Katsumoto Kato

Pseudoaneurysm of the cystic artery associated with upper gastrointestinal bleeding.

Pseudoaneurysm of the cystic artery is a cause of hemobilia, and is extremely rare, with only eight cases having been reported in the world literature. We report a case of pseudoaneurysm of the cystic artery in a 72-year-old Japanese man. The patient experienced epigastric pain and melena, and was found to have jaundice and liver dysfunction. Repeated gastroendoscopy did not reveal the cause of the alimentary tract bleeding; however, color-Doppler ultrasonography detected an aneurysm of the cystic artery in the gallbladder. Selective hepatic arteriography demonstrated that the posterior branch of the cystic artery was markedly dilated and that an aneurysm had formed in the midst of the artery. We diagnosed hemobilia due to the pseudoaneurysm of the cystic artery, and associated gastrointestinal bleeding. Cholecystectomy was performed immediately. Pathologically, the gallbladder showed acute calculous cholecystitis. This case emphasizes the importance of including hemobilia in the differential diagnosis whenever gastrointestinal bleeding is associated with signs of biliary disorder; color-Doppler imaging is a favorable modality for the diagnosis of pseudoaneurysm of the cystic artery.

Serum insulin-like growth factor II in chronic liver disease

Insulin-like growth factor II is secreted primarily by the liver and is reported to be transcribed in many primary hepatocellular carcinoma (PHC) cell lines. We have studied diagnostic significance of serum IGF- II in chronic liver diseases using specific enzyme immunoassay. Serum IGF-II levels (mean±se) were decreased in chronic hepatitis (538 ±51 ng/ml; N=29), liver cirrhosis (427±45; 50) and PHC (260±41; 17) compared to controls (830±49; 57). Serum IGF- II was not different from controls in any of nonhepatic diseases such as diabetes (1032±97; 19). pancreatic cancer (1413±282; 8), chronic pancreatitis (999±126; 17), peptic ulcer (1186±43; 11), irritable bowel syndrome (1002 ±109; 12), gastrointestinal tract cancer (1250±216; 21) and chronic renal failure (733±135; 14). In liver diseases serum IGF-II showed a significant correlation with liver function test (negative with retention of indocyanine green and total bile acids; positive with albumin, thrombo-test, and cholinesterase). These results suggest that serum IGF-II reflects a reduced production of IGF-II in the liver and that it can be an index for the residual capacity of liver function.

AETIOPATHOGENESIS OF HEPATOCELLULAR CARCINOMA: CASE REPORT: Multiple systemic lymph node metastases from a small hepatocellular carcinoma

Abstract  Extrahepatic lymph node metastases from hepatocellular carcinoma (HCC) are usually observed in patients with advanced and poorly differentiated HCC. We encountered a patient with multiple, systemic lymph node metastases from a small HCC (18 mm in diameter), which was nodular and had a capsule at the time of resection (a partial hepatectomy of the postero‐inferior subsegment of the right lobe of the liver). Widespread lymphadenopathy resembling malignant lymphoma developed 2 months after surgery. A biopsy specimen from a supraclavicular lymph node revealed metastatic HCC. The patient died 2.5 months after the detection of the lymphadenopathy. Lymph node metastases can occur in small HCC less than 2 cm in diameter and may adversely affect the long‐term prognosis of patients with these curatively resectable small HCC.

Gastroduodenal Vascular Ectasia in Patients with Liver Cirrhosis

The purpose of this study was to determine the incidence of hemorrhage due to vascular ectasia of the upper gastrointestinal tract in patients with liver cirrhosis and to assess the prevalence in cirrhotic patients without clinically overt gastrointestinal bleeding. Out of 96 cirrhotic patients with upper gastrointestinal bleeding, vascular ectasia was diagnosed in 6 patients (6.3%) as the cause of bleeding. These 6 patients had numerous spotty or confluent erythemas consisting of ectatic and tortuous capillaries throughout the antrutn and 4 patients required blood transfusion before diagnostic en‐doscopy. Several sessions of endoscopic electrocoagulation resulted in eradication of almost all the abnormal vascular lesions and marked improvement of their anemia without further transfusion. The procedure was well tolerated and no resultant complications were encountered. Among 206 cirrhotic patients without clinically overt gastrointestinal bleeding 25 patients (12.1%) were diagnosed with vascular ectasia. The hemoglobin level was significantly lower in patients with vascular ectasia than those without vascular ectasia but the other features did not differ between the two groups. Vascular ectasia is an important cause of upper gastrointestinal bleeding and anemia in patients with liver cirrhosis. Endoscopic electrocoagulation may be a safe and effective treatment for controlling blood loss from gastroduodenal vascular ectasia in this subset of patients. (Dig Endosc 1999; 11: 241–245)

Infectious mononucleosis in Japan: Comparison with acute viral hepatitis type A

In order to clarify the characteristics of infectious mononucleosis hepatitis (IMH) in Japan, 20 cases with IMH treated at Kamo Hospital during the past 6 years (Group I) were analysed in comparison with cases of acute viral hepatitis, especially type A. The test for heterophil antibody was positive in only two cases. During the same period 209 cases were treated for acute viral hepatitis (type A: 77 cases = Group A; type B: 61 cases; type non‐A, non‐B: 71 cases). In Group I the common clinical symptoms and signs were headache, sore throat and lymph node swelling; jaundice was not as common as in Group A. GOT and GPT activities increased moderately in the acute stage, but they were significantly lower than those in Group A. LDH, AP, GGT and LAP activities were disproportionately higher to GPT activity in Group I. Liver biopsy in the convalescent stage showed that lipofuscin deposition and sinusoidal mononuclear cell infiltration were more prominent in Group I, while sinusoidal neutrocyte infiltration and focal necrosis at periportal areas were more common in Group A. Differential diagnosis of the two diseases could be made using these clinical features and histological findings. However, immunological differentiation is required for specific diagnosis because some features such as fever, prolonged elevation of thymol turbidity test, atypical lymphocytes in peripheral blod and predilection for young people were observed in both groups. Furthermore, the present study indicated that IMH is no longer rare and most cases do not demonstrate heterophil antibody in Japan.

Clinical investigation on abnormal glucose tolerance in liver cirrhosis.

SummaryThe changes of blood glucose, serum insulin, serum free fatty acid and its fatty acid composition following oral glucose load were observed in twenty-nine cirrhotic patients. The insulin secretory response was significantly lower in the cirrhotic patients with overt diabetes than in those without overt diabetes. There were no definite relation between serum free fatty acid level or its composition and glucose intolerance. These results suggest that the diabetic state in most of the cirrhotic patients with overt diabetes is due to essential diabetes and that serum free fatty acid level and its composition are not important factors contributory to the glucose intolerance in liver cirrhosis.

The thermometry of gastric mucosa

related to the fa te of any bleeding gas t r ic lesion, the re fo re knowing the c h a n g e in the gas t r ic blood flow which occurs wi th gas t r ic b leeding or wi th blood t r an s fu s s ion is cl inically wor thwhi le . In th is regard , an e x p e r i m e n t a l s t udy was conduc t ed in the dogs. Blood in the a m o u n t equ iva len t to 3.0% of the body weight was d r a w n f rom a b r anch of the left gas t r ic a r te ry and t h e n th is blood was t r a n s f u s e d into the s a m e dog. D u r i n g these procedures , the blood flow of the left gastroepiploic a r t e ry was m e a s u r e d by an e l ec t romagne t i c flow me te r and the f emora l a r te r ia l p res su re was checked as well. As resul t , a t r end was observed t ha t the ra te of gas t r ic blood flow s l ight ly inc reases du r ing and af te r (1 hour) gas t r i c b leeding and t ha t it t h e n keeps gross ly c o n s t a n t du r ing and af ter (1 hour) blood t r an s fu s i on . T h u s , it is unl ike ly tha t gas t r ic b leeding m i g h t r educe the func t iona l act ivi ty of the s t o m a c h or tha t blood t r a n s f u s i o n m i g h t p romote the gas t r ic blood flow and cause r ecu r rence of gas t r ic b leeding.

On the inhibition of gastrin induced ulcer by gastrointestinal hormones

Trying to clealify the gastric acid, pepsin and protein secretion systems, we made use of the perfusion method on rat stomach (Schilds rat). Effects of tetragastrin, dextran sulfate and hydrocotisone were examined on pH, conductivity, pepsin activity and protein concentration successively. Following the i.v. administration of each dose of tetragastrin (0.032--2.0/~g), pH curve declined instantenously, while the conductivity, pepsin activity and protein concentration rose almost simultaneously. These pat terns gradually returned to normal level within 40 minutes to 1 hour which were well reproducible for 6 hours. Good dose responces were observed with the maximal dose of tetragastrin (1.0 pg). Dextran sulfate (1--12mg/100g i .v . )which has been said to inhibit pepsin activity in vitro, seemed to have no effects on pH, pepsin activity and protein concentration and did not move the maximal gastrin pattern. However, it is very interesting that remarkable increase of pepsin activity and protein concentration were observed 4 hours after i.v. administration of hydrocortisone (2--10 mg/100 g), while the pH remained almost flat. This finding is very suggestive to the pharmacological actions of hydrocortisone on the gastric mucosa.

A study of gastrin induced ulcer

Histamine-stimulated gastric secretion was inhibited by enterogastrone, but not inhibited by secretin or CCK/PZ, while gastrin-stimulated gastric secretion was inhibited by these three duodenal hormones. From the results of this experiment, we concluded that the site of action of gastr in is separated from that of histamine, and that enterogastrone inhibits gastric secretion acting at the site where histamine acts; CCK/PZ, acting at the site where gastrin act to produce gastric secretion, inhibit gastric secretion.

A basic and clinical study on the papilla vateri

Fresh materials of 35 dissections were utilized for X-ray exposure of duodenal papilla vateri and the adjacent biliary tract in order to examine the inter-relation among the form of papilla, its size and the terminal portion of the common bile duct and afterwards the tissue of the papilla and its neighbourhood was microscopically reviewed. Furthermore hypotonic duodenography, cholangiography and the functional examination of pancreas were tried to 95 clinical cases, including some biopsies of the papilla. From these trials the following results were obtained. 1) Marked fibrous proliferation was histologically encountered in case of large papilla longer than 15mm in longitudinal diameter, though its form should be taken into consideration when we discuss the size of papilla. 2) Many of popillas longer than 15mm were related to the disorders in gall bladder, bile duct or pancreas. In such case the stenosing figure was radiographically found at the terminal portion of common duct and the maximal diameter throughout the common bile duct was inclined to be wider than 7 ram. These results show that papilla vateri longer than 15 mm in diameter hints at possible pancreatic or biliary tract diseases and neccessiates a full clinical investigation of them. It is also to be considered in the course of treatment.