Delayed Severe Hemobilia after Endoscopic Biliary Plastic Stent Insertion

Hemobilia is a rare gastrointestinal bleeding, usually caused by injury to the bile duct. Hemobilia after endoscopic retrograde cholangiopancreatography (ERCP) is generally self-limiting and patients will spontaneously recover, but some severe and fatal hemorrhages have been reported. ERCP-related bowel or bile duct perforation should be managed promptly, according to the type of injury and the status of the patient. We recently experienced a case of late-onset severe hemobilia in which the patient recovered after endoscopic biliary stent insertion. The problem was attributable to ERCP-related bile duct perforation during stone removal, approximately 5 weeks prior to the hemorrhagic episode. The removal of the stent was performed 10 days before the onset of hemobilia. The bleeding was successfully treated by two sessions of transarterial coil embolization.

Colonic Langerhans Cell Histiocytosis Presenting as an Isolated Polyp / 대한내과학회지

A 56-year-old male underwent a screening colonoscopy. An 8-mm sessile polyp was removed from the descending colon using snare polypectomy. Histology showed Langerhans cells and eosinophil infiltration of the submucosa. Immunohistochemical staining was positive for S-100 protein and CD1a antigen, which confirmed the diagnosis of Langerhans-cell histiocytosis. On further workup, there was no evidence of involvement of any other organs. Here, we report a very rare case of colonic Langerhans-cell histiocytosis presenting as an isolated polyp.

Anomalous Separate Origin of Left Anterior Descending Coronary Artery: Presented as Acute Anterior Myocardial Infarction

Coronary artery anomalies are rare presentations in primary percutaneous coronary interventions of acute myocardial infarction. Herein, we report the case of a 59-year-old man with acute anterior myocardial infarction who had anomalous separate origin of left anterior descending artery (LAD) and left circumflex artery (LCX) from the left coronary aortic sinus. Coronary angiography showed a normal right coronary artery and LCX, but no visualization of the LAD. After several unsuccessful attempts to cannulate the LAD, we found the LAD ostium located by the side of the LCX ostium. There was total occlusion at proxymal LAD. Coronary computed tomography angiography demonstrated the precise, separate origin of LAD and LCX from the left coronary aortic sinus.

Cut-Off Value and Factors Associated with a False Positive D-Dimer Result for Venous Thromboembolism in Koreans / 대한내과학회지

BACKGROUND/AIMS: The D-dimer value is a simple blood test used to evaluate venous thromboembolism (VTE). However, due to its low specificity, another test is needed for a definite diagnosis, such as a radiographic test. We evaluate the factors associated with a false positive D-dimer test and propose a new cut-off value for detecting VTE more effectively in Koreans. METHODS: This was a retrospective, observational study. From January 2009 to December 2009, 2,047 patients (988 men, 63 +/- 15 years) had the D-dimer value checked to evaluate VTE. The main outcome of interest was a positive D-dimer test. Odds ratio and 95% confidence intervals were determined using logistic regression analysis. The new D-dimer cut-off was evaluated using receiver operating characteristics (ROC) curves. RESULTS: The result was positive in 1,093 patients (53%), for a false positive percentage for VTE of 95% and a false negative percentage for VTE of 1%. Significant false positive predictors for a positive D-dimer were increasing age, trauma, postoperative, acute infection, tuberculosis, stroke, malignancy, chronic renal failure, acute coronary syndrome, heart failure, and lung disease. The discriminative value of the D-dimer test was assessed using ROC curve analysis. A D-dimer value of 0.68 mg/L on admission was the best cut-off value for predicting the development of VTE with a sensitivity of 95% and specificity of 57%. CONCLUSIONS: Many factors affect the D-dimer value and we must consider these factors before using the D-dimer value to evaluate VTE. A D-dimer value of 0.68 mg/L appears to be a good cut-off value for evaluating VTE more effectively in Koreans.

Antithrombotic or Anti-Platelet Agents in Patients Undergoing Permanent Pacemaker Implantation

BACKGROUND AND OBJECTIVES: The growing implantations of electrophysiological devices in the context of increasing rates of chronic antithrombotic therapy in cardiovascular disease patients underscore the importance of an effective periprocedural prophylactic strategy for prevention of bleeding complications. We assessed the risk of significant bleeding complications in patients receiving anti-platelet agents or anticoagulants at the time of permanent pacemaker (PPM) implantation. SUBJECTS AND METHODS: We reviewed bleeding complications in patients undergoing PPM implantation. The use of aspirin or clopidogrel was defined as having taking drugs within 5 days of the procedure and warfarin was changed to heparin before the procedure. A significant bleeding complication was defined as a bleeding incident requiring pocket exploration or blood transfusion. RESULTS: Permanent pacemaker implantations were performed in 164 men and 96 women. The mean patient age was 73+/-11 years old. Among the 260 patients, 14 patients took warfarin (in all of them, warfarin was changed to heparin at least 3 days before procedure), 54 patients took aspirin, 4 patients took clopidogrel, and 25 patients took both. Significant bleeding complications occurred in 8 patients (3.1%), all of them were patients with heparin bridging (p<0.0001). Heparin bridging markedly increased the length of required hospital stay when compare with other groups and the 4 patients (1.5%) that underwent the pocket revision for treatment of hematoma. CONCLUSION: This study suggests that hematoma formation after PPM implantation was rare, even among those who had taken the anti-platelet agents. The significant bleeding complications frequently occurred in patients with heparin bridging therapy. Therefore, heparin bridging therapy was deemed as high risk for significant bleeding complication in PPM implantation.

A Case of Gastrointestinal Stromal Tumor Mistaken for Abscess Following Embolization of Superior Mesenteric Artery

Bowel ischemia following embolization is the major complication of arterial embolization in gastrointestinal bleeding. Although mild ischemia recovers with conservative treatment, perforation should be treated surgically. We report a case of gastrointestinal stromal tumor mistaken for an abscess following embolization of superior mesenteric artery. A 72-year-old female was referred to the emergency room complaining of hematochezia and hematemesis. Endoscopic examination revealed a tiny mucosal defect with spurting bleeding at distal duodenum. Hemostasis could be achieved by embolization of superior mesenteric artery. After ten days, abdominal CT scan showed an abscess-like feature around distal duodenum, but the small bowel series did not show leakage of contrast. Endoscopy revealed round intestinal wall defect. She underwent laparotomy owing to the possibility of perforation and abscess, but surgical findings showed 5 cm mass based on the jejunum just caudal to ligament of Treitz. The mass was finally diagnosed as gastrointestinal stromal tumor combined with necrosis.

A Case of Gastrointestinal Stromal Tumor Mistaken for Abscess Following Embolization of Superior Mesenteric Artery

Bowel ischemia following embolization is the major complication of arterial embolization in gastrointestinal bleeding. Although mild ischemia recovers with conservative treatment, perforation should be treated surgically. We report a case of gastrointestinal stromal tumor mistaken for an abscess following embolization of superior mesenteric artery. A 72-year-old female was referred to the emergency room complaining of hematochezia and hematemesis. Endoscopic examination revealed a tiny mucosal defect with spurting bleeding at distal duodenum. Hemostasis could be achieved by embolization of superior mesenteric artery. After ten days, abdominal CT scan showed an abscess-like feature around distal duodenum, but the small bowel series did not show leakage of contrast. Endoscopy revealed round intestinal wall defect. She underwent laparotomy owing to the possibility of perforation and abscess, but surgical findings showed 5 cm mass based on the jejunum just caudal to ligament of Treitz. The mass was finally diagnosed as gastrointestinal stromal tumor combined with necrosis.

A Case of Multiple Pulmonary Nodular Pneumocystis jirovecii Pneumonia in an Acquired Immune Deficiency Syndrome Patient / 감염과화학요법

Pneumocystis jirovecii pneumonia (PCP) is a frequent manifestation of Acquired Immune Deficiency Syndrome (AIDS). The classic chest radiographic finding is perihilar ground glass opacities that may progress to more diffuse lung involvement. Atypical radiographic appearances include a normal chest film, lobar or segmental consolidation, cystic lesions, cavitation, pneumothorax, pleural effusion, and solitary or multiple pulmonary nodules. Although PCP is common in AIDS, presenting with nodular pulmonary densities is rare. We encountered the case of a 33-year-old man with AIDS whose chest radiography showed multiple bilateral nodular patterns suggestive of malignancy. We performed a transcutaneous lung biopsy and diagnosed him with PCP by Gomori methenamine-silver staining. Along with fungal and mycobacterial infections, intrathoracic Kaposi's sarcoma, and lymphoma, PCP should be considered in the differential diagnosis of nodular pulmonary disease in AIDS patients.

A Case of Pseudomembranous Tracheobronchitis Complicated by Coinfection of 2009 Pandemic Influenza A/H1N1 and Staphylococcus aureus / 감염과화학요법

An influenza pandemic due to a novel influenza A/H1N1 virus occurred after April 2009. This virus has some characteristics that differentiate it from the seasonal influenza virus. The 2009 pandemic influenza A/H1N1 virus can frequently infect the lower respiratory tract, and it might cause acute tracheobronchitis as well as pneumonia. Viral-bacterial interaction is well known as an important mechanism of the pathogenesis of respiratory complications of influenza. Herein, we report on a case that presented with pseudomembranous tracheobronchitis complicated by coinfection with 2009 pandemic influenza A/H1N1 and Staphylococcus aureus. We also review the relevent literature.