The efficacy of adefovir dipivoxil monotherapy and the incidence of genotypic resistance to adefovir dipivoxil in patients with lamivudine-resistant chronic hepatitis B infection / 대한간학회지

BACKGROUND/AIMS: Adefovir dipivoxil (ADV) is a nucleotide analogue that inhibits wild-type hepatitis B virus (HBV) and lamivudine (LMV)-resistant HBV mutants. The aim of this study was to elucidate the efficacy of ADV monotherapy and the incidence of genotypic resistance to ADV in patients with LMV-resistant chronic HBV infection. METHODS: This study involved 124 patients with chronic HBV infection who had received ADV monotherapy due to the presence of LMV-resistant HBV mutants. The efficacy of ADV was evaluated by the normalization of serum alanine aminotransferase (ALT) level and by the reduction of serum HBV DNA level (with cutoff levels of 2x10(4) IU/mL and 2x10(2) IU/mL). The cumulative rate of HBeAg loss or seroconversion was assessed in HBeAg-positive patients. The development of mutations in the reverse trancriptase region of HBV DNA polymerase was evaluated by direct sequencing analysis during ADV monotherapy. RESULTS: The mean serum HBV DNA level was 5.94 log10IU/mL. At 12 and 24 months after ADV monotherapy, the cumulative rates of serum ALT normalization were 69.4% and 75.5%, respectively, and those of serum HBV DNA reduction were 79.8% and 89.2% for a cutoff level of 2x10(4) IU/mL, and 44.2% and 59.0% for a cutoff of 2x10(2) IU/mL. The mean serum HBV DNA levels at 12 and 24 months were significantly lower than baseline, at 3.24 and 3.04 log10IU/mL, respectively (P<0.001). At 12 months after ADV treatment, the cumulative rates of HBeAg loss and seroconversion were 15.8% and 10.5%, respectively, and the rtN236T and rtA181T/V mutants in HBV DNA polymerase were identified in 25% and 64% of patients, respectively. CONCLUSIONS: Although ADV monotherapy is effective, it leads to a high rate of mutations of HBV DNA reverse transcriptase gene in patients with chronic HBV infections who have LMV-resistant HBV mutants.

The effect of propofol for conscious sedation during colonoscopy-A Prospective, Randomized Study / 대한내과학회지

BACKGROUND: The objectives of this study were to assess propofol as sedative agents for colonoscopy in the safety and efficacy, compared with midazolam plus meperidine. METHODS: 120 patients undergoing colonoscopy in a prospective study were randomly assigned to one of three medication regimens. Patients in group A (n=42) received i.v. 25 mg of meperidine and 2.5 mg of midazolam. Patients in group B (n=41) received i.v. a median dose of 96.59 mg of propofol (range 40-180) and patients in group C (n=37) received i.v. 25 mg of meperidine and a median dose of 77.03 mg of propofol (range 40-150), administered by a nurse with endoscopist supervision. Endpoints were patient satisfaction, procedure and recovery times and complications. RESULTS: The mean time to sedation was much faster in 2 groups using propofol (group A: 152+/-105.9 sec, group B: 52.9+/-46.5 sec, group C: 56+/-63.7sec; p<0.001). The mean time to reach the cecum was not different among the 3 groups. There were total 3 episodes of oxygen desaturation to <90%, as one in each group, but the patients were spontaneously recovered with only increasing O2 concentration and arousal. Patients in group C expressed better overall mean satisfaction than patients in group A (p=0.049), but difference was not found between group A and group B. The amnestic effect was better in two groups using propofol than group A (p=0.017) The mean dose of propofol was lower in the patients who received propofol combined with low dose of meperidine than those with propofol only (77.03 mg vs 96.59 mg, p=0.009). CONCLUSION: Nurse-administered propofol sedation with endoscopist supervision is believed to be safe and useful for colonoscopy with careful monitoring.

A Case of Multiple Pedunculated Polypoid Gastric Carcinoids / 대한소화기내시경학회지

Gastric carcinoids usually appear as a single polypoid tumor or yellowish rounded submucosal tumor in the fundus or body of the stomach. Multiple gastric carcinoids are associated with pernicious anemia, chronic atrophic gastritis and Zollinger-Ellison syndrome. These are believed to be due to hypergastrinemia. In Korea, carcinoids usually appear as single round-based submucosal tumor or sessile polyps. Multiple pedunculated polypoid carcinoids were rarely reported. A 27-year old woman was admitted to our hospital due to melena. The endoscopy revealed multiple pedunculated polypoid lesions in the fundus and body, predominantly in Yamada type III and IV. The histopathologic examination revealed the diagnosis of gastric carcinoid tumors. Serum fasting gastrin level was normal. We report a case of multiple pedunculated polypoid gastric carcinoids without atrophic gastritis or hypergastrinemia with a review of relevant literatures.

A Case of Oligoarthritis Associated with Gastric Adenocarcinoma / 대한류마티스학회지

Malignancy may cause variable musculoskeletal symptoms which resemble connective tissue disorder. This symptoms as a fine sign of hidden neoplasm can precede the diagnosis of underlying malignancy. But only one case of stomach cancer associated with cancer arthritis was reported in the world. This fact is very interesting in Asia which has high prevalence of stomach cancer. We experienced one case of gastric adenocarcinoma with oligoarthritis involving both knee and right elbow. A 48-year-old man was diagnosed stomach cancer by gastric endoscope and biopsy. After then, he complained pain, tenderness, heating sensation, swelling of both knee and right elbow with high fever. Both knee MRI showed abundant synovial effusion and soft tissue edema. Full dose of nonsteroidal anti-inflammatory drug was not effective to control fever and arthritis. But fever and arthritis were gone after resection of tumor.

A case of an anomalous union of the pancreaticobiliary duct associated with incomplete pancreas divisum / 대한내과학회지

There are many pancreatic ductal anomalies in which there are clinically significant anomalies associated with acute and chronic pancreatitis or pancreatic carcinoma. Many anomalies of pancreatic duct are diagnosed at clinical evaluation of causes of recurrent acute pancreatitis. ERCP is the gold standard method of diagnosis. Noninvasive method such as MRCP or EUS may also establish the diagnosis. There are many reports for the clinical significance and management of pancreas divisum and anomalous union of the pancreaticobiliary duct. There have been rare cases with the coexistence of a pancreas divisum and anomalous union of the pancreaticobiliary duct in the world and only one case in Korea. The case of a 33 year old man with epigastic pain and fever was recently experienced. It was diagnosed to be the coexistence of a pancreas divisum and anomalous union of the pancreaticobiliary duct by ERCP, PTC and MRCP. We report this case with review of the anomalies.

Relationship between Serum HBV DNA Levels and Liver Histology in Chronic Hepatitis B / 대한소화기학회지

BACKGROUND/AIMS: Serum HBV DNA levels are correlated with hepatic histologic activity in chronic HBV infection based on HBeAg. Liver injury may persist, even though HBV DNA are not detected by hybridization assay. This study was to investigate whether serum HBV DNA levels determined by more sensitive quantitative method are correlated with histologic activities in chronic HBV infections. METHODS: This study included 66 chronic HBV infected patients. HBV DNA level was quantified by Cobas Amplicor HBV Monitor(TM). RESULTS: Serum HBV DNA levels in HBeAg-positive patients were significantly higher than HBeAg-negative patients. In HBeAg-positive patients, serum HBV DNA levels showed a significant negative correlation with portal-periportal activity and fibrosis (r=-0.451, -0.446 respectively). AST levels were correlated with lobular, portal-periportal activity and fibrosis (r=0.432, 0.365, 0.301 respectively), whereas ALT levels were related to lobular activity (r=0.294). Elevated AST levels predicted lobular activity, portal-periportal activity, and fibrosis with moderate to severe degree (OR 1.733, 95% CI 1.083-2.775; OR 1.518, 95% 1.028-2.243, p=0.336; OR 17.897, 95% CI 1.517-211.208, p=0.022, respectively). CONCLUSIONS: In HBeAg-positive patients, serum HBV DNA level correlates inversely with histologic activity. On the other hands AST level correlates with histologic activity and the stage of moderate or severe degree.

Palliative Self-expandable Metal Stents for Malignant Gastric Outlet Obstruction / 대한소화기내시경학회지

BACKGROUND/AIM: Gastric outlet obstruction due to malignancy causes various symptoms and malnutrition and so decreases the quality of life and shortens the survival. The aim of this study was to assess the feasibility, effectiveness, safety, and outcome of a self-expandable metal stent as a palliative methods. METHODS: From January, 2000 to August, 2002, 29 consecutive patients (36 cases of stent insertion) with inoperable gastric outlet obstruction were treated palliatively with through-the scope stents (Nitis Taewoong, Korea, 29 uncovered, 7 covered). All patients had malignancy. We reviewed the success rate, complications and clinical outcome. RESULTS: There were 21 cases with advanced gastric cancer, 5 with pancreatic head cancer and 2 with cholangiocarcinoma. The other one had primary duodenal carcinoma. Technical success was achieved in thirty four cases (94.4%). After successful placement, 26 patients could eat soft or solid foods with careful education about foods impaction. During the follow-up (mean: 2.6 months, range: 1~9 months), there were no procedure related early complication. Seven stent occlusion occurred due to tumor in-growth (6 case) and over-growth (1 case). CONCLUSIONS: Endoscopic self-expandable metal stent placement in patients with inoperable gastric outlet obstruction is a highly successful, safe and effective palliative method.

A Case of Spontaneous Submucosal Dissection of the Esophagus / 대한소화기내시경학회지

Spontaneous submucosal dissection of the esophagus is a rare esophageal disorder which reveals characteristic features on radiologic and endoscopic examinations. It usually presents with acute epigastric pain, typically accompanied by dysphagia and odynophagia. We experienced a case of a 56-year-old man complaining of chest discomfort and right upper quadrant abdominal discomfort. The findings of upper gastrointestinal endoscopy and barium esophagogram were compatible with submucosal dissection of the esophagus. Chest CT scan showed multiple ulcers that formed a longitudinal tunnel canal. The patient was managed conservatively with nothing by mouth and intravenous hydration. Forty days after the first upper gastrointestinal endoscopy, the patient's symptoms disappeared completely and the massive dissection of the esophagus was much improved except for slight depression on the upper esophagus.

Two cases of Cushing's syndrome diagnosed by IPSS with normal or low plasma ACTH / 대한내과학회지

Cushing's syndrome results from prolonged exposure to high levels of glucocorticoid hormones. ACTH-dependent Cushing's syndrome accounts for about 85% of endogenous causes. Autonomous pituitary ACTH secretion, called Cushing's disease, is responsible for 80% of these causes, whereas ectopic ACTH secretion is responsible for 20% of them. Appropriate therapy of patients with Cushing's syndrome depends on accurate diagnosis and classification of the disorder. In addition to the history and clinical evaluation, the laboratory evaluation of a patient with Cushingoid appearance is necessary to establish the diagnosis and determine the cause of hypercortisolism. A major problem in the differential diagnosis of ACTH-dependent Cushing's syndrome is distinguishing Cushing's disease from the ectopic ACTH syndrome. Both entities can have similar clinical and laboratory features. In addition, both pituitary microadenoma and ectopic ACTH-secreting tumors may be radiologically occult. Bilateral inferior petrosal sinus and peripheral vein catheterization with simultaneous collection of samples for measurement of ACTH is one of the most specific tests available to localize the source of ACTH production. We report two cases of Cushing's syndrome diagnosed by inferior petrosal sinus sampling associated with normal or low ACTH levels on routine basal hormone assay.

Esophageal acid clearance in patients with ineffective esophageal motility / 대한내과학회지

BACKGROUND: Failed or hypotensive peristalsis, two of the diagnostic criteria for NEMD, correlates with impaired anterograde propulsion and retrograde escape of esophageal contents. The aim of this study was to evaluate esophageal acid clearance (EAC) in patients with ineffective esophageal motility (IEM). METHODS: Of 252 patients performing esophageal manometry and ambulatory esophageal pH monitoring, 51 patients with normal motility and acid reflux and 40 patients with IEM and acid reflux were included. RESULTS: The amplitude of peristaltic waves in the proximal and distal esophagus and lower esophageal sphincter pressure was lower significantly in patients with IEM than those with normal motility. Percentage of time of pH<4 in total, upright, and supine period and number of reflux episodes was not different in both. Supine EAC was significantly increased in patients with IEM when compared to those with normal motility. Upright EAC was not different in both. CONCLUSION: We concluded supine EAC is increased in patients with IEM. Since IEM is frequently associated with gastroesophageal reflux disease (GERD), a more intensive therapy must be needed. We propose IEM can be as a specific entity of primary esophageal motility disorder, especially in patients with GERD.

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.

Importances of the Endoscope Cleaning and Disinfecion Techniques in the Prevention of Endoscopic Transmission of Helicobacter pylori / 대한소화기내시경학회지

BACKGROUND/AIMS: H. pylori has been implicated in the pathogenesis of chronic gastritis, gastric ulcer, duodenal ulcer, and gastric cancer. The mode of H. pylori spread among individuals still largely unknown, but three possibilities such as fecal-oral, oral-oral, and gastro-oral transmission were reported. We were not exclusive possibility of H. pylori infection via endoscopic equipmemt, because endoscope was inserted directly into the gastrointestinal tract. METHODS: Fifty eight patients with upper gastrointestinal symptoms, who had visited Pusan National University Hospital from February 1999 to May 1999 were examined endoscopically and two biopsies were taken in each antrum and fundus for rapid urease test. After endoscopy, we collected the washing fluid from the surface and channel of the endoscope before and after cleaning and disinfection. Then we examined H. pylori contamination by H. pylori DNA PCR. RESULTS: The numbers of chronic gastritis, gastric ulcer, duodenal ulcer, gastric ulcer with duodenal ulcer, and gastric cancer were 15, 20, 18, 3, and 2, respectively. The positive rates were 84.5% (49/58) with CLO test, 58.6% (34/58) with H. pylori DNA PCR of the washing fluid of the endoscope surface and channel. In patients with CLO test positive, the positive rates of H. pylori DNA PCR is 44.9% (22/49) in endoscope channel, 24.5% (12/49) in surface before disinfection, but H. pylori DNA was not detected in any cases after washing and disinfection recommended by The Korean Society of Gastrointestinal Endoscopy. CONCLUSIONS: This study demonstrates that endoscopes were frequently contaminated by H. pylori during procedures performed on H. pylori-positive patients and were a potential source of nosocomial spread of the infection. However, this study also shows that the risk of endoscopic transmission of H. pylori infection could be minimized when appropriate cleaning and disinfection techniques were used.

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.

Clinical Significance of Growth Hormone, Insulin-like Growth Factor-1, and Insulin-like Growth Factor Binding Protein-3 in Patients With Posthepatitic Liver Cirrhosis / 대한간학회지

BACKGROUND/AIMS: Although an Insulin-like growth factor-1(IGF-1) and an Insulin-like growth factor binding protein-3(IGFBP-3) have been reported to be valuable indices of nutritional state in cirrhotic patients, there is still a dispute. The controversy may be caused by the fact that most studies included heterogeneous groups of patients such as alcoholic and posthepatitic cirrhosis. The aim of this study was two fold: to evaluate whether the Growth hormone(GH), IGF-1, and the IGFBP-3 are significant or not as valuable indices of hepatic function as well as the nutritional state in hepatitis B or C associated cirrhotic patients. METHODS: This study consisted of 36 patients with liver cirrhosis associated with hepatitis B or C. Patients with alcoholic cirrhosis were excluded. The serum GH, IGF-1, and IGFBP-3 were measured while patients were fasting. The variables of liver function and nutritional state included Child-Pugh score, serum bilirubin, albumin, prothrombin time, triceps skinfold thickness(TSF), and midarm muscle circumference (MAMC). The correlation between the variables of liver function or nutritional state and the serum GH, IGF-1, or IGFBP-3 was evaluated. RESULTS: The IGF-1 correlated very well with IGFBP-3 (p<0.001). Both the IGF-1 and IGFBP-3 correlated inversely with Child-Pugh score (p<0.01, P<0.001 respectively). IGFBP-3 correlated very well with the serum bilirubin level as well as the albumin level (p<0.001). Neither the IGF-1 nor IGFBP-3 showed any correlation with TSF or MAMC. CONCLUSIONS: Both IGF-1 and IGFBP-3 were clinically significant as indices of hepatic function in the patients with hepatitic B or C associated cirrhosis but neither of them were significant as indices of nutritional state.