Adenocarcinoma Arising from Heterotopic Gastric Mucosa in Cervical Esophagus: A Case Report

Heterotopic gastric mucosa (HGM) of the upper esophagus, referred as "cervical inlet patch (CIP)", is a benign lesion that is present in 3.8-10% of the adult population. Adenocarcinomas arising from HGM of the upper esophagus are exceedingly rare. The authors report one additional case of histologically confirmed adenocarcinoma arising from a CIP. The patient had concomitant primary adenocarcinoma of the colon. The right hemicolectomy specimen and total esophagectomy specimen after preoperative chemoradiotherapy showed histologically different adenocarcinomas. The residual esophageal tumor was characterized by large mucin pools, fibrous septa, and floating tumor cells. HGM of both the fundic and antral types was seen on the surface and sides of the tumor. The independent origins of the two cancers were confirmed by immunohistochemical studies for cytokeratins 7 and 20. Without further treatment, the patient remained free of disease after 29 months of follow-up.

A Case of Esophageal Squamous Cell Carcinoma Misconceived as Submucosal Tumor / 대한내과학회지

No abstract available.

A Case of Amyloidosis Presenting with Massive Small Bowel Bleeding / 대한소화기내시경학회지

The gastrointestinal (GI) tract is one of the commonly affected organs in amyloidosis. However, it is difficult to make a correct diagnosis of GI amyloidosis because of its varied clinical manifestation and nonspecific endoscopic findings. Moreover, GI bleeding as a presenting symptom is rare, but can be serious in some cases. Therefore, missed diagnosis and delayed management in GI amyloidosis may potentially lead to a critical outcome. We report a 51-year-old man with multiple myeloma whose major symptom was massive hematochezia due to GI amyloidosis. In our case, amyloid deposits could be distinctly visualized endoscopically in the stomach and the colon. They were manifested as submucosal hematomas in the small bowel resulting in massive bleeding that was successfully controlled with the aid of intraoperative endoscopy.

A Case of Solitary Rectal Ulcer Syndrome with Characteristic Findings of Evacuation and Magnetic Resonance (MR) Defecography / 대한소화관운동학회지

Solitary rectal ulcer syndrome is an uncommon, chronic benign condition characterized by rectal bleeding, the passage of mucus, tenesmus and excessive straining during defecation. Occasionally, solitary rectal ulcer syndrome has been reported to be associated with defecation disorder such as pelvic floor dyssynergia, rectal intussusception and rectal prolapse. However, it is ambiguous how these associated defecation disorders contribute to make the rectal ulcer. We report a case of solitary rectal ulcer syndrome suggesting the pathophysiology of rectal ulcer by typical findings of evacuation defecography and MR defecography. A 40-year-old man presented with lower abdominal pain, rectal bleeding, passage of mucus and tenesmus intermittently for the past 4 years. Colonoscopy showed a large geographic and circumferential ulcer at the 10 cm distance from the anal verge. A biopsy revealed fibromuscular proliferation of laminar propria, hyperplasia of crypt and focal superficial ulceration. Finally, he was diagnosed as solitary rectal ulcer syndrome. Evacuation defecography showed paradoxical movement of puborectal sling and unusual invagination of rectal walls during defecation. In addition, rectum showed spastic movement and anterior rectal wall directly merged into posterior rectal wall making a kissing appearance. The invagination of the rectum at evacuation defecography proved to be the rectal wall thickening at MR defecography. After 9 sessions of biofeedback therapy, his defecation symptoms improved. However, ulcer was still observed without interval change.

Clinical Factors Associated with Response to Biofeedback Therapy for Patients with Chronic Constipation / 대한소화기학회지

BACKGROUND/AIMS: Biofeedback therapy has been widely used for the treatment of constipated patients. However, there are only a few reports about the clinical factors that can predict the effectiveness of biofeedback therapy. The aim of this study was to evaluate prognostic factors before the initiation of biofeedback treatment in constipated patients. METHODS: Biofeedback treatment was performed in 114 patients with constipation. After classifying the patients into two groups, responder and non-responder by subjective and objective parameters, univariate and multivariate analysis were performed to evaluate the factors associated with effectiveness of biofeedback therapy. RESULTS: Eighty-five patients (74.6%) responded to biofeedback therapy. Pre-treatment balloon expulsion test, paradoxical contraction on manometry, defecation index and anal residual pressure during straining were the factors that influenced the results of biofeedback treatment. On multivariate analysis, defecation index (odds ratio=67.5, p<0.05) and paradoxical contraction on manometry (odds ratio=0.053, p<0.05) were the factors that showed significant difference between the responders and non-responders. CONCLUSIONS: This study suggests that several pre-treatment prognostic factors are associated with response to biofeedback for the constipated patients. Using prognostic factors, we may be able to evaluate the patterns of pelvic floor dysfunction and responsiveness of biofeedback therapy for the patients with constipation.

A Case of Neurotoxicity Following 5-Fluorouracil-based Chemotherapy

5-Fluorouracil (5-FU) is a commonly used chemotherapeutic agent. However, its neurotoxicity is rare and not well recognized. We report a case of 5-FU neurotoxicity with organic brain syndrome and progression to multifocal leukoencephalopathy in a 44-year-old male patient having malignant gast- rointestinal stromal tumor. 5-FU-induced neurotoxicity should, therefore, be considered as an important differential diagnosis in cancer patients with neurological abnormality and history of chemotherapy.

A Case of Adenocarcinoma in Ileocecal Valve Mimicking Inflammatory Bowel Disease / 대한소화기내시경학회지

Adenocarcinoma of the ileocecal valve is rare. It's clinical manifestations are non-specific such as intestinal intussusception, obstruction and right lower abdominal discomfort according to type of cancer. Particularly infiltrative type carcinoma of the ileocecal valve may be easily misdiagnosed as inflammatory bowel disease by radiological imagings and clinical symptoms. We experienced one case of adenocarcinoma of the ileocecal valve mimiking inflammatory bowel disease in radiological features. Colonoscopic findings also could not differentiate malignancy with chronic inflammatory condition. We report a case of adenocarcinoma of the ileocecal valve, which endoscopic findings mimic chronic inflammatory disease, with a review of literature.

Clinical Characteristics of Non-B, Non-C Hepatocellular Carcinoma and Detection of HBV, HCV and TTV Viremia / 대한간학회지

BACKGROUND/AIMS: About 15% of Korean hepatocellular carcinoma (HCC) are negative both of Hepatitis B surface antigen (HBsAg) and anti-hepatitis C virus (anti-HCV) in their sera. They can be classified as a non-B, non-C hepatocellular carcinoma group (NBNC group). The aims of our study were, firstly, to describe the clinical characteristics of Korean NBNC HCC and compare them with those of HBsAg-positive HCC (HBV group) and anti-HCV-positive HCC (HCV group). Secondly we wanted to assess the frequency of viremia of HBV, HCV and transfusion-transmitted virus (TTV) in NBNC HCC patients. METHODS: We prospectively collected clinical data and sera from 113 NBNC HCC patients and performed PCR for HBV DNA, HCV RNA and TTV DNA. We also collected clinical data from 125 HBsAg-positive HCC patients and 61 anti-HCV-positive HCC patients during a similar period. RESULTS: The mean age of the NBNC HCC group was 59 years, in-between that of the HBV and the HCV groups. A History of heavy alcohol drinking was found in 48% of the NBNC HCC group. This was significantly higher than that of the HBV group, but similar to that of the HCV group. Serum alphaFP level in the NBNC HCC group was more frequently in the normal range compared to that in the HBV and HCV groups. The detection rates of HBV DNA, HCV RNA and TTV DNA in the NBNC HCC group were 17%, 13%, and 67% respectively. CONCLUSIONS: The NBNC HCC patients seemed to comprise a heterogeneous group of various etiologies and clinical presentations. About one third of these patients displayed evidence of viremia of HBV or HCV.

Expression of P-glycoprotein and p53 Protein in Stage IV Hepatocellular Carcinoma Treated with Systemic Chemotherapy / 대한간학회지

BACKGROUND/AIMS: Hepatocellular carcinoma (HCC) is a drug-resistant tumor. The expression of a multidrug resistant gene, P-glycoprotein (P-gp) is a major mechanism of drug resistance. The aims of our study were, firstly, to observe the expression rate of P-gp in HCC tissue obtained by percutaneous fine needle aspiration (PCNA) from stage IV HCC patients; secondly to examine the association between P-gp and chemotherapeutic response; and finally to investigate the correlation between p53 protein expression and P-gp expression. Subjects and METHODS: We studied 29 cases of stage IV HCC treated by systemic chemotherapy. Expression of P-gp and p53 were evaluated by immunohistochemical staining of HCC tissue with human monoclonal antibody, JSB-1 (Anti P-gp) and DO-7 (Anti p53), respectively. We analyzed the results of immunohistochemical staining of HCC tissues of the patients in relation to chemotherapeutic response and other clinical characteristics. RESULTS: The expression rate of P-gp was 27.6%. Partial response to anti-cancer chemotherapy was observed in 16.7% of the patients. Although we could not see a statistically significant association between P-gp expression and chemotherapeutic response, none of the responsive patients showed P-gp expression. p53 protein expression was found in 45% of the patients. There was no significant correlation between p53 protein expression and P-gp expression. CONCLUSIONS: Although the number of our study subjects was small, chemotherapy- responsive patients didn't show P-gp expression. P-gp expression might be used as a predictor of response to potentially toxic anti-cancer chemotherapy in HCC patients. Further study is warranted to confirm our results.

Analysis of the Efficacy of Medical Treatment and the Cumulative Operation Rates of Behcet's Colitis According to the Colonoscopic Classification / 대한소화기내시경학회지

BACKGROUND/AIMS: The lesions of Behcet's colitis showed aphthoid or punched-out ulceration, but the macroscopic types of lesions have not been defined. The aim of this study was to predict the clinical outcome of patients with Behcets colitis according to colonoscopic findings. METHODS: We retrospectively reviewed the medical records and colonoscopic photographs of 50 patients with Behcet's colitis. Colonoscopic findings were categorized according to three types: volcano-, geographic- and aphthous-type. The efficacy of medical treatment was assessed by follow-up colonoscopy or double-contrast barium enema 4 to 8 weeks after treatment and recurrence of the lesions was evaluated during the follow-up period. Cumulative operation rates were obtained by the Kaplan-Meier method. RESULTS: Macroscopic types of colonic ulcers revealed 25 out of 50 (50%) patients with volcano-type, 11 (22%) with geographic-type, and 14 (28%) with aphthous-type lesions. Complete remission rates by medical treatment and operation rates in volcano-type ulcerations were 6 of 25 (24%) and 13 of 25 (52%), geographic-type 8 of 11 (73%) and 1 of ll (9%), and aphthous-type 9 of 14 (64%) and 2 of 14 (14%), respectively. The recurrence rate in volcano-type ulcerations was 9 of 19 (47%), geographic-type 1 of 9 (11%) and aphthous-type 1 of 11 (9%), CONCLUSIONS: Volcano-type ulcerations in Behcets colitis showed less favorable response to medical treatment and more episodes of operation and recurrence than geographic- and aphthous-type ulcerations.

The Hemostatic Effect and Prognosis of Endoscopic Ethanol Injection in Bleeding Peptic Ulcer / 대한소화기내시경학회지

BACKGROUND AND AIMS: Endoscopic injection therapy improves the outcome in bleeding peptic ulcer, but the optimum regimen is unknown. Although endoscopic injection therapy is effective in controlling initial hemorrhage from a peptic ulcer, between 10% to 30% of patients suffer rebleeding. The aim of this study was to evaluate the initial and ultimate success rate of hemostasis, the rebleeding rate, hospital stay (days), and the emergency operation rate in patients who had undergone endoscopic ethanol injection for bleeding peptic ulcer. METHODS: Thirty nine patients presented with active bleeding (spurting), visible vessels, or blood clots on endoscopic findings were given an endoscopic ethanol injection with a total of 1.0-3.0 ml of ethanol. The initial and ultimate success rate of hemostasis, rebleeding rate, and emergency operation rate after the endoscopic injection was evaluated. RESULTS: 1) The initial success of hemostasis was 38/39 (97.4%). 2) The rebleeding rate after ethanol injection was 8/39 (20.5%). 3) The success rate of the second trial of ethanol injection was 3/8 (37.8%). 4) Emergency operations were conducted in5/39 (12.8%). 5) The ultimate success rate of hemostasis was 34/39 (87.2%). 6) There were no mortalities [0/39 (0%)] related to the ethanol injections and bleeding peptic ulcers. 7) There were no complications [0/39 (0%)] related to the ethanol injections. 8) The mean duration of hospitalization was 9.5 4.5 days. CONCLUSIONS: Endoscopic ethanol injection in the treatment of bleeding peptic ulcers was as effective and safe as any other injection or mechanical hemostatic method. Further prospective studies or endoscopic trials for hemostasis are needed to reduce the rebleeding rate and emergency operation rate of bleeding peptic ulcer.

A Case of Gastric Schwannoma Presenting with Submucosal Tumor / 대한소화기내시경학회지

Most submucosal tumors of the stomach are of mesenchymal origin. According to the advances of immunohistochemical staining and electron microscopy, spindle cell tumors which were considered as leiomyoma or leiomyosarcoma appeared to be heterogeneous group; from smooth muscle cell, neural, bidirectionally differentiated cells of smooth muscle cell and neural cell, or immature mesenchymal cell. Therefore, the gastrointestinal mesenchymal tumors are referred to as gastrointestinal stromal tumors. The biologic behavior of gastrointestinal stromal tumors is difficult to predict, except benign leiomyoma and schwannoma. Recently, we experienced a case of 5 cm-diameter submucosal tumor with a central ulcer on body of the stomach, endoscopically. The tumor was a well cir- cumscribed submucosal mass located in the midbody along greater curvature. Micros- copically, the tumor was composed of fasciculating bundles of spindle cells with benign nuclear atypia and peripheral lymphoid cell cuffing. The tumor cells revealed a diffuse strong immunoreactivity to S-100 protein and vimentin, but were negative to desmin and smooth muscle actin. Ultrastructurally, many tumor cells showed a number of thin elon-gated and interdigitating dendritic-like cell processes, distinct uniform basal laminae, frequent cellular attachments and microfilaments. The findings supported the schwannian nature of the tumor.

Endoscopic Mucosal Resection of Gastric Adenoma: A Follew-up Study / 대한소화기내시경학회지

BACKGROUND/AIMS: Endoscopic mucosal resection (EMR) is a useful method in both the accurate diagnosis and treatment of gastric mucosal lesions. A gastric adenoma is a neoplastic lesion which has malignant potential, and therefore it is advisable to have it removed completely when discovered. We evaluated the role of EMR in the treatment of gastric adenomas by analyzing the follow-up endoscopic results of patients treated with EMR for such lesions. METHODS: We analyzed the initial endoscopic findings, EMR results, and follow-up endoscopic outcomes of 35 patients with 41 gastric adenomas, from June 1994 to January 1997 in Seoul National University Hospital.

Gastric Mucormycosis in a Renal Transplant Recipient / 대한소화기내시경학회지

Mucormycosis is a rare opportunistic infection caused by fungi of the nrder Mucorales. It occurs almost exclusively in immunocompromised patients, and the prognosis is grave. Rhinocerebral and pulmonary diseases are the most comrnon forms. Gastric mucormycosis is very rare and the manifestations range from colonization of peptic ulcers to infiltrative disease with vascular invasion and dissemination. Only one case of gastric mucormycosis was reported in Korean literature. We recently experienced a case of gastric mucormycosis in a renal transplant recipient. The 29-year-old male patient received a renal transplant from his rnother seven years ago, and had been on immunosuppressive therapy. He experienced intermittent epigastric pain for one week, and a gastroscopy revealed a huge gastric ulcer covered with black necrotic material. The diagnosis of gastric mucormycosis was confirmed on a histologic examination, and amphctericin B was administered. Despite two weeks of intensive medical therapy he expired due to shock and multiorgan failure. This is the first case of gastric mucormycosis in an organ transplant recipient in Koren.