Liver transplantation-associated hypercalcemia followed by acute renal dysfunction

A 34-year-old woman with liver insufficiency due to glycogen storage disease III underwent a living spousal liver transplantation. Soon after the successful operation, moderate hypercalcemia along with hyperbilirubinemia emerged without clarified reasons. The hypercalcemia persisted for over a month despite calcitonin treatment and the serum calcium level surged to 13.2 mg/dl with albumin correction. Renal dysfunction was indicated by an acute increase in serum creatinine (approximately 0.8 to approximately 2.8 mg/ml), which was assumed to be hypercalcemia-induced and was effectively treated with bisphosphonate, pamidronate (30 mg, i.v.). Recent topics related to transplantation-associated hypercalcemia are discussed.     

Multiple ulcers with perforation of the small intestine in buerger's disease: a case report

We present the case of a young man with Buerger's disease that involved the gastrointestinal tract. The patient experienced sudden onset of abdominal pain during the period of treatment for peripheral manifestations. Radiographic workup revealed free air in the abdomen. A laparotomy was performed, and the resected specimen revealed regularly distanced and multiple ulcers in proximity of the perforation, which was accompanied by occluded intramural arteries of the small intestine. Although visceral localization of Buerger's disease is unusual, several cases have been previously reported. Nevertheless, the manifestation of regularly distanced skip intestinal ulcers in Buerger's disease is apparently unique. In addition, detailed pathological findings delineated this rare condition.     

Physiological changes in circulating mannose levels in normal,glucose-intolerant,and diabetic subjects

Mannose is an essential hexose that is required for glycoprotein synthesis. Although circulating mannose levels are known to be influenced by metabolic disorders, how physiological levels of mannose fluctuate in normal and diabetic subjects is largely unknown. We describe a new accurate and sensitive assay for determining circulating mannose levels, which we used to measure plasma mannose levels in 273 normal and diabetic (DM) subjects. Our results revealed a clear correlation (r = 0.754) between fasting plasma mannose (FPM) and fasting plasma glucose (FPG) levels. Our mannose assay showed sensitivity and specificity comparable to that seen for hemoglobin A(1c) (HbA(1c)) assay in subjects with impaired glucose tolerance (IGT) or DM whose FPG levels were normal. Mannose levels were found to increase less than glucose levels in response to an oral glucose tolerance test (OGTT). Furthermore, plasma mannose levels did not significantly change following a meal and more closely correlated with the coefficient of variation (CV) of daily glucose levels than did glucose itself. In conclusion, the close correlation between FPM and FPG levels taken together with the small fluctuations seen in plasma mannose in response to glucose suggests that the measurement of mannose using our assay could potentially play a supplementary role in the diagnosis and screening of patients with mild DM.     

Bedside swallowing assessments and brain computerized tomography findings in patients with chronic cerebral infarction and their outcomes

With the aims of evaluating the predictive value of the Smithard method of bedside swallowing assessment, and of elucidating the brain computed tomography (CT scan) findings characteristic of dysphagia, we studied the outcome and brain CT findings over a 2.2‐year follow‐up period after swallowing assessment in 102 patients with chronic cerebral infarction was performed. The subjects were 61 elderly men, average age 75.1 years, and 41 women, average age 78.1 years. They were divided into a positive group (n = 33), who displayed some difficulty swallowing water, and a negative group (n = 69). Outcomes were compared between the two groups in terms of survival, cause of death, recurrent stroke and onset of pneumonia. Brain CT findings were compared for the type, number and laterality of infarcts, the grade of periventricular lucency (PVL), presence of ventricular dilatation (VD), and degree of cortical atrophy (CA). The time elapsed since stroke till assessment tended to be longer for the positive group (mean 7.1 years) than the negative group (4.4 years), and dementia, impaired consciousness and dependent ADL status were all more common. During the observation period, 18 subjects died, 15 in the positive group as opposed to three in the negative group, resulting in a significantly higher annual death rate (29.9%vs 2.2%, χ² = 28.3, P < 0.0001). Aspiration pneumonia was thought to be the cause of death in all 15 cases in the positive group, whereas the single case of death from pneumonia in the negative group was thought to have been due to a relapse of Wallenberg's syndrome. The sensitivity and specificity of a positive swallowing assessment as a predictor of pneumonia were estimated as 0.55 and 0.94, respectively. CT findings of multiple infarction, bilateral cerebral hemispheric lesion, high grade PVL, VD and severe CA were more common in the positive group. Multiple regression analysis showed that bilateral infarction, PVL, CA and VD contributed significantly to dysphagia. From the above, aspiration pneumonia was frequently seen in the positive group, and this method showed high sensitivity and specificity in predicting this complication. The Smithard method of bedside swallowing assessment is therefore a useful screening method for identifying patients at high risk of developing pneumonia. The CT findings indicated that dysphagia is more likely with high grade PVL, VD and CA, as well as multiple infarcts. These results suggest that the etiology of dysphagia involves not only the pyramidal tracts, but a combination of factors including extrapyramidal tracts, impaired consciousness, reduced cognitive function and impairment of ADL.     

Association of the number of metastatic perigastric lymph nodes with long-term survival in gastric cancer

BACKGROUND/AIMS: The presence of metastases in lymph nodes is an important prognostic factor in patients with gastric cancer. Currently, the total number of metastatic lymph nodes (MLN) is thought to be more prognostically significant than the anatomical distribution of MLN. METHODOLOGY: The associations of the total number of MLN and of the number of perigastric (PG) MLN with long-term survival were retrospectively evaluated using uni- and multivariate analysis in 481 nodepositive gastric cancer patients who underwent potentially curative resections. RESULTS: The number of PG MLN was a better prognostic indicator than the total number of MLN (indices of correlation 0.2908 and 0.3424, respectively). Good surgical results were obtained in patients with 5 PG MLN or fewer. CONCLUSIONS: The number of perigastric metastatic lymph nodes is a more conveniently obtained and reliable prognostic factor than the total number of metastatic lymph nodes in patients with node-positive gastric cancer.     

Hepatic AdipoR2 signaling plays a protective role against progression of nonalcoholic steatohepatitis in mice

It is unclear how hepatic adiponectin resistance and sensitivity mediated by the adiponectin receptor, AdipoR2, contributes to the progression of nonalcoholic steatohepatitis (NASH). The aim of this study was to examine the roles of hepatic AdipoR2 in NASH, using an animal model. We fed C57BL/6 mice a methionine-deficient and choline-deficient (MCD) diet for up to 8 weeks and analyzed changes in liver pathology caused by either an AdipoR2 short hairpin RNA-expressing adenovirus or an AdipoR2-overexpressing adenovirus. Inhibition of hepatic AdipoR2 expression aggravated the pathological state of NASH at all stages: fatty changes, inflammation, and fibrosis. In contrast, enhancement of AdipoR2 expression in the liver improved NASH at every stage, from the early stage to the progression of fibrosis. Inhibition of AdipoR2 signaling in the liver diminished hepatic peroxisome proliferator activated receptor (PPAR)-alpha signaling, with decreased expression of acyl-CoA oxidase (ACO) and catalase, leading to an increase in lipid peroxidation. Hepatic AdipoR2 overexpression had the opposite effect. Reactive oxygen species (ROS) accumulation in liver increases hepatic production of transforming growth factor (TGF)-beta1 at all stages of NASH; adiponectin/AdipoR2 signaling ameliorated TGF-beta-induced ROS accumulation in primary cultured hepatocytes, by enhancing PPAR-alpha activity and catalase expression. CONCLUSION: The adiponectin resistance and sensitivity mediated by AdipoR2 in hepatocytes regulated steatohepatitis progression by changing PPAR-alpha activity and ROS accumulation, a process in which TGF-beta signaling is implicated. Thus, the liver AdipoR2 signaling pathway could be a promising target in treating NASH.     

Unusual cases of acute cholecystitis and cholangitis: Tokyo Guidelines

Unusual cases of acute cholecystitis and cholangitis include (1) pediatric biliary tract infections, (2) geriatric biliary tract infections, (3) acalculous cholecystitis, (4) acute and intrahepatic cholangitis accompanying hepatolithiasis (5) acute biliary tract infection accompanying malignant pancreatic-biliary tumor, (6) postoperative biliary tract infection, (7) acute biliary tract infection accompanying congenital biliary dilatation and pancreaticobiliary maljunction, and (8) primary sclerosing cholangitis. Pediatric biliary tract infection is characterized by great differences in causes from those of adult acute biliary tract infection, and severe cases should be immediately referred to a specialist pediatric surgical unit. Because biliary tract infection in elderly patients, who often have serious systemic conditions and complications, is likely to progress to a serious form, early surgery or biliary drainage is necessary. Acalculous cholangitis, which often occurs in patients with serious concomitant conditions, such as those in intensive care units (ICUs) and those with disturbed cardiac, pulmonary, and nephric function, has a high mortality and poor prognosis. Cholangitis accompanying hepatolithiasis includes recurrent pyogenic cholangitis, an epidemic disease in Southeast Asia. Biliary tract infections, which often occur after a biliary tract operation and treatment of the biliary tract, may have a fatal outcome, and should be carefully observed. The causes of acute cholangitis associated with pancreaticobiliary maljunction differ before and after operation. Direct cholangiography is most useful in the diagnosis of primary sclerosing cholangitis. If cholangiography visualizes a typical bile duct, differentiation from acute pyogenic cholangitis is easy. This article discusses the individual characteristics, diagnostic criteria, treatment guidelines, and prognosis of these unusual types of biliary tract infection.