Sung Bum Kim

Characteristics of delayed hemorrhage after endoscopic sphincterotomy.

Background and Aims:  Hemorrhage is one of the most common complications associated with endoscopic sphincterotomy (EST). Although most hemorrhage occurs immediately after EST, delayed hemorrhage may occur, even several days after EST. We analyzed the incidence, clinical features, treatment and risk factors for delayed hemorrhage following EST.

Association between Helicobacter pylori status and metachronous gastric cancer after endoscopic resection

AIM To investigate the effect of Helicobacter pylori (H. pylori) status test and H. pylori eradication on the occurrence of metachronous gastric cancer (MGC) after endoscopic submucosal dissection (ESD) of early gastric cancer (EGC) and risk factors of MGC. METHODS The authors retrospectively reviewed the medical records of 433 patients (441 lesions) who underwent ESD for EGC from January 2005 to January 2015 in Yeungnam University Hospital. Patients were categorized into two groups; the H. pylori tested group (n = 257) and the H. pylori non-tested group (n = 176) based on performance of H. pylori status test after ESD of EGC. The H. pylori tested group was further categorized into three subgroups based on H. pylori status; the H. pylori-eradicated subgroup (n = 120), the H. pylori-persistent subgroup (n = 42), and the H. pylori-negative subgroup (n = 95). Incidences of MGC and risk factors of MGC were identified. RESULTS Median follow-up duration after ESD was 30.00 mo (range, 6-107 mo). Total 15 patients developed MGC during follow-up. MGC developed in 11 patients of the H. pylori tested group (7 in the H. pylori-negative subgroup, 3 in the H. pylori-eradicated subgroup, and 1 in the H. pylori-persistent subgroup) and 4 patients of the H. pylori non-tested group (P > 0.05). The risk factors of MGC were endoscopic mucosal atrophy in the H. pylori tested group and intestinal metaplasia in all patients. CONCLUSION H. pylori eradication and H. pylori status test seems to have no preventive effect on the development of MGC after ESD for EGC. The risk factors of MGC development were endoscopic mucosal atrophy in the H. pylori tested group alone and intestinal metaplasia in all patients.

[Ten-day Sequential Therapy versus Bismuth Based Quadruple Therapy as Second Line Treatment for Helicobacter pylori Infection].

BACKGROUND/AIMS Ten-day sequential therapy has been evaluated as the first line therapy for Helicobacter pylori eradication but studies on sequential therapy as a second line therapy is lacking. The aim of this study was to compare the efficacy of 10-day sequential therapy and quadruple therapy as second line treatment for H. pylori eradication after failure of standard triple therapy. METHODS Patients who did not respond to standard triple therapy for H. pylori eradication were assigned to either 10-day sequential or bismuth based quadruple therapy as second line treatment from January 2009 to December 2014 at Yeungnam University Medical Center. Post treatment H. pylori status was determined by rapid urease test, giemsa staining, or (13)C-urea breath test. Eradication rate and side effects of both therapies were compared. RESULTS A total of 158 H. pylori infected patients were included and 70 patients were treated by bismuth based quadruple therapy and 88 patients by 10-day sequential therapy. Age and sex were not significantly different between the two groups. Eradication rate was 84.3% (59/70) in quadruple group and 56.8% (50/88) in sequential group. Side effects occurred significantly higher in quadruple group than sequential group (27.1% vs. 11.4%, p=0.011). CONCLUSIONS For second line H. pylori eradication after failure of standard triple therapy, bismuth based quadruple therapy showed significantly higher H. pylori eradication rate than 10-day sequential therapy. Further prospective studies are needed to evaluate the efficacy of 10-day sequential therapy as a second line H. pylori eradication treatment.

Risk Factors of Advanced Adenoma in Small and Diminutive Colorectal Polyp

The aims of this study were to review the clinicopathological characteristics of diminutive (≤ 5 mm) and small polyps (> 5 mm but < 10 mm) and to evaluate the risk factors of advanced adenoma for polyps of diameter < 10 mm in the colon. The medical records of 4,711 patients who underwent first colonoscopy at outpatient clinics or health promotion center were reviewed retrospectively. We analyzed the presence and risk factors of advanced adenoma, which was defined as a villous or tubulovillous polyp, high-grade dysplasia or intramucosal carcinoma histologically. Total 5,058 polyps were detected in the 4,711 patients, and 93.0% (4,704/5,058) polyps were < 10 mm in size. Among them, advanced adenoma was noted in 0.6% (28/4,704) with a villous component in 19, high-grade dysplasia in 3, and adenocarcinoma in 6. Advanced and non-advanced adenomas differed significantly in age group, gender, and polyp size. Multivariate analysis showed that an advanced age (> 65 years), a male gender, and a polyp size of > 5 mm were risk factors of advanced adenoma. The incidence of advanced adenoma in polyps of < 10 mm was 0.6%. Polyp size, male gender, and age of > 65 years are independent risk factors of advanced adenoma.

Sex differences in prevalence and risk factors of asymptomatic cholelithiasis in Korean health screening examinee: A retrospective analysis of a multicenter study.

Abstract The aim of this study was to evaluate sex difference in the prevalence and risk factors for asymptomatic cholelithiasis in Korean health screening examinees. Examinees who underwent examination through health promotion center at 5 hospitals of Daegu-Gyeongbuk province in 2014 were analyzed retrospectively. All examinees were checked for height, weight, waist circumference, and blood pressure, and underwent laboratory tests and abdominal ultrasound. Diagnosis of cholelithiasis was made by ultrasound. Of the total of 30,544 examinees, mean age was 47.3 ± 10.9 years and male to female ratio was 1.4:1. Asymptomatic cholelithiasis was diagnosed in 1268 examinees with overall prevalence of 4.2%. In age below 40 years, females showed higher prevalence of asymptomatic cholelithiasis than males (2.7% vs. 1.9%, P = 0.020), whereas prevalence of asymptomatic cholelithiasis was higher in males than females older than 50 years (6.2% vs. 5.1%, P = 0.012). Multiple logistic regression analysis revealed age (≥50 years), obesity, and high blood pressure as risk factors for asymptomatic cholelithiasis in males and age, obesity, hypertriglyceridemia, and chronic hepatitis B infection in females (P < 0.05). Overall prevalence of asymptomatic cholelithiasis was 4.2% in Korean health screening examinees. Females showed higher prevalence of asymptomatic cholelithiasis than males younger than 40 years, whereas it was higher in males older than 50 years. Age and obesity were risk factors for asymptomatic cholelithiasis in both sexes. Males had additional risk factors of high blood pressure and females had hypertriglyceridemia and chronic hepatitis B infection.

Hepatology: Fascioliasis: A rare cause of hepatic pseudoaneurysmal rupture

A 54-year-old female visited our emergency department with a complaint of severe whole abdominal pain for a day. She had been admitted to our hospital one month ago and diagnosed as hyperesosinophilic syndrome due to peripheral eosinophilia and hepatic infiltration and was on treatment with oral steroid. Vital signs were unremarkable. General appearance was acutely ill looking and there was tenderness on whole abdomen, especially right upper quadrant. Laboratory findings were as follows; hemoglobin 7.5 g/dL, white blood cell, 8,650 /mm, eosinophil segment, 25.7%, platelet 303,000 /mm and peripheral eosinophil count, 2,600 K/μL. Abdominal computed tomography (CT) scan showed subcapsular hemorrhage and hemoperitoneum with suspicious ongoing bleeding within segment 6 and multiple low density infiltrations on both lobes of liver accompanied by a cystic duct stone (Fig 1a). Hepatic angiogram revealed pseudoaneurysm with active bleeding at A6 branch of hepatic artery and obliteration by transarterial embolization with coil and gelform was successfully performed. On the 49 day of hospitalization, total bilirubin level was elevated to 4.1 mg/dL and follow up abdominal CT scan showed an impacted distal common bile duct (CBD) stone and endoscopic retrograde cholangiopancreatography (ERCP) showed an amorphous filling defect at proximal CBD. Following the sphincterotomy, a black pigment stone was removed (Fig. 1b) and an about 1.6 cm sized, movable liver fluke was extracted by sweeping with a retrieval balloon (Fig. 1c). Pathologic examination of the fluke was confirmed as fasciola hepatica. She was treated with triclobendazole. Pseudoaneurysm of hepatic artery may arise from inflammation or infection of liver, including fasciola hepatica. Pseudoaneurymal rupture is rare but, has a high mortality. Differential diagnosis with fascioliasis and toxocariasis should be needed in cases with peripheral eosinophilia and migrating multiple hepatic involvements. We report a case of hemoperitoneum and subcapsular hemorrhage following pseudoaneurymal rupture caused by fasciola hepatica, directly visualized on ERCP.

Successful stone removal by endoscopic retrograde cholangiopancreatography in situs inversus totalis with Billroth-II gastrectomy.

An 82-year-old female with a history of situs inversus totalis visited our hospital with complaints of abdominal pain and fever for 2 days. She had history of diabetes mellitus, cerebral infarction, and Alzheimer’s disease, and underwent Billroth-ll (B-II) gastrectomy due to stomach cancer 15 years previously. General appearance was acute ill looking and there was tenderness on right upper quadrant of abdomen. Laboratory findings were as follows: white blood cell, 22,120/mm3; total bilirubin, 3.63 mg/dL; direct bilirubin, 3.57 mg/dL; aspartate aminotransferase, 625 IU/L; alanine aminotransferase, 629 IU/L; alkaline phosphatase, 2,132 IU/L; and γ-glutamyl transpeptidase, 363 IU/L. An abdominal computed tomography scan revealed transposition of the visceral organs from the right to left side and a stone in the dilated common bile duct (CBD) (Fig. 1). Endoscopic retrograde cholangiopancreatography (ERCP) was performed with a cap-assisted forward-viewing endoscope (Olympus, Tokyo, Japan) in patient with gastrojejunostomy (Fig. 2). A cholangiogram revealed transposition of the pancreatic duct oriented to the right side and the gallbladder and dilated CBD with a floating stone to the left side (Fig. 3). After biliary cannulation using catheter with a straight end at the 7 o’clock direction of major papilla, a guidewire was placed across the ampullary orifice (Fig. 4). Following endoscopic papillary balloon dilatation (EPBD) using a controlled radial expansion balloon (10 mm; Boston Scientific Microvasive, Cork, Ireland), a CBD stone was successfully retrieved using a basket (Fig. 5). Fig. 1 Abdominal computed tomography scan (coronal view) showing situs inversus totalis and a bile duct stone (white arrow) and multiple gall bladder stones. Fig. 2 A cap-fitted forward-viewing endoscope demonstrating Billroth-II gastrectomy with gastrojejunostomy status. Fig. 3 A cholangiogram of endoscopic retrograde cholangiopancreatography demonstrating transposition of pancreatic duct oriented to the right side and gallbladder and dilated common bile duct with a movable filling defect to the left side. Fig. 4 A cap-fitted forward-viewing endoscope showing guide wire placed in orifice of bile duct at 7 o’clock position. Fig. 5 A complete stone removal using endoscopic papillary balloon dilatation. Although a few cases of modified ERCP techniques in situs inversus have been reported,1–5 this is the first report of ERCP in situs inversus totalis combined with B-II gastrectomy. Comparing ERCP using conventional duodenoscope in situs inversus totalis, access to the major papilla with forward-viewing endoscope in situs inversus with B-ll gastrectomy status seems to be technically safer and easier. In this case, neither a patient nor an endoscopist require any positional change during ERCP. Our case demonstrates that CBD stone removal by EPBD can be safely performed, even in a case of B-II gastrectomy combined with situs inversus totalis.

Hepatobiliary and Pancreatic: Intrahepatic cholangiocarcinoma with distant cutaneous metastases to the face: Hepatobiliary and Pancreatic: Intrahepatic cholangiocarcinoma with distant cutaneous metastases to the face

A 62-year-old man was admitted to our hospital with a 2-month history intermittent epigastric discomfort. He felt general weakness and had lost 5 kg. His past medical and familial history were unremarkable. Physical examination revealed several erythematous papules on his forehead and left lower lip that varied in size and appeared 2 months ago (Fig. 1a and b). Blood examination revealed the following values: white blood cells, 11 740/μL; hemoglobin, 12.1 g/dL; platelets, 161 × 10/μL; serum albumin, 3.67 g/ dL; serum bilirubin, 1.01 mg/dL; serum aspartate aminotransferase, 67 IU/L; serum alanine aminotransferase, 53 IU/L; serum alkaline phosphatase, 376 IU/L; and serum gamma-glutamyl transferase, 438 IU/L. Abdominal computed tomography (CT) revealed multiple lower-density masses in both lobes of the liver (Fig. 1c). Ultrasound-guided percutaneous needle biopsy of the liver mass and punch biopsy of a forehead papule were performed. The results of both biopsies showed moderately differentiated adenocarcinoma as confirmed by positive immunohistochemical staining for cytokeratin 7 and cytokeratin 19 (Fig. 2). The serum cancer antigen 19-9 level was 4877 (normal range: 0–37) U/mL. Based on these findings, the patient was finally diagnosed with intrahepatic cholangiocarcinoma with distant cutaneous metastases to the face. Chemotherapy was not administered because of the patient’s poor performance status and he subsequently died 2 months after diagnosis. Cutaneous metastases from internal malignancies are rare, occurring in only 0.7–9% of cases. Cholangiocarcinoma accounts for 2% of all cancers and is an extremely rare cause of cutaneous metastases. Although approximately 21 cases have been published from 1978 to 2014, only eight have reported distant cutaneous metastasis as the first sign of cholangiocarcinoma. Cutaneous metastases from cholangiocarcinoma can be divided into two subtypes: distant metastases and direct cutaneous invasion through percutaneous biliary drainage catheter, which occur with similar frequency. The gross morphology of cutaneous metastases mostly comprises erythematous nodules, papules, or plaques ranging from solitary to multiple lesions; however, morphea-like sclerotic cutaneous metastases have also been reported. The scalp is the most common site of cutaneous metastasis from cholangiocarcinoma. To the best of our knowledge, this report presents the first case of distant cutaneous metastases from cholangiocarcinoma that was confined to the face. The mechanism is thought to be hematogenous dissemination through the Batson venous plexus of the vertebrae, which have no valves; therefore, tumor cells can settle in the intracranial sinus and cause skin metastasis. Previous reports showed that cutaneous metastases indicate advanced-stage cancer and were associated with poor prognosis. The median survival of patients with cutaneous metastases from cholangiocarcinoma was only 4 months, ranging from 21 days to 12 months. In the present case, the patient deteriorated within 2 months following diagnosis. Physicians should consider the possibility of cutaneous metastasis if patients have skin lesions, particularly in those with a history of malignancy.

Splenic rupture following transcatheter arterial embolization of splenic artery pseudoaneurysm caused by acute pancreatitis.

A 32-year-old man visited our emergency department complaining of severe left upper quadrant abdominal pain. He had history of alcoholic acute pancreatitis complicated with multiple peripancreatic pseudocysts and splenic vein thrombosis with splenic artery pseudoaneurysm and obliteration of the pseudoaneurysm was done by transarterial coil embolization 6 months ago. An abdominal computerized tomography scan at admission showed decreased perfusion at lower pole of spleen with focal splenic infarct, fluid collection at adjacent areas of pancreatic tail and stomach, and pseudocyst at pancreatic tail (Fig. 1). The patient received conservative treatment. On the 16th day of hospitalization, sudden onset of severe abdominal pain developed. His blood pressure declined to 80/50 mmHg, and remained to be persistently below 90 mmHg despite intravenous fluid therapy and use of inotropics. An emergent abdominal computed tomography scan revealed hemoperitoneum with active bleeding around splenic hilum and pancreatic tail (Fig. 2). An emergency surgery was performed and pin point bleeding from lateral wall of spleen was noted. Splenectomy with clipping of short gastric and splenic vessels was done. The patient was discharged without complication on the 10th postoperative day. Figure 1. Abdominal computed tomography scan at admission. Decreased splenic perfusion and focal splenic infarct (arrow) were noted. Figure 2. Abdominal computed tomography scan at the time of hemoperitoneum. Active bleeding around the spleen (arrow) and hemoperitoneum had developed. Pseudoaneurysm of the splenic artery, infarction, and rupture of the spleen are uncommon complications of acute or chronic pancreatitis. In our case, splenic vein thrombosis and adhesion around the pancreas and spleen due to previous severe acute pancreatitis as well as decreased splenic perfusion due to embolization may have contributed to development of splenic infarction with rupture. Treatment of a ruptured spleen depends primarily on hemodynamic stability of the patient, followed by extent of spleen injury and degree of hemoperitoneum. In our case, the patient underwent surgery due to hemodynamic instability. We report a case of splenic infarction and subsequent splenic rupture, treated by open splenectomy, following transcatheter embolization of an asymptomatic splenic artery pseudoaneurysm associated with acute pancreatitis.

A case report of motesanib-induced biliary sludge formation causing obstructive cholangitis with acute pancreatitis treated by endoscopic sphincterotomy.

Background: Gallbladder toxicity was reported in most motesanib studies with varying frequency and at variable times after initiation of treatment. Method and Results: A 44-year-old man was admitted due to severe epigastric pain. The patient was diagnosed with non–small cell lung cancer 9 months ago and received 6 cycles of chemotherapy with motesanib, paclitaxel, and carboplatin. Ultrasonography showed a large amount of sludge within gallbladder. Computed tomography scan demonstrated diffuse dilatation of biliary tree with distended gallbladder without evidence of stone and mild pancreatic swelling. Endoscopic retrograde cholangiopancreatography showed yellowish viscous mucoid plug impacting ampullary orifice and dilated bile duct with amorphous filling defect at distal half of common duct. Endoscopic sphincterotomy was performed to prevent biliary obstruction and recurrent pancreatitis after removal of mucoid material. Conclusion: To the best of our knowledge, this is the first report of obstructive cholangitis and acute pancreatitis associated with sludge formation during motesanib therapy. Endoscopic sphincterotomy appears to be useful to treat and prevent biliary obstruction caused by motesanib-induced biliary sludge.