Cholangiography of icteric type hepatoma

OBJECTIVES

Icteric type hepatoma caused by floating tumor debris in the major bile duct was rare. Such cases were often incorrectly identified as biliary carcinoma or choledocholithiasis until pathological proof. The goal of this study was to analyze the cholangiograms of icteric type hepatomas, and to identify the characteristic cholangiographic features of this rare disease.

METHODS

A retrospective analysis of 20 cholangiographies of icteric type hepatomas during a 10-yr period was carried out.

RESULTS

There were 15 males and five females in this series. Seventeen (85%) patients were hepatitis B virus carriers, and liver cirrhosis was detected in 16 (80%) patients. Serum alpha-fetoprotein levels in 13 (65%) of the patients were over 400 ng/ml. The cholangiographic findings included: 1) intraductal filling defects resulting in partial or complete obstruction and ductal dilation in 14 cases (70%), 2) abrupt complete obstruction of the common hepatic duct with an irregular cut surface in three cases (15%), and 3) tumor encasement and stricture of the biliary system in three cases (15%). Management of these patients included hepatic resection, choledochotomies with T tube stenting, or PTCD. Most of them died within one-half year after diagnosis, but one patient in our series, who received hepatic resection, survived more than 70 months.

CONCLUSIONS

It is important to recognize this group of patients. Because with proper management, good palliation or cure is possible. The cholangiographic appearances, when taken alone, are not diagnostic of icteric type hepatomas. Once these cholangiograms are seen in patients with associated risks of developing a hepatoma, such as liver cirrhosis, chronic viral hepatitis, and elevated serum alpha-fetoprotein, however, an icteric type hepatoma should be suspected.

Rheumatoid factor in hepatitis B virus surface antigen positive patients

Rheumatoid factor (RF) is often found in the sera of patients with nonrheumatic diseases in comparison with normal individuals. We collected 95 healthy HBs antigen positive adults and 98 healthy HBs antigen negative adults. RF was present in 14.74% (14/95) of the HBs antigen positive group while it was present in 3.06% (3/98) of the HBs antigen negative group (p < 0.05). RF was positive in 15.38% (2/13) of the HBe antigen positive patients whereas it was positive in 14.63% (12/82) of the HBe antigen negative patients (p > 0.05). RF was found positive in 16.90% (12/71) of the anti-HBe antibody positive group while it was positive in 8.33% (2/24) of the anti-HBe antibody negative group (p > 0.05). We conclude that the positive rate of RF in HBs antigen positive patients is significantly higher than in that of HBs antigen negative patients. The incidence of RF positivity of the HBe antigen positive group is not higher than that of the HBe antigen negative group. The positive rate of RF in anti-HBe antibody positive group has a tendency to be higher than in that of their negative counterparts though there was no significant difference between them.

The role of laparoscopy in the evaluation of ascites of unknown origin

The role of laparoscopy in the diagnostic evaluation of ascites of unknown origin was studied in 129 patients. Laparoscopic results were as follows: (1) Carcinomatosis peritonei in 78 (60.5%). Peritoneal biopsies in 76 of these cases revealed malignancy in 67 (adenocarcinoma 62, lymphoma 4, mesothelioma 1) and tuberculosis in 5; specimens were inadequate for diagnosis in 4. (2) Tuberculous peritonitis in 26 (20.2%). Peritoneal biopsies in 24 of these cases revealed tuberculosis in 22 and non-specific chronic peritonitis in 2. (3) Cirrhosis in 7 (5.4%). (4) No gross abnormality in 18 (14.0%). Of the latter, causes of ascites had already been identified in 13 (72.2%), including chronic renal failure in 7, systemic lupus erythematosus in 2, constrictive pericarditis in 2, chronic pancreatitis with chylous ascites in 1, and retroperitoneal lymph node metastasis with chylous ascites in 1. Thus, laparoscopic observation in combination with biopsy established the cause of ascites of unknown origin in 111 (86.0%) of 129 patients. Most of the 18 patients without gross laparoscopic abnormality had underlying disease identified as a cause of ascites; laparoscopy was indicated in these cases to exclude other processes that may also cause ascites.

Role of endoscopic retrograde pancreatography in pancreatic ascites

We present a case of pancreatic ascites. The diagnosis was strongly suspected on the basis of ascitic fluid analysis and was confirmed by observation of pancreatic duct contrast leakage at endoscopic retrograde pancreatography (ERP). Computed tomography was not helpful in this case. For localization and final confirmation of the lesion, ERP is the most valuable investigative method.

Conformation of bilirubin oxidase in native and denatured states

The conformation of bilirubin oxidase (EC 1.3.3.5) from Myrothecium verrucaria was studied by circular dichroism (CD). The far-UV CD spectrum showed a single minimum at 215 nm and a maximum near 198 nm, suggesting the dominance of beta-sheets. There was another negative band at 187 nm that is absent from the spectra of model alpha-helix or beta-sheet. CD analysis by the method of Chang et al. agreed well with the estimates based on the Chou and Fasman sequence-predictive method, but the Provencher-Glöckner method of CD analysis agreed well with the sequence-predictive method of Garnier et al. At pH 12 the 215- and 187-nm bands completely disappeared and the protein was denatured. This denaturation was accompanied by the appearance of a large positive band at 250 nm, probably due to ionization of tyrosine residues. In 20 mM sodium dodecyl sulfate the magnitude of the 215-nm band increased, but the spectrum transformed to that of partial helices after heating at 100 degrees C. In 6 M guanidine hydrochloride the far-UV CD spectrum was monotonic and became more negative at the lower wavelength limit (near 212 nm), suggesting that the secondary structure of the protein was disrupted. However, the near-UV CD spectrum retained residual aromatic bands even after heating at 100 degrees C. Thus, our denaturation studies suggest that bilirubin oxidase has a rigid tertiary structure.

Circular dichroic analysis of denatured proteins: inclusion of denatured proteins in the reference set

We hypothesize that inclusion of denatured proteins in the set of reference native proteins may better represent the unordered form in the current circular dichroism (CD) analyses of proteins involving unfolding ones. Adding three denatured-protein spectra and one oligopeptide spectrum to 16 reference protein spectra markedly improved the correlation coefficients (r) between CD calculations and X-ray determinations for the unordered form and, to a lesser extent, for beta-turn, but the r-values for alpha-helix and beta-sheet decreased slightly. With 20 reference proteins the estimates of the unordered form of denatured proteins were significantly improved. Thus, we suggest that as a compromise the new set of reference proteins be used for estimating the changes in conformation for unfolding proteins. However, the current use of 16 reference native proteins appears to be adequate for CD analysis of native proteins and the expansion to 20 reference proteins including denatured ones may not enhance the analysis of native proteins.

[Acute upper gastrointestinal bleeding in Chang Gung Memorial Hospital: comparison between 1980 and 1989]

Upper gastrointestinal (UGI) bleeding remains a great medical problem despite the improvement in both diagnostic and therapeutic management. We retrospectively analyzed 560 cases (male 429 cases, female 131 cases, mean age 45.8 +/- 23.1 years) of acute UGI bleeding within one year from January to December 1980, and 1872 cases (male 1395 cases, female 477 cases, mean age 48.7 +/- 27.5 years) within one year from January to December 1989, in order to define the changing pattern of etiology in the past 10 years. The major cause of bleeding was duodenal ulcer bleeding, which occurred at the age of 20-40 years. The incidence significantly decreased (57.8% in 1980 VS. 46.3% in 1989, P < 0.001). The second common cause was gastric ulcer (11.1% VS. 13.5%), which occurred mainly at the age of 50-70 years. The third was esophageal varices bleeding with a significantly increased incidence (6.6% VS. 11.4%, P < 0.001), which occurred mainly at the age of 40-60 years. The other less common causes included gastric cancer (5.9% VS. 5.8%), which occurred mainly at the age of 50-70 years, gastric erosion (5.2% VS. 6.1%), Mallory Weiss tear (2.1% VS. 3.1%), esophagitis (1.9% VS. 2.9%), Dieulafoy's ulcer (1.6% VS. 2.7%), vascular lesion (1.6% VS. 2.6%), and non-diagnostic cases (6.2% VS. 5.6%). The ratio of male to female for each etiology of UGI bleeding was about 3 to 1 in both 1980 and 1989.(ABSTRACT TRUNCATED AT 250 WORDS)

Ganglioneuroma of the duodenum. Report of a case and literature review

A 43-year-old male presented with upper gastro-intestinal bleeding. A polypoid tumor mass in the second part of the duodenum was found by endoscopic examination. Pathology revealed an extremely rare case of ganglioneuroma. The surgical local resection of the tumor was a sufficient procedure because of a lack of malignant potential. This is the fourth case since the first case was reported by Dahl et al in 1957 (1). We review the literature concerning duodenal paragangliomas, and discuss the histogenesis.

Comparing the human and schistosomal hypoxanthine-guanine phosphoribosyltransferases by circular dichroism

The hypoxanthine-guanine phosphoribosyltransferases (HGPRTases) of human and the parasitic trematode, Schistosoma mansoni, are of biomedical importance. The conformations of these two enzymes were studied by circular dichroism (CD). The schistosomal HGPRTase is estimated to contain 27% alpha-helix and 30% beta-structure. This result is consistent with what is predicted from a tertiary model (Craig, S.P., Cohen, F.E., Yuan, L., McKerrow, J.H. and Wang, C.C. (1991) in Molecular & Immunological Aspects of Parasitism (Wang, C.C., ed.), pp. 122-138, Am. Assoc. Adv. Sci., Washington DC, USA), which proposes that the enzyme is an alpha/beta barrel protein. The human enzyme is estimated to contain 21% alpha-helix and 53% beta-form. The two enzymes are different in their thermostability. The human enzyme remains active after being heated to 85 degrees C for 15 min, while the schistosomal enzyme only retains its activity at temperature below 65 degrees C. The transition temperature (T1/2) of the schistosomal HGPRTase was determined by CD measurement to be 57.5 degrees C. One of the enzyme substrates, phosphoribose pyrophosphate (PRPP), stabilizes the HGPRTases by preventing the human enzyme from unfolding at 85 degrees C and partially protecting the schistosomal enzyme from unfolding at 65 degrees C. It is suggested that the amino-acid substitutions in the human enzyme improve the spatial structure and stability of its alpha-helices, which may lead to an enhanced thermostability.

Collisionally activated dissociation and tandem mass spectrometry of intact hemoglobin beta-chain variant proteins with electrospray ionization

Electrospray ionization collisionally activated dissociation (CAD) mass spectra of multiply charged human hemoglobin beta-chain variant proteins (146 amino acid residues, 15.9 kDa), generated in the atmospheric pressure/vacuum interface and in the collision quadrupole of a triple-quadrupole mass spectrometer, are shown and compared. Several series of structurally informative singly and multiply charged b- and y-mode product ions are observed, with cleavage of the Thr 50-Pro 51 CO-NH bond to produce the complementary y96 and b50 sequence ions as the most favored fragmentation pathway. The eight different beta-globin variants studied differ by a single amino acid substitution and can be differentiated from the observed m/z shifts of the assigned product ions. The overall fragmentation patterns for the variant polypeptides are very similar, with the exception of the Willamette form, in which Arg is substituted for Pro- 51, and multiply charged y96 product ions are not observed. Circular dichroism spectra of normal beta A and beta Willamette show very little difference under a variety of solvent conditions, indicating that fragmentation differences in their respective CAD mass spectra are substantially governed by primary rather than secondary structure.

Eosinophilic gastroenteritis: 10 years experience

Eight patients (five men, three women), mean age 36.9 +/- 13.5 (17-60) yr, were diagnosed to have eosinophilic gastroenteritis. The condition was proved in five patients by biopsies through endoscope, and in three, by operation. All had hypereosinophilia (absolute eosinophil count of 1,337-21,787/cm3). According to Klein classification, two had mucosal disease, three had muscle layer disease, and three, subserosal disease. The most common symptoms were abdominal pain (100%), diarrhea (62.5%), vomiting (62.5%), and nausea (50%). Four patients (50%) had symptoms for more than 1 yr before diagnosis. Barium studies revealed mucosal edema and/or thickening of the small intestinal wall in three cases (including one case with ulceration), partial gastric outlet obstruction in one case, and narrowing of lumen of the terminal ileum in one case. Hypotonic duodenogram revealed double contour in one case. Ultrasound examination revealed thickening of the intestinal wall in two cases; computer tomography revealed thickening of the intestinal wall in one case. All patients were treated with steroid (40 mg/day for initial dose and relapse; 5-10 mg/day for maintenance). The symptoms subsided and the eosinophil counts returned to normal within 2 wk in seven patients and 1 month in one. Of six patients being followed up for 2-10 yr, one had remission, four needed small maintenance dose of steroid, and one suffered from relapse with intestinal perforation.

Hepatolithiasis, a clinical study

Ninety-seven hepatolithiasis cases were reviewed retrospectively. Primary hepatolithiasis was about equal in both sexes, with most patients under 39 years of age. Most secondary hepatolithiasis patients who were female-predominant, were older than 40. Common presenting symptoms were abdominal pain, either epigastric or right upper quadrant of abdomen as noted in 93%; chills and fever in 70%; nausea and vomiting in 49.5%; jaundice was noted only in 39% of the patients. Blood tests showed elevation of alkaline phosphatase in 79.8%, and gamma-GT in 88.3%. Left branch involvement was much more common that right. Escherichia coli (E. coli) was the main organism isolated in most of the cases. Abdominal ultrasonography reached a diagnostic rate of 91.01%, and the condition could be missed in cases of intrahepatic muddy stones, pneumobilia and misidentification of the location of the stones. Endoscopic retrograde cholangiography (ERC) showed a clearer picture of the biliary tree, but failed in cases of distorted anatomy because of previous operation, stones impacted in the ampulla orifice, presence of diverticulum or poor opacification of the bile duct because of stricture or stone impaction.

Conformational stability of porcine serum transferrin

The conformation of porcine serum ferric transferrin (Tf) and its stability against denaturation were studied by circular dichroism. Tf was estimated to have 19-24% alpha-helix and 50-55% beta-sheet based on the methods of Chang et al. (Chang, C.T., Wu, C.-S.C., & Yang, J.T., 1978, Anal. Biochem. 91, 13-31) and Provencher and Glöckner (Provencher, S.W. & Glöckner, J., 1981, Biochemistry 20, 33-37). Removal of the bound ferric ions (apo-Tf) did not alter the overall conformation, but there were subtle changes in local conformation based on its near-UV CD spectrum. The Tfs were stable between pH 3.5 and 11. Denaturation by guanidine hydrochloride (Gu-HCl) showed two transitions at 1.6 and 3.4 M denaturant. The process of denaturation by acid and base was reversible, whereas that by Gu-HCl was partially reversible. The irreversible thermal unfolding of Tfs began at temperatures above 60 degrees C and was not complete even at 80 degrees C. The bound irons (based on absorbance at 460 nm) were completely released at pH < 4 or in Gu-HCl solution above 1.7 M, when the protein began to unfold, but they remained intact in neutral solution even at 85 degrees C. The NH2- and COOH-terminal halves of the Tf molecule obtained by limited trypsin digestion had CD spectra similar to the spectrum of native Tf, and the COOH-terminal fragment had more stable secondary structure than the NH2-terminal fragment.

Herpes esophagitis: a cause of upper gastrointestinal bleeding in an immunocompetent patient

Herpes esophagitis presents as dysphagia and odynophagia in the majority of cases. Rarely has hematemesis been reported. We report a case of herpes esophagitis presenting with hematemesis in an immunocompetent patient. This 67-year-old man suffered from herpes esophagitis, proven by a panendoscopic examination, with characteristic histological findings. He presented with hematemesis and passage of tarry stools, but was otherwise healthy with normal humoral, cell-mediated immunity and was negative for human immunodeficiency virus antibody. Only supportive treatment was given. He has been well for the past nine months since the initial diagnosis.

Retrograde jejunogastric intussusception caused by a jejunal polyp

A 70-year-old male presented with epigastric pain, vomiting and upper gastrointestinal bleeding 11 years after a subtotal gastrectomy. Retrograde jejunogastric intussusception was diagnosed by endoscopy and barium meal study and finally confirmed by laparotomy. After reduction of the intussusception, a small polyp was found at 20 cm distal to the anastoma, which served as the leading point of intussusception. The pathophysiology and clinical manifestations of this disease were reviewed.

Gastric adenocarcinoma simulating benign gastric ulcer

The pathologic features and prognosis of patient in whom gastric cancer simulates at endoscopy as a benign gastric ulcer has been poorly characterized. We performed a retrospective study with particular reference to the long term prognosis on 191 patients treated for gastric adenocarcinoma over the period 1980-1986. In 176 of these 191 patients (92.2%), the endoscopic findings suggested cancers, while in the remaining 15 patients (7.8%), the endoscopic appearance suggested benign ulcer. Comparing gastric cancers masquerading as benign gastric ulcers with those appeared malignant endoscopically, the former had higher resectability rate (100% vs 77.3%), higher incidence of early gastric cancer (73.3% vs 6.25%), less poorly differentiated carcinoma (33.3% vs 65.4%), less lymph node metastasis (13% vs 69.5%) and a higher five-year survival rate (86.6% vs 24.8%) (p less than 0.05 in all). Our study indicated that gastric adenocarcinomas simulated benign gastric ulcers at endoscopy are mostly early gastric cancers that carry a much better prognosis.

Computed tomographic finding in adenomyomatosis of the gallbladder

We report on an uncommon case of symptomatic generalized adenomyomatosis of the gallbladder. It was initially suspected by ultrasonography and further confirmed by computed tomography (CT). A postcontrast CT scan at the level of the gallbladder body demonstrated the characteristic rosary sign. The rosary sign is formed by the enhanced proliferative mucosal epithelium with the intramural diverticula surrounded by the unenhanced hypertrophied muscle coat of the gallbladder. Similar CT scans were obtained sequentially in the caudal direction. These CT scan findings indicated generalized adenomyomatosis of the gallbladder. The patient received a cholecystectomy. The pathologic report showed specific changes of adenomyomatosis corresponding to the findings on the CT scan. Generalized adenomyomatosis of the gallbladder, therefore, can be accurately diagnosed by CT.

Conformation of concanavalin A and its fragments in aqueous solution and organic solvent-water mixtures

The conformations of concanavalin A (con A), an all-beta protein, and its three CNBr-cleaved fragments were studied by CD. Con A in buffer showed a 197 nm maximum and a 223 nm minimum, which were red-shifted by 6-7 nm from those of regular all-beta proteins and beta-sheet of (Lys)n. Fragment 1 (residue 1-42) resembled an unordered form with a CD maximum at 200 nm, but fragments 2 (residues 43-129) and 3 (residues 130-237) showed a regular CD spectrum with two extrema at 192-193 nm (+) and 214-216 nm (-). Equimolar mixture of the three fragments showed some degree of interaction, but did not reconstitute the conformation of native con A, probably because of the loss of bound Ca2+ and Mn2+ ions in the fragments. In ethanol-, methanol-, and dioxane-water mixed solvents, con A and its fragments remained as beta-sheet. In contrast, addition of trifluoroethanol and sodium dodecyl sulfate induced alpha-helix at the expense of beta-sheet for con A and its fragments in aqueous solution. In 80% trifluoroethanol, the induced helicities exceeded their sequence-predicted helix-potentials, but in 10 mM sodium dodecyl sulfate the helicities agreed well with corresponding predictions.

Adjunctive choledochoduodenostomy to choledocholithotomy in the treatment of calculous biliary tract disease

Between 1986 and 1991, 16 selected patients with calculous biliary tract disease (CBTD) underwent side-to-side choledochoduodenostomy (CDS) as an adjunct to either primary (10 patients) or secondary (six patients) choledocholithotomy. Patients selected for adjunctive CDS were those with common bile duct dilatation > or = 1.5 cm in size. All operations were elective procedures. The stoma of the CDS was about 3.0 cm in size, measured directly. There were no operative deaths. There were no early complications related to the CDS procedure itself, except for two (12.5%) wound infections. CDS significantly eliminates bile stasis which is indicated by a fall in both the serum levels of alkaline phosphatase (from 228 +/- 118 to 72 +/- 22 IU/L, p < 0.01) and total bilirubin (from 4.7 +/- 4.7 to 0.9 +/- 0.2 mg/dL, p < 0.01) postoperatively. Late complications (ascending cholangitis or sump syndrome) of CDS or recurrent symptoms of CBTD were not encountered during the average follow-up period of 21 +/- 18 months. From our clinical results, we suggest that adjunctive CDS to choledocholithotomy is a safe and effective procedure in the treatment of selected patients with CBTD.

Beta-II conformation of all-beta proteins can be distinguished from unordered form by circular dichroism

The CD spectrum of certain all-beta globular proteins resembles that of unfolded proteins with a characteristic negative band around 200 nm. The conformation of this class is tentatively termed beta-II, which had two features that were absent for unfolded proteins. First, beta-II proteins usually had CD bands due to aromatic side groups in the near-ultraviolet region. Second, the CD intensities both in the far- and in the near-uv region of these compact and rigid proteins usually showed a sharp transition upon thermal denaturation, whereas those of an unordered form changed linearly with rising temperature.

Solution structure and dynamics of epidermal growth factor and transforming growth factor alpha

Circular dichroism (CD) and Fourier transform infrared spectroscopic studies have shown that the secondary structure of transforming growth factor alpha (TGF-alpha) is very similar to that of epidermal growth factor (EGF). The infrared spectra revealed a minor difference between the two proteins, in particular in the beta-sheet structure. A large difference was observed with CD between the two proteins in the apparent conformation each adopts when the disulfide bonds are reduced. Reduced TGF-alpha showed a distinct alpha-helical conformation only at a high trifluoroethanol concentration, whereas reduced EGF assumed an alpha-helical conformation in the absence of trifluoroethanol. This indicates that these two proteins adopt different secondary structures in the absence of disulfide bonds, although they assume similar folding structures in their presence. These data suggest that the disulfide bonds to a large degree dictate the conformation of these two proteins. Additionally, differences in the dynamic behavior between EGF and TGF-alpha were also observed. Infrared experiments showed that the hydrogen-deuterium exchange rate is much higher for TGF-alpha than for EGF, indicating that TGF-alpha is a more flexible molecule. The rate of reduction of the disulfide bonds by dithiothreitol was also faster for TGF-alpha. Therefore, it can be concluded that although EGF and TGF-alpha have a similar overall conformation, TGF-alpha is a more flexible molecule than EGF.