Clinical Significance of Urinary Neutrophil Gelatinase-associated Lipocalin Levels in Defining the Various Etiologies of Acute Kidney Injury in Liver Cirrhosis Patients / 대한소화기병학회잡지

BACKGROUND/AIMS: A diagnosis of hepatorenal syndrome (HRS) is based on a differential evaluation of acute kidney injury (AKI), which may aggravate the clinical course. This study assessed the clinical significance of the urinary neutrophil gelatinase-associated lipocalin (u-NGAL) levels in a differential diagnosis of AKI in patients with liver cirrhosis (LC). METHODS: Patients with LC who developed AKI were enrolled prospectively. Clinically, patients with AKI were classified into prerenal azotemia (PRA), HRS, and acute tubular necrosis (ATN) groups. RESULTS: Fifty-five patients (male, 74.5%) with LC who exhibited AKI upon admission were enrolled; 28, 9, and 18 patients were included in the PRA, HRS, and ATN groups, respectively. The baseline model for end-stage liver disease (MELD) scores was similar in the subgroups. The median event creatinine level, measured at the time of the AKI diagnosis, was similar in the HRS and ATN subgroups. On the other hand, the median event u-NGAL level differed significantly between the three subgroups (PRA, HRS, and ATN: 37 vs. 134 vs. 2,625 ng/mL, p=0.003). In particular, the median u-NGAL level of the HRS group was clearly different from those of the PRA (p<0.001) and ATN (p<0.001) groups. Multivariable analysis revealed the natural logarithm of the u-NGAL level (hazard ratio [HR] 1.77, p=0.031) and the MELD score (HR 1.17, p=0.027) to be independent prognostic factors for in-hospital mortality in patients with LC and AKI. CONCLUSIONS: The median u-NGAL level differentiated HRS from ATN and served as a clinical indicator of in-hospital mortality for patients with LC and AKI.

Clinical Significance of Urinary Neutrophil Gelatinase-associated Lipocalin Levels in Defining the Various Etiologies of Acute Kidney Injury in Liver Cirrhosis Patients / 대한소화기학회지

BACKGROUND/AIMS: A diagnosis of hepatorenal syndrome (HRS) is based on a differential evaluation of acute kidney injury (AKI), which may aggravate the clinical course. This study assessed the clinical significance of the urinary neutrophil gelatinase-associated lipocalin (u-NGAL) levels in a differential diagnosis of AKI in patients with liver cirrhosis (LC).METHODS: Patients with LC who developed AKI were enrolled prospectively. Clinically, patients with AKI were classified into prerenal azotemia (PRA), HRS, and acute tubular necrosis (ATN) groups.RESULTS: Fifty-five patients (male, 74.5%) with LC who exhibited AKI upon admission were enrolled; 28, 9, and 18 patients were included in the PRA, HRS, and ATN groups, respectively. The baseline model for end-stage liver disease (MELD) scores was similar in the subgroups. The median event creatinine level, measured at the time of the AKI diagnosis, was similar in the HRS and ATN subgroups. On the other hand, the median event u-NGAL level differed significantly between the three subgroups (PRA, HRS, and ATN: 37 vs. 134 vs. 2,625 ng/mL, p=0.003). In particular, the median u-NGAL level of the HRS group was clearly different from those of the PRA (p<0.001) and ATN (p<0.001) groups. Multivariable analysis revealed the natural logarithm of the u-NGAL level (hazard ratio [HR] 1.77, p=0.031) and the MELD score (HR 1.17, p=0.027) to be independent prognostic factors for in-hospital mortality in patients with LC and AKI.CONCLUSIONS: The median u-NGAL level differentiated HRS from ATN and served as a clinical indicator of in-hospital mortality for patients with LC and AKI.

Clinical Interpretation of Elevated CA 19-9 Levels in Obstructive Jaundice Following Benign and Malignant Pancreatobiliary Disease / 대한소화기학회지

BACKGROUND/AIMS: Elevated carbohydrate antigen (CA) 19-9 level may be unable to differentiate between benign and malignant pancreatobiliary disease with obstructive jaundice. The study aims to determine the clinical interpretation and the diagnostic value of CA 19-9 level in pancreatobiliary diseases with coexistent obstructive jaundice. METHODS: We retrospectively reviewed the data of 981 patients who underwent biliary drainage due to obstructive jaundice following pancreatobiliary disease at Sanggye Paik Hospital for 5 years. 114 patients with serial follow-up data for CA 19-9 level were included in this study (80 patients with malignancy and 34 patients with benign diseases). We compared the levels of CA 19-9 levels and the biochemical value before and after biliary drainage. RESULTS: The rate of CA 19-9 elevation (>37 U/mL) was significantly different between the benign group and the malignant group (59% vs. 90%, p=0.001). Despite the decrease in serum bilirubin after biliary drainage, CA 19-9 levels remained elevated in 12% of patients in the benign group and in 63% of patients in the malignant group (p<0.001). Finally, 12% of patients in the benign group turned out to have malignant disease. A receiver operating characteristic analysis provided a cut-off value of 38 U/mL for differentiating benign disease from malignant disease after biliary drainage (area under curve, 0.787; 95% confidence interval, 0.703 to 0.871; sensitivity, 62%; specificity, 88%). CONCLUSIONS: This study suggested that we should consider the possibility of malignant causes if the CA 19-9 levels remain high or are more than 38 U/mL after resolution of biliary obstruction.

Non-umbilical Cutaneous Metastasis of Pancreatic Adenocarcinoma as the First Clinical Manifestation: A Case Report / 대한소화기학회지

Non-umbilical cutaneous metastases from pancreatic adenocarcinomas are extremely rare. Only a few cases have been reported in the literature. An 83-year-old Korean woman, with no previous medical history, presented with a painful nodule on her scalp. Histologic examination of the nodule revealed a metastatic adenocarcinoma, and immunohistochemical staining was positive for cytokeratin (CK) 7 and CK 19. These findings were consistent with a metastatic carcinoma of pancreatic origin. An abdominal computed tomography scan identified a mass on the pancreatic head and multiple enlarged lymph nodes. Pathological examination of an endoscopic ultrasound-guided fine needle biopsy of the pancreatic mass determined that it was a poorly differentiated carcinoma. The patient refused any treatment owing to her old age and short life expectancy. Four months later, the disease progressed rapidly, and the patient died.

Evaluation of Xpert C. difficile, BD MAX Cdiff, IMDx C. difficile for Abbott m2000, and Illumigene C. difficile Assays for Direct Detection of Toxigenic Clostridium difficile in Stool Specimens

BACKGROUND: We evaluated the performance of four commercial nucleic acid amplification tests (NAATs: Xpert C. difficile, BD MAX Cdiff, IMDx C. difficile for Abbott m2000, and Illumigene C. difficile) for direct and rapid detection of Clostridium difficile toxin genes. METHODS: We compared four NAATs on the same set of 339 stool specimens (303 prospective and 36 retrospective specimens) with toxigenic culture (TC). RESULTS: Concordance rate among four NAATs was 90.3% (306/339). Based on TC results, the sensitivity and specificity were 90.0% and 92.9% for Xpert; 86.3% and 89.3% for Max; 84.3% and 94.4% for IMDx; and 82.4% and 93.7% for Illumigene, respectively. For 306 concordant cases, there were 11 TC-negative/NAATs co-positive cases and 6 TC-positive/NAATs co-negative cases. Among 33 discordant cases, 18 were only single positive in each NAAT (Xpert, 1; Max, 12; IMDx, 1; Illumigene, 4). Positivity rates of the four NAATs were associated with those of semi-quantitative cultures, which were maximized in grade 3 (>100 colony-forming unit [CFU]) compared with grade 1 (<10 CFU). CONCLUSIONS: Commercial NAATs may be rapid and reliable methods for direct detection of tcdA and/or tcdB in stool specimens compared with TC. Some differences in the sensitivity of the NAATs may partly depend on the number of toxigenic C. difficile in stool specimens.

Pure red-cell aplasia and autoimmune hemolytic anemia in a patient with acute hepatitis A

Pure red cell aplasia (PRCA) and autoimmune hemolytic anemia (AIHA) have rarely been reported as an extrahepatic manifestation of acute hepatitis A (AHA). We report herein a case of AHA complicated by both PRCA and AIHA. A 49-year-old female with a diagnosis of AHA presented with severe anemia (hemoglobin level, 6.9 g/dL) during her clinical course. A diagnostic workup revealed AIHA and PRCA as the cause of the anemia. The patient was treated with an initial transfusion and corticosteroid therapy. Her anemia and liver function test were completely recovered by 9 months after the initial presentation. We review the clinical features and therapeutic strategies for this rare case of extrahepatic manifestation of AHA.

Optimal Timing of Endoscopic Clipping for Determining the Resection Line for Laparoscopy-assisted Distal Gastrectomy / 대한소화기학회지

BACKGROUND/AIMS: Pre-operative endoscopic clipping for determining the resection line in patients with early gastric cancer has been used safely, and its efficacy has been demonstrated. However, the optimal timing of endoscopic clipping for determining the resection line in early gastric cancer patients undergoing laparoscopy-assisted distal gastrectomy has not been investigated. METHODS: A retrospective analysis of 92 patients with early gastric cancer who underwent gastric resection after endoscopic clipping at Inje University Sanggye Paik Hospital (Seoul, Korea) was performed. We analyzed the clinical and endoscopic features of patients, number of clips, time from clipping to surgery, and number of patients showing detachment of clips from the gastric wall before surgery. Patients were categorized according to the following two groups: group A included patients whose clips were applied within one day before surgery and group B included patients whose clips were applied more than one day before surgery. RESULTS: Of the 92 patients, 56 were included in group A and 36 were included in group B. In 11 patients (12.0%, five in group A and six in group B, p=0.329), the clips were detached from the gastric wall before surgery. The mean time from clipping to surgery did not differ significantly between the detached and non-detached groups (11 patients, mean 4.6+/-4.6 days vs. 81 patients, mean 3.0+/-4.0 days, p=0.227). CONCLUSIONS: The timing of endoscopic clipping for localization of tumors in early gastric cancer patients undergoing gastrectomy is not important for determining the resection line.

A Case of Hepatic Peribiliary Cysts in a Patient with Alcoholic Liver Cirrhosis / 대한소화기학회지

Hepatic peribiliary cysts (HPCs) are characterized by cystic dilatations of the peribiliary glands located throughout the branches of the biliary systems. Specifically, they are mainly located along the hepatic hilum and major portal tracts. The natural history and prognosis of HPCs are uncertain. In fact, almost all HPCs have been discovered incidentally during radiological examination or autopsy, and they are considered to be clinically harmless. Recently, several cases of HPCs associated with obstructive jaundice or liver failure were reported in patients with pre-existing liver disease in several studies. However, until now there have been no reports of such a case in Korea. Herein, we report a case of HPCs that show a disease course with a poor prognosis. These HPCs developed in a 47-year-old man with progressive alcoholic liver cirrhosis.

The Clinical Factors for Predicting Severe Diverticulitis in Korea: A Comparison with Western Countries

BACKGROUND/AIMS: It is unclear whether the risk factors associated with complicated diverticulitis in Asian and Western countries are the same. We evaluated the risk factors associated with severe diverticulitis (SD) in Korea and compared the clinical characteristics of diverticulitis according to location. METHODS: A retrospective review of 190 patients hospitalized with acute diverticulitis from January 2005 to June 2010 was conducted. SD was defined as one of the following: perforation, abscess, obstruction, sepsis, or peritonitis that required an urgent operation. RESULTS: Twenty-four patients (12.6%) were diagnosed with SD. SD was significantly associated with older age, a fever over 38degrees C, changes in bowel habits and a high visceral adipose tissue (VAT)/total adipose tissue (TAT) ratio. Multivariate analysis showed that the risk factors for developing SD were an age of 40 years or more (odds ratio [OR], 3.2; p=0.032), male gender (OR, 4.0; p=0.021) and left-sided diverticulitis (OR, 6.2; p=0.017). Right-sided diverticulitis (n=175, 92.1%) was significantly associated with younger ages, fewer changes in bowel habits, fewer comorbidities and non-SD. CONCLUSIONS: This study suggests that the risk factors for developing SD in Korea, where right-sided diverticulitis is predominant, are the male gender, an age of more than 40 years old, and left-sided diverticulitis. Given that there are different risk factors for developing SD in Western countries, different strategies for the treatment of diverticulitis in the Korean population seem to be needed.

A Case of Tuberculous Peritonitis Developed during Chemotherapy for Tuberculous Pleurisy as Paradoxical Response / 대한소화기학회지

After the start of anti-tuberculous treatment, paradoxical worsening of tuberculous lesions has been described. However, abdominal tuberculosis as paradoxical response is relatively rare. This report describes the 26-year-old female who suffered from peritoneal tuberculosis while treating tuberculous pleurisy with anti-tuberculous medications. It was considered as paradoxical response, rather than treatment failure or else. She was successfully managed with continuing initial anti-tuberculous medications. When a patient on anti-tuberculous medications is presented with abdominal symptoms, the possibility of paradoxical response should be considered to avoid unnecessary tests and treatments, which may result in more suffering of the patient. Herein, we report a case of peritoneal tuberculosis as paradoxical response while treating tuberculous pleurisy.

A Case of Corrosive Injury-Induced Pharyngeal Stricture Treated by Endoscopic Adhesiolysis Using an Electrosurgical Knife

Here, we report a case of corrosive injury-induced pharyngeal stricture in a 69-year-old female, which was successfully treated with endoscopic adhesiolysis using an electrosurgical knife. The patient had ingested sodium hydroxide in an attempted suicide, and immediate endoscopy revealed corrosive injuries of the pharynx, esophagus, and stomach. When a liquid diet was permitted, she complained of nasal regurgitation of food. Follow-up endoscopy revealed several adhesive bands and a web-like scar that did not allow passage of the endoscope into the hypopharyngeal area. For treatment of the hypopharyngeal stricture, the otolaryngologist attempted to perform an excision of the fibrous bands around the esophageal inlet using microscissors passed through an esophagoscope, but this procedure was not effective. We then dissected the mucosal adhesion and incised the adhesive bands using an electrosurgical knife. After this procedure, nasal regurgitation of food no longer occurred. To our knowledge, this case is the first report of endoscopic adhesiolysis with an electrosurgical knife in a patient with a corrosive injury-induced pharyngeal stricture.

A Case of Chlamydia trachomatis Peritonitis Mimicking Tuberculous Peritonitis / 대한소화기학회지

Lymphocytic ascites with low serum-ascites albumin gradient (SAAG) are observed mainly in tuberculous peritonitis, peritoneal carcinomatosis, and pancreatic disease. However, pelvic inflammatory disease (PID) induced generalized peritonitis causing diffuse ascites has been rarely described. We report a 26-year old female patient, who was diagnosed as generalized peritonitis with diffuse ascites due to Chlamydia trachomatis infection. Gynecologic examination did not show the clue of PID and in the analysis of ascites, low SAAG, predominant lymphocyte count and high level of adenosine deaminase were noted. Although the best impression was tuberculous peritonitis on the base of these findings, the laparoscopic finding was consistent with PID and the PCR for C. trachomatis infection in cervical swab was positive. This case suggests that C. trachomatis peritonitis should be considered as a rare cause of low SAAG and lymphocytic ascites in sexually active women and should be intensively evaluated including laparoscopic examination.

A Case of Stercoral Perforation of Sigmoid Colon Diagnosed by Colonoscopy / 대한소화기내시경학회지

Stercoral perforation of the colon is a rare disease. Yet, in recent times, the number of reported cases has increased because of the growing elderly population. Stercoral perforation of the colon usually occurs in the elderly or bedridden patients with chronic constipation. Stercoral perforation may cause a massive hemorrhage or peritonitis. The prognosis of stercoral perforation is poor, as the reported postoperative mortality is 35~40%. So, early diagnosis and proper treatment are very important for improving survival. However, making an early diagnosis may be difficult because of the nonspecific initial symptoms. We experienced a case of stercoral perforation that was diagnosed by colonoscopy. The defect was in the sigmoid colon, and it was covered with peritoneum. The patient completely recovered after resection and anastomosis of the perforated colon. We report here on this case with a review of the relevant literature.

Clinical Factors Predicting for Neoplastic Transformation of Gastric Hyperplastic Polyps / 대한소화기학회지

BACKGROUND/AIMS: Hyperplastic polyps (HPs) are the most common cause of all benign epithelial gastric polyps, constituting 30 to 93%. Although gastric HPs are usually considered as benign lesions compared with adenoma, neoplastic transformation has been known to occur rarely. We aimed to identify the clinical factors of gastric HPs predicting for neoplastic transformation. METHODS: Between January 2002 to August 2010, a total of 274 gastric HPs, which had been removed by endoscopic polypectomy or surgical resection from 210 patients, were analyzed retrospectively. RESULTS: Neoplastic transformation was found in 15 cases (5.5%) of 274 HPs including 10 cases of low grade dysplasia (3.7%), 2 cases of high grade dysplasia (0.7%) and 3 cases of adenocarcinoma (1.1%). Neoplastic transformations were significantly associated with >1 cm in size (n=10 [66.7%] vs. n=91 [35.1%], p=0.024), with pedunculated shape (n=9 [60.0%] vs. n=62 [23.9%], p=0.002), with previous history of gastrectomy (n=3 [20.0%] vs. n=3 [1.2%], p=0.002) and with synchronous neoplastic lesions occurring elsewhere in the gastric mucosa (n=5 [33.3%] vs. n=31 [12.0%], p=0.021). However, no significant difference was found between HPs with and without neoplastic transformation in terms of age, sex, number of polyps detected per patient, location, macroscopic appearance such as erosion, hyperemia. CONCLUSIONS: Neoplastic transformation of gastric HPs had significant relationships with >1 cm in size, pedunculated shape, postgastectomy state, and synchronous neoplastic lesion. Therefore, endoscopic polypectomy should be considered in these HPs to avoid the risk of missing HPs with neoplastic potential.

Outbreak of Swine-Origin Influenza A (H1N1); Experience of a Regional Center in Seoul during a Month, August-September 2009 / 대한임상미생물학회지

BACKGROUND: The aim of this study is to clarify the epidemiology of swine-origin influenza A (H1N1) virus 2009 (S-OIV) during the first month of outbreak at one of influenza clinic in Seoul, Korea. METHODS: We documented the epidemiologic and clinical features of S-OIV-confirmed cases who visited a university hospital in Northeastern Seoul between August 21 and September 20, 2009. Nasopharyngeal swab of patients with acute febrile respiratory illnesses were evaluated with rapid influenza antigen tests and multiplex RT-PCR for S-OIV and seasonal influenza A. RESULTS: A total of 5,322 patients with acute febrile respiratory illnesses were identified at our influenza clinic for the study period. S-OIV was confirmed in 309 patients by RT-PCR. The patients ranged from 2 months to 61 years of age and 189 patients (61.2%) were teenagers. Eighty-one patients had known contact with S-OIV-confirmed patients in schools (N=61), households (N=15), and healthcare facilities (N=3). Frequent symptoms were fever (94.5%), cough (73.1%), sore throat (52.1%), and rhinorrhea (50.5%). Gastrointestinal symptoms were also present in 10 patients (4.9%). Ten patients (4.9%) required hospitalizations. Seventy patients (22.7%) could not take oseltamivir at the first visits, however, all of them recovered without complication. Rapid antigen tests showed the sensitivity of 44.4% (130/294). Patients with positive antigen tests, compared with negative antigen tests, showed higher frequencies of rhinorrhea (60.8% vs 43.3%, P=0.004) and stuffy nose (33.8% vs 20.1%, P=0.012). CONCLUSION: S-OIV infections spread predominately in school-aged children during the early accelerating phase of the outbreak. Rapid influenza antigen tests were correlated with nasal discharge and obstruction.

A Case of Spontaneous Regression of Hepatocellular Carcinoma with Multiple Lung Metastases / 대한소화기학회지

Spontaneous regression of hepatocellular carcinoma (HCC) is extremely rare. We report a case of 67-year-old man having HBV-associated HCC with multiple lung metastases which regressed spontaneously. The patient had single liver mass and received surgical resection. The mass was confirmed as HCC histopathologically. Nine years after surgical resection, a 3.3 cm sized recurred HCC was detected on the resection margin in CT scan. Transarterial chemoembolization (TACE) was performed 3 times, and lung metastases developed thereafter. The patient received 2 more sessions of TACE, however, metastatic lung nodules were in progress very rapidly. We decided to stop TACE and followed the patient regularly without any anti-cancer treatment. Nine months after development of lung metastasis, the size and number of metastatic lung nodules decreased and were not detected anymore after 14 months. Serum alpha-fetoprotein levels also decreased to normal range and no viable tumor was noted in the liver. The patient is still alive 12 years after the first diagnosis of HCC and 16 months after lung metastasis developed.

A case of hemophagocytic syndrome complicated by acute viral hepatitis A infection / 대한간학회지

Hemophagocytic syndrome (HPS) is a rare but serious condition that is histopathologically characterized by activation of macrophage or histiocytes with hemophagocytosis in bone marrow and reticuloendothelial systems. Clinically it presents with high fever, hepatosplenomegaly, pancytopenia, liver dysfunction, and hyperferritinemia. Hepatitis A virus is a very rare cause of secondary HPS. We report a case of a 22-year-old woman infected by hepatitis A virus who was consequently complicated with HPS. She presented typical clinical features of acute hepatitis A, and showed clinical and biochemical improvements. However, HPS developed as a complication of acute hepatitis A and the patient died of intraperitoneal bleeding caused by hepatic decompensation and disseminated intravascular coagulation.

A Case of Duodenal Amyloidosis Accompanied with Candidiasis that was Diagnosed by Endoscopy / 대한소화기내시경학회지

This report describes a case of a 63-year-old female who suffered from gastrointestinal amyloidosis. The patient presented with abdominal pain, nausea, vomiting and watery diarrhea for a week. Previously, the patient had been treated for rheumatoid arthritis. Endoscopy showed the presence of erythematous mucosa and yellowish exudates in the bulb, a finding that was compatible with duodenal candidiasis. Colonoscopy showed diffuse erythematous and easy friability in the entire colon, a finding suggestive of infectious colitis. The pathology report indicated that the lesion had amyloid, which was stained by Congo red. Endoscopic findings of amyloidosis are non-specific, such as friable mucosa, granulation, polyp, erosion and ulceration. Therefore, it is difficult to diagnose amyloidosis with endoscopic findings. However, if the patient has risk factors of secondary amyloidosis such as rheumatoid arthritis, gastrointestinal amyloidosis based on the endoscopic finding should be considered. We report a case of duodenal amyloidosis accompanied with candidiasis, which has not been previously reported.

A Patient with Jejunal Mucinous Adenocarcinoma Metastatic to the Stomach Presenting with Submucosal Tumors in the Stomach and Jejunum / 대한소화기내시경학회지

The small bowel is the least common site for cancer to arise. Only approximately 1% of all gastrointestinal neoplasms arise in the small bowel. Mucinous adenocarcinoma is diagnosed when the amount of extracellular mucin in a tumor is over 50%. Because it is a very rare disease, there is little data available concerning its incidence, most common site of origin, and common sites of metastasis. There are no case reports describing primary mucinous adenocarcinoma of the jejunum in Korea. We report a case of jejunal mucinous adenocarcinoma metastatic to the stomach presenting as a submucosal tumor.

An Adult Case of Small Bowel Intussusception Caused by Hemangioma Presenting with Intestinal Bleeding / 대한소화기학회지

Intussusception is primarily a disease of children, and is relatively rare in adults. Unlike childhood intussusception, adult intussusception has an identifiable leading lesion such as malignant or benign neoplasm. However, intussusception caused by hemangioma is very rare. There were few cases of small bowel intussusception caused by hemangioma in adults, but those reports were presented with abdominal pain. This report describes a 65-year-old female who suffered from small bowel intussusception caused by hemangioma presenting with intestinal bleeding. Upper gastrointestinal endoscopy and colonoscopy were performed, but bleeding focus was not found. Abdominal computed tomography showed the target sign of small bowel with a leading point of mass. This mass turned out to be a hemangioma after the small bowel resection. Therefore, small bowel intussusception by hemangioma should be also considered as a bleeding focus when an adult patient presented intestinal bleeding without bleeding focus in the stomach and colon. Herein we report a case of small bowel intussusception caused by hemangioma presenting with intestinal bleeding.