S.H. Um

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.

A Case of Primary Adenosquamous Carcinoma of the Liver Presented with Liver Abscess

Primary adenosquamous carcinoma of the liver is a very rare type of cholangiocarcinoma and is defined as a cancer containing both squamous and adenomatous components in the same lesion. Recently, we experienced a primary adenosquamous carcinoma of the liver presented as liver abscess. A 63-year-old man was presented with a 4-day history of fever and chill. The radiologic study showed a 4 cm-sized, central hypoattenuated mass with peripheral rim enhancement in the left lobe of the liver. Ultrasonography-guided aspiration and biopsy suggested an adenocarcinoma with abscess in the liver. At laparotomy, the tumor occupied the left lobe of the liver and invaded the right diaphragm. An extended left lobectomy and a partial excision of the involved diaphragm were done. Grossly, the tumor was 6×5×5 cm in size and had an eccentric necrosis. Microscopically, the tumor was composed of adenocarcinoma and squamous cell carcinoma with a transitional area.

Virologic response is not durable after adefovir discontinuation in lamivudine-resistant chronic hepatitis B patients

Background/Aims We investigated the durability of the biochemical and virologic responses after adefovir (ADV) discontinuation in lamivudine-resistant (LMV-R) chronic hepatitis B (CHB) patients, and the outcomes of ADV discontinuation compared to that of ADV maintenance. Methods The indication for ADV treatment cessation was an undetectable level of hepatitis B virus (HBV) DNA documented on two occasions at least 6 months apart. All patients received additional ADV for at least 12 months after the confirmation of undetectable HBV DNA (Cobas TaqMan PCR assay, <70 copies/mL). Of 36 patients who had a sufficient ADV therapeutic effect, 19 discontinued ADV treatment, while the others maintained it. A virologic rebound was arbitrarily defined as the redetection of HBV DNA at a level higher than 105 copies/mL. Results In the ADV discontinuation group, ADV treatment and additional therapy were administered for medians of 33 months (range, 12-47 months) and 18 months, respectively. The patients were followed for a median of 12 months (range, 3-30 months) after ADV cessation. During that period, 18 of 19 patients (95%) experienced viral relapse. Viral rebound was observed in six patients (32%). However, 12 of 18 patients (67%) exhibited serum HBV DNA levels of less than 105 copies/mL. Biochemical relapses were observed in four of the six patients with viral rebound. In the ADV maintenance group, patients were treated for a median of 53 months (range, 31-85 months), and 9 patients (53%) experienced viral breakthrough. Conclusions During short-term follow-up after ADV discontinuation, most patients (95%) exhibited viral relapse, whereas and viral breakthrough occurred in about half of patients (53%) maintained on ADV therapy. Therefore, the durability of virologic response after ADV discontinuation in LMV-R patients was unsatisfactory. In addition, and viral breakthrough was not infrequent in the ADV continuation group.

Concurrent inferior vena cava and hepatic vein stenoses after orthotopic liver transplantation: a case report.

Outflow obstruction or stenosis of a hepatic graft is a rare but serious complication after liver transplantation, with a reported incidence of 1% to 6%. It can cause signs of portal hypertension, renal dysfunction, or lower-extremity edema depending on the level of obstruction, which may lead to patient mortality. Most reported cases show a stenosis at either the inferior vena cava (IVC) or one of the hepatic veins. Herein we have reported our experience of concurrent suprahepatic IVC and hepatic vein stenoses after orthotopic liver transplantation with related imaging findings and a successful treatment outcome. Due to the complexity of stenoses, two self-expandable metallic stents were placed simultaneously using different venous accesses.

Virologic and biochemical responses to clevudine in patients with chronic HBV infection-associated cirrhosis: data at week 48.

Summary.  Clevudine shows high rates of virologic and biochemical responses in patients with chronic hepatitis B. However, the efficacy and safety of clevudine in patients with cirrhosis are unknown. The aims of this study were to evaluate the safety and to assess the virologic and the biochemical responses to clevudine in patients with cirrhosis with chronic hepatitis B virus (HBV) infection. We reviewed data from treatment‐naïve patients with chronic hepatitis B with and without cirrhosis who started clevudine between April 2007 and March 2008 (n = 52, hepatitis B without cirrhosis n = 21 and chronic hepatitis B with cirrhosis n = 31) at Korea University Ansan/Guro Hospital. All of the patients were treated for more than 48 weeks. The mean age was older in the patients with cirrhosis. Baseline HBV DNA levels were 6.9 and 7.78 log copies/mL (P = 0.042), and alanine aminotransferase (ALT) levels were 104.9 and 147.4 IU/L (P = 0.204), for those with and without cirrhosis, respectively. Virologic response (HBV DNA <1000 copies/mL) (87.1%vs 71.4%, P = 0.24) and biochemical response (83.9%vs 80.9%, P = 0.99) at week 48 were not significantly different between the two groups. Early virologic response at week 12 was even higher in the patients with cirrhosis (61.3%vs 28.6%, P = 0.026). Neither ALT flare nor newly onset hepatic decompensation was found in the patients with cirrhosis, whereas ALT flare was transiently observed in 14.3% of the chronic hepatitis group. In conclusion, although clevudine may produce a transient elevation of ALT during the early treatment period, such findings were not observed in patients with cirrhosis and the virologic and biochemical responses of the groups were comparable.

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.

Switching to tenofovir vs continuing entecavir for hepatitis B virus with partial virologic response to entecavir: a randomized controlled trial

Entecavir 0.5 mg (ETV) is widely used among treatment‐naïve chronic hepatitis B (CHB) patients. However, 10%‐30% of patients show partial virologic response (PVR) to the drug. If the hepatitis B virus (HBV) continues to replicate, the underlying liver disease may progress. Herein, we compared the efficacy of switching to tenofovir disoproxil fumarate (TDF) with that of continuing ETV in CHB patients with PVR to ETV. This was an open‐label randomized controlled trial including CHB patients who had been receiving 0.5 mg of ETV for >12 months, but who still had detectable HBV DNA levels of >60 IU/mL without known resistance to ETV. Sixty patients were enrolled and 45 qualified for the study: Twenty‐two patients were randomly assigned into the TDF group and 23 into the ETV group. After 12 months of treatment, the virologic response rate (HBV DNA <20 IU/mL) was significantly higher in the TDF group than in the ETV group, as measured using per‐protocol analysis (55% vs 20%; P = .022) and intention‐to‐treat analysis (50% vs 17.4%; P = .020). The reduction in HBV DNA was greater (−1.13 vs −0.67 log10 IU/mL; P = .024), and the mean HBV DNA level was lower (1.54 vs 2.01 log10 IU/mL; P = .011) in the TDF group than in the ETV group. In conclusion, to achieve optimal response in CHB patients with PVR to ETV, switching to TDF would be a better strategy than continuing ETV. Appropriate modification of therapy would further improve the outcome of chronic HBV infection.