A 65-year-old woman who had liver cirrhosis(Child-Pugh class B)due to hepatitis C infection was diagnosed with hepatocellular carcinoma with hepatic vein invasion, portal vein tumor invasion, and lung metastasis. No recommended treatment was noted in the clinical practice guidelines for hepatocellular carcinoma with vascular invasion in patients with Child- Pugh class B liver cirrhosis. After initiating arterial injection chemotherapy, marked decreases in tumor size of lung metastasis, vascular invasion, and primary liver cancer were observed. Based on our experience and previous reports, hepatic arterial infusion chemotherapy was considered valuable for hepatocellular carcinoma with vascular invasion, even in patients with Child-Pugh class B liver cirrhosis.

An 81-year-old woman developed liver dysfunction after two months' treatment with direct-acting antivirals (DAAs) for chronic hepatitis C virus (HCV) infection. She was positive for serum anti-nuclear antibody, with an elevated immunoglobulin G level. A liver biopsy revealed high-grade interface hepatitis and infiltrate of lymphocytes and plasma cells. DAA-associated drug-induced autoimmune hepatitis (DI-AIH) was considered. Her liver dysfunction improved after discontinuing DAA therapy and starting prednisolone treatment. The differential diagnosis for AIH should include liver injury during DAA therapy for chronic HCV infection.

A 78-year-old man was referred to our hospital with suspected liver abscess. Fever and inflammatory reaction resolved after percutaneous drainage and administration of antibiotics. However, leukocyte count was remarkably increased, and hypercalcemia was noted. The liver mass was also enlarged, as observed in the follow-up abdominal CT scans. Therefore, a percutaneous needle biopsy was performed, and the histopathological findings indicated the presence of adenocarcinoma. Additional blood examination revealed high serum levels of granulocyte colony-stimulating factor (G-CSF) and parathyroid hormone-related protein (PTHrP). Lastly, the patient was diagnosed with cholangiocarcinoma producing G-CSF and PTHrP. Chemoradiotherapy with S-1 was initiated, which was partially effective. However, the patient died 134 days after initiating the therapy. Only two cases of cholangiocarcinoma producing G-CSF and PTHrP have been reported to date. Here we reported an additional case of cholangiocarcinoma producing G-CSF and PTHrP.

症例は71歳，女性．Vogt-小柳-原田病に対して当院眼科にてステロイド内服加療中であったが，腹痛，嘔吐，下痢，発熱が出現したため当科を受診した.感染性腸炎と診断し，絶食・補液・抗菌薬投与で加療を開始したところ，症状は数日で改善し，炎症反応もおさまったため抗菌薬投与を終了した．しかし，食事再開後に炎症が再燃し，CTにて骨盤内に膿瘍形成を認めた．抗菌薬投与を再開したが，膿瘍が消失せず症状も遷延したため，超音波内視鏡下経直腸膿瘍ドレナージを施行した．術中・術後偶発症はなく，症状・炎症反応は改善し，CTでも膿瘍の縮小が確認できた．骨盤内膿瘍に対する超音波内視鏡下経直腸膿瘍ドレナージは比較的低侵襲で有効な治療法と考えられる．しかし本邦では施行例が少なく，手技の標準化のためには，今後さらなる症例の蓄積と検討が必要である.

Background : A risk factor during endoscopic retrograde cholangiopancreatography (ERCP) is peristalsis of the duodenum. Common antispasmodic drugs such as scopolamine butylbromide and glucagon are associated with a risk of complications in patients with heart, prostate, diabetes mellitus, and thyroid disease. l-menthol has an antispasmodic effect on the smooth muscles of the stomach, bowel, and colon. Methods : We prospectively evaluated ERCP without gastrectomy at Teikyo University Mizonokuchi Hospital, between July 2014 and March 2016. Results : The total number of eligible patients was 359. The complete procedure rate with l-menthol alone was 90.5%. The median total procedure time was 23 seconds. In almost 80% of cases, appropriate peristalsis of duodenum for ERCP l-menthol alone was observed. Conclusion : We propose that l-menthol can be useful as an antispasmodic drug during ERCP.

当院における敗血症性肝障害の臨床的特徴をretrospectiveに調査し，発症早期に予後予測に役立つ因子を検討した．過去1年間の敗血症116例中，敗血症性肝障害を61例（52.6%）に認めた．敗血症性肝障害を合併した例は非合併例に比べて死亡率が有意に高かった．敗血症性肝障害合併例は非合併例と比較してDICの併発例が多く，DIC非併発例でも血清FDP, D-dimer値が高値であることから，敗血症性肝障害の発生にDICが関与していると考えられた．またDICを併発した敗血症性肝障害における死亡例と生存例の比較では死亡例で血清ALPが有意に高値であり，γ-GTPも死亡率に影響を与える可能性があった．敗血症性肝障害例において総ビリルビン値の推移を生存例と死亡例で比較したところ，死亡例で有意に総ビリルビン値の上昇を認め，経過中に黄疸を呈し死亡した例は10例であった．また死亡した10例中，3例からMRSAが検出されており，菌種別の死亡率ではMRSAが最も高かった．予後予測因子について多変量解析（ロジスティック回帰分析）で検討した結果，敗血症性肝障害発生時においてはALP高値が唯一の予後予測因子であった．以上から敗血症性肝障害の発症時に血清ALP, γ-GTPが高値であること，またMRSAが検出されることは，早期の予後予測マーカーになる可能性があると考えられた．

A 68-year-old man came to our hospital because he got edema in his left leg. Abdominal CT scan revealed multiple liver metastasis and pelvic CT scan showed marked thickening of the rectal wall and the border with the bladder became indistinct. Colonoscopic examination revealed stenosis of the rectum without mucosal abnormality. Histological examination of boring biopsies from this lesion led to the suspicion adenocarcinoma. His condition turned worse and died 1 month later. From the autopsy findings we diagnosed advanced bladder cancer with direct rectal invasion. Because this metastasis form is very rare, we report on this case along with a review of the literature.

The patient was a 43-year-old woman who was admitted to our hospital for an abdominal ultrasonography, that revealed a liver tumor. Computed tomography and magnetic resonance imaging showed a solid hepatic tumor, with adipose components, measuring 39 mm in her caudate lobe. We could not rule out the possibility of hepatocellular carcinoma. Histopathological examination of the tumor specimen obtained by using endoscopic ultrasound-guided fine-needle aspiration showed enlarged alveolars cells with oval nuclei and eosinophilic cytoplasm, and enlarged clear cells with clear cytoplasm. The tumor cells stained positive for α-SMA and HMB-45, and thereby a diagnosis of PEComa was made.

The administration of monosodium glutamate (MSG) to mice induces hepatic steatosis and inflammation. In this study, we investigated the metabolic features of MSG-treated mice and the histological changes that occur in their livers and adipose tissue. MSG mice were prepared by subcutaneously injecting MSG into newborn C57BL/6J male mice. The control mice were subcutaneously injected with saline. Another group of mice was fed a methionine- and choline-deficient diet (MCD). Compared with the control mice, the MSG mice had higher serum levels of insulin and cholesterol than the control mice, whereas the opposite was true for the MCD mice. Microvesicular steatosis and inflammatory cell infiltration were detected in both the MSG and MCD mouse livers. Enlarged adipocytes and crown-like structures were observed in the epididymal fat of the MSG mice, whereas neither of these features was seen in the MCD mice. Flow cytometric analysis revealed increased frequencies of monocytes and M1 macrophages in the livers and epididymal fat tissue of the MSG mice, respectively. The MSG mice exhibited the characteristic liver histopathology of nonalcoholic steatohepatitis (NASH) as well as metabolic syndrome-like features, which suggested that MSG mice are a better model of human NASH than MCD mice.

大腸癌イレウスおよび大腸癌による悪性狭窄に対する大腸ステント治療を8例経験した。bridge to surgeryの6例，緩和療法の2例とも偶発症を認めず，手術までの期間が平均48.4日と既報告より長かったが，大腸閉塞スコアを落とすことはなかった。緩和療法例でも生存期間中にステントの閉塞を認めず，患者QOLの向上に有用であると考えた。

An 82-year-old woman who had been administered an α-glucosidase inhibitor for diabetes consulted our hospital complaining of nausea and vomiting. Her abdomen was soft, and there was no abdominal tenderness. A plain chest X-ray and contrast-enhanced abdominal CT revealed pneumatosis cystoides intestinalis (PCI) with free air. The patient was treated conservatively with “nil by mouth”, hydration, and oxygen supplementation, which led to improvement of the symptoms. Although PCI with pneumoperitoneum caused by the administration of an α-glucosidase inhibitor is extremely rare, gastrointestinal perforation should be excluded in such patients and careful observation is required.

AimTo reveal the site of immunoglobulin (Ig)M production in primary biliary cirrhosis (PBC) we performed immunohistochemical analysis on spleens collected from patients with PBC.MethodsSplenic tissue samples were collected at the time of the autopsy from patients with hepatic failure. Immunostaining for IgM, CD21 and CXCL13 were performed using the splenic tissue samples.ResultsThe samples from five out of eight cases with PBC but not in eight cases of chronic hepatitis C virus infection showed accumulation of IgM positive cells in CD21 positive lymph follicles. The CXCL13 positive cells also accumulated in the center of the lymph follicles where the IgM positive cells accumulated.ConclusionThe present results suggest that excess IgM is produced from the spleen of PBC. Furthermore, it was suggested that CXCL13 positive follicular dendritic cells possibly contribute to this process.

Reported cases of gastric volvulus without hiatal hernia in Japan including our case (2005 to 2013) .

症例は58歳の男性．アルコール性肝硬変による腹水で入院となった．Child-Pough scoreは12点であった．塩分制限食および利尿剤に抵抗性の難治性腹水で，アルブミン製剤の投与でも改善せず，穿刺排液により意識障害を生じ，肝性脳症と肝不全を発症した．腹水濾過濃縮再静注法（Cell-free Concentrated Ascites Reinfusion Therapy：CART）の導入以降は肝性脳症の発症なく，腹水は減少した．禁酒の継続が成功し，血清アルブミン値は2.4 g/dlから3.6 g/dlに上昇し，CARTを離脱した．Child-Pough scoreは6点に改善した．CARTは本邦の肝硬変診療ガイドラインでは穿刺排液と同等に有効とされているが，穿刺排液と比較して肝性脳症，腎障害，電解質異常などの合併症の出現率が低い．本症例から，特に肝予備能不良の肝硬変例では，CARTは副作用が少なく有効な腹水治療法であると考えた．

A 71-year-old man taking acarbose for diabetes visited the hospital with a chief complaint of lower abdominal pain. Plain X-ray examination of the abdomen showed dilation of the small intestine and ileus, while non-contrast CT scan showed a high density area with multiple solids in the stomach and small intestine. One of these solids was wedge-shaped, and found in the lower small intestine with stool retention on the oral side. Inquiry from the doctor confirmed that the patient had eaten rice cakes the day prior to presenting at the hospital, and a diagnosis of dietary ileus was made. Symptoms improved after insertion of an ileus tube. rice cakes─a traditional food in Japan─appear as high density area on CT. These items are frequently eaten particularly at New Year, when an aged person may fatally choke if a rice cake becomes lodged in their throat. In this reported case, it is possible that acarbose inhibited the digestion of carbohydrate, resulting in ileus.

malignancy. High grade dysplasia (OR 6.66 [95% CI, 1.52-29.08]) and ductal dilatation (OR 10.96 [95% CI, 2.25-53.42]) were independently associated with malignancy in multivariate analysis. Fourteen (56%) of 25 patients with high grade dysplasia on endoscopic biopsy were revealed as carcinoma after resection. Conclusions The malignancy rate in ampullary adenomas on endoscopic biopsy was 26.4%. Adenoma with high grade dysplasia and ductal dilatation are significant predictors of malignancy in the ampullary adenoma.

Chronic hepatitis C (CHC) patients frequently suffer from thyroid disorders during interferon therapy. However, the mechanism remains unclear. In this study, we investigated the association between serum B-cell-activating factor belonging to the TNF family (BAFF) levels and the presence of antithyroid peroxidase antibody (anti-TPO) in CHC patients treated with pegylated interferon alpha and ribavirin combination therapy. Six months after the therapy, anti-TPO antibody was detected in 10 (males, 1; females, 9) of 50 patients. The mean age of these patients was higher than that of the anti-TPO-negative patients (61 yr versus 55 yr). Before treatment, the serum BAFF levels of the anti-TPO-positive patients were higher than those of the anti-TPO-negative patients. After starting therapy, the serum BAFF levels of both the anti-TPO-positive and -negative patient groups were elevated. Our findings suggest that the serum BAFF concentration before therapy can predict the risk of thyroid autoimmunity in elderly female patients with CHC.