A Case of Massive Hemobilia after a Long Period of Time Since Open Cholecystectomy / 대한췌담도학회지

A 77-year-old woman was admitted with 5 days history of melena. She had an open cholecystectomy 30 years ago. Abdominal computed tomography and duodenoscopy revealed massive hemobilia. Angiography showed right hepatic arterial fistula to common bile duct near the surgical clip. Embolization was done successfully and the patient recovered. We experienced a case of a massive hemobilia which was occurred after a long period of time since open cholecystectomy without pseudoaneurysmal change of the right hepatic artery. And we suggest the direct vessel injury and fistula between the bile duct and a blood vessel as a possible cause of hemobilia in this case.

Common bile duct dilatation after cholecystectomy: a one-year prospective study / 대한외과학회지

PURPOSE: Bile duct dilatation after cholecystectomy continues to be a matter of controversy. We aimed determine the magnitude of common bile duct (CBD) dilatation after cholecystectomy followed up to 1 year. METHODS: Sixty-four cases (age, 47.3 +/- 11.7 years; men, 28; women, 36) enrolled in this study. They received laparoscopic cholecystectomy in Chungbuk National University Hospital for symptomatic cholelithiasis or gallbladder polyps with normal bile duct, less than 7 mm. The CBD diameter was measured by one radiologist using ultrasonography at the maximum point after full length evaluation of extrahepatic bile duct. Forty-five and thirty-one cases were followed at 6 months and 1 year, respectively. RESULTS: The CBD was dilated slightly from 4.1 mm at baseline to 5.1 mm at 6 months and 6.1 mm at 12 months after cholecystectomy. The number of cases of CBD dilatation of more than 7 mm at 6 months and at 12 months after cholecystectomy were 11 (24.4%) and 9 (29.0%), respectively. Seven cases at 6 months and 5 cases at 12 months showed bile duct dilation of more than 3 mm compared to baseline. There were no cases having bile duct dilation of more than 10 mm. CONCLUSION: Postcholecystectomy dilatation of the bile duct occured slightly in most cases. But some cases showed more than 3 mm dilatation over baseline. Asymptomatic bile duct dilatation of up to 10 mm can be considered as normal range in patients after cholecystectomy.

Hypertriglyceridemia-induced acute pancreatitis in pregnancy: A case report / 대한내과학회지

Hypertriglyceridemia-induced pancreatitis is a rare, but serious, complication of pregnancy. We report a case of acute pancreatitis associated with type V hyperlipoproteinemia in pregnancy. A 36-year-old primigravida was admitted at 16 weeks of gestation with severe abdominal pain. Chemical analysis showed high serum pancreatic enzymes and very high serum triglyceride. Abdominal magnetic resonance imaging (MRI) showed diffuse swelling of the pancreas and a peripancreatic fluid collection. A diagnosis of acute pancreatitis with type V hyperlipoproteinemia was made. She recovered from the acute pancreatitis with conservative management and the serum triglyceride decreased rapidly with dietary restriction of fat, insulin/glucose, fenofibrate, and omega-3. We review the management of hypertriglyceridemia-induced acute pancreatitis in pregnancy.

A Case of Streptococcus salivarius Meningitis in a Patient with Cerebrospinal Fluid Rhinorrhea after Skull Base Fracture / 대한임상미생물학회지

Streptococcus salivarius meningitis is very uncommon, and most cases are iatrogenic, occurring after invasive procedures such as spinal anesthesia or lumbar puncture etc.. Post-traumatic occurrence of this infection is especially rare. A 20-year-old man with a previous history of skull base fracture was seen at the emergency department with signs of acute bacterial meningitis. The CSF had a few gram positive cocci with neutrophilic pleocytosis, which were identified as S. salivarius by the Vitek system (bioMerioux, Inc., Hazelwood, MO, USA), rapid ID 32 Strep (bioMerieux, Marcy-l'Etoile, France) and 16S rRNA sequencing. The microorganism showed intermediate resistance to penicillin (MIC=0.25 microg/mL) but was susceptible to cefotaxime (MIC=0.25 microg/mL) and vancomycin (MIC= 0.75 microg/mL). The patient was treated with ceftriaxone and vancomycin. He also had his CSF leakage repaired by an endoscopic approach. To our knowledge, this is the first case of S. salivarius meningitis reported in Korea.

A case of acute pancreatitis complicated by pseudocystocolonic fistula / 대한내과학회지

Pseudocystocolonic fistula is a rare, but occasionally lethal event in acute pancreatitis. Surgery has been the mainstay treatment, but recent literature has reported improvements in non-surgical therapies. Here, we report a case of acute pancreatitis complicated by pseudocystocolonic fistula that was treated by non-surgical means. A 58-year-old man, who consumed excessive alcohol, was admitted with severe abdominal pain. Abdominal computed tomography (CT) showed multiple pancreatic pseudocysts and fistula in the descending colon associated with acute pancreatitis. The fistula opening was identified by colonoscopy, and a diagnosis of pseudocystocolonic fistula was made. The pseudocyst was lavaged with saline through a percutaneous cystic drainage catheter and the patient became asymptomatic. Follow-up abdominal CT confirmed the disappearance of the colonic fistula and multiple pseudocysts. We also provide a review of the most effective non-surgical therapies for pseudocystocolonic fistula associated with acute pancreatitis.

Bile Duct Cancer afterSubtotal Gastrectomy for Early Gastric Cancer: Report of 2 Cases

Patients with early gastric cancer (EGC) may be associated with an increased risk of having a second primary cancer. Metachronous primary malignancies may have an influence on the long term prognosis of these patients. We report here on two cases of bile duct cancer after performing subtotal gastrectomy for EGC. A 59-year-old man underwent pylorus preserving pancreaticoduodenectomy (PPPD) under the diagnosis of bile duct cancer, and this was done 5 years after he had undergone gastrectomy. The pathological specimens were different between the EGC and bile duct cancer according to their morphology and immunohistochemical staining, and this case was determined to be metachronous double cancer. The second case was a 39-year-old man who received PPPD for bile duct cancer 4 years after undergoing gastrectomy. Double primary malignancies of bile duct cancer and gastric cancer are very rare.

A Congenital Cystic Adenomatoid Malformation with Intact Pulmonary Vascularities

Congenital cystic adenomatoid malformation (CCAM) is a rare pulmonary disease. It is thought to represent the abnormal proliferation of immature alveoli and other mesenchymal components secondary to abrupt halting of terminal alveolus formation after 16 weeks of gestation. Radiographic parameters such as size, number, and content are variable. On grayscale ultrasound, anechoic, thin-walled cysts are usually noted in pleural or cardiodiaphragmatic locations. To our knowledge, there has been no report of a CCAM showing normal pulmonary vascularities. We report a case of CCAM with normal pulmonary vascularities found within the hypodense lesions on dynamic chest CT.

Gallbladder Perforation without Gallstones or Cholecystitis

A case of gallbladder perforation without cholecystitis or trauma is described herein. The patient was a 74-year-old woman who initially presented with right lower quadrant pain of the abdomen. A laparotomy was performed with the impression of an acute appendicitis at a local clinic. However, the appendix was normal and a large amount of bile was noted in the peritoneal cavity. The patient was referred to our hospital. An exploratory laparotomy was performed with the suspicion of a hollow viscous perforation. A pin point perforation of the gallbladder fundus was identified. There were no gallstones or definite inflammation of the gallbladder wall. Although gallbladder perforation without cholecystitis or trauma is rare, gallbladder perforation without cholecystitis should be considered in elderly patients with bile peritonitis of unknown etiology.

The Treatment of a Giant Mediastinal Bronchial Artery Aneurysm by Transarterial Coil Embolization: A Case Report

Cases of bronchial artery aneurysms (BAAs) are rare; to the best of our knowledge, only 50 cases have been reported in the literature to date. BAAs require optimal treatment due to the possibility of life-threatening hemorrhaging if the aneurysm was to rupture. BAAs are usually treated by surgical resection of the aneurysmal artery. However, when the patient is unstable due to massive or recurrent hemoptysis, a bronchial artery embolization is a useful alternative treatment method. We report a case of a giant mediastinal bronchial artery aneurysm that was treated by coil embolization.

Methods of Counting Ribs on Chest CT: The Modified Sternomanubrial Approach

PURPOSE: The purpose of this study was to evaluate the accuracy of each method of counting ribs on chest CT and to propose a new method: the anterior approach with using the sternocostal joints. MATERIALS AND METHODS: CT scans of 38 rib lesions of 27 patients were analyzed (fracture: 25, metastasis: 11, benign bone disease: 2). Each lesion was independently counted by three radiologists with using three different methods for counting ribs: the sternoclavicular approach, the xiphisternal approach and the modified sternomanubrial approach. The rib lesions were divided into three parts for evaluation of each method according to the location of the lesion as follows: the upper part (between the first and fourth thoracic vertebra), the middle part (between the fifth and eighth) and the lower part (between the ninth and twelfth). RESULTS: The most accurate method was a modified sternomanubrial approach (99.1%). The accuracies of a xiphisternal approach and a sternoclavicular approach were 95.6% and 88.6%, respectively. A modified sternomanubrial approach showed the highest accuracies in all three parts (100%, 100% and 97.9%, respectively). CONCLUSION: We propose a new method for counting ribs, the modified sternomanubrial approach, which was more accurate than the known methods in any parts of the bony thorax, and it may be an easier and quicker method than the others in clinical practice.

Computed Tomographic Appearance of the Anterior Diaphragm: Evaluation with 64-slice MDCT

PURPOSE: To re-evaluate the appearance of the anterior diaphragm by the use of MDCT. MATERIALS AND METHODS: We performed a retrospective review of 81 consecutive patients that underwent chest CT by using 64 channel MDCT. We classified the anterior diaphragm as three types (types 1-3) based on 5 mm axial scans: a line behind the xiphoid, a discontinuity and opening anteriorly, and the presence of broad and poorly defined bands. We also classified the anterior diaphragm as three types (types A-C) using 2 mm sagittal reformation images, based on the shape of the anterior diaphragmatic fibers traveling from the base of the pericardium to the xiphoid: a downward slope, an upward slope, and a flat shape, and compared the two groups using a correlation determined by statistical analysis. RESULTS: We could classify the appearance of the anterior diaphragm for all cases on the axial scans and sagittal reformation images. The number of types 1, 2, 3 on the axial scans was 30.9%, 38.3%, and 30.9% and the number of types A, B, C on the sagittal reformation images was 33.3%, 22.2%, and 44.4%, respectively. Type A was seen for 92% of type 1 cases, type C was seen for 88% of type 3 cases, and type B was seen for 54.8% of type 2 cases. The types seen between the axial and sagittal reformation images showed a significant agreement (r=0.868, p < 0.01). CONCLUSION: The shape of the anterior diaphragm correlated with the relationship between the base of the pericardium and the xiphoid.

Subcutaneous Fat Necrosis of the Newborn: A Case Report

Subcutaneous fat necrosis in the newborn is an uncommon transient disorder of the subcutaneous adipose tissue that develops after birth. We describe the characteristic ultrasonography and CT findings of a case of pathologically confirmed subcutaneous fat necrosis located at the subcutaneous fat layer of the neck, back, and shoulders with a review of the literature.

Differential Diagnosis of a Follicular Carcinoma and Papillary Carcinoma of the Thyroid Gland Based on Sonographic Findings

PURPOSE: The purpose of this study was to evaluate and compare the sonographic findings of a conventional papillary carcinoma, follicular carcinoma and a follicular variant of a papillary carcinoma. MATERIALS and METHODS: A total of 308 nodules from 231 patients that were diagnosed with a papillary carcinoma and a follicular carcinoma by surgery after sonography were analyzed. The nodules consisted of a conventional papillary carcinoma (255, 83%), a follicular variant of a papillary carcinoma (25, 8%), and a follicualar carcinoma (28, 9%). We compared and analyzed the sonographic findings of each nodule for content, margin, echotexture, shape, calcification and halo sign. RESULTS: A conventional papillary carcinoma showed significant different sonographic findings than a follicular carcinoma and a follicular variant of a papillary carcinoma for an ill-defined or well-defined spiculated margin (63.1%), marked hypoechogenicity (85.9%) and microcalcification (49%). A follicular carcinoma showed a significant difference than a conventional papillary carcinoma for a well-defined smooth margin (92.9%), iso, hypo- or hyperechogenicity (89.3%), wider than tall shape (100%) and halo sign (82.1%). The follicular variant of a papillary carcinoma showed similar findings to a follicular carcinoma except for marked hypoechogenicity (44%, p = 0.006) and taller than wide shape (16%, p = 0.027). CONCLUSION: The follicular carcinoma and follicular variant of a papillary carcinoma showed similar sonographic findings, but findings of a conventional papillary carcinoma were different.

Hepatic Artery Pseudoaneurysm after Laparoscopic Cholecystectomy

A laparoscopic cholecystectomy is the gold standard for symptomatic gallbladder stones. Reports of a pseudoaneurysm following a cholecystectomy have recently increased. Herein, the case of a 36-year-old man, who had an unusual complication following a routine laparoscopic cholecystectomy for gallbladder stones, is reported. On postoperative day 6, the patient was readmitted via the emergency room with severe abdominal pain and right shoulder pain. A selective hepatic angiography revealed a pseudoaneurysm of the branch of the right hepatic artery, which was treated with transarterial embolization. A pseudoaneurysm is an uncommon complication of a laparoscopic cholecystectomy. If any suspicion of a pseudoaneurysm is presented, prompt attention and angiography are necessary, as the condition can cause life-threatening bleeding.

Differentiation between Morgagni Hernia and Pleuropericardial Fat with Using CT Findings / 대한흉부외과학회지

BACKGROUND: Generally hernia is diagnosed with simple chest or gastrointestinal x-ray. Sometimes CT or MRI can give lots of information for the diagnosis. However, there was no study for the differentiation with using CT findings between Morgagni hernia and pleuropericardial fat. The aim of this study was to evaluate the useful CT findings for differentiating Morgagni hernia from pleuropericardial fat. MATERIAL AND METHOD: We retrospectively analyzed CT scans of eight patients with Morgagni hernia and 20 patients with abundant pleuropericardial fat without peridiaphragmatic lesions. All CT scans were performed with coverage of the whole diaphragm in the inspiration state. We evaluated 1) the presence of the defect of the anterior diaphragm, 2) the interface between the lung and fat, 3) the angle between the chest wall and fat, 4) the continuity between the extrapleural fat and fat, 5) the presence of the vessels within fat, and 6) the presence of a thin line surrounding fat. RESULT: In all cases with Morgagni hernia, the defect of the anterior diaphragm was seen. The interface was well-defined, smooth, and convex to the lung. The angle with the chest wall was acute. The continuity with the extrapleural fat was not seen. In the cases with abundant pleuropericardial fat, the defect of the anterior diaphragm was seen in three (15%). The interface was usually irregular (n=10) and flat (n=17). The angle with the chest wall was variable. The continuity with the extrapleural fat, that was markedly increased in amount, was usually seen (n=16). The thin line surrounding fat was seen in four cases with Morgagni hernia, however, not seen in all cases with pleuropericardial fat. All of the above findings were statistically significant, however, vessels within fat was not significant to differentiate Morgagni hernia (n=8/8) from pleuropericardial fat (n=14/20). CONCLUSION: The useful CT findings of Morgagni hernia were fatty mass with sharp margin, convexity toward lung, acute angle with chest wall, and thin line surrounding hernia. Branching structure within fatty mass representing omental vessels that has been known as a characteristic finding of Morgagni hernia was not useful for differentiating Morgagni hernia from pleuropericardial fat.

Anatomic Landmarks of Fluoroscopy Guided Puncture of the Pulseless Femoral Artery

PURPOSE: We wanted to improve puncturing the pulseless femoral artery by evaluating the anatomic landmarks that suggest the course of the femoral artery on fluoroscopy. MATERIALS AND METHODS: We analyzed 37 hemipelvis spot images that were centered on the arterial sheath after puncture of the femoral artery. The inguinal angles were measured between the inguinal line connecting the anterior superior iliac spine and the symphysis pubis, and the line of the arterial sheath. Inguinal ligament ratios were measured as the distance from the symphysis pubis to the arterial sheath to the length of the inguinal ligament on the inguinal line. The femoral head ratios were measured as the distance from the medial margin of the femur head to the arterial sheath to the transverse length of the femur head. RESULTS: The mean inguinal angle was 66.5degree (+/-7.8degree) and the mean inguinal ligament ratio was 0.42 (+/-0.03). The mean femoral head ratio was 0.08 (+/-0.18). In comparing the men and women, there was no significant difference in the inguinal angle and the femoral head ratio, but the inguinal distance ratio was larger in women (men: 0.41+/-0.033, women: 0.44+/-0.031, p < 0.05). CONCLUSION: The femoral artery generally courses just lateral to the medial margin of the femur head (femoral head ratio: 0.08) and the medial 40% of the inguinal ligament (inguinal ligament ratio: 0.42). So, consideration of these relations may be helpful for puncturing the pulseless femoral artery.

Ultrasound-Guided Fine-Needle Aspiration Biopsy of Multiple Thyroid Nodules

PURPOSE: To standardize the number of nodules which necessitates ultrasound-guided, fine-needle, aspiration biopsy in patients who have multiple thyroid nodules with the same sonographic characteristics as each other. MATERIALS and METHODS: From February, 2002 to March, 2004, among patients whose diagnosis was confirmed by ultrasound-guided, fine-needle, aspiration biopsy, 545 nodules of 203 patients were found in sonography with more than two thyroid nodules. Each thyroid gland nodule was classified on a score from 0 to 2 points on the basis of the following 5 characteristics: internal content, margin, echogenicity, shape and calcification in sonography. When the score of all characteristics was the same, by deciding on nodules with the same sonographic char-acteristics and with the score of at least one characteristic being different, we divided the nodules with different sonographic characteristics in a patient. By methods such as given in the preceding descriptions, patients with multiple thyroid nodules were separated into two groups: one in which all nodules had the same sonographic characteristics and another in which nodules have at least one different sonographic characteristic. Then, each pathologic result was searched for the same case and different case in each patient group. RESULTS: Among the 203 patients who were diagnosed with multiple thyroid nodules in ultrasonography, 79 patients (38.9%) had nodules with the same ultrasonographic characteristics and 124 patients (61.1%) had nodules with at least one different ultrasonographic characteristic. All 79 patients' nodules with the same ultrasono-graphic characteristics in each patient showed the same pathologic result in all cases (100.0%) and there was no case showing a different pathologic result. Otherwise, among the 124 patients' nodules with different ultrasono-graphic characteristics, each patient showed the same pathologic result in 111 (89.5%) and different pathologic result in 13 (10.5%). CONCLUSION: In patients who have multiple thyroid nodules, if a patient's nodules have the same sonographic characteristics, we can perform ultrasound-guided, fine-needle, aspiration biopsy about only one nodule and if a patient's nodules have different sonographic characteristics from each other, we must perform the biopsy for all nodules.

Retroperitoneal Malignant Peripheral Nerve Sheath Tumors Complicated with Type I Neurofibromatosis

Neurofibromatosis is an infrequent genetic disorder that was first clinically described by von Recklinghausen and it was classified into 7 types by Riccardi. Type I neurofibromatosis is the most common type, and it is characterized by neurofibromas of variable size and multiple cafe-au-lait spots with minimal CNS lesion, if any. Malignant tumors develop in 2 to 13% of patients with type I neurofibromatosis, but they are rarely found in the retroperitoneum. We surgically resected huge retroperitoneal malignant peripheral nerve sheath tumors in 2 patients with sporadic type I neurofibromatosis. One patient survived 10 months and the other survived 3 months after operation. Retroperitoneal malignant peripheral nerve sheath tumor shows a poor prognosis even after surgical resection because of frequent recurrence and the lack of effective adjuvant therapy. Early diagnosis and development of new adjuvant therapy are required to effectively treat this malady.

Hemobilia from Ruptured Hepatic Artery Aneurysm in Polyarteritis Nodosa

Hemobilia, in patients with the diagnosis of polyarteritis nodosa, is rare at clinical presentation and has a grave prognosis. We describe a case of massive hemobilia, due to aneurysmal rupture, in a patient with polyarteritis nodosa. A 39-year-old man was admitted to the hospital with upper abdominal pain. The patient had a history of partial small bowel resection, for intestinal infarction, about 5 years prior to this presentation. Abdominal computed tomography demonstrated multiple high attenuation areas in the bile duct and gallbladder. Hemobilia with blood seepage was visualized on endoscopic retrograde cholangiopancreatography; this bleeding stopped spontaneously. The following day, the patient developed a massive gastrointestinal bleed with resultant hypovolemic shock. Emergent hepatic angiogram revealed multiple microaneurysms; a communication was identified between a branch of the left hepatic artery and the bile duct. Hepatic arterial embolization was successfully performed. The underlying disease, polyarteritis nodosa, was managed with prednisolone and cyclophosphamide.

A Case of Primary Pancreatic T-cell Lymphoma

Primary pancreatic lymphoma is a rare extranodal manifestation of any histopathologic subtype of non-Hodgkin's lymphoma that predominantly involves the pancreas, and it comprises less than 0.5% of all pancreatic malignancies. Histopathologically, most primary pancreatic lymphomas are the B-cell phenotypes, and T-cell lymphomas are extremely rare. We describe here the ultrasonography and computed tomography (CT) findings of a pathologically confirmed pancreatic T-cell lymphoma in a 37-year-old female patient. Ultrasonography showed diffuse pancreatic enlargement and a slightly bulging mass in the head and tail of pancreas that had markedly heterogeneous echogeneity. The lesion abutted onto the adjacent vessels, but there was no evidence of luminal narrowing or obstruction. The CT scan showed diffuse enlargement of the pancreas and the bulging contoured mass at the pancreatic head and tail with inhomogeneous enhancement, including multiple hypodense areas. It also showed the patent peripancreatic vessels and multiple LN enlargements around the pancreas.