A Case of Aortoesophageal Fistula Complicated by a Stent for Benign Esophageal Stricture / 대한소화기내시경학회지

Self-expandable metallic stents (SEMS) are widely used for the palliative treatment of malignant strictures of the gastrointestinal tract. Recently, several studies tested whether a SEMS is an effective and safe option for benign esophageal stricture. Serious complications such as hemorrhage, compression of the bronchus, bronchoesophageal fistula, and esophageal rupture were infrequently encountered as complications of esophageal stent placement. Aortoesophageal fistula is extremely rare as a complication of esophageal SEMS insertion; only seven cases have been reported worldwide. We now report a case of an 80-year old female with aortoesophageal fistula after placement of a SEMS for an esophageal stricture.

A Case of Colonic Duplication Cyst Mimicking Gastrointestinal Stromal Tumor

Duplications of the gastrointestinal tract are rare congenital malformations that are usually present during the first decade of life. However, a smaller number of cases may remain occult until adulthood. Overall, the colon is the least common site of congenital gastrointestinal duplications. Colonic duplications can present with symptoms of diverticulitis and can be confused with acquired giant cysts or masses. We present a rare case of a duplication cyst of the colon in a female adult. Although the preoperative evaluations, including an abdominal CT scan and colonoscopy, were suggestive of a gastrointestinal tumor of the colon, the final diagnosis was a colonic duplication cyst based on the histopathologic examination of the resected specimen. Even if intestinal duplication cysts are uncommon, they should be considered in the differential diagnosis of intestinal masses.

A case of jejuno-jejunal intussusception caused by a small intestinal lipoma / 대한내과학회지

Intussusception is a prolapse of a segment of the intestine into the lumen of the adjacent intestine. The majority of intussusceptions occur in infancy and early childhood. Intussusception arising in adulthood represents only about 5% of all intussusceptions and is usually caused by a malignant small bowel lesion acting as an apex for intussusception. Lipoma is not a common tumor in the gastrointestinal tract, and gastrointestinal lipomas may be submucosal or subserosal. Most of them are asymptomatic, although they may cause abdominal pain, bowel obstruction, and gastrointestinal bleeding. Intestinal intussusception caused by lipoma is uncommon and is particularly rare when the lipoma is located in the small intestine. We report an unusual case of intussusception in an adult male patient, which was caused by a lipomatous lesion located in the proximal jejunum acting as a lead point.

Risk Factors for Lymph Node Metastasis after Endoscopic Resection for Early Colorectal Cancer

BACKGROUND/AIMS: Although endoscopic resection is widely used for the treatment of early colorectal cancer, the risk factors for lymph node metastasis are not clear. This study was designed to determine the risk factors for lymph node metastasis in patients with colorectal cancer who are treated by endoscopic resection. METHODS: The medical records of patients with histologically-proven early colorectal cancers who were treated by endoscopic resection between January 2002 and September 2008 were retrospectively reviewed. Information regarding the demographic data of patients and the clinicopathologic characteristics were recorded and analyzed. RESULTS: Twenty-nine patients who underwent subsequent surgical treatment after endoscopic resection for early colorectal cancer were enrolled in this study. Six patients (20.7%) had lymph node metastases on surgical pathologic examination. The predictive factors for lymph node metastasis were tumor morphology (non-polypoid flat tumors [p=0.019]), absence of background adenomas (p=0.033), and deep submucosal invasion > or = 2,000 um (p=0.012). Unexpectedly, the presence of vascular invasion was not associated with lymph node metastasis. CONCLUSIONS: The presence of vascular invasion might not be an absolute indication for additional surgical treatment of early colorectal cancer; however, deep submucosal invasion, accompanied by a gross tumor with a non-polypoid flat morphology, and the absence of background adenomas are potential risk factors for lymph node metastasis.

Hemobilia from Pancreatic Arteriovenous Malformation: Successful Treatment with Transportal Coil Embolization of Draining Veins / 대한소화기학회지

Pancreatic arteriovenous malformations (AVM) are extremely rare diseases frequently complicated by gastrointestinal hemorrhage. While surgical resection of affected lesion is preferred for the treatment of pancreatic AVM, angiographic intervention can be used as an alternative treatment, especially in surgically high-risk patients. We experienced a patient with pancreatic AVM manifested by hemobilia and biliary sepsis. Superior mesenteric and common hepatic arteriography showed pancreaticoduodenal AVM composed of nidus supplied by numerous fine feeding arteries and of draining veins encircling the common bile duct (CBD). Hemobilia was controlled by transportal coil embolization of draining veins of AVM around the CBD. Herein, we report this case with the review of literatures.

An Ampulla of Vater Carcinoid Tumor that Presented with Upper Gastrointestinal Bleeding / 대한소화기내시경학회지

A Carcinoid tumor of the ampulla of Vater is extremely rare, accounting for less than 0.3% of all gastrointestinal carcinoids. Most reported cases have arisen from the gallbladder. An ampullary carcinoid most commonly presents with jaundice or upper abdominal discomfort, and bleeding from the tumor is exceedingly rare. A diagnosis is most frequently made postoperatively due to submucosal spread of the tumor. As the metastatic potential cannot be predicted by tumor size, a Whipple pancreaticoduodenectomy rather than local excision is considered the treatment of choice. We herein report a case of a primary carcinoid tumor located at the ampulla of Vater that presented as gastrointestinal bleeding; the tumor was diagnosed by an endoscopic biopsy after a papillary sphinterotomy.

Clinical Outcomes of Lamivudine Therapy in HBeAg Positive Chronic Hepatitis B with Minimally Elevated ALT / 대한간학회지

BACKGROUND/AIMS: The aim of this study was to compare the efficacy of lamivudine therapy between chronic hepatitis B (CHB) patients, whose ALT levels less than 2 times the upper limit of normal (ULN) and patients whose ALT levels are more than 2 times ULN. METHODS: We retrospectively analyzed 508 consecutive patients with HBeAg-positive CHB who were treated with lamivudine for 1 year or more. Forty-six patients (Group A) with pretreatment ALT levels less than 2 times ULN were retrospectively compared with 462 patients (Group B) whose ALT levels are more than 2 times ULN. RESULTS: HBeAg seroconversion was achieved in 15 (32.6%) of group A and 162 (35.1%) of group B. The cumulative rates of HBeAg seroconversion in group A and B were 19% and 21% at 12 months; 35% and 31% at 24 months; and 38% and 39% at 36 months, respectively. HBV breakthrough was observed in 20 (43.5%) of group A and 192 (41.6%) of group B. The cumulative breakthrough rates of group A and B were 18% and 12% at 12 months; 33% and 29 % at 18 months; 45% and 42% at 24 months, respectively. Post-treatment relapse in group A and B occurred in 56% (5/9) and 41% (44/108), respectively. Therefore, the rates of the HBeAg seroconversion, breakthrough, and post-treatment relapse were not significantly different between these two groups. CONCLUSIONS: Lamivudine therapy in HBeAg-positive CHB patients whose ALT levels are minimally elevated is as effective as in treatment of the patients whose pretreated ALT levels are twice more than ULN.

A Case of Intra-abdominal Desmoid Tumor after Total Colectomy in a Patient with Familial Adenomatous Polyposis / 대한소화기내시경학회지

Familial adenomatous polyposis (FAP) arises from germline mutations of the adenomatous polyposis coli (APC) gene. FAP is characterized by the occurrence of hundreds to thousands of adenomas throughout the colorectum, and there is nearly a 100% risk of colorectal cancer. In addition to polyposis coli, patients with FAP can develop a variety of extracolonic manifestations. Recent advances in screening and surgery have reduced the colon cancer occurrence and death in FAP patients, leaving desmoid tumors as a leading cause of their morbidity and mortality. Treatment of desmoid tumors is generally considered to be challenging for both the doctor and the patient. We report here on an 18 year old man with resectable intra-abdominal desmoid tumor that developed after total colectomy due to FAP and we include a review of the relevant literature.

A Randomized, Comparative Study of Rabeprazole vs. Ranitidine Maintenance Therapies for Reflux Esophagitis: Multicenter Study / 대한소화기학회지

BACKGROUND/AIMS: Reflux esophagitis is a recurring condition for which many patients require maintenance therapy. This comparative, randomized multicenter study was designed to evaluate the effect of long-term maintenance treatment comparing proton pump inhibitor, rabeprazole and H2 receptor antagonist, ranitidine. METHODS: Eighty four patients with healed reflux esophagitis confirmed by endoscopy were randomly allocated to receive maintenance treatment with either rabeprazole 10 mg once daily or ranitidine 300 mg once daily for 32 weeks. Patients were seen every 8 weeks or at symptomatic relapse. RESULTS: Of 84 initially treated patients, 73 entered the maintenance study. The percentage of asymptomatic patients after 90-day and 210-day treatment were 97% and 81.5%, for rabeprazole and 74.3% and 62.3%, for ranitidine, respectively. After 32 weeks, the relapse rates of esophagitis were 21.3% in the rabeprazole group and 62.9% in the ranitidine group (RR: 0.405, 95% CI: 0.215-0.766). CONCLUSIONS: Maintenance treatment with rabeprazole (10 mg once daily) is superior to ranitidine (300 mg once daily) in keeping the patients with reflux esophagitis in remission over a 32 week period.

A Case of Broncho-esophageal Fistula Treated by Histoacryl(R) Injection Therapy / 대한소화기내시경학회지

Broncho-esophageal fistula is a disease of varying etiologies. Spontaneous fistula occurs as a result of malignancy, radiotherapy or inflammatory disease. The majority of fistulas are caused by iatrogenic causes. Treatment of fistula usually consists of surgery and conservative management. Recently, it has been reported that broncho-esophageal fistula can be treated endoscopically using tissue adhesive agent such as Histoacryl(R) and fibrin glue. We report a case of broncho-esophageal fistula as a complication of tuberculosis that was successfully treated by radiological Histoacryl(R) injection therapy with a review of literatures.

Endoscopic Mucosal Resection in Early Gastric Cancer Involving Duodenum / 대한소화기내시경학회지

It is difficult to perform endoscopic mucosal resection (EMR) in case of early gastric cancer involving duodenal bulb. To achieve complete resection, we applied a new METHOD: that is, EMR with an insulation-tipped diathermic knife (IT knife) was peformed by the retroflexion of endoscope in the bulb. This method was tried in 4 patients. For the antral side of the tumor, EMR was done using a needle knife or IT knife. The duodenal side of the tumor was resected by IT knife with the retroflexion of endoscope in the bulb. The complete resection was performed in 2 patients, an incomplete resection in one patient, and the laparoscopic subtotal gastrectomy was performed in the remaining one patient because reconstruction of partitional resection was very difficult and adenocarcinoma was found to involve the muscularis mucosa. We think that EMR with IT knife by endoscopic retroflexion in the bulb is effective for some cases of early gastric cancer involving the duodenal bulb.

Endoscopically Exposed Coil after Embolization for Bleeding Duodenal Ulcer / 대한소화기내시경학회지

Endoscopy has been the method of choice for the initial diagnosis and treatment of gastrointestinal bleeding. However, in the case of difficult localization or endoscopic failure, angiographic or surgical alternative may be recommended. The role of angiography has been emphasized recently to control upper GI bleeding. We experienced a case with deep ulcer displaying exposed vessel along the duodenal bulb, which imposed serious rebleeding risk. Although, active bleeding was controlled by the epinephrine injections in that patient, rebleeding risk was still high. So the patient underwent emergency angiography with embolization of the pancreaticoduodenal artery and gastroduodenal artery using multiple microcoils. Follow-up endoscopic examinations showed a coil protruding into the lumen from the ulcer bed, and the exposed coil at the ulcer base was completely by the regenerated epithelium three months later. Here in, we describe the rare case of a endodcopically exposed coil after embolization for bleeding duodenal ulcer which is the first case ever reported in Korea.

Combination Chemotherapy with 5-Fluorouracil and Heptaplatin as First-line Treatment in Patients with Advanced Gastric Cancer

Heptaplatin is a recently developed platinum derivative. This agent has been reported to have a response rate of 17% as a single agent, and tolerable toxicity in the treatment of advanced gastric cancer. The aim of this study was to evaluate the efficacy and toxicity of a combination of 5-fluorouracil (5-FU) and heptaplatin in patients with advanced gastric cancer. Forty-seven chemotherapy-naive patients with advanced or recurred gastric cancer were recruited. 5-FU was administered over 120 hr by continuous intravenous infusion from day 1 to 5, at a daily dose of 1,000 mg/m2 and heptaplatin was administered over 1 hr by intravenous infusion on day 1 at 400 mg/m2, and this cycle was repeated every 4 weeks. The response rate was 21%, median progression-free survival was 1.9 months (95% CI, 1.6 to 2.2 months). Median overall survival was 6.2 months (95% CI, 4 to 8.4 months) and the 1-yr survival rate was 29% for all patients. The most frequent toxicity was proteinuria. Toxicities were generally mild and reversible. This study demonstrates that the combination of 5-FU/heptaplatin combination is less active but tolerated in patients with advance gastric cancer.

Infestation state of clonorchis sinensis in patients with pancreatobiliary diseases in ulsan: based on bile examination / 대한내과학회지

BACKGROUND: Bile examination is believed to be the most precise method for detecting Clonorchis sinensis (CS) eggs. We carried out bile examination to evaluate infestation state of CS in patients with pancreatobiliary diseases in Ulsan, known as an endemic area of CS infestation. METHODS: We examined CS eggs in bile in three hundreds and nine patients with pancreatobiliary diseases. The bile was obtained from endoscopic nasobiliary or percutaneous transhepatic biliary drainage tubes. RESULTS: The overall egg positive rate was 27.5% (35.3% in male, 17.6% in female). The egg positive rate was not significantly different according to the age group: 20.0% in thirties, 26.7% in forties, 24.2% in fifties, 29.9% in sixties, 36.2% in seventies and 16.7% in eighties or more. The egg positive rate according to the disease, except CS cholangitis, was not also statistically different: 32.6% in bile duct cancer, 38.5% in gallbladder cancer, 11.1% in ampulla of Vater cancer, 24.0% in pancreatic cancer, 26.4% in gallstone diseases and 12.5% in the reminder. The location of gallstone and whether CS related diseases or CS unrelated diseases did not affect the egg positive rates. The egg positive rate in patients with normal radiological findings including cholangiography was 17.0%. CONCLUSION: This result shows that regardless of age, sex, and sorts of diseases, the infestation rate of CS was very high. On the basis of our results, it is therefore presumes that clonorchiasis is still endemic disease in Korea.

Duodenal Duplicated Cyst Manifested by Acute Pancreatitis and Obstructive Jaundice in an Elderly Man

A duodenal duplication cyst is an uncommon congenital anomaly that is usually encountered during infancy or in early childhood. Duodenal duplication cysts generally appear on the first or second portion of the duodenum and may cause duodenal obstruction, hemorrhage or pancreatitis. Here, we report a case of a duodenal duplication cyst on the second and third portion of the duodenum in an old aged man with obstructive jaundice and acute pancreatitis, which was treated successfully by a surgical excision.

A Case of Juxtapapillary Duodenal Duplication Cyst Manifested by Recurrent Pancreatitis / 대한소화기내시경학회지

Duodenal duplication cyst is an uncommon congenital anomaly that is usually encountered during infancy or in early childhood. The clinical manifestation is that of duodenal obstruction or, less commonly, obstructive jaundice, acute pancreatitis, or gastrointestinal bleeding. Here, we report a case of duodenal duplication cyst on the juxtapapillary region in a 19-year-old woman with an unusual clinical manifestation of recurrent pancreatitis and peculiar endoscopic finding of the cyst.

Santorinicele Containing a Pancreatic Duct Stone in a Patient with Incomplete Pancreas Divisum

Santorinicele, a focal cystic dilatation of the distal duct of Santorini, has been suggested as a possible cause of the relative stenosis of the accessory papilla, is associated with complete pancreas divisum, which results in acute episodes of pancreatitis or pain. This report describes a case of a santorinicele, which was initially detected by upper gastrointestinal endoscopy as a polypoid mass, in a patient with recurrent abdominal pain. The mass was subsequently proved to be a santorinicele containing a pancreatic duct stone associated with incomplete pancreas divisum on endoscopic retrograde pancreatography. To the best of our knowledge this is believed to be the first description of a santorinicele associated with these characteristic findings.

Two Cases of Intussusception Occurring through the Stoma after Gastric Surgery / 대한소화기내시경학회지

Intussusception is a rare but potentially serious complication of gastric surgery, and 6 cases have been reported in Korea. Diagnosis can be made by endoscopy, upper gastrointestinal series or computed tomography, but it needs a high index of suspicion for diagnosis. Early diagnosis and prompt surgical intervention is mandatory to avoid mortality. We report two cases of intussusception occurring through the stoma after gastric surgery. A 58-year-old woman presented with epigastric pain and vomiting followed by hematemesis, 30 years after gastrojejunostomy for pyloric obstruction caused by duodenal ulcer. Endoscopy showed jejunogastric intussusception and CT scan was compatible with the diagnosis. She was managed by segmental resection and anastomosis of the jejunum. Another 60-year-old man presented with epigastric pain and hematemesis, 7 years after total gastrectomy with a Roux-en-Y anastomosis for advanced gastric cancer. He was diagnosed as having chronic type jejunal intussusception by endoscopy and CT scan, and intussusception was resolved spontaneously.

Efficacy of Lamivudine in Patients with Hepatitis B e Antigen-Negative Chronic Liver Diseases / 대한간학회지

BACKGROUND/AIMS: Lamivudine therapy is effective in inhibiting HBV replications in patients with HBeAg-negative chronic liver disease. However, the sustained response rate appears to be particularly poor, because the vast majority of patients relapse soon after cessation of therapy. The aim of this study was to evaluate the efficacy of lamivudine, the breakthrough rate, and the relapse rate of discontinuing therapy after response in patients with HBeAg-negative chronic liver disease. METHODS: Fifty-nine patients with HBeAg-negative chronic liver disease who have received lamivudine for at least 6 months, were studied. The mean duration of treatment was 14 months. Complete response was defined as undetectable serum HBV DNA by bDNA and normalization of ALT levels. Once HBV DNA disappearance and ALT normalization were observed, lamivudine therapy was continued for at least two additional months. The mean follow-up after cessation of treatment was 6 (1-22) months. RESULTS: Fifty-six patients were undetectable HBV DNA. The cumulative HBV DNA loss rates at 3 months and 5 months were 90% and 95%, respectively. The ALT normalization was observed in 52 patients. The cumulative ALT normalization rates at 6 months and 10 months were 78% and 86%, respectively. The complete response was observed in 52 patients. The cumulative rates of complete response at 10 months and 18 months were 80% and 88%, respectively. A predictive factor for complete response was only the duration of lamivudine treatment. Virological breakthrough was observed in 5 (8.5%). Thirty-four patients stopped taking lamivudine after 7.7 (2-15) months of the additional therapy. Seventeen of those patients (50%) experienced relapse. The cumulative relapse rates at 3 months, 6 months and 10 months were 24%, 47%, and 66%, respectively. The only predictive factor for relapse was the duration of additional lamivudine treatment after response. CONCLUSIONS: Lamivudine was an effective treatment of HBeAg negative chronic liver disease. Relapse, however, was usually observed after cessation of lamivudine. Our results showed that long-term lamivudine therapy is required in order to decrease the high relapse rates in patients with HBeAg-negative chronic liver disease.

Diagnostic Usefulness of Intradermal Test for Clonorchiasis in Patients with Pancreatobiliary Diseases / 대한소화기학회지

BACKGROUND/AIMS: The diagnosis of clonorchiasis is based on demonstrating eggs in stool or bile. It is believed that bile examination is the most precise method for detecting eggs. We evaluated diagnostic usefulness of intradermal test (IDT) by comparing it with the result of bile examination. METHODS: For 88 patients with pancreatobiliary diseases, we examined Clonorchis sinensis eggs in bile and performed IDT for clonorchiasis. The bile was obtained from endoscopic nasobiliary or percutaneous transhepatic biliary drainage tubes. RESULTS: We calculated ROC curve to decide the cut-off value of IDT in determining diagnostic accuracy on the basis of bile examination. We chose a value of 40 mm2, which significantly improved the sensitivity, without reducing the specificity. With a cut-off value of 40 mm2, the sensitivity, specificity, positive and negative predictive values of IDT were 81.5%, 67.2%, 52.4%, and 89.1%, respectively. The value of IDT was not affected by age and showed no difference between benign and malignant diseases. However, in egg-positive patients, the mean value was lower in malignant diseases than in benign diseases. CONCLUSIONS: In patients with pancreatobiliary diseases, IDT with a cut-off value of 40 mm2 seems to be a valuable supplementary diagnostic test for clonorchiasis in view of its high sensitivity.