Association between Smoking and the Progression of Computed Tomography Findings in Chronic Pancreatitis

BACKGROUND/AIMS: Smoking and alcohol intake are two well-known risk factors for chronic pancreatitis. However, there are few studies examining the association between smoking and changes in computed tomography (CT) findings in chronic pancreatitis. The authors evaluated associations between smoking, drinking and the progression of calcification on CT in chronic pancreatitis. METHODS: In this retrospective study, 59 patients with chronic pancreatitis who had undergone initial and follow-up CT between January 2002 and September 2010 were included. Progression of calcification among CT findings was compared according to the amount of alcohol intake and smoking. RESULTS: The median duration of follow-up was 51.6 months (range, 17.1 to 112.7 months). At initial CT findings, there was pancreatic calcification in 35 patients (59.3%). In the follow-up CT, progression of calcification was observed in 37 patients (62.7%). Progression of calcification was more common in smokers according to the multivariate analysis (odds ratio [OR], 9.987; p=0.006). The amount of smoking was a significant predictor for progression of calcification in the multivariate analysis (OR, 6.051 in less than 1 pack per day smokers; OR, 36.562 in more than 1 pack per day smokers; p=0.008). CONCLUSIONS: Continued smoking accelerates pancreatic calcification, and the amount of smoking is associated with the progression of calcification in chronic pancreatitis.

A case of hepatoblastoma misdiagnosed as combined hepatocellular carcinoma and cholangiocarcinoma in an adult

Hepatoblastoma usually occurs in children under the age of 2 years, with very few cases reported in adults. We experienced a case of adult hepatoblastoma in a 36-year-old female with chronic hepatitis B . She had experienced sudden onset abdominal pain. Her serum alpha-fetoprotein level was markedly elevated, and abdominal CT showed a 9-cm mass with internal hemorrhage in the right hepatic lobe with hemoperitoneum, so an emergency hepatic central bisectionectomy was performed. The initial histologic examination revealed that the mass mimicked combined hepatocellular carcinoma and cholangiocarcinoma with spindle-cell metaplasia of the cholangiocarcinoma element. Follow-up abdominal CT performed 3 months later showed a 5.5-cm metastatic mass in the left subphrenic area. Laparoscopic splenectomy with mass excision was performed, and hepatoblastoma was confirmed histologically. A histologic re-examination of previously obtained surgical specimens also confirmed the presence of hepatoblastoma. Metastatic hepatoblastoma was found at multiple sites of the abdomen during follow-up, and so chemotherapy with cisplatin, 5-fluorouracil (5-FU), and vincristine was applied, followed by carboplatin and doxorubicin . Despite surgery and postoperative chemotherapy, she died 12 months after symptom onset.

A Case of Biliary Cast Syndrome after Cadaveric Liver Transplantation / 대한소화기학회지

We experienced one fatal case of biliary cast syndrome after cadaveric liver transplantation involving both intrahepatic ducts. A 58-year-old man underwent cadaveric liver transplantation because of hepatitis B virus related liver cirrhosis and concomitant hepatocellular carcinoma. Five weeks after the liver transplantation, postoperative course was complicated by development of acute cholangitis. Subsequent endoscopic retrograde cholangiography revealed diffuse intrahepatic bile duct strictures without filling defects. Percutaneous liver biopsy, which was done to exclude rejection, revealed biliary cast. Successful endoscopic removal was precluded due to its diffuse involvement. Because of the deterioration of patient's condition by refractory biliary obstruction and cholangitis, retransplantation from cadaveric donor was performed. Debridement of the biliary tree after graft removal yielded a near-complete cast of the intrahepatic ductal system. Biliary cast syndrome should be suspected when jaundice or cholangitis is associated with dilated ducts on abdominal imaging studies in cadaveric liver transplantation recipients. Initial therapeutic options include removal of biliary cast after endoscopic or percutaneous cholangiography. Although endoscopic retrieval of biliary cast by endoscopic retrograde cholangiopancreatography could be employed as a first-line management, other modalities such as endoscopic nasobiliary drainage, percutaneous transhepatic drainage, or retransplantation should be considered when complete removal is not feasible and the condition of the recipient deteriorates.

Remission of Refractory Intestinal Behcet's Disease with Infliximab / 대한류마티스학회지

Behcet's disease is a chronic, relapsing vasculitis of unknown origin that affects nearly all organs. The most frequent extra-oral sites of gastrointestinal involvement are the ileocecal lesion and the colon. The lesions are typically resistant to medical treatment and frequently recur with surgical treatment. We describe a patient who had intestinal Behcet's disease complicated perforation and enterocutanous fistula with a good response to infliximab.

A Case of McCune-Albright Syndrome with Associated Multiple Endocrinopathies

McCune-Albright syndrome (MAS) is a rare disorder that develops from an activating mutation in the Gs gene. It is characterized by an association with Polyostotic fibrous dysplasia, and precocious puberty, Caf-au-lait pigmentation, and other endocrinopathies that result from the hyperactivity of a variety of endocrine glands. Recently we encountered a patient with MAS with fibrous dysplasia, skin pigmentation, acromegaly, hyperprolactinemia and a thyroid nodule. A 23-year-old male presented for an evaluation of a change in his facial structures. Fibrous dysplasia was diagnosed by a bone biopsy and radiographic studies. The GH level increased paradoxically after an oral glucose load. The plasma prolactin, IGF-1 and alkaline phosphatase were high. Thyroid ultrasonography revealed multiple nodules. The brain MRI demonstrated a mass in the left pituitary gland. Genetic analysis identified a change from Arg (CGT) at codon 201 to Cys (TGT).

Endoscopic Ultrasonography in Upper Gastrointestinal Subepithelial Lesions / 대한소화기내시경학회지

BACKGROUND/AIMS: Endoscopic ultrasonography (EUS) is known for its value to characterize incidentally found subepithelial lesions, and we so reviewed our data to validate the norm. METHODS: We analyzed the records of the patients with suspected subepithelial lesions at the time of endoscopy, which was performed from Aug. 2001 to Oct. 2004. RESULTS: The data includes 622 patients (248 males) with average age of 52 years (age range 15~83 years). Extraluminal compression was noted in 10.1% of the patients. Intraluminal lesions were dominant in the stomach and their average size was 14.8 mm. The inner three wall layers were the predominant layers of origin. Mesenchymal tumors were the most frequent EUS impression. Pathologic findings were available for 88 patients and 80.7% of them were benign. Compared with the pathology, the diagnostic accuracy of EUS was 78.4%. The differentiation of malignant and benign GISTs by the EUS findings was 56.3%. Among the 60 EUS cases that had follow up data available (at mean interval of 12.2 months) and who also had less than 3 cm benign lesions, growth was detected only in 10 cases (17%). Pathology confirmed that the lesions in 3 of them were benign. CONCLUSIONS: More than 10% of the subepithelial lesions found from endoscopy were extraluminal compression. The majority of intramural lesions were benign. The EUS impression was relatively accurate and helpful for the management of upper gastrointestinal submucosal lesions.

The Usefulness of Endoscopic Ultrasonography in the Diagnosis of Common Bile Duct Stones / 대한소화기내시경학회지

BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for diagnosis and treatment of common bile duct stones (CBDS). However it is associated with some complications. Endoscopic ultrasonography (EUS) is an efficient diagnostic tool for CBDS with better accuracy than ultrasonography (USG) or computed tomography (CT) and lower complication rate than ERCP. We evaluated the diagnostic usefulness of EUS in suspicious CBDS. METHODS: From Oct. 2001 to Mar. 2004, 84 patients with the suspicion of CBDS, without definite evidence on CT and/or USG were evaluated with EUS. The reports were reviewed retrospectively. RESULTS: Patients were 38 males, 46 females with mean age of 56 years old. CBDS were found in 25 (29.8%) patients. In the diagnosis of CBDS undetected in CT and/or USG, EUS gave 96% sensitivity, 96.6% specificity, 92.3% positive predictive value and 98.3% negative predictive value. When CBDS were found in EUS, the average sizes of CBD and CBDS were 8.8 mm (4~16.7) and 6.4 mm (3.3~9.1) respectively. Diagnostic ERCP was avoided in 54 (64.3%). EUS provided additional diagnosis such as gallbladder stones, gallbladder cancer, ampullary cancer and adenoma. No complication was associated with EUS. CONCLUSIONS: EUS is reasonably safe and accurate procedure in detecting CBDS. EUS may possibly replace diagnostic ERCP in CBDS.