The Availability of Positron Emission Tomography for Diagnosis of Thyroid Nodule / 대한내분비외과학회지

PURPOSE: Whole body Positron Emission Tomography (PET) was used to evaluate the existence of cancer cells. However, PET had limitations in identifying thyroid cancer cells because of their slow progression, and evidence regarding its accuracy in finding thyroid cancer cells is insufficient. Therefore, we investigated the usefulness of PET for evaluation of patients with thyroid nodules by studying the relationships between PET and thyroid ultrasonography. METHODS: We evaluated 4,627 patients who had undergone PET from January 2007 to October 2011 and selected 370 patients who had undergone thyroid ultrasonography. We compared and analyzed the amount of thyroid SUVmax of PET, the pattern of glucose uptake, and findings of thyroid ultrasonography based on their size, shape, location, and FNAC. RESULTS: Of 370 patients, 197 (53.2%) subjects were found to have thyroid nodules, and 211 (57.0%) subjects had higher sugar metabolism, regardless of having thyroid nodules. No statistical correlations were observed among nodule size, nodule location,and higher sugar metabolism, however, noticeable relationships were observed between the shape of the cells on thyroid ultrasonography and FDG uptake of PET. In cases of papillary thyroid cancer, there was higher FDG uptake, compared to benign lesions in particular, SUVmax of the papillary thyroid cancer showed a significantly elevated level of FDG uptake. CONCLUSION: Despite its limited usefulness in identifying the characteristics of thyroid nodules being benign or malignant, PET is appropriate for evaluation of the malignancy of thyroid cells

Comparative Study of the Clinical Features and Treatment for Right and Left Colonic Diverticulitis

PURPOSE: Colonic diverticulitis is an uncommon disease in Korea, but the incidence of the disease is increasing. The right colon is the more preferred site for diverticulitis in Korea, but the incidence of left diverticulitis is increasing. Therefore, comparing the clinical features and treatments for right diverticulitis with those for left diverticulitis may help us to treat the disease more properly. METHODS: This study was performed retrospectively by reviewing the medical records of 96 patients with colonic diverticulitis, in whom either conservative or operative treatments were performed. RESULTS: Eighty-six patients had right diverticulitis (RD), and 10 patients had left diverticulitis (LD). The mean age of the patients was older for LD. Sixteen patients (18.6%) with RD had complications, and 7 patients (8.1%) underwent operations. On the other hand, 4 patients (40%) with LD had complications, and 3 patients (30%) underwent operations. The rates of complications and operations among old-aged patients were higher. The operations for 7 patients with RD who underwent surgery were 6 ileocecectomies and 1 diverticulectomy. On the other hand, the operations for the 3 patients with LD who underwent surgery were 2 resections and anastomoses and 1 diverticulectomy. The reasons for the operations were abscess formation, recurrence, perforation, and development of generalized peritonitis without response to conservative treatment. CONCLUSION: The incidence of LD is lower than that of RD in Korea, but the rate of complications and operations seems higher in LD. Therefore, patients who complain of left lower abdominal pain need to be thoroughly examined for LD.

Eosinophilic Gastroenteritis Causing Gastro- intestinal Obstruction

Eosinophilic gastrointestinal disorder is uncommon and it has rarely been reported. The presence of increased numbers of eosinophils in the biopsy specimens of the gastrointestinal tract, the infiltration of eosionophils in intestinal crypts and gastric glands, the absence of involvement of other organs and the exclusion of other causes of eosinophilia support the diagnosis of eosinophilic gastroenteritis. This is characterized by infiltration of eosinophils in the gastrointestinal wall, and it's associated with protein-losing enteropathy, hypoalbuminemia, motility abnormalities and ascites. Although it is an idiopathic disorder, allergic and immunologic etiologies have been suggested. Steroid is the treatment of choice, but an operation is necessary in case of a surgical abdomen or if the patient is refractory to steroid therapy. Recently, authors experience 2 cases of eosinophilic gastroenteritis causing gastro-intestinal obstruction, and report here with clinical evaluation and literature review.

Incidental Adenomyoma of Stomach Associated with Early Gastric Cancer

An adenomyoma of the gastrointestinal tract is a rare, benign, tumor-like condition histologically characterized by glandular structures embedded within a smooth muscle stroma. An adenomyoma has been considered to be as an abortive variant of an ectopic pancreas. An ectopic pancreas is defined as the presence of pancreatic tissue that lacks anatomic and vascular continuity with the main body of the pancreas. Common sites of an ectopic pancreas are the stomach, duodenum, and upper jejunum. An adenomyoma may rarely undergo a malignant transformation or cystic dystrophy. Recently, the authors an experienced a case of an incidental adenomyoma of the stomach associated with early gastric carcinoma. We report that case here.

SMV Thrombosis on Taking Oral Contraceptive with Protein C and Protein S Deficiency

Mesenteric venous thrombosis (MVT) is uncommon, but it is often aggravated to a lethal form of intestinal ischemia. Multiple risk factors are associated with mesenteric venous thrombosis, including hypercoagulable or inflammatory states, previous abdominal surgery, abdominal trauma, portal hypertension and oral contraceptives. The use of estrogen-containing oral contraceptives accounts for 4% to 5% of all the cases of MVT. Oral contraceptives have been reported to decrease antithrombin III, increase the levels of prothrombin complex factor and factor VIII, and to inhibit the fibrinolytic system. We describe here a case of 42-year-old woman who had taken oral contraceptives for 7 years and she was diagnosed to have Protein C and Protein S deficiency, and superior mesenteric venous (SMV) and portal vein thrombosis. She underwent segmental resection of the small bowel. She was later discharged without suffering with short bowel syndrome or any other complications.

Terminal Ileal Burkitt's Lymphoma in an Adult

A Burkitt's lymphoma is a rare disease belonging to the aggressive non-Hodgkin's lymphomas, which usually occurs in children or adolescents. Burkitt's lymphoma was first reported in the medical literature as a jaw sarcoma of East African children, and those of the gastrointestinal tract occurring in adults have rarely been reported in Korea. Herein, we report an unusual case of a primary intestinal Burkitt's lymphoma, presenting with a palpable abdominal mass and abdominal pain, in a 46-year-old man. An ileocecectomy was performed, and the diagnosis confirmed by histological examination.

Localized Peritonitis due to Perforation of Multiple Jejunal Diverticula

We report the case of a 77-year-old woman who presented with periumbilical pain from perforation of jejunal diverticula. The patient underwent surgery and multiple jejunal diverticula were found distributed from 30 cm to 60 cm distal to the ligament of Treitz. A segment of the jejunum containing all diverticula was resected and end-to-end anastomosis was performed. The postoperative course was uneventful. The patient continued to do well at last follow-up, 26 months after operation. Diverticulum of the jejunum is uncommon and the majority of patients are asymptomatic. Symptoms indicating diverticulum are few and often nonspecific; they may present either as generalized abdominal pain associated with intestinal disturbances or in more serious case, they can lead to complications requiring emergency surgery. In light of these considerations, we thought it useful to report a case of complicated multiple jejunal diverticula and draw attention to its complications that can be a source of gastrointestinal symptoms.

Carcinoid Tumor of the Stomach

A carcinoid tumor of the stomach is a neuroendocrine tumor originating from enterochromaffin cells in the submucosa of the stomach and has no specific clinical symptoms. They are uncommon, accounting for no more than 0.3% of all gastric tumors. However, this frequency has increased markedly due to endoscopic screening. Herein, the case of a 47-year-old man with a polypoid lesion (2 cm diameter) detected on endoscopic examination is reported. It was diagnosed as a carcinoid tumor before an operation. Although the tumor size was slightly larger than 2 cm in diameter, the lesion was treated by wedge resection as there was no lymph node involvement or other distant metastasis. The postoperative has course was uneventful. The patient has continued to do well for over 15 months of follow up.

The Value of the Total Lymphocyte Count as a Risk Index of Hospital Infection in Critically Ill Patients / 대한마취과학회지

BACKGROUND: Lymphocytopenia is a common finding in critically ill patients while lymphocyte depletion in critically ill patients is presumed to have little clinical significance. However, a total lymphocyte count has been reported to provide prognostic information in surgical patients. The aim of this study was to evaluate the association of a total lymphocyte count (TLC) with a prognostic criterion in critically ill patients. METHODS: The patients were divided into three groups according to their TLC on admission to intensive care unit (ICU) (Group 1: TLC > 1.0 x 10(9)/L, Group 2: 0.7 x 10(9)/L < TLC < 1.0 x 10(9)/L, and Group 3: TLC <0.7 x 10(9)/L). Outcomes examined were patients' in-hospital mortality, length of hospital stay and incidence of infection. RESULTS: Patients with a TLC less than 0.7 x 10(9)/L (Group 3) had an infection twice (32% VS 15%) as often as those with a TLC more than 0.7 109/L (Group 1 2). But, in the hospital stay and mortality, there was no significant difference among the groups. CONCLUSIONS: TLC is very useful indicator in critically ill patients with a high risk of hospital infection on ICU admission.

The Effect of Positive end Expiratory pressure on the Pulmonary Capillary Pressure in Acute Lung Injury Patients / 결핵

BACKGROUND: Positive end expiratory pressure (PEEP) ventilation is well established as an integral part of the management of patients with the acute lung injury. PEEP is a key element in the treatment of hypoxemia resulting from pulmonary edema. Pulmonary capillary pressure (Pcap) is the most important factor influencing lung edema formation, and an understanding of how Pcap is altered by variations of PEEP or pulmonary arterial occlusion pressure (PAOP) is important to improve the treatment of acute lung injury patients. This study was performed to evaluate the effects of PEEP on the pulmonary capillary pressure in acute lung injury patients. METHODS: This was a prospective study of 11 acute lung injury patients. The effect of PEEP on pulmonary circulation at four different levels (0,4,8, and 12cm H2O) was analyzed. Pcap was estimated visually at bed side with Swan Ganz catheters. The pulmonary vasculature was analyzed by calculating the pressure difference at the arterial and venous parts of the circulation. RESULTS: As PEEP increased from 0 to 12 cm H2O, the mean puhnonary arterial pressure (PAP) and Pcap increased respectively from 22.7 ± 7.4 to 25.3 ± 7.3 mmHg and 15.3 ± 3.3 to 17.8 ±3.2 mmHg (p<0.05). Similarly, PAOP increased from 9.8 ± 2.1 to 12.8 ± 2.1 mmHg and the central venous pressure increased from 6.1 ± 1.6 to 9.3 1: 2.3 mmHg(p<0.05). However, the pressure gradient at the arterial (PAP-Pcap) and venous (Pcap-Pcwp) part of pulmonary circulation remained unchanged at all evaluated PEEP levels. CONCLUSION: Although Pcap increasoo gradually with increased PEEP, the pressure gradient at the arterial and venous part of the pulmonary vasculature remained unchanged at all evaluated PEEP levels in acute lung injury patients.

Rupture of the rectosigmoid colon with evisceration of the small bowel through the anus

Spontaneous rupture of the rectosigmoid colon and herniation of the small intestine through the rupture site and eventual evisceration through the anus is a very rare event. In the literature, only 42 cases have been reported. The majority of them occurred in patients with rectal prolapse and one case was reported in association with a third-degree uterine prolapse. We experienced an 81-year-old female patient with rectal prolapse and second-degree uterine prolapse complicated by spontaneous perforation of the rectosigmoid colon and anal evisceration of the small intestine. Segmental resection of the nonviable small intestine, primary repair of the ruptured rectosigmoid colon, and sigmoid loop colostomy were performed, and the patient recovered well. In our patient, both rectal and uterine prolapses cooperatively damaged the anterior wall of the rectosigmoid colon and resulted in perforation. So, rectal and uterine prolapses should be treated before the complication develops. In this patient, uterine prolapse should be treated because of the recurrence of this rare episode.

Decreased Phenytoin Absorption in Patients with Continuous Enteral Feedings / 대한구급학회지

This report supports interactions between phenytoin and both enteral feeding products and nasogastric feeding tube. Five patients in ICU were treated with intravenous phenytoin, which yield detectable therapeutic serum concentrations. After switching to a comparable phenytoin capsule administered by nasogastric feeding tube, their serum phenytoin concentration fell to below assay sensitivity concentrations. Two of them experienced seizures. They were administered by intravenous phenytoin again or another antiepileptic drug, so the seizures were controlled. Some fact of decreased phenytoin absorption in enteral feeding patients is that phenytoin interact enteral feeding product and adhere the nasogastric feeding tube itself. We conclude that it is necessary to use phenytoin with caution in enteral feeding patients.

Surgical Treatment of Crohn's Disease

PURPOSE: This study was undertaken to investigate the preoperative diagnosis, indication for operation, postoperative complication, postoperative medical treatment and recurrence rate in patients with Crohn's disease who were treated with operation. METHODS: Forty patients with Crohn's diseases had been operated on at the Department of Surgery, Yonsei University College of Medicine during the period from Jan 1986 to May 1999 and they were reviewed retrospectively. We studies symptoms, surgical indications, preoperative and postoperative treatments, involvement sites, types of operation and recurrence rate in Crohn's disease. RESULTS: The male to female ratio was 1.5: 1, and age distribution was from 8 to 69 years old with mean age of 33 years old. The duration of symptoms varies from within 1 day to above 10 years and most of them had within 1 month as 17 cases (42.5%). Symptoms are abdominal pain, hematochezia, anorexia, abdominal mass and diarrhea. The most frequent symptom was the abdominal pain as 85%. Crohn's disease was diagnosed only 45% before operation, less than what we expected. In another hand it surprised us find out that tuberculosis enteritis was diagnosed as much as 20%. The most common indication of operation was medical treatment failure as 13 cases, and fistula was 7 cases, intestinal obstruction with stenosis and tumor were 6 cases each other. The involvement of small bowel was most common as 40%, and the most common operative findings were ulceration and fistula for 17 cases and 12 cases respectively. Small bowel cases were treated with segmental resection and anastomosis in all 16 cases. Large bowel cases were performed right hemicolectomy in 10 cases and total colectomy in 1 case. Both small and large bowel involvement cases, right hemicolectomy was done in 4 cases, right hemicolectomy and segmental resection of small bowel was done in 6 cases. The recurrence rate of postoperative medical treatment was 16% and 28% for 5 years and 10 years respectively. The recurrence rate with no postoperative medical treatment was 13% and 26% for each 5 years and 10 years. There was no significantly difference in both groups. CONCLUSION: The major surgical indications for Crohn's disease were medical treatment failure, fistula and intestinal obstruction. Specially in Korea, differential diagnosis with tuberculosis enteritis was very important. Postoperative complication and recurrence rate has relatively low incidence. Our study suggest that postoperative medical treatment was controversial.