Non-operative Treatment of Gastric Ulcer Perforation with Contrast Leakage in an Elderly Patient / 대한내과학회지

Peptic ulcer remains an important public health concern due to an aging society and the increasing use of non steroidal anti-inflammatory drugs (NSAIDs). Perforated peptic ulcer is a major life-threatening complication of peptic ulcer. While the preferred treatment is surgery, conservative treatment does not result in significantly different outcomes in young, hemodynamically stable patients. However, conservative treatment of perforated peptic ulcer is associated with high failure rates in elderly patients. We report a case of an 87-year-old patient with a perforated peptic ulcer with contrast agent leakage. The patient was treated conservatively without complications; the treatment included non per os (NPO), insertion of a Levin tube, intravenous antibiotics, and a proton pump inhibitor.

Predictive Factors for Severe Outcomes in Ischemic Colitis

BACKGROUND/AIMS: Ischemic colitis includes a wide clinical spectrum ranging from mild to severe forms. This study aimed to determine the factors that are related to the occurrence of severe ischemic colitis. METHODS: This multicenter study was conducted retrospectively in Korea. The patients were divided into mild and severe groups. This study surveyed clinical characteristics, blood tests, endoscopic findings, and imaging studies. RESULTS: In the comparison of comorbidities, the severe group had a higher ratio of chronic kidney disease than the mild group (p=0.001). In the blood test, the severe group had a reduced number of platelets (p=0.018) and a higher C-reactive protein value (p=0.001). The severe group had a higher ratio of involvement of the right colon (p=0.026). The Eastern Cooperative Oncology Group (ECOG) performance status score of the patients showed that the severe group had higher scores than the mild group (p=0.003). A multivariate analysis showed that chronic kidney disease and high ECOG performance status scores were significant risk factors. CONCLUSIONS: If patients diagnosed with ischemic colitis are also treated for chronic kidney disease or have poor performance status, more attention and early intervention are necessary.

Levofloxacin, Metronidazole, and Lansoprazole Triple Therapy Compared to Quadruple Therapy as a Second-Line Treatment of Helicobacter pylori Infection in Korea

BACKGROUND/AIMS: Several rescue therapies have been recommended to eradicate Helicobacter pylori infection in patients with a failure of first-line eradication therapy, but they still fail in more than 20% of cases. The aim of this study was to evaluate the efficacy and safety of levofloxacin, metronidazole, and lansoprazole (LML) triple therapy relative to quadruple therapy as a second-line treatment. METHODS: In total, 113 patients who failed first-line triple therapy for H. pylori infection were randomly assigned to two groups: LML for 7 days and tetracycline, bismuth subcitrate, metronidazole and lansoprazole (quadruple) for 7 days. RESULTS: According to intention-to-treat analysis, the infection was eradicated in 38 of 56 patients (67.9%) in the LML group and 48 of 57 (84.2%) in the quadruple group (p=0.042). Per-protocol analysis showed successful eradication in 38 of 52 patients (73.1%) from the LML group and 48 of 52 (92.3%) from the quadruple group (p=0.010). There were no significant differences in the adverse effects in either treatment group. CONCLUSIONS: LML therapy is less effective than quadruple therapy as a second-line treatment for H. pylori infection. Therefore, quadruple therapy should be considered as the primary second-line strategy for patients experiencing a failure of first-line H. pylori therapy in Korea.

Two Cases of Gastric Marginal Zone B Cell Lymphoma Treated with a Single Agent Chemotherapy / 대한소화기내시경학회지

Gastric marginal zone B cell lymphoma of the MALT type (MALT lymphoma) is usually accompanied by a Helicobacter pylori (H. pylori) infection. Most gastric MALT lymphomas regress after the eradication of H. pylori. Therefore, H. pylori eradication therapy is an effective first-line treatment for gastric MALT lymphoma. A second-line treatment for patients who fail to respond to eradication therapy, including radiotherapy and chemotherapy, produces a good response and survival rate. We encountered 2 cases of H. pylori eradication-resistant gastric MALT lymphoma, which were treated with cyclophosphamide monotherapy. A complete response was obtained in both cases after a treatment duration of 3 months and remission continued for 15 and 18 months, respectively. Treatment-related toxicity was mild. Oral monochemotherapy might be an alternative, effective and safe treatment modality for patients with gastric MALT lymphoma who are resistant to H. pylori eradication therapy.

A Case of Fitz-Hugh-Curtis Syndrome in a Male / 대한소화기학회지

Fitz-Hugh-Curtis syndrome has been described as focal perihepatitis accompanying pelvic inflammatory disease caused by Neisseria gonorrhea and Chlamydia trachomatis. The highest incidence occurs in young, sexually active females. However, the syndrome has been reported to occur infrequently in males, according to the foreign literature. The predominant symptoms are right upper quadrant pain and tenderness, and pleuritic right sided chest pain. The clinical presentation is similar in men and women. In women, the spread of infection to liver capsule is thought to occur directly from infected fallopian tube via the right paracolic gutter. In men, hematogenous and lymphatic spread is thought to be postulated. Recently, we experienced a case of Fitz-Hugh-Curtis syndrome occurred in a man. As far as we know, it is the first report in Korea, and we report a case with a review of the literature.

A Case of Metastatic Adenocarcinoma of the Appendix from Stomach Adenocarcinoma / 대한소화기내시경학회지

Adenocarcinoma of the appendix is a rare neoplasm. Metastatic adenocarcinoma of the appendix from stomach adenocarcinoma is also a very rare finding. A 72-year-old man complained of right lower quadrant abdominal pain for 10 days, and he was diagnosed with acute appendicitis. Appendectomy was performed by a general surgeon. Adenocarcinoma was found on the postoperative biopsy. Subsequently, gastric adenocarcinoma was diagnosed on the gastroscopy with biopsy, and this was proven to be the original site of the appendiceal adenocarcinoma.

Two Cases of Phytobezoars Treated by Adminsitration of Coca-Cola by Oral Route / 대한소화기학회지

Bezoars are concretions of foreign bodies found in the gastrointestinal tract. In the past, most common method for the treatment of bezoar was surgical management. However, the current treatment methods include chemical dissolution and endoscopic mechanical lithotripsy. There were few reports on the treatment of phytobezoars by nasogastric Cola lavage. However, there was no report succeeded by oral route alone. In our two cases, phytobezoars were treated by oral administration of Coca-Cola. Our patients drank 700-800 mL of Coca-Cola daily, and after two months, complete dissolutions of bezoars were achieved. We report two cases of phytobezoars completely treated by drinking Coca-Cola.

A Case of Inflammatory Fibroid Polyp of the Cecum Causing Intussusception / 대한소화기내시경학회지

Inflammatory fibroid polyp is a polypoid lesion of the gastrointestinal tract, composed of fibrous tissue, blood vessels, and inflammatory infiltration often dominated by eosinophilic leukocytes. It is infrequent, localized, and non-neoplastic condition. It is most often formed in the gastric antrum and ileum, and rarely in the esophagus, small bowel or colon. The polyp in the stomach is mainly located in the submucosa of the antrum, and may cause intermittent epigastric pain, vomiting, antral obstructive symptoms or rarely bleeding. When present in small bowel, it is usually localized in the ileum and presents with obstructive symptoms but clincal manifestations are different according to the location. Intussusception resulting from the mass is not common. We report a case of inflammatory fibroid polyp of the cecum causing intussusception. A 42-year-old male patient was referred to the hospital for the evaluation of right lower quadrant abdominal pain and palpable mass. A contrast-enhanced CT scan of the whole abdomen and colonoscopic examination revealed intussusception with a cecal mass. Inflammatory fibroid polyp causing intussusception was histologically confirmed by surgical wedge resection.

A case of appendiceal mucinous cystadenoma presented as microhematuria and positive fecal occult blood test / 대한내과학회지

Appendiceal mucocele denotes an obstructive dilatation of appendiceal lumen due to abnormal accumulation of mucus and relatively rare disease with its 0.2~0.3% incidence of all appendices removed at surgery. It is not easy to diagnose appendiceal mucocele preoperatively because most of them are asymtomatic and discovered incidentally either at surgery or other medical examinations such as ultrasonography or colonoscopy for another reason. We report a case of appendiceal mucinous cystadenoma of 57-year-old woman who was admitted for further evaluations about her positive fecal occult blood test and microhematuria which was found on her medical examination for health incidentally.

A Case of Crohn's Disease Confined to the Stomach / 대한소화기내시경학회지

Although Crohn's disease is usually found in the ileum and colon, it can be located in the whole gastrointestinal tract from the oral cavity to the anus. The frequency of gastroduodenal Crohn's disease is rare and is reported to range between 0.5% and 4.0% in Crohn's disease. And when Crohn's disease does involve the upper gastrointestinal tract, there is nearly always concomitant disease in the small bowel and colon. Very rarely, isolated Crohn's disease of the stomach and duodenum may occur. Definite diagnosis requires histologic confirmation, however, endoscopic biopsies often fail to reveal granuloma. Thus, if absence of definite histologic findings, combining clinical, radiologic and endoscopic findings suggest this condition. We experienced a first case of Crohn's disease confined to stomach and reported with review of the literature.

Two Cases of Gastritis Cystica Profunda Diagnosed by Endoscopic Polypectomy / 대한소화기내시경학회지

Gastritis cystica profunda (GCP) is a rare disease in which mature glandular epithelium extends into the muscularis mucosae or below. Mainly GCP lesions developed at gastroenterostomy stomas. We experienced two cases of GCP which were not related with any gastric surgery. The first case was 76-year-old woman who visited for epigastic pain and dyspepsia. The second case was 55-year-old woman complaining right upper quadrant pain. The polyps are found on the greater curvature of the antrum at first case, and on the lesser curvature of the antrum at second case. Each polyp was successfully removed by polypectomy.

Serum ALT and HBV DNA Levels in Patients with HBeAg-Negative Chronic Hepatitis B / 대한간학회지

BACKGROUND/AIMS: HBeAg-negative chronic hepatitis B (CHB) has a poor long-term prognosis. Since no precise clinically relevant HBV thresholds are known in HBeAg-negative CHB, the decision to treat is difficult. The aim of this study was to evaluate the levels of serum HBV DNA and transaminase and to investigate the correlation of these values in patients with HBeAg-negative CHB. METHODS: The study analyzed the sera from 82 patients with HBeAg-negative CHB, 61 men and 21 women. The mean age was 45 years. The patients were divided into two groups according to serum ALT levels: the patients with lower ALT level (n=52, UNL or= 2 X UNL). The level of serum HBV DNA was determined by the Cobas Amplicor HBV Monitor(TM) (Roche). RESULTS: The median serum HBV DNA level was 2.7 X 10(5) copies/mL in patients with HBeAg-negative CHB. The median serum HBV DNA level of patients with a higher ALT level (1.0 X 10(6) copies/mL) was significantly higher than that of patients with a lower ALT level (5.6 X 10(4) copies/mL)(p<0.001). The serum ALT level was correlated with serum HBV DNA levels in patients with HBeAg-negative CHB (r=0.416, p<0.001). The serum level of HBV DNA in patients with cirrhosis (median 2.0 X 10(5) copies/mL) did not differ from patients without cirrhosis (median 4.7 X 10(5) copies/mL). CONCLUSIONS: The level of serum HBV DNA was higher in patients with higher serum ALT level than it was in patients with lower serum ALT, and it was closely correlated with serum ALT levels in HBeAg-negative CHB.

A Case of a Bleeding Duodenal Diverticulum by a Dieulafoy-like Lesion / 대한소화기내시경학회지

Duodenal diverticula are first reported by Chomel in 1710. Duodenal diverticula are relatively common in adults with a prevalence of 23% in ERCP. The most duodenal diverticulum is asymptomatic. Complications such as obstruction, cholangitis, biliary stones, ulceration, perforation and hemorrhage can occur in approximately 10%. However, relatively few cases of bleeding from a duodenal diverticulum have been reported. The cause of bleeding from a duodenal diverticulum is uncertain and various suspected etiologies were suggested, such as ectopic gastric mucosa, stasis-induced ulceration, erosion into major vessels, aortoenteric fistulas, intradiverticular polyp, aspirin-induced erosion. We report a case of a bleeding duodenal diverticulum by a Dieulafoy-like lesion and suggest this lesion as one of possible causes of bleeding in duodenal diverticulum.

A Case of the Duodenal Tuberculosis Presenting as Hematemesis / 대한소화기내시경학회지

Despite the modern advance in effective chemotherapy, gastrointestinal tuberculosis is considered to be relatively frequent in developing countries. The ileocecal region is the most common site of intestinal tuberculosis and duodenal involvement is rare. The isolated duodenal tuberculosis are reported 9 cases in Korea. The symptoms and signs of gastrointestinal tuberculosis are nonspecific and vague. In the absence of pulmonary tuberculosis, the diagnosis may be difficult. Pain and vomiting are common symptoms of duodenal tuberculosis. Patients may present with upper gastrointestinal bleeding. Therefore, tuberculosis should be considered in the differential diagnosis of gastrointestinal bleeding. We herein report a case of duodenal tuberculosis presenting as hematemesis and necessitating hospitalization. After anti-tuberculosis therapy, we have confirmed the healing of the lesion by the follow-up endoscopy, and review the current literature.

An associatioin of cagA+ helicobacter pylori infection with cell proliferation in gastric mucosae of gastritis and gastric cancer patients / 대한내과학회지

BACKGROUND: It has been suggested that cytotoxin associated gene A (cagA) is a marker of more virulent strains of H. pylori and cagA bearing H. pylori is more pathogenic in the gastrointestinal diseases. On the other hand, according to several reports H. pylori causes the cell proliferation, which may be an important mechanism of gastric carcinogenesis. So, we studied to elucidate whether there is the association of the cagA positive H. pylori infection with cell proliferation on the gastric mucosae of the patients with gastritis and gastric cancer or not. METHODS: In this study, 27 gastritis and 35 gastric cancer patients were included. PCR assay for the detection of H. pylori(ureA PCR) and cagA bearing H. pylori(eagA PCR) were performed on the gastric mucosal biopsy specimen. Immunohistochemical study using the MIB 1 Ab against Ki 67 antigen was carried out to evaluate the cell proliferation. RESULTS: The prevalence of H. pylori infection was 85.2%(23/27) in the patients with gastritis and 54.3%(19/ 35) in the patients with gastric cancer. The prevalence of cagA+ strain of H. pylori was 52.2%(12/23) and 47.4%(9/ 19) in the patients with gastritis and gastric cancer. In the patients with gastritis, the degree of cell proliferation was not different in the ureA positive(24.8%) and ureA negative(21.7%) gastric mucosae. Moreover, the difference of cell proliferation was not observed according to the presence or absence of cagA gene(29.4% vs 19.9%) among the ureA positive gastric mucosae. In the patients with gastric cancer, cell proliferation indices were 25.5% and 27.5% in the ureA postive and cagA negative gastric mucosae, 28.1% and 22.2% in the cagA positive and cagA negative group among the ureA positive gastric mucosae. There was no significant difference statistically. CONCLUSIONS: There was no association of cagA+ strain of H. pylori with cell proliferation in the gastric mucosae of the patients with gastritis and gastric cancer. It was presumed that more studies are needed to elucidate the role of H. pylori infection in the gastric carcinogenesis.

Compositional Characteristics of Gallstones in Pusan & Kyungnam area / 대한내과학회지

OBJECTIVES: The composition of gallstones is very variable depending on many factors such as diet, sex, race, genetic background, and so on. The compositional changes of gallstones have been reported in Korean people. Author studied the compositional characteristics of gallstones in Pusan area to see geographical difference. MATERIAL AND METHODS: Gas chromatography and Mass spectrophotometry was performed on the gallstones obtained from the 34 patients who had been taken cholecystectomy because of acute or chronic cholecystitis. Cholesterol gallstone was defined as the composition of the cholesterol is more than 50%. RESULTS: The cholesterol gallstone was 67.6% (23/34) in the 34 patients. There was sexual difference in the cholesterol gallstone group, which the ratio of male and female was 1:2.3(7/16), while there was no difference in the non-cholesterol stone(5:6). The cholesterol stone consisted with cholesterol, bilirubin, bile acid, and palmitic acid and the propotion of them was 75.6%, 4.6%, 15.0%, and 1.8% respectively. While the proportion of non-cholesterol stone was 30.2%, 26.8%, 37.5%, and 5.5% respectively. CONCLUSIONS: The cholesterol stone was major fraction of gallstone of the patients in Pusan area. There was no difference on the compostion of gallstones between those of patients in Pusan area and in the other area of Korea.

A Case of Gastric Kaposi's Sarcoma Successfully Treated with VP-16 / 대한소화기내시경학회지

Kaposi's sarcoma, a rare tumor, usually presents itself with skin lesions. However, extracutaneous lesions are common and the gastrointestinal tract is often involved. Gastric Kaposi's sarcoma is usually asymptomatic, but may cause massive gastrointestinal hemorrhage, perforation, intestinal obstruction, intussusception, protein-losing enteropathy, or sepsis. The gastroscopic appearances of Kaposi's sarcoma range from reddish purple maculopapules to polypoid, umbilicated nodules. In Korea, only one case of gastric Kaposi's sarcoma had been reported until now. A case of gastric Kaposi's sarcoma treated with VP-16 (etoposide) is here in reported with the endoscopic findings before and after chemotherapy.

Clinical significance of lens culinaris agglutinin-A reactive AFP for differential diagnosis of hepatocellular carcinoma and liver cirrhosis / 대한내과학회지

AFP has been the most useful tumor marker of hepatocellular carcinoma (HCC) because AFP is tumor specific and organ specific. However it can be elevated in liver cirrhosis (LC) and chronic hepatitis as well. AFP in hepatocellular carcinoma has been known to be highly reactive Lens Culinaris Agglutinin-A (LCA-A). The aim of our study is to find whether LCA-A reactive AFP (AFP-L3) is useful in differentiation of HCC and LC with high serum AFP level (>20 ng/ml). METHODS: The material consists of sera from 18 patients with HCC and 16 patients with LC whose serum AFP concentration was above 20 ng/ml. Sera were tested for AFP-L3 by lectin-affinity electrophoresis, coupled with antibody affinity blotting with alpha-fetoprotein differentiation kit L (Wako Pure Chemical Industries, Osaka, Japan). AFP-L3 fraction percentage was checked by densitometry (580nm, Cliniscan II, Helena). RESULTS: AFP-L3 detection rate in membrane was 61.1% in HCC and 37.5% in LC. When cut-off value level is 15%, the positive rate was 61.1% in HCC and 31.2% in LC, and sensitivity and specificity of AFP-L3 fraction in HCC was 61.1% and 68.8% respectively. In according to these results, AFP-L3 was a useful marker in differentiation HCC and LC with high serum AFP level. There was no significant relation in AFP-L3 fraction and tumor size, but there was significant relation between AFP-L3 fraction and total AFP serum level(P=0.049). CONCLUSION: These results lead us to conclude that the level of AFP-L3 is a useful marker in differentiation of HCC and LC with high serum AFP level.

Clinical significance of lens culinaris agglutinin-A reactive AFP for differential diagnosis of hepatocellular carcinoma and liver cirrhosis / 대한내과학회지

AFP has been the most useful tumor marker of hepatocellular carcinoma (HCC) because AFP is tumor specific and organ specific. However it can be elevated in liver cirrhosis (LC) and chronic hepatitis as well. AFP in hepatocellular carcinoma has been known to be highly reactive Lens Culinaris Agglutinin-A (LCA-A). The aim of our study is to find whether LCA-A reactive AFP (AFP-L3) is useful in differentiation of HCC and LC with high serum AFP level (>20 ng/ml). METHODS: The material consists of sera from 18 patients with HCC and 16 patients with LC whose serum AFP concentration was above 20 ng/ml. Sera were tested for AFP-L3 by lectin-affinity electrophoresis, coupled with antibody affinity blotting with alpha-fetoprotein differentiation kit L (Wako Pure Chemical Industries, Osaka, Japan). AFP-L3 fraction percentage was checked by densitometry (580nm, Cliniscan II, Helena). RESULTS: AFP-L3 detection rate in membrane was 61.1% in HCC and 37.5% in LC. When cut-off value level is 15%, the positive rate was 61.1% in HCC and 31.2% in LC, and sensitivity and specificity of AFP-L3 fraction in HCC was 61.1% and 68.8% respectively. In according to these results, AFP-L3 was a useful marker in differentiation HCC and LC with high serum AFP level. There was no significant relation in AFP-L3 fraction and tumor size, but there was significant relation between AFP-L3 fraction and total AFP serum level(P=0.049). CONCLUSION: These results lead us to conclude that the level of AFP-L3 is a useful marker in differentiation of HCC and LC with high serum AFP level.

The Clinical Significance of Serum Hyaluronic Acid and Type IV Collagen Levels in Chronic Viral Hepatitis and Liver Cirrhosis / 대한내과학회지

OBJECTIVE: Histopathologic evaluation has been used to evaluate the degree of hepatic fibrosis. This method may have limitations because percutaneous liver biopsy is invasive and histopathologic change shows heterogenicity in the liver. It has been reported that the biochemical markers may have an important role in evaluating the degree of hepatic fibrosis. This study was performed to evaluate the clinical significances of serum hyaluronic acid (HA) and type IV collagen (IV-C) levels on hepatic fibrosis in the patients with chronic viral hepatitis B and liver cirrhosis. METHODS: This study included fifty eight patients with chronic viral liver diseases caused by HBV. Scheuer's classification was used to determine the degree of hepatic fibrosis. The levels of hyaluronic acid and type IV collagen was evaluated by one-step sandwich binding protein assay and one-step sandwich enzyme immunoassay respectively. RESULTS: The level of hyaluronic acid and type IV collagen in stage III (HA:589.4+/-193.7ng/ml, IV-C:444.5+/- 221.3ng/ml) and IV (727.5+/-306.1ng/ml, IV-C:519.2+/-210.5 ng/ml) were higher than stage I (HA:207.2+/-206.8ng/ml, IV-C:210.0+/-92.0ng/ml) and II (HA:223.7+/-172.9ng/ml, IV- C:209.6+/-70.7ng/ml) in the patients with chronic viral hepatitis and cirrhosis. At cutoff value of 500ng/ml for HA and 250ng/ml for IV-C in chronic hepatitis B patients, the sensitivities were 85% and 85%, and specificities were 89.5% and 78.9%, and diagnostic efficiencies were 87.9% and 81% respectively for discriminating patients with advanced hepatic fibrosis (stageIII-IV) from those with mild hepatic fibrosis (stageI-II). CONCLUSION: The serum levels of hyaluronic acid and type IV collagen correlated significantly with the degree of hepatic fibrosis in the patients with chronic viral hepatitis B and cirrhosis. The serum hyaluronic acid and type IV collagen is useful biochemical markers for evaluating hepatic fibrosis and follow up of the patients with chronic viral hepatitis B and cirrhosis.