Comparison of Transient Elastography and Hepatic Fibrosis Assessed by Histology in Chronic Liver Disease / 대한소화기학회지

BACKGROUND/AIMS: Transient elastography (Fibroscan, Echosens, France) is a new, simple, and non-invasive method to assess the degree of hepatic fibrosis by measuring liver stiffness. Recent reports have shown that liver stiffness measurement using Fibroscan allowed accurate prediction of hepatic fibrosis in patient with chronic hepatitis C. The aim of this study was to evaluate accuracy of Fibroscan for the detection of hepatic fibrosis in Korea with various etiologies of chronic liver disease by comparison with fibrosis assessed by histologic examination. METHODS: Fifty-four patients with chronic liver diseases, which were histologically confirmed within recent 6 months were enrolled. Etiologies were HBV, HCV infection, autoimmune hepatitis, and non alcoholic steatohepatitis. Hepatic fibrosis was graded on the basis of standard guideline proposed by the Korean Study Group for the Pathology of Digestive Diseases. RESULTS: Fibroscan values were significantly higher in F3 (16.96 kPa) and F4 (19.86 kPa) than others (p=0.003). Liver stiffness measurement was significantly correlated to the fibrosis stage (r=0.614, p<0.0001). CONCLUSIONS: Liver stiffness measurement by Fibroscan is a promising method for the assessment of hepatic fibrosis in chronic liver disease because it accompanies no complication.

Prevalence and risk factors of gallstones in a general health screened population / 대한내과학회지

BACKGROUND: Gallstone is the most common disease of the biliary system. Most cases of gallstone are asymptomatic and we incidentally found gallstones during a community health survey. Our study was designed to determine the prevalence and risk factors for gallstone in a population who underwent health screening. METHODS: We enrolled a total of 36,314 persons who visited the health promotion center in Kyungpook National University Hospital in Korea from 1998 to 2004. They had their gallbladder or biliary system examined with using ultrasonography. The body mass index and biochemical parameters from liver function tests, the lipid profiles and the fasting blood sugar were all measured. All the subjects were divided into several groups and the particular prevalence for gallstone disease for each group was calculated. Chi-square tests and logistic regression analysis assessed the risk factors for gallstone disease. RESULTS: Among 36,314 persons, (19,345 males (53.3%) and 16,969 females (46.7%)), gallstone was found in 735 persons (2.0%). On univariate analysis, the risk factors for gallstone disease were age, body mass index, fasting blood sugar, total cholesterol, LDL-cholesterol, triglyceride and serum aspartate aminotransferase. On multivariate logistic regression analysis, the the risk factors were high body mass index, older age and high fasting blood sugar. CONCLUSIONS: The risk factors seem to show a common pathogenesis for gallstone disease. Although the relation between gallstone disease and metabolic syndrome has not been established, it appears to be associated with metabolic syndrome, but further study on a general population is required.

An Impacted Clamshell in the Duodenum Mistaken for a Gall Stone

Although most ingested foreign bodies pass through the gastrointestinal tract spontaneously, those that are sharp, pointed, or large require removal to avoid serious complications. Here we report an interesting case of a 60-year-old man who swallowed a clamshell that passed through the pylorus and was caught in the duodenum. Radiologic findings made it look like a biliary stone. Endoscopic retrieval of the clamshell with a Dormia Basket was performed safely and the patient was discharged uneventfully on the day of the procedure.

A Case of Cholestatic Hepatitis Induced by Epstein-Barr Virus Infection / 대한간학회지

Acute viral hepatitis in human can be caused by a large number of viruses with a wide range of clinical manifestations and laboratory findings. EBV is a rare causative agent of an acute hepatitis, during the course of infectious mononucleosis. Hepatic manifestations of EBV are usually mild and resolve without serious complications. EBV is rather uncommonly confirmed as an etiologic agent in acute viral hepatitis of adults and it rarely causes cholestatic hepatitis. We report a case of EBV hepatitis with cholestatic feature that was verified through serum viral marker and liver biopsy.

Kaposi Sarcoma in Patient with Membranous Glomerulonephropathy during Corticosteroid Therapy / 대한신장학회잡지

Membranous glomerulonephropathy is a common cause of nephrotic syndrome in adults. Kaposi sarcoma is a well-known entity with distinct clinical forms such as nodular cutaneous lesions, generalized lymphadenopathy and visceral involvement. Incidence of Kaposi sarcoma is greater in patients with immunosuppression, particularly those having undergone renal transplantation, but also in patients with other underlying disorders treated with immunosuppressive therapy, notably, corticosteroids. We present a case of Kaposi sarcoma in patient with membranous glomerulopathy during corticosteroid therapy. A 49- year-old man was admitted with a complain of facial and leg edema, 5-kg weight gain for 1 month, and foamy urine. Kidney biopsy showed membranous glomerulopathy. We started corticosteroid therapy to the patient. Two month later, his 24 hr urinary protein was decreased to 2.1 g/day. But, the well defined, various-sized, purple-colored papules and plaque appeared on the both hands and feet. He underwent skin biopsy, which revealed abnormally proliferated and dilated vessels, vascular slits, spindle-shaped cells and extravasated erythrocytes in the dermis. The findings were in accordance with Kaposi sarcoma. So he received cryotherapy with discontinuing corticosteroid. Four months after cryotherapy, skin lesions were cleared leaving slight hypopigmentation and amount of proteinuria was preserved without definite aggravation.

Treatment with alpha-glucosidase inhibitor for severe reactive hypoglycemia: A case report / 대한내과학회지

Gastrectomy or vagotomy may result in reactive hypoglycemia, which, in some cases, can reduce the plasma glucose levels to 30~40 mg/dL due to rapid digestion and absorption of food, especially carbohydrate. We treated the patient with frequent episode of severe hypoglycemia. Reactive hypoglycemia is caused by an excessive insulin secretion after a sharp rise in plasma glucose. He had undergone total gastrectomy due to stomach cancer 4 years before. Since nutritional treatment did not successfully manage his reactive hypoglycemia, an alpha-glucosidase inhibitor, voglibose was administered. His hypoglycemic symptoms disappeared and a rapid change of plasma glucose and insulin levels were attenuated after the alpha-glucosidase inhibitor treatment. The effects of alpha-glucosidase inhibitor were documented in a 5-hour oral glucose tolerance test, where not only insulin and C-peptide rise was clearly attenuated, but also the blood glucose concentration did not fall low enough to induce hypoglycemic symptoms. This therapy was very effective and the patient has not had any recurrence of reactive hypoglycemia since the initiation of the therapy.

Two Cases with Adrenal Myelolipoma Treated by Surgical Resection / 대한내분비학회지

An increasing number of incidental adrenal masses are found during the evaluation for unrelated problems, which is the result of the development of sensitive noninvasive methods for the imaging of abdominal lesions, such as ultrasonography, computed tomographic scanning, and MRI. When there is no evidence of adrenocortical or medullary dysfunction for such adrenal masses, they are commonly referred to as "incidentalomas". Among these incidentalomas, adrenal myelolipoma is a rare, benign, endocrinologically inactive tumor, the histological structure of which consists of mature adipose tissue cells and normal hemopoietic tissues resembling bone marrow. Even though most eventually prove to be nonhyperfunctioning adrenocortical adenomas, we must not exclude a more serious pathology. Because of the rarity of adrenal myelolipoma, its natural history, proper prognostic considerations and treatment recommendations still need to be investigated. We experienced 46 year-old man with abdominal discomfort, and a 26 year-old man with no specific symptoms, have large incidentalomas (>5 cm) in adrenal sites, detected by abdominal sonography for routine health work-up. The ACTH, cortisol, renin, aldosterenone, metanephrine, VMA and tumor marker levels were normal, which was suggestive of nonfunctional adrenal tumors. Surgical treatments were performed for rule out malignant adrenal tumors due to the tumor size (>5 cm) and hemorrhage within the tumors. The surgical pathology was that of adrenal myelolipomas. An adrenal myelolipoma is a rare, benign, nonfunctional adrenal tumor, but only three cases have been reported in Korea. We report two cases of adrenal myelolipoma found incidentally by surgical treatment for a large tumor size (>5 cm).

Prevalence of Helicobacter pylori infection and its association with cardiovascular risk factors in Korean adults / 대한내과학회지

BACKGROUND: Chronic inflammation plays an important role in the pathophysiology of atherosclerosis. Among the many pathogens causing chronic inflammation, Helicobacter pylori is the major pathogen for gastric diseases in Korean people. The purpose of this study is to evaluate the prevalence of Helicobacter pylori infection and its association with cardiovascular risk factors in healthy Korean adults. METHODS: In 32,998 healthy subjects, the proportion of seroposive subjects for H. pylori and its association with cardiovascular risk factors were evaluated in participants in health screening program. H. pylori infection status was tested with serum IgG antibody test with ELISA and blood pressure, body mass index, serum lipid profiles, hsCRP were tested. RESULTS: 67% of participants were infected with H. pylori serologic test. Seropositivity was highest in age group of over sixty and male subjects tended to be more infected with H. pylori (p0.05). In multiple logistic regression models, adjusted by age, sex and other variables, total cholesterol was associated with H. pylori seropositivity (odds ratio 1.004, 95% confidence intervals 1.002~1.006, p<0.001) and HDL was inversely related with H. pylori independently (odds ratio 0.990, 95% confidence intervals 0.987~0.992, p<0.001). Age and sex was also positively associated with H. pylori (odds ratio for age 1.029, 95% confidence intervals 1.026~1.032, p<0.001, odds ratio for women to men 0.818, 95% confidence intervals 0.750~0.893, p<0.001). CONCLUSION: The results of this study is that H. pylori infection is prevalent in Korean adults and is independently correlated with cardiovascular risk factors such as total cholesterol and HDL in atherogenic way in healthy subjects. This may support the previous hypothesises that H. pylori might be one of the atherosclerotic pathogens.

Thyroid dysfunction and their relation to cardiovascular risk factors such as lipid profile, hsCRP, waist hip ratio in Korea / 대한내과학회지

BACKGROUND: Thyroid abnormalities affect a considerable portion of the population. Overt hypothyroidism is associated with an elevated risk of cardiovascular disease and adverse changes in blood lipids. Subclinical hypothyroidism is also associated with an increase risk of cardiovascular disease. So we performed the study to investigate the prevalence of overt and subclinical thyroid disorders and their association between cardiovascular risk factors. METHODS: This study was performed in 66,260 subjects (43,588 men, 22,672 women ; between 20~80 years of age, mean age 41.5+/-9.6). Serum free thyroxine (FT4), thyroid stimulating hormone (TSH), total cholesterol, low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C) were measured with RIA using commercial kits. High sensitivity C-reactive protein (hsCRP) were measured with nephelometry. RESULTS: The prevalence of overt thyrotoxicosis, subclinical thyrotoxicosis, overt hypothyroidism and subclinical hypothyroidism was 5/1000 (334 subjects), 6.4/1000 (426 subjects), 1.6/1000 (108 subjects), 6.4/1000 (375 subjects) population. Mean plasma total cholesterol and LDL-C were elevated in overt hypothyroidism than normal (202.1 mg/dL and 121.8 mg/dL versus 197.1 mg/dL and 120.1 mg/dL)(p < 0.05). Also in subclinical hypothyroidism, mean total cholesterol and LDL-C level were elevated compared to normal group (201.9 mg/dL and 123.7 mg/dL)(p=0.015, p=0.047). Waist-to-hip ratio (WHR) was lower in overt thyrotoxicosis and was higher in hypothyroidism. CONCLUSION: The prevalence of thyroid dysfunction was not significantly different from those of other countries. It was also age dependent and higher in women but it was lower than expected. Patients with hypothyroidism exhibit higher levels of waist-to-hip ratio as index of obesity. Patients with subclinical hypothyroidism exhibited increased levels of the atherogenic parameters (Total cholesterol, LDL-C). Therefore screening and treatment for subclinical hypothyroidism may be warranted due to the adverse effects on lipid metabolism.

Thyroid dysfunction and their relation to cardiovascular risk factors such as lipid profile, hsCRP, waist hip ratio in Korea / 대한내과학회지

BACKGROUND: Thyroid abnormalities affect a considerable portion of the population. Overt hypothyroidism is associated with an elevated risk of cardiovascular disease and adverse changes in blood lipids. Subclinical hypothyroidism is also associated with an increase risk of cardiovascular disease. So we performed the study to investigate the prevalence of overt and subclinical thyroid disorders and their association between cardiovascular risk factors. METHODS: This study was performed in 66,260 subjects (43,588 men, 22,672 women ; between 20~80 years of age, mean age 41.5+/-9.6). Serum free thyroxine (FT4), thyroid stimulating hormone (TSH), total cholesterol, low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C) were measured with RIA using commercial kits. High sensitivity C-reactive protein (hsCRP) were measured with nephelometry. RESULTS: The prevalence of overt thyrotoxicosis, subclinical thyrotoxicosis, overt hypothyroidism and subclinical hypothyroidism was 5/1000 (334 subjects), 6.4/1000 (426 subjects), 1.6/1000 (108 subjects), 6.4/1000 (375 subjects) population. Mean plasma total cholesterol and LDL-C were elevated in overt hypothyroidism than normal (202.1 mg/dL and 121.8 mg/dL versus 197.1 mg/dL and 120.1 mg/dL)(p < 0.05). Also in subclinical hypothyroidism, mean total cholesterol and LDL-C level were elevated compared to normal group (201.9 mg/dL and 123.7 mg/dL)(p=0.015, p=0.047). Waist-to-hip ratio (WHR) was lower in overt thyrotoxicosis and was higher in hypothyroidism. CONCLUSION: The prevalence of thyroid dysfunction was not significantly different from those of other countries. It was also age dependent and higher in women but it was lower than expected. Patients with hypothyroidism exhibit higher levels of waist-to-hip ratio as index of obesity. Patients with subclinical hypothyroidism exhibited increased levels of the atherogenic parameters (Total cholesterol, LDL-C). Therefore screening and treatment for subclinical hypothyroidism may be warranted due to the adverse effects on lipid metabolism.

A Case of Secondary Achalasia due to Recurrence of Stomach Cancer / 대한소화관운동학회지

Achalasia can be provoked by organic causes, and it is called secondary achalasia. Sometimes it is very difficult to distingush secondary achalasia from primary achalasia. We report a case of secondary achalasia due to recurrence of stomach cancer. A 45-year-old man came to our hospital due to three months history of dysphagia and regurgitation. Barium esophagogram showed concentric narrowing at the distal esophagus and dilatation of proximal esophagus. The esophagogastroduodenoscopy showed stenosis of gastroesophageal junction and the endoscope could not pass through it, but there was no evidence of malignancy. Esophageal manometry showed aperistalsis, compatible with achalasia. Abdominal CT showed soft tissue density near the gastroesophageal junction. However it was not possible to differentiate whether it was due to adhesion or malignancy. For correct diagnosis and treatment, explorolaparotomy was performed and it was diagnosed as secondary achalasia due to recurrence of stomach cancer.

Sequelae after Treatment of Acute Renal Infarction

PURPOSE: Acute renal infarction is relatively rare disease showing variable clinical manifestations according to the extent of renal parenchymal involvement. We reviewed the clinical features of acute renal infarction and attempted to observe the late sequelae of renal infarction. METHOD: From 1994 to 2001, 12 patients with acute renal infarction were treated at Division of Vascular Surgery, Kyung-pook National University Hospital, Daegu, Korea. They were 9 male and 3 female patients with mean age of 47 years (17 to 77 years). We retrospectively reviewed their clinical features and followed up late status of renal function and blood pressure. RESULT: The causes of renal infarction were arterial embolism in 7 and trauma in 5 patient. Among 14 kidneys involving bilateral renal involvement in 2 patients, 8 kidneys revealed partial renal infarction and 6 kidneys revealed total renal infarction. Abdominal and/or flank pain developed in all patients. Contrast enhanced abdominal CT, and aortography were used to confirm the diagnosis of acute renal infarction. Four patients underwent surgical treatment (1 renal artery embolectomy, 2 renal artery bypass, 1 nephrectomy) and others were treated conservatively including anticoagulaton for the patients with embolism. During the follow-up period, we found 4 (33.3%) late renal functional impairment and 3 (25%) newly developed hypertension to persist. CONCLUSION: Two common causes of acute renal infarction were arterial embolism and abdominal trauma. After treatment of 12 patients with acute renal infarction involving 14 kidneys, we observed renal impairment and/or hypertension to persist even in the patient suffered from partial renal infarction.

Assessment of Focal Liver Lesions with 4-Phase Dynamic FLASH MR Imaging: Usefulness of Early Image Acquisitionfor Characterization of Arterial Phase

PURPOSE: To document the usefulness of early image acquisition using the contrast-enhanced dynacic MR imagingfor characterization of various focal hepatic lesions during the arterial phase. MATERIALS AND METHODS:Seventy-nine patients with 145 focal liver lesions (71 hemangiomas, 59 hepatocellular carcinomas and 15metastases) underwent breathhold dynamic MR imaging using a fast low-angle shot sequence. After obtainingunenhanced T1-weighted images, four phase MR images were obtained 10, 35, 60 and 300 seconds after starting theinjection. Patterns of contrast enhancement were analyzed for each lesion, with an emphasis on first phase images. RESULTS: Forty-two of the 59 HCCs (71%) showed prominent contrast enhancement during the first phase. HCCssmaller than 2cm in diameter showed a more homogeneous enhancement pattern than those which measured 2cm ormore(24/25 vs 12/17;P<.05). Hemangiomas showed a globular enhancement pattern during the same phase in 51 of 71cases (72%), a finding which was more apparent in those whose diameter was 2cm or more(35/54 vs 16/17, p<.05).During the first phase of imaging, 12 of the 15 metastases showed peripheral enhancement of their thick rim. CONCLUSION: The use of early image acquisition on dynamic MR sequences is helpful in character-izing lesionsaccrding to their pattern of contrast enhancement.

Correlation of OPLL with Spinal Instability

PURPOSE: To evaluate the relationship between spinal instability and ossification of the posteriorlongitudinal ligament(OPLL). MATERIALS AND METHODS: In 70 patients(M:F=45:25, mean age=53years) diagnosed as OPLLon the bosis of with surgical operation field findings and radiological evaluation[ plain film(n=70), CT(n=64),MRI(n=55) ], involved levels were the cervical spine(n=32), lumbar spine(n=23), and both the cervical and lumbarspine(n=15). Spinal instability was radiologically diagnosed as horizontal displacement of one vertebra by anotherof more than 3.5mm, or a difference in rotation from either adjacent vertebra by more than 11degree in lateralcervical spine and a difference of more than 1.5mm from the posterior body margins to the point of intersection oftwo lines drawn parallel to the opposing segmental endplate in extension lateral lumbar spine. We divided OPLLinto group I(continuous, segmental, mixed) and group II(retrodiscal), and compared spinal instability in these twogroups. RESULTS: In cervical OPLL, group I comprised 33 cases and group II 14. In group I, spinal instability wasnoted in 8/33 cases(24%)) or 10/123 segments(8.1%). Spinal instability in group II, on the other hand, was foundin 13/14 cases(93%) or 17/26 segments(65%). Ossification occurred at the retrodiscal level in 37 cases, byt incase was continuous. In group II, spinal instability was found in 25 of 37 cases(69%), oe in 29 of 55segments(53%). CONCLUSION: Compared to other types of OPLL, the frequency of retrodiscal OPLL in association withspinal instability was high. Spinal instability may thus be the most important cause of retrodiscal OPLL.

Nontumorous Perfusion Defects in the Liver during CT Arterial Portography: Correlation with Hepatic Arteriography

PURPOSE: To determine the relation between characteristic findings of hepatic arteriography and nontumorous perfusion defects which on CT arterioportography (CTAP) had been inadequately described. MATERIALS AND METHODS: To identify pseudolesions, the CTAP results of 46 patients with perfusion defects which were not recognized on conventional CT or ultrasonography were reviewed and compared with MRI, iodized-oil CT, surgical findings, and histopathologic reports. Typical and atypical pseudolesions were divided according to location, shape and cause, as revealed in previous reports. The number, shape and the location of pseudolesion seen on CTAP were determined and hepatic arteriography correlatively reviewed to determine vascular change in the corresponding area. RESULTS: Seventy-two additional lesions of 46 patients were detected. Among these, 12 cases were true lesions. Sixty pseudolesions were divided into typical (n = 18) and atypical (n = 42) ; the typical pseudolesions were found in familiar locations adjacent to the porta hepatis, falciform ligament or gall bladder and except for increased vascular staining around the gall bladder in two lesions, specific vascular changes were not seen. The shapes of the atypical pseudolesion were wedged (n = 22), nodular (n = 15) and flat (n = 5). They were located subcapsularly (n= 30) or nonspecifically within liver parenchyma (n = 12). The early appearance of a small portal vein branch with subsequent focal hepatic parenchymal staining, which suggests a small AP shunt, was identified on the hepatic arteriography, and on CTAP matched the areas of 96% atypical pseudolesions (26/34) which were more than 1cm in size. CONCLUSION: A small AP shunt should be regarded as a cause of nontumorous, nonsegmental perfusion defectson CTAP.

Detection of Hepatocelluar Carcinoma in MR Arterial Portography; Diagnostic Significance as a Pre-Operative Evaluation

PURPOSE: To evaluate the usefulness of fast magnetic resonance (MR) sequences combined with MR arterialportography in the preoperative assessment of hepatocellular carcinoma. MATERIALS AND METHODS: Twelve patients suffering from nodular hepatocellular carcinoma complicated by liver cirrhosis underwent T2-weighted turbo spinecho and T1-weighted multisection FLASH with and without fat-suppression MR imaging during single breath-holdsession in each sequence. MR arterial portography was performed with Gd-DTPA injected through a catheter into the superior mesenteric or splenic artery during the T1-weighted FLASH sequence. The pathologic findings of surgical specimen or follow-up lipiodol CT findings were compared with the MR imaging. RESULTS: MR arterial portography depicted 17 of the 19 masses (sensitivity, 89%) and the sensitivity of non-contrast fast MR sequences was 74%(14/19). The sensitivity for combined interpretation of all the above sequences was 89% (17/19). MR arterial portography showed perfusion defects from two cysts, one hemangioma, one inflammatory mass, and innumerable tiny regenerating nodules. Static T1-and T2-weighted imaging clearly differentiated, however, benign lesions and true hepatocellular carcinoma. CONCLUSION: MR arterial portography combined with other fast MR imaging allows tissue characterization as well as high detection rate in the evaluation of hepatocellular carcinoma complicated with cirrhosis.