Three Cases of Secondary Esophageal Tuberculosis Presenting as an Esophageal Submucosal Tumor / 대한소화기내시경학회지

Although esophageal tuberculosis is a rare disease throughout the world, esophageal tuberculosis should be included as one of differential diagnosis made in Korea where the prevalence of tuberculosis is still high. Esophageal tuberculosis might be mistaken for carcinoma due to lack of specific symptom, diagnostic study or pathologic diagnosis in clinical setting. The diagnosis would be difficult when esophageal ulcerative lesions or submucosal tumor are present, especially. When the result after a biopsy is not confirmative, the diagnosis can be made with the detection of mycobacteria by microbiologic study or polymerase chain reaction. We experienced three patients with esophageal tuberculosis; a 41-year-old woman with dysphagia, a 34-year-old woman with dysphagia and odynophagia, and a 52-year-old woman with epigastric pain. Esophageal submucosal tumors were found in all the patients with upper gastrointestinal endoscopy. The diagnosis of tuberculosis were finally made by removal of tumor and biopsy or tuberculosis polymerase chain reaction. They all got improved after the treatement with anti-tuberculosis medications. Herein, we report 3 cases of esophageal tuberculosis with review of related literatures.

Usefulness of Urinary Trypsinogen-2 Dipstick Test for Diagnosis of Acute Pancreatitis / 대한소화기학회지

BACKGROUND/AIMS: The clinical usefulness of urinary trypsinogen-2 dipstick test is still in controversy. We evaluated the usefulness of urinary trypsinogen-2 dipstick test in patients with acute pancreatitis. METHODS: Urinary trypsinogen-2 dipstick test was prospectively performed in 50 patients with acute pancreatitis, 50 patients with non-pancreatic abdominal pain, and 50 healthy controls. RESULTS: On admission, urinary trypsinogen-2 dipstick test was positive in 36 of 50 patients with acute pancreatitis (sensitivity, 72%) and in 4 of 50 patients with non-pancreatic abdominal pain (specificity, 92%). On the other hand, it was all negative in controls. The sensitivity and specificity of serum lipase were 78% and 94%, respectively. At 24 hours after admission, the positive rate of urinary trypsinogen-2 dipstick test rose from 72% to 94% (p=0.02). The results of urinary trypsinogen-2 dipstick test was positive in 14 of 15 patients with severe pancreatitis and 22 of 35 patients with mild pancreatitis according to the criteria by Atlanta International Symposium, 1992. CONCLUSIONS: Urinary trypsinogen-2 dipstick test is comparable to serum lipase in diagnosing acute pancreatitis. Delayed measurement and severe pancreatitis are more likely to yield positive results with urinary trypsinogen-2 dipstick test. Thus, we suggest that the cut-off value of urinary trypsinogen-2 dipstick test should be lowered to increase its sensitivity.

Altered Colonic Transit in TNBS-induced Experimental Colitis in Guinea Pig and Distribution of Nitric Oxide Synthase in the Colonic Wall / 대한소화기학회지

BACKGROUND/AIMS: Inflammation-induced alterations in smooth muscle contractility may be due to the effects on smooth muscle itself, neurotransmitters or enteric nerves. In dextran sulfate sodium-induced colitic rat, the delay in colonic transit was caused by decreased activity and production of neuronal nitric oxide synthase (nNOS) in the myenteric plexus of the distal colon. The aim of this study was to investigate the relationship between the delay in colonic transit and the distribution of inducible NOS (iNOS) and nNOS immunoreactive cells in the myenteric plexus of trinitrobenzene sulfonic acid (TNBS)-induced colitic guinea pig. METHODS: Sacrificed and their colonic tissues of forty-five TNBS-induced colitic guinea pigs were used to measure the colonic transit, and analyzed by immunohistochemistry. RESULTS: Colonic transit was delayed significantly at 3, 7 and 14 days after administration of TNBS. In control, nNOS immunoreactivity was present in the mucosa, submucosa, lamina propria, and ganglion cells of the myenteric plexus, while after TNBS treatment, reduced nNOS cells were found. However, the number of nNOS ganglion cells in the myenteric plexus was similar to those seen in controls. After administration of TNBS, iNOS immunoreactivity was increased in the mucosa and submucosa, but the number of iNOS positive ganglion cells in the myenteric plexus was not changed compared to control. CONCLUSIONS: It is suggested that in TNBS-induced guinea pig colitis, delayed colonic transit is not associated with the expression of nNOS nor iNOS in the myenteric plexus.

Type of Electric Currents Used for Standard Endoscopic Sphincterotomy Does Not Determine the Type of Complications / 대한소화기학회지

BACKGROUND/AIMS: The blended current is usually used for endoscopic sphincterotomy (EST) to minimize bleeding. The pure cutting current may induce less edema of the ampulla and therefore result in less injury to the pancreas theoretically. The aim of this study was to evaluate effects of electric currents used on the development of serum pancreatic enzyme evaluation, clinical pancreatitis or bleeding after EST. METHODS: One hundred and eighteen consecutive patients who underwent EST with standard papillotome alone for the treatment of choledocholithiasis were reviewed. All EST had been performed by two endoscopists whose experience on EST was similar: one uses 'blended current' (BC group, n=74), while the other uses 'pure cutting current' (PC group, n=44). RESULTS: Baseline clinical, laboratory, and procedural parameters were similar in both groups. The incidences of hyperamylasemia and hyperlipasemia were similar between two groups. There was no significant difference in the incidence of clinical pancreatitis between two groups (BC 6.8% vs PC 0.0%, p=0.1557). All episodes of pancreatitis were mild. No episodes of significant bleeding occurred after EST. The incidences of sepsis, cholangitis and perforation were also not different between two groups. CONCLUSIONS: Development of complications after standard EST such as hyperamylasemia, clinical pancreatitis, and bleeding may not depend on the electric current used.

Clinical & Pathological Characteristics of Intraductal Papillary Mucinous Tumor of the Pancreas

PURPOSE: Intraductal papillary mucinous tumors of the pancreas (IPMT) are becoming increasingly recognized. Despite a better understanding of these conditions, IPMT still present difficulty relating to the predictive factors and the risk of relapse after surgery. The aim of this study was to investigate the clinical, and pathological characteristics of IPMT. METHODS: Between October 1998 and July 2002, 22 patients with IPMT underwent surgery. We retrospectively examined the clinicopathological features and surgical outcomes of these patients. RESULTS: The types of IPMT were as follows: dysplasia (1); adenoma (4); borderline malignancy (9); carcinoma in situ (3); and carcinoma, both non-invasive (3) and invasive (2). Lymph node metastasis was not found, but stromal invasion was found in the 2 cases of invasive carcinoma. The locations of the IPMT were as follows: head (6); uncinate process (11); body (4); and tail (1). There were 11 main duct types, 10 branched duct types and 1 combined. All patients underwent surgical resection, including 3 pancreaticoduodenectomies, 12 pylorus-preserving pancreaticoduodenectomies, 4 distal pancreatectomies with splenectomies, 2 near-total pancreatectomies with splenectomies, and 1 enucleation. There were no operative or hospital deaths. A recurrence of the IPMT following surgery occurred in 2 cases. Their pathological features were a carcinoma in situ and a borderline malignancy, but not the invasive type. However, one case of recurrence expired 7 month after surgery. A combination of other malignancies in these patients was found in 2 cases. CONCLUSION: IPMT has a favorable prognosis, when compared with pancreatic duct carcinoma. However, long-term follow-up after surgery is necessary, even for a curative resection due to a recurrence or a combination of other malignancies. Because combination of other malignancies exist infrequently, surgeons should be aware of the possibility of co-existing other malignancies.

A Case of Complete Resolution of Mediastinal Pseudocyst and Pleural Effusion by Endoscopic Stenting of Pancreatic Duct

We report a case of a mediastinal pseudocyst with a pleural effusion that developed in a patient suffering from alcohol-related chronic pancreatitis. A 53-year-old man was admitted to another institution complaining of pleuritic chest pain and coughing. A chest X-ray revealed a pleural effusion with a collapse of the right middle and lower lobes. Pleural fluid taken by thoracentesis was exudative, and the patient was transferred to our institution. A CT scan showed a loculated cystic lesion in the mediastinum and pancreatic changes that were consistent with chronic pancreatitis. The endoscopic retrograde cholangiopancreatography (ERCP) findings were compatible with chronic pancreatitis showing severe pancreatic ductal stricture at the head with an upstream dilation and distal bile duct stricture. After a one week of treatment with fasting and octreotide without improvement, both pancreatic and biliary stents were placed endoscopically. After stenting, the pleural effusion and pseudocyst rapidly resolved. The stents were changed 3 months later, at which time a repeated CT demonstrated a complete resolution of the pseudocyst. Since the initial stenting, he has been followed up for 7 months and is doing well with no recurrence of the symptoms, but he will need to undergo regular stent changes. Overall, endoscopic pancreatic stenting appears to be a good option for managing selected cases of mediastinal pancreatic pseudocysts.

Liver cirrhosis and pregnancy: A case report and a review of the reported cases in Korea / 대한내과학회지

Pregnancy is rarely encountered in women with liver cirrhosis, but can occur in all forms of liver cirrhosis. The amount of data regarding pregnancy in cirrhotic patients is not great and thus no clear-cut guidelines for management can be outlined. Another interesting point of pregnancy in liver cirrhosis would be how pregnancy affects liver function in cirrhotic patients. In Korea, only 6 pregnancies in 5 patients have been reported. Recently, we experienced a case of pregnancy in a patient with liver cirrhosis. A 36 year-old, primigravida woman presented at 23 weeks of gestation. B-viral liver cirrhosis was diagnosed 2 months earlier when she had developed generalized edema and ascites. We observed a recovery of hyperbilirubinemia and hypoalbuminemia after a therapeutic termination of pregnancy. This case may illustrate that pregnancy can deteriorate liver function in some patients with liver cirrhosis. We report this case with an analysis of the reported cases in Korea.

A Case of Malignant B-Cell Lymphoma Involving the Stomach in a Patient with Neurofibromatosis Type 1 / 대한소화기내시경학회지

Neurofibromatosis type 1, an autosomal dominant disorder, is clinically characterized by the presence of cafe-au-lait spots and cutaneous neurofibromas. Malignancy is a frequently cited and feared complication of neurofibromatosis. Neurofibromatosis has been reported to be associated with some CNS tumors, neurofibrosarcoma, pheochromocytoma, and nonlymphocytic leukemia. Also malignant lymphoma may develop in patients with neurofibromatosis. In Korea, only a case of lung cancer and a case of pheochromocytoma have been reported to develop in patients with neurofibromatosis type 1. Recently, we experienced a case of malignant lymphoma involving the stomach in a 70-year-old woman with neurofibromatosis type 1. An esophagogastroduodenoscopy revealed a 5 cm sized ulcerofungating mass on the greater curvature of the upper body. Histologic diagnosis of the biopsied specimen was B-cell diffuse small and large cell lymphoma. This case illustrates that malignant lymphoma should be included in the differential diagnosis of gastric tumors in patients with neurofibromatosis type 1.

A Case of a Giant Brunner's Gland Hamartoma Originating from the Pyloric Ring / 대한소화기내시경학회지

Brunner's gland hamartoma, also called as Brunner's gland adenoma or Brunner's gland hyperplasia, is a relatively rare disease that results from benign proliferation of the Brunner's gland normally present in the duodenum. It is mostly located at the duodenal bulb, occasionally second or third portion, but is rarely found at the pyloric ring, jejunum or proximal ileum. In Korea, total 27 cases of Brunner's gland hamartoma have been reported, but none of them had their origin at the pyloric ring only. We report a case of Brunner's gland hamartoma, found incidentally, originating from the pyloric ring in a 54-year-old woman, which was resected endoscopically after retracting the tumor into the stomach.

A Clinical Study on the Effect of Transcatheter Arterial Embolization in the Treatment of Peptic Ulcer Bleeding / 대한소화기내시경학회지

BACKGROUND/AIMS: Transcatheter arterial embolization (TAE) has been increasingly used in the treatment of patients with gastrointestinal bleeding due to improved catheter and guidewire technologies and emergence of safer embolization materials. We evaluated the clinical characteristics of patients in whom TAE was performed and the outcome of the treatment. METHODS: Eleven patients (M:F=9:2, mean age=60.6 years) underwent TAE between April 2001 and August 2002. Causes of bleeding were gastric ulcer in 9 cases and duodenal ulcer in 2 cases. Seven patients had comorbid diseases, but 4 patients did not. RESULTS: Successful TAE without rebleeding was achieved in 10 of 11 patients (90.9%). One patient failed to respond to TAE and died due to multiorgan failure. Another patient died due to other causes despite a successful TAE. There were no TAE-related complications. CONCLUSIONS: TAE is a safe and effective modality in the treatment of patients with peptic ulcer bleeding who do not respond to endoscopic hemostasis. Thus, TAE seems to be included in the treatment algorithm of peptic ulcer bleeding regardless of surgical risks of patients and be placed before surgery, but prospective randomized studies are needed.

Autoimmune Pancreatitis with Effective Steroid Therapy

Autoimmune pancreatitis has recently been described as a clinical entity that causes chronic pancreatitis. This unique form of chronic pancreatitis is characterized by minimal attacks of abdominal pain, irregular narrowing of the pancreatic duct, and a diffuse enlargement of the pancreas. Autoimmune pancreatitis is associated with hypergammaglobulinemia. In addition, there is histological evidence of lymphoplasmacytic inflammation, the occasional coexistence of other autoimmune diseases, and has a favorable response to glucocorticoid treatment. Recently autoimmune pancreatitis has been increasingly reported particularly in Japan. We report two patients with autoimmune pancreatitis who were treated successfully with corticosteroid therapy.

Migration of Pyloric Self-Expanding Metallic Stent to the Esophagus / 대한소화기내시경학회지

Self-expandable metallic stent (SEMS) has been reported to provide effective treatment alternatives with minimal morbidity for patients with malignant gastroduodenal obstruction. Limitations of SEMSs are stent occlusion due to tumor ingrowth or overgrowth and stent migration. Migrated stents may remain in the stomach or travel distally. To our knowledge, however, migration of pyloric SEMS to the esophagus has not been reported. We experienced such a case in a 65-year-old woman who had undergone a gastrojejunostomy and choledochojejunostomy due to unresectable pancreatic head cancer. Pyloric SEMSs (Niti-S Pyloric Bare Stent, 18x60 mm, Taewoong Medical, Korea) were deployed at the obstructed efferent and afferent loops. After severe vomiting, a pyloric SEMS placed at the afferent loop migrated into the esophagus, which caused severe chest pain and intractable hiccup. It was removed endoscopically. This case illustrates that pyloric SEMS can migrate to the esophagus through the lower esophageal sphincter.

A Case of the Main Pancreatic Duct Injury Due to Blunt Abdominal Trauma Cured by Conservative Management Including Octreotide Administration / 대한소화기내시경학회지

Pancreatic trauma is uncommon, but carries high morbidity and mortality rates, especially when diagnosis is delayed or inappropriate surgery is attempted. The principal cause of pancreas specific complication and pancreas specific mortality is the presence of an injury to the pancreatic ductal system. It has been suggested that the main pancreatic duct injury is an indication of surgery or endoscopic therapy depending on the extent of leakage. Recently, we experienced a 53-year-old man who had an injury to the main pancreatic duct due to blunt abdominal trauma by a handlebar. Endoscopic retrograde pancreatography correctly diagnosed a leak at the main pancreatic duct, but his stable clinical condition and narrow main pancreatic duct precluded surgery or endoscopic therapy. Interestingly, this case was successfully treated by conservative management including octreotide administration.

A Case of Hepatosubphrenic Fistula Treated by Histoacryl(R) Injection by ERCP / 대한소화기내시경학회지

Acute hepatic failure, liver infarction, abscess, intrahepatic biloma, and multiple intrahepatic aneurysms could be complicated after transcatheter arterial embolization (TAE) in a patient with hepatocellular carcinoma. Conservative managements such as nutritional support and control of sepsis for gastrointestinal fistula have been recommended for the last few decades. Histoacryl(R) has been applied to treat gastrointestinal fistula. We report a case of liver abscess after TAE followed by hepatosubphrenic abscess in a patient with hepatocellular carcinoma. The fistula between liver abscess and subphrenic abscess was occluded with Histoacryl(R) injection by ERCP. Endoscopic nasobiliary drainage and percutaneous drainage were performed respectively. Both abscesses were treated, but the patient died of hepatic failure.

Determination of the origin of the extrahepatic bile duct stones by magnetic resonance cholangiography (MRC) / 대한내과학회지

BACKGROUND: Extrahepatic bile duct stones can be classified into two types. Primary stones are formed de nevo in the bile duct, whereas secondary stones migrate from the gallbladder into the bililary tree. The differentiation between primary and secondary stones is very difficult before operation. The aim of this study is to determine the origin of extrahepatic bile duct stones by analyzing MRC features. METHODS: MRC was obtained in 38 patients with stones in both the common duct and gallbladder. MRC findings were compared for gross characteristics and MR signal patterns between common duct stone and gallbladder stone pairs. The gross morphologic characteristics of gallstones on MRC were classified into oval, polygonal, round, rod, sandy and mixed shape. Gallstone patterns seen on heavily T2-weighted images were categorized into one of two patterns: dark, and mixed signal. RESULTS: According to the morphologic characteristics on MRC images, the common duct stones were oval (n=9), polygonal (n=15), round (n=6), sandy (n=4), mixed (n=3) and rod (n=1). The visualized MR signal patterns of common duct stones on heavily T2-weighted images were dark (n=28) and heterogenous (n=10). CONCLUSION: On MRC, the gross morphologic characteristics and gallstone patterns of common duct stones were similar to those of their paired gallbladder stones in 60.5 to 78.9% of patients.

Determination of the origin of the extrahepatic bile duct stones by magnetic resonance cholangiography (MRC) / 대한내과학회지

BACKGROUND: Extrahepatic bile duct stones can be classified into two types. Primary stones are formed de nevo in the bile duct, whereas secondary stones migrate from the gallbladder into the bililary tree. The differentiation between primary and secondary stones is very difficult before operation. The aim of this study is to determine the origin of extrahepatic bile duct stones by analyzing MRC features. METHODS: MRC was obtained in 38 patients with stones in both the common duct and gallbladder. MRC findings were compared for gross characteristics and MR signal patterns between common duct stone and gallbladder stone pairs. The gross morphologic characteristics of gallstones on MRC were classified into oval, polygonal, round, rod, sandy and mixed shape. Gallstone patterns seen on heavily T2-weighted images were categorized into one of two patterns: dark, and mixed signal. RESULTS: According to the morphologic characteristics on MRC images, the common duct stones were oval (n=9), polygonal (n=15), round (n=6), sandy (n=4), mixed (n=3) and rod (n=1). The visualized MR signal patterns of common duct stones on heavily T2-weighted images were dark (n=28) and heterogenous (n=10). CONCLUSION: On MRC, the gross morphologic characteristics and gallstone patterns of common duct stones were similar to those of their paired gallbladder stones in 60.5 to 78.9% of patients.

A Case of Metastatic Amelanotic Malignant Melanoma of the Duodenum / 대한소화기내시경학회지

Malignant melanoma is one of the most common malignancies associated with metastatic disease to the gastrointestinal tract. Malignant melanotic melanomas metastasized to the stomach and duodenum, stomach, small bowel, and rectum have been reported in Korea. However, amelanotic malignant melanoma metastasized to the gastrointestinal tract, to our knowledge, has not been reported in Korea. Recently, we experienced a case of amelanotic malignant melanoma metastasized to the duodenum in a 48 year-old man. The primary site was presumed to be the soft tissue near the right knee. Pulmonary and pancreatic metastasis were also noted at presentation. Despite systemic chemotherapy, the patient died of progressive disease at about 13 months after presentation.

A Case of Congenital Anomaly of the Pancreatic Duct Discovered in a Child with Recurrent Acute Pancreatitis / 대한소화기내시경학회지

Congenital pancreatic duct anomalies result from an error in the complex developmental process. Congenital pancreatic duct anomalies may be categorized by their mechanisms into migration anomaly, fusion anomaly, and duplication anomaly. These ductal abnormalities have been implicated to be potential causes for both acute and chronic pancreatitis. We have recently observed a congenital anomaly of the pancreatic ducts in which bifurcated main pancreatic ducts drain through the major papilla in a 10 year-old boy presenting with recurrent acute pancreatitis. Although its causal relationship with acute pancreatitis is unclear, this kind of pancreatic ductal anomaly has not been found in the literature.

Lower gastrointestinal bleeding due to cytomegalovirus ileal ulcers in an immunocompetent man

Cytomegalovirus (CMV) infections are commonly reported in severely immunocompromised hosts and ulcers of the alimentary tract are frequently observed in systemic CMV infections. However, invasive and ulcerative disease of the gastrointestinal (GI) tract caused by CMV has also been reported in healthy adults. Many reports show that a CMV infection can produce localized ulcerations in the esophagus, stomach, small intestine, and colon in nonimmunocompromised individuals. The most common site of involvement by CMV infection in the GI tract is the colon followed by the upper GI tract and the least common site is the small intestine. Although GI bleeding is one of the major presenting symptoms of patients with CMV infections of the GI tract, lower GI bleeding due to CMV ileal ulcers in immunocompetent patients, to our knowledge, has not been reported in the English literature. Recently, we experienced a case of lower GI bleeding due to CMV ileal ulcers in a 57-year-old man who had no evidence of immunocompromise. This case suggests that small intestinal ulcers due to CMV infection should be included in the differential diagnosis of lower GI bleeding even in immunocompetent hosts.

A New Covered Biliary Metal Stent versus Uncovered Wallstent for Malignant Biliary Obstruction / 대한소화기내시경학회지

BACKGROUND/AIMS: In order to provide a complete obstacle to tumoral growth, we designed a new self-expandible metal stent fully covered with polyurethane membrane. The purpose of the study was to compare the safety and effectiveness of a new membrane-covered Niti-S stent versus conventional uncovered Wallstent. METHODS: In a prospective trial, 59 patients with malignant extrahepatic biliary obstruction received either a newly developed covered metal stent (Niti-S stent, 30 cases) or an uncovered metal stent (Wallstent, 29 cases) by the endoscopic transpapillary route. RESULTS: Effective biliary decompression was achieved in all patients initially, and short-term results were similar in both groups. Stent failure was observed in 4 of the 30 patients (13%) after a median period of 165 days in the Niti-S group and in 8 of the 29 patients (28%) after a median period of 152 days in the Wallstent group. The reasons of stent failure were occlusion (n=3) and migration (n=1) in the covered Niti-S stent group and occlusion (n=8) in uncovered Wallstent group. According to the Kaplan-Meier life table analysis, the patency rates after 90, 180, and 360 days were 100%, 90%, and 74% in covered Niti-S stent group and 100%, 73%, and 61% in uncovered Wallstent group respectively. The occluded membrane-covered Niti-S stent was easily removed endoscopically and a new Niti-S stent was reinserted in one patient. CONCLUSIONS: The new, membrane-covered Niti-S stent has a lower stent failure rate and a tendency toward long-term patency rate compared to uncovered Wallstent. The covering may effectively prevent tumor ingrowth and it is sometimes possible to remove an occluded Niti-S stent.