Late Presentation of Metastatic Renal Cell Carcinoma as a Bleeding Duodenal Mass / 대한내과학회지

Gastrointestinal metastasis of a renal cell carcinoma is very rare, and the clinical course of the disease ranges from months to several decades. We experienced a case of solitary duodenal metastasis about 22 years after a right nephrectomy for clear-cell type renal cell carcinoma in a 77-year-old man who complained of melena. This case is the longest reported time interval between surgical nephrectomy to presentation with a duodenal metastasis. Patients usually present with recurrence within a year after radical nephrectomy but can present after many years, warranting lifelong surveillance.

Predictable Factors of Histologic Discrepancy of Gastric Cancer between the Endoscopic Forceps Biopsy and Endoscopic Treatment Specimen / 대한소화기학회지

BACKGROUND/AIMS: Recently, variable gastrointestinal track tumors including early stage malignancies are treated by endoscopic procedure. However, the discrepancy of histologic diagnosis may sometimes exist between the pretreatment forceps biopsy results and those of post treatment specimen. So the prediction of malignant lesion is important in the aspect of treatment selection. In this study, we investigated the predictable factors of the histologic discrepancy through the clinical, endoscopic features of the lesion diagnosed as adenocarcinoma in the post-endoscopic treatment specimen after the adenoma was diagnosed by the endoscopic forceps biopsy. METHODS: From March 2005 to April 2009, 129 gastric tumor lesions (129 patients) which were not diagnosed as malignancy and treated with endoscopic procedure were enrolled retrospectively. We compared the pretreatment endoscopic forceps biopsy results and post-treatment specimen biopsy results, then, analyzed the tumor characteristics. RESULTS: Twenty-one cases (16.3%) were diagnosed as malignancy after endoscopic treatment. Especially, discrepancy occurred more frequently in depressed lesions than in flat or elevated lesions (41.7% vs. 13.7%, p=0.012), and in lesions diagnosed as high grade adenomas than low or moderate grade adenomas (33.3% vs. 11.1%. p=0.004). CONCLUSIONS: In cases of depressed type lesions in the pretreatment endoscopy or those diagnosed as high grade adenoma in the pretreatment forceps biopsy, we should consider combined malignant lesion. Therefore, treatment modalities ensuring accurate diagnosis and potentially curative resection, should be carefully selected and performed in cases which have these features.

Esophageal Gland Duct Adenoma

Benign ductal or glandular neoplasms of the esophagus unrelated to Barrett esophagus are extremely rare. Only 9 cases have been reported in the English language literature. We now report a case of esophageal gland duct adenoma incidentally found in a 73-year-old man. A 0.8 cm-sized, polypoid submucosal lesion in the distal esophagus was removed. Histologically, the lesion was well circumscribed and consisted of several ducts or cysts with focal papillary configurations. Interstitial lymphocytic infiltration with germinal centers was also observed. The lining cells of ducts or cysts were composed of two layers: an inner intensely eosinophilic luminal duct cell layer and an outer myoepithelial cell layer that was accentuated by alpha-smooth muscle actin. There was no significant nuclear atypia or mitosis. Mucin production was occasionally observed in a few goblet cells. To the best of our knowledge, this is the first case of benign ductal or glandular neoplasm of the esophagus among Koreans.

A Case of Ampullary Adenomyoma Associated with Dilatations of Pancreatic and Biliary Ducts / 대한소화기내시경학회지

Adenomyoma is a nonneoplastic lesion that can be found anywhere in the gastrointestinal tract, but it's rarely found in the ampulla of Vater. To the best of our knowledge, it is a benign lesion, but most cases are misdiagnosed as carcinoma or adenoma by a preoperative endoscopic or radiologic procedure, and this leads to unnecessarily extensive surgical resection. We report here on a case of ampulla of Vater adenomyoma that resulted in biliary and pancreatic duct dilatation. The tumor was diagnosed by endoscopic papillectomy.

Polyarteritis Nodosa Localized in Small Intestine: A Case Report / 대한소화기내시경학회지

Polyarteritis nodosa is a systemic necrotizing vasculitis that affects mainly small and medium-sized arteries that involve multiple organs. In addition to the systemic involvement of classical vasculitis, localized vasculitis involves blood vessels within a confined vascular distribution or single organ without clinical evidence of generalized inflammation. Localized vasculitis of the gastrointestinal tract is a rare entity. In particular, a limited involvement of the small bowel is an unusual manifestation of polyarteritis nodosa. In this report, we describe a case of biopsy-proven polyarteritis nodosa presenting as small bowel bleeding without other systemic manifestations.

A Case of Lymphoid Polyp in the Ampulla of Vater Associated with Tubulopapillary Adenoma / 대한소화기내시경학회지

Lymphoid polyp is a very rare disease that commonly occurs in the rectum. It is a benign, focal or diffuse lesion that typically occurs where clusters of lymphoid follicles are present. The polyp is composed of well differentiated lymphoid tissue. It can generally be differentiated from malignant lymphoma by the proliferation of normal lymphoid tissue, which has a prominent follicular pattern and a clearly defined germinal center. There have been only a few reports of lymphoid polyps of the rectum, and there have been no reports of lymphoid polyp in the ampulla of Vater. We experienced a case of lymphoid polyp in the ampulla of Vater associated with tubulopapillary adenoma, and the patient first presented with jaundice, weight loss and general weakness.

Pancreatic and Biliary Strictures Associated with Cholangitis and Bile Reflux Following Endoscopic Papillectomy of Ampullary Adenoma / 대한소화기내시경학회지

Ampullary adenoma is rare but clinically important because it is a premalignant lesion. Use of endoscopic gastroduodenoscopy has increased detection of adenoma of the major duodenal papilla. Endoscopic papillectomy is a promising technique to supplant surgical ampullectomy, because it is less aggressive and more stable. However, various complications include bleeding, perforation, pancreatitis and cholangitis. We describe pancreatic and biliary strictures associated with cholangitis, and bile reflux through the pancreatic duct to the minor duodenal papilla after endoscopic papillectomy. Pancreatic and biliary strictures have not been hitherto reported complications. We performed endoscopic papillary balloon dilatation, minor papilla papillotomy and inserted a drain tube through the accessory pancreatic duct.

A Case of Primary Gastric Tuberculosis Presenting with Melena / 대한소화기내시경학회지

We experienced a case of primary gastric tuberculosis presented with melena. A 61-year-old male was admitted with epigastric pain and melena. Upper endoscopy revealed an irregular shaped gastric ulcer on the posterior wall of the body. Histological examination of endoscopic specimen revealed chronic inflammation with fibrosis, granulomas and acid-fast bacilli. Cultures for acid-fast bacilli subsequently grew Mycobacterium tuberculosis. There was no evidence of the tuberculous lesion anywhere else. Primary gastric tuberculosis remains an extremely uncommon clinical entity; the definitive diagnosis is made by biopsy and positive culture for the organism. We report a case of primary gastric tuberculosis with review of the literature.

The Predictors of Effectiveness on Urokinase Instillation Therapy into Loculated Pleural Effusion / 결핵

BACKGROUND: As the pleural inflammation progresses, exudative pleural fluid becomes loculated rapidly with pleural thickening. Complete drainage is important 13 prevent pleural fibrosis, entrapment and depression of lung function Intrapleural urokinase instillation therapy has been advocated as a method to facilitate drainage of gelatinous pleural fluid and to allow enzymatic debriment of pleural surface. This study was designed to investigate the Predictors of effeotiveness of intrapleural urokinase in treatment of loculated pleural effusion METHOD: Thirty-five patients received a single radiographically guided pig-tail catheter ranging in size from 10 to 12 French Twenty-two patients had tuberculous pleural effusions, and 13 had non-tuberculous postpneumonic empyemas. A total of 240,000 units of urokinase was dissolved in 240 ml of normal saline and the aliquots of 80mL was instilled into the pleura1 cavity via pig-tail catheter per every 8hr. Effectiveness of intrapleural urokinase instillation therapy was assessed by biochemical markers, ultrasonography, and technical details. A greater than 50% improvement on follow-up chest radiographs was defined as success group. RESULT: Twenty-seven of 35 (77.1%) patients had successful outcome to urokinase instillation therapy. Duration of symptoms before admission was shorter in sucess group (11.8α6.9day) than in failure group (26.62α16.5day) (P<0.05). Amount of drained fluid during urokinsse therapy was larger in success group (917.1α392.7ml) than in failure group (613.8α259.7ml) (P<0.05). Pleural fluid glucose was higher in success group (89.7 α35.9mg/dl) than in failure group (41.2α47.1mg/dl) (P<0.05). Pleural fluid LDH was lower in success group (878.4α654.31U/L) than in failure group (2711.1α973.1IU/L) (P<0.05). Honeycomb septated pattern on chest ultrasonography was observed in six of eight failure group, but none of success group(P<0.05). CONCLUSION: Longer duration of symptoms before admission smaller amount of drained fluid during urokinase therapy, lower glucose value, higher LDH value in pleural fluid examination and honeycomb septation pattern on chest ultrasonography were predictors for failure group of intrapleural urokinase instillation therapy.

Evaluation of Steroid Therapy in Tuberculous Pleurisy: A Prospective, randomized study / 결핵

BACKGROUND: Tuberculous pleurisy has been treated with a combined regimen of corticosteroids-antimicrobial therapy. But whether such combination therapy add to benefits is unknown. We evaluate the effects of corticosteroid and its routine application in relief of clinical symptoms, absorption of pleural effusion, and pleural adhesions. METHODS: A prospective, randomized study of the role of corticosteroid in the treatment of tuberculous pleurisy was performed in 83 patients(nonsteroid group:50 patients, steroid group: 33 patients) from June, 1991 to September, 1994. RESULTS: 1) The mean duration from symptoms(fever, chest pain, dyspnea) to relief was 3.8 days in the steroid group, and 7.4 days in the nonsteroid group(P0.05). 3) The incidence of pleural adhesions was 17/33(51.5%) in the steroid group and 32/50(64%) in the nonsteroid group(p>0.05). 4) Side effects of corticosteroids were observed in only one patient causing epigastric pain and discontinuation of drug. CONCLUSION: Corticosteroid exert benefitial role in the more rapid relief of clinical symptoms to patients with tuberculous pleurisy, but absortion of pleural effusion and occurrence of pleural adhesions was not influenced significantly. Therefore, its routine application should be reevaluated.