Fatal Biliary-Systemic Air Embolism during Endoscopic Retrograde Cholangiopancreatography: A Case with Multifocal Liver Abscesses and Choledochoduodenostomy

We report a rare case of a massive fatal embolism that occurred in the middle of endoscopic retrograde cholangiopancreatography (ERCP) and retrospectively examine the significant causes of the event. The patient was a 50-year old female with an uncertain history of previous abdominal surgery for multiple biliary stones 20 years prior. The patient presented with acute right upper quadrant pain. An abdominal computed tomographic (CT) scan revealed the presence of multiple stones in the common bile duct (CBD) and intra-hepatic duct (IHD) with biliary obstruction, multifocal liver abscesses, and air-biliarygram. Emergency ERCP showed a wide and straight opening of choledochoduodenostomy, which may have been created during a previous surgery, and multiple filling defects in the CBD. With the use of a forward endoscope, mud stones were extracted through the opening of the choledochoduodenostomy. Cardiac arrest suddenly developed during the procedure, and despite immediate resuscitation, the patient died due to a massive systemic air embolism. We reviewed previously reported fatal cases and accessed factors facilitating air embolisms in this case.

Bacterial etiology in hospitalized patients with acute exacerbations of chronic obstructive pulmonary disease / 대한내과학회지

(AECOPD). While critically ill patients requiring admission need proper antibiotic treatment for the causative pathogen, little is known about the bacterial etiology of AECOPD in Korea. We therefore studied the bacterial etiology of hospitalized patients with COPD in our institution. METHODS: The study enrolled 149 patients who were admitted to the hospital in Sungnam with the diagnosis of AECOPD between July 1, 2004 and June 1, 2007. We retrospectively reviewed the clinical data and results of sputum cultures. RESULTS: Of the 149 subjects with sputum collected, 51% (76 cases) had positive bacterial cultures [age 70.7+/- 9.2 years (mean+/- SD); 116 males] of sputum. Pseudomonas aeruginosa (24 cases, 30.4%) was the organism cultured in sputum most commonly, followed by Streptococcus pneumonia (15 cases, 18.9%), Acinetobacter sp. (9 cases, 11.4%), and Klebsiella pneumonia (7 cases, 8.9%). Patients whose FEV1 was 50% (17/96 vs. 4/53, respectively, p=0.002). Patients taking systemic steroids also had a higher rate of sputum culture of P. aeruginosa (85.7%). CONCLUSIONS: P. aeruginosa was the pathogen most commonly isolated in hospitalized patients with COPD. This species should be considered when physicians select empirical antibiotics to treat patients with AECOPD.

The Usefulness of Angiotensin Converting Enzyme in the Differential Diagnosis of Crohn's Disease and Intestinal Tuberculosis

BACKGROUND: Since the pathologic findings of Crohn's disease (CD) and intestinal tuberculosis (IT) overlap to a large degree, the development of other biomarkers will be of great help for making the differential diagnosis of these 2 diseases. The aim of the present study is to examine the clinical efficacy of using the tissue angiotensin converting enzyme (ACE) assay in making the differential diagnosis between CD and IT. METHODS: Tissue specimens were obtained from 36 patients who were diagnosed with CD or IT by the colonoscopic biopsy, as well as by the clinical findings. The expression of tissue ACE was detected by immunohistochemical staining. The optimal cut-off value of the immunoreactive scoring (IRS) system we used to differentiate CD from IT was determined by analysis of the ROC curve and AUROC. RESULTS: Granuloma was present in 15 of 19 patients with CD (78.9%) and in 15 of 17 patients with IT (88.2%). ACE was present in the cytoplasm of the epithelioid cells in the granulomas from 13 of 15 patients with CD and in 14 of 15 patients with IT. The IRS scores of ACE were greater in the patients with CD than that of the patients with IT (8.07+/-4.38 vs. 4.13+/-2.47, respectively, p=0.006). In differentiating CD from IT, the AUROC curve for the IRS of ACE was 0.767 with a sensitivity of 66.7%, a specificity of 93.3% and the cut-off point was 7.5. CONCLUSIONS: The results of our study suggest that the assessment of the tissue ACE expression can be helpful for making the differential diagnosis between CD and IT.

A Case of Coronary Artery Aneurysm after Sirolimus-Eluting Stent Implantation

This report describes the case of a 26-year-old male diagnosed with angina on exertion. A diagnostic coronary angiography revealed significant luminal narrowing at the middle third of the left anterior descending artery and proximal circumflex artery. The patient underwent implantation of sirolimus-eluting stents. Eight months after implantation of the stents, a follow-up coronary angiography showed intrastent coronary artery aneurysms. We suggest that the implantation of the sirolimus-eluting stent caused late formation of a coronary artery aneurysm.