Gastric Outlet Obstruction Due to Gastric Amyloidosis Mimicking Malignancy in a Patient with Ankylosing Spondylitis

Amyloidosis is a group of disorders characterized by the extracellular accumulation of insoluble, fibrillar proteins in various organs and tissues. It is classified, on the basis of the identity of the precursor protein, as primary, secondary, or familial amyloidosis. Gastrointestinal amyloidosis usually presents as bleeding, ulceration, malabsorption, protein loss, and diarrhea. However, gastric amyloidosis with gastric outlet obstruction mimicking linitis plastica is rare. We report a case of gastrointestinal amyloidosis with gastric outlet obstruction in a patient with ankylosing spondylitis. The patient was indicated for subtotal gastrectomy because of the aggravation of obstructive symptoms, but refused the operation and was transferred to another hospital. Three months later, the patient died of aspiration pneumonia during medical treatment.

Bleeding Complications Associated With the Use of Low Molecular Weight Heparin According to the Degree of Renal Impairment / 대한신장학회지

PURPOSE: Low molecular weight heparin (LMWH) is safe and effective in the treatment of acute coronary syndrome (ACS) and venous thromboembolism. Compared with unfractionated heparin (UFH), it is known to have less bleeding tendency in the general population. However, it is not certain whether bleeding complications are decreased by LMWH in patients with renal failure. We postulated that the use of LMWH may lead to increase in bleeding tendency in patients with renal dysfunction. METHODS: We conducted a retrospective study in 486 hospitalized patients who were diagnosed as cerebral infarction or ACS, and treated with enoxaparin or nadroparin from January 2008 to December 2009. Bleeding complications were compared in 3 groups according to estimated glomerular filtration rate (GFR> or =60, 30-59, and <30 mL/min/1.73m2). Age, hypertension (HTN), diabetes mellitus (DM), smoking and usage of antithrombotics were examined and the relationship of these variables with bleeding tendency was analyzed. RESULTS: Compared with group I, the frequency of total bleeding complications increased in patients with group II (p=0.002) and III (p=0.005) regardless of adequate dose reduction. Multiple logistic regression analysis after adjustment for age, HTN, DM, and usage of antithrombotics revealed that decreased GFR groups [odds ratio (OR) of group II was 5.79 (95% confidence interval (CI), 1.23-29.97; p=0.042), OR of group III 5.92 (95% CI, 1.22-27.61; p=0.029)] and DM [OR of DM 7.88 (95% CI; 1.46-46.32, p=0.026)] were two independent factors which affect major bleeding. CONCLUSION: These findings suggest that renal insufficiency, even if it is mild, could affect major bleeding complications in the use of LMWH.

Clinical Effectiveness of Percutaneous Angioplasty for Acute and Chronic Mesenteric Ischemia: A Six Case Series / 대한소화기학회지

Intestinal ischemia is divided into three categories, namely, acute mesenteric ischemia (AMI), chronic mesenteric ischemia (CMI), and colonic ischemia. AMI can result from arterial or venous thrombi, emboli, and vasoconstriction secondary to low-flow states. It is an urgent condition which can result in high mortality rate. The predominant causative factor of CMI is stenosis or occlusion of the mesenteric arterial circulation, and it is characterized by postprandial abdominal pain and weight loss. Surgery is the treatment of choice for intestinal ischemia. However, it has been recently reported that percutaneous transluminal angioplasty with stent placement and/or thrombolysis is an effective therapy in various types of mesenteric ischemia. We report six cases of mesenteric ischemia which were successfully treated by percutaneous angioplasty, and review the literature from South Korea.

Clinical Effectiveness of Percutaneous Angioplasty for Acute and Chronic Mesenteric Ischemia: A Six Case Series / 대한소화기학회지

Intestinal ischemia is divided into three categories, namely, acute mesenteric ischemia (AMI), chronic mesenteric ischemia (CMI), and colonic ischemia. AMI can result from arterial or venous thrombi, emboli, and vasoconstriction secondary to low-flow states. It is an urgent condition which can result in high mortality rate. The predominant causative factor of CMI is stenosis or occlusion of the mesenteric arterial circulation, and it is characterized by postprandial abdominal pain and weight loss. Surgery is the treatment of choice for intestinal ischemia. However, it has been recently reported that percutaneous transluminal angioplasty with stent placement and/or thrombolysis is an effective therapy in various types of mesenteric ischemia. We report six cases of mesenteric ischemia which were successfully treated by percutaneous angioplasty, and review the literature from South Korea.

Trend analysis of grading systems for level of evidence and strength of recommendation

When clinicians or healthcare professionals are to make decisions, they can judge the quality of evidence and reliability of recommendations by 'Level of evidence' and 'Grade of recommendation'. Because of this, the step of grading evidence and recommendations is very important in developing clinical practice guidelines. The objective of this study was to identify the various grading systems and criteria of the clinical practice guidelines. We reviewed 101 guidelines from the National Guideline Clearinghouse Database and chose 66 sets of guidelines to analyze in terms of the grading systems for level of evidence and strength of recommendation. The grading systems for 'Level of evidence' were classified into 4 types by criteria such as study design, study quality, consistency, limitations, strength of evidence, and validity. Type II was the most common evidence grading system applied by 12 organizations (37.5%) and 30 sets of guidelines (45.5%). The grading systems for 'Grade of recommendation' were classified into 4 types by criteria such as level/quality of evidence, strength of recommendations, study quality, consistency, applicability, balance between benefit and harm, and effectiveness/usefulness. Type I was the most common recommendation grading system applied by 9 organizations (33.4%) and 23 sets of guidelines (40.4%). A formal grading system based on consistent and clear approaches is needed because the process of grading work can be subjective when clinical practice guideline users are making decisions. It is necessary for clinical practice guideline developers to have a common criterion so that they can judge the grade of evidence and recommendations objectively in the development of clinical practice guidelines.

Tools for assessing quality and risk of bias by levels of evidence

Tools for assessing methodological quality or risk of bias in randomized controlled trials (RCTs) and non-randomized studies (NRS) were reviewed. The van Tulder scale and Cochrane's assessment of risk of bias are the two most useful methodological quality evaluation tools for RCTs. Cochrane's tool includes sequence generation, allocation of sequence concealment, blinding, incomplete outcome data, selective outcome reporting, and other potential sources of bias. The Cochrane Collaboration Group recommends the Downs and Black instrument and the Newcastle-Ottawa Scale for evaluating the quality of NRS. In conclusion, this study offers useful information to physicians about tools for assessing the quality of evidence in clinical guidelines. Further research is needed to provide an essential core for evidence-based decision making regarding levels and/or grades of recommendations.

A Case of Idiopathic Sclerosing Mesenteritis with Retroperitoneal Fibrosis / 대한소화기학회지

Sclerosing mesenteritis is a rare inflammatory disease of the bowel mesentery. It produces tumor-like masses of the mesentery composed of varying degrees of fibrosis, chronic inflammation, and fat necrosis. It has been described variously as fibrosing mesenteritis, retractile mesenteritis, mesenteric Weber Christian disease, and systemic nodular panniculitis. The etiology and pathogenesis of the disease are as yet unknown, but autoimmune disorder, previous abdominal surgery, trauma, and ischemia could play a role. The clinical features include abdominal pain, vomiting, diarrhea, and constipation. Occasionally, patients with this condition may present with bowel obstruction. Rarely, It can be associated with other idiopathic inflammatory disorders such as retroperitoneal fibrosis, sclerosing cholangitis, and orbital pseudotumors. We report a case of idiopathic sclerosing mesenteritis with retroperitoneal fibrosis in a 58-year-old man.

Intramural gallbladder hematoma mimicking gallbladder neoplasm in a 55-year-old male patient / 대한외과학회지

Hemorrhage in the gallbladder (GB) is usually associated with cholecystitis, GB neoplasm, trauma, hemobilia, and cystic artery aneurysm. Our patient had not experienced any previous abdominal trauma, and GB hemorrhage was unlikely to result from cholecystitis or bleeding diathesis. A 55-year-old male was admitted because of right upper quadrant pain. Both prothrombin time and partial thromboplastin time were normal. Abdominal computed tomography, endoscopic ultrasound and magnetic resonance cholangiopancreatography were performed. Image studies revealed GB wall thickening and an intraluminal mass. Laparoscopic cholecystectomy was performed. Upon opening the GB postoperatively, a large amount of fresh blood and old blood clot was noted. The incidence of GB hematoma is very rare. GB hematoma should always be considered in the differential diagnosis of GB tumor. In such a situation, surgical intervention is needed for further patient evaluation and management. We present a rare case of intramural GB hematoma, of which we were unable to make a definitive diagnosis preoperatively.

A Case of Exceptionally Rapid Growing Cardiac Myxoma / 영남의대학술지

Myxoma is the most common type of primary cardiac tumor and about 75% of myxomas occur in the left atrium of the heart. Most myxomas are diagnosed by echocardiography. The growth rate of myxoma is clearly unknown and newly developed myxoma is difficult to understand clearly the onset of growth. We describe the case of a newly developed huge left atrial myxoma (7x7 cm)which showed no echocardiographic evidence of the tumor four years ago. Four years later the patient underwent transthoracic echocardiography due to preoperative evaluation that was normal. Nine months later, she presented with dyspnea. Transthoracic echocardiography showed a large mass located in left atrium. Pathology showed a myxoma that measured 7x7 cm implying a growth rate of 0.15x0.15 cm/month.

Incidence of tuberculosis in Korean diabetics: Comparison with that in non-diabetic hypertensive subjects / 대한내과학회지

BACKGROUND/AIMS: Tuberculosis remains a major cause of mortality in South Korea, and the prevalence of diabetes is also increasing rapidly. Diabetes is a well known risk factor for tuberculosis. However, the risk varies according to race and regional prevalence. We assessed the potential impact of diabetes as a risk factor for tuberculosis in South Korea. METHODS: We performed a retrospective cohort study in a secondary referral hospital. The incidence of tuberculosis in a diabetic cohort was compared with that in a non-diabetic hypertensive cohort for 6 years. Diabetics who visited our diabetic clinic and non-diabetic hypertensive patients who visited our cardiology clinic from Jan 2004 to April 2004 were assigned to the diabetic cohort and the non-diabetic hypertensive cohort, respectively. Patients in each cohort had to receive medications to control their diseases. Patients with end-stage renal disease, malignancy, or HIV infection were excluded. Relative risk and tuberculosis-free survival rates of each cohort were calculated. RESULTS: The incidences of tuberculosis were 32 in the diabetic cohort (n=2491; mean age, 59.1+/-11.8 years; 44.5% male) and ten in the non-diabetic hypertensive cohort (n=1885; mean age, 59.9+/-12.8 years; 41.6% male). The estimated annual incidences per 100,000 persons were 282.8 and 112.9, respectively. The relative risk was 2.220 (p=0.028; 95% confidence interval, 1.090~4.523). However, no significant difference in cumulative tuberculosis-free survival rate was observed between the cohorts (p=0.075). CONCLUSIONS: A trend for a higher incidence of tuberculosis existed in diabetics, as compared to non-diabetic hypertensive patients, among a Korean population.