A Case of Xanthogranulomatous Cholecystitis / 대한내과학회지

Xanthogranulomatous cholecystitis is an extremely rare benign inflammatory disease of the gall bladder characterized by yellowish focal nodular appearance with tissue necrosis and lipid-containing histiocyte (xanthomacell). Recently, we experienced a case of xanthogranulomatous cholecystitis. A 71-year old woman was admitted with the complaints of RUQ pain for 1 month. On abdominal ultrasound examination, there were diffuse gallbladder wall thickening, echogenic nodule with acoustic shadow, the calculous cholecystiti and the gall badder cancer were strongly suspected and the operation was performed. At operation the gall bladder was marked enlarged and wall thickening with two brownish, oval shaped, smooth surfaced stones. The specimen was revealed a xanthogranulomatous cholecystitis by the pathology.

Assessment of Autonomic Disturbance by 24-hour Heart Rate Variability in Patients with Liver Cirrhosis / 대한내과학회지

OBJECTIVE: Heart rate variability(HRV) is helpful to diagnosis autonomic disturbance and sympathetic-parasympathetic imbalance in patients with myocardial infarction and diabetes mellitus. Patients with liver cirrhosis demonstrate reduced blood pressure despite increased heart rate and increased cardiac output, indicating a fall in peripheral vascular resistance. Autonomic disturbance may contribute to this phenomenon. The aim of the present study is to evaluate the degree of autonomic disturbance and the circadian rhythm of autonomic nervous system by estimating HRV with 24 hour-Holter recorder, METHODS: 24 hour-HRV with Del Mar Avionics 563 Holter recorder and cardiovascular reflex tests were carried out on 32 patients with liver cirrhosis and 20 control subjects. We evaluated the presence of autonomic disturbance, and assessed quantitatively the autonomic disturbance. RESULTS: 1) Among cardiovascular reflex tests, Valsalva test, standing test and deep breathing test were showed a significantly decreased response in liver cirrhosis compared with control groups. 2) The standard deviation of 24hours average R-R intervals were showed a significantly decrease in liver cirrhosis than control groups(P<0.0001). The HRV of low frequency(LF. P<.D.001), high frequency(HF, P<0.0001) and total power spectral density (P<0.0001) in liver cirrhosis were statistically lower than control. 3) The LF/HF ratio of patients with liver cirrhosis was showed higher than control at night CONCLUSION: Non-invasive assessment of 24 hour-HRV has a few advantages in the diagnosis and degree of autonomic disturbance, evaluation of diurnal variation of autonomic tone.

A Case of Granulomatous Pancreatitis Caused by Syphilis / 대한내과학회지

Granulomatous pancreatitis is a granulomatous inflammatory disease of the pancreas and can he described only in infectious granulomas and pancreatic involvement by systemic granulomatosis. Sarcoidosis, isolated pancreatic involvement without systemic granulomatosis or a manifestation of systemic sarcoidosis, is more common cause of granulo-mataus pancreatitis than infectious granuloma. There has been some reports show a characteristic histological finding of the pancreatic involvement of sarcoidasis. Noncaseating granuloma is thought to be the characteristic finding of pancreatic sarcoidosis. But granulomatous pancreatitis caused by syphilis in a syrnptomatic patient is a very rare disease and, till now, to our knowledge, only a case was reported in 1987, Germany. We experienced a 55-year-old female patient with granulomatous pancreatitis caused by tertiary syphilis who presented as a recent onset jaundice, diarrhea, fatigue and vague epigastric discomfort. Radical pancreaticoduo-denectomy was performed, which showed noncaseating granulomatous pancratitis with vasculitis. To our knowledge, this is the first case of granulomatous pancreatitis caused by syphilis in Korea. We hereby report a case of granulomatous pancreatitis caused by syphilis with a brief review of literature.

Eosinophilic gastroenteritis associated with food allergy and bronchial asthma

I n some patients, eosinophilic gastroenteritis(EG) occurs in those with food allergy. We experienced a non-atopic asthmatic who had an EG associated with food allergy to fish and eggs, and blood eosinophilia. A skin prick test and RAST to causative food allergens showed a negative result. A fiber-optic endoscopic biopsy from the gastric mucosa showed an intense eosinophilic infiltration. We could find symptomatic improvement and a disappearance of eosinophilic infiltration in gastric mucosa after complete avoidance from the causative food and oral cortcosteroid. It was suggested that fiber-optic endoscopic biopsy might be needed to identify coexisting EG if an allergic patient with blood eosinophilia complains of severe gastrointestinal symptoms.

A Clinical Study on Hypertensive Encephalopathy

Hypertensive encephalopathy is an acute clinical syndrome that shows central nerve dysfunction with sudden and marked elevation in blood pressure. But its pathophysiologic mechanisms, clinical courses and prognosis are still not clear. In order to study clinical manifestations and response to treatment in patients with hypertensive encephalopathy, we reviewed 45 patients with hypertensive encephalopathy who were admitted in Dept. of Internal Medicine, National Medical Center, from January 1975 to December 1984. The following results were obtained: 1) The ratio of male to female was 1.1:1. The peak age of incidence was in the 6th and 7th decade with mean age of 57.5 years. 2) Among 45 patients, only 29 had known history of hypertension and the average duration of hypertension was 8.1+/-3.6 years. 3) The most common sympotm was severe headache (68.9%). And altered consciousness, nausea and/or vomiting, focal neurologic signs and visual disturbance were also common symptoms in decreasing order of frequency. 4) Funduscopic examination showed hypertensive retinopathy in 20 of 24 (91.7%) patients and lumbar puncture revealed increased CSF pressure in 12 of 20 (60%) patients. 5) In most patients, the mean interval to symptomatic improvement was 2.1 days after administration of anti hypertensive agents, but in 6 patients with initial mean arterial blood pressure above 170mmHg, 4 patients showed delayed response and 2 patients were expired.

Studies on Hemodynamic Assessment and Ventricular Performance in Patients with Mitral Valvular Disease

The cardiac performance is regulated by the intergration of preload, afterload, contractility (inotropism), heart rate and synergy of ventricular contraction, which are the major determinants that govern the stroke volume and cardiac output. Valvular heart disease may be considered to impose two different types of stress on the cardiac chamber proximal to the lesion. There are either pressure overload(increased after load) or volume overload(increased preload). The compensatory mechanism of the pressure overload and volume overload offer to hypertrophy and dilatation of the chamber. Hypertrophy, increased muscle mass, calls upon the development of greater systolic force. Dilatation, overfilled chamber volume enables increased strength and extent of shortening by Frank Starling's mechanism. In these view, we shall discuss the hemodynamic parameters; cardiac output, stroke volume, ventricular end-diastolic pressure, and the rate of ventricular pressure rise(peak dp/dt), mitral valve gradient and pulmonary circulation. The authors had an opportunity to study 40 cases of mitral valvular heart disease which were accepted during the left ventricular angiography at the cardiac catheterization room and at the fields of operative findings during the period Jan. 1977, throught Sept. 1980, at the Department of Internal Medicine, National Medical Center. The following conclusions were drawn: 1) Cardiac index was 2.65 L/min/m2in average, among 18 cases with mitral stenosis and 2.54 L/min/m2 in average, among 15 cases with mitral valve area of less than 1.0 cm2. Cardiac index was 2.58 L/min/m2in average, among 19 cases with mitral stenoinsufficiency and 3.43 L/min/m2 in average, among 3 cases with pure mitral insufficiency. 2) The mean right ventricular end-diastolic pressure elevated more than 0-8 mmHg were found in 12 cases with mitral stenosis out of 18 cases and mean miral valve area was 0.8m2. The mean left ventricular end-diastolic pressure was also elevated more than 0-12 mmHg in 6 cases out of 12 cases with mitral stenosis in addition to right ventricular failure. These 12 cases of mitral stenosis had cardiac function more than class III clinically. 3) 15 cases with mitral valve area, less than 1.0cm2 demonstrated left ventricular diastolic filling pressure gradient (MVG) of 17.3mmHg in average, the pulmonary vascular resistance of 568 dyndsecd cm(-5) in average, and the right ventricular peak systolic pressure of 72mmHg in average respectively. In all instances, the right ventricular end-diastolic pressure was 11.2mmHg in average and right ventricular peak dp/dt was 571mmHg in average. 4) Among 22 cases with mitral insufficiency, and/or mitral stenoinsufficiency 16 cases showed mean left ventricular end-diastolic pressure elevated more than 0-12mmHg. 10 cases out of these 16 cases disclosed also right ventricular end-diastolic pressure elevated more than 0-8 mmHg. These 16cases of mitral insufficiency and/or mitral stenoinsufficiency had cardiac function more than class III clinically. 5) 16 cases with mitral insufficiency and/or mitral stenoinsufficiency who had mean left ventricular end-diastolic pressure more than 0-12 mmHg showed pulmonary vascular resistance, 358 dyndsecd cm(-5) in average, systemic vascular resistance, 1621 dyne/sec/cm5 in average and left ventricular peak dp/dt, 768-2102mmHg/sec in range. 6) Pulmonary hypertension elevated more than 50mmHg of pulmonary arterial systolic pressure was found in 14 cases out of 18 case with mitral stenosis and in 10 cases out of 22 cases with mitral stenoinsufficiency and/or mitral insufficiency. Pulmonary vascular resistance, however, was markedly variable.