Hepatic Hemangioma with Kasabach-Merritt Syndrome in an Adult Patient / 대한소화기학회지

Hemangiomas are the most common benign tumors of the liver. They are generally asymptomatic, but giant hemangiomas can lead to abdominal discomfort, bleeding, or obstructive symptoms. Kasabach-Merritt syndrome is a rare but life-threatening complication of hemangioma, characterized by consumptive coagulopathy with large vascular tumors. More than 80% of Kasabach-Merritt syndrome cases occur within the first year of life. However, there are few reports of Kasabach-Merritt syndrome with giant hepatic hemangioma in adults and, as far as we know, no reports of Kasabach-Merritt syndrome with hepatic hemangioma treated with first line medical treatment only. The most important treatment for this syndrome is removal of the large vascular tumor. However, surgical treatment entails risk of bleeding, and the patient's condition can mitigate against surgery. We herein present a case of unresectable giant hepatic hemangioma with disseminated intravascular coagulopathy. The patient was a 60-year-old woman who complained of hematochezia, ecchymosis, and abdominal distension. She refused all surgical management and was therefore treated with systemic glucocorticoids and beta-blockers. After two weeks of steroid therapy, she responded partially to the treatment. Her laboratory findings and hematochezia improved. She was discharged on hospital day 33 and observed without signs of bleeding for three months.

Endoscopic Ultrasonographic Characteristics of Gastric Schwannoma Distinguished from Gastrointestinal Stromal Tumor / 대한소화기학회지

BACKGROUND/AIMS: Gastric schwannoma (GS), a rare neurogenic mesenchymal tumor, is usually benign, slow-growing, and asymptomatic. However, GS is often misdiagnosed as gastrointestinal stromal tumors (GIST) on endoscopic and radiological examinations. The purpose of this study was to evaluate EUS characteristics of GS distinguished from GIST. METHODS: A total of 119 gastric subepithelial lesions, including 31 GSs and 88 GISTs, who were histologically identified and underwent EUS, were enrolled in this study. We evaluated the EUS characteristics, including location, size, gross morphology, mucosal lesion, layer of origin, border, echogenic pattern, marginal halo, and presence of an internal echoic lesion by retrospective review of the medical records. RESULTS: GS patients comprised nine males and 22 females, indicating female predominance. In the gross morphology according to Yamada's classification, type I was predominant in GS and type III was predominant in GIST. In location, GSs were predominantly located in the gastric body and GISTs were predominantly located in the cardia or fundus. The frequency of 4th layer origin and isoechogenicity as compared to the echogenicity of proper muscle layer was significantly more common in GS than GIST. Although not statistically significant, marginal halo was more frequent in GS than GIST. The presence of an internal echoic lesion was significantly more common in GIST than GS. CONCLUSIONS: The EUS characteristics, including tumor location, gross morphology, layer of origin, echogenicity in comparison with the normal muscle layer, and presence of an internal echoic lesion may be useful in distinguishing between GS and GIST.

Diffuse Metastasis to the Thyroid: Unique Ultrasonographic Finding and Clinical Correlation

Cases of metastases to the thyroid gland seem to be increasing in recent years. The clinical and ultrasonographic findings of diffuse metastases have been sparsely reported. Thirteen cases of diffuse metastases to the thyroid gland were documented by thyroid ultrasonography-guided fine needle aspiration cytology between 2004 and 2013. We retrospectively reviewed the patients with diffuse thyroid metastases. The most common primary site was the lung (n=9), followed by unknown origin cancers (n=2), cholangiocarcinoma (n=1), and penile cancer (n=1). Eleven patients were incidentally found to have thyroid metastases via surveillance or staging FDG-PET. Other 2 patients were diagnosed during work-up for hypothyroidism and palpable cervical lymph nodes. On ultrasonography, the echogenicity of the enlarged thyroid gland was heterogeneously hypoechoic or isoechoic, and reticular pattern internal hypoechoic lines were observed without increased vascularity found by power Doppler ultrasonography (3 right lobe, 2 left lobe, and 8 both lobes). In the 8 patients who had involvement of both lobes, 3 had hypothyroidism. In conclusion, ultrasonographic finding of diffuse metastasis is a diffusely enlarged heterogeneous thyroid with reticular pattern internal hypoechoic lines. Thyroid function testing should be performed in all patients with diffuse thyroid metastases, especially those with bilateral lobe involvement.

Benign Teratoma of the Thyroid Gland

Although pathology reports of thyroid tissue in ovarian teratomas are abundant, benign teratomas of the thyroid are extremely rare in adolescents and adults. Therefore, their clinical characteristics are still not well characterized. We report a case of a 54-year-old woman with a growing mass in her neck. Left lobectomy of the thyroid revealed it to be a benign thyroid teratoma composed of tissues from all three germ layers. Preoperative evaluations included thyroid ultrasonography (US), ultrasound-guided fine needle aspiration cytology (FNAC), and computed tomography (CT) of the neck. A 4.7-cm, well defined, predominantly hypoechoic mass intermingled with hyperechoic internal lesions, was observed in the inferior portion of the left thyroid lobe with substernal extension on US. The posterior extent of the nodule was not visualized due to deep attenuation of the echo. US-guided FNAC failed to reveal any thyroid follicular cells, but suggested a benign cystic tumor. Neck CT hinted at the diagnosis of teratoma because the mass contained large amounts of fat, and the margin was well defined. Extrathyroidal extension and cervical lymphadenopathy were not seen. She underwent left thyroid lobectomy, and histologic examination confirmed benign thyroid teratoma. To the best of our knowledge, this is the first case report of benign thyroid teratoma in Korea.

Anemia and nutrition in end stage renal disease patient

Anemia and malnutrition are common complications of end-stage renal disease. They increase the morbidity and mortality of end-stage renal disease patients and affect their quality of life. However, the mechanisms of anemia and malnutrition are already known, and their therapeutic guidelines are being established. Appropriate iron supplementation and the development of erythropoiesis-stimulating agents have made anemia easier to manage than in the past. In addition, adequate protein and calorie intake have allowed end-stage renal disease patients to maintain a neutral or positive nitrogen balance. These therapeutic approaches have decreased the morbidity and mortality of these end-stage renal disease patients. This review is a summary of the treatment of anemia and nutrition in end-stage renal disease, based on the Kidney Disease Outcomes Quality Initiative (KDOQI) guideline on anemia and other anemia guidelines, and also on the KDOQI guideline on nutrition and European Best Practice Guideline (EBPG) on nutrition.

A Case of Metformin-Induced Lactic Acidosis with Acute Kidney Injury Misdiagnosed as Hepatorenal Syndrome in a Cirrhosis Patient / 대한내과학회지

Metformin is a well-established drug for the treatment of type 2 diabetes mellitus. The incidence of metformin-induced lactic acidosis is low, but the estimated mortality rate is approximately 50% in cases with lactic acidosis in combination with metformin therapy. Lactic acidosis occurs most often in patients with compromised cardiac, pulmonary, hepatic, and/or renal function. Acute kidney injury is a relatively frequent problem in cirrhosis patients. Hepatorenal syndrome is a diagnosis of exclusion, making its diagnosis difficult in the clinical field. We report a case of metformin-induced lactic acidosis with acute kidney injury that was misdiagnosed as hepatorenal syndrome in a cirrhosis patient.

Rhabdomyolysis of Calf Area Associated with Lithotomy Position for Laparoscopic Myomectomy / 대한내과학회지

Rhabdomyolysis is a syndrome characterized by muscle necrosis and release of intracellular muscle constituents into the circulation. It can occur in various diseases and conditions involving destruction of muscle membranes, including muscle strain, persistent coma, drug or alcohol abuse, connective tissue disease, excessive exercise, and surgery. Many factors have been implicated in the development of rhabdomyolysis during surgery; these include patient positioning with obstructed blood flow of either a femoral vessel at the hip or a popliteal vessel at the knee. Rhabdomyolysis can also be caused by muscle compression due to operative positioning during prolonged surgery. Surgery performed in the lithotomy position sometimes results in serious complications of rhabdomyolysis and acute renal failure. We report a case of rhabdomyolysis of both calves associated with the lithotomy position for laparoscopic myomectomy.

A Case of Metformin-Induced Lactic Acidosis with Acute Kidney Injury Misdiagnosed as Hepatorenal Syndrome in a Cirrhosis Patient / 대한내과학회지

Metformin is a well-established drug for the treatment of type 2 diabetes mellitus. The incidence of metformin-induced lactic acidosis is low, but the estimated mortality rate is approximately 50% in cases with lactic acidosis in combination with metformin therapy. Lactic acidosis occurs most often in patients with compromised cardiac, pulmonary, hepatic, and/or renal function. Acute kidney injury is a relatively frequent problem in cirrhosis patients. Hepatorenal syndrome is a diagnosis of exclusion, making its diagnosis difficult in the clinical field. We report a case of metformin-induced lactic acidosis with acute kidney injury that was misdiagnosed as hepatorenal syndrome in a cirrhosis patient.

Prevalence and Factors of Chronic Kidney Disease / 대한신장학회지

PURPOSE: The prevalence of chronic kidney disease (CKD) is increasing. Accordingly, hospitalization and mortalities associated with CKD also have increased. The present study aimed to determine the prevalence of CKD, and explore the causative risk factors. METHODS: One thousand one hundred and forty-seven patients who underwent the mass health screening test at Chonnam National University Hospital between July 2007 and December 2007 were studied. The prevalence of CKD and possible risk factors such as gender, previous history of diabetes mellitus and hypertension, smoker status (current and ex-smoker), BMI, increased LDL cholesterol, triglyceride levels, HDL cholesterol level and anemia were analyzed. RESULTS: There were 631 male and 616 female subjects. Mean age was 48.6 years and mean glomerular filtration rate was 117.2+/-28.7 ml/min/1.73m2. The prevalence of CKD was 10.3%, and the prevalence of advanced CKD (CKD stage 3-5) was 0.5%. The prevalence of advanced CKD was higher in subjects with diabetes. The awareness of CKD was very low. Factors independently associated with CKD were sex favoring men (odd ratio [OR], 2.106; 95% CI, 1.436-3.090), smoker (OR, 0.575; 95% CI, 0.382-0.867), DM (OR, 2.395; 95% CI, 1.338-4.286), inadequate blood sugar (OR, 2.536; 95% CI, 1.267-5.077), HDL<40 mg/dL (OR, 0.418; 95% CI, 0.191-0.915) in a univariate analysis. With a multivariate analysis, female gender (OR, 2.123; 95% CI, 1.209-3.730) was the only independent risk factor for CKD. CONCLUSION: Since the CKD is a public health burden, closer attention is needed to prevent the CKD in the high-risk group.

Impact of renal dysfunction on clinical outcomes of acute ischemic stroke / 대한내과학회지

BACKGROUND/AIMS: Chronic kidney disease is recognized as an independent risk factor for coronary artery disease. It is unknown whether renal function predicts clinical outcomes of acute ischemic stroke. The present study was aimed at examining the correlation between the degree of renal dysfunction and stroke outcome. METHODS: Our retrospective study included 282 consecutive patients hospitalized due to acute ischemic stroke. Renal function was assessed by the estimated Glomerular filtration rate (GFR), using two METHODS: Cockcroft-Gault equation and Modification of Diet in Renal Disease (MDRD) equation. Each of the estimated GFRs were categorized into three groups (Group I: > or = 60 mL/min/1.73 m2, Group II: 45~59 mL/min/1.73 m2, Group III: 15~44 mL/min/1.73 m2). From collected patient databases, we compared mortality and rate of hospitalization to GFR at 1 month and 12 months follow up. RESULTS: Our study found that, based on the GFR, the 1 year mortality, using the Cockcroft-Gault equation, was 6.0% in group I, 20.3% in group II and 21.1% in group III and, using the MDRD equation, 9.1%, 12.5% and 37.5%, respectively. Patients with lower GFRs exhibited an increased odds ratio for 1 year mortality when estimated by the Cockcroft-Gault equation: 3.97 (1.7~9.2, 95% CI) in group II and 4.16 (1.2~14.5, 95% CI) in group III. Based on the MDRD equation, patients with lower GFRs also exhibited an increased odds ratio for 1-year mortality: 1.43 (0.5~4.4, 95% CI) in group II and 6.00 (1.3~26.8, 95% CI) in group III. The adjusted odds ratio for 1-year mortality also increased based on our analysis using either equation. CONCLUSIONS: Decline of GFR and severity of chronic kidney disease are associated with poor clinical outcomes of acute ischemic stroke.