A Case of Percutaneous Transhepatic Gallbladder Papillary Balloon Dilatation / 대한내과학회지

Endoscopic retrograde cholangiopancreatography (ERCP) fails occasionally due to a surgically altered anatomy, periampullary diverticulum, difficult cannulation, or poor general condition of the patient. In these cases, alternative treatment options are necessary, including percutaneous transhepatic biliary drainage (PTBD) or percutaneous transhepatic gallbladder biliary drainage (PTGBD). Here, we report a case of cholangitis treated with percutaneous transhepatic gallbladder papillary balloon dilatation (PTGBPBD). A 61-year-old male was admitted for cholangitis associated with biliary sludge. ERCP cannulation had failed due to the position of the papilla within a large periampullary diverticulum, and PTBD had failed due to a non-dilated intrahepatic bile duct. Following PTGBD, papillary balloon dilatation was completed successfully through the PTGBD tract. The patient tolerated the procedure and was discharged without complications. We conclude that PTGBPBD is an acceptable and safe procedure in a patient with cholangitis who underwent failed ERCP or PTBD procedures.

A Case of Percutaneous Transhepatic Gallbladder Papillary Balloon Dilatation / 대한내과학회지

Endoscopic retrograde cholangiopancreatography (ERCP) fails occasionally due to a surgically altered anatomy, periampullary diverticulum, difficult cannulation, or poor general condition of the patient. In these cases, alternative treatment options are necessary, including percutaneous transhepatic biliary drainage (PTBD) or percutaneous transhepatic gallbladder biliary drainage (PTGBD). Here, we report a case of cholangitis treated with percutaneous transhepatic gallbladder papillary balloon dilatation (PTGBPBD). A 61-year-old male was admitted for cholangitis associated with biliary sludge. ERCP cannulation had failed due to the position of the papilla within a large periampullary diverticulum, and PTBD had failed due to a non-dilated intrahepatic bile duct. Following PTGBD, papillary balloon dilatation was completed successfully through the PTGBD tract. The patient tolerated the procedure and was discharged without complications. We conclude that PTGBPBD is an acceptable and safe procedure in a patient with cholangitis who underwent failed ERCP or PTBD procedures.

Hepatitis B Core Antigen Expression in Hepatocytes Reflects Viral Response to Entecavir in Chronic Hepatitis B Patients

BACKGROUND/AIMS: Hepatitis B core antigen is known to be a major target for virus-specific T cells and also reflects the progression of liver dissease and viral replication. Hepatitis B core antigen expression in hepatocytes leads to altered histological activity, viral replication, and immune response. The purpose of this study is to evaluate whether the topographical distribution of hepatitis B core antigen expression can predict the viral response to entecavir in patients with chronic hepatitis B. METHODS: We enrolled 91 patients with treatment-naive chronic hepatitis B. All the patients underwent liver biopsy, and the existence and pattern of hepatitis B core antigen evaluated by immunohistochemistry. All patients received 0.5 mg of entecavir daily following a liver biopsy. We checked the viral response at 3, 6, and 12 months during antiviral therapy. RESULTS: Of the 91 patients, 64 (70.3%) had hepatitis B core antigen expression. Of the subcellular patterns, the mixed type was dominant (n=48, 75%). The viral response was significantly higher in the hepatitis B core antigen-negative group than in the hepatitis B core antigen-positive group (88.9% and 54.7%, respectively; p=0.001) after 12 months of entecavir therapy. CONCLUSIONS: Chronic hepatitis B patients who are hepatitis B core antigen-negative have a better response to entecavir therapy than do hepatitis B core antigen-positive patients.

Effects of Metabolic Syndrome on Fibrosis in Chronic Viral Hepatitis

BACKGROUND/AIMS: Metabolic syndrome, comprising diabetes, hypertension, central obesity, and dyslipidemia, is increasingly prevalent worldwide. We aimed to study the relationship between metabolic syndrome and the risk of liver fibrosis in patients with chronic hepatitis B (CHB) and chronic hepatitis C (CHC). METHODS: In total, 954 patients (CHB, 850; CHC, 104 patients) with liver biopsy were included in the retrospective analysis. Extensive clinical and histological data were available. Metabolic syndrome was defined using the International Diabetes Federation definition of metabolic syndrome, 2006 criteria. Histological lesions were evaluated according to the histology activity index system. RESULTS: Metabolic syndrome was present in 6% of patients and significantly more prevalent in patients with CHC than in patients with CHB (5% vs 13%, p<0.001). Patients with metabolic syndrome were older among patients with CHB and patients with CHC, and, as expected, were mainly overweight or obese. Fibrosis was significantly more severe in patients with metabolic syndrome than in those without, regardless of whether they had CHB and CHC (CHB, 3.3+/-2.1 vs 2.4+/-1.3, p=0.025; CHC, 2.6+/-1.5 vs 1.3+/-0.7, p=0.006). Liver fibrosis (stages 3 to 4) was independently associated with increased age, higher transaminase level and metabolic syndrome (odds ratio, 2.421; p=0.017). CONCLUSIONS: Metabolic syndrome is associated independently with severe fibrosis in patients with chronic viral hepatitis B and C.

Prevalence of Occult Hepatitis B Virus Infection in Hemodialysis Patients / 대한소화기학회지

BACKGROUND/AIMS: The prevalence of occult HBV infection depends on the prevalence of HBV infection in the general population. Hemodialysis patients are at increased risk for HBV infection. The aim of this study was to determine the prevalence of occult HBV infection in hemodialysis patients. METHODS: Total of 98 patients undergoing hemodialysis in CHA Bundang Medical Center (Seongnam, Korea) were included. Liver function tests and analysis of HBsAg, anti-HBs, anti-HBc and anti-HCV were performed. HBV DNA testing was conducted by using two specific quantitative methods. RESULTS: HBsAg was detected in 4 of 98 patients (4.1%), and they were excluded. Among 94 patients with HBsAg negative and anti-HCV negative, one (1.1%) patient with the TaqMan PCR test and 3 (3.2%) patients with the COBAS Amplicor HBV test were positive for HBV DNA. One patient was positive in both methods. Two patients were positive for both anti-HBs and anti-HBc and one patient was negative for both anti-HBs and anti-HBc. CONCLUSIONS: The present study showed the prevalence of occult HBV infection in HBsAg negative and anti-HCV negative patients on hemodialysis at our center was 3.2%. Because there is possibility of HBV transmission in HBsAg negative patients on hemodialysis, more attention should be given to prevent HBV transmission.

A case of Henoch-Schonlein purpura with intracerebral hemorrhage / 대한내과학회지

Henoch-Sch?nlein purpura (HSP) is an immunologically medicated systemic vasculitis of small blood vessels affecting the skin, gastrointestinal tract, joints, and kidneys predominantly. Neurological complications in HSP include headache, focal cerebral deficit, coma, convulsion, subarachnoid hemorrhage, and chorea. However, intracerebral hemorrhage complicating HSP is rare. We describe a case of HSP with an intracerebral hemorrhage in a 67-year-old female who was diagnosed with HSP and complained of left homonymous hemianopsia and numbness in the right hand during treatment. Brain imaging showed an intracerebral hemorrhage in the occipital lobe. Her symptoms improved after conservative care. Ultimately, the patient died because of vasculitis and a worsening infection. We report the case of an elderly female with an intracerebral hemorrhage in HSP and review the literature.

A Case of Focal Segmental Glomerulosclerosis Associated with Renal Cell Carcinoma / 대한신장학회지

The association between malignancy and glomerular disease has been reported in older patients. Although the relationship between membranous glomerulonephritis or minimal change disease and solid tumors or hematologic malignancies, respectively, are known widely, focal segmental glomerulosclerosis have been described rarely in patients with solid tumors. We describe a patient with renal cell carcinoma who presented to nephrotic syndrome, volume overload and renal failure. On renal biopsy at contra-lateral kidney of renal cell carcinoma, the patient was diagnosed at focal segmental glomerulosclerosis. The proteinuria and renal function were ameliorated after resection renal cell carcinoma. We suggest that the focal segmental glomerulosclerosis is associated with renal cell carcinoma. This is the first case of the clinical cause of focal segmental glomerulosclerosis associated with renal cell carcinoma of papillary type.

Associations of Expressions of HBcAg and HBsAg with the Histologic Activity of Liver Disease and Viral Replication

BACKGROUND/AIMS: Subcellular localization of hepatitis B virus (HBV) core antigen (HBcAg) and HBV surface antigen (HBsAg) is known to be related to the activity of liver disease and the level of HBV replication. The aim of this study was to determine the correlation between histologic activity, viral replication, and the intracellular distributions of HBcAg and HBsAg. METHODS: We enrolled 670 patients with chronic hepatitis B who underwent liver biopsy at Bundang CHA hospital between 1997 to 2007. The data from medical records were reviewed retrospectively. RESULTS: The stage of fibrosis was higher (3.31+/-1.34 vs. 2.43+/-1.39, mean+/-SD, p0.05). CONCLUSIONS: These observations suggest that the histologic activity of hepatitis is higher and viral replication is lower in cHBcAg positive patients than in those with nHBcAg.

Hyponatremia with Non-Cardiogenic Pulmonary edema, Seizure and Rhabdomyolysis after Bowel Preparation / 대한신장학회지

Oral sodium phosphate is commonly used to evacuate the colon and rectum before colonoscopy or colorectal surgery. However, this substance is known to cause electrolyte abnormalities including hyponatremia. The hyponatremic patient usually presents with headache, nausea, vomiting and confusion, but can also present with non-cardiogenic pulmonary edema, seizure and rhabdomyolysis. However, non-cardiogenic pulmonary edema, seizure and rhabdomyolysis caused by hyponatremia associated with bowel preparation have only rarely been reported. We report a case of severe complications including non-cardiogenic pulmonary edema, seizure and rhabdomyolysis associated with hyponatremia following ingestion of sodium phosphate for colonoscopy in a 41-year-old healthy male.

Case Series of ERCP and EST with Rotatable Papillotome (Autotome(R)) in Patients with Billoth II Gastrectomy / 대한소화기내시경학회지

Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST) are the mainstays of the diagnosis and treatment of variable hepatobiliary and pancreatic diseases. The success rate of ERCP and EST in patients who have undergone a Billroth II gastrectomy is lower than in patients with a normal anatomy. Because the view of the ampulla is rotated 180o in patients with Billroth II, several methods (ex, precut biliary needle-knife papillotome or wire-guided billroth II papillotome) have been used for endoscopic sphincterotomy instead of a pull-type papillotome. Using the recently devised pull-type and rotatable papillotome (Autotome(R)), we performed successful ERCP and EST in 2 patients with a Billroth II gastrectomy without complications.