Naruhiko Nagata

Transcatheter arterial chemoembolization plus radiofrequency ablation therapy for early stage hepatocellular carcinoma: comparison with surgical resection.

Radiofrequency ablation (RFA) is becoming a well‐known local therapy for hepatocellular carcinoma (HCC). Transcatheter arterial chemoembolization (TACE) is expected to enhance the effects of subsequent RFA by reducing arterial blood flow. However, the long‐term efficacy of this combined therapy has not been elucidated. In this study, the survival rates of patients who received TACE combined with RFA (TACE + RFA) were compared with those of patients treated surgically.

Relationship between serum levels of anti-low-density lipoprotein-acetaldehyde-adduct antibody and aldehyde dehydrogenase 2 heterozygotes in patients with alcoholic liver injury.

We prepared low-density lipoprotein (LDL)-acetaldehyde-adduct (hereafter abbreviated as LDL-adduct) and anti-LDL-adduct antibody by using Watanabe hyperlipidemic rabbits, and determined values of serum anti-LDL-adduct antibody levels by the ELISA method in healthy adults and patients with alcoholic liver injury. In the nondrinking group in healthy adults, values of anti-LDL-adduct antibody levels were 25 ± 13 μg/ml, and there was no significant difference between moderate drinkers without diseases and the nondrinking group in healthy adults. Values of anti-LDL-adduct antibody in alcoholic disease groups, 17 ± 9 μg/ml for the patients with the fatty liver group, 21 ± 14 μg/ml for the hepatic fibrosis group, 70 ± 21 μg/ml for the alcoholic hepatitis group, 41 ± 50 μg/ml for the alcoholic cirrhosis group, and 19 ± 18 μg/ml for the alcoholic pancreatitis group. Examinations of aldehyde dehydrogenase 2 (ALDH2) genetic variations by the polymerase chain reaction-single-strand conformation polymorphism (PCR-SSCP) method in the healthy group and the liver injury group revealed a tendency for patients with ALDH21 /22 in the liver injury group to have relatively mild liver lesions. When comparing anti-LDL-adduct antibody levels between ALDH2 genetic variations, those for the patients with ALDH21 /21 (36 ± 40 μg/ml) were significantly higher than those for patients with ALDH1 /22 (11 ± 5 μg/ml). Results of the present study suggest that genetic variation may influence the progression of liver injury.

Carbon Dioxide (CO2) vs Iodinated Contrast Digital Subtraction Angiography during Balloon-occluded Retrograde Transvenous Obliteration (BRTO) Using Foam Sclerosant for Gastric Varices

PURPOSE To compare the visualization of the target gastric varices (GV) on balloon-occluded retrograde transvenous venography (BRTV) using iodinated contrast material vs carbon dioxide (CO(2)) in preparation for subsequent balloon-occluded retrograde transvenous obliteration (BRTO) using foam sclerotherapy. MATERIALS AND METHODS In 16 consecutive patients with nonruptured GV, BRTV was performed first using iodinated contrast material and then with CO(2). BRTV was repeated whenever there were changes in the catheter or patient position or when coil embolization of collaterals was needed. Each visualization grade of GV (grade 1 = GV only; grade 2 = GV > collaterals; 3 = GV < collaterals; grades 4-5 = collaterals only) was determined by two observers in consensus. During foam BRTO, the GV visualization grade was recorded again and confirmed by C-arm computed tomography (CT). RESULTS In 38 pairs of BRTV, GV grades were significantly (P < .0001) lower (ie, favoring BRTO) on CO(2) BRTV (mean ± standard deviation, 1.8 ± 0.8) than on iodine BRTV (3.4 ± 0.8). GV grades on foam BRTO (1.4 ± 0.7) were similar to the grades obtained on the most recent CO(2) BRTV (1.3 ± 0.5) but were significantly smaller (P < .0001) than on iodinated BRTV (3.1 ± 0.9). GV were opacified by foam on initial C-arm CT in 14 patients (87.5%), and complete thrombosis of GV was obtained without any complication in all 16 patients (100%). CO(2) reached the GV even when iodinated contrast material could not (grade 4) in seven of our 16 patients (43.8%), leading to successful BRTO. CONCLUSIONS CO(2) BRTV visualized GV better than did iodine BRTV and changed the management of more than 40% of patients by enabling successful foam BRTO in patients in which conventional liquid BRTO could not be performed.

Off-treatment durability of antiviral response to nucleoside analogues in patients with chronic hepatitis B

BackgroundOff-treatment durability of nucleoside analogue (NA) therapy in patients with chronic hepatitis B has not been well investigated. In this study we monitored antiviral effect of NA therapy and evaluated off-treatment durability after NA cessation in patients with chronic hepatitis B.Patients and methodsA total of 94 consecutive patients (39 HBeAg-negative and 55 HBeAg-positive patients) who received NA therapy were followed up for approximately 9 years. We discontinued NA according to the following criteria; undetectable serum HBV-DNA by polymerase chain reaction (PCR) on three separate occasions at least 6 months apart in HBeAg-negative patients (APASL stopping recommendation), and seroconversion from HBeAg-positive to HBeAb-positive and undetectable serum HBV-DNA by PCR for at least 12 months in HBeAg-positive patients.ResultsThe cumulative rate of relapse after NA cessation was 48 % and 40 % in HBeAg-negative and -positive patients, respectively. Higher baseline serum alanine aminotransferase level was the only significant predictor for maintaining remission. No patients experienced decompensation after relapse. HBsAg loss occurred at an annual rate of 1.4 % and 0.4 % in HBeAg-negative and -positive patients, respectively. Hepatocellular carcinoma developed at an annual rate of 0.6 % in both HBeAg-negative and -positive patients.ConclusionsAlmost half of the patients did not relapse after cessation of NA therapy in both HBeAg-negative and -positive patients. Therefore, NA therapy could be discontinued with close monitoring if the APASL stopping recommendation is satisfied even in HBeAg-negative patients.

TYPE 1 GASTRIC CANCER PRESENTING AS PROTEIN‐LOSING GASTROENTEROPATHY AND BALL‐VALVE SYNDROME

A 70-year-old woman visited Tokai University Hachioji Hospital due to increasing bilateral pretibial edema and occasional nausea. Blood chemistry revealed low serum concentrations of total protein (4.6 g/dL), albumin (2.4 g/dL), and IgG (468 mg/dL). Heart, liver, renal, or thyroid diseases were denied. Abdominal contrast computed tomography (CT) scan revealed a 7 cm-diameter tumor in the duodenal bulbi with a stalk arising from the distal stomach (Fig. 1). Esophagogastroduodenoscopy revealed a deformed pyloric ring (scarfring sign, Fig. 2A) and a tumor in the duodenal bulbi (Fig. 2B), suggesting ball-valve syndrome. The head of the tumor was endoscopically pulled back into the stomach with grasping forceps. Alfa1-antitrypsin clearance test (205 mL/ day; normal 20 mL/day) and Tc-labeled albumin scintigraphy localized the site of protein loss to the gastric tumor. Distal gastrectomy was carried out. The relatively soft tumor had invaded up to the submucosal layer without lymph node metastasis. Dilated lymphatic vessels were occasionally observed. This tumor was pathologically well-differentiated tubular adenocarcinoma with cauliflower-like shape, the features of which are characteristic of gastric cancers with protein-losing gastroenteropathy. After surgery, total protein and albumin levels normalized, and the patient’s complaints disappeared. The causes of protein-losing gastroenteropathy include erosive and non-erosive gastrointestinal disorders, and disorders involving increased central venous pressure or mesenteric lymphatic obstruction. Amount of protein loss parallels with surface area in gastric cancers. The present type 1 gastric cancer might be large enough to manifest protein loss. Although the effect of ball-valve syndrome on protein-losing gastroenteropathy is unclear, constriction of the tumor stalk by the pyloric ring might have caused ischemia or lymphatic obstruction, resulting in protein loss. As far as we know, this is the first case with gastric cancer presenting protein-losing gastroenteropathy and ball-valve syndrome. Clinicians should think of gastrointestinal diseases presenting as protein loss as a differential diagnosis when they see patients with edema.

Weight‐based high‐ and low‐dose ribavirin in combination with peginterferon α‐2b therapy for genotype 2 chronic hepatitis C: A randomized trial

Aim:  The optimal ribavirin dose in the treatment of patients infected with hepatitis C virus (HCV) genotype 2 remains to be elucidated. We aimed to seek the optimal ribavirin dose required for this genotype in a randomized trial.

Meloxicam as an adjuvant to peginterferon-α-2a and ribavirin treatment for genotype 1 chronic hepatitis C: A randomized trial

In this multicenter, randomized trial, we evaluated the effectiveness of meloxicam – a non‐steroidal anti‐inflammatory drug – as an adjuvant for enhancing antiviral efficacy and preventing neutropenia during the treatment of patients with genotype 1 chronic hepatitis C using peginterferon and ribavirin.

A Case of Budd-Chiari Syndrome Associated with Polycythemia Vera.

症例は43歳, 女性. 1993年9月頃より腹水の貯留, 黄疸が出現し, 1994年1月入院. 血液検査では全血球系の著増とともに著明な肝障害が認められた. 血液所見および骨髄生検より真性多曲症ならびに急性肝不全と診断した. また腹部超音波検査にて右・中・左肝静脈は血栓で充満し面流は認められず, 血栓による肝静脈の閉塞が考えられた. 入院後急速に肝不全が進行し, 1カ月の経過でDIC, 多臓器不全のため死亡. 病理解剖では肝静脈内に器質化した血栓が認められ, 肝細胞はzone 3を中心に広範な変性, 壊死を示していた. 本邦におけるBudd-Chiari症候群の多くは膜様閉塞に伴うものであり, 肝静脈血栓によるBudd-Chiari症候群の報告は少ない. 特に真性多血症に伴う肝静脈閉塞は本例を含め2例のみで極めて稀な症例と考えられる.

Clinical and epidemiological studies on 252 cases of acute hepatitis A during the past 15 years.

当院に1980年から1994年12月までの15年間に入院したA型急性肝炎患者252例を対象としてretrospectiveに検討し,その背景因子,臨床的特徴を解析した.A型急性肝炎の発生年度には明らかに周期性があり,過去15年間で1990年が最も多く,最近5年間に増加傾向が認められた.近年好発年齢が高齢化し,女性の占める割合が増加する傾向がみられた.肝機能成績の特徴として最近5年間の症例の血清GPT最高値はそれ以前と比べて有意に高値であった.A型急性肝炎発症後,GPT高値が3ヵ月以上最長7ヵ月持続した遷延例が6例認められたが,慢性肝炎に移行した症例はみられなかった.プロトロンビン時間40%以下の重症型が最近2年間に集中して6例認められ,その特徴として男性,高齢であることが指摘された.重症型では血清GPT, T. Bil最高値は非重症型に比較して有意に高値で,1例が劇症肝炎に移行したが救命された.以上より,A型急性肝炎の最近の動向として好発年齢の高齢化,女性例の増加,重症型の出現がみられ,その臨床像および病態の変化が示唆された.