Tsuyoshi Rai

A case of hepatic inflammatory pseudotumor with primary biliary cirrhosis.

Inflammatory pseudotumor (IPT) of the liver is an unusual non-neoplastic benign lesion. A 75-year-old man was hospitalized for esophageal varices and gastric cancer. Three years before admission, he had been diagnosed as having primary biliary cirrhosis (PBC) without Sjögrens syndrome. Computed tomography (CT) and magnetic resonance imaging (MRI) scans showed multiple masses (S3, S5, S6) less than 2 cm in diameter in the liver. Since these masses were difficult to distinguish from hepatocellular carcinoma, or metastatic liver carcinoma, one of the masses (S5) was removed during an operation for gastric cancer. Histological examination demonstrated marked infiltration of plasma cells and some histiocytes, findings consistent with the histological features of IPT. The coexistence of hepatic IPT and PBC in this case may have been an accidental event. However, the immunological and environmental factors associated with PBC are thought to be involved in the development of IPT; in addition, cholangitis associated with PBC could have contributed to the development of IPT.

Successful treatment of pseudoaneurysms of celiac and superior mesenteric arteries by combined endovascular and surgical approach

Pseudoaneurysm after pancreas resection poses serious complications, including rupture and hemorrhage. Here we report a case of delayed massive hemorrhage from celiac and superior mesenteric arteries, which was successfully treated with a combined endovascular and surgical approach. The patient was a 52-year-old man who presented with pseudoaneurysms of the celiac and superior mesenteric arteries after distal pancreatectomy. Following the detection of sentinel bleeding from the abdominal drain, emergency angiography of the celiac and superior mesenteric arteries revealed stenosis of the celiac artery and pseudoaneurysms in the superior mesenteric artery. We occluded these lesions with a platinum coil, using an interventional radiological technique combined with bypass grafting between the abdominal aorta and the SMA, using the saphenous vein. However, re-bleeding into the abdominal cavity occurred from the proximal SMA pseudoaneurysm. We inserted an endoluminal stent-graft into the abdominal aorta and completed bypass grafting between the aorta and bilateral renal arteries. The hemorrhage ceased and the postoperative course was uneventful. The patient was discharged 34 days after the treatment (149 days after the initial operation). In conclusion, this combined endovascular and surgical approach is feasible and seems appropriate for pseudoaneurysms arising from proximal sites in visceral arteries.

Autoimmune hepatitis complicated by late‐onset systemic lupus erythematosus

A 69‐year‐old man with autoimmune hepatitis (AIH) was admitted to hospital with high fever and cough. Chest roentgenogram and computed tomography showed pleural and pericardial effusion. Serological tests showed a high titer of antinuclear antibodies and positive anti‐DNA antibody and lymphocytopenia. He fulfilled the American College of Rheumatology criteria for systemic lupus erythematosus (SLE). After administration of corticosteroids, his symptoms and liver dysfunction improved. To the authors’ knowledge, this is the first male case of overlap between AIH and late‐onset SLE.

Two Cases of Primary Biliary Cirrhosis Complicated With Syringomyelia

1. Johnson SJ, Mathew J, MacSween RN, et al. Post-infantile giant cell hepatitis: Histological and immunohistochemical study. J Clin Pathol 1994;47:1022–7. 2. Phillips MJ, Blendis LM, Poucell S, et al. Syncytial giant-cell hepatitis. Sporadic hepatitis with distinctive pathological features, a severe clinical course, and paramyxoviral features. N Engl J Med 1991;324:455–60. 3. Pappo O, Yunis E, Jordan JA, et al. Recurrent and de novo giant cell hepatitis after orthotopic liver transplantation. Am J Surg Pathol 1994;18:804–13. 4. Roberts E, Ford-Jones EL, Phillips MJ. Ribavirin for syncytial giant cell hepatitis. Lancet 1993;341:640–1. 5. Durand F, Degott C, Sauvanet A, et al. Subfulminant syncytial giant cell hepatitis: Recurrence after liver transplantation treated with ribavirin. J Hepatol 1997;26:722–6. 6. Hassoun Z, N’Guyen B, Cote J, et al. A case of giant cell hepatitis recurring after liver transplantation and treated with ribavirin. Can J Gastroenterol 2000;14:729–31.

A case of autoimmune hepatitis in which Raynaud's phenomenon developed after occurrence of anticentromere antibody

症例は72歳の女性. 1990年1月, 肝機能障害と黄疸のため当科入院となった. 肝炎ウイルスマーカーは陰性. 抗核抗体が320倍と陽性で, 高γグロブリン血症と肝生検の結果から自己免疫性肝炎 (AIH) の診断でプレドニゾロン, アザチオプリンを投与され肝機能は改善した. 1990年1月入院時の抗核抗体の染色パターンは均一・斑紋 (homogeneous/speckled) 型を示していたが, 1997年1月には抗セントロメア抗体を示す散在性斑紋型に変化し, さらに同年2月からこれまで認められなかったレイノー現象が出現した. この間の肝機能は正常範囲で安定していた. AIHの経過中に抗核抗体の染色パターンが変化した報告はなく, さらにセントロメア抗体の出現後にその抗体と関連が指摘されているRaynaud現象が出現しており, 抗核抗体とその症状の出現の経過を追えた貴重な症例と考られた.

Role of CPG DNA in concanavalin A-induced hepatitis in mice

OBJECTIVE To investigate the effects of an intradermal injection of oligodeoxynucleotides (ODNs) containing unmethylated CpG motifs on concanavalin A (Con A)-induced hepatitis, an experimental model of immune-mediated hepatitis. METHODS Con A was injected intravenously into Balb/c mice. Twelve hours after Con A challenge, blood and liver samples were obtained. CpG ODN was injected intradermally 48 hours before Con A challenge. The extent of liver injury was assessed by determining serum alanine transaminase (ALT) and by liver histology. Serum levels of cytokines, including interferon (IFN)-gamma, tumor necrosis factor (TNF)-alpha, interleukin (IL)-4 and IL-5, were measured by enzyme-linked immunosorbent assay. RESULTS Co-administration of Con A and CpG ODN significantly increased serum ALT in mice compared with that in the case of administration of Con A alone (10,268 +/- 4,654 and 1,140 +/- 832 IU/1, respectively, p<0.05). In liver histology, mice treated with CpG ODN and Con A showed more extensive midzonal necrosis than did mice treated with Con A alone. These mice also showed significant increases in serum TNF-alpha and IFN-gamma and decrease in serum IL-5. CONCLUSIONS The results indicate that CpG ODNs aggravate Con A-induced hepatitis by stimulating the production of T-helper-1 (Th1) cytokines, TNF-alpha and IFN-gamma, suggesting that bacterial DNA that contains unmethylated CpG motifs may contribute to the exacerbation of immune-mediated liver injury.

⁎4536 Do collaterals around esophageal wall and perforating veins influence variceal recurrence? - analysis of thirty-three patients by endoscopic ultrasonography-.

Background: The development of the esophageal varices has been demonstrated to be related to the severity of the esophageal collateral veins (ECVs) adjacent to the muscularis externa (peri-ECVs) and external to the esophageal wall but with out contact with the muscularis externa (para- ECVs) as well as the veins perforating the esophageal wall (Gastrointestinal Endosc 1999;50). In the present study, we investigated whether the recurrence of esophageal varices after initial endoscopic injection sclerotherapy (EIS) is correlated with the severity of peri- and para- ECVs and the perforating veins. Patients and Methods: Thirty-three patients who had been treated once with EIS were enrolled in this study. During a follow-up of more than 2 years after the initial EIS, 10 patients were found to have recurrent esophageal varices and 23 patients showed no signs of recurrence. The collateral and perforating veins were analyzed with a 20-MHz ultrasound catheter probe. Recurrence of esophageal varices was determined on the basis of the appearance of the esophageal varices, with a grade of F0 or higher together with red color sign positive, or varices with F1 or higher forms. Results: In the recurrence group, a higher incidence of severe-type peri-ECVs (8/10, 80% vs. 2/23, 8.7%; p

7017 Capability of performing eus in the patient who have abnormal findings at distal common bile duct and common channel on ercp.

Background: It is difficult to judge whether abnormal findings in the distal common bile duct (CBD) and/or common channel, such as irregularity of the bile duct wall, on endoscopic retrograde cholangiopancreatography (ERCP) are benign or malignancy. The aim of this study was to evaluate the ability of endoscopic ultrasonography (EUS) to identify a malignant tumor in the distal CBD. Patients and Method: EUS was performed on 16 patients in whom ERCP indicated the possibility of a malignant tumor in the distal CBD and/or common channel. Cases in which a tumor was not detected by EUS were judged to be negative if the findings did not change over a one-year follow-up period. Results: The accuracy of EUS for identifying a tumor in the distal CBD was 81.3% (13/16), the sensitivity was 100% (16/16), the specificity was 76.9% (10/13), the positive predictive value was 50% (3/6), and negative predictive value was 100% (10/10). Three cases were misdiagnosed due to tumorous findings; debris, numerous small stones, and inflammation, respectively. Conclusion: EUS is reliable for identifying of the tumor in the distal CBD and/or common channel. EUS should be performed if ERCP indicates the possibility of a tumor in the distal CBD and/or common channel. If EUS findings are negative, it is reasonable to conclude that there is no tumor. If EUS findings are positive, biopsy or cytology should be performed.

4527 The role of para-esophageal collateral veins in patients with portal hypertension: eus and liver scintigraphy analysis.

Background: In patients with portal hypertension, many collaterals develop around the esophageal wall. Endoscopic ultrasonography (EUS) can reveal the para-esophageal collateral veins (para-ECVs) around the esophageal wall (Gastrointestinal Endosc 1999;50). Liver scintigraphy using 99mTc-phytate enables quantitative grading of the ratio of portal venous to total hepatic blood flow. Collaterals that have developed around the esophageal wall are thought to cause a reduction in the portal blood flow ratio (PBFR). To verify the role of para-ECVs on portal venous blood flow, we investigated the relationship between the development of para- ECVs and the PBRF by EUS and liver scintigraphy. Patients and Method: Twenty patients who did not associate with fundal gastric varices were studied before and after endoscopic injection screlotherapy (EIS). To quantify the degree of development of blood vessels outside the esophageal wall, the cross-sectional area of each para-ECVs observed by EUS was calculated, and the sum total of the areas was used as an index of development of para-ECVs. Portal blood flow was calculated by liver scintigraphy using 99mTc-phytate. Results: The correlation between PBRF and the total cross sectional area of the para-ECVs before and after treatment was examined. Before EIS, the PBRF was 53.42±12.34 % (mean±SD), and the total crosssectional area of the para-ECVs was 34.15±22.39 mm2 (mean±SD). The correlation between the PBRF and the total cross sectional area of para- ECVs before EIS was not significant. On the other hand, the PBFR was 53.42±12.34 % (mean±SD) and the total cross-sectional area of the para- ECVs was 34.15±22.39 mm2 (mean±SD) after EIS. After treatment, the correlation between these two parameters was significant (r=0.70, p

4537 Collaterals around the esophageal wall; comparison of endoscopic ultrasound imaging and microscopic findings on autopsy.

Background: In a previous study, we demonstrated the collaterals around the esophageal wall observed by endoscopic ultrasound (EUS) in patients with portal hypertension can be divided into two groups, peri-esophageal collateral veins (peri-ECVs) and para-esophageal collateral veins (para- ECVs), and that the peri-ECVs and the perforating veins play an important role in the development of esophageal varices (Gastrointestinal Endosc 1999;50). Aim: To compare EUS imaging with microscopic findings in the peri- and para-ECVs and the perforating veins. Patients and Methods: Four patients with esophageal varices treated by endoscopic injection sclerotherapy were studied. After the therapy, the esophago-gastric junction (EGJ) to the upper 5 cm was scanned by EUS. In autopsy, the esophagus with surrounding tissue was removed, and 1 cm cross sections of the EGJ to the upper 5 cm were cut. EUS imaging and microscopic findings were compared. Results: EUS showed that peri-ECVs were developed in all cases and that para-ECVs were developed in 3 cases. Perforating veins were visualized in all cases. On the basis of microscopic findings in autopsy, the collaterals around the esophageal wall were divided into two groups: collaterals adjacent to the muscularis externa of the esophagus, and collaterals distal to the esophageal wall without contact with the muscularis externa. These collaterals were observed in all cases and were considered to correspond to the peri- and para-ECVs observed by EUS. Veins connecting vessels in the submucosal layer and veins around the esophageal wall were observed in all cases. These veins were considered to correspond to the perforating veins observed by EUS. Conclusion: The veins corresponding to peri-ECVs, para-ECVs and perforating veins observed by EUS were identified in autopsy. EUS has shown to be useful for an understanding of vascular structure around the esophageal wall.