Low-dose steroid-induced tumor lysis syndrome in a hepatocellular carcinoma patient

Tumor lysis syndrome is rare in hepatocellular carcinoma (HCC), but it has been reported more frequently recently in response to treatments such as transcatheter arterial chemoembolization (TACE), radiofrequency thermal ablation (RFTA), and sorafenib. Tumor lysis syndrome induced by low-dose steroid appears to be very unusual in HCC. We report a patient with hepatitis-C-related liver cirrhosis and HCC in whom tumor lysis syndrome occurred due to low-dose steroid (10 mg of prednisolone). The patient was a 90-year-old male who presented at the emergency room of our hospital with general weakness and poor oral intake. He had started to take prednisolone to treat adrenal insufficiency 2 days previously. Laboratory results revealed hyperuricemia, hyperphosphatemia, and increased creatinine. These abnormalities fulfilled the criteria in the Cairo-Bishop definition of tumor lysis syndrome. Although the patient received adequate hydration, severe metabolic acidosis and acute kidney injury progressed unabated. He finally developed multiple organ failure, and died 3 days after admission. This was a case of tumor lysis syndrome caused by administration of low-dose steroid in a patient with HCC.

Visceral Fat as a Useful Parameter in the Differential Diagnosis of Crohn's Disease and Intestinal Tuberculosis

BACKGROUND/AIMS: Because of the similarities in the clinical presentations of Crohn's disease (CD) and intestinal tuberculosis (ITB), differential diagnosis is critical. Mesenteric adipose tissue hypertrophy and creeping fat are characteristic features of CD. The purpose of this study was to assess the usefulness of visceral fat for the differential diagnosis of CD and ITB. METHODS: We conducted a retrospective review of 50 patients with findings of CD or ITB between January 2005 and July 2008. Abdominal computed tomography (CT) was performed on all subjects during their first evaluation. The abdominal fat area was assessed using quantitative abdominal CT. RESULTS: The ratio of visceral fat to total fat (VF/TF) was significantly higher in male CD patients than in male ITB patients. The ratio of visceral fat to subcutaneous fat (VF/SF) was also higher in CD patients than in patients with ITB. For a VF/TF cut-off value of 0.46, the sensitivity and specificity for the diagnosis of CD were 42.1% and 93.3% respectively, with positive and negative predictive values of 88.9% and 56.0%, respectively. CONCLUSION: Measurement of the abdominal fat area using CT can be clinically useful for the differential diagnosis of CD and ITB.

Association between Symptoms of Irritable Bowel Syndrome and Methane and Hydrogen on Lactulose Breath Test

Whether hydrogen and methane gas produced during lactulose breath test (LBT) are associated with symptoms of irritable bowel syndrome (IBS) is not determined. We aimed to investigate whether hydrogen and methane on LBT are associated with IBS symptoms. Sixty-eight IBS patients meeting the Rome III criteria for IBS, and 55 healthy controls, underwent LBT. The IBS subjects recorded their customary gastrointestinal symptoms on a questionnaire using visual analogue scales. LBT positivity was defined to be above 20 ppm rise of hydrogen or 10 ppm rise of methane within 90 min. Gas amounts produced during LBT were determined by calculating area under the curve of hydrogen and methane excretion. Symptom severity scores were not different between the LBT (+) IBS and LBT (-) IBS subjects and also between methane producers and non-methane producers. Gas amounts produced during LBT were not associated with IBS symptoms, except a weak correlation between total gas amounts and a few IBS symptoms such as bloating (r = 0.324, P = 0.039), flatulence (r = 0.314, P = 0.046) and abdominal pain (r = 0.364, P = 0.018) only in LBT (+) IBS. In conclusion, hydrogen and methane gas on LBT are not useful for predicting the customary symptoms and subtypes of IBS.

International Live Endoscopic Multichannel Demonstration Using Superfast Broadband Internet Connections

BACKGROUND/AIMS: Telemedicine is a convenient and efficient tool for remote education in various fields. The telemedicine system can also be used to educate doctors and medical students. The aim of our study was to establish the effectiveness of the telemedical system for use in a live endoscopic multichannel demonstration conference and to test the effectiveness and usefulness of a multicenter-based live endoscopic demonstration through live, interactive, high resolution video transmission using advanced networks and the digital video transport system (DVTS). METHODS: This study is a prospective multicenter pilot study. A live demonstration of an endoscopic submucosal dissection (ESD) and an endoscopic retrograde cholangiopancreatography (ERCP) using advanced network technology was performed. RESULTS: The DVTS successfully transmitted uncompressed, high-resolution, digital lectures with endoscopy video during a multichannel endoscopic live demonstration of ESD and ERCP over multiple advanced networks. The overall satisfaction rating when the endoscopic lecture demonstration was performed by combining DVTS was generally good. CONCLUSIONS: We believe that a multicenter-based live endoscopic demonstration is a very effective conferencing method when using advanced networks and DVTS.

Correlation between Complicated Diverticulitis and Visceral Fat

The aim of this study was to examine the relationship of complications related to diverticulitis and visceral obesity. The study was based on a retrospective case note review conducted at the Hanyang University Hospital. Patients were diagnosed with diverticulitis based on clinical symptoms and abdominal computed tomography (CT) findings and divided into two groups: those admitted with complicated diverticulitis and those with a simple diverticulitis episode. We compared the body mass index (BMI) and degree of visceral obesity, measured by abdominal CT. The study included 140 patients, 87 (62.1%) were simple diverticulitis and 53 (37.9%) were complicated diverticulitis. In the complicated diverticulitis group, 9 (6.4%) cases were recurrent, 29 (20.7%) were perforation or abscess patients, and 28 (20%) were patients with systemic inflammatory response syndrome (SIRS). Of the SIRS patients, 13 were involved in other complication groups. When comparing in the two groups, the complicated diverticulitis group had a significantly higher visceral fat area (128.57 cm2 vs 102.80 cm2, P = 0.032) and a higher ratio of visceral fat area/subcutaneous fat area (0.997 vs 0.799, P = 0.014). Visceral obesity is significantly associated with complications of diverticulitis.

Differences in Clinical Characteristics between Patients with Non-Erosive Reflux Disease and Erosive Esophagitis in Korea

Gastroesophageal reflux disease (GERD) is caused by abnormal reflux of gastric contents into the esophagus. GERD can be divided into two groups, erosive esophagitis and non-erosive reflux disease (NERD). The aim of this study was to compare the clinical characteristics of patients with erosive esophagitis to those with NERD. All participating patients underwent an upper endoscopy during a voluntary health check-up. The NERD group consisted of 500 subjects with classic GERD symptoms in the absence of esophageal mucosal injury during upper endoscopy. The erosive esophagitis group consisted of 292 subjects with superficial esophageal erosions with or without typical symptoms of GERD. Among GERD patients, male gender, high body mass index, high obesity degree, high waist-to-hip ratio, high triglycerides, alcohol intake, smoking and the presence of a hiatal hernia were positively related to the development of erosive esophagitis compared to NERD. In multivariated analysis, male gender, waist-to-hip ratio and the presence of a hiatal hernia were the significant risk factors of erosive esophagitis. We suggest that erosive esophagitis was more closely related to abdominal obesity.

Young Aged Colorectal Cancer Patients: Do They Have a Bad Prognosis? / 대한소화기내시경학회지

BACKGROUND/AIMS: Many previously published articles have reported poor outcomes for young patients with colorectal cancer as compared to that of older patients with colorectal cancer. However, these studies have tended to be small and have various biases. This study was retrospectively designed to determine the clinical course and survival rate of young patient with colorectal cancer. METHODS: All the patients who underwent surgery for colorectal cancer at Hanyang University Hospital between 1995 and 2001 were identified. These patients were assigned to two age groups: the 45 years old and below 45 years old group (123 patients) and the group over the age of 45 (421 patients). RESULTS: The size of the tumor mass was significantly larger in the young group. There were no significant differences between the two groups for the stage at the time of diagnosis, the differentiation, the degree of lymph node involvement, the cancer location and the gross finding. The median cancer specific survival time was worse for the old group as compared with that of the young group. Age, differentiation, lymph node involvement and the Duke stage were the significant prognostic factors on univariate analysis. Age and the Duke stage were the independent prognostic factors that were significantly correlated with survival on the multivariate analysis using the Cox proportional hazard model. CONCLUSIONS: Contrary to prior reports, younger patients with colorectal cancer appear to have a better survival rate than that of older patients with colorectal cancer.

Colonic Metastasis from Primary Lung Adenocarcinoma / 대한소화기학회지

Primary lung cancer is a leading cause of cancer-related deaths in Korea. Approximately 50% of patients have metastatic disease at the time of presentation. The preferential sites of extrapulmonary spread include lymph nodes, liver, brain, adrenal glands, and bones. Gastrointestinal metastasis from primary lung cancer is extremely rare and only a few case reports have been published. Herein, we report a case of metastatic colon cancer from primary lung adenocarcinoma, presenting multiple cecal polypoid masses.

Comparison of a Digital Video Transfer System with a Satellite Broadcasting System Used in a Teleconference: From the Trainee Point of View / 대한소화기내시경학회지

BACKGROUND/AIMS: Telemedicine is a useful tool for remote education to overcome limitations of location. We have shared medical knowledge by the use of a real-time, high quality digital video transfer system (DVTS). The study aim was to evaluate the use of the DVTS by viewer questionnaire. METHODS: After an endoscopic live demonstration using DVTS and satellite broadcasting system (SBS), questions were provided for the degree of satisfaction about image and sound of the presentation. A questionnaire was composed of 11 questions concerning factors such as a comparison of image quality between the two systems. The preference between DVTS with SBS was analyzed. RESULTS: For image quality, SBS was more preferable than DVTS (65.6% versus 16.7%). However, 16.7% found no difference between the use of DVTS and SBS. For the time delay between the image and sound, 62.5% preferred SBS and 11.5% preferred DVTS. The satisfaction for combining DVTS with SBS were 68% as good and 22% as very good. CONCLUSIONS: We have demonstrated the feasibility of telemedicine by the demonstration of a satisfactory teleconference, although DVTS was utilized as an assistant tool. DVTS should prove to be a promising tool as a useful and economic means to provide remote medicine.

Telemedicine System Using a High-Speed Network: Past, Present, and Future

There is no doubt that telecommunication saves a great deal of time and expense when exchanging information, and recent technological advances have increased its popularity in business and educational applications. Telemedicine is a rapidly developing application of clinical medicine in which medical information is transferred via the Internet or another communication network for the purpose of consultations, and sometimes also for remote medical procedures or examinations. A telemedicine system can also be applied to medical education. Many doctors and medical students could benefit from telementoring and tele-education based on videoconferencing systems. However, telemedicine in general has not yet become popular in clinical practice or medical education. In our university, we have used a telemedicine system to educate doctors and medical students since 2003. Since our first telemedical conference with Kyushu University Hospital on February 12, 2003 when we have regularly performed telemedical conferences. Here we introduce a general methodology for telemedicine, our experiences of medical conferencing using telemedicine, and future possible directions.

A Deep Neck Infection Due to Esophageal Perforation That Was Caused by Upper Gastrointestinal Endoscopy / 대한소화기내시경학회지

Diagnostic upper gastrointestinal endoscopy is a very commonly performed procedure. Physicians use it as a safe diagnostic tool to evaluate patients with a wide range of problems and complaints, but it can cause several complications in few cases. Esophageal perforation is a rare complication of upper gastrointestinal endoscopy, but it is associated with a relatively high mortality rate. Surgical management is required in most such cases. However, medical treatment can be considered for selected patients who are without a large perforation or systemic effects such as sepsis. Deep neck abscess can develop in patients who have had difficult intubations, and this may be related to retropharyngeal trauma or unapparent perforations. We experienced a case of deep neck infection due to an esophageal perforation that developed as a complication of diagnostic upper gastrointestinal endoscopy, and we successfully treated this patient with incision and drainage.

Is End Stage Renal Disease a Poor Prognosis Factor of Ischemic Colitis? / 대한소화기학회지

BACKGROUND/AIMS: In general, ischemic colitis has a very good prognosis. However, there are a lot of controversies in relation to the prognostic factors. The aim of this study was to evaluate risk factors of severe ischemic colitis. METHODS: A retrospective study was undertaken of patients with ischemic colitis hospitalized at the Hanyang University Hospital during the interval 2004-2006. Patients were divided into two groups: those with mild course and those with severe course which led to operation, systemic inflammatory response syndrome, or death. RESULTS: A total of 41 cases (M/F=13/28, mean age=63.8 years) of biopsy proven ischemic colitis were included, of which 31 (75.6%) had a mild course and 10 (24.4%) a severe course. Coexisting medical diseases of patients were hypertension (n=24), diabetes (n=14), end-stage renal disease (n=11), cardiovascular disease (n=5), and malignancy (n=5). Male (p=0.049), alcoholics (p=0.025), end-stage renal disease (p=0.013), LDH (p=0.002), CRP (p=0.014), and peritoneal irritation sign (p=0.001) were the significant risk factors of severe ischemic colitis in univariate analysis. In multivariate logistic regression analysis, end-stage renal disease (p=0.026) was the only significant risk factor of severe ischemic colitis. CONCLUSIONS: Careful attention must be paid to end-stage renal disease patients having ischemic colitis.

Endoscopic Pancreatic Sphincterotomy: Indications and Complications

BACKGROUND/AIMS: Although a few recent studies have reported the effectiveness of endoscopic pancreatic sphincterotomy (EPST), none has compared physicians' skills and complications resulting from the procedure. Thus, we examined the indications, complications, and safety of EPST performed by a single physician at a single center. METHODS: Among 2,313 patients who underwent endoscopic retrograde cholangiopancreatography between January 1996 and March 2008, 46 patients who underwent EPST were included in this retrospective study. We examined the indications, complications, safety, and effectiveness of EPST, as well as the need for a pancreatic drainage procedure and the concomitant application of EPST and endoscopic sphincterotomy (EST). RESULTS: Diagnostic indications for EPST were chronic pancreatitis (26 cases), pancreatic divisum (4 cases), and pancreatic cancer (8 cases). Therapeutic indications for EPST were removal of a pancreaticolith (10 cases), stent insertion for pancreatic duct stenosis (9 cases), nasopancreatic drainage (7 cases), and treatment of sphincter of Oddi dysfunction (1 case). The success rate of EPST was 95.7% (44/46). Acute complications of EPST included five cases (10.9%) of pancreatitis and one of cholangitis (2.2%). EPST with EST did not reduce biliary complications. Endoscopic pancreatic drainage procedures following EPST did not reduce pancreatic complications. CONCLUSIONS: EPST showed a low incidence of complications and a high rate of treatment success; thus, EPST is a relatively safe procedure that can be used to treat pancreatic diseases. Pancreatic drainage procedures and additional EST following EPST did not reduce the incidence of procedure-related complications.

A Case of Mucinous Adenocarcinoma of the Colon Presenting with Psoas Abscess / 대한소화기학회지

A colon cancer presenting as psoas muscle abscess is very rare. A 27-year-old woman was admitted with abdominal pain, fever, and discomfort on left thigh. She had been administered on anti-tuberculosis medication for colonic tuberculosis since 3 months ago. Abdominal CT scan revealed a mass lesion obstructing the descending colon with an abscess formation within left psoas muscle. We undertook segmental resection of obstructing descending colon after the percutaneous drainage of psoas abscess. The pathologic report was mucinous adenocarcinoma of the colon. We report the first case of colon cancer manifested with psoas abscess in Korea, with the review of literature associated with the correlation of colon cancer and tuberculosis.

A Case of Acute Pancreatitis Induced by Multiple Drugs in a Patient with Ulcerative Colitis / 대한소화기학회지

Acute pancreatitis is a serious disease with fatality rate up to 15%. We recently experienced a case of acute pancreatitis induced by multiple drugs in a patient with ulcerative colitis. A 20-year-old female visited with abdominal pain and hematochezia and diagnosed of ulcerative colitis. Sulfasalazine and prednisolone were used. However, acute pancreatitis occurred after 4 weeks of treatment with additional azathioprine treatment. Drug-induced pancreatitis was suspected, and she was recovered with conventional therapy for acute pancreatitis. Therefore, it was proposed that acute pancreatitis was induced by azathioprine. However, after the administration of sulfasalazine, pancreatitis relapsed. Furthermore, even the re-administration of 5-ASA and azathioprine induced relapse of acute pancreatitis. We concluded that acute pancreatitis was induced by multiple drugs in this patient with ulcerative colitis.

A Case of Toxic Megacolon Associated with Fulminant Pseudomembranous Colitis / 대한소화기내시경학회지

The clinical presentation of Clostridium difficile infection ranges from asymptomatic carriage, colitis with or without pseudomembranes, to fulminant colitis. Although not common, fulminant Clostridium difficile colitis can result in bowel perforation and peritonitis with a high mortality rate. We report a case of toxic megacolon associated with fulminant pseudomembranous colitis. We experienced a case of a 65-year-old male patient who presented with abdominal distension and pain for three days during treatment of pneumonia. We were able to diagnose the case as a toxic megacolon associated with fulminant pseudomembranous colitis. In spite of oral metronidazole treatment and conservative treatment, the clinical course worsened and the patient went into septic shock. The patient underwent a total colectomy but the clinical situation did not improve and the patient died.

Association between Insulin, Insulin Resistance, and Gallstone Disease in Korean General Population / 대한소화기학회지

BACKGROUND/AIMS: Diabetes is one of the risk factors of gallstone diseases. Many studies found a positive association between insulin and gallstones in individuals with diabetes. However, this association is unclear in non-diabetes. So we conducted a case-control study for the evaluation of the association between gallstone diseases and fasting serum insulin level, insulin resistance in non-diabetic Korean general population. METHODS: This study was a prospective case-control study on 118 Korean subjects which included clinical examination, abdominal ultrasound, and blood chemistries. Serum fasting insulin level were determined by radioimmunoassay and concentrations of cholesterol, glucose, and triglycerides by standard enzymatic colorimetric methods. Insulin resistance was determined by the homeostasis model assessment (HOMA-IR). Body mass index (BMI), percentage of body fat, and waist hip ratio were also measured. RESULTS: We studied 118 subjects with no clinical evidence of diabetes mellitus and serum glucose<126 mg/dL. Compared with controls (n=89), cases (n=29) had higher levels of serum insulin, glucose, triglyceride levels, and BMI. In t-test and chi-square test for variables, the association between gallstone disease and serum insulin, HOMA-IR index, and BMI were statistically significant (p<0.05). In multiple logistic regression analysis, gallstone disease risk increased with the level of serum insulin (p=0.024, odds ratio=1.376) and HOMA-IR index (p=0.013, odds ratio=2.006). CONCLUSIONS: We suggest that hyperinsulinemia and insulin resistance could be associated with gallstone formation in individuals without clinical diagnosis of diabetes mellitus and with normal serum glucose level.

A Role of Endoscopic Balloon Dilatation after Partial Infundibulotomy in Billroth II Patients / 대한소화기내시경학회지

BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is difficult to perform in patients with a Billroth II anastomosis due to the anatomical alterations. This study evaluated retrospectively the efficacy and safety of endoscopic balloon dilatation after a partial infundibulotomy with a needle knife in patients who had undergone a Billroth II operation. METHODS: Between January 1, 2004 and December 31, 2005, 11 patients, who had undergone a prior Billroth II gastrectomy, underwent ERCP because of a suspicion of pancreatobiliary diseases. Infundibulotomy was performed using a needle knife sphincterotome. After a partial infundibulotomy, a dilation balloon was passed over a prepositioned guidewire and placed in the biliary orifice. Under endoscopic and fluoroscopic control, the balloon was then inflated with diluted contrast over a period of 1 to 2 minutes. RESULTS: A total of 10 patients (7 male and 3 female) were enrolled in this study. Eight had common bile duct stones, 1 bile duct cancer, and 1 pancreatic cancer. The common bile duct was dilated by a balloon. The calculi were removed in 6 patients, and a common bile duct stent was implanted in two cases via endoscopy. No complications such as acute pancreatitis or apparent infections of the biliary tracts were encountered in these cases except for mild fever, temporary high serum levels of aminotransferase and amylase after ERCP in 3 cases. No severe bleeding or perforation occurred in patients undergoing balloon dilatation. CONCLUSIONS: An infundibulotomy with balloon dilatation is a valuable alternative to endoscopic sphinterotomy in the treatment of patients with bile duct diseases, who have undergone prior Billroth II gastrectomies.

A Role of Endoscopic Balloon Dilatation after Partial Infundibulotomy in Billroth II Patients / 대한소화기내시경학회지

BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is difficult to perform in patients with a Billroth II anastomosis due to the anatomical alterations. This study evaluated retrospectively the efficacy and safety of endoscopic balloon dilatation after a partial infundibulotomy with a needle knife in patients who had undergone a Billroth II operation. METHODS: Between January 1, 2004 and December 31, 2005, 11 patients, who had undergone a prior Billroth II gastrectomy, underwent ERCP because of a suspicion of pancreatobiliary diseases. Infundibulotomy was performed using a needle knife sphincterotome. After a partial infundibulotomy, a dilation balloon was passed over a prepositioned guidewire and placed in the biliary orifice. Under endoscopic and fluoroscopic control, the balloon was then inflated with diluted contrast over a period of 1 to 2 minutes. RESULTS: A total of 10 patients (7 male and 3 female) were enrolled in this study. Eight had common bile duct stones, 1 bile duct cancer, and 1 pancreatic cancer. The common bile duct was dilated by a balloon. The calculi were removed in 6 patients, and a common bile duct stent was implanted in two cases via endoscopy. No complications such as acute pancreatitis or apparent infections of the biliary tracts were encountered in these cases except for mild fever, temporary high serum levels of aminotransferase and amylase after ERCP in 3 cases. No severe bleeding or perforation occurred in patients undergoing balloon dilatation. CONCLUSIONS: An infundibulotomy with balloon dilatation is a valuable alternative to endoscopic sphinterotomy in the treatment of patients with bile duct diseases, who have undergone prior Billroth II gastrectomies.

Clinical Feature of Pseudomembranous Colitis with Ascites / 대한소화기내시경학회지

BACKGROUND/AIMS: Ascites is a fairly common condition, but the clinical features of pseudomembranous colitis with ascites are not well-known. The aim of this study was to determine how the existence of ascites is related to the clinical factors. METHODS: Between March 2002 and June 2006, 67 pseudomembranous colits patients were diagnosed by performing lower endoscopy and biopsy. The patients' ascites was identified by abdominal plain radiography, ultrasonography or computerized tomography. The extension of colitis was evaluated by ultrasonography or computerized tomography. RESULTS: 16 patients (23.9%) had ascites. The serum WBC (p=0.01), hypoalbuminemia (p<0.01), CRP (p<0.01), recurrence (p<0.01), and extension of colitis (p<0.01) were associated with the existence of ascites. The four patients who had undergone paracentesis had a low SAAG level and PMN dominant ascites. CONCLUSIONS: There were correlations of ascities with leukocytosis, hypoalbuminemia, CRP, extension of colitis and recurrence of PMC.