Imaging Findings of an Intraluminal Duodenal Diverticulum Associated with Adult Duodeno-Duodenal Intussusception and Recurrent Pancreatitis: A Case Report

Intraluminal duodenal diverticulum (IDD) is a rare congenital abnormality, consisting of a sac-like mucosal lesion in the duodenum. Cases of IDD can present with gastrointestinal bleeding, duodenal obstruction, or pancreatitis. Here, we report a rare case of a 25-year-old female presenting with IDD complicated by duodeno-duodenal intussusception and recurrent pancreatitis. The diagnosis was based on findings from radiologic examinations (CT and MRI), upper gastrointestinal series (barium swallow), and gastroduodenofiberscopy. Laparoscopic excision of the presumed duodenal duplication was performed. The subsequent histopathologic evaluation of the excised sac revealed normal mucosa on both sides, but the absence of a proper muscle layer confirmed the diagnosis of IDD. Radiologic detection of a saccular structure in the second portion of the duodenum can indicate IDD with duodeno-duodenal intussusception as the lead point

ERCP Room Setting: What Doctors Starting ERCP Need to Know / 대한췌담도학회지

To date, there is no standardization of the endoscopi c retrograde cholangiopancreatography (ERCP) room setting regarding with the size, equipment or space arrangement. Therefore, the authors visited 11 tertiary hospitals that recently remodeled or newly designed the ERCP room to analyze and identify their advantages and disadvantages. The ERCP room should have enough space for equipments including fluoroscopy, endoscopy, electrosurgical unit, preparation table and for patient movement. The EUS room does not require an independent space unless it is a very large scale hospital, and the ERCP room can be shared. Considering the pros and cons of each equipment, adequate fluoroscopic device should be selected depending on the hospital circumstance. Expensive equipment for X-ray fluoroscopy system is not necessarily good, and it is necessary to install equipment suitable for each hospital situation by understanding the advantages and disadvantages of fluoroscopy. For prevention of ERCP-related radiation hazard, both endoscopist and assistants should wear radiation-blocking apron, thyroid protectors, and lead glasses. Furthermore, a shield that can block radiation between the endoscopist and the patient should be installed to protect high-energy scattered waves. One-way direction should be designed to prevent cross infection when moving the endoscopic equipment from the ERCP to the cleaning room. If possible, it is recommended to keep a cardiopulmonary resuscitation cart in the ERCP room.

ERCP Room Setting: What Doctors Starting ERCP Need to Know / 대한췌담도학회지

To date, there is no standardization of the endoscopi c retrograde cholangiopancreatography (ERCP) room setting regarding with the size, equipment or space arrangement. Therefore, the authors visited 11 tertiary hospitals that recently remodeled or newly designed the ERCP room to analyze and identify their advantages and disadvantages. The ERCP room should have enough space for equipments including fluoroscopy, endoscopy, electrosurgical unit, preparation table and for patient movement. The EUS room does not require an independent space unless it is a very large scale hospital, and the ERCP room can be shared. Considering the pros and cons of each equipment, adequate fluoroscopic device should be selected depending on the hospital circumstance. Expensive equipment for X-ray fluoroscopy system is not necessarily good, and it is necessary to install equipment suitable for each hospital situation by understanding the advantages and disadvantages of fluoroscopy. For prevention of ERCP-related radiation hazard, both endoscopist and assistants should wear radiation-blocking apron, thyroid protectors, and lead glasses. Furthermore, a shield that can block radiation between the endoscopist and the patient should be installed to protect high-energy scattered waves. One-way direction should be designed to prevent cross infection when moving the endoscopic equipment from the ERCP to the cleaning room. If possible, it is recommended to keep a cardiopulmonary resuscitation cart in the ERCP room.

Practice of Endoscopic Retrograde Cholangiopancreatography in Korea: Results from a National Survey / 대한췌담도학회지

BACKGROUND/AIMS: The aim of this study is to describe the outcome of the national survey and to determine the endoscopic retrograde cholangiopancreatography (ERCP) quality in Korea by comparing with the quality indicators. METHODS: We used the database of Health Insurance Review & Assessment Service and then performed anonymous national survey. RESULTS: Completed questionnaires were returned by 129 of 157 ERCP endoscopists. In Korea, annual ERCP rates have been consistently increased over years. Individual ERCP volume was high (>200 per year) in about half of ERCP endoscopists. Most ERCP endoscopists performed all of level I procedures. However, manometry, cholangiopancreatoscopy, and pancreatic procedures were performed mostly in institutions with high hospital volume. The rate of overall success was more than 90% in most ERCP endoscopists. However, the rate of precut sphincterotomy was high in more than a fourth of ERCP endoscopists. Twelve ERCP endoscopists experienced post-ERCP mortality within recent 1 year. ERCP training and radiation protection during ERCP did not meet the standard of quality indicators especially in institutions with low or moderate hospital volume. CONCLUSIONS: Technical issues during ERCP procedures in Korea fulfill the standard of quality indicators. However, a great effort is needed to improve issues about ERCP training and radiation protection.

Safety of Sedated Therapeutic Endoscopic Retrograde Cholangiopancreatography in Patients Older than 70 Years Old / 이화의대지

OBJECTIVES: The purpose of this study was to compare the safety and efficacy of midazolam sedated Endoscopic retrograde cholangiopancreatography (ERCP) with unsedated ERCP in patients 70 years of ages and older. METHODS: Seventy elderly patients 70 years of age or older who underwent ERCP were divided into two groups: midazolam sedated group (n=43) and unsedated group (n=27). Procedure time, success rate, complications related with ERCP procedure, satisfaction score were analyzed between two groups. RESULTS: Mean procedure time was 20.6 minutes for sedated group and 21.0 minutes for unsedated group (P=0.88). Success rate was 87.5% for sedated group and 100% for unsedated group (P=0.07). Incidence of complications from ERCP procedure showed no significant differences between the sedated and unsedated groups (P=0.10). There was no mortality in both groups related to the sedation or post-ERCP complication. Compared to the unsedated procedure, the sedated ERCP procedure was associated with higher patient satisfaction (P<0.001) and better repeat compliance (P=0.004). CONCLUSION: There was no significant difference in success rate and complications at sedated and unsedated ERCP in patients 70 years of age and older. Unsedated ERCP showed 66.6% satisfaction score compared to sedated ERCP.

Acute Respiratory Distress Syndrome after Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma: A Case Report / 이화의대지

Transcatheter arterial chemoembolization (TACE) has become an effective alternative treatment strategy for patients with inoperable hepatocellular carcinoma (HCC). Although TACE is relatively safe, acute respiratory distress syndrome associated with pulmonary lipiodol embolism is a rare and potentially fatal complication. We report a rare case of acute respiratory distress syndrome after TACE for inoperable HCC. A 75-year-old man, with huge HCC in right lobe, was treated by TACE for the first time. Seven hours after uneventful TACE procedure, he felt dyspneic and his oxygen saturation recorded by pulse oximetry (SpO2) fell to 80% despite of applying non-rebreathing mask. He underwent mechanical ventilation with a protective ventilatory strategy. We experienced a case of acute respiratory distress syndrome after TACE for HCC.

Clinicopathologic Charateristics and Gallbladder Dysfunction in Patients with Endoscopic Bile Reflux / 이화의대지

OBJECTIVES: To investigate clinicopathologic findings and gallbladder (GB) function in patients with endoscopic bile reflux at outpatients clinic. METHODS: We classified endoscopic bile reflux into two groups by bile reflux index (BRI). Those who scored above 14 were the BRI (+) group, and those below 14 were the BRI (-) group. We analyzed clinical characteristics, endoscopic findings including Helicobacter pylori, GB function by DISIDA scan, and electron microscope (EM) findings of endoscopic bile reflux. And we compared clinicopathologic characteristics and GB function between two groups. RESULTS: Endoscopic bile reflux identified in 9.7% of all cases with gastrointestinal symptoms. There are cholecystectomy in 6.7%, gastrectomy in 2.7%, and GB dysfunction in 20.0%. They had prominent gastrointestinal symptoms with variable endoscopic findings. Foveolar hyperplasia is the most common pathologic finding and H. pylori colonization of the stomach was inhibited in cases of bile reflux gastritis. Bile reflux also had distinguishable ultra-structural changes identifiable by EM. BRI (+) group had more old age, GB dysfunction than BRI (-) group. Clinical symptoms and endoscopic findings did not differ between the two groups of endoscopic bile reflux. CONCLUSION: Endoscopic bile reflux was common findings with young adults (30's) at outpatients clinic. Foveolar hyperplasia is common pathologic finding. GB dysfunction were identified as significant risk factors for BRI (+) group.

Clinical Significance of New Classification of Mild Acute Pancreatitis / 이화의대지

OBJECTIVES: This study aimed to provide an actualized classification system for acute pancreatitis (AP) by applying new principle and investigated the benefits of new classification. METHODS: Medical records and computed tomography (CT) images of 235 consecutive patients with AP admitted to the Ewha Womans University Mokdong Hospital between 2005 and 2010 were reviewed. The patients of severe pancreatitis who has necrosis were only 68 cases, these are too small for comparing to mild form. So we analyzed mild form of pancreatitis preferentially into two groups; group A, without morbidity and without organ failure (145 patients, mild acute pancreatitis, MAP); group B, with morbidity and without organ failure (22 patients, aggressive mild acute pancreatitis, AMAP). Clinical characteristics, laboratory findings, duration of hospitalization, need for the intensive care unit (ICU), organ failure, needs of intervention, another severity indexes and death were evaluated. RESULTS: AMAP (group B) was higher proportion of need for the ICU care and of organ failure than MAP after age-adjusting (P<0.01). Also AMAP had higher incidence of associated malignancy, pseudocysts, and increasing fasting sugar level. CONCLUSION: The AMAP is a different type of MAP. We need new category of different grade of mild form pancreatitis, because AMAP showed different clinical course. New classification of mild acute pancreatitis is relatively effective, and has clinically significant value.

The Outcome of Laparoscopic Common Bile Duct Exploration (LCBDE) for the Choledocholithiasis that ERCP Failed to Remove

PURPOSE: With the advent of endoscopic technology, ERCP (endoscopic retrograde cholangiopancreatography)/ES (endoscopic sphincterotomy) has become the main treatment for CBD stones. However, when ERCP fails to remove CBD stones, it remains unclear whether laparoscopic treatment is an alternative or not. The aim of this study was to investigate the outcome of LCBDE for the management of difficult choledocholithiasis. METHODS: This study was a retrospective analysis of 68 LCBDE cases that were performed at the Ewha Womans University School of Medicine, Mokdong Hospital from January, 2000 to March, 2006. Group A was defined that primary LCBDE was performed without ERCP/ES. Group B was defined that secondary LCBDE was performed after ERCP/ES had failed. The operative outcomes and postoperative complications were compared between the two groups. RESULTS: Primary LCBDE was performed for 33 patients (Group A) and secondary LCBDE after failure of ERCP/ES was performed for 35 patients (Group B). No significant differences in gender, mean age and associated diseases were noted between the two groups. The stone clearance rate was 100% for both groups. There were no significant differences between the two groups for the mean operative time (201.5 min for Group A vs 188.7 min for Group B: P=0.415), the open conversion rate (9.1% vs 0%, respectively: P=0.068), the complication rate (12.1% vs 8.6%, respectively: P=0.630) and the duration of the hospital stay (14.3 days vs 11.9 days, respectively: P=0.169). The recurrence rate along with a mean follow-up of 24 months showed no significant difference between the two groups (12.1% vs 2.9%, respectively). CONCLUSION: When ERCP is impossible or stone retrieval is incomplete, LCBDE is an alternative treatment for difficult CBD stones.

The Infection Rate of Helicobacter pylori and Its Relation to Gastrointestinal Symptoms in Patients with Chronic Renal Failure / 대한소화기내시경학회지

BACKGROUND/AIMS: Helicobacter pylori (H. pylori) can survive in the acid milieu of stomach by producing urease, which generates acid neutralizing ammonia by splitting gastric urea and creates a satisfactory environment for H. pylori. Thus the patients with chronic renal failure (CRF) with increased diffusion of blood urea to gastric lumen may be theoretically more susceptible to colonization with H. pylori. To investigate the infection rate of H. pylori in CRF and its relation to gastrointestinal symptoms, we performed prospective controlled study. METHODS: We performed gastroscopy in forty-two patients with CRF. Rapid urease test and histologic examination for H. pylori infection were performed. Histological gastritis was graded by updated Sydney classification. Gastrointestinal symptoms were assessed in all CRF patients and serum blood urea nitrogen and creatinine levels were also measured. RESULTS: Twenty-one (50.0%) demonstrated H. pylori infection in patients with CRF. H. pylori infection and major endoscopic findings were not related to the gastrointestinal symptoms in patients with CRF. In H. pylori-positive CRF patients, density of H. pylori and grade of histological gastritis were not related to the severity of gastrointestinal symptoms. CONCLUSIONS: The infection rate of H. pylori was 50% in patients with CRF. Gastrointestinal symptoms in CRF were related to factors other than H. pylori infection.

Perigastric Devascularization with or without Fundectomy for Gastric Variceal Bleeding

PURPOSE: Catastrophic bleeding of the gastric varices has been considered a life threatening emergency. Sclerotherapy cannot easily control the bleeding, and there is a high risk of rebleeding despite successful intervention. Surgery is often necessary to save the life. The purpose of this study was to elucidate the role of surgery and analyze the factors determining operative mortality in gastric variceal bleeding. METHODS: A retrospective study was performed of 30 patients who underwent operation for gastric variceal bleeding with portal hypertension at Ewha Womans University Mok-Dong Hospital from Jul. 1994 to Feb. 2001. Among them, 23 patients received perigastric devascularization with fundectomy and the remainder received perigastric devascularization alone. RESULTS: There was one case of recurrent bleeding from esophageal varix at 8 months postoperative. This was controlled with sclerotherapy. The overall operative mortality rate was 30.0%. Preoperative hepatic functional reserve was a significant factor. The mortality rate was 0% (0/5) in Child-Pugh group A, 27.8% (5/18) in group B, and 57.1% (4/7) in group C (p<0.05). The preoperative success of intervention influenced postoperative outcomes. There was no mortality in the successfully controlled group (0/5). In the failure group, 5 of 7 patients expired (p<0.05). Preoperative transfusion amount was also a significant factor in determining survival. There was 15.8% (3/19) mortality rate in patients trans fused less than 10 units, and a 54.5% (6/11)rate in those receiving more than 10 units (p<0.05). CONCLUSION: This operative approach was effective for saving lives from an otherwise uniformly fatal disease. The rebleeding rate at the follow-up period was low. Proper selection of patients and an early surgical decision could lower the operative mortality.

Effect of Helicobacter pylori Infection on Reflux Gastritis after Gastrectomy / 대한소화기내시경학회지

BACKGROUND/AIMS: Reflux gastritis after gastrectomy is believed to be due to reflux of bile into residual stomach. However the substances that cause gastritis have not yet been precisely defined. Helicobacter pylori (H. pylori) infection is considered one of the most important pathogenetic factors in gastritis. The prevalence of H. pylori infection and the role of its infection on reflux gastritis after gastrectomy were investigated. METHODS: Eighty-one patients who had undergone subtotal gastrectomy were enrolled. Rapid urease test and histologic examination for H. pylori infection were performed during gastrofiberscopy. An eradication of H. pylori was attempted in fifteen H. pylori-positive patients who suffered from gastritis symptoms after gastrectomy. Follow-up endoscopy was performed more than 4 weeks after the end of eradication treatment. RESULTS: Forty-nine patients (60.5%) demonstrated H. pylori infection in their residual stomach. The histological gastritis score in patients with H. pylori infection was significantly higher than that without infection. Ten of the 15 patients (66.7%) with H. pylori infection had their infection successfully eradicated. And also their symptoms and histological gastritis score were significantly improved. CONCLUSIONS: H. pylori infection does play an important role on reflux gastritis after subtotal gastrectomy.

Association Between Polymorphisms of Ethanol-Metabolizing Enzymes and Susceptibility to Alcoholic Cirrhosis in a Korean Male Population

Alcohol is oxidized to acetaldehyde by alcohol dehydrogenase (ADH) and cytochrome P-4502E1 (CYP2E1), and then to acetate by aldehyde dehydrogenase (ALDH). Polymorphisms of these ethanol-metabolizing enzymes may be associated with inter-individual difference in alcohol metabolism and susceptibility to alcoholic liver disease. We determined genotype and allele frequencies of ALDH2, CYP2E1, ADH2, and ADH3 in male Korean patients with alcoholic cirrhosis (n=56), alcoholics without evidence of liver disease (n=52), and nondrinkers (n=64) by using PCR or PCR-directed mutagenesis followed by restriction enzyme digestion. The prevalences of heterozygous ALDH2*1/*2 plus homozygous ALDH2*2/*2 in patients with alcoholic cirrhosis (7.1%) and alcoholics without evidence of liver disease (3.8%) were significantly lower than that in nondrinkers (45.3%). The c2 allele frequencies of the CYP2E1 in alcoholic cirrhosis, alcoholics without evidence of liver disease, and nondrinkers were 0.21, 0.20, and 0.20, respectively. Allele frequencies of ADH2*2 in the three groups were 0.78, 0.74, and 0.77 and those of ADH3*1 were 0.94, 0.98, and 0.95. Therefore, we confirmed the observation that the ALDH2*2 gene protects against the development of alcoholism. However, the development of cirrhosis in Korean alcoholic patients was not associated with polymorphisms of ethanol-metabolizing enzymes.

Efficacy and Safety of Weekend Therapy for the Eradication of Helicobacter pylori Infection / 대한소화기내시경학회지

BACKGROUND/AIMS: Because treatment duration directly influences both patient compliance and side effects in the eradication of Helicobacter pylori (H. pylori), shortening the duration remains the main goal of therapeutic strategies. The aim of the present study was to evaluate the efficacy and safety of short-term regimen (weekend therapy) for curing the H. pylori infection. METHODS: Twenty-eight patients with H. pylori-positive peptic ulcer received omeprazole 40 mg once daily for 7 days (from Monday to Sunday), bismuth 240 mg q.i.d., amoxicillin 1 g q.i.d., and metronidazole 500 mg q.i.d. for only 2 days (Saturday and Sunday). We compared the eradication rate with that of seventy-eight patients with H. pylori-positive peptic ulcer who had received either OAC (omeprazole, amoxicillin, and clarithromycin) or BMA (bismuth, metronidazole, and amoxicillin) regimens during the same period. H. pylori infection was assessed before treatment by rapid urease test or histologic examination. Four weeks after the end of treatment, the infection was also assessed by rapid urease test, histologic examination or urea breath test in weekend group and by urea breath test in control group. RESULTS: H. pylori eradication rates were 61.1% by per-protocol analysis and 39.3% by intention-to-treatment analysis. There were no treatment associated serious side effects, and only one patient (5.6%) showed mild epigastric discomfort. All patients completed the course of treatment. CONCLUSIONS: Weekend therapy have relatively low eradication rate, however, this therapeutic approach is safe and shows good compliance for the treatment of H. pylori infection.

Cholangiocarcinoma Associated with Hepatolithiasis

BACKGROUND: The authors experienced cholangiocarcinomas associated with intrahepatic duct stones, so we reviewed and summarized the clinical features of these patients to shed light on the pathogenetic implication of hepatolithiasis on the development of cancer and to emphasize the role of hepatic resection in the management of hepatolithiasis. METHODS: We performed 54 hepatic resections in 106 hepatolithiasis patients (51%) during 5 years from Sep. 1993 to Jun. 1998. The medical records of these patients were retrospectively reviewed. Clinical and demographic findings were analyzed and compared with those for all the hepatolithiasis cases. Statistical analysis was done with the chi-square test and Student t-test. RESULTS: Eight patients out of 106 intrahepatic duct stone patients were associated with a cholangiocarcinoma (7.5%). The mean age was 59.5 13.4 years, and the male to female ratio was 1:3. Chief complaints were right upper quadrant pain (87.5%), fever (50%), jaundice (25%), indigestion (25%), and weight loss (12.5%). Clinically, 4 cases were presented as acute cholangitis, and 1 case was pancreatitis. The locations of the tumors were the right lobe in 2 cases, the left lobe in 3 cases, and the hilar portion in 3 cases. Preoperative diagnosis was clinically possible only in one case. Intraoperative diagnoses were possible in 5 cases with clinical suspicion of cancer and were confirmed by using frozen biopsy. Three cases were incidentally diagnosed as cancer by postoperative pathological reports. We missed the presence of cancer in these cases due to associated hepatic abscesses. The operations performed were a right lobectomy in 1 case, an extended right lobectomy in 1 case, a left lobectomy in 2 cases, a left lateral segmentectomy in 2 cases, and an extrahepatic bile duct resection with hepaticojejunostomy in 1 case. A palliative hepaticojejunostomy was done in 1 case, and the patient died 3 months later. Another patients survived for over 2 years after operations. CONCLUSION: Aggressive hepatic resection for hepatolithiasis is recommended in view of highly coincident hidden cancer and the difficulty in diagnosis that cancer. Molecular and genetic investigations are needed to verify the etiological correlation between hepatolithiasis and cholangiocarcinomas.

TProtective effect of chlormethiazole, a sedative, against acetaminophen-induced liver injury in mice

OBJECTIVES: The hepatotoxicity of acetaminophen is not a result of the parent compound but is mediated by its reactive metabolite N-acetyl-p-benzoquinone imine. Cytochrome P4502E1 (CYP2E1) is the principal enzyme of this biotransformation, which accounts for approximately 52% of the bioactivation in human microsomes. Recently, chlormethiazole a sedative drug, is reported to be an efficient inhibitor of CYP2E1 activity in human beings. In this study we wished to evaluate whether chlormethiazole, an inhibitor of CYP2E1, could prevent acetaminophen-induced liver injury in mice. METHODS: Acetaminophen, at doses ranging from 200 to 600 mg/kg, was injected into the peritoneum of female C57BL/6 inbred mice fasted for four hours. Chlormethiazole (60 mg/kg) or 5% dextrose water was given 30 min before or 2 h after acetaminophen. Serum aminotransferase activities, histologic index score, survival rate and hepatic malondialdehyde levels were compared. RESULTS: Pretreatment with chlormethiazole 30 min before 400 mg/kg of acetaminophen completely inhibited acetaminophen-induced liver injury (median 118.5 U/L, range 75 to 142 vs. 14,070 U/L, range 5980 to 27,680 for AST; 49 U/L, range 41 to 64 vs. 15,330 U/L, range 13,920 to 15,940 for ALT). In mice receiving chlormethiazole 2 h after acetaminophen, the mean AST and ALT levels were also less elevated, reaching only 20% of the value of acetaminophen-only group. These protective effects were confirmed histologically. Whereas more than 50% of mice died at 500 mg/kg of acetaminophen, all the mice pretreated with chlormethiazole survived at the same dose. CONCLUSION: Chlormethiazole effectively reduces acetaminophen-induced liver injury in mice. Further studies are needed to assess its role in humans.

Quantitative Evaluation of Hyperintensity on T1-weighted MRI in Liver Cirrhosis: Correlation with Child-Pugh Classification and Hepatic Encephalopathy

PURPOSE: To investigate the differences in signal changes in the globus pallidus and white matter, as seen on T1-weighted MR brain images, and to determine whether these differences can be used as an indicator of subclinical hepatic encephalopathy. MATERIALS AND METHODS: A total of 25 cases of liver cirrhosis were evaluated.and as a control group, 20 subjects were also studied. Using a 1.5T MRI scannet, brain MR images were btained, and the differences in signal intensity in both the globus pallidus and thalamus and in both white and gray matter were then quantified using the contrast to noise ratio(CNR). On the basis of the Child-Pugh classification, 25 patients with liver cirrhosis were divided into three groups, with eight in group A, eight in B, and nine in C. Using clinical criteria, hepatic encephalopathywas diagnosed in seven of the 25 patients. Thereafter, CNRs(CNR1 and CNR2) were conpared between the control and cirrhotic groups and between cirrhotic groups with or without hepatic encephalopathy. RESULTS: In the control group, mean values were 3.2 +/-5.9 for CNR1 and 8.4 +/-8.0 for CNR2. In the cirrhotic group, these values were 10.6 +/-9.0 for CNR1 and 9.8 +/-6.4 for CNR2. A statistically significant difference was noted between normal and cirrhotic groups only for CNR1(p < 0.05). CNR values in patients with liver cirrhosis were 8.5 +/-11.5 for CNR1 and 11.7 +/-8.7 for CNR2 in the Child A group, 10.4 +/-5.1 for CNR1 and 9.3 +/-3 . 2 for CNR2 in the B group, and 12.8 +/-9.7 for CNR1 and 8.7 +/-6.5 for CNR2 in the C group. There was no significant difference in mean CNRI values between patients with or without hepatic encephalopathy. CONCLUSION: Differences in signal intensities in the globus pallidus and white matter, as seen on T1-weighted MR brain images, cannot be used as an indicator of hepatic encephalopathy in patients with liver cirrhosis.

The Role of the Helicobacter pylori CagA Gene in Gastric Cancer Tissue of Koreans / 대한소화기내시경학회지

BACKGROUND AND AIMS: To further understand the relationship between the cagA gene and gastric cancer, the positive rates of the cagA gene in cancer and non-cancer tissues were investigated separately in patients with gastric cancer. METHODS: The cagA gene was detected by PCR and the ureC gene was analyzed as a positive control for the presence of Helicobacter pylori. Each of two endoscopic biopsies were obtained from cancer and non-cancer tissues of 41 patients with gastric cancer. RESULTS: 1) The positive rate of the cagA gene in cancer tissues was 29.3% (12/41), which was significantly lower than that in non-cancer tissues (63.4%). 2) Twelve (29.3%) out of 41 were positive for the cagA gene in both cancer and non-cancer tissues, 14 were positive in only non-cancer tissues, none were positive in only cancer tissues, and 15 (36.6%) were negative in both sites. 3) The ureC gene was negative in cancer tissue in 12 (85.7%) among 14 cases who were cagA gene negative in the cancer tissue but positive in the non-cancer tissue. 4) There was no difference in the positive rate of the cagA gene according to age, stage, site, and pathologic cell type. CONCLUSIONS: These findings indicate that the positive rate of the cagA gene in cancer tissue was lower than that in non-cancer tissues and this might be related to a low infection rate of H. pylori in cancer tissue rather than the presence of cagA negative H. pylori in cancer tissues.

Incidence and Significance of Periampullary divertucula at Endoscopic retrograde cholangiopancreatography / 대한내과학회지

OBJECTIVES: Diverticula on the second part of the duodenum have a 1-5% incidence in barium studies reports. They have been associated to : choledocholithiasis, biliary dysfunction, acute pancreatitis, diverticulitis, duodencolic fistula, bleeding, malabsorption, and bowel obstruction. With forward viewing endoscope diverticula are not easy to see but with side viewing scope are commonly seen and widely accepted as a cause of difficult cannulation and/or sphinterotomy. The purpose of this study is to determine the incidence of periampullary diverticula and to see whether our results are in accordance wtih above statements included in difficult cannulation and/or sphincterotomy at endoscopic retropgrade cholangiography (ERCP) in retrospectively examine our own series. Also to examine their association with biliary and pancreatic diease. PATIENTS AND METHODS: Three hundred and thirty one consecutive ERCP reports were reviewed with special reference to the following : sex, age, presence of duodenal diverticula, difficulty of cannulation and/or sphinterotomy. RESULTS: Seventy-nine patients (24%) had one or more periampullary diverticula. Age and sex made no difference. Thirty-two (10.3%) had a difficult or unsuccessful cannulation and only five of those patients (1.6%) had periampullary diverticulum (p<0.001). But the failure rate of large sphincterotomy was more common in patient with periampullary diverticum (73.5%) than without diverticulum (24.6%) (p<0.001). The disease of the patients who had diverticulum, gallstone is the most frequent incidence (77.2%). Diverticulum was more frequently found in choledocholithiasis patients (45.3%) than studied patients (24%). CONCLUSION: Periampullary diverticula are a common finding during ERCP and less likely to cause a unsuccessful cannulation, but the cause of unsuccessful sphincteromy.

A Case of Mucin - producing Cholangiocarcinoma in the Patient with Recurrent Cholangitis / 대한소화기내시경학회지

Free-floating tumor debris or mucobilia as a cauae of intermittent obstruction has been described infrequently. A middle aged woman with intermittent jaundice caused by abundant mucus from an intrahepatic mucinous cholangiocarcinoma is presented. Symptoms of juandice, midepigastric pain and fever developed despited an intitial cholecystectomy and common bile duct stone extraction using endoscopic retrograde cholangography (ERCP). Intraductal mucin was diagnosed through on ERCP and confirmed intraoperatively and pathologically as the cause of the obstructive juandice. The patient remained asymptomatic and without evidence of disease for more than 2 years postoperatively. Description is presented of the patient who was admitted presented with recurrent cholangitis caused by profuse secretion of mucus by mucin-producing cholangiocaricnoma, with a review of relevant literature.