Hyo Jeong Oh

Endoscopic ultrasound-guided biliary drainage with placement of a fully covered metal stent for malignant biliary obstruction

AIM To determine the utility of endoscopic ultrasound-guided biliary drainage (EUS-BD) with a fully covered self-expandable metal stent for managing malignant biliary stricture. METHODS We collected data from 13 patients who presented with malignant biliary obstruction and underwent EUS-BD with a nitinol fully covered self-expandable metal stent when endoscopic retrograde cholangiopancreatography (ERCP) fails. EUS-guided choledochoduodenostomy (EUS-CD) and EUS-guided hepaticogastrostomy (EUS-HG) was performed in 9 patients and 4 patients, respectively. RESULTS The technical and functional success rate was 92.3% (12/13) and 91.7% (11/12), respectively. Using an intrahepatic approach (EUS-HG, n = 4), there was mild peritonitis (n = 1) and migration of the metal stent to the stomach (n = 1). With an extrahepatic approach (EUS-CD, n = 10), there was pneumoperitoneum (n = 2), migration (n = 2), and mild peritonitis (n = 1). All patients were managed conservatively with antibiotics. During follow-up (range, 1-12 mo), there was re-intervention (4/13 cases, 30.7%) necessitated by stent migration (n = 2) and stent occlusion (n = 2). CONCLUSION EUS-BD with a nitinol fully covered self-expandable metal stent may be a feasible and effective treatment option in patients with malignant biliary obstruction when ERCP fails.

Association of serum alanine aminotransferase and γ-glutamyltransferase levels within the reference range with metabolic syndrome and nonalcoholic fatty liver disease

Background/Aims Nonalcoholic fatty liver disease (NAFLD) has recently been found to be a novel component of metabolic syndrome (MS), which is one of the leading causes of chronic liver disease. The serum alanine aminotransferase (ALT) and γ-glutamyltransferase (GGT) levels are suggested to affect liver fat accumulation and insulin resistance. We assessed the associations of serum ALT and GGT concentrations within the reference ranges with MS and NAFLD. Methods In total, 1,069 subjects enrolled at the health promotion center of Wonkwang University Hospital were divided into 4 groups according to serum ALT and GGT concentrations levels within the reference ranges. We performed biochemical tests, including liver function tests and lipid profiles, and diagnosed fatty liver by ultrasonography. Associations of ALT and GGT concentrationgrading within the reference range with fatty liver and/or MS were investigated. Results The presence of MS, its components, and the number of metabolic abnormalities [except for high-density lipoprotein-cholesterol (HDL-C) and fasting blood glucose] increased with the ALT level, while the presence of MS, its components, and the number of metabolic abnormalities (except for HDL-C) increased with the GGT level. The odds ratios for fatty liver and MS increased with the ALT level (P<0.001 and P=0.049, respectively) and the GGT level (P=0.044 and P=0.039, respectively). Conclusions Serum ALT and GGT concentrations within the reference ranges correlated with the incidence of NAFLD and MS in a dose-dependent manner. There associations need to be confirmed in large, prospective studies.

Effect of Helicobacter pylori Eradication on the Development of Reflux Esophagitis and Gastroesophageal Reflux Symptoms: A Nationwide Multi-Center Prospective Study.

Background/Aims A two-year, prospective, nationwide multicenter study was undertaken to evaluate the effect of Helicobacter pylori eradication on the development of reflux esophagitis (RE) and gastroesophageal reflux disease (GERD) symptoms in the Korean population. Methods In total, 1,489 subjects without RE were enrolled at the outpatient clinics of 12 tertiary hospitals nationwide, and 452 subjects underwent follow-up (F/U) for 2 years to evaluate the development of RE and GERD symptoms. Results RE was found in 33 subjects (7.3% of 452 subjects) and 14 subjects (7.3% of 192 subjects) during the first and second year of F/U, respectively. H. pylori status was not associated with the development of RE. RE was found in six (9.0%) of 67 H. pylori-negative patients, in 26 (11.2%) of 233 eradicated subjects and in eight (7.0%) of 114 noneradicated subjects (p=0.532). Multivariate analysis showed that age ≥60 years (odds ratio [OR], 7.11; 95% confidence interval [CI], 1.92 to 26.41), alcohol consumption (OR, 4.43; 95% CI, 1.03 to 19.19) and F/U cholesterol levels ≥200 mg/dL (OR, 5.03; 95% CI, 1.32 to 19.17) were significant risk factors for the development of RE. There was no significant difference in the development of GERD symptoms or weight according to H. pylori status during the 2-year F/U. Conclusions Eradication of H. pylori did not affect the development of reflux esophagitis or GERD symptoms among patients in outpatient gastroenterology clinics in South Korea.

The Degrees of Hepatocyte Cytoplasmic Expression of Hepatitis B Core Antigen correlate with Histologic Activity of Liver Disease in the Young Patients with Chronic Hepatitis B Infection

Subcellular localizaton of HBcAg have been found to be related to the activity of liver disease and HBV replication. The aim of this study was to determine whether the degree of expression of HBcAg in the hepatocyte nucleus and cytoplasm reflects the level of viral replication and histological activity in chronic HBV infection. A total of 102 patients with biopsy proven chronic hepatitis B were included. There was a highly significant correlation between the levels of HBV DNA in serum and the degree of expression of HBcAg in the nucleus for HBeAg-positive(p=0.000) and negative patients(p=0.04). There was a highly significant, correlation between the degrees of expression of HBcAg in hepatocyte cytoplasm and histologic activities (p<0.01) for HBeAg-positive patients. The degrees of expression of HBcAg in the hepatocyte cytoplasm correlated positively with the lobular activities (p<0.01), but not correlated with the portal activity and fibrosis for HBeAg-negative patients. In conclusion, in the young patients with chronic B viral hepatitis, the degree of expression of HBcAg in the hepatocyte nucleus may affect viral load, and the degree of expression of HBcAg in the hepatocyte cytoplasm may affect histologic activities of liver disease.

What Are the Risk Factors for Acute Suppurative Cholangitis Caused by Common Bile Duct Stones

BACKGROUND/AIMS Acute suppurative cholangitis (ASC), a severe form of acute cholangitis, is a life-threatening condition that must be treated with appropriate and timely management. The purpose of this study was to identify the factors that predispose patients to ASC. METHODS We retrospectively investigated 181 patients (100 men, 81 women; age, 70.66±7.38 years, mean±SD) who were admitted to Wonkwang University Hospital between January 2005 and June 2007 for acute cholangitis with common bile duct (CBD) stones. All patients underwent endoscopic retrograde cholangiopancreatogram to remove the stones. Variables and factors that could be assessed upon admission were analyzed to identify the risk factors for the development of ASC. RESULTS Of the 181 patients, 44 (24.3%) presented with ASC. On multivariate analysis, the followings were found to be independent risk factors for the development of ASC: impacted common bile duct stone (p=0.010), current smoker status (p=0.008), advanced age (>70 years; p=0.002), and gallstone (p=0.016). The most commonly isolated organisms in bile culture were Enterococcus species, Escherichia coli, and Klebsiella species. CONCLUSIONS Impacted bile-duct stones, current smoking, advanced age, and gallstones were identified as independent risk factors for the development of ASC in patients with CBD stones. These results suggest that emergency biliary drainage is beneficial in patients with these risk factors.

Co-development of autoimmune hepatitis and Sjögren's syndrome triggered by the administration of herbal medicines.

Autoimmune hepatitis (AIH) has been reported in association with Sjögrens syndrome (SS). Drug-induced AIH has been rarely reported. A rare case of the co-development of AIH and SS in a 53-year-old woman after the consumption of herbal medicines is described. After admission, the patient complained of dryness in her mouth, and she was subsequently diagnosed with SS, which had not been detected previously. The patients bilirubin and aminotransferase levels initially decreased following conservative management; however, they later began to progressively increase. A diagnosis of AIH was made based on the scoring system proposed by the International Autoimmune Hepatitis Group. The patient was administered a combination of prednisolone and azathioprine, and the results of follow-up liver-function tests were found to be within the normal range. This is an unusual case of AIH and SS triggered simultaneously by the administration of herbal medicines.

ENDOSCOPIC DRAINAGE OF MULTILOCULATED PANCREATIC ABSCESSES WITH SINGLE ENDOSCOPIC CYSTOGASTROSTOMY

Multiple pancreatic abscesses pose a difficult challenge for endoscopists and this condition has received little attention in the medical literature. We report on our experience with endoscopic drainage of multiloculated pancreatic abscesses via a communication tract between the cavities. A 50-year-old man was admitted because of chronic alcoholic pancreatitis with pancreatic duct disruption. After a plastic stent was placed in the pancreatic duct, follow up was lost. Six months later, he was readmitted for fever. An abdominal computed tomography (CT) scan showed multiple cavities located along the peripancreatic space, including one compressing the gastric wall and a larger one in the space distant to the wall (Fig. 1). After confirming a large abscess cavity in contact with the antrum of the stomach using endoscopic ultrasonography, the bulging area of antrum was punctured and two 8.5 Fr pigtail plastic stents and a 7 Fr nasocystic catheter were sequentially inserted into this cavity. However, high fever developed on day 3. After dilatation of the transmural tract with a 15 mm balloon dilator, a conventional gastroscope through this tract advanced to a large cavity and a large amount of whitish pus with exudate in the cavity was observed. Then, on one side of the cavity, whitish pus flew out via a small hole, considered as a communicating tract between the cavities (Fig. 2). Under fluoroscopic guidance, through the hole, the guidewire was inserted into the other cavity in the space distant to the gastric wall and then a 10 Fr nasocystic tube was placed.With irrigating the cavity for 1 week via this tube, the patient’s symptoms improved. A follow-up CT after 4 weeks showed marked resolution of abscess cavities. The tube was then removed. There has been no recurrence during the 2-year follow up. This current report emphasizes transmural drainage of multiloculated pancreatic abscesses via a communication tract between the cavities.

Endoscopic removal of gastric band with small bowel obstruction.

Gastric banding is a popular treatment for morbid obesity. Band erosion leading to intraluminal migration or intrusion occurs uncommonly. We report a rare case of endoscopic removal of a migrated gastric band resulting in small bowel obstruction A 31-year-old woman who had undergone vertical banded gastroplasty laparoscopically for the treatment of morbid obesity 2 years prior was admitted to our emergency room with periumbilical pain for 3 days. Physical examination revealed increased bowel sounds and mild direct tenderness on the periumbilical area without peritoneal irritation sign. A plain film showed multiple air fluid levels and a band lying in the central abdomen (Fig. 1). Computed tomography (CT) demonstrated that the band was lying within the jejunum. After conservative therapy for 3 days, her symptoms and physical examination did not change.We planned to carry out laparoscopic exploration. Follow-up X-ray and CT confirmed intraluminal band location in the distal ileum. No evidence of free gas or air bubbles was found. We tried to remove the band endoscopically. Colonoscopy showed the impacted band within the distal ileum and a distally located connecting tube (Fig. 2).The surrounding mucosa was erythematous and edematous. The impacted band did not move through repetitive trial by long forceps, snare and net. The snare was passed via the distally located cable and crossed the center of the band ring carefully. Then the band was removed and retrieved without immediate complication. The patient was discharged on the fifth day after the procedure. Small bowel obstruction following intragastric band migration is relatively rare and its consequence could be underestimated. In rare cases, laparoscopic extraction methods have been carried out to remove it. However, if there is evidence that the band has migrated distally to the ileum and the patient’s condition is stable, then colonoscopic removal may be preferred to retrieve the band carefully as in the present case.