浅野 岳晴

A 54-year-old man was admitted with obstructive jaundice. Computed tomography showed common bile duct stricture and a tumor around the celiac artery. Repeated endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) and endoscopic retrograde cholangiopancreatography (ERCP) as well as a laparotomic biopsy around the celiac artery were diagnostically unsuccessful. Since the bile duct stricture progressed, EUS-FNA and ERCP were performed a third time, finally leading to the diagnosis of diffuse large B-cell lymphoma. The treatment plan and prognosis of obstructive jaundice differ greatly depending on the disease. It is important to conduct careful follow-up and repeated histological examinations with appropriate modifications until a diagnosis is made.

A 66-year-old man underwent a single endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) session and distal pancreatectomy for the pancreatic body adenocarcinoma measuring 12 mm in diameter. At 3 years after surgery, we diagnosed needle tract seeding (NTS) and performed total gastrectomy. NTS can occur with small tumors or after a single session of EUS-FNA.

Immunoreconstitution inflammatory syndrome (IRIS) was reported to occur in 7-13% of AIDS patients on anti-retroviral therapy (ART). IRIS due to Mycobacterium infection is one of the most difficult IRIS types to manage. A male patient in his early 70s was diagnosed with AIDS and treated with an ART. One year after starting ART, abdominal ultrasound was performed for screening and a 4 cm hypoechoic mass was found from the outside of the stomach to the surface of the hepatic lateral segment. Based on various imaging tests, including contrast CT, a malignant tumor, such as malignant lymphoma, was suspected. Then, a percutaneous tumor biopsy was performed. Pathologically, the tumor was recognized as mycobacterial granulomas. Disseminated mycobacterium avium complex can produce granulomas anywhere in the body. The patient was diagnosed with a mycobacterial infection associated with IRIS. When an intra-abdominal mass is found in a patient with HIV, both malignancy and mass formation due to opportunistic infections should be considered differential diseases.

Pruritus is known to be a common complication in hepatitis patients, but the exact frequency and degree are not fully elucidated. Thus, we evaluated pruritus of 450 patients with chronic liver disease at our hospital. Pruritus was observed in 240 (53%) of the patients. Pruritus was significantly associated with males (OR = 1.51, P = 0.038) and patients with alkaline phosphatase (ALP) ≥ 200 U/L (OR = 1.56, P = 0.0495) and was significantly less in HBsAg-positive patients (OR = 0.449, P = 0.004). Seasonally, there was no difference in the frequency of pruritus between summer and winter. Of the 24 refractory pruritus patients treated with nalfurafine, 17 (71%) indicated improvement of itch, which is defined as a decrease in the visual analog scale score ≥ 30 mm. Pruritus was improved by nalfurafine both during daytime and nighttime in the Kawashima's scores evaluation. All patients who received nalfurafine exhibited improved Kawashima's scores ≥ 1 point during the daytime or nighttime. In conclusion, pruritus occurred in > 50% of patients with chronic liver disease, and predictors of pruritus were males and ALP ≥ 200 U/L. Nalfurafine may be useful for pruritus, regardless of whether daytime or nighttime.

AIM: This study aimed to evaluate the real-world efficacy and safety of 12-week sofosbuvir/velpatasvir (SOF/VEL) treatment for patients with decompensated liver cirrhosis caused by hepatitis C virus (HCV) infection. METHODS: A total 72 of patients with Child-Pugh (CP) class B or C were enrolled. We evaluated the sustained virologic response at 12 weeks after the end of treatment (SVR12), adverse events (AEs), and changes in the liver function. RESULTS: All participants had genotype 1 or 2 HCV infection. At baseline, the numbers of patients with CP class B and C were 59 and 13, respectively. The overall SVR12 rate was 95.8% (69/72); 94.9% (56/59) in CP class B and 100% (13/13) in CP class C. The serum albumin level, prothrombin time and ascites were significantly improved (P < 0.01); however, the serum bilirubin level and encephalopathy did not improve. Among patients who achieved SVR12, 75.0% showed an improvement in their CP score, while 5.9% showed a worsening. The presence of large portosystemic shunt (diameter ≥6 mm) and hyperbilirubinemia (≥2.0 mg/dL) were independent factors that interfered with the improvement in the CP score (P < 0.05). The most common AEs were encephalopathy (15.3%) and skin symptoms (7.9%). Two patients discontinued SOF/VEL due to AEs. CONCLUSIONS: Treatment with SOF/VEL for 12 weeks was relatively safe and effective for patients with decompensated cirrhosis. An SVR provided an improvement of the liver function in the majority of patients. However, large portosystemic shunt and hyperbilirubinemia were independent factors that interfered with the improvement in the CP score.

An 83-year-old man with a history of carbon ion radiotherapy for hepatocellular carcinoma nine years ago presented to a primary care hospital with a fever and abdominal pain. He underwent computed tomography, which revealed the rupture of a hepatic pseudoaneurysm close to the fiducial marker for carbon ion radiotherapy and bleeding into the bile duct. He was successfully treated with transcatheter arterial embolization. Thereafter, re-rupture occurred from a site proximal to the first rupture, and this was treated similarly. It is necessary to be alert for not only tumor recurrence but also pseudoaneurysm occurrence after carbon ion radiotherapy.

We report the case of a woman in her 40s with an asymptomatic, congenital intrahepatic portosystemic venous shunt diagnosed during a routine examination for uterine cervical cancer. Contrast-enhanced computed tomography (CT) and superior mesenteric arterial portography showed a complex intrahepatic portosystemic venous shunt with concomitant portal vein aneurysm near the hepatic hilum. The shunt appeared likely to be difficult to occlude via the usual endovascular procedure because the shunt point was narrow and short. Therefore, we performed coil embolization using a double microcatheter single vascular access technique and successfully treated without any complications.

BACKGROUND: Hepatocellular carcinoma (HCC), the fifth most common cancer type and the third highest cause of cancer death worldwide, develops in different types of liver injuries, and is mostly associated with cirrhosis. However, non-alcoholic fatty liver disease often causes HCC with less fibrosis, and the number of patients with this disease is rapidly increasing. The high mortality rate and the pathological complexity of liver diseases and HCC require blood biomarkers that accurately reflect the state of liver damage and presence of HCC. METHODS AND FINDINGS: Here we demonstrate that a circulating protein, apoptosis inhibitor of macrophage (AIM) may meet this requirement. A large-scale analysis of healthy individuals across a wide age range revealed a mean blood AIM of 4.99 ± 1.8 µg/ml in men and 6.06 ± 2.1 µg/ml in women. AIM levels were significantly augmented in the younger generation (20s-40s), particularly in women. Interestingly, AIM levels were markedly higher in patients with advanced liver damage, regardless of disease type, and correlated significantly with multiple parameters representing liver function. In mice, AIM levels increased in response to carbon tetrachloride, confirming that the high AIM observed in humans is the result of liver damage. In addition, carbon tetrachloride caused comparable states of liver damage in AIM-deficient and wild-type mice, indicating no influence of AIM levels on liver injury progression. Intriguingly, certain combinations of AIM indexes normalized to liver marker score significantly distinguished HCC patients from non-HCC patients and thus could be applicable for HCC diagnosis. CONCLUSION: AIM potently reveals both liver damage and HCC. Thus, our results may provide the basis for novel diagnostic strategies for this widespread and fatal disease.

症例は50歳の女性．繰り返す膵炎と心窩部痛の精査目的に当院紹介．造影CT，USで腫瘍や膵管・胆管拡張は認めなかったが，胆道シンチグラフィにて十二指腸への胆汁排泄遅延を認めた．入院時血液検査所見（無症状時）では肝胆道系，膵酵素，IgG4値の異常は認めなかった．ERCP所見は胆管挿管困難にてprecut施行後に胆管造影・IDUS実施したが器質的閉塞は認めなかった．主乳頭からは膵管像得られず，副乳頭からの膵管造影で背側膵管のみ造影された．膵炎の原因は膵管癒合不全と診断し，副膵管口切開術を施行した．また，biliary typeの十二指腸乳頭括約筋機能不全（SOD）も合併していると診断し，乳頭括約筋切開術も同時に施行した．その後，内視鏡的乳頭バルーン拡張術の追加を要したが，以後は膵炎の再燃も認めず自覚症状も改善している．膵管癒合不全を伴ったSODの報告は稀であり若干の文献的考察を加えて報告する．<br>

症例は73歳，男性．C型慢性肝炎にて当院通院中であった．1999年，肝細胞癌（S5単発，径3 cm）が認められ肝右葉前区域切除術を施行した．術後は4-6カ月ごとに腹部USおよびCT検査にて経過観察していた．2009年3月の腹部CT検査にて，肝右葉の手術断端に，内部が不均一で一部造影効果を示す病変が認められた．同病変は同年5月のCTにて増大傾向を認め，仮性動脈瘤と診断された．腹部血管造影では，右肝動脈の前区域枝起始部に3 cm大の仮性動脈瘤を認めた．破裂予防のため，瘤のコイル塞栓術を施行した． 仮性動脈瘤の破裂の頻度や破裂後の死亡率は高率であるため，より早期の治療が望ましいとされている．また肝癌術後の画像フォローでは，術後晩期においても再発腫瘍の有無のみならず，動脈瘤や血栓などの血管変化にも留意する必要があると考えられた．

60歳女性．突然ショック状態となり，造影CTにて脾臓および転移性肝腫瘍からの腹腔内出血と診断した．同部位に対するTAEにて血行動態は安定したが，第13病日死亡した．剖検にて腹膜播種，肝・肺・リンパ節転移をともなう脾原発血管肉腫と診断した．本疾患は原発臓器のみならず転移巣からも出血をともなうことがあり，TAEが出血性ショックに対する一時止血に有用であったと考えられ，本邦報告42例の検討とともに報告する．<br>

脂肪肉腫は大腿や後腹膜に好発するwhite adipose tissueの悪性腫瘍で，高率に再発，血行性転移がみられる．患者は60歳男性．化学療法と手術を施行し原発巣は十分にcontrolされていたが，肝に転移巣が出現した．病変は肝内に限局し，化学療法抵抗性を示したため，radiofrequency ablation（RFA）治療を行い，焼灼十分を確認した．転移性肝癌に対しても，化学療法等と組み合わせた集学的治療の一環として，RFAが有効な手段になると考えた．

脂肪肉腫は大腿や後腹膜に好発するwhite adipose tissueの悪性腫瘍で，高率に再発，血行性転移がみられる．患者は60歳男性．化学療法と手術を施行し原発巣は十分にcontrolされていたが，肝に転移巣が出現した．病変は肝内に限局し，化学療法抵抗性を示したため，radiofrequency ablation（RFA）治療を行い，焼灼十分を確認した．転移性肝癌に対しても，化学療法等と組み合わせた集学的治療の一環として，RFAが有効な手段になると考えた．<br>