Intrahepatic Cholangiocarcinoma with Central Calcification / 대한췌담도학회지

A 50-year-old woman complained of jaundice and dyspepsia that started 2 weeks prior to consultation. Abdomen-pelvic computed tomography showed a 3 cm mass in the right hepatic duct with central calcification, which was spreading into the second branch. Repeated biopsies through endoscopic retrograde cholangiopancreatography were needed for pathology, which was consistent with an adenocarcinoma. Imaging studies including positron emission tomography showed no evidence of distant metastasis. The patient underwent right lobectomy with bile duct resection. The final diagnosis was intrahepatic cholangiocarcinoma with central calcification. We reported a very rare case of centrally calcified mass growing in the second branch of the right hepatic duct. The possibility of intrahepatic cholangiocarcinoma with central calcification should be considered for differential diagnosis of intrahepatic calcification.

Tuberculous Prostatic Abscess with Prostatorectal Fistula after Intravesical Bacillus Calmette-Guérin Immunotherapy

Intravesical bacillus Calmette-Guérin (BCG) immunotherapy is a common treatment modality for bladder cancer after transurethral resection of a bladder tumor. This therapy is generally safe, and development of a prostatic abscess with a prostatorectal fistula after intravesical BCG immunotherapy is a very rare complication. This finding was incidentally obtained by the authors, who examined a patient with colonoscopy for evaluation of abdominal pain. The patient was successfully treated with antitubercular drugs. To the authors’ knowledge, this is the first report of a patient with a tuberculous prostatic abscess with prostatorectal fistula after BCG immunotherapy in South Korea.

Mechanical ventilation-associated pneumothorax presenting with paroxysmal supraventricular tachycardia in patients with acute respiratory failure / 영남의대학술지

The prevalence of pneumothorax cases among Intensive Care Unit patients who require mechanical ventilation ranges from 4%-15%. A pneumothorax remains one of the most serious complications of positive pressure ventilation. It can be diagnosed in a critically ill patient through a physical examination or radiographic studies that include chest radiographs, ultrasonography, or computed tomography scanning. However, in a critically ill patient, the diagnosis of a pneumothorax is often complicated by other diseases and by difficulties in imaging sick and unconscious patients. Although electrocardiogram changes associated with a pneumothorax have been described for many years, there has been no report of such among patients who require mechanical ventilation. In this paper, we report 2 cases of a spontaneous pneumothorax with paroxysmal supraventricular tachycardia in patients who required invasive mechanical ventilation due to acute respiratory failure.

Two Cases of Gastrocolocutaneous Fistula with a Long Asymptomatic Period after Percutaneous Endoscopic Gastrostomy

Gastrocolocutaneous fistula is a rare complication of the percutaneous endoscopic gastrostomy (PEG) procedure. Typical symptoms usually occur in the first few months. We recently encountered 2 patients with 8- and 33-month asymptomatic periods. A 74-year-old man presented with watery diarrhea for 1 month. He had undergone PEG 9 months earlier. During workup, an upper endoscopy and abdominal CT scan revealed the migration of the feeding tube into the transverse colon. He was discharged with a nasogastric tube after treatment. A 77-year-old man presented with sudden loosening of his PEG tube with a duration over 3 days. He had undergone PEG procedure three times until that time. During workup, a gastrocolocutaneous fistula was diagnosed. However, when previous studies were reviewed, an abdominal CT scan, which was done 6 months ago before the third PEG, showed the fistula already existed at that time, suggesting that it was created about 33 months earlier when he underwent the second PEG procedure. The patient died of pneumonia aggravation despite conservative treatment. Both a high index of suspicion and the careful inspection of the upper endoscopy are very important for early diagnosis regardless of symptoms.

Primary Adenocarcinoma of Duodenum Located in Third Portion Cured by Wedge Resection

Primary adenocarcinoma of duodenum is an uncommon neoplasm. Besides its rarity, vague symptoms and signs with the lack of physical findings can delay diagnosis and result in poor treatment outcome. Aggressive surgical managements including pancreaticoduodenectomy was generally recommended for localized cancers despite high operational mortality. However, if early stage cancer is detected, wedge resection can be a therapeutic option. The authors encountered a 2.5x1.5 cm sized subepithelial tumor like mass with spontaneous bleeding and central dimpling located in the third portion of duodenum on esophagogastroduodenoscopy. After repeated deep biopsy, the patient underwent wedge resection and regional lymph node dissection of the duodenum. Finally, the mass was proven as adenocarcinoma and the patient remains in good condition without recurrence for over 2 years. Due to it's low incidence and high mortality, meticulous endoscopic examination of duodenum is essential for early diagnosis and limited operational methods may improve survival and quality of life of patients.

Primary Adenocarcinoma of Duodenum Located in Third Portion Cured by Wedge Resection

Primary adenocarcinoma of duodenum is an uncommon neoplasm. Besides its rarity, vague symptoms and signs with the lack of physical findings can delay diagnosis and result in poor treatment outcome. Aggressive surgical managements including pancreaticoduodenectomy was generally recommended for localized cancers despite high operational mortality. However, if early stage cancer is detected, wedge resection can be a therapeutic option. The authors encountered a 2.5x1.5 cm sized subepithelial tumor like mass with spontaneous bleeding and central dimpling located in the third portion of duodenum on esophagogastroduodenoscopy. After repeated deep biopsy, the patient underwent wedge resection and regional lymph node dissection of the duodenum. Finally, the mass was proven as adenocarcinoma and the patient remains in good condition without recurrence for over 2 years. Due to it's low incidence and high mortality, meticulous endoscopic examination of duodenum is essential for early diagnosis and limited operational methods may improve survival and quality of life of patients.

Adipsic Hypernatremia Associated with Deficiency of Antidiuretic Hormone Release / 대한내과학회지

Adipsic hypernatremia is a rare disorder of hypothalamic osmoreceptor dysfunction for thirst. It is frequently associated with a deficiency in antidiuretic hormone (ADH) release. We report the first case in Korea of adipsic hypernatremia combined with subnormal ADH response to osmotic stimuli without any demonstrable structural lesion. A 69-year-old woman was admitted to the hospital with general weakness. In a hypernatremic hyperosmolar state, she denied thirst and did not drink spontaneously. Her plasma ADH level was markedly subnormal but she had no large volume of dilute urine. Investigation of osmoregulation by infusion of hypertonic saline revealed adipsia and an absolute deficiency in antidiuretic hormone release, despite a serum osmolarity in excess of 321 mOsmol/kg. There was no structural lesion of the hypothalamus and no abnormal finding in hypothalamic-pituitary function. After diagnosis, she was treated successfully with intentional water intake alone.