A Case of Argon Plasma Trimming of a Biliary Metallic Stent Causing a Duodenal Obstruction / 대한소화기내시경학회지

Metallic stents are being widely used in patients with a malignant obstruction of the biliary tract. The advent of metallic stents was heralded as a solution to the problem of plastic stent occlusion. Metallic stents prolong stent patency by lowering occlusion rates, but they may malfunction for several reasons, including occlusion from tumor ingrowth or migration after the procedure. Distal migration or impaction of metallic stents against the duodenal wall may cause severe complications, including duodenal obstruction, perforation and acute upper gastrointestinal bleeding. Several techniques have been developed to manage distal migration of a biliary metallic stent and remove the malfunctioning stent endoscopically. We report on a 43-year-old male who underwent endoscopic palliative biliary drainage because of obstructive pancreatic head cancer. We transected the distal end of the metallic stent using an argon plasma coagulator, treating the duodenal obstruction without any complications.

Two Cases of Crohn's Disease Presented with Hematochezia in Patients with Hemophilia

The etiology of Crohn's disease, which is a chronic inflammatory condition that potentially involves any location of the alimentary tract from the mouth to the anus, is unknown. However, there is strong evidence that vascular damage could play a role in the pathogenesis of Crohn's disease. Crohn's disease is mediated by multifocal gastrointestinal infarctions, which occur at an early stage in the disease process. Persistent activation of coagulation in patients with Crohn's disease has been shown. In contrast, hemophilia is an inherited disorder of coagulation. The deficiencies of clotting factors usually involve occult or overt bleeding. The pathogenic mechanisms of Crohn's disease and hemophilia are incompatible. An association between Crohn's disease and hemophilia has not been reported in Korea. We managed 21- and 33-year-old men with Crohn's disease associated with hemophilia, who presented with hematochezia.

Percutaneous Endoscopic Gastrostomy Prevents Gastroesophageal Reflux in Patients with Nasogastric Tube Feeding: A Prospective Study with 24-Hour pH Monitoring

BACKGROUND/AIMS: Percutaneous endoscopic gastrostomy (PEG) has been widely used for patients with swallowing dysfunction. However, its beneficial effects in the treatment of gastroesophageal reflux (GER) are controversial. The aim of this study was to evaluate the effect of PEG on the prevention of GER in patients with nasogastric tube (NGT) feeding. METHODS: Continuous 24-hour pH monitoring was performed prospectively in 21 patients receiving NGT feeding before and 7.3+/-2.2 days after PEG placement to compare the severity of GER. RESULTS: We studied 21 patients with a mean age of 59.8+/-14.1 years. The mean duration of NGT placement was 5.8+/-5.4 months. The causes of swallowing dysfunction included cerebral infarction, cerebral hemorrhage and other central nervous system (CNS) lesions. When all of the patients were considered, there were no significant differences in reflux parameters after PEG placement compared to before PEG placement. However, all seven patients who had preexisting GER showed significant improvement (p<0.05) of the reflux parameters, including the frequency of acid reflux, duration of acid reflux, total time with a pH below 4.0 and the fraction of time with a pH below 4.0, after PEG placement. CONCLUSIONS: PEG might prevent GER in patients receiving NGT feeding, especially in those patients with GER.

A Case of Acute Pancreatitis Caused by the Necrotic Tissue of Gallbladder Cancer / 대한소화기내시경학회지

The most common cause of acute pancreatitis is gallstones. However, idiopathic causes comprise about 10 to 15% of all cases of acute pancreatitis. Biliary sludge is thought to be a cause of idiopathic acute pancreatitis and mainly via obstruction of the common bile duct. Cholesterol polyps of the gallbladder, cholesterolosis and hemobilia can be associated with biliary pain. Fragments of the gallbladder polyps and blood clots can lead to acute pancreatitis in a way similar to that of biliary sludge. Yet it has never been reported that the necrotic tissue of gallbladder cancer can lead to acute pancreatitis. Herein, we report on the case of a 52-year-old man with acute pancreatitis that was caused by the necrotic tissue of gallbladder cancer. The necrotic tissue in the bile duct was revealed on endoscopic retrograde cholangiopancreatography (ERCP). The patient was successfully treated by laparoscopic cholecystectomy along with liver segmentectomy.

Sacroiliitis Is Common in Crohn's Disease Patients with Perianal or Upper Gastrointestinal Involvement

BACKGROUND/AIMS: Sacroiliitis (SI) is one of the most frequent extraintestinal manifestations in inflammatory bowel disease (IBD) patients, but the exact prevalence has not been evaluated in Asia. There are few data on the association between SI and other clinical features of IBD. The prevalence of SI was evaluated using computed tomography (CT) and the phenotypic parameters associated with SI in Korean IBD patients were determined. METHODS: Eighty-two patients with ulcerative colitis (UC) and 81 patients with Crohn's disease (CD) were evaluated clinically. The presence of SI was evaluated using bone window setting of abdomino-pelvic CT images by two radiologists. RESULTS: The prevalence rates of SI were 12.2% and 21.0% in the UC and CD groups, respectively. There was no relationship between the localization or extent of intestinal inflammation and the presence of SI in the UC group. Multivariate analyses confirmed that perianal and upper-gastrointestinal (from the mouth through to the jejunum) diseases were associated with the occurrence of SI in the CD group (p=0.026 and p=0.047, respectively). CONCLUSIONS: SI was as common among Korean IBD patients as among Western patients. Perianal or upper-gastrointestinal involvement is associated with SI in CD patients.

Successful Resection of Locally Advanced Gastrointestinal Stromal Tumor of the Ampulla of Vater after Treatment with Imatinib / 대한소화기학회지

Gastrointestinal stromal tumor (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract arising from Cajal's cells, expressing CD 117. The standard treatment for primary GIST is complete surgical resection. Imatinib mesylate, a specific tyrosine kinase inhibitor, is effective against locally advanced and metastatic GIST. There are several reports of the effect of preoperative imatinib in patients with unresectable and locally advanced primary GIST. We report a case of unresectable primary GIST of the ampulla of Vater, which we were able to completely resect after treatment with a dosage of imatinib 400 mg daily for 5 months. Twelve months later, the patient was treated with imatinib and doing well with no evidence of recurrence.

A Case of Primary Jejunal Mucinous Adenocarcinoma Diagnosed by Single Balloon Enteroscopy / 대한소화기내시경학회지

The small bowel rarely develops neoplasm, and tumor of the small bowel accounts for only 1~2% of all gastrointestinal neoplasm. Most cases of jejunal and ileal adenocarconoma are of the well or moderately differentiated type. Mucinous adenocarcinoma is diagnosed when the amount of extracellular mucin in a tumor is over 50% and its incidence in the small bowel is very low. A 49-year-old man presented with postprandial abdominal pain and vomiting for the previous 2 months. The abdominal computed tomography scan showed about a 6.5 cm-sized mass at the proximal jejunum. Single balloon enteroscopy was done preoperatively for making the diagnosis and the biopsy showed mucinous adenocarcinoma of the proximal jejunum. Under the diagnosis of primary jejunal cancer. We report here on our case for which a definite diagnosis was made before surgery by performing single balloon enteroscopy, and we review the relevant medical literature.

Antineoplastic effect of endogenous peroxisome proliferator-activated receptor gamma ligand, 15-deoxy-delta(12,14)-prostaglandin J2, on cholangiocarcinoma cells / 대한내과학회지

BACKGROUND/AIMS: Peroxisome proliferator-activated receptor (PPAR)-gamma ligand is known to inhibit the growth of several kinds of cancer cells, yet its effect on cholangiocarcinoma is indecisive. We investigated the effect of an endogenous ligand of PPAR-gamma, 15-deoxy-delta (12,14)-prostaglandin J2 (15-deoxy-PGJ2) on cholangiocarcinoma cells that were established from intrahepatic cholangiocarcinoma tissue of Korean patients. METHODS: Four cholangiocarcinoma cell lines, Cho-CK, Choi-CK, JCK and SCK, were studied. The mRNA expression of PPAR-gamma, bcl-2, and bax were examined by RT-PCR. Cell viability was determined by MTT assay. The cell cycle was analyzed by flow cytometry, and apoptosis by cell death detection ELISA kit. Caspase activity was measured by colorimetric assay. The effect of caspase inhibitors on 15-deoxy-PGJ2-induced apoptosis was determined by measuring cell viability using the MTT assay. RESULTS: PPAR-gamma mRNA was expressed in all cholangiocarcinoma cells. 15-deoxy-PGJ2 inhibited proliferation of all cells in a dose- and time-dependent manner. All cells treated with 15-deoxy-PGJ2 showed increased dose-dependent apoptosis. Caspase 3 was activated in all cells and caspase 9 was activated in all but JCK cells after 15-deoxy-PGJ2 treatment. Caspase 8 activity showed no significant change. The pan-caspase inhibitor, Z-VAD-FMK, and the caspase-3 inhibitor, Z-DEVD-FMK, blocked 15-deoxy-PGJ2-induced apoptosis in all cells dose-dependently. The expression of bcl-2 was decreased in Cho-CK, Choi-CK and SCK cells, and bax expression was not changed significantly after 15-deoxy-PGJ2 treatment. CONCLUSIONS: PPAR-gamma mRNA was expressed in all Korean cholangiocarcinoma cells. Our data suggest that 15-deoxy-PGJ2 exerts an antineoplastic effect against cholangiocarcinoma cells by inducing apoptosis through caspase activation.

Familial diffuse gastroesophageal leiomyomatosis: A presentation in a mother and her son with Alport syndrome / 대한내과학회지

Diffuse gastroesophageal leiomyomatosis is a rare, benign neoplastic condition characterized by thickening of the esophageal wall as a result ofaberrant smooth muscle proliferation. Gastroesophageal leiomyomatosis may occur in isolation or as a familial disorder and has been associated with other conditions, such as Alport syndrome. Alport syndrome is a hereditary disorder of basement membrane type IV collagen, characterized by progressive nephritis, sensorineural deafness and ocular abnormalities. In this article, we present an interesting case of gastroesophageal leiomyomatosis occurring in a single family in whichthe mother and her son had Alport syndrome. This case is the first report in Korea that gastroesophageal leiomyomatosis is associated with two generations of Alport syndrome.

Pseudo-Obstruction of Jejunum due to AA Amyloidosis Associated with Latent Syphilis

Amyloidosis uncommonly presents with intestinal pseudo-obstruction. According to previous reports, patients with primary AL amyloidosis presented with a chronic process with symtom duration of more than 1 year, but patients with secondary AA amyloidosis presented as an acute illness, usually less than 10 weeks. Localized gastrointestinal amyloidosis limited to the jejunum, without involvement of stomach, duodenum, colon, or rectum, is very rare. Imaging studies in small intestinal amyloidosis generally show a symmetrical uniform appearance. AA amyloidosis with acute-phase reactant serum amyloid A protein is associated with inflammatory, infectious or neoplastic disorders. To our knowledge, no case of amyloidosis associated with latent syphilis has been reported to date. We present a case of a 56-year-old man who presented with clinical and radiographic features of a small bowel obstruction and obscure gastrointestinal bleeding. Investigations including laparoscopy and other laboratory dataled to a diagnosis of pseudo-obstruction of the jejunum due to AA amyloidosis associated with latent syphilis. After appropriate treatment for latent syphilis, abdominal symptoms had been disappeared, but jejunal dilatation was still present two years later.

A case of sparganosis presenting as hematochezia / 대한내과학회지

Sparganosis is a parasite infection caused by a sparganum, which is a plerocercoid larva of cestodes in the genus Spirometra. Recently, we experienced an unusual case of sparganosis of the descending colon in a 68.year.old female who presented with acute abdominal pain and severe hematochezia. At colonoscopy, a large hematoma was seen in the descending colon. The biopsy specimen showed the degenerating sparganum of a parasitic worm. We report this with a brief review of literature.

Endoscopic Submucosal Dissection of Early Gastric Cancer That Occurred in a Patient with Chronic Myelogenous Leukemia / 대한소화기내시경학회지

Synchronous double malignancies of early gastric cancer and chronic myelogenous leukemia (CML) are very rare. There are few reports regarding the effect of the CML or imatinib on stomach cancer, and it is difficult to make a decision for the proper timing of treatment for early gastric cancer (EGC) in a patient with CML. A 56-year-old man was diagnosed with early gastric cancer. During the evaluation of his disease, he was also diagnosed as having Philadelphia chromosome positive chronic myleogenous leukemia. He started to take 400 mg of imatinib per day. Two weeks later, he underwent endoscopic submucosal dissection (ESD) for the early gastric cancer. Although there was a bleeding complication, complete resection was successfully performed. ESD is an effective treatment modality for EGC in CML patients, but physicians should keep a watchful eye for bleeding complications after the procedure. Further studies and more experience are needed to determine the proper timing of treatment for these patients.

Mesalazine-induced Eosinophilic Pneumonia in a Patient with Crohn's Disease / 대한소화기학회지

Mesalazine (5-aminosalicylic acid) and sulfasalazine are widely used in the treatment of inflammatory bowel disease. The pulmonary toxicity related to sulfasalazine was well-recognized complication and it was caused by sulfapyridine moiety in sulfasalazine. However, the lung injury related to mesalazine has rarely been reported. A thirty five-year-old man with Crohn's disease who was treated with mesalazine complained fever and dry cough. The finding of bilateral wandering pulmonary infiltration, peripheral eosinophilia and increased eosinophils in bronchoalvolar lavage were consistent with eosinophilic pneumonia. His symptoms and laboratory findings were markedly improved after the discontinuation of mesalazine. The mesalazine-induced eosinophilic pneumonia was diagnosed according to his clinical course. This report shows that the eosinophilic pneumonia should be considered in patients who develope pulmonary involvement with inflammatory bowel disease receiving mesalazine therapy.

Two Cases of Acute Myeloid Leukemia with t(16;21)(p11;q22) and TLS/FUS-ERG Fusion Transcripts / 대한진단검사의학회지

Many AML-associated chromosomal abnormalities, such as t(8;21), t(15;17), inv(16), t(9;11), t(9;22) and t(6;9) are well known. The chromosomal aberration of t(16;21)(p11;q22) in AML is rare and it is known to be associated with poor prognosis, young age (median age, 22 yr), and involvement of various subtypes of the French-American-British classification. We report here 2 AML patients with t(16;21)(p11;q22), proved by conventional cytogenetics and/or reverse transcription (RT)-PCR. Erythrophagocytosis by leukemic blasts was observed in both of the cases. One patient was a 24 yr-old male with acute myelomonocytic leukemia. His karyotype was 46,XY,t(16;21)(p11;q22),del(18)(p11.2) and RT-PCR revealed the TLS/FUS-ERG fusion transcripts. Although he received allogeneic peripheral blood stem cell transplantation after the first remission, he died 9 months after the initial diagnosis due to relapse of the disease and graft-versus-host disease. The other patient was a 72 yr-old male with acute myeloid leukemia without maturation. His karyotype was 45,XY,-16,add(21)(q22) and the presence of t(16;21)(p11;q22) was detected by RT-PCR. He was transferred to another hospital with no more follow-up. We suggest that the presence of t(16;21)(p11;q22) and/or TLS/FUS-ERG fusion transcripts has to be considered in cases of AML with erythrophagocytosis.

A Case of a Primitive Neuroectodermal Tumor Detected from a Duodenal Metastasis / 대한소화기내시경학회지

A primitive neuroectodermal tumor (PNET) belongs to the Ewing's sarcoma family and is a malignant small round cell tumor of neural crest origin. The most common site of an extraosseous Ewing's sarcoma is in the soft tissue of the body and extremities. A PNET in the ovary is uncommon. A PNET in the ovary is most often found with a metastasis and the prognosis is poor. The diagnosis of this tumor is confirmed following a pathohistological examination of tissue obtained after an open biopsy or surgery, but no case of a PNET has been diagnosed by the use of endoscopy in Korea. We present a case of a primitive neuroectodermal tumor of the ovary, which metastasized to the duodenum as diagnosed by use of an endoscopic biopsy in a 32-year-old woman who presented with abdominal discomfort.

Peroxisome proliferator-activated receptor gamma ligands exert antineoplastic effects in hepatocellular carcinoma cells / 대한내과학회지

BACKGROUND/AIMS: Thiazolidinediones, which are synthetic insulin sensitizers, are known activators of peroxisome proliferator-activated receptor gamma (PPARgamma). PPARgamma ligands, including endogenous 15-deoxy-delta12,14-prostaglandin J2 (15d-PGJ2), are thought to elicit antineoplastic effects in various cancer cells. In this study, the antineoplastic effects of PPARgamma ligands against hepatocellular carcinoma (HCC) cells were investigated. METHODS: HepG2, Hep3B, and PLC/PRF5 cells were cultured with troglitazone (TGZ), pioglitazone (PGZ), rosiglitazone (RGZ), or 15d-PGJ2 at concentrations of 20-100 micrometer. Cell viability, cell cycle arrest, apoptosis, and caspase activity were measured using the MTT assay, flow cytometry, enzyme-linked immunosorbent assay (ELISA), and colorimetric assays, respectively. The effects of various caspase inhibitors were also measured using a cell death detection ELISA. RESULTS: All three cell lines expressed the PPARgamma gene. TGZ and 15d-PGJ2 strongly inhibited growth in HepG2, Hep3B, and PLC/PRF5 cells. In contrast, PGZ and RGZ showed a much weaker effect in all cell lines. In terms of cell cycle arrest and apoptosis, TGZ induced G0/G1 arrest in HepG2 cells and increased the apoptotic fraction in Hep3B and PLC/PRF5 cells. In contrast, 15d-PGJ2 induced apoptosis only in HepG2 and Hep3B cells. TGZ and 15d-PGJ2 increased caspase-3 activity significantly and increased caspase-9 activity slightly. TGZ- and 15d-PGJ2-induced apoptoses were inhibited by a pancaspase inhibitor (Z-VAD-FMK) and a caspase-3 specific inhibitor (Z-DEVD-FMK) in a dose-dependent manner. CONCLUSIONS: TGZ and 15d-PGJ2 elicit antineoplastic effects in various HCC cells via caspase-dependent apoptotic induction. Their differential effects on similar cell types suggest that another antineoplastic mechanism, most likely a PPARgamma-independent pathway, is involved.

A Case of Sigmoidorectal Intussusception after Self-Expandable Colonic Stent Placement

Self-expandable metallic stents are widely used to relieve acute colorectal obstruction that's secondary to malignancy. They are utilized for both palliation and preoperative decompression prior to colorectal surgery. Although stents have been documented as a relatively safe therapeutic modality, procedure-related complications such as perforation, bleeding, stent reobstruction and migration can occur during or after colonic stent placement. Therefore, clinicians must be aware of the various complications associated with colonic stent placement. We present here a very rare case of sigmoidorectal intussusception that developed after fluoroscopic placement of a self-expandable metallic stent for preoperative decompression of sigmoid colon cancer. We misdiagnosed the intussusception as a distal stent migration on the plain radiography. On the sigmoidoscopic examination to evaluate the unrelieved colonic obstruction, we diagnosed a sigmoidorectal intussusception of the stent-implanted malignant tumor. The patient was successfully treated by laparoscopic partial reduction, followed by a curative anterior resection. This case demonstrates that careful examination must be done in cases of unrelieved colonic obstruction with suspicious stent migration, and intussusception must be considered as a rare complication of self-expandable metallic stent placement in the colon.

A Case of Terminal Ileitis Caused by Ascaris lumbricoides / 대한소화기내시경학회지

The major causes of terminal ileitis are inflammatory bowel disease and NSAIDs but parasites such as Anisakis rarely induce ileitis. Ascaris lumbricoides, the most common intestinal helminth in Korea, may enter the pancreaticobiliary ducts and cause pancreatitis or cholangitis. However, no case of A. lumbricoides-associated terminal ileitis has been previously reported in Korea. We report a case of a 58-year-old woman who presented with epigastric discomfort and bloating, and was diagnosed with terminal ileitis due to A. lumbricoides detected during colonoscopy.

A Case of Sister Mary Joseph's Nodule as a Presenting Sign of Gastric Cancer / 대한소화기학회지

The cutaneous metastasis of a visceral malignancy to the umbilicus is known as "Sister Mary Joseph's nodule (SMJN)". It is considered to be a predictor of poor prognosis because it mostly occurs in advanced, metastasizing cancer. However, it is a very rare condition as an initial presenting sign of primary cancer. We recently encountered a 48-year-old man presented with an umbilical lump. The lesion was a firm, ill-delineated, painful nodule with regular surface in the umbilicus. Abdominal computed tomography showed a 2.2 cm sized, ill-defined, delayed enhancing mass at the periumbilical area accounting for umbilical nodule. Diffuse irregular thickening of peritoneum and diffuse wall thickening of stomach implied the diagnosis of gastric cancer. Esophagogastroduodenoscopy revealed diffuse nodular infiltrative lesion from cardia through body of the stomach, compatible with Bormann type 4 advanced gastric cancer. Later, histopathologic confirmation showed a presence of signet ring cell adenocarcinoma from biopsy specimens. We experiened a case presenting with an umbilical metastasis as the first sign of gastric adenocarcinoma. It is thought that direct extension of tumor through the peritoneum might be the route for umbilical metastasis. Careful examination of all umbilical lesions must be needed for the early diagnosis of internal malignancy.

The Inventory Levels of Red Blood Cells from Sentinel Hospitals in Korea according to the Blood Type / 대한수혈학회지

BACKGROUND: A survey for determining the inventory levels of blood products in hospitals is needed, not only for the effective management of the blood products, but also for controlling and planning of the blood supply in Korea. However, any nation-wide survey has never been reported in Korea. Our aims were to provide the information about the status of the RBCs inventory levels of each blood type in the hospitals, and to suggest guidelines for estimating the inventory levels of hospitals. METHODS: We analyzed the data of the average daily usage, the ideal inventory levels and the minimal inventory levels of RBCs according to the each blood type for 28 sentinel hospitals that participate in the 'blood inventory monitoring system'. This system is a surveillance program for monitoring the usage and inventory levels of blood products. RESULTS: The hospitals showed different levels for the average daily usage, the ideal inventory and the minimal inventory according to each blood type. The average daily usage, the ideal inventory level and the minimal inventory level of blood type A were the highest compared to those of the other blood types. For each blood type, the average ideal inventory level is about 5 times higher than the average daily usage, and the average minimal inventory level is about 2 times higher than the average daily usage. CONCLUSION: This is the first nation-wide report on the average daily usage, the ideal inventory levels and the minimal inventory level of each blood type for Korean hospitals, and this data will be helpful to understand the inventory status and estimate the inventory levels of blood products.