Usefulness of Non-invasive Markers for Predicting Significant Fibrosis in Patients with Chronic Liver Disease

The purpose of this prospective study was to verify and compare the strengths of various blood markers and fibrosis models in predicting significant liver fibrosis. One hundred fifty-eight patients with chronic liver disease who underwent liver biopsy were enrolled. The mean age was 41 yr and male patients accounted for 70.2%. The common causes of liver disease were hepatitis B (67.7%) and C (16.5%) and fatty liver (9.5%). Stages of liver fibrosis (F0-4) were assessed according to the Batts and Ludwig scoring system. Significant fibrosis was defined as > or =F2. Sixteen blood markers were measured along with liver biopsy, and estimates of hepatic fibrosis were calculated using various predictive models. Predictive accuracy was evaluated with a receiver-operating characteristics (ROC) curve. Liver biopsy revealed significant fibrosis in 106 cases (67.1%). On multivariate analysis, alpha2-macroglobulin, hyaluronic acid, and haptoglobin were found to be independently related to significant hepatic fibrosis. A new predictive model was constructed based on these variables, and its area under the ROC curve was 0.91 (95% confidence interval, 0.85-0.96). In conclusion, alpha2-macroglobulin, hyaluronic acid, and haptoglobin levels are independent predictors for significant hepatic fibrosis in chronic liver disease.

A Case of Ulcerative Colitis with Prolonged Remission Following Azathioprine-Induced Pancytopenia

Azathioprine (AZA) is widely used for the treatment of inflammatory bowel disease. Bone marrow suppression is a common side effect with AZA treatment. However, data from AZA trials has indicated that a leukocyte count less than 5,000/mm3 was a good predictor of induction and maintenance of remission. Moreover, there is evidence that eradication of sensitized leukocytes by leukapheresis or bone marrow transplantation improves inflammatory bowel disease. We report a case of a patient who had a chronic relapse of ulcerative colitis requiring the frequent use of systemic steroids, but presented prolonged remission following AZA-induced severe pancytopenia. Also colonoscopy showed accelerated healing of diffuse active ulcers following just recovery from pancytopenia.

Giant Hyperplasia of the Caudate Lobe in a Patient with Liver Cirrhosis: Case Report and Literature Review

The caudate lobe often exhibits enlargement and nodularity in cases of cirrhosis, which makes differentiation of hepatocellular carcinoma from other mass-like lesions of the caudate lobe difficult in cirrhotic patients. A 12x6 cm mass-like enlargement of the caudate lobe was incidentally found by computed tomography in a 38-year-old man suffering from alcoholic liver cirrhosis. Magnetic resonance imaging, liver colloidal scan, and sonoguided liver biopsy were used for the differential diagnosis. A literature review revealed two case reports, all of which (like ours) presented with an enlarged caudate lobe supplied with blood via a branch of the portal vein. Therefore, in cases of giant hyperplasia of the caudate lobe, confirmation of the caudate lobe blood supply and the enhancement pattern might be important for the differentiation.

A Case of Ischemic Colitis in a Patient with Takayasu's Arteritis / 대한소화기학회지

Ischemic colitis is one of the most common intestinal ischemic injury in which more than 90% of patient are over 60 year-old. It results from impaired perfusion of blood to the bowel and is rarely caused by vasculitis such as systemic lupus erythematosus, polyarteritis nodosa, and Takayasu's arteritis. Takayasu's arteritis affects the aortic arch, medium-sized and large arteries but rarely involves inferior mesenteric artery. We report a case of Takayasu's arteritis involving inferior mesenteric artery which developed ischemic colitis in a 70 year old female. To the author's knowledge this is the first case report in Korea. A 70 year old woman who had suffered from Takayasu's arteritis for 5 years was admitted for sudden abominal pain and hematochezia. On sigmoidoscopy, there were multiple segmental longitudinal ulcerations around splenic flexure and diffuse hemorrhagic edematous mucosa from descending colon to sigmoid colon. On abdominal CT angiography, inferior mesenteric artery was not traced. We diagnosed it as ischemic colitis combined with Takayasu's arteritis. After the conservative treatment, abdominal pain and hematochezia disappeared. She was followed up to 2 years without recurrence of symptoms.

A Case of Ulcerative Colitis Relapsed by Influenza Vaccination / 대한소화기학회지

Although a large number of studies have reported the causes of the exacerbation of ulcerative colitis (UC), the effect of influenza vaccination on the relapse of UC has not been reported. We experienced a case of prompt exacerbation of quiescent UC due to influenza vaccination. A 39-year-old woman was diagnosed as UC 4-years ago and was well controlled with oral mesalazine. She experienced abdominal pain and frequent bowel movements with hematochezia 3 days after the vaccination. On admission, laboratory findings showed elevated erythrocyte sedimentation rate and C-reactive protein. Sigmoidoscopy showed marked edematous mucosa on rectum and sigmoid colon with fine ulceration and spontaneous bleeding. She recovered from the exacerbation of UC after steroid treatment. Vaccination should be administered to the patients with inflammatory bowel disease with the caution of its possible side effects.

Four cases of gastric submucosal mass suspected as anisakiasis

Anisakiasis is a parasitic disease caused by ingestion of raw fish infected with anisakid larvae. Endoscopic changing patterns of submucosal lesions in chronic gastric anisakiasis have not been known yet. Here we report 4 cases of suspected gastric anisakiasis which were improved during follow-up periods without surgical treatment. The patients presented with abdominal pain, nausea and vomiting after consuming raw marine fish, and visited our gastroenterology outpatient department. Their endoscopic findings showed firm and yellowish submucosal masses accompanied with eccentric erosions. Histologic findings showed severe eosinophilic infiltrations. In blood tests, peripheral eosinophil counts and total IgE levels were elevated. We believed that all cases were caused by larval anisakid infections. The submucosal mass lesions disappeared during the follow-up periods of 2 to 4 mo.

A Case of Partial Intestinal Obstruction due to Ascaris lumbricoides / 대한소화기내시경학회지

Ascaris lumbricoides (A. lumbricoides) is the largest and most common human intestinal helminth in the world. However, the prevalence of ascariasis has, in recent years, been very low in Korea. The majority of patients infected with A. lumbricoides are asymptomatic. However, sometimes these infections may give rise to intestinal obstructions or pancreatobiliary disease, via retrograde migration through the ampulla of Vater. Intestinal obstruction associated with A. lumbricoides is a complication that is frequently observed in children living in endemic areas. However, no cases of A. lumbricoides-associated intestinal obstruction have been reported in Korea since 1967. In this report, we describe the case of a 78-year-old man, who presented with sustained nausea and postprandial vomiting, and was diagnosed with a partial intestinal obstruction due to A. lumbricoides after undergoing an esophagogastroduodenoscopy.

A Case of Carcinoid Tumor of the Common Bile Duct / 대한소화기학회지

Majority of malignant neoplasms arising from the extrahepatic bile duct are adenocarcinomas. Carcinoid tumors at this site are extremely rare. We report a 67-year-old woman with malignant carcinoid tumor of the common bile duct. She presented with obstructive jaundice of 1 week's duration. Abdominal CT and ERCP revealed a common bile duct mass. She underwent Whipple's operation and was diagnosed as malignant carcinoid tumor histologically and immunohistochemically.

Clinical Factors that Predicts Successful Eradication of Helicobacter pylori / 대한소화기학회지

BACKGROUND/AIMS: Antibiotic resistance and compliance are regarded to be important which affect the eradication of Helicobacter pylori (H. pylori). However, it is not easy to apply the antibiotic resistance test in clinical field. We investigated other clinical factors predicting the successful eradication of H. pylori. METHODS: From January 2004 to March 2005, 195 patients with documented H. pylori infection received proton pump inhibitor (PPI)-based triple therapy for one week and were assessed for the underlying chronic illnesses, smoking, alcohol habit, therapeutic indication and compliance. RESULTS: The intention-to-treat (ITT) eradication rates were 69.2%, while per protocol (PP) analysis with 169 patients showed an initial eradication rate of 79.9%. The eradication rates of H. pylori according to the underlying disease were 73.9% (17/23) in diabetes, 66.7% (18/27) in hypertension, 66.7% (2/3) in renal disease, 100% (9/9) in liver disease, 63.7% (7/11) in cardiovascular disease and 64.3% (9/14) in chronic NSAIDs user. There was no statistical difference in the eradication rates according to the therapeutic indication, underlying disease, sex, age, smoking, alcohol, and PPI. However, the eradication rate was statistically lower in patients with multiple underlying diseases. Eradication rate was significantly higher in patients with good compliance than in those with poor compliance in taking medications (p<0.05). CONCLUSIONS: Underlying chronic disease does not affect the H. pylori eradication rate significantly. In clinical practice, apart from antibiotic resistance test, drug compliance is the most important factor affecting the H. pylori eradication rate.

A Case of Granular Cell Tumor of the Stomach in a Patient with Extramammary Paget's Disease / 대한소화기내시경학회지

Granular cell tumor is an uncommon submucosal neoplasm of uncertain etiology and histogenesis. Having been reported in virtually all other sites, granular cell tumors of the gastrointestinal tract are rare. Reported cases in the gastrointestinal tract account for 5~9% of all granular cell tumors, most commonly in the esophagus. Only one case of gastric granular cell tumor has been reported in Korea. We report a case of asymptomatic gastric granular cell tumor coexisting with gastric adenoma in 56-year-old male who had extramammary Paget's disease in the right scrotum, and it was successfully managed by endoscopic polypectomy.

A Case of Coffee Enema-Induced Colitis / 대한소화기내시경학회지

A coffee enema which has been suggested as a part of a cancer treatment, has been misused as a treatment for obesity and constipation among the general population. Its proponents claim that caffeine is absorbed in the colon, which leads to vasodilatation in the liver and stimulation of the hepatocellular function to detoxify the products of the tumor cell metabolism. However, the clinical efficacy of the anti-cancer effect of coffee enemas has not been demonstrated. Many side effects of coffee enemas have been reported. These include severe electrolyte imbalance, polymicrobial enteric septicemia, and even death. We experienced a patient who presented with abdominal pain and a bloody stool after receiving a coffee enema to relieve constipation. We report this case of coffee enema-induced colitis with a review of the relevant.

A Case of Polyp with High Grade Dysplasia in Ulcerative Colitis / 대한소화기내시경학회지

Patients with ulcerative colitis (UC) have the increased risk of colorectal cancer. The risk of colorectal cancer development in UC is associated with the extent of colitis and duration of disease. It is generally agreed that there is little or no increased risk associated with proctitis or proctosigmoiditis. A dysplasia-associated lesion or mass (DALM) is difficult to distinguish from sporadic adenoma. The DALM indicate a high association with colon cancer. The presence of DALM as a premalignant lesion has been considered as an indication for colectomy because of the high risk of progression to malignancy within a short period. We report a case of polyp with high grade dysplasia in a 27-year-old man of ulcerative colitis confined to rectum and sigmoid colon.

A Case of Crohn's Disease with Giant Pseudopolyposis and Ileocolic Fistula / 대한소화기내시경학회지

Pseudopolyp is a common association of ulcerative colitis but may also occur in Crohn's disease, ischemic colitis and infective colitis. Pseudopolyps are results of the repair process, representing islands of granulation tissue surrounded by mucosa with ulceation. When a pseudopolyp is larger than 1.5 cm, it is often called a "giant pseudopolyp". Such lesions of inflammatory origin are often confused with polypoid carcinoma or infiltrating submucosal malignancy. We report a case of asymptomatic Crohn's disease as giant pseudopolyposis mimicking malignancy on sigmoid colon, with a review of relevant literatures.

Complications of percutaneous endoscopic gastrostomy and risk factors of peristomal wound infection / 대한내과학회지

BACKGROUND: Percutaneous Endoscopic Gastrostomy (PEG) is a widely used method for providing nutritional support for patients who require prolonged tube feeding. This technique is known to be a safer, more convenient, and less expensive procedure than surgical gastrostomy. Although the overall incidence of complication is low, several complications such as peristomal wound infection, bleeding, panperitonitis, gastrocolic fistula, etc. were reported. Among these complications, peristomal wound infection is common and troublesome. METHODS: A retrospective review of medical records was conducted on patients undergoing PEG placement between January 1995 and March 2003. One hundred sixteen cases of 137 cases which were performed during this period were included, excluding 21 cases as exchanges of PEG. We reviewed the complications associated with PEG placement and analyzed the risk factors of peristomal wound infection. RESULTS: In 61 (52.6%) of 116 cases, several complications developed after the procedure. The peristomal wound infection occurred in 37 cases (31.9%) and bleeding in 2 cases (1.7%). Mild complications included peristomal pain in 37 cases (31.9%); stomal leakage in 2 cases (1.7%); and oozing in 1 case (0.9%). The rate of wound infection was significantly higher in patients who had Diabetes mellitus (p<0.01), who had leukocytosis (p<0.05) and who had not received prophylactic antibiotics (p<0.05). But the rate was not different according to age, sex or underlying disease. CONCLUSION: Peristomal wound infection was the most common complication of PEG. Diabetes mellitus and leukocytosis were risk factors of peristomal wound infection after PEG, and prophylactic antibiotics significantly reduced the risk of wound infection.

The Study of Branching Anomaly and Tortuosity of Radial Artery for Trans-Radial Coronary Procedure

BACKGROUND AND PURPOSE: The radial artery has currently been regarded as a useful vascular access site for coronary procedures. We want to evaluate the incidence and clinical significance of anomalous branching pattern and tortuosity of radial artery. MATERIALS AND METHOD: From May 1997 to May 1999, retrograde radial artery angiography was performed in 1191 cases. Branching anomaly and tortuosity of upper extremity artery, procedure times and local vascular complications were analyzed. RESULTS: 1) Anomalous radial arterial branching was found in 3.2%. Most common one was high origin of the radial artery (2.4%). 2) Tortuosity of radial artery was found in 4.2%. Most common tortuosity were S shape in 1.8% and omega shape in 1.8% of cases. 3) Cross over to other artery, radial artery occlusion and perforation occurred in 24 cases, 6 cases and 4 cases, respectively. Prolonged procedure times, crossover to other artery and radial artery perforation was related with tortuosity of radial artery, not with anomalous branching. CONCLUSION: The incidence in branching anomaly and tortuosity of radial artery was not frequent in our study. Radial artery tortuosity was associated with old age, prolonged procedure time and radial artery perforation. In selected cases, pre- or intra-procedural angiographic assessment of radial artery might be helpful in performing safe procedure.

Guidewire-Induced Perforation of Distal Circumflex Artery Treated with Transcatheter Embolization of Polyvinyl Alcohol Form

Coronary artery perforation is a rare and serious complication in coronary angioplasty. Some patients complicated by coronary perforation may develop cardiac tamponade, which is generally due to massive hemorrhage in the pericardial space between the epicardium and the pericardium. We report a case of coronary artery perforation producing impending tamponade, which was successfully treated by transcatheter embolization of distal circumflex artery using polyvinyl alcohol.

The Severity of Extent of Coronary Atherosclerosis Related to Plasma Homocysteine

BACKGROUND AND PURPOSE: Hyperhomocysteinemia is supposed to be a risk factor for vascular occlusive disease. We want to evaluate the relationship between plasma homocysteine and the severity of coronary artery disease (CAD). METHODS: In 121 consecutive patients (men:62%: age:60+/-10 years) undergoing coronary angiography, plasma homocysteine, vitamin B(12), vitamin B(6) and folate levels were measured and angiographic findings were evaluated for the number of diseased vessels (diameter stenosis 50%), severity of stenosis of CAD and extent of CAD. Extent of CAD was defined as an index derived by assigning a score of 0-3 per segment depending on the proportion of lumen length irregularity and dividing the sum by the number of visualized segments. RESULTS: Twenty-two patients had normal coronary artery: 35 patients, minimal CAD (diameter stenosis < 50%): 30 patients, 1 vessel disease (VD): 22 patients, 2VD and 12 patients, 3VD. Homocysteine levels w+re not significantly different between the groups (normal:7.6+/-4.2 mmol/L: minimal CAD:8.4+/-3.1mmol/L: 1VD: 8.0+/-4.8mmol/L: 2VDs: 10.2+/-6.0 mmol/L: 3VDs: 9.2+/-5.3 mmol/L). There was no relation between the stenosis scores of CAD and homocysteine levels (r=0.1). The extent scores of CAD were weakly correlated to the plasma homocysteine levels (r=0.22, p<0.05) and low density lipoprotein (LDL) cholesterol levels (r=0.28, p<0.01), and reversely correlated to high density lipoprotein (HDL) cholesterol levels (r=-0.31, p<0.01). The plasma homocysteine levels were reversely correlated to vitamin B12 (r=-0.27, p<0.01) and folate (r=-0.23, p<0.05) levels. In conclusion, the plasma homocysteine level was weakly but significantly correlated with the extent of CAD, not with the severity of stenosis.

A Case of Asymptomatic Left Ventricular Pseudoaneurysm after Myocardial Infarction

Left ventricular pseudoaneurysms are result of localized rupture of myocardium. The etiologies of pseudo-aneurysm are mainly transmural myocardial infarction, myocarditis, tuberculosis, syphilis, blunt or penestrating chest trauma and various types of cardiac surgery. It is important to be aware of any characteristic clinical, radiographic, echocardiographic or angiographic features, which distinguish pseudoaneurysm from true aneurysm. Pseudoaneurysm has a relatively high incidence of cardiac rupture than true aneurysm. Therefore, a surgical repair is mandatory in most cases of left ventricular pseudoaneurysm. We report a case of 71-year-old male with coronary artery disease of 3 vessel and asymptomatic left ventricular pseudoaneurysm after silent myocardial infarction.

The Effect of Local Delivery of IBMX on the Neointimal Proliferation in Rat Carotid Balloon Injury Model

BACKGROUND: Hyperplastic neointima is one of the major mechanisms of restenosis following balloon angioplasty in selected patients with symptomatic angina pectoris. Elevation of cellular cyclic nucleotide levels such as cAMP and cGMP are known to inhibit the proliferation of vascular smooth muscle cells. 3-isobutyl-1-methylxanthine (IBMX) increases intracellular cAMP and cGMP by nonselective inhibition of phosphodiesterases (PDEs). We conducted this study under the hypothesis that local delivery of IBMX could inhibit neointimal hyperplasia after balloon injury of the rat carotid artery. METHODS: Left common carotid artery of 10 week old male Sprague-Dawley rats were subjected to arterial injury by 2F Fogarty balloon catheter. After injury, animals were allocated to the control groups (control 1: injury control and control 2: pluronic gel plus DMSO control) and IBMX group, which received pluronic polymer gel, DMSO and IBMX mixture periadventitially. After 3 weeks, the rats were killed by overdose of ketamine, and the injured left arteries were pressure-fixed with 10% formalin and subjected to histomorphological analysis. RESULTS: Mean body weight of rats was not statistically different among study groups. The mean area of neointima (control group 1:0.28+/-0.05 mm2,Control group 2:0.27+/-0.08 mm2 , IBMX group:0.18+/-0.08 mm2 : p<0.05) and the mean ratio of neointima to medial area[versus (control group 1:1.89+/-0.37, control group 2:1.95+/-0.41, IBMX group: 1.41+/-0.47: p<0.05)] were significantly less in IBMX group. The mean area of external elastic lamina was significantly larger in control group 1 than IBMX group (0.57+/-0.07 mm2 versus 0.47+/-0.10 mm2 ) and mean luminal area showed no significant difference among groups (control group1:0.14+/-0.07 mm2 , control group 2: 0.10+/-0.05 mm2 , control group 3: 0.16+/-0.06 mm2). CONCLUSION: Peri-adventitial single administration of IBMX showed its effectiveness in reducing the neointimal proliferation in rat carotid balloon injury model. Furthermore we observed the positive correlation between intimal area and EELA suggesting vascular remodeling depending on the intima volume.