We report a patient who developed a Barrett,s esophageal ulcer 10 years after esophagomyotomy for achalasia. A-59-year-old female was admitted to the hospital with dysphagia for 2 months. In 1982, she had undergone a modified Heller esophagomyotomy for achalsia. After esophagogram, esophageal manometry, 24hr esophageal pH monitoring, esophagoscophy achalasia and Barrett,s esophageal ulcer was diagnosed. So, she had been treated with omeprazole and sucralfate and has been followed up in a asymtomatic state currently. In Barrett,s esophagus, there is a metaplasia of the normal stratified squamous mucosa to columnar epithelium, caused by the reflux of acid. It appears in approximately 10% of patients with chronic gastroesophageal reflux and is associated with increased probability of adenocarcinoma of the esophagus. Among the predis- posing factors of gastroesophageal reflux, there is treatment of esophageal achalsia by forceful dilatation or by the esophagomyotomy. The resultant ralaxation of lower esophageal sphinter, combined with deficient propulsive esophageal peristalsis, predisposed to gastroesophageal reflux. Actually an increased incidence of gastroesophageal reflux, esophagitis and stricture are well-known complications after esophagomyotomy. But in spite of higher risk of gastroesophageal reflux after esophagomyotomy the development of Barrett,s mucosa has been rarely reported and only recently recognized. Diagnosis of Barrett,s esophagus in such patients is difficult and the cumulative effects of achalasia and Barrett's esophagus predispose these patient to higher risk of developing esophageal carcinoma. So, high index of awareness and regular endoscopic surveillance are required.
Adenocarcinoma ; Barrett Esophagus ; Constriction, Pathologic ; Deglutition Disorders ; Diagnosis ; Dilatation ; Epithelium ; Esophageal Achalasia* ; Esophageal pH Monitoring ; Esophagitis ; Esophagus ; Female ; Gastroesophageal Reflux ; Humans ; Incidence ; Manometry ; Metaplasia ; Mucous Membrane ; Omeprazole ; Peristalsis ; Sucralfate ; Ulcer*

No abstract available.

PURPOSE: To evaluate the technical feasibility and safety of vascular plug assisted retrograde transvenous obliteration (PARTO) for bleeding gastric varix performed in the emergent clinical setting and describe the mid-term clinical results. MATERIALS AND METHODS: From April 2012 to January 2015, emergent PARTO was tried in total 9 patients presented with active gastric varix bleeding. After initial insufficient or failure of endoscopic approach, they underwent PARTO in the emergent clinical setting. Gelatin sponge embolization of both gastrorenal (GR) shunt and gastric varix was performed after retrograde transvenous placement of a vascular plug in GR shunt. Coil assisted RTO (CARTO) was performed in one patient who had challenging GR shunt anatomy for vascular plug placement. Additional embolic materials, such as microcoils and NBCA glue-lipiodol mixture, were required in three patients to enhance complete occlusion of GR shunt or obliteration of competitive collateral vessels. Clinical success was defined as no variceal rebleeding and disappearance of gastric varix. RESULTS: All technical and clinical success-i.e., complete GR shunt occlusion and offending gastric varix embolization with immediate bleeding control-was achieved in all 9 patients. There was no procedure-related complication. All cases showed successful clinical outcome during mean follow up of 17 months (12-32 months), evidenced by imaging studies, endoscopy and clinical data. In 4 patients, mild worsening of esophageal varices or transient ascites was noted as portal hypertensive related change. CONCLUSION: Emergent PARTO is technically feasible and safe, with acceptable mid-term clinical results, in treating active gastric varix bleeding.
Aged ; Ascites/complications ; Balloon Occlusion ; Embolization, Therapeutic ; *Emergency Medical Services ; Esophageal and Gastric Varices/*complications ; Feasibility Studies ; Female ; Gastrointestinal Hemorrhage/*complications/*therapy ; Humans ; Male ; Middle Aged

BACKGROUND/AIMS: It has been unclear whether immediate antiviral therapy or observation under the expectation of spontaneous inactivation of hepatitis B virus (HBV), is more appropriate for the treatment of chronic hepatitis B (CHB) with acute exacerbation. We intended to analyze the short-term natural course of CHB with acute exacerbation and evaluate the efficacy of lamivudine. METHODS: We analyzed 35 CHB patients with acute exacerbation (positive HBV DNA or HBeAg and ALT>400 IU/L) between March 2000 and May 2003. We regularly checked serum HBV DNA, HBeAg and liver function tests including ALT every 1 to 3 months. If ALT was above 100 IU/L during the follow-up period, patients were treated with 100 mg lamivudine orally once a day. We compared the efficacy of lamivudine use between this group and the group provided with immediate lamivudine trial at their first visit. RESULTS: 27 CHB patients with acute exacerbation were observed without immediate lamivudine trial. In 5 of these patients normal ALT, negative HBeAg and HBV DNA were maintained during 19 months (group 1a). Slightly elevated or normal ALT was maintained without HBeAg seroconversion in 3 patients (group 1b). However, serum ALT flared up above 100 IU/L in 19 patients within 5 months. So, lamivudine was tried on these patients (group 2). The serum HBV DNA was extremely low, being 6.5 pg/mL in group 1a compared to 518.1 pg/mL in group 2. Spontaneous inactivation of HBV was observed in 71.4% (5/7) of patients with HBV DNA less than 20 pg/ mL at the first visit. ALT was lower and HBV DNA was higher in group 2 than the 8 patients who received immediate lamivudine trial at the first visit (group 3). The response rate of lamivudine was similar between group 2, 56.3% (9/16) and group 3, 62.5% (5/8). CONCLUSIONS: Spontaneous inactivation of HBV was expected in CHB with acute exacerbation and extremely low level of HBV DNA (less than 20 pg/mL) in a short term follow-up period. Immediate lamivudine therapy might be more appropriate in most CHB patients with acute exacerbation.
Acute Disease ; Adolescent ; Adult ; Anti-HIV Agents/*therapeutic use ; English Abstract ; Female ; Hepatitis B, Chronic/*drug therapy/virology ; Humans ; Lamivudine/*therapeutic use ; Male ; Middle Aged

BACKGROUND: Peroral cholangioscopy (PCS) was usually conducted for a differential diagnosis in cases which were difficult to diagnose on a routine endoscopic retrograde cholangiogram (ERC) or during fragmentation of a large bile duct stone with electrohydraulic lithotripsy. This study was conducted to evaluate the clinical utility of a PCS in biliary diseases. METHOD: We retrospectively reviewed the clinical records of 31 patients in whom a PCS was performed to evaluate various biliary diseases from July 1991 to Aug. 1996. RESULT: A peroral cholangioscope was successfully inserted into the bile duct in 90.3% (28/31) of the patients. The underlying diseases included bile duct stones (11 cases), bile duct cancer (9 cases), benign bile duct strictures (2 cases), benign bile duct turnors (2 cases), biliary cystadenocarcinoma (2 cases), emboli of the HCC in the bile duct(1 case), and common bile duct polyposis (1 case). Most PCSs were performed for the differential diagnosis between benign and malignant bile duct strictures or obstructions (14 cases) and fragmentation of large bile duct stone with electrohydraulic lithotripsy (10 cases). Overall, the success rate was 78.6% (22/28) in achieving the purpose 88.9% (16/18) in diagnostic aim and 60.0% (6/10) in therapeutic aim. Complications from the PCS occurred in 4 cases (14.3%). Cholangitis and acute pancreatitis was found in 1 case and asymptomatic hyperamylasemia were discovered in 2 cases. CONCLUSION: PCS plays a major role in confirming difficult cases to diagnose using on ERC and fragment to remove large cornmon bile duct stones.
Bile ; Bile Duct Neoplasms ; Bile Ducts ; Cholangitis ; Common Bile Duct ; Constriction, Pathologic ; Cystadenocarcinoma ; Diagnosis, Differential ; Humans ; Hyperamylasemia ; Lithotripsy ; Pancreatitis ; Retrospective Studies

Hepatitis B virus (HBV) reactivation is the frequent complication after cytotoxic chemotherapy in HBsAg-positive non-Hodgkin's lymphoma (NHL) patients. Pre-chemotherapy viral load may be a risk factor and HBeAg-positive status is associated with increased viral load. The aim of this study was to investigate the long-term treatment outcome of lamivudine in preventing HBV reactivation and its associated morbidity according to HBeAg status. Twenty-four adult HBsAg-positive NHL patients were taken 100mg of lamivudine daily before the initiation of chemotherapy. The median duration of lamivudine therapy was 11.5 months (range: 1-54 months) and the median number of chemotherapy cycles was 6 (range: 1-16 cycles). The steroid containing chemotherapy regimens were used in 18 patients (75%), and the anti-CD20 monoclonal antibody containing chemotherapy regimen was used in 6 patients (25%). Four patients received autologous peripheral blood stem cell transplantation without resultant HBV reactivation. Hepatitis related to HBV reactivation was developed in 1 patient among 14 HBeAg-positive patients and no one among 10 HBeAg-negative. One patient developed HBV reactivation after lamivudine withdrawal, and 4 patients developed the YMDD (tyrosine-methionine-aspartate-aspartate) mutation during lamivudine therapy. There were no statistical differences in HBV reactivation rate during chemotherapy according to the HBeAg status. Our results demonstrate that lamivudine should be considered preemptively before the chemotherapy for all HBsAg-positive NHL patients to prevent HBV reactivation, regardless of pre-chemotherapy HBeAg status. Finally, compared with the chronic hepatitis B patients, similar rate of HBV reactivation after lamivudine withdrawal and development of YMDD mutation was observed in NHL patients.

Background/Aims: Colonic stenting as a bridge to elective surgery is an alternative for emergency surgery in patients with acute malignant colonic obstruction. However, since its benefits are uncertain, we aimed to establish whether it has better clinical outcomes. Methods: The patients with acute malignant left-sided colon obstruction enrolled from January 2009 to December 2018 in National Health Insurance Service Ilsan Hospital. The patients were enrolled to undergo colonic stenting as a bridge to elective surgery or emergency surgery. The following oncological outcomes were assessed: incidence of complete remission, disease progression, local recurrence, and systemic recurrence. Results: Out of 40 patients, 33 received self-expanding metallic stent (SEMS) as a bridge-tosurgery, and 7 underwent emergency surgery. More stoma was made in case of emergency surgery with statistical significance (p < 0.001). There were no significant differences in complete remission rate in curable left-sided malignant colonic obstruction between SEMS as a bridgeto-surgery and emergency surgery. Complete remission was achieved for 3 patients (42.9%) in the non-stent group and 27 patients (81.8%) in the stent group. There was no statistically significant difference in oncologic outcomes between the two groups (p = 0.069). According to multi-variate analysis, advanced TNM stage, Adjuvant chemotherapy, and SEMS bridge-tosurgery were significantly associated with disease-free survival. Disease-free survival rate differed significantly between the two groups (p = 0.024). Conclusions SEMS as a bridge-to-surgery might be an effective strategy and reduce stoma formation in acute malignant left-sided colon obstruction.

PURPOSE: To estimate long-term outcomes after treatment modification in patients with chronic hepatitis B (CHB) treated with entecavir (ETV) and telbivudine (LdT). MATERIALS AND METHODS: The study enrolled 131 nucleos(t)ide analogue (NA)-naïve CHB patients treated with ETV or LdT. During the 3-year study, NA treatment history including the incidence, the type of treatment modification, reasons for the modification, and overall complete virologic response (CVR) rate were retrospectively evaluated using the patients' medical records. RESULTS: Among the 131 patients, 84 and 47 were initially treated with ETV and LdT, respectively. During the course of 3-year study, 82 patients in the ETV group (97.6%) maintained initial treatment whereas only 19 in the LdT group (40.4%). In the LdT group, 26 patients (92.9%) switched to another NA and another NA was added in 2 (7.1%) patients. An assessment of the CVR rate at 3 years, including treatment modification, showed that 89.3% and 95.7% of patients in the ETV and LdT groups, respectively, had undetectable serum hepatitis B virus DNA levels (p=0.329). Among LdT patients with treatment modification, the cumulative incidence rate of a CVR for rescue therapy was significantly higher in the tenofovir than in the ETV group (p=0.009). CONCLUSION: During the 3-year study, there were no significant differences in the CVR between the ETV and LdT groups if appropriate rescue therapy was considered.
DNA ; Hepatitis B virus ; Hepatitis B, Chronic* ; Hepatitis, Chronic* ; Humans ; Incidence ; Medical Records ; Retrospective Studies ; Tenofovir

BACKGROUND/AIMS: Viral suppression of the hepatitis B virus (HBV) can be induced by lamivudine, but the relapse seen in many patients after cessation of lamivudine therapy is troublesome. We thought that the host immune response is important to prevent viral relapse. We compared the frequency of HBV-specific CD8+ T cells in the peripheral blood and their expansion capacity after exposure to viral antigen between the patients showing sustained HBeAg seroconversion after use of lamivudine and those patients without sustained response. METHODS: We analyzed HBV-specific CD8+ T cells that were isolated from the blood of 14 patients with HLA-A2 who showed lamivudine induced HBeAg seroconversion (HBV DNA < 0.5 pg/mL, and the cells were negative for HBeAg) at the end of lamivudine therapy. The purified T cells were directly stained ex vivo, after they had been stimulate with synthetic peptide, using the HBV core 18-27-specific HLA tetramer (Tc 18-27) and monoclonal antibody to CD8. The HBV viral load was quantified by the Amplicor HBV Monitor assay. RESULTS: In patients with a sustained HBeAg response (the sustained group) for a duration of 15.5 months of follow-up, the median number of Tc 18-27 cells out of the 5 X 10(4) CD8+ T cells was 49.5 (15-135). On the contrary, in patients who experienced relapse (the relapsed group) during a median of 7.5 months of follow-up, the median number of Tc 18-27 cells out of the 5 X 10(4) CD8+ T cells was 13.5 (0-95). Especially, among patients with a viral load of HBV DNA < 1 X 10(3) copies at the end of treatment, the median number of Tc 18-27 cells out of 5 X 10(4) CD8+ T cells was 87 (45-135) in sustained group compared to 12 (6-50) in the relapsed group. All patients in the sustained group demonstrated a vigorous expansion of the core 18-27-specific CD8+ T cells after stimulation with viral peptide, in contrast to only 3 out of 8 patients in the relapsed group. CONCLUSIONS: This study demonstrates that the frequency and functional responsiveness of the circulating HBV-specific CD8+ T cells may be important for obtaining a sustained HBeAg response to lamivudine.
Adult ; Antiviral Agents/*therapeutic use ; CD8-Positive T-Lymphocytes/*immunology ; English Abstract ; Female ; Hepatitis B/drug therapy/*immunology/virology ; Hepatitis B e Antigens/*blood ; Hepatitis B virus/*immunology ; Humans ; Lamivudine/*therapeutic use ; Male ; Recurrence ; Viral Load

OBJECTIVES: The course after hepatitis B virus infection appears not to be related to variations in virulence of the HBV itself and may be influenced by the host immune response, which in turn may be regulated by the major histocompatibility complex. The purpose of this study was to determine whether the clearance of HBV was related to a particular HLA allele in Korean. METHODS: We studied total 1372 Korean persons who had visited Yonsei University Medical Center for renal transplantation from January in 1990 to August in 1997. Hepatitis B-viral markers and HLA-DR types were examined by retrospective study. RESULTS: 1) Among 1372 subjects, 924 were male and 448 were female(Mean age, M:37.4yrs, F:38.3yrs). Healthy donors in total subjects were 424. 2) Commonly, HLA-DR4 was most frequent among the total subjects, also in the group of Non-Exposure, Chronic Carrier, Clearance, and Antibody. 3) HLA-DR6 was significantly frequent in the group of Clearance and Antibody compared with the group of Chronic Carrier(p<0.001, RR=3.72 and p<0.001, RR=3.58, respectively). HLA-DR9 was significantly frequent in the group of Chronic Carrier compared with the group of Clearance and Antibody(p<0.001, RR=3.33 and p<0.001, RR=3.32). Results in healthy donors were same as above. 4) HLA-DR13 was significant between the HLA-DR6 subgroups(DR13, DR14) which may influence the clearance of HBV. CONCLUSION: HLA-DR6(esp, HLA-DR13) may be associated with elimination of HBV as one of the host factors influencing the immune response to HBV and HLA-DR9 with persistent HBV infection.
Academic Medical Centers ; Alleles ; Hepatitis B virus* ; Hepatitis B* ; Hepatitis* ; HLA-DR Antigens* ; HLA-DR4 Antigen ; HLA-DR6 Antigen ; Humans ; Kidney Transplantation ; Major Histocompatibility Complex ; Male ; Retrospective Studies ; Tissue Donors ; Virulence