Influence of climatic factors in the incidence of upper gastrointestinal bleeding

BACKGROUND AND AIM: Previous reports have indicated seasonal fluctuations in the incidence of peptic ulcer activity, but the reasons for the seasonal pattern are not clear. We assessed the seasonal incidence of hematemesis caused by peptic ulcers or gastroesophageal varices, and the correlations between those and climatic factors. METHODS: We examined the number of cases of upper gastrointestinal (GI) bleeding caused by gastric ulcer (GU), duodenal ulcer (DU), or gastroesophageal varices (varix) diagnosed by urgent endoscopies between 1 January 1996 and 31 December 1999 in our hospital (Tokyo Metropolitan Bokutou Hospital). We evaluated the monthly and seasonal incidence of them and investigated correlations among the incidence and climatic factors. RESULTS: Four hundred and forty-one patients participated in this study, including 275 patients with GU (62.4%), 51 (11.6%) with DU, and 115 (26.0%) with varix. The number of cases of hematemesis caused by GU showed significant monthly and seasonal fluctuations (P = 0.0002, P = 0.0018): it decreased in summer and increased in autumn-winter. Moreover, there were inverse relations between the monthly number of cases of hematemesis caused by GU and the mean temperature (P = 0.0016) and vapor pressure (P = 0.0013), and a parallel relation to the mean atmospheric pressure (P = 0.0057). In contrast, the number of cases of hematemesis caused by DU and varices did not show any monthly or seasonal fluctuations. CONCLUSIONS: We found that the incidence of hematemesis because of GU had an inverse relationship to temperature and vapor pressure, and had a parallel relation to atmospheric pressure. Therefore, climatic factors may play an important role in hemorrhage from GU.     

Fatal liver failure due to reactivation of lamivudine-resistant HBV mutant

We report a case of fatal liver failure due to reactivation of lamivudine-resistant HBV. A 53-year-old man was followed since 1998 for HBV-related chronic hepatitis. Serum HBV-DNA was 150 MEq/mL (branched DNA signal amplification assay) and ALT levels fluctuated between 50-200 IU/L with no clinical signs of liver cirrhosis. Lamivudine (100 mg/d) was started in May 2001 and serum HBV-DNA subsequently decreased below undetectable levels. In May 2002, serum HBV-DNA had increased to 410 MEq/mL, along with ALT flare (226 IU/L). The YMDD motif in the DNA polymerase gene had been replaced by YIDD. Lamivudine was continued and ALT spontaneously decreased to the former levels. On Oct 3 the patient presenting with general fatigue, nausea and jaundice was admitted to our hospital. The laboratory data revealed HBV reactivation and liver failure (ALT: 1828 IU/L, total bilirubin: 10 mg/dL, and prothrombin INR: 3.24). For religious reasons, the patient and his family refused blood transfusion, plasma exchange and liver transplantation. The patient died 10 d after admission. The autopsy revealed remarkable liver atrophy.     

Clinical and pathological features of a prolonged type of acute intrahepatic cholestasis

Aim: We examined the clinical and pathological features of drug-induced acute intrahepatic cholestasis (AIC) to elucidate the pathogenesis of prolonged cases. Methods: Twenty-six cases of drug-induced AIC were divided into prolonged and non-prolonged groups. Serum bilirubin levels and other biochemical data were compared between the two groups. Biopsy liver specimens were examined by light and electron microscopy. The localization of multidrug resistance protein 2 (MRP2) was immunohistochemically assessed by the Envision technique. Results: The causative drugs of four prolonged cases were found to be tiopronin, chlorpromazine and diclofenac. Two of the patients either died or underwent liver transplantation. The maximal total bilirubin levels (35.2 +/-> 13.8 mg/dL) were significantly higher and a half-life of total bilirubin (78.8 +/-> 69.6 days) was markedly longer in the prolonged cases, in comparison to the non-prolonged cases (16.8 +/-> 8.1 mg/dL, 22.1 +/-> 12.7 days, respectively). The liverbiopsy specimens revealed canalicular cholestasis and a slight degree of lobular inflammation. In the prolonged cases, liver cell injury and cholestasis was marked, and the interlobular bile ducts disappeared in the portal triads. The reaction products of MRP2, recognized on the bile canaliculi in a control liver, were weakened and found in the pericanalicular vesicles in AIC. Conclusion: These results indicated disturbances in the canalicular bilirubin transport through MRP2 in the prolonged cases, resulting from severe cholestasis, liver cell injury and vanishing bile ducts. The histological findings of the liver at the acute icteric phase may be important to understand the pathogenesis and to predict the prognosis in AIC.     

Balloon-occluded transarterial chemoembolization using a 1.8-French tip Coaxial microballoon catheter for hepatocellular carcinoma: Technical and safety considerations

Objective: To evaluate the technical feasibility and safety considerations of balloon-occluded transarterial chemoembolization (B-TACE) using a newly developed 1.8-French (Fr) tip microballoon catheter for hepatocellular carcinoma (HCC). Material and methods: Between February 2013 and May 2013, 31 patients (20 males, 11 females; age range 56–85 years) underwent B-TACE using a 1.8-Fr tip microballoon catheter for unresectable HCC. The technical success rate, procedural complications, and adverse events of B-TACE were retrospectively investigated. Results: A total of 31 patients were subjected to 70 sessions of B-TACE using a 1.8-Fr tip microballoon catheter. The level of B-TACE was sub-subsegmental in 11, subsegmental in 35, segmental in 14, lobar in five, and right inferior phrenic artery in five sessions. The overall technical success rate was 99% (69 out of 70 sessions). As procedural complications, rupturing of the microballoon (n = 3) and aneurysmal dilatation at the site of balloon occlusion (n = 2) were encountered. There were no significant differences in any parameters between blood biochemical examination before and between two to four weeks after the procedure. Conclusion: A 1.8-Fr tip microballoon catheter enables selective catheterization in patients with HCC and B-TACE using the 1.8-Fr tip microballoon catheter is a safe procedure.     

Oleic acid to stearic acid ratio might be a potential marker for insulin resistance in non-obese Japanese

Results from a recent study indicate that a higher level of oleic acid/stearic acid ratio was associated with metabolically unhealthy obesity. This was further validated in cross-sectional and interventional studies; however, this was not extensively studied in a non-obese population. We recruited 260 Japanese subjects with serum free fatty acid profiles undergoing anti-aging health examinations. The determinants for oleic acid/stearic acid ratio were investigated using multiple regression analyses. To compare different markers, the subjects were classified based on oleic acid/stearic acid ratio and the combination of oleic acid/stearic acid ratio and triglyceride levels. The oleic acid/stearic acid ratio exhibited a positive correlation with the logmatic transformed triglyceride/high-density lipoprotein cholesterol ratio and the fasting triglycerides-glucose index, both of which were used as markers for insulin resistance. Multiple regression analyses revealed that the triglyceride/high-density lipoprotein cholesterol ratio and fasting triglyceride-glucose index were positively associated with the oleic acid/stearic acid ratio. Most markers were the worst in the highest triglyceride group in both oleic acid/stearic acid groups. In addition, most markers were worse in high oleic acid/stearic acid ratio group than low group. In conclusion, oleic acid/stearic acid ratio might be a useful marker for insulin resistance in non-obese Japanese subjects.     

Effect of in vitro interferon-beta administration on hepatitis C virus in peripheral blood mononuclear cells as a predictive marker of clinical response to interferon treatment for chronic hepatitis C

AIM:To test whether in vitro incubation of peripheral blood mononuclear cells (PBMC) with interferon (IFN) could efficiently decrease hepatitis C virus-RNA (HCV-RNA) amount and to analyze whether this effect was associated with clinical response to IFN.METHODS:Twenty-seven patients with histologically proven chronic hepatitis C were given intravenous administration of 6 million units (MU) IFN-β daily for 6 weeks followed by three times weekly for 20 weeks. PBMC collected before IFN therapy were incubated with IFN-β and HCV-RNA in PMBC was semi-quantitatively determined.RESULTS: Twenty-five patients completed IFN therapy.Eight patients (32%) had sustained loss of serum HCV-RNA with normal serum ALT levels after IFN therapy (complete responders).HCV-RNA in PBMC was detected in all patients,whereas it was not detected in PBMC from healthy subjects.In vitro administration of IFN-β decreased the amount of HCV-RNA in PMBC in 18 patients (72%). Eight of these patients obtained complete response. On the other hand,none of the patients whose HCV-RNA in PBMC did not decrease by IFN-β was complete responders. Multiple logistic regression analysis revealed that the decrease of HCV-RNA amount in PBMC by IFN-β was the only independent predictor for complete response (P<0.05).CONCLUSION:The effect of in vitro IFN-β on HCV in PBMC reflects clinical response and would be taken into account as a predictive marker of IFN therapy for chronic hepatitis C.     

Vaginal bleeding in a patient with type C liver cirrhosis without a past history of laparotomy: successful treatment with partial splenic artery embolization

A 47-year-old female patient with type C liver cirrhosis underwent endoscopic injection sclerotherapy for esophageal varices 13?years ago. The patient had no past history of hysterectomy or any other gynecological disorders. She was admitted to our hospital because of persistent vaginal bleeding and exacerbation of anemia. A contrast-enhanced computed tomography scan revealed marked dilation of not only the inferior mesenteric vein, but also the left ovarian vein, the uterine vein and the internal iliac vein. A celiac arteriography showed that the blood in the splenic vein was flowing almost totally hepatofugally into the dilated inferior mesenteric vein. An ovarian venography demonstrated knob-shaped dilation of the left ovarian vein draining into the left internal iliac vein. A proximally wedged left ovarian venography visualized the right ovarian vein and the right internal iliac vein with contrast medium via a palisade venous plexus from the dilated uterine and ovarian veins. Partial splenic embolization (PSE) was performed to increase platelet count and to reduce splenic venous blood flow into the ovarian vein. Following the PSE, the platelet count increased, and the blood flow in the dilated ovarian vein and uterine vein diminished. In addition, the portal blood flow became hepatopetal, and remarkably increased. There has as yet been no case report in which vaginal bleeding developed in women with liver cirrhosis without any past history of hysterectomy or other gynecological disorders. The present case report may be warranted in view of the rarity of the condition.