Usefulness of the Forrest Classification to Predict Artificial Ulcer Rebleeding during Second-Look Endoscopy after Endoscopic Submucosal Dissection

BACKGROUND/AIMS: Delayed post-endoscopic submucosal dissection (ESD) bleeding (DPEB) is difficult to predict and there is controversy regarding the usefulness of prophylactic hemostasis during second-look endoscopy. This study evaluated the risk factors related to DPEB, the relationship between clinical outcomes and the Forrest classification, and the results of prophylactic hemostasis during second-look endoscopy. METHODS: Second-look endoscopy was performed on the day after ESD to check for recent hemorrhage or potential bleeding and the presence of artificial ulcers in all patients. RESULTS: DPEB occurred in 42 of 581 patients (7.2%). Multivariate analysis determined that a specimen size ≥40 mm (odds ratio [OR], 3.03; p=0.003), and a high-risk Forrest classification (Forrest Ib+IIa+IIb; OR, 6.88; p<0.001) were risk factors for DPEB. DPEB was significantly more likely in patients classified with Forrest Ib (OR, 24.35; p<0.001), IIa (OR, 12.91; p<0.001), or IIb (OR, 8.31; p<0.001) ulcers compared with Forrest III ulcers. There was no statistically significant difference between the prophylactic hemostasis and non-hemostasis groups (Forrest Ib, p=0.938; IIa, p=0.438; IIb, p=0.397; IIc, p=0.773) during second-look endoscopy. CONCLUSIONS: The Forrest classification of artificial gastric ulcers during second-look endoscopy seems to be a useful tool for predicting delayed bleeding. However, routine prophylactic hemostasis during second-look endoscopy seemed to not be useful for preventing DPEB.

A Case of Acute Gastric Pneumatosis Associated with Advanced Pancreatic Cancer

Pneumatosis intestinalis (PI) is a rare condition that is characterized by multiple subserosal and submucosal gas-filled areas in the bowel wall. Gastric pneumatosis describes the presence of gas within the stomach wall. This is caused by a disruption in gastric mucosa leading to the dissection of air into the wall. The extract cause of PI is still unknown; however, it may be associated with coexisting disease. Gastric PI has been rarely documented. So, we report on a 75-year-old man with acute gastric pneumatosis following his palliative chemotherapy. He underwent 3rd cycle of gemcitabine and erlotinib 3 weeks prior to admission. The treatment was started with nasogastric tube insertion and parenteral nutrition. Then, gastric pneumatosis was improved. However, the patient was died because of worsening underline disease and general condition. We suggest that chemotherapy should be considered the case of pneumatosis and careful X-ray interpretation will be necessary for detecting the pneumatosis earlier.

The Effect of Antiplatelet Agent on Platelet Function in End-stage Renal Disease

OBJECTIVE: Uremic bleeding is well recognized problem. In patients with renal failure, the safety of antiplatelet therapy is doubtful and there is little data about the platelet function in dialysis patients who are prescribed antiplatelet agents. The aim of this study is to investigate the platelet function in dialysis patients who were taking antiplatelet agents. METHODS: The cross-sectional study was performed on 49 patients who have been undergoing dialysis (A group, 19 patients), normal renal function (B group, 30 patients). All of them have taken aspirin and clopidogrel. The control group (C group) consisted of 30 patients who have been undergoing dialysis, not taking aspirin or clopidogrel. The in-vitro closure time was measured using a PFA-100 device that had cartridges holding a membrane with a central aperture and this was coated with either collagen/epinephrine (CEPI) or collagen/adenosine diphosphate (CADP). In vitro closure time was measured by each cartridge defined CADP and CEPI. RESULTS: The CADP and CEPI were higher in the patients with end stage renal disease (ESRD) and who were not taking dual blockers than the normal range (CADP: 80-162, CEPI: 64-121). CADP prolonged in A group compared to C group. Hemodialysis, platelet count <201x106/L, hematocrit, antiplatelet medication are relevant to the prolongation of CEPI and CADP in binary logistic regression analyses. CONCLUSION: Platelet function in ESRD patients was deteriorated irrespective of antiplatelet medication, which became even worse if they took antiplatelet drugs. Therefore, we have to take careful attention to the increased bleeding tendency of ESRD patients due to the antiplatelet drugs.

Acute Fulminant Myocarditis Following Scrub Typhus Infection / 대한내과학회지

Scrub typhus is an acute febrile illness caused by Orientia tsutsugamushi that is characterized by focal or disseminated vasculitis and perivasculitis. Scrub typhus can have fatal complications, such as acute respiratory distress syndrome, septic shock, and acute kidney injury. However, there are few reports of fatal myocarditis caused by scrub typhus. We present a case of acute fatal myocarditis combined with acute kidney injury complicating scrub typhus.

Takotsubo Cardiomyopathy Associated with Severe Hypocalcemia Secondary to Idiopathic Hypoparathyroidism

The etiology and pathophysiology of takotsubo cardiomyopathy have not yet been fully clarified. We report a case of takotsubo cardiomyopathy associated with severe hypocalcemia secondary to hypoparathyroidism. A 69-year-old woman presented with acute pulmonary edema caused by severe left ventricular dysfunction with apical ballooning compatible with takotsubo cardiomyopathy. Laboratory tests revealed severe hypocalcemia secondary to idiopathic hypoparathyroidism. Coronary angiography showed normal coronary artery function. Her symptoms and signs of heart failure improved dramatically with the correction of hypocalcemia through calcium and calcitriol replacement.

A Case of Retroperitoneal Neurilemmoma Arising from Adjacent to Kidney / 대한비뇨기과학회지

Neurilemmoma, also refired to as Schwannoma, neurinoma and perineural fibroblastoma, is well capsulated solitary tumor of Schwann cell origin. The most common sites for benign solitary neurilemmoma are the extremities or the head and neck region. In the retroperitoneum, they are commonly seen in the presacral region. It is incidentally detected and confirmed by pathologic findings. We report a case of retroperitoneal neurilemmoma arising from adjacent to kidney, in 49 years old man.