BACKGROUND/AIMS: Although the initial rate of hemostasis achieved by endoscopic treatment for acute non-variceal gastrointestinal bleeding (NVGIB) is high, recurrent or persistent bleeding occurs in 10% to 25% of the patients. The aim of this study was to assess the efficacy and safety of transcatheter arterial embolization (TAE) in patients with acute upper and lower NVGIB who could not be managed by endoscopic treatment. METHODS: A retrospective analysis of the clinical data was done in 43 patients (M/F: 26/17, mean age: 60 years) whom underwent angiography or TAE for acute upper and lower NVGIB between January 1998 and December 2003. Among 43 patients, 18 had upper NVGIB, 19 had lower NVGIB, and 6 had obscure gastrointestinal bleeding. Demographic characteristics and outcome parameters including the rates of hemostasis, in-hospital death, and complications were analyzed. RESULTS: Thirty-four patients underwent TAE while 9 patients underwent angiography. TAE was used as the first line treatment in 17 patients and as the second line treatment in others. Hemostasis was achieved in 29 of 34 patients (85.3%) by TAE. According to the site of bleeding, hemostasis was achieved in 14 of 17 patients (82.4%) with upper NVGIB and in 15 of 17 patients (88.2%) with lower NVGIB. There was no significant angiography or TAE-related complications such as bowel ischemia or infarction except a hematoma on the angiography site in one patient. CONCLUSIONS: TAE is effective and safe in patients with acute upper or lower NVGIB who cannot be managed by endoscopic treatment.
Adult ; Aged ; Aged, 80 and over ; Catheterization ; *Embolization, Therapeutic/methods ; English Abstract ; Female ; Gastrointestinal Hemorrhage/*therapy ; *Hemostatic Techniques ; Humans ; Male ; Middle Aged

BACKGROUND/AIMS: Ineffective esophageal motility (IEM) is a distinct manometric entity characterized by a hypocontractile esophagus. Recently, IEM replaced the nonspecific esophageal motility disorder (NEMD), and its associations with gastro-esophageal reflux disease (GERD) and respiratory symptoms are well known. We evaluated the relationship of IEM with GERD, and the diagnostic value of IEM for GERD. METHODS: We retrospectively analyzed recent 3-year (Jan. 1998-Sep. 2002) datas of esophageal manometry, acid perfusion test and simultaneous 24 hr-ambulatory pH-metry with manometry studies in 270 consecutive patients with esophageal and/or GERD symptoms. The prevalence of IEM in GERD group and non-GERD group, and the variables of pH-metry and manometry among esophageal motility disorders were compared. In addition, the sensitivity, specificity, positive predictive value, negative predictive value of IEM, esophageal symptom, and acid perfusion test for GERD were calculated. RESULTS: There was no significant difference in IEM prevalence rate between GERD group and non-GERD group. In addition, there was no significant difference in GERD prevalence rate and esophageal acid clearance in variety of motility disorder groups. Total percent time of pH <4 in IEM group did not show any difference when compared with other groups except in the achalasia group. In regard of diagnostic value to detect GERD, all positive results showed high specificity (97%) in IEM with esophageal symptom and positive acid perfusion test. CONCLUSIONS: The diagnosis of IEM using esophageal manometry in patients with various esophageal symptoms does not strongly suggest on association with GERD. However, IEM with concomitant esophageal symptoms and positive acid perfusion test has diagnostic values for GERD.
Adult ; English Abstract ; Esophageal Motility Disorders/*complications/diagnosis ; Esophageal pH Monitoring ; Female ; Gastroesophageal Reflux/*complications/diagnosis ; Humans ; Male ; Manometry ; Middle Aged ; Predictive Value of Tests ; Sensitivity and Specificity

BACKGROUND/AIMS: Quadruple therapy can be considered as a first-line therapy in areas where the resistance rate to clarithromycin is high. Comparison study of triple therapy and quadruple therapy for Helicobacter pylori (H. pylori) eradication is still lacking in Korea despite the increasing prevalence of antibiotic resistance. This study was conducted to compare the efficacy of triple and quadruple therapy as a first-line treatment in H. pylori infected patients with peptic ulcer. METHODS: Consecutive 149 cases of peptic ulcer disease associated with H. pylori infection were randomized either to proton pump inhibitor (PPI, bid), amoxicillin (1,000 mg, bid), and clarithromycin (500 mg, bid) (PAC group) or to PPI (bid), bismuth subcitrate (300 mg, qid), metronidazole (500 mg, tid), and tetracycline (500 mg, qid) (PBMT group) eradication treatments for 7 days. Outcome of eradication therapy was assessed by 13C-urea breath test performed 4-6 weeks after eradication. RESULTS: Eradication rates in PAC and PBMT group were 78.7% (59/75) and 71.6% (53/74) by intention to treat analysis, respectively (p=0.424). By per protocol analysis, eradication rates of PAC and PBMT group were 85.5% (59/69) and 85.5% (53/62), respectively (p=1.012). Adverse reactions occurred in 5 (6.6%) and 7 (9.5%) patients in PAC and PBMT group, respectively (p=0.346). CONCLUSIONS: One week-quadruple therapy as a first-line treatment for H. pylori infection does not offer any advantage over PPI-based triple therapy in Korean patients.
Adolescent ; Adult ; Aged ; Antacids/administration & dosage ; Anti-Infective Agents/administration & dosage ; Drug Therapy, Combination ; English Abstract ; Female ; Helicobacter Infections/complications/*drug therapy/microbiology ; *Helicobacter pylori ; Humans ; Male ; Middle Aged ; Peptic Ulcer/microbiology ; Proton Pumps/antagonists & inhibitors

The first family of hereditary pancreatitis was described in 1952. The mode of inheritance is autosomal dominant trait with an 80% of penetrance rate. Although hereditary pancreatitis is rare, this disorder has provided valuable insights in understanding the pathophysiology of pancreatitis and pancreatic cancer. The causative gene of hereditary pancreatitis was identified in 1996 through mutational analysis of genes within chromosome 7q35. Most forms of hereditary pancreatitis are caused by one of two common mutations, R122H in the third exon or N29I in the second exon of the cationic trypsinogen gene (protease serine 1, PRSS1). R122H mutation is the most common PRSS1 mutation. Additional mutations of the cationic trypsinogen gene have been described. In Korea, first family of hereditary pancreatitis with cationic trypsinogen gene mutation revealed an arginine to histidine amino acid substitution at the residue 122. Patients with hereditary pancreatitis present with symptoms at an early age and have significant risk for the development of chronic pancreatitis and pancreatic cancer. The risk of pancreatic cancer is estimated to be 53-fold higher after the age of 50 years than the general population. The risk of pancreatic cancer is not related to the type of mutation. Since hereditary pancreatitis is a strong risk factor for pancreatic cancer, it is important to establish a diagnostic criteria for diagnosis and surveillance. However, there are potential benefits, risks and limitations in genetic testing for hereditary pancreatitis. It is difficult to provide the proper treatment, but recent developments in therapeutic approaches may be helpful in caring hereditary pancreatitis. This article includes the current status, pathogenesis, clinical features, and management of hereditary pancreatitis including the aspects of pancreatic cancer.
Amino Acid Substitution ; English Abstract ; Humans ; Mutation ; Pancreatitis/diagnosis/*genetics/therapy ; Trypsin/*genetics ; Trypsinogen/*genetics

The management of pancreatitis remained controversial over the past decades, varying from conservative medical treatment to surgical treatment. However, in recent years, treatment of severe acute pancreatitis is shifting from an early surgical debridement and necrosectomy to an aggressive intensive medical care. While the treatment is conservative in the earlier phase of the disease, surgery might be considered in the later phase. In chronic pancreatitis and in pancreatic pseudocyst, various surgical approaches are available these days. Apart from the conventional open surgery, laparoscopic procedure became popular since it is minimally invasive and effective. In addition, with the great improvements in interventional radiology and endoscopic techniques, multidisciplinary approaches including medical, interventional, and surgical management become much more important in the proper treatment of pancreatitis. In this review, pancreatitis is classified into three categories (acute pancreatitis, chronic pancreatitis, and pancreatic pseudocyst) for convenience, and the surgical treatment is described in each category.
Acute Disease ; English Abstract ; Humans ; Pancreatic Pseudocyst/surgery ; Pancreatitis/*surgery ; Pancreatitis, Chronic/surgery

Chronic pancreatitis is a progressive disease without curative treatment. Abdominal pain is the most predominant symptom of chronic pancreatitis that initially brings most of the patients to the physician's attention. Some studies have correlated the course of pain in chronic pancreatitis in comparison with the duration of the disease, progressing exocrine and endocrine pancreatic insufficiency, and morphological changes such as pancreatic calcification and duct abnormalities. Furthermore, the course of pain has been studied after alcohol abstinence or surgery in some groups. However, there are only few well-performed and valid studies, and some of them even have produced diversing results, in part. Further controlled studies harvoring a large number of patients in a multicenter setting should be considered. Therapeutic efforts on chronic pancreatitis have focused on palliative treatment of pain which is present in about 80% of cases. Endoscopic treatment of pain in chronic pancreatitis is useful and feasible in many patients. Selecting candidate for endotherapy is mandatory. Main indication of pancreatic stent insertion in chronic pancreatitis is the presence of an obvious ductal stricture. Complications of chronic pancreatitis are also indications of endoscopic intervention. Exocrine and endocrine insufficiencies should be meticulously managed to prevent complications and to maintain good quality of life.
English Abstract ; Humans ; Pancreatitis, Chronic/*diagnosis/*therapy

Medical management of acute pancreatitis relies on supportive care such as fluid resuscitation and pain control. Prophylactic antibiotics can reduce the opportunity of infection in severe pancreatitis. The effect of somatostatin or protease inhibitors still needs to be evaluated through further study. Early endoscopic retrograde cholangiopancreatography (ERCP) can ameliorate the course of severe biliary pancreatitis. Although sterile pancreatic necrosis, acute fluid collection, and pseudocyst usually resolve spontaneously, endoscopic or percutaneous drainages are needed when these complications are infected.
Acute Disease ; English Abstract ; Humans ; Pancreatitis/complications/*therapy

Acute pancreatitis is an inflammatory disease of pancreas which come from various etiologies. The pathologic spectrum of acute pancreatitis varies from mild edematous pancreatitis to severe necrotizing pancreatitis. To diagnose and to predict severity in acute pancreatitis, various biochemical marker, imaging modalities and clinical scoring sytstem are needed. Ideal parameters should be accurate, be performed easily and enable earlier assess. Unfortunately, no ideal parameter is available up to date. Serum amylase and lipase are still useful for the diagnosis but meaningless in predicting severity. C-reactive protein and inflammatory cytokines are promising single parameters to predict the severity. CT finding is also an useful determinant of severity, but is expensive and is delayed in assessment.
Acute Disease ; English Abstract ; Humans ; Pancreatitis/*diagnosis ; Severity of Illness Index

Pancreatic inflammatory disease can be classified as acute pancreatitis (AP) and chronic pancreatitis (CP) primarily by clinical criteria, with an obvious difference by restoration of normal function in the former or by permanent residual damage in the latter. Gallstones and alcohol are the most common causes of AP. Recent investigations have established that AP from all cause may disrupt normal stimulus-secretion coupling function within the acinar cell. This disruption within the acinar cell leads to an event termed 'co-localization' in which the digestive and lysosomal enzymes merge resulting in a premature activation of proteases. The mechanisms of inflammatory cells which adhere to endothelial cell are determined by a variety of mediators of cytokines released at the site of tissue damage. Cytokines hold the key for both local and systemic inflammatory response in AP. Besides, CP is a debilitating disease characterized by progressive and irreversible destruction of pancreatic tissue leading to exocrine and endocrine insufficiencies. Alcohol intake is the most common cause of CP. Mutations in the cationic trypsinogen gene were identified as causative gene for hereditary pancreatitis. The recognition of frequent cystic fibrosis transmembrane conductance regulator (CFTR) mutations and serine protease inhibitor, Kazal type 1 (SPINK1) mutations in idiopathic CP has hightened the awareness of importance of genetic mutations in CP. Pancreatic stellate cells represent the main cellular source of extracellular matrix in CP and play a key role in pancreatic fibrosis.
Acute Disease ; English Abstract ; Humans ; Pancreatitis/*etiology/physiopathology ; Pancreatitis, Chronic/etiology/physiopathology

Usual sources of subphrenic abscess with intestinal fistula are previous abdominal operation, inflammatory bowel disease and malignancy. Reported cases of intestinal fistula caused by adenocarcinoma were complicated by direct invasion. In this report, a 70-year-old male had a subphrenic abscess with intestinal fistula and the cause was a metastatic adenocarcinoma of unknown origin. As far as we know, this has not been reported previously in the literatures. The abscess went on chronic course for six months because intermittent administration of antibiotics modified its clinical presentation. The fistulous tract between the abscess and ileum was demonstrated by tubogram via the drainage catheter in abscess. The patient underwent surgical treatment because the cause of fistula was obscure. Invasion of the ileum by metastatic adenocarcinoma was diagnosed by the histologic examination of surgical specimen. Therefore, when a fistula develops without any apparent cause, there is a possibility of malignancy, and surgical approach must be considered. An early surgical approach will prevent the delay in treatment and reduce the mortality.
Adenocarcinoma/complications/diagnosis/*secondary ; Aged ; English Abstract ; Humans ; Ileal Diseases/diagnosis/*etiology ; Ileal Neoplasms/complications/diagnosis/*secondary ; Intestinal Fistula/diagnosis/*etiology ; Male ; *Neoplasms, Unknown Primary ; Subphrenic Abscess/diagnosis/*etiology