Ga Hee Kim

Gastrointestinal: Emphysematous gastritis

A 41-year-old man was admitted to hospital with fever, melena and abdominal distension. He had been previously diagnosed with cancer of the common hepatic duct (Klatskin’s tumor) and was subsequently treated with a biliary metallic stent. Upper gastrointestinal endoscopy revealed extensive ulceration with exudate formation in the body and antrum of the stomach (Fig. 1). He also appeared to have retention of dirty gastric fluid. A plain abdominal radiograph showed dilatation of the stomach and raised the possibility of gas bubbles in the stomach wall. An abdominal gastric ultrasound study showed a thickened gastric wall with highamplitude echoes consistent with intramural gas. This was confirmed by an abdominal computed tomography scan (Fig. 2). There were bubbly and linear collections of gas in the posterior wall of the stomach (arrows) as well as radiological features of ascites. Enterobacter cloacae was isolated from cultures of the gastric fluid and blood. The patient died after 25 days despite aggressive antibiotic therapy. Bacterial infections of the stomach are usually categorized as suppurative gastritis or phlegmonous gastritis. The variant with gas bubbles in the wall of the stomach is called emphysematous gastritis. These disorders are rare and mostly occur in the setting of immunosuppression due to acquired immunodeficiency syndrome (AIDS), alcoholism or advanced age. A minority of patients have gastrointestinal disorders such as recent corrosive gastritis or gastrointestinal infarction. Typical symptoms include upper abdominal pain and fever and there is often hypotension and signs of peritonitis. Endoscopic findings include an edematous gastric wall with erosions (necrosis), granularity and a green-black exudate. The appearance can be confused with an infiltrating carcinoma. Histologically, there is an intense polymorphonuclear infiltration in the submucosa with vascular thrombosis and numerous grampositive and gram-negative organisms. Streptococci are thought to be the most important causative agent but other organisms such as Clostridium welchii are presumably present in the subgroup with emphysematous gastritis. Suppurative gastritis is uniformly fatal if untreated. However, treatment with antibiotics and with resection or drainage of the stomach can reduce mortality to 50%-60%. Whether this also applies to patients with emphysematous gastritis remains unclear.

Clinical and Endoscopic Features of Metastatic Tumors in the Stomach

Background/Aims Metastasis to the stomach is rare. The aim of this study was to describe and analyze the clinical outcomes of cancers that metastasized to the stomach. Methods We reviewed the clinicopathological aspects of patients with gastric metastases from solid organ tumors. Thirty-seven cases were identified, and we evaluated the histology, initial presentation, imaging findings, lesion locations, treatment courses, and overall patient survival. Results Endoscopic findings indicated that solitary lesions presented more frequently than multiple lesions and submucosal tumor-like tumors were the most common appearance. Malignant melanoma was the tumor that most frequently metastasized to the stomach. Twelve patients received treatments after the diagnosis of gastric metastasis. The median survival period from the diagnosis of gastric metastasis was 3.0 months (interquartile range, 1.0 to 11.0 months). Patients with solitary lesions and patients who received any treatments survived longer after the diagnosis of metastatic cancer than patients with multiple lesions and patients who did not any receive any treatments. Conclusions Proper treatment with careful consideration of the primary tumor characteristics can increase the survival period in patients with tumors that metastasize to the stomach, especially in cases with solitary metastatic lesions in endoscopic findings.

A Large-Sized Phytobezoar Located on the Rare Site of the Gastrointestinal Tract

Bezoars are concretions of undigested material and are most often observed in the stomach. They can occur at any site in the gastrointestinal tract; however, duodenal localization is very rare. We report the case of a 71-year-old male who had undergone subtotal gastrectomy with gastroduodenostomy and experienced severe epigastric discomfort, abdominal pain, and vomiting for a few days. An approximately 7×8 cm-sized mass was found on an abdominal computed tomography scan. On following endoscopy, a large bezoar was revealed in the duodenum and was removed using an endoscopic removal technique, assisted by a large amount of Coca-Cola infusion.

Efficacy and Complications of Enteral Feeding Tube Insertion After Liver Transplantation

BACKGROUND Adequate nutritional support for patients undergoing major surgery significantly affects postoperative recovery. Data on enteral feeding after liver transplantation (LT) are scarce. The aim of this work was to determine the efficacy and complications of feeding tubes inserted with the use of fluoroscopic assistance, endoscopic assistance, or transperitoneal jejunostomy in patients who underwent LT. METHODS From January 2008 to August 2013, 2,058 LTs were performed at Asan Medical Center, Seoul, Korea. Enteral feeding tubes were inserted in 155 patients (7.5%) after LT: with the use of fluoroscopic placement in 81 (52%), endoscopic placement in 49 (32%), and transperitoneal jejunostomy in 25 (16%). We retrospectively analyzed the efficacy and complications of enteral feeding tubes. RESULTS The median age was 55 years (interquartile range [IQR] 49-60). Enteral feeding indications were a high risk of gastric aspiration (n = 90), gastric stasis (n = 27), pneumonia (n = 23), gastrointestinal bleeding (n = 12), and bowel rest (n = 3). Median enteral feeding durations were 14.5 days (IQR 8.0-30.7) for fluoroscopic placement, 20.0 days (IQR 8.0-40.0) for endoscopic placement, and 37.5 days (IQR 18.2-86.2) for transperitoneal jejunostomy. Times to establishment of oral feeding were 13.0 days (IQR 6.2-25.7) for fluoroscopic placement, 24.0 days (IQR 10.5-43.5) for endoscopic placement, and 37.0 days (IQR 17.0-64.2) for transperitoneal jejunostomy. After tube insertion, tube dislocation and blockage occurred in 34 patients (22%) and 16 patients (25%), respectively. CONCLUSIONS Enteral feeding tube insertion in patients who can not maintain a nasogastric tube or start oral intake for a long time is important for nutritional support after LT. Proper feeding method selection according to patient condition can help patients by improving nutritional support after major operations such as LT.

A New Technique Using Ultra-slim Endoscopy for High-Grade Crohn's Stricture

Crohns disease (CD) is a chronic inflammatory bowel disease of unknown etiology. Most patients with CD will eventually develop a stricturing or penetrating complication. Colonoscopic findings may predict the clinical course in patients with CD. Moreover, since CD patients are at increased risk for developing dysplasia and colorectal cancer, surveillance colonoscopy is necessary for the detection of malignancies. We describe here a CD patient with a high-grade anorectal stricture who successfully underwent a total colon examination with an ultra-slim upper endoscope after an insertion failure with a standard colonoscope and gastroscope.

Diagnostic Trends and Clinical Characteristics of Eosinophilic Esophagitis: A Korean, Single-center Database Study

Background/Aims The prevalence of eosinophilic esophagitis (EoE) is reportedly increasing in Western countries. However, its prevalence in Korea remains unknown. We investigated the diagnostic trends and clinical characteristics of EoE in Korea. Methods Using an endoscopic database maintained at a tertiary care center, we retrospectively reviewed the biopsy reports regarding 18 399 biopsy specimens collected from all patients who underwent esophagogastroduodenoscopy and esophageal biopsy at this facility between 2006 and 2014. The presence of more than 15 eosinophils per high-power field with symptoms related to esophageal dysfunction was considered to indicate EoE. Results A total of 37 patients (male:female ratio, 29:8; mean age, 44.0 ± 13.0 years) were diagnosed with EoE. These patients presented with dysphagia (21.6%), epigastric pain (21.6%), heartburn (24.3%), and other symptoms (32.4%). Typical endoscopic appearance of EoE was noted in 33 cases (89.1%) and included linear furrows in 24 cases (64.8%), ringed esophagus in 10 cases (27.0%), and white exudates in 11 cases (29.7%). The median eosinophilic count was 25 per high-power field (interquartile range, 20–70). Notable histopathological findings included eosinophilic microabscesses in 21 cases (56.7%). The diagnosis rate of EoE was found to have increased from 2006 and to 2014 (P-value < 0.001 by the Cochran-Armitage trend test). Conclusions The number of patients with EoE appears to have increased significantly over the 9-year period investigated, while the number of endoscopic investigations increased only marginally. Greater awareness of EoE and the role of esophageal biopsies should be considered.

Novel endoscopic categorization for prediction of chemoradiotherapy response in locally advanced esophageal cancer: Post-CRT evaluation of esophageal cancer

Preoperative chemoradiotherapy (CRT) followed by esophagectomy is a well‐known treatment modality for patients with locally advanced esophageal cancer (EC). This study developed an algorithm to predict pathological complete response (CR) in these patients using post‐CRT endoscopic category with biopsy and validated the proposed algorithm.

G.P.234

Spinal muscular atrophy (SMA) is a heterogeneous neuromuscular disease of progressive degeneration of anterior horn motor neuron due to homozygous mutation of the survival motor neuron gene (SMN1). Recently, the difference in the SMN2 copy number is considered a critical factor influencing the severity of the disease. We present 2 patients of the same family diagnosed as late onset SMA, genetically confirmed to have homozygous deletion of exon 7 and 8 in SMN1 but showed marked intra-familial variability due to difference in the SMN2 copy number variation. A 43-year old female patient presented with progressive proximal limb weakness which started during high school but did not deteriorate until her age of 40. She visited our clinic at the age of 43 when she started to have difficulty in hiking. Her elder brother was also affected but remarkably more severe in weakness. He had running difficulties during high school but his limb weakness significantly deteriorated to lose independent ambulation since late teen. After nerve conduction study, needle electromyography, muscle imaging and genetic studies, SMN1 revealed the deletion of exon 7 and 8 to make genetic diagnosis of late onset type III SMA. We also measured copy number of SMN2 by MLPA method. Interestingly, SMN2 copy number inversely matched with the severity showing 4 copies with the proband, 3 copies with her brother. We clearly demonstrated the presence of phenotypic variability within the same family, clinically and neuro-radiologically, and it matched with the difference in SMN2 copy numbers. We suggest that SMN2 copy number may be a valuable tool to explain intra-familial variability of SMA severity, and to predict the prognosis with better precision.