[Acute pancreatitis triggered by an impacted minor papillary stone in a patient with pancreas divisum improved after spontaneous evacuation of the pancreatic stone:a case report].

A 56-year-old woman with epigastric pain was admitted to our hospital. Blood tests and abdominal computed tomography (CT) suggested acute pancreatitis. Abdominal CT revealed a pancreas divisum and stone in the minor papilla. Stone impaction was the most likely cause of the acute pancreatitis. The patient's abdominal pain promptly improved after admission. The patient was treated conservatively, and the pancreatitis resolved. Abdominal CT on the 10th day confirmed spontaneous evacuation of the pancreatic stone. This is a rare case of acute pancreatitis in a patient with pancreas divisum triggered by an impacted stone in the minor papilla, which improved after spontaneous evacuation of the pancreatic stone.

[Voluntary inoculation of hepatitis B vaccine at pediatric medical institutions].

We conducted a questionnaire survey on voluntary inoculation of hepatitis B (HB) vaccine to children at 79 pediatric clinics. The voluntary vaccination rate was 65.2%, the desired vaccination target was "all infants" at 84.8% of clinics, the recommended method was "only when the patient wishes" at a rate of 80.0%, and "actively recommended" at 20.0%. If there was a request, 71.7% of clinics answered that they would like to recommend it in the future, and 38.9% said that it was difficult to recommend it because of the voluntary nature of vaccination. The requests were "expansion of the scope of regular vaccination" at 60.9% of clinics and "enlightenment activities and information provision" at 54.3%. Since it was suggested that voluntary vaccination is difficult to recommend, it is necessary to proactively provide information and public relations activities regarding its necessity to medical personnel and parents.

[Questionnaire survey on hepatitis B vaccine in clinics].

We conducted a questionnaire survey on the status of implementation of hepatitis B vaccination and HBs antibody testing. It involved medical personnel covering 484 regional medical institutions in the Osaka Province. Results showed that the recognition rate was 30.1%, the hepatitis B vaccination implementation rate was 38.9%, and that of HBs antibody testing was 38.9%. Although 42.5% of the medical institutions had experienced needle-stick injuries, some medical institutions did not respond properly. The low implementation rate of hepatitis B vaccination and HBs antibody test could be explained by lack of recognition for hepatitis B infection control guidelines. Therefore, we can achieve a possible improvement in the control of infection in the Province, if sensitization programs on hepatitis B infection control are organized in the various regional medical institutions in order to provide adequate information and raise awareness on the importance of respecting these guidelines.

[The effect of introducing an on-call system for attending physicians].

Gastroenterologists working in hospitals that have adopted the chief physician system are often required to work overtime during the night and on holidays treating critically ill patients and ordering emergency tests. To help alleviate the attending physician's duties, our hospital initiated an on-call system in October 2019 to replace the existing system. Changes in overtime hours worked and business stress before and after the introduction of the on-call system were verified. After the introduction of the on-call system, both overtime hours and the number of holidays worked decreased and work stress was reduced. We report that the on-call system is a suitable alternative to the attending physician system because it increases the work efficiency and satisfaction of attending physicians.

Familial Mediterranean Fever without Fever.

Familial Mediterranean fever (FMF) is an autosomal recessive hereditary disease commonly observed around the Mediterranean basin presenting as recurrent febrile episodes. We herein describe a Japanese case of genetically-confirmed FMF, in which fever was lacking during attacks. An otherwise healthy 34-year-old man presented with frequent episodes of abdominal pain, which resolved spontaneously. During the attacks, the patient was afebrile, but the inflammatory marker levels in his blood were increased. Abdominal CT demonstrated enhancement of the jejunal membrane. After the initiation of colchicine therapy, the patient experienced no attacks for more than one year. The diagnosis of FMF was confirmed by a genetic analysis.

[Early onset of metronidazole-induced peripheral neuropathy in a patient with amoebic colitis:a case report].

Peripheral neuropathy reportedly develops after a long period of metronidazole administration. Here, we report a case of amoebic colitis in which peripheral neuropathy occurred approximately 24 hours after administering metronidazole. A 76-year-old man presented with mucous and bloody stool. Initially, lower gastrointestinal endoscopy and stool analysis confirmed the occurrence of amoebic colitis, and metronidazole was then intravenously administered. The following day, however, the patient experienced a diminished sensation in a glove-and-stocking distribution in his extremities, followed by bilateral burning foot pain. After the withdrawal of metronidazole, the symptoms improved and finally disappeared 3 months later.

[A case of cholangiolocellular carcinoma found to be hepatic hemangioma at 16-month follow up].

We report a rare case of hepatic cholangiolocellular carcinoma (CoCC) with long-term observation. A 73-year-old woman was found to have a solitary hepatic tumor with a diameter of 10mm on dynamic computed tomography (CT), which showed peripheral enhancement in the arterial phase and enhancement retention in the delayed phase. Although it was initially diagnosed as hepatic hemangioma, the follow up examination conducted 16 months later revealed that the tumor had grown to 18mm. Doubling time of the tumor was calculated to be 177 days. Because magnetic resonance imaging results were not typical for hepatic hemangioma, hepatocellular carcinoma was suspected and partial hepatectomy was performed. Histologically, the tumor was comprised dense proliferation of small irregular tubules with fibrous stroma. Immunohistochemistry revealed that the carcinoma cells were positive for cytokeratin (CK) 7, CK19, and neurnal cell adhesion molecule. Cells were negative for hepatocyte paraffin 1. Periodic acid-Schiff and Alcian blue staining showed an absence of mucin in the tumor cells, and epithelial membrane antigen was strongly positive on the luminal surface of tubules. These findings were typical of CoCC;therefore, CoCC should be ruled out when dynamic CT images suggest hepatic hemangioma.

[A case of a gas-forming liver abscess caused by Clostridium perfringens after transcatheter arterial chemoembolization].

An 80-year-old man had a medical history of chronic hepatitis C and pancreatoduodenectomy. We detected recurrence of hepatocellular carcinoma, and performed transcatheter arterial chemoembolization, instead of radiofrequency ablation or surgery, because of the patient's medical history of bile duct reconstruction and liver dysfunction. On the second day, he was diagnosed with a gas-forming liver abscess and underwent liver abscess drainage. Clostridium perfringens and sordellii were detected by aspiration and the blood culture. Meropenem and Clindamycin were administered intravenously. He was treated shortly after the occurrence before the involvement of severe hemolysis and recovered from the acute phase.

[A case of freeze-dried gas gangrene antitoxin for the treatment of Clostridium perfringens sepsis].

A 66-year-old man was admitted to our hospital with high fever. We diagnosed a gas-containing liver abscess and performed percutaneous abscess drainage. However, 15 hours after admission, he developed massive intravascular hemolysis and acidosis. Sepsis due to Clostridium perfringens was suspected and we treated the patient intensively with multidisciplinary approaches, including antibiotics, mechanical ventilation, and renal replacement therapy. Furthermore, we administered freeze-dried gas gangrene antitoxin. Despite intensive care, the patient died 43 hours after admission.

Perivascular epithelioid cell tumor (PEComa) of the liver diagnosed by contrast-enhanced ultrasonography.

Perivascular epithelioid cell (PEC) is a unique cell which expresses both myogenic and melanocytic markers, and forms PEComa. A 36-year-old woman presented with a 35 mm-diameter liver tumor. MRI showed poor fat component in the tumor. Contrast-enhanced ultrasonography using the newly developed enhancing reagent, Sonazoid, clearly demonstrated early-phase enhancement of the tumor and rapid drainage of the reagent to veins, suggesting a PEComa. Lateral segmentectomy of the liver was performed. Histologically, epithelioid tumor cells around the vessels were immunostained with both HMB-45 and alpha-smooth muscle actin, confirming the diagnosis of PEComa. No recurrence has been found for 18 months following the operation.

[A case of rectal GIST treated with imatinib mesylate neoadjuvant therapy to preserve the anus].

A 64-year-old man was admitted to our hospital with anal pain on evacuation. MRI revealed a large rectal submucosal tumor, more than 6 cm in diameter. Fine needle histological diagnosis indicated GIST with moderate risk. The patient was treated with imatinib mesylate in order to preserve the anus. The anal pain and tumor size decreased. Trans-anal local excision was performed. This case suggests that imatinib mesylate can make it possible to treat large rectal GIST cases by preserving anus, if neoadjuvant chemotherapy can be effective.

Role of cell-cycle turnover and oxidative stress in telomere shortening and cellular senescence in patients with chronic hepatitis C.

BACKGROUND: In addition to the telomere shortening that occurs with cell division, oxidative stress can damage or shorten telomeres and induce a condition termed premature senescence, possibly before telomeres become critically short. We investigated the effects of cell-cycle turnover and oxidative stress on cellular senescence in hepatitis C virus (HCV)-related chronic liver injury. METHOD: Using quantitative fluorescence in situ hybridization, the telomere lengths of hepatocytes in biopsy specimens from HCV-positive patients were estimated. We assessed clinicopathological parameters that reflect cell-cycle turnover, including Ki-67 positive index, serum alanine aminotransferase (ALT) level and degree of fibrosis, and also oxidative stress-related parameters, such as 8-hydroxy-2'-deoxyguanosine (8-OHdG) expression. Nuclear size and DNA content of hepatocytes were measured as morphological features of senescence. RESULTS: Telomere shortening correlated with the degree of cell turnover, hepatic fibrosis and morphological features of aging cells. Furthermore, the rate of telomere shortening per year was positively correlated with fibrosis progression. In cases of no or mild fibrosis, telomere lengths of positive patients were generally shorter than those of 8-OHdG-negative patients, and this trend achieved statistical significance in advanced-stage fibrosis. HCV carriers with persistently normal serum ALT level (PNAL) showed significantly longer telomeres than patients with active hepatitis and mild fibrosis. There was no significant difference in telomere lengths between HCV carriers with PNAL and normal controls. CONCLUSIONS: Cell-cycle turnover is the primary mechanism of telomere shortening, and can induce fibrosis progression and cellular senescence. However, oxidative stress can be an accelerator of senescence, especially in advanced-stage fibrosis.

Premature telomere shortening and impaired regenerative response in hepatocytes of individuals with NAFLD.

AIMS: The risk factors associated with poor prognosis of nonalcoholic fatty liver disease (NAFLD) are not fully understood. Our aim was to assess the role of progressive hepatocellular telomere shortening in the clinical course of NAFLD. METHODS: We measured average telomere lengths in liver tissue samples from 44 patients with NAFLD by quantitative fluorescence in situ hybridization using a telomere-specific probe. Patients in which telomeres measured at least 80% of the lengths of age-matched controls were categorized as group A. Those patients with telomeres measuring less than 80% of the control lengths formed group B. RESULTS: Within group B, some samples showed a remarkable shortening of hepatocyte telomeres in younger patients, whereas some group A patients showed almost normal telomere lengths until their seventies. Among clinicopathological factors, body mass index (BMI), homeostasis model assessment insulin resistance (HOMA-IR), histological degree of steatosis and intensity of 8-hydroxy-2'-deoxyguanosine (8-OHdG) immunostaining were all significantly higher in group B than in group A. Ki-67 immunohistochemistry demonstrated that group B liver tissues were significantly less proliferative than those from group A, despite no significant difference in the necroinflammatory activities of group A and B samples. In group B patients, the ratios of Ki-67 positive index to alanine aminotransferase value were significantly lower than group A. CONCLUSIONS: Greater insulin resistance can result in more severe hepatic steatosis among group B patients, leading to an overproduction of reactive oxygen species, which may accelerate telomere erosion. Furthermore the regenerative response of hepatocytes with prominent telomere shortening may be impaired, making these cells vulnerable to the effect of a 'second-hit' insult.

Multifocal intraportal invasion of breast carcinoma diagnosed by laparoscopy-assisted liver biopsy.

Hepar lobatum carcinomatosum (HLC) is defined as an acquired hepatic deformity consisting of an irregularly lobulated hepatic contour caused by intravascular infiltration of metastatic carcinoma. To date, only nine cases of HLC have been reported in the literature. We report a case of a 68-year-old woman showing hepatic metastasis of breast carcinoma in radiologically unidentified form. Initially, she received left partial mastectomy for breast cancer but solid hepatic metastases were identified in S(2) and S(6), 9 mo after surgery. Then, they responded to chemotherapy and radiologically disappeared. After radiological disappearance of the liver tumors, the patient's blood chemistry showed abnormal liver function. A CT scan demonstrated heterogeneous enhancement effect in the liver in the late phase, suggesting uneven hepatic blood supply. Hepatic deformity was not obvious. Laparoscopy revealed a slightly deformed liver surface with multiple indentations and shallow linear depressions. Furthermore, a wide scar was observed on the surface of S(2) possibly at the site where the metastatic tumor existed before chemotherapy. Liver biopsy from the wide scar lesion showed intraportal tumor thrombi with desmoplastic change. Because of its similarity to the histology of the original breast cancer, we concluded that the hepatic functional abnormalities and slightly deformed liver surface were derived from the circulatory disturbance caused by microscopic tumor thrombi. Besides, since the wide scar was located at the site of the pre-existing tumor, it is probable that chemotherapy was an important cause of fibrous scarring as a result of tumor regression. These morphologic findings are compatible with those of HLC. Laparoscopy-assisted liver biopsy was useful to make definite diagnosis, even though the hepatic deformity was radiologically undetectable.

In vivo expression patterns of survivin and its splicing variants in chronic liver disease and hepatocellular carcinoma.

AIM: Our aim was to clarify the significance of expression levels and post-transcriptional splicing patterns of survivin during multistep hepatocarcinogenesis and tumor progression. METHODS: Using immunohistochemistry, we first elucidated the expression of survivin protein in tissues of hepatocellular carcinoma (HCC) and the adjacent non-cancerous tissues. Furthermore, we investigated survivin gene expression patterns in these tissues. RESULTS: Survivin protein was expressed not only in most HCC tissues but also in some cirrhotic nodules. In non-cancerous regions, the levels of survivin mRNA increased in proportion to their stage of progression. Survivin protein was expressed mainly in periportal areas, where proliferating cells were localized. In HCC, mRNA levels of survivin and survivin Delta Ex3 correlated with high proliferative activity, whereas the levels of surviving 2B did not. DISCUSSION: These findings of mRNA and protein expressions of survivin in chronically injured avers indicate that it has an important role in hepatocarcinogenesis. A lack of correlation between proliferative activity and survivin 2B mRNA levels in HCC is suggestive of a previous hypothesis that this variant decreases sruvivin function in a dominant negative manner. Thus, our data suggest different functions of these splicing variants and their important roles in tumor progression.

Tumor size-independence of telomere length indicates an aggressive feature of HCC.

Using quantitative fluorescence in situ hybridization (Q-FISH), the average telomere length of hepatoma cells was assessed by the average telomeric signal intensity of cancer cells relative to that of stromal cells. We demonstrated first the applicability of Q-FISH for tissue sections by comparing Q-FISH and Southern blotting results. Tumors less than 50mm in diameter and with a relative telomeric intensity of less than 0.6 were categorized as group A and the remainder as group B. In group A, the telomere length correlated negatively with tumor size, whereas in group B there was no correlation. Compared with the group A tumors, the group B tumors were of significantly more advanced stage, showed higher telomerase and proliferative activities, and exhibited less differentiated histology. Therefore, we considered that a lack of correlation between telomere length and tumor size, namely, size-independence of telomere length, is associated with unfavorable clinicopathological features of hepatocellular carcinomas.

Centrosome aberration accompanied with p53 mutation can induce genetic instability in hepatocellular carcinoma.

Centrosome duplication is controlled in a cell cycle-specific manner and occurs once every cell cycle, thereby ensuring the balanced segregation of chromosomes during the mitotic phase. Numerical or structural abnormalities can arise in the centrosomes of malignant cells. Under defective cell cycle checkpoint systems, cancer cells with abnormal centrosomes can survive and re-enter the cell cycle, promoting unbalanced chromosome segregation and genetic instability. We investigated the centrosome aberrations in 33 patients diagnosed with hepatocellular carcinoma (HCC), using fluorescent pericentrin immunostaining. We also studied the p53 mutation, proliferative activity, and DNA ploidy in these cases. In normal hepatocytes, one centrosome was identified per cell as a round dot, usually in the vicinity of the nuclear membrane. However, in cancer cells from HCC tissue, several patterns of centrosome abnormalities occurred, including supernumerary centrosomes and centrosomes with an abnormal shape and size. Although the frequency of abnormal centrosomes in each tissue was relatively low compared with previous reports in other cancers, nevertheless, centrosome aberration was found in 30 out of 33 HCC tissues. The percentage of tumor cells with abnormal centrosomes was significantly higher in the nondiploid tumors (15.8+/-15.9 per thousand ) than in the diploid tumors (5.4+/-5.1 per thousand ) (P<0.05), and tended to be higher in the tumors with p53 mutation (11.6+/-13.1 per thousand ) than in those with wild-type p53 (5.6+/-6.8 per thousand ). Furthermore, 82% of nondiploid tumors exhibited p53 mutation, whereas only 41% of diploid tumors showed p53 mutation. The percentage of tumor cells with centrosome abnormalities were not related to tumor stage, size or proliferative activity. Therefore, our results indicate that hepatic cancer cells, under centrosome aberration and a defective checkpoint system possibly caused by p53 mutation, have the potential for genetic instability and aggressive behavior. This potential effect occurs irrespective of the tumor size or stage.

Differentiation of follicular from mucosa-associated lymphoid tissue lymphoma by detection of t(14;18) on single-cell preparations and paraffin-embedded sections.

A 57-year-old woman was referred to the Kyoto Prefectural University of Medicine because of multiple polypoid lesions in the duodenum. On the basis of the histopathologic findings, mucosa-associated lymphoid tissue lymphoma had been diagnosed. The polypoid lesions did not show any improvement in spite of antimicrobial therapy for elimination of Helicobacter pylori. Because the disease remained stable during the clinical course, no other specific treatment was administered. We performed fluorescence in situ hybridization (FISH) analysis on a single-cell preparation obtained from the duodenal lesions, to assess the specific chromosome translocation. We identified BCL2/IGH fusion at a frequency of 83%. Two-color FISH was also performed on paraffin-embedded tissue sections, which demonstrated BCL2/IGH fusion-positive cells in neoplastic follicles. These findings, together with the CD10+ immunophenotyping of tumor cells, led to a diagnosis of primary follicular lymphoma of the duodenum. Interphase FISH with the IGH gene and oncogene probes is a rapid and powerful tool for assessing genomic changes in gastrointestinal lymphoma on single-cell preparations and tissue sections. This technique is particularly useful in view of the increasingly small core biopsy samples and needle aspirations obtained for diagnostic purposes.