A Case of Boerhaave's Syndrome Involving Nasogastric Tube Penetration into the Pleural Cavity / 대한소화기내시경학회지

Boerhaave's syndrome, spontaneous esophageal rupture, is lethal and associated with a 70% survival rate despite emergent surgical management in recent reports. Early diagnosis and management is critical for more favorable outcome. But, it is difficult to diagnose early because of the low incidence and lack of specific symptoms and signs. We experienced 37 year-old male patient with Boerhaave's syndrome who was heavy drinker, and suffered from chronic renal failure. He visited a hospital because of hematemesis and severe back pain. He was transferred to our hospital with a nasogastric tube insertion, which was penetrating the distal esophagus. A radiologic examination revealed that the distal tip was located in the left pleural cavity. It was assumed that the tube had passed through the preexisting perforation site. Operation was not performed emergently due to delay in diagnosis and severe hyperkalemia. The patient was in a septic condition, but had recovered slowly after systemic broad spectrum antibiotic therapy, pleural drainage and intrapleural antibiotic injections. An esophagography revealed no leakage of gastro-grafin on the 14th hospital day, and he later completely recovered from sepsis.

A Case of Portal Hypertension Secondary to Intrahepatic Arterioportal Fistula / 대한내과학회지

Intrahepatic arterioportal fistulae are rare, but can induce serious complications such as portal hypertension. We present a patient who developed portal hypertension secondary to an intrahepatic arterioportal fistula which was successfully embolized with occlusive balloon and microcoils. A 47-year-old previously healthy male was admitted to our hospital following an episode of melena and abdominal distension. The noteworthy feature in his previous medical history was a hepatic injury caused by a traffic accident when he was aged 9. He didn't drink liquor at all. General appearance was pale and acutely ill. The abdomen was markedly distended and a very noisy bruit over the liver area was continously heard. Laboratory findings, including liver function tests were completely normal except for anemia (Hb 5.7g/dL) and hepatitis viral markers were all negative. Endoscopy demonstrated gastroesophageal varices as the source of bleeding which was treated with variceal ligation. Computed tomography showed a dilated vascular structure in the periphery of the liver at the arterial phase, which suggested a intrahepaic arterioportal fistula. The fistula was also subsequently identified with duplex ultrasound and angiography. Occlusion of the right hepatic artery was performed with occlusive balloon and microcoils. Ascites was rapidly corrected in accordance with a large amount of diuresis and gastroesophageal varices were also completely disappeared whithin a month. On follow-up examination 18 months after hepatic embolization, duplex ultrasound and selective angiography revealed a minute flow of blood through this fistula, but the patient remains well with no recurrence of signs of portal hypertension.