Respiratory effects of balloon occluded retrograde transvenous obliteration of gastric varices: a prospective controlled study

BACKGROUND AND AIM

We evaluated the respiratory effects of balloon-occluded retrograde transvenous obliteration (BRTO) performed for the treatment of gastric varices complicating liver cirrhosis.

METHODS

From 2005 to 2009, we performed BRTO in 20 patients with gastric fundal varices, by intravariceal injection of 5% ethanolamine oleate (EO) as the sclerosant. We studied the effect of BRTO on the respiratory gas exchange, chest X-ray findings, computed tomography (CT) findings, pulmonary function parameters, and (99m) Tc-MAA lung perfusion scintigraphy findings. Subjects undergoing balloon-occluded retrograde transvenous varicerography (BRTV) without injection of the sclerosant served as the controls.

RESULTS

  Arterial blood gas analysis revealed a decrease in the mean arterial partial oxygen tension (PaO(2)) (P < 0.01), and increase in the alveolar-arterial oxygen tension difference (AaDO(2)) after BRTO (P < 0.01), as compared with the results obtained before the BRTO, while breathing room air. No changes were observed after BRTV as compared with the previous findings. In addition, a significant correlation was observed between the change of the PaO(2) and the volume of the sclerosant injected (rs = 0.511, P = 0.011). Left-pleural effusion was noted on the chest CT in 20% of the patients. On pulmonary function testing, decrease of the vital capacity was noted in two of the 20 patients after BRTO.

CONCLUSION

The aforementioned results suggest that BRTO performed using EO as the sclerosant induces pulmonary function disorders. The effect was found to depend on the total amount of EO injected. Therefore, careful respiratory monitoring seems necessary in patients undergoing BRTO, particularly those in whom large volumes of the sclerosant are used.

[A case of hepatocellular carcinoma complicated with Caroli's disease]

A 29-year-old man was admitted with right hypochondralgia and fever. Markedly dilated bile ducts were observed, mainly in the right lobe of the liver. Based on both the clinical findings and imaging, we diagnosed Caroli's disease and choledochal cyst complicated with cholangitis. Hepatocellular carcinoma (HCC) was also observed in segment 3, and the tumor measured 4cm in diameter. The patient was successfully treated with hepatectomy of the right lobe, partial hepatectomy of the left lateral lobe, and bile duct reconstruction. A histopathological examination revealed moderately differentiated HCC without any components of cholangiocellular carcinoma (CCC). Although Caroli's disease is complicated with CCC, a case of Caroli's disease complicated with HCC, as in the present case, is quite rare and therefore is considered to be worthy of reporting.

Emergency balloon-occluded retrograde transvenous obliteration for gastric varices

BACKGROUND

We evaluated the efficacy of emergency balloon-occluded retrograde transvenous obliteration (B-RTO) performed within 24 h after initial hemostasis for the prevention of rebleeding from ruptured gastric varices.

METHODS

From December 1995 to March 2003, 11 patients who had undergone B-RTO within 24 h after the control of gastric variceal bleeding at Maebashi Red Cross Hospital were investigated. They were followed up for complete eradication, recurrence of varices, and rebleeding. Efficacy was determined by endoscopic examination and computed tomography.

RESULTS

The 4 patients with acute bleeding from ruptured gastric varices were treated with endoscopic therapy-endoscopic variceal ligation (EVL) in 2 patients, and clipping treatment in 2. Initial hemostasis was achieved in all 4; the other 7 patients had already stopped bleeding at endoscopy. After hemostasis was achieved, emergency B-RTO was immediately performed within 24 h and was successful in all 11 patients. Ten (90.9%) of the 11 gastric varices were obliterated and the other 1 (9.1%) was diminished in size. During the mean follow-up period of 1136 days, no rebleeding or recurrence as found. Four patients died during the follow-up period, but none died from variceal bleeding. Survival rates were 90.9% and 70.7%, respectively, at 1 year and 3 years. In 6 patients, development of esophageal varices appeared during the follow-up period, all of which were controlled by usual endoscopic therapy. No severe side effects were found after the B-RTO treatment.

CONCLUSIONS

Emergency B-RTO is an effective treatment for the prevention of rebleeding from ruptured gastric varices.

Short-term complications of retrograde transvenous obliteration of gastric varices in patients with portal hypertension: effects of obliteration of major portosystemic shunts

The type, incidence, and severity of complications of balloon-occluded retrograde transvenous obliteration (B-RTO) for gastric varices should be precisely estimated. Complications were evaluated in 38 patients who had fundic gastric varices and 43 B-RTO procedures during injection of ethanolamine oleate (phase 1), within 4 h after injection (phase 2), 24 h after injection (phase 3), and from 24 h to 10 days after injection (phase 4). Endoscopic evaluation at 8 weeks showed resolution of gastric varices in 35 of 38 patients (92%) and smaller varices in the remaining three (8%). B-RTO caused transient hypertension in 35% of patients, hemoglobinuria in 49%, and fever in 33% during phases 1, 2, and 3, respectively. Pleural effusion, pulmonary infarction, ascites, gastric ulcers with unique appearance, localized mosaic-like change of gastric mucosa, and hemorrhagic portal hypertensive gastropathy were noted in phase 4. There were no fatalities. Lactate dehydrogenase, aspartate aminotransferase, and bilirubin increased on day 1. Each datum was retrieved within 7 days. The severity of lactate dehydrogenase elevation correlated significantly with the volume of infused ethanolamine oleate. Thus, B-RTO is a safe and effective management of fundic varices. However, short-term hemodynamic change after B-RTO may cause gastric mucosal damage. Pulmonary infarction and pleural effusion are potential complications.

The nitric oxide prodrug, V-PYRRO/NO, protects against cadmium toxicity and apoptosis at the cellular level

The liver is an important target tissue of cadmium. The compound O2-vinyl 1-(pyrrolidin-1-yl)diazen-1-ium-1,2 diolate (V-PYRRO/NO) is a liver-selective nitric oxide (NO) prodrug that is metabolized by hepatic P450 enzymes to release NO in hepatocytes. In vivo, V-PYRRO/NO can protect against the toxicity of various hepatotoxicants, including cadmium. Since NO is an effective vasodilator, whether this protective effect against cadmium toxicity is at the level of the hepatic vascular system or actually within the liver cells has not been defined. Thus, we studied the effects of V-PYRRO/NO pretreatment on cadmium-induced toxicity and apoptosis in cultured rat liver epithelial (TRL 1215) cells. Cells were pretreated with V-PYRRO/NO at 500 or 1000 microM for up to 24 h, then exposed to cadmium (as CdCl2) for additional 24 h and cytotoxicity was measured. Cadmium was significantly less cytotoxic in V-PYRRO/NO (1000 microM) pretreated cells (LC50=6.1+/-0.6 microM) compared to control cells (LC50=3.5+/-0.4 microM). TRL 1215 cells acted upon the prodrug to release NO, producing nitrite levels in the extracellular media after 24 h of exposure to 500 or 1000 microM V-PYRRO/NO measured at 87.0+/-4.2 and 324+/-14.8 microM, respectively, compared to basal levels of 7.70+/-0.46 microM. V-PYRRO/NO alone produced small increases in metallothionein (MT), a metal-binding protein associated with cadmium tolerance. However, V-PYRRO/NO pretreatment greatly enhanced cadmium induction of MT. V-PYRRO/NO pretreatment also markedly reduced apoptotic cell death induced by cadmium (5 microM), apparently by blocking cadmium-induced activation of the c-Jun N-terminal kinase (JNK) pathway. Thus, the prodrug, V-PYRRO/NO, protects against the adverse effects of cadmium directly within rat liver cells apparently through generation of NO and, at least in part, by facilitation of cadmium-induced MT synthesis.

Effects of antioxidative agents on apoptosis induced by ischaemia-reperfusion in rat intestinal mucosa

BACKGROUND AND AIM

We have previously demonstrated that ischaemia-reperfusion induces apoptosis in the intestinal mucosa. To evaluate that reactive oxygen species enhanced intestinal apoptosis after ischaemia-reperfusion, we examined whether antioxidants reduced apoptosis.

METHODS

Rats were infused through a duodenal tube with antioxidative agents, glutathione, rebamipide and dymethylsulfoxide during 2 h before an ischaemic insult. The superior mesenteric artery was occluded for 60 min, followed by 60 min reperfusion. Apoptosis was evaluated by percentage fragmented DNA (fragmented DNA/total DNA) and immunochemical staining.

RESULTS

Increase in apoptosis in the intestinal mucosa after ischaemia-reperfusion was attenuated by intraduodenal infusion of antioxidative agents, but was not completely abolished.

CONCLUSION

Scavenging effects of the antioxidative agents attenuated increases in intestinal apoptosis, indicating that oxidative stress after ischaemia-reperfusion plays an important role in induction of apoptosis in the intestinal mucosa.

Metallothionein is a potential negative regulator of apoptosis

Apoptotic resistance can either be desirable or undesirable, depending on the conditions. In cancer chemotherapy, it is critical that tumor cells are selectively and effectively killed while leaving normal cells undamaged. Since acquisition of apoptotic resistance appears to be a common occurrence during malignant transformation, elucidating the mechanisms underlying apoptotic resistance is an area of intense study. Previous studies have revealed that metallothionein (MT) can protect cells from apoptosis induced by oxidative stress and metals. In the present study, we tested the hypothesis that the presence of MT may somehow modulate apoptosis. Our results revealed a strong linear negative correlation between basal MT levels and etoposide-induced apoptosis in the human tumor cell lines PLC/PRF/5, H460, and HepG2 (r = -0.991). In HepG2 cells, 24 h pretreatment with cadmium resulted in concentration-dependent increases in MT levels and marked decreases in etoposide-induced apoptosis. Zinc pretreatment also resulted in increased MT synthesis and decreased etoposide-induced apoptosis. More importantly, induced MT levels were negatively correlated with sensitivity to etoposide-induced apoptosis (r = -0.965). These suggest that MT may play a role in regulating apoptosis and that modulating MT expression may provide a strategy for altering cellular resistance to chemotherapeutic compounds.

Severe manifestation of acute hepatitis A recently found in Gunma, Japan

BACKGROUND

The incidence of acute hepatitis A infection in Japan peaked 10 years ago and has been decreasing since then. However, an increase in severe cases of the disease has been documented recently. We experienced an outbreak in 1998-1999, and compared the clinical features of the disease in 1998-1999 (recent outbreak) and in 1987-1988 (past outbreak) in our prefecture (Gunma).

METHODS

Forty patients with acute hepatitis A were admitted to nine Gunma hospitals from October 1998 to September 1999. Their clinical features were compared with those of 100 patients with acute hepatitis A admitted to the same hospitals in 1987-1988.

RESULTS

Both outbreaks occurred mostly during the winter-spring season. Secondary familial infection was significantly decreased in the recent outbreak. Patients in the recent outbreak were 7 years older than those in the past outbreak. Laboratory findings, such as serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels and prothrombin time, were worse in the recent than in the past outbreak. Severe-type hepatitis and fulminant hepatitis occurred in 5 patients (12.5%) in the recent outbreak but in only 2 patients (2.0%) in the past outbreak.

CONCLUSIONS

Clinical data and manifestations were more severe in the recent outbreak than in the past outbreak of acute hepatitis A. It is important to be aware of hepatitis A virus infection and to take into account the available vaccination against hepatitis A virus in Japan.

Simple liver cyst with spontaneous regression

We report a-55-year-old woman with spontaneous regression of simple liver cyst. The size of the cyst gradually became reduced without any treatment, and a reduction in diameter from 77 mm to 10 mm was observed after 8 years of follow-up. Spontaneous regression of congenital cysts of the liver in an adult seems to be very rare, and its mechanism is discussed.

Induction of apoptosis in cells by cadmium: quantitative negative correlation between basal or induced metallothionein concentration and apoptotic rate

Metallothionein (MT) often reduces the adverse effects of cadmium (Cd), but how it may alter Cd-induced apoptosis is unclear. The goal of this study was to define the role of MT in Cd-induced apoptosis using cell lines with widely varying sensitivity to Cd. Effects of Cd on growth of human hepatocellular carcinoma cell lines (HepG2 and PLC/PRF/5) were investigated and compared with Chang cells. These cells were cultured with 0, 5, 10, 20, 40, 80, and 120 microM of Cd for 3, 6, 12, and 24 h. Significant cytolethality was observed in HepG2 and PLC/PRF/5 cells in a time- and concentration-dependent manner, with LC(50) values of 24 microM and 13 microM, respectively. However, Chang cells were much less sensitive to Cd-induced cytotoxicity (LC(50), 64 microM). Apoptotic cell death occurring at cytolethal concentrations was demonstrated in all cell lines by DNA fragmentation on agarose gel electrophoresis or by ELISA. When MT was measured, there was a highly significant negative linear correlation between the basal cellular MT concentration or Cd-induced MT and the rate of apoptosis induced by Cd in these cell lines. Treating HepG2 cells with zinc (Zn) made the relatively sensitive HepG2 cell line resistant to Cd-induced apoptosis, likely due to Zn-induced MT. In fact, there was also a significant negative linear correlation between the amount of Zn-induced MT in HepG2 cells and the rate of Cd-induced apoptosis. These findings revealed that basal or induced MT perturbs Cd-induced apoptotic cell death in various cell lines, and a strong negative correlation exists between cellular MT content and the rate of apoptosis induced by Cd.

Prevalence of hepatitis G virus in liver disease

The prevalence of hepatitis G virus (HGV) in liver disease of non-A, -B, -C viral hepatitis, hepatitis B and hepatitis C was determined. Two of 44 patients (4.5%) with liver injury without any hepatitis A, B or C marker were positive for HGV. One of five cases of hepatocellular carcinoma was positive for HGV. One of three cases with fulminant hepatitis was positive for HGV. This case was negative at the onset of fulminant hepatitis and became positive after plasmapheresis. No patient with acute (n=8) or chronic (n=5) hepatitis or liver cirrhosis (n=8) was positive for HGV in non-A, -B, -C liver disease. One of 30 patients with various HBV-positive liver diseases and nine (17.3) of 52 patients with type C liver disease were positive for HGV. In patients with hepatitis C, four (28.6%) of 14 HGV-co-infected patients were complicated with diabetes mellitus compared with four (10.5%) of 38 single hepatitis C virus (HCV)-infected patients (not significant). In 12 HGV-positive patients, eight of 10 (80%) had a history of blood transfusion. In HCV-positive patients, co-infection with HGV was not a risk factor in patients with diabetes mellitus as a complication. HGV appeared to cause non-A, -B, -C hepatitis rarely, and its main route of infection was blood transfusion.

Quantitative analysis of hepatitis B virus precore mutant in hepatitis type B

Active liver disease has been detected in chronic hepatitis B after seroconversion from positive HBe antigen to positive anti-HBe antibody. Active replication of HB virus (HBV) containing a precore stop-codon mutation has been implicated in this condition. The usual methods, such as direct sequencing, to characterize the responsible mutant of HBV are not suitable for routine clinical use. Here we employed the competitive mutation site specific assay (CMSSA) to detect precore mutant HBV-DNA in patients with positive HB surface antigen. In patients with HBe antigen, precore mutant HBV-DNA was significantly higher than in patients with HBe antibody. The level of precore mutant HBV-DNA in patients with elevated serum ALT was significantly higher than in patients with normal serum ALT. Sex, age and the level of serum HBV-associated DNA polymerase levels were not correlated with levels of precore mutant HBV-DNA. Ten of 11 negative patients for the precore mutant by polymerase chain reaction followed by restriction fragment length polymorphism assay (PCRRFLP) were positive for the precore mutant by CMSSA. These results suggest that the precore mutant has already emerged in the HBeAg-positive phase as determined by CMSSA, which is more sensitive than PCR-RFLP and is useful for evaluating the clinical course of patients with chronic hepatitis B.

Accidental transmission of HCV and treatment with interferon

Accidental transmission of contagious pathogens, especially hepatitis C virus (HCV), by needlestick or other means as an occupational hazard for medical staff is of concern. We retrospectively analysed cases of work-related accidental injury with pathogens such as hepatitis B virus (HBV), HCV, syphilis and human immunodeficiency virus (HIV) reported to the centres for disease control at 15 hospitals (total 5776 beds) in the Gunma prefecture, Japan, from December 1990 to August 1993 (24.7 months). There were 416 such cases (16.8 cases/month), with an incidence of 0.2-3.5 accidents per month per hospital. Such accidents occurred in 297 (71.2%) nurses, 98 (23.5%) medical doctors, 13 (3%) laboratory technicians, four (1.0%) hospital maintenance workers, one (0.2%) assistant nurse, one secretary and two others. There were 323 (77.6%) injuries caused by needlestick, 42 (10.1%) from suture needles or surgical knife cuts, 17 (4.1%) from blood splatters from patients into the eyes or mouth, 10 (2.4%) from contact with injured skin and 24 (5.8%) simple skin contacts. Of the pathogens, 60.3% were HCV, 22.6% HBV, 5.8% syphilis, 0.7% HIV and 10.6% were of unknown origin. Four cases (1.6%) of HCV infection were found and treated with one or two courses of interferon therapy, and HCV was subsequently cleared. All four patients were cured with interferon therapy. None of the HBV-injured cases resulted in infection, possibly because of prophylaxis with HB immunoglobulin and HB vaccine. No HIV or syphilis infection was contracted. In summary, chronic HCV infection acquired as an occupational hazard can be cured by appropriate treatment, such as with interferon, after early detection of the infection.

Prediction of effect of interferon on chronic hepatitis C

Clinical, pathological, and virological analysis including hypervariable region-1 of hepatitis C virus (HCV) was performed to predict the effect of interferon (IFN) on 41 patients with chronic hepatitis type C. The low virus load, low frequency of the mutation in the hypervariable region-1 as the change of amino acid and high level of serum aminotransferase make one estimate the good effect of IFN on patients with HCV. Mutation in the hypervariable region-1 of HCV measured by fast assay fluorescence single-stranded conformational polymorphism was more frequent in nonresponders to IFN than responders. The most frequently mutated position was amino acid number 406. This indicates that the specific mutation site might affect the response of IFN.

The possible role of zinc and metallothionein in the liver on the therapeutic effect of IFN-alpha to hepatitis C patients

We have studies zinc deficiency in hepatitis C patients (complete responder [CR] 22, nonresponder [NR] 25) with relation to the therapeutic effect of interferon-alpha (IFN-alpha). Circadian variations in serum zinc levels were high in the morning (basal level) and then gradually decreased during the day in both chronic hepatitis C patients and healthy controls. Basal zinc levels in serum were significantly lower in chronic hepatitis C patients (73 +/- 3 micrograms/dL, n = 12) than in controls (93 +/- 5 micrograms/dL). An injection of 10 MU of IFN-alpha to hepatitis C patients augmented the serum zinc reductions, up to 40% in 8 h. Serum cortisol levels were significantly elevated 8 h (25.6 +/- 2.3 micrograms/dL) after IFN-alpha dose. Forty-seven chronic hepatitis C patients were treated with IFN-alpha for 24 wk, and serum zinc and copper levels were determined 12 and 24 wk during and after the completion of IFN-alpha therapy. Serum zinc levels and zinc/copper ratio were higher in CRs than in NRs to IFN therapy at each time-point. Hepatic metallothionein staining became prominent after IFN therapy in most of CRs, whereas it diminished NRs. These data suggest that nutritional status of zinc influences the effect of IFN on hepatitis C patients.

Hepatocellular carcinoma with pleural metastasis complicated by hemothorax

Hemothorax can be caused by rupture of hepatocellular carcinoma (HCC). Hemoperitoneum is a well-known cause of death caused by rupture of a primary HCC lesion. Rupture of a HCC metastasis has not been adequately described. This is the first report of a HCC patient who died of hemothorax due to rupture of a pleural metastasis. The patient, a woman, died in respiratory failure 2 wk after rupture of her HCC metastasis in the pleura. Autopsy revealed moderately differentiated HCC in the liver, lung, and pleura. We discuss treatment options for ruptured pleura-based HCC metastases.

Increased formation of oxidative DNA damage, 8-hydroxydeoxyguanosine, in human livers with chronic hepatitis

8-Hydroxydeoxyguanosine (oh8dG) is a promutagenic DNA lesion produced by oxygen radicals. We examined alterations in the oh8dG level in human livers which have chronic hepatitis, liver cirrhosis, and hepatocellular carcinoma. The oh8dG content in livers with chronic hepatitis was significantly higher than the oh8dG content in normal livers (P < 0.05). There was also a significant correlation between the oh8dG content in noncancerous liver tissues with individual serum alanine aminotransferase concentration (r = 0.515; P < 0.001). Thus, chronic inflammation in the liver produces oxidative DNA damage, which may increase the risk for genomic alterations causing hepatocarcinogenesis.

Evaluation of the therapeutic effect of TAE on primary liver cancer

The therapeutic effect of transcatheter arterial chemoembolization (TAE) performed on 31 patients with primary liver cancer was evaluated using the following procedures: (1) the alpha-fetoprotein (AFP) reduction rates and prognoses were analyzed according to the tumor reduction rates (TR), and (2) the AFP reduction rates and prognoses were also analyzed according to the tumor necrosis rates (TN) estimated by regarding every region with Lipiodol retention as being necrotic. The following results were obtained. The AFP level was 400 ng/ml or higher in 15 patients (48%). Their AFP reduction rates were as favorably high as 65.4%-99.8% (mean, 88.1%), and the AFP level was normalized in 3 patients. The cumulative survival rates after the initial treatment were relatively high, i.e., 78.4% in the 1st year, 58.1% in the 2nd year, and 38.7% in the 3rd year. These results suggested the effectiveness of the TAE treatment undertaken in this study. Regarding the TR, the tumor was reduced in size by 50% or more in only 5 patients (16%), and most patients had a TR of less than 25%. On the other hand, the majority, 25 patients (81%), had a TN ranging between 50% and less than 100%, including 7 who had a TN ranging between 50% and less than 90% and 18 who had a TN ranging between 90% and less than 100%. There was no significant correlation between the AFP reduction rate and the TN or TR. Regarding evaluation of the cumulative survival rates by TR and TN, the 1-year survival rate was lower in patients having a TR of less than 25% than in those having a TR of 25% or more. Patients having a TN of less than 50% showed a poor outcome as compared with those having a TN of 50% or more. Although the TR was found to be less than 50% in a majority of the patients when the therapeutic effect of TAE on the liver cancer was evaluated according to the TR, many of these patients showed a good outcome. Thus, the conventional efficacy evaluation, in which a tumor reduction of 50% or more is considered to be effective, should be reconsidered. On the other hand, the TN was found to be 50% or more in most of the patients, suggesting the necessity of a more detailed classification of TN. In relation to the survival rate, patients having a TN of less than 50% showed a poor outcome.