Helicobacter pylori Infection and Peptic Ulcer Disease in Patients with Liver Cirrhosis

BACKGROUND/AIMS: We investigated the prevalence and relationship of peptic ulcer disease and Helicobacter pylori infection to liver cirrhosis. METHODS: We examined 288 patients with liver cirrhosis, 322 patients with non-ulcer dyspepsia, and 339 patients with peptic ulcer disease. Rapid urease test and Wright-Giemsa staining were used for diagnosis of H. pylori infection. RESULTS: The prevalence of peptic ulcer disease in patients with cirrhosis was 24.3%. The prevalence of peptic ulcer disease in patients with cirrhosis divided into Child-Pugh classes A, B, and C was 22.3%, 21.0%, and 31.3%, respectively (p>0.05). The prevalence of H. pylori infection in the patients with cirrhosis, non-ulcer dyspepsia, and peptic ulcer without chronic liver disease were 35.1%, 62.4%, and 73.7%, respectively (p0.05). The prevalence of H. pylori infection in patients with hepatitis virus-related liver cirrhosis and in the patients with alcohol-related liver cirrhosis was 42.5% and 22.0%, respectively (p<0.001). The prevalence of H. pylori infection in patients with Child-Pugh classes A, B, and C liver cirrhosis was 51.5%, 30.5%, and 20.0%, respectively (p<0.001). CONCLUSIONS: Factors other than H. pylori may be involved in the pathogenesis of peptic ulcer disease in the setting of liver cirrhosis.

A Case of Spontaneous Perforation of the Common Bile Duct Associated with Cholangitis / 대한소화기학회지

Spontaneous perforation of the common bile duct (CBD) is a rare event in adults. Most cases of CBD perforation are iatrogenic after invasive procedures such as endoscopic retrograde cholangiopancreatography (ERCP) or cholecystectomy. We report a case of an 81-year-old woman who presented with severe right upper abdominal pain, fever, and chills. Abdominal CT showed multiple gallbladder and CBD stones and loculated fluid collection in the inferoposterior portion of the stomach. ERCP showed the leakage of contrast media into the peritoneal cavity from the CBD. We performed endoscopic sphincterotomy (EST) and endoscopic nasobiliary drainage (ENBD) to decompress the CBD instead of emergent surgical intervention. One week later, cholangiography via ENBD tube revealed that there was no more leakage of the contrast media from the CBD. We performed cholecystectomy, removal of the CBD stones after exploration of the CBD, and T tube insertion. The perforated site of the CBD was closed and there was no more fluid collection in the inferoposterior portion of the stomach. Medical treatment including endoscopic procedures was useful for healing of the perforated CBD.

A Case of Retroperitoneal Schwannoma of the Vagus Nerve / 대한소화기학회지

Schwannomas are benign nerve sheath tumors that originate from any anatomical site. Most schwannomas occur in the head, neck or limbs, but rarely occur in the retroperitoneal space. Furthermore, the schwannoma originating from the vagus nerve of retroperitoneal space is much rare. We experienced a case of retroperitoneal schwannoma of the vagus nerve. A 34-year-old male was refered to our hospital for the evaluation of abdominal mass on ultrasonography. Endoscopic examination revealed submucosal tumor-like lesion on high body of the stomach. Computed tomography (CT) revealed that the stomach was compressed by a solid tumor in the retroperitoneum. On exploratory laparotomy, this mass turned out to be a baseball sized mass in the retroperitoneal space. The mass was excised in an encapsulated state. Histological examination with immunohistochemical stains revealed a schwannoma of the vagus nerve.

Therapeutic Efficacy of Balloon-Occluded Retrograde Transvenous Obliteration in the Treatment of Gastric Varices in Cirrhotic Patients with Gastrorenal Shunt / 대한소화기학회지

BACKGROUND/AIMS: Rupture of gastric varices was one of the most dreadful complications of cirrhosis. Recently, a new interventional procedure, balloon-occluded retrograde transvenous obliteration (B-RTO) was introduced for the treatment of gastric variceal bleeding. This study was performed to evaluate the therapeutic efficacy of B-RTO in the treatment of gastric varices with gastro-renal shunts. METHODS: From March 2000 to June 2003, we performed B-RTO in 17 patients with gastric varices and gastrorenal shunts. All patients had history or high risk factors of gastric variceal bleeding. For the evaluation of therapeutic efficacy, we performed esophagogastroduodenoscopy (EGD) and computed tomography (CT) at 1, 6 and 12 months after B-RTO. Successful B-RTO was judged by combined CT findings and EGD findings (disappearance of gastric varices or markedly reduced gastric variceal size or bleeding risk) during follow-up periods (1-14 months, mean:6.18). We analyzed the clinical factors related to clinical success of B-RTO. RESULTS: Technical success were achieved in all patients except one (94.1%). Gastric varices were disappeared or decreased after B-RTO in 13 patients (81.2%). Complications related to procedure included transient hematuria (n=5), puncture site oozing (n=1) and partial splenic infarction (n=1), and all were conservatively managed. During the follow up periods, neither significant hepatic nor renal functional damages occurred. Statistically, no significant factors related with B-RTO success. CONCLUSIONS: B-RTO is effective and safe in the management of gastric varices in cirrhotic patients with gastrorenal shunt.

Idiopathic Hypereosinophilic Syndrome Presenting As a Single Mass in the Liver / 대한소화기학회지

Hypereosinophilic syndrome is characterized by persistent blood eosinophilia of 1,500/mm3 or more in the absence of known causes and multiorgan dysfunction by eosinophil-related tissue damage. In Korea, some cases of hypereosinophilic syndrome with hepatic involvement have been described with prolonged benign clinical courses. Most of them were diffuse or multifocal lesions in imaging studies, and any case presenting as a large single mass lesion has not been described. Herein we report a case of hypereosinophilic syndrome with hepatic involvement in a 48-year-old woman who presented with a giant single mass. By abdominal CT scan, a lobulated well-margined heterogenous mass lesion was detected in the left lateral segment of the liver. Liver biopsy revealed severe eosinophilic infiltration and centrilobular necrosis of hepatocytes. The lesion completely disappeared after steroid administration for eleven months.

Two Cases of Autoimmnune Hepatitis Associated with Systemic Lupus Erythematosus / 대한간학회지

Autoimmune hepatitis (AIH) is a chronic necroinflammatory liver disease of unknown cause associated with circulating autoantibodies and high serum globulin level. Systemic lupus erythematosus (SLE) is a disease of unknown etiology in which tissues and cells are damaged by pathogenic autoantibodies and immune complex, affecting multiple organs including the liver, kidney, and CNS. The difference between the hepatic involvement of SLE and autoimmune hepatitis has not been clearly defined in the past due to similarities in clinical and biochemical features. A scoring system for the diagnosis of AIH has been established, and AIH and SLE-associated hepatitis have been defined as two different entities, although both have the same autoimmune features such as polyarthralgia, hypergammaglobulinemia and circulating autoantibodies. AIH has been considered to occur infrequently in SLE. We report two cases of AIH which simultaneously satisfied the criteria of SLE.

Esophageal Tuberculosis Mimicking Malignancy / 대한소화기내시경학회지

Pulmonary tuberculosis is still endemic in Korea, but esophageal tuberculosis, especially primary esophageal tuberculosis, is very rarely seen. A 76-year-old male is presented dysphagia. The clinical presentation, barium swallow study, and chest CT were suggestive of carcinoma of the esophagus. Findings that can suggest the diagnosis are enlarged lymph nodes, ulceration, and luminal narrowing. The major differential diagnosis was primary esophageal tuberculosis. This was not excluded on biopsy obtained at endoscopy. Operation was done for severe dysphagia and exclusion of malignancy. The patient was finally diagnosed as primary esophageal tuberculosis.

A Case of Primary Leiomyosarcoma of the Liver / 대한간학회지

Primary hepatic leiomyosarcoma is a very rare malignant tumor of the liver and rather slowly progressing disease. When the tumor is solitary or even multiple but located in one lobe, the treatment of choice is an operation. We report a case of huge leiomyosarcoma in a 58-year old female patient treated by surgical resection.

Esophageal tuberculosis revealed by rare presentation with massive hematemesis and aortoesophageal fistula / 대한내과학회지

Esophageal tuberculosis is rare, with only 30 cases previously reported in the English literature. Pulmonary tuberculosis is still endemic in Korea, but esophageal tuberculosis, especially primary esophageal tuberculosis, is very rarely seen. Patients usually present with progressive dysphagia or odynophagia. A case of esophageal tuberculosis in an 43-year-old male is presented massive hematemesis. Endoscopy showed exposed vascular mass lesion with oozing blood in the mid-esophagus. The patient died of massive hematemesis despite endoscopic and surgical intervention.

Pedunculated Colonic Leiomyoma-Diagnosed and Removed by Endoscopic Resection / 대한소화기내시경학회지

In colon, smooth muscle tumors are extremely rare and represent only 3% of digestive tract leiomyomas. A 51-year- old women was admitted with complaints of epigastric pain and weight loss. Colonoscopy revealed a large pedunculated polyp covered with almost normal mucosa in the proximal transverse colon. After clipping of the stalk, we performed polypectomy successfully by colonoscopic snare electrocoagualtion. We report a case of endoscopic removal of colonic pedunculated leiomyoma with a review of literature.

Effect of Age and Liver Cirrhosis on the Gluthathione Concentration and Glutathione Peroxidase Activity in the Plasma, Erythrocytes and Gastric Mucosa of Human

BACKGROUND: The role of aging in damage to DNA have been of increasing in recent years. DNA damage correlated with biochemical and physiologic changes that are characteristic of cellular impairment in aging and disease. Reduction of oxygen in tissue produces a number of oxygen free radicals which may induce cellular damage and even cell death. Glutathione, its function in reductive processes that are essential for the synthesis (and the degradation) of proteins, formation of deoxyribonucleotide precursors of DNA, regulation of enzymes, and protection of the cell against reactive oxygen compounds and free radicals. The aim of this study was, 1) to measure the glutathione concentration and glutathione proxidase activity of erythroyte, plasma, human gastric mucosa in elderly and liver cirrhosis patient 2) to investigate a role of glutathione mediated cellular defense mechanism against oxidative stress between in liver cirrhosis patient and in elderly. METHODS: We measured glutathione concentration and glutathione peroxidase activity in the plasma, erythrocytes, gastric mucosa of human in 4 group (Group A: 10 patients of liver cirrhosis and portal hypertensive gastropathy in age 40~55 years, Group B: same number and disease of patients in age over 65 years, group C: healthy person of age over 65 years, Group D: control). Glutathione concentration of erythocyte, plasma and human gastric mucosa was measured by spectrophotometer using Bioxytech GSH-400. Glutathione peroxidase activity of plasma was measured by Paglia & Valentine method using Bioxytech pl. Gpx and of erythocyte and human gastric mucosa was measured by using Bioxytech Gpx.340. Statistical significance of the different group was determined by ANOVA. A p<0.05 was considered significant. RESULT: Glutathione concentration of erythrocytes and gastric mucosa was decreased in Group A, B, C compared to group D. plasma concentration of glutathione was decreased in group A, B compared to group C, D. Activity of glutathione peroxidase was not different in any group (ANOVA, p<0.005). CONCLUSION: Even though glutathione concentration of erythrocyte and human gastric mucosa was decreased in elderly and in liver cirrhosis patient, our study shows decreased glutathione related defense mechanism against oxidative stress is different in view of plasma concentration of glutathione.

The Usefulness of Quantitative Culture of Bronchoalveolar Lavage Fluid in the Diagnosis of Bacterial Pneumonia / 대한내과학회지

BACKGROUND: The aim of this study is to evaluate the usefulness of quantitative culture of bronchoalveolar lavage(BAL) fluid for the diagnosis of bacterial pneumonia and identification of causative agents. METHODS: Study group consisted of 30 episodes in 28 patients, enrolled from January 1995 through June 1996. Inclusion criteria were 1) presence of respiratory symptoms such as cough, sputum or dyspnea 2) increased peripheral blood leukocyte count(> or =11,000/mm3) 3) Fever(> or =38.3 degrees C) 4) purulent sputum 5) new or progressive infiltrate on chest radiography. For the diagnosis of pneumonia and its causative agents, sputum smear and culture, blood culture and BAL fluid studies were performed. BAL fluid studies included differential count of white blood cell, BAL fluid smear and culture, detection of elastin fibers and presence of intracellular organisms(ICO). Quantitative culture of BAL fluid was considered positive if colony-forming units was more than 1.0 x 104/ml. Positive criteria for ICO was presence of microorganism in more than five per 100 of phagocytes. RESULT: Recruited were 22 males and 6 females. The mean age was 57.5+/-13.5 years(range 25-84). Of 30 episodes underwent BAL fluid studies, 19 cases were diagnosed to be bacterial pneumonia. S. aureus(7 cases) was the most common causative agent and was followed by P. aeruginosa(4), E. cloacae(2), A. baumanii(1), H. influenzae(1) and -hemolytic Streptococcus(1). Sensitivity of quantitative culture of BAL fluid for the diagnosis of bacterial pneumonia was 68.4% and its specificity was 63.6%. Elastin fibers were detected in 5 cases(31%) and ICO over 5% in 3 cases(15.7%). When criteria of quantitative culture of BAL fluid, detection of ICO and elastin fibers were applied together, diagnostic rate of pneumonia was 84.2%(16/19). CONCLUSON: Quantitative culture of BAL fluid was more sensive and specific compared to sputum and blood culture for the diagnosis of bacterial pneumonia. It was suggested that detection of ICO and elastic fibers in BAL fluid could raise the diagnostic rate of bacterial pneumonia.

Torsade de Points Ventricular Tachycardia Associated with Piprinhydrinate(Diphenylpyraline, Plokon(R))

Torsade de Points is unique polymorphic ventricular tachycardia associated with QT interval prolongation. The mechanism of Torsade de Points was not defined exactly but triggered activity associated with afterdepolarization and/or dispersion of repolarization were known possible explanation. Torsade de points is most often induced by various drugs such as antiarrythmic agents, antipsychotic agents, antibiotis, and antihistamines. Astemizole(Hismanal(R)) and Terfenadine among antihistamines are reported that cause leading to a Torsade de Points. We experienced the case of Torsade de Points which was induced with Piprinhydrinate(Diphenylpyraline, Plokon(R)), antihistamine of ethanolamine derivatives, expressed recurrent syncope and dizziness in a young lady.

A Case of ST-Segment Elevation in a Patient with Subarachnoid Hemorrhage

There are several EKG changes in cerebrovascular disease(CVD). The wide prominent of inverted T wave is frequently developed in patients with CVD. There were case reports for CVD in patient with ST-segment elevation without myocardial infarction, but the exact mechanism is unknown. EKG abnormalities associated with subarachnoid hemorrhage were first described by Byer et al, in 1947.1 We report the case of 72 years old female patient who developed subarachnoid hemorrhage and intraventricular hemorrhage with ST-segment elevation.