Inflammatory Myofibroblastic Tumor Misdiagnosed as Intrahepatic Cholangiocarcinoma / 대한소화기학회지

An inflammatory myofibroblastic tumor (IMT) is a rare tumor that is currently classified as an intermediate cancer according to the World Health Organization classification system. The pathophysiology of its occurrence is still unknown. Imaging tests, such as CT or MRI, can be helpful in diagnosis, but the final diagnosis is confirmed by a pathological examination through a biopsy and immunohistochemistry stain. The patient, in this case, presented an asymptomatic intrahepatic mass discovered incidentally on an imaging examination. Initially, intrahepatic cholangiocarcinoma was suspected, but she was finally diagnosed with IMT through a histological examination after a liver resection.

Solid Pseudopapillary Neoplasm of the Pancreas with Lymph Node Metastasis in a Young Male Patient / 대한소화기학회지

Solid pseudopapillary pancreatic neoplasms are rare. The male-to-female ratio is 1:9, and metastasis occurs only in a few cases. A 39-year-old male with a solid pseudopapillary neoplasm (SPN) with lymph node metastasis underwent ultrasonography, CT, and MRI, which revealed a mass (8 cm) in the pancreatic head. Fluorodeoxyglucose (FDG)-PET showed a hypermetabolic lymph node in the root area of the superior mesenteric artery (SMA). The patient underwent pylorus-preserving pancreaticoduodenectomy, which confirmed a peripancreatic lymph node metastasis. The lymph node of the SMA root area remained because of the encasing of the superior mesenteric artery. After 14 months of follow-up (with no adjuvant therapy initiated), the residual metastatic lymph nodes showed no change and no recurrence. In conclusion, surgery of the primary tumor for patients with SPN is recommended, even in cases with metastatic lymph nodes remaining.

Endoscopic Removal Through a Gastrostomy of Swallowed Acupuncture Needles / 대한소화기학회지

Acupuncture is a representative treatment field in oriental medicine that is used widely in various medical conditions. Although acupuncture is considered a safe procedure, it can cause complications. This paper reports the case of a 44-year-old quadriplegic woman who received a percutaneous gastrostomy (PEG) tube and was referred for the endoscopic removal of swallowed acupuncture needles. The needles were removed successfully by endoscopy through the PEG tube using the rendezvous technique without significant complications

Endoscopic Diagnosis of Aortoesophageal Fistula Not Presenting Hematemesis / 대한소화기학회지

Aortoesophageal fistula (AEF) is an extremely rare but lethal cause of massive gastrointestinal hemorrhage. Characteristic symptoms are mid-thoracic pain, sentinel minor hemorrhage, and massive hemorrhage after a symptom-free interval. Prompt diagnosis and immediate treatments are necessary to reduce mortality. However, AEF is difficult to diagnose because it is uncommon and often leads to death with massive bleeding before proper evaluation. We report a case of endoscopic diagnosis of AEF that did not present with hematemesis; it was treated with thoracic endovascular aortic repair (TEVAR) and surgery. A 71-year-old female presented to the emergency department with epigastric discomfort. Endoscopy demonstrated a submucosal tumor-like protrusion and pulsating mass with blood clots. Contrast-enhanced chest CT confirmed AEF due to descending thoracic aortic aneurysm. The patient immediately underwent TEVAR to prevent massive bleeding and subsequently underwent surgery. Endoscopists should consider AEF if they see a submucosal tumor-like mass with a central ulcerative lesion or a pulsating protrusion covered with blood clots in mid-esophagus during an endoscopy.

Hyperglycemia aggravates decrease in alpha-synuclein expression in a middle cerebral artery occlusion model / 한국실험동물학회지

Hyperglycemia is one of the major risk factors for stroke. Hyperglycemia can lead to a more extensive infarct volume, aggravate neuronal damage after cerebral ischemia. α-Synuclein is especially abundant in neuronal tissue, where it underlies the etiopathology of several neurodegenerative diseases. This study investigated whether hyperglycemic conditions regulate the expression of α-synuclein in middle cerebral artery occlusion (MCAO)-induced cerebral ischemic injury. Male Sprague-Dawley rats were treated with streptozotocin (40 mg/kg) via intraperitoneal injection to induce hyperglycemic conditions. MCAO were performed four weeks after streptozotocin injection to induce focal cerebral ischemia, and cerebral cortex tissues were obtained 24 hours after MCAO. We confirmed that MCAO induced neurological functional deficits and cerebral infarction, and these changes were more extensive in diabetic animals compared to non-diabetic animals. Moreover, we identified a decrease in α-synuclein after MCAO injury. Diabetic animals showed a more serious decrease in α-synuclein than non-diabetic animals. Western blot and reverse-transcription PCR analyses confirmed more extensive decreases in α-synuclein expression in MCAO-injured animals with diabetic condition than these of non-diabetic animals. It is accepted that α-synuclein modulates neuronal cell death and exerts a neuroprotective effect. Thus, the results of this study suggest that hyperglycemic conditions cause more serious brain damage in ischemic brain injuries by decreasing α-synuclein expression.

A Case of Ciliated Foregut Cyst of the Gallbladder / 대한소화기학회지

Congenital cysts of the gallbladder are extremely rare, hence only a few ciliated foregut cysts of gallbladder have been reported. We report a case of a 20-year-old woman presenting with mild right upper quadrant abdominal discomfort, with normal levels of serum bilirubin and liver function tests. Abdominal ultrasonography revealed a well-defined cystic mass measured about 2 cm attached to the neck of gallbladder, with internal echogenic debris suggesting a complicated cyst, such as a hemorrhagic cyst. Abdominal computed tomography and magnetic resonance cholangiopancreatography revealed similar findings. Laparoscopic cholecystectomy showed a slightly distended gallbladder. The size of cyst on the neck was 1.6x1.2 cm, and it contained mucosa lined by ciliated pseudostratified columnar epithelium and underlying smooth muscle layers. Histopathology identified a ciliated foregut cyst of gallbladder.

A Case of Sorafenib-induced DRESS Syndrome in Hepatocelluar Carcinoma / 대한소화기학회지

Sorafenib is currently the only targeted therapy available for advanced stage hepatocellular carcinoma (HCC). Cutaneous adverse events associated with sorafenib treatment include hand-foot skin reaction, but there has been no report of drug reaction (or rash) with eosinophilia and systemic symptoms (DRESS) syndrome. Here, we report a case of 72-year-old man with HCC and alcoholic liver cirrhosis who developed skin eruptions, fever, eosinophilia, and deteriorated hepatic and renal function under sorafenib treatment. He has since successfully recovered with conservative care.

Interstitial Pneumonitis in a Patient with Chronic Hepatitis C and Chronic Renal Failure on Interferon Therapy / 대한소화기학회지

After 4-months of alpha interferon (IFN-alpha), a 64-year old woman with chronic hepatitis C developed a cough and dyspnea and showed diffuse infiltrative opacities on her chest X-ray. Her symptoms persisted after stopping the IFN-alpha therapy. Pulmonary function testing revealed a reduced forced vital capacity. High-resolution computed tomography of the lung showed peripheral and peribronchovascular ground glass attenuation and consolidation associated with reticulation. Bronchoalveolar lavage was performed for further evaluation and showed a lymphocyte level of 8.2%, an uncommon finding in IFN-alpha-induced interstitial pneumonitis. We performed a lung biopsy to diagnose her disease and it suggested interstitial pneumonitis. This was considered to be due to the immunomodulatory effects of INF-alpha. Although rare, any sign of significant pulmonary involvement should be evaluated.

A Case of Pneumatosis Intestinalis in Refractory Acute Precursor B-Cell Lymphoblastic Leukemia-Lymphoma / 대한내과학회지

Pneumatosis intestinalis (PI) is an imaging phenomenon that represents air in the bowel wall. The cause of PI is variable, although specific etiologic factors remain unknown. It is an infrequent complication in leukemia patients and is associated with several medical and surgical conditions. PI often represents a benign condition, but it can also require surgery. Therefore, the assessment of PI with or without complications can be difficult. Herein, we report on an unusual case of a 63 year-old woman with refractory acute precursor B-cell lymphoblastic leukemia-lymphoma who presented with PI resulting from the leukemic process, and finally expired due to sepsis.

Response: A Retrospective Study on the Efficacy of a Ten-Milligram Dosage of Atorvastatin for Treatment of Hypercholesterolemia in Type 2 Diabetes Mellitus Patients (Korean Diabetes J 2010;34:359-67)

No abstract available.

A case of subdural hematoma in patient with chronic myeloid leukemia treated with high-dose imatinib mesylate / 대한혈액학회지

Imatinib mesylate (IM) is used to treat a wide range of diseases, including Philadelphia chromosome-positive chronic myeloid leukemia (CML), on account of its high tolerability and low incidence of minor adverse events. Hemorrhage is thought to be a rare complication of IM. Recently, IM has been associated with reduced alpha2-plasmin inhibitor and platelet dysfunction. We report here the case of a 33-year-old female patient with CML who experienced subdural hematoma after an incremental increase in IM dosage due to a loss of complete molecular response. This case indicates that physicians should be alert to this atypical cause of headache in patients taking high-dose IM.

Treatment of Hepatocellular Carcinoma with Portal Vein Thrombosis by Sorafenib Combined with Hepatic Arterial Infusion Chemotherapy

Treatment with sorafenib prolongs both the median survival and time to progression by nearly 3 months in patients with advanced hepatocellular carcinoma. Although the effects of combining sorafenib therapy with other anticancer treatment modalities have not been clarified, combination treatment is strongly expected to be beneficial. We report the case of a 50-year-old man who exhibited a partial response and portal vein thrombosis (PVT) revascularization after sorafenib combined with hepatic arterial infusion chemotherapy (HAIC). He exhibited a decrease in tumor size and PVT after 2 months of sorafenib monotherapy. However, no additional response was seen during the subsequent 2 months. To achieve a better tumor response, we combined HAIC with sorafenib. Daily cisplatin (7 mg/m2 on days 1-5) and 5-fluorouracil (170 mg/m2 on days 1-5) were infused repeatedly every 4 weeks, and the sorafenib prescription was modified. After four cycles of combined therapy, both the tumor size and PVT were much improved and exhibited partial response.

A Case of Meckel's Diverticulum Diagnosed for Recurrent Hematochezia in Old Age / 대한소화기내시경학회지

The small bowel is the most common site of an unknown origin of gastrointestinal bleeding. Meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract in children. The complications from Meckel's diverticulum such as bleeding decrease with age, and so Meckel's diverticular bleeding is very rare in old age patients. The diagnosis of Meckel's diverticulum may be very difficult and especially in old age patients. Capsule endoscopy and double balloon enteroscopy have recently become useful diagnostic tools for assessing diverticular bleeding and small bowel lesions as these techniques can examine the entire small intestine. We report here on a case of Meckel's diverticulum that was detected by capsule endoscopy and double balloon enteroscopy and this was confirmed by surgery in a 76-year-old man with recurrent hematochezia.

A Retrospective Study on the Efficacy of a Ten-Milligram Dosage of Atorvastatin for Treatment of Hypercholesterolemia in Type 2 Diabetes Mellitus Patients / 당뇨병

BACKGROUND: There have been few clinical studies on 10 mg atorvastatin as a starting dosage for treatment of hypercholesterolemia in type 2 diabetes mellitus (T2DM) patients. This retrospective study aims to evaluate the efficacy of 10 mg dosage of atorvastatin in clinical setting. METHODS: One hundred five enrolled patients with high levels of low density lipoprotein cholesterol (LDL-C, > 100 mg/dL) took 10 mg atorvastatin. After 6 months, they were divided into 'Responder group' (LDL-C or = 100 mg/dL), and the response rate was calculated. Thereafter, we subdivided the 'Responder group' into Maintenance (10 mg), Reduced dosage (5 mg), and Discontinuance group (0 mg). The 'Non-Responder group' was subdivided into Maintenance (10 mg) and Double dosage group (20 mg). After consecutive 6 months, the response rates of each 10 mg Maintenance groups were compared to those of the other groups, respectively. RESULTS: Following the first 6 months, the response rate of 10 mg fixed dosage was 74.3%. In the 'Responder group', response rates of 10 mg, 5 mg and Discontinuance groups following 6 months were 52.6%, 53.1%, and 12.5%, respectively. In the 'Non-responder group', response rates of 10 mg and 20 mg groups were 28.6% and 50.0%. Baseline LDL-C levels and body mass index (BMI) of 'Responder group' were significantly lower than those of 'Non-responder group' (P = 0.004, respectively). CONCLUSION: Hypercholesterolemia treatment with 10 mg, fixed dosage of atorvastatin was effective in three quarters of the subjects during the first 6-month treatment; however, a significant number of patients with high LDL-C levels and/or BMI require higher starting and maintenance dosage.

Comparison of Vascular Calcification Scores on Plain Radiographs as Predictors of Coronary Artery Disease in Hemodialysis Patients / 대한신장학회지

PURPOSE: Vascular calcification (VC) scores on simple plain radiographic films are known to be associated with coronary artery disease (CAD) and mortality. The present study was designed to demonstrate a correlation between VC scores of the hands and pelvis, and feet and lateral lumbar spine on plain radiographs. In addition, we analyzed the usefulness of checking all the plain radiographs for assessment of pre-existing CAD. METHODS: We recruited 61 hemodialysis (HD) patients from OO Dialysis Center. We checked the plain radiographic films of the feet, hands, pelvis, and lateral lumbar spine and evaluated VC scores with previously reported methods. We defined CAD based on myocardial scans, echocardiography, or coronary angiography. RESULTS: Positive associations were found between the VC scores of the feet, VC scores of the hands and pelvis, scores of abdominal aortic calcifications (AACs), and CAD. Approximately 30% of patients who had CAD could be missed based on a single VC scoring method. Patients who showed any one finding among the AAC scores >5, VC scores of the pelvis and hands >3 or arterial media calcifications of the feet on plain radiographs had a high sensitivity (93.8%) and a high negative predictive value (96.3%) for the presence of CAD. CONCLUSION: Each VC score was highly inter-correlated. All three VC scoring methods on plain radiographic films are useful screening tests for the presence of CAD in HD patients.

A Case of Jeujunogastric Intussusception Presented with Hematemesis after Distal Gastrectomy / 대한소화기학회지

Adult intussusception represents 5% of all cases of intussusception and accounts for only 1-5% intestinal obstructions. Intussusception is a rare complication after gastric surgery with an incidence estimated at 0.1%. Early diagnosis of the acute onset intussusception is critical because mortality rates increase abruptly with delay in surgical treatment. We present here a case of jejunogastric intussusception diagnosed by gastroscopy in a patient with a history of distal gastrectomy due to early gastric cancer who had experienced hematemesis.

Characteristics of Lesions Misdiagnosed as Obscure Gastrointestinal Bleeding / 대한소화기내시경학회지

BACKGROUND/AIMS: Double balloon enteroscopy (DBE) and capsule endoscopy (CE) are useful for evaluation of obscure gastrointestinal bleeding (OGIB). However, many bleeding sources within reach of conventional upper and lower endoscopes can be missed in patients who have undergone DBE and CE for OGIB. The aim of this study was to determine the incidence and characteristics of OGIB lesions within reach of a conventional endoscope in patients undergoing DBE and CE for the indication of OGIB. METHODS: This retrospective study included 134 patients who were evaluated for OGIB between March 2003 and May 2009 at Soonchunhyang University Hospital. RESULTS: Of the 134 patients, 76 underwent CE, 28 patients underwent DBE, and 30 underwent both CE and DBE. The incidence of OGIB lesions within reach of a conventional upper and lower endoscopy was 9.7% (n=13) and the mean age of patients was 51 years (range: 20 to 69 years). The most commonly missed lesion was duodenal ulcer (n=8). The other missed lesions were gastric ulcer (n=2), terminal ileal ulcer (n=2) and ileocecal valve ulcer (n=1). CONCLUSIONS: The duodenum should be observed closely in initial upper and lower endoscopy by experienced endoscopists. Performing a second EGD and ileocolonoscopy before DBE and CE may increase the diagnostic yield and improve cost-effectiveness in patients with OGIB.

A Case of Endoscopic Removal of Hypopharyngeal Papilloma under General Anesthesia with Nasotracheal Intubation / 대한소화기내시경학회지

Benign tumors of the hypopharynx are uncommon and papillomas are quite rare. Papillomas grow very slowly and they are well defined, mobile and sometimes pedunculated masses. In order to minimize the patient's discomfort, many endoscopists tend to pass the scope quickly through the throat, without trying to visualize the oral and hypopharyngeal lesion. As for the treatment of hypopharyngeal lesions, cases of endoscopic treatment are rare and any guidelines have not yet been defined. We present here a case of endoscopic removal of a hypopharyngeal papilloma with the patient under general anesthesia and nasotracheal intubation.

Characteristics of necrotizing fasciitis in three university hospitals in Korea / 대한내과학회지

BACKGROUND: Necrotizing fasciitis is a life threatening severe soft tissue infection primarily involving the fascia and the subcutaneous tissue with thrombosis of the cutaneous microcirculation. The purpose of the study was to analyze the microbiological and clinical characteristics of necrotizing fasciitis in Korea and to suggest adequate antibiotic therapy. METHODS: We retrospectively reviewed medical records of three Soonchunhyang University Hospitals in Seoul, Bucheon and Cheonan. Patients admitted for skin graft or secondary treatment were excluded. Blood cultures were obtained at the time of admission and pus cultures were obtained at the time of first operative debridement. RESULTS: Twenty two patients (16 males, 6 females, 16~82 years old, median age: 59 years old) were enrolled for this study. Fourteen pateints underwent surgical treatment and 2 of them died of necrotizing fasciitis. Gram positive organisms were isolated in 13 cases and gram negative organisms were isolated in 11 cases. Third generation cephalosporin resistant gram negative organisms were isolated in 3 cases. CONCLUSIONS: This study suggest that characteristics of necrotizing fascitis in Korea were; high proportion of aged person, predominance of type 2 necrotizing fascitis and increasing tendency of third generation cephalosporin resistant gram negative bacterial infections. Consequently, initial choice of empirical antibiotics for necrotizing fasciitis should consider 3rd generation cephalosporin resistant gram negative organisms. Prompt surgical debridement and adequate antimicrobial therapy are mandatory for improved survival.

Successful Hemoperfusion in Acute Phenobarbital Intoxication / 대한신장학회잡지

Phenobarbital is long acting barbiturate with low lipid solubility that act as central nervous system depressants and used as anticonvulsant, sedative, hypnotic drug. In acute severe barbiturate intoxication, through CNS depression, coma, respiratory arrest and hypotension may occur, which are the major causes of mortality. Mortality is 3% for blood levels over 80 mg/mL and the lethal dose in adult is estimated as 6 to 10 g. We report a case of phenobarbital intoxication in a 20 years old female, who was successfully treated by emergency hemoperfusion. She was in semicomatous state and had respiratory difficulty on the day of admission. It was estimated that she intakes 1.6 g of phenobarbital. She was treated with mechanical ventilation, urine alkalization and charcoal administration. Hemoperfusion was attempted to remove rapidly phenobarbital from blood. After hemoperfusion the blood phenobarbital level was decreased from 96 mg/mL to 67 mg/mL. On 2nd hospital day, the blood phenobarbital level was 56 mg/mL and she recovered her self respiration and mentality.