Does hepatic oxidative stress enhance activation of nuclear factor-E2-related factor in patients with nonalcoholic steatohepatitis?

The imbalance of hepatic oxidant and antioxidant status is an important pathophysiological mechanism in nonalcoholic steatohepatitis (NASH). The nuclear factor-E2-related factor (Nrf2) is a key transcription factor regulating a plethora of antioxidant genes involved in antioxidant defense. To clarify the mechanisms of hepatic antioxidant defenses in human NASH, the aim of the current study was to examine oxidative stress-induced Nrf2 activation in the livers of patients with NASH. Liver biopsies were obtained from 19 NASH patients. Normal liver tissue was obtained from surgical resection specimens of 15 patients. The proportion of hepatocytes with 8-hydroxydeoxyguanosine (8-OHdG)-positive nuclei was increased in NASH livers compared with that in normal livers. Hepatic Nrf2 protein levels were increased with enhanced accumulation of hepatocellular nuclear Nrf2, which was positively correlated with that of 8-OHdG. Hepatic expression of γ-glutamylcysteine synthetase (γGCS), glutathione peroxidase 2 (GPx2), thioredoxin (TRX), and heme oxygenese 1 (HO-1), but not thioredoxin reductase 1 (TrxR1), was upregulated, and the protein levels of γGCS were positively correlated with those of Nrf2. Collectively, our findings lead to the hypothesis that oxidative stress may enhance Nrf2 activation in the livers of patients with NASH.

Hemorrhagic radiation gastritis successfully treated with repeated intra-arterial steroid infusions

Intra-arterial steroid infusion therapy has previously been shown to be effective for inflammatory bowel disease; however, few cases in which it has been used for the treatment of hemorrhagic radiation gastritis have been reported. We report the case of a 70-year-old Japanese man with hemorrhagic radiation gastritis induced by radiation therapy for para-aortic lymph node metastases of hepatocellular carcinoma. Two months after completing radiation therapy, acute persistent bleeding occurred in the gastric irradiation area. Although argon plasma coagulation was performed five times over a month, the bleeding continued and the patient showed persistent anemia that required 50 units of blood transfusion. Finally, the patient was given intra-arterial steroid infusions through the right gastric artery and the right gastroepiploic artery. After three intra-arterial steroid infusions, the melena stopped, and the anemia no longer progressed. Hemorrhagic radiation gastritis was successfully treated with repeated intra-arterial steroid infusions through the regional vessels to the gastric mucosa. Repeated intra-arterial steroid infusions could be a clinically useful option for the treatment of intractable bleeding from radiation gastritis.

Enhanced hepatic Nrf2 activation after ursodeoxycholic acid treatment in patients with primary biliary cirrhosis

The cytoprotective mechanisms of ursodeoxycholic acid (UDCA) in primary biliary cirrhosis (PBC) have not been fully clarified. UDCA has some antioxidant properties. Nuclear factor-E2-related factor-2 (Nrf2) plays a critical role in protecting a variety of tissues against oxidative stress. Therefore, to investigate the potential antioxidant effects of UDCA in PBC, we determined the intracellular status of both oxidant stress and antioxidant defenses in paired pre- and posttreatment liver biopsies from 13 PBC patients by immunodetection of 8-hydroxydeoxyguanosine (8-OHdG), Nrf2-, and Nrf2-mediated antioxidant proteins. After UDCA treatment, the number of 8-OHdG-positive hepatocytes or bile duct cells decreased with improvement of hepatic injury. The hepatic levels of both total and phosphorylated Nrf2 protein were increased, along with upregulation of nuclear phosphorylated Nrf2 expression in bile duct cells. In addition, the levels of both thioredoxin (TRX) and thioredoxin reductase 1 (TrxR1) protein were increased in the liver after UDCA. The upregulation of hepatic TRX or TrxR1 protein expression positively correlated with that of total Nrf2 protein expression. In conclusion, UDCA treatment can enhance hepatic Nrf2 activation and upregulate hepatic TRX and TrxR1 protein expression. Hepatic Nrf2 activation may play a role in the therapeutic response to UDCA in PBC.

Atypically enhanced cavernous hemangiomas of the liver: centrifugal enhancement does not preclude the diagnosis of hepatic hemangioma

The imaging features of an atypically enhanced hepatic hemangioma have not been well described in the literature, and the presence of such atypia may sometimes cause clinical problems in the differential diagnosis. Herein, we report a case of hepatic hemangioma demonstrating a previously unreported atypical enhancement pattern. On dynamic computed tomography during hepatic arteriography, a centrifugal enhancement pattern and subsequent peritumoral ring-shaped enhancement mimicking corona enhancement were found in cavernous hemangiomas of the liver in a 68-year-old Japanese man. Histopathological diagnosis of cavernous hemangioma of the liver was made on a biopsy specimen. Considering the importance of differentiating benign hepatic tumor from various forms of malignancy, radiologists and hepatologists should be aware of rare enhancement patterns sometimes seen in hepatic hemangioma. Establishing knowledge of the entire spectrum of atypical hepatic hemangioma may benefit the rational approach to future cases.

Genetic analysis of the susceptibility in rats to aberrant crypt foci formation by 2-amino-1-methyl-6-phenylimidazo [4,5-b]pyridine, PhIP

2-Amino-1-methyl-6-phenylimidazo[4,5-b]pyridine (PhIP), the most abundant heterocyclic amine produced while cooking fish and meat, induces aberrant crypt foci (ACF) and colon cancers in rats. We previously reported that F344 rats were sensitive and ACI rats resistant to ACF formation by PhIP, and that the genetic susceptibility in F344 rats to ACF formation by PhIP was autosomally dominant over ACI rats. To identify candidate susceptibility genes in F344 rats, a preliminary genome-wide linkage analysis was employed using a subset of 170 progeny of (F344 x ACI)F1 x ACI backcross rats with either high or low sensitivity to ACF formation by PhIP. Three chromosomes, 1, 6 and 16, demonstrated the presence of loci with a logarithm of the odds (lod) scores of more than 1.0, and a susceptible gene for ACF formation by PhIP was suggested to reside on chromosomes 16.

Serum thrombopoietin levels in patients with chronic hepatitis and liver cirrhosis

OBJECTIVE

Thrombocytopenia is a common manifestation of cirrhosis. The aim of this study was to examine the relationship between serum thrombopoietin concentrations, circulating platelet levels, and the stage of hepatic fibrosis in patients with chronic viral hepatitis.

METHODS

The study included 48 patients with chronic viral hepatitis (14 with stage 1 fibrosis; five with stage 2 fibrosis; three with stage 3 fibrosis; 26 with cirrhosis) and 30 healthy volunteers. Serum thrombopoietin levels were measured using an enzyme-linked immunosorbent assay. Spleen size, platelet counts, and prothrombin time were measured.

RESULTS

Thrombopoietin levels of patients with fibrosis stage 1 (2.50 +/- 1.60 fmol/ml) or stage 2 (1.89 +/- 0.65) were significantly higher than those in patients with cirrhosis (1.21 +/- 0.55) or healthy volunteers (1.26 +/- 0.74). Mean platelet counts of patients with cirrhosis (8.0 +/- 4.6 x 10(4)/microl) were significantly lower than those with fibrosis stage 1 (18.6 +/- 3.9) or stage 2 (16.0 +/- 5.8), or healthy volunteers (24.5 +/- 7.3). Patients with cirrhosis had larger spleens (30.9 +/- 18.4 cm2) than those with fibrosis stage 1 (18.2 +/- 6.4). Platelet counts showed a significant inverse relationship to spleen size (p = -0.51, p < 0.0005) and a significant positive relationship with thrombopoietin levels (p = 0.34, p < 0.02). Thrombopoietin levels were significantly correlated to prothrombin time (p = 0.45, p < 0.005).

CONCLUSIONS

Serum thrombopoietin levels are elevated in patients with an early stage of chronic viral hepatitis. As the disease progresses from mild fibrosis to cirrhosis, decreased production of thrombopoietin may contribute to the further development of thrombocytopenia in cirrhosis.

Improved long-term survival following complete eradication of esophageal varices by sclerotherapy

BACKGROUND/AIMS

Conflicting results have been reported concerning the effect of endoscopic injection sclerotherapy upon the long-term survival of cirrhotic patients with esophageal varix. The recurrence and rebleeding of esophageal varices seems to be an important factor influencing long-term survival. We investigated the long-term survival of patients after complete eradication of esophageal varices.

METHODOLOGY

Forty patients treated by endoscopic injection sclerotherapy for acute esophageal variceal bleeding were studied. The recurrence rate of varices and the long-term survival of patients in whom complete eradication of esophageal varices was obtained were compared with those of patients in whom the eradication of varices was incomplete.

RESULTS

The frequency of the recurrence/deterioration rate of varices and rebleeding in the complete eradication group was significantly lower than that in the incomplete eradication group (10.7% vs. 100%, 0% vs. 58.3%, respectively, p < 0.01). Accumulated 5-year survival rate of the complete eradication group was significantly higher than that of the incomplete eradication group (68.2% vs. 43.2%, p < 0.05).

CONCLUSIONS

Complete eradication of esophageal varices by endoscopic injection sclerotherapy is effective both in preventing variceal re-bleeding and in improving the survival of cirrhotic patients with esophageal varices.

Failure to respond to interferon-alpha 2a therapy is associated with increased hepatic iron levels in patients with chronic hepatitis C

Recent reports suggest the hepatic iron concentration (HIC) may influence the activity of hepatitis and the response to interferon (IFN) therapy in patients with chronic hepatitis C (CH-C). We have evaluated iron status in 28 patients with CH-C and determined if pretreatment iron status can predict the response to IFN-alpha therapy in these patients. Increased serum iron, transferrin saturation, and ferritin levels were observed in 3 (11%), 11 (39%), and 5 (18%) patients, respectively. Hepatic iron deposits were histologically detected in 17 (61%) patients, and 14 of them had stainable hepatocytic iron. However, all HIC values were within the normal range (203-1279 microg/g). Seven of 17 patients treated with IFN-alpha for 6 mo had normalization of serum transaminases and disappearance of serum HCV-RNA (responders). Nonresponders had a significantly higher median HIC compared with responders (710 vs 343 microg/g, respectively; p < 0.05). There was no significant difference in other pretreatment iron parameters, serum HCV-RNA level, or HCV-genotype between responders and nonresponders. In conclusion, mild hepatic iron accumulation occurs in patients with CH-C. Increased hepatic iron stores are associated with poor response to IFN therapy. Pretreatment HIC may be an additional host-specific parameter with a predictive value for responsiveness to IFN therapy, in addition to well-known predictive viral factors.

Effects of acute and chronic ethanol administration on hepatic hemodynamics and hepatic oxygen consumption in awake rats

BACKGROUND/AIMS AND METHODS

We investigated the effects of acute and chronic ethanol administration on hepatic hemodynamics and hepatic oxygen delivery and consumption in awake rats, using the radiolabeled microsphere technique and measurement of oxygen content in blood.

RESULTS

Acute oral and intraarterial ethanol administration produced a significant increase in liver blood flow and hepatic oxygen delivery, but resulted in a significant (25-41%) decrease in hepatic oxygen consumption. These changes lasted up to 5 h after ethanol administration. At 24 h, hepatic oxygen consumption was significantly increased by 33% over control values. During withdrawal in rats fed liquid diets containing alcohol for 6 weeks, hepatic oxygen delivery was maintained at the same level as control pair-fed rats, while hepatic oxygen consumption increased by 28%. Further, in abstinent rats, acute ethanol readministration resulted in a 41% increase in hepatic oxygen delivery but a 32% decrease in hepatic oxygen consumption.

CONCLUSIONS

These findings demonstrate, in awake animals, a biphasic response of hepatic oxygen consumption following acute ethanol administration and an increase in hepatic oxygen consumption following chronic ethanol intake. Furthermore, acute ethanol treatment reduced hepatic oxygen consumption in spite of an increase in hepatic oxygen delivery.

[Deterioration of liver function following endoscopic injection sclerotherapy of esophageal varices--significance of a new index for liver function "delta TB"]

Changes of liver functions associated with endoscopic injection sclerotherapy (EIS) in which less than 6 ml of 5% ethanolamin oleate was used were investigated in 50 patients with remarkable esophageal varices. The index used for evaluating hepatic reserve was the difference of total bilirubin in serum between immediately and 15 hours after EIS and was tentatively named as "delta TB" (normal range < or = 0.1). In the patients classified as Child-Pugh A (n = 25), Child-Pugh B (n = 19) and Child-Pugh C (n = 6), delta TB was 0.04 +/- 0.30, 0.23 +/- 0.41, and 0.54 +/- 0.21, respectively. One month after the entire sessions of EIS, the changes of liver function tests before and after EIS were compared in 45 cases. It was disclosed that delta TB was elevated in parallel with the severity of their liver dysfunction before EIS. Also, delta TB seems to reflect the prognosis of the patients treated by EIS for some extent, since the survival period of the cases treated by EIS were correlative with delta TB (r = -0.734, p < 0.01), and delta TB of 20 cases who survived for longer than 5 years after EIS was 0.04 +/- 0.32. Therefore, delta TB seems to be a useful marker for estimating the influence of EIS on liver function.

[Complete eradication by endoscopic injection sclerotherapy reduces the recurrence of esophageal varices]

Endoscopic intravariceal injection sclerotherapy (EIS) using sclerosant mixed with contrast medium was done in 100 patients without hepatocellular carcinoma. They were followed longer than 12 months (mean; 58 +/- 29 months) after EIS. The recurrence rate of esophageal varices in cases with complete eradication (n = 79) and cases with incomplete eradication of (n = 21) was 8.9% and 85.7%, respectively (p < 0.01). In 21 cases, complete eradication was achieved by intravariceal injection and additional therapy using paravariceal injection was not performed. The recurrence rate of this group was only 4.8%. Endoscopic varicealography during injection sclerotherapy were evaluated in 91 cases. At final session of EIS, narrowing of diameter (less than 1 mm) and irregularity of vessel walls were observed in small vessels (devastated vessels). Appearance rate of devastated vessel in 75 cases with completely eradicated esophageal varices was 65.3%. In contrast, among 16 cases with incomplete eradication of varices, devastated vessels were seen only in 6.3% (p < 0.01). It is concluded that the important point in preventing the recurrence of esophageal varices after EIS was the complete eradication of esophageal varices by intravariceal injection sclerotherapy resulting in the eradication of the routes to esophageal varices from port-splenic venous system. For the sake of accomplishment of this treatment, appearance of devastated vessel is very useful.

[Deterioration of liver function following endoscopic injection sclerotherapy of esophageal varices--significance of the new liver function test "intravariceal injection (I.I.) index"]

Changes of liver functions associated with endoscopic injection sclerotherapy (EIS) were investigated in 143 patients with remarkable esophageal varices. The index used for evaluating hepatic reserve was the ratio between the increase of total bilirubin and the increase of LDH after EIS [I.I. index = (delta T.Bil./delta LDH) x 100] in cases treated by intravariceal injection of 5% ethanolamine oleate. I.I. index value caused by hemolysis was stable and always below 0.2, while the elevation of I.I. index above 0.2 was regarded as the reflection of the deterioration of liver function. After the entire sessions of EIS, the changes of liver function tests before and after EIS were estimated in 104 cases using 3 factors as follows; (1) delta T.Bil.; increase of total bilirubin more than 0.5 mg/dl (2) delta PT; decrease of prothrombin time more than 5% (3) delta ICG R15; increase of ICG R15 more than 5%. I.I. index of group I (without any changes of 3 factors mentioned above; n = 66) was 0.22 +/- 0.16, approximately within normal range. However, in group II (with 1 factor; n = 29), group III (with 2 factors; n = 5), group IV (with all factors; n = 4), I.I. index was elevated according to the severity of their liver dysfunction. The cases whose I.I. index value increased gradually during the course of EIS, were apt to deteriorate the liver functions and therefore, should be carefully observed. Also, I.I. index seems to reflect the prognosis of the patients treated by EIS for some extent, since the survival period of the cases treated by EIS were correlative with the value of I.I. index (r = -0.542, p < 0.01), and I.I. index of 32 cases who survived for longer than 5 years after EIS was almost normal (0.22 +/- 0.15).

The clinical usefulness of preoperative CEA determination in gastric cancer

Between 1980 and 1984, preoperative serum carcinoembryonic antigen (CEA) was determined in 468 patients with gastric cancer to evaluate its clinical usefulness. The positive rate of preoperative CEA was 20.9 per cent in these 468 patients. A significantly higher CEA positive rate was obtained in those patients with liver metastasis (69.2 per cent), n3-4 (40.0 per cent), stage IV gastric cancer (37.0 per cent) and Pap, Tub1 histological type (26.3 per cent) (p less than 0.01). It is interesting that the positive rate of the 49 unresectable patients was 51.0 per cent, which was significantly higher than 17.4 per cent of the 419 resectable cases (p less than 0.01). CEA levels in 16 of the 39 patients with liver metastasis were more than 100 ng/ml. In contrast, serosal invasion and peritoneal metastasis were less correlated to the CEA positive rate. In the 419 resected cases, the 5 year survival rate in the higher CEA group of more than 50 ng/ml (35 cases) was 4.4 per cent, which was significantly lower than 64.0 per cent in the negative group (346 cases) (p less than 0.01). These results show that CEA determination in patients with gastric cancer is useful for the prediction of prognosis, as well as for a diagnostic tool to discover the presence of liver or lymph node metastasis.

The usefulness of CEA as an indicator for early detection and a guide to the treatment of recurrent gastric cancer

The usefulness of carcinoembryonic antigen (CEA) as an indicator for recurrence and a guide to the treatment was evaluated from a retrospective analysis of 88 patients with recurrent gastric cancer. Sixty-two of these patients (70.5 per cent), 25 of whom had a preoperative positive assay, and 37 a negative assay, had elevated levels of CEA after disease progression. Averaged CEA level in patients with liver metastasis was significantly higher (872 ng/ml) than in those with peritoneal metastasis (68 ng/ml), with lymph node metastasis (103 ng/ml) or with local metastasis (93 ng/ml) (p less than 0.01). An elevation of CEA was found prior to the clinical manifestation of recurrence, and the average lead time was 4 months. In 25 patients with a lead time of more than 4 months, survival time after CEA elevation was 13.3 months, which was longer than the 6.5 months of 28 patients with less than 4 months. Thirty-seven of the 88 patients were treated after recurrence. The average survival period after the detection of recurrence was 9.4 months in patients with surgical treatments followed by chemotherapy, 5.9 months in those with chemotherapy alone and 3.8 months in those with surgery alone. The average survival period of 26 patients with positive CEA assays in recurrence was 5.1 months longer than of patients with negative assays. This fact suggested that early detection of recurrence followed by various treatments, in the elevated CEA group, contributes to favorable results.

Primary leiomyosarcoma of the lesser sac--report of a case

A case of leiomyosarcoma arising in the lesser sac in a 64-year-old man is presented. A second operation was required because of local recurrence 6 years following the first operation. A review of the literature revealed that only eight cases of leiomyosarcoma arising in the lesser sac, including our case, were reported. Almost all of these patients had symptoms of abdominal pain or distension. The tumor tended to grow to a large size and about 90 percent were over 10 cm in the maximal diameter. The prognosis of these series was poor and our own patient seems to be the second 5 year survivor.