Colonoscopy evaluation after short-term anti-tuberculosis treatment in nonspecific ulcers on the ileocecal area.

AIM: To evaluate the efficacy of colonoscopy follow-up after short-term anti-tuberculosis treatment in patients with nonspecific ulcers on ileocecal areas being suspicious of tuberculous colitis. METHODS: We prospectively analyzed the colonoscopic findings before and after short term anti-tuberculosis treatment in 18 patients with nonspecific ulcers on the ileocecal area and compared them with 7 patients of confirmed tuberculous colitis by acid-fast bacilli or caseating granuloma on colonic biopsy. RESULTS: Mean duration for short-term follow-up was 107.3 d with combined chemotherapy containing isoniazid, rifampicin, ethambutol and pyrazinamide. Seven patients with tuberculous colitis showed complete healing of active ulcers after short-term medication. After short-term anti-tuberculosis treatment, follow-up colonoscopy findings divided 18 patients with nonspecific ulcers into two groups by ulcer state. One is the "suspicious tuberculous colitis group" showing healing of ulcers and erosions and another is the "suspicious inflammatory bowel disease group" showing active ulcers with or without aggravation of the lesion. Finally, all 9 of the "suspicious tuberculous colitis group" were diagnosed as tuberculous colitis showing no recurrence of ulcers after termination of 9 mo of anti-tuberculosis medication. Patients of the "suspicious inflammatory bowel disease group" were finally diagnosed as Crohn's disease or nonspecific colonic ulcers during long-term follow up. CONCLUSION: Follow-up colonoscopy shows a healing stage ulcer or scarring change without an active ulcer with just 2 mo to 3 mo of medication in patients with tuberculous colitis. Colonoscopy follow-up after short term anti-tuberculosis trial in patients with nonspecific ulcers on the ileocecal area is valuable in making early differential diagnosis of tuberculous colitis.

[A case of mucinous noncystic carcinoma of the pancreas].

Mucinous (colloid) carcinoma is defined as pools of stromal extracellular mucin containing scanty, floating carcinoma cells. It is a well-defined entity in breast or large bowel. However, mucinous noncystic carcinoma of the pancreas (MNCC) is uncommon, comprising between 1% and 3% of all carcinomas of the pancreas. In the past, MNCC generally had been categorized together with ordinary ductal adenocarcinoma or misdiagnosed as mucinous cystadenocarcinoma or signet-ring cell carcinoma. The new WHO classification lists MNCC as a variant of ductal adenocarcinoma. Herein, we report a 32-year-old woman with incidentally found pancreatic body mass who underwent subtotal pancreatectomy. She was diagnosed as MNCC histologically.

Association between low thigh fat and non-alcoholic fatty liver disease.

BACKGROUND AND AIM: Some people have a fatty liver despite having low visceral fat and a low body mass index (BMI). We investigated whether fat distribution, especially thigh subcutaneous fat and thigh intramuscular fat, is associated with non-alcoholic fatty liver disease (NAFLD). METHODS: The patients consisted of 408 men and women. NAFLD was defined by an ultrasound scan and excluded other liver diseases. Visceral, subcutaneous abdominal, intramuscular, and subcutaneous thigh adipose tissue was measured by computed tomography. RESULTS: The frequency of NAFLD decreased over a quartile of thigh fat independently of BMI in the female patients. Additional adjustments for age and visceral fat area did not change the results. This finding was not observed in the male patients. To investigate the relationship between each fat distribution and NAFLD, we performed a logistic regression analysis. Fat distribution was divided into four groups: visceral fat, abdominal subcutaneous fat, thigh subcutaneous fat, and thigh intramuscular fat. All four fat components were chosen as variables for the regression model. Age, BMI, and the homeostasis model assessment (HOMA) index were then adjusted successively. A larger subcutaneous fat area was negatively associated with NAFLD after adjustment for visceral fat and abdominal subcutaneous fat areas in women, but not in men. It did not change even after age adjustment, BMI, and the HOMA index. CONCLUSION: Low femoral subcutaneous fat amounts were shown to be independently associated with fatty liver disease in women. These results show the importance of accurate measurements of other regional body compositions as well as visceral fat amounts when investigating NAFLD.

Distant skeletal muscle metastasis from intrahepatic cholangiocarcinoma presenting as Budd-Chiari syndrome.

Intrahepatic cholangiocarcinoma is a malignant neoplasm arising from the biliary epithelium, which frequently invades adjacent organs or metastasizes to other visceral organs such as the lungs, bones, adrenals, and brain. However, distant skeletal muscle metastasis of cholangiocarcinoma has never been described before to the best of our knowledge and, furthermore, Budd-Chiari syndrome secondary to intrahepatic cholangiocarcinoma is also extremely rare. Here we present the first case overall of distant muscle metastasis from intrahepatic cholangiocarcinoma presenting as Budd-Chiari syndrome. A 44-year-old man admitted to the hospital with complaints of abdominal distension, edema of both legs, back pain and anorexia of 30 d' duration. Computed tomography and ultrasonography-guided percutaneous muscle biopsy established intrahepatic cholangiocarcinoma with disseminated thrombosis from inferior vena cava to bilateral iliac and femoral veins, and multiple skeletal muscle metastases in bilateral buttock and erector spinal muscle.

[A case of ulcerative colitis relapsed by influenza vaccination].

Although a large number of studies have reported the causes of the exacerbation of ulcerative colitis (UC), the effect of influenza vaccination on the relapse of UC has not been reported. We experienced a case of prompt exacerbation of quiescent UC due to influenza vaccination. A 39-year-old woman was diagnosed as UC 4-years ago and was well controlled with oral mesalazine. She experienced abdominal pain and frequent bowel movements with hematochezia 3 days after the vaccination. On admission, laboratory findings showed elevated erythrocyte sedimentation rate and C-reactive protein. Sigmoidoscopy showed marked edematous mucosa on rectum and sigmoid colon with fine ulceration and spontaneous bleeding. She recovered from the exacerbation of UC after steroid treatment. Vaccination should be administered to the patients with inflammatory bowel disease with the caution of its possible side effects.

[A case of ischemic colitis in a patient with Takayasu's arteritis].

Ischemic colitis is one of the most common intestinal ischemic injury in which more than 90% of patient are over 60 year-old. It results from impaired perfusion of blood to the bowel and is rarely caused by vasculitis such as systemic lupus erythematosus, polyarteritis nodosa, and Takayasu's arteritis. Takayasu's arteritis affects the aortic arch, medium-sized and large arteries but rarely involves inferior mesenteric artery. We report a case of Takayasu's arteritis involving inferior mesenteric artery which developed ischemic colitis in a 70 year old female. To the author's knowledge this is the first case report in Korea. A 70 year old woman who had suffered from Takayasu's arteritis for 5 years was admitted for sudden abdominal pain and hematochezia. On sigmoidoscopy, there were multiple segmental longitudinal ulcerations around splenic flexure and diffuse hemorrhagic edematous mucosa from descending colon to sigmoid colon. On abdominal CT angiography, inferior mesenteric artery was not traced. We diagnosed it as ischemic colitis combined with Takayasu's arteritis. After the conservative treatment, abdominal pain and hematochezia disappeared. She was followed up to 2 years without recurrence of symptoms.

[Clinical factors that predicts successful eradication of Helicobacter pylori].

BACKGROUND/AIMS: Antibiotic resistance and compliance are regarded to be important which affect the eradication of Helicobacter pylori (H. pylori). However, it is not easy to apply the antibiotic resistance test in clinical field. We investigated other clinical factors predicting the successful eradication of H. pylori. METHODS: From January 2004 to March 2005, 195 patients with documented H. pylori infection received proton pump inhibitor (PPI)-based triple therapy for one week and were assessed for the underlying chronic illnesses, smoking, alcohol habit, therapeutic indication and compliance. RESULTS: The intention-to-treat (ITT) eradication rates were 69.2%, while per protocol (PP) analysis with 169 patients showed an initial eradication rate of 79.9%. The eradication rates of H. pylori according to the underlying disease were 73.9% (17/23) in diabetes, 66.7% (18/27) in hypertension, 66.7% (2/3) in renal disease, 100% (9/9) in liver disease, 63.7% (7/11) in cardiovascular disease and 64.3% (9/14) in chronic NSAIDs user. There was no statistical difference in the eradication rates according to the therapeutic indication, underlying disease, sex, age, smoking, alcohol, and PPI. However, the eradication rate was statistically lower in patients with multiple underlying diseases. Eradication rate was significantly higher in patients with good compliance than in those with poor compliance in taking medications (p<0.05). CONCLUSIONS: Underlying chronic disease does not affect the H. pylori eradication rate significantly. In clinical practice, apart from antibiotic resistance test, drug compliance is the most important factor affecting the H. pylori eradication rate.

[A case of carcinoid tumor of the common bile duct].

Majority of malignant neoplasms arising from the extrahepatic bile duct are adenocarcinomas. Carcinoid tumors at this site are extremely rare. We report a 67-year-old woman with malignant carcinoid tumor of the common bile duct. She presented with obstructive jaundice of 1 week's duration. Abdominal CT and ERCP revealed a common bile duct mass. She underwent Whipple's operation and was diagnosed as malignant carcinoid tumor histologically and immunohistochemically.

Malignant carcinoid tumor of the common bile duct: report of a case.

Carcinoid tumors of the extrahepatic bile duct are exceedingly rare and account for between 0.1% and 2% of all gastrointestinal carcinoid tumors, with most reported cases arising from the gallbladder. We herein present what we believe is only the 47th reported case of a primary carcinoid tumor occurring in the extrahepatic bile ducts. A 67-year-old woman sought treatment for obstructive jaundice accompanied by epigastric pain. Laboratory and imaging studies gave results that were consistent with a malignant obstruction in the common bile duct. We performed a pylorus-preserving pancreaticoduodenectomy. Pathologically, an ill-demarcated mass was noted in the common bile duct measuring 1.6 x 1.5 x 0.5 cm in size. The tumor had invaded the adjacent pancreatic tissues. Immunohistochemically, the mass demonstrated chromogranin, synaptophysin, and CD56 positivity. The final pathologic diagnosis was well-differentiated carcinoid tumor of a malignant nature. The patient, who underwent a curative surgical resection, was alive and disease-free at the time of writing.

Four cases of gastric submucosal mass suspected as anisakiasis.

Anisakiasis is a parasitic disease caused by ingestion of raw fish infected with anisakid larvae. Endoscopic changing patterns of submucosal lesions in chronic gastric anisakiasis have not been known yet. Here we report 4 cases of suspected gastric anisakiasis which were improved during follow-up periods without surgical treatment. The patients presented with abdominal pain, nausea and vomiting after consuming raw marine fish, and visited our gastroenterology outpatient department. Their endoscopic findings showed firm and yellowish submucosal masses accompanied with eccentric erosions. Histologic findings showed severe eosinophilic infiltrations. In blood tests, peripheral eosinophil counts and total IgE levels were elevated. We believed that all cases were caused by larval anisakid infections. The submucosal mass lesions disappeared during the follow-up periods of 2 to 4 mo.

[A case of intraductal papillary mucinous neoplasm of the pancreas arising from pancreas divisum without ventral pancreatic duct of Wirsung].

Most reported cases of intraductal papillary mucinous neoplasms (IPMNs) originate from Wirsung's duct or their branches. IPMNs arising from Santorini's duct and its branches have rarely been reported. Eight cases of IPMN arising from Santorini's duct have been published worldwide. However, these cases are associated with incomplete type of pancreas divisum. Recently, one report of IPMN with complete absence of Wirsung's duct has been reported. This patient was a 57-year-old woman who was admitted to the hospital due to progressive jaundice. On endoscopic retrograde cholangiopancreatography, there was a severely bulging ampulla of Vater and patulous minor papilla draining mucinous material and a cystic lesion communicating with the dilated Santorini's duct without any communication with Wirsung's duct. A pancreaticoduodenectomy was performed and the pathologic examination of resected specimen showed no evidence of Wirsung's duct, but an IPMN arising from Santorini's duct with peripancreatic lymph node metastasis. Herein, we report a case of invasive IPMN arising from pancreatic head without ventral pancreatic duct with a review of the relevant literatures.

[Transient intestinal obstruction due to stool impaction in the elderly].

BACKGROUND/AIMS: Acute intestinal obstruction is an urgent disease to be diagnosed and treated promptly. In elderly, fecal impaction may be an important and preventable cause of colonic obstruction. We investigated the clinical features of patients presenting with identical features of intestinal obstruction transiently due to fecal impaction. METHODS: From February 2001 to March 2004, nineteen patients were diagnosed as transient intestinal obstruction due to fecal impaction. We evaluated clinical characteristics, radiologic findings, sigmoidoscopic or colonoscopic findings and managements. RESULTS: Male and female ratio was 1:1.1. Mean age was 79.3 years. All 19 patients had abdominal pain and distension. On digital rectal examination, the hard feces was palpable in only 8 patients (42%) while others showed empty rectum. The abnormal laboratory findings included leukocytosis in 5 patients (26%), anemia in 10 patients (53%) and electrolyte abnormalities in 7 patients (37%). Simple abdominal X-rays showed diffuse small and/or large bowel dilatations. In only 3 patients (16%) air-fluid levels were definite, but most patients showed abundant feces in the rectum and colon. During emergency sigmoidoscopy, abdominal pain and distension were relieved and there were Bristol type 1 hard stool in the recto-sigmoid junction in 7 patients (37%) and multiple rectal ulcers in 1 patient. On colonoscopy, there were no mass or pathologic obstruction in all patients. Patients were discharged after the adequate medication and toilet training. CONCLUSIONS: In elderly patients, fecal impaction is odd and preventable cause of intestinal obstruction. It is often significant to differentiate fecal impaction from other pathologic conditions in patients with chronic constipation.

[Immunohistochemical study of p53 mutation and p16, p14 alterations encoded by INK4a-ARF in mucin-hypersecreting bile duct tumor].

BACKGROUND/AIMS: Mucin-hypersecreting bile duct tumor is rare, and has an unusual histologic characteristic of having various degrees of cellular atypia ranging from dysplasia to invasive carcinoma in the same specimen. To gain insight into the role of p16, p14 and p53 in the carcinogenic process of bile duct tumor, we analyzed the expression status of these proteins in mucin-hypersecreting bile duct tumor. METHODS: Immunohistochemical staining of p16, p14 and p53 were performed in 34 paraffin embedded tissues obtained from 22 patients of mucin-hypersecreting bile duct tumor. RESULTS: Thirty-four specimens were categorized into low-grade dysplasia (9), high-grade dysplasia (4), carcinoma in situ (CIS, 11) and invasive carcinoma (10) based on the degree of cytologic and structural atypia. p53 overexpressions were found in 6 (17.6%, 3 in CIS, 3 in invasive carcinoma) and more frequently observed in the advanced histologic stages (p<0.05). Loss of p16 staining was found only in 2 (6%) of low-grade dysplasia specimen. Loss of p14 staining was found in 21 (61.7%, 7 in low-grade dysplasia, 2 in high-grade dysplasia, 8 in CIS, and 4 in invasive carcinoma) and was frequently observed in low-grade and high-grade dysplasia compared to p53 (p<0.05). CONCLUSIONS: In mucin-hypersecreting bile duct tumor, p14 and p53 may play a role in the early and advanced stage of carcinogenesis, respectively. Further study regarding genetic and epigenetic alterations in p14 and p53 gene may be needed.

Comparison of histology and extracellular matrix between autoimmune and alcoholic chronic pancreatitis.

OBJECTIVES: In autoimmune chronic pancreatitis (AIP), the histology is known to be characteristic and histologic recovery including pancreatic fibrosis has been reported after steroid therapy. The aims of this study were to demonstrate whether these histologic findings were unique to AIP and evaluate any differences in the composition of extracellular matrix between AIP and ordinary chronic pancreatitis. METHODS: Histologic findings and extracellular matrix proteins (collagen types I, III, and IV and fibronectin) were evaluated in 15 patients with clinically proven AIP and compared with those of 8 patients with surgically treated alcoholic chronic pancreatitis (ACP). RESULTS: The pattern of fibrosis was mainly loose fibrosis with stromal edema in AIP, while it was dense fibrosis in ACP. Acinar atrophy was more diffuse and severe in AIP than ACP. While diffuse with same stage of inflammatory activity was observed in AIP, multifocal inflammation with different stage of inflammatory was seen in ACP. For extracellular matrix proteins, dense deposition (compared with normal controls) of collagen type III was observed more frequently in ACP than AIP (P < 0.05). ACP showed decreased deposition of collagen type IV more frequently than AIP (P = 0.001). CONCLUSION: Fibrosis and inflammation are common to both AIP and ACP, but the pattern is very different between the 2 groups, and the deposition of collagen types III and IV is substantially different between AIP and ACP.

Regression of pancreatic fibrosis after steroid therapy in patients with autoimmune chronic pancreatitis.

Autoimmune chronic pancreatitis (AICP) is a clinically attractive entity because of its dramatic response to steroid therapy. Reported cases of AICP until now have focused on mainly clinical, radiologic, and laboratory features with steroid therapy. There are, however, few reports that demonstrate histologic recovery, especially regression of pancreatic fibrosis in patients with AICP. Fibrosis in chronic pancreatitis is generally believed to be irreversible. Our observation of reversibility of pancreatic fibrosis is, therefore, noteworthy. We illustrate this with 2 cases of AICP in which pancreatic fibrosis as well as inflammatory infiltration regressed after a short course of oral steroid therapy.

Autoimmune chronic pancreatitis.

In recent years a peculiar type of chronic pancreatitis with underlying autoimmunity has been described. Lymphoplasmacytic infiltration and fibrosis on histology and elevated IgG levels or detected autoantibodies on laboratory data support the concept of autoimmune chronic pancreatitis (AIP). Pancreatic imaging reveals a rare association of diffuse enlargement of the pancreas and irregular narrowing of the main pancreatic duct, which is unique and specific to AIP. Although AIP is not a common disease, it is increasingly being recognized as knowledge of this entity builds up. Clinically it is very important to be aware of this disease because AIP can clinically disguise as pancreaticobiliary malignancies, ordinary chronic, or acute pancreatitis. Above all, AIP is a very attractive disease to clinicians in terms of its dramatic response to oral steroid therapy in contrast to ordinary chronic pancreatitis. This review discusses the clinical, laboratory, histologic, and imaging findings that are seen in patients with AIP, especially focusing on the diagnosis.

Endoscopic sphincterotomy vs. endoscopic papillary balloon dilation for choledocholithiasis in patients with liver cirrhosis and coagulopathy.

BACKGROUND: To determine whether endoscopic papillary balloon dilation decreases the risk of hemorrhage without increasing the risk of acute pancreatitis, the results of endoscopic papillary balloon dilation were compared with those of endoscopic biliary sphincterotomy in patients with cirrhosis and coagulopathy. METHODS: Twenty-one patients with liver cirrhosis with coagulopathy had endoscopic papillary balloon dilation for choledocholithiasis from January 2001 to September 2003. Twenty patients with cirrhosis and coagulopathy who underwent endoscopic biliary sphincterotomy from January 1998 to December 2000, served as a historical control group. RESULTS: The rate of endoscopic biliary sphincterotomy related hemorrhage was 30% (6/20), whereas the rate for endoscopic papillary balloon dilation related hemorrhage was 0% (p=0.009). With regard to rates of hemorrhage in relation to Child-Pugh class, most (n=5) of the bleeding complications occurred in patients with Child-Pugh class C cirrhosis; bleeding occurred in only one patient with Child-Pugh B cirrhosis. There was no significant difference between the endoscopic biliary sphincterotomy and the endoscopic papillary balloon dilation groups for procedure-related pancreatitis (10% vs. 4.7%, respectively; p>0.05). CONCLUSIONS: Endoscopic papillary balloon dilation may significantly reduce the risk of bleeding compared with endoscopic biliary sphincterotomy in patients with advanced cirrhosis and coagulopathy. In these patients, the substitution of endoscopic papillary balloon dilation for endoscopic biliary sphincterotomy is recommended for treatment of choledocholithiasis.