Adrenalectomy for solitary adrenal metastasis from colon cancer / 대한내과학회지

A 68 year-old woman visited our hospital because of constipation and hematochezia. Colonoscopy revealed an invasive fungating mass with a narrowing of lumen and severe ulceration at the sigmoid colon. An abdominal/pelvic CT scan showed an irregular wall thickening with a 10cm long narrowing at the sigmoid colon, and a 2 cm long right adrenal mass. We did an anterior resection and adrenalectomy. The histology of the specimens of the resected sigmoid colon and adrenal gland was the same. Finally, we diagnosed this case as being an adrenal metastasis from an advanced sigmoid colon cancer. The patient has been well for a year since the adrenalectomy, and been treated by the oral chemotherapeutic agent: doxifluridine 600 mg, leucovorin 90 mg.

Bowel Cleansing Method of Sodium Phosphate: Onset and Duration of Bowel Activity / 대한소화기내시경학회지

BACKGROUND/AIMS: Divided-dose oral sodium phosphate laxative is recommended for bowel cleansing before colonoscopy. Patients need information about the onset and duration of activity of the preparation. This study was designed to develop practical prescribing information for the patients to reduce anxiety and insomnia concerning bowel movement. METHODS: one hundred ninety patients were requested to take 45 mL sodium phosphate in the previous evening and the morning of the procedure, and to complete a questionnaire. The overall quality of bowel cleansing were assessed by endoscopists. RESULTS: Bowel activity began 2.25 (90 percentile: 3.58) hours after the first dose and continued for 6.55 (90 percentile: 8.5) hours. For the second dose the time of onset was 0.85 (90 percentile: 1.67) hours, and bowel activity continued for 3.6 (90 percentile: 5.17) hours. CONCLUSIONS: The onset of bowel activity from the first dose of sodium phosphate starts within 4 hours and it is completed within 8.5 hours for most. We can recommend the patients to take the first dose of NaP solution at 4 p.m. of the previous day of the exam and second dose more than 5 hours earlier before the colonoscopy in the care that the onset of the bowel activity after the first dose take longer thna 4 hours.

Chronic vocal tic disorder presenting as a chronic cough / 대한내과학회지

Scleroderma renal crisis is defined as the new onset of accelerated arterial hypertension and/or rapidly progressive oliguric renal failure. The pathogenesis is not well understood but there is increasing evidence that renin- angiotensin system is involved. We report an one female patient with diffuse scleroderma and renal crisis. Initial treatment with ACE inhibitor was not effective in controlling blood pressure until the temporal initiation of hemodialysis. Predialysis serum creatinine level was 8.4 mg/dL, but after initiation of hemodialysis, adequate control of blood pressure was achieved with ACE inhibitor alone. This case illustrated many features of the syndrome of scleroderma renal crisis and supported the early use of captopril and emergency hemodialysis if indicated.

A Case of Pernicious Anemia with Positive Anti Intrinsic Factor Antibody and Antiparietal Cell Antibody / 대한내과학회지

We present a case of pernicious anemia without history of operation in 52 year old female. She suffered from oral ulcer, gum bleeding, nausea, vomiting, and beefy tongue. She had dysesthesia on the both arm and foot, and hypesthesia of global and stocking type by neurologic examination. Laboratory findings were as follows: serum cobalamin 9.1 pg/mL (normal range: 180-710pg/mL), anti intrinsic factor antibody (strong positive), antiparietal cell Antibody 1:10 (positive), first stage of Schilling test (1.4%). The findings of peripheral blood and bone marrow were compatible with megaloblastic anemia. We report a case of pemicious anemia with positive anti intrinsic factor antibody and antiparietal cell antibody.

The Clinical Significance of Serial Measurement of Cardiac Troponin-T after Percutaneous Transluminal Coronary Angioplasty(PTCA)

BACKGROUND: During and immediately after percutaneous transluminal coronary angioplasty(PTCA), reversible ischemic electrocardiographic change and/of left ventricular dysfunction are developed. But it is not investigated whether there are potential myocardial cell damages following PTCA or not, and the clinical Significance of myocardial cell damage following PTCA. Recently cardiac Troponin-T has been developed as a new myocardial specific marker, especially myocardial damage. The object of this study is to investigate whether potential Myocardial damage following PTCA was occurred and the utility of cardiac Tropoin-T for predicting the complications during and immediately after PTCA. METHODS: The study group comprised 12 patients(M/F;8/4mean age;60 +/- 4year,AMI in 6) undergoing PTCA, Samples for Troponin-T were obtained before, directly after, after 2 hours, 6 hours, and after 12 hours and was determined by enzyme immunoassay on an ES 300 analyzer(Boehringer Mannheim). Discrimination limit for myocardial cell damage is 0.1 ng/ml in normal baseline level but if the baseline level is elevated such as acute myocardial infarction or unstable angina, myocardial cell damage is defined with further increase of cardiac Troponin-T(>0.1 ng/ml) compare to baseline level. RESULTS: 1) The mean duration of total balloon inflation is 10.7 +/- 2(3-22) minutes and the mean duration of single maximal inflation is 3.9 +/- 0.6(1-8) minutes. There are no significant change in concentration of Troponin-T by inflation time. None of the patients showed electroca rdiographic evidence for myocardial infarction. 2) Troponin-T were increased in 2 patients with unstable angina(0.01 vs 0.11 ng/ml) which were developed major dissection including acute closure during PTCA, and 2 patients with acute myocardial infarction(2.37 vs 3.73 ng/ml) which didn't developed dcomplication. The increase of cardiac Troponin-T were observed in 2 of 10 patients with uncomplicated PTCA(20%). 3)The subacute complications were not developed. CONCLUSION: The cardiac Troponin-T were increased significantly in two AMI patients with uncomplicated PTCA(2/10,20%). The increase of cardiac Troponin-T following PTCA is associated with periprocedural complications but the prognostic significance to detect postprocedural complication did not define in this study because there were no subacute complications after PTCA and may be limited value due to time course of complication(usaully within 1 hour after PTCA) and relatively long analytic time.

Prognostic Values of Exercise Testing after Acute Myocardial Infarction

BACKGROUND: Uncomplicated myocardial infarction is often the harbinger of future cardiac events such as unstable angina pectoris,recurrent myocardial infarction or death. The feasibility and safety of exercise testing performed soon after myocardial infarction have been established but the prognostic value of exercise test after myocardial infarction remain inconclusive. The object of this study is to determine whether exercise test results can be utilized to predict of future cardiac events after uncomplicated myocardial infarction. METHODS: The study group comprised 149 patients with an uncomplicated myocradial infarction. A low level exercise test was performed before discharge from the hospital 8 to 10 days after myocardial infarction. The exercise thst results was considered positive if there was new > or =1mm horizontal or downsloping ST segment depression at 0.08 sec after the J point compared with baseline. The patients were followed for the development of new cardiac events. RESULTS: 1) The exercise test after acute myocardial infarction was performed in 149 patients without complication. The mean duration of exercise test was 14 min(range 1-20 min) and the mean work-load(Metabolic equivalents) was 3.7+/-1.1 METs. 2) 37 patients had ST-segment depression, 13 had ST-segment elevation and 27 had an inadequate blood pressure response to exercise. During the exercise, there were angina in 5 patients, dyspnea in 17 and no symptom in 127 patients. 3) During the follow-up period(1 to 75 month, mean 27.4 month), 29 patients experienced post-myocardial infarction angina, 1 had recurrent myocardial infarction, 4 had revascularization therapy(PTCA 2, CABG 2),5 had ischemic cardiomyopathy and 5 died a cardiac death. 4) The patients with cardiac events such as cardiac death, myocardial infarction and post MI angina had a significantly shorter exercise duration(13.1+/-4.0 and 14.6+/-2.7min, p<0.05), lower exercise tolerance(3.5+/-1.0 and 3.9+/-1.0 METs, p<0.05) and lower peak heart rate(117 +/- and 126+/-5, p<0.05). 5) The ST-segment depression, lower exercise tolerance(<3.0 METs) and history of hypertension were associated significantly with cardiac events(p<0.05) but ST-segment elevation, inadequate blood pressure response to exercise, the use of thrombolytic agents and non-Q wave infarction did not predict future cardiac events. Conclusions: The exercise test after acute myocardial infarction is safe and of limited value for predicting patients at risk of cardiac events in the follow-up period. The ST-segment depression and lower exercise tolerance(<3.0 METs) can predict cardiac events and the prognosis of the patients of this group can be improved with aggressive management and careful follow-up.

Early Assessment of Reperfusion Therapy in Acute Myocardial Infarction Using Cardiac Troponin-T

BACKGROUND: An earlier index of reperfusion is desirable to determine whether additional therapy is necessary for myocardial salvage. Using the washout phenomenon of biochemical markers, many investigator have reported noninvasive methods for detection coronary reperfusion in patients with acute myocardial infarction. Recently cardiac Troponin-T has been developed as a new myocardial specific marker, especially myocardial damage. The object of this study is to investigate the utility of cardiac Troponin-T for early assessment of reperfusion therapy. METHODS: The study group comprised 10 patients with acute myocardial infarction and reperfusion therapy that was initiated within 6 hours after the onset of symptoms. Blood samples were taken before treatment, every 30 min interval for 3 hours and then 6, 24, 72 hours after the onset of reperfusion therapy to measuring Troponin-T, Creatin Kinase(CK), and CK-MB level. Serum concentration of cardiac Troponin-T level was measured with immunoassed using ES-300, Boehringer Mannheim. We compared the real reperfusion that was assessed by coronary angiogram, chest pain disappearence and resolusion of St-segment elevation with an index of coronary reperfusion, the increase in Troponin-T(big up tri, open Troponin-T) 60, 90 min after repefusion therapy(Successful Reperfusion Index : Tn-T 60(90)-0>0.3 ng/ml) and the sensitivity, specificity, Positive, and negative predictive value were calculated using this threshold(Successful Reperfusion Index). RESULTS: 1) The studied patients(M/F : 7/3, mean age 54+/-12 year) were treated within 3 hour with thrombolytic therapy(7 patients, t-PA) or emergency angioplasty(3 patients). 2) The cardiac Troponin-T levels in eight patients with successful reperfusion showed early peak within 24 hours after reperfusion therapy were initiated but in 2 patients without successful reperfusion showed sustained increase without early peak within 24 hours. The CK-MB levels in patients with successful reperfusion also showed early peak within 24 hours but 5 of 8 patients showed no significant increase until 2 hours after reperfusion therapy. 3) The sensivity, specificity, positive and negative predictive value for detecting reperfusion using a threshold value of 0.3 ng/ml of big up tri, open Troponin-T 90 min(60 min) after reperfusion therapy was 100%(56%), 50(100%), 89%(100%), and 100%(20%), respectively. CONCLUSION: Serial measurements of cardiac Troponin-T, especially reperfusion index(0.3 ng/ml of big up tri, open Troponin-T 90 min after reperfusion therapy) are useful for early assessment of reperfusion therapy in acute myocardial infarction.

A Case of Anti-Thrombin III Deficiency Discovered by Myocardial Infarction

Anti-thrombin III deficiency is known as a disease of autosomal dominant trait and relatively common, but in Korea, exact incidence and mortality is not known, In general, Anti-thrombin III deficiency is expressed to venous thromboembolism like deep vein thrombosis or pulmonary embolism. But, arterial embolism is very rare. We experienced a case of Antithrombin III deficiency expressed as myocardial infarction of inferior wall by huge thrombosis in the mid and distal right coronary artery.