Fasting and Postprandial Analysis of Bowel Sounds and Plasma 5-hydroxytryptamine Level / 대한소화기학회지

BACKGROUND/AIMS: Auscultation of bowel sounds is a traditional technique for evaluating patients with abdominal symptoms. It is, however, subjective and qualitative method in general. Recently, analysis of bowel sounds becomes possible. We analyzed bowel sounds in healthy volunteers and measured platelet depleted plasma 5-hydroxytryptamine (5-HT) that may be associated with postprandial symptoms in irritable bowel syndrome. METHODS: We recorded both fasting and postprandial bowel sounds for 30 minutes in 16 healthy volunteers with a sensitive electronic stethoscope attached to a digital recorder. The files were saved in computer as wav files and analyzed with a specialized program. Blood samples were also taken before and 1 hour after meal for 5-HT analysis. RESULTS: Meal challenge made no statistically significant changes in the 5-HT concentrations and all the sound parameters including sound to sound interval, sounds/minute, average of sound amplitudes, sound length, percentage of bowel sounds representing sound clustering and dominant frequency of sounds. CONCLUSIONS: Postprandial changes in bowel sounds and plasma 5-HT were insignificant in healthy Korean volunteers.

Pyloric Injection of Botulinum Toxin for Treatment of Diabetic Gastroparesis: A Report of Four Cases / 대한소화기내시경학회지

Gastroparesis is a disorder of gastric motility that results in delayed gastric emptying. Up to 58% of patients with diabetes mellitus may have diabetic gastroparesis, a syndrome characterized by nausea, vomiting, early satiety, and bloating. The pathophysiology of this disorder is not completely understood, but it is believed to include fundic dysaccommodation, a decrease in gastroduodenal pressure gradient and antral hypomotility. In addition to antral and fundic dysfunction, patients with diabetes may typically have pyloric dysfunction or spasm. Treatment consists of a change in diet to small volume, frequent meals and the use of the prokinetic agents. This case report describes the four patients with severe diabetic gastroparesis whose symptoms persisted despite of dietary changes and the use of prokinetic agents in high doses. All of them were treated with pyloric injection of botulinum toxin and three had significant symptomatic and scintigraphic improvement.

Type of Electric Currents Used for Standard Endoscopic Sphincterotomy Does Not Determine the Type of Complications / 대한소화기학회지

BACKGROUND/AIMS: The blended current is usually used for endoscopic sphincterotomy (EST) to minimize bleeding. The pure cutting current may induce less edema of the ampulla and therefore result in less injury to the pancreas theoretically. The aim of this study was to evaluate effects of electric currents used on the development of serum pancreatic enzyme evaluation, clinical pancreatitis or bleeding after EST. METHODS: One hundred and eighteen consecutive patients who underwent EST with standard papillotome alone for the treatment of choledocholithiasis were reviewed. All EST had been performed by two endoscopists whose experience on EST was similar: one uses 'blended current' (BC group, n=74), while the other uses 'pure cutting current' (PC group, n=44). RESULTS: Baseline clinical, laboratory, and procedural parameters were similar in both groups. The incidences of hyperamylasemia and hyperlipasemia were similar between two groups. There was no significant difference in the incidence of clinical pancreatitis between two groups (BC 6.8% vs PC 0.0%, p=0.1557). All episodes of pancreatitis were mild. No episodes of significant bleeding occurred after EST. The incidences of sepsis, cholangitis and perforation were also not different between two groups. CONCLUSIONS: Development of complications after standard EST such as hyperamylasemia, clinical pancreatitis, and bleeding may not depend on the electric current used.

Usefulness of Urinary Trypsinogen-2 Dipstick Test for Diagnosis of Acute Pancreatitis / 대한소화기학회지

BACKGROUND/AIMS: The clinical usefulness of urinary trypsinogen-2 dipstick test is still in controversy. We evaluated the usefulness of urinary trypsinogen-2 dipstick test in patients with acute pancreatitis. METHODS: Urinary trypsinogen-2 dipstick test was prospectively performed in 50 patients with acute pancreatitis, 50 patients with non-pancreatic abdominal pain, and 50 healthy controls. RESULTS: On admission, urinary trypsinogen-2 dipstick test was positive in 36 of 50 patients with acute pancreatitis (sensitivity, 72%) and in 4 of 50 patients with non-pancreatic abdominal pain (specificity, 92%). On the other hand, it was all negative in controls. The sensitivity and specificity of serum lipase were 78% and 94%, respectively. At 24 hours after admission, the positive rate of urinary trypsinogen-2 dipstick test rose from 72% to 94% (p=0.02). The results of urinary trypsinogen-2 dipstick test was positive in 14 of 15 patients with severe pancreatitis and 22 of 35 patients with mild pancreatitis according to the criteria by Atlanta International Symposium, 1992. CONCLUSIONS: Urinary trypsinogen-2 dipstick test is comparable to serum lipase in diagnosing acute pancreatitis. Delayed measurement and severe pancreatitis are more likely to yield positive results with urinary trypsinogen-2 dipstick test. Thus, we suggest that the cut-off value of urinary trypsinogen-2 dipstick test should be lowered to increase its sensitivity.

A case of enteropathy-type intestinal T-cell lymphoma, confused with celiac disease / 대한내과학회지

Primary gastrointestinal lymphomas are commonly B-cell type, in contrast to the rare T-cell type, which has been noted as a complication of celiac disease that has not been reported in Korea so far. Primary T-cell lymphoma is commonly associated with enteropathy, and we report a case of small bowel T-cell lymphoma associated with enteropathy, with minimal mucosal lesion such as flattening of folds, which was difficult to differentiate with celiac disease clinically and pathologically.

A Case of a Giant Brunner's Gland Hamartoma Originating from the Pyloric Ring / 대한소화기내시경학회지

Brunner's gland hamartoma, also called as Brunner's gland adenoma or Brunner's gland hyperplasia, is a relatively rare disease that results from benign proliferation of the Brunner's gland normally present in the duodenum. It is mostly located at the duodenal bulb, occasionally second or third portion, but is rarely found at the pyloric ring, jejunum or proximal ileum. In Korea, total 27 cases of Brunner's gland hamartoma have been reported, but none of them had their origin at the pyloric ring only. We report a case of Brunner's gland hamartoma, found incidentally, originating from the pyloric ring in a 54-year-old woman, which was resected endoscopically after retracting the tumor into the stomach.

A Stent-Guided Sphincterotomy in Patients with a Difficult Periampullary Diverticulum or with a Billroth-II Gastrectomy / 대한소화기내시경학회지

BACKGROUND/AIMS: Patients with a congenitally or surgically altered anatomy such as a large diverticulum in which an ampullary orifice exists or a Billroth-II gastrectomy, have an increased complication rate after endoscopic sphincterotomy (EST) compared to normal anatomies. An experience involving a stent-guided sphincterotomy using an endoprosthesis is herein reported. METHODS: 10 patients with a Billroth-II gastrectomy and 9 patients with a large diverticulum received a stent-guided EST. In the diverticula cases, all the ampullary orifices were located either inside the diverticulum or in an unusual position. All patients had common bile duct stones and symptoms of cholangitis. After a 0.035 inch guide wire was inserted through the side-viewing duodenoscope, a 10 Fr. endoprosthesis (MTW, Germany) was inserted and a needle-knife sphincterotome was introduced. In patients with a Billroth-II anatomy, the incision was made from the papillary orifice of the 12 o'clock position toward 6 o'clock. In patients with periampullary diverticula, the incision was made with sweeps of the needle-knife in a 6 to 12 o'clock direction. The cautery current was applied to the mucosa along the stent and the stent was retrieved by a polypectomy snare through the biopsy channel without removal of an endoscope. RESULTS: Among the 19 patients, the guide wire and stent insertion were possible in all except one patient due to the inability of selective cannulation. An EST was performed in all patients after stent insertion. There were no serious complications during and after the stent-guided EST except for two minor bleedings which were treated with a coagulation current using the needle-knife. Consequently, complete endoscopic stone removal was achieved in all patients including three patients in whom a mechanical lithotriptor was needed. CONCLUSIONS: In stent-guided EST, the stent not only guides the adequate direction of the incision but also allows a controlled incision under a favorable visual field. Therefore, blind cutting and exploration during EST can be avoided and successful EST is possible even in difficult situations such as that created by an altered anatomy.

Overall Success and Factors Predicting Failure for Endoscopic Extrahepatic Biliary Stone Extraction / 대한내과학회지

OBJECTIVES: Developments in endoscopic technique and equipments have improved duct clearance rate in patients with extrahepatic bile duct(EHBD) stone. In this study, we reviewed our experience in extracting EHBD stones with standard and more advanced technique and equipments such as mechanical lithotripsy and extra corporeal shock wave lithotripsy. Aims of this study were to determine the overall success rate of endoscopic ex tracting for EHBD stone, to identify risk factors for failed duct clearance at initial and final therapeutic ERCP. METHODS: We retrospectively reviewed 214 consec utive patients who underwent Endoscopic Retrograde Cholangiopancreatography(ERCP) for EHBD stone over 45 months period. Factors evaluated for failed duct clearance included stone size, stone number, stone shape, concomitant stone of gallbladder and intrahepatic duct, presence of distal bile duct stricture, periampullary diverticula(PAD), Billroth-II gastrojejunostomy, and sepsis at admission. RESULTS: The overall success rate of endoscopic treatment for EHBD stone was 93.5% (200/214). The causes of failed duct clearance were failed endoscopic sphincterotomy in 5/214 (2.3%), technical failure of extracting stone in 5/214(2.3%), and aggravation of acute cholecystitis between therapeutic endoscopic sessions in 4/214(1.9%). Risk factors for failed duct clearance with endoscopic extraction of EHBD stone were size and shape of the stone, concomitant stone of gallbladder and intra hepatic duct, and stricture of distal common bile duct. The duct clearance rate with initial therapeutic ERCP was 56.5%(121/200). Risk factors for failed duct clearance with initial therapeutic ERCP were size, shape and number of stone, and sepsis at admission. The com plications of endoscopic treatment for EHBD stone were major bleeding in 5/200 (2.5%), pancreatitis in 18/200 (9.0%), but there was no perforation. CONCLUSION: Eventhough risk for failure of endo scopic treatment for EHBD stone were giant or piston shaped stone, concomitant stone of gallbladder and intra hepatic duct, and stricture of distal common bile duct, we conclude that endoscopic treatment for EHBD stone is safe and effective treatment modality, and choice of treatment.

A Case of IgA Nephropathy Associated with Non-Hodgkin's Lymphoma / 대한신장학회잡지

The development of glomerular injury in patients with malignancy is considered as paraneoplastic syndrome. The most frequently observed renal lesions associated with malignancies are the membraneous glomerulonephritis on carcinomas and minimal change nephrotic syndrome on Hodgkin's disease. However, glomerular diseases on non-Hodgkin's lymphoma were only occasionally reported. Here we report a case of IgA nephropathy associated with non-Hodgkin's lymphoma. A 53-year-old woman who had complained of gross hematuria and fever was admitted to Wonju Christian Hospital. A urinalysis revealed 2+ proteinuria and red blood cells >30/HPF. A 24-hour urinary protein excretion was 379mg. She was diagnosed as IgA nephropathy on renal biopsy. Subsequently, biopsy of her enlarged neck node was performed for evaluation of fever of unknown origin and it revealed non-Hodgkin's lymphoma (Ki-1 positive anaplastic lymphoma null cell type). Combination chemotherapy was instituted with cyclophosphamide, adriamycin, vincristine and prednisone. After 3 cycles of chemotherapy, she showed no evidence of proteinuria and hematuria with clinical and radiological improvement of malignant lymphoma. Therefore we suggest of certain association between IgA nephropathy and non-Hodgkin's lymphoma by the observation of corresponding disease activity.