Cerebral venous thrombosis in a patient with Crohn's disease

Patients with inflammatory bowel disease (IBD) have an elevated risk of venous thromboembolism compared with the general population. The most common sites of venous thromboembolism in IBD patients are the deep veins of the legs, the pulmonary system, and portal and mesenteric veins. However, cerebral venous thrombosis is rarely associated with IBD. This report describes a case of cerebral venous thrombosis in a patient with Crohn's disease. A 17-year-old girl, diagnosed 4 years earlier with Crohn's disease, presented with headache and vomiting. Magnetic resonance imaging of the brain with venography showed venous thrombosis in the cortical veins, superior sagittal sinus, right transverse sinus, and right internal jugular vein. The patient immediately started anticoagulation therapy with intravenous heparin infusion followed by daily oral rivaroxaban 10 mg. Follow-up imaging after 2 weeks showed resolution of the thrombosis, with recanalization of the cortical veins, superior sagittal sinus, right transverse sinus, and right internal jugular vein. She continued rivaroxaban therapy for 6 months, and remained well, without neurologic sequelae. A high level of concern for cerebral venous thrombosis may be important when treating active IBD patients, because anticoagulation treatment can prevent fatal complications.

Life-threatening Duodenal Ulcer Bleeding from a Ruptured Gastroduodenal Artery Aneurysm in a Patient with Neurofibromatosis Type 1 / 대한소화기학회지

Vasculopathy is rarely reported in neurofibromatosis type 1, but when it occurs it primarily involves the aorta and its main branches. Among vasculopathies, aneurysmal dilatation is the most common form. Although several case reports concerning aneurysms or pseudoaneurysms of visceral arteries in neurofibromatosis type 1 patients have been reported, there are no reports describing gastroduodenal artery aneurysms associated with neurofibromatosis type 1. We experienced a case of life-threatening duodenal ulcer bleeding from a ruptured gastroduodenal artery aneurysm associated with neurofibromatosis type 1. We treated our patient by transarterial embolization after initial endoscopic hemostasis. To our knowledge, this is the first reported case of its type. High levels of suspicion and prompt diagnosis are required to select appropriate treatment options for patients with neurofibromatosis type 1 experiencing upper gastrointestinal bleeding. Embolization of the involved arteries should be considered an essential treatment over endoscopic hemostasis alone to achieve complete hemostasis and to prevent rebleeding.

A Case of Cavernous Lymphangioma of the Small Bowel Mesentery / 대한소화기학회지

Lymphangioma is a benign vascular lesion with characteristics of subepithelial tumor which can proliferate in the lymphatic system. Lymphangioma of the small-bowel mesentery is rare, having been reported in less than 2% of all lymphangiomas. Lymphangioma does not require any specific treatment because it is absolutely a benign tumor. However, surgical exploration is rarely required for cases with disease-related symptoms or complications, or for those misdiagnosed as a malignant lesion. We recently experienced a case of mesenteric cavernous lymphangomas in a 53-year-old female who was misdiagnosed as having a liposarcoma. The final diagnosis was confirmed by a pathologic examination of the specimen that was obtained via laparoscopic exploration. Herein, we report a very rare case of mesenteric cavernous lymphangioma along with a brief review of relevant literature.

Anaphylactic Shock Caused by Ingestion of Polyethylene Glycol

Colonoscopy is the current standard method for evaluation of the colon. The diagnostic accuracy and therapeutic safety of colonoscopy depend on the quality of colonic cleansing and preparation. Generally, all these preparations have been demonstrated to be safe for use in healthy individuals without significant comorbid conditions. Based on safety and efficacy concerns, polyethylene glycol (PEG) is most commonly utilized as a bowel preparation solution for colonoscopy. Adverse events in patients receiving PEG are mostly clinically non-significant. However, fatal adverse events rarely have been shown to occur in the few individuals who experience vomiting or aspiration. Anaphylactic shock associated with ingestion of PEG electrolyte solution is an extremely rare fatal complication, and reported mainly in Western countries. Here, we report the first case of anaphylactic shock following the ingestion of PEG solution in Korea.

A Patient with Duodenal Mucinous Adenocarcinoma Presenting as a Laterally Spreading Tumor

Primary duodenal carcinoma is rare. Duodenal mucinous adenocarcinoma (DMA) is even rarer, and its associated manifestations and typical endoscopic or imaging findings are not well characterized. Herein, we report a case of primary DMA in an asymptomatic 58-year-old man who visited our hospital for a regular health screening. Upper endoscopy revealed an approximately 4-cm lesion in the second portion of the duodenum, but the mass was not visualized on computed tomography. Biopsies revealed a tubular adenoma that was subsequently resected. Frozen biopsies demonstrated DMA with a background of low-grade tubular adenoma for which we performed Roux-en-Y duodenojejunostomy and jejunojejunostomy. To our knowledge, this is the first report of a patient with DMA in Korea.

Association of Gallbladder Polyp with the Risk of Colorectal Adenoma

BACKGROUND/AIMS: Gallbladder polyps and colorectal adenomas share many common risk factors; however, their association has never been studied. The aim of this study was to investigate this association in asymptomatic healthy subjects. METHODS: Consecutive asymptomatic subjects who underwent both screening colonoscopy and abdominal ultrasonography at Kyung Hee University Hospital in Gang Dong between July 2010 and April 2011 were prospectively enrolled. The prevalence of colorectal adenoma was compared between subjects with or without gallbladder polyps. Furthermore, a logistic regression analysis was performed to determine the independent risk factors for colorectal adenoma in these subjects. RESULTS: Of the 581 participants, 55 presented with gallbladder polyps and 526 did not have gallbladder polyps. Participants with gallbladder polyps showed a trend toward a higher prevalence of colorectal adenoma than those without gallbladder polyps (52.7% vs. 39.2%, P=0.051). Although the result was not statistically significant, gallbladder polyps were found to be a possible risk factor for colorectal adenoma (odds ratio=1.796, 95% confidence interval=0.986-3.269, P=0.055), even after adjusting for potential confounding factors. There was no difference observed in colorectal adenoma characteristics between the two groups. CONCLUSIONS: Our results suggest a possible association between gallbladder polyps and colorectal adenomas. Future studies with larger cohorts are warranted to further investigate this matter.

Clinical Characteristics and Outcomes of Diverticulitis by Physician's Specialty

BACKGROUND/AIMS: Several factors affecting the severity and outcomes of diverticulitis have been reported, but there is little research on physician specialty related with this disease. Therefore, we evaluated the clinical characteristics and outcomes of diverticulitis depending on physician's specialty. METHODS: Medical records of 239 patients, who had been hospitalized with first-diagnosed acute colonic diverticulitis at Kyung Hee University Hospital in Gang Dong (Seoul, Korea) from June 2006 to December 2012, were retrospectively analyzed. The patients were classified according to whether they had been managed by gastroenterologists or not. Clinical characteristics and treatment outcomes were compared between two groups. RESULTS: Of these 239 patients, 38 (15.9%) patients were treated by a gastroenterologist and 201 (84.1%) patients by a non-gastroenterologist. Clinical characteristics such as age, gender, body mass index, comorbidity, medication, laboratory results, recurrence and complication were not significantly different between two groups. However, right-sided diverticulitis predominated in the non-gastroenterologist group (79% vs. 91%, P=0.028). From the sub-group analysis of uncomplicated diverticulitis, intravenous antibiotics was used for a shorter period of time by gastroenterologists than non-gastroenterologists (3.3+/-1.9 days vs. 4.4+/-2.8 days, P=0.032). Multivariate logistic regression analysis showed that the 3 day administration of intravenous antibiotics significantly depended on the physician's specialty (odds ratio 7.984, 95% confidence interval 1.990-32.043, P=0.003). CONCLUSIONS: The results suggest that the duration of intravenous antibiotics for treating uncomplicated colonic diverticulitis was shortened by gastroenterology specialists without increasing operation or recurrence.

Predicting factors of present hepatitis C virus infection among patients positive for the hepatitis C virus antibody

BACKGROUND/AIMS: To identify the predicting factors of present hepatitis C virus (HCV) infection among patients with positivity for antibodies to HCV (anti-HCV). METHODS: We analyzed patients who showed positive enzyme immunoassay (EIA) results and performed an HCV RNA test as a confirmatory test at Kyung Hee University Hospital at Gangdong from June 2006 to July 2012. The features distinguishing the groups with positive and negative HCV RNA results were reviewed. RESULTS: In total, 490 patients were included. The results of the HCV RNA test were positive and negative in 228 and 262 patients, respectively. The index value of anti-HCV, mean age, platelet counts, total bilirubin, prothrombin time international normalized ratio, albumin and alanine transaminase (ALT) levels differed significantly between the two groups. On multivariable analysis, an index value of anti-HCV >10 [odds ratio (OR)=397.27, P40 IU/L (OR=3.64, P=0.001), and albumin <3.8 g/dL (OR=2.66, P=0.014) were related to present HCV infection. CONCLUSIONS: Although EIA is not a quantitative test, considering the anti-HCV titer with ALT and albumin levels may be helpful in predicting present of HCV infection.

The Improvement of Nutritional Support with Percutaneous Endoscopic Gastrostomy

BACKGROUND/AIMS: Percutaneous endoscopic gastrostomy (PEG) is the most common method of enteral nutrition for patients who require long term artificial nutrition. PEG has been used as a method of nutritional support; however, improvement of nutritional support via PEG has not yet been reported. In this study, we analyzed the efficacy of nutritional support via PEG. METHODS: We conducted a retrospective analysis of 196 consecutive patients who underwent PEG at Kyung Hee University Hospital in Gang Dong from 2006 to 2012. We analyzed clinical characteristics, the method of nutritional support, and the proportion of intake to establish recommendations for nutritional requirements and the duration needed to reach the level of appropriate nutrition. RESULTS: A total of 196 patients included 130 men and 66 women, and their mean age (standard deviation) was 69.1+/-14.0 years. Compared with caloric and protein supplementation before PEG, 113 kcal (13.8% of baseline) and 4.8 g of protein (17.5% of baseline) could be additionally supplied with PEG (P=0.001, respectively). The number of patients who could take more than 90% of the recommended requirements of caloric and protein supplementation after PEG showed increased caloric and protein intake by 25.4% and 20.2%, respectively, in comparison with those before PEG (P=0.001 and P=0.001, respectively). The mean duration of catch-up for more than 90% of the recommended caloric and protein intake was approximately 11 days. Procedure related complications and early mortality were reported in 8.1% and 0% of patients, respectively. CONCLUSIONS: PEG is an effective and safe nutritional support method for patients who require long term artificial nutrition.

Preoperative Carbohydrate Antigen 19-9 Levels Can Predict Stage and Survival Rate in Patients with Colorectal Cancer

BACKGROUND/AIMS: The purpose of this study was to determine whether preoperative carbohydrate antigen 19-9 (CA 19-9) levels can predict the stage of diseases or survival rate in patients with resectable colorectal cancer (CRC). METHODS: A total of 247 patients who underwent curative resections at Kyung Hee University Hospital at Gangdong between 2006 and 2011 were enrolled. We investigated the correlations of preoperative serum levels of CA19-9 with clinicopathological features of CRC. Receiver operative curve was constructed for evaluating the efficiency of the serum CA 19-9 levels in the stratifying stage of CRC. Survival analysis was performed with Kaplan-Meire method and log-rank test. Cox regression analysis was used for the multivariate analysis for survival. RESULTS: Abnormal level of serum CA 19-9 (>37 IU/mL) were associated with advanced T stage (P60 U/mL was an independent predictor of survival rate in the patients with TNM stage III CRC.

Gastric tuberculosis presenting with a huge abdominal mass

Tuberculosis of the stomach is extremely rare. We report the case of a 38-year-old woman who presented with epigastric discomfort and a palpable mass that persisted for a period of one month. We also report our findings from the abdominal computed tomographic, upper endoscopic and endoscopic ultrasonographic examinations of the patient. Abdominal computed tomography (CT) showed the presence of a large mass with an irregularly contoured low attenuation lesion. Upper endoscopy and endoscopic ultrasonography revealed a protruding ulcerative mass with an ill-defined heteroechoic subepithelial lesion originating from the gastric submucosal layer. This was previously misdiagnosed as a gastrointestinal stromal tumour. Endoscopic biopsy specimen was positive on acid-fast bacillus staining, and polymerase chain reaction for Mycobacterium tuberculosis was also positive. Abdominal CT and endoscopy at the patient's three-month follow-up showed near complete resolution of the lesion.

Clinicopathological Characteristics of Colorectal Cancer according to Gender Difference

BACKGROUND/AIMS: Colorectal cancer (CRC) has been one of the major causes of death and has become a major public health concern. The incidence of CRC has been increasing regardless of gender in Korea. Until now, however, the studies on gender-based clinicopathological characteristics of CRC focused on pathology have never been reported. Therefore, we aimed to evaluate the difference in clinicopathological characteristics of CRC according to gender in Korea. METHODS: Medical records of 342 patients with advanced CRC who underwent surgical resection at Kyung Hee University Hospital at Gangdong from June 2006 to December 2011 were retrospectively analyzed. The data of the clinicopathological characteristics of CRC by gender difference were compared. RESULTS: Of these 341 patients, 203 (60%) patients were male and 138 (40%) patients were female. The male preponderance was noted in all age groups for total CRC and left-sided CRC. However, for right-sided colon cancer, this male preponderance was significantly decreased with increasing age groups (P=0.025) and was finally reversed in elderly groups (age > or =60 years). The microsatellite instability represented by negative staining for hMLH1 and hMSH2 was more frequently detected in women than men (P=0.037). CONCLUSIONS: The male preponderance in right-sided colon cancer decreased with increasing age groups and finally reversed in age groups more than 60 years. Microsatellite instability with immunohistochemical staining was more frequently detected in women. However, further studies with a large number of patients are warranted on this issue.

The Box Simulator Is Useful for Training Novice Endoscopists in Basic Endoscopic Techniques

PURPOSE: The present study was aimed at evaluating the usefulness of box simulators for training novice endoscopists. MATERIALS AND METHODS: An explanation of the goals, contents, and features of the simulator was given to study participants. The participants then received "hands-on training" in gastrointestinal endoscopy techniques using a box simulator. Subsequently, they were asked to answer 19 structured questions about the simulator. Ratings were scored on a scale from 1 to 5 for questions concerning their first impression of the simulator. Questions on the usefulness of the simulator and the training course were answered as "agree", "disagree", or "no opinion". RESULTS: A total of 32 participants filled out the questionnaire. The mean scores on the simulator's usefulness, features, and realistic movements before the training were between 1.5 and 2.0. There were no significant differences between the mean values of the scores given by novice users compared to non-novice users. However, after receiving training on the simulator, 90.6% of the participants considered the box simulator a generally useful tool for learning basic endoscopic techniques, and 90.6% agreed that the simulator was useful for improving hand-eye coordination. CONCLUSION: Box simulators may be useful for training novice endoscopists in basic gastrointestinal endoscopic techniques.

Obstructive Jaundice Caused by Clonorchiasis-associated Duodenal Papillitis: A Case Report

We describe an unusual presentation of Clonorchis sinensis infection with obstructive jaundice due to duodenal papillitis which was relieved dramatically by endoscopic sphincterotomy. A 26-yr-old male presented with complaints of fatigue, weight loss and painless jaundice. The history was significant for frequent ingestion of raw freshwater fish. The patient underwent endoscopic retrograde cholangiopancreatography for evaluation of obstructive jaundice. The duodenal papilla was markedly edematous with a bulging configuration and hyperemic changes at the orifice. Cholangiography revealed mild bile duct dilatation and irregular wall changes with multiple indentations. However, there were no biliary stricture or stones noted as the cause of obstructive jaundice. We performed an endoscopic sphincterotomy for effective bile drainage through the duodenal papilla. After the sphincterotomy, the patient's jaundice was dramatically improved. Pathology of the duodenal papilla showed eosinophilic infiltration of the mucosa. Parasitic eggs, consistent with the diagnosis of C. sinensis, were found in the bile sample.

Cytomegalovirus Colitis Causing Cecal Perforation and Massive Lower Gastrointestinal Bleeding / 대한소화기내시경학회지

Cytomegalovirus (CMV) infection is associated with significant morbidity and mortality in immunocompromised patients. It may cause serious illness including bleeding, ulceration and perforation of the gastrointestinal tract. However, bowel perforation, toxic megacolon, and massive lower gastrointestinal bleeding caused by CMV in one patient is not common. In this report, we present a case of CMV colitis causing cecal perforation and massive lower gastrointestinal bleeding in a patient with lupus nephritis. In our case, severe lower gastrointestinal bleeding developed during successful treatment of CMV infection with ganciclovir. Even though the outcome of CMV colitis has improved since ganciclovir has been available for immunocompromised patients, reductions in gastrointestinal bleeding from colonic ulcers of CMV colitis may be possible during successful treatment with ganciclovir. This case suggests the possibility of lower gastrointestinal bleeding from a colon ulcer of CMV colitis should be considered during successful treatment with ganciclovir in immunocompromised patients.

A Case of Early-stage Squamous Cell Carcinoma of the Anal Canal Diagnosed by Endoscopic Mucosal Resection / 대한소화기내시경학회지

In the past, abdominoperineal resection was routinely performed for anal canal cancer, yet it is now known that squamous cell carcinoma of the anal canal has a favorable prognosis and it rarely requires radical surgery. Furthermore, T1 anal cancer, which represents about 10% of all anal canal cancers, has an excellent prognosis. Endoscopic mucosal resection (EMR), which has been used for removal of early-stage adenocarcinoma of the rectum, has not been reported as a treatment option for squamous cell carcinoma of the anal canal because making the endoscopic diagnosis of early-stage anal canal cancer is very difficult. We have experienced a case of early-stage squamous cell carcinoma of the anal canal that was identified without symptoms during routine screening colonoscopy and it was removed by EMR. As far as we know, it is the first case of early-stage anal canal cancer that was diagnosed and treated by endoscopic mucosal resection.

The Significance of Fecal Immunochemical Test to Screen for Colorectal Cancer in National Cancer Screening Program

BACKGROUND/AIMS: Colorectal cancer (CRC) is one of the major causes of death and poses a major public health concern. The National CRC Screening Programme (NCSP) provides annual CRC screening using a fecal occult blood test for individuals >50 years of age since 2004. The purpose of the current study was to determine the outcomes and efficacy of a fecal immunochemical test (FIT) based on the NCSP in a quality-controlled university hospital setting. METHODS: We retrospectively reviewed the medical records and a standardized questionnaire from the NCSP of 3,852 individuals who underwent a FIT between March and December 2009. All of the subjects submitted a stool specimen for a FIT, while a double-contrast barium enema or colonoscopy was performed as a confirmatory examination for FIT-positive individuals. The CRC screening rate and rate of detection colorectal adenomas, advanced adenomas, and colorectal cancers by FIT were evaluated. RESULTS: The CRC screening rate with FIT was very high (72.3%), but the positive rate of detection by FIT was only 1.3%. The rate of detection for colorectal cancers, adenomas, and advanced adenomas by FIT was 0.08%, 0.39%, and 0.13%, respectively. The quantitative values of FIT in individuals with colorectal adenomas and cancers were significantly higher than other colorectal diseases. Men (P=0.001) and elderly individuals (P=0.039) were significantly more common in the FIT-positive group than the FIT-negative group. Approximately 28% of the subjects with FIT-positive tests did not receive a confirmatory examination. CONCLUSIONS: Although the FIT had a low rate of detection, the FIT was a useful screening tool for detection of CRC in the NCSP. It will be important to increase CRC screening rates and confirmatory examination rates.