Clinical characteristics and the risk factors for rebleeding in patients with bleeding peptic ulcer / 대한내과학회지

BACKGROUND/AIMS: Bleeding is a serious complication of peptic ulcer. Although endoscopic therapy is effective for achieving hemostasis of active bleeding, rebleeding occurs in 10~30% of these patients. Recently, treatment with proton pump inhibitor (PPI) after hemostasis has decreased the rate of rebleeding. In this study, we analyzed risk factors of peptic ulcer rebleeding and we evaluated whether the rebleeding rate could be different depending on the PPI treatment method. METHODS: From March 2003 through February 2006, 639 patients visited the emergency room (ER) due to gastrointestinal hemorrhage. Among them, 191 patients were diagnosed to have peptic ulcer by endoscopy, and they were retrospectively analyzed for their clinical, laboratory and endoscopic findings. The PPI treatment method was categorized into the IV bolus group, the 8 mg/hr continuous infusion group and the others group. RESULTS: Emergency endoscopy was performed within 24 hours in 86.9% of the patients with bleeding peptic ulcer. Rebleeding occurred in 9 cases (4.7%) within 7 days after hemostasis. On the basis of univariate analysis, shock on ER arrival (p=0.013) and over 5 units of packed red cells (PRCs) transfusion (p=0.016) were significant risk factors for rebleeding, yet the PPI treatment method did not affect the rate of rebleeding. CONCLUSIONS: The rebleeding rate of peptic ulcer in our study was 4.7%, and this was lower than the previous reports, and the rebleeding rate in our report may have been caused by the early hemostatic therapy together with intravenous infusion of PPI. These approaches are necessary as soon as the patients are stabilized, and especially for the group of patients who are at a high risk for rebleeding, such as those who experience shock at the ER and those who need over 5 units of PRC transfusion.

Effect of Low-dose, Enteric Coated Aspirin on Gastrointestinal Bleeding in Patients with Coronary Artery Disease

BACKGROUND/AIMS: This study was performed to determine whether low-dose aspirin and/or clopidogrel can induce gastrointestinal bleeding and gastroduodenal mucosal injury. METHODS: A total of 387 patients who underwent coronary angiography at Seoul National University Bundang Hospital were assigned to one of three antiplatelet treatment groups: (1) control, (2) 100-mg enteric coated aspirin, and (3) 100-mg enteric coated aspirin plus clopidogrel. The incidences of gastroduodenal mucosal injury and gastrointestinal bleeding were prospectively evaluated, and risk factors for gastrointestinal bleeding were analyzed. RESULTS: The rate of gastroduodenal mucosal injury was higher in the aspirin-plus-clopidogrel group than in the aspirin group (p=0.012), and higher in the aspirin group than in the control group (p=0.049). The rate of gastrointestinal bleeding was significantly higher in the aspirin-plus-clopidogrel group (9.4%) than in the control group (2.4%, p=0.048). The risk factors for gastrointestinal bleeding were older age (> or =60 years) and the presence of at least two comorbid disorders. CONCLUSIONS: Low-dose enteric coated aspirin was found to be safe in patients with coronary artery disease, but the addition of clopidogrel increased the rate of gastrointestinal bleeding. Combined clopidogrel and aspirin should be used with caution in older patients having at least two comorbid conditions.

Recent Etiology and Clinical Features of Acute Viral Hepatitis in a Single Center of Korea / 대한간학회지

BACKGROUND AND AIMS: The etiology of acute viral hepatitis in Korea has been dynamically changing during the recent years. The aim of this study was to investigate the recent etiology and the clinical features of acute viral hepatitis in a single center of Korea. METHODS: We performed a retrospective analysis of a prospective cohort of 55 patients who were diagnosed with acute viral hepatitis A to E during the period from May 2005 to August 2006. In addition to the clinically acute manifestations, the confirmatory serological tests were performed for the diagnosis of acute hepatitis A, B, C and E. RESULTS: The proportion of patients with acute viral hepatitis A, B, C, E and others were 56.4% (n=31), 12.7% (n=7), 18.2% (n=10), 9.1% (n=5) and 3.6% (n=2), respectively. The mean age of the patients with acute hepatitis A, B, C and E were 29.1+/-4.38, 38.7+/-11.72, 45.3+/-17.62 and 32.4+/-6.58 years, respectively. There was no fatal case. All cases of acute hepatitis B and six out of ten cases of acute hepatitis C recovered spontaneously. Four out of the five patients with acute hepatitis E had no history of travel to endemic area. CONCLUSIONS: The most common etiology of acute viral hepatitis in Korea is hepatitis A virus, and hepatitis C and B virus were the next most common causes. The sporadic cases of acute hepatitis E were not rare, and coinfection of HAV and HEV was observed. A multicenter, prospective study is warranted in the future.

Acute Exacerbation of Hepatitis in Liver Cirrhosis with Very High Levels of alpha-Fetoprotein But No Occurrence of Hepatocellular Carcinoma

Aminotransferase levels do not always increase during acute hepatitis or during an acute flare-up of chronic hepatitis. Persistently increased levels of serum alpha-Fetoprotein in an adult with liver disease suggest not only the presence or progression of hepatocellular carcinoma or its recurrence after hepatic resection or after other therapeutic approaches such as chemotherapy or chemoembolization, but also it suggests that there is an acute exacerbation of hepatitis or liver cirrhosis. We report here on two unusual cases of HBV- and HCV-related liver cirrhosis with acute exacerbation of hepatitis in which there was an insignificant elevation of the aminotransferase levels, but there were markedly increased alpha-Fetoprotein levels observed. The levels of alpha-Fetoprotein decreased gradually in both cases since the beginning of antiviral therapy, which implies that the increased levels were due to aggravation of the accompanying hepatitis. These cases also emphasize that using only the measurement of alpha-Fetoprotein is not sufficient for the diagnosis of hepatocellular carcinoma, and that this diagnosis also requires a more specific measurement such as AFP L3 along with the standard imaging studies.

A Case of Broncholithiasis Caused by Aspergillus with Broncho-Obstructive Pneumonia and Massive Hemoptysis / 결핵및호흡기질환

A broncholith is a calcified mediastinal lymph node, which partially or completely erodes into the bronchial lumen, and is related to the late tissue response to healing of granulomatous pulmonary infections, most commonly histoplasmosis or tuberculosis. However, there have been a few reports on broncholithiasis caused by Aspergillus. We experienced a case of broncholithiasis caused by Aspergillus, with broncho-obstructive pneumonia and massive hemoptysis. A 39 year-old woman was admitted to our hospital with right middle lobar pneumonia. On the fourth day following admission, massive hemoptysis developed, so an emergent bronchial artery embolization was performed. On the ninth day following admission, a broncholith on the lateral segmental bronchus of the right middle lobe was found by bronchoscopy, which was proved to be Aspergillus hypae with calcification on histological examination. After the simple bronchoscopic removal of the broncholith and empirical antibiotic therapy, the patient recovered without any complications.

A Case of Spontaneous Gallbladder Perforation

Gallbladder perforation is an almost exclusive complication of cholecystitis, which accompanies severe inflammation of the gallbladder with or without cholelithiasis. Whether it is of a calculous or acalculous origin, gallbladder perforation, as a complication of acute cholecystitis, has common symptoms, signs, laboratory data, radiological findings and treatment modalities. Even though many reports of gallbladder perforation have been published, there are few reports of gallbladder perforation without any clinical and radiological indications. We experienced a case of a 70-year-old woman with acute abdomen, which was found to be peritonitis caused by spontaneous gallbladder perforation that was devoid of clues suggesting this condition. Although rare and unusual, this case shows that this disorder should be considered in elderly patients presenting with peritonitis with an unknown etiology.