 2 direct

serial magnification study demonstrate the

secretin effect more obviously.

(166) S T U D I E S O N C Y T O L O G I C

E X A M I N A T I O N OF BILE F O R C A R C I N O M A O F P A N C R E A S

M. Akashi, T. Moriyama, M. Uchimura, and R. Tsuchiya

Second Department of Surgery, Nagasaki University School of Medicine

The value of the cytologic examination

of bile for carcinoma of pancreas was investigated with an analysis of data thus

obtained in 19 carcinomas of pancreas. For cellular materials of the cytologic examination of bile, not only bile but also phy-

siologic saline and contrast medium, with

which the biliary tract were washed, were used as well. These cellular materials were

collected during the percutaneous transhepatic cholangiography, the laparotomy,

the external biliary drainage and the autopsy.


Malignant cells were identified cytologi-

cally in 11 of 13 carcinomas of the head of pancreas, an accuracy of 84 per cent and in

one of nine carcinomas of the body and the tail of pancreas, an accuracy of 13 per cent.

For studies on origin of cancer cells in bile, the postmortem materials of I 1 carcino-

mas of the pancreas were demonstrated.

Data on the histologic sections suggested that

cancer cells in bile might possibly originate from not only the invasive lesions of the

biliary tract, but pancreatic juice with cancer

ceils, which was mixed with bile in the obstructive biliary tract.

In summary, the cytologic diagnosis of

bile can be reliable for the definitive diagnosis

of carcinoma of the head of pancreas, hut not helpful in establishing the diagnosis

of carcinoma of the body and the tail of pancreas.

(167) P A R O T I D SALIVA AS A

M E D I U M F O R T H E D I A G N O S I S OF T H E P A N C R E A T I C

DISEASES

G. Kakizaki, N. Noto, T. Oizumi, T. Soeno, and T. Maeta.

Department of Surgery, Akita University School of Medicine

T. Saito

Department of Surgery, Tohoku University School of Medicine

Nine patients with pancreatic diseases and thirteen patients without pancreatic diseases

were subjected for the investigation of parotid saliva.

In these patients, pilocarpine was injected intramuscuarly with a dose of 0.13 mg per

Kg of body weight. After the beginning of salivary secretion, parotid saliva was col-

lected for twenty-five minutes in every five

minutes intervals. The results revealed that the volume flow of parotid saliva was reduced and the maximum bicarbonate

concentration and amylase contents in parotid saliva were decreased in patients with pan-

creatic diseases.

A possibility was emphasized that changes

of the maximum bicarbonate concentration

and amylase content in parotid saliva might reflect the existency of the pancreatic dis-

eases.

(168) T H E E X A M I N A T I O N F O R

A N E W M E T H O D OF A M Y L A S E

ASSAY BY M E A N S OF BLUE S T A R C H

S. Naito, T. Saito, K. Shimizu, T. Nakajima, M. Tanaka, T. Kin,

and S. Sugiyama

Juntendo University Medical School Izu- nagaoka Hospital, Internal Medicine

Blue Starch was designed by Aceska et al. of Swedish chemist to assay .the a-amylase

in human serum, urine and duodenal juice

(pancreatic juice). The dye Cibachron F 3GA conjugated at 6th position of glucose

in maltose unit with insoluble situation to water and formed up tablets of each 200mg,

whereby a-amylase hydralized the starch to

maltose the dye solved in water and through 620rap colorimetric assay was available.

This study was carried out to investigate the efficency of the Blue Starch method for an

assay to amylase activity in serum, urine and

duodenal juice. The Blue Starch method was assumed as

a distinguished reproducibili ty with convenient

technic and t h e relationship of this new method wi th former designed methods such

as Smith Roe or Caraway method was satisfactorily an outline.

However, the low value within normal

area of amylase activity was scattered and the best efficiency was observed from 300 to

10,000 unit. A practical problem was indicated that the protein contents in a

sample influenced in assay, the activity of amylase in urine increased in order to add the bovin serum albumin previous incubation, as well as in the pancreatic juice by pan-

creozymin-secretin stimulation.

Proceedings of the 58th Annual Meeting, 1972--Tokyo--(II) 189

(169) STUDIES ON DIAGNOSES OF PANCREATIC AND HEPATIC DISEASES BY THE UNIVERSAL

CAELOMOSCOPE

H. Takayama, T. Tomono, N. Kamijo, Y. Kimura, T. Matsuo, M. Shimada,

and B. Terashima

Suwa Red Cross Hospital

M. Oda, S. Furuta, and K. Kashiwabara

Internal Medicine, School of Medicine, Shinshu University

S. Oka

Tokyo Welfare Pension Hospital

M. Sugiura, M. Karasawa, and K. Ito

Sugiura Laboratory

K. Takei

Takei Medical Optical Works

The authors have made the universal caelomoscope which can be applied clinically for the diagnose of pancreatic diseases. By using of the caelomoscope and the gas- trothermometer, the surfase temperature of liver and pancreas can be estimated precisely to the extent of 1/100~

We use Machida RX500 lightning model with cooling and heat proof attachment as the source of the light.

The thermister was introduced into per- itoneal cavity through this caelomoscope, and make its tip touched to a certain portion of hepatic surface or other aimed organ's

surface. Patients submitted to this study are as

follows; one case of chronic hepatitis, 1 cho- langiolitic hepatitis, 1 cancer of gallbladder and 1 gastric ulcer.

Lower temperature was noted on the surface of liver cysts than on the other part.

In the case of carcinoma of gallbladder, the difference of temperature seemed to be more variable and wide.

On visible surface of normal pancreas, it is higher 8/100~ in central than in peripheral region.

(170) STUDY OF PANCREATIC ENZYME SECRETION (II) THE

MECHANISM OF ACTIVATION AND DEGRADATION OF PANCREA-

TIC JUICE TRYPSINOGEN IN DUODENUM AND EFFECT OF

BILE ON IT

Y. Ishihara, A. Kuroda, N. Sato, T. Noro, H. Ishikawa, and Y. Tajima

1st Department of Surgery, University of Tokyo

In pancreatic juice some enzymes such as amylase (Am) and lipase are active, but the others such as trypsinogen (Tg), Chymotrypsinogen and procarboxypeptidase are inactive and activated by enterokinase (EK) in duodenal juice after secreted into duodenum.

Changes of Am. and Tg. and trypsin (Tr) in rabbit pancreatic juice and human duodenal aspirates were studied. In rabbit pancreatic juice total protein (TP), Am. and Tg. concentration changed in parallel manner and Am/TP, Tg/TP, Am/Tg ratio maintained almost constant level after tetra- gastrin, pancreozymin and acetylcholine stimulations. In human duodenal aspirates, however, Tr. and Am. changed indepen- dently and Tr/Am ratio increased according to the degree of bile content, which suggested accelerating effect of bile on activation of Tg.

In the mixture of rabbit pancreatic juice, duodenal juice and bile, under incubation at 37~ Tg. was activated to Tr. but at the same time Tg. was rapidly degraded to inter protein and peptides, and addition of biles inhibited the degradation of Tg. and consequently increased activation of Tg. By in vitro experiments using pancreatic juice, Tg., Tr., Chymotrypsin (Chy) and EK, it is found that degradation of Tg. was made by Chy. and addition of calcium inhibited this process.

In conclusion, pancreatic juice maintains constant Tg/Am ratio. Activation of Tg. to Rr. by EK in duodenum occurs concomi-


tantly with degradation of Tg. which is

caused by Chy. and inhibited by calcium and

bile.

(171) A C L I N I C A L S T U D Y O F

P H O S P H O L I P A S E A A C T I V I T Y IN P A N C R E A T I T I S (II)

S. Hashihira, T. Nishii R. Mori,

Y. Takeda, T. Yamadori , A. Wakabayashi,

and S. Iwata

2nd Dept. of Internal Medicine Osaka Medical College

A comparative study was conducted on

phospholipase A (PLA) and amylase in pancreatitis and the relationship of PLA to

red cells was discussed. The following observations were made.

1) Examinat ion of the exocrine secretory

function of the pancreas with the PS test revealed a significant positive correlation

between PLA and amylase in non-calcified chronic pancreatitis, pancreatic calculus

and the control. The secretory patterns also showed a similar trend.

2) In chronic pancreatitis, however, a

dissociation of 32% was found between the two enzymes and compared to PLA, amylase was more strongly disturbed. 3) In acute pancreatitis, chronic pancrea-

titis and biliary diseases, PLA showed an abnormally high serum level compared to

amylase and PLA was more closely related to abdominal pain than amylase.

4) Hemolysis occurred when human blood and PLA were mixed and incubated, but this phenomenon was inhibited by CDP-choline.

(172) O N T H E C O R R E L A T I O N O F C H R O N I C P A N C R E A T I T I S

W I T H A C U T E P A N C R E A T I T I S A N D C H O L E L I T H I A S I S

M. Shiraso, K. Tokutake, H. Sato,

S. Matsuno, N. Haga, Y. Saito, Y. Suda, and T. Sato

The First Department of Surgery, Tohoku University School of Medicine, Sendal

In the follow-up study of the complaints and

the pancreatic exocrine function in the

patients who had been confirmed by surgery as acute pancreatitis, the diagnosis of chronic

pancreatitis was obtained in 20.7% out of

346 patients. Secretin test was positive in 30 out of 101

patients of cholelithiasis. And pancreatic

fibrosis was detected in 8 of 125 from whom

pancreas biopsies were taken. Then chronic pancreatitis was confirmed in 3.8% of cho-

lelithiasis in whom both exocrine function

and histology were examined. It was also confirmed that the location of

the gallstone was not correlated with the

function and the histology of the pancreas. But The occurrence of chronic pancreatitis in

the patients with cholesterol stone was twice as much as in ones with bilirubin stone.

From these results, it was suggested that

the chronic pancreatitis would be caused by the common etiologic background in which

the cholesterol stone was formed, rather than by the mechanical factor of stones at the ampullar portion.

(173) A L C H O L I C C H R O N I C P A N C R E A T I T I S IN CHIBA

T. Kuroda and T. Tsunoda

Funabashi Central Hospital

In our series of 32 chronic pancreatitis

patients, 18 patients were associated with alcholism (56%), and 6 with gall-stones.

Among young patients, a first pain attack

appeared after 7 years of alcholism (about 70 gr. of ethanol per day), but among senior after 15~25 years (120~240 gr. of ethanol

per day). A diabetic type curve for 50 gr. GTT.

was present in 10 patients (56%), a border

type curve in 3 patients, and a normal type curve in 5 patients.

Liver fibrosis was present in 2 patients and

non-specific reactive hepatitis in 5 patients with liver biopsy.


(174) E X T E R N A L P A N C R E A T I C

S E C R E T I O N A F T E R O P E R A T I O N

O F U P P E R A B D O M E N

T. Kamata , H. Kanno , Y. Aneha,

and K. Kikuchi

Dept. of Surgery, Sendai National

Hospital

This study was designed to detect the

correlat ion between postoperat ive abdomina l

pa in and external pancrea t ic secretion after

operat ion of upper abdomen .

Pancreozymin-Secret in test was performed

a few days after opera t ion by the use of

amel iorated Dreil ing-type tube indwelt in

duodenum dur ing operat ion. Addit ional ly

de te rmina t ion of amylase activity in serum

and urine, blood sugar and biopsy of pancreas

were carried out. These examinat ions were

done in 62 cases compris ing 25 cases of gastric

cancer, 20 of gastric or duodena l ulcer, 15

of gall stone and two of cholecystitis. Those

cases were classified into three groups by the

grade of damage of pancreas dur ing operat ion:

viz. R I with no damage such as by cholecys-

tectomy, R 2 wi th damage such as by opera-

t ion of gastric cancer or of pene t ra t ing

gastric ulcer, R 3 wi th severe damage by

extended radical gastrectomy for gastric cancer.

Results obta ined were as follows.

1) M a x i m u m b ica rbona te concentra t ion

was found in 34% of R, cases, 54 ~ of Ro and /O

82% of R 3 cases.

2) Decrease of amylase output was

found in all the cases of R3, and of R 2 with exception of merely one case.

3) Postoperative abdomina l pa in was

compla ined by eleven cases, seven of 24 R~

and R a cases (29(}/o) and four 38 R 1 cases (10%).

4) Among twelve cases undergoing panc-

reat ic biopsy, only two were abnormal , show-

ing slight fibrosis, one of which was abno rma l

also by pancri~ozymin-secretin test while ano the r one was normal .

5) There was no correlat ion between the

result of pancreozymin-secret in test and

amylase activity of ur ine or serum.

(175) R E - E X A M I N A T I O N O F

T H E P E P T I C U L C E R A T I O N IN

P A N C R E A T I T I S

M. Abe

Hiratsuka City Municipal Hospital

K. Imamura , O. Kondo , Y. Yuki, and

S. O m a t a

Yokohama City Municipal Hospital

The purpose of this paper is to re-examine

the peptic ulcerat ion in pancreati t is .

The association between peptic ulcerat ion

an d pancreat i t is has been examined in a

series of 234 pat ients with pancreatit is, 11 of

whom had painless pancreat i t is disease.

Radiological evidence of peptic ulceration and

gastrointest inal haemor rhage was found in

43 (18.4%) of these who h a d had attacks of

pancreati t is , bu t the incidence of peptic

ulcerat ion was in fact only 9.4o/0 .

Chronic pancreat i t is was diagnosed by means

of surgery, the presence of pancreat ic calcifica-

t ion on radiographs of the abdomen, or by the

f inding of an abnorma l i ty in the pancreozy-

min-secret in pancreat ic exocrine function test.

Chronic pancreat i t is was also diagnosed in

pat ients with a strongly suggestive story of

pancreat i t is in whom two or more of the

following biochemical and radiological abnor-

malities were present : a border l ine pancrea t ic

funct ion test, an e levated ur ine and serum

amylase level, a positive provocative enzyme

test, or an abno rma l glucose tolerance test

and hypotonic duodenography .

The fasting serum gastr in level of pat ients

wi th chronic pancreat i t i s was significantly

low compared to those in normal controles.

The present observat ion would suggest

t ha t in many cases of these it can not be

a t t r ibu ted to peptic ulcerat ion except gastro-

intest inal haemor rhage as to serum gastrin level.

192 Proceedings of the 58th Annual Meeting, 1972--Tokyo--(II)

(176) T H E S T U D Y O N O R G A N

R E L A T I O N S H I P B E T W E E N B I L I A R Y

T R A C T A N D S T O M A C H (I) : O N

T H E F U N C T I O N O F G A L L BLAD-

D E R A F T E R G A S T R E C T O M Y

AND P O S T G A S T R E C T O M Y

C H O L E C Y S T I T I S :

S. Okamoto , H. Nagahara , H. Motoyama,

H. Watanabe , T. Maekawa, T. Miyakawa,

Y. Watanabe , Y. Anazawa, and T. M u r a k a m i ,

Department of Surgery, Juntendo Univdersity, School of Medicine

In recent years, wi th the progress of gastric

surgery, the cases of total gastrectomy a n d

fundectomy are increased. But the same

time, more considerat ions have to be pa id for

the organ relat ionship between bi l iary t rac t

and stomach, as the vagus nerves are cut

dur ing the surgery.

This is to repor t the clinical study and the

function of ga l lb ladder after gastrectomy.

I. C L I N I C A L S T U D Y Among the 2351 cases of gastric surgery for

the past ten years, 65 cases, 2.6% of cholelithiasis were found.

Post gas t rectomy cholecystitis with stone

were seen in seven cases; Most of cases were

accompanied wi th remarkable in f lammat ion

of gal lbladder, c o m m o n duct stones and in-

t rahepat ic stone.

Four cases were complicated with acute

gangrenous cholecystitis in early per iod after

gastrectomy. These cases showed remarkab le

inf lammat ion and no stones. Two cases

were seen after total gastrectomy and other

two cases were after Billroth I I method.

II. G A L L B L A D D E R F U N C T I O N BE- F O R E A N D A F T E R G A S T R I C S U R G E R Y .

Both the bile flow curve at the level of gall-

bladder and cholecystography are taken

at the same t ime after the venous injection

of 131 IBSP 10/to pre and post operat ively

to the 33 cases of the s tomach diseases and to 11 cases as control.

The bile flow curve of gall b ladder was

shown as % / m i n by the semi- logal i thm

diagram and by obta in ing the ratio of bile

flow from the gal lbladder , gal lbladder funct ion

was studied.

Contrac t ion activity of gal lb ladder is

generally decreased by the gastric surgery,

tha t is more remarkab le in cases with t run-

cal vagotomy compared with control cases.

The cholecystographies pre and post

t runcal vagotomy in dog and the decrease

of weight of h u m a n gall stone pu t into the

canine gal lb ladder were also stqdied.

There are m a n y papers on ga l lb ladder

function after gastrectomy but our s tudy re-

vealed t ha t ga l lb ladder is di lated and its

function is decreased by the gastric surgery,

part icular ly by t runca l vagotomy.

This is supposed to be by cut t ing the

vagus nerve.

(177) G A L L S T O N E F O R M A T I O N

A F T E R G A S T R I C R E S E C T I O N

T. Motoyama, T. Kawamura , and

Y. Kusaka

Department of Surgery, Iwate Medical College, Morioka

The present communica t ion is to repor t

nine cases of bile duct diseases developed

after gastric resection. Seven out of n ine

cases had gallstones and an analysis was

made concerning the mechanism of gallstone

format ion in connect ion with bile stasis,.

postvagotomy dyskinesia and bile infection.

Seven pat ients originally underwent ei ther

Billroth I or I I operat ion for gastric ulcer in

five and duodena l ulcer in two cases. Dura-

tion after gastric resection and the develop-

ment of gallstones ranged from five to 28

years with the average of 14 years. Five

out of seven pat ients had an initial symptom

of t ight hypochondra lg ia and fever was

associated in three patients. U p o n lapa-

rotomy, the ga l lb ladder was general ly dis-

tended and mixed stones with p r edominan t

bi l i rubin componen t were found in most of

the cases. Pancreozymin-secret in test after

gastric resection revealed dis turbed pancrea t ic

exocrine secretion which ~'nJicated impai red

contract ion of the gal lbladder. Cholecysto-

gram taken one m o n t h after gastric resection

showed dis tended ~.allbladder with poor con-


tractility after ingestion of ,egg-yolk in 17

percent. Contaminat ion of duodenal juice was found in 38 percent of hyperacidity and 50 percent of hypoacidity cases with higher

incidence in cholelithiasis than in gastric

lesions. After operation, the rate of contamination increased up to 63 percent in chole-

cystectomy cases and 100 percent in gastrectomy cases and the findings were the same

even after three months.

(178) F O L L O W - U P S T U D I E S O F B I L I A R Y T R A C T S U R G E R Y

M. Sugiura, F. Shima, S. Abe,

S. Ichihara, M. Nomura, T. Ushiyama S. Futagawa, and M. Ishida

2nd Department to Surgery, Faculty of Medicine, Tokyo University

The follow-up studies of 81.3% of 267

patients who were subjected to biliary surgery during 7 years were presented.

The common causes of the sequelae of

biliary tract surgery were residual or reformed stones, stricture of biliary tract, stenosis of

papilla of Vater, and portal hypertension. The operative procedures, such as stone

removal with sphincterplasty, hepaticoje-

junostomy, sphincterplasty alone, and esophageal transection with para-esophagogastric

devascularization and splenectomy, were needed on 61 patients with postbiliary surgery

syndrome.

The incidence of the sequelae due to residual stones could be reduced by the

radiological examinations and instrumental explorations during surgery.

There were some cases who had dilatation

of the common bile duct without stenosis of the papilla of Vater at first operation. Sphincterplasty could be often beneficial in such cases.

The cholangiograms of some cases after first surgery revealed the dilatation of the common bile duct. Further studies should

be done for the evaluation of sphincterplasty as a therapeutic procedure for these patients.

(179) A S T U D Y OF P E R C U T A -

N E O U S B I L I A R Y D R A I N A G E

G. Oba ta et al.

First Department of Surgery, Chiba University School of Medicine

In cases of obstructive jaundice, drainage

operations such as cholecystostomy have been usually performed before radical operation,

because one stage operation often brings great hazard. But the drainage operation can not always be performed without any trouble.

So, easier and safer method of drainage was studied.

After percutaneous transhepatic cholangiography was carried out to visualize the

position and the cause of the obstruction, a needle (external diameter 2 mm.) covered

with a polyethylene tube is introduced

percutaneously into the dilated intrahepatic bile duct and withdrawn leaving the tube

in the punctured bile duct. Then through the tube, a polyvinyl tube is led into the

common hepatic duct or choledochus for biliary drainage.

The effect of the percutaneous drainage was similar to that of the drainage operation.

This procedure was carried out in 40 patients. And after jaundice had been

relieved, one stage operation performed in

23 cases.

Percutaneous biliary drainag is a useful procedure that ensures one stage operation

for obstructive jaundice and enables to examine the bile or to obtain cholangio-

grams repeatedly. I t can be also utilized for lavage of the bile duct and infusion of

agents (e.g. antibiotics for suppurative cholangitis or chelating agents for intra-

hepatic calculi) into the bile duct.

194 Proceedings of the 58th Atinual .Meeting, 1972-- Tolryo--( H)

(180) P H Y S I O L O G I C A L A N D

P H O T O - O P T I C A L O B S E R V A T I O N

U S I N G T - T U B E A F T E R B I L I A R Y

S U R G E R Y

Y. Sugiyama, K. Suzuki, M. Abo,

M. Takeuchi , E. Tann , K. K i m u r a

A. Iwaya, H. Takahashi , and K. O n o

Department of Surgery, Faculty of Medicine, Hirosaki University, Hirosaki (Director:

Prof. K. Oh-Uti)

The purpose of this study is to know the

physiology of bile flow in the pat ients wi th

gallstone disease who have undergone bi l iary

operat ion in our clinic.

Three exper iments were s imultaneously

performed for this study, such as radiocine-

ma tog raphy wi th concomitant electromyo-

graphy of Odd ' s muscle, manomet r ic measure-

men t of bile duc t and the pa inproduc ing

test by raising the biliary pressure via the

tube.

The results obta ined are as follows:

1) Bile flow to the duodenum was control-

ed by Oddi ' s muscle independent ly of duodena l

wall muscle.

2) The te rmina l port ion of c o m m o n bile

duct appeared to have not only contrac t ive

movemen t bu t dynamic action evacua t ing

in t raduc ta l contents into the duodenum.

However, in the cases having a long t e rm

history of in t racholedochal gallstones, there

were showed nei ther the contract i l i ty nor

evacuat ing movement .

3) The basal pressure of the bile duc t was

founded from 80 m m H 2 0 to 142 m m H20 ,

and the 3 cases showing high level pressure

revealed residual stones.

4) The pa in-produc ing pressure of the

common bile duc t was showed from 850 m m

H 2 0 to 210 m m H20 . In the case indica t ing

m i n i m u m value of pa in-producing pressure

residual stones were founded in the c o m m o n

bile duct.

J . Inoue, S. Miyaishi, T. Sasaki,

Y. Kuroyanagi , T. Sato, H. Kato,

C. Kido, and K. Hib ino

Aichi Cancer Center Hospital, Nagoya

The 80 gal lbladders excised surgically

were examined by X-ray filled with radio-

paque.

The a b n o r m a l findings (shapes) of photo-

graphics in re la t ion to macroscopic and

histologie findings were studied.

The character is t ic pat terns of t hem were

as follows: 18 cases radiologically character iz-

ed by a symmetr ica l constriction of the gall-

b ladder were simply due to nar rowing of

the lumen except 1 case. Eighteen cases

demons t ra t ing radiologically an uni la tera l

constriction were also noted.

This was due to inf lammatory scar or

bend wi thout scar. The differentiat ion of

those two factors could be made by irregulari ty

of the marg in of the constricted wall. Nine

of the 10 cases wi th an irregular marg in had

inf lammatory scar, whereas 3 of the 8 cases

wi thout it were the bended gallbladder. The

irregular serrat ion of the gal lb ladder was

observed in 48 of 63 cases excluding 17 cases

of the constr icted gallbladder. This f inding

was considered to be due to granulomatous

inf lammat ion of the muscle layer and papil-

lary proliferat ion of the mucosa. In the

remain ing 15 the regular contour of the

gal lbladder was demonstrated. I t was to

be noted, however, a correlation between

the severity of the irregular serrat ion and the

thickness of the gal lbladder was not always

parallel. In 28 of 80 cases the radiological

divert iculum-like out pouchings (herniations)

of the gal lb ladder were demonst ra ted radio-

logically. These were confirmed histologi-

cally similar to Aschoff-Rokitansky sinuses.

Four teen of the 28 cases were associated

with a constrict ion of the gallbladder.

(181) F U N D A M E N T A L S T U D I E S

O N X - R A Y D I A G N O S I S O F G A L L -

B L A D D E R DISEASES

Proceedings of the 58th Annual Meeting, 19 7 2-- Tokyo--( H ) 195

(182) T H E D I A G N O S I S OF C A N C E R OF T H E P A N C R E A S A N D B I L I A R Y

SYSTEM BY C O M B I N E D P E R C U - T A N E O U S T R A N S H E P A T I C C H O -

L A N G I O G R A P H Y , H Y P O T O N I C D U O D E N O G R A P H Y A N D CYTO-

L O G I C M E T H O D

M. Kishikawa, T. Takeuchi, H. Murate, A. Tanabe, M. Kozuka, M. Ito,

N. Kato, Y. Yazaki, K. Goto, M. Miyaji, K. Suzuki, K. Ito,

and J . Yokoi.

1st Int. Med. Nagoya City Univ.

Percutaneous transhepatic cholangio-

graphy (P.T.C.) and hypotonie duodenography (H.D.G.) were taken at same t ime

for diagnosis of the pancreas and biliary system. Furthermore, cytologic diagnosis

of the intrahepatic bile and duodenal juice which obtained during these procedures,

was combined to approach more reliable

diagnosis. For cytology, modified cytologic technic was employed in this study, i.e.

the sample was suspended in chilled saline water for protection of cellular degeneration

and centrifused and smeared with "Auto- smear" for collection of the ceils.

Of 95 patients, 43 cases were cofirmed to be cancer and 52 cases to be benign lesion

in the pancreas and biliary tract by operation or autopsy. Of 34 cases with cancer examined

cytologically, 22 cases were positive in the bile or duodenal juice. All of 52 patients

without cancer were negative and no false positive. Malignant cells were detected in high percentage in carcinoma of the bile

duct and gallbladder in the bile, and so did in carcinoma of Vater 's ampulla in the duodenal juice. Five patients with cancer were

difficult to differentiate from benign lesion by the combined X-ray examination of P.T.C. and H.D.G., but three were positive by cy-

tology. Therefore, the accuracy of diagnosis of cancer in the pancreas and biliary system was improved by the combined application

of the three diagnostic methods. In ten of seventeen cases with cancer,

elevated activities of G,O.T. , G.P.T. and

AI-P. continued to decrease during three weeks after the onset of jaundice, but remained

higher than the normal level. It should be

notewothy that the enzyme activities decreased in spite of the persistent obstructive jaundice with cancer.

(183) P A N C R E O Z Y M I N - C H O L E C Y S T O G R A P H Y

I. Endo*, S. Kato*, M. Miyazaki*, N. Murayama*, and A. Kawamura**,

*Department of Surgery, **Department of Internal Medicine, Tokyo Dental

College

Serial cholecystography using pancreozymin

(Pz) 2u/Kg as a gallbladder stimulant was performed and changes in gallbladder, biliary

tract and duodenum, complains of the patients were observed in 9 controls and 20 patients

who complained of right upper quadrant abdominal pain - 9 cystic duct syndrome

(C.D.S.), 4 adenomyomatosis of the gallbladder, 2 acute cholecystitis, 2 choleli-

thiasis, 3 cholecystopathy. In the control subjects, the extent of gallbadder shadow

became minimum at 10 min after Pz injection and Ca 40% on the average compaired with before Pz injection.

At 5 min the extent was more than 75% in most of the patients, but in most of the

controls less than 75%. In C.D.S. patients, the reduction of the extent was diminished and

prolonged, in 5 cases even a temporary increase of the extent was noticed, the extent of shadow was more than 75~; at 5 min in 7 C.D.S. patients, and was minimum in

15 or 30 min. Three patients complained mild right

upper quadrant abdominal pain. Duodenum was visualized well at 3 to 10

min and disappeared at 15 min in the controls, but in serious C.D.S. patients, it was

visualized late at 15 or 20 min or non-visualized therefore the impaired visualization of duodenum may be one of the indicator for im-

paired gallbladder evacuation. In 3 adenomyornatosis patients whose

cholecystogram showed remarkable stricture

196 Proceedings of the 58th Annual Meeting, 1972-- Tokyo-- ( H)

which were confirmed at operation in the mid-portion of the gall-bladder, infundibular portion became promptly small so far as 33 to 12% at 3 or 5 rain after the injection of Pz, then dilated promptly to 74 to 60% at I0 or 15 min, whereas fundal portion showed remarkable impaired contraction and the extent of the shadow was about 90% at 5 rain. The reduction of the shadow of fundal portion in 2 cases progressed over 30 rain.

These findings may be available for the differential diagnosis between mere bend and stricture caused by adenomyomatosis.

(184) P E R C U T A N E O U S CHOLAN- G I O G R A M , H Y P O T O N I C D U O - D E N O G R A M AND D U O D E N O F I - BERSCOPIC F E A T U R E IN T H E

I N F L A M M A T O R Y DISEASES OF PAPILLA

T. Ono Int. Med., National Cancer Center Hospital.

M. Ohto, et al.

1st Dept. of Int. Med., Chiba Univ. School of Med.

The features of inflammatory diseases of papilla are followed. (1) The choledochusend in the percutaneous

cholangiogram is described as the stenosis

or sclerosis in constant. (2) The papillary shadows in the hypotonic

duodenogram are variable in shape and aize.

(3) The endoscopic papillary features are variable too.

(4) The histological changes in papilla are discrepant between the biliary side and the duodenum.

(5) The diseases of papilla in biliary side is of consequence than in duodenum.

Conclusion Percutaneous cholangiography is useful

for diagnosis of the papillary diseases, but hypotonic duodenography and duodenofiber scopic findings are little.

(185) F I N D I N G S OF P E R C U T A - NEOUS T R A N S H E P A T I C CHOLAN-

G I O G R A P H Y OF THE P O S T C H O L E - C Y S T E C T O M Y CASES W I T H COM-

PLAINTS B. Murohisa

Gastroenterological Department, Hamamatsu Medical Center.

Percutaneous transhepatic cholangiography was carried out on fifty cases, in which 8 cases were post-cholecystectomy cases for the past one year. Analysis of the findings of post-cholecystectomy cases are shown in the table.

No. Symptoms I) i) Upper abd. pain (colic)

2) Fever (38~ 2) Rt. Hypochondralgia (colic)

3) 1) Upper abd. pain (colic) 2) Jaundice 3) Fever (41~

4) Heavy feeling on the back (Rt.)

5) Rt. hypochondralgia (colic)

6) 1) Rt. hypochondralgia (colic)

2) Transient jaundice

7) 1) Rt. hypochondralgia (colic)

2) Nausea and vomiting 8) Rt. hypochondralgia

(colic)

DIC PTC Findings Not done

Well visualized

Not visualized

Faintly visualized

Faintly visualized

Faintly visualized

Not visualized

Poor

1) Dilatation of common duct. 2) A stone in common duct. Two stones in common duct.

1) Dilatation of common duct. 2) A common duct stone.

Cystic duct remnant .

Stricture of sphincter of Oddi.

1) Dilatation of intrahepatic duct. 2) Narrowing of common duct. 3) Shortening of common duct. 4) Cystic duct remnant. 1) Choledochal cysts

(intrahepatic and common duct.) 2) Narrowing of common duct. Ascaris in intrahepatic duct.

Visualization

Proceedings of the 58th Annual Meeting, 1972-- T&yo--( H ) 197

(186) A C O M P A R A T I V E S T U D Y OF

S U R G I C A L F I N D I N G S AND

C H O L A N G I O G R A M S IN BILE D U C T CANCER, W I T H SPECIAL REF-

E R E N C E T O P E R C U T A N E O U S D O U B L E C H O L A N G I O G R A P H Y

M. Uchimura S. Hirai, M. Akashi

M. Furukawa G. Nakashima H. Furuse, and R. Tsuchiya

Second Department of Surgery Nagasaki University

Percutaneous cholangiography is the best

diagnostic procedure to find the organic change

of the bile duct. It is difficult, however, to evaluate indication for surgical removal of

the bile duct cancer on X-ray findings,

because reliable details of obstructed region such as depth of cancerous infiltration and

intraductal morphology are not available in the routine method owing to poor mixture of the

bile and the contrast medium.

Since May 1963 we have performed percutaneous perhepatic cholangiography on

279 cases, dividing the findings into five

types: V-type, U-type, straighthorizontal type, rat-tailed type, and stenotic type.

This time we evaluated routine cholan-

giography and the so-called "double cholangiography" technique in which air is

injected after saline water irrigation of the bile duct, comparing with surgical findings

on 28 cases of bile duct cancer operated since September 1969. Excluded from this study

are bile duct cancer in the liver and gall- bladdef cancer.

In upper and middle bile duct cancer, there were two V-types, one U-type, four

horizontal types, and two stenotic types of the upper bile duct and three stenotic types of the middle bile duct. In lower bile duct

cancer, there were three stenotic U-types of the upper bile duct and two U-types of

the middle bile duct. Ampul la cancer had two U-types of the upper bile duct and pancreatic head cancer had three such types.

Resection of the lesions were possible in four middle bile duct cancer cases, and five

lower bile duct cancer cases, and three am-

pulla cancer, 12 cases in total. They formed horizontal type in middle bile duct cancer

and U-type in lower bile duct and ampulla

cancer. However, U-type was also found in the inoperative cases of pancreatic head can-

cer causing difficulty in differentiation. Double cholangiography was performed

on 22 of these 28 operated cases, showing

V-type and stenotic type as demonstrated in routine cholangiography without ela-

sticity of the wall. Horizontal type becomes U-type in double cholangiography and the

wall is dilated easily. The final end of the bile duct is better visualized in lower bile

duct cancer and ampulla cancer. U-type of pancreatic head cancer took the shape of

V-type with stenosis of the lower bile duct. Resection of the lesion was possible in

four of five middle bile duct cancer which

presented four U-type of the middle portion of the bile duct, four U-types of the lower

bile duct and three irregularity of the end portioon of the common bile duct demon-

strating good wall elasticity. Thus U-type stenosis and irregular common bile duct end

in double cholangiography are good indication for resection of cancerous lesions.

(187) P A T H O L O G I C A L S T U D I E S ON T H E P A P I L L A R Y C A N C E R

T. Fukuda, F. Hanyu, N. Sakakibara, H. Suzuki, H. Ide, and K. M o m m a

Department of Surgery, Institute of Gastroenterology, Tokyo Women's

Medical College

Paying some regards to its histology, we classified papillary cancer into the following four groups;

1) papillary cancer on the duodenal side, 2) so-called papillary cancer,

3) cancer in the lower end of the common bile duct,

4) cancer in the distal end of the pancreatic duct.

So-called papillary cancer was found in 5 cases, the cancer in the lower end of the common bile duct in 5 cases, the papillary

cancer on the duodenal side in 3 cases and


the distal end of the pancreatic duct in 1 case. The last one (cancer in the distal end of

the pancreatic duct) was identified histolo- gically.

Radical resection was performed in 12 cases, among which the smallest one is so-

called papillary cancer and the largest one

is cancer arised from the lower end of the

common bile duct. All the cases of the papillary cancer on the

duodenal side and the so-called papil lary

cancer were polypoid type and 2 out of 5 cases of the lower end of the common bile

duct were ulcerated type.

(188) A S U L F A T E D G L Y C O P R O T E I N , CAPABLE O F C O A G U L A T I N G CAL-

C I U M C A R B O N A T E , I S O L A T E D

F R O M P A T H O L O G I C A L H U M A N

BILE

H. Nagashima, T. Matsushiro,

N. Suzuki, T. Saitoh, N. Nakamura,

W. Takahashi, T. Maeta, T. Hatanaka, N. Kobayashi, and T. Sato

The First Department of Surgery, Tohoku University School of Medicine

Water-soluble fraction (Fr. 1) obtained

either from pathological human bile or normal human bile was fractionated centrifugally

in the presence of salts to give six fractions

(Frs. 2, 2R, 3,4,5, and 6). Of these fractions, the major fraction (Fr. 3) obtained from the

pathological bile was shown to have strong coagulation effect for calcium carbonate suspension in water, whereas any coagulation

effect was not found in the fractions obtained from the normal bile.

Gel-filtration on DEAE-Sephadex A-25 of Fr. 3 from the pathological bile afforded

Fr. 3W. This fraction had the similar coagulation effect for calcium carbonate suspension to Fr. 3.

Fr. 3W showed a single band each at p H

3.0, pH 7.0 and p H 9.0 in cellulose acetate electrophoresis. This fraction contained

galactose (27.2%), glucosamine (17.3%), galactosamine (9.6%), L-fucose (15.9%),

sulfate (1.5%) and minute quantities of

xylose and arabinose. Contents of threo- nine, serine and proline were relatively high

in the protein moiety. The data indicated that Fr. 3W was a sulfated glycoprotein.

Since Fr. 3W was suggested to be an

abnormal component in the bile, an important role of sulfated glycoprotein (s) in gall-

stone formation was indicated.

(189) S U R F A C E - C H E M I C A L

S T U D I E S O N T H E S I G N I F I C A N C E

OF L I T H O C H O L I C A C I D O N

G A L L S T O N E F O R M A T I O N (I)

M. Hagano and T. Furusawa

1st Dept. of Surg., Fac. of Med. Kyushu Univ.

It has been well established that bile salts

and phospholipids chiefly lecithin play the main roles in the solubilization of cholesterol

in bile. The existence of lithocholic acid

was disclosed by recent GLC studies. The aim of the present study has been to clarify

the effect of lithocholic acid on the solubilization of cholesterol by bile salts and leci-

thin. All experiments were carried out at 23•176 First, the solubilization of sodium

lithocholate by bile salts (sodium cholate and sodium deoxycholate), lecithin systems was

studied by turbidimetry. The amount of solubilized sodium lithocholate by bile salts

was 7.8%, and that by bile salts lecithin 6.1%. The time dependency of solubili-

zation of cholesterol was thoroughly checked. The amount of solubilized cholesterol dec-

reased with increasing amount of sodium lithocholate to some extent.

The solubilization of cholesterol by bile

salts, lecithin was dependent on the L/B ratio, below 0.25 the co-existence of sodium lithocholate decreasing the amount of solu-

bilized cholesterol, but above that hardly altering it in tt'_e checked concentration range.


(190) R E L A T I O N S H I P B E T W E E N

BILE C O M P O S I T I O N A N D GALL- S T O N E F O R M A T I O N IN S Q U I R -

R E L M O N K E Y S

T. Osuga and O.W. Portman

Department of Primate Nutrition, Oregon Regional Primate Research Center, Beaver-

ton, Oregon 97000, and the Department of Biochemistry, University of Oregon

Medical School, Portland, Oregon, U.S.A.

We investigated the mechanisms of cho-

lesterol gallstone formation in squirrel mon-

keys by measuring cholesterol, phospholipid, and different bile acid concentrations

in gallbladder and hepatic bile and in the

gastrointestinal tract. A group of monkeys which was fed a semipurified diet that

resulted in a high incidence of gallstones

(Group 3) had higher concentrations of cholesterol relative to phospholipid and bile

acids than monkeys fed a corresponding diet with an unsaturated fat and no choles-

terol Group 2). Monkeys fed a commercial

natural diet (Group 1) had no gallstones and the lowest concentration of cholesterol

relative to the cholesterol-stabilizing factors in the gallbladder bile. The animals in Group 2 with gallstones had higher relative cholesterol

concentrations than monkeys in that group

without stones. The presence of gallstones

in individuals was predicted from gallbladder bile compositions and any one of several

indices of the maximum level of cholesterol that could be stabilized in micellar forms.

In most monkeys the concentration of cholesterol relative to bile acids and phospho-

lipids was higher in hepatic than in gallbladder bile, although the proportions of different

bile acids were similar in the two types of bile. Deoxycholic acid was present in re-

latively low concentrations in the biles of animals from Group l, al though deoxycholic

and lithocholic acids, which are bacterial products, were produced in the large intestine of all animals. The poor size of tauro-

cholic acid was much higher in monkeys from Group 1 than in the other monkeys.

(191) A S C A N N I N G E L E C T R O N M I C R O S C O P I C S T U D Y O F H U M A N

G A L L S T O N E S

T. Ogata, S. Tanaka, K. Takahashi,

and H. Kibayashi

Dept. of Surgery, Okayama University Me- dical School, Okayama

The fine surface and cut-surface structure

of gallstones were observed under a scanning electron microscope. In cholesterol gall-

stones, the fracture surface generally showed a crystalline plane radiating pattern, often

with dendritic growths around the nucleus. On the surface or fractured plane of a cho-

lesterol stone, paral lelogram crystals or corrugated crystals were sometimes seen.

In higher magnification, the surface of a

crystalline plane is seen to be composed of lamellae of about 200 A in thickness, which

was frequently associated with spiral growth. In bilirubin stones, an accumulation of

spherical granules 2 or 3 microns in diameter,

or mud-like amorphous substances were observed. In the laminated stones, layers

with different structures 30 microns in thickness were arranged alternately. From

infrared spectroscopic analysis, it was eluci- dated that the layers with amorphous struc-

ture were composed of bilirubin, the layer of multiple holes were bilirubin and lipid,

and the columnar crystals were cholesterol.

Lipid stones were composed of plane-like or leaf-like crystals.

Limy biles were composed of calcium carbonate or calcium oxalate.

In the limy bile with calcium oxalate, needle- like crystals 30 microns in length were assembl-

ed in an arrangement which tended to give the whole a spherical structure. In the

limy bile with calcium oxalate and calcium carbonate, cuboid crystals, and spherical

or oval crystals were also observed in addition to needle-like crystals.


(192) S T U D Y O F E T I O L O G I C A L D I S P O S I T I O N O F A C U T E P A N C R E A -

T I T I S W I T H C H O L E S T E R O L S T O N E

H. Yamazaki, K. Komaki, H. Tanimura,

and Y. Hikasa

Dept. of Surgery R. Ogawa

Dept. of Intern. Med. Kyoto University

The difference in endemic incidence of

acute pancreatitis with cholesterol stones

is considered probably due to different

dietary customs, such as Japanese or European. We had previously noticed that metabolic

disturbance in the essential fatty acids (EFA) has a close relationship to the formation

of cholesterol stones. In the same way, the high incidence of gallstones in patients with

acute pancreatitis could also he explained by disturbed metabolism of EFA as a result

of the following examinations. 1) Trypsin or autogenous bile decreased

permeability of the membranes of pancreatic acinar cells in hamsters fed on lithogenic

(EFA dificient) diets, respectively. Addition

of bile on trypsin more decreased it due to stimulated endogenous trypsin.

2) Urinary pancreatongenic isoamylase

in lithogenic diet groups showed higher level

than those in hamsters fed on non-lithogenic

diets. 3) In human cholecystectomized cases,

patients with cholesterol stones showed that urinary pancreatogenic isoamylase main-

tained high level not only before operation but also 2 or 4 months p.o. later except transient increase due to surgical injury.

4) In patients with pigmented stones or mixed stones it showed low level and rapidly

recovered from a transient increase due to infection or operation.

(193) A N E W O X I D A T I O N EN- Z Y M E P R E S E N T IN H U M A N

SALIVA

H. Nakagawa

Tokyo National Chest Hospital

Findings concerning the physiological role of saliva in the alimentary canal in man

are not so many. This means that the

salivary contents have not been estimated to be significant. The author found recent-

ly a new oxidation enzyme which catalyzes promptly the oxidation of Rifampicin, which

is a semisynthetic antibiotic, in human

saliva, and has been investigating its catalytic

properties.

The saliva obtained from normal subject

was centrifugalized for 20 minutes at 10,000

r.p.m at 5~ and its supernatant solution was used. When Rifampicin was incubated

with the centrifugalized saliva in acid condition corresponding to the physiological

acidity of gastric juice, it was observed that Rifampicin was promptly and remarkably

oxidized into Rifampicin-quinone. The oxidation velocity was rapid being completed

within 15 minutes at room temperature, and the rapid oxidation with the salivary catalyst

was a striking contrast to a slow autooxida-

tion of Rifampicin in the presence of divalent copper. At room temperature around 20~ the oxidation catalyst of saliva was unstable

being destroyed nearly in a few hours. How- ever, under the keeping at 5~ its activity

was maintainable in relatively stable for several days. The original enzyme present

in saliva having about neutral pH was sub- stantially inactive, and its catalytic activity

first appeared when the acidity of the saliva was brought to p H below 3. The activated

enzyme also restored reversibly into the original one by varying the pH above 4. Such

a pH depentent activity of this enzyme was very similar to the activation of pepsinogen

into pepsin in a strong acid condition. The oxidation of Rifampicin by the salivary enzyme was completely inhibited in the

presence of cyanides, cysteine, H2S , and further inhibited partially with DETA, and

any thio-compounds. This suggests that

the present enzyme may be an oxidase

with copper which seems to be essential

for its activity. The hydrogen acceptor participating in the enzymatic oxidation


of Rifampicin was decided to he molecular

oxygen, from an evidence that the 0 2 uptake accompanied by the Rifampicin oxidation

with the enzyme fractions which had been

isolated from saliva was correlated well

with its oxidation activity, on a gasmetric analysis in a Warburg's manometer. Physio-

logical meaning about the presence of such an oxidase in saliva has not yet been clarified.

However, it may be imagenated that this

enzyme must have any physiological function in the alimentary canal, perhaps important

as a preliminary treatment of certain sub-

stances prior to their intestinal absrption. It was further pointed out that there was a significant individual difference in the enzyme

activity of saliva which was sampled in fasting.

(194) CLINICAL APPLICATION

OF SIALOSCINTIGRAM AND RADIOSIALOGRAM W I T H 99mTC

IN PATIENTS W I T H COLLAGEN DISEASES

M. Osada Department of Gastroenterology

H. Koizumi

Department of Internal Medicine M. Katayama

Department of Radiology H. Sakamoto

Department of Otology Kawasaki City Hospital

We presented before the 57th General Meeting, the Japanese Society of Gastro-

enterology, that the technical advances about Sialoscintigram and Radiosialogram, such as introduction of 99mTC and the new collimator,

had further enforced its clinical utility. The subjects were 23 patients with collagen

diseases (SLE: II, PSS:2,RA:3, RA with PSS: 2, Sj6gren's syndrom:I, DM: I) and the allied diseases (Wegener's granulomatosis :

I, Beh~et~ syndrome: I, colitis ulcerosa: I). This radioisotopic method indicated the

salivary dysfunction despite absence of xerostomia in the cases of collagn diseases

and the allied diseases.

(195) MEASUREMENT OF TRANS- MUCOSAL POTENTIAL DIFFERENCE

OF THE H U M A N STOMACH

UNDER ENDOSCOPIC

C O N T R O L

T. Manome, M. Sesoko, M. Kobayashi, Y. Komine, Y. Saito, N. Watanabe,

Y. Okabe, M. Ogino, T. Naruke, T. Hoshika, T. Miyano, and K. Tsuneoka

3rd Department of Internal Medicine, Nippon Medical School, Tokyo, Japan

Changes in transmucosal potential difference of the stomach (PD) may reflect active trans-

port of ions across the mucosa at the gastric acid secretion, or injury potential at mucosal

damage. We have investigated PD under

endoscopic control. Method; The gastric electrolyte bridge

was a polyethylen tube filled with 3.33 N. solution of KCL 3% agar. Placement

of the bridge and subsequent verification were made under endoscopic control. Using skin (finger) as the site of the reference

electrode, the electrolyte bridge led to balanc-

ed Calomel half cells which were connected

to potentiometer. Result: In patients with chronic gastritis

PD ranged from 2.0 to 25.0 (av.15.8) mV

in fundic gland area, and from 17.5 to 45.0 (av. 31.3) mV in pyloric gland area (mucosal

negative). In patients with gastric ulcer there was significant decrease of PD at the

basis of ulcer and the mucosal fold surround- ing the basis of ulcer where mucosal membrane assumed hyperemic and swollen,

compared with adjacent mucosa. However, PD at the scar was about as equal as surround-

ings. Though it requires luther examinations

as for the method and the condtions in the mucous membrane, we wish to put into prac-

tice for recognition of the atrophic border, guide to treatment of gastric ulcer, and differential diagnosis of benign and malignant

lesions.

202 Proceedings of the 58th Annual Meeting, 1972-- Tokyo-- (H)

(196) G A S T R O I N T E S T I N A L

D I V E R T I C U L A : R E P O R T O F 54 CASES

S. Kitajima, I. Nakada, Y. Sasamori, H. Munakata, K. Tanaka, H. Oguro,

T. Numata , and K. Oh-Ut i

Department of Surgery, Faculty of Medicine, Hirosaki University, Hirosaki (Director:

Prof. K. OH-UTI)

Fifty five cases of the gastrointestinal

diverticula were admitted in our clinic for the last twenty years.

Their details were as follows : 14 cases of the esophagus, 1 of the stomach, 29 of the

duodenum, 1 of the ileum, I of the Mechel 's

diverticulum and 8 of the large bowel. Esophageal diverticula:

Most of the cases were found of the mid- esophagus.

Two cases of the giant diverticulum and 2 cases with esophagobronchial fistula were

also observed. Duodenal diverticula:

Hal f cases accompanied with biliary diseases including cholelithiasis.

Multiple diverticula were found in 6 case (20.7%).

Diverticula of the large bowel:

Most of the cases were found among male of 50 years and upward.

Compared with the upper gastrointestinal tract, the cases of severer diverticulitis were

observed in the large bowel. Two cases showed massive bleeding and one case had perityphilitic abscess.

(197) E F F E C T OF A L C O H O L

ON I N T E S T I N A L D I S A C C H A R I - DASE A C T I V I T Y

Y. Yoshida, S. Goto S. Yanagiya, K. Takashina, and F. Matsunaga

The 1st Department of Internal Medicine, Hirosaki University School of Medicine,

Hirosaki, Japan and

G. Sasaki

Department of Internal Medicine

Noshiro-Minsei Hospital Noshiro, Japan

In order to study the roll of environmental factors in the etiology of adult lactase de-

ficiency, alcohol effect on intestinal disaccharidase activity was studied in both

clinical cases and experimental animals. Enzyme assay was done by Dahlqvist 's

method in the biopsied materials from the

upper jejunal mucosa. Disaecharldase activities were as follows:

lactase 6 .6• units, maltase 305.6• units, sucrase 106=~37.2 units in 17 alcohol

drinkers, and lactase 6.34-3.7 units, maltase

259.1~79.4 units, sucrase 94.1=b35.7 units in 52 non-drinkers. Enzyme activities were somewhat higher in alcohol drinkers than

in non-drinkers. The same tendency was observed in various digestive diseases, namely

in peptic ulcer, port-gastrectomy, hepatic diseases, and irritable colon syndrome.

Wistar rats were fed with alcohol (10~20

ml. of 20% ethanol/rat/day), and the disaccharidase activity were assayed with passage

of time. Lactase, maltase, sucrase began to increase in activity after 2 weeks, and were definitely elevated after 6 weeks in

comparison with the rats on normal diet.

However, after 8 to 12 weeks the elevated activities gradually returned to the original level.

It was concluded t h a t alcohol did not

depress the intestinal disaccharidase activity but it might rather increase the activity in a certain period of time during alcohol intake.

(198) S T U D I E S O N M I L K IN- T O L E R A N C E , W I T H SPECIAL

R E F E R E N C E T O E V A L U A T I O N OF

S E R U M G A L A C T O S E LEVEL O N L A C T O S E T O L E R A N C E T E S T

(LTT) W I T H E T H A N O L

A. Kimura, T. Sasagawa, G. Takahashi, and H. Sugiyama

Division of Internal Medicine, Nagaoka Chuo-sogo Hospital

In an effort to improve the reliability of the lactose tolerance test in the detection of


lactose deficiency, blood galactose and glucose levels were measured after the oral administration of lactose (20gm.) with ethanol, and, glucose and galactose (1:1, each 10gm.) with ethanol. The concentration of blood sugar was measured by autoanalyzer. The concentration of galactose was measured by galactose-oxidase method (Galactostat, products of Worthington Biochemical Corp., was used.). About the dosis of ethanol, which blocks the intrahepatic conversion of galactose to glucose, we tested 0.3, 0.2, 0.15 and 0 ml./kg, body wt.. It is concluded that 0.2ml./kg. of ethanol is minimal sufficient and clinically convenient dosis. The addition of ethanol caused a slight increase in blood glucose concentration. Fasting blood galactose was always 0-2.5 mg./dl.. Galactose and glucose tolerance test caused 14-27mg./dl. of increase at maximum in blood galactose in normal adult (30 or 45 rain. after administration). Twenty gram of lactose with 0.2ml./kg. body wt. of ethanol were administrated to 20 subjects. All cases whose intestinal mucosal lactase activities were lower than 1 unit/gm, wet wt. showed the rise in blood galactose less than 5mg./dl.. It is concluded that this technique would discriminate between normal and lactase deficient patients. Further examination, especially in white people, should be required. And, it is proposed that a single or twice blood galactose measurement after a small lactose-ethanol cocktail can be used as a screening test for Iactase deficiency.

References

1) Fischer W. Zapf J. : Klin Wochenschr. 43: 1243-1246, 1965

2) Hjelm M.: Clin Chim Acta 15: 87-96, 1967.

3) Kern F.Jr Heller M.: Gastroenterology 54." 1250, 1968.

4) Isokoski M. Jussila J. Sarna S.: Gas- troenterology 62: 28-32, 1972.

(199) FUNDAMENTAL AND CLINICAL STUDIES OF SMALL INTESTINAL BIOPSIS. (VI) DIS-

ACCHARIDASE ACTIVITY AND LACTOSE TOLERANCE TEST

K. Iwaki, S. Okada, H. Koizumi, M. Iwasaki, Y. Kawashima, H. Kaneda, K. Takahashi, T. Honda, and K. Ariga

The III Dept. of Medicine Nihon University

It is very important problems for the clinical study correlating between biospy specimens of small intestinal mucosa and absorption of nuctritive substances.

We have studied (1) the opinionare from the patient with milk intolerance, (2) Clinical study of lactose tolerance test, (3) disaccharidase activity from small intestinal biopsy and (4) change of component of food.

The frequency of milk intoleranc was 17.3% of 1.477 cases. Although this cause was reported as lactase deficiency, it is presumed those were included in some factors after taking milk.

This lactase enzyme is considered adapta- tion enzyme resulting from disaccharidase of small intestinal mucosa, abstinence of food, recovery of lactose tolerance with animal test.

Milk intolerance cases were high incidence in surgical stomach. We are considering these etiology due to deficiency of lactose 1 and lactose 2.

(200) DISACCHARIDASE ACTIVITY IN THE SMALL INTESTINE BY

ENDOSCOPIC BIOPSY

Woo pak Sa, H. Hozawa, and H. Hiratsuka

Hiratsuka Gastroenteric Hospital, Tokyo, Japan

We carried out direct endoscopic biopsy of the gastrointestinal tract by the flexible intestinal fiberscope and spoke the results of disaccharidase activity. Method: 1) We used about 3 meter intestinal

fiberscope (Type FIS-IIIb, Machida, Tokyo).

204 Proceedings of the 584h Anmtal Meeting, 1972--Tokyo--(H)

2) By means of a transintestinal tube the instrument was introduced perorally into

the gastrointestinal tract and endoscopic biopsy was made on the voluntary portions

of the gut.

3) We measured disaccharidase activity

by Dahlqvist 's method. The measured

enzymes are lactase I, Lactase II, Sucrase,

and Maltase.

Conclusion : l) It is not difficult and safe to introduce

the endoscope with the help of intestinal string. But the preparation is compli-

cated and the view in the gastrointestinal tract is limited because the gut is shortened

with it.

As compared with blind biopsy, endosco-

pic biopsy is profitable that we can gain the specimens of the bowel every time,

confirm to stop bleeding and carry out

voluntary parts of the intestine. 2) As the results of our data, disaccharidase

activity were settled generally in homo- genates of the je junum and ileum except

that they seemed toward weaker in the

terminal ileum. 3) One technician assayed enzyme activity

of two or three specimens from the same part of a patient. Disaccharidase activity

showed difference. We must re-examine

the method of enzymatic assay.

(201) E N Z Y M E A C T I V I T I E S OF

J E J U N A L M U C O S A OF R A T S W I T H E X P E R I M E N T A L BLIND L O O P

T. Susuki, Y. Kato, T. Mizuno, H. Oya, S. Yoshino, and T. Hattori

First Department of Internal Medicine, Nagoya University School of Medicine

It has been well established that blind

loops cause malabsorption and that some

diseases with malabsorption show lowered activities of enzymes of small intestinal

mucosa. This report concerns with the

activities of enzymes of jejunal mucosa in

experimental blind loop syndrome of the rat.

Adult white male rats of Wistar strain

weighing 200 to 250 Gm. were used. Fil- ling blind loops, 10 cm in length and 40 cm

proximal to the cecum, were constructed in

rats according to the method described by Cameron. A month after the operation

measurement of fecal fat and activities of enzymes of rat je junal mucosa, i.e., alkaline

phosphatase, leucine aminopeptidase and

disaccharidases (lactase, sucrase and maltase) were carried out.

Fecal fat for 3 days was 0.92• (mean 4-S.D.) Gm. in the operated and 0.294-4-0.18

Gm. in control rats. Lactase activity was inversely related to fecal fat. The activity was

9.34-2.5 u. /Gm, protein in rats with blind loop and 18.3• protein in controls.

There was no significant difference between the two groups in activities of the other

enzymes. The operated rats showed an abnormal proliferation of flora in the hy-

pertrophied and dilated blind loop filled with ehyme. In the present study lactase

was found to be the only enzyme whose activity was affected in association with the increase in fecal fat. I t can be assumed that

the functional disturbance in the cells of small intestinal epithelium evidenced by

reduced lactase level results in steatorrhea. Further study is required to elucidate whether the functional disturbance of small intestinal

mucosa is caused by an abnormal proliferation of flora or not, and whether that is the cause of steatorrhea or the result of malabsorption.

ERRATA:

page 27, line 3:

page 38, line 2:

Previous number, Vol. 8, No. 1, 1973.

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