Oral sodium phosphate (NaP) is increasingly used to prepare patients for gastrointestinal procedures such as colonoscopy. Severe hyperphosphatemia may complicate bowel-cleansing preparation using oral NaP. The risk of hyperphosphatemia is known to increase with excessive and/or repeated doses, increased intestinal absorption, or impaired renal excretion of phosphate. Hyperphosphatemia may produce acute renal failure, but the mechanism is not yet clear. Some authors suggest that renal injury is caused by intrarenal calcium-phosphate deposition, but others suggest that direct tubular toxicity or a disturbance in renal hemodynamics may induce renal injury. A 74-year-old woman was admitted with generalized weakness after taking NaP for colonoscopy. She had no underlying diseases such as renal disease. She was hypotensive and had carpopedal spasm with hypocalcemia, severe hyperphosphatemia, metabolic acidosis, and non-oliguric acute renal failure. She was treated with aggressive hydration, calcium replacement and aluminum-containing antacid, but hyperphosphatemia was aggravated (35.6 mg/ dL). Hemodialysis was done and phophate concentration was lowered to 5.5 mg/dL. It is suggested that caution should be taken when using phosphate- containing laxatives especially for elderly patients even if they have no underlying diseases.
Acidosis ; Acute Kidney Injury ; Aged ; Calcium ; Colonoscopy ; Female ; Hemodynamics ; Humans ; Hyperphosphatemia* ; Hypocalcemia ; Intestinal Absorption ; Laxatives ; Renal Dialysis ; Sodium* ; Spasm ; Tetany*

BACKGROUND: Continuous veno-venous hemofiltration (CVVH) is one of the continuous renal replacement therapies for managing patients with refractory edema or oliguric renal failure with unstable vital signs. High-flux hemofilters are usually used for CVVH, but low-flux hemodialyzers are not used for CVVH. We tried temporary veno-venous hemofiltration (TVVH) procedures using low-flux hemodialyzers for 9 patients with acute or chronic renal failure who were on mechanical ventilation with positive end-expiratory pressure (PEEP) in the ICU. METHODS: All of the nine patients with acute or chronic oligo-anuric renal failure could not receive hemodialysis treatment in the hemodialysis room, because they were on mechanical ventilation with PEEP in the ICU due to severe fluid overload with elevated CVP and acute pulmonary edema. Low-flux hemodialyzers with effective membrane area of 1.0- 1.1 m2 and blood pumps on the discarded hemodialysis machines were used for TVVH procedures. RESULTS: Mean duration of TVVH was 17.0+/-16.7 hours and mean ultrafiltration rate was 440+/-203 mL/hour. After finishing the TVVH procedures, CVP decreased from 22.9+/-8.5 cmH2O to 6.4+/-2.4 cmH2O. Of nine patients, 6 patients (67%) were able to be off the mechanical ventilation with clinical improvement. CONCLUSION: Even if CVVH is usually done with expensive high-flux hemofilters and CVVH machines, simplified and cheaper TVVH procedures using low- flux hemodialyzers and discarded hemodialysis machines with functioning blood pumps can be done with good results and cost effectiveness, especially in institutions not equipped with facilities such as CVVH machines or portable water purification systems for hemodialysis in the ICU.
Cost-Benefit Analysis ; Edema ; Hemofiltration* ; Humans ; Kidney Failure, Chronic ; Kidneys, Artificial* ; Membranes ; Positive-Pressure Respiration ; Pulmonary Edema ; Renal Dialysis ; Renal Insufficiency ; Renal Replacement Therapy ; Respiration, Artificial ; Ultrafiltration ; Vital Signs ; Water Purification

An endoscopic mucosal resection (EMR) is considered to be a potential alternative to surgery for a gastrointestinal tumor on account of it being an improved technique. Since its introduction in Japan in the early 1980s, it is now an accepted modality for removing precancerous lesions or early gastric cancer from the GI tract because it is minimally invasive and preserves the patient's quality of life. The major complications of EMR is bleeding and perforation. The treatment guidelines for iatrogenic perforation after EMR have not been established. Herein, we report a successful case of EMR induced gastric perforation with fluid collection that was successfully treated with non-surgical management.
Gastrointestinal Tract ; Hemorrhage ; Japan ; Quality of Life ; Stomach Neoplasms

PURPOSE: The endoscopic management of a fully covered self-expandable metal stent (SEMS) has been suggested for the primary treatment of patients with anastomotic leaks after total gastrectomy. Embedded stents due to tissue ingrowth and migration are the main obstacles in endoscopic stent management. MATERIALS AND METHODS: The effectiveness and safety of endoscopic management were evaluated for anastomotic leaks when using a benign fully covered SEMS with an anchoring thread and thick silicone covering the membrane to prevent stent embedding and migration. We retrospectively reviewed the data of 14 consecutive patients with gastric cancer and anastomotic leaks after total gastrectomy treated from January 2009 to December 2016. RESULTS: The technical success rate of endoscopic stent replacement was 100%, and the rate of complete leaks closure was 85.7% (n=12). The mean size of leaks was 13.1 mm (range, 3–30 mm). The time interval from operation to stent replacement was 10.7 days (range, 3–35 days) and the interval from stent replacement to extraction was 32.3 days (range, 18–49 days). The complication rate was 14.1%, and included a single jejunal ulcer and delayed stricture at the site of leakage. No embedded stent or migration occurred. Two patients died due to progression of pneumonia and septic shock 2 weeks after stent replacement. CONCLUSIONS: A benign fully covered SEMS with an anchoring thread and thick membrane is an effective and safe stent in patients with anastomotic leaks after total gastrectomy. The novelty of this stent is that it provides complete prevention of stent migration and embedding, compared with conventional fully covered SEMS.
Anastomotic Leak* ; Constriction, Pathologic ; Gastrectomy* ; Humans ; Membranes* ; Pneumonia ; Retrospective Studies ; Self Expandable Metallic Stents ; Shock, Septic ; Silicon ; Silicones ; Stents* ; Stomach Neoplasms ; Ulcer

Endoscopic Submucosal Dissection (ESD) has recently become a widely accepted treatment for premalignent lesions of the stomach and early gastric cancer. Post-ESD stenosis is a rare complication of ESD, but this can be caused by the removal of a large lesion when lesions are located near the cardia or pylorus. We experienced two cases of post-ESD stenosis. One developed in a high risk patient and this was treated by repeated balloon dilation. The other occurred in a patient who was without risk factors, but the stenosis improved spontaneously. It is important that we should perform early follow-up endoscopy in patients who are at a high risk for post-ESD stenosis, and administer effective treatment.
Cardia ; Constriction, Pathologic ; Endoscopy ; Follow-Up Studies ; Humans ; Pyloric Stenosis ; Pylorus ; Risk Factors ; Stomach ; Stomach Neoplasms

Thrombi in the right atrium (RA) are infrequent, and are rarely diagnosed before death. In addition, right heart thrombi are frequently associated with major pulmonary thromboembolism, and carry a very high risk of mortality, and therefore, require accurate diagnosis and prompt treatment. RA thrombi are generally associated with dilatation of the atrium, a low cardiac output state, intracardiac catheters, such as endocardial pacemakers and central venous hyperalimentation catheters, recent cardiac surgery, involving the atrium, and peripheral deep vein thrombosis. In addition, some systemic diseases, such as malignant tumors, amyloidosis and nephrotic syndrome, have been shown to contribute to the formation of an intracardiac thrombus. Echocardiography is valuable in the diagnosis of RA thrombi. There are some options in the treatment of RA thrombi, such as anticoagulant therapy using heparin, thrombolytic therapy and surgical removal. However, there is still adverse criticism as to the selection of the correct treatment method. A patient with RA thrombi, who presented with sudden cardiogenic shock, was diagnosed by two-dimensional echocardiography. He had been in a prolonged bed-ridden state because of quadriparesis caused by an injury to the cervical spine. The RA thrombi were successfully treated with anticoagulant and thrombolytic agents.
Amyloidosis ; Cardiac Catheters ; Cardiac Output, Low ; Catheters ; Diagnosis ; Dilatation ; Echocardiography ; Fibrinolytic Agents ; Heart ; Heart Atria ; Heparin ; Humans ; Mortality ; Nephrotic Syndrome ; Pulmonary Embolism ; Quadriplegia ; Shock, Cardiogenic ; Spine ; Thoracic Surgery ; Thrombolytic Therapy ; Thrombosis ; Venous Thrombosis

Cryptococcus neoformans, an encapsulated fungus, is an important opportunistic pathogen that can cause meningitis in immunocompromised patients. Since patients with cryptococcemia have high mortality, it is essential to make an early diagnosis and promptly initiate antifungal therapy. However, it is often very difficult to differentiate between cryptococcal meningitis and hepatic encephalopathy in patients with liver cirrhosis, and there is delay in making the diagnosis. Therefore, these patients have a particularly grave prognosis and consequently many patients die before culture results become available. In one study, starting antifungal therapy within 48 hours of the blood culture was associated with improved survival, but patients with liver cirrhosis were significantly less likely to receive antifungal therapy within 48 hours compared to those without liver cirrhosis. Recently, the authors experience a case of a 68-year-old woman with liver cirrhosis who presented with fever and a drowsy mental status. She had a previous history of having been admitted for infection-associated hepatic encephlopathy. Cryptococcal meningitis and cryptococcemia were diagnosed by spinal puncture and culture of cerebrospinal fluid. In spite of adequate treatment, the patient developed multi-system organ failure and eventually expired. Herein, we report a case of cryptococcal meningitis mimicking hepatic encephalopathy in a patient with liver cirrhosis.
Aged, 80 and over ; Brain/radiography ; Cryptococcus/isolation & purification ; Female ; Hepatic Encephalopathy/complications/*diagnosis ; Hepatitis C, Chronic/complications/pathology ; Humans ; Liver Cirrhosis/etiology/pathology ; Meningitis, Cryptococcal/complications/*diagnosis/microbiology ; Tomography, X-Ray Computed

Primary lung lymphoma is an uncommon tumor, which constitutes 0.5% of primary lung cancer, and 3% of extranodal lymphoma. The most frequent radiologic presentation of pulmonary parenchymal lymphoma is single mass or nodule. But we have experienced a case which was radiologically presented as patchy lung infiltration at first, and then progressive multiple reticulonodular infiltrations in lung. A 48-year-old woman was admitted to the hospital because of fever and cough. Chest PA obtained on admission revealed multiple patchy infiltration. Eventually, open lung biopsy was performed and the specimen disclosed extranodal NK/T cell lymphoma, and in bone marrow aspiration, hemophagocytosis was present. We report a case of primary extranodal NK/T cell lung lymphoma presented as patchy lung infiltrations, which was treated with chemotherapy.
Biopsy ; Bone Marrow ; Cough ; Drug Therapy ; Female ; Fever ; Humans ; Lung Neoplasms ; Lung* ; Lymphoma* ; Middle Aged ; Thorax

Foreign body ingestion is common in children, but magnet ingestion is rare. Ingestion of one magnet does not creat a serious problem; however, ingesting multiple magnet can lead to hazardous complications such as pressure necrosis, intestinal perforation, fistula formation, obstruction and intestinal volvulus. Most cases with complications after multiple magnet ingestion require surgical intervention. We report a case of a fistula following the ingestion of seven small, flat and round magnets that were removed successfully by endoscopic submucosal dissection without surgery.
Child ; Eating ; Fistula ; Foreign Bodies ; Humans ; Intestinal Perforation ; Intestinal Volvulus ; Magnets ; Necrosis

Granulomatous appendicitis is a rare condition that accounts for less than 0.1~0.2% of all the cases of appendicitis. The great majority of cases are subacute or recurrent appendicitis and they are treated with interval appendectomy. The remaining causes include Yersinia infection, foreign body reaction, infection by mycobacteria, fungi or parasites, and Crohn's disease isolated to the appendix. Crohn's disease isolated to the appendix has several characteristics such as slow progression, a low recurrence rate and a good prognosis. Crohn's disease isolated to the appendix has recently been called "Idiopathic Granulomatous Appendicitis", and some authors have tried to distinguish it from Crohn's disease involving the appendix. We experienced a case of isolated appendiceal Crohn's disease in a 39-year-old woman and we report on it here along with a review of relevant literature.
Adult ; Appendectomy ; Appendicitis ; Appendix ; Crohn Disease ; Female ; Foreign-Body Reaction ; Fungi ; Humans ; Parasites ; Prognosis ; Recurrence ; Weight Loss ; Yersinia Infections