Usefulness of the Forrest Classification to Predict Artificial Ulcer Rebleeding during Second-Look Endoscopy after Endoscopic Submucosal Dissection

BACKGROUND/AIMS: Delayed post-endoscopic submucosal dissection (ESD) bleeding (DPEB) is difficult to predict and there is controversy regarding the usefulness of prophylactic hemostasis during second-look endoscopy. This study evaluated the risk factors related to DPEB, the relationship between clinical outcomes and the Forrest classification, and the results of prophylactic hemostasis during second-look endoscopy. METHODS: Second-look endoscopy was performed on the day after ESD to check for recent hemorrhage or potential bleeding and the presence of artificial ulcers in all patients. RESULTS: DPEB occurred in 42 of 581 patients (7.2%). Multivariate analysis determined that a specimen size ≥40 mm (odds ratio [OR], 3.03; p=0.003), and a high-risk Forrest classification (Forrest Ib+IIa+IIb; OR, 6.88; p<0.001) were risk factors for DPEB. DPEB was significantly more likely in patients classified with Forrest Ib (OR, 24.35; p<0.001), IIa (OR, 12.91; p<0.001), or IIb (OR, 8.31; p<0.001) ulcers compared with Forrest III ulcers. There was no statistically significant difference between the prophylactic hemostasis and non-hemostasis groups (Forrest Ib, p=0.938; IIa, p=0.438; IIb, p=0.397; IIc, p=0.773) during second-look endoscopy. CONCLUSIONS: The Forrest classification of artificial gastric ulcers during second-look endoscopy seems to be a useful tool for predicting delayed bleeding. However, routine prophylactic hemostasis during second-look endoscopy seemed to not be useful for preventing DPEB.

Diagnostic Accuracy of Brush Cytology with Direct Smear and Cell-block Techniques according to Preparation Order and Tumor Characteristics in Biliary Strictures / 대한소화기학회지

BACKGROUND/AIMS: There are few data supporting the diagnostic yield of brush cytology depending on the order of cytologic preparation method or the location or shape of tumors in biliary strictures. We investigated diagnostic yields and variations in brush cytology with direct smear and cell-block preparations according to sampling preparation sequence and tumor location and shape in biliary strictures. METHODS: Patients who had undergone ERCP with tissue sampling between August 2009 and April 2013 were analyzed retrospectively. Group A was examined using brush cytology with direct smear followed by cell-block with or without biopsy, while the reverse order was performed for group B. RESULTS: Among 138 enrolled patients, 92 patients (A: 36, B: 56) underwent both brush cytology with direct smear and cell-block preparations. No differences in sensitivity, specificity, or accuracy were observed according to the sampling preparation method and the location or shape of tumors in biliary strictures. The cellularity observed from brush cytology with direct smear was better than that from cell-block according to the location of the tumor (p<0.01). The diagnostic yield was increased in both groups with addition of an endobiliary biopsy. CONCLUSIONS: No difference in diagnostic accuracy was observed between the sequences of preparation for brush cytology with direct smear and cell-block techniques. Brush cytology showed better cellularity for diagnosis.

A Case of Acute Gastric Pneumatosis Associated with Advanced Pancreatic Cancer

Pneumatosis intestinalis (PI) is a rare condition that is characterized by multiple subserosal and submucosal gas-filled areas in the bowel wall. Gastric pneumatosis describes the presence of gas within the stomach wall. This is caused by a disruption in gastric mucosa leading to the dissection of air into the wall. The extract cause of PI is still unknown; however, it may be associated with coexisting disease. Gastric PI has been rarely documented. So, we report on a 75-year-old man with acute gastric pneumatosis following his palliative chemotherapy. He underwent 3rd cycle of gemcitabine and erlotinib 3 weeks prior to admission. The treatment was started with nasogastric tube insertion and parenteral nutrition. Then, gastric pneumatosis was improved. However, the patient was died because of worsening underline disease and general condition. We suggest that chemotherapy should be considered the case of pneumatosis and careful X-ray interpretation will be necessary for detecting the pneumatosis earlier.

Natural Course of Benign Pulmonary Metastasizing Leiomyoma / 대한내과학회지

Benign metastasizing pulmonary leiomyoma is a rare disease that is usually detected several years after hysterectomy or myomectomy. Recently, we experienced two cases, one with monthly chest pain and the other without symptoms, which were diagnosed with benign metastasizing leiomyoma in the lung. A 48-year-old woman who underwent hysterectomy 12 years earlier was referred to us because of multiple pulmonary nodules on chest radiography, and chest pain for 6 months. Thoracoscopic tumor excision was performed. Pathologically, she was diagnosed with benign metastasizing leiomyoma in the lung. After that, chest computed tomography showed tumors with a progressive reduction in size. The other 48-year-old woman, who had undergone myomectomy for uterine leiomyoma 8 years before, visited our hospital for evaluation of incidentally revealed bilateral multiple nodules on chest radiography. The microscopic finding of percutaneous transthoracic needle biopsy revealed a benign pulmonary metastasizing leiomyoma originating from uterine leiomyoma. Multiple nodules on chest radiography were more increased than those performed 1 year and 3 months prior to admission. However, chest X-ray showed tumors that had progressively decreased in size at 6 months after diagnosis of menopause.

Clinical Course in Patients with an Intentional Amlodipine Overdose / 대한내과학회지

BACKGROUND/AIMS: Calcium channel blockers (CCBs) are anti-hypertensive medications that are used worldwide. CCB overdose has increased in proportion to the use of these drugs. Although amlodipine is the most widely used CCB, many physicians are not familiar with amlodipine overdose. We report the clinical outcome in patients with an intentional amlodipine overdose. METHODS: We retrospectively reviewed the medical records of the patients who visited Soonchunhyang University Cheonan Hospital with an amlodipine overdose from January 2002 through December 2010. We recorded the initial vital signs, blood chemistry, electrocardiography, and estimated amount of amlodipine ingested. RESULTS: Nine patients were enrolled, of whom two patients died. Both patients who died had ingested more than 200 mg/m2 of amlodipine, while all of the patients who ingested less than 200 mg/m2 of amlodipine survived. Three patients had blood sugar levels exceeding 200 mg/dL and two of these died despite high-dose insulin therapy in combination with glucose infusion (hyperinsulinemia/euglycemia therapy). Although three patients also took a glimepiride overdose, none had hypoglycemia. The amount of amlodipine ingested relative to the body surfaced area (BSA) was 197.1 +/- 92.3 mg/m2 in patients with an abnormal ECG and 58.5 +/- 27.1 mg/m2 in patients with a normal ECG. CONCLUSIONS: Amlodipine overdose can induce hyperglycemia, resulting in lethal cardiogenic shock owing to the decreased calcium influx, inappropriate energy production, and weakened inotropic effect. Therefore, amlodipine-induced hyperglycemia indicates a poor prognosis.

Successful Bile Duct Cannulation Guided by Indigocarmine Injection via PTGBD / 대한소화기내시경학회지

Even though percutaneous transhepatic gallbladder drainage (PTGBD) is performed prior to ERCP or following ERCP because of the patients' medical condition or failed bile duct cannulation, there are no definite endoscopic landmarks that are useful for successful bile duct cannulation in some cases. We report here on 4 patients in whom selective bile duct cannulation, as guided by the endoscopic landmarks, was successful following indigocarmine injection via PTGBD.