Clinical Endoscopy

Barrett's Esophagus - With Emphasis on Endoscopic Disgnosis: Jun Haeng Lee, M.D.; Korean J Gastrointest Endosc 2009;39(4):185-198. Published online October 30, 2009

Abstract PDF: Barrett's esophagus is a metaplastic change of the esophageal mucosa, such that the normal squamous epithelium is replaced by specialized columnar epithelium. During the last decades, there has been a significant change in the definition, endoscopic diagnosis, pathologic diagnosis, surveillance and management of Barrett's esophagus. Because of the rising prevalence of gastroesophgeal reflux disease in Korea, problems related to Barrett's esophagus are expected to be much more common in the near future. In this review, methods of endoscopic diagnosis of Barrett's esophagus are discussed in detail. Management strategies in the context of Korean epidemiology are also suggested. (Korean J Gastrointest Endosc 2009; 39:185-198)

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The Effect of Peppermint Oil on Peristalsis during Gastroscopy: Sanghoon Park, M.D., Hoon Jai Chun, M.D., Eun Sun Kim, M.D., Sung Chul Park, M.D., Eun Suk Jung, M.D., Bora Keum, M.D., Yeon Seok Seo, M.D., Yoon Tae Jeen, M.D., Soon Ho Um, M.D., Chang Duck Kim, M.D. and Ho Sang Ryu, M.D.; Korean J Gastrointest Endosc 2009;39(4):199-204. Published online October 30, 2009

Abstract PDF: Background
/Aims: Gastrointestinal peristalsis may hinder inspection of the gastrointestinal track or its treatment during endoscopy. Antispasmodic agents such as hyoscine-N-butylbromide are commonly administered before endoscopy for alleviating peristalsis, although it causes unwanted complications. Peppermint oil (PMO) has a spasmolytic effect on viscera and it has been used as an adjunctive remedy for some disorders. We evaluated the antispasmodic effect of PMO solution during gastroscopy, and we determined if there are any adverse effects.
Methods
1.6% PMO solution was sprayed on the antrum of the examinees (n=40) during gastroscopy. Observation was performed 5 cm ahead of the pyloric ring to count the peristaltic waves for 3 minutes before and after spraying PMO. The intensity of peristalsis was graded from 0 (none) to 4 (severe), and the pulse rate of all the examinees was recorded every minute.
Results
The number of peristaltic contractions decreased after PMO spraying from 7.02±2.25 to 3.17±2.57 times/3 minutes (p＜0.01). The peristaltic intensity also decreased from 3.15±1.18 to 1.34±0.95 (p＜0.01) with a difference of 1.80± 1.29. On observing the examinees' pulse rates, using PMO did not induce tachycardia. No adverse effect during and after the investigation with PMO solution was reported.
Conclusions
PMO showed a significant antispasmodic effect, and it reduced the number of peristaltic contractions and the intensity of gastric peristalsis. It also did not have any significant side effects. PMO solution may be used as an effective antispasmodic agent during gastroscopy. (Korean J Gastrointest Endosc 2009; 39:199-204)

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The Incidence of Minor Complications and Patients' Time Requirements for Colonoscopy: Hyun Seok Cho, M.D., Dong Soo Han, M.D., Hye Sun Park, M.D., Sang Bong Ahn, M.D., Tae Jun Byun, M.D., Tae Yeob Kim, M.D., Chang Soo Eun, M.D., Yong Cheol Jeon, M.D. and Joo Hyun Sohn, M.D.; Korean J Gastrointest Endosc 2009;39(4):205-211. Published online October 30, 2009

Abstract PDF: Background
/Aims: Colonoscopy is an important method to screen for colorectal neoplasm and it is known to be a relatively safe procedure. Yet various minor complications, such as abdominal pain or discomfort, may result from colonoscopy or from additional colonoscopic procedures. In this study, we estimated the incidence of minor complications, the related risk factors and the total time requirement for colonoscopy.
Methods
We conducted a prospective analysis from 201 patients who visited Hanyang University Guri Hospital for colonoscopy during February to April, 2008. On the first day after colonoscopy, we asked the patients about the length of personal time devoted to the colonoscopy, such as the time taken for bowel preparation. We contacted all the patients by telephone 3 days after colonoscopy and we asked about any minor complications after colonoscopy, what was the most difficult part of the procedure and the time it took to get back to normal activity.
Results
Minor complications occurred in 66 patients (32.8%), of which abdominal discomfort was the most common complaint (74.2%). The incidence of minor complications was increased significantly in proportion to the procedure time (p＜0.0001). Bowel preparation was the most difficult part of the procedure for patients (88.0%). The mean duration of colonoscopy was 20 minutes, while the entire time allotted for colonoscopy from bowel preparation to arriving home was an average of 8.24 hours. The mean recovery time to normal activity was 19.02 hours.
Conclusions
Minor complications are relatively common when undergoing colonoscopy, and the duration of the procedure is significantly related to the incidence of minor complications. The majority of patients have difficulty with bowel preparation, so further studies concerning the development of a comfortable and effective preparation method are needed. (Korean J Gastrointest Endosc 2009;39:205-211)

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A Case of Eosinophilic Esophagitis Found Incidentally during the Evaluation of a Gastric Submucosal Tumor: Su Bum Park, M.D., Gwang Ha Kim, M.D., Mun Ki Choi, M.D., Hyung Seok Nam, M.D., Hyun Seok You, M.D., Bong Eun Lee, M.D., Geun Am Song, M.D. and Do Youn Park, M.D.; Korean J Gastrointest Endosc 2009;39(4):212-216. Published online October 30, 2009

Abstract PDF: Over the last several years, eosinophilic esophagitis in adults is an increasingly recognized disease in various parts of world. A 77-year-old male with a gastric submucosal tumor was referred to our department for endoscopic ultrasonography. During the examination, there was some resistance in inserting the echoendoscope into the esophagus. Detailed endoscopic examination of the esophagus showed narrow lumen and scattered whitish plaques, and biopsy of the esophagus revealed more than 20 eosinophils per high-power field. We diagnosed this case as eosinophilic esophagitis and treated successfully by topical steroid. We report a case of eosinophilic esophagitis found incidentally during endoscopic ultrasonography for a gastric submucosal tumor. (Korean J Gastrointest Endosc 2009; 39:212-216)

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A Case of Cytomegalovirus-Associated Esophageal and Duodenal Ulcers in a Critically Ill Immunocompetent Patient: Su-Yeon Lee, M.D., You Sun Kim, M.D., Jin-Ho Lee, M.D., Jong Hyeok Park, M.D., Sang-Ryul Lee, M.D., Soo-Hyung Ryu, M.D., Jung Hwan Lee, M.D. and Jeong Seop Moon, M.D.; Korean J Gastrointest Endosc 2009;39(4):217-221. Published online October 30, 2009

Abstract PDF: Cytomegalovirus (CMV) infection usually occurs in immunocompromised individuals such as patients who receive chemotherapy, glucocorticoid therapy, and patients infected with human immunodeficiency virus (HIV). CMV infection can also occur in immunocompetent adults, but active infection is apparently rare. CMV infection can present anywhere in the gastrointestinal tract, most commonly in the colon and rarely in the small intestine. Simultaneous CMV infection in the stomach, small bowel and colon of immunocompetent adults has rarely been reported. We report a case of cytomegalovirus-associated esophageal and duodenal ulcers in an immunocompetent adult where the patient had undergone a neurosurgical operation. (Korean J Gastrointest Endosc 2009;39:217-221)

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Esophageal Impaction of Trichobezoar Caused by Endoscopic Removal: Sang Hee Park, M.D., Jin Soo Moon, M.D.* and Tae Gil Huh, M.D.†; Korean J Gastrointest Endosc 2009;39(4):222-225. Published online October 30, 2009

Abstract PDF: Trichobezoar usually occurs in patients who have trichotillomania combined with trichophagia. Bezoars can result in serious complications including gastric ulceration, bleeding, perforation and small bowel obstruction when undiagnosed. The three main venues of bezoar removal (chemical dissolution, endoscopic removal and surgical removal) are chosen mainly by the size and composition of the bezoar. Trichobezoars generally require endoscopic or surgical removal. An 8-year-old girl visited our emergency room with recurrent epigastric pain and vomiting. Gastroduodenoscopy showed a 2×10 cm trichobezoar causing pyloric obstruction. During endoscopic removal of trichobezoar, esophageal impaction occurred. The trichobezoar was pushed into the stomach and was removed through surgical gastrostomy under general anesthesia. We report this case as an instructive reference for the proper treatment of trichobezoar in children. (Korean J Gastrointest Endosc 2009;39:222-225)

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Xanthogranulomatous Inflammation of Gastric Wall Presented as a Submucosal Tumor: Si Hyung Lee, M.D. and Byung Ik Jang, M.D.; Korean J Gastrointest Endosc 2009;39(4):226-229. Published online October 30, 2009

Abstract PDF: Xanthogranulomatous inflammation is a rare condition characterized by aggregation of foamy histiocytes, fibrosis and parenchymal destruction. A 53-year-old man presented suffering from dyspepsia. Endosonography revealed a submucosal lesion that was a 2.6 cm-sized hypoechoic mass. We could not differentiate the lesion as a benign or malignant mesenchymal tumor, particularly a gastrointestinal stromal tumor, necessitating a wedge resection. The stomach wall was focally thickened, measuring 1.0 cm in size. No definite mass was grossly evident. Microscopic examination revealed multiple foamy histiocytes and subserosal fibrosis. Xanthogranulomatous inflammation of the gastric wall was diagnosed. (Korean J Gastrointest Endosc 2009;39:226-229)

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Calcifying Fibrous Pseudotumor of the Stomach That Was Diagnosed by Endoscopic Submucosal Dissection: Dong Yeub Eun, M.D., Yong Dae Park, M.D., Dong Wook Lee, M.D., Jung Soo Lee, M.D., Jong Kyu Kwon, M.D., Seung Min Shin, M.D., Sang Man Park, M.D. and Kyung Rak Sohn, M.D.*; Korean J Gastrointest Endosc 2009;39(4):230-235. Published online October 30, 2009

Abstract PDF: Calcifying fibrous pseudotumor (CFPT) is very rare and especially at an intrinsic visceral location such as the stomach. The CFPT is generally located in the subcutaneous or deep soft tissue and the subserosal area of organs and it is mainly diagnosed during childhood or young adulthood. The etiology and pathophysiology of CFPT are unclear. Herein we describe a case of gastric CFPT and we review the related literature. A thirty-year-old asymptomatic female patient visited our hospital for the evaluation of a submucosal tumor that was seen on previous endoscopy. On the endoscopic ultrasonography (EUS), a subepithelial lesion was found at the gastric angle and it was a slightly hypoechoic, homogenous mass located at the submucosal layer of the gastric wall. Endoscopic submucosal dissection was performed under the suspicion of carcinoid. On the microscopic findings, most of the tissue was composed of hyalinized collagenous tissue. Mild lymphocytic infiltration and several dystrophic calcifications were also seen. Immunohistochemically, bcl-2 and CD34 staining was negative, so we diagnosed the mass as CFPT. (Korean J Gastrointest Endosc 2009;39:230-235)

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A Case of Cystic Brunner's Gland Hyperplasia with Intracystic Inverted Growth: Seok In Hong, M.D., Jin Il Kim, M.D., Ho Sang Lee, M.D., Gun Min Kim, M.D., Jin Min Park, M.D., Dae Young Cheung, M.D., Soo-Heon Park, M.D. and Jae Kwang Kim, M.D.; Korean J Gastrointest Endosc 2009;39(4):236-239. Published online October 30, 2009

Abstract PDF: Cystic Brunner's gland hyperplasia is a benign lesion of the duodenum that may not be familiar to gastroenterologists because of its rarity. Moreover, cystic Brunner's gland hyperplasia with intacystic inverted growth is more uncommon lesion. Here, we report a case of cystic Brunner's gland hyperplasia in a 34-year-old man. An endoscopy of the upper digestive tract revealed the presence of a 1.2 cm sized polypoid mass of the duodenal second portion. Endoscopic submucosal dissection was performed to remove the mass. Microscopically, a cystic lesion was seen in the submucosa underneath the normal surface duodenal mucosa. Hyperplastic Brunner's glands were seen close by the cyst. The cyst was lined by a layer of columnar epithelium similar to that of Brunner's gland ducts with no cytologic atypia. Also, a part of the cyst lining was inverted into the cyst lumen with fibrovascular core. Therefore, The final diagnosis was a cystic Brunner's gland hyperplasia with intracystic inverted growth. (Korean J Gastrointest Endosc 2009;39:236-239)

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Intramural Duodenal Hematoma following Endoscopic Epinephrine and Thrombin Injection for Bleeding Duodenal Ulcer in a Geriatric Patient with a History of Anticoagulant Drug Use: Jung Bok Park, M.D., Won Ki Bae, M.D., Hyoung Don Lee, M.D., Jung Hoon Kim, M.D., Nam-Hoon Kim, M.D., Kyung-Ah Kim, M.D., June Sung Lee, M.D. and Young Soo Moon, M.D.; Korean J Gastrointest Endosc 2009;39(4):240-243. Published online October 30, 2009

Abstract PDF: Intramural duodenal hematoma is a rare injury of the duodenum due mainly to blunt abdominal trauma and, less commonly, a hematologic disorder, anticoagulant drug use and post-therapeutic endoscopy. Intramural duodenal hematoma following endoscopic intervention is even rarer. Patients usually present with gradual onset of vomiting and abdominal pain approximately 48 h post-injury. The hematoma usually resolves in 1∼2 weeks with conservative therapy. Surgery is usually reserved for patients with suspected duodenal perforation, bile or pancreatic duct compression and inadequate resolution of the hematoma after 1∼2 weeks of conservative therapy. We describe a patient with a history of anticoagulant drug use who developed intramural duodenal hematoma after endoscopic hemostasis of a bleeding duodenal ulcer. Conservative therapy produced a successful outcome. (Korean J Gastrointest Endosc 2009;39:240-243)

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A Case of Chronic Lymphocytic Leukemia Involvement of the Terminal Ileum and Colon That Was Seen on Colonscopy as a Form of Lymphoid Hyperplasia: Min JI Lee, M.D., Hoon Go, M.D., Yun Jung Lee, M.D., Sung Hee Jung, M.D., Hyang Le Lee, M.D., Hyeon Woong Yang, M.D., An Na Kim, M.D. and Sang Woo Cha, M.D.; Korean J Gastrointest Endosc 2009;39(4):244-247. Published online October 30, 2009

Abstract PDF: Follicular lymphoid hyperplasia is commonly seen when performing pediatric endoscopy. But in adults, these findings can imply an underlying gastrointestinal or systemic illness, besides the normal variant. On the other hand, colonic involvement of chronic lymphocytic leukemia (CLL) is seen in about 5% to 20% of autopsy cases. However, there have been few reports on the colonoscopic appearance that corresponds to colonic involvement by CLL, and the reported colonoscopic appearances have included polyps, ulcers, granularity, submucosal nodules, erythema, the red ring sign etc. We report here on a case of CLL neoplastic lymphocyte involvement of the terminal ileum and colon as a form of lymphoid hyperplasia, and this was seen when performing colonoscopy. (Korean J Gastrointest Endosc 2009;39:244-247)

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A Case of Esophageal Peptic Stricture Concomitant with Vascular Ring in Mid-Esophagus: Ki Byung Lee, M.D., Hyun Chul Lim, M.D., Hye Yeon Park, M.D., Jae Joon Jung, M.D.* and Hyo Jin Park, M.D.; Korean J Gastrointest Endosc 2009;39(4):248-251. Published online October 30, 2009

Abstract PDF: Esophageal strictures may result from common conditions such as gastroesophageal reflux disease. Dysphagia is by far the most common presenting complaint in patients with esophageal peptic stricture. Symptomatic peptic strictures are treated by dilatation via ballooning or bougienation. Vascular ring is a term given to a combination of vascular and often ligamentous structures that encircle the trachea and esophagus. Symptomatic vascular ring, also known as dysphagia lusoria, is generally treated by conservative management. However, surgery should be considered when symptoms persist regardless of the treatment. We experienced a case involving a 41-year-old man with dysphagia diagnosed with peptic stricture on upper endoscopy and concomitant vascular ring on chest CT, which proved asymptomatic. (Korean J Gastrointest Endosc 2009;39:248-251)

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A Case of Endoscopic Ultrasound Guided Cholangiography with Antegrade Drainage: Sang Ryul Lee, M.D., Jung Hwan Lee, M.D., Su-Yeon Lee, M.D., Hyung Hun Kim, M.D., Jong Hyeok Park, M.D., Soo Hyung Ryu, M.D., You Sun Kim, M.D. and Jeong Seop Moon, M.D.; Korean J Gastrointest Endosc 2009;39(4):252-256. Published online October 30, 2009

Abstract PDF: An 84-year-old woman presented with obstructive jaundice due to unresectable gallbladder cancer with a left renal cell carcinoma. Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD) were unsuccessful because of tumor obstruction of the duodenal bulb, right hepatic duct and distal common bile duct. Endoscopic ultrasound (EUS)-guided biliary drainage with a transgastric approach was performed. A guide-wire was passed through the biliary obstruction and was successfully advanced into the duodenum via the ampulla. The procedure was completed in an antegrade fashion. The obstructed biliary system was successfully decompressed by the insertion of a biliary covered metal stent through the malignant stricture. There were no complications related to the use of this procedure. (Korean J Gastrointest Endosc 2009;39:252-256)

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