Giant hepatic hemangiomas: diagnostic and therapeutic dilemmas

This report describes four cases of surgically treated giant hepatic hemangiomas which illustrate some diagnostic and therapeutic difficulties encountered in the management of this condition. An important diagnostic triad has emerged, which should alert the physician to the possibility of a complicated hepatic hemangioma: the clinical signs of an acute inflammatory liver process contrasted with a normal white blood cell count and liver function tests. Hemangiomas of the left lobe were either missed or poorly demonstrated on selective hepatic angiographic examination, and in two patients the diagnosis was made only at the time of laparotomy. Hepatic resection was successfully performed in all patients; there was minimal morbidity and none of the patients died. In two patients with multiple hemangiomas, only symptomatic or easily resectable lesions were removed. All patients are alive and well; three have been followed up for more than 5 years. We conclude that resection in asymptomatic cases should be carried out only in those cases that require a diagnostic laparotomy and in those where the lesion is easily resectable. The majority of patients with symptomatic and complicated tumors should undergo resection, but even in these patients continued conservative treatment is appropriate when the risk of major resection outweighs the small risk of live-threatening bleeding.     

Aspergillus brain abscess. A case report

The history and findings in a patient with erythroleukaemia who developed a fungal brain abscess during the agranulocytic phase of induction treatment is reported. The radiological features of fungal infection are reported, with emphasis on the importance of clinical judgement in making the diagnosis. The autopsy findings further illustrate the increasing importance of this previously very rare condition.     

A simple breathing circuit to maintain isocapnia during measurements of the hypoxic ventilatory response

We report the development and testing of a simple breathing circuit that maintains isocapnia in human subjects during hypoxic hyperpnea. In addition, the circuit permits rapid switching between two gas mixtures with different partial pressures of oxygen. Eleven volunteers breathed repeated cycles of exposure to air (2 min of 21% O(2), balance N(2)) and hypoxia (2 min of 8.3+/-0.1% O(2), balance N(2)). Hypoxia induced significant increases in minute ventilation, breathing frequency and tidal volume (P < 0.05) that were consistent over repeated cycles of hypoxia (P > 0.1, one-way ANOVA). The system successfully maintained isocapnia in all subjects, with an average change in end-tidal CO(2) of only -0.2 mmHg during hyperventilation in hypoxia (range 0.4 to -0.8 mmHg). This system may be suitable for repeated tests of the hypoxic ventilatory response (HVR) and may prove useful for exploring intra- and inter-individual variability of HVR in humans.     

Adaptive responses of rats to prolonged treatment with epinephrine

Rats were given a daily injection of L-epinephrine, 100 micrograms/100 g body wt, for 6 wk. The hearts of the epinephrine-treated animals were heavier (11.5%), and blood glucose and plasma insulin concentrations were lower than those of control rats. Acute responses to epinephrine were compared in the two groups. An increase in blood glucose and decreases in plasma insulin, liver glycogen, and muscle glycogen occurred in both groups. The magnitude of these responses were similar in the two groups except for the decrease in muscle glycogen, which was smaller in the chronic epinephrine-treatment group. There were no changes in respiratory capacity, citrate synthase or succinate dehydrogenase activities, or in cytochrome c concentration in skeletal muscle in response to 6 wk of epinephrine treatment. These results are compatible with the suggestion that catecholamines may play a role in some of the metabolic and cardiac adaptations to exercise training. However, they argue strongly against the hypothesis that catecholamines are responsible for inducing the increase in muscle mitochondria that occurs in response to exercise training.     

Injection sclerotherapy for variceal bleeding in patients with irresectable hepatocellular carcinoma

BACKGROUND/AIMS: Patients with cirrhosis and advanced hepatocellular carcinoma are seldom cured, and have limited survival. Bleeding from esophageal varices in such patients is a major complication which, if untreated, may be a terminal event. This study evaluated the efficacy of injection sclerotherapy in controlling acute bleeding from esophageal varices and the benefit of repeated injection to eradicate varices in patients with cirrhosis and irresectable hepatocellular carcinoma. METHODOLOGY: Between 1975 and 1997, nineteen of 688 patients (2.8%) treated for bleeding esophageal varices had cirrhosis and irresectable hepatocellular carcinoma. There were 13 men and 6 women; median age, 42 years (range: 20-81). Eight patients were Child's-Pugh grade B and 11 grade C; 11 patients were Okuda stage II and 8 stage III. RESULTS: In 13 patients (68.4%) bleeding was controlled by injection sclerotherapy after a mean of 3 injections (range: 1-5), and of these esophageal varices were completely eradicated in 7 patients (53.9%), none of whom rebled. Twelve patients (63%) were discharged from hospital and had a mean survival of 100 days. Seven patients died in hospital, 5 of liver failure precipated by recurrent bleeding and 2 of hepatocellular carcinoma. Median survival for Child's-Pugh grade B patients was 80 days (range: 9-405) compared to 28 days (range: 8-117) for the grade C (P = 0.25). CONCLUSIONS: Injection sclerotherapy controlled acute variceal bleeding in most patients with hepatocellular carcinoma and provided effective palliative therapy with no further bleeding after eradication of varices.     

Animal models of fulminant hepatic failure

The six requirements for a satisfactory animal model of fulminant hepatic failure are reversibility, reproducibility, death from liver failure, a therapeutic window, a large animal model, and minimal hazard to personnel. Different models may be required to evaluate the various types of liver failure seen in man. The available models include surgical anhepatic and devascularization procedures, as well as hepatotoxic drug administration using agents such as carbon tetrachloride, acetaminophen, or galactosamine. Currently combined surgical and drug models appear to provide the best model but the search for the ideal models continues.Presented at the Proceedings of the International Meeting on Normal and Neoplastic Growth in Hepatology, Bari, Italy, June 1989.     

Pancreatic carcinoma

Background: The aim of this study was to establish the implications of a normal pancreatogram in patients with pancreatic cancer. Methods: We reviewed all ERCP done at our institution for the period 1983–92 and studied 62 of 727 patients who had a diagnosis of pancreatic (n= 416) or biliary (n= 311) cancer but a normal pancreatic duct. Results: Thirty of the 62 patients had pancreatic cancer. In 15 cases, the ERCP diagnosis was incorrect, and in 19 cases, Santorini's duct was not visualized. Other imaging revealed a pancreatic head mass in 25 patients (2.5–>7 cm). Only three patients had resectable tumors; another eight underwent laparotomy. Five had bypass surgery, 10 required biliary stenting, and nine had no treatment. Four patients died in hospital, and eight were lost to follow-up. In the remaining 18 patients, median survival was 7 months (range, 1–30 months). Conclusion: A normal pancreatogram does not exclude the diagnosis of pancreatic cancer, nor does it confer a better prognosis. Received: 4 September 1997/Accepted: 24 October 1997