1983年 · 第03卷第02期

Up to Sept 1982, a total of 142,995 fiberoptic gastroscopic examinations, 4,532 colonoscopic examinations including 401 colonic polypectomies and 1,674 endoscopic retrograde cholangiopancreatographic (ERCP) examination have been performed in 24 hospitals. The complications encountered during and after the above manipulations amounted to 14,810 (0.22%), 11 (2.5%) and 20 (0.012%) respectively. Of the 148 cases with complications after gastroscopic examinations, 59 were severe ones such as hemorrhage, laceration and perforation, 11 of them underwent surgical intervention with 2 deaths, and the other one died of acute cardiac failure. The other 89 cases were of mild complications such as mandibular dislocation and parotid gland swelling. Of the 20 cases of colonic complications, 11 had perforation (0.22%), 6 had hemorrhage; 9 of them necessitated surgical intervention, but no one died. Of the 20 complicated cases after ERCP, 5 got cholangitis which caused 2 deaths, 14 got pancreatitis and the other one died of duodenal perforation.

The occurrence and prevention of complications are discussed briefly.

Sixty nine cases of obstructive jaundice from 880 laparoscopic examinations have been studied since 1956. Laparoscopy was proved to be helpful in making differential diagnosis in 62/69 (89.86%) Sixty-two cases included 12 cases of intrahepatic cholestasis, 24 of biliary cirrhosis, 18 of benign extrahepatic obstructive jaundice (mainly cholelithiasis), 12 of malignant extrahepatic obstructive jaundice (carcinoma of pancreatic head in 8, carcinoma of ampulla of Vater in 2 and hepatic bileduct adenocarcinoma in 2) and 3 of Dubin-Johnson's syndrome. However, 2 of acute intrahepatic cholestasis, 2 of cholelithiasis, 1 of carcinoma of ampulla of Vater and 2 of hepatic bilednet, adenocarcinoma were missed.

The diagnostic criteria of the various obstructive jaundice in laparoscopy are discussed. Both the liver appearance and biliary tract reproduction depend upon the degree and/or the period of cholestasis. The endoscopic changes of gallbladder, such as the size, color and visceral tension, are also helpful in differential diagnosis.

Pyloric sphincter pressure (PSP) was assessed with a sensitive miniature transducer under gastroscopy. The mean amplitude of the pyloric high pressure zone was 21.8 ± 1.3 mmHg in 50 normal Chinese adults. The PSP of chronic gastritis (30), peptic ulcer (38) and gastric carcinoma (6) was diminished, and those diseases were also found to have pyloric dysfunction. This data not only present the pathophysiology and clinic menifestations, but also help to choose the effective drugs for the treatment. Furthermore, if the PSP ≤10 mmHg in duodenal ulcer, it suggests that the protective reflux function of pylorus is lost.

During 1978 to 1982, 107 cases of varioliform gastritis were observed among 5,165 gastroscopic exam. Ninty one were male and 16 female, with an average age of 41.5 ± 13.0 yr. The clinical manifestations of varioliform gastritis were nonspecific, including dyspepsia (81.3%), belching (57.9%), regurgitation(38.3%) and abdominal fulless (35.5%) Under endoscopy, the lesions were round or oval in shape, 0.5-2.0 cm in diameter, protruding out from gastric mucosa with a small pit in the center. In active stage, the surfaces of lesions were usually covered with bloody, yellowish or greyish exudate which cleared up in the healed stage, leaving a pinkish pit with a smooth surface. The lesions located mainly at the antrum (82.2%), and less frequently at the gastric body (13.1%) or both (4.7%). In 95.3% of cases the lesions were multiple, while in the remaining cases the lesions were single. The associated diseases were duodenal ulcer (33.6%), gastric ulcer (13.1%) and combined duoden o-gastric ulcer (5.6%). Forty six patients experienced upper GI hemorrhage once at least, among them 29 (63.1%) asscciated with peptic ulcer. Pathologically, varioliform gastritis could be divided into necrotic-erosive type and hyperplastic-healed type. Twenty six cases were followed up for 3 mo-2 yr; the superficial hemorrhagic inflammatory erosions progressed to typical varioliform lesions in 13, while in other 13 the lesions disappeared completely in 6 and remained unchanged in 7.

The roentgenographic findings of gastritis verrucosa in 20 cases are analyzed. X-ray sigins could be divided in to 3 types; round type (16 cases), rod type (2 cases) and mixed type (2 cases). The authors experience that the double contrast examintaion of the stomach is a good method in diagnosis of the disease. Some technical procedures are briefly discussed. The authors also suggest that the differential diagnosis between nodule shapes of gastritis verrucosa and multiple sessile polypi should be emphpsized.

Twenty-four samples of gallstone by ascaris in different stages were studied with stereoscope and electron microscope scanning. On the external and internal surfaces of the ascaris body, we observed the deposition of bile pigments and cholesterol crystals, the aggregation of cholesterol crystals and the formation of microlith. The important role of mucuslike material seen under the electron microscope scanning in the formation of gallstone is further confirmed by this study.

Among the 511 cases of ERCP, 31 cases (6.1%) were found to have choledchoduodenal fistula. The diagnosis was ascertained by direct endoscopic observation of fistula orifice of passing out of cannula through the fistula opening during cannulation. The pathogenesis, classification, differeutial diagnosis and treatmeut of the fistulas are discussed.

Four hundred eighteen polyps of large bowel were resected with high frequency electric coagulation in 246 cases. Among them 19 cases (7.7%) had bleeding during operation, 5 cases (2.0%) after operation and 3 cases (1.2%) both during and after operation. The main cause of bleeding during operation was inadvertent cutting of pedicles of polyps by snare loop without electrocoagulation in 11 cases, improper use of coagulation or cutting electric current in 6 cases and defect in snare wire in 2 cases. Postoperative bleeding was due to inadequate management of hemorrhage during operation in 3 cases and presence of large central artery in pedicle and arteriosclerosis in 1 case, and the other 4 cases were probably caused by unrestricted postoperative diet and physical over-activity.

The management and prevention of such hemorrhage are proposed.

Colonoscopic examination performed in 16 patients with intestinal arteriovenous malformations (AVMs) during 1977 to 1982 are reported. All the patients presented a history of profuse rectal bleeding, and among them 11 patients had been operated on for resection of the portion of AVMs, no one case rebled. On the basis of endoscopic findings, AVMs could be classified as following types; diffuse lesion (6), local lesion (7), haemangiomas (2) and punctate angiomas (1). The endoscopic characteristics of each type are briefly discussed.

Twenty-six patients with esophageal varices undergone endoscopic injection of 5% sodium morruhuate are reported. Sixteen of them were emergency cases and the remaining 10 selective. The grading of liver function by Childs' method was grade A in 7 cases, grade B in 7 and grade C in 12. Splenectomies, shunting operations, devascularization and transection procedures had been performed previously in 18 patients. In 93.6% of emergency cases hemorrhage was controlled successfully by sclerotherapy. Two emergency cases died. Ten selective cases were injected for prophylaxis. All were improved after the treatment. This procedure is thus specially preferable in the management of patients with acute variceal bleeding and impaired renal function, who could not withstand a major operations. The techniques and complications are briefly explained and discussed.

The middle molecular weight substances were detected spectrophotomatically at the wave lengths of 254 and 206 nm in the serum, liver, brain and urine of rats with galactosamine-induced fulminant hepatic failure (FHF), with the same determination done in the normal rats as control. Such substances were found to fall into peak 7 and were found to be accumulated in the serum but almost disappeared in the liver and reduced in the brain of FHF rats. In the urine of normal rats, middle molecular weight substances could be detected both at wave lengths of 254 and 206, but in FHF rats only peak 7 at 206 nm but not at 254 wave length was demonstrated. These findings suggest that middle molecular weight substances in FHF are of multiple sources. By using gradient ion-exchange chromatography the middle molecular weight substances detected at the wave length of 254 nm could be further differentiated into several subpeaks which were increased in the serum but obviously reduced in the urine and liver of FHF rats. However, in the brain tissue of FHF rats, the subpeak 7 f was obviously elevated among other reduced subpeaks. The increase of 7 f in the brain of FHF rats may indicate that this substance is one of the possible "toxic" metabolites contributing to hepatic encephalopathy.

The bile precipitate formed in the process of incubation of bile pigment gallstone sample is considered as the in vitro model of bile pigment gallstone. If the calcium ion concentration in the bile sample is raised artificially, the volume of the precipitate, the amount of bilirubin, glycoprotein and calcium in the precipitate increased markedly. In contrast, the above mentioned four indices decrease markedly if the calcium ion concentration is decreased. The bile calcium ion concentration determined by calcium ion selective electrode is well correlated with the volume of bile precipitate formed during incubation (r = 0.59, P<0.01). The result suggests that the bile sample with higher calcium ion concentration is much more apt to form lithiasis. Three chelating agents with different chelating ability to calcium and magnesium ions were used as dissolving agents for pigment gallstone. The dissolving power was parallel to its own effective chelating constant completely, and concordant with its own efficiency to chelate calcium and magnesium from the bile pigment gallstone. The results from precipitating test and stone dissolving test both suggest that calcium and other metal ions are important factors that affect the pathogenesis of bile pigment gall-stone. The role of the metal ions in the formation of bile pigment gallstone is to form compounds with bilirubin and glycoprotein. The compounds thus formed are very difficult to dissolve.

The composition and structure of black gallstones from 61 cases were studied by macro-analysis, infrared spectroscopy, grading spectroscopy and electron microscope scanning. It was demonstrated that black gallstones could be divided into pure type (7), mixed type (34) and atypical type (20). The pure type is exclusively of the cholecystic calculus. It is small in size, amorphous in cut surface with round particles embeded in rocklike plates on the image and contains metallic elements such as silver, lead, zinc, copper, iron and relative large amount of calcium. The infrared spectrogram of pure black gallstone showed a characteristic curve, which could be used as one of the markers for classification of the pure type. Although the mixed type has the characteristics of black gallstone, it is admixed with some other components when analyzed by infrared spectroscopy. The atypical one appears black in color, but it is of bilirubin-related, mixed cholesterol-pigmented or fatty acidic stone in fact.