C.D. Kim

Biliary papillary hyperplasia with clonorchiasis resembling cholangiocarcinoma.

Infection by the liver fluke Clonorchis sinensis is very common in the Far East. It causes low grade inflammatory changes and proliferation in the biliary tree. Initially there is desquamation of the biliary epithelium, followed by hyperplasia and adenomatous proliferation. Cholangiocarcinomas are potential long term complications. We present a case of biliary papillary hyperplasia with clonorchiasis resembling cholangiocarcinoma in a 69-yr-old Korean man. Early recognition of biliary hyperplasia and treatment of Clonorchis sinensis is important to prevent development of cholangiocarcinoma, especially in the Far East.

Double-Blind Placebo-Controlled Study of Cisapride in Patients with Nonspecific Esophageal Motility Disorder Accompanied by Delayed Esophageal Transit

BACKGROUND Nonspecific esophageal motility disorder (NEMD) represents a difficult therapeutic challenge because of the heterogeneous nature of the esophageal motor functions. We studied the effects of cisapride on the esophageal symptoms and esophageal motor function in a group of patients with NEMD showing delayed esophageal transit. METHODS Seventy eligible patients were entered into a 4-week, double-blind randomized comparison of 10 mg of cisapride or placebo, four times daily. Symptom assessment, esophageal manometry after wet swallows, and esophageal scintigraphy after intake of a liquid and solid bolus were performed in each patient before and after treatment. RESULTS After 4 weeks of treatment cisapride significantly increased the prevalence of esophageal peristaltic contractions (percentage of total contractions, P < 0.05 versus base line and placebo) and significantly improved esophageal emptying of the solid bolus (P < 0.05 versus placebo) but not of the liquid bolus. Placebo did not have any significant effects versus base line on these variables. Both placebo and cisapride improved the distal esophageal amplitude versus base line (no significant intergroup differences). Symptom scores were significantly reduced after 4 weeks of treatment versus base line in both groups (no significant intergroup differences except for heartburn and regurgitation, P < 0.05). On global evaluation of treatment, significantly more patients in the cisapride group were rated as markedly or moderately improved, when compared with placebo. CONCLUSIONS The results of the present study showed that cisapride is effective and well tolerated in patients with NEMD accompanied by delayed esophageal transit. Symptomatic improvement may possibly be related to its beneficial action on the esophageal body by increasing the number of peristaltic contractions and esophageal emptying of solids.

The effect of the respiratory cycle on liver stiffness values as measured by transient elastography

Summary.  The findings of several studies suggest that liver stiffness values can be affected by the degree of intrahepatic congestion respiration influence intrahepatic blood volume and may affect liver stiffness. We evaluated the influence of respiration on liver stiffness. Transient elastography (TE) was performed at the end of inspiration and at the end of expiration in patients with chronic liver disease. The median values obtained during the inspiration set and during the expiration set were defined as inspiratory and expiratory liver stiffness, respectively. A total of 123 patients with chronic liver disease were enrolled (mean age 49 years; 64.2% men). Liver cirrhosis coexisted in 29 patients (23.6%). Expiratory liver stiffness was significantly higher than inspiratory liver stiffness (8.7 vs 7.9 kPa, P = 0.001), while the expiratory interquartile range/median ratio (IQR ratio) did not differ from the inspiratory IQR ratio. Expiratory liver stiffness was significantly higher than inspiratory liver stiffness in 49 (39.8%) patients (HE group), expiratory liver stiffness was significantly lower than inspiratory stiffness in 15 (12.2%) patients, and there was no difference in 59 (48.0%) patients. Liver cirrhosis was more frequent in those who had a lower liver stiffness reading in expiration, and only the absence of liver cirrhosis was significantly associated with a higher reading in expiration in multivariate analysis. In conclusion, liver stiffness was significantly elevated during expiration especially in patients without liver cirrhosis. The effect of respiration should be kept in mind during TE readings.

Efficacy of Helicobacter pylori eradication therapy in chronic liver disease

BACKGROUND/AIMS Peptic ulcers occur more commonly in patients with liver cirrhosis (LC). Helicobacter pylori is recognized as the most important etiology in the pathogenesis of peptic ulcers. We investigated the efficacy of proton pump inhibitor (PPI)-based triple therapy in patients with chronic liver disease and peptic ulcer. PATIENTS AND METHODS One hundred sixty-three patients with LC or chronic hepatitis (CH) with a peptic ulcer and proven H. pylori infection were included. The combination of PPI, amoxicillin (1.0 g), and clarithromycin (500 mg), each given twice daily, was administered for 1 or 2 weeks. The eradication of H. pylori was determined by the rapid urease test, histology, or the 13C-urea breath test at least 4 weeks after completing the treatment. RESULTS The eradication rate of H. pylori was similar between the LC and CH groups; 82.6% and 88.1%, respectively. In addition, there were no significant differences in eradication rates between the patients with Child-Pugh class A and Child-Pugh class B/C disease. The side effects in each group were generally mild. Only the serum ALT levels showed a significant correlation with the success of H. pylori eradication in both the LC and CH groups. CONCLUSION The PPI-based triple therapy achieves high eradication rates for H. pylori infection, in patients with chronic liver disease, without significant side effects.

Gastrointestinal: A retroperitoneal liposarcoma that formed a fistula into the descending colon

Liposarcoma frequently occurs in the retroperitoneum and lower extremities, accounting for 9.8–16% of all soft tissue sarcomas. Liposaromas vary by histology and can be classified into four types. Those four types are well differentiated, myxoid/round cell, pleomorphic and dedifferentiated. This classification corresponds to the clinical aspect and prognosis of patients. Dedifferentiated liposarcoma (DDL) has both a well differentiated liposarcoma and a high grade nonlipogenic sarcoma within the tumor. It is difficult to diagnose DDL histologically. DDL can show a variety of histological appearances. The most common phenotype is malignant fibrous histiocytoma. Other phenotypes include leiomyosarcoma, osteosarcoma, rhabdomyosarcoma, and angiosarcoma. For DDL, prognosis is generally poor compared with the other types of liposarcoma. It shows high recurrence rate of 40-83%, metastasis rate of 15–30%, and the overall 5-year survival rate of 20%. DDLs often originate in the retroperitoneum, extremities, trunk, testis, and spermatic cord. A 61-year-old man was admitted to our hospital with 38.8°C of fever and general weakness. He had a history of a 20 ¥ 10 cm well-differentiated retroperitoneal liposarcoma and underwent debulking surgery and intraoperative radiotherapy eight years previously. After surgery, there was no remnant mass visible on the abdominal computed tomography (CT) scan. On the current admission, physical examination revealed a palpable mass in the left mid abdomen. CT scan revealed a 8.5 ¥ 8.3 cm sized large mass abutting the descending colon and left kidney in the left retroperitoneal cavity. The tumor encased a segment of the bowel loop and there was air density suspicious of tumor fistulization into the colonic lumen. Colonoscopy showed a fistula into the descending colon 30 cm from the anal verge (Figure 1). A yellowish mass was seen through the fistula with erythematous and edematous mucosal changes around the fistula. We suspected that the liposarcoma had recurred, and the patient underwent left colon segmental resection. The specimen showed a 9.5 ¥ 8.5 cm sized, welldemarcated, yellowish-gray, lobulated, glistening, and firm mass. Microscopic findings showed a dedifferentiated liposarcoma containing a well-differentiated component with fat lobules and a nonlipogenic hypercellular area. There were scattered atypical lipocytes (Figure 2, upper panel) and pleomorphic spindle cells (Figure 2, lower panel, H&E, orig. mag. ¥200) consistent with a subtype of malignant fibrous histiocytoma.

Achalasia associated with multiple esophageal diverticula.

Case Report: A 66-year-old man had a 2-year history of worsening dysphagia to solids and liquids. In the previous 2 months, the patient had episodes of immediate regurgitation of swallowed food and fluids. Since the onset of dysphagia, he had been treated irregularly with antacids without much benefit. Physical examination and routine blood test were unremarkable. Barium esophagogram demonstrated 3 right-sided esophageal diverticula of 4.5 cm, 3.3 cm and 1.5 cm in diameter along the mid to distal esophagus (Fig. 1). Upper GI endoscopy revealed 3 diverticula in the esophagus and food stagnation within the diverticula (Fig. 2A). Esophageal manometry was performed, and there was no peristalsis in the body. Each swallow resulted in simultaneous contractions with amplitudes ranging from 40 to 65 mmHg (Fig. 3). Resting LES pressure measured 66 mmHg and did not show complete relaxation. A total dose of 100 IU of botulinum toxin (Botox; Allergan, Inc. , Irvine, CA, USA) was injected at 4 sites using a sclerotherapy needle (Fig. 2B). After botox injection therapy, the symptomatic response was accompanied by a decrease of lower esophageal sphincter pressure from 66 to 28 mmHg after injection, and the patient was discharged 3 days later. After 6 months, he had no dysphagia or vomiting. Discussion: As botulinum toxin has been used clinically since the early 1970s to correct localized muscular spasms, it entered gastroenterological practice in the early 1990s for treatment of achalasia. 3 Another report demonstrated successful treatment with botulinum toxin injection of the pylorus in symptomatic diabetic gastroparesis patients. 4 Injections of botulinum toxin have been used in esophageal motility disorders, especially achalasia, safely and with good clinical success, and there is little evidence of systemic toxicity or complications. 5 Botulinum toxin injection could be recommended as an alternative treatment, especially in older patients with either increased risk for dilation or who have failed to respond to other treatment modalities. 6 We report a successfully treated rare case of achalasia-associated multiple esophageal diverticula.

483 IL28B POLYMORPHISM IS ASSOCIATED WITH NECROINFLAMMATORY ACTIVITY AND ADVANCED FIBROSIS IN PATIENTS INFECTED WITH CHRONIC HEPATITIS DUE TO GENOTYPE NON-1 HCV

482 IS LIVER FIBROSIS PROGRESSION FASTER IN HUMAN IMMUNODEFICIENCY VIRUS/HEPATITIS C VIRUS COINFECTED PATIENTS ON ANTIRETROVIRAL THAN IN HCV ONLY INFECTED PATIENTS? F.H.D.L. Pace, M.L.G. Ferraz, A.E.B. Silva. Internal Medicine – Gastroenterology and Hepatology, Universidade Federal Juiz de Fora, Juiz de Fora, Internal Medicine – Gastroenterology and Hepatology, Universidade Federal de Sao Paulo, Sao Paulo, Brazil E-mail: fpace@oi.com.br

493 CLINICAL SIGNIFICANCE OF PRECORE AND CORE PROMOTER MUTATIONS IN KOREAN CHRONIC HEPATITIS B PATIENTS

Background and Aims: The clinical significance of precore/core promoter mutations of hepatitis B virus (HBV) in chronic hepatitis B (CHB) patients is controversial. We aimed to clarify the relationships between precore (G1896A) and core promoter (A1762T, G1764A) variants and serum HBV DNA levels, hepatic inflammation, and liver fibrosis in Korean CHB patients. Methods: A total of 226 treatment-naive CHB patients were studied. Mutations in the precore/core promoter regions were detected by RFMP. Liver biopsies were performed to assess fibrosis in 186 patients, while 40 patients had imaging findings compatible with cirrhosis. Serum alanine aminotransferase (ALT) levels were used as surrogate markers for hepatic inflammation. Results: Ninety patients (39.8%) showed eAg seroconversion. Core promoter and precore mutations were found in 87.2% and 52.2% of patients, respectively. Both types of mutations were more frequent in HBeAg negative patients than in HBeAg positive patients (P < 0.001). HBeAg negative patients were older with more advanced liver fibrosis but had lower serum ALT and HBV DNA levels compared to HBeAg positive patients (all P < 0.001). HBeAg positive patients with core promoter variants did not differ from those without such variants in serum HBV DNA levels, but were older with higher ALT levels and advanced fibrosis (all P < 0.01). HBeAg positive patients with precore variants had lower serum HBV DNA levels than those without mutations (P =0.023). Advanced fibrosis was associated with older age in both HBeAg positive and negative patients (P < 0.05), while core promoter variants were independently associated with disease progression (≥F2) in HBeAg positive patients (P =0.007). ALT levels showed independent correlations with viral load in both groups (P < 0.05). Precore variants showed inverse correlations with HBV DNA levels in HBeAg positive patients (P =0.015). Neither type of variant was correlated with fibrosis, serum ALT and HBV DNA levels in HBeAg negative patients. Conclusion: A1762T/G1764A and G1896A variants are closely associated with HBeAg seroconversion in persistently viremic Korean CHB patients. In HBeAg positive patients, precore variants are associated with enhanced host immune response and are capable of decreasing serum HBV DNA levels, while core promoter variants are associated with liver damage and progression of liver fibrosis.

165 THE PROGNOSIS AND ITS RELATED FACTORS IN PATIENTS WITH HEPATITIS B VIRUS-RELATED LIVER CIRRHOSIS IN THE ANTIVIRAL ERA

164 CORRELATION OF PLATELET COUNT WITH ENDOTOXAEMIA IN CIRRHOTIC PATIENTS WITH THROMBOCYTOPENIA AND EFFECTS OF RIFAXIMIN G. Kalambokis, A. Mouzaki, M. Rodi, E. Tsianos. 1st Division of Internal Medicine and Hepato-Gastroenterology Unit, Medical School, University of Ioannina, Ioannina, Division of Haematology, Department of Internal Medicine, Medical School of Patras, Patras, Greece E-mail: geodora@mail.gr

Education and Imaging. Gastrointestinal: a retroperitoneal liposarcoma that formed a fistula into the descending colon.

Liposarcoma frequently occurs in the retroperitoneum and lower extremities, accounting for 9.8–16% of all soft tissue sarcomas. Liposaromas vary by histology and can be classified into four types. Those four types are well differentiated, myxoid/round cell, pleomorphic and dedifferentiated. This classification corresponds to the clinical aspect and prognosis of patients. Dedifferentiated liposarcoma (DDL) has both a well differentiated liposarcoma and a high grade nonlipogenic sarcoma within the tumor. It is difficult to diagnose DDL histologically. DDL can show a variety of histological appearances. The most common phenotype is malignant fibrous histiocytoma. Other phenotypes include leiomyosarcoma, osteosarcoma, rhabdomyosarcoma, and angiosarcoma. For DDL, prognosis is generally poor compared with the other types of liposarcoma. It shows high recurrence rate of 40-83%, metastasis rate of 15–30%, and the overall 5-year survival rate of 20%. DDLs often originate in the retroperitoneum, extremities, trunk, testis, and spermatic cord. A 61-year-old man was admitted to our hospital with 38.8°C of fever and general weakness. He had a history of a 20 ¥ 10 cm well-differentiated retroperitoneal liposarcoma and underwent debulking surgery and intraoperative radiotherapy eight years previously. After surgery, there was no remnant mass visible on the abdominal computed tomography (CT) scan. On the current admission, physical examination revealed a palpable mass in the left mid abdomen. CT scan revealed a 8.5 ¥ 8.3 cm sized large mass abutting the descending colon and left kidney in the left retroperitoneal cavity. The tumor encased a segment of the bowel loop and there was air density suspicious of tumor fistulization into the colonic lumen. Colonoscopy showed a fistula into the descending colon 30 cm from the anal verge (Figure 1). A yellowish mass was seen through the fistula with erythematous and edematous mucosal changes around the fistula. We suspected that the liposarcoma had recurred, and the patient underwent left colon segmental resection. The specimen showed a 9.5 ¥ 8.5 cm sized, welldemarcated, yellowish-gray, lobulated, glistening, and firm mass. Microscopic findings showed a dedifferentiated liposarcoma containing a well-differentiated component with fat lobules and a nonlipogenic hypercellular area. There were scattered atypical lipocytes (Figure 2, upper panel) and pleomorphic spindle cells (Figure 2, lower panel, H&E, orig. mag. ¥200) consistent with a subtype of malignant fibrous histiocytoma.