A Case of Recovery from Suspended Animation caused by Puffer fish Poisoning: a case report

Tetrodotoxin is a neurotoxin produced by about 90 species of puffer fish and causes paralysis of central nervous system and peripheral nerves by blocking the movement of all monovalent cations. Ingestion of tetrodotoxin produces clinical manifestations such as paresthesias(within 10-45 min), vomiting, lightheadedness, salivation, muscle twitching, dysphagia, difficulty in speaking, convulsion and death that expressed by cardiopulmonary arrest with loss of brain stem reflex sometimes. Tetrodotoxin prevents or delays ischemia induced neuronal death by way of following 3 mechanisms. Firstly, it reduces the energy demand of the brain tissues. Secondly, it delays or even prevents anoxic depolarization. Finally, it diminishes ischemia induced cell swelling and cerebral edema. We report a case of puffer fish poisoning which presented with cardiopulmonary arrest and loss of brain stem reflex, but completely recovered by aggressive cardiopulmonary resuscitation.

Treatment Using an Endoscopic Sphincterotomy for Two Patients with Choledochocele / 대한소화기내시경학회지

A choledochocele is a cyst like herniation of the intramural segment of the distal common bile duct protruding into the duodenal lumen. It is controversial whether this disease entity represents a type III variation of a choledochal cyst or an acquired lesion due to a calculus, papillitis or sphincter of Oddi dysfunction. The choledochocele is the rarest form of choledochal cysts and represents only 1.4-5.0% of all choledochal cysts. The diagnosis of choledochocele can be confirmed with certainly using a cholangiography. During a side viewing duodenoscopy followed by retrograde cholangiopancreatography, the mucosa appears normal but the papilla may be larger than usual. When probing the choledochocele with a cannulating catheter, its surface may be appear to be soft and compressible, similar to the pillow sign. After contrast dye is instilled into the bile duct, a round, cyst-like contrast filled structure can be identified adjacent to the terminatian of the common bile duct and an air halo sign may be visible around it. The established treatment of choledochocele is surgical resection of the cyst with anastomosis of the common bile duct to the small intestine, but transduodenal sphincteroplasty or endoscopic sphincterotomy has been advocated as an alternative to excision because of the very low risk of malignant degeneration, operative complications and morbidity. The choice of therapy for the patients with symptomatic choledochchocele is to establish effective drainage of the common bile duct and pancreatic duct. The objective can be achieved using an endoscopic sphincterotomy or transduodenal sphinateroplasy. It has been determined in recent years that endoscopic sphincterotomy is v effective and often followed by a positive prognosis. We report two patients with reicurrent pancreatitis and the common bile duct dilatation secondary to a choledochoce]e, who were treated effectively by endoscopic sphincterotomy.

A Case of Bleeding Duodenal Varices in a Patient with Idiopathic Portal Hypertension / 대한소화기내시경학회지

Bleeding duodenal varices are a rare complication in patients with portal hypertension. Cirrhosis followed by portal vein obstruction and splenic vein obstruction are the most common causes. Although the prognosis of bleeding duodenal varices is usually poor, an awareness of its characteristic presentation may enable diagnostic and therapeutic proce- dures to be performed rapidly with an increased likelihood of a reaching successful out- come. In this study, we report a case of bleeding duodenal varices in a 23-year-old woman with idiopathic portal hypertension who was also suffering with recurrent melena. Panendoscopy identified prominant tortuous varices with central erosion in the 3rd portion of the duodenum and no esophageal and gastric varices. The varices were successfully treated by distal splenorenal shunt.

A Case of a Congenital Web of the Common Bile Duct Treated with Balloon Dilatation / 대한소화기내시경학회지

The web of the common bile duct is an extremely rare anomaly and the cause of the obstructive jaundice. We experienced a case of the congenital web of common bile duct in a 42 years old male who complained of jaundice for 10 days prior to admission without choledocholithiasis and cholangitis. An endoscopic retrograde cholangiopancreatography revealed a common bile duct web (transverse, diaphragmatic type) and the diagnosis was confirmed by an endoscopic forcep biopsy. We reported a case of the congenita1 web of the common bile duct which was treated with a stent insertion and balloon dilatation.

Sequential Substitution from Sandimmune to Implanta and from Implanta to its Microemulsion Formulation, Neoplanta as Cyclosporine Preparations in Renal Transplant Patients / 대한신장학회잡지

Clinical trial of cyclosporines produced from two different manufacturers were performed in thirty three renal transplant patients for 16 months divided into 2 phases. A 1:1 conversion on a milligram-to- milligram basis was used for switching from Sandimmune(Sandoz Pharma Ltd, Switzerland) to Implanta(Hanmi Pharma Co, Korea) as the first phase and from Implanta to its microemulsion formulation, Neoplanta, as the second phase. Throughout two phases, the cyclosporine dose, blood pressure and hemoglobin were not changed significantly. Serum creatinine was reduced from the baseline(1.76+/-0.5mg/dL) only during the middle 2 months of the first phase(month 3 : 1.57+/-0.4mg/dL, P<0.05, month 5 : 1.58+/-0.4mg/dL, P<0.05), but it was not changed significantly during the second phase at all. However, blood urea nitrogen(BUN) was increased from baseline throughout the second phase, significantly. Cyclosporine trough level was reduced from baseline(180.87+/-57.5 ng/mL) during the late 3 months of the first phase(month 6 : 131.69+/-61.2ng/mL, P<0.05, month 7 : 137.27+/-82.1ng/mL, P<0.05, month 8 : 135.06+/-58.2ng/mL, P<0.05), while those were increased from baseline to during the early 2 months (month 1 : 172.48+/-64.1ng/mL, P<0.05, month 2 : 170.12+/-49.6ng/mL, P<0.05) and returned to baseline during the remaining 6 months of the second phase. No one developed rejection, but 8 admissions in 7 patients occurred due to cyclosporine nephrotoxicity related elevation of serum creatinine(n=2 in the first phase, n=3 in the second phase), cellulitis in leg(n= 1), partial colectomy for colon cancer(n=1) and reduction of fractured arm(n=1), respectively. Mild abdominal discomfort in 2 patients and nausea with fishy smell on cyclosporine intakes in 3 patients during the early first phase were noted transiently, but no one developed such adverse side effects during the second phase. In conclusion, there were no discernible differences in safety and effectiveness in cyclosporine products from two different manufacturers. Furthermore, the comparable effects between the conventional cyclosporine(Implants) and the microemulsion formulation(Neoplanta) were noted without requiring the dose reduction after the 1:1 conversion.

A Clinical Usefulness of Premedication with Hyoscine-N-butyl bromide (Buscopan(R)) in Colonoscopy: A Randomized, Double Blinded, Prospective Study / 대한소화기내시경학회지

BACKGROUND: Use of antispasmodic medication prior to colonoscopy is controversial but someone believes antispasmodic may improve visualization of colonic mucosa and ease colonoscope insertion. So, we designed a study to assess the effect of premedication with the antispasmodic, hyoscine-N-butyl bromide(Buscopan(R)) on the performance of colonoscopy. METHODS: This study was prospective, double blinded, randomized, controlled study, One hundred three consecutive patients were randomized to receive intravenous buscopan lml(n=52) or placebo(n=51) combined with our standard initial medication(me-peridine 50 mg and midazolam 2 mg). Insertion of colonoscopy was timed, and 100 mm visual analogue scales (VAS) were used for asscssing difficulty of procedure, colonic motility, frequency of positional change, frequency of external compression, difficulty of assistance and degree of discomfort experienced by the patients. RESULTS: There were no significant differences of intubation time between buscopan group(mean time, 7.23 min., range 2~15) and placebo group(7.07 min., range 3~25), (p=0.83) and withdrawal time between buscopan group (6.46 min., range 2-22) and placebo group(6.76 min., range 2 25), (p=0.69). Also, there was no significant differences in intubation time between males and females(buscopan; males 7.00 min., females 7.60 min., p=0.34, placebo; males 7.0~5 min., females 7.08 min., p 0.44). The VAS scores checked by endoscopist(p=0.29), assistant(p=0.32) and patient (p=0.15) were not significantly different in both groups. There were no significant differences in intubation time, VAS scores nf endoscopist, assistant, and patients. CONCLUSION: Premedication with intravenous bu.opan has no advantage on colonoscopy procedure. Use of antispasmodic medication prior to colonoscopy was not considered as recommendable agent.

The Clinical Characteristics of Acute Pyelonephritis Associated with Acute Renal Failure as an Initial Presentation / 대한내과학회지

BACKGROUND: Acute renal failure (ARF) due to acute pyelonephritis (APN) in patients in the absence of obstructive uropathy, diabetes, or chronic renal failure was reported rarely (12 cases in the last 25 yrs in Clin Inf Dis, 1992; 243-6 by SR Jones)2). Acute renal failure is a rare complication of acute pyelonephritis in patients who do not have urinary obstruction. Although urinary tract infections are common in adults, pyelonephritis is rarely considered in the differential diagnosis of acute renal failure, and when clinicians weigh the possible consequences of bacteriuria, renal failure is not considered to be a reasonable possibility. METHODS: We observed 6 patients of acute pyelonephritis associated with acute renal failure as an initial manifestation on admission in the past 6 months. The analysis of clinical features of these 6 patients (APN+) compared to 7 patients of APN without ARF (APN-) revealed following data. RESULTS: All were female in both groups. The mean age was 331.7 years in APN+ and 48+6 years in APN-, respectively (p, ns). All in both APN- and APN+ were caused by E. coli. But, none in both groups except 1 in APN- had bacteremia. The previous history of UTI was present in 5 in APN-, but none in APN+. Duration of clinical symptoms before admission (8.4+/-0.5 vs. 4.4+/-1.0 days, P<0.05) and admission days (24.2+/-1.8 vs. 11.1+/-1.5 days, p=0.000) were significantly longer in APN+. On admission, HUN and serum creatinine was 45+/-2.7mg/dL and 3.5+/-0.2mg/dL in APN+, respectively. No one in APN+ required dialysis, and subsequently recovered renal function with prompt antibiotic therapy resulting in no significant difference compared to that of APN on discharge (serum creatinine, 1.0+/-0.1 vs. 0.9+/-0.1mg/dL). No differences in leukocytosis and serum electrolyte levels on admission were present. However, significant anemia was noted in APN+ (hemoglobin, 9.0+/-0.7 vs. 11.9+/-0.2gm/dL). The days of fever and leukocytosis before disappearance were not different in both groups, but those of flank pain (12.8+/-1.5 vs. 5.7+/-0.7 days, P=0.001) and pyuria (16+/-1.9 vs. 6.4+/-0.6 days, P=0.000) significantly longer in APN+. Upon ultrasonography, all in APN+ showed enhanced echogenicity, but I in APN . (P=P value, NS=not significant) CONCLUSION: Upon these data, we concluded that ARF associated with APN as an initial manifestation was accompanied by several distinct clinical characteristics, which could be used for the early recognition of its unusual occurrence and subsequent appropriate management including antibiotics leading to a favorable outcome.