Katsuhisa Toda

Nocturnal branched-chain amino acid administration improves protein metabolism in patients with liver cirrhosis: Comparison with daytime administration

BACKGROUND In an attempt to optimize oral branched-chain amino acid (BCAA) administration to improve serum albumin in cirrhotic patients, we compared the effects of nocturnal and daytime BCAA administration on protein metabolism in cirrhotic patients. METHODS Twelve cirrhotic patients were enrolled in a short-term study. Patients were administered either conventional daytime BCAA granule or nocturnal BCAA for a week, and metabolic analyses were performed, followed by a crossover study in the next week. Another 12 patients, who showed no improvement of serum albumin level with previous daytime BCAA administration, were randomly assigned to either a nocturnal or a daytime BCAA administration group in a long-term study. RESULTS Low Fischers ratio, reduced respiratory quotient, and low serum albumin were observed at entry in cirrhotic patients. Whereas daytime BCAA administration improved nitrogen balance and Fischers ratio, these 2 were further significantly improved after nocturnal BCAA administration. There were no changes in parameters of energy metabolism throughout the study. In the 3-month follow-up, a significant increase in serum albumin was observed in patients administered nocturnal BCAA but not in those administered daytime BCAA. CONCLUSIONS Nocturnal BCAA administration improved serum albumin in cirrhotic patients who showed no improvement in serum albumin level with daytime BCAA administration. This effect could be partly caused by the improved protein sparing with this administration method.

Oral branched‐chain amino acid supplementation improves the oxidized/reduced albumin ratio in patients with liver cirrhosis

Aim:  Branched‐chain amino acid (BCAA) supplementation improves hypoalbuminemia in decompensated cirrhotics. Recently, it was clarified that the ratio of oxidized albumin within total albumin rises with progression of liver cirrhosis. We conducted a feasibility study to investigate whether BCAA supplementation might improve this ratio.

Inflammatory pseudotumor of the liver with primary sclerosing cholangitis

Abstract: Inflammatory pseudotumor (IPT) of the liver is a rare benign variant of hepatic masses, and its exact etiology has not been elucidated. We report a case of IPT associated with primary sclerosing cholangitis (PSC). The patient was a 50-year-old man admitted to our hospital because of jaundice. Abdominal ultrasonography (US) and computed tomography showed multiple dilations of the intrahepatic bile ducts and multiple masses in the liver. On magnetic resonance imaging, the masses were slightly hypointense on T1-weighted images and slightly hyperintense on T2-weighted images. On T1-weighted images after the bolus infusion of Gd chelate, the masses had no contrast enhancement, and they were hypointense in the arterial phase and portal venous phase. However, they were slightly enhanced and became almost isointense relative to the surrounding normal liver parenchyma in the delayed phase. Endoscopic retrograde cholangiography demonstrated multiple irregular strictures and dilations of the intrahepatic bile ducts. Angiography demonstrated no abnormal findings, but, interestingly, subsequent dynamic CO2-enhanced US showed a strongly hyperechoic string, indicating that an artery had penetrated through the hypoechoic mass. A US-guided percutaneous needle biopsy revealed that the lesions were morphologically comparable to IPT. After cholangiography and microscopic analysis of the tumor, the final diagnosis was determined to be IPT of the liver with PSC. A number of previous reports have suggested a possible relationship between IPT and PSC, based on pathological findings. This report confirmed, based on clinical findings, that PSC is one of the causes of hepatic IPT.

Erectile dysfunction in patients with chronic viral liver disease: its relevance to protein malnutrition

BackgroundIn patients with chronic liver disease (CLD), quality of life is generally accepted as poor, especially for physical function. However, sufficient data regarding erectile function has not been shown in patients with CLD. The international index of erectile function (IIEF) is widely used to assess erectile function, and a short form of the IIEF was recently developed (IIEF-5). Using this questionnaire, we evaluated erectile dysfunction (ED) in patients with CLD.MethodsA total of 117 Japanese patients (64 with chronic hepatitis [CH] and 53 with liver cirrhosis [LC]) were analyzed. The etiologies were hepatitis B virus (HBV) in 21, HCV in 94, and non-B non-C in 2. The IIEF-5 and Medical Outcomes Study Short Form 36 (SF-36) were administered to the patients, and biochemical analyses for items serum albumin, prothrombin time, bilirubin, and ammonia were also performed.ResultsThe incidence of ED was 85% in the total cohort with CLD, 78% in those with CH, and 92% in those with LC (P < 0.05 between CH and LC). ED was found in 50% of CLD patients under age 50 years, in 79% aged 50–59, and in 100% aged over 60 (P, overall <0.001). The scores for ED severity correlated with increasing grades of a modified Child-Pugh classification (P < 0.05). Simple regression analysis showed age (P < 0.01), physical function (P < 0.001), role physical (P < 0.001), and social functioning (P < 0.05) on the SF-36, and serum albumin (P < 0.001) as significant determinants of ED. Multiple regression analysis identified age (P < 0.001) and serum albumin (P < 0.001) as independent significant factors that determined ED.ConclusionsThese data clearly demonstrate that liver disease is the cause of ED in patients with CLD, and serum protein status could be relevant to this condition in these patients.

Therapeutic effect of intraarterial prednisolone injection in severe intestinal Behçet's disease.

A 64-year-old woman with severe intestinal Behçets disease who was unresponsive to conventional therapies, including intensive intravenous steroid injections, underwent intraarterial steroid injection therapy. After the infusion of prednisolone into the mesenteric arteries, her colon ulcers improved markedly, and the frequency of bloody stools decreased immediately. The present case suggests that intraarterial steroid injection therapy may be potentially useful in severe intestinal Behçets disease.

Carbon dioxide insufflation vs. conventional saline irrigation for peroral video cholangioscopy.

BACKGROUND AND STUDY AIMS Recent studies have evaluated the efficacy of peroral cholangioscopy (POCS) for diagnosis of biliary diseases. In order to obtain clear images with POCS, saline irrigation, which is performed to replace yellow bile, is carried out for an extended duration. The aim of this study was to evaluate the feasibility of replacing saline irrigation with CO₂ insufflation during POCS. PATIENTS AND METHODS A total of 36 patients who had bile duct lesions and were due to undergo POCS were enrolled in the study. Of these patients, 18 underwent POCS using saline irrigation followed by CO₂ insufflation, and 18 patients underwent the reverse approach. The two methods were compared with regard to the time required to obtain a clear endoscopic image and the quality of the images. RESULTS The median time required to obtain a clear endoscopic image using CO₂ insufflation (5.0 min) was significantly shorter than that required for saline irrigation (22.5 min; P < 0.001). The quality of the endoscopic images obtained was similar in 27 cases. However, CO₂ insufflation provided better images in four cases that showed an abundance of mucin or biliary sludge, and saline irrigation was superior to CO₂ insufflation in five cases that showed severe stricture with bleeding and tall papillary lesions. CONCLUSIONS CO₂ insufflation during POCS can reduce procedure time and simplify cholangioscopy. The overall image quality was similar to that obtained with conventional saline irrigation.

Prevalence of Diabetes and Incidence of Angiopathy in Patients with Chronic Viral Liver Disease

Patients with chronic liver disease (CLD) often develops glucose intolerance. We explored the prevalence of diabetes mellitus in viral CLD, and analyzed factors profoundly affecting the diabetic angiopathies. 229 CLD patients (124 chronic hepatitis and 105 liver cirrhosis) entered the study. The diagnosis of diabetes was made with the criteria by World Health Organization. Laboratory investigation included serum asparate aminotransferase, alanine aminotransferase, albumin, fasting blood sugar, hemoglobin A1c (HbA1c), fasting immunoreactive insulin, and HOMA-R (FBS*IRI/405). The incidence of macro- and microangiopathy were also examined. Forty (17.5%) CLD patients were diagnosed diabetes, giving a significantly higher incidence than that of general cohort (5.3%) (p<0.001). Among them, 12 (30%) had the triopathy, significantly lower than that in a matched group of diabetic patients without CLD (65%) (p<0.001). Significantly increased levels of HbA1c and HOMA-R were observed in diabetic CLD with angiopathy compared with diabetic CLD without. Incidence of diabetes was increased in viral CLD patients. The rate of diabetic angiopathies in CLD, however, was relatively low, this could be explained by low coagulability in these patients. Poor control of hyperglycemia, partly due to insulin resistance, might explain the onset of angiopathy in diabetic CLD.

Infected mediastinal cyst following endoscopic ultrasonography-guided fine-needle aspiration with rupture into the esophagus

A 37-year-old woman with a mediastinal mass detected by afollow-up chest computer tomography (CT) after gastrec-tomy for gastric cancer was referred to us for endoscopicultrasonography-guided fine-needle aspiration (EUS-FNA).EUSshowedawell-demarcatedhypoechoiclesion,measuring25 ¥ 13 mm,in the upper mediastinum.A single pass of FNAwith a 19 gauge needle yielded a clear jelly-like specimen.Cytologicalexaminationshowedmucusandbenignsquamousepithelium.The lesion was diagnosed as a bronchogenic cystfrom these findings.An oral prophylactic antibiotic was initi-ated because of the FNA for the cystic lesion.Six days after FNA, the patient presented at our hospitalwith fever, chest pain and dysphasia; chest CT showed asignificantly enlarged mediastinal cyst (Fig. 1).These findingswere consistent with infected mediastinal cyst. Broad spec-trum intravenous antibiotics were initiated with completeimprovementofsymptomsinacoupledays.Afollow-upchestCT showed the shrunken cyst, which was filled with air(Fig. 2a);esophagogastroduodenoscopyshowedafistulawithulceration in the esophagus (Fig. 2b). The patient was dis-charged without deterioration of her symptoms. Repeat CTand esophagogastroduodenoscopy confirmed the resolutionof a fistula and cyst.EUS-FNA for mediastinal lesions is a well-establishedtechnique to obtain pathological specimens.

Endoscopic ultrasound-guided fine-needle aspiration of lesions near the aortoiliac bifurcation via an upper gastrointestinal approach.

Background and Aims:  Endoscopic ultrasound (EUS)‐guided fine‐needle aspiration (FNA) is widely used to investigate posterior mediastinal and upper abdominal lesions. Previously, we noticed that the aortoiliac bifurcation can be visualized by transduodenal EUS scanning, and the surrounding area might be a potential target for EUS‐guided FNA. This study aimed to determine the feasibility of using EUS‐guided FNA to study lesions near the aortoiliac bifurcation via the upper gastrointestinal approach.