Endoscopic Nasobiliary Drainage for Bile Leak Caused by Injury to the Ducts of Luschka / 대한소화기학회지

A 51-year-old man underwent laparoscopic cholecystectomy for gallbladder stones. He had developed fever, chills, and abdominal pain four days after the procedure. In the drain tube, bile was persistently observed. An endoscopic retrograde cholangiopancreatography (ERCP) showed a leakage from the small duct into the right intrahepatic duct. We determined that the bile leak was caused by an injury to the ducts of Luschka. An endoscopic sphincterotomy (ES) using a 5-F nasobiliary tube (NBT) was performed, and the leak was resolved in five days. Herein, we report a bile leak caused by an injury to the ducts of Luschka after laparoscopic cholecystectomy. The leak was treated with ES using 5-F NBT, and the resolution of the leak was confirmed without repeated endoscopy.

Hepatic Immunoglobulin G4-related Inflammatory Pseudotumor Mimicking Hepatocellular Carcinoma

Immunoglobulin G4-related disease is a recently recognized entity characterized by a mass-forming or regional lesion that contains an extensive infiltration of IgG4-producing plasma cells with dense fibrosis. Immunoglobulin G4-related disease can affect any organ system, but solitary hepatic lesion of Immunoglobulin G4-related disease is very rare. This entity mimics primary malignant hepatic tumor, such as hepatocellular carcinoma or intrahepatic cholangiocarcinoma. We experienced a case of hepatic IgG4-related inflammatory pseudotumor in a 50-year-old woman, mimicking hepatocellular carcinoma.

Primary Anorectal Malignant Melanoma Treated With Endoscopic Mucosal Resection

Anorectal melanoma is a rare neoplasm that accounts for less than 1-4% of anorectal malignant tumors. The main therapeutic modality for anorectal melanoma is surgical treatment, with abdominoperineal resection or wide local excision being the most common approaches. A 77-year-old male with a history of cerebral infarction and hypertension presented with anal bleeding. Here, we report a case of anorectal melanoma treated by endoscopic mucosal resection with adjuvant interferon therapy rather than surgical resection. The patient has been disease-free for 5 years after endoscopic treatment.

Evaluation of Transnasal Esophagogastroduodenoscopy as a Surveillance Endoscopy in a General Medical Checkup

BACKGROUND/AIMS: Transnasal esophagogastroduodenoscopy (T-EGD) has been reported to be well tolerated and is known to reduce patient discomfort that occurs with conventional EGD (C-EGD) performed via an oral route. We aimed to evaluate factors that influence preferences for T-EGD as a surveillance EGD in a general medical checkup. MATERIALS AND METHODS: A total of 658 subjects (median age, 49 years; 45% men) underwent T-EGD procedures by 8 endoscopists using a 5.2-mm diameter endoscope. All examinees and endoscopists were asked to assess the T-EGD examinations using the post-endoscopy questionnaire. The post-endoscopy questionnaire included a 10-point visual analogue scale, which asked the patient to place a cross on the line according to examinee's or endoscopist's experience of the endoscopy procedure. Zero represented the worst experience and 10 the best experience. RESULTS: T-EGD was feasible in 96.6% of the subjects. Younger age ( or =35 years) or male examines preferred T-EGD as the modality for the next examination. The endoscopist's overall discomfort level was higher in the beginner group than in the expert group. CONCLUSIONS: The T-EGD may be better tolerated than C-EGD and offers a more comfortable surveillance endoscopic procedure to older (> or =35 years), male, or sedated C-EGD-experienced examinees in a general medical checkup. More experience with and education about T-EGD may help to improve the tolerance of the beginner group of endoscopists.

Laparoscopy-Assisted Percutaneous Endoscopic Gastrostomy in a Patient with Distorted Anatomy / 대한내과학회지

Percutaneous endoscopic gastrostomy (PEG), which was first introduced in 1980, was quickly adopted for use in pediatric and adult patients. However, problems such as severe kyphoscoliosis, interposed organs, or other forms of distorted anatomy, may prevent effective and safe PEG tube placement. In such cases, laparoscopy-assisted PEG (LAPEG) is a useful optional procedure for patients with distorted anatomy and an initial unsuccessful PEG attempt. Furthermore, less invasive measures are preferable over surgical gastrostomy. We present a 27-year-old-male patient with severe kyphoscoliosis and a history of PEG-related complications with a colocutaneous fistula appearing 10 months earlier in whom a feeding tube was successfully placed by LAPEG. There were no LAPEG-related complications in the perioperative period, either technical or metabolic. After discharge, the patient was effectively fed using the bolus method.

Pill-induced Intramural Hematoma of the Esophagus

Intramural hematoma of the esophagus is a rare cause of chest pain. Varying degrees of submucosal dissection and rupture of the esophagus can induce intramural hematoma of the esophagus. It is viewed as a complication of endoscopic sclerotherapy of esophageal varices, and is likely caused by an elevation in intraesophageal pressure due to factors such as blood coagulation abnormality, drugs, trauma or vomiting. We describe one case of pill-induced spontaneous intramural hematoma that was successfully managed by conservative treatment and discuss the case with a review of the literature.

Endoscopic Management for Colocutaneous Fistula as a Complication of Percutaneous Endoscopic Gastrostomy

Percutaneous endoscopic gastrostomy (PEG) has become a safe and effective technique for enteral feeding. Colocutaneous fistula, which is a rare complication of PEG, is thought to be formed during insertion of the original PEG tube when the colon becomes interposed between the stomach and the abdominal wall. We present a patient who developed colocutaneous fistula after PEG tube exchange. Three years ago, a PEG tube for enteral feeding was placed in a 27-year-old male with cerebral palsy and severe scoliosis. Two months after PEG tube exchange, he was admitted to our hospital because fecal material was observed in the tube and exit site. The diagnosis of colocutaneous fistula was made after injection of gastrografin in the fistula opening of the abdominal wall. Endoscopic management for the fistula opening of the colon was successfully performed using metal-clips and we were able to avoid surgical therapy for the fistula.

Differential LINE-1 Hypomethylation of Gastric Low-Grade Dysplasia from High Grade Dysplasia and Intramucosal Cancer

BACKGROUND/AIMS: Gastric epithelial dysplasia is considered a precancerous lesion with a variable clinical course. There is disagreement, however, regarding histology-based diagnoses, which has led to confusion in choosing a therapeutic plan. New objective markers are needed to determine which lesions progress to true malignancy. We measured LINE-1 methylation levels, which have been reported to strongly correlate with the global methylation level in gastric epithelial dysplasia and intramucosal cancer. METHODS: A total of 145 tissue samples were analyzed by two histopathologists. All tissues were excised by therapeutic endoscopic mucosal resection and paired with adjacent normal tissue samples. A modified long interspersed nucleotide elements-combined bisulfite restriction analysis (COBRA-LINE-1) method was used. RESULTS: Gastric epithelial dysplasia and intramucosal cancer tissues had significantly lower levels of LINE-1 methylation than adjacent normal gastric tissues. High-grade dysplasia and intramucosal cancer were distinguishable from low-grade dysplasia based on LINE-1 methylation levels. Furthermore, the distinction could be determined with high sensitivity and specificity, as shown by the receiver operating characteristic (ROC) curve (AUC, 0.82; 95% confidence interval, 0.74 to 0.88). CONCLUSIONS: LINE-1 methylation levels may provide a diagnostic tool for identifying high-grade dysplasia and intramucosal cancer.

A Case of Splenic Rupture after Diagnostic Colonoscopy / 대한소화기내시경학회지

Splenic injury during colonoscopy is a rare, but potentially life-threatening complication. We report here on the case of a 75-year-old female patient with a ruptured spleen after screening colonoscopy and we review the relevant literature.

Two Cases of Eosinophilic Esophagitis Treated with a Proton Pump Inhibitor and a Systemic Steroid / 대한소화기내시경학회지

Eosinophilic esophagitis is a chronic inflammatory disorder characterized by dense eosinophilic infiltration of the esophageal mucosa. As an emerging disease during the last decade, eosinophilic esophagitis has gained increased recognition in both the medical and research communities. The pathogenesis is incompletely understood and food allergies and aeroallergens have been implicated. The most common clinical symptoms in adults are dysphagia and food impaction. We diagnosed two cases as eosinophilic esophagitis and treated them with a proton pump inhibitor and a systemic steroid. We confirmed improvements in clinical presentation and histologic findings and report these cases.

A case of hepatocellular carcinoma in the caudate lobe successfully treated by transcatheter arterial chemoembolization using drug-eluting beads / 대한간학회지

Hepatocellular carcinoma (HCC) in the caudate lobe remains one of the most intricate locations where various treatments tend to pose problems with regard to the optimal approach. Surgical resection has been regarded as the most effective treatment; however, isolated resection of the caudate lobe is strenuous and associated with a high rate of early recurrence. Percutaneous ablation might be technically difficult or impossible to perform due to the deep location of tumors and adjacent large vessels. Treatment with drug-eluting beads (DEB) can potentially enhance the therapeutic efficacy for patients with unresectable HCC by drawing on the slower, more consistent drug delivery process. We described a case of a 62-year-old man with HCC in the caudate lobe who was successfully treated by DEB.

Risk Factors Predicting the Development of Complication after Foreign Body Ingestion / 대한소화기내시경학회지

BACKGROUND/AIMS: Complications related to foreign body ingestion are uncommon, and especially a food bolus, but some ingested foreign bodies are associated with severe and life threatening morbidity. The aim of this study is determine the predictive risk factors for complications resulting from foreign body ingestion in patients who are without gastrointestinal tract obstruction. METHODS: We retrospectively analyzed the data of 147 patients who were diagnosed with a foreign body in the GI tract without obstruction between Jan. 2000 to Aug. 2008. RESULTS: Animal bone fragment and coin were the most common type of foreign bodies in adults and children, respectively. Multivariate analysis showed age (p=0.019), the duration of impaction (p=0.013) and the location of the impacted foreign body (p=0.011) were significant independent risk factors associated with the development of complications. Especially, the most important risk factor for children was the location of the impacted foreign body and for adults it was the duration of impaction. CONCLUSIONS: Old age, a longer duration of impaction and impaction at the upper esophageal sphincter or upper esophagus are important predictive factors of complication after foreign body ingestion in patients without gastrointestinal tract obstruction. For cases with these factors, more intensive awareness by the physician should be adapted.

Inter-departmental Differences in the Eradication Therapy for Helicobacter pylori Infection: A Single Center Study / 대한소화기학회지

BACKGROUND/AIMS: Eradication rates of Helicobacter pylori (H. pylori) tend to decrease over the last few years. Apart from the antibiotic resistance and patients compliance, various factors have an influence on the efficacy of eradication therapy. We analyzed the inter-departmental differences in the eradication therapy for H. pylori infection. METHODS: Between January 2003 and June 2007, total 3,072 eradication regimens were prescribed to patients. Eradication rates according to departments - gastroenterology (GE), general internal medicine (IM) and family medicine (FM) - were analyzed retrospectively. RESULTS: The overall eradication rate of first-line triple therapy was 82.5% and second-line quadruple therapy was 71.2%. In the department of IM and FM, the eradication therapy was applied more frequently to the patients with erosion only, not ulcer. Overall eradication rates according to the departments were 87.0% in GE, 81.1% in IM and 77.2% in FM (p=0.02 GE vs. IM and p<0.01 GE vs. FM, respectively). Eradication rate in patients with peptic ulcer was also significantly higher in GE compared with IM or FM. CONCLUSIONS: In primary clinic (IM and FM), the eradication therapy was frequently applied to erosion. The eradication rates of H. pylori in GE department were significantly higher than those of IM or FM. Inter-departmental differences of the eradication rate might be caused by patients' compliance to prescribed medication.

A Case of Subcutaneous Emphysema Following Percutaneous Endoscopic Gastrostomy / 대한소화기내시경학회지

Percutaneous endoscopic gastrostomy (PEG) has widely accepted for providing safe, long-term enteral nutrition for patients with swallowing disabilities. Though safe and technically simple, this procedure is often associated with some complications, such as wound infection, bleeding, stroma leaks and tube transposition. Major complications are rare and these include aspiration pneumonia, perforations, peritonitis and necrotizing fasciitis. We report here on a patient who developed extensive subcutaneous emphysema with hemoperitoneum and peritonitis following PEG. Medical treatment without removal of the PEG led to resolution of the emphysema and the peritonitis and successful PEG feeding.

A Case of the Common Bile Duct Web Treated with a Retrievable Covered Metallic Stent / 대한소화기내시경학회지

The web of the common bile duct is an extremely rare condition and is attributed to obstructive jaundice. Most cases have been found incidentally during a surgical procedure, since no specific preoperative clinical manifestations exist. Typically, the web of the biliary tree appears as a slit- or shelf-like radiolucent narrowing on a cholangiography. We experienced a case of the web of the common bile duct with obstructive jaundice in a 62 year- old female who complained of right upper quadrant pain. The patient was diagnosed via an endoscopic retrograde cholangiopancreaticography, and treated by way of a cholecystectomy, membranectomy and T-tube insertion. Four months after the surgical procedure, the patient had a recurrence of the web-like structure in the common bile duct and was subsequently treated successfully using a retrievable covered metallic stent insertion.

Clinical Features of 141 Cases of Pyogenic Liver Abscess Over a 10-year Period and Antibiotic Sensitivity to the Causative Organisms

BACKGROUND: Pyogenic liver abscess is an acute infectious disease caused by bacteria and can become severe and potentially life-threatening, with a mortality rate of 6-18%. The purpose of this study is to provide the basic informations for the management of liver abscess and the choice of the most effective and economic antibiotics. MATERIALS AND METHODS: We investigated clinical, laboratory, radiologic findings and the results of bacteriological studies retrospectively by reviewing the medical records of 141 cases of pyogenic liver abscess patients, admitted to Catholic University St Vincent's Hospital from January 1998 to December 2007. RESULTS: Patients demographics revealed a mean age of 57.1, (age: 18 to 87), and 71 of the 141 patients were male (50.4%). Cure was achieved in 51 (98.1%) of the 52 patients who were treated with the combination of percutaneous drainage and antibiotics, and in 80 (90.0%) of 89 patients who were treated only with antibiotics. However, there were no significant differences in mortality (P=0.092) and the time to defervescence between both groups. The mean duration of percutaneous drainage was 15.8+/-9.7 days. Sixty-four of 141 patients showed positive culture results, and K. pneumoniae (70.3%) was the most common organism. Among 45 K. pneumoniae, the rates of resistance were 73.3% to ampicillin, 66.7% to piperacillin, 8.9% to cefazolin, 2.2% to cefuroxime, 0% to ceftriaxone, and 0% to ciprofloxacin. CONCLUSIONS: Combination treatment of intravenous antibiotics and percutaneous drainage was effective for the treatment of pyogenic liver abscess. Initial broad spectrum antibiotic coverage and then switch to first or second cephalosporin according to the susceptibility results, could be recommended especially in patients with monomicrobial K. pneumoniae liver abscess.

Clinical Features of 141 Cases of Pyogenic Liver Abscess Over a 10-year Period and Antibiotic Sensitivity to the Causative Organisms

BACKGROUND: Pyogenic liver abscess is an acute infectious disease caused by bacteria and can become severe and potentially life-threatening, with a mortality rate of 6-18%. The purpose of this study is to provide the basic informations for the management of liver abscess and the choice of the most effective and economic antibiotics. MATERIALS AND METHODS: We investigated clinical, laboratory, radiologic findings and the results of bacteriological studies retrospectively by reviewing the medical records of 141 cases of pyogenic liver abscess patients, admitted to Catholic University St Vincent's Hospital from January 1998 to December 2007. RESULTS: Patients demographics revealed a mean age of 57.1, (age: 18 to 87), and 71 of the 141 patients were male (50.4%). Cure was achieved in 51 (98.1%) of the 52 patients who were treated with the combination of percutaneous drainage and antibiotics, and in 80 (90.0%) of 89 patients who were treated only with antibiotics. However, there were no significant differences in mortality (P=0.092) and the time to defervescence between both groups. The mean duration of percutaneous drainage was 15.8+/-9.7 days. Sixty-four of 141 patients showed positive culture results, and K. pneumoniae (70.3%) was the most common organism. Among 45 K. pneumoniae, the rates of resistance were 73.3% to ampicillin, 66.7% to piperacillin, 8.9% to cefazolin, 2.2% to cefuroxime, 0% to ceftriaxone, and 0% to ciprofloxacin. CONCLUSIONS: Combination treatment of intravenous antibiotics and percutaneous drainage was effective for the treatment of pyogenic liver abscess. Initial broad spectrum antibiotic coverage and then switch to first or second cephalosporin according to the susceptibility results, could be recommended especially in patients with monomicrobial K. pneumoniae liver abscess.

Clinical Features and Prognostic Factors in Ischemic Colitis / 대한소화기내시경학회지

BACKGROUND/AIMS: Ischemic colitis mainly occurs in elderly patients and encompasses a wide clinical spectrum from mild, transient to severe and gangrenous forms. Since life expectancy is now increasing, more often physicians will encounter patients with this disease entity. Our aim was to review the clinical features of ischemic colitis and to analyze the effect of clinical factors on the duration of hospital stay and evaluate predictive factors of poor prognosis. METHODS: We retrospectively analyzed the medical records of 294 patients diagnosed with ischemic colitis during 10 years from March 1997 to February 2007. RESULTS: The mean hospital stay was 12.4+/-6.6 days. According to the use of multiple regression analysis, age, sex, clinical symptoms, hypertension, constipation, use of laxatives or antibiotics did not affect hospital stay. Factors that significantly increased hospital stay were diabetes mellitus (p=0.007), colonic involvement of more than three segments (p=0.009) and the presence of an ulcer on a colonoscopic finding (p=0.008). CONCLUSIONS: Diabetes mellitus, colonic involvement of more than three segments and the presence of an ulcer on a colonoscopic finding are important predictive factors of poor prognosis in patients with ischemic colitis. In cases with one of these factors, more intensive treatment options should be adapted.

A Case of Carcinosarcoma in a Patient with Corrosive Esophagitis / 대한소화기학회지

Carcinosarcoma of the esophagus is a rare malignancy accounting for approximately 1-2% of all esophageal neoplasms. It presents as a bulky intraluminal polypoid lesion mainly in the mid to lower esophagus, which harbors both carcinomatous and sarcomatous components histologically. It often presents relatively early because of its rapid intraluminal growth. We report the case of a 69-year-old man who had suffered from dysphagia for 1 month. He was previously admitted to the hospital due to corrosive esophagitis caused by ingestion of acetic acid. Endoscopy and radiological studies revealed a bulky polypoid mass with superficial ulcerations and mucosal friability, measuring 10 cm in length approximately, in the mid-esophagus. Subtotal esophagectomy with esophagogastrostomy was done. Microscopically it was composed of sarcomatous component intermingled with squamous cell carcinoma. Immunohistochemical stains reveal cytokeratin, 34betaE12, and p63 positivity in the nests of carcinoma, and desmin and vimentin positivity in the spindle cells of sarcomatous stoma.

Crohn's Disease in Association with IgA Nephropathy / 대한소화기학회지

Urological complications are not uncommon in Crohn's disease (CD). The most common manifestations are renal stones, enterovesical fistulas, and ureteral obstruction, but renal parenchymal disease has rarely been reported. IgA nephropathy, the most common form of primary glomerulonephritis, is usually isolated, but can be sometimes associated with chronic extrarenal disorders such as inflammatory bowel disease. We describe a case of 36 year-old man with CD associated with IgA nephropathy. He was diagnosed as CD 6 years ago and at that time, isolated proteinuria was observed. He presented recurrent proteinuria and elevation of creatinine level while he had been managed well with mesalamine and azathioprine. The renal biopsy was performed and IgA nephropathy (type IV) was diagnosed. Strict blood pressure control with angiotensin converting enzyme inhibitor and calcium channel blocker resulted in clinical improvement and normalization of serum creatinine level.