Metachronous Development of Peritoneal Carcinomatosis in a Patient with Autoimmune Pancreatitis / 대한소화기학회지

Autoimmune pancreatitis (AIP) is a rare and unique type of chronic pancreatitis. The prognosis of AIP, particularly when associated with pancreatic cancer or a related malignancy, is not known. Only a few cases, where metachronous pancreas-related cancer developed during follow-up, have been reported. Most of these patients either underwent surgery or steroid therapy. This paper reports a case of a 66-year-old woman with untreated type I AIP who developed peritoneal carcinomatosis more than 2 years later. Initially, the patient had a markedly elevated serum IgG4 level and a diffuse, infiltrative mass-like lesion in the pancreatic head, in which the biopsy results were consistent with type I AIP. The patient was not treated with steroids because of a cerebellar infarction. Twenty-eight months after the diagnosis of AIP, peritoneal carcinomatosis developed without noticeable changes in the pancreas from the initial findings.

Endoscopic Resection of Xanthogranulomatous Gastritis Presenting as a Subepithelial Tumor: A Case Report

Xanthogranulomatous gastritis (XGG) presenting as a subepithelial tumor (SET) is a very rare entity. We report a case of SET-like XGG diagnosed and treated with endoscopic resection. A 55-year-old female patient was initially referred with a 1.5-cm SET located at the anterior wall of the middle antrum. Endoscopic ultrasound examination revealed submucosal invasion without any perigastric lymph node enlargement. Endoscopic resection was performed for an accurate diagnosis and treatment, and the lesion was diagnosed histopathologically as XGG. At the 18-month follow-up after endoscopic resection, there was no evidence of XGG recurrence. SET-like XGG is very rare and the diagnosis is a preoperative challenge. However, inflammatory tumors should be considered in the differential diagnosis of SET

A Ruptured Cystic Artery Pseudoaneurysm with Concurrent Cholecystoduodenal Fistula: A Case Report and Literature Review

Pseudoaneurysms of the cystic artery and cholecystoduodenal fistula formation are rare complications of cholecystitis and either may result from an inflammatory process in the abdomen. A 68-year-old man admitted with acute cholecystitis subsequently developed massive upper gastrointestinal (GI) bleeding. Abdominal computed tomography showed acute calculous cholecystitis and hemobilia secondary to bleeding from the cystic artery. Angiography suggested a ruptured pseudoaneurysm of the cystic artery. Upper GI endoscopy showed a deep active ulcer with an opening that was suspected to be that of a fistula at the duodenal bulb. The patient was managed successfully with multimodality treatment that included embolization followed by elective laparoscopic cholecystectomy. Presently, there is no clear consensus regarding the clinical management of this disease. We have been able to confirm various clinical features, diagnoses, and treatments of this disease through a literature review. A multidisciplinary approach through interagency/interdepartmental collaboration is necessary for better management of this disease.

A Case of Endoscopically Treated Gastric Lymphangioma

No abstract available.

Online Registry for Nationwide Database of Current Trend of Helicobacter pylori Eradication in Korea: Interim Analysis

Eradication of Helicobacter pylori using first-line therapy is becoming less effective. Subjects who had been treated for H. pylori infection were prospectively enrolled through an on-line database registry from October 2010 to December 2012. Demographic data, detection methods, treatment indication, regimens, durations, compliance, adverse events, and eradication results for H. pylori infection were collected. Data of 3,700 patients from 34 hospitals were analyzed. The overall eradication rate of the first-line therapy was 73.0%. Eradication failure was significantly associated with old age, concomitant medication, and comorbidity. Regional differences in eradication rates were observed. The most common first-line therapy was proton pump inhibitor-based triple therapy (standard triple therapy, STT) for 7 days (86.8%). The eradication rates varied with regimens, being 73% in STT, 81.8% in bismuth-based quadruple therapy, 100% in sequential therapy, and 90.3% in concomitant therapy. The eradication rate in treatment-naïve patients was higher than that in patients previously treated for H. pylori infection (73.8% vs. 58.5%, P < 0.001). The overall eradication rate for second-line therapy was 84.3%. There was no statistical difference in eradication rates among various regimens. H. pylori eradication rate using STT is decreasing in Korea and has become sub-optimal, suggesting the need for alternative regimens to improve the efficacy of first-line therapy for H. pylori infection.

Online Registry for Nationwide Database of Current Trend of Helicobacter pylori Eradication in Korea: Interim Analysis

Eradication of Helicobacter pylori using first-line therapy is becoming less effective. Subjects who had been treated for H. pylori infection were prospectively enrolled through an on-line database registry from October 2010 to December 2012. Demographic data, detection methods, treatment indication, regimens, durations, compliance, adverse events, and eradication results for H. pylori infection were collected. Data of 3,700 patients from 34 hospitals were analyzed. The overall eradication rate of the first-line therapy was 73.0%. Eradication failure was significantly associated with old age, concomitant medication, and comorbidity. Regional differences in eradication rates were observed. The most common first-line therapy was proton pump inhibitor-based triple therapy (standard triple therapy, STT) for 7 days (86.8%). The eradication rates varied with regimens, being 73% in STT, 81.8% in bismuth-based quadruple therapy, 100% in sequential therapy, and 90.3% in concomitant therapy. The eradication rate in treatment-naïve patients was higher than that in patients previously treated for H. pylori infection (73.8% vs. 58.5%, P < 0.001). The overall eradication rate for second-line therapy was 84.3%. There was no statistical difference in eradication rates among various regimens. H. pylori eradication rate using STT is decreasing in Korea and has become sub-optimal, suggesting the need for alternative regimens to improve the efficacy of first-line therapy for H. pylori infection.

A Case of Acute Phlegmonous Gastritis Diagnosed with Endoscopic Submucosal Biopsy and Bacterial Culture and Improved by Antibiotics Treatment

Phlegmonous gastritis is a rare disease of acute suppurative inflammation in the stomach wall. It is rapidly progressive and potentially fatal. Its mortality rate remains very high because the clinical diagnosis is often delayed. Many patients with phlegmonous gastritis undergo surgery. We present the case of 63-year-old woman with epigastric pain, fever, nausea and vomiting. The presumed diagnosis of acute phlegmonous gastritis was made by esophagogastroduodenoscopy, abdominal computed tomography, endoscopic ultrasonography and deep submucosal biopsy assisted with hook knife. Acinetobacter baumannii was cultured in the aspiration from the stomach. We treated the patient with antibiotics alone. Early recognition of phlegmonous gastritis by endoscopic biopsies and bacteriological study may improve the prognosis of these patient.

Gastroprotective Effects of Grape Seed Proanthocyanidin Extracts against Nonsteroid Anti-Inflammatory Drug-Induced Gastric Injury in Rats

BACKGROUND/AIMS: To investigate the gastroprotective effects of grape seed proanthocyanidin extracts (GSPEs) against nonsteroid anti-inflammatory drug (NSAID)-induced gastric mucosal injury in rats. METHODS: Sprague-Dawley rats were randomly allocated to the normal control, indomethacin, low-dose GSPE, high-dose GSPE and misoprostol groups. All groups except the normal control group received pretreatment drugs for 6 consecutive days. On the 5th and 6th day, indomethacin was administered orally to all groups except for normal control group. The microscopic features of injury were analyzed. The levels of gastric mucosal glutathione, gastric mucosal prostaglandin E2 (PGE2), and proinflammatory cytokines were investigated. RESULTS: The total areas of ulceration in the GSPE and misoprostol groups were significantly decreased compared with the indomethacin group (p<0.05). However, a difference in ulcer formation among the drug treatment groups was not observed. Meanwhile, the glutathione levels in the high-dose GSPE group were higher than those of both the indomethacin and misoprostol groups (p<0.05) and were similar to those of the normal control group. Additionally, there was no difference among the groups in the levels of gastric mucosal PGE2 and proinflammatory cytokines. CONCLUSIONS: High-dose GSPE has a strong protective effect against NSAID-induced gastric mucosal injury, which may be associated with the antioxidant effects of GSPE.

Atrophic Gastritis: Reversible after Treatment?

Chronic atrophic gastritis is a result of chronic inflammation characterized by the replacement of oxyntic and antral gastric glandular structures by connective tissue or by glandular structures inappropriate for location such as metaplastic atrophy. Chronic atrophic gastritis is considered as one of the major risk factors for noncardiac gastric cancer or mucosa associated lymphoid tissue lymphoma. Since chronic inflammation is generally considered to be triggered by Helicobacter pylori infection, many studies have evaluated whether H. pylori eradication therapy could make histologic improvement or reversal. However, it is controversial whether eradication of H. pylori improves atrophy or metaplasia. There has been a lot of conflict, but many previous studies including meta-analyses tend to demonstrate that it is possible that gastric atrophy could be improved after H. pylori eradication in the corpus but not in the antrum. Also, intestinal metaplasia seems to be irreversible even after H. pylori eradication.

Atrophic Gastritis: Reversible after Treatment?

Chronic atrophic gastritis is a result of chronic inflammation characterized by the replacement of oxyntic and antral gastric glandular structures by connective tissue or by glandular structures inappropriate for location such as metaplastic atrophy. Chronic atrophic gastritis is considered as one of the major risk factors for noncardiac gastric cancer or mucosa associated lymphoid tissue lymphoma. Since chronic inflammation is generally considered to be triggered by Helicobacter pylori infection, many studies have evaluated whether H. pylori eradication therapy could make histologic improvement or reversal. However, it is controversial whether eradication of H. pylori improves atrophy or metaplasia. There has been a lot of conflict, but many previous studies including meta-analyses tend to demonstrate that it is possible that gastric atrophy could be improved after H. pylori eradication in the corpus but not in the antrum. Also, intestinal metaplasia seems to be irreversible even after H. pylori eradication.

Ectopic Pancreas Bleeding in the Jejunum Revealed by Capsule Endoscopy

Ectopic pancreas is defined as pancreatic tissue found outside the usual anatomic location. It is often found incidentally at different sites in the gastrointestinal (GI) tract. The incidence of ectopic pancreatic tissue in autopsy series is 1% to 2%, with 70% of the ectopic lesions found in the stomach, duodenum and jejunum. Although it is usually a silent anomaly, an ectopic pancreas may become clinically evident when complicated by inflammation, bleeding, obstruction or malignant transformation. We report a case of ectopic pancreas located in the jejunum and presenting as an obscure GI bleeding, which was diagnosed by capsule endoscopy.

The Relationship between Gastric Juice Nitrate/Nitrite Concentrations and Gastric Mucosal Surface pH

PURPOSE: To investigate gastric juice nitrate/nitrite concentration according to mucosal surface pH extent (area) of gastric corpus intimately contacting the gastric juice. MATERIALS AND METHODS: We included ninety-nine patients with dyspepsia. To evaluate gastric mucosal surface pH and its extent, gastric chromosocpy was performed by spraying phenol red dye on the corpus mucosa and estimating the extent of area with color changed. Nitrate/nitrite concentrations and pH of gastric juice were measured by ELISA and pH meter, respectively. Silver staining was done to histologically confirm the presence of Helicobacter pylori. RESULTS: Intragastric nitrate/nitrite concentrations in patients, showing phenol red staining mucosa were higher than those of unstaining mucosa (p=0.001): the more extensive in the area of phenol red staining area of corpus, the higher gastric juice pH found (r=0.692, p<0.001). Furthermore, the intragastric nitrate/nitrite concentrations correlated positively with gastric juice pH (r=0.481, p<0.001). CONCLUSION: The changes of mucosal surface pH and its extent in gastric corpus might affect either pH or nitrate/nitrite level of gastric juice.

A Case of Abdominal Actinomycosis Presenting as Ileocecal Ulcers and Recurrent Lower Gastrointestinal Bleeding

Abdominal actinomycosis is a rare chronic suppurative infection that is difficult to diagnose precisely without an operation. It also tends to be misdiagnosed as a malignancy, intestinal tuberculosis, diverticular disease, or Crohn's disease. A 54-year-old man presented with loose stools, hematochezia, and vague abdominal pain in the right lower quadrant. He had had a history of hematochezia and recurrent colon ulcers on colonoscopy seven times within the past 3 years. A colonoscopy at admission revealed multiple, variably sized and shaped ulcerations in the terminal ileum, cecum, and ascending and transverse colons. Biopsies from the cecal ulcer demonstrated sulfur granules. This is the first cases of abdominal actinomycosis presenting as a recurrent lower gastrointestinal hemorrhage due to ileocolic ulcerations in Korea.

Differential LINE-1 Hypomethylation of Gastric Low-Grade Dysplasia from High Grade Dysplasia and Intramucosal Cancer

BACKGROUND/AIMS: Gastric epithelial dysplasia is considered a precancerous lesion with a variable clinical course. There is disagreement, however, regarding histology-based diagnoses, which has led to confusion in choosing a therapeutic plan. New objective markers are needed to determine which lesions progress to true malignancy. We measured LINE-1 methylation levels, which have been reported to strongly correlate with the global methylation level in gastric epithelial dysplasia and intramucosal cancer. METHODS: A total of 145 tissue samples were analyzed by two histopathologists. All tissues were excised by therapeutic endoscopic mucosal resection and paired with adjacent normal tissue samples. A modified long interspersed nucleotide elements-combined bisulfite restriction analysis (COBRA-LINE-1) method was used. RESULTS: Gastric epithelial dysplasia and intramucosal cancer tissues had significantly lower levels of LINE-1 methylation than adjacent normal gastric tissues. High-grade dysplasia and intramucosal cancer were distinguishable from low-grade dysplasia based on LINE-1 methylation levels. Furthermore, the distinction could be determined with high sensitivity and specificity, as shown by the receiver operating characteristic (ROC) curve (AUC, 0.82; 95% confidence interval, 0.74 to 0.88). CONCLUSIONS: LINE-1 methylation levels may provide a diagnostic tool for identifying high-grade dysplasia and intramucosal cancer.

A Case of Gastritis Cystica Polyposa Presenting as a Hyperplastic Polyp / 대한내과학회지

Gastritis cystica polyposa (GCP) is a rare lesion characterized by hyperplastic and cystic dilatation of the gastric mucosal glands infiltrating into the underlying submucosa. In most cases, it develops in patients who have undergone a gastroenterectomy, but can occasionally be found in an unoperated stomach. GCP may present as a submucosal tumor or polyp, and rarely as a giant gastric mucosal fold. We experienced a case of GCP that presented as a hyperplastic polyp, and it was unrelated to any gastric surgery. Upper endoscopy revealed the presence of a subpedunculated polyp in the posterior wall of the antrum. The lesion was successfully removed by endoscopic mucosal resection and diagnosed as a GCP.

A Case of Primary Extragastrointestinal Stromal Tumor Presenting as Peritoneal Dissemination / 대한소화기학회지

Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor of the gastrointestinal tract, but also occurs at a lower frequency in extra-gastrointestinal regions such as omentum, mesentery, retroperitoneum and undefined abdominal sites. This tumor is called extragastrointestinal stromal tumor (EGIST). EGIST is mostly diagnosed as a cystic mass, but rarely occurs as a disseminated abdominal tumor. We experienced a 70-year-old man with primary EGIST presenting as peritoneal dissemination. Abdominal CT showed diffuse peritoneal thickening with a large amount of ascites, but no definite mass lesion. Laparoscopic biopsy was performed and histologic findings showed tumor composed of epithelioid cells. In the results of immunohistochemical stains, the tumor showed positive reactivity with CD117 (c-kit), CD34, vimentin and actin, but negative reactivity with desmin and S-100 protein. On account of unresectability and histologic parameters of malignant behavior, he was started on imatinib.

A Case of Pseudomalignant Erosion in an Inflammatory Polyp at the Esophagogastric Junction / 대한소화기내시경학회지

Some cases of polypoid lesions arisen from the gastric mucosa just below a lower esophageal erosion. This lesion can have various sizes and shapes. It is known as a hyperplastic lesion associated with esophagitis or an inflammatory lesion. Sometimes only a polyp is found without an erosion. This polypoid lesion is often called as sentinel polyp and is usually considered to be a benign lesion. Here we report a case of a pseudomalignant erosion in which an inflammatory polyp at the esophagogastric junction was successfully removed by endoscopic submucosal dissection even though the polyp was initially mistaken for a squamous cell carcinoma.

Undifferentiated Adenocarcinoma of the Colon with Rhabdoid Features / 대한소화기내시경학회지

Malignant rhabdoid tumors were first described in 1978 by Beckwith and Palmer as a rare variant of Wilms' tumors with a "rhabdomyosarcomatoid" pattern and a particularly poor prognosis. Week reclassified this disease as a distinct disease in 1989 and thereafter, there have been several reports about malignant rhabdoid tumor that occurred in various organs, including the colon. The histologic characteristics of rhabdoid tumor are noncohesive or loosely cohesive cells with high cellularity, an eccentric large nucleus and eosinophilic cytoplasm, and the cytoplasm is usually positive for vimentin and it contain hyaline inclusions. On immunohistochemical staining, the cells are usually positive for vimentin and cytokeratin and they are negative for desmin. This tumor progresses rapidly and it has a very poor prognosis, but survival is better if there is no lymphatic or distant metastasis. We experienced a patient who suffered with undifferentiated adenocarcinoma with rhabdoid features in the ascending colon.

A Case of Malignant Duodenocolic Fistula Treated with Covered Metallic Stents / 대한소화기내시경학회지

Malignant duodenocolic fistula is a rare complication of colon cancer, and this usually develops as the right-side colon cancer that invades the duodenal bulb. The fistula often results in watery diarrhea, weight loss and feculent vomiting. A barium enema or duodenography have been the most useful diagnostic procedures, and the fistula is directly confirmed by an endoscopic examination. Curative resection is not possible in many cases due to metastasis or local invasion, so a palliative operation can be performed to relieve symptoms, but it cannot completely prevent the vomiting or diarrhea. Seven Korean cases of malignant duodenocolic fistula have been previously reported on, and an operation was performed in six cases. We report here on a case of duodenocolic fistula with intestinal obstruction that arouse from a right-side colon cancer, and this was successfully managed by placing covered metallic stents at the duodenum and hepatic flexure.

A Case of Endoscopic Removal of a Broken off Gastric Balloon from a Sengstaken-Blakemore Tube / 대한소화기내시경학회지

A Sengstaken-Blakemore (S-B) tube, when used approximately, still has a place in the management of acute variceal bleeding, and controls bleeding in 40~90% of the cases. However its use is accompanied by number of complications such as esophageal ulcer, pulmonary aspiration, and malfunction of the tube, which requires replacement. We recently observed a very unusual complication: the remaining gastric balloon of a S-B tube was broken off in the fundus of stomach by the patient's traction. The gastric balloon was easily and safely removed using an endoscopic snare after deflating the gastric balloon with a needle puncture.