Is the Impedance Baseline Helpful in the Evaluation of Globus Patients?

BACKGROUND/AIMS: Gastroesophageal reflux disease (GERD) has been suggested to be responsible for 23-68% of globus cases. The impedance baseline (IB) acquired by 24-hour multichannel intraluminal impedance monitoring has been proven to represent esophageal mucosal integrity. We aimed to investigate whether the IB is helpful for evaluating globus patients. METHODS: Twenty-four-hour multichannel intraluminal impedance pH tracings (MII-pH) were evaluated in globus patients. Differences in the IB between the acid reflux, non-acid reflux, and no reflux groups were analyzed. Receiver operating characteristic (ROC) curves were obtained to determine the optimal measurement point from the lower esophageal sphincter (LES). RESULTS: A total of 62 patients were analyzed. MII-pH showed that acid reflux, non-acid reflux, and no reflux were present in 13, 5, and 44 patients, respectively. The acid reflux group had a significantly lower IB than the other groups at a location 3 cm from the LES. ROC curve analysis revealed that placement at a position 3 cm from the LES resulted in moderate diagnostic accuracy (area under the curve = 0.88). When we set 2500 Omega as the cut-off value for acid reflux at a position 3 cm from the LES, the additional diagnostic yield for acid reflux was increased by 19.4% compared with that obtained by MII-pH. CONCLUSIONS: IB is complementary to pH findings enabling identification of a subset of patients with co-existing acid reflux. Catheter placement at a location 3 cm from the LES and a cut-off value of 2500 Omega may be reasonable criteria for estimating acid reflux.

Steroid Responsive Pancreatic Mass-Forming Type 2 Autoimmune Pancreatitis / 대한소화기학회지

Autoimmune pancreatitis (AIP) has two distinct subsets. Type 1 AIP or lymphoplasmacytic sclerosing pancreatitis is systemic disease with the elevation in serum levels of the IgG4. Type 2 AIP, also called duct-centric pancreatitis, features granulocyte epithelial lesions with duct obstruction in the pancreas without systemic involvement. Here, we report a case of type 2 AIP diagnosed by pathology, which is the first report in Korea. The case is a 56-year-old woman who presented with anorexia and vomiting. Computed tomography revealed mass-like lesion in the pancreatic head and the compression of the distal common bile duct and the head portion of the main pancreatic duct. Serum levels of the IgG4 were normal. Histologic examination revealed a dense neutrophil infiltration in the pancreatic parenchyme associated with extensive fibrosis, thereby confirming the diagnosis of type 2 AIP. The abnormalities in the clinical, laboratory, and radiological findings improved after oral steroid treatment.

Two cases of advanced hepatocellular carcinoma achieving a complete response with metronomic chemotherapy via the hepatic artery / 대한내과학회지

Advanced hepatocellular carcinoma (HCC) has a poor prognosis and few effective therapies. Recently, low-dose antiangiogenic (also called metronomic) chemotherapy has been tested in patients with advanced HCC. Here, we report two patients with advanced HCC who showed a good response after metronomic chemotherapy. The first was a 54-year-old man who was diagnosed with advanced HCC with lung metastasis. After three cycles of metronomic chemotherapy, the size of tumor and pulmonary metastatic lesions had decreased markedly on follow-up computed tomography. The second was a 54-year-old woman who was diagnosed with HCC with portal vein thrombosis. Metronomic therapy was performed. After 9 months, tumor enhancement in the arterial phase had disappeared completely, and the portal vein thrombus was decreased slightly. Metronomic therapy is an interesting treatment option for patients with advanced HCC. More clinical data and studies are needed to confirm this result.

Recognition of Advance Directives by Advanced Cancer Patients and Medical Doctors in Hospice Care Ward / 한국호스피스완화의료학회지

PURPOSE: We undertook this study to find out the recognitions of terminal cancer patients and doctors about advance directives (ADs), of how they would do in non-response medical conditions and whether ADs could be one of medical options for their dying with dignity. METHODS: One hundred thirty four cancer patients in the Hospice Unit, St. Vincent's Hospital, and 97 medical doctors in the Department of Internal Medicine, Catholic Medical Center, were asked about ADs, including Do-Not-Resuscitate (DNR), medical power of attorney, living will and medical options. RESULTS: One hundred thirty patients (97%) and 38 doctors (39.2%) were unfamiliar with ADs, however, 128 patients (95.5%), 95 doctors (97.9%) agreed with it. Seventy nine patients (59.0%) and 96 doctors (99.0%) wanted DNR rather then intensive treatments if they were in non-response medical conditions. Eighty four patients (62.7%) and 75 doctors (77.3%) were agreeable to medical power of attorney. One hundred Thirty four patients (100.0%) and 94 doctors (96.9%) did not want medical options to be in terminal conditions, and hoped to die in peace. CONCLUSION: Most of patients did not know about ADs and how to make it. However, they showed positive attitudes about it. If we advertise it properly, it is highly likely that a large number of cancer patients would make their living wills easily by ADs. Nevertheless, many legal and ethical problems have to be solved. Doctors should engage their patients in an ongoing communication about the end-of-life. Therefore, let the patients have opportunities to plan their own deaths.

A case of Zollinger-Ellison syndrome: localization of gastrinoma by selective intra-arterial calcium injection / 대한내과학회지

Zollinger-Ellison syndrome is a very rare disease that's caused by tumor having gastrin-producing cells, and this is accompanied by hypergastrinemia leading to gastric acid hypersecretion, peptic ulcer and their complications. A 60-year-old man presented with epigastric pain and soreness he had experienced for 7 days. The endoscopic findings showed reflux esophagitis and multiple active ulcers at the antrum, the duodenal bulb and the 2nd and 3rd portions of the duodenum. The fasting serum gastrin level was markedly elevated above 1,470 pg/mL and this was consistent with the findings of gastrinoma. We confirmed the presence of gastrinoma via the abdomen CT scan and selective intra-arterial calcium injection. This is the first Korean case report of gastrinoma that was localized by selective intra-arterial calcium injection.

Renal Biopsy Findings of Prospective Kidney Donors and Clinical Course of Renal Allografts / 대한이식학회지

PURPOSE: To evaluate the pathology of prospective kidney donors and assess the clinical outcomes of the renal allografts. METHODS: We reviewed the records of 12 prospective kidney donors who underwent kidney biopsy. The indications of kidney biopsy were asymptomatic microscopic hematuria (n=88, 66.7%), decreased glomerular filtration rate (GFR, n=22, 16.7%), mild proteinuria (n=11, 8.3%), history of gross hematuria (n=11, 8.3%). RESULTS: Kidney biopsy in 8 prospective donors with asymptomatic microscopic hematuria showed: 5 (62.5%) thin basement membrane disease (TBMD); 1 IgA nephropathy; 1 Alport's syndrome; 1 mild mesangial widening. Two prospective donors with decreased GFR showed IgA nephropathy and tubulointerstitial lesion. The one with mild proteinuria showed arterionephrosclerosis and the one with a history of gross hematuria showed tubulointerstitial lesion. 4 (33.3%) of the 12 who underwent kidney biopsy were accepted as kidney donors.; 3 donors with TBMD and the donor with mild mesangial widening, who all had microscopic hematuria. Among the 4 donations, there was 1 graft failure and 3 allografts (1 mild mesangial widening, 2 TBMD) have maintained graft function at latest follow up. CONCLUSION: The most common cause of asymptomatic microscopic hematuria in prospective kidney donors was TBMD. Long-term follow up is needed to assess the clinical outcomes of these allografts.

Lymphocele Presenting by Scrotal Swelling after Kidney Transplantation / 대한신장학회지

The lymphocele after renal transplantation is usually observed around the graft. We here report an unusual case of lymphocele mimicking hydrocele. The patient was admitted due to scrotal edema. We initially diagnosed this patient as a case of hydrocele, but biochemical data of aspirated fluid was consistent with lymphatic fluid, and abdominal CT revealed fistula between scrotum and graft. This finding suggests that the lymphatic fluid accumulated around the transplant kidney has migrated to the scrotum to form a lymphocele. In conclusion, lymphocele is a rare cause of scrotal swelling but should be considered as a possibility when a transplant patient develops scrotal swelling.

Acute Renal Failure Caused by Oral Polyethylene Glycol Ingestion / 대한소화기내시경학회지

Polyethylene glycol (PEG) electrolyte lavage solution and sodium phosphate solution are used for bowel cleansing before performing colonoscopy. PEG electrolyte lavage solution is the most widely used because PEG is absorbed by intestinal mucosa in only very small amounts and it very well cleans the bowels. The minor side-effects associated with PEG solution, i.e., nausea, vomiting and abdominal distention, are relatively common. However, PEG electrolyte lavage solution-induced acute renal failure has rarely been reported on. We report here on a case of acute renal failure after bowel preparation with using polyethylene glycol.

Spontaneous Cauda Equina Syndrome in a Renal Transplant Patient with Long-term Azathioprine Treatment / 대한이식학회지

Azathioprine is a conventional immunosuppressant in renal transplantation but long-term administration may lead to hematologic complications. We here report a cauda equina syndrome caused by spontaneous epidural hematoma in a renal transplant recipient who had undergone long-term azathioprine treatment. A 34 year-old male was admitted to our hospital with complaints of numbness of the lower extremities and back pain. He had received renal transplantation 14 years ago and had been on sole therapy with azathioprine for 11 years. Three months before admission, the patient developed pancytopenia, and a subsequent bone marrow biopsy revealed hypocellularity. Azathioprine was replaced by tacrolimus and steroids thereafter. After a three months discontinuation of azathioprine, an epidural hematoma developed and resulted in cauda equina syndrome. Regular follow-up of complete blood count and change of immunosuppressants with less bone marrow toxicity should be considered in patients receiving azathioprine for long-term period.