Analysis of the influence of dabigatran on coagulation factors and inhibitors.

INTRODUCTION: Dabigatran is an oral intake thrombin inhibitor for preventive administration against stroke accompanied by atrial fibrillation. Although dabigatran causes prolonged activated partial thromboplastin time (APTT), the effect of dabigatran on each coagulation factor and coagulation factor inhibitor remains to be investigated. Our aim was to analyze the influence of dabigatran on coagulation factors and coagulation factor inhibitors. METHODS: We administered dabigatran to 40 patients. In 26 of these 40, we analyzed the activity of several coagulation factors and their inhibitors. We used Fisher's exact test to determine statistical significance. RESULTS: The activities of many coagulation factors changed during the dabigatran therapy. Factor II levels decreased in all patients showing prolongation of partial thromboplastin (PT) and APTT. The antifactor VIII inhibitor was positive in the majority of patients with prolonged PT and APTT, while activities of protein C, protein S, and antifactor IX inhibitor were not associated with PT and APTT prolongation. CONCLUSION: Dabigatran affects the activities of many coagulation factors, including factors II, V, VIII, and IX, as well as the antifactor VIII inhibitor.

Ruptured duodenal varices: an autopsy case report.

Bleeding from duodenal varices is a rare and life-threatening complication of cirrhosis. The diagnosis and management of this disease remains problematic. We herein report an autopsy case of a patient who suffered from recurrent bleeding from duodenal varices. A 48 year-old man with cirrhosis presented with upper gastrointestinal bleeding. He had three episodes of massive melena during the 6 months prior to admission. However, the source of bleeding was not known. Emergent endoscopy revealed jet bleeding from varices in the second to third portion of the duodenum. Endoscopic ethanol injection sclerotherapy was attempted but rebleeding occurred and the patient died.

Autoimmune cholangiopathy associated with rheumatoid arthritis.

We herein describe a patient with autoimmune cholangiopathy complicated with rheumatoid arthritis. A 58-year-old female was admitted to our hospital due to complications of arthralgia in her fingers, shoulders, elbows, knees and ankles. She presented with abnormally elevated levels of transaminases, alkaline phosphatase and was also negative for hepatitis B virus, hepatitis C virus and the serum mitochondrial antibody test, but had high titers of serum antinuclear antibody, rheumatoid factor and rheumatoid arthritis hemagglutination. A liver biopsy specimen showed chronic non-suppurative destructive cholangitis. She was thus diagnosed to have autoimmune cholangiopathy and rheumatoid arthritis. She began treatment with prednisolone 40 mg per day. After 20 days of steroid therapy, her hepatic function tests improved and the arthralgia symptoms disappeared. This is, to our knowledge, the first case of autoimmune cholangiopathy associated with rheumatoid arthritis, in which both symptoms improved with steroid therapy.

Hepatocellular carcinoma with metastasis to the rib complicated by hemothorax. An autopsy case.

A 64-year old man was admitted to our hospital with multiple hepatocellular carcinoma (HCC) lesions in the liver, lung and bone. Three weeks after admission, the patient became complicated with right upper chest pain. A chest radiograph showed a marked increase in right pleural effusion. Thoracentesis demonstrated a hemothorax. Despite treatment with a continuous pleural tap and blood transfusions, the patient's clinical status worsened and he developed severe dyspnea. His right pleural effusion might be considered to be caused by a rupture of the HCC metastasis in the right 2nd rib. The patient died due to respiratory and hepatic failure 26 hours after his occurring the pleural effusion. An autopsy revealed moderately differentiated HCC in the liver, lung and bone. The HCC metastasis of the right 2nd rib was found to have torn the nearby pleura. We described a rare case in which hemothorax was caused by a ruptured rib-based HCC.

[Thyroid function in patients with Yusho: 28 year follow-up study].

To evaluate chronic effect of polychlorinated biphenyl (PCB) on thyroid functions, thyroid hormone levels and thyroidal autoantibodies were studied in 81 patients with Yusho in 1996. Serum level of thyroid stimulating hormone (TSH) was elevated in 7 cases (8.6%). All of them showed normal triiodothyronine (T3), thyroxine (T4) and free T4 levels, and regarded as latent hypothyroidism. There were no significant correlations between blood PCB concentrations and TSH levels, T2 levels, T4 levels or free T4 levels. Thyroglobulin antibodies were detected in 8 cases (19.5%) of 41 Yusho patients with high PBC concentration (higher than 3.0 ppb), and in only one case (2.5%) of 40 patients with low PBC concentration (lower than 2.9 ppb). We conclude that thyroglobulin antibody in patients with Yusho is not frequent and it may be associated with blood PCB concentration.

Primary biliary cirrhosis associated with ulcerative colitis.

A rare case of concurrent primary biliary cirrhosis and ulcerative colitis is described in a 61 year-old Japanese male. Primary biliary cirrhosis was diagnosed on the basis of characteristic histologic findings and a positive serum mitochondrial antibody test. Ulcerative colitis was diagnosed from typical findings on colonoscopy and the histologic features of a sigmoid colon biopsy specimen. This is the 12th report of a patient presenting with the combination of primary biliary cirrhosis and ulcerative colitis. The potential autoimmune relationships on the basis of these conditions are discussed.

A rare case of hepatic injury associated with ovarian hyperstimulation syndrome.

A 26-year-old married woman was admitted to our hospital because of massive ascites and hepatic injury. The patient had been treated with human menopausal gonadotropin and clomiphene citrate to prevent recurrence of spontaneous abortions. About 1 month later, she developed upper abdominal pain and noticed dark urine. On admission, she had elevated concentrations of serum transaminases with an asparate aminotransferase of 127 IU/L and alanine aminotransferase of 194 IU/L. An abdominal ultrasound showed massive ascites. Her serum concentration of estradiol was high at 12,100 pg/mL, which was much greater than the value of early stage of pregnancy (2,279-7,353 pg/mL). She was thus diagnosed as having ovarian hyperstimulation syndrome. Following a period of bed rest, her liver function normalized and the ascites disappeared. Based on the above findings, the patient was considered to have suffered from ovarian hyperstimulation syndrome, complicated by hepatic injury.

Recurring encephalopathy abolished by gastrorenal shunt ligation in a diabetic hemodialysis patient.

A 57-year-old man was admitted to our hospital for hepatic encephalopathy. He previously had undergone a partial gastrectomy for gastric ulcer, and also had been on maintenance hemodialysis because of diabetic nephropathy. Despite treatment with branched-chain amino acids and lactulose, encephalopathy occurred repeatedly. The findings of his laboratory examinations, computed tomography, and liver biopsy were not suggestive of chronic liver damage. Angiography revealed a portal-systemic shunt from the superior mesenteric vein via the left gastric vein to the left renal vein. A ligation of the gastrorenal shunt was performed. After the shunt ligation, hepatic encephalopathy no longer recurred, and no medication was required to prevent it. The insulin requirements also decreased, the plasma ammonia concentration then decreased, and serum concentration of several amino acids related to the ammonia metabolism also decreased. The molar ratio of branched-chain amino acids to aromatic amino acids increased. The ligation of the portal-systemic shunt was thus considered to be the key to the successful treatment of hepatic encephalopathy in this unusual case.