Interobserver Variability and Accuracy of High-Definition Endoscopic Diagnosis for Gastric Intestinal Metaplasia among Experienced and Inexperienced Endoscopists

Accurate diagnosis of gastric intestinal metaplasia is important; however, conventional endoscopy is known to be an unreliable modality for diagnosing gastric intestinal metaplasia (IM). The aims of the study were to evaluate the interobserver variation in diagnosing IM by high-definition (HD) endoscopy and the diagnostic accuracy of this modality for IM among experienced and inexperienced endoscopists. Selected 50 cases, taken with HD endoscopy, were sent for a diagnostic inquiry of gastric IM through visual inspection to five experienced and five inexperienced endoscopists. The interobserver agreement between endoscopists was evaluated to verify the diagnostic reliability of HD endoscopy in diagnosing IM, and the diagnostic accuracy, sensitivity, and specificity were evaluated for validity of HD endoscopy in diagnosing IM. Interobserver agreement among the experienced endoscopists was "poor" (kappa = 0.38) and it was also "poor" (kappa = 0.33) among the inexperienced endoscopists. The diagnostic accuracy of the experienced endoscopists was superior to that of the inexperienced endoscopists (P = 0.003). Since diagnosis through visual inspection is unreliable in the diagnosis of IM, all suspicious areas for gastric IM should be considered to be biopsied. Furthermore, endoscopic experience and education are needed to raise the diagnostic accuracy of gastric IM.

The Miss Rate for Colorectal Adenoma Determined by Quality-Adjusted, Back-to-Back Colonoscopies

BACKGROUND/AIMS: Colonoscopy is considered to be the gold standard for detecting adenomatous polyps. Polyps are missed during colonoscopic examination at a rate that varies from 6% to 27%. The adenoma miss rate affects colonoscopic surveillance intervals and procedural quality. We aimed to assess the adenoma miss rate and the variables affecting the rate using same-day, quality-adjusted, back-to-back colonoscopies. METHODS: This prospective study was performed at a single institution and included 149 patients. Two consecutive same-day colonoscopies were performed by two experienced endoscopists. The adenoma miss rates and variables affecting the missed adenomas, including polyp characteristics and procedure times, were evaluated. RESULTS: The miss rates of polyps, adenomas, and advanced adenomas were 16.8%, 17%, and 5.4%, respectively. The smaller polyps and increased number of polyps detected during the first colonoscopy were more likely to be missed. A longer insertion time during the colonoscopy was correlated with an increased adenoma detection rate. CONCLUSIONS: There was a significant miss rate in the detection of colonic adenomas even in quality-adjusted, back-to-back colonoscopies. The adenoma miss rate can be reduced with a sufficient observation time during colonoscopic insertion. The development of specific technological methods to reduce the adenoma miss rate is necessary.

A fatal case of hepatitis B virus (HBV) reactivation during long-term, very-low-dose steroid treatment in an inactive HBV carrier

Hepatitis B virus (HBV) may be reactivated after chemotherapy or immunosuppressive therapy, and therefore administration of antiviral agents before such treatment is recommended. Most reported cases of reactivation are associated with high doses of immunosuppressive agents or combination therapy. We present a case of a previously inactive HBV carrier with an acute severe flare-up during a long-term, very-low-dose (2.5 mg/day) steroid treatment for rheumatoid arthritis. We suggest that even a minimal dose of single-regimen oral steroid can cause reactivation of indolent, inactive HBV.

A Case of Methicillin-Resistant Staphylococcal Enterocolitis with Subsequent Development of Lymphocytic Colitis

Staphylococcus aureus (S. aureus) is occasionally a normal inhabitant of the gastrointestinal tract, and rarely considered a cause of enterocolitis. Methicillin-resistant Staphylococcal enterocolitis may cause persistent diarrhea leading to severe complications and even death, without appropriate treatment. Lymphocytic colitis (LC), a subtype of microscopic colitis, is a relatively common cause of chronic watery diarrhea. We report the case of a 73-year-old woman with profuse watery diarrhea caused by methicillin-resistant S. aureus. Soon after treatment of her enterocolitis with vancomycin the patient's general condition and symptoms improved, although the diarrhea persisted. Through colonoscopic biopsy and immunohistochemical staining, overt LC was diagnosed, and prompt therapy with budesonide was initiated.

A Case of Hepatosplenic T-cell Lymphoma with Colonic Involvement

Hepatosplenic T-cell lymphoma is a rare histologic type of peripheral T-cell lymphoma that usually presents with hepatosplenomegaly, B-symptoms, and often with rapid and aggressive progression. There have been no previous domestic reports of a hepatosplenic T-cell lymphoma involving the colon. We report a case of a 61-year old man with colonic invasion of a hepatosplenic T-cell lymphoma. He presented the sudden onset of fever accompanied by severe pancytopenia and rapid liver enzyme elevation without evidence of lymphadenopathy. Multiple tiny erosions were noted during colonoscopy. In addition, many immature lymphocytes with vague nucleoli, abundant eosinophilic cytosol, and nuclei of small-to-medium size were seen within the sinusoids on liver biopsy. A similar pattern existed on colonic mucosa obtained from colonoscopic biopsy. Thus, with the aid of such a specific clinical presentation and the results of immunohistochemical staining, we made a definitive diagnosis of hepatosplenic T-cell lymphoma with colonic involvement.

A Case of Hepatosplenic T-cell Lymphoma with Colonic Involvement

Hepatosplenic T-cell lymphoma is a rare histologic type of peripheral T-cell lymphoma that usually presents with hepatosplenomegaly, B-symptoms, and often with rapid and aggressive progression. There have been no previous domestic reports of a hepatosplenic T-cell lymphoma involving the colon. We report a case of a 61-year old man with colonic invasion of a hepatosplenic T-cell lymphoma. He presented the sudden onset of fever accompanied by severe pancytopenia and rapid liver enzyme elevation without evidence of lymphadenopathy. Multiple tiny erosions were noted during colonoscopy. In addition, many immature lymphocytes with vague nucleoli, abundant eosinophilic cytosol, and nuclei of small-to-medium size were seen within the sinusoids on liver biopsy. A similar pattern existed on colonic mucosa obtained from colonoscopic biopsy. Thus, with the aid of such a specific clinical presentation and the results of immunohistochemical staining, we made a definitive diagnosis of hepatosplenic T-cell lymphoma with colonic involvement.

Fulminant Hepatic Failure with Hepatitis B Virus Reactivation after Rituximab Treatment in a Patient with Resolved Hepatitis B / 대한소화기학회지

It is well known that the reactivation of hepatitis B virus (HBV) may occur as an acute hepatitis after chemotherapy or immunosuppressive therapy. Although most of these cases have been reported in HBsAg-positive patients, there have been a few reports of HBV reactivation in HBsAg-negative patients. There have been concerns for the need to screen the reactivation as well as anti-viral prophylaxis in HBsAg-negative patients with possible HBV occult infection who are planning to undergo chemotherapy or immunosuppressive therapy. Rituximab, an anti-CD20 monoclonal antibody, is effective in the treatment of non-Hodgkin's lymphoma. However, rituximab can affect the immunity against HBV, consequently increasing viral replication. In fact, there have been reports of HBV reactivation after treatment with rituximab. Here, we report a case of HBV reactivation following rituximab plus systemic chemotherapy in diffuse large B cell lymphoma patient who was HBsAg negative, anti-HBs positive, and anti-HBc positive, ultimately leading to treatment-unresponsive fulminant hepatic failure.

A Case of Extranodal Histiocytic Sarcoma of Stomach Mimicking Gastric Adenocarcinoma / 대한소화기학회지

Histiocytic sarcoma is a rare malignant neoplasm that originates from a histiocytic hematopoietic lineage characterized by histiocytic differentiation and its corresponding immunophenotypic features. Patients with histiocytic sarcoma usually have a poor prognosis due to its aggressive clinical behavior. Here we report a rare case of extranodal histiocytic sarcoma of the stomach which was confirmed through immunohistochemical staining. A 71-yearold man was presented with epigastric pain. Gastroscopy, abdominal CT, and EUS revealed a mass located on the posterior wall of upper body and fundus of the stomach. Grossly, grayish white solid masses were seen extending down to the submucosal layer. Microscopically, the tumor cells had eosinophilic cytoplasm, abundant vacuole, and mitosis. Immunohistochemical staining revealed that the tumor cells were positive for LCA, CD68, and lysozyme. Early detection and accurate diagnosis of this rare neoplasm is important because it can make a great difference in prognostic outcomes. To make an accurate and definitive diagnosis, immunohistochemical staining is essential in the confimation of histiocytic orign.

Postinfectious Irritable Bowel Syndrome after Clostridium difficile Infection

BACKGROUND/AIMS: Post-infectious irritable bowel syndrome (PI-IBS) frequently follows bacterial enterocolitis, and there are various reported incidences and clinical courses according to different pathogens. However, there have rarely been any reports regarding the PI-IBS caused by Clostridium difficile infection (CDI). The aims of this study were to evaluate the incidence and the risk factors for developing IBS following CDI. METHODS: We recruited 86 patients with CDI from January 2005 to October 2007 and also we recruited a comparative control group of 86 patients who had no previous history of any gastroenterological disease. The bowel symptoms were prospectively evaluated by phone through a set questionnaire. RESULTS: Of all the CDI patients, a total of 41 patients (47.6%) completed the questionnaires, and IBS developed in 8 patients (19.5%), of which 7 patients (87.5%) were the diarrhea type. A total of 51 patients (59.3%) from the control group completed the questionnaires, of which 4 patients (7.8%) developed IBS. Although there was no statistically significant difference (p=0.099), there was a tendency towards a higher incidence of developing IBS in the CDI patients group, as compared to that of the control group. Comparing the group that developed IBS with the group that didn't among the CDI patients, there were no significantly different factors except for a previous admission history before CDI. CONCLUSIONS: The incidence of PI-IBS after CDI was 19.5%, and the IBS was predominantly the diarrhea-type. In the future, a large scale study needs to be conducted in order to evaluate the PI-IBS incidence after CDI and the risk factors that predispose patients to such conditions.

Postinfectious Irritable Bowel Syndrome after Clostridium difficile Infection

BACKGROUND/AIMS: Post-infectious irritable bowel syndrome (PI-IBS) frequently follows bacterial enterocolitis, and there are various reported incidences and clinical courses according to different pathogens. However, there have rarely been any reports regarding the PI-IBS caused by Clostridium difficile infection (CDI). The aims of this study were to evaluate the incidence and the risk factors for developing IBS following CDI. METHODS: We recruited 86 patients with CDI from January 2005 to October 2007 and also we recruited a comparative control group of 86 patients who had no previous history of any gastroenterological disease. The bowel symptoms were prospectively evaluated by phone through a set questionnaire. RESULTS: Of all the CDI patients, a total of 41 patients (47.6%) completed the questionnaires, and IBS developed in 8 patients (19.5%), of which 7 patients (87.5%) were the diarrhea type. A total of 51 patients (59.3%) from the control group completed the questionnaires, of which 4 patients (7.8%) developed IBS. Although there was no statistically significant difference (p=0.099), there was a tendency towards a higher incidence of developing IBS in the CDI patients group, as compared to that of the control group. Comparing the group that developed IBS with the group that didn't among the CDI patients, there were no significantly different factors except for a previous admission history before CDI. CONCLUSIONS: The incidence of PI-IBS after CDI was 19.5%, and the IBS was predominantly the diarrhea-type. In the future, a large scale study needs to be conducted in order to evaluate the PI-IBS incidence after CDI and the risk factors that predispose patients to such conditions.

The actual condition of drug-resistant tuberculosis and treatment outcomes at a tuberculosis specialized hospital / 대한내과학회지

BACKGROUND: During the last decade, the reports of drug-resistant tuberculosis in Korea were not common. Therefore, we investigated the anti-tuberculosis drug resistance rate according to medical history and radiological findings, as well as the relationship between the drug resistance and treatment outcomes to provide guidelines for selection of drug regimen before drug sensitivity test. METHODS: The study population was composed of 745 hospitalized patients who received drug susceptibility test for M. tuberculosis and anti-tuberculosis chemotherapy for the last 5 years. RESULTS: The majority had resistance to at least one drug (91.3%; 3.8+/-2.6 drugs). Drug resistance rate of first line drugs was 25~55%; especially higher in retreatment cases and those with the cavity on chest X-ray. Drug resistance was not correlated with radiographic finding. The success rate for treatment was higher in new cases, patients with less severe disease status and those without cavity on chest X-ray. When new cases had no resistance to all of EHR (84.1%), the negative conversion rate by first line drugs was above 70~90%. For retreatment patients, the negative conversion rate was above 70% only when they were susceptible to all of EHR (31%). The relapse rate was 4~13%. CONCLUSIONS: Probably the prevalence of drug-resistant tuberculosis in Korea will be considerably high. The drug resistance and treatment outcome was affected more by history of previous medical treatment than radiological findings. The previous EHRZ regimen is very effective as the initial treatment in new case, but revised retreatment regimen composed of at least 4 drugs is needed in the previously treated patients.

Predictive factors of development and progression of esophageal varices in patients with liver cirrhosis / 대한내과학회지

BACKGROUND: Recent guidelines recommend that all cirrhotics undergo screening upper endoscopy to identifly risk patients for bleeding from varices. The aim of this study was to determine whether clinical and laboratory variables were predictive of the occurrence and progression of esophageal varices. METHODS: This is a retrospective analysis of cirrhotics who had a screening upper endoscopy during 10 years after liver biopsy. Fifty-eight patients were recruited. Univariate/multivariate analysis was used to evaluate associations between the development and progression of esophageal varices and patients characteristics including platelet count, liver chemistry value, prothrombin time, shunt index(heart to liver uptake ratio) through transrectal TI-201 liver scan, probability(P)-value (Y=3.3431-0.8160 x ALT/AST ratio-0.0343 x prothrombin time+2.6963 x shunt index, P=e(y)/(e(y)+1)), ascites, splenomegaly, hepatic encephalopathy. RESULTS: There were 36 patients without esophageal varices or with stable varices during 10 years and 22 patients with new developed esophageal varices or progressive varices during 10 years as determined by upper endoscopy. On multivariate analysis, patients with a probability(P)-value of > or = 0.647 and a platelet count of < or = 100,500/mm3 had a risk of the development and progression of esophageal varices. CONCLUSIONS: Non-endoscopic predictors (probability(P)-value and platelet count) could be used to stratify patients with cirrhosis for the risk of the development and progression of esophageal varices and such stratification could be used to improve the effectiveness of screening upper endoscopy for esophageal varices.

A Case of Giant Pedunculated Submucosal Lipoma Causing Intussusception of the Colon / 대한소화기내시경학회지

Intussusception is a relatively common cause of intestinal obstruction in children. However, it is quite uncommon in adults, representing < or =1% of intestinal obstructions in this patient population. Colonic lipoma is rare, usually small, and occurs mainly in the right colon, particularly in the cecum. They often occur in elderly women. Intermittent episodes of intussusception are not uncommon in patients with colonic lipoma but they are usually caused by larger pedunculated lipomas. Almost all gastrointestinal lipomas are submucosal or subserosal, and most are asymptomatic, even though they can cause abdominal pain, bowel obstruction, and gastrointestinal bleeding. Colonic lipoma with a dramatic presentation requiring urgent surgery is rare. Symptomatic lipomas or complicated cases require surgical or endoscopical intervention. We report a case of symptomatic giant pedunculated colonic lipoma causing intussusception requiring surgical intervention, with a successful recovery after surgery.

The Role of Plasma B-type Natriuretic Peptide Measurements in the Differential Diagnosis of Acute Dyspnea / 결핵및호흡기질환

BACKGROUND: The B-type natriuretic peptide (BNP) is a cardiac neurohormone that is specifically secreted from the ventricles in response to volume expansion and a pressure overload. Differentiating congestive heart failure from the pulmonary causes of dyspnea is very important for patients presenting with acute dyspnea. METHODS: A retrospective study was carried out on 261 patients who were admitted to the emergency department of Hanyang University Hospital due to acute dyspnea from March to July 2004. The serum BNP levels of the patients were measured using the ELISA method. RESULTS: The BNP levels were 382, 111-1140 pg/ml (median, interquartile range) in the heart failure group (n=119) and 29, 7-81 pg/ml in the non-heart failure group (n=142). The BNP levels according to the subgroups of heart failure were 820, 354-1620 pg/ml, 1650, 239-1990 pg/ml, and 378, 106-1120 pg/ml for the chronic obstructive pulmonary disease (COPD) with combined left heart failure (n=5), cor pulmonale (n=3), and left heart failure groups (n=111), respectively. The BNP levels according to the subgroups of non-heart failure were 39, 21-101 pg/ml, 59, 10-129 pg/ml, and 15, 6-47 pg/ml for the COPD (n=20), other pulmonary diseases (n=56), and other causes groups (n=66), respectively. The BNP levels were significantly different according to the underlying etiology (p<0.001), and were significantly higher in the COPD patients with left heart failure than in those without (p=0.002). When the patients with no cardiovascular risk factor such as diabetes mellitus, hypertension, smoking or renal failure were analyzed, the BNP levels were also significantly higher in the patients with heart failure than in those without(p<0.001). When 133 pg/ml was designated as the BNP cut-off level the sensitivity for predicting heart failure was 73 percent and the specificity was 87 percent. CONCLUSION: BNP measurements are useful for determining the presence of heart failure in the patients presenting with acute dyspnea. The possibility of heart failure must be seriously considered in patients with high BNP levels even when they have a pre-existing pulmonary disease such as COPD or no risk factors for heart failure.

Acute Pancreatitis due to Hypertriglyceridemia: Report of 2 Cases / 대한소화기학회지

Hypertriglyceridemia (HTG) is a rare but well known cause of acute pancreatitis (AP), which can be a life- threatening complication if the degree of HTG is severe enough. It might be primary in origin or secondary to alcohol abuse, diabetes mellitus, pregnancy, or drugs. A serum triglyceride (TG) level of more than 1,000 to 2,000 mg/dL in patients with type I, IV, or V hyperlipidemia (Fredrickson's classification) is the identifiable risk factor. HTG-induced AP typically presents as an episode of AP or recurrent AP. The clinical course of HTG-induced AP is not different from other causes. Routine management of HTG-induced AP should be similar to other causes. A thorough family history of lipid abnormalities should be obtained, and an attempt to identify secondary causes should be made. The mainstay of treatment includes dietary restriction of fatty meal and lipid-lowering medications (mainly fibric acid derivatives). Although there are limited experiences with plasmapheresis, lipid apheresis, heparinization and insulin application, these can support the treatment of HTG- induced AP. We report two cases of HTG-induced AP which were successfully treated by plasmapheresis.

A Case of Candida Parapsilosis Ankle Arthritis after Intra-articular Steroid Injection / 감염과화학요법

Candida species are uncommon cause of infectious arthritis. The increasing use of potent antibiotics, immunosuppressives, artificial joints, and especially the injection of steroid into the joints predispose to the fungal arthritis. Candida arthritis occurs by hematogenous dissemination or by direct inoculation of fungus into the joint cavity. Fifty three-year-old diabetic patient, who received intra-articular steroid injection into right ankle joint several times, was hospitalized because of aggravating ankle pain and swelling. Candida parapsilosis was isolated from the joint aspiration fluid and MRI findings were compatible with septic arthritis with osteomyelitis of distal tibia, distal fibula, talus, and calcaneus. The patient was successfully treated with 3 weeks of amphotericin B and 7 months of oral fluconazole. We report this case with review of pertinent literatures, emphasizing a high index of suspicion for the fungal infection in patients with predisposing risk factors.

VZV Pneumonia in Patients with Systemic Lupus Erythematosus / 감염과화학요법

Varicella-zoster virus (VZV) is a member of the herpesviridae, which shares the characteristics of latent infection and reactivation. VZV causes two distinct clinical entities; varicella (chickenpox) and herpes zoster (shingles). Varicella pneumonia is the most common complication of adult varicella, especially in patients who are immunocompromised. We present two cases of VZV pneumonia occuring in patients with systemic lupus erythematosus (SLE) who were being treated with cytotoxic drugs and steroid. Both patients were treated with acyclovir and responses were good.

A Case of Sepsis by Mycobacterium abscessus in a Patient with Rheumatoid Arthritis / 감염과화학요법

Mycobacterium abscessus is a rapid growing pathogenic nontuberculous mycobacterium, which causes systemic disseminated infections as well as localized infections such as skin and soft tissue infections. We experienced a case of M. abscessus sepsis secondary to septic arthritis, osteomyelitis, and cellulitis in a rheumatoid arthritis patient. A 68-year old female with rheumatoid arthritis developed skin and soft tissue infections in upper and lower extremities. Acid fast bacilli were identified from the pus smear of hand. While receiving anti-tuberculosis medication, M. abscessus was identified in blood culture, pus from hand, synovial fluid of foot, and urine. With surgical debridement and medications containing clarithromycin, her condition gradually improved and was discharged.

A Case of Candida Parapsilosis Ankle Arthritis after Intra-articular Steroid Injection / 감염과화학요법

Candida species are uncommon cause of infectious arthritis. The increasing use of potent antibiotics, immunosuppressives, artificial joints, and especially the injection of steroid into the joints predispose to the fungal arthritis. Candida arthritis occurs by hematogenous dissemination or by direct inoculation of fungus into the joint cavity. Fifty three-year-old diabetic patient, who received intra-articular steroid injection into right ankle joint several times, was hospitalized because of aggravating ankle pain and swelling. Candida parapsilosis was isolated from the joint aspiration fluid and MRI findings were compatible with septic arthritis with osteomyelitis of distal tibia, distal fibula, talus, and calcaneus. The patient was successfully treated with 3 weeks of amphotericin B and 7 months of oral fluconazole. We report this case with review of pertinent literatures, emphasizing a high index of suspicion for the fungal infection in patients with predisposing risk factors.

VZV Pneumonia in Patients with Systemic Lupus Erythematosus / 감염과화학요법

Varicella-zoster virus (VZV) is a member of the herpesviridae, which shares the characteristics of latent infection and reactivation. VZV causes two distinct clinical entities; varicella (chickenpox) and herpes zoster (shingles). Varicella pneumonia is the most common complication of adult varicella, especially in patients who are immunocompromised. We present two cases of VZV pneumonia occuring in patients with systemic lupus erythematosus (SLE) who were being treated with cytotoxic drugs and steroid. Both patients were treated with acyclovir and responses were good.