The role of iron in the pathophysiology and treatment of chronic hepatitis C.

Increased hepatic iron content may be observed in patients with chronic hepatitis C infection, and may contribute to disease severity. The presence of hemochromatosis gene mutations is associated with increased hepatic iron accumulation and may lead to accelerated disease progression. Hepatic iron depletion has been postulated to decrease the risk of hepatocellular carcinoma in patients with cirrhosis due to chronic hepatitis C. It is possible that iron depletion stabilizes or improves liver histology and slows disease progression in these individuals. The present article reviews the prevalence and risk factors for hepatic iron overload in chronic hepatitis C, with emphasis on the available data regarding the efficacy of iron depletion in the treatment of this common liver disease.

Good stents gone bad: endoscopic treatment of proximally migrated pancreatic duct stents.

BACKGROUND: Pancreatic duct stents are used for a variety of endoscopic pancreatic manipulations, and small surgical stents are used prophylactically to bridge pancreatic-enteric anastomoses. With increasing use of pancreatic stents, many complications have been recognized. OBJECTIVE: To determine the complications and outcomes of pancreatic stent migration. DESIGN: Case series from a retrospective review of all cases of upstream or proximally migrated pancreatic duct stents, placed either endoscopically or surgically, identified between 2000 and 2007. SETTING: Tertiary referral center. PATIENTS: This study involved 33 patients; 23 postendoscopic and 10 postsurgical stents. MAIN OUTCOME MEASUREMENTS: Retrieval rates, minor/major complications. RESULTS: Endoscopic stents had a successful retrieval rate of 78%. Most patients were asymptomatic. The most common procedure was balloon extraction (8 of 18; 44%). Nine patients required multiple procedures (3 patients, 2 attempts; 5 patients, 3 attempts; 1 patient, 4 attempts). Five stents could not be retrieved. Of these, 4 were associated with downstream stenosis. Four patients underwent surgery, and 1 patient was treated with observation. Complications included pancreatic duct disruption (1 of 23), stent fragmentation (1 of 23), and postprocedure pancreatitis (1 of 23). Surgically placed stents had a successful retrieval rate of 80%. Most surgical stents had migrated into the biliary tree (8 of 10). All of these patients were symptomatic with pain or fever. Two stents could not be retrieved; 1 of those patients underwent surgery. LIMITATION: Retrospective study. CONCLUSION: The majority of upstream-migrated stents can be endoscopically removed. Despite manipulation of the pancreatic duct, pancreatitis was infrequent. Surgically placed pancreatic stents migrate downstream and into the open biliary anastomosis and are associated with pain, cholangitis, or liver abscesses.

Squamous cell carcinoma arising within a choledochal cyst.

Choledochal cysts are rare congenital or acquired cystic dilatations of the intra- or extrahepatic bile ducts. Their exact pathophysiology remains unclear. Extensive complications exist with untreated cysts, including biliary stasis and inflammation, with resultant stricture and stone formation, cholangitis, pancreatitis, and malignant degeneration. Most commonly reported malignancies include cholangiocarcinoma, adenocarcinoma, and gallbladder cancer. We report the case of a 41-year-old female with a history of chronic calcific pancreatitis, choledocholithiasis, and a large type I choledochal cyst, who presented with flu-like symptoms followed by painless jaundice and weight loss. Endoscopic retrograde cholangiopancreatography and direct cholangioscopy revealed a mass at the biliary bifurcation, a 4-cm choledochal cyst with multiple calculi, absence of anomalous pancreaticobiliary ductal union, and multiple calcifications in the pancreatic head. Pathology demonstrated a synchronous choledochal cyst and squamous cell carcinoma, an infrequently reported phenomenon. We report the associated rare finding of chronic calcific pancreatitis, without anomaly of the pancreatic biliary junction. This suggests that the formation of calculi within the choledochal cyst may contribute to chronic calcific pancreatitis, possibly by virtue of papillary stenosis.

Bioprosthetic valve degeneration due to cholesterol deposition in a patient with normal lipid profile.

Hypercholesterolemia has been identified as a risk factor for bioprosthetic valvular degeneration, and it has been suggested that statin therapy reduces this risk. The case of a 77-year-old man with low levels of low-density lipoprotein cholesterol (LDL-C) and apolipoprotein B who developed marked LDL-C crystal deposition and a severe foreign body giant cell reaction 21.5 years after aortic bioprosthetic replacement is reported. This observation confirms that cholesterol deposition contributes to bioprosthetic valve degeneration, but that this can occur even in patients with low levels of LDL-C. It suggests that the characteristics of the valve are more critical than the patient's level of LDL-C.

Different food sources affect the gustatory response of Anaphes iole, an egg parasitoid of Lygus Spp.

The gustatory response of female Anaphes iole wasps to naturally occurring carbohydrates, a commercial food source, and host (Lygus lineolaris) frass was determined. Wasps responded to all 14 of the sugars at the highest concentration tested (2 M). At this concentration, sucrose, glucose, maltose, melezitose, fructose, and erlose all elicited > 90% acceptance. The lowest concentration that evoked a response (= acceptance threshold) for these sugars was < 1/256 M, with the exception of glucose. which was 1/16 M. Raffinose, trehalose, mannose, galactose, melibiose, rhamnose, stachyose, and lactose led to < 50% gustatory response by the wasps at 2 M, and were categorized as "moderately stimulatory sugars." The acceptance threshold for these sugars was > 1/4 M, with the exception of raffinose, which was 1/256 M. In trials with moderately stimulatory sugars combined with either sucrose or maltose, only the rhamnose+maltose mixture significantly inhibited the gustatory response of A. iole. Food and water deprived parasitoids readily accepted the moderately stimulatory sugars. Eliminade, a commercial food supplement, was readily accepted (92%) by A. iole. Conversely, the wasps did not feed on host frass. Chemical analysis of L. lineolaris frass demonstrated the presence of glucose, sucrose, fructose, trehalulose, and melezitose, apparently at concentrations below those perceived by A. iole. The latter two compounds were previously known only from homopteran honeydew (trehalulose and melezitose) and bacteria (trehalulose). With respect to gustatory response to nectar and honeydew sugars, A. iole differs markedly from other hymenopterans that have been studied in that this parsitoid accepted all the naturally occurring sugars with which it was tested. Moreover, this parasitoid had lower acceptance thresholds than other hymenopterans for many of the sugars. This broad and sensitive range of gustatory perception might be helpful in the development of a food source for the wasp that is not exploited by the host.