Necessity of Upper Gastrointestinal Endoscopy in Patients with Noncardiac Chest Pain / 대한내과학회지

BACKGROUND/AIMS: Gastroesophageal reflux disease (GERD) is the most frequent cause of noncardiac chest pain (NCCP) in Western countries. Gastroduodenal disease has a high prevalence in Korea; thus, it is important to evaluate the stomach/duodenum. We retrospectively reviewed the findings in patients with chest pain who were diagnosed by coronary angiography (CAG) to be normal or who had minimal coronary lesions to evaluate the necessity of performing esophagogastroduodenoscopy (EGD) in patients with NCCP. METHODS: A total of 565 patients with chest pain underwent CAG followed by EGD from February 2000 to March 2011 at Konyang University Hospital. We excluded patients who underwent EGD more than 3 days after CAG or had significant coronary lesions. We retrospectively reviewed the EGD findings of the remaining 349 patients. RESULTS: Of the 349 patients, 151 were male, and the average age of the patients was 57.7+/-11.44 years. After performing EGD, GERD was diagnosed in 35 patients (10.0%; LA [Los Angeles classification]-A, 30; LA-B, three; LA-C, two) and peptic ulcer was diagnosed in 48 patients (13.8%; gastric ulcer, 34; duodenal ulcer, 10; gastric and duodenal ulcer, four). Gastritis was diagnosed in 253 patients (72.5%; erosive, 89; erythematous, 90; hemorrhagic, 10; mixed, 64). Duodenitis, esophagitis, Barrett's esophagus, hiatus hernia, and gastric cancer was diagnosed in 36 (10.3%), three (0.9%), two (0.6%), three (0.9%), and one patient, respectively. CONCLUSIONS: Unlike the situation in the west, stomach/duodenal lesions other than GERD are common causes of NCCP in Korea, Therefore, prior to proton pump inhibitor testing or empirical therapy, EGD is necessary to evaluate NCCP and to rule out gastroduodenal lesions.

Cecal Fecaloma Due to Intestinal Tuberculosis: Endoscopic Treatment

Colorectal fecaloma is a mass of accumulated feces that is much harder in consistency than a fecal impactation. The rectosigmoid area is the common site for fecalomas and the cecum is the most unusual site. Diagnosis is usually made by distinctive radiographic findings of a mobile intraluminal mass with a smooth outline and no mucosal attachment. Most of the fecalomas are successfully treated by conservative methods such as laxatives, enemas and rectal evacuation. When conservative treatments have failed, endoscopic procedures or a surgical intervention may be needed. We report here that a cecal fecaloma caused by intestinal tuberculosis scar was successfully removed by endoscopic procedures.

Spontaneous Intramural Hematoma of the Sigmoid Colon Caused by Anti-platelet Agents / 대한소화기내시경학회지

A 71-year-old man presented at the emergency department with an acute onset of hematochezia and abdominal pain that had developed 1 day previously. He had no history of surgery and was taking aspirin (100 mg) and clopidogrel (75 mg). CT revealed a short segmental concentric lower density bowel wall thickening at the proximal sigmoid colon. Sigmoidoscopy showed blue-colored elevated lesions and ruptured intramural hematomas with submucosal bleeding in the sigmoid colon. These findings correspond to intramural hematomas of the sigmoid colon. His symptoms were reduced with conservative treatment stopping aspirin and clopidogrel for 20 days. Here we report a case of non-traumatic intramural hematoma of the colon in a patient receiving dual antiplatelet agents. This had never been reported.

Endoscopic Findings and Clinical Significance of Portal Hypertensive Colopathy / 대한소화기학회지

BACKGROUND/AIMS: The endoscopic findings and clinical relevance of portal hypertensive colopathy are not well described in Korea. We aimed to do a retrospective study of mucosal changes in the colon of patients with liver cirrhosis and to find their association with clinical characteristics. METHODS: We reviewed the clinical data and endoscopic findings of 48 patients with liver cirrhosis and 48 patients, matched for age and sex, with irritable bowel disease (IBS) who underwent colonoscopy over a 5 year span. RESULTS: Patients with liver cirrhosis were more likely to have colitis-like lesions and vascular abnormalities than IBS patients. Low platelet count (p=0.005) and severe esophageal varices (p=0.011) were associated with portal hypertensive colopathy, whereas the etiologies and severity of cirrhosis were not associated with these findings. CONCLUSIONS: Portal hypertensive colopathy can be defined with colitis-like lesions or vascular lesions. These lesions are more frequently present in patients with more severe esophageal varices and thrombocytopenia.

Clinical Features of Pyogenic Liver Abscess according to Age Group / 대한소화기학회지

BACKGROUND/AIMS: Pyogenic liver abscess remains a major diagnostic and therapeutic challenge, despite advances in diagnostic technology and new strategies for treatment. This study was conducted to compare the differences in clinical features and outcomes of pyogenic liver abscess according to age. METHODS: In total, 166 patients were enrolled and included 63 (75 years old, group III) patients in each group. We reviewed the medical records retrospectively including etiology, underlying diseases, characteristics of the liver abscess, laboratory and microbiologic findings, treatment, and outcome of the patients. RESULTS: Group I had higher prevalence rates of male patients and chronic alcoholics, but lower prevalence rates of biliary disease, hypertension, and malignancy. In laboratory findings, group II had higher incidence of thrombocytopenia, elevated blood urea nitrogen and creatinine. There were no differences in symptoms and microbiologic findings in blood and pus among the three groups. Liver abscesses were more common in right liver in Group I. The lengths of stay and the treatment modalities were similar in three groups. CONCLUSIONS: Although there were differences in sex ratio, etiology, underlying disease among the different age groups, they did not cause difference in treatment and clinical outcome of pyogenic liver abscess. Thus, we recommend active treatments in patients of all age.

A Case of Duodenal Gastrointestinal Stromal Tumor Mimicking a Vascular Neoplasm / 대한소화기내시경학회지

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal neoplasm of the gastrointestinal tract. They are preferentially located in the stomach and small intestine. However, the duodenum is an unusual location for GIST. Here we present a case of a 67-year-old woman with a GIST of the 3rd portion of duodenum mimicking vascular neoplasm as an obscure acute gastrointestinal bleeding. The upper gastrointestinal endoscopy and colonoscopy failed to find the lesion. Finally, a large protruded lesion with ulcer was found at the 3rd portion of duodenum using a colonoscope through the oral approach. A spurting bleeding was developed during hypertonic saline epinephrine injection for treatment of oozing bleeding at the margin of the ulcer. Abdominal 3D CT-angiography showed a round and hypervascular structure at the posterior wall of duodenum. A wedge resection of the third portion of the duodenum was performed. Microscopic findings revealed GIST.

Clinical Aspects of Intraabdominal Cystic Lymphangioma in Korea / 대한소화기학회지

BACKGROUND/AIMS: Cystic lymphangioma is an uncommon disease, and rarely develops in the intraabdomen. The aim of this article was to discuss about clinical characteristics of intraabdominal cystic lymphangioma developed in Korea. METHODS: Age, sex, symptoms, locations and size of the lesions, diagnostic methods, treatments, complications and recurrence were analyzed in 13 pathologically confirmed cases of intraabdominal cystic lymphangioma and 18 cases of literature consideration reported in Korea. RESULTS: Intraabdominal cystic lymphangioma commonly developed in adults compared to the other lymphangioma, and frequently located in the mesentery. Abdominal pain was the most common symptom, but it was a non-specific finding. Tenderness and abdominal mass were not significantly associated. The size of mass was diverse. Abdominal ultrasonography and abdominal CT were diagnostic tools most commonly used, but preoperative diagnosis was possible only in 22.6%. All patients were discharged without any complications, and no recurrence was reported. CONCLUSIONS: Preoperative diagnosis of intraabdominal cystic lymphangioma is difficult and symptoms and signs are not specific. Intra-abdominal cystic lymphangioma should be suspected in patients with non specific abdominal pain and intraabdominal mass and active diagnostic evaluation is mandatory.

Clinical Features of Iatrogenic Mallory-Weiss Syndrome / 대한소화기내시경학회지

BACKGROUND/AIMS: The detection of iatrogenic Mallory-Weiss syndrome during the course of upper GI endoscopy is apparently rare. The aim of this study was identify the clinical features of the disease and associated medical conditions. METHODS: We retrospectively analyzed 46 cases (0.08%) of iatrogenic Mallory- Weiss syndrome identified from 54,188 consecutive upper GI endoscopies performed at our institution during a period of 85 months. RESULTS: A total of 36 patients (78.2%) had retching or belching during the procedure. Hiatal hernias were noted in 20 patients (43.5%). We identified a difference of the attack rate by sex and age for iatrogenic Mallory-Weiss syndrome; the disorder developed predominantly in men. All of the patients had a mucosal tear and oozing and 16 patients underwent endoscopic hemostasis. After being diagnosed with iatrogenic Mallory-Weiss syndrome, 17 patients underwent follow- up endoscopy and all of the patients showed good results without rebleeding. No patient showed a complicated clinical course. CONCLUSIONS: A small number of patients had iatrogenic Mallory-Weiss syndrome and most of the patients showed a good prognosis. If there is a predictable risk factor identified during an upper GI endoscopy or an associated medical condition, special care needs to be taken to minimize belching or retching.

Two cases of buried bumper syndrome after percutaneous endoscopic gastrostomy / 대한내과학회지

Percutaneous endoscopic gastrostomy (PEG) is used for nutritional support in patients who require prolonged tube feeding. However, numerous complications have been reported since its introduction. Buried bumper syndrome is an uncommon, but well-documented, complication of PEG placement. The condition often results from excessive pressure exerted on the gastric mucosa by the tight anchorage between the internal and external bumpers. This leads to mucosal erosion and embedding of the internal bumper in the gastric wall, which obstructs feeding. We report two cases of buried bumper syndrome: one was corrected using the push technique and the other was removed surgically.

A case of ectopic opening of the common bile duct (CBD) associated with hematemesis / 대한내과학회지

Ectopic opening of the common bile duct (CBD) in the duodenal bulb is not an incidental finding, but a pathologic condition that can be associated with clinical entities, such as recurrent duodenal ulcer, choledocholithiasis. or cholangitis. We report a case of ectopic CBD with hematemesis in a 61 year-old male patient. Esophagogastroduodenoscopy showed several active ulcers with a fresh blood clot at the duodenal bulb, which had a mucosal deformity and a small opening with suspicious drainage of bile, and the second part of the duodenum had no papilla-like structure. MRCP showed a trident-like pancreatobiliary tree. The biliary tree was visualized via a suspicious ectopic opening of the bile duct at the duodenal bulb. The distal CBD looked hook-shaped and had no filling defect. We report a unique case of ectopic opening of the CBD in the duodenal bulb, which presented as hematemesis.

Spontaneous rupture of the lateral thoracic artery in patients with liver cirrhosis

Bleeding in patients with liver cirrhosis is primarily caused by gastroesophageal varix in association with extensive collateral circulation, portal hypertensive gastropathy, a Mallory-Weiss tear and peptic ulcer disease. The spontaneous rupture of an artery, as a result of coagulopathy, is extremely rare in patients with liver cirrhosis; however, we recently observed a case of a spontaneous rupture of the lateral thoracic artery in a 47 year-old male patient with alcoholic liver cirrhosis. The patient expired despite repeated transcatheter arterial embolization of the lateral thoracic artery and best supportive care. This is, to our knowledge, the first documented case of the spontaneous rupture of the lateral thoracic artery in a patient with liver cirrhosis.

A Case of Eosinophilic Esophagogastroenteritis with Transmural Involvement / 대한소화기내시경학회지

Eosinophilic gastroenteritis is an uncommon disorder characterized by eosinophilic inflammation of the gastrointestinal tract that can present with various gastrointestinal manifestations, depending on the specific site of the affected gastrointestinal tract and the specific layer of the affected gastrointestinal wall. The depth of infiltration is the basis for a proposed classification as mucosal, muscular and serosal subtypes. Diagnostic criteria include the demonstration of eosinophilic infiltration of the bowel wall and lack of evidence of extra-intestinal disease. We experienced a 56-year-old woman that presented with postprandial epigastric pain and, 3 weeks later, with low abdominal pain. An abdominal examination showed tenderness and rebound tenderness in the whole abdomen and a hypoactive bowel sound. Endoscopy demonstrated the presence of mild edematous mucosa in the esophagus and stomach. There was eosinophilic infiltration in the esophagus, stomach and duodenum on as determined by a histological examination and muscular layer hypertrophy as determined on an endoscopic ultrasound examination. A CT scan showed wall thickening of the lower esophagus and gastric antrum to the mid-jejunum with mesenteric fat haziness, and a small amount of ascites was seen in the pelvic cavity. Eosinophilia was seen in the serum and from a fluid examination of aspirated fluid determined by culdocentesis. There was no evidence of parasitic infection based on a serum immunoassay and stool examination. The symptoms disappeared with oral prednisolone management and the patient was discharged from the hospital. This case showed continuous involvement from the lower esophagus to the mid-jejunum with transmural eosinophilic infiltration.

Two Cases of Acute Renal Failure Associated with Nonfulminant Acute Hepatitis A / 대한소화기학회지

We report two cases of acute renal failure in patients with nonfulminant acute hepatitis A. First case is a healthy 25 year-old man complained of myalgia and jaundice. Initial laboratory results showed BUN 40 mg/dL, creatinine 5.23 mg/dL, AST 2,220 IU/L, ALT 3,530 IU/L, total bilirubin 6.26 mg/dL, and positive anti-HAV IgM antibody. Supportive treatments including fluid therapy were started. Serum creatinine and total bilirubin levels were 7.98 mg/dL and 7.66 mg/dL respectively on the 5th hospital day, and decreased gradually. He was discharged on the 12th hospital day, and was being followed up in outpatient department. Second case is a 33 year-old woman who admitted for bilateral flank pain, high fever, nausea, and vomiting. She was diagnosed as acute pyelonephritis and acute hepatitis A. On admission, BUN 13 mg/dL, creatinine 0.74 mg/dL, AST 3,720 IU/L, ALT 2,280 IU/L, total bilirubin 0.9 mg/dL were noted, and acute renal failure developed next day. Fluid therapy with antibiotics administration were started, and maximal BUN and creatinine was 41.7 and 8.09 mg/dL respectively on the 8th day. She recovered without dialysis and was discharged on the 19th hospital day. Proper and prompt comprehensive supportive measures would decrease the need for dialysis in patient of acute renal failue associated with acute hepatitis A.

A Case of Henoch-Schonlein Purpura with Psoas Muscle Abscess and Full-blown Gastrointestinal Complications / 대한소화기학회지

Henoch-Schonlein purpura (HSP) is a vasculitis involving small vessels of skin, joints, gastrointestinal (GI) tract, and kidneys. The patients typically show palpable purpura with one or more characteristic manifestations including abdominal pain, hematuria or arthritis. HSP shows gastrointestinal symptoms in 50~85% of patients, and in 14~40% of patients GI symptoms precede purpuric rash which makes the diagnosis of HSP difficult. We present a case of Henoch-Schonlein purpura with GI bleeding, septic shock by ileal microperforation, small bowel obstruction as a result of ileal stricture and psoas muscle abscess.

A Case of Acute Lower Gastrointestinal Bleeding from Appendiceal Ulcer / 대한소화기내시경학회지

The common causes of acute lower gastrointestinal bleeding include diverticulosis, colonic vascular ectasia, neoplasm and colitis. Acute lower gastrointestinal bleeding from the appendix is a very rare malady and the causes are reported as angiodysplasia, diverticulum, appendicitis and endometriosis. We report here on the case of a 47-year-old man, who was taking enteric coated aspirin, with severe lower gastrointestinal bleeding that was due to appendiceal ulcer. An active bleeding was identified as coming from the appendiceal orifice during colonoscopy. He was treated by simple appendectomy. Histologic evaluation showed ulceration with both acute and chronic inflammation, along with thickened vessel walls in the submucosa of the appendix.

A case of herpes simplex virus esophagitis by primary infection in an immunocompetent patient / 대한내과학회지

Herpes simplex virus esophagitis (HSVE) is a rare disease and most of cases were reported in the immunocompromised state. In the immunocompetent individuals, HSVE was reported in only a few cases worldwidely, moreover some case of which was not a pure HSV infection but a mixed infections with other pathogens. We report a case of HSVE with 72 years-old immunocompetent male patient. He complained about vomiting, poor oral intake. We couldn't find any evidence that he was in immunocompromised state. Upper gastrointestinal endoscopy demonstrated that the esophagus mucosa was friable, having hemorrhagic tendency, and there were multiple ulcers, which was covered with whitish patch, became confluent like a map at the distal. Microscopic examinations revealed that the squamous epithelium at the ulcer margin was infiltrated with inflammatory cells and have intranuclear eosinophilic inclusion body. This case report describes of HSVE by primary infection in an immunocompetent patient without any other infection.

Clinical features of gastritis cystica profunda in patients without history of gastric surgery (Gastric Cancer Patients vs. Non-cancerous Patients) / 대한내과학회지

BACKGROUND: The relationship between gastric cancer and gastritis cystica profunda (GCP) has been frequently reported on, but there have been no systemic studies on whether or not GCP is a precancerous lesion. The aim of this study is to retrospectively analyze the groups in which some of the patients were accompanied by carcinoma and the other patients were non-cancerous (35 GCP cases were without previous surgery). METHODS: From February 2000 through July 2005, 35 cases of GCP without antecedent gastric surgery were diagnosed histologically. We reviewed the medical records, the endoscopic findings and the histologic findings of the patients. RESULTS: In these cases, the age ranged from 33 and 82 years (mean: 63+/-10.1 years). The endoscopic findings of GCP were various: there were 6 erosions and 9 ulcers in the cancer group and 12 polyps in the non-cancer group (p=0.000). The mean size of the lesions was 21.4+/-17.8 mm in the cancer group and 14.6+/-9.3 mm in the non-cancer group (p=0.337). Hypertension was associated with 15 cases (42.9%) in the cancer group and with 2 cases (5.7%) in the non-cancer group (p=0.000). There were 13 smokers (37.1%) in the cancer group and 6 smokers (17.1%) in the non-cancer group (p=0.028). For the histologic findings, 6 GCP patients were associated with dysplasia of adenomas, 4 GCP patients with intestinal metaplasias and 28 GCP patients (80%) with precancerous lesions and carcinomas. CONCLUSIONS: In this study, 18 GCP patients (51.4%) were associated with carcinoma and 10 GCP patients (29%) were associated with precancerous lesions. These results suggest that GCP is a precancerous or paracancerous lesion and it may be one step in the development of carcinoma. The underlying mechanisms of gastric carcinogenesis might be confirmed if we investigate the gene mutations and environmental differences of documented GCP cases that are without previous surgery.

Pancreatic Metastasis and Obstructive Jaundice in Small Cell Lung Carcinoma

Primary lung cancer frequently metastasizes to distant organs. The pancreas is a relatively infrequent site of metastasis. Furthermore, obstructive jaundice resulting from pancreatic metastasis is extremely rare. This paper examines the case of a 65-year-old woman with small cell lung cancer initially presenting with extrahepatic biliary obstruction. The patient underwent percutaneous transhepatic biliary drainage. The obstruction was relieved with a stent placement, then the woman was treated with combination chemotherapy (irinotecan, cisplatin) and a complete remission achieved in six months.

Clinical Features of Acute Hepatitis A in the Western Part of Daejeon and Chungnam Province: Single Center Experience / 대한소화기학회지

BACKGROUND/AIMS: There was an outbreak of hepatitis A in the western part of Daejeon with adjacent Chungnam province in the late 1990's. The aim of this study was to characterize the clinical features and courses of acute hepatitis A in this area. METHODS: A total of 177 cases, who were diagnosed as acute hepatitis A between June 2000 and December 2004, were reviewed retrospectively. CONCLUSIONS: The mean age was 26 and 96% of the cases were under 40 years old. The ratio of male to female was 1.2:1. There were two hospitalized cases in 2000, 3 in 2001, 73 in 2002, 60 in 2003, and 39 in 2004, respectively. The number of diagnosis was most prevalent in June (20.3%). Common occupations were students (62 cases) and homekeepers (21 cases). It was found that 51 patients experienced consumption history of raw fish or shellfish, and that 18 cases had history of exposure to contaminated underground water. Eighteen cases were infected by family members or friends. A history of travel to domestic areas was noted in 31 cases, and to overseas areas in 6 cases (especially Southeast Asia). Only four cases were vaccinated against hepatitis A. HBsAg was positive in 10 cases, and anti-HCV in 2 cases, but none of these had active diseases. The common symptoms were anorexia, jaundice and fatigue. The common ultrasonographic findings were fatty liver (68/157) and acute hepatitis (39/157). In most cases, ALT and total bilirubin level normalized within 8 weeks. No cases of fulminant hepatitis or death were observed. CONCLUSIONS: The majority of cases with acute hepatitis A were completely recovered without sequelae. It is necessary to investigate specific indications for hepatitis A vaccination either in this area or throughout Korea.

A Case of Gastric Ectopic Pancreas Complicated by Chronic Pancreatitis / 대한소화기내시경학회지

An ectopic pancreas is defined as the presence of pancreatic tissue lacking the anatomical and vascular continuity of the main body of the pancreas. Most cases of ectopic pancreas are found incidentally in the stomach and duodenum. The most commonly reported symptoms are abdominal pain, epigastric discomfort, nausea, vomiting and bleeding. An ectopic pancreas is subject to various pathological changes occurring in the pancreas itself: namely, cyst, pancreatitis, hemorrhage, necrosis and neoplastic changes. We report a case of a 28-year old man with epigastric pain in whom the surgical pathological diagnosis was an ectopic pancreas of the stomach with chronic inflammation.