[The usefulness of clip application in preventing migration of self-expandable metal stent in patients with malignant gastrointestinal obstruction].

BACKGROUND/AIMS: Management of malignant gastrointestinal obstruction presents a significant challenge. Recently, self-expandable metal stent (SEMS) has emerged as an effective, safe, and less invasive alternative for the treatment of malignant intestinal obstruction. Accordingly, we reviewed our experience in SEMS insertion with hemoclip placement. METHODS: Between June 2004 and December 2005, a total of 40 SEMS were tried to place in 38 patients with malignant intestinal obstruction. Two stents were placed again due to recurrent obstruction and delayed stent migration after initial stent placement. We analyzed the technical and clinical success rates and complications. RESULTS: Total stent placement was successful in 38/40 (95%). In 2 cases, stent placement was failed due to complete obstruction. Twenty-eight stents for palliation of malignant intestinal stenosis, 9 stents for one-staged operation for malignant colonic obstruction, and 1 stent for management of tracheoesophageal fistula were placed. Stent migration occurred in 6/38 (15.8%). Early stent migration rate was significantly lower in the clipping group (0/19, 0%) than in the non-clipping group (5/19, 26.3%, p=0.04). Recurrent obstruction occurred in 2/38 (6.1%) due to tumor ingrowth and in 1/38 (2.6%) due to hard food materials. CONCLUSIONS: Application of the clips reduce early stent migration in patients with malignant gastrointestinal obstruction.

[Methylation pattern of DNA repair genes and microsatellite instability in hepatocelluar carcinoma].

BACKGROUND/AIMS: Epigenetic silencing of DNA repair genes, O6-methylguanine-DNA methyltransferase (MGMT), hMLH1 and hMSH3, by promoter hypermethylation have been observed in various cancers. However, the relationship between hypermethylation of DNA mismatch repair genes and microsatellite instability (MSI) has not been studied in hepatocellular carcinoma (HCC) associated with cirrhosis. METHODS: We investigated the methylation pattern of CpG islands of 3 genes using methylation-specific PCR (MSP) and MSI in 40 patients with paired hepatocellular carcinoma and associated cirrhosis. RESULTS: hMSH3 and MGMT were the most methylated genes in both cirrhosis (70% and 68%, respectively) and HCC (75% and 73%, respectively). The methylation of hMLH1 was rarely found in both cirrhosis (8%) and HCC (5%). Gene promoters methylated in cirrhosis were also methylated in HCC with the exception of 9 cases found to be methylated either in cirrhosis or HCC. Of 40 cases of HCC associated with cirrhosis, three had MSI-positive phenotype in which two were MSI-low and one was MSI-high. One MSI-positive phenotype was present both in cirrhosis and in HCC, while two were only in HCC. There was no significant correlation between aberrant DNA methylation of mismatch repair genes and MSI status in HCC associated with cirrhosis. Immunohistochemical expressions of hMLH1, MGMT, and hMSH3 proteins were present in 16 (40%), 6 (15%), and 11 (28%) of 40 cases of HCC respectively. There was no significant correlaton between the aberrant DNA methylation of mismatch repair genes and clinical characteristics such as histological differentiation, postoperative recurrence and mortality. CONCLUSIONS: The methylation of MGMT and hMSH3 among DNA repair genes are frequent, but those of hMLH1 and MSI is very rare in both cirrhosis and HCC. There is no significant correlation between the methylation of DNA repair genes and clinical characteristics of HCC.

Sedation-free colonoscopy using an upper endoscope is tolerable and effective in patients with low body mass index: a prospective randomized study.

OBJECTIVE: Small-caliber upper endoscopes can be used safely and effectively for sedation-free colonoscopy. The objective of the study is to assess the efficacy of a small-caliber upper endoscope (9.2 mm) comparing with a standard colonoscope (12.2 mm). METHODS: In a prospective trial, patients undergoing sedation-free colonoscopy were randomly assigned to the upper endoscope (E) or the standard colonoscope (C). Outcome measures included patient self-assessed pain score (4-point scale), endoscopist-assessed pain score (4-point scale), cecal intubation rate, difficult cecal intubation rate (>900 s), number of polyps detected, and complication rates. RESULTS: A total of 244 patients were entered. Clinical characteristics were not different between the two groups. Cecal intubation was achieved in 91.0% of the patients in each group. The mean patient self-assessed pain score (SD) was significantly lower in the E group compared with the C group: 1.44 (0.81) versus 2.08 (1.10), p < 0.001. The mean endoscopist assessment of patient pain score (SD) was significantly lower in the E group compared with the C group as well: 1.27 (0.67) versus 1.58 (0.90), p= 0.003. In patients with low body mass index (BMI < 22 kg/m(2)), the cecal intubation rate was significantly higher in the E group (97.7%vs 79.4%, p= 0.026) and the difficult cecal intubation rate was significantly lower in the E group (9.3%vs 32.4%, p= 0.011). There were no significant differences in the number of polyps detected and complication rates between the two groups. CONCLUSION: A small-caliber upper endoscope is tolerable and effective for sedation-free colonoscopy, especially in patients with low BMI.

[Influence of CYP2C19 polymorphism and Helicobacter pylori status on the antisecretory effect of omeprazole in gastroesophageal reflux disease].

BACKGROUND/AIMS: The acid suppressive effect of omeprazole (OMP) is influenced by the metabolic capacity of gastric acid suppression, which is dependent on CYP2C19 polymorphism. The aim of this study was to determine the influence of CYP2C19 polymorphism and Helicobacter pylori (H. pylori) infection on the intragastric acid suppression of OMP. METHODS: Thirty one patients with gastroesophageal reflux disease were treated with a daily oral dose of 20 mg OMP for 28 days. Patients were genotyped for CYP2C19 polymorphism by polymerase chain reaction-restriction fragment length polymorphism and classified into three groups: homogenous extensive metabolizers (Ho-EMs), heterogenous extensive metabolizers (Ht-EMs) and poor metabolizer (PMs). H. pylori infection status were assessed before OMP treatment. Intragastric pH was monitored over twenty four-hours before (day 0) and after (day 29) the treatment with OMP. RESULTS: Twenty four-hour intragastric mean pH in the PMs group was significantly higher than those in Ho-EMs and Ht-EMs (5.3+/-1.3 vs. 2.8+/-0.6, 3.6+/-1.4) (p<0.005). Twenty four-hour intragastric mean pH after the administration of OMP in the H. pylori positive group was significantly higher than the H. pylori negative group (4.7+/-1.4 vs. 3.2+/-1.4) (p<0.001). There was no significant difference in acid suppressive activity of OMP between H. pylori positive and negative group according to CYP2C19 polymorphism. CONCLUSIONS: The acid suppressive effect of OMP on intragastric pH is dependent on CYP2C19 polymorphism and the H. pylori-infected status in patients with gastroesophageal reflux disease. H. pylori infection may play a role in enhancing the acid suppressive potential of OMP.

Expression of cyclooxygenase-2, p53 and Ki-67 in gastric cancer.

It has been reported that p53 mutation may contribute to upregulate cyclooxygenase (COX)-2 expression that is observed in malignant tissues. These molecules are involved in carcinogenesis by affecting tumor cell proliferation. The aim of this study was to examine the relationship between COX-2 or p53 expression and clinico-pathological characteristics including tumor cell proliferation in gastric cancer. COX-2 and p53 expressions were investigated with immunostaining, in tissue specimens obtained from 119 patients who underwent surgery for gastric cancer. The Ki-67 labeling index (LI) was counted by Ki-67 immunostaining. COX-2 and p53 expressions correlated significantly with depth of tumor invasion. However, there was no association between COX-2 or p53 expression and survival. p53 expression did not correlate with COX-2 expression. There was no significant difference in various clinicopathological variables between Ki-67 LI subgroups. The mean Ki-67 LI value of COX-2 positive tumors was significantly higher than that of negative tumors. The mean Ki-67 LI value of p53 positive tumors was not significantly higher than that of negative tumors. The mean Ki-67 LI value of both COX-2 and p53 positive tumors was significantly higher than that of both negative tumors. These results imply that COX-2 expression is associated with tumor cell proliferation of gastric cancer.

Antibiotic prophylaxis using third generation cephalosporins can reduce the risk of early rebleeding in the first acute gastroesophageal variceal hemorrhage: a prospective randomized study.

Bacterial infection may be a critical trigger for variceal bleeding. Antibiotic prophylaxis can prevent rebleeding in patients with acute gastroesophageal variceal bleeding (GEVB). The aim of the study was to compare prophylactic third generation cephalosporins with on-demand antibiotics for the prevention of gastroesophageal variceal rebleeding. In a prospective trial, patients with the first acute GEVB were randomly assigned to receive prophylactic antibiotics (intravenous cefotaxime 2 g q 8 hr for 7 days, prophylactic antibiotics group) or to receive the same antibiotics only when infection became evident (on-demand group). Sixty-two patients in the prophylactic group and 58 patients in the on-demand group were included for analysis. Antibiotic prophylaxis decreased infection (3.2% vs. 15.5%, p=0.026). The actuarial rebleeding rate in the prophylactic group was significantly lower than that in the on-demand group (33.9% vs. 62.1%, p=0.004). The difference of rebleeding rate was mostly due to early rebleeding within 6 weeks (4.8% vs. 20.7%, p=0.012). On multivariate analysis, antibiotic prophylaxis (relative hazard: 0.248, 95% confidence interval (CI): 0.067-0.919, p=0.037) and bacterial infection (relative hazard: 3.901, 95% CI: 1.053-14.448, p=0.042) were two independent determinants of early rebleeding. In conclusion, antibiotic prophylaxis using third generation cephalosporins can prevent bacterial infection and early rebleeding in patients with the first acute GEVB.

[Comparison of terlipressin and octreotide with variceal ligation for controlling acute esophageal variceal bleeding--a randomized prospective study].

BACKGROUND/AIMS: Terlipressin and octreotide had been used to control acute variceal bleeding and to prevent early rebleeding after endoscopic hemostasis. We compared the efficacy and safety of terlipressin and octreotide combined with endoscopic variceal ligation (EVL) for the treatment of acute esophageal variceal bleeding and we evaluated their clinical significance as related to rebleeding. METHODS: The eighty eight cirrhotic patients were randomized to the terlipressin group (n=43; 2 mg i.v. initially and 1 mg i.v. at every 4 hours for 3 days) or the octreotide group (n=45; continuous infusion of 25 microgram/h for 5 days) combined with EVL for the treatment of acute esophageal variceal bleeding. RESULTS: The initial hemostasis rates were 98% (42/43 cases) in the terlipressin group and 96% (43/45 cases) in the octreotide group. The 5-day and 42-day rebleeding rates were 12% (5/43 cases) and 28% (12/43 cases), respectively, in the terlipressin group and 9% (4/45 cases) and 24% (11/45 cases), respectively, in the octreotide group. No significant difference was demonstrated between the terlipressin and octreotide groups. The mortality at 42 days was similar in both group, but a high mortality rate (48%) was shown to be related to 42-day rebleeding. The risk factors related to 42-day rebleeding were Child-Pugh class C (aOR=30.2, 95% CI=7.7-117.9), ascites above grade II (aOR=6.6, 95% CI=2.2-19.2) and advanced hepatocellular carcinoma (aOR=4.6, 95% CI=1.1-18.9). CONCLUSIONS: Comparing terlipressin and octreotide combined with EVL showed them to be equally safe and effective therapeutic agents in patients with acute esophageal variceal bleeding. The high risk factors related to early rebleeding were poor liver function and advanced hepatocellular carcinoma.

Expression of survivin in gastric cancer and its relationship with tumor angiogenesis.

BACKGROUND/AIMS: Survivin, a member of inhibitors of apoptosis, has been found in various human cancers. Its expression is associated with tumor progression and adverse outcome. Angiogenesis is an essential process for the primary tumor to grow and invade the adjacent normal structures. Angiogenic factors such as vascular endothelial growth factor induce survivin expression in endothelial cells. The current study was designed to investigate the possible role of survivin and vascular endothelial growth factor status for angiogenesis in human gastric cancer. METHODS: In this study, we conducted an immunohistochemical investigation of survivin and vascular endothelial growth factor expression in 106 tissue samples obtained from gastric cancer patients undergoing surgical treatment. To assess tumor angiogenesis, microvessel density was counted by staining endothelial cells immunohistochemically using anti-CD34 monoclonal antibody. RESULTS: The positive expression of survivin and vascular endothelial growth factor in gastric cancer tissues was demonstrated in 50.0 and 69.8% of cases, respectively. The expression of survivin did not associate with vascular endothelial growth factor expression. Expression of survivin was significantly associated with tumor size, depth of invasion, lymph node metastasis, tumor stage and poor survival (P=0.011, 0.004, 0.020, 0.002, 0.046, respectively). High microvessel density was significantly associated with lymph node metastasis and poor survival (P=0.006 and 0.017, respectively). The mean microvessel density value of survivin positive tumors was 87.4+/-34.4 and significantly higher than that of survivin negative tumors (P=0.016). The mean microvessel density value of vascular endothelial growth factor positive tumors was 98.7+/-37.0 and significantly higher than that of vascular endothelial growth factor negative tumors (P=0.001). A combined analysis of survivin and vascular endothelial growth factor status showed that the mean microvessel density value of both positive tumors was 103.7+/-33.1 and significantly higher than that of both negative tumors (P<0.001). CONCLUSION: These results suggest that survivin may play an important role in carcinogenesis by stimulating tumor angiogenesis in human gastric cancer.

Agenesis of the dorsal pancreas: a case report and review of the literature.

Partial or complete agenesis of the dorsal pancreas is a rare congenital anomaly that results from the embryological failure of the dorsal pancreatic bud to form the body and tail of the pancreas. To date, four cases have been reported in Korea. We report an additional case; a 25-year-old woman presented with diabetes mellitus and abdominal pain. Abdominal computed tomography (CT) revealed a normal-appearing pancreatic head, but the body and tail were not visualized. Endoscopic cholangiopancreatogram (ERCP) revealed a short pancreatic duct in the uncinate process and the head and the duct of Santorini draining into the minor papilla. Abdominal magnetic resonance imaging (MRI) findings were similar to the CT and ERCP results. The patient was diagnosed with partial agenesis of the dorsal pancreas by CT, ERCP and MRI.

[Clinical effectiveness of transcatheter arterial embolization for acute upper and lower non-variceal gastrointestinal bleeding].

BACKGROUND/AIMS: Although the initial rate of hemostasis achieved by endoscopic treatment for acute non- variceal gastrointestinal bleeding (NVGIB) is high, recurrent or persistent bleeding occurs in 10% to 25% of the patients. The aim of this study was to assess the efficacy and safety of transcatheter arterial embolization (TAE) in patients with acute upper and lower NVGIB who could not be managed by endoscopic treatment. METHODS: A retrospective analysis of the clinical data was done in 43 patients (M/F: 26/17, mean age: 60 years) whom underwent angiography or TAE for acute upper and lower NVGIB between January 1998 and December 2003. Among 43 patients, 18 had upper NVGIB, 19 had lower NVGIB, and 6 had obscure gastrointestinal bleeding. Demographic characteristics and outcome parameters including the rates of hemostasis, in-hospital death, and complications were analyzed. RESULTS: Thirty-four patients underwent TAE while 9 patients underwent angiography. TAE was used as the first line treatment in 17 patients and as the second line treatment in others. Hemostasis was achieved in 29 of 34 patients (85.3%) by TAE. According to the site of bleeding, hemostasis was achieved in 14 of 17 patients (82.4%) with upper NVGIB and in 15 of 17 patients (88.2%) with lower NVGIB. There was no significant angiography or TAE-related complications such as bowel ischemia or infarction except a hematoma on the angiography site in one patient. CONCLUSIONS: TAE is effective and safe in patients with acute upper or lower NVGIB who cannot be managed by endoscopic treatment.

[Expression of PTEN and its correlation with angiogenesis in gastric carcinoma].

BACKGROUND/AIMS: Phosphatase and tensin homolog deleted on chromosome ten (PTEN) is a recently clarified tumor suppressor gene located in 10q23.3. Alterations of this gene are associated with tumor progression and unfavorable outcome in various human cancers. Recently, PTEN has a possible role in angiogenesis by modulating angiogenic factor including vascular endothelial growth factor (VEGF). The aim of this study was to investigate the roles of PTEN and VEGF status for angiogenesis in human gastric cancer. METHODS: We conducted an immunohistochemical investigation of PTEN and VEGF expression in 90 cases of paraffin section obtained from gastric cancer patients undergone surgical treatment. RESULTS: Negative expression of PTEN and positive expression of VEGF in gastric cancer tissues, were demonstrated in 40.0% and 77.8% of cases, respectively. However, no significant correlation was found between PTEN, VEGF expression and various clinicopathological parameters. PTEN expression did not correlate significantly with VEGF expression (p=0.301). High microvessel density (MVD) was significantly associated with lymph node metastasis and poor survival (p=0.014, 0.011, respectively). The mean MVD value of PTEN negative tumors was 90.4+/-43.0 and significantly higher than that of PTEN positive tumors (p=0.028). The mean MVD value of VEGF positive tumors was 86.4+/-6.7 and significantly higher than that of VEGF negative tumors (p=0.002). The mean MVD value of PTEN negative and VEGF positive tumors was 98.0+/-42.2, and significantly higher than those of the others. CONCLUSIONS: These results suggest that loss of PTEN expression may play a critical role in tumor progression and metastasis by stimulating tumor angiogenesis in human gastric cancer.

[Expression of cyclin dependent kinase inhibitors of KIP family in gastric cancer].

BACKGROUND/AIMS: The cyclin-dependent kinase inhibitors (CDKI) including p21, p27, and p57 of the kinase inhibitor protein (KIP) family are negative regulators of cell cycle progression and potentially act as tumor suppressor. Tumor behavior and growth are influenced by the extent of tumor cell proliferation. The aim of this study was to evaluate the expression of KIP family CDKI in gastric cancer tissue, and to examine the relationship between these expression and various clinicopathological parameters including tumor cell proliferation. METHODS: We conducted an immunohistochemical analysis of p21, p27, and p57 expression in 109 gastric cancer tissues. Tumor cell proliferation was assessed by immunohistochemistry with antibody against Ki-67. RESULTS: Negative expression of p21, p27, and p57 was demonstrated in 45.9%, 65.1%, and 57.8% of cancer tissues, respectively. Negative expression of p21 correlated with larger tumor size, poor differentiation, depth of invasion, lymph node metastasis and advanced TNM stage (p=0.048, 0.041, 0.001, 0.005, and 0.001 respectively). Negative expression of p21 correlated with poor survival (p=0.037). Tumors with negative p21 expression had higher Ki-67 expression than those with positive p21 expression (p=0.024). No significant correlation could be observed between status of p27 and p57 expression and various clinicopathological parameters including survival and tumor cell proliferation. CONCLUSIONS: These results suggest that negative expression of p21 may play an important role in carcinogenesis by stimulating tumor cell proliferation, and may help in predicting the prognosis of gastric cancer.

Zollinger-Ellison syndrome associated with neurofibromatosis type 1: a case report.

BACKGROUND: Neurofibromatosis type 1 is an autosomal dominant neurocutaneous disorder with characteristic features of skin and central nervous system involvement. Gastrointestinal involvement is rare, but the risk of malignancy development is considerable. Zollinger-Ellison syndrome is caused by gastrin-secreting tumors called gastrinomas. Correct diagnosis is often difficult, and curative treatment can only be achieved surgically. CASE PRESENTATION: A 41-year-old female affected by neurofibromatosis type 1 presented with a history of recurrent epigastric soreness, diarrhea, and relapsing chronic duodenal ulcer. Her serum fasting gastrin level was over 1000 pg/mL. An abdominal CT scan revealed a 3 x 2-cm, well-enhanced mass adjacent to the duodenal loop. She was not associated with multiple endocrine neoplasia type 1. Operative resection was performed and gastrinoma was diagnosed by immunohistochemical staining. The serum gastrin level decreased to 99.1 pg/mL after surgery, and symptoms and endoscopic findings completely resolved without recurrences. CONCLUSION: Gastrinoma is difficult to detect even in the general population, and hence symptoms such as recurrent idiopathic peptic ulcer and diarrhea in neurofibromatosis type 1 patients should be accounted for as possibly contributing to Zollinger-Ellison syndrome.

A case of osteoclast-like giant cell tumor of the pancreas with ductal adenocarcinoma: histopathological, immunohistochemical, ultrastructural and molecular biological studies.

Osteoclast-like giant cell tumor of the pancreas is a very rare neoplasm, of which the histiogenesis remains controversial. A 63-yr-old woman was hospitalized for evaluation of epigastric pain. An abdominal computerized tomography revealed the presence of a large cystic mass, arising from the tail of pancreas. A distal pancreatectomy with splenectomy was performed. Histologically, the tumor was composed of mononuclear stromal cells intermingled with osteclast-like giant cells. In addition, there was a small area of moderately to well differentiated ductal adenocarcinoma. The final pathologic diagnosis was osteoclast-like giant cell tumor of the pancreas with ductal adenocarcinoma. Here, we describe the histopathological, immunohistochemical, ultrastructural and molecular biological findings of this tumor with review of the literature pertaining to this condition.

Neostigmine for the treatment of acute hepatic encephalopathy with acute intestinal pseudo-obstruction in a cirrhotic patient.

We treated a 49-yr-old man with neostigmine, who had liver cirrhosis, acute hepatic encephalopathy, and acute intestinal pseudoobstruction. He was admitted in a state of hepatic confusion. On physical examination, the abdomen was distended; and bowel sound was absent. Plain abdomen film revealed multiple air-fluid levels and distention of bowel loops. Initially, we gave him lactulose enemas every 6 hr for one day without improvement in his mental state. Furthermore, he became to a state of coma. Therefore, we gave him 0.5 mg of neostigmine subcutaneously to improve his peristaltic movement, and 2 L of polyethylene glycol electrolyte solution through a nasogastric tube for 4 hr to reduce the production and absorption of gut-derived toxins of nitrogenous compounds. After these treatments, the venous ammonia level decreased to the normal range within 12 hr, and the coma disappeared after 2 days. We suggest that neostigmine may be one of the most effective treatments to initiate peristaltic movement and bowel cleansing in cirrhotic patients with acute hepatic encephalopathy and acute intestinal pseudoobstruction.

Optimal injection volume of epinephrine for endoscopic prevention of recurrent peptic ulcer bleeding.

BACKGROUND: Although the initial rate of hemostasis achieved by endoscopic epinephrine injection for peptic ulcer bleeding is high, bleeding recurs in 14.6% to 35.5% of patients. The aim of this study was to compare rates of recurrent bleeding after endoscopic injection of two different volumes of epinephrine in patients with peptic ulcer bleeding. METHODS: A total of 72 patients with peptic ulcer with active bleeding or a non-bleeding visible vessel were randomly assigned to 15 to 25 mL or 35 to 45 mL injections of a 1:10,000 solution of epinephrine. RESULTS: The two groups were similar with respect to all background variables. The mean volume of epinephrine injected was 19.4 mL: 95% CI [18.7, 20.1] in the 15 to 25 mL group and 41.1 mL: 95% CI [40.0, 42.2] in the 35 to 45 mL group. Initial hemostasis was achieved in 35 of 36 patients (97.2%) in the 15 to 25 mL group and in all 36 patients in the 35 to 45 mL group. The 35 to 45 mL volume was significantly more effective in preventing recurrent bleeding than the 15 to 25 mL volume (0% vs. 17.1%; p < 0.05). For ulcers in the gastric body, the 35 to 45 mL volume was significantly more effective in preventing recurrent bleeding than the 15 to 25 mL volume (0% vs. 31.6%; p = 0.003). For ulcers in other locations, including the gastric antrum and the duodenum, there were no significant differences in the rate of recurrent bleeding between the two groups. CONCLUSIONS: Injection of 35 to 45 mL of a 1:10,000 solution of epinephrine is more effective than injection of 15 to 25 mL of the same solution for prevention of recurrent bleeding from ulcers in the body of the stomach.

Primary non-Hodgkin's lymphoma of the common bile duct presenting as obstructive jaundice.

Primary non-Hodgkin's lymphoma of the extrahepatic bile duct presenting as obstructive jaundice is an extremely rare disease. At this writing, a review of the medical literature disclosed 17 reported cases of primary non-Hodgkin's lymphoma arising from the extrahepatic bile duct. We, herein, report an additional case of obstructive jaundice caused by primary non-Hodgkin's lymphoma of the common bile duct, in a 21-year-old woman. Our patient showed clinical evidence of obstructive jaundice, and endoscopic retrograde cholangiopancreatography and abdominal magnetic resonance imaging demonstrated a long strictured segment of the common bile duct with proximal bile duct dilatation. These clinical and radiological findings resembled those of cholangiocarcinoma. Resection of the common bile duct tumor, cholecystectomy, lymph node dissection, and Roux-en-Y hepaticojejunostomy were carried out. Histology and immunohistochemistry of the resected specimen confirmed a diffuse large B-cell-type malignant lymphoma involving the common bile duct. She received four courses of combination chemotherapy, including cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP), and 3060 cGy external irradiation. She has been well, without evidence of tumor recurrence, 17 months after the surgery. In summary, first, primary non-Hodgkin's lymphoma of the extrahepatic bile duct, despite its rarity, should be considered in the differential diagnosis of causes of obstructive jaundice. Second, an accurate histopathologic diagnosis and surgical resection, if feasible, combined with chemotherapy with or without radiotherapy may be the approach to offer a chance for cure.

Klebsiella pneumoniae septic arthritis in a cirrhotic patient with hepatocellular carcinoma.

Despite septic arthritis is increasingly being reported in elderly patients with diabetes or alcoholism, reported cases of spontaneous bacterial arthritis in cirrhotic patients are extremely rare. We present the first reported case of K. pneumoniae septic arthritis and spontaneous bacterial peritonitis in a cirrhotic patient with hepatocellular carcinoma. K. pneumoniae, one of the most common causative organisms of spontaneous bacterial peritonitis in cirrhotic patients, was isolated from both the blood and the joint fluid, which suggests that the route of infection was hematogenous. After the treatment with cefotaxime and closed tube drainage, the condition of the patient was improved, and subsequently, the joint fluid became sterile and the blood cultures were proved negative. Therefore, this case provides further evidence for the mode of infection being bacteremia in cirrhotic patients and suggests that the enteric bacteremia in cirrhotics may cause infection in different organ systems.

A prospective, randomized trial comparing mechanical methods of hemostasis plus epinephrine injection to epinephrine injection alone for bleeding peptic ulcer.

BACKGROUND: The hemostatic efficacy of mechanical methods of hemostasis, together with epinephrine injection, was compared with that of epinephrine injection alone in bleeding peptic ulcer. METHODS: Ninety patients with a peptic ulcer with active bleeding or a non-bleeding visible vessel were randomly assigned to undergo a mechanical method of hemostasis (23 hemoclip application, 22 band ligation) plus epinephrine injection, or epinephrine injection alone. RESULTS: The two groups were similar with respect to all background variables. Initial hemostasis was achieved in 44/45 (97.8%) patients in both groups. The mean number of hemoclips and elastic bands applied were 2.8: 95% CI[2.5, 3.1] and 1.1: 95% CI[1.0, 1.2], respectively, and the mean volume of epinephrine injected was 19.9 mL: 95% CI[19.3 mL, 20.5 mL]. The rate of recurrent bleeding in the combination group (2/44, 4.5%) was significantly lower in comparison with the injection group (9/44, 20.5%, p < 0.05). The mean number of therapeutic endoscopic sessions needed to achieve permanent hemostasis in the combination group (1.04: 95% CI[1.01, 1.07]) was significantly lower vs. the injection group (1.22: 95% CI[1.15, 1.30]). CONCLUSIONS: The combination of an endoscopic mechanical method of hemostasis plus epinephrine injection is more effective than epinephrine injection alone for the treatment of bleeding peptic ulcer.

A prospective, randomized trial of endoscopic band ligation vs. epinephrine injection for actively bleeding Mallory-Weiss syndrome.

BACKGROUND: Effective hemostatic treatment is mandatory for patients with actively bleeding Mallory-Weiss syndrome. This study evaluated the respective efficacy and the safety of endoscopic band ligation and endoscopic epinephrine injection in Mallory-Weiss syndrome. METHODS: Thirty-four consecutive patients with actively bleeding Mallory-Weiss syndrome were prospectively enrolled and were randomly assigned to undergo endoscopic band ligation or endoscopic injections of a 1:10,000 solution of epinephrine. Demographic characteristics, endoscopic variables, and outcome parameters, including rates of hemostasis and recurrent bleeding, were analyzed. RESULTS: The number of elastic bands applied was one or two; the mean volume of epinephrine injected was 18.0 mL: 95% CI[16.8, 19.2]. There was no significant difference between the groups with respect to age, gender, alcohol ingestion, presenting symptoms, Hb level, shock, comorbid diseases, coagulopathy, tear location, blood transfusion, or duration of hospitalization. Primary hemostasis was achieved in all 17 patients in the band ligation group and in 16 of 17 patients (94.1%) in the epinephrine injection group. There was no recurrence of bleeding or major complication in either group. CONCLUSIONS: In this small study, no difference was detected in the efficacy or the safety of band ligation vs. epinephrine injection for the treatment of actively bleeding Mallory-Weiss syndrome.