Comparison on Endoscopic Hemoclip and Hemoclip Combination Therapy in Non-variceal Upper Gastrointestinal Bleeding Patients Based on Clinical Practice Data: Is There Difference between Prospective Cohort Study and Randomized Study? / 대한소화기학회지

BACKGROUND/AIMS: Endoscopic hemoclip application is an effective and safe method of endoscopic hemostasis. We conducted a multicenter retrospective study on hemoclip and hemoclip combination therapy based on prospective cohort database in terms of hemostatic efficacy not in clinical trial but in real clinical practice. METHODS: Data on endoscopic hemostasis for non-variceal upper gastrointestinal bleeding (NVUGIB) were prospectively collected from February 2011 to December 2013. Among 1,584 patients with NVUGIB, 186 patients treated with hemoclip were enrolled in this study. Subjects were divided into three groups: Group 1 (n=62), hemoclipping only; group 2 (n=88), hemoclipping plus epinephrine injection; and group 3 (n=36), hemocliping and epinephrine injection plus other endoscopic hemostatic modalities. Primary outcomes included rebleeding, other therapeutic management, hospitalization period, fasting period and mortality. Secondary outcomes were bleeding associated mortality and overall mortality. RESULTS: Active bleeding and peptic ulcer bleeding were more common in group 3 than in group 1 and in group 2 (p<0.001). However, primary outcomes (rebleeding, other management, morbidity, hospitalization period, fasting period and mortality) and secondary outcomes (bleeding associated mortality and total mortality) were not different among groups. CONCLUSIONS: Combination therapy of epinephrine injection and other modalities with hemoclips did not show advantage over hemoclipping alone in this prospective cohort study. However, there is a tendency to perform combination therapy in active bleeding which resulted in equivalent hemostatic success rate, and this reflects the role of combination therapy in clinical practice.

Comparison between Endoscopic Therapy and Medical Therapy in Peptic Ulcer Patients with Adherent Clot: A Multicenter Prospective Observational Cohort Study / 대한소화기학회지

BACKGROUND/AIMS: The optimal management of bleeding peptic ulcer with adherent clot remains controversial. The purpose of this study was to compare clinical outcome between endoscopic therapy and medical therapy. We also evaluated the risk factors of rebleeding in Forrest type IIB peptic ulcer. METHODS: Upper gastrointestinal (UGI) bleeding registry data from 8 hospitals in Korea between February 2011 and December 2013 were reviewed and categorized according to the Forrest classification. Patients with acute UGI bleeding from peptic ulcer with adherent clots were enrolled. RESULTS: Among a total of 1,101 patients diagnosed with peptic ulcer bleeding, 126 bleedings (11.4%) were classified as Forrest type IIB. Of the 126 patients with adherent clots, 84 (66.7%) received endoscopic therapy and 42 (33.3%) were managed with medical therapy alone. The baseline characteristics of patients in two groups were similar except for higher Glasgow Blatchford Score and pre-endoscopic Rockall score in medical therapy group. Bleeding related mortality (1.2% vs. 10%; p=0.018) and all cause mortality (3.7% vs. 20.0%; p=0.005) were significantly lower in the endoscopic therapy group. However, there was no difference between endoscopic therapy and medical therapy regarding rebleeding (7.1% vs. 9.5%; p=0.641). In multivariate analysis, independent risk factors of rebleeding were previous medication with aspirin and/or NSAID (OR, 13.1; p=0.025). CONCLUSIONS: In patients with Forrest type IIB peptic ulcer bleeding, endoscopic therapy was associated with a significant reduction in bleeding related mortality and all cause mortality compared with medical therapy alone. Important risk factor of rebleeding was use of aspirin and/or NSAID.

A Patient with Achalasia Misdiagnosed as Asthma Until Age 17 / 대한내과학회지

Achalasia is a primary esophageal motility disorder characterized by functional obstruction of the distal esophagus and subsequent dilation of the proximal esophagus. The most common symptoms in children and adolescents are vomiting, progressive dysphagia, weight loss, recurrent pneumonia, nocturnal cough, and chest pain. A girl who had been diagnosed with asthma poorly responsive to inhaled steroids until age 17, presented at the hospital with cough, sputum, and fever. Finally, she was diagnosed with achalasia and underwent esophageal balloon dilatation, which relieved her GI and pulmonary symptoms. We report this case with a literature review.

A Case of Intrapancreatic Accessory Spleen Mistaken as a Pancreatic Mass due to Different Enhancing Pattern from Normal Spleen / 대한소화기학회지

Most cases of accessory spleen show similar features as normal spleen in imaging studies. However, some accessory spleen has unusual scan feature which can be misdiagnosed. We present a case of intrapancreatic accessory spleen that was discovered incidentally during a workup for abdominal pain in a 47-year-old woman. CT and MRI revealed a different enhancing pattern from that of the spleen. Further evaluation with endoscopic ultrasonography failed to identify the pancreatic mass. Therefore, it was surgically removed and diagnosed pathologically as an accessory spleen.

A Solitary Colonic Neurofibroma in a Patient without Neurofibromatosis / 대한소화기내시경학회지

Neurofibromas are usually manifestations of neurofibromatosis type 1 (Nf1). There are usually multiple lesions on presentation. Solitary neurofibromas of the colon are extremely rare. A 34-year-old Asian male came to our hospital for non-specific findings, except for a complaint of loose stools for 2 months. A colonoscopy was performed. A sessile polyp 0.4 cm in diameter was detected at the sigmoid colon. Microscopically, a biopsy from the polyp showed proliferation of spindle cells in the mucosa, myxoid changes and infiltration of inflammatory cells. Immunohistochemical staining was positive for S-100 protein. The above morphological and immunohistochemical characteristics were consistent with a diagnosis of a neurofibroma. Only 13 cases of isolated colonic neurofibromatosis without Nf1 have been documented in the literature. We report this case as an isolated neurofibroma of the colon is even a rarer manifestation, and only three cases have been published in the clinical literature.

The usefulness of transient elastography (Fibroscan(R)) for predicting esophageal varices and esophageal variceal hemorrhage in patients with chronic liver diseases / 대한내과학회지

BACKGROUND/AIMS: This study was conducted to evaluate the efficacy of transient elastography (Fibroscan(R)) for predicting esophageal varices and esophageal variceal hemorrhage in patients with chronic liver diseases. METHODS: We studied 245 patients (mean age: 50.1 years, male/female: 181/64) with chronic liver diseases to determine the relation between the clinical or serologic markers associated with liver fibrosis and tissue elastography, and these tests were performed in Feb 2007. The causes of chronic liver diseases were hepatitis B virus in 139 (56.7%), hepatitis C virus in 30 (12.2%), alcohol in 38 (15.5%), nonalcoholic fatty liver disease in 23 (9.4%), autoimmune liver disease in 3 (1.2%), and unknown 12 (4.9%). RESULTS: Transient elastography was correlated with APRI (r=0.712) and the grades of esophageal varices (r=0.635). The AUROC values of transient elastography were 0.916 (95% CI: 0.838-0.954) for the presence of esophageal varices, 0.875 (95% CI: 0.819-0.931) for the esophageal varices grade > or =2, and 0.895 (95% CI: 0.846-0.945) for esophageal variceal hemorrhage. The cutoff values for 90% specificity were 15.3 kPa for esophageal varices, 20.7 kPa for esophageal varices grade > or =2 and 34.8 kPa for esophageal variceal hemorrhage, while the negative predictive values were 90%, 94% and 97%, respectively. CONCLUSIONS: Transient elastography was correlated with the presence of esophageal varices, the grades of esophageal varices and the presence of esophageal variceal hemorrhage. Therefore, this data may help to screen those patients how might undergo upper gastrointestinal endoscopy.

Clinical Overview of Acute Lower Gastrointestinal Bleeding / 대한소화기내시경학회지

BACKGROUND/AIMS: Acute lower gastrointestinal bleeding (LGIB) is a common disorder that requires hospitalization. Colonoscopy is considered as the procedure of choice for diagnosing acute LGIB. The aim of this study was to analyze the clinical characteristics, endoscopic diagnosis and clinical course of acute LGIB. METHODS: From January 2000 to August 2007, 117 patients with hematochezia, who visited Yeungnam University hospital emergency center and underwent colonoscopy or sigmoidoscopy, were reviewed retrospectively. The male to female ratio was 2.25 (81:36). The mean age was 59.1+/-16.9 years. RESULTS: The mean time from presentation to endoscopy was 12.6 hours. The cause of bleeding was identified in 88.9% of the cases after endoscopy. The causes of the acute LGIB were colitis: 26 cases, post polypectomy bleeding: 17 cases, colon ulcer: 16 cases, diverticular bleeding: 13 cases, colon cancer: 9 cases, angiodysplasia: 7 cases and hemorrhoid: 6 cases. Thirty six patients were treated by the endoscopic method; the mean duration of admission was 10.6+/-10.0 days and the mean amount of transfusion was 3.0+/-1.9 U. Those numbers showed statistically significant differences according to the diagnosis. CONCLUSIONS: The most common cause of acute LGIB was colitis and the causes of bleeding were a significant factor that affects the severity of bleeding and the duration of admission.

A Case of Intramural Duodenal Hematoma Complicated with Obstructive Jaundice and Pancreatitis following Endoscopic Hemostasis / 대한소화기내시경학회지

An intramural duodenal hematoma is rarely observed in adults and may occur as an iatrogenic complication after endoscopic treatment for duodenal ulcer bleeding, particularly in patients with bleeding disorders or undergoing anticoagulant therapy. Upper gastrointestinal endoscopy, abdominal CT scan and hypotonic duodenography are used to establish a diagnosis. We report a case of an intramural duodenal hematoma complicated with obstructive jaundice and pancreatitis after endoscopic hemostasis in a patient with a cerebral infarction. A 64-year-old male had duodenal ulcer bleeding, which was treated by a local injection of epinephrine followed by hemoclipping. One to three days after the endoscopic treatment, he complained of abdominal pain and jaundice. The abdominal CT scan revealed acute, edematous pancreatitis and a huge hematoma in the 2nd to 4th portion of the duodenum. The follow-up endoscopy revealed severe stenosis of the duodenal lumen caused by an intramural hematoma. He was treated with conservative management for 18 days. There was gradual improvement in the hematoma that had been complicated by jaundice and pancreatitis.

Colon Cancer in Behcet's Disease / 영남의대학술지

Behcet's disease has rarely been reported in association with malignant diseases. In most cases the autoimmune nature of the disease itself or immunosuppressive drug use has been blamed for malignant transformation. Solid tumors in addition to lymphoid and hematological malignancies are also seen during the course of Behcet's disease. We present here a case of colon cancer in a 40-year-old man with Behcet's disease. A near total colectomy was performed and postoperative chemotherapy and radiotherapy was administered to treat visceral peritoneal invasion. Recurrent evidence was not found. We present the clinical details of this rare case of colon cancer with Behcet's disease.

The effect of upper gastrointestinal endoscopy using conscious sedation with propofol / 대한내과학회지

BACKGROUND: Propofol can be used to provide general anesthesia or sedation. The objectives of this study were to assess propofol as sedative agents for outpatient GI endoscopy, amnestic effects, hemodynamic state and oxygenation during the procedure. METHODS: From April and June 2000, 50 patients scheduled outpatient gastrointestinal endoscopy were enrolled in this study. 30 healthy outpatients requesting sedation at diagnostic gastroscopy were received a bolus dose of propofol 2.5 mg/kg and compared with 20 patients with non-sedation. Pulse rate, blood-pressure and arterial oxygen saturation was monitored. RESULTS: Statistically significant decrease in arterial oxygen saturation were observed since 5 min after endoscopy in patients receiving propofol (p=0.006). Patients receiving sedative endoscopy, pulse rate during endoscopy was significantly increased compared with propofol group (p=0.009). Patients receiving propofol are more tolerable than patients with non-sedative endoscopy (p=0.001), therefore all patients receiving propofol wanted the same sedative endoscopy in their next endoscopy. CONCLUSION: Propofol is believed to be a useful, safe sedative agent for upper gastrointestinal endoscopy with satisfactory sedation and conditions. However, due to its untoward effect of hypoxia, careful monitoring is recommended.