A Case of Endoscopic Treatment of Multiple Carcinoid Tumors in Stomach / 대한소화기내시경학회지

Multiple carcinoid tumors in stomach are very rare tumors and associated with pernicious anemia, chronic atrophic gastritis and Zollinger-Ellison syndrome. These are believed to be due to hypergastrinemia, resulting in chronic stimulation of enterochromaffine-like (ECL) cells, leading to hyperplasia, metaplasia and ultimately neoplasia. The carcinoid tumor is potentially malignant, even though it may grow slowly, so the treatment of choice must be endoscopic lumpectomy or surgical gastrectomy. The prognosis depends on the site of the tumor and its size. Most carcinoid tumors are less than 1 cm in size and metastasis is uncommon but metastasis in tumors with size over 2 cm is common. A case of multiple carcinoid tumors in stomach, which was successfully removed by endoscopy, is herein reported.

A Study on the Usefulness of ERCP in Patients with Pyogenic Liver Abscess / 대한소화기내시경학회지

BACKGROUND/AIMS: This study was undertaken to evaluate the usefulness of ERCP in patients with pyogenic liver abscess. METHODS: An endoscopic retrograde cholangiographic study of 70 consecutive cases of pyogenic liver abscess was conducted during the period from January, 1993 to December, 1997. Among 70 cases of pyogenic liver abscess, the male to female ratio was 1.69 :1, and the peak incidence was in the sixth decade. RESULTS: The common associated diseases were liver cirrhosis (11.4%), diabetes mellitus (8.5%), and malignancy (5.7%). The most common origins of the abscess in decreasing order of frequency were, transbiliary infection (51%), hematogenous spread, and trauma-associated causes. The ascending infection through the biliary tract as the etiology of liver abscess, has been common since the 1970's. The positive rate of abdominal US, CT, and ERCP in the diagnosis of the etiology of the liver abscess was 68, 82, 84% respectively. The treatments of the pyogenic liver abscess were, surgical drainage in 15 cases (21%) and percutaneous drainage in 51 cases (73%). Among 70 patients treated for pyogenic liver abscess, 12 patients had CBD stones and 11 patients were cured by EST. CONCLUSIONS: The most common origin of liver abscess is ascending infection through the biliary tract and ERCP may be a effective tool in the assessment and management of the etiology of pyogenic liver abscess.

A Case of Synchronous Primary Triple Cancers Including Stomach, Esophagus and Liver / 대한소화기내시경학회지

Multiple primary malignant cancer is a disease of more than two cancers occuring in an individual independently. The incidence of multiple primary malignant cancer is increasing gradually due to accurate cancer statistics, early diagnosis and treatment. Multiple primary malignant cancer may be divided into two groups, synchronous or metachronous depending on the interval between their diagnoses. Synchronous cancer is diagnosed simultaneously or within an interval of 6 months and metachronous cancer at interval of more than 6 months. Here, we report a case of synchronous primary triple cancers including stomach, esophagus and liver. The patient was a 63-year-old man with dysphagia. We performed endoscopy, chest and abdominal CT. We found cancers in stomach, esophagus and liver and confirmed triple primary cancer through endoscopic biopsy and sono-guided liver biopsy.

A case of cholangiocarcinoma associatd with neurofibromatosis type 1 / 대한내과학회지

Neurofibromatosis is characterized by multiple cutaneous neurofibromas, cafe-au-lait spots and a broad spectrum of clinical, pathologic and radiologic finding. The incidence of malignant neoplasms complicating neurofibromatosis has never been satisfactorily estabilished ; estimates range from 3% to 15%. The malignant tumors are usually derived from neural crest tissue. Gastrointestinal involvement appears to be rare and usually consists of neurofibromas, ganglioneuromas and leiomyomas. Hepatobiliary involvement in neurofibromatosis is rare and mostly located at the periampullary region. Most of theses tumors are carcinoids or less frequently neurofibromas. The authors report a case of peripheral cholangiocarcinoma associated with neurofibromatosis type 1.

Diagnostic Utility of Endoscopic Ultrasonograpy (EUS) for Common Bile Duct (CBD) Stones not Confirmed by Endoscopic Retrograde Cholangiopancreatography (ERCP) / 대한소화기내시경학회지

BACKGROUND AND AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is the best imaging procedure for the diagnosis of common bile duct (CBD) stones. But the difficulties of diagnosis are mostly due to problems involving cannulation, microlithiasis and pancreatitis etc. The diagnostic utility of endoscopic ultrasonography (EUS) for the diagnosis of CBD stones not detected by ERCP was retrogradely assessed in 8 patients. METHODS: All the patients (N=98) underwent ERCP, and in the case where CBD stones were not confirmed by ERCP, EUS was performed. Final diagnosis was determined by ERCP with an endoscopic sphincterotomy (EST) or operative exploration. RESULTS: 98 patients with CBD stones were studied. The first ERCP successfully imaged CBD stones in 90 patients and an EST was performed in 84 patients. In 6 patients, stones were removed through operative exploration. ERCP images were incomplete or of poor quality in 8 patients. EUS images were excellent or good in all 8 cases, where ERCP was ineffective. Factors associated with incomplete results for CBD stones included; inability to cannulate the ampulla of Vater (N=1), nonvisualized CBD (N=4), microlithiasis (N=2), and association with the periampullary fistula (N=1). The second ERCP and EST successfully confirmed the diagnosis of CBD stones in 6 patients. In 2 patients, operative exploration was needed to confirm the diagnosis of CBD stones. CONCLUSIONS: An EUS appears to be an accurate and useful diagnostic tool for assessing CBD stones in cases where an ERCP was ineffective.

A Case of a Budd-Chiari Syndrome Associated with a Large Atrial Thrombus in Antithrombin Deficiency and Antiphospholipid Syndrome / 대한혈액학회지

Antiphospholipid antibody is associated with a clinical syndrome of vascular thrombosis, thrombocytopenia, recurrent fetal loss and cerebrovascular accident whether or not the clinical diagnosis of SLE coexists. Antithrombin deficiency leads to thromboembolism in the venous system. It develops an asymptomatic venous occlusion in many cases, but when it develops cerebral venous thrombosis, mesenteric venous thrombosis or Budd-Chiari syndrome, it leads to special clinical problems. We report the finding of a low anti-thrombin level and IgM anticardiolipin antibody in a patient who has had episodes of a large thrombus in the right atrium and Budd-Chiari syndrome due to the thrombus.

A Case of Squamous Cell Carcinoma of the Common Bile Duct / 대한소화기내시경학회지

A 57-year-old female with jaundice and right upper quadrant abdominal pain, was found on exploration to have squamous cell carcinoma of the common bile duct. Squamous cell carcinoma of the common bile duct is a very rare tumor, simulating adenocarcinoma in its clinical presentation and aggressiveness. Although no consistent causative factors for this tumor has been demonstrated, it has been theorized that the normal columnar epithelium of the bile duct under the influence of an inflammatory stimulus, can develop into squamous epithelium with the ongoing process leading to squamous metaplasia, and eventually carcinoma. Cholelithiasis has been implicated as a cause for bile duct cancer, which was manifested in this patient. The prognosis of this carcinoma was grave, despite all forms of surgical and medical management. A case of squamous cell carcinoma of the common bile duct is reported with a review of relevant literature.

The Evaluation and Treatment of the Obstructive Biliary Disease through the Percutaneous Transhepatic Choledocoscopy (PTCS ) / 대한소화기내시경학회지

BACKGROUND/AIMS: Obstructive jaundice is developed from the cholangiocarcinoma, biiliary tract stone, biliary benign stricture and pancreatic head cancer and is rapidly progress to cholangitis or sepsis. So early decompression, accurate diagnosis and treatment are very important. Percutaneous transhepatic choledocoscopy (PTCS) and endoscopic retrograde choledocoscopy (ERCS) have been used for evaluation of the obstructive jaundice. We performed, through the PTCS, electrohydraulic lithotripsy (EHL) for biliary tract stone rernoval, biopsy for diagnosis of biliary stric and self expandible metalic coil stent (EndocoilTM stent, Instent Co.) insertion on biliary stricture to evaluate the usefullness of PTCS in patients with obstructive jaundice. METHODS: Between Auguest 1994 and September 1995, PTCS was performed in 37 patients with obstructive jaundice. First, percutaneous transhepatic biliary drainage (PTBD) with 7Fr. drainage tube was done. Three days later, we exchainged the 7Fr. drainage tube with 16Fr.. Seven days later, through the PTCS, we performed EHL, biopsy and EndocoilTM stent insertion.

Endoscopic Ligation Therapy for Upper Gastrointestinal Bleeding / 대한소화기내시경학회지

Upper gastrointestinal bleeding occurs so rapidly that emergency measures are required to avoid exsanguination. Many diseases cause bleeding from the gastrointestinal tract. Patients with upper gastrointestinal bleeding must be quickly assessed and resuscitated. An endoscopy is the diagnostic procedure of choice because of its high rate of accuracy and immediate therapeutic potential. An endoscopy however, must be performed only following adequate resuscitation and clinical assessment of the patient. Recently, reports have described the usefulness of endoscopic O-ring band ligation in the management of upper gastrointestinal bleeding. Endoscopic O-ring band ligation is mucosal ligation using intraluminal negative pressure with an elastic O-ring. We performed an emergency endoscopy in 3 patients who had massive or recurrent episodes of upper gastrointestinal bleeding, identified as having resulted from Dieulafoy lesion and Anisakiasis. We tried to perform an endoscopic ligation using an O-ring band, and were successful in achieving hemostasis. Our conclusion is that endoscopic ligation using an O-ring band can be used effectively to control active upper gastrointestinal bleeding resulting from Anisakiasis and a Dieulafoy lesion.

Functional Dyspepsia and Subgroups in Korea and Short Term Outcome of Therapeutic Trial of Cisapride: Multicenter Study / 대한소화관운동학회지

BACKGROUND/AIMS: The aims of this study were to determine subgoups of functional dyspesia and to evaluate the short-term effect of cisapride in patients with functional dyspepsia in Korea. METHODS: 1025 patients, with a mean age of 42.6 years, with symptoms of functional dyspepsia, were recruited consecutively and upper gastrointestinal symptoms were investigated by interview in 41 hospitals in Korea. In an open, multicenter trial, 1025 patients received Smg of cisapride three times a day (TID) for at least .2 weeks for the treatment of symptoms of functional dyspepsia. When necessary, the dose of cisapride was increased to 10mg TID and the duration of therapy was extended to 4 weeks. RESULTS: The most frequently reported symptoms of functional dyspepsia were epigastric discomfort or fullness (85%), bloating (70%), belching (53%), early satiety (52%) and epigastric pain (46%) retrospectively. Subgroups of functional dyspepsia were as follows; dysmotility-like 73.5%, ulcer-like 39.7%, reflux-like 13.0%, and unspecified dyspepsia 14.0%. However, 33.2% of subjects with functional dyspepsia could be classified into more than one subgroup. Upper gastrointestinal symptoms were decreased to average 50.3% (range; 42.2 to 59.2%) after 2 weeks of cisapride treatment and to 25% (19.2 to 29.9%) after 4 weeks. cisapride therapy resulted in good or excellent improvement in 59.0% of the patients after two weeks, in 75% of patients after 4 weeks. Adverse events were occurred in 52 patients (5.8% of all patients), most commonly, loose stools or diarrhea (3.5%), abdominal pain (1.1%), and dizziness (0.3%). The majority of adverse events was mild and transient in nature and led to premature discontinuation of treatment in 4 patients. CONCLUSIONS: Although the majorities of patients with functional dyspepsia have dysmotility like symptoms in Korea, there is such overlap among the dyspepsia subgroups. Most patients responded well to a short therapeutic trial with cisapride without significant side effects.

A Case Report of Esophageal Involvement in Behcets Disease / 대한소화기내시경학회지

Behcet's disease is a recurrent and multisystemic disorder which usually persists over many years and is classified under vasculitic syndrome. A classic triad in this disorder is composed of a recurrent oral ulcer, genital ulceration and uveitis. While intestinal Behcet's disease most commonly affects the ileoecal region, dysphagia associated with esophageal ulceration is very uncommon. A 34-year-old-female patient visited our hospital because of dysphagia, epigastric pain and fever. The patient had ulcers on the oral mucosa, soft palate and extemal genitalia. Multiple irregularly marginated ulcers surrounded with hyperemic edematous mucosa were found on the middle and distal esophagus and lesser curvature of the stomach by an esophagogastroduodenoscopic examination. The pathologic findings were non-specific ulcers with necrotizing vasculitis in the vulva and with suspicious vasculitis in the esophagus. So she was diagnosed to have a Behcets disease and was treated with steroid and sulfasalazine. In this study we report a case of esophageal involvement of Behcet's disease with a review of the literature.

Diagnostic and Therapeutic Reliability of Endoscopic Retrograde Cholangiography in Postcholecystectomy Patients / 대한내과학회지

OBJECTIVES: Accurate assessment of the retained or recurrent bile duct stone is important in postcholecystectomy patients who have signs of cholangitis or other pancreatobiliary disease. This study was performed to evaluate the diagnostic and therapeutic reliability of endoscopic retrograde cholangiography in postcholecystectomy patients. METHODS: From October 1975 through August 1995, we reviewed 311 patients retrospectively who had undergone on cholecystectomy. Our study was based on assessment of their age, sex, symptoms and physical findings, comparison between sonographic and endoscopic retrograde cholangiographic findings, and stone removal rate using endoscopic sphincterotomy, basket, electro-hydraulic lithotripsy. RESULTS: The ratio of male to female was 1:1.67, and the mean age was 56+/-14.3 years. After cholecystectomy, they visited our clinic within 2 years in 25 patients(8.4%), beyond 2 years in 286 patients(91.6%). Most common symptoms and physical findings were epigastric pain or tenderness(63.6%). We detected bile duct stone using endoscopic retrograde cholangiography 219 patients. In case of the bile duct stone, we successfully removed it using endoscopic sphincterotomy, basket, electrohydraulic lithotripsy in 194 patients(88.6%). CONCLUSION: From the above results, we concluded that endoscopic retrograde cholangiography was the most effective diagnostic and therapeutic method in postch- olecystetomy patients who have signs of cholangitis.

A Case of Spontaneous Regression of Small Cell Lung Cancer / 대한암학회지

Small cell lung cancer is the most aggressive tumor among lung cancers and has a greater tendency to be widely disseminated by the time of diagnosis. Without treatment, the median survial time of small cell lung cancer patients is only 2~4 months. However, though spontaneous regression of the malignant tumor has been frequently reported, spontaneous regression of the small cell lung cancer is rare. In this study a spontaneous regression of the small cell lung cancer is reported, along with a brief review of the literature. A 69 year-old woman was admitted for an evaluation for dyspnea. A chest roentgenogram obtained on admission revealed an abnormal mass shadow at the right hilus. She was diagnosed as having small cell lung cancer through a bronchoscopic biopsy. However this tumor regressed spontaneously without specific treatment after 12 months.

Electrohydraulic Lithotripsy(EHL) of Large Common Bile Duct Stone and Endocoil Insertion with Percutaneous Transhepatic Choledochoscopy / 대한소화기내시경학회지

BACKGROUND/AIMS: Electrohydraulic lithotrypsy(EHL) under cholangioscopic control has been performed for difficult bile duct stones. The percutaneous transhepatic approach is technically easy and useful in diagnosis and treatment of bile duct obstruction and stones. Biliary stenting with self expanding metal stent is gaining increasingly wider acceptance as a palliative treatment of bile duct obstruction. METHODS: Between Sep. 1994 and Sep. 1996, EHL under choledochoscopy by percutaneous transhepatic approach was performed in 30 cases(Male: 13, Female: 17). After PTBD with 7F pig tail catheter, the percutaneous transhepatic passage was dilated over guide wire with dilaters of increasing size up to 16Fr in 3-Sdays. In one week, after fistula had been estabilished, choledochoscopy was performed. RESULTS: (1) Mean age was 61.3 years. Mean stone number was 2.5. And mean stone size was 1.6 X 2.3 cm. (2) Com.plete removal of the stone was achieved in all patients(100%). (3) There were no serious complications. (4) In six cases, Endocoils were implanted with successful decompression of obstructions and simultaneous removal of biliary stones located at both side of stricutre. CONCLUSIONS: Percutaneous transhepatic choledochoscopy is easy and safe and assists in the diagnosis and treatment of biliary stricture and the management of difficult CBD stone.

Esophagus, Stomach & Intestine; Evaluation of Endoscopic Ultrasonography in Gastric Carcinoma / 대한소화기내시경학회지

BACKGROUND: Endoscopic Ultrasonography(EUS), a combination of endoscopy and ultrasonography is one of the most useful tools for diagnosis of digestive system diseases. EUS is useful in staging the primary tumor invasion and regional lymph node metastasis because of its ability to image the gut wall and adjacent structures in unique detail. We performed a study preoperatively for assessing the accuracy and limitation of EUS in gastric carcinoma. METHODS: In 75 patients(Male 54, Female 21, Mean age 62.3 years) with a gastric carcinoma confirmed by endoscopic biopsy, we performed EUS preoperatively. The results were compared with the postoperative histopathologic staging. RESULTS: 1) In assessing the depth of tumor invasion, EUS accuracy on depth of invasion was 76.0% and overstaging and understaging were 14.7% and 9.3%, respectively. 2) In assessing the lymph node metastasis, the accuracy rate of EUS was 65.3%. A rate of false-positive diagnosis was 27.3%, and a rate of false-negative diagnosis was 24.5%.3) In assessing the incidence of lymph node metastasis for each T stage, the involve rate was 10.5% in pT1, 36.4% in pT2, 95.7% in pT3, 100% in pT4. CONCLUSIONS: EUS is the most accurate diagnostic methods presently available to determine tumor infiltration depth and lymph node metastasis.

589 Cases of Endoscopic Ultrasound Diagnosis in Upper Gastrointestinal Tract and Pancreaticobiliary System Diseases / 대한소화기내시경학회지

Endoscopic ultrasonography (EUS)-a combination of endoscopy a.nd ultrasonography was one of the most useful tools for diagnosis of digestive system diseases. This technique was known to be very effective in the assessment of depth of invasion in gastric cancer and in pancreatico-biliary diseases. We performed EUS in 589 patients with upper gastrointestinal and pancreatico-biliary tract lesion prior to surgery for past 22 months and examined the diagnostic accuracy of EUS, respectively. The results were compared to surgical histology in esophagus and stomach cancer,to concordance witb endoscopic retrograde cholangiopancreatography(ERCP) results for pancreaticobiliary diseases. 1) In 589 patients diagnosed with EUS, the mean age of the patients was 55.9 years with a male to female ratio of 1.7: 1. 2) Patients were divided into three groups; post-upper gastrointestinal endoscopy, post ERCP and undiagnosed with other diagnostic tools. 3) Among post-upper gastrointestinal endoscopy, 64 cases were operated due to esophageal and gastric cancer and then compared to surgical histology. After compared, EUS accuracy on depth of invasion was 78.1% and sensitivity and specificity on lymph node metastasis in gastric cancer were 76.9% and 74.3%, respectively. 4) In post-ERCP cases, EUS results were compared to ERCP results and then concordance rate was 95.4%. 5) In undiagnosed cases, EUS was performed and results were reported.

A Case of Occult Adenocarcinoma of Cystic Duct Associated with GB Empyema / 대한소화기내시경학회지

A case of adenocarcinoma of cystic duct associated with GB empyema is presented. A 72 year old male was admitted to Kwangju Christian hospital because of abdominal pain in right upper quadrant for 4 days. He underwent explolaparotomy under the impression of GB empyema or GB cancer. For seeking causative factor of GB empyema, serial sections of cystic duct and mapping were performed. We can find adenocarcinoma of cystic duct in the specimen removed at cholecystectomy. The criteria for disgnosis of cystie duct carcinoma which was outlined by Farrar. These criteria are; 1) The growth must be restricted to the cystic duct, 2) There is no neoplastic process in the gall bladder, hepatic and common bile duct. 3) Histopathological examination must be comfirm carcinoma. Here we report a case of adenocarcinoma of cystic duct associated with GB empyema with brief review of Literature.

A Case of Cystic Duct Stone and Cholecystitis Misdiagnosed as Gall Bladdr Carcinoma: A case report / 대한소화기내시경학회지

A 56 year old female was admitted because of the right upper quadrant mass for 4 days. She complained of intermittent colicky RUQ pain, fever and chills. So diagnostic procedures was performed: Blood chemistry testings. Ultrasonography. Barium enema, Liver scan, Hepatobiliary scan, ERCP and Abdomen CT, which diagnosed as gall bladder carcinoma. So explolaparotomy was performed and gross operative finding was gall bladder carcinoma with metastatic lymph node and cystic duct stone. So cholecystectomy, hemigastrectomy and anterior segmentectomy of right liver was done. But the biopsy result was cystic duct stone, cholecystitis and gall bladder empyema.

Clinical Significance of Periampullary Choledochoduodenal Fistula / 대한소화기내시경학회지

Sine 1976, 2380 eases of ERCP were performed at the Kwangju Chrietian Hospital. Nighty eight patients with periampullary choledochaduodenal fistula diagnosed at ERCP were revewed, Following result were obtained 1) Cases were most commonly noted from fifth decade to seventh decade, and sex distribution was similar. 2) Right upper quadrant abdominal was most common clinical manifestation, and duration of illness prior to diagnosis were from 2 months to 20 years. Several weeks or days before ERCP, sudden disappearance of pain suggeeted spontaneous extrustion of a stone from the common bile duct to the duodenum with resultant PACD formation. 3) On past history, various types biliay operations had carried out in 26 patients. Subtotal gastrectomy with gastrojejunostomy in 1 patients, operation for CBD ascaris removal in 1 patient. 4) Most PACDF had finding formed recently on ERCP and fibrosis, inflamation, granulation, atrophic change, adhesive stenosis were noted additionally. 5) Most common cause of PACD by ERCP was biliary teact stone. 6) Endoscopic sphincteropapillotomy(EST) were performed in 39 patients with PACDF due to CBD stone and surgical intervention were done in 36 patients due to CBD stone also. It was interesting that EST were performed in 3 patients with old stenotic fistula.

A Case of Cholangiocarcinoma Associated with Clonorchiasis: A Case Report / 대한소화기내시경학회지

A fifty-five year old male was admitted because of fever and chill for one month. He complained of upper abdominal pain, malaise, anorexia and weight loss. So diagnostic procedures were performed: stool exam., bload chemistry testing, ultrasonography, radionuclide scintigraphy. ERCP, abdominal CT, and sonoguided liver aspiration, which revealed intrahepatic cholangiocarcinoma associated with clonorchiasis.