Predictive factors that influence the survival rates in liver cirrhosis patients with spontaneous bacterial peritonitis

BACKGROUND/AIMS: Spontaneous bacterial peritonitis (SBP) has been known to greatly influence the survival rate of patients with liver cirrhosis. However, the factors that affect the survival rate in patients with SBP need to be clarified. METHODS: This study enrolled 95 liver cirrhosis patients diagnosed with SBP. The laboratory findings of their serum and ascitic fluid were examined and the characteristics of the isolated microorganisms in their peritoneal fluid were analyzed. RESULTS: The proportion of patients with culture-positive SBP was 41.1%, and 47 microorganisms were isolated from the ascitic fluid. The proportions of cultured bacteria that were Gram negative and Gram positive were 57.4% and 40.4%, respectively. The proportions of Escherichia coli, Klebsiella species, and Streptococcus species were 25.5%, 19.1%, and 19.1%, respectively. Enterococcus species represented 12.8% of the microorganisms cultured. The overall survival rates at 6, 12, and 24 months were 44.5%, 37.4%, and 32.2%, respectively. There was no relationship between the bacterial factors and the survival rate in SBP. Multivariate analysis revealed that the presence of hepatocellular carcinoma (HCC; P=0.001), higher serum bilirubin levels (> or =3 mg/dL, P=0.002), a prolonged serum prothrombin time (i.e., international normalized ratio >2.3, P1.3 mg/dL, P<0.001), and lower glucose levels in the ascitic fluid (<50 mg/dL, P<0.001) were independent predictive factors of overall survival rate. CONCLUSIONS: HCC, higher serum bilirubin levels, a prolonged serum prothrombin time, renal dysfunction, and lower ascitic glucose levels are associated with higher mortality rates in cirrhotic patients with SBP.

A Case of Duodenal Diverticulum Mimicking a Peripancreatic Abscess / 대한내과학회지

The duodenum is the second most common site, after the colon, of diverticuli in the alimentary tract. Although most patients with duodenal diverticuli are asymptomatic, previous studies have demonstrated a possible association between duodenal diverticuli and choledocholithiasis and pancreatitis. In addition, duodenal diverticuli mimicking periampullary tumors and cystic neoplasms of the pancreas have been reported. We report a case of a duodenal diverticulum that mimicked a peripancreatic abscess. A 65-year-old woman was admitted for epigastric pain and vomiting. Abdominal CT confirmed the diagnosis of acute pancreatitis. Follow-up abdominal CT performed for a sustained fever revealed several newly developed peripancreatic abscesses. Most of the abscesses were drained percutaneously, but those around the uncinate process seldom respond to treatment. This patient was confirmed to have a duodenal diverticulum by endoscopy and duodenography. Duodenal diverticuli must be considered in a differential diagnosis of peripancreatic abscesses.

Metastatic Common Bile Duct Cancer from Pulmonary Adenocarcinoma Presenting as Obstructive Jaundice / 대한소화기학회지

We report an extremely rare case of metastatic common bile duct cancer from pulmonary adenocarcinoma presenting as obstructive jaundice. The patient was a 76-year-old male, who presented with generalized weakness and right upper quadrant pain. Plain chest X-ray noted multiple small nodules in both lung fields. Abdominal computed tomography scan showed a stricture of the mid common bile duct along with ductal wall enhancement. Endoscopic retrograde cholangiography revealed a concentric, abrupt narrowing of the mid-common bile duct suggestive of primary bile duct cancer. However, pathology comfirmed metastatic common bile duct cancer arising from pulmonary adenocarcinoma with immunohistochemical study with thyroid transcriptional factor-1 (TTF-1).

Guidelines for Bowel Preparation before Video Capsule Endoscopy

The preparation for video capsule endoscopy (VCE) of the bowel suggested by manufacturers of capsule endoscopy systems consists only of a clear liquid diet and an 8-hour fast. While there is evidence for a benefit from bowel preparation for VCE, so far there is no domestic consensus on the preparation regimen in Korea. Therefore, we performed this study to recommend guidelines for bowel preparation before VCE. The guidelines on VCE were developed by the Korean Gut Image Study Group, part of the Korean Society of Gastrointestinal Endoscopy. Four key questions were selected. According to our guidelines, bowel preparation with polyethylene glycol (PEG) solution enhances small bowel visualization quality (SBVQ) and diagnostic yield (DY), but it has no effect on cecal completion rate (CR). Bowel preparation with 2 L of PEG solution is similar to that with 4 L of PEG in terms of the SBVQ, DY, and CR of VCE. Bowel preparation with fasting or PEG solution combined with simethicone enhances the SBVQ, but it does not affect the CR of VCE. Bowel preparation with prokinetics does not enhance the SBVQ, DY, or CR of VCE.

A Prospective Study of Factors Influencing on the Clinical Characteristics of Colonic Diverticulosis / 대한소화기학회지

BACKGROUND/AIMS: The prevalence of colonic diverticulosis in Korea is increasing in conjunction with the adoption of western dietary pattern, extension of lifespan, and advances in diagnostic modalities. The clinical characteristics of colonic diverticulosis seem to be gradually becoming similar to those of Western societies. Therefore, factors associated with the clinical characteristics of colonic diverticulosis in Korea were investigated. METHODS: The data of 200 patients diagnosed with colonic diverticulosis using colonoscopy between May 2010 and April 2012 at Inje University Seoul Paik Hospital (Seoul, Korea) were prospectively collected. Clinical parameters acquired through a questionnaire include age, body mass index, waist circumference, exercise, diet, smoking, drinking habits, etc. Correlation between these factors and the clinical features of diverticulosis were analyzed. RESULTS: Mean age of the patients was 54.9+/-11.9 (range 17-79) years and male to female ratio was 2.2:1. Most diverticula were located on the right side of the colon (83%) and the mean number of diverticulum was 4.07+/-3.9. Factor associated with the location of diverticulum on the left side was age (p=0.001). There was a positive correlation between the waist circumference and the number of diverticulum (partial correlation coefficient r'=0.143, p=0.047). Diverticulitis occurred more frequently in younger patients than in older patients (p=0.002). CONCLUSIONS: Colonic diverticulosis in older patients is found more frequently on the left colon, and the number of diverticulosis is associated with central obesity.

A Case of Conservatively Resolved Intramural Esophageal Dissection Combined with Pneumomediastinum / 대한소화기학회지

Intramural esophageal dissection (IED) is a rare form of esophageal injury. We report a rare case of spontaneous IED complicated with pneumomediastinum and successfully improved by conservative management. A 46-year-old man presented to the emergency department with chest pain and hematemesis. The endoscopic diagnosis was suspicious of IED. Chest CT scan performed to rule out complication noted IED combined with pneumomediastinum. He was managed conservatively with nil per oral, intravenous antibiotics and parenteral nutrition. Follow up study after 2 weeks later showed near complete resolution of IED. IED should be included in the differential diagnosis for unexplained acute chest pain, especially, associated with dysphagia and hematemesis. IED with pneumomediastinum or mediastinitis require prompt surgery. So far, there is no case report of IED combined with pneumomediastinum which resolved without surgical treatment. In this case, IED combined with pneumomediastinum has improved by conservative management, so we present a case report.

Clinical Significance of Erosive or Ulcerative Lesions Isolated in Terminal Ileum

BACKGROUND/AIMS: Although terminal ileal erosive or ulcerative lesions are frequently observed on colonoscopic examination, their clinical significance are unclear. We evaluated clinical course and significance of isolated terminal ileal erosive or ulcerative lesions. METHODS: We retrospectively analyzed clinical features, number, size and histologic findings of 186 patients with isolated terminal ileal erosive or ulcerative lesions on colonoscopic examination from December 2003 to February 2012. RESULTS: The indications for colonoscopy included screening for colorectal cancer or surveillance in 122 patients (65.6%), evaluations for symptoms in 64 patients (34.4%). Of the 186 patients, 170 underwent biopsy at the terminal ileal lesions. Histologic findings were mostly non-specific chronic inflammation except two cases of Crohn's disease, one case of cytomegalovirus ileitis, and one case of intestinal tuberculosis. Forty six patients underwent follow-up colonoscopy and the mean duration was 17.8+/-14.2 months (range, 1-64 months). Of those who showed non-specific ileitis (44 patients), 35 (79.5%) showed resolution of lesions without specific treatment. In the remaining 9 (20.5%) patients, lesions were continued and two patients were diagnosed as Crohn's disease and Behcet's ileitis, respectively. There were no significant differences in the duration of follow-up, presence of symptoms, number and size of terminal ileal lesions between the patients who resolved and not resolved. CONCLUSIONS: Most isolated terminal ileal erosive or ulcerative lesions reveal non-specific histological findings and have a propensity to resolve without treatment. However, in small portions of patients, isolated terminal ileal lesions need careful attention because it is possible to be early inflammatory bowel diseases.

A Case of a Zotarolimus-Eluting Stent Fracture in the Left Anterior Descending Artery in a Patient Undergoing Hemodialysis / 전남의대학술지

Although stent fracture after implantation of a drug-eluting stent (DES) is a rare complication, it has been suggested to be a cause of restenosis. To date, most DES fractures have been associated with sirolimus-eluting stents. We describe here a case of a zotarolimus-eluting stent fracture after 8 months of stent placement in a calcified left anterior descending artery lesion in a patient undergoing hemodialysis.

Successful Localization of Distant Metastasis in Parathyroid Carcinoma Using Intraoperative Parathyroid Hormone Assay

Intra-operative parathyroid hormone (IOPTH) assay is a useful tool to confirm complete excision of all hyper-functioning parathyroid gland tissue. In this report, we describe a case with successful localization of distant metastasis in a patient with parathyroid carcinoma using the IOPTH assay. A 53-year-old man presented to our clinic with a serum calcium level of 11.8 mg/dL and an intact PTH level of 233.3 pg/mL. He had been treated for parathyroid carcinoma eleven years ago. Two suspected metastatic lesions were detected on the chest computed tomography. Due to the vastly different surgical field necessary to excise each lesion, we preferentially removed only one lesion and we monitored the other remaining suspected lesion without resection via IOPTH assay. Six months later, the patient's serum calcium and intact PTH levels remained within their normal ranges. To the best of our knowledge, this is the first case to effectively utilize IOPTH assay for the management of metastatic parathyroid carcinoma.

Clinical Features of Hyponatremia: Changes Related to Increasing Use of Thiazide-Combination Diuretics / 대한신장학회지

PURPOSE: In this study, the etiology and the change of clinical characteristics of hyponatremia, in relation to the increased used of thiazide diuretics, have been assessed. METHODS: To perform a retrospective cohort study, a total sum of 322 patients who have been admitted in a single tertiary referral hospital between 2004 and 2009, were included. RESULTS: The most common cause of hyponatremia was due to thiazide diuretics (37.6%). Among the 121 patients who suffered from thiazide induced hyponatremia, 60 (48.0%) patients took combination thiazide. The incidence of hyponatremia has shown a tendency to increase from 2004 to 2009 (trend test, p<0.001). The incidence of hyponatremia due to the use of combination types has also increased (trend test, p<0.001). Thiazide induced hyponatremia showed no difference when compared to hyponatremia due the other causes, except the fact that the portion of female patients was higher (73.6% vs 64.6%, p<0.001), mean age was older (74.7 vs 69.9 years-old, p<0.001), and incidence of cerebrovascular accident was also higher (19.8% vs 6.5%, p<0.001). CONCLUSION: The use of thiazide is increasing and hence thiazide-induced hyponatremia is also increasing. This is thought to be particularly related to the increase of thiazide-combined drugs. Thiazideinduced hyponatremia shows a higher incidence in old age, female sex and those who have a history of a cerebrovascular event. Hence more caution is needed when using thiazide diuretics as antihypertensives, and plasma sodium levels should be monitored carefully.

A Case of a Zotarolimus-Eluting Stent Fracture in the Left Anterior Descending Artery in a Patient Undergoing Hemodialysis / 전남의대학술지

Although stent fracture after implantation of a drug-eluting stent (DES) is a rare complication, it has been suggested to be a cause of restenosis. To date, most DES fractures have been associated with sirolimus-eluting stents. We describe here a case of a zotarolimus-eluting stent fracture after 8 months of stent placement in a calcified left anterior descending artery lesion in a patient undergoing hemodialysis.

Recurrent Systemic Capillary Leak Syndrome Responding to the Corticosteroid Therapy / 대한신장학회지

Systemic capillary leak syndrome (SCLS) is a rare devastating condition that is caused by unexplained marked capillary hyperpermeability, resulting in hypovolemic shock, hemoconcentration, and hypoproteinemia. Most patients have prodromal symptoms such as non-specific gastrointestinal symptoms, myalgia, or dizziness. In the current case, we observed the patient with recurrent SCLS show perivascular lymphocytic infiltration on skin biopsy and eosinophilic infiltrates on random biopsies from duodenum to colon. This finding might be due to distinct eosinophilic enterocolitis or secondary to SCLS. However, there has been rare data for the prevention of the recurrent attack of SCLS, although the mortality is high. Therefore, we report a case of frequently relapsing SCLS responding to the corticosteroid therapy.