Hemobilia is a cause of obscure gastrointestinal hemorrhage. Most cases have an iatrogenic or traumatic origin but cases of hemobilia with non-traumatic causes are rare. The non-traumatic causes of hemobilia are inflammation, gallstones, neoplasm and vascular lesions. Currently, various therapeutic options are available for hemobilia, and transarterial embolization is now the first line of intervention used to stop the bleeding of hemobilia, which shows a high success rate of approximately 80% to 100% with a lower morbidity and mortality rate than with surgery. We report a rare case of non-traumatic hemobilia caused by a pseudoaneurysm of the hepatic artery that was successfully treated with transarterial embolization.
Aneurysm, False* ; Gallstones ; Gastrointestinal Hemorrhage ; Hemobilia* ; Hemorrhage ; Hepatic Artery* ; Inflammation ; Mortality

BACKGROUND: Derepressed AmpC beta-lactamase producing Enterobacter cloacae, Citrobacter f reundii, and Serratia marcescens are important nosocomial pathogens and the infections are difficult to treat, because they are multi-drug resistant. The aim of this study was to determine the isolation rate and trend, and antimicrobial susceptibility of derepressed strains isolated from clinical specimens. METHODS: E. cloacae, S. marcescens, and C. f reundii isolated from 1996 through 2000 were enrolled in the study. Antimicrobial susceptibility was tested by NCCLS disk diffusion method. Derepressed strain was defined as strain non-susceptible to third generation cephalosporin. The isolation patterns of important gram-negative bacilli with the derepressed strains were analyzed with respect to years, patient's locations and specimens. RESULTS: Among the clinical isolates, the derepressed strains of E. cloacae, S. marcescens, and C. f reundii were 65%, 70%, and 56%. The proportion of the derepressed strains : E. cloacae increased from 68% in 1996 to 71% in 1998, however, decreased to 59% in 2000, S. marcescens increased from 68% in 1996 to 73% in 2000, C. f reundii decreased from 69% in 1996 to 41% in 2000. The proportion of the derepressed strains were high among the isolates from blood and respiratory specimens of inpatient and intensive care patient. The resistance rates of the depressed strains were 47~62% to third generation cephalosporin and aztreonam, 15~85% to aminoglycoside, 68% to cotrimoxazole, and 31% to levofloxacin. CONCLUSION: Among the clinical isolates of E. cloacae, S. marcescens, and C. f reundii, the derepressed strains were as high as 56~70%, and they were commonly isolated from blood and sputum specimens of inpatient and intensive care patient, and showed high resistance rates to the most antimicrobial agents.
Anti-Infective Agents ; Aztreonam ; beta-Lactamases* ; Citrobacter freundii ; Citrobacter* ; Cloaca ; Diffusion ; Enterobacter cloacae ; Enterobacter* ; Humans ; Inpatients ; Critical Care ; Levofloxacin ; Serratia marcescens ; Serratia* ; Sputum ; Trimethoprim, Sulfamethoxazole Drug Combination

BACKGROUND: Carrying antimicrobial resistance genes is a burden to bacteria. Therefore, in the absence of antimicrobial selective pressure, susceptible bacteria are expected to replace resistant ones. The cost was reported to decrease with time, but the effect of different species of susceptible bacteria on extended-spectrum -lactamase (ESBL)-, AmpC beta-lactamase-, and VIM-2 metallo-beta-lactamase-producing gram-negative bacilli are not known. The aim of this study was to determine the effect in vitro. METHODS: Antimicrobial-susceptible and -resistant strains of Escherichia coli, Enterobacter aerogenes, Klebsiella p neumoniae, and Acinetobacter baumannii were subcultured daily in glucose limited minimal salt medium at 30degrees C and 37degrees C, and the numbers of cells (CFU/mL) were determined by culturing on Mueller-Hinton agar and MacConkey agar plates. RESULTS: Continued incubation without subculture of both individual and mixed cultures at 37degrees C showed higher counts of a ESBL-producing K. p neumoniae than a susceptible E. coli. Daily subcultures of two strains in a tube showed the counts were : ESBL-producing K. pneumoniae >susceptible E. coli; susceptible E. aerogenes >ESBL-producing K. p neumoniae; susceptible E. aerogenes >VIM-2-beta-lactamase-producing Acinetobacter baumannii. The counts were similar for susceptible K. p neumoniae and AmpC beta-lactamasehyperproducing E. aerogenes. Initial low count of a susceptible E. coli and an ESBL-producing K. p neumoniae at 30degrees C gradually increased with continued subculture. CONCLUSION: Growth of not all resistant bacteria are slower and the growth improves with continued subculture. Coexistence of a susceptible bacteria with resistant bacteria in GLMS medium both at 30degrees C and 37degrees C does not reduce the number of resistant bacteria.
Acinetobacter baumannii ; Agar ; Anti-Infective Agents* ; Bacteria ; Enterobacter aerogenes ; Escherichia coli ; Glucose ; Klebsiella ; Pneumonia

Terfenadine is widely used because of nonsedating effect. But It could rarely provoke a potentially lethal ventricular tachyarrhythmia. Recently, we experienced two cases of torsades de pointes(TDP) of occurred after combined use of terfenadine and ketoconazole in usual dose. In one case, 31-yr-old female presented palpitation and recurrent syncope of sudden onset after ingestion of terfenadine 60mg and ketoconzole 200mg 5 times. On attack, ECG showed a polymorphic ventricular tachycardia, and after attack, showed prolongation of QT interval and TU wave changes. Her laboratory findings were not contributory. TDP was controlled with MgSO4 and isoproterenol infusion. Then, QT interval was normalized and no further episode occurred. In the other case, 32-yr-old female presented palpitation and recurrent syncope of sudden onset after ingestion of terfenadine 60mg and ketoconzole 200mg 5 times. ECG showed prolongation of QT interval and TU wave changes. Her laboratory findings were not contributory. TDP was controlled with MgSO4 and isoproterenol infusion. Then, QT interval was normalized and no further episode occurred.
Eating ; Electrocardiography ; Female ; Humans ; Isoproterenol ; Ketoconazole* ; Syncope ; Tachycardia ; Tachycardia, Ventricular ; Terfenadine* ; Torsades de Pointes*

Gastritis cystica profunda (GCP) is a rare disease in which cystically dilated gastric foveolae or glands extend into the muscularis mucosae or below. The pathogenesis of GCP has been described as an interruption of the muscularis mucosae and migration of epithelial elements to submucosa caused by presence of suture materials after surgery or erosion of the gastric mucosa in chronic gastritis and ischemia. Macroscopically, GCP may present not only as a giant gastric mucosal folds but also as a submucosal tumor or as solitary or diffuse polyps. An endoscopic ultrasonographic (EUS) findings clearly differ from findings in the other disordes. The combination of EUS and mucosectomy appears to be very useful for the diagnosis of GCP. Therefore, all unnecessary surgical procedures should be avoided in cases of GCP. We report a case of GCP associated with gastric perforation which presented as diffuse giant gastric folds and clinically advanced gastric cancer was suspected.
Diagnosis ; Endosonography ; Gastric Mucosa ; Gastritis* ; Ischemia ; Mucous Membrane ; Polyps ; Rare Diseases ; Stomach Neoplasms ; Sutures

BACKGROUND/AIMS: Intestinal tuberculosis can be difficult to diagnose because it may mimic many other intestinal diseases. The aim of this study was to evaluate the diagnostic yield of colonoscopic biopsy and frequency of concomittent extra-intestinal tuberculosis in intestinal tuberculosis. METHODS: The medical records of 225 consecutive patients with intestinal tuberculosis (81 men, 144 women; mean age 40.6 yrs) were analyzed retrospectively. RESULTS: Histological examination of colonoscopic biopsy specimens revealed granulomas in 163 (72.4%) of the 225 patients. However, caseous necrosis was found in only 25 (11.1%) patients, and acid-fast bacilli (AFB) were noted in 39 (17.3%) of the 225 patients. Mycobacterium tuberculosis was isolated from the culture of biopsy specimens in 52 (29.3%) of 177 patients. Eighty-four patients (37.3%) had concomitant extra-intestinal tuberculosis and 67 (29.8%) showed active pulmonary tuberculosis. Histological examination of the biopsy specimens enabled the diagnosis of intestinal tuberculosis by the presence of either caseating granulomas or AFB in 52 (23.1%) patients. Combination of histological examination and Mycobacterium culture established the diagnosis in 87 (38.7%) patients. Before getting the result of Mycobacterium culture, the diagnosis could be made, by either histological examination or the presence of extra-intestinal tuberculosis in 107 (47.6%) patients. Combination of caseating granulomas, AFB staining, Mycobacterium culture, and the presence of extra-intestinal tuberculosis resulted in the diagnosis in 126 (56.0%) patients. CONCLUSIONS: To increase the diagnostic yield, AFB staining and Mycobacterium culture should be routinely performed on biopsy specimens in addition to routine histological examination for caseating granulomas.
Adolescent ; Adult ; Aged ; *Biopsy, Needle ; *Colonoscopy ; English Abstract ; Female ; Humans ; Intestinal Diseases/*diagnosis ; Male ; Middle Aged ; Mycobacterium tuberculosis/isolation & purification ; Tuberculosis, Gastrointestinal/complications/*diagnosis ; Tuberculosis, Pulmonary/complications

BACKGROUND/AIMS: Alcohol may be a cocarcinogen in patients with chronic viral hepatitis. We investigated the effect of alcohol on the development of hepatocellular carcinoma (HCC) in liver cirrhosis (LC) caused by hepatitis B virus (HBV). METHODS: All patients with LC or HCC associated with HBV or alcohol, admitted between March 2001 and June 2005, were included. Patients were divided into three groups according to the etiology of LC: Alcohol (AL), HBV, or HBV+alcohol (HBV+AL). Age and laboratory data at the enrollment of study were analyzed. The logistic regression coefficiency for the prevalence of HCC was calculated by using variables such as age, gender, serologic markers, and etiology of LC. RESULTS: In LC patients (n=342), the proportions of AL, HBV, and HBV+AL groups were 44%, 39%, and 17%, respectively. The proportions of HCC in AL, HBV and HBV+AL groups were 17%, 55%, and 76%, respectively. Age at the diagnosis of HCC was younger in HBV+AL than in AL group (p=0.036). In logistic regression analysis for the risk factor of HCC, odds ratio of age was 1.056 (p<0.001). Odds ratios of HBV and HBV+AL group comparing AL were 8.449 (p<0.001) and 17.609 (p<0.001), respectively. Therefore, old age and chronic alcohol intake in patients with HBsAg were the risk factors of HCC. CONCLUSIONS: Chronic alcohol intake may be an additive factor for the development of HCC in patient with LC caused by HBV. However, a prospective cohort study is needed to confirm these findings.
Adult ; Aged ; Carcinoma, Hepatocellular/*epidemiology/etiology ; Cross-Sectional Studies ; Female ; Hepatitis B, Chronic/*complications/epidemiology ; Hepatitis, Alcoholic/complications/epidemiology ; Humans ; Liver Cirrhosis/*complications/virology ; Liver Cirrhosis, Alcoholic/*complications/epidemiology/virology ; Liver Neoplasms/*epidemiology/etiology ; Male ; Middle Aged ; Odds Ratio ; Regression Analysis ; Retrospective Studies ; Risk Factors

BACKGROUND/AIMS: Cowden's disease is an autosomal dominant hereditary disease characterized by the various hamartomatous and neoplastic lesions of multiple organs. We analyzed gastrointestinal manifestations of 5 cases of Cowden's disease and suggest several findings which are helpful to gastroenterologists for the early diagnosis. METHODS: The clinical characteristics of 5 unrelated patients with Cowden's disease were evaluated. Four patients were male, one patient was female, and their ages at the time diagnosis ranged from 17 to 49 years. All patients had the pathognomonic mucocutaneous lesions and thyroid nodules. RESULTS: In all patients, the esophagus was affected by acanthosis. In 4 patients, the stomach was affected by numerous variable sized polyps. In 4 patients, the duodenum was involved by several polyps. In 4 patients, the entire small bowel and in one patients, only the terminal ileum was affected by numerous polyps. In all patients, the colon, especially the sigmoid colon and rectum, showed numerous variable sized polyps. Family history was positive for stomach cancer in two patients. CONCLUSIONS: Cowden's disease should be considered in patients with esophageal acanthosis among patients with colonic polyposis, although the mucocutaneous lesions, unfamiliar to gastroenterolgists, are pathognomonic criteria for the diagnosis.
Colon ; Colon, Sigmoid ; Diagnosis* ; Duodenum ; Early Diagnosis ; Esophagus ; Female ; Genetic Diseases, Inborn ; Hamartoma Syndrome, Multiple* ; Humans ; Ileum ; Male ; Polyps ; Rectum ; Stomach ; Stomach Neoplasms ; Thyroid Nodule

PURPOSE: Malnutrition is common in CAPD patients and depends on many factors such as dialysis-related and nondialysis-related factors. The present study aimed to assess nutritional status, dialysis adequacy and their relationships with overall mortality and morbidity. METHODS: We studied 102 patients who had been receiving CAPD for at least 6 months. Dialysis adequacy was assessed by parameters derived from urea kinetic modeling(UKM) and nutritional status was assessed by serum biochemical measurement, normalized protein catabolic rate(nPCR), normalized protein equvalent of total nitrogen appearance(nPNA) and urea kinetic studies. Spearman's simple correlation and multiple linear stepwise regression analysis were used to assess correlation between dialysis adequacy and nutritional status in CAPD patients. We compared the differences between patients who suf fered morbid events, defined as either an infectious complication or hospitalization, and patients who remained well. RESULTS: The results showed that the total dialysis dose(total weekly Kt/Vurea) has statistically significant correlation with nPCR(r=0.234, p=0.028), nPNA (r=0.246, p=0.021), total weekly creatinine clearance (WCC)(r=0.479, p=0.0001), serum albumin levels(r= 0.233, p=0.029), serum cholesterol(r=0.266, p=0.013), serum BUN(r=-0.290, p=0.006) and serum creatinine levels(r=-0.408, p=0.0001). nPNA was positively correlated with serum cholesterol(r=0.217, p=0.045), serum transferrin(r=0.218, p=0.042) and serum ferritin levels(r=0.220, p=0.043). Patients who suffered morbid events had an old age(p=0.001), long duration of CAPD(p=0.0001), higher CRP(p=0.021), lower serum albumin level(p=0.020), lower hematocrit(p=0.049) and lower WCC(p=0.017). Conclusions : These results indicate that adequate dialysis is very important for the maintenance of adequant nutrition because nutritional status positively correlated with dialysis dose, which is best assessed by UKM. In addition, assessment of nutritional status and dialysis adequacy are important in predicting clinical outcomes in CAPD patients.
Creatinine ; Dialysis* ; Ferritins ; Hospitalization ; Humans ; Malnutrition ; Mortality ; Nitrogen ; Nutritional Status* ; Peritoneal Dialysis, Continuous Ambulatory ; Serum Albumin ; Urea