An obese patient with acute cholecystitis, nonalcoholic steatohepatitis and cirrhosis: A case report.

INTRODUCTION: Laparoscopic cholecystectomy for patients with acute cholecystitis and liver cirrhosis is associated with increased risk. We present an obese patient with acute cholecystitis and liver cirrhosis caused by nonalcoholic steatohepatitis (NASH), who was successfully managed with laparoscopic cholecystostomy and a low-carbohydrate diet with exercise. PRESENTATION OF CASE: A 61-year-old woman presented with right upper quadrant abdominal pain. Ultrasonography and computed tomography were consistent with acute cholecystitis with multiple stones and cirrhosis. The patient had no history of alcohol intake, and serologic tests were negative. The patient's body mass index was 39 kg/m2 (154 cm, 93 kg) and NASH was suspected. Percutaneous transhepatic drainage was impossible because of the anatomic position of the gallbladder. Emergency laparoscopic cholecystostomy was performed initially for drainage. A low-carbohydrate diet and exercise were started for weight loss and her weight reduced by 19 kg over three months. Open cholecystectomy was performed uneventfully, and liver biopsy suggested NASH. DISCUSSION: Laparoscopic cholecystostomy is a reasonable temporary alternative to cholecystectomy in patients with acute cholecystitis and increased surgical risk. Weight loss with diet and exercise can be effective in patients with NASH. A low-carbohydrate diet is a reasonable treatment for NASH, because glucose is converted to triglycerides and stored as lipid in the liver. CONCLUSION: Laparoscopic cholecystostomy was effective in this obese patient with acute cholecystitis and NASH cirrhosis. Using a low-carbohydrate diet with exercise, her weight decreased, and subsequent open cholecystectomy was uneventful.

The Speed of Sound in Rat Liver With Steatohepatitis: Ex Vivo Analysis Using Two Types of Ultrasound Systems.

We have previously reported a non-invasive method that would be clinically applicable for measurement of speed of sound (SOS) in the liver. The objective of the present study was to confirm the utility of this new method for assessing over time the SOS in liver with progressive steatohepatitis of different grades and stages. Rats were divided into two groups-a control group and a steatohepatitis group-prepared by keeping the rats on a methionine and choline-deficient diet for 43 wk. The SOS through the liver tissue was measured using the new method in comparison with a pulse-receiver as the standard. The SOS through liver with steatohepatitis temporarily decreased with the fat deposition level and then increased in parallel with the progression of inflammation and fibrosis. Monitoring the change in SOS through liver tissue in individual patients with fatty liver would have considerable potential for assisting the non-invasive detection of early-stage steatohepatitis.

An inguinal hernia with cryptorchidism with a Leydig cell tumor in an elderly man: A case report.

INTRODUCTION: Cryptorchidism is common in children but is rare in the elderly. It often presents with a constellation of signs and symptoms similar to routine inguinal hernias. We present the case of an elderly man with cryptorchidism containing a Leydig cell tumor and provide clinical insights. PRESENTATION OF CASE: An-84-year old man was admitted with an incarcerated right lower quadrant hernia. Both testes were absent on palpation of the scrotum. After reduction of the hernia, computed tomography scan revealed a round lesion in the hernia sac, which was suspected to be the ectopic testis. Laparoscopic exploration was performed in combination with an open anterior approach. The hernia orifice was the right internal inguinal ring, and the inguinal canal was obliterated by adhesions because the spermatic cord did not pass through it. The ectopic testis was resected with the hernia sac, and the hernia repaired with a KUGEL™ patch (Bard, USA). DISCUSSION: Laparoscopic exploration was useful to delineate the anatomy of this unusual inguinal hernia. The open anterior approach was necessary to dissect the ectopic testis and the hernia sac. Pathological findings revealed tumor cells with clear cytoplasm in the resected testis, diagnosed as a Leydig cell tumor. CONCLUSION: The combination of laparoscopic and anterior approaches facilitated the surgical treatment of an unusual inguinal hernia with cryptorchidism. The resected ectopic testis should undergo thorough histopathologic examination.

A new method for measuring the speed of sound in rat liver ex vivo using an ultrasound system: correlation of sound speed with fat deposition.

The speed of sound correlates well with the fat content of the liver. Therefore, non-invasive quantification of sound speed in the liver might be of diagnostic value. Here we describe a new non-invasive method that would be clinically applicable for measurement of sound speed in the liver. Sprague-Dawley rats were divided into two groups: a control group and a fatty liver group prepared by keeping the rats on a choline-deficient diet for 6 wk. The livers were subjected to pathologic and biochemical analysis; the speed of sound through the liver tissue was measured using our proposed method and a pulser-receiver as standard. Our results indicated that use of the proposed method makes it feasible to diagnose fatty liver with good accuracy on the basis of sound speed. This approach would have considerable potential for non-invasive diagnosis of fatty liver and would be a valuable adjunct to conventional liver diagnostic procedures.

Primary hepatic choriocarcinoma in a 49-year-old man: report of a case.

We report a case of hepatic choriocarcinoma in a man diagnosed at autopsy after a rapid downhill clinical course. The patient was a 49-year-old man who presented with acute right-sided abdominal pain. There were no masses palpable on physical examination. Radiographic findings showed large multi-nodular tumors mainly in the right lobe of the liver. Fludeoxyglucose-positron emission tomography scan showed uptake only in the liver, and no uptake in the testes. We initially planned to perform a liver resection for the presumed diagnosis of intra-hepatic cholangiocarcinoma. However, the tumors grew rapidly and ruptured. Multiple lung metastases rapidly developed resulting in respiratory failure, preventing liver resection or even biopsy. He died 60 d after initial presentation with no pathological diagnosis. Postmortem studies included histopathological and immunohistological examinations which diagnosed a primary choriocarcinoma of the liver. Primary hepatic choriocarcinoma is very rare but should be considered in the differential diagnosis of a liver tumor in a middle aged man. Establishing this diagnosis may enable treatment of the choriocarcinoma. Liver biopsy and evaluation of serum human chorionic gonadotropin are recommended in these patients.

Resolution of cyclic vomiting after appendectomy in a girl.

Cyclic vomiting syndrome is a disorder characterized by recurrent, discrete, stereotypical episodes of nausea and vomiting. Although chronic or recurrent appendicitis may be a cause of recurrent abdominal pain, it rarely meets the diagnostic criteria for cyclic vomiting syndrome. Furthermore, mast cell counts are histologically high in chronic appendicitis. We report a 10-year-old Japanese girl with a cyclic pattern of vomiting that met the stringent diagnostic criteria for cyclic vomiting syndrome, and which was resolved after appendectomy. Histopathologic examination of the resected appendix showed not only acute mucosal inflammation but also chronic inflammatory changes. Because we speculated that recurrent or chronic appendicitis may have been related to the patient's vomiting bouts, we also immunohistochemically investigated the density of mast cells in the specimen. We found that the mast cell density was markedly high in the lamina propria of the appendix. In our patient, a type I hypersensitivity reaction with release of mediators by mast cells could have been the initial factor triggering the recurrent appendicitis, and this stressor could have initiated the vomiting cascade. In conclusion, chronic or recurrent appendicitis could be one of the causes of cyclic vomiting, and must be considered in the differential diagnosis of cyclic vomiting syndrome.

[A case of advanced small intestinal cancer treated with S-1 plus cisplatin].

A66 -year-old woman was referred to our hospital because of abdominal pain in 2005. Computed tomography(CT) showed severe wall thickening of the proximal part of the jejunum and extensive intraperitoneal lymph node swelling. Therefore she was diagnosed with primary advanced small intestinal cancer. Surgery was performed to prevent the gastrointestinal obstruction and bleeding. Extensive lymph node metastases, including those in the paraaortic area, were observed. Because a curative resection seemed impossible, only a partial resection of jejunum was performed. After the operation, a regimen of chemotherapy with S-1(80mg/body, alternate-day dosage)and CDDP(100mg/body), was administered once every 5 weeks. At the end of the 4th course, the tumor marker was normalized and CT showed a marked decrease in the size lymph nodes; a complete response(CR)was achieved. But when a total 9 courses of chemotherapy was completed during the 17- month follow-up period after the operation, the tumor marker re-rose, and CT showed extensive intraperitoneal lymph node swelling again, so it was diagnosed the recurrence of as a disease. Chemotherapy was administered again, but was not effective. The patient died 29 months after the operation.