Delayed Severe Hemobilia after Endoscopic Biliary Plastic Stent Insertion

Hemobilia is a rare gastrointestinal bleeding, usually caused by injury to the bile duct. Hemobilia after endoscopic retrograde cholangiopancreatography (ERCP) is generally self-limiting and patients will spontaneously recover, but some severe and fatal hemorrhages have been reported. ERCP-related bowel or bile duct perforation should be managed promptly, according to the type of injury and the status of the patient. We recently experienced a case of late-onset severe hemobilia in which the patient recovered after endoscopic biliary stent insertion. The problem was attributable to ERCP-related bile duct perforation during stone removal, approximately 5 weeks prior to the hemorrhagic episode. The removal of the stent was performed 10 days before the onset of hemobilia. The bleeding was successfully treated by two sessions of transarterial coil embolization.

A Case of Interstitial Pneumonitis Induced by Acitretin / 대한내과학회지

Retinoids are effective systemic agents in the treatment of psoriasis. Acitretin, a synthetic aromatic derivative of retinoic acid, has replaced etretinate in retinoid therapy of psoriasis because of its more favorable pharmacokinetic profile, including a significantly shorter half-life. Most of the adverse effects associated with acitretin are teratogenicity, hepatotoxicity, pseudotumor cerebri, pancreatitis, hyperlipidemia, hyperostosis, and mucocutaneous side effects. There are two reports worldwide describing patients who developed acute respiratory distress syndrome associated with acitretin. This suggests the possibility of serious lung complications associated with acitretin. We report a case of a 61-year-old man who developed interstitial pneumonitis that might have been induced by acitretin during the treatment of pustular psoriasis. In these cases, immediate withdrawal of retinoic acid is necessary, and corticosteroid therapy should be considered.

Catastrophic Antiphospholipid Syndrome Improved by Anticoagulation Alone / 대한내과학회지

Catastrophic antiphospholipid syndrome (APS) is an accelerated subtype of APS that results in multiorgan failure. Although catastrophic APS represents about 0.8% of all APS cases, it is usually a life-threatening medical condition that requires high clinical awareness. Catastrophic APS has been managed by various therapies, including anticoagulation, corticosteroids, plasma exchange and IV immunoglobulin, but it still has a high mortality rate. A few cases treated by anticoagulation and steroids have been reported in Korea. In this paper, we report a case of catastrophic APS that improved after anticoagulation therapy alone. Thus, we consider hat our case shows another clinical aspect of catastrophic APS.

A Case of Fournier's Gangrene Caused by Streptococcus anginosus / 감염과화학요법

Fournier's gangrene is a rare, rapidly progressive, necrotizing fasciitis of the genital, perianal and perineal regions. It is usually caused by a synergistic infection of aerobic and anaerobic organisms. A 51-year-old male patient with diabetes mellitus and chronic renal insufficiency on peritoneal dialysis was admitted with severe scrotal pain and swelling that lasted 4 days. An emergent non-contrast-enhanced computed tomography revealed extensive gas formation, fatty haziness and edema in the left scrotal and inguinal area. The patient was successfully treated with immediate surgical debridements and antibiotics. Streptococcus anginosus group Streptococcus anginosus was isolated from surgical wound cultures and identified with biochemical identification methods and direct sequencing of DNA. Herein, we report a rare case of Fournier's gangrene caused by S. anginosus. We also review the relevant literature

Iatrogenic Esophageal Submucosal Dissection: A Case Report / 대한소화기내시경학회지

Nasogastric tube insertion is a routine clinical procedure for nutritional support, gastric aspiration and decompression. Although it is generally a safe procedure, complication rates range from 0.3~8%. Submucosal esophageal dissection is a rare disorder caused by mucosal tearing and bleeding between the mucosal and muscular layers of the esophagus, leading to their separation. We report a case of submucosal esophageal dissection secondary to the accidental iatrogenic intramural insertion of a nasogastric tube.

Clinical Characteristics of Nosocomial Infective Endocarditis in a Tertiary Referral Hospital

BACKGROUND AND OBJECTIVES: Despite case reports of nosocomial infective endocarditis (NIE), the clinical characteristics of the hospital acquired infective endocarditis have not been investigated in Korea. SUBJECTS AND METHODS: The clinical records of patients with infective endocarditis, treated at Asan Medical Center between January 1989 and December 2003, were retrospectively analyzed. RESULTS: Of the 309 case of native-valve endocarditis, 17 (5.5%) cases were found to be NIE. The mean age of these 17 patients was 51+/-17 years, which included 9 women and 8 men. Staphylococcus aureus was the most frequent causative organism of NIE in 11 cases (65%), of which nine (82%) had methicillin-resistant strains. The prevalence of right-sided vegetation in NIE was higher than that of community acquired infective endocarditis (CIE)(29 vs. 10%, p<0.05); however, left-sided vegetation was observed in more than 70% of patients with NIE (12/17). Surgeries, with or without wound infection (59%) and insertion of a central venous catheter (29%), were the two most common possible sources of NIE. In hospital mortality was significantly higher in patients with NIE than in those with CIE (47 vs. 11%, p<0.001). CONCLUSION: Patients with NIE, which comprises a minor portion of those with infective endocarditis, show unique clinical characteristics in terms of causative organisms, risk factors, sites of vegetation and in-hospital mortality.

Early and late clinical outcomes after primary stenting of the unprotected left main coronary artery stenosis in the setting of acute myocardial infarction / 대한내과학회지

BACKGROUND: Acute left main coronary artery occlusion is a dramatic condition with very high mortality. The study was aimed to evaluate the effect of primary stenting in patients with left main coronary artery disease in the setting of acute myocardial infarction. METHODS: Between June 1997 and April 2002, primary stenting for left main coronary artery disease was performed in eighteen patients with acute myocardial infarction. We evaluated clinical outcomes and prognostic determinants in this clinical setting. RESULTS: Mean ages of patients were 59 +/- 12 years. Fourteen patients had cardiogenic shock on admission. Angiographic success (TIMI flow >or= 2 and diameter stenosis or= 2) was identified as a good prognostic determinant of in-hospital survival. During mean follow-up of 39 +/- 22 months, there was no late death and 1 patient received bypass surgery. Probability of freedom from death at 3-year was 56 +/- 12%. CONCLUSION: Primary stenting is a valuable therapeutic strategy for left main coronary disease in the setting of acute myocardial infarction, and it might save the life especially in patients with good pre-intervention TIMI flow (grade >or= 2). Long-term clinical outcome of patients surviving to hospital discharge is favorable.