Validation of International Autoimmune Hepatitis Group Scoring System for Diagnosis of Type 1 Autoimmune Hepatitis in Korea / 대한간학회지

BACKGROUND/AIMS: There are no pathognomonic features of autoimmune hepatitis (AIH). Its diagnosis requires the exclusion of various other conditions. The aim of this study was to validate indirectly the International Autoimmune Hepatitis Group (IAHG) scoring system in diagnosing AIH. METHODS: Twenty-six patients with Type 1 AIH and female patients with chronic hepatitis B (n=34), chronic hepatitis C (n=25), or toxic hepatitis (n=13) were evaluated according to 9 categories of pretreatment minimum required parameters proposed by IAHG. Aggregate scores of AIH to those of non-AIH groups, which were assessed before and after extracting the proportions of etiologic factors, were also compared and evaluated. RESULTS: While aggregate scores of non-AIH groups, before extracting the proportions of etiologic factors, were 5.2+/-1.8, 5.6+/-1.1, and 7.4+/-1.2 in that order, those of AIH groups were 12.8+/-1.7. These were significantly higher than those of non-AIH groups (p<0.01). All patients in AIH groups and only 1 patient in a non-AIH group showed aggregate scores of more than 10. Aggregate scores after extracting the proportions of etiologic factors were more than 4 in all, except 2, patients. These should have been consistent with 10 if there were no etiologic factors in non-AIH groups. CONCLUSION: The IAHG scoring system might have a relatively excessive importance to the scores of categories excluding distinct etiologies from AIH. It might be difficult to differentiate AIH from chronic liver diseases of indistinct cause based on the IAHG scoring system.

Clinical and Microbiological Characteristics of Spontaneous Bacterial Peritonitis (SBP) in A Recent Five Year Period / 대한간학회지

BACKGROUNDS/AIMS: Recently, treatment failure with the third generation of cephalosporin was increasingly noted in patients with spontaneous bacterial peritonitis (SBP). We therefore were to evaluate the pattern of antibiotic resistance and its clinical significance. METHODS: We retrospectively analyzed 580 episodes of SBP occurring between 1995 and 1999. There were 87 episodes of SBP in 1995, 222 in 1998, and 271 in 1999. The pattern of isolated organisms and antibiotic resistance, and prognostic factors for survival, were analyzed. RESULTS: Microorganisms were isolated in 41% of total episodes. The three most frequently isolated organisms were E. coli (48%), K. pneumoniae (15%), and Aeromonas (8%). The percentage of resistant strains to cefotaxime (9%, 14%, 32%) and ciprofloxacin (13%, 21%, 32%) significantly increased. The proportion of E. coli producing extended spectrum beta-lactamase (ESBL) also increased significantly (0%, 16%, 33%). The need of secondary antibiotics such as imipenem due to treatment failure was significantly increased from 0% in 1995 to 33% in 1999. Overall in-hospital mortality, however, was not changed (20%, 20%, 24%, respectively). The factor affecting early mortality was renal failure at diagnosis. Prognostic factors for long-term survival were the presence of associated malignancy and ESBL-producing microorganisms. CONCLUSION: Microorgansims resistant to third generation cephalosporin and quinolone were increasingly isolated over the 5 years in patients with SBP. Measures to prevent in-hospital spread of resistant strains and indiscreet use of antibiotics should therefore be instituted.

Therapeutic Efficacy of Lamivudine in Patients With Hepatitis B Virus-Related Decompensated Cirrhosis in Korea / 대한간학회지

BACKGROUND/AIMS: Although several clinical trials have suggested that lamivudine treatment can be very effective in patients with decompensated HBV-associated cirrhosis, its role and clinical efficacy are still uncertain because of the study designs. The aim of this study is to evaluate the efficacy of lamivudine in consecutively enrolled patients with decompensated cirrhosis. METHODS: Twenty-four patients with decompensated HBV-associated cirrhosis (Child-Pugh score >or=8) were enrolled consecutively and treated with lamivudine 100 mg or 150 mg daily for 2-51 months (median: 16 months). They were all positive for HBV DNA and 21 were positive for serum HBeAg. Eight were Child-Pugh class B and 16 were class C. Clinical improvement was defined as a decrease of Child-Pugh score of at least 2 points. RESULTS: At 6th month after lamivudine, all the patients cleared serum HBV DNA. The cumulative rates for HBeAg loss were 28.6% at 6th and 46.6% at 12th month. The cumulative viral breakthrough rates at 12th and 24th month were 20.0% and 37.5%. Fourteen patients (60.8%) showed clinical improvement, while 8 (34.8%) showed no change and 1 got worse, at 6th month after lamivudine. Most clinical improvement developed within the initial 6 months. The cumulative mortality rates were 20.8% at 1 year and 37.5% at 2 year. CONCLUSIONS: These data suggest that lamivudine can result in clinical improvement in about 60% of patients with HBV-related decompensated cirrhosis. Because most improvement occurrs within 6 months after starting lamivudine, liver transplantation should be actively considered in cases which do not show clinical improvement despite 6-month lamivudine treatment.

Therapeutic Efficacy of Transjugular Intrahepatic Portosystemic Shunt on Bleeding Gastric Varices / 대한간학회지

BACKGROUND/AIMS: Gastric variceal bleeding is a severe complication of liver cirrhosis with a high mortality. The purpose of this study was to determine the efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in patients with gastric variceal bleedings and predictive factors for survival. METHODS: We retrospectively analyzed the medical records of 30 consecutive patients with gastric variceal bleedings from January 1998 to March 2001. The causes of cirrhosis were viral hepatitis in 17, alcohol in 12, and biliary cirrhosis in 1. Eighteen patients were in Child-Pugh class B and 9 in class C at the time of TIPS. The median follow-up period was 403 days (3-1,215 days). RESULTS: TIPS insertion was successful in all 30 patients. The portal pressure gradient (PPG) was significantly reduced from 23+/-8 mmHg to 11+/-5 mmHg (p<0.05). Hepatic encephalopathy, which developed in 3 patients and was aggravated in 1, was improved with medical therapy. Patients with non-alcoholic etiology experienced deterioration of liver function after TIPS. Those with alcoholic etiology did not. The 6-month and 1-year rebleeding rates were 22% and 41%, respectively. 56% of bleeding episodes were associated with stent dysfunction. The degree of PPG reduction and the development of stent dysfunction were independent predictive factors for rebleeding. The 6-month and 1-year survival rates were 83% and 79%. The causes of death were hepatic failure in 3 (37.5%), recurrent variceal bleeding in 3, and others in 2. Child-Pugh class C was the only prognostic factor for survival. CONCLUSIONS: TIPS was effective in acute hemostasis and the prevention of rebleeding in patients with gastric variceal bleeding. Especially, it can be safely applied to patients with alcoholic etiology and in Child-Pugh class A or B.

A Case of Intraductal Papillary Mucinous Tumor Arising from the Accessory Pancreatic Duct / 대한소화기내시경학회지

Mucin-producing tumors of the pancreas were first reported by Ohhashi and Takagi in 1980. Since then, many cases of intraductal papillary mucinous tumor (IPMT) of the pancreas, which is almost homonymous to mucin-producing tumors of the pancreas, have been reported. IPMTs are generally regarded as tumors with a favorable prognosis. Some IPMTs have invasiveness and this is always associated with a poor prognosis. Most IPMTs arise from the main pancreatic duct and IPMTs arising from the accessory pancreatic duct are relatively rare. Only 6 cases have been reported in the literature so far. Our patient was a 43-year old man who was admitted to the hospital due to recurrent pancreatitis. An endoscopic retrograde pancreatography revealed a patulous minor papilla orifice extruding mucin and a cystic lesion in a branch of the accessory duct. A pancreaticoduodenectomy was performed and a pathologic examination of the resected specimen showed intraductal papaillary mucinous neoplasm, low grade malignancy, in the accessory pancreatic duct and its branch. We herein report this interesting case with a review of the literature.

Efficacy of Repeated Arterial Infusion of Cisplatin and 5-Fluorouracil via a Percutaneously Implantable Port System in Advanced Hepatocellular Carcinoma / 대한간학회지

BACKGROUND/AIMS: A prospective study was performed to evaluate the efficacy of low dose administration of cisplatin (CDDP) and 5-fluorouracil (5-FU) by repeated arterial infusion via a percutaneously implantable port system (PIPS) for advanced hepatocellular carcinoma (phase II trial). METHODS: Ten patients with hepatocellular carcinoma belonging to TNM stage IV, but without extrahepatic spread, were enrolled. Nine patients had main portal vein thrombosis. All the patients were positive for HBsAg. Patients were repeatedly treated with an arterial infusion of CDDP and 5-FU (10 mg and 250 mg, respectively, for 5 hours on days 1-5) via a PIPS at four week intervals. The response was assessed by dynamic CT after two courses of chemotherapy. RESULTS: Insertion of PIPS was successful in 8 of 10 patients. Two patients could not receive a second course of chemotherapy because one died of progressive hepatic failure and the other developed local infection and pseudoaneurysm formation. All the remaining 6 patients exhibited tumor progression after two courses of chemotherapy. The median survival time was 89 days (range, 59-204). The causes of death were progressive hepatic failure in one patient and uncontrolled esophageal variceal bleeding in one patient. CONCLUSIONS: Arterial infusion chemotherapy with CDDP and 5-FU via a PIPS was not an effective treatment for patients with advanced hepatocellular carcinoma.

Safety and Usefulness of Percutaneous Transhepatic Cholecystoscopy (PTCCS) in High-Risk Surgical Patients Manifesting Acute Cholecystitis / 대한소화기내시경학회지

BACKGROUND/AIMS: The aim of the present study is to identify the diagnostic and therapeutic usefulness of percutaneous transhepatic cholecystoscopic examination (PTCCS) in high-risk surgical patients manifesting acute cholecystitis. METHODS: Between January 1992 and June 1998, 33 consecutive patients who underwent percutaneous transhepatic cholecystostomy (PC) and subsequent PTCCS for the management of acute cholecystitis were included. RESULTS: PC and subsequent PTCCS were successfully accomplished in all of 33 patients. During PTCCS, minor complication (2 of minor bleeding during electrohydraulic lithotripsy, 2 of tube dislodgement and 1 of bile leakage to peritoneum) occurred in five patients. PTCCS revealed 26 cases of gallstones, 3 cases of sludge ball, 3 cases of gallbladder carcinoma and 1 case of clonorchiasis related with acute cholecystitis. Three cases of the gallbladder cancers which were not predicted radiologically were incidentally found during PTCCS. For 26 patients with gallstones, PTCCS and concomitant stone removal were successfully carried out in one to four consecutive sessions (mean 2.2 sessions). Gallstones recurred in three (3/22, 14%) patients during the mean follow-up period of 27 months. All of them remain asymptomatic. CONCLUSIONS: PTCCS may be justified in the management of acute cholecystitis in selected patients with high surgical risk.

The mRNA Expression of Tumor Necrosis Factor-Related Apoptosis-Inducing Ligand (TRAIL) and Its Receptors in Hepatocellular Carcinoma and Surrounding Liver Tissues / 대한간학회지

BACKGROUND/AIMS: TRAIL-induced apoptosis was believed to occur in tumor cell lines, while not in normal cells, which suggested that TRAIL might be safe as an antitumor therapy. Some authors advocate that this exclusive TRAIL-induced apoptosis depended on whether or not TRAIL-R3 mRNA was expressed. In this study we investigated the difference in the expression of TRAIL and its receptors mRNA between human hepatocellular carcinoma (HCC) and surrounding liver tissues. METHODS: Intra-operative sampling of HCC and paired surrounding liver tissue was performed in 12 patients who underwent hepatic resection due to HCC. After RT-PCR, using total RNA extracts from the tissues, amplified RT-PCR, products were analyzed qualitatively for the expression of TRAIL and its receptors mRNA. Both tissues were compared semi-quantitatively for the expression of TRAIL-R3 mRNA with beta-actin using the method of Nicoletti et al. RESULTS: 1) TRAIL mRNA was expressed in HCC and surrounding liver tissues in all cases. 2) TRAIL-R1, -R2, and -R3 mRNA were also expressed in HCC and surrounding liver tissues in all cases. 3) The ratio of the expression of TRAIL-R3 mRNA to beta-actin mRNA was 0.22+/-0.15 in HCC and 0.34+/-0.21 in surrounding liver tissues (p=0.124, paired t-test). 4) TRAIL, TRAIL-R1, -R2 and -R3 mRNA were expressed in all HCC cases irrespective of the degree of tumor cell differentiation. CONCLUSIONS: TRAIL, TRAIL-R1, -R2, and TRAIL-R3 mRNA were expressed in all of the HCC and surrounding liver tissues. There was no quantitative difference in the expression of TRAIL-R3 mRNA between both tissues.

A Case of Mucin-Hypersecreting Intrahepatic Bile Duct Tumor Combined with Pancreatic Intraductal Papillary Mucinous Tomor (IPMT) / 대한소화기내시경학회지

Intraductal papillary mucinous tumor (IPMT) of the pancreas is a recently understood unique clinicopathologic disease entity comprising approximately 1% of all exocrine pancreatic tumors and 11% of cystic neoplasms of pancreas. It has been reported worldwide, mostly in Japan. It is generally characterized by recurrent pancreatitis, mucin oozing from the papilla of Vater, and dilated pancreatic duct with intraductal filling defects. Microscopically, the mucin-producing columnar epithelium forms papillary proliferation into the dilated pancreatic duct and this feature differentiates IPMT of the pancreas from the more common mucinous cystic neoplasms of the pancreas which usually do not communicate with the pancreatic duct. On the other hand, mucin-hypersecreting bile duct tumors have been rarely reported in the English literature. We herein present the first case of mucin-hypersecreting bile duct tumor combied with IPMT of the pancreas with a review of the related literature.

A Case of Syphilitic Aortitis with Aortic Insufficiency and Aortic Aneurysm / 감염

Syphilitic aortitis, passing out of our mind, is the most common systemic manifestation of late syphilis and is more typically manifestated 10 to 30 years afterward. This diagnosis has been made less frequently in recent decades than in the past, because of public awareness of syphilis and screening program. Treponema pallidum lodge within vasa vasorum, especially ascending aorta cause the histologic changes, which are responsible for the three major forms of symptomatic cardiovascular syphilis, including aortic insufficiency, coronary ostial stenosis, and aortic aneurysm. We experienced a case of syphilitic aortitis with aortic insufficiency and aortic aneurysm in a 48-year-old man presented with progressive dyspnea. Echocardiography, chest CT, and later surgical correction were performed and surgical specimen revealed the histologic finding consistent with syphilitic aortitis. We report this case with a review of the literature.

A Case of Pancreas Divisum Associated with a Pancreatic Duct Stone and Stricture for which Extracorporeal Shock Wave Lithotripsy was Effective / 대한소화기내시경학회지

A 40-year-old man was presented with recurrent abdominal pain. An ERCP (Endoscopic RETROGRADE Cho-langiopancreatography) revealed complete pancreas divisum and pancreatic duct stricture with a stone. Initially, endoscopic stone removal through the minor papilla origice was unsuccessful due to an impacted pancreatic stone associated with a dominant stricture at the dorsal pancreatic duct. Extracorporeal shock wave lithotripsy (ESWL) was performed twice and the impacted pancreatic stone was fragmented. After ESWL, endoscopic stone removal became possible and pancreatic stenting was performed for the correction of the dorsal duct stricture. This case in herein reported in which ESWL was successful in treating an impacted dorsal pancreatic duct stone associated with pancreas divisum.