大学院医学系研究科（医学）

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.

Background and Aim: Image definition and complete small bowel examination rate are possible factors contributing to missed lesions during capsule endoscopy.This study aimed to determine the effect of coadministration of polyethylene glycol (PEG) and dai-kenchu-to (DKT) on these factors using PEG and DKT as pretreatment before capsule endoscopy. Methods: Patients who underwent capsule endoscopy at our hospital between November 2007 and August 2012 were included in the study. Patients were divided into the following three groups: those receiving no pretreatment (control, n=133), those orally administered PEG (PEG, n=20), and those orally administered PEG and DKT (15g) (PEG + DKT, n=25). Image definition and complete small bowel examination rate were examined retrospectively between the three groups. Results: Image definition in the PEG + DKT group was significantly higher than that in the control group (p<0.05), but there was no significant differences between the PEG and control groups. The complete small bowel examination rate was significantly lower in the PEG group than in the control and PEG + DKT groups (p<0.05). Conclusions: Coadministration of PEG and DKT improved image definition and prevented a reduction of the complete small bowel examination rate due to PEG in capsule endoscopy.