Successful Management of Periampullary Diverticular Bleeding with Hemoclipping Using Side-viewing Endoscope during Endoscopic Retrograde Cholangiopancreatography / 대한소화기학회지

Periampullary diverticulum is commonly found during endoscopy and can occur at any age although its prevalence increases with age. Periampullary diverticular bleeding is a rare and difficult to diagnose during clinical practice because of its unique appearance and location. This often can lead to massive bleeding and interfere with adequate bleeding control. Endoscopic management on duodenal diverticular bleeding is limited compared to colonic diverticular bleeding due to lack of experience. Herein, we report a case of active bleeding from a periampullary diverticulum during bile duct stone extraction diagnosed by side-viewing endoscope and successfully controlled using hemoclips without any complications.

A Case of Pylephlebitis with Pseudomonas aeruginosa Sepsis and Liver Abscess Secondary to Diverticulitis / 대한소화기학회지

Pylephlebitis, or suppurative thrombophlebitis of the portal venous system, is a rare condition occurring secondary to abdominal infections such as diverticulitis. Pylephlebitis can be diagnosed via ultrasonography or CT scan, and is characterized by the presence of a thrombus in the portal vein and bacteremia. However, the diagnosis may be delayed due to the vague nature of the clinical symptoms, causing morbidity and mortality due to pylephlebitis to remain high. Early diagnosis and immediate antibiotic therapy are important for favorable prognosis. Therefore, pylephlebitis should be considered in the differential diagnosis for cases of nonspecific abdominal pain and fever. We report a case of pylephlebitis secondary to diverticulitis, associated with Pseudomonas aeruginosa sepsis. Such cases have not been widely reported.

Mechanism of Action of Cholecystokinin on Colonic Motility in Isolated, Vascularly Perfused Rat Colon

BACKGROUND/AIMS: It is generally believed that cholecystokinin (CCK) stimulates colonic motility, although there are controversial reports. It has also been suggested that postprandial peptide YY (PYY) release is CCK-dependent. Using a totally isolated, vascularly perfused rat colon, we investigated: (1) the roles of CCK and PYY on colonic motility, (2) to determine if CCK modulates PYY release from the colon to influence the motility and (3) to clarify whether the action of CCK and PYY on colonic motility is mediated via the influence of cholinergic input. METHODS: An isolated whole rat colon was used. Luminal pressure was monitored via microtip catheter pressure transducers from proximal and distal colon. After a control period, CCK-8 or PYY was administerd intraarterially with or without an anti-PYY serum, loxiglumide or atropine at 12, 60 and 240 pM. Each dose was given for a period of 15-minute and the contractile response was expressed as % changes over basal. PYY concentration in the portal effluent was determined by radioimmunoassay. RESULTS: Exogenous CCK-8 increased colonic motility which paralleled the increase in PYY release in the portal effluent. Exogenous PYY also significantly increased colonic motility although it was less potent than CCK. The stimulating effect of CCK-8 was significantly inhibited by an anti-PYY serum, and was completely abolished by loxiglumide, and almost completely abolished by atropine. CONCLUSIONS: CCK increases colonic motility via CCK1 receptor and it is mediated partly by PYY. Cholinergic input is required for the increased motility by either PYY or CCK.

A Case of Fishbone-induced Esophageal Perforation Closed by Endoscopic Clipping / 대한소화기내시경학회지

Esophageal perforation continues to be associated with high mortality - 20% to 30% - despite advances in surgical techniques. Traditional surgery has been the mainstay of treatment for perforation, but recent advances in endoscopic closure devices has increased therapeutic options for selected patients. Our patient had a fishbone-induced esophageal perforation. He was treated successfully with endoscopic clipping, antibiotics and parenteral nutrition. We report this case and provide a review of the relevant literature.

A Case of Limy Bile Associated with Cholangitis and Calcified Gallbladder / 대한소화기내시경학회지

Limy bile is characterized by excessive precipitation of calcium carbonate, and generally preceded by gallbladder obstruction. Three case reports have been found in the domestic literatures. It is rare that limy bile syndrome associates cholangitis or calcified gallbladder. We report the case of a patient with limy bile, located in the gallbladder, common bile duct, and intrahepatic duct, with association of calcified gallbladder. This case showed characteristic radiologic and endoscopic findings. The patient was treated by endoscopic sphincterotomy and laparoscopic cholecystectomy.

Liver Abscess Caused by Gemella morbillorum / 대한소화기학회지

Gemella morbillorum, an anaerobic-to-aerotolerant Gram-positive coccus, is a normal flora of the oral cavity, respiratory tract, urogenital organ and gastrointestinal tract, and infections caused by this organism are unusual. It has been associated mainly with endocarditis and bacteremia, and rarely with arthritis, spondylodiscitis, meningitis, brain abscess and septic shock. Liver abscess caused by G. morbillorum is very rare, and only a few cases were reported. We experienced a case of liver abscess by G. morbillorum in a 56-year-old woman presented with fever. We report this case with a review of literatures.

Choledocho-duodenal Fistula Caused by Tuberculosis / 대한소화기내시경학회지

Choledocho-duodenal fistula is a rare condition. It is usually developed as a complication of the gallstone disease, and rarely developed by penetrating peptic ulcer, trauma and neoplasm. Tuberculosis as a etiology of choledocho-duodenal fistula is very rare, and only a few cases were reported. We experienced a case of choledocho-duodenal fistula due to tuberculous lymphadenitis in a 26 year-old man presented with epigastric pain. After 6 months of anti-tuberculous medication, He was free of symptom and the fistula was closed spontaneously. We report the case with a review of literatures.

A Case of Subphrenic Abscess with Ileal Fistula Caused by Metastatic Adenocarcinoma of Unknown Origin / 대한소화기학회지

Usual sources of subphrenic abscess with intestinal fistula are previous abdominal operation, inflammatory bowel disease and malignancy. Reported cases of intestinal fistula caused by adenocarcinoma were complicated by direct invasion. In this report, a 70-year-old male had a subphrenic abscess with intestinal fistula and the cause was a metastatic adenocarcinoma of unknown origin. As far as we know, this has not been reported previously in the literatures. The abscess went on chronic course for six months because intermittent administration of antibiotics modified its clinical presentation. The fistulous tract between the abscess and ileum was demonstrated by tubogram via the drainage catheter in abscess. The patient underwent surgical treatment because the cause of fistula was obscure. Invasion of the ileum by metastatic adenocarcinoma was diagnosed by the histologic examination of surgical specimen. Therefore, when a fistula develops without any apparent cause, there is a possibility of malignancy, and surgical approach must be considered. An early surgical approach will prevent the delay in treatment and reduce the mortality.

Postprandial Colonic Motor Activity in Patients with Irritable Bowel Syndrome / 대한소화관운동학회지

BACKGROUND/AIMS: The purpose of this study was to discover the physiologic difference of a postprandial motor response in different segments of the colon between patients with irritable bowel syndrome and healthy subjects. METHODS: Irritable bowel syndrome patients are categorized into three groups according to their main symptoms; loose stool-dominant (A, n=5), abdominal pain-dominant (B, n=5), constipation-dominant (C, n=6) and the normal control group (n=5). The intraluminal pressure activity was measured with a colonoscopically positioned multilumen manometric catheter. The change of the colonic motility index (MI) is presented as a percent change (mean+/-SE%) over the basal period in response to a meal. RESULTS: 1) In the transverse, descending and sigmoid colon of healthy subjects, the percentage changes in the basal MI during the first 30 min after the meal are significantly increased (p < 0.05-0.01). 2) In the sigmoid colon, the percentage changes in the basal MI during the first 30 min after the meal were 62+/-18 in A, 29+/-18 in B, 12+/-8 in C and 306+/-102% in heathy subjects respectively, which shows a significant difference between the MI of control and healthy subjects (p < 0.05). 3) In B and C, the percentage changes in the basal MI during the first 30 min after the meal in the descending colon were 105+/-38, 11+/-7, respectively, which shows a significant difference between the two groups (p < 0.05). In A and C, the percentage changes in the basal MI during the first 30 min after the meal in the sigmoid colon was 62+/-18, 12+/-8, respectively, which shows a significant change between the two groups (p < 0.05). CONCLUSION: This study suggests that postprandial intraluminal pressure differences play a role in the pathophysiology of irritable bowel syndrome.

A Case of Crohn's Disease with Blood Pressure Falling Intestinal Bleeding / 대한소화기내시경학회지

Life-threatening gastrointestinal hemorrhage is a rare complication in Crohn's disease. The authors experienced a case of Crohn's disease manifested with massive lower intestinal bleeding. A 22-year-old woman, who had underwent small bowel resection for bowel perforation and intestinal fistula, was admitted with lower abdominal pain and massive hernatochezia. A radioisotope bleeding scan and mesenteric angiography revealed suspi- cious intestinal bleeding in the small bowel area. The colonoscopy showed multiple shallow ulcers at the terminal ileum and scars on the cecum. In spite of medical management with the diagnosis of Crohn's disease, she continuecl to rebleed and required fistuloplasty and ileal resection. In the surgical specimen was discovered multiple exposed small vessels and diffuse blood oozing at terminal ileum. After surgery, there were no more bleeding episodes and she recovered with the aid treatment of sulfasalazine and prednisolone.

Clinical Usefulness of 24-hour Ambulatory Blood Pressure Monitoring in Hypertensive Pregnancy / 대한내과학회지

OBJECTIVES: In the third trimester hypertensive pregnancies, we would like to evaluate effects of white coat hypertension, severity of hypertension and diurnal variation of blood pressure on the fetal outcome by using 24- hour ambulatory blood pressure monitoring. METHODS: Hypertensives(n=50) and normotensives (n=14) in the third trimester of the pregnancy underwent 24-hour ambulatory blood pressure monitoring. We excluded hypertensives(n=5) who became pre-eclampsia patients. Hypertensives(n=45) were classified as white coat hypertensives(n=14, mean ambulatory blood pressure 160 mmHg or diastolic blood pressure >100mmHg) and mild hypertensives(n=26). Sustained hypertensives were also divided into two groups which had diurnal variation of blood pressure or not. To exclude effects of hypertension severity, effects of diurnal variation were evaluated in hypertensives with similar mean arterial blood pressure. Gestational age, body weight, body weight for gestational age were used as parameters of the fetal outcome. RESULTS: 1) The prevalence of white coat hypertension was 28%(14/50). 2) There were no significant differences in the fetal outcome between normotensives(n=14) and white coat hypertensives(n=14). 3) Body weight of fetus and body weight for gestational age in moderate to severe hypertensives(n=5) were less than those of mild hypertensives(n=26), but gestational age was not significantly different between two groups. 4) Body weight of fetus and body weight for gestational age in sustained hypertensives without diurnal variation(n=10) were less than those with diurnal variation(n=8), but gestational age was not significantly different between two groups. 5) All hypertensives who became pre-eclampsia (n=5) were severe hypertensives and had no diurnal variation of blood pressure. CONCLUSION: White coat hypertension in the third trimester was quite often and did not affect on the fetal outcome. The more severe hypertension and/or absence of diurnal variation of blood pressure caused poor fetal outcome. Patients who became pre-eclampsia were severe hypertensives and had no diurnal variation of blood pressure. Ambulatory blood pressure monitoring may have several roles in the antenatal management of hypertenison.

Postoperative FP ( 5-Fluorouracil , Cisplatin ) Chemotherapy for Patients with High - Risk Gastric Cancer / 대한암학회지

PURPOSE: Although adjuvant chemotherapy after resection of gastric cancer is a popular practice in Korea, there are still controversies about the effectiveness of the treatment. The fact that the relatively less effective drugs have been used and the rarity of large-scaled controlled studies may be partially responsible for the controversies. FP(5-FU, Cisplatin) combination is one of the most active regimen against advanced gastric cancer, consistently showing a response rate of 50~60%. We tried the FP chemotherapy as an adjuvant treatment for high-risk patients after curative resection of gastric cancer. MATERIALS AND METHODS: Between February 1992 and June 1996, 35 patients with completely resected high-risk gastric cancer(postoperative stage III or IV except thase with M1) received six courses of FP chemotherapy. Endpoints were toxicities of treatment, relapse free survival, and overall survival. RESULTS: With a median follow-up time of 17.1 months, Kaplan-Meier estimates of 2-year overall survival was 63.3% and relapse free survival estimates was 49%. There were no differences between stage III and IV patients in terms of overall survival or relapse free survival. Hematologic and non-hematologic toxicities were tolerable for most of the patients. CONCLUSION: Postoperative FP combination chemotherapy was tolerable for patients with high-risk(stage III and IV) gastric cancer. It is too early to determine the long term survival rates for this patients, but 2-year overall and relapse free survival were comparable to that of historical non-cisplatin containing regimens. Randomized phase III studies are warranted.

Right-side Bochdalek Hernia with Unusual Kidney Herniation in an Old Patient / 대한내과학회지

Bochdalek hernia through Bochdalek foramen, defect at the posterolateral side of the diaphragm is one of the congenital diaphragmatic hernias. It usually occurs in infants, but very rare in old age and also on the right side. We experienced the right-side Bochdalek hernia including kidney herniation in 68 years old man man ifested by hemoptysis. CT scan revealed diaphragmatic defect and herniated liver, colon and kidney. Thoracotomy was performed and the 10 cm-sized large defect was closed with patch. After then, the patient has been well without symptom.

A Case of an Organoaxial Type of Chronic Gastric Volvulus / 대한소화기내시경학회지

Gastric volvulus is a rotation of the stomach of at least 180 associated with a closed loop obstruction. Pare described the first case of gastric volvulus m 1579. Laxity of the gastric ligament, a congenital or acquired diaphragmatic defect, increased abdominal pressure, and a genetic component contributing to gastric volvulus. Gastric volvulus has been classified clinically as acute and chronic gastric volvulus, and can be classified anatomically as organoaxial, mesenteroaxial or a mixed type. Gastric volvulus occurs in children usually before 1 year of age or elderly patients. In acute gastric volvulus, and be patients complain of sudden abdominal or chest pain. The chest pain, which can radiate to the arms and neck accompanied by dyspnea, may initially lead to consideration of ischemic heart disease. Chronic gastric volvulus is difficult to diagnose because it may be associated with mild and nonspecific symptoms such as epigastric discomfort, fullness or heartburn. We experienced a case of 83 year old male with an organoaxial type of chronic gastric volvulus, iagnosed by upper gastrointestinal series, and treated with conservative rnanagement.

FPL ( 5-Fluorouracil / Cisplatin / Levamisole ) Combination Chemotherapy for Metastatic or Recurrent Gastric Carcinoma / 대한암학회지

PURPOSE: FP(5-FU, Cisplatin) combination is one of the most active regimen for the advanced gastric cancer with a response rate of 50~60%. In spite of this high response rate, there is little evidence that FP regimen results in survival benefit for patients with advanced gastric cancer. This study was performed to evaluate the efficacy and toxicity of this regimen with the addition of levamisole, an immunomodulatory agent, known as enhancing the antitumor effects of 5-FU in other cancer. MATERIALS AND METHODS: Previously untreated patients with metastatic or recurrent gastric cancer were treated with 5-FU(1000 mg/M2 civ, D1~5), cisplatin(60 mg/M2 iv, Dl) every 3 weeks, and levamisole(150 mg/day, Dl~3) every 2 weeks. The major endpoints were response rate, response duration, and toxicities. RESULTS: Between June 1992 and Aug. 1996, thirty three patients were included in this study. Patients received 2~18 cycles of chemotherapy(median 5). Among the evaluable 31 patients, 18 patients(58%, 95% C.I. 40.4~75.7) showed objective responses including one(3.2%) clinical complete response. The median response duration was 7.7 months(95% C.I. 3.6~11.8). During total of 189 cycles of chemotherapy, 79 episodes(41.7%) of leucopenia were observed. There was no death from concurrent infection. CONCLUSION: FPL combination therapy is at least as effective as conventional FP chemotherapy, but resulted in somewhat more myelosuppression.

Kallmann's Syndrome Associasted with Slipped Capital Femoral Epiphysis / 대한내분비학회지

The Kallmanns syndrome is the most common form of isolated hypogonadotropic hypogonadism in which anosmia or hyposmia resulting from agenesis of hypoplasia of the olfactory lobes is associated with LHRH deficiency, This syndrome is genetically heterogeneous and can be trans-mitted as an X-linked, autosomal dominant or autosomal recessive trait. The hypogonadotropic hypogonadism results in absent or incomplete pubertal development and may be associated with anosmia or hyposmia, mid-line defect(color blindness, cleft-lip or