Usefulness of Percutaneous Transhepatic Cholangioscopic Lithotomy for Removal of Difficult Common Bile Duct Stones

BACKGROUND/AIMS: Approximately 5% to 10% of common bile duct (CBD) stones are difficult to remove by conventional endoscopic methods. Percutaneous transhepatic cholangioscopic lithotomy (PTCSL) can be an alternative method for this condition, but is not well established yet. The aim of this study was to evaluate the clinical efficacy and safety of PTCSL for removal of difficult CBD stones. METHODS: This study is a retrospective review of 34 consecutive patients who underwent unsuccessful removal of CBD stones using conventional endoscopic methods between December 2008 and July 2010 and were subsequently treated using PTCSL. RESULTS: Among 443 patients with CBD stones, 34 patients (7.8%) failed to achieve stone removal using conventional endoscopic methods. Of these 34 patients, 33 were treated using PTCSL. In all 33 cases (100%), complete stone removal was achieved using PTCSL. Most complications (15/17, 88.2%) were mild and transient. Major complications occurred in two patients (6.1%) who experienced hemobilia, and percutaneous transhepatic biliary drainage tract disruption, respectively; which were fully recovered without mortality. CONCLUSIONS: Despite prolonged hospital stay and temporary decline of quality of life, PTCSL is an effective and safe method in the management of difficult CBD stones, especially in patients with difficulty in approaching the affected bile duct.

A Gastric Composite Tumor with an Adenocarcinoma and a Neuroendocrine Carcinoma: A Case Report

A 70-year-old woman was admitted to our department with epigastric discomfort and nausea over the duration of 1 month. An esophagogastroduodenoscopy showed the presence of a 1.0x1.0 cm-sized flat lesion with central ulceration at the greater curvature side of the antrum. A biopsy demonstrated the presence of an adenocarcinoma of well differentiated, intestinal type in the stomach. Endoscopic submucosal dissection was done and the diagnosis of a composite neuroendocrine carcinoma with an adenocarcinoma of the stomach was confirmed. We report a case of a gastric composite tumor with an adenocarcinoma and neuroendocrine carcinoma confirmed by endoscopic submucosal dissection with a review of the literature.

A Case of Intrahepatic Cholangiocarcinoma Associated with Type IV Choledochal Cyst / 대한소화기학회지

Anomalous union of the pancreaticobiliary duct (AUPBD) is a congenital anomaly that is defined as a junction of the bile duct and pancreatic duct outside the duodenal wall. This anomaly results in a loss of normal sphincteric mechanisms at the pancreaticobiliary junction. As a result, regurgitation of pancreatic juice into the biliary system develops and causes choledochal cysts, choledocholithiasis, cholangitis, pancreatitis and malignancy of the biliary tract. Gallbladder cancer or common bile duct cancer associated with AUPBD and choledochal cysts have been frequently reported. But, intrahepatic cholangiocarcinoma associated with this condition has been only rarely reported. Here, we report a case of intrahepatic cholangiocarcinoma associated with AUPBD and choledochal cyst.

A Case of Gastrointestinal Amyloidosis as a Complication of Crohn's Disease / 대한소화기내시경학회지

Amyloidosis is a disorder resulting from extracellular deposition of insoluble fibrils and causes dysfunction in many organs. Secondary amyloidosis, caused by chronic infectious and inflammatory disease, may involve the kidneys, liver, bone marrow and gastrointestinal tract. Involvement of the gastrointestinal tract is common and presents various symptoms according to location. Amyloidosis as a complication of Crohn's disease is a rare but serious complication that may worsen the prognosis. We report a case of gastrointestinal amyloidosis in a 59-year-old male patient with Crohn's disease that was diagnosed with an endoscopic forceps biopsy of the stomach, terminal ileum and colon.

A Case of Clonorchiasis with Focal Intrahepatic Duct Dilatation Mimicking an Intrahepatic Cholangiocarcinoma

Biliary strictures can be caused by various diseases. Intrahepatic duct (IHD) strictures are usually related to IHD stones and cholangitis. However, focal IHD strictures without IHD stones often create diagnostic problems. Parasitic diseases such as clonorchiasis can be a rare cause of an IHD stricture. Human clonorchiasis (Clonorchis sinensis infection) is an endemic parasitic disease in Eastern Asia, including Korea, and patients acquire the infestation by eating raw fish. On radiological examinations, clonorchiasis shows typically diffuse, minimal, or mild dilatation of the small IHD, particularly in the periphery, without dilatation of the extrahepatic duct. However, diagnosis of clonorchiasis can sometimes be difficult when radiological changes are atypical. We report a case of focal left IHD dilatation caused by clonorchiasis that was confused with a malignancy.

A Case of Clonorchiasis with Focal Intrahepatic Duct Dilatation Mimicking an Intrahepatic Cholangiocarcinoma

Biliary strictures can be caused by various diseases. Intrahepatic duct (IHD) strictures are usually related to IHD stones and cholangitis. However, focal IHD strictures without IHD stones often create diagnostic problems. Parasitic diseases such as clonorchiasis can be a rare cause of an IHD stricture. Human clonorchiasis (Clonorchis sinensis infection) is an endemic parasitic disease in Eastern Asia, including Korea, and patients acquire the infestation by eating raw fish. On radiological examinations, clonorchiasis shows typically diffuse, minimal, or mild dilatation of the small IHD, particularly in the periphery, without dilatation of the extrahepatic duct. However, diagnosis of clonorchiasis can sometimes be difficult when radiological changes are atypical. We report a case of focal left IHD dilatation caused by clonorchiasis that was confused with a malignancy.

Isolated and Combined Influences of Diabetes and Hypertension on the Myocardial Function and Geometry

BACKGROUND AND OBJECTIVES: Because hypertension and left ventricular hypertrophy (LVH) frequently coexist with diabetes, in this study we sought to compare the myocardial functional and structural changes in diabetic patients who were with or without hypertension with those myocardial functional and structural changes in non-diabetic subjects with hypertension (essential hypertension), in order to identify the role of diabetes alone, in relation to the myocardial dysfunction. SUBJECTS AND METHODS: We studied 50 patients with essential hypertension (HTN, 20 men and 30 women; mean age: 59+/-12 years), 54 diabetes mellitus patients without hypertension (DM, 24 men and 30 women; mean age: 60+/-9 years), 53 diabetes mellitus patients with hypertension (DM+HTN, 23 men and 30 women; mean age: 61+/-7 years), and 49 normal subjects (22 men and 27 women; mean age: 56+/-13 years). We used echocardiography that was comprised of the standard 2-dimensional and conventional Doppler imaging for estimating the left ventricular mass index (LVMI), the relative wall thickness (RWT) and the Doppler-derived myocardial performance index (MPI, Tei index). Subjects were considered to have normal geometry (NG) if both the LVMI and RWT were normal (LVMI < or = 104 g/m2 in females, LVMI < or = 116 g/m2 in males, RWT < or = 0.43), concentric hypertrophy (CH) if both were elevated, eccentric hypertrophy (EH) if the LVMI was elevated and the RWT was normal, and concentric remodeling (CR) if the LVMI was normal and the RWT was elevated. RESULTS: The Tei index was significantly higher in the patients with essential hypertension and diabetes, especially in the DM+HTN group (HTN=0.48+/-0.13; DM=0.41+/-0.09; DM+HTN=0.53+/-0.11), as compared to the controls (0.31+/-0.11, p<0.05). The LVMI and RWT were significantly higher in the patients with essential hypertension and diabetes, and especially in the DM+HTN group (HTN=132.2+/-44.4 g/m2 and 0.45+/-0.11; DM=125.9+/-34.4 g/m2 and 0.44+/-0.07; DM+HTN=153.9+/-42.9 g/m2 and 0.48+/-0.07), as compared to the controls (108.9+/-22.2 g/m2 and 0.39+/-0.05, p<0.05). CONCLUSION: Our study demonstrated the early appearance of adverse myocardial functional and geometric changes in the diabetic patients, and the study also showed that the contributory effects of diabetes to the myocardial impairment and LV hypertrophy were produced by the presence of hypertension. The Tei index is a very sensitive method for the detection and evaluation of myocardial impairment in diabetic patients.

A Case of Sigmoid Volvulus Treated by Emergency Endoscopic Reduction and Surgical Colonic Resection / 대한소화기내시경학회지

An intestinal obstruction is a common cause of acute abdominal diseases which need emergency measures. Sigmoid volvulus is one of rare causes of colonic obstruction and occupies 2~3% of its causes in Korea. Volvulus requires a prompt diagnosis and decompression in order to prevent its progression to strangulation and gangrene. Although 90% of sigmoid volvulus can be diagnosed just by plain abdominal x-ray, computed tomography or barium enema can be done for more accurate diagnoses. For the successful treatment, accurate early examination, endoscopic reduction and surgical colonic resection are required. Endoscopic reduction has low mortality but is liable to recur, whereas emergency colonic resection has little recurrence rate but a high mortality. We experienced a case of a sigmoid volvulus in a 55-year-old male who companied of sudden abdominal pain. After diagnosed as sigmoid volvulus through plain abdominal x-ray and abdominal computed tomography, endoscopic reduction was done in the early period of development, and the sigmoid resection was performed after 7 days. We report our experience with a review of the literature regarding the diagnosis and treatment of sigmoid volvulus.

A Case of Boerhaave's Syndrome after Bowel Preparation with Polyethylene Glycol / 대한소화기내시경학회지

Polyethylene glycol (Colyte(R)) electrolyte lavage solution is widely used for bowel preparataion before colonoscopy and surgery. The minor complications associated with PEG solution, i.e., nausea and bloating have been reported on. However, major complications such as PEG electrolyte lavage solution-induced Mallory-Weiss tear, esophageal rupture, asystole and aspiration have rarely been reported on. Spontaneous rupture of the esophagus (Boerhaave's syndrome) is a very rare disease and it is often diagnosed late or it is misdiagnosed because of the atypical clinical symptoms. Its mortality increases proportionally to the time between esophageal rupture and treatment. It can cause a fatal outcome unless it is treated early. We authors report here on a case of spontaneous esophageal rupture after bowel preparation with polyethylene glycol.

Microbiologic Analysis of Severe Childhood Pneumonia by Bronchoalveolar Lavage / 소아알레르기및호흡기학회지

PURPOSE: Pneumonia is rather common and benign disease in children but its course is various. Many clinicians used the empirical antibiotics to treat pneumonia without identification of causative organism. This study was performed to find the pathogenic organism from the fluid culture by bronchoscopy with BAL (bronchoalveolar lavage) in severe pneumonia patients. METHODS: We studied 21 cases (male 15, female 6) who were admitted with severe pneumonia in the Department of Pediatrics, Sunlin Hospital from March to October in 1999. These patients had no underlying disease such as immunologic deficiency. We took laboratory tests including CBC, CRP, ESR, PB smear, mycoplasmal antibody and blood culture at admission day. We performed bronchoscopy with BAL, and wet smear and culture of that fluid. RESULTS: Organisms were cultured in nineteen cases out of 21 cases. Seven cases of Streptococcus mitis, five of Stenotrphomonas maltophilia, five cases of Streptococcus oralis, two of Moraxella species, two of Acinetobacter junii, one of Acinetobacter spesies, one Staphylococcus hominus, one alpha-h-Streptococcus, one Klebsiella pneumoniae, one Pseudomonas aeruginosa, one Enterobacter cloacae. Two organisms were cultured in nine cases. CONCLUSION: The positive rate of BALF culture was very high (90.5%). But, further studies are necessary for the patients with severe pneumonia preceded the use of antibiotics.