Ileocolonoscopic findings in patients with ankylosing spondylitis: a single center retrospective study

BACKGROUND/AIMS: In some Western countries, up to 50% of patients with ankylosing spondylitis (AS) have subclinical gut inflammation. This study was conducted to evaluate the prevalence and severity of gut inflammation and to determine clinical factors associated with colonic inflammation in Korean AS patients who performed ileocolonoscopy without evidence of established inflammatory bowel diseases before. METHODS: One hundred and eight AS patients who underwent ileocolonoscopy were included in this study. Patients were divided into two groups based on gross ileocolonoscopic findings; patients with inflammatory lesions, and patients without inflammatory lesions. RESULTS: Inflammatory lesions in ileocolonoscopic findings were found in 40 patients. The Ankylosing Spondylitis Disease Activity Score C-reactive protein was higher in the group with inflammatory lesions and gut lesions were found often in the terminal ileum. The risk of inflammatory lesions was higher for AS patients whose symptoms required ileocolonoscopy than for AS patients who underwent routine ileocolonoscopy screening (odds ratio, 3.96). However, abnormal lesions were detected also in 17.6% of the patients who underwent ileocolonoscopy for routine screening and most of them were erosion and ulcer. Among patients with inflammatory lesions (n = 40), 23 showed subclinical gut inflammation associated with AS and 17 were diagnosed finally as Crohn's disease (n = 12), intestinal tuberculosis (n = 4), and ulcerative colitis (n = 1). CONCLUSIONS: Our findings suggest that ileocolonoscopy might be recommended regularly in AS patients even without gastrointestinal symptoms, especially in the patients with high AS activity.

An Atraumatic Fracture of the Odontoid Process in a Newly Diagnosed Rheumatoid Arthritis Patient

Rheumatoid arthritis (RA) is a systemic autoimmune disorder which can affect all of the synovial joints including the cervical spine. Cervical involvement typically begins early in the disease process and shows relatively slow progression. Fractures of the odontoid process are mainly noted after a major trauma to the cervical spine. A case of a 77-year-old woman with paresthesia of the extremities caused by spontaneous atraumatic fracture of the odontoid process, which was revealed as a manifestation of RA, is presented in this report.

Refractory Macrophage Activation Syndrome in a Patient with Systemic Lupus Erythematosus Treated with Tocilizumab / 대한내과학회지

Macrophage activation syndrome (MAS) is a secondary hemophagocytic lymphohistiocytosis caused by autoimmune diseases, such as systemic lupus erythematosus (SLE). It is characterized by fever, cytopenia, coagulopathy, hepatosplenomegaly, elevated liver enzyme, and high ferritin, typically combined with hemophagocytic histiocyte proliferation in the bone marrow. Here, we report a case of MAS in a patient with SLE treated successfully by tocilizumab. She was transferred to our hospital due to persistent fever of unknown origin. Initial blood tests revealed cytopenia, elevated liver enzyme, and high ferritin. Bone marrow histology revealed the presence of hemophagocytic histiocytes. The patient was initially treated with high dose corticosteroids; however, fever and cytopenia were not controlled. Additional treatments with cyclosporine, intravenous immunoglobulin, and rituximab were applied consecutively, but the fever and cytopenia persisted. Symptom resolution was finally achieved following treatment with tocilizumab, resulting in rapid improved of fever, and resolution of pancytopenia within 2 months.

Factors related to outcomes in lupus-related protein-losing enteropathy

BACKGROUND/AIMS: Protein-losing enteropathy (PLE), characterized by severe hypoalbuminemia and peripheral edema, is a rare manifestation of systemic lupus erythematosus. This present study aimed to identify the distinctive features of lupus-related PLE and evaluate the factors related to the treatment response. METHODS: From March 1998 to March 2014, the clinical data of 14 patients with lupus PLE and seven patients with idiopathic PLE from a tertiary center were reviewed. PLE was defined as a demonstration of protein leakage from the gastrointestinal tract by either technetium 99m-labelled human albumin scanning or fecal alpha1-antitrypsin clearance. A positive steroid response was defined as a return of serum albumin to > or = 3.0 g/dL within 4 weeks after initial steroid monotherapy, and remission as maintenance of serum albumin > or = 3.0 g/dL for at least 3 months. A high serum total cholesterol level was defined as a level of > or = 240 mg/dL. RESULTS: The mean age of the lupus-related PLE patients was 37.0 years, and the mean follow-up duration was 55.8 months. Significantly higher erythrocyte sedimentation rate and serum total cholesterol levels were found for lupus PLE than for idiopathic PLE. Among the 14 patients with lupus PLE, eight experienced a positive steroid response, and the serum total cholesterol level was significantly higher in the positive steroid response group. A positive steroid response was associated with an initial high serum total cholesterol level and achievement of remission within 6 months. CONCLUSIONS: In lupus-related PLE, a high serum total cholesterol level could be a predictive factor for the initial steroid response, indicating a good response to steroid therapy alone.

A Large Neuroendocrine Tumor of the Major Duodenal Papilla Removed by Endoscopic Papillectomy / 대한내과학회지

Neuroendocrine tumors (NET) of the major duodenal papilla are rare and the natural history of this disease is not clear. We experienced a case in a 31-year-old male. Duodenoscopy revealed an enlarged major duodenal papilla with central umbilication and nodularity. Endoscopic ultrasonography (EUS) demonstrated a 3-cm hypoechoic mass that was confined to the submucosa. A biopsy led to the diagnosis of a grade 1 NET. The patient refused surgery, so we performed an endoscopic papillectomy. The tumor was removed completely. The resected specimen confirmed the diagnosis of a well-differentiated NET and all resection margins were negative. Surgical resection is currently considered to be the gold standard for the treatment of a large NET of the major duodenal papilla; however, endoscopic resection is a possible treatment modality for patients at high surgical risk or who are reluctant to undergo surgery.

Clinical Usefulness of Bile Cytology Obtained from Biliary Drainage Tube for Diagnosing Cholangiocarcinoma / 대한소화기학회지

BACKGROUND/AIMS: Biliary drainage is performed in many patients with cholangiocarcinoma (CCA) to relieve obstructive jaundice. For those who have undergone biliary drainage, bile cytology can be easily performed since the access is already achieved. This study aims to determine the clinical usefulness of bile cytology for the diagnosis of CCA and to evaluate factors affecting its diagnostic yield. METHODS: A total of 766 consecutive patients with CCA underwent bile cytology via endoscopic nasobiliary drainage or percutaneous transhepatic biliary drainage from January 2000 to June 2012. Data were collected by retrospectively reviewing the medical records. We evaluated the diagnostic yield of bile cytology with/without other sampling methods including brush cytology and endobiliary forcep biopsy, and the optimal number of repeated bile sampling. Several factors affecting diagnostic yield were then analyzed. RESULTS: The sensitivity of bile cytology, endobiliary forceps biopsy, and a combination of both sampling methods were 24.7% (189/766), 74.4% (259/348), and 77.9% (271/348), respectively. The cumulative positive rate of bile sampling increased from 40.7% (77/189) at first sampling to 93.1% (176/189) at third sampling. On multivariate analysis, factors associated with positive bile cytology were perihilar tumor location, intraductal growing tumor type, tumor extent > or =20 mm, poorly differentiated grade tumor, and three or more samplings. CONCLUSIONS: Although bile cytology itself has a low sensitivity in diagnosing CCA, it has an additive role when combined with endobiliary forceps biopsy. Due to the relative ease and low cost, bile cytology can be considered a reasonable complementary diagnostic tool for diagnosing CCA.

A Needle Penetrating the Stomach Cavity after Acupuncture

Although acupuncture is known as a safe procedure that is widely used in many countries, complications including infection, hemorrhage, hematoma, pneumothorax, nerve damage, and cardiac tamponade have been reported. A needle penetrating the stomach after acupuncture, however, is very rare. Here, we report the case of 47-year-old woman who experienced abdominal pain 2 days after receiving acupuncture. Upper gastrointestinal endoscopy identified an approximately 2.5-cm long needle in the posterior wall of the antrum. The needle was removed endoscopically using rat tooth forceps with no complications.

Regression of Russell Body Gastritis after Helicobacter pylori Eradication

Russell body gastritis is a very rare gastric inflammatory lesion, which presents as dense infiltration of plasma cells containing immunoglobulin structures of Russell body. The lesion is closely associated with Helicobacter pylori-induced chronic gastritis and mimics malignant tumors, such as marginal zone B-cell lymphoma of mucosa-associated lymphoid tissues and signet-ring cell carcinoma. We report a case of Russell body gastritis which regressed 6 months after eradication of H. pylori. Herein we described endoscopic features of Russell body gastritis and histological details of differential diagnosis.

A Case of Metastatic Hepatocellular Carcinoma of the Orbit / 영남의대학술지

Orbital metastasis from hepatocellular carcinoma is very rare, with only 14 biopsy-proven cases from hepa tocellular carcinoma cases reported in English literature and three cases reported in Korea. Common symptoms of orbital metastasis are proptosis, visual loss, ocular pain and oculomotor dysfunction. For its precise diagnosis, we can perform fine needle aspiration biopsy, orbit CT or MRI, and ultrasonography. Radiotherapy is the mainstay in the treatment of orbital metastasis. In addition, chemotherapy, hormonal therapy and surgical intervention can play a role in the treatment of orbital metastasis according to the primary cancer and symptoms. However, the prognosis of orbital metastasis is poor. We report herein a rare case of a patient with orbital metastasis from hepatocellular carcinoma, which was treated with various modalities that included resection, and who had good clinical and radiological responses to radiation therapy and sorafenib (Nexavar, Bayer HealthCare).