Effect of Trimebutine and Rifaximin on Breath Hydrogen and Methane by Glucose Breath Test in Patients With Functional Bloating: A Randomized Double-blind Clinical Trial.

Background/Aims: Drugs that stabilize intestinal motility may improve the efficacy of nonabsorbable antibiotics, such as rifaximin, against small intestinal bacterial overgrowth (SIBO). We compared the efficacy of rifaximin alone with that of its combination with trimebutine maleate against SIBO. Methods: We performed a randomized double-blind placebo-controlled trial (https://cris.nih.go.kr, no. KCT0004836) that included patients with functional bloating, no constipation, and SIBO using the hydrogen (H2)-methane (CH4) glucose breath test (GBT). Patients were randomized into 2 groups in a 1:1 ratio, namely rifaximin (1200 mg/day) + trimebutine maleate (600 mg/day) group and rifaximin + placebo group, for 2 weeks. Patients completed a symptom questionnaire and underwent a GBT at baseline and at 1 month after treatment withdrawal. The primary outcome was SIBO eradication. The secondary outcomes included changes in the concentrations of exhaled gases, symptoms, and presence of adverse events. Results: The complete eradication rate of SIBO was 35.9% (14/39) in the rifaximin group, and 34.1% (14/41) in the combined group with no significant differences. In both groups, no significant differences were observed in GBT profiles before and after the treatment, respectively. However total breath H2 and CH4 concentration were conspicuously decreased in the combined group after treatment. The combined group exhibited substantial relief of bloating. The adverse events were similar in the 2 groups. Conclusion: While the combination therapy was not superior over rifaximin alone for SIBO eradication, it improves the symptom of bloating with numerically reducing the concentration of breath H2/CH4.

Characteristics of Early Pancreatic Cancer: Comparison between Stage 1A and Stage 1B Pancreatic Cancer in Multicenter Clinical Data Warehouse Study.

BACKGROUND: Little is known about the characteristics of early pancreatic cancer. We aimed to identify the characteristics, clues for early detection, and prognostic factors for early pancreatic cancer by analyzing a large number of patients with stage 1 pancreatic cancer. METHODS: A clinical data warehouse that includes databases of all the medical records of eight academic institutions was used to select and analyze patients with pancreatic cancer that had been diagnosed from January 2010 to May 2023. RESULTS: In total, 257 stage 1 pancreatic cancer patients were included. There were 134 men (52%), and the average age was 67.2 ± 9.9 years. Compared to patients with stage 1B pancreatic cancer (2-4 cm), patients with stage 1A pancreatic cancer (≤2 cm) had more tumors in the body and tail than in the head (p = 0.028), more new-onset diabetes and less old diabetes (p = 0.010), less jaundice (p = 0.020), more follow-up of IPMN (intraductal papillary mucinous neoplasm, p = 0.029), and more histories of acute pancreatitis (p = 0.013). The pathological findings showed that stage 1A pancreatic cancer involved more IPMNs (p < 0.001) and lower pancreatic intraepithelial neoplasia (p = 0.004). IPMN was present in all 13 pancreatic tumors that were smaller than 1 cm. In multivariate analysis, positive resection margin (odds ratio [OR] 1.536, p = 0.040), venous invasion (OR 1.710, p = 0.010), and perineural invasion (OR 1.968, p = 0.002) were found to be risk factors affecting disease-free survival, while old diabetes (odds ratio [OS] 1.981, p = 0.003) and perineural invasion (OR 2.270, p = 0.003) were found to be risk factors affecting overall survival. CONCLUSIONS: IPMN is closely associated with early pancreatic cancer and may provide an opportunity for early detection. The presence of perineural invasion was a crucial prognostic factor for both overall and disease-free survival in patients with stage 1 pancreatic cancer.

Tracking incidentally discovered pancreatic cysts smaller than 30 mm: Natural course and predictors of malignancy.

BACKGROUND AND AIMS: The aim of this study was to assess the natural course and predictors of malignancy in incidentally detected small pancreatic cysts (PCs). METHOD: We retrospectively included patients with PCs smaller than 30 mm followed up with the same cross-sectional imaging modality at least 12 months apart between January 2010 and December 2019 in three academic institutions. Cyst growth, pancreatic cancer incidence, and associated factors associated with pancreatic cancer were analyzed. RESULTS: A total of 1109 patients were followed up for a median of 34 months (range, 12‒118 months). Cyst growth and rapid cyst growth (≥ 5 mm/2 years) during follow-up were observed in 20.7% and 8.3%, respectively, both with higher rates for 15‒30 mm sized PCs. Eight patients were diagnosed with pancreatic cancer. The standardized incidence ratio for pancreatic cancer in small PCs was calculated as 5.2 [95% Confidence interval (CI): 1.3‒20.5].  The development of pancreatic cancer was associated with rapid growth [hazard ratio (HR): 8.1, 95% CI: 1.5‒43.4, p = 0.015] and newly developed worrisome features (HR: 11.7, 95% CI: 1.7‒79.6, p = 0.012) in competing risk analysis. CONCLUSIONS: One-fifth of small incidentally detected PCs increased in size. Rapid growth and newly developed worrisome features were predictors of malignancy.

Change in skeletal muscle mass is associated with hepatic steatosis in nonalcoholic fatty liver disease.

The association between nonalcoholic fatty liver disease (NAFLD) and sarcopenia is known. We aimed to determine the association between skeletal muscle mass changes and NAFLD status. This retrospective single-center study analyzed patients who underwent health screening twice between November 2009 and December 2017, with a temporal gap of 6 ± 0.5 years. The degree of sarcopenia was assessed using appendicular skeletal muscle mass (ASM) adjusted for weight and body mass index (BMI). Changes in hepatic steatosis and fibrosis status were evaluated using noninvasive serum markers. Patients with a decrease in ASM/BMI (n = 353) had increased hepatic steatosis index (HSI) and fatty liver index (FLI) scores during 6 years (p < 0.05). The baseline sarcopenia group had a greater elevation in NAFLD fibrosis score (NFS) over 6 years than those without baseline sarcopenia. ASM changes over 6 years showed a negative correlation with variations in HSI (ß = - 0.96 in ASM/Weight and -28.93 in ASM/BMI) and FLI (ß = - 5.44 in ASM/Weight and - 167.12 in ASM/BMI). Subgroup analyses showed similar results according to sex and age. Sarcopenia may worsen steatosis and vice versa. Skeletal muscle status can be used to predict the course of NAFLD and establish individualized treatment strategies.

Lactase Deficiency Diagnosed by Endoscopic Biopsy-based Method is Associated With Positivity to Glucose Breath Test.

Background/Aims: Lactase deficiency, which has many similarities with small intestinal bacterial overgrowth (SIBO), causes various gastrointestinal symptoms. We estimate the prevalence of SIBO in patients with intestinal symptoms from dairy products and investigate the association between lactase deficiency (LD) and SIBO. Methods: This prospective study included patients with functional intestinal symptoms from dairy product indigestion. A questionnaire on gastrointestinal symptoms, a hydrogen (H2)-methane glucose breath test (GBT) for SIBO, and lactose intolerance quick test (LQT) for LD using upper gastrointestinal endoscopy were performed. Results: A total of 88 patients, 29 (33.0%) with severe and 36 (40.9%) with mild LD were included. Sixteen patients (18.2%) were GBT positive. Patients with LQT negativity indicating severe LD showed a higher positivity to GBT or GBT (H2) than the historic controls (27.6% vs 6.7%, P = 0.032). There was no difference in the items on the symptom questionnaire according to the presence of LD or SIBO, except for higher symptom scores for urgency in GBT-positive patients. There were more LQT-negative patients in the GBT (H2)-positive group than in the other groups (27.6% vs 10.2%, P = 0.036). Moreover, only GBT (H2)-positivity was significantly associated with a higher risk of LQT negativity in multivariate analysis (OR, 4.19; P = 0.029). Conclusions: SIBO producing H2 is common in patients with severe LD suspected lactose intolerance. SIBO may be a new therapeutic target for managing intestinal symptoms in patients with lactose intolerance.

Efficacies of prokinetics and rifaximin on the positivity of a glucose breath test in patients with functional dyspepsia: a randomized trial.

BACKGROUND AND AIM: prokinetics could eradicate small intestinal bacterial overgrowth. This study aimed to evaluate the efficacy of mosapride, rifaximin and a combination of mosapride and rifaximin for the treatment of small intestinal bacterial overgrowth. METHODS: we randomly assigned patients with functional dyspepsia diagnosed with small intestinal bacterial overgrowth in a 1:1:1 ratio to receive mosapride, rifaximin or a combination of both for two weeks. The hydrogen-methane glucose breath test and symptom questionnaire were surveyed before and after the treatment. Primary outcome was eradication rate of small intestinal bacterial overgrowth. Secondary outcomes were changes in the gas concentration, symptoms and safety. RESULTS: the eradication rates were 17.2 % (5/29) for mosapride, 32.1 % (9/28) for rifaximin, and 34.6 % (9/26) for the combined groups, with no significant differences among the three groups. Total hydrogen concentration during the glucose breath test significantly decreased in the rifaximin group (p = 0.001). Total methane concentration significantly decreased in the rifaximin and combined groups (p = 0.005). Significant symptomatic improvements were observed in chest and abdominal discomfort with mosapride, in flatulence with rifaximin, and in chest discomfort with the combined groups. Adverse events were similar between the groups. CONCLUSIONS: rifaximin has an advantage of reducing gas, whereas mosapride can help to decrease breath hydrogen concentration. Certain intestinal symptoms improved with mosapride alone or combined with rifaximin.

Efficacies of prokinetics and rifaximin on the positivity of a glucose breath test in patients with functional dyspepsia: a randomized trial

Background and aim: prokinetics could eradicate small intestinal bacterial overgrowth. This study aimed to evaluate the efficacy of mosapride, rifaximin and a combination of mosapride and rifaximin for the treatment of small intestinal bacterial overgrowth. Methods: we randomly assigned patients with functional dyspepsia diagnosed with small intestinal bacterial overgrowth in a 1:1:1 ratio to receive mosapride, rifaximin or a combination of both for two weeks. The hydrogen-methane glucose breath test and symptom questionnaire were surveyed before and after the treatment. Primary outcome was eradication rate of small intestinal bacterial overgrowth. Secondary outcomes were changes in the gas concentration, symptoms and safety. Results: the eradication rates were 17.2 % (5/29) for mosapride, 32.1 % (9/28) for rifaximin, and 34.6 % (9/26) for the combined groups, with no significant differences among the three groups. Total hydrogen concentration during the glucose breath test significantly decreased in the rifaximin group (p = 0.001). Total methane concentration significantly decreased in the rifaximin and combined groups (p = 0.005). Significant symptomatic improvements were observed in chest and abdominal discomfort with mosapride, in flatulence with rifaximin, and in chest discomfort with the combined groups. Adverse events were similar between the groups. Conclusions: rifaximin has an advantage of reducing gas, whereas mosapride can help to decrease breath hydrogen concentration. Certain intestinal symptoms improved with mosapride alone or combined with rifaximin (AU)

Relationship between untreated obstructive sleep apnea and breath hydrogen and methane after glucose load.

Background: Patients with sleep disturbances have gastrointestinal symptoms. Breath hydrogen (H2) and methane (CH4) indicating small intestinal bacterial overgrowth (SIBO) might be related with these symptoms. The study was conducted to assess the link between breath profiles and untreated obstructive sleep apnea (OSA). Methods: : This prospective study enrolled consecutive patients with OSA using polysomnography. Heart rate variability (HRV) was used as a measurement for the balance of autonomic nervous system during polysomnography. Glucose breath test (GBT) to evaluate breath H2 and CH4 and bowel symptom questionnaire to investigate associated intestinal symptoms were performed. Results: Among 52 patients with OSA, 16 (30.8%) showed positivity to GBT. Although no significant difference was shown in GBT positivity between patients with healthy controls and patients with OSA (13.3% vs 30.8%, P = 0.109), breath H2 and CH4 levels in the OSA group were significantly higher than those in controls (P < 0.05). Flatulence was significantly common in OSA groups with GBT positivity than those without GBT positivity. Multivariate analysis demonstrated that waist-to-hip ratio (odds ratio = 12.889; 95% confidence interval (CI): 1.257-132.200; P = 0.031) and low-to-high-frequency ratio of HRV (odds ratio = 1.476; 95% CI: 1.013-2.151, P = 0.042) are independently related to GBT positivity in patients with OSA. Conclusion: : Elevated breath H2 or CH4 after glucose load might not be an uncommon finding in patients with untreated OSA. Abdominal obesity and autonomic imbalance dysfunction are significantly associated with GBT positivity in OSA patients. SIBO could be considered as target for therapeutic management in OSA patients.

Serum Pepsinogen and Gastrin Levels: Reliable Markers to Predict Small Intestinal Bacterial Overgrowth.

BACKGROUND: Serum pepsinogen, a useful indicator of gastric acidity, could reflect small intestinal bacterial overgrowth. The aim of this study is to evaluate the relationship between small intestinal bacterial overgrowth and profiles including pepsinogen or gastrin. METHODS: We conducted a prospective study with 62 patients with a functional gastrointestinal disorder. All patients underwent glucose breath test for small intestinal bacterial overgrowth, immediately followed by upper endoscopy to survey gastric injury and Campylobacter-like organism test for Helicobacter pylori and serum laboratory tests including gastrin, pepsinogen I and II. RESULTS: The positivity to small intestinal bacterial overgrowth was 17.7%. Significantly, low total hydrogen concentration during a glucose breath test, low prevalence for gastric injury, and high H. pylori positivity rate were shown in groups with pepsinogen I/II ratio ≤ 3.5 compared to those with pepsinogen I/II ratio > 3.5 or in groups with serum gastrin > 35.4 pg/mL comparing to those with serum ≤ 35.4 pg/mL, respectively. A high gastrin level was independently associated with H. pylori infection. A proportionally correlated tendency between pepsinogen I/II ratio and total hydrogen concentration was shown, whereas that of inverse proportion between H2 and gastrin was observed. Old age was solely independent predicting factor for small intestinal bacterial overgrowth (P = .03) in the multivariate analysis. CONCLUSION: Old age was significantly related to the presence of small intestinal bacterial overgrowth in functional gastrointestinal disorder patients. Although pepsinogen and small intestinal bacterial overgrowth seem irrelevant, elevated gastrin level may cautiously indicate a decreased breath hydrogen concentration. Further studies should consider the function of intestinal motility and gastric acidity in patients with hydrogen-producing small intestinal bacterial overgrowth.

Quality of Life in Newly Diagnosed Moderate-to-Severe Ulcerative Colitis: Changes in the MOSAIK Cohort Over 1 Year.

Background/Aims: Improving quality of life has been gaining importance in ulcerative colitis (UC) management. The aim of this study was to investigate changes in health-related quality of life (HRQL) and related factors in patients with moderate-to-severe UC. Methods: A multicenter, hospital-based, prospective study was performed using a Moderate-to-Severe Ulcerative Colitis Cohort in Korea (the MOSAIK). Changes in HRQL, evaluated using the 12-Item Short Form Health Survey (SF-12) and Inflammatory Bowel Disease Questionnaire (IBDQ), were analyzed at the time of diagnosis and 1 year later. Results: In a sample of 276 patients, the mean age was 38.4 years, and the majority of patients were male (59.8%). HRQL tended to increase in both the IBDQ and SF-12 1 year after diagnosis. A higher partial Mayo score was significantly related to poorer HRQL on the IBDQ and SF-12 in a linear mixed model (p<0.01). Inflammatory markers such as C-reactive protein (CRP) or erythrocyte sedimentation rate also showed a negative correlation on HRQL (p<0.05). Patients whose IBDQ score improved by 16 or more (71.2%) in 1 year were younger, tended to be nonsmokers, and had a lower partial Mayo score and CRP than those whose IBDQ score did not. There was no significant association between HRQL and disease extent, treatments at diagnosis, or the highest treatment step during the 1-year period. Conclusions: Optimally controlled disease status improves HRQL in patients with moderate-to-severe UC. The partial Mayo score and inflammatory markers may be potential indicators reflecting the influence of UC on patient`s daily lives.

Unilateral versus bilateral Y-type stent-in-stent metal stent insertions in inoperable malignant hilar biliary strictures: A multicenter retrospective study.

BACKGROUND: To date, there is controversy regarding unilateral versus bilateral stent placement in patients with malignant hilar biliary strictures (MHBSs). The aim of this study was to compare the clinical outcomes and complications of unilateral and bilateral (stent-in-stent method) stent placements for these patients. METHODS: We conducted a multicenter retrospective analysis of patients with inoperable MHBS who underwent endoscopic self-expandable metal stent (SEMS) placement from January 2009 to December 2019. Two groups classified according to the stent procedure method were compared for demographic, procedural, and postprocedure factors. Survival analysis for patency loss and overall survival was also conducted. RESULTS: A total of 236 subjects were included. A superior technical success rate was found in the unilateral stent group (98.8% vs. 82.5%, P < 0.001), whereas the clinical success rate was higher in the bilateral group (85.7% vs. 70.5%, P = 0.028). There was no significant difference with respect to complications or patency loss, and the bilateral group had better overall survival (P < 0.01). In the Cox proportional hazard model, MHBSs from lymph node compression were associated with a higher risk of death (HR = 9.803, P = 0.003). In contrast, bilateral SEMS insertion showed reduced postprocedural mortality (HR = 0.316, P = 0.001). CONCLUSIONS: Y-type stent-in-stent bilateral SEMSs are technically difficult but demonstrated more favorable overall survival for palliative bile drainage of inoperable MHBS patients compared to unilateral insertions.

Serum Gastrin Predicts Hydrogen-Producing Small Intestinal Bacterial Overgrowth in Patients With Abdominal Surgery: A Prospective Study.

OBJECTIVES: Small intestinal bacterial overgrowth (SIBO) might be associated with a history of abdominal surgery. We aimed to evaluate the prevalence of SIBO and to investigate serum gastrin and pepsinogen as predictors of SIBO in patients with a history of hysterectomy, gastrectomy, or cholecystectomy. METHODS: This prospective study surveyed 146 patients with a history of hysterectomy, gastrectomy, or cholecystectomy, and 30 healthy controls, who underwent a hydrogen (H2)-methane (CH4) glucose breath test (GBT) for SIBO. Serum pepsinogen I and II and gastrin levels were reviewed. RESULTS: GBT positivity (+) was significantly higher in patients with histories of abdominal surgery than that in in controls (37.6% vs 13.3%, P < 0.01). Among GBT+ patients, 36.0% (18/50), 96.2% (25/26), and 17.1% (12/70) were in the hysterectomy, gastrectomy, and cholecystectomy groups, respectively. Among the GBT subtypes, 43.6% (24/55), 10.9% (6/55), and 45.5% (25/55) of patients were in the GBT(H2)+, GBT(CH4)+, and GBT(mixed)+ groups, respectively. The gastrectomy group had significantly more GBT+ or GBT(H2)+ patients than the other surgical groups. Gastrin levels were higher in GBT(H2)+ patients and lower in GBT(CH4)+ patients than those in GBT- patients. Previous gastrectomy and elevated gastrin levels were independent predictive factors of GBT(H2)+. DISCUSSION: SIBO is not uncommon in patients with histories of abdominal surgeries, but it is more common in patients who have undergone gastrectomy. Serum gastrin level could be a serologic predictor of H2-producing SIBO. The relationship between serum gastrin and SIBO requires further research.

Low-grade Rectal Neuroendocrine Tumor Recurring as Multiple Hepatic Metastasis after Complete Endoscopic Removal: A Case Report.

The World Health Organization classified rectal neuroendocrine tumors (NETs) as malignant in 2010 owing to their distant metastasis potential. On the other hand, in cases of small rectal NETs (<10 mm), which have a low risk of metastasis, endoscopic removal is the first-line therapeutic option, and regular surveillance is not recommended. The authors report a case of a small, well-differentiated rectal NET, which recurred as multiple hepatic metastases 5 years after apparent complete removal using endoscopic methods.

Clinical Impact of Common Bile Duct Angulation on the Recurrence of Common Bile Duct Stone: A Meta-analysis and Review.

Background/Aims: Local and systemic factors, such as diabetes, obesity, and hyperlipidemia, are considered risk factors for the recurrence of choledocholithiasis after successful endoscopic clearance. Local factors include the presence of bile sludge, common bile duct (CBD) diameter, and CBD angulation. Among them, it is unclear if acute CBD angulation is preferable to the recurrence of a CBD stone. Methods: PubMed, EMBASE, CINAHL, the Cochrane Library databases, and google website were searched for randomized controlled trials reported in English and undertaken until August 2019. Meta-analysis was performed on all randomized controlled trials for the recurrence of CBD stones between the patients with acute CBD angulation. Results: Eight randomized trials (1,776 patients) were identified, and the total recurrent rate of CBD stones was 18.8% (334/1,776). A CBD angle ≤145° was significantly associated with an increased risk of recurrent CBD stone (OR=2.65, p<0.01). In two prospective studies, acute CBD angulation was not proven to be associated with a recurrence (p=0.39). Conclusions: Approximately 20% of patients with a CBD stone showed recurrence after the complete clearance of the CBD stone, and a CBD angle ≤145° could increase the risk of recurrence. Overall, a large-scale prospective study should be necessary.

Acute Pancreatitis associated with Acute Hepatitis A in an Old Aged Patient.

Acute pancreatitis caused by acute hepatitis A is extremely rare, with only a small number of cases in young adults having been reported. This paper presents a 74-year-old female patient with an acute abdomen, which proved to be acute pancreatitis with acute hepatitis A. A survey of acute viral hepatitis A as a root cause of pancreatitis should be considered when clinicians encounter patients with acute pancreatitis without any known etiology of pancreatitis.

Microbiology and risk factors for gram-positive Cocci bacteremia in biliary infections.

BACKGROUND: The rapid antibiotics treatment targeted to a specific pathogen can improve clinical outcomes of septicemia. We aimed to evaluate the clinical characteristics and outcomes of biliary septicemia caused by cholangitis or cholecystitis according to causative organisms. METHODS: We performed a retrospective cohort study in 151 patients diagnosed with cholangitis or cholecystitis with bacterial septicemia from January 2013 to December 2015. All patients showed clinical evidence of biliary tract infection and had blood isolates that demonstrated septicemia. RESULTS: Gram-negative, gram-positive, and both types of bacteria caused 84.1% (127/151), 13.2% (20/151), and 2.6% (4/151) episodes of septicemia, respectively. The most common infecting organisms were Escherichia coli among gram-negative bacteria and Enterococcus species (Enterococcus casseliflavus and Enterococcus faecalis) among gram-positive bacteria. There were no differences in mortality, re-admission rate, and need for emergency decompression procedures between the gram-positive and gram-negative septicemia groups. In univariate analysis, previous gastrectomy history was associated with gram-positive bacteremia. Multivariate analysis also showed that previous gastrectomy history was strongly associated with gram-positive septicemia (Odds ratio = 5.47, 95% CI: 1.19-25.23; P = 0.029). CONCLUSIONS: Previous gastrectomy history was related to biliary septicemia induced by gram-positive organisms. This information would aid the choice of empirical antibiotics.

Acute Pancreatitis with Hypercalcemia as Initial Manifestation of Multiple Myeloma.

A case of acute pancreatitis associated with hypercalcemia resulting from a newly diagnosed multiple myeloma is reported. There have been several prior reports of hypercalcemia-induced pancreatitis in patients with multiple myeloma, but very few showed the following two aspects: pancreatitis as the first manifestation of hematologic malignancy and recovery after serum calcium levels fell into normal range. When clinicians encounter a patient with hypercalcemic status and acute pancreatitis without any known etiology of pancreatitis, multiple myeloma as a root cause of pancreatitis should be considered.

Efficacy of endoscopic ultrasound after removal of common bile duct stone.

Objective: Endoscopic retrograde cholangiopancreatography (ERCP) is a standard procedure for choledocholithiasis. Nonetheless, the recurrence rate remains quite high. This study aimed to investigate the prevalence and related factors of remnant biliary stone or sludge using endoscopic ultrasound (EUS) after the removal of common bile duct (CBD) stone and to evaluate the long-term clinical outcomes. Methods: A prospective study enrolling a consecutive series of patients who underwent ERCP for CBD stone removal was performed between June 2014 and November 2015. Following confirmation of complete CBD stone removal by the operator, EUS was performed to determine whether biliary stone or sludge remained. Patients underwent cholecystectomy if a gallstone was identified and were subsequently followed up at a regular interval of 3-6 months. We investigated whether symptomatic recurrence would occur. Results: A total of 130 patients were enrolled. The presence of remnant biliary stone or sludge after ERCP was confirmed in 36.9% (48/130) of patients. Acute angulation of the distal CBD was the sole factor associated with remnant biliary stone or sludge (p < .01). During the follow-up period, the overall recurrence rate was 17.7% (23/130). Recurrent symptomatic choledocholithiasis was predicted by remnant biliary sludge and large CBD diameter in multivariate analysis. Conclusions: Acute angulation of the distal CBD was associated with remnant biliary stone or sludge after ERCP. Remnant biliary sludge on EUS and large CBD diameter were strong predictors of symptomatic recurrence. EUS evaluation following CBD stone removal could be an effective strategy in the treatment of choledocholithiasis.

Dermatophyte abscesses caused by Trichophyton rubrum in a patient without pre-existing superficial dermatophytosis: a case report.

BACKGROUND: Trichophyton usually causes a superficial skin infection, affecting the outermost layer of the epidermis, the stratum corneum. In immunocompromised patients, deeper invasion into the dermis and even severe systemic infection with distant organ involvement can occur. Most cases of deeper dermal dermatophytosis described in the literature so far involved pre-existing superficial dermatophytosis. CASE PRESENTATION: We report a 68-year-old woman presented to our clinic with a 3-month history of palpable nodules on the right ankle without pre-existing superficial dermatophytosis. Magnetic resonance imaging showed multiple, well-demarcated, cystic lesions around the lateral malleolus, located in the subcutaneous or dermal layers. The sizes varied from 0.5 cm to 4 cm in diameter. The patient underwent complete excision of the lesions. Fungal culture yielded Trichophyton rubrum on Sabouraud dextrose agar. Histopathology showed organizing abscesses with degenerated fungal hyphae. After the 12-week oral itraconazole therapy, the lesions were completely resolved. CONCLUSION: Dermatophytes should be considered as a possible cause of deep soft tissue abscesses in immunocompromised patients, even though there is no superficial dermatophytosis lesion.

[Emphysematous gastritis with concomitant portal venous air].

Emphysematous gastritis is a rare form of gastritis caused by infection of the stomach wall by gas forming bacteria. It is a very rare condition that carries a high mortality rate. Portal venous gas shadow represents elevation of intestinal luminal pressure which manifests as emphysematous gastritis or gastric emphysema. Literature reviews show that the mortality rate is especially high when portal venous gas shadow is present on CT scan. Until recently, the treatment of emphysematous gastritis has been immediate surgical intervention. However, there is a recent trend of avoiding surgery because of the frequent occurrence of post-operative complications such as anastomosis leakage. In addition, aggressive surgical treatment has failed to show significant improvement in prognosis. Recently, the authors experienced a case of emphysematous gastritis accompanied by portal venous gas which was treated successfully by conservative treatment without immediate surgical intervention. Herein, we present a case of emphysematous gastritis with concomitant portal venous air along with literature review.