A Case of Peutz-Jeghers Syndrome with Small Bowel Neuroendocrine Carcinoma / 대한내과학회지

Peutz-Jeghers syndrome (PJS) is an autosomal dominant inherited disorder characterized by hamartomatous polyps in the gastrointestinal tract and mucocutaneous melanin pigmentation. Hamartomas are not generally regarded as premalignant, although patients with PJS are at increased risk for common and unusual types of gastrointestinal and non-gastrointestinal malignancies. However, most of the reported gastrointestinal malignancies have been adenocarcinomas, and few reports of an association of this syndrome with a neuroendocrine tumor (NET) have been published. Moreover, no case of this syndrome with NET has been reported in Korea. Here, we report a 21-year old male with PJS who had a small bowel neuroendocrine carcinoma.

Gastrointestinal Metastasis from a Primary Adenocarcinoma of the Lung Presenting with Acute Abdominal Pain / 대한소화기학회지

Symptomatic gastro-intestinal metastasis in lung cancer is extremely rare and only a few case reports have been published. Here, we report a case with lung adenocarcinoma that presented with acute abdominal pain, nausea and vomiting due to duodenum, jejunum, and colon obstruction by the gastro-intestinal metastasis. The patient underwent colonoscopy and the pathologic report was adenocarcinoma. When there are similar histologic findings in both colon and pulmonary lesion, the question is whether both lesions are primary cancer or the colon lesions are metastases from lung cancer. Microscopic examination of a conventional pathologic section was not sufficient to make this determination. Immunohistochemistry was positive for thyroid transcription factor-1 (TTF-1) and cytokeratin 7 (CK7), and negative for cytokeratin 20 (CK20) and caudal-related homeobox transcription factor-2 (CDX-2) on colon mucosa specimen. Accordingly, we used immunohistochemical marker for differential diagnosis of primary adenocarcinoma of the lung with gastro-intestinal metastasis.

A Case of Synchronous Esophagus and Stomach Cancer Successfully Treated by Combined Chemotherapy / 대한소화기학회지

Although cases of simultaneous esophagus and stomach cancer have been reported sporadically, there are rare reports of successful treatment using chemotherapy. We report a case of synchronous esophageal and gastric cancer successfully treated using docetaxel and cis-diammineedichloro-platinum (CDDP) combination chemotherapy instead of surgery. A 82-years-old man with anorexia and progressive weight loss was diagnosed with synchronous esophageal and gastric cancer by endoscopy. Both cancers were diagnosed as resectable by the preoperative clinical staging. However, surgery was contraindicated because of severe lung dysfunction. Moreover, he actively refused radiotherapy and endoscopic management. Therefore, the patient was given combined chemotherapy with docetaxel (65 mg/m2) and CDDP (60 mg/m2). The esophageal and gastric lesion completely disappeared on endoscopy, and there were no residual tumor cells on endoscopic biopsy after three cycles of chemotherapy. Metastatic lymph nodes also completely disappeared on the CT scan. The patient received a total of ten cycles of chemotherapy, without severe adverse effects. The patient remained asymptomatic for 18 months after discontinuation of the chemotherapy, without evidence of local recurrence or distant metastasis. Surgery or endoscopic treatment of both esophageal and gastric cancers is desirable, but, if medically inoperable, chemotherapy can be alternative treatment option.

Comparison of Serum Procalcitonin with Ranson, APACHE-II, Glasgow and Balthazar CT Severity Index Scores in Predicting Severity of Acute Pancreatitis / 대한소화기학회지

BACKGROUND/AIMS: The aim of this study is to assess serum procalcitonin (PCT) for early prediction of severe acute pancreatitis compared with multiple scoring systems and biomarkers. METHODS: Forty-four patients with acute pancreatitis confirmed by radiological evidences, laboratory assessments, and clinical manifestation were prospectively enrolled. All blood samples and image studies were obtained within 24 hours of admission. RESULTS: Acute pancreatitis was graded as severe in 19 patients and mild in 25 patients according to the Atlanta criteria. Levels of serum PCT were significantly higher in severe acute pancreatitis (p=0.001). The accuracy of serum PCT as a predicting marker was 77.3%, which was similar to the acute physiology and chronic health examination (APACHE)-II score, worse than the Ranson score (93.2%) and better than the Balthazar CT index (65.9%). The most effective cut-off level of serum PCT was estimated at 1.77 ng/mL (AUC=0.797, 95% CI=0.658-0.935). In comparision to other simple biomarkers, serum PCT had more accurate value (77.3%) than C-reactive protein (68.2%), urea (75.0%) and lactic dehydrogenase (72.7%). Logistic regression analysis revealed that serum PCT has statistical significance in acute severe pancreatitis. Assessment of serum PCT levels and length of hospital stay by simple linear regression analysis revealed effective p-value with low R square level, which could make only possibilty for affection of serum PCT to admission duration (r2=0.127, p=0.021). CONCLUSIONS: Serum PCT was a promising simple biomarker and had similar accuracy of APACHE-II scores as predicting severity of acute pancreatitis.

A Case of Acute Cholecystitis with a Perforation Complicating Endoscopic Retrograde Cholangiopancreatography / 대한소화기내시경학회지

The incidence of acute cholecystitis complicating endoscopic retrograde Cholangiopancreatography (ERCP) is rarely reported at 0.2% but is usually associated with a cystic duct obstruction caused by gallstones, gallbladder polyps, or cancer. However, acute cholecystitis with a gallbladder perforation after ERCP without a history of cystic duct obstruction can develop very rarely and has not yet been reported in Korea. We report a case of acute cholecystitis with gallbladder perforation and aggravation of a pancreatic pseudocyst after diagnostic ERCP in a man with a pancreatic cystic lesion. He has been successfully cured using only percutaneous transhepatic gallbladder drainage and antibiotics with no surgery.

Efficacy of I-scan Endoscopy in the Diagnosis of Gastroesophageal Reflux Disease with Minimal Change

BACKGROUND/AIMS: The aim of the study was to evaluate the efficacy of i-scans for the diagnosis of gastroesophageal reflux disease, especially where only minimal change is involved. METHODS: The esophageal mucosa was inspected using an i-scan following conventional white light endoscopy. The examination with iscan was performed under tone enhancement (TE) esophagus (e) mode. Patients with subtle distal esophageal mucosal changes without definite mucosal breaks, such as blurring of Z-line (B), mucosal coarseness (C), hyperemic or purplish discoloration (D), erythema (E), ectopic gastric mucosal islet (I) and mixed type were classified as minimal change. RESULTS: A total of 156 patients were included. Using i-scan endoscopy, the number of minimal change was found to further increase from 94 (conventional endoscopy; 19B, 9C, 29D, 13E, 5I, 19 mixed type) to 109 (i-scan; 15B, 8C, 29D, 16E, 5I, 36 mixed type). And 14 patients who had single type by conventional endoscopy were converted to mixed type after i-scan. Therefore, 29 of 156 patients were upgraded after i-scan, they were account for 19% (p<0.0001; 95% confidence interval, 0.13 to 0.25). CONCLUSIONS: The use of i-scan endoscopy significantly improves the identification of minimal change and helps to identify more precisely the type of minimal change.

Efficacy of I-scan Endoscopy in the Diagnosis of Gastroesophageal Reflux Disease with Minimal Change

BACKGROUND/AIMS: The aim of the study was to evaluate the efficacy of i-scans for the diagnosis of gastroesophageal reflux disease, especially where only minimal change is involved. METHODS: The esophageal mucosa was inspected using an i-scan following conventional white light endoscopy. The examination with iscan was performed under tone enhancement (TE) esophagus (e) mode. Patients with subtle distal esophageal mucosal changes without definite mucosal breaks, such as blurring of Z-line (B), mucosal coarseness (C), hyperemic or purplish discoloration (D), erythema (E), ectopic gastric mucosal islet (I) and mixed type were classified as minimal change. RESULTS: A total of 156 patients were included. Using i-scan endoscopy, the number of minimal change was found to further increase from 94 (conventional endoscopy; 19B, 9C, 29D, 13E, 5I, 19 mixed type) to 109 (i-scan; 15B, 8C, 29D, 16E, 5I, 36 mixed type). And 14 patients who had single type by conventional endoscopy were converted to mixed type after i-scan. Therefore, 29 of 156 patients were upgraded after i-scan, they were account for 19% (p<0.0001; 95% confidence interval, 0.13 to 0.25). CONCLUSIONS: The use of i-scan endoscopy significantly improves the identification of minimal change and helps to identify more precisely the type of minimal change.

A Case of Pathologic Splenic Rupture as the Initial Manifestation of Acute Myeloid Leukemia M2

A pathologic splenic rupture refers to a rupture without trauma. A splenic rupture as the initial manifestation of acute myeloid leukemia is extremely rare. In this study, we described a rare case of acute myeloid leukemia presenting principally as an acute abdomen due to a pathologic splenic rupture in a 35-year old male patient. We can assert that a pathologic splenic rupture in hematologic diseases is a potentially life-threatening complication, which necessitates immediate operative intervention. Any such patient complaining about left upper abdominal tenderness should be closely observed, and further diagnostic investigations (ultrasonograph of the abdomen, abdominal CT scan) should be initiated in order to rule out a splenic rupture. The oncologist should be aware of this rare initial presentation of acute myeloid leukemia (AML) M2, as the condition generally necessitates a prompt splenectomy.

Clinical Manifestations of Elderly Patients Admitted Because of Severe Hyponatremia / 대한신장학회지

PURPOSE: Recently the incidence of severe hyponatremia is increasing in old patients but there is no report about clinical findings of old patients with hyponatremia. We evaluated the cause and clinical manifestations of severe hyponatremia in old patients who had been admitted via emergency room. METHODS: We retrospectively reviewed clinical records of the hyponatremic patients who had been admitted from 2000 to 2007. We enrolled 53 patients (Age >60 years, Na <125 mEq/L) without severe liver cirrhosis, heart failure or chronic kidney disease. We analyzed data to evaluate the differences of clinical manifestations according to the presence of symptoms, taking diuretics, urine sodium concentrations and the degree of hyponatremia. RESULTS: Mean serum sodium concentration was 111.4+/-6.9 mEq/L and urine sodium concentration was 68.7+/-43.8 mEq/L. There was no difference in serum sodium concentration according to age. Twenty-nine (54.7%) patients had nausea and vomiting and 19 patients (35.8%) had neurologic symptoms. Patients with neurologic symptoms showed lower serum and urine sodium concentration than patients without neurologic symptoms. The main causes of severe hyponatremia were poor oral intake (79.2%), diuretics use (37.7%) and recent operation (15.1%). The mean sodium concentration of the fluid administered to achieve 125 mEq/L of serum sodium level was 336.5+/-160.6 mEq/L. CONCLUSION: The urinary sodium loss, e.g., diuretics abuse, may be the main cause of severe hyponatremia in elderly patients over 60 years. In elderly patients, diuretics should be carefully administered with frequent electrolyte monitoring.