General lectures (II

Proceedingsof the 59th Annual Meeting, 1973-Kagoshima

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G e n e r a l L e c t u r e s (II) (101)

THE EFFECT OF CALCIUM ON H U M A N GASTRIC SECRETION K. Segawa, S. Nakazawa, N. Koide, K. Imai, N. Matsuo, Y. Yamamoto and M. Shiobara

2nd Dept. of Int. Med., Nagoya Univ., Sch. of Med. The effect of calcium on gastric secretion was studied in 10 duodenal ulcer patients, 6 gastric ulcer patients and 1 case of Z-E syndrome. After the overnight fasting, the patients' gastric contents were evacuated by gastric tube and the saline was administered intravenously at the rate of 5.5 ml/min. The gastric juice was collected through the tube every one hour. After the 2 basal collections, calcium-gluconate containing 15mg/kg of calcium ion was added to the saline solution and it was infused over following 4 hours. During calcium infusion the gastric juice was collected every hour, and venous blood was also drawn at the same time. For the samples of gastric juice, the acid and peptic activity were estimated, and for blood samples, serum gastrin level was assayed by the radioimmunological method. The followings were the results of this investigation : Before calcium infusion, serum calcium level was 4.484-.06mEq/l and it rised to 4.41 4-.56, 5.234-.08, 5.534-. 11 and 5.734-.37 mEq/1, respectively at 1st, 2nd, 3rd and 4th hour of calcium infusion. Gastric secretory volume per hour was 63.004-8.64, 40.924-8.51 ml respectively for 1st and 2nd basal collection and it was 45.284-5.64, 78.714- 12.56, 72.644- 10.02 and 86.64• 11.49 ml respectively for calcium induced collection. The acid output per hour was 3.494-.01 and 1.874-.47 at the time of 1st and 2nd basal collection and it was 2.174-.53, 5.504-1.39, 5.294-1.10 and 7.01 4-1.31 Emq respectively at the time of 1st, 2ncl, 3rd a.nd 4th calcium-induced collection. Peptic activity assayed for 1st and 2nd basal collection and for lsti 2nd, 3rd and 4th calcium induced sample were respectively 5.774-1.20,

5.73• 7.67-4-.02, 9.81• 11.67• and 12.844-4.34 tyr. mg/ml. Serum gastrin level was assayed for the smples before calcium infusion and 1,2,3 and 4 hours after calcium infusion. Ist level was respectively 43.56 4-7.92, 31.524-6.85, 61.934- 12.43, 65.854-9.94 and 74.25• pg/ml. The mean value of calcium stimulated acid output was 4.834-.93 mEq/h. This was equal tO 374-8% of tetragastrin-induced acid output. To the contrary its rate in Z-E syndrome was 73%. Summary: calcium infusion test could be carried out without any side effect. Through this test we knew that calcium retains the ability of gastric acid secretion, peptic secretion and gastrin release. (102) STUDIES ON T H E PH VALUES IN THE R E M N A N T STOMACH - - W I T H SPECIAL REFERENCE T O THE STOMAL ULCER CASES-H. Shimada, K. Kawai, K. Machida, N. Okabe, Y. Hoshi, Y. Koizumi and T. Watanuki.

1st Dept. of Surg., Jikei Univ. Sch. of Med., Tokyo Easy and dependable accessment of the gastric acidity using telemetering capsule has developed new field of gastric junction tests. The gastric acidity was measured by the pH capsule, gastric secretion was stimulated by subcutaneous use of tetragastrin 4r/kg and potassium bicarbonate was loaded for neutralization. The results obtained were as follows: 1) During immediate postoperative periods, pH of the remnant stomach fell into two groups, pH below 3.0 and pH over 5.0. But it gradually shifted into individual proper pH and stabilized 6 months after the surgery. 2) In the good gastrin responsive groups, most of the patients with post-operative complaints had basal pH value lower than 3.0. 3) The acid content of the gastric remnant is approximated by measuring amount of potassium bicarbonate required to raise pH over 4.0, 45 minutes after gastrin load. Free

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acid in the remnant stomach was below 0.25 mEq in the non-stomal ulcer group, while it was high between 0.5 and 4.0 mEq in the stomal group. 4) All 24 cases of stomal ulcer but one had basal p H below 2.0 and symptomatic. The ulcer was solitary and U1 III to IV in nature. Majority of the ulcers were located in the efferent loops. Only one patient had the ulcer in the remnant stomach. Operation was performed on 11 cases with good results. (103) I N T R A - G A S T R I C P R E S S U R E BY A R A D I O - T E L E M E T E R I N G C A P S U L E (II) : INTRA-GASTRIC PRESSURE CHANGE UNDER DIFFERENT CONDITIONS BY A R A D I O - T E L E M E T E R I N G CAPSULE AND CORRELATION OF INTRAGASTRIC P R E S S U R E A N D PH Y. Hiroshima, Y. M.atsusaka, K. Katase, Y. Sakuma and N. Matoba

Osaka ~l/Iun. Kita Citizen's Hosp. N. Murata

Matsushita Electric Industrial Co. a) Intra-gastric pressure change was noted in various conditions as follows: 1) Stand up and sit down 2) Speaking 3) Cough 4) Deep Breathing 5) Laughing 6) Belching 7) Hiation 8) Borborygmus b) The acceleration of intra-gastric pressure change was obtained after taking whisky and tea, but not appeared after taking milk. c) After injection of Prifinium promide, the decline ofintragastric pressure was observed in a subject whose pressure fluctuation was accelerated, on the other hand the acceleration of the pressure fluctuation observed in cases of declined intra-gastric pressure. d) The acceleration of intra-gastric pressure was obtained following the administration of Bethanechol Chloride and Metoclopra.~..ide.

c) Any correlation was not recognized between intra-gastric pressure and pH by 2 channel method after the administration of Tetragastrine and Sodium Bicarbonate. (104) O N T H E A R T E R I O - V E N O U S A N A S T O M O S E S IN E X P E R I MENTAL STOMACH ULCER Y. Toyama, S. Murai, A. Nukaga, N. Ishimatsu, Y. Watanabe and M. Abe

4th Dept. of Int. 3lied. (Prof. M. Abe, M.D.) Tokyo Jikeikai Univ. of Med. In experimental stomach ulcers in rats, their vascular changes have been investigated by means of a plastic model of the blood vessels. Because of the pressure in injecting acryl ester, the diameter of the plastic model of the vessels underwent some artificial changes. We think the artificial changes can be prevented if a fixing solution is injected into the vessels with constant pressure for a period. At present, we consider that it is preferable to inject 10~ formalin solution for two minutes, with a pressure of 120 mm Hg. We produced reserpine ulcer, gastrin ulcer and curling's ulcer in rats. Their plastic models were produced. In case of reserpin ulcer, around the ulcers anastomoses between arterioles and venules were seen on the muscularis mucosa. On the other hand, in cases of gastrin ulcer and curling's ulcer, the arteriovenous anastomoses were seen in the submucosa but not on the muscularis mucosa. (105) S T U D Y O N T H E D I S T R I B U TION OF MUCOSAL CAPILLARIES OF CANINE STOMACH Y. Ono, K. Hirai, S. lwabuchi, K. Suzuki, T. Aoki, K. Masamura, K. Yoshida, ,J. Ikeuchi and F. Nagao

2rid Dept. of Surg., Jikei Univ. Sch. of Med. (Director: Prof. F. Nagao) We studied on the distribution of mucosal capillaries of canine stomach by photolucency method using Olympus E.M.M. type II photoelectric cell. The less the number of mucosal capillaries is, the greater is the photolucency, because

Proceedings of the 59th Annual Meeting, 1973-Kagoshima the capillaries are filled with I n d i a n Ink. F o u r t e e n dogs were used in our experiment. Left thoracotomy was performed u n d e r general anesthesia to expose the thoracic a o r t a into which a polyethylene catheter was introduced, a n d I n d i a n Ink, w a r m e d a r o u n d 37~ was injected via this catheter at constant pressure. Microscopical paraffin sections were o b t a i n e d from each specimen. Results: T h e average value of d e t e r m i n e d each photolucencies in fundic gland area was 19.4%, a n d t h a t of pyloric gland area was 35.7%. T h e n , this difference was highly significant. ( P < 0 . 0 1 ) O n each of various parts of the stomach, n a m e l y anterior wall, posterior wall, lesser curvature, a n d greater curvature, this difference in photolucency similarly existed between fundic a n d pyloric g l a n d area. A t the level of 1 cm oral to mucosal boundary, n o significant difference in photolucency was observed a m o n g these four regions. ( P < 0 . 0 5 ) Similarly, at the level of 1 cm anal to mucosal boundary, n o significant difference was observed a m o n g these four regions. ( P < 0 . 0 5 ) O n the line of the greater curvature, the value of 4 cm oral to mucosal b o u n d a r y a n d t h a t of 1 cm oral to mucosal b o u n d a r y are statiscally different in spite of the same fundic g l a n d area. ( P < 0 . 0 5 ) Summary: As the photolucency is inversely proportional to the n u m b e r of capillaries (vascularity), the v a s c u l a r i t y of fundic g l a n d area is greater by twofold t h a n t h a t of pyloric g l a n d area. And, on the line of greater c u r v a t u r e two different vascularities were observed in the same fundic gland area. After all, it seems likely t h a t the local difference in mucosal vascularity exists in differeng parts of canine stomach. (106)

MUCOSAL VASCULARITY OF FUNDIC AREA AND PYLORIC AREA A. Kobayashi, S. Toriie, M. Nakajima, M. Kcthli, K. Ida, K. K a w a i a n d M. M a s u d a

3rd Dept. of Int. Med. Kyoto Pref. Univ. of Med.

187

T. Hattori a n d S. Fujita

2nd Dept. of Pathol., Kyoto Pref. Univ. of Med. A l t h o u g h Dr. Oi reported the location of gastric ulcer has relations to intermediate zone of gastric mucosae, we suppose t h a t it has relation not only to intermediate zone b u t also to difference of mucosal vascularity. I n this paper, we d e m o n s t r a t e d the difference of vascularity between fundic area a n d pyloric area. O u r present study was done with two technical methods to visualize vascular pattern. O n e of t h e m was to observe the specimens u n d e r light microscope, which were obtained from resected stomach after injecting black ink t h r o u g h m a i n gastric artery. A n o t h e r m e t h o d was to observe the corrosion casts u n d e r scanning electron microscope. This study revealed that there are capillary anastomotic nets in the middle p a r t of the glands, w h i c h we n a m e " C a p i l l a r y meshes of glandular p o r t i o n " , a n d that they are fine a n d dense in fundic area, whereas gross a n d r o u g h in pyloric area. T h e mucosal vascular distribution in fundic area is two a n d half times as dense as in pyloric area. (107) E X P E R I M E N T A L S T U D I E S OF GASTRIC BLOOD FLOW --PARTICULARLY ON THE RESPONSE TO STIMULAT I O N BY H O R M O N A L SUBSTANCES--T. T a m a d a , K. Inoue, T. Usui, S. Yamaya, K. Ohtsuka, Y. Shiraki, S. Fujishima, O. T o c h i k u b o a n d S. M i y a m o t o

2nd Dept. of lnt. Med., Yokohama City Univ. Sch. of Med. A. U e d a

Dept. of Int. Med., Kanagawa Pref. Hosp., Centerfor Adult Dis. W e have reported our serial studies on the correlation of the secretory function a n d the blood flow of the stomach in the rabbits with the use of 133Xe-clearance method. This report includes our further investiga-

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tions in which the response of the gastric blood flow following the administration of various hormonal substances such as gastric hormones in the rabbits. After the rabbits were laparotomized under the intraperitoneal anesthesia, x~aXe-physiologic saline (Neiser) was injected into the subserosa of the stomach, and measurement of the gastric blood flow which was achieved by the analysis of the 183Xe-clearance curve and was expressed as the mean transit time (t), was carried out. And the changes of the gastric blood flow at the time of developement of "serotonin-ulcer" in the rats were also studied. The results of these studies are summarized as follows: (1). There was no significant differences of the gastric blood flow between at the corpus (t-=2.49~z0.58 rain.) and at the pylorus (}-~2.69• min.). (2). Increases of the gastric blood flow in the rabbits were observed with a peak at 15 to 30 minutes following the i.v. injection of tetragastrin (5 ug/kg) and histalog (1 ktg/kg), respectively. (3). I.v. injection of secretin (10 u) yielded a significant decrease of the gastric blood flow in the rabbits particularly 60 minutes after the injection both at the corpus and at the pylorus. (4). No blood pressure changes were observed following the i.v. injection of these substances. (5). Significant increases of the gastric blood flow were also observed following i.v. injection of serotonin (20 pg/kg) at the time of developement of "serotonin-ulcer" in the rats. The m e a n transit time (t-) before and 15, 30, and 60 minutes after the injection were 2.20~0.48, 3.96-4-0.98, 4.37• and 4.16:~0.93 minutes respectively, showing a significant increase. O n the other hand, the blood pressure fell transiently for about 30 minutes following the injection. These results seem to reveal that developement of gastric ulcer could be induced by decrease of the gastric blood flow and the blood pressure following the serotonin-injection, as a result of constrictive effect on the vessels and the smooth muscles. These phenomena were assumed to be a state of reduction of protective abilities

of the living. (108)

STUDIES ON THE ETIOLOGY AND TREATMENT OF PEPTIC ULCER K. Asano, M. Kunisada, H. Miyake, Y. Fujii, S. Yoshimoto and K. Hiramatsu

Dept. of Int. Med., Okayama City Hosp. The etiology of peptic ulcer and the effect of prostaglandin on stomach were investigated by measurement of gastric and duodenal blood flows. It has been found that there are differences of blood flow between the regional border of corpus and antrum, and between anterior wall and posterior wall of corpus. T h e gastric blood flow was maximum in anterior wall of corpus, and minimum in antrum. The significant increase of blood flow by histamine occurred in fundic gland area, and remarkable increase of blood flow occurred in corpus, especially at the muscular layer of lesser curvature by the administration of acetylchofine. These results mean that there are the warps of blood flow among each gastric regions. The significant increase of blood flow of stomach with ulcer was observed at the surrounding area of ulcer in experimental ulcer of rabbit stomach and human gastric ulcer. The blood flow of duodenum was also studied by the same method. T h e blood flow of anterior wall of duodenum was much than posterior wall, and the blood flow of anterior wall of bulbus was the most variable by the stimulation with some agents. These results suggest that there are relationship among the gastroduodenal blood flow, gastroduodenal functions and peptic ulcer. The variations of blood flow induced by acetylcholin and histamine were inhibited by the administrations of atropine or some antiulcer agents. Prostaglandin has recently been reported to inhibit the gastric motility and secretion. Therefore, the effect of prostaglandin on the gastric blood flow was studied.

Proceedingsof the 59th Annual Meeting, 1973-Kagoshima Prostaglandin E 1 and a potent synthetic prostaglandin (PG226) also inhibited the variations of blood flow induced by acetylcholine and histamine. (109) C L I N I C A L S I G N I F I C A N C E OF P E R I V A T E R I A N D U O D E NAL D I V E R T I C U L A S. Nakano, T. Takeda, K. Kitamura, Y. Horiguchi and K. Okada

2nd Dept. of Int. Med. (Dept. of Gastroenterl) Ohgaki Mun. Hosp. Large (above 20 mm in diameter) and double duodenal diverticula in the perivaterian portion were seen at the rate of 36% of all (210 cases). As associated diseases, choledocho-, cholelithiasis and pancreatic lesions were seen very often. (33% and 11% respectively.) Incidence of hyperamylasuria and diabetic pattern in G.T.T. were observed frequently. (30% and 700/0 respectively.) As for pancreozymin secretin test, abnormal function of the exocrein pancreas was seen frequently with retarded bile secretion. (37%) Symptomatology and functions of the pancreas and biliary tract were studied in 36 cases without associated diseases in order to elucidate the clinical significance of the perivaterian large diverticula. Most frequent sign was upper abdominal pain (30~70%). Fever and jaundice were observed in 22% of them. Abnormal junction of the exocrine pancreas and retarded bile secretion were observed in 30% and 60% of them respectively. 5 in 210 cases were picked up for analysis because each entry of the common bile duct and the pancreatic duct was seen in the duodenal diverticula. Chief complaint was jaundice in 2 of them. Pancreozymin secretin test was carried out in 4 cases and abnormal function of the exocrine pancreas was obtained in half of them. Elevated blood amylase after the stimulation of the hormones was also observed in the same incidence. As for bile secretion, the bile concentration was low in the half of them. Conclusively, large diverticula of perivaterian portion evokes bad influence on the

189

pancreas and biliary tract frequently and it may play an important role in etiology of biliary and pancreatic inflammation. (110) C O M P A R A T I V E STUDY BETWEEN X-RAY & ENDOSOPIC F I N D I N G OF DUODENAL ULCER M. Okada, T. Kuwabara, M. Tanaka, K. Konno, T. Hattori, K. Isobe, A. Iwasaki T. Unoura, M. Matsumoto, T. Yoshida, I. Takahashi, M. Abe, H. Maeda, T. Hayashi, H. Koizumi, M. Iwasaki, K. Takahashi, T. Honda and K. Ariga

3rd Dept. of Int. Med., Nihon Univ. Sch. of Med. 61 cases of single duodenal ulcer (located 39 cases in the anterior wall and 22 cases in the ante-posterior wall) was investigeted. The subjects were picked up adequate roentgenographic examinations with method of fullness, compulsion and double contrast. Also the duodenal ulcers were demonstrated as scaring .duodenal ulcer by duodenoscopy and biopsy. It is easier to make a diagnosis as scaring duodenal ulcer with no niche, just shows radiating folds to the scaring point on the roentgenographic examination. But there are some problems on the distribution of the scaring duodenal ulcer with niche. (111)

H I S T O C H E M I C A L AND C H E M I C A L S TU D I ES OF D U O D E N I T I S S. Mohri, Y. Suga, T. Ono and K. Kobayashi

3rd Dept. of Int. Med., Osaka City Univ. Med. Sch. Previously we had reported that endoscopic, histological, microscopic (dissecting type), and histochemical studies of acute or chronic inflammatory change in the duodenum were very important as essential approach for diagnosis of the so-called duodenitis. The aim of this paper is to discuss chemical investigation by reference to histochemical

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approach in biopsy specimens which obtained by duodenofiberscope and in materials which obtained experimental studies in dogs by stimulation using ethyl alcohol (20--30%) and HC1 (2%). The results are as follows: 1. In the human duodenum, the activity of the alkaline phosphatase was measured by the Kind and King's method. 1 u n i t = l T phenol/rag, prot. Normal group (endoscopically): 750-2000 The group with inflammatory change (endoscopically): 200-- 1000/~. The activity of the alkaline phosphatase in the group with inflammatory change was lower than normal. 2. The activity of the alkaline phosphatase in dogs A. Normal group : 10• 102/~ B. The group of the dogs which were obtained acute inflammatory change by stimulation of HCI (2%): 10• ~ 50x 102/t C. The group using ethyl alcohol (20-30%): 5 x l l 3 ~ - - 1 0 • ~/t D. The group of the dogs which were obtained chronic inflammatory change by repeated stimulation: 30• 102120• 10~/t The alkaline phosphatase activities in the groups with acute inflammatory change (B and C) were lower than in normal groups. On the other hand, in the group with chronic inflammatory change, its activity became same level compared with normal group.

thyroidisms accompanying stomach ulcer and animal experiment with respect to the same subject as well. A. Clinical Results a) There have been five patients with hyperthyroidisms accompanying stomach ulcer for the past five years, which was 1.7% of the total patients with stomach ulcer treated in the IInd department of internal medicine, Kansai Medical School. There were four cases with hyperacidity of gastric juice whereas the other with hypoacidity among the patients. B. Animal Experiment The animals used were normal white rats, divided into three groups which orally received Thiouracil, 0.05 g/rat L-Thyroxine 10 rag/rat L-Thyroxine 20 rag/rat, and respectively for the thirty days, while the each group of animals served as control was fed in the same nutritional conditons for the same period. Gastric analysis for the determination of Triosob resin sponge uptake in sera, and volume, acidity, acid output and peptic activity of gastric juice were performed sacrificing the animals twenty hours after pyloric ligation or occurrence of stress ulcer. a) The incidence of ulceration was lower in Thiouracil group with paralleled notable decrease in volume, acidity, and peptic activity of gastric juice, while in Throxine group diminished incidence of ulceration was exhibited with increased dosing of the drug accompanying the similar findings of gastric juice obtained in Thiouracil group. b) The incidence of stress gastric ulcer was lower in Thiouracil group in contrast with higher incidence in Thyroxine group. (113)

(1 t2)

HYPERTHYROIDISMS AND STOMACH ULCER T. Mizuno, Y. Sameshima, Y. Shiozaki, M. Sasakawa A. Hiramatsu, K. Ikehara, T. Nagata and K. Tatsumi 2nd Dept. of lnt. Med., Kansai Med. Sch. The present work introduced the results of clinical investigation in patient with hyper-

STUDIES ON RELATIONSHIP BETWEEN PEPTIC ULCER AND C H R O N I C PANC R E A T I T I S (II) M. Abe (Director), M. Aoki, S. Iwasaki T. Aizawa, K. Kajiwara and K. Sata Hiratsuka Civic Hosp., Int. Med. S. Omata, K. Imamura, K. Kondo and H. Sajima

Proceedingsof the 59th Annual Meeting, 1973-Kagoshima Yokohama Civic Hosp., Int. Med. Y. Sato, H. Kiryu, S. Mimoto and T. Masuoka

Nihon Kokan Hosp., Int. Med. Gastrin is a potent stimulant of acid secretion and serum gastrin levels can now be measured using sensitive radioimmunoassay. Fasting serum gastrin levels and acid secretion during 6 months to one year has been measured by radioimmunoassay in 14 patients with duodenal ulcer, 12 patients with duodenal ulcer and chronic pancreatitis and compared with that in normal controls. Fasting serum gastrin levels in duodenal Ulcer is Sometimes in the low part of the normal range. It is known that in dogs, gastrin secretion is inhibited at a p H of between 1 and 3 (feed back mechanism), in patients with duodenal ulcer and chronic pancreatitis the fasting levels of gastrin and gastric acid secretion were generally lower compared to some of patients with duodenal ulcer. Also diurnal (8:00-18:00) serum gastrin levels produced similar patterns. T h e effect of protein meal was also assessed in a group of these patients. There is a peak at 45-60 minutes with a gradual fall to normal. In patients with duodenal ulcer and chronic pancreatitis gastrin levels at 45, 60, 75 minutes were significantly lower than those of some groups of patients with duodenal ulcer. (114) P A T H O G E N E S I S O F A C U T E ULCER AND CHANGES OF DEFENSE MECHANISM OF THE GASTRIC AND DUODENAL MUCOSA IN OBSTRUCTIVE JAUNDICE K. Kira, R. Mizumoto, H. Kuratsuka, and I. Honjo

t91

duodenal ulcer is from a difference in between mucosal structure, especially mucopolysaccharides, of the stomach and the duodenum, and also that the mucous barrier covers the mucosa and acts as defense mechanism against peptic juice and it consists of two kinds of layer, one is a superficial glycoprotein layer and another is a profound mucoprotein layer. In this study, changes of mucosal structure of the stomach and pathogenesis of acute ulcer were observed in the rat with obstructive jaundice after ligation of the common bile duct and confinement in the stress cage for 18 hours. 1) O n e of four rats, treated only by ligation of the common bile duct, showed superficial mucosal defect with decrease of mucoprotein in the mucous barrier. 2) Three of four rats, treated only by confinement in the stress cage, showed multiple erosions with decrease of glycoprotein of the mucous barrier, 3) W h e n rats were treated by ligation of the common bile duct .with confinement in the stress cage, all four rats sho.wed multiple and deep ulcers up to the muscularis mucosae with destruction of the two mucous layers of the barrier. As mucoprotein layer of the mucous barrier is destructed in the obstructive jaundice and glycoprotein layer in+ the stress, it seems that the mucosa is digested by self-secreted peptic juice and acute ulcer develops in the jaundice after ooerative stress. (115) G A S T R I C C H A N G E S O N THE PATIENTS TREATED WITH LONG-TERM DIALYSES Y. Hojo, H. Nakajima, T. Tosaka, O. Arai, N. Kobayashi and N. O b a t a

1st Dept. of Surg., Kyoto Univ. Med. Sch.

Dept. of lnt. Med., Nagaoka Red-Cross Hosp.

In obstructive jaundice, gastrointestinal bleeding occurs occasionally and makes one of the important causes of death postoperatively. We have reported that a difference in between pathogenesis of gastric ulcer and

It is often known that uremic patients treated with long-term dialyses, have digestive complaints. T h e n we try to make clear the reason in this paper. M a t e r i a l and M e t h o d ; 56 patients managed with peritoneal dialyses

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or hemodialysis from July, 1969 in our hospital were comprised in the substance of this study. 24 patients were examined by the gastric X-ray. 26 patients were gastroendoscopied. 16 patients were revealed in the gastric juice after injection of the Tetragastrin and 34 patients were measured the serum gastrin by radio-immunoassay.

Results: Hematoemesis and melena were found in 14.3%, gastric carcinoma in 1.8%, peptic ulcer in 12.5%, Antrum-gastritis in 5.4%, mucosal bleeding in 38.5%. Linear redness, as it were K a m m r 6 t u n g , were shown in 23.1%. Hyperplasia of the mucosal folds were also seen in 44.8%. Gastric juice analysis revealed 87.2 mEq/1 on the average of the peak acid output and 8.88 m E q / h on one hour acid output. The mean level of serum gastrin were 397.3 pg/ml.

Comment; The discussion has been centering on sex, age, method, duration of dialysing uremic patients and their digestive disorders. I t was thought that there were no relationship between mechanism of peptic ulceration on dialysed patients and gastric acid output. Linear redness and mucosal bleeding were frequent in treating over one year. 4 cases were accompanied by bleeding, 2 cases were bled along the linear redness. The level of serum gastrin was clearly high, comparing with normal control group who was 163.1pg/ml on the average. The serum gastrin level on dialysed patients was inversely proportional to the gastric acid output. It was reasonable to presume that hypergastrinemia was dependent on suppression of disintegration and renal excretion of the gastrin according to low sensitivity to the target organ. (116) N E W M E T H O D S F O R DETERMINATION OF SERUM LEUCINE AMINOPEPTID A S E (LAP) A N D MONOAMINE OX-

I D A S E (MAO) S. Ito, T. Takaoka, Y. Uragami Y. K i t a m u r a and S. Kishi

2nd Dept. of Int. Ailed., Sch. of Med., Tokushima Univ. S. Fujii and H. Okuda

Dept. of Enzyme-Physiol. Inst. for Enzyme Res., Sch. of Med. Tokushima Univ. A new methods was presented for estimation of leucine aminopeptidase (LAP) and monoamine oxidase (MAO). The principle of the method consists in measurement of ammonia liberated by the action of deaminases with a direct colorimetric determination of a m m o n i a reported by Fujii and Okuda. Leucine naphthylamide has been widely used as the substrate for the estimation of LAP in the present clinical examination, but leucine amide was used in our new method. In the early stage of hepatitis and obstructive jaundice, serum LAP activity was much higher by our new m e t h o d than by the method in which leucine naphthylamide was used as the substrate. It was demonstrated that the plasma of normal rats and CC14-treated rats contained several isozymes which showed different substrate specificities toward leucine amide and leucine naphthylamide. These results suggest that leucine amide is preferable substrate for estimation of plasma LAP in clinical examinations. (117)

CLINICAL SIGNIFICANCE OF THE ANALYSIS OF SERUM ALKALINE P H O S P H A T A S E I S O Z Y M E S : (II) ANALYSIS OF ALKALINE PHOSP H A T A S E I S O Z Y M E S BY CELLULOSE ACETATE ELECTROPHORESIS ON THE PATIENTS OF HEPATO-BILIARY DISEASES K. Hirano, H. Kano, M. Ogino, Y. Ueda, K. Nishiwaki and N. Iwamura

Dept. of Gastroenterl. T. Aoki

Dept. of Clin, Pathol., Chukyo Hosp. Using the method

presented

before the

Proceedingsof the 59th Annual Meeting, 1973-Kagoshima meeting of the Japanese Society of Gastroenterology in 1972, the sera of 77 patients with hepato-biliary diseases were subjected to cellulose acetate electrophoresis and analyzed for the alkaline phosphatase isozymes. The results were classified into 4 types according to the electrophoretic pattern of the isozymes: type Ia (al peak=>a2 peak), type Ib (otl 100). However, 4 cases who showed improvement of histological findings had decreased V-GTP activity (less than I00). There was close correlation between 7-GTP activity and BSP (r=0.89). It is suggested that the determination of r-GTP activity is beneficial in the prognosis of active chronic hepatitis.

(122) CLINICAL SIGNIFICANCE OF ?'-GLUTAMYL TRANSPEPTIDASE A C T I V I T Y (T-GTP) IN CHRONIC LIVER DISEASES Y. Nakamura, M. Wada and Y. Nakai

Dept. of Int. Med. and Clin. Lab., Sch. of Med., Kurume Univ., Kurume

Dept. of Int. Med., Nagoya City Johoku Hosp., Kita-Ku, Nagoya The determination of r - G T P activity is known to be of diagnostic value in obstructive jaundice, alcoholic cirrhosis, hepatoma, and active stage of chronic liver disease. Our present study deals with the correlation between the /'-GTP activity and histological picture of active chronic hepatitis. The F-GTP level was determined by modified Oslowski method. The materials included 100 normal controls (23.3~13.7) in which male obtained higher activity than female. Among 83 patients, 51 had chronic hepatitis, the remainder of patients were classified into fulminant hepatitis, terminal stage of acute hepatitis, chronic active hepatitis, partial obstructive jaundice .and alcoholic liver diseases. Liver biopsy was performed in 18 cases of active chronic hepatitis. The degree of cellular infiltration of Glisson's capsule,

(123) STUDIES OF GAMMA GLUTAMYL TRANSPEPTIDASE S. Inoue, T. Arima and S. Yamasaki

The mechanism of elevation of serum gamma glutamyl transpeptidase (/'-GTP) activity was studied clinically and experimentally. High r - G T P levels were demonstrated in patients with intrahepatic cholestasis, primary and secondary liver cancer and extrahepatic biliary obstruction. Significant increases in r - G T P activity were observed in sera of dogs following common bile duct ligation, but no increase in the sera of rabbits with hepatic in injuries by CC14 administration. There was found high histochemical activity of the enzyme surrounding the bile canaliculi and in the walls of hepatic veins of rats liver with ligation of common bile duct. High histochemical enzyme activity was found in the human hepatoma cells, while high activity was seen in liver tissue surrounding the hepatoma mass in autopsy materials. Two or three isozymes of the enzyme were demonstrated by agar electrophoresi of sera in the hepatobiliary disease. In sera of patients with hepatoma, higth

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activity of ?'-GTP was shown at electrophoretic mobility of a2 globulin. (124) S T U D I E S ON A S P I R I N ESTERASE A C T I V I T Y (VII) T. Takano, Y. Katsuta, T. Yano, K. Isoda, T. Aramaki, N. Fukuda, T. Ichikawa and H. Okumura

1st Dept. of Int. Med., Nihon Med. Sch., Tokyo As previously reported, anoxemia and liver fibrotic of chronic liver diseases are observed to reflect sensitively on aspirin esterase activity (AE). The present studies are to clarify whether or not it becomes a good indication for the prognosis of chronic liver diseases and to know the relationships to hepatic area, total scanning score by Johnson's method and histological findings. The mortality of 31 cirrhotic patients who were observed for 2 years was 32%. The mortality of 16 patients showing low level of serum AE ( < 162/tg) was 44%, in contrast, 15 patients whose AE level were within normal limit was 20%. In 28 patients with chronic hepatitis, serum AE, r-globulin, Z T T and T T T were tested twice at 2 year intervals and were compared to each other. The mean value of r-globulin significantly incresed in 17 patients whose serum AE decreased and that of Z T T decreased in 11 patients with increased AE. The relation of serum AE to such histological findings of the liver as inflammation, necrosis, degeneration, cholestatic and fibritic changes were examined. Serum AE had a significant negative correlation to inflammation and necrosis in 7 cirrhotic patients, but was not correlated to histological findings in 18 patients of chronic hepatitis. The hepatic and splenic areas and total scanning score by Jonson's method were estimated by hepatic scannogram using 198Au in chronic hepatitis and liver cirrhosis. Serum AE had a significant correlation to hepatic area only in chronic hepatitis, but no correlation to total scanning score in both diseases. (125)

E F F EC T S OF B U C O L O M E

AND O T H E R D R U G S ON L I V E R M I C R O S O M A L ENZYMES AND C Y T O P L A S M I C O R G A N I C ANIONB I N D I N G PROTEINS Y. Adachi, R. Inoue, Y. Iwasaki, S. Tanaka, T. Yamamoto and G. Wakisaka

Kyoto Univ., Fac. Meal., Div. First Int. Med. Jaundice of Gilbert's disease is known to be successfully treated with phenobarbital (PB) and phetharbital (PT). As it was reported previously, bucolome (BC) was found by us to have the same effect on jaundice of Gilbert's disease, and these three drugs showed the induction of UDP-glucuronyl-transferase (GT) activity in rat liver. In the present report the effects of these three drugs on microsomal enzymes and cytoehromes as well as bromsulphalein(BSP)-binding capacity of cytoplasmic proteins were observed in rat liver to study the mechanism of action of these drugs on the bilirubin metabolism respectively. (Melhod) Four groups of male Wistar rats (around 100 g) were given (1) water (2) BC 50 mg/100 g/day (3) PB 10 mg/100 g/day (4) PT 25 mg/100 g/day orally. After 7 days of administration, liver microsomal and 105,000• supernatant fractions were prepared. Activities of GT and aniline hydroxylase(AH), contents of cytochromes P-450 and b5 were determined in microsomal fraction. BSP-binding capacities of cytoplasmic protein fractions of Y and Z were measured by the Sephadex G-75 upward column chromatography. (Results) BC administration produced slight increase in liver weight and GT activity. But it showed no effect on AH, cytochromes P-450 and b5, and BSP-binding capacities of Y and Z fractions. Administration of PB and PT, on the other hand, produced marked increase in liver weight, induced GT and AH activities as well as cytochromes P-450 and b5. BSPbinding capacity of Y fraction showed marked increase, but that of Z fraction showed diminished capacity after PB and PT administra-

Proceedingsof the 59th Annual Meeting, 1973-Kagoshima tion. From these results, it is concluded that BC induces GT relatively and selectively and it gives only slight effects on BSP-binding capacities of cytoplasmic proteins. It is suggested, therefore, that the action of BC on liver cell bilirubin metabolism differs considerably from those of PB and PT. (126) CLINICAL E V A L U A T I O N OF SERUM P R O T E I N SUBF R A C T I O N LEVELS IN VARIOUS LIVER DISEASES H. Nakaya, S. Takase, F. Ikegami and A. Takada

Dept. of Int. Med., Kanazawa Med. Univ. K. Kobayashi and J. Takeuchi

1st Dept. of Int. Med., Sch. of Med., Kanazawa Univ. Serum protein sub-fraction level was estimated in several liver diseases and the meaning of its changes was analyzed from several respects. M a t e r i a l a n d M e t h o d : Sixty three patients with liver diseases, including 15 of acute hepatitis(A.H), 8 of sub-acute hepatitis(S.A.H), 20 of chronic hepatitis active form(C.A.H), 9 of chronic hepatitis inactive form(C.I.H), 7 of compensated liver cirrhosis(C.L.C) and 6 cases of decompensated liver cirrhosis(D.L.C) were studied. The diagnosis of all cases were confirmed by liver biopsy specimens except for 2 cases of A.H. Serum protein subfraction levels were estimated by the universal immunodiffusion method according to Terano et al. R e s u l t s : Serum prealbumin(prealb.) level was decreased remarkably in A.H and S.A.H and moderately in C.A.H and D.L.C. ot2-HS glycoprotein(ot2-HS gh), /3x-CA globin (fix-CA gl.) hemopexin and /~2-I glycoprotein (~2-I gl.) levels were significantly decreased only in S.A.H and D.L.C. Significant decrecreases in haptoglobin and transferrin were seen only in D.L.C. Ceruloplasmin was increased in A.H and decreased in S.A.H. Significant increases of macroglobulin and ax-antitrypsin were observed in A.H, C.A.H and L.C. In S.A.H, a2-HS gh level was

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significantly lower than that of A.H, while prealb, level was decreased in both diseases without any significant difference. However, prealb, level was returned to normal level accompanying with its clinical improvement in A.H, but the level remained constantly low during all its clinical course in S.A.H. In C.H, significant differences between active and inactive form were only observed in prealb, and /~2-I gl. levels. Several protein sub-fractions showed remarkably low levels in D.L.C but scarcely lowered in C.L.C. /~I-CA gl. level was not significantly different between A.H and C.A.H, and not related to the presence of Australia antigenemia in chronic liver diseases. However, in the highly active C.A.H without Au-antigenemia, Ill-CA gl. level and the ratio of/~I-CA gl. to a2-HS gl. was decreased, indicating an increased comsumption of the complement in highly active C.A.H. These results suggested that the measurement of serum protein sub-fraction level is one of the good indices of the diagnosis and evaluation of the prognosis in various liver diseases. (127) EFFECT OF BETAMETHASONE ON ALBUMIN SYNTHESIS IN ISOLATED PERFUSED LIVER OF NORMAL AND CCL 4 INTOXICATED RATS Y. Kato, A. Funayama, S. Kakumu, S. Ito and S. Okuyama

3rd Dept. of Int. Med., Nagoya Univ. Sch. of Med. The effect of betamethasone on plasma albumin synthesis was studied i!~ isolated perfused liver of normal and CCI 4 intoxicated rats using carbonate-14C. Livers of normal and CCI 4 intoxicated rats were perfused with heparinized rat blood diluted with KrebsHenseleit bicarbonate buffer for 3 hours. At 90 minutes after the start of perfusion, 4 mg of betamethasone or 500/tg of actinomycin D was added respectively into the perfusate. On the other experiments, betamethasone and aetinomysin D was added

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simultaneously. The rate of albumin synthesis was calculated from the specific activity of newly formed urea and the total 14C in guanido carbon of arginine in albumin. Albumin synthesis rate of normal rats was 5.4mg/hour/100g body weight, and the rate increased to 8.7 mg by the addition of betamethasone. The difference was significant statistically. The synthesis rate of the intoxicated livers in acute stage was 4.3mg/hour/100g body weight. This was lower than the rate of normal rats. The rate increased to 7.3 mg by the addition of betamethasone. The difference was also significant statistically. The synthesis rate of cirrhotic livers was 3.1 mg/hour/100 g body weight, and the rate increased to 5.3 mg after the addition of betamethasone. In order to elucidate the mechanism of the action of betamethasone on albumin synthesis, the additon of betamethasone and actinomycin D were held in normal liver perfusion. The synthesis rate after the addition of actinomycin D was 5.0 mg/hour/100 g body wight, and the rate after the simultaneous infusion of betamethasone and actinomycin D was 5.2 mg. That is, actinomycin D did n o t inhibit the albumin synthesis of normal livers, but inhibited the increase of synthesis rate by the addition of betamethasone. From these results, it was clarified that the rate of albumin synthesis decreased significantly in proportion to the progress of the injury of the liver, the synthesis rate in normal and CC14 intoxicated livers was promoted by the addition of betamethasone and actinomycin D inhibited the increase of albumin synthesis rate by the addition of betamethasone. (128) SERUM G L Y C O P R O T E I N ANALYSIS FOR THE ACCURATE DIAGNOSIS OF LIVER CARCINOMA AND RELATED DISEASES Y. Taoka, T. Endo, R. Chizuka, T. Yanagida, and S. Chizuka

Tokyo Rosai Hosp. (Tokyo Univ., Sch. of Med., Ohta-ku, Tokyo)

Analysis for electrophoretical patterns of serum glycoproteins (periodic acid-Schiff staining) on "Cellogel" in patients of liver carcinoma and related diseases is very useful for accurate diagnosis. In primary liver carcinoma (mainly hepatoma) are recognized prominent and wide a l and a2-GP peaks ("malignant pattern"), and also ot1 is usually higher than 0t2 whereas a2 is more prominent than otl in metastatic liver carcinoma. Protein-bound sialic acid is significantly increased in metastatic liver carcinoma and protein-bound hexosamine is enhanced in other carcinoma without liver metastasis. No remarkable change is noticed for proteinbound amino-sugars between primary liver carcinoma and liver cirrhosis without malignancy. On serum glycoprotein subcomponents are markedly increased ot1-acid glycoprotein (a 1-AG) and a 1-antitrypsin (a 1-AT), haptoglobin (Hp) and ceruloplasmin (Cp) in liver carcinoma and other carcinoma without liver metastasis whereas 0~2-macroglobulin (a2-M) and ot2-heat stable glycoprotein are rather decreased in these conditions. No definite correlation is illustrated in this paper between primary and metastatic liver carcinoma and related diseases for haptoglobin subtypes (1-1, 2-1, 2-2). (129) SOME CHARACTERS AND CLINICAL SIGNIFICANCE OF LP-X H. Usui, T. Ando, T. Takai, T. Wakahara, M. Kojima, T. Fukazawa and Y. Takahashi

1st Dept. of Int. Med. G~, Univ. The presence of abnormal lipoprotein (Lp-X) in the blood of patients with obstructive jaundice was proved from the study with electron microscope, lipid analysis, gel filtration, electrophoresis and immunology. The electron microscope revealed the presence of the abnormal disks with major axis 400-600A in the blood of patients with obstrutive jaundice. The special disks have

Proceedingsof the 59th Annual Meeting, 1973-Kagoshima the tendency to form a rouleaux. The composition of the disks was characterized by high PL, low TG, abnormally low cholesterol ester ratio and low level of protein content. T h e fraction containing the purified disks did not react with anti a- or /9-Lp antibody. Gel filtration of the serum of the patient showed abnormal fractions between chylomicron and L D L . Anti L p - X antibody reacted with the abnormal fractions and the lipid compositon of the abnormal fractions was similar to that of purified Lp-X. Clinically, L p - X was observed in cholestatic hepatitis (6/13), extra-hepatic biliary obstruction (16/20) primary biliary cirrhosis (2/2) and metastatic liver tumor (5/8), and the incidence of L p - X was increased as the level of serum alkaline phosphatase increased. It was concluded that the detection of L p - X was useful for analyzing the presence of biliary obstruction. (130)

TRANSFERRIN IN LIVER DISEASE AND ITS PROGNOSIS --EFFECT OF TRANSFERRIN ON LIVER REGENERATIONS. Miyamura, T. Urakawa, T. Shima, K. Miyaji and T . Okazaki

3r&Dept. of Int. Med., Mie Univ. Sch'. of Med. The liver is an organ active for regeneration and repair and Such function should be taken into consideration in liver disease. However there is no such indicator in the current liver function tests. We have reported the usefulness of serum T I B C to serve such purpose. Sixty five per cent of the cases of acute hepatitis with a serum T I B C value below 330/.tg/dl on admission took a prolonged course, all cases of fatal fulminant hepatitis were below 200/tg/dl and cases of liver cirrhosis were of low values Acccording to Higgins method two-thirds of liver were. resected and the variation of transferrin was investigated during the course of regeneration. At the peak of regeneration there was an increase in hepatic TIBC. After

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the peak there was an increase in serum T I B C parallel to the hepatic TIBC. F r o m this result the produced transferrin was assumed to be related to liver regeneration. To confirm this assumption various amounts of human apotransferrin were injected intraperitoneally into rats of 200 g and the incorporation of 3H-thymidine into hepatic D N A was found maximal at the level of 1 0 m g which is equivalent to 100/tg/dl of h u m a n TIBC. W h e n was injected the animal serum which was obtained at the peak of liver regeneration, despite the low level of transferrin, the SH-thymidine incorporation was increased. Thus though factors other than transferrin also play a roll in liver regeneration, transferrin itself activates liver regeneration. (131) M E T A B O L I S M O F V O L A T I L E FATTY ACID IN RAT LIVER IN EXPERIMANTAL BILIARY OBSTRUCTION S. Kashimura, K. Koyama, H. Yamauchi, Y. Matsuo, Y. Takagi, L Muto, Y. Owada, T. Otowa and T. Sato

1st Dept. of Surg., Tohoku Univ. Sch. of Med., Sendai It is the clinical evidence that considerable number of patients with severe obstructive jaundice in our clinic died of hepatic coma. However, the etiological factors of the condition are still obscure. T h e purpose of this paper is to examine the metabolism of volatile fatty acid (VFA) which has been considered to be one of the important factors inducing hepatic coma. In one group, 20 of Wistar rats were subjected to ligation and section of the common bile duct. In another group of 7 rats, 20% carbon tetrachloride (CCL4) solution was injected into the peritoneal cavity. The rats of the former group were killed every week during four weeks and those of t h e latter group were done 48 hours after the injection. The thin liver slices were prepared for the examination of the metabolism of VFA. The consumption of V F A was diminished

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of graded degree correspondiing to the duration of the bile duct obstruction, especially remarkable at three weeks after the biliary obstruction and the most conspicuous decrease was found in the liver of CCL 4 injection rats. Diminution in the consumption of VFA was preceded by that of ketogenesis, which was most apparent at two weeks after the biliary obstruction and the magnitude of the decrease in ketogenesis was higher than that of the decrease in the consumption of VFA. However, both of them became almost the same at three weeks after the ligation. The volume of diminution in VFA exceeded that of ketogenesis at four weeks after that, and similar tendency was demonstrated in the liver of CCL 4 injection rats. It was clarified that the consumption of VFA decreased in volume in proportion to the duration of the biliary obstruction and its diminution was caused mainly by that in ketogenesis. It was also presumed that the disturbance in ketogenesis was presented in the earlier stage than that in the TCAcycle in the liver in biliary obstruction, but both TCA-cyele and ketogenesis were disturbed at the period of three weeks after the hiliary obstruction. The studies on metabolism of VFA and ketogenesis possibly enable us to determine the grade of the hepatic dysfunction in patients with bitiary obstruction and to forecast the occurrence of hepatic coma. (132) METABOLISM OF CHYLOMICRON-TRIGLYCERIDES (TG) AND FREE FATTY ACIDS (FFA) BY ISOLATED HEPATOCYTES C. Naito and K. Okada

1st Dept. of Int. Med., Facul. of Med., Tokyo Univ., Tokyo Isolated hepatocytes were prepared gently using collagenase and hyaluronidase. Trypan blue stainable cells were less than 5%. When 14C-chylomicron was incubated with isolated hepatoeytes at a low temperature (4~ total 1~C uptake by the cells was equal to that incubated at 37~ However, the incorporation of a*C into metaholites of fatty

acids (Co 2 and ketone bodies) was much less at the low temperature. When x~C-oleic acid was used instead of 14C-chylomicron, the similar results were observed. These results, taking together with the fact that 14C-chylomicron contained 14C-FFA (3 to 4%), suggested that 14C-chylomicron was taken up by hepatocytes in the form of not 14C-TG but 14C-FFA. When postheparin serum containing high activity of lipoprotein lipase was added to the incubation medium, not only total x4C uptake by hepatocytes but also the incorporation of 1~C into metabolites of fatty acids increased significantly. However, no effects of post-heparin serum addition were observed on the uptake and incorporation of 14C from 14C-oleic acid. Moreover, when Krebs-Ringer phosphate buffer was used as the incubation medium instead of dialyzed serum, total 14C uptake by hepatocytes from t4C-chylomicron and the ~4C activity of T G fraction of hepatocyte lipids increased significantly. Nevertheless, the incorporation of 14C into metabolites of fatty acids did not increase at all. In the medium of Krebs-Ringer buffer solution, adhesion of chylomicron to the surface of hepatocytes has been suggested. Therefore, the increase in radioactivity of total and T G fraction appeared to be due to the adhesion, but not to the real uptake by the cells. C o n c l u s i o n : Chylomicron-TG can be taken up by hepatocytes only after hydrolysed to FFA but not as such. (133) A STUDY ON CHANGES OF BLOOD G L U T H A T I O N E (GSH AND GSSG) AND G-6-PD ACTIVITY IN JAUNDICE K. Sugawara, T. Nokiba, Y. Fujii, H. Kido. M. Sasaki, Y. Su~ai and G. Nishimura

1st Dept. of Surg., Nihon Univ., Sch. of Med. In the 55th meeting of this society, we reported tendencies of a decrease of blood GSH and an increase of blood GSSG in obstructive jaundice. This time, we performed, in jaun-

Proceedingsof the 59th Annual Meeting, 1973-Kagoshima diced cases, experimental and clinical studies on changes of G - 6 - P D activity which has an intimate relationship with the oxidation and reduction of gluthatione and the comparison was made with those of gluthatione. Experimentally, using dogs, bile ducts were ligated and severed. By the time went on, icterus index increased. But blood GSH and G S H / H t index showed tendencies to decrease. O n the contrary, blood G S S G showed an increase. The activity of blood G - 6 - P D showed a definite tendency to decrease. The activity was almost completely found in the blood corpuscles. In liver tissue of bile duct ligated dogs, we noted a decrease of G S H and an increase of GSSG. But G - 6 - P D activity in liver showed an increase, contrary to the change in blood. In 28 patients with jaundice of various origins, the relationships between the degree of jaundice and GSH, G S S G and G - 6 - P D activity in b l o o d were studied. Blood G S H showed a decrease but no direct relationship was observed between G S H level and icterus index. No difference was noted in G S S G level from the control. As for G - 6 - P D activity in blood, most of the cases showed an increase if jaundice was slight or moderate, and a decrease if jaundice was marked. In a study of a hepatitis patient and a case of post-operative carcinoma of the head of the pancreas, we found that the activity of G - 6 - P D was more closely related with icterus index than blood GSH, when jaundice was improving. In these cases, blood G - 6 - P D activity was increasing as icterus index was decreasing.

(134) H E P A T I C F U N C T I O N A L RESERVE IN OBSTRUCTIVE JAUNDICE FROM A STANDPOINT OF MITOCHONDRIAL METABOLISM H. Nanbu, Y. K a m i y a m a , T. Yamada, Y. Yamaoka, H. Takeda, T. Ohsawa, T. Kamano, T. Mizukami, O. Kitamura, K. Ozawa, H. Takasan and .

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I. Honjo

1st Dept. of Surg., Kyoto Univ. Sch. of Med. The hepatic mitochondrial metabolism in regard to the cytochrome a(+a3)-turnover n u m b e r of phoshporylative capacity and the contents of respiratory enzymes were investigated in 11 patients of obstructive jaundice and 109 rabbits subjected to ligation of the common bile duct. These could be classified into three groups; mitochondria having normal or enhanced A T P synthesis capacity with normal contents of cytochrome a(+a3) (group I), lowered A T P synthesis capacity with normal level of cytochrome a ( + a a ) (group II), and severely inhibited A T P synthesis capacity with marked decrease of cytochrome a ( + a s ) content (group III). The hepatic functional reserve, estimated from the postoperative hepatic dysfunctions and mortality, was maintained enough in group I, fairly in group II and poor in group III.

(135) H I S T O L O G I C A L C H A N G E S O F R A T L I V E R BY A D M I N I S T R A TION OF HEMOLYSATE R. Miyasaki, T. Katayama, T. Amakawa, K. Hirose, Y. Furukawa, M. Noguchi, M . ' O k a m o t o and H. M a e z a w a

1st Dept. of Int. Med., Tokyo Med. and Dent. Univ. This report describes the hepatic changes of rats after injection of hemolysate. Two ml of the hemolysate, produced by the method reported previously, was administered into rats intraperitoneally once a week for 6 months. T h e n the liver was examined morphologically by light and electron microscope. And the serum G O T , Al-p and 131I-BSP retention rate were measured. In the light microscopy, the degeneration and the decrease content of glycogen of hepatocyte were recognized, but the cell necrosis was scarcely found. Kupffer cells

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became proliferated a n d enlarged moderately. A n d the additional features were the formation of vacuole a n d the proliferation of fiber along the sinusoidal m a r g i n of hepatocyte. I n electron microscopy, the vacuole was delimited by a single m e m b r a n e a n d the nucleus, mitochondrion, a n d endoplasmic reticulum of the hepatocyte h a d a n o r m a l appearance. T h e cytoplasmic process of endothelial lining of sinusoids b e c a m e so thick that no fenestration was observed. Collagen fibers were ploriferated in space of Dissse which was not uniform in width. It was estimated t h a t these sinusoidal changes is identical with socalled "capillarization" of sinusoid. In the functional studies, serum G O T , G P T a n d Al-p were in n o r m a l range, b u t x3XI-BSP retention rate in the rats administered the hemolysate were increased t h a n that in the control. F r o m these histological a n d functional studies, it was c o n c l u d e d t h a t some substance in the hemolysate led to damages of the liver, especially sinusoidal walls a n d sinusoidal surface of hepatocytes. (136) M E T A B O L I S M O F V I T A M I N B-12 I N L I V E R D I S E A S E W I T H SPECIAL REFERENCE TO TRANSCOBALAMINS AND NATURAL OCCURRENCE OF COBALAMINS N. T a n a k a , S. Y a m a d a , T. Hisata, C. H a t a , J . Sawa, Y. Kato, Y. M i t u d a a n d S. O o h i r a

2nd Dept. of Int. Med., Jikei Univ., Sch. of Med. T h e d e t e r m i n a t i o n of serum B-12 concentration a n d u n s a t u r a t e d B-12 binding capacity, separation of T r a n s c o b a l a m i n 11 a n d T r a n s c o b a l a m i n 1, m e a s u r e m e n t of endogenous B-12 in T r a n s c o b a l a m i n s , a n d investigation of natural occurrence of cobalamin in serum a n d T r a n s c o b a l a m i n s were done on sera from healthy individuals a n d patients with acute hepatitis. In acute hepatitis the elevation of serum vitamin ]3-12 was m a r k e d a n d the u n s a t u r a t e d

vitamin B-12 b i n d i n g capacity was slightly decreased as c o m p a r e d with healthy individuals. M e t h y l c o b a l a m i n in serum a n d T r a n s c o b a l a m i n 1 from healthy individuals a n d acute hepatitis patients were found as the m a j o r form of occurrence, b u t D B C C a n d Hydroxocob a l a m i n were slightly increased in serum a n d T r a n s c o b a l a m i n 1 from acute hepatitis patients as c o m p a r e d with h e a l t h y individuals. I n T r a n s c o b a l a m i n 11 from healthy individuals the proportion of occurrence of O H - B - 12, C H - B - 1 2 , a n d D B C C was considerably similar, b u t D B C C was relatively increased in T r a n s c o b a l a m i n 11 from acute hepatitis patients, suggesting t h a t it is due to a release of D B C C from the d a m a g e d liver. (137) P O S T O P E R A T I V E N U T R I TION CONTROL SPECIAL REFERENCE TO AMINOACID METABOLISM ----ESPECIALLY ON AMINOACID METABOLISM IN DIABETES MELLITUS-A. Hayasaka, T. O k u y a m a , S. Fukui, T. Takeda, T. Furuichi, S. Yamamitsu, K. Y a m a u c h i , a n d Y. Konishi

1st Dept. ofSurg., Sapporo Med. Col. O u r recent study on this p a r t i c u l a r condition was r e p o r t e d a n d s u m m a r i z e d as follow: I) B r a n c h e d c h a i n amino-acid becomes higher in its c o n c e n t r a t i o n t h a n n o r m a l r a n g e even in a m i l d case a n d the level tends to increase more in a m o d e r a t e or severe case.

2)

Arg. reveals higher level even in a mild case. 3) All other amino-acids show same t e n d e n c y in their levels as above.

Proceedings oft he 59th Annual Meeting, 1973-Kagoshima (138) S T UDI ES ON T H E P R O F I L E ANALYSIS OF O R G A N I C ACIDS (I) D E V E L O P M E N T OF A NEW T E C H N I Q U E F O R ANALYSING O R G A N I C ACIDS R E L A T E D T O TC A CYCLE S. Maeda, S. Setoyama and S. Otsuji

Central Clin. Lab., Kagoshima Univ. Hosp., Kagoshima P u r p o s e : A new chromatographic technique was devised to analyse simultaneously organic acids related to T C A cycle. The chromatogram was designated as TCAAcidogram. The purpose of this study was to apply TCA-Acidogram to the clinical and biochemical researches and to the diagnosis or follow-up of various pathological conditions. M a t e r i a l s and M e t h o d s Partition chromatography with silicic acid column and gradient elution with tert. amyl-alcohol/ chloroform were found to be suitable for the analysis. Automatic indicator titration be O-Nitrophenol Na was applied to column eluate in order to continuously measure absorbancy at 350nm of each separated organic acids. R e s u l t s : Acids were well separated in TCA-Acidogram of 11 authentic acids mixture. TCA-Acidograms of some biological materials were as follows: Acetate, fumarate, lactate, succinate, trans-aconitate, malate and citrate were clearly identified in rat liver. The chromatographic difference between normal and CCI 4 treated rats was discussed. Acetate, lactate, succinate and trans-aconitate were demonstrated in gastric juice. Additional peak of citrate was appeared in ulcer and the difference was revealed between normal and ulcer profiles. Pyruvate, fumarate, lactate, succinate, alpha-ketoglutarate, trans-aconitate, cis-aconitate, malate and citrate were detected in serum. In liver cirrhosis, those acids were decreased and increased acetate peak was additionally identified. The difference of profiles was discmsed between normal and liver cirrhosis. It could be conceivable that TCA-Acidogram of biological materials would promote

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understanding and clarification of biochemical mechanism in various pathological processes. (139) M E T A B O L I C A L T E R A T I O N OF E R Y T H R O C Y T E F R O M TH E PATIENT WITH CHRONIC L I V E R LESI O N S T. Ibata, H. Niu, A. Ogawa, E. Tujioka, T. Maeda, M. Takewa, T. Matumoto, K. Tamada, A. Maeda, H. Sumita, Y. Iseki, S. Yukawa, Y. Nitta, K. Isida and H. Nomoto

Dept. of Metabolism, Int. Med., Wakayama Med. Col. Several metabolic changes of matured erythrocyte from liver damaged patients were studied. M e t h o d s and M a t e r i a l s : Several enzyme activities, added glucose or xylitol utilization and lipids of human erythrocyte having chronic hepatitis or liver cirrhosis were observed. Lactate was measured by Barker-Summersons method and pyruvata was by Marbachs. Glucose-6-phosphate dehydrogenase, 6phosphogluconate dehydrogenase, glyceraldehyde-3-phosphate dehydrogenase, glutathione reductase, pyruvate kinase and lactic dehydrogenase were by Miwa's method. Reduced glutathione of erythrocyte was measured with the method described by Beutler. R e s u l t s and d i s c u s s i o n : 1. Low levels of glutathion reductase activity and reduced glutathione of erythrocytes from chronic hepatitis and from liver cirrhosis were obtained, on the contrary with the elevated glucose-6-plmsphate dehydrogenase from that of erythrocytes. 2. Suspension of erythrocytes in xylitol added Krebs-Ringer solution was incubated for 3 hours at 37~ and production ofpyruvate and production of pyruvate and lactate were measured. The ratio of lactate/pyruvate from chronic hepatitis, esp. from liver cirrhosis was very

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high value, that was suggested increased N A D H 2 to N A D or increased permeability of xylitol into erythroeyte from patient having liver cirrhosis. 3. Lactate producing activity of erythrocytes from diabetics was disturbed, but when advanced liver damage was combinated, the activity recovered to or exceeded normal value. O n the other hand, the lipid constitutions of erythrocyte from chronic hepatitis or liver cirrhosis were resemble to that of spherocytosis, namely the quantities of phosphatidyl serine to total lipids was decreased. These experimental results suggested the possibility of characteristic change of erythrocyte membrane from patient with chronic liver lesions.

was significantly correlative to H K activity; and in thin type, it had significantly negative correlation with the activities of H K , P F K and PK. 4. Correlation between the activities of enzymes and serum lipids: Significant correlation was found in between phospholipid and the activities of P F K and PK, and also found in both between non-esterified fatty acid and the activity of P F K and between triglyceride and that of PK.

(140) S T U D I E S O N T H E LEUKOCYTE GLYCOLYTIC RATE-LIMITING ENZYME IN D I A B E T I C S (I) S. Setoyama, S. Maeda and S. Otsuji

Dept. of Int. Med., Mishuku Hosp.

Central Clin. Lab. Kagoshima Univ. Hosp., Kagoshima The purpose of this study was to reveal some aspects of pathological mechanism and to promote the clinical understanding of diabetes mellitus. Materials and Method: Leukocyte preparation was isolated from human venous blood by the modified polyvinylpyrrolidone separation procedure devised by authors. Both in 30 normal subjects and in 50 diabetics (composed of 13 severe, I0 moderate and 27 mild types), the activities ofhexokinase (HK), phosphofructokinase (PFK) and pyruvate kinase (PK) were determined. R e s u l t s : 1. Average P K activity of diabetics was significantly lower than that of normal subjects. 2. Both average P K activties of 27 mild and of 13 severe diabetics were significantly lower than that of normal subjects, but the differences of average P F K and H K activities between diabetics and normal subjects were not significant. 3. Correlation between the degree of obesity of diabetics and the activities of enzymes: In mild diabetics, it

(141) H E P A T I C C H A N G E S IN ACUTE CIRCULATORY FAILURE R. Sato, G. Sato, S. Toyokawa, G. Yamamoto, S. Ohtomi, M. H a g a and Y. Ueno

M. Fukuda

Dept. of Clin. Pathol. R. Endo

Laboratory We reviewed 580 autopsied cases which had done in the past several years in our hospital and evaluated them in both morphological and functional aspects. 58 out of 580 cases, with exception of 18 cases of acute or subacute hepatitis showed hepatic necrosis caused by acute circulatory failure, in which 11 cases were of focal and zonal necrosis, 30 cases of submassive central necrosis and 17 cases of massive necrosis. Their primary diseases were made of liver cirrhosis with massive hemorrhage from ruptured varices, hemorrhagic gastro-duodenal ulcer, acute heart failure in myocardial infarction or valvular diseases, mesenteric insufficienty, malignant tumor and other disorders. Hepatic degeneration and necrosis were considered to be caused by acute circulatory failure in liver followed by low cardiac output which resulted into ischemia or hypoxia in liver cells. Findings of liver function tests were very similar to them of acute hepatic parenchymal damage, especially of subacute hepatic necrosis. Levels of serum G O T and G P T showed significant elevation and G O T to G P T ratio

Proceedingsof the 59th Annual Meeting, 1973-Kagoshima was over 1.0 in many cases. Elevated levels of L D H and I C D H were more remarkable than those of G O T and G P T . Elevation of serum bilirubin level was lower in spite of abnormally high levels of liver enzymes. T h e r e were often presented leukocytosis, increased B U N and serum creatinine. (142) C H A N G E S O F H E P A T I C ARTERIAL FLOW AND LIVER FUNCTION T. Yokota, J. Ohsawa, A. Kohno, E. Ohtoshi, H. Yasugi, H. Ichikawa, R. M i z u m o t o and I. Honjo.

1st Dept. of Surg., Kyoto Univ. Med. Sch. It is very important to study on the effect of the hepatic artery in various conditions upon liver function, because the liver in portal hypertention is mainly supplied by the hepatic artery with vascular disturbance of the portal flow and because complication of cirrhotic liver restricts operability of primary carcinoma of the liver. 1. The portal branches of the right half of the liver and the hepatic vein of the left half were ligated after the performance of large side to side portacaval anastomosis in dog. U n d e r these circumstances, right half of the liver was supplied merely by the hepatic artery with normal outflow tract into the hepatic vein and left half merely by the hepatic artery with retrograde outflow tract via the portal vein above the shunt. T h e function of the liver with postsinusoidal block in the left half was compared with that of the liver with presinusoidal block in the right half of the same dog, using 131I-BSP excretion rate in the bile, bile volume and oxygen consumption rate immediate and 8 weeks, after the operation. Immediate after the operation, bile volume, '31I-BSP excretion rate and oxygen consumption rate in the right half with presinusoidal block were the.same as that in the left half with postsinusoidal block, showing no damage to the liver cell in each side. 8 weeks after the operation, 181I-BSP excretion rate in the right

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half was about two times higher than in the left half and oxygen consumption rate in the right half was significantly higher than in the left half. On the histological section, the liver in the left half showed more prominent degenerative changes than in the right half. These results indicate that retrograde flow of the hepatic artery into the portal vein is less effective than normograde flow into the hepatic vein. 2. Resectability of the liver in various conditions of the hepatic artery was investigated. When the hepatic vein was ligated with portacaval anastomosis and liver showed postsinusoidal block, many dogs survived more than 2 weeks after 30~ hepatectomy, but all died after 50% hepatectomy. When the portal vein was ligated with portacaval anastomosis and when the liver showed presinusoidal block, many dogs survived more than 2 weeks after 50% hepatectomy, but few dogs survived after 70% hepatectomy. It is concluded that the liver function with retrograde outflow of hepatic artery in postsinusoidal block was only 50~176 of that with normograde flow of hepatic artery in presinusoidal block.

(143) S T U D I E S O N H E P A T I C CIRCULATION : ALTERATIONS OF HEPATIC BLOOD FLOW IN DOGS WITH HEPATIC INTOXICATION BY D I M E T H Y L N I T R O SAMINE (DMNA) K. Ando, H. Suzuki, T. Nishiwaki, T. Kishimoto, T. Miki, K. Takeshige, M. Sawada, R. H i d e m u r a

Dept. of Surg., Nagoya Univ. S. Yamamoto and S. Itoh

Dept. of Surg., Aichi Med. Col. Values of hepatic blood flow (HFB) estimated by different methods are not necessarily consistent. Comparative studies were carried out between clearance methods with results obtained by electromagnetic flowmeter (EMF) as the standards in dogs with hepatic intoxication induced by Dimethylnitrosamine (DM-

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NA). Hepatic arterial flow (HAF) and portal venous flow (PVF) were directly measured using E M F , HBF being calculated as the sum of these two components. Clearance studies were performed using Indocyanine green (ICG, 0.25mg/kg) and colloidal radiogold (Au 198, 50/tCi). Peripheral disappearance rate (K) and hepatic extraction ratio(ER) were calculated for each indicator. To test the effects of superimposed mechanical reduction of HBF, the same clearance studies were repeated on the same animals after 40 and 70% hepatectomies(HX), hepatic arterial ligation(HAL) and end-to-side portacaval anastomosis(PCA). In animals with D M N A - i n d u c e d hepatic intoxication, both H A F and HBF as measured by E M F were increased by 42 and 14% respectively compared with normal controls. This observation corresponds to the observation in hepatic intoxication by carbon tetrachloride (CC14). While values of HBF obtained by Au lg8 clearance method and E M F were in fair approximation, dissociation was noted between results obtained by I C G method and E M F . Although the effect of D M N A on the liver was morphologically less severe than that of CC14, the effect on the functional aspect of the liver was fairly severe. It might be concluded that alterations of HBF induced by D M N A intoxication is reflected more closely on Au xgs clearance than on I C G clearance, since impairment of the liver induced by D M N A is more functional than morphological. (144) S T U D I E S O N H E P A T I C H E M O D Y N A M I C S BY SCINTIPHOTOSPLENO PORTOGRAPHY T. Kashiwagi, M. Kishida and O. I m a m u r a

Dept. of Med., Kansai Rosai Hosp. T. Suematus and T. K a m a d a

1st Dept. of Med., Osaka Univ. Med. Sch. A new method of visualization of portal venous system was developed. After injecting 99mTcO4- (5-8 mCi/ml)

into the spleen, scintiphoto was taken by Picker Dyna Camera. This method was named scintiphotosplenopor tography. Twenty-eight patients were studied. Patterns of portal circulation were classified into four groups. Ia: no collaterals, no tortuous vein Ib: no collaterals with tortuous vein I I : collaterals with liver image I I I : collaterals without liver image Patterns with collaterals were thought to suggest the existence of portal hypertension. In the present study, scintiphoto seemed to be more reliable for the detection of esophageal varices than the conventional X-ray and endoscopic examinations.

(145)

CORRELATION OF BILIARY TRACT DISEASES AND PORTAL HYPERTENSION. K. Sakoda, T. Kawada, Y. Arima, T. K a m i m u r a , M. Takesue, T. Katsuki and H. Akita

2nd Dept. of Surg., Kagoshima Univ. Sch. of Med. Recently, it has been demonstrated that biliary tract infection is one of the most frequent antecedent cause of portal vein obstruction and cholelithiasis occurs with unusual frequency in hypersplenism and liver cirrhosis. In this paper, four cases of portal vein obstruction, three cases of hypersplenism, and nine cases of liver cirrhosis and fibrosis accompanied by biliary tract diseases with gallstone are reported. The cases of portal vein obstruction were accompanied by cholelithiasis in one, cholelithiasis, choledocholithiasis, and intrahepatic caliculi in two, and intrahepatic caliculi with biliary fistula in another one. In all cases hepato-petal and fugal collaterals developed. Splenic pulp pressure elevated remarkably. Serum bilirubin, especially direct bilirubin increased. Histologically liver revealed inflammatory infiltration and proliferation of connective tissue mainly in portal areas.

Proceedings of the 59th Annual Meeting, 1973-Kagoshima The cases of hypersplenism had cholesterol stone in one and bilirubin stone in two associated with the high values of indirect serum bilirubin. Portal hypertension was recognized in one case. T h e cases of liver cirrhosis and fibrosis had bilirubin stone in eight and cholesterol stone in one. Histologically liver revealed portal cirrhosis in four, postnecrotic cirrhosis in three, and fibrosis in two. Portal pressure was elevated remarkably. O f the 48 patients with liver cirrhosis recognized by laparotomy 7 (14.6%) had gallstone in biliary tract. A higher incidence of gallstone have been reported in cirrhotic patients by several investigators. The association and relationships of biliary tract diseases and portal hypertension should be further investigated. (146) H I G H I N F L O W P O R T A L HYPERTENSION AND ITS SURGICAL TREATMENT Y. Yakeishi

Dept. of Surg., Hiroshima Red-Cross Hosp. I. Takehisa, K. Miyasato and H. Yoshida

2nd Dept. of Surg., Sch. of Med., Tokushima Univ. H e m o d y n a m i c studies and follow-up examination after splenectomy, microangiogram and electron-microscopic studies of the removed spleen, direct measurement of splenic artery blood flow, and histometrical studies in the splenic arterial system were undertaken between so-called Bant's disease, hepatic cirrhosis and normal control cases. A marked decrease in portal vein pressure after splenectomy was seen in cases which had shown the most severe arterial congestion without severe sinus hyperplasia. The number of branches of splenic penicilliary was greater in so-called Banti's disease (37.5 branches/cm 2) than in the congested spleen (24 branches/cm2). In the spleen of'so-called Banti's disease, capillaries and penicilliary arteries are extremely tortuous and form many close capillary plexus. The splenic blood flow was on the

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average 123.3ml/min and the blood flow per unit weight of spleen was 0.86 m / g m / m i n in the control cases. In the cases of so-called Banti's disease, the splenic blood flow showed a marked increase, that is 2-5 times above the value of the control cases and in the cases of hepatic cirrhosis, the splenic blood flow was only a little larger than that of the control cases.

T h e elevation of the portal vein pressure seemed to be related mainly to an increased blood flow which entered into the portal vein through the spleen in the earlier stages of so-called Banti's disease. From this point of view, it can be called a high inflow portal hypertension. For this kind of portal hypertension, we recommend the distal spleno-renal shunt as a rational surgical treatment. (147) L A C T U L O S E F O R T H E TREATMENT OF PORTOSYSTEMIC ENCEPHALOPATHY: A DOUBLE-BLIND TEST BY C R O S S - O V E R M E T H O D R. Hidemura, K. Kubota, S. Aoki, S. Suzuki, T. Kishimoto, T. Miyahara, K. Ando, T. Nishiwaki, T. Miki, K. Takeshige, and M. Sawada

Dept. of Surg., Nagoya Univ. S. Itoh and S. Y a m a m o t o

Dept. of Surg., Aichi Med. Col. Effectiveness of lactulose in the treatment of portosystemic encephalopathy has already been demonstrated and was reported previously. A series of double-blind tests were carried out in clinical materials to reevaluate the effectiveness of lactulose. Included in this study were 8 patients (4 males and 4 females, age ranging from 44 to 60) who had undergone end-to-side portaeaval anastomoses 5 to 17 years previously. Preliminarily, an optimal dosis of 50~ lactulose solution was determined in each individual with clinical signs and symptoms as indices. A double-blind test was then carried out using 20 and 50~ solution for

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a total period of 4 weeks each solution for 2 weeks. Subjective symptoms, bowel habit, results of liver function tests, blood ammonia level, psychoneurological signs were closely observed. To be noted was that completion of tests with 20% solution was impossible without supplementing with 50% solution in the middle of the course because of appearance of signs and symptoms pertinent to portosystemic encephalopathy. Blood ammonia level was affected by a maximum of 20% by the difference of concentration of lactulose solution. Fecal p H was consistently lower while the patient was on 50% solution than while he was on 20% solution. In 7 cases out of 8 were noticeable differences between psychoneurological signs in two test periods, while no remarkable difference was observed in neurological reflexes as well as liver function indicated by blood chemical studies. In a strictly controlled double-blind test, effectiveness of laetulose o n protosystemic encephalopathy was reconfirmed.

(148)

ESTIMATION OF COLLAGENASE IN EXPERIMENTAL FIBROSIS OF RAT LIVER K. Fujiwara, T. Sakai, T. O d a and S. Igarashi

enzyme activity was measured by liberating soluble peptides from native reconstituted fibrils of guinea pig skin neutral soluble collagen labelled with 14C-glycine as a substrate. Identification o f c o l l a g e n a s e : The enzyme samples were purified by affinity chromatography, then were incubated with acid soluble rat skin collagen. The reaction products were examined by disc electrophoresis. (Results) Collagenase activities in the control and slight fibrotic group were negligible i n the crude samples, but significantly increased after treating with SCN, especially more evident in the latter. Besides, a good correlation between the activity and the hydroxyproline content in the fibrotic liver tissue was observed, while in the marked fibrotic group it was much higher even in the crude samples. The activity was also increased by treating with trypsin in the control group. Disc electrophoresis showed several fragments smaller than a A and /~A after incubating collagen with all the purified samples obtained by the affinity chromatography. ( C o n c l u s i o n ) Collagenase in liver tissue was detected as an active enzyme form, as well a s an inactive form. The activity of the two forms was found to increase in the fibrotic liver tissue of rats.

1st Dept. of Int. Med., Tokyo Univ. Collagenase activity, active or masked, was determined in rat liver and its relationship to the fibrosis of the liver was studied. Inactive form of the enzyme was activated by treating with trypsin or NaSCN.

(Materials and Methods) Fibrotic liver: Male Wistar rats were administered with 0.1 ml C C L 4 subcutaneously twice a week for 4 to 18 weeks. Preparation o f the e n z y m e : The enzyme samples for assay were prepared as follows, 1) the liver homogenate with 0.1% Triton X-100 (crude), 2) the crude sample after incubation with 5 mg/ml trypsin (trypsin treated), 3) the homogenate following dialysis against 3M N a S C N (SCN treated). Substrate and m e t h o d for assay: The

(149) T H E E F F E C T O F E L A S T A S E ON EXPERIMENTAL LIVER F I B R O S I S (III) M. Fukuhara, T. Tsujii, T. Tamura, Y. Matsuoka, H. Takahashi, T. Sakamoto, S. Fukuda, M. Oku, T. Matsui, T. Morita, Y. Oyazato, K. Kimura, W. Moriya, and S. Fukui.

1st Dept. of lnt. Med., Nara Med. Univ. Previously we reported that elastase inhibits the development of experimental liver fibrosis caused by CCI 4. The effect of elastase on established liver cirrhosis and the mechanism of inhibition of liver cirrhosis by

Proceedings of the 59th Annual Meetings, 1973-Kagoshima elastase were studied in this report. Experimental method Sprague-Dawley male rats were divided into 6 groups (Group A, B, C, D, E, F). A subcutaneous injection of CC1, was given to A twice a week for 20 weeks. To B was subcutaneously injected elastase everyday in addition to CC1,. C was given elastase for 10 weeks in addition to CCI 4 after 10 weeks' treatment with CC14. E was given elastase only for 4 weeks after 20 weeks' treatment with CCI 4. F was given elastase only for 6 weeks. Each group was examined in liver H O P , A M P S , and lysosomal enzymes (cathepsin, /~-glucuronidase, collagenolytic activity) at definite intervals. Digestive activity ofelastase for soluble collagen extracted from guinea pig skin was observed by disc electrophoresis. R e s u l t s Gradual increase in H O P of B was obviously small as compared with that of A, but there was no difference between those of C and A. H O P of E was distinctly less than that of D. Change in A M P S of B showed a pattern similar to that of A, but A M P S quantity of B was obviously small as compared with that of A. A M P S quantity of C, D, and E did not differ from that of A. There was no difference in lysosomal activity among A, B, and C. Lysosomal level of D and E was higher than that of A. There was no difference in /5-glucuronidase activity between D and E. Cathepsin activity was higher in E than in D, while collagenolytic activity higher in D than in E. There was observed no remarkable change in lysosomal activity of F through the experimental period. Digestive effect of elastase on soluble collagen was shown as disappearance of fl-fraction on disc electrophoresis. Moreover, there was histochemically observed no increase in elastic fiber during development of liver fibrosis by CC14. The above results suggest that the inhibitory effect of elastase on liver fibrosis may be attributed to its collagenolytic action, which may be non-specific proteolytic action of elastase. (150) C L I N I C A L S T U D Y O F SUPERFICIAL VASCULAR

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PATTERN OF THE L I V E R BY P E R ITONEOSCOPY K. Suzuki, S. Morimoto, S. Tsuiki, K. Shoji, Y. Nakai, M. Hata, J. Kubo, K. Yoshizawa, K. Nagayama, Y. Ozawa, M. Yoshida and M. Horiguchi

Dept. of Gastroenterl. 3rd Hosp., Jikei Univ. Sch. of Med. We emphasize the hepatic pre-cirrhosis is very important state of the liver disease because it is irreversible and may progress to cirrhosis. So, we give diagnosis carefully by many examinations, such as biochemical, structural, hemodynamical and endoscopical. For the peritoneoscopical examination, it is very important to accept the stage of the surface, edge and color of the liver, etc. Nevertheless, correct diagnosis is now very difficult by peritoneoscopy. M a n y authors reported about intrahepatic vascular derangements of hepatic cirrhosis. But, there are few reports concerning superficial vascular pattern of the liver, so we tried to observe the superficial vascular pattern of the liver by peritoneoscopy. We could see m a n y vessels beneath the surface of the precirrhotic and cirrhotic liver, but so many vessels beneath the surface of the normal, fatty liver and the liver of hepatitis. Furthermore, individual vessel beneath the surface of the normal liver showed branching in a Y-shape and extending smoothly. But that of the pre-cirrhotic and cirrhotic liver showed various morphological changes ; distortion, flexion, dilatation, constriction, interruption and augmentation and tortuosity of small branches. These changes could not be shown in the other hepatic diseases, so we consider these vascular changes is due to proliferation of connective tissue, regeneration of parenchyma and disturbance of intrahepatic circulation. We consider if we observe the number and morphological pattern of the superficial vessels of the liver by peritoneoscopy, we can more easily and correctly give diagnosis

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of the liver disease, especially hepatic precirrhosis a n d cirrhosis. (151) C I L I N C A L A N D P A T H O L O G I CAL STUDIES ON CIRRHOSIS O F T H E L I V E R (III) GASTROINTESTINAL BLEEDING ON CIRRHOSIS OF THE LIVER A. M a c h i i , Y. Nitta, Y. Also, N. K i t a h a r a , E. Kitazawa, K. Fukuda, N. Saiti, Y. M u r a k a m i , Y. Nao

Dept. of Int. Med., Sch. of Med., Keio Univ. T h e 29 fatal cases of cirrhosis of the liver seen at o u r clinic between 1969 a n d 1972 were studied. T h e 15 cases of the study g r o u p were recognized gastrointestinal bleeding (group A) a n d the r e m a i n i n g 14 cases were n o t recognized gastrointestinal bleeding (group B). I n g r o u p A there were 14 males a n d 1 t~male a n d in group B there were 6 males a n d 8 females. Interval from clinical onset of cirrhosis of the liver to d e a t h was 2.7 years o n the average in g r o u p A a n d 2.6 years in group B. J a u n d i c e was found in 7 cases of g r o u p A a n d in 13 cases of g r o u p B. Ascites was f o u n d in 11 cases of group A a n d in 14 cases of g r o u p B. T h e period from a p p e r a n c e of ascites was 2.5 months on the average in g r o u p A a n d 11 m o n t h s in g r o u p B. I n the past history acute hepatitis was seen in 5 cases of g r o u p B a n d heavy drinkers were seen in 8 cases of group A a n d in 3 cases of group B. S e r u m G O T a n d L D H level were increased in group A t h a n in g r o u p B. Decrease of serum a l b u m i n a n d increase of serum T-globulin were seen in group B t h a n in group A. Oesophageal varices were found in 4 cases of g r o u p A a n d in 7 cases of group B. T h e d u r a t i o n of bleeding was 1-4 days in 8 cases a n d was over 30 days in 2 cases. Autopsy findings; T h e r e were 10 cases of autopsy in each groups. I n group A, At-type of cirrhosis of the liver was found in 1 case a n d B-type was found in 8 cases. I n group B, At-type was found in 4 cases a n d B-type was

in 6 cases. H e p a t o m a was f o u n d in 5 cases of group A a n d in 6 cases of group B. Peptic ulcer was f o u n d in one case in each groups. T h e weight of liver was 1612 g. on the average in group A a n d 8 1 9 g . in group B. T h e volume of ascites was 2815 ml on the average in group A a n d 3811 ml in group B. Oesophageal varices was found in 8 cases of g r o u p A a n d in 4 cases of these cases in the total length of the oesophagus a n d in 5 cases of group B in the lower portion of the oesophagus. I n the fatal cases of cirrhosis of the liver clinical features a n d pathological findings of gastrointestinal bleeding were studied. (152) F O L L O W - U P S T U D I E S O N 146 C A S E S O F L I V E R C I R R H O S I S --WITH SPECIAL REFERENCE TO SURVIVAL AFTER THE APPEARANCE OF PHYSICAL SIGNS-I. Okazaki, K. Funatsu, K. M a r u y a m a , B. Takagi, S. Yasuraoka, K. Ishii, S. Matsuzaki, H. Takahashi, H. Ishii, K. K a m e g a y a , a n d K. S a m b e

Dept. of Int. Med., Sch. of Med., Keio Univ. T h e present study reported 5 year survival curves in 146 cases of liver cirrhosis diagnosed between 1965 a n d 1972. 82 patients (56%) were diagnosed b y laparoscopy a n d / o r liver biopsy, 50 cases (34%) by definite diagnostic physical signs such as massive ascites, esophageal varices a n d so forth, 14 cases (10%) based u p o n liver scintigram a n d selective celiac a n g i o g r a p h y in addition to physical a n d laboratory findings. T h e 146 subjects i n c l u d e d 15 cases w h o were complicated with h e p a t o m a at the first time of consultation. 5 year survival curves were contructed by the lifetable m e t h o d of Cutler a n d Ederer. 0.5, 1, 2, 3, 4 a n d 5 year survival rates of 146 cases were 83.9, 75.8, 72.2, 66.9, 62.6 a n d 53.1%, respectively. Those of 131 cases (only liver cirrhosis at the first time of diagnosis) were 92.2, 84.7, 80.6, 74.6, 69.8 a n d 59.2%, respectively. 5 year survival rates of 75 cases of compensated a n d 56 cases of

Proceedings of the 59th Annual Meetings, 1973-Kagoshima decompensated liver cirrhosis were 74.5% and 39.5%. The present data suggest improved survival rates compared with those of previous reports, most probably reflecting the improved treatment of decompensated liver cirrhosis. 5 year survival rates after the appearance of jaundice, ascites and the physical signs of portal hypertension were 41.9, 11.7 and 58.9%, respectively. The therapeutic effects of steroids and diuretics were also investigated. No significant effects of steroid therapy on the survival rates of cirrhotic patients were observed. Diuretics were supposed to be slightly effective as far as the first 2 years' survival rates were concerned. (153) R E G U L A T I O N OF GALLBLADDER PRESSURE W I T H SPECIAL REFERENCE TO A U T O N O M I C NERVES H. Ishikawa, Y. Tajima, A. Kuroda, Y. Ishihara, N. Sato, I. Ishikawa and T. Noro

1st Dept. of Surg., Tokyo Univ. Sch. of Med., Tokyo The nervous regulation of the gallbladder pressure was investigated on 35 dogs. Gallbladder pressure was measured through polyethylene catheter which was inserted into the gallbladder and connected to electromanometer. 1) Gallbladder pressure was elevated by electrical stimulation of the peripheral ends of vagal nerves and infusion of cholinergic drugs. 2) Gallbladder pressure was decreased by electrical stimulation of the peripheral ends of the splanchnic nerves and beta-stimulation by isoproterenol infusion. 3) Gallbladder pressure did not change by division of both vagal and splanchnic nerves. 4) When autonomic denervation and adrenalectomy were performed, gallbladder pressure seeroed to increase gradually to its initial pressure after evacuation of gallbladder bile and fall gradually to its initial pressure after injection of saline solution into the

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gallbladder. From this experiment, it is supposed that gallbladder pressure is regulated by the autonomic action of the gallbladder. 5) The common bile duct was divided and a polyethylene catheter was introduced into the proximal end of the common bile duct and outflow of the bile from the catheter was recorded. Thereafter, any effect of the sphincter of Oddi on bile flow was left out in this experiment. Following injection of Pancreozymin, gallbladder pressure elevated markedly, and outflow of bile from the catheter increased simultaneously, and ceased 30 minutes after injection of Pancreozymin. On the contrary, in dogs with ligated cystic duct, outflow of bile from the catheter increased transiently, but did not decrease to zero, 30 to 60 minutes after injection of Pancreozyrain. 6) From these experiments, it is supposed that: Before contraction of the gallbladder, gallbladder pressure and flow of gallbladder bile are regulated by the dual sympathetic and parasympathetic innervation, and autonomic action of the gallbladder. During contraction, gallbladder pressure is elevated, and outflow of gallbladder bile is increased by stimuli of Pancreozymin and vagal nerves. After contraction, gallbladder pressure is decreased below the initial pressure by stimuli of the splanchnic nerves, and inflow of bile into the gallbladder is induced. (154) ABSORPTION AND BILIARY E X C R E T I O N OF D I G I T O X I N IN JEJUNAL PERFUSION OF RATS Y. Kakumoto, H.S. Mekjian and N.R. Thomford

The Ohio State Univ., Col. of Med., U.S.A. Digitalis glycosides are commonly used as important cardiotonic agents. But relatively little is known about their metabolism under normal physiologic conditions. The purpose of this study is to determine jej~unal absorption, liver extraction and biliary excretion of digitoxin using ~H-digitoxin as a tracer.

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Proceedings of the 59th Annual Meeting--1973--(H)--

Also the effect of bile acids on them was studied. Using 42 Wistar rats, ten centimeters of jejunal loop was prepared for perfusion. Biliary fistula was made at the same time for collection of bile. The perfusate was Krebs Ringer solution with PEG. 5 Gm./L., digitoxin 5 ug./ml., 3H-digitoxin 2.5 uc./dl., pH. 8 and temperature 37~ Three hours after surgery, w h e n the rat was awakened from anesthesia, the jejunum is perfused at a constant rate (0.47 ml./min.) with an infusion pump. After 20 minutes equilibration perfusion, test perfusion was performed 75 minutes. Radioactivity was counted with Tricarbo 3375 counter (Packard). When sodium taurocholate was infused into the ileum during jejunal perfusion, bile acid output increased markedly (p