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A case of primary carcinoid tumor of the liver associated with hepatocellular carcinoma is reported. A 75-year-old male was treated for hepatic cirrhosis and hepatocellular carcinoma. He died of hepatic failure. The autopsy revealed a carcinoid tumor of the liver and hepatocellular carcinoma (Edmondson type II). The carcinoid tumor was positive for immunostaining with chromogranin and NSE, and neuroendocrine secretory granules were seen at the ultrastructural level. Neither tumor showed any mixed areas nor was primary carcinoid tumor found elsewhere. Primary carcinoid of the liver is very rare, and this case is the first report, to our knowledge, of primary carcinoid tumor of the liver associated with hepatocellular carcinoma.

症例は14歳,女性.1歳2カ月時思春期早発症と診断され内科的治療を受けた.4歳時頭部CTスキャンにて視床下部過誤腫を発見され,部分切除を受けたが,高身長・乳房の発達・肥満が続くため,8歳より酢酸シプロテロンの投与を受けていた.12歳ころよりGOT, GPTの上昇を認め,平成元年1月肝障害と肥満の精査のため当科入院となった,入院時身長145.5cm,体重61.5kg.肝は正中でやや硬く3横指触知した.肝機能検査ではGOT 1931U/L,GPT1471U/Lと上昇しており,ICGR15は23%と停滞していた.腹部エコ-ではbright liverの所見を呈し,肝シンチではfiying bat patternを示した.肝生検では炎症細胞浸潤に乏しい脂肪性肝硬変の所見であった.内分泌学的検査では視床下部性の下垂体機能低下症・肥満を示唆する所見が得られた.肝病変の進展には肥満に加えて,抗アンドロゲン製剤の使用を含めた内分泌学的異常の関与が想定された.

Sera from 533 patients with chronic liver diseases were tested for the presence of antibodies to hepatitis C virus (anti-HCV).Anti-HCV were found in 69.8% of patients with chronic hepatitis, 63.9% with cirrhosis, and 80.6% with hepatocellular carcinoma. A higher prevalence of antibody was detected in patients with a history of blood transfusion.In 18.1% of patients with clinically diagnosed alcoholic liver injury, anti-HCV were detected. Only one of 10 patients histologically diagnosed as having alcoholic liver injury was anti-HCV seropositive.Ant-HCV were detected in 3 of 11 patients with primary biliary cirrhosis, but two had a history of blood transfusion.Anti-HCV were not detected in patients with autoimmune hepatitis during steroid treatment, nor in patients with fatty liver or asymptomatic hepatitis B virus carriers.

The incidence of acute hepatitis A infection in Japan peaked 10 years ago and has been decreasing since then. However, an increase in severe cases of the disease has been documented recently. We experienced an outbreak in 1998–1999, and compared the clinical features of the disease in 1998–1999 (recent outbreak) and in 1987–1988 (past outbreak) in our prefecture (Gunma). Forty patients with acute hepatitis A were admitted to nine Gunma hospitals from October 1998 to September 1999. Their clinical features were compared with those of 100 patients with acute hepatitis A admitted to the same hospitals in 1987–1988. Both outbreaks occurred mostly during the winter-spring season. Secondary familial infection was significantly decreased in the recent outbreak. Patients in the recent outbreak were 7 years older than those in the past outbreak. Laboratory findings, such as serum aspartatate aminotransferase (AST) and alanine aminotransferase (ALT) levels and prothrombin time, were worse in the recent than in the past outbreak. Severe-type hepatitis and fulminant hepatitis occurred in 5 patients (12.5%) in the recent outbreak but in only 2 patients (2.0%) in the past outbreak. Clinical data and manifestations were more severe in the recent outbreak than in the past outbreak of acute hepatitis A. It is important to be aware of hepatitis A virus infection and to take into account the available vaccination against hepatitis A virus in Japan.

Hepatic polyamines were assayed in 15 patients with liver diseases, 5 with fulminant hepatitis (FH); 3 with exacerbated liver cirrhosis (ELC); and 7 with liver cirrhosis (LC). Hepatic putrescine and N1-acetylspermidine, as percentages of total polyamines, were elevated and spermine was decreased in all 15 patients. The increase in hepatic N1-acetylspermidine levels appeared to be greater in patients with FH and ELC than in those with LC. These results suggest that the production of N1-acetylspermidine in human liver is closely associated with the induction of spermidine/spermine N1-acetyltransferase activity in liver diseases.

The localization of the cholestatic factor (CF) was immunocytochemically investigated in liver biopsy specimens obtained from patients with various liver diseases. CF was detected in seven of nine patients with drug-induced liver injury, three of four with acute viral hepatitis, three of five with alcoholic liver injury and in the two patients with autoimmune hepatitis. Fourteen of these 15 CF-positive patients had jaundice in their clinical courses. CF was stained diffusely in the cytoplasm of hepatocytes throughout the lobules in a granular pattern. Electron-microscopically, it was localized on the ribosomes and polysomes as well as on the filamentous structures around the bile canaliculi. However, CF was not detected in liver specimens from normal controls and patients with primary biliary cirrhosis and extrahepatic biliary obstruction. These findings suggest that CF plays an important role in intrahepatic cholestasis in various liver diseases.

クロールプロマジン及びアルドメット服用後,肝機能異常が現われ,肝生検にて著明な肝内胆管病変を呈した症例を経験した.症例は71歳,女性で,クロールプロマジンを約18カ月,アルドメットを1カ月服用後肝障害が現われた.肝組織では肝内胆管の破壊像が認められ,同一門脈域に類上皮細胞肉芽腫及びリンパ濾胞を形成する多数の炎症細胞浸潤が認められたが,胆汁うっ滞の所見は認められなかった.組織上では原発性胆汁性肝硬変(PBC)と類似した点もみられたが,門脈域への形質細胞の浸潤がめだたず,肝内胆管の数の減少も認められない点でPBCとは異なっていた.また,抗ミトコンドリア抗体も陰性であった.本例は薬剤の中止により肝機能はすみやかに改善し,リンパ球刺激試験で両薬剤が陽性であったことより,クロールプロマジン,アルドメット両薬剤の関与により多彩な組織像を呈した薬剤性肝障害と考えられた.

A 52-year-old man was admitted to the hospital because of easy fatigability. He didn't have jaundice, itching, hypercholesterinemia and xanthoma. Liver function tests were as follows : total bilirubin, 0.9mg/dl ; GOT, 51IU/l ; GPT, 85IU/l ; alkaline phosphatase, 216IU/l ; γ-GTP, 36IU/l ; total protein, 7.9g/dl ; γ-globulin, 1.79g/dl. HBs antigen and α-fetoprotein were negative. Antimitochondrial antibody and other autoantibody were negative. IgM level was 111mg/dl.Blind liver biopsy specimens showed chronic active hepatitis with changes of interlobular bile ducts. But papillary appearance of the epithelium was not observed, plasma cells were rarely infiltrated and granuloma was never seen. In these points, the present findings differed from the bile duct lesions in CNSDC found in early stage of PBC.

Primary biliary cirrhosis (PBC) is histologically characterized by chronic non-suppurative destructive cholangitis (CNSDC), and is also a granulomatous disease. The characteristics of granulomas and the correlation between granulomas and bile duct changes were morphologically investigated in 31 patients with granulomas, compared with in those without granulomas.Results were as follows : 1) Most of the granulomas (93%) were poorly-defined, and well-organized granulomas with distinct fibrosis were rare (7 %).2) Granulomas with multinucleated giant cells (MGCs) were not always well-organized and were found both in portal area and near central veins. MGCs sometimes had inclusions with negative H-E stain.3) Seventy-two per cent of granulomas were found in portal area, some of them were in contact with damaged bile ducts, others surrounded them.4) The patients with granulomas were rather early in the histologic stages. Twenty-three of 31 patients with granulomas were asymptomatic.5) Ratio of disappearance of interlobular bile ducts was significantly lower in PBC patients with granulomas than in those without granulomas.From these results, it was suggested that granulomas in PBC were closely related to interlobular bile duct lesions and that something derived from interlobular bile ducts seemed to play an important role for granuloma formation.

Eighty nine healthy volunteers working at medical institution were given inactivated HB vaccine and followed up changes of HBs-Ab levels for 49 months.Three doses of vaccine induced antibody in 70.5% out of 78 vaccine recipients at 28 weeks after the first dose. Active immunization occurred more frequently in female than in male.At 49 months after the first dose, HBs-Ab positive rate decreased to 37.4% out of 32 subjects. All of those positive volunteers have had high HBs titer (Cut off index≥50) at 7 months after the first dose. But there was no sex or age difference in HBs-Ab titer.These results suggest that inactivated HB vaccine is useful for active immunization of HBs-Ab. However, further investigation is needed to make clear whether re-vaccination is necessary or not.

原発性胆汁性肝硬変(PBC)における肉芽腫の存在意義を明らかにする目的で,肉芽腫の特徴および肉芽腫と胆管病変との関連について病理組織学的に検討した.肉芽腫はpoorly-definedのものが多く,巨細胞を有し,膠原線維の増加をみる器質化された肉芽腫はまれであった.肉芽腫の存在部位はいずれも門脈域であったが,一部の肉芽腫は障害された小葉間胆管に接していたり,あるいはそれらを囲むように存在していた.肉芽腫を認めたPBC例は認めなかった例に比し,組織学的病期分類では早期のものが多く,また無症候性PBC例が多かった.さらに,門脈域1個あたりの小葉間胆管の数は,肉芽腫を認めた例で認めなかった例より多く,小葉間胆管が観察されない門脈域の比率は,肉芽腫を認めた例で認めなかった例より低く,いずれも有意の差がみられた.

A case of hepatocellular carcinoma (HCC) complicated with vascular invasion of the portal vein, hepatic vein, and pulmonary artery, accompanied by inferior vena caval and renal vein thrombosis, is reported. The patient was a 38-year-old female, positive in serum HBsAg and anti-HBe. Because portal trunk thrombosis was pointed out at the first diagnosis, incomplete transcatheter hepatic arterial embolization was carried out three times and one-shot therapy of anti-cancer agent given once. Four months after the first therapy, the patient died of oliguria and hypotension of sudden onset. The autopsy revealed not only intrahepatic vascular invasion but also tumor growth in the bilateral pulmonary arteries and thrombosis from the inferior vena cava to both renal veins unaccompanied by right atrial growth. Because the renal vein was thrombosed and HCC was accompanied by vascular invasion, especially pulmonary arterial invasion, the patient was thought to have become oliguric and hypotensive before severe hepatic failure. The metastatic tumor had grown in the pulmonary trunk without intra-atrial expansion because of the histological tight junction between the tumor and the wall of that vessel.

Propionibacterium acnes加熱死菌をマウスに静注し,7日後にlipopolysaccharideを追加静注すると,肝小葉内に小肉芽腫,sinusoid内に細胞浸潤が認められるようになり,肝細胞壊死が出現する.この急性肝障害モデルにおける浸潤細胞の経時的変化を主にその組織化学的側面から検討した.小肉芽腫数やsinusoid内浸潤細胞数はlipopolysaccharide投与後,次第に増加し,特に18時間後には投与前に比し有意に高値であった.また,小肉芽腫内およびsinusoid内浸潤細胞はそのほとんどがα1-アンチトリプシン陽性細胞とNaphthol AS-D Chloroacetate Esterase陽性細胞であり,前者は経時的に減少し,逆に後者は増加する傾向がうかがわれた.以上の結果より,この急性肝障害モデルにおける肝組織内浸潤細胞の主体はマクロファージ系細胞と好中球系細胞であり,急性肝障害の発現にはこの両者が関与している可能性が示唆された.

Morphological changes of interlobular bile ducts in asymptomatic or symptomatic primary biliary cirrhosis (PBC) and chronic hepatitis with ductal lesions were investigated. It was supposed that bile duct lesions found in PBC and chronic hepatitis could be distinguished histologically. There were identical epithelial changes between symptomatic PBC and asymptomatic one, but granulomas were more often found in asymptomatic PBC than in symptomatic PBC. Numbers of interlobular bile ducts per portal tract and the rates of portal tracts without interlobular duct in asymptomatic PBC were intermediate between symptomatic PBC and chronic hepatitis. Serial sections revealed that some bile ducts were able to be followed by ductules in asymptomatic PBC. From these results, numbers of interlobular bile ducts are undoubtedly decreased in asymptomatic PBC but not so much as in symptomatic one. This observation may be attributable partially for taking asymptomatic course.

A 57-year-old man with hepatocellular carcinoma (HCC) invading the hepatic duct was treated with transcatheter arterial embolization (TAE). The dilated hepatic duct was decompressed his jaundice disappeared and he survived for 10 months after the first TAE, succumbing due to bleeding from gastric erosion. Although total bilirubin was 26.7 mg/dl and massive ascites was noted on occasion of the first TAE, hepatic dysfunction did not worsen and both icterus and ascites decreased, disappearing one month after the therapy. Autopsy revealed HCC with trabecular arrangement originating in the left lobe and growing into the left hepatic duct accompanied by liver cirrhosis and follicular carcinoma of the thyroid gland. Severe icterus caused by bile duct obstruction does not correlate with the grade of hepatic failure in HCC with liver cirrhosis, so TAE was effective and should be tried as a first choice therapy in such a poor risk case.

症例, 48才,主婦.糖尿病性ケトーシスにて入院.精査にて抗平滑筋抗体陽性Felty症候群と診断. red color signを伴う食道静脈瘤を有することから脾摘出が施行され,以後IgG減少と抗平滑筋抗体消失を認めた.本例はインスリン依存型糖尿病合併Felty症候群にて脾摘出後自己抗体消失をみた1例であり,本症の抗平滑筋抗体出現機序において脾の存在が重要な意義を有するものと考え,自己免疫異常における脾の意義について検討を加えた.