Posterior Epidural Migration of a Lumbar Intervertebral Disc Fragment Resembling a Spinal Tumor: A Case Report

Posterior epidural migration of a lumbar intervertebral disc fragment (PEMLIF) is uncommon because of anatomical barriers. It is difficult to diagnose PEMLIF definitively because of its relatively rare incidence and the ambiguity of radiological findings resembling spinal tumors. This case report describes a 76-year-old man with sudden-onset weakness and pain in both legs. Electromyography revealed bilateral lumbosacral polyradiculopathy with a mass-like lesion in L2-3 dorsal epidural space on lumbosacral magnetic resonance imaging (MRI). The lesion showed peripheral rim enhancement on T1-weighted MRI with gadolinium administration. The patient underwent decompressive L2-3 central laminectomy, to remove the mass-like lesion. The excised lesion was confirmed as an intervertebral disc. The possibility of PEMLIF should be considered when rim enhancement is observed in the epidural space on MRI scans and electrodiagnostic features of polyradiculopathy with sudden symptoms of cauda equina syndrome.

Efficacy of Niti-S ComVi Stents for Palliation of Malignant Gastrointestinal Obstruction / 대한소화기내시경학회지

BACKGROUND/AIMS: Niti-S ComVi stents are flexible and retain the shape-memory of the original configuration. ComVi stents are effective in preventing tumor ingrowth because polytetrafluoroethylene is inserted between two stent wires. The aim of this study was to examine the efficacy of Niti-S ComVi stents for the palliation of a malignant gastrointestinal obstruction. METHODS: Between April 2004 and April 2006, 17 patients (20 cases) underwent Niti-S ComVi stenting, using a through-the- scope method. The technical and clinical success, complication, and outcome were analyzed. RESULTS: Stent insertion was technically successful in 18 cases (90%). Malposition to the afferent loop occurred in 2 cases. Symptomatic improvement was achieved in 14 cases (70%). The mean gastric outlet obstruction score was 0.2 before stenting and 1.6 after stenting. The complications encountered were stent migration (2 cases) and obstruction (5 cases), which were treated by re-stenting and balloon dilatation. Twelve patients died with a median survival of 67 days. Five patients were still alive with a median follow up of 151 days. The overall median stent patency time was 60 days. The mean waist diameter of the stents was expanded to 57% of full expansion immediately after deployment, and 77% after 36 hours. CONCLUSIONS: Niti-S ComVi stenting is an effective palliative technique for inoperable or postoperative recurrent tumors, and significantly improves the quality of life.

A Case Report of X-linked Recessive Bulbospinal Muscular Atrophy (Kennedy`s Syndrome)

We had 58-year-old-man with chronic lower back pain, progressive whole extremities and facial muscle weakness, dysarthria and recurrent aspiration during swallowing, without any sensory disturbance. His two brothers had similar symptoms from their 6th decade. He had muscle atrophy on tongue, both hand lower leg muscles with some fasciculations. All tendon reflexes were absent without pathologic pyramidal reflex. Nerve conduction studies revealed low median, ulnar, and sural sensory nerve action potential amplitude. On EMG study, there were chronic denervation potentials on most of muscles of extremities. On DNA analysis, there were abnormal expansions of CAG repeats in the androgen receptor gene. We confirmed a X-linked recessive bulbospinal muscular atrophy (Kennedy's syndrome).

Cyclo-oxygenase-2 and p53 Immunoreactivity in Superficial Early Colorectal Carcinoma / 대한소화기학회지

BACKGROUND/AIMS: De novo colorectal carcinoma shows more aggressive behavior including submucosal invasiveness. Both p53 and cyclo-oxygenase-2 (COX-2) have been shown to be involved in colon carcinogenesis, progression from adenoma to carcinoma, and submucosal invasion by tumor. We performed this study to evaluate the expression of p53 and COX-2 protein in de novo carcinoma, compared with ex-adenoma carcinoma. METHODS: Twenty three flat adenomas, 19 ex-adenoma carcinomas, 6 de novo carcinomas were included in this study. The expression of p53, COX-2 and Ki-67 were examined immunohistochemically. RESULTS: Both ex- adenoma carcinomas and de novo carcinomas showed similar size and shape. Positive staining for p53 was detected in 3 of 23 (13%) flat adenomas, in 11 of 19 (57.8%) ex-adenoma carcinomas (p<0.05), and in 1 of 6 (16.6%) de novo carcinomas. Increased numbers of COX-2 positive tumor cells were observed in 1 of 23 (4.3%) flat adenomas, in 2 of 19 (10.5%) ex-adenoma carcinomas, and in 3 of 6 (50%) de novo carcinomas. COX-2 positive expression showed increased tendency in de novo carcinoma (p=0.073). There was no correlation between COX-2, p53, and Ki-67 expression. CONCLUSION: De novo carcinoma shows increased tendency of COX-2 expression, but decreased p53 expression when compared to ex-adenoma carcinoma. These immunohistochemical findings are in accordance with the fact that de novo carcinoma has no preceding adenoma, with more frequent submucosal invasion despite the small lesion size.

Effectiveness of Through-the-scope Self-expandable Metal Stent in Malignant Upper Gastrointestinal Obstruction / 대한소화기내시경학회지

BACKGROUND/AIMS: Self-expandable metal stents (SEMS) have been used in the palliation of malignant obstruction. The purpose of this study was to evaluate the effectiveness, safety, and outcome of SEMS using through-the-scope (TTS) method in the patients with malignant upper gastrointestinal obstruction including recurrent gastric cancer after gastrectomy. METHODS: Thirty one patients (36 stents) were treated with SEMS between October 2000 and June 2004; nineteen had inoperable malignant gastric outlet obstruction, ten had recurrent gastric cancer after gastrectomy, and two had metastatic duodenal cancer. We analyzed the technical and clinical success, complication, and outcome. RESULTS: The technical success rate was 88.8% (32/36 stents) in total cases; 95.0% (19/20) in malignant gastric outlet obstruction, 84.6% (11/13) in recurrent gastric cancer after gastrectomy, and 66.7% (2/3) in metastatic duodenal cancer. The success rate of dietary intake was 86.1% (31/36 stents). Complications occurred in 7 of 36 stents (19.4%), including stent migration (1 patient), aspiration pneumonia (1 patient), and recurrent obstruction (5 patients). The mean survival duration period was 118.1+/-180.2 days and mean patency period was 92.2+/-89.9 days. CONCLUSIONS: SEMS using TTS is an effective, safe, and less invasive palliative treatment in malignant upper gastrointestinal obstruction including recurrent gastric cancer after surgery.

A Case of Endoscopic Polypectomy Using a Hand-Made Detachable Snare Made of Nylon Fishing Line / 대한소화기내시경학회지

Hemorrhage is the most common complication of polypectomy. Though most bleeding stops spontaneously and can be managed with conservative therapies, some may necessitate intensive therapies. The detachable snare was firstly introduced in 1986. It has been reported that the use of detachable snare can effectively prevent both immediate and delayed bleeding. The detachable snare has been reformed, and now a commercial article is used in practice. But, it is expensive and cannot be used in larger polyps measuring over its fixed size of loop. A hand-made detachable snare made of nylon fishing line was introduced to prevent postpolypectomy bleeding in 2003. We have further improved it and experienced a case of successful removal of a large colonic polyp using our hand-made snare. The hand-made detachable snare is inexpensive and seems to be practical in ligating the polyp regardless of its size.

Solitary Intra-abdominal Tuberculous Lymphadenopathy Mimicking Duodenal GIST

Tuberculosis remains prevalent in developing countries and has recently re-emerged in the Western world. Intra-abdominal tuberculosis can mimic a variety of other abdominal disorders, and here we describe a patient with solitary tuberculous mesenteric lymphadenopathy mimicking duodenal gastrointestinal stromal tumor (GIST). A 22-year-old woman complained of epigastric discomfort and was presumed to have a duodenal GIST after an endoscopic examination and abdominal CT scan. However, exploratory laparotomy revealed an enlarged node penetrating the duodenal bulb, which was diagnosed histopathologically as tuberculous lymphadenitis. This case suggests that in regions with a high prevalence of tuberculosis, intra-abdominal tuberculosis is often mistaken as a malignant neoplasm. A high index of suspicion and the accurate nonsurgical diagnosis of intra-abdominal tuberculosis continues to be a challenge.

Treatment of Rectal Stricture with Crohn's Disease Using Local Steroid Injection Following Dilation by Bougienation / 대한소화기내시경학회지

Crohn's disease has shown increased frequency in Korea. When unresponsive to medical therapy, intestinal stricture, a serious complication of Crohn's disease, sometimes requires surgical resection. However, surgical therapy has many problems because the stricture tend to recur frequently. Recently, endoscopic therapy such as bougienation or balloon dilatation has been used in treatment of intestinal stricture, because of its inexpensiveness, simplicity and safety. Combined steroid injection therapy using has shown more effective outcome than endoscopic dilatation alone by suppression of wound healing and reduction of fibrosis. We report a case of complicated rectal stricture in a patient with Crohn's disease, which dilated successfully using injection of triamcinolone following bougienation.

The Study of Endoscopic Mucosal Resection on Gastric Adenoma and Early Gastric Cancer: The Factors Affecting Complete Resection Rate of EMR and Histological Discrepancy between the Endoscopic Biopsy and the Resected Specimen / 대한소화기내시경학회지

BACKGROUND/AIMS: Endoscopic mucosal resection (EMR) has been known as a method of local treatment for early gastric cancer (EGC) or gastric adenoma. The purpose of this study was to identify the factors affecting complete resection rate (CRR) of EMR and to identify histological discrepancy between endoscopic biopsy and the resected specimen obtained by EMR. METHODS: Forty four gastric adenomas and twenty seven EGCs in 63 patients were treated by EMR from January, 1999 until August, 2002. We analysed the factors affecting CRR on the basis of location, macroscopic type, size, piecemeal resection, and EMR methods. RESULTS: The CRR in antrum was 72%. The CRR of the method using endoscopic resection with hypertonic saline-epinephrine solution, injection, precutting and snaring (ER-HSE) was 78%. The CRR according to en bloc resection was 77%. Sixty six percents of histological coincidence was noted between the endoscopic biopsy and the resected specimen of gastric adenoma. CONCLUSIONS: In this study, the CRR of the ER-HSE method and the lesion located in antrum is higher than that other groups. Gastric adenoma should be removed by EMR because of histologic discrepancy between the endoscopic biopsy and the resected specimen.

A Case of Tuberculosis Affecting Stomach and Duodenum Simultaneously, Mimicking Malignant Tumor / 대한소화기내시경학회지

Gastrointestinal tuberculosis has steadily decreased with the development of anti-tuberculous treatment, improvement of personal hygiene resulting from a rise in the standard of living, early diagnosis of pulmonary tuberculosis, and so forth. However, gastrointestinal tuberculosis can occasionally be found clinically in South Korea where the prevalence of tuberculosis is as much as 2.2%. Prevalence of gastric tuberculosis is low, compared with other gastrointestinal tuberculosis. While there have recently been several reports on the occurrence of gastric tuberculosis and duodenal tuberculosis assuming the form of malignancy, few cases have been reported of the tuberculosis affecting stomach and duodenum simultaneously. In this article we report the case in which tuberculosis affects both stomach and duodenum, which was initially misconceived as a double primary cancer.

A Case of Reactivated Tuberculous Colitis After 9 Months of Anti-tuberculous Therapy / 대한소화기학회지

Tuberculous colitis, an important extra-pulmonary tuberculosis, is still prevalent in the developing countries and has been resurging in the Western world. The duration and dose of anti-tuberculous therapy have not yet been clarified in the tuberculous colitis. We experienced a case of tuberculous colitis, which relapsed after 9 months of therapy. A 28-year-old man presented with hematochezia and was diagnosed as tuberculous colitis on the basis of colonoscopic findings. He was treated with anti-tuberculous agents for 9 months successfully. Three months later, however, he complained of hematochezia again, suggesting the relapse of tuberculous colitis. He had taken anti-tuberculous therapy for another 15 months and showed no evidence of relapse. Although anti-tuberculous therapy is efficient for tuberculous colitis, rare cases of reactivation should be reminded.

Cardiac tamponade complicated by chronic recurrent pancreatitis / 대한내과학회지

Chronic pancreatitis causes a variety of complications such as glucose intolerance, pancreatic pseudocyst and duodenal obstruction. However pericardial effusion is very rarely complicated with chronic pancreatitis and life-threatening. The hypothesis of the development of pleuropericardial effusion in chronic pancreatitis has been variously proposed; fistula formation through esophageal or aortic hiatus, local transfer of pancreatic enzyme. Recently, we experienced a case of pleuropericardial effusion complicated by chronic recurrent pancreatitis causing cardiac tamponade. There was a contrast leakage appearing from the pancreatic duct to the mediastinum in endoscopic retrograde pancreaticography. The transpapillary pancreatic stent insertion led to the disappearance of pleuropericardial effusion on the radiography. We report this unusual manifestation of chronic recurrent pancreatitis with the review of literature.

The Experimental Study of Physiological Change in the Submucosal Layers after the Saline Injection / 대한소화기내시경학회지

BACKGROUND/AIMS: In EMR, submucosal saline injection is used in order to prevent perforation and hemorrhage, but it is not well known on the physiological change of submucosal layer by injected saline. This study was undertaken to assess experimentally the physiological change of submucosal layer after the saline injection on mongrel's surgical specimens. METHODS: Twenty one fresh specimens were obtained from esophagus, stomach and colon for 3 mongrels' experiments. Saline was injected from 1 mL to 20 mL into submucosa of all specimens on which target areas were made by electrocautery markings. By gross morphology of the elevated area and endoscopic sonographic image and by histological features on submucosa of each specimen, mucosal extension was measured after saline injection. RESULTS: The height of blebs and minimal diameters of target areas made increased up to a fixed dose, but did not increased after that. However, the maximal and minimal diameters of elevated areas and the difference between these diameters increased proportional to the volume of injected saline. Moreover, retained salines were interspersed evenly among the connective tissues in submucosa despite of the increasing dose of injected saline. CONCLUSION: Morphological change in submucosa is not changed proportional to the volume of injected saline.

Safe Endoscopic Removal of a Sharp Foreign Body Using Latex Glove / 대한소화기내시경학회지

Most of swallowed foreign bodies pass spontaneously. However, sharp objects are usually lodged in the proximal esophagus and cause aspiration, bleeding, obstruction, and perforation. Therefore, prompt retrieval of lodged foreign bodies are necessary. The safe extraction of sharp foreign bodies using endoscopic technique is difficult because sharp objects carry a significant risk of mucosal injury and perforation. Endoscopic techniques for retrieval of foreign body include methods using protector hood and overtube. The former is not available, the later is uncomfortable and its diameter is the limiting factor. Method using a latex glove is available, comfortable, and its diameter is not limited. The thickness of the glove is thinner than protector hood, but we think that a latex glove would seem to be a effective alternative. We report a case in which a sharp foreign body was endoscopically removed using a latex glove without complication.

A Case of Diverticulitis of Sigmoid Colon Mimicking Carcinoma / 대한소화기내시경학회지

Diverticular disease of the colon in Korea is different from developed Western countries. Diverticulosis leads to the complications in about 20% of cases. The diverticulitis of the right colon is difficult to be differentiated from acute appendicitis. According as increase of elderly populations, incidence of the diverticulitis of the left colon increase. Therefore we should be differenciated from other diseases. In very rare case, frequent recurrence and recovery of the diverticulitis leads to a chronic state with complications such perforation, microabscess, fistula, adhesion and fibrous hypertrophy. These findings may be misdiagnosed as malignancy because of protruding mass and stricture on colonoscopy. We present a case of an pseudotumor that looks like a malignancy in the sigmoid on colonoscopy. After surgical resection, the lesion turned out to be a complicated diverticulitis.

Electron microscopic study of adhesion between Helicobacter pylori and gastric epithelial cell / 대한내과학회지

BACKGROUND: The purpose of this study was to investigate the ultrastructural relation of H. pylori and gastric epithelial cells in their adhesion. METHODS: Endoscopic biopsy of gastric antrum and body was performed from 15 patients (9 men, 6 women) with chronic gastritis. These specimens were processed and observed by transmission electron microscope (Hitachi H-600). RESULTS: On the basis of morphological appearances, the different types of adhesion of the organism with the epithelial cells were categorized as filamentous connection, adhesion pedestals, membrane fusion. Coccoid and intermediate forms were associated with filamentous connection whereas bacillary forms were associated with adhesion pedestals and membrane fusion. CONCLUSION: Various types of adhesion were associated with H. pylori and gastric epithelium. Further studies are needed to investigate biophysiologic influence to epithelial cells by ultrastructural relationship.(Korean J Med 60:16-21, 2001)

Endoscopic Band Ligation for Non-variceal, Non-ulcer Gastrointestinal Hemorrhage and Post-polypectomy Hemorrhage / 대한소화기내시경학회지

BACKGROUND/AIMS: There is no consensus as to the best treatment for non-variceal, non-ulcer gastrointestinal hemorrhage. Endoscopic band ligation is an inexpensive, readily available, and easily learned technique in contrast to conventional thermal methods of endoscopic hemostasis. The purpose of this study is to define the effectiveness of endoscopic band ligation for non-variceal, non-ulcer gastrointestinal hemorrhage and post-polypectomy hemorrhage. METHODS: Twenty eight patients were treated by band ligation between July 1996 and October 2000. The lesions treated were: Dieulafoy's lesion in 13, Mallory-Weiss tear in 7, angiodysplasia in 1, post-polypectomy bleeding in 4, post-endoscopic mucosal resection bleeding in 2, post-endoscopic biopsy bleeding in 1. RESULTS: Endoscopic band ligation was successful in 25 of 28 cases. Additional sclerotherapy was necessary in two cases of Dieulafoy's lesion. The remaining case was early band detachment. CONCLUSIONS: Endoscopic band ligation is effective for non-variceal, non-ulcer bleeding. It has the advantage of ease of use and is relatively inexpensive.

Usefulness of laparoscope for the staging of advanced gastric cancer without distant metastasis in abdominal CT and EUS / 대한내과학회지

BACKGROUND: The proper staging of advanced gastric cancer has crucial role in determining resectability and operative method, to prevent unnecessary operation and to predict the prognosis and survival rate. Although marked improvements have been made in computed tomography (CT) technology and endoscopic ultrasonography (EUS) in recent years, reassessment of the laparoscopy for gastric cancer is required as a preoperative staging tool. Therefore, we determined the usefulness of laparoscopy for staging of advanced gastric cancer without distant metastasis in CT and EUS. METHODS: Staging laparoscopy was performed in 48 patients with advanced gastric cancer staged T3 or T4 by CT and EUS. Laparoscopy was carried out with the patients under local anesthesia, and included visual inspection of abdomen, and biopsies for suspicious metastatic lesions. Laparoscopic results were compared with the postoperative pathologic findings. RESULTS: Laparoscopy was performed successfully in 48 patients. Laparoscopy disclosed unrecognized distant metastases in 7 patients (14.6%) judged to be eligible for potentially curative resection by CT and EUS. Preoperative laparoscopy showed an accuracy of 74% for serosal infiltration. CONCLUSION: Our results suggest that laparoscopy is an effective means of evaluating resectability of advanced gastric cancer staged T3 or T4 and can provide valuable help in planning surgical approach.

The diagnostic value of serum and fecal pancreatic elastase-1 in patients with pancreatic disease / 대한내과학회지

BACKGROUND: The aims of this study were to evaluate the diagnostic value of pancreatic elastase-1(PE-1) in patients with pancreatic diseases and compare the significance of PE-1 with that of pancreatic exocrine function test by pure pancreatic juice (PPJ) collection. METHODS: For evaluation of PE-1, seventy nine patients with pancreatic diseases were examined. For evaluation of exocrine pancreatic function by PPJ, twenty three patients with Chronic pancreatitis(CP) were examined. PPJ was collected by endoscopic cannulation of main pancreatic duct under the intravenous bolus injection of secretin (0.25 CU/kg body weight) and cholecystokinin (CCK, 40 ng/kg body weight). RESULTS: Pancreatic exocrine functions were significantly decreased in patients with CP showing moderate and severe ductal changes on pancreatogram. The mean concentration of fecal PE-1 was significantly decreased in patients with CP and pancreatic cancer, but not in patients with acute pancreatitis. When we analyzed the PE-1 concentration according to Cambridge classification, the concentration of fecal PE-1 was significantly decreased only in patients with moderate and severe CP. With a cut off of 200 ug fecal PE-1/g, the sensitivity of PE-1 was 25%, 60%, and 100%, respectively, for mild, moderate and severe CP, and the specificity was 88.1%. The mean concentration of serum PE-1 was increased both in patients with acute and chronic pancreatitis, but there was no difference between both group. CONCLUSION: Fecal PE-1 is useful for diagnosis of pancreatic exocrine insufficiency in patients with CP, especially in moderate and severe grade of pancreatic exocrine insufficiency. The diagnostic value of fecal PE-1 was also similar to secretin-CCK test in pancreatic exocrine insufficiency.

Changes of Esophageal Motor Function Depending on the Different Types of the Bolus / 대한소화관운동학회지

BACKGROUND/AIMS: It is suggested that diffuse esophageal spasm (DES), nutcracker esophagus (NUT), and hypertensive lower esophageal sphincter (HLES) could be re-classified together as a spastic esophageal motility disorder of similar clinical backgrounds. However, there were no studies to evaluate the pathophysiological characteristics of these motor abnormalities. The aim of the study was to evaluate the changes of esophageal motor function depending on the different types of the bolus (water vs semi-solid bolus). METHODS: Twenty-one healthy subjects and 42 subjects with primary esophageal motility disorders (4 DES, 12 NUT, 5 HLES, 12 nonspecific esophageal motility disorders, 9 normal) underwent a perfusion manometry with a low compliance pneumo-hydraulic capillary infusion system. Consecutively, each patient had 10 swallows of water and 10 swallows of Jello, 5 ml each. RESULTS: In the healthy controls, the Jello swallow showed an increased amplitude and duration of distal esophageal contractions, and the velocity of peristalsis was decreased (p < 0.05). Among all patients diagnosed by manometry with the water swallow, 2 cases diagnosed with HLES (40%) and 4 with NUT (33%) were changed to a diagnoses of DES after the Jello swallow. Moreover, HLES was found in 1 patient with DES (25%) and in 6 patients with NUT (50%). CONCLUSIONS: Semi-solid bolus swallows increase the contractile force of the esophagus more than water swallows. A conventional manometric diagnosis could be changed to a different spastic motility disorder of the esophagus after a semi-solid bolus swallow. It is suggested that DES, NUT, and HLES can be considered as a spectrum of spastic esophageal motility disorders sharing a similar pathophysiology.