Optimal Methods for the Management of Iatrogenic Colonoscopic Perforation

BACKGROUND/AIMS: Colonoscopic perforations have been managed with exploratory laparotomy, and have resulted in some morbidity and mortality. Recently, laparoscopic surgery is commonly performed for this purpose. The aim of this study was to compare the outcomes of several management strategies for iatrogenic colonoscopic perforations. METHODS: We retrospectively reviewed the medical records of patients who had been treated for colonoscopic perforation between January 2004 and April 2013 at CHA Bundang Medical Center in Korea. RESULTS: A total of 41 patients with colonoscopic perforation were enrolled. Twenty patients underwent conservative management with a success rate of 90%. Surgical management was performed in 23 patients including two patients who were converted to surgical management after the failure of the initial conservative management. Among 14 patients who underwent surgery at 8 hours after the perforation, there was no considerable difference in adverse outcomes between the laparotomy group and the laparoscopic surgery group. The medical costs and claim rate were 1.45 and 1.87 times greater in the exploratory laparotomy group, respectively. CONCLUSIONS: Conservative management of colonoscopic perforation could be an option for patients without overt symptoms of peritonitis or with a small defect size. If surgical management is required, laparoscopic surgery may be considered as the initial procedure even with a delayed diagnosis.

A Case of Hemosuccus Pancreaticus Associated with Pseudoaneurysm of Splenic Artery / 대한췌담도학회지

Splenic artery pseudoaneurysm (SAP) is a rare condition, occurring from many causes like pancreatitis, peptic ulcer, surgery, abdominal trauma and iatrogenic origins. SAP poses a great challenge to clinicians because it can lead to a variety of symptoms from abdominal pain, nausea, vomiting to massive bleeding into gastrointestinal tracts as well as abdominal cavity. A 43-year-old female who had previously been managed for alcoholic chronic pancreatitis and thrombotic thrombocytopenic purpura was admitted with hematochezia and dizziness. Patient went into shock from bleeding, however, there was no bleeding focus on initial CT scan and gastroduodenoscopy. Shock occurred repeatedly due to the severe blood loss from gastrointestinal tracts. On the 4th day in hospital, duodenal bleeding was suspected on gastrointestinal bleeding scan and bleeding from ampulla of Vater was found on follow-up gastroduodenoscopy. SAP which causes hemosuccus pancreaticus was diagnosed on angiography and it was treated successfully by embolization.

Gastrointestinal Cancers in a Peutz-Jeghers Syndrome Family: A Case Report

A 17-year-old man was diagnosed as Peutz-Jeghers syndrome (PJS) because of pigmented lip and multiple gastrointestinal polyps. He had anemia and underwent polypectomy on the duodenum and colon. His maternal family members were patients with PJS. His mother used to be screened with endoscopy to remove large polyps. One and half years later, he underwent jejunal segmental resection due to intussusceptions. He underwent endoscopic polypectomy every 2 to 3 years. When he was 23 years old, high-grade dysplasia was found in colonic polyp and his mother underwent partial pancreatectomy due to intraductal papillary mucinous carcinoma. When he was 27 years old, diffuse gastric polyps on the greater curvature of corpus expanded and grew. Therefore, wide endoscopic polypectomy was done. Histological examination revealed focal intramucosal carcinoma and low-grade dysplasia in hamartomatous polyps. We report cases of cancers occurred in first-degree relatives with PJS.

Endoscopic Resection of Giant Colonic Lipoma: Case Series with Partial Resection

Colonic lipoma, a very rare form of benign tumor, is typically detected incidentally in asymptomatic patients. The size of lipoma is reported variously from 2 mm to 30 cm, with higher likelihood of symptoms as the size is bigger. Cases with symptom or bigger lesion are surgically resected in principle; endoscopic resection, which has developed recently with groundbreaking advance of endoscopic excision technology, is being used more often but with rare report of success due to high chance of complications such as bowel perforation or bleeding. The authors report here, together with a literature review, our experiences of three cases of giant colonic lipomas showing complete remission after aggressive unroofing technique, at certain intervals, using snare catheter at the origin of the lipoma so that the remaining lipoma could be drained out of the exposed surface spontaneously, in order to reduce complications.

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.

Endoscopic Treatment of Refractory Gastroesohageal Reflux Disease

Though efficient acid suppression with proton pump inhibitors (PPIs) remains the mainstay of treatment of gastroesophageal reflux disease (GERD), some of the patients showed refractory response to PPIs, necessitating further intervention. After increasing dose of PPIs and other kinds of pharmacological intervention adopting prokinetics or others, variable endoscopic treatments are introduced for the treatment of these refractory cases. The detailed introduction regarding endoscopic treatment for GERD is forwarded in this review article. Implantation of reabsorbable or synthetic materials in the distal esophagus was tried in vain and is expelled from the market due to limited efficacy and serious complication. Radiofrequency energy delivery (Stretta) and transoral incisionless fundoplication (EsophyX) are actively tried currently.

PTPBD for Managing Extrahepatic Bile Duct Stones in Patients with Failed or Contraindicated ERCP / 대한내과학회지

BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) occasionally fails due to surgically altered anatomy, difficult cannulation, or poor general condition. This study evaluated the safety and effectiveness of percutaneous transhepatic papillary balloon dilatation (PTPBD) for managing extrahepatic bile duct stones. METHODS: Between 2001 and 2010, 17 out of 509 patients with extrahepatic bile duct stones and acute cholangitis were enrolled retrospectively. After PTPBD of the sphincter, the stones were extracted using an occlusion balloon to push the stone over a guidewire into the duodenum. The procedure success was evaluated based on residual stones. In addition, the size and number of stones and complications were analyzed. RESULTS: Of the 17 patients, nine had a previous gastrectomy, four had poor general condition, and four had unsuccessful cannulation. The stone diameter ranged from 8 to 25 mm. Seven, five, and five patients had one, two, or three or more stones, respectively. The results were successful in 16 out of 17 patients, with no residual stones. Treatment failed in one patient, who was then treated with the rendezvous technique with endoscopy. No procedure-related major complication occurred. Three patients had mild transient elevations of the serum amylase levels. CONCLUSIONS: PTPBD was safe and effective for managing extrahepatic bile duct stones in patients with unsuccessful or contraindicated ERCP.

Rifaximin Plus Levofloxacin-Based Rescue Regimen for the Eradication of Helicobacter pylori

BACKGROUND/AIMS: This study assessed the efficacy of a rifaximin plus levofloxacin-based rescue regimen in patients that had failed both triple and quadruple standard regimens for the eradication of Helicobacter pylori. METHODS: We treated patients for H. pylori between August 2009 and April 2011. The triple regimen consisted of combined treatment with amoxicillin, clarithromycin, and pantoprazole for 1 week. For failed cases, a quadruple regimen of tetracycline, metronidazole, bismuth dicitrate, and lansoprazole for 1 week was administered. The rescue regimen for persistently refractory cases was rifaximin 200 mg t.i.d., levofloxacin 500 mg q.d., and lansoprazole 15 mg b.i.d. for 1 week. RESULTS: In total, 482 patients were enrolled in this study. The eradication rates associated with the first and second regimens were 58% and 60%, respectively. Forty-seven out of 58 patients who failed with the second-line regimen received rifaximin plus levofloxacin-based third-line therapy. The eradication rate for the third regimen was 65%. The cumulative eradication rates were 58%, 85%, and 96% for each regimen, respectively. CONCLUSIONS: A rifaximin plus levofloxacin-based regimen could be an alternative rescue therapy in patients with resistance to both triple and quadruple regimens for the eradication of H. pylori.

Effect of Proton Pump Inhibitor in Patients with Acute Pancreatitis: Pilot Study / 대한소화기학회지

BACKGROUND/AIMS: Oxygen free radicals play an important role in acute pancreatitis. Pantoprazole as a proton pump inhibitor (PPI) has pancreatic anti-secretory effect and a pronounced inhibitory reactivity towards hydroxyl radicals. The objective of the study was to investigate the effect of pantoprazole on the course of acute pancreatitis. METHODS: We conducted a prospective randomized trial involving 40 patients with acute pancreatitis. Patients were divided into two groups. One group received PPI and the other group did not receive PPI. In the PPI group, patients received pantoprazole 40 mg intravenously twice a day for fasting time, and then 40 mg orally twice a day until discharge. RESULTS: There were no significant differences in baseline characteristics and laboratory markers between two groups. In the pantoprazole group, mean hospital stay was 7.4 days, time to start oral intake was 69.0 hours, and time to pain relief was 59.7 hours. Acute physiology and chronic health evaluation (APACHE) II score was 3.15 at admission day and 2.35 at discharge. On the other hand, in the non-pantoprazole group, mean hospital stay was 7.6 days, time taken to start oral intake was 71.4 hours, and time taken to pain relief was 61.8 hours. APACHE II score was 4.4 at admission and 2.85 at discharge. However, there were no significant differences between two groups. CONCLUSIONS: Treatment with pantoprazole did not have influence on the clinical course of acute pancreatitis. But, considering it was a pilot study, large scale prospective trials will be needed.

An Impacted Pancreatic Stone in the Papilla Induced Acute Obstructive Cholangitis in a Patient with Chronic Pancreatitis

Obstructive jaundice is very rarely caused by impaction of a pancreatic stone in the papilla. We report here on a case of obstructive jaundice with acute cholangitis that was caused by an impacted pancreatic stone in the papilla in a patient with chronic pancreatitis. A 48-year-old man presented with acute obstructive cholangitis. Abdominal computed tomography with the reconstructed image revealed distal biliary obstruction that was caused by a pancreatic stone in the pancreatic head, and there was also pancreatic ductal dilatation and parenchymal atrophy of the pancreatic body and tail with multiple calcifications. Emergency duodenoscopy revealed an impacted pancreatic stone in the papilla. Precut papillotomy using a needle knife was performed, followed by removal of the pancreatic stone using grasping forceps. After additional sphincterotomy, a large amount of dark-greenish bile juice gushed out. The patient rapidly improved and he has remained well.

Effect of Proton Pump Inhibitor and Clopidogrel Combination on the Outcome of Patients with Ischemic Heart Disease / 대한내과학회지

BACKGROUND/AIMS: It has recently been suggested that proton pump inhibitors (PPIs) might reduce the inhibitory effect of clopidogrel on platelet aggregation. Co-administration of a PPI and clopidogrel in patients with ischemic heart disease may thus alter clinical outcome. We investigated the effect of concomitant use of a PPI with clopidogrel in Korean patients with ischemic heart disease. METHODS: This is a retrospective cohort study of 99 patients with acute coronary syndrome taking clopidogrel and PPIs after discharge from CHA Bundang Medical Center between January 1, 2003, and December 31, 2007. The control group consisted of 99 patients who were matched for age and sex but were not taking PPIs. RESULTS: Patients who received clopidogrel plus PPI had a greater than two times higher risk of re-admission or death (adjusted hazard ratio 2.51; 95% confidence interval [CI] 1.43~4.40; p = 0.001) than those who received clopidogrel alone. Lansoprazole use was associated with an increased risk of re-admission or death (adjusted hazard ratio 2.66; 95% CI 1.45~4.89; p = 0.002). Combined period of administration or Helicobacter pylori infection did not affect the risk of re-admission or death. CONCLUSIONS: Particular attention should be paid when patients with ischemic heart disease are prescribed a combination of clopidogrel and a PPI, since this combination was associated with an elevated risk of re-admission or death.

The Role of 18F-FDG PET/CT in the Evaluation of Gastric Cancer Recurrence after Curative Gastrectomy

PURPOSE: 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) scans are frequently performed for the screening or staging of malignant tumors. This study aimed to assess the usefulness of 18F-FDG PET/CT in detection of gastric cancer recurrence after curative gastrectomy. MATERIALS AND METHODS: Eighty nine patients who had undergone curative gastrectomy due to gastric cancer and had 18F-FDG PET/CT and contrast CT scans within 2 weeks for surveillance in asymptomatic patients (n = 11) or to clarify suspected recurrence (n = 78) were consecutively collected and retrospectively analyzed. They had clinical follow-up for at least 12 months after PET/CT and CT scans. RESULTS: Fifteen of the 89 patients (16.9%) were diagnosed with recurrent gastric cancer in 21 organs. Forty one organs showed an increase in FDG uptake, and only 9 of these organs were diagnosed with recurrent gastric cancer by 18F-FDG PET/CT. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of the 18F-FDG PET/CT were 42.9%, 59.7%, 29.3%, 78.2%, and 57.3%, respectively. On the CT scan, 18 of 21 recurrent gastric cancers were detected, and 7 cases were in agreement with the 18F-FDG PET/CT. The sensitivity and specificity of the CT scan were 85.8% and 87.3%, respectively, which are superior to the 18F-FDG PET/CT. When we diagnosed a recurrence based on either 18F-FDG PET/CT or CT scans, the sensitivity increased to 95.2% and the specificity decreased to 45.6%, when compared with the contrast CT scan alone. CONCLUSION: 18F-FDG PET/CT is an insufficient diagnostic method in detection of recurrence after curative gastrectomy, and even less accurate than contrast CT scan alone.

A Case of Massive Portal Venous Gas Caused by Fatal Intestinal Infarction

Hepatic portal venous gas (HPVG), a rare radiologic finding, is associated in some cases with severe or lethal conditions requiring urgent surgical intervention. Computed tomography has recently demonstrated a wider range of clinical conditions associated with HPVG, some of which are benign and do not necessarily require surgery. However, HPVG remains an ominous sign in cases of bowel ischemia or necrosis. We report on a case of massive HPVG caused by a fatal intestinal infarction, which showed rapid disease progression, eventually resulting in death due to septic shock. The HPVG in this case was huge and could therefore be confused with an air-biliarygram.

The Usefulness of F18-FDG PET/CT in Detection of Colonic Neoplasm

BACKGROUND/AIMS: The diagnostic value of 2-18F-fluoro-2-deoxy-D-glucose positron emission tomography (FDG PET)/CT in the detection of colon carcinoma and adenoma was evaluated retrospectively. METHODS: Between May 2007 and June 2008, 102 patients (42 males and 60 females: age range, 28-89 years) underwent both FDG PET/CT and colonoscopy in < a 3 month interval. FDG uptake on PET/CT was divided into physiologic and pathologic uptake by a nuclear medicine specialist. Pathologic confirmation was obtained in all patients. RESULTS: Forty-three patients had no abnormal findings on both FDG PET/CT and colonoscopy. One hundred five and 59 colonic lesions were detected on FDG PET/CT and colonoscopy, respectively. Eleven of 24 lesions with pathologic FDG uptake were histologically-confirmed to be malignancies. Among 18 lesions with physiologic FDG uptake, 1 carcinoma and 1 adenoma were revealed. One carcinoma, 25 adenomas, and 11 hyperplastic polyps did not reveal FDG uptake. Interpretation of pathologic FDG uptake in the colon had a sensitivity of 84.6% and 28.2%, a specificity of 90.4% and 88.1%, a positive predictive value of 45.8% and 45.8%, and a negative predictive value of 98.4% and 77.8% for carcinomas and adenomas, respectively. CONCLUSIONS: FDG PET/CT is a very useful diagnostic method for the detection of colon cancer, but the sensitivity is low for adenomas, which may need further evaluation, such as a screening endoscopy.

The Usefulness of F18-FDG PET/CT in Detection of Colonic Neoplasm

BACKGROUND/AIMS: The diagnostic value of 2-18F-fluoro-2-deoxy-D-glucose positron emission tomography (FDG PET)/CT in the detection of colon carcinoma and adenoma was evaluated retrospectively. METHODS: Between May 2007 and June 2008, 102 patients (42 males and 60 females: age range, 28-89 years) underwent both FDG PET/CT and colonoscopy in < a 3 month interval. FDG uptake on PET/CT was divided into physiologic and pathologic uptake by a nuclear medicine specialist. Pathologic confirmation was obtained in all patients. RESULTS: Forty-three patients had no abnormal findings on both FDG PET/CT and colonoscopy. One hundred five and 59 colonic lesions were detected on FDG PET/CT and colonoscopy, respectively. Eleven of 24 lesions with pathologic FDG uptake were histologically-confirmed to be malignancies. Among 18 lesions with physiologic FDG uptake, 1 carcinoma and 1 adenoma were revealed. One carcinoma, 25 adenomas, and 11 hyperplastic polyps did not reveal FDG uptake. Interpretation of pathologic FDG uptake in the colon had a sensitivity of 84.6% and 28.2%, a specificity of 90.4% and 88.1%, a positive predictive value of 45.8% and 45.8%, and a negative predictive value of 98.4% and 77.8% for carcinomas and adenomas, respectively. CONCLUSIONS: FDG PET/CT is a very useful diagnostic method for the detection of colon cancer, but the sensitivity is low for adenomas, which may need further evaluation, such as a screening endoscopy.

Colonoscopic Clipping as a Treatment for Appendiceal Bleeding

Bleeding from the appendix has been reported very rarely in patients with lower-gastrointestinal-tract bleeding. In general, after a colonoscopic diagnosis of appendiceal bleeding, laparoscopic or surgical appendectomy would be recommended. Two patients with continuous bleeding from the appendix were treated with partial occlusion of the appendiceal orifice by colonoscopic clipping. In neither case was there evidence of further active bleeding over the following 12 months. This is the first report of such a treatment in the English literature.

Fatal Biliary-Systemic Air Embolism during Endoscopic Retrograde Cholangiopancreatography: A Case with Multifocal Liver Abscesses and Choledochoduodenostomy

We report a rare case of a massive fatal embolism that occurred in the middle of endoscopic retrograde cholangiopancreatography (ERCP) and retrospectively examine the significant causes of the event. The patient was a 50-year old female with an uncertain history of previous abdominal surgery for multiple biliary stones 20 years prior. The patient presented with acute right upper quadrant pain. An abdominal computed tomographic (CT) scan revealed the presence of multiple stones in the common bile duct (CBD) and intra-hepatic duct (IHD) with biliary obstruction, multifocal liver abscesses, and air-biliarygram. Emergency ERCP showed a wide and straight opening of choledochoduodenostomy, which may have been created during a previous surgery, and multiple filling defects in the CBD. With the use of a forward endoscope, mud stones were extracted through the opening of the choledochoduodenostomy. Cardiac arrest suddenly developed during the procedure, and despite immediate resuscitation, the patient died due to a massive systemic air embolism. We reviewed previously reported fatal cases and accessed factors facilitating air embolisms in this case.

A case of leiomyosarcoma arising from the posterior mediastinum / 대한내과학회지

Primary mediastinal leiomyosarcoma is an extremely rare neoplasm that arises from smooth muscle, usually in the esophagus or main vessels, but rarely from small vessels in the soft tissues of the mediastinum. The clinical findings depend mostly on its size and the subsequent compression of neighboring structures. The treatment of choice is surgical removal. We report the case of a 78-year-old female who presented with esophageal compression symptoms due to a 9-cm inhomogeneous mass in the posterior mediastinum. A computed tomography (CT)-guided gun biopsy and immunohistochemistry established the pathological diagnosis of leiomyosarcoma with a high grade of malignancy. Surgery was performed because of local invasion involving the aorta and diaphragm. The literature is reviewed and the pathology discussed

Bowel Obstruction Caused by an Intramural Duodenal Hematoma: A Case Report of Endoscopic Incision and Drainage

Complications associated with an intramural hematoma of the bowel, is a relatively unusual condition. Most intramural hematomas resolve spontaneously with conservative treatment and the patient prognosis is good. However, if the symptoms are not resolved or the condition persists, surgical intervention may be necessary. Here we describe internal incision and drainage by endoscopy for the treatment of an intramural hematoma of the duodenum. A 63-yr-old woman was admitted to the hospital with hematemesis. The esophagogastroduodenoscopy (EGD) showed active ulcer bleeding at the distal portion of duodenal bulb. A total of 10 mL of 0.2% epinephrine and 2 mL of fibrin glue were injected locally. The patient developed diffuse abdominal pain and projectile vomiting three days after the endoscopic treatment. An abdominal computed tomography revealed a very large hematoma at the lateral duodenal wall, approximately 10X5 cm in diameter. Follow-up EGD was performed showing complete luminal obstruction at the second portion of the duodenum caused by an intramural hematoma. The patient's condition was not improved with conservative treatment. Therefore, 21 days after admission, endoscopic treatment of the hematoma was attempted. Puncture and incision were performed with an electrical needle knife. Two days after the procedure, the patient was tolerating a soft diet without complaints of abdominal pain or vomiting. The hematoma resolved completely on the follow-up studies.

Hepatitis B core antigen expression pattern predicts response to lamivudine therapy in patients with chronic hepatitis B / 대한간학회지

BACKGROUNDS/AIMS: Negative hepatitis B core antigen (HBcAg) staining in hepatocytes is indicative of viral replication by an active immune response. HBcAg is expressed mainly in the cytoplasm in patients with active hepatitis and hepatocyte regeneration, and mainly in the nuclei of hepatocytes in patients with minimal liver injury in the absence of hepatocyte regeneration. The aim of this study was to elucidate whether the existence and expression pattern of HBcAg predicts the response to antiviral treatment. METHODS: The study involved 58 patients with biopsy-proven chronic hepatitis B who were treated with lamivudine. Hepatitis B e antigen (HBeAg), antibody to HBeAg, hepatitis B virus DNA, and alanine aminotransferase in serum were recorded every 3 months. The inflammation grade and the fibrosis stage of chronic hepatitis were scored from 0 to 4 according to lobular inflammation, portal inflammation, periportal inflammation, and fibrosis. RESULTS: The 58 patients included 49(84%) HBcAg-positive patients, with HBcAg staining confined to the cytoplasm in 15(31%) and in both cytoplasm and nuclei in 34(69%). The grade of lobular inflammation and the total histology score were significantly higher in patients with cytoplasmic expression of HBcAg than in HBcAg-negative patients (lobular inflammation: 2.9 vs 2.1, P=0.02; total histology score: 12.2 vs 10.3, P=0.04). The virologic responses at 3, 6, 9, and 12 months differed significantly between the cytoplasmic and mixed expression groups (P<0.01). CONCLUSIONS: The expression pattern of HBcAg (including its possible absence) before initial therapy appears to predict the response to antiviral treatment.