Kwang Chul Koh

The role of mucosal biopsy in the diagnosis of chronic diarrhea: value of multiple biopsies when colonoscopic finding is normal or nonspecific.

Objectives There are controversies about taking routine mucosal biosy when the gross colonoscopic finding is normal. This study was conducted to determine the frequency of clinically important histological abnormalities, prospectively, in chronic diarrhea patients with grossly normal or nonspecific colonoscopic findings. Methods One hundred and eighteen patients suffering from nonbloody diarrhea with average frequency of more than two times a day for more than 4 weeks were included. Multiple biopsies (cecum, ascending colon, mid-transverse colon, descending colon, sigmoid colon and rectum) were taken during colonoscopic examinations and each biopsy specimen was reviewed by one pathologist after H&E and Masson-trichrome staining. Results Clinically significant abnormalities (2 collagenous colitis, 1 lymphocytic colitis, 7 eosinophilic enterocolitis, 1 ulcerative colitis and 4 melanosis coli) were observed in 9 patients (7.6%). Sixteen cases (13.6%) of borderline histological abnormalities were observed (8 cases of possible collagenous colitis and 8 cases showing some features of lymphocytic colitis). Ninety two cases (78.8%) showed nonspecific inflammation only. Conclusion Clinically important histological lesions can exist in significant percentage in spite of normal or nonspecific colonoscopic findings, which can justify routine mucosal biopsy in the evaluation of chronic diarrhea patients. The clinical significance of borderline histological abnormalities needs to be determined by careful follow-up studies.

A case of ischemic colitis associated with pheochromocytoma.

A 40-year-old woman was admitted because of abdominal pain and diarrhea. She sometimes experienced paroxysmal hypertension, sweating, headache, and palpitation. Sigmoidoscopic findings showed well-demarcated diffuse mucosal edema, hyperemia, and easy touch bleeding from distal descending colon up to the splenic flexure area. Barium x-ray showed loss of haustral marking, thumb printing appearance, and diffuse luminal stenosis in the transverse, descending, and sigmoid colon. On the abdominal computed tomogram, a 3.8-cm sized well-enhanced right adrenal mass was incidentally found. Twenty-four hour urinary excretion of vanillyl mandelic acid, norepinephrine, and normetanephrine were increased. Iodine131 metaiodobenzylguanidine scan showed hot uptake on the right adrenal gland compatible with pheochromocytoma. Exploratory laparotomy was done under the impression of ischemic colitis associated with pheochromocytoma. Adrenalectomy and resection of the stenotic left colon were performed. After surgery, pain subsided, blood pressure fell gradually, blood sugar and catecholamine level became normal, and bowel habit returned to normal.

Influence of hepatitis B virus reactivation on the recurrence of HBV-related hepatocellular carcinoma after curative resection in patients with low viral load.

It is unclear whether the reactivation of hepatitis B virus (HBV) influences the prognosis of hepatocellular carcinoma (HCC) after resection in patients with chronic hepatitis B. The aim of this study was to identify the influence of HBV reactivation on the recurrence of hepatitis B‐related HCC after curative resection in patients with low viral load (HBV DNA <2000 IU/mL). We retrospectively analysed a total of 130 patients who underwent curative resection for HBV‐related early stage HCC (single nodule; <5 cm/two or three nodules; <3 cm) with pre‐operative HBV DNA levels <2000 IU/mL with serial HBV DNA tests. The predictive factors including HBV reactivation for the recurrence of HBV‐related HCC after curative resection were investigated. Fifty‐three patients (41%) had HBV reactivation after resection among 130 patients. HBV reactivation was observed in 22 of 53 patients with undetectable baseline HBV DNA and in 31 of 77 patients with detectable baseline HBV DNA. Cumulative recurrence rates after resection at 1, 2 and 3 years were 17.0%, 23.3% and 31.4%, respectively. The multivariable analysis demonstrated that the risk factors for the recurrence were the presence of microvascular invasion (hazard ratio (HR) 2.62, P = 0.003), multinodularity (HR 4.61, P = 0.005), HBV reactivation after resection (HR 2.03, P = 0.032) and HBeAg positivity (HR 2.06, P = 0.044). HBV reactivation after curative resection is associated with the recurrence of HBV‐related HCC in patients with low viral load.

Four patients with hepatitis A presenting with fulminant hepatitis and acute renal failure and who underwent liver transplantation

Hepatitis A is generally known as a mild, self-limiting disease of the liver, but in rare instances it can progress to fulminant hepatitis, which may require liver transplantation for recovery. Such cases are known to be related to old age and underlying liver disease. We report four cases of hepatitis A in which patients presented with fulminant hepatitis and acute renal failure and underwent liver transplantation. The following common features were observed in our cases: (1) occurrence in relatively old age (>/=39 years old), (2) association with acute renal failure, (3) presence of hepatomegaly, and (4) microscopic features of submassive hepatic necrosis.

A Case of Nonalcoholic Steatohepatitis and Small Intestinal Bacterial Overgrowth with Peripheral Edema Caused by Intestinal Bypass Surgery and Relieved by Repair

Intestinal bypass surgery, particularly jejuno-ileal bypass surgery, performed for the purpose of weight reduction may cause an unexpected exacerbation of nonalcoholic steatohepatitis (NASH). Here, we report a case of NASH caused by small intestinal bacterial overgrowth, which developed after jejuno-colic bypass surgery and resolved dramatically after surgical correction.

Static and dynamic prognostic factors for hepatitis-B-related acute-on-chronic liver failure.

Background/Aims Hepatitis-B-related acute-on-chronic liver failure has a poor prognosis. However, the advent of potent oral antiviral agents means that some patients can now recover with medical treatment. We aimed to identify the prognostic factors for hepatitis-B-related acute-on-chronic liver failure including the initial as well as the dynamically changing clinical parameters during admission. Methods Sixty-seven patients were retrospectively enrolled from 2003 to 2012 at Samsung Medical Center. The patients were classified into three categories: Recovery group (n=23), Liver transplantation group (n=28), and Death group (n=16). The Liver transplantation and Death groups were combined into an Unfavorable prognosis group. We analyzed the prognostic factors including the Model for End-Stage Liver Disease (MELD) scores determined at 3-day intervals. Results A multivariable analysis showed that the unfavorable prognostic factors were a high initial MELD score (≥28) (odds ratio [OR] =6.64, p=0.015), moderate-to-severe ascites at admission (OR=6.71, P=0.012), and the aggravation of hepatic encephalopathy during hospitalization (≥grade III) (OR=15.41, P=0.013). Compared with the baseline level, significant reductions in the MELD scores were observed on the 7th day after admission in the Recovery group (P=0.016). Conclusions Dynamic changes in clinical parameters during admission are useful prognostic factors for hepatitis-B-related acute-on-chronic liver failure.

Inducible nitric oxide synthetase in gastroduodenal disease infected with cagA bearing Helicobacter pylori infection in Korea

peptide/day). For stimulated secretion, PYY agonists were administered in graded doses (0.15, 0.5, 1.5, 5, 15 nmol/kg-h; 0.5 h/dose, 1 peptide/day) during infusion of 0.625 nmol/kg-h gastrin-17. Results: IV administration of PYY had no effect on unstimulated acid secretion. Basal pepsin secretion was inhibited by PYY (5 nmol/kg-h) and PYY[3-36] (0.5 and 5 nmol/kg-h), but [Pro34]pyY was ineffective. When administered during infusion of gastrin-17, all three PYY analogs inhibited acid secretion. The Y2 agonist was slightly more potent (significant inhibition at 0.5 nmol/kg-h) than either PYY or the Y, agonist; maximal inhibition was approximately 50% for all three PYY forms. Pepsin secretion during gastrin-17 administration was inhibited by PYY and PYY[3-36] at doses of 1.5 nmol/kg-h and higher, but [Pro34]PYY was 10-fold less potent.

Bacteriological study of bile in patients with cholangitis due to biliary tract obstruction

Acute cholangitis is a serious complication secondary to obstruction of the extrahepatic biliary tract, due mainly to common bile duct stones, but also to malignant tumoral obstruction. The prevalence of bacterial species in the bile of patients with cholangitis have been reported widely. And there was no avalable study in bacteriologic features of bile during past 10 years in Korea. In recent years, increased attention has been focused on the Enterococcus due to increasing in incidence of nosocomial infection and resistance to broad range of antimicrnbial agents of this organism. The purpose of this study wa s to analyse the bacteriologic features of bile in patients with cholangitis. Bacteriological examination w a s made of bile from 356 patients with cholangitis due to biliary tract obstruction, 105 of them with common bile duct stone and 251 of them with malignant disease. Bile specimens were taken during percutaneous transhepatic biliary drainage or endoscopic nasobiliary drainage. The specimens were cultured aerobically and anaerobically and then the antibiotic s~nsitivity test was done. The overall positive culture rates was 81.4%. There was significant difference in positive culture rates between the patients with common bile duct stone and the patients with malignant disease. ( 88.5% vs 78.4%, p<0.05 ) But there was no significant difference in bacteriological features between the patients with common bile duct stone and the patients with malignant disease. The commonly isolated organisms were Enterncoccus ( 21.6% ), E.coli (19.7%), and Klebsiella ( 17.2% ) respectively. The isolation rate of anaerobes were only 2%. The rate of polymicrobial infection was 78.1%. The rate of ampicillin-resistant Enterococcus was 35%. The rate of gentamicin-resistant Enterococcus was 28%. The rates of 3rd generation cephalosporins-resistant Klebsiella were over 30%. This study shows that 1) many microorganisms have resistance to a broad range of antimicrobial agents, and 2) the antibiotic coverage against Enterococcus should be considered for the treatment of cholangitis due to the increasing tendency to Enterococcus infection.