B. Keum

The effect of the respiratory cycle on liver stiffness values as measured by transient elastography

Summary.u2002 The findings of several studies suggest that liver stiffness values can be affected by the degree of intrahepatic congestion respiration influence intrahepatic blood volume and may affect liver stiffness. We evaluated the influence of respiration on liver stiffness. Transient elastography (TE) was performed at the end of inspiration and at the end of expiration in patients with chronic liver disease. The median values obtained during the inspiration set and during the expiration set were defined as inspiratory and expiratory liver stiffness, respectively. A total of 123 patients with chronic liver disease were enrolled (mean age 49u2003years; 64.2% men). Liver cirrhosis coexisted in 29 patients (23.6%). Expiratory liver stiffness was significantly higher than inspiratory liver stiffness (8.7 vs 7.9u2003kPa, Pu2003=u20030.001), while the expiratory interquartile range/median ratio (IQR ratio) did not differ from the inspiratory IQR ratio. Expiratory liver stiffness was significantly higher than inspiratory liver stiffness in 49 (39.8%) patients (HE group), expiratory liver stiffness was significantly lower than inspiratory stiffness in 15 (12.2%) patients, and there was no difference in 59 (48.0%) patients. Liver cirrhosis was more frequent in those who had a lower liver stiffness reading in expiration, and only the absence of liver cirrhosis was significantly associated with a higher reading in expiration in multivariate analysis. In conclusion, liver stiffness was significantly elevated during expiration especially in patients without liver cirrhosis. The effect of respiration should be kept in mind during TE readings.

Anaphylactic shock-induced ischemic proctocolitis following bee stings: first case report

for hematochezia following resuscitation from a hypotensive shock. The history revealed that while working outdoors, the patient had been attacked by a swarm of bees and received multiple stings, rendering him unconscious. Following initial recovery at the local hospital, he developed hematochezia and was referred to us. On examination at admission, the patient was alert and not pale, and his vital signs were stable. He denied any previous allergic history related to drugs or other substances, and he was not taking any medication. There was no notable family history. Pain and tenderness were elicited in the periumbilical region but without rebound tenderness. Digital rectal examination revealed bloody and mucoid discharge. The initial laboratory results showed leukocytosis and mild elevation of serum aminotransferases without anemia. Abdominopelvic computed tomography (CT) disclosed edematous wall thickening in the rectosigmoid and cecal regions. Electrocardiography did not show any sign of cardiac arrhythmia. On sigmoidoscopy, the rectal mucosa was hemorrhagic and greatly swollen with narrowing of the lumen, whitish exudates, and intermittent, deep ulcerations (● Fig. 1a). This presentation persisted as the scopewas advanced and then relatively normal mucosa was seen at 25 cm from the anal vergewith a sharply distinct margin (● Fig. 1b). Total colonoscopy carried out the next day revealed cecal pathology with similar findings (● Fig. 1c). Following administration of empirical antibiotics, bowel rest, and copious intravenous hydration, the abdominal pain subsided and the hematochezia ceased. The patient resumed his normal diet 11 days after admission. Pathologic examination verified the diagnosis of ischemic colitis. Followup total colonoscopy before discharge revealed much improvement (● Fig. 1d– f), and a later endoscopic review examination revealed minimal changes in the colonic mucosa with no evidence of stricture or other deformities. Ischemic colitis is the most commonmanifestation of mesenteric ischemia [1], and a few cases of acute ischemic colitis of unusual etiology have been reported [2– 5]. Our patient’s young age and otherwise apparently healthy constitution with no notable medical history are suggestive of low probability of atherosclerotic change and susceptibility to any kind of bowel ischemia. Our patient therefore exemplifies a rare instance of anaphylactic shock caused by bee stings leading to ischemic colitis, and is the only case of its kind to be reported to date.

Splenic infarction after cyanoacrylate injection for fundal varices

to hepatitis B infection, who had undergone regular endoscopic variceal therapy for fundal varices, was admitted for secondary prophylaxis. The laboratory findings were unremarkable apart from a low platelet count (34 × 103/μL) and prolonged prothrombin time (17.7 s, international normalized ratio [INR] 1.46, 59%). Endoscopic examination revealed small esophageal varices and large fundal varices with the red color sign. Two injections of 2mL of N-butyl-2-cyanoacrylate (Histoacryl; B. Braun, Tuttlingen, Germany) diluted with Lipiodol (Guerbet, Aulnay Sous Bois, France) were administered into the fundal varices. The patient had undergone multiple sessions of endoscopic injection therapy in the past with no occurrence of complications. However, 2 days after the last endoscopic cyanoacrylate therapy, he developed abdominal pain and fever, and his white blood cell (WBC) count rose to 14 × 103/μL. Abdominal computed tomographic (CT) angiography revealed remnants of cyanoacrylate in the splenic vein with nonenhancing splenic parenchyma, suggestive of cyanoacrylate-induced splenic infarction (● Fig. 1). Intravenous antibiotics were immediately initiated along with supportive management. Both the abdominal pain and fever gradually subsided and the WBC count normalized. The patient was discharged on day 20 in the hospital without any further complications or symptoms. A follow-up CT showed persistent, large, hypoattenuated lesions in the spleen, but the patient remained asymptomatic during the 9 months’ follow-up in the outpatient department (● Fig. 2). Endoscopic injection of cyanoacrylate is generally considered to be the usual treatment for gastric varices, but complications such as fever, deep ulceration, chest pain, andvascular occlusion can occur. Although splenic infarction after administration of cyanoacrylate is rare, it has been reported tooccurwhen largevolumesof cyanoacrylate are injected rapidly. This is because of the consequent splenic venous occlusion [1]. With adequate supportive management the splenic infarct can be left in situ. Its clinical course may be self-limiting and the patient may not require surgical treatment, such as splenectomy [2].

Candida esophagitis complicated by esophageal stricture.

department of gastroenterology with dysphagia accompanied by odynophagia without weight loss. The patient was immunocompetent and her only medication was synthyroid, which she had been taking for the past 15 years due to hypothyroidism. The patient said that she had her first recurrent episodes of odynophagia 7 years previously and recalled that endoscopic examination at that time had revealed severe candida esophagitis. Her symptoms improved after taking medication for 1 month. She was without symptoms for a couple of years, but about 5 years prior to the current presentation, she began to experience dysphagia from time to time when taking pills or swallowing meat, and these episodes had become more frequent and had worsened during the past year. The patient visited a gastroenterologist and underwent endoscopy, which revealed narrowing of the esophagus and whitish plaques scattered throughout the mucosa. The endoscopy performed at our hospital also revealed esophageal luminal narrowing at 23 cm from the central incisor, with irregular mucosa and multiple ulcers and whitish exudates (● Fig. 1). The scope (GIF-H260, Olympus, Japan) could not pass beyond the stricture. Multiple biopsies were taken and revealed fungal infection, consistent with candidiasis, with ulcer and pseudoepitheliomatous hyperplasia. The patient was prescribed fluconazole and at follow-up endoscopy 6 weeks later the esophageal stenosis and mucosal lesion had improved. However, the lumen was still not wide enough for the GIFH260 to pass and only the GIF-Q260, which has a smaller caliber, could pass through the stricture site (● Fig. 2). During the follow-up at the outpatient department, endoscopy was performed again because the patient complained of gradual worsening of dysphagiawith solid foods. Endoscopic examination showed more stenotic lumen through which even the GIF-Q260 could not pass (● Fig. 3). Barium esophagogram demonstrated narrowing deformity with an irregular base in the upper and mid-esophagus; the distal esophagus was normal (● Fig. 4). Our case demonstrates the importance of proper and timely management of candida esophagitis, as inadequate and delayed treatment can result in esophageal stricture that can become debilitating.

Successful hybrid NOTES resection of early gastric cancer in a patient with concomitant advanced colon cancer

scopic surgery) is currently of greatest interest to endoscopists and laparoscopic surgeons [1–3]. Early gastric cancer (EGC) is generally managed with endoscopic submucosal resection (ESD) if indicated. We present a case of EGC removed by hybrid NOTES, with a concomitant colon cancer resected via laparoscopic colectomy. A 62-year-old man was diagnosed with simultaneous gastric and colonic cancer. The gastric cancer was an EGC in the form of a moderately differentiated adenocarcinoma on the upper body; the mass in the ascending colon was also moderately differentiated adenocarcinoma (● Fig. 1). Computed tomography and positron emission tomography showed no definite evidence of metastasis. Although total gastrectomy with right colectomy was the treatment of choice, the patient was concerned about his expected quality of life after the surgical resection. ESD of the EGC was also considered, but this was not suitable even on the basis of an expanded indication [4]. We therefore decided to perform hybrid NOTES for gastric adenocarcinoma and laparoscopy-assisted colectomy. After successful removal of the colon cancer by the colorectal surgeon (J. K.) using a standardized laparoscopic technique, the endoscopist (B. K.) used an improved insulated-tip (IT2) knife and endoscopic papillotome to cut around the EGC for a fullthickness incision. The stomach was artificially perforated and collapsed, and a surgeon (S. S. P.) helped by holding back the shrunken stomach. The lesion was cut around for about two-thirds of the total diameter, and laparoscopic removal was completed via a wedge resection with stapling (● Fig. 2). Pathologically, the gastric lesionwas a poorly differentiated tubular adenocarcinoma (type IIb + IIc) invading the lamina propria. The colon cancer was diagnosed as a moderately differentiated adenocarcinomawith three positive lymph nodes. The resection margins of both cancers were free of carcinoma. Endoscopic follow-up and a CT scan taken after 4 months revealed no distinct recurrence of either lesion. Current NOTES researchers who still have access to only a handful of pre-existing equipment without any innovative new devices will benefit from the possibility of performing hybrid NOTES. In an institution with an experienced laparoscopic surgeon and also a skillful endoscopist, hybrid NOTES is a reasonable choice for patients requiring organ preservation. It will also function as a crucial makeshift bridge for crossing over to authentic NOTES in the near future.

Endoscopic retrieval of a metal stent embedded in the colon wall.

tions after inserting a self-expandable metal stent (SEMS) into the colon [1–3]. We report a case of a migrated SEMS from the ascending colon that had been impacted into thewall of the transverse colon. A patient diagnosed with cancer of the ascending colon with stenosis was admitted. The length of the stenotic colon cancer lesion was about 5 cm, and an uncovered SEMS was inserted (Hanaro Stent, uncovered; 100mm in length, 24mm in diameter; MITech, Seoul, Korea). The patient was treated with oxaliplatin, 5fluorouracil, and leucovorin (FOLFOX) chemotherapy. After 6 weeks with the stent inserted, the patient complained of severe colicky abdominal pain. A simple abdominal radiograph showed that the metal stent had migrated from the ascending colon to the transverse colon (● Fig. 1). The colonoscopy revealed that the migrated uncovered stent was impacted and embedded within the bowel wall, in the transverse colon (● Fig. 2a). Endoscopic retrieval of a metal stent embedded in the colon wall

Successful salvage treatment of peptic duodenal stenosis with repeat insertion of self-expanding stent after failed balloon dilation.

due to early satiety and indigestion. He had had peptic ulcer disease for several years and had received proton pump inhibitor (PPI) therapy for a prolonged period at another center without satisfactory outcome. Endoscopic examination revealed a narrowed pyloric channel that precluded passage of a scope (● Fig. 1a). Urea breath test result was negative, proving that previous Helicobacter pylori eradication treatment had been successful. To alleviate the patientʼs symptoms, we carried out repeated endoscopic balloon dilation at 7–10-day intervals, using through-the-scope (TTS) balloon dilation catheters up to 12mm diameter. However, after five sessions of this intervention there was no improvement in the symptoms. As the patient did not want to undergo surgery, endoscopic self-expanding metallic stent (SEMS) installation was attempted. A 7-cm, partial covered stent (Hanarostent, M. I. Tech Co., Ltd., Seoul, Korea) was deployed using an endoscope and the TTS method (● Fig. 1b). There were no immediate complications and the patient was put on a liquid diet that night. After 2 weeks, follow-up endoscopy revealed a patent stent in a fairly good position. Considering the possibility of in-stent growth of granulation tissue, the stent was removed after the fourth week of insertion via endoscopy with forceps (● Fig. 1c). Use of argon plasma coagulation (APC) to ablate the in-growing granulation tissue (● Fig. 1d) allowed reinsertion of the SEMS at 4–8 weeks intervals at the endoscopistʼs discretion. The removal/insertion process was repeated six times. The final endoscopic examination revealed a significantly wider pyloric channel, which allowed easy passage of an endoscope (● Fig. 2). The patient is currently on double doses of PPI, and has had no signs or symptoms of obstruction over 1 year of follow-up. Endoscopic balloon dilation is a common method for management of benign pyloric stricture [1–3], but has been criticized for suboptimal results, repeat procedures, and rare complications such as bowel perforation [4,5]. The present case exemplifies endoscopic SEMS insertion as another way for managing benign pyloric strictures, and our patient is the first successful case to be reported. SEMS may be used as a salvage treatment for pyloric stenosis or even as the main intervention. Removal with APC of tissue growing through the stent mesh or over the stent ends also enables prolonged SEMS placement.

Primary malignant melanoma with surrounding melanosis in the anorectum

emergency room with hematochezia. Apart from a low hemoglobin level (8.9 g/dL), laboratory findings were unremarkable. On colonoscopy, a large mass with a dark-stained surface was observed extending from the anus up to 3 cm above the anal verge (● Fig. 1). When the mass was examined after retroflexion, it was noted that the ulcerating mass itself was surrounded by black pigmented mucosa (● Fig. 2). Biopsy samples were taken from both the darkly stained mass and the pigmented mucosa. Histologic examination of the mass showed neoplastic cells with black pigmentation, which proved to be malignant melanocytes and were positive for HMB45 andMelan-A on immunohistochemical staining. The surrounding pigmented mucosa was shown to be simple melanosis (● Fig. 3). In order to exclude the possibility of the mass being a metastatic lesion rather than a primary lesion, a thorough physical examination and imaging studies were carried out. There was no evidence of any other primary lesions or distant metastases. Therefore the anorectal mass was diagnosed to be primarymelanoma. The patient underwent abdominoperineal resection (● Fig. 4), and the histologic report was consistent with the previous findings: primary malignant melanoma surrounded by black pigmented mucosa. The patient is currently on chemotherapy. Primary melanoma most frequently occurs in the skin and retina but it can also occur in the gastrointestinal tract, which is the third most common site. However, anorectal malignant melanoma is a rare neoplasm and has a poor prognosis [1]. It is important to rule out the possibility of the lesion being a metastasis rather than a primary focus. Although controversy still exists about the most appropriate therapeutic strategies, surgical excision remains the mainstay of treatment [2]. Adjuvant chemotherapy and radiation therapy have not been proved to have a significant role in increasing survival.

Successfully cured primary esophageal lymphoma in a patient with acquired immune deficiency syndrome (AIDS).

primary presentation of human immunodeficiency virus (HIV)-associated extranodal non-Hodgkin’s lymphoma (NHL) [1]. Although rare, this disease should be suspected in patients with acquired immunodeficiency syndrome (AIDS) who have recurrent esophageal symptoms and esophageal ulcerations or a mass not responding to antiviral or antifungal therapy [2]. Endoscopy is essential to pathologic diagnosis, serving as a useful tool for differential diagnosis of esophageal diseases seen in AIDS patients. We report a completely healed case of esophageal NHL in an HIV-seropositive patient. A 39-year-old man diagnosed as having AIDS 6 years ago presented with odynophagia and dysphagia since 2 months for both solids and liquids. Esophagogastroduodenoscopy (EGD) revealed two lesions (l Fig. 1): the lesion in the upper esophagus showed mild inflammatory changes around an ulcer with a dirty base, whereas the mid-esophageal lesion, which was protruding into the lumen, consisted of an ulcer with irregular margins and a whitish layer on the top. Pathologic examination confirmed these lesions as NHL of diffuse large B-cell type (l Fig. 2). There was no notable abnormality in the thorax, abdomen, or pelvis, except for suspected mild wall thickening in the upper and mid-esophagus on computed tomography. Bone marrow biopsy showed normocellular marrow and normal karyotype, resulting in a definitive diagnosis of primary malignant lymphoma confined to the esophagus. Combination chemotherapy with CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) was administered every 3 weeks, in conjunction with highly active antiretroviral therapy (HAART) (zidovudine, lamivudine, and indinavir). After 6 cycles of chemotherapy, the patient has been in a state of complete remission for nearly 3 years. A follow-up EGD 4 years after diagnosis (l Fig. 3) showed completely healed lesions with a minute persistent deformity. The endoscopic findings of HIV-seropositive primary esophageal lymphoma are variable, with no proven pathognomonic features. Histologic diagnosis is challenging; therefore, repeated endoscopic biopsies followed by empirical therapy and follow-up examinations are important and required for confirmation of diagnosis [3]. Successfully cured primary esophageal lymphoma in a patient with acquired immune deficiency syndrome (AIDS)