Liver volume index predicts the risk of esophageal variceal hemorrhage in cirrhotic patients on propranolol prophylaxis

BACKGROUND/AIMS@#Non-selective β-blockers (NSBBs) are used for primary prevention of esophageal variceal hemorrhage (VH) in patients with portal hypertension, but a significant number of patients develop VH while on NSBB therapy. In this study, we sought to determine whether liver volume can predict the risk of primary prophylaxis failure in cirrhotic patients on NSBB therapy.@*METHODS@#A retrospective cohort of 309 patients on prophylactic propranolol was analyzed. Liver volume was measured in portal venous phase images of multidetector computed tomography. Predictors of VH were assessed using a Cox proportional hazards model with competing-risks analysis. A nomogram was developed for estimation of the risk of primary prophylaxis failure.@*RESULTS@#During a median follow-up of 36 months, 37 patients on propranolol developed VH. Liver volume index, the ratio of measured-to-expected liver volume, was an independent predictor of VH (adjusted hazard ratio [HR], 2.70; 95% confidence interval [CI], 1.37 to 5.33; p = 0.004) as were the presence of large varices and the absence of ascites. A nomogram-based volume score of > 0.6 was predictive of prophylaxis failure (HR, 7.54; 95% CI, 2.88 to 19.73; p < 0.001). Time-dependent receiver operating characteristic curve analysis revealed that a nomogram-based risk score had significantly better discriminatory power than the North Italian Endoscopy Club index in predicting prophylaxis failure at 6 and 8 years.@*CONCLUSIONS@#Liver volume index is an independent predictor of first VH and a nomogram-based volume score stratifies the VH risk in cirrhotic patients on propranolol prophylaxis.

Surveillance Rate and its Impact on Survival of Hepatocellular Carcinoma Patients in South Korea: A Cohort Study / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Though regular surveillance of hepatocellular carcinoma (HCC) for high-risk patients is widely recommended, its rate and effectiveness are not clear. The aim of this study is to investigate the actual rate of HCC surveillance and its related factors and to clarify its impact on survival in a Korean HCC cohort. MATERIALS AND METHODS: From 2012 to 2015, 319 newly diagnosed HCC patients were prospectively enrolled at a tertiary hospital. Patient interviews based on a structured questionnaire survey were conducted. Surveillance was defined as liver imaging test ≥ 2 times with at least 3-month interval within 2 years prior to HCC diagnosis. RESULTS: Surveillance rate was 39.8%. Of the HCC patients with high-risk factors, only 182 (57.1%) had knowledge for the need for regular surveillance, and 141 (44.2%) had the accurate information about the method (ultrasound-based study). Surveillance group showed a higher proportion of early HCC (p < 0.001) and a longer overall survival (p < 0.001) compared to non-surveillance group. The multivariable Cox regression analysis indicated Child-Pugh class A, history of anti-viral therapy, low serum α-fetoprotein level, non-advanced Barcelona Clinic Liver Cancer stage as independent predictors of overall survival, while regular surveillance was not (p=0.436). CONCLUSION: Less than half of the newly diagnosed Korean HCC patients were under surveillance and the accurate perception for the need of HCC surveillance was insufficient. Of those under surveillance, most patients were diagnosed with early stage HCC, which led to the improved survival. Comprehensive efforts to optimize the surveillance program for the target population are warranted.

Anisakiasis Induced Segmental Jejunum Obstruction / 대한소화기학회지

Human anisakiasis is a disease caused by an infestation of the third stage larvae of family anisakidae. The ingested larvae invade the gastrointestinal wall, causing clinical symptoms that include abdomen pain, nausea, and vomiting. Although enteric anisakiasis is extremely rare, it can induce intestinal obstruction. We report a case in which emergency surgery was needed due to intestinal obstruction that coincided with symptoms related to anisakiasis, along with a brief literature review.

A Case of Triple Early Gastric Cancer with Bone Marrow Metastasis / 대한내과학회지

The clinical outcome of early gastric cancer (EGC) has gradually been improving, and the 5-year survival rate for patients with EGC has been reported to exceed 85% in most studies. However, in some rare cases, EGC is associated with distant metastasis. Bone metastases from stomach cancer are usually osteolytic lesions. Although there have been a few reports of EGC with bone marrow metastasis, cases of triple EGC with bone marrow metastasis are rare. We report a 50-year-old male patient who was diagnosed with triple EGC with bone marrow metastasis. This case can be considered to be rare because the patient had no spread of the disease to other organs.

Penumomediastinum and Subcutaneous Emphysema Developed Following Gastric Endoscopic Submucosal Dissection: Two Cases

Endoscopic submucosal dissection (ESD) is extensively used for the management of early gastric cancer. But many possible complications can occur. We report here two cases where subcutaneous empysema and pneumomediasinum occurred after ESD of early gastric cancers without perforation. The lesions were close to the esophagogastro-junction. The reason subcutaneous empysema and pneumomediasinum developed is lack of serosa of esophagus. Insufflated air may leak when the muscular layer is exposed during ESD. After intravenous antibiotics and total parenteral nutirition were administered, the patients improved without any other complications.

A Case of Spontaneous Esophagopleural Fistula Successfully Treated by Endoscopic Stent Insertion

The most common cause of esophagorespiratory fistulas (ERFs) is associated with malignancy. The use of self-expandable metal stents is effective for the treatment of malignant ERFs, but benign ERF is rare, which is why its optimal treatment is not defined yet. There have been few reports describing benign esophagopleural fistula and its treatments in South Korea. Here, we report a rare case of spontaneous esophagopleural fistula, which was successfully treated by endoscopic placement of a membrane covered metal stent.

Clinical Efficacy of Entecavir and Factors Predicting Long-Term Treatment Response in Nucleoside-Naive Patients with Chronic Hepatitis B / 대한내과학회지

BACKGROUND/AIMS: The aims of this study were to characterize the treatment response to entecavir and to examine factors affecting that response. METHODS: A total of 77 nucleoside-naive patients with chronic hepatitis B who had received entecavir (0.5 mg daily) for at least 48 weeks were consecutively enrolled between March 2007 and March 2011. The rates of virological response (hepatitis B virus [HBV] DNA < 116 copies/mL), biochemical response (alanine aminotransferase < or = upper limit of normal), hepatitis B e antigen (HBeAg) loss, and seroconversion were retrospectively analyzed. RESULTS: The cumulative rates of virological response at 12, 24, 48, 96, and 144 weeks were 59.7%, 82%, 88.3%, 89.6%, and 93.1%, respectively; biochemical response rates were 51.9%, 74%, 84.4%, 94.8%, and 98.3%, respectively; HBeAg loss rates were 10.5%, 18.4%, 28.9%, 36.8%, and 47.4%, respectively; and HBeAg seroconversion rates were 7.9%, 18.4%, 21.1%, 28.9%, and 39.5%, respectively. In multivariate analysis, independent predictors associated with HBV DNA polymerase chain reaction (PCR) negativity were the absence of HBeAg at baseline (p = 0.006) and early virological response (HBV DNA < 2,000 copies/mL after 12 weeks of therapy; p = 0.027). In univariate analysis, early virological response was an independent factor predicting HBeAg loss (p = 0.001). CONCLUSIONS: Entecavir induced excellent biochemical and virological responses in nucleoside-naive patients with chronic hepatitis B. Early virological response was an independent factor predicting HBV PCR negativity and HBeAg loss, and can be used to predict long-term treatment response to entecavir.

Is Endoscopic Mucosal Resection a Sufficient Treatment for Low-Grade Gastric Epithelial Dysplasia?

BACKGROUND/AIMS: The rate of diagnosis of gastric adenoma has increased because esophagogastroduodenoscopy is being performed at an increasingly greater frequency. However, there are no treatment guidelines for low-grade dysplasia (LGD). To determine the appropriate treatment for LGD, we evaluated the risk factors associated with the categorical upgrade from LGD to high grade dysplasia (HGD)/early gastric cancer (EGC) and the risk factors for recurrence after endoscopic treatment. METHODS: We compared the complication rates, recurrence rates, and remnant lesions in 196 and 56 patients treated with endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR), respectively, by histologically confi rming low-grade gastric epithelial dysplasia. RESULTS: The en bloc resection rate was significantly lower in the EMR group (31.1%) compared with the ESD group (75.0%) (p1 cm with surface redness and depressions. CONCLUSIONS: For the treatment of LGD, EMR resulted in a higher incidence of uncertain resection margins and a lower en bloc resection rate than ESD. However, there was no signifi cant difference in recurrence rate.

A Case of Gastroduodenal Fistula Caused by Gastric Ulcer

Gastroduodenal fistula or double pylorus is a very rare condition. It is a fistulous communication between gastric antrum and duodenal bulb. It can be either congenital or acquired. In most cases it is thought to be a complication of gastric ulcer. We recently experienced a case of gastroduodenal fistula in 70 year-old man presenting as epigastric pain. He was diagnosed with non ST elevation myocardial infarction previously, and was taking aspirin. Gastroduodenal communication was revealed by endoscopy. We report a case of gastroduodenal fistula that developed in man who was taking aspirin, with review of the literature.

A Case of Duodenal Leiomyoma Showing False Positive Fluorine-18-fluorodeoxyglucose Positron-Emission Tomography

Duodenal leiomyomas are rare benign tumors of mesenchymal origin. Generally, Fluorodeoxyglucose (FDG)-PET would have a negative finding in leiomyomas. A 52-year-old man was referred to our hospital with melena. Gastroendoscopy revealed the presence of a huge submucosal tumor with ulceration at the duodenum bulb. Subsequent CT demonstrated a poorly enhanced oval mass adjoining the duodenal bulb. FDG-PET scan demonstrated an excessive accumulation of FDG in the lesion. A definitive diagnosis of duodenal leiomyoma was made on the basis of the pathologic finding of his surgical specimen. We report in this first case that duodenal leiomyma may show a potential pitfall of giving a positive FDG-PET result. Through this case, we would like to caution clinicians against PET-dependent evaluations of malignant potential of duodenal submucosal tumors.

A Case of Mantle Cell Lymphoma Exhibiting Features of Gastric Linitis Plastica Type of Advanced Gastric Cancer

Mantle cell lymphoma has a broad spectrum of endoscopic presentations, such as thick, rigid folds that are indispensible on air insufflation, superficial confluent ulceration, or a polypoidal mass protruding into the lumen. The exact diagnosis is difficult to make because the lesion is in the submucosal layer and inaccessible by biopsy. Lesions will often exfoliate necrotic cells which make interpretation difficult, or they may be too small in number and size and thus indistinguishable from anaplastic carcinoma. We report a case of mantle cell lymphoma with diffuse wall thickening of the whole stomach in a 51-year-old man. The series of endoscopic findings in this case support the role of differential diagnosis of linitis plasica type of advanced gastric cancer with mantle cell lymphoma.