Cw Song

Biliary papillary hyperplasia with clonorchiasis resembling cholangiocarcinoma.

Infection by the liver fluke Clonorchis sinensis is very common in the Far East. It causes low grade inflammatory changes and proliferation in the biliary tree. Initially there is desquamation of the biliary epithelium, followed by hyperplasia and adenomatous proliferation. Cholangiocarcinomas are potential long term complications. We present a case of biliary papillary hyperplasia with clonorchiasis resembling cholangiocarcinoma in a 69-yr-old Korean man. Early recognition of biliary hyperplasia and treatment of Clonorchis sinensis is important to prevent development of cholangiocarcinoma, especially in the Far East.

Double-Blind Placebo-Controlled Study of Cisapride in Patients with Nonspecific Esophageal Motility Disorder Accompanied by Delayed Esophageal Transit

BACKGROUND Nonspecific esophageal motility disorder (NEMD) represents a difficult therapeutic challenge because of the heterogeneous nature of the esophageal motor functions. We studied the effects of cisapride on the esophageal symptoms and esophageal motor function in a group of patients with NEMD showing delayed esophageal transit. METHODS Seventy eligible patients were entered into a 4-week, double-blind randomized comparison of 10 mg of cisapride or placebo, four times daily. Symptom assessment, esophageal manometry after wet swallows, and esophageal scintigraphy after intake of a liquid and solid bolus were performed in each patient before and after treatment. RESULTS After 4 weeks of treatment cisapride significantly increased the prevalence of esophageal peristaltic contractions (percentage of total contractions, P < 0.05 versus base line and placebo) and significantly improved esophageal emptying of the solid bolus (P < 0.05 versus placebo) but not of the liquid bolus. Placebo did not have any significant effects versus base line on these variables. Both placebo and cisapride improved the distal esophageal amplitude versus base line (no significant intergroup differences). Symptom scores were significantly reduced after 4 weeks of treatment versus base line in both groups (no significant intergroup differences except for heartburn and regurgitation, P < 0.05). On global evaluation of treatment, significantly more patients in the cisapride group were rated as markedly or moderately improved, when compared with placebo. CONCLUSIONS The results of the present study showed that cisapride is effective and well tolerated in patients with NEMD accompanied by delayed esophageal transit. Symptomatic improvement may possibly be related to its beneficial action on the esophageal body by increasing the number of peristaltic contractions and esophageal emptying of solids.

Effects of Levosulpiride in Patients with Functional Dyspepsia Accompanied by Delayed Gastric Emptying

Objectives Levosulpiride is the levo-enantiomer of sulpiride, a well-known antiemetic, antidyspeptic and antipsychotic drug. This study was undertaken to investigate the effects of levosulpiride on dyspeptic symptoms and gastric motor function in a group of patients with functional dyspepsia showing delayed gastric emptying. Method Forty two eligible patients were entered into a 3 week, double-blind randomized comparison of 25mg of levosulpiride or placebo t.i.d.. Symptom assessment and gastric scintigraphy following the intake of scrambled egg sandwich, were performed in each patient before and after treatment. Results The improvement of symptom score in levosulpiride group was higher than the placebo group (p<0.05). We assessed global efficacy, which was excellent in 1 (6%), good 11 (65%), fair 4 (24%), nil 1 (6%) of those receiving levosulpiride, and fair 9(60%), nil 5 (33%), poor 1 (6%) of those receiving placebo. Levosulpiride tended to be more effective than placebo in relieving the dyspeptic symptoms especially in the subgroups of dysmotility-like (p<0.05) and nonspecific (p<0.05) as compared to other subgroups (p=0.16). The reduction of gastric emptying time after levosulpiride treatment was more marked than Placebo group (p<0.05). We found a significant correlation between changes of symptom score and gastric emptying time (r=0.47, p=0.01. No serious adverse effects were reported after administration of either levosulpiride or placebo. Only two patients reported mild somnolence during levosulpiride administration. Conclusions Levosulpiride is effective and well tolerated in patients with functional dyspepsia accompanied by delayed gastric emptying. Its efficacy may be related to its action on the gastric motor function by improving the delayed gastric emptying.

Potentiation of cholecystokinin and secretin-induced pancreatic exocrine secretion by endogenous insulin in humans.

To investigate the effects of endogenous insulin on pancreatic exocrine secretion in humans, we evaluated the pure pancreatic juice obtained by endoscopic cannulation of the main pancreatic duct in 21 healthy subjects (14 men and seven women). Samples of pancreatic juices were collected after intravenous injection of either glucose (50%, 40 ml), secretin (0.25 CU/kg), and cholecystokinin-8 (CCK) (40 ng/kg), or a combination of glucose, secretin, and CCK in six 5-min periods. The responses of plasma glucose, insulin, and C-peptide to intravenous administration of glucose were measured. After infusion of glucose, the plasma insulin and C-peptide levels were significantly increased and remained at high levels during 30-min experiments, intravenous administration of secretin and CCK resulted in significant increases of pancreatic secretion including volume, bicarbonate, and protein output. When glucose was simultaneously administered with secretin and CCK, pancreatic secretion was significantly increased, more than the effects achieved by the secretin and CCK. However, glucose alone did not increase basal pancreatic secretion. These observations suggest that endogenous insulin intensifies pancreatic secretion stimulated by secretin and CCK in humans.

7191 Electron microscopic study of association between helicobacter pylori and gsatric epithelial cells.

Backgrounds: To study pathophysiologic roles of Helicobacter pylori, we investigate the ultrastructural relation of Helicobacter pylori to the gastric epithelial cells. Subjects and Methods: Endoscopic biopsy of gastric antrum and body were performed from thirty-one patients(18men and 13women) with chronic gastritis. These specimens were processed and observed by transmission and scanning electron microscope(Hitachi H-600, Hitachi S- 450). Results: 1) Helicobacter pylori were spiral, coccoid, and intermediate or un-defined forms. 2)Most of the Helicobacter pylori were present in the mucus gel layer, on the surface of gastric epithelium and were common at the area around the junctional complexes. 3)Coccoid forms were most common in the mucosal layer. 4)The gastric epithelial cells show increased cytoplasmic electron density, few microvilli, disruption of apical membrane, presence of cell fragments in intercellular space and mucosal layer. Junctional complexes were frequently observed deep in the intercellular space between the cytoplasmic elevation filled with secretory granules. Complete destruction of junctional complex was not common. Conclusions: Helicobacter pylori had variable relations to the gastric epithelial cells in human stomach. These features may contribute to the pathogenic action of the organism.

4728 Classification of gastric stromal tumor according to immunohistochemical phenotype.

Backgrounds: Gastrointestinal stromal tumor(GIST) is a mesenchymal tumor which originates from the GI tracts. Although recent immunohistochemical study has helped classifying mesenchymal tumor and forming diagnostic criteria for benign and malignant tumors according to cells origin and differentiation, it is yet to be settled. This study has classified gastric stromal tumor by using immunohistochemical staining. Materials and Methods: Immunohistochemical staining was performed on the gastric stromal tumor specimens attained by endoscopic resection and surgery. Smooth muscle actin, Desmin, Neuron-specific enolase, S-100, CD 34 and Vimentin has been used as immunohistochemical antibodies and the guideline for Ackermans surgical pathology has been used as criteria for diagnosing malignancy(Ackermans surgical pathology 8th ed, 1996). Smooth muscle type was classified as benign, borderline and malignant according to the size and number of mitosis. Neural type was classified as malignant, and combined smooth muscle-neural type and uncommitted type were classified as either potentially malignant or malignant. Results: Subjects consisted of 12 males and 26 females with average age being 53 ± 12.8 years old. 22 cases has been endoscopically resected, 16 surgically removed, with the mean length of tumor being 25.3 ± 18.1 mm. The results of immunohistochemical staining showed 12 cases(31.6%) of smooth muscle type, 7 cases(18.4%) of neural type, 1 case(2.6%) of combined smooth muscle-neural type and 18 cases(47.4%) of uncommitted type. On the basis of above immunohistochemical results and histologic findings, 12 cases(31.6%) were regarded as benign, 17 cases(44.7%) as potentially malignant or malignant, and 9 cases(23.7%) as malignant(Table). Conclusion: When classified by immunohistochemical staining, 68.4% of gastric stromal tumor proved to be potentially malignant or malignant.

⁎4727 Reassessment of usefulness of eus in differentiation of benign and malignant gastric stromal tumors which were diagnosed according to pathologic guidelines of ackerman's surgical pathology.

Backgrounds: GISTs originate from mesenchymal tissue within the GI tract, and it is difficult to differentiate between benign and malignancy by endoscopy. Although recent development of EUS allows a trial of differentiation from benign and malignant stromal tumors, its diagnostic accuracy is controversial. The aim of this study is to determine whether EUS can differentiate between benign and malignant gastric stromal tumors. Materials and Methods: EUS was performed prior to endoscopic resection or surgical resection of 38 gastric stromal tumors. EUS features such as tumor size(diameter>4 cm), irregular extraluminal border, echogenic foci, and cystic spaces, which were proposed by Chak A et al. as EUS findings of malignant GISTs(Gastrointest Endosc 1997) were evaluated. Pathologic diagnosis was based on guidelines of Ackermans surgical pathology (Ackermans surgical pathology 8th ed, 1996). Results: Subjects consisted of 12 males and 26 females. 22 cases has been endoscopically resected, 16 cases surgically removed. The results of immunohistochemical staining showed 12 cases of smooth muscle type, 7 cases of neural type, 1 case of mixed type and 18 cases of uncommitted type. On the basis of above immunohistochemical results and histologic findings, 12 cases were regarded as benign, 17 cases as potentially malignant or malignant, and 9 cases as malignant. Analyses of EUS features according to the criteria of Chak et al. are shown in the following table. Conclusion: When gastric stromal tumors were diagnosed with criteria from Ackermans surgical pathology, EUS features, which were proposed by Chak et al, were assessed to be less useful in differentiating between benign and malignant stromal tumors.

4718 Clinical studies of 13c-urea breath test in korea.

Backgrounds/Aims: 13C-urea breath test(UBT) has been an useful test for the diagnosis of H. pylori infection. However, the results of UBT were variable according to country, age, race and test methods such as feeding, sampling time, and test meal. The aim of study was to improve standardization of UBT in Korea by determining the cut-off value for the initial diagnosis of H. pylori infection and evaluating the effect of meal and the timing of breath sample collection. Materials and Methods: Two different studies were performed. First, 159 patients with dyspepsia were studied by means of endoscopy, histology(H-E and Giemsa stain), anti- H.pylori IgG ELISA and UBT. UBT was performed with HelikitTM(pre-mixed with 75 mg of 13C-urea and 750 mg of citrate) and isotope-ratio mass spectrometer (IRMS). H. pylori infection was established when histology was positive or more than two of the tests positive. Cut-off value was analyzed. Second, 25 healthy volunteers, for whom the results on H. pylori both by histology and fasting UBT were concordant, were enrolled. Fasting UBT were done after 4-hour fast and nonfasting UBT within 1 hour after square meal respectively on the same subjects at a week interval. The breath sample collected just before and at 5,10,15,20,25,30 minutes after Helikit TM ingestion. Results: Optimal cut-off value was 3. 8 per mili with sensitivity of 94.7% and specificity of 100% by receiver operating characteristic (ROC) curve analysis. At second study, δ 13 CO 2 was significantly decreased at nonfasting state than fasting, but nonfasting did not interfere with the results in H. pylori infected subjects. One subject with H. pylori infected showed false negative at 5 minutes. In H. pylori negative subjects, test results were not influenced by nonfasting and no early peak of δ 13 CO 2 within 10 minutes was found. Conclusion: 13C-UBT in Korea can be simplified using 10- minute breath samples and a cutoff of 3.8 per mili under the conditions of 75 mg of 13C-urea,citric acid,IRMS,initial diagnosis and adults. Furthermore, nonfasting state does not alter the accuracy of the test, making the test more profitable.

4497 Cyclooxygenase-2 expression in colorectal polyp.

Backgrounds/Aim:Recent studies have shown that cyclooxygenase(COX)-2 involves in the tumorigenesis in colorectal neoplasia. However, the timing of COX-2 expression during adenoma-carcinoma sequence is not completely established. The aim of this study was to evaluate COX-2 expression in colorectal polyp according to histologic type. Materials and Methods:52 patients with colorectal polyp from endoscopic polypectomy or surgical resection were enrolled. Polyps were divided histologically as follows;12 hyperplastic polyps(HP), 13 adenomas with low grade dysplasia(LGD), 12 adenomas with high grade dysplasia(HGD) and 15 malignant polyps(MP, carcinoma arising from adenoma). They were stained for COX-2 by avidinbiotin immunohistochemical technique using polyclonal IgG antibody. The intensity and extent of staining were semi-quantitatively accessed by two pathologists, blinded to outcome. Results:COX-2 was stained in varying intensity in tumor cells of 7 per 12 HGDs and 11 per 15 MPs, though was not in those of all LGDs and HPs. Percentage of COX-2 expression in tumor epithelial cells was 20 to 40% in 6 HGDs and above 50% in 10 MPs. Strong COX-2 staining was also observed in stromal components such as mononuclear cells, endothelial cells of all adenomas and carcinomas. Conclusion: The frequency and intensity of COX-2 expression was increased in both adenoma with high grade dysplasia and carcinoma. These results suggest that up-regulation of COX-2 has an important role in tumor progression from the late stage of colorectal adenoma.

Significance of pleural effusion on the prognosis and severity in patients with acute pancreatitis

Background/Aims: The presence of pleural effusion has been proposed as a marker for severe pancreatitis. There is a controversy about whether pleural effusion in acute pancreatitis is associated with more severe disease. The aim of this study was to clarify the association between pleural effusion and severity in patients with acute pancreatitis. Methods: We evaluated retrospectively for 216 patients (M:137, F:77) with acute pancreatitis who admitted to our hospital during last 5 years. The diagnosis of acute pancreatitis was based on the typical signs and symptoms, enzyme elevation, and radiological findings. For grading of the severity, APACHE II and Ranson score at admission were used. The patients subdivided into four etiological groups: alcohol, gallstones, idiopathic and others(post-ERCP, trauma, drug, etc). Results: Pleural effusion was seen in 46(21.3%) of 216 of patients with pancreatitis. Alcohol was the most common etiology (19:27.1%), followed by gallstones (15:32.6%), idiopathic (8:17.4%) and others (4:8.7%). The effusions were bilateral in 21(47.8%), left-sided in 19(39.2%), and right-sided in 6(13%). Results of relationship between the etiology and severity of acute pancreatitis with and without pleural effusion are as follows.