Macroamilasemia en el Hospital Víctor Lazarte Echegaray de Trujillo, Perú: reporte de un caso / Macroamylasemia at the Hospital Víctor Lazarte Echegaray in Trujillo (Peru): Case report

Resumen La macroamilasemia debe sospecharse en todo paciente con aumento catalítico de amilasa α plasmática persistente y sin clínica de dolor abdominal, descartando otras etiologías de patología pancreáticas y extrapancreática. La macroamilasemia se caracteriza por la unión de complejos de amilasa α con inmunoglobulina, más frecuente inmunoglobulina A; pueden presentarse 3 tipos de macroamilasemia. Es importante realizar el diagnóstico diferencial de otras patologías que puedan causar el aumento de la amilasa y así evitar los procedimientos innecesarios. Se presenta el caso de un paciente de 53 años, de sexo femenino, que ingresó a emergencia por clínica de dolor abdominal y hiperamilasemia, que fue diagnosticada inicialmente de pancreatitis aguda.

Abstract Macroamylasemia should be suspected in any patient with a persistent catalytic increase of plasma α-amylase but no other clinical signs of abdominal pain after ruling out other causes of pancreatic and extra-pancreatic disease. The binding of α-amylase complexes with immunoglobulin, most commonly immunoglobulin A, characterizes this condition. Macroamylasemia is classified into three kinds. To prevent unnecessary procedures, it is critical to make a differential diagnosis of other conditions that can cause amylase increase. The present article reports the case of a 53-year-old female patient who was admitted to the emergency room with abdominal pain and hyperamylasemia, who was initially diagnosed with acute pancreatitis.

Evaluation of Asymptomatic Hyperamylasemia and Hyperlipasemia / 대한췌담도학회지

There are increasing number of cases of serum amylase and lipase levels being examined as part of health screening, but the clinical significance of these amylase and lipase levels is unclear. When the clinicians encounter patients with elevated pancreatic enzymes, the most common causes such as acute pancreatitis, hepatic or renal dysfunction should be ruled out first by thorough history taking, physical examination, and laboratory tests. Further tests including abdominal ultrasonography or computed tomography, lipid profile, tumor marker, isoenzyme, and calculation of amylase-to-creatinine clearance ratio or polyethylene glycol precipitation test should be performed to exclude other causes. If the pancreatic enzymes are continuously elevated through repeated tests without any apparent etiology, the diagnosis is made with chronic non-pathological pancreatic hyperenzymemia (CNPH). Magnetic resonance cholangiopancreatography is very useful and important modality for the patients with CNPH but the clinical significance of magnetic resonance cholangiopancreatography with secretin stimulation is still unclear. They can be evaluated through endoscopic ultrasonography with preference but it is less suitable for follow-up. Individualized approaches should be made after considering the need for active treatment or periodic follow-up for the benign pancreatic diseases associated with CNPH. It is difficult to conclude until more long-term data are reported because there are only limited number of researches and consensus on the range of tests to be performed for diagnosis, clinical significance of benign findings and end of follow-up in patients with CNPH.

Determinación de la frecuencia de hiperamilasemia y pancreatitis en pacientes llevados a colangiopancreatografía retrógrada endoscópica / Determining Frequency of Hyperamylasemia and Pancreatitis in Patients after Endoscopic Retrograde Cholangiopancreatography

Resumen Hemos visto con preocupación que, en el postquirúrgico de la colangiopancreatografía retrógrada endoscópica (CPRE), existe confusión en cuanto a la aparición de pancreatitis y a la elevación transitoria de las amilasas (hiperamilasemia sin repercusión clínica), por lo que nos dimos a la tarea de realizar esta investigación, cuyo objetivo principal era determinar la prevalencia del incremento de niveles séricos de amilasas y de pancreatitis en los pacientes sometidos a colangiopancreatografía retrógrada endoscópica, según variables demográficas, clínicas y procedimentales. Es un estudio descriptivo, prospectivo, analítico y observacional, la población de estudio estuvo integrada por 98 pacientes atendidos en Unión de Cirujanos SAS, quienes requirieron colangiopancreatografía retrógrada endoscópica. Resultados: la frecuencia de pancreatitis aguda después de la CPRE fue del 2%, en 2 de los 98 casos estudiados; el 30% presentó hiperamilasemia (30 pacientes); la canulación del conducto pancreático mostró asociación con pancreatitis post-CPRE, con un valor de p<0,05. De los 2 pacientes que presentaron pancreatitis post-CPRE, a uno de ellos se le realizó contraste del conducto pancreático. La dilatación con balón se asoció con la hiperamilasemia (p<0,041). Conclusiones: la pancreatitis post-CPRE se presentó en un 2% de los pacientes, y este porcentaje se encuentra incluido dentro de los pacientes que presentaron hiperamilasemia, uno de los criterios para el diagnóstico de pancreatitis. Nuestro grupo se encuentra en el rango inferior del promedio internacional (1,8% al 7,2%). La hiperamilasemia asintomática se presentó en un 30%. Recomendamos que, si después de la CPRE, el paciente no presenta dolor, no se midan las amilasas, porque estas van a estar elevadas en gran número de los casos y, entonces, solo causaría confusión.

Abstract We have seen with concern that there is confusion regarding the appearance of pancreatitis and the transient elevation of amylases (hyperamylasemia without clinical repercussions) in the postoperative period following ERCP (endoscopic retrograde cholangiopancreatography). For this reason, we embarked on the task of determining the prevalence of increased serum amylases and pancreatitis in patients who have undergone endoscopic retrograde cholangiopancreatography according to demographic, clinical and procedural variables. This is a descriptive, prospective, analytical and observational study. The study population consisted of 98 patients treated in the Union of SAS Surgeons who required endoscopic retrograde cholangiopancreatography. Results: Acute pancreatitis was found in 2% of the patients who had undergone ERCP (Two of the 98 cases studied). Thirty patients (30%) presented hyperamylasemia. Cannulation of the pancreatic was associated with post-ERCP pancreatitis (p <0.05). Pancreatic duct contrast had been used in one of the two patients who presented post-ERCP pancreatitis. Balloon dilation was associated with hyperamylasemia (p <0.041). Conclusions: Post-ERCP pancreatitis was found in two patients (2%), both of whom also presented hyperamylasemia which is one of the criteria for diagnosis of pancreatitis. The rate in our group is at the lower end of the international range of averages from 1.8% to 7.2%. Asymptomatic hyperamylasemia was present in 30% of our group. Following ERCP, we recommend that there is no need to measure amylases in patients who do not present pain. Amylase levels will be elevated in a large number of cases and will only cause confusion.

The Incidence, Associated Factors and Clinical Impact of Hyperamylasemia in Self-poisoning Patients

PURPOSE: This study was conducted to investigate the incidence, associated factors and clinical impact of hyperamylasemia in self-poisoning patients. METHODS: This study was based on a toxicology case registry of patients treated from 2009 to 2013 at a tertiary care university hospital. We retrospectively investigated the demographics, clinical variables, laboratory variables and intoxicants. Hyperamylasemia was defined as an elevation in serum amylase level to above the upper normal limit within 24 hours after admission. We analyzed the predisposing factors and clinical outcomes of patients in the hyperamylasemia group. RESULTS: Hyperamylasemia was identified in 49 (13.3%) of the 369 patients. Using multivariate logistic regression, the odds ratios for HA were 3.384 (95% confidence interval, 1.142-8.013, p=0.014), 3.261 (95% confidence interval, 1.163-9.143, p=0.025) and 0.351 (95% confidence interval, 0.154-0.802, p=0.013) for pesticides, multi-drug use and sedatives, respectively. In the hyperamylasemia group, the peak amylase levels during 72 hours were correlated with the peak lipase levels (r=0.469, p=0.002) and peak aspartate aminotransferase levels (r=0.352, p=0.013). Finally, none of these patients had confirmed acute pancreatitis. CONCLUSION: Hyperamylasemia occurred rarely in these self-poisoning patients, and pesticide and multi-drug use were independent predictors of hyperamylasemia. Peak amylase levels were correlated with the peak lipase and aspartate aminotransferase levels.

Hyperamylasemia Related to Sertraline / 가정의학회지

No abstract available.

Does the abdominal ultrasonography reliable in the diagnosis of postoperative pancreatic fistula after pancreaticoduodenectomy in the first postoperative week?

PURPOSE: We evaluated the efficacy of ultrasonography (US) in the early postoperative period after pancreaticoduodenectomy (PD) to diagnose postoperative-pancreatic-fistula (POPF). Early diagnosis is important to prevent POPF-dependent mortality after PD. The value of radiological modalities for early diagnosing POPF is not clear. METHODS: Forty-five patients who underwent transabdominal-US in the first postoperative week after PD were retrospectively evaluated. Two types of grouping methods were performed. Firstly, peripancreatic or perianastomotic fluid collections at least 2 cm in diameter were considered to be a primary positive result on US. Patients then divided into 2 groups: group 1, US-positive and group 2, US-negative. Secondly, to increase the power of US, in addition to primary positive results, the presence of fever, leukocytosis or hyperamylasemia was considered to be a secondary positive result (group 1S). The remaining patients were considered to have secondary negative results (group 2S). The sensitivity and specificity for both grouping methods were calculated for the diagnosis of PF and clinically important PF (ciPF), according to the International Study Group on Pancreatic Fistula criteria. RESULTS: For the first grouping method, the sensitivity was 36% and 28% and the specificity was 80% and 85% for PF and ciPF, respectively. For the second grouping method, the sensitivity was 36% and 29% and the spesificity was 74% and 81% for PF and ciPF, respectively. The unloculated fluid collections were not related to a significant increase in the risk of POPF (P = 0.694). CONCLUSION: Abdominal-US has low sensitivity and high specificity for the early diagnosis of POPF after PD.

Percutaneous Papillary Large Balloon Dilation during Percutaneous Cholangioscopic Lithotripsy for the Treatment of Large Bile-Duct Stones: A Feasibility Study

When access to a major duodenal papilla or endoscopic retrograde cholangiopancreatography has failed, percutaneous transhepatic cholangioscopic lithotripsy (PTCS-L) may be useful for removing common bile duct (CBD) stones. However, the feasibility and usefulness of percutaneous transhepatic papillary large-balloon dilation (PPLBD) during PTCS-L for the removal of large CBD stones has not been established. We aimed to determine the safety and efficacy of PPLBD for the treatment of large CBD stones. Eleven patients with large CBD stones in whom the access to the major papilla or bile duct had failed were enrolled prospectively. Papillary dilation was performed using a large (12-20 mm) dilation balloon catheter via the percutaneous transhepatic route. Post-procedure adverse events and efficacy of the stone retrieval were measured. The initial success rate of PPLBD was 100%. No patient required a basket to remove a stone after PPLBD. Electrohydraulic lithotripsy was required in 2 (18.2%) patients. The median time to complete stone removal after PPLBD was 17.8 min and no adverse events occurred after PPLBD. Asymptomatic hyperamylasemia was not encountered in any patients. This study indicates that PPLBD is safe and effective for removal of large CBD stones.

Percutaneous Papillary Large Balloon Dilation during Percutaneous Cholangioscopic Lithotripsy for the Treatment of Large Bile-Duct Stones: A Feasibility Study

When access to a major duodenal papilla or endoscopic retrograde cholangiopancreatography has failed, percutaneous transhepatic cholangioscopic lithotripsy (PTCS-L) may be useful for removing common bile duct (CBD) stones. However, the feasibility and usefulness of percutaneous transhepatic papillary large-balloon dilation (PPLBD) during PTCS-L for the removal of large CBD stones has not been established. We aimed to determine the safety and efficacy of PPLBD for the treatment of large CBD stones. Eleven patients with large CBD stones in whom the access to the major papilla or bile duct had failed were enrolled prospectively. Papillary dilation was performed using a large (12-20 mm) dilation balloon catheter via the percutaneous transhepatic route. Post-procedure adverse events and efficacy of the stone retrieval were measured. The initial success rate of PPLBD was 100%. No patient required a basket to remove a stone after PPLBD. Electrohydraulic lithotripsy was required in 2 (18.2%) patients. The median time to complete stone removal after PPLBD was 17.8 min and no adverse events occurred after PPLBD. Asymptomatic hyperamylasemia was not encountered in any patients. This study indicates that PPLBD is safe and effective for removal of large CBD stones.

Effect of Intravenous Lipid Emulsion in the Patient with Acute Poisoning : A Systematic Review

PURPOSE: The purpose of this study was to evaluate the usefulness of intravenous lipid emulsion as well as adverse events in acute poisoning patients. METHODS: Literature was accessed through PubMed, EMBASE, Cochrane library, Web of science, and KoreaMed. All forms of literatures relevant to human use of intravenous lipid emulsion for acute poisoning were included. Cases reports or letters without description of clinical outcomes for each case were excluded. The literature search was conducted by two investigators in March, 2015, with publication language restricted to English and Korean. The effect, onset time, and adverse event of lipid emulsion and final outcome of each case were analyzed. RESULTS: Eighty-one published articles were included, excluding articles whose title and abstract were not relevant to this study. No articles were classified as high level of evidence. Sixty-eight case reports were identified, consisting of 25 local anesthetics and 43 other drugs, such as tricyclic antidepressants and calcium channel blockers. Although most cases described significant clinical improvements, some of them showed no beneficial effect or worsening of clinical course. Several adverse events including hyperamylasemia and laboratory interference were reported. CONCLUSION: Although there were many case reports illustrating successful use of lipid for various drug poisonings, the effect cannot be estimated due to significant possibility of publication bias. Therefore, lipids might be considered in severe hemodynamic instability resulting from lipophilic drug poisoning, however further studies should follow to establish the use of lipid as the standard of care.

Amylase-Producing Primary Peritoneal Carcinoma / 대한내과학회지

A paraneoplastic syndrome is a disease or symptom that is the consequence of the presence of cancer in the body but is not due to the local presence of cancer cells. Thus, successful treatment of the underlying tumor often improves such syndromes. Amylase-producing lung cancer, multiple myeloma, and ovarian cancer are reported only rarely. In Korea, no cases of hyperamylasemia have been reported in patients with primary peritoneal carcinoma. We report an interesting case of hyperamylasemia suspected to have been induced by primary peritoneal carcinoma. The patient's amylase isoenzyme patterns indicated salivary-type amylase. Hyperamylasemia was reduced in parallel with the response to chemotherapy. These data confirmed the diagnosis of amylase-producing primary peritoneal carcinoma.

Risk factors associated with the development of hyperamylasemia and post-ERCP pancreatitis in the Cuban National Institute / Factores de riesgo con el desarrollo de la hiperamilasemia y pancreatitis post PCRE en el Cuban National Institute

Contexto: La pancreatitis aguda es la complicación más frecuente de la PCRE y algunos factores de riesgo son asociados con el desarrollo de hiperamilasemia y pancreatitis post PCRE. Objetivos: Identificar factores nuevos asociados con hiperamilasemia y pancreatitis post PCRE en pacientes que acudieron a nuestro centro. Material y métodos: Un estudio retrospectivo de cohorte se llevó a cabo en 170 pacientes en quienes se realizó una CPRE diagnóstico-terapéutica por enfermedad biliopancreática. 67 pacientes desarrollaron hiperamilasemia (39,4%) y 6 pancreatitis post PCRE (3,5%). Se aplicaron los siguientes criterios diagnósticos: Hiperamilasemia: elevación de la amilasa sérica por encima del valor normal (90IU).Pancreatitis aguda post PCRE: dolor abdominal continuo por más de 24 horas y elevación de la amilasa tres veces por encima del valor normal. Resultados: El número de canulaciones, más de 4 (19 pacientes), (p=0,006; RR= 3,00) se asoció significativamente con el desarrollo de la hiperamilasemia y la puesta de stents biliares (14 pacientes) se asoció como un factor protector (p=0,00; RR= 0,39). Los factores asociados con el desarrollo de la pancreatitis post PCRE se relacionaron con el paciente (localización peridiverticular de la papila (p=0,00; RR= 2,00) y disfunción del Esfinter de Oddi (p=0,000; RR=1,20). Conclusiones: Factores técnicos fueron asociados con el desarrollo de la hiperamilasemia, sin embargo, los relacionados con el desarrollo de la pancreatitis post PCRE fueron mayoritariamente relacionados al paciente.

Context: Acute pancreatitis is the most common complication in ERCP, and some risk factors were associated with the development of hyperamylasemia and post-ERCP pancreatitis. Objectives: identifying new factors associated with the development of hyperamylasemia or post-ERCP pancreatitis in patients attended at our center. Material and methods: A (retrospective) cohort study was carried out in 170 patients on which a diagnostic-therapeutic ERCP was done due to biliopancreatic disease. 67 patients developed hyperamylasemia (39.4%) and 6 post-ERCP pancreatitis (3.5%). The following diagnostic criteria were applied: Hyperamylasemia: increase in the serum amylase level above the normal value (90I/U). Acute post-ERCP pancreatitis: clinical: continuous abdominal pain for over 24 hours and biochemical: elevation of amylase 3 times above normal value (90U/I). Results: The number of cannulations more than 4 (19 patients), (p=0.006; RR= 3.00) was associated significantly with the development of hyperamylasemia and the placing of biliary stent (14 patients), (p=0.00; RR= 0.39) was a protective factor. The factors associated with the development of post-ERCP pancreatitis were related with the patient (peridiverticular location of the papilla (p=0.00; RR= 2.00) and the sphincter of Oddi dysfunction (p=0.000; RR=1.20). Conclusion: Technical factors were associated with the development of hyperamylasemia, however, the factors associated with the development of post-ERCP pancreatitis in our universe of study were related mainly with the patient.

Medical Findings in Korean Women with Bulimia Nervosa / 신경정신의학

OBJECTIVES: Medical complications are common and often serious in patients with eating disorders, however, little is known about complications in patients with bulimia nervosa. METHODS: We conducted a retrospectively investigation of clinical characteristics and hematologic, biochemical, hormonal, and bone density evaluations in 90 Korean women with bulimia nervosa together with 100 healthy Korean women of comparable ages. RESULTS: In patients with bulimia nervosa, 20% were anemic, 3.3% were hypokalemic, 14.4% had increased alanine aminotransferase, 24.4% were lower in serum protein, 8.8% were hypercholesterolemia, and 77.8% were hyperamylasemia. Osteopenia at any one site was identified in 26.7% of patients and the lowest-ever body mass index was the main determinant of bone mineral density in patients with bulimia nervosa. CONCLUSION: In this study, many features of medical findings reported in anorexia nervosa were found in bulimia nervosa, however, the findings in bulimia nervosa were milder form than in anorexia nervosa. Management of any physical abnormalities in bulimia nervosa should focus on correction of the eating disorder.

Is prophylactic somatostatin effective to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis or hyperamylasemia? A randomized, placebo-controlled pilot trial / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Effects of prophylactic somatostatin on post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) and hyperamylasemia remain inconclusive. This study aimed to examine whether high-dose, long-term continuous infusion of somatostatin can reduce the incidence of PEP and post-ERCP hyperamylasemia.</p><p><b>METHODS</b>This was a randomized, placebo-controlled pilot trial. One hundred and twenty-four patients scheduled for ERCP from December 2008 to May 2010 randomly received one of the following three interventions: pre-ERCP somatostatin (0.5 mg/h for 24 hours, starting 1 hour prior to ERCP; n = 36), post-ERCP somatostatin (0.5 mg/h for 24 hours, starting 1 hour after ERCP; n = 47), or placebo (saline for 24 hours, starting 1 hour prior to ERCP; n = 41). Serum amylase and lipase concentrations were measured 1 to 3 hours prior to ERCP and 6, 24, and 48 hours after ERCP.</p><p><b>RESULTS</b>The three groups did not differ in age, gender, medical history, or ERCP procedure (catheterization using contrast or guidewire, pancreatic duct visualization, procedure time, or procedure type). The rate of PEP was 13.7% (17/124) in the overall study sample and 16.7% (6/36), 10.6% (5/47), and 14.6% (6/41) in the pre-ERCP somatostatin, post-ERCP somatostatin, and placebo groups, respectively (P = 0.715). The rate of post-ERCP hyperamylasemia was 19.4% (7/36), 21.3% (10/47), and 46.3% (19/41) in the pre-ERCP somatostatin, post-ERCP somatostatin, and placebo groups, respectively (P = 0.011).</p><p><b>CONCLUSIONS</b>High-dose, long-term continuous infusion (0.5 mg/h for 24 hours) of somatostatin, performed as either a pre- or post-ERCP, can reduce the incidence of hyperamylasemia, but not PEP.</p>

Analysis of clinical application of endoscopic retrograde cholangiopancreatography for the pancreatic diseases in children / 中华儿科杂志

<p><b>OBJECTIVE</b>To study the feasibility and risk of endoscopic retrograde cholangiopancreatography (ERCP) for children in clinic, and to evaluate the effects of ERCP in diagnosis and treatment of the pancreatic diseases in children.</p><p><b>METHOD</b>Totally 98 patients under 14 years of age who underwent ERCP from 1994 to 2011 were enrolled in the study. The data of diagnosis, anesthesia type, treatments, and postoperative complications were collected.</p><p><b>RESULT</b>The 98 patients were 4 to 14 years old, of whom 32 cases suffered from acute pancreatitis (30 cases with biliary disease and 2 with hyperlipidemia); 42 cases had chronic pancreatitis, of whom 36 had calculus of pancreatic duct, pancreatic pseudocyst was seen in 6 cases. Pancreas divisum was found in 20 cases, choledochopancreatic junction anomaly in 6 cases,and annular pancreas in 1 case. The operations of dissection of pancreatic duct and biliary duct, calculus removal, insertion of endoprosthesis and draining tube in pancreatic duct or biliary duct were performed. No patients died from ERCP complications. In observation of postoperative complications, acute pancreatitis after ERCP occurred in 1 case, with the incidence rate of 1%, 1 case had bleeding (1%), and 5 cases had hyperamylasemia (5%). All the complications were cured within 1 week. The average hospital stay was 5.51 d.</p><p><b>CONCLUSION</b>ERCP is useful and safe in children under suitable condition of doctors and equipments, and no high rates of complications were observed.</p>

Factores de riesgo asociados a pancreatitis e hiperamilasemia postcolangiopancreatografía retrógrada endoscópica (CPRE) / Risk factors for endoscopic retrograde cholangiopancreatography (ERCP) associated with pancreatitis and hyperamylasemia

Materiales y métodos: Se trata de un estudio prospectivo, observacional, analítico, de corte transversal, realizado en el Hospital El Tunal, en aquellos pacientes que fueron sometidos a CPRE. Antes del procedimiento, el paciente llenaba un formulario con las principales variables epidemiológicas, laboratorios e imágenes, después se le realizaba la CPRE y permanecían hospitalizados mínimo 24 horas postprocedimiento al cabo de las cuales se les tomaba el nivel de amilasa y se evaluaban si tenían dolor o algunas de las complicaciones.Resultados: En total se reclutaron 152 pacientes que cumplieron los criterios de inclusión ya que tenían indicación de realizarles una CPRE porque cursaban con colestasis y dilatación de la vía biliar extrahepática. El 61,8% de los pacientes eran mujeres (n-94). El promedio de edad observado fue 60,07 ± 15,9 años. Conclusión: Nuestro trabajo muestra que la pancreatitis post-CPRE es una complicación muy frecuente y aún más, la hiperamilasemia asintomática si bien no tiene implicaciones para el paciente sí la tiene para la práctica clínica ya que nuestra recomendación es que después de una CPRE si el paciente no tiene dolor abdominal no deben solicitarse las amilasas dado que en el 60% de los casos va a estar elevada generando confusión. En cuanto a los 4 factores de riesgo identificados, lo cuales son potencialmente modificables, el trabajo sugiere que lo más importante es que la CPRE sea realizada por un profesional con entrenamiento.

Materials and methods. This is a cross sectional, analytical, prospective and observational study of patients who underwent ERCP at the Hospital El Tunal. Before undergoing ERCP all patients filed out a form about their most important epidemiological variables, laboratory study results and imaging study results. After undergoing the procedure they remained in the hospital for at least 24 hours during which time amylase levels, pain, and other complications were monitored and evaluated.Results. 152 patients met the study’s inclusion requirements. All underwent ERCP because of cholestasis and dilation of the extrahepatic bile duct. 94 of these patients (61.8%) were women. Patients average age was 60.07 ± 15.9 years. Conclusion. Our work demonstrates that pancreatitis following ERCP is a very common complication, but that asymptomatic hyperamylasemia is even more common. Even though the latter does not have any implications for the patient, it does have implications for clinical practice. Our current recommendation for monitoring a patient following an ERCP is that no testing for amylases needs to be done if that patient has no abdominal pain since 60% of these cases will have elevated levels of amylase which could generate confusion. Of the four risk factors which were identified which might potentially be modified, the most important is that the ERCP should be performed by a well trained professional.

One-Step Transpapillary Balloon Dilation under Cap-Fitted Endoscopy without a Preceding Sphincterotomy for the Removal of Bile Duct Stones in Billroth II Gastrectomy

BACKGROUND/AIMS: Endoscopic sphincterotomy may be limited in Billroth II gastrectomy because of difficulty in orientating the duodenoscope and sphincterotome as a result of altered anatomy. This study was planned to investigate the efficacy and safety of endoscopic transpapillary large balloon dilation (EPBD) without preceding sphincterotomy for removal of large CBD stones in Billroth II gastrectomy. METHODS: Between March 2010 and February 2011, one-step EPBD under cap-fitted forward-viewing endoscopy was performed in patients who had undergone Billroth II gastrectomy at two tertiary referral centers. Main outcome measurements were successful duct clearance and EPBD-related complications. RESULTS: Successful access to major duodenal papilla was performed in 13 patients, but successful selective CBD cannulation was achieved in 12 patients (92.3%). Median maximum transverse stone size was 11.5 mm (10 to 14 mm). The mean number of stones was 2 (1-5). The median CBD diameter was 15 mm (12 to 19 mm). Mean procedure time from successful biliary access to complete stone removal was 17.8 min. Complete duct clearance was achieved in all patients. Four patients (33.3%) needed one more session of ERCP for removal of remnant stones. Asymptomatic hyperamylasemia in two patients and minor bleeding in another occurred. CONCLUSIONS: Without preceding sphincterotomy, one-step EPBD (> or =10 mm) under cap-fitted forward-viewing endoscopy may be safe and effective for the removal of large stones (> or =10 mm) with CBD dilatation in Billroth II gastrectomy.

Surgical experience and clinical outcome of traumatic pancreatic injury

BACKGROUNDS/AIMS: Traumatic pancreatic injury is rare and various surgical procedures can be applied according to the severity of injury. We reviewed our experience of pancreatic injury and investigated the clinical outcome. METHODS: Fifty-six patients were treated conservatively or with surgery for pancreatic injury at the Department of Surgery, Korea University Medical Center of Korea University College of Medicine from January 2001 to February 2012. RESULTS: Forty-one men and 15 women were included (mean age, 32 years; range, 5-66 years). Twelve patients were hypotensive at admission. According to the American Association for the Surgery of Trauma grade, 15 patients were grade I, 16 were grade II, 10 were grade III, 13 were grade IV, and one patient was grade V. A total of 41 patients underwent exploratory surgery. Complications developed in 35 patients, and 19 patients demonstrated intra-abdominal abscesses associated with pancreatic leakage. Four mortalities occurred. More adult patients (n=42) required intensive care than that of pediatric patients (n=14) (p=0.03). However, more pediatric patients had hyperamylasemia at admission (p=0.023). A significantly higher proportion of patients in the hypotensive group had blunt abdominal injuries, associated extra-abdominal injuries, combined intra-abdominal injuries, longer ICU stays, and a higher mortality rate. CONCLUSIONS: Associated intra-abdominal and extra-abdominal injuries are frequent in patients with traumatic pancreatic injury. Despite the complication rate, most patients recovered. Mortalities were associated with combined injuries being placed into bleeding, hypovolemic shock, and multiorgan failure.

A Case of Hyperamylasemia Associated with Lung Adenocarcinoma / 대한내과학회지

Hyperamylasemia in patients with lung cancer is relatively rare, occurring in 1-3% of all cases of the disease. The pathogenesis of hyperamylasemia in solid cancers is not clear. In Korea, no cases of hyperamylasemia have been reported in patients with adenocarcinoma of the lung. Instead, the lung cancers in patients with hyperamylasemia have in most cases been adenocarcinomas. We report a case of a 64-year-old woman with hyperamylasemia that was suspected to have been induced by mucinous adenocarcinoma of the lung. The patient's amylase isoenzyme pattern was of the salivary type. Systemic chemotherapy normalized her serum amylase levels and produced a partial response in her lung cancer.

Clinical Effects of Bile Aspiration Just before Contrast Injection during Endoscopic Retrograde Cholangiopancreatography / 대한소화기학회지

BACKGROUND/AIMS: This study was designed to determine whether bile aspiration before contrast injection cholangiogram prevent of post-ERCP cholangitis, liver function worsening, cholecystitis and pancreatitis. METHODS: One hundred and two patients in the bile aspiration group before contrast injection from December 1, 2008 to December 30, 2009 and 115 patients in the conventional control group from January 1, 2010 to June 30, 2010 were analyzed. The incidence of post-ERCP cholangitis, liver function worsening, cholecystitis, pancreatitis, and hyperamylasemia only were compared between these two groups. RESULTS: In the 102 patients with the bile aspiration group, post-ERCP cholangitis in 3 patients (2.9%), liver function worsening in 4 patients (3.9%), cholecystitis and pancreatitis in none, and hyperamylasemia only in 6 patients (5.8%) occurred. In the 115 patients with control group, post-ERCP cholangitis in 1 patient (0.4%), liver function worsening in 9 patients (7.8%), cholecystitis in none, pancreatitis in 3 patients (2.6%), hyperamylasemia only in 10 patients (8.6%) developed. The two groups did not significantly differ in terms of the incidence of post-ERCP cholangitis, liver function worsening, pancreatitis, and hyperamylasemia only (p>0.05). CONCLUSIONS: Initially bile juice aspiration just before contrast injection into the bile duct rarely prevented post-ERCP cholangitis, liver function worsening, and pancreatitis in patients with the extrahepatic bile duct obstruction.

A Case of Hyperamylasemia Associated with Lung Adenocarcinoma / 대한내과학회지

Hyperamylasemia in patients with lung cancer is relatively rare, occurring in 1-3% of all cases of the disease. The pathogenesis of hyperamylasemia in solid cancers is not clear. In Korea, no cases of hyperamylasemia have been reported in patients with adenocarcinoma of the lung. Instead, the lung cancers in patients with hyperamylasemia have in most cases been adenocarcinomas. We report a case of a 64-year-old woman with hyperamylasemia that was suspected to have been induced by mucinous adenocarcinoma of the lung. The patient's amylase isoenzyme pattern was of the salivary type. Systemic chemotherapy normalized her serum amylase levels and produced a partial response in her lung cancer.