A Case of de novo MPO-associated Central Nervous System Vasculitis Following Heterogeneous mRNA1273 COVID-19 Booster Vaccination

The coronavirus disease-19 (COVID-19) pandemic leaded to inevitable expeditious vaccine rollout without sufficient safety profile. Especially, severe acute respiratory syndrome coronavirus 2 infection has known to induce overreacted immune responses such as releasing of proteinase-3 and myeloperoxidase (MPO) by neutrophil. This overreacted immune response leads to the concern of the development of autoimmune diseases after COVID-19 vaccination. We report the case of de novo MPO-associated systemic vasculitis involving central nervous system following heterogeneous mRNA1273 COVID-19 booster vaccination.

Guidewire Impaction in the Main Pancreatic Duct in a Patient with Chronic Pancreatitis:A Case Report / 대한소화기학회지

The guidewire is an essential accessory in ERCP. Although rare, guidewires can cause complications, such as subcapsular hepatic hematoma, perforation, knotting, fracture, and impaction, during ERCP. This report describes a guidewire impaction during the endoscopic treatment of a patient with symptomatic chronic pancreatitis. The methods used to treat guidewire impaction are not well known. In the present case, the impacted guidewire was retrieved by inserting another guidewire and dilating the space adjacent to it. Endoscopists should check for the free movement of the guidewire before stent deployment. Additionally, it is important to ask for help from experienced senior staff to overcome any challenges during the procedure. In conclusion, endoscopists should be aware of the possibility of a guidewire impaction during ERCP.

Undifferentiated Pancreatic Carcinoma with Osteoclast-like Giant Cells: A Case Report / 대한췌담도학회지

Undifferentiated pancreatic carcinoma with osteoclast-like giant cells (UC-OGC) is uncommon, accounting for only 1% of all pancreatic carcinomas. We report a case of a 39-year-old man with undifferentiated pancreatic carcinoma with osteoclast-like giant cells who underwent successful surgical resection and chemotherapy.

Acute Abdominal Pain due to Accessory Splenic Infarction in an Adult: A Case Report / 대한소화기학회지

Accessory spleens are common congenital anatomic variations that are usually asymptomatic. On the other hand, they can be clinically significant if complicated by hemorrhage, torsion, or infarction. This paper describes a case of an infarcted accessory spleen in a 30-year-old male who presented with abdominal pain. Abdominal CT and MRI revealed an isolated mass, 4.5 cm in size, in the perisplenic area. An infarcted accessory spleen was suspected. The patient underwent laparoscopic accessory splenectomy. Histopathology identified the mass as splenic tissue that had undergone ischemic necrosis. A definitive diagnosis of an infarcted accessory spleen was made, and the patient was discharged on day 5 after surgery symptom-free.

Acute Abdominal Pain due to Accessory Splenic Infarction in an Adult: A Case Report / 대한소화기학회지

Accessory spleens are common congenital anatomic variations that are usually asymptomatic. On the other hand, they can be clinically significant if complicated by hemorrhage, torsion, or infarction. This paper describes a case of an infarcted accessory spleen in a 30-year-old male who presented with abdominal pain. Abdominal CT and MRI revealed an isolated mass, 4.5 cm in size, in the perisplenic area. An infarcted accessory spleen was suspected. The patient underwent laparoscopic accessory splenectomy. Histopathology identified the mass as splenic tissue that had undergone ischemic necrosis. A definitive diagnosis of an infarcted accessory spleen was made, and the patient was discharged on day 5 after surgery symptom-free.

Low-level viremia and cirrhotic complications in patients with chronic hepatitis B according to adherence to entecavir

Background/Aims@#Low-level viremia (LLV) after nucleos(t)ide analog treatment was presented as a possible cause of hepatocellular carcinoma (HCC) in patients with chronic hepatitis B (CHB). However, detailed information on patients’ adherence in the real world was lacking. This study aimed to evaluate the effects of LLV on HCC development, mortality, and cirrhotic complications among patients according to their adherence to entecavir (ETV) treatment. @*Methods@#We performed a retrospective observational analysis of data from 894 consecutive adult patients with treatment-naïve CHB undergoing ETV treatment. LLV was defined according to either persistent or intermittent episodes of <2,000 IU/mL detectable hepatitis B virus DNA during the follow-up period. Good adherence to medication was defined as a cumulative adherence ≥90% per study period. @*Results@#Without considering adherence in the entire cohort (n=894), multivariate analysis of the HCC incidence showed that LLV was an independent prognostic factor in addition to other traditional risk factors in the entire cohort (P=0.031). Good adherence group comprised 617 patients (69.0%). No significant difference was found between maintained virologic response and LLV groups in terms of the incidence of liver-related death or transplantation, HCC, and hepatic decompensation in good adherence group, according to multivariate analyses. @*Conclusions@#In patients with treatment-naïve CHB and good adherence to ETV treatment in the real world, LLV during treatment is not a predictive factor for HCC and cirrhotic complications. It may be unnecessary to adjust their antiviral agent for patients with good adherence who experience LLV during ETV treatment.

Is screening and surveillance for early detection of gastric cancer needed in Korean Americans?

The incidence rate of gastric cancer in Korean Americans is over five times higher than that in non-Hispanic whites, and is similar to the incidence of colorectal cancer in the overall United States population. In Korea, the National Cancer Screening Program recommends endoscopy or upper gastrointestinal series for people aged 40 years and older every 2 years. However, the benefit of gastric cancer screening in Korean Americans has not been evaluated. Based on epidemiologic studies, Korean Americans appear to have more similar gastric cancer risk factors to Koreans as opposed to Americans of European descent, though the risk of gastric cancer appears to decrease for subsequent generations. Therefore, in accordance with recent recommendations regarding screening for gastric cancer in Korea, endoscopic screening for gastric cancer in Korean Americans should be considered, especially in those with known atrophic gastritis/intestinal metaplasia or a family history of gastric cancer. In the future, additional studies will needed to assess whether a screening program for gastric cancer in Korean Americans will result in a survival benefit.

Comparison of Laparoscopic and Open Distal Pancreatectomy with Focus on the Development of Postoperative Pancreatic Fistula / 대한내시경복강경외과학회지

PURPOSE: To assess the technical feasibility of laparoscopic distal pancreatectomy (LDP) focusing on the development of postoperative complications including pancreatic fistula (POPF). METHODS: From March 2001 to April 2010, 57 patients underwent a distal pancreatectomy. The patients were divided into two groups, LDP group (L group, n=15) and open distal pancreatectomy group (O group, n=42). The clinicopathological characteristics, surgical variables and postoperative outcomes of these 2 groups were compared retrospectively. RESULTS: Patients with a malignancy constituted 7% of the L group and 31% of the O group (p=0.084). The tumor size was significantly larger in the O group (2.6 vs. 5.3 cm). The body mass index (BMI) was significantly higher in the L group (24.9 vs. 22.9 kg/m2). One case of a pancreas pseudocyst in the L group was converted to open surgery due to intraoperative bleeding. The L group showed significantly less intraoperative bleeding, earlier start of solid meals and shorter hospital stay. There was no significant difference in the incidence of postoperative complications and POPF between the 2 groups. POPF of ISGPF grade B developed in 0 and 2 patients in the L group and O group, respectively. One intestinal obstruction and 1 fluid collection that required intervention was encountered in the O group. One patient with adenocarcinoma who underwent LDP was alive 25 months after surgery without recurrence. CONCLUSION: LDP provides the advantages of minimal access surgery with a comparable rate of POPF to ODP. LDP is considered suitable for benign and borderline-malignant pancreatic lesions.

Pancreatic cystic lesion-Surgery or follow-up evaluation / 대한내과학회지

The decision of surgical treatment for pancreatic cystic lesions may mainly depend on the malignant potential of each lesion. Surgical excision is the most optimal treatment for the mucinous cystic neoplasm due to its high malignant potential. On the other hand, intraductal papillary mucinous neoplasm (IPMN) is divided into main duct type and branch-duct type. Main duct IPMN has high risk of malignant transformation. Therefore, surgical resection has been recommended for all main duct IPMN. Branch duct IPMN has relatively low malignant potential, and usually shows slow progression. A branch duct IPMN that is asymptomatic, less than 3 cm in size and without mural nodules may be followed-up without resection. Serous cystic neoplasm is usually benign in nature. Surgical treatment for serous cystic neoplasm should be considered when definitive diagnosis being uncertain, larger than 4 cm in size, or presence of symptoms. Solid pseudopapillary neoplasm also has low malignant potential which needs surgical excision. Surgical treatment for pancreatic pseudocyst is considered in limited cases with complication, such as infection or bleeding, and which is not controlled with non-surgical treatment. Management strategy for pancreatic cystic lesions should be individualized, and the decision to resect or follow-up a lesion should be based on factors such as the presence or absence of symptoms, patient age, cyst size, grading of malignant potential, location of the lesion, and the surgical risk of the patient.

A Case of Aortoesophageal Fistula Complicated by a Stent for Benign Esophageal Stricture / 대한소화기내시경학회지

Self-expandable metallic stents (SEMS) are widely used for the palliative treatment of malignant strictures of the gastrointestinal tract. Recently, several studies tested whether a SEMS is an effective and safe option for benign esophageal stricture. Serious complications such as hemorrhage, compression of the bronchus, bronchoesophageal fistula, and esophageal rupture were infrequently encountered as complications of esophageal stent placement. Aortoesophageal fistula is extremely rare as a complication of esophageal SEMS insertion; only seven cases have been reported worldwide. We now report a case of an 80-year old female with aortoesophageal fistula after placement of a SEMS for an esophageal stricture.

Case Review of Impacted Bile Duct Stone at Duodenal Papilla: Detection and Endoscopic Treatment

PURPOSE: A bile duct stone impacted at the duodenal papilla is an urgent condition that can rapidly lead to either suppurative cholangitis or acute pancreatitis due to almost complete obstruction of the bilio-pancreatic outflow. This study evaluated the clinical characteristics and results of endoscopic treatment for a bile duct stone impacted at the duodenal papilla. MATERIALS AND METHODS: Forty-six patients who had been diagnosed with an impacted papillary stone were retrospectively reviewed. RESULTS: The typical features of acute cholangitis (Charcot's triad) and pancreatitis were only observed only in 10 patients (21.7%) and 17 patients (37.0%), respectively. After the endoscopic retrograde cholangiopancreatography, 30 patients (65.2%) were found to have a solitary stone impacting the duodenal papilla and 16 patients had one or more stones in the bile duct. On the radiological studies, the former patients were associated more commonly with no visible stone or no bile duct dilatation (p < 0.05). All impacted papillary stones were successfully removed by endoscopic sphincterotomy: 23 by a needle knife and 23 by a pull type papillotome. The procedure-related complications (n = 7, 4 bleeding, 3 pancreatitis) were not serious and did not differ, based on endoscopic findings and the procedure used. CONCLUSION: A bile duct stone impacted at the duodenal papilla requires both clinical and radiographic evidence to support the diagnosis. Endoscopic sphincterotomy, either with a needle knife or a pull type papillotome, was safe and effective for removing the impacted papillary stone.

Combined Inferior Vena Cava Resection during Pancreatoduodenectomy

There is no consensus for the surgical indications, as well as the surgical technique, for the treatment of inferior vena cava (IVC) invasion by pancreas head cancer. The authors experienced a case of pancreas head cancer invading the anterior wall of the IVC. We performed en bloc excision of the anterior wall of the IVC combined with pancreatoduodenectomy in this case under the assumption that only a margin-negative surgical resection could offer a chance for cure. Technically, the sequence of dissection and addressing the IVC at the end of dissection are considered to be important to secure the operative field surrounding the IVC and to achieve a margin-negative resection. There has been no recurrence up to now, 8 months after the extensive radical operation.

Combined Inferior Vena Cava Resection during Pancreatoduodenectomy

There is no consensus for the surgical indications, as well as the surgical technique, for the treatment of inferior vena cava (IVC) invasion by pancreas head cancer. The authors experienced a case of pancreas head cancer invading the anterior wall of the IVC. We performed en bloc excision of the anterior wall of the IVC combined with pancreatoduodenectomy in this case under the assumption that only a margin-negative surgical resection could offer a chance for cure. Technically, the sequence of dissection and addressing the IVC at the end of dissection are considered to be important to secure the operative field surrounding the IVC and to achieve a margin-negative resection. There has been no recurrence up to now, 8 months after the extensive radical operation.

A Case of Colonic Duplication Cyst Mimicking Gastrointestinal Stromal Tumor

Duplications of the gastrointestinal tract are rare congenital malformations that are usually present during the first decade of life. However, a smaller number of cases may remain occult until adulthood. Overall, the colon is the least common site of congenital gastrointestinal duplications. Colonic duplications can present with symptoms of diverticulitis and can be confused with acquired giant cysts or masses. We present a rare case of a duplication cyst of the colon in a female adult. Although the preoperative evaluations, including an abdominal CT scan and colonoscopy, were suggestive of a gastrointestinal tumor of the colon, the final diagnosis was a colonic duplication cyst based on the histopathologic examination of the resected specimen. Even if intestinal duplication cysts are uncommon, they should be considered in the differential diagnosis of intestinal masses.

A Case of Cholethorax following Percutaneous Transhepatic Cholangioscopy / 결핵및호흡기질환

Cholethorax (bilious pleural effusion) is an extravasation of bile into the thoracic cavity via a pleurobiliary fistula (and also a bronchobiliary fistula). It is an extremely rare complication of thoraco-abdominal injuries. It can be caused by congenital anomaly and also by hepatobiliary trauma, severe infection or iatrogenic procedures. The definitive diagnosis is made with aspiration of bilious fluid from the pleural space during thoracentesis, by finding a fistulous tract during endoscopic retrograde cholangiopancreatography (ERCP) or cholagioscopy, or with finding an abnormal pleural accumulation of radioisotope during hepatobiliary nuclear imaging. Its symptoms include coughing, fever, dyspnea and pleuritc chest pain. Herein we report on a case of cholethorax following performance of percutaneous transhepatic cholangioscopy (PTCS) to remove incidentally discovered common bile duct (CBD) stones.

Risk Factors for Lymph Node Metastasis after Endoscopic Resection for Early Colorectal Cancer

BACKGROUND/AIMS: Although endoscopic resection is widely used for the treatment of early colorectal cancer, the risk factors for lymph node metastasis are not clear. This study was designed to determine the risk factors for lymph node metastasis in patients with colorectal cancer who are treated by endoscopic resection. METHODS: The medical records of patients with histologically-proven early colorectal cancers who were treated by endoscopic resection between January 2002 and September 2008 were retrospectively reviewed. Information regarding the demographic data of patients and the clinicopathologic characteristics were recorded and analyzed. RESULTS: Twenty-nine patients who underwent subsequent surgical treatment after endoscopic resection for early colorectal cancer were enrolled in this study. Six patients (20.7%) had lymph node metastases on surgical pathologic examination. The predictive factors for lymph node metastasis were tumor morphology (non-polypoid flat tumors [p=0.019]), absence of background adenomas (p=0.033), and deep submucosal invasion > or = 2,000 um (p=0.012). Unexpectedly, the presence of vascular invasion was not associated with lymph node metastasis. CONCLUSIONS: The presence of vascular invasion might not be an absolute indication for additional surgical treatment of early colorectal cancer; however, deep submucosal invasion, accompanied by a gross tumor with a non-polypoid flat morphology, and the absence of background adenomas are potential risk factors for lymph node metastasis.

Hemobilia from Pancreatic Arteriovenous Malformation: Successful Treatment with Transportal Coil Embolization of Draining Veins / 대한소화기학회지

Pancreatic arteriovenous malformations (AVM) are extremely rare diseases frequently complicated by gastrointestinal hemorrhage. While surgical resection of affected lesion is preferred for the treatment of pancreatic AVM, angiographic intervention can be used as an alternative treatment, especially in surgically high-risk patients. We experienced a patient with pancreatic AVM manifested by hemobilia and biliary sepsis. Superior mesenteric and common hepatic arteriography showed pancreaticoduodenal AVM composed of nidus supplied by numerous fine feeding arteries and of draining veins encircling the common bile duct (CBD). Hemobilia was controlled by transportal coil embolization of draining veins of AVM around the CBD. Herein, we report this case with the review of literatures.

An Ampulla of Vater Carcinoid Tumor that Presented with Upper Gastrointestinal Bleeding / 대한소화기내시경학회지

A Carcinoid tumor of the ampulla of Vater is extremely rare, accounting for less than 0.3% of all gastrointestinal carcinoids. Most reported cases have arisen from the gallbladder. An ampullary carcinoid most commonly presents with jaundice or upper abdominal discomfort, and bleeding from the tumor is exceedingly rare. A diagnosis is most frequently made postoperatively due to submucosal spread of the tumor. As the metastatic potential cannot be predicted by tumor size, a Whipple pancreaticoduodenectomy rather than local excision is considered the treatment of choice. We herein report a case of a primary carcinoid tumor located at the ampulla of Vater that presented as gastrointestinal bleeding; the tumor was diagnosed by an endoscopic biopsy after a papillary sphinterotomy.

Clinical Outcomes of Lamivudine Therapy in HBeAg Positive Chronic Hepatitis B with Minimally Elevated ALT / 대한간학회지

BACKGROUND/AIMS: The aim of this study was to compare the efficacy of lamivudine therapy between chronic hepatitis B (CHB) patients, whose ALT levels less than 2 times the upper limit of normal (ULN) and patients whose ALT levels are more than 2 times ULN. METHODS: We retrospectively analyzed 508 consecutive patients with HBeAg-positive CHB who were treated with lamivudine for 1 year or more. Forty-six patients (Group A) with pretreatment ALT levels less than 2 times ULN were retrospectively compared with 462 patients (Group B) whose ALT levels are more than 2 times ULN. RESULTS: HBeAg seroconversion was achieved in 15 (32.6%) of group A and 162 (35.1%) of group B. The cumulative rates of HBeAg seroconversion in group A and B were 19% and 21% at 12 months; 35% and 31% at 24 months; and 38% and 39% at 36 months, respectively. HBV breakthrough was observed in 20 (43.5%) of group A and 192 (41.6%) of group B. The cumulative breakthrough rates of group A and B were 18% and 12% at 12 months; 33% and 29 % at 18 months; 45% and 42% at 24 months, respectively. Post-treatment relapse in group A and B occurred in 56% (5/9) and 41% (44/108), respectively. Therefore, the rates of the HBeAg seroconversion, breakthrough, and post-treatment relapse were not significantly different between these two groups. CONCLUSIONS: Lamivudine therapy in HBeAg-positive CHB patients whose ALT levels are minimally elevated is as effective as in treatment of the patients whose pretreated ALT levels are twice more than ULN.

A Case of Intra-abdominal Desmoid Tumor after Total Colectomy in a Patient with Familial Adenomatous Polyposis / 대한소화기내시경학회지

Familial adenomatous polyposis (FAP) arises from germline mutations of the adenomatous polyposis coli (APC) gene. FAP is characterized by the occurrence of hundreds to thousands of adenomas throughout the colorectum, and there is nearly a 100% risk of colorectal cancer. In addition to polyposis coli, patients with FAP can develop a variety of extracolonic manifestations. Recent advances in screening and surgery have reduced the colon cancer occurrence and death in FAP patients, leaving desmoid tumors as a leading cause of their morbidity and mortality. Treatment of desmoid tumors is generally considered to be challenging for both the doctor and the patient. We report here on an 18 year old man with resectable intra-abdominal desmoid tumor that developed after total colectomy due to FAP and we include a review of the relevant literature.