Colonoscopic Missing Rate of Colorectal Polyps / 대한소화기내시경학회지

BACKGROUND/AIM: Colonoscopy has been known as the best diagnostic and therapeutic modality for colorectal polyps. However, it has been difficult to assess its accuracy. METHODS: We studied the data from patients who had colonoscopic polypectomy within 30 days after the initial examination. RESULTS: From 218 patients, a total of 362 polyps were found, 51 (14.1%) of which were missed. There were 17 patients with missed polyps among 59 patients who had two or more polyps on the initial examination. According to the location, the missing rates were variable: the splenic and hepatic flexure had the highest missing rates, and the sigmoid colon had the lowest missing rate. In our study, there was no difference of missing rate according to the size and shape. CONCLUSIONS: There is a significant colonoscopic missing rate for colorectal polyps in routine clinical practice, especially in patients with multiple colonic polyps and at the site of the colonic flexure.

Frequency and clinical characteristics of suspected hereditary non-polyposis colorectal cancer / 대한내과학회지

BACKGROUND: The current diagnosis of hereditary non-polyposis colorectal cancer (HNPCC) is dependent on a detailed family history based on the Amsterdam criteria proposed by the International Collaborative Group on HNPCC (ICG-HNPCC) in 1990. On recognizing the shortcomings of the ICG-HNPCC criteria, the Korean Hereditary Colorectal Cancer Registry (a subdivision of the Korean Hereditary Tumor Registry) designated the term 'suspected HNPCC' for families who do not fullfill the criteria of the ICG-HNPCC but in whom a genetic basis for colon cancer is strongly suggested. The present study was designed to determine the frequency and define the clinical characteristics of suspected HNPCC. METHODS: We analysed the clinical characteristics of 42 suspected HNPCC patients and their family members and compared these characteristics with that of 1,692 non-hereditary colorectal cancer patients. RESULTS: The frequency of suspected HNPCC was 2.4% in our study. The mean age of suspected HNPCC patients at the time of diagnosis was 45.1+/-9.6 years and that of non-hereditary colorectal cancer patients was 57.4+/-11.9 years. The incidence of synchronous colorectal cancers in HNPCC was 7.1% and that of non-hereditary colorectal cancers was 0.9%. In suspected HNPCC families, 18 patients had extracolonic malignancies and the stomach cancer was the most common (55.5%).CONCLUSION: The frequency of suspected HNPCC among total colorectal cancer cases was 2.4% in our study. Tumors in suspected HNPCC differed from non-hereditary colorectal cancers in an early age of onset.

A Prospective Endoscopic Blind Trial Comparing Precolonoscopy Bowel Cleansing Methods / 대한소화기내시경학회지

BACKGROUND AND AIMS: Although some authors have suggested that sodium phosphate (NaP) is more effective than polyethylene glycol (PEG) in bowel cleansing, there has been no crossover study proving the superiority of NaP over PEG in bowel cleansing and patients' compliance. The aim of this study was to compare the two solutions for colonoscopy, PEG and NaP, through crossover design with regard to patients' compliance, cleansing ability and side effects. METHODS: Thirty patients underwent two separate colonoscopies for colonic polyp(s) with PEG and NaP, respectively. Before and after bowel preparation, blood pressure, body weight, and serum biochemical parameters were measured in all patients. In addition, a detailed questionnaire was used to assess side effects and the patients' preference. The presence of bubbles, types of residual stool, and overall quality of colon cleansing were assessed by one endoscopist blinded to the type of preparation used. In each colonoscopy, two biopsy specimens were taken at rectum. RESULTS: In the NaP group, but not in the PEG group, there were significant changes in several biochemical parameters including sodium ( +3.0 +/- 3.0 mEq/L), potassium ( -0.3 +/- 0.3mEq/L), calcium ( -0.5 +/- 0.5 mg/dL), phosphorus ( +3.9 +/- 2.2 mg/dL) and osmolarity ( +10.1 +/- 9.3 mOsm/kg) after bowel preparation. In addition, the degree of body weight change was greater with NaP ( -2.2 +/- 2.3 kg) than with PEG ( -1.2 +/- 2.0 kg) (p=0.06) and the formation of bubbles that disturb luminal observation was more frequently found in the NaP group (p<0.01). There was no difference, however, in the type of residual stool and the overall quality of bowel preparation between the two groups and no significant mucosal change was noted after bowel preparation in both groups. Moreover, PEG was found to be more difficult to take than NaP (p<0.05) and among the 30 patients, 26 (87%) preferred NaP, while only two favored PEG (p<0.01). CONCLUSIONS: We conclude that NaP can replace PEG at least in patients with good general condition. Further studies to decrease the incidence of bubbles and to establish subgroups suitable for NaP are needed.

Long-Term Recurrent Bleeding Rate of Bleeding Peptic Ulcer / 대한소화기내시경학회지

BACKGROUND AND AIMS: Bleeding from a peptic ulcer is one of the common and serious complications associated with the rate of reported mortality, which ranges from 5% to 10%. Endoscopic therapy is effective in controlling active bleeding and reducing the emer-gency surgery, the immediate mortality rate and the incidence of early rebleeding. But few recent studies have documented the long-term recurrent bleeding rate after discharge in patients with bleeding peptic ulcers. The aim of this study was to determine the long-term recurrent bleeding rate and factors predisposing to recurrent bleeding. METHODS: Eighty-eight patients with bleeding peptic ulcers discharged after medical treatment between Dec. 1990 and Jul. 1992 were included in this study and retrospectively followed up with medical records and telephone interviews. The end point of follow-up was recur-rent hemorrhage, surgery for treatment of ulcer complication, or death. RESULTS: By July 1997, retrospective follow-up was available in 76 patients. Recurrent bleeding occurred in 23 patients (30.3%) with bleeding peptic ulcers and the median follow-up period was 69 months (range, 1 ~79 months). The estimated cumulative recurrent bleeding rate after 1, 2, 3, 4, 5 and 6 years was 11.8%, 14.5%, 19.9%, 24.2%, 27.2% and 34.2%, respectively. There was no difference between the recurrent bleeding group and the non-recurrent bleed-ing group according to age, sex, prior NSAIDs use, previous history of bleeding or pepticulcer, site of ulcer, stigmata of recent hemorrhage at initial examination, method of treatment and amount of transfusion. CONCLUSION: Recurrent bleeding occurred in one-third of patients with bleeding peptic ulcers after 6 years of follow-up and one-third of recurrent bleeders rebled within 1 year. The factors predisposing to recurrent bleeding in the long-term follow-up could not be found. Therefore, further studies designed to identify factors predisposing to recurrent bleeding are needed and the evaluation of Helicobacter pylori status in bleeding peptic ulcer is needed because Helicobacter pylori is an important factor of peptic ulcer recurrence.

A Case of a Granular Cell Tumor of the Stomach / 대한소화기내시경학회지

Granular cell tumors of the gastrointestinal tract are uncommon, and the esophagus is the gastrointestinal site most frequently affected. Such tumors are rarely seen in the stomach, colon, or rectum. Azzopardi first described a granular cell tumor of the stomach in 1956. Since then a few gastric granular cell tumors have been reported in corresponding literature. It is believed that there have been no reported case of a granular cell tumor of the stomach in Korea. Subsequently one case of a granular cell tumor of the stomach in 38 year-old female who complained epigastric soreness is herein reported, and was successfully managed by endoscopic resection.

Frequency and Predictive Factors of Recurrent Spontaneous Bacterial Peritonitis in Cirrhosis / 대한내과학회지

OBJECTIVES: Spontaneous bacterial peritonitis (SBP) is a frequent and severe complication of cirrhosis. In the most recently published studies, the prevalence of SBP among hospitalized cirrhotics with ascites has been estimated to be around 10-15%, the mortality rate related to this complication being more than 50%. SBP is thought to appear as a consequence of the impaired defensive mechanisms against infection present in cirrhotic patients, such as depressed reticuloendothelial system phagocytic activity, impaired leukocyte function, reduced serum compliment levels, and low antibacterial activity of ascitic fluid. It has proposed that ascitic fluid opsonin capacity is directly correlated to ascitic protein concentration and that this explains an observed predisposition to infection in patients with low ascitic fluid protein concentration. This present study aims to investigate the frequency of the recurrence of SBP in a large series of cirrhotic patient who recovered from the first episode of SBP and to identify any possible predictors of recurrent SBP. METHOD: We reviewed records of chart in 312 consecutive cirrhotics with ascites patients treated in our hospital between January, 1988 and August, 1995. RESULTS: The incidence of SBP was 21.8%(68 cases) and showed 80.9% in male, 19.1% in female. Seventeen(25%) of the 68 patients included in the study after the resolution of their first episode of SBP developed one or more episodes of SBP during follow-up. SBP recurred once in 16 of these patients, twice in 1 patients. The cumulative probability of SBP recurrence was 47.1% at 6 months, 64.7% at 12 months, and 82% at 18 months of follow-up. This study reveals that neither ascitic fluid total protein nor the severity of liver disease(Child's class) predicts the occurence of recurrent SBP. CONCLUSON: We conclude that the occurrence of recurrent SBP is unrelated to the type of liver disease, and severity of liver disease did not predict the presence of recurrent SBP. Also, ascitic fluid total protein < or =1.0 g/dl, prothrombin time < or =45% may not be a sensitive predictor of recurrent SBP.

A Preliminary Study on the Expression of C-X-C Chemokine Genes in Colonic Mucosa of Patients with Ulcerative Colitis

PURPOSE: Chemokines are potent regulators of the host inflammatory or immune responses. Mucosal synthesis of chemokines may be important in the pathogenesis of mucosal inflammation in ulcerative colitis (UC). We performed this study to investigate the expression of C-X-C chemokine genes in UC. METHODS: Mucosal tissues were obtained from six normal controls and six UC patients by endoscopic biopsies. In patients with UC, mucosal tissues were separately obtained from both involved and uninvolved regions. RNA was extracted and mRNA levels of five C-X-C chemokines were determined by quantitative reverse transcription-PCR using internal RNA standards. RESULTS: Mucosal mRNA levels of all chemokines tested increased in the involved region of UC compared with the uninvolved region of UC or normal controls. CONCLUSION: Our data suggest that mucosal expression of C-X-C chemokines contributes to the pathogenesis of UC

Unexposed Ampullary Cancer / 대한소화기내시경학회지

BACKGROUND: Ampullary cancer is a malignant lesion in the pancreatobiliary system with a relatively good prognosis because of its slow growth, early appearance of symptoms and high resectability. Hndoscopic retrograde cholangiopancreaticography(ERCP) is an important and useful method in the diagnosis of ampullary cancer because it identifies the location of lesions endoseopically and by opacification of the bilio-pancreatic ducts and allows confirmation by biopsy, But the diagnostic accuracy of endoscopic forcep biopsy was variable according to the macroscopic appearance of ampullary cancer. In unexposed type ampullary cancer, biopsy after endoscopic sphincterotomy or intraluminal cannulatian biopsy has been recommended because the cancer tissue was either not visible at all or barely visible from the lumen of the duodenum. The purpose of this study was to evaluate the contribution of endoscopic sphincterotomy to the diagnosis of ampullary cancer and to compare the clinical eharasteristics of unexposed type ampullary cancer with those of exposed type ampullary cancer. METHOD: Thirty-one cases of the ampullary cancers over the past 5 years were reviewed. Macroscopically, thirty one ampullary cancers were classified into two types. The unexposed type ampullary cancer was defined normal ampullary mucosa with or without protruding. The exposed type ampullary cancer was defined abnormal ampullary mucosa including nodular, ulcerative, nodulo-ulcerative and polypoid appearance. Ampullary cancers were diagnosed preoperatively by forcep biopsy, biopsy after endoscopic sphincterotomy, or brushing cytology. RESULT: The proportion of unexposed type in ampullary cancer was 29%(9 cases). There were no differences of age, sex, diagnostic clue, distal common bile duct(CBD) shape and CBD dilatation by ERCP between unexposed and exposed type ampullary cancers. The serum bilirubin, alkaline phosphatase and GGT were lower in unexposed type comparting with exposed type. The unexposed ampullary cancers could be diagnosed with biopsy after endoscopic sphincterotomy except one case. Biopsy samples were successfully obtained immediately after sphincterotomy in 3 patients and a few days (3 days later-1 month later) after sphincterotomy in 5 patients. CONCLUSION: Weconsider the possibility of unexposed ampullary cancer in cases of jaundice or duct dilatation with normal ampullary cancer in cases of jaundice or duct dilatation with normal ampulla mucosa and should perform biopsy after endoscopic sphincterotomy.

Fine Structure and Albumin Gene Expression in Intrasplenically Transplanted Hepatocytes / 대한내과학회지

BACKGROUND: The morphological characteristics of hepatocytes transplanted into the spleen have been studied. However few attempts has been made to determine the expression of genes in intrasplenically transplanted hepatocytes. The aim of this study was to explore whether the pattern of expression of albumin gene in intrasplenically transplanted hepatocytes is similar to that in adult liver, resulting in the long-term expression of this hepatocyte-specific gene. METHODS: Hepatocytes isolated from liver of syngeneic Fischer 344 rats and transplanted into the spleen of rats from the same strain survived for 12 months in the absence of immunosuppressive drugs. Microscopic examination of intrasplenic hepatocytes and Northern blotting for albumin gene expression of RNA extracted from liver and spleen was performed. RESULTS: Microscopy demonstrated that hepatocytes attached themselves only in the red pulp of the spleen and isolated hepatocytes preserved the fine structures characteristic of normal hepatic parenchymal cells. Throughout the 12 months period, intrasplenically transplanted hepatocytes expressed albumin mRNA. CONCLUSIONS: Intrasplenically transplanted hepatocytes represent a unique in vivo system of extrahepatic maintenance of hepatocytes. This novel transplantation system could be used to investigate hepatocyte engraft, proliferation and gene expression.

Clinical Characteristics of Periampullary Diverticulum / 대한소화기내시경학회지

Background/Aims: Periampuilary diverticulum has been known to be associated with various bilio-pancreatic diseases such as choledocholithiasis and disturbs performing selective cannuiation of ERCP and EST. This present study aims to investigate anatomical morphology of periampullary diverticulum and to determine whether periampullary diverticulurn influences difficulty and complication performing of ERCP and to analyse the relationship between periampullary diverticulum and choledocholithiasis. Methods: We reviewed records of chart and diverticular pictures in 1389 cases of underwent ERCP and evaluated the incidence, size, direction, location of periampullary diverticulum and its influence against performing of ERCP and investigated its relationship with bilio-pancreatic diseases such as choledocholithiasis.(continue..)

Two Cases of Graves Disease Associated The Empty Sella Syndrome / 대한내분비학회지

The empty sella syndrome is characterized by obesity, frequent pregnancy, headache and high blood pressure, but its exact cause remains unknown. Usually the incomplete diaphragmatic sella has been considered as the cause of the empty sella syndrome, but some authors recently have suggested that the antipituitary antibody way be related to development of pituitary atrophy and the pituitary empty sella syndrome, and thus it may be clinically useful as screening test for the empty sella syndrome. We experienced two empty sella syndromes associated Graves disease and applied the antipituitary antibody as the diagnostic tool of the empty sella syndrome. But none of this two patients had antipituitary antibody and we report these cases with reviews of literatures.

A Case of Calcitonin Secreting Pheochromocytoma / 대한내분비학회지

Pheochromocytoma is a catecholamine producing turnor and raise with less than 0.1% of hypertensive patients. It is developed, most commonly, in sporadic pheochromocytoma or multiple endocrine neoplasia type 2. Therefore, when hypercalcitoninemia is found in a patient with pheochromocytoma, the possibility of multiple endocrine neoplasia type 2 or the ectopic secretion of calcitonin must be considered. Recently we experienced a 45 year old male patient with sporadic pheochrornocytoma. He also had hypercalcitoninemia and normocalcemia. After the removal of pheochromocytoma, serum calcitnnin level returned to normal. Secretion of calcitonin was confirmed by immunohisto- chemical stain.