Endoscopic ultrasound-guided cystogastrostomy for successful drainage of pancreatic pseudocyst: a pediatric case report.

A 15-year-old boy was admitted to our hospital with a recent increase in the size of a preexisting pancreatic pseudocyst. At 11 years of age, he was diagnosed with acute lymphoid leukemia (ALL) and received chemotherapy with L-asparaginase (L-Asp); he developed the pancreatic pseudocyst following L-Asp-induced acute pancreatitis. The pancreatic pseudocyst had increased to 120mm in diameter. He developed epigastralgia and portal hypertension. Endoscopic ultrasound (EUS)-guided cystogastrostomy with the placement of a 7-cm 7-Fr plastic stent and a 5-Fr NB pigtail catheter led to the near-complete resolution of the pseudocyst. There were no signs of recurrence within the first year after intervention. EUS-guided drainage, increasingly used for pseudocysts, should be considered as an effective treatment approach for pediatric pancreatic pseudocysts.

Usefulness of radiofrequency ablation with micro-convex probe for hepatocellular carcinoma.

BACKGROUND/AIMS: It was aimed to assess whether a micro-convex probe is superior to the present conventional probe for ultrasonography from the points of safety and efficacy during percutaneous radiofrequency ablation therapy for hepatocellular carcinoma. METHODOLOGY: Twenty-one patients with 23 hepatocellular carcinoma lesions who had one or 2 lesions, each 4 cm or less in diameter, and liver function of Child-Pugh class A or B were enrolled. All the patients except for 2 patients were seropositive for hepatitis C virus. Radiofrequency ablation was carried out under a real-time US guidance. The cooled-tip electrodes used were single and clustered. RESULTS: It was possible to perform safe and accurate percutaneous radiofrequency ablation procedure using micro-convex probes for the treatment of all hepatocellular carcinoma nodules. It was also possible to treat hepatocellular carcinoma located in the right subphrenic region without artificial pleural effusion under intercostal ultrasonography guide. Improved clustered needles were successfully applied to treat the nodules more than 3 cm in diameter with less resistance for penetration compared with the conventional needle. The findings of advanced dynamic flow image on ultrasonography to assess the therapeutic efficacy indicated the consistency with those of dynamic CT which was done 3 to 5 days later radiofrequency ablation. Major complication of radiofrequency ablation procedure was noted in none. CONCLUSIONS: These results suggest that micro-convex probe with clustered tips is superior to conventional probe for ultrasonography from the points of safety and efficacy during radiofrequency ablation for hepatocellular carcinoma nodule located in the right subphrenic region and for larger sized nodule more than 3 cm.

Noninvasive assessment of liver disease - measurement of hepatic fibrosis using tissue strain imaging.

The development of hepatic fibrosis in patients with liver disease is associated with an increased risk of liver cancer. Assessing the degree of hepatic fibrosis is therefore one of the most important factors in treatment planning. Liver biopsy is commonly performed to assess hepatic fibrosis, but this method is associated with complications such as hemorrhage. Recently, a number of studies on the noninvasive assessment of hepatic fibrosis have appeared in the literature. The present study was conducted to determine whether an easily performed myocardial examination technique can also be applied to the assessment of hepatic fibrosis. The statistical software Minitab, which performs hypothesis testing based on the P value, was used for statistical analysis. The mean strain values were 0.26 in the normal adult group, 0.155 in the chronic hepatitis group, and 0.058 in the cirrhosis group. Statistically significant differences were observed between the groups. The results of the present study suggest that noninvasive tissue strain imaging may become the method of choice for assessing hepatic fibrosis in routine clinical practice.

Hepatocellular Carcinoma 11 and a Half Years after the Resolution of Chronic Hepatitis C Virus Infection Successfully Treated with Interferon.

A 41-year-old Japanese man had received successful interferon (IFN) therapy against chronic hepatitis C in 1994. Since then, serum hepatitis C virus (HCV) RNA had been negative, and aminotransferase levels had been continuously normal. He had abstained from alcohol. However, his serum aminotransferase levels showed slight elevation as his body weight increased gradually. He was diagnosed as having fatty liver and diabetes mellitus. In January 2006, 11 and a half years after the resolution of HCV infection, he was found to have a hepatic nodule 4.0 cm in diameter at liver S4/8 region by plain abdominal CT at an annual follow-up examination. He was diagnosed as having hepatocellular carcinoma (HCC) by angiography. The tumor was curatively resected and its histological diagnosis was moderately differentiated HCC. Noncancerous lesion of the liver revealed fibrosis of stage F2 and mild inflammation of grade A1 with mild steatosis. This case suggests that all patients with chronic HCV infection should be followed as long as possible for the potential development of HCC even after clearance of the virus.

Expression of Toll-like receptors in chronic hepatitis C virus infection.

BACKGROUND: Toll-like receptors (TLRs) are involved in innate immunity. Certain viruses interact with TLRs and mediate antiviral effects as well as immune responses. The aim of this study was to investigate the effect of TLRs on pathogenesis in hepatitis C virus (HCV)-infected patients. METHODS: Peripheral blood mononuclear cells (PBMC) and CD14+ (monocytes) or CD14- cells from 25 patients with chronic liver disease and 15 healthy subjects were studied for expression of TLRs 2-9 and cytokines of extracted RNA using real-time PCR. Then TLR expression was examined in HepG2 cells transfected with entire or parts (core-NS3, NS3-NS5B) of the HCV open reading frame. TLR expression was calculated as the relative mRNA levels. RESULTS: Expression of TLRs 4, 7 and 8 in CD14+ cells of PBMC was increased in patients. Levels of tumor necrosis factor (TNF)-alpha, interleukin (IL)-6 and IL-12 p35 for PBMC were also increased in patients. When PBMC were incubated with HCV core protein, enhancement of TLR2 expression and suppression of TLR4 and TLR7 were noted in patients. Similar alteration of TLRs expression was observed in controls. Among HepG2 transfectants, only TLR3 expression was changed; it was suppressed in entire gene transfectant and enhanced in core-NS3 transfectant. Expression of some proteins related to the TLR signaling pathway was suppressed in the entire gene transfectant. CONCLUSIONS: The results suggest a correlation between expression levels of TLRs and cytokines, and chronic HCV infection. TLR3 recognizes double-stranded RNA and induces type 1 interferon synthesis. Collectively, suppressed expression of TLR3 in cells transfected with entire HCV may be responsible for continuous HCV infection, although a part of the HCV gene enhances its expression.