Acute Cholangitis Caused by Boryong Strain of Orientia tsutsugamushi

Scrub typhus present with a variety clinical manifestations caused by Orientia tsutsugamushi, it is sometimes accompanied by severe complications. The clinical course of this complication is not well clear. Herein, we first report a case with acute cholangitis and acalculous cholecystitis caused by the Boryong genotype of O. tsutsugamushi. A 82-year-old woman presented with fever and acute abdominal pain on the right upper quadrant. Initially, the patient showed an abnormality of liver enzymes of cholestatic pattern. An acute cholangitis and cholecystitis were suspected on the enhanced computed tomography (CT), and emergent endoscopic retrograde cholangiopancreatography (ERCP) performed. However, neither ERCP nor CT detected common bile duct stones or sludge. The patient's illness progressed despite bile drainage and antibiotic therapy. On the fifth day in hospital, an immunofluorescence IgG assay for O. tsutsugamushi was positive, and the patient newly developed a skin rash and an eschar lesion on the right abdomen. The polymerase chain reaction amplification of Orientia genes from blood and bile was positive, genotype of both samples was identified the Boryong type. The presentation of scrub typhus as an acute cholangitis is not reported till now. In endemic areas, scrub typhus would be considered a rare etiology of acute cholangitis.

Acute Cholangitis Caused by Boryong Strain of Orientia tsutsugamushi

Scrub typhus present with a variety clinical manifestations caused by Orientia tsutsugamushi, it is sometimes accompanied by severe complications. The clinical course of this complication is not well clear. Herein, we first report a case with acute cholangitis and acalculous cholecystitis caused by the Boryong genotype of O. tsutsugamushi. A 82-year-old woman presented with fever and acute abdominal pain on the right upper quadrant. Initially, the patient showed an abnormality of liver enzymes of cholestatic pattern. An acute cholangitis and cholecystitis were suspected on the enhanced computed tomography (CT), and emergent endoscopic retrograde cholangiopancreatography (ERCP) performed. However, neither ERCP nor CT detected common bile duct stones or sludge. The patient's illness progressed despite bile drainage and antibiotic therapy. On the fifth day in hospital, an immunofluorescence IgG assay for O. tsutsugamushi was positive, and the patient newly developed a skin rash and an eschar lesion on the right abdomen. The polymerase chain reaction amplification of Orientia genes from blood and bile was positive, genotype of both samples was identified the Boryong type. The presentation of scrub typhus as an acute cholangitis is not reported till now. In endemic areas, scrub typhus would be considered a rare etiology of acute cholangitis.

In Vivo Endoscopic Removal of Ancylostoma duodenale in a Patient with Abdominal Pain

A 20-year-old Cambodian male living in Korea for 2 years as a foreign worker visited our gastroenterology outpatient clinic. He had a small farm in Cambodia. He complained of postprandial upper abdominal pain with nausea and vomiting for 2 years. Gastroduodenoscopy showed hyperemic mucosa near the major papilla in the duodenum and two small and slender reddish worms. These were removed with endoscopic biopsy forceps. Under microscopy, these were identified as Ancylostoma duodenale by the characteristic morphology of 2 pairs of cutting teeth in the buccal cavity and 3 lobes in the copulatory bursa. After removal of two worms, his symptom improved. Soil-transmitted helminths (STH) present a global health problem. In the Republic of Korea, STH, including hookworms, were highly prevalent until the 1970s. With mass fecal examination followed by selective mass chemotherapy with anthelmintics from 1969 to 1995, the prevalence of STH has rapidly decreased since the 1980s. Since 2004, no hookworms have been found in nationwide surveys on the prevalence of intestinal parasitic infection. Therefore, we report a case of in vivo endoscopic removal of A. duodenale in a patient with abdominal pain.

Endoscopic Ultrasound-Guided Perirectal Abscess Drainage without Drainage Catheter: A Case Series

A perirectal abscess is a relatively common disease entity that occurs as a postsurgical complication or as a result of various medical conditions. Endoscopic ultrasound (EUS)-guided drainage was recently described as a promising alternative treatment. Previous reports have recommended placement of a drainage catheter through the anus for irrigation, which is inconvenient to the patient and carries a risk of accidental dislodgement. We report four cases of perirectal abscess that were successfully treated with only one or two 7 F double pigtail plastic stent placements and without a drainage catheter for irrigation.

Reduced Autophagy in 5-Fluorouracil Resistant Colon Cancer Cells

We investigated the role of autophagy in SNUC5/5-FUR, 5-fluorouracil (5-FU) resistant SNUC5 colon cancer cells. SNUC5/5-FUR cells exhibited low level of autophagy, as determined by light microscopy, confocal microscopy, and flow cytometry following acridine orange staining, and the decreased level of GFP-LC3 puncta. In addition, expression of critical autophagic proteins such as Atg5, Beclin-1 and LC3-II and autophagic flux was diminished in SNUC5/5-FUR cells. Whereas production of reactive oxygen species (ROS) was significantly elevated in SNUC5/5-FUR cells, treatment with the ROS inhibitor N-acetyl cysteine further reduced the level of autophagy. Taken together, these results indicate that decreased autophagy is linked to 5-FU resistance in SNUC5 colon cancer cells.

Hemoperitoneum from Spontaneous Rupture of a Metastatic Abdominal Lymph Node in Gallbladder Cancer: A Case Report / 대한소화기학회지

Gallbladder (GB) cancer is asymptomatic in nature, making diagnosis and treatment difficult. The lymph node status is the strongest predictor of long-term survival for patients with GB cancer, and a complete removal of regional lymph nodes is important for patients undergoing radical resection of GB cancer. Unfortunately, lymph node metastases are common in the early stages of GB cancer. However, there have only been a few cases describing the symptoms or complications of metastatic lymph nodes in patients with GB cancer. Although hemoperitoneum caused by metastatic lymph nodes can occur with several cancers, it is very rare. To the best of our knowledge, hemoperitoneum from spontaneous ruptures of metastatic lymph nodes with GB cancer has not yet been reported. Herein, we describe such a case in a patient newly diagnosed with GB cancer.

Acute Pancreatitis Induced by Compression of Main Pancreatic Duct due to Large Stones and Catheter in the Common Bile Duct / 대한췌담도학회지

Acute pancreatitis is occasionally caused by endoscopic treatments or radiologic interventions of the pancreatobiliary tract. However, no reports indicate that acute pancreatitis resulted from the insertion of a percutaneous transhepatic cholangiography (PTCS) catheter in the common bile duct (CBD). A 65-year-old woman visited our hospital with acute cholangitis due to about 3 cm-sized CBD stones. We planned to perform PTCS because of the large stones and altered anatomy (Billroth II). The patient was discharged after tract dilatation and insertion of a PTCS catheter in the distal CBD without manipulations of Ampulla of Vater (AOV). However, she visited the emergency room due to acute pancreatitis at three days after discharge. Computed tomography revealed upstream dilation of the main pancreatic duct following the compressed area of a large stone and catheter. Thus, we report a case that presented with acute pancreatitis induced by insertion of a PTCS catheter without manipulations of AOV.

Clinical Significances of Chronic Cholecystitis according to Gallbladder Contraction / 대한췌담도학회지

BACKGROUND/AIMS: Chronic cholecystitis and contraction of gallbladder (GB) have been regarded as precancerous lesions. The aim of study is to clarify whether chronic cholecystitis and GB contraction have clinical significance. METHODS: This study included 409 patients underwent cholecystectomy for chronic cholecystitis between January 2006 and June 2011 at a single center. Data regarding radiologic findings and blood tests were collected retrospectively. RESULTS: About 384 patients (94%) had GB stones. Among 409 patients, 104 (25.4%) patients had contracted GB and 305 (74.6%) patients did not. Biliary pain was more common in the contracted GB group (42.3% vs. 31.1%). The contracted GB group had a higher proportion of diffuse wall thickening type and a higher conversion rate to open cholecystectomy. Only seven patients (1.7%) were finally diagnosed with GB cancers. All patients were over 60 years of age and complained of biliary pain; however, only one patient had contraction of GB. CONCLUSIONS: Biliary pain, diffuse wall thickening, and conversion to open cholecystectomy were more frequent in the contracted GB group. Although incidental GB cancers were rarely diagnosed, all were older and had biliary pain. These will be used as significant evidences when making a treatment plan in chronic cholecystitis and contracted GB.

Clinical Significances of Chronic Cholecystitis according to Gallbladder Contraction / 대한췌담도학회지

BACKGROUND/AIMS: Chronic cholecystitis and contraction of gallbladder (GB) have been regarded as precancerous lesions. The aim of study is to clarify whether chronic cholecystitis and GB contraction have clinical significance. METHODS: This study included 409 patients underwent cholecystectomy for chronic cholecystitis between January 2006 and June 2011 at a single center. Data regarding radiologic findings and blood tests were collected retrospectively. RESULTS: About 384 patients (94%) had GB stones. Among 409 patients, 104 (25.4%) patients had contracted GB and 305 (74.6%) patients did not. Biliary pain was more common in the contracted GB group (42.3% vs. 31.1%). The contracted GB group had a higher proportion of diffuse wall thickening type and a higher conversion rate to open cholecystectomy. Only seven patients (1.7%) were finally diagnosed with GB cancers. All patients were over 60 years of age and complained of biliary pain; however, only one patient had contraction of GB. CONCLUSIONS: Biliary pain, diffuse wall thickening, and conversion to open cholecystectomy were more frequent in the contracted GB group. Although incidental GB cancers were rarely diagnosed, all were older and had biliary pain. These will be used as significant evidences when making a treatment plan in chronic cholecystitis and contracted GB.

Regression of esophageal varices during entecavir treatment in patients with hepatitis-B-virus-related liver cirrhosis

Recent studies suggest that liver cirrhosis is reversible after administering oral nucleos(t)ide analogue therapy to patients with hepatitis B virus (HBV) infection. However, few studies have addressed whether esophageal varices can regress after such therapy. We report a case of complete regression of esophageal varices during entecavir therapy in patients with HBV-related liver cirrhosis, suggesting that complications of liver cirrhosis such as esophageal varices can regress after the long-term suppression of HBV replication.

Regression of esophageal varices and splenomegaly in two patients with hepatitis-C-related liver cirrhosis after interferon and ribavirin combination therapy

Some recent studies have found regression of liver cirrhosis after antiviral therapy in patients with hepatitis C virus (HCV)-related liver cirrhosis, but there have been no reports of complete regression of esophageal varices after interferon/peg-interferon and ribavirin combination therapy. We describe two cases of complete regression of esophageal varices and splenomegaly after interferon-alpha and ribavirin combination therapy in patients with HCV-related liver cirrhosis. Esophageal varices and splenomegaly regressed after 3 and 8 years of sustained virologic responses in cases 1 and 2, respectively. To our knowledge, this is the first study demonstrating that complications of liver cirrhosis, such as esophageal varices and splenomegaly, can regress after antiviral therapy in patients with HCV-related liver cirrhosis.

Is it necessary to delay antiviral therapy for 3-6 months to anticipate HBeAg seroconversion in patients with HBeAg-positive chronic hepatitis B in endemic areas of HBV genotype C?

BACKGROUND/AIMS: Spontaneous HBeAg seroconversion occurs frequently in the immune reactive phase in HBeAg-positive chronic hepatitis B (CHB). Therefore, observation for 3-6 months before commencing antiviral therapy is recommended in patients with alanine aminotransferase (ALT) levels that exceed twice the upper limit of normal (ULN). However, HBeAg seroconversion occurs infrequently in patients infected with hepatitis B virus (HBV) genotype C. The aim of the present study was to determine whether the waiting policy is necessary in endemic areas of HBV genotype C infection. METHODS: Ninety patients with HBeAg-positive CHB were followed prospectively without administering antiviral therapy for 6 months. Antiviral therapy was initiated promptly at any time if there was any evidence of biochemical (i.e., acute exacerbation of HBV infection or aggravation of jaundice) or symptomatic deterioration. After 6 months of observation, antiviral therapy was initiated according to the patient's ALT and HBV DNA levels. RESULTS: Only one patient (1.1%) achieved spontaneous HBeAg seroconversion. Biochemical and symptomatic deterioration occurred before 6 months in 17 patients (18.9%) and 5 patients, respectively. High ALT and HBV DNA levels were both independent risk factors for biochemical deterioration. Of 15 patients with HBV DNA > or =5.1x107 IU/mL and ALT > or =5xULN, biochemical deterioration occurred in 7 (46.7%), including 1 patient receiving liver transplantation due to liver failure. CONCLUSIONS: Spontaneous HBeAg seroconversion in patients with HBeAg-positive CHB is rare within 6 months. Biochemical deterioration was common and may lead to liver failure. Immediate antiviral therapy should be considered, especially in patients with high ALT and HBV DNA levels in endemic areas of genotype C infection.

Comparison between Midazolam Used Alone and in Combination with Propofol for Sedation during Endoscopic Retrograde Cholangiopancreatography

BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is an uncomfortable procedure that requires adequate sedation for its successful conduction. We investigated the efficacy and safety of the combined use of intravenous midazolam and propofol for sedation during ERCP. METHODS: A retrospective review of patient records from a single tertiary care hospital was performed. Ninety-four patients undergoing ERCP received one of the two medication regimens, which was administered by a nurse under the supervision of a gastroenterologist. Patients in the midazolam (M) group (n=44) received only intravenous midazolam, which was titrated to achieve deep sedation. Patients in the midazolam pulse propofol (MP) group (n=50) initially received an intravenous combination of midazolam and propofol, and then propofol was titrated to achieve deep sedation. RESULTS: The time to the initial sedation was shorter in the MP group than in the M group (1.13 minutes vs. 1.84 minutes, respectively; p<0.001). The recovery time was faster in the MP group than in the M group (p=0.031). There were no significant differences between the two groups with respect to frequency of adverse events, pain experienced by the patient, patient discomfort, degree of amnesia, and gag reflex. Patient cooperation, rated by the endoscopist as excellent, was greater in the MP group than in the M group (p=0.046). CONCLUSIONS: The combined use of intravenous midazolam and propofol for sedation during ERCP is more effective than midazolam alone. There is no difference in the safety of the procedure.

Comparison of the Clinical Characteristics of Patients with Small Bowel and Gastric Anisakiasis in Jeju Island

BACKGROUND/AIMS: Anisakiasis is frequent in Jeju Island because of the people's habit of ingesting raw fish. This study evaluated the clinical characteristics of patients with small bowel anisakiasis and compared them with those of patients with gastric anisakiasis. METHODS: We retrospectively reviewed the medical records of 109 patients diagnosed with anisakiasis between May 2003 and November 2011. RESULTS: Of the 109 patients diagnosed with anisakiasis, those with suspicious anisakiasis (n=38) or possible anisakiasis (n=12) were excluded. The age and gender distributions did not differ between patients with small bowel anisakiasis (n=30; age, 45+/-13 years) and those with gastric anisakiasis (n=29; age, 46+/-10 years). The mean duration of hospitalization was 5.4+/-4.3 days for patients with small bowel anisakiasis and 0.5+/-1.7 days for patients with gastric anisakiasis. Small bowel anisakiasis was accompanied by leukocytosis (76.7% vs 25.5%, p=0.003) and elevated C-reactive protein levels (3.4+/-3.2 mg/dL vs 0.5+/-0.3 mg/dL, p=0.009). Contrast-enhanced abdominopelvic computed tomography showed small bowel wall thickening with dilatation in 93.3% (28/30) of patients and a small amount of ascites in 80.0% (24/30) of patients with small bowel anisakiasis. CONCLUSIONS: Compared with gastric anisakiasis patients, small bowel anisakiasis patients had a longer hospitalization time, higher inflammatory marker levels, and small bowel wall thickening with ascites.

Obesity and Gallbladder Diseases / 대한소화기학회지

Obesity is an important health problem in the world and related to many critical diseases, such as diabetes, cardiovascular disease, and metabolic syndrome. Obesity leads to fat infiltration of multiple organs and infiltrated adipose tissue produces many cytokines resulting in the dysfunction of organs such as the gallbladder. In the biliary diseases, obesity and overweight have been known as a major risk factor for gallstones. According to current studies, obesity, insulin resistance, hyperinsulinemia, and metabolic syndrome are related to various gallbladder diseases including gallbladder stones, cholecystitis, gallbladder polyps, and gallbladder cancers. We reviewed further literature on the obesity and gallbladder diseases, in aspects of epidemiology, mechanism, pathology and prevention.

A Case of Peutz-Jeghers Syndrome Diagnosed by Wireless Capsule Endoscopy

Peutz-Jeghers syndrome (PJS), is a rare autosomal dominant hereditary disorder. Intestinal hamartomatous polyps in association with melanocytic pigmentation of the skin and mucous membranes characterize PJS. Patients with PJS often have complications associated with the polyps, such as intestinal obstruction, intussusception, acute or chronic gastrointestinal bleeding, and the development of various types of cancer. Enteroclysis, small bowel follow-through, and push enteroscopy are generally used to identify the presence and location of small bowel polyps. Wireless capsule endoscopy (CE) has been confirmed as a feasible, safe, and sensitive test for the surveillance of small bowel polyps in patients with PJS and could replace radiographic small bowel surveillance. Here, a case of PJS newly diagnosed by CE is reported. The patient, a 30-year-old man who had developed rectal polyps associated with anal extrusion 7 years previously, had six episodes of hematochezia.

A Case of Kallmann's Syndrome with Frontal Lobe Atrophy and Mental Retardation

Kallmann's syndrome is a rare condition, and this is defined as hypogonadotropic hypogonadism and anosmia or hyposmia. The syndrome may be associated with cleft lip, cleft palate, color blindness, skeletal abnormalities, renal agenesis, sensory neural hearing loss, obesity, etc. About 10 cases of Kallmann's syndrome have been reported in Korea, but there are no reports on cases of Kallmann's syndrome with atrophy of the frontal lobe, severe mental retardation and unilateral renal agenesis. We experienced a case of 17-year-old boy with abnormalities of the olfactory system, as was noted on magnetic resonance imaging (MRI). He had an atrophy of the frontal lobe, mental retardation, a micropenis and unilateral renal agenesis. Hormonal assay documented low levels of luteinizing hormone (LH), follicle stimulating hormone (FSH), testosterone and thyroid-stimulating hormone (TSH). So, we report here on an unusual case of Kallmann's syndrome along with briefly reviewing the relevant medical literature.

Clinical Characteristics of Type 2 Diabetes Patients according to Family History of Diabetes / 당뇨병

BACKGROUND: Type 2 diabetes mellitus (T2DM) has a strong genetic component, and its prevalence is notably increased in the family members of T2DM patients. However, there are few studies about the family history of T2DM. We carried out this study to assess the influences of family history on clinical characteristics in T2DM patients. METHODS: This is a cross-sectional study involving 651 T2DM patients. Patient history and physical examination were performed and fasting blood was taken. If any first degree relative was diabetic, a family history of diabetes was considered to exist. RESULTS: Among the total 621 patients, 38.4% had a family history of diabetes. Patients with a family history had a younger age, higher weight, younger age at diagnosis and higher triglyceride level than did those without a family history. Dyslipidemia medication and metabolic syndrome were more prevalent in familial diabetes. Sex, blood pressure, previous treatment for diabetes, HbA1C, C-peptide, total cholesterol, high density lipoprotein cholesterol, and low density lipoprotein cholesterol were not different between familial and non-familial diabetes. Upon multiple linear regression analysis, the family history of diabetes remained significantly associated with serum triglyceride level. CONCLUSION: In T2DM patients with a family history of diabetes, the disease tended to develop earlier. Metabolic syndrome and cardiovascular risk factors are more prevalent in familial T2DM than they were in non-familial T2DM. These results support the necessity of earlier screening for diabetes in family members of T2DM patients and more active prevention against cardiovascular disease in T2DM patients with a family history.

Distribution of hepatitis C virus genotypes in Jeju Island / 대한간학회지

BACKGROUNDS/AIMS: The hepatitis C virus (HCV) genotype affects clinical outcomes of HCV infection, in terms of the response to antiviral therapy and progression of chronic liver diseases, and shows geographic differences in distribution. The aim of this study was to elucidate the HCV genotypes in patients with chronic HCV infection in Jeju, which is an island off the Korean peninsula. METHODS: The study population consisted of 162 patients with anti-HCV antibodies and HCV-RNA. HCV genotypes were determined using genotype specific primers. RESULTS: HCV genotype 2a predominated (62.3%), followed by genotype 1b (34.0%) and 2b (3.7%). The prevalence of genotypes differed significantly with age, with HCV genotypes 1 and 2 being more frequent in older and younger subjects (P=0.035), respectively. HCV-RNA levels were higher in patients with genotype 1 than in those with genotype 2 (P=0.001). HCV genotype was not significantly related to sex, clinical diagnosis and potential risk factors. CONCLUSIONS: HCV genotype 2a is most common in Jeju, followed by genotype 1b. Our results suggest that the distribution of the HCV genotype differs between regions in Korea.