Discrepancy between the Actual Clinical Status of Patients with Hepatocellular Carcinoma and Expectations from Hepatocellular Carcinoma Surveillance: a Single-Center Study

BACKGROUND/AIMS: The National Liver Cancer Screening Program (NLCSP) has been implemented for the past 15 years in Korea. However, the actual clinical experience in Korea is inconsistent with the expectations of the hepatocellular carcinoma (HCC) surveillance program. To evaluate the actual clinical situation of HCC diagnoses, we investigated disease severity in patients with HCC and the diagnostic environment. METHODS: From January 2011 to December 2015, all patients who were diagnosed with HCC in a single secondary hospital in Daejeon city were retrospectively enrolled in this study. Severity of HCC was evaluated according to the Barcelona Clinic Liver Cancer (BCLC) staging system. RESULTS: Over the course of 5 years, 298 participants were enrolled. The mean age of participants was 64.0 years. Positive hepatitis B surface antigen was confirmed in 134 patients (45.0%), 35 patients (11.7%) tested positive for anti-hepatitis C virus antibody, and 93 patients (32.2%) had more than 40 g/day of alcohol consumption. The proportions of patients according to BCLC stages were as follows: BCLC-0, 28 patients (9.4%); BCLC-A, 42 patients (14.1%); BCLC-B, 26 patients (8.7%); BCLC-C, 134 patients (45.0%); and BCLC-D, 68 patients (22.8%). The diagnostic environments were as follows: 19 patients were in the NLCSP group (6.4%), 114 in the group with presenting signs (38.3%), 110 in the regular outpatient care group (36.9%), and 55 patients in the incidental diagnosis group (18.5%). CONCLUSIONS: Most patients (67.8%) had advanced stage HCC at diagnosis, and curative treatment was not indicated due to the severity disease. Thus, the actual situation is far worse than the theoretical expectation of HCC surveillance, suggesting that many high-risk patients for HCC are missed in surveillance.

Hepatic Failure Due to Hepatitis E Virus Infection in a Patient with Necrotic Hepatocellular Carcinoma

In patients with hepatocellular carcinoma (HCC) or liver cirrhosis (LC) accompanied by hepatitis E virus (HEV) infection, hepatic failure often leads to debility. Here, we report about a 63-year-old man with alcoholic LC who was referred to our hospital with jaundice and abdominal distension 10 days earlier. Abdominal computed tomography showed necrotic HCC accompanied by left lobe shrinkage without tumor progression. Laboratory and imaging findings revealed no acute infection focus. The patient reported no herbal medicine or alcohol consumption, and there was no evidence of acute viral hepatitis. One month later, HEV immunoglobulin M positivity was confirmed, and deterioration of liver function due to HEV infection was suspected. The patient often ate raw oysters and sashimi, as well as boar meat, which is a well-known risk food for HEV infection. His umbilical hernia deteriorated due to tense ascites and infection by skin abrasion. The patient progressed to hepatorenal syndrome and eventually died. Liver function preservation is important when treating HCC patients. Therefore, clinicians should pay more attention to the prevention of HEV and others causes of direct liver injury.

Acute Pancreatitis in a Pregnant Patient with Type IV Hyperlipoproteinemia / 대한췌담도학회지

Most cases of hypertriglyceridemia (HTG)-induced gestational pancreatitis occur when a person with hyperlipidemia is overweight due to pregnancy or has secondary triggers associated with triglycerides (TGs). In Korea, 6 cases of HTG-induced gestational pancreatitis have been reported, but none of the affected patients had TG levels below 1,000 mg/dL. A 36-year-old female at 30 weeks of gestation was admitted due to pain in her upper abdomen. Initial biochemical analysis revealed a TG level of 260 mg/dL, an amylase level of 2,951 U/L and a lipase level of 3,500 U/L. Abdominal ultrasonography showed pancreatic swelling with a hypoechogenic rim. After several days, the patient was discharged and had a normal delivery at 38 weeks of gestation. This case report is the first to describe acute pancreatitis occurring in the presence of type IV hyperlipoproteinemia even though the TG level was less than 500 mg/dL, contrary to findings in previously reported cases.

Common Bile Duct Stone Removal with Side-viewing Duodenoscope after Forward-Viewing Endoscope-Guided Pancreatic Stent Insertion in a Patient with Periampullary Diverticulum / 대한췌담도학회지

No abstract available.

High-Grade Mixed Adenoneuroendocrine Carcinoma in the Cecum: A Case Report

Gastrointestinal neoplasms with an exocrine and a neuroendocrine component are rare. Such neoplasms are called “mixed adenoneuroendocrine carcinomas” (MANECs) according to the most recent World Health Organization classification of gastrointestinal tract neoplasms. MANECs have no specific findings that distinguish them from pure adenocarcinomas. In addition, the optimal management strategy of MANECs is largely unknown. We describe the case of a 32-year-old man with dizziness and abdominal bloating. A cecal mass was suspected based on an image study done at a local clinic. We evaluated the cecal mass by using colonoscopy, contrast enhanced computed tomography of the abdomen, positron emission tomography-computed tomography, and laboratory studies. The patient underwent a right hemicolectomy and adjuvant chemotherapy. The final histopathological diagnosis was a high-grade MANEC of the ascending colon, tumor stage T3N2M0.

Effectiveness of cholangioscopy using narrow band imaging for hepatobiliary malignancies

PURPOSE: Recently, cholangioscopy using narrow band imaging (NBI) has been used as a diagnostic modality for better visualization in hepatobiliary malignancies; however, there are few reports on it. Our aim is to evaluate the effectiveness of cholangioscopy using NBI in hepatobiliary malignancies. METHODS: Between January 2007 and December 2016, 152 cholangioscopies using percutaneous approach were conducted in total 123 patients. Among these, 36 patients were suspicious of hepatobiliary malignancies. Thirteen patients with an ambiguous margin on endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP), for whom NBI tipped the balance in diagnosis of lesion and decision of lesion extent by adding NBI, were involved in our study. RESULTS: Underlying diseases were all malignant in 13 patients (11 bile duct cancers, 1 liver cancer, 1 pancreas cancer with common bile duct invasion). In 7 cases with papillary type tumor, minute superficial spreading tumor was detected by NBI more easily, and NBI provided a better visualization of tumor vessel and margin evaluation in 4 cases with infiltrative tumor. In 2 cases with mucin-hypersecreting tumor, NBI showed better penetration through the mucin and gave us a much clearer image. Nine patients ultimately underwent surgical resection. The margins predicted by NBI cholangioscopy were consistent with the pathological margins on the resected specimens. CONCLUSION: In conclusion, cholangioscopy using NBI is very useful for evaluation of suspected hepatobiliary malignancies with an ambiguous margin on ERCP or MRCP. It can give us an accurate pathologic mapping, and this information seems to be essential before deciding on a treatment strategy.

ERCP and Direct Cholangioscopy with Gastroscope in Patients with Ectopic Opening of the Bile Duct into the Duodenal Bulb: A Report of 3 Cases / 대한췌담도학회지

Ectopic openings of the common bile duct into the duodenal bulb, which are associated with biliary tract disease or recurrent/refractory duodenal ulcers, are rare. We report three such cases, all of which were documented with gastroscope, and two of which were managed with endoscopic retrograde cholangiopancreatography (ERCP) via gastroscope. We suggest that ERCP can be performed with gastroscope, since it may offer a better working position in certain cases.

Gastrointestinal Stromal Tumor of the Stomach Presenting as Multilobular with Diffuse Calcifications

Gastrointestinal stromal tumors (GISTs) are the most common primary mesenchymal neoplasms of the gastrointestinal tract and usually appear as a well-circumscribed mass. However, it may be difficult to confirm the extent of the disease for some GISTs. A 70-year-old asymptomatic female presented for a regular physical exam. An esophagogastroduodenoscopy showed a 2.0 cm protruding mass on the gastric fundus. Endoscopic ultrasound revealed an ill-defined heterogenous hypoechoic lesion (3.0×1.5 cm). A computed tomography (CT) scan demonstrated a 4.5 cm multifocal calcified mass at the gastric body as well as at the gastric fundus. Laparoscopic gastric wedge resection was performed according to the extent of multifocal calcifications that are shown on the CT. Intraoperative specimen mammography and intraoperative biopsy might be helpful to obtain a tumor-free margin. Final pathologic diagnosis was an intermediate risk GIST in multilobular form. In patients with diffuse multifocal calcifications in the stomach, the possibility of GIST should be considered.

Incidence and Clinical Outcomes of Clostridium difficile Infection after Treatment with Tuberculosis Medication

BACKGROUND/AIMS: To determine the incidence and clinical characteristics of tuberculosis (TB) medication-associated Clostridium difficile infection. METHODS: This multicenter study included patients from eight tertiary hospitals enrolled from 2008 to 2013. A retrospective analysis was conducted to identify the clinical features of C. difficile infection in patients who received TB medication. RESULTS: C. difficile infection developed in 54 of the 19,080 patients prescribed TB medication, representing a total incidence of infection of 2.83 cases per 1,000 adults. Fifty-one of the 54 patients (94.4%) were treated with rifampin. The patients were usually treated with oral metronidazole, which produced improvement in 47 of the 54 patients (87%). Twenty-three patients clinically improved with continuous rifampin therapy for C. difficile infection. There were no significant differences in improvement between patients treated continuously (n=21) and patients in whom treatment was discontinued (n=26). CONCLUSIONS: The incidence of C. difficile infection after TB medication was not low considering the relatively low TB medication dosage compared to other antibiotics. It may not be always necessary to discontinue TB medication. Instead, decisions concerning discontinuation of TB medication should be based on TB status.

Pathological differences between forceps biopsy specimens and endoscopic resection specimens in early gastric cancer patients / 고신대학교의과대학학술지

OBJECTIVE: Endoscopic resection(ER) is effective therapy on EGC and which is treated according to the histological diagnosis of forcep biopsy. But sometimes the histological diagnosis of forcep biopsy and post-ER does not match with each other and it might lead to wrong treatment. The aim of this study is to find the frequency of histologic differences between forcep biopsy and post-ER, and to confirm the characteristics of lesions which make errors. METHODS: We selected the confirmed cancer cases of 141 patients of 1359 gastric tumor lesions which were treated under the ER in Eulji university hospital from May 2005 to March 2013. They were sorted by the age and sex of patient, location of lesion, present of ulcer and depression to identify the discordance between forcep biopsy and ER. The discordant group was compared with non-cancer-diagnosed controlled group, retrospectively. RESULTS: 70 cases(5.5%) of 1283 cases of "cancer negative" in forceps biopsy were found to be diagnosed cancer on final diagnosis of cancer by post-ER result. In this discordant group showed characteristics of bigger size that are with more frequently in tumor size >==15mm(17.9% vs. 31.4%, p=0.03), have depressed lesion(14.3% vs. 41.4%, p==15mm, presented with depressed lesion and ulceration, we should consider combined cancer, even the result of forcep biopsy was negative. Therefore, more careful and accurate resection should be taken with characters listed above.

A Case of Metastatic Renal Cell Carcinoma Bleeding of the Pancreas Manifesting As Cholangitis / 대한췌담도학회지

Renal cell carcinoma (RCC) is the second most common urological malignancy and it has diverse range of clinical manifestation. One third of the patients show the metastasis at the time of the diagnosis. The common sites of metastasis are the lung, bone, lymph nodes and metastasis to the pancreas is rare. In case of pancreatic metastasis, more than half of the patients are asymptomatic. Patients with symptoms visit hospital complaining of abdominal pain, weight loss, steatorrhea and rarely biliary obstruction. Although about 40% of all patients visit hospital with hemorrhage, cholangitis caused by spontaneous pancreatic hemorrhage is rare. We report an interesting case of 61-year-old woman with cholangitis caused by bleeding due to pancreatic metastasis from renal cell carcinoma.

A case of variceal bleeding from the jejunum in liver cirrhosis

While esophagogastric varices are common manifestations of portal hypertension, variceal bleeding from the jejunum is a rare complication of liver cirrhosis. In addition, ectopic variceal bleeding occurs in the duodenum and at sites of previous bowel surgery in most cases, including of stomas. We report a case of obscure overt gastrointestinal bleeding from jejunal varices in a 55-year-old woman who had not previously undergone abdominal surgery, who had liver cirrhosis induced by the hepatitis C virus. Emergency endoscopy revealed the presence of esophageal varices without stigmata of recent bleeding, and no bleeding focus was found at colonoscopy. She continued to produce recurrent melena with hematochezia and received up to 21 units of packed red blood cells. CT angiography revealed the presence of jejunal varices, but no active bleeding was found. Capsule endoscopy revealed fresh blood in the jejunum. The patient submitted to embolization of the jejunal varices via the portal vein, after which she had a stable hemoglobin level and no recurrence of the melena. This is a case of variceal bleeding from the jejunum in a liver cirrhosis patient without a prior history of abdominal surgery.

The Use of Gabexate Mesylate and Ulinastatin for the Prevention of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis

BACKGROUND/AIMS: Acute pancreatitis is a common complication of endoscopic retrograde cholangiopancreatography (ERCP). Only a few pharmacologic agents have been shown to have potential efficacy for the prophylactic treatment of post-ERCP pancreatitis (PEP). The aim of this study was to determine whether prophylactic gabexate and ulinastatin can decrease the incidence of PEP. METHODS: From January 2005 to April 2010, 1,679 patients undergoing ERCP treatment were consecutively enrolled in the study. After selective exclusion, a total of 1,480 patients were included in the analysis. The patients were separated into 3 groups according to the prophylactic administration of gabexate (593 patients), ulinastatin (229 patients), or saline solution (658 patients) and analyzed retrospectively. The primary outcome measurements were the incidence of pancreatitis and hyperamylasemia. RESULTS: PEP occurred in 21 of the 593 (3.5%) patients who received gabexate, 16 of the 229 (7.0%) patients who received ulinastatin, and 48 of the 658 (7.3%) patients who received a saline solution. The incidence of PEP was significantly different between the gabexate and ulinastatin or saline solution groups (p<0.05). CONCLUSIONS: Gabexate prophylaxis is effective in preventing PEP. However, there is no difference in the beneficial effects of the prophylactic administration of ulinastatin and a saline solution.

Typhoid Fever Complicated by Intussusception, Splenic Infarction, and Hepatitis

Salmonella typhi infections usually manifest with high fever and gastrointestinal symptoms, however, occurrence of severe complications in other organs, such as pneumonitis, bronchitis, hepatitis, nephritis, encephalitis, and osteomyelitis, is possible. Although common surgical complications include ileal perforation and gastrointestinal haemorrhage, few cases of intussusception have been reported. Splenic infarction is another uncommon complication. In this report, we present a case of typhoid fever complicated with simultaneous small bowel intussusception and splenic infarction. A 27-year-old male patient with no previous history of interest underwent examination for fever, acute abdominal pain, and watery diarrhea of seven days duration. Findings on the initial examination indicated fever of 39.1degrees C, a distended abdomen with direct and rebound tenderness of diffuse localization, and rigidity. Abdominal computed tomography showed hepatomegaly, multiple lymphadenopathies, multiple segmental splenic infarctions, and small bowel ileus with intussusception, however, findings from the small bowel enema study showed spontaneous resolution of the intussusception. Despite antibiotic therapy, abdominal symptoms continued, therefore, the patient underwent exploratory laparotomy with suspicion of intestinal perforation. Surgical findings included multiple enlarged lymphadenopathies and coarse appearance of the liver, but no perforation was found. Results of the Widal test showed positivity for flagellar (H), somatic (O) and A antigens (1:640 dilutions each). Blood cultures showed Salmonella typhi. lymph nodes and biopsy showed mesenteric lymphadenitis, with enlarged lymph nodes due to distension of the sinusoids by macrophages, which showed erythrophagocytosis and tingible bodies. In addition, liver biopsy showed a granulomatous aggregate comprised of macrophages with an epithelioid configuration. After intravenous administration of antibiotics, the patient showed progressive improvement and was discharged for outpatient department follow up.

A Patient with Distinct Evidences of Spontaneous Regression and Recurrence of Gastric Cancer for 13 Years

Spontaneous regression (SR) of malignancy is a rare phenomenon, especially in patients with gastric cancer. A 77-year-old male, who was already diagnosed with gastric adenocarcinoma by endoscopic biopsy from a private clinic, was referred to our hospital. Despite our strong recommendation, the patient refused surgical therapy. A follow-up endoscopy was performed 3 months later, which revealed that the ulcer had changed into a white scar. Endoscopic biopsy revealed only chronic inflammation. Two and 6 years later, cancer recurred, and SR was confirmed both times, histologically, at the gastric body. The patient is still alive without any gastrointestinal symptoms after 13 years of follow-up. The cause of SR is yet uncertain and there are only a few suggestions of scientific mechanisms. We, herein, report this very rare case of repeated recurrence and SR of gastric cancer without clear cause.

Clinical Differences According to Genotype in Acute Viral Hepatitis A in Daejeon, Korea / 대한내과학회지

BACKGROUND/AIMS: Acute viral hepatitis A is a major health problem in Korea and the influx of genotype IIIA is thought to be one reason. We examined the differences in the clinical characteristics and laboratory findings of genotypes IA and IIIA in Daejeon. METHODS: From November 2009 to June 2010, 81 patients positive for IgM anti-HAV were enrolled prospectively. The hepatitis A was genotyped using real-time polymerase chain reaction. The clinical characteristics and laboratory results were compared on the basis of genotype. RESULTS: The mean patient age was 32.6 +/- 7.4 years. The mean hospitalization was 7.7 +/- 2.4 days. The patient occupation varied. Clinically, vomiting and diarrhea were relatively more prevalent in genotype IIIA than in IA. Abdominal pain and skin spots were relatively more prevalent in genotype IA than in IIIA. The hemoglobin, peak aspartate aminotransferase (AST) level, and C-reactive protein were statistically higher in genotype IIIA than in IA. The distributions of the peak AST, alanine aminotransferase (ALT) and total bilirubin values tended to be perched in genotype IIIA than in IA. The international normalized ratio (INR) tended to be slightly prolonged in genotype IIIA than in IA. CONCLUSIONS: Recently, genotype IIIA of acute viral hepatitis A has become prevalent in Daejeon. Hepatitis A genotype IIIA probably causes worse laboratory abnormalities than genotype IA.

A Case of Phlegmonous Gastritis Associated with Marked Gastric Distension

Phlegmonous gastritis is an acute and severe infectious disease that is occasionally fatal if the diagnosis is delayed. Alcohol consumption, an immunocompromised state (e.g., due to HIV infection, rheumatoid arthritis, diabetes mellitus, or adult T-cell lymphoma), and mucosal injury of the stomach are reported to be predisposing factors. The main treatments for phlegmonous gastritis are antibiotics administration or surgery. In this case, the patient's stomach was markedly distended due to long-lasting gastric-outlet obstruction, which is thought to be the predisposing factor for phlegmonous gastritis. We inserted a metal stent at the obstructed site palliatively due to strong refusal by the patient for surgery. The patient recovered after stenting and antibiotic therapy.

The role of flexible sigmoidoscopy in the diagnosis of Clostridium difficile-associated diarrhea / 대한내과학회지

BACKGROUND/AIMS: Clostridium difficile is an important cause of diarrhea in hospitalized patients. C. difficile-associated diarrhea (CDAD) is usually diagnosed following a stool test for C. difficile cytotoxin or stool culture for the presence of toxigenic C. difficile. However, the reported sensitivities of these tests are variable. Sigmoidoscopy may be an effective diagnostic method in patients with a false-negative stool test for cytotoxin. This study examined the role of flexible sigmoidoscopy in the diagnosis of CDAD. METHODS: Among the patients who had diarrhea and were examined with sigmoidoscopy in Eulji University Hospital between January 2005 and July 2008, 102 patients suspected of having antibiotic-associated diarrhea (AAD) based on their clinical symptoms were enrolled. Of the 102 patients, 74 were diagnosed with CDAD based on C. difficile cytotoxin or sigmoidoscopic findings of pseudomembranous colitis. The medical records of these 74 patients were reviewed retrospectively. RESULTS: Of the 74 patients, sigmoidoscopic findings revealed a pseudomembrane in 63 patients (85.1%) and colitis in nine (12.2%), while two patients (2.7%) appeared normal. Of the 63 patients with pseudomembranous colitis at sigmoidoscopy, the stool C. difficile cytotoxin assay was negative in 27 (42.9%). CONCLUSIONS: Flexible sigmoidoscopy was highly sensitive in pseudomembranous colitis and is useful in diagnosing patients with a delayed or negative stool test for C. difficile cytotoxin. Therefore, we recommend flexible sigmoidoscopy in patients suspected of having C. difficile-associated diarrhea for the diagnosis of CDAD.

A Case of Obstructive Jaundice Caused by Paradoxical Reaction during Antituberculous Chemotherapy for Abdominal Tuberculosis

Abdominal tuberculosis is not a rare disease, but obstructive jaundice caused by tuberculosis (tuberculous lymphadenitis, tuberculous enlargement of the head of pancreas, and/or tuberculous stricture of the biliary tree) is rare. We recently experienced a case of obstructive jaundice as a result of paradoxical reaction of periportal tuberculous lymphadenopathy that was treated successfully with corticosteroid and biliary drainage. No similar cases have been reported previously.

A Case of Gastrointestinal Amyloidosis in Asymptomatic Multiple Myeloma

Amyloidosis is a disorder characterized by extracellular deposition of amyloid materials in multiple organs and tissues. Amyloidosis commonly shows a systemic involvement. Gastrointestinal involvement is common in amyloidosis and is usually asymptomatic. The gastrointestinal manifestations include gastroparesis, diarrhea, steatorrhea, constipation, intestinal pseudo-obstruction, and bleeding. The diagnosis of amyloidosis is difficult because there are absence of systemic symptoms and nonspecific endoscopic findings. Asymptomatic multiple myeloma is an asymptomatic plasma-cell proliferative disorder associated with a high risk of progression to symptomatic multiple myeloma or amyloidosis. Recently, we experienced a 60-year-old man who presented with hematochezia and weight loss as manifestations of gastrointestinal amyloidosis involving the stomach and the colon induced in asymptomatic multiple myeloma confirmed by endoscopic biopsies and bone marrow biopsy. We report a case with a review of the literature.