Association between disseminated intravascular coagulation scores and mortality in patients with traumatic brain injury

Objective@#Disseminated intravascular coagulation (DIC) is common in patients with traumatic brain injury (TBI) and is associated with the prognosis of TBI. We aimed to analyze and compare the performances of the International Society on Thrombosis and Hemostasis (ISTH), the Korean Society on Thrombosis and Hemostasis (KSTH) and the Japanese Association for Acute Medicine (JAAM) scoring systems in predicting in-hospital mortality. @*Methods@#In this retrospective observational study, severe trauma patients with TBI who visited our emergency department between January 2018 and December 2020 were included. Receiver operating characteristic analysis was performed to examine the prognostic performance of the three different DIC scoring systems. The primary outcome was inhospital mortality. @*Results@#A total of 851 patients were included, and the in-hospital mortality rate was 17.7% (n=151). According to the multivariate analysis results, the ISTH (odds ratio [OR], 1.784; 95% confidence interval [CI], 1.320-2.412), KSTH (OR, 2.735; 95% CI, 2.022-3.698) and JAAM (OR, 1.751; 95% CI, 1.473-2.083) scores were associated with in-hospital mortality. The areas under the curves (AUCs) of ISTH, KSTH and JAAM scores for predicting in-hospital mortality were 0.686 (95% CI, 0.654-0.717), 0.708 (95% CI, 0.676-0.738) and 0.762 (95% CI, 0.731-0.790), respectively. The AUC of the JAAM score was significantly different from that of the ISTH and KSTH scores. @*Conclusion@#Three different DIC scores were associated with in-hospital mortality in TBI patients. Among the DIC scores, the JAAM score can be a useful tool for predicting in-hospital mortality in TBI patients.

Estimation of Central Venous Pressure using Ultrasound Imaging of Inferior Vena Cava

PURPOSE: There have been several studies addressing the correlation between central venous pressure (CVP) and ultrasonographic findings of the inferior vena cava (IVC). We performed the present study to discover the degree of correlation between CVP and the area of IVC as measured with ultrasound, and to determine which portion of the IVC shows the best correlation with CVP. METHODS: The present study was prospectively performed in emergency medical center of Chonnam National University Hospital from March 1 to October 31, 2006. Two intrahepatic portions and one extrahepatic portion of the IVC were evaluated. RESULTS: All tested areas of the IVC, and the collapsibility indices measured at each location, showed a substantial correlation with CVP. However, in multiple logistic regression analysis performed to identify the location best correlated with CVP, the area of the IVC just below the hepatic vein-IVC junction proved to be the only location to correlate with CVP with statistic significance. CONCLUSION: Measurement of IVC area using ultrasound can yield important information about a patient's volume status, especially in patients for whom central venous catheter insertion is contraindicated. We suggest that the portion of the IVC just below the hepatic vein-IVC junction is the optimal locatin for area measurement to estimate CVP.

Hypothermic Carotid Arterial Flush for Induction of Selective Cerebral Hypothermia during Cardiac Arrest

PURPOSE: Hypothermia has been demonstrated to protect the brain from reperfusion injury in patients suffering from cardiac arrest. We hypothesized that infusion of normal saline at 4 degrees C into the carotid artery (hypothermic carotid arterial flush, HCAF) during cardiac arrest would achieve selective cerebral hypothermia during cardiac arrest and cardiopulmonary resuscitation (CPR), without a detrimental effect on the rate of return of spontaneous circulation (ROSC) or significant impairment of cardiopulmonary function after ROSC. METHODS: Ventricular fibrillation was induced in 18 dogs weighing 12~18 kg, and circulatory arrest was maintained for 9 minutes. The subjects were then resuscitated using open cardiac massage. Group I (n=6) received no normal saline, while the dogs of group II (n=6) and group III (n=6) received infusions of 15 ml/kg and 30 ml/kg of normal saline solution, respectively, at 4 degrees C into both carotid arteries (cephalad) via 18 gauge catheters. RESULTS: Tympanic temperature decreased from 37.7 (37.5~37.7) degrees C to 34 degrees C within 1.2 (1~2) min and 1.0 (1~2) min from the start of HCAF in groups II and III, respectively. Thereafter, tympanic temperatures were maintained below 34 degrees C to 7.7 (1.5~14.5) min and 21.2 (12~37) min, respectively, from the start of HCAF in groups II and III. There were no significant differences in CPR-related variables or post-ROSC hemodynamic and laboratory variables between the two groups. CONCLUSION: HCAF rapidly induces selective cerebral hypothermia without detrimental effects on the rate of ROSC or significant impairment of cardiopulmonary function after ROSC.

The Expression of TGF-beta1 in Patients with Chronic Atrophic Gastritis / 대한소화기내시경학회지

BACKGROUND/AIMS: Mucosal atrophy is defined as the loss of appropriate glands in the gastric mucosa; such a finding suggests that this malady is associated with an excessive ratio of apoptotic cells to proliferating epithelial cells. However, exactly why the genesis and progression of the atrophic changes takes place in the gastric mucosa of some, but not all of the subjects infected with H. pylori, is seldom described. TGF-beta1 (transforming growth factor-beta1) is a potent growth inhibitor in epithelial tissues, and it also induces apoptosis of epithelial cells. We evaluated its role in the pathogenesis of atrophic gastritis by analyzing the expression of TGF-beta1. METHODS: The subjects were 14 patients with chronic atrophic gastritis and 43 patients with chronic gastritis. The exclusion criteria were as follows; those patients who had a previous history of gastrectomy, PPI, H. pylori eradication, NSAIDs, stomach cancer and/or a severe bleeding tendency. Biopsy specimens were obtained from the antrum, angle and body of the stomach, respectively and we performed RT-PCR for determining the expression of TGF-beta1 mRNA with using an additional angle specimen. RESULTS: The clinical parameters were similar in both groups. The rate of H. pylori infection was also similar in both groups. The TGF-beta1 levels were significantly higher for the chronic atrophic gastritis group than for the chronic gastritis group. CONCLUSIONS: The results that the TGF-beta1 levels are significantly higher in the chronic atrophic gastritis group suggest that TGF-beta1 is associated with the development of atrophic gastritis. The apoptotic process induced by TGF-beta1 may be linked to the development of atrophic gastritis.

Endosonographic Findings Useful in the Differentiation between Malignant and Benign Causes of Thickened Gallbladder Wall / 대한소화기내시경학회지

BACKGROUND/AIMS: The early diagnosis of possible cancer in thickened gallbladder wall is very important. This study was aimed to confirm the usefulness of endoscopic ultrasonography in differential diagnosis of gallbladder cancer in thickened gallbladder wall, and to find out the findings of endoscopic ultrasonography which favor malignancy. METHODS: We reviewed 67 cases of patients who underwent cholecystectomies and who also showed thickened gallbladder wall in their preoperative endoscopic ultrasonography. According to the post-surgical pathologic diagnosis, the cases were classified into malignant and benign diseases, and they were statistically compared with several findings of endoscopic ultrasonography of thickened gallbladder wall. RESULTS: Pathologic diagnosis included 10 cancers and 57 benign diseases. The sensitivity (90%) and specificity (98%) of endoscopic ultrasonography for diagnosis of gallbladder cancer were superior to those of other techniques. Wall thickness, associations of gallstones, loss or preservation of layered structure and irregularity of inner surface of thickened wall were significant variables in the differential diagnosis between malignant and benign causes of thickened gallbladder wall (p<0.05). CONCLUSIONS: Endoscopic ultrasonography is useful to diagnose gallbladder cancer within thickened wall. Loss of layered structure and irregular inner surface of thickened wall are independent predictive factor of gallbladder cancer.

The Value of Endoscopic Ultrasound Guided Fine Needle Aspiration Biopsy in the Differential Diagnosis of Pancreatic Mass / 대한소화기내시경학회지

BACKGROUND/AIMS: Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) is a technique used to distinguish benign and malignant pancreatic mass histologically. The aim of this study was to determine the value and safety of EUS-FNA for the differential diagnosis of pancreatic solid mass. METHODS: The records of forty patients (M : F=24 : 16, median age: 56 yr) who underwent EUS-FNA for the diagnosis of pancreatic solid masses between October 2003 and July 2004 were analyzed. Histological findings obtained by EUS-FNA were compared with the final diagnosis. The sensitivity, specificity, overall diagnostic accuracy, and the rate of complication of EUS-FNA were analyzed. RESULTS: The sites of the lesions were as follows: pancreatic head, n=20 (50%); body, n=10 (25%); tail, n=7 (18%); multifocal, n=3 (8%). The sensitivity, specificity, accuracy and negative predictive values were 71%, 78%, 73%, and 64%, respectively. The diagnostic accuracy was 90% in body lesions, however 65% in head lesions. Transient abdominal pain occurred in one patient (3%) after the procedure; however, there was no case of severe complication.CONCLUSIONS: EUS-FNA is shown to be an effective and safe procedure for establishing a tissue diagnosis in patients with solid pancreatic masses.

Clinical Usefulness of Glucocorticoid Receptor beta Expression and NF-kappa B Activity in Patients with Ulcerative Colitis / 대한소화기학회지

BACKGROUND/AIMS: Glucocorticoid resistance poses a challenging clinical problem in inflammatory bowel disease because more than one fourth of patients with severe ulcerative colitis do not respond to anti-inflammatory steroids. Recently, it has been reported that glucocorticoid response is related to the expression of human glucocorticoid receptor beta (hGRbeta) and nuclear factor-kappa B (NF-kappaB) activity. The aims of this study were to clarify whether these factors may predict the responsiveness before treatment. METHODS: Total RNA was extracted from peripheral blood mononuclear cell (PBMC) and colonic mucosa in 17 patients of ulcerative colitis before steroid administration. RNA was reverse transcribed and the resulting complementary DNA was amplified using specific primers for hGR alpha and beta. Concomitantly, NF-kappaB activity in colonic mucosa was assessed by immunohistochemical stain. RESULTS: The expression of hGRbeta mRNA was detected in 10 patients (58.8%) in PBMC and 8 patients (47.1%) in colon, respectively. Operations were performed in 5 patients due to steroid unresponsiveness. Only 5 of 17 patients (29.4%) were consistent in the expression of hGRbeta between PBMC and colon. Seven of 15 patients (46.7%) showed an alteration in the expression of hGRbeta in PBMC after glucocorticoid treatment. NF-kappaB activity was found in both epithelial cell and lamina propria in 12, epithelial cell alone in 1, lamina propria alone in 1 and all negative in 3 patients, respectively. CONCLUSIONS: The expression of hGRbeta was discordant between PBMC and colon in the same patient and showed a change in the expession after the glucocorticoid treatment in nearly half. The expression of hGRbeta and colonic NF-kappaB activity patterns do not provide useful information about glucocorticoid response in patients with ulcerative colitis.

Relationship between duodenal ulcers and cagA, vacA, and iceA genotypes of Helicobacter pylori / 대한내과학회지

BACKGROUND: The aims of this study were to evaluate whether genotypes of Helicobacter pylori are different between the gastric antrum and duodenal bulb in order to assess the roles of duodenal H. pylori strains in development of duodenal ulcer. METHODS: Forty-eight H. pylori infected patients (duodenal ulcer 28, chronic gastritis 20) were included for the study. Biopsy specimens were taken separately from the antrum and duodenal bulb for the histologic examination and H. pylori culture. cagA, vacA, and iceA genotypes of H. pylori were examined by polymerase chain reaction and H. pylori DNA subtypes by random amplified polymorphic DNA (RAPD) fingerprinting. RESULTS: H. pylori genotypes were not significantly different between antrum and duodenal bulb of the duodenal ulcer and chronic gastritis. RAPD fingerprinting showed different H. pylori strains between the gastric antrum and duodenal bulb in 2 patients with duodenal ulcer. Most prevalent genotype was cagA+ vacA s1/m1 iceA1 in duodenal ulcer (15/16). CONCLUSION: The host factor or other genotypes may play the major roles in duodenal ulcerogenesis compared with H. pylori genotype itself.

Gastric Intramural Hematoma Simulating Submucosal Tumor Following Extracorporeal Shockwave Lithotripsy in a Patient with Pancreatic Duct Stones / 대한소화기내시경학회지

Gastric intramural hematoma is a very rare disease entity. There is no reported case of gastric intramural hematoma in Korea following the extracorporeal shockwave lithotripsy (ESWL). Most have been associated with hereditary coagulopathy, but abdominal trauma, peptic ulceration, and inadvertent ingestion of foreign bodies have been listed as etiologic agents. This is the first description of a case of gastric intramural hematoma simulating gastric submucosal tumor, which regressed spontaneously, following ESWL in a patient with pancreatic duct stones.

A Case of Gastric Emphysema with Portal Vein Emphysema associated with the Episode of Severe Vomiting / 대한소화기내시경학회지

Gastric emphysema is rare but it has a fulminant course with high mortality rate. We report a 58-year old man who visited the emergency room because of severe vomiting and nausea which had started 2 days ago. He underwent curative pylorus-preserving pancreaticoduodenectomy due to ampullary cancer 4 months ago. He was diagnosed as gastric emphysema with combined portal vein emphysema. Only with conservative treatment such as intravenous fluids infusion and decompression of the stomach by nasogastric tube, the condition of the patient slowly improved. The patient was able to discharge without surgical intervention.

Efficacy of Percutaneous Cholangioscopic Ethanol Injection in Hepatocellular Carcinoma Invading the Bile Duct / 대한소화기내시경학회지

BACKGROUND/AIMS: To evaluate the clinical outcomes of the percutaneous cholangioscopic ethanol injection in the hepatocellular carcinoma (HCC) invading the bile duct, we conducted a retrospective study. METHODS: Ten patients who received the percutaneous cholangioscopic ethanol injection were selected patients were diagnosed as HCC invading the bile duct between January 1998 and February 2004. Treatment response, complications, survival or death and survival time were analyzed. RESULTS: Ten patients received mean of 5.3 sessions (range 2~19) of cholangioscopic ethanol injection. Eight patients had decreased tumor mass, and the rest 2 patients had no response. Complications were pain (n=10), hemobilia (n=6: bleeding was minimal), cholangitis (n=2), bile duct rupture (n=1), and bile duct stricture (n=1). Nine patients died from severe hepatic failure and sepsis, one patient has survived for 19 months as of now. Median survival time was 5 months (range 2~19 months). Percutaneous transhepatic biliary drainage (PTBD) could be removed in two patients. CONCLUSIONS: Percutaneous cholangioscopic ethanol injection in HCC invading the bile duct showed size reduction of mass. PTBD could be no longer needed in some patients. However, supportive cares such as PTBD may be appropriate considering their short survival period and risk of procedure.

The Expression of Matrix Metalloproteinases (MMPs), Tissue Inhibitor of Metalloproteinases (TIMPs) and Angiogenesis in Relation to the Depth of Tumor Invasion and Lymph Node Metastasis in Submucosally Invasive Colorectal Carcinoma / 대한소화기학회지

BACKGROUND/AIMS: Lymph node (LN) metastasis occurs in approximately 10% of patients with submucosally invasive colorectal carcinoma. This study was performed to determine the role of matrix metalloproteinases (MMPs), tissue inhibitors of metalloproteinases (TIMPs) production and microvessel formation on the LN metastasis in submucosally invasive colorectal carcinoma. METHODS: A total of forty-one subjects with surgically resected submucosally invasive colorectal carcinoma were included in this study. Immunohistochemical staining of MMP-2, MMP-9, TIMP-1, TIMP-2, and urokinase-type plasminogen activator were performed. Angiogenesis was evaluated by counting the number of microvessels in each pathologic specimen as identified by CD34 immunohistochemical staining. RESULTS: The depth of submucosal invasion was not significantly correlated with the expression of MMP-2, MMP-9, TIMP-1, TIMP-2, or urokinase-type plasminogen activator, but the microvessel count was significantly correlated with the absolute depth of invasion (r=0.312, p<0.05). Upregulation of TIMP-2 was positively correlated with adjacent lymphatic invasion (p<0.05) and increased TIMP-2 expression was correlated with LN metastasis in submucosally invasive colorectal carcinoma (p=0.088). CONCLUSIONS: These results suggest that the expression of TIMP-2 and the microvessel count may be useful parameters for considering additional surgery after endoscopic treatment of submucosally invasive colorectal carcinoma.

A Case of Duodenal Relapse of Epstein-Barr Virus-positive, CD56-negative Extranodal NK/T-cell Lymphoma, Nasal Type / 대한소화기내시경학회지

Mature T-cell and natural killer-cell neoplasms account for 10 to 15% of all non-Hodgkin's lymphomas. Of the various subtypes of mature T-cell and NK-cell lymphomas, extranodal NK/T-cell lymphoma, nasal type (nasal type NK/T-L) is relatively more common among Asians including Koreans. Nasal type NK/T-L is an aggressive, Epstein-Barr virus-associated lymphoma with characteristic expression of NK-cell antigen CD56. In this report, we present an unusual case of EBV(+), CD56(-) NK/T-L of oropharynx which recurred in duodenum after the period of complete remission lasting for 10 years. A 58-year-old woman presented with 3 months history of abdominal pain. Gastroduodenoscopy showed the diffuse wall thickening with multiple ulcerations in bulb and proximal second portion of the duodenum. Pathological examination revealed the infiltration of atypical lymphocytes, which was positive for CD3, CD4, CD5, TIA-1, and EBV and was negative for CD15, CD20, and CD56, consistent with NK/T-L of mature T-cell origin. The past medical history included the presence of oropharyngeal mass 10 years earlier, which was diagnosed as polymorphic reticulosis. The mass resolved completely after the radiation therapy, and she remained free of the disease for 10 years. Upon review, the oropharyngeal biopsy showed an identical morphology and immunophenotype with duodenal lesion. In conclusion, we experienced an unusal case of NK/T-cell lymphoma, nasal type recured in the duodenum.

The Usefulness of Colonoscopic Biopsy in the Diagnosis of Intestinal Tuberculosis and Pattern of Concomitant Extra-intestinal Tuberculosis / 대한소화기학회지

BACKGROUND/AIMS: Intestinal tuberculosis can be difficult to diagnose because it may mimic many other intestinal diseases. The aim of this study was to evaluate the diagnostic yield of colonoscopic biopsy and frequency of concomittent extra-intestinal tuberculosis in intestinal tuberculosis. METHODS: The medical records of 225 consecutive patients with intestinal tuberculosis (81 men, 144 women; mean age 40.6 yrs) were analyzed retrospectively. RESULTS: Histological examination of colonoscopic biopsy specimens revealed granulomas in 163 (72.4%) of the 225 patients. However, caseous necrosis was found in only 25 (11.1%) patients, and acid-fast bacilli (AFB) were noted in 39 (17.3%) of the 225 patients. Mycobacterium tuberculosis was isolated from the culture of biopsy specimens in 52 (29.3%) of 177 patients. Eighty-four patients (37.3%) had concomitant extra-intestinal tuberculosis and 67 (29.8%) showed active pulmonary tuberculosis. Histological examination of the biopsy specimens enabled the diagnosis of intestinal tuberculosis by the presence of either caseating granulomas or AFB in 52 (23.1%) patients. Combination of histological examination and Mycobacterium culture established the diagnosis in 87 (38.7%) patients. Before getting the result of Mycobacterium culture, the diagnosis could be made, by either histological examination or the presence of extra-intestinal tuberculosis in 107 (47.6%) patients. Combination of caseating granulomas, AFB staining, Mycobacterium culture, and the presence of extra-intestinal tuberculosis resulted in the diagnosis in 126 (56.0%) patients. CONCLUSIONS: To increase the diagnostic yield, AFB staining and Mycobacterium culture should be routinely performed on biopsy specimens in addition to routine histological examination for caseating granulomas.

Clinical Characteristics at Diagnosis and Course of Korean Patients with Crohn's Disease / 대한소화기학회지

BACKGROUND/AIMS: The aim of this study was to evaluate the clinical characteristics and course of Korean patients with Crohn's disease (CD). METHODS: A total of 113 patients who were newly diagnosed as having CD at the Asan Medical Center between October 1989 and December 2001 were included. RESULTS: The male to female ratio was 1.9:1 and the mean age at diagnosis was 24.2 +/- 7.8 years. The disease location was the small bowel in 19.5%, the large bowel in 11.5%, and the both small and large bowels in 69.0% of the patients. Empirical anti-tuberculous medications were administered to 53 cases (46.9%). Major complications of CD were intestinal obstruction (25.7%) and perianal fistula (42.5%). The cumulative remission rate was 75.7% at 1 year and 80.7% at 3 years from diagnosis. The cumulative relapse rate was 30.7% at 1 year and 53.0% at 3 years from remission. The cumulative operation rate was 11.5% at 1 year and 13.1% at 3 years from diagnosis. CONCLUSIONS: There are no differences in the remission and recurrence rates between Korean and Western patients with CD. Although the cumulative operation rate seems to be lower in Korea than in Western countries, the cause of the difference is uncertain. Further studies are needed to determine the characteristics of CD in Korea.

Two Cases of Intussusception Occurring through the Stoma after Gastric Surgery / 대한소화기내시경학회지

Intussusception is a rare but potentially serious complication of gastric surgery, and 6 cases have been reported in Korea. Diagnosis can be made by endoscopy, upper gastrointestinal series or computed tomography, but it needs a high index of suspicion for diagnosis. Early diagnosis and prompt surgical intervention is mandatory to avoid mortality. We report two cases of intussusception occurring through the stoma after gastric surgery. A 58-year-old woman presented with epigastric pain and vomiting followed by hematemesis, 30 years after gastrojejunostomy for pyloric obstruction caused by duodenal ulcer. Endoscopy showed jejunogastric intussusception and CT scan was compatible with the diagnosis. She was managed by segmental resection and anastomosis of the jejunum. Another 60-year-old man presented with epigastric pain and hematemesis, 7 years after total gastrectomy with a Roux-en-Y anastomosis for advanced gastric cancer. He was diagnosed as having chronic type jejunal intussusception by endoscopy and CT scan, and intussusception was resolved spontaneously.

A Gastric Hyperplastic Polyp with Intramucosal Adenocarcinoma / 대한소화기내시경학회지

Adenomatous polyps have been well known to be premalignant, but it is still controversial how to treat and follow them up. Up to date, endoscopic resection has been the choice of treatment, particularly exceeding 2 cm, though there is no concensus on the indications for the excision of hyperplastic polyps. The incidence of malignant tissue found in hyperplastic polyps has been reported to be less than 3%, which is considerably lower than the incidence of greater than 6% reported in adenomas. There have been few reports of hyperplastic polyps in which malignant changes developed during endoscopic surveillance. We report a case of hyperplastic gastric polyp with intramucosal, well-differentiated adenocarcinoma with reviewing references.

Clinical Characteristics of Patients with Chronic Constipation after Radical Hysterectomy or Delivery / 대한소화기학회지

BACKGROUND/AIMS: This study was aimed to analyze the clinical characteristics of patients who developed constipation after radical hysterectomy or delivery and to investigate the results of biofeedback therapy for these patients. METHODS: Thirty-five chronic constipation patients with radical hysterectomy (radical hysterectomy group), 27 chronic constipation patients with delivery (delivery group) and 27 constipation patients with no history of hysterectomy or delivery (control group) were included. Clinical characteristics of these patients, including the results of biofeedback therapy, were analyzed. RESULTS: The delivery group showed higher rates of pelvic floor dyssynergia than the control group (14/27, 52% vs. 6/27, 22%; p<0.05). The prevalence of slow transit constipation was lower in the radical hysterectomy group and delivery group than in the control group (7/35, 20% and 5/27, 19% vs. 12/27, 44%; p<0.05). The prevalence of anatomical abnormalities was not different between the groups. The radical hysterectomy group showed higher rate of obstructive sensation and the delivery group showed higher rate of hard stool and digital maneuvers. The biofeedback therapy was effective in 10 out of 12 patients (91%) among the radical hysterectomy and delivery group. CONCLUSIONS: Radical hysterectomy and delivery seem to induce functional constipation, which may be caused by anorectal dysfunction such as pelvic floor dyssynergia. The biofeedback treatment was effective in functional constipation after radical hysterectomy or delivery.

Clinical Characteristics of 17 Cases of Autoimmune Chronic Pancreatitis / 대한소화기학회지

BACKGROUND/AIMS: Autoimmune pancreatitis is a distinctive type of chronic pancreatitis with reversibility. We analyzed the largest number of patients with autoimmune pancreatitis among the studies carried out at a single institution in Korea. METHODS: We retrospectively analyzed the clinical, radiologic, laboratory and histologic features in 17 patients who were diagnosed as autoimmune pancreatitis. RESULTS: The patients were predominately elderly men who presented with jaundice or nonspecific gastrointestinal symptoms. In most of the patients, serum pancreatic enzymes were normal or mildly elevated with an accompanying cholestatic biochemical profile. Elevated IgG levels and detection of autoantibodies were observed in 47% (8/17) and 35% (6/17), respectively. Thirteen patients showed histologic findings of lymphoplasmacytic infiltration and fibrosis, and one patient showed predominant infiltration of eosinophils. Fifteen patients revealed radiologic images of diffuse swelling of pancreas and the sclerosing pattern on direct pancreatogram. All of the features improved in response to oral steroid therapy. Two cases showed focal narrowing with upstream duct dilatation and thus, they were diagnosed as focal type. Diabetes mellitus concurred in 13 cases and primary sclerosing cholangitis and Sjogren's syndrome were present in 1 case, respectively. CONCLUSIONS: The recognition of autoimmune pancreatitis allows patients to avoid unnecessary surgery and recover with the administration of oral steroid.

The Clinical Course of ERCP-related Bowel Perforation / 대한소화기내시경학회지

BACKGROUND/AIMS: The management of small-bowel perforations associated with endoscopic retrograde cholangiopancreatography (ERCP) or endoscopic sphincterotomy (EST) is still controversial. The purpose of this study was to analyze the treatment and outcome of patients with ERCP-related perforations in a single tertiary medical center. METHODS: Of 18,379 cases of ERCPs performed between January 1990 and December 2003, twenty-six patients (0.14%) with perforation were identified and medical chart were reviewed retrospectively. RESULT: EST were performed in 10,231 patients and perforation occurred in 18 patients. Four out of 18 patients with small-bowel perforation related to EST underwent surgical operation and the rest 14 patients recovered with conservative treatment alone. Of the rest 8 perforation patients unrelated to EST, perforation occurred during the insertion of endoscope in 7 patients and catheter manipulation in 1 patient. All but one perforations associated with mechanical injury by endoscope itself were managed with an emergent laparotomy, and the one patient with perforation related to catheter manipulation recovered with conservative treatment. CONCLUSIONS: A small-bowel perforation related to endoscope per se usually required a surgery, but sphincterotomy related perforations rarely did so. The prevalence and mortality rate of small-bowel perforations associated with ERCP and/or EST were 0.14% and 0%, respectively, in a single tertiary medical center.