Extended Spectrum-beta-Lactamase or Carbapenemase Producing Bacteria Isolated from Patients with Acute Cholangitis

BACKGROUND/AIMS: This study assessed the antibiotic resistance organisms isolated from the blood and bile of acute cholangitis and evaluated risk factors associated with them and their impact on clinical outcomes. METHODS: The identities and antibiotic resistance profiles of bacteria isolated from 433 cases of acute cholangitis from 346 patients were analyzed. Risk factors and the outcomes of patients infected with them were assessed. RESULTS: Microorganisms were isolated from 266 of 419 blood cultures and 256 of 260 bile cultures. Isolates from bile and blood were identical in 71% of the cases. A total of 20 extended spectrum-beta-lactamase (ESBL)-producers and 4 carbapenemase-producing organisms were isolated from blood, and 34 ESBL-producers and 13 carbapenemase-producers were isolated from bile. Sixty-four (14.8%) cases were infected with any one of these bacteria isolated from blood or bile. Risk factors associated with them in blood were nosocomial infection and prior biliary intervention. In bile, indwelling biliary device was a risk factor associated with them. Antibiotic-resistant bacteria were associated with mortality, independent of other prognostic factors. CONCLUSIONS: ESBL or carbapenemase-producing bacteria were frequently isolated in acute cholangitis patients especially with prior biliary intervention and nosocomial infection. Isolation of antibiotic-resistant bacteria was an independent risk factor of mortality.

Erratum: Extended Spectrum-beta-Lactamase or Carbapenemase Producing Bacteria Isolated from Patients with Acute Cholangitis

The publisher wishes to apologize for incorrectly displaying the author (Jung-Ho Han) name. We correct his name from Jung-Ho Han to Joung-Ho Han.

Appendiceal Intussusception Showing Various Shapes During a Colonoscopy / 대한소화기내시경학회지

Appendiceal intussusception is a rare disease with variable clinical findings, ranging from acute appendicitis to chronic recurrent abdominal pain or rectal bleeding. Occasionally, it is incidentally discovered with no symptoms. Because a preoperative diagnosis is difficult, it can be diagnosed either after surgery, in the case of acute appendicitis, or after a polypectomy, based on being mistaken for a polyp. During a colonoscopy, an appendiceal intussusception should be suspected if the appendiceal orifice is not observed at the cecum and there is a polypoid lesion at the location where the appendiceal orifice is expected. Treatments are usually determined according to preceding diseases. It is important that the colonoscopist avoid careless endoscopic removal by mistaking the intussusception for a polyp.

The Efficacy and Safety of Fully Covered Self-expandable Metal Stents in Benign Extrahepatic Biliary Strictures / 대한소화기내시경학회지

BACKGROUND/AIMS: For the endoscopic treatment of benign biliary strictures (BBS), it has been a drawback to use plastic stents or uncovered self-expandable metal stents. We investigated the efficacy and safety of temporary placing fully covered self-expandable metal stents (FCSEMS) in BBS. METHODS: We enrolled 12 cases that followed up more than 6 months after insertion of a FCSEMS in BBS via ERCP. The cohort consisted of 9 patients with recurrent cholangitis, 2 patients with postcholecystectomy and 1 patient with chronic pancreatitis. The efficacy was assessed according to the resolution of strictures and also the restricture after stent removal, and the safety was evaluated according to the complications associated with stent placement. Finally, the removability of FCSEMSs was assessed. RESULTS: The median time of FCSEMS placement was 6.0 months. Resolution of the BBS was confirmed in 8 cases (67%) after a median post-removal follow-up of 8.5 months. Restricture after stent removal happened in 4 cases (33%). The complications were severe abdominal pain (n=2), pancreatic abscess (n=1) and stent migration (n=6). In 7 cases, all the FCSEMSs were successfully removed by grasping them with forceps. CONCLUSIONS: Temporary placement of a FCSEMS in BBS showed good therapeutic effects, relative safety and easy removability. Further evaluation is needed for determining the causes of restricture and for developing a new stent with antimigration features.

Clinical Observation after Resection of Lower Gastrointestinal Carcinoid Tumor

BACKGROUND/AIMS: The increase of colonoscopy procedures has led to an increase in the diagnosis of carcinoid tumors in the lower gastrointestinal tract. The purpose of this study was to identify the clinical and pathological characteristics that affect the treatment and recurrence of carcinoid tumors of the lower gastrointestinal tract. METHODS: A 10-year (1999-2009) retrospective analysis of 41 patients with carcinoid tumors of the lower gastrointestinal tract at the Chungbuk National University Hospital was conducted. Patient and tumor characteristics, treatment and recurrence were analyzed. RESULTS: The mean age was 47.4+/-12.4 (range, 22-79 years) and the male to female ratio was 1:0.64. The mean tumor size was 9.4+/-4.8 (3-20) mm. In the lower gastrointestinal tract, the rectum was the most frequent location of the lower gastrointestinal carcinoid tumors (92.7%). Twenty-nine out of 41 patients were treated by endoscopy (mean size of tumor: 8.0+/-3.4 mm) and 12 were treated by surgery (mean size of tumor: 13.8+/-5.8 mm)(P=0.011). Among the patients treated by endoscopy, only one patient had a complete resection. However, the histology showed that 10 patients treated by endoscopy had positive resection margins; all 10 cases (35.7%) had a polypectomy (P=0.013). The mean follow-up duration was 19.2+/-14.5 months, and there were two recurrences of rectal carcinoid tumors. CONCLUSIONS: Both endoscopic and surgical resections were effective methods for the treatment of lower gastrointestinal carcinoid tumors. However, endoscopic polypectomy should be carefully considered because of the possibility of more frequent incomplete histological resections. Moreover, even for small rectal carcinoid tumors, follow-up examination should be performed to evaluate for tumor recurrence.

Four Cases of Primary Epiploic Appendagitis

Primary epiploic appendagitis (PEA) occurs due to inflammation of an epiploic appendage, which is a peritoneal pouch that arises from the serosal surface of the colon. PEA is often associated with infarction caused by torsion or spontaneous venous thrombosis. PEA is a self-limited disease with a course of approximately 10 days, and it requires only symptomatic management for pain. But it clinically manifests with localized abdominal pain that is often mistaken for appendicitis, diverticulitis, or cholangitis. Therefore, PEA had been diagnosed at surgery for the past few decades. Making the preoperative diagnosis of PEA through ultrasound and computed tomography (CT) has recently become possible. We report here on four cases of PEA that were diagnosed and treated by symptomatic management.

Genotypic resistance to entecavir in chronic hepatitis B patients / 대한간학회지

BACKGROUND/AIMS: The prevalence and clinical characteristics of entecavir (ETV) resistance is not well known. The aim of this study was to determine the frequency of genotypic resistance in nonresponders and virologic breakthrough (VBT) patients. METHODS: The medical records of 76 chronic hepatitis B patients treated for a least 6 months from October 2006 to October 2008 were reviewed retrospectively. We divided patients into two groups: nucleoside analogue (NA)-naive patients (n=38) and LAM experienced patients (n=38). NA-naive and LAM experienced patients received ETV at 0.5 and 1.0 mg/day, respectively. The virologic response and VBT were investigated in both groups. We used the multiplex restriction fragment mass polymorphism (RFMP) method to test genotypic resistance at the rtI169, rtT184, rtS202, rtM204, and rtM250 sites. RESULTS: Age, gender, serum ALT, and HBV DNA level before treatment did not differ between the groups. Neither VBT nor nonresponse was observed in the NA-naive group, whereas VBT and nonresponse were observed in three patients each in the lamivudine (LAM)-experienced group; all six patients had YMDD mutation at study enrollment, all three patients with VBT had genotypic resistance to ETV, but the three nonresponse patients did not have genotypic resistance to ETV. CONCLUSIONS: We suspect that VBT is mostly associated with genotypic resistance to ETV. However, nonresponse might be associated with the continuance or reselection of the YMDD mutant in LAM-experienced patients.

A Case of Leiomyoma in the Common Bile Duct / 대한소화기학회지

Leiomyomas, originating in the bile duct, are very rare, and only few cases have been reported in the literature. We experienced a case of leiomyoma of the distal common bile duct, mimicking bile duct cancer. A 39-year-old woman presented with intermittent jaundice and general weakness for three months. Clinical profiles showed obstructive jaundice, and the abdominal computed tomography and cholangiography revealed diffuse bile duct dilatation with distal common bile duct stricture. A pylorus-preserving pancreaticoduodenectomy was performed and the pathologic specimen disclosed leiomyoma of the common bile duct accompanying severe fibrosis. This is the first case of leiomyoma in the bile duct reported in Korea.

Hemobilia from Ruptured Hepatic Artery Aneurysm in Polyarteritis Nodosa

Hemobilia, in patients with the diagnosis of polyarteritis nodosa, is rare at clinical presentation and has a grave prognosis. We describe a case of massive hemobilia, due to aneurysmal rupture, in a patient with polyarteritis nodosa. A 39-year-old man was admitted to the hospital with upper abdominal pain. The patient had a history of partial small bowel resection, for intestinal infarction, about 5 years prior to this presentation. Abdominal computed tomography demonstrated multiple high attenuation areas in the bile duct and gallbladder. Hemobilia with blood seepage was visualized on endoscopic retrograde cholangiopancreatography; this bleeding stopped spontaneously. The following day, the patient developed a massive gastrointestinal bleed with resultant hypovolemic shock. Emergent hepatic angiogram revealed multiple microaneurysms; a communication was identified between a branch of the left hepatic artery and the bile duct. Hepatic arterial embolization was successfully performed. The underlying disease, polyarteritis nodosa, was managed with prednisolone and cyclophosphamide.

Clinical Manifestations of Acute Renal Failure with Loin Pain Developed after the Anaerobic Exercise / 대한신장학회잡지

BACKGROUND: Rhabdomyolysis is a well known cause of the exercise induced acute renal failure (ARF), but the patch renal vasoconstriction with severe loin pain which developed after the anaerobic exercise is not. Although there are a few cases about ARF resulted from the patchy renal vasoconstriction in Korea, there are only a few reports about comparisons of their clinical manifestations. METHODS: Eight patients of ARF with severe loin pain after the exercise, were admitted to Chungbuk national university hospital from April 1994 to March 2004. For all patients, we obtained basic clinical findings and laboratory studies, and performed an enhanced computed tomography (CT) initially and delayed CT without contrast media at least 6 hours after. RESULTS: All the patients were previously healthy young men. The main symptom was loin pain in five patients and all patients experienced the anaerobic exercise before. Six patients took analgesics and fever was observed in seven patients. There was no marked elevation of creatinine phosphokinase (CPK). The initial mean creatinine (Cr) was 3.50+/-1.49 mg/dL and the maximum Cr was 8.8 mg/dL. All the patients fully recovered their renal function. We observed the typical patchy wedge-shaped contrast enhancement CT findings in seven patients. CONCLUSION: Differential diagnosis between rhabdomyolysis and the patchy renal vasoconstriction in newly developed ARF after exercise is important. Our eight patients showed typical clinical manifestations. In cases which implicate the pathy renal vasoconstriction by their typical clinical findings, the enhanced CT and the delayed postcontrast CT are helpful for diagnosis.

The Mathematical Model for Predicting the Probability of Minimal Change Nephrotic Syndrome Using Clinical Parameters / 대한신장학회잡지

PURPOSE: We retrospectively investigated to find out the equation of calculating the probability of minimal change nephrotic syndrome (MCNS) using clinical parameters. We prospectively investigated to determine the usefulness of the mathematical model. METHODS: We retrospectively examined 56 patients with nephrotic syndrome (NS) (30 MCNS and 26 non-MCNS) diagnosed by kidney biopsy. A mathematical model for calculating the probability of MCNS was obtained through multiple logistic analysis in SAS statistics package. In addition, we prospectively studied 28 patients with NS. Clinical MCNS and non-MCNS were classified according to the probability of 85% in the mathematical model. Kidney biopsy was performed, and serum albumin and urinalysis were measured after 2 weeks of steroid treatment. RESULTS: In the retrospective study, the mathematical model was P=ea/(1+ea), a=17.2507 - 5.5777xON - 4.2256xALB-0.000579x24PROT - 1.2569xUBL+2.1703xUAL. The mode of onset (ON), 24 hours urine protein (24PROT), serum albumin concentration (ALB), the grade of hematuria (UBL) and proteinuria (UAL) were included as clinical parameters. At the probability of 85%, the sensitivity and specificity for predicting MCNS was 73.3% and 100% respectively. In the prospective study, the result of kidney biopsy was consistent with clinical MCNS and non-MCNS according to a mathematical model. All clinical MCNS showed negative proteinuria on urinalysis and a significant increase in serum albumin after 2 weeks treatment (1.85+/-0.30 g/dL to 2.88+/-0.26 g/dL, p<0.05). CONCLUSION: We conclude that the mathematical model for predicting the probability of MCNS may be useful in diagnosis of the MCNS.

Clinical Significance of Urinary G1 Cells in the Differentiation of Hematuria / 대한신장학회잡지

BACKGROUND: Recently, G1 cells, characterized by distinctive doughnut-like shape with blebs have been reported as a reliable marker for glomerular hematuria. We investigated the validity of the urinary G1 cells in distingushing glomerular from non-glomerular hematuria. In addition, we evaluate the influence of urine osmolality, pH and proteinuria on dysmorphic erythrocytes and G1 cells. METHODS: One hundred and twenty patients with hematuria including 60 glomerular (GH) and 60 non- glomerular hematuria (NGH) were examined. The percentage of urinary dysmorphic erythrocytes and G1 cells using phase-contrast microscopy was determined. Urine osmolality, pH, and spot urine protein/ creatinine ratio were examined. RESULTS: The proportion of G1 cells differed significantly between the two group (7.8+/-16.0% in GH vs. 0% in NGH, p<0.05). At the cut-off value of 50 % dysmorphic erythrocytes, the sensitivity and specificity for the detection of GH was 88.3% and 93.3%, respectively. At the cut-off value of 1% G1 cells, sensitivity and specificity were 60.0% and 100%, respectively. When both of 50% dysmorphic erythrocytes and 1% G1 cells were considered as the cut-off value, the sensitivity and specificity were 91.0% and 100%, respectively. There was a significant difference in the percentage of dysmorphic erythrocytes and G1 cells at different urine pH. There was a significant correlation between urine osmolality and dysmorphic erythrocytes (r=0.41, p< 0.05), but not for G1 cells. No significant correlations were observed between G1 cells and proteinuria or pH. CONCLUSION: Evaluation of both urinary G1 cell and dysmorphic erythrocytes at the same time could improve the diagnostic value for differentiating glomerular hematuria.

The Effect of Hemodialysis on Signal-Averaged Electrocardiography (SAECG) in Patients with End-Stage Renal Disease / 대한신장학회잡지

BACKGROUND: The presence of late potentials on the signal-averaged electrocardiography (SAECG) is predictive of ventricular tachycardia and sudden cardiac death. We investigated the acute effect of HD on the SAECG in patients with end-stage renal disease (ESRD). METHODS: Twenty HD patients with normal sinus rhythm on a routine ECG were enrolled. SAECGs were recorded immediately before, within 30 minute after, and then 24 hour after the completion of HD. Serum electrolyte, BUN, calcium, echocardiogram and body weight were examined before and after the HD. RESULTS: Positive late potentials on SAECG were detected in 8 patients (40%) before HD, 12 patients (60%) at 30 minute after HD, and 5 patients (25%) at 24 hour after HD. There was a significant change in QRSd (QRS duration) after HD: (110.3+-9.7 msec before HD; 112.3+-9.3 msec at 30 minute after HD; 109.5+-8.6 msec at 24 hour after HD) (p<0.05). The reduction of serum potassium was greater in positive late potential (n=12) than in negative late potential group after HD (n=8) (p<0.05). A significant negative correlation was seen between the changes of dialysis-induced serum total CO2 and QRSd changes (r=-0.534, p<0.05). CONCLUSION: SAECG parameters tended to be aggravated after HD in patient with ESRD. Prolongation of QRSd after HD could be explained by the changes of potassium and bicarbonate.