WCIM 2014 SEOUL KOREA 113
Poster Session
The Korean Journal of Internal Medicine Vol. 29, No. 5 (Suppl. 1)
PS 0250 Gastroenterology
The Progression of Cholelithiasis Presenting in Recur- rent Stress Induced Cardiomyopathy : A Case Report
Young Rak CHOI1, Joung-Ho HAN1, Mi Jin KIM1, Hee Bok CHAE1, Seon Mee PARK1, Sei Jin YOUN1
Chungbuk National University Hospital, Korea1
Cholelithiasis is the most common of the biliary tract diseases and often manifested as cholecystitis or cholangitis. The symptoms vary from symptomless, typical right upper abdominal pain, jaundice, fever, and vomiting. As old age quite often combined with underlying diseases and atypical symptoms, it is diffi cult to make an exact early diagnosis. Especially when gallstone is passed out or small in size, in other words, if diffi cult to be identifi ed by radiology, it is also diffi cult to fi nd causes of pain despite repeated testing. A 66-year-old man was rushed to the emergency room due to severe chest pain with labored respiration and treated with medication under the diagnosis as cardiomyopathy with unclear causative factors. Abdominal ultrasound and liver function test observed no clear abnormal findings. After then, he repeated being hospitalized and discharged from the hospital for the same symptoms and when he visited the emergency room the third time, cholelithiasis was identifi ed as cause of recurrent stress induced cardiomyopathy. All of his symptoms improved after remov- ing common bile duct stone with endoscopic retrograde cholangiopancreatography and later did not recur. Thus, when diagnosing elderly patients for chest pain, careful approach is required in various ways and if symptoms are repeated, it is necessary to take appropriate examinations of accurate cause even after treatment and suspect continuously. In particular, considering that progression of cholelithiasis might be the causative factor of recurrent stress induced cardiomyopathy will be of great help for exact differential diagnosis.
PS 0251 Gastroenterology
Clinical Signifi cance of The Neutrophil-Lymphocyte Ratio (NLR) as an Early Predictive Marker for Adverse Outcomes in Patients with Acute Pancreatitis
Mi Jin RYU1, Ji Young PARK1, Tae Joo JEON1, Seung Suk BAEK1, Tae Hwan HA1, Ye Na CHOI1, Won Chang SHIN1
Inje University Sanggye Paik Hospital, Korea1
Background: The neutrophil-lymphocyte ratio (NLR) is known as a predictive marker for poor outcomes in diverse benign and malignant diseases. The aim of this study was to investigate the prognostic value of the NLR in patients with acute pancreatitis and to determine an optimal cut-off value for the prediction of adverse outcomes of acute pancreatitis.
Methods: We retrospectively analyzed 490 patients with acute pancreatitis diagnosed at Sanggye Paik hospital between March 2007 and December 2012. NLRs were calcu- lated at admission, and at 24, 48, and 72 hours after admission. Patients were divided into groups according to the severity of acute pancreatitis and occurrence of organ failure, and a comparative analysis was performed to assess difference in the NLR be- tween groups.
Results: Among the 490 patients, 70 were in the severe acute pancreatitis group with 31 patients experiencing organ failure. The NLR in the severe acute pancreatitis group was signifi cantly higher than that in the mild acute pancreatitis group on all 4 days (median, 6.14, 6.71, 5.70, and 4.00 vs. 4.74, 4.47, 3.20, and 3.30, respectively, P <0.05).
The NLR in the group with organ failure was significantly higher than that in the group without organ failure on all 4 days (median, 7.09, 6.72, 6.27, and 6.24 vs. 4.85, 4.49, 3.35, and 2.34, respectively, P <0.05). The optimal cut-off values of the baseline NLR from the ROC curves were 4.76 in predicting severity and 4.88 in predicting organ failure in acute pancreatitis.
Conclusions: An elevated baseline NLR is correlated with the manifestation of severe acute pancreatitis and organ failure.
PS 0252 Gastroenterology
CBD Obstruction Due to a Large Stone at the Duodenal Stump
Jae Kyoung SHIN1, Bohye KIM1, Sodam HONG1, Hui Kyong KIM1, Sae Ahm KIM1, Sung Hoon CHOI2, Kwang Hyun KO3
General Internal Medicine, Cha Bundang Medical Center, Korea1, Division of Hepatobiliary and Pancreas, Department of Surgery, Cha Bundang Medical Center, Korea2, Digestive Disease Center, Cha Bundang Medical Center, Korea3
Enterolith is a rare complication of Billroth II gastrectomy, and most cases of entero- liths have been reported in association with the diverticula, tuberculosis, and Crohn’s disease of small bowel. We report a case of a patient in whom a large enterolith de- veloped in the duodenal stump ensuing CBD obstruction and cholangitis, necessitating surgery. A 77-year-old Asian woman visited a local hospital for poor oral intake, gen- eral weakness and epigastric discomfort. The patient has undergone Billroth II subtotal gastrectomy for stomach cancer 14 years ago. At presentation, physical examination revealed tenderness on epigastric area. Laboratory tests showed an elevated ESR, CRP, procalcitonin and biliary stasis (total bilirubin 1.87mg/dL, AST/ALT: 12/69 IU/L. ALP:
1443IU/L, γ-GTP: 340 U/L). On the abdominal CT showed mild IHD and CBD dilatation upto 12mm due to distal CBD obstruction by compacted a 48mm sized, calcifi ed and large stone at duodenal stump(Fig.1). For decompression, percutaneous transhepatic cholecystostomy catheter was inserted under ultra-sonography and fluoroscopy guidance on the second hospital day. On tubogram in contrast to fi lling defects in gall bladder suggesting GB stone, cystic duct and CBD were patent. However, there was no visible contrast passage to the duodenum. Laparoscopic removal of the enterolith which located in the duodenum, not in the diverticulum was performed on the 9th hospital day (Fig.2). No intestinal obstruction was found during the operation. While the GB stones were black, small and multiple, about a 5cm-sized large brownish stone was found in the duodenum(Fig.3). Without any signifi cant complication, the patient was discharged 11 days after the operation. To the best of our knowledge, this is the fi rst case report of cholangitis occurred directly by a single large stone at a duodenal stump, not secondary to afferent loop obstruction nor by a biliary stone.
114 32nd World Congress of Internal Medicine (October 24-28, 2014) WCIM 2014
PS 0253 Gastroenterology
A Case of Recurrent Gallstone Ileus
Min Seok YOO1, Yunju JO1, Young Sook PARK1, Seong Hwan KIM1, Byoung Kwan SON1, Young Kwan JO1, Sang Bong AHN1, Donghee KIM2
Seoul Eulji Hospital, Korea1, Seoul Eulji Hospital, Korea2
Background: Gallstone ileus is caused by impaction of a gallstone in the bowel after being passed through a cholecysto-enteric fi stula. It is an important, but rare cause of mechanical bowel obstruction. The appropriate surgical management of gallstone ileus remains controversial. One-stage procedure, includes enterolithotomy with cholecys- tectomy and fi stula division, is recommended for adequately stabilized patients with a low operative risk. In our case, the surgeon performed enterolithotomy alone due to the patient’s condition and severe adhesion around the gallbladder. Unfortunately, this case showed a recurrence of gallstone ileus due to remnant large gallstone even though performing gastrojejunostomy.
Case report: An 82-year old woman presented with one day history of nausea, vomiting and epigastric pain. She had a past medical history of hypertension, diabe- tes mellitus and underwent a total knee replacement. Plain abdominal radiographs demonstrated dilated small bowel loops and a stone in the inferior left quadrant.
Gallstone ileus was diagnosed by abdominal computed tomography(CT) based on the presence of choledoduodenal fi stula with impacted GB stones, segmental jejunal obstruction caused by an impacted calcifi ed stone. She underwent a laparotomy and a 4x4x2cm black pigmented stone was found to be impacted about 50cm distal from Treitz ligament. Gallstone removal was done with enterolithotomy, but because of se- vere adhesion around gallbladder the surgeon could not perform cholecystectomy and repair of choledoduodenal fi stula. Instead gastrojejununostomy was performed. Two weeks after discharge, she presented with a further episode of epigastric pain associ- ated with vomiting. Abdominal CT revealed a large stone in the proximal efferent loop, causing small bowel obstruction. Esophagogastroduodenoscopy disclosed a large stone impaction in proximal efferent loop. We attempted to remove the stone endoscopi- cally, but failed because of its large size. At laparotomy, a 4x4x3cm black pigmented gallstone removal was performed.
PS 0254 Gastroenterology
Usefulness of Endoscopic Biliary Drainage (EBD)-Guided Bile Aspiration Cytology for Diagnosis of Malignancy of Pancreatobiliary Tract
Do Young KIM1, Tae Gyoon KIM1, Seo Young YANG1, Woong Sun YOO1, Wonhyeong PARK1, Sung Hoon KIM1, Ji Sun JANG1, Jae So BANG1, Soo Hyun YANG1
Veterans Health Service Medical Center, Korea1
Background: Bile aspiration cytology has been conventionally used for endoscopic pathologic diagnosis of bile duct invasion or pancreas invasion malignancy. However, bile aspiration cytology often does not yield a definitive diagnosis because of the possibility of collecting only a small amount of the specimens, risk of occurrence of cholangitis, and exposure to biliary digestive enzymes. In our study, the ENBD-guided bile aspiration cytology was retrospectively studied how useful for diagnosis of bile duct invasion or pancreas invasion malignancy.
Methods: The study involved 63 patients who underwent EBD-guided bile duct cytol- ogy for the diagnosis of bile duct or pancreas invasion malignancy from January 2010 to April 2014. The diseases were pancreatic cancer in 16 patients, Klatskin tumor in 10, ampulla of Vater cancer in 3, bile duct cancer in 23, gallbladder cancer in 3, Neu- roendocrine tumor in 1, metastasis of other cancers in 6, and benign biliary stricture in 1. After endoscopic retrograde cholangiography(ERCP), bile aspiration cytology was performed by endoscopic biliary drainage.
Results: Malignant cells by EBD-guided bile aspiration cytology are showed in 12(19%) of 63 patients. Cytology-positive patients were found bile duct cancer in 9(39%) of 23 patients, gallbladder cancer in 1(33%) of 3, and metastasis of other cancers in 2(33%) of 6. From 27 patients of whom ERCP-guided biopsy showed malignancy, only 12 of them actually proved to be malignant by cytology.
Conclusions: The results show that bile aspiration cytology can be useful in detecting CBD cancer or metastasis from CBD, but not in distant lesions such as pancreatic can- cer or Klatskin tumor.
PS 0255 Gastroenterology
Genetic Polymorphism on the Characteristic of Gall Bladder Stones in Indonesia (Preliminary Studies of Cholelithiasis)
Barlian SUTEDJA1,2, Teguh WIDJAJADI2, Noer TADJUDIN2, Sony SUGIHARTO2, Tjondro SETIAWAN2, Siufui HENDRAWAN2, Indria INTAN2, Gatot S Lawrence LAO3 Gading Pluit Hospital, Indonesia1, Postgraduate School, Hasanuddin University, Indonesia2, R&D CerebroVascular Center, Indonesia Army Central Hospital Gatot Soebroto (RSPAD); R&D Gading Pluit Hospital, Indonesia3
Background: Gall Bladder Stone (Cholelithiasis) is considered as silent killer, as most of the patient come to see their doctors, if there is sudden acute upper gastrointes- tinal problems, such as vomitus that sometimes can lead to severe consequences. In this study we report the characteristic of GB Stones from Gading Pluit Hospital Indo- nesia
Methods: From 2011-2013 we have conducted GB stone surgery, with laparoscopic approach. There has been 486 cases that have undergone the procedure. Blood sam- ple are collected for routine blood examination, blood chesmistry, as well as collection of nucleated blood component for further genetic polymorphism study
Results: Of the 486 cases collected, 128 (26.3%) cases are cholesterol stone, 232 (47.9%) cases are pigmented stones, 116 (23.9%) cases are mixed stones, and 9 cases can not be analized. The distribution among gender are for cholesterol stones 60 and 68; pigmented stones 108 and 125; mixed stones 49 and 67; 5 and 4 unidentifi ed stones for male and female respectively. As the characteristic of the GB stones com- pared to the stones reported by Western countries is different, further study regarding the genetic polymorphism of stones is underway
Conclusions: GB Stones in Indonesia is different from Western Countries; the genetic polymorphism might play a signifi cant role.
