The endoscopic diagnosis and treatment for Mallory-Weiss syndrome / 대한내과학회지

BACKGROUND: Mallory-Weiss syndrome is a laceration of gastroesophageal junction due to abruptly increased intraabdominal pressure. Bleeding from Mallory-Weiss tears stops spontaneously within 2-3 days without specific therapy in 80-90% of cases, but in some cases, aggressive treatment is required due to massive bleeding. METHODS: Among two hundreds and fifteen cases of upper gastrointestinal bleeding from January 1997 to January 1999, twenty three cases (10.7%) were diagnosed as Mallory-Weiss syndrome by endoscopy. We assessed the site, number, coexisting diseases, precipitating factors and bleeding lesion according to the time interval after the tears. After supportive care or specific therapy, we performed follow-up endoscopy to evaluate the healing of the lesions. RESULT: The mean age was 49.1 years and male:female ratio was 4.8:1. The most common precipitating factors were nausea, vomiting and alcohol drinking. In twenty cases, coexisting diseases such as gastritis and esophageal varix were detected. As for the number of tears, one tear was the most common (69.6%), while two tears were identified in five cases and three were in two cases. Thirteen cases of the Mallory-Weiss tears were located on the gastroesophageal junction, seven cases on the lower esophagus, one case on the cardia and two cases from lower esophagus to cardia. Eighteen cases were diagnosed by endoscopy within 24 hours after bleeding, of whom fourteen cases had active bleeding. Among four cases diagnosed after 24 hours, endoscopic finding revealed active bleeding in two cases and blood clots in the other two cases. We treated thirteen cases with supportive care, one case with hypertonic saline injection and nine cases who had active bleeding or deep and long tears with endoscopic band ligation. One or two weeks later, we performed follow-up endoscopy, and no bleeding was detected in all cases. CONCLUSION: We diagnosed twenty three cases of Mallory-Weiss syndrome by endoscopy and treated all cases with supportive care or endoscopic band ligation successfully.

Isolated Ostial left Main Stenosis Diagnosed by Transesophageal Doppler Echocardiography

The therapeutic strategy of the left main disease is quite different frorn usual coronary artery disease. Therefore, the diagnostic evaluation should be done carefully. Eventhough coronary angiography has been considered as a gold standard for the diagnosis of left main disease, its diagnosis is not possible in all cases. In questionable situation, direct visualization of the left main coronary artery and Doppler measurements of coronary blood flow by transesophageal echocardiography may give some diagnostic aids. We report a case of suspected isolated ostial left main stenosis, which was helped diagnotically by perfoming transesophageal Doppler echocardiography.

Significance of Serum Troponin-T Level in Acute Ischemic Pain Syndrome / 대한내과학회지

OBJECTIVES: In coronary arterial disease, quantitative assessment of the extent of myocardial damage is important both in management of the patient and prediction of prognosis. Measurement of serum Troponin-T is a new method for detecting myocardial cellular injury, used as more specific marker of tissue damage and reperfusion status in acute myocardial infarction, This study was performed to evaluate the significance of serum Troponin-T measurement in various acute chest pain syndrome. METHODS: 37 patients who presented anterior ischemic chest pain enrolled from April, 1994 to September, 1995, From the initial period of admission, serial measurements of serum level of cardiac enzymes (CK, CK MB, Myoglobin, Troponin-T) were made. Then release time, peak time and normalization time of each enzyme were derived and compared each other. To evaluate whether Troponin-T level can reflect the extent of ischemic injury, correlation between peak Troponin-T level and peak CK MB level was analysed by regression method. RESULTS: 1) Acute myocardial infarction was confirmed in 15 cases; Q-wave myocardial infarction was 10 cases(anterior wall-5 cases, inferior wall-4 cases, lateral wall-1 cases), and non Q-wave myocardial infarction was 5 cases. Unstable angina was 22 cases. All cases had significant stenosis in coronary angiography. 2) The appearance in the serum level of 4 cardiac enzymes was as follows. The release time(hours) of 4 cardiac enzymes(Troponin-T, CK, CK MB, Myoglobin) were 7.1(1-30), 9.3(1-30), 9.9(1-30), 6.2(1-30). The peak time(hours) of 4 cardiac enzymes were 23.0(1.5-96), 21.6(2-66), 16.9(2-42), 12.7(3-40). The normalization time(hours) of the enzymes were over 72, 53.7(11-86), 52.3(11-94), 32.3(10-82). 3) Elevation pattern of cardiac enzymes showed concordance of all 3 enzymes(Troponin-T, CK MB, Myoglobin) in 29 of 43 cases(67.4%), There was concordance of 2 enzymes in 10 cases; 5 cases of CK MB and Myoglobin, 5 cases of Troponin-T and Myoglobin. In 4 cases, only Myoglobin level was increased. 4) There was significant correlation between peak Troponin-T level and peak CK level(r=0.66, p=0.0178), significant correlation was also observed between peak Troponin-T level and peak CK MR level(r=0.90, p=0.0001). CONCLUSION: In acute myocardial infarction serum Troponin-T was detectable as early as CK MB, and lasted longer after other enzyme level was normalized. There was significant correlation between peak Troponin-T level and peak CK, CK MB level, suggesting Troponin-T as useful marker for assessing the extent of myocardial damage.

Anterior Mitral Leaflat Perforation in Patients with Bicuspid Aortic Valve Endocarditis

Mitral valve perforation is a rare cause of severe mitral regurgitation, which occurs most commonly as a secondary involvement of aortic valve endocarditis. The probable mechanisrns are direct extension of the infection from the aortic valve, infected aortic regurgitant jet striking the ventricular surfaces of the mitral-aortic intervalvular fibrosa(MAIVF) and the anterior mitral leaflet(AML). Early recognition of these subaortic complications in patients with aortic valve endocarditis is important because (1) these complications may produce severe mitral regurgitation and hemodynamic collapse, (2) the presence of severe mitral valve involvement may present as primary mitral valve disease, (3) these complications can be overlooked during aortic valve replacement, and (4) cause difficulty in valve replacement and high mortality. We report two cases of AML perforation observed in patients with bicuspid aortic valve endocarditis.

Myocardial Contrast Echocardiography for the Assessment of Coronary Blood Flow Reserve

BACKGROUND: The assessment of coronary blood flow reserve measured by intracoronary Dopper syudy is a useful method for evaluation of functional impairment of coronary artery disease irrespective of significant anatomic stenosis. To validate the usefullness of myocardial contrast echocardiography in clinical assessment of coronary blood flow reserve, several variables analysed by myocardial contrast echocardiography were compared with coronary flow reserve measured by Dopper catheter study. METHODS: During the coronary angiography, coronary flow reserve was measured by intracoronary Dopper-tipped guidewire with coronary blood flow velocity ratio in 16 patients without angiographically significant coronary artery disease. For the measurement of coronary flow reserve, we analyzed the time-video intensity curve of short axis image of the left ventricle follwing infusion of sonicated hexabrix before and after intracoronary administration of adenosine. RESULTS: 1) There was no significiant difference or correlation between peak intensity, peak intensity ratio, washout time, half time of washout, and washout time ratio analysed by contrast echocardiography and coronary blood flow reserve measured by intracoronary Doppler study(p>0.05). But inverse correlation was observed between half time ratio of contrast washout and coronary flow reserve(r=0.63,p<0.05). 2) There was no significiant difference between non myocardial infarction group and myocardial infartion group in coronary flow reserve and half time ratio of contrast washout. 3) No significant difference was observed before and after administrantion of sonicated hexabrix in hemodynamic variables. CONCLUSION: Among several variables of myocardial contrast echocardiography analysis half time ratio of washout was significantly correlated with coronary flow reserve. Thus assesssment of coronary flow reserve with myocardial contrast echocardiography is promising method in the evaluation of dymamic coronary perfusion and myocardial viability.

Intravascular Ultrasonographic Detection of Atherosclerotic Lesions in Spastic Segments of the Coronary Arteries in Patients with Variant Angina

Coronary artery spasm plays an important role for evoking myocardial ischemia and infarction as well as sudden cardiac death in patients with variant angina. The coronary anatomy in patients with variant angina has been defined both at autopsy and during coronary arteriography. Severe porximal coronary atherosclerosis of at least one major vessel occurs in 3/4 of patients and the remainder have normal coronary arteries. Coronary angiography is a relatively insensitive diagnostic tool especially in the early stages of coronary artery disease. Due to arterial remodelling, angiographic luminogram may show little or no narrowing even though a large part of the total vessel area is occupied by plaque. Intravascular ultrasonography(IVUS) enables accurate determination of vessel dimensions and wall characteristics and is more sensitive in delineating early intimal changes than angiography. We experienced 2 cases that IVUS showed focal or diffuse atherosclerosis in spastic segments of the coronary arteries, even though they appeared angiographically normal.

Atrioventricular plane displacement in the patients with congestive heart failure

No abstract available.