Drug Rash with Eosinophilia and Systemic Symptoms Syndrome in a Patient on Sulfasalazine for Ulcerative Colitis

Drug rash with eosinophilia and systemic symptoms (DRESS) is a life-threatening systemic drug reaction characterized by fever, rash, hematological abnormalities, lymphadenopathy, and multiple internal organ involvement. Unfortunately, a long latency period as well as clinicians' unawareness of the disease entity often results in a delay of prompt diagnosis and treatment in clinical practice. A search of the literature revealed only few reports on DRESS in patients with inflammatory bowel diseases. The pathogenesis of the disease is not clearly understood, although several possible mechanisms, such as drug detoxification, slow acetylation, and reactivation of human herpes viruses, have been proposed in its development. Here, we present a rare case of DRESS associated with viral reactivation and defects in drug metabolism in a 22-year-old man who had been on sulfasalazine for 6 weeks to treat ulcerative colitis.

A Case of a Spontaneous Hemoperitoneum as the Presentation of a Gastric Arteriovenous Malformation / 대한소화기내시경학회지

Spontaneous hemoperitoneum is rare. The most common etiologies are gynecologic, splenic, and hepatic. Gastric arteriovenous malformations are commonly associated with intraluminal bleeding, but gastric arteriovenous malformations are an unusual cause of spontaneous intraperitoneal hemorrhage. A 54-year-old man presented with acute onset of epigastric pain. The patient was given an operation and pathology confirmed that it was a gastric arteriovenous malformation.

Two Cases of Crohn's Disease Presented with Hematochezia in Patients with Hemophilia

The etiology of Crohn's disease, which is a chronic inflammatory condition that potentially involves any location of the alimentary tract from the mouth to the anus, is unknown. However, there is strong evidence that vascular damage could play a role in the pathogenesis of Crohn's disease. Crohn's disease is mediated by multifocal gastrointestinal infarctions, which occur at an early stage in the disease process. Persistent activation of coagulation in patients with Crohn's disease has been shown. In contrast, hemophilia is an inherited disorder of coagulation. The deficiencies of clotting factors usually involve occult or overt bleeding. The pathogenic mechanisms of Crohn's disease and hemophilia are incompatible. An association between Crohn's disease and hemophilia has not been reported in Korea. We managed 21- and 33-year-old men with Crohn's disease associated with hemophilia, who presented with hematochezia.

A Case of Capillary Hemangioma in the Jejunum Detected by Single Balloon Enteroscopy in a Patient with Anemia / 대한소화기내시경학회지

Hemangiomas are uncommon benign vascular tumors that account for up to 10% of all small bowel tumors. The jejunum is the most common location, and gastrointestinal bleeding is a frequent clinical presentation. Histologically, hemangiomas are classified as cavernous, capillary, or mixed types. Capillary hemangiomas are dense collections of capillaries usually with a hyperplastic endothelium. There have been a few cases of small bowel capillary hemangioma revealed by capsule endoscopy and confirmed after surgical resection. But preoperative detection of hemangiomas in the small intestine has not been reported, as far as we know, associated with the use of balloon-assisted enteroscopy. This report describes a 44-year-old male with a small bowel mass considered to be a cause of severe iron deficiency anemia. In this case, we performed capsule endoscopy and single balloon enteroscopy to examine the lesion. The patient then underwent a segmental resection of the jejunum, which confirmed the presence of a capillary hemangioma with surface ulceration.

Clinical Parameters Including Serum Pepsinogen Level and Management Strategy in Patients with Gastric Low-Grade Dysplasia

BACKGROUND/AIMS: There are no proper guidelines for the management of gastric low-grade dysplasia (LGD). We evaluated clinical parameters, histological results and follow-up endoscopies to find a management strategy of LGD. MATERIALS AND METHODS: A total of 590 patients with LGD, high-grade dysplasia (HGD), functional dyspepsia (FD), early or advanced gastric cancer (early gastric cancer [EGC] or advanced gastric cancer [AGC]) were consecutively enrolled. We examined the association of clinical parameters including low serum pepsinogen (PG) I/II ratio < or =3.0 with the disease phenotypes. Histological results between initial forceps-biopsy and endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) specimens were compared. RESULTS: The PG I/II ratio in FD was 4.2+/-1.7, but was significantly low in LGD (2.8+/-1.6, P<0.0001). The ratio was not further decreased in the HGD, EGC, and AGC groups. In FD patients with the ratio of < or =3.0, smoking habits and high salt intake were independent risk factors for gastric dysplasia or gastric cancer. In about 11% (n=8/70) of LGD lesions, the pathologic diagnoses were upgraded to HGD or EGC after endoscopic resection. Neither serious complications nor recurrence at the primary site were found. CONCLUSIONS: It is proposed that endoscopic resection followed by endoscopic surveillance might be a beneficial strategy for patients with LGD having a PG I/II ratio of < or =3.0.

Sacroiliitis Is Common in Crohn's Disease Patients with Perianal or Upper Gastrointestinal Involvement

BACKGROUND/AIMS: Sacroiliitis (SI) is one of the most frequent extraintestinal manifestations in inflammatory bowel disease (IBD) patients, but the exact prevalence has not been evaluated in Asia. There are few data on the association between SI and other clinical features of IBD. The prevalence of SI was evaluated using computed tomography (CT) and the phenotypic parameters associated with SI in Korean IBD patients were determined. METHODS: Eighty-two patients with ulcerative colitis (UC) and 81 patients with Crohn's disease (CD) were evaluated clinically. The presence of SI was evaluated using bone window setting of abdomino-pelvic CT images by two radiologists. RESULTS: The prevalence rates of SI were 12.2% and 21.0% in the UC and CD groups, respectively. There was no relationship between the localization or extent of intestinal inflammation and the presence of SI in the UC group. Multivariate analyses confirmed that perianal and upper-gastrointestinal (from the mouth through to the jejunum) diseases were associated with the occurrence of SI in the CD group (p=0.026 and p=0.047, respectively). CONCLUSIONS: SI was as common among Korean IBD patients as among Western patients. Perianal or upper-gastrointestinal involvement is associated with SI in CD patients.

Change of Circulating Leptin, Adiponectin, Resistin, and Visfatin Level after Treatment of Patients with Active Inflammatory Bowel Disease

BACKGROUND/AIMS: The aim of this study was to evaluate the change in circulating levels of adipokines, including leptin, adiponectin, resistin, and visfatin, after induction therapy of patients with active inflammatory bowel disease (IBD). METHODS: We prospectively evaluated 20 patients with Crohn's disease (CD) and 14 patients with ulcerative colitis (UC) who received induction therapy. The disease activity, body mass index (BMI), and C-reactive protein (CRP) and serum adipolines levels were checked before treatment and 10 weeks after treatment. RESULTS: After induction therapy, significant reduction of disease activity was noted in patients with CD (CD activity index, 267.9+/-73.7 vs. 50.8+/-36.5, P<0.001) and patients with UC (Mayo score, 9.8+/-2.2 vs. 1.4+/-1.6, P<0.001). The mean serum leptin, adiponectin, resistin, and visfatin levels were 4.0+/-2.7 ng/mL and 4.4+/-2.3 ng/mL (P=0.323), 27.0+/-20.5 microg/mL and 33.8+/-26.5microg/mL (P=0.084), 9.0+/-4.0 ng/mL and 10.2+/-3.2 ng/mL (P=0.108), and 4.6+/-3.7 ng/mL and 2.5+/-4.1 ng/mL (P=0.046) before and after infliximab treatment, respectively. No significant correlation between the changes in BMI, CRP level, or the clinical indices of activity and alterations of the measured adipokines was demonstrated. CONCLUSIONS: The serum levels of leptin, adiponectin, and resistin showed no significant alterations, whereas the serum visfatin level decreased significantly after induction therapy, suggesting a possible pro-inflammatory property of visfatin and a role as a marker of successful therapy of IBD.

Three Cases of Appendicitis Diagnosed by Colonoscopy in Patients with Atypical Presentations / 대한소화기내시경학회지

The diagnostic considerations are broad for patients who clinically present with obscure abdominal pain. Acute appendicitis can be diagnosed according to the clinical signs and symptoms, yet this can often be extremely challenging. Difficulties particularly arise when the presentation is atypical. Investigations that may help include laboratory tests, non-invasive imaging and laparoscopy. We experienced 3 cases of acute appendicitis that were diagnosed by colonoscopy. The colonoscopy revealed a bulging of the appendix into the cecal lumen. The mucosa was erythematous and edematous with pus draining from the appendiceal orifice. These findings were suggestive of appendicitis, which was confirmed after surgical appendectomy. In our experience, making the colonoscopic diagnosis of appendicitis might be helpful for patients with atypical symptoms, but colonoscopy should not be used for the diagnosis in the beginning if appendicitis is initially suspected.

Antineoplastic effect of endogenous peroxisome proliferator-activated receptor gamma ligand, 15-deoxy-delta(12,14)-prostaglandin J2, on cholangiocarcinoma cells / 대한내과학회지

BACKGROUND/AIMS: Peroxisome proliferator-activated receptor (PPAR)-gamma ligand is known to inhibit the growth of several kinds of cancer cells, yet its effect on cholangiocarcinoma is indecisive. We investigated the effect of an endogenous ligand of PPAR-gamma, 15-deoxy-delta (12,14)-prostaglandin J2 (15-deoxy-PGJ2) on cholangiocarcinoma cells that were established from intrahepatic cholangiocarcinoma tissue of Korean patients. METHODS: Four cholangiocarcinoma cell lines, Cho-CK, Choi-CK, JCK and SCK, were studied. The mRNA expression of PPAR-gamma, bcl-2, and bax were examined by RT-PCR. Cell viability was determined by MTT assay. The cell cycle was analyzed by flow cytometry, and apoptosis by cell death detection ELISA kit. Caspase activity was measured by colorimetric assay. The effect of caspase inhibitors on 15-deoxy-PGJ2-induced apoptosis was determined by measuring cell viability using the MTT assay. RESULTS: PPAR-gamma mRNA was expressed in all cholangiocarcinoma cells. 15-deoxy-PGJ2 inhibited proliferation of all cells in a dose- and time-dependent manner. All cells treated with 15-deoxy-PGJ2 showed increased dose-dependent apoptosis. Caspase 3 was activated in all cells and caspase 9 was activated in all but JCK cells after 15-deoxy-PGJ2 treatment. Caspase 8 activity showed no significant change. The pan-caspase inhibitor, Z-VAD-FMK, and the caspase-3 inhibitor, Z-DEVD-FMK, blocked 15-deoxy-PGJ2-induced apoptosis in all cells dose-dependently. The expression of bcl-2 was decreased in Cho-CK, Choi-CK and SCK cells, and bax expression was not changed significantly after 15-deoxy-PGJ2 treatment. CONCLUSIONS: PPAR-gamma mRNA was expressed in all Korean cholangiocarcinoma cells. Our data suggest that 15-deoxy-PGJ2 exerts an antineoplastic effect against cholangiocarcinoma cells by inducing apoptosis through caspase activation.

Metastatic Large Cell Neuroendocrine Carcinoma Combined with Gastric Adenocarcinoma / 대한소화기내시경학회지

A 67 year-old man was admitted due to findings that were suspicious for malignancy on gastroscopy at a primary clinic. We also performed gastroscopy and this showed the presence of a 3 cm sized nodular elevated lesion at the angle of the stomach. A biopsy demonstrated the presence of adenocarcinoma of the stomach. A distal gastrectomy with D2 lymph node dissection was performed and the microscopic features of the resected specimen confirmed the diagnosis of adenocarcinoma of the stomach and also metastatic large cell neuroendocrine carcinoma of lymph nodes of an unknown primary origin. Although double primary gastric adenocarcinoma and gastric neuroendocrine tumor with regional lymph node metastasis has been seldom reported, a double primary carcinoma of gastric adenocarcinoma and metastatic large cell neuroendocrine carcinoma of lymph nodes has seldom been reported. We report on this unusual case along with a review of the relevant medical literature.

Endoscopic Submucosal Dissection of Early Gastric Cancer That Occurred in a Patient with Chronic Myelogenous Leukemia / 대한소화기내시경학회지

Synchronous double malignancies of early gastric cancer and chronic myelogenous leukemia (CML) are very rare. There are few reports regarding the effect of the CML or imatinib on stomach cancer, and it is difficult to make a decision for the proper timing of treatment for early gastric cancer (EGC) in a patient with CML. A 56-year-old man was diagnosed with early gastric cancer. During the evaluation of his disease, he was also diagnosed as having Philadelphia chromosome positive chronic myleogenous leukemia. He started to take 400 mg of imatinib per day. Two weeks later, he underwent endoscopic submucosal dissection (ESD) for the early gastric cancer. Although there was a bleeding complication, complete resection was successfully performed. ESD is an effective treatment modality for EGC in CML patients, but physicians should keep a watchful eye for bleeding complications after the procedure. Further studies and more experience are needed to determine the proper timing of treatment for these patients.

Peroxisome proliferator-activated receptor gamma ligands exert antineoplastic effects in hepatocellular carcinoma cells / 대한내과학회지

BACKGROUND/AIMS: Thiazolidinediones, which are synthetic insulin sensitizers, are known activators of peroxisome proliferator-activated receptor gamma (PPARgamma). PPARgamma ligands, including endogenous 15-deoxy-delta12,14-prostaglandin J2 (15d-PGJ2), are thought to elicit antineoplastic effects in various cancer cells. In this study, the antineoplastic effects of PPARgamma ligands against hepatocellular carcinoma (HCC) cells were investigated. METHODS: HepG2, Hep3B, and PLC/PRF5 cells were cultured with troglitazone (TGZ), pioglitazone (PGZ), rosiglitazone (RGZ), or 15d-PGJ2 at concentrations of 20-100 micrometer. Cell viability, cell cycle arrest, apoptosis, and caspase activity were measured using the MTT assay, flow cytometry, enzyme-linked immunosorbent assay (ELISA), and colorimetric assays, respectively. The effects of various caspase inhibitors were also measured using a cell death detection ELISA. RESULTS: All three cell lines expressed the PPARgamma gene. TGZ and 15d-PGJ2 strongly inhibited growth in HepG2, Hep3B, and PLC/PRF5 cells. In contrast, PGZ and RGZ showed a much weaker effect in all cell lines. In terms of cell cycle arrest and apoptosis, TGZ induced G0/G1 arrest in HepG2 cells and increased the apoptotic fraction in Hep3B and PLC/PRF5 cells. In contrast, 15d-PGJ2 induced apoptosis only in HepG2 and Hep3B cells. TGZ and 15d-PGJ2 increased caspase-3 activity significantly and increased caspase-9 activity slightly. TGZ- and 15d-PGJ2-induced apoptoses were inhibited by a pancaspase inhibitor (Z-VAD-FMK) and a caspase-3 specific inhibitor (Z-DEVD-FMK) in a dose-dependent manner. CONCLUSIONS: TGZ and 15d-PGJ2 elicit antineoplastic effects in various HCC cells via caspase-dependent apoptotic induction. Their differential effects on similar cell types suggest that another antineoplastic mechanism, most likely a PPARgamma-independent pathway, is involved.

A Case of Terminal Ileitis Caused by Ascaris lumbricoides / 대한소화기내시경학회지

The major causes of terminal ileitis are inflammatory bowel disease and NSAIDs but parasites such as Anisakis rarely induce ileitis. Ascaris lumbricoides, the most common intestinal helminth in Korea, may enter the pancreaticobiliary ducts and cause pancreatitis or cholangitis. However, no case of A. lumbricoides-associated terminal ileitis has been previously reported in Korea. We report a case of a 58-year-old woman who presented with epigastric discomfort and bloating, and was diagnosed with terminal ileitis due to A. lumbricoides detected during colonoscopy.

A Case of Gastric Huge Intramucosal Hematoma after Snare Polypectomy / 대한소화기내시경학회지

Endoscopic polypectomy is a widely used therapeutic modality for the treatment of polypoid lesions in the gastrointestinal tract. Postpolypectomy bleeding is the most common procedure-related complication. Bleeding can occur immediately after the polypectomy or be delayed from hours to up to days. The severity of bleeding ranges from slight oozing to spurting arterial bleeding that requires immediate endoscopic hemostasis. Because severe hemorrhage can be a cause of repeat endoscopy, blood transfusion, hospitalization or surgery, endoscopists must carefully observe the patient's symptoms and hemodynamic status after an endoscopic polypectomy. Here, we report a large intramucosal hematoma and subsequent huge ulcer in the stomach as a rare complication of endoscopic snare polypectomy.

A case of primary biliary cirrhosis manifestated with idiopathic thrombocytopenic purpura and Sjogren's syndrome / 대한내과학회지

Primary biliary cirrhosis (PBC) is rare in Korea. Although its pathogenesis is not fully understood, immunologic dysregulation is suspected because it is frequently associated with other immunologic disorders. A few cases of primary biliary cirrhosis associated with idiopathic thrombocytopenic purpura (ITP) has previously been reported. However, PBC associated with ITP and Sjogren's syndrome simultaenously has not been reported yet. We experienced a 72-year-old woman had been finally diagnosed as PBC, ITP and Sjogren's syndrome. To the best of our knowledge, this is the first case in the world. We report this case with review of related literature.

A Case of Primary Malignant Fibrous Histiocytoma of the Diaphragm / 결핵

A malignant fibrous histiocytoma (MFH) is a major subset of soft tissue sarcomas, which occurs principally on the extremities or in the retroperitoneum, as well as on the head and neck of elderly patient. However, it is an extremely rare event when a MFH occurs primarily in the diaphragm of a young people. A 25-year-old woman visited our hospital complaining of right chest pain. The chest X-ray showed a diaphragmatic mass. An exploratory thoracotomic biopsy revealed a primary MFH of the diaphragm. The patient was treated with combined chemotherapy consisting of ifosfamide and doxorubicin. A partial response was seen after 6 cycles of chemotherapy. However, she died of brain metastasis 12 months after the diagnosis.