Subepithelial tumors (SETs) are often found accidentally during gastroscopy, most commonly in the stomach. If a raised lesion is observed around the major papilla, the relationship with the common bile duct or pancreas should be evaluated, and not only SET but also cancer or autoimmune disease should be considered in the differential diagnosis. Herein, we present a case of prominent major papilla mimicking a SET that was accidentally discovered during endoscopy. The patient was asymptomatic, and the physical and laboratory findings were normal. The biopsy findings were nonspecific and imaging findings suggested possible malignancy; thus, surgical ampullectomy was performed. The histopathological results confirmed IgG4-related ampullitis. This case suggests that immunoglobulin G4 (IgG4)-related disease may manifest with atypical findings, hindering its diagnosis and treatment.

A polypoid lesions of the gallbladder (PLGs) is defined as any elevated lesion of the mucosal surface of the gallbladder wall. Even though most of the gallbladder polyps are benign in nature, malignant polyps are found in some cases. Because advanced gallbladder cancer displays poor prognosis, early detection and appropriate early measures are important for curative treatment and improvement in long-term survival. Patients who have GB polyps are usually almost always asymptomatic and often diagnosed incidentally by abdomen CT scan or transabdominal ultrasonography (TAUS) imaging. However TAUS and CT scan can not differentiate precancerous and cancerous lesions from cholesterol polyps. To increase the diagnostic accuracy, New imanging modality is being performed. Of the available tests, the accuracy of EUS (or CEH-EUS) for the differentiation of neoplastic from nonneoplastic polyps was higher than that of transabdominal US or CT scan. The cholecystectomy should be undertaken only in cases where there are clinical signs of gallbladder polyps, polyps with diameters greater than 10 mm, fast-growing polyps, sessile polyps or wide-based polyps, patient aged over 50, concurrent gallstones, polyps of the gallbladder in fundibulum or abnormal gallbladder wall US. Gallbladder polyps that are not resected should be followed-up with serial ultrasound examinations. guidelines on the screening interval are not yet available, but follow-up with the same modality is generally recommended after 3-6 months. If there are no changes in size, contour, or vascualrity, the follow-up should be individualized; most often a follow up after another 12-24 months could be recommended up to 5 years at least.
Abdomen ; Cholecystectomy ; Cholesterol ; Diagnosis* ; Follow-Up Studies ; Gallbladder Neoplasms ; Gallbladder* ; Gallstones ; Humans ; Mass Screening ; Polyps* ; Prognosis ; Tomography, X-Ray Computed ; Ultrasonography

Complications that may occur after an endoscopic retrograde cholangiopancreatography (ERCP) procedure include pancreatitis, bleeding, cholangitis, cholecystis, perforation, and post-ERCP pancreatitis (PEP). Of these, PEP is the most common complication and 10% of patients can die from severe pancreatitis. Prevention of PEP requires the selection of an appropriate patient group according to their ERCP indications and a full awareness of the risk factors. The incidence rate can be reduced to some extent through medication and ERCP manipulation changes. The use of a spile through the guidewire during ERCP manipulation and temporary pancreatic duct stent insertion can be effective, and the administration of suppository NSAIDs as medication reduces the occurrence of PEP. Drugs such as glyceryl trinitrate (GTN), nafamostat, and somatostatin can be considered as the second best treatment in the cases where NSAIDs are contraindicated or where a plastic catheter cannot be inserted or fails after insertion into the pancreatic duct.
Anti-Inflammatory Agents, Non-Steroidal ; Catheters ; Cholangiopancreatography, Endoscopic Retrograde ; Cholangitis ; Hemorrhage ; Humans ; Incidence ; Nitroglycerin ; Pancreatic Ducts ; Pancreatitis* ; Plastics ; Risk Factors ; Somatostatin ; Stents

Endoscopic sphincterotomy (EST) is a basic procedure for pancreatobiliary endoscopy and is currently widely performed as a standard procedure for the treatment of various pancreatobiliary diseases worldwide. Later, in 1982, endoscopic papillary balloon dilation (EPBD) was introduced as an alternative to EST, and EPBD is known to reduce the risk of bleeding and perforation compared to EST. In order to safely and effectively perform EST and EPBD procedures, it is essential to select an appropriate target for the procedure, as well as to understand and familiarize with the anatomical structure of the duodenal papilla, related instruments, and basic techniques of EST and EPBD.

Hepatocellular carcinoma (HCC) is usually associated with chronic liver disease such as liver cirrhosis. Primary HCC lesions and even recurrent intrahepatic lesions can be treated successfully by using variable modalities applicable to intrahepatic lesions. HCC can cause intrahepatic multiple occurrence and extrahepatic metastasis. Extrahepatic metastasis occurs in up to about 60% of patients of HCC, and a major of patients with extrahepatic HCC had late intrahepatic stage of tumor. Themost frequent site of extrahepatic metastasis of HCC was the lung. HCC metastasized to soft tissues was unusually reported. Extrahepatic metastasis of HCC, especially to unusual site, should not be overlooked and must be able to be controlled. We experienced a case that HCC was metastasized to the pronator quadratus muscle of right wrist and chould be removed surgically.
Carcinoma, Hepatocellular* ; Humans ; Liver Cirrhosis ; Liver Diseases ; Lung ; Muscle, Skeletal ; Neoplasm Metastasis* ; Wrist*

During laparoscopic cholecystectomy, a surgical clip is used to control the cystic duct and cystic artery. In the past, metallic clips were usually used, but over recent years, interest in the use of Hem-o-lok clips has increased. Surgical clip migration into the common bile duct (CBD) after laparoscopic cholecystectomy has rarely been reported and the majority of reported cases involved metallic clips. In this report, we describe the case of a 53-year-old woman who presented with abdominal pain caused by migration of a Hem-o-lok clip into the CBD. The patient had undergone laparoscopic cholecystectomy 10 months previously. Abdominal CT revealed an indistinct, minute, radiation-impermeable object in the distal CBD. The object was successfully removed by sphincterotomy via ERCP using a stone basket and was identified as a Hem-o-lok clip.
Abdominal Pain* ; Arteries ; Cholangiopancreatography, Endoscopic Retrograde ; Cholecystectomy ; Cholecystectomy, Laparoscopic* ; Common Bile Duct ; Cystic Duct ; Female ; Foreign-Body Migration ; Humans ; Middle Aged ; Surgical Instruments ; Tomography, X-Ray Computed

We describe moderate hyperbilirubinemia in a 28-year-old man who suffered from gallstones and splenomegaly, with combined disorders of hereditary spherocytosis (HS) and Gilbert's syndrome (GS). Since it is difficult to diagnose HS in the absence of signs of anemia, we evaluated both the genetic mutation in the UGT1A1 gene and abnormalities in the erythrocyte membrane protein; the former was heterozygous for a UGT1A1 allele with three mutations and the latter was partially deficient in ankyrin expression. This is the first report of the concomitance of HS and GS with three heterozygous mutations [T-3279G, A (TA)7TAA, and G211A] in the UGT1A1 gene.
Adult ; Alleles ; Ankyrins/metabolism ; Electrophoresis, Polyacrylamide Gel ; Gallstones/surgery ; Gilbert Disease/complications/*diagnosis/genetics ; Glucuronosyltransferase/chemistry/genetics/metabolism ; Heterozygote ; Humans ; Male ; Mutation ; Protein Structure, Tertiary ; Sequence Analysis, DNA ; Spherocytosis, Hereditary/complications/*diagnosis/genetics ; Splenomegaly/diagnosis

Previous studies reported that oxaliplatin is associated with sinusoidal obstruction syndrome. However few reports on oxaliplatin induced liver fibrosis are found in the literature. Furthermore pathogenesis of liver fibrosis is not well known. We report a case of 45-yr-old Korean man in whom liver fibrosis with splenomegaly developed after 12 cycles of oxaliplatin based adjuvant chemotherapy for colon cancer (T4N2M0). Thorough history taking and serological examination revealed no evidence of chronic liver disease. Restaging CT scans demonstrated a good response to chemotherapy. Five month after chemotherapy, he underwent right hepatectomy due to isolated metastatic lesion. The liver parenchyma showed diffuse sinusoidal dilatation and centrilobular vein fibrosis with necrosis without steatosis. We could conclude that splenomegaly was due to perisinusoidal liver fibrosis and liver cell necrosis induced portal hypertension by oxaliplatin. In addition, to investigate the pathogenesis of liver fibrosis, immunohistochemical stains such as CD31 and alpha-smooth muscle actin (alpha-SMA) were conducted with control group. The immunohistochemical stains for CD31 and alpha-SMA were positive along the sinusoidal space in the patient, while negative in the control group. Chemotherapy with oxaliplatin induces liver fibrosis which should be kept in mind as a serious complication.
Actins/metabolism ; Antigens, CD31/metabolism ; Antineoplastic Combined Chemotherapy Protocols/*therapeutic use ; Camptothecin/*analogs & derivatives/therapeutic use ; Chemotherapy, Adjuvant ; Colonic Neoplasms/*drug therapy ; Fluorouracil/therapeutic use ; Humans ; Hypertension, Portal/etiology ; Immunohistochemistry ; Leucovorin/therapeutic use ; Liver Cirrhosis/*diagnosis/etiology/pathology ; Liver Neoplasms/secondary/surgery ; Male ; Middle Aged ; Organoplatinum Compounds/*administration & dosage/adverse effects/therapeutic use ; Splenomegaly/*diagnosis/etiology ; Thrombocytopenia/etiology ; Tomography, X-Ray Computed

Small cell carcinoma (SCC) is predominantly found in the lungs, and extrapulmonary small cell carcinoma (EPSCC) is a relatively rare disease, encompassing 2.5-4% of all SCCs. EPSCCs are commonly found in the esophagus, pancreas, skin, uterus, breasts, and prostate. SCC of the head and neck is aggressive and has a propensity for distant and regional spread. However, solitary metastasis to the pancreas is very rare. We report a case of laryngeal SCC with pancreatic metastasis in a 42-year-old man. The patient underwent resection of a primary SCC followed by a pylorus preserving pancreatoduodenectomy.
Adult ; Breast ; Carcinoma, Small Cell ; Esophagus ; Head ; Humans ; Larynx ; Lung ; Neck ; Neoplasm Metastasis ; Pancreas ; Pancreaticoduodenectomy ; Prostate ; Pylorus ; Rare Diseases ; Skin ; Uterus

Primary signet ring cell carcinoma (SRC) of colon at early stage is quite rare. Only 26 cases were reported until now. We report an early stage of primary SRC which was misdiagnosed as a juvenile polyp and treated with polypectomy followed by surgical resection. A 21-year-old male was administered for hematochezia. Abdominopelvic enhanced computed tomography revealed a polyp with active bleeding at the proximal rectum just below the rectosigmoid junction. Colonoscopy examination revealed a colon polyp with 0.5 cm sized head. Polypectomy was performed with snare and the polyp was completely removed. Biopsy revealed SRC. Surgical resection was also performed and there were no residual tumor or lymph node metastasis in the surgical specimen.
Biopsy ; Carcinoma, Signet Ring Cell ; Colon ; Colonoscopy ; Gastrointestinal Hemorrhage ; Head ; Hemorrhage ; Humans ; Lymph Nodes ; Male ; Neoplasm Metastasis ; Neoplasm, Residual ; Polyps ; Rectum ; SNARE Proteins ; Young Adult