The Relationship Between Existence of Typical Symptoms and Psychological Factors in Patients With Erosive Esophagitis

BACKGROUND/AIMS: In Asian countries including Korea, the prevalence of gastroesophageal reflux disease (GERD) is on the rise and its clinical impact has been emphasized. The purpose of this study was to investigate the clinical characteristics of esophagitis patients with or without symptoms, and their association with psychological factors. METHODS: Subjects diagnosed as erosive esophagitis of Los Angeles-A or more in screening by upper gastrointestinal endoscopy were enrolled. Questionnaires regarding GERD symptoms and Symptom Checklist-90-Revision were used to identify the presence of psychological symptoms. RESULTS: There was no difference between the subjects' general characteristics (gender, age, body mass index, smoking and alcohol intake) according to the existence of typical symptoms in these patients with erosive esophagitis. Patients with typical GERD symptoms were more likely to have atypical symptoms, dyspepsia and higher scores on psychological symptoms (somatization, obsessive-compulsiveness and phobic anxiety) than those without. CONCLUSIONS: Psychological symptoms and other gastrointestinal symptoms should be considered in the patients with erosive esophagitis.

Is End Stage Renal Disease a Poor Prognosis Factor of Ischemic Colitis? / 대한소화기학회지

BACKGROUND/AIMS: In general, ischemic colitis has a very good prognosis. However, there are a lot of controversies in relation to the prognostic factors. The aim of this study was to evaluate risk factors of severe ischemic colitis. METHODS: A retrospective study was undertaken of patients with ischemic colitis hospitalized at the Hanyang University Hospital during the interval 2004-2006. Patients were divided into two groups: those with mild course and those with severe course which led to operation, systemic inflammatory response syndrome, or death. RESULTS: A total of 41 cases (M/F=13/28, mean age=63.8 years) of biopsy proven ischemic colitis were included, of which 31 (75.6%) had a mild course and 10 (24.4%) a severe course. Coexisting medical diseases of patients were hypertension (n=24), diabetes (n=14), end-stage renal disease (n=11), cardiovascular disease (n=5), and malignancy (n=5). Male (p=0.049), alcoholics (p=0.025), end-stage renal disease (p=0.013), LDH (p=0.002), CRP (p=0.014), and peritoneal irritation sign (p=0.001) were the significant risk factors of severe ischemic colitis in univariate analysis. In multivariate logistic regression analysis, end-stage renal disease (p=0.026) was the only significant risk factor of severe ischemic colitis. CONCLUSIONS: Careful attention must be paid to end-stage renal disease patients having ischemic colitis.

A Case of Small Duodenal Carcinoid Tumor with Liver Metastasis / 대한소화기학회지

Carcinoid tumors are slow growing submucosal tumors with metastatic potential that arise from enterochromaffin cell. The annual incidence of carcinoid tumor is 2 to 3 per 100,000. Carcinoid tumor of duodenum is very rare with an incidence of about 8% among gastrointestinal carcinid tumor. As a endoscopic examination and immnohistochemical stain are developed, an rate of detection is increasing. Among the possible factor of metastatic prediction, tumor size >10 mm, central depression or ulcer, invasion below submucosa, lymphatic or venous invasion are associated with higher metastatic potential. Specially, in case of tumor size <10 mm, in duodenum, there is no report of metastasis to liver in Korea. But, recently, we experienced a rare care of duodenal carcinoid measured by less than 10 mm with liver metastsis. Thus, we report here this case with a review of literature.

Endoscopic Pancreatic Sphincterotomy: Indications and Complications

BACKGROUND/AIMS: Although a few recent studies have reported the effectiveness of endoscopic pancreatic sphincterotomy (EPST), none has compared physicians' skills and complications resulting from the procedure. Thus, we examined the indications, complications, and safety of EPST performed by a single physician at a single center. METHODS: Among 2,313 patients who underwent endoscopic retrograde cholangiopancreatography between January 1996 and March 2008, 46 patients who underwent EPST were included in this retrospective study. We examined the indications, complications, safety, and effectiveness of EPST, as well as the need for a pancreatic drainage procedure and the concomitant application of EPST and endoscopic sphincterotomy (EST). RESULTS: Diagnostic indications for EPST were chronic pancreatitis (26 cases), pancreatic divisum (4 cases), and pancreatic cancer (8 cases). Therapeutic indications for EPST were removal of a pancreaticolith (10 cases), stent insertion for pancreatic duct stenosis (9 cases), nasopancreatic drainage (7 cases), and treatment of sphincter of Oddi dysfunction (1 case). The success rate of EPST was 95.7% (44/46). Acute complications of EPST included five cases (10.9%) of pancreatitis and one of cholangitis (2.2%). EPST with EST did not reduce biliary complications. Endoscopic pancreatic drainage procedures following EPST did not reduce pancreatic complications. CONCLUSIONS: EPST showed a low incidence of complications and a high rate of treatment success; thus, EPST is a relatively safe procedure that can be used to treat pancreatic diseases. Pancreatic drainage procedures and additional EST following EPST did not reduce the incidence of procedure-related complications.

A Case of Mucinous Adenocarcinoma of the Colon Presenting with Psoas Abscess / 대한소화기학회지

A colon cancer presenting as psoas muscle abscess is very rare. A 27-year-old woman was admitted with abdominal pain, fever, and discomfort on left thigh. She had been administered on anti-tuberculosis medication for colonic tuberculosis since 3 months ago. Abdominal CT scan revealed a mass lesion obstructing the descending colon with an abscess formation within left psoas muscle. We undertook segmental resection of obstructing descending colon after the percutaneous drainage of psoas abscess. The pathologic report was mucinous adenocarcinoma of the colon. We report the first case of colon cancer manifested with psoas abscess in Korea, with the review of literature associated with the correlation of colon cancer and tuberculosis.

Analysis of Dynamics of Gait in Parkinson's Disease with 3-Demensional Gait Analysis System

BACKGROUND: Gait disturbance is one of the most disabling symptoms of Parkinson's disease (PD). To better understand of the dynamics of gait in PD, we quantitatively evaluated the spatiotemporal and kinematic parameters of gait in PD patients and normal controls with 3-demensional gait analysis system. METHODS: The diagnosis of PD was based on UK Brain Bank criteria. Subjects with PD were recruited from Parkinson disease clinic of Korea University Medical Center. The severity was indicated by Hoehn and Yahr stage and Unified Parkinson disease rating scale (UPDRS). The gait analysis and assessment was performed in the off condition. RESULTS: Thirty PD patients and thirty normal controls were included. The statistical significant results of gait analysis between PD and control groups were as followings; reduced walking velocity, reduced stride length, increased double supporting time, reduced pelvic oblique movement with preserved pelvic tilting, reduced maximal flexion and extension of hip joint, reduced flexion angle of knee joint especially in terminal stance phase and swing phase, and reduced plantar flexion of ankle. But there were no significant difference between PD and control groups in cadence. And these parameters except cadence had significant correlation with clinical disability in PD patients. The cadence did not correlated significantly with clinical disability. CONCLUSIONS: The PD patients showed statistically gait cycle change with preserved cadence, reduced range of motion in hip, knee, and ankle joint with preserved ankle dorsiflexion in the profiles. These features were aggravated in advanced stage.

Treatment with Repeated Lumbar Epidural Blood Patches for a Patient with Orthostatic Headache after Suboccpital Craniectomy

Orthostatic headache after suboccipital craniectomy has been rarely reported. A 32-year-old man underwent emergent suboccipital craniectomy due to acute bilateral cerebellar infarctions with massive brain edema. Although his neurological deterioration halted after the craniectomy, he still suffered from a severe disabling orthostatic headache. We performed two epidural blood patches at the levels of the lumbar and thoracic spine. He improved considerably a few days after the repetitive epidural blood patches. Epidural blood patches may be a useful treatment modality for post-craniectomy postural headaches.

A Clinical Observation on Twelve Cases of Primary Aldosteronism / 대한내분비학회지

BACKGROUND: Primary aldosteronism describes a group of disorders characterized by long-standing aldosterone excess, with suppressed renin activity, resulting in hypertension and hypokalemia. The protean clinical and biochemical characteristics of this syndrome have important implications regarding its pathophysiology and responsiveness to treatment. METHODS: The cases of 12 primary aldosteronisms, diagnosed at Hanyang University Hospital between 1996 and 1999, were reviewed. RESULTS: The 12 cases were composed of 9 aldosterone-producing adenoma, 2 adrenal hyperplasia and a case of idiopathic hyperaldosteronism. There were 9 women and 3 men. The mean age was 46 yrs (range, 23 to 64 yrs). At the initial visit, the mean blood pressure was 160+/-26/104+/-14 mmHg, and one case of idiopathic hyperplasia had normal blood pressure. The mean serum K+ level was 2.6+/-0.5 mEq/L (range, 1.5 to 3.5 mEq/L). The mean plasma renin activity and plasma aldosterone concentration were 0.4+/-0.4 ng/ml/hr (range, 0.2 to 1.6 ng/ml/hr) and 407.5+/-199.8 pg/mL (range, 225 to 800 pg/mL), respectively. Different steps of diagnostic modalities were applied for the preoperative differential diagnosis. All patients, with the exception of the one with idiopathic hyperaldosteronism, were managed by a unilateral laparoscopic adrenalectomy, as they were all diagnosed under the impression of adrenal adenomas. Ultimately, 9 cases were proven to have adrenal adenomas. One hypertensive case, with hypokalemia, had adrenal hyperplasia, and the case with normotension was found to have adrenal nodular hyperplasia from the pathology. The size of the tumors ranged from 1.4 to 2.4 cm in diameter. Among the 11 cases that underwent an adrenalectomy, the blood pressures in 6 cases normalized after the operation, while the other 5, including the one with unilateral hyperplasia, were still in need of antihypertensives for the control of elevated blood pressures, even after the operation. The other case of idiopathic hyperaldosteronism was managed by the prescription of spironolactone. CONCLUSION: From these, it can be suggested that the clinical diversity of the syndrome, especially in the pathophysiology and response to operation, awaits the development of a better preoperative lateralization procedure

Outbreak of Hepatitis by Orientia tsutsugamushi in the Early Years of the New Millenium / 대한간학회지

BACKGROUND/AIMS: Orientia -tsutsugamushi infection is an acute febrile disease due to the accidental transmission through human skin of forest dwelling vector Leptotrombidium larva. The authors observed liver dysfunctions in patients diagnosed with tsutsugamushi disease (Scrub typhus) in the past 3 years and report the data in the hope of bringing attention to this disease in the differential diagnosis of autumn-season hepatitis, especially of non-A, non-B and non-C hepatitis. METHODS: Medical records of 22 patients diagnosed with tsutsugamushi disease by the hemagglutinin method between October 2000 and November 2002 were reviewed. RESULTS: Female gender was dominant in the ratio of 3.4:1. Mean age was 56.4 +/- 2.6. Admission was between 23rd September and 15th November with the peak between mid October and early November. Fever, being the most common symptom, was observed in 21 cases, myalgia in 13, arthralgia in 12, chills in 6, and skin rash in 6. An incubation period of 7-9 days was most common (10 cases), 13-15 days (4), 10-12 days (3), within 3 days (3), and 4-6 days (2). Average ALT, AST and GGTP were increased to 93.2 +/- 17.3 IU/L (18 +/- 345 IU/L), 92.5 +/- 11.7 IU/L (34-255 IU/L) and 132.2 +/- 14.5 IU/L (19-251 IU/L), respectively, but total bilirubin was normal. All the patients improved with doxycycline therapy. CONCLUSIONS: Since it usually shows liver dysfunction, it is important to take Orientia tsutsugamushi into consideration in differential diagnosis of autumn-season, febrile hepatic disease.

HBV DNA Levels, Aminotransferase and Histological Activity in Young Male Patients with HBeAg Positive Chronic Hepatitis B / 대한간학회지

BACKGROUND/AIM: A significant correlation between HBV DNA and liver damage was found in precore mutant strains but there was no significant association between viral replication and liver damage in HBeAg positive patients. Laboratory tests are often requested to predict hepatitis activity (grade) and fibrosis (stage) in HBeAg positive chronic hepatitis B. We assessed ALT, AST, and HBV-branched DNA to find which is the best for predicting hepatitis activity and fibrosis. METHODS: Routine biochemical liver function tests and HBV DNA in sera were assessed in 119 young patients positive with HBsAg and HBeAg. The mean age of patients was 21+/-2 years. All patients were male. By logistic regression analysis the relationships between laboratory data, hepatitis activity, fibrosis, or risk of chronic active hepatitis were analyzed. RESULTS: There was a significant correlation between aminotransferase (AST, ALT) and hepatitis activity/ fibrosis. A significant inverse relationship between the HBV bDNA and hepatitis activity was demonstrated (Pearson's correlation coefficient: lobular activity,-0.305; porto-periportal activity, -0.410). But HBV bDNA was not correlated with severity of fibrosis. AST and HBV bDNA was the important test for predicting the more severe hepatitis activity (lobular activity and porto-periportal activity: score> or =3, respectively) CONCLUSION: The higher AST, but the lower HBV bDNA, in sera shows the more severe hepatitis activity. AST and HBV bDNA could be helpful for assessing the hepatitis activity in young male patients with HBeAg positive chronic hepatitis B if proper reference values are used.

A Case of Fulminant Hepatic Failure in Wilson's Disease Combined with Systemic Lupus Erythematosus / 대한간학회지

Patients with systemic lupus erythematosus (SLE) have a chance of developing liver involvement in their lifetime. The main cause of liver involvement in SLE patients is previous treatment with hepatotoxic drugs or hepatotropic viral hepatitis. Wilson's disease is a hereditary disorder and is usually diagnosed in patients presenting either neuropsychiatric disorders or manifestations related to chronic liver disease. Fulminant hepatic failure as the initial manifestation of Wilson's disease is rare. The relationship between systemic lupus erythematosus and Wilson's disease has not been established. We report a case of a 12-year-old girl with SLE who presented fulminant hepatic failure as an initial manifestation of Wilson's disease. The diagnosis was established with decreased serum ceruloplasmin level and the presence of Kayser-Fleischer ring. We treated with repeated plasma exchange. Despite repeated plasma exchange she died of multi-organ failure on the 16th hospital day. Considering this case, Wilson's disease should be considered as a cause of fulminant hepatic failure, especially in juvenile age cases.

A Comparison of Patients With Hepatocellular Carcinoma Between A Short-term (Less Than 6 months) Survival Group and A Long-term (Over 24 Months) Survival Group After Treatment with Transcatheter Arterial Chemoembolization / 대한간학회지

BACKGROUND/AIM: Although hepatocellular carcinoma(HCC) shows poor prognosis, transcatheter hepatic arterial chemoembolization(TACE) can improve survival rate in some patient groups. This study investigated the synergy effect of the different clinical indices on the survival time in patients with HCC underwent TACE. MATERIALS AND METFODS: A retrospective study of 241 patients with HCC who underwent TACE with a mixture of lipiodol, mitomycin-C and adriamycin, alone or followed by gelfoam was conducted. Three different survival groups (A, less than 6 months; B, between between 6 and 23 months; and C, over 24 months) were compared. RESULTS: Alkaline phosphatase was lowest in group C (p=0.0001). The longer the survival, the lower (p=0.027, p=0.007) the AST and AST/ALT ratio were. Albumin was higher (p=0.032), GGT and LDH were lower (p=0.003, p=0.002) in the long-term survival group. The long-term survival group revealed an absence of both ascites(p<0.002) and portal vein thrombosis(p<0.001), and lower TNM stage (P<0.0001). The single nodular type of HCC was more frequent (P<0.0001) and the size of tumor was smaller in the long-term survival group (P<0.0001). Child-Pugh class was lower in the long-term survival group (p=0.017). The higher serum albumin and elder age, the higher albumin and the lower alkaline phosphatase or alpha-fetoprotein, represented synergic effects on a long term survival. The higher albumin and the smaller size or the lower tumor stage, the higher albumin and platelet revealed similar synergy effects. Although the age or platelet is high, low albumin showed poor prognosis. CONCLUSION: Patients with small-sized single, nodular HCC in a low Child-Pugh class without evidence of ascites and portal vein thrombosis, and the higher level of serum albumin but lower levels of alpha-fetoprotein, alkaline phosphatase, GGT, and LDH, can expect a long-term survival over 24 months by the treatment of TACE. There are meaningful synergies of the different clinical variables affecting the survival times in the patients with HCC undergoing TACE.

Distribution of HBV Genotypes in Patients With Chronic HBV Infection in Korea / 대한간학회지

BACKGROUND/AIMS: Chronic HBV infection is associated with a wide spectrum of clinical manifestations, including asymptomatic carrier state, chronic hepatitis, liver cirrhosis, and hepatocellular carcinoma. Genotypically, HBV genomes have been classified into seven groups, designated A to G. Several studies have suggested recently that HBV genotypic differences influence the severity of liver disease and clinical outcomes. The distribution of HBV genotypes in Korea and its clinical relevance are poorly understood. We investigated the prevalence of HBV genotypes in Korea and the association between the distinct genotypes and the severity of liver disease. METHODS: A total of 214 HBV-DNA positive serum samples, were used for the genotyping. All patients were HBV-bDNA positive chronic HBsAg carriers. 199 patients were histologically verified with liver cirrhosis (6), chronic hepatitis (192) and fatty liver (1). The other patients were clinically diagnosed with liver cirrhosis (13) or hepatocellular carcinoma (2). HBV genotype was determined by PCR using type-specific primers. RESULTS: Genotyping was possible in all patients. Out of 214 patients, 213 (99.5%) were HBV genotype C. Only one (0.5%) was genotype A. The patient with genotype A had minimal hepatitis as diagnosed by liver biopsy. CONCLUSIONS: These results indicate that almost all chronic HBV infections are genotype C in Korea. HBV genotypic difference therefore does not influence the clinical outcome of HBV infection in Korea. Because genotype C may be associated with more severe liver disease, the predominance of genotype C in Korea may result in more severe outcomes than in other countries where other genotypes are predominant.

An Outbreak of Hepatitis A in South Korean Military Personnel: A Clinical and Epidemiologic Study / 대한간학회지

BACKGROUND/AIMS: Increasing the susceptibility of young populations to HAV infection could result in an outbreak in a high-risk group. The author investigated the characteristics of hepatitis A outbreaks among Korean military personnel to obtain the fundamental data for determining the necessity for selective HAV vaccination. METHODS: A case was defined as a person who had an onset of an illness compatible with acute viral hepatitis A between 4 February and 6 April 1998. RESULTS: A widespread outbreak of hepatitis A affected 102 military personnel. The epidemic curve indicated a common-source exposure in the initial stage. At the end of the first month of the initial onset, the occurrence was specific to the location of the military post. Investigation suggested that contamination most likely occurred prior to the local distribution of food. The mean age was 23 years. The overall attack rate was 91 cases per 10000 persons at risk. All cases were jaundiced. The most frequently reported symptoms included icteric sclerae, dark urine, anorexia, malaise and fatigue, nausea, fever, abdominal pain, headache, upper respiratory symptoms, vomiting, itching, diarrhea, light-colored stools, myalgia, arthralgia, and skin rash. The laboratory test showed the serum total bilirubin of 5.5 mg/dL, AST of 344 IU/L, and ALT of 868 IU/L (mean value). CONCLUSION: All patients were clinically apparently diseased with jaundice and were completely recovered. The outbreak was food borne common-source exposure. The changing epidemiology hepatitis A in Korea calls for the economic evaluation of costs and benefits for selective HAV vaccination in high risk adult groups including military personnel.