급성 담낭염의 비수술적 담낭배액술 - 내시경적 경비 담낭배액술 및 경피경간 담낭배액술을 중심으로

봉형근(Hyung Keun Bong),문종호(Jong Ho Moon),이영홍(Young Hong Lee),조영덕(Young Deok Cho),김진오(Jin Oh Kim),조주영(Joo Young Cho),김연수(Yun Soo Kim),이준성(Joon Seong Lee),이문성(Moon Sung Lee),황성규(Seong Gyu Hwang),심찬섭(Chan 대한소화기학회 1998 대한소화기학회지 Vol.30 No.1

N/A Background/Aims: Acute cholecystitis is the most common biliary emergency and until now, the choice of the treatment of this disease is surgical operation. But, the. Mortality and morbidity associated with surgical cholecystostomy in those patients are relatively high. Recently, PTCCD and ENGBD were developed as a useful method of nonsurgical cholecystic drainage in high surgical risk group of acute cholecystitis. The purpose of this study was tn assess the usefulness of nonsurgical cholecystic drainage such as PTCCD and ENCrBD in the patients with acute cholecystitis. Methods: Of 59 patients with acute cholecystitis treated with nonsurgical cholecystic drainage, 47 were calculous cholecystitis and 12 were acalculous cholecystitis. Nonsurgical chole- cystic drainages were successful in all 59 cases: PTCCD in 45 patients, ENGBD in rernaining 14 patients. 39 patients were treated with nonsurgical cholecystic drainages due to high surgical risk. In remaining 20 patients there were cholangiocarcinoma in 5 patients, netastatic heptna in 2, gallstone pancreatitis in 1, advanced gastric cancer in 2, refusal of surgery in 10. Results: The prompt clinical recovery were achieved in 42 patients(93.3%) with PTCCD and cornpletely in all 2 cases with ENGBD. In the group with 35 calculous cholecystitis performed PTCCD, 28 under- went PTCCS-L, 4 elective surgery and 3 died because of the underlying condition, In the group with 10 acalculous cholecystitis performed PTC(D, 8 patients need nr further treatment except drainage and remaining 2 patients underwent elective surgery. Jn the group with 12 calculous cholecystitis treated by ENGBD, 10 underwent elective surgery, l F.SWI. And I gallstone dissolu- tion with MTBE. In 2 acalculous cholecystitis treated by ENGBD, the one patient took no further treatment and the other underwent elective surgery. Complications related to PT( CD occurred in 10 of 45 patients, but there was no mortality re]ated to this procedure. No complications were noted related to ENGBD. Conclusions: We conclude that nonsurgical cholecystic drainage witli ENGBD and PTCCD were safe, effective and useful procedures for the management of acute cholecystitis, especially in high surgical risk group, (Korean J Gastroenterol 1997; 30:81 - 89)

간내담관담석의 경피경간 담도내시경적 치료성적

봉형근(Hyung Keun Bong),이영흥(Young Heung Lee),조영덕(Young Doek Cho),김진오(Jin Oh KIm),조주영(Joo Young Cho),김연수(Yun Soo Kim),이준성(Jun Seong Lee),이문성(Moon Sung Lee),황성규(Seong Gyu Hwang),심찬섭(Chan Sup Shim) 대한내과학회 1998 대한내과학회지 Vol.54 No.6

N/A Objective: Intrahepatic stones provide a quite different spectrum of problems f by surgeons in the tem hemisphere. Although unilateral left intrahepatic stones have been treated by left hepatic lobectomy, bilateral or right intrahepatic stones can be even more troublesome because they frequently cannot be completely removed by conventional surgical stone extraction procedure. Recently, the use of a flexible fiberoptic choledochoscope, electrohydraulic lithotriptor (EHL) and dilators make it possible to completely remove intrahepatic stones by nonsurgi- cal procedures in the majority of c Methods: During the last 5 years, we treated intrahepatic stones in 114 patients with a fiberoptic choledochoscope, EHL and dilators via percutaneous transhepatic route. For construction of percutaneous transhepatic routes, we punctured intrahepatic ducts by ultrasonographic guidance and then dilated the tracts by PTBD set (Nipro Co., Japan) under fluoroscopic guidance. Choledochoscopy were performed at 4-6 weeks later, and Dormina basket, EHL, balloon or bougie dilators were used for removal of stones. Results: Success rates according to the locations of stones were 87.5% (14/16) in unilateral right intrahepatic stones, 92.9% (39/42) in unilateral left intrahepatic stones, and 89.3% (50/56) bilateral intrahepatic stones. Overall success rate was 90.4% (103/114). Causes of incomplete removal of the stones in our patients included the failure of construction or maintenance of percutaneous transhepatic routes in 4 cases, intrahepatic bile duct stricbm proximal to impacted stones in 3, acute ductal angulation in 2, and stones located at the very distal branches of intrahepatic ducts in 2 cases. Complications associated with the procedure were transient fever in 8 cases, severe hemobila in 2 cases and bihary perforation in 3 cases. Conclusion: These results suggest that gemutaneaus transhepatic choledochoscopic approach is a relatively safe and effective method for treatment of intrahepatic stones.

내시경적 유두괄약근 절개술후 발생한 기종격증 및 피하기종

조영덕(Young Deok Cho),봉형근(Hyung Keun Bong),김진오(Jin Oh Kim),조주영(Joo Young Cho),김연수(Yun Soo Kim),이준성(Joon Seong Lee),이문성(Moon Sung Lee),황성규(Seong Gyu Hwang),심찬섭(Chan Sup Shim) 대한소화기학회 1997 대한소화기학회지 Vol.29 No.3

Perforation, bleeding, cholangitis, and pancreatitis are common complications of endoscopic sphincterorny(EST) that is considered a common effective method for treatment of distal bile duct obstruction and removal of bile duct stones. Perforation of duodenutn complicates endoscopic sphincterotomy in approximately 1% of cases. But, retroperitoneal, mediastinal and subcutaneous emphysema are very rare complications of endoscopic sphincterotomy. A 50-year-old woman was admitted to our hospital due to right upper quadrant abdominal pain for 1 week. An ERCP revealed markdly dilated commom bile duct and rnultiple ductal filling defects. For removal of' stones, EST was performed with pull type papillotome. About 1 hour later after procedure, she complained of chest pressure, shortness of breath and abdominal distension. The chest X-ray film revealed a pneumomediastinum, segmental atelectasis of left lower lung fields and subcutaneous emphysema. The simple abdominal X-ray showed mottled air densities in the right midabdomen and crescentic air densities in the right perirenal space. We report on a rare case of retroperitoneal duodenal perforation, pneumomediastinum and subcutaneous emphyserna following endoscopic sphinctero- tomy, in a patient with common bile duct stones. (Korean J Gastroenterol 1997; 29:399-403)

대장편평선종의 임상적 고찰

박용순(Yong Soon Park),최우봉(Woo Bong Choi),함정식(Jung Sik Ham),장재영(Jae Young Jang),이영홍(Young Hong Lee),김진오(Jin Oh Kim),조영덕(Young Deok Cho),봉형근(Hyung Keun Bong),김연수(Yun Soo Kim),조주영(Joo Young Cho),이준성(Joon S 대한내과학회 1997 대한내과학회지 Vol.53 No.2

N/A Objectives: To determine accurate diagnosis and proper treatment, we reviewed colonoscopic and histologic findings of flat adenoma of colon, Methods: We studied retrospectively 2148 cases of colonoscopic findings performed in our hospital from March of 1993 to September of 1995. Results: 1) The incidence of adenoma is 9.5%(203 cases), and that of flat adenoma is 1.6%(34 cases). 2) The location of flat adenoma is 3 cases in rectum(8.8%), 15 cases in sigmoid colon(44.1%), 9 cases in descending colon(26.5%), 3 cases in transverse colon(8.8%) and 4 cases in ascending colon and cecum(11.8%). 3) The diameter of flat adenoma was smaller than 5mm in 17 cases(50.0%), between 5-10mm in 8 cases(23.5%) and larger than 10mm in 9 cases (26.5%). Mean size was 9.2mm. 4) In colonoscopic features, type IIa was 25 cases (73.5%), type IIa + IIc was 5 cases(14.7%) and lateral spreading tumor was 4 cases(11.8%). 5) In histologic findings, tubular adenoma was 26 cases(76.5%), tubulovillous adenoma was 6 cases (17.6%) and serrated adenoma was 2 cases(5.9%). 6) The incidence of severe dysplasia or carcinoma was zero in smaller than 5mm, 25.0%(2 case) in 5-10mm and 55.6%(5 cases) in larger than 10mm. 7) The incidence of severe dysplasia or carcinoma was 11.5%(3 cases) in tubular adenoma and 66.7%(6 cases) in tubulovillous adenoma. 8) It was confirmed by abdominal CT scan or operation that lesions were limited to intraepithelium in 4 cases, mucosa in 2 cases submucosa in 1 case and no lymph node metastasis in any case. Conclusion: Even though flat adenoma of colon was smaller than polypoid adenoma, the incidence of malignant change was higher. When it was smaller than 10mm, the incidence of submucosal invasion or lymph node invasion was rare. Therefore endoscopic mucosal resection(EMR) can be the treatment of choice in flat adenoma smaller than 10mm, and after EMR, it is desirable to decide the treatment modality depending on the histologic findings.

만성 HBsAg보유자에서 중합효소 연쇄반응법에 의한 혈청 HBV DNA의 검출

정일권(Il Kwun Jung),주재학(Jae Hak Joo),차상우(Sang Woo Cha),봉형근(Hyung Keun Bong),김진오(Jin Oh Kim),박찬욱(Chan Wook Park),이준성(Joon Seong Lee),이문성(Moon Sung Lee),조성원(Sung Won Cho),심찬섭(Chan Sup Shim) 대한소화기학회 1995 대한소화기학회지 Vol.27 No.6

N/A Background/Aims: The purpose of this study was to investigate the serum HBV DNA status and clinical significance of polymerase chain reaction(PCR) in patients with chronic hepatitis B and asymptomatic HBsAg carriers. Methods: The subjects of this study were 80 patients with chronic hepatitis B(53 HBeAg posiiive patients, 27 HBeAg negative patients), 19 asymptomatic HBsAg carriers(8 HBeAg positive patients, l l HBeAg negative patients). Serum HBV DNA was measured by Dot blot hybrydization with a ' P labeled HBV DNA in all patients studied, and the PCR was used to detect serum HBV DNA in Dot blot negative patients. The PCR was performed with 2 primers in the C gene region of HBV. Amplified sequences were detected with ethidium bromide staining(PCR-EB) and southern blot hybridization(PCR-SBH). Dot blot allowed the detection of 10 ' pg of cloned HBV DNA, while 10 pg and 10' pg were detected by PCR-EB and PCR-SBH, respectively. Results: In the 80 patients with chronic hepatitis, 76patients(95%) were positive for HBV DNA by Dot blot or PCR. All 53 HBeAg positive chronic hepatitis patients had HBV DNA detectable by Dot blot(77.4%) or PCR(18.97c by PCR-EB, 3.7% by PCR-SBH). Out of 27 HBeAg negative patients, 23(85.2%) were positive for HBV DNA by Dot blot (40.8/o) or PCR (29.61o by PCR-EB, 14,8% by PCR-SBH). In the 19 asymptomatic HBsAg carriers, 13(68.4%) were positive for HBV DNA by Dot blot or PCR. All 8 HBeAg positive asymptomatic carriers had sufficient HBV DNA detectable by Dot blot. Out of 1 l HBeAg negative carriers, 5(45.5 7c) were positive for HBV DNA by Dot blot (9.1%) or PCR(36.4%). The positive rate for HBV DNA in patients with chronic hepatitis was significantly higher than that in asymptomatic HBsAg carriers(P=0.002 by Fisher exact test) and there is a significant difference in serum HBV DNA between HBeAg positive and negative asymtomatic HBsAg carriers(P=0.02 by Fisher exact test). Conclusions: These results suggest that minute amount of HBV DNA detected by PCR may have pathogenic relevance in chronic hepatitis B, and PCR may be used as a prognostic factor in asymptomatic HBsAg carriers. (Korean J Gastroenterol 1995;27: 651 - 658)

내시경적 식도정맥류 결찰요법 ( EVL ) 이 식도운동에 미치는 영향 - 식도내압검사를 중심으로

김영석(Young Seok Kim),권강호(Kwang Ho Kwun),정일권(Il Kwun Jung),이은학(Eun Hag Lee),봉형근(Hyung Keun Bong),송동화(Dong Hwa Song),박찬욱(Chan Wook Park),이준성(Joon Seong Lee),이문성(Moon Sung Lee),조성원(Sung Won Cho),심찬섭(Chan 대한소화기학회 1995 대한소화기학회지 Vol.27 No.1

N/A Background/Aims: For treating and eradicating bleeding esophageal varices, endoscopic variceal ligation(EVL) is currently acceptable practiced method, however esophageal motility change associated with endoscopic variceal ligation is uncertain. Although Longterm follow-up for rebleeding rate, recurrence rate, complication and survival rate after endoscopic variceal ligation are reported, there is a few report of esophageal motility change after endoscopic variceal ligation. To assess the effect of endoscopic variceal ligation on esophageal function prospectively, parameters measured by pneumohydraulic capillary infusion system, included lower esophageal sphincter(LES) pressure, % LES relaxation, amplitude, duration, velocity and progression of peristaltic waves and dysmotility, were compaired hetween before and after endoscopic variceal ligation in 12 patients with csophngeal varix. Results: Endoscopic variceal ligation has no impact on lower Esophageal sphincter(LES) tone. However, a significant increase in the amplitude of peristaltic waves was observed in the patients at'ter endoscopic variceal ligation in the mid-esophagus(8cm above lower esophageal sphincter: 57.2 ' 19.4 versus 65.7 ' 20.3, l3cm above lower esophageal sphincter; 5S,7 ' 23.8 versus 62.l ' 2I.S). There was no modification of duration, velocity and progression of peristaltic waves or dysmotility. Conclusions: Endoscopic variceal ligation is associated with a increasing esophageal body pressure without the other esophageal motility change. (Korean J Gastroenterol 1995;27:9 -17)

고령자 담석증의 임상적 고찰

차상우(Sang Woo Cha),천갑진(Gab Jin Chun),박용순(Yong Soon Park),송동화(Dong Hwa Song),조영덕(Young Deok Cho),김진오(Jin Oh Kim),봉형근(Hyung Keun Bong),조주영(Joo Young Cho),김연수(Yun Soo Kim),이준성(Joon Seong Lee),이문성(Moon Sun 대한소화기학회 1996 대한소화기학회지 Vol.28 No.2

N/A Background/Aims: Gallstone is uncommon before adolescence, and its incidence increases v:ith age. In elderly patients, one of the important characteristics of the ga]lstone disease is that they often have bile duct stones causing acute obstructive cholangitis. Another is that they could be accompained by other diseases. Methods: We analyzed 2,154 patients surgical]y or radiologically proven gallstone patients at the Soon Chun Hyang University Hospita] from l984 to 1994 and compared the clinical characteristics of elderly patients group(over 60 years) with younger patients group(under 60 years). Results: The peak incidence of gallstone (fisease wos noted in the 6th decade and the mean age was 55 years. Elderly patients group were 40.6%(874 cases) and younger patients group were 59.4%(l,280 cases'). Male to female ratio of eler]y patients vras I:1.IO. The location of stones was gallbladder(GB) in l,395 cases(64.9%), multiple sites in 416 cases(19.3%), common bile duct(CBD) in 214 cases(9.9%) and intrahepatic duct(IHD) in 129 cases(5.9%). In elderly patients group, the ]ocation of stones was multiple sites in l86 cases(2l.3%)and CBD in 120 cases(l3.7%). Frequency of stones in multiple sites and GB was significontly higher in elderly patients group than younger patients group(pO.OJ). The prominent clinical manifestations were right upper quadrant abdominal pain(24.5%), epigastric pain(19.4%), and no symptoms(l0.8%). In elderly patients group, chilling and jaundice were significantly higher than younger patients group(p 0.01). The associated diseases were cardiac diseases(l3.7%), diabetes me]litus(8.1%), malignancy (7.3%), liver cirrhosis(6.4%), and hepatitis(5.2%). Cardiac diseases, respiratory diseases, diabetes rnellitus and malignancy were more frequently associated in elder]y patients group than in younger group(p0.01). The incidence of complication was 10.7%(230/2,154)and mortality rate was 1.1% (24/2,154). In elderly patients group, the incidence of complication* and mortality* was signifi- cantly higher than younger patients group(*: p0.01; **: p0.05). Conclusions: The incidence of stones in CBD and mutiple sites, complication and morta]ity rate were higher, and chilling and jaundice were more frequently noted in elderly patients group than younger patients group. Our results suggest that ear]y diagnosis and proper treatment migbt be necessary in elderly patients with the gallstone disease. (Korean J Gastroenterol 1996; 28:260-266)

소화성궤양 환자에서 Helicobacter pylori의 DNA지문 분석

홍수진(Su Jin Hong),박용순(Yong Soon Park),이영홍(Young Hong Lee),조영덕(Young Deok Cho),김진오(Jin Oh Kim),봉형근(Hyung Keun Bong),조주영(Joo Young Cho),이준성(Joon Seong Lee),이문성(Moon Sung Lee),김연수(Yun Soo Kim),황성규(Seong G 대한소화기학회 1997 대한소화기학회지 Vol.29 No.3

N/A Background/Aims: The gastric pathogen Helicobacter pylori establishes long-term chronic infection that can lead to gastritis, peptic ulcers, and gastric cancer. However, little is known about the source and route of infection of this organism, and the mechanism of pathogenicity is only now beginning to be unravelled. Urease might allow the survival of the bacteria in an acidic environment, a prerequisite for colonization. H. pylori is cytotoxic to cultured human gastric epithelial cells and this toxicity is due in part to ammonia produced by hydrolysis of urea. We performed this study to evalute the usefulness of DNA fingerprinting of urease genes as a sensitive epidemiological tool for the typing of H. pylori clinical isolates. Methods: Clinical isolates of H. pylori were obtained by biopsy from 18 patients with peptic ulcer at the time of endoscopic examination. Biopsy tissues were cultured under microaerophilic conditions. DNA of H. pylori were extracted for PCR amplification. This study used the polymerase chain reaction(PCR) to amplify the urease structural subunit genes, ureA and ureB, which, when digested with restriction endonucleases, allow the differentiation of patterns on 1.5% agarose gels. Results: The 2.4 kb PCR products amplified and subjected to Hae III restriction endonuclease digestion produced 11 distinct patterns on agarose gels, with five patterns occurring within two or three isolates. Conclusions: The urease genes of H. pylori had genetic heterogeneity, but it could be of considerable tool for epidemiological studies. Moreover the method is useful for studies of relation between H. pylori induced diseases and different strains because unique pattems were shown in two or three isolates. In conclusion, DNA fingerprinting of H. pylori could be available for epidemiological studies of H. pylori infections and for clinical applications. (Korean J Gastroenterol 1997; 29:317 - 325)

악성 폐쇄성황달에 대한 각종 내시경적 역행성담관배액법 ( ERBD ) 비교 평가

심찬섭(Chan Sup Shim),조영덕(Young Deok Cho),문종호(Jong Ho Moon),이영홍(Young Hong Lee),김진오(Jin Oh Lee),봉형근(Hyung Keun Bong),조주영(Joo Young Cho),김연수(Yun Soo Kim),이준성(Joon Seong Lee),이문성(Moon Sung Lee) 대한내과학회 1998 대한내과학회지 Vol.54 No.4

N/A Objectives : Endoscopic biliary drainage has been established as the palliative treatment of choice for malignant obstructive jaundice. At present, the major drawback of endoscopic biliary stenting is occlusion of the endoprosthesis with sludge, resulting in recurrence of jaundice or cholangitis. Recently, there are variable stents that have different materials, sizes, and designs have been used in efforts to overcome this problem To determine the success rate of stent insertion, successful drainage rate, duration of patency, complications related to stent insertion, and cause of stent malfunction, plastic endoprosthesis compared to metal stents in palliative treatment of malignant biliary obstruction. Method: We retrospectively evaluated 157 patients (total number of stent insertion: 308 cases) with unresectable malignant biliary obstruction to receive either a plastic stent(group I, 261 cases) or metal stent(group II, 47 cases). The patients who were recieved plastic stent were subdivided to general plastic stents(group Ia, polyethylene, polyurethane, polyvinylchloride, 225 cases) and Tannenbaum stent(group 1b, Teflon, 36 times) group. And the patients who were received metal stent were subdivided to uncovered metal stents(group IIa, Gianturco- Rosch, Wall, Strecker, EndoCoil stent, 26 times) and membrane covered self-expandable metal stent(group Ilb, 21 cases) group. Results 1) There were no statistical difference in successful rate of stent insertion and drainage effect of stent according to the types of stent(p>0.05). 2) Median patency of the stent was significantly prolonged in patients with a metal stent(group II) compared with those with a plastic stent(group I) (249 vs 123 days; p < 0.05). Median patency of the gorup Ib was significantly prolonged than those of group Ia(137 vs 109 days ; P < 0.05), but there was no statistical difference in median patency between group IIa and Ilb(233 vs 267 days; p > 0.05). 3) The rate of early complication related to stent insertion showed no significant difference in plastic and metal stent groups(P > 0.05). 4) Major causes of stent malfunction in plastic and metal stent were sludge(90% vs 21,4%), tumor ingrowth (4.4% vs 71.4%), and dislocation(5.6% vs 7.2%), respectively. Conclusion : Metal stents have a longer patency than plastic stent in patients with malignant biliary obstruction. In plastic stents, Tannenbaum stents have a slighlty longer patency than other plastic stents, but there were no differences in the success rates, drainage effect and complication rates according to types of stents.

공복 및 식후 장기간 경피경간적 Oddi 괄약근 내압검사

홍수진(Su Jin Hong),이남수(Nam Su Lee),주재학(Jae Hak Joo),조영덕(Young Deok Cho),김진오(Jin Oh Kim),봉형근(Hyung Keun Bong),이준성(Joon Seong Lee),이문성(Moon Sung Lee),김연수(Yun Soo Kim),황성규(Seong Gyu Hwang),심찬섭(Chan Sup Shi 대한소화기학회 1995 대한소화기학회지 Vol.27 No.4

N/A Background/Aims: The short-term perendoscopic manometry of the sphincter of Oddi(SO) may not be representative of overall SO motility. In an attempt to overcomc this limitation, we performed SO manometry using a motility catheter placed via a percutaneous transhepatic biliary drainage catheter in patients with intrahepatic duct stones who had undergone percutaneous transhepatic cholangioscopic lithotripsy. Methods: Long-term recording of percutaneous transhepatic manometry of SO(PTMSO) were performed to 15 of 19 patients, during fasting and after feeding. Results: The mean recording time was 90.0 ' 45.0 min(total: 1,628 min) during fasting and 77.0 23. L min(total: 1,156 min) after feeding. The frequency of contractions of SO in basal fasting conditions varied from 0 to 13/min(mean ' SD: 3.2 l.4/min), and high frequency contractions (HFC; frequency 8/min, duration >2 mins) were observed in l 1 patients from a total of 16 occasions without biliary pain. The mean duration of HFCs and mean interval between HFCs were 4.8 ' l.l min and 72.0 12.4 min respectively. The motility of SO was suppressed by food intake for up to 30min after feeding. In 4 patients, antroduodenal manometry via transnasal route and PTMSO was recorded simultaneously with the total recording time of 926 min. The HFCs of SO were recorded 20 times with 4.5 min of mean durations and 46 min of mean intervals. Migrating motor complexes(MMC.) were recorded in the antroduodenum simultaneously. All occasions of HFCs of SO(20) coincided completely with the phase III of the duodenal MMCs. Conclusions: In fasting, HFCs of SO were frequently observed periodically without biliary pain and completely coincided with the phase III of duodenal MMCs. This finding suggests that some cases of HFCs, previously regarded as tachyoddia' in SO dysfunction by using endoscopically placed motility catheter, may not he the true tachyoddia in SO dysfunction. (Korean J Gastroenterol 1995;27:423 432)