The effects of transjugular intrahepatic portosystemic shunt on portal hypertensive gastropathy

In addition to variceal bleeding, haematemesis may occur due to haemorrhagic gastritis in patients with portal hypertension. This has been known as portal hypertensive gastropathy (PHG). We have evaluated the effects of the transjugular intrahepatic portosystemic shunt (TIPS) on portal venous pressure (PVP) and endoscopic gastric mucosal changes observed in patients with portal hypertension. We performed TIPS in 12 patients with complications due to portal hypertension as follows: variceal bleeding in nine patients (bleeding from oesophageal varices in seven and gastric varices in two), refractory ascites in three and haemorrhage from severe PHG in one. Endoscopic examinations were performed before and after TIPS for all patients. Changes of PVP and gastric mucosal findings on endoscopy were analysed. Before TIPS, PHG was seen in 10 patients. Portal venous pressure decreased from an average of 25.1 ± 8.8 to 17.1 ± 6.2 mmHg after TIPS ( P < 0.005). On endoscopy, PHG improved in nine of 10 patients. Oesophagogastric varices improved in eight of 11 patients. In one patient with massive haematemesis, haemorrhage from severe PHG completely stopped after TIPS. Because TIPS effectively reduced PVP, this procedure appeared to be effective for the treatment of uncontrollable PHG.     

Gastric Mucosal Blood Flow Before and After TAE

Abstract: An evaluation of gastrointestinal complications after transcatheter arterial embolization (TAE) was conducted by endoscopy in order to investigate the pathogenesis of post TAE gastrointestinal complications. In addition, the gastric mucosal blood flow (GMBF) was evaluated by a laser doppler. The incidence of complications following the administration of a H₂–blocker was 34.1%, whereas the incidence following the administration of PGE1 and without medication were 2.3% (P >0.01) and 9.4%, respectively. In the group which did not receive medication, just after a TAE the GMBF decreased markedly in the lesser curvature of the gastric antrum (P >0.01), and in the lesser and greater curvature of the gastric body. This persisted from 1 to 7 days after the TAE with the GMBF showing a tendency to recover. On the other hand, in the group who received PGE1, the GMBF did not decrease in any site of the stomach following TAE. These findings suggested that the ischemia which occurred due to a decrease in the GMBF caused the gastrointestinal complications seen.     

Growing cavernous haemangioma of the liver: 11-fold increase in volume in a decade

A 57 year old Japanese male was incidentally found to have a 7.5 cm diameter hepatic haemangioma. Eleven years later he was operated on because the haemangioma had grown into a 17 cm mass causing upper abdominal fullness. Volumetry on computerized tomograms disclosed that the haemangioma had grown from 123 cm3 to 1343 cm3 in volume. Quantitative documentation on growing hepatic haemangioma has been rare.     

Gastrointestinal Complications Following Transcatheter Arterial Embolization through Subsegmental Catheterization for Hepatic Malignancies

Abstract: We assessed gastrointestinal complications after transcatheter arterial embolization (TAE) performed over the three-year period from 1991–1994. Gastric erosion, gastroduodenal ulcer and hemorrhagic gastritis were investigated in a series of 273 cases (408 TAEs) with hepatic malignancies. Gastric erosions were found in 60 cases (7.6%), gastroduodenal ulcer in 24 cases (5.9%) and hemorrhagic gastritis in six cases (1.5%). Gastroduodenal complications occurred in a total of 60 cases (61 instances) (15.0%). Neither the formerly occurring geographic ulcers in the gastric antrum nor fatal hemorrhagic gastritis/ ulcers were encountered in the present study. This relative mildness of complications is probably attributable to superselective catheterization into the proximal hepatic artery. Such complications are due not only to ischemic changes resulting from backflow of embolic materials into the gastroduodenal artery, but also to transient liver damage caused by TAE. The incidence of complications in those taking anti-ulcer medications was 24.7% for Ha-blockers (p<0.01), 14.3% for combination therapy and 16.5% for no medication, as compared to 9.8% for PGE1 and 9.6% for Teprenone. Therefore PGE1 or Teprenone, which increase gastric mucosal blood flow, should be used to reduce the occurrence of these complications after TAE.     

The joint JMA-JICA project in Nepal

Nepal is among the 20 countries with the lowest human development index, according to the criteria of the United Nations Development Program (UNDP), and has a very high under-five mortality rate, according to the United Nations Children's Fund (UNICEF).¹ In December 1992, the Japan Medical Association (JMA) and the Japan International Cooperation Agency (JICA) began jointly carrying out a maternal and child health (MCH) project. Its beneficiaries are the population of Kavre District, the District Public Health Office in Kavre, the Central Region Health Directorate, and the Ministry of Health of Nepal. The MCH project stems from a request to Japan made by His Majesty's Government of Nepal to implement and evaluate a new health system policy in a model area, the Kavre District. The project's main goal is to improve the general health and to reduce the maternal, infant, and under-five child mortality rates by providing basic primary health care services and means of disease prevention. It will improve the government's medical care delivery system, better educate the population and promote community action in questions related to health and hygiene. This is the first cooperative project organized by JICA that involves the participation of a nongovernmental organization, in this case, the JMA. The JMA will construct the primary Health Care (PHC) Center, equip it with a dormitory and safe water supply system, and provide sufficient drugs for 2 years. The Japan International Cooperation Agency will dispatch MCH experts and provide medical equipment and supplies. The government of Nepal will dispatch a medical staff of 12 members, including a medical doctor, nurses, midwives, and laboratory technician, and other assistants as counterparts, and will be supported and monitored by the National Children's Hospital Medical Research Center of Japan. This joint project and new health policy will be evaluated after 2 years to decide whether the new PHC center system should be expanded.     

Choice of treatments for small hepatocellular carcinoma: Hepatectomy, embolization or ethanol injection

The results of hepatectomy, percutaneous ethanol injection therapy and transcatheter arterial embolization for small hepatocellular carcinoma (HCC) of 3 cm or less in diameter from the published literature were compared with the authors' experiences with surgical treatment. The survival rates for those treated by hepatectomy and ethanol injection were almost the same, being more than 90% at 1 year and 70% at 3 years. The overall results achieved by embolization were inferior to those achieved by the other two therapeutic modalities, although the 1 year survival rate was not worse. The cancer-free survival rates after hepatectomy and ethanol injection were also similar. Most of the patients with small HCC had associated liver cirrhosis or chronic active hepatitis, but the degree of liver dysfunction and the level of hepatic reserve varied. Anatomically, the number, size, and location of the cancer also varies. Choice of treatment for small HCC should be made based upon the degree of liver function and the anatomic status of the cancer. For example, a patient with multiple (more than four) cancer nodules is a good candidate for embolization. Ethanol injection is indicated for a small HCC, deeply seated in a severely diseased liver. Hepatectomy is the first choice for a small HCC situated near the surface of a liver with relatively good liver function.     

Duodenal Adenoma Removed by Endoscopic Polypectomy

Abstract: We report two duodenal adenoma cases treated by endoscopic polypectomy. Case 1, a 59-year-old male, visited our hospital for further examination of a duodenal polyp found elsewhere. X-ray examination revealed a semi-pedunculated polyp with an irregular surface in the second portion of the posterior wall of the duodenum. Case 2, a 68-year-old male, was admitted to our hospital for endoscopic polypectomy of a duodenal polyp. Upper GI series demonstrated a semi-pedunculated round polyp with a shallow central depression. Endoscopic polypectomy was performed for both lesions and the polyps were successfully removed. The resected polyps were 11 × 10 mm and 13 × 12 mm in size, respectively. The polyps were histologically diagnosed as tubulovillous and tubular adenomas, respectively, with no evidence of malignancy. Endoscopic polypectomy provides histological confirmation of adenoma of the gastrointestinal tract, and it is frequently applicable to the duodenum.     

Reactive Lymphoreticular Hyperplasia of the Stomach Showing a Submucosal Tumor

Abstract: Reactive lymphoreticular hyperplasia of the stomach has been reported rarely. Furthemore, submucosal tumors of the type found in this condition are rare and only 7 such cases have been reported. A 57-year-old male visited our hospital with his chief complaint being tarry stool. An UGI and endoscopy showed a submucosal tumor with a central depression in the posterior wall of the gastric body. Microscopically and immunohistochemically, lymphoid hyperplasia of the stomach was recognized, but it was very difficult to differentiate the condition from malignant lymphoma. The patient is in good health with no medication 2 years after surgery.