Capsule Endoscopy with Retention of the Capsule in a Duodenal Diverticulum: A Case Report / 대한소화기학회지

Capsule endoscopy is being increasingly recognized as a gold standard for diagnosing small bowel disease, but along with the increased usage, capsule retention is being reported more frequently. We report a case of capsule endoscopy retention in a diverticulum of the duodenal proximal third portion, which we treated by esophagogastroduodenoscopy. A 69-year-old male visited hospital with hematochezia. He had hypertension and dyslipidemia for several years, and was taking aspirin to prevent heart disease. CT and colonoscopy revealed a diverticulum in the third portion of the duodenum, rectal polyps, and internal hemorrhoids. Capsule endoscopy was performed but capsule impaction occurred. The capsule was later detected by CT in the diverticulum. Endoscopy was performed a day later and the capsule was removed using a net. A small bowel series was conducted after capsule removal, and no stenosis was found. The patient fully recovered and no recurrence of hematochezia was observed at his one month exam. This is the first case in Korea of capsule retention in a duodenal diverticulum, with successful removal by endoscopy.

A case of liver metastasis of gastric hepatoid adenocarcinoma / 대한간학회지

We report herein a case of hepatoid adenocarcinoma of the stomach with liver metastasis. Gastric carcinoma generally presents as adenocarcinoma and rarely shows a hepatoid pattern, which can produce alpha-fetoprotein (AFP). The stomach is one of the common sites at which hepatoid adenocarcinoma has been detected. A 75-year-old female patient was admitted to the hospital with a symptom of epigastric discomfort. Gastrofibroscopy revealed a large tumor occupying the greater curvature of the stomach body. The level of serum AFP was markedly increased. Abdominal computed tomography revealed multiple liver masses. Biopsy samples of the gastric lesion and liver masses finally confirmed her case as hepatoid adenocarcinoma in the stomach with liver metastasis. The AFP-producing gastric carcinoma needs special attention because it often presents with early liver metastasis and has a poor prognosis.

A Case of Sigmoid Intussusception Diagnosed by Sigmoidoscopy / 대한소화기내시경학회지

Intussusception most commonly occurs in children, and in more than 90% of cases, no cause is found. In contrast, intussusception in adults is relatively rare but over 90% of patients have an organic lesion as the cause. Only 5% of cases of intussusception occur in adults and most involve the small intestine and are benign, whereas colonic intussusceptions are usually malignant. We report here a case of a 70-year-old man with intussusception who was referred with a one-day history of hematochezia and abdominal pain. The intussusception was caused by a sigmoid colonic tumor. The CT findings suggested that we could reasonably proceed to a sigmoidoscopy to confirm the site of obstruction. We speculated that the sigmoid colon tumor induced the anterograde intussusception. As with our patient, it is important to recognize the need to diagnose the primary lesion exactly and promptly.

A Case of Huge Gastric Phytobezoar Removed by Endoscope using Argon Plasma / 대한소화기내시경학회지

Bezoars are persistent concretions of indigestible material that are usually found in the stomach. With the significant development of endoscopic techniques, many authors have reported the removal of bezoars using methods such as endoscopic forceps, snares, electrohydraulic lithotripsy, laser. However, there are no reports of using argon plasma to remove a bezoar in Korea. Argon plasma coagulation is a non-contact electrosurgical technique, which is an inexpensive, easily learned, and effective method in gastrointestinal endoscopy. In addition, this method is associated with a decreased risk of perforation and tissue damage by maintaining a controllable depth of coagulation. We report a 71-year-old man with a 11x11x8 cm sized huge gastric phytobezoar found by endoscopy. The bezoar was broken into pieces using the argon plasma coagulator. Endoscopic forceps and a basket were then used to crush and extract its fragments. The bezoar was removed safely without any complications. We report this case with a review of the relevant literature.

Detection of Aberrant p16INK4A Methylation in Sera of Patients with Liver Cirrhosis and Hepatocellular Carcinoma

Hepatocellular carcinomas (HCCs) show genomic alterations, including DNA rearrangements associated with HBV DNA integration, loss of heterozygosity, and chromosomal amplification. The genes most frequently involved are those encoding tumor suppressors. The p16INK4A tumor suppressor gene frequently displays genetic alteration in HCC tissues. The present study was performed to examine the incidence of methylated p16INK4A in the sera of liver cirrhosis (LC) and HCC patients, and to evaluate its role as a tumor marker of HCC. The sera of 23 LC patients and 46 HCC patients were examined in this study. The methylation status of p16INK4A was evaluated by methylation-specific PCR of serum samples. Methylated p16INK4A was detected in 17.4% (4/23) of LC patients and in 47.8% (22/46) of HCC patients. No association was demonstrated between p16INK4A methylation and serum AFP level. As the status of p16INK4A methylation was not associated with serum AFP level, it may have a role as a tumor marker of HCC.

Problem in interpretation of laryngopharyngeal reflux disease according to the location of proximal probe in 24 hour ambulatory esophageal dual probe pH monitoring / 대한내과학회지

BACKGROUND: The diagnostic criteria of laryngopharyngeal reflux disease (LPRD) is defined differently according to the location of the proximal pH probe: upper esophagus, upper esophageal sphincter (UES) or hypopharynx. Clinically the location of proximal probe is determined by the location of distal probe, which is usually fixed on 5 cm above the lower esophageal sphincter. This study was performed to evaluate the difference in the diagnosis of LPRD between the results from considering the location of the proximal probe and not considering it. METHODS: This study consisted of 76 patients performed esophageal manometry and 24 hour ambulatory pH monitoring of esophagus using the dual probe. According to location of the proximal probe, the patients were divided into 3 groups : upper esophagus, UES and hypopharynx group. Firstly, we used the diagnostic criteria not considering the location of the probe concordantly in all 76 patients : criteria of the upper esophagus, UES and hypopharynx respectively. And then, we used the diagnostic criteria considering the location of the proximal probe. The results were compared. RESULTS: When the diagnostic criteria of upper esophagus was used, 3.9% (3/76) was diagnosed as LPRD. In the case of UES and hypopharynx, 18.4% (14/76) and 38.2% (29/76) was diagnosed as LPRD. When the diagnostic criteria considering the location of the proximal probe was used, 27.6% (21/76) was diagnosed as LPRD. Significant difference was found between the result considering the location of the probe and 3 results not considering it (p<0.01). CONCLUSION: It is thought to be appropriate to use the diagnostic criteria considering the location of the proximal probe for the more accurate diagnosis of LPRD.

NF-kappaB Binding Activity and Cyclooxygenase-2 Expression in Persistent betaCCI(4)-Treated Rat Liver Injury

The involvement of NF-kappaB binding activity is known to be important in the mechanism of acute liver injury and in the induction of cyclooxygenase (COX-2). This study was performed to evaluate NF-kappaB binding activity and the expression of COX-2 in chronic liver injury induced by carbon tetrachloride (betaCCI(4)). Liver tissues from Sprague - Dawley rats were collected at 1, 3, 5, and 7th week after intraperitoneal injection of 0.1 mL of betaCCI(4)/100 g body weight twice a week. Reactive oxy-gen species (ROS) were measured in the postmitochondrial fraction by dichlorofluorescein formation with a fluorescent probe. An electrophoretic mobility shift assay was performed for NF-kappaB binding activity. Western blot was performed to measure the level of COX-1, COX-2, p65, p50, and I B proteins. ROS and NF-kappaB activity increased during the CCl4-induced chronic liver injury. The expression of nuclear p65 protein and p50 protein increased compared with that of the control, while the cytoplasmic I B protein decreased as the inflammation persisted. The expression of COX-2 in betaCCI(4)-treated rat liver increased compared with that of the control. It could be suggested that ROS produced by betaCCI(4) treatment increased NF-kappaB binding activity and thereby COX-2 expression, and these might be implicated in the progress of chronic liver damage.

Clinical Feature and the Effects of Endoscopic Band Ligation of Dieulafoy-like Lesion / 대한소화기내시경학회지

BACKGROUND/AIMS: The Dieulafoy lesion is an important cause of gastrointestinal bleeding. The bleedings from caliber- persistent vessel or abnormally large and tortuous submucosal artery are usually located on proximal stomach. Endoscopic band ligation (EBL) is currently regarded as the treatment of choice of Dieulafoy lesions. This study reports on the clinical features, the efficacy and safety of EBL. METHODS: 10 patients with Dieulafoy-like lesion (median age: 47 yr range: 22~71, M:F 8:2 ) were treated using EBL. EBL was performed as the primary hemostatic tratment as follows in 8 cases of urgency and 2 cases of emergency. RESULTS: The location of all lesions (n=10) were in stomach, 8 in body (4 in posterior wall), 2 in fundus. The bleeding focuses were identified during the first endoscopy. Five lesions were bleeding, 5 had adherent clots or protruding vessels without active bleeding. Hemostasis were achieved with first session of EBL in 9 patients successfully, one case in the fundus was failed due to early band release. CONCLUSION: EBL is a simple, effective, and safe endoscopic method of Dieulafoy-like lesions and, it should be proposed as a primary option.

Direct Percutaneous Endoscopic Jejunostomy in a Patient with Previous Subtotal Gastrectomy / 대한소화기내시경학회지

It is generally considered that enteral feeding is superior to parenteral nutritional support. Thus enteral meal should be given whenever patients have proper gastrointestinal function to take enteral feeding. Because the morbidity and mortality for surgical jejunostomy have been reported as high as 50% and 10% respectively, direct percutaneous endoscopic jejunostomy has been developed to reduce the morbidity and mortality. A 55-year-old male patient, who was suffering from dysphagia and oropharyngeal aspiration, was transferred to the division of gastroenterology to be done permanent enteral feeding. His stomach was resected (subtotal gastrectomy with billroth II anastomosis) due to peptic ulcer hemorrhage 10 years before. We performed direct percutaneous endoscopic jejunostomy without any complication. Herein, we report a successful case.

A case of gastric antral vascular ectasia treated with argon plasma coagulation / 대한내과학회지

Gastric antral vascular ectasia (GAVE) is a rare but important cause of chronic gastrointestinal bleeding. Endoscopically, it has characteristic thickened red vascular folds radiating from the pylorus to the antrum. Diagnosis is made primarily by endoscopy. Histologic examination of the endoscopic mucosal biopsies may confirm the endoscopic diagnosis. Many treatment modalities of the gastric antral vascular ectasia exist. One of them, the argon plasma coagulation (APC) is an excellent therapeutic tool. Inactive argon gas is converted to ionized form by means of electrical energy. Ionized argon plasma conducts high frequency electrical energy to tissues and leads coagulation necrosis of tissues. We experienced a case of gastric antral vascular ectasia presenting melena for about one month in a 72-year-old man treated endoscopically in four sessions with argon plasma coagulation.

A Case of Penetrating Gastric Ulcer Mimicking Hypervascular Tumor / 대한소화기내시경학회지

Peptic ulcer which extend beyond the serosa of the bowel wall may not perforate freely into the peritoneal cavity but instead penetrate adjacent structures (confined perforation). It has been reported that the frequency of penetration of peptic ulcer has been estimated around 20 percent in patients undergoing laparotomy for peptic ulcers. A 46-year- old male was admitted with chief complaint of hematemesis. Endoscopic examination revealed submucosal tumor like lesion with central ulcer and active bleeding which was located at the upper body, posterior wall of the stomach. Angiography demonstrated hypervascular tumor like lesion supplied by left gastric artery and short gastric branches of splenic artery. Postoperative biopsies showed inflammatory cell infiltration at the typical ulcer base and no evidence of malignancy. There was loss of acinus structure and fibrous adhesion with omentum at the pancreas. We report a case of gastric ulcer penetrating into pancreas, spleen with hypervascular nature with brief review of literatures.

Hepatic Zinc Concentration in Patients with Chronic Viral Hepatitis / 대한간학회지

BACKGROUND AND AIMS: Zinc is an essential, mostly intracellular, trace element which participates in many oxidative or deoxidative reactions and in a protective action on liver cell activity. Plasma zinc levels are known to decrease in patients with liver disease including chronic viral hepatitis. The aim of this study was to reveal whether hepatic zinc concentrations have a correlation with grades of necroinflammation or stages of fibrosis in the patients with chronic viral hepatitis. METHODS: This study consisted of 50 subjects (43 chronic hepatitis B, 4 chronic hapatitis C, and 3 cirrhosis). Each specimen of liver tissue was classified with the grade of lobular inflammation, portal/periportal inflammation, and stage of fibrosis according to Scheuer's method. Hepatic zinc concentration was determined by ICP-Atomic Emission Spectrometry. RESULTS: The mean hepatic zinc concentration in the 50 chronic viral hepatitis patients was 233.66 g/g dry weight of liver tissue. The hepatic zinc levels were significantly correlated with the grades of portal/periportal inflammation (rs=-0.385, p=0.006), and grades of lobular inflammation(rs=-0.342, p=0.015). The stages of fibrosis were also negatively related (rs=-0.423, p=0.002). The zinc concentrations differed significantly among grades of lobular inflammation (p=0.013) and among stages of fibrosis (p=0.044). CONCLUSIONS: Hepatic zinc concentrations showed negative correlation with grades of portal/periportal inflammation, lobular inflammation, and stage of fibrosis in the patients of chronic viral hepatitis. These results suggest that decreased hepatic zinc concentration might be associated with severe hepatic injury and reflect decreased protective activity on liver cell injury.

Two Cases of Congenital Hepatic Fibrosis with Polycystic Kidney Disease / 대한간학회지

Congenital hepatic fibrosis (CHF) is a rare developemental abnormality, which is characterized pathologically by periportal fibrosis with irregularly shaped proliferating bile ducts. In most, if not all, cases CHF is associated with autosomal recessive polycystic kidney disease. Recently, we experienced two cases, confirmed by percutaneous needle liver biopsy, of CHF with polycystic kidney disease. The first patient was a 19-year-old man and presented with hematemesis and hepatosplenomegaly. Esophageal varix was noted by an endoscopic examination and an endoscopic variceal ligation was performed. Abdominal CT scanning revealed innumerable cysts of both kidneys. The pateint also had cystic dilation of subarchnoid space in the basal cistern and posterior fossa detected through brain MRI. The second patient was a 24-year-old man admitted for an evaluation of splenomegaly. He had no esophageal varix but, splenic varix and splenorenal shunt were detected through an abdominal CT scanning. Innumerable renal cysts were also present. The diagnosis of CHF was confirmed in both cases by its typical histologic features. We report these cases with a review of the relevant literatures.

The Effect of Cisapride Tartrate in Patients with Functional Dyspepsia and Functional Constipation / 대한소화관운동학회지

BACKGROUNDS/AIMS: This study was performed prospectively to evaluate the short - term effect of cisapride tartrate on the frequency and the degree of symptoms in patients with functional dyspepsia and functional constipation. METHODS: One-hundred thirty-two patients with a mean age of 44.7 years in men and 43.1 years in women, who presented with symptoms of both functional dyspepsia and functional constipation were recruited, and the frequency and the degree of symptoms corresponding to functional dyspepsia and functional constipation were assessed by an interview in 10 hospitals respectively. In an open, multicenter trial, 132 patients received 10 mg of cisapride tartrate three times a day (TID) for 8 weeks. Patients wrote a defecation diary for 8 weeks and checked symptom scores, which represented the degree of symptoms of dyspepsia and constipation, at the 4th and 8th week. RESULTS: The frequently reported symptoms of functional dyspepsia were epigastric fullness (2.34+/-0.80), bloating (2.05+/-0.82), early satiety (1.67+/-0.99), anorexia (1.04+/-0.95) and nausea (0.94+/-0.93). The mean defecation frequency per week was 3.07+/-2.35 and patients showed subjective symptom scores as follows; 97.0+/-25.26 % in the rate of sense of incomplete evacuation, 1.85+/-0.73 in the hardness of stool and 1.62+/-0.57 in difficulty to pass stool. After adminstration of cisapride tartrate in the case of functional dyspepsia, 66.1% of patients at the 4th week and 81.5 % of patients at the 8th week showed good or excellent improvements. In the case of functional constipation, 82.7% of patients also showed good or excellent improvements. Overall improvements of symptoms in both functional dyspepsia and functional constipation were 78.2% at the 8th week. CONCLUSION: Cisapride tartrate reduced the frequency and the degree of symptoms in functional dyspepsia and functional constipation without significant adverse effects. Functional dyspepsia and functional constipation without significant adverse effects.

The Clinical Study of Hematoimmunologic Features and Opportunistic Infections of Patients with AIDS / 대한내과학회지

The number of persons with HIV infection in Korea have increased steadily, total number of HIV infection in Korea were 478 on August, 1995. To investigate the clinicoimmunologic manifestation of AIDS in Korea, we reviewed complete blood counts (CBC), CD4 counts, serum beta2-microglobulin level, opportunistic infections and cause of death for 19 AIDS patients who had been admitted or visited at Pusan national university hospital during the period of January, 1990 to August, 1995. 1) The predominant mode of HIV transmission was heterosexual contact(18), other modes of transmission were homosexual contact(1). Clues of diagnosis of HIV infection were routine occupational health examination(14), and opportunistic infection symptoms such as fever, coughing(4). 2) Mean CD4 cell counts(/mm3) were 53 +/- 72 totally, 22 +/- 27 for 8 dead patients at mean 2 month before, 91 +/- 87 for 7 living patients. There were not significant difference(p>0.05). 3) Serum beta2-microglobulin(MG;ug/ml) was measured at 12 patients, mean serum beta2-MG level was4.8 +/- 7.3 totally, 7.1 +/- 10.3 for 6 dead patients at mean 1.3 month before, 2.5 +/- 0.4 for 6 living patients. There were not significant(p>0.05). 4) At CBC examination, WBC(/mm3) was 5,932 +/- 2,899 totally, 5,452 +/- 3,436 for 10 dead patients, 6,500 +/- 2,221 for 9 living patients(p>0.05). Hb(g/dl) was 11,4 +/- 2.8 totally, 9.4 +/- 1.8 for dead patients, 13.6 +/- 1.8 for living patients(p<0.05). Lymphocyte count(/mm) was 1,255 +/- 800 totally, 731 +/- 424 for dead patients, 1,838716 for living patients(p<0.05). ESR(mm/h) was 72 +/- 47 totally, 97 +/- 33 for dead patients, 47 +/- 47 for living patients(p<0.05). 5) Opportunistic infections had developed at 14 patients, candidiasis 7, pneumocystis carinii pneumonia 5, tuberculosis 3, cytomegalovirus infection 2, herpes zoster 3, toxoplasmosis 1, cryptococcal infection 2, bacterial pneumonia 5, and herpes simplex l. Malignant lymphoma had developed in 1 patient. 6) Mean survival interval from diagnosis of HIV infection to death was 32.8 +/- 19.1 months, and the most common cause of death was pneumocystis carinii pneumonia, and other causes of death were meningitis, bacterial pneumonia and AIDS-wasting syndrome. Based on these results, We concluded that CD4 counts, serum beta2-microglobulin level, Hb, total lymphocyte count and ESR in AIDS patients are specific laboratory markers of progression and prognosis of AIDS, the most common opportunistic infection was candidiasis, and the most common cause of death in AIDS patients was pneumocystis carinii pneumonia.

Endoscopic Findings of Colonic Tuberculosis / 대한소화기내시경학회지

The purpose of this paper is to review the colonoscopic fingings of twenty two patients with colonic tuberculosis which were diagnosed by colonoscopic finding, histopathology, and follow-up observation after antituberculosis chemotherapy at Pusan National University Hospital from January 1992 to December 1994. The results were as follows: 1) The male to female ratio was 1: 1.2, and the average age of the patients was 39.4 years with a slight predominance in women. The age of peak incidence was the 4th decade 40.9%). 2) Abdominal pain(95%), diarrhea(63%), and weight loss(50%) were the most common clinical findings. Others were constipation, melena, and palpable abdominal mass. The location of the pain was right lower abdomen, epigastrium, central abdomen, and left lower abdomen in decreasing order. 3) Hematologic findings showed decrease in hemoglobin level, increase in ESR, and positive CRP(61.5%). The white blood cell counts were mostly normal. 4) The stool examination showed positive occult blood in 7 cases among 18 cases (38.9%). Acid-fast bacteria was observed in stool of one case. 5) On colonoscopy, the lesion sites were ileoeecal valve(75%), ascending colon(72.7 %), terminal ileum(52.6%), cecum(42.9%), transverse colon(31.8%), descending colon (27.3%), sigmoid colon(9%), and rectum(9%) in decreasing order of frequency. Most of them involved ileocecal area. 6) On colonoscopy, the shape of ulcer revealed circular(41%), fusion(36%), and irregular pattern(18%). It found skipped area in 9 cases, pseudopolyp in 8 cases, patency of ileocecal valve in 5 cases, and severe deformity of ileocecal valve in 6 cases. 7) Microscopic finding of biopsy specimens revealed noncaseating granulomatous inflammation in 12 cases, and nonspecific ulcerative inflammation in 10 cases. In conclusion the diagnostic yield may be greatly enhanced by obtaining multiple target biopsies frorn tbe deep portion of the ulcer bed and margins. Judged from the colonoscopic finding and clinical improvement after antituberculosis chemotherapy, more accurate diagnosis can be acquired.