2022 Seoul Consensus on Clinical Practice Guidelines for Functional Constipation

Chronic constipation is one of the most common digestive diseases encountered in clinical practice. Constipation manifests as a variety of symptoms, such as infrequent bowel movements, hard stools, feeling of incomplete evacuation, straining at defecation, a sense of anorectal blockage during defecation, and use of digital maneuvers to assist defecation. During the diagnosis of chronic constipation, the Bristol Stool Form Scale, colonoscopy, and a digital rectal examination are useful for objective symptom evaluation and differential diagnosis of secondary constipation. Physiological tests for functional constipation have complementary roles and are recommended for patients who have failed to respond to treatment with available laxatives and those who are strongly suspected of having a defecatory disorder. As new evidence on the diagnosis and management of functional constipation emerged, the need to revise the previous guideline was suggested. Therefore, these evidence-based guidelines have proposed recommendations developed using a systematic review and meta-analysis of the treatment options available for functional constipation. The benefits and cautions of new pharmacological agents (such as lubiprostone and linaclotide) and conventional laxatives have been described through a meta-analysis. The guidelines consist of 34 recommendations, including 3 concerning the definition and epidemiology of functional constipation, 9 regarding diagnoses, and 22 regarding managements. Clinicians (including primary physicians, general health professionals, medical students, residents, and other healthcare professionals) and patients can refer to these guidelines to make informed decisions regarding the management of functional constipation.

Successful Endoscopic Resection of a Rectal Gastrointestinal Stromal Tumor Larger Than 5 cm / 대한소화기학회지

Preoperative imatinib treatment for rectal gastrointestinal stromal tumors (GISTs) has been reported to reduce the tumor size and help preserve the anal sphincter function. On the other hand, preoperative imatinib may prevent an accurate assessment of the recurrent risk. The endoscopic resection of rectal GIST is rarely reported because of challenges that include securing the visual field and avoiding perforation. This paper reports a case in which a 5.5×4.0 cm sized rectal GIST was treated effectively by an endoscopic submucosal dissection (ESD) without preoperative imatinib. To date, the patient had no tumor recurrence or complications and is receiving adjuvant imatinib treatment. This case shows that ESD may be a good treatment option to preserve the anus in rectal GIST treatment.

Salvage Endoscopic Resection for Residual Lesion after Definitive Chemoradiotherapy in Esophageal Cancer / 대한소화기암학회지

Definitive chemoradiotherapy (CRT) with its significant efficacy and safety in esophageal cancer is reserved for patients with unresectable tumor or those who decline surgery. However, the incidence of locoregional failure or recurrence after definitive CRT remains high. Although esophagectomy is the standard treatment for locoregional failure or recurrence, this approach is associated with high mortality and morbidity. A 56-year-old man diagnosed with esophageal squamous cell carcinoma who refused to undergo surgery received definitive CRT. An endoscopy for response assessment performed after 2 months revealed a residual lesion, which was completely resected by salvage endoscopic submucosal dissection. To the best of our knowledge, endoscopic resection in locoregional failure or recurrence after definitive CRT is very rarely reported, and there are no guidelines or consensus to date. Here, we report a case of successful salvage endoscopic resection of residual lesion after definitive CRT.

The Usefulness of Serum Lipid Concentration as a Predictor of Convulsion in Patients with Glufosinate Ammonium Poisoning

PURPOSE: Glufosinate ammonium (GA; phosphinothricin) can induce neurological complications such as altered mental status, amnesia, and convulsions. This study was conducted to evaluate whether blood lipid profiles can help predict convulsions in patients with GA poisoning. METHODS: This study was a retrospective review of data acquired at a tertiary academic university hospital from March 2014 to July 2016. Independent t-test, Mann-Whitney test and Analysis of covariance (ANCOVA) of demographic and laboratory findings of 50 patients with GA poisoning were performed to identify correlations of general characteristics and laboratory findings, including blood lipid profiles of GA-poisoned patients between with and without convulsions. RESULTS: Convulsion as a GA complication showed a significant association with poison volume, age, white blood cell count, and creatine phosphokinase (CK), albumin, lactate dehydrogenase (LDH), low-density lipoprotein (LDL), and high-density lipoprotein (HDL) content in blood according to an independent t-test and Mann-Whitney test. However, ANCOVA demonstrated significant association with LDL and triglyceride. CONCLUSION: Blood lipid profiles, especially serum LDL and triglyceride, were useful in predicting convulsions in patients with GA poisoning.

The Utility of Measuring the Difference between the Two Optic Nerve Sheath Diameters Using Ultrasonography in Predicting Operation Indication in Patients with Traumatic Brain Hemorrhage

PURPOSE: An increase in optic nerve sheath diameter (ONSD) has been associated with elevated intracranial pressure due to brain lesions, such as hemorrhage, infarction, and tumor. The aim of this study was to evaluate whether the difference of both ONSDs can predict surgical treatment in patients with traumatic brain hemorrhage. METHODS: A prospective analysis of the data acquired between September 2016 and November 2016 was performed. We included 155 patients with traumatic brain hemorrhage undergoing computed tomography in the emergency room. We performed an ultrasonography to measure ONSDs for all included patients. The primary outcome of this study was operation indication in patients with traumatic brain hemorrhage. RESULTS: The average age was 63.4±17.0 years (male 60.3±17.3, female 69.8±14.4). There were 61 (39.35%) patients with an indication for operation and 94 (60.65%) patients with an indication for no operation. Indications for operation showed a strong association with the difference of both ONSDs in patients with subdural hemorrhage (p<0.001), no association between them in patients with epidural and intracerebral hemorrhage. In patients with subdural hemorrhage, the area under the curve was 0.988 (0.653-0.998), and the cut-off value for the difference of ONSDs with respect to determining the indications for operation was 0.295 mm f maximizing the sum of the sensitivity (96.9%) and specificity (90.7%) using the receiver operating curve. CONCLUSION: A difference of both ONSDs above 0.295 mm was useful in predicting the indications for operation in patients with traumatic subdural hemorrhage, but not in patients with epidural and intracerebral hemorrhage.

Top of the Basilar Syndrome after 2nd Cervical Spine Fracture

Top of the basilar (TOB) syndrome occurs with occlusion of the rostral portion of the basilar artery that supplies blood to the midbrain, thalamus, and temporal and occipital lobes. Symptoms associated with TOB include decreased alertness, abnormal eye movement, dysarthria, and disorders of cerebellar function. A 47-year-old man was transferred to our hospital to manage C2 vertebral fracture sustained in a traffic accident. He was alert on arrival; however, he lapsed into semicoma. He was diagnosed with TOB. Thrombolytic agents could not be administered due to a contraindication in cervical spine fracture. Brain magnetic resonance imaging showed acute infarction of the pons, cerebellum, and posterior cerebral artery territory. This rare case demonstrates that C2 vertebral fracture can result in TOB.

Experience of a Medical Assistance for Disaster Caused by a Typhoon of Haiyan in the Philippines

PURPOSE: On November 8, 2013, Typhoon Haiyan attacked the Philippines, causing damage to many houses and trees as well as loss of many lives. A medical team from our hospital and university was sent to Philippines in order to provide medical assistance. We wish to describe our experiences of disaster medicine and discuss problems and improvement points. METHODS: We analyzed the characteristics of patients who received medical treatment administered by us at Tagobon city in the Philippines for five days. RESULTS: We provided medical services to 951 patients for five days. Most patients visited us for medical treatment not trauma. Almost all chief complaints were associated with respiratory, gastrointestinal, dermatologic, and ophthalmologic symptoms. We mainly treated the patients with medications. CONCLUSION: During the subacute period after the disaster, most patients complained of medical and dermatologic problems due to lack of sanitation rather than traumatic complications. Medical assistance for disaster should be administered appropriately according to the types of diseases that occurduring each period after disaster.

Methemglobinemia from Antifreeze Containing Sodium Nitrite

Sodium nitrite is commercially used as a coloring agent, food preservative, and corrosion inhibitor. Accidental poisoning with sodium nitrite from contaminated food and water causes gastrointestinal irritation, vasodilatation, and methemoglobinemia with subsequent tissue hypoxia. We describe an outbreak case of sodium nitrite-induced methemoglobinemia following the ingestion of noodles contaminated with industrial antifreeze. The eEight patients involved initially complained that their noodles tasted 'unpleasant' and soon afterwards experienced nausea, vomiting, dizziness, and fatigue. Some of them noted cyanosis on their lips and fingers. Subsequent investigations demonstrated a high methemoglobin concentration which was corrected by the intravenous administration of methylene blue three hours after the onset of symptoms. The patients made a prompt, uncomplicated recovery and were discharged home 4 four days later. Industrial antifreeze contains sodium nitrite and calcium nitrite. Because an accidental poisoning of industrial antifreeze causes fatal methemoglobinemia, emergency physicians should promptly identify its symptoms and institute treatment with methylene blue promptly. In addition, industrial agencies must caution construction businesses against such contamination events.

Delayed Esophageal Perforation after Cervical Spine Plating

Although anterior approaches to the cervical spine are popular and safe, they cause some of complications. Esophageal perforation after anterior spinal fusion is a rare but potentially life-threatening complication. We present a rare case of delayed esophageal perforation caused by a cervical screw placed via the anterior approach. A 43-year-old man, who had undergone surgery for complete cord injury at another orthopedic department 8 years previously, was admitted to our institute due to painful neck swelling and dysphagia. Radiological studies revealed a protruding screw and esophageal perforation. The perforation was found during surgery and was successfully repaired. This case emphasizes the need for careful long-term follow-up to check for delayed esophageal perforation in patients that have undergone anterior cervical spine plating.

Validation of the Pentax-AWS Airwayscope as a Prehospital Intubation Device by Korean Level 1 Emergency Medical Technicians; A Simulation Study Using an Airway Training Manikin

PURPOSE: Tracheal intubation in the pre-hospital setting may be lifesaving in severely ill and injured patients. The aim of the current study was to evaluate whether use of the video laryngoscope, when used by Korean level 1 emergency medical technicians, resulted in faster or more secure facilitation of tracheal intubation, compared with the conventional laryngoscope with the immobilized cervical spine lying on the ground. METHODS: Thirty two level 1 EMTs working as 119 rescuers performed tracheal intubation on a manikin using the Macintosh laryngoscope (McL) and the Pentax-AWS(R) airwayscope (AWS) "on-the-bed" and "on-the-ground" in simulations with or without cervical spine immobilization. We compared intubation time, dental injury, and visual analog scale for both types of laryngoscope. RESULTS: In the McL trial, four participants failed on the bed, and 11 failed on the ground with cervical immobilization. In the AWS trial, all participants successfully secured the airway regardless of cervical spine immobilization both on the bed and on the ground. With the AWS, intubation time was not lengthened due to cervical spine immobilization either on the bed or on the ground. The AWS score was better than the McL on the visual analog scale in ease of handling the laryngoscope both on the bed and on the ground. And use of the AWS resulted in the lowest number of dental compressions. CONCLUSION: We conclude that the AWS is an effective and safe device for use in pre-hospital intubation with cervical spine immobilization, not only on the bed but also on the ground, when used by Korean level 1 EMTs. However, conduct of further studies is required in order to validate the clinical relevance of these findings.

Two Cases of Post Traumatic Cerebral Infarction in Head Injury

We present cases of post traumatic infarction after head injury. Two patients were admitted to our emergency room after traffic accidents. They developed neurological deficiency after a few hours to days after the accidents. In both cases, an initial computed tomography scan of the head was normal. A follow-up computed tomography obtained later revealed a hypodense lesion at cerebral hemisphere and a diffusion-weighted magnetic resonance imaging disclosed an area of infarction. The patients were conservatively medicated. One patient died due to a medical complication and the other patient fully recovered in several weeks. Hospital admission, careful observation and early diffusion-weighted magnetic resonance examination should be considered for patients with persistent neurological deficits.

Analysis of the Risk Factors Influencing the Severity of Injury in Pediatric Multiple Trauma Patients

PURPOSE: The purpose of this study is, first, to analyze the risk factors that influence the severity of injury in pediatric multiple trauma patients and, second, to present solutions for the problems related to the treatment of such patients. Our living situations are so complicated that the danger of accidents is truly open to children who are not prepared. We need to draw attention to the increased numbers of various accidents involving children. METHODS: We studied patients who visited the Emergency Medical Center at Chosun University Hospital from January 1, 2006, to December 31, 2008. Using medical records, we evaluated the general characteristics: the mechanism of injury, the vital signs, the revised trauma score (RTS), the injury severity score (ISS), and the hemoglibin value, which was checked at the time of visit, and the presence or the absence of emergent on regular surgery. We divided the level of injury as follows: light level (1-8 points), mid level (9-15 points), and serious level (above 16 points). We analyzed the medical data by using SPSS 17.0 for windows. RESULTS: The average age of the patients examined was 8.6 years. The number of 6- to 11-year-old patients was 96, which was the largest, but the degree of injury severity was the highest among infant (0-2 years), according to ISS 7.95(+/-6.85). The frequency of accidents was highest on sunny days, and most accidents occurred from 16:00 to 20:00. The cause of multiple trauma for children was the greatest in the traffic accident, (95 patients, 49.0%). In addition, the trauma caused by traffic accidents showed the highest ISS value (9.02+/-6.42) and the most serious degree (P=0.004). The ISS level of injury (8.40+/-6.64) for patients moved from a secondary hospital was higher than that (6.49+/-5.57) for patients who visited the medical center directly. The severity of injury was highest for patients who used a 119 ambulance (8.84+/-5.80). According to the injured parts of body, Injuries to the arms and the feet most frequent (79 patients, 40.7%), but the level of injury was the highest for internal organs and chest, 16.42+/-8.56 and 11.23+/-6.97, respectively. CONCLUSION: We used Abbreviated Injury Scale (AIS) in order to examine the characteristics by injured body part for pediatric multiple trauma patients. Because the degree of injury was the highest for internal organs or the chest, we need to more seriously examine and provide for patients who are suspected of having injuries to the internal organs or the chest. We need to quickly determine the need for surgery in patients with serious injuries to the arms and the feet, which is the greatest in frequency. In particular, we need to consider the surgical care of patients who are not very high in the severity of injury to their brains.

A Study on the Effect of the Depressive Disorder in Suicidal Attempt Aspect

PURPOSE: The number of suicide attempts has increased in Korea. Depressive disorders are a major cause. This study investigated the clinical characteristics and outcomes of attempted suicide victims who had been admitted to the emergency department based on a psychiatric disorder. METHODS: We performed a retrospective analysis of 168 suicide attempters who visited the Chosun University hospital emergency medical center between June 1st, 2007 and May 31st, 2008. From chart reviews, we divided the victims into three groups by psychiatric histories, especially depressive disorder. We analyzed the effect of various factors including age, sex, previous suicide attempts outcome of suicide attempts. We used Pearson's chi-square test to chart the statistical data. RESULTS: Depressive patients had significantly more suicide attempts than other psychiatric patients and more than those who had no psychiatric history. Repeated attempts were also more frequent in depressive patients (64%). Sixty percent of depressive patients were admitted into our hospital or local clinic and eight percent of depressive suicide attempters died. Compared to other national statistics, there were fewer persons who consulted with a psychiatrist, but depressive patients had more interviews with psychiatrists (62.9%) than did the other groups. CONCLUSION: Even if the depressive disorder patient group shows a high recurrence rate, it also shows a high psychiatric interview acceptance rate and a relatively low rank on physical and psychiatric severity. Therefore, it is possible to prevent the recurrence of suicide attempts for the depressive group and to reduce the fatality rate. This can be done through on-going educational opportunities and psychiatric interviews. The rate of psychiatric consultations in Korea are significantly lower than in other countries. This situation requires more active psychiatric consultations and interviews later on.

Virulence Characteristics of Sucrose-fermenting Vibrio vulnificus Strains / 대한진단검사의학회지

We identified 6 sucrose-fermenting Vibrio vulnificus strains and examined their virulence characteristics. They were all encapsulated, motile, capable of producing toxins and utilizing transferrin-bound iron, cytotoxic to cultured cells, and virulent enough to kill mice. They could be definitely identified only by genetic identification methods such as PCR, and not by conventional culture-based identification methods such as API 20E (bioMerieux, France). These results indicate that it is essential to adopt genetic approaches as early as possible in order to avoid misdiagnosis of such strains, especially in clinical situations.

A Study on Organophosphate Poisoning Patients: Comparison of the Survivor Group and Dead Group

PURPOSE: Organophosphate insecticide poisoning is common in Korea, but there is no definitive guideline for determining the severity of the poisoning and the predictive factors. Therefore, we evaluated the organophosphate poisoned patients and we divided them into two groups, the survivors and the dead, and the results might be useful for treating organophosphate poisoning patients. METHODS: We performed a retrospective analysis of 68 organophosphate poisoned patients who visited the Chosun University Hospital Emergency Medical Center during a 24-month period from January, 2007 to December, 2008. We made a work sheet of the patients' characteristics and the collected data was analyzed and we compared this data between the survivor group and the dead patient group. RESULTS: There were significant differences between the survivor group and the dead patient group for the mean age, the alcohol intake state and the typically expressed signs. The dead patients had lower blood pressure, tachycardia and a lower Glasgo Coma Score (GCS) score than the survivor group. On the arterial blood gas analysis, the dead patients had more severe acidemia and they had lower saturations. Increased serum amylase levels were found in the dead patients. The survivors' initial and follow up serum pseudocholinesterase activity (after 6~8 days) was significantly higher than that of the dead group. The total amount of atropine injected to patient was less in the survivors than that in the dead patients. CONCLUSION: Old age and expressing the typical intoxication signs, a lower GCS score and blood pressure, showing acidosis on the gas analysis and low serum cholinesterase activity may be useful as poor prognostic indicators for patients with organophosphate poisoning. We suggest that physicians must pay careful attention to the signs and prognostic factors of organophosphate insecticide poisoned patients.

Analysis of the Factors that Influence the Severity of Injury of Pedestrian Traffic Accident Patients in an Emergency Department

PURPOSE: Pedestrian traffic accident (TA) deaths account for 40% of Korea's annual TA fatalities. With that in mind, we reviewed the cases of traumatic pedestrian TA patients admitted to emergency medical centers in Korea. We analysed factors affecting the severity of injury in order to investigate risk factors for subsequent traumatic threats. METHODS: Prospective methods were applied using a prepared trauma recording format. Trauma records included patient factors (age, gender, occupation, underlying disease), accident factors (time of accident, weather conditions, transportation time, vehicle type causing the accident, influence of alcoholic on both drivers and victims, accident location), and other factors (means of initial hospital admittance transportation). We reviewed medical records to obtain data for vital signs, Glasgow coma scale (GCS), abbreviated injury scale (AIS), injury severity score (ISS), and trauma and injury severity score (TRISS). We divided subjects into 3 groups according to their ISS scores: mild (1-8 points), moderate (9-15 points), severe (>==16 points). These groups were compared with each other regarding degree of severity? RESULTS: We analyzed data for 23,392 traumatized patients that presented at an EMC. Of the 23,392, 252 (3.1%) were pedestrian TA patients. Among this pedestrian cohort, males 156 patients (male 61.9% and female 38.1%; p=0.332). Mean age was 43.1 (+/-19.9). Severity was greater in those over 40 years of age compared those under 40 (p=0.000). Farmer's had the greatest severity than patients in other occupations (p=0.004). Those with an underlying disease showed a higher degree of severity (p=0.028). The most common accident site was city roads (85.7%) but the degree of severity at such sites did not was not significantly greater (p=0.052). Sports utility vehicle (SUV) had the highest rate of accident severity (p=0.004). Cases involving drunken drivers had victims with higher severity (p=0.005). CONCLUSION: Factors that increase the rate of fatalities pedestrian TAs are: older age, underlying illness, working in the agricultural sector, driving an SUV, the patient being in a drunken state.

A Case of Toxic Epidermal Necrolysis (TEN) Induced by Nonsteroidal Anti-Inflammatory Drug (NSAID)

A patient who was transferred to our Emergency Medical Center from a local clinic with a dermatologic disorder of unknown origin presented to us with TEN with a 40% skin slough. The patient was a 53-year-old women with complaints of erythematous rash and blisters on her trunk and both proximal extremities. She had taken NSAIDS, 1300 mg per oral, every 8 h for 5 days. Five days after administration of NSAIDS began, the doctors at the local clinic noted that a rash with blisters had begun on her back and progressed to her extremities. After 4 days of that progression she came to us. On physical examination, she had asymptomatic multiple clear filled bullae and erosion with brown- to black-colored hyperpigmentation on her trunk and proximal extremities involving 40% of the body surface. She was admitted to a private room to prevent secondary infections, and her management included fluid replacement, third-generation cephalosporin and corticosteroid administration, and intensive wound care. Fifteen days after admission, no further treatment was required, and only a small scar and a mild dispigmentation lesion could be seen. Emergency department physicians should think about TEN if the patient has extensive exfolating skin lesions. Treatment of patients with suspected TEN must be directed at minimizing fluid and electrolyte loss and preventing secondary infection, and an effort should be made to identify the suspicious drug and to educate patient to avoid the drug.

Influence on a Doctorless Island Residents' Health Care Utilization by Video Telemedicine

PURPOSE: Video telemedicine system is efficient method of health care delivery that uses communication technologies via the internet and video-conferring to provide real-time video remote health provider, patient, or both. Video telemedicine system has the potential to improve access to the specialty of emergency medicine, particularly in rural and remote settings. Inadequate maintenance of ongoing health issues can result in high-cost care for both acute illness and long-term complications, whereas prevention of even a small percentage of these costs can pay for the cost of a video telemedicine system. METHODS: We visited a doctorless island on September 8th, 2006 and studied the public health status of the citizens, making charts while giving a free medical examination and treatment. We maintained and analyzed the charts for one year and then surveyed citizens to evaluate the effectiveness of video telemedicine system and to query them regarding future remedies. RESULTS: Out of 178 cases using video telemedicine system, 99 cases were the first medical examination and 12 cases were emergent, with 7 cases resulting in transfer to a mainland hospital. Of the patients transferred to the 3rd grade hospital, 41.4% had a heart problem. Thirty-eight cases were newly diagnosed via video telemedicine system, including 12 cases of vertebral disease (31.5%). 74.0% of citizens were satisfied with the video telemedicine system and among them 45.0% indicated satisfaction with the ease of seeing a doctor. After experiencing video telemedicine system, 100% of the citizens were agreed to continue video telemedicine system on the 'doctorless island', so more support and development is needed. CONCLUSION: Evidence suggests that a variety of video telemedicine system techniques can be applied effectively and safely to deliver emergency medicine across a variety of clinical settings. The utility and efficacy of telemedicine is discussed. Patient satisfaction is generally reported as high.

A Case of Acute Toxic Encephalopathy due to an Oxycodone Overdose

Acute encephalopathies can be defined as an acute central nervous system (CNS) insult, due to an underlying pathology. The clinical symptoms almost always include an acute state of confusion and cognitive impairment. Toxic encephalopathies can occur acutely or chronically depending on the toxic drugs and other substances as well as the individual metabolism of the drug. The organs acutely affected include the heart, lung and kidneys. However, the brain, spinal cord and sympathetic nerves can be affected chronically. If the toxic substance passes through the bloodbrain barrier into the hypothalamus and the posterior pituitary gland, the result can be diabetes insipidus. If the substance affects the anterior pituitary gland, the result can include hormone dysfunction, impaired immune function and altered cognition or personality. We report a patient that developed acute toxic encephalopathy after the prescribed dose of oxycodone was exceeded.

A Patient with Methemoglobinemia after Herbicide Intoxication has Hemolytic Anemia Induced by Methylene Blue

Methylene blue is the first choice for treating methemoglobinemia, any increase in normal methemoglobin levels. Methemoglobin is an abnormal hemoglobin in which the iron has been oxidized to the ferric(+3) state, making it incapable of oxygen transport. Methemoglobinemia most commonly results from exposure to oxidizing chemicals, but may also arise form genetic, dietary, or even idiopathic etiologies. Patients with low methemoglobin levels are asymptomatic, but high methemoglobin levels can lead to headaches or even death. Methylene blue, the first-line treatment for methemoglobinemia, can also produce hemolytic anemia. Jaundice or dark urine during methylene blue treatment may indicate hemolytic anemia. A 47-year-old female patient with a history of depressive mood disorder developed significant methemoglobinemia after ingesting a Propanil overdose. Twenty-two hours after ingestion, methemoglobin levels in the blood were 73.2%. She was treated with intravenous methylene blue in the therapeutic range (1 mg/kg every 4 h for 3days). The 2nd day after methylene blue use, methemoglobin levels in the blood were 33%, and the 5th day decreased to 10% with better general condition. The patient had hyperbilirubinemia after hemolytic anemia, but she recovered completely.