Rapid advances in the technology of gastrointestinal endoscopy as well as the evolution of science have made it necessary for us to continue update in either various endoscopic techniques or state of art lectures relevant to endoscopy. International Digestive Endoscopy Network (IDEN) 2013 was held in conjunction with Korea-Japan Joint Symposium on Gastrointestinal Endoscopy (KJSGE) during June 8 to 9, 2013 at Seoul, Korea. Two days of impressive scientific program dealt with a wide variety of basic concerns from upper gastrointestine (GI), lower GI, pancreaticobiliary endoscopy to advanced knowledge including endoscopic submucosal dissection forum. IDEN seems to be an excellent opportunity to exchange advanced information of the latest issues on endoscopy with experts from around the world. In this special issue of Clinical Endoscopy, we prepared state of art review articles from contributing authors and the current highlights will skillfully deal with very hot spots of each KJSGE, upper GI, lower GI, and pancreaticobiliary sessions by associated editors of Clinical Endoscopy.

Endoscopic forceps biopsy is essential before planning an endoscopic resection of upper gastrointestinal epithelial tumors. However, forceps biopsy is limited by its superficiality and frequency of sampling errors. Histologic discrepancies between endoscopic forceps biopsies and resected specimens are frequent. Factors associated with such histologic discrepancies are tumor size, macroscopic type, surface color, and the type of medical facility. Precise targeting of biopsies is recommended to achieve an accurate diagnosis, curative endoscopic resection, and a satisfactory oncologic outcome. Multiple deep forceps biopsies can induce mucosal ulceration in early gastric cancer. Endoscopic resection for early gastric cancer with ulcerative findings is associated with piecemeal resection, incomplete resection, and a risk for procedure-related complications such as bleeding and perforation. Such active ulcers caused by forceps biopsy and following submucosal fibrosis might also be mistaken as an indication for more aggressive procedures, such as gastrectomy with D2 lymph node dissection. Proton pump inhibitors might be prescribed to facilitate the healing of biopsy-induced ulcers if an active ulcer is predicted after deep biopsy. It is unknown which time interval from biopsy to endoscopic resection is appropriate for a safe procedure and a good oncologic outcome. Further investigations are needed to conclude the appropriate time interval.

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Subepithelial lesions are frequently encountered and remain a diagnostic challenge. Imaging of subepithelial lesions using endoscopic ultrasound (EUS) can be helpful in narrowing the differential diagnosis of the lesion; however, definitive diagnosis typically requires tissue. Many methods for acquiring tissue exist including EUS-guided fine needle aspiration, Trucut biopsy, and fine needle biopsy. Obtaining adequate tissue is important for cytologic and histologic exams including immunohistochemical stains, thus a great deal of effort has been made to increase tissue acquisition in order to improve diagnostic yield in subepithelial lesions.

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Probe-based confocal microscopy (pCLE) is actively being investigated for applications in the esophagus and stomach. The use of pCLE allows real-time in vivo microscopy to evaluate the microarchitecture of the mucosal epithelium. pCLE appears to be particularly useful in identifying mucosal dysplasia and early malignancies that cannot be clearly distinguished using high-definition white light endoscopy, chromoendoscopy, or magnification endoscopy. In addition, the ability to detect dysplastic tissue in real-time may shift the current screening practice from random biopsy to targeted biopsy of esophageal and gastric cancers and their precursor lesions. We will review the use of pCLE for detection and surveillance of upper gastrointestinal early luminal malignancy.

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Foregut neuroendocrine tumors (NETs) include those arising in the esophagus, stomach, pancreas, and duodenum and seem to have a broad range of clinical behavior from benign to metastatic. Several factors including the advent of screening endoscopy may be related to increased incidence of gastrointestinal NETs; thus, many foregut NETs are diagnosed at an early stage. Early foregut NETs, such as those of the stomach and duodenum, can be managed with endoscopic treatment because of a low frequency of lymph node and distant metastases. However, controversy continues concerning the optimal management of early foregut NETs due to a lack of controlled prospective studies. Several issues such as indications, technical issues, and outcomes of endoscopic treatment for early foregut NETs are reviewed based on some published studies.

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Although techniques and instruments for endoscopic submucosal dissection (ESD) have improved, bleeding is still the most common complication. Minimizing the occurrence of bleeding is important because blood can interfere with subsequent procedures. Generally, ESD-related bleeding can be divided into intraprocedural and postprocedural bleedings. Postprocedural bleeding can be further classified into early post-ESD bleeding which occurs within 48 hours after ESD and late post-ESD bleeding which occurs later than 48 hours after ESD. A basic principle for avoiding intraprocedural bleeding is to watch for vessels and coagulate them before cutting. Several countertraction devices have been designed to minimize intraprocedural bleeding. Methods for reducing postprocedural bleeding include administration of proton-pump inhibitors or prophylactic coagulation after ESD. Medical adhesive spray such as n-butyl-2-cyanoacrylate is also an option for preventing postprocedural bleeding. Various endoscopic treatment modalities are used for both intraprocedural and postprocedural bleeding. However, hemoclipping is infrequently used during ESD because the clips interfere with subsequent resection. Bleeding that occurs as a result of ESD can usually be managed easily. Nonetheless, more effective ways to prevent bleeding, including reliable ESD techniques, must be developed.

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Endoscopic mucosal resection was introduced in the 1990s, and endoscopic submucosal dissection (ESD) in 2003. Currently, ESD is becoming the main procedure for the resection of early gastric cancer (EGC) and is leading to the development of extended indications for endoscopic resection. Many reports showed that the endoscopic and oncologic outcome of endoscopic treatment in the extended indication group was acceptable in terms of curability and safety. Especially, ESD showed better results to remove extended indication EGCs with relatively high resection rate and low local recurrence rate. However, more long-term follow-up data are needed for clinical application of the extended criteria of ESD due to the risk of lymph node metastasis. We should also keep in mind that accurate diagnosis, characterization of the lesion, and proper appreciation of technical aspects are most essential in therapeutic endoscopy.

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Colorectal endoscopic submucosal dissection (ESD) still remains a technically difficult procedure. The maintenance of tissue tension and good submucosal exposure during dissection is one of the most important factors for an effective and safe dissection. Although various traction methods have been developed, traction by gravity is one of the most useful method for colorectal ESD. Traction using adjunctive devices can thus be reserved for extremely difficult cases or for endoscopists in their learning periods for colorectal ESD.

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In colonoscopic study, benign colorectal strictures with or without symptomatic pain are not rarely encountered. Benign colorectal stricture can be caused by a number of problems, such as anastomotic stricture after surgery, inflammatory bowel disease, postendoscopic submucosal dissection, diverticular disease, ischemic colitis, and so on. There are various modalities for the management of benign colorectal stricture. Endoscopic balloon dilatation is generally considered as the primary treatment for benign colorectal stricture. In refractory benign colorectal strictures, several treatment sessions of balloon dilatation are needed for successful dilatation. The self-expandable metal stent and many combined techniques are performed at present. However, there is no specific algorithmic modality for refractory benign colorectal strictures.

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Lower gastrointestinal bleeding (LGIB) is defined as acute or chronic abnormal blood loss distal to the ligament of Treitz. The incidence of LGIB is only one fifth of that of the upper gastrointestinal tract and is estimated to be 21 to 27 cases per 100,000 adults per year. Acute bleeding is arbitrarily defined as bleeding of <3 days' duration resulting in instability of vital signs, anemia, and/or need for blood transfusion. Chronic bleeding is defined as slow blood loss over a period of several days or longer presenting with symptoms of occult fecal blood, intermittent melena, or scant hematochezia. Bleeding means that the amounts of blood in the feces are too small to be seen but detectable by chemical tests. LGIB is usually chronic and stops spontaneously. Bleeding stop (80%), but male gender and older patients suffer from more severe LGIB. The optimal timing of colonoscopic intervention for LGIB remains uncertain. Urgent colonoscopy may serve to decrease hospital stay. However, urgent colonoscopy is difficult to control, and showed no evidence of improving clinical outcomes or lowering costs as compared with routine elective colonoscopy.

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The advent of deep enteroscopy (DE) has dramatically changed diagnostic and therapeutic approaches to small bowel diseases. Unlike capsule endoscopy, which is unable to obtain biopsies or treat a disease, DE techniques have diagnostic and therapeutic capabilities. Double-balloon enteroscopy (DBE) was introduced in 2001, and single-balloon enteroscopy (SBE) and spiral enteroscopy (SE) were subsequently developed for small bowel investigation. In published reports comparing these different enteroscopy techniques, most comparative parameters (depth of insertion, complications, learning curve, diagnostic yield, and therapeutic yield) were comparable among DBE, SBE, and SE. However, the procedure duration appears to be shorter for SE than for DBE and SBE. The rate of complete enteroscopy is clearly superior for DBE, compared with SE and SBE. Because these results do not indicate an increase in diagnostic or therapeutic yield, the clinical impact of complete enteroscopy remains controversial. According to previous studies, the three DE methods seem to be equally effective and safe in the clinical setting. Although larger randomized controlled trials are needed to evaluate the procedural characteristics and clinical impact, the selection of an enteroscopic technique should be based on availability and the endoscopist's experience.

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Although endoscopic hemostasis remains initial treatment modality for nonvariceal gastrointestinal (GI) bleeding, severe bleeding despite endoscopic management occurs in 5% to 10% of the patients, requiring surgery or transcatheter arterial embolization (TAE). TAE is now considered the first-line therapy for massive GI bleeding refractory to endoscopic management. GI endoscopists need to be familiar with indications, principles, outcomes, and complications of TAE, as well as embolic materials available.

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Endoscopic mucosal resection (EMR) is an endoscopic alternative to surgical resection of mucosal and submucosal neoplastic lesions. Prior to the development of knives, EMR could be performed with accessories to elevate the lesion. After the development of various knives, en bloc resection was possible without other accessories. So, recently, simple snaring without suction or endoscopic submucosal dissection using knife in the epithelial lesions such as adenoma or early mucosal cancer has been performed. However, for easy and complete resection of subepithelial lesions such as carcinoid tumor, a few accessories are needed. Complete resection of rectal carcinoid tumors is difficult to achieve with conventional endoscopic resection techniques because these tumors often extend into the submucosa. The rate of positive resection margin for tumor is lower in the group of EMR using a cap (EMR-C) or EMR with a ligation device (EMR-L) than conventional EMR group. EMR-C and EMR-L (or endoscopic submucosal resection with a ligation device) may be a superior method to conventional EMR for removing small rectal carcinoid tumors.

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The conventional management of pancreatic fluid collections (PFCs) involves surgery or percutaneous drainage. While surgery is associated with significant complications and mortality, percutaneous drainage is associated with prolonged hospitalization and oftentimes the need for other adjunctive treatment measures. Therefore, the use of endoscopy to drain PFCs is becoming increasingly popular. Randomized trials have demonstrated that endoscopic ultrasound-guided drainage is superior to conventional endoscopy in terms of technical success and potentially decreases the rates of procedural complications. While transmural drainage is usually undertaken by deployment of plastic endoprosthesis, of late, fully covered self-expandable metal stents are being placed with increasing frequency. However, the benefits of this approach are unclear and require further validation in prospective trials.

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Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is routinely performed for establishing tissue diagnosis in patients with gastrointestinal tumors. The concept of delivering chemotherapy based on molecular markers and the ability to establish a reliable diagnosis in lieu of an onsite cytopathologist has fuelled the recent trend in procuring core tissue by means of EUS-guided fine needle biopsy. To overcome the technical limitations induced by the rigidity of the Trucut biopsy needle, a new ProCore needle with reverse bevel technology has been developed. Recent data suggests that the newly developed flexible 19 gauge needle can also procure core tissue and has easy maneuverability when navigating the transduodenal route. Irrespective of the needles being used, the best clinical outcomes can be attained only by practicing evidence-based techniques, procuring adequate quantity of sample for ancillary studies, and processing the specimens appropriately.

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Endoscopic management of symptomatic pancreatic fluid collections (PFCs) is now considered to be first line therapy. Expanded use of endoscopic ultrasound (EUS) techniques has resulted in increased applicability, safety, and efficacy of endoscopic transluminal PFC drainage. Steps include EUS-guided trangastric or transduodenal fistula creation into the PFC followed by stent placement or nasocystic drain deployment in order to decompress the collection. With the remarkable improvement in the available accessories and stents and development of exchange free access device; EUS drainage techniques have become simpler and less time consuming. The use of self-expandable metal stents with modifications to drain PFC has helped in overcoming some previously encountered challenges. PFCs considered suitable for endoscopic drainage include collection present for greater than 4 weeks, possessing a well-formed wall, position accessible endoscopically and located within 1 cm of the duodenal or gastric walls. Indications for EUS-guided drainage have been increasing which include unusual location of the collection, small window of entry, nonbulging collections, coagulopathy, intervening varices, failed conventional transmural drainage, indeterminate adherence of PFC to the luminal wall or suspicion of malignancy. In this article, we present a review of literature to date and discuss the recent developments in EUS-guided PFC drainage.

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Biliary stents are widely used not only for palliative treatment of malignant biliary obstruction but also for benign biliary diseases. Each plastic stent or self-expandable metal stent (SEMS) has its own advantages, and a proper stent should be selected carefully for individual condition. To compensate and overcome several drawbacks of SEMS, functional self-expandable metal stent (FSEMS) has been developed with much progress so far. This article looks into the outcomes and defects of each stent type for benign biliary stricture and describes newly introduced FSEMSs according to their functional categories.

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Iatrogenic duodenal perforation associated with endoscopic retrograde cholangiopancreatography (ERCP) is a very uncommon complication that is often lethal. Perforations during ERCP are caused by endoscopic sphincterotomy, placement of biliary or duodenal stents, guidewire-related causes, and endoscopy itself. In particular, perforation of the medial or lateral duodenal wall usually requires prompt diagnosis and surgical management. Perforation can follow various clinical courses, and management depends on the cause of the perforation. Cases resulting from sphincterotomy or guidewire-induced perforation can be managed by conservative treatment and biliary diversion. The current standard treatment for perforation of the duodenal free wall is early surgical repair. However, several reports of primary endoscopic closure techniques using endoclip, endoloop, or newly developed endoscopic devices have recently been described, even for use in direct perforation of the duodenal wall.

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Percutaneous transhepatic cholangioscopy (PTCS) is the most widely used modality for diagnosis and treatment of biliary disease. Although many other novel technologies have been developed based on recent advances in endoscopy, PTCS has its own role. In diagnostics, PTCS is used for evaluation of indeterminate biliary strictures, bile duct tumors, and postoperative biliary strictures that cannot be reached by a peroral approach. In therapeutics, the removal of bile duct stones, dilatation of bile duct strictures including postoperative anastomosis site strictures, and local tumor therapy are indications of PTCS. Especially in a therapeutic role, PTCS has the advantage of maneuverability due to a shorter endoscopic length compared to other cholangioscopic modalities. Hence, PTCS has its own indispensable diagnostic and therapeutic roles.

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Advantages of direct peroral cholangioscopy (POC) using an ultraslim endoscope include use of conventional endoscopy equipment, operation by a single endoscopist, and superior image quality of the biliary tree with easy application of enhanced endoscopy and a large working channel. The major diagnostic indications of this system are an evaluation of biliary strictures, filling defects, or unclear findings on cholangiogram or other imaging studies. Therapeutic application using a direct POC system can be broadened by a larger working channel. However, direct POC is difficult to apply in patients with a narrow diameter bile duct, far distal common bile duct lesion, or failed anchoring of the scope with accessories. An air embolism is a rare complication of direct POC but can be a fatal problem. Cholangitis can also occur during or after the procedure. Use of a CO₂ system instead of room air during the POC procedure and administration of antibiotics before and after the procedure are strongly recommended. Continuous development of specialized endoscopes and accessories is expected to facilitate the diagnostic and therapeutic roles of direct POC.

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For tissue diagnosis of suspected pancreatic cancer, endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is the procedure of choice with high safety and accuracy profiles. However, about 10% of cytologic findings of EUS-FNA are inconclusive. In that situation, careful observation, surgical exploration, or alternative diagnostic tools such as bile duct brushing with endoscopic retrograde cholangiopancreatography or computed tomography-guided biopsy can be considered. However, some concerns and/or risks of these options render repeat EUS-FNA a reasonable choice. Repeated EUS-FNA may impose substantial clinical impact with low risk.

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Currently, endoscopic retrograde cholangiopancreatography (ERCP) is the preferred procedure for biliary drainage for various pancreatico-biliary disorders. ERCP is successful in 90% of the cases, but is unsuccessful in cases with altered anatomy or with tumors obstructing access to the duodenum. Due to the morbidity and mortality associated with surgical or percutaneous approaches in unsuccessful ERCP cases, biliary endoscopists have been using endoscopic ultrasound-guided biliary drainage (EUS-BD) more frequently within the last decade in different countries. As with any novel advanced endoscopic procedure that incorporates various approaches, advanced endoscopists all over the world have innovated and adopted diverse EUS-BD techniques. Indications for EUS-BD include failed conventional ERCP, altered anatomy, tumor preventing access into the biliary tree and contraindication to percutaneous access (i.e., ascites, etc.). EUS-BD utilizing EUS-guided rendezvous technique is conducted by creating a tract from either the stomach or the duodenum into the bile duct. Although EUS-BD has rapidly been gaining attraction and popularity in the endoscopic world, the indications and methods have yet to be standardized. There are several access routes and techniques that are employed by advanced endoscopists throughout the world for BD. This article reviews the indications and currently practiced EUS-BD techniques, including indications, technical details (intrahepatic or extrahepatic approach), equipment, patient selection, complications, and overall advantages and limitations.

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Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is one of the least invasive and most effective modality in diagnosing pancreatic adenocarcinoma in solid pancreatic lesions, with a higher diagnostic accuracy than cystic tumors. EUS-FNA has been shown to detect tumors less than 3 mm, due to high spatial resolution allowing the detection of very small lesions and vascular invasion, particularly in the pancreatic head and neck, which may not be detected on transverse computed tomography. Furthermore, this minimally invasive procedure is often ideal in the endoscopic procurement of tissue in patients with unresectable tumors. While EUS-FNA has been increasingly used as a diagnostic tool, most studies have collectively looked at all primary pancreatic solid lesions, including lymphomas and pancreatic neuroendocrine neoplasms, whereas very few studies have examined the diagnostic utility of EUS-FNA of pancreatic ductal carcinoma only. As with any novel and advanced endoscopic procedure that may incorporate several practices and approaches, endoscopists have adopted diverse techniques to improve the tissue procurement practice and increase diagnostic accuracy. In this article, we present a review of literature to date and discuss currently practiced EUS-FNA technique, including indications, technical details, equipment, patient selection, and diagnostic accuracy.

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• The role of endoscopic ultrasound-guided fine-needle aspiration/biopsy in the diagnosis of mediastinal lesions
  Jingjing Zhou, Ting Cai, Dongwen Wu, Xiong Chen, Fen Wang
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  International Journal of Gastrointestinal Intervention.2023; 12(4): 163.     CrossRef
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• Optimal Techniques for EUS-Guided Fine-Needle Aspiration of Pancreatic Solid Masses at Facilities without On-Site Cytopathology: Results from Two Prospective Randomised Trials
  Woo Hyun Paik, Joon Hyuk Choi, Yangsoon Park, Jung Bok Lee, Do Hyun Park
  Journal of Clinical Medicine.2021; 10(20): 4662.     CrossRef
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  Diagnostic Pathology.2020;[Epub]     CrossRef
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• Needle-compatible miniaturized optoelectronic sensor for pancreatic cancer detection
  Seung Yup Lee, Julia M. Pakela, Kyounghwan Na, Jiaqi Shi, Barbara J. McKenna, Diane M. Simeone, Euisik Yoon, James M. Scheiman, Mary-Ann Mycek
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• High-resolution endoscopic ultrasound imaging and the number of needle passages are significant factors predicting high yield of endoscopic ultrasound-guided fine needle aspiration for pancreatic solid masses without an on-site cytopathologist
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  Eun Young Kim
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Mucosa-associated lymphoid tissue lymphoma mainly arises in the stomach, with fewer than 30% arising in the small intestine. We describe here two cases of primary duodenal mucosa-associated lymphoid tissue lymphoma which were evaluated by endoscopic ultrasonography. A 52-year-old man underwent endoscopy due to abdominal pain, which demonstrated a depressed lesion on duodenal bulb. Endoscopic ultrasonographic finding was hypoechoic lesion invading the submucosa. The other case was a previously healthy 51-year-old man. Endoscopy showed a whitish granular lesion on duodenum third portion. Endoscopic ultrasonography image was similar to the first case, whereas abdominal computed tomography revealed enlargement of multiple lymph nodes. The first case was treated with eradication of Helicobacter pylori, after which the mucosal change and endoscopic ultrasound finding were normalized in 7 months. The second case was treated with cyclophosphamide, vincristine, prednisolone, and rituximab every 3 weeks. After 6 courses of chemotherapy, the patient achieved complete remission.

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• Review of lymphoma in the duodenum: An update of diagnosis and management
  Masaya Iwamuro, Takehiro Tanaka, Hiroyuki Okada
  World Journal of Gastroenterology.2023; 29(12): 1852.     CrossRef
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• Early, Isolated Duodenal Mucosa-Associated Lymphoid Tissue Lymphoma Presenting without Symptoms or Grossly Apparent Endoscopic Lesions and Diagnosed by Random Duodenal Biopsies
  Mihajlo Gjeorgjievski, Issa Makki, Pradeep Khanal, Mitual B. Amin, Ann Marie Blenc, Tusar Desai, Mitchell S. Cappell
  Case Reports in Gastroenterology.2016; 10(2): 323.     CrossRef

A gastric inverted hyperplastic polyp is a rare type of gastric polyp and is characterized by downward growth of a variety of mucosal components into the submucosa. The polyp consists of columnar cells resembling foveolar epithelium and pyloric gland epithelium and can coexist with gastritis cystica profunda. Frequently, adenocarcinoma can coexist, but the relation is not clear. A 77-year-old male underwent endoscopic submucosal dissection due to early gastric cancer. A gastric inverted hyperplastic polyp was found in the removed specimen and gastric cystica profunda was also found. We report a case of gastric inverted hyperplastic polyp coexisting with gastric cystica profunda and gastric adenocarcinoma.

Citations

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• A gastric inverted polyp with atypical hyperplasia
  Yanyang Zou, Yusheng Tian
  Asian Journal of Surgery.2024; 47(3): 1686.     CrossRef
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A 17-year-old man was diagnosed as Peutz-Jeghers syndrome (PJS) because of pigmented lip and multiple gastrointestinal polyps. He had anemia and underwent polypectomy on the duodenum and colon. His maternal family members were patients with PJS. His mother used to be screened with endoscopy to remove large polyps. One and half years later, he underwent jejunal segmental resection due to intussusceptions. He underwent endoscopic polypectomy every 2 to 3 years. When he was 23 years old, high-grade dysplasia was found in colonic polyp and his mother underwent partial pancreatectomy due to intraductal papillary mucinous carcinoma. When he was 27 years old, diffuse gastric polyps on the greater curvature of corpus expanded and grew. Therefore, wide endoscopic polypectomy was done. Histological examination revealed focal intramucosal carcinoma and low-grade dysplasia in hamartomatous polyps. We report cases of cancers occurred in first-degree relatives with PJS.

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• Familial and hereditary gastric cancer, an overview
  Fátima Carneiro
  Best Practice & Research Clinical Gastroenterology.2022; 58-59: 101800.     CrossRef
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Esophageal carcinoid tumors remain some of the rarest of all carcinoid tumors, with only several cases previously reported in the literature. The endoscopic mucosal resection of selected carcinoid tumors has been shown to be a valid, safe, and effective method of treatment. Endoscopic ultrasonography is the technique of choice to select patients eligible for endoscopic resection. Here, we report successful endoscopic mucosal resection of a low esophageal carcinoid tumor and review the relevant literature. The present case is the first reported case of esophageal carcinoid tumor in Korea.

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• Role of Advanced Gastrointestinal Endoscopy in the Comprehensive Management of Neuroendocrine Neoplasms
  Harishankar Gopakumar, Vinay Jahagirdar, Jagadish Koyi, Dushyant Singh Dahiya, Hemant Goyal, Neil R. Sharma, Abhilash Perisetti
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Amyloidosis is characterized by extracellular deposition of insoluble protein fibrils that stain with Congo red application and appear apple green under polarized light. The presenting symptoms result from the involvement of many affected, nonspecific and generalized organ systems. Our patient was an 80-year-old woman with no medical history. She presented with a 2-week history of nausea and vomiting. An esophagogastroduodenoscopy showed erythematous and edematous mucosa on the antrum with pyloric stenosis. Histopathologic examination of the biopsy specimen showed the deposition of amorphous, homogeneous, and acidophilic material in the gastric mucosa. Amyloidal protein was proven by positive Congo red stain. A serum and urine immunfixation electrophoresis showed lambda light chain band. She developed symptoms of repeated greenish color vomiting. A follow-up esophagogastroduodenoscopy showed progressed antral obstruction. However, she refused further evaluation and treatment and was managed conservatively. She later died of disease progression after 34 hospital days.

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• A Case of Primary Gastric Amyloidosis with Fulminant Heart Failure
  Seonghun Hong, Young-Woon Chang, Jong Kyu Byun, Min Je Kim, Jung Min Chae, Sun Hee Park, Chi Hyuk Oh, Yong-Koo Park
  The Korean Journal of Gastroenterology.2015; 66(4): 227.     CrossRef

A 49-year-old woman presented with chronic abdominal discomfort, significant weight loss, and chronic intermittent diarrhea. She suddenly developed massive upper gastrointestinal bleeding and was referred for further treatment. Endoscopy indicated a large mass in the upper gastric body with antral and duodenal bulb involvement. Endosonography showed a large well-defined isoechoic gastric subepithelial mass with multiple intra-abdominal and peripancreatic lymphadenopathy, suspected to be malignant on the basis of fine needle aspiration cytology. The tumor was surgically removed, and histopathology showed typical characteristics of a neuroendocrine tumor. On the basis of immunohistochemical staining, somatostatinoma, a rare neuroendocrine tumor, was diagnosed. Gastrointestinal bleeding is a rare presentation and the stomach is an uncommon tumor location.