Peritonitis Caused by Internal Migration of the Percutaneous Transhepatic Biliary Drainage Catheter / 대한췌담도학회지

Percutaneous transhepatic biliary drainage (PTBD) is a modality that is used to decompress obstructive jaundice due to impacted stones, benign stricture or cancer. The PTBD catheter is removed percutaneously after the restoration of internal biliary drainage. We experienced a case of a 62-year-old man with peritonitis due to the migration of the PTBD catheter into the peritoneal cavity; we successfully removed it using peroral endoscopy. Although rare, the PTBD catheter may migrate into the peritoneal cavity during the removal of it. In these cases, clinicians should consider the peroral endoscopic removal of the PTBD catheter.

A Case of Cytomegalovirus-associated Giant Gastric Ulcer in a Patient Who Healed by Discontinuing Immunosuppressive Therapy

Cytomegalovirus (CMV) is not a rare infection and is frequently observed in immuoncompromised patients. CMV infection is usually asymptomatic in immunocompetent patients however it can be a major cause of morbidity and mortality in immunocompromised patients. The diagnosis of CMV gastric ulcer is not easy because of the absence of characteristic endoscopic features and the difficulty in the identification of infection by routine histologic examinations. We experienced a case of CMV-associated giant gastric ulcer in a patient receiving immunosuppressive therapy. She was a 45-year-old woman with dermatomyositis and had received steroid therapy to control her disease. Epigastric pain developed during therapy and upper endoscopy revealed a gastric ulcer. Despite proton pump inhibitor therapy, her epigastric pain aggravated and follow-up endoscopy revealed a huge gastric ulcer approximately 10 cm in diameter. Histologic findings showed intracellular inclusion bodies after immunostaining which confirmed CMV-associated gastric ulcer. Steroid therapy was discontinued and she received proton pump inhibitors without antiviral agents. Her symptoms improved and follow-up endoscopy revealed successful healing of the CMV-associated gastric ulcer. If an unusual gastric ulcer develops in the immunocompromised patients, CMV gastric ulcer should be suspected and examination for inclusion bodies using CMV immunostaining should be considered.

A Case of Recurrent Liver Abscess Due to Choledochoduodenal Fistula / 영남의대학술지

Cholelithiasis, duodenal ulcer, duodenal perforation and tumor invasion may lead to choledochoduodenal fistula (CDF). CDF often has no specific symptoms and may be incidentally detected in an upper gastrointestinal radiographic study or endoscopy; but in some cases, it may be accompanied by recurrent cholangitis and liver abscess. In this paper, a case of recurrent liver abscess caused by CDF is reported. A 62-year-old female was admitted to the authors' hospital because of right upper quadrant pain and fever. The abdominal computed tomography showed a liver abscess in the right lobe. A duodenal fistulous orifice was detected with endoscopy, and a contrast was injected through the duodenal orifice using a catheter under fluoroscopy. The injection of the contrast revealed a fistulous track between the duodenal bulb and the common hepatic duct. In fistulas complicated by recurrent liver abscess, surgery or medical management may be needed. The CDF in this case study was treated via endoscopic clipping.

Migration of a Biliary Self-Expanding Metal Stent into the Stomach after Stent Placement in a Patient with Periampullary Cancer / 대한소화기내시경학회지

Migration of a biliary self-expanding metallic stent (SEMS) may occur proximally or distally after placing a stent for the palliative treatment of patients with unresectable periampullary malignancy. However, migration of a biliary SEMS into the stomach has not yet reported in the English medical literature. Herein we report on a case of periampullary cancer for which a stent that was placed to treat this malady migrated into the stomach. A biliary SEMS had been placed in the distal common bile duct in an 82-year-old woman who was diagnosed with periampullary cancer. The abdominal CT and esophagogastroduodenoscopic findings disclosed that the biliary SEMS had migrated into the stomach and there was marked luminal narrowing of the second portion of the duodenum due to the enlarged periampullary tumor. The migrated stent was easily removed by using a polypectomy snare. We presume that the distally migrated SEMS might have moved into the stomach against the normal direction of peristaltic movement instead of migrating to the intestine because of the duodenal obstruction caused by the growing mass.

A case of bronchus-associated lymphoid tissue (BALT) lymphoma in the patient with rheumatoid arthritis / 대한내과학회지

Bronchus-associated lymphoid tissue (BALT) lymphoma is a rare disorder and it is a characteristic subgroup of low-grade B-cell extranodal non-Hodgkin's lymphoma that is classified as marginal zone lymphoma. We report here on a patient with rheumatoid arthritis who developed BALT lymphoma. She had no pulmonary symptoms and the pulmonary nodules were incidentally detected by routine chest radiography. Chest CT showed a 2.8cm sized ill-defined focal consolidation of homogenous attenuation in the posterobasal segment of the right lower lobe. The histological diagnosis from the wedge resection specimen revealed low grade B cell lymphoma of BALT. To the best of our knowledge, this case is the first to report BALT lymphoma that developed in a Korean patient with rheumatoid arthritis. BALT lymphoma should be included in the differential diagnosis of the pulmonary nodules in patients with rheumatoid arthritis.

The role of the PET-CT in staging of lung cancer / 대한내과학회지

BACKGROUND: PET-CT can provide both a physiological and anatomical image with the benefits of both PET and CT scanners. This may improve the accuracy of a diagnosis of a mediastinal lymph node metastasis. The aims of this study were to compare PET-CT versus CT on the nodal staging of lung cancer and to determine if it could be used to avoid an invasive diagnostic examination. The benefit of the additional PET-CT as preoperative evaluation of the lung cancer was also assessed. METHODS: The results of CT and PET-CT scanning in 22 patients with a proven non-small cell lung cancer (NSCLC) were correlated with the pathological findings of lymph node sampling using mediastinoscopy or surgery. RESULTS: The sensitivity, specificity, accuracy, positive and negative predictive values of CT for detecting metastatic lymphadenopathy were 44%, 77%, 64%, 57%, and 67%, respectively. For PET-CT, these were 78%, 92%, 86%, 88%, and 86%, respectively. The earlier detection of a bone metastasis was obtained by PET-CT in 3 cases, which was not detected in bone scan. CONCLUSIONS: Better results for nodal staging and higher negative-predictive values by PET-CT (than CT) can avoid the need for invasive mediastinal staging of the lung cancer with negative mediastinal lymph node metastasis. An additional histological evaluation by mediastinoscopy needs to be done when positive findings are detected by PET-CT. PET-CT is also helpful in detecting a distant metastasis and avoiding unnecessary surgery. More accurate diagnostic staging can be expected using the simultaneous execution of PET-CT with a conventional preoperative evaluation of lung cancer.

Decreased Protein S Activity Related to the Disease Activity of Behcet's Disease / 대한류마티스학회지

OBJECTIVE: To see whether the active inflammation in Behcet's disease (BD) can cause thrombotic disorders by decreasing the protein S activity (PSA), we evaluated the relationship between PSA decrease and disease activity of BD. METHODS: We included 122 patients with BD whose PSAs were measured between August 1998 and April 2005. In 51 BD patients, the PSA was measured again when there were changes in the number of items of "The Behcet's Disease Current Activity Form (BDCAF)". RESULTS: Thrombosis rate was 2.5% (3/122), and the PSA was low in all 3 of the patients. The incidence of low PSA in total 122 BD patients was 27% (33/122). The incidence of low PSA in active BD patients was 33.7% (31/92), and it was significantly more frequent in active BD patients than in inactive patients, 6.7% (2/30) (chi2-test, p value=0.0038). The decrease of PSA had good correlation with the number of BDCAF items (r=-0.351, p=0.012). CONCLUSION: The PSA decrease is related to the disease activity of BD. PSA could be not only the risk factor for thrombotic disorder but also the activity marker for the BD and other inflammatory diseases.