Acute Liver Failure Complicated with Severe Heart Failure.

A young pregnant woman was hospitalized due to hepatitis B virus (HBV)-related acute liver failure (ALF). The cardiac function was normal on admission. However, she developed ALF concurrently with a coma and severe cardiac failure. The patient was diagnosed with severe acute cardiomyopathy due to diffuse hypokinesis of the left ventricle wall on ultrasound cardiography. Following intensive treatment, both the liver and cardiac function dramatically recovered. Although some factors, such as HBV, pregnancy and systemic inflammatory response syndrome, are possible causes of acute cardiomyopathy in the present case, ALF itself may be a risk factor for heart failure.

Hepatic peribiliary cysts with rapidly progressive refractory obstructive jaundice and esophageal varices.

A 54-year-old man with decompensated alcoholic liver cirrhosis presented with acute cholangitis. Although no localized lesions were detected in the liver on contrast-enhanced computed tomography and no risky varices were noted on endoscopy, hepatic peribiliary cysts (HPBCs) developed along the intrahepatic portal vein in the course of only 40 days. Moreover, esophageal varices with the red color sign grew rapidly during the same period, and the patient ultimately died due to rupture. HPBC formation is a rare complication of liver disease, including cirrhosis. Although HPBCs are generally harmless, on rare occasions they may induce the rapid progression of esophageal varices.

Refractory primary hepatic actinomycosis with direct infiltration to the diaphragm and thorax: the usefulness of contrast-enhanced ultrasonography.

An 80-year-old man was admitted to our hospital with a diagnosis of primary hepatic actinomycosis determined based on a percutaneous aspiration biopsy. The abscesses and state of liquefaction were easily and effectively visualized on contrast-enhanced ultrasonography. Ampicillin/sulbactam was administered; however, lesions of hepatic actinomycosis suddenly infiltrated the diaphragm and right thorax six months later. A drainage tube was inserted into the right thoracic space, and the pleural effusion gradually decreased. The patient received continuous antibiotic therapy for nearly two years and remained free of hepatic actinomycosis on follow-up more than one year later.

Churg-Strauss syndrome manifesting as cholestasis and diagnosed by liver biopsy.

A 56-year-old woman was referred to our hospital due to fever and cholestatic liver dysfunction. Her eosinophil count was normal and she had no abdominal pain or neurological manifestations. We performed a liver biopsy and found fibrinoid necrosis of the hepatic artery with granulomatous reaction and eosinophilic infiltration in the portal area in the liver. Later, sensory abnormalities of the arms and legs appeared and the eosinophil count increased. Serum immunoglobulin E and immunoglobulin G4 were elevated and rheumatoid factor was strongly positive. Endoscopic retrograde cholangiopancreatography revealed no abnormality of the bile duct and pancreatic duct. We made a diagnosis of Churg-Strauss syndrome and began corticosteroid treatment. Fever and liver function immediately improved. In the present patient, Churg-Strauss syndrome manifested first in the liver, before hypereosinophilia and neural manifestations. We believe that Churg-Strauss syndrome is an autoimmune liver disease, and it is important to recognize that the liver may be involved in Churg-Strauss syndrome.

Excess copper chelating therapy for Wilson disease induces anemia and liver dysfunction.

A 37-year-old man was diagnosed with Wilson disease at the age of 14. His first manifestations were neurological. He was treated with trientine for more than 10 years and suffered from anemia and liver dysfunction. Wilson disease is a genetic disorder characterized by accumulation of copper in the body. Excess copper is toxic, but copper is an essential trace element. Copper-binding ceruloplasmin is important for iron metabolism. Excess copper chelating treatment-induced anemia and iron deposition in the liver was suspected. Proper monitoring of copper status is important for the management of Wilson disease.

Pancreatic pseudocysts in post-gastrectomy patients treated via the duodenal minor papilla with an oblique-viewing endoscope.

Endoscopic retrograde cholangiopancreatography (ERCP) in patients after Billroth II or Roux-en-Y reconstruction is challenging because of difficulties in insertion of the endoscope into the afferent loop, which is a great distance away from the papilla of Vater, and cannulation into the desired duct from a reverse position. To facilitate ERCP, various endoscopes have been selected according to operator preference. Previously, we reported that an oblique-viewing endoscope (XK-200; Olympus, Tokyo, Japan) can contribute to successful performance of ERCP and associated procedures in Billroth II gastrectomy patients. We report here our experience with two post-gastrectomy patients with chronic pancreatitis who were treated with an oblique-viewing endoscope from the minor papilla.

[A case of severe alcoholic hepatitis successfully treated by granulocytapheresis].

A 34-year-old woman was admitted because of severe liver dysfunction due to excessive alcohol intake. Liver biopsy performed on the fifth day showed liver tissue with marked granulocyte infiltration and pericellular fibrosis. As there were no improvements in white blood cell count and serum total bilirubin levels despite the use of corticosteroids and plasma exchange, hemodiafiltration, we performed granulocytapheresis (GCAP). Peripheral white blood cells decreased from just after GCAP. Her condition remained stable and she was discharged on the 54th day. We suggest that GCAP can be recommended as an effective therapy for severe alcoholic hepatitis.

ERCP afterRoux-en-Y reconstruction can be carried out using an oblique-viewing endoscope with an overtube.

BACKGROUND: We report that an oblique-viewing endoscope facilitates endoscopic retrograde cholangiopancreatography (ERCP) in Billroth II reconstruction. With this endoscope, we carried out ERCP in Roux-en-Y reconstruction. METHODS: Fifteen patients with Roux-en-Y reconstruction were enrolled. Eleven of these patients had undergone gastrectomy, while Whipple's operation or choledochectomy had each been carried out in two patients. Among the 11 post-gastrectomy patients, eight had bile duct stones, and there was one case each of pancreatic abscess with chronic pancreatitis, bile duct obstruction due to gallbladder, or pancreatic cancer. The remaining four patients suffered from stenotic anastomosis of choledochojejunostomy. All procedures were carried out with an oblique-viewing endoscope. RESULTS: The papilla of Vater or anastomosis was reached in 10 patients. In these 10 patients, all planned procedures were completed. Endoscopic papillary balloon dilatation (EPBD) was carried out in three patients with bile duct stones. The remaining three patients with bile duct stones underwent sphincterotomy with tube stent placement, EPBD after sphincterotomy with biliary tube stent placement, and biliary tube stent placement, respectively. Pancreatic stent placement via the minor papilla was carried out in one patient with pancreatic abscess, and a biliary tube stent was introduced in the patient with gallbladder cancer. Two patients underwent cutting of a stenotic anastomosis with a needle knife, followed by balloon dilatation. None of the patients experienced any complications. CONCLUSION: The results appear to support the feasibility of using an oblique-viewing endoscope for ERCP in Roux-en-Y reconstruction. Further studies including a large population of patients should be planned to confirm these results.

Encoscopic management of stenotic anastomosis using a rendezvous technique after pancreatogastrostomy.

A 46-year-old female patient was referred to our hospital for endoscopic treatment of stenotic pancreatogastrostomy. She had undergone pylorus-preserving pancreatoduodenectomy due to duodenal carcinoma of the papilla of Vater 5 years before referral. Two years after the operation, she had to be hospitalized several times during a 1-year period because of acute recurrent pancreatitis caused by stenosis of the anastomosis of the pancreatoduodenostomy. An endoscopic ultrasound (EUS)-guided rendezvous technique was selected to puncture the main pancreatic duct via a transgastric approach. We identified the dilated main pancreatic duct with a convex array echoendoscope from the lower gastric body near the anastomosis and successfully punctured the dilated main pancreatic duct. The guidewire passed through the stenosis to the gastric cavity and we could place a stent through the stenotic anastomosis. After the procedure, the patient has not experienced acute recurrent pancreatitis for 9 months. Pancreatogastrostomy has been the preferred method used to carry out post-pancreatoduodenectomy reconstruction. However, stenosis of the anastomosis has been reported as one of the late complications of pancreatogastrostomy. The main symptom of this complication is recurrent epigastralgia due to obstructive pancreatitis. As a result, patients are compelled to stay in the hospital for an extended duration with no oral intake allowed. Surgical resection of the stenosis is often the treatment of choice but can be troublesome due to post-operative adhesions. Here, we report a case of pancreatogastrostomy complicated by stenosis, which was treated using the EUS-guided rendezvous technique.

Increased soluble IL-2 receptor levels during interferon and ribavirin treatment are associated with a good response in genotype 2a/2b patients with chronic hepatitis C.

OBJECTIVES: Serum levels of soluble interleukin-2 receptor (sIL-2R) are known to serve as a marker for the activation of T lymphocytes. We measured serum levels of sIL-2R in patients with chronic hepatitis C (CHC) during interferon (IFN)-based treatment to determine the correlation between those levels and therapeutic efficacy, and to clarify whether there is a difference in the activation of T lymphocytes among HCV genotypes after the treatment. METHODS: Forty-four patients received IFN-alpha2b monotherapy (group IFN-M), whereas 82 patients received the combination therapy with IFN-alpha2b and ribavirin (group IFN+R). We measured serum sIL-2R levels in these patients before (T0) and 2 weeks (T2) after the treatment. RESULTS: The sustained virologic response rates in genotype 2a/2b patients were significantly higher than those in genotype 1b patients in both groups (P<0.005). In sustained virologic responders, sIL-2R levels at T2 were significantly higher than those at T0 in both groups (P<0.001). In nonresponders, sIL-2R levels at T2 were not different from those at T0 in group IFN-M, but were significantly higher than those at T0 in group IFN+R (P=0.0072). In genotype 1b patients, sIL-2R levels at T2 were not different from those at T0 in group IFN-M, but were significantly higher than those at T0 in group IFN+R (P=0.0064). In genotype 2a/2b patients, sIL-2R levels at T2 were significantly higher than those at T0 in both groups (P<0.0005). CONCLUSION: These findings suggest that the activation of T lymphocytes after IFN-based treatment contributes to a high-sustained virologic response rate, especially in genotype 2a/2b patients.

Grasping forceps-assisted endoscopic mucosal resection of early gastric cancer with a novel 2-channel prelooped hood.

BACKGROUND: Endoscopic mucosal resection with a cap-fitted panendoscope (EMRC) such as a soft prelooped hood is a useful, effective, and safe technique. One problem with this method is that the lesion cannot always be maintained in the center of the cap because the procedure is performed blindly after aspiration. OBJECTIVE: We developed a 2-channel prelooped hood that facilitates EMRC while simultaneously allowing both grip of the center in the lesion and irrigation of the aspiration site and evaluated the usefulness of this end hood for early gastric cancer. DESIGN: Retrospective study. SETTING: Between August 2003 and October 2004, patients underwent our novel EMR. PATIENTS: Twelve cases of early gastric cancer. INTERVENTIONS: Two side holes were fabricated by drilling in the cap portion of a conventional soft prelooped hood, and then the irrigation tube and the accessory channel tube were glued to the exterior surface of the holes. We placed the fabricated transparent hood at the tip of the endoscope and performed grasping forceps-assisted endoscopic aspiration mucosectomy. MAIN OUTCOME MEASUREMENTS: Accurate aspiration and the rate of en bloc resection. RESULTS: We obtained a satisfactory field of view and accurate aspiration in the center of the tumor in all lesions. The rate of en bloc resection was 91.7% (11/12). LIMITATIONS: Gastric intramucosal cancer. CONCLUSION: Grasping forceps-assisted endoscopic mucosal resection with a novel 2-channel prelooped hood is safe and useful for mucosal resection of intramucosal cancers less than 20 mm and may help center the lesion in the cap before resection.

EMR of upper GI lesions when using a novel soft, irrigation, prelooped hood.

BACKGROUND: EMR with a cap-fitted endoscope, including a soft, prelooped hood, is a useful, effective, and safe technique. One problem with this method, however, is that the lesion cannot always be kept in the center of the cap because the procedure is performed blindly after aspiration. A soft, prelooped hood with attached irrigation tube was developed. The usefulness of this device for EMR of upper-GI intramucosal cancers was evaluated. METHODS: The end-hood piece was fabricated by drilling a side hole in the cap portion of a conventional soft, prelooped hood and then attaching an irrigation tube with glue to the exterior surface of the hole. The fabricated transparent hood was placed at the tip of an endoscope, and aspiration mucosectomy under irrigation was performed in 15 patients with upper-GI intramucosal cancer. When the field of view at the aspiration site was obscured by oozing blood, the site was irrigated. RESULTS: A satisfactory view was obtained of all lesions. The mean diameter of specimens was 24.5 mm (interquartile range: 15-35). The proportion of en bloc resected lesions was 86.7% (13/15). Bleeding was the only complication (4/15; 26.7%) and was controlled by using endoscopic hemostatic techniques under irrigation. CONCLUSIONS: EMR when using the soft, prelooped hood with irrigation tube is effective and safe for intramucosal cancers 20 mm or less in diameter.