Clinical Endoscopy

Comparison of the Eradication Rates of Quadruple Therapy between Non-ulcer Dyspepsia and Peptic Ulcer Disease as a Second-line Treatment for Helicobacter pylori Infection: Su Jin Chung, M.D., Dong Ho Lee, M.D.*, Nayoung Kim, M.D.*, Sook Hyang Jung, M.D.*,Jin Wook Kim, M.D.*, Jin Hyeok Hwang, M.D.*, Young Soo Park, M.D.*, Kwang Hyuk Lee, M.D.*, Hyun Chae Jung, M.D. and In Sung Song, M.D.; Korean J Gastrointest Endosc 2006;33(2):63-68. Published online August 30, 2006

Abstract PDF: Background
/Aims: Initial PPI-based triple therapy for a Helicobacter pylori (H. pylori) infection is less effective in patients with non-ulcer dyspepsia (NUD) than in those with peptic ulcer disease (PUD). However, there are no reports of the effects of second-line treatment. We retrospectively analyzed the difference in the eradication rates of second-line quadruple therapy between NUD and PUD patients. Methods: Between June 2003 and September 2005, patients who failed to respond to the initial PPI-based triple therapy, received seven days bismuth- based quadruple therapy as a second-line treatment. Four to six weeks after completing the schedule, a ¹³C-urea breath test was performed to detect H. pylori. Results: A total of 87 patients received second-line quadruple therapy. Of these, 43 patients had NUD and 44 patients had PUD (19 with gastric ulcers, 23 with duodenal ulcers, 2 with both ulcers). The eradication rates were 76.7% (33/43) and 90.9% (40/44) in the NUD and PUD groups, respectively. The eradication rates in the NUD group were significantly lower than those in the PUD group (p=0.034). Conclusions: The seven days bismuth-based second-line quadruple therapy for H. pylori infection appears to be less effective in patients with NUD than in those with PUD. Therefore, an extension of the treatment duration for quadruple therapy or a more potent regimen may be needed as a second-line therapy for NUD patients. (Korean J Gastrointest Endosc 2006;33:63⁣68)

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Endoscopic Treatment with Band Ligation and Electrocoagulation for Non-Variceal, Non-Ulcer Upper Gastrointestinal Bleeding: Hwa Min Kim, M.D., Yang Suh Ku, M.D., Moon Gi Chung, M.D., Young Nam Kim, M.D., Do Yoon Lim, M.D., Kwang An Kwon, M.D., Dong Kyun Park, M.D., Sun Suk Kim, M.D., Yeon Suk Kim, M.D., So Young Kwon, M.D., Yu Kyung Kim, M.D., Duck Joo Choi, M.D. and Ju Hyun K; Korean J Gastrointest Endosc 2006;33(2):69-76. Published online August 30, 2006

Abstract PDF: Background
/Aims: This study compared the therapeutic efficacy of endoscopic band ligation (EBL) with that of electrocoagulation for treating non-variceal, non-ulcer (NVNU) upper gastrointestinal (UGI) bleeding. Methods: This study included 89 patients who underwent EBL and 56 patients in whom monopolar electrocoagulation was performed for NVNU UGI bleeding. The lesions treated were Mallory-Weiss tear in 91 patients, Dieulafoy's lesion in 42 patients and angiodysplasia in 12 patients. Results: The initial hemostatic rate was 97% in the EBL group and 91% in the electrocoagulation group, but this was not statistically different. Rebleeding occurred in 5 of 89 patients (5.6%) in the EBL group and in 8 of 56 patients (14.3%) in the electrocoagulation group (p=0.07). Thrombocytopenia or prothrombin time prolongation was confirmed to be a significant risk factor for rebleeding. The rebleeding rate in the high risk group was significantly lower than in the EBL group (9% vs. 30%, respectively, p=0.03). The median procedure time was significantly shorter in the EBL group compared with that in the electrocoagulation group (median 5.6 minutes vs. 8.3 minutes, respectively, p=0.04). Conclusions: EBL and electrocoagulation are both effective for treating NVNU UGI bleeding, and EBL is especially safe and effective for the cases with a high risk for rebleeding. (Korean J Gastrointest Endosc 2006;33:69⁣76)

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Submucosal Saline-Epinephrine Injection in Colonoscopic Polypectomy: What is the Proper Application?: Sang Huyb Lee, M.D., Kyoung Soo Lee, M.D., Yeol Keun Woo, M.D., Byong Duk Ye, M.D., Jong Yeul Lee, M.D., Su Cheol Park, M.D., Kwang Hyuck Lee, M.D.*, Young Soo Park, M.D.*, Jin-Hyeok Hwang, M.D.*, Sook Hyang Jung, M.D.*, Nayoung Kim, M.D.*, Dong Ho Lee, M; Korean J Gastrointest Endosc 2006;33(2):77-84. Published online August 30, 2006

Abstract PDF: Background
/Aims: Indications for submucosal saline- epinephrine injection (SSEI) for prevention of postpolypectomy bleeding, in the colon, is variable among endoscopists. The aim of this study was to determine the proper indication for SSEI. Methods: Clinical data of 1,745 polypectomies was evaluated. Postpolypectomy bleeding after snare polypectomy were evaluated in 1,039 polypectomies. Subgroup analysis was performed in 4 subgroups by size (≤8 mm or ＞8 mm) and gross morphology (pedunculated or sessile), also. Results: Submucosal saline-epinephrine injection was used in 679 snare polypectomies. The size of polyps was 9.5⁑4.3 mm. Distribution of polyps showed left side shift in the colon. Sessile polyps (79.4%) and benign adenoma (75.3%) were predominant. Twenty seven episodes (2.6%) of bleeding occurred after snare polypectomy. Rectal polyp, malignant polyp and procedure without SSEI increased bleeding after snare polypectomy with odds ratio 4.71, 10.48 and 3.44, respectively. However, SSEI significantly reduced the bleeding only in patients who had ＞8 mm sized sessile polyps with odds ratio 16.41 regardless of location and histopathology. Conclusions: SSEI should be performed in colonoscopic snare polypectomy for ＞8 mm sized sessile polyps, and might be performed in others for prevention of bleeding at the discretion of the clinician. (Korean J Gastrointest Endosc 2006;33:77⁣84)

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The Clinical Efficacy of Percutaneous Bilateral Internal Drainage in Advanced Hilar Malignancy by T-Configured Dual Stent Placement: Comparison with Unilateral Endoscopic Stent Placement: Joo Ho Lee, M.D., Sang Yong Lee, M.D., Jung Hyun Lee, M.D., Hyo Jin Jung, M.D., Tae Oh Kim, 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.*, Chang Won Kim, M.D.* and Suk Hong Lee, M.D.*; Korean J Gastrointest Endosc 2006;33(2):85-93. Published online August 30, 2006

Abstract PDF: Background
/Aims: Endoscopic or percutaneous internal drainage is a well-established palliative treatment for unresectable biliary tumors. Previous studies dealing with the unilateral versus bilateral liver lobe drainage have reported inconsistent results. This study evaluated the clinical efficacy of bilateral drainage with a newly designed T configured dual stent (T-stent) placement. Methods: From 2001 to 2004, 46 hilar malignancies, which were not suitable for endoscopic retrograde biliary drainage (ERBD) on MR cholangiography were treated with the percutaneous placement of two self-expandable metallic endoprostheses in a T configuration through a single transhepatic access. The outcomes were examined retrospectively. The hilar malignancies, which were drained by unilateral ERBD were also reviewed. Results: The 46 hilar malignancies drained by a T stent included a cholangiocarcinoma (n=36), gallbladder cancer (n=6), and metastatic cancer (n=4). Procedure related cholangitis occurred in 3 out of 46 patients (6.5%). The mean survival and stent patency times were 256 and 194 days, respectively. The 34 hilar malignancies drained by unilateral ERBD included cholangiocarcinoma (n=29), gallbladder cancer (n=3), and pancreatic cancer (n=2). Procedure related cholangitis occurred in 7 out of 34 patients (20.6%). The mean survival and stent patency times were 292 and 186 days, respectively. There were no statistically significant differences in the cholangitis frequency, survival and stent patency between the two groups. The frequency of cholangitis, mean survival and patency time in Klatskin tumors, which were drained by the T-stent (n=36) and ERBD (n=29), were compared. There were no significant differences in survival and stent patency time. Conclusions: T-configured dual stent placement can be used effectively in advanced biliary hilar malignancies. It can be used as a safe palliative drainage method in advanced hilar tumors, which are not suitable for ERBD. (Korean J Gastrointest Endosc 2006;33:85⁣93)

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A Case of Liver Abscess Caused by Toothpick Penetrating Gastric Wall: Hyun Cheol Koo, M.D., Jae Pil Han, M.D., Ick Keun Kim, M.D., In Il Park, M.D., Jue Yong Lee, M.D., Kyung Min Sohn, M.D., Kwang Ho Baik, M.D., Jin Bong Kim, M.D. and Dong Jun Kim, M.D.; Korean J Gastrointest Endosc 2006;33(2):94-99. Published online August 30, 2006

Abstract PDF: The ingestion of foreign bodies into the gastrointestinal tract is common, and most are passed out spontaneously without causing any problems. However, a perforation can cause a variety of complications involving considerable morbidity and mortality. Moreover, clinical presentation of a perforation can vary and patients are often unaware of the episode. Hence, a pre-operative diagnosis is difficult under these circumstances. We report an unusual case of a liver abscess that developed secondary to a toothpick that had penetrated the gastric wall and migrated to the liver. The liver abscess was treated successfully with internal drainage by inserting an endoscopic pigtail catheter through the hepato-gastric fistula. The toothpick was removed using an endoscopic snare. (Korean J Gastrointest Endosc 2006;33:94⁣99)

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Endoscopic Removal of Bleeding Duodenal Lipoma Using a Detachable Snare: Gun-Min Kim, M.D., Woo-Chul Chung, M.D., Seong-Su Hwang, M.D.*, Kang-Moon Lee, M.D., Bo-In Lee, M.D., U-Im Chang, M.D., Jin-Mo Yang, M.D., Kyu-Yong Choi, M.D. and In-Sik Chung, M.D.; Korean J Gastrointest Endosc 2006;33(2):100-104. Published online August 30, 2006

Abstract PDF: Duodenal lipomas are relatively uncommon and asymptomatic unless they are large. Tumors greater than 4 cm in diameter can cause obstructive symptoms as a result of intussusception necessitating a surgical resection. However, acute upper gastrointestinal bleeding is an extremely rare complication. Duodenal lipomas are most often submucosal but they can also be subserosal. Their shape can vary, and they can be either sessile or pedunculated. The overlying mucosa is usually normal but it may be ulcerated. Those that cause symptoms require treatment. Endoscopic snare polypectomy has been used to treat clinically symptomatic lipomas. A detachable snare may reduce the risk of complications after a polypectomy, including bleeding and perforation. We report a case of duodenal lipoma accompanied by massive upper GI bleeding that was treated by an endoscopic polypectomy using a detachable snare. (Korean J Gastrointest Endosc 2006;33:100⁣104)

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Two Cases of Sigmoid Volvulus Treated by Emergency Colonoscopic Reduction Procedure: Jin Man Kim, M.D., Sang Yong Lee, M.D., Bong Gap Kim, M.D., Jong Ho Hwang, M.D., Hyo June Kwon, M.D., Hong Suk Choi, M.D., Su Min Jang, M.D., Jae Nam Lee, M.D. and Sang Ho Lee, M.D.; Korean J Gastrointest Endosc 2006;33(2):105-109. Published online August 30, 2006

Abstract PDF: A volvulus of the colon is a twisting of a redundant segment of the colon at its narrow mesentery. A sigmoid volvulus is the most common type. This disorder may spontaneously reduce and recur as a chronic problem. However, it more frequently becomes acute as a result of an obstruction, which can lead to strangulation and gangrene with a high mortality if not treated promptly. Colonoscopic reduction and decompression is the preferred initial treatment for patients with a sigmoid volvulus who show no signs of bowel strangulation, which may be the cause of the high mortality associated with emergency surgery. We experienced 2 cases of a sigmoid volvulus in a 44-year-old female and a 51-year-old male. The sigmoid volvulus was diagnosed by simple abdominal film and treated successfully by an emergency colonoscopic reduction. We report our experience on the use of colonoscopy to treat sigmoid volvulus with a reviews of the relevant literlature. (Korean J Gastrointest Endosc 2006;33:105⁣ 109)

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A Case of Rectal Gastrointestinal Stromal Tumor (GIST) Presenting with Hematochezia: Eun Young Choi, M.D., Ho Kil, M.D., Won Joong Jeon, M.D., Seon Mee Park, M.D. Seok Hyung Kim, M.D.*, Kil Sun Park, M.D.^† and Sei Jin Youn, M.D.; Korean J Gastrointest Endosc 2006;33(2):110-115. Published online August 30, 2006

Abstract PDF: Gastrointestinal stromal tumors (GIST) are the most common mesenchymal neoplasms affecting the gastrointestinal tract. The main sites for GIST are the stomach and small intestine but they can also occur in the rectum, albeit rarely. We report a 58-year-old woman who presented with hematochezia. Endoscopically, a submucosal tumor with mucosal ulceration was located approximately 2 cm from the anal verge. The pelvic CT and MRI scanning findings demonstrated a large low-density lesion with intraluminal growth from the lower rectum and an absence of tumor infiltrations to other organs. The patient underwent an abdominoperineal resection of the rectum. A histopathological examination showed fascicular proliferation of spindle shaped cells. The mitotic rate was more than 30 mitotic figures per 50 high-power fields. A immunohistochemical examination revealed most of the tumor cells to be positive for the c-kit protein, CD34 and SMA (α-smooth muscle action). The tumor was diagnosed as a GIST of the rectum. (Korean J Gastrointest Endosc 2006;33:110⁣115)

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Two Cases of Colon Anisakiasis: Asymphtomatic Cecal Anisakiasis and Ascending Colon Anisakiasis Detected One Month Later after Infestation: Sang Jung Kim, M.D., Jeong Wook Kim, M.D., Kwang Jin Kim, M.D., Chae Heo, M.D., Suk Won Kim, M.D., Sang Pyo Han, M.D., Young Hwan Seo, M.D., Jae Hyuk Do, M.D., Jae Gyu Kim, M.D. and Sill Moo Park, M.D.; Korean J Gastrointest Endosc 2006;33(2):116-120. Published online August 30, 2006

Abstract PDF: Anisakiasis of the gastrointestinal tract is usually caused by the ingestion of raw marine fish infested with Anisakis larvae. A majority of cases present as gastric and intestinal anisakiasis. Anisakiasis of colon is rare and asymptomatic colon anisakiasis has a particularly low incidence. A 45- year-old man received colonoscopy that revealed a 1.0 cm sized whitish linear larva penetrating the mucosa of the cecum and it was removed by colonscopy. He had no complaint before the colonoscopy. A 52-year-old man complained of right upper quadrant abdominal pain with weight loss for one month. Colonoscopy revealed a 1.5 cm sized whitish linear larva penetrating the mucosa of the distal part of ascending colon. Abdominal pain and weight loss were improved by colonoscopic removal of larva. (Korean J Gastrointest Endosc 2006;33:116⁣120)

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A Case of Anal Gland Cyst Treated by Endoscopic Resection: Chang Sue Park, M.D., Dong Han Im, M.D., Hyun Chul Whang, M.D., Joon Seok Oh, M.D., Hyun Ju Kim, M.D., Hwa Mock Lee, M.D., Jin Kwang An, M.D., Kwang Jin Kim, M.D., Jong Yun Cheong, M.D., Won Il Park, M.D. and Ung Suk Yang, M.D.; Korean J Gastrointest Endosc 2006;33(2):121-124. Published online August 30, 2006

Abstract PDF: The anal canal is the most distal part of the gastrointestinal tract, and it is developed and formed during the embryonic period. Infection is the most common disease process that occurs around the anorectum, yet tumors or cysts are occasionally encountered. The abnormal development of these parts of the gastrointestinal track during the embryonic period can result in congenital lesions that are discovered in young children or adults. A 72-year-old woman presented to us with postprandial lower abdominal discomfort and fecal incontinence. An anorectal mass was felt on the rectal examination. The colonoscopy demonstrated a submucosal tumor that was closely located to the anorectal junction. The tumor was excised with a snare and it was diagnosed as an anal gland cyst due to the histologic features. It is necessary to differentiate anal gland cyst from the other diseases that have submucosal characters, such as carcinoid tumor. (Korean J Gastrointest Endosc 2006;33:121⁣124)

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Successful Removal of Common Bile Duct Stone Using Endoscopic Papillary Balloon Dilation (EPBD), in A 28-month-old Child with Down's Syndrome: Jee Heon Kang, M.D., Do Hyun Park, M.D., Jeung Hoon Park, M.D., Myung Ho Oh, M.D.*, Seung Hyo Han, M.D., Hyoung Su Ahn, M.D., Yong Ha Lee, M.D., Sang-Heum Park, M.D., Suck-Ho Lee, M.D., Il-Kwun Chung, M.D., Hong-Soo Kim, M.D. and Sun-Joo Kim, M.D.; Korean J Gastrointest Endosc 2006;33(2):125-129. Published online August 30, 2006

Abstract PDF: Although cholelithiasis is an uncommon condition in infants, a recent study documented the increasing detection of this disorder. This increase may be explained by the wide use and improvement in abdominal ultrasound. Choledocholithiasis with cholestatic jaundice in infants usually requires therapeutic intervention, even though the incidence of spontaneous resolution has been reported to be higher in infants than adults. Choledocholithiasis in children has traditionally been managed surgically with open common duct exploration. Recently, endoscopic stone removal was accepted as a standard therapy in pediatric choledocholithiasis. We report a case of the successful removal of common bile duct stone using endoscopic papillary balloon dilation (EPBD), in a 28-month-old infant with Down's syndrome. (Korean J Gastrointest Endosc 2006;33:125⁣129)

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A Case of Choledochal Cyst (Type IVa) and Anomalous Pancreaticobiliary Ductal Union Combined with Pancreatic Duct Stone: Jung Yun Lee, M.D., Hyeon Woong Yang, M.D., Gyu Yup Hwang, M.D., Wook Cho, M.D., Ju Eui Ahn, M.D., Sang Woo Cha, M.D., An Na Kim, M.D., Sang Jeong Yoon, M.D., Sung Hee Jung, M.D. and Young A Park, M.D.; Korean J Gastrointest Endosc 2006;33(2):130-133. Published online August 30, 2006

Abstract PDF: Pancreatic duct stones are commonly associated with recurrent pancreatitis. They are believed to develop as a result of the calcification of an intraductal protein plug. A choledochal cyst is a relatively rare anomaly usually presenting with abdominal pain, jaundice and palpable mass. APBDU (anomalous pancreaticobiliary ductal union) is frequently associated with various pancreatobiliary diseases, including choledochal cyst, biliary tumor, pancreatitis and pancreas divisum. We report a 48-year-old woman who presented with right upper quadrant pain with a pancreatic duct stone, a choledochal cyst and APBDU. She underwent endoscopic pancreatic sphincterotomy, a surgical choledochal cyst excision and Roux-en-Y choledochojejunostomy. (Korean J Gastrointest Endosc 2006; 33:130⁣134)

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