Hemochromatosis and Hepatocellular Carcinoma Secondary to Immunoglobulin G4-Related Disease with Hepatopathy: A Case Report

Immunoglobulin G4-related disease (IgG4-RD) is a recently characterized illness in which lymphocytes and plasma cells infiltrate various anatomical sites. IgG4-hepatopathy, a manifestation of IgG4-RD, is a broader term covering various patterns of liver injury. The clinical course, including the malignant potential of IgG4-RD, remains unclear. Here we report the first case of secondary hemochromatosis and hepatocellular carcinoma (HCC) developing from IgG4-hepatopathy. A 67-year-old man was admitted to our hospital for treatment of deteriorating glucose tolerance. Blood test results showed hypergammaglobulinemia, especially IgG4. He was readmitted 2 months later with dyspnea due to lung disease and pleural effusion, and elevated transaminase levels. He underwent liver and lung biopsies. IgG4-RD was diagnosed and he was treated with steroid therapy, which improved serum IgG4 levels and imaging abnormalities. A follow-up computed tomography (CT) scan conducted 38 months later revealed a tumor (diameter, 50 mm) in liver segments 7 and 8. The resected specimen revealed HCC and abundant siderosis in the background liver, indicating a diagnosis of hemochromatosis. IgG4-positive cells were scarce, probably because of corticosteroid therapy. In the present case, IgG4-RD was well controlled with prednisolone (PSL) and an immunosuppressive agent, and chronic hepatitis was not severe, even though the patient subsequently developed HCC. However, extensive siderosis consistent with hemochromatosis was unexpectedly noted. These findings suggest that secondary hemochromatosis and HCC developed during IgG4-RD with hepatopathy. We believe this case sheds light on IgG4-RD.

Sequencing and bioinformatics-based analyses of the microRNA transcriptome in hepatitis B-related hepatocellular carcinoma

MicroRNAs (miRNAs) participate in crucial biological processes, and it is now evident that miRNA alterations are involved in the progression of human cancers. Recent studies on miRNA profiling performed with cloning suggest that sequencing is useful for the detection of novel miRNAs, modifications, and precise compositions and that miRNA expression levels calculated by clone count are reproducible. Here we focus on sequencing of miRNA to obtain a comprehensive profile and characterization of these transcriptomes as they relate to human liver. Sequencing using 454 sequencing and conventional cloning from 22 pair of HCC and adjacent normal liver (ANL) and 3 HCC cell lines identified reliable reads of more than 314000 miRNAs from HCC and more than 268000 from ANL for registered human miRNAs. Computational bioinformatics identified 7 novel miRNAs with high conservation, 15 novel opposite miRNAs, and 3 novel antisense miRNAs. Moreover sequencing can detect miRNA modifications including adenosine-to-inosine editing in miR-376 families. Expression profiling using clone count analysis was used to identify miRNAs that are expressed aberrantly in liver cancer including miR-122, miR-21, and miR-34a. Furthermore, sequencing-based miRNA clustering, but not individual miRNA, detects high risk patients who have high potentials for early tumor recurrence after liver surgery (P = 0.006), and which is the only significant variable among pathological and clinical and variables (P = 0,022). We believe that the combination of sequencing and bioinformatics will accelerate the discovery of novel miRNAs and biomarkers involved in human liver cancer.

Identification of obstructive jaundice-related microRNAs in mouse liver

BACKGROUND/AIMS

Although microRNAs are known to be post-transcriptional regulators in physiological and pathological events in the liver, their role in the obstructive jaundice liver remains unclear.

METHODOLOGY

We sequenced the small RNA libraries of the bile duct ligation (BDL) mouse liver to detect the in vivo microRNA expression profiles of obstructive jaundice. We also validated the differential expression of microRNAs in the BDL liver using real-time PCR. Laser microdissection was performed to identify the origin of BDL-related microRNAs. An IL6-treated normal intrahepatic biliary epithelial cell line was used as an in vitro model of obstructive jaundice.

RESULTS

We found microRNAs that were upregulated in the BDL liver (let-7a, let-7d, let-7f, let-7g, miR-21, miR-125a-5p, miR-125b-5p, miR-194, miR-199a-3p, miR-199a-5p, miR-214, miR-221, and miR-486). Furthermore, laser-microdissection analysis showed that miR-199a-5p was significantly upregulated in the intrahepatic bile duct of the BDL liver. The in vitro expression of miR-199a-5p was appreciably elevated in accordance with increased proliferation of IL6-treated cells.

CONCLUSIONS

We revealed dynamic changes in microRNA expression during obstructive jaundice using the BDL model. MiR-199a-5p was likely associated with the proliferation of intrahepatic bile ducts. Our data will facilitate further study of the pathophysiological role(s) of microRNAs in the obstructive jaundice liver.

MicroRNA profiling of human intrahepatic cholangiocarcinoma cell lines reveals biliary epithelial cell-specific microRNAs

Intrahepatic cholangiocarcinoma (ICC), which arises in the small bile ducts of the liver, is the second most common liver malignancy. Although modulation of microRNA (miRNA) expression has been shown to be a potent sign of malignant tumors, miRNA profiles of ICC remains unclear. We performed sequencing analysis of the small RNA libraries of 2 ICC cell lines (HuCCT1 and MEC) and one normal intrahepatic biliary epithelial cell line (HIBEpiC) to produce the miRNA profiles of ICC in vitro. Furthermore, by means of the real-time polymerase chain reaction (PCR) we validated the differential expression of miRNAs cloned exclusively or predominantly from each of the cell lines. A total of 35,759 small RNA clones were obtained from the 3 cell lines. We identified 27 miRNAs that were expressed exclusively or predominantly in each cell line. Subsequent validation with the real-time PCR confirmed that the miRNAs hsa-miR-22, -125a, -127, -199a, -199a*, -214, -376a, and -424 were expressed specifically in HIBEpiC but were downregulated in the ICC cell lines. Our study provides important information for facilitating studies of the functional role(s) of miRNAs in carcinogenesis of the hepatobiliary system. The biliary epithelial cell-specific miRNAs identified in this study may serve as potential biomarkers for ICC.

Diagnosis and initial management of cholangiocarcinoma with obstructive jaundice

Cholangiocarcinoma is the second most common primary hepatic cancer. Despite advances in diagnostic techniques during the past decade, cholangiocarcinoma is usually encountered at an advanced stage. In this review, we describe the classification, diagnosis, and initial management of cholangiocarcinoma with obstructive jaundice.

Features and choice of treatment of acute and chronic pancreatic pseudocysts--with special reference to invasive intervention

AIMS

It was the aim of this study to characterize the features of acute and chronic pancreatic pseudocysts (PPs) and to identify the factors predictive of the need for invasive treatment.

METHODS

Thirty-six patients with PPs treated at Nippon Medical School between January 1995 and December 2004 were studied retrospectively. The cases were divided into 4 groups based on 4 features: association with acute pancreatitis, association with chronic pancreatitis, spontaneous resolution, and persistent symptoms requiring therapeutic intervention. Group 1 included 9 patients with acute PPs which resolved spontaneously. Group 2 included 9 patients with acute PPs with persistent symptoms or associated complications requiring interventional treatment. Group 3 included 9 patients with chronic PPs which resolved spontaneously, and group 4 included 9 patients with chronic PPs with persistent symptoms or associated complications requiring interventional treatment.

RESULTS

Among the 36 patients, 13 were women and 23 were men. The etiologies were pancreatitis due to alcoholism in 18 cases (50.0%), biliary tract disease in 8 cases (22.2%) and other conditions in 10 cases (27.8%). The average duration of follow-up was 24.2 +/- 18.5 months. The patients in group 1 were significantly older than those in group 2 (67.6 +/- 16.1 vs. 40.6 +/- 14.1 years; p = 0.011). The mean size of the PPs was significantly larger in groups 1 and 4 than in group 3 (p < 0.05) and significantly larger in group 2 than in group 4 (p < 0.05). There were no significant differences between groups 1 and 2 in the size of the PPs or in the Ranson score of previous pancreatitis. The increase in size of the PPs during follow-up in each of the spontaneously resolved groups (groups 1 and 3) differed significantly from that in each of the interventional treatment groups (groups 2 and 4; p < 0.05). The main cause of the acute pancreatitis in group 1 was biliary tract disease, while that in group 2 was alcoholism (significantly different, p < 0.05). The number of patients with symptoms related to pseudocysts at the time of diagnosis was significantly higher in group 1 than in group 3.

CONCLUSIONS

Growth of the PPs during follow-up is the strongest predictor of the need for invasive treatment in both acute and chronic cases. Among acute PPs, the size of the pseudocyst is not in itself a predictor of invasive treatment. Invasive treatment may pose higher risks for pseudocysts with an etiology of alcoholic acute pancreatitis. However, the size of the pseudocyst may be a more important prognostic factor than an etiology of pancreatitis. and IAP.

Occult gallbladder carcinoma after laparoscopic cholecystectomy: a report of four cases

Eighty-four patients underwent laparoscopic cholecystectomy (LC) from January through August 2006. Of these patients, 4 (4.7%) were found to have occult gallbladder carcinoma (GC) either during or after the procedure. Two of the patients were women and 2 were men. The mean age was 75.0 years. One patient had mucosal tumors, 2 had subserosal tumors, and 1 had a serosal lesion. One of the 2 patients with subserosal tumors underwent radical surgery. In a previous study, 0.83% (10 of 1,195) of patients who had undergone LC were found to have occult GC, either during of after the procedure. The prevalence of gallbladder carcinoma has recently been increasing. GC has been reported in 0.3% to 1.5% of patients who have undergone cholecystectomy. Since the introduction of laparoscopic surgery, the number of cholecystectomies being performed has increased, which may explain why occult GC seems to be occurring more frequently. The prognosis for GC is poor, and surgical resection is the only potentially curative treatment. However, GC is difficult to diagnose at an early stage and difficult to recognize even in the advanced stages. Fifteen percent to 30% of patients show no preoperative or intraoperative evidence of malignancy. Occult GC is also increasing. Because flat infiltrating GC and GC with cholecystitis and numerous stones are difficult to diagnose preoperatively, we recommend taking frozen sections from patients who are of advanced age (older than 70 years), have a long history of stones, or have a thickened gallbladder wall.

Successful transjugular balloon dilatation of the hepatic vein stenosis causing hypoalbuminemia after pediatric living-donor liver transplantation

Hepatic vein (HV) stenosis after liver transplantation is a rare but life-threatening complication that leads to graft loss. The incidence of HV stenosis after living-donor liver transplantation (LDLT) and split liver transplantation is not so rare, and is reported to range from 2 to 8.6%. Recently, the minimal invasiveness of radiologic interventions and the innovative techniques have led to their widespread adoption for the treatment of various complications after liver transplantation. We report a five-year-old boy with HV stenosis post-LDLT with only scarcity of clinical information including edema with hypoalbuminemia and elevated hyaluronic acid value. Doppler ultrasonography was effective to suggest stenosis, and angiography confirmed its diagnosis. The stenosis was successfully treated with balloon dilatation using interventional radiologic technique through the jugular vein. In conclusion, we suggest that if liver transplanted patients manifest ascites or/and edema with hypoalbuminemia and elevated hyaluronic acid in sera, HV stenosis should be suspected even if the other laboratory values are normal.

Successful percutaneous ultrasound-guided drainage for treatment of a splenic abscess

We report a case of splenic abscess that was successfully treated with percutaneous ultrasound-guided drainage and without splenectomy. A 40-year-old woman was admitted to Nippon Medical School Hospital because of pyrexia and left upper quadrant pain, which had persisted despite antibiotic treatment. On admission, computed tomography demonstrated a low-density area in the spleen, which had been been seen on computed tomography 3 months earlier. Ultrasonography demonstrated a hypoechoic area in the spleen. Initial laboratory tests revealed a serum C-reactive protein concentration of 19.7 mg/dl and a white blood cell count of 15,800 /microl. The serum glucose concentration was 267 mg/dl, and the glycolated hemoglobin value was 7.7%. A splenic abscess was diagnosed and was treated with percutaneous drainage. Milky yellow fluid was obtained, and the patients left upper quadrant abdominal pain and pyrexia resolved. A culture of the drainage fluid yielded Escherichia coli. The drainage catheter was removed 12 days after insertion. The patient was discharged 6 days later. The splenic abscess has not recurred during 3 months of follow-up. Our results suggest that ultrasound-guided percutaneous drainage is a safe and effective alternative to surgery for the treatment of splenic abscess and allows preservation of the spleen.

Fixation of the greater omentum for prevention of delayed gastric emptying after left hepatectomy with lymphadenectomy for cholangiocarcinoma

BACKGROUND/PURPOSE

Delayed gastric emptying (DGE) sometimes occurs after left hepatectomy with lymphadenectomy. We performed fixation of the greater omentum to the peritoneum to prevent DGE and other complications in patients undergoing left hepatectomy with lymphadenectomy for cholangiocarcinoma.

METHODS

Patients undergoing left hepatectomy with lymphadenectomy for cholangiocarcinoma were divided into a fixation group (n = 9) and a nonfixation group (n = 10). In the fixation group, the greater omentum was sutured to the peritoneum 3 cm from the greater curvature of the stomach to prevent contact between the stomach and the cut surface of the liver.

RESULTS

Mean age, sex, disease, and hepatectomy procedures were similar in the two groups. DGE developed in six patients in the nonfixation group (60.0%) versus no patients in the fixation group (P = 0.011). The total number of complications was higher in the nonfixation group (16 complications) than in the fixation group (3 complications; P = 0.003). Overall morbidity was higher in the nonfixation group (60.0%) than in the fixation group (22.2%). Postoperative hospitalization was longer in the nonfixation group (67.4 days) than in the fixation group (20.2 days; P = 0.0041).

CONCLUSIONS

Fixation of the greater omentum to the peritoneum decreases the occurrence of DGE and other complications after left hepatectomy with lymphadenectomy for cholangiocarcinoma.

Usefulness of laparoscopic hepatectomy

BACKGROUND

The aim of this study was to investigate the advantages of laparoscopic hepatectomy over open surgery for liver tumors.

PATIENTS AND METHOD

A retrospective study was performed of 10 patients with liver tumors (9 with hepatocellular carcinoma and 1 with focal nodular hyperplasia) at our hospital. Five patients who had received laparoscopic hepatectomy (Lap-Hx group) were compared with 5 patients who had undergone open hepatectomy (O-Hx group) in the same period. The operative procedure was partial hepatectomy and cholecystectomy in both groups. For liver excision, a microwave coagulation device and an ultrasonically activated scalpel were used.

RESULTS

Mean patient age was 55.6 +/- 13.9 years in the Lap-Hx group and 51.8 +/- 14.1 years in the O-Hx group. Four patients in the Lap-Hx group had hepatocellular carcinoma with liver cirrhosis and 1 patient had focal nodular hyperplasia. All patients in the O-Hx group had hepatocellular carcinoma and 4 patients had associated liver cirrhosis. The mean tumor size was 2.6 +/- 1.5 cm in the Lap-Hx group and 3.0 +/- 1.8 cm in the O-Hx group. The two groups did not thus differ significantly in the preoperative background factors. Blood loss and duration of the postoperative hospital stay were significantly less in the Lap-Hx than in the O-Hx groups(213 +/- 82 vs 247 +/- 97 min; 154 +/- 128 vs 648 +/- 468 ml, p=0.05: and 10.4 +/- 2.3 vs 18.0 +/- 5.1 days, p=0.017), but operating time did not differ significantly.

CONCLUSIONS

Laparoscopic hepatectomy has the advantages of reducing the amount of operative blood loss because of the magnified view afforded by the laparoscope and shortening the hospital stay. The procedure is therefore recommended for patients with appropriate liver tumors, in particular, hepatocellular carcinoma in the cirrhotic liver.

Mucin-producing bile duct carcinoma arising from primary sclerosing cholangitis: a case report

A 60-year-old woman with primary sclerosing cholangitis (PSC) and high levels of ALP, gamma-GTP, and DUPAN-2 was admitted to our institution for examination. The patient did not have ulcerative colitis or pancreatic intraductal papillary mucinous neoplasm. Imaging studies revealed atypical dilation of bile ducts in the left lobe of the liver. Repeated cytologic examinations of the bile showed atypical cells consistent with adenocarcinoma. The patient underwent extended resection of the left lobe of the liver and was found to have intraductal papillary carcinoma with associated mucin-producing bile duct carcinoma. This carcinoma fills dilated bile duct lumens with mucin. This tumor differs morphologically from typical cholangiocarcinoma, which is usually seen in the late stages of PSC. Just one case of mucin-producing bile duct carcinoma arising from PSC has been reported worldwide. The patient has had no signs of recurrence after 27 months. Patients with mucin-producing bile duct carcinoma, as in the case of its pancreatic counterpart, may have a better prognosis and a higher survival rate than patients with typical cholangiocarcinomas.

Effect of transforming growth factor-β1 on human intrahepatic cholangiocarcinoma cell growth

AIM: To elucidate the biological effects of transforming growth factor-β1 (TGF-β1) on intrahepatic cholan-giocarcinoma (ICC).

METHODS: We investigated the effects of TGF-β1 on human ICC cell lines (HuCCT1, MEC, and HuH-28) by monitoring the influence of TGF-β1 on tumor growth and interleukin-6 (IL-6) expression in ICC cells.

RESULTS: All three human ICC cell lines produced TGF-β1 and demonstrated accelerated growth in the presence of TGF-β1 with no apoptotic effect. Studies on HuCCT1 revealed a TGF-β1-induced stimulation of the expression of TGF-β1, as well as a decrease in TGF-β1 mRNA expression induced by neutralizing anti-TGF-β1 antibody. These results indicate that TGF-β1 stimulates the production and function of TGF-β1 in an autocrine fashion. Further, IL-6 secretion was observed in all three cell lines and exhibited an inhibitory response to neutralizing anti-TGF-β1 antibody. Experiments using HuCCT1 revealed a TGF-β1-induced acceleration of IL-6 protein expression and mRNA levels. These findings demonstrate a functional interaction between TGF-β1 and IL-6. All three cell lines proliferated in the presence of IL-6. In contrast, TGF-β1 induced no growth effect in HuCCT1 in the presence of small interfering RNA against a specific cell surface receptor of IL-6 and signal transducer and activator of transcription-3.

CONCLUSION: ICC cells produce TGF-β1 and confer a TGF-β1-induced growth effect in an autocrine fashion. TGF-β1 activates IL-6 production, and the functional interaction between TGF-β1 and IL-6 contributes to ICC cell growth by TGF-β1.

Incidental gallbladder cancer diagnosed during and after laparoscopic cholecystectomy

With the increasingly widespread acceptance of laparoscopic cholecystectomy (LC), the number of cases of incidental gallbladder carcinoma (GBC) has increased; however, management of incidental GBC is a difficult issue in the absence of established guidelines. The present study aims to evaluate the treatment of patients with incidental GBC diagnosed with LC. We performed a 14-year review of 10 patients with GBC discovered with LC. From April 1991 through March 2004, we performed LC for 1,195 patients at Nippon Medical School Main Hospital. Of these patients, 10 (0.83%) were found to have GBC. Seven patients were women and 3 were men, with a mean age of 61.4 years. Four patients had mucosal tumors (pT1a), 5 had subserosal tumors (pT2), and 1 had a serosal lesion (pT3). Eight of the 10 patients underwent radical surgery. Two patients with pT1a tumors underwent no additional surgery. All 4 patients with pT1a tumors are alive without recurrence. One patient with a pT2 tumor with metastases to the liver and pericholedochal lymph nodes found with additional resection died of recurrence of metastasis to the liver and lung 70 months after LC. One patient with a pT2 tumor died of primary lung cancer 35 months after LC. The remaining 3 patients with pT2 tumors are alive without recurrence 51 to 128 months after surgery. One patient with a pT3 tumor is alive with no recurrence for 9 months. For stage Tis or T1a tumors, LC is sufficient. Patients with T1b tumors should undergo liver-bed resection and lymphadenectomy, and patients with >pT2 tumors should undergo systematic liver resection with lymphadenectomy. Even when incidental GBC diagnosed with LC is advanced, adequate additional surgery may improve the prognosis.

Fracture of an expandable metallic stent placed for biliary obstruction due to common bile duct carcinoma

We report our second case of fracture of a SMART self-expandable metallic stent (Cordis Endovascular, Warren, NJ) placed to treat biliary obstruction due to an unresectable common bile duct carcinoma. An 82-year-old man presented with jaundice. Computed tomography and ultrasonography on admission demonstrated a mass in the lower common bile duct. The mass was identified as a common bile duct obstruction. A SMART stent was inserted. Ten months after stent insertion, two additional SMART stents were inserted to relieve obstructive jaundice due to occlusion of the first stent. Fourteen months after insertion of the first stent, endoscopic examination revealed stenosis of the duodenum due to invasion of the common bile duct carcinoma, prompting us to perform a gastrojejunostomy 1 month later. Three months after gastrojejunostomy, the patient presented with obstructive jaundice and cholangitis. A fracture of one of the stents was then discovered on plain X-ray films and percutaneous transhepatic cholangiography. Two SMART stents were inserted simultaneously. In conclusion, we report the fracture of a SMART stent placed for common bile duct carcinoma. Fracture should be considered as a possible complication after metallic stent insertion.

Combined neuroendocrine cell carcinoma and adenocarcinoma of the gallbladder: report of a case

A 58-year-old man with a chief complaint of epigastralgia was admitted to our hospital. Physical examination disclosed a large, firm mass in the right hypochondrium. Abdominal computed tomography confirmed thickening of the gallbladder wall and a 15 x 8 cm mass occupying almost all of the right lobe and medial segment of the liver. With a preoperative diagnosis of malignant gallbladder tumor infiltrating the liver, right hepatic trisegmentectomy was performed. Histopathologic examination showed atypical cells with small round to oval nuclei and sparse eosinophilic cytoplasm, proliferating in a solid and focal nesting pattern. Near this small cell proliferation was a focus of tubular adenocarcinoma that showed a zone of transition from the small cell neuroendocrine pattern. The small cells demonstrated immunohistochemical reactivity for chromogranin A. Electron microscopy disclosed neurosecretory granules 150 nm in diameter, representing dense round core vesicles, confirming a neuroendocrine cell lineage. The patient was diagnosed with neuroendocrine cell carcinoma combined with adenocarcinoma of the gallbladder. Tumor recurrence became evident 3 months after surgery, and he died 4 months after surgery.

Postoperative bile leakage managed successfully by intrahepatic biliary ablation with ethanol

We report a case of postoperative refractory bile leakage managed successfully by intrahepatic biliary ablation with ethanol. A 75-year-old man diagnosed with hepatocellular carcinoma underwent extended posterior segmentectomy including the caudate lobe and a part of the anterior segment. The hepatic tumor attached to the anterior branch of the bile duct was detached carefully and resected. Fluid drained from the liver surface postoperatively contained high concentrations of total bilirubin, at a constant volume of 150 mL per day. On d 32 after surgery, a fistulogram of the drainage tube demonstrated an enhancement of the anterior bile duct. Endoscopic retrograde cholangiography demonstrated complete obstruction of the proximal anterior bile duct and no enhancement of the peripheral anterior bile duct. On d 46 after surgery, a retrograde transhepatic biliary drainage (RTBD) tube was inserted into the anterior bile duct under open surgery. However, a contrast study of RTBD taken 7 mo post-surgery revealed that the fistula remained patent despite prolonged conservative management, so we decided to perform ethanol ablation of the isolated bile duct. Four mL pure ethanol was injected into the isolated anterior bile duct for ten minutes, the procedure being repeated five times a week. Following 23 attempts, the volume of bile juice reached less than 10 mL per day. The RTBD was clamped and removed two days later. After RTBD removal, the patient had no complaints or symptoms. Follow-up magnetic resonance imaging demonstrated atrophy of the ethanol-injected anterior segment without liver abscess formation.

One-step palliative treatment method for obstructive jaundice caused by unresectable malignancies by percutaneous transhepatic insertion of an expandable metallic stent

AIM: To describe a simple one-step method involving percutaneous transhepatic insertion of an expandable metal stent (EMS) used in the treatment of obstructive jaundice caused by unresectable malignancies.

METHODS: Fourteen patients diagnosed with obstructive jaundice due to unresectable malignancies were included in the study. The malignancies in these patients were a result of very advanced carcinoma or old age. Percutaneous transhepatic cholangiography was performed under ultrasonographic guidance. After a catheter with an inner metallic guide was advanced into the duodenum, an EMS was placed in the common bile duct, between a point 1 cm beyond the papilla of Vater and the entrance to the hepatic hilum. In cases where it was difficult to span the distance using just a single EMS, an additional stent was positioned. A drainage catheter was left in place to act as a hemostat. The catheter was removed after resolution of cholestasis and stent patency was confirmed 2 or 3 d post-procedure.

RESULTS: One-step insertion of the EMS was achieved in all patients with a procedure mean time of 24.4 min. Out of the patients who required 2 EMS, 4 needed a procedure time exceeding 30 min. The mean time for removal of the catheter post-procedure was 2.3 d. All patients died of malignancy with a mean follow-up time of 7.8 mo. No stent-related complication or stent obstruction was encountered.

CONCLUSIONS: One-step percutaneous transhepatic insertion of EMS is a simple procedure for resolving biliary obstruction and can effectively improve the patient’s quality of life.

Cholecystitis Caused by Infiltration of Immature Myeloid Cells: A Case Report

A 59-year-old man with myelodysplastic syndrome who was hospitalized for evaluation of fever and generalized fatigue had elevated levels of C-reactive protein and pancytopenia. A search for a site of infection and empiric treatment with antibiotics were unsuccessful. Over 5 to 6 weeks right upper quadrant pain and rebound tenderness developed. Sonographic Murphys sign was present. Computed tomography showed thickening of the gallbladder wall, and repeated ultrasonography demonstrated changes consistent with cholecystitis. Open cholecystectomy was performed as an emergency procedure. Macroscopically the resected gallbladder showed an edematous and thickened wall. Histopathologic examination revealed transmural infiltration by atypical mononuclear cells with distinct nuclei. The cells showed immunohistochemical staining for CD15, indicating myeloid lineage. By 10 days after surgery, counts of leukocytes and leukoblasts had markedly increased, reaching 36,700/microL and 76.0%, respectively. The blast crisis was thought to indicate progression from myelodysplastic syndrome to leukemia. The patient died of progressive disease 12 days after surgery. We have described a rare case of acute cholecystitis caused by infiltration of immature myeloid cells to the gallbladder. An acute abdomen complicating hematologic disorders is life-threatening and requires prompt and appropriate treatment.

Short hairpin RNA modulates transforming growth factor beta signaling in life-threatening liver failure in mice

BACKGROUND & AIMS

Transforming growth factor beta (TGF-beta) receptor II (TGF-betaRII), which is essential for TGF-beta signaling and is involved in the causation or participates in the pathway of various human disorders, is consequently considered a key target for therapeutics and analysis of the pathophysiology associated with disruption of the TGF-beta system. In the liver, TGF-beta plays an essential role in hepatocyte apoptosis, growth inhibition, and progression of fibrogenesis. There is a critical need to introduce technology involving the TGF-beta system, such as RNA interference (RNAi), which has high potential for in vivo therapeutics and analytical activities.

METHODS

Here, we investigated the effect of short hairpin RNA targeting TGF-betaRII, using hepatocyte injury in human and mouse cell lines and liver injury mouse models.

RESULTS

We demonstrated that short hairpin RNA targeting TGF-betaRII can be used to silence TGF-betaRII genes in mouse and human cell lines, and physiologic and morphologic changes in hepatocytes suffering from acute injury are spared by RNAi-mediated gene silencing of the target gene and by suppressing downstream signal transduction. Furthermore, short hairpin RNA targeting TGF-betaRII protected mice from life-threatening acute liver failure.

CONCLUSIONS

Our study suggests the potential use of TGF-betaRII silencing by RNAi as an analytical tool for TGF-beta signaling and gene-specific therapy in human disorders.

Splenic artery embolization before laparoscopic splenectomy in children

BACKGROUND

This study assessed the safety and utility of preoperative splenic artery embolization before laparoscopic splenectomy in children.

METHODS

Five young girls with a mean age of 13.2 years underwent laparoscopic splenectomies at the authors' institution from August 1998 to April 2003. Three of the patients had idiopathic thrombocytopenic purpura, and two had hereditary spherocytosis. Preoperative splenic artery embolization was performed the day before the surgery in all cases. The laparoscopic splenectomy was performed using traditional laparoscopic procedures and standard laparoscopic instruments with the patient in the right semilateral position.

RESULTS

The mean spleen weight was 252.6 g, and the mean length was 11.6 cm. All the patients reported postembolic pain, but not to a level unmanageable by intravascular narcotics. There were no severe complications in the splenic artery embolization. The laparoscopic splenectomies were completed in a mean of 211 min, with a mean estimated blood loss of 9 ml. None of the operations required conversion to traditional open laparotomy, and none of the patients died or experienced operative complications.

CONCLUSION

The authors concluded that splenic artery embolization is safe and useful as an adjuvant procedure performed before elective laparoscopic splenectomy in children.

Collagen IV is a predictor for clinical course in patients with malignant obstructive jaundice

BACKGROUND/AIMS

Increases in the serum extracellular matrix proteins (ECMPs) have been described in studies on cholestasis, therefore we investigated the serum levels of collagen IV, aminoterminal propeptide of type III procollagen, and hyaluronic acid prior to percutaneous transhepatic biliary drainage (PTBD) to evaluate its potential as a predictor for prolonged bilirubin clearance and clinical course in patients with malignant obstructive jaundice (MOJ).

METHODOLOGY

Serum levels of ECMPs were prospectively investigated in 42 patients with MOJ prior to PTBD. The study group was subdivided according to the bilirubin clearance, and was also subdivided according to the determined level of collagen IV (cut-off point of 260 ng/mL).

RESULTS

Serum collagen IV was identified as an independent risk factor for prolonged bilirubin clearance (P=0.006). Receiver-operating-characteristic curve analysis revealed that serum collagen IV had a diagnostic accuracy of 79% at the cut-off point of 260 ng/mL. Furthermore, these results indicated that the level of collagen IV is a reliable marker of postoperative liver failure (P=0.029) and predictor of death from liver failure (P=0.02).

CONCLUSIONS

Elevated serum collagen IV is a feature of MOJ commonly associated with prolonged bilirubin clearance, and a useful indicator of clinical course, postoperative morbidity, and mortality in patients with MOJ.

Tumor marker measurements of cells in a fine needle used for aspiration cytology

OBJECTIVE

To investigate whether the needle washing could yield sufficient cells for tumor marker (TM) measurements as an ancillary technique to ensure the accuracy of fine needle aspiration cytology (FNAC) of tumors.

STUDY DESIGN

After obtaining preliminary data that aspirated tumor cells within a 22-gauge needle could be collected by washing it with distilled water for TM measurements, we studied tumor cell numbers and TM values obtained by washing a 22-gauge needle directly after tumor aspiration and another needle after FNAC.

RESULTS

Using 8 resected hepatobiliary and pancreatic carcinomas, the used needles yielded 16.8+/-10.5 x 10(4) cells per milliliter. Used needles from 6 adenocarcinomas expelled 479.2+/-406.5 ng/mL of carcinoembryonic antigen, and 6,561.3+/-5,713.1 ng/mL of CA 19-9, while the needles from 2 hepatomas showed normal values of those markers.

CONCLUSION

A needle used for FNAC contains sufficient cells for TM measurements, which can be ancillary to the differential diagnosis.

[Hepatic arterial infusion and occlusion technique for the evaluation of the hepatic resection to control the local liver tumor]

We report 2 cases of metachronous liver metastases from gastric cancer and 1 case of hepatocellular carcinoma (HCC) that are treated with a hepatic arterial infusion (HAI) to control the progression of local liver tumor. The treatments consist of HAI of epirubicin and mitomycin C plus degradable starch microspheres (DSM) to achieve temporary vascular occlusions. Hepatic resections were not performed in all cases because of the appearance of multiple liver metastases, or the hepatic vascular occlusion in 2 cases of gastric cancer, and the liver damage in the case of HCC. Therefore, HAI with DSM is useful for the evaluation of the hepatic resection in controlling of the local liver tumor.

Hand-assisted laparoscopic hepatectomy after partial splenic embolization

The case of a patient with hepatocellular carcinoma and thrombocytopenia secondary to liver cirrhosis who underwent successful hand-assisted laparoscopic hepatectomy after partial splenic embolization is described. A 67-year-old man with severe liver cirrhosis was admitted for treatment of hepatocellular carcinoma. His early phase of hepatic angiography showed two hypervascular tumors in segment 6. The patients liver function was poor, with the indocyanine green retention at 15 min of 49.5%, a total serum bilirubin concentration of 2.0 mg/dl, an albumin concentration of 2.8 g/dl, and an hyaluronic acid concentration of 649 ng/ml. The platelet count was 3.0 x 10(4)/microl secondary to hypersplenism. Partial splenic embolization decreased the splenic volume by 50% preoperatively. At 2 months later, the platelet count was 6.0 x 10(4)/microl, and hand-assisted laparoscopic partial hepatectomy was performed uneventfully. The patients postoperative course was unremarkable, and he was discharged on postoperative day 12.

Hepatic Pseudoaneurysm Ruptured into the Jejunal Limb after Hepatectomy for the Treatment of Gall Bladder Carcinoma

A 74-year-old woman with advanced carcinoma of the gall bladder underwent anterior and medial segmentectomies, extrahepatic bile duct resection, lymph node dissection, and hepaticojejunostomy with retrograde transhepatic biliary drainage. On the sixteenth postoperative day, bleeding was noted through the biliary drain, but it stopped spontaneously. Two days later, the biliary drain showed bleeding again. Ultrasonography revealed mild dilatation of the intrahepatic bile duct. Cholangiography via the drain disclosed a defect in the jejunal limb. Emergency angiography revealed an aneurysm, 2 cm in diameter, in the posterior branch of the right hepatic artery. Contrast medium demonstrated extravasation into the jejunal limb. The pseudoaneurysm was embolized with coils. No further hemorrhage was noted, and the patient was discharged 30 days after operation.

Simple Closure of a Perfoated Duodenal Diverticulum: "A Case Report"

Spontaneous perforation of a duodenal diverticulum is a rare but serious complication with significant mortality rates. Just over 100 cases have been reported in the world literature. One case of perforated duodenal diverticulum treated by simple closure is reported. An elderly female was admitted to our hospital with an acute abdomen. Computed tomography of the abdomen showed retroperitoneal air around the duodenum and right kidney. Laparotomy with a Kocher maneuver disclosed a perforated diverticulum in the second portion of the duodenum. Although diverticulectomy is the most common treatment, simple closure of the perforated duodenal diverticulum with drainage was performed to avoid injury to the distal common bile duct and ampulla of Vater, which were close to the diverticulum. The patient has fully recovered and has been asymptomatic with no signs of recurrence for 25 months.

One-step insertion of an expandable metallic stent for unresectable common bile duct carcinoma

BACKGROUND

This report describes a one-step insertion of an expandable metallic stent to treat obstructive jaundice due to unresectable common bile duct carcinoma.

METHODS

A percutaneous transhepatic cholangiogram is obtained, and the bile duct obstruction is negotiated with a guide wire. After advancing the catheter into the duodenum, contrast material is injected to measure the length of the stenosis. After an expandable metallic stent is positioned, an external biliary drainage catheter is left in place to provide temporary drainage. The catheter is removed after stent patency is confirmed after 3 days.

CONCLUSIONS

One-step insertion of an expandable metallic stent for biliary obstruction is a useful method that shortens hospitalization. Once it has been decided to use stent palliation, the stent should be inserted without undue delay to maximize symptomatic relief and cost benefits.

Postoperative Management and Complications in Living-related Liver Transplantation

Living-related liver transplantation is widely accepted as a treatment for patients with end-stage liver disease, with survival rates of up to 80%. Liver transplant recipients are at risk for the same postoperative complications as any patient undergoing a major intraabdominal operation, in addition to several complications specific to this procedure. Maintenance immunosuppression relies principally on administration of tacrolimus and methylprednisolone. Nevertheless, approximately 36% of liver transplant recipients suffer acute rejection in the early posttransplant period and require bolus steroid therapy as a rescue agent. Vascular complications, including hepatic arterial thrombosis and portal vein thrombosis, are additional major problems. When they occur in the immediate postoperative period, they can produce fulminant hepatic necrosis requiring retransplantation, so intensive anticoagulation therapy is needed as prophylaxis against these vascular complications. If thrombosis of the hepatic artery or portal vein is diagnosed early in the postoperative course, emergency thrombectomy with reanastomosis should be attempted. Outflow obstruction by hepatic vein stenosis sometimes causes liver dysfunction, pleural effusion, and hepatosplenomegaly. Percutaneous transhepatic or transjugular approached hepatic vein dilatation is very useful in case of hepatic vein stenosis. Recipients are generally immunocompromised secondary to immunosuppressive therapy and their poor clinical condition and are at high risk for postoperative infection. Infection is a major cause of morbidity and the most common cause of death in liver transplant recipients. Antibiotic, antifungal, and antiviral agents are used empirically, and serologic examinations and bacterial investigations of blood, sputum, stool, urine, and discharge from drains should be performed as well as antibiotic sensitivity tests when necessary. Other complications related to the operation are intraabdominal bleeding, bile leakage, biliary anastomotic stenosis, and intestinal perforation. The postoperative course of liver transplant recipients with these complications depends on making an accurate diagnosis promptly and initiating appropriate management. Postoperative complications of living-related liver transplantation are protean, so it is very important to communicate with professionals in each specialized field to ensure optimal treatment.

Graft survival following three occurrences of hepatic arterial thrombosis after living-related liver transplantation. A case report

Hepatic arterial thrombosis is a major cause of morbidity and graft loss in patients undergoing liver transplantation. We report the case of a patient who underwent living-related liver transplantation and suffered three instances of early hepatic arterial thrombosis requiring revascularization in the first 8 days after grafting. The patient was discharged with good graft function. A 21-month-old female with biliary atresia underwent living-related liver transplantation using her mother's extra-lateral segment. The donor middle hepatic artery was anastomosed end-to-end to the posterior branch of the donor's hepatic artery. The time of operation was 8 hr 36 min, and the blood loss was 193 mL. On postoperative day 5, the patient was returned to surgery to close a perforation in the transverse colon. At operation we found hepatic arterial thrombosis and performed a thrombectomy and redid the arterial anastomosis. Hepatic arterial thrombosis recurred during the operation, so we interposed the recipient's right radial artery between the graft artery and recipient posterior branch. On postoperative day 8, ultrasound showed a fluid collection in Winslow's pouch. After removing the fibrin clot, we discovered that hepatic arterial thrombosis had recurred in the interposed artery. We revascularized the graft using the right gastroepiploic artery. Arterial blood flow was restored, and graft function remained excellent.

Middle hepatic vein reconstruction using a peritoneal patch: report of a case

A 67-year-old male complaining of constipation with a change in stool caliber for several months visited our hospital in June 1999. A positive test for occult blood in the feces led to the disclosure of a type II carcinoma of the sigmoid colon with multiple liver metastases. A lymph node dissection with a sigmoidectomy disclosed no metastases histologically, so a left hepatectomy and enucleations of the metastases were performed. In addition, the invaded middle hepatic vein (MHV) was resected and repaired using a peritoneal patch. The patient's postoperative course was uneventful until July 2000, when computed tomography of the liver showed a single nodule measuring 3 cm in diameter in segment 6. The metastasis was excised in August. Since then, the patient has shown normal tumor marker values. The MHV has remained patent for 24 months after its reconstruction. A resection of the liver metastases including venous reconstruction is beneficial for patients since it results in a longer survival and allows for venous drainage of the residual liver. The peritoneum is also accessible, enabling the fitting of a patch graft for hepatic vein repair.

Association between Helicobacter bilis in bile and biliary tract malignancies: H. bilis in bile from Japanese and Thai patients with benign and malignant diseases in the biliary tract

Japan and Thailand have high incidences of bile duct carcinoma and gallstones. The presence of Helicobacter bilis (H. bilis) detected by polymerase chain reaction (PCR) and 16S rRNA analysis in bile samples from Chileans with chronic cholecystitis was reported. The association between H. bilis in bile and biliary tract malignancies has not been investigated, and therefore the aim of this study is to determine whether malignant diseases of the biliary tract are associated with the presence of H. bilis in bile samples obtained from two high-risk populations. Bile samples from 45 Japanese and 40 Thai patients were subjected to PCR analysis using H. bilis-specific primers, and six of the H. bilis amplicons were sequenced. Thirteen out of 15 (87%) Japanese and 11 out of 14 (79%) Thai patients with bile duct or gallbladder cancer tested positive for the presence of H. bilis in their bile. Eight out of 16 (50%) Japanese and 10 out of 26 (38%) Thai patients with gallstone and / or cholecystitis tested positive for H. bilis. Only 4 out of 14 (29%) subjects without biliary disease tested positive for H. bilis among the Japanese. Bile duct and gallbladder cancer showed significantly higher positive rates for H. bilis than did the non-biliary diseases among the Japanese (P < 0.01) and the odds ratios for bile duct or gallbladder cancer with H. bilis in comparison with gallstone and / or cholecystitis were 6.50 (95%CI 1.09 - 38.63) in the Japanese and 5.86 (1.31 - 26.33) in the Thai patients. In conclusion, H. bilis infection in bile was associated with biliary tract and gallbladder cancers in two high risk populations, Japanese and Thai.

Hypersplenism induced by hepatectomy

BACKGROUND/AIMS

We encountered a case of posthepatectomy splenic enlargement and hypersplenism followed by disseminated intravascular coagulopathy with airway hemorrhage causing death.

METHODOLOGY

We, therefore, retrospectively investigated postoperative splenic enlargement, hypersplenism and disseminated intravascular coagulopathy by computed tomography and laboratory data in 57 hepatectomized patients with a malignant or benign disease in the postoperative period.

RESULTS

Of 32 patients with hepatocellular carcinoma or biliary tract carcinoma (group A), 12 with metastatic hepatic lesions (group B), and 13 with benign liver disease (group C); remarkable (20%) splenic enlargement was noted in 8 patients in group A, 2 in group B, and 2 in group C. Seven of the 12 patients were associated with liver cirrhosis, 5 with preoperative splenomegaly, and 8 had undergone major hepatectomy. Postoperative hypersplenism developed in 5 patients in group A, and one patient in group C. All of them were associated with liver cirrhosis or chronic hepatitis and preoperative splenomegaly, and five had undergone hepatic lobectomy or more extensive resections. All except for the disseminated intravascular coagulopathy case recovered. Statistically, splenic enlargement was significantly related to the extent of hepatectomy; lobectomy versus segmentectomy = 28.3 +/- 28.5% (n = 14) versus 12.4 +/- 13.8% (n = 20), (unpaired Student's t test, P = 0.037). Platelet counts of the patients with liver cirrhosis or chronic hepatitis is lower than those without the diseases, both pre- and postoperatively (14.0 +/- 6.0 x 10(4)/mm3 vs. 21.5 +/- 6.2 x 10(4)/mm3, P = 0.0001).

CONCLUSIONS

Postoperative hypersplenism was noted only in the patients with liver cirrhosis or chronic hepatitis and preoperative splenomegaly, and developed more frequently after larger hepatectomies than after smaller hepatectomies; 5 (45%) of 11 versus 1 (7%) of 14, chi 2 test, P = 0.026).

Growth control of human biliary epithelial cells by interleukin 6, hepatocyte growth factor, transforming growth factor beta1, and activin A: comparison of a cholangiocarcinoma cell line with primary cultures of non-neoplastic biliary epithelial cells

A well characterized human cholangiocarcinoma (CC) cell line, SG231, was compared with primary cultures of normal human biliary epithelial cells (BECs) for alterations in interleukin 6 (IL-6) and hepatocyte growth factor (HGF)-mediated stimulation and transforming growth factor beta1 (TGF-beta1) and activin A-mediated inhibition of growth. Results were compared with immunolabeling of the original tumor and after injection of SG231 into the liver of BALB/cByJ-scid mice. In vitro, both BECs and CCs expressed met, gp80, and gp130 messenger RNA (mRNA) and protein, but the levels of expression were higher in the CCs than in the BECs. In both the CCs and BECs, exogenous HGF or IL-6 induced phosphorylation of met or gp130, respectively, and a concentration-dependent increase in DNA synthesis. However, the CCs but not BECs, continued to grow in basal serum-free medium (SFM) and spontaneously produced both IL-6 and HGF under these conditions, which resulted in auto-phosphorylation of gp130 and met, respectively; and neutralizing anti-HGF or anti-IL-6 alone inhibited CC growth, indicative of autocrine growth control circuits. Conversely, activin A inhibits the growth of both BECs and CCs, but does not significantly increase apoptosis. Activin-A-induced growth inhibition of both CCs and BECs can be reversed by 100 ng/mL exogenous IL-6, but not by 10 to 100 ng/mL HGF. TGF-beta1 inhibited the growth of BECs but had no mitoinhibitory or proapoptotic effects on CCs. Immunolabeling of the original tumor and after inoculation into scid mice showed positive staining for met, gp130, gp80, and IL-6. This study contributes to a further understanding of BEC growth control and derangements that can occur during cholangiocarcinogenesis.

The effect of interleukin-6 (IL-6)/gp130 signalling on biliary epithelial cell growth, in vitro

The effect of IL-6 on the growth of mouse biliary epithelial cells (BEC), in vitro, was tested by comparing BEC obtained IL-6-deficient mice (IL-6(-/-)) to wild-type littermate controls (IL-6(+/+)), in two different media: simple serum-free media (S-SFM), and complete serum-free media (C-SFM) containing forskolin, which stimulates BEC IL-6 production. In S-SFM, neither IL-6(+/+)nor IL-6(-/-)BEC constitutively produced IL-6 mRNA or protein, and there was no difference between IL-6(+/+)and IL-6(-/-)BEC growth. In contrast, when the BEC were maintained in C-SFM, over 48 h, the growth of IL-6(+/+)BEC was 40% greater than IL-6(-/-)BEC (P<0.006). Enhanced IL-6(+/+)BEC growth in C-SFM was associated with induced expression of IL-6 mRNA and IL-6 protein secretion into the medium, upregulation of the IL-6Ralpha (gp80) and phosphorylation of the signal transducing molecule gp130. In C-SFM, anti-IL-6 neutralizing antibodies blocked enhanced IL-6(+/+)BEC growth, whereas exogenous rhIL-6 stimulated retarded growth of IL-6(-/-)BEC. Thus, under conditions that mimic an inflammatory or stressful microenvironment in vivo, BEC produce, secrete and respond to IL-6, via upregulation and activation of the IL-6Ralpha (gp80)/gp130 signaling system in an autocrine/paracrine manner.

Acute obstructive cholangiopathy in interleukin-6 deficient mice: compensation by leukemia inhibitory factor (LIF) suggests importance of gp-130 signaling in the ductular reaction

AIM

The hypothesis that interleukin-6-IL-6/gp130 signaling is involved in liver and biliary epithelial cell (BEC) biology and growth control was tested by subjecting homozygous IL-6 deficient mice (IL-6-/-) and wild type (IL-6+/+) littermate controls to bile duct ligation (BDL).

MATERIALS AND METHODS

During the first week after BDL, the two groups were compared with respect to routine liver injury tests, liver histology, BEC and hepatocyte DNA synthesis, together with the expression of mRNA and protein of IL-6 as well as related growth factors, and their receptors.

RESULTS

During the first week after BDL, there was marked upregulation of IL-6 mRNA and protein in the IL-6+/+ mice only in the vicinity of the biliary tree; whereas, biliary/peri-biliary IL-6R, HGF and met mRNA and protein increased in both groups. IL-6, HGF mRNA and protein localized to periductal inflammatory cells and stellate cells, while met and IL-6R protein were upregulated in the BEC and, to a lesser extent, in hepatocytes. This occurred during maximal proliferation of the BEC. Despite the absence of IL-6 in the IL-6-/- mice, there were only mildly phenotypic differences between the two groups, and no differences in mortality. Compared to IL-6+/+ controls, IL-6-/- mice showed slightly less BEC proliferation, a trend toward more liver injury, and significantly higher total serum bilirubin (TB) levels, suggestive of impaired biliary tree integrity. These changes were associated with slightly less HGF mRNA and protein expression in the IL-6-/- mice, but the differences were not significant. Leukemia inhibitory factor (LIF), another gp-130 ligand, also showed marked peri-biliary upregulation after BDL in both groups, and also induced BEC DNA synthesis, in vitro.

CONCLUSIONS

The mild phenotypical differences between IL-6+/+ and IL-6-/- mice in the acute response to BDL is most likely attributable to the redundancy of the gp-130 signaling system. However, the long-term response to BDL results in a distinct phenotype in the IL-6-/- mice, marked by a relentless rise in serum total bilirubin and an inability to maintain compensatory increase in liver mass.

Mitosis and apoptosis in the liver of interleukin-6-deficient mice after partial hepatectomy

Recently, it was shown that hepatocyte DNA synthesis after partial hepatectomy (PH) is impaired in interleukin-6-deficient (IL-6(-/-)) mice, which results in significantly delayed, but eventual, recovery of normal liver weight, compared with the IL-6(+/+) controls. Four possible compensatory mechanisms might explain this phenomenon: 1) hepatocyte hypertrophy; 2) activation of the oval cell compartment and subsequent maturation to hepatocytes; 3) non-oval biliary epithelial cell (BEC) proliferation; and/or 4) differential rates of apoptotic cell death in the regenerating liver. These hypotheses were tested by subjecting IL-6(-/-) and IL-6(+/+) mice to PH and determining sequential liver weight, histology, hepatocyte and BEC 5'-bromo-2'-deoxyuridine (BrdU) labeling, liver DNA content, alpha-fetoprotein (AFP) mRNA production, and apoptosis at several time points after PH. Consistent with previous studies, we show that the absence of IL-6 significantly impairs hepatocyte DNA synthesis and delays liver weight recovery after PH, but the defect observed in this study is less severe than that previously reported, and no excess mortality, massive necrosis on histology, nor differences in liver injury test are seen. Interestingly, the IL-6(-/-) mice show more hepatocyte BrdU pulse labeling than the IL-6(+/+) controls at 24 hours, but less at 36, 48, and 60 hours. Continuous BrdU infusion up to 60 hours after PH showed a cumulative hepatocyte labeling index of 79.5% in IL-6(+/+) mice and 70.8% in IL-6(-/-) mice, respectively (P <.03). However, despite a lower labeling index and significantly delayed weight recovery, hepatic mass was equally restored in the two groups by 96 hours. There was no evidence of oval cell proliferation in the IL-6(-/-) mice, as determined by routine histology and AFP mRNA analysis, and non-oval BEC proliferation was also slightly impaired in the IL-6(-/-) mice compared with the IL-6(+/+) mice. In addition, liver DNA content per gram of liver showed an increase compared with normal at 60 hours in both groups, but by 96 hours, there was no difference between the two groups. Thus, neither oval cell nor BEC proliferation, nor hepatocyte hypertrophy, could account for the eventual equivalent weight recovery. There was, however, a difference between the two groups in the rate of apoptosis. In normal livers of both IL-6(-/-) and IL-6(+/+) mice, apoptotic cells were uncommon, and even fewer such cells were detected at 24, 36, and 48 hours after PH. Between 60 and 96 hours after PH, a wave of apoptosis spread through the livers of both groups. The number of apoptotic cells was directly proportional to the magnitude of hepatocyte BrdU labeling and liver DNA content after PH, and the difference between the nadir of apoptosis at 24 hours and the peak at 96 hours was greater for the IL-6(+/+) mice. In addition, a direct comparison between the two groups at 96 hours showed that hepatocyte apoptosis was significantly lower in the IL-6(-/-) versus the IL-6(+/+) mice (P <. 02). Treatment of the IL-6(-/-) mice with rIL-6 completely reversed the hepatocyte proliferation defect and increased the subsequent level of total apoptotic bodies. The fine control of liver weight recovery during regeneration after PH is a complex process that involves both mitosis and apoptosis. IL-6 affects this process by recruiting, and possibly synchronizing, the entry of hepatocytes into cell cycling, which quickly restores liver mass. However, this robust response generates superfluous hepatocytes, which are eliminated via apoptosis, similar to many other processes involving organ growth.

Interleukin-6, hepatocyte growth factor, and their receptors in biliary epithelial cells during a type I ductular reaction in mice: interactions between the periductal inflammatory and stromal cells and the biliary epithelium

The interleukin-6 (IL-6)/gp-80 and hepatocyte growth factor (HGF)/met ligand/receptor systems have been shown to stimulate biliary epithelial cell (BEC) DNA synthesis in vitro. The mRNA and protein production of these two in vitro mitogens were mapped in vivo during the first week after bile duct ligation (BDL) when peak BEC DNA synthesis is seen. Changes around the biliary tree were compared with those seen in the peripheral liver using a combination of Northern blotting and a unique biliary tree isolation technique, in which the bile ducts and the surrounding portal stroma and inflammatory cells are separated from the hepatocytes by perfusion digestion. Further localization was performed with in situ hybridization and immunohistochemistry. In the normal liver, there is low-level expression of HGF mRNA by periportal stellate cells, and HGF protein localizes to these cells and to neutrophils; extracellular HGF protein is present in the bile. There is no detectable IL-6 mRNA by Northern analysis or IL-6 protein expression in the normal liver, but both met and IL-6 receptor (IL-6R) mRNA are detectable; met mRNA is expressed strongly in the biliary tree, and met protein is expressed weakly on hepatocytes and strongly on BEC. IL-6R mRNA is weakly expressed in the biliary tree, and IL-6R protein is detectable on hepatocytes, with a periportal-to-perivenular gradient, but not on BEC. During the first 3 days after BDL, HGF mRNA expression is increased in both the biliary tree and in the peripheral liver, and production is localized to stellate cells, periductal neutrophils, and stromal cells, which typically accompany the proliferating ductules. IL-6 mRNA and protein were detected only near the biliary tree after BDL, and not in the peripheral liver, and the production was localized to periductal hematolymphoid cells, which had the morphological appearance of macrophages and/or dendritic cells. There is also a distinct up-regulation of met and gp-80 mRNA and protein in the biliary tree, which is stronger than that seen in the peripheral liver. Met protein expression is increased, and IL-6R(gp-80) protein is induced on the proliferating BEC, consistent with the participation of both the HGF/met and IL-6/gp-80 systems in the early phases of type I ductular reactions. These observations show that periductal hematolymphoid and stromal cells are the source of BEC growth factors, and receptors for these factors are up-regulated on BEC during active ductular proliferation. Complex interactions between the inflammatory, stromal, and BEC results in a dysmorphogenic repair response that eventually leads to cirrhosis.

Effect of mixing ratio in lecithin/bile acid mixed micelles on Na(+)-K+ ATPase

Lecithin and bile acid form mixed micelles in the bile. We found that the mixing ratio in lecithin/bile acid mixed micelles directly changes the activity of Na(+)-K+ ATPase. Na(+)-K+ ATPase activity was suppressed to 13.3% of that in the buffer alone at a lecithin/bile acid mixing ratio of 0.1 in the presence of 10(-2) M bile acid (that is, a concentration level close to that of the hepatic bile). With increase in the mixing ratio in the presence of 10(-2) M bile acid, the activity of the enzyme was found to be augmented accordingly. Thus addition of lecithin to an extent such that the mixing ratio reached 0.6 led to an enhancement of enzymatic activity to 193.8%. If lecithin addition is made in the presence of bile acid at the near gallbladder concentration of 10(-1) M, however, the Na(+)-K+ ATPase activity can be observed to increase with the increase in the lecithin/bile acid ratio. Yet, at the same mixing ratio of 0.6, the enzyme activity was arrested at only 25.7%. However, this change in mixing ratio had no effect on ouabain-insensitive ATPase. The state of mixed micelles may exert the same effect on Na(+)-K+ ATPase activity in vivo.

Immunohistochemical localization of Na+, K+-ATPase in human normal and malignant pancreatic tissues

Localization of Na+, K+-ATPase in the human pancreas was investigated immunohistochemically using rabbit antisera against Na+, K+-ATPase of the human kidney. The reaction product existed only on the luminal surfaces of both centroacinar and ductal cells in normal pancreatic tissue, whereas in chronic pancreatitis the localization of Na+, K+-ATPase was found frequently on the luminal surfaces of both centroacinar and ductal cells, and on the basolateral surfaces of some ductal cells. However, in acinar cells, the distribution of Na+,K+-ATPase was not detected in either the normal pancreas or chronic pancreatitis. In pancreatic carcinoma tissues, Na+,K+-ATPase existed very rarely in malignant cells. These results indicate that Na+,K+-ATPase is immunohistochemically localized on the membranes of centroacinar and ductal cells of the human pancreas, and that the antigenicity of Na+,K+-ATPase in pancreatic carcinoma cells differs from that in normal cells.