Clinical Endoscopy

The Effects of Endoscopic Sodium Alginate Powder (Alto Shooter^TM) in Peptic Ulcer Bleeding: Ilhyun Baek, M.D., Heung Young Oh, M.D., Gwang Ho Baik, M.D., Taeho Hahn, M.D., Jin Bae Kim, M.D., Jin Lee, M.D. and Myung Seok Lee, M.D.; Korean J Gastrointest Endosc 2004;29(6):489-494. Published online December 30, 2004

Abstract PDF: Background
/Aims: Peptic ulcer bleeding can be treated by endoscopic laser, argon plasma coagulation, heater probe, or electrocoagulation. However, techinical difficulties and significant rebleeding rate after such endoscopic hemostasis, offer some beneficial effect of Alto Shooter^TM as an adjuvant therapy in active peptic ulcer bleeding. Methods: Twenty-three patients with active peptic ulcer bleeding were randomized to Alto Shooter^TM & argon plasma coagulation therapy (ALTO⁢APC) or argon plasma coagulation therapy alone (APC). Forrest classifications were used to compare the effect of bleeding control. Results: The Forrest classifications in two groups before treatment were Ib (6 patients), IIa (11 patients) in "ALTO⁢APC", Ib (2 patients) and IIa (4 patients) in "APC". The Forrest classifications of two groups at follow-up endoscopy were Ia (1 patient), Ib (1 patient), IIc (14 patients), III (1 patient) in "ALTO⁢APC" and IIc (6 patients) in "APC". There was no significant difference in hemostatic effect between "ALTO⁢APC" (p=0.001) and "APC" (p=0.001) groups. Conclusions: Alto Shooter^TM offers no advantage over conventional endoscopic argon plasma coagulation therapy in controlling active peptic ulcer bleeding. Therefore routine addition of Alto Shooter^TM treatment may not be recommended after initial successful endoscopic argon plasma coagulation therapy in active peptic ulcer bleeding. (Korean J Gastrointest Endosc 2004;29:489⁣494)

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Effects of Chronic Alcohol Consumption on Midazolam Induced Sedation during Colonoscopy: Young Sook Park, M.D., Jong Yong Lee, M.D., Yu Seoung Seo, M.D., Chung Hyeon Kim, M.D., Jung Don Lee, M.D., Hyun Suk Lee, M.D., Kye Hyung Kwon, M.D.,Tae Hun Kim, M.D. and Yun Ju Jo, M.D.; Korean J Gastrointest Endosc 2004;29(6):495-499. Published online December 30, 2004

Abstract PDF: Background
/Aims: It is suggested that patients consuming large amounts of alcohol are difficult to be sedated by midazolam probably due to cross tolerance. We studied to know the adequate administration doses of midazolam in patients with chronic alcohol consumption. Methods: Study I; We prospectively studied 117 outpatients presenting for colonoscopy. According to alcohol consumption we divided four groups such as group I: 0 g/day, group II: ＜10 g/day, group III: 10∼40 g/day, group IV: ＞40 g/day. We initially administered 0.06 mg/kg midazolam and add up to spontaneous eye closure. We measured grade of amnesia, level of consciousness, endoscopist's assessment and VAS scale for pain after recovery. Study II; We measured induction time after 0.08 mg/kg midazolam in 60 patients who drink alcohol. Results: Additional amount of midazolam was not significantly different between the groups (group I: 0.0145 mg/ kg, group II: 0.0214 mg/kg, group III: 0.0181 mg/kg, group IV: 0.0199 mg/kg). There were no differences of sedation parameters between the groups. However the induction time was prolonged and correlated with alcohol consumption. Conclusions: For adequate sedation in patients with chronic alcohol consumption, longer induction time rather than increasing dosage is required. (Korean J Gastrointest Endosc 2004;29:495⁣499)

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The Clinical Usefulness of Fecal Elastase-1 Test as an Exocrine Pancreatic Function Test for the Diagnosis of Chronic Pancreatitis: Sung Hee Lee, M.D. and Ho Soon Choi, M.D.; Korean J Gastrointest Endosc 2004;29(6):500-513. Published online December 30, 2004

Abstract PDF: Background
/Aims: The quantitative analysis of fecal elastase-1 has been proposed as a noninvasive test for the examination of pancreatic exocrine function. Therefore, we evaluated the diagnostic value of fecal elastase-1 by comparing with endoscopic intraductal secretin test (IDST) which is used as a direct exocrine function test for the diagnosis of chronic pancreatitis. Methods: Fecal elastase-1 concentrations were measured by ELISA in spot stool samples of 40 healthy control subjects, 21 patients with liver disease, and 12 patients with chronic pancreatitis diagnosed with endoscopic retrograde cholangiopancreatography (ERCP) and IDST. Chronic pancreatitis were then sub- classified into mild (I), moderate (II) and severe form (III), using the Cambridge classification according to ERCP finding. The linear regression analysis to evaluate the correlation between the concentration of fecal elastase-1 and IDST was performed during ERCP. The cut-off value of fecal elastase-1 to discriminate chronic pancreatitis was calculated based on receiver operating characteristic curve, and the clinical usefulness of fecal elastase-1 in the diagnosis of chronic pancreatitis was evaluated. Results: There were several significant correlations between fecal elastase-1 and various parameters of IDST: pancreatic juice secretory volume (r=0.797, p＜0.002), bicarbonate concentration (r=0.846, p＜0.001), elastase-1 concentration in pancreatic juice (r=0.671, p＜0.017), and amylase output (r=0.783, p＜0.003). The mean value of fecal elastase-1 concentration in the patients with chronic pancreatitis (197±77μg/g stool) was significantly lower than those in the healthy control subjects (815±133μg/g stool) and patients with liver disease (594±206μg/g stool) (p＜0.05). The cutoff value of fecal elastase-1 to discriminate between the healthy control and chronic pancreatitis patients was 201μg/g stool. With this cutoff value, the accuracy, sensitivity, and specificity of fecal elastase-1 to diagnose chronic pancreatitis were 78.8%, 67.7%, and 82.5%, respectively, compared to the morphological severity (the sensitivity of mild, moderate, and severe chronic pancreatitis was 33.3%, 66.7%, 83.3%, respectively). Conclusions: Measurement of fecal elastase-1 is a reliable and sensitive non-invasive test for the diagnosis of moderate to severe forms of chronic pancreatitis. (Korean J Gastrointest Endosc 2004;29:500⁣508)

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A Case of Gastric Wall Abscess Associated with Gastritis Cystica Profunda: Jin Hong Park, M.D.*, Hyong Wook Kim, M.D., Won Il Park, M.D., Jong Yun Cheong, M.D., Dong Hyun Lee, M.D., Jeong Heo, M.D., Gwang Ha Kim, M.D., Dae Hwan Kang, M.D., Geun Am Song, M.D., Mong Cho, M.D. and Ung Suk Yang, M.D.; Korean J Gastrointest Endosc 2004;29(6):509-513. Published online December 30, 2004

Abstract PDF: Gastric wall abscess is a form of phlegmonous gastritis and has been very rarely reported. The pathogenesis of gastric wall abscess is thought to involve a focal injury to the gastric mucosa such as a penetrating trauma from an ingested foreign body or an endoscopic biopsy, where by bacterial infection occurs. Gastritis cystica profunda is a rare disease in which hyperplasia of mature glandular epithelium extends into the tissues beneath the submucosa. It shows multiple small cysts in the mucosa and submucosa of the stomach. To our knowledge, the association of gastric wall abscess with gastritis cystica profunda has never been reported yet. We, recently, experienced a case of gastric wall abcess associated with gastritis cystica profunda. Herein, we report it with a brief review with literatures. (Korean J Gastrointest Endosc 2004;29:509⁣513)

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A Case of Gastric Carcinoid Tumor Accompanied with Bleeding: Hee Jung Lee, M.D., Kyu Chan Huh, M.D., In Beom Jeong, M.D., Sun Moon Kim, M.D., Tae Hee Lee, M.D., Euyi Hyeog Im, M.D., Young Woo Choi, M.D., Bum Kyeong Kim, M.D.* and Young Woo Kang, M.D.; Korean J Gastrointest Endosc 2004;29(6):514-519. Published online December 30, 2004

Abstract PDF: Gastric carcinoid tumor is a rare neoplasm that occupies less than 1% of total gastric tumor. Especially, gastric carcinoid tumor with hemorrhage has been very rare. A sixty-three-year old male patient was admitted to the hospital because of hematemesis and melena. On the endoscopic examination, a 2 cm-long polypoid mass with central ulcer and hemorrhagic erosions was seen on the anterior wall of the mid-body without active bleeding. Endoscopic ultrasonography revealed that the lesion was limited to submucosa without evidence of metastasis to adjacent lymph node. We experienced a case of gastric carcinoid tumor accompanied with upper gastrointestinal bleeding. The patient underwent extended wedge resection and omentectomy under the diagnosis of type 3 carcinoid tumor. This tentative diagnosis was based on clinical and pathological findings. We report a case of gastric carcinoid with bleeding that is probably type 3. (Korean J Gastrointest Endosc 2004;29:514⁣519)

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A Case of Primary Aortoduodenal Fistula: Seong Gyu Yoon, M.D., Bung Kyu Na, M.D., Koon Hee Han, M.D., Young Don Kim, M.D., Jung Won Hwang, M.D., Hyun Il Hong, M.D., Seung Chan Lee, M.D., Hyoun Sung Kim, M.D., Jin Kun Jang, M.D. and Gab Jin Cheon, M.D.; Korean J Gastrointest Endosc 2004;29(6):520-523. Published online December 30, 2004

Abstract PDF: Aortoenteric fistula is a rare and life-threatening cause of upper gastrointestinal hemorrhage. Fistulas may be classified as primary or secondary. Secondary aortoenteric fistulas usually occur at the sA Case of Primary Aortoduodenal Fistulauture line following arterial reconstruction with prosthetic material and developed in 0.5∼2.4% of the patients. The incidence of primary fistulas was reported in 0.04∼0.07% in a large autopsy series and is 0.69∼2.36% in patients with abdominal aortic aneurysm. Atherosclerosis is now the dominant cause. The mortality rate of patients with primary aortoduodenal fistula (ADF) is extremely high, principally because the diagnosis is difficult and seldomly established before the massive bleeding results in emergency operation or death. This occurs predominantly in the third and fourth parts of the duodenum. Symptoms of ADF consist of flank pain or abdominal pain, hematemesis, melena, and an abdominal mass. ADF is curable, if diagnosed and treated with surgical intervention before the onset of lethal massive hemorrhage. We report a case of primary ADF with a review of the literatures. (Korean J Gastrointest Endosc 2004;29:520⁣523)

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A Case of Diffuse Infiltrative Colon Cancer Coexisting with Colonic Tuberculosis: Chang Yoon Ha, M.D., Hye-Kyung Jung, M.D., Jung Hwa Ryu, M.D., Hae Sun Jung, M.D., Gun Woo Pyun, M.D., Doe Young Kim, M.D., Il Hwan Moon, M.D. and Min-Sun Cho, M.D.*; Korean J Gastrointest Endosc 2004;29(6):524-528. Published online December 30, 2004

Abstract PDF: Inflammatory bowel disease has a potential risk of developing colorectal cancer. However, there is little causal relationship between intestinal tuberculosis and colon cancer because intestinal tuberculosis is curable disease and has relatively short disease course. But there were a few case reports of intestinal tuberculosis associated with colon cancer. Diffuse infiltrating colon cancer, characterized by tumor cells in the presence of inflammatory changes with much fibrosis, is very rare in the colon. We experienced a 49-year-old woman who had tuberculous colitis combined with diffuse infiltrative colon cancer. She visited our hospital because of chronic diarrhea and abdominal pain. Colonoscopy showed multiple geographic ulcers in the transverse colon and partial intestinal obstruction. Histological examination revealed non-caseating granuloma and Mycobacterium tuberculosis was cultured in biopsied tissue. She took an anti- tuberculosis drug for 2 weeks, but her symptoms were aggravated. Therefore, extended right hemicolectomy was performed and revealed mucin-secreting, diffuse infiltrating adenocarcinoma. Herein, we report a rare case of diffuse infiltrative colon cancer coexisting with colonic tuberculosis with a review of liferatures. (Korean J Gastrointest Endosc 2004;29:524⁣528)

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A Case of Hemorrhagic Colitis Complicated by Thrombotic Thrombocytopenic Purpura: Hyeon Seong Kim, M.D., Young Seok Cho, M.D., Yoon Seok Koh, M.D., Kon Ho Shim, M.D., Young Ki Choi, M.D., Hyung Keun Kim, M.D., Seong Hyun Son, M.D., Chang Wook Kim, M.D., Sung Soo Kim, M.D., Hiun Suk Chae, M.D., Sok Won Han, M.D., Chang Don Lee, M.D., Ky; Korean J Gastrointest Endosc 2004;29(6):529-533. Published online December 30, 2004

Abstract PDF: Hemorrhagic colitis may be seen as a complication of inflammatory bowel disease, as well as infectious colitis related to several pathogens, including enterohemorrhagic E. coli, Shigella, Yersinia and Campylobacter. Also, it is seen in the form of antibiotic-associated hemorrhagic colitis. However, Escherichia coli serotype O157:H7 is now recognized as an important identifiable cause of hemorrhagic colitis. Occasionally, patients with E. coli serotype O157:H7 infection are diagnosed as having thrombotic thrombocytopenic purpura (TTP), a condition similar to hemolytic uremic syndrome (HUS) but with more prominent neurological findings and less renal involvement. We report a case in a 47-year-old woman who developed hemorrhagic colitis complicated by TTP, responded to steroid and antibiotic treatment. (Korean J Gastrointest Endosc 2004; 29:529⁣533)

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A Case of Endometriosis Presenting as Constipation: Sang Hyen Joo, M.D., Woo Jin Jeong, M.D., Jeong Soo Kim, M.D., Won Il Park, M.D., Gwang Ha Kim, M.D., Jeong Heo, M.D., Dae Hwan Kang, M.D., Geun Am Song, M.D., Mong Cho, M.D., Suk Kim, M.D.* and Do Youn Park, M.D.^†; Korean J Gastrointest Endosc 2004;29(6):534-538. Published online December 30, 2004

Abstract PDF: Endometriosis is the abnormal growth of endometrial tissue outside of uterine cavity. The incidence of endometriosis is estimated about 8∼15% of the reproductive women. The intestinal invasion is showed at about 3∼34%. The intestinal invasion may be involved in rectosigmoid colon, appedix, ileum, and cecum in order of decreasing frequency. Until now, only 7 cases have been reported in Korea. Most cases are diagnosed after surgery. And then the diagnosis need to be confirmed by surgical pathology. Recently, a 42 year-old woman visited due to severe constipation. A flexible sigmoidoscopy revealed submucosal tumor on rectosigmoidal juction 20 cm above the anal verge. The surgical resection was performed and the biopsy showed the endomtriosis involving mucosa, submucosa, muscularis, serosa, subserosa and lymph node. (Korean J Gastrointest Endosc 2004;29:534⁣538)

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A Case of Biliary Ascariasis Associated with a Common Bile Duct Stone: Hee Ju Oh, M.D., Tae Nyeun Kim, M.D.,Ji Yun Lee, M.D., Jae Won Choi, M.D., Kook Hyun Kim, M.D., Sang Jin Lee, M.D., Eun Ju Lee, M.D., Hyun A Oh, M.D., Hyung Chul Lee, M.D., Jun Hwan Kim, M.D., Byeong Ik Jang, M.D., Moon Kwan Chung, M.D., Chae Hoon Lee, M.; Korean J Gastrointest Endosc 2004;29(6):539-542. Published online December 30, 2004

Abstract PDF: Ascaris lumbricoides is the commonest intestinal parasite. The parasites are the most numerous intestinal parasites in less-developed countries and in areas with poor sanitation. However, it's prevalence is very low in Korea recently. A. lumbricoides produces no symptoms in most patients but sometimes it may give rise to intestinal obstruction or pancreatobiliary disease. Highly motile mature worms may enter the ampulla of Vater and migrate into the bile or pancreatic ducts and can cause cholangitis, biliary stone, cholecystitis, pancreatitis and liver abscess. The cases of biliary ascariasis are rare in Korea. We report a 59-year-old female, who presented with intermittent epigastic pain, diagnosed as biliary ascariasis associated with common bile duct stone after endoscopic retrograde cholangiopancreatography (ERCP). The common bile duct (CBD) stone was removed by sphincterotomy and lithotripsy, and then we directly removed ascaris with a basket without any complication. (Korean J Gastrointest Endosc 2004;29:539⁣542)

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