Inflammatory Myofibroblastic Tumor of the Liver: A Diagnostic Challenge

Inflammatory myofibroblastic tumor (IMT) is an uncommon myofibroblastic neoplasm that was formerly included within the broad category of inflammatory pseudotumor (IPT). IMT is rarely encountered in the liver. Similar to IMT of other organs, the interchangeable use of the terms IMT and IPT in liver has made the analysis of these lesions difficult. In this review, clinical and pathological features of IMT of the liver are reviewed and the differential diagnosis of IMT is discussed, with emphasis on IPT and the other entities included in this large category. IMT can mimic malignant tumors. There are no known unique diagnostic clinical, laboratory, or radiological features. The definitive diagnosis of IMT depends on careful pathological examination. The histopathological evaluation of hepatic IMT reveals that, the myxoid/vascular pattern is the most frequently observed, followed by, in decreasing frequency, fibrous histiocytoma-like pattern and hypocellular fibrous pattern. In IMT of the liver, anaplastic lymphoma kinase (ALK) expression reliably predicts the presence of an ALK gene rearrangement. The diagnosis of hepatic IMT depends on the dominant histopathological pattern, and the management of the disease is still controversial. IMT of the liver is a distinctive neoplasm of intermediate biological potential, and should be distinguished from the variety of lesions that are included under the broad category of IPT. Therefore, to avoid confusion regarding the true incidence and behavior of hepatic IMT, the term IPT should not be used interchangeably with IMT. The rarity of IMT in liver should not minimize its consideration in the differential diagnosis of liver tumors, especially in patients with tumor markers in normal range.     

Gastric cancer among peptic ulcer patients: Retrospective, long-term follow-up

BACKGROUND: Patients with duodenal ulcer are not at high risk although Helicobacter pylori infection is no doubt associated with gastric cancer development. However, little is known about the risk after long-term follow-up. AIMS: We investigated the incidence for gastric cancer development in peptic ulcer patients in a long term. PATIENTS AND METHODS: Between 1965 and 2004, endoscopic follow-up of more than 1 year was conducted on 1504 peptic ulcer patients in our hospital. They consisted of 978 gastric ulcer patients, 444 duodenal ulcer patients and 82 gastric and duodenal ulcer patients. Gastric and duodenal ulcer patients were excluded from the analysis because of their limited number. RESULTS: Gastric cancers developed in 32 (3.3%) of gastric ulcer patients and 3 (0.68%) of duodenal ulcer patients. Kaplan-Meier analysis showed that the incidence of gastric cancer in duodenal ulcer patients was significantly lower than that in gastric ulcer patients (log-rank test, p=0.0059). Cox's proportional hazard model denoted the relative risk for duodenal ulcer against gastric ulcer adjusted by sex and age as 0.23 (95% CI: 0.072-0.77, p=0.016). CONCLUSION: The risk for patients with duodenal ulcer to develop gastric cancer over the long term is significantly less than in those with gastric ulcer.     

Arterioportal Fistula: a Rare Cause of Portal Hypertension and Abdominal Pain

Esophageal varices are commonly caused by portal hypertension secondary to cirrhosis. We report the case of a 71-year-old woman who presented with esophageal variceal bleeding due to portal hypertension caused by an arteriovenous fistula. The fistula, which was probably brought about by a liver biopsy performed 18 years previously, was complicated by bleeding. Since this event, the patient has reported right upper quadrant pain. Embolization resulted in elimination of the varices as well as abdominal discomfort.     

Spontaneous Rupture of a Gastric Stromal Tumor Causing Hemoperitoneum

We describe a 39-year-old man with spontaneous rupture of a gastric stromal tumor causing hemoperitoneum. Ultrasonography showed a large mass broadly abutting the stomach and liver. Computed tomography demonstrated a heterogeneous enhanced mass arising from the stomach and focal perforation of the tumor with hemoperitoneum; endoscopic ultrasonography showed an exophytic heterogeneous mass originating from the gastric muscle layer. Angiography revealed that the right gastric artery was the main artery supplying the tumor. A gastric stromal tumor with bloody fluid in the peritoneal cavity was seen at the laparotomy. The tumor was excised completely, and subsequent histological and immunohistochemical studies indicated that it was a gastric stromal tumor. We report a relatively rare case of gastric stromal tumor causing hemoperitoneum due to spontaneous rupture of the tumor.     

Diagnosis and therapy of non-variceal upper gastrointestinal bleeding

Non-variceal upper gastrointestinal bleeding(UGIB) is defined as bleeding proximal to the ligament of Treitz in the absence of oesophageal, gastric or duodenal varices. The clinical presentation varies according to the intensity of bleeding from occult bleeding to melena or haematemesis and haemorrhagic shock. Causes of UGIB are peptic ulcers, Mallory-Weiss lesions,erosive gastritis, reflux oesophagitis, Dieulafoy lesions or angiodysplasia. After admission to the hospital a structured approach to the patient with acute UGIB that includes haemodynamic resuscitation and stabilization as well as pre-endoscopic risk stratification has to be done. Endoscopy offers not only the localisation of the bleeding site but also a variety of therapeutic measures like injection therapy, thermocoagulation or endoclips. Endoscopic therapy is facilitated by acid suppression with proton pump inhibitor(PPI) therapy. These drugs are highly effective but the best route of application(oral vs intravenous) and the adequate dosage are still subjects of discussion. Patients with ulcer disease are tested for Helicobacter pylori and eradication therapy should be given if it is present. Non-steroidal antiinflammatory drugs have to be discontinued if possible. If discontinuation is not possible, cyclooxygenase-2 inhibitors in combination with PPI have the lowest bleeding risk but the incidence of cardiovascular events is increased.     

Patients with Gastric Antral Vascular Ectasia (GAVE) Are at a Higher Risk of Gastrointestinal Bleeding in the Absence of Cirrhosis

Background and Aims: Gastric antral vascular ectasia (GAVE) is commonly found in patients with cirrhosis, but it is also associated with other diseases in the absence of cirrhosis. Whether GAVE confers a different severity of gastrointestinal (GI) bleeding between patients with and without cirrhosis remains unknown. We aim to examine whether there is a difference in clinically significant GI bleeding due to GAVE in patients with or without cirrhosis. Methods: This is a retrospective case-control study of patients who were diagnosed with GAVE between January 2000 and June 2014. Patients were categorized into cirrhosis and noncirrhosis groups, and those with an additional GI bleeding source were excluded. Univariate comparisons and multivariable models were constructed using logistic regression. Results: In total, 110 patients diagnosed with GAVE on esophagogastroduodenoscopy (EGD) were included in our analysis; 84 patients had cirrhosis (76.4%) and 26 (23.6%) did not. Active GI bleeding was more prevalent in patients without cirrhosis (63.4% vs. 32.1%, p=0.003) despite similar indications for EGD, and endoscopic treatment with argon plasma coagulation (APC) was required more often in this group, approaching statistical significance (27% vs. 10.7%, p=0.056). There was no difference in bleeding severity, as evidenced by similar re-bleeding rates, surgery, or death attributed to uncontrolled bleeding. The strongest independent risk factor for GI bleeding was the absence of cirrhosis (odds ratio (OR): 5.151 (95% confidence interval (CI): 1.08-24.48, p=0.039). Conclusions: Patients with GAVE in the absence of cirrhosis are at higher risk for active GI bleeding and require more frequent endoscopic treatment than similar patients with cirrhosis. It may be worthwhile to treat GAVE in this population even in the absence of active bleeding.     

介入治疗对兔VX2肝癌MMP-2基因表达的影响

目的研究MMP-2在兔VX2肝癌中表达的意义以及介入治疗对其表达的影响。方法建立兔VX2肝癌的动物模型,将实验动物分为介入组和对照组,比较2组的肝功能变化、肿瘤体积增长率,用原位杂交和免疫组化方法研究各组的MMP-2基因及蛋白表达情况。结果对照组的AST和ALT分别高于同一时间段介入组。各组肿瘤随着时间延长体积均增大,但介入治疗后尤其是术后2、3周体积增长减缓,与对照组相比,有显著性差异。原位杂交及免疫组化显示MMP-2mRNA及蛋白表达主要定位于癌细胞胞浆。介入组MMP-2mRNA及蛋白表达的阳性率较对照组明显减少(P<0·05)。转移组MMP-2mRNA及蛋白表达的阳性率较无转移组明显增加(P<0·05)。结论介入治疗能改善肝功能,延缓肿瘤生长,减少转移。MMP-2的高表达预示着高转移潜能。