Clinical Endoscopy

Case Study in the Broken Endoscope: Jae Geol Lee; Korean J Gastrointest Endosc 2010;42(3):15-18. Published online March 27, 2010

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Indications for Enteroscopy: Which Patients Should Be Recommended for Enteroscopy?: Hwang Choi, M.D.; Korean J Gastrointest Endosc 2011;42(3):137-142. Published online March 28, 2011

Abstract PDF: Balloon-assisted endoscopy (double-balloon or single-balloon endoscopy) is a novel method used to examine the entire small bowel. Enteroscopy has advantages in that tissues can be obtained to get a detailed image, and it is feasible for endoscopic treatments such as hemostasis, dilatation, and polypectomy. Indications for enteroscopy are obscure gastrointestinal bleeding, small bowel involvement due to inflammatory bowel disease, an investigation of a small bowel tumor or polyposis, and difficulty of a colonoscopy. Enteroscopy should be recommended to patients with recurrent mid-gut bleeding of obscure origin, suspected Crohn's disease, suspicious small bowel tumor on abnormal imaging, and surveillance of polyposis syndrome including familial adenomatous polyposis and Peutz-Jeghers syndrome. We may consider enteroscopy in patients with chronic abdominal pain or diarrhea and increased inflammatory markers. We must also understand the contraindications, complications, and limitations of enteroscopy. (Korean J Gastrointest Endosc 2011;42:137-142)

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Analysis of the Clinicopathologic Features of Eosinophilic Esophagitis: Comparative Study with Nonobstructive Dysphagia: Kwang Hyun Kim, M.D., Il Hyung Chung, M.D., Jie-Hyun Kim, M.D., Young Hoon Youn, M.D., Sun Och Yoon, M.D.*, Hyojin Park, M.D. and Sang In Lee, M.D.; Korean J Gastrointest Endosc 2011;42(3):143-151. Published online March 28, 2011

Background/Aims: Eosinophilic esophagitis (EoE) has emerged as one of the most common causes of dysphagia and esophageal food impactions. However, it is doubtful that gastroenterologists and pathologists make the correct diagnosis of EoE because of the insufficient recognition of EoE based on the endoscopic and pathological findings. This study was performed to investigate the symptoms and the endoscopic and pathologic findings of EoE as compared with those of nonobstructive dysphagia (NOD).

Methods: We retrospectively reviewed the medical records and the endoscopic and pathologic findings from 12 patients who were diagnosed with EoE based on an eosinophil count of ≥20 per high-power field (HPF) and 13 patients diagnosed with NOD, and these patients were treated at our hospital from June 2006 till October 2010.

Results: The endoscopic findings of EoE included rings (41.7%), furrows (75.0%), exudates (33.3%), mucosal friability (8.3%) and multi-findings (6.7%). Furrows and multi-findings were identified more frequently in EoE as comparison to that in NOD. The pathologic findings revealed that the maximal eosinophil counts/HPF were 87.2 (range 20∼232) and 2.2 (0∼11) in EoE and NOD, respectively. Moreover, eosinophil microabscess (58.3%), degranulation (100%) and spongiosis (91.7%) were more significantly observed in EoE compared with that in NOD.

Conclusions: EoE had specific endoscopic and clinicopathologic features that distinguish it from NOD. For patients with dysphagia, the endoscopic and pathologic findings of EoE should be kept in mind. (Korean J Gastrointest Endosc 2011;42:143-151)

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Narrow Band Imaging and White Light Colonoscopy for Detection of Polyps: Seok Jae Han, M.D., Eun Young Kim, M.D., Jae Bum Park, M.D., Jong Woon Cheon, M.D., Ka Young Kim, M.D., Young Kook Shin, M.D., Jang Seok Oh, M.D., Byung Seok Kim, M.D., Jimin Han, M.D., Jin Tae Jung, M.D., Joong Goo Kwon, M.D., Chang Hyeong Lee, M.D. and; Korean J Gastrointest Endosc 2011;42(3):152-156. Published online March 28, 2011

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Background/Aims: Narrow band imaging (NBI) is a new technique that is expected to improve the detection rate of colorectal polyps, but results have been inconsistent. The aim of this study was to compare the polyp miss rate and the characteristics of missed colorectal polyps using white light (WL) and NBI.

Methods: 62 patients were randomized into two groups. In the first group (NBI first, NBIF), a colonoscopic examination of each segment (cecum-ascending, transverse, descending, and rectosigmoid colons) was performed first with NBI followed by a re-examination of the same segment using WL. An opposite sequence was applied for the other group (white light first, WLF).

Results: 67 polyps were found in the first examination, and 31 polyps were found on the re-examination, resulting in a polyp miss rate of 31.6%. The polyp miss rate was 39% for WLF and 23% for NBIF (p＞0.05). Seventy-four small polyps (＜5 mm) were found, and miss rates for NBIF and WLF were 20% and 46%, respectively (p=0.01). The polyp miss rate at the rectosigmoid was 11% for NBIF and 54% for WLF (p=0.01).

Conclusions: The polyp miss rate was not significantly different between NBI or WL when a colonoscopy was performed. NBI resulted in a lower polyp miss rate for small (＜5 mm) and rectosigmoid polyps than WL. (Korean J Gastrointest Endosc 2011;42:152-156)

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A Case of Ingesting Multiple Magnets Removed by Endoscopic Submucosal Dissection: So Hyun Gil, M.D., Yong Keun Cho, M.D., Jin Woong Cho, M.D., Ji Woong Kim, M.D., Gum Mo Jung, M.D., Young Jae Lee, M.D. and Sang Hoon Park, M.D.; Korean J Gastrointest Endosc 2011;42(3):157-160. Published online March 28, 2011

Abstract PDF: Foreign body ingestion is common in children, but magnet ingestion is rare. Ingestion of one magnet does not creat a serious problem; however, ingesting multiple magnet can lead to hazardous complications such as pressure necrosis, intestinal perforation, fistula formation, obstruction and intestinal volvulus. Most cases with complications after multiple magnet ingestion require surgical intervention. We report a case of a fistula following the ingestion of seven small, flat and round magnets that were removed successfully by endoscopic submucosal dissection without surgery. (Korean J Gastrointest Endosc 2011;42:157-160)

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Methylene Blue Solution-induced Acute Esophageal Mucosal Injury: First Case Report: Ock Bae Ko, M.D., Do Hoon Kim, M.D., Jung-Min Kang, M.D. and Hwoon-Young Jung, M.D.; Korean J Gastrointest Endosc 2011;42(3):161-164. Published online March 28, 2011

Abstract PDF: Methylene blue (MB) based chromoendoscopy has been used for more than a decade to increase detection rates of specialized intestinal metaplasia, dysplasia, and esophageal adenocarcinoma. It is also used to detect anastomotic leakage after an operation. A 67-year-old man with no previous medical problems had complaints of jaundice and weight loss for 2 months. He was diagnosed with a Klatskin tumor and was referred to our hospital. An initial esophagogastroduodenoscopy (EGD) was performed before the operation. No abnormality was observed in the esophagus. MB solution was infused via an L-tube to check for leakage in the anastomosis. Subepithelial hemorrhagic and edematous mucosal changes with friability and a bluish mucosal discoloration were noted 2 days later from the mid to lower esophagus on EGD. Nine months later, an EGD revealed an unremarkable esophageal mucosa. MB solution is considered safe; however, a large volume or high concentration of MB solution might be harmful. (Korean J Gastrointest Endosc 2011;42:161-164)

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Two Cases of Acute Gastric Volvulus: Sung Ho Kim, M.D., Jong-Jae Park, M.D., Seung Han Kim, M.D., Jung Wan Choe, M.D., Moon Kyung Joo, M.D., Beom Jae Lee, M.D., Jae Seon Kim, M.D. and Young-Tae Bak, M.D.; Korean J Gastrointest Endosc 2011;42(3):165-169. Published online March 28, 2011

Abstract PDF: Gastric volvulus is torsion of the stomach axis accompanied by obstruction and/or strangulation. It is a very rare condition, but it is considered a clinical emergency when it occurs acutely. Acute gastric volvulus requires an early diagnosis and prompt surgical treatment because a delayed diagnosis may lead to gastric obstruction, ischemia and necrosis. We experienced two cases of acute gastric volvulus due to diaphragmatic hernia and the patients were successfully treated with surgery. Here, we report on these two cases with the review of the reported literature on 26 adult cases of gastric volvulus in South Korea. (Korean J Gastrointest Endosc 2011;42:165-169)

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A Case of Inserting Two Self-expandable Metal Stents in Dual Malignant Colonic Obstructions: Ju Wan Kim, M.D., Chang Hwan Choi, M.D., Ji Hoon Park, M.D., Bong Ki Cha, M.D., Ki-Seong Kim, M.D., Seung Mun Jung, M.D., Jae Hyuk Do, M.D. and Se Kyung Chang, M.D.; Korean J Gastrointest Endosc 2011;42(3):170-174. Published online March 28, 2011

Abstract PDF: Malignant colonic obstruction can lead an emergency operation for decompression, and this can cause post-operative complications due to poor bowel preparation. Self-expandable metal stent (SEMS) insertion is useful for avoiding an emergency operation and unnecessary complications. However, SEMS insertion for dual malignant colonic obstructions is very rare. We report here on a case of two SEMS that were inserted in dual malignant colonic obstructions caused by synchronous colon cancer. A 66-year-old man visited our hospital due to abdominal distension. Sigmoidoscopy and an abdominopelvic computerized tomographic (CT) scan revealed synchronous colon cancer at the splenic flexure and distal descending colon with dual obstruction. The initial SEMS insertion on the descending colon was not effective for decompression due to the proximal obstruction. After the second SEMS insertion on the splenic flexure through the first stent, all the signs and symptoms due to obstruction disappeared. SEMS insertion is considered to be useful for treating dual malignant colonic obstruction caused synchronous colon cancer. (Korean J Gastrointest Endosc 2011;42:170-174)

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A Case of Ischemic Colitis after Bee Venom-induced Anaphylaxis: Sung Hoon Kim, M.D., Koon Hee Han, M.D., Jong Kyu Park, M.D., Sang Jin Lee, M.D., Young Don Kim, M.D., Woo Jin Jeong, M.D., Gil Hyun Kang, M.D.* and Gab Jin Cheon, M.D.; Korean J Gastrointest Endosc 2011;42(3):175-178. Published online March 28, 2011

Abstract PDF: Anaphylaxis is a potentially life-threatening allergic reaction, presenting with various clinical symptoms. The most common etiologies of anaphylactic reactions include allergic responses to food, medications, latex, and Hymenoptera stings. In its classic form, anaphylaxis typically involves the cutaneous, respiratory and cardiovascular systems. Gastrointestinal symptoms, including nausea, vomiting, diarrhea and cramping abdominal pain, can occur transiently but mucosal lesions are rarely detected. We recently experienced a case of ischemic colitis presenting with hematochezia after bee venom-induced anaphylactic shock. To the best of our knowledge, this is the first case in Korea. We report the case with a review of the literature. (Korean J Gastrointest Endosc 2011;42:175-178)

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A Case of Chronic Neuropathic Pseudo-obstruction of the Colon: Sunyong Kim, M.D., Min Kyung Kim, M.D., Uk Jo, M.D., Jung Min Chae, M.D., Jae Myung Cha, M.D., A Ri Shin, M.D., Sung-Jig Lim, M.D.* and Ahrim Moon, M.D.*; Korean J Gastrointest Endosc 2011;42(3):179-184. Published online March 28, 2011

Abstract PDF: Colonic pseudo-obstruction, which is characterized by repetitive episodes or continuous symptoms and signs of a bowel obstruction, is a rare disease that results in colorectal dilatation without any obstructing lesions. Cases with neuropathic chronic colonic pseudo-obstruction have rarely been reported in Korea. We report a case of neuropathic colonic pseudo-obstruction, which results in decreased number of interstitial cells of Cajal and hypoganglionosis, in a 50-year-old man with chronic constipation accompanied by megacolon. (Korean J Gastrointest Endosc 2011;42:179-184)

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A Case of Acute Cholecystitis with a Perforation Complicating Endoscopic Retrograde Cholangiopancreatography: Seung Hee Ryu, M.D., Myung Hwan Noh, M.D., Ji Sun Han, M.D., Su Mi Woo, M.D., Byung Geun Kim, M.D., Chien Ter Hsing, M.D., So Young Park, M.D. and Joon Mo Kim, M.D.; Korean J Gastrointest Endosc 2011;42(3):185-189. Published online March 28, 2011

Abstract PDF: The incidence of acute cholecystitis complicating endoscopic retrograde Cholangiopancreatography (ERCP) is rarely reported at 0.2% but is usually associated with a cystic duct obstruction caused by gallstones, gallbladder polyps, or cancer. However, acute cholecystitis with a gallbladder perforation after ERCP without a history of cystic duct obstruction can develop very rarely and has not yet been reported in Korea. We report a case of acute cholecystitis with gallbladder perforation and aggravation of a pancreatic pseudocyst after diagnostic ERCP in a man with a pancreatic cystic lesion. He has been successfully cured using only percutaneous transhepatic gallbladder drainage and antibiotics with no surgery. (Korean J Gastrointest Endosc 2011;42:185-189)

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Spontaneous Biloma Caused by Pancreatic Cancer and Treated by Endoscopic Biliary Stenting: Ji Young Park, M.D., Jin Lee, M.D., Soon Jae Lee, M.D., Se Ah Kwon, M.D., Dong Hee Koh, M.D., Min Ho Choi, M.D., Hyun Joo Jang, M.D. and Sea Hyub Kae, M.D.; Korean J Gastrointest Endosc 2011;42(3):190-194. Published online March 28, 2011

Abstract PDF: Biloma is a rare disorder, and is defined as an abnormal extrahepatic or intrahepatic collection of bile within a defined capsular space. The common causes of biloma are iatrogenic and trauma. Spontaneous biloma, especially caused by pancreatic cancer, is very rare. An 86-year-old man was admitted with abdominal pain and fever. The patient denied a history of abdominal surgery, endoscopic retrograde cholangiography, or trauma. Abdominal computed tomography demonstrated a huge collection of fluid in the left lobe of the liver, dilatation of the intra and proximal common bile duct, and a heterogeneous enhancing mass in the pancreatic head portion. Percutaneous drainage under ultrasound guidance was performed, and the fluid analysis was compatible with biloma. A plastic stent was endoscopically inserted into the common bile duct to treat continuous drainage of the fluid despite percutaneous drainage. We report a case of biloma developed spontaneously in a patient with pancreatic cancer and successfully treated by endoscopic biliary stenting. (Korean J Gastrointest Endosc 2011;42:190-194)

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A Case of Argon Plasma Trimming of a Biliary Metallic Stent Causing a Duodenal Obstruction: Jun-Hyung Cho, M.D., Seok Ho Dong, M.D., Chang Hyun Cho, M.D., Jae Young Jang, M.D., Hyo Jong Kim, M.D., Byung-Ho Kim, M.D., Young Woon Chang, M.D. and Rin Chang, M.D.; Korean J Gastrointest Endosc 2011;42(3):195-200. Published online March 28, 2011

Abstract PDF: Metallic stents are being widely used in patients with a malignant obstruction of the biliary tract. The advent of metallic stents was heralded as a solution to the problem of plastic stent occlusion. Metallic stents prolong stent patency by lowering occlusion rates, but they may malfunction for several reasons, including occlusion from tumor ingrowth or migration after the procedure. Distal migration or impaction of metallic stents against the duodenal wall may cause severe complications, including duodenal obstruction, perforation and acute upper gastrointestinal bleeding. Several techniques have been developed to manage distal migration of a biliary metallic stent and remove the malfunctioning stent endoscopically. We report on a 43-year-old male who underwent endoscopic palliative biliary drainage because of obstructive pancreatic head cancer. We transected the distal end of the metallic stent using an argon plasma coagulator, treating the duodenal obstruction without any complications. (Korean J Gastrointest Endosc 2011;42:195-200)

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Gastric Involvement in Autoimmune Pancreatitis: Seung Don Baek, M.D., Myung Hwan Kim, M.D., Yun Ku Kim, M.D., Do Hoon Kim, M.D., Jihun Kim, M.D.*, Sang Soo Lee, M.D., Dong Wan Seo, M.D. and Sung Koo Lee, M.D.; Korean J Gastrointest Endosc 2011;42(3):201-204. Published online March 28, 2011

Abstract PDF: Autoimmune pancreatitis is now considered to be a systemic fibroinflammatory disease that can involve multiple organs. As it is associated with IgG4-positive plasma cells by an autoimmune mechanism, extrapancreatic organs as well as the pancreas could be affected with a lymphoplasmacytic infiltrate. The proximal bile duct, the salivary gland, the retroperitoneum and the kidney are well known to be involved with, but less is known about the involvement of hollow viscus which is pathologically associated with autoimmune pancreatitis. We report here on a case of gastric involvement in a 53-year-old man with autoimmune pancreatitis. (Korean J Gastrointest Endosc 2011;42:201-205)

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