Cholecystectomy for Prevention of Recurrence after Endoscopic Clearance of Bile Duct Stones in Korea

PURPOSE: Cholecystectomy in patients with an intact gallbladder after endoscopic removal of stones from the common bile duct (CBD) remains controversial. We conducted a case-control study to determine the risk of recurrent CBD stones and the benefit of cholecystectomy for prevention of recurrence after endoscopic removal of stones from the CBD in Korean patients. MATERIALS AND METHODS: A total of 317 patients who underwent endoscopic CBD stone extraction between 2006 and 2012 were included. Possible risk factors for the recurrence of CBD stones including previous cholecystectomy history, bile duct diameter, stone size, number of stones, stone composition, and the presence of a periampullary diverticulum were analyzed. RESULTS: The mean duration of follow-up after CBD stone extraction was 25.4+/-22.0 months. A CBD diameter of 15 mm or larger [odds ratio (OR), 1.930; 95% confidence interval (CI), 1.098 to 3.391; p=0.022] and the presence of a periampullary diverticulum (OR, 1.859; 95% CI, 1.014 to 3.408; p=0.045) were independent predictive factors for CBD stone recurrence. Seventeen patients (26.6%) in the recurrence group underwent elective cholecystectomy soon after endoscopic extraction of CBD stones, compared to 88 (34.8%) in the non-recurrence group; the difference was not statistically significant (p=0.212). CONCLUSION: A CBD diameter of 15 mm or larger and the presence of a periampullary diverticulum were found to be potential predictive factors for recurrence after endoscopic extraction of CBD stones. Elective cholecystectomy after clearance of CBD stones did not reduce the incidence of recurrent CBD stones in Korean patients.

A Delayed Hepatico-colonic Fistula after Radiofrequency Ablation in Hepatocellular Carcinoma / 대한내과학회지

Percutaneous radiofrequency thermal ablation (RFA) performed under ultrasound guidance is a safe, effective therapeutic modality for managing liver malignancies. Although surgical resection remains the treatment of choice for hepatocellular carcinoma (HCC), RFA has emerged as a reliable alternative. Potential complications of RFA include liver abscess, ascites, pleural effusion, skin burns, hypoxemia, pneumothorax, subcapsular hematoma, hemoperitoneum, liver failure, tumor seeding, and biliary lesions. Here, we report a rare complication after RFA for HCC: a delayed liver abscess and transverse colonic fistula. The patient was treated successfully with percutaneous abscess drainage, antibiotics, liver segmentectomy, and segmental resection of the fistula and involved colon. Due to its rarity, we report this case and review the literature.

Unusual Complication of Crohn's Disease: Portal Hypertension Related with Rapid Progression of Portal Vein and Superior Mesenteric Vein Thrombosis / 대한내과학회지

Thromboembolic events are rare among systemic complications of inflammatory bowel disease; however, they are a significant cause of mortality when they occur. Several reports have considered thromboembolic events in patients with ulcerative colitis presenting with venous or arterial thromboembolism, such as cerebral thrombosis, deep vein thrombosis, pulmonary thromboembolism, portal vein thrombosis, or mesenteric vein thrombosis. However, increased coagulability related to Crohn's disease is extremely rare compared with that of ulcerative colitis. We report a case of a 42-year-old man with complicated portal hypertension that occurred due to extensive portal vein and mesenteric vein thrombosis. He had a monozygotic twin brother who was also in remission with Crohn's disease. The patient showed protein C and protein S deficiencies; however, he recovered with early anticoagulation therapy.

Angiogenic Inhibitor Induced Complicated Reflux Esophagitis / 이화의대지

Sunitinib an inhibitor of the vascular endothelial growth factor receptor, is highly effective against renal cell carcinoma and is now widely used in patients with metastatic disease. Gastroesophageal reflux disease (GERD) is rarely reported as a side effect of sunitinib. We report two cases of GERD with upper gastrointestinal bleeding related to sunitinib administration. Both cases responded well to conservative management. Microscopic findings in both cases showed cellular atypia such as hyperchromasia, increases in nuclear size, and multinucleation. The cellular atypia of the squamous mucosa appears to be associated with reparative processes.

Clinical Characteristics and Treatment Outcome of Colonic Diverticulitis in Young Patients / 대한소화기학회지

BACKGROUND/AIMS: The clinical course and the most appropriate management of colonic diverticulitis in young patients are currently unresolved. This retrospective study was designed to compare young patients (40 years) regarding clinical characteristics of acute colonic diverticulitis and to determine whether differences exist in treatment outcome. METHODS: Three-hundred sixty eight patients presenting with acute colonic diverticulitis from March 2001 through April 2011 at Ewha Womans University Mokdong Hospital were reviewed retrospectively. The differences in clinical characteristics, treatment modality and recurrence between each group were analyzed. RESULTS: Two-hundred and six patients were aged 40 years or younger and 162 patients were older than 40 years. The older group was diagnosed more frequently with severe diverticulitis. Surgical treatment was significantly more frequent in the older group than in the younger group (15.4% vs. 4.4%, p<0.001). No significant difference was found in treatment modality between the two groups in patients with recurrence. The difference in recurrence between groups was not statistically significant. In multivariate analysis, left colonic diverticulitis was significantly associated with severe diverticulitis (OR, 14.651; 95% CI, 4.829-44.457) and emergency surgery (OR, 13.745; 95% CI, 4.390-43.031). CONCLUSIONS: When patients with colonic diverticulitis are treated conservatively, young age is no longer an independent risk factor for subsequent poor outcome. Diverticulitis in young patients does not have a particularly aggressive or fulminant course. Therefore, we recommend that diverticulitis management should be based on the severity and location of the disease, and not on the age of the patient.

A Case of Jejunal Gastrointestinal Stromal Tumor Diagnosed by Videocapsule Endoscopy and Single-Balloon Enteroscopy / 이화의대지

Gastrointestinal stromal tumors (GISTs) are common mesenchymal tumors that arise in the wall of the gastrointestinal tract. We report a case of obscure gastrointestinal bleeding due to a GIST of the jejunum successfully documented by videocapsule endoscopy (VCE) and single-balloon enteroscopy (SBE). A 36-year-old man with hematochezia was referred for further evaluation of no evidence of bleeding focus on esophagogastroduodenoscopy and colonoscopy. A VCE showed a suspicious ulcerative hyperemic mass that located in about 1 hour apart from duodenal second portion. SBE revealed a nonbleeding 4x2 cm mass with an ulcer at the proximal jejunum. The patient underwent laparoscopic resection without complication. Histological examination revealed a well circumscribed, dumbbell-shaped firm mass comprised of spindle cells. Immunohistochemical staining for CD 117 was diffusely positive, whereas staining for S-100, CD 34 and MIB-1 was all negative. It was confirmed to be a low-grade GIST at the proximal jejunum.

Recurred Cryptogenic Liver Abscess Secondary to Colon Cancer in a Non-diabetic Man / 이화의대지

The causes of pyogenic liver abscess has been known as biliary tract disease or intrabadominal infection but the large proportions of the patients has no apparent underlying disorders. Recently colonic mucosal lesions were reported in patients with cryptogenic liver abscess and it has been suggested that colonic mucosal break may play a role in developing liver abscess in otherwise healthy patients. We experienced a patient of severe recurrent liver abscess complicated with endophthalmitis only 3 months after successful treatment of initial cryptogenic liver abscess and a polypoid colon cancer was discovered by chance. It seems prudent to proceed colonoscopic examination in patients with cryptogenic liver abscess especially when it is recurrent.

Impact of Rheumatologic Consultations on Detecting Interstitial Lung Disease Associated with Connective Tissue Disease

OBJECTIVE: In patients with interstitial lung disease (ILD) associated with connective tissue disease (CTD), chronic ILD related symptoms may often dominate the clinical picture or precede systemic findings and thus often be seen by a non-rheumatologist. The purpose of this study was to evaluate the importance of rheumatologic consultation during ILD work up. METHODS: We retrospectively reviewed 64 patients with ILD from a single tertiary center for their clinical and laboratory characteristics, rheumatologic consultation status, and result of the consultation. American College of Rheumatology criteria for classification of each connective tissue disease were utilized. Undifferentiated connective tissue disease (UCTD) was classified by pre-specified criteria. RESULTS: A total of 23 (36%) of the ILD patients had associated CTD. Five (8%) patients had underlying CTD before the diagnosis of ILD, whereas 18 (28%) patients were diagnosed with CTD after the rheumatologic consultation. ILD patients with CTD were predominantly female, had significantly more frequent radiographic diagnoses of nonspecific interstitial pneumonia, increased frequencies of high titer antinuclear antibody positivity, and rheumatoid factor positivity. Rheumatologic consultation was referred in 36 (56%) patients. In 18 (50%) of the referred patients, CTD was diagnosed. In 61% of the patients diagnosed with CTD as a result of rheumatologic consultation, changes in therapy occurred. CONCLUSION: A substantial proportion of patients with ILD are found to have an underlying CTD upon evaluation by a rheumatologist. Since ILD associated with CTD mimics idiopathic interstitial pneumonia, rheumatologic consultation may have a significant impact on the clinical care of ILD.