A Case of Massive Duodenal Diverticular Bleeding Treated with Endoscopic Hemostasis

Duodenal diverticulum is commonly found at 2nd portion of duodenum undergoing duodenal procedure. It is generally asymptomatic and not harmful. But occasionally it causes massive upper gastrointestinal bleeding. Bleeding from duodenal diverticulum is very difficult to diagnose and manage since vision of the lesion by conventional direct endoscope is limited. Recently, emphasis has been placed on aggressive and careful endos- copic diagnosis and hemostasis with hemoclip or local injection. We report a case of massive duodenal diverti- cular bleeding on a senile patient which was treated successfully by endoscopic hemoclip therapy.

Pyridostigmine for Treatment of Acute Colonic Pseudo-obstruction(Ogilvie's syndrome) in a Older Patient on CAPD

In acute colonic pseudo-obstruction(Ogilvie's syndrome, 1948), there is no distal obstruction but colonic obstruction symptom and distended colon is shown radiologicaly and clinically. The etiology of this syndrome are complex of any medical and surgical problem. Elderly patients who are undergoing CAPD have multiple medical problems. But among them only one case which was diagnosed with this syndrome was reported in Korea. Neostigmine is unstable medicine due to muscarinic effects if neostigmine(anticholinesterase inhibitor) has side effects to the CAPD patients with multiple medical problems, it can be fatal. We use pyridostigmine, which has less muscarinic effect, and has similiar potency compared to neostigmine to acute colonic pseudo-obstruction, and thus achieved radiological improvement.

A Case of Hypertrophic Form of Duodenal Tuberculosis Mimiking Duodenal Cancer / 대한소화기내시경학회지

The prevalence of intestinal tuberculosis has been markedly decreased with the development of antituberculous chemotherapy, improved economic conditions, preventive medicine and early detection and treatment of pulmonary tuberculosis. An even more impressive resurgence of pulmonary and extrapulmonary tuberculosis has been seen in recent years among persons infected with the human immunodeficiency virus. The most common site of intestinal tuberculosis is the ileocecal region, and duodenum is a rare site. Symptoms and signs of duodenal tuberculosis are nonspecific. The gross pathologic appearance of the duodenal tuberculous lesions has to its traditional categorization into three forms: 1) ulcerative, 2) hypertrophic, and 3) ulcerohypertrophic (mixed). Hypertrophic lesions of the duodenal tuberculosis should be differentiated from duodenal adenocarcinoma and lymphoma. We herein report a case of duodenal tuberculosis presenting as intraluminal protruding mass in gastroduodenoscopy and multiple intraabdominal lymphadenopathy on abdominal CT. We have confirmed the duodenal tuberculosis by endoscopic biopsy, and review the current literatures.

Endoscopic Removal of Fish Bones Impacted in the Rectosigmid Colon / 대한소화기내시경학회지

Impaction of an ingested foreign body in the colon is uncommon but surgical or endoscopic intervention is occasionally needed when serious complications such as perforation, obstruction or hemorrhage occur. Several factors may predispose a patient to ingestion and subsequent impaction of lower intestinal foreign body. It is more common in the elderly who wear dentures, in the mentally infirm, in chronic alcoholics or rapid eating. The majority of impaction occurs at narrowing and angulation such as ileocecal valve or rectosigmoid junction. The diagnosis of lower intestinal foreign body should be considered, among more common conditions, in the differential diagnosis of elderly patients who present with altered bowel habits. We report the case with a literature review that successfully endoscopically removed the fish bones impacted in the rectosigmoid colon complicated by rectal bleeding.

A Case of Acute Renal Failure Caused by Amphetamine-Associated Rhabdomyolysis / 대한신장학회잡지

Amphetamine toxicity is well known in western countries since several decades ago. Taken in excessive amount, amphetamine causes systemic symptoms such as hyperpyrexia, tachycardia, hyperkinesia, delirium, seizure and circulatory collapse. Acute renal failure following amphetamine ingestion is caused by the direct toxicity of the drug, circulatory collapse, coagulopathy, retroperitoneal hematoma or tubular obstruction by rhabdomyolysis. This is a case of a amphetamine intoxicated 41-year male patient presenting with features of acute renal failure, which is not accompanied by circulatory collapse, nor by coagulopathy. Muscle enzymes and bone scan findings were compatible with nontraumatic muscle injuries, and the renal pathology was tubular necrosis with specific myoglobin casts. Therefore a drug induced rhabdomyolysis causing myoglobinuric tubular injury is highly suspected. The fact that the outcome of the renal disease itself was good despite fatal dosage of this drug is also compatible with myoglobinuric renal failures reported by foreign authors. This is probably the first reported case of acute renal failure caused by amphetamine associated rhabdomyolysis in Korea.

Atypically Located Brainstem Schwannoma

Intracranial schwannoma constitutes 8-10% of all primary intracranial tumors. The majority of them derive from cranial nerves, especially from the vestibulocochlear nerve. Intraparenchymatous schwannoma of the cent ral nervous system, on the other hand, is very rare. We report a rare case of brainstem schwannoma with the review of literature 8.

Evaluation of Apoptosis in the Normal Rat Brain after Intraoperative Irradiation

Radiation therapy is one of the most important treatment modalities following surgery of the primary malignant or metastatic brain tumors. But radiation can be harmful to normal healthy brain tissues around the tumor. There have been numerous reports of radiation induced damage such as delayed necrosis to human brain after therapeutic exposure. Apoptosis is a form of cell death with morphological and biochemical features that differ from those of necrosis. The aim of this study is to evaluate the apoptosis in normal rat brain after irradiation. Twenty one Sprague-Dawley rats were given a single dose of 10 Gy using high dose rate Ir-192 over 5 minutes at the right frontal region. Apoptosis was evaluated by the TUNEL method(In-situ end labelling technique) and mutant p53 protein, bc1-2 and bax genes were evaluated by immunohistochemical stain. Apoptosis was assessed at 1 week(group A, n=5), 2 week(group B, n=), 4 week(group C, n=), 6 week(group D, n=), 8 week(group E, n=) after irradiation. Apoptosis was noted with 20% of cases(1/5) in group A, 40% of cases(2/5) in group B, 60% of cases(3/5) in group C, 67% of cases(2/3) in group D and 100% of cases(3/3) in group E. Overall apoptosis positive rate was 52.4%(11/21). Apoptosis was most prominently found in external granular and external pyramidal layer(82%, 9/11) and found one case in internal pyramidal layer and the other one case in corticowhite matter junction. There were no positive stainning for mutant p53 protein, bc1-2 and bax gene in all cases pertaining to the phenomenon of apoptosis. In conclusion, apoptosis was evident in the rat brain after irradiation and the incidence of apoptosis was increased with time after irradiation. But the genes related to apoptosis after irradiation were not apparent in this study. Further evaluation including biochemical and clonogenic study needs to clarify the mechanism of apoptosis in normal brain after irradiation.

The Relationship of Preoperative Computerized Tomographic Scan Image and Amount of Postoperative Closed System Drainage in the Recurrence of Chronic Subdural Hematoma

Although chronic subdural hematoma(CSDH) is a well known entity, there is little knowledge concerning whether the results of radiological imaging can be used to predict CSDH recurrence or whether surgical methods can influence this rate. The aims of this study are to evaluate; 1) the relationship between the recurrence rate of CSDHs and their appearance on preoperative computerized tomography(CT) or magnetic resonance(MR) images and 2) relationship between the recurrence rate of CSDHs and the amount of postoperative drainage, and 3) the usefulness of one burr-hole irrigation with close-system drainage. From January 1991 through March 1998, 166 patients who were surgically treated were included. Thirty-six of these patients underwent bilateral operation and thus 202 operative sites of CSDH were analyzed. Preoperative CT was done in 151 patients and MR was done in the others. The cases of CSDH were separated into low-, iso-, layered-, high-, mixed-density groups on the basis of the appearance on CT images, and high-, nonhigh-intensity groups on T1-weighted MR images. All patients had underwent one burr-hole irrigation with closed system drainage and the drain was kept in place for 5 days. The amount of postoperative drainage decreased significantly from the 2nd day after operation compared to the 1st day after operation and decreasing tendency was continued through the rest of the days(p<0.0001) Overall recurrence rate was 3.5% and there was no significant relationship between the recurrence rate and their appearance on preoperative CT or MR. The average amount of postoperative drainage was larger in unrecurred CSDHs(381.0+/-36.9 ml, mean+/-standard error) than recurred cases(188.9+/-40.7ml). One burr-hole irrigation with closed-system drainage was useful regardless of CT findings. The amount of postoperative drainage, which means permeability of hematoma membrane, may be useful in predicting the propensity of CSDHs to recur.

Management Outcome in Cerebral Aneurysms of Posterior Circulation

A series of 51 consecutive patients with 55 cerebral aneurysms of the vertebrobasilar system is presented. Thirty aneurysms had their origins at the basilar artery(BA) bifurcation, 7 at the origin of the superior cerebellar artery (SCA), 4 at the posterior cerebral artery(PCA), 4 at the BA trunk, 8 from the vertebral artery(VA) at the origin of the posterior inferior cerebellar artery(PICA), and two from the PICA. The patient population consisted of 31 women and 21 men, with a mean age of 50 years(range 30-70 years). The overall mortality and morbidity rates at 6 months were 17.6%(9/51) and 13.7%(7/51), respectively. The most common cause of death was rebleeding(55.6%, 5/9). Nineteen patients had underwent only conservative treatment due to aneurysms classified as inoperable(6 cases), fatal rebleeding(5 cases), refusal against surgery(5 cases), poor Hunt and Hess grade that did not improve(2 cases), and one aneurysm that spontaneously disappeared. Treatments consisted of neck clipping in 16 patients, wrapping in 6, and endovascular therapy in 10. All of these treatment modalities were carried out after 2 weeks from initial insult. Treatment outcome was evaluated with Glasgow Outcome Scale(GOS) at 6 months after initial insult. Patients with Hunt and Hess(H-H) Grades I and II at admission had good outcome in 70.6%, whereas only 60% of patients with H-H Grades III and IV showed good outcome. But there was no statistically significant difference. Five patients with aneurysms which were located proximally had better outcome than those with distal aneurysm(100% good outcome vs 66.7%). All of ten patients who were treated with endovascular therapy showed good outcome, whereas only 13 out of 22(59.1%) patients who underwent either clipping or wrapping showed good outcome. There was statistically significant difference(p<0.05). As for the comparison of outcome according to the size of aneurysm and age of patients, we found no statistically significant difference. These results indicated that the location of aneurysm was one of important prognostic factor in vertebrobasilar system. Endovascular treatment may be a promising treatment option and considering the very high mortality from rebleeding early management may contribute to reduce the mortality and morbidity in posterior circulation aneurysm.

Prognostic Factors in Patients with Diffuse Axonal Injury

Diffuse axonal injury(AI) s a severe form of traumatic brain injury and it is associated with immediate coma lasting from six hours to prolonged coma. Object of this study was to review various clinical parameters which might have been related to outcome of patients with DAI and, thus, to provide some valuable guidelines in management. A series of 41 patients of DAI treated in our institution between October 1992 to September 1997 are included in this study. Clinical factors such as age, sex, Glasgow Coma Scale(CS), duration of coma, presence of hypotension at admission, hypoxemia, signs of hypothalamic injury, abnormal eyeball movement, abnormal light reflex, abnormal electrocardiography, cerebral infarct, and seizure are reviewed and analyzed in conjunction with outcome. Among all clinical factors evaluated for the statistical significances only initial GCS, hypoxemia, abnormal light reflex, signs of hypothalamic injury, abnormal motor response(decortication or decerebration) at admission revealed to have significant correlation with outcome. Factors such as age, hypotension, abnormal ECG, cerebral infarct, seizure were not statistically significant in our study. Other findings, such as causes of deaths(old age associated with either expanding hemorrhage or hemorrhage in posterior fossa) in 2 of 9 patientswith initial GCS greater than 13 and highest mortality rate for patients with combined hypoxemia and hypotension, should also be stressed. These findings suggest that when such clinical settings are evident physicians should be borne in mind that these will play unfavorable role to patients in terms of outcome and prognosis. Thus, careful and prompt attention should be given to these patients, especially treating elderly patients, even though they may have good initial GCSs.

Three-Dimensional Computed Tomographic Angiography(3-D CTA) in Acute Subarachnoid Hemorrhage: A Case Report

In almost one in six patients with spontaneous subarachnoid hemorrhage(SAH) no lesion responsible for the bleed will be found by cerebral angiography. Current management strategies include repeat cerebral angiography after a period of 1-8 weeks during which a number of these patients will rebleed with considerable morbidity and even mortality. We report the case of a 51-year-old female patient with spontaneous SAH. Brain computed tomography (CT) demonstrated localized focal hematoma in the basal frontal interhemispheric fissure suggesting the presence of an anterior communicating artery(ACoA) aneurysm. Cerebral angiography was incomplete because of severe arther-osclerosis of left internal carotid artery and findings were negative. Cerebral three-dimensional computed tomographic angiography(3-D CTA) performed the next day showed a small aneurym arising from the ACoA. This was confirmed at surgery. It is suggested that 3-D CTA, guided by the CT findings, probably is useful in the diagnosis of patients with acute SAH and has a place in the management of patient with SAH of "unknown etiology" before repeat catheter angiography is undertaken.

Application of TSRH Instrumentation In Degenerative Lumbar Surgery

The patients with degenerative lumbar spine disease were treated using TSRH(Texas Scottish Rite Hospital) universal instrumentation system. The patient population consisted of 6 men and 4 women with a mean age of 56 years(43 to 65 years). All patients suffered chronic back pain with other neurological symptoms and signs. Neurological improvement was obtained in all cases postoperatively. Complication include pneumonia in 1 case, deep vein thrombosis in 1 case, flaccid neurogenic bladder in 1 case. Autogenous bone graft, obtained from iliac bone, between transverse process provided excellent bony fusion in 7 cases on radiologic evaluation between 9 months to 12 months after operation. TSRH universal instrumentation system have several advantages compared with other pedicle screw rod systems ; easy to handle, low morbidity, shorter operative time and easier relieval of root compression.

The Influence of Blood Glucose Change on Dopamine, Norepinephrine and Serotonin Concentration in the Frontal Lobe, Hippocampus and Striatum of Transient Ischemic Rat's Brain

Hyperglycemia during either global or regional ischemia is widely known to be detrimental, and ischemia induced release of diverse neurotransmitters and the ensuing activation of specific postsynaptic receptors have been suggested to play a important role in the development of ischemic selective vulunerability. This study was undertaken to investigate the influence of blood glucose change on tissue concentration of some catecholamines ; dopamine, norepinephrine, serotonin, of the transient ischemic rat's brain, estimated by high performance liquid chromatography(HPLC) assay system, following transient bilateral forebrain ischemia in the rat's model subjected to 20 minutes of normothermic ischemia by two vesseles occulusion plus profound cortex, hippocampus and striatum respectively by HLPC. The concentrations of catecholamines were significantly decreased in all sampled areas in experimental groups compared with the control group(p0.05) of catecholamines level between each experimental group(hyper-, hypo- and normoglycemic group) according to the change of blood sugar. The results suggested that blood glucose level did not influence the tissue concentration of dopamine, norepinephrine and serotonin in frontl cortex, hippocampus and striatum of transient ischemic rat's brain.