Interobserver Variability and Accuracy of High-Definition Endoscopic Diagnosis for Gastric Intestinal Metaplasia among Experienced and Inexperienced Endoscopists

Accurate diagnosis of gastric intestinal metaplasia is important; however, conventional endoscopy is known to be an unreliable modality for diagnosing gastric intestinal metaplasia (IM). The aims of the study were to evaluate the interobserver variation in diagnosing IM by high-definition (HD) endoscopy and the diagnostic accuracy of this modality for IM among experienced and inexperienced endoscopists. Selected 50 cases, taken with HD endoscopy, were sent for a diagnostic inquiry of gastric IM through visual inspection to five experienced and five inexperienced endoscopists. The interobserver agreement between endoscopists was evaluated to verify the diagnostic reliability of HD endoscopy in diagnosing IM, and the diagnostic accuracy, sensitivity, and specificity were evaluated for validity of HD endoscopy in diagnosing IM. Interobserver agreement among the experienced endoscopists was "poor" (kappa = 0.38) and it was also "poor" (kappa = 0.33) among the inexperienced endoscopists. The diagnostic accuracy of the experienced endoscopists was superior to that of the inexperienced endoscopists (P = 0.003). Since diagnosis through visual inspection is unreliable in the diagnosis of IM, all suspicious areas for gastric IM should be considered to be biopsied. Furthermore, endoscopic experience and education are needed to raise the diagnostic accuracy of gastric IM.

A Case of Sparganosis by Ingestion of Undercooked Snakes That Mimicked Peritoneal Carcinomatosis / 대한내과학회지

Sparganosis is a zoonosis caused by sparganum. Humans can be exposed to sparganum by ingesting undercooked snakes or drinking infected copepods harboring sparganum. Sparganosis commonly manifests as migrating subcutaneous masses and may involve multiple organ systems such as the musculoskeletal system, central nervous system, the eyes, and the genitourinary system. We report here a case of laparoscopically confirmed sparganosis caused by ingestion of undercooked snakes. The sparganosis involved the liver and peritoneum and was initially difficult to differentiate from peritoneal carcinomatosis.

A fatal case of hepatitis B virus (HBV) reactivation during long-term, very-low-dose steroid treatment in an inactive HBV carrier

Hepatitis B virus (HBV) may be reactivated after chemotherapy or immunosuppressive therapy, and therefore administration of antiviral agents before such treatment is recommended. Most reported cases of reactivation are associated with high doses of immunosuppressive agents or combination therapy. We present a case of a previously inactive HBV carrier with an acute severe flare-up during a long-term, very-low-dose (2.5 mg/day) steroid treatment for rheumatoid arthritis. We suggest that even a minimal dose of single-regimen oral steroid can cause reactivation of indolent, inactive HBV.

A Case Report of Bile Duct Duplication Arising from the Hepatic Hilum / 대한내과학회지

Anatomic variation in the hepatobiliary tract is relatively common, although bile duct duplication is rare. Detection of biliary tract variation is important because it is closely related to complications such as cholangitis, cholecystitis, pancreatitis, stone formation, and gastrointestinal tract malignancy. Therefore, preoperative imaging and a high index of suspicion are required to make an accurate diagnosis of a biliary tract anomaly. A 44-year-old woman presented with a 2-year history of epigastric pain after eating a meal and gallbladder sludge with chronic cholecystitis. The presumed diagnosis was gallbladder duplication. However, during surgery it was observed that the tubular structure was parallel with the fissure for the ligamentum venosum and ended at the lesser curvature of the stomach. The pathologic diagnosis was bile duct duplication. We report a case of a unique variant of bile duct duplication arising from the hepatic hilum.

A Case of Hepatosplenic T-cell Lymphoma with Colonic Involvement

Hepatosplenic T-cell lymphoma is a rare histologic type of peripheral T-cell lymphoma that usually presents with hepatosplenomegaly, B-symptoms, and often with rapid and aggressive progression. There have been no previous domestic reports of a hepatosplenic T-cell lymphoma involving the colon. We report a case of a 61-year old man with colonic invasion of a hepatosplenic T-cell lymphoma. He presented the sudden onset of fever accompanied by severe pancytopenia and rapid liver enzyme elevation without evidence of lymphadenopathy. Multiple tiny erosions were noted during colonoscopy. In addition, many immature lymphocytes with vague nucleoli, abundant eosinophilic cytosol, and nuclei of small-to-medium size were seen within the sinusoids on liver biopsy. A similar pattern existed on colonic mucosa obtained from colonoscopic biopsy. Thus, with the aid of such a specific clinical presentation and the results of immunohistochemical staining, we made a definitive diagnosis of hepatosplenic T-cell lymphoma with colonic involvement.

A Case of Hepatosplenic T-cell Lymphoma with Colonic Involvement

Hepatosplenic T-cell lymphoma is a rare histologic type of peripheral T-cell lymphoma that usually presents with hepatosplenomegaly, B-symptoms, and often with rapid and aggressive progression. There have been no previous domestic reports of a hepatosplenic T-cell lymphoma involving the colon. We report a case of a 61-year old man with colonic invasion of a hepatosplenic T-cell lymphoma. He presented the sudden onset of fever accompanied by severe pancytopenia and rapid liver enzyme elevation without evidence of lymphadenopathy. Multiple tiny erosions were noted during colonoscopy. In addition, many immature lymphocytes with vague nucleoli, abundant eosinophilic cytosol, and nuclei of small-to-medium size were seen within the sinusoids on liver biopsy. A similar pattern existed on colonic mucosa obtained from colonoscopic biopsy. Thus, with the aid of such a specific clinical presentation and the results of immunohistochemical staining, we made a definitive diagnosis of hepatosplenic T-cell lymphoma with colonic involvement.

A Case of Methicillin-Resistant Staphylococcal Enterocolitis with Subsequent Development of Lymphocytic Colitis

Staphylococcus aureus (S. aureus) is occasionally a normal inhabitant of the gastrointestinal tract, and rarely considered a cause of enterocolitis. Methicillin-resistant Staphylococcal enterocolitis may cause persistent diarrhea leading to severe complications and even death, without appropriate treatment. Lymphocytic colitis (LC), a subtype of microscopic colitis, is a relatively common cause of chronic watery diarrhea. We report the case of a 73-year-old woman with profuse watery diarrhea caused by methicillin-resistant S. aureus. Soon after treatment of her enterocolitis with vancomycin the patient's general condition and symptoms improved, although the diarrhea persisted. Through colonoscopic biopsy and immunohistochemical staining, overt LC was diagnosed, and prompt therapy with budesonide was initiated.

A Case of Pleural Effusion Associated with Acute Hepatitis A / 대한소화기학회지

Hepatitis A virus (HAV) infection is common in developing countries, including Korea. It can be accompanied by extrahepatic complications such as renal failure, arthritis, and vasculitis. Pleural effusion is a very rare complication of HAV infection, which has been reported usually in children, and has benign clinical courses. Here we report a case of pleural effusion with ascites which occurred in an adult hepatitis A patient. A 26-year-old-woman presented generalized myalgia and fever and was diagnosed as acute hepatitis A. Despite of the improvement of laboratory findings, fever and cough persisted. Pleural effusion newly appeared on the serial chest radiologic images. After the fever settled down, the pleural effusion resolved spontaneously at 13th day of admission.

Postinfectious Irritable Bowel Syndrome after Clostridium difficile Infection

BACKGROUND/AIMS: Post-infectious irritable bowel syndrome (PI-IBS) frequently follows bacterial enterocolitis, and there are various reported incidences and clinical courses according to different pathogens. However, there have rarely been any reports regarding the PI-IBS caused by Clostridium difficile infection (CDI). The aims of this study were to evaluate the incidence and the risk factors for developing IBS following CDI. METHODS: We recruited 86 patients with CDI from January 2005 to October 2007 and also we recruited a comparative control group of 86 patients who had no previous history of any gastroenterological disease. The bowel symptoms were prospectively evaluated by phone through a set questionnaire. RESULTS: Of all the CDI patients, a total of 41 patients (47.6%) completed the questionnaires, and IBS developed in 8 patients (19.5%), of which 7 patients (87.5%) were the diarrhea type. A total of 51 patients (59.3%) from the control group completed the questionnaires, of which 4 patients (7.8%) developed IBS. Although there was no statistically significant difference (p=0.099), there was a tendency towards a higher incidence of developing IBS in the CDI patients group, as compared to that of the control group. Comparing the group that developed IBS with the group that didn't among the CDI patients, there were no significantly different factors except for a previous admission history before CDI. CONCLUSIONS: The incidence of PI-IBS after CDI was 19.5%, and the IBS was predominantly the diarrhea-type. In the future, a large scale study needs to be conducted in order to evaluate the PI-IBS incidence after CDI and the risk factors that predispose patients to such conditions.

Postinfectious Irritable Bowel Syndrome after Clostridium difficile Infection

BACKGROUND/AIMS: Post-infectious irritable bowel syndrome (PI-IBS) frequently follows bacterial enterocolitis, and there are various reported incidences and clinical courses according to different pathogens. However, there have rarely been any reports regarding the PI-IBS caused by Clostridium difficile infection (CDI). The aims of this study were to evaluate the incidence and the risk factors for developing IBS following CDI. METHODS: We recruited 86 patients with CDI from January 2005 to October 2007 and also we recruited a comparative control group of 86 patients who had no previous history of any gastroenterological disease. The bowel symptoms were prospectively evaluated by phone through a set questionnaire. RESULTS: Of all the CDI patients, a total of 41 patients (47.6%) completed the questionnaires, and IBS developed in 8 patients (19.5%), of which 7 patients (87.5%) were the diarrhea type. A total of 51 patients (59.3%) from the control group completed the questionnaires, of which 4 patients (7.8%) developed IBS. Although there was no statistically significant difference (p=0.099), there was a tendency towards a higher incidence of developing IBS in the CDI patients group, as compared to that of the control group. Comparing the group that developed IBS with the group that didn't among the CDI patients, there were no significantly different factors except for a previous admission history before CDI. CONCLUSIONS: The incidence of PI-IBS after CDI was 19.5%, and the IBS was predominantly the diarrhea-type. In the future, a large scale study needs to be conducted in order to evaluate the PI-IBS incidence after CDI and the risk factors that predispose patients to such conditions.

A Remote Educational System in Medicine Using Digital Video Transfer System / 대한소화기내시경학회지

BACKGROUND/AIMS: Telemedicine has opened the door to a wide range of learning experience to the doctors and students working and studying at various remote locations. However, there are limitations to this technology, such as the lack of any approved international standards of ethics. The aim of our study was to establish a telemedical education system using the Digital Video Transfer System (DVTS) on the high-speed network. METHODS: The Asia Pacific Information Infrastructure (APII) link was used to connect Korea with Japan, and the Korea Advanced Research Network (KOREN) was used to connect Busan with Seoul. Teleconferencing and video streaming between Hanyang University Hospital in Seoul and Kyushu University Hospital in Japan were realized using DVTS over the Ipv4 network. RESULTS: Four endoscopic surgeries and two endoscopic procedures were successfully transmitted between Seoul and Kyushu, while concomitant teleconferences were taking place between the two cities throughout the operations. An adequate bandwidth of 60 Mbps was kept for two-line transmissions. The quality of transmitted video image showed no frame loss with a rate of 30 images per second. The sound was also clear, and the time delay was less than 0.3 sec. CONCLUSIONS: We have established an international medical network with high-quality video transmission over Internet medium and this was easy to perform, reliable and economical.

A case of cytomegalovirus colitis in an immunocompetent adult presenting as pancolitis / 대한내과학회지

CMV is common cause of life-threatening opportunistic viral infection in immunocompromised patients, especially in transplant recipients and those who are infected with HIV. Although CMV infection is generally asymptomatic in healthy adults, CMV colitis can occur in immunocompetent adults. While the right colon is the most common site of gastrointestinal CMV infection, it is extremely rare for it to involve the whole colon. We report a rare case of cytomegalovirus (CMV) colitis in an immunocompetent adult presenting as pancolitis. The usual course of gastrointestinal CMV infection is self limited in an immunocompetent adult, but our case revealed that conservative treatment was not enough, and the administration of ganciclovir was essential for the improvement of disease.

A Case of Thyrotoxicosis Presented as Rhabdomyolysis / 대한내분비학회지

There have been a few reports on rhabdomyolysis caused by thyroid storm, but no cases of thyrotoxicosis related rhabdomyolysis have been reported until now. Here, a rare case of rhabdomyolysis, accompanied by thyrotoxicosis, is reported. A 21-year-old man was admitted to our hospital with severe pain and weakness in both legs. The initial laboratory findings revealed a high muscle enzyme level and severe hypokalemia. In evaluation of the rhabdomyolysis, the thyroid function test was compatible with that of Graves' disease, with the rhabdomyolysis subsequently diagnosed, presenting as thyrotoxicosis. The possible mechanisms for this complaint were hypokalemia-induced muscle ischemia, a thyrotoxicosis-induced excessive hypermetabolic state and pressure-induced muscle ischemia. Therefore, the work up for the cause of rhabdomyolysis should include thyrotoxicosis. The management of rhabdomyolysis is hydration, prevention of acute renal failure, correction of aggravating factors and treatment of the underlying cause, for example, thyrotoxicosis.

Incidence of Gallbladder Stones in Renal Transplant Recipients / 대한소화기학회지

BACKGROUND/AIMS: Gallbladder stone is one of the major cause of morbidity in adults. Renal transplantation has been found to increase the risk of gallbladder stone formation. The real incidence of gallbladder stones in renal transplant recipients is not exactly known. We performed this study to identify the risk factors for cholecystolithiasis. METHODS: We compared the prevalence of gallbladder stone in 222 renal transplantation patients with that in 222 age and sex matched controls. Patients who had chronic liver disease, renal disease, and diabetes were excluded from the control group. RESULTS: In our study, the incidence of gallbladder stones is 8.6% (19/222 patients) in renal transplantation patients, which was significantly higher than 3.60% (8/222 control) in the control group (p=0.029). In the most of our renal transplantation patients, cholecystolithiasis was asymptomatic. We did not find a difference in age, sex, duration after transplantation, causes of renal failure, resistance index between patients with and without gallbladder stones in renal transplantation patients. CONCLUSIONS: Our results suggest that the incidence of gallbladder stones is higher in renal transplant recipients than non-transplant population in Korea. Further studies will be needed to focus the factors contributing to the gallbladder stone formation after renal transplantation, especially in regard to immunosuppressive drugs.