Goro Sugioka

HYPEREOSINOPHILIC SYNDROME WITH EXTENSIVE MYOCARDIAL INVOLVEMENT AND MITRAL VALVE THROMBUS INSTEAD OF MURAL THROMBI

A 68‐year‐old woman complained of repeated signs of congestive heart failure during the last 10 years. Clinical examination revealed persistent marked eosinophilia of the peripheral blood. Postmortem examination of the heart revealed multiple thrombo‐embolic materials of the small vascular lumina throughout the myocardium, associated with marked perivascular and stromal infiltration of eosinophils, many foci of myocardial necrosis, and diffuse myocardial fibrosis. There was also an organizing thrombus in the posterior mitral valve. Neither subendocardial fibrosis, overlying mural thrombi in the endocardium, pulmonary infiltration of eosinophils nor systemic granulomatous or healed vasculitis in the lungs and other organs were found. The disease is preferably consistent with a diagnosis of hypereosinophilic syndrome of Hardy et al., a group of ill‐defined and overlapping conditions, and best descriptively termed as eosinophilic interstitial myocarditis.

Diagnostic value of endoscopic retrograde pancreatography in chronic pancreatitis based on the new criteria proposed by the Japan Pancreas Society in 1995 : Comparison with the criteria proposed by the Japanese Society of Gastroenterology in 1983

This study evaluated the new criteria for the diagnosis of chronic pancreatitis (CP) with endoscopic retrograde pancreatography (ERP) proposed by the Japan Pancreas Society in 1995 by comparing it with the older criteria of the Japanese Society of Gastroenterology proposed in 1983. No significant differences were noted between the two when the diagnostic sensitivity of ERP was considered in calcifying CP. Among 54 patients of noncalcifying CP (group I) with ERP diagnosis of moderate or advanced pancreatitis by the previous criteria, only one of 22 with the localized type was definite CP. The remaining 21 were ruled out as either definite or probable CP, and six were classified as having chronic obstructive pancreatitis based on the new criteria. In contrast, a diagnosis of definite CP was made not only for all the 32 patients with CP (group I) of diffuse type but also in 11 cases of CP (group II) with diffuse minimal pancreatitis showing irregular dilatation of the side branches with scattered distribution throughout the gland. In a series of 15 follow-up patients with CP (group II) having initial ERP diagnosis of minimal pancreatitis, CP group I developed in three of five cases of diffuse minimal pancreatitis, which is consistent with definite CP by the new criteria, whereas progression to this group of CP was found in none of the 10 patients with localized minimal pancreatitis. These results indicate that although localized CP is excluded from CP, the incidence of diffuse noncalcifying CP diagnosed by ERCP was increased with the new criteria, and detecting radiologic features with diffuse irregular dilatation of the branch ducts based on these criteria may lead to early diagnosis of CP.

Aberrant hepatic duct connected with the main pancreatic duct by anomalous pancreato-biliary ductal union: Case report

An aberrant hepatic duct directly connected to the main pancreatic duct with anomalous arrangement of the pancreato-biliary ductal system is reported here, the first report of such a case, to our knowledge. A 53-year-old woman was admitted to our hospital because of cholecystolithiasis with abdominal pain in the right upper quadrant. Endoscopic retrograde cholangiopancreatography (ERCP) showed that an aberrant hepatic duct, which independently drained the right posterior segment of the liver, connected to the main pancreatic duct at a high insertion site distal to the sphincter area of the major papilla. The common bile duct (containing stones), on the other hand, united with the main pancreatic duct in a normal fashion. Cholecystectomy and bile duct lithotomy were performed. The aberrant hepatic duct was separated from the main pancreatic duct just above the junction, and was anastomosed side-by-side to the common hepatic duct. The embryologic development of this lesion is not clear, but is discussed in this report.

Leucocyte migration inhibition with insoluble rat liver cell membrane in patients with chronic liver diseases

肝硬変103例の患者末梢血リンパ球を採取して,非特異的・特異的T細胞機能の一端を検索し,つぎの成績をえた.1) 慢性肝炎と肝硬変の末梢血リンパ球のPHA反応は,減退する傾向があり,そのT細胞populationも,減少する傾向がみられた(P<0.05).2) ラット肝から分画した不溶性の細胞膜に対するMIF活性は,慢性肝炎非活動型,同活動型,肝硬変のいずれも,健常者に比べて有意に(P<0.05)充進しており,これらの膜免疫陽性者は陰性者に比べてHBAgに対する細胞性反応も充進しているものが多かった(P<0.10).しかしラット腎から分画した細胞膜に対しては,肝疾患の1例も細胞性に反応しなかった.3) この特異的な細胞性免疫亢進の状態は,流血抗体の血中出現とは,まったく平行しなかった.

Histological studies of the liver in extrahepatic obstructive jaundice with special reference to morphogenesis of hepatic fibrosis

In order to study the fibrogenesis of bi l iary cirrhosis, histological studies were carr ied out on liver specimens obtained by needle biopsy, laparotomy or autopsy in 46 cases (calculosis of the bile duct, 11; carcinoma of the head of the pancreas, 10; carc inoma of the bile duct, 17 and miscellaneous, 8). Among these 46 cases, no fibrotic change was revealed in 16 (34.8%), sl ight fibrosis in 12 (26.1%), considerable degree of fibrosis in 13 (28.3%) and definite pictures of bil iary c i r rhosis in 5 (10.9%), respectively. Mean durat ions of jaundice due to the extrahepat ic obst ruct ion in each group was 40.3+_9.3, 87.2+--33.2, 181.2_+44.2 and 873.6 days, respectively. Concerning the fibrogenesis of the l iver in extrahepat ic obs t ruct ive jaundice, fibrosis began mainly f rom the periportal areas, and in a few cases it began f rom the centrolobular areas. In some eases, the two pat terns of fibrosis coexisted more or less in termingl ing wi th each other. At the early stage of obstruct ion, s l ight fibrosis of the l iver was predominant ly found in the portal and perihepatocellular areas. As the fibrosis progressed, per iductular fibrosis became prominent . Serial microscopic examinat ion of the liver specimens revealed tha t fibrous bands or iginated f rom the per iportal and /or in t ra lobular areas accompanied wi th marked bile ductular proliferat ion mainly connected wi th the fibrous bands in the neighboring portal tr iads. And part ly, they also connected wi th the small fibrotic s t r ings around centra l veins caused by parenchymal degeneration. It was assumed that these connections of the fibrous bands might gradually divide hepatic lobules into small pseudolobules.

From the aspect of internal medicine

It is utmost importance to differentiate the character of jaundice accurately in an early stage, pertaining to the t rea tment and prognosis of jaundiced patients. From the aspects of clinical signs, liver function tes ts and peritoneoscopy, studies were made on the difference between hepatocellular jaundice such as hepatitis or liver cirrhosis and extrahepatic obstructive jaundice as caused by caricinoma of head region of the pancreas, and carcinoma or calculosis of the bile duct. The possible alteration of the liver induced by extrahepatic obstruction of the bile duct and the factors contr ibuting to the establ ishment of such al terat ion were also discussed. Incidence of Pat ients with Jaundice Number of patients admitted to the Firs t Department of Internal Medicine of Kanazawa University Hospital during the period of 5 years from January, 1961 to December, 1965 was 2,302 in total. Among these, 416 (18.I%) had certain disorders in the liver or in the bile duct. In 227 out of these 416 (54.6%), jaundice was observed with icterus index of more than 11. Extrahepatic obstructive jaundice was encountered in 67 patients; calculosis of the bile duct 20, pancreatic carcinoma 17, carcinoma of the bile duct 10, carcinoma of the gall-bladder 6, primary carcinoma of the liver associated with cirrhosis 2, metastat ic carcinoma of the liver 4, carcinoma of the papilla of Vater 3 and miscellaneous 5. On the other hand, intrahepatic obstructive jaundice due to cholangiolitic hepatitis was observed in only 2, obviously being less compared with extrahepatic one. Hopatocellular jaundice was observed in 119 cases; acute hepatitis 69, chronic hepatitis 12 and liver cirrhosis without hepatoma 38. Thir teen cases of primary carcinoma of the liver (with cirrhosis 12 and without cirrhosis 1) and 9 cases of metastatic carcinoma of the liver were equivocal to determine whether jaundice was of obstructive nature due to intrahepatic obstruction by carcinoma, of hepatocellular one due to insufficiency of liver cell function, or of others . Jaundice caused by other origins was seen in 17 cases. Since the number of cases with intrahepatic obstructive jaundice was very small, discussion was made mainly on extrahepatic obstructive jaundice in this paper comparing with hepatocellular jaundice. Clinical Pictures In 20 cases with extrahepatic obstructive jaundice due to stone in the bile duct f requent initial symptoms were fever (48.1%), jaundice (44.4%), abdominal pain (44.4%) and pain in the back (29.6%). When extrahepatic obstructive jaundice was due to carcinoma of the pancreas, the bile duct, the gall-bladder and the papilla of Vater, and primary and metastatic carcinoma of the liver, principal onset symptoms of 42 cases were jaundice (46.6%), anorexia (30.2%) and strongly stained urine (27.9%). In 119 cases with hepatocellular jaundice as seen in hepatit is and liver cirrhosis, onset symptoms were jaundice (64.5%), fatigue (57.9%), anorexia (36.1%) and fever (28.5%). Accordingly, it is often difficult to dist inguish extrahepatic obstructive jaundice from hepatocellular one at an early stage of the disease solely on clinical symptoms. In extrahepatic obstructive jaundice due to carcinoma of the bile duct and head region of the pancreas, mean values* of icterus index, alkaline phosphatase activity (Bessey-Lowry) and cholesterol level in the serum were 108.5+15.9 units (32 cases), 19.3• units (29 cases) and 2452_+30.8 mg/dl (25 cases), respectively, while in extrahepatic obstructive jaundice due to stone 402_+11.9 units (23 cases), 9.8--+4.9 units (20 cases) and 191.6_+20.4 mg/dl (17 cases), respectively. Therefore, these values were higher in extrahepatic obstructive jaundice due to carcinoma than in the one due to stone, revealing a significant statistic difference (p>0.05). Ratio of icterus index to alkaline phosphatase activity (MG/A1-P) was 16.6--+3.6 in 46 cases of hepatocellular