A Case of Non-traumatic Hemobilia due to Warfarin Therapy / 대한소화기학회지

Hemobilia is a hemorrhage into the biliary tract that may follow surgical trauma, liver biopsy, aneurysms, extra- or intra-hepatic tumors of the biliary tract, gallstones, and inflammatory lesion of liver, especially helminthic or pyogenic. Sometimes, it is associated with primary liver cancer. An 84 year-old woman was admitted because of continuous right upper quadrant pain 4 days before admission. Physical examination revealed decreased skin turgor, icteric sclerae and severe tenderness on right upper quadrant abdomen. She had no hepatosplenomegaly, and no rebound tenderness. She has been taking warfarin for 3 weeks before admission because of atrial fibrillation. On admission, serum bilirubin and transaminase were elevated. The level of hemoglobin and hematocrit were 11.3 g/dL and 37.4%, respectively. HBsAg was negative, but IgG anti-HBc and anti-HBs were positive and anti-HCV was negative. Parasite skin test and stool ova count demonstrated non-specific findings. Stool occult blood was strongly positive, and prothrombin time was markedly prolonged. According to endoscopic retrograde cholangiopancreatography, common bile duct was dilated, and filled with blood clot but there was no stone in bile tree. After two weeks, serum transaminase, bilirubin, hemoglobin, hematocrit, and CA19-9 were normalized. We report a case of hemobilia, occurring in a patient with continuous warfarin use.

A Gastric Foreign Body Incidentally Diagnosed by a Follow-up Abdominal Computed Tomography for Hepatoma / 대한소화기내시경학회지

Foreign bodies in the stomach usually are accidentally swallowed and rarely produce symptoms. For diagnosis, suspicion and report of related history with abdominal symptoms are important. Simple radiographs and endoscopy easily identify foreign objects. Abdominal computed tomography may be useful in some cases, although it is not essential. We experienced a case of a gastric foreign body incidentally diagnosed by a follow-up abdominal computed tomography (CT) for hepatoma. A 53-year-old male with B viral liver cirrhosis and hepatoma, visited our hospital for a routine follow-up check of hepatoma. He had a symptom of epigastric discomfort for two weeks. An abdominal CT showed a foreign body penetrating the stomach wall, and it was successfully removed endoscopically.

Esophageal Ulcer Induced by Alendronate / 대한소화기내시경학회지

Alendronate sodium (Fosamax(R)) is an aminophosphonate used in treatment of postmenopausal osteoporosis by inhibition of osteoclastic activity. Esophageal ulcers related to alendronate use have been reported at the rate of 2~6%. However, there have been no reports of esophagitis or esophageal ulcer by alendronate in Korea. We present a case of esophageal ulcer caused by alendronate. The patient presented with retrosternal pain and severe odynophagia for a few days. Esophagogastroduodenoscopy revealed multiple deep ulcers at the esophagus. Her symptoms resolved completely after stopping alendronate. A follow-up esophagogastroduodenoscopy 6 weeks later revealed complete healing of the ulcers.

The Changes of Ammonia and Epidermal Growth Factor Concentration in Gastric Juice before and after the Helicobacter pylori Eradication / 대한소화기학회지

BACKGROUND/AIMS: Helicobacter pylori (H. pylori) infection is the cause of peptic ulcer diseases, and gastric cancer. Hydrolysis of urea generating ammonia may cause cytotoxic effects on the gastric epithelium. The ammonia may induce the synthesis of epidermal growth factor (EGF) in gastric epithelium as an adaptive cytoprotective mechanism. The first aim was to examine the concentration of ammonia and EGF in gastric juice before and after H. pylori eradication in functional dyspepsia patients. The second aim was to examine the correlation among ammonia concentration, EGF concentration, and inflammatory score of gastritis. METHODS: The concentration of ammonia and EGF were measured by ELISA. The grade and severity of gastritis were measured according to the updated Sydney system. RESULTS: The concentration of ammonia in gastric juice was much higher in the H. pylori positive subjects (10,787 +/- 6,584 micro mol/L) than in the negative subjects (2,339 +/- 1,158 micro mol/L, p<0.0001). The concentrations of EGF in gastric juice was much higher in the positive subjects (1,462 +/- 393 pg/mL) than in the negative subjects (1,088 +/- 499 pg/mL, p<0.005). The concentration of ammonia and EGF in gastric juice showed significant correlation (r=0.63, p<0.0001). The concentrations of ammonia and histologic severities showed significant correlation (r=0.41, p<0.0001). Moreover, the level of EGF in gastric juice and histologic severities showed positive correlation (r=0.20, p<0.005). CONCLUSIONS: As the concentration of ammonia in gastric juices increased, the concentration of EGF was also increased in functional dyspepsia with H. pylori infection. The concentration of EGF in gastric juice may play a role in the adaptive cytoprotection in H. pylori- induced gastritis.

A Case of Iatrogenic Rectal Perforation Repaired by Endoscopic Clipping / 대한소화기내시경학회지

Although colonoscopy is commonly performed, it is an invasive procedure that might produce complications such as hemorrhage and perforation. Colonic perforation is an abdominal emergency with high mortality requiring surgical intervention. Sometimes non-surgical teatment can be applied when perforation is small sized, located in the retoperitoneal spaces or surgical approach is impossible. We are reporting a case of colon perforation in 64-year-old female patient. The patient visited our hospital with symptoms of dizziness and dyspnea. She was anemic and we planned to find the possible cause of anemia. Rectal perforation was developed during the diagnostic colonoscopy. However the operation was not applicable due to arrhythmia and cardiogenic shock. Therefore endoscopic clipping was done at the perforation site. Afterwards nasogastric decompression, intravenous antibiotics and total parenteral nutrition were applied. She was treated successfully without any complications.

Early Diagnosis of Adenocarcinoma of the Ampulla of Vater during Treatment of Herpes Zoster / 대한소화기내시경학회지

Herpes zoster infection may herald the presence of a hidden malignancy. We encountered a case of a carcinoma of the ampulla of Vater in a 72-year-old female in which the ampullary lesion was found during a work-up for excluding certain causes of Herpes zoster infection. An esophagogastroduodenoscopy showed a polypoid mass at the ampulla of Vater. A pylorus-preserving pancreaticoduodenectomy was performed and the pathology of the resected specimen confirmed well differentiated adenocarcinoma in the background of villous adenoma. The stage of the tumor was T2N0M0. This case illustrates that it may be necessary to do some diagnostic work-ups in patients with Herpes zoster infection to exclude underlying diseases. However, the extent of the work-ups should be determined in the future based on the cost-effectiveness data.

Early Diagnosis of Adenocarcinoma of the Ampulla of Vater during Treatment of Herpes Zoster / 대한소화기내시경학회지

Herpes zoster infection may herald the presence of a hidden malignancy. We encountered a case of a carcinoma of the ampulla of Vater in a 72-year-old female in which the ampullary lesion was found during a work-up for excluding certain causes of Herpes zoster infection. An esophagogastroduodenoscopy showed a polypoid mass at the ampulla of Vater. A pylorus-preserving pancreaticoduodenectomy was performed and the pathology of the resected specimen confirmed well differentiated adenocarcinoma in the background of villous adenoma. The stage of the tumor was T2N0M0. This case illustrates that it may be necessary to do some diagnostic work-ups in patients with Herpes zoster infection to exclude underlying diseases. However, the extent of the work-ups should be determined in the future based on the cost-effectiveness data.

Clinical Features of Hepatocellular Carcinoma in the 1990s / 대한소화기학회지

BACKGROUND/AIMS: There has been a shift of the etiologies of chronic liver disease in the 1990s. Therefore, we studied clinical characteristics of hepatocellular carcinoma (HCC) in the 90s. METHODS: Medical records of 806 patients diagnosed as having primary HCC were reviewed. Etiology, clinical and laboratory characteristics were evaluated according to the time of diagnosis (the early period, 1992~1995; the late period, 1996~2000). RESULTS: The mean age was 55.7 years and male to female ratio was 4.6:1. The proportion of the symptomatic patients at the time of diagnosis was decreased from 67.4% of the early period to 41.3% of the late period. On the other hand, that of the patients detected by a periodic check-up was increased up to 58.7% in the late period from 32.6% in the early period (p<0.01). The majority of the patients accompanied cirrhosis (73.3%) and the main cause of HCC was HBV (78.6%) with no changes in the etiologic distribution according to the periods. The proportion of the candidates for surgical resection was significantly increased to 12.4% in the late period compared with 7.1% in the early period. CONCLUSIONS: Although the proportion of HCC which can be treated curatively has increased in the later half of the 1990s, its absolute number is still small. More meticulous periodic examination may be required in high risk patients.

Relationship between Esophageal Lesions Observed by Endoscopy and Nasogastric Intubation: A Study of 185 Cases of Percutaneous Endoscopic Gastrostomy / 대한소화기학회지

BACKGROUND/AIMS: Percutaneous endoscopic gastrostomy (PEG) is a method widely used for long-term enteral nutrition in dysphagia. Mostly, it is preceded by nasogastric intubation (NI) for short-term enteral nutrition; endoscopic findings associated with NI are encountered during PEG. The purpose of this study was to discuss such findings and to delineate a relationship between these findings, especially esophageal lesions and the duration of NI. METHODS: This study involved 185 individuals who had undergone PEG at Kyung Hee Medical Center from January 1999 to May 2002. The medical records were examined retrospectively. RESULTS: The dysfunction of the CNS comprised 98.4% of the causes of dysphagia. The duration of NI was 15.2 weeks on average, with median value of 8.7 weeks, indicating that PEG was performed relatively soon. Endoscopic findings revealed esophagitis in 63 cases, esophageal ulcers in 27 and active bleedings in another 10. The incidence of esophageal lesions was shown to be higher in subjects with duration of NI under 12 weeks than in those with duration over 12 weeks (p=0.032). CONCLUSIONS: PEG was carried out in many cases during the early stages of dysphagia, and NI-associated esophageal lesions appeared to be more prevalent within 12 weeks of NI duration. These results may be of help in deciding the timing of PEG.

Crohn's Disease of the Upper Gastrointestinal Tract: Endoscopic and Histologic Characteristics and Prevalence of Helicobacter pylori Infection / 대한소화기내시경학회지

BACKGROUND/AIMS: It is well known that Crohn's disease (CD) can affect all gastrointestinal tract. However, there was no report that evaluated upper gastrointestinal CD in Korea. Therefore, we assessed the endoscopic and histological characteristics of gastrointestinal CD and the prevalence of Helicobacter pylori infection in Korea. METHODS: We examined forty-six patients who were diagnosed as having CD in Kyung Hee University Hospital. We analyzed the endoscopic and histological characteristics by endoscopic examination with biopsy and the prevalence of H. pylori infection. We also investigated the immunohistochemical characteristics of the biopsy specimen and assessed the effects of medications on both histologic and bacteriologic status. RESULTS: High proportion (69.6%) of CD patients showed upper gastrointestinal mucosal alterations. Erosive endoscopic alteration was the most common finding with major involvement in the antrum and duodenum. In H. pylori negative CD patients, granuloma and focal gastritis were found in 30.6% and 44.4% of cases, respectively. There were no significant correlations between histologic features and clinical characeteristics of CD. CONCLUSIONS: We conclude that histologic demonstration of focal gastritis and/or granuloma on endoscopic biopsy specimens in oligosymptomatic patients, especially in H. pylori negative patients, might be considered as patients with possible CD.

A Case of Secondary Achalasia Presented by Diffuse Leiomyomatosis of Alport Syndrome / 대한소화기내시경학회지

Alport syndrome (AS) is one of the most common familial nephropathy characterized by microscopic hematuria with or without proteinuria, irregular thickening or thinning of the glomerular basement membrane, progressive bilateral sensorineural hearing loss and ocular changes including anterior lenticonus and retinal lecks. AS with diffuse leiomyomatosis (ASDL) is defined by the association of AS with esophageal, tracheobronchial, and genital leiomyomatosis. Since the first case of ASDL was reported in 1983, a number of cases have been reported in the western countries. ASDL has a X-linked dominant trait with different penetrance and expressivity between female and male. We experienced an ASDL who is the first case in Korea. A 13-year-old boy was diagnosed as AS by microscopic hematuria, sensorineural hearing loss and congenital cataract. And also he had suffered from achalasia symptoms such as severe dysphagia and frequent vomiting due to diffuse esophageal leiomyomatosis. The lesion was confirmed by total esophagectomy and pathologic findings.

A Case of Mesalazine-induced Eosinophilic Pneumonia in a Patient with Ulcerative Colitis / 결핵

Measlazine(5-Aminosalicylic acid, 5-ASA), a component of Sulfasalazine (sulfapyridine bound to 5-ASA), is used to treat inflammatory bowel disease. Most adverse pulmonary effects caused by sulfasalazine have been attributed to sulfapyridine. However, lung toxicity associated with measlazine(5-ASA) is rare. Here we report a case of eosinophilic pneumonia in a 44-year-old woman with ulcerative colitis, who was treated with mesalazine. She developed symptoms of a dry cough, mild night fever, and evertional dyspnea. Bilateral peripheral pulmonary infiltrates, peripheral blood eosinophilia, and histologic features were consistent with eosinophilic pneumonia. The symptoms improved quite rapidly after the discontinuation of mesalazine and initiation of steroid therapy. Therefore, adverse pulmonary reactions to mesalazine must be considered in a differential diagnosis of pulmonary involvement in patients with inflammatory bowel disease who are receiving with measlazine therapy.

Autoimmune hepatitis in a patient with myasthenia gravis and thymoma: a report on the first case in Korea

Myasthenia gravis is an autoimmune disease that results from an antibody-mediated reaction and occurs with thymoma in 15+ACU- of patients. It is very rarely associated with autoimmune hepatitis. Four cases of myasthenia gravis with autoimmune hepatitis have been reported in the world. We recently experienced a case of 30-year-old man with myasthenia gravis associated with thymoma and autoimmune hepatitis. This condition is the first case that has not been reported previously in Korea. We report this rare condition along with a brief review of the literature.

Relationship to Magnetic Resonance Signal Hyperintensity in Globus Palidus and Blood Manganese Concentration in Cirrhotic Patients with Extrapyramidal Symptoms / 대한간학회지

BACKGROUND/AIMS: Increasing evidence suggests that manganese deposition in globus pallidus is responsible for MRI signal hyperintensity and for extrapyramidal symptoms in cirrhotics. However, the relationships between blood manganese, the severity of liver dysfunction, the pallidal signal intensity, and neurological signs have not been well established. METHODS: Blood manganese concentrations were measured together with brain MRI and neurological evaluation in six controls, six patients with Parkinson's disease with normal liver function, and fourteen cirrhotic patients with hepatic encephalopathy including six cirrhotics with extrapyramidal symptoms. The neurological state was evaluated using the Columbia scale and the pallidal index (PI). The ratio of globus pallidus to frontal subcortical white-matter signal intensity was measured-multiplied by 100. RESULTS: Pallidal signal hyperintensity was observed in 85.7% of cirrhotics, and the PI was higher in cirrhotics with extrapyramidal signs or high grade varices than those without them, but there was no increase in the Parkinson's disease patients. No correlations were demonstrated between the blood manganese level and PI as well as the Child-Pugh score. The blood manganese level was not significantly different between cirrhotics and other groups. However, there was an overt increase only in two cirrhotic patients with extrapyramidal signs. The Columbia scale did not reveal any correlations with the blood manganese level and the Child-Pugh score. CONCLUSIONS: Cirrhotics with extrapyramidal signs showed a significant increase in PI, but there was no increase in the patients with Parkinson's disease. The PI was not significantly correlated with the blood manganese level. These findings suggest that extrapyramidal signs in cirrhotics might be caused by a different mechanism than those in Parkinson's disease, which could possibly be related with manganese.

A Case of Minimal Change Nephrotie Syndrome Associated with Diclofenac / 대한신장학회잡지

NSAIDs are now the most widely prescribed of all drugs for the therapy of a large variety of disorders including rheumatologic disorders, and so the population of patients who are at risk for adverse effects of these drugs is rapidly expanding. A number of renal and electrolyte problems have been associated with the use of NSAIDs, including alterations in glome-rular filtration rate, hyperkalemia, acute interstitial nephritis and papillary necrosis. While the use of NSAIDs has also been associated with minimal change nephrotic syndrome, this complication has almost invariably occured in association with an acute interstitial nephritis. Recently, we experienced a case of minimal change nephrotic syndrome without significant interstitial inflammation associated with the use of NSAIDs. This patient is a 64-year-old female who developed the generalized edema and about 10kg of weight gain since three days ago. She had taken the anti-inflammatory drugs for five years intermittently and started taking diclofenac sodium, 25mg orally three times a day, 10 days before admission for increasing pain in her knees. Laboratory findings disclosed the following values WBC 5,200/mm3 with only 0.6% eosinophils, total serum protein 4.0g/dL, albumin 1.2 g/dL, BUN 17mg/dL, creatinine 0.8mg/dL, sodium 140 mmol/L, potassium 4.0mmol/L, chloride 113mmol/L, total cholesterol 338mg/dL, triglyceride 203mg/dL; 24-hour protein excretion 3.6g, creatinine clearance 52.8 mL/min ; serologic tests were unremarkable. A renal biopsy revealed no abnormality except for focal mild interstitial infiltration of chronic inflammatory cells with a few atrophic tubules on light microscopy. Immunofluorescence studies showed diffuse trace mesangial deposits of IgM, and electromicroscopy revealed diffuse obliteration of the epithelial foot process and villous transformation of the epitherial cell cytoplasms without electrondense deposits. These findings were consistent with minimal-change disease. Diclofenac was discontinued on admission because of the likelihood the renal disease was drugrelated and she treated with low-dose(40-80mg/d) of furosemide. Fourteen days after stopping diclofenac, her massive edema and weight gain resolved and laboratory studies showed a 24-hour urine protein excretion of 80mg and serum albumin of 2.7g/dL. There has been no relapse for five months since then.

A Case of Sigmoid Colon and Jejunal Metastases from Large Cell Lung Cancer / 대한소화기내시경학회지

Lung cancer begins insidiously, metastasizes early, and is frequently nonresectable at the time of diagnosis. Gastrointestinal metastases are considered the most unusual. A 60 year-old man was admitted for the evaluation of dizziness. For two weeks prior to admission, he had mild blood-tinged sputum and melena. He had right cervical lymphadenopathy, measured by 2 2 cm. Laboratory studies demonstrated hemoglobin of 3.7 g/dL. Posteroanterior and lateral chest radiographs revealed mass-like lesion of right upper lobe. An umblicated mass was found in the sigmoid colon by colonoscopic examination and biopsy was done. He developed abdominal pain, tenderness and rebound tenderness at admission 10 days. Abdominal CT showed that focal thickened wall and suspicious perforated lesion at the ileum. Operation was done. In recent time, we experienced a case in which perforation of gastrointestinal metastases developed with malignant tumors of the lung.

The Change of the Etiology, Complications and Cause of Death of the Liver Cirrhosis in 1990s / 대한간학회지

BACKGROUND: Alcoholic liver disease has increased. The causes of death in liver cirrhosis have changed. The author tried to categorize the etiology and complications of liver cirrhosis and analyze the causes of death in the 1990s. METHOD: The author retrospectively reviewed medical records of 1,175 patients diagnosed as having liver cirrhosis at Kyung Hee University Hospital from January 1991 through December 1998. The etiology, complications and the cause of death were compared between the early (1991-1994) and the late (1995-1998) periods. RESULTS: The proportion of male patients (73.3%) was still about 3 times that of female patients. There was no difference in age at the time of diagnosis between early and late periods (51.4 11.1 and 51.2 11.2 years respectively). Hepatitis B virus (HBV) infection was still the most common cause of liver cirrhosis (57.0%) and alcohol was the next (31.1%). The complications of liver cirrhosis at the time of diagnosis were, in order: esophageal varices, ascites, and variceal bleeding. But there was no significant difference between the periods. The proportion of Child grade B was the most common at the time of diagnosis in both periods, but Child grade A increased in the late period. The most common cause of death was liver failure and the next cause was variceal bleeding in the early period. Hepatorenal syndrome was the second most common cause in the late period. CONCLUSION: There was no change in the etiology between early and late periods. HBV infection was still the most common etiology but the incidence of alcoholic liver cirrhosis might have increased in the 1990s. The proportion of the Child B at initial diagnosis was the highest (around 50%) but that of Child A increased in the late period. Among the causes of death, liver failure and hepatorenal syndrome had a tendency to increase in the late period.

A Case of Behcet's Disease with Pleural Effusion / 결핵

Behcet's disease is a complex multisystem disease that features recurrent aphthous stomatitis, recurrent genital ulcerations, and eye lesions(uveitis or chorioretinitis). Among the systemic manifestat ions, pulmonary involvement is known to be rare and only a few cases have been documented. The most important features of pulmonary lesions in Behcet's disease are recurrent hemoptysis, which is often massive, and fatal pleuritic chest pain and recurrent high fever and fleeting nature of the pulmonary infiltrates. We report a case of Behcet's disease manifestated as high fever and pleural effusions which was complicated by pulmonary infarction ans a result of pulmonary arteritis.

A Case of Lung Cancer associated with von Recklinghausens Disease / 결핵

Von Recklinghausen's disease is an autosomal dominant hereditary disease associated with characteristic cafeau-lait spots of skin and multiple neurofibromatosis. It is complicated by malignancies, which in most cases is neurofibrosarcoma. The development of lung cancer in von Recklinghausen's disease is rare. A 61-year-old male was admitted for cough and sputum for 20 days. He had multiple cafe-au-lait spots and subcutaneous neurofibromas in whole body area and Lisch nodules in both iris and he had been diagnosed von Recklinghausen s disease 35 years ago. Chest radiography showed emphysematous buliae in both upper lung field and mass in right upper lung field. Chest CT scan revealed subcarinal lymph node enlargement. Bronchoscopic biopsy was done in mass in superior segment of right lower lobe and the results showed squamous cell carcinoma. The presence of von Recklinghausen's disease and lung cancer are noteworthy.