Rapidly Growing Acinar Cell Carcinoma of the Pancreatic Head: A Case Report and Literature Review / 대한췌담도학회지

Pancreatic acinar cell carcinoma (ACC) is a rare neoplasm accounting less than 1% of malignant pancreatic tumors. A 47-year-old male patient visited the emergency room with epigastric pain. Computed tomography or magnetic resonance imaging revealed a 4.7-cm heterogeneously enhanced solid and cystic mass with internal necrosis located in the head of the pancreas. Radiological diagnosis was borderline malignancy such as neuroendocrine tumor or solid pseudopapillary neoplasm. Two months later, the necrotic mass in the pancreas head had grown up to 11 cm, compressing the duodenum, superior mesenteric vein, and proximal transverse colon. Pylorus preserving pancreatoduodenectomy with segmental resection of transverse colon was performed. Histopathological examination revealed that the tumor was pancreatic ACC. The patient recovered without any complication and was doing well without recurrence for 12 months after surgery.

Effect of intraperitoneally administered propentofylline in a rat model of postoperative pain

Background@#In this study, we sought to evaluate whether systemic propentofylline (PPF) has antiallodynic effects in a rat model of postoperative pain, and to assess the mechanism involved. @*Methods@#After plantar incision, rats were intraperitoneally injected with various doses of PPF to evaluate its antiallodynic effect. To investigate the involved mechanism, rats were intraperitoneally injected with yohimbine, dexmedetomidine, prazosin, naloxone, atropine or mecamylamine, following the incision of the rat hind paws, and then PPF was administered intraperitoneally. The mechanical withdrawal threshold (MWT) was evaluated using von Frey filaments at various time points and serum levels of tumor necrosis factor (TNF)-α, interleukin (IL)-1β, and IL-6 were measured to determine the inflammatory response level. @*Results@#MWT was significantly increased after intraperitoneal injection of 30 mg/ kg of PPF when compared with the control group. Injection of PPF and yohimbine, atropine or mecamylamine showed significant decreases in the MWT, while injection of PPF and dexmedetomidine showed a significant increase. Systemic administration of PPF inhibited the post-incisional increase in serum level of TNF-α and IL-1β. @*Conclusions@#Systemic administration of PPF following surgery presented antiallodynic effects in a rat model of postoperative pain. The antiallodynic effects against mechanical allodynia could be mediated by α-adrenergic and cholinergic receptors.

Age-related Reference Intervals for Total Collagen-I-N-terminal Propeptide in Healthy Korean Population

BACKGROUND: Procollagen type I N-terminal propeptide (PINP) is one of the most clinically useful bone formation biomarkers. Therefore, the purpose of this study was to independently evaluate the performance of automated total PINP assay and established age- and gender-specific reference intervals for PINP in healthy Korean population. METHODS: The imprecision, linearity, and detection capability of Elecsys total PINP assay was determined and reference interval was established using 599 serums from Korean population with normal bone mineral densities based on bone densitometry. Age groups were divided into 20s, 30s, 40s, 50s, 60s and over. RESULTS: Elecsys total PINP had excellent performance in imprecision, linearity, and detection capability. When partitioning age groups in Korean male and female populations, there was significant difference in total PINP between different age groups. In male populations, PINP level was decreased with increasing age, then it remained steady after middle-age. In female populations, there was a decreasing tendency similar to that in the male population with a sharp increase in the 50 to 59 age group. CONCLUSIONS: Elecsys total PINP assay showed precise and reliable performance in our study. We established age-related PINP reference intervals for Korean male and female population with normal bone mineral densities.

Comparison of Fatigue Severity and Quality of Life between Unexplained Fatigue Patients and Explained Fatigue Patients / 가정의학회지

BACKGROUND: Recently, despite the high prevalence of fatigue in patients, there is a lack of research on the quality of life (QoL) in unexplained fatigue patients, indicating that they are not properly diagnosed and treated. The aim of this study was to compare fatigue severity and QoL between patients with explained and unexplained fatigue. METHODS: The study consisted of 200 Korean adults who complained of fatigue without underlying disease. Fatigue Severity Scale, Short Form Health Survey-36 version 2 (SF-36v2), and Beck Depression Inventory-II (BDI-II) self-questionnaires were administered. Participants were dichotomized to two groups, namely, patients with unexplained or explained fatigue, sorted according to laboratory examination results. The chi-square test, t-test, and Wilcoxon rank-sum test were used, and analysis of covariance was calculated after adjusting for age, sex, body mass index, smoking status, and physical component summary (PCS) of SF-36v2 or BDI-II. RESULTS: PCS of SF-36v2 between the two groups showed significant difference. Compared to patients with explained fatigue, those with unexplained fatigue showed lower physical component scores of QoL. CONCLUSION: QoL of patients with unexplained fatigue could largely diminish than those with explained fatigue. The primary clinician should be aware of poor QoL in patients with unexplained fatigue to identify who is in need of more attention and intervention.

Diagnostic Yield and Clinical Impact of Video Capsule Endoscopy in Patients with Chronic Diarrhea: A Korean Multicenter CAPENTRY Study

BACKGROUND/AIMS: In some cases, chronic diarrhea is unexplained, and small bowel disorders may be one of the causes. The aim of this study was to assess the diagnostic yield and clinical impact of video capsule endoscopy (VCE) in patients with chronic diarrhea. METHODS: We retrospectively analyzed records from October 2002 to August 2013 in the VCE nationwide database registry (n=2,964). Ninety-one patients from 15 medical centers (60 males and 31 females; mean age, 47±19 years) were evaluated for VCE as a result of chronic diarrhea. RESULTS: The duration of chronic diarrhea was 8.3±14.7 months. The positive diagnostic yield of VCE was 42.9% (39/91). However, 15.4% (14/91) exhibited an inconsistent result, and 41.8% (38/91) were negative. Abnormal findings consistent with chronic diarrhea included erosions/aphthous ulcers (19.8%), ulcers (17.6%), mucosal erythema (3.3%), edema (1.1%), and luminal narrowing (1.1%). The most common diagnoses were functional diarrhea associated with irritable bowel syndrome in 37 patients (40.7%) and Crohn’s disease in 18 patients (19.8%). After VCE examination, the diagnosis was changed in 34.1% of the patients (31/91). Hematochezia (odds ratio [OR], 8.802; 95% confidence interval [CI], 2.126 to 36.441) and hypoalbuminemia (OR, 4.811; 95% CI, 1.241 to 18.655) are predictive factors of a positive diagnostic yield. CONCLUSIONS: VCE had a favorable diagnostic yield and clinical impact on the management of patients with chronic diarrhea.

Prevalence and Risk Factors of Gallbladder Polypoid Lesions in a Healthy Population

PURPOSE: To determine the prevalence of and investigate the risk factors for gallbladder (GB) polypoid lesions in a healthy population. MATERIALS AND METHODS: A total of 23827 subjects who underwent abdominal ultrasonography in conjunction with health screening examinations were retrospectively analyzed. The prevalence of risk factors for GB polypoid lesions were evaluated. In addition, risk factors according to the number of polypoid lesions and the presence of stones with polypoid lesions were investigated. To analyze these risk factors, a control group was established with a 1:2 ratio matched for age and sex. RESULTS: The prevalence of GB polypoid lesions was identified as 9.96%. On multivariate analysis, chronic hepatitis B infection (CHB) and the presence of metabolic syndrome (MS) were risk factors for GB polypoid lesions. CHB and MS were also significant independent risk factors for multiple GB polypoid lesions when compared with solitary GB polypoid lesions. In addition, gastric Helicobacter pylori infection and MS were significant risk factors for GB polypoid lesions with stones when compared with GB polypoid lesions without stones. CONCLUSION: The prevalence of GB polypoid lesions in a healthy Korean population was 9.96%. Patients with CHB and MS need to be carefully examined for such lesions.

Oral udenafil and aceclofenac for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis in high-risk patients: a randomized multicenter study

BACKGROUND/AIMS: Acute pancreatitis is a common complication of endoscopic retrograde cholangiopancreatography (ERCP). Combination therapy w ith ora l udenafil and aceclofenac may reduce the occurrence of post-ERCP pancreatitis by targeting different pathophysiological mechanisms. We investigated whether combining udenafil and aceclofenac reduced the rates of post-ERCP pancreatitis. METHODS: A prospective, randomized, double-blind, placebo-controlled, multicenter study was conducted in four academic medical centers. Between January 2012 and June 2013, a total of 216 patients who underwent ERCP were analyzed for the occurrence of post-ERCP pancreatitis. Patients were determined to be at high risk for pancreatitis based on validated patient and procedure-related risk factors. RESULTS: Demographic features, indications for ERCP, and therapeutic procedures were similar in each group. There were no significant differences in the rate (15.8% [17/107] vs. 16.5% [18/109], p = 0.901) and severity of post-ERCP pancreatitis between the udenafil/aceclofenac and placebo groups. One patient in each group developed severe pancreatitis. Multivariate analyses indicated that suspected dysfunction of the sphincter of Oddi and endoscopic papillary balloon dilation without sphincterotomy were associated with post-ERCP pancreatitis. CONCLUSIONS: Combination therapy with udenafil and aceclofenac is not effective for the prevention of post-ERCP pancreatitis.

Mechanism of Severe Acute Pancreatitis: Focusing on Development and Progression / 대한췌담도학회지

Acute pancreatitis (AP) is an inflammatory disorder and the severity range from mild to severe form. The mortality of severe form of AP is still high despite of tremendous improvement of diagnostic modalities and therapeutic options. Although pathogenesis of AP is still not fully understood, autodigestion theory is regarded as an initial common pathophysiologic mechanism of AP for about 2 centuries. However, it is obscure which mechanisms are involving the disease severity. Upregulation of adhesion molecules, leukocytes, proinflammatory cytokines and chemokines are also concerned local injury, systemic exacerbation of inflammation and ultimately organ failure. In addition, transcription factor Nuclear factor-kappa B is also influence the severity through upregulate the proinflammatory genes. The patterns of acinar cell death are closely correlated with disease severity of AP. The degree of acinar cell apoptosis is reversed correlated whereas necrotic cell death is proportionate to severity.

Indications for Detection, Completion, and Retention Rates of Small Bowel Capsule Endoscopy Based on the 10-Year Data from the Korean Capsule Endoscopy Registry

BACKGROUND/AIMS: Capsule endoscopy (CE) is widely used. However, CE has limitations including incomplete examination, inadequate bowel preparation, and retention. The aim of this study was to estimate the indications for and detection, completion, and retention rates of small intestine CE based on the 10-year data from the Korean Capsule Endoscopy Registry. METHODS: Twenty-four hospitals participated in this study. Clinical information, such as reasons for CE, method and quality of bowel preparation, and incomplete examination and capsule retention rates, was collected and analyzed. RESULTS: A total of 2,914 CEs were registered. The most common reason for CE was obscure gastrointestinal bleeding (59%). Significant lesions were detected in 66% of cases. Positive CE diagnosis occurred in 63% of cases. The preparation method did not significantly affect the quality of bowel preparation for CE. The overall incomplete rate was 33%, and was high in the elderly and those with poor bowel preparation. Capsule retention was 3% and high in patients with small bowel tumors and Crohn's disease and in children under 10 years of age. CONCLUSIONS: CE is a valuable technique; while the overall detection rate is high, incompletion and retention rates are also relatively high. CE should be carefully considered in the elderly and children less than 10 years of age, as well as in patients with small bowel tumors and Crohn's disease.

Bilateral ovarian metastasis from distal common bile duct carcinoma developing after choledochal cyst excision

Ovarian metastases represent about 3-5% of all ovarian malignancies. Most of these tumors originate in the digestive tract and cholangiocarcinoma rarely involves the ovary. A 60-year-old woman was admitted for the investigation of abdominal distension that had lasted 1 week. One and a half years prior, the patient had undergone choledochal cyst excision, Roux-en Y hepaticojejunostomy and cholecystectomy. Computed tomography scans of the abdomen revealed a papillary mass in the remnant distal common bile duct and enlargement of both ovaries with a huge amount of ascites. An explorative laparotomy disclosed no peritoneal seeding with resectable cholangiocarcinoma and bilateral ovarian mass. Pylorus-preserving pancreatoduodenectomy and bilateral salphingo-oophorectomy with hysterectomy were performed. Histologically, it was a well-differentiated adenocarcinoma and all surgical margins were free of tumor. Both ovarian masses were consistent with metastatic adenocarcinoma from the common bile duct. The patient received six cycles of postoperative adjuvant systemic chemotherapy, dying after 10 months due to pulmonary embolism.

Guideline for Capsule Endoscopy: Obscure Gastrointestinal Bleeding

Capsule endoscopy (CE) is considered as a noninvasive and reliable diagnostic tool of examining the entire small bowel. CE has been performed frequently at many medical centers in South Korea; however, there is no evidence-based CE guideline for adequate diagnostic approaches. To provide accurate information and suggest correct testing approaches for small bowel disease, the guideline on CE was developed by the Korean Gut Image Study Group, a part of the Korean Society of Gastrointestinal Endoscopy. Operation teams for developing the guideline were organized into four areas: obscure gastrointestinal bleeding, small bowel preparation, Crohn's disease, and small bowel tumor. A total of 20 key questions were selected. In preparing this guideline, MEDLINE, Cochrane library, KMbase, KISS, and KoreaMed literature searches were performed. After writing a draft of the guideline, opinions from various experts were reflected before approving the final document. The guideline should be regarded as recommendations only to gastroenterologists in providing care to their patients. These are not absolute rules and should not be construed as establishing a legal standard of care. Although further revision may be necessary as new data appear, this guideline is expected to play a role for adequate diagnostic approaches of various small bowel diseases.

Guidelines for Bowel Preparation before Video Capsule Endoscopy

The preparation for video capsule endoscopy (VCE) of the bowel suggested by manufacturers of capsule endoscopy systems consists only of a clear liquid diet and an 8-hour fast. While there is evidence for a benefit from bowel preparation for VCE, so far there is no domestic consensus on the preparation regimen in Korea. Therefore, we performed this study to recommend guidelines for bowel preparation before VCE. The guidelines on VCE were developed by the Korean Gut Image Study Group, part of the Korean Society of Gastrointestinal Endoscopy. Four key questions were selected. According to our guidelines, bowel preparation with polyethylene glycol (PEG) solution enhances small bowel visualization quality (SBVQ) and diagnostic yield (DY), but it has no effect on cecal completion rate (CR). Bowel preparation with 2 L of PEG solution is similar to that with 4 L of PEG in terms of the SBVQ, DY, and CR of VCE. Bowel preparation with fasting or PEG solution combined with simethicone enhances the SBVQ, but it does not affect the CR of VCE. Bowel preparation with prokinetics does not enhance the SBVQ, DY, or CR of VCE.

Learning Curve of Capsule Endoscopy

BACKGROUND/AIMS: Capsule endoscopy (CE) has become an important tool for the diagnosis of small bowel disease. Although CE does not require the skill of endoscope insertion, the images should be interpreted by a person with experience in assessing images of the gastrointestinal mucosa. This investigation aimed to document the number of cases needed by trainees to gain the necessary experience for CE competency. METHODS: Fifteen cases were distributed to 12 trainees with no previous experience of CE during their gastroenterology training as clinical fellows. Twelve trainees and an expert were asked to read CE images from one patient each week for 15 weeks. The diagnosis was reported using five categories (no abnormalities detected, small bowel erosion or ulcer, small bowel tumor, Crohn disease, and active small bowel bleeding with no identifiable source). We then examined, using the kappa coefficient, how the degree of mean agreements between the trainees and the expert changed as the training progressed each week. RESULTS: The agreement rate of CE diagnosis increased as the frequencies of interpretation increased. Most of the mean kappa coefficients were >0.60 and >0.80 after week 9 and 11, respectively. CONCLUSIONS: Experience with approximately 10 cases of CE is appropriate for trainees to attain CE competency.

A Case of Isolated Light Chain Deposition Disease in the Duodenum

Light chain deposition disease (LCDD) is a rare disorder associated with a clonal proliferation of plasma cells, which synthesize abnormal monoclonal immunoglobulin light chains. LCDD is characterized by systemic deposition of light chains in various organs, with the kidneys being most commonly affected. There have been few reports of isolated LCDD. We report a rare case of LCDD limited to a duodenal polyp. A 63-yr-old man visited our hospital for health screening without symptoms in 2009. On gastrofiberscopy, a duodenal polyp was observed. The biopsy showed diffuse infiltration by atypical plasma cells, which were positive for kappa-type light chains by immunohistochemistry. While the patient refused further management, we could find no evidence of recurrence until 2 yr after the initial diagnosis. It has been reported that isolated LCDD has relatively good prognosis compared to systemic LCDD. However, treatment for this disease has not been established yet.

A Case of Acute Myocarditis as the Initial Presentation of Crohn's Disease

We experienced a case of acute myocarditis as the initial presentation of Crohn's disease. A 19-year-old woman was admitted with impaired consciousness, shock, and respiratory failure. She had suffered from frequent diarrhea and abdominal pain for several years. Cardiac troponin I and creatine kinase-MB fraction levels were elevated to 5.32 and 16.66 ng/mL, respectively. A 12-lead electrocardiogram showed sinus tachycardia, and a chest radiograph revealed interstitial pulmonary edema. An echocardiogram showed dilated ventricles with akinesia of the basal to apical inferoseptal, anteroseptal, anterior, and inferior left ventricular walls and severely impaired systolic function. Intensive care with inotropic support was effective, and her clinical condition gradually improved. Two weeks later, a colonoscopy revealed ulceration with stenosis in the terminal ileum and multiple aphthous ulcers in the rectum. A biopsy of the rectum revealed non-caseating granulomatous inflammation. She was diagnosed with Crohn's disease presenting with acute myocarditis.

A Case of Inserting Two Self-expandable Metal Stents in Dual Malignant Colonic Obstructions / 대한소화기내시경학회지

Malignant colonic obstruction can lead an emergency operation for decompression, and this can cause post-operative complications due to poor bowel preparation. Self-expandable metal stent (SEMS) insertion is useful for avoiding an emergency operation and unnecessary complications. However, SEMS insertion for dual malignant colonic obstructions is very rare. We report here on a case of two SEMS that were inserted in dual malignant colonic obstructions caused by synchronous colon cancer. A 66-year-old man visited our hospital due to abdominal distension. Sigmoidoscopy and an abdominopelvic computerized tomographic (CT) scan revealed synchronous colon cancer at the splenic flexure and distal descending colon with dual obstruction. The initial SEMS insertion on the descending colon was not effective for decompression due to the proximal obstruction. After the second SEMS insertion on the splenic flexure through the first stent, all the signs and symptoms due to obstruction disappeared. SEMS insertion is considered to be useful for treating dual malignant colonic obstruction caused synchronous colon cancer.

A Case of Undifferentiated Carcinoma with Osteoclast-Like Giant Cells in the Pancreas / 대한내과학회지

Undifferentiated carcinomas with osteoclast-like giant cells are rare pancreatic and periampullary neoplasms that mimic giant cell tumors of bone morphologically. Recently, we experienced an osteoclast-like giant cell tumor arising in the tail of the pancreas. A 76-year-old male was admitted with epigastric discomfort and indigestion. Abdominal computed tomography (CT) and abdominal magnetic resonance imaging (MRI) showed a 3x3-cm mass containing necrotic and hemorrhagic areas in the tail of the pancreas. A distal pancreatectomy and splenectomy were performed. Histological examination showed tumor cell components consisting of mononuclear pleomorphic cells admixed with osteoclastic giant cells. The final diagnosis was undifferentiated carcinoma with osteoclast-like giant cells with ductal adenocarcinoma in the pancreas.

A Metastatic Granulocyte Colony-Stimulating Factor Producing Sarcomatoid Carcinoma of the Lung Causing Jejunal Intussusception: Report of a Case

A 75-year-old man was referred to our hospital with intestinal obstruction caused by intussusception. Abdominal computed tomography (CT) revealed seven polypoid masses in the small intestine, while chest CT revealed a mass in the right lower lobe. Preoperative laboratory tests showed white blood cell (WBC) and neutrophil differential counts of 63,630/mm3 and 95%, respectively. The serum granulocyte colony-stimulating factor (G-CSF) was 114 pg/mL, which was elevated (normal range, <18.1 pg/mL). After resection of the small bowel, the WBC count decreased to 20,510/mm3. The pathology showed a poorly differentiated carcinoma with sarcomatous components confirmed by positive immunostaining of cytokeratin (AE1/AE3) and vimentin in the small intestine. Furthermore, immunohistochemistry with specific monoclonal antibodies against G-CSF was positive. A lung biopsy revealed the same histological findings as the small intestine lesion. Therefore, the patient was diagnosed as having a G-CSF producing sarcomatoid carcinoma of the lung with metastasis to the small intestine.

The Frequency and Risk Factors of Colorectal Adenoma in Health-Check-up Subjects in South Korea: Relationship to Abdominal Obesity and Age

BACKGROUND/AIMS: Obesity is associated with the risk of colorectal cancer. However, there is a lack of information about the relationship between obesity and colorectal adenoma. We investigated whether general and abdominal obesity are risk factors for colorectal adenoma. METHODS: Subjects who received health check-ups, including colonoscopy, from April 2006 to September 2007 in Chung-Ang University Hospital were included (n=1,316). The frequency and characteristics of colorectal adenomas were analyzed according to demographic features, past history, blood tests, body mass index, and components of metabolic syndrome. Abdominal obesity was defined as a waist circumference of > or =80 cm in women and > or =90 cm in men. RESULTS: The sex ratio of the subjects was 1.9:1 (male:female) and their age was 47.7+/-10.0 years (mean+/-SD). In univariate analysis, abdominal obesity was significantly associated with the frequency of colorectal adenoma (26.5% "yes" vs 16.9% "no"; p or =100 mg/dL) or fatty liver (p or =60 years; OR, 6.7; 95% CI, 3.5-12.5), and abdominal obesity (OR, 1.5; 95% CI, 1.0-2.2) were independent risk factors for colorectal adenoma (p<0.05). The frequency of multiple adenomas (more than two sites) was also significantly higher in subjects with abdominal obesity. However, the effect of abdominal obesity on the development of colorectal adenoma decreased in elderly people. CONCLUSIONS: Abdominal obesity is an independent risk factor for colorectal adenoma and its multiplicity, especially in younger people in South Korea.

A Case of Recurrent Pancreatitis Induced by Trimethoprim-Sulfamethoxazole Re-Exposure

A 32-year-old man presented with epigastric pain. He had a previous episode of acute pancreatitis of undetermined cause 2 years earlier. The patient had taken trimethoprim (80 mg) and sulfamethoxazole (400 mg) twice daily because of acute urethritis 3 days prior to admission. No definite cause of acute pancreatitis could be identified on baseline studies. A thorough history-taking revealed that the patient had an episode of acute pancreatitis while taking trimethoprim (80 mg) and sulfamethoxazole (400 mg) twice daily for 2 weeks for prostatitis prior to the previous admission. Therefore, a cause-and-effect relationship between trimethoprim-sulfamethoxazole (TMP-SMX) and repeated episodes of pancreatitis was highly suggested. The patient was presumably diagnosed as TMP-SMX-induced pancreatitis. The final diagnosis was TMP-SMX-induced pancreatitis. Since drugs are rare causes of acute pancreatitis and the diagnosis of drug-induced pancreatitis is difficult to establish, we report this interesting case along with a review of medical literature.