Chronic Hemorrhage from a Fistula between a Gastroduodenal Artery Aneurysm and the Duodenum / 대한내과학회지

Gastroduodenal artery (GDA) aneurysm is a very rare event, but it induces life-threatening clinical manifestations upon rupture or bleeding. The causes of GDA aneurysm are atherosclerosis, infection, trauma, surgery, iatrogenic lesions, mycotic or tuberculous disease, and autoimmune disease. We report the case of a 77-year-old female who presented with melena and vomiting. Upper gastrointestinal endoscopy revealed a 4 cm pulsatile extrinsic mass with a duodenal fistula at the duodenal bulb. Abdominal computed tomography showed a large aneurysm of the GDA. We successfully conducted transcatheter embolization of the aneurysm. After the procedure, the patient did not present with melena, and her hemoglobin level was stable. Follow-up endoscopy showed that the GDA aneurysm-duodenal fistula had decreased in size and was leaking a small amount of blood. An arteriography was performed and showed no evidence of contrast filling in the aneurysmal sac.

A Case of Primary Jejunal Adenocarcinoma Diagnosed by Enteroscopy using Pediatric Colonoscope / 대한소화기학회지

A 39-year-old man presented with dizziness and melena for 2 months. Abdominal CT scan showed constrictive wall thickening with enhancement and proximal loop dilatation of the jejunum. On endoscopic examination, there was large amount of bile stained fluid in duodenum. Enteroscopy using pediatric colonoscope demonstrated an encircling mass with obstruction approximately 20 cm distal to the ligament of Treitz. Endoscopic jejunal biopsy showed moderately differentiated adenocarcinoma. Small intestinal adenocarcinoma is uncommonly encountered in clinical practice. Because small intestine is relatively inaccessible via routine endoscopy, diagnosis of small intestinal neoplasm is often delayed for several months after the onset of symptoms. Most of the patients are diagnosed in advanced stage. Therefore, when a small bowel neoplasm is suspected, enteroscopy is the most useful study. If enteroscope is not available, enteroscopy using pediatric colonoscope may permit earlier preoperative diagnosis. We report a case of primary jejunal adenocarcinoma diagnosed by endoscopic biopsy using pediatric colonoscope.

Littoral Cell Angioma (LCA) Associated with Liver Cirrhosis

A littoral cell angioma (LCA) is a rare benign vascular tumor of the spleen. A 60-year-old man, with multiple nodules in imaging study and liver cirrhosis graded as Child-Pugh classification class A, was transferred for splenomegaly. A thrombocytopenia was found on hematological evaluation. Because there was no evidence of hematological and visceral malignancy, a splenectomy was performed for a definitive diagnosis. The histological and immunohistochemical features of the splenic specimens were consistent with a LCA. After the splenectomy, the thrombocytopenia recovered to the normal platelet count. There has been no previous report of a LCA combined with liver cirrhosis. Herein, the first case of a LCA in Korea, diagnosed and treated by a splenectomy, is reported.

The Prevalence of Antimicrobial Resistance in Helicobacter pylori Isolated in Daejeon / 대한임상미생물학회지

BACKGROUND: The most commonly used regimen for the eradication of Helicobacter pylori is combination of a proton pump inhibitor, clarithromycin, and two other antibiotics, metronidazole and amoxicillin. The increase in resistance to antibiotics seems to result in a decrease in eradication efficacy for H.pylori. We investigated the prevalence of antibiotic resistance in H.pylori isolated in Daejeon area. METHODS: A total of 31 clinical isolates of H.pylori were collected from the patients who underwent upper gastrointestinal endoscopy in Keonyang University Hospital during the period from March to July 2004. Antibiotic susceptibility tests for metronidazole, amoxicillin, and clarithromycin were performed by the E test (AB Biodisk, Sweden) on an egg yolk medium containing triphenyltetrazolium. The resistance break points for amoxicillin, metronidazole, and clarithromycin were defined as 0.5 microgram/mL, 8 microgram/mL, 1 microgram/mL, respectively. RESULTS: Resistance to amoxicillin, metronidazole, and clarithromycin was detected in 7.4% (2/27), 25.8% (8/31), 3.6% (1/28), respectively. CONCLUSION: The resistance to amoxicillin and clarithromycin was uncommon in Daejeon area.

Solitary Peutz-Jeghers Polyp of the Colon / 대한소화기내시경학회지

Peutz-Jeghers syndrome is an autosomal-dominant inherited disorder characterized by polyposis of the alimentary tract, the abnormal mucocutaneous pigmentation, and family history of Peutz-Jeghers syndrome. A single Peutz-Jeghers polyp arising in a patient without pigmentation and family history of Peutz-Jeghers syndrome is termed a solitary or isolated hamartomatous polyp of Peutz-Jeghers type. These solitary polyps are found most frequently in the small intestine but also occur in the large bowel and stomach as well. In a healthy 48-year-old man, a single large polyp was found incidentally in the ascending colon during colonoscopy and treated by snare polypectomy. Microscopic exam of the resected specimen revealed the features of hamartomatous polyp of Peutz-Jeghers type. There was no evidence of other polyps on esophagogastroduodenoscopy and small bowel series. We report a patient with solitary Peutz-Jeghers polyp of the colon, who had no stigmata associated with Peutz-Jeghers syndrome.

Serial Endoscopic Observation in a Case of Spontaneous Submucosal Dissection of the Esophagus / 대한소화기내시경학회지

Spontaneous submucosal esophageal dissection is a rare disorder, characterized by a longitudinal dissection along the axis of the esophagus between submucosa and muscle layer without an obvious cause. The diagnosis is made by typical esophagographic or endoscopic findings which are double-barreled esophagus in esophagography or mucosal defect in upper esophagus and false lumen running along the distal side of the esophagus on esophagoscopy. The condition usually follows a benign course with good prognosis requiring a supportive treatment, but rarely treated by endoscopy or surgery. A 74-year-old man was admitted to our hospital complaining of chest pain and odynophagia after upper respiratory infection. We diagnosed a case of spontaneous submucosal dissection of the esophagus and observed its healing process by series of endoscopy with a conservative treatment.

A Case of Acute Acalculous Cholecystitis Complicating Endoscopic Retrograde Cholangiopancreatography / 대한소화기내시경학회지

Endoscopic retrograde cholangiopancreatography (ERCP) has gained wide acceptance as a valuable tool for the diagnosis and management of disease of the pancreas and biliary tract. Complications associated with ERCP include bleeding, perforation, pancreatitis, and cholangitis, and the incidence is about 5~10%. Acute acalculous cholecystitis can be developed rarely after ERCP. It tends to have more complicated course, resulting in higher morbidity and mortality. We report a case of acute acalculous cholecystitis complicating therapeutic ERCP in a 52-year-old man with primary common bile duct stone. He underwent open cholecystectomy because of uncontrolled infection and rapid progression to septic shock. Although acute acalculous cholecystitis is one of rare complications developed after ERCP, it should be considered as one of the differential diagnosis in patients who complain of abdominal pain after ERCP because of high mortality rate and the need for prompt surgical management.

A Case of Sarcomatoid Combined Hepatocellular-Cholangiocarcinoma / 대한소화기학회지

Combined hepatocellular-cholangiocarcinoma (HCC-CC) with sarcomatoid features is an extremely rare primary liver cancer, of which only four cases have been reported. We report a case of sarcomatoid combined HCC-CC in a 60-year-old woman who complained of right upper quadrant pain and presented with a 7 cm mass in the S4 region of the liver in abdominal CT. Ultrasonography-guided needle biopsy diagnosed it as HCC, and left lobectomy of the liver followed. Microscopically, the tumor consisted of two portions: HCC portion showing trabecular pattern, which had partially sarcomatous area with spindle-shaped tumor cells, and CC portion with glandular pattern. Immunohistochemically, HCC portion reacted positively with alpha-fetoprotein while CC portion demonstrated positive reactivity with carcinoembryonic antigen and mucicarmine. Sarcomatoid cells reacted positively for cytokeratin. She died of tumor recurrence and hepatic failure 12 months after the operation. Combined HCC-CC has poor prognosis, and sarcomatoid HCC has high metastatic potential and poor prognosis compared with ordinary HCC.

A Case of Gastric Adenocarcinoma Arising from Gastritis Cystica Profunda / 대한소화기내시경학회지

Gastritis cystica profunda (GCP) is a disease characterized by gastric foveolae elongation along with hyperplasia and cystic dilatation of the gastric glands extending into the tisssue beneath the submucosa. It mainly occurs on the site of gastroenterostomy, but can occasionally be found in an unoperated stomach. GCP may present as a submucosal tumor or polyp, and rarely a giant gastric mucosal fold. This lesion has traditonally been regarded as a benign lesion. However, there are many debates over its malignant potential. Further investigations on the relation between GCP and gastric carcinoma may be necessary. To our knowledge, this is the second description of adenocarcinoma arising from GCP in an unoperated stomach.

Prospective controlled study of endoscopic ultrasonography and endoscopic retrograde cholangiography in patients with suspected choledocholithiasis / 대한내과학회지

BACKGROUND: Endoscopic ultrasonography (EUS) and endoscopic retrograde cholangiography (ERC) are accurate for the diagnosis of commom bile duct stone. But sometimes, endoscopic sphincterotomy is done unnecessarily in patients with suspected choledocholithiasis. Endoscopic ultrasonography is a promising procedure for the diagnosis of extrahepatic cholestasis due to noninvasiveness and accuracy. We compared the effectiveness of endoscopic ultrasonography with endoscopic retrograde cholangiography in detecting the extrahepatic choledocholithiasis. METHODS: sixty nine patients suspected choledocholithiasis were evaluated using endoscopic ultrasonography (EUS) and endoscopic retrograde cholangiography (ERC). Endoscopic sphincterotomy with instrumental exploration was then done when EUS or ERCP image showed the stones. RESULTS: Choledocholithiasis was confirmed in 53 (76.8%) patients. Seven patients were false negative on ERC, of whom all were true positive on endoscopic ultrasonography. Six patients false negative on ERC had small stone (<5 mm in diameter) in dilated bileduct and one patients had impacted stone on the ampulla of Vater. CONCLUSION: EUS could be an accurate for the diagnosis of choledocholithiasis and may prevent inappropriate invasive exploration of the common bile duct.

Genetic Polymorphisms of Alcohol-metabolizing Enzymes and Cytokines in Patients with Alcohol Induced Pancreatitis and Alcoholic Liver Cirrhosis / 대한소화기학회지

BACKGROUND/AIMS: Susceptibility to organ damage induced by alcohol may be related to inherited variations (polymorphisms) in alcohol-metabolizing enzymes, or polymorphisms affecting cytokines. The aim of this study was to compare the genotype and allelic frequencies of ADH2, ADH3, ALDH2, cytochrome P450-2E1, IL-1, IL-6, IL-8 and tumor necrosis factor-alpha in patients with alcoholic pancreatitis and alcoholic liver cirrhosis with those of controls. METHODS: We determined the polymorphism of genes of the above-mentioned alcohol-metabolizing enzymes and cytokines in 29 alcoholic pancreatitis patients (AP), 22 alcoholic liver cirrhosis patients (LC) and 100 healthy blood donors (control). The genotypes were characterized by restriction fragment length polymorphism after amplification of genomic DNA by polymerase chain reaction. RESULTS: The allelic frequency of CYP2E1*c2 was significantly different in three groups (AP: LC: Control=0.224: 0.136: 0.320, p<0.05). There was no significant difference in the other genotypes or allelic frequencies of the three groups. The allelic frequencies of CYP2E1*c2 and ALDH2*2 were more frequent in the control than patients with alcoholic liver cirrhosis (LC: Control=0.136: 0.320, p<0.05, LC: Control= 0.114: 0.265, p<0.05). Allelic frequencies of ADH2 was statisitcally different between LC and control (ADH2*1; LC: Control=0.727: 0.495, ADH2*2; 0.227: 0.360, ADH2*3; 0.046: 0.145, p<0.05). CONCLUSIONS: There was no difference in the frequencies of genotype and allele of enzymes and cytokines among the three groups. However, frequency of ADH2*1 was significantly higher and those of CYP2E1*c2 and ALDH2*2 were significantly lower than LC group than control.

Evaluation of Asan Helicobacter Test for Diagnosis of Helicobacter pylori Infection / 대한임상미생물학회지

BACKGROUND: Helicobacter pylori is the single most common pathogen that causes chronic bacterial infection in human. The authors designed a new type of urease detection method (Asan Helicobacter test) that can be used for rapid early detection of H. pylori as well as a transport medium. This medium has a strong acidity with a minimal concentration of urea for the purpose of the detection of H. pylori. The current study was to evaluate the bacteriological and clinical usefulness of this medium. METHOD: 252 antral biopsies from patients underwent upper gastrointestinal endoscopies in Inha University Hospital were inserted Asan Helicobacter Test and CLO test. 37 antral biopsies from patients underwent upper gastrointestinal endoscopies in Konyang University Hospital were inserted Asan Helicobacter Test. Biopsies were cultured on nonselective media only. RESULT: The sensitivity and specificity of the Asan Helicobacter test were comparable with the CLO test (88.0% and 94.0%, respectively), and the results agreed in 99.2% of 252 cases with the CLO test. With this transport medium, all 23 specimens that showed positive reaction among 37 patients yielded satisfactory isolation of H. pylori. CONCLUSION: These findings suggest that the reagent in the kit inhibit the growth of microbial contaminant due to low pH and do not suppresses growth of H. pylori due to low concentration of urea. This kit may be used as a transport medium as well as a rapid urease test for H. pylori.

A Case of Adenomyoma Causing Jejunal Bleeding / 대한소화기내시경학회지

Adenomyoma, a benign tumor generally considered to be a form of pancreatic heterotopia, is composed of smooth muscle and undifferentiated columnar epithelium. A 62-year-old female was admitted with melena. Small bowel enteroscopy using a pediatric colonoscope revealed a small sized nodular mass with active bleeding in the proximal jejunum. After a endoscopic resection of the tumor, the bleeding ceased. Histologic examination disclosed an adenomyoma. We report a case of the adenom-yoma causing jejunal bleeding with a review of the literature.

Usefulness of Endoscopic Mucosal Resection for Curative Treatment of Early Gastric Cancer / 대한소화기학회지

BACKGROUND/AIMS: Endoscopic mucosal resection (EMR) has been widely accepted as a curative treatment of early gastric cancer (EGC). The aim of this study was to determine the usefulness and limitations of EMR for treatment of EGC by analyzing our own experience. METHODS: We retrospectively evaluated 51 EGC lesions (45 mucosal and 6 submucosal cancers) from 49 patients who had undergone EMR between Oct. 1997 and Aug. 2002 at Inha Universtiy Hospital. RESULTS: Among 45 lesions of mucosal cancer, enbloc resection was performed in 13 lesions and piecemeal resection in 32 lesions. Complete resection rates of enbloc and piecemeal resection were 84.6% and 43.8%, respectively (p=0.012). Complete resection rate of the lesions smaller than 1 cm in size was 71.4%, 1 to 2 cm in size 52%, and greazter than 2 cm in size 37.5%. Complete resection rates of well, moderately, and poorly differentiated EGC were 59.4%, 71.4%, and 16.7%, respectively (p=0.048). Thirty-three patients underwent a follow-up endoscopy at I month after EMR and two were found to have residual cancers. One patient who had a piecemeal EMR showed cerical and abdominal lymph node metastasis 10 months after EMR. CONCLUSIONS: In selected patients with EGC, EMR can be a curative treatment modality. However, complete resection rate is low in large sized and poorly differentiated EGCs and when piecemeal resection is performed.

A Case of Common Bile Duct Stone Formed around a Surgical Clip after Laparoscopic Cholecystectomy / 대한소화기학회지

Laparoscopic cholecystectomy has now rapidly replaced open cholecystectomy. Rarely a calculus may arise from a metallic surgical clip migrated into the common bile duct (CBD) after this surgical procedure was performed. We report a 50-year-old man with CBD stone formed around a surgical clip, who had undergone a laparoscopic cholecystectomy because of acute calculous cholecystitis 14 months before. Abdominal CT revealed a single stone in mildly dilated CBD. A high density core within the CBD stone, was suspected to be a surgical clip. The stone was removed using a retrieval balloon catheter and basket after endoscopic sphincterotomy.

A case of adrenal lymphangioma misdiagnosed as biliary cystadenoma / 대한내과학회지

Lymphangioma is resulted from faulty development or ectasia of lymphatic vessels. Adrenal lymphangioma was reported first in 1965 and very rare with approximately 20 cases having been reported so far in worldwide. Adrenal lymphangioma is usually asymptomatic and most often identified incidentally at imaging study or autopsy. If symptoms do occur, they are related to size and position of the lesion and contain fever, abdominal pain, or palpable mass. Laboratory findings are nonspecific and usually not helpful as a diagnostic tool. Although ultrasonography and computerized tomography play a major role in the exploration of adrenal cysts, the nature of unexpected adrenal cysts is confirmed by histology. Recently, we experienced a case of 50-year-old female patient, who complained right upper abdominal pain and suspected with biliary cystadenoma in radiologic studies. The surgical enucleation was performed and final diagnosis was adrenal lymphangioma. Considering of rare incidence, we report a case of lymphangioma arising from right adrenal gland with a review of the relevant literature.

The Usefulness of Endoscopic Retrograde Biliary Drainage Using Plastic Stents for Patients with Common Bile Duct Stone / 대한소화기내시경학회지

BACKGROUND/AIMS: Endoscopic sphincterotomy is considered the primary option for treatment of common bile duct (CBD) stones. In some cases, however, complete stone removal is difficult or even impossible. Endoscopic retrograde biliary drainage (ERBD) has been suggested to be an alternative treatment in such cases or in patients with high surgical risks. In this study, we evaluated the effectiveness of ERBD using a plastic stent for treatment of CBD stones. METHODS: From Mar. 1996 to Aug. 1999, ERBD was performed in 12 patients with CBD stones. Indications for ERBD were old age in 4, a large perivater diverticulum in 4, refusal of surgery in 2, bleeding risk and biliary stricture in 1 each. Nine had one of the significant associated medical conditions. RESULTS: Six of the 12 patients were symptom-free at the time of evaluation (mean 32.9 months). Of the remaining 6 patients, 3 had operation, 1 had a successful endoscopic stone removal, 1 had a stent exchange, and 1 was lost to follow-up at 26 months. Thus, overall success rate of ERBD for treatment of CBD stones was 75% (9/12). Median symptom-free duration was 41 months (range 18~59 months). CONCLUSIONS: In view of its relatively high success rate and long-term effect, ERBD is an alternative modality for treatment of CBD stones, especially in patients with high surgical risks.

Successful Cyclophosphamide Therapy in Recurrent Eosinophilic Colitis Associated with Hypereosinophilic Syndrome

Eosinophilic colitis is a relatively rare complication of hypereosinophilic syndrome which is characterized by abdominal pain and bloody diarrhea and is usually treated with steroids and hydroxyurea. However, no standard regimen exists in cases of intractable disease despite several treatment attempts with Interferon- alpha, cyclosporin, etoposide, and vincristine, etc. We here report a case of a 43-year-old woman with recurrent eosinophilic colitis as a complication of hypereosinophilic syndrome who was successfully treated with cyclophosphamide.

A Case of Massive Bleeding in Jejunal Tuberculosis Treated by Transcatheter Embolization / 대한소화기내시경학회지

Common complications of the intestinal tuberculosis are perforation, obstruction, fistulas, and malabsorption. Massive gastrointestinal bleeding is an extremely rare complication of intestinal tuberculosis. Moreover, this may be the first report in the world on transcatheter arterial embolization against the massive bleeding from intestinal tuberculosis patient. We experienced a case of lower gastrointestinal bleeding due to extensive intestinal tuberculosis as massive as vital sign was unstable. Colonoscopy and esophagogastroduodenoscopy did not reveal bleeding focus. Active jejunal bleeding was suspected by technetium99m labelled RBC scintigraphy. Emergency superior mesenteric artery angiography showed active bleeding focus from jejunal branch of artery and transcatheter arterial embolization was tried with microcoil. After embolization, he had no more hematochezia and vital sign became stabilized. On third hospital day, upper endoscopy was done using pediatric colonoscopy and there were multiple circular ulcers on the proximal jejunum but no evidence of mesenteric ischemia. Small bowel tuberculosis should be suspected as a cause of lower gastrointestinal bleeding in case of negative colonoscopy and upper endoscopy. We suggest that the transcatheter embolization could be taken into consideration as a first-line method of treatment for massive bleeding from intestinal tuberculosis before surgical resection.

A case of epidermoid cyst of the liver / 대한내과학회지

Congenital solitary nonparasitic cysts of the liver are rare condition in all age groups. Since 1856, only approximately 900 cases having been reported in the world literature. Epidermoid cysts of the liver are extremely rare type of congenital nonparasitic hepatic cysts, characterized by a fibrous wall entirely lined with stratified squamous epithelium, but lacking hair or skin appendages. This condition has yet to be reported in Korea. Because they have a potential for malignant transformation, it is important to totally resect the epidermoid cyst of the liver. Recently, we experienced a case of 44-year-old female patient with epidermoid cyst of the liver, which condition was complicated by a secondary infection. For this patient, an enucleation of entire cyst was performed. Given the rarity of this case, the following is a report of this case and a review of the relevant literature.