Cannulation of the Portal Vein during Endoscopic Retrograde Cholangiopancreatography in a Patient with Choledocholithiasis / 대한소화기학회지

Cannulation of the portal vein is a rare complication of ERCP. This paper reports a case of portal vein catheterization during ERCP in a patient with choledocholithiasis. A 62-year-old man was admitted to the Presbyterian Medical Center with right upper quadrant pain and jaundice. ERCP was performed under the suspicion of obstructive jaundice caused by a radiolucent stone. Bile duct cannulation using a pull-type papillotome was attempted, but it failed. After needle-knife fistulotomy, wire-guided cannulation was performed successfully, and 10 mL contrast was injected. On the other hand, the fluoroscopy image showed that the contrast medium disappeared very quickly. Pure blood was collected when the catheter was aspirated to identify the bile reflux, indicating possible cannulation of the portal vein. The procedure was terminated immediately and abdominal computed tomography showed air in the portal vein. One day after, a follow-up CT scan showed no air in the portal vein. The patient underwent repeated ERCP, and the common bile duct was cannulated. In most cases, isolated portal vein cannulation does not result in severe morbidity. However, it is important to aware of this rare complication so that no further invasive procedure is performed on the patient.

Cannulation of the Portal Vein during Endoscopic Retrograde Cholangiopancreatography in a Patient with Choledocholithiasis / 대한소화기학회지

Cannulation of the portal vein is a rare complication of ERCP. This paper reports a case of portal vein catheterization during ERCP in a patient with choledocholithiasis. A 62-year-old man was admitted to the Presbyterian Medical Center with right upper quadrant pain and jaundice. ERCP was performed under the suspicion of obstructive jaundice caused by a radiolucent stone. Bile duct cannulation using a pull-type papillotome was attempted, but it failed. After needle-knife fistulotomy, wire-guided cannulation was performed successfully, and 10 mL contrast was injected. On the other hand, the fluoroscopy image showed that the contrast medium disappeared very quickly. Pure blood was collected when the catheter was aspirated to identify the bile reflux, indicating possible cannulation of the portal vein. The procedure was terminated immediately and abdominal computed tomography showed air in the portal vein. One day after, a follow-up CT scan showed no air in the portal vein. The patient underwent repeated ERCP, and the common bile duct was cannulated. In most cases, isolated portal vein cannulation does not result in severe morbidity. However, it is important to aware of this rare complication so that no further invasive procedure is performed on the patient.

Bedside Endoscopic Ultrasound-guided Transgastric Gallbladder Aspiration and Lavage in a High-risk Surgical Case Due to Acute Cholecystitis Accompanied by Multiorgan Failure / 대한소화기학회지

Cholangitis and cholecystitis are intra-abdominal infections that show poor prognosis upon progression to sepsis and multiorgan failure. Administration of antibiotics with high antimicrobial susceptibility and removal of infected bile at the initial treatment are important. After undergoing ERCP for diagnostic purposes, a 58-year-old man developed acute cholangitis and cholecystitis accompanied by rhabdomyolysis, multi-organ failure, and severe sepsis. Broad-spectrum antibiotics with bedside endoscopic nasobiliary drainage were administered, but clinical symptoms did not improve. Therefore, bedside EUS-guided transgastric gallbladder aspiration and lavage was performed, resulting in successful treatment of the patient. We report the above described case along with a discussion of relevant literature.

A Case of Cryptococcal Meningitis Mimicking Hepatic Encephalopathy in a Patient with Liver Cirrhosis Caused by Chronic Hepatitis C / 대한소화기학회지

Cryptococcus neoformans, an encapsulated fungus, is an important opportunistic pathogen that can cause meningitis in immunocompromised patients. Since patients with cryptococcemia have high mortality, it is essential to make an early diagnosis and promptly initiate antifungal therapy. However, it is often very difficult to differentiate between cryptococcal meningitis and hepatic encephalopathy in patients with liver cirrhosis, and there is delay in making the diagnosis. Therefore, these patients have a particularly grave prognosis and consequently many patients die before culture results become available. In one study, starting antifungal therapy within 48 hours of the blood culture was associated with improved survival, but patients with liver cirrhosis were significantly less likely to receive antifungal therapy within 48 hours compared to those without liver cirrhosis. Recently, the authors experience a case of a 68-year-old woman with liver cirrhosis who presented with fever and a drowsy mental status. She had a previous history of having been admitted for infection-associated hepatic encephlopathy. Cryptococcal meningitis and cryptococcemia were diagnosed by spinal puncture and culture of cerebrospinal fluid. In spite of adequate treatment, the patient developed multi-system organ failure and eventually expired. Herein, we report a case of cryptococcal meningitis mimicking hepatic encephalopathy in a patient with liver cirrhosis.

Clinicopathological characteristics of synchronous and metachronous gastric neoplasms after endoscopic submucosal dissection

BACKGROUND/AIMS: Endoscopic submucosal dissection (ESD) has become accepted as a minimally invasive treatment for gastric neoplasms. However, the development of synchronous or metachronous gastric lesions after endoscopic resection has become a major problem. We investigated the characteristics of multiple gastric neoplasms in patients with early gastric cancer (EGC) or gastric adenoma after ESD. METHODS: In total, 512 patients with EGC or gastric adenoma who had undergone ESD between January 2008 and December 2011 participated in this study. The incidence of and factors associated with synchronous and metachronous gastric tumors were investigated in this retrospective study. RESULTS: In total, 66 patients (12.9%) had synchronous lesions, and 13 patients (2.5%) had metachronous lesions. Older (> 65 years) subjects had an increased risk of multiple gastric neoplasms (p = 0.012). About two-thirds of the multiple lesions were similar in macroscopic and histological type to the primary lesions. The median interval from the initial lesions to the diagnosis of metachronous lesions was 31 months. The annual incidence rate of metachronous lesions was approximately 3%. CONCLUSIONS: We recommend careful follow-up in patients of advanced age (> 65 years) after initial ESD because multiple lesions could be detected in the remnant stomach. Annual surveillance might aid in the detection of metachronous lesions. Large-scale, multicenter, and longer prospective studies of appropriate surveillance programs are needed.

A Case of Pneumorrhachis and Pneumoscrotum Following Colon Endoscopic Submucosal Dissection

Endoscopic submucosal dissection has been a useful treatment of selected colorectal neoplasia cases. The incidence of perforation related to colorectal endoscopic submucosal dissection is 5-20%. However, while there have been numerous reports regarding retroperitoneal, mediastinal, pleural and subcutaneous emphysema after therapeutic colonoscopy, pneumoscrotum is a relatively rare manifestation of perforation associated with colorectal endoscopic submucosal dissection. In particular, pneumorrhachis, or air within the spinal cord, following therapeutic colonoscopy, is extremely rare. Herein, we report a conservatively treated perforation case as having pneumorrhachis, penumoscrotum, and pneumoperitoneum after colorectal endoscopic submucosal dissection.

A Case of Ingesting Multiple Magnets Removed by Endoscopic Submucosal Dissection / 대한소화기내시경학회지

Foreign body ingestion is common in children, but magnet ingestion is rare. Ingestion of one magnet does not creat a serious problem; however, ingesting multiple magnet can lead to hazardous complications such as pressure necrosis, intestinal perforation, fistula formation, obstruction and intestinal volvulus. Most cases with complications after multiple magnet ingestion require surgical intervention. We report a case of a fistula following the ingestion of seven small, flat and round magnets that were removed successfully by endoscopic submucosal dissection without surgery.

Role of the Alternans of Action Potential Duration and Aconitine-Induced Arrhythmias in Isolated Rabbit Hearts

Under conditions of Na+ channel hyperactivation with aconitine, the changes in action potential duration (APD) and the restitution characteristics have not been well defined in the context of aconitine-induced arrhythmogenesis. Optical mapping of voltage using RH237 was performed with eight extracted rabbit hearts that were perfused using the Langendorff system. The characteristics of APD restitution were assessed using the steady-state pacing protocol at baseline and 0.1 microM aconitine concentration. In addition, pseudo-ECG was analyzed at baseline, and with 0.1 and 1.0 microM of aconitine infusion respectively. Triggered activity was not shown in dose of 0.1 microM aconitine but overtly presented in 1.0 microM of aconitine. The slopes of the dynamic APD restitution curves were significantly steeper with 0.1 microM of aconitine than at baseline. With aconitine administration, the cycle length of initiation of APD alternans was significantly longer than at baseline (287.5 +/- 9.6 vs 247.5 +/- 15.0 msec, P = 0.016). The functional reentry following regional conduction block appears with the progression of APD alternans. Ventricular fibrillation is induced reproducibly at pacing cycle length showing a 2:1 conduction block. Low-dose aconitine produces arrhythmogenesis at an increasing restitution slope with APD alternans as well as regional conduction block that proceeds to functional reentry.

A Case of Argon Plasma Coagulation Therapy for Hemorrhagic Radiation-induced Gastritis / 대한소화기내시경학회지

Hemorrhagic radiation-induced gastritis is a rare but serious complication of upper gastrointestinal radiation treatment, and no simple and effective treatment method has yet been developed. Studies on effective treatment methods for achieving hemostasis in patients with hemorrhagic radiation-induced gastritis are necessary, because the new indications for upper gastrointestinal radiotherapy in the field digestive oncology can potentially lead to an increased incidence of radiation-induced gastric vasculopathy. For the first time in Korea and to the best of our knowledge, we report here on a 59-years-old male patient with hemorrhagic gastritis that was induced by external radiotherapy for ampullary adenocarcinoma. This was all well-treated using Argon plasma coagulation (APC).

Two Cases of Pyloric Stenosis Caused by Endoscopic Submucosal Dissection / 대한소화기내시경학회지

Endoscopic Submucosal Dissection (ESD) has recently become a widely accepted treatment for premalignent lesions of the stomach and early gastric cancer. Post-ESD stenosis is a rare complication of ESD, but this can be caused by the removal of a large lesion when lesions are located near the cardia or pylorus. We experienced two cases of post-ESD stenosis. One developed in a high risk patient and this was treated by repeated balloon dilation. The other occurred in a patient who was without risk factors, but the stenosis improved spontaneously. It is important that we should perform early follow-up endoscopy in patients who are at a high risk for post-ESD stenosis, and administer effective treatment.

A Case of Fibrolipoma of the Colon / 대한소화기내시경학회지

Lipomas of the gastrointestinal tract are rare, and most of them are frequently seen in the colon. This tumor is classified into subtypes by the proportion of the inner mesenchymal components. Fibrolipoma, as a variant type of lipoma, is rich in the fibrous component. It is generally detected incidentally, but sometimes symptoms such as bleeding, abdominal pain or anemia can be observed according to the size, shape and location of the tumor. It can be resected surgically or endoscopically, and then it can be confirmed by the pathologic diagnosis. Recurrence can occur, so follow-up evaluation is needed. We report here on a case of a fibrolipoma of the colon, and the tumor was endoscopically resected.

Myocardial protective effects of nicorandil and verapamil during ischemia-reperfusion in an isolated perfused rat heart

BACKGROUND: To reduce or prevent myocardial injury during an ischemia-reperfusion episode, some pharmacological interventions, including administering nicorandil or verapamil, have becomepopular in clinical situations. Nicorandil is a N-(2-hydroxyethyl)- nicotinamide nitrate ester, and it's effective mainly by opening the K+ ATP channels in the mitochondrial membrane, and verapamil is useful for reducing the endothelial injury of coronary vessels during ischemia. In this study, we aimed to determine the cardioprotective effect when both drugs are used simultaneously. METHODS: Isolated rat hearts (the Langendorff perfusion model) were perfused with Krebs-Henseleit bicarbonate buffer. After 30 minutes of controlled perfusion, we added nicorandil or verapamil separately and both drugs were administered together in another group (the mixed group) and we then induced ischemia for 30 minutes. We measured the heart rate, the developed ventricularpressure and the dP/dT during the control period during drug infusion and during reperfusion at 15, 30, 45 and 60 minutes. RESULTS: During reperfusion, the mixed group showed more favorable results for the developed left ventricular pressure (LVP), the dP/dT and the rate pressure product (RPP). The heart rate was significantly decreased as reperfusion processed in all the groups. CONCLUSIONS: For myocardial protection during ischemia-reperfusion, a mixed drug regimen is more beneficial than a single drug regimen, and this occurs without inducing a significant decrease of the heart rate.

Blood Pressure Response during the Exercise Treadmill Test and the Risk of Future Hypertension and Cardiovascular Disease

BACKGROUND AND OBJECTIVES: Many studies had established the risk factors for cardiovascular disease. The Duke treadmill score has gained widespread acceptance for making the prognosis and diagnosis for patients with cardiac disease. Recently, the changes in blood pressure during and after exercise have also been studied to predict the prognosis of cardiac disease. We examined the relationship between the incidence of hypertension or cardiovascular disease and the changes of blood pressure during a routine exercise treadmill test. SUBJECTS AND METHODS: 256 men were screened, and they performed exercise treadmill tests from March to May, 2000. Those subjects with histories of hypertension and ischemic heart disease or who were newly diagnosed with ischemic heart disease were excluded. 109 subjects were selected for the final analysis. The follow up period was 78 months. Review of medical records and telephone interviews were used for follow up. We defined clinical events as new onset hypertension, ischemic heart disease, congestive heart failure, cerebrovascular accident, diabetes and atrial fibrillation. The peak systolic blood pressure of 182.5mmHg had the highest specificity and sensitivity on the receiver operating characteristic (ROC) curve of the systolic blood pressure for prediction of clinical events. We defined a hypertensive response as a peak systolic blood pressure over 180 mmHg. RESULTS: 43 (39.4%) of the subjects had a hypertensive response on their exercise treadmill test. The mean exercise capacity was higher in the hypertensive response group. No significant differences were found between the hypertensive and non-hypertensive response groups, in terms of age, gender, body weight, height, body mass index and resting blood pressure. 18 (41.8%) of the hypertensive response subjects had clinical events, while only 11 (16.6%) of the non-hypertensive response subjects had clinical events. The hypertensive response group had more clinical events (p=0.006). 14 (32.5%) of the hypertensive response subjects had hypertension, while only 10 (15.1%) of the non-hypertensive response group had hypertension. The hypertensive response group had more hypertension (p=0.044). On the multivariate analysis, the hypertensive response on the exercise treadmill test was an independent risk factor for hypertension and clinical events (odds ratio=3.990, 95% confidence interval; 1.473-10.808, p=0.006). CONSLUSION: These results indicate that the exercise blood pressure response seems to be a risk factor for hypertension and clinical events. Careful medical care and close follow up may be needed for subjects with a hypertensive blood pressure response on the exercise treadmill test. Further study is needed to understand the significance of an exaggerated blood pressure response on the exercise treadmill test.

Predictive Factors of Serious Etiology in Patients with Syncope

PURPOSE: To stratify the risk of syncope by analyzing related risk factors of patients with possibly serious etiology who visit the emergency room with syncope. METHODS: We studied 201 patients who visited the emergency room of Kyungpook National University Hospital with syncope from January 2004 to December 2006. We defined serious etiology as arrhythmia, angina pectoris, myocardial infarction, septic shock, meningitis, cerebral infarction, subarachnoid hemorrhage, brain tumor, significant hemorrhage, and malfunction of cardiac pacemaker requiring immediate treatment and intervention. We analyzed the relationship between 81 risk factors and serious etiology to stratify the risk for patients with syncope. RESULTS: The patient group consisted of 105 males and 96 females with an average age of 56.4+/-20.7 years. Fifty-four patients had serious etiology. Among the 81 risk factors, those identified through univariate and multivariate analysis as having high predictive sensitivity and specificity were shortness of breath (odds ratio [OR]: 18.34, 95% confidence interval [CI]: 5.59-60.16); abnormal electrocardiography (OR: 10.29, 95% CI: 1.43-74.33); hematocrit or =47 years (OR: 6.24, 95% CI: 1.14-34.17); and admission via an out-patient department or by transfer from outside hospital (OR: 4.07, 95% CI: 1.15-14.36). CONCLUSION: Risk factors correlated with serious etiology for syncope are shortness of breath, abnormal electrocardiography, hematocrit or =47 years, and admission via an out-patient department or transfer from an outside hospital.

A Case of Chronic Gastric Eosinophilic Abscess Treated by Endoscopic Submucosal Dissection / 대한소화기내시경학회지

Anisakiasis is a parasitic disease caused by ingestion of raw fish infected with anisakis larvae. The endoscopic features of the gastic mucosa are edema, ulceration and hemorrhage. Chronic gastric anisakiasis forming a submucosal tumor is rare. A 53-year old female was diagnosed with having a 1 cm sized gastric submucosal mass-like lesion by gastroscopy. Endoscopic ultrasonography showed an inhomogenous low echoic tumor with an irregular margin in the submucosal layer. The patient underwent an endoscopic submucosal dissection and band ligation. A serological assay with an enzyme-linked immunosorbent assay for an anisakiasis specific IgG antibody were positive. The pathological finding of the resected mass was centrally denatured larvae with eosinophilic abscess in the submucosal layer. We report a case of chronic gastric anisakiasis that presented as a gastric submucosal tumor that was removed by the endoscopic submucosal dissection method, with a review of the relevant literature.

A Case of Successful Non-surgical Management of Iatrogenic Gastric Perforation with Fluid Collection after Endoscopic Mucosal Resection / 대한소화기내시경학회지

An endoscopic mucosal resection (EMR) is considered to be a potential alternative to surgery for a gastrointestinal tumor on account of it being an improved technique. Since its introduction in Japan in the early 1980s, it is now an accepted modality for removing precancerous lesions or early gastric cancer from the GI tract because it is minimally invasive and preserves the patient's quality of life. The major complications of EMR is bleeding and perforation. The treatment guidelines for iatrogenic perforation after EMR have not been established. Herein, we report a successful case of EMR induced gastric perforation with fluid collection that was successfully treated with non-surgical management.

A Case of Appendicular and Rectal Metastasis from Gastric Cancer Detected by Endoscopic Resection / 대한소화기내시경학회지

A hematogenous or lymphogenous metastasis and a direct or disseminated invasion can occur in cases of a gastrointestinal metastasis. Moreover, a hepatic or peritoneal metastasis is common in advanced gastric cancer. However, a colonic metastasis, particularly an appendicular metastasis, is quite rare. Recently, we experienced a case with an appendicular submucosal tumor-like elevated lesion and multiple rectal elevated lesions during a colonoscopy in an advanced gastric cancer patient. The appendicular lesion was resected endoscopically and a biopsy of the rectal lesions was performed. The pathologic diagnosis was an appendicular and rectal metastasis of a signet ring cell carcinoma. We describe a case of appendicular and rectal metastasis from gastric cancer. The results highlight the importance of considering a metastatic carcinoma when an appendicular or rectal mass is found incidentally in a malignant neoplasm patient.

Conservative Treatment of Colonoscopic Perforations / 대한소화기내시경학회지

BACKGROUND/AIMS: Colonoscopic perforation can be treated by both operative or non-operative methods. Non-operative management, and especially conservative management, may be appropriate for selected individuals. We wanted to verify the usefulness of performing conservative management for treating colonoscopic perforations. METHODS: We reviewed the medical records of the colonoscopic perforation cases that occurred in the recent 5 yrs. 11 cases of perforation occurred from among 8,536 colonoscopic procedures. RESULTS: Ten cases occurred from a therapeutic procedure (five from polypectomy and another five occurred from an endoscopic (submucosal dissection) and one case occurred from a diagnostic procedure. The perforation sites were the ascending colon (three cases), transverse colon (two cases), descending colon (one case), sigmoid colon (two cases), and rectum (three cases). There were five intraperitoneal perforations and five retroperitoneal perforations. All the cases were detected within 12 hours and all the cases had received good bowel preparation. 10 cases were managed conservatively (nothing by mouth, broad spectrum antibiotics and, Levin tube suction). One case was managed by an operative procedure due to the large size of the defect and the patient's wish. All the patients recovered without complications. The mean hospital stay was 9.5 days. CONCLUSIONS: Colonoscopic perforation can managed conservatively in selected cases, such as for those cases that will undergo post-therapeutic colonoscopy and those cases that have undergone good bowel preparation.

A Case of Mesenteroaxial Gastric Volvulus Diagnosed Using Endoscopic Procedure / 대한소화기내시경학회지

Gastric volvulus is characterized by an abnormal rotation of the stomach typically 180degrees left to right around a line joining the relatively fixed pylorus and the esophagus. Gastric volvulus can be classified anatomically as organoaxial, mesenteroaxial or combined, and symptomatically as acute or chronic. Acute gastric volvulus is an extremely rare emergency surgical condition. The classical triad of gastric volvulus are severe nausea with a paradoxical inability to vomit, localized epigastric pain and an inability to pass a nasogastric tube. Gastric volvulus may be suspected on a plain radiological examination of the abdomen as well as by its symptoms. It is confirmed by the specific findings on the esophagogastroduodenoscopy. We report a case of acute mesenteroaxial gastric volvulus, that was treated using laparoscopic reduction and anterior gastropexy.

Two Cases of Juvenile Retention Polyp of Right Colon in Adult / 대한소화기내시경학회지

Colorectal polyps are classified histologically as either neoplastic or nonneoplastic polyps. A juvenile polyp, which is sometimes referred to as a retention polyp, is a type of nonneoplastic polyp. Juvenile polyps are found most commonly in children less than 10 years of age. However, they are also encountered, albeit rarely, in adolescents or adults of all ages. The most common clinical problem is painless rectal bleeding. Most juvenile polyps are found in the rectosigmoid colon, and more than 90% are detected within 20 cm from the anal verge. In Korea, there are some reports of juvenile polyps located in the rectosigmoid colon in adults. We report two cases of juvenile colon polyps in adult that presented as a hematochezia, which were located at the hepatic flexure and ascending colon.