Recurrent Cholangitis due to Hem-o-lok Clip Migration after Laparoscopic Common Bile Duct Exploration Treated with Endoscopic Retrograde Cholangiopancreatography / 대한췌담도학회지

Clip migration into the common bile duct (CBD) is a rare complication of laparoscopic biliary surgery. We report a case of Hem-o-lok clip migration-induced CBD stone in a 66-year-old man who underwent laparoscopic cholecystectomy (LC) and laparoscopic common bile duct exploration (LCBDE) 4 years ago. The patient visited the emergency room for upper abdominal pain. CT scan revealed increased CBD diameter and multiple CBD stones. We performed endoscopic retrograde cholangiopancreatography for CBD stone extraction. Cholangiography revealed multiple suspected filling defects in the CBD; stones and unknown foreign body were removed using Basket. The foreign body found in the duodenum was a Hem-o-lok clip. When epigastric pain develops in a patient who has undergone LC and LCBDE, it is possible that biliary stone occurs due to clip migration.

Recurrent Cholangitis due to Hem-o-lok Clip Migration after Laparoscopic Common Bile Duct Exploration Treated with Endoscopic Retrograde Cholangiopancreatography / 대한췌담도학회지

Clip migration into the common bile duct (CBD) is a rare complication of laparoscopic biliary surgery. We report a case of Hem-o-lok clip migration-induced CBD stone in a 66-year-old man who underwent laparoscopic cholecystectomy (LC) and laparoscopic common bile duct exploration (LCBDE) 4 years ago. The patient visited the emergency room for upper abdominal pain. CT scan revealed increased CBD diameter and multiple CBD stones. We performed endoscopic retrograde cholangiopancreatography for CBD stone extraction. Cholangiography revealed multiple suspected filling defects in the CBD; stones and unknown foreign body were removed using Basket. The foreign body found in the duodenum was a Hem-o-lok clip. When epigastric pain develops in a patient who has undergone LC and LCBDE, it is possible that biliary stone occurs due to clip migration.

Cholangitis Caused by Hereditary Spherocytosis in Adulthood Treated by Endoscopic Retrograde Cholangiopancreatography / 대한췌담도학회지

Hereditary spherocytosis is a disease caused by deficiency of erythrocyte lipid membrane protein. Hereditary spherocytosis shows hemolysis of erythrocyte, and it leads to anemia, jaundice by elevation of indirect bilirubin. Almost of patients are diagnosed in their infancy, and can be cured by splenectomy about their age 6–7. Herein, we report a rare case of 33-year-old male was suffered from gallbladder stone and cholangitis those are thought to be the late complications of hereditary spherocytosis. We performed endoscopic retrograde cholangiopancreaticography to remove common bile duct stones. After he got cholecystectomy and splenectomy, there was no recurrence of choledocholithiasis. This is the first case in Korea who didn’t undergo splenectomy until grown up, shows cholangitis as a late disease manifestation of hereditary spherocytosis.

Discrepancy between the Actual Clinical Status of Patients with Hepatocellular Carcinoma and Expectations from Hepatocellular Carcinoma Surveillance: a Single-Center Study

BACKGROUND/AIMS: The National Liver Cancer Screening Program (NLCSP) has been implemented for the past 15 years in Korea. However, the actual clinical experience in Korea is inconsistent with the expectations of the hepatocellular carcinoma (HCC) surveillance program. To evaluate the actual clinical situation of HCC diagnoses, we investigated disease severity in patients with HCC and the diagnostic environment. METHODS: From January 2011 to December 2015, all patients who were diagnosed with HCC in a single secondary hospital in Daejeon city were retrospectively enrolled in this study. Severity of HCC was evaluated according to the Barcelona Clinic Liver Cancer (BCLC) staging system. RESULTS: Over the course of 5 years, 298 participants were enrolled. The mean age of participants was 64.0 years. Positive hepatitis B surface antigen was confirmed in 134 patients (45.0%), 35 patients (11.7%) tested positive for anti-hepatitis C virus antibody, and 93 patients (32.2%) had more than 40 g/day of alcohol consumption. The proportions of patients according to BCLC stages were as follows: BCLC-0, 28 patients (9.4%); BCLC-A, 42 patients (14.1%); BCLC-B, 26 patients (8.7%); BCLC-C, 134 patients (45.0%); and BCLC-D, 68 patients (22.8%). The diagnostic environments were as follows: 19 patients were in the NLCSP group (6.4%), 114 in the group with presenting signs (38.3%), 110 in the regular outpatient care group (36.9%), and 55 patients in the incidental diagnosis group (18.5%). CONCLUSIONS: Most patients (67.8%) had advanced stage HCC at diagnosis, and curative treatment was not indicated due to the severity disease. Thus, the actual situation is far worse than the theoretical expectation of HCC surveillance, suggesting that many high-risk patients for HCC are missed in surveillance.

Hepatic Failure Due to Hepatitis E Virus Infection in a Patient with Necrotic Hepatocellular Carcinoma

In patients with hepatocellular carcinoma (HCC) or liver cirrhosis (LC) accompanied by hepatitis E virus (HEV) infection, hepatic failure often leads to debility. Here, we report about a 63-year-old man with alcoholic LC who was referred to our hospital with jaundice and abdominal distension 10 days earlier. Abdominal computed tomography showed necrotic HCC accompanied by left lobe shrinkage without tumor progression. Laboratory and imaging findings revealed no acute infection focus. The patient reported no herbal medicine or alcohol consumption, and there was no evidence of acute viral hepatitis. One month later, HEV immunoglobulin M positivity was confirmed, and deterioration of liver function due to HEV infection was suspected. The patient often ate raw oysters and sashimi, as well as boar meat, which is a well-known risk food for HEV infection. His umbilical hernia deteriorated due to tense ascites and infection by skin abrasion. The patient progressed to hepatorenal syndrome and eventually died. Liver function preservation is important when treating HCC patients. Therefore, clinicians should pay more attention to the prevention of HEV and others causes of direct liver injury.

Selective Biliary Cannulation for a Papilla in the 9 o'clock Position Using Pull and Rotatable Sphincterotome / 대한췌담도학회지

No abstract available.

Acute Pancreatitis in a Pregnant Patient with Type IV Hyperlipoproteinemia / 대한췌담도학회지

Most cases of hypertriglyceridemia (HTG)-induced gestational pancreatitis occur when a person with hyperlipidemia is overweight due to pregnancy or has secondary triggers associated with triglycerides (TGs). In Korea, 6 cases of HTG-induced gestational pancreatitis have been reported, but none of the affected patients had TG levels below 1,000 mg/dL. A 36-year-old female at 30 weeks of gestation was admitted due to pain in her upper abdomen. Initial biochemical analysis revealed a TG level of 260 mg/dL, an amylase level of 2,951 U/L and a lipase level of 3,500 U/L. Abdominal ultrasonography showed pancreatic swelling with a hypoechogenic rim. After several days, the patient was discharged and had a normal delivery at 38 weeks of gestation. This case report is the first to describe acute pancreatitis occurring in the presence of type IV hyperlipoproteinemia even though the TG level was less than 500 mg/dL, contrary to findings in previously reported cases.

Common Bile Duct Stone Removal with Side-viewing Duodenoscope after Forward-Viewing Endoscope-Guided Pancreatic Stent Insertion in a Patient with Periampullary Diverticulum / 대한췌담도학회지

No abstract available.

First Report of Clavinema mariae (Nematoda: Philometridae) in Cultured Rockfish, Sebastes schlegeli, in Cheonsuman (Bay), the Republic of Korea

In July 2012, philometrid nematodes were discovered in cultured rockfish (Sebastes schlegeli) in Cheonsuman (Bay), the Republic of Korea. The nematodes were detected in the epithelial tissues of the rockfish and were identified as Clavinema mariae based on morphological studies using light and scanning electron microscopy. They revealed the characteristics same as previously identified C. mariae, notably having a long body with narrow posterior half, no caudal projection, a cylindrical-shaped esophagus, a well-developed anterior bulbous part of the esophagus, cephalic papillae, and a dorsal esophageal gland. This is the first confirmation of C. mariae infection in rockfish in Korea.

Effectiveness of cholangioscopy using narrow band imaging for hepatobiliary malignancies

PURPOSE: Recently, cholangioscopy using narrow band imaging (NBI) has been used as a diagnostic modality for better visualization in hepatobiliary malignancies; however, there are few reports on it. Our aim is to evaluate the effectiveness of cholangioscopy using NBI in hepatobiliary malignancies. METHODS: Between January 2007 and December 2016, 152 cholangioscopies using percutaneous approach were conducted in total 123 patients. Among these, 36 patients were suspicious of hepatobiliary malignancies. Thirteen patients with an ambiguous margin on endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP), for whom NBI tipped the balance in diagnosis of lesion and decision of lesion extent by adding NBI, were involved in our study. RESULTS: Underlying diseases were all malignant in 13 patients (11 bile duct cancers, 1 liver cancer, 1 pancreas cancer with common bile duct invasion). In 7 cases with papillary type tumor, minute superficial spreading tumor was detected by NBI more easily, and NBI provided a better visualization of tumor vessel and margin evaluation in 4 cases with infiltrative tumor. In 2 cases with mucin-hypersecreting tumor, NBI showed better penetration through the mucin and gave us a much clearer image. Nine patients ultimately underwent surgical resection. The margins predicted by NBI cholangioscopy were consistent with the pathological margins on the resected specimens. CONCLUSION: In conclusion, cholangioscopy using NBI is very useful for evaluation of suspected hepatobiliary malignancies with an ambiguous margin on ERCP or MRCP. It can give us an accurate pathologic mapping, and this information seems to be essential before deciding on a treatment strategy.

High-Grade Mixed Adenoneuroendocrine Carcinoma in the Cecum: A Case Report

Gastrointestinal neoplasms with an exocrine and a neuroendocrine component are rare. Such neoplasms are called “mixed adenoneuroendocrine carcinomas” (MANECs) according to the most recent World Health Organization classification of gastrointestinal tract neoplasms. MANECs have no specific findings that distinguish them from pure adenocarcinomas. In addition, the optimal management strategy of MANECs is largely unknown. We describe the case of a 32-year-old man with dizziness and abdominal bloating. A cecal mass was suspected based on an image study done at a local clinic. We evaluated the cecal mass by using colonoscopy, contrast enhanced computed tomography of the abdomen, positron emission tomography-computed tomography, and laboratory studies. The patient underwent a right hemicolectomy and adjuvant chemotherapy. The final histopathological diagnosis was a high-grade MANEC of the ascending colon, tumor stage T3N2M0.

ERCP and Direct Cholangioscopy with Gastroscope in Patients with Ectopic Opening of the Bile Duct into the Duodenal Bulb: A Report of 3 Cases / 대한췌담도학회지

Ectopic openings of the common bile duct into the duodenal bulb, which are associated with biliary tract disease or recurrent/refractory duodenal ulcers, are rare. We report three such cases, all of which were documented with gastroscope, and two of which were managed with endoscopic retrograde cholangiopancreatography (ERCP) via gastroscope. We suggest that ERCP can be performed with gastroscope, since it may offer a better working position in certain cases.

A Case of Metastatic Renal Cell Carcinoma Bleeding of the Pancreas Manifesting As Cholangitis / 대한췌담도학회지

Renal cell carcinoma (RCC) is the second most common urological malignancy and it has diverse range of clinical manifestation. One third of the patients show the metastasis at the time of the diagnosis. The common sites of metastasis are the lung, bone, lymph nodes and metastasis to the pancreas is rare. In case of pancreatic metastasis, more than half of the patients are asymptomatic. Patients with symptoms visit hospital complaining of abdominal pain, weight loss, steatorrhea and rarely biliary obstruction. Although about 40% of all patients visit hospital with hemorrhage, cholangitis caused by spontaneous pancreatic hemorrhage is rare. We report an interesting case of 61-year-old woman with cholangitis caused by bleeding due to pancreatic metastasis from renal cell carcinoma.

A case of variceal bleeding from the jejunum in liver cirrhosis

While esophagogastric varices are common manifestations of portal hypertension, variceal bleeding from the jejunum is a rare complication of liver cirrhosis. In addition, ectopic variceal bleeding occurs in the duodenum and at sites of previous bowel surgery in most cases, including of stomas. We report a case of obscure overt gastrointestinal bleeding from jejunal varices in a 55-year-old woman who had not previously undergone abdominal surgery, who had liver cirrhosis induced by the hepatitis C virus. Emergency endoscopy revealed the presence of esophageal varices without stigmata of recent bleeding, and no bleeding focus was found at colonoscopy. She continued to produce recurrent melena with hematochezia and received up to 21 units of packed red blood cells. CT angiography revealed the presence of jejunal varices, but no active bleeding was found. Capsule endoscopy revealed fresh blood in the jejunum. The patient submitted to embolization of the jejunal varices via the portal vein, after which she had a stable hemoglobin level and no recurrence of the melena. This is a case of variceal bleeding from the jejunum in a liver cirrhosis patient without a prior history of abdominal surgery.

Effect of simultaneous therapy of arthrocentesis and occlusal splints on temporomandibular disorders: anterior disc displacement without reduction

OBJECTIVES: This study sought to evaluate the effect of simultaneous application of arthrocentesis and occlusal splint. MATERIALS AND METHODS: A retrospective study of 43 patients (3 males, 40 females) whose symptoms had improved was conducted at the Department of Oral and Maxillofacial Surgery, Dong-A University Hospital between 2008 and 2010. Subjects were divided into three groups: Group A (17 patients with arthrocentesis and occlusal splints simultaneously applied), Group B (13 patients whose symptoms did not improve with occlusal splints, undergoing arthrocentesis after occlusal splint use for 8 weeks), and Group C (13 patients that only used occlusal splints). We compared these groups in maximum comfortable opening (MCO) and the visual analogue scale of pain and noise. Follow-up was performed at 1 week, 1 month, 3 months, and 6 months. RESULTS: The improvement of symptoms was noted in all three groups, but Group A had a quicker improvement than the other groups, in terms of pain reduction and MCO increases. CONCLUSION: The simultaneous application of arthrocentesis and occlusal splints can reduce patient discomfort more quickly.

Effect of simultaneous therapy of arthrocentesis and occlusal splints on temporomandibular disorders: anterior disc displacement without reduction

OBJECTIVES: This study sought to evaluate the effect of simultaneous application of arthrocentesis and occlusal splint. MATERIALS AND METHODS: A retrospective study of 43 patients (3 males, 40 females) whose symptoms had improved was conducted at the Department of Oral and Maxillofacial Surgery, Dong-A University Hospital between 2008 and 2010. Subjects were divided into three groups: Group A (17 patients with arthrocentesis and occlusal splints simultaneously applied), Group B (13 patients whose symptoms did not improve with occlusal splints, undergoing arthrocentesis after occlusal splint use for 8 weeks), and Group C (13 patients that only used occlusal splints). We compared these groups in maximum comfortable opening (MCO) and the visual analogue scale of pain and noise. Follow-up was performed at 1 week, 1 month, 3 months, and 6 months. RESULTS: The improvement of symptoms was noted in all three groups, but Group A had a quicker improvement than the other groups, in terms of pain reduction and MCO increases. CONCLUSION: The simultaneous application of arthrocentesis and occlusal splints can reduce patient discomfort more quickly.

A Patient with Distinct Evidences of Spontaneous Regression and Recurrence of Gastric Cancer for 13 Years

Spontaneous regression (SR) of malignancy is a rare phenomenon, especially in patients with gastric cancer. A 77-year-old male, who was already diagnosed with gastric adenocarcinoma by endoscopic biopsy from a private clinic, was referred to our hospital. Despite our strong recommendation, the patient refused surgical therapy. A follow-up endoscopy was performed 3 months later, which revealed that the ulcer had changed into a white scar. Endoscopic biopsy revealed only chronic inflammation. Two and 6 years later, cancer recurred, and SR was confirmed both times, histologically, at the gastric body. The patient is still alive without any gastrointestinal symptoms after 13 years of follow-up. The cause of SR is yet uncertain and there are only a few suggestions of scientific mechanisms. We, herein, report this very rare case of repeated recurrence and SR of gastric cancer without clear cause.

Occurrence of Intestinal Pseudo-obstruction in a Brainstem Hemorrhage Patient

Intestinal pseudo-obstruction is a massive colonic dilation with signs and symptoms of colonic obstruction, but without a mechanical cause. A 49-year-old female patient complained of nausea, vomiting, and abdominal distension 1 month after a massive brainstem hemorrhage. No improvement was seen with conservative treatments. An extended-length rectal tube was inserted to perform glycerin enema. In addition, bethanechol (35 mg per day) was administered to stimulate colonic motility. The patient's condition gradually improved over a 2-month period without any surgical intervention. Extended length rectal tube enema and bethanechol can be used to improve intestinal pseudo-obstruction in stroke patients.

The Use of Gabexate Mesylate and Ulinastatin for the Prevention of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis

BACKGROUND/AIMS: Acute pancreatitis is a common complication of endoscopic retrograde cholangiopancreatography (ERCP). Only a few pharmacologic agents have been shown to have potential efficacy for the prophylactic treatment of post-ERCP pancreatitis (PEP). The aim of this study was to determine whether prophylactic gabexate and ulinastatin can decrease the incidence of PEP. METHODS: From January 2005 to April 2010, 1,679 patients undergoing ERCP treatment were consecutively enrolled in the study. After selective exclusion, a total of 1,480 patients were included in the analysis. The patients were separated into 3 groups according to the prophylactic administration of gabexate (593 patients), ulinastatin (229 patients), or saline solution (658 patients) and analyzed retrospectively. The primary outcome measurements were the incidence of pancreatitis and hyperamylasemia. RESULTS: PEP occurred in 21 of the 593 (3.5%) patients who received gabexate, 16 of the 229 (7.0%) patients who received ulinastatin, and 48 of the 658 (7.3%) patients who received a saline solution. The incidence of PEP was significantly different between the gabexate and ulinastatin or saline solution groups (p<0.05). CONCLUSIONS: Gabexate prophylaxis is effective in preventing PEP. However, there is no difference in the beneficial effects of the prophylactic administration of ulinastatin and a saline solution.

Typhoid Fever Complicated by Intussusception, Splenic Infarction, and Hepatitis

Salmonella typhi infections usually manifest with high fever and gastrointestinal symptoms, however, occurrence of severe complications in other organs, such as pneumonitis, bronchitis, hepatitis, nephritis, encephalitis, and osteomyelitis, is possible. Although common surgical complications include ileal perforation and gastrointestinal haemorrhage, few cases of intussusception have been reported. Splenic infarction is another uncommon complication. In this report, we present a case of typhoid fever complicated with simultaneous small bowel intussusception and splenic infarction. A 27-year-old male patient with no previous history of interest underwent examination for fever, acute abdominal pain, and watery diarrhea of seven days duration. Findings on the initial examination indicated fever of 39.1degrees C, a distended abdomen with direct and rebound tenderness of diffuse localization, and rigidity. Abdominal computed tomography showed hepatomegaly, multiple lymphadenopathies, multiple segmental splenic infarctions, and small bowel ileus with intussusception, however, findings from the small bowel enema study showed spontaneous resolution of the intussusception. Despite antibiotic therapy, abdominal symptoms continued, therefore, the patient underwent exploratory laparotomy with suspicion of intestinal perforation. Surgical findings included multiple enlarged lymphadenopathies and coarse appearance of the liver, but no perforation was found. Results of the Widal test showed positivity for flagellar (H), somatic (O) and A antigens (1:640 dilutions each). Blood cultures showed Salmonella typhi. lymph nodes and biopsy showed mesenteric lymphadenitis, with enlarged lymph nodes due to distension of the sinusoids by macrophages, which showed erythrophagocytosis and tingible bodies. In addition, liver biopsy showed a granulomatous aggregate comprised of macrophages with an epithelioid configuration. After intravenous administration of antibiotics, the patient showed progressive improvement and was discharged for outpatient department follow up.