A study of the awareness of chronic liver diseases among Korean adults / 대한간학회지

BACKGROUND/AIMS: Chronic liver disease is closely associated with lifestyle, and public enlightenment of the lifestyle factors is important in reducing prevalence of chronic liver disease. The KASL (Korean Association for the Study of the Liver) conducted a survey of basic information and epidemiological data regarding chronic liver diseases. METHODS: A survey of chronic liver disease involving a total of 2,794 respondents was conducted. The respondents included patients and their guardians, visitors for health check-ups, and online pollees who completed a questionnaire on the awareness of fatty liver or chronic liver disease. RESULTS: Of the entire cohort, 854 (39.7%) said they have had or still have fatty liver or an elevated transaminase level (>40 IU/L), but only 23.4% of the respondents had visited a hospital. It was found that 35% of healthy subjects and 45% of patients and their guardians misunderstood hepatitis B as the hereditary disesase. Furthermore, 26% of the subjects responded that patients with inactive hepatitis B do not require regular follow-up. While 17.9% answered that it is not too late to test for liver cancer when symptoms arise, 38.8% believed that liver transplant in liver cancer patients has a low success rate and is thus not recommended. CONCLUSIONS: Despite the inundation of information and widespread media advertising, the awareness of chronic liver disease is unsatisfactory among Korean adults. Systematic nationwide studies are needed to obtain data and information regarding the prevalence of chronic liver disease and patterns of use of the health-care system.

Pathological Complete Remission of Advanced Hepatocellular Carcinoma with Main Portal Vein Tumor Thrombosis by Hepatic Arterial Infusion Chemotherapy

Cures for advanced hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) are rare and difficult. We report a case of pathologically confirmed complete remission of HCC induced by hepatic arterial infusion chemotherapy (HAIC). A 45-year-old male patient had a massive HCC in the right lobe of the liver and tumor thrombus in the right and main portal veins. He achieved a partial response after two cycles of HAIC with 5-fluorouracil (750 mg/m2) and cisplatin (25 mg/m2). After the completion of six cycles he received a curative partial hepatectomy, and histopathology revealed complete necrosis without any viable tumor cell. He was in good health at a 4-month follow-up. These results suggest that this regimen is a promising therapeutic modality for the treatment of advanced HCC with PVTT.

Spontaneous submucosal dissection of the entire esophagus in a healthy man / 대한내과학회지

Esophageal submucosal dissection can be caused by foreign bodies and endoscopic procedures. It rarely develops spontaneously. If a submucosal hematoma and false lumen are observed at esophagogastroduodenoscopy, the lesion will heal after 7 to 10 days of conservative treatment. A 71-year-old man with sudden-onset chest pain, dyspnea, and a small amount of hematemesis was examined using chest computed tomography (CT) and esophagogastroduodenoscopy. He was diagnosed with submucosal dissection of the esophagus. After 13 days of conservative treatment, esophagogastroduodenoscopy showed mucosal exfoliation and a healing ulcer, and he was discharged without complications.

A case of submucosal gastric lymphoepithelioma-like carcinoma / 대한내과학회지

Gastric lymphoepithelioma-like carcinoma (LELC) is a rare disease with a good prognosis. Submucosal LELC is very rare and difficult to diagnose by endoscopic biopsy. Endoscopic ultrasonography is the best modality for diagnosing submucosal tumors. Submucosal LELC can be confused with benign submucosal tumors. Here, we report a case of a submucosal gastric lymphoepithelioma-like carcinoma.

A case of cytomegalovirus esophagitis associated with upper gastrointestinal bleeding / 대한내과학회지

Cytomegalovirus (CMV) infections are common in immunocompromised patients, although they may occur occasionally in immunocompetent patients. The majority of CMV infections in immunocompetent adults are asymptomatic or associated with mild mononucleosis-like syndrome. CMV involvement of the colon is the most common site of infection in the gastrointestinal tract and is more commonly a cause of massive gastrointestinal bleeding compared to CMV involvement of the upper gastrointestinal tract and small intestine. However, although rarely, CMV esophagitis can be the source of upper gastrointestinal bleeding. We report an immunocompetent patient with cytomegalovirus esophagitis and massive upper gastrointestinal bleeding who had undergone left lobectomy and cholecystectomy for intrahepatic duct stones and gallstones.

Long-term clevudine therapy in nucleos(t)ide-naive and lamivudine-experienced patients with hepatitis B virus-related chronic liver diseases / 대한간학회지

BACKGROUNDS/AIMS: Clevudine is an effective antiviral nucleoside analogue, but there are few data regarding its long-term effects, resistance, and safety. The aim of this study was to evaluate the long-term clinical efficacy of clevudine over a 1-year treatment period in nucleos(t)ide-naive and lamivudine-experienced chronic hepatitis B patients. METHODS: Nucleos(t)ide-naive (group A, n=196) and lamivudine-experienced (serum hepatitis B virus, HBV DNA >2,000 copies/mL without resistant mutants at the start of clevudine therapy, group B, n=75) patients were included in this study. Basic clinical characteristics including age, sex, the presence of cirrhosis, laboratory data, and hepatitis B surface antigen (HBeAg) positivity were similar between the two groups. Pretreatment serum levels of HBV DNA were 7.4 and 6.6 log10 copies/mL (P<0.001). The mean treatment duration was 8 months for both groups (range for group A: 3-21 months; range for group B: 3-20 months). Genotypic analysis for resistant mutations in the reverse transcriptase of HBV was performed after viral breakthrough. RESULTS: After 1 year of therapy, 75.0% and 51.9% of groups A and B, respectively, had HBV DNA levels of <2,000 copies/mL (P=0.032), and HBeAg seroconversion rates were 16.9% and 16.7%, respectively. The rates of viral breakthrough at 1 year were 10.0% (8/80) and 44.4% (12/27), respectively (P<0.001). Proven sites of mutation of HBV DNA polymerase in naive patients were, for example, L80I, L180M, A181V/T, M204I and V207I. Ten patients complained of prominent fatigue and revealed elevated serum levels of aspartate aminotransferase (AST) and creatine phosphokinase (CPK). Two of these patients presented with severe myopathy from which they recovered completely after quitting clevudine. CONCLUSIONS: Clevudine is one of the recommended first-line medicines for the treatment of chronic hepatitis B, but it is not free from resistance, particularly in patients with a history of previous lamivudine treatment, but also in naive patients. Clevudine should be avoided in previously lamivudine-exposed patients. In addition, reelevation of serum AST and CPK levels is not a rare occurrence, and close observation and follow-up tests are essential.

Two cases of gallbladder cancer diagnosed by detection of hemobilia / 대한내과학회지

Hemobilia is a hemorrhage into the biliary tract and is a relatively rare cause of bleeding in the digestive tract. Gallbladder cancer is the most common tumor in the biliary tract. Gastrointestinal bleeding including hemobilia is reported in only 3% of cases of gallbladder cancer. Here, we report two rare cases of gallbladder cancer diagnosed by the detection of hemobilia. One case was an anemic patient with no abnormal endoscopic findings; capsule endoscopy showed blood in the duodenum and repeat gastroendoscopy revealed hemorrhage from the ampulla of Vater. The diagnosis of early gallbladder cancer was made and the patient underwent surgery and was followed-up. The other case presented with a symptom triad including hemobilia, and endoscopic retrograded cholangiopancreatography (ERCP) revealed hemobilia and a filling defect in the gallbladder. This patient also underwent radical cholecystectomy with the diagnosis of gallbladder cancer.

A Case of Peritoneal Seeding from a Ruptured Hepatocellular Carcinoma with Direct Invasion into the Stomach Causing Gastrointestinal Hemorrhage / 대한소화기학회지

Hepatocellular carcinoma (HCC) rarely invades the gastrointestinal (GI) tract. It occurs in 0.7% to 2% of clinical HCC cases. Moreover, gastric invasion with GI hemorrhage via peritoneal seeding is very rare. We report the case of 67-year-old woman who had a history of HCC rupture and was admitted due to left upper quadrant abdominal pain. The patient was diagnosed with three omental metastatic masses and underwent hepatic segmentectomy and omental tumorectomy. Two months later, the patient had massive melena, and an esophagogastroduodenoscopy showed very large ulcerated friable mass on the gastric body. The histology was consistent with the diagnosis of metastatic HCC. The patient died from persistent GI hemorrhage 93 days after the admission. This case illustrates the very rare event of peritoneal seeding of a ruptured HCC causing direct invasion of the stomach, followed by GI hemorrhage.

Clinical Characteristics of Intrahepatic Cholangiocarcinoma and Prognostic Factors in Patients Who Received Non-surgical Treatment / 대한소화기학회지

BACKGROUND/AIMS: This study was conducted to analyze the prognostic factors in patients with intrahepatic cholangiocarcinoma (ICC) who did not receive surgery. METHODS: Between August 1997 and November 2007, the medical records of 175 patients (mean age; 66 years, male/female 126/49), who were diagnosed as ICC, were reviewed retrospectively. RESULTS: Clonorchiasis and hepatolithiasis was found in 14.9%, and 6.3% of all patients, and no risk factors were identified in 77.8% of them. Surgical resection was performed in 29.1% (51 patients), chemotherapy +/- radiotherapy in 12.6% (22 patients), and palliative therapy in 58.3% (102 patients). The proportion of patients with stage I was 23.4% (41 patients). The prognostic factors in patients who did not receive surgery were alkaline phosphatase (ALP) and bilirubin levels by univariate and multivariate analysis. The median survival of patients with normal ALP and bilirubin levels was six months, whereas only one month in patients with elevated ALP and bilirubin levels (p<0.001). Tumor characteristics of patients with elevated bilirubin and ALP levels were infiltrative tumor, bile duct involvement, and very huge tumor. CONCLUSIONS: The prognostic factors of ICC in patients who did not receive surgery were ALP and bilirubin levels, but not lymph node metastasis.

Clinical Overview of Acute Lower Gastrointestinal Bleeding / 대한소화기내시경학회지

BACKGROUND/AIMS: Acute lower gastrointestinal bleeding (LGIB) is a common disorder that requires hospitalization. Colonoscopy is considered as the procedure of choice for diagnosing acute LGIB. The aim of this study was to analyze the clinical characteristics, endoscopic diagnosis and clinical course of acute LGIB. METHODS: From January 2000 to August 2007, 117 patients with hematochezia, who visited Yeungnam University hospital emergency center and underwent colonoscopy or sigmoidoscopy, were reviewed retrospectively. The male to female ratio was 2.25 (81:36). The mean age was 59.1+/-16.9 years. RESULTS: The mean time from presentation to endoscopy was 12.6 hours. The cause of bleeding was identified in 88.9% of the cases after endoscopy. The causes of the acute LGIB were colitis: 26 cases, post polypectomy bleeding: 17 cases, colon ulcer: 16 cases, diverticular bleeding: 13 cases, colon cancer: 9 cases, angiodysplasia: 7 cases and hemorrhoid: 6 cases. Thirty six patients were treated by the endoscopic method; the mean duration of admission was 10.6+/-10.0 days and the mean amount of transfusion was 3.0+/-1.9 U. Those numbers showed statistically significant differences according to the diagnosis. CONCLUSIONS: The most common cause of acute LGIB was colitis and the causes of bleeding were a significant factor that affects the severity of bleeding and the duration of admission.

A case of severe hypophosphatemia related to adefovir dipivoxil treatment in a patient with liver cirrhosis related to hepatitis B virus / 대한간학회지

Adefovir dipivoxyl (ADV) effectively suppresses hepatitis B virus (HBV) replication but exhibits nephrotoxicity with severe hypophosphatemia when administered at a high dosage. This is the first report of severe hypophosphatemic osteomalacia induced by ADV at 10 mg/day. A 42-year-old man with HBV-related chronic liver disease presented with generalized bone pain, especially in the left ankle. He had been taking ADV for more than 1.5 years following a clinical breakthrough due to lamivudine-resistant HBV. Aggravating severe hypophosphatemia and elevated serum alkaline phosphatase levels with high bone fraction had been noted after 6 months of ADV therapy. Bone densitometry, simple bone X-rays, and a whole-body bone scan demonstrated osteoporosis and multiple areas with hot uptake, especially in the left ankle. All the image findings and symptoms improved after correcting the hypophosphatemia.

The usefulness of transient elastography (Fibroscan(R)) for predicting esophageal varices and esophageal variceal hemorrhage in patients with chronic liver diseases / 대한내과학회지

BACKGROUND/AIMS: This study was conducted to evaluate the efficacy of transient elastography (Fibroscan(R)) for predicting esophageal varices and esophageal variceal hemorrhage in patients with chronic liver diseases. METHODS: We studied 245 patients (mean age: 50.1 years, male/female: 181/64) with chronic liver diseases to determine the relation between the clinical or serologic markers associated with liver fibrosis and tissue elastography, and these tests were performed in Feb 2007. The causes of chronic liver diseases were hepatitis B virus in 139 (56.7%), hepatitis C virus in 30 (12.2%), alcohol in 38 (15.5%), nonalcoholic fatty liver disease in 23 (9.4%), autoimmune liver disease in 3 (1.2%), and unknown 12 (4.9%). RESULTS: Transient elastography was correlated with APRI (r=0.712) and the grades of esophageal varices (r=0.635). The AUROC values of transient elastography were 0.916 (95% CI: 0.838-0.954) for the presence of esophageal varices, 0.875 (95% CI: 0.819-0.931) for the esophageal varices grade > or =2, and 0.895 (95% CI: 0.846-0.945) for esophageal variceal hemorrhage. The cutoff values for 90% specificity were 15.3 kPa for esophageal varices, 20.7 kPa for esophageal varices grade > or =2 and 34.8 kPa for esophageal variceal hemorrhage, while the negative predictive values were 90%, 94% and 97%, respectively. CONCLUSIONS: Transient elastography was correlated with the presence of esophageal varices, the grades of esophageal varices and the presence of esophageal variceal hemorrhage. Therefore, this data may help to screen those patients how might undergo upper gastrointestinal endoscopy.

The Short Term Efficacy of Entecavir Therapy in Chronic Hepatitis B / 영남의대학술지

BACKGROUND/AIMS: Entecavir is a synthetic nucleoside analogue, cyclopentyl guanine nucleoside, which has a potent antiviral effect and the least viral breakthrough in hepatitis B virus (HBV) replication. Entecavir has been available in Korea since 2007 but there are few reports on its effects. The aim of this study was to evaluate the virological response (VR) and biochemical response (BR) to entecavir in HBV patients at 3, 6 and 9 months after treatment with entecavir. MATERIALS AND METHODS: Thirty-three chronic hepatitis B patients who took entecavir for at least 9 months were enrolled. We investigated VR and BR by retrospectively reviewing medical records. Patients who satisfied the following criteria were chosen: 1) initial alanine aminotransferase (ALT) levels = 1.5upper limit of normal (ULN) and 2) initial HBV DNA levels = 5 log10 copies/ml. We measured ALT levels every 3 months until month 9. HBV DNA was measured every 2 or 3 months by polymerase chain reaction (PCR) method. RESULTS: Most patients taking entecavir showed good BR (ALT < 40 IU/L). The BR rates were 61%, 73% and 67% at months 3, 6 and 9, respectively. VR (HBV DNA < 5 log(10) copies/ml or 2 log lower than initial HBV DNA) rates were 82%, 91% and 91% at months 3, 6 and 9, respectively. Undetectable HBV DNA (HBV DNA < 4 log(10) copies/ml) rates were 49%, 73% and 85% at months 3, 6 and 9, respectively. Two patients presented with virological breakthrough without adverse effects until month 9. CONCLUSIONS: Entecavir showed good BR and VR from month 3 and these effects continued through the 9-month observation period. This suggests that entecavir is also a good choice for the first line treatment of chronic hepatitis B (CHB). Further studies are needed to determine the long-term efficacy and drug resistance of entecavir in Korean CHB patients.

A Solitary Colonic Neurofibroma in a Patient without Neurofibromatosis / 대한소화기내시경학회지

Neurofibromas are usually manifestations of neurofibromatosis type 1 (Nf1). There are usually multiple lesions on presentation. Solitary neurofibromas of the colon are extremely rare. A 34-year-old Asian male came to our hospital for non-specific findings, except for a complaint of loose stools for 2 months. A colonoscopy was performed. A sessile polyp 0.4 cm in diameter was detected at the sigmoid colon. Microscopically, a biopsy from the polyp showed proliferation of spindle cells in the mucosa, myxoid changes and infiltration of inflammatory cells. Immunohistochemical staining was positive for S-100 protein. The above morphological and immunohistochemical characteristics were consistent with a diagnosis of a neurofibroma. Only 13 cases of isolated colonic neurofibromatosis without Nf1 have been documented in the literature. We report this case as an isolated neurofibroma of the colon is even a rarer manifestation, and only three cases have been published in the clinical literature.

An adult case of glycogen storage disease type IIIa / 대한간학회지

Glycogen storage disease type III (GSD III) is a very rare disorder caused by a deficiency in the activities of glycogen debranching enzymes (amylo-1-6-glucosidase and 4-alpha-glucanotransferase). GSD III is characterized by the accumulation of abnormal glycogen in the liver and skeletal muscle. The primary clinical manifestations are hepatomegaly, fasting hypoglycemia, and hyperlipidemia in infants. We report a rare case of GSD III in an adult. A 52-year-old woman presented to our clinic due to dyspnea on exertion, severe general weakness, and hepatomegaly. Hypertrophic cardiomyopathy was diagnosed based on echocardiogram findings. The microscopic findings of liver and skeletal muscle biopsies were consistent with the diagnosis of GSD. DNA analysis prompted by clinical and pathologic findings led to a definitive diagnosis of GSD IIIa. Diet therapy with cornstarch was started, and the patient was followed closely. This represents the first reported case of GSD IIIa diagnosed in an adult in Korea.

Comparison of therapeutic results between combination therapy of peginterferon alpha-2a plus ribavirin and interferon alpha-2b plus ribavirin according to treatment duration in patients with chronic hepatitis C / 대한간학회지

BACKGROUND/AIMS: This study compared the efficacy and safety of combined peginterferon alfa (PEG-IFN) and ribavirin with that of combined interferon alpha (IFN-alpha) and ribavirin, according to the treatment duration in Korean patients with chronic hepatitis C. METHODS: Medical records of 86 patients treated with PEG-IFN and ribavirin (mean age, 50.7 years; males/females, 57/29; genotypes 1/2, 59/27) and 134 patients treated with IFN-alpha and ribavirin (mean age, 50.9 years; males/females 74/60; genotypes 1/2, 79/55) were reviewed. Ribavirin was administered at doses of 600-1,200 mg and 600-800 mg in patients with genotypes 1 and 2, respectively. RESULTS: Sustained virological responses (SVRs) were evident in 68.4% and 41.7% of genotype 1 patients treated for 48 weeks in the PEG-IFN and IFN-alpha groups, respectively (P=0.021), and in 94.1% and 64.9% of genotype 2 patients treated for 24 weeks (P=0.026). Some genotype 1 patients treated for 24 weeks in the PEG-IFN group, who all exhibited negative HCV PCR results at week 12, showed an SVR of 87.5% (7/8). CONCLUSIONS: The rate of SVRs in Korean patients with chronic hepatitis C was higher for combined PEG-IFN and ribavirin than for combined IFN-alpha and ribavirin. Further study is needed to clarify the outcome of short-term therapy in patients with a rapid or early virological response.

A Case of Hepatocellular Carcinoma with intradural growth Presenting as Obstructive Jaundice / 영남의대학술지

The incidence of hepatocellular carcinoma presenting as obstructive jaundice is 0.7~9%. The mechanisms of obstructive jaundice include bile duct invasion by tumor, tumor thrombi, blood clots, direct bile duct compression by tumor, and intraductal tumor growth. We report a rare case of hepatocellular carcinoma with intraductal growth. A 46-year-old woman was admitted due to colicky right upper abdominal pain and jaundice for 4 days. Computed tomography showed dilatation of the left intrahepatic duct, and endoscopic retrograde cholangiography showed a filling defect in the left main intrahepatic duct. We performed a left lobectomy with a Roux-en-Y hepaticojejunostomy. The tumor was diagnosed as a hepatocellular carcinoma with intraductal growth.

Ulcerative Colitis Mimicking Acute Hemorrhagic Colitis / 영남의대학술지

Ulcerative colitis (UC) is a chronic inflammatory disorder of the gastrointestinal tract that affects the large bowel. Its etiology remains controversial. However, an infectious or immunologic origin is considered the primary cause. The onset of UC is typically slow and insidious, but some patients may present acutely with symptoms mimicking infectious colitis. We report a case of ulcerative colitis mimicking acute hemorrhagic colitis at initial presentation. A 60-year-old man was referred to Yeungnam University Hospital for bloody diarrhea and abdominal pain. Sigmoidoscopy revealed mildly edematous mucosa in the rectum and hyperemic mucosa with petechiae in the sigmoid colon. The patient was treated with antibiotics for several days, and his symptoms improved. However, after one month, his bloody diarrhea relapsed. Follow-up sigmoidoscopy revealed mucosal friability in the rectum and sigmoid colon. He was diagnosed with ulcerative colitis, and his symptoms were improved with mesalazine and a steroid enema.

Expression of beta-catenin, hMLH1, p53, Bcl-2, Bax and COX-2 in Serrated Adenomas of Colon / 대한소화기내시경학회지

BACKGROUND/AIMS: Serrated adenoma of the colorectum is a recently proposed entity that is characterized by a saw-toothed structure of hyperplastic polyp and also the cytologic atypia of conventional adenoma. In contrast to conventional adenomas, the molecular features of serrated adenomas have been poorly studied. METHODS: The expression of beta-catenin and the DNA mismatch repair protein hMLH1, apoptosis regulating protein Bcl-2, Bax, p53 and COX-2 were analyzed in 28 serrated adenoma specimens and 28 tubular adenoma specimens. RESULTS: No differences were observed in the frequency of beta-catenin loss in the cell membrane between the serrated and tubular adenoma specimens. The frequency of hMLH1 loss was significantly higher in the serrated adenomas than in tubular adenomas (p 60 years old). In the tubular adenoma specimens, the frequency of p53 overexpression was increased in the dysplastic epithelium. CONCLUSIONS: The expressions of hMLH1, Bax and Bcl-2 were decreased in the serrated adenoma than in the tubular adenoma. Our data suggest that the serrated adenoma and tubular adenoma may have different pathway in their development. However, further studies including normal mucosa, hyperplastic polyp and cancer specimens are needed.

A common hepatic duct web in association with choledocholithiasis / 대한내과학회지

Biliary web is a very rare disease and it can be diagnosed by its characteristic findings on endoscopic retrograde cholangiogram. The etiology of biliary web is variable. We were able to diagnose a common hepatic duct web in association with choledocholithiasis by performing endoscopic retrograde cholangiogram and operation. A 31-year-old woman visited our emergency room because of colicky right upper abdominal pain she had experienced for several hours. The endoscopic retrograde cholangiogram showed web-like stricture and stone at the common hepatic duct. She was treated by cholecystectomy with Roux-en-Y hepaticojejunostomy. We report here on this rare case along with a review of the literature.