Palliative radiation therapy for bleeding from gastric cancer: A case series of seven patients.

The hemostatic effect of palliative radiation therapy (RT) for unresectable gastric cancer is unclear. We performed palliative RT (20 Gy in 5 fractions or 30 Gy in 10 fractions) in 7 consecutive patients with bleeding. The number of blood transfusions decreased significantly post-RT, supporting the hemostatic effect of palliative RT.

[Transudative chylothorax complicated with liver cirrhosis due to primary biliary cholangitis:case report].

A 70-year-old woman who was diagnosed with liver cirrhosis as a result of primary biliary cholangitis and heart failure by myocardial infarction 1 month ago complained of dyspnea and was admitted to our hospital. Image inspections showed right massive pleural effusion, so we performed thoracentesis and drainage. Despite no history of trauma or malignancy, we obtained milky white-yellow pleural effusion by drainage and it turned out to be transudative chylothorax. Because there were no signs of heart failure exacerbation or other diseases, we suspected that the transudative chylothorax was caused by liver cirrhosis. For cardioprotection and improvement of portal hypertension, we used conservative treatments such as increasing diuretic dosage, inducing branched-chain amino acids, and switching ß-blocker medication from bisoprolol to carvedilol. Even though thoracentesis and drainages were performed twice for improvement of hypoxemia, right pleural effusion gradually decreased with the disappearance of dyspnea and she was discharged from our hospital on the 20th hospital day. We have been following her for 10 months and have found no evidence of pleural effusion. Although liver cirrhosis complicated with chylothorax is rare, several case reports have shown all patients with chylothorax caused by liver cirrhosis were transudative. It is assumed that portal hypertension by liver cirrhosis is associated with transudative chylothorax. This patient's case is complicated by insufficient ascites to be punctured. Other studies have reported that chylothorax occurs as a result of chylous ascites passing through the diaphragm in patients with liver cirrhosis;however, our case does not appear to fit the mechanism. Another study has proposed that portal hypertension increased lymph fluid production in the liver, this flow in the thoracic duct, and increased intrathoracic pressure resulting in the occurrence of chylothorax. We believe that switching ß-blocker medication from bisoprolol to carvedilol is one of the reasons this patient's right chylothorax gradually decreased. According to one case study, a nonselective ß-blocker improves chylothorax by lowering portal hypertension. As a result, a nonselective ß-blocker such as carvedilol that improves portal hypertension may contribute to a reduction in cirrhotic chylothorax in this case. Bisoprolol, a selective ß-blocker, has no effects on portal pressure and intrathoracic pressure. Our case report suggests that portal hypertension causes transudative chylothorax complicated by liver cirrhosis and that medication for portal hypertension improvement, such as a nonselective ß-blocker, is one option for treatment.

A patient with sarcoidosis who developed heterochronic involvements in different organs from initial organs during 7 years.

A 59-year-old woman, who was given a diagnosis of sarcoidosis by supraclavicular lymph node biopsy 5 years previously, was admitted for further examination following abnormal radiologic findings. Nodular pulmonary and abdominal lesions were observed by computed tomography, and liver biopsy was performed and showed epithelioid cell granulomas. She was asymptomatic and was followed up with no therapy. At 1 year follow-up, the pulmonary and abdominal lesions had nearly complete resolution. Nodular pulmonary and abdominal lesions in patients with sarcoidosis can mimic metastatic disease, lymphoma, and infection, and can reappear during disease activity. Therefore, differential diagnosis and continual follow-up are important.

Steroid treatment in patients with membranous nephropathy and hepatitis B virus surface antigenemia: a report of two cases.

Although the clinical benefits of antiviral treatment in the management of membranous nephropathy (MN) in patients with chronic hepatitis B virus (HBV) infection have been suggested, it should be evaluated more carefully. In this report, we present two cases with quiescent HBV who were administered lamivudine for either the initial treatment of MN or to control the reactivation of HBV during treatment with corticosteroids. No clinical benefit of lamivudine as an initial treatment was observed in one patient, which obliged us to commence administration of prednisolone (PSL). On the other hand, lamivudine seemed to play a pivotal role in the remission of an acute exacerbation of hepatitis B during treatment with PSL and mizoribine in the other patient. These two patients seemed to tolerate administration of PSL with or without an immunosuppressive agent well, since gradual and prompt improvements of nephrotic status were confirmed within a few months, thus suggesting the potential benefit of steroid treatment. There is little consensus regarding the optimal choice of steroids and immunosuppressants for the treatment of MN with chronic HBV infection, due to the potential for stimulation of viral replication and precipitation of hepatic flares. Our observations, however, suggest that treatment with PSL still should be reserved for quiescent HBV carriers with MN. Further studies will be required to determine the optimal timing and appropriate duration of antiviral treatment in such patients requiring long-term immunosuppression.

A case of acute hepatitis C caused by interspousal transmission after 30 years of marriage.

We describe a case of interspousal transmission of hepatitis C virus (HCV) infection after 30 years of marriage which was confirmed by gene analysis. A 60-year-old man was referred to our hospital because of severe hepatic dysfunction. Laboratory findings showed that HCV-Ab titer and qualitative Amplicor HCV were both positive in low levels. Because the patient regularly consumes various health foods, it was initially difficult to rule out drug-induced hepatopathy, but the patient was diagnosed with acute hepatitis C when HCV antibody titer increased 4 months later. Because his wife also tested positive for HCV antibody, interspousal transmission was suspected, and gene analysis was performed. Both husband and wife had HCV 1b, and the base sequence homology of 1087 base pairs (bp) in the NS5B region was 98.6% (99.4% at the amino acid level). In addition, upon analysis of the E1 and E2 junctional region sequence (268 bp) including hypervariable region 1 (HVR-1), a close relationship (89.2-99.6%) between clones obtained from each spouse was observed, thus confirming that the source of infection was his wife. Thorough medical history taking suggested that sexual intercourse was the most likely route of infection. In previous large-scale clinical studies, the frequency of HCV infection between married couples has been extremely low, but it is important to obtain informed consent regarding the potential risk of infection.

Biliary guidewire facilitates bile duct biopsy and endoscopic drainage.

BACKGROUND: The introduction of a guidewire through bile duct strictures may facilitate transpapillary bile duct biopsy and subsequent biliary drainage. METHODS: Endoscopic bile duct biopsy was attempted in 61 patients with bile duct strictures. After the introduction of a guidewire into the bile duct, biopsy forceps were inserted via the papilla. Both devices were inserted through the working channel (3.2 mm in diameter) of a conventional duodenoscope. After the procedure, an endoscopic naso-biliary drainage catheter was advanced along the guidewire. The success rate of inserting the biopsy forceps, the sensitivity of the biopsy, and the success rate of endoscopic biliary drainage after the biopsy were analyzed prospectively. RESULTS: The final diagnosis was malignant strictures in 50 patients and benign strictures in 11. The success rate of inserting biopsy forceps without performing endoscopic papillary balloon dilation was 85%. The sensitivity of the biopsy for primary bile duct cancer (83%) was significantly higher (P < 0.05) than that of pancreatic cancer (47%). All patients had successful endoscopic biliary drainage after the procedure. CONCLUSION: A previously placed guidewire facilitates insertion of biopsy forceps and endoscopic biliary drainage. The histological diagnosis of cancer is more likely with bile duct cancer than with pancreatic cancer.

Photodynamic effects on rabbit auricular veins after photosensitization with porfimer sodium: Implications of the results with respect to the treatment of esophageal varices with photodynamic therapy.

BACKGROUND: There are numerous clinical applications for photodynamic therapy in the GI tract. The principal reason for the wide variety of lesions amenable to photodynamic therapy is the ability to treat large areas of mucosa without the need for complete visualization. This report describes observed hemodynamic and histologic changes in rabbit auricles after photodynamic therapy and the feasibility of photodynamic therapy for esophageal varices. METHODS: Porfimer sodium and an argon-dye laser (630 nm, 300 mW/cm(2)) were used. Twenty rabbits were grouped according to porfimer sodium dose: group 1 (2.0 mg/kg, n = 10); group 2 (1.0 mg/kg, n = 6); group 3 (0.2 mg/kg, n = 4). Rabbit auricular veins were classified according to time duration of laser illumination: V(0), no illumination; V(5), 5 minutes; V(10), 10 minutes; V(15), 15 minutes. Hemodynamic changes were observed with a laser Doppler blood flow meter. Histologic changes were evaluated by light microscopy. RESULTS: For groups 1 and 2, there was a significant decrease in blood flow for V(15) after photodynamic therapy, but not in group 3. There was a significant difference in the grade of thrombus between V(5) and V(15) in groups 1 and 2, and between V(10) and V(15) in group 2. There was a significant difference in the grade of venous dilation (congestion) for V(15) between groups 1 and 3 (p < 0.05, Kruskal-Wallis test). CONCLUSIONS: Endoscopic photodynamic therapy could possibly improve the outcome for endoscopic treatment of esophageal varices beyond that achieved by sclerotherapy or band ligation alone.