Nutritional Therapy Related Complications in Hospitalized Adult Patients: A Korean Multicenter Trial

PURPOSE: Nutritional therapy (NT), such as enteral nutrition (EN) or parenteral nutrition (PN), is essential for the malnourished patients. Although the complications related to NT has been well described, multicenter data on symptoms in the patients with receiving NT during hospitalization are still lacking. METHODS: Nutrition support team (NST) consultations, on which NT-related complications were described, were collected retrospectively for one year. The inclusion criteria were patients who were (1) older than 18 years, (2) hospitalized, and (3) receiving EN or PN at the time of NST consultation. The patients' demographics (age, sex, body mass index [BMI]), type of NT and type of complication were collected. To compare the severity of each complication, the intensive care unit (ICU) admission, hospital stay, and type of discharge were also collected. RESULTS: A total of 14,600 NT-related complications were collected from 13,418 cases from 27 hospitals in Korea. The mean age and BMI were 65.4 years and 21.8 kg/m2. The complications according to the type of NT, calorie deficiency (32.4%, n=1,229) and diarrhea (21.6%, n=820) were most common in EN. Similarly, calorie deficiency (56.8%, n=4,030) and GI problem except for diarrhea (8.6%, n=611) were most common in PN. Regarding the clinical outcomes, 18.7% (n=2,158) finally expired, 58.1% (n=7,027) were admitted to ICU, and the mean hospital days after NT-related complication were 31.3 days. Volume overload (odds ratio [OR]=3.48) and renal abnormality (OR=2.50) were closely associated with hospital death; hyperammonemia (OR=3.09) and renal abnormality (OR=2.77) were associated with ICU admission; “micronutrient and vitamin deficiency” (geometric mean [GM]=2.23) and volume overload (GM=1.61) were associated with a longer hospital stay. CONCLUSION: NT may induce or be associated with several complications, and some of them may seriously affect the patient's outcome. NST personnel in each hospital should be aware of each problem during nutritional support.

Correlation of Endoscopic Findings of Gastric Mucosa-Associated Lymphoid Tissue Lymphoma with Recurrence after Complete Remission

BACKGROUND/AIMS: In gastric mucosa-associated lymphoid tissue (MALT) lymphoma, the clinical significance of various endoscopic findings has not yet been determined. This study aimed to compare the time to complete remission (CR) and relapse-free survival (RFS) in gastric MALT lymphoma based on endoscopic findings. METHODS: In this single-center retrospective cohort study, the medical records of 122 consecutive adult patients with gastric MALT lymphoma were collected over a period of 12 years. CR was defined by the absence of macroscopic or microscopic features of lymphoma on two subsequent follow-ups. Relapse was clinically defined by a positive endoscopic biopsy after CR. RESULTS: The median time to CR did not differ significantly between treatment methods. However, it was significantly longer in the group with polypoid endoscopic appearance than in the groups with diffuse infiltration or ulceration (7.83, 3.43, and 3.10 months, respectively; p=0.003). Six patients relapsed after CR. Kaplan-Meier analysis showed that RFS differed significantly between groups based on Ann Arbor staging, treatment methods, and initial endoscopic findings. CONCLUSIONS: In gastric MALT lymphoma, the endoscopically defined polypoid type was characterized by a longer duration to CR, with a higher likelihood of recurrence, compared to the endoscopically defined diffuse infiltration or ulceration types.

Protective Effect of Proton Pump Inhibitor for Survival in Patients with Gastroesophageal Reflux Disease and Idiopathic Pulmonary Fibrosis

BACKGROUND/AIMS: The prevalence of gastroesophageal reflux disease (GERD) is high in patients with idiopathic pulmonary fibrosis (IPF). GERD may cause chronic microaspiration that leads to repeated subclinical lung injury, which leads to pulmonary fibrosis. Although some studies have suggested that proton pump inhibitors (PPI) were associated with a good prognosis in IPF, their effects remain unclear. METHODS: We retrospectively reviewed 786 consecutive adult patients with IPF at Seoul National University Bundang Hospital between April 2003 and March 2015. RESULTS: Mean duration of follow-up was 2.6 ± 2.8 years. Of the 786 patients with IPF, 107 (13.6%) were given diagnoses of GERD, and 103 (13.1%) died due to IPF-related pneumonia or respiratory failure. The prevalence of GERD and the cumulative incidence of de novo GERD increased depending on the period of follow-up in patients with IPF. Patients administered PPI for more than four months had a lower IPF-related mortality rate than patients on PPI less than 4 months (Log-rank P-value = 0.024 in Kaplan-Meier curve). In a univariate and multivariate Cox regression hazard model, younger age (hazard ratio [HR], 1.06; 95% CI, 1.03-1.10; P = 0.001), higher initial forced vital capacity (HR, 0.98; 95% CI, 0.96-0.99; P = 0.004), and longer duration of PPI use (HR, 0.97; 95% CI, 0.95-1.00; P = 0.022), but not a diagnosis of GERD, were significantly associated with lower IPF-related mortality. CONCLUSIONS: In Korean patients with IPF, the prevalence of GERD was lower than in other countries. PPI use for at least 4 months may have a protective effect against IPF-related mortality.

A Case of Activated Charcoal Aspiration Treated by Early and Repeated Bronchoalveolar Lavage / 결핵및호흡기질환

Activated charcoal is an inert substance and it is used in standard therapy in patients with acute intoxication. Charcoal has some side effects such as pulmonary aspiration, gastrointestinal complications, and electrolyte abnormalities. Although aspiration of charcoal is a rare complication, it can cause fatal sequelae. We report a 69-year old man who developed acute respiratory failure associated with charcoal aspiration after management of glyphosate poisoning. The patient was drowsy and suffered severe vomiting during transport to our hospital. On arrival, acute respiratory failure was observed due to charcoal aspiration, but the clinical state was improved with repeated bronchoscopy with a bronchoalveolar lavage (BAL). We presumed that the aspirated charcoal was an important factor in evoking a lung injury. Early bronchoscopy with a BAL might be an effective method for eliminating charcoal from the lung, especially in the case of a large amount of aspiration, and be helpful in decreasing respiratory failure due to charcoal aspiration.

A Case of Chemical Pneumonitis Induced by Teflon Inhalation / 대한내과학회지

Chemical pneumonitis is defined as lung irritation caused by inhalation of substances toxic to the lungs. Acute chemical pneumonitis causes swelling of the lung tissue, movement of fluid into the air spaces in the lung, and a decreased ability to absorb oxygen and eliminate carbon dioxide. Teflon (polytetrafluoroethylene) is a commonly used synthetic fiber or insulator. To our knowledge, chemical pneumonitis and acute respiratory failure induced by Teflon inhalation has not been previously reported in Korea. We experienced a 44-year-old patient who had a cough and dyspnea that were aggravated 10 h after smoking tobacco wet by Teflon for 5 min at his workplace. Upon arrival at the emergency room, his blood pressure was low and his arterial blood gas analysis revealed hypoxemia. A chest radiograph showed diffuse haziness on both mid- to-lower lung fields. Following treatment by conservative therapy, including oxygen supply and steroid use, his condition was relatively good and his chest radiograph normalized.

Clinical Usefulness of 64-Channel Multidetector Computed Tomography, Capsule Endoscopy, and Double-Balloon Enteroscopy in Obscure Gastrointestinal Bleedings

OBJECTIVE: Obscure gastrointestinal bleeding primarily originates from small-bowel lesions. It is difficult to detect the lesions by using classical diagnostic modalities, and thus, new methods have been developed. The aim of study was to evaluate the clinical usefulness of 64-channel multidetector computed tomography, capsule endoscopy, and double-balloon enteroscopy for detection of obscure gastrointestinal bleeding. METHODS: This retrospective study analyzed the findings of 64-channel multidetector computed tomography, capsule endoscopy, and double-balloon enteroscopy in patients with obscure gastrointestinal bleeding treated at Soonchunhyang University Seoul Hospital between January 1, 2008 and September 30, 2010. RESULTS: Five of 22 positive findings (22.7%) were obtained using 64-channel multidetector computed tomography. The computed tomography could not detect active bleeding lesions but it played an important role on the evaluation of extraluminal lesions. The diagnostic yield of capsule endoscopy was 82.4%. No cases of capsule retention were detected in this study. Bleeding lesions were identified in all cases through the use of double-balloon enteroscopy. One hemoclipping and 2 biopsies were performed. CONCLUSION: Sixty-four-channel multidetector computed tomography can be used to evaluate extraluminal lesions. Capsule endoscopy is the most convenient endoscopy method. Invasive procedures can be performed using double-balloon enteroscopy. These methods can be used complementarily to diagnose and treat occult gastrointestinal bleeding. Use of capsule endoscopy after screening with 64-channel multidetector computed tomography in the case of patients with occult gastrointestinal bleeding is suggested. In case of lesions wherein invasive procedures are required, use of double-balloon is preferred.

Association of Carotid Atherosclerosis and Arterial Stiffness with Obesity

OBJECTIVE: Few studies related to carotid intima media thickness and arterial pulse wave velocity in obese people were reported in Korea. We evaluated carotid intima media thickness (IMT) and arterial pulse wave velocity (PWV) according to existence of obesity. METHODS: From January 2009 to March 2010 at Soonchunhyang University Seoul Hospital, we enrolled 118 healthy adults (male: 67, female: 51) without past history of hypertension, diabetes, hypercholesterolemia, heart disease and renal failure. We devided the population into two groups according to body mass index (BMI, kg/m2); non-obese (n=68, 18.5 to 25 kg/m2) group, obese (n=50, > or =25 kg/m2) group. We measured carotid IMT and PWV of aorta as well as arteries of upper and lower extremities. RESULTS: Carotid IMT showed statistically significant increase in obese group (0.54+/-0.11 mm vs. 0.58+/-0.10 mm; P=0.041). IMT is independently and significantly related to age and systolic blood pressure. There is no statistical difference of the PWVs of aorta, upper extremity and lower extremity in obese group compared with non-obese group. BMI showed significant correlations with systolic blood pressure, diastolic blood pressure and IMT. CONCLUSION: Carotid IMT that was mainly determined by age and systolic blood pressure significantly increased in obese group compared to non-obese group, while neither aortic PWV nor arterial PWVs of upper and lower extremities showed significant difference between the two groups.

A Case of Multiple Liver Metastasis of True Gastric Leiomyosarcoma after Complete Surgical Resection

Primary leiomyosarcomas of the stomach are very rare tumors originating from mesenchymal tissues and account for only 1% of all malignant gastric neoplasm. We present here a case of primary gastric leiomyosarcoma in a 79-year-old man who presented with a 10 day history of epigastric pain and gastric subepithelial tumor. Endoscopic examination showed a 5 cm in diameter, subepithelial tumor located in the body of the stomach. Radiological investigations showed nonspecific findings except for the primary gastric lesion. Complete histological evaluation including immnuohistochemical staining after complete surgical resection revealed a true leiomyosarcoma of the stomach. One year later, the patient presented with dyspepsia. Endoscopic and radiological evaluation showed a recurrent leiomyosarcoma with multiple liver metastases. Our experience suggests that a careful clinical follow-up after surgical resection should be recommended in patients with gastric leiomyosarcomas because of their aggressive clinical behavior.

Clinical Usefulness of Preoperative and Postoperative Chest Computed Tomography for Colorectal Cancer

PURPOSE: This research sought to identify the utility value of chest computed tomography (CT) when it comes to the diagnosis of lung metastasis in cases of colorectal cancer. METHODS: From September 2004 to January 2008, 266 patients who were treated for colorectal cancer at Department of Surgery, Hanyang University College of Medicine, were divided into two groups: one that underwent preoperative and postoperative periodical chest CT (periodical inspection group, PIG; May 2006 to January 2008, 135 patients) and one that did not undergo periodical chest CT (non-periodical inspection group, NPIG; September 2004 to April 2006, 131 patients) for comparison. RESULTS: The overall lung metastasis diagnosis rates did not manifest any significant difference. The times to diagnose lung metastasis patients were 6.3 months and 15.7 months for the PIG and the NPIG, respectively (P = 0.022). The size of the metastatic lung nodule was smaller in the PIG than in the NPIG (< 1 cm in 9/9 patients vs. < 1 cm in 6/9 patients in the PIG and the NPIG, respectively; P = 0.02). A solitary lung metastasis was more frequently found in the PIG (5/9 patients) than in the NPIG (1/11 patients) (P = 0.024). During the follow-up period, 100% (2/2 patients) and 60% (3/5 patients) of the patients in the PIG and the NPIG, respectively, with stage III cancer underwent a lung metastasectomy (P = 0.002). CONCLUSION: Chest CT enables early diagnosis with a smaller size and a lower number of lung metastases in patients with colorectal cancer. Moreover, pulmonary the rate of the pulmonary resection for selected patients may be improved. However, the contribution of chest CT to increasing the survival rate must be investigated in a prospective randomized study.

A case of lung metastasis of papillary thyroid carcinoma presenting with tuberculous pleurisy / 대한내과학회지

Papillary thyroid carcinoma is the most prevalent type of thyroid cancer. Metastasis of this carcinoma commonly occurs in the lung and has been reported to present 5 to 30 years after the initial diagnosis of thyroid cancer. Pleural effusion can mask this metastatic spread. In patients with pleural effusion, laboratory measurement of the adenosine deaminase (ADA) level in the pleural fluid can be effective in identifying and ranking pulmonary metastasis in the differential diagnosis. A 70-year-old female patient visited our hospital with dyspnea. She presented with a considerable amount of pleural effusion. A pleural biopsy was performed and the Ziehl-Neelsen stains revealed a few acid-fast bacilli, but the ADA level in the pleural fluid was 2.4 IU/L. After drainage of the pleural effusions, we discovered pulmonary nodules by computed tomography (CT), which were later diagnosed through histologic examination as pulmonary metastasis from papillary thyroid carcinoma. We report this case.

Microsatellite Instability Is Associated with the Clinicopathologic Features of Gastric Cancer in Sporadic Gastric Cancer Patients

PURPOSE: Replication error is an important mechanism in carcinogenesis. The microsatellite instability (MSI-H) of colorectal cancers is associated with the development of multiple cancers. The influence of MSI-H on the development of multiple gastric cancers in sporadic gastric cancer patients has not been defined. This study was performed to reveal the association between the clinicopathologic features and MSI in sporadic gastric cancers. MATERIALS AND METHODS: Between July 2004 and March 2009, the clinicopathologic characteristics, including MSI status, were evaluated in 128 consecutive patients with sporadic gastric cancers. None of the patients had hereditary non-polyposis colorectal cancer of familial gastric cancer. The markers that were recommended by the NCI to determine the MSI status for colorectal cancers were used. RESULTS: MSI-H cancers were found in 10.9% of the patients (14/128). Synchronous gastric cancers were shown in 4 patients (3.1%). Synchronous cancers were found in 2 of 14 patients with MSI-H gastric cancer (14.3%) and 2 of 114 patients with MSS gastric cancer (1.8%; P=0.059, Fisher's exact test). Among the patients with synchronous cancer 50% (2/4) had MSI-H cancer, but 9.7% of the patients (12/124) without synchronous cancer had MSI-H cancer. MSI-H (RR, 24.7; 95% CI, 1.5~398.9; P=0.024) was related with to synchronous gastric cancer, but age, gender, family history, histologic type, location, gross morphology, size, and stage were not related to synchronous gastric cancer. CONCLUSIONS: MSI is associated with the intestinal-type gastric cancer and the presence of multiple gastric cancers in patients with sporadic gastric cancer. Special attention to the presence of synchronous and the development of metachronous multiple cancer in patients with MSI-H gastric cancer is needed.

Long-term Graft Outcome of Living Donor Renal Transplantation: Single Center Experience / 대한이식학회지

PURPOSE: The number of potential renal transplant recipients far exceeds the number of cadaveric donors. For this reason, living-related donors (LRD) and living-unrelated donors (LURD) have been used to decrease the cadaveric donor shortage. We analyzed 571 living donor transplants for 25 years in our center. METHODS: From 1978 to 2003, 571 patients underwent LRD (n=253) or LURD (n=318) kidney transplantation. The patients were divided into precyclosporin era (1978~1987, n=43, era I), cyclosporin era (1988~1997, n=368, era II), and cyclosporin plus mycophenolate- mofetil era (1998~2003, n=160, era III). We compared the graft survival rate of the recipients according to the immunosuppressants and analyzed the variables such as donor's and recipient's age, sex, HLA matching and acute rejection rate. We also compared the long-term survival rate between LRD and LURD. RESULTS: 1 and 10-year graft survival rates of all patients were 94.3% and 75.5%, respectively. 1 and 10-year graft survival rates were 74.4% and 36.2% in era I, 94.3 % and 78.4% in era II. 1 and 5-year graft survival rates were 96.7% and 90.5% in era III (P<0.001). The occurrence rate of acute rejection was 23.3% (era I), 22.3% (era II), and 14.3% (era III) (P=0.000). 1 and 10-year graft survival rates were 92.3% and 81.3% in LRD transplants, and 94.1% and 86.5% in LURD transplants, respectively (P =0.1909). CONCLUSION: The graft survival rates of living donor transplants are improving due to advances of patient care and new immunosuppressive agents. We suggest that living donors will be an important source of kidney transplantations.

Adventitial Cystic Disease of Popliteal Artery

Adventitial cystic disease of popliteal artery is a rare cause of lower extremity claudication in the middle aged. We diagnosed an adventitial cystic disease using duplex sonography and spiral CT angiography and operated on a 58 year old man with progressive lower extremity claudication for 4 months. An operation was performed by removing all cystic lesions through the posterior approach of popliteal fossa and interposition graft 6mm PTFE. Preoperative claudication symptom was disappeared and postoperative CT angiography showed patent graft at 17 months after operation

Intravenous Leiomyomatosis with Cardiac Extension: 1 Case

Intravenous leiomyomatosis (IVL) is a rare neoplasm that is characterized by a histologically benigh-looking smooth muscle cell tumor growing within the uterine and the extrauterine venous system. We report here on patient had a uterine and extrauterine leiomyoma that extended into the right atrium through the inferior vena cava. A 19-year old female patient was suffering from dyspnea, swelling of the lower extremity, abdominal pain and abdominal distension. She had total abdominal hysterectomy performed at a private clinic due to uterine leiomyoma 4 months previously. 4 months after the first operation, we again completely excised the recurred intraperitoneal tumor mass. At 6 months after the re-operation, the tumor mass recurred intraperitoneally. A preoperative abdominal CT scan and an echocardiogram revealed multiple tumor masses that were located intraperitoneally and they extended to the right atrium. We performed intraperitoneal tumor excision and removal of the intravenous tumor mass via the right iliac vein by the one-stage approach. At present, the patient has shown a clinically favorable outcome except for local recurrence of tumor mass in the pelvic cavity. The cure of this complex disease emphasizes the need for a planned systemic approach by a multidisciplinary surgical team. We present here an unusual case of intravenous leiomyomatosis that originated from the uterus and it extended to the inferior vena cava and right atrium.