Determining the etiology of small bowel obstruction in patients without intraabdominal operative history: a retrospective study

Purpose@#Most of the causes of small bowel obstruction (SBO) in patients without a history of abdominal surgery are unclear at initial assessment. This study was conducted to identify the etiology and clinical characteristics of SBO in virgin abdomens and discuss the proper management. @*Methods@#A retrospective review involving operative cases of SBO from a single institute, which had no history of abdominal surgery, was conducted between January 2010 and December 2020. Clinical information, including radiological, operative, and pathologic findings, was investigated to determine the etiology of SBO. @*Results@#A total of 55 patients were included in this study, with a median age of 57 years and male sex (63.6%) constituting the majority. The most frequently reported symptoms were abdominal pain and nausea or vomiting. Neoplasm as an underlying cause accounted for 34.5% of the cases, of which 25.5% were malignant cases. In patients aged ≥60 years (n=23), small bowel neoplasms were the underlying cause in 12 (52.2%), of whom 9 (39.1%) were malignant cases. Adhesions and Crohn disease were more frequent in patients aged <60 years. Coherence between preoperative computed tomography scans and intraoperative findings was found in 63.6% of the cases. @*Conclusion@#There were various causes of surgical cases of SBO in virgin abdomens. In older patients, hidden malignancy should be considered as a possible cause of SBO in a virgin abdomen. Patients with symptoms of recurrent bowel obstruction who have no history of prior abdominal surgery require thorough medical history and close follow-up.

Cancer patients with neutropenic septic shock: etiology and antimicrobial resistance

Background/Aims@#Among patients with febrile neutropenia that developed after chemotherapy, high-risk patients, such as those having clinical instability or Multinational Association of Supportive Care in Cancer score of < 21, require hospitalization for intravenous empiric antibiotic therapy. Monotherapy with an anti-pseudomonal ß-lactam agent is recommended. Although many studies reported the microbial etiology of infections and resistant patterns of febrile neutropenia, the patients were not well characterized as having neutropenic septic shock. Therefore, this study aimed to determine the microbial spectrum of infections and resistance patterns of their isolates in patients with chemotherapy-induced neutropenic septic shock. @*Methods@#Data of adult patients diagnosed with neutropenic septic shock in the emergency department between June 2012 and December 2016 were extracted from a prospectively compiled septic shock registry at a single academic medical center. Thereafter, microbiological studies and antimicrobial susceptibility tests were conducted. @*Results@#In total, 109 bacteria were found in patients with neutropenic septic shock. Gram-negative bacteria were the predominant causative organisms (84, 77.1%). Moreover, 33 microorganisms (30.3%) were multidrug-resistant (MDR) bacteria with extended-spectrum ß-lactamase-producing Escherichia coli (17, 50%) being the commonest. The most commonly affected sites in patients with MDR bacterial infections were the gastrointestinal tract (45%) and unknown (43.5%). Approximately 48.5% of MDR bacteria were resistant to cefepime but not to piperacillin- tazobactam or carbapenem. @*Conclusions@#MDR bacteria were prevalent in patients with chemotherapy-induced neutropenic septic shock. Therefore, piperacillin-tazobactam or carbapenem may be considered as empiric antibiotics if MDR bacteria are suspected to be causative agents.

The Management of Retained Rectal Foreign Body

Purpose@#Because insertion of a foreign body (FB) into the anus is considered a taboo practice, patients with a retained rectal FB may hesitate to obtain medical care, and attending surgeons may lack experience with removing these FBs. We performed this study to evaluate the clinical characteristics of Korean patients with a retained rectal FB and propose management guideline for such cases based on our experience. @*Methods@#We retrospectively investigated 14 patients between January 2006 and December 2018. We assessed demographic features, mechanism of FB insertion, clinical course between diagnosis and management, and outcomes. @*Results@#All patients were male (mean age, 43 years) and presented with low abdominal pain (n = 2), anal bleeding (n = 2), or concern about a retained rectal FB without symptoms (n = 10). FB insertion was most commonly associated with sexual gratification or anal eroticism (n = 11, 78.6%). All patients underwent general anesthesia for anal sphincter relaxation with the exception of 2 who underwent FB removal in the emergency department. FBs were retrieved transanally using a clamp (n = 2), myoma screw (n = 1), clamp application following abdominal wall compression (n = 2), or laparotomy followed by rectosigmoid colon milking (n = 2). Colotomy and primary repair were performed in four patients, and Hartmann operation was performed in one patient with fecal peritonitis. No morbidity or mortality was reported. All patients refused postextraction anorectal functional and anatomical evaluation and psychological counseling. @*Conclusion@#Retained rectal FB is rare; however, colorectal surgeons should be aware of the various methods that can be used for FB retrieval and the therapeutic algorithm applicable in such cases.

Single-Incision, Two-Port Laparoscopic Appendectomy as an Alternative to Transumbilical Single-Port Laparoscopic Appendectomy

PURPOSE: We designed a modified technique to perform an advanced procedure using conventional instruments and did not employ specialized single-incision laparoscopic surgery (SILS) port equipment. We compared postoperative results for transumbilical, single-port laparoscopic appendectomy (TUSPLA) and single-incision, 2-port laparoscopic appendectomy (SITPLA). METHODS: This retrospective study enrolled 77 patients who underwent TUSPLA or SITPLA to provide more minimally invasive surgery between May 2017 and April 2018. TUSPLA was performed in 39 patients and 38 underwent SITPLA. In the SITPLA group, two 5-mm trocars were inserted through the umbilicus and an extra puncture site was used for a left-handed instrument. Demographic characteristics, operative data, and postoperative outcomes were collected and compared between the groups. RESULTS: The mean total operative time in the SITPLA group was shorter than in the TUSPLA group (p=0.003). The mean laparoscopic instrumental time was also shorter (p<0.001) in the SITPLA. The number of postoperative analgesics in the SITPLA group was less than in the TUSPLA group (p=0.002). The length of hospital day after surgery was shorter in the SITPLA group than in the TUSPLA group (p=0.008). There were no other significant differences between the groups. CONCLUSION: SITPLA had a shorter operative time, required less pain management, and had a similar cosmetic outcome when compared with TUSPLA.

Nutritional Therapy Related Complications in Hospitalized Adult Patients: A Korean Multicenter Trial

PURPOSE: Nutritional therapy (NT), such as enteral nutrition (EN) or parenteral nutrition (PN), is essential for the malnourished patients. Although the complications related to NT has been well described, multicenter data on symptoms in the patients with receiving NT during hospitalization are still lacking. METHODS: Nutrition support team (NST) consultations, on which NT-related complications were described, were collected retrospectively for one year. The inclusion criteria were patients who were (1) older than 18 years, (2) hospitalized, and (3) receiving EN or PN at the time of NST consultation. The patients' demographics (age, sex, body mass index [BMI]), type of NT and type of complication were collected. To compare the severity of each complication, the intensive care unit (ICU) admission, hospital stay, and type of discharge were also collected. RESULTS: A total of 14,600 NT-related complications were collected from 13,418 cases from 27 hospitals in Korea. The mean age and BMI were 65.4 years and 21.8 kg/m2. The complications according to the type of NT, calorie deficiency (32.4%, n=1,229) and diarrhea (21.6%, n=820) were most common in EN. Similarly, calorie deficiency (56.8%, n=4,030) and GI problem except for diarrhea (8.6%, n=611) were most common in PN. Regarding the clinical outcomes, 18.7% (n=2,158) finally expired, 58.1% (n=7,027) were admitted to ICU, and the mean hospital days after NT-related complication were 31.3 days. Volume overload (odds ratio [OR]=3.48) and renal abnormality (OR=2.50) were closely associated with hospital death; hyperammonemia (OR=3.09) and renal abnormality (OR=2.77) were associated with ICU admission; “micronutrient and vitamin deficiency” (geometric mean [GM]=2.23) and volume overload (GM=1.61) were associated with a longer hospital stay. CONCLUSION: NT may induce or be associated with several complications, and some of them may seriously affect the patient's outcome. NST personnel in each hospital should be aware of each problem during nutritional support.

Clinical Manifestations of Superior Mesenteric Venous Thrombosis in the Era of Computed Tomography

PURPOSE: Thrombosis of the portal vein, known as pylephlebitis, is a rare and fatal complication caused by intraperitoneal infections. The disease progression of superior mesenteric venous thrombosis (SMVT) is not severe. This study aimed to determine the clinical features, etiology, and prognosis of SMVT. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 41 patients with SMVT from March 2000 to February 2017. We obtained a list of 305 patients through the International Classification of Disease-9 code system and selected 41 patients with SMVT with computed tomography. Data from the medical records included patient demographics, comorbidities, review of system, laboratory results, clinical courses, and treatment modalities. RESULTS: The causes of SMVT were found to be intraperitoneal inflammation in 27 patients (65.9%), malignancy in 7 patients (17.1%), and unknown in 7 patients (17.1%). Among the patients with intraperitoneal inflammation, 14 presented with appendicitis (51.9%), 7 with diverticulitis (25.9%), and 2 with ileus (7.4%). When comparing patients with and without small bowel resection, the differences in symptom duration, bowel enhancement and blood culture were significant (P=0.010, P=0.039, and P=0.028, respectively). CONCLUSION: SMVT, caused by intraperitoneal inflammation, unlike portal vein thrombosis including pylephlebitis, shows mild prognosis. In addition, rapid symptom progression and positive blood culture can be the prognostic factors related to extensive bowel resection. Use of appropriate antibiotics and understanding of disease progression can help improve the outcomes of patients with SMVT.

The Outcomes of Management for Colonoscopic Perforation: A 12-Year Experience at a Single Institute

PURPOSE: Optimal management of colonoscopic perforation (CP) is controversial because early diagnosis and prompt management play critical roles in morbidity and mortality. Herein, we evaluate the outcomes and clinical characteristics of patients with CP according to treatment modality to help establish guidelines for managing CP. METHODS: Our retrospective analysis included 40 CP patients from January 1, 2003, to December 31, 2014. Patients with CP were categorized into 2 groups according to therapeutic modality: operation (surgery) and nonoperation (endo-luminal clip application or conservative treatment) groups. RESULTS: The postoperative morbidity rate was 40%, and no mortalities were noted. The incidence of abdominal pain and tenderness in patients who received only conservative management was significantly lower than in those who underwent surgery (P < 0.001 and P = 0.004, respectively). Patients tended to undergo surgery more often for diagnosis times longer than 24 hours and for diagnostic CPs. The mean hospital stays for the operation and nonoperation groups were 14.6 ± 7.77 and 5.9 ± 1.62 days, respectively (P < 0.001). Compared to the operation group, the nonoperation group began intake of liquid diets significantly earlier after perforation (3.8 ± 1.32 days vs. 5.6 ± 1.25 days, P < 0.001) and used antibiotics for a shorter duration (4.7 ± 1.29 days vs. 8.7 ± 2.23 days, P < 0.001). CONCLUSION: The time of diagnosis and the injury mechanism may be useful indications for conservative management. Nonoperative management, such as endo-luminal clip application, might be beneficial, when feasible, for the treatment of patients with CP.

Clinical Course of Three Cases of Pneumatosis Intestinalis / 대한소화기학회지

Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by multiple gas-filled cysts of varying size in the wall of gastrointestinal tract. PCI may idiopathic or secondary to various disorders. The etiology and pathogenesis of PCI are unclear. Treatment is usually conservative, and includes oxygen and antibiotics therapy. Surgery is reserved for cases of suspected inconvertible intestinal obstruction or perforation. Eleven patients who were diagnosed with PI between 2005 and 2015 were reviewed. We report three cases of PCI and describe causes and complications. The most important point in the treatment of PCI is to determine whether the patient needs surgery. Conservative care should be considered first if the patient is stable. If any complication is observed, such as ischemia in the intestine, surgery is needed. It is important to choose the best treatment based on prognostic factors and CT findings.

A Case of Bilateral Vocal Fold Paralysis Induced by Concurrent Rheumatoid Arthritis Involvement of Laryngeal Nerve and Cricoarytenoid Joint

Rheumatoid arthritis (RA) is a connective tissue disease involving the larynx in 30% of the patients. Foreign body sensation, hoarseness, and cough are common symptoms in laryngeal involvement. An urgent tracheostomy is required when acute airway obstruction occurs in case of bilateral vocal fold paralysis. The most common cause of bilateral vocal fold paralysis in RA patients is a cricoarytenoid joint arthritis. Laryngeal nerve degeneration is rare cause of bilateral vocal fold paralysis in RA patients. In this case report, an emergent tracheostomy was performed on a 64-years-old male patient with acute dyspnea, and concurrent involvement of RA on laryngeal nerve and cricoarytenoid joint was revealed by laryngeal electromyography and histopathology. The vocal fold mobility was restored after 3-months medical treatment.

Diabetic Neuropathic Cachexia in a 50-Year-Old Woman with Type 2 Diabetes: First Case Report in Korea / 임상당뇨병

Diabetic neuropathic cachexia (DNC) is one of the rarest presentations of diabetic neuropathy associated with profound weight loss. A 50-year-old Korean woman with poorly controlled type 2 diabetes complained of intractable pain in the trunk and lower extremities, and total body weight loss of 17% over a 6 month period. The patient's symptoms persisted after glucose control and various medications for neuropathic pain. A diagnosis of DNC was made based on the rapid onset of severe pain, polyneuropathy, and marked weight loss without evidence of end organ disease other than mild retinopathy, and the exclusion of other possible causes. Spontaneous improvement of the patient's neuropathic pain and gradual weight gain occurred after 6 months of supportive care. Since the original report of DNC, 31 cases have been published in the English-language literature; however, ours is the first reported case in Korea. Clinicians must be aware of this debilitating complication of diabetes because of its severity and rapid progression.

A Case of Paroxysmal Atrial Fibrillation and Sinus Bradycardia due to Coronary Artery Spasm / 대한내과학회지

Paroxysmal atrial fibrillation may be induced by coronary spasm presenting with typical angina-like pain and palpitations. It is typically treated using rate or rhythm control strategies, although sustained coronary spasm can induce sinus bradycardia with dizziness and syncope. In the present case, we reached a diagnosis of paroxysmal atrial fibrillation and sinus bradycardia due to coronary artery spasm using the methyl-ergonovine provocation test during angiography. While the treatment of coronary spasm can resolve paroxysmal atrial fibrillation, sinus bradycardia, and variant angina, the mechanism remains unclear, although it may be associated with sinus node ischemia. Similar symptoms, particularly chest discomfort, should be carefully considered in cases of paroxysmal atrial fibrillation.

Henoch-Schonlein purpura secondary to infective endocarditis in a patient with pulmonary valve stenosis and a ventricular septal defect

No abstract available.

Erratum: A case of Wegener's granulomatosis mimicking recurrent hemophagocytic lymphohistiocytosis

In the article cited above, Fig. 3 was input incorrectly.

Relapsed Esophageal Web in a Patient with Plummer-Vinson Syndrome

Plummer-Vinson syndrome is characterized by dysphagia, iron deficiency anemia, and upper esophageal web. The associated symptoms can be resolved by administering iron supplements as well as by endoscopic intervention. Relapse in patients with Plummer-Vinson syndrome is very rare. We describe a case of a 42-year-old woman with Plummer-Vinson syndrome whose symptoms were successfully treated with endoscopic dilatation and iron supplementation at first admission; however, 1 year later, she revisited our hospital because of dysphagia. On second admission, investigations revealed esophageal web relapse in Plummer-Vinson syndrome. She was again successfully treated with endoscopic dilatation and iron supplementation. After first admission, her anemia was not normalized due to poor compliance and loss of follow-up. We experienced a case of esophageal web relapse due to uncorrected iron deficiency anemia in a patient with Plummer-Vinson syndrome. This experience indicates that continuous iron supplementation and long-term follow-up is important in patients with Plummer-Vinson syndrome.

Relapsed Esophageal Web in a Patient with Plummer-Vinson Syndrome

Plummer-Vinson syndrome is characterized by dysphagia, iron deficiency anemia, and upper esophageal web. The associated symptoms can be resolved by administering iron supplements as well as by endoscopic intervention. Relapse in patients with Plummer-Vinson syndrome is very rare. We describe a case of a 42-year-old woman with Plummer-Vinson syndrome whose symptoms were successfully treated with endoscopic dilatation and iron supplementation at first admission; however, 1 year later, she revisited our hospital because of dysphagia. On second admission, investigations revealed esophageal web relapse in Plummer-Vinson syndrome. She was again successfully treated with endoscopic dilatation and iron supplementation. After first admission, her anemia was not normalized due to poor compliance and loss of follow-up. We experienced a case of esophageal web relapse due to uncorrected iron deficiency anemia in a patient with Plummer-Vinson syndrome. This experience indicates that continuous iron supplementation and long-term follow-up is important in patients with Plummer-Vinson syndrome.

A case of Wegener's granulomatosis mimicking recurrent hemophagocytic lymphohistiocytosis

No abstract available.

Bedside Sonographic Characteristics of Early and Late Appendicitis

PURPOSE: Studies on the relationship between appendiceal inflammation and bedside ultrasonographic findings are lacking. The purpose of this study was to determine statistically significant parameters to diagnose appendicitis earlier by comparing ultrasonographic findings and clinical features between early and late appendicitis. METHODS: A registry of right lower quadrant (RLQ) pain ultrasound from December 2011 to December 2012 was reviewed. Among these cohorts, patients pathologically proven to have appendicitis were selected and divided into two groups: an early appendicitis group, patients who complained of a diffuse abdominal pain, and a late appendicitis group, patients who complained of a localized right lower quadrant pain. The two groups were compared according to gender, age, bedside ultrasonographic findings, inflammatory markers, clinical features, and postoperative pathological findings. RESULTS: A total of 102 patients were enrolled in this study. Among them, 42 patients (41.2%) were in the early appendicitis group and 60(58.8%) were in the late appendicitis group. Appendiceal diameter and noncompressibility did not differ between the groups. However, periappendiceal fat infiltration and fluid were less prevalent in the early group (p=0.031 vs. p=0.022, respectively). CONCLUSION: Appendiceal diameter and non-compressibility were the only bedside ultrasound findings found in early appendicitis patients. Emergency physicians can detect early appendicitis and prevent complications before the migration of abdominal pain to the RLQ by bedside ultrasonography.

Bedside Sonographic Characteristics of Early and Late Appendicitis

PURPOSE: Studies on the relationship between appendiceal inflammation and bedside ultrasonographic findings are lacking. The purpose of this study was to determine statistically significant parameters to diagnose appendicitis earlier by comparing ultrasonographic findings and clinical features between early and late appendicitis. METHODS: A registry of right lower quadrant (RLQ) pain ultrasound from December 2011 to December 2012 was reviewed. Among these cohorts, patients pathologically proven to have appendicitis were selected and divided into two groups: an early appendicitis group, patients who complained of a diffuse abdominal pain, and a late appendicitis group, patients who complained of a localized right lower quadrant pain. The two groups were compared according to gender, age, bedside ultrasonographic findings, inflammatory markers, clinical features, and postoperative pathological findings. RESULTS: A total of 102 patients were enrolled in this study. Among them, 42 patients (41.2%) were in the early appendicitis group and 60(58.8%) were in the late appendicitis group. Appendiceal diameter and noncompressibility did not differ between the groups. However, periappendiceal fat infiltration and fluid were less prevalent in the early group (p=0.031 vs. p=0.022, respectively). CONCLUSION: Appendiceal diameter and non-compressibility were the only bedside ultrasound findings found in early appendicitis patients. Emergency physicians can detect early appendicitis and prevent complications before the migration of abdominal pain to the RLQ by bedside ultrasonography.

A Case of Incidental Struma Ovarii Confounded with the Metastasis of Papillary Thyroid Cancer

A focal radioactive iodine uptake in the pelvis of a patient with differentiated thyroid cancer needs differential diagnosis besides bone metastasis. Struma ovarii is a rare monodermal ovarian teratoma composed predominantly of mature thyroid tissue; 5-10% of these tumors are malignant. As diagnosis and surgery of thyroid cancer have increased recently, incidental cases of struma ovarii, after radioactive iodine treatment, were occasionally reported. Rare cases of ovary metastasis of thyroid cancer were also reported. We report a case of benign struma ovarii incidentally found in a patient with papillary thyroid cancer. The patient showed a sustained high level of thyroglobulin and focal radioactive iodine uptake in the right pelvis, confused with distant metastasis, after total thyroidectomy and radioactive iodine treatment.

Hepatic Resection in Patients with Hepatocellular Carcinoma Accompanied by Portal Vein Thrombus

PURPOSE: Although surgical resection is the most effective treatment for hepatocellular carcinoma (HCC) accompanied by portal vein tumor thrombus (PVTT), the recurrence rate is very high and prognosis is poor. This retrospective analysis aimed to establish a surgical strategy for patients with portal vein thrombus and to identify predictors of tumor thrombus in these patients. METHODS: From 2006 to 2007, 63 hepatocellular carcinoma patients with portal vein thrombus detected by preoperative imaging underwent hepatic resection, and their clinical data were retrospectively analyzed. Possible prognostic factors for survival were analyzed with postoperative survival curves, and significant factors were determined by univariate and multivariate analysis. RESULTS: 31 patients (49.2%) with portal vein tumor thrombus were detected by pathologic reports in 63 HCC patients with portal vein thrombus. Significant prognostic factors included Serum Albumin or =100 IU/L, Tumor size> or =10 cm, non-expanding type, PVTT and Alpha-feto protein (AFP)> or =104 IU/L by univariate analysis. Independent prognostic factors included PVTT. CONCLUSION: PVTT is not always detected in patients with HCC accompanied by portal vein thrombus. Although patients have a portal vein tumor thrombus, some patients have greater long-term survival. Hepatic resection should be considered for patients with portal vein thrombus.