Clinical Significance of Fecal Lactoferrin and Multiplex Polymerase Chain Reaction in Patients with Acute Diarrhea

BACKGROUND/AIMS: The diagnostic yield of fecal leukocyte and stool cultures is unsatisfactory in patients with acute diarrhea. This study was performed to evaluate the clinical significance of the fecal lactoferrin test and fecal multiplex polymerase chain reaction (PCR) in patients with acute diarrhea. METHODS: Clinical parameters and laboratory findings, including fecal leukocytes, fecal lactoferrin, stool cultures and stool multiplex PCR for bacteria and viruses, were evaluated prospectively for patients who were hospitalized due to acute diarrhea. RESULTS: A total of 54 patients were included (male, 23; median age, 42.5 years). Fecal leukocytes and fecal lactoferrin were positive in 33 (61.1%) and 14 (25.4%) patients, respectively. Among the 31 patients who were available for fecal pathogen evaluation, fecal multiplex PCR detected bacterial pathogens in 21 patients, whereas conventional stool cultures were positive in only one patient (67.7% vs 3.2%, p=0.000). Positive fecal lactoferrin was associated with presence of moderate to severe dehydration and detection of bacterial pathogens by multiplex PCR (21.4% vs 2.5%, p=0.049; 100% vs 56.5%, p=0.032, respectively). CONCLUSIONS: Fecal lactoferrin is a useful marker for more severe dehydration and bacterial etiology in patients with acute diarrhea. Fecal multiplex PCR can detect more causative organisms than conventional stool cultures in patients with acute diarrhea.

The Temporary Placement of Covered Self-Expandable Metal Stents to Seal Various Gastrointestinal Leaks after Surgery

Gastrointestinal leakage is one of the most serious post surgical complications and is a major source of mortality and morbidity. The insertion of a covered self-expandable metal stent could be a treatment option in selected cases. However, it is unclear how long the stent should be retained to achieve complete sealing, and membrane-covered stents have the problem of a high migration rate. We observed four cases of postsurgical leakage following the primary closure of a duodenal perforation, esophagojejunostomy, and esophagogastrostomy, each of which was successfully managed by the temporary placement of covered stents. In all cases, the optimal time of stent removal could be estimated by the markedly decreased amount of drainage, the lack of leakage observed on radiocontrast images, and the endoscopic findings. In this case series, all of the stents could be removed within 7 weeks. For those cases with a high risk of migration, stents with temporary fixations to earlobes and/or partially uncovered proximal flanges were used. These results suggest that the application of a covered stent could be a treatment option for various gastrointestinal leaks after surgery, particularly when the defect cannot be sealed by conservative care and the leakage has good external drainage.

Diagnostic Accuracy and Interobserver Agreement in Predicting the Submucosal Invasion of Colorectal Tumors Using Gross Findings, Pit Patterns, and Microvasculatures

BACKGROUND/AIMS: Depth of invasion is one of the most important factors for establishing treatment strategy for colorectal tumors. METHODS: Three blinded experts reviewed electronic photos and video clips of 33 early colorectal cancer-like lesions. They estimated the depth of invasion based on conventional white light endoscopy (CWE), magnifying chromoendoscopy (MCE), and magnifying narrow band imaging endoscopy (MNE). RESULTS: The lesions included nine mucosal low-grade neoplasias, 16 mucosal high grade neoplasias, and eight carcinomas with invasion to the submucosal layer or beyond. The diagnostic accuracy for submucosal invasion by CWE ranged from 67% to 82%, while those by MCE and MNE ranged from 85% to 88% and 85% to 88%, respectively. The diagnostic accuracy significantly differed between CWE and MCE (p=0.034) and between CWE and MNE (p=0.039). The kappa values for CWE, MCE, and MNE among the endoscopists were 0.564, 0.673, and 0.673, respectively. CONCLUSIONS: The estimation of submucosal invasion for early colorectal cancer-like lesions based on MCE or MNE is more accurate than CWE. MCE and MNE were demonstrated to have substantial agreement for predicting submucosal invasion.

Ultrathin Endoscope-Assisted Method for the Management of Upper Gastrointestinal Obstruction to Avoid Technical Failure

BACKGROUND/AIMS: Endoscopic management of upper gastrointestinal obstruction is safe and feasible. However, its technical and clinical success rate is about 90%, which is primarily due to inability to pass a guide-wire through the stricture. The aim of this study was to evaluate the usefulness of an ultrathin endoscope for correct placement of guide wire to avoid technical failure in upper gastrointestinal obstruction. METHODS: Retrospective assessment of ultrathin endoscope to traverse the stenosis of the upper gastrointestinal tract in technically difficult cases was performed. Technical and clinical success rates and immediate complications were analyzed. RESULTS: Nine cases were included in this study (eight cases of stent insertion and one case of balloon dilatation). Technical success was achieved in all of the patients (100%) and oral feeding was feasible in all of the cases (100%). Immediate complications, such as migration, perforation, and hemorrhage, did not develop in any of the cases. CONCLUSIONS: Ultrathin endoscope-assisted method for upper gastrointestinal obstruction is potentially safe and useful to avoid technical failure.

Expression of MUC5AC and Trefoil Peptide 1 (TFF1) in the Subtypes of Intestinal Metaplasia

BACKGROUND/AIMS: Alterations of the expression pattern of mucins and trefoil peptides have been described in gastric adenocarcinomas and in their precursor lesions. The aim of this study was to determine the progression patterns of intestinal metaplasia (IM) subtypes by analyzing the expression patterns of TFF1 and MUC5AC in different subtypes of IM of the stomach. METHODS: Endoscopic gastric biopsies of the antrum and body were obtained from patients with dyspepsia and endoscopic IM. Alcian blue/periodic acid-Schiff staining and the high iron diamine technique were used to classify the subtypes of IM. Immunoreactivity for MUC5AC and TFF1 was estimated in different types of IM. RESULTS: IM was detected in 128 samples from 80 patients; type I was found in 48 samples, type II was found in 37 samples, and type III was found in 43 samples. There was a gradual decrease in MUC5AC and TFF1 expression during the progression of IM from type I to type III via the type II intermediate. CONCLUSIONS: This downregulation of MUC5AC and TFF1 expression may challenge the sequential progression of IM from type I to type III via the type II intermediate, and it might be associated with gastric carcinogenesis.

A Case of Radiolucent Foreign Body (Temporary Resin Bridge) Aspiration Accompanied by Inflammatory Polyps / 결핵및호흡기질환

This case demonstrates the rare occurrence of a radiolucent temporary resin bridge aspiration in adults while they are in a conscious and awaken state and the resultant formation of inflammatory polyps. Although no unique findings were noted in a chest x-ray, careful history taking accompanied by physical examinations can lead to clinical suspicion of foreign body aspiration in an earlier stage. Moreover, flexible bronchoscopy is a tool useful not only for the evaluation process but also for managing the aspirated foreign material.

A Case of Gastric Syphilis Manifested by Upper Gastrointestinal Bleeding / 대한소화기내시경학회지

Syphilis is a chronic systemic infection caused by Treponema pallidum; it is sexually transmitted and characterized by episodes of active disease interrupted by periods of latency. Syphilitic involvement of the stomach can occur via the blood flow in the primary or secondary period of syphilis, but its incidence is very rare. Because gastric syphilis has no pathognomic clinical findings and it shows variable gastroscopic findings, it's not so easy to diagnose. After gastric syphilis is correctly diagnosed, it can be easily cured by appropriate antibiotic therapy. The clinicians need to be aware of this disease entity when the patient has mucosal inflammation and ulceration of stomach with the past history of syphilis, or if the patient has lived in edemic areas of syphilis. We report on a case of gastric syphilis that manifested with upper gastrointestinal bleeding. It was initially thought to be stomach cancer, but it was correctly diagnosed by serologic testing and the histopathologic findings.

A Case of Osmotic Demyelination Syndrome after Hemodialysis Treatment in a Uremic Patient with Severe Hyperosmolality / 대한신장학회잡지

Osmotic demyelination syndrome (ODS) is a distinctive clinical syndrome with characteristic MR features in the central pons (central pontine myelinolysis) and in other brain locations (extrapontine myelinolysis). Rapid correction of hyponatremia is associated with ODS, but hyperosmolality rarely causes it. Here we report a case of ODS developed in a hemodialysis patient with severe uremia and concomitant hyperosmolality. A 67-year-old male was presented with general weakness and dyspnea. Laboratory findings showed severe uremia (blood urea nitrogen, 167 mg/dL; serum creatinine, 15 mg/dL), hyperosmolality (336 mOsm/kg H2O), and normal range of sodium (145 mEq/L). After the first hemodialysis treatment, his consciousness was changed to lethargic state. We initially suspected dialysis disequilibrium syndrome, but the symptoms were aggravated. MRI showed edema in central pons and symmetrical extrapotine lesions in the subcortical white matter, lateral thalamus, and posterior capsule, consistent with ODS. In spite of aggressive measures including continuous renal replacement therapy, he died of sepsis at the 26th hospital day.

A Case of Central Vein Stenosis in a Hemodialysis Patient with History of Humerus Osteomyelitis Ipsilateral to Arteriovenous Fistula / 대한신장학회잡지

Central vein stenosis (CVS) is a serious complication in hemodialysis patients mostly related to central vein catheterization. Although rare, CVS may also develop without any previous history of central venous catheterization. Here we report a case of central vein stenosis in a hemodialysis patient with the history of humerus osteomyelitis ipsilateral to arteriovenous fistula. The patient did not have any previous history of central vein catheterization. She received radial artery-cephalic vein fistula operation for maintenance hemodialysis. Venography was performed because of inadequate vein maturation 2 months after the operation. Venography shows complete occlusion of left innominate vein, multiple collateral veins and backflow of left internal jugular vein. After percutaneous transluminal angioplasty with stent insertion, the innominate vein was fully dilated and the collateral vessels completely disappeared.