Is propofol safe when administered to cirrhotic patients during sedative endoscopy?

BACKGROUND/AIMS: In patients with liver cirrhosis, drugs acting on the central nervous system can lead to hepatic encephalopathy and the effects may be prolonged. Recently, misuse of propofol has been reported and the associated risk of death have become an issue. Propofol is commonly used during sedative endoscopy; therefore, its safety in high-risk groups must be further investigated. We performed a pilot study of the safety and efficacy of propofol during endoscopy in Korean patients with cirrhosis. METHODS: Upper gastrointestinal endoscopy was performed under sedation with propofol along with careful monitoring in 20 patients with liver cirrhosis and 20 control subjects. The presence or development of hepatic encephalopathy was assessed using the number connection test and neurologic examination. RESULTS: Neither respiratory depression nor clinically significant hypotension were observed. Immediate postanesthetic recovery at 5 and 10 minutes after the procedure was delayed in the cirrhotic patients compared with the control group; however, at 30 minutes, the postanesthetic recovery was similar in both groups. Baseline psychomotor performance was more impaired in cirrhotic patients, but propofol was not associated with deteriorated psychomotor function even in cirrhotic patients with a minimal hepatic encephalopathy. CONCLUSIONS: Sedation with propofol was well tolerated in cirrhotic patients. No newly developed hepatic encephalopathy was observed.

A Case of Primary Small Cell Neuroendocrine Carcinoma of the Liver / 대한소화기학회지

Small cell neuroendocrine carcinoma is a type of undifferentiated, malignant neuroendocrine tumor. Most of neuroendocrine tumors exhibit well-differentiated features and are classified as carcinoid tumors. However, carcinomas of the liver with anaplastic characters, which are classified as small-cell carcinomas are extremely rare and only few cases have been reported in the literature. We report an unusual case of primary small cell neuroendocrine carcinoma of the liver in a 67-year-old man. The patient was found to have a palpable mass on right upper quadrant of abdomen on physical examination. The diagnosis was made by immunohistochemical stains of biopsied specimen from the liver. Other possible primary site was excluded by radiologic and endoscopic evaluations. The tumor was composed of small monotonous and hyperchromatic poorly differentiated cells with higher nuclear to cytoplasmic ratio, and were positive for neuroendocrine tissue markers such as synaptophysin, c-kit, and CD56.

Comparison of the Effectiveness of Quadruple Salvage Regimen for Helicobacter pylori Infection according to the Duration of Treatment / 대한소화기학회지

BACKGROUND/AIMS: At present, triple therapy schemes are recommended by national and international consensus conferences for the treatment of Helicobacter pylori (H. pylori) infection. However, even with the most effective current treatment regimens, about 10-20% of patients fail to eradicate H. pylori, necessitating alternative strategy to eradicate H. pylori in primary treatment failure. Therefore, we performed this study to evaluate the efficacy of quadruple therapy and to compare 1 and 2-week quadruple regimen as a second-line therapy. METHODS: The hospital records of 155 patients who failed to the standard triple therapy (proton pump inhibitor, amoxicillin, clarithromycin) were reviewed retrospectively, and divided the 1 or 2 weeks OBMT regimen (omeprazole 20 mg bid, bismuth salt 120 mg qid, metronidazole 500 mg tid, tetracycline 500 mg qid). Presence of H. pylori infection and side-effects of the treatment regimen were assessed 4 weeks after the cessation of treatment. CONCLUSIONS: One hundred and eight male and 47 female (mean age, 52.2+/-15.4) patients were enrolled. The overall eradication rate of H. pylori with quadruple therapy was 83.9% and the eradication rate was similar between 1 and 2 weeks of OBMT regimen (76.8% in OBMT 1 week, 87.9% in OBMT 2 weeks, respectively p=0.110). CONCLUSIONS: Quadruple therapy is an effective salvage regimen for H. pylori eradication after the failure of standard triple therapy. One week quadruple therapy is not significantly different from 2-weeks regimen as the second-line option for H. pylori eradication.

Clinical Characteristics of Nontraumatic Rhabdomyolysis in Patients with Liver Cirrhosis / 대한소화기학회지

BACKGROUND/AIMS: Rhabdomyolysis is a serious and lethal condition that can be induced not only by traumatic causes but also by a variety of nontraumatic causes. However, there are few reports about rhabdomyolysis developed in patients with liver cirrhosis. We carried out this study to elucidate the clinical characteristics and courses of rhabdomyolysis in patients with liver cirrhosis. METHODS: We analyzed 19 cases of nontraumatic rhabdomyolysis in patients with liver cirrhosis who had admitted at Korea University Ansan Hospital between October 2001 and September 2004. RESULTS: Alcohol (50%) was the main etiology of rhabdomyolysis in alcoholic liver cirrhosis patients, and the precipitating factors were not apparent (69.2%) in majority of nonalcoholic liver cirrhosis patients with rhabdomyolysis. Nonalcoholic liver cirrhosis patients had complaints of pain referable to the musculoskeletal system, but alcoholic liver cirrhosis patients had no typical complaints. Mortality of rhabdomyolysis in liver cirrhosis patients was high (42.1%), especially in decompensated liver cirrhosis patients (p=0.04). In nonalcoholic liver cirrhosis patients, the development of oliguria (p=0.007) and acute renal failure (p=0.049) in the course of rhabdomyolysis increased the mortality significantly. CONCLUSIONS: In cirrhosis patients, rhabdomyolysis showed a poor prognosis, especially in nonalcoholic liver cirrhosis with oliguria, acute renal failure, or decompensated liver cirrhosis. It is believed that a high clinical suspicion for the occurrence of rhabdomyolysis in liver cirrhosis patients can lead to quicker recognition and better patient care.

Comparison of 4 L of PEG Versus Combination of 2 L of PEG and 45 mL of Sodium Phosphate for Colonoscopy Colon Cleansing: A Prospective Randomized Trial / 대한소화기내시경학회지

BACKGROUND/AIMS: Polyethyleneglycol (PEG) is safe but its large volume and bad taste reduces patients' compliance. Sodium phosphate (NaP) is a hyperosmotic agent and its small volume can increase patients' compliance but electrolyte imbalance is a problem. Therefore, we conducted a study to determine whether patients' compliance can be enhanced and electrolyte imbalance reduced by combining these two agents. METHODS: Forty-one admitted patients receiving colonoscopy at Korea University Hospital from June 28, 2004 to August 14, 2004 were randomly divided into two groups for colon cleansing with either PEG 4 L (n=21) or PEG 2 L plus NaP 45 mL (n=20). Patients were assessed for patient tolerance, quality of preparation, and changes of biochemical parameters. RESULTS: Overall discomfort was statistically lower in the combination group, PEG 2 L plus NaP 45 mL (p=0.035). Although patients in the combination group reported less fullness (p=0.076) and nausea (p=0.087), the findings were not statistically significant. The quality of the preparation was comparable between the two groups (p=0.872). The phosphorus level in the combination group showed a statistically significant increase (0.58+/-0.46) after colon cleansing (p=0.020) but was not clinically significant. CONCLUSIONS: The combination of NaP 45 mL and PEG 2 L showed less overall discomfort with comparable quality of preparation and without serious electrolyte abnormality compared to 4 L of PEG. Therefore, the combination of NaP 45 mL and PEG 2 L could be used as an alternative colonoscopic colon cleansing agent when patients have trouble taking 4 L of PEG alone.

Effect of Helicobacter pylori Infection on the Cardiovascular Diseases / 대한소화기학회지

No abstract available

A Case of Synchronous Double Cancer: Klatskin's Tumor and Ampullary Adenocarcinoma / 대한소화기내시경학회지

Multiple cancers in the extrahepatic biliary tree are relatively rare. Many such cases are a double cancer of the common bile duct and the gallbladder. We report a case of a double primary cancer that occurred synchronously at the hilum of the extrahepatic duct and the ampulla of Vater with a review of the relevant literature. A 57-year-old man was admitted to our institution after a 15 day of painless jaundice and a urine color change. Ultrasonography showed a dilation of both intrahepatic ducts. Upper endoscopy revealed a protruding ulcerative mass at the ampulla of Vater and endoscopic retrograde cholangiography showed a dilated common bile duct and a mildly dilatated pancreatic duct, but both intrahepatic bile ducts were not visualized. An upper abdominal CT scan showed a dilation of both intrahepatic bile ducts and an infiltrating mass at the bifurcation area. Magnetic resonance cholangiopanreatography showed narrowing bile duct lumen that was obstructed by the tumor at the hepatic duct bifurcation, which dilated both intrahepatic ducts. A histological examination of the ampulla of Vater revealed a well differentiated adenocarcinoma of the ampulla of Vater. The final diagnosis was a synchronous double cancer of Klatskin's tumor and an adenocarcinoma of the ampulla of Vater.

Comparison of Helicobacter pylori Eradication Rate according to Different PPI-based Triple Therapy : Omeprazole, Rabeprazole, Esomeprazole and Lansoprazole / 대한소화기학회지

BACKGROUND/AIMS: Helicobacter pylori (H. pylori) is an important cause of various gastrointestinal diseases. H. pylori eradication is essential for the cure and prevention of associated diseases. Nowdays, proton pump inhibitor (PPI)-based triple therapy is the standard eradication regimen. The aims of this study were to compare the H. pylori eradication rate of different PPI-based triple therapies and to find out the factors influencing the eradication rate. METHODS: From May 2002 through Febraury 2004, H. pylori infected patients were treated with the eradication regimen based on one of the four PPIs (omeprazole, rabeprazole, esomeprazole and lansoprazole) for 1 or 2 weeks. After two weeks, drug compliance, adverse effects, and smoking history during the eradication therapy were obtained. The follow-up H. pylori test was performed 4 weeks after the completion of therapy. The data were analyzed by Chi-square test and multiple logistic regression analysis. RESULTS: Overall eradication rate was 83.5%. There was no significant difference in eradication rate among four PPIs (p=0.379). Odds ratio (OR) for omeprazole and rabeprazole was 1.15 (95% CI 0.50-2.68); for omeprazole and esomeprazole, OR 1.63 (95% CI 0.68-3.89); and for omeprazole and lansoprazole, OR 1.13 (95% CI 0.50-2.56). Smoking habit, site of ulcer, and the duration of therapy affected the eradication rate significantly. CONCLUSIONS: The efficacy of four different PPIs for H. pylori eradication is similar to each other. Smoking, site of ulcer, and the duration of treatment have significant effects on eradication rates.

Lymphogenous Pancreatic Metastasis of Gastric Cancer Detected by Elevated CA 19-9 Level / 대한소화기내시경학회지

Pancreatic metastasis of gastric cancer almost takes the form of direct continous invasion to the pancreas from the primary lesions or dissemination. Isolated lymphogenous pancreatic metastasis of stomach cancer is rare. A 39-year-old woman was admitted to our institution due to high serum CA 19-9 level. Abdominal computed tomography showed a diffusely enlarged pancreas, and endoscopic retrograde cholangiopancreatography revealed a segmental stricture of pancreatic duct on mid-body. Ultrasonography guided pancreatic biopsy revealed a metastatic poorly differentiated adenocarcinoma with lymphatic tumor emboli. We perfomed esophagogastroduodenoscopy and total colonoscopy. There was a ulcerative lesion at the posterior wall of high body with clubbing change of surrounding mucosal folds. Endoscopic biopsy of the stomach lesion revealed a poorly differentiated adenocarcinoma. Positron emission tomography-computed tomography scan revealed bone metastasis in the sternum. Herein, we report a case of 39 year old female with the diagnosis of gastric adenocarcinoma, with lymphogenous pancreatic metastasis and solitary sternal metastasis detected by elevated serum CA 19-9 level.

Analysis of Gastrointestinal Transit Rate in Capsule Endoscopy / 대한소화기내시경학회지

BACKGROUND/AIMS: Capsule endoscope (CE) is a new method of investigating entire small bowel (SB). Some reported that current battery time was sufficient for observing entire SB, but others reported negatively. The aims of this study were to determine the factors influencing the entire SB transit rate. METHODS: From Sep. 2002 to Aug. 2003, CE was performed in 197 cases and they were devided into complete/incomplete transit according to getting ileocecal valve image within battery time. sixteen cases were excluded due to anatomical abnormality or artificial procedure. one hundred eighty one cases were analyzed with multiple logistic regression. RESULTS: The complete SB transit rate was 63.5%. Mean battery time was 7 and 1/2 hrs. Gastric transit time (GTT) was significantly shorter in complete group than in incomplete group but the other factors (age, sex, preparation, symptom) were not significant. Mean small bowel transit time in complete group was 4 and 1/2 hrs and ranged from 1 to 8 hrs. In incomplete group (66 cases), 2 cases were reached to distal jejunum, 11 cases to proximal ileum, and the other 53 cases to distal ileum. CONCLUSIONS: Complete SB transit rate of CE was 63.5% in the 181 cases under current battery time. GTT was the only significant factor influencing gastrointestinal transit rate of CE.

Interpretation of Capsule Endoscopy: Expert versus Novice / 대한소화기내시경학회지

BACKGROUND/AIMS: Capsule endoscopy (CE) is a new method enabling noninvasive diagnosis of small bowel diseases. There have been few studies examining the possibility of interobserver variation according to proficiency. We evaluated the interobserver variability between expert and novice for reviewing CE images. METHODS: Among patients who were taken CE from June 2003 to July 2003, twenty patients were randomly selected. Captured images were assessed by an expert and a novice separately. The expert has experience of more than 150 CE interpretation and the novice only had experience in performing EGD and colonoscopy. The novice had trained on interpretation of the CE with 5 cases before this study. Interobserver agreement was evaluated using kappa coefficient. RESULT: CE findings were divided into normal/ abnormal groups. Abnormal groups were classified into small focal, large focal, multiple diffuse, structural deformity groups. Compared with the expert, the novice missed 2 cases (Meckel's diverticulum and angiodysplasia). There was no disagreement in other cases. CONCLUSION: There is 90% (18/20) interobserver agreement between the expert and the novice for the interpetation of findings CE (k=0.737). Normal findings and diffuse large lesions tended to have higher concordance, whereas small focal lesion and structural deformities were more likely to be a source of disagreement.

Extraintestinal Tuberculosis is Useful for Differential Diagnosis of Intestinal Tuberculosis / 대한소화기학회지

No abstract available.

Efficacy of 14 Day OBMT Therapy as a Second-line Treatment for Helicobacter pylori Infection / 대한소화기학회지

BACKGROUND/AIMS: As a second-line treatment for H. pylori eradication in the case of first-line OAC (omeprazole, amoxicillin, clarithromycin) treatment failure, a minimum of one-week OBMT quadruple therapy composed of omeprazole, bismuth, metronidazole, tetracycline has been recommended in European countries and one or two weeks in USA. In Korea, one-week OBMT quadruple therapy is recommended for the case of first-line OAC treatment failure. Because H. pylori eradication rate of one-week OBMT therapy in Korea is about 80%, the eradication rate of one week therapy is not satisfactory. We analyzed the effect of two-week second-line OBMT therapy. METHODS: Between June 2002 and June 2003, 107 patients who were H. pylori positive (44 males and 63 females: mean age 51.8 years) after primary eradication therapy received two-week OBMT therapy. Four weeks after completion of therapy, 13C-urea breath test was performed to detect H. pylori. RESULTS: After two weeks of OBMT therapy, eradication was achieved in 103 of 107 patients (96.3%) and in 68 of 71 peptic ulcer patients (95.8%). CONCLUSIONS: Two-week OBMT therapy should be considered as a retreatment regimen with the eradication rate more than 90%.

A Case of Chronic Ulcerative Colitis Complicated by Budd-Chiari Syndrome and Colon Cancer / 대한소화기내시경학회지

Ulcerative colitis is a chronic inflammatory bowel disease and may have many intestinal and extraintestinal complications. Compared with general population, patients with longstanding ulcerative colitis have an increased risk of colorectal cancer. Patients with ulcerative colitis have an increased frequency of thromboembolism too. However, hepatic vein thrombosis is a very rare extraintestinal complication. This is the first reported case of a young patient with ulcerative colitis who developed synchronous colonic neoplasm and chronic Budd-Chiari syndrome manifested as esophageal variceal bleeding. We report a case of ulcerative colitis complicated by Budd-Chiari syndrome and colon cancer in a 28-year-old female.

A Case of Chronic Gastrointestinal Bleeding from a Meckel's Diverticulum Detected by Wireless Capsule Endoscopy / 대한소화기학회지

Meckel's diverticulum is an embryonic derivative of the omphalomesenteric duct and the most commonly encountered congenital anomaly of the gastrointestinal tract. Its incidence records about 2%. Among them, only 5% are symptomatic with complications-bleeding, intestinal obstruction, inflammation, and perforation. In particular, bleeding is a common complication and has always been caused by an ulceration of the ileal mucosa adjacent to the acid-producing ectopic mucosa in a Meckel's diverticulum. Wireless capsule endoscopy is a new method enabling non-invasive diagnostic endoscopy of the entire small intestine. We experienced a case of Meckel's diverticulum detected by wireless capsule endoscopy in a 34 year-old man who presented with chronic obscure gastrointestinal bleeding.

A Case of Metastatic Gastric Synovial Sarcoma / 대한소화기내시경학회지

Synovial sarcomas are malignant soft tissue neoplasms that develop from tendon and bursa near the large joints and frequently occur in the lower extremities of young male adults. They usually recur within 2 years after surgical treatment. The lung is a common metastatic site and rarely reported as the primary site of synovial sarcoma. The stomach is a very rare primary site of synovial sarcoma and recently only two cases of primary gastric synovial sarcoma were reported. We report a case of metastatic gastric synovial sarcoma in a 53-year-old male 4 years after surgical treatment of primary lung synovial sarcoma. The tumor had histologic, immunohistochemical and ultrastructural features of biphasic synovial sarcoma of the soft tissue.

A Case of NSAID Induced Small Bowel Ulcer Bleeding Diagnosed by Capsule Endoscopy / 대한소화기내시경학회지

The small intestine has always been a problematic segments for endoscopic exploration in patients with obscure gastrointestinal bleeding. Recent emergence of capsule endoscopy has entailed a relevant diagnostic imaging advance for gastrointestinal conditions. Capsule endoscope can be used to detect small bowel bleeding. Some studies report that capsule endoscopy has the high diagnostic yield and is superior to enteroscopy and other diagnostic methods. We report here the first case of small bowel bleeding detected by using capsule endoscope in Korea, in a woman with hematochezia and a history of aspirin ingestion.

A Case of Tubular Esophageal Duplication Presenting with Hematemesis / 대한소화기내시경학회지

A 35-year old male developed epigastric pain and hematemesis one week before admission. Esophagogastroduodenoscopy was performed and a communication between the esophagus and another opening was discovered. On a follow-up CT and barium esophagogram, a tubular duplication was suspected and the patient was referred to the department of cardio-thoracic surgery. A pathological diagnosis of esophageal duplication (tubular type) was established. The patient was discharged and is currently being followed up. Esophageal duplication is a rare congenital malformation. Moreover, it has not heen reported in Korea that esophageal duplication presents with hematemesis.

A case of dedifferentiated liposarcoma in retroperitoneum / 대한내과학회지

Dedifferentiated liposarcoma occurs in less than 10% of all liposarcomas and is found most often in the retroperitoneum and extremities. Although cases of the primary dedifferentiated liposarcoma have been sporadically reported internationally, only one case with 8x4.5x4 cm size originated from spermatic cord and one case with 10x7x5 cm size in right gluteal region have been reported in Korea, but not in retroperitoneum. We report one case of the primary giant dedifferentiated liposarcoma occurred in retroperitoneum with 32x22x20 cm size and 4,250 g weight. A 56-year old man was admitted due to the weight loss and diffuse abdominal pain. The abdominal computed tomography showed that a round huge mass was pressing the surrounding structures and showed delayed enhancement. Surgical excision was carried out. Histologically the tumor was composed of well differentiated liposarcomatous area and malignant fibrous histiocytoma-like dedifferentiated area. The patient refused further treatment and now he is undergoing the follow-up.

A Case of Small Intestinal Burkitt's Lymphoma in an Adult / 대한소화기내시경학회지

Burkitt's lymphoma is a rare disease that belongs to the aggressive non-Hodgkin's lymphomas. Burkitt's lymphoma usually occurs in children or younger persons. There is a strong association between endemic Burkitt's lymphoma and Epstein-Barr virus, whereas the association is weaker in the sporadic form occurring in Western countries. Burkitt's lymphoma of the gastrointestinal tract occurring in adults has not been reported in Korea. We herein report an unusual case of Burkitt's lymphoma presenting with a palpable abdominal mass in a 52-year-old man infected with Epstein-Barr virus. A computed tomographic scan showed marked low density wall thickening of the terminal ileum. An endoscopy revealed a narrow lumen, shallow ulcerations, and irregular nodularity of the terminal ileum. Small bowel resection and hemicolectomy were performed and a histologic examination of the resected specimen confirmed the diagnosis. Six cycles of adjuvant chemotherapy were given and the patient has been doing well without evidence of recurrence.