Terai Shuji

Application of cell therapy using stem cell into intractable diseases has been noted as the medicine in the next generation taking the place of organ transplantation. Bone marrow cells have been focused as a candidate of the source of this therapy. Liver failure is a terminal state of all advanced liver diseases and thousands of patients are dying of decompensated liver cirrhosis in every year in Japan. Liver transplantation must be the strongest weapon to relieve those patients. However, particularly in Japan, liver transplantation has not been popularized. In this sense, we thought of autologous bone marrow cells transplantation for decompensated liver cirrhosis. Basic studies using animal model revealed that transplanted bone marrow cells into syngenic mouse suffering from liver cirrhosis migrated into the damaged liver and transdifferentiated to the hepatocytes. Based upon the animal studies, clinical trial of this new cell therapy supported by the Ministry of Health, Labor and Welfare is ongoing. It is early to estimate this therapy. However, free from liver failure has been observed in some cases.

Duodenal varices（DV）are the most common of ectopic varices. Although bleeding from DV is rare, it is difficult to control bleeding and sometimes fatal. We have encountered four clinical cases of ruptured DV. Case 1：A man in his 80s presented with a history of partial gastrectomy with Billroth-II reconstruction and LC due to chronic hepatitis C. We performed single-balloon endoscopy and injected 67% N-butyl-2-cyanoacrylate（NBCA）for DV on the afferent loop with red plug. Case 2：A woman in her 40s with primary biliary cirrhosis complained of tarry stool and anemia. We performed endoscopic injection sclerotherapy（EIS）with 67% NBCA for spurting bleeding point in duodenum. Case 3：A man in his 50s with liver cirrhosis（LC）due to chronic hepatitis B complained of tarry stool. We performed endoscopic variceal ligation（EVL）and balloon-occluded retrograde transvenous obliteration（B-RTO）for DV. Case 4：A man in his 60s with alcoholic LC complained of tarry stool. We performed EIS with 67% NBCA for DV. We added EVL, clipping, and argon plasma coagulation after EIS to control bleeding. To control bleeding was achieved in all cases.

A 36-year-old man diagnosed with Charcot-Marie-Tooth(CMT)disease type 1B was treated in the department of neurology of this hospital. Due to a liver injury(AST 237IU/ml, ALT 496IU/ml)which occurred in November 200X, he was introduced to our department. As a result of scrutiny, we diagnosed him with chronic hepatitis C genotype 2a(HCV-RNA 5.4logIU/ml).He will be admitted to the hospital for Interferon(IFN)therapy in April next year. Although the mechanism is unknown, there are a few reports of peripheral neuropathy related to IFN therapy. Therefore, IFN therapy is generally unfavorable for patients with neuromuscular disorders. There are several IFN preparations used in Japan. IFN alfa associated peripheral neuropathy appears less than 0.1-5% of the time. While there is no report of peripheral neuropathy related to IFN beta, we performed IFN beta and Rivabirin combination therapy with a severe follow-up by a neurologist. We could accomplish treatment without the exacerbation of neurologic symptoms. He achieved sustained viral response. When IFN therapy was provided for chronic hepatitis B or chronic hepatitis C complicated with peripheral neuropathy, there is some possibility of performing antiviral therapy safely by using IFN beta.

Spontaneous rupture of hepatocellular carcinoma(HCC)is well known. However, rupture of HCC after transcatheter arterial chemoembolization(TACE)is a rare but potentially fatal complication. Herein, we report a case of ruptured HCC after TACE in a 73-year-old man with chronic liver injury(non-B and non-C).He had previously undergone subsegmental resection of S7 of the liver for HCC. One year later, multiple HCCs were detected. TACE was performed for the recurrent HCCs located on the surface of S2 of the liver. Epigastric pain and decreased blood pressure were observed after the treatment. Although his symptoms improved immediately, the patient gradually became anemic. Radiological examination after TACE revealed a hematoma around the S2 lesion. Therefore, we diagnosed rupture of HCC. We performed TAE and could control the bleeding. Few possible mechanisms of ruptured HCC after TACE include increasing pressure inside the tumor and capsular injury due to TACE. Consequently, HCC which has a high risk of rupture after TACE should be assured embolization and careful observation.