C-reactive Protein Can Predict Patients with Cirrhosis at a High Risk of Early Mortality after Acute Esophageal Variceal Bleeding

Objective The aim of this study was to identify patients with a high risk of early mortality after acute esophageal variceal bleeding by measuring the C-reactive protein (CRP) level. Methods We retrospectively evaluated 154 consecutive cirrhotic patients admitted with acute esophageal variceal bleeding. Differences between categorical variables were assessed by the chi-square test. Continuous variables were compared using the Mann-Whitney U-test. Multivariate logistic regression analyses consisting of clinical laboratory parameters were performed to identify risk factors associated with the 6-week mortality. The discriminative ability and the best cut-off value were assessed by a receiver-operating characteristic (ROC) curve analysis. Results Child-Pugh C patients showed a significantly higher 6-week mortality than Child-Pugh A or B patients (38% vs. 6%, p<0.0001). The 6-week mortality in Child-Pugh C patients was associated with the age (p<0.0001), etiology of cirrhosis (p=0.003), hepatocellular carcinoma (p=0.0003), portal vein thrombosis (p=0.005), baseline creatinine (p=0.0001), albumin (p=0.001), white blood cell count (p=0.038), baseline CRP [p=0.0004; area under the ROC (AUROC)=0.765; optimum cut-off value at 1.30 mg/dL] and bacterial infection (p=0.019). We determined that CRP ≥1.30 mg/dL was an independent predictor for 6-week mortality in Child-Pugh C patients [odds ratio (OR)=8.789; 95% confidence interval (CI): 2.080-47.496; p=0.003], along with a creatinine level of 0.71 mg/dL (OR=17.628; 95% CI: 2.349-384.426; p=0.004) (73% mortality if CRP ≥1.30 mg/dL vs. 19% if CRP<1.30 mg/dL, p<0.0001). Conclusion In Child-Pugh C patients with esophageal variceal bleeding, a baseline CRP ≥1.30 mg/dL can help identify patients with an increased risk of mortality.

Early Prediction of the Outcome Using Tumor Markers and mRECIST in Unresectable Hepatocellular Carcinoma Patients Who Underwent Transarterial Chemoembolization

OBJECTIVE

We examined early predictors of the outcome in hepatocellular carcinoma (HCC) patients after transarterial chemoembolization (TACE).

METHODS

We analyzed 116 patients with unresectable HCC treated with initial TACE. α-Fetoprotein (AFP) or des-γ-carboxy prothrombin (DCP) response was assessed in patients who had baseline AFP levels ≥200 ng/ml or DCP ≥60 mAU/ml; a positive response was defined as a reduction of >50% compared to baseline 1 month after TACE.

RESULTS

A baseline AFP level ≥200 ng/ml was associated with a poor overall survival (OS) (29.4 vs. 6.1 months; p <0.0001). AFP response had no significantly prognostic effects on the OS. Conversely, although the baseline DCP did not influence the OS, DCP responders showed a significantly better OS than nonresponders (67.0 vs. 19.8 months, p = 0.020). The baseline AFP (p = 0.004) and initial tumor response evaluated by the modified Response Evaluation Criteria in Solid Tumors (mRECIST) (p = 0.012) were found to be independent predictors of the OS. The combination of the baseline AFP and initial assessment by mRECIST allowed stratification of the OS.

CONCLUSIONS

The combination of the baseline AFP level and mRECIST is useful for the early prediction of the OS in HCC patients who underwent TACE.

[Liver injury and hepatic encephalopathy induced by the herbal medicine Hochuekkito]

A 57-year-old man was admitted with pruritus and jaundice following treatment for fatigue with the herbal medicine Hochuekkito. The patient was prescribed prednisolone and ursodeoxycholic acid, but he developed progressive cholestasis that required intravenous methylprednisolone pulse therapy. After treatment with plasma exchange for prolonged prothrombin time, the patient recovered; however, his liver function deteriorated because of liver injury induced by trimethoprim-sulfamethoxazole for pneumocystis pneumonia. After reduction of trimethoprim-sulfamethoxazole, his liver function almost returned to normal by day 130 of admission. It has remained normal for 10 months since then. Therefore, when prescribing Hochuekkito, the possibility of drug-induced liver injury should be taken in account.

Clinicopathological differentiation between sclerosing cholangitis with autoimmune pancreatitis and primary sclerosing cholangitis

BACKGROUND

The present study was undertaken to identify the clinicopathological differences between sclerosing cholangitis with autoimmune pancreatitis (SC-AIP) and primary sclerosing cholangitis (PSC).

METHODS

We retrospectively compared the clinical, cholangiographic, and liver biopsy findings between 24 cases of PSC and 24 cases of SC-AIP.

RESULTS

Patient age at the time of diagnosis was significantly lower in the PSC group than in the SC-AIP group. The peripheral blood eosinophil count was significantly higher in the PSC group than in the SC-AIP group, but the serum IgG4 level was significantly higher in the SC-AIP group. Cholangiography revealed band-like strictures, beaded appearance, and pruned-tree appearance significantly more frequently in PSC, whereas segmental strictures and strictures of the distal third of the common bile duct were significantly more common in SC-AIP. Liver biopsy revealed fibrous obliterative cholangitis only in the PSC specimens. No advanced fibrous change corresponding to Ludwig's stages 3 and 4 was observed in any of the SC-AIP specimens. IgG4-positive plasma cell infiltration of the liver was significantly more severe in SC-AIP than in PSC. Subsequent cholangiography showed no improvement in any of the PSC cases, but all SC-AIP patients responded to steroid therapy, and improvement in the strictures was observed cholangio-graphically.

CONCLUSIONS

Based on the differences between the patients' ages and blood chemistry, cholangiographic, and liver biopsy findings, SC-AIP should be differentiated from PSC.

Autoimmune pancreatitis can be classified into early and advanced stages

OBJECTIVES

Although a number of pathological studies using various names/synonyms for autoimmune pancreatitis (AIP) have been reported, they do not mention the pathological staging related to origin/pathogenesis. Here, we propose a pathological staging for AIP lesions.

METHODS

We histopathologically examined pancreatic tissue specimens of 31 AIP patients (14 pancreatectomized and 17 needle-biopsied materials) provided by 15 hospitals in Japan and studied the relevance of clinical manifestations to the pathological stage of AIP.

RESULTS

Based on the presence or absence of acinar cells in AIP lesions, pancreatic tissue specimens were successfully divided into 20 cases in the early stage and 11 cases in the advanced stage, respectively. In the early stage, fibrosis was distributed in the interlobular and intralobular areas, admixed with acinar atrophy. Lymphoplasmacytic infiltration caused the narrowing of the ductal lumen and obliterative phlebitis. The common bile duct wall was also involved. In the advanced stage, the lesion was replaced by massive/extensive interlobular fibrosis with lymphoplasmacytic infiltrates to various degrees. Phlebitis was mild. Comparative analysis of clinical parameters between the early and advanced stages showed a significantly higher prevalence of jaundice and positive antinuclear antibodies in the early stage, and decreased serum lipase levels in the advanced stage.

CONCLUSIONS

Autoimmune pancreatitis can be divided into early and advanced stages according to the presence or absence of acinar cells. Our pathological staging will facilitate understanding and evaluation of the clinical course in AIP.

Prevalence of pancreatic and biliary tract tumors in pancreas divisum

BACKGROUND

The present study was undertaken to evaluate the prevalence of pancreatic and biliary tract tumors in pancreas divisum (PD).

METHODS

A retrospective single-center study was performed, and a total of 118 cases of complete PD and 7850 cases of fused pancreas were identified among the 8537 consecutive new endoscopic retrograde cholangiopancreatography (ERCP) examinations performed between 1980 and 2002. The prevalence of pancreatic cancer (PCA), intraductal papillary mucinous neoplasms (IPMNs), other pancreatic tumors, and biliary tract cancer in the patients with PD and the patients with a fused pancreas were compared.

RESULTS

The prevalence of the pancreatic tumors in the PD patients was: PCA, 10%; IPMN, 5.1%; other pancreatic tumors, 2.5%. The prevalence of pancreatic tumors in the patients with a fused pancreas was: PCA, 4.8%; IPMN, 2.6%; and other pancreatic tumors, 1.1%. The prevalence of PCA was significantly higher in the patients with PD than in those with a fused pancreas (P = 0.008; OR, 2.24). The percentages of PD patients with PCA who had pancreatic-type pain and a serum pancreatic enzyme elevation were significantly higher than among the PD patients without PCA. The prevalence of biliary tract cancer was 0.8% in the PD group and 5.3% in the fused pancreas group, and it was significantly lower in PD than in fused pancreas (P = 0.031).

CONCLUSIONS

The results of this study showed a significantly higher prevalence of PCA in PD than in fused pancreas. We concluded that patients with PD, especially patients presenting with pancreatic-type pain and pancreatic enzyme elevation, should be carefully followed up because of the risk of developing PCA.

Biliary tract involvement in autoimmune pancreatitis

OBJECTIVES

Autoimmune pancreatitis (AIP) is a unique clinical entity that has been recently proposed, and it is frequently associated with bile duct stricture. The aim of this study was to investigate the pathophysiology of the biliary tract involvement in patients with AIP.

METHODS

We evaluated the clinicopathologic findings in 16 patients with AIP. Surgical resection was performed in 7 of the patients because of suspicion of a pancreatic tumor; 8 of the other patients were treated with oral prednisolone (PSL) therapy, and the remaining patient was observed clinically and not treated. The pancreas, bile duct, and gallbladder in the surgical cases were examined histologically and immunohistochemically. We also assessed the clinical manifestations and diagnostic imaging findings before and after oral PSL therapy in the 8 patients treated with PSL.

RESULTS

Stricture of the extrahepatic bile duct was detected in 88% (14/16) of the patients. Thickening of the bile duct wall was detected in 94% (15/16), and thickening of the gallbladder wall was observed in 56% (9/16). Histologically, the bile duct and gallbladder wall were characterized by diffuse lymphoplasmacytic infiltration and marked interstitial fibrosis. Immunohistochemically, the diffusely infiltrating cells consisted of predominantly CD8- or CD4-positive T lymphocytes and IgG4-positive plasma cells. These findings were the same as in the inflammatory process that was observed in the pancreas. After oral PSL therapy, the pancreatic enlargement and irregular narrowing of the main pancreatic duct improved to almost their normal size in all 8 patients; however, stricture of the extrahepatic bile duct persisted in 4 of the patients (57%, 4/7) in whom it was detected before PSL therapy.

CONCLUSIONS

Based on the pathophysiologic and histologic findings and the response to PSL therapy, the biliary involvement in AIP developed by the same mechanism as the pancreatitis. CD8- and CD4-positive lymphocytes and IgG4-positive plasma cells may play an important role in the pathogenesis of AIP.

Multimodality treatments with endoscopic mucosal resection of esophageal squamous cell carcinoma with submucosal invasion

BACKGROUND AND STUDY AIMS

A standard treatment for esophageal squamous cell carcinoma (SCC) with submucosal invasion is considered to be radical resection at present. In this study, we evaluated the efficacy of multimodality treatments with endoscopic mucosal resection (EMR) of esophageal SCC with submucosal invasion.

METHOD

Eighteen cases of SCC with submucosal invasion were treated with EMR. Lymphatic invasion was found in 11 cases (67%), and there were no cases of blood vessel invasion. EMR was performed prior to any other treatment. Chemotherapy and/or radiotherapy were added if indicated by the histopathological features.

RESULTS

There were no cases of local recurrence. Lymph-node recurrence was detected in 1 case treated with EMR alone. There were no cases of cancer death. The overall survival rate was 83% in all patients.

CONCLUSIONS

Multimodality treatments with EMR were effective in treating esophageal SCC with submucosal invasion.

[Reflux esophagitis]

There are some factors which influence reflux esophagitis, in our country atrophic gastritis is important for the degree of it especially. Helicobacter pylori(H.P.) infection is popular in aged patients, so atrophic gastritis is also popular in such patients, then the frequency of reflux esophagitis is low comparing with other countries. But because of the late of H.P. infection comes to be higher and the eradication therapy for the peptic ulcer diseases has been done in these days, the late of atrophic gastritis comes to be lower and reflux esophagitis comes to be higher. In aged patients medication and physical factors influence reflux esophagitis and these factors are different in each patient. So it is very important to treat the patient of reflux esophagitis considering of each factor.

Lifting of lesions during endoscopic mucosal resection (EMR) of early colorectal cancer: implications for the assessment of resectability

BACKGROUND AND STUDY AIMS

This study assessed the indications for and limitations of endoscopic mucosal resection (EMR) for early colorectal cancer, focusing on the way in which the lesion lifts after submucosal injection.

PATIENTS AND METHODS

The study included 94 patients with early colorectal cancer who received EMR treatment. The lifting of the lesion after submucosal injection was analyzed (classified as completely lifted/soft; completely lifted/hard; incompletely lifted; and non-lifted) along with the endoscopic findings, pathological findings, and clinical course.

RESULTS

Almost all completely lifted/soft lesions were mucosal cancers. Some of the completely lifted/hard lesions were staged as sm2. The incompletely lifted lesions included stages sm1 to sm3. Non-lifting lesions were almost always deeper than sm3. The lifting condition was significantly associated with the depth of invasion, and the lesion type was related to the extent of lifting but not to tumor size or recurrent disease. Recurrent disease was noted in three patients who underwent piecemeal EMR.

CONCLUSIONS

The indication for EMR is easily assessed on the basis of the lifting characteristics of the tumor after submucosal injection, which was found to be significantly related to the depth of invasion. The factor limiting the indication for EMR is not the size of a tumor, but its lifting condition.

ERCP imaging

Localization and spread of pancreatic diseases has been a reality since the availability of endoscopic pancreatography in the late 1960s, particularly after development of a fiberscope for this purpose. Endoscopic pancreatography allowed the clinician to discern the position and site of cancers, cysts, and localized inflammations. Ductal anomalies, such as annular pancreas, nonfusion, and anomalous junction of pancreatobiliary connection, were clearly recognized also. The pancreatography opacified the real lumen instead of the virtual images of ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI), so that precise studies comparing histopathologic details could be performed. The pancreatic ductal information visualized by using the fiberscope changed our understanding of chronic inflammation of the pancreas. Chronic diffuse pancreatitis, upstream pancreatitis, ductitis, and duct-narrowing pancreatitis were specified from their pathogenetic differences. Although the noninvasive methods such as US and CT will be the first choice for the diagnosis of pancreatic diseases, pancreatography will still be important for the morphologic studies of the pancreas in various disease conditions.

[Portal hemodynamic changes from TIPS--evaluation with pulse Doppler method]

Transjugular intrahepatic portosystemic shunt (TIPS) was applied in three patients with Child C liver cirrhosis. Portal venous pressure was reduced by an average of 10.7 mmHg, and results such as the disappearance of esophageal varices and reduction in ascites were obtained. The portal hemodynamics of these three patients was observed before and after TIPS using the pulse Doppler method. When portal hemodynamics in the main portal vein was examined before TIPS, it was found that the mean blood flow velocity had decreased, the blood flow volume was reduced and the cross-sectional area of the vein had increased. The congestion index was high and there was definite congestion of the portal venous system. After TIPS, the blood flow velocity and volume increased, the cross-sectional area of the vein was reduced and the congestion index was lower. Congestion of the portal venous system was improved in these three patients and the clinical efficacy of TIPS was proven by these results. If the stent can be detected sonographically, stent patency is easily confirmed with the pulse Doppler method which is usefull examination technique for follow-up of patients undergoing TIPS.

[Diagnosis of cholelithiasis--endoscopic pancreatocholangiography]

Endoscopic cholangiography is fundamentally evaluated as X-ray anatomy of the biliary system as well as the principal technique for endoscopic treatments that is endoscopic papillotomy and endoscopic drainage, while gallstone is routinely diagnosed by ultrasonography in medical practice. By endoscopic cholangiography, stones in the cystic duct and the common bile duct are confirmedly diagnosed in the same quality as gallbladder stones, and the anatomical information of the cystic duct, the gallbladder, and the duodenal papilla are clearly demonstrated, which are required in many therapeutic procedures for gallstones diseases including laparoscopic cholecystectomy.

Technical guidance of endoscopic pancreatocholangiography

Endoscopic pancreatocholangiography, frequently abbreviated as ERCP, is an X-ray examination of the pancreatic and biliary ducts cannulating the duodenal papilla using the fiberscope. This procedure is the only clinical examination of the pancreatic duct, and is an indispensable technique for endoscopic treatments and further investigations: endoscopic papillotomy, drainage, lithotomy, endoprothesis, pancreatoscopy, and collection and cytology of pure juice. For this examination, a skill in endoscopy is required, and the understanding of the papilla orifice, which consists of prolapsed ampullar folds in the living body, is essential. The catheter should be inserted straight toward the individual duct: the pancreatic and the biliary duct. As ultrasonography and computed tomography are advanced, the clinical roll of ERCP should be reevaluated. However, the pancreatography expresses exactly the ductal pathology, which is reflected by the background pathology of the pancreas: chronic pancreatitis, nonfusion, pancreatobiliary maljunction, small cancerous, mucous-producing tumors, and cystic lesions.

[Non-fusion of the ventral and dorsal pancreatic ducts]

Non-fusion of the ventral and dorsal pancreatic ducts is an anomaly of the ductal system of the pancreas; no connection between the ventral and the dorsal pancreatic ducts. The pancreas, however, keeps normal shape examined by US, CT, and laparotomy. The dorsal pancreatography through the accessory papilla is essential in diagnosis of non-fusion, because the short pancreatic duct through the main papilla is sometimes observed in chronic pancreatitis, anomalous defect of the distal pancreas, pancreatic cancer, and cyst. The 30 cases of the non-fusion were experienced in our institute which were all confirmed by dorsal pancreatography; they were nearly half of the confirmed cases in Japan. The incidence is 0.5% in about 6000 endoscopic pancreatographies during 1969-1984. The age distribution is 25-79 year-old, the average 44.7, and 19 cases are male and 11 female. The pancreatitis-like pain is frequently observed in cases with non-fusion. The 13 cases, 43%, in our series complained of pancreatic pain (called P-group), but the other 17 did not (called non-P group). The age distribution, sex, and the incidence of alcohol intake, DM, gallstone diseases, however, are not different between these two groups. The figure of the ventral pancreatic duct was not characteristic in both groups. The obvious chronic pancreatitis (chronic dorsal pancreatitis) is only two even in P-group and none in non-P group. The pancreatitis-like pain may be occurred by the reason why the functionally lesser accessory papilla which is an only out-left of the larger dorsal pancreas in non-fusion could not adapt the over-load for the pancreas, for example by alcohol. The non-fusion of the pancreatic duct system is not a direct cause of pancreatitis but might be a disposition of it.

[Carcinoembryonic antigen (CEA), serum amylase and pancreozymin-secretin test in relation to stages of pancreatic cancer]

In cases of surgically proved pancreatic carcinoma, preoperative values of serum CEA, serum amylase and pancreozymin-secretin test (PST) were seen if they related to the macroscopic stages of the tumor determined by "General Rules for Surgical and Pathological Studies on Cancer of Pancreas" offered by Japanese Pancreatic Society in April 1982. Serum CEA was determined in 43 cases, serum amylase in 34 cases and PST was done in 28 cases. All of CEA, amylase and PST showed no statistically significant relationship to the stages of the carcinoma. This may suggest that these tests may not be a useful indicator of the stage of tumor.

Remote contrast injector in ERCP for protection from X-ray exposure

To protect the assistants from radiation during ERCP, a remote contrast injector employing a lever mechanism (push lever type) was developed. Using this remote injector, safe, finely controlled and easy injection of the contrast material was achieved without X-ray exposure to the assistants in ERCP.

Lipase activity in blood following endoscopic pancreatography: demonstration of its pancreatic origin and existence of ductal or acino-venous pathways in man

The presence of a lipase activity has been observed in the blood of patients undergoing an endoscopic retrograde cholangio-pancreatography (ERCP). The identity between this serum lipase and pancreatic lipase has been demonstrated by their similarity in in chromatographic, immunological, and catalytic properties. Lipase activity in serum increased when pancreatography was accompanied by a passage of the contrast medium to the kidney demonstrating the presence of ductal or acino-venous pathways in man.