Utility of Magnetic Resonance Cholangiopancreatography for the Diagnosis of Cholangiocarcinoma in a Patient with Situs Inversus / 대한소화기내시경학회지

Situs inversus is a rare condition with genetic predisposition and is characterized by transposition of both heart and intra-abdominal viscera to the opposite side of the body. Cholangiocarcinoma in this condition has rarely been reported. We present a case of adenocarcinoma of the common hepatic duct proximal to the cystic duct in a 68-year-old male with total situs inversus. The patient presented with complaints of abdominal pain, intermittent fever and chilling sensation without jaundice. Magnetic resonance cholangiopancreatography prior to surgery demonstrated segmental narrowing of the common hepatic duct proximal to the cystic duct and two stones in the proximal portion of the narrowed segment. Open laparotomy was performed to remove the lesion. Cholangiocarcinoma was confirmed pathologically. Magnetic resonance cholangiopancreatography was the only pre-operative diagnostic method which had suggested malignancy in this case.

A Case of Primary Esophageal Tuberculosis Confused as Esophageal Cancer / 대한소화기내시경학회지

Tuberculous involvement of the esophagus is very rare even in the presence of extensive pulmonary tuberculosis or in the endemic area. This is resulted from local extension to the esophagus from contiguous tuberculosis organs or miliary spread. Such secondary involvement is more common than primary tuberculosis, in which there is no evidence of tuberculosis elsewhere. The diagnosis of esophageal tuberculosis may be difficult. So the radiologic, endoscopic, histologic findings and clinical feature including the response to chemotherapy may be needed to avoid misdiagnosis. Most cases can be treated successfully with antituberculosis medication. A 67-year-old man was admitted to our hospital complaining of swallowing difficulty for 2 months. On the gastrofibroscopic examination, 22 cm sized protruding mass with central deep ulceration was discovered at the mid-esophagus. The biopsy showed the ulcer with chronic granulomatous inflammation and multinucleated giant cells consistent with tuberculosis. After antituberculosis medication, the lesion of esophageal tuberculosis was healed completely remaining minimal ulcer scar.

Endoscopic Hemoclipping Using a Transparent Cap in Technically Difficult Cases / 대한소화기내시경학회지

BACKGROUND/AIMS: There was some technical difficulty in applying the hemoclip on the posterior wall of the body, cardia of the stomach and posterior wall of duodenum because the angle of approach was tangential. Use of transparent cap on the tip of the endoscope could reduce some of these problems. The purpose of this study was to examine the efficacy of endoscopic hemoclipping using a transparent cap. METHODS: From August 1997 to July 2000, 74 patients with bleeding peptic ulcer and stigmata of recent hemorrhage were treated with endoscopic hemoclipping. There was technical difficulty in applying the hemoclip in 18 patients and the transparent cap was used. RESULTS: There was no statistically significant difference between the patients treated with cap and the patients treated without cap in initial hemostasis rate (91.1% vs 94.4%), rebleeding rate (11.8% vs 11.7%), and permanent hemostasis rate (92.9% vs 94.4%). CONCLUSIONS: Use of transparent cap on the tip of the endoscope was an efficient method when the angle of approach was tangential.

Herpes Simplex Esophagitis Presenting as Melena: A case report / 대한소화기내시경학회지

A 29-year-old man was admitted because of melena for 5 days. Two years ago, he underwent allogenic bone marrow transplantation for chronic myeloid leukemia and received immunosuppressive agents. Esophagogastroduodenoscopy showed a picture - multiple scattered deep ulcers and friable pseudomembranes - of highly suggestive of a herpes simplex esophagitis and biopsy revealed multinucleated giant cells and pathognomonic intranuclear inclusion bodies. Esophageal lesions and melena improved after acyclovir therapy.

A Case of Steakhouse Syndrome Associated with Nutcracker Esophagus / 대한소화관운동학회지

The most common type of food-related foreign body in esophagus is impacted meat bolus and sudden esophageal obstruction after eating poorly chewed meat has been called the "steakhouse syndrome". It is frequently caused by underlying esophageal stenosis including abnormal ring, the sequalae of reflux esophagitis, malignancy and rarely esophageal motility disorders. A 55-year-old male patient was admitted to our hospital complaining swallowing difficulty after ingestion of a lump of chicken 3 days ago. Impacted meat bolus was found at distal esophagus on emergency endoscopy. However, there was no definite anatomical stenotic lesion after removal of meat with the polypectomy snare. Esophageal manometry showed segmental, high amplitude of esophageal pressure at lower esophagus with normal peristalsis and occasional triple peaked waves. The manometry finding was consistent with nutcracker esophagus. We report a case of steakhouse syndrome associated by nutcracker esophagus without abnormality on endoscopy and esophagography.

A Case of Colonic Pseudo-Obstruction in a Patient with Parkinson's Disease / 대한소화관운동학회지

Colonic pseudo-obstruction (CPO) is a syndrome characterized by obstructive symptoms and signs without mechanical obstruction. Parkinson's disease is one of the various clinical situations developing CPO. Recently, one study group reported that neostigmine was significantly more effective than placebo in rapidly decreasing colonic dilatation in the majority of patients with acute CPO. We experienced a 69-year-old male patient with Parkinson's disease who complained abdominal distension. There was a marked colonic dilatation on plain abdominal radiographs without mechanical obstruction. Colonic dilatation failed to improve with conservative management. Immediate clinical response was achieved after patient received 2.0 mg of neostigmine intravenously under monitoring by electrocardiography. One month later, he had recurrent colonic dilatation, but no clinical response to second administration of neostigmine, leading to colonic decompression. After a third recurrence of colonic dilatation, the patient was refractory to conservative management, and he underwent surgical treatment.

A Multicenter Clinical Trial of Cisapride Tartrate in Diabetic Patients with Dysmotility Like Dyspeptic Symptoms / 대한소화관운동학회지

BACKGROUND/AIMS: We evaluated the effects of cisapride tartrate on gastrointestinal symptoms and gastric emptying times in diabetic patients with dysmotility like dyspeptic symptoms. METHODS: Cisapride was administered before each meal in 61 patients for 4 weeks. The intensity of gastrointestinal symptoms before and after cisapride administration was scored from 0 to 4, in the order of increasing severity of symptoms. In addition, a gastric emptying test was performed. RESULTS: A significant reduction in the total intensity score of symptoms was observed during the first two weeks, from 8.5+/-2.1 to 4.0+/-3.0 (p < 0.05), and a further reduction was noted during the next two weeks, to 2.8+/-2.8 (p < 0.05). Good to excellent improvement was obtained in 70.4% of the patients, but the improvement in symptoms was not related to age, duration of diabetes, glucose, Hb A1c, neuropathy, or retinopathy. Treatment with cisapride induced a significant regression of symptoms and a significant improvement of delayed gastric emptying from 104.0+/-31.7 minutes to 79.5+/-17.1 (p < 0.05). However, there was a lack of association between the changes in gastric emptying times and improvements in symptoms(r(2)=0.00186). Only 3 patients complained of loose stool, nausea, or dizziness. CONCLUSIONS: Cisapride was effective in improving dysmotility like dyspeptic symptoms in diabetic patients without serious side effects.

The Clinical Spectrum of Gastroesophagel Reflux Disease in Korea / 대한소화관운동학회지

BACKGROUND/AIM: Heartburn, which was the most common symptom of reflux disease, was unreliably interpreted by Korean patients. Our aim was to evaluate the clinical spectrum of gastroesophageal reflux disease(GERD) in Korea. METHODS: Patients who were diagnosed by an endoscopy or ambulatory pH monitoring at a tertiary medical facility were given a validated questionnaire and the clinical spectrums were prospectively investigated. RESULTS: Seventy one patients were included. Heartburn was occurring in 39 patients and the frequency of heartburn on two or more days a week were found in only 12 patients. Negative impact of reflux symptoms on health related well being were found in 16 patients. The reflux related atypical symptoms were hoarseness(55%), globus sensation(45%), cough(25%), and chest pain(20%). Twenty two patients complained of epigastric pain or discomfort more than 6 times a year, with 13 patients listing abdominal pain as the most bothersome one. The clinical spectrums were not different between endoscopy negative patients and those with esophagitis. CONCLUSIONS: Typical reflux symptoms are absent in a substantial proportion of Korean patients with GERD. True dyspepsia could result from gastroesophageal reflux. GERD needs to be clarified in patients with chronic laryngeal symptoms, cough or chest pain.

The Prevalences of Gastrointestinal Symptoms in a Rural Community in Korea / 대한소화관운동학회지

BACKGROUND/AIMS: Chronic gastrointestinal (GI) symptoms are believed to be common in the general population, but there is a lack of data from Korea. The aim of this study was to estimate the prevalence of chronic gastrointestinal symptoms in a rural community in Korea by using the Bowel Symptom Questionnaire (BSQ), which was based on the multinational diagnostic Rome criteria for functional bowel disorders, as a measure of GI symptoms. METHODS: A cross-sectional survey, using a reliable and valid questionnaire based on the fulfillment of the Rome criteria, was performed in a densely populated district in a Korean rural community on the residents aged 18-69 yr (mean 48 +/- 14 yr). 95.5% responded (n=420). All respondents were interviewed at their home or offices by a team of interviewers. RESULTS: Two thirds of Korean rural residents experience gastrointestinal symptoms and one fifth of them visit a clinic or hospital at least once a year. Prevalences of weekly heartburn, gastroesophageal reflux disease, dyspepsia, irritable bowel syndrome (IBS), and chronic constipation were 5.2% (95% confidence interval [CI], 3.1-7.4), 2.6% (95% CI, 1.1-4.2), 15.5% (95% CI, 11.9-19.0), 8.6% (95% CI, 5.8-11.3), and 24.3% (95% CI, 20.1-28.5) respectively. The prevalence of dyspepsia was 25%, taking medication usage into consideration. Ulcer-like dyspepsia (11.2%) was the most common subtype and 40% of the subjects with dyspepsia were classified into more than one subtype of dyspesia. There was an overlap between subjects with IBS and dyspepsia with 6.1% of dypeptics having IBS and 11.1% of IBS patients having dypepsia. CONCLUSIONS: The prevalence of GERD was low in Korea compared with that of the Western contries. The prevalences of dyspepsia and IBS were similar to those of the Western countries. The most common gastrointestinal symptom in a rural community in Korea is dyspepsia.

A Case of a Diffuse Esophageal Spasm Diagnosis by Ambulatory 24 hour Manometry / 대한소화관운동학회지

Diffuse esophageal spasm (DES) is a motility disorder of the esophagus characterized by symptoms of retrosternal chest pain and intermittent dysphagia. The diagnosis of DES has relied on criteria obtained from a standard esophageal manometry (more than one simultaneous contraction in a series of 10 wet swallows with the rest being peristaltic). Because symptoms and/or typical manometric findings are not always documented during the standard manometry, 24 hour manometry may be more useful in such cases. We recently assessed a 29-year-old male patient who complained of chest pain and dysphagia. He showed nonspecific findings on the laboratory based manometry, but DES was diagnosed by his typical manometric findings on the 24 hour manometry. Therefore, a 24 hour manometry should always be performed when the patient's history suggests the presence of DES and the laboratory based manometry failed to detect the symptomatic contractions of DES. Following we report this case with a review of the literature.

The Pattern of Gastroesophageal Reflux in Patients with Gastroesophageal Reflux Disease / 대한소화관운동학회지

BACKGROUND/AIMS: Generally, it is recommended for patients with gastroesophageal reflux disease to sleep with the head of the bed elevated; however, many patients in Korea do not have heartburn symptoms during the night. METHODS: We investigated the pattern of acid reflux in patients who were diagnosed as having definite pathological acid reflux on 24-hour pH monitoring. RESULTS: One hundred patients were categorized into 3 groups; upright refluxer (68%), supine refluxer (2%), or combined refluxer (30%). Acid reflux was rare in supine positions but instead, usually occurred in upright positions. Acid reflux was found to occur most commonly after meals. The reflux symptoms occurred during pH monitoring with the average frequency of 5.5 times (total of 254 times) in 46 patients. The acid related symptoms were more common in the upright period and postprandially than the supine period. The presence of an esophagitis, an esophageal motility disorder, or the LES pressure did not make a significant difference between upright refluxer and supine refluxer. CONCLUSIONS: Gastroesophageal reflux was found to be rare in supine positions but usually occurred in upright positions. Gastroesophageal reflux occurred most commonly after meals, and was frequently associated with reflux symptoms.

A case of achalasia without dilatation of the esophageal body / 대한소화관운동학회지

Achalasia is a motility disorder of the esophagus consisting of abnormal relaxation of the lower esophageal sphincter and aperistalsis of the esophageal body. Esophageal dilatation and bird beak appearance are characteristic radiologic findings of achalasia, but achalasia patients do not always show typical findings on esophagography. We recently experienced a 38-year-old female patient who complained of chest pain and dysphagia. She showed no dilatation of the esophagus with delayed emptying of the contrast media in esophagography, but achalasia was diagnosed by typical manometric findings. The patient's symptoms improved after a balloon dilatation. Therefore, esophageal manometry should always be performed when the patient's history suggests the presence of achalasia without typical radiologic findings. We report this case with a review of the literature.