Hepatic portal venous gas in paralytic ileus / 영남의대학술지

Hepatic portal venous gas (HPVG) is a rare radiographic finding associated with severe intra-abdominal disease and fatal outcome. Most cases of HPVG are historically related to mesenteric ischemia accompanied by bowel necrosis. The current spread of computed tomography scan promotes not only the early detection of related severe diseases but also the identification of other causes of HPVG. It has been reported in many non-fatal conditions, such as inflammatory bowel disease, intra-abdominal abscess, bowel obstruction, paralytic ileus, endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy, and gastric dilatation. Among these, paralytic ileus is a very rare condition, with no case yet reported in South Korea. Reported herein is a case of HPVG in paralytic ileus, which was treated well internally and was promptly resolved.

A Case of Recurrent Liver Abscess Due to Choledochoduodenal Fistula / 영남의대학술지

Cholelithiasis, duodenal ulcer, duodenal perforation and tumor invasion may lead to choledochoduodenal fistula (CDF). CDF often has no specific symptoms and may be incidentally detected in an upper gastrointestinal radiographic study or endoscopy; but in some cases, it may be accompanied by recurrent cholangitis and liver abscess. In this paper, a case of recurrent liver abscess caused by CDF is reported. A 62-year-old female was admitted to the authors' hospital because of right upper quadrant pain and fever. The abdominal computed tomography showed a liver abscess in the right lobe. A duodenal fistulous orifice was detected with endoscopy, and a contrast was injected through the duodenal orifice using a catheter under fluoroscopy. The injection of the contrast revealed a fistulous track between the duodenal bulb and the common hepatic duct. In fistulas complicated by recurrent liver abscess, surgery or medical management may be needed. The CDF in this case study was treated via endoscopic clipping.

A Case of Gastric Glomus Tumor / 영남의대학술지

Gastric glomus tumor is a rare mesenchymal tumor that originates from modified smooth muscle cells of the glomus body. Glomus tumors are commonly observed in peripheral soft tissue, such as dermis or subungal region, but rarely in the gastrointestinal tract. A 39-year-old woman was admitted due to epigastric soreness. Upper gastrointestinal endoscopy revealed a subepithelial mass measuring 3.5cm with central ulceration at the lesser curvature-posterior wall of the antrum. Characteristically, contrast enhanced abdominal computed tomography scan demonstrated high enhancement of the submucosal mass up to the same level of the abdominal aorta in the arterial phase; this enhancement persisted to delayed phase. Due to the risk of bleeding and malignancy, wedge resection of the submucosal tumor was performed. Histologic findings were compatible with a glomus tumor.

A Case of Gastric Wall Hematoma and Ischemic Necrosis After Endoscopic Biopsy / 영남의대학술지

Hematoma of gastric wall is very rare, and occasionally associated with coagulopathy, trauma, peptic ulcer disease, and therapeutic endoscopy. Ischemic gastric necrosis is also rare because of the abundant anastomotic supply to the stomach, and it is usually associated with surgery and disruption of the major vessels. Endoscopic submucosal injection of hypertonic saline-epinephrine (HS-E) is a safe, cost-effective, and widely used therapy for hemostasis but it may cause tissue necrosis and perforation. We describe a case of gastric wall hematoma with oozing bleeding after endoscopic gastric mucosa biopsy in 71-year old woman with chronic renal failure and angina pectoris undergoing anti-platelet medication. We injected a small dose of HS-E (7ml) for controlling oozing bleeding. Two days later, endoscopy showed huge ulcer with necrotic tissue at the site of previously hematoma. Therefore we should pay particular attention for hematoma and mucosal necrosis when performing endoscopic procedure in a patients with high bleeding and atherosclerotic risk.

A Case of Ischemic Colitis by Oral Sulfate Free-Polyethylene Glycol

Ischemic colitis is the most common form of gastrointestinal ischemia. Factors that can contribute to the development of ischemic colitis include atherosclerosis, congestive heart failure, sustained hypovolemia, vasculitis, and mechanical colonic obstruction. Also, pharmacologic agents, including diuretics, pseudoephedrine, non-steroidal anti-inflammatory drugs, and oral contraceptives may be the cause of colonic ischemia. Oral sulfate-free polyethylene glycol (SF-PEG, Colyte-F(R)) has frequently been used as a cleaning agent in bowel preparation for colonoscopy. Some cases of ischemic colitis produced by oral hyperosmotic laxatives have been reported; however, no case has been reported regarding ischemic colitis caused by SF-PEG. Herein we report a rare case of ischemic colitis caused by oral sulfate-free polyethylene glycol, which was given for bowel preparation before colonoscopy in a 70-year-old man with chronic constipation.

A Case of Ischemic Colitis by Oral Sulfate Free-Polyethylene Glycol

Ischemic colitis is the most common form of gastrointestinal ischemia. Factors that can contribute to the development of ischemic colitis include atherosclerosis, congestive heart failure, sustained hypovolemia, vasculitis, and mechanical colonic obstruction. Also, pharmacologic agents, including diuretics, pseudoephedrine, non-steroidal anti-inflammatory drugs, and oral contraceptives may be the cause of colonic ischemia. Oral sulfate-free polyethylene glycol (SF-PEG, Colyte-F(R)) has frequently been used as a cleaning agent in bowel preparation for colonoscopy. Some cases of ischemic colitis produced by oral hyperosmotic laxatives have been reported; however, no case has been reported regarding ischemic colitis caused by SF-PEG. Herein we report a rare case of ischemic colitis caused by oral sulfate-free polyethylene glycol, which was given for bowel preparation before colonoscopy in a 70-year-old man with chronic constipation.

A Case of Plummer-Vinson Syndrome in an Elderly Patient / 대한소화기내시경학회지

Plummer-Vinson syndrome is a complex syndrome characterized by upper esophageal webs, dysphagia, and iron deficiency anemia. This syndrome develops principally in middle-aged women, and only rarely in patients over age 80. We present a case of Plummer-Vinson syndrome occurring in an 82-year-old woman who visited the hospital because of progressive dysphagia. Esophagogram and endoscopic examination showed an upper esophageal web, and laboratory examination revealed iron deficiency anemia. Dysphagia improved after endoscopic balloon dilatation, and iron deficiency anemia improved after iron supplementation. Even Plummer-Vinson syndrome can be improved by sufficient amounts of oral ferrous sulfate and endoscopic balloon dilatation, it is important to identify the cause of iron deficiency anemia and to check for the presence of malignant disease. The common causes of anemia differ between middle-aged and elderly women, and the clinician needs to look for malignancy-induced chronic gastrointestinal tract blood loss and chronic inflammatory diseases. We report a rare case of Plummer- Vinson syndrome in a woman over 80 years of age.

Two cases of infliximab treatment in Patients with Behcet's disease and intractable colon ulcers / 대한내과학회지

Behcet's disease is a chronic disease characterized by recurrent systemic vasculitis. The pathogenesis remains unclear. This disease involves various organs of the body and it can have a variety of symptoms with an unpredictable course. The diagnosis of Behcet's disease is made in patients with oral and genital ulcers and uveitis. In addition, gastrointestinal symptoms are frequently present; however, intestinal ulcers are infrequent. The most common extra-oral sites of gastrointestinal involvement are ileocecal and colon lesions. The lesions are typically resistant to medical treatment and frequently recur after surgical treatment. Here we present two cases treated with the monoclonal antibody anti-tumor necrosis factor (TNF) and regression of all symptoms.

A Case of Mucosal Necrosis of the Stomach after Endoscopic Injection Therapy with Hypertonic Saline-Epinephrine (HS-E) for a Bleeding Peptic Ulcer with an Exposed Vessel / 대한소화기내시경학회지

Peptic ulcer bleeding is a frequent cause of upper G-I bleeding. Endoscopic injection therapy with hypertonic saline-epinephrine (HS-E) is a cost-effective and widely used therapy for hemostasis; however, 1~3% of patients experience bleeding or perforation. A 70 year-old male patient was admitted with melena and hematemesis. An endoscopy on admission showed the presence of a 1 cm- sized well-demarcated ulcer with pulsatile bleeding at the lesser curvature of the distal antrum. Approximately 28 mL of HS-E solution was injected around the exposed vessel. Follow-up endoscopy performed 7 days later showed the presence of a 2 cm-sized newly developed mucosa necrosis at the lesser curvature of the pyloric channel, which was caused by ischemic necrosis of the gastric mucosa after HS-E injection. Endoscopic injection therapy with HS-E solution is a relatively safe technique, but mucosa necrosis can occur with the use of a dose of HS-E that is considered safe. We report a case of gastric mucosa necrosis following endoscopic HS-E injection therapy of a bleeding peptic ulcer.

Remission of intestinal Behcet's disease treated with anti-tumor necrosis factor alpha monoclonal antibody (Infliximab)

Behcet's disease (BD) is a chronic relapsing multisystem disease characterized by oral ulceration, genital ulceration and ocular lesions. Gastrointestinal involvement is rare, often difficult to treat and associated with a high mortality rate. We treated a 47-year-old Korean man with BD who had a recurrent intestinal ulcer with tumor necrosis factor alpha antibody (infliximab); he initially underwent right hemicolectomy due to uncontrolled intestinal bleeding. For patients with intestinal BD who fail to respond to conventional treatment, infliximab may be a safe and effective new therapeutic option.

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.

The Causes and Endoscopic Management of Bile Leak / 대한소화기내시경학회지

BACKGROUND/AIMS: This study evaluated the efficacy of endoscopic treatment in a bile leak that occurred through various causes. METHODS: The medical records of 35 patients (mean age 55.4 years; male/female 25/10), who were diagnosed with a bile leak by endoscopic retrograde cholangiopancreatography in Yeungnam University Hospital from January 1998 to January 2006, were reviewed. RESULTS: The most common cause of the bile leak was an open cholecystectomy (n=13, 37.1%) followed by a laparoscopic cholecystectomy (n=10, 28.6%), trauma (n=2, 5.7%), transarterial chemoembolization (n=3, 8.6%), spontaneous (n=3, 8.6%), and a hepatic resection (n=4, 11.4%). Thirty-four patients were treated endoscopically by the insertion of a plastic stent with/without a sphincterotomy (70.6%, 24/34), a nasobiliary drainage (11.8%, 4/34), or a sphincterotomy alone (17.6%, 6/34). Of these 34 patients, 30 were cured by the endoscopic treatment, 2 patients died from liver failure despite the use of nasobiliary drainage and 2 patients did not improve after endoscopic treatment. One patient underwent surgery without endoscopic treatment because of a transsection of the common bile duct. With the exception of the two who died from liver failure, the overall cure rate of endoscopic treatment was 90.9% (30/33). There were no complications associated with the endoscopic treatment. CONCLUSIONS: Endoscopic treatment for a bile leak is safe and effective regardless of the cause.

A Case of Gastrogastric Fistula as a Complication of Benign Gastric Ulcer / 대한소화기내시경학회지

Gastrogastric fistula is an extremely rare complication of benign gastric ulcer. We report a case of gastrogastric fistula in a 67-year-old male who presented with symptoms of dyspnea on exertion, pretibial pitting edema, and dyspepsia. He suffered from a peptic ulcer 9 years ago and from a gastric outlet obstruction 5 years ago. A gastrogastric fistula was observed by endoscopy, and the biopsy forceps were passed through the fistulous tract. The patient was treated with proton pump inhibitors, and H. pylori was eradicated. Gastrogastric fistula, unlike other types of gastric fistulas, can be cured using non-surgical therapy as long as complications such as peritonitis, gastric outlet obstruction, and bleeding do not occur.

Clinical Features of Cholestatic Hepatitis / 영남의대학술지

BACKGROUND: Cholestatic hepatitis is failure of bile to reach the duodenum with hepatocellular damage and no demonstable obstruction of the major bile ducts. The prognosis of usually good with recovery in less than 4 weeks after withdrawal of the offending drug. However, a prolonged causes of Chronic liver disease is needed. MATERIALS AND METHODS: From January 1991 through January 2000, 14 patients diagnosed as cholestatic hepatitis by liver biopsy were included. The possible causative drug, clinical features, laboatory findings, and progression of cholestatic hepatitis were evaluated. The semiquantitative study of liver lesions was performed by two independent observers. RESULTS: Causes of cholestatic hepatitis are 5 cases of oriental medicine, 3 cases of anti-tuberculosis medication, 1 case of ticlopidine and antibiotics and 4 cases of unknown causes. The clinical features of cholestatic hepatitis were jaundice, itching, urine color change, and general weakness. During 6 to 50 months, LFT of 5 patients showed prolonged elevation. Elevated total cholesterol > or =250 mg/dL in 6 patients, pheripheral blood eosinophilia in 5 patients, auto-antibody positive in 6 patients were observed respectively. The biopsies showed intralobular bilirubinostasis with a mixed portal inflammatory infiltration. CONCLUSION: In chlestatic hepatitis, durations of abnormal LET are variable regardless of causative drugs. If chlestatic hepatitis progresses toward chronic course, viral hepatitis, primary biliary cirrhosis, and autoimmune hepatitis should be differentially diagnosed and sequential liver biopsies are needed.

A case of pimary malignant melanoma originated from esophageal melanosis / 대한내과학회지

Primary malignant melanoma of the esophagus(PMME) is an extremely rare but aggressive disease that composes less than 0.1% of all primary malignant neoplasm of the esophagus. PMME was first reported in 1906 and nearly 180 cases of primary esophageal malignant melanoma have been published in the medical literature. Symptoms of the primary malignant melanoma of the esophagus mimic that of any malignant obstructing lesion of the esophagus and the metastatic spread by lymphatics and vascular routes are common. Resection of the tumor with an anastomotic procedure seems to be the treatment of choice, however prognosis is poor. At present, chemotherapy and immunotherapy have no major role in treatment. We report a case of 67-year-old man with primary malignant melanoma of the esophagus originated from esophageal melanosis with a review of the literature.

Endoscopic Treatment of Bleeding Angioectasia of the Upper Gastrointestinal Tract / 대한소화기내시경학회지

BACKGROUND/AIMS: Angioectasia of the gastrointestinal tract have been recognized with increasing frequency as an important cause of acute and chronic gastrointestinal bleeding. The purpose of this study is to define the response of endoscopic treatment for bleeding angioectasia of upper gastrointestinal tract and to evaluate long term efficacy of endoscopic treatment. METHODS: A clinical study was done on 18 patients (20 cases) of angioectasia bleeding of upper gastrointestinal tract who admitted to Yeungnam University hospital from January 1989 to October 1998. Endoscopic therapy was done by electrocauterizaton, laser therapy, O-band ligation. In cases of failure to achieve hemostasis after endoscopic retreatment, we have done operation or used antifibrinolytic agent. RESULTS: The mean age was 60.6+/-11.2 years (range 31-77 years). Bleeding control was succeeded in 19 cases and one case was failed by endoscopic therapy. This patient was operated. Recurred bleeding was observed in 4 patients during long term follow-up period. Bleeding was controlled after endoscopic re-treatment in two of four patients. The other patients (Osler-Weber-Lendu syndrome 2 patients) were periodically required of transfusion after endoscopic therapy. Tranexamic acid was given to these patients. CONCLUSIONS: Endoscopic therapy for bleeding angioectasia could reduce bleeding or make it stop, but repeated treatment was often necessary for multiple angioectasia. Tranexamic acid may be a useful treatment for refractory bleeding due to multiple angioectasia, such as Osler-Weber-Lendu syndrome.

Endoscopic Diagnosis of Right-Sided Colonic Diverticulitis / 대한소화기내시경학회지

BACKGROUND/AIMS: Recently, it has been well known that the incidence of colonic diverticulosis is increasing in Korea. However, cases of right-sided colonic diverticulitis are rare although diverticula are located in right-sided colon more than left-side. The major clinical symptom of right-sided colonic diverticulitis is acute right lower quadrant pain which may mimic acute appendicitis. Therefore, we evaluated the clinical characteristics of the patients with right-sided colonic diverticulitis and safety of the colonoscopic examinations in these patients. METHODS: The evidence of diverticulitis was confirmed by the presence of pus at the diverticular lesions on colonoscopy. We retrospectively analyzed clinical menifestations, laboratory findings, colonoscopic findings and the presence of complications after colonoscopy, and radiologic findings of the patients with right-sided colonic diverticulitis. RESULTS: All the patients with right-sided colonic diverticulitis had abdominal pain. Physical examinations showed abdominal tenderness in all patients and leukocytosis was noticed in 8 out of 12 patients (66%). There was no complication during and after colonoscopy. All the patients were managed with conservative treatment including broad-spectrum antibiotics and improved without clinical aggravation. CONCLUSIONS: The colonoscopic examination may be helpful to diagnose right-sided colonic diverticulitis.

The Significance of Small Polyp of colon in Koreans / 영남의대학술지

BACKGROUND: There are two theories in the development of colon cancer. One is the adenoma-carcinoma sequence theory and the other is the de novo cancer theory. Western countries believe in the adenoma-carcinoma sequence theory, however there are many recent reports from Japan about cancers developing from small adenomas. METHODS: The present study analyzed 408 polyps from 508 cases that were taken by colonoscopic polypectomy at the Departmant of Internal Medicine, Yeung-Nam University Hospital. RESULTS: The percentage of patients who have polyp was 41.3%(210cases out of 526cases) and the peak incidence was noted in patients in their 50's and 60's. There was no difference between the sexes, but we noted significant increase in the incidence of polyps in patients over age of thirty. We found 395 polyps below 1cm and 13 polyps above 1cm. Among 408 polyps, 5 cases cancerous polyps and 3 cases showed polyp size of less than 1cm each. The first case was a polyp of 0.4cm in size with elevated mucosa at the ascending colon. The second was 0.5cm in size with round elevation and hyperemic mucosa in the rectum. The third polyp was 0.6cm in size with tubular elevation at the hepatic flexure. CONCLUSIONS: colon polyp is common disease in Koreans. even small polyps can have cancer tissue, which should be removed if discovered during colonoscopy. We believe that not all colon cancer originates in the manner described by the adenoma-carcinoma sequence theory. However further studies with a larger sample population are needed to determine the exact role colon polyps plays in the development of colon cancer.

Genotypes of Hepatitis C Virus and Short Term Efficacy of alpha-nterferon Therapy in Patients with HCV Infection in Taegu / 대한간학회지

BACKGROUND/AIMS: It has been reported that the difference in the hepatitis C virus (HCV) genotype due to genetic heterogeneity of HCV influence the clinical features, prognosis of HCV associated liver disease and response to interferon therapy. Prevalence of different genotypes of HCV may also vary between geographic areas. The aim of this study was to examine the relationship between the response to interferon alpha (IFN-a) therapy and HCV genotypes in patients with chronic HCV infection in Taegu and its environs. METHODS: One hundred seventy six patients known to be HCV antibody and HCV-NA positive were evaluated for HCV genotypes by restriction fragment length polymorphism. Among patients who had elevated ALT levels, 67 patients have been investigated for the role of the HCV genotype on disease outcome and the response of IFN-a therapy. RESULTS: Genotype 1b were found in 59.0% of patients (103/176), genotype 2a in 37.5% (66/176). The mode of transmission of HCV infection was guessed as transfusion in genotype 1b, but as parenteral infection in genotype 2a. According to their response to IFN-a therapy, 73 patients were divided into three groups, complete response, 18 (60%) of 30 patients with genotype 2a and 21 (48.8%) of 43 patients with genotype 1b: partial response, 5 (16.7%) of 30 patients with genotype 2a and 7 (16.2%) of 43 patients with genotype 1b: no response, 7 (23.3%) of 30 patients with genotype 2a and 15 (34.9%) of 43 patients with genotype 1b. Good response to IFN-a therapy was observed among patients group showing normal platelet count in patients with genotype 1b and normal GGT in patients with genotype 2a. CONCLUSIONS: The most frequently identified genotype was genotype 1b in Taegu and its environs, followed by genotype 2a. The HCV genotype was not a reliable predictor of response to IFN-a therapy. When a standardized regimen of IFN-a was administered, pretreatment serum platelet counts and GGT level seem to be useful predictor of IFN-a therapy in HCV infection. Further investigations are required in order to establish a correlation between viral factors and therapeutic responses.