The experience of transumbilical endoscopic appendectomies

Minimally invasive surgery is being widely accepted in various fields of surgery. Although several appendectomy techniques have been reported but, there is no standardization. We report here the experiences of transumbilical endoscopic appendectomy in humans. Between July 2008 and September 2010, ten patients with appendicitis successfully underwent transumbilical endoscopic appendectomies. There were 7 cases of suppurative, 2 cases of gangrenous and 1 case of perforated in operative findings. The ages of the patients were 13-56 years (mean age, 32.7 +/- 15.4 years). Under general anesthesia, a 15-mm port was inserted through the umbilicus and then a two-channel endoscope was inserted in the peritoneal cavity. After appendix identification, counter-traction of the appendix with a direct abdominal wall puncture using a straight round needle prolene was performed to achieve good visualization of the operative field. Tissue dissection was performed using an endoscopic needle knife. Tissue grasping and resected appendix retrieval were done with endoscopic forceps. The average operation time was 79.5 +/- 23.6 minutes (range, 45 to 110 minutes). No procedures were converted to laparoscopic or open appendectomy. Hospital stay was 4-6 days. All patients completely recovered without complications. As it is highly maneuverable, we believe transumbilical endoscopic appendectomy can be a feasible method. And, as surgeons want to proceed from laparoscopic surgery to natural orifice transluminal endoscopic surgery, this procedure could be a triable method.

Four Cases of Primary Epiploic Appendagitis

Primary epiploic appendagitis (PEA) occurs due to inflammation of an epiploic appendage, which is a peritoneal pouch that arises from the serosal surface of the colon. PEA is often associated with infarction caused by torsion or spontaneous venous thrombosis. PEA is a self-limited disease with a course of approximately 10 days, and it requires only symptomatic management for pain. But it clinically manifests with localized abdominal pain that is often mistaken for appendicitis, diverticulitis, or cholangitis. Therefore, PEA had been diagnosed at surgery for the past few decades. Making the preoperative diagnosis of PEA through ultrasound and computed tomography (CT) has recently become possible. We report here on four cases of PEA that were diagnosed and treated by symptomatic management.

Two Cases of Eosinophilic Esophagitis Treated with a Proton Pump Inhibitor and a Systemic Steroid / 대한소화기내시경학회지

Eosinophilic esophagitis is a chronic inflammatory disorder characterized by dense eosinophilic infiltration of the esophageal mucosa. As an emerging disease during the last decade, eosinophilic esophagitis has gained increased recognition in both the medical and research communities. The pathogenesis is incompletely understood and food allergies and aeroallergens have been implicated. The most common clinical symptoms in adults are dysphagia and food impaction. We diagnosed two cases as eosinophilic esophagitis and treated them with a proton pump inhibitor and a systemic steroid. We confirmed improvements in clinical presentation and histologic findings and report these cases.

Histopathologic Analysis of Adenoma and Adenoma-related Lesions of the Gallbladder / 대한소화기학회지

BACKGROUND/AIMS: In order to determine the malignant potential of gallbladder adenoma for progression to carcinoma, we evaluated the histopathologic features of adenoma and adenoma-related lesions on cholecystectomized specimens. METHODS: Among 1,847 cholecystectomized specimens, 63 specimens from 26 benign adenomas, 9 carcinomas in situ (CIS), and 28 invasive carcinomas were selected. A pathologist reviewed all specimens and selected benign adenomas, CIS in the adenoma, and adenoma residue in invasive carcinomas. Adenomas and adenoma-related lesions were classified according to morphology (tubular, tubulopapillary, and papillary) and the consisting epithelium (biliary, pyloric metaplasia, and intestinal metaplasia). The age and the size of the benign adenomas and carcinomas in the adenoma were also compared. RESULTS: Adenoma and adenoma-related lesions were found in 34 out (1.8%) of all resected gallbladder. Among 9 CIS and 28 invasive carcinomas, adenoma-related lesions were detected in 7 and 1 case, respectively. All eight carcinomas arising in the adenoma were well-differentiated solitary tumors. The diameters of the carcinomas in the adenoma were, on average, larger than that of the benign adenomas (1.8 cm vs. 0.9 cm, p=0.01). The patients with carcinomas in the adenoma were, on average, older than those with benign adenomas, although the difference was insignificant (57 years vs. 47 years, p=0.09). The morphology and consisting epithelium did not differ between the benign adenomas and carcinomas in the adenoma. The malignant transformation occurred in 23.5% of adenomas. CONCLUSIONS: Gallbladder adenoma is a rare disease, although malignant transformation occurs frequently. Adenoma is a precancerous lesion and the adenoma-carcinoma sequence is one of the gallbladder cancer carcinogenesis.

A Case of Splenic Rupture after Diagnostic Colonoscopy / 대한소화기내시경학회지

Splenic injury during colonoscopy is a rare, but potentially life-threatening complication. We report here on the case of a 75-year-old female patient with a ruptured spleen after screening colonoscopy and we review the relevant literature.

A case of hepatocellular carcinoma in the caudate lobe successfully treated by transcatheter arterial chemoembolization using drug-eluting beads / 대한간학회지

Hepatocellular carcinoma (HCC) in the caudate lobe remains one of the most intricate locations where various treatments tend to pose problems with regard to the optimal approach. Surgical resection has been regarded as the most effective treatment; however, isolated resection of the caudate lobe is strenuous and associated with a high rate of early recurrence. Percutaneous ablation might be technically difficult or impossible to perform due to the deep location of tumors and adjacent large vessels. Treatment with drug-eluting beads (DEB) can potentially enhance the therapeutic efficacy for patients with unresectable HCC by drawing on the slower, more consistent drug delivery process. We described a case of a 62-year-old man with HCC in the caudate lobe who was successfully treated by DEB.

A case of juxtapapillary gangliocytic paraganglioma treated with endoscopic resection / 대한내과학회지

Gangliocytic paraganglioma is a rare tumor that is usually seen in the duodenum. This neoplasm generally behaves in a benign fashion, although instances of recurrence and lymph node metastasis have been described. We experienced a case of incidentally found gangliocytic paraganglioma treated with endoscopic resection. A 61-year-old man was referred because of submucosal tumor adjacent to the major papilla. Endoscopic biopsy revealed paraganglioma. Abdominal CT showed that there was no evidence of a duodenal mass or lymphadenopathy. This tumor was resected endoscopically by electrosurgical snare polypectomy. The excised tumor measured 1.0 cm in diameter. Histopathological examination revealed a benign gangliocytic paraganglioma and the resection margins were free of tumor. At the 6-month follow-up, the patient was still asymptomatic and no residual tumor was detected at the resection site.

The Usefulness of 64-Multidetector CT Cholangiography for Diagnosis of Distal Common Bile Duct Obstruction: Comparison with Endoscopic Retrograde Cholangiopancreatography / 대한소화기내시경학회지

BACKGROUND/AIMS: The aim of this study was to evaluate the diagnostic accuracy of 64-multidetector CT (MDCT) cholangiography for determining the causes of distal common bile duct (CBD) obstruction. METHODS: Two hundred fifty consecutive patients underwent 64-MDCT for diagnosing the clinical and biochemical signs of bile duct obstruction. The causes of bile duct obstruction were assessed by the pre- and post-enhanced axial and coronal multiplanar reformation images of 64-MDCT. The results were compared with ERCP, biopsy and surgery. RESULTS: The sensitivity and specificity of MDCT for CBD stones were 96.1% and 84.9%, respectively. In seven patients, The CBD stones in 7 patients could not be detected on MDCT. Eleven patients with stones in the distal CBD, as detected on MDCT, had no stones seen on ERCP. For malignant obstruction, the sensitivity and specificity of MDCT were 97.0% and 98.6%, respectively. Three patients who were diagnosed with periampullary cancers on MDCT were disclosed to have severe papillitis on ERCP. One patient who was diagnosed with CBD stone by MDCT was disclosed to have ampullary cancer. The overall accuracy of MDCT for determining the causes of biliary obstruction was 90.5%. CONCLUSIONS: MDCT cholangiography is a non-invasive method with relatively high sensitivity and high specificity for diagnosing the causes of distal CBD obstruction.

A Case of Splenic Artery Aneurysm Mimicking Gastric Submucosal Tumor / 대한소화기내시경학회지

Splenic artery aneurysm is an uncommon clinical entity. Most of these aneurysms are asymptomatic, but if an aneurysm ruptures, it can be fatal and its mortality rate reaches 70 percent. Regardless of the presence of symptoms, if the size of the asymptomatic aneurysm is larger than 2 cm in diameter or the patient is pregnant, then the anurysm should be treated. A 74-year-old female visited our hospital complaining of nonspecific epigastric discomfort. Endoscopic examination of the stomach revealed a submucosal tumor like protruding mass in the body and it was finally diagnosed as a splenic artery aneurysm by computed tomography. We report here on a case of a splenic artery aneurysm that mimicked a submucosal tumor, and this aneurysm was treated with surgery.

A case of primary gastric actinomycosis / 대한내과학회지

Actinomycosis is a chronic suppurative and granulomatous disease caused by a Gram-negative anaerobic bacterium, Actinomyces israelii, which is among the normal flora of the oral cavity and gastrointestinal tract of humans and animals. It is characterized by sulfur granule formation and can involve the cervicofacial area, chest, abdomen, and pelvis. The most common predisposing factors are the presence of an intrauterine contraceptive device, previous trauma, appendectomy, colon diverticulum, and gastrointestinal perforation. Primary gastric actinomycosis is an extremely rare disease. Three cases of gastric actinomycosis have been reported in people who had a subtotal gastrectomy for stomach cancer in Korea. We report a case of primary gastric actinomycosis in a 59-year-old man with untreatable hepatocelluar carcinoma. His actinomycosis was cured with penicillin therapy.

Clinical Significance of Bowel Wall Thickening Detected with 64-Slice Multidetector Computed Tomography / 대한소화기학회지

BACKGROUND/AIMS: The multidetector computed tomography (MDCT) scanning frequently leads to the incidental discovery of bowel wall thickening. The aim of this study was to determine the utility of gastroscopy and colonoscopy in the management of patients who had incidental discovery of bowel wall thickening on MDCT. METHODS: From May 2006 to March 2008, the abdominal MDCT reports of all patients in Chungbuk National University Hospital were reviewed. Cases with any bowel thickening was selected and then patients who received gastroscopy or colonoscopy after abdominal MDCT were re-selected. RESULTS: Gastroscopy revealed abnormal findings in 22 (95.7%) out of 23 patients, and 10 patients (43.5%) had stomach cancers. Colonoscopy revealed abnormal findings in 35 (85.4%) out of 41 patients, and 12 patients (29%) had malignant tumors. In the patients who had lymph node enlargement (p<0.001), dirty fat infiltration (p=0.025), and irregular wall thickening (p<0.001) on MDCT malignancy was observed more frequently. CONCLUSIONS: We recommend gastroscopy and colonoscopy to patients who had incidentally found bowel wall thickening on MDCT, especially those with lymph node enlargement, dirty fat infiltration, and irregular wall thickening.

A Case of Congenital Hepatic Fibrosis Presented with Recurrent Acute Cholangitis / 대한소화기학회지

Acute cholangitis usually develops in congenital hepatic fibrosis (CHF), accompanied by cystic dilated bile ducts. However, it can also develop in simple CHF and may lead to critical course. A 30-year old man presented with recurrent acute cholangitis without bile duct dilatation. He visited the hospital for febrile sense and abdominal pain in the right upper quadrant. He had been admitted several times for hepatosplenomegaly and cholangitis since childhood and received a liver biopsy 15 years ago. Abdominal computed tomography (CT) and endoscopic retrograde cholangiopancreatography (ERCP) revealed hepatosplenomegaly and a mildly dilated bile duct without stones or biliary cysts. His condition improved after conservative treatment. However, during a two-month follow up period, the patient experienced three episodes of acute cholangitis. A liver biopsy was performed and showed periportal fibrosis and intrahepatic ductular dysplasia, characteristics of congenital hepatic fibrosis. The periportal fibrosis and the infiltration of inflammatory cells were aggravated compared to 15 years ago. There was no evidence of hepatic cirrhosis. He was diagnosed with congenital hepatic fibrosis with recurrent acute cholangitis without intrahepatic duct dilatation, and conservatively treated with antibiotics.

The mechanism of action of neuropeptide Y in rat colonic motility / 대한내과학회지

BACKGROUND/AIMS: Neuropepetide Y (NPY) is involved in the regulation of several gut functions, but the neuronal action of NPY has not been fully investigated. This study was designed to investigate the effect and mechanism of action of NPY on motility in the proximal and distal rat colon. METHODS: Rat colon with an intact superior mesenteric artery was isolated. After a basal period, NPY was administered at concentrations of 14 pM, 70 pM, 140 pM, and 280 pM. Intraluminal pressures were monitored in the proximal and distal colon. The contractile response was expressed as a percent change of motility indices over the basal level. After a pre-infusion of atropine (AT), tetrodotoxin (TTX), propranolol, hexamethonium, and phentolamine, NPY was infused at a concentration of 140 pM, and pressures were monitored. RESULTS: NPY increased the colonic motility at concentrations of 14, 70, 140, and 280 pM in the proximal colon (28.5+/-28.2%, 48.4+/-34.3%, 122.9+/-97.3%, 68.2+/-28.1%, respectively) and in the distal colon (44.9+/-25.9%, 103.8+/-72.0%, 237.1+/-131.0%, 93.0+/-63.9%, respectively) in a dose-dependent manner. The enhancing effect of NPY (140 pM) on colonic motility was significantly suppressed by pretreatment with atropine, propranolol, and TTX. However, the effect of NPY was not inhibited by hexamethonium or phentolamine. CONCLUSION: NPY increases colonic motility. The enhancing effect of NPY on colonic motility may require cholinergic input via muscarinic receptors or adrenergic input via beta-receptors.

A case of virus-associated hemophagocytic syndrome / 대한내과학회지

Hemophagocytosis refers to the pathologic finding of activated macrophages engulfing erythrocytes, leukocytes, platelets, and their precursor cells. Hemophagocytic syndrome (HS) (more properly referred to as hemophagocytic lymphohistiocytosis) is a distinct clinical entity characterized by fever, pancytopenia, splenomegaly, and hemophagocytosis in the bone marrow, spleen, and lymph nodes. HS is associated with a variety of viral, bacterial, fungal, and parasitic infections, as well as with collagen vascular diseases and malignancies. Epstein-Barr virus (EBV)-associated HS is almost always a fatal disease. The authors present a case of EBV-associated HS. The patient had fever and hepatosplenomegaly and showed pancytopenia, jaundice, and positive EBV viral markers in serum, positive EBV DNA in the liver biopsy specimen, and hemophagocytosis in the bone marrow. The patient died unexpectedly 1 month after admission. We report the details of this case of fatal EBV-associated hemophagocytic syndrome along with a brief review of the literature.

The Short Term Efficacy of Entecavir Therapy in Chronic Hepatitis B / 영남의대학술지

BACKGROUND/AIMS: Entecavir is a synthetic nucleoside analogue, cyclopentyl guanine nucleoside, which has a potent antiviral effect and the least viral breakthrough in hepatitis B virus (HBV) replication. Entecavir has been available in Korea since 2007 but there are few reports on its effects. The aim of this study was to evaluate the virological response (VR) and biochemical response (BR) to entecavir in HBV patients at 3, 6 and 9 months after treatment with entecavir. MATERIALS AND METHODS: Thirty-three chronic hepatitis B patients who took entecavir for at least 9 months were enrolled. We investigated VR and BR by retrospectively reviewing medical records. Patients who satisfied the following criteria were chosen: 1) initial alanine aminotransferase (ALT) levels = 1.5upper limit of normal (ULN) and 2) initial HBV DNA levels = 5 log10 copies/ml. We measured ALT levels every 3 months until month 9. HBV DNA was measured every 2 or 3 months by polymerase chain reaction (PCR) method. RESULTS: Most patients taking entecavir showed good BR (ALT < 40 IU/L). The BR rates were 61%, 73% and 67% at months 3, 6 and 9, respectively. VR (HBV DNA < 5 log(10) copies/ml or 2 log lower than initial HBV DNA) rates were 82%, 91% and 91% at months 3, 6 and 9, respectively. Undetectable HBV DNA (HBV DNA < 4 log(10) copies/ml) rates were 49%, 73% and 85% at months 3, 6 and 9, respectively. Two patients presented with virological breakthrough without adverse effects until month 9. CONCLUSIONS: Entecavir showed good BR and VR from month 3 and these effects continued through the 9-month observation period. This suggests that entecavir is also a good choice for the first line treatment of chronic hepatitis B (CHB). Further studies are needed to determine the long-term efficacy and drug resistance of entecavir in Korean CHB patients.

Two Cases of a Solitary Peutz-Jeghers Polyp in the Rectum / 대한소화기내시경학회지

Peutz-Jeghers syndrome is a rare autosomal dominant disorder in which multiple hamartomatous polyps are present in the gastrointestinal tract in association with distinctive mucocutaneous pigmentation. A single hamartomatous polyp arising in a patient without pigmentation or familial history of Peutz-Jeghers syndrome is termed a solitary Peutz-Jeghers polyp; such a case is rare and would result in a case report being presented even in other countries. We experienced two cases of a solitary Peutz-Jeghers polyp that developed in the rectum, and report the cases with a review of the literature.

A case of symptomatic heterotopic pancreas with huge pseudocyst formation / 대한내과학회지

Heterotopic pancreas is the presence of pancreatic tissue that lacks anatomic and vascular continuity with the main body of the pancreas. Most patients with heterotopic pancreas are asymptomatic. Any pathologic change in the normal pancreas also can occur in heterotopic pancreas; namely, pancreatitis, cyst formation, hemorrhage, necrosis and neoplastic chang. But pancreatic pseudocyst formation is extremely rare in heterotopic pancreas. Recently, we experienced a case of gastric heterotopic pancreas in a 22-year-old women complicated by chronic pancreatitis with pseudocyst formation. She underwent a antrectomy with Billroth I reconstruction. Symptoms were relieved after operation. Microscopic findings were compatible with gastric heterotopic pancreas with pseudocyst formation. Herein, we report a case of symptomatic heterotopic pancreas with huge pseudocyst formation and the pertinent literatures were reviewed briefly.

Clinical Features of Patients with Choledocholithiasis Showing High Levels of Aminotransferases / 대한소화기학회지

BACKGROUND/AIMS: We aimed to determine the clinical features of patients with common bile duct (CBD) stones with high serum levels of AST or ALT. METHODS: A retrospective review of 93 patients with CBD stones was done. Clinical characteristics, diameters of CBD, and prior diagnosis before endoscopic retrograde cholangiopancreatography (ERCP) were assessed between two groups (group 1 with serum AST or ALT levels 400 IU/L and group 2 with AST and ALT < or = l00 IU/L). RESULTS: Nineteen patients in group 1 and 17 patients in group 2 were enrolled. The most common presenting symptom was abdominal pain in both groups. Patients in group 1 was about 14 years younger than group 2 (p=0.003). The duration of symptoms in group 1 and group 2 were 4.1 and 36.8 days, respectively (p=0.005). The diameter of CBD was smaller in group 1 (11.4 mm) than in group 2 (16.3 mm) (p=0.001). Most patients were diagnosed as CBD stones by abdominal ultrasound or computed tomography before ERCP, except two patients in group 1 who were diagnosed as hepatitis initially. All of the patients were recovered by stone removal through ERCP and antibiotics treatment. There were inverse correlations between the diameter of CBD and AST or ALT levels (r=-0.517, p=0.002 and r=-0.504, p=0.002, respectively). CONCLUSIONS: CBD stones with high levels of AST or ALT are frequently observed in younger patients with shorter duration of symptoms and a smaller diameter of CBD. ERCP seems to be a valuable method in the diagnosis and treatment of these patients.

A Case of Primary Small Cell Carcinoma Arising from the Common Bile Duct / 대한소화기학회지

Small cell carcinoma is usually seen in the lung, but rarely involves the gastrointestinal tract including biliary tract. A 65 year-old man was admitted because of obstructive jaundice. A smooth-surfaced round intraluminal mass with proximal bile duct dilatation was seen in the proximal common bile duct on endoscopic retrograde cholangiogram. Under the diagnosis of bile duct cancer, pylorus-preserving pancreatoduodenectomy was done. Pathology revealed a 2 cm sized small cell carcinoma in the proximal common bile duct and distal common hepatic duct. On immunohistochemical stain, the tumor cells were positive for neuroendocrine markers CD56 and synaptophysin. After surgery, the patient received 5 cycles of adjuvant chemotherapy with VIP (etoposide, ifosfamide, and cisplatin) regimen. However, the patient died of liver metastasis 12 months after the diagnosis. We report a case of extrapulmonary small cell carcinoma arising from the common bile duct.

Clinical Experience of 48 Acute Toxic Hepatitis Patients / 대한간학회지

BACKGROUND/AIMS: Although many individual cases of toxic hepatitis have been reported in Korea, there are few comprehensive systematic studies on acute toxic hepatitis. The first aim of this study is to investigate the frequency and clinical characteristics of acute toxic hepatitis patients. The second aim of this study is to investigate the efficacy of steroid therapy for immunoallergic idiosyncrasy. METHODS: Between March 1998 and March 2004 forty eight patients were included in this study. The medical records were reviewed retrospectively. Acute toxic hepatitis was diagnosed by score of more than 3 in RUCAM criteria. All the patients were tested for hepatitis A, B and C. Other tests included antibodies to CMV and EBV, ANA, AMA and SMA. RESULTS: Seventy-three percent of the patients were female and the mean age of the patients was 47. Twenty cases of acute toxic hepatitis (42%) were related to prescribed medications. The other causes were herbs (35%) and traditional therapeutic preparations (23%). Common symptoms were jaundice (35%), fatigue (10%), fever (9%) and abdominal pain (9%). The biochemical pattern of hepatotoxicity was divided into three groups: hepatocellular (81%), mixed (13%), and cholestatic types (6%). Three patients who have prolonged and severe jaundice were classified into immunoallergic idiosyncrasy based upon clinical and histologic findings. Prednisolone was prescribed in all three cases whose bilirubin levels had been higher than 15 mg/dL for at least 7 days. Jaundice and the laboratory findings rapidly improved within 8 days since the treatment began. CONCLUSIONS: In a demographic point of view, most patients of acute toxic hepatitis were middle aged women. Jaundice was the most commonly observed symptom. Prescribed drugs were the most common cause of acute toxic hepatitis. Although most cases of toxic hepatitis will recover with supportive care after cessation of the causative agent, steroid treatment may be helpful for the patients with severe jaundice patients who have immunoallergic idiosyncrasy.