Clinical Endoscopy

Catheter Probe Endoscopic Ultrasonography Using the Jelly-Filled Method for Esophageal Subepithelial Lesions: Tae In Ha, M.D., Gwang Ha Kim, M.D., Jae Sup Eum, M.D., Chan Ho Park, M.D., Hyoung Yoel Park, M.D., Cheul Woong Choi, M.D., Kyung Yeob Kim, M.D., Il Du Kim, M.D., Pyo Jun Kim, M.D., Hye Jeong Lee, M.D., Sun Mi Lee, M.D., Tae Oh Kim, M.D., Dae Hwan Kang, M; Korean J Gastrointest Endosc 2008;36(3):125-131. Published online March 30, 2008

Abstract PDF: Background
/Aims: The catheter probe endoscopic ultrasonography (EUS) system is widely used to evaluate upper gastrointestinal tract lesions. The depiction of the esophageal wall by probe EUS remains problematic due to the difficulty of the filling of water in the esophageal lumen. In addition, filling the esophagus with water can be associated with an increased risk of aspiration. To resolve such problems, we recently applied the use of probe EUS with the jelly-filled method for the evaluation of subepithelial lesions. The procedure is characterized by filling the esophageal lumen with jelly. In this study, we evaluated the efficacy of probe EUS by using the jelly-filled method for esophageal subepithelial lesions. Methods: We analyzed the records of the patients with suspected subepithelial lesions at the time of endoscopy that was performed from November 2005 to June 2007. Esophageal subepithelial lesions with both EUS findings and pathological reports were retrospectively compared. Results: The study included 181 patients (96 males, 85 females), with an average age of 55.5 years (age range, 29∼78 years). Sixty-eight patients had lesions in the upper esophagus, 60 patients had lesions in the middle esophagus and 53 patients had lesions in the lower esophagus. Secondary layers of esophageal lesions were predominant (91/181) in the cases. Pathological findings were available for 34 patients. Compared with the pathological findings, the diagnostic accuracy of EUS was 91.1%. Conclusions: Probe EUS by using the jelly-filled method is convenient and safe to perform and provides clear and full-circumferential imaging of a lesion. It is an alternative method to use in place of previously used probe-EUS procedures for the assessment of esophageal subepithelial lesions. (Korean J Gastrointest Endosc 2008;36:125-131)

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The Colonoscopic Miss Rates of Colorectal Polyps as Determined by a Polypectomy: Se Young Park, M.D., Won Moon, M.D., Seun Ja Park, M.D., Moo In Park, M.D., Kyu Jong Kim, M.D., Sun Jung Kim, M.D., Hong Jun You, M.D. and Woo Seong Jeon, M.D.; Korean J Gastrointest Endosc 2008;36(3):132-137. Published online March 30, 2008

Abstract PDF: Background
/Aims: Colonoscopy is the most effective method to detect and remove colonic polyps and for colorectal cancer screening and prevention. However, polyps are frequently missed during colonoscopy. The aim of this study was to determine the miss rates of polyps by colonoscopy and to evaluate the factors that affect the miss rates. Methods: Within sixty days after a first-time colonoscopy, consecutive polypectomies were performed in 317 patients who had one or more colon polyps. Results: The overall miss rate for polyps was 26.6%. As the withdrawal time increased, the number of polyps detected on the first colonoscopy decreased, and the miss rate decreased significantly (respectively p=0.000, p=0.028). The withdrawal time for an expert operator was shorter than the withdrawal time for a beginner operator (p=0.001). The miss rate for a beginner operator and expert operator was not different (p=0.271) due to interference with withdrawal time. The most frequent location of a polyp was the ascending colon and the most frequent size of a polyp was ≤5 mm. Conclusions: Although colonoscopy is the gold standard for colorectal polyp detection, it is imperfect even when meticulously performed. To reduce the miss rates of polyps, it is important that a careful examination with sufficient withdrawal time is performed, the colonoscopy is complete to the cecum, and that the bowel preparation is adequate. (Korean J Gastrointest Endosc 2008;36:132-137)

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Endoscope-guide Infusion of Sodium Phosphate: A Novel Bowel Cleansing Method, Efficacy and Safety Comparisons with Polyethylene Glycol: Kyu-Jong Kim, M.D., Seun Ja Park, M.D., Eun Kyung Shin, M.D., Jun Young Song, M.D., Do Hyun Kim, M.D., Sung Eun Kim, M.D., Won Moon, M.D. and Moo In Park, M.D.; Korean J Gastrointest Endosc 2008;36(3):138-144. Published online March 30, 2008

Abstract PDF: Background
/Aims: Single full-dose oral sodium phosphate (NaP) on the examination day instead of a conventional divided-dose has been used in some patients to reduce burdens and sleep disturbance caused by bowel movement. However, this treatment may be inconvenient to some patients who are adversely affected by the full dose or its-related symptoms. This study compared the quality of bowel preparation, side effects, and patient's acceptance after a full-dose of NaP into the duodenum under an endoscopic examination and with those from conventional polyethylene glycol (PEG). Methods: A total of 60 admitted patients receiving both endoscopy and colonoscopy each day were divided randomly into two groups and given either PEG 4 L (n=33) or an endoscopic infusion of NaP 90 mL (n=27). Before and after the bowel preparation and 1 day later, the blood pressure, body weight, and serum biochemical parameters were measured. In addition, a detailed questionnaire was used to assess the patient's side effects. The quality of bowel cleansing was assessed by a single endoscopist who was blinded to the type of preparation used. Results: Although changes in the serum biochemical parameters (phosphate: increase, potassium: decrease) were observed in the NaP group, all were normalized after 1 day without side effects. There were significant difference in symptoms after the preparation, such as vomiting, but this was not serious. The suction volume was significantly lower in the NaP group. Conclusions: A duodenal infusion of NaP might be used as a new bowel cleansing method in patients having trouble with other procedures. (Korean J Gastrointest Endosc 2008;36:138-144)

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Three Cases of Eosinophilic Esophagitis with Dysphagia as a Chief Complaint: Byungjun Lee, M.D., Hyojin Park, M.D., Hongsun Yoon, M.D., Hyun Ki Kim, M.D.* and Hee Sun Kim, M.D.^†; Korean J Gastrointest Endosc 2008;36(3):145-149. Published online March 30, 2008

Abstract PDF: The incidence of adult eosinophillic esophagitis has been on the increase greatly in recent years, but the disease has been rarely reported in Korea. Eosinophilic esophagitis is a chronic inflammatory disease causing dysphagia and food impaction. A round ring, longitudinal furrows and mucosal friability are the major findings seen by endoscopy. Eosionophilc esophagitis is confirmed by pathology when more than 20 eosinophils are found on microscopy with use of a high power field. We experienced three cases of eosinophilic esophagitis with complaints of dysphagia. (Korean J Gastrointest Endosc 2008;36:145-149)

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A Benign Ulcer of the Gastric Fundus Reminiscent of a Malignant Submucosal Tumor: Yun Hwa Jung, M.D., Byung Wook Kim, M.D., Hyung Gil Kim, M.D.*, Hyoung Jin Chang, M.D., Do Seon Song, M.D., Min Huh, M.D., Min Kuk Kim, M.D., Hyun Jung Jung, M.D., Jeong Seon Ji, M.D., Jeong Won Jang, M.D., Hwang Choi, M.D., Kyu Yong Choi, M.D. and In Sik; Korean J Gastrointest Endosc 2008;36(3):150-153. Published online March 30, 2008

Abstract PDF: The gastric fundus is a rare site for benign ulcer occurrence as it consists of parietal cells, which secret gastric acid. It is resistant to gastric acid and pepsin, and has an abundant blood supply. Varices or other vascular lesions, such as polyps and submucosal tumors, are more frequently found in the gastric fundus. When an ulcer is found in the gastric fundus, it is important to consider underlying conditions such as a malignancy. In this case, a benign gastric ulcer in the gastric fundus dome formed a protruding mass-like lesion with central necrosis, which was reminiscent of a malignant submucosal tumor. Proper follow-up gastroscopy with endoscopic ultrasonography helped to differentiate these similar lesions. We report here a case of a benign gastric ulcer in the fundus dome that was reminiscent of a malignant submucosal tumor, with a review of the literature. (Korean J Gastrointest Endosc 2008;36:150-153)

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A Case of Extensive Necrosis of the Gastric Mucosa Following Ethanol Injection Therapy: Su Min Jang, M.D., Jung Sik Choi, M.D., Hyun Seok Ryu, M.D., Jae Nam Lee, M.D., Sung Hoo Park, M.D., Sang Yong Lee, M.D. and Sang Ho Lee, M.D.; Korean J Gastrointest Endosc 2008;36(3):154-158. Published online March 30, 2008

Abstract PDF: A bleeding peptic ulcer is the most common cause of upper gastrointestinal bleeding as well as for hospitalization and death. Many endoscopic methods of treating bleeding peptic ulcers are currently being studied and developed. Among them, the endoscopic pure ethanol injection therapy is favored because of its high efficacy, low cost, and rapid administration. Pure ethanol is an excellent agent to stop bleeding and manifests itslef by inducing tissue dehydration, fixation and vessel compression, which in turn causes arterial coagulation and tissue necrosis. However, an excessive injection volume may bring about extensive mucosal necrosis; hence, caution should be taken when deciding upon the injection volume and depth. We report a case of extensive necrosis of the gastric mucosa following endoscopic ethanol injection therapy of a bleeding peptic ulcer along with a review of the relevant literature. (Korean J Gastrointest Endosc 2008;36:154-158)

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A Case Study of a Gastric Collision Tumor with an Adenocarcinoma and a Carcinoid Tumor: Soung Won Jeong, M.D., Yon Soo Kim, M.D., Joo Young Cho, M.D., In Seop Jung, M.D., Su Jin Hong, M.D., Chang Beom Ryu, M.D., Jin Oh Kim, M.D., Joon Seong Lee, M.D., Moon Sung Lee, M.D., So-Young Jin, M.D.*, Jae Jun Kim, M.D.^†, Chan Sup Shi; Korean J Gastrointest Endosc 2008;36(3):159-164. Published online March 30, 2008

Abstract PDF: Adenocarcinoma is the most common malignant gastric neoplasm, contrary to a gastric carcinoid which is relatively uncommon. The occurrence of an adenocarcinoma and a typical carcinoid tumor is rare and are morphologically classified into two subgroups. The first type is a composite- type tumor, which is characterized as a randomly assorted adenocarcinoma and a typical carcinoid tumor. The second type is a collision-type tumor, which is a double tumor with a "side by side" or "overlay" pattern. To the best of our knowledge, only 2 cases of the collision type tumors have been reported in the Korean literature. We have encountered a collision tumor which occurred in the antrum of the stomach and which invaded the regional lymph nodes by means of a highly malignant gastric carcinoid. The following report is a description of the collision tumor case as well as a literature review. (Korean J Gastrointest Endosc 2008;36:159-164)

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A Case of Terminal Ileitis Caused by Ascaris lumbricoides: Sung Hoon Jung, M.D., Young Woon Chang, M.D., Jaejun Shim, M.D., Young Hwangbo, M.D., Chang Kyun Lee, M.D., Jae Young Jang, M.D., Seok Ho Dong, M.D., Hyo Jong Kim, M.D., Byung Ho Kim, M.D. and Rin Chang, M.D.; Korean J Gastrointest Endosc 2008;36(3):165-168. Published online March 30, 2008

Abstract PDF: The major causes of terminal ileitis are inflammatory bowel disease and NSAIDs but parasites such as Anisakis rarely induce ileitis. Ascaris lumbricoides, the most common intestinal helminth in Korea, may enter the pancreaticobiliary ducts and cause pancreatitis or cholangitis. However, no case of A. lumbricoides-associated terminal ileitis has been previously reported in Korea. We report a case of a 58-year-old woman who presented with epigastric discomfort and bloating, and was diagnosed with terminal ileitis due to A. lumbricoides detected during colonoscopy. (Korean J Gastrointest Endosc 2008;36: 165-168)

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A Case of Sigmoid Intussusception Diagnosed by Sigmoidoscopy: Eui Jong Chung, M.D., Byung Wook Ha, M.D., Young Tak Seo, M.D., Young Hwan Ham, M.D., Mi Jin Kim, M.D., Tae Gun Moon, M.D., Sang Su Bae, M.D. and Hyung Jun Chu, M.D.; Korean J Gastrointest Endosc 2008;36(3):169-172. Published online March 30, 2008

Abstract PDF: Intussusception most commonly occurs in children, and in more than 90% of cases, no cause is found. In contrast, intussusception in adults is relatively rare but over 90% of patients have an organic lesion as the cause. Only 5% of cases of intussusception occur in adults and most involve the small intestine and are benign, whereas colonic intussusceptions are usually malignant. We report here a case of a 70-year-old man with intussusception who was referred with a one-day history of hematochezia and abdominal pain. The intussusception was caused by a sigmoid colonic tumor. The CT findings suggested that we could reasonably proceed to a sigmoidoscopy to confirm the site of obstruction. We speculated that the sigmoid colon tumor induced the anterograde intussusception. As with our patient, it is important to recognize the need to diagnose the primary lesion exactly and promptly. (Korean J Gastrointest Endosc 2008;36:169-172)

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A Case of Acute Lower Gastrointestinal Bleeding from a Benign Appendiceal Ulcer: Sang Cheol Cho, M.D., Young Ho Seo, M.D., Chung Su Park, M.D., Sang Hyun Park, M.D., An Doc Chung, M.D., Bong Kyu Lee, M.D., So Young Chu, M.D., Nam Hun Lee, M.D., Keun Yeong Song, M.D.*, Sung Hwan Song, M.D.*, In Kyoung Lee M.D.^† and Hya; Korean J Gastrointest Endosc 2008;36(3):173-176. Published online March 30, 2008

Abstract PDF: A hemorrhoid is the most common cause of acute lower gastrointestinal (LGI) bleeding. Diverticulosis, angiodysplasia and ischemic colitis can also cause LGI bleeding. Acute LGI bleeding from the appendix is very rare. We experienced a case of a 33‐year‐old woman with acute LGI bleeding from the appendix. Colonoscopy demonstrated an active hemorrhage from the orifice of the appendix. The patient was treated with a appendectomy, and a histological examination showed the presence of a small ulcer with inflamed granulation tissue in the mucosa and submucosa. (Korean J Gastrointest Endosc 2008;36: 173-176)

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Obstructive Colitis Proximal to Obstructive Lesion of the Colon Cancer: You Kyoung Oh, M.D., Jin Il Kim, M.D., Dae Young Cheung, M.D., Soo-Heon Park, M.D., Jae Kwang Kim, M.D., In Kyu Lee, M.D.*, Seung Eun Jung, M.D.^† and Kyung Shin Park, M.D.^‡; Korean J Gastrointest Endosc 2008;36(3):177-180. Published online March 30, 2008

Abstract PDF: Obstructive colitis is a rare inflammatory condition that occurs in a dilated segment of the colon proximal to an obstructing lesion. A 69-year-old patient presented with abdominal pain and distension. The colonoscopy findings revealed a near total obstruction from sigmoid colon cancer. The mucosa of the obstructive lesion was erythematous and hemorrhagic but normal mucosa was found immediately above the 3 cm long obstructive lesion. The proximal bowel of the normal mucosa showed colitis with hemorrhagic mucosal changes and yellowish exudative plaques. Surgery was performed as a segmental resection after placing a metallic stent to decompress the proximal colonic loop. In conclusion, obstructive colitis should be considered if an ulcero-inflammatory lesion with a colonic obstruction and a skip lesion in the proximal colon are detected. (Korean J Gastrointest Endosc 2008;36:177- 180)

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A Case of the Common Bile Duct Web Treated with a Retrievable Covered Metallic Stent: Yun Sun Im, M.D., Woo Chul Chung, M.D., Kang Moon Lee, M.D., Jeong Rok Lee, M.D., Jin Dong Kim, M.D., Chang Nyol Paik, M.D., Jin Mo Yang, M.D. and Hyung Min Chin, M.D.*; Korean J Gastrointest Endosc 2008;36(3):181-186. Published online March 30, 2008

Abstract PDF: The web of the common bile duct is an extremely rare condition and is attributed to obstructive jaundice. Most cases have been found incidentally during a surgical procedure, since no specific preoperative clinical manifestations exist. Typically, the web of the biliary tree appears as a slit- or shelf-like radiolucent narrowing on a cholangiography. We experienced a case of the web of the common bile duct with obstructive jaundice in a 62 year- old female who complained of right upper quadrant pain. The patient was diagnosed via an endoscopic retrograde cholangiopancreaticography, and treated by way of a cholecystectomy, membranectomy and T-tube insertion. Four months after the surgical procedure, the patient had a recurrence of the web-like structure in the common bile duct and was subsequently treated successfully using a retrievable covered metallic stent insertion. (Korean J Gastrointest Endosc 2008;36:181-186)

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A Case of a Carcinoid Tumor of the Ampulla of Vater: Wook Jin Lee, M.D., Myung-Hwan Kim, M.D., Hyoung-Chul Oh, M.D., Kyung Eun Kim, M.D.*, Sang Soo Lee, M.D., Dong-Wan Seo, M.D. and Sung Koo Lee, M.D.; Korean J Gastrointest Endosc 2008;36(3):187-190. Published online March 30, 2008

Abstract PDF: Carcinoid tumors involving the Ampulla of Vater are very rare lesions which may result in painless jaundice. The preoperative diagnosis of a carcinoid tumor is difficult because the carcinoid tumor of the Ampulla of Vater is frequently located in the submucosa and rarely presents an ulcerative lesion on the surface mucosa. In contrast to patients with intestinal carcinoid tumors, patients with carcinoid tumor of the Ampulla of Vater are frequently free of clinical and laboratory findings that hint to the carcinoid syndrome. The natural history of this disease entity has not been well established; however, the prognosis is generally believed to be good. In this study, we report a case of a carcinoid tumor of the Ampulla of Vater with an ulcerative lesion, which was diagnosed preoperatively and treated by surgical excision. (Korean J Gastrointest Endosc 2008;36:187-191)

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