PTPBD for Managing Extrahepatic Bile Duct Stones in Patients with Failed or Contraindicated ERCP / 대한내과학회지

BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) occasionally fails due to surgically altered anatomy, difficult cannulation, or poor general condition. This study evaluated the safety and effectiveness of percutaneous transhepatic papillary balloon dilatation (PTPBD) for managing extrahepatic bile duct stones. METHODS: Between 2001 and 2010, 17 out of 509 patients with extrahepatic bile duct stones and acute cholangitis were enrolled retrospectively. After PTPBD of the sphincter, the stones were extracted using an occlusion balloon to push the stone over a guidewire into the duodenum. The procedure success was evaluated based on residual stones. In addition, the size and number of stones and complications were analyzed. RESULTS: Of the 17 patients, nine had a previous gastrectomy, four had poor general condition, and four had unsuccessful cannulation. The stone diameter ranged from 8 to 25 mm. Seven, five, and five patients had one, two, or three or more stones, respectively. The results were successful in 16 out of 17 patients, with no residual stones. Treatment failed in one patient, who was then treated with the rendezvous technique with endoscopy. No procedure-related major complication occurred. Three patients had mild transient elevations of the serum amylase levels. CONCLUSIONS: PTPBD was safe and effective for managing extrahepatic bile duct stones in patients with unsuccessful or contraindicated ERCP.

Rifaximin Plus Levofloxacin-Based Rescue Regimen for the Eradication of Helicobacter pylori

BACKGROUND/AIMS: This study assessed the efficacy of a rifaximin plus levofloxacin-based rescue regimen in patients that had failed both triple and quadruple standard regimens for the eradication of Helicobacter pylori. METHODS: We treated patients for H. pylori between August 2009 and April 2011. The triple regimen consisted of combined treatment with amoxicillin, clarithromycin, and pantoprazole for 1 week. For failed cases, a quadruple regimen of tetracycline, metronidazole, bismuth dicitrate, and lansoprazole for 1 week was administered. The rescue regimen for persistently refractory cases was rifaximin 200 mg t.i.d., levofloxacin 500 mg q.d., and lansoprazole 15 mg b.i.d. for 1 week. RESULTS: In total, 482 patients were enrolled in this study. The eradication rates associated with the first and second regimens were 58% and 60%, respectively. Forty-seven out of 58 patients who failed with the second-line regimen received rifaximin plus levofloxacin-based third-line therapy. The eradication rate for the third regimen was 65%. The cumulative eradication rates were 58%, 85%, and 96% for each regimen, respectively. CONCLUSIONS: A rifaximin plus levofloxacin-based regimen could be an alternative rescue therapy in patients with resistance to both triple and quadruple regimens for the eradication of H. pylori.

A Case of Massive Portal Venous Gas Caused by Fatal Intestinal Infarction

Hepatic portal venous gas (HPVG), a rare radiologic finding, is associated in some cases with severe or lethal conditions requiring urgent surgical intervention. Computed tomography has recently demonstrated a wider range of clinical conditions associated with HPVG, some of which are benign and do not necessarily require surgery. However, HPVG remains an ominous sign in cases of bowel ischemia or necrosis. We report on a case of massive HPVG caused by a fatal intestinal infarction, which showed rapid disease progression, eventually resulting in death due to septic shock. The HPVG in this case was huge and could therefore be confused with an air-biliarygram.

Renal cell carcinoma developed in a patient treated with huge simple renal cyst sclerotherapy / 대한내과학회지

Simple renal cysts are a common cystic disease of the kidneys, which is not symptomatic in most cases and is diagnosed by radiological examination. However, if the cyst is huge or symptomatic, it must be treated. Renal cyst aspiration and alcohol sclerotherapy is a safe and effective treatment for symptomatic simple renal cysts. Simple renal cysts have benign clinical features in the main and transformation of a simple renal cyst into renal cell carcinoma has rarely been reported. However, one case of renal cell carcinoma during renal cyst follow-up has been reported. We report a case of renal cell carcinoma that developed in a patient who was being treated with huge simple renal cyst sclerotherapy.

Fatal Biliary-Systemic Air Embolism during Endoscopic Retrograde Cholangiopancreatography: A Case with Multifocal Liver Abscesses and Choledochoduodenostomy

We report a rare case of a massive fatal embolism that occurred in the middle of endoscopic retrograde cholangiopancreatography (ERCP) and retrospectively examine the significant causes of the event. The patient was a 50-year old female with an uncertain history of previous abdominal surgery for multiple biliary stones 20 years prior. The patient presented with acute right upper quadrant pain. An abdominal computed tomographic (CT) scan revealed the presence of multiple stones in the common bile duct (CBD) and intra-hepatic duct (IHD) with biliary obstruction, multifocal liver abscesses, and air-biliarygram. Emergency ERCP showed a wide and straight opening of choledochoduodenostomy, which may have been created during a previous surgery, and multiple filling defects in the CBD. With the use of a forward endoscope, mud stones were extracted through the opening of the choledochoduodenostomy. Cardiac arrest suddenly developed during the procedure, and despite immediate resuscitation, the patient died due to a massive systemic air embolism. We reviewed previously reported fatal cases and accessed factors facilitating air embolisms in this case.

A Case of Clopidogrel-induced Neutropenia in Chronic Renal Failure / 대한신장학회지

Clopidogrel, a thienopyridine derivative, is an anti-platelet agent that acts as an antagonist of the platelet adenosine diphosphate receptor and considered for essential prophylaxis for intracoronary stent thrombosis in the treatment of ischemic heart disease. Clopidogrel is considered as safe as aspirin but a few cases of severe hematologic adverse reactions associated with clopidogrel had been reported such as neutropenia, aplastic anemia, thrombocytopenic purpura, and thrombocytopenia. We report a rare case of neutropenia induced by clopidogrel in chronic renal failure in a patient who underwent percutaneous coronary intervention.