BackgroundOsmotic demyelination syndrome (ODS) primarily occurs after rapid correction of severe hyponatremia. There are no proven effective therapies for ODS, but we describe the first case showing the successful treatment of central pontine myelinolysis (CPM) by plasma exchange, which occurred after rapid development of hypernatremia from intravenous sodium bicarbonate therapy.Case presentationA 40-year-old woman presented with general weakness, hypokalemia, and metabolic acidosis. The patient was treated with oral and intravenous potassium chloride, along with intravenous sodium bicarbonate. Although her bicarbonate deficit was 365 mEq, we treated her with an overdose of intravenous sodium bicarbonate, 480 mEq for 24 hours, due to the severity of her acidemia and her altered mental status. The next day, she developed hypernatremia with serum sodium levels rising from 142.8 mEq/L to 172.8 mEq/L. Six days after developing hypernatremia, she exhibited tetraparesis, drooling, difficulty swallowing, and dysarthria, and a brain MRI revealed high signal intensity in the central pons with sparing of the peripheral portion, suggesting CPM. We diagnosed her with CPM associated with the rapid development of hypernatremia after intravenous sodium bicarbonate therapy and treated her with plasma exchange. After two consecutive plasma exchange sessions, her neurologic symptoms were markedly improved except for mild diplopia. After the plasma exchange sessions, we examined the patient to determine the reason for her symptoms upon presentation to the hospital. She had normal anion gap metabolic acidosis, low blood bicarbonate levels, a urine pH of 6.5, and a calyceal stone in her left kidney. We performed a sodium bicarbonate loading test and diagnosed distal renal tubular acidosis (RTA). We also found that she had Sjögren’s syndrome after a positive screen for anti-Lo, anti-Ra, and after the results of Schirmer’s test and a lower lip biopsy. She was discharged and treated as an outpatient with oral sodium bicarbonate and potassium chloride.ConclusionThis case indicates that serum sodium concentrations should be carefully monitored in patients with distal RTA receiving intravenous sodium bicarbonate therapy. We should keep in mind that acute hypernatremia and CPM can be associated with intravenous sodium bicarbonate therapy, and that CPM due to acute hypernatremia may be effectively treated with plasma exchange.

Background/AimsEarly gastric cancer (EGC) with ulcerations can be treated via endoscopic resection (ER) when it is differentiated pathologically, limited to the mucosa, and <3 cm in diameter. The presence of ulceration is a key factor in deciding treatment strategies and is usually diagnosed during endoscopic examination. The aim of this study was to evaluate whether ulcerations in EGC can be clearly defined among endoscopists and which factors are related to the differences.MethodsA survey questionnaire, composed of demographic features and endoscopic images of seven patients with EGC, was presented to the endoscopists via e-mail. The endoscopists were asked whether such patients have ulcerations in the lesions.ResultsThe questionnaires were e-mailed to 197 endoscopists, and 103 doctors replied. The presence of an endoscopic ulceration was defined differently among the endoscopists, depending on the duration of endoscopic practice and the experience of endoscopic submucosal dissection. The differences were especially high in the lesions without mucosal breaks and converging folds, which were expected to be viewed as non-ulcerative.ConclusionsBefore ER, endoscopic ulcerations in EGC must be reviewed by experienced endoscopists to reduce overestimations, and adequate educational programs for trainees should be established.

Objectives. Endoscopic resection (ER) is commonly performed to treat gastric epithelial neoplasms and subepithelial tumors. The aim of this study was to predict the risk factors for surgery after ER-induced perforation. Methods. We retrospectively reviewed the data on patients who received gastric endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR) between January 2010 and March 2015. Patients who were confirmed to have perforation were classified into surgery and nonsurgery groups. We aimed to determine the risk factors for surgery in patients who developed iatrogenic gastric perforations. Results. A total of 1183 patients underwent ER. Perforation occurred in 69 (5.8%) patients, and 9 patients (0.8%) required surgery to manage the perforation. In univariate analysis, anterior location of the lesion, a subepithelial lesion, two or more postprocedure pain killers within 24 hrs, and increased heart rate within 24 hrs after the procedure were the factors related to surgery. In logistic regression analysis, the location of the lesion at the anterior wall and using two or more postprocedure pain killers within 24 hrs were risk factors for surgery. Conclusion. Most cases of perforations after ER can be managed conservatively. When a patient requires two or more postprocedure pain killers within 24 hrs and the lesion is located on the anterior wall, early surgery should be considered instead of conservative management.

Laparoscopic wedge resection of the stomach is a widely accepted treatment for primary resectable gastrointestinal stromal tumors (GISTs). However, it is difficult to determine the appropriate incision line from outside of the stomach, and many attempts have been made to avoid unnecessary resection of unaffected gastric tissues. Recently a technique called non-exposed endoscopic wall-inversion surgery (NEWS) was introduced to avoid exposure of GIST to the peritoneum. Here, we describe the first published case of NEWS for GIST of the stomach practiced in Korea.