Endoscopic Ultrasound-guided Fine-needle Aspiration Biopsy of a Renal Mass

Traditionally, tissue biopsies of kidney lesions are usually performed with CT or percutaneous ultrasound guidance, but biopsies using EUS have rarely been reported. In this report, we describe a case of renal cell carcinoma (RCC) diagnosed using EUS-guided fine-needle aspiration biopsy. A 75-year-old woman taking aspirin due to stable angina continued to exhibit weight loss and anemia and visited the gastroenterology department. No bleeding was observed on upper and lower gastrointestinal endoscopy. A contrast-enhanced mass was observed in the left kidney, accompanied by 8.9×10.8 cm-sized necrosis suggesting RCC on abdominal CT. Chest CT showed masses in both lungs. We planned to administer targeted therapy after pathological confirmation using EUS. Aspirin was continued, and we performed fine-needle biopsy using a 22-gauge needle three times. No adverse events were observed after the procedure. Pathological examination confirmed RCC, clear cell type, and the patient is currently undergoing treatment with sunitinib. EUS-guided fine-needle aspiration biopsy is safe for liver, pancreatic, or other tumors accessible from the upper gastrointestinal tract. This technique shows fewer adverse events. To the best of our knowledge, there have been no other reports on EUS-guided fine-needle aspiration biopsy to identify RCC in Korea.

Endoscopic Ultrasound-guided Fine-needle Aspiration Biopsy of a Renal Mass

Traditionally, tissue biopsies of kidney lesions are usually performed with CT or percutaneous ultrasound guidance, but biopsies using EUS have rarely been reported. In this report, we describe a case of renal cell carcinoma (RCC) diagnosed using EUS-guided fine-needle aspiration biopsy. A 75-year-old woman taking aspirin due to stable angina continued to exhibit weight loss and anemia and visited the gastroenterology department. No bleeding was observed on upper and lower gastrointestinal endoscopy. A contrast-enhanced mass was observed in the left kidney, accompanied by 8.9×10.8 cm-sized necrosis suggesting RCC on abdominal CT. Chest CT showed masses in both lungs. We planned to administer targeted therapy after pathological confirmation using EUS. Aspirin was continued, and we performed fine-needle biopsy using a 22-gauge needle three times. No adverse events were observed after the procedure. Pathological examination confirmed RCC, clear cell type, and the patient is currently undergoing treatment with sunitinib. EUS-guided fine-needle aspiration biopsy is safe for liver, pancreatic, or other tumors accessible from the upper gastrointestinal tract. This technique shows fewer adverse events. To the best of our knowledge, there have been no other reports on EUS-guided fine-needle aspiration biopsy to identify RCC in Korea.

Azathioprine-Induced Non-Cirrhotic Portal Hypertension in a Patient with Crohn’s Disease / 대한내과학회지

Thiopurine-based drugs such as azathioprine and 6-MP are among the most common immunosuppressants used to treat inflammatory bowel disease, autoimmune hepatitis, various autoimmune diseases, and patients undergoing organ transplantation. The drugs are associated with various complications, of which one of the most serious is hepatotoxicity that may trigger non-cirrhotic portal hypertension. We report a case with this side-effect in a patient taking azathioprine to treat Crohn’s disease.

Local Recurrence and Its Risk Factor after Incomplete Resection of Colorectal Advanced Adenomas: A Single Center, Retrospective Study / 대한소화기학회지

BACKGROUND/AIMS: Colonoscopy can detect precancerous lesions, which can subsequently be removed and reduce incidences of and mortality from colorectal cancer (CRC). However, recently published data have highlighted a significant rate of CRC in patients who previously underwent colonoscopy. Among many reasons, incomplete resection has been considered as a significant contributor. However, to date, there have only been a few studies regarding incompletely resected polyps, especially advanced colorectal adenoma (ACA). Hence, we aimed to evaluate the prognosis of incompletely resected ACA. METHODS: We retrospectively reviewed the medical records of patients with ACA who had underwent endoscopic treatment with incomplete resection. The primary outcomes were (1) the incomplete resection rate of ACA, as determined by a histopathologic examination and (2) the recurrence rate of incompletely resected ACA. We also investigated the probable contributing factors that may have led to a relapse of incompletely resected ACA. RESULTS: A total of 7,105 patients had their colorectal polyps resected by endoscopic treatment, and 2,233 of these were considered as ACA. Of these, 354 polyps (15.8%) were resected incompletely, and only 163 patients were followed-up. Of those followed-up, 31 patients (19.0%) experienced local recurrence. The risk factors for recurrence after incomplete resection were evaluated; age, morphology of adenoma, and use of rescue therapy, such as argon plasma coagulation, were found to be associated with adenoma recurrence. CONCLUSIONS: Incompletely resected ACA in older patients or in patients with sessile-type adenomas should be monitored strictly, and if incomplete resection is suspected, rescue therapy must be considered.

Clinical Outcomes of the Endoscopic Submucosal Dissection of Early Gastric Cancer Are Comparable between Absolute and New Expanded Criteria

BACKGROUND/AIMS: Advances in endoscopic submucosal dissection (ESD) techniques have led to the development of expanded criteria for endoscopic resection of early gastric cancer (EGC). The aim of this study was to evaluate the short- and long-term outcomes for ESD using indication criteria. METHODS: A total of 1,105 patients underwent ESD for EGC at six medical centers. The patients were classified into the following two groups based on the lesion size, presence of ulceration and pathological review: an absolute criteria group (n=517) and an expanded criteria group (n=588). RESULTS: The curative resection rates (91.1% vs 91.3%, p=0.896) were similar in the absolute criteria group and the expanded criteria group. The en bloc resection rates (93.4% and 92.3%, respectively; p=0.488) and complete resection rates (98.3% and 97.4%, respectively; p=0.357) did not differ between the groups. The cumulative disease-free survival rates and the overall survival rates were similar between the groups (p=0.778 and p=0.654, respectively). Independent factors for the curative resection of EGC included tumor location (upper vs middle and lower, 2.632 [1.128-6.144] vs 3.497 [1.560-7.842], respectively) and en bloc resection rate 12.576 [7.442-21.250]. CONCLUSIONS: The expanded criteria for ESD in cases of EGC is comparable with the widely accepted pre-existing criteria.

Clinical Outcomes of the Endoscopic Submucosal Dissection of Early Gastric Cancer Are Comparable between Absolute and New Expanded Criteria

BACKGROUND/AIMS: Advances in endoscopic submucosal dissection (ESD) techniques have led to the development of expanded criteria for endoscopic resection of early gastric cancer (EGC). The aim of this study was to evaluate the short- and long-term outcomes for ESD using indication criteria. METHODS: A total of 1,105 patients underwent ESD for EGC at six medical centers. The patients were classified into the following two groups based on the lesion size, presence of ulceration and pathological review: an absolute criteria group (n=517) and an expanded criteria group (n=588). RESULTS: The curative resection rates (91.1% vs 91.3%, p=0.896) were similar in the absolute criteria group and the expanded criteria group. The en bloc resection rates (93.4% and 92.3%, respectively; p=0.488) and complete resection rates (98.3% and 97.4%, respectively; p=0.357) did not differ between the groups. The cumulative disease-free survival rates and the overall survival rates were similar between the groups (p=0.778 and p=0.654, respectively). Independent factors for the curative resection of EGC included tumor location (upper vs middle and lower, 2.632 [1.128-6.144] vs 3.497 [1.560-7.842], respectively) and en bloc resection rate 12.576 [7.442-21.250]. CONCLUSIONS: The expanded criteria for ESD in cases of EGC is comparable with the widely accepted pre-existing criteria.

Prevalence of Common Skin Diseases and Their Associated Factors among Military Personnel in Korea: A Cross-sectional Study

This study was conducted to clarify the prevalence of common skin diseases and their associated factors among military personnel in Korea. Four dermatologists visited adjacent military units and examined soldiers. A structured questionnaire that included questions about known skin diseases, demographic information, and questions for the Perceived Stress Index was completed for each participant. The soldiers that had been diagnosed with a skin disease answered one additional questionnaire (Skindex-29) which assess the influence of an individual's skin disease on daily life. Of 1,321 soldiers examined, 798 (60.4%) had one or more skin diseases. The three most common skin problems were acne (35.6%), tinea pedis (15.2%) and atopic dermatitis (5.1%). The diseases closely related to the period of military service were acne, tinea pedis, viral warts and corns. The diseases related to the amount of stress were atopic dermatitis, seborrheic dermatitis, and acne. The most troublesome skin diseases were atopic dermatitis, tinea cruris, and seborrheic dermatitis. These results demonstrated that the prevalence of skin disease among military personnel in Korea is very high, and that some of the skin disorders may have a significant influence on their daily lives.

Biliary Cast Formation with Sclerosing Cholangitis in Critically Ill Patient: Case Report and Literature Review

Sclerosing cholangitis in critically ill patients (SC-CIP) is a rare condition that is not familiar to many radiologists. In addition, the associated imaging findings have not been described in the radiological literature. We report a case of biliary cast formation with SC-CIP and describe the radiological findings of CT, magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiography (ERC). A diagnosis of SC-CIP should be considered in intensive care unit (ICU) patients with persistent cholestasis during or after a primary illness. The typical CT, MRCP and ERC findings include new biliary casts in the intrahepatic duct with multiple irregular strictures, dilatations, and relative sparing of the common bile duct.

Clinical Characteristics of Gastroesophageal Reflux Disease with Esophageal Injury in Korean: Focusing on Risk Factors / 대한소화기학회지

BACKGROUND/AIMS: Recent studies suggest that the prevalence of gastroesophageal reflux disease (GERD) is increasing in Korea. However, studies on risk factors for GERD have yielded inconsistent results. The aims of this study were to compare clinical features between symptomatic syndromes without esophageal injury (=non-erosive disease [NED]) and syndromes with esophageal injury (=erosive disease [ED]), and to determine risk factors associated ED. METHODS: A total of 450 subjects who visited gastroenterology clinics of six training hospitals in Daegu from March 2008 to April 2010 were consecutively enrolled. The subjects were asked to complete a questionnaire which inquired about gastroesophageal reflux symptoms. The questionnaire also included questions about smoking, alcohol drinking, consumption of coffee, use of drugs, exercise, and other medical history. The subjects were subdivided into NED and ED groups. RESULTS: The proportion of subjects in each NED and ED group was 172 (38.2%) and 278 (61.8%). Male gender, smoking, alcohol drinking, consumption of coffee, large waist circumference, infrequent medication of antacids, aspirin and NSAIDs, infrequent and mild GERD symptoms were all significantly associated with ED on univariate analysis. Age, hiatal hernia, diabetes mellitus, body mass index, change in weight during 1 year, and number of typical GERD symptoms were not independent risk factors for ED. However, the association between ED and alcohol drinking, infrequent medication of antacids, mild typical GERD symptoms remained as strong risk factors after adjustments on multivariate logistic analysis. CONCLUSIONS: Independent risk factors associated with ED were alcohol drinking, infrequent medication of antacids and mild typical GERD symptoms.

Is Endoscopic Resection Currently Available in Non-tertiary or Non-academic Hospitals? / 대한소화기내시경학회지

BACKGROUND/AIMS: Endoscopic mucosal resection (EMR) has been gaining popularity with the advances in the technique and the accumulating experience. The objectives of this study are to assess the current situation of endoscopic resection (ER) in primary clinics and community-based hospitals and to suggest an affordable training program. METHODS: A questionnaire about the indications to perform ER for gastric or colonic lesions was sent to the doctors working in the non-tertiary hospitals by mail. RESULTS: The responders who were performing EMR or polypectomy for gastric lesions accounted for 43% (31/72) and 44.8% (47/101), respectively, of the total responders. The percentage of responders who had experience with performing EMR or polypectomy for colonic lesions accounted for 56.6% (30/53) and 87.3% (62/71), respectively, of the total responders. The indication for ER for treating gastric and colonic lesions was restricted to the size of 1~2 cm irrespective of the type or location of lesion. Most of the responders assumed that ER should be performed in their clinics and they wanted to have a chance to improve these techniques. CONCLUSIONS: The infrastructure for therapeutic endoscopy, such as ER, should be progressively expanded. Therefore, well designed schematic training programs are currently needed to advance using ER more commonly in clinical practice.

A case of Klebsiella psoas abscess due to diverticulitis and intestinal tuberculosis / 대한내과학회지

A 38-year-old male-to-female transgender patient who had undergone a transsexual operation 20 years earlier presented with right flank pain and chills. Abdominal CT scan and gastrografin colon enema revealed a right psoas abscess and an abnormal communication between the large bowel and this psoas abscess. She underwent a right hemicolectomy and was finally diagnosed as having a Klebsiella psoas abscess due to perforated diverticulitis and intestinal tuberculosis. Additional antibiotics and antituberculous medication were required. A secondary psoas abscess due to diverticulitis is rare, and to our knowledge, no case combined with intestinal tuberculosis has previously been reported. We present the case with a brief review of related reports.

A case of Klebsiella psoas abscess due to diverticulitis and intestinal tuberculosis / 대한내과학회지

A 38-year-old male-to-female transgender patient who had undergone a transsexual operation 20 years earlier presented with right flank pain and chills. Abdominal CT scan and gastrografin colon enema revealed a right psoas abscess and an abnormal communication between the large bowel and this psoas abscess. She underwent a right hemicolectomy and was finally diagnosed as having a Klebsiella psoas abscess due to perforated diverticulitis and intestinal tuberculosis. Additional antibiotics and antituberculous medication were required. A secondary psoas abscess due to diverticulitis is rare, and to our knowledge, no case combined with intestinal tuberculosis has previously been reported. We present the case with a brief review of related reports.

The Effect of Active Immunization on the Clinical Courses of Varicella / 대한피부과학회지

BACKGROUND: Varicella is a disease caused by varicella zoster virus with vesicular skin eruption. Usually the symptom improves automatically though there have been rare cases, that developed serious complications. It can be prevented by immunization with live attenuated varicella vaccine. But among immunized children "breakthrough varicella" has been reported in about 5~20%. OBJECTIVE: The aim of this study is to evaluate the effects of live attenuated varicella vaccine on clinical course of varicella. METHODS: A total of 104 varicella patients were divided into two groups; vaccinated and unvaccinated. We evaluated patients about the demographic characters and clinical features of varicella through interview and medical examination. Because varicella is more serious in adolescents and adults, we also divided the patients into two groups by age of 12 for male and 10 for female. RESULTS: The immunized group showed a statistically noticeable distinction. The patients showed more mild prodromal symptoms, small amount of rash in oral mucosa, and on the palms and soles. Small counts of total skin lesion and less itching were observed. They also required a shorter period of hospital treatment and disease duration. CONCLUSION: Immunization is known to decrease the incidence of varicella, but the study also confirmed that immunization can weaken serious symptoms in breakthrough varicella.

A Case of Eccrine Spiradenoma in a Neurofibromatosis Type-1 Patient / 대한피부과학회지

Eccrine spiradenoma is a rare benign tumor which is differentiated into the direction of eccrine gland. Neurofibromatosis type-1 is an autosomal dominantly inherited disorder that is characterized by neurofibroma, cafe au lait spots and axillary freckles of the skin. We report a case of a 42-year-old man with a painful, solid nodule on his right arm for 4~5 months. He was diagnosed with neurofibromatosis type-1 in childhood. He has several cafe au lait spots and diffuse freckles on whole body. On microscopy, the tumor was sharply demarcated with encapsulated lobules in the dermis. The lobules consisted of two undifferentiated epithelial cells. There was hyperpigmentation of the basal cell layer in the epidermis without increase in the number of melanocyte. We herein report an unusual case of eccrine spiradenoma in neurofibromatosis type-1 patient.

A Case of Gastric Glomus Tumor / 대한소화기학회지

Glomus tumor is a tumor arising from glomus body, a nodular form of arteriolovenular anastomosis that functions to regulate blood flow according to temperature. Gastrointestinal glomus tumors are rare and most frequently occur in the stomach as a subepithelial tumor. A 46-year-old woman presented with an incidental finding of a subepithelial tumor in the stomach. Endoscopic ultrasonography (EUS) showed a 1.4x1 cm sized well circumscribed heterogeneous hypoechoic tumor with a few tubular structures in the fourth sonographic layer of the gastric wall. Characteristically, more hypoechoic halo equal to the echogenecity of proper muscle layer enclosed the tumor. Contrast enhanced abdominal computerized tomography (CT) revealed high enhancement of tumor up to the same level of portal vein in arterial phase and this enhancement persisted to portal phase. For histolgogic confirmation and treatment, endoscopic enucleation was attempted but failed due to fibrotic adhesion with the surrounding tissue. Histologic findings of biopsy specimen were compatible with glomus tumor. Although it is difficult to diagnose glomus tumor preoperatively, these characteristic findings in EUS and CT seem to be useful in distinguishing glomus tumor from other tumors arising from the fourth sonographic layer of gastric wall.

A Study of Diet Restriction in Chronic Idiopathic Urticaria / 대한피부과학회지

BACKGROUND: Although the pathogenesis of chronic idiopathic urticaria (CIU) has not yet been fully elucidated, several previous studies have identified food additives or high amounts of histamine containing foods as possible eliciting factors of chronic idiopathic urticaria (CIU). OBJECTIVE: The aim of this study was to evaluate the effect of restricting pseudoallergens and histamines from the diets of patients affected with CIU. METHODS: Fourteen CIU patients with Acetylsalicylic acid (ASA) intolerance were prescribed a pseudoallergen restricted diet, whilst, fifteen CIU patients with ASA tolerance were prescribed a histamine restricted diet for 4 weeks. A control group of thirty nine CIU patients were not given a restricted diet. After 4 weeks, we estimated the improvement of symptoms and the change in the number of antihistamine tablets taken in each of the three groups. RESULTS: Neither of the restricted diets induced a significant improvement of symptoms compared with the control group (p>0.05). Furthermore, there was no significant decrease in the number of antihistamine tablets taken in the restricted diet groups compared with the control group as well (p>0.05) CONCLUSION: According to our results, we suggest that pseudoallergen or histamine restricted diets are not necessary in CIU patients.

A Case of Latex Anaphylactic Shock during Operation / 대한피부과학회지

Latex is the milky sap obtained by tapping the rubber tree, Hevea brasiliensis. The prevalence of latex allergy has been on the increase alongside the wider use of latex-manufactured products. The number of reports of latex-induced anaphylaxis during operation is therefore increasing. We report the case of a 56-year-old male patient who developed severe anaphylactic shock while under anesthesia when the tourniquet was deflated during elbow arthrolysis. A subsequent allergy workup revealed an IgE-mediated hypersensitivity to latex.

Quality of Life and the Family Impact of Atopic Dermatitis in Children / 대한피부과학회지

BACKGROUND: Atopic dermatitis (AD) in children may profoundly affect their quality of life (QOL), in addition to familial life plus cause financial burden. OBJECTIVE: The aim of this study was to show how AD affects children's QOL, family life and contributes to financial burden, and to evaluate this relationship with severity of AD. METHODS: The target population comprised of children aged 0~6 years with AD who visited our out-patient department between May 2004 and October 2005. The Infants' Dermatologic Quality of Life Index (IDQOL), the Dermatitis Family Impact questionnaire (DFI) and the Financial Impact questionnaire (FI) were used to quantify the impact of AD on each area. Eczema severity was assessed using the Eczema area and severity index (EASI) score. The student' T-test and simple linear regression were used for statistical analysis. RESULTS: A total of 101 children completed all the questionnaires. The mean score for IDQOL was 11.50, DFI was 10.05 and FI was 16.10. The highest scoring question for IDQOL was itching and scratching, the lowest one was family activities. For the DFI they were main carer's life effect and shopping. The mean score of EASI was 8.81 and this was linearly related with IDQOL (R2=0.126, p<0.001), DFI (R2=0.154, p<0.001) and FI (R2=0.145, p<0.001), but not as highly. CONCLUSION: We have shown that children's quality of life, family life and financial burden are related to the severity of AD. The IDQOL, DFI and FI may potentially be of value to help guide appropriate management of AD and can be used as an added parameter in clinical trials involving AD management.

A Case of Familiar Painful Piezogenic Pedal Papules / 대한피부과학회지

We report a case of painful pizogenic pedal papules in a 10-year-old female patient who had developed tense, skin-colored papules with pain on both heels when weight was placed on the feet. Histopathologic findings showed subcutaneous fatty tissue protruding into the lower dermis and a basophilic degenerative change of part of the collagen in the dermis. Her father also had the same skin lesions on his both heels.

The Effect of Second Look Endoscopy in Patients with Peptic Ulcer Bleeding / 대한소화기내시경학회지

BACKGROUND/AIMS: Performing second look endoscopy has been suggested in order to reduce recurrent bleeding. We assessed whether second look endoscopy reduces the risks of recurrent bleeding and the mortality rate for patients suffering with peptic ulcer bleeding. METHODS: From February 2003 to June 2004, we have performed a prospective, randomized, controlled study of 141 patients with bleeding peptic ulcers, and these patients had been admitted to Kyungpook National University Hospital. Seventy patients in the study group were randomized to receive scheduled second look endoscopy. Seventy one patients in the control group were observed closely. RESULTS: Seventeen of the admitted 141 patients were found to have rebleeding after initial therapeutic endoscopy. The overall rebleeding rate was 12.1%. Although the duration of the hospital stay was significantly lower for the study group than for the control group (p<0.05), the rebleeding rate was similar for both groups (p<0.05). The two groups were similar in respect to the mortality during the period of hospitalization, the volume of hypertonic saline epinephrine that was injected and the number of hemoclips that were used. CONCLUSIONS: From these results, we can conclude that scheduled second look endoscopy with retreatment did not reduce the risk of recurrent bleeding for patients with peptic ulcer bleeding. Therefore, scheduled second look endoscopy should be selectively performed for the patients who are at a high risk for peptic ulcer bleeding.