A Case of Signet-ring Cell Carcinoma of the Ampulla of Vater / 대한소화기내시경학회지

Signet-ring cell carcinoma of the ampulla of Vater is so rare that only 16 cases have been reported. Here we report a case of a 47-year-old man with signet-ring cell carcinoma in the ampulla of Vater. The patient was hospitalized for right upper quadrant abdominal pain and jaundice which had developed 10 days prior. Computed tomography (CT) and ultrasonography (US) revealed dilatation of the common bile duct and the intrahepatic bile duct. On duodenoscopy, a bulging mass with an irregular margin in the major papilla was noted. Histologic findings showed a signet-ring cell carcinoma. Surgical resection was not done because lymph node metastasis was noted during the operation. Hence, conservative treatment including chemotherapy and bile drainage was done.

The Adequate Induction Dose of Propofol for Conscious Sedation During Esophagogastroduodenoscopy in Persons 60 Years or Older / 대한소화기내시경학회지

BACKGROUND/AIMS: Propofol is an effective sedative drug in endoscopic procedures, but it has potentially serious adverse effects, so close monitoring of the vital signs should be performed during endoscopy. This study was undertaken to determine the adequate induction dose of propofol for safe and effective sedation during esophagogastrodudenoscopy (EGD) in persons 60 years or older. METHODS: Three hundred patients who visited our hospital for EGD were randomly assigned to three groups (A,B and C). An initial induction dose of 0.5 mg/kg, 0.75 mg/kg and 1.0 mg/kg of propofol was allocated to groups A, B and C, respectively. RESULTS: The 0.5 mg/kg, 0.75 mg/kg and, 1 mg/kg dose of propofol were all safe as an initial dose of propofol for achieving sedation during EGD in persons 60 years or older. There was no difference in the total amount of propofol among the three groups. Group C had a significantly shorter induction time and a lower dose was required for an additional injection of propofol without increasing adverse events, as compared to the two other groups. CONCLUSIONS: We suggest that 1 mg/kg of propofol is an effective induction dose for sedation during EGD in persons 60 years or older.

The Adequate Dose of Propofol for Inducing Sedation during Performance of Upper Gastrointestinal Endoscopy in Koreans / 대한소화기내시경학회지

BACKGROUND/AIMS: Propofol sedation is increasingly being used when performing upper gastrointestinal endoscopy because of its rapid onset and good recovery profile. For achieving safe sedation during endoscopy, close monitoring of the vital signs is necessary because of the sedation's potentially serious adverse effects. There are only a few studies on the induction of sedation with using propofol for endoscopy in Korea. The present study was undertaken to evaluate the adequate initial injected dose of propofol for achieving safe and effective sedation when performing upper gastrointestinal endoscopy in Koreans. METHODS: From March 2008 to July 2008, 150 subjects who visited Kwangju Christian Hospital were randomized into 3 groups. An initial bolus dose of 0.5 mg/kg, 1.0 mg/kg and 1.5 mg/kg of propofol was allocated to groups A, B and C, respectively. The effectiveness and safety profiles of each injected dose of propofol were prospectively assessed by measuring various parameters of the vital signs and the adverse events. RESULTS: Group C had a significantly shorter induction time and the patients in group C did not require additional injections of propofol without increasing adverse events, as compared to that of the other 2 groups. CONCLUSIONS: 1.5 mg/kg of propofol was found to be more appropriate than 0.5 mg/kg or 1.0 mg/kg of propofol as the initial injected dose for induction of sedation during performance of upper gastrointestinal endoscopy in Koreans.

A Case of an Eosinophilic Granuloma Mimicking a Submucosal Tumor in the Ascending Colon Probably Caused by Anisakis / 대한소화기내시경학회지

Anisakiasis in the gastrointestinal tract is caused by the ingestion of raw marine fish that contain Anisakis lavae. In rare cases, Anisakiasis is found as an eosinophilic granuloma that mimics a submucosal tumor. The diagnosis is usually made after surgical resection. Several cases of gastric anisakiasis imitating a submucosal lesion have been reported. However, colonic anisakiasis forming a submucosal lesion is very rare and only a few cases have been reported. All of the cases were confirmed after surgery. Recently, we encountered a male patient with a submucosal lesion on the ascending colon during a health screening. Several biopsies were performed on the same site as the lesion. The pathological finding was eosinophilic granuloma. We tentatively diagnosed the patient with eosinophilic granuloma due to Anisakis as the patient consumed raw seafood and eosinophilia was detected on a laboratory test. We decided not to perform any procedure. One month later, the eosinophilic granuloma disappeared as seen on a follow-up colonoscopy.

A Case of Refractory Esophageal Stricture Induced by Lye Ingestion and Treated by Temporary Placement of Newly Designed Self-Expanding Metal Stent and Wetting with Mitomycin C / 대한소화기내시경학회지

Ingestion of strong acids or strong alkalies may produces severe inflammation on the mucosa of the esophagus and this may also causes esophageal stricture. Several forms of non-operative dilatations have been utilized for the treatment of esophageal stricture and they have shown good results. Yet some patients do not achieve acceptable symptom relief despite of intensive dilatation. Temporary placement of esophageal stent has recently been used in some of these patients. Furthermore, mitomycin C has been used as a conservative treatment for refractive esophageal stricture in children, yet its efficacy has not been well established. We experienced a case of a 64-year old man with severe, recurrent esophageal stricture, and this was successfully managed by temporary placement of an esophageal stent, together with a spray of mitomycin C. We report on this case along with the review of the literature.

A Case of Pneumoperitoneum, Pneumoretroperitoneum, Pneumomediastinum, and Subcutaneous Emphysema after Endoscopic Submucosal Resection / 대한소화기내시경학회지

Flexible fiberoptic colonoscopy is extensively used for the diagnosis and management of colorectal disease. Many possible complications can occur. The most common and most serious complications are hemorrhage, perforation and respiratory problems. Colonic perforation usually results in a fatal and emergent condition. However, management of iatrogenic colonic perforation has been controversial. The choice between the medical versus the surgical approach has been dependent on the mechanism of the perforation, bowel preparation, location, size of the defect and severity of symptoms. We report here a case where colonic perforation emerged during endoscopic submucosal resection of a rectal tumor. The rectal perforation was accompanied with pneumoperitoneum, subcutaneous emphysema, pneumoretroperitoneum and pneumomediastinum. As the bowel preparation was excellent, intravenous antibiotics and total parenteral nutirition were administered. The patient was treated successfully without any complications.

A Case of Pneumoperitoneum, Pneumoretroperitoneum, Pneumomediastinum, and Subcutaneous Emphysema after Endoscopic Submucosal Resection / 대한소화기내시경학회지

Flexible fiberoptic colonoscopy is extensively used for the diagnosis and management of colorectal disease. Many possible complications can occur. The most common and most serious complications are hemorrhage, perforation and respiratory problems. Colonic perforation usually results in a fatal and emergent condition. However, management of iatrogenic colonic perforation has been controversial. The choice between the medical versus the surgical approach has been dependent on the mechanism of the perforation, bowel preparation, location, size of the defect and severity of symptoms. We report here a case where colonic perforation emerged during endoscopic submucosal resection of a rectal tumor. The rectal perforation was accompanied with pneumoperitoneum, subcutaneous emphysema, pneumoretroperitoneum and pneumomediastinum. As the bowel preparation was excellent, intravenous antibiotics and total parenteral nutirition were administered. The patient was treated successfully without any complications.

Three Cases Of Gas-Forming Liver Abscesses Successfully Treated By Early Pigtail Catheter Drainage / 대한내과학회지

Many advances, including the development of antibiotics, the advent of diagnostic techniques and the use of nonsurgical drainage have decreased the mortality rate of pyogenic liver abscess. But, early prompt diagnosis and proper treatment is mandatory in gas-forming pyogenic liver abscess because it may run a fulminating course to death. Gas-forming pyogenic liver abscess mostly occurred to old diabetics. Symptoms of duration are shorter and the prognosis is poorer in the gas-forming than in the non-gas-forming liver abscess. We report three cases of gas-forming pyogenic liver abscess which occurred in old diabetic patients. They were successfully managed by parenteral antibiotics and early percutaneous drainage under sonographic guidance. Early and adequate drainage of pus by pigtail catheter may play a crucial role on the treatment of gas-forming liver abscess.

A case of gastric adenocarcinoma presented as internal jugular vein thrombosis / 대한내과학회지

The migratory thrombophlebitis and thromboembolic disorders of the venous and arterial systems in the setting of malignancy are termed Trousseau's syndrome. The overall incidence of clinical thromboembolic events in patients with cancer has been reported to vary between 1~11%. Pancreatic carcinoma has been associated with the greatest risk of thromboembolic events. Other tumor type also prone to an increased risk of thromboembolic events, including lung, prostate, stomach, acute leukemia and colon cancer. Hypercoagulability associated cancer may result from activation of coagulation, injury to the endothelium, or alteration of blood flow. Unlike other coagulopathies, Trousseau's syndrome may manifest with thromboses in unusal areas, including the upper extremities, face and visceral organs. Neck vein thrombosis associated with distant cancers have been rarely reported. Jugular vein thrombosis associated with gastrc cancer is very rare. We report one case of gastic adenocarcinoma presented as internal jugular vein thrombosis.

A case of cholangiocarcinoma associatd with neurofibromatosis type 1 / 대한내과학회지

Neurofibromatosis is characterized by multiple cutaneous neurofibromas, cafe-au-lait spots and a broad spectrum of clinical, pathologic and radiologic finding. The incidence of malignant neoplasms complicating neurofibromatosis has never been satisfactorily estabilished ; estimates range from 3% to 15%. The malignant tumors are usually derived from neural crest tissue. Gastrointestinal involvement appears to be rare and usually consists of neurofibromas, ganglioneuromas and leiomyomas. Hepatobiliary involvement in neurofibromatosis is rare and mostly located at the periampullary region. Most of theses tumors are carcinoids or less frequently neurofibromas. The authors report a case of peripheral cholangiocarcinoma associated with neurofibromatosis type 1.

A Study on the Usefulness of ERCP in Patients with Pyogenic Liver Abscess / 대한소화기내시경학회지

BACKGROUND/AIMS: This study was undertaken to evaluate the usefulness of ERCP in patients with pyogenic liver abscess. METHODS: An endoscopic retrograde cholangiographic study of 70 consecutive cases of pyogenic liver abscess was conducted during the period from January, 1993 to December, 1997. Among 70 cases of pyogenic liver abscess, the male to female ratio was 1.69 :1, and the peak incidence was in the sixth decade. RESULTS: The common associated diseases were liver cirrhosis (11.4%), diabetes mellitus (8.5%), and malignancy (5.7%). The most common origins of the abscess in decreasing order of frequency were, transbiliary infection (51%), hematogenous spread, and trauma-associated causes. The ascending infection through the biliary tract as the etiology of liver abscess, has been common since the 1970's. The positive rate of abdominal US, CT, and ERCP in the diagnosis of the etiology of the liver abscess was 68, 82, 84% respectively. The treatments of the pyogenic liver abscess were, surgical drainage in 15 cases (21%) and percutaneous drainage in 51 cases (73%). Among 70 patients treated for pyogenic liver abscess, 12 patients had CBD stones and 11 patients were cured by EST. CONCLUSIONS: The most common origin of liver abscess is ascending infection through the biliary tract and ERCP may be a effective tool in the assessment and management of the etiology of pyogenic liver abscess.

A Case of a Budd-Chiari Syndrome Associated with a Large Atrial Thrombus in Antithrombin Deficiency and Antiphospholipid Syndrome / 대한혈액학회지

Antiphospholipid antibody is associated with a clinical syndrome of vascular thrombosis, thrombocytopenia, recurrent fetal loss and cerebrovascular accident whether or not the clinical diagnosis of SLE coexists. Antithrombin deficiency leads to thromboembolism in the venous system. It develops an asymptomatic venous occlusion in many cases, but when it develops cerebral venous thrombosis, mesenteric venous thrombosis or Budd-Chiari syndrome, it leads to special clinical problems. We report the finding of a low anti-thrombin level and IgM anticardiolipin antibody in a patient who has had episodes of a large thrombus in the right atrium and Budd-Chiari syndrome due to the thrombus.

Diagnostic Utility of Endoscopic Ultrasonograpy (EUS) for Common Bile Duct (CBD) Stones not Confirmed by Endoscopic Retrograde Cholangiopancreatography (ERCP) / 대한소화기내시경학회지

BACKGROUND AND AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is the best imaging procedure for the diagnosis of common bile duct (CBD) stones. But the difficulties of diagnosis are mostly due to problems involving cannulation, microlithiasis and pancreatitis etc. The diagnostic utility of endoscopic ultrasonography (EUS) for the diagnosis of CBD stones not detected by ERCP was retrogradely assessed in 8 patients. METHODS: All the patients (N=98) underwent ERCP, and in the case where CBD stones were not confirmed by ERCP, EUS was performed. Final diagnosis was determined by ERCP with an endoscopic sphincterotomy (EST) or operative exploration. RESULTS: 98 patients with CBD stones were studied. The first ERCP successfully imaged CBD stones in 90 patients and an EST was performed in 84 patients. In 6 patients, stones were removed through operative exploration. ERCP images were incomplete or of poor quality in 8 patients. EUS images were excellent or good in all 8 cases, where ERCP was ineffective. Factors associated with incomplete results for CBD stones included; inability to cannulate the ampulla of Vater (N=1), nonvisualized CBD (N=4), microlithiasis (N=2), and association with the periampullary fistula (N=1). The second ERCP and EST successfully confirmed the diagnosis of CBD stones in 6 patients. In 2 patients, operative exploration was needed to confirm the diagnosis of CBD stones. CONCLUSIONS: An EUS appears to be an accurate and useful diagnostic tool for assessing CBD stones in cases where an ERCP was ineffective.

A Case of Squamous Cell Carcinoma of the Common Bile Duct / 대한소화기내시경학회지

A 57-year-old female with jaundice and right upper quadrant abdominal pain, was found on exploration to have squamous cell carcinoma of the common bile duct. Squamous cell carcinoma of the common bile duct is a very rare tumor, simulating adenocarcinoma in its clinical presentation and aggressiveness. Although no consistent causative factors for this tumor has been demonstrated, it has been theorized that the normal columnar epithelium of the bile duct under the influence of an inflammatory stimulus, can develop into squamous epithelium with the ongoing process leading to squamous metaplasia, and eventually carcinoma. Cholelithiasis has been implicated as a cause for bile duct cancer, which was manifested in this patient. The prognosis of this carcinoma was grave, despite all forms of surgical and medical management. A case of squamous cell carcinoma of the common bile duct is reported with a review of relevant literature.

A Case Report of Esophageal Involvement in Behcets Disease / 대한소화기내시경학회지

Behcet's disease is a recurrent and multisystemic disorder which usually persists over many years and is classified under vasculitic syndrome. A classic triad in this disorder is composed of a recurrent oral ulcer, genital ulceration and uveitis. While intestinal Behcet's disease most commonly affects the ileoecal region, dysphagia associated with esophageal ulceration is very uncommon. A 34-year-old-female patient visited our hospital because of dysphagia, epigastric pain and fever. The patient had ulcers on the oral mucosa, soft palate and extemal genitalia. Multiple irregularly marginated ulcers surrounded with hyperemic edematous mucosa were found on the middle and distal esophagus and lesser curvature of the stomach by an esophagogastroduodenoscopic examination. The pathologic findings were non-specific ulcers with necrotizing vasculitis in the vulva and with suspicious vasculitis in the esophagus. So she was diagnosed to have a Behcets disease and was treated with steroid and sulfasalazine. In this study we report a case of esophageal involvement of Behcet's disease with a review of the literature.

A Case of Chronic Neutrophilic Leukemia with Multiple Myeloma / 대한혈액학회지

Chronic neutrophilic leukemia(CNL) is a rare disorder characterized by persistent neutrophilia of mature cell type without evidence of infection, hepatosplenomegaly, elevated neutrophil alkaline phosphatase score and the absence of Philadelphia chromosome We report a typical case of CNL with multiple myeloma(IgG-lambda type) in 68 years old female. Many neutrophils had toxic granule and vacuole. The peripheral blood smear showed neutrophlic leukocytosis(50,940/microliter, neutrophil 94%) with rare immature form. The cytogenetic study showed normal karyotype without Philadelphia chromosome. She was diagnosed as multiple myeloma with paraproteinemia, lytic bone lesion of skull, and immature plasma cells in bone marrow.

A Case of Spontaneous Regression of Small Cell Lung Cancer / 대한암학회지

Small cell lung cancer is the most aggressive tumor among lung cancers and has a greater tendency to be widely disseminated by the time of diagnosis. Without treatment, the median survial time of small cell lung cancer patients is only 2~4 months. However, though spontaneous regression of the malignant tumor has been frequently reported, spontaneous regression of the small cell lung cancer is rare. In this study a spontaneous regression of the small cell lung cancer is reported, along with a brief review of the literature. A 69 year-old woman was admitted for an evaluation for dyspnea. A chest roentgenogram obtained on admission revealed an abnormal mass shadow at the right hilus. She was diagnosed as having small cell lung cancer through a bronchoscopic biopsy. However this tumor regressed spontaneously without specific treatment after 12 months.

Endoscopic Ligation Therapy for Upper Gastrointestinal Bleeding / 대한소화기내시경학회지

Upper gastrointestinal bleeding occurs so rapidly that emergency measures are required to avoid exsanguination. Many diseases cause bleeding from the gastrointestinal tract. Patients with upper gastrointestinal bleeding must be quickly assessed and resuscitated. An endoscopy is the diagnostic procedure of choice because of its high rate of accuracy and immediate therapeutic potential. An endoscopy however, must be performed only following adequate resuscitation and clinical assessment of the patient. Recently, reports have described the usefulness of endoscopic O-ring band ligation in the management of upper gastrointestinal bleeding. Endoscopic O-ring band ligation is mucosal ligation using intraluminal negative pressure with an elastic O-ring. We performed an emergency endoscopy in 3 patients who had massive or recurrent episodes of upper gastrointestinal bleeding, identified as having resulted from Dieulafoy lesion and Anisakiasis. We tried to perform an endoscopic ligation using an O-ring band, and were successful in achieving hemostasis. Our conclusion is that endoscopic ligation using an O-ring band can be used effectively to control active upper gastrointestinal bleeding resulting from Anisakiasis and a Dieulafoy lesion.