Endoscopic removal of impacted magnetic foreign bodies in the gastroesophageal junction.

Ingestion of foreign bodies is common in gastroenterology practice. Most of them are spontaneously passed through gastrointestinal tract. However, ingestion of multiple magnets can cause serious complications, because magnets attract each other and they hold the gastrointestinal wall. Here, we describe a patient who ingested multiple magnets that attracted each other between distal esophagus, and a part of them was impacted into the esophageal wall. In general, impacted magnetic foreign bodies should be removed by surgical intervention because of a high perforation risk. But, in this case, we used an insulated-tip knife for endoscopic submucosal dissection technique to make an incision to expose the impacted magnetic foreign bodies, and removed them successfully without surgery. With this report, we hope to encourage gastroenterologists to consider this new technique as one of procedures for difficult cases, including impacted foreign bodies.

Autoamputation of a giant colonic lipoma.

Most colonic lipomas are asymptomatic and need no treatment, whereas lesions larger than 2 cm can cause acute abdominal pain, changes in bowel habits, gastrointestinal bleeding, intussusception or bowel obstruction. Autoamputation of polypoid lesions in the gastrointestinal tract is indeed a rare phenomenon, and its precise mechanism remains unknown. It presumably occurs due to ischemic necrosis of the polyp by peristalsis-induced torsion or tension. Here, we report a case of autoamputation of a giant colonic lipoma in a 48-year-old man. In our case, colonoscopic examination showed a huge autoamputated mass in the rectum and a remnant long stalk in the transverse colon. The autoamputated mass in the rectum was completely removed after fragmentation using an electrosurgical snare, and the remnant long stalk located in the transverse colon was also resected safely by endoscopic snare polypectomy. To our knowledge, these endoscopic treatments for removal of an autoamputated mass and a remnant long stalk of colonic lipoma have not been reported previously.

A case of recurrent infection caused by a pancreaticoduodenal fistula associated with a pancreatic arteriovenous malformation.

Although arteriovenous malformations (AVM) occur frequently in digestive organs, pancreatic AVM is rare. The clinical symptoms of pancreatic AVM are variable and include gastrointestinal bleeding, abdominal pain, jaundice, portal hypertension, pancreatitis, and duodenal ulcer. However, choledochoduodenal or pancreaticoduodenal fistulas complicated with ascending infection and pancreatitis is extremely rare. Herein, we report a case of pancreaticoduodenal fistula associated with a pancreatic AVM that induced recurrent anemia and ascending infection.

A Comparison of clinical characteristics between medically-treated patients and surgically-treated patients with ischemic colitis.

BACKGROUND/AIMS: Ischemic colitis (IC) is usually a self-limiting disease. But, it can cause necrosis that requires urgent surgical treatment. We sought to evaluate clinical difference in IC patients between medical and surgical treatment groups, and to identify prognostic factors for adverse outcomes. METHODS: We conducted a retrospective analysis of clinical characteristics in patients with IC treated in Chonnam National University Hospital between May 2001 and April 2010. A total of 81 patients with IC were enrolled. We classified the patients into two groups-a medical treatment group and a surgical treatment group-and evaluated their clinical features, treatment outcomes and mortality. RESULTS: Absence of hematochezia, vomiting, abdominal tenderness, abdominal rebound tenderness, heart rate over 90 beats/min, systolic blood pressure less than 100 mm Hg, hyponatremia and increased LDH or serum creatinine level were observed more frequently in surgically-treated patients (p<0.05). Most cases in the medically-treated group resolved without complications (98.3%). But, about half of the cases (52.4%) of the surgically-treated group resolved and the mortality rate was 47.6%. CONCLUSIONS: In patients with ischemic colitis, several clinical factors are associated with surgical treatment. Although IC is often selflimited, our data suggests that special attention and aggressive therapy is warranted in treating these patients.

[A case of large retroperitoneal lipoma mimicking liposarcoma].

Lipomas are the most common benign tumors of adipose tissue among adults. Lipomas can occur almost anywhere in the trunk, extremities, mediastinum, and pelvis, but retroperitoneal lipomas are extremely rare. It should be distinguished from well differentiated liposarcoma in order to provide the appropriate treatment and follow up. We experienced a case of 60-year-old patient with large retroperitoneal lipoma mimicking liposarcoma causing palpable abdominal mass and pain. Abdominal computerized tomography (CT) showed 33 x 22 cm sized bulky fat-containing mass with contrast enhanced solid portion in right retroperitoneum. Positron emission tomograpgy (PET) revealed increased 18F-FDG uptake at solid portion shown in abdominal CT. Imaging studies confirmed a high index of suspicion on liposarcoma. Laparotomy showed a large encapsulating tumor arising from retroperitoneum with fat necrosis. Pathologic examination of resected specimen revealed normal mature adipocytes without atypical cells, compatible with lipoma.

Usefulness of physical maneuvers for prevention of vasovagal syncope.

BACKGROUND: It is known that approximately two-thirds of patients with vasovagal syncope have prodromal symptoms and when these start, physical maneuvers that can increase venous return may abort the syncopal attack. The aims of this study were to evaluate the effects of 3 physical maneuvers, squatting, leg-crossing with muscle tensing, and handgrip, on improving hemodynamic status, and to compare the effect of each on aborting or preventing vasovagal syncope. METHODS AND RESULTS: Of 50 patients who underwent the head-up tilt test (HUT) to evaluate syncope, 27 patients with positive HUT were classified as group I (14 men, 13 women; mean age 44.5+/-15.3 years), 23 patients with negative HUT were classified as group II (13 men, 10 women; mean age 41.2 +/-16.7 years), and 21 normal subjects were classified as group III (10 men, 11 women; mean age 28.6+/-6.3 years). The effects of the physical maneuvers were evaluated in 21 patients from group I who underwent a repeat HUT 1 week after the initial test. Leg-crossing significantly increased systolic blood pressure (SBP) in all 3 groups (8.0+/-5.8 mmHg in group I, 7.0+/-8.5 mmHg in group II, 8.7+/-5.7 mmHg in group III; p < 0.05), but not diastolic blood pressure (DBP). Squatting significantly increased SBP and DBP in all 3 groups (7.1 +/-5.1, 4.6+/-5.8 mmHg in group I, 7.8+/-5.9, 4.3+/-4.7 mmHg in group II, 6.5+/-5.0, 3.7+/-3.9 mmHg in group III; p < 0.05). However, handgrip did not exert any significant influence on the hemodynamics in any group nor did heart rate change significantly during the physical maneuvers in any group. During the repeat HUT, prodromal symptoms with hypotension developed in 13 of the 21 patients and of these 5 fainted immediately after and were not able to do the physical maneuvers. Squatting and leg-crossing aborted syncope in 7 of 8 patients, but handgrip aborted syncope in only 1 patient. CONCLUSION: Squatting and leg-crossing with muscle tensing improved the hemodynamics of normal subjects as well as those of patients with vasovagal syncope. Squatting and leg-crossing can be used as a simple and effective preventive maneuver in patients with vasovagal syncope.