Drug-Induced Liver Injury: Twenty Five Cases of Acute Hepatitis Following Ingestion of Polygonum multiflorum Thunb

BACKGROUND/AIMS: Complementary medicines, including herbal preparations and nutritional supplements, are widely used without prescriptions. As a result, there has been growing interest in the risk of hepatotoxicity with these agents. It is difficult to determine causal relationships between these herbal preparations and hepatotoxicity. We report on 25 patients diagnosed with toxic hepatitis following ingestion of Polygonum multiflorum Thunb. METHODS: Twenty-five patients (median age, 48 years [24 to 65 years]; M:F=18:7) with suspected P. multiflorum Thunb-induced liver injury were admitted to our hospital between 2007 and 2009. We analyzed clinical and histological data, including the types and the duration of P. multiflorum Thunb intake and the duration of hospital care. We also determined the type of liver injury using the R ratio (serum activity of ALT/serum activity of ALP). RESULTS: The types of complementary medicine used included tea (n=16), liquor (n=5), tea and liquor (n=2), powder (n=1), and honeyed pudding (n=1). The most common presenting sign was jaundice (76%), and 18 patients (72%) had evidence of hepatocellular liver injury. Histological findings were consistent with acute hepatitis in all cases (n=10) for which liver biopsy was performed. Twenty-three patients (91.6%) recovered with conservative management, 1 patient (4%) had a liver transplant, and 1 patient (4%) died of hepatic failure. CONCLUSIONS: In our cases, we found that P. multiflorum Thunb could be hepatotoxic and could lead to severe drug-induced liver injury, and even death.

Successful Endoscopic Papillary Balloon Dilatation for a Patient with Recurrent Sump Syndrome / 대한소화기내시경학회지

Sump syndrome is a rare late complication of choledochoenteric anastomosis, and this caused by the accumulation of food debris, choledocholithiasis, bile sludge and cholesterol crystals in the distal common bile duct. This syndrome is characterized by symptoms such as abdominal pain and fever. The treatment modality for this syndrome has been surgery in the past. However, endoscopic treatment such as endoscopic sphinterotomy is currently regarded as the primary therapeutic approach for this condition. We experienced a patient with a history of choledochoduodenostomy and who developed sump syndrome as a complication of the surgery. Endoscopic sphinterotomy was performed for treatment, but this only produced the recurrence of the disease. The recurrent sump syndrome was eventually successfully controlled by performing endoscopic papillary balloon dilatation.

True splenic cyst producing high levels of cystic fluid CA 19-9 and CEA: A case report / 대한내과학회지

True non-parasitic splenic cysts are rare. Series have reported over 30 cases of true splenic cysts producing elevated serum CA 19-9 levels. A 27-year-old woman presented with a painless mass in her left upper abdomen. Computed tomography (CT) of the abdomen showed a 16-cm cyst in the spleen. The serum CA 19-9 and CEA levels were 432 U/mL and 1.67 ng/mL, respectively. The cystic fluid CA 19-9 and CEA levels were markedly elevated. A splenectomy was performed. The pathology showed a benign true epidermoid cyst, which was negative for CEA. The serum CA 19-9 level returned to normal after removing the splenic cyst. This is the first reported case of a true benign splenic cyst producing high levels of CA 19-9 and CEA in Korea.

Endodontic file in an appendix / 대한내과학회지

Once ingested foreign bodies pass through the stomach, 80 to 90 percent of them will exit via the gastrointestinal tract and they are excreted naturally in 7-10 days; surgical treatment is not required in most case. But once foreign bodies permeate the appendix, it is difficult for them to be excreted again to the cecum; therefore, this can possibly cause appendicitis or perforation. Especially in case of long, pointed, thin, stiff, sharp and/or metalic objects, the risk of perforation will increase. We attempted to remove an endodontic file in the appendix by colonoscopy. This was done in a patient who came to hospital because he swallowed an endodontic file during endodontic therapy. But we failed to retrieve it, and so we got rid of the foreign body by performing elective surgery before the occurrence of complications. We report here on surgical removal of an apppendiceal foreign body along with a review of the literature.

A Case of Gastric Suture Granuloma Suspected of Malignant Submucosal Tumor / 대한소화기내시경학회지

A gastric suture granuloma is an uncommon postsurgical complication. When nonabsorbable sutures are used, the inflammation can persist months after the original procedure with the subsequent formation of an abscess around the sutures surrounded by granulation tissue. Suture granulomas are usually asymptomatic, and have clinical importance as a differential diagnosis of a gastric submucosal tumor. The incidence of suture granuloma is low using absorbable sutures in gastrointestinal anastomosis. We report a case of a 70 year old man diagnosed with a suture granuloma. Approximately 30 years earlier, he underwent primary closure due to gastric ulcer perforation. When a gastroscopy was performed to assess upper abdominal soreness, it revealed a submucosal tumor that indicated a malignancy, which was diagnosed as a suture granuloma after surgery.

Upper Gastrointestinal Bleeding due to Direct Invasion of Hepatocellular Carcinoma to the Duodenum / 대한소화기내시경학회지

Although a metastasis to the gastrointestinal tract (GI) is rare in patients with hepatocellular carcinoma (HCC), it can occur by hematogenous or lymphatic spread, or by direct invasion of a tumor. A 61-year old woman who had a progressing large primary liver cancer presented with upper gastrointestinal (UGI) bleeding. UGI endoscopy showed a large duodenal submucosal tumor-like mass with a central ulcer and adherent blood clots. Endoscopic biopsy and coagulation using argon plasma probe were performed. The microscopic examination revealed a HCC. We report this unusual case of HCC with direct invasion of the duodenum.

A Case of Hyperglycemic Hyperosmolar State Associated with Graves' Hyperthyroidism: A Case Report

Hyperglycemic hyperosmolar state (HHS) is an acute complication mostly occurring in elderly type 2 diabetes mellitus (DM). Thyrotoxicosis causes dramatic increase of glycogen degradation and/or gluconeogenesis and enhances breakdown of triglyc-erides. Thus, in general, it augments glucose intolerance in diabetic patients. A 23-yr-old female patient with Graves' disease and type 2 DM, complying with methimazole and insulin injection, had symptoms of nausea, polyuria and generalized weakness. Her serum glucose and osmolarity were 32.7 mM/L, and 321 mosm/kg, respectively. Thyroid function tests revealed that she had more aggravated hyperthyroid status; 0.01 mU/L TSH and 2.78 pM/L free T3 (reference range, 0.17-4.05, 0.31-0.62, respectively) than when she was discharged two weeks before (0.12 mU/L TSH and 1.41 pM/L free T3). Being diagnosed as HHS and refractory Graves' hyperthyroidism, she was treated successfully with intravenous fluids, insulin and high doses of methimazole (90 mg daily). Here, we described the case of a woman with Graves' disease and type 2 DM developing to HHS.

A Case of Syndrome of Inappropriate Antidiuretic Hormone Secretion and Pneumomediastinum Complicated by Bougienation in Malignant Esophageal Stricture / 대한소화기내시경학회지

Bougienation is generally an effective method providing temporary relief of obstruction to facilitate stent insertion in patients with malignant esophageal stricture. The complicated by after bougienation such as esophageal perforation, mediastinitis, bronchoesophageal fistula, pneumomediastinum, pneumothorax were reported. However, syndrome of inappropriate antidiuretic hormone secretion (SIADH) complicated by bougienation has rarely been reported. Thus, we report a case of SIADH and pneumomediastinum complicated by bougienation in a patient with malignant esophageal stricture.