Clinical Endoscopy

Long-term Outcome of Endoscopic Mucosal Resection for Gastric Adenoma and Factors Related to Recurrence: Yeom Seok Lee, M.D., Kyung Hoon Chae, M.D., Won Seok Heo, M.D., Jae Hoon Jung, M.D., Yoon Sae Kang, M.D., Yeon Soo Kim, M.D., Ki Oh Park, M.D., Seon Mun Kim, M.D., Jae Kyu Seong, M.D., Seok Hyun Kim, M.D., Byung Seok Lee, M.D. and Hyun Yong Jeong, M.D.; Korean J Gastrointest Endosc 2005;30(3):119-125. Published online March 31, 2005

Abstract PDF: Background
/Aims: Endoscopic mucosal resection (EMR) has been known as a method of local treatment for early gastric cancer (EGC) or gastric adenoma. It has been widely accepted as a useful method due to its minimal invasiveness, safety and satisfactory result. The purpose of this study was to identify the factors affecting the recurrence after EMR. Methods: Three hundred twenty adenomas in 297 patients were treated by EMR from January, 1991 until July 2003. Among those, 197 lesions in 184 patients that could have been followed-up were analyzed retrospectively. Results: The mean follow-up period was 15.0 (1∼89) months. Of the 197 lesions, there were 35 recurrences (17.7%). The recurrence rate was higher in lesions associated with severe mucosal atrophy and intestinal metaplasia in surrounding mucosa (p=0.035). Other factors showed no statistically significant difference in recurrence rate. Conclusions: In this study, we concluded that the presence of intestinal metaplasia and severe atrophic background mucosa were related to the recurrence of gastric adenoma after EMR. (Korean J Gastrointest Endosc 2005; 30:119⁣125)

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The Efficacy of 38 mg Low Dose Capsule-Based ¹³C-urea Breath Test for the Diagnosis of Helicobacter pylori Infection: Yong Sik Kim, M.D., Hoon Jai Chun, M.D., Yoon Tae Jeen, M.D., Han Kyum Kim, M.D., Jin Hai Hyun, M.D., In Sik Chung, M.D.*, Myung Gyu Choi, M.D.*, Sang Woo Kim, M.D.*, In Seok Lee, M.D.*, Gyeong Sin Park, M.D.*, Chan Sup Shim, M.D.^†, Joo Young C; Korean J Gastrointest Endosc 2005;30(3):126-132. Published online March 31, 2005

Abstract PDF: Background
/Aims: Urea breath test (UBT), the noninvasive test for diagnosing Helicobacter pylori infection, was developed in 1987 and had advanced in accuracy and convenience by improvement of analytic device, ¹³C or ¹⁴C urea regimen, expiration sampling protocol and test meal. However, conventional UBT using 75 mg or 100 mg of ¹³C-urea is expensive and time consuming. The objective of this study was to evaluate the diagnostic performance of UBT using capsulated 38 mg low dose ¹³C-urea (HeliFinder^Ⱂ) developed by Medichems Co., Ltd. Methods: A total of one hundred forty seven volunteers were enrolled and examined at Catholic University, Korea University, and Soon Chun Hyang University hospital. UBT was performed using 38 mg ¹³C urea capsule and compared with the gold standard methods (rapid urease test and histology). Baseline and 20 min breath samples were collected. We used ∆¹³C 2.0‰ as the cut-off value suggested by the manufacturer. Results: Of the 147 subjects, 142 cases were available for analysis. The sensitivity and specificity of UBT using the 38 mg ¹³C urea capsule at 20 min were 98.7% and 100% respectively. Conclusions: A 20 min, 38 mg capsule based ¹³C urea breath test protocol is more efficient, cost effective, and convenient than conventional protocol. (Korean J Gastrointest Endosc 2005;30:126⁣132)

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Expression of Cyclooxygenase-2 and p53 Protein in Colonic Adenoma with Malignant Change: Seok Hyun Kim, M.D., Jae Hoon Jung, M.D., Yoon Sae Kang, M.D., Yeon Soo Kim, M.D., Ki Oh Park, M.D., Yeum Seok Lee, M.D., Seon Mun Kim, M.D., Seung Won Seo, M.D., Jae Kyu Seong, M.D., Byung Seok Lee, M.D., Hyun Yong Jeong, M.D. and Gyu Sang Song, M.D.*; Korean J Gastrointest Endosc 2005;30(3):133-139. Published online March 31, 2005

Abstract PDF: Background
/Aims: The aim of this study was to investigate the value of expression of COX-2 and p53 protein in colonic adenoma with or without malignant change. Methods: We studied twenty-five cases of colonic adenoma with malignant change and twenty-five cases of colonic adenoma without malignant change treated by colonoscopic polypectomy in Chungnam National University Hospital from January, 1999 to July, 2002. We compared the expression of COX-2 and p53 protein by immunohistochemical stain in both group. Results: In immunohistochemical staining, the expression of COX-2 was demonstrated 68.0% (17 of 25) of colonic adenoma with malignant change and not different with that of colonic adenoma without malignant change. The overexpression of p53 protein was detected immunohistochemically in 88.0% (22 of 25) of colonic adenoma with malignant change and 32% (8 of 25) of colonic adenoma only (p＜0.05). Conclusions: The degree of COX-2 expression was similar in colonic adenoma and colonic adenoma with malignant change, but the expression of p53 in colonic adenoma with malignant change was significantly higher (p＜0.05). These results suggest COX- 2 might operate on early step of adenoma-carcinoma sequence. Also these results remind us that mutation of p53 gene operates on the late step of adenoma-carcinoma sequence. (Korean J Gastrointest Endosc 2005;30:133⁣139)

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A Case of Esophageal Perforation Following Anterior Cervical Spinal Fusion: Jung Mi Kim, M.D., Ho Soon Choi, M.D., Dae Won Jun, M.D., Sun Young Yang, M.D., Sung Hee Han, M.D., Hang Lak Lee, M.D. and Oh Young Lee, M.D.; Korean J Gastrointest Endosc 2005;30(3):140-144. Published online March 31, 2005

Abstract PDF: Esophageal perforation is uncommon, however, due to the lack of serosa, inflammation spread is rapid and common to neighboring structures, causing mortality and morbidity. Initial symptoms for esophageal perforation have not been clarified, but when the diagnosis and proper treatment is delayed, its clinical course is fatal. Prompt recognition and proper treatment of esophageal perforation or rupture is mandatory. We report a case of 21-year-old man patient with esophageal perforation after anterior fusion of the cervical spine. Diagnosis was made by clinical suspicion and confirmed by esophagography and esophagoscopy. The patient was successfully treated by primary closure with good clinical course. (Korean J Gastrointest Endosc 2005; 30:140⁣144)

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A Case of Swallowing Syncope Caused by Endoscopic Examination: Chang Soo Choi, M.D., Tae Hyeon Kim, M.D., Nam Ho Kim, M.D., Suck Chei Choi, M.D. and Yong Ho Nah, M.D.; Korean J Gastrointest Endosc 2005;30(3):145-149. Published online March 31, 2005

Abstract PDF: Swallowing syncope is thought to be induced by an abnormal esophagovagal reflex arc that leads to transient bradyarrhythmia. Bradyarrhythmia in the response to swallowing produce decreased cardiac output and cerebral perfusion which result in loss of consciousness. Dysarrhythmia are common during any procedure which involves the manipulation of upper gastrointestinal tract, such as endoscopy of the esophagus or stomach. Swallowing syncope represents an extreme form of this phenomenon. We report a patient who had bradycardia and fainting episode during endoscopic examination. High degree atrioventricular block was detected in 24 hr Holter monitoring. (Korean J Gastrointest Endosc 2005;30:145⁣149)

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Gastric Intramural Hematoma Simulating Submucosal Tumor Following Extracorporeal Shockwave Lithotripsy in a Patient with Pancreatic Duct Stones: Kyung-Jo Kim, M.D.*, Sung Koo Lee, M.D., Myung Hwan Kim, M.D., Dong Wan Seo, M.D., Sang Soo Lee, M.D., and Young Il Min, M.D.; Korean J Gastrointest Endosc 2005;30(3):150-154. Published online March 31, 2005

Abstract PDF: Gastric intramural hematoma is a very rare disease entity. There is no reported case of gastric intramural hematoma in Korea following the extracorporeal shockwave lithotripsy (ESWL). Most have been associated with hereditary coagulopathy, but abdominal trauma, peptic ulceration, and inadvertent ingestion of foreign bodies have been listed as etiologic agents. This is the first description of a case of gastric intramural hematoma simulating gastric submucosal tumor, which regressed spontaneously, following ESWL in a patient with pancreatic duct stones. (Korean J Gastrointest Endosc 2005;30:150⁣154)

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A Case of Inflammatory Fibroid Polyp in the Duodenum: Jae Eun Park, M.D., Seung Wook Jung, M.D., Dae Jin Kim, M.D., Kwang Hyun Kim, M.D., Gun Hyun Kim, M.D., Se Hwan Kim M.D., Seung Yeop Lee M.D., Hyun Soo Kim, M.D., Sang Moon Lee M.D. and Dong Ja Kim, M.D.*; Korean J Gastrointest Endosc 2005;30(3):155-159. Published online March 31, 2005

Abstract PDF: Inflammatory fibroid polyp is a relatively uncommon, localized benign lesion of the gastrointestinal wall. It is seen mostly as a single entity and the majority of inflammatory fibroid polyps have been reported with pathologic examination in the stomach but rarely in small intestines. A 70-year-old woman was presented with intermittent epigatric discomfort and gastroduodenoscopy showed a polypoid lesion with oval shaped, central depression, and normal mucosal covering. Endoscopic ultrasonography showed 8⁓6 mm sized hypoechoic tumor which was located mainly in the third layer of the duodenal wall with indistinct margin. The tumor was successfully removed by endoscopic resection after the injection of hypertonic saline solution with epinephrine and banding. The tumor consisted of loose fibrous stroma, small blood vessels and inflammatory cells. We present a case of inflammatory fibroid polyp of the duodenum with review of the literatures. (Korean J Gastrointest Endosc 2005;30:155⁣159)

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Duodenal Perforation due to Hemoclipping for the Dieulafoy's Lesion in a Duodenal Diverticulum: Hyeuk Park, M.D., Kwang Hyun Ko, M.D., Jeong Ki Kim, M.D., Hong Youp Choi, M.D., Sung Pyo Hong, M.D., Sung Kyu Hwang, M.D., Pil Won Park, M.D. and Kyu Sung Rim, M.D.; Korean J Gastrointest Endosc 2005;30(3):160-163. Published online March 31, 2005

Abstract PDF: Duodenal diverticulum usually originates in the second portion of the duodenum and occasionally causes duodenal obstruction, hemorrhage, perforation and diverticulitis. A bleeding from Dieulafoy's lesion in a duodenal diverticulum is rare. It is not easily dignosed and treated by forward viewing endoscopy. Recently, a case was reported describing the hemorrhage from the Dieulafoy's lesion in a duodenal diverticulum which was treated by hemoclip with forward viewing endoscopy. Hemoclip application is considered to be the most appropriate endoscopic treatment, because sclerotherapy, electrocoagulation or band ligation for Dieulafoy's lesion in the duodenal diverticulum may increase risk of duodenal perforation. We report a case of duodenal perforation due to hemoclip application for the treatment of Dieulafoy's lesion in a duodenal diverticulum. (Korean J Gastrointest Endosc 2005;30:160⁣163)

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A Case of Colonic Tuberculosis Presenting as Massive Bleeding: Kyung Young Namgung, M.D., Myung Jin Kang, M.D., Hong Mok Im, M.D., Mi Sung Kim, M.D., Byung Sung Ko, M.D., Hyun Taek Ahn, M.D. and Hyang Mi Shin, M.D.*; Korean J Gastrointest Endosc 2005;30(3):164-167. Published online March 31, 2005

Abstract PDF: Tuberculous involvement of the colon is an uncommon clinical entity. Other colonic disease which should be considered in the differential diagnosis include inflammatory bowel disease such as Crohn's disease, ulcerative colitis and colon cancer. Intestinal tuberculosis most frequently involves the ileocecal area. The common presenting symptoms are abdominal pain, fever, weight loss and malabsorption. Pathologically, tuberculous colitis may present as an ulcerative type, hypertrophic type or in combination. Massive bleeding is said to be very rare even in the ulcerative type because of an obliterative endarteritis. We report a case of colonic tuberculosis presenting with massive bleeding in 52-year-old man with alcoholic liver cirrhosis, which was diagnosed by colonoscopic biopsy and acid-fast stain. (Korean J Gastrointest Endosc 2005;30:164⁣167)

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A Case of Iatrogenic Colonic Perforation Repaired by Endoscopic Clipping: Hee Jung Lee, M.D., Tae Hee Lee, M.D., Sun Moon Kim, M.D., Euyi Hyeog Im, M.D., Kyu Chan Huh, M.D., Young Woo Choi, M.D. and Young Woo Kang, M.D.; Korean J Gastrointest Endosc 2005;30(3):168-172. Published online March 31, 2005

Abstract PDF: As colonoscopy is widely used as a diagnostic tool in Korea, it produces many complications such as colonic bleeding and perforation. These are considered to be an usual event, not as a concept of complication. Therefore, the adverse events are given the term of incidental events, not as the complications in the recent days. Medical treatment may be offered as an alternative to surgical method for immediate management of these complications. Colonic perforation usually results in fatal and emergent condition requiring surgical intervention. Others described the application of endoclip as a therapeutic endoscopic maneuver twenty years ago, and in 1997, Yoshikane et al. used clips to close a colonic perforation after performing the endoscopic mucosal resection of an early cancer. Since then, endoscopic repairs of iatrogenic perforation have frequently been used in many cases. We report a 69 year-old man who was successfully treated by endoscopic clipping of iatrogenic colonic perforation site during polypectomy without complications. (Korean J Gastrointest Endosc 2005;30:168⁣172)

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A Case of Rectal Gastrointestinal Stromal Tumor with Bleeding: Jeong Ah Shin, M.D., Seong Jun Kim, M.D., Won Chang Shin, M.D., Jin Ho Lee, M.D., Won Choong Choi, M.D., Kwan Yeop Kim, M.D., Myeong Ja Jeong, M.D.* and Sung-Jig Lim, M.D.^†; Korean J Gastrointest Endosc 2005;30(3):173-177. Published online March 31, 2005

Abstract PDF: Gastrointestinal stromal tumors (GIST), although uncommon mesenchymal tumors of the gastrointestinal tract, are occasionally encountered on endoscopic examination. GIST can be found all gastrointestinal tract, but rare in the rectum. We report a 72-year-old woman presented with intermittent bloody stool for a year. On rectal examination, a firm fixed mass was felt on the anterior wall of the rectum. Computed tomography revealed the 4.8⁓4.5 cm sized exophytic and centrally depressed mass on the rectum without the evidence of adjacent organ invasion or metastasis. On colonoscopic examination, there was a round elevated lesion having central ulcer with adherent blood clots. Endoscopic deep biopsy examination revealed a submucosal tumor consisting of spindle cells with elongated cigar-shaped nuclei arranged in fascicles and whorls. Mitotic counts were fewer than 5 per 50 high-power fields. The tumor cells were positive for KIT and CD34 immunohistostaining and negative for SMA. Local excision recommended, but the patient discharged against the advice. Korean J Gastrointest Endosc 2005;30:173⁣177)

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Two Cases of Hemobilia Associated with Common Bile Duct Stones: Jeong Ki Kim, M.D., Kwang Hyun Ko, M.D., Hyeuk Park, M.D., Hong Youp Choi, M.D., Sung Pyo Hong, M.D., Seong Gyu Hwang, M.D., Pil Won Park, M.D. and Gyu Sung Rim, M.D.; Korean J Gastrointest Endosc 2005;30(3):178-181. Published online March 31, 2005

Abstract PDF: Hemobilia is a disease caused by injury or conditions that cause the abnormal communication between intrahepatic blood vessels and biliary tract, resulting in leakage of blood into the biliary tract. In the past, trauma had been the most common cause of hemobilia. However, with the increasing invasive procedures in the hepatobiliary tract, iatrogenic origin has become the major cause of hemobilia. Also, non-traumatic etiologies of hemobilia include vascular malformation such as aneurysm, gallstone, inflammation, biliary tumor, hepatocellular carcinoma and coagulopathy. Among these non-traumatic etiologies, choledocholithiasis is a rare cause of hemobilia. The authors have experienced two cases of hemobilia caused by choledocholithiasis, which was diagnosed by abdominal ultrasonography, abdominal CT and duodenoscopy. Both patients were treated by the endoscopic sphincterotomy and stone removal with basket. (Korean J Gastrointest Endosc 2005;30:178⁣182)

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