Chronic Hemorrhage from a Fistula between a Gastroduodenal Artery Aneurysm and the Duodenum / 대한내과학회지

Gastroduodenal artery (GDA) aneurysm is a very rare event, but it induces life-threatening clinical manifestations upon rupture or bleeding. The causes of GDA aneurysm are atherosclerosis, infection, trauma, surgery, iatrogenic lesions, mycotic or tuberculous disease, and autoimmune disease. We report the case of a 77-year-old female who presented with melena and vomiting. Upper gastrointestinal endoscopy revealed a 4 cm pulsatile extrinsic mass with a duodenal fistula at the duodenal bulb. Abdominal computed tomography showed a large aneurysm of the GDA. We successfully conducted transcatheter embolization of the aneurysm. After the procedure, the patient did not present with melena, and her hemoglobin level was stable. Follow-up endoscopy showed that the GDA aneurysm-duodenal fistula had decreased in size and was leaking a small amount of blood. An arteriography was performed and showed no evidence of contrast filling in the aneurysmal sac.

A Case of Primary Jejunal Adenocarcinoma Diagnosed by Enteroscopy using Pediatric Colonoscope / 대한소화기학회지

A 39-year-old man presented with dizziness and melena for 2 months. Abdominal CT scan showed constrictive wall thickening with enhancement and proximal loop dilatation of the jejunum. On endoscopic examination, there was large amount of bile stained fluid in duodenum. Enteroscopy using pediatric colonoscope demonstrated an encircling mass with obstruction approximately 20 cm distal to the ligament of Treitz. Endoscopic jejunal biopsy showed moderately differentiated adenocarcinoma. Small intestinal adenocarcinoma is uncommonly encountered in clinical practice. Because small intestine is relatively inaccessible via routine endoscopy, diagnosis of small intestinal neoplasm is often delayed for several months after the onset of symptoms. Most of the patients are diagnosed in advanced stage. Therefore, when a small bowel neoplasm is suspected, enteroscopy is the most useful study. If enteroscope is not available, enteroscopy using pediatric colonoscope may permit earlier preoperative diagnosis. We report a case of primary jejunal adenocarcinoma diagnosed by endoscopic biopsy using pediatric colonoscope.

The Prevalence of Antimicrobial Resistance in Helicobacter pylori Isolated in Daejeon / 대한임상미생물학회지

BACKGROUND: The most commonly used regimen for the eradication of Helicobacter pylori is combination of a proton pump inhibitor, clarithromycin, and two other antibiotics, metronidazole and amoxicillin. The increase in resistance to antibiotics seems to result in a decrease in eradication efficacy for H.pylori. We investigated the prevalence of antibiotic resistance in H.pylori isolated in Daejeon area. METHODS: A total of 31 clinical isolates of H.pylori were collected from the patients who underwent upper gastrointestinal endoscopy in Keonyang University Hospital during the period from March to July 2004. Antibiotic susceptibility tests for metronidazole, amoxicillin, and clarithromycin were performed by the E test (AB Biodisk, Sweden) on an egg yolk medium containing triphenyltetrazolium. The resistance break points for amoxicillin, metronidazole, and clarithromycin were defined as 0.5 microgram/mL, 8 microgram/mL, 1 microgram/mL, respectively. RESULTS: Resistance to amoxicillin, metronidazole, and clarithromycin was detected in 7.4% (2/27), 25.8% (8/31), 3.6% (1/28), respectively. CONCLUSION: The resistance to amoxicillin and clarithromycin was uncommon in Daejeon area.

Serial Endoscopic Observation in a Case of Spontaneous Submucosal Dissection of the Esophagus / 대한소화기내시경학회지

Spontaneous submucosal esophageal dissection is a rare disorder, characterized by a longitudinal dissection along the axis of the esophagus between submucosa and muscle layer without an obvious cause. The diagnosis is made by typical esophagographic or endoscopic findings which are double-barreled esophagus in esophagography or mucosal defect in upper esophagus and false lumen running along the distal side of the esophagus on esophagoscopy. The condition usually follows a benign course with good prognosis requiring a supportive treatment, but rarely treated by endoscopy or surgery. A 74-year-old man was admitted to our hospital complaining of chest pain and odynophagia after upper respiratory infection. We diagnosed a case of spontaneous submucosal dissection of the esophagus and observed its healing process by series of endoscopy with a conservative treatment.

A Case of Acute Acalculous Cholecystitis Complicating Endoscopic Retrograde Cholangiopancreatography / 대한소화기내시경학회지

Endoscopic retrograde cholangiopancreatography (ERCP) has gained wide acceptance as a valuable tool for the diagnosis and management of disease of the pancreas and biliary tract. Complications associated with ERCP include bleeding, perforation, pancreatitis, and cholangitis, and the incidence is about 5~10%. Acute acalculous cholecystitis can be developed rarely after ERCP. It tends to have more complicated course, resulting in higher morbidity and mortality. We report a case of acute acalculous cholecystitis complicating therapeutic ERCP in a 52-year-old man with primary common bile duct stone. He underwent open cholecystectomy because of uncontrolled infection and rapid progression to septic shock. Although acute acalculous cholecystitis is one of rare complications developed after ERCP, it should be considered as one of the differential diagnosis in patients who complain of abdominal pain after ERCP because of high mortality rate and the need for prompt surgical management.

Littoral Cell Angioma (LCA) Associated with Liver Cirrhosis

A littoral cell angioma (LCA) is a rare benign vascular tumor of the spleen. A 60-year-old man, with multiple nodules in imaging study and liver cirrhosis graded as Child-Pugh classification class A, was transferred for splenomegaly. A thrombocytopenia was found on hematological evaluation. Because there was no evidence of hematological and visceral malignancy, a splenectomy was performed for a definitive diagnosis. The histological and immunohistochemical features of the splenic specimens were consistent with a LCA. After the splenectomy, the thrombocytopenia recovered to the normal platelet count. There has been no previous report of a LCA combined with liver cirrhosis. Herein, the first case of a LCA in Korea, diagnosed and treated by a splenectomy, is reported.

Solitary Peutz-Jeghers Polyp of the Colon / 대한소화기내시경학회지

Peutz-Jeghers syndrome is an autosomal-dominant inherited disorder characterized by polyposis of the alimentary tract, the abnormal mucocutaneous pigmentation, and family history of Peutz-Jeghers syndrome. A single Peutz-Jeghers polyp arising in a patient without pigmentation and family history of Peutz-Jeghers syndrome is termed a solitary or isolated hamartomatous polyp of Peutz-Jeghers type. These solitary polyps are found most frequently in the small intestine but also occur in the large bowel and stomach as well. In a healthy 48-year-old man, a single large polyp was found incidentally in the ascending colon during colonoscopy and treated by snare polypectomy. Microscopic exam of the resected specimen revealed the features of hamartomatous polyp of Peutz-Jeghers type. There was no evidence of other polyps on esophagogastroduodenoscopy and small bowel series. We report a patient with solitary Peutz-Jeghers polyp of the colon, who had no stigmata associated with Peutz-Jeghers syndrome.

Usefulness of Colonic Biopsy and Intraluminal Fluid Culture in Acute Diarrhea / 대한내과학회지

No abstract available.

Evaluation of Asan Helicobacter Test for Diagnosis of Helicobacter pylori Infection / 대한임상미생물학회지

BACKGROUND: Helicobacter pylori is the single most common pathogen that causes chronic bacterial infection in human. The authors designed a new type of urease detection method (Asan Helicobacter test) that can be used for rapid early detection of H. pylori as well as a transport medium. This medium has a strong acidity with a minimal concentration of urea for the purpose of the detection of H. pylori. The current study was to evaluate the bacteriological and clinical usefulness of this medium. METHOD: 252 antral biopsies from patients underwent upper gastrointestinal endoscopies in Inha University Hospital were inserted Asan Helicobacter Test and CLO test. 37 antral biopsies from patients underwent upper gastrointestinal endoscopies in Konyang University Hospital were inserted Asan Helicobacter Test. Biopsies were cultured on nonselective media only. RESULT: The sensitivity and specificity of the Asan Helicobacter test were comparable with the CLO test (88.0% and 94.0%, respectively), and the results agreed in 99.2% of 252 cases with the CLO test. With this transport medium, all 23 specimens that showed positive reaction among 37 patients yielded satisfactory isolation of H. pylori. CONCLUSION: These findings suggest that the reagent in the kit inhibit the growth of microbial contaminant due to low pH and do not suppresses growth of H. pylori due to low concentration of urea. This kit may be used as a transport medium as well as a rapid urease test for H. pylori.

Effect on culture of Helicobacter pylori by the use of HCl-KCl buffer / 대한임상병리학회지

BACKGROUND: The selective media for culture of Helicobacter pylori(H. pylori) are Egg yolk emulsion medium, modified Thayer-Martin medium and Skirrow's medium. The non-selective media for culture of H. pylori are brucella agar, trypticase soy agar, and brain heart infusion agar. The selective media are more expensive and difficult to prepare than non-selective media, whereas non-selective media are difficult to isolate H. pylori due to contamination of upper respiratory tract bacteria. The objects of this study are to reduce upper respiratory contaminants by use of HCl-KCl buffer (H-K buffer) for primary isolation, and to compare with culture, CLO test, histologic examination and H. pylori IgG antibodies. METHODS: Seventy one patients underwent upper gastrointestinal endoscopy with biopsy. For 32 patients, two biopsies were taken from antrum: One for direct inoculation into blood agar plate, the other for pretreatment of H-K buffer. For fifty six patients, we performed culture, CLO test, histology, and H. pylori IgG. RESULTS: 1) Among the 32 patients, H. pylori were isolated in 25 patients (23 patients for direct inoculation and 25 patients for H-K pretreatment). Twelve cases among H-K buffer treatment group did not show contamination, whereas only two among direct inoculation group showed no contamination. The average number of contaminating colony forming unit (CFU) of direct inoculation and H-K buffer treatment were 77 and 9, respectively. 2) The positive rates of culture and CLO test, histology, and H. pylori IgG for H. pylori infection were 71.4%, 67.9%, 75.0%, and 57.1%, respective

Lower Esophageal Sphincter Pressure(LESP) and 24-hour(h) Esophageal pH Monitoring in Continuous Ambulatory Peritoneal Dialysis(CAPD) Patients / 대한신장학회잡지

Upper gastrointestinal symptoms such as epigastric fullness, nausea, and vomiting are often observed in CAPD patients. Intraabdominal pressure depends on the amount of dialysate and the body positions. It is not clear whether upper gastrointestinal symptoms are manifestations of raised intraperitoneal pressure produced by dialysate. To investigate the changes of LESP according to the amount of dialysate and the body position and the relationship between LESP and parameters of 24-h esophageal pH monitoring, esophageal manometry and 24-h esophageal pH monitoring were performed in 12 CAPD patients. The sex ratio was 1:2. The duration of CAPD of patients except one was less than 1 month. The mean age was 47.5 15.5(SD) years old. There were no changes in supine LESPs according to the infused volume of dialysate. Sitting LESPs at 500, 1500, and 2000ml were elevated significantly compared to basal sitting LESP(27.1 5.5, 27.0 6.0, and 28.5 7.0 vs. 23.9 5.7mmHg, p<0.05). Supine LESPs at basal and 500ml of dialysate significantly higher than sitting LESPs(30.2 9.1 and 31.2 8.5 vs. 23. 9 5.7 and 27.1 5.5mmHg, p<0.05). There were no differences in LESP by age, sex, and diabetic status. Supine LESP at 2000ml strongly correlated with total reflux episodes(r=-0.92, p<0.01), fraction time of pH<4.0(r=-0.85, p<0.01), and total reflux score(DeMeester)(r=-0.88, p<0.01), but other LESPs did not. When the patients were divided into group I(<30mmHg) and group II(330mmHg) by supine LESP at 2000ml, group I had more total reflux episodes(73.7 27.0 vs. 14.0 10.3, p<0.05), fraction time of pH<4.0(4.0 3.7 vs. 0.5 0.4%, p<0.05), and total reflux score(15.2 10.5 vs. 2.8 1.5, p<0.05). In conclusion, CAPD patients seem to have a risk of gastroesophageal reflux due to elevated intraperitoneal pressure by dialysate, especially if supine LESP at 2000ml was lower than 30mmHg.

A Case of Gastroduodenal Intussusception caused by Gastric Leiomyoma / 대한소화기내시경학회지

Gastroduodenal intussusception is an rare condition usually caused by prolapse of a gastric tumor with subsequent invagination of a portion of the stomach wall into the duodenum. Symptoms are protean, but classically patients have presented with episodic epigastric abdominal distress, a history of intermittent vomiting and gastroduodenal bleeding, either as melena, hematochezia, or stools positive for occult blood. Examination generally discloses a fullness or mass in the epigastrium. Its typical radiologic presentation includes luminal narrowing, distally converging gastric folds, infolding and outpouching of the gastric wall, a filling defect, and a coil-spring pattern. A 71-year-old man was admitted for epigastric pain and melena which required blood transfusions. Endoscopy showed an unexplained pulling-down of part of the gastric body and the pylorus couldn't be identified. An upper GI barium examination demonstrated a huge lobulated mass from the distal antrum of stomach to the duodenal cap. On abdominal sonography, double contour of stomach wall was seen at the proximal portion of narrowing stomach. At surgery, a large, intraluminally exophyting gastric mass prolapsed into duodenum was excised and diagnosed as leiomyoma of stomach.

Evaluation of Urea Breath Test for the Detection of Helicobacter pylori Infection / 대한임상미생물학회지

BACKGROUND: Helicobacter pylori (H. pylori) is closely associated with gastritis, peptic ulcer and gastric carcinoma. We evaluated the reliability and usefulness of 73C-urea breath test (13C-UBT) for the detection of H. pylori infection and searched for the cut-off value of the test. METHOD : We investigated 45 patients, who underwent esophagoduodenoscopy with multiple biopsy specimens taken for culture, histology and rapid urease test, and 13C-UBT. Sensitivity and specificity of UBT were calculated against the combined biopsy-based test results. RESULT: Of 45 patients, 26 were found to be H. pylori-positive according to combined biopsy-based test-results. Sensitivity and specificity of the 13C-UBT were 100.0% and 89.5 %, respectively. CONCLUSION: The urea breath test provides a simple and reliable and noninvasive method of assessing HL pylori infection status.

Evaluation of Urea Breath Test for the Detection of Helicobacter pylori Infection / 대한임상미생물학회지

BACKGROUND: Helicobacter pylori (H. pylori) is closely associated with gastritis, peptic ulcer and gastric carcinoma. We evaluated the reliability and usefulness of 73C-urea breath test (13C-UBT) for the detection of H. pylori infection and searched for the cut-off value of the test. METHOD : We investigated 45 patients, who underwent esophagoduodenoscopy with multiple biopsy specimens taken for culture, histology and rapid urease test, and 13C-UBT. Sensitivity and specificity of UBT were calculated against the combined biopsy-based test results. RESULT: Of 45 patients, 26 were found to be H. pylori-positive according to combined biopsy-based test-results. Sensitivity and specificity of the 13C-UBT were 100.0% and 89.5 %, respectively. CONCLUSION: The urea breath test provides a simple and reliable and noninvasive method of assessing HL pylori infection status.

Clinical Observation on Acute Myocardial Infarction in Korean Adults

BACKGROUND: Recently, the incidence of acute myocardial infarction increased with prolongation of life spans, improvements in food and life styles in Korea, But only few studies were reported after the newly developed diagnostic methods and treatment modalities were introduced. So, the study on left ventricular ejection fraction, findings in coronary angiography, uses of thrombolytic agents was needed. METHOD: A retrospective clinical study was done on 654 patients with acute myocardial infarction who had been admitted to Severance hospital from January 1985 to December 1991 within 30 days after the onset of symptoms. Coronary angiogram and radionuclide ventriculography was done as usual methods. RESULT: The mean age was 58.5 years, and the ratio of males to females was 3.3:1, The major risk factors were smoking, hypertension and diabetes mellitus in males. and hypertension, diabetes mellitus and obesity in females. Arrhythmias were found in 360 patients(56.4%). The most frequent arrhythmia was premature ventricular contraction. Sinus bradycardia and atrioventricular were more frequent in inferior infarction but sinus tachycardia, ventricular tachycardia were more frequent in anterior infarction. The peak serum CK and CK-MB levels were higher in patients of anterior infarction than in those of inferior and non-Q wave infarction. The left ventricalar ejection fractions were higher in the patients with non-Q wave infarction, inferior infarction than in the patients with anterior infarction. There was no difference in left ventricular ejection fraction between patients who received thrombolytic therapy and not treated patients. Coronary angiograms were performed in 362 patients and 184 patients (50.8%) had one-vessel disease. The short-term mortality rate was 15.1%. The most common cause of death was cardiogenic shock(60.6%). Poor prognosis was found in patients with a history of previous myocardial infarction, those over 60 years old, those with a complete heart block and those of the female sex. The short-term mortality was higher in anterior infarction than inferior infarction and short-term mortality was higher in Q wave infarction than non-Q wave infarction. CONCLUSION: This study suggests that smoking was the most common risk factor but hypercholesterolemia and obesity were less significant. According to coronary angiogram, one-vessel disease was the most common, and the rate of insignificant reduction in luminal diameter was higher than western countries. The short-term mortality rate of acute myocardial infarction was higher than those of western countries. The cause of high mortality rate was considered due to delay in transportation of patients to hospital. The education about acute myocardial infarction should be done to public and transportation system must be improved.

Two Cases of Henoch-Sch nlein Purpura Complicated by Gastrointestinal Bleeding / 대한소화기내시경학회지

In the course of Henoch-Sch nlein purpura, diverse gastrointestinal manifestations are common. Two cases of Henoch-Sch nlein purpura complicated by upper and lower gastrointestinal bleeding is herein reported. For both patients, peculiar endoscopic pictures revealed, severe ulcerations and frank bleeding. A biopsy showed typical leukocytoclastic vasculitis which were the same as with the skin biopsy. The endoscopic finding was determined not to be pathognomonic, but instead characteristic of Henoch-Sch nlein purpura. Therefore, an endoscopy can be useful in the diagnosis of Henoch-Sch nlein purpura, especially for those patients without a typical skin rash.

A case of idiopathic hypereosinophilic syndrome with segmental pulmonary involvement / 천식및알레르기

Eosinophilia accompanied by eosinophilic invasion and organ dysfunction may develope idiopathic hypereosinophilic syndrome. Any organ can be involved including bone marrow, lung, skin, heart, gastrointestinal tract and nervous system. Cough, dyspnea, pleural effusion or chest pain are common pulmonary manifestation, and they may be attributed to parenchymal infiltration, pulmonary embolism or heart failure. We report a 43-year-old woman with idiopathic hypereosinophilic syndrome involving bone marrow, skin, and lung. The patient developed acute dyspnea and chest pain. High resolution CT demonstrated multiple wedge-shaped segmental involvement with pleural effusion thought to be a pulmonary infarction or heart failure. Echocardiography could not find any abnormality. Lung biopsy showed interstitial eosinophilic infiltration with increased eosinophils in BAL fluid. She was treated with high dose corticosteroid and hydroxyurea. Within few days, most of her symptoms disappeared and chest radiography nearly cleared up.

Biliary Ascariasis with Choledocholithiasis and Biliary Pancreatitis: Endoscopically Treated / 대한소화기내시경학회지

A 60-year-old man with biliary ascariasis accompanied by choledocholithiasis and biliary pancreatitis, is herein reported. His chief complaints were epigastric pain, nausea, and vomiting. He had a past history of eating raw fish and vegetables. An endoscopic retrograde cholangiopancreatography (ERCP) revealed multiple CBD stones and a live ascaris adult worm in the common bile duct which was not detected by an abdominal CT. The management of biliary obstruction caused by Ascaris lumbricoides has usually been surgical, but this report describes the endoscopic removal of the ascaris located in the common bile duct.

Gastric malignant stromal tumor with long stalk impacted into duodenum

Most GIST have traditionally been classified as submucosal origin by upper gastrointestinal series (UGIS) or endoscopy. However, we experienced a gastrointestinal mesenchymal origin tumor expressed by polypoid mass with a long stalk. The gastric outlet was obstructed by the polypoid mass on the duodenum. The microscopic findings of the resected mass showed a stromal cell component by immunohistochemical stain. We experienced gastric stromal tumor found as a polypoid mass with long stalk which was easily detected by endoscopy. It would not have been suspected as a stromal tumor as a result of endoscopic findings only.

A case of adrenal lymphangioma misdiagnosed as biliary cystadenoma / 대한내과학회지

Lymphangioma is resulted from faulty development or ectasia of lymphatic vessels. Adrenal lymphangioma was reported first in 1965 and very rare with approximately 20 cases having been reported so far in worldwide. Adrenal lymphangioma is usually asymptomatic and most often identified incidentally at imaging study or autopsy. If symptoms do occur, they are related to size and position of the lesion and contain fever, abdominal pain, or palpable mass. Laboratory findings are nonspecific and usually not helpful as a diagnostic tool. Although ultrasonography and computerized tomography play a major role in the exploration of adrenal cysts, the nature of unexpected adrenal cysts is confirmed by histology. Recently, we experienced a case of 50-year-old female patient, who complained right upper abdominal pain and suspected with biliary cystadenoma in radiologic studies. The surgical enucleation was performed and final diagnosis was adrenal lymphangioma. Considering of rare incidence, we report a case of lymphangioma arising from right adrenal gland with a review of the relevant literature.