Usefulness of Urinary Trypsinogen-2 Dipstick Test for Diagnosis of Acute Pancreatitis / 대한소화기학회지

BACKGROUND/AIMS: The clinical usefulness of urinary trypsinogen-2 dipstick test is still in controversy. We evaluated the usefulness of urinary trypsinogen-2 dipstick test in patients with acute pancreatitis. METHODS: Urinary trypsinogen-2 dipstick test was prospectively performed in 50 patients with acute pancreatitis, 50 patients with non-pancreatic abdominal pain, and 50 healthy controls. RESULTS: On admission, urinary trypsinogen-2 dipstick test was positive in 36 of 50 patients with acute pancreatitis (sensitivity, 72%) and in 4 of 50 patients with non-pancreatic abdominal pain (specificity, 92%). On the other hand, it was all negative in controls. The sensitivity and specificity of serum lipase were 78% and 94%, respectively. At 24 hours after admission, the positive rate of urinary trypsinogen-2 dipstick test rose from 72% to 94% (p=0.02). The results of urinary trypsinogen-2 dipstick test was positive in 14 of 15 patients with severe pancreatitis and 22 of 35 patients with mild pancreatitis according to the criteria by Atlanta International Symposium, 1992. CONCLUSIONS: Urinary trypsinogen-2 dipstick test is comparable to serum lipase in diagnosing acute pancreatitis. Delayed measurement and severe pancreatitis are more likely to yield positive results with urinary trypsinogen-2 dipstick test. Thus, we suggest that the cut-off value of urinary trypsinogen-2 dipstick test should be lowered to increase its sensitivity.

Lifestyle Disease

The term "lifestyle disease" was introduced in response to the proposal by the Council on Public Health in Japan (December, 1996), replacing the traditional name of "adult disease". This new term represents a concept of "a group of diseases where symptomatic appearances and progress are affected by living practices including eating, exercising, rest, smoking, and drinking". Generally, the development of a lifestyle disease is influenced by external environmental factors such as various pathogenic organisms, toxic substances and hereditary factors. However, it is clear that in many cases the development and aggravation of diseases such as diabetes, high blood pressure, cancer, cerebrovascular disease and heart disease also deeply involves lifestyle habits such as eating, exercise, and rest.

Type of Electric Currents Used for Standard Endoscopic Sphincterotomy Does Not Determine the Type of Complications / 대한소화기학회지

BACKGROUND/AIMS: The blended current is usually used for endoscopic sphincterotomy (EST) to minimize bleeding. The pure cutting current may induce less edema of the ampulla and therefore result in less injury to the pancreas theoretically. The aim of this study was to evaluate effects of electric currents used on the development of serum pancreatic enzyme evaluation, clinical pancreatitis or bleeding after EST. METHODS: One hundred and eighteen consecutive patients who underwent EST with standard papillotome alone for the treatment of choledocholithiasis were reviewed. All EST had been performed by two endoscopists whose experience on EST was similar: one uses 'blended current' (BC group, n=74), while the other uses 'pure cutting current' (PC group, n=44). RESULTS: Baseline clinical, laboratory, and procedural parameters were similar in both groups. The incidences of hyperamylasemia and hyperlipasemia were similar between two groups. There was no significant difference in the incidence of clinical pancreatitis between two groups (BC 6.8% vs PC 0.0%, p=0.1557). All episodes of pancreatitis were mild. No episodes of significant bleeding occurred after EST. The incidences of sepsis, cholangitis and perforation were also not different between two groups. CONCLUSIONS: Development of complications after standard EST such as hyperamylasemia, clinical pancreatitis, and bleeding may not depend on the electric current used.

Ovarian Cystadenofibroma in a Patient with Familial Adenomatous Polyposis / 대한소화기내시경학회지

Familial adenomatous polyposis (FAP) is a hereditary disease characterized by the appearance of numerous polyps in the large bowel with a high potential for malignant transformation unless untreated. A variety of extracolonic manifestations were reported such as osteoma, epidermoid cyst, desmoid tumor, gastroduodenal polyps, small bowel tumor, congenital hypertrophy of the retinal pigment epithelium, hepatobiliary tumor, thyroid tumor, and tumor of the central nervous system. However, the ovarian involvement of FAP as an extracolonic manifestation was very rare and there have been only few reports. We experienced a rare case of ovarian cystadenofibroma in a patient with FAP as an extracolonic manifestation. We also found colon cancer with multiple hepatic metastasis initially manifested as intestinal obstruction in the same patient. Surgical treatment and subsequent chemotherapy for colon cancer and intraoperative radiofrequency ablation of hepatic metastasis were performed.

A Case of Gangliocytic Paraganglioma in Duodenum / 대한소화기학회지

Duodenal gangliocytic paraganglioma derived from neural crest is a peculiar neuroendocrine tumor. It is incidentally found during radiographic studies or due to gastrointestinal hemorrhage caused by frequent ulceration of the overlying mucosa. Most lesions are pedunculated and submucosal with distinctive histology consisting of endocrine cells, ganglion cells and spindle-shaped Schwann cells. We experienced a duodenal gangliocytic paraganglioma in a 40-year-old woman presenting with episodes of melena. Esophagogastroduodenoscopy revealed a submucosal ulcerated tumor in the second portion of duodenum and a biopsy confirmed gangliocytic paraganglioma. The tumor was enucleated through a duodenotomy. It's size was 5.5 X 3 X 1.5 cm sized and revealed positive cellular reaction for chromogranin, synaptophysin, neuron-specific enolase, and neurofilament by immunohistochemistry. The majority of the reported duodenal gangliocytic paraganglioma were of benign nature. Therefore, radical surgery or a lymph node dissection could be avoided if that disease was confirmed. However, thorough investigation for lymph node metastasis and postoperative follow-up are needed. We report the first case of a duodenal gangliocytic paraganglioma in Korea with a review of literature.

Autoimmune Pancreatitis with Effective Steroid Therapy

Autoimmune pancreatitis has recently been described as a clinical entity that causes chronic pancreatitis. This unique form of chronic pancreatitis is characterized by minimal attacks of abdominal pain, irregular narrowing of the pancreatic duct, and a diffuse enlargement of the pancreas. Autoimmune pancreatitis is associated with hypergammaglobulinemia. In addition, there is histological evidence of lymphoplasmacytic inflammation, the occasional coexistence of other autoimmune diseases, and has a favorable response to glucocorticoid treatment. Recently autoimmune pancreatitis has been increasingly reported particularly in Japan. We report two patients with autoimmune pancreatitis who were treated successfully with corticosteroid therapy.

Endoscopic Mucosal Resection Using Insulated-tip Electrosurgical Knife / 대한소화기내시경학회지

BACKGROUND/AIMS: Endoscopic mucosal resection (EMR) has become a standard treatment for gastric mucosal neoplasm. A new EMR technique, using an insulated-tip electrosurgical knife (IT-EMR), was developed for large mucosal lesions. The aim of this study was to evaluate the efficacy and complication of IT-EMR. METHODS: IT-EMR was performed for 28 gastric mucosal lesions in 27 patients. En bloc resection rate, complete resection rate and complications were evaluated. RESULTS: IT-EMR was performed successfully in 27 lesions, and one lesion was failed because of the presence of a non-lifting sign. En bloc resections were achieved in 24 lesions (88.9%), and piecemeal resections in 3 lesions. Complete resections were achieved in 23 lesions (85.2%). There were 6 episodes (22%) of bleeding which were controlled completely by endoscopic treatment, and there was no perforation. Ten lesions (37%) were adenocarcinoma, 4 (14.8%) were high-grade dysplasia, and 12 (44.5%) were low-grade dysplasia. CONCLUSION: IT-EMR for large gastric mucosal neoplasm is a useful method for wide safety margin completeness of resection by en bloc resection.

Oral Tegafur-uracil Plus Folinic Acid versus Intravenous 5-fluorouracil Plus Folinic Acid as Adjuvant Chemotherapy of Colon Cancer

To compare, in terms of compliance, toxicity, quality of life (QOL) and efficacy, intravenous 5-fluorouracil plus folinic acid with oral tegafur-uracil plus folinic acid as postoperative adjuvant chemotherapy after curative resection in patients with Dukes' stage B2 and C2 colon cancer. Among all patients with adenocarcinoma of the colon operated on between July 1997 and June 1999, 122 with Dukes' stage B2 or C2 colon cancer were enrolled in this study. Fifty-three patients were treated with intravenous 5-fluorouracil plus folinic acid (5-FU group) and 69 with oral tegafur-uracil plus folinic acid (UFT group). Compliance, toxicity, QOL and efficacy were evaluated. Compared with the 5-FU group, patients in the UFT group experienced a lower incidence of grade 1 toxicity. The incidences of grade 2-4 toxicity were similar in the two treatment groups. However, severe toxicity (grade 3 or 4) was rare in both groups. A steady and significant increase of the QOL score, both during and after therapy, was evident in both groups suggesting that chemotherapy is quite tolerable and does not deteriorate the patients' QOL. At the median follow-up duration of 28 months, the survival rate and disease free survival rate for the UFT and 5-FU groups were 94.9% vs. 92.5% and 87.5% vs. 84.1%, respectively (p > 0.05). These data suggest that oral tegafur-uracil modulated with oral folinic acid as an adjuvant chemotherapy in patients with Dukes' stage B2 and C2 colon cancer may be a good alternative to infusional 5- fluorouracil.

Migration of Pyloric Self-Expanding Metallic Stent to the Esophagus / 대한소화기내시경학회지

Self-expandable metallic stent (SEMS) has been reported to provide effective treatment alternatives with minimal morbidity for patients with malignant gastroduodenal obstruction. Limitations of SEMSs are stent occlusion due to tumor ingrowth or overgrowth and stent migration. Migrated stents may remain in the stomach or travel distally. To our knowledge, however, migration of pyloric SEMS to the esophagus has not been reported. We experienced such a case in a 65-year-old woman who had undergone a gastrojejunostomy and choledochojejunostomy due to unresectable pancreatic head cancer. Pyloric SEMSs (Niti-S Pyloric Bare Stent, 18x60 mm, Taewoong Medical, Korea) were deployed at the obstructed efferent and afferent loops. After severe vomiting, a pyloric SEMS placed at the afferent loop migrated into the esophagus, which caused severe chest pain and intractable hiccup. It was removed endoscopically. This case illustrates that pyloric SEMS can migrate to the esophagus through the lower esophageal sphincter.

Endoscopic Findings and Results of Long-term Follow-up of Low Grade Gastric MALT Lymphoma / 대한소화기내시경학회지

BACKGROUND/AIMS: We aimed to evaluate the long-term outcome of patients with MALT lymphoma in respect to various treatment modalities and clinicopathologic characteristics, including endoscopic findings. We also tried to deduce suitable strategic guideline to treat MALT lymphoma. METHODS: We retrospectively studied 55 patients (24 males and 31 females) aged 23 to 74 years who had primary low-grade gastric MALT lymphoma that were diagnosed between May 1992 and August 2002. RESULTS: The majority of endoscopic findings showed lesions with ulceration or with color and surface change of mucosa. All but one was H. pylori positive when tested. Treatment modalities included anti H. pylori treatment, radiation, surgery and/or chemotherapy. Eradication was successful in all the 29 patients associated with H. pylori infection. Complete remission was obtained in 24 patients (82.8%). Only one patient suffered a relapse after 28 months during the follow up (2~74 months). The duration to reach complete remission was 12 months (85 percentile, 2~33 months). Six patients showed complete remission with radiation therapy. Two of them were H. pylori treatment failure cases. One of 14 patients treated by surgery displayed relapse during follow-up (12~20 months). Endoscopically, the ulcerative and/or the protruding type showed unfavorable response to anti H. pylori treatment. CONCLUSION: H. pylori eradication alone should be considered as an initial treatment for MALT lymphoma and radiation therapy could be preferred in patients with no evidence of H. pylori infection or who do not response to H. pylori eradication therapy 12 months after successful eradication.

Development of Decision Support System for Case Management Under the DRG PPS(Prospective Payment System): for the Case of Cesarean Section / 대한의료정보학회지

Recently, we have experienced with various changes in the health insurance. Korean government is implementing the prospective payment system(PPS) as a pilot project to reduce medical expenditure. Case management is an effective way to reduce costs, while not sacrificing quality of service, under the PPS. In this study, the integrated decision support system(DSS) for case management was presented to support two case management activities ; utilization management and discharge planning. This system can be used in three ways ; prospective, concurrent, and retrospective management. By monitoring cases from medical record database, the DSS provides basic patient information, payment information, medical service information to the case manager. In the future, data warehouse should be introduced to integrate various databases related to case management and to improve quality of information produced by the DSS.

A Case of Hepatosubphrenic Fistula Treated by Histoacryl(R) Injection by ERCP / 대한소화기내시경학회지

Acute hepatic failure, liver infarction, abscess, intrahepatic biloma, and multiple intrahepatic aneurysms could be complicated after transcatheter arterial embolization (TAE) in a patient with hepatocellular carcinoma. Conservative managements such as nutritional support and control of sepsis for gastrointestinal fistula have been recommended for the last few decades. Histoacryl(R) has been applied to treat gastrointestinal fistula. We report a case of liver abscess after TAE followed by hepatosubphrenic abscess in a patient with hepatocellular carcinoma. The fistula between liver abscess and subphrenic abscess was occluded with Histoacryl(R) injection by ERCP. Endoscopic nasobiliary drainage and percutaneous drainage were performed respectively. Both abscesses were treated, but the patient died of hepatic failure.

Usefulness of hydrocolonic sonograpy in the staging of colorectal cancer / 대한내과학회지

BACKGROUND: The purpose of this study was to evaluate the usefulness of hydrocolonic sonography (HUS) in local staging of colorectal cancer. METHODS: Thirty patients with colorectal cancer underwent HUS for clinical TNM staging before operation and then the preoperative staging was correlated with postoperative histological stage. RESULTS: All cases were correctly localized by HUS. The accuracy of depth of invasion (T staging) was 70% in overall cases. When divided into colon and rectal cancer, T staging was more accurate in colon cancer (88%), however, less accurate in rectal cancer (46.1%). The accuracy was higher especially in aspect of pericolic fat infiltration (93%). In N staging, the accuracy was 60% in overall cases, 71% in colon cancer and 46% in rectal cancer, respectively. The accuracy of N staging by HUS were somewhat poor on the whole due to technical properties. CONCLUSION: HUS is very valuable with respect to T staging, especially in colon cancer rather than in rectal cancer. N staging was somewhat doubtful in both. Because HUS is easy, noninvasive, and readily available at any place, it would be useful method for local staging colon cancer, especially T staging.

A Case of Congenital Anomaly of the Pancreatic Duct Discovered in a Child with Recurrent Acute Pancreatitis / 대한소화기내시경학회지

Congenital pancreatic duct anomalies result from an error in the complex developmental process. Congenital pancreatic duct anomalies may be categorized by their mechanisms into migration anomaly, fusion anomaly, and duplication anomaly. These ductal abnormalities have been implicated to be potential causes for both acute and chronic pancreatitis. We have recently observed a congenital anomaly of the pancreatic ducts in which bifurcated main pancreatic ducts drain through the major papilla in a 10 year-old boy presenting with recurrent acute pancreatitis. Although its causal relationship with acute pancreatitis is unclear, this kind of pancreatic ductal anomaly has not been found in the literature.

Total Necrosis of Hepatocellular Carcinoma Due to Spontaneous Occlusion of Feeding Artery

Spontaneous total necrosis of hepatocellular carcinoma is extremely rare, with only 15 cases reported to date in the English literature, and the involved mechanism remains unresolved. This paper describes a case of spontaneous necrosis of hepatocellular carcinoma in a 70-year-old man with chronic hepatitis. The patient suffered epigastric pain on admission and computed tomography revealed a 4 cm mass with low density in the left lobe of the liver. Fine needle aspiration biopsy revealed a few scattered, naked and irregular nuclei exhibiting nuclear hyperchromasia in the dirty necrotic background, a finding highly suggestive of malignancy. The lobectomized liver revealed a 3.5 cm, well encapsulated, round, and nearly totally necrotic mass. On microscopic examination, the tumor was found to be composed of thick trabeculae of necrotic tumor cells, supporting the diagnosis of hepatocellular carcinoma. After surgery and throughout 13 months of follow up the patient has recovered well.

Determination of the origin of the extrahepatic bile duct stones by magnetic resonance cholangiography (MRC) / 대한내과학회지

BACKGROUND: Extrahepatic bile duct stones can be classified into two types. Primary stones are formed de nevo in the bile duct, whereas secondary stones migrate from the gallbladder into the bililary tree. The differentiation between primary and secondary stones is very difficult before operation. The aim of this study is to determine the origin of extrahepatic bile duct stones by analyzing MRC features. METHODS: MRC was obtained in 38 patients with stones in both the common duct and gallbladder. MRC findings were compared for gross characteristics and MR signal patterns between common duct stone and gallbladder stone pairs. The gross morphologic characteristics of gallstones on MRC were classified into oval, polygonal, round, rod, sandy and mixed shape. Gallstone patterns seen on heavily T2-weighted images were categorized into one of two patterns: dark, and mixed signal. RESULTS: According to the morphologic characteristics on MRC images, the common duct stones were oval (n=9), polygonal (n=15), round (n=6), sandy (n=4), mixed (n=3) and rod (n=1). The visualized MR signal patterns of common duct stones on heavily T2-weighted images were dark (n=28) and heterogenous (n=10). CONCLUSION: On MRC, the gross morphologic characteristics and gallstone patterns of common duct stones were similar to those of their paired gallbladder stones in 60.5 to 78.9% of patients.

Determination of the origin of the extrahepatic bile duct stones by magnetic resonance cholangiography (MRC) / 대한내과학회지

BACKGROUND: Extrahepatic bile duct stones can be classified into two types. Primary stones are formed de nevo in the bile duct, whereas secondary stones migrate from the gallbladder into the bililary tree. The differentiation between primary and secondary stones is very difficult before operation. The aim of this study is to determine the origin of extrahepatic bile duct stones by analyzing MRC features. METHODS: MRC was obtained in 38 patients with stones in both the common duct and gallbladder. MRC findings were compared for gross characteristics and MR signal patterns between common duct stone and gallbladder stone pairs. The gross morphologic characteristics of gallstones on MRC were classified into oval, polygonal, round, rod, sandy and mixed shape. Gallstone patterns seen on heavily T2-weighted images were categorized into one of two patterns: dark, and mixed signal. RESULTS: According to the morphologic characteristics on MRC images, the common duct stones were oval (n=9), polygonal (n=15), round (n=6), sandy (n=4), mixed (n=3) and rod (n=1). The visualized MR signal patterns of common duct stones on heavily T2-weighted images were dark (n=28) and heterogenous (n=10). CONCLUSION: On MRC, the gross morphologic characteristics and gallstone patterns of common duct stones were similar to those of their paired gallbladder stones in 60.5 to 78.9% of patients.

Clinical characteristics and prognosis of hepatocellular carcinoma in relation to the type of hepatitis virus / 대한내과학회지

BACKGROUND: Hepatocellular carcinoma(HCC) is one of the important causes of cancer-related mortality and morbidity in East Asia, including Korea. Most of the hepatocellular carcinoma in Korea are associated with hepatitis B and C virus infection. The clinical characteristics and prognosis of the patients with HCC were evaluated in relation to the type of hepatitis virus. METHODS: A retrospective analysis of the clinical data and survival rate was done in 603 patients(M:F=4.9:1, mean age; 54.2 years) who were admitted to Yonsei medical center from April, 1991 through April, 1994. RESULTS: Among 603 patients, tests for HBsAg and anti-HCV was done simultaneously in 455 patients. Out of the 455 HCC patients, 303 patients (66.6%) were classified as Group B(HBsAg+ve, anti-HCV-ve), 102 patients (22.4%) were classified as Group C (HBsAg-ve, anti-HCV+ve), 45 patients (9.9%) were classified as Group non-BC (HBsAg-ve, anti-HCV-ve), and 5 patients (1.1%) were classified as Group BC (HBsAg+ve, anti-HCV+ve). The mean age of the patients in Group C was older than that of Group B (64.9 vs. 51.3 yr) (p400 ng/mL) was significantly higher in Group B than in Group C (70.0 vs. 52.0%)(p<0.05). According to the gross type, nodular type was more common in Group C than in Group B(72.0 vs. 38.1%) (p<0.01). The incidence of portal vein thrombosis was significantly lower in Group C compared with that in Group B (16.7 vs. 31.4%)(p<0.05). The number of the patients whose tumor size of less than 5 cm was significantly higher in Group C than in Group B (35.3 vs. 17.8%) (p<0.05). Using multivariant analysis, independent prognostic factors were found to be Child grading, FP level, size of the tumor, gross type, and the type of hepatitis virus. The cumulative survival rate of 1, 2, and 3 year in each Group was 31.5%, 17.5%, and 10.8%, respectively in Group B, and 55.7%, 30.2%, and 21.6%, respectively in Group C. The median duration of survival of Group B was significantly shorter than that of Group C(5.0 vs. 13 months)(p<0.05). CONCLUSION: About 90 % of HCC was associated with hepatitis B or C viral infection in Korea. Hepatitis B virus associated HCC had poorer prognosis compared with hepatitis C virus associated HCC in Korea.

A New Covered Biliary Metal Stent versus Uncovered Wallstent for Malignant Biliary Obstruction / 대한소화기내시경학회지

BACKGROUND/AIMS: In order to provide a complete obstacle to tumoral growth, we designed a new self-expandible metal stent fully covered with polyurethane membrane. The purpose of the study was to compare the safety and effectiveness of a new membrane-covered Niti-S stent versus conventional uncovered Wallstent. METHODS: In a prospective trial, 59 patients with malignant extrahepatic biliary obstruction received either a newly developed covered metal stent (Niti-S stent, 30 cases) or an uncovered metal stent (Wallstent, 29 cases) by the endoscopic transpapillary route. RESULTS: Effective biliary decompression was achieved in all patients initially, and short-term results were similar in both groups. Stent failure was observed in 4 of the 30 patients (13%) after a median period of 165 days in the Niti-S group and in 8 of the 29 patients (28%) after a median period of 152 days in the Wallstent group. The reasons of stent failure were occlusion (n=3) and migration (n=1) in the covered Niti-S stent group and occlusion (n=8) in uncovered Wallstent group. According to the Kaplan-Meier life table analysis, the patency rates after 90, 180, and 360 days were 100%, 90%, and 74% in covered Niti-S stent group and 100%, 73%, and 61% in uncovered Wallstent group respectively. The occluded membrane-covered Niti-S stent was easily removed endoscopically and a new Niti-S stent was reinserted in one patient. CONCLUSIONS: The new, membrane-covered Niti-S stent has a lower stent failure rate and a tendency toward long-term patency rate compared to uncovered Wallstent. The covering may effectively prevent tumor ingrowth and it is sometimes possible to remove an occluded Niti-S stent.

Successful Treatment of Multiple Superficial Gastric Antral Bleeding with Alto Shooter(TM) in a Patient with End Stage Renal Disease / 대한소화기내시경학회지

Diffuse or multifocal superficial gastrointestinal bleeding can be treated by endoscopic laser, argon plasma coagulation, heater probe, or electrocoagulation. However, these methods need relatively expensive equipments and clinical experience. Recently, Alto Shooter(TM) (Kaigen Co. Ltd., Osaka, Japan) which can spray 100% sodium alginate was developed to control gastrointestinal bleeding as a topical therapy. We herein present a 47-year-old man with end stage renal disease in whom multiple superficial gastric antral bleeding was successfully managed by the use of Alto Shooter(TM). This method is easy and relatively cheap to use and seems to control superficial bleeding effectively from vascular lesions or after endoscopic biopsy.