A Case of Brunner's Gland Hyperplasia of the Duodenal Second Portion with Annular Stricture Causing an Induced Obstruction / 대한소화기내시경학회지

Brunner's gland hyperplasia is a tumor arising from the Brunner's gland and the lesions account for 10.6% of benign duodenal tumors. These lesions are usually asymptomatic and detected incidentally by endoscopy or by a UGI barium study. In the case of severe and atypical forms, these lesions cause bleeding, intestinal obstruction or intussuception. However, Brunner's gland hyperplasia causing an annular duodenal stricture and subsequent intestinal obstruction has been rarely reported. We report here a very rare case of Brunner's gland hyperplasia presenting as an annular stricture and obstruction.

The Usefulness of Double Balloon Enteroscopy for Diagnosis and Treatment of Small Bowel Diseases

BACKGROUND/AIMS: Double balloon eneterscopy is a promising endoscopic method to examine the entire small bowel and to conduct therapeutic procedures. This study was performed to evaluate the clinical outcome and usefulness of double balloon enteroscopy. METHODS: We enrolled patients with suspected small bowel disease. Double balloon enteroscopy was performed in 61 patients and 89 procedures were undetaken between August 2004 and October 2007 at Hangang Sacred Heart Hospital. RESULTS: Indications for double balloon enteroscopy were obscure gastrointestinal bleeding, chronic abdominal pain or diarrhea and the presence of a suspicious small bowel tumor. Double balloon enteroscopy contributed to the diagnosis of small bowel diseases in 82.0% of patients. In 46 patients (75.4%), specific treatments were influenced by the results of double balloon enteroscopy. There were no significant complications. CONCLUSIONS: Double balloon enteroscopy is one of the most useful methods for the diagnosis and treatment of small bowel disease.

A 5-year review of clinical characteristics and mortality of burn patients with candidemia in a tertiary burn center / 대한내과학회지

BACKGROUND: Nosocomial candidemia is one of the most common blood-stream infection and associated with a high fatality rate in burn patients. To determine the clinical characteristics, strains of Candida species and to identify contributing factors to death, we analyzed severely burned patients with candidemia. METHODS: 60 cases with candidemia were reviewed retrospectively from January 1999 to December 2003 at a tertiary burn center in Korea. Candidemia was defined as at least one blood culture that grew Candida organisms. RESULTS: Burn size of all patients were 46+/-20.9% of total body surface area burn and overall mortality was 41.7%. 97 strains of Candida species from 60 cases were isolated. Candida albicans was the most frequently isolated species (53.6%), followed by C. tropicalis (20.6%), C. glabrata (15.5%) and C. parapsilosis (10.3%). Among various predisposing factors for candidemia, significant factors associated with death were endotracheal tube insertion or tracheostomy, mechanical ventilation, the use of vasoactive agents, arterial catheterization and nasogastric tube insertion in univariate analysis, but significant independent factors for mortality were mechanical ventilation (OR=26.63, 95% CI; 1.60, 444.18, p=0.022) and the use of vasoactive agents (OR=23.18, 95% CI; 2.80, 192.35, p=0.004) in multivariate analysis. Among 59 patients indwelling central venous catheters, only 24 patients (40.7%) received antifungal therapy with catheter removal while 19 patients (32.2%) had antifungal therapy without catheter removal. CONCLUSIONS: Clinical severity, such as mechanical ventilation or vasoactive agents dependencies, may contribute to high fatality in severely burned patients with candidemia.

A Case of Gastrointestinal Stromal Tumor of the Proximal Jejunum Diagnosed by Double Balloon Enteroscopy / 대한소화기내시경학회지

A gastrointestinal stromal tumor (GIST) is a rare disease but is the most common nonepithelial neoplasm in the gastrointestinal tract. GIST accounts for 0.1~3.0% of gastrointestinal malignancies, and 20~30% of GISTs are found in the small intestine. GIST with extraluminal growth is difficult to diagnose. We report a case of a jejunal GIST with obscure bleeding that was diagnosed using double balloon enteroscopy.

Clinical Characteristics and Risk Factors of Mortality among Severe Burn Patients with Isolation of Vancomycin-Resistant Enterococci / 감염과화학요법

BACKGROUND: Vancomycin-resistant enterococci (VRE) are multi-drug resistant organisms that have emerged as important nosocomial pathogens in recent years. Patients with burn injury are highly vulnerable to VRE infection. We evaluated the colonization and infection rate of VRE among severe burn patients. MATERIALS AND METHODS: We retrospectively reviewed VRE isolation in a tertiary hospital burn center from January 2000 to December 2003. We analyzed and compared the clinical characteristics of VRE colonized (isolated in rectal swab) and infected patients. We also analyzed the risk factors of mortality in VRE infection group by using univariate and multivariate analyses. RESULTS: VRE was isolated from 104 of severe burn patients. Mean percent of total body surface area of 104 patients was 45.43+/-22.15%. The most commonly isolated VRE was Enterococcus faecium (82.6%). The VRE infection rate of VRE colonization group was 19/93 (20.4%). There were no differences in clinical characteristics, underlying conditions, and isolates species between VRE colonization and infection groups. The mortality rate of VRE infection group was 40%. The risk factors for mortality were bacteremia (P=0.001) and mechanical ventilation (P=0.024) in univariate analysis. However, independent risk factor for death was only VRE bacteremia [odd ratio=32.803, 95% confidence interval (2.884, 373.129), P=0.005] in multivariate analysis. CONCLUSION: Significant portion of severe burn patients with VRE colonization could progress to VRE infection. Severe burn patients with VRE bacteremia have higher risk of death than patients without VRE bacteremia.

A Case of Disseminated Coccidioidomycosis Involving Lung and Skin in Patient with Diabetes Mellitus and Iatrogenic Cushings Syndrome / 결핵및호흡기질환

Coccidioidomycosis is caused by a dimorphous fungus, Coccidioides, which consists of two species, C. immitis and C. posadasii. Although these organisms are genetically distinct and do not exchange DNA, they appear identical phenotypically and the disease or immune response to the organisms is also identical. Coccidioides grows as a mycelium in the soil and is mainly found in Southwestern United States, northwestern Mexico, and Argentina. An infection usually results from inhaling the spores of the fungus in an endemic area. Patients with a localized infection and no risk factors for complications often require only a periodic reassessment to demonstrate the resolution of the self-limited process. However, patients with extensive spread of infection or high risk of complications as a result of immunosuppression or other preexisting factors require a variety of treatment strategies such as antifungal therapy, surgical debridement, or both. Korea is not endemic area of a coccidioidomycosis. We report a case of disseminated coccidioidomycosis involving the lung and skin, which was detected incidentally after sunburn in a 69 year-old Korean male with diabetes mellitus and iatrogenic Cushings syndrome, with a review of the relevant literature.

Clinical Characteristics in Patients with Vancomycin-Resistant Enterococci Colonization or Infection during 5 years in a Private General Hospital / 대한구급학회지

BACKGROUND: Vancomycin-resistant enterococci (VRE) is increasing rapidly through the world and is now a major cause of nosocomial infection. The transmission dynamics and factors contributing their dissemination are complex. We conducted a study to investigate clinical characteristics in patients with VRE colonization or infection during recent 5 years. METHODS: 154 cases that had the VRE infection or colonization from January 1, 2000 to April, 2004, were reviewed. We analyzed the risk factors of VRE infection and colonization and also compared various parameters contributing their dissemination between burn and non-burn patients with VRE. RESULTS: Total 212 strains of VRE were isolated from 154 patients. Of 212 strains of VRE, Enterococcus faecium (178 strains, 83.9%) were most common and followed by E. casseliflavus (28 strains, 13.2%), E. faecalis (5 strains, 2.4%) and E. gallinaum (1 strains, 0.5%). The most common place of VRE isolation was in burn intensive care unit (ICU), 95 cases (61.7%); 27 cases (17.5%) in general wards; 17 cases (11.0%) in surgical ICU; 15 cases (9.7%) in medical ICU. Compared with patients with VRE colonization, patients with VRE infection had older age, higher APACHE II scores and high death rate significantly. Then, VRE colonization were more common in burn patients while VRE infection were more common in non-burn patients. CONCLUSIONS: The findings from this study suggest that VRE infection are not uncommon among hospitalized patients. More strict infection control, close surveillance and judicious use of antibiotics may be warranted to prevent infection and transmission of VRE.

Clinical Characteristics and Risk Factors of Mortality among Severe Burn Patients with Isolation of Vancomycin-Resistant Enterococci / 감염과화학요법

BACKGROUND: Vancomycin-resistant enterococci (VRE) are multi-drug resistant organisms that have emerged as important nosocomial pathogens in recent years. Patients with burn injury are highly vulnerable to VRE infection. We evaluated the colonization and infection rate of VRE among severe burn patients. MATERIALS AND METHODS: We retrospectively reviewed VRE isolation in a tertiary hospital burn center from January 2000 to December 2003. We analyzed and compared the clinical characteristics of VRE colonized (isolated in rectal swab) and infected patients. We also analyzed the risk factors of mortality in VRE infection group by using univariate and multivariate analyses. RESULTS: VRE was isolated from 104 of severe burn patients. Mean percent of total body surface area of 104 patients was 45.43+/-22.15%. The most commonly isolated VRE was Enterococcus faecium (82.6%). The VRE infection rate of VRE colonization group was 19/93 (20.4%). There were no differences in clinical characteristics, underlying conditions, and isolates species between VRE colonization and infection groups. The mortality rate of VRE infection group was 40%. The risk factors for mortality were bacteremia (P=0.001) and mechanical ventilation (P=0.024) in univariate analysis. However, independent risk factor for death was only VRE bacteremia [odd ratio=32.803, 95% confidence interval (2.884, 373.129), P=0.005] in multivariate analysis. CONCLUSION: Significant portion of severe burn patients with VRE colonization could progress to VRE infection. Severe burn patients with VRE bacteremia have higher risk of death than patients without VRE bacteremia.

A case of paroxysmal atrial fibrillation induced by internal jugular venous catheterization for hemodialysis / 대한내과학회지

Right internal jugular vein is preferred for central venous catheter insertion because of fewer complications. However, insertion-related complications can occur such as arterial puncture, pneumothorax, and hemothorax. Arrhythmia can also occur, but it has been reported to temporarily occur only during guidewire insertion. We report a case of symptomatic paroxysmal atrial fibrillation induced by right internal jugular venous catheterization for hemodialysis. The chest X-ray taken after insertion of the catheter showed that the catheter was advanced too deeply into right atrium from an unusually lower puncture site. The atrial fibrillation persisted nearly 24 hours and was corrected by removal of the catheter. We experienced that paroxysmal atrial fibrillation can be complicated by central venous catheterization, and appropriate selection of puncture site and catheter length is important to avoid it.