Percutaneous pancreatic-duct puncture with rendezvous technique can treat stenotic pancreaticojejunostomy.

Stenotic pancreatico-enteric anastomosis is one of the serious late complications after a pancreaticoduodenectomy. We report a case of stenotic pancreaticojejunostomy with a pancreatic juice fistula drained externally, which was treated using percutaneous procedures combined with a rendezvous method. A 77-year-old woman was referred to our hospital for an endoscopic treatment to remove a percutaneous drainage tube from a fluid collection due to pancreatic juice fistula. She had undergone pylorus-preserving pancreatoduodenectomy with Roux-en-Y reconstruction due to duodenal carcinoma of Vater's papilla 1 year before the referral to our hospital. Soon after the operation, she had developed a fluid collection adjacent to the anastomosis due to pancreatic juice fistulas and subsequently had undergone its percutaneous drainage. After admission, we tried to dilate the stenotic anastomosis with an endoscopic procedure from the anastomosed jejunal lumen, using an oblique-viewing endoscope. The endoscope reached a portion of the anastomosis, but did not allow us to visualize the entire anastomosis. We punctured the main pancreatic duct under ultrasonography and fluoroscopy, and advanced the needle into the anastomosed jejunum through the stenotic anastomosis. After putting a guidewire into the anastomosed jejunum through the needle, we introduced an oblique-viewing endoscope into the anastomosed jejunum and caught hold of the guidewire using grasping forceps. Maintaining tension on the guidewire with a slight pulling force, with some effort we were able to place a 5-Fr drainage catheter into the jejunum percutaneously and through the anastomosis via the main pancreatic duct. Three weeks after these procedures, we performed balloon dilation of the anastomosis. One week after balloon dilation, removed the percutaneous catheter.

[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.

Iatrogenic hyperadrenocorticism and steatohepatitis caused by unapproved medicine.

A 54-year-old man experienced weight gain. He was diagnosed as having hyperglycemia, hypertension and liver damage. Liver biopsy showed steatohepatitis. We initially suspected him as having hyperadrenocorticism. However, both adrenocorticotropic hormone and cortisol levels were low. Later, it was revealed that he took medicine to relieve his gonalgia. His hyperglycemia, hypertension and liver damage improved after he discontinued taking the medicine. An analysis of this medicine showed that it contained desoximetasone, a glucocorticoid compound that had not been approved for medical use in Japan. To adequately diagnose clinical conditions, it is necessary to survey the patient's medicinal history in detail.

Prostaglandin E2 inhibits platelet-derived growth factor-stimulated cell proliferation through a prostaglandin E receptor EP2 subtype in rat hepatic stellate cells.

Prostaglandin (PG) E2 inhibits hepatic stellate cell (HSC) mitogenesis. PGE-specific receptors are divided into four subtypes that are coupled either to Ca2+ mobilization (EP1 and EP3) or to the stimulation of adenyl cyclase (EP2 and EP4). The aims of the current study were to identify PGE receptor subtypes in cultured rat HSC and to examine which PGE receptor subtype(s) mediates the inhibitory effect of PGE2 on platelet-derived growth factor (PDGF)-stimulated proliferation. Reverse transcription-polymerase chain reaction analysis was performed to detect PGE receptor subtype mRNA expression. Cell proliferation was determined by measuring [3H]thymidine incorporation, and intracellular cyclic AMP was measured by radioimmunoassay. Cultured rat HSC expressed mRNAs for all four subtypes of PGE receptor. PGE2- and EP2-selective agonist produced dose-dependent inhibitory effects on PDGF-stimulated proliferation. Neither EP1-, EP3-, nor EP4-selective agonists showed any inhibitory effect. An adenylate cyclase inhibitor strongly blunted the inhibition of DNA synthesis elicited by PGE2 and the EP2 agonist. The EP2 agonist generated higher and more prolonged increases in intracellular cyclic AMP than the EP4 agonist. Activation of the PGE EP2 receptor has an antiproliferative effect in HSC that may be mediated by cyclic AMP-related signal transduction pathways.