Clinicopathlogic characteristics of multiple synchronous early gastric cancers / 대한내과학회지

BACKGROUND: With the progress of limited surgery and endoscopic treatment for early gastric cancer (EGC), multiple synchronous EGCs, a cause of recurrence, become more important. The objective of this study was to elucidate the characteristics of multiple synchronous EGCs with an emphasis on features of preoperatively undiagnosed lesions. METHODS: We retrospectively reviewed medical records of 496 patients who underwent a gastrectomy for EGC at our institution between January 2004 and December 2004. RESULTS: Twenty-four patients (4.8%) had multiple synchronous EGCs with 24 main and 27 accessory lesions. Multiple synchronous EGCs showed male predominance (p=0.03). Other characteristics including lymph node metastasis were the same as with single EGC. Out of 27 accessory lesions, six lesions (22%) were not detected preoperatively in six patients (25%). Macroscopically five lesions were flat and one lesion was depressed. Five lesions were located at the anterior or posterior wall of the middle and low third portion and one lesion was located at the lesser curvature side of the upper third portion of the stomach. Two lesions were 4 mm, one lesion was 8 mm, two lesions were 12 mm and one lesion was 15 mm in size (mean diameter = 9.1 mm). Histologically, four lesions were of the differentiated type and two lesions were of the undifferentiated type. CONCLUSIONS: Multiple synchronous EGCs have same clinicopathologic features as a single EGC except for male predominance. Considering the possibility of a synchronous lesion, one should examine the entire stomach precisely with special attention to the anterior, posterior wall and lesser curvature side of the same or neighboring area of a known EGC lesion before treatment.

An Evaluation of Web-based Informations about Gastroesophageal Reflux Diseases in Korea / 대한소화기학회지

BACKGROUND/AIMS: Internet has become an important source of medical information not only for medical personnels but also for patients. The aim of this study was to evaluate the quality of internet based medical information about 'gastroesophageal reflux' or 'reflux esophagitis' in Korea. METHODS: The first 15 internet sites using the key words 'gastroesophageal reflux' or 'reflux esophagitis' were retrieved from the 7 most frequently used internet search engines. The quality of information from a total of 108 websites was evaluated using a checklist. RESULTS: Among total 108 sites related to 'gastroesophageal reflux' or 'reflux esophagitis', fifty-six sites (51.8%) were made by hospitals or clinics and 94 sites (87.0%) were made for patients. Of the 108 sites, eleven web sites (10.1%) had more than three JAMA benchmarks (authorship, references, currency, and disclosure). Higher quality sites (at least three JAMA benchmarks) were less likely to contain inaccurate information than lower quality sites (fewer than three JAMA benchmarks)-3/11 (27.2%) vs. 60/97 (61.9%) (p<0.01). Despite the fact that articles in the literature emphasized an insufficient evidence to support an association between the lifestyle, dietary behaviors, and GERD, such guidelines continue to be recommended as first-line therapy in most websites. CONCLUSIONS: Informations about gastroesophageal reflux disease were incomplete in the majority of medical web sites. These would bring about confusion to patients seeking for an information about GERD through the internet. There is a need for better sources in evidence based informations about gastroesophaeal reflux diseases on the web.

A Case of Autoimmune Pancreatitis Diagnosed by Immunohistochemical Staining of IgG4 / 대한소화기내시경학회지

Autoimmune pancreatitis is a distinct entity with characteristic morphological, histological and clinical features. Since the first report in 1961, there have been many reports on autoantibodies associated with autoimmune pancreatitis. Lymphoplasmacytic infiltration with fibrosis is the characteristic histological feature of autoimmune pancreatitis. Elevation of immunoglobulin G4 (IgG4), a subtype of IgG, can be seen in autoimmune pancreatitis. A few reports of autoimmune pancreatitis based on immunostaining of IgG4 have been published, but no reports have been published in Korea. We present here the first report of autoimmune pancreatitis, based on an increased serum IgG4 level and plasma cell infiltration that showed IgG4 positivity by immunohistochemical staining of the major papilla.

A Case of Eneropathy-associated T-cell Lymphoma Presenting with Persistent Abdominal Pain and Diarrhea / 대한소화기내시경학회지

Enteropathy-associated T-cell lymphoma (EATL) is an unusual primary gastrointestinal lymphoma, and it is particularly associated with celiac sprue. These patients typically suffer from abdominal pain, diarrhea and/or weight loss. Primary intestinal T-cell lymphoma without celiac sprue is known to be rare. We report here on a case of EATL that presented with persistent abdominal pain and diarrhea, but this patient was without celiac sprue.

A Case of Eneropathy-associated T-cell Lymphoma Presenting with Persistent Abdominal Pain and Diarrhea / 대한소화기내시경학회지

Enteropathy-associated T-cell lymphoma (EATL) is an unusual primary gastrointestinal lymphoma, and it is particularly associated with celiac sprue. These patients typically suffer from abdominal pain, diarrhea and/or weight loss. Primary intestinal T-cell lymphoma without celiac sprue is known to be rare. We report here on a case of EATL that presented with persistent abdominal pain and diarrhea, but this patient was without celiac sprue.

Comparative Usefulness of Erythrocyte Sedimentation Rate and C-reactive Protein in Assessing the Severity of Ulcerative Colitis / 대한소화기학회지

BACKGROUND/AIMS: Although erythrocyte sedimentation rate (ESR) is included as a laboratory parameter in Truelove and Witts' classification, C-reactive protein (CRP) is also used for severity assessment in ulcerative colitis (UC). Frequently, the discordance between ESR and CRP is observed in clinical practice. The aim of this study was to determine which parameter is more related with clinical activity in UC patients. METHODS: A total of 155 patients with UC were identified from January 2004 to March 2005. Their medical records were reviewed within these patients, a total of 541 assessments of disease activity were made. Correlation of clinical activity and laboratory tests were evaluated by Pearson's correlation coefficient. RESULTS: Pearson's correlation coefficients of ESR and CRP with clinical symptoms were 0.376 and 0.258, respectively. The correlation coefficient between ESR and CRP was 0.403 (p=0.000). A total of 131 (24.2%) assessments revealed discordance between ESR and CRP. When discordance occurred, the correlation coefficients with clinical symptoms were 0.338 for ESR (p=0.000) and 0.034 for CRP (p>0.01). Dividing discordant patients into high ESR/low CRP group and low ESR/high CRP group, the coefficients were 0.420 for ESR and 0.226 for CRP in high ESR/low CRP group, and 0.333 for ESR and 0.068 for CRP in low ESR/high CRP group. CONCLUSIONS: The correlation analysis indicates that ESR appears to be a more reliable laboratory parameter of disease activity than CRP in assessing the severity of UC. In particular, when the level of ESR and CRP is discordant, ESR is more useful in assessing the disease activity in UC patients.

A Case of Spontaneous Gallbladder Perforation

Gallbladder perforation is an almost exclusive complication of cholecystitis, which accompanies severe inflammation of the gallbladder with or without cholelithiasis. Whether it is of a calculous or acalculous origin, gallbladder perforation, as a complication of acute cholecystitis, has common symptoms, signs, laboratory data, radiological findings and treatment modalities. Even though many reports of gallbladder perforation have been published, there are few reports of gallbladder perforation without any clinical and radiological indications. We experienced a case of a 70-year-old woman with acute abdomen, which was found to be peritonitis caused by spontaneous gallbladder perforation that was devoid of clues suggesting this condition. Although rare and unusual, this case shows that this disorder should be considered in elderly patients presenting with peritonitis with an unknown etiology.

A Case of Sigmoid Colonic Perforation due to Migration of a Plastic Stent for Endoscopic Retrograde Biliary Drainage / 대한소화기내시경학회지

Placement of an endoprosthesis for billiary obstruction has been advocated as an effective alternative for internal-external drainage catheters or surgical procedure. Endoscopic retrograde biliary drainage (ERBD) is a method of transpapillary insertion and placement of drainage tube in the billiary tree under the direct view of endoscope. Early complications following ERBD that develop within 4 weeks include obstruction of the stent, cholangitis, hemorrhage, acute pancreatitis, and bile duct or duodenal perforation. Late complications include obstruction of the stent and cholangitis, migration of the stent, and intestinal perforation. We expierenced a case of sigmoid colonic perforation following ERBD in a patient with multiple biliary tract stone and cholangitis. Thus we report this case with a brief review of the literature.

A Case of Obstructive Jaundice after Insertion of Metallic Stent for Duodenal Obstruction by Recurrent Duodenal Ulcer / 대한소화기내시경학회지

Insertion of self-expandable metallic stent has been performed as a palliative therapeutic modality for cases with gastrointestinal obstruction caused by inoperable malignancies such as pancreatic cancer, stomach cancer, and cholangiocarcinoma. Although the clinical efficacy is not established yet, it can also be performed for benign gastroduodenal obstruction. Especially, when balloon dilatation is failed and patients are at high risk for surgery or general anesthesia, and when patients refuse operation, insertion of metallic stent can be considered. Complications of this therapeutic modality include intestinal perforation, hemorrhage, migration or malposition of metallic stent, and occlusion of stent by ingrowth and overgrowth of tumor or impaction of food. We report a rare case of obstructive jaundice developed after the insertion of gastroduodenal stent for duodenal obstruction caused by recurrent duodenal ulcer.

Efficacy of Triple Therapy with Rabeprazole for Helicobacter pylori Infection in relation to CYP2C19 Genotype / 대한소화기학회지

BACKGROUND/AIMS: Genetic polymorphism of cytochrome P450 CYP2C19 influences the efficacy of proton pump inhibitor (PPI) in Helicobacter pylori (H. pylori) eradication therapy. We investigated the difference in the cure rates of H. pylori infection by triple (rabeprazole plus amoxacillin and clarithromycin) therapy in relation to CYP2C19 genotype status. METHODS: One hundred and sixteen H. pylori infected patients with gastric ulcer and duodenal ulcer completed the triple therapy with 10 mg of rabeprazole b.i.d., 1,000 mg amoxacillin b.i.d. and 500 mg of clarithromycin b.i.d. for one week. The genotype of CYP2C19 was determined by a PCR-restriction fragment length polymorphism method. RESULTS: According to the univariate analysis, heterozygous extensive metabolizers (hetero EMs) and poor metabolizers (PMs) showed the highest (87.0%) and the lowest (80.0%) eradication rates, respectively. The difference in the therapeutic efficacy of rabeprazole among the different CYP2C19 genotypes was insignificant. With regard to gender, age and smoking history in relation to eradication rate, a statistical significance was noted only with age with odds ratio of 1.063 and p-value of 0.0202. CONCLUSIONS: In the eradication therapy of H. pylori, no statistically significant difference in therapeutic efficacy of rabeprazole was found among different CYP2C19 genotypes.

Acute Acalculous Cholecystitis Associated with Cholecystoduodenal Fistula and Duodenal Bleeding: A Case Report

Although acute acalculous cholecystitis (AAC) accounts for less than 10% of acute cholecystitis in the adult population, gangrene and perforation are much more frequent compared to the usual cases of acute cholecystitis (calculus cholecystitis). However, spontaneous biliary-enteric fistula is well recognized in AAC, 90% of which are cholecystoduodenal fistula (CDF) though it is an uncommon disorder. The majority of the CDF are caused by cholelithiasis. As patients are usually associated with complicated clinical illness, the diagnosis is often difficult to make and required surgery is often delayed. We have studied a rare complication of acute acalculous cholecystitis which was presented as intermittent upper gastrointestinal bleeding. Ulceration of the superficial branch of the cystic artery has been observed due to acalculous cholecystitis associated with a cholecystoduodenal fistula. We have performed a transfixing ligation of the bleeding vessel, cholecystectomy and simple closure of the CDF. We have finally made a diagnosis of early gallbladder cancer through a frozen section. There was no serious complication after the operation and the patient has achieved an uneventful recovery.