A Case of Enteropathy-Type T-Cell Lymphoma Diagnosed by Small Bowel Enteroscopy: A Perspective on Imaging-Enhanced Endoscopy

Enteropathy-type T-cell lymphoma (ETL) or enteropathy-associated T-cell lymphoma is a very rare malignant intestinal tumor. ETL is usually diagnosed by surgery. Endoscopic findings of ETL are not well known, and there are few reports of findings from endoscopy that has been performed only using white light. Additionally, there are no definite treatment guidelines for ETL. Therefore, we report a case of ETL diagnosed by enteroscopy with imaging-enhanced endoscopy and also review recently developed treatment options.

Analysis of the Fixation Failure in Intertrochanteric Hip Fractures Treated with Hip Nailing

PURPOSE: To analyze the patterns of and risk factors for fixation failure after hip nailing in intertrochanteric (IT) hip fractures. MATERIALS AND METHODS: Fourteen patients who sustained a fixation failure after hip nailing for IT hip fractures were enrolled in this study. The mean age at the index surgery was 74.5 years and the mean time to the fixation failure was 6.6 weeks. All of the serial radiographs up to the fixation failure and pre-operative 3-D computed tomography were analyzed. RESULTS: According to AO classification, there were 7 stable fractures and 7 unstable ones. Of the total of 14 cases, 10 showed a comminution of the greater trochanter tip and incomplete anatomical reduction of the medial and anterior cortex at the fracture site. Of the 10 cases with appropriate position of the lag screw within the femoral head, 9 showed a high pertrochanteric fracture (HPF) pattern. The mechanism of the fixation failure was rotation of the femoral head in 7 of 9 cases with HPF and varus collapse of the proximal fragment in 4 of the other 5 cases. CONCLUSION: The HPF pattern, the comminution of the greater trochanter tip, and incomplete reduction of the medial and anterior cortex may be additional risk factors of fixation failure after treating IT hip fractures with hip nailing in.

Operative Treatment of Pediatric Humeral Diaphyseal Fractures with Flexible Intramedullary Nails / 대한정형외과학회잡지

PURPOSE: Most humeral fractures of children are treated satisfactorily with conservative method, thus surgical treatment is often reserved for limited conditions. In cases of an open fracture, inadequate reduction or multiple traumas, children with humeral shaft fractures require operative treatment. The aim of our study was to evaluate results and complications of pediatric humeral shaft fractures that were treated with flexible intramedullary nails. MATERIALS AND METHODS: A retrospective study was performed for 12 patients who were treated operatively by flexible intramedullary nails between March 2009 and September 2011. Surgical indications were an open fracture, an inability to maintain an adequate reduction, concomitant fractures, refractures and combined radial nerve injury. All patients were treated with 2 titanium flexible intramedullary nails by antegrade or retrograde techniques, according to the site of the fractures. RESULTS: The mean follow-up period was 15 months, and all patients achieved union status without major complications. There were no neurovascular injuries or infection during surgical procedures. However, 4 patients showed irritation at the insertion site of the nail, and 2 of them underwent early removal of nails at about 6 weeks due to skin lesions as well as pain and discomfort. One boy showed a fracture next to the proximal insertion site of the antegrade nail. All patients showed a full range of motion, and went back to daily life by the final follow-up. CONCLUSION: Flexible intramedullary nails are considered as a good option for the fracture of the pediatric humeral shaft. Surgeons should pay attention and use proper techniques to avoid complications.

Early Bile Duct Cancer Detected by Direct Peroral Cholangioscopy with Narrow-Band Imaging after Bile Duct Stone Removal

Cholangioscopy not only enables the direct visualization of the biliary tree, but also allows for forceps biopsy to diagnosis early cholangiocarcinoma. Recently, some reports have suggested the clinical usefulness of direct peroral cholangioscopy (POC) using an ultra-slim endoscope with a standard endoscopic unit by a single operator. Enhanced endoscopy, such as narrow band imaging (NBI), can be helpful for detecting early neoplasia in the gastrointestinal tract and is easily applicable during direct POC. A 63-year-old woman with acute cholangitis had persistent bile duct dilation on the left hepatic duct after common bile duct stone removal and clinical improvement. We performed direct POC with NBI using an ultra-slim upper endoscope to examine the strictured segment. NBI examination showed an irregular surface and polypoid structure with tumor vessels. Target biopsy under direct endoscopic visualization was performed, and adenocarcinoma was documented. The patient underwent an extended left hepatectomy, and the resected specimen showed early bile duct cancer confined to the ductal mucosa.

Wire-Guided Endoscopic Snare Retrieval of Proximally Migrated Pancreatic Stents after Endoscopic Papillectomy for Ampullary Adenoma

With the increasing use of pancreatic duct (PD) stents after endoscopic papillectomy (EP), complications such as proximal migration of the stent have become increasingly prevalent. A PD stent that migrates within a nondilated PD may be difficult to remove endoscopically. We performed endoscopic retrieval of proximally migrated PD stents after EP in 5 patients. Endoscopic retrieval was performed immediately after EP in one patient, the next day in 3 patients, and 2 weeks later in one patient. Wire-guided endoscopic retrieval was attempted in 4 patients, and the migrated stents were removed successfully in these 4 patients. No significant procedure-related complications occurred, other than mild pancreatitis in a single patient. In one patient, endoscopic retrieval performed immediately after EP failed when using the conventional method, and the migrated stent was removed using a minisnare without a guidewire the next day; this patient developed severe pancreatitis. Wire-guided endoscopic snare retrieval seems to be a safe and effective method for removing proximally migrated PD stents after EP.

Comparison among Endoscopic Variceal Obliteration, Endoscopic Band Ligation, and Balloon-occluded Retrograde Transvenous Obliteration for Treatment of Gastric Variceal Bleeding / 대한소화기학회지

BACKGROUND/AIMS: Endoscopic variceal obliteration (EVO), endoscopic variceal ligation (EVL), and balloon-occluded retrograde transvenous obliteration (BRTO) are used to manage gastric variceal bleeding. We compared the re-bleeding rates and survival times of these modalities. METHODS: The study enrolled 103 patients with suspected gastric variceal bleeding between July 2001 and May 2009. For the management of gastric variceal bleeding, 52 patients underwent EVO; 36, EVL; and 15, BRTO. We evaluated their laboratory results and vital signs, and calculated the Child score, Child classification, and Model for End-stage Liver Disease score. Rebleeding was defined as new-onset hematemesis, hematochezia, melena, or endoscopically proven bleeding. Time-to-rebleeding and survival time were examined by Kaplan-Meyer analysis. A value of p<0.05 indicated statistical significance. RESULTS: There were no significant differences in baseline characteristics among the three groups. The overall follow-up period averaged 65.13 months. During follow-up, rebleeding occurred in 17 patients (11 EVO, 5 EVL, and 1 BRTO). The times-to-rebleeding were 63.59, 75.79, and 51.41 months for EVO, EVL, and BRTO, respectively, and did not differ significantly (p=0.515). The median survival times were 77.42, 70.14, and 42.79 months, respectively, and also were not different significantly (p=0.978). CONCLUSIONS: There were no significant differences in the time-to-rebleeding or survival time among EVO, EVL, and BRTO. Further prospective, large-scale studies are needed.

Correlation of Narrow Band Imaging with Magnifying Colonoscopy and Histology in Colorectal Tumors

BACKGROUND/AIMS: Narrow band imaging (NBI) is a new technique that uses optical filters for imaging of mucosal morphology. The aim of this study was to correlate findings of NBI with magnifying colonoscopy and histology for prediction of neoplastic colorectal lesion. METHODS: Between September 2005 and December 2007, 107 colon polyps from 68 patients were detected by conventional colonoscopy and subsequently evaluated by NBI with magnifying colonoscopy and analyzed for a pit pattern and a capillary pattern. More analysis was done regarding thickness and irregularity of capillary features. RESULTS: Pit pattern with NBI magnification to discriminate between neoplastic and non-neoplastic lesions had a sensitivity of 88.9% and a specificity of 87.5%; capillary pattern yielded test performance characteristics of 91.9% and 87.5%. In respect of capillary thickness, invisible capillaries were found significantly more often in hyperplastic lesions. All thick capillaries were found in neoplastic polyps, and found significantly more often in carcinomas with submucosal massive invasion (sm-m) (p<0.01). In respect of capillary irregularity, invisible capillaries were found significantly more often in hyperplasic lesions, and severely irregular capillaries were found significantly more often in sm-m lesions (p<0.01). CONCLUSIONS: Observation of capillary thickness and irregularity by NBI magnification is useful for correlating histological grade with carcinoma, especially with depth of submucosal invasion.

Correlation of Narrow Band Imaging with Magnifying Colonoscopy and Histology in Colorectal Tumors

BACKGROUND/AIMS: Narrow band imaging (NBI) is a new technique that uses optical filters for imaging of mucosal morphology. The aim of this study was to correlate findings of NBI with magnifying colonoscopy and histology for prediction of neoplastic colorectal lesion. METHODS: Between September 2005 and December 2007, 107 colon polyps from 68 patients were detected by conventional colonoscopy and subsequently evaluated by NBI with magnifying colonoscopy and analyzed for a pit pattern and a capillary pattern. More analysis was done regarding thickness and irregularity of capillary features. RESULTS: Pit pattern with NBI magnification to discriminate between neoplastic and non-neoplastic lesions had a sensitivity of 88.9% and a specificity of 87.5%; capillary pattern yielded test performance characteristics of 91.9% and 87.5%. In respect of capillary thickness, invisible capillaries were found significantly more often in hyperplastic lesions. All thick capillaries were found in neoplastic polyps, and found significantly more often in carcinomas with submucosal massive invasion (sm-m) (p<0.01). In respect of capillary irregularity, invisible capillaries were found significantly more often in hyperplasic lesions, and severely irregular capillaries were found significantly more often in sm-m lesions (p<0.01). CONCLUSIONS: Observation of capillary thickness and irregularity by NBI magnification is useful for correlating histological grade with carcinoma, especially with depth of submucosal invasion.

The crude incidence rate of stomach cancer in Chuncheon-si during 2000-2002 / 대한내과학회지

BACKGROUND: Stomach cancer is the most common cancer in Korea, and it can be easily diagnosed by performing endoscopy. Helicobacter pylori (H. pylori) is associated with stomach cancer, and there has been much recent interest in the epidemiology of stomach cancer. Therefore, we estimated the incidence of stomach cancer in Chuncheon-si during 2000-2002. METHODS: From July 1st, 2000 through June 30th, 2002, we investigated the subjects who were confined to be newly diagnosed cases living in Chuncheon-si. The data was collected from the medical records from all the medical facilities located in Chuncheon-si. RESULTS: The total number of cases of newly diagnosed stomach cancer during this period (2000-2002) was 186 (117 males and 69 females). The annual crude incidence rate of stomach cancer was estimated to be 37.0 per 100,000 persons overall, and 47.0 and 27.2 in the males and females, respectively. The annual age standardized incidence rate for the Korean population was 33.7 per 100,000 persons overall, and 42.2 and 25.1 for the males and females, respectively. The major symptoms of stomach cancer patients were epigastric pain (61.8%) and weight loss (31.2%). The proportion of early gastric cancer was 34.9% (60 among 172 persons) of the cases of stomach cancer. 64 patients (74%) were H. pylori positive. CONCLUSIONS: We report here on the estimated incidence rate of the stomach cancer and the characteristics of the stomach cancer patients in Chuncheon-si during 2000-2002. This study has generated basic epidemiologic data to identify the effect of H. pylori eradication on the future incidence rate of stomach cancer.

Two Cases of Acute Hepatitis E in Patients with Hyperthyroidism / 대한소화기학회지

Acute hepatitis E occur commonly as outbreaks in endemic areas, but can occur sporadically in other part of the world. Acute hepatitis E has been reported rarely in Korea. A case of concurrent acute hepatitis E virus (HEV) infection and hyperthyroidism was reported in an inactive hepatitis B surface antigen carrier. We experienced two cases of concomitant acute HEV infection in patients with hyperthyroidism. The first case had acute HEV infection with subclinial hyperthyroidism while taking propylthiouracil. The second case suffered from acute HEV infection in a patient with Graves' disease intractable to propylthiouracil. Herein, we suggest the possible association between HEV infection and hyperthyroidism.

Clinical features of tsutsugamushi disease in Chuncheon / 대한내과학회지

BACKGROUND: Tsutsugamushi disease is an acute febrile disease in Korea. Some patients with tsutsugamushi disease have severe illness, which needs care in intensive care unit, and may die due to the disease. We analyzed the cases with tsutsugamushi disease who lived in Chuncheon and neighboring communities to find out clinical manifestations, laboratory findings especially in severe cases. METHODS: We reviewed the clinical records of the 81 cases who were diagnosed as tsutsugamushi in Chuncheon Sacred Heart Hospital from April, 1997 to December, 2002. We analyzed the clinical and laboratory findings of the 81 cases, and the treatment results of 79 cases who recieved the treatment in this hospital. We also compared the characteristics of the patients between admission to general ward and intensive care unit (ICU). RESULTS: Seventy three cases developed the disease in autumn. Seventy cases had fever. 58 cases had eschar in their bodies. With the doxycycline treatment, forty five cases subsided the fever within 48 hours, but in 13 cases, fever continued after 5 days of treatment. Twenty five cases were admitted to ICU, 8 cases among them were treated with ventilator, 3 cases died due to the multi-organ failure. When we compared the clinical characteristics of the patients admitted to ICU with those to general wards, leukocyte count, the level of BUN and creatinine were higher, the albumin level was lower in ICU patients than those of general ward patients. CONCLUSION: Tsutsugamushi disease can progress to severe disease, and be fatal to the patients. So it is necessary to diagnose early and treat carefully. We suggest that leukocyte count, BUN, creatinine, or albumin can be used to predict the prognosis.

Therapeutic Efficacy of Balloon-Occluded Retrograde Transvenous Obliteration in the Treatment of Gastric Varices in Cirrhotic Patients with Gastrorenal Shunt / 대한소화기학회지

BACKGROUND/AIMS: Rupture of gastric varices was one of the most dreadful complications of cirrhosis. Recently, a new interventional procedure, balloon-occluded retrograde transvenous obliteration (B-RTO) was introduced for the treatment of gastric variceal bleeding. This study was performed to evaluate the therapeutic efficacy of B-RTO in the treatment of gastric varices with gastro-renal shunts. METHODS: From March 2000 to June 2003, we performed B-RTO in 17 patients with gastric varices and gastrorenal shunts. All patients had history or high risk factors of gastric variceal bleeding. For the evaluation of therapeutic efficacy, we performed esophagogastroduodenoscopy (EGD) and computed tomography (CT) at 1, 6 and 12 months after B-RTO. Successful B-RTO was judged by combined CT findings and EGD findings (disappearance of gastric varices or markedly reduced gastric variceal size or bleeding risk) during follow-up periods (1-14 months, mean:6.18). We analyzed the clinical factors related to clinical success of B-RTO. RESULTS: Technical success were achieved in all patients except one (94.1%). Gastric varices were disappeared or decreased after B-RTO in 13 patients (81.2%). Complications related to procedure included transient hematuria (n=5), puncture site oozing (n=1) and partial splenic infarction (n=1), and all were conservatively managed. During the follow up periods, neither significant hepatic nor renal functional damages occurred. Statistically, no significant factors related with B-RTO success. CONCLUSIONS: B-RTO is effective and safe in the management of gastric varices in cirrhotic patients with gastrorenal shunt.