Failure of Conservative Treatment in Two Cases of Polyarteritis Nodosa with Superior Mesenteric Artery Involvement Presenting with Abdominal Pain

Polyarteritis nodosa (PAN) is a systemic necrotizing vasculitis affecting medium- or small-sized arteries. Its diagnosis may be delayed because it is a rare disease, and patients presenting with PAN demonstrate variable clinical manifestations and non-specific laboratory abnormalities. Gastrointestinal involvement occurs in 14~65% of patients with PAN and is a significant cause of morbidity and mortality. Thus, early diagnosis is very important in PAN with gastrointestinal involvement. We report two cases of rapidly progressive PAN presenting with abdominal pain, having failed conservative treatment.

The Prevalence of Colonic Neoplasm in Cryptogenic Pyogenic Liver Abscess: A Prospectively Enrolled Cross-sectional Study / 대한소화기학회지

BACKGROUND/AIMS: Several studies suggest that pyogenic liver abscess (PLA) is associated with colon neoplasm. A colonoscopic exam for cryptogenic PLA might detect a hidden colon neoplasm, through which intestinal flora can be transmitted into the liver. However, there are no prospectively enrolled cross-sectional data for colonic neoplasm in cryptogenic PLA. METHODS: Patients with PLA were prospectively enrolled from two university hospitals. Among them, all the patients with cryptogenic PLA were recommended for colonoscopic exam to check for colonic neoplasm. RESULTS: One hundred eighty-three patients with PLA were enrolled in the study for 22 months. One hundred and one (55.2%) patients did not have a definite cause of liver abscess at initial evaluation. The median diameter of the largest lesion was 5.7 cm (1.0-14.0 cm), and 74.3% of the patients were treated by percutaneous abscess drainage. Ninety-one percent of the patients who had an identified pathogen yielded Klebsiella. Sixty-two patients underwent colonoscopic exams, and no one had a colonic cancer, one had an adenomatous polyp with high grade dysplasia (1.6%), and 27 had adenomatous polyps with low grade dysplasia (43.5%; 41.0% in male and 43.5% in female). Of fifty patients who underwent an esophagogastroduodeno-scopic exam, nine had gastric ulcers, one had an esophageal ulcer, and one had hemorrhagic gastritis. CONCLUSIONS: The prevalence of colonic neoplasm among the patients with cryptogenic PLA was not as high as that in previous studies. Further well-designed, large-scale studies are required to assess the association of the colon neoplasm and cryptogenic PLA.

Giant Brunner’s Gland Hamartoma of the Duodenal Bulb Presenting with Upper Gastrointestinal Bleeding and Obstruction

Brunner’s gland hamartomas are small benign lesions that are most commonly found in the bulb of the duodenum. They are very uncommon, and most are found incidentally during upper gastrointestinal series or esophagogastroduodenoscopy. The lesions tend to be asymptomatic, but patients may present with symptoms of duodenal obstruction or hemorrhage secondary to ulceration. Histologically, a Brunner's gland hamartoma consists of the components of Brunner's gland cells, as well as glandular, adipose and muscle cells. In this study, we report the case of a 30-year-old man who presented with upper gastrointestinal bleeding and obstructive symptoms due to a giant Brunner's gland hamartoma in the duodenal bulb. The hamartoma was successfully removed by endoscopic resection. No significant complications were observed. Microscopically, the lesion was found to be entirely composed of variable Brunner's glands and adipocytes.

Hepatic Portal Venous Gas

Hepatic portal venous gas (HPVG) is a rare disease presenting as acute abdomen. There were first described in children with necrotizing enterocolitis in 1955. HPVG is caused by mesenteric ischemia but may have various etiologies. Predisposing factors that develop mesenteric ischemia include gastric ulcer disease, bowel obstruction, diverticulitis and sepsis. The presence of the air in the portal and mesenteric vein on radiographics has been associated with a mortality rate of more than 75% in earlier studies. Abdominal computed tomography has proven useful for detecting portomesenteric venous gas and pneumatosis intestinalis. We report a case of the patient with hepatic portal venous gas with pneumatosis intestinalis, which showed rapid progress of the disease and eventually died within 24 hours of admission.

Colonic pseudoobstruction / 대한내과학회지

No abstract available.

A Case of Choledocho-Duodeno-Colonic Fistula / 대한소화기내시경학회지

Biliary-enteric fistula is a rare disease, and the common causes of biliary-enteric fistula are gallstone, peptic ulcer, malignancy and trauma. It is known that the most common type of biliary-enteric fistula is the cholecysto-duodenal fistula, yet the combination of choledocho-duodeno-colonic fistula is a rare finding. A 78-year-old woman was admitted because she had suffered with right upper quadrant pain, a febrile sense and chills for 2 days. We confirmed the choledocho-duodeno-colonic fistula by performing gastroduodenoscopy, abdominal CT and an upper GI series. So, we report here on an usual case of choledocho-duodeno-colonic fistula, along with a review of the relevant literatures.

A Case of Polypoid Esophageal Carcinosarcoma with Spontaneous Resected Stalk / 대한소화기내시경학회지

Carcinosarcomas of the esophagus are rare malignant neoplasms that consist of both carcinomatous and sarcomatous components, which comprise approximately 1~2% of all esophageal neoplasms. Usually, esophageal carcinosarcomas are the polypoid type, and patients with esophageal carcinosarcoma have progressive dysphagia. The multiplicity in terminology appears to be related to the uncertain histogenesis of these tumors. We report a case of a polypoid esophageal carcinosarcoma with a spontaneous resected stalk in a 45 year-old male patient who presented with progressive dysphagia and weight loss.

Hemoclipped Dieulafoy's Lesion in Giant Diverticulum in the 3rd Portion of Duodenum / 대한소화기내시경학회지

A duodenal diverticulum is common in the second portion of the duodenum and can occur at any age. An obstruction, bleeding, perforation, diverticulitis are not an uncommon complicationa of duodenal diverticulum. As a rare complication, bleeding in the duodenal diverticulum may be massive, and duodenal diverticulum is resected primarily as a result of the difficulty in determining the site of bleeding. However, there has been a recent increase in endoscopic diagnosis and the treatment of diverticular bleeding. Band ligation increases the risk of duodenal diverticular perforation because of the thin diverticular wall. An endoscopic hemoclip is a preferable method for endoscopic sclerotherapy. We report a 48- year-old man with a giant duodenal diverticulum that was treated with a hemoclip. The duodenal diverticular perforation was treated effectively with supportive care.

Mature Cystic Teratoma / 대한내과학회지

No abstract available.

A Case of Primary Squamous Cell Carcinoma of the Thyroid Gland / 대한내분비학회지

Primary squamous cell carcinoma of the thyroid gland is an extremely rare case to observe and represents less than 1% in all the primary thyroid malignancies. Normally, squamous epithelium is absent in the thyroid gland and presently; its origin is believed to arise from metaplasia of follicular epithelium. Cancer has very aggressive clinical behavior and a very poor prognosis with survival rates of less than 1 year. The best chances of survival have been achieved with complete resection followed by postoperative radiotherapy. Recently, we came across a case of 80-year-old woman with primary squamous cell cacinoma of the thyroid gland present in the background of Hashimoto's thyroiditis. The patient had swelling in the anterior neck portion from the past 20 days. On physical examinaton, 3x3cm2 hard and fixed ill defined mass was detected in the right lobe of thyroid. Repeated fine needle aspiration biopsy of the thyroid revealed the presence of carcinoma. Apparently, Palliative thyroidectomy was performed after 3 months of diagnosis. During operation, the tumor was revealed as a mass of 100mm in diameter and infiltrated the surrounding muscles, trachea and other soft tissue in the neck. After the operation, the patient's condition deteriorated and ultimately after 5 months of her initial visit, she died due to respiratory failure.

A case of primary biliary cirrhosis associated with autoimmune primary hypothyroidism / 대한내과학회지

Primary biliary cirrhosis (PBC) is an idiopathic chronic non-suppurative destructive inflammation of intrahepatic bile ducts and rare in Korea. Although its pathogenesis is not fully understood, immunologic dysregulation is suspected because of presence of antimitochondrial antibody (AMA) and association with other autoimmune disease, such as autoimmune thyroid disease. Evidence of hypothyroidism in PBC is relatively common in western countries, however it has not been reported in Korea. And it is uncertain whether the reason is ethnic factor or unawareness of the disease. Recently, we experienced a 50-year-old women with hypothyroidism who had elevated alkaline phosphatase and gamma glutamyl transpeptidase. This is the first case of hypothyroidism associated with PBC in Korea.

Cholecystogastric Fistula and the Transmigration of the Gallstone / 대한소화기내시경학회지

The internal biliary fistula between the gallbladder or bile duct and intestinal tract is a rare disease. Because symptoms and signs of biliary fistula are not specific, these patients are commonly investigated with computed tomography, endoscopic retrograde cholangiopancreatography (ERCP) and barium study. Among them, a cholecystogastric fistula is a very rare type of biliary fistula. We recently experienced a case of cholecystogastric fistula and transmigration of the gallstone to the stomach. A 53-year-old woman was transferred with the impression of gallbladder cancer. On evaluating the cause of right upper abdominal pain and nausea, we confirmed the cholecystogastric fistula with gastroscopy, upper GI series and ERCP. Cholecystectomy and the repair of the fistula was done.

A Case of Strangulated Intussusception Caused by the Small Intestinal Lipoma in Adult / 대한소화기내시경학회지

An intussusception in adulthood is an unusual cause of bowel obstruction. It accounts for up to 5% of all intussusception. Approximately 90% of cases are secondary to a definite lesion such as malignancy or lipoma. Most patients are asymptomatic and the lesion is often detected incidentally at colonoscopy, operation and autopsy. Strangulated intussuscetion is a rare case and also requires emergency operation. A 32-year-old woman visited our emergency room because of severe epigastric pain. Abdominal CT revealed a low density mass in bowel loop and distended small bowel loops filled with fluid. Colonoscopic finding showed huge purple-colored coil-spring lesion in the ascending colon. From this findings, we diagnosed a strangulated intussusception. Surgically removed specimen revealed a small intestinal lipoma.

A Case of Colonic Muco-Submucosal Elongated Polyp / 대한소화기내시경학회지

Colonic muco-submucosal elongated polyp (CMSEP) is a rare disease which has been firstly reported by Matake. Only 21 cases have been reported since 1994. Although the mechanism of generation of such polyps remains unknown, their elongation may be caused by intestinal motion for a long period. The occurrence sites were distributed throughout the colon, excluding the rectum. CMSEP is coverd with normal mucosa and consisted of edematous, loose, fibrous, connective tissue and dense, fibrous submucosal layer, often dilatation of blood vessels and lymphatics. We present a case of CMSEP diagnosed by a colonoscopic polypectomy.

An Imported Case of Babesiosis / 감염

Babesiosis is a tick-borne, malaria-like illness caused by Babesia species that infect erythrocytes of mammals incidentally. The family Babesiidae is characterized by consisting of non-pigmented intraerythrocytic parasites that reproduce within erythrocytes by asynchronous, asexual budding into two or four daughter cells (tetrad). We experienced a case of human babesiosis presenting fever and chills. The patient was a 49-year old man, who had been in Africa (Ethiopia, Uganda). Three weeks before admission intermittent spiking fever had developed, which had been accompanied by severe chills. The peripheral blood smear (Giemsa-stain) revealed characteristic forms of an intracellular quadruplet parasite compatible with Babesia. The patient was improved significantly by the treatment with quinine and clindamycin for a week.

Prognostic Value of APACHE 3 Score System in the Patients with Hemoptysis Who ware Admitted at Medical Intensive Care Unit / 대한내과학회지

BACKGROUND: Massive hemoptysis is one of the major medical emergency with high risk of mortality. Though the best predictor of mortality associated with hemoptysis appears to be the amount of bleeding within the first 24 hours, catastrophic hemorrhage could be occurred to the patients who were apparently in a stable condition with scanty hemoptysis at the time of admission. We evaluated APACHE III score system to find if it could be a prognostic index that can predict the mortality of the patients with hemoptysis. METHODS: We identified all the patients who had admitted with hemoptysis in the Medical Intensive Care Unit of Asan Medical Center between May 25, 1989, and July 31, 1995. A retrospective analysis was done in 66 patients with hemoptysis on APA- CHE III score. RESULTS: The overall mortality rate was 17.4% (12/69). In univariate analysis of possible prognostic factors, independent predictors of mortality were age(P=0.016), amount of hemoptysis(P=0.012), AaDO2 (P=0.017), requirement of transfusion(P=0.036), mechanical ventilatory care(P<0.05) and APACHE III score(P=0.02), In multivariate analysis with sex, age, amount of hemoptysis, AaDO2, requirement of transfusion and APACHE III score, APACHE III score was the only independent predictor of mortality(P=0.015, odd ratio=19.3, 95% confidence interval, 3.4 to 249.7) CONCLUSION: APACHE IU score may be a clinically significantly important independent predictor of outcome in the patients with hemoptysis. In addition, invasive procedure, such as bronchial artery embolizaticn or operation, could be considered in advance in the patients with more than 30 points of APACHE III.

Two Cases of Salmonella typhi Liver Abscess after Transarterial- Chemoembolization / 감염

Hepatocellular carcinoma (HCC) is one of the most common malignancies in Korea. Transarterial chemoembolization (TACE) is an effective modality for treating HCC with a few complications. Liver abscess is most common infectious complication during post-TACE period. However, liver abscess caused by Salmonella typhi has never been reported. We experienced two cases of liver abscess following TACE, caused by S. typhi. Th clinical manifestations of S. typhi liver abscess are similar with other pyogenic liver abscesses. The CT scans showed liver abscesses mixed with necrotic materials after TACE, and the cultures of blood and abscess aspirates yielded S. typhi. The patients did not respond well only with the antibiotic treatment and was controlled after percutaneous drainage. A possible pathogenesis of these liver abscesses is considered as secondary infection in the necrotic liver tissues in biliary carrier of S. typhi.