We report a case of a man who developed duodenal bleeding caused by direct hepatocellular carcinoma (HCC) invasion, which was successfully treated with endoscopic ethanol injection. A 57-year-old man with known HCC was admitted for melena and exertional dyspnea. He had been diagnosed with inoperable HCC a year ago. Urgent esophagogastroduodenoscopy (EGD) showed two widely eroded mucosal lesions with irregularly shaped luminal protruding hard mass on the duodenal bulb. Argon plasma coagulation and Epinephrine injection failed to control bleeding. We injected ethanol via endoscopy to control bleeding two times with 14 cc and 15 cc separately without complication. Follow-up EGD catched a large ulcer with necrotic and sclerotic base but no bleeding evidence was present. He was discharged and he did relatively well during the following periods. In conclusion, Endoscopic ethanol injection can be used as a significantly effective and safe therapeutic tool in gastrointestinal tract bleeding caused by HCC invasion.
Argon Plasma Coagulation ; Carcinoma, Hepatocellular ; Cytochrome P-450 CYP1A1 ; Dyspnea ; Endoscopy ; Endoscopy, Digestive System ; Epinephrine ; Ethanol ; Follow-Up Studies ; Gastrointestinal Tract ; Hemorrhage ; Humans ; Melena ; Middle Aged ; Phenobarbital ; Ulcer

BACKGROUND/AIMS: Three-dimensional (3D) imaging is gaining popularity and has been partly adopted in laparoscopic surgery or robotic surgery but has not been applied to gastrointestinal endoscopy. As a first step, we conducted an experiment to evaluate whether images obtained by conventional gastrointestinal endoscopy could be used to acquire quantitative 3D information. METHODS: Two endoscopes (GIF-H260) were used in a Borrmann type I tumor model made of clay. The endoscopes were calibrated by correcting the barrel distortion and perspective distortion. Obtained images were converted to gray-level image, and the characteristics of the images were obtained by edge detection. Finally, data on 3D parameters were measured by using epipolar geometry, two view geometry, and pinhole camera model. RESULTS: The focal length (f) of endoscope at 30 mm was 258.49 pixels. Two endoscopes were fixed at predetermined distance, 12 mm (d12). After matching and calculating disparity (v2-v1), which was 106 pixels, the calculated length between the camera and object (L) was 29.26 mm. The height of the object projected onto the image (h) was then applied to the pinhole camera model, and the result of H (height and width) was 38.21 mm and 41.72 mm, respectively. Measurements were conducted from 2 different locations. The measurement errors ranged from 2.98% to 7.00% with the current Borrmann type I tumor model. CONCLUSIONS: It was feasible to obtain parameters necessary for 3D analysis and to apply the data to epipolar geometry with conventional gastrointestinal endoscope to calculate the size of an object.
Aluminum Silicates ; Endoscopes ; Endoscopes, Gastrointestinal ; Endoscopy, Gastrointestinal ; Laparoscopy ; Pilot Projects ; Resin Cements

BACKGROUND/AIMS: Hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors (statins) and peroxisome proliferator-activated receptor gamma (PPARgamma) ligands can modulate cellular differentiation, proliferation, and apoptosis through various pathways. It has been shown that HMG-CoA reductase inhibitors and PPARgamma agonists separately inhibit pancreatic stellate cell (PaSC) activation. We studied the effects of a combination of both types of drugs on activated PaSCs via platelet-derived growth factor (PDGF), which has not previously been reported. The present study was performed to elucidate the underlying mechanisms of these effects by focusing on the impact of the signaling associated with cell-cycle progression. METHODS: Primary cultures of rat PaSCs were exposed to simvastatin and troglitazone. Proliferation was quantified using the BrdU method, and cell-cycle analysis was performed using a fluorescent activated cell sorter. The protein expression levels of smooth muscle actin (SMA), extracellular signal-regulated kinase (ERK), and a cell cycle machinery protein (p27Kip1) were investigated using Western blot analysis. RESULTS: Simvastatin reversed the effects of PDGF on cell proliferation in a dose-dependent manner. The combination of a low concentration of simvastatin (1 mM) and troglitazone (10 mM) synergistically reversed the effects of PDGF on cell proliferation but had no effect on cell viability. The expression of a-SMA was markedly attenuated by combining the two drugs, which blocked the cell cycle beyond the G0/G1 phase by reducing the levels of phosphorylated ERK and reversed the expression of p27Kip1 interrupted by PDGF. CONCLUSIONS: Simvastatin and troglitazone synergistically inhibited cell proliferation in activated PaSCs by blocking the cell cycle beyond the G0/G1 phase. This inhibition was due to the synergistic modulation of the ERK pathway and the cell cycle machinery protein p27Kip1.
Actins ; Acyl Coenzyme A ; Animals ; Apoptosis ; Blotting, Western ; Bromodeoxyuridine ; Cell Cycle ; Cell Proliferation ; Cell Survival ; Chromans ; Hydroxymethylglutaryl-CoA Reductase Inhibitors ; Ligands ; MAP Kinase Signaling System ; Muscle, Smooth ; Oxidoreductases ; Pancreatic Stellate Cells ; Phosphotransferases ; Platelet-Derived Growth Factor ; PPAR gamma ; Rats ; Simvastatin ; Thiazolidinediones

BACKGROUND/AIMS: To investigate the efficacy of early scheduled follow-up endoscopic retrograde cholangiopancreatography (ERCP) after common bile duct (CBD) stone removal. METHODS: Patients who underwent endoscopic CBD stone removal and who had at least one risk factor for stone recurrence were enrolled. Six months after complete clearance of the CBD, patients underwent follow-up ERCP at an ambulatory care center, irrespective of symptoms. RESULTS: The incidence of symptoms and cholangitis at follow-up ERCP was significantly lower in Group A (ERCP at 6 months after stone removal) than that in Group B (ERCP at >6 months) (14.3% vs 71.4%, p=0.00; 9.5% vs 33.3%, p=0.02, respectively). However, the recurrence rates of CBD stones were not different between Groups A and B (33.3% vs 47.6%). When comparing the subgroups, Group AR (stone recurrence in Group A) displayed significantly fewer symptoms and lesser cholangitis and spent fewer days in the hospital than did Group BR (stone recurrence in Group B) (21.4% vs 70%, p=0.02; 14.3% vs 60%, p=0.02; 2.43+/-1.87 vs 6.10+/-3.35, p=0.00, respectively). CONCLUSIONS: Our data suggest that, irrespective of symptoms, early scheduled follow-up ERCP for patients who are at a high risk of recurrence is effective and safe.
Ambulatory Care ; Cholangiopancreatography, Endoscopic Retrograde ; Cholangitis ; Common Bile Duct ; Follow-Up Studies ; Humans ; Incidence ; Recurrence ; Risk Factors

Myocardial involvement with clinical symptoms is a rare manifestation of systemic lupus erythematosus (SLE), despite the relatively high prevalence of myocarditis at autopsies of SLE patients. In this review, we report the case of a 19-year-old male SLE patient who initially presented with myopericarditis and was successfully treated with high dose of glucocorticoids.
Autopsy ; Glucocorticoids ; Humans ; Lupus Erythematosus, Systemic ; Male ; Myocarditis ; Pericarditis ; Prevalence ; Young Adult

A 65-year-old woman was referred for management of chest pain and ST segment elevation on electrocardiography. Emergency coronary angiography revealed a well demarcated thrombus that near totally occluded the mid portion of the left anterior descending artery, with a Thrombolysis In Myocardial Infarction (TIMI) flow grade 1, and a fusiform aneurysm on the left main coronary artery. No significant stenosis was observed after aspiration of the thrombus; however, complete coronary reperfusion by urgent aspiration did not improve her dyspnea and tachypnea. Echocardiography revealed a D-shaped left ventricle; thus, we performed a chest computed tomography scan and diagnosed a pulmonary embolism. The patient's coagulation studies were normal. She was prescribed chronic anticoagulation, and we carried out transthoracic echocardiography using second harmonic imaging with agitated saline. Second harmonic imaging with the Valsalva maneuver revealed no right-to-left shunt. We report here a case of concurrent coronary embolism and pulmonary embolism without right-to-left shunt.
Aged ; Aneurysm ; Arteries ; Chest Pain ; Constriction, Pathologic ; Coronary Aneurysm ; Coronary Angiography ; Coronary Vessels ; Dihydroergotamine ; Dyspnea ; Echocardiography ; Electrocardiography ; Embolism ; Emergencies ; Female ; Humans ; Myocardial Infarction ; Myocardial Reperfusion ; Pulmonary Embolism ; Tachypnea ; Thorax ; Thromboembolism ; Thrombosis ; Valsalva Maneuver

BACKGROUND/AIMS: Obesity is reported to be associated with erosive esophagitis (EE). However, the temporal association of obesity and abdominal obesity with EE is unclear. We conducted this study to investigate the temporal association of obesity, especially abdominal obesity with EE. METHODS: Among 1,182 subjects who underwent health screening examinations including upper endoscopy in both 2003 and 2006, a total 1,029 subjects with a normal esophagogastric junction on upper endoscopy in 2003 were enrolled. All subjects completed questionnaires and anthropometric measurements were obtained twice by trained personnels. The patients with newly developed EE were compared to the subjects without newly developed EE. RESULTS: Among 1,029 subjects, 42 (4.1%) were newly diagnosed with EE and 82 (8.0%) with hiatal hernia. The mean body mass index (BMI) in both examinations was significantly different between the two groups based on the development of erosive esophagitis (p<0.05 in both examinations). The mean waist circumference (WC) in both examinations was also significantly different between the two groups (p<0.01 in both examinations). The multivariate analysis demonstrated that EE was not associated with the BMI in 2003 and the increase of BMI; however, it was associated with the WC in 2003 (Odds ratio, 7.21; 95% CI, 1.78 to 29.19; >90 cm vs <80 cm). CONCLUSIONS: Our study showed that abdominal circumference is an independent risk factor for EE, demonstrating a temporal relationship between abdominal obesity and EE.
Body Mass Index ; Endoscopy ; Esophagitis ; Esophagogastric Junction ; Hernia, Hiatal ; Humans ; Mass Screening ; Multivariate Analysis ; Obesity ; Obesity, Abdominal ; Risk Factors ; Waist Circumference ; Surveys and Questionnaires

BACKGROUND/AIMS: Substantial time and attention are required to read and interpret the recordings of capsule endoscopic images. A suspected blood identification system (SBIS) has been developed to assist in the reading of capsule images. This software automatically marks "red tags" that correlate with suspected blood or red areas. However, the sensitivity and accuracy of the system have not been well characterized. We investigated the usefulness of the SBIS in capsule endoscopy according to various small bowel bleeding lesions. METHODS: Two expert endoscopists reviewed the capsule images. Angiodysplasias, ulcers and erosion were considered as significant lesions, and active bleeding lesions were considered when bleeding or blood clots were seen in the capsule images. The red tags that were automatically marked by the use of the rapid software were compared to the significant lesions reviewed by the endoscopists. RESULTS: A total of 95 patients were enrolled in the study. The endoscopists identified 159 significant lesions and 71 lesions marked by red tags were identified by the SBIS. Among the 71 lesions, 31 lesions correctly coincided with the significant lesions. The overall sensitivity and positive predictive value of the use of the SBIS were 20% and 44%, respectively. The sensitivities of active ulcers and active bleeding lesions were 83% and 93%, respectively. CONCLUSIONS: The SBIS should be considered as a rapid screening tool to identify active bleeding lesions, and a complete review of capsule images by a physician is still needed.
Angiodysplasia ; Capsule Endoscopy ; Hemorrhage ; Humans ; Mass Screening ; Ulcer

BACKGROUND/AIMS: Severe acute pancreatitis occurs in about 20% of the patients with acute pancreatitis and can be associated with multiorgan failure and local complications. In patients with predicted severe acute pancreatitis, overall mortality rates are about 15-30%. The aim of this study was to determine the factors correlated with mortality in patients with severe acute pancreatitis. METHODS: We reviewed five hundread and seventy two consecutive cases of acute pancreatitis from January, 2000 to December, 2005. Of them, 109 patients who fulfilled the criteria of Atlanta classification for severe acute pancreatitis were enrolled. Data were collected by chart reviews including age, gender, etiology, body mass index (BMI), modified Glasgow score, APACHE II score, APACHE III score, Balthazar CT index, and other laboratory parameters performed within 48 hours after the initial admission. RESULTS: Severe acute pancreatitis was most commonly caused by alcohol. Overall mortality rate was 20.2% in severe acute pancreatitis and 10 (45%) deaths occurred within the first week. Multiple logistic regression analysis identified serum creatinine, corrected calcium concentrations, and CT index as predictors of mortality in patients with severe acute pancreatitis. The risk score (R) was calculated by combining 3 prognostic values with regression coefficients; R=2.512 log(e) (creatinine mg/dL)+1.729 log(e) (CT index)-4.780 log(e) (corrected calcium mg/dL). The AUC for this score was 0.877 and a cutoff level of 0 was determined to predict the mortality with 83.3% sensitivity and 89.5% specificity. CONCLUSIONS: The newly designed risk score comprising 3 parameters can be used as the significant early predictor for hospital mortality in severe acute pancreatitis.
Acute Disease ; Adolescent ; Adult ; Aged ; Aged, 80 and over ; Female ; Humans ; Male ; Middle Aged ; Multiple Organ Failure/etiology ; Multivariate Analysis ; Pancreatitis/complications/diagnosis/*mortality ; Predictive Value of Tests ; Prognosis ; ROC Curve ; Retrospective Studies ; Severity of Illness Index ; Survival Analysis

A double or bilobed gallbladder is a rare congenital anomaly, occurring at a rate of 1/4,000~5,000. We encountered a case of a double gallbladder that was diagnosed by an endoscopic retrograde cholangiogram. In view of the paucity of this anomaly, we report the case of a patient with a double gallbladder (Y duplication) accompanied by a common bile duct (CBD) stone. We also discuss the characteristics, classification, embryology and treatment of the double gallbladder.
Cholangiopancreatography, Endoscopic Retrograde ; Classification ; Common Bile Duct* ; Embryology ; Gallbladder* ; Humans