Kwang-Ro Joo

Intrahepatic biliary intraductal papillary mucinous neoplasm with gallbladder agenesis: case report.

We report here on a case of intraductal papillary mucinous neoplasm (IPMN) of the bile duct, associated with gallbladder agenesis. A 65-year-old woman was admitted to the hospital with epigastric pain, anorexia, and nausea. Abdominal computed tomography scan and magnetic resonance imaging showed a 5 × 2.5 cm lobulated cystic lesion in the lateral lobe of the liver. The gallbladder was not seen on both imaging modalities. Endoscopic retrograde cholangiopancreatography suggested the diagnosis of biliary IPMN due to abundant mucin that protruded from the papilla and the lobulated cystic lesion. Laparoscopic wedge resection of the liver was performed. The final pathology was consistent with biliary IPMN. The specimen showed multifocal high-grade dysplasia with negative resection margins. The patient experienced no postoperative complications and was discharged 5 days after the operation.We report here on a case of intraductal papillary mucinous neoplasm (IPMN) of the bile duct, associated with gallbladder agenesis. A 65-year-old woman was admitted to the hospital with epigastric pain, anorexia, and nausea. Abdominal computed tomography scan and magnetic resonance imaging showed a 5×2.5 cm lobulated cystic lesion in the lateral lobe of the liver. The gallbladder was not seen on both imaging modalities. Endoscopic retrograde cholangiopancreatography suggested the diagnosis of biliary IPMN due to abundant mucin that protruded from the papilla and the lobulated cystic lesion. Laparoscopic wedge resection of the liver was performed. The final pathology was consistent with biliary IPMN. The specimen showed multifocal high-grade dysplasia with negative resection margins. The patient experienced no postoperative complications and was discharged 5 days after the operation.

Aggressive hilar inflammatory myofibroblastic tumor with hilar bile duct carcinoma in situ

Inflammatory myofibroblastic tumor (IMT) of the biliary tree is extremely rare and is generally a benign condition, though malignant change is possible. Making a differential diagnosis between this lesion and other malignant conditions is very difficult on preoperative imaging studies. Hence, the final diagnosis of IMT may be made during or after operation depending on the pathologic examination. We treated a 63-year-old woman who received right hepatectomy with caudate lobectomy under the suspicion of hilar cholangiocarcinoma. Frozen biopsy during the operation showed carcinoma in situ and there were stromal cells in the bile ducts resection margins. The postoperative hospital course was uneventful except for minor bile leakage. At postoperative month 4, she developed jaundice, ascites and pleural effusion. Computed tomography images showed a mass-like lesion in the porta hepatis with portal vein thrombosis and a right chest wall mass. Excisional biopsy was done and the pathology report was malignant spindle cell tumor suggestive of an aggressive form of IMT. Her condition rapidly deteriorated regardless of the best supportive care and she expired at postoperative month 5. Further investigation is necessary to clarify the reasons for recurrence and infiltration of this disease.

Rectal perforation due to benign stricture caused by rectal burns associated with hot coffee enemas

A 27-year-old woman visited our hospital complaining of lower abdominal and anal pain, developed several minutes after a hot coffee enema to relieve constipation. Abdominopelvic computed tomography (CT) revealed marked wall thickening in the entire rectum and surrounding fluid collection that suggested severe necrotic mucosal change (● Fig.1). Sigmoidoscopy showed necrotic mucosal lesions with hemorrhage and exudates in the rectum (● Fig.2). She recovered with supportive treatment, and follow-up sigmoidoscopy showed benign stricture and ulcer scars (● Fig.3). On the 46th clinical day, the patient revisited the emergency department for terrible abdominal pain that had suddenly developed during straining and bowel movements. She was diagnosed with rectal perforation and peritonitis on the basis of CT scans. Laparoscopy revealed a 4-cm perforation of the upper rectum with fecal soilage (● Fig.4). Primary repair and temporary colostomy was performed. On the 130th clinical day, she was asymptomatic and sigmoidoscopy showed scarring with mild stricture (● Fig.5). Finally, she was discharged in satisfactory condition after a colostomy take-down procedure. In alternative medicine, coffee enemas are used to treat various diseases, including cancer and constipation,without valid evidence of efficacy [1]. The potential complications of coffee enemas are not well known, but include rectal burns, proctocolitis, benign stricture, and even death [2–6]. Recently, three cases of colorectal complications caused by coffee enema were reported, two cases of rectal burns by thermal injury [4,5], and a third case of proctocolitis by chemical irritation [6]. To our knowledge, this is the first case of spontaneous rectal perforation from benign stricture caused by hot coffee enemas, and the first to outline the natural history of rectal burns associatedwith hot coffee enemas. This case suggests that coffee enemas may lead to serious complications and their use as an alternative medical treatment should be reconsidered.

Malposition of a percutaneous endoscopic gastrostomy tube in the jejunum.

for replacement of a percutaneous endoscopic gastrostomy (PEG) tube. He had originally undergone PEG tube placement at our hospital 2 years ago, and after insertion the position of the hub had been checked by gastroscopy. However, placement of the most recent PEG tube had been done at another hospital 1 year ago, with no gastroscopic evaluation. When the patient attended our hospital 1 year later for replacement of the PEG tube, we could not find its hub in the stomach on gastroscopy. Instead, a scar was detected at the previous gastrostomy site. A nonenhanced abdominal computed tomography (CT) scan taken to check the location of the PEG tube revealed that it had been inserted into the small intestine (● Fig. 1a,b). Gastrografin infusion also showed the hub in the small intestine (● Fig. 2). Removal of the malpositioned tube was planned, and we cut the PEG tube at the level of the skin and pushed the remainder of the tube into the lumen, anticipating that the remnant of the PEG tube would be eliminated with stool. After 3 days the hub appeared in the stool. PEG is a safe and effective procedure, but a variety of complications can occur [1]. Croaker and Najmaldin [2] reported that the PEG tube can pass through the small bowel wall, but it is unlikely that this type of malposition would remain undetected and asymptomatic. Treatment involves removal of the PEG tube and repair of the small bowel. Pearce et al. [3] reported safe removal of the tube in 71/73 patients by the cut and push method, without endoscopic support. We conclude that after PEG tube replacement, gastroscopy should be considered for checking the position of the tube and for any evidence of complications.

Intra-ampullary protruding mass: unusual presentation of mucinous carcinoma of the pancreas

hospital with chronic alcoholic pancreati− tis. He had a history of daily intake of al− cohol and intermittent abdominal pain over the past 15 years. The biochemical tests were normal except for a mild in− crease in the gamma glutamyl transpepti− dase level. Cancer antigen (CA) 19±9 was 118.1 U/mL (normal value < 27 U/mL). Ab− dominal computed tomography scan showed an enlarged pancreatic head with calcifications, a marked dilated up− stream pancreatic duct, and parenchymal atrophy (l Fig. 1 a and l Fig. 1 b). Magnetic resonance cholangiopancrea− tography also revealed intraductal filling defects in the dilated pancreatic duct (l Fig. 2). Under the impression of chronic pancreatitis with massive pan− creaticolithiasis, endoscopic retrograde cholangiopancreatography was per− formed. The major papilla was slightly enlarged, and yellowish mucin−like mate− rial was noted at the orifice (l Fig. 3 a). We initially thought that this material might be bile−tinged, fragmented pancre− atic duct stones because the patient had a massive pancreaticolithiasis. However, endoscopic pancreatic sphincterotomy revealed it to be an intra−ampullary soft mass protruding from the pancreas head (l Fig. 3 b). A biopsy was performed and the pathology revealed a mucinous carci− noma with well−defined pools of mucin and malignant epithelial cells (l Fig. 4).