Renal Expression of an Ammonia Transporter in Rats with a Unilateral Ureteral Obstruction / 대한내과학회지

BACKGROUND/AIMS: Urinary tract obstruction induces a form of renal tubular acidosis with a urinary acidification defect caused by decreasing net acid excretion, which is predominantly due to a decrease in urinary ammonia excretion. The present study examined whether this decrease is associated with changes in the renal expression of an ammonia transporter family member, Rh C glycoprotein (Rhcg), in rats with a unilateral ureteral obstruction. METHODS: Male Sprague-Dawley rats underwent a 24-h unilateral ureteral obstruction. Rhcg expression was then evaluated by immunoblotting and immunohistochemistry. Cell height, total cellular expression, expression in the apical 25% of the cell, and % of total expression in the apical region were quantified by immunohistochemistry with quantitative morphometric analysis. RESULTS: After 24 h of unilateral ureteral obstruction, the serum bicarbonate level and total urinary ammonia excretion were decreased. Both light microscopy and immunohistochemistry with quantitative morphometric analysis demonstrated that the total intensity of Rhcg expression was decreased in the obstructed kidneys, whereas Rhcg expression did not change in the cortical collecting duct (CCD) and outer medullary collecting duct (OMCD) of nonobstructed kidneys in rats with a 24-h unilateral ureteral obstruction. CONCLUSIONS: The rats with a unilateral ureteral obstruction showed decreased urinary ammonia excretion associated with decreased Rhcg expression in the CCD and OMCD. These changes suggest that the ammonia transporter Rhcg mediates a urinary acidification defect associated with unilateral ureteral obstruction.

Paranoid Adipsia-induced Severe Hypernatremia and Uremia treated with Hemodialysis

We describe a patient with severe hypernatremia and uremia caused by paranoid adipsia who was treated successfully with hydration and hemodialysis. A previously healthy 40-year-old woman developed the paranoid idea that her water was poisoned, so she refused to drink any water. On admission, her blood urea nitrogen was 208mg/dL, creatinine 4.90mg/dL, serum osmolality 452mOsm/L, serum sodium 172mEq/L, urine specific gravity > or =1.030, urine osmolality 698mOsm/L, and urine sodium/potassium/chloride 34/85.6/8mEq/L. We diagnosed her with uremic encephalopathy and started intravenous dextrose, but the sodium correction was incomplete. She underwent two sessions of hemodialysis to treat the uremic encephalopathy and hypernatremia, and recovered fully without neurological sequelae. Although the standard treatment for severe hypernatremia is hydration, hemodialysis can be an additional treatment in cases of combined uremic encephalopathy.

Endoscopic Treatment of Duodenal Bleeding Caused by Direct Hepatocellular Carcinoma Invasion with an Ethanol Injection

We report a case of a man who developed duodenal bleeding caused by direct hepatocellular carcinoma (HCC) invasion, which was successfully treated with endoscopic ethanol injection. A 57-year-old man with known HCC was admitted for melena and exertional dyspnea. He had been diagnosed with inoperable HCC a year ago. Urgent esophagogastroduodenoscopy (EGD) showed two widely eroded mucosal lesions with irregularly shaped luminal protruding hard mass on the duodenal bulb. Argon plasma coagulation and Epinephrine injection failed to control bleeding. We injected ethanol via endoscopy to control bleeding two times with 14 cc and 15 cc separately without complication. Follow-up EGD catched a large ulcer with necrotic and sclerotic base but no bleeding evidence was present. He was discharged and he did relatively well during the following periods. In conclusion, Endoscopic ethanol injection can be used as a significantly effective and safe therapeutic tool in gastrointestinal tract bleeding caused by HCC invasion.

The Efficacy of Early Scheduled Follow-Up Endoscopic Retrograde Cholangiopancreatography after Common Bile Duct Stone Removal

BACKGROUND/AIMS: To investigate the efficacy of early scheduled follow-up endoscopic retrograde cholangiopancreatography (ERCP) after common bile duct (CBD) stone removal. METHODS: Patients who underwent endoscopic CBD stone removal and who had at least one risk factor for stone recurrence were enrolled. Six months after complete clearance of the CBD, patients underwent follow-up ERCP at an ambulatory care center, irrespective of symptoms. RESULTS: The incidence of symptoms and cholangitis at follow-up ERCP was significantly lower in Group A (ERCP at 6 months after stone removal) than that in Group B (ERCP at >6 months) (14.3% vs 71.4%, p=0.00; 9.5% vs 33.3%, p=0.02, respectively). However, the recurrence rates of CBD stones were not different between Groups A and B (33.3% vs 47.6%). When comparing the subgroups, Group AR (stone recurrence in Group A) displayed significantly fewer symptoms and lesser cholangitis and spent fewer days in the hospital than did Group BR (stone recurrence in Group B) (21.4% vs 70%, p=0.02; 14.3% vs 60%, p=0.02; 2.43+/-1.87 vs 6.10+/-3.35, p=0.00, respectively). CONCLUSIONS: Our data suggest that, irrespective of symptoms, early scheduled follow-up ERCP for patients who are at a high risk of recurrence is effective and safe.

Renal Expression of Ammonia Transporters in Rats with Amiloride-Induced Renal Tubular Acidosis / 대한내과학회지

BACKGROUND/AIMS: Renal tubular acidosis (RTA) decreases the net acid excretion, predominantly due to a decrease in urinary ammonia excretion. This study examined whether this decrement is associated with changes in the renal expression of the ammonia transporter family members, Rh B glycoprotein (Rhbg) and Rh C glycoprotein (Rhcg), in rats with amiloride-induced RTA. METHODS: Male Sprague-Dawley rats were treated intraperitoneally with amiloride (3 mg/kg/day) for 6 days. Rhbg and Rhcg expression was evaluated by immunoblotting and immunohistochemistry. Cell height, total cellular expression, expression in the apical 25% of the cell, and apical expression as a percentage of total expression were quantified using immunohistochemistry with quantitative morphometric analysis. RESULTS: After amiloride treatment for 6 days, the serum bicarbonate level was decreased, and serum potassium was increased. The total urinary ammonia excretion and potassium excretion were decreased. The total Rhbg and Rhcg protein expression levels were not changed in the cortex or outer medulla of the kidney. Light microscopy and immunohistochemistry with quantitative morphometric analysis demonstrated that total Rhcg expression was decreased in the cortical collecting duct (CCD) and outer medullary collecting duct (OMCD) in amiloride-induced RTA, whereas Rhbg immunoreactivity was unchanged. CONCLUSIONS: Rats with amiloride-induced RTA have decreased urinary ammonia excretion associated with decreased Rhcg expression in the CCD and OMCD, suggesting that the ammonia transporter Rhcg plays an important role in the pathogenesis of amiloride-induced RTA.

A Case of Biopsy-Proven Acute Tubular Necrosis Associated with Vancomycin Overdose / 대한신장학회지

Vancomycin has been associated with acute kidney injury, particularly in the concomitant treatment with aminoglycoside or in the presence of other risk factor such as preexisting renal disease, sepsis, or hemodynamic instability. Vancomycin-related nephrotoxicity typically manifests as acute tubulointerstitial nephritis. Biopsy-proven acute tubular necrosis associated with vancomycin intoxication in the absence of aminoglycoside has been reported only in very few cases. We report a case of biopsy-proven acute tubular necrosis associated with vancomycin intoxication that was treated by continuous venovenous hemodiafiltration. A 28-year-old male without preexisting renal disease received a massive overdose of vancomycin. The plasma vancomycin level was 440.3 microg/mL. Renal biopsy revealed acute tubular necrosis that there is marked thinning of the tubular epithelium with dilatation of the tubular lumens and severe foamy epithelial cell changes in tubules. Continuous venovenous hemodiafiltration resulted in efficient reduction of serum vancomycin levels, which was followed clinically by recovered of renal function.

A Case of Trichosporon inkin Continuous Ambulatory Peritoneal Dialysis Peritonitis Identified by 18S rRNA Sequencing / 대한신장학회지

Fungal peritonitis in peritoneal dialysis patients is hard to treat without catheter removal and shows higher mortality. Although Candida species is the most common pathogen of fungal peritonitis, there are few reports about Trichosporon inkin induced peritonitis. The authors report the first case of Trichosporon induced peritonitis identified by 18S rRNA sequencing. A 52-year-old male presented to emergency room due to generalized abdominal pain. He had been on continuous ambulatory peritoneal dialysis for 3 years because of end stage renal disease caused by diabetic kidney disease. Dialysate white blood cell count was 800/mL3 with 77% of neutrophils and culture showed Trichosporon inkin via Vitek II system. With removal of catheter and treatment of antifungal agent, the patient was fully recovered and stable on hemodialysis. In case of immunocompromised dialysis patients, uncommon fungal pathogens should be taken into considerations.

Factors Affecting Complete Small Bowel Study and Diagnostic Yield in MiroCam(R) Capsule Endoscopy

BACKGROUND/AIMS: Mirocam(R) capsule endoscopy has been widely used in Korea; however, data with respect to Mirocam(R) capsule endoscopy is lacking. We have assessed the factors affecting complete small bowel studies and diagnostic yield in Mirocam(R) capsule endoscopic studies. METHODS: We retrospectively analyzed 103 cases that were assessed with Mirocam(R) capsule endoscopy between June 2007 and February 2010 at Guro Korea University Hospital. RESULTS: The mean age of the 103 cases was 55.47 years (range, 16-99 years) and 67 cases (65%) were male. The indications for capsule endoscopy were hematochezia/melena (77 cases, 74.8%), anemia (8 cases, 7.8%), abdominal pain (12 cases, 11.7%), and miscellaneous (weight loss and chronic diarrhea; 6 cases, 5.8%). The mean stomach transit time was 59.9+/-88.3 minutes (range, 1-630 minutes) and the mean small bowel transit time was 396.0+/-131.7 minutes (range, 117-708 minutes). The rate of successfully performing a complete small bowel study was 82.5% (85 cases), and the stomach transit time was a significant factor for a complete small bowel study (OR=0.991, 95% CI=0.984-0.998, P=0.012). The diagnostic yield was 51.5% (53 cases); visual quality was a significant factor in determining the diagnostic yield (OR=6.776, 95% CI=1.32-34.70, P=0.022). CONCLUSIONS: In a Mirocam(R) capsule endoscopic study, short stomach transit time was a significant factor affecting completion of the small bowel study. Achieving excellent visual quality by good bowel preparation was a significant factor for improving the diagnostic yield.

A Case of Narrow Opened Priampullary Diverticular Bleeding with Diagnostic Difficulty / 대한소화기내시경학회지

A duodenal diverticulum is most common in the medial aspect of the second portion of the duodenum and rarely causes symptoms. An obstruction, bleeding, perforation, jaundice and pancreatitis are uncommon complications of a duodenal diverticulum. Bleeding from the periampullary diverticulum should be considered in the diagnosis of a patient who presents with upper gastrointestinal bleeding of unknown origin. The second portion of the duodenum is sometimes difficult to observe entirely from the tangent line with the use of a forward-viewing endoscope. The diagnosis and treatment of periampullary diverticular bleeding may be achieved more easily by use of a side-viewing endoscope. We report here a case of narrow opened periampullary diverticular bleeding diagnosed by the use of a side-viewing endoscope with difficulty

The Usefulness of 64-Multidetector CT Cholangiography for Diagnosis of Distal Common Bile Duct Obstruction: Comparison with Endoscopic Retrograde Cholangiopancreatography / 대한소화기내시경학회지

BACKGROUND/AIMS: The aim of this study was to evaluate the diagnostic accuracy of 64-multidetector CT (MDCT) cholangiography for determining the causes of distal common bile duct (CBD) obstruction. METHODS: Two hundred fifty consecutive patients underwent 64-MDCT for diagnosing the clinical and biochemical signs of bile duct obstruction. The causes of bile duct obstruction were assessed by the pre- and post-enhanced axial and coronal multiplanar reformation images of 64-MDCT. The results were compared with ERCP, biopsy and surgery. RESULTS: The sensitivity and specificity of MDCT for CBD stones were 96.1% and 84.9%, respectively. In seven patients, The CBD stones in 7 patients could not be detected on MDCT. Eleven patients with stones in the distal CBD, as detected on MDCT, had no stones seen on ERCP. For malignant obstruction, the sensitivity and specificity of MDCT were 97.0% and 98.6%, respectively. Three patients who were diagnosed with periampullary cancers on MDCT were disclosed to have severe papillitis on ERCP. One patient who was diagnosed with CBD stone by MDCT was disclosed to have ampullary cancer. The overall accuracy of MDCT for determining the causes of biliary obstruction was 90.5%. CONCLUSIONS: MDCT cholangiography is a non-invasive method with relatively high sensitivity and high specificity for diagnosing the causes of distal CBD obstruction.

Changes in Liver Stiffness after Acute or Chronic Liver Injury due to Viral Hepatitis - Does Fibrosis Exist after Recovery from Acute Viral Hepatitis? / 대한소화기학회지

BACKGROUND/AIMS: Liver stiffness (LS) measurement by transient elastography can estimate the degrees of liver fibrosis in patients with chronic liver disease. However, longitudinal data of LS after recovery of acute viral hepatitis are still lacking. In the present study, we aimed to evaluate among LS of patients at various stages of viral hepatitis and normal control. METHODS: Patients who had admitted at Korea University Ansan Hospital between January 2006 and January 2007 due to acute viral hepatitis and recovered were recruited (group A, n=22). We compared the liver biochmistry and LS of group A with those of healthy control group (group B, n=23), current acute viral hepatitis group (group C, n=49), and chronic viral hepatitis group (group D, n=66). RESULTS: Mean ALT, total bilirubin, and LS level of group A were not different from group B (p=0.318, p=0.116, p=0.125, respectively). However, group A had lower ALT, total bilirubin, and LS values compared to group C (all p<0.001), and lower ALT and LS values compared to group D (p=0.007, p<0.001). The mean total bilirubin was not significantly different from group D (p=0.117). CONCLUSIONS: Our data suggest that liver fibrosis is a long-term sequela of chronic hepatitis, and not developed in patients who recovered from acute viral hepatitis.

A Case of a Double Gallbladder with Common Bile Duct Stones / 대한소화기내시경학회지

A double or bilobed gallbladder is a rare congenital anomaly, occurring at a rate of 1/4,000~5,000. We encountered a case of a double gallbladder that was diagnosed by an endoscopic retrograde cholangiogram. In view of the paucity of this anomaly, we report the case of a patient with a double gallbladder (Y duplication) accompanied by a common bile duct (CBD) stone. We also discuss the characteristics, classification, embryology and treatment of the double gallbladder.

Pneumoretroperitoneum, Pneumomediastinum, Peumopericardium, and Subcutaneous Emphysema after Colonoscopic Examination

Colonoscopy is regarded as a relatively safe procedure and is widely performed. However, complications such as bleeding, perforation, and coagulation syndromes can occur during colonoscopy. Although bowel perforation is as rare as 0.4-1.9% of cases, it is the most serious and awful adverse event which can lead to a death. Colon perforation may occur as either intraperitoneal or extraperitoneal, or in combination. Right subdiaphragmatic free air suggests intraperitoneal perforation while pneumoretroperitoneum, pneumomediastinum, pneumopericardium, and subcutaneous emphysema suggest extraperitoneal perforation. Combined intraperitoneal and extraperitoneal perforation is very rare. Herein, we present a case of combined intraperitoneal and extraperitoneal colon perforation which manifested as pneumoretroperitoneum, pneumomediastinum, pneumopericardium, and subcutaneous emphysema. The lesion was closed with endoscopic clipping.

The Role of Nitric Oxide in Experimental Cerulein Induced Pancreatitis

An enhanced formation of nitric oxide(NO), due to the induction of inducible nitric oxide synthase(iNOS), has been implicated in the pathogenesis of shock and inflammation, but its role in acute pancreatitis still remains controversial. To clarify the role of NO in acute pancreatitis, the present experiment investigated the expression of iNOS and the effect of NOS inhibition on cerulein-induced pancreatitis in rats. Group I received intraperitoneal (ip) injection of normal saline. Group II received two ip injections of cerulein (20 microgram/kg). Group III received injections of N(G)-nitro-L-arginine methyl este(L-NAME) (30 mg/kg) with cerulein. Group IV received L-arginine(250 mg/kg) with cerulein and L-NAME. The expression of iNOS in the pancreas was examined by western blot analysis. The plasma concentration of NO metabolites was measured. The severity of pancreatitis was assessed by measuring serum amylase, pancreas water content and histopathological examination. Compared with controls, the cerulein group displayed significantly increased expression of iNOS and raised plasma NO metabolites. Treatment with L-NAME significantly decreased hyperamylasemia, plasma NO level, and the extent of pancreatic injury. Treatment with L-arginine reversed the effects of L-NAME. These findings suggest that an enhanced formation of NO by iNOS plays an important role in the development of acute pancreatitis, and inhibition of NO production has the beneficial effects in reducing pancreas injury.

A Case of Tubular Esophageal Duplication Presenting with Hematemesis / 대한소화기내시경학회지

A 35-year old male developed epigastric pain and hematemesis one week before admission. Esophagogastroduodenoscopy was performed and a communication between the esophagus and another opening was discovered. On a follow-up CT and barium esophagogram, a tubular duplication was suspected and the patient was referred to the department of cardio-thoracic surgery. A pathological diagnosis of esophageal duplication (tubular type) was established. The patient was discharged and is currently being followed up. Esophageal duplication is a rare congenital malformation. Moreover, it has not heen reported in Korea that esophageal duplication presents with hematemesis.

Effects of Gabexate Mesilate for the Prevention of Pancreatic Damage Related to ERCP / 대한소화기내시경학회지

BACKGROUND/AIMS: Recent studies reported that 1g of gabexate mesilate (GM) was effective in preventing endoscopic retrograde cholangiopancreatography (ERCP)-related pancreatic damage. The aim of this study was to evaluate the effectiveness of low dose GM for the prevention of ERCP-related pancreatic damage. METHODS: This study was performed prospectively with 102 consecutive patients (68 for the GM group, 34 for the placebo group) who were scheduled for ERCP. Infusion of GM (500 mg) was started 30 minutes before ERCP and continued for 12 hours afterward. The serum amylase and lipase were measured before ERCP and 4, 8, and 24 houps after ERCP. RESULTS: The incidence of hyperenzymemia was 45.6% in the GM group and 55.9% in the control group (p=0.40). Acute pancreatitis was developed in only one patient who was given the placebo. Although difficult cannulation, visualization of the pancreatic duct, performance of therapeutic procedures, and longer total procedure time were associated with an increased incidence of hyperenzymemia, the incidence of pancreatic damage was not affected by the GM treatment in these conditions. CONCLUSIONS: Prophylactic treatment with 500 mg of GM has no advantage for the prevention of ERCP-related pancreatic damage. Considering the cost effectiveness, further studies are necessary to identify the patients at greatest risk fot acute pancreatitis.

Endoscopic Removal of an Impacted Sharp Foreign Body in the Esophagus / 대한소화기내시경학회지

BACKGROUND/AIMS: Sharp impacted esophageal foreign bodies can be very difficult to manage. When attempting to remove such objects inappropriately, life threatening complications, such as perforation can occur. Terefore, surgical intervention generally affords a safer approach. The aim of this study was to evaluate the safety and efficacy of endoscopic remval of sharp impacted esophageal foreign bodies using a dilatation method with an oral side balloon. METHODS: A total of 17 patients (7 Male, 10 Female)with sharp impacted esophageal foreign bodies underwent endoscopic Extraction. The following technique was successfully performed; an oral side balloon (Top Co., Japan) for esophageal variceal sclerotherapy was attached on the distal part of the endoscope. Under local anesthesia, the endoscope was inserted near the proximal part of the esophageal foreign body. Then, the oral side balloon was gradually dilated. Dilataion of the proximal part of the esophagus made it possible to release the sharp impacted foreign body from the esophageal wall. RESULTS: The types of foreign bodies were fish bones (6 cases), press-through packages (6 ases), chichen bones (3 cases), dentures (1 case), and a watch (1case). Endoscopic removal was successful in all 17 cases without complications such as perforation. CONCLUSIONS: This method of using an oral side balloon is safe and effective in removing sharp impacted esophageal foreign bodies, preventing, surgery and possible perforation.

The Clinical Value of Endoscopic Ultrasonography (EUS) in Rectal Carcinoid Tumor / 대한소화기내시경학회지

BACKGROUND/AIMS: Carcinoid tumor of the rectum is relatively uncommon lesion with malignant potential, representing 17-27% of gastrointestinal tract carcinoid. The selection of treatment in rectal carcinoid tumor is determined by the depth of invasion and the presence of metastasis. In this study, we evaluated the clinical utility of EUS in selecting the management of the rectal carcinoid tumor. METHODS: Total 8 patients with rectal carcinoid tumor diagnosed by means of colonoscopy and EUS from 1994 to 1999 were included in this study. None had specific symptoms of carcinoid syndrome. The treatment modality of all tumors were selected by EUS before resection. We examined histologic feature after resection of tumors in order to evaluate the effectiveness of EUS. RESULTS: In total 8 patients, the image of tumors was oval to round. The internal echo was generally hypoechoic and homogenous. The margins were clearly visualized, and the contour was somewhat smooth. All tumor were resected completely. The overall accuracy of determining the depth of invasion using endoscopic ultrasonography was 87% (7 of 8 lesions). CONCLUSIONS: EUS is considered to be helpful in evaluating the malignant behavior of rectal carcinoid tumor. It is suggested that the criteria of the selection based on the EUS findings is available in the choice of treatment for rectal carcinoid tumor.

Prevalence and clinical significance of abnormal p53 gene in patients with ampullary adenocarcinoma / 대한내과학회지

BACKGROUND: Although abnormalities of p53 gene and their relation to clinicopathologic parameters have been identified in some human malignancies, there is little published data on their prevalence and clinical significance in ampullary adenocarcinoma (AAC). The aim of this study is to determine the prevalence of p53 abnormalities in AAC and to evaluate their relation to clinicopathologic features. METHOD:35 formaline-fixed paraffin-embedded tissues of AAC were examined for detection of p53 abnormalities by both single-strand conformation polymorphism (SSCP) analysis of polymerase chain reaction- amplified DNA fragments corresponding to exons 5-8 and immunohistochemistry (IHC) using monoclonal antibody to p53 protein (Novocastra, DO7), and the association between the p53 abnormalities and clinicopathologic parameters was analyzed. RESULT: In 22.9% of AAC, p53 gene muation was demonstrated by SSCP analysis, mainly at PCR-amplified exon 8 and exon 7. The p53 protein overexpression by IHC was 48.6% of AAC. Six SSCP and IHC-positive (17.2%) cases and 16 normal (45.7%) cases showed concordant results between the methods, although 13 cases (37.1%) showed discordance, including 11 IHC-positive (31.4%) and 2 SSCP-positive (5.7%) cases. Overall, the prevalence of p53 abnormalities was 54.3%. No significant associations between the p53 abnormalities and clinicopathological parameters such as clinical manifestations, histologic differentiation, and tumor stage were observed. CONCLUSION: The p53 abnormalities detected in 55% of AAC are not associated with prognostic factor, suggesting that abnormal p53 gene may play a role in the development of AAC, but not in its invasiveness.

Adenosquamous Carcinoma Arising in Choledochal Cyst / 대한소화기내시경학회지

Cystic dilatation of the biliary tree, so called choledochal cyst, is an uncommon disease and is not uncommonly associated with carcinoma. The most symptoms on. presentation are abdominal pain, weight loss, jaundice, and palpable mass. The prognosis of these lesions is dismal. Recently we experienced a case of carcinoma arising in a choledochal cyst in 27-year-old male complaining jaundice and fever. ERCP revealed marked dilated the CBD and obstruction of the proximal portion of the CHD. A computerized tomographic scan and percutaneous cholangiogram showed cystic dilatation of both intrahepatic ducts and solid mass in the left hepatic duct. The patient was treated with surgical resection. Pathologic studies disclosed an adenosquamous carcinoma.