Clinical Endoscopy

The Effect of Fixed Dose of Flumazenil on Recovery after Sedative Endoscopy by Midazolam: Kye Hyoung Kwon, M.D., Young Sook Park, M.D., Tae Hun Kim, M.D., Yun Ju Jo, M.D., Moon Hee Song, M.D., Chung Hyeon Kim, M.D. and Seong Hwan Kim, M.D.; Korean J Gastrointest Endosc 2006;32(6):361-367. Published online June 30, 2006

Abstract PDF: Background
/Aims: Midazolam is widely used as a form of conscious sedation during endoscopy because of its rapid onset and safety. However, its relatively long half-life and paradoxical reactions are still a concern for doctors and patients. Flumazenil is a competitive benzodiazepine antagonist that acts to reverse the sedative and hypnotic effects of midazolam but its role and adequate dose have not been fully documented. This study evaluated the effect of a fixed dose of flumazenil on the recovery from sedative endoscopy by midazolam. Methods: First study: 100 patients who received 0.05 mg/kg midazolam for conscious sedation were randomized into two groups: intravenous 0.25 mg flumazenil and a placebo. All patients were assessed using OAA/S (Observers Assessment of Alertness/Sedation Scale) scale (responsiveness, speech, facial expression and ptosis of eyelid) before the endoscopy, immediately after the procedure and every 5 minutes thereafter. The recovery time was defined as the time at which the OAA/S scale reached the pre-endoscopy level. Second study: In 40 patients, the OAA/S scale was assessed only after full recovery without any exogenous stimuli. The total dose of midazolam and the procedure time were assessed. Results: The flumazenil group demonstrated a significantly shorter recovery time than the placebo group (p＜0.0001). These results were not affected by age, gender, total midazolam dose and procedure time. There was a larger difference in the recovery time between the two groups in the second study than in the first. Conclusions: A fixed low dose flumazenil significantly reduced the recovery time after sedative endoscopy by midazolam. Flumazenil will be helpful for the early return to daily activities and for preventing post sedative complication. (Korean J Gastrointest Endosc 2006;32:361⁣367)

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Evaluation of Colon Pattern using Virtual CT Colonoscopy in Patients with Difficult Colonscopic Insertion: Won Yeop Bae, M.D., Jeong Hoon Park, M.D., Jae Hak Lee, M.D., Do Hyun Park, M.D., Suck Ho Lee, M.D., Hyun Cheol Kim, M.D.*, Il Kwun Chung, M.D., Hong Soo Kim, M.D., Sang Heum Park, M.D. and Sun Joo Kim, M.D.; Korean J Gastrointest Endosc 2006;32(6):368-373. Published online June 30, 2006

Abstract PDF: Background
/Aims: The successful colonoscopic insertion has been predicted by several clinical factors including female gender, obesity, poor bowel preparation, and a history of surgery. In addition, anatomical differences, such as Kudo's pattern (B, C of the sigmoid colon), rotation of the hepatic and splenic flexure, and the diameter of the sigmoid colon have also been considered to affect the success of colonoscopic insertion. The aim of this study was to evaluate the anatomical factors using virtual CT colonscopy in the case where the colonoscopic insertion is difficult. Methods: From April 2005 to June 2005, 32 patients who experienced a delayed insertion time ≥10 minutes during colonoscopy (Group I) and other 34 patients whose insertion time was ＜10 minutes (Group II) were examined by virtual CT colonoscopy. The shape of the sigmoid colon was compared with Kudo's pattern, rotation of hepatic (HFR) and splenic flexure (SFR), and the diameter of the most distended sigmoid colon at the supine position (SCD) in both groups. Excessive SFR or HFR was defined if the splenic flexure or hepatic flexure was rotated by more than 360^o from the natural course of the colon. Results: There were significant differences between group I (M：F=16：16, mean age: 61.7⁑13.8, SCD: 40.9⁑7.4 mm) and group II (M：F=25：9, mean age: 46.9⁑11.4, SCD: 39.7⁑7.2 mm) in terms of gender, age, BMI (24.1⁑3.5 kg/m² in group I, 23.5⁑2.1 kg/m² in group II), and the colonoscopic insertion time (18.1 minutes in group I, 6.3 minutes in group II). The Kudo's pattern was as follows: pattern A：B：C=23.3%：36.7%：40.0% in group I, and pattern A：B：C=50.0%：37.5%：12.5% in group II. Excessive rotation of the splenic flexure was 50% in group I, and 21.9% in group II. However, there were no clinical significant difference in bowel preparation, sedation, previous bowel operation, the type of cathartics and SCD. Conclusions: Anatomical differences can affect a difficult colonoscopic insertion, which includes shape of the sigmoid colon, excessive rotation of the splenic flexure. However a further large randomized trial study will be needed. (Korean J Gastrointest Endosc 2006;32:368⁣373)

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Clinical Features of Gastrointestinal Bleeding in Patients with Chronic Renal Failure: Hyung Keun Kim, M.D., Young-Soo Kim, M.D., Young Seok Cho, M.D., Jeong-Seon Ji, M.D., Sung Soo Kim, M.D., Young Ok Kim, M.D., Sun-Ae Yun, M.D., Hiun Suk Chae, M.D., Kyu Yong Choi, M.D. and In Sik Chung, M.D.; Korean J Gastrointest Endosc 2006;32(6):374-380. Published online June 30, 2006

Abstract PDF: Background
/Aims: Gastrointestinal bleeding (GIB) in patients with chronic renal failure (CRF) is a common complication with a high mortality. However, the cause or mechanism of this condition is unclear. Therefore, this study investigated the clinical features of GIB in patients with CRF. Methods: The clinical features of 35 patients with CRF who were admitted to the Uijeongbu St. Mary's Hospital for GIB from January 1998 to August 2003 were examined retrospectively. Results: Thirty-five out of 803 patients had CRF (4.4%). The mean age of those with CRF was 62⁑11 years and 16 patients were male. The treatment for CRF was hemodialysis in 22 (62.9%), pre-dialysis in 10 (28.6%) and peritoneal dialysis in 3 (8.6%). The cause of GIB in CRF patients was an ulcer (45.7%), vascular disease (37.1%), hemorrhagic gastritis (8.6%), and Mallory-Weiss laceration (2.9%), etc. Rebleeding after the first treatment occurred in 5 patients (14.3%). Three of these patients (60%) had vascular disease. Surgical treatment for rebleeding was performed in 3 patients (60%) and the mortality rate in rebleeding patients was 60%. Conclusions: The most common cause of GIB in CRF patients is an ulcer followed by vascular disease. Vascular disease in cases with rebleeding is high with a high mortality rate. (Korean J Gastrointest Endosc 2006;32:374⁣380)

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Three Cases of Gastric Anisakiasis Mimicking Submucosal Tumor: Sang Wook Park, M.D., Young Eun Joo, M.D., Pil Jin Jung, M.D., Min Ho Park, M.D., Nam Hun Lee, M.D., Im Kwan Jhu, M.D., Geun Soo Park, M.D., Chang Hwan Park, M.D., Wan Sik Lee, M.D., Hyun Soo Kim, M.D., Sung Kyu Choi, M.D., Jong Sun Rew, M.D. and Sei Jong; Korean J Gastrointest Endosc 2006;32(6):381-386. Published online June 30, 2006

Abstract PDF: Gastric anisakiasis is a parasitic infestation that occurs after eating raw marine fish that contain Anisakis larvae. The diagnosis is usually confirmed by endoscopy, which often reveals the presence of the larvae itself, mucosal edema, erosion, ulceration, and hemorrhage. However, gastric anisakiasis mimicking submucosal tumor is extremely rare. To date, six cases have been reported in Korea. We report three additional cases of gastrtic anisakiasis mimicking submucosal tumor. An asymptomatic 56-year-old man and a 40-year-old woman underwent endoscopis examination during a physical checkup, and a 63-year-old woman visited our hospital complaining of epigastric discomfort. The endoscopic findings indicated submucosal tumors in all cases. Endoscopic ultrasonography revealed inhomogeneous, hypoechoic lesions in submucosal layer (1 case) and muscle layer (2 cases). A laparoscopic and endoscopic resection was carried out for definite diagnosis and treatment. The pathologic findings of the resected specimens were eosinophilic granuloma caused by Anisakis. (Korean J Gastrointest Endosc 2006;32:381⁣386)

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A Case of Bleeding Meckel's Diverticulm Diagnosed by Wireless Capsule Endoscopy: Hyun Joo Song, M.D., Ki-Nam Shim, M.D., Kum Hei Ryu, M.D., Hye Jung Yeom, M.D., Tae Hun Kim, M.D., Sung-Ae Jung, M.D., Kwon Yoo, M.D. and Hea-Soo Koo, M.D.*; Korean J Gastrointest Endosc 2006;32(6):387-391. Published online June 30, 2006

Abstract PDF: Meckel's diverticulum is a remnant of the vitelline duct located in the distal ileum, and it is the most common cause of small bowel bleeding in patients who are under the age of 25 years. The ectopic gastric mucosa in Meckel's diverticulum causes ulceration and acute gastrointestinal bleeding. Capsule endoscopy is now a valuable tool for diagnosing obscure gastrointestinal bleeding. However, the identification of a Meckel's diverticulum by wireless capsule endoscopy has rarely been reported on. An 18-year-old man was admitted for recurrent melena and anemia. He underwent a small bowel series that showed a jejunal diverticulum, and capsule endoscopy then revealed a jejunal diverticulum with multiple ulcerations. After 2 months, he had fresh hematochezia and so he underwent small bowel segemental resection that included the jejunal diverticulum. The operation revealed Meckels' diverticulum at 180 cm distant from the ileocecal valve at the mesenteric side. We report here on a case of bleeding Meckel's diverticulum that was diagnosed by wireless capsule endoscopy, and we include a review of the relevant literature. (Korean J Gastrointest Endosc 2006;32:387⁣391)

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A Case of Dieulafoy's Lesion in the Jejunum Treated by Double Balloon Enteroscopy: Min Ho Choi, M.D., You Sang Ko, M.D., Mi Jeong Kim, M.D., Su Hee Park, M.D., Yeong Je Chae, M.D., Hyun Joo Jang, M.D., Chang Soo Eun, M.D., Sea Hyub Kae, M.D. and Jin Lee, M.D.; Korean J Gastrointest Endosc 2006;32(6):392-396. Published online June 30, 2006

Abstract PDF: Dieulafoy's lesion is an unusual cause of gastrointestinal hemorrhage that results from the erosion of an abnormally large submucosal artery. In most cases, the lesion is encountered in the proximal stomach within 6 cm of the gastroesophageal junction. However, similar lesions have been reported in the antrum, duodenum, colon, and rectum. In particular, jejunal Dieulafoy's lesion is extremely rare. We report a case of jejunal Dieulafoy's lesion with recurrent and massive bleeding, which was diagnosed and treated with the double-balloon enteroscopy. (Korean J Gastrointest Endosc 2006;32:392⁣396)

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Colonoscopic Removal of an Inverted Appendix: Soon Je Kim, M.D., Joon Ho Wang, M.D. and Jae Dong Lee, M.D.; Korean J Gastrointest Endosc 2006;32(6):397-399. Published online June 30, 2006

Abstract PDF: An inverted appendix is a rare condition that occurs congenitally or is the result of surgery or intussusception associated with diseases such as appendix tumors, mucocele, fecalith, or worms. An inverted appendix produces similar abdominal symptoms to acute appendicitis, that vary from non-specific to acute or chronic pain in the right lower abdomen. There are no reports of this condition in Korea that the authors are aware of. We report a case 31-year-old male who visited our hospital complaining of pain in the right lower abdomen. A barium enema showed a moving tubular filling defect. An inverted appendix that appeared as a polyp was dissected by colonoscopy. (Korean J Gastrointest Endosc 2006; 32:397⁣399)

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A Case of Cap Polyposis Treated by Conservative Management: Kum Hei Ryu, M.D., Sung-Ae Jung, M.D., Seong-Eun Kim, M.D., Hee Jung Oh, M.D., Ji Hyun Song, M.D., Hyun Joo Song, M.D., Hye Jung Yeom, M.D., Tae Hun Kim, M.D., Ki-Nam Shim, M.D., Kwon Yoo, M.D., Il Hwan Moon, M.D. and Shi Nae Lee, M.D.*; Korean J Gastrointest Endosc 2006;32(6):400-404. Published online June 30, 2006

Abstract PDF: Cap polyposis is a rare intestinal disease that is characterized by the presence of inflammatory polyps consisting of elongated, tortuous and distended crypts that are covered by a 'cap' of granulation tissue. The pathogenesis and proper treatment of cap polyposis are still unclear. We experienced a case of cap polyposis, that was treated successfully by conservative management without the need for a pharmacotherapy or resection. (Korean J Gastrointest Endosc 2006;32:400⁣404)

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A Case of Bleeding Due to Angiodysplasia of the Ampulla of Vater: Jong Ryul Eun, M.D. and Byung Ik Jang, M.D.; Korean J Gastrointest Endosc 2006;32(6):405-408. Published online June 30, 2006

Abstract PDF: Although angiodysplasia can be found along the whole gastrointestinal tract, it is extremely rare at the ampulla of Vater. We experienced a case of chronic bleeding due to an angiodysplasia of the major papilla. A 53-year-old man was admitted due to intermittent melena and dyspnea for approximately 4 months. Esophagogastroduodenoscopy revealed bleeding from the ampulla of Vater. A subsequent examination with side-viewing duodenoscopy revealed vascular ectasia around the orifice of the major papilla and blood oozing from this lesion. Hemostasis was successfully performed by endoscopic bipolar electrocoagulation. No further bleeding was observed and the previous vascular abnormality disappeared at the follow-up duodenoscopy. (Korean J Gastrointest Endosc 2006;32: 405⁣408)

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A Case of Gastric Ectopic Pancreas Complicated by Chronic Pancreatitis: Seung Hyun Jung, M.D., Euyi Hyeog Im, M.D., Yong Moon Kim, M.D., Sun Moon Kim, M.D., Tae Hee Lee, M.D., Kyu Chan Huh, M.D., Young Woo Choi, M.D., Young Woo Kang, M.D., Hyoun Sik Min, M.D.* and Beom Kyoung Kim, M.D.^†; Korean J Gastrointest Endosc 2006;32(6):409-412. Published online June 30, 2006

Abstract PDF: An ectopic pancreas is defined as the presence of pancreatic tissue lacking the anatomical and vascular continuity of the main body of the pancreas. Most cases of ectopic pancreas are found incidentally in the stomach and duodenum. The most commonly reported symptoms are abdominal pain, epigastric discomfort, nausea, vomiting and bleeding. An ectopic pancreas is subject to various pathological changes occurring in the pancreas itself: namely, cyst, pancreatitis, hemorrhage, necrosis and neoplastic changes. We report a case of a 28-year old man with epigastric pain in whom the surgical pathological diagnosis was an ectopic pancreas of the stomach with chronic inflammation. (Korean J Gastrointest Endosc 2006;32:409⁣413)

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