Superior Mesenteric Artery Syndrome Treated with Percutaneous Radiologic Gastrojejunostomy / 대한소화기학회지

Superior mesenteric artery (SMA) syndrome is a rare condition that must be differentiated from other gastrointestinal diseases manifesting as upper abdominal pain, nausea, or vomiting. The description of SMA syndrome is compression of the third portion of the duodenum by the SMA and the abdominal aorta. SMA syndrome is managed with nasoenteral nutrition or surgical strategies such as laparoscopic duodenojejunostomy. However, SMA syndrome treated using enteral nutrition by percutaneous radiologic gastrojejunostomy has not been reported. Here, we report our experience of successfully managing a case of SMA syndrome with percutaneous radiologic gastrojejunostomy.

A Case of Successful Treatment of Portal Venous Gas Caused by Acute Pancreatitis / 대한소화기학회지

Hepatic portal venous gas (HPVG) has been considered a rare entity associated with a poor prognosis. Portal vein gas is most commonly caused by mesenteric ischemia but may have a variety other causes. HPVG can be associated with ischemic bowel disease, inflammatory bowel disease, intra-abdominal abscess, small bowel obstruction, acute pancreatitis, and gastric ulcer. Because of high mortality rate, most HPVG requires emergent surgical interventions and intensive medical management. We experienced a case of hepatic portal venous gas caused by acute pancreatitis and successfully treated with medical management.

A Case of IgG4 Associated Sclerosing Cholangitis without Clinical Manifestations of Autoimmune Pancreatitis / 대한소화기학회지

IgG4-related systemic diseases are characterized by a diffuse or mass forming inflammatory reaction rich in lymphocytes and IgG4-positive plasma cells (lymphoplasmacytic infiltration), fibrosclerosis of variable organs and obliterative phlebitis. They usually involve various organs including the pancreas, bile duct, gallbladder, salivary gland, retroperitoneum, kidney, lung, and prostate. However, most of them are accompanied by autoimmune pancreatitis, and good response to steroid treatment is one of the hallmarks of this disease. We report a case of an 67-year-old man with IgG4 associated sclerosing cholangitis, who was diagnosed by endoscopic retrograde cholangiopancreatography and successfully treated with steroid therapy.

A Case of Ectopic Sebaceous Glands in the Esophagus / 대한소화기내시경학회지

A 42-year-old man without any signs or symptoms of illness underwent esophagogastroduodenoscopy (EGD) for a routine health check up. On esophagogastroduodenoscopy, multiple small and yellowish mucosal plaques were detected in the mid to distal esophagus. These plagues proved to be ectopic sebaceous glands of the esophagus according to the histologic examination. On the immunohistochemical staining with anti-Keratin 14, the basal cells and the heterotopic sebaceous glands were immunoreactive for keratin 14. The histogenesis of this extremely rare lesion is not completely clear. There have been some reports on ectopic esophagus sebaceous glands combined with esophageal cancer or gastric cancer. However, malignant transformation of the ectopic sebaceous gland itself has not yet been reported on. This case was regularly followed up for 12 months, and no interval change or malignant transformation was found both endoscopically and histologically.

A case of Morgagni hernia with intestinal obstruction / 대한내과학회지

Although Morgagni hernias are rarely symptomatic, an 88-year-old woman presented with severe abdominal pain and distension due to large bowel obstruction. The transverse colon and omentum were herniated through an anterior medial diaphragmatic defect in the right thorax. The plain abdominal X-rays indicated intestinal obstruction and the plain chest X-ray showed hazy mass-like densities. The multi-detector row computed tomography (MDCT) findings were compatible with a Morgagni hernia. This diagnosis of a Morgagni hernia was confirmed at immediate surgery.

A case of hepatitis A and E coinfection in an autoimmune hepatitis patient / 대한내과학회지

In Korea, the number of Hepatitis A virus (HAV) infections has suddenly increased and has become the most common cause of acute viral hepatitis during recent years. A 36-year-old female was diagnosed with acute fulminant hepatitis caused by HAV. Her clinical symptoms and AST/ALT recovered after supportive treatment; however, a re-elevation of AST/ALT was observed. Weperformed another viral marker study, autoimmune marker study and liver biopsy to rule out another hepatic insult. As a result, anti- HEV IgM, an anti-nuclear antibody and anti-smooth muscle antibody were positive and liver histology showed chronic hepatitis. In conclusion, we report a case of hepatitis A and E coinfection in an autoimmune hepatitis patient.

A Case of a Duodenal Gastrointestinal Stromal Tumor with a Bleeding Ulcer / 대한소화기내시경학회지

Duodenal gastrointestinal stromal tumors (GISTs) are relatively rare tumors that commonly present with gastrointestinal bleeding. Evaluation with endoscopic ultrasonography (EUS) is a useful technique for the differential diagnosis of GISTs from other submucosal tumors. A 58-year-old man presented with melena and anemia. An esophago-gastroduodenoscopy showed the presence of a submucosal tumor in the second portion of the duodenum with central ulceration and a flat spot. EUS showed the presence of a suspicious malignant GIST that originated from the proper muscle layer, which was successfully resected. We report a case of a duodenal GIST with a bleeding ulcer. Positive reactivity for CD117 and S-100 was demonstrated by immunohistochemical staining.

Anti-Tuberculosis Agents Induced Pseudomembranous Colitis Treated with Maintaining Anti-Tuberculosis Drugs / 대한소화기내시경학회지

Tuberculosis is one of the main infectious health problems in Korea, and a combination of antibiotics is required to treat this illness. The combination therapy with rifampicin, isoniazid, ethambutol and pyrazinamide has many adverse reactions and there have been several case reports about pseudomembranous colitis (PMC) after anti- tuberculosis treatment. Rifampicin is regarded as a main cause of anti-tuberculosis induced PMC because of its bacteriocidal effect, and interruption of the offending drug, such as rifampicin, is usually necessary to treat the PMC. However, in patents with uncompensated tuberculosis, the discontinuance of anti-tuberculosis medication accentuates the disease severity, and continuance of the anti-tuberculosis medication is necessary to overcome the tuberculosis. We report here on a case in which the anti- tuberculosis agents induced PMC in 32 year old female who was diagnosed with active pulmonary tuberculosis. She was treated with maintenance of the anti-tuberculosis medication and also the addition of both oral metronidazole and probiotics.

A Case of Esophageal and Gastric Foreign Bodies Induced by Cyanoacrylate Ingestion / 대한소화기내시경학회지

Foreign bodies of the upper gastrointestinal tract are found in all age groups, and the foreign bodies can be ingested incidentally or intentionally. They are usually common in children, but they have also been discovered in adults with esophageal disease, artificial teeth, mental retardation, in patients seeking secondary gains and in alcoholics. The types of foreign bodies vary for different social and cultural conditions, and can include coins, corks, toys, fish bones, toothbrushes, needles, nails and pens. Foreign bodies of the upper gastrointestinal tract are usually passed into the intestinal tract spontaneously, but sometimes intervention is required. We report a case of an 80-year-old man with a past medical history of depressive disorder that had ingested adhesives. The adhesives present in the esophagus were removed by the use of therapeutic endoscopy. However, the adhesives in the stomach were too large to remove by the use of an endoscopic procedure, and gastrotomy was performed.

A Case of Successful Treatment of Stomal Variceal Bleeding with Transjugular Intrahepatic Portosystemic Shunt and Coil Embolization

Variceal bleeding from enterostomy site is an unusual complication of portal hypertension. The bleeding, however, is often recurrent and may be fatal. The hemorrhage can be managed with local measures in most patients, but when these fail, surgical interventions or portosystemic shunt may be required. Herein, we report a case in which recurrent bleeding from stomal varices, developed after a colectomy for rectal cancer, was successfully treated by placement of transjugular intrahepatic portosystemic shunt (TIPS) with coil embolization. Although several treatment options are available for this entity, we consider that TIPS with coil embolization offers minimally invasive and definitive treatment.

A Case of Choledochocele with Parapapillary Diverticulum Presenting as Pancreatitis / 대한소화기내시경학회지

Choledochocele, classified as choledochal cyst: type III, is a rare cystic or diverticular dilatation of the terminal biliary tree that causes abdominal pain, recurrent pancreatitis, and obstructive jaundice. It is the rarest of the choledochal cysts and has lower malignant potential than any other type of choledochal cyst. Although its anatomic structure does not fit the criteria for pancreatobiliary maljunction, pancreaticobiliary reflux may occur in patients with choledochocele. Herein, we report the case of a 63-year-old woman with recurrent episodes of acute pancreatitis that were caused by a choledochocele with two parapapillary diverticula. She was successfully treated by endoscopic needle-knife sphincterotomy without severe complications and remained asymptomatic at the 6-month follow-up.

Acute Lower Gastrointestinal Bleeding from the Appendix Diagnosed by Abdominal Multidetector Computed Tomography: A Case Report and Review of the Literature

Appendiceal bleeding is a kind of lower gastrointestinal bleeding. For treatment, it is essential to identify the location of the lower gastrointestinal tract bleeding. Appendiceal bleeding has some diagnostic difficultie. It is a very rare condition, and colonoscopy shows only the appendiceal orfice. Recently, multidetector computed tomography has increasingly been used in the diagnostic evaluation of most vascular diseases. Herein, we report the case of an appendiceal bleeding diagnosed by using abdominal multidetector computed tomography, and we present a the literature.

A Case of Spontaneous Dissection of the Superior Mesenteric Artery Treated by Percutaneous Stent Placement / 대한소화기학회지

Acute mesenteric ischemia can result from emboli, arterial and venous thrombi or vasoconstriction secondary to low-flow states. Isolated spontaneous dissection of the superior mesenteric artery is a rare cause of acute mesenteric ischemia. The mortality rates of acute mesenteric ischemia averages 71% with a range of 59-93%. Diagnosis before the occurrence of intestinal infarction is the most important factor in improving survival rate for patients with acute mesenteric ischemia. A 68-year-old female presented with postprandial epigastric pain, and a dissection of the superior mesenteric artery and a gallbladder polyp were shown in abdominal computed tomographic scan. After the percutaneous metalic stent placement and laparoscopic cholecystectomy, her symptoms improved. We report a case of spontaneous dissection of main trunk of the superior mesenteric artery which was successfully treated by percutaneous stent placement with a review of literature.

The effect of Helicobacter pylori eradication on the improvement of the symptoms in patients with functional dyspepsia and peptic ulcer disease / 대한내과학회지

BACKGROUND: In the functional dyspepsia, Helicobacter pylori has been suggested as a causative agent. But, the effect of H. pylori eradication is still debated on functional dyspesia. The purpose of this study was to evaluate the effectiveness of the H. pylori eradication therapy in the improvement of the symptoms in patients with functional dyspepsia. METHODS: The convenience sample consisted of 123 patients with functional dyspepsia and 80 patients with peptic ulcer diseases who were infected with H. pylori. All patients had received eradication therapy of H. pylori for one or two weeks and additional therapy with H2RA or PPI for one to five weeks. After the treatment was completed, the patients were asked about their symptomatic improvement every three months. The degree of symptom was rated on a five-point Likert scale. RESULTS: Overall eradication rate of H. pylori was 82.8% (168/203), and there were no significant differences in the eradication rate between the two groups and between one-week and two-week eradication therapies. The mean follow-up period was 12 months. The symptomatic improvement in both group was maintained over 12 months in most patients (PUD 72.5% vs. FD 67.4%). In addition, the symptomatic improvement in the patients with eradication success was maintained significantly longer than those with eradication failure in both group (FD p=0.007 vs. PUD p=0.014). CONCLUSIONS: The eradication therapy of H. pylori can be one of the therapeutic options for patients with functional dyspepsia and that eradication failure may cause the recurrence of the symptom.

A Case of Anomalous Drainage of the Common Bile Duct into the Duodenal Bulb with Pancreatic Duct Anomaly / 대한소화기내시경학회지

The common bile duct normally enters the posteromedial aspect of the second part of the duodenum. However, anomalous drainage of the common bile duct into the stomach, pyloric channel, duodenal bulb and fourth portion of the duodenum has been reported in the literature. An anomalous pancreatic duct, with ectopic drainage of the common bile duct, is particularly rare. Herein, we report the case of a 69-year-old woman who showed pancreatic ductal variation and anomalous drainage of the common bile duct into the duodenal bulb. The patient required a cholecystectomy and choledochoenteric anastomosis to relieve the obstructive jaundice and abdominal pain.

The Usefulness of Endoscopic Retrograde Biliary Drainage Using Plastic Stents for Patients with Common Bile Duct Stone / 대한소화기내시경학회지

BACKGROUND/AIMS: Endoscopic sphincterotomy is considered the primary option for treatment of common bile duct (CBD) stones. In some cases, however, complete stone removal is difficult or even impossible. Endoscopic retrograde biliary drainage (ERBD) has been suggested to be an alternative treatment in such cases or in patients with high surgical risks. In this study, we evaluated the effectiveness of ERBD using a plastic stent for treatment of CBD stones. METHODS: From Mar. 1996 to Aug. 1999, ERBD was performed in 12 patients with CBD stones. Indications for ERBD were old age in 4, a large perivater diverticulum in 4, refusal of surgery in 2, bleeding risk and biliary stricture in 1 each. Nine had one of the significant associated medical conditions. RESULTS: Six of the 12 patients were symptom-free at the time of evaluation (mean 32.9 months). Of the remaining 6 patients, 3 had operation, 1 had a successful endoscopic stone removal, 1 had a stent exchange, and 1 was lost to follow-up at 26 months. Thus, overall success rate of ERBD for treatment of CBD stones was 75% (9/12). Median symptom-free duration was 41 months (range 18~59 months). CONCLUSIONS: In view of its relatively high success rate and long-term effect, ERBD is an alternative modality for treatment of CBD stones, especially in patients with high surgical risks.

Detection of Helicobacter pylori Antigen in Stool by Enzyme Immunoassay

Invasive techniques for diagnosis of Helicobacter pylori (H. pylori) infection require an endoscopic examination which is expensive and inconvenient and may cause complications. Stool cultures for H. pylori or a direct detection of H. pylori antigen in stools by PCR are expensive, tedious, and have a low sensitivity. We recently used an enzyme immunoassay (EIA) to detect H. pylori antigen in stool specimens. A total of 41 patients were seen at Inha University Hospital, Inchon, Korea between September and October 1998. There were 26 men and 15 women who had an average age of 37.6 years which ranged from 5 to 71 years in the present study. All of these patients came to the hospital complaining of an upper abdominal discomfort and were subjected to endoscopy and biopsies. Fifteen had a gastric ulcer, 13 had a duodenal ulcer, 1 had an early gastric cancer, and there were 12 chronic gastritis patients as shown by endoscopy. The biopsy specimens were examined by histology, CLOTM test, and cultures and these results were used as gold standards. Stool specimens were tested for the H. pylori antigen by EIA. A dual wavelength cut-off of 0.100 that was recommended by the manufacturer gave a good performance (87.1% sensitivity, 100% specificity, 100% positive predictive value, 71.4% negative predictive value, and a 90.2% efficiency). But the adjusted cut-off value using the receiver operating characteristic curve improved the performance of the test (using the cut-off value of 0.024, the sensitivity, specificity, PPV, NPV, and efficiency were 100%, 90.0%, 96.9%, 100%, and 97.6% respectively). Re-evaluation of the cut-off value may be needed for Korean patients. This technique is non-invasive, rapid, easy-to-use, and shows good performance characteristics for diagnosis of H. pylori infections. Therefore, this technique may be a substitute for gastric endoscopy especially in children and some patients who are unable to tolerate an endoscopic examination and it may be substituted for a serologic test in epidemiological research.

A case of epidermoid cyst of the liver / 대한내과학회지

Congenital solitary nonparasitic cysts of the liver are rare condition in all age groups. Since 1856, only approximately 900 cases having been reported in the world literature. Epidermoid cysts of the liver are extremely rare type of congenital nonparasitic hepatic cysts, characterized by a fibrous wall entirely lined with stratified squamous epithelium, but lacking hair or skin appendages. This condition has yet to be reported in Korea. Because they have a potential for malignant transformation, it is important to totally resect the epidermoid cyst of the liver. Recently, we experienced a case of 44-year-old female patient with epidermoid cyst of the liver, which condition was complicated by a secondary infection. For this patient, an enucleation of entire cyst was performed. Given the rarity of this case, the following is a report of this case and a review of the relevant literature.

Successful Cyclophosphamide Therapy in Recurrent Eosinophilic Colitis Associated with Hypereosinophilic Syndrome

Eosinophilic colitis is a relatively rare complication of hypereosinophilic syndrome which is characterized by abdominal pain and bloody diarrhea and is usually treated with steroids and hydroxyurea. However, no standard regimen exists in cases of intractable disease despite several treatment attempts with Interferon- alpha, cyclosporin, etoposide, and vincristine, etc. We here report a case of a 43-year-old woman with recurrent eosinophilic colitis as a complication of hypereosinophilic syndrome who was successfully treated with cyclophosphamide.

A Case of Massive Bleeding in Jejunal Tuberculosis Treated by Transcatheter Embolization / 대한소화기내시경학회지

Common complications of the intestinal tuberculosis are perforation, obstruction, fistulas, and malabsorption. Massive gastrointestinal bleeding is an extremely rare complication of intestinal tuberculosis. Moreover, this may be the first report in the world on transcatheter arterial embolization against the massive bleeding from intestinal tuberculosis patient. We experienced a case of lower gastrointestinal bleeding due to extensive intestinal tuberculosis as massive as vital sign was unstable. Colonoscopy and esophagogastroduodenoscopy did not reveal bleeding focus. Active jejunal bleeding was suspected by technetium99m labelled RBC scintigraphy. Emergency superior mesenteric artery angiography showed active bleeding focus from jejunal branch of artery and transcatheter arterial embolization was tried with microcoil. After embolization, he had no more hematochezia and vital sign became stabilized. On third hospital day, upper endoscopy was done using pediatric colonoscopy and there were multiple circular ulcers on the proximal jejunum but no evidence of mesenteric ischemia. Small bowel tuberculosis should be suspected as a cause of lower gastrointestinal bleeding in case of negative colonoscopy and upper endoscopy. We suggest that the transcatheter embolization could be taken into consideration as a first-line method of treatment for massive bleeding from intestinal tuberculosis before surgical resection.