Search

Intramural esophageal dissection (IED) is a rare form of esophageal injury. We report a rare case of spontaneous IED complicated with pneumomediastinum and successfully improved by conservative management. A 46-year-old man presented to the emergency department with chest pain and hematemesis. The endoscopic diagnosis was suspicious of IED. Chest CT scan performed to rule out complication noted IED combined with pneumomediastinum. He was managed conservatively with nil per oral, intravenous antibiotics and parenteral nutrition. Follow up study after 2 weeks later showed near complete resolution of IED. IED should be included in the differential diagnosis for unexplained acute chest pain, especially, associated with dysphagia and hematemesis. IED with pneumomediastinum or mediastinitis require prompt surgery. So far, there is no case report of IED combined with pneumomediastinum which resolved without surgical treatment. In this case, IED combined with pneumomediastinum has improved by conservative management, so we present a case report.

Background/aims: Endoscopic retrograde cholangiopancreatography (ERCP) is the most accurate modality in diagnosis of choledocholithiasis. However, it carries some complications. Endoscopic ultrasonography (EUS) is less invasive than ERCP and used for the diagnosis of choledocholithiasis. Recent studies showed that a usefulness of EUS for the diagnosis of small choledocholithiasis without common bile duct (CBD) dilatation. For such a reason, ERCP is being replaced by EUS in the diagnosis of bile duct stones. The aim of this study was to investigate the accuracy of EUS for the diagnosis of choledocholithiasis without CBD dilatation., Methods: A total of 66 patients with suspected choledocholithiasis without CBD dilatation were enrolled. EUS were performed in all cases within 48 hours after computed tomography (CT) or ultrasonography (US). Final diagnosis was obtained by ERCP or clinical course (minimum 6 months follow-up). We analyzed the accuracy of US, CT, and EUS, respectively., Results: CT and US were performed in 51 and 15 cases, respectively. CBD stones were detected in 23 (35%) patients by ERCP. EUS showed 100% sensitivity, 95% specificity, 92% positive predictive value, and 100% negative predictive value for identifying CBD stones. CT or US showed 26%, 93%, 67%, and 70%, respectively. There were no EUS-related complications., Conclusions: EUS was more effective than CT or US and as accurate as ERCP for the diagnosis of small choledocholithiasis without CBD dilatation. Thus, EUS may help to avoid unnecessary diagnostic ERCP and its complication.

Background/aims: Colorectal adenoma and cancer are known to be associated with obesity. Leptin, an adipocyte-derived hormone that plays a crucial role in obesity has been suggested as a growth factor in colon cancer. However, the association between adenoma and leptin remains controversial. We evaluated the leptin expression in human colorectal adenoma and its correlation to clinicopathologic factors., Methods: Leptin expression was assessed by immunohistochemistry in 91 samples of colorectal adenoma larger than 5 mm, which were removed by endoscopic polypectomy. All patients underwent colonoscopy for cancer screening at Seoul Paik Hospital from 2007 to 2008 and we only included the patients less than 50 years of age. Leptin expression and its relationship with clinicopathologic features were analyzed., Results: Eighty samples were available for the interpretation of leptin expression and showed positive in 42 (52.5%) cases and negative in 38 (47.5%) cases. As body mass index (BMI) increased based on World Health Organization (WHO) classification the positivity of leptin expression also increased (ptrend=0.02). In leptin positive group, the correlation of leptin expression with adenoma size and histological showed positive tendency without statistical significance., Conclusions: Leptin expression of colorectal adenoma was associated with BMI. The question of whether leptin contributes to colorectal adenoma development is unresolved and will require additional studies.

Background/aims: Clostridium difficile is the predominant cause of nosocomial diarrhea. Recently, the incidence of Clostridium difficile infection (CDI) increases in Europe and North America. A retrospective study was performed to evaluate the change of incidence and clinical features of CDI in Korea., Methods: From January 2003 to December 2008, inpatients diagnosed with CDI in Seoul Paik hospital were enrolled. The diagnosis of CDI was made when patients complained diarrhea with any positive results in C. difficile toxin assay, stool culture, or endoscopy. The incidence, recurrence rate, and clinical features were compared between early period (2003-2005) and late period (2006-2008)., Results: The incidence of CDI was 21.73 cases per 10,000 admitted patients in early period group, and significantly increased to 71.71 cases per 10,000 admitted patients in late period group (p < 0.01). The hospital stay duration at the time of CDI diagnosis was shorter in late period group. Cephalosporin had the highest ratio as the causative antibiotics of CDI. However, there was no difference in recurrence rate between early and late period groups. Recurrence associated clinical factor was serum albumin level., Conclusions: The incidence of CDI showed increasing tendency during recent 6 years. The awareness of increasing disease burden is the first step in control of CDI.

Background/aims: The aim of this study was to investigate the frequency of heartburn produced by beverages available in Korea and to clarify the mechanism causing heartburn., Methods: We measured pH, titratable acidity, and osmolality of 35 beverages in vitro and correlated them with the severity of heartburn reported by questionnaire in 382 patients from November 2004 to June 2005., Results: Coffee (1.15) and soju (1.12) showed the highest heartburn score, while oolong tea (0.17) and carrot juice (0.18) showed the lowest heartburn score among all beverages. Titratable acidity of citrus juices correlated with heartburn (r=0.78; p=0.023). Soft drinks had the lowest pH, which was unrelated with heartburn scores (r=-0.54; p=0.460). Increasing pH among alcoholic beverages was correlated with heartburn scores (r=0.84; p=0.037), and osmolality was inversely associated with heartburn scores (r=-0.86; p=0.028). The heartburn score of decaffeinated coffee was significantly lower than that of regular coffee (p<0.001). Regular milk caused more heartburn than low-fat milk (p=0.008)., Conclusions: Our findings provide dietary information that helps to select appropriate beverages to the patients with heartburn.

Leiomyosarcoma is a rare tumor of the liver. It usually arises from many other organs including uterus, gastrointestinal tract, retroperitoneum, and soft tissues. Primary hepatic leiomyosarcoma progresses very slowly and is not associated with chronic liver disease. When the tumor is detected early enough to be treated by operation, the prognosis is favorable. While several cases of primary hepatic leiomyosarcoma have been reported in Korea, there was no case associated with acute bleeding. We report a 80-year old male patient with huge primary hepatic leiomyosarcoma, who presented with acute bleeding and IVC obstruction. The patient was treated by embolization and IVC stenting.

Adefovir dipivoxil (ADV) is effective in the treatment of chronic hepatitis patients with wild type and lamivudine-resistant hepatitis B virus. The occurrence of viral resistance to long-term adefovir therapy is rare, the cumulative rates of resistance were 0%, 3%, 11%, 18%, and 28% at 1, 2, 3, 4, and 5 years of therapy, respectively. The emergence of adefovir resistant mutant in patients with lamivudine resistance is more common than in treatment-naive patients. Two major mutations of adefovir resistance are rtN236T and rtA181V/T. Other mutations in the HBV polymerase (rtP237H, rtN238T/D, rtV84M, rtS85A, rtV214A, rtQ215S) reduce sensitivity to adefovir, but the significance of these mutations is unclear. The adefovir mutations slightly decrease adefovir susceptibility in vitro, suggesting mild clinical course after the occurrence of adefovir resistance. However, some patients show viral rebound and hepatic decompensation. Lamivudine, entecavir, and tenofovir are used currently for salvage therapy in patients with adefovir resistance. To reduce adefovir resistance, combination therapy with adefovir and lamivudine in patients with lamivudine resistance may be a treatment option.

Backgrounds/aims: The prognosis of cirrhotic patients with hepatocellular carcinoma (HCC) depends on both residual liver function and tumor characteristics. The aims of this study was to construct a new prognostic index for HCC patients: the modified CLIP score, and to compare its discriminatory ability and predictive power with those of the CLIP score that is currently the most commonly used integrated staging score in patients of HCC., Methods: A retrospective analysis of 237 cases of HCC diagnosed at Dong-A university hospital was performed. Prognostic analysis was performed for single variables by estimating survival distributions with the Kaplan-Meier's method, and statistically compared by the log-rank test., Results: Patients had a mean age of 57.5 years and were predominantly males (79.7%). The overall median survival period was 25.7 months. It was correlated to ascites, portal vein thrombosis, AFP, tumor size, and Child-Pugh classification. The median survival period was 41.0, 25.2, 13.8, 13.4, and 6.5 months for CLIP scores 0, 1, 2, 3, and 4 to 6, respectively (P<0.001), and 42.1, 34.0, 25.7, 14.0, and 6.8 months for modified CLIP scores 0, 1, 2, 3, and 4 to 6, respectively (P<0.001). The Kaplan-Meier's curve showed that the modified CLIP score had additional explanatory power above that of the CLIP score., Conclusions: The modified CLIP score, compared with the CLIP score, particularly in the score 2- to 3- patient groups of HCC, had greater discriminant ability and survival predictive power, but was not able to discriminate 4- to 6- patient group.

Background/aims: De novo colorectal carcinoma shows more aggressive behavior including submucosal invasiveness. Both p53 and cyclo-oxygenase-2 (COX-2) have been shown to be involved in colon carcinogenesis, progression from adenoma to carcinoma, and submucosal invasion by tumor. We performed this study to evaluate the expression of p53 and COX-2 protein in de novo carcinoma, compared with ex-adenoma carcinoma., Methods: Twenty three flat adenomas, 19 ex-adenoma carcinomas, 6 de novo carcinomas were included in this study. The expression of p53, COX-2 and Ki-67 were examined immunohistochemically., Results: Both ex- adenoma carcinomas and de novo carcinomas showed similar size and shape. Positive staining for p53 was detected in 3 of 23 (13%) flat adenomas, in 11 of 19 (57.8%) ex-adenoma carcinomas (p < 0.05), and in 1 of 6 (16.6%) de novo carcinomas. Increased numbers of COX-2 positive tumor cells were observed in 1 of 23 (4.3%) flat adenomas, in 2 of 19 (10.5%) ex-adenoma carcinomas, and in 3 of 6 (50%) de novo carcinomas. COX-2 positive expression showed increased tendency in de novo carcinoma (p = 0.073). There was no correlation between COX-2, p53, and Ki-67 expression., Conclusion: De novo carcinoma shows increased tendency of COX-2 expression, but decreased p53 expression when compared to ex-adenoma carcinoma. These immunohistochemical findings are in accordance with the fact that de novo carcinoma has no preceding adenoma, with more frequent submucosal invasion despite the small lesion size.

Dieulafoy lesion is an abnormally large calibered submucosal artery associated with a minute mucosal defect in the gastrointestinal mucosa. It is a rare cause of profuse, but intermittent gastrointestinal bleeding. The lesion is usually located in the stomach, although it may occur anywhere in the gastrointestinal tract. Dieulafoy lesion is extremely rare in the neonates. We report two newborn infants with a gastric Dieulafoy lesion which was treated by endoscopic epinephrine injection therapy without complication and recurrence.

Background/aims: There are several staging systems to decide the stage of hepatocellular carcinoma (HCC), but yet incomplete. Okuda stage which includes both tumor characteristics and liver function is widely used. The aims of this study were to assess the usefulness of known prognostic factors and Okuda staging system in 237 cases of HCC., Methods: A retrospective analysis of 237 cases of HCC diagnosed from 2000 to 2002 was performed. We analyzed prognostic factors such as age, sex, liver cirrhosis, Child-Pugh classification, tumor size, albumin, bilirubin, alpha-FP, ascites, encephalopathy and Okuda stage. Prognostic analysis was performed for single variables and estimating survival distributions were analyzed by the Kaplan-Meier method, statistically compared by the log-rank test., Results: Patients had a mean age of 57.5 years and were predominantly men (79.7%). Liver cirrhosis were noticed in 214 cases (90.3%). The overall median survival period was 25.7 months. The median survival period was correlated to bilirubin, ascites, alpha-FP, tumor size, and Child-Pugh classification, but not to age, sex, and pattern of viral infection. The median survival period of the Okuda stage I, II and III cases was 35.8, 11.9 and 8.5 months (p<0.001)., Conclusions: The median survival period of patients with HCC is significantly correlated to Okuda staging system, and survival period has improved than the initial data when the Okuda staging system was published in 1985. However, in order to discriminate early staged HCC more accurately, other prognostic factors such as alpha-FP and tumor morphology should be included in future staging system for HCC.

Primary small cell carcinoma of the liver is an extremely rare tumor. Extrapulmonary small cell carcinoma shares many features of pulmonary small cell carcinoma, including the histological appearance, the aggressive clinical behavior and the frequent short-lasting response to either chemotherapy or radiotherapy. We experienced a 56-year-old man with small cell carcinoma that arose in the liver. Abdominal CT scan showed an 8 cm size, low density mass in the segment 4 of the liver and also multiple lymphadenopathies. Chest X-ray showed no abnormal finding, but the chest CT showed a right lower paratracheal lymphadenopathy. The pathological findings showed nests of small round cells with fine granular chromatin, inconspicuous nucleoli and scanty cytoplasm. Distinct and strong immunoreactions were seen for CD56 and c-kit, and sparse immunoreaction was seen for synaptophysin. Thyroid transcription factor-1 showed no immunoreaction. The tumor did not decrease in size despite chemotherapy. We report this case along with a review of the relevant literatures.

Villous tumors of the stomach are somewhat rare with approximately 100 cases only reported in the literatures and have tendency to undergo malignant transformation as high as 72%. They are frequently multiple and associated with other gastrointestinal neoplasm. Thirty percent of them are associated with an independent gastric carcinoma. Gastric villous tumor has certain radiologic characteristics that may permit a preoperative diagnosis and also some distinctive clinicopathologic features which make early diagnosis and proper treatment possible. We experienced a 64-year-old man who complained of prolonged general weakness, weight loss for several months and left upper quadrant pain for four days. Esophagogastroduodenoscopy and barium study of upper gastrointestinal tract demonstrated typical, irregular, frond-like surfaced villous tumor occupying nearly whole gastric lumen and located eccentrically along the lesser curvature side. Endoscopic biopsy of the tumor revealed a gastric villous tumor with carcinomatous change.

Tuberculous colitis, an important extra-pulmonary tuberculosis, is still prevalent in the developing countries and has been resurging in the Western world. The duration and dose of anti-tuberculous therapy have not yet been clarified in the tuberculous colitis. We experienced a case of tuberculous colitis, which relapsed after 9 months of therapy. A 28-year-old man presented with hematochezia and was diagnosed as tuberculous colitis on the basis of colonoscopic findings. He was treated with anti-tuberculous agents for 9 months successfully. Three months later, however, he complained of hematochezia again, suggesting the relapse of tuberculous colitis. He had taken anti-tuberculous therapy for another 15 months and showed no evidence of relapse. Although anti-tuberculous therapy is efficient for tuberculous colitis, rare cases of reactivation should be reminded.

Background/aims: Tamoxifen has been tried in patients with hepatocellular carcinoma (HCC), however, its inhibitory mechanism remains unknown. In this study, we evaluated the effects of tamoxifen on HCC cell growth and the expression of transforming growth factor-beta1 (TGF-beta1) which had been known as an important cytokine in growth of HCC., Methods: Hep 3B cells were cultivated in estrogen free media with 0.1 micro M, 0.5 micro M, 1 micro M, 5 micro M, and 10 micro M of tamoxifen for 6 days. Viable cells were counted daily and the TGF-beta1 concentrations in supernatant were measured by ELISA method., Results: The number of viable HCC cells increased rather significantly after the treatment of tamoxifen of lower concentration (0.1micro M) compared with that of the control (2.59x10(7) vs. 1.97x107; p<0.05). As the concentration of treated tamoxifen was higher, the number of viable HCC cells became gradually less, resulting in the significant decrease of it at the highest concentration (10micro M) compared with that of the control (1.40x10(7) vs. 1.97x10(7); p<0.05). TGF-beta1 concentration in supernatant of tamoxifen-treated samples was significantly decreased compared with those of controls, regardless of the amount of treated tamoxifen., Conclusions: These results suggest that tamoxifen may suppress TGF-beta1 expression to an extent, although it has different effects on the proliferation of HCC cells, at the various concentrations of this agent in vitro. Such effects of tamoxifen on TGF-beta1 expression may inhibit the growth and progression of HCCs over-expressing TGF-beta1 in vivo.

Background/aims: Recently, treatment failure with the third generation of cephalosporin was increasingly noted in patients with spontaneous bacterial peritonitis (SBP). We therefore were to evaluate the pattern of antibiotic resistance and its clinical significance., Methods: We retrospectively analyzed 580 episodes of SBP occurring between 1995 and 1999. There were 87 episodes of SBP in 1995, 222 in 1998, and 271 in 1999. The pattern of isolated organisms and antibiotic resistance, and prognostic factors for survival, were analyzed., Results: Microorganisms were isolated in 41% of total episodes. The three most frequently isolated organisms were E. coli (48%), K. pneumoniae (15%), and Aeromonas (8%). The percentage of resistant strains to cefotaxime (9%, 14%, 32%) and ciprofloxacin (13%, 21%, 32%) significantly increased. The proportion of E. coli producing extended spectrum beta-lactamase (ESBL) also increased significantly (0%, 16%, 33%). The need of secondary antibiotics such as imipenem due to treatment failure was significantly increased from 0% in 1995 to 33% in 1999. Overall in-hospital mortality, however, was not changed (20%, 20%, 24%, respectively). The factor affecting early mortality was renal failure at diagnosis. Prognostic factors for long-term survival were the presence of associated malignancy and ESBL-producing microorganisms., Conclusion: Microorgansims resistant to third generation cephalosporin and quinolone were increasingly isolated over the 5 years in patients with SBP. Measures to prevent in-hospital spread of resistant strains and indiscreet use of antibiotics should therefore be instituted.