Case Reports in Hepatology http://www.hindawi.com The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. The Successful Use of Inhaled Nitric Oxide in the Management of Severe Hepatopulmonary Syndrome after Orthotopic Liver Transplantation Thu, 03 Apr 2014 07:01:08 +0000 http://www.hindawi.com/journals/crihep/2014/415109/ Hepatopulmonary syndrome (HPS) is characterized by pulmonary vasodilation and subsequent hypoxemia in the setting of hepatic dysfunction. There is currently no pharmacologic intervention that has been shown to significantly affect outcomes and liver transplantation remains the mainstay of therapy. Unfortunately, patients undergoing liver transplantation are at high risk of significant hypoxemia and mortality in the early postoperative period. In the following case series, we present two cases of patients with severe HPS who underwent liver transplantation and experienced marked hypoxemia in the early postoperative period. In both cases, we successfully treated the patients with inhaled nitric oxide for their severe refractory life-threatening hypoxemia which led to immediate and dramatic improvements in their oxygenation. Although the use of inhaled nitric oxide in patients with HPS has been sporadically reported in pediatric literature and in animal studies, to our knowledge, our cases are the first recorded in adult patients. Joshua Santos, Philip Young, Igor Barjaktarevic, Catherine Lazar, Irawan Susanto, and Tisha Wang Copyright © 2014 Joshua Santos et al. All rights reserved. Nonalcoholic Steatohepatitis in a Patient with Ataxia-Telangiectasia Mon, 06 Jan 2014 12:05:24 +0000 http://www.hindawi.com/journals/crihep/2014/761250/ Ataxia-telangiectasia (A-T) is a rare disease characterized by neurodegenerative alterations, telangiectasia, primary immunodeficiency, extreme sensitivity to radiation, and susceptibility to neoplasms. A-T patients have inactivation of ataxia-telangiectasia-mutated (ATM) protein, which controls DNA double-strand break repair and is involved in oxidative stress response, among other functions; dysfunctional control of reactive oxygen species may be responsible for many of the clinical manifestations of this disease. To the best of our knowledge, hepatic lesions of steatohepatitis have not previously been reported in A-T patients. The present study reports the case of a 22-year-old man diagnosed with A-T at the age of 6 years who was referred to our Digestive Disease Unit with a three-year history of hyperlipidemia and liver test alterations. Core liver biopsy showed similar lesions to those observed in nonalcoholic steatohepatitis. Immunohistochemical staining disclosed the absence of ATM protein in hepatocyte nuclei. We suggest that the liver injury may be mainly attributable to the oxidative stress associated with ATM protein deficiency, although other factors may have made a contribution. We propose the inclusion of A-T among the causes of nonalcoholic steatohepatitis, which may respond to antioxidant therapy. Trinidad Caballero, Mercedes Caba-Molina, Javier Salmerón, and Mercedes Gómez-Morales Copyright © 2014 Trinidad Caballero et al. All rights reserved. Granulomatous Hepatitis Secondary to Histoplasma Infection after Treatment with Infliximab Sat, 14 Dec 2013 10:09:31 +0000 http://www.hindawi.com/journals/crihep/2013/807537/ Classical presentation of Histoplasma infection includes fever and respiratory symptoms. Opportunistic microorganisms must be suspected on immunocompromised patients who develop bizarre symptoms. We present a case of a female patient with rheumatoid arthritis who received treatment with Infliximab during one and a half year; she developed granulomatous hepatitis secondary to Histoplasma infection. The patient was admitted with acute hepatitis and thrombocytopenic coagulopathy. A liver biopsy was performed revealing granulomatous hepatitis, microvesicular steatosis, isolated apoptotic cells, and parenchyma microabscesses. PAS and Gömöri stains revealed areas with mycotic microorganisms morphologically compatible with Histoplasma spp. and confirmed by culture. L. Barrera, J. Álvarez, M. Tapias, V. Idrovo, and R. López Copyright © 2013 L. Barrera et al. All rights reserved. An Unusual Congenital In Situ Malrotation of the Liver Tue, 03 Dec 2013 10:04:52 +0000 http://www.hindawi.com/journals/crihep/2013/493713/ Congenital anomaly of the liver is an uncommon and usually incidental finding. This report describes a case of in situ liver malrotation that has never been reported in the literature. Published literature relevant to the finding are briefly discussed. Hua Zhong Copyright © 2013 Hua Zhong. All rights reserved. Fulminant Liver Failure Associated with Abdominal Crush Injury in an Eleven-Year Old: A Case Report Tue, 22 Oct 2013 14:19:26 +0000 http://www.hindawi.com/journals/crihep/2013/524371/ An 11-year-old obese male was involved in an all-terrain vehicle rollover accident. He had elevated transaminase levels along with a lactic acidosis. The imaging studies did not reveal any major intra-abdominal or thoracic injuries. The physical exam was unremarkable. The patient had an unremarkable PICU course and was transferred to the floor the next day. Within 24 hours of his transfer, he was noted to have interval worsening in liver function tests. He developed fulminant liver failure (FLF), renal failure, and encephalopathy. An ultrasound of the liver revealed increased echogenicity in the right lobe with focal sparing. Patient was listed for transplant. Investigations into any underlying medical cause of FLF were negative. Liver failure was presumed to be related to ischemia/reperfusion injury of the liver. The renal failure was due to rhabdomyolysis and was supported with renal replacement therapy. Patient received supportive care for FLF and was noted to have significant recovery of liver and renal function with time. He was discharged home after a 3-week hospitalization. Patients with crush abdominal injuries and elevated transaminase levels without evidence of parenchymal liver disruption may need to be closely monitored for liver failure related to ischemia reperfusion. Erin Gordon and Sameer Kamath Copyright © 2013 Erin Gordon and Sameer Kamath. All rights reserved. Spontaneous Bacterial Peritonitis Caused by Listeria monocytogenes Associated with Ascitic Fluid Lymphocytosis: A Case Report and Review of Current Empiric Therapy Sun, 15 Sep 2013 10:35:24 +0000 http://www.hindawi.com/journals/crihep/2013/832457/ Spontaneous bacterial peritonitis (SBP) is a potentially deadly complication of ascites. We describe a case of SBP caused by Listeria monocytogenes in a patient with alcoholic cirrhosis. This was associated with the unusual finding of ascitic fluid lymphocytosis, which previously had only been associated with tuberculoid or malignant ascites. Given increasing rates of cefotaxime-resistant SBP alongside the possibility of Listeriosis, the use of cefotaxime as first-line therapy in SBP should be reevaluated. Todd Yecies and Sanae Inagami Copyright © 2013 Todd Yecies and Sanae Inagami. All rights reserved. Transjugular Retrograde Obliteration prior to Liver Resection for Hepatocellular Carcinoma Associated with Hyperammonemia due to Spontaneous Portosystemic Shunt Mon, 19 Aug 2013 08:57:34 +0000 http://www.hindawi.com/journals/crihep/2013/809543/ A 67-year-old woman had hepatocellular carcinoma (HCC) measuring 3.7 cm at S8 of the liver with hyperammonemia due to a spontaneous giant mesocaval shunt. Admission laboratory data revealed albumin, 2.9 g/dL; total bilirubin, 1.3 mg/dL; plasma ammonia level (NH3), 152 g/dL; total bile acid (TBA) 108.5 μmoL/L; indocyanine green retention rate at 15 min (ICG15), 63%. Superior mesenteric arterial portography revealed a hepatofugal giant mesocaval shunt, and the portal vein was not visualized. Before surgery, transjugular retrograde obliteration (TJO) for the mesocaval shunt was attempted to normalize the portal blood flow. Via the right internal jugular vein, a 6 F occlusive balloon catheter was inserted superselectively into the mesocaval shunt. The mesocaval shunt was successfully embolized using absolute ethanol and a 50% glucose solution. Eleven days after TJO, NH3, TBA, and ICG15 decreased to 56, 44, and 33, respectively. Superior mesenteric arterial portography after TJO revealed a hepatopetal portal flow. Partial hepatectomy of S8 was performed 25 days after TJO. The subsequent clinical course showed no complications, and the woman was discharged on postoperative day 14. We conclude that the combined therapy of surgery and TJO is an effective means of treating HCC with hyperammonemia due to a spontaneous portosystemic shunt. Fumio Chikamori and Nobutoshi Kuniyoshi Copyright © 2013 Fumio Chikamori and Nobutoshi Kuniyoshi. All rights reserved. Severe Starvation-Induced Hepatocyte Autophagy as a Cause of Acute Liver Injury in Anorexia Nervosa: A Case Report Tue, 30 Jul 2013 14:34:52 +0000 http://www.hindawi.com/journals/crihep/2013/749169/ Introduction. Mild elevation of transaminase may be observed in anorexia nervosa, but acute liver injury is uncommon. A complex programmed cell death in response to starvation, called autophagy, has been described in experimental and human studies. Case Presentation. A 24-year-old woman suffering from anorexia nervosa was hospitalized for severe malnutrition. At admission, there were biological signs of acute liver injury but no electrolytic imbalance. After having ruled out the most common causes of liver injury, the patient was carefully refed. As liver tests remained abnormal, liver biopsy was performed. At histology and electron microscopy, numerous signs suggestive of starvation-induced hepatocyte autophagy were found. Discussion. Severe starvation can be associated with acute liver injury that is slowly reversible with careful enteral nutrition. In this clinical situation, profound hepatic glycogen depletion in association with autophagy appears as the leading cause of liver injury. S. Restellini, L. Spahr, and L. Rubbia Brandt Copyright © 2013 S. Restellini et al. All rights reserved. Death from Liver Failure despite Lamivudine Prophylaxis during R-CHOP Chemotherapy due to Rapid Emergence M204 Mutations Tue, 30 Jul 2013 08:06:55 +0000 http://www.hindawi.com/journals/crihep/2013/454897/ Background. Rapid and early emergence of clinically significant LAM resistance is thought to be unlikely during the first year of treatment, and as a result LAM is thought to be a reasonable choice as a first line agent for prophylaxis during chemotherapy. Aim. To report fatal HBV reactivation despite appropriate LAM prophylaxis in two previously treatment-naive individuals undergoing R-CHOP chemotherapy. Case Presentation. Case 1 is a 65-year-old man with chronic HBV infection: HBeAg-negative, HBV DNA 6.65E5 IU/mL, ALT 43 IU/L, and Fibroscan 4.4 kPa, consistent with F0, who was diagnosed with lymphoma that was treated with R-CHOP and LAM prophylaxis. HBV DNA fell to 2.18E1 IU/mL within 2 months of starting LAM. Four months after chemotherapy, despite ongoing LAM of 7-month duration with confirmed adherence, severe asymptomatic hepatitis was noted during routine monitoring with ALT 1019 IU/L, HBeAg negative, HBV DNA 1.43E7 IU/mL, and genotyping confirmed L80I and M204I mutations. He died 14 days after flare diagnosis despite a switch to tenofovir (HBV DNA had fallen to 1.94E5 IU/mL 2 weeks after starting tenofovir). Case 2 is a 50-year-old man who was found to have HBeAg-negative hepatitis B, ALT 37 IU/L, and no clinical features of cirrhosis (platelets 283, APRI 0.19) after lymphoma diagnosis. Lymphoma was treated with R-CHOP and LAM prophylaxis. Pretreatment HBV DNA was not done but was 8.90E4 IU/mL 3 weeks after starting LAM and 3.96E3 IU/mL 3 months after starting LAM. Two months after chemotherapy, despite ongoing LAM of 7-month duration with confirmed adherence, severe symptomatic hepatitis presenting with jaundice, abdominal pain, and confusion was noted. ALT 902 IU/L, HBeAg negative, HBV DNA 1.02E8 IU/mL, and genotyping confirmed L80I, M80V, and M204V/S mutations. He died 3 days after flare diagnosis despite the addition of tenofovir. Conclusion. Lamivudine should not be used for prophylaxis of patients with chronic hepatitis B with detectable HBV DNA undergoing chemotherapy with rituximab containing cytotoxic chemotherapy even if they have never had exposure to lamivudine in the past. In this setting, lamivudine failure due to resistance can develop quickly leading to liver failure that cannot be salvaged with tenofovir. Whether LAM is safe for prophylaxis with rituximab-based cytotoxic chemotherapy for patients with undetectable HBV DNA is unknown, but agents with a high barrier to resistance may be preferable. Lay Lay Win, Jeff Powis, Hemant Shah, Jordan J. Feld, and David K. Wong Copyright © 2013 Lay Lay Win et al. All rights reserved. Tocilizumab-Induced Acute Liver Injury in Adult Onset Still’s Disease Mon, 15 Jul 2013 10:54:03 +0000 http://www.hindawi.com/journals/crihep/2013/964828/ Background. Tocilizumab, a monoclonal humanized anti-IL-6 receptor antibody, is used in treatment of refractory adult onset Still’s disease (AOSD). Mild to moderate liver enzyme elevation is a well-known side effect, but severe liver injury has only been reported in 3 cases in the literature. Case. A young female suffering from corticoid and methotrexate refractory AOSD was treated by tocilizumab. After 19 months of consecutive treatment, she developed acute severe liver injury. Liver biopsy showed extensive hepatocellular necrosis with ballooned hepatocytes, highly suggestive of drug-induced liver injury. No other relevant drug exposure beside tocilizumab was recorded. She recovered totally after treatment discontinuation and an initial 3-day course of intravenous N-acetylcysteine with normalization of liver function tests after 6 weeks. Conclusion. Acute severe hepatitis can be associated with tocilizumab as documented in this case. Careful monitoring of liver function tests is warranted during tocilizumab treatment. Michael Drepper, Laura Rubbia-Brandt, and Laurent Spahr Copyright © 2013 Michael Drepper et al. All rights reserved. Pleuro-Pulmonary Nocardiosis as Opportunistic Infection in a Patient with Chronic Hepatitis C under Combination Treatment with Pegylated Interferon, Ribavirin, and Boceprevir Wed, 10 Jul 2013 11:23:20 +0000 http://www.hindawi.com/journals/crihep/2013/529041/ Nocardiosis is an infrequent but serious pulmonary infection caused by Gram-positive aerobic actinomycetes. In this paper, we report on a 48-year-old patient with pleuropulmonary nocardiosis and cirrhosis due to chronic hepatitis C virus infection treated with triple antiviral treatment complicated by prolonged neutropenia. Csilla Putz-Bankuti, Harald H. Kessler, Thomas Valentin, Eva Leitner, Emina Talakic, Helmut Schoellnast, Peter Fickert, Guenter J. Krejs, and Rudolf E. Stauber Copyright © 2013 Csilla Putz-Bankuti et al. All rights reserved. Hepatitis B Virus Reactivation Induced by Infliximab Administration in a Patient with Crohn’s Disease Sun, 09 Jun 2013 19:26:44 +0000 http://www.hindawi.com/journals/crihep/2013/461879/ A 47-year-old man diagnosed with Crohn’s disease was treated with infliximab. He tested negative for hepatitis B surface antigen (HBsAg) and hepatitis B surface antibody (anti-HBs) but positive for anti-HB core antibody (anti-HBc). He tested positive for hepatitis B virus (HBV-) DNA 3 months after treatment and was administered entecavir. HBV-DNA test showed negative results 1 month later. ALT was persistently within the normal range, and HBV-DNA was persistently negative thereafter despite the continuation of infliximab every 8 weeks. In our hospital, 14 patients with inflammatory bowel disease, who tested negative for HBsAg, were treated with infliximab; 2 of them tested positive for anti-HBs and/or anti-HBc, and HBV reactivation was observed in 1 patient (the present patient). The present case and these findings highlight that careful follow-up is needed in patients with inflammatory bowel disease treated with infliximab who test positive for anti-HBc and/or anti-HBs. Yuka Miyake, Aki Hasebe, Tetsuya Tanihira, Akiko Shiraishi, Yusuke Imai, Haruka Tatsukawa, Hiroka Yamago, Hiromasa Nakahara, Yuko Shimizu, Keiko Ninomiya, Atsushi Hiraoka, Hideki Miyata, Tomoyuki Ninomiya, and Kojiro Michitaka Copyright © 2013 Yuka Miyake et al. All rights reserved. Drug-Induced Liver Injury Caused by Adalimumab: A Case Report and Review of the Bibliography Tue, 14 May 2013 16:24:04 +0000 http://www.hindawi.com/journals/crihep/2013/406901/ The most serious adverse drug reaction of adalimumab (ADR) is tuberculosis reactivation. We describe a case of a 35-year-old man, with rheumatoid arthritis (RA) and hepatitis C virus genotype 1a with a liver biopsy in 2001 with a METAVIR score pattern A1 F0; he received interferon alpha 2b for six months, but treatment was suspended because of reactivation of RA. Liver function tests after treatment were similar to previous ones showing a minimal cholestatic pattern. In 2008, methotrexate was prescribed, but the drug was withdrawn at the third month because of the appearance of pruritus and Ggt rise. Viral load at that moment was 9300000 UI/mL, log 6,9. The liver biopsy showed a Metavir Score A2 F1. Adalimumab was started in 2010, and at the third month of treatment, Ggt showed a rise of 23 times normal value (NV), alkaline phosphatase 2,5 times NV with AST and ALT with no change. A new liver biopsy showed portal inflammation with eosinophils and a METAVIR A1 F2. We think that adalimumab appears to be responsible for the liver injury, because of temporal relationship, liver biopsy findings, other clinical conditions being discarded, and the improvement of clinical symptoms and biochemical abnormalities when adalimumab was suspended. Bernardo Frider, Andres Bruno, Marcelo Ponte, and Marcelo Amante Copyright © 2013 Bernardo Frider et al. All rights reserved. Hepatic Artery Mycotic Aneurysm Associated with Staphylococcal Endocarditis with Successful Treatment: Case Report with Review of the Literature Sun, 12 May 2013 07:58:33 +0000 http://www.hindawi.com/journals/crihep/2013/610818/ Mycotic hepatic artery aneurysm is a vascular pathology associated with bacterial endocarditis. It is rare in occurrence after the introduction of effective antibiotics. We present a young patient with injection drug abuse associated staphylococcal endocarditis which was successfully treated with antibiotics and valve replacement who presented with abdominal pain. He was found to have mycotic aneurysm of hepatic artery which was successfully treated with coil embolization. Dhara Chaudhari, Atif Saleem, Pranav Patel, Sara Khan, Mark Young, and Gene LeSage Copyright © 2013 Dhara Chaudhari et al. All rights reserved. Acute Cholestatic Hepatitis A Virus Infection Presenting with Hemolytic Anemia and Renal Failure: A Case Report Wed, 08 May 2013 14:04:07 +0000 http://www.hindawi.com/journals/crihep/2013/438375/ Hepatitis A virus is the most common acute viral hepatitis worldwide with approximately 1.5 million cases annually. Hepatitis A virus infection in general is self-limited. In rare cases, hepatitis A virus infection may cause renal failure, hemolytic anemia, and/or cholestasis. We report the first case of acute cholestatic hepatitis A virus infection complicated by hemolytic anemia, and renal failure in one patient. A 42-year-old Caucasian male presented with cholestasis, hemolytic anemia and renal failure after consuming street tacos in Central and South America while on a business trip. His protracted course required corticosteroid therapy, multiple sessions of plasma exchange, and numerous units of packed red blood cells. This case demonstrates the importance of vaccination in high-risk adults. A prompt diagnosis of acute hepatitis A virus infection is essential, as uncommon presentations may delay diagnosis leading to permanent morbidity and potentially death in fulminant cases. We also demonstrate the efficacy of treatment of cholestatic hepatitis A virus infection, hemolytic anemia, and renal failure with corticosteroids and plasma exchange. Robert T. Lapp and Fedja Rochling Copyright © 2013 Robert T. Lapp and Fedja Rochling. All rights reserved. Chinese Skullcap in Move Free Arthritis Supplement Causes Drug Induced Liver Injury and Pulmonary Infiltrates Sun, 14 Apr 2013 18:56:47 +0000 http://www.hindawi.com/journals/crihep/2013/965092/ Herbal medications are being increasingly used by the American population especially for common conditions like arthritis. They have been reported to cause adverse effects, including significant hepatotoxicity, but reporting remains sporadic. We report here a patient who developed drug induced liver injury following the intake of Move Free, which is an over-the-counter arthritis supplement. We propose that Chinese skullcap, which is one of the herbal ingredients of the medication, is responsible for the adverse event. There was a strong temporal association between the intake of supplement and onset of symptoms, and also there have been a few recent case reports implicating the same component. A unique observation in our case is the occurrence of pulmonary infiltrates simultaneously with the hepatotoxicity, and this side effect has not been well documented before. Both the hepatic and pulmonary complications completely resolved over few weeks after the patient stopped taking the medication. Since these supplements are readily available over the counter, we feel that it is important to document possible adverse outcomes to raise awareness in the medical community and also among patients. Renumathy Dhanasekaran, Victoria Owens, and William Sanchez Copyright © 2013 Renumathy Dhanasekaran et al. All rights reserved. A Case of Solitary Necrotic Nodule Treated with Laparoscopic Hepatectomy: Spontaneous Regression of Hepatocellular Carcinoma? Tue, 19 Mar 2013 15:30:15 +0000 http://www.hindawi.com/journals/crihep/2013/723781/ Solitary necrotic nodule of the liver is a rare benign lesion with a completely necrotic core and a hyalinized fibrotic capsule containing elastic fibers. The pathogenetic mechanism is still unclear. We here describe a case of SNN, whose central reticulin fibers within the nodule suggest the origin as hepatocellular carcinoma or other hepatocyte-origin tumors, treated with laparoscopic anatomical segmentectomy of the liver. A 76-year-old Japanese female, with no prior medical history and no symptom, visited our hospital with the heterogeneous hypoechoic lesion in the liver segment VI incidentally pointed out in abdominal ultrasonography. Computed tomography with contrast demonstrated a 1.1 cm sized low-density lesion with mild ring enhancement on the rim in the arterial phase. Since the possibility of malignant tumor with necrotic change could not be ruled out, she underwent laparoscopic anatomical segmentectomy of the liver. In the histological examination of the surgical specimen, the liver nodule was necrotic tissue without viable cells and signs of inflammation, which had fibrous capsule and central cystic change and showed trabecular pattern alignment of ghost cells and reticulin fibers orthogonal to the capsule. Also, the findings of chronic hepatitis were observed in the background liver. Hirokazu Tomishige, Zenichi Morise, Yoshikazu Mizoguchi, Norihiko Kawabe, Hidetoshi Nagata, Hisanori Ohshima, Jin Kawase, Satoshi Arakawa, Rie Yoshida, and Masashi Isetani Copyright © 2013 Hirokazu Tomishige et al. All rights reserved. Surviving Emphysematous Gastritis after Hepatectomy Thu, 14 Mar 2013 14:35:19 +0000 http://www.hindawi.com/journals/crihep/2013/106383/ Emphysematous gastritis is a rare variant of phlegmonous gastritis due to invasion of stomach wall by gas-forming bacteria. It is characterised by abnormal presence of gas in the stomach by imaging, in association with clinical sepsis. Patients suffering from this condition usually present with an underlying pathology. We are reporting a middle-aged Chinese male with hepatitis B virus related hepatocellular carcinoma. He underwent partial hepatectomy and was diagnosed with emphysematous gastritis 4 days after index operation. Emergency laparotomy, including upper endoscopy, was performed. He was managed with antibiotics and discharged 18 days after second operation. This paper shows a review of the literature about the disease, with particular attention to pathology, clinical features, and management. Harry Hok Yee Yu, Simon Tsang, Tan To Cheung, and Chung Mau Lo Copyright © 2013 Harry Hok Yee Yu et al. All rights reserved. Epithelioid Angiomyolipoma of Liver with an Inflammatory Component: A Case Report Sun, 10 Mar 2013 13:54:10 +0000 http://www.hindawi.com/journals/crihep/2013/738708/ Angiomyolipomas (AMLs) are benign mesenchymal tumors seen in kidneys in association with tuberous sclerosis. They are uncommon in liver. Angiomyolipomas of liver show great histological diversity and various types and patterns are described. Among them, epithelioid and inflammatory angiomyolipomas are rare. We report a case of epithelioid angiomyolipoma of Liver with an inflammatory component. Jyothi C. R., Dhanya P. Menon, Joy Augustine, and A. K. Abdul Siyad Copyright © 2013 Jyothi C. R. et al. All rights reserved. Hypofractionated Stereotactic Radiotherapy after Transarterial Chemoembolisation Failure in an Unresectable Hepatocellular Carcinoma: A Case Presentation Sun, 10 Mar 2013 10:23:51 +0000 http://www.hindawi.com/journals/crihep/2013/146215/ Introduction. Transarterial chemoembolization is the first-line treatment in unresectable hepatocellular carcinoma. There is no standard treatment after transarterial chemoembolization failure. We report the case of a patient with advanced hepatocellular carcinoma who showed a complete response and a long cancer control with hypofractionated stereotactic radiotherapy after transarterial chemoembolization failure. Case Presentation. A 70-year-old Caucasian woman was treated with transarterial chemoembolization for advanced hepatocellular, but no cancer control was obtained. A hypofractionated stereotactic radiotherapy was planned delivering 40 Gy in 5 fractions. A dramatic reduction in alpha-fetoprotein was observed. Contrast-enhanced ultrasonography at 1 and 2 months showed large necrotic areas. Computerised tomography scan showed a 90% objective tumour response, then a complete remission at 3 and 6 months after treatment, respectively. Status of patient remained unchanged for 2 years. Conclusions. Hypofractionated stereotactic radiotherapy can improve survival and prognosis of unresectable hepatocellular carcinoma patient. Francesco Fiorica, Carlo Greco, Sergio Boccia, Sergio Sartori, Antonio Stefanelli, Francesco Cartei, and Stefano Ursino Copyright © 2013 Francesco Fiorica et al. All rights reserved. Acute Abdomen Secondary to Incarcerated Umbilical Hernia after Treatment of Massive Cirrhotic Ascites Sun, 10 Mar 2013 10:21:57 +0000 http://www.hindawi.com/journals/crihep/2013/948172/ Umbilical herniation is common in patients with liver cirrhosis and ascites. Rarely, they suffer from incarceration and strangulation of the umbilical hernia after treatment of ascites. We report 3 cases of umbilical hernia incarceration following removal of massive ascites with different treatment modalities. Physicians managing this group of patients should be aware of this rare and potentially fatal complication. Hiang Keat Tan and Pik Eu Chang Copyright © 2013 Hiang Keat Tan and Pik Eu Chang. All rights reserved. Spontaneous Intraperitoneal Rupture of a Hepatic Hydatid Cyst with Subsequent Anaphylaxis: A Case Report Wed, 06 Mar 2013 17:40:09 +0000 http://www.hindawi.com/journals/crihep/2013/320418/ Hydatid cyst rupture into the abdomen is a serious complication of cystic hydatid disease of the liver (Cystic Echinococcosis) with an incidence of up to 16% in some series and can result in anaphylaxis or anaphylactoid reactions in up to 12.5% of cases. At presentation, 36–40% of hydatid cysts have ruptured or become secondarily infected. Rupture can be microscopic or macroscopic and can be fatal without surgery. Hydatid disease of the liver is primarily caused by the tapeworm Echinococcus granulosus and occurs worldwide, with incidence of up to 200 per 100,000 in endemic areas. Our case describes a 24-year-old Bulgarian woman presenting with epigastric pain and evidence of anaphylaxis. Abdominal CT demonstrated a ruptured hydatid cyst in the left lobe of the liver. A partial left lobe hepatectomy, cholecystectomy, and peritoneal washout was performed with good effect. She was treated for anaphylaxis and received antihelminthic treatment with Albendazole and Praziquantel. She made a good recovery following surgery and medical treatment and was well on follow-up. Intraperitoneal rupture with anaphylaxis is a rare occurrence, and there do not seem to be any reported cases from UK centres prior to this. Benjamin Tinsley, Aula Abbara, Raghunandan Kadaba, Hemant Sheth, and Gurjinder Sandhu Copyright © 2013 Benjamin Tinsley et al. All rights reserved. Combined Hepatocellular Carcinoma and Fibrolamellar Carcinoma Presenting as Two Adjacent Separate Lesions in a Young Boy: First Case Report from Asia Sun, 03 Mar 2013 15:50:31 +0000 http://www.hindawi.com/journals/crihep/2013/101862/ We report a rare case of combined hepatocellular carcinoma and fibrolamellar carcinoma arising in a noncirrhotic liver, in a 14-year-old boy who underwent right hepatectomy. We discuss the clinicopathological and immunohistochemical features and the clinical outcome in this unusual tumor. Pradyumn Singh and Banumathi Ramakrishna Copyright © 2013 Pradyumn Singh and Banumathi Ramakrishna. All rights reserved. Acute Pancreatitis Complicating Acute Hepatitis E Virus Infection: A Case Report and Review Thu, 31 Jan 2013 19:11:38 +0000 http://www.hindawi.com/journals/crihep/2013/531235/ Acute pancreatitis complicating fulminant viral hepatitis has been well recognized; however, acute pancreatitis occurring in nonfulminant hepatitis is very rare. The case presented describes moderate pancreatitis in a young male, manifesting during the course of nonfulminant acute hepatitis E infection. The diagnosis of acute viral hepatitis E was confirmed by serology and reverse transcriptase polymerase chain reaction (RT-PCR) to demonstrate Hepatitis E virus (HEV) RNA in both stool and serum. Patients with acute viral hepatitis presenting with severe abdominal pain should have a diagnosis of acute pancreatitis suspected and appropriate investigations including serum amylase, lipase, biliary ultrasonography and/or contrast-enhanced computed tomography of the abdomen should be undertaken. The identification of this unusual complication of Hepatitis E is important; however, the prognosis for patients with Acute Pancreatitis Complicating Acute Hepatitis E Virus Infection is good, and uncomplicated recovery with conservative treatment is expected. Hemanta Kumar Nayak, Nitish L. Kamble, Nishant Raizada, Sandeep Garg, and Mradul Kumar Daga Copyright © 2013 Hemanta Kumar Nayak et al. All rights reserved. Conservative Treatment for Cystic Duct Stenosis in a Child Sun, 20 Jan 2013 14:28:36 +0000 http://www.hindawi.com/journals/crihep/2013/146261/ Introduction. Few cases of common bile duct stenosis have been reported in the literature, and observations of strictures in the cystic duct are even more rare. Surgical cholecystectomy is the treatment needed in most cases of gallbladder hydrops. This paper describes the diagnosis and successful medical treatment of a rare pediatric case of cystic duct stenosis and gallbladder hydrops. Case Report. A formerly healthy one-year-old girl was admitted with colicky abdominal pain. Blood tests were normal, except for an increase in transaminases. Abdominal ultrasound excluded intestinal intussusception and identified a distended gallbladder with biliary sludge. MR cholangiography revealed a dilated gallbladder containing bile sediment and no detectable cystic duct, while the rest of the intra- and extrahepatic biliary tree and hepatic parenchyma were normal. This evidence was consistent with gallbladder hydrops associated with cystic duct stenosis. The baby was treated with i.v. hydration, corticosteroids, antibiotics, and ursodeoxycholic acid. Her general condition rapidly improved, with no further episodes of abdominal pain and normalization of liver enzymes. This allowed to avoid cholecystectomy, and the child is well 1.5 years after diagnosis. Conclusions. Although cholecystectomy is usually necessary in case of gallbladder hydrops, our experience suggests that surgical procedures can be avoided when the distension is caused by a cystic duct stenosis. Marco Gasparetto, Laura Giordano, Mara Cananzi, Valeria Beltrame, Gianni Bisogno, and Graziella Guariso Copyright © 2013 Marco Gasparetto et al. All rights reserved. Primary Pleomorphic Liposarcoma of Liver: A Case Report and Review of the Literature Thu, 10 Jan 2013 11:11:01 +0000 http://www.hindawi.com/journals/crihep/2013/398910/ Primary liver liposarcoma is a rare disease. The knowledge of the clinical course, management, and prognosis of primary liver liposarcoma are all limited because of its rarity. Twelve cases of primary liposarcoma of the liver have been previously reported. We present the thirteenth case, which occurred in an adult male patient. A 42-year-old male patient came to our outpatient department with complaints of pain abdomen, mass per abdomen, and weight loss. Ultrasonography showed a mass arising from the the left lobe of liver. CT abdomen showed a heterogenous enhancing mass from left lobe of liver with multiple cystic and necrotic areas compressing the stomach and spleen with no evidence of metastasis. Differential diagnosis included adenoma and primary malignancy. Exploratory laparotomy and resection were done. HPE was found to be pleomorphic liposarcoma of liver. P. R. Thippeswamy Naik, Prem Kumar, and P. Vinod Kumar Copyright © 2013 P. R. Thippeswamy Naik et al. All rights reserved. Hepatic Myelopathy in a Patient with Decompensated Alcoholic Cirrhosis and Portal Colopathy Tue, 18 Dec 2012 14:17:49 +0000 http://www.hindawi.com/journals/crihep/2012/735906/ Cirrhotic or hepatic myelopathy is a rare neurological complication of chronic liver disease usually seen in adults and presents as a progressive pure motor spastic paraparesis which is usually associated with overt liver failure and a surgical or spontaneous systemic portocaval shunt. We describe the development of progressive spastic paraparesis, in a patient with alcoholic cirrhosis with portal hypertension and portal colopathy who presented with the first episode of hepatic encephalopathy. The patient had not undergone any shunt procedure. Madhumita Premkumar, Avishek Bagchi, Neha Kapoor, Ankit Gupta, Gaurav Maurya, Shubham Vatsya, Siddharth Kapahtia, and Premashish Kar Copyright © 2012 Madhumita Premkumar et al. All rights reserved. Metronidazole-Induced Encephalopathy in a Patient with End-Stage Liver Disease Mon, 17 Dec 2012 17:07:03 +0000 http://www.hindawi.com/journals/crihep/2012/209258/ Purpose. Metronidazole-induced encephalopathy (MIE) has been rarely reported. We report a case in a patient with end-stage liver disease (ESLD). Summary. A 63-year-old male with ESLD secondary to hepatitis C virus presented with progressively worsening fatigue, slurred speech, aphasia, vomiting, and left-sided facial droop after completing a 2-week course of metronidazole for recurrent Clostridium difficile-associated diarrhea. He completed a previous course of metronidazole 3 weeks prior to presentation. He is on the liver transplant waiting list and has known hepatic encephalopathy. MRI revealed hyperintense T2 signals involving the bilateral dentate nuclei, inferior colliculi and splenium of the corpus callosum, and increased diffusion restriction at the splenium of the corpus callosum. His neurological function improved over the next several days. He underwent liver transplantation 6 days after admission. A follow-up MRI 6 weeks after presentation revealed resolution of abnormalities; however, paresthesias persisted 6 months after MIE diagnosis. Conclusion. An ESLD patient with hepatic encephalopathy developed MIE after a relatively short course of metronidazole. Metronidazole has been shown to accumulate in patients with ESLD. Increased awareness for neurotoxicity when using metronidazole in ESLD patients is warranted, especially in those with potentially confounding hepatic encephalopathy. John P. Knorr, Imran Javed, Neha Sahni, Ceylan Z. Cankurtaran, and Jorge A. Ortiz Copyright © 2012 John P. Knorr et al. All rights reserved. Acute Acalculous Cholecystitis Induced by Acute Hepatitis B Virus Infection Wed, 12 Dec 2012 09:57:14 +0000 http://www.hindawi.com/journals/crihep/2012/132345/ During the course of acute viral hepatitis, some functional and anatomical changes to the gallbladder can occur. Acute acalculous cholecystitis (ACC) is a rare complication of acute hepatitis B virus infection; only few cases are reported as ACC associated with acute hepatitis B virus infection. ACC cases are self-limiting, while other limited cases can progress to a gangrenous state, perforation, and even death. We present a 27-year-old female case diagnosed to have acute acalculous cholecystitis and associated with acute hepatitis B virus infection, and she recovered within one week of her presentation without complication or surgical intervention. Riyadh Ali Mohammed, Wisam Ghadban, and Osama Mohammed Copyright © 2012 Riyadh Ali Mohammed et al. All rights reserved. Hepatobiliary Cystadenocarcinoma Thu, 01 Nov 2012 10:51:58 +0000 http://www.hindawi.com/journals/crihep/2012/298957/ Biliary cystadenocarcinomas are rare tumors that are poorly understood. Preoperative imaging is imprecise and treatment is not standardized. We describe the presentation and treatment of one of these rare tumors and review the limited published literature. Neal Wilkinson Copyright © 2012 Neal Wilkinson. All rights reserved.