Clinical Endoscopy

The Role of Endoscopic Examination for Making the Diagnosis of Autoimmune Pancreatitis: Sung-Hoon Moon, M.D. and Myung Hwan Kim, M.D., Ph.D.; Korean J Gastrointest Endosc 2008;37(4):237-242. Published online October 30, 2008

Abstract PDF: Autoimmune pancreatitis (AIP) is a peculiar type of chronic pancreatitis that responds rather dramatically to corticosteroid therapy. The most important point when diagnosing AIP is to distinguish it from pancreatobiliary malignancies. The typical imaging features of AIP are diffuse enlargement of the pancreas and a diffusely attenuated main pancreatic duct with an irregular wall. The atypical imaging features of AIP include a discrete pancreatic mass, focal pancreatic enlargement and focal narrowing of the main pancreatic duct. EUS and a histopathologic examination should be performed for patients with these atypical imaging features. Endobiliary biopsy and brush cytology are recommended at the time of ERCP in the case of obstructive jaundice associated with bile duct narrowing. This review discusses the role of endoscopic examination for making the diagnosis of autoimmune pancreatitis.(Korean J Gastrointest Endosc 2008;37: 237-242)

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Incidence and Risk Factors of Reflux Esophagitis after a Subtotal Gastrectomy: Seung Joo Kang, M.D., Mi Na Kim, M.D., Su Hyun Kim, M.D., Jin Myung Park, M.D., Hyun Jin Jo, M.D., Mun Sun Choi, M.D., Sang Hyub Lee, M.D.*, Young Soo Park, M.D.*, Jin Hyeok Hwang, M.D.*, Jin Wook Kim, M.D.*, Sook Hyang Jung, M.D.*, Nayoung Kim, M.D.*, D; Korean J Gastrointest Endosc 2008;37(4):243-252. Published online October 30, 2008

Abstract PDF: Background/Aims: The aims of this study were to evaluate the incidence of reflux esophagitis in patients after a subtotal gastrectomy and to determine risk factors for reflux esophagitis. Methods: Among 225 patients who underwent a subtotal gastrectomy from June 2003 to December 2004 at Seoul National University Bundang Hospital, 201 patients who received follow-up for more than six months and underwent at least one endoscpoic examination were retrospectively reviewed. We used the Los Angeles (LA) classification system and included a minimal change for reflux esophagitis. Results: There were 173 patients who underwent a Billroth I procedure and 28 patients who underwent a Billroth II procedure. The cumulative incidence of reflux esophagitis was 40.8%. A patient age ≥65 years (p=0.04), a follow-up duration ≥40 months (p=0.03), bile reflux gastritis (p＜0.01) and postoperative obesity (p=0.02) were significant risk factors for the development of reflux esophagitis including a minimal change. The number of postoperative endoscopies ≥4 (p=0.012), bile reflux gastritis (p=0.002) and postoperative obesity (p=0.038) were risk factors for a minimal change. A patient age ≥65 years (p=0.04), a follow-up duration ≥40 months (p=0.03) and Helicobacter pylori eradication before surgery (p＜0.01) were independent risk factors for LA grade A/B reflux esophagitis. Conclusions: Bile reflux gastritis is a risk factor for the development of reflux esophagitis after a subtotal gastrectomy. Preoperative helicobacter eradication is also associated with reflux esophagitis, except for a minimal change, but further studies are needed. (Korean J Gastrointest Endosc 2008;37:243-252)

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The Usefulness of a Suspected Blood Identification System (SBIS) in Capsule Endoscopy according to Various Small Bowel Bleeding Lesions: Ju Young Kim, M.D., Hoon Jai Chun, M.D., Chul Young Kim, M.D., Jin Su Jang, M.D., Yong Dae Kwon, M.D., Sanghoon Park, M.D., Bora Keum, M.D., Yeon Seok Seo, M.D., Yong Sik Kim, M.D., Yoon Tae Jeen, M.D., Hong Sik Lee, M.D., Soon Ho Um, M.D., Sang Woo Lee,; Korean J Gastrointest Endosc 2008;37(4):253-258. Published online October 30, 2008

Abstract PDF: Background/Aims: Substantial time and attention are required to read and interpret the recordings of capsule endoscopic images. A suspected blood identification system (SBIS) has been developed to assist in the reading of capsule images. This software automatically marks "red tags" that correlate with suspected blood or red areas. However, the sensitivity and accuracy of the system have not been well characterized. We investigated the usefulness of the SBIS in capsule endoscopy according to various small bowel bleeding lesions. Methods: Two expert endoscopists reviewed the capsule images. Angiodysplasias, ulcers and erosion were considered as significant lesions, and active bleeding lesions were considered when bleeding or blood clots were seen in the capsule images. The red tags that were automatically marked by the use of the rapid software were compared to the significant lesions reviewed by the endoscopists. Results: A total of 95 patients were enrolled in the study. The endoscopists identified 159 significant lesions and 71 lesions marked by red tags were identified by the SBIS. Among the 71 lesions, 31 lesions correctly coincided with the significant lesions. The overall sensitivity and positive predictive value of the use of the SBIS were 20% and 44%, respectively. The sensitivities of active ulcers and active bleeding lesions were 83% and 93%, respectively. Conclusions: The SBIS should be considered as a rapid screening tool to identify active bleeding lesions, and a complete review of capsule images by a physician is still needed. (Korean J Gastrointest Endosc 2008;37:253-258)

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Comparison of the Efficacy of Bismuth Containing PPI-based Quadruple Therapy with PPI-based Triple Therapy Only as First-line Treatment for Helicobacter pylori Infection: Hyun Jin Jo, M.D., Dong Ho Lee, M.D.*, Seung Joo Kang, M.D., Mi Na Kim, M.D., Su Hyun Kim, M.D., Jin Myung Park, M.D., Mun Sun Choi, M.D., Hyun Chae Jung, M.D., In Sung Song, M.D., Nayoung Kim, M.D.*, Sook Hyang Jung, M.D.*, Jin Wook Kim, M.D.*, Young Soo; Korean J Gastrointest Endosc 2008;37(4):259-264. Published online October 30, 2008

Abstract PDF: Background/Aims: In recent years, increasing antimicrobial resistance has resulted in falling eradication rates with standard therapies. To overcome the falling eradication rates, rescue therapy have been suggested to be used. However, there is no surveillance of using bismuth- based regimen as first line Helicobacter pylori eradication therapy in Korea. This study aimed to assess the efficacy of bismuth containing PPI-based quadruple therapy as a first line treatment. Methods: From August 2007 through February 2008, 191 patients with Helicobacter pylori positive peptic ulcer disease (PUD) or chronic gastritis (CG) who received first line therapy for 7 days were retrospectively evaluated. 39, 37, 53, 62 patients received PAC (pantoprazole 40 mg, amoxicillin 1 g, clarithromycin 500 mg bid), L-PAC (pantoprazole 40 mg, amoxicillin 750 mg, clarithromycin 250 mg bid), PACB (PAC plus bismuth 300 mg bid), L-PACB (L-PAC plus bismuth 300 mg bid). Results: There was no significant difference in eradication rates between bismuth containing and non- containing group. However, in PUD, the eradication rate of PACB (95.2%) is somewhat higher than that of PAC (86.2%) without statistical significance. Conclusions: In PUD, Future study designed with a double-blind controlled large scale might reveal that PPI-based standard quadruple therapy containing a bismuth is superior to the standard triple therapy. (Korean J Gastrointest Endosc 2008;37: 259-264)

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Risk Factors for Post-ERCP Pancreatitis in Patients Pretreated with Nafamostat Mesilate: Il Doo Kim, M.D., Dae Hwan Kang, M.D., Jin Hyun Park, M.D., Jung Ho Bae, M.D., Pyo Jun Kim, M.D., Yong Wook Kim, M.D., Cheol Woong Choi, M.D., Jae Sup Eum, M.D., Sun Mi Lee, M.D., Tae Oh Kim, M.D., Gwang Ha Kim, M.D. and Geun Am Song, M.D.; Korean J Gastrointest Endosc 2008;37(4):265-270. Published online October 30, 2008

Abstract PDF: Backgound/Aims: Pancreatitis is the most common and important complication of an endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to identify risk factors for post ERCP-pancreatitis in patients pretreated with nafamostat mesilate, a synthetic protease inhibitor. Methods: A total of 247 patients who underwent an ERCP were evaluated prospectively. Potential risk factors of post-ERCP pancreatitis in patients pretreated with nafamostat mesilate were evaluated. Results: Twenty-four patients (9.7%) and nine patients (3.6%) developed post-ERCP hyperamylasemia and pancreatitis, respectively. As determined by univariate analysis among the potential risk factors, we found a procedure time over 20 minutes, pancreatic duct cannulation over four times, prior post-ERCP pancreatitis and the absence of a common bile duct (CBD) stone as risk factors for post-ERCP hyperamylasemia. We also found a patient age under 60 years, a procedure time over 20 minutes, pancreatic duct cannulation over four times and the absence of a CBD stone as risk factors for post-ERCP pancreatitis (p＜0.05). As determined by multivariate analysis, pancreatic cannulation over four times is independently associated with post-ERCP hyperamylasemia (p=0.038; OR, 5.165; 95% CI, 1.093∼24.412) and post-ERCP pancreatitis (p=0.002; OR, 33.122; 95% CI, 3.526∼311.138). Conclusions: A repeated pancreatic duct cannulation is the most important risk factor for post-ERCP pancreatitis in patients pretreated with nafamostat mesilate. (Korean J Gastrointest Endosc 2008; 37:265-270)

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A Case of a Gastric Bezoar Combined with Superior Mesenteric Artery Syndrome: Min Kyoung Kang, M.D., Chang-Il Kwon, M.D., Ji Eun Lee, M.D., Yong Hun Kim, M.D., Kwang Hyun Ko, M.D., Sung Pyo Hong, M.D., Pil Won Park, M.D. and Hee Jin Kim, M.D.*; Korean J Gastrointest Endosc 2008;37(4):271-275. Published online October 30, 2008

Abstract PDF: Superior mesenteric artery syndrome is caused by compression of the third part of the duodenum between the superior mesenteric artery (SMA) and the aorta. Recently, we experienced a case of a gastric bezoar combined with SMA syndrome. A 58-year-old man presented with upper abdominal pain, bloating and weight loss of 5 kg. An endoscopic examination identified a huge gastric bezoar. The bezoar was broken and fragmented into small pieces using an argon plasma coagulator and endoscopic snare catheter. Hypotonic duodenography showed a longitudinal linear band that was presumed to be a vascular impression of the third portion of the duodenum and contrast-enhanced spiral CT showed a reduced distance of 8.4 mm but a normal angle of 38.5^o between the arota and the SMA. A second endoscopic examination demonstrated prominent pulsations that compressed the duodenal wall at the third portion. Luminal expansion with full inflation of air was not attempted under endoscopy. (Korean J Gastrointest Endosc 2008;37:271-275)

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Endoscopic Removal of Small Bowel Bezoars using Colonoscopy through the Oral Approach: Su Jung Baik, M.D., Ki-Nam Shim, M.D., Seong-Eun Kim, M.D., Hye-Kyung Jung, M.D., Sung-Ae Jung, M.D., Kwon Yoo, M.D., Il Hwan Moon, M.D. and Joo-Ho Lee, M.D.*; Korean J Gastrointest Endosc 2008;37(4):276-279. Published online October 30, 2008

Abstract PDF: Bezoars are accumulations of foreign materials and foods in the gastrointestinal tract and can be the cause of small bowel obstruction. A bezoar usually begins as a gastric phytobezoar that migrates to the small bowel in patients who have undergone gastric surgery and have delayed gastric emptying. We report a case of diagnosed small bowel obstruction due to the presence of a persimmon phytobezoar (diospyrobezoar) in a patient with a history of gastric surgery. Abdomen-pelvis computed tomography demonstrated the presence of an air-containing localized lesion (5×3.5 cm), a suspicious bezoar in the jejunum. The gastroduodendoscopy failed to reach to the lesion but diospyrobezoars were found in the proximal jejunum at 120 cm from the upper incisors using a colonoscope inserted using the oral approach. Most of the bezoars were fragmented by a tripod and were removed with a snare. The patient was discharged after symptomatic improvement without surgery. We report this case with a review of the relevant literature. (Korean J Gastrointest Endosc 2008; 37:276-279)

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A Case of Gastritis Cystica Profunda Presenting with a Submucosal Cystic Tumor: Ji Hyun Lee, M.D., Gye Sung Lee, M.D., Eom Seok Lee, M.D., Hyun Mo Kang, M.D., Jae Su Kim, M.D., Young Gul Yoon, M.D., In Sung Jung, M.D. and Mi Seon Lee, M.D.*; Korean J Gastrointest Endosc 2008;37(4):280-283. Published online October 30, 2008

Abstract PDF: Gastritis cystica profunda (GCP) is a lesion characterized by elongation of the gastric foveolae with hyperplasia and cystic dilatation of the gastric glands that extends into the submucosal layer. In most cases, gastritis cystica profunda develops in patients who have undergone a gastroenterostomy, with or without gastric resection. GCP may present not only as a submucosal tumor or as solitary or diffuse polyps, but GCP is also rarely seen as a giant gastric mucosal fold. A patient arrived at our hospital with dyspepsia. Gastroduodenoscopy (EGD) showed the presence of a submucosal tumor measuring 3 cm in the widest diameter in the body of the stomach. A CT scan demonstrated the cystic nature of the lesion and endoscopic ultrasound (EUS) depicted a homogeneous hypoechoic, unilocular cystic mass without any internal solid component. EGD, CT and EUS findings suggested that the lesion was more likely to be benign than malignant. The lesion was treated with an endoscopic mucosal resection (EMR), and the lesion was finally diagnosed as gastritis cystica profunda. A follow-up EGD demonstrated that all mucosal surfaces were well healed four weeks after the EMR. (Korean J Gastrointest Endosc 2008;37:280-283)

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A Case of a Cavernous Hemangioma in the Distal Jejunum Detected by Double-Balloon Enteroscopy in a Patient with Small Bowel Obstruction: Yu Jin Lim, M.D., Jin Lee, M.D., Jae Hoon Yang, M.D., Dong Hee Koh, M.D., Min Ho Choi, M.D., Hyun Joo Jang, M.D., Woo Young Jang, M.D.* and Sea Hyub Kae, M.D.; Korean J Gastrointest Endosc 2008;37(4):284-287. Published online October 30, 2008

Abstract PDF: Primary neoplasms of the small intestine are relatively rare. Early diagnosis and treatment of small bowel disease is difficult due to the low sensitivity of conventional examination methods. Double-balloon enteroscopy allows an exact examination of the small intestine, including a biopsy and other procedures, and the use of this technique provides an improvement in the diagnosis and treatment of small bowel disease. We report a case of a cavernous hemangioma of the distal jejunum that was detected by the use of double-balloon enteroscopy in a patient with recurrent periumbilical pain and small bowel obstruction that was treated by a small bowel segmental resection. (Korean J Gastrointest Endosc 2008;37:284-287)

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A Case of an Intestinal Pseudo-obstruction in Post-encephalitis Mental Retardation: Ji Hyung Nam, M.D., Yun Jeong Lim, M.D., Jung Bae Park, M.D., Su Yeon Park, M.D.* and Jin Ho Lee, M.D.; Korean J Gastrointest Endosc 2008;37(4):288-292. Published online October 30, 2008

Abstract PDF: A 44-year-old female patient, with developmental disabilities and mental retardation after central nervous system (CNS) infection during infancy, presented with a complaint of severe abdominal distension and weight loss for the past two months. The patient was diagnosed with an intestinal pseudo-obstruction, based on radiological findings and an endoscopic finding of marked gaseous distension of the stomach and the small bowel without stenosis and mechanical obstruction. The patient had delayed gastrointestinal mobility. We report a case of an intestinal pseudo-obstruction accompanied with mental retardation after CNS infection. (Korean J Gastrointest Endosc 2008;37:288-292)

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Two Cases of Benign and Malignant Lesion Caused Ileocolic Intussusception: Preoperative Colonoscopic Reduction was Attempted for These Patients: Il Young Lee, M.D., Jae Woo Kim, M.D., Chang Jin Yea, M.D., Myeong Hun Chae, M.D., Joong Kyung Sung, M.D., Ki Tae Suk, M.D., Soon Koo Baik, M.D. and Mee Yon Cho, M.D.*; Korean J Gastrointest Endosc 2008;37(4):293-298. Published online October 30, 2008

Abstract PDF: In contrast to the idiopathic cause of intussusception in children, adult intussusception in most patients is associated with organic causes. The majority of these patients are brought to the operating room with the preoperative diagnosis of bowel obstruction, and the surgeon discovers an intussusception intraoperatively. But the increasing use of abdominal CT may improve the ability to diagnose intussusception. There is no universal agreement upon the correct treatment of adult intussusception, although most authors agree that surgical intervention is necessary. In the more recent reports, colonoscopic reduction of intussusception has been reported for selected patients. For patients in whom the involved ileum is extremely long, it is advisable to attempt an operative reduction or colonoscopic reduction selectively. Thus, we report here on two patients with benign and malignant lesion, respectively, that caused ileocolic intussusception; preoperative colonoscopic diagnosis and reduction were attempted for these patients, although the patients were not reduced by colonoscopic procedure. (Korean J Gastrointest Endosc 2008;37:293-298)

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A Case of Primary Melanoma of the Anus that Spread to the Submucosa of the Rectum: Sung Whan Cho, M.D., Won Il Park, M.D., Hyung Yook Kim, M.D., Kwang Jin Kim, M.D. and Ung Suk Yang, M.D.; Korean J Gastrointest Endosc 2008;37(4):299-302. Published online October 30, 2008

Abstract PDF: Primary malignant melanoma of the anorectum is rare, representing about 1% of all colorectal carcinoma and less than 1% of all melanomas. The most common symptom of malignant melanoma of the anorectum is anal bleeding and this is often misdiagnosed as hemorrhoids. A 72-year-old female patient was admitted due to intermittent anal bleeding for 6 months. Colonoscopic examination showed a large exophytic mass with an irregularly ulcerated and greenish-brown pigmentation on the anus and the examination also simultaneously showed a submucosal tumor-like lesion in the rectum that was located 5 cm from the anal verge. Light microscopy of the tumor revealed malignant melanocytes and the tumor cells reacted positively for immunohistochemical staining with S-100 protein and HMB-45. Distant metastasis to the brain was detected on brain MRI. (Korean J Gastrointest Endosc 2008;37:299-302)

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Hyponatremic Encephalopathy Following a Sulfate Free Polyethylene Glycol-based Bowel Preparation for Colonoscopy: Kyung Sun Ok, M.D., You Sun Kim, M.D., Won Cheol Jang, M.D., Tae Yeob Jeong, M.D., Jin Gook Huh, M.D., Soo Hyung Ryu, M.D., Jung Hwan Lee, M.D. and Jeong Seop Moon, M.D.; Korean J Gastrointest Endosc 2008;37(4):303-307. Published online October 30, 2008

Abstract PDF: Hyponatremia associated with the use of both a sodium phosphate (NaP) and polyethylene glycol (PEG) solution for colonoscopy preparation has been reported in patients with impaired renal handling of water. A PEG solution is believed to affect serum electrolytes less than NaP, but the use of a PEG solution can lead to nausea, vomiting, intestinal hyperactivity and dehydration, often resulting in a raised plasma antidiuretic hormone (ADH) concentration. Non-osmolar stimuli such as pain, stress, nausea, and vomiting can stimulate ADH release. We report a case of severe hyponatremic encephalopathy after sulfate-free PEG ingestion for a colonoscopy in a healthy middle-aged woman. We think that physicians should be familiar with the medical history and current medication schedule of patients prior to bowel preparation. The levels of serum electrolytes should be checked in patients with impaired ability to excrete free water and any mental aberrations before undertaking colonoscopy procedures. (Korean J Gastrointest Endosc 2008;37:303-307)

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A Case of Multiple Colon Ulcers due to Complications of S-1 (TS-1): Hye Jeong Park, M.D., Dong Soo Han, M.D., Hyun Chul Kim, M.D., Hyun Seok Cho, M.D., Chang Soo Eun, M.D., Yong Cheol Jeon, M.D., Joo Hyun Sohn, M.D. and Jung-Hye Choi, M.D.; Korean J Gastrointest Endosc 2008;37(4):308-311. Published online October 30, 2008

Abstract PDF: S-1 (TS-1) is an oral anticancer drug that contains a prodrug of 5-fluorouracil. This drug exhibits high efficacy with it is used as single therapy or in combination therapy for gastrointestinal cancer, and especially advanced gastric cancer. There have not been any reports about grade 3 or 4 adverse events when using S-1. We report here on a case of multiple colon ulcers after S-1 chemotherapy in a patient with advanced gastric cancer. (Korean J Gastrointest Endosc 2008;37:308-311)

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A Case of Successful Laparoscopic Management on Appendiceal Bleeding Diagnosed by Colonoscopy: Dong Baek Kang, M.D., Jeong Kyun Lee, M.D., Bin Na Yang, M.D., Seung Ho Kim, M.D., Jung Taek Oh, M.D., Won Chul Park, M.D., Ki Hoon Kim, M.D.* and Eun Young Cho, M.D.*; Korean J Gastrointest Endosc 2008;37(4):312-314. Published online October 30, 2008

Abstract PDF: Appendiceal causes of lower gastrointestinal bleeding are rare, and identification of the bleeding site is critical. Identification of the bleeding site can be difficult. The differential diagnosis of bleeding in the appendix includes diverticulum, appendicitis, angiodysplasia, Crohn's disease, and appendiceal intussusception, which leads to mucosal erosion and vascular exposure by underlying inflammation. Laparoscopic surgery is commonly performed as a therapeutic procedure for the appendix, also can be a valuable tool in the diagnosis and treatment of hemorrhaging from the appendix. Appendiceal bleeding is rare, and laparoscopic management cases are not widely reported. Herein, we report a case of successful laparoscopic management of appendiceal bleeding diagnosed by colonoscopy with a review of the literature. (Korean J Gastrointest Endosc 2008;37:312-315)

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