A Prospective Randomized Trial Comparing Preference of Sulfate Free Polyethylene Glycol with Standard Polyethylene Glycol / 대한소화기내시경학회지

BACKGROUND/AIMS: The standard polyethylene glycol (PEG) solution for colonic cleansing has a salty taste and a large volume of it is required, which can cause failure for the patient to ingest the required dosage. This has been a limitation for its usage. Sulfate free PEG (SF-PEG) has a less salty taste due to removal of the sodium sulfate, but the published studies in western countries about the preference and the degree of patient's satisfaction with these two solutions has shown conflicting results. The object of this study was to compare SF-PEG with PEG solution in regard to preference, the degree of patient's satisfaction and the adverse effects in Korean patients. We also attempted to determine whether these factors were associated with preference. METHODS: Ninety-four patients scheduled for colonoscopy were given one liter of both solutions (SF-PEG and PEG) and then the patients were allowed to select either of the two solutions for the further two liters intake under informed consent. Before colonoscopy, the preferred solution, the degree of patient's satisfaction, the adverse effects and other information were recorded by questionnaire. RESULTS: Fifty-nine patients among the 94 patients (63%) preferred the SF-PEG solution (p<0.05). Especially, the young patients under the age of 35 preferred the SF-PEG solution (83% vs 58%; p=0.045), and patients who had already experienced colonoscopy with PEG solution tended to prefer the SF-PEG (54% vs 78%; p=0.054). CONCLUSIONS: Korean patients preferred the SF-PEG over PEG, and especially young aged patients and the patients who had already taken the PEG solution. Similar results were obtained for both solutions concerning the adverse effects, cleansing quality and compliance, and the degree of satisfaction was not much improved, which was probably due to the same large volume of fluid that is required for colon cleaning.

A Case of Ulcerative Colitis with Prolonged Remission Following Azathioprine-Induced Pancytopenia

Azathioprine (AZA) is widely used for the treatment of inflammatory bowel disease. Bone marrow suppression is a common side effect with AZA treatment. However, data from AZA trials has indicated that a leukocyte count less than 5,000/mm3 was a good predictor of induction and maintenance of remission. Moreover, there is evidence that eradication of sensitized leukocytes by leukapheresis or bone marrow transplantation improves inflammatory bowel disease. We report a case of a patient who had a chronic relapse of ulcerative colitis requiring the frequent use of systemic steroids, but presented prolonged remission following AZA-induced severe pancytopenia. Also colonoscopy showed accelerated healing of diffuse active ulcers following just recovery from pancytopenia.

Incidentally Detected Autoimmune Pancreatitis in a Patient with Retroperitoneal Fibrosis / 대한소화기학회지

No abstract available.

A Case of Mucinous Noncystic Carcinoma of the Pancreas / 대한소화기학회지

Mucinous (colloid) carcinoma is defined as pools of stromal extracellular mucin containing scanty, floating carcinoma cells. It is a well-defined entity in breast or large bowel. However, mucinous noncystic carcinoma of the pancreas (MNCC) is uncommon, comprising between 1% and 3% of all carcinomas of the pancreas. In the past, MNCC generally had been categorized together with ordinary ductal adenocarcinoma or misdiagnosed as mucinous cystadenocarcinoma or signet-ring cell carcinoma. The new WHO classification lists MNCC as a variant of ductal adenocarcinoma. Herein, we report a 32-year-old woman with incidentally found pancreatic body mass who underwent subtotal pancreatectomy. She was diagnosed as MNCC histologically.

A Case of a False Positive FDG-PET/CT Scan in Esophageal Leiomyoma / 대한소화기내시경학회지

Esophageal leiomyoma is relatively rare disease, but can appears with a high uptake of fluorodeoxuglucose (FDG), a false-positive finding on a FDG PET/CT scan. A 64- year-old woman after a total thyroidectomy due to papillary and follicular carcinoma showed a high uptake of FDG in the distal esophagus on a subsequent FDG PET/ CT scan. The presence of an esophageal leiomyoma was suspicious from preoperative findings of endoscopic ultrasound and computed tomography, and an esophagectomy and proximal gastrectomy were performed, as the presence of a malignant lesion could not be excluded. As high uptake of FDG in the lesion on an FDG PET/CT scan corresponds to an esophageal cancer, an esophagectomy and proximal gastrectomy were performed and the lesion was confirmed as an esophageal leiomyoma after surgical biopsies. We report this case with a review of the relevant literature.

A Case of Ulcerative Colitis Relapsed by Influenza Vaccination / 대한소화기학회지

Although a large number of studies have reported the causes of the exacerbation of ulcerative colitis (UC), the effect of influenza vaccination on the relapse of UC has not been reported. We experienced a case of prompt exacerbation of quiescent UC due to influenza vaccination. A 39-year-old woman was diagnosed as UC 4-years ago and was well controlled with oral mesalazine. She experienced abdominal pain and frequent bowel movements with hematochezia 3 days after the vaccination. On admission, laboratory findings showed elevated erythrocyte sedimentation rate and C-reactive protein. Sigmoidoscopy showed marked edematous mucosa on rectum and sigmoid colon with fine ulceration and spontaneous bleeding. She recovered from the exacerbation of UC after steroid treatment. Vaccination should be administered to the patients with inflammatory bowel disease with the caution of its possible side effects.

A Case of Ischemic Colitis in a Patient with Takayasu's Arteritis / 대한소화기학회지

Ischemic colitis is one of the most common intestinal ischemic injury in which more than 90% of patient are over 60 year-old. It results from impaired perfusion of blood to the bowel and is rarely caused by vasculitis such as systemic lupus erythematosus, polyarteritis nodosa, and Takayasu's arteritis. Takayasu's arteritis affects the aortic arch, medium-sized and large arteries but rarely involves inferior mesenteric artery. We report a case of Takayasu's arteritis involving inferior mesenteric artery which developed ischemic colitis in a 70 year old female. To the author's knowledge this is the first case report in Korea. A 70 year old woman who had suffered from Takayasu's arteritis for 5 years was admitted for sudden abominal pain and hematochezia. On sigmoidoscopy, there were multiple segmental longitudinal ulcerations around splenic flexure and diffuse hemorrhagic edematous mucosa from descending colon to sigmoid colon. On abdominal CT angiography, inferior mesenteric artery was not traced. We diagnosed it as ischemic colitis combined with Takayasu's arteritis. After the conservative treatment, abdominal pain and hematochezia disappeared. She was followed up to 2 years without recurrence of symptoms.

The Effect of Fixed Dose of Flumazenil on Recovery after Sedative Endoscopy by Midazolam / 대한소화기내시경학회지

BACKGROUND/AIMS: Midazolam is widely used as a form of conscious sedation during endoscopy because of its rapid onset and safety. However, its relatively long half-life and paradoxical reactions are still a concern for doctors and patients. Flumazenil is a competitive benzodiazepine antagonist that acts to reverse the sedative and hypnotic effects of midazolam but its role and adequate dose have not been fully documented. This study evaluated the effect of a fixed dose of flumazenil on the recovery from sedative endoscopy by midazolam. METHODS: First study: 100 patients who received 0.05 mg/kg midazolam for conscious sedation were randomized into two groups: intravenous 0.25 mg flumazenil and a placebo. All patients were assessed using OAA/S (Observers Assessment of Alertness/Sedation Scale) scale (responsiveness, speech, facial expression and ptosis of eyelid) before the endoscopy, immediately after the procedure and every 5 minutes thereafter. The recovery time was defined as the time at which the OAA/S scale reached the pre-endoscopy level. Second study: In 40 patients, the OAA/S scale was assessed only after full recovery without any exogenous stimuli. The total dose of midazolam and the procedure time were assessed. RESULTS: The flumazenil group demonstrated a significantly shorter recovery time than the placebo group (p<0.0001). These results were not affected by age, gender, total midazolam dose and procedure time. There was a larger difference in the recovery time between the two groups in the second study than in the first. CONCLUSIONS: A fixed low dose flumazenil significantly reduced the recovery time after sedative endoscopy by midazolam. Flumazenil will be helpful for the early return to daily activities and for preventing post sedative complication.

The Effect of Fixed Dose of Flumazenil on Recovery after Sedative Endoscopy by Midazolam / 대한소화기내시경학회지

BACKGROUND/AIMS: Midazolam is widely used as a form of conscious sedation during endoscopy because of its rapid onset and safety. However, its relatively long half-life and paradoxical reactions are still a concern for doctors and patients. Flumazenil is a competitive benzodiazepine antagonist that acts to reverse the sedative and hypnotic effects of midazolam but its role and adequate dose have not been fully documented. This study evaluated the effect of a fixed dose of flumazenil on the recovery from sedative endoscopy by midazolam. METHODS: First study: 100 patients who received 0.05 mg/kg midazolam for conscious sedation were randomized into two groups: intravenous 0.25 mg flumazenil and a placebo. All patients were assessed using OAA/S (Observers Assessment of Alertness/Sedation Scale) scale (responsiveness, speech, facial expression and ptosis of eyelid) before the endoscopy, immediately after the procedure and every 5 minutes thereafter. The recovery time was defined as the time at which the OAA/S scale reached the pre-endoscopy level. Second study: In 40 patients, the OAA/S scale was assessed only after full recovery without any exogenous stimuli. The total dose of midazolam and the procedure time were assessed. RESULTS: The flumazenil group demonstrated a significantly shorter recovery time than the placebo group (p<0.0001). These results were not affected by age, gender, total midazolam dose and procedure time. There was a larger difference in the recovery time between the two groups in the second study than in the first. CONCLUSIONS: A fixed low dose flumazenil significantly reduced the recovery time after sedative endoscopy by midazolam. Flumazenil will be helpful for the early return to daily activities and for preventing post sedative complication.

A Case of Partial Intestinal Obstruction due to Ascaris lumbricoides / 대한소화기내시경학회지

Ascaris lumbricoides (A. lumbricoides) is the largest and most common human intestinal helminth in the world. However, the prevalence of ascariasis has, in recent years, been very low in Korea. The majority of patients infected with A. lumbricoides are asymptomatic. However, sometimes these infections may give rise to intestinal obstructions or pancreatobiliary disease, via retrograde migration through the ampulla of Vater. Intestinal obstruction associated with A. lumbricoides is a complication that is frequently observed in children living in endemic areas. However, no cases of A. lumbricoides-associated intestinal obstruction have been reported in Korea since 1967. In this report, we describe the case of a 78-year-old man, who presented with sustained nausea and postprandial vomiting, and was diagnosed with a partial intestinal obstruction due to A. lumbricoides after undergoing an esophagogastroduodenoscopy.

A Case of Intraductal Papillary Mucinous Neoplasm of the Pancreas Arising from Pancreas Divisum without Ventral Pancreatic Duct of Wirsung / 대한소화기학회지

Most reported cases of intraductal papillary mucinous neoplasms (IPMNs) originate from Wirsung's duct or their branches. IPMNs arising from Santorini's duct and its branches have rarely been reported. Eight cases of IPMN arising from Santorini's duct have been published worldwide. However, these cases are associated with incomplete type of pancreas divisum. Recently, one report of IPMN with complete absence of Wirsung's duct has been reported. This patient was a 57-year-old woman who was admitted to the hospital due to progressive jaundice. On endoscopic retrograde cholangiopancreatography, there was a severely bulging ampulla of Vater and patulous minor papilla draining mucinous material and a cystic lesion communicating with the dilated Santorini's duct without any communication with Wirsung's duct. A pancreaticoduodenectomy was performed and the pathologic examination of resected specimen showed no evidence of Wirsung's duct, but an IPMN arising from Santorini's duct with peripancreatic lymph node metastasis. Herein, we report a case of invasive IPMN arising from pancreatic head without ventral pancreatic duct with a review of the relevant literatures.

Can EUS Help to Differentiate Macrocystic Serous Cystadenoma from Mucinous Cystadenoma of the Pancreas by Its Morphologic Characteristics? / 대한소화기내시경학회지

BACKGROUND/AIMS: A macrocystic variant of a serous cystadenoma (M-SCA) is usually indistinguishable from a mucinous cystadenoma (MCA) as a result of their morphologic similarity on conventional imaging studies. However, a MCA requires a resection due to its malignant potential. The aim of this study was to determine the EUS morphological characteristics of a M-SCA to determine if they could be used to help differentiate it from MCA. METHODS: The clinical and EUS morphologic characteristics were examined in 31 consecutive patients with M-SCA and MCA who underwent surgery. RESULTS: Resected specimens were available from 11 M-SCAs and 20 MCAs. Significant differences were observed with regard to the age and location within the pancreas. On EUS, most of the M-SCA contained microcysts (82%) compared with only 15% of MCA cases, and a lobulated configuration of the cyst was observed more frequently in the M-SCA cases than in the MCA (91% vs. 25%). The combination of microcysts and the lobulated configuration of the cysts had a 100% specificity and positive predictive value for differentiating M-SCA from MCA. CONCLUSIONS: M-SCA tends to occur at a relatively younger age than MCA, and is located mainly in the head of the pancreas. Although there is considerable morphological similarity between M-SCA and MCA on the conventional imaging modalities, the morphological characteristics obtained from EUS including microcysts with a lobulated configuration may help to make a distinction between M-SCA and MCA.

A Case of Carcinoid Tumor of the Common Bile Duct / 대한소화기학회지

Majority of malignant neoplasms arising from the extrahepatic bile duct are adenocarcinomas. Carcinoid tumors at this site are extremely rare. We report a 67-year-old woman with malignant carcinoid tumor of the common bile duct. She presented with obstructive jaundice of 1 week's duration. Abdominal CT and ERCP revealed a common bile duct mass. She underwent Whipple's operation and was diagnosed as malignant carcinoid tumor histologically and immunohistochemically.

Clinical Factors that Predicts Successful Eradication of Helicobacter pylori / 대한소화기학회지

BACKGROUND/AIMS: Antibiotic resistance and compliance are regarded to be important which affect the eradication of Helicobacter pylori (H. pylori). However, it is not easy to apply the antibiotic resistance test in clinical field. We investigated other clinical factors predicting the successful eradication of H. pylori. METHODS: From January 2004 to March 2005, 195 patients with documented H. pylori infection received proton pump inhibitor (PPI)-based triple therapy for one week and were assessed for the underlying chronic illnesses, smoking, alcohol habit, therapeutic indication and compliance. RESULTS: The intention-to-treat (ITT) eradication rates were 69.2%, while per protocol (PP) analysis with 169 patients showed an initial eradication rate of 79.9%. The eradication rates of H. pylori according to the underlying disease were 73.9% (17/23) in diabetes, 66.7% (18/27) in hypertension, 66.7% (2/3) in renal disease, 100% (9/9) in liver disease, 63.7% (7/11) in cardiovascular disease and 64.3% (9/14) in chronic NSAIDs user. There was no statistical difference in the eradication rates according to the therapeutic indication, underlying disease, sex, age, smoking, alcohol, and PPI. However, the eradication rate was statistically lower in patients with multiple underlying diseases. Eradication rate was significantly higher in patients with good compliance than in those with poor compliance in taking medications (p<0.05). CONCLUSIONS: Underlying chronic disease does not affect the H. pylori eradication rate significantly. In clinical practice, apart from antibiotic resistance test, drug compliance is the most important factor affecting the H. pylori eradication rate.

Four cases of gastric submucosal mass suspected as anisakiasis

Anisakiasis is a parasitic disease caused by ingestion of raw fish infected with anisakid larvae. Endoscopic changing patterns of submucosal lesions in chronic gastric anisakiasis have not been known yet. Here we report 4 cases of suspected gastric anisakiasis which were improved during follow-up periods without surgical treatment. The patients presented with abdominal pain, nausea and vomiting after consuming raw marine fish, and visited our gastroenterology outpatient department. Their endoscopic findings showed firm and yellowish submucosal masses accompanied with eccentric erosions. Histologic findings showed severe eosinophilic infiltrations. In blood tests, peripheral eosinophil counts and total IgE levels were elevated. We believed that all cases were caused by larval anisakid infections. The submucosal mass lesions disappeared during the follow-up periods of 2 to 4 mo.

Carcinoid Tumor of the Extrahepatic Bile Duct

Carcinoid tumors of the extrahepatic bile ducts are exceedingly rare, accounting for between 0.1 and 2% of all gastrointestinal carcinoid tumors, with most reported cases arising from the gallbladder. Only 34 cases of carcinoid tumor arising from the extrahepatic bile duct have been documented in the world literature. We report one case of a carcinoid tumor of the common bile duct. A 67-year-old woman sought treatment for obstructive jaundice, accompanied by epigastric pain. The laboratory and imaging studies were consistent with a malignant obstruction in the common bile duct. We performed a Pylorus preserving pancreaticoduodenectomy. Pathologically, an ill-demarcated mass, measuring 1.6x1.5x0.5 cm in size, was noted in the common bile duct, with infiltration to the adjacent pancreatic tissues. Immunohistochemically, the mass was shown to be chromogranin, synaptophysin and CD56 positive. The final pathological diagnosis was one of a well- differentiated carcinoid tumor of a malignant nature. The patient, who underwent a curative surgical resection, was alive and disease free at time of this published report.

Efficacy of Percutaneous Cholangioscopic Ethanol Injection in Hepatocellular Carcinoma Invading the Bile Duct / 대한소화기내시경학회지

BACKGROUND/AIMS: To evaluate the clinical outcomes of the percutaneous cholangioscopic ethanol injection in the hepatocellular carcinoma (HCC) invading the bile duct, we conducted a retrospective study. METHODS: Ten patients who received the percutaneous cholangioscopic ethanol injection were selected patients were diagnosed as HCC invading the bile duct between January 1998 and February 2004. Treatment response, complications, survival or death and survival time were analyzed. RESULTS: Ten patients received mean of 5.3 sessions (range 2~19) of cholangioscopic ethanol injection. Eight patients had decreased tumor mass, and the rest 2 patients had no response. Complications were pain (n=10), hemobilia (n=6: bleeding was minimal), cholangitis (n=2), bile duct rupture (n=1), and bile duct stricture (n=1). Nine patients died from severe hepatic failure and sepsis, one patient has survived for 19 months as of now. Median survival time was 5 months (range 2~19 months). Percutaneous transhepatic biliary drainage (PTBD) could be removed in two patients. CONCLUSIONS: Percutaneous cholangioscopic ethanol injection in HCC invading the bile duct showed size reduction of mass. PTBD could be no longer needed in some patients. However, supportive cares such as PTBD may be appropriate considering their short survival period and risk of procedure.

A Case of Coffee Enema-Induced Colitis / 대한소화기내시경학회지

A coffee enema which has been suggested as a part of a cancer treatment, has been misused as a treatment for obesity and constipation among the general population. Its proponents claim that caffeine is absorbed in the colon, which leads to vasodilatation in the liver and stimulation of the hepatocellular function to detoxify the products of the tumor cell metabolism. However, the clinical efficacy of the anti-cancer effect of coffee enemas has not been demonstrated. Many side effects of coffee enemas have been reported. These include severe electrolyte imbalance, polymicrobial enteric septicemia, and even death. We experienced a patient who presented with abdominal pain and a bloody stool after receiving a coffee enema to relieve constipation. We report this case of coffee enema-induced colitis with a review of the relevant.

Clinical Application and Safety of Endoscopic Pancreatic Sphincterotomy in 339 Cases / 대한소화기내시경학회지

BACKGROUND/AIMS: Endoscopic pancreatic sphincterotomy (EPST) has been performed more frequently in recent years. However, it is less widely practiced than biliary sphincterotomy due to lack of firm scientific data regarding its indication and safety. The aims of this study are to evaluate EPST with regard to indications, complications, and safety. METHODS: We retrospectively reviewed and analyzed the results of EPST performed in three hundred thirty nine patients from January 2000 to April 2004.RESULTS: Complications occurred in 37 patients (10.7%) which included pancreatitis, hemorrhage, perforation, cholangitis, sepsis, and stenosis of sphincterotomy site. They were successfully managed by medical treatment. No mortalities were reported. CONCLUSIONS: EPST is a relatively safe procedure in various pancreatic diseases. Incidence of long-term complications awaits further investigations. EPST enlarges our endotherapeutic armamentarium and deserves additional evaluation.

The etiology of acute viral hepatitis for the last 3 years / 대한내과학회지

BACKGROUND: In Korea, the most common cause of acute viral hepatitis used to be the hepatitis B virus, but now the etiology of acute viral hepatitis seems to be changing. We investigated the etiology of newly developed acute viral hepatitis for the last 3 years. METHODS: We retrospectively reviewed the medical records of patients, who visited Asan Medical Center for jaundice during recent 3 years. Among them, one hundred eighty six patients were diagnosed as acute viral hepatitis by typical clinical feature and positive results in any one of the following tests: IgM anti-HAV, IgM anti-HBc, HCV PCR, and IgM anti-HEV. RESULTS: The proportion of acute viral hepatitis A, B, C, and E were 49.5% (n=92), 45.2% (n=84), 3.8% (n=7), and 1.6% (n=3), respectively. The patients' age of acute hepatitis A (29.1 +/- 1.75 years) was significantly younger than that of acute hepatitis B (38.2 +/- 3.07 years) (p<0.001). There were 10 cases of fulminant hepatic failure, all of which were caused by hepatitis B virus. Of seven patients diagnosed as acute hepatitis C, three patients were treated with interferon-alpha and ribavirin, and all achieved sustained virologic response. Three patients, who were diagnosed as acute hepatitis E, recovered spontaneously. CONCLUSION: Nowadays, the most common causes of acute viral hepatitis in Korea are in the order of the hepatitis A virus and the hepatitis B virus. The most prevalent age of acute hepatitis A is the 20th, while acute hepatitis B is most common in the 30th. Although the acute hepatitis C and E seems to be rare, they do occur sporadically in Korea.