Clinical Endoscopy

식도정맥류에 대한 내시경적 결찰술과β차단제의 병합치료효과 (Combined Therapy of Endoscopic Variceal Ligation andβ-Blocker for Esophageal Varices ): Korean J Gastrointest Endosc 1999;19(2):165-170. Published online November 30, 1998

Abstract PDF: Background
/Aims: Endoscopic variceal ligation (EVL) has been accepted as safe and useful treatment for esophageal varices. However, the main problem is the recurrence after eradication of varices.β-blockers have been shown to be effective for prevention of vari-ceal bleeding. We evaluate the efficacy of the combined therapy of EVL and β-blocker against recurrence of esophageal varices. Methods: 39 patients followed from October 1992 through February 1998 after eradication of esophageal varices by EVL were divided into two groups: group 1; 20 patients received EVL alone, group 2; 19 patients received EVL and propranolol for follow-up periods. The rate of recurrence and rebleeding were observed in two groups. Results: Follow-up periods in group 1 and 2 after an initial eradication of esophageal varices were 1039.6 (291-1499) and 928.3 (448-1793) days, re-spectively. During follow-up periods, the recurrence rate was lower in group 2 (27.8%) than group 1 (60.0%) (p ＜0.05). The periods from last session to recurrence were 609.1 (128-1460) and 666.2 (405-1007) days in group 1 and 2, respectively. The rebleeding and mortality rates were 15.0% and 25.0% in group 1. Conclusions: Combined therapy of EVL and β-blocker could decrease the recurrence rate after eradication of esophageal varices, as compared with EVL alone. The further large, long-term study should be re-quired.(Korean J Gastrointest Endosc 19: 165 ∼170, 1999)

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식도정맥류 결찰요법에 있어서 첫시술의결찰수와 정맥류 절성적 (The Effect of Initial Ligation Numbers on the Eradication of Esophageal Varix with Endoscopic Variceal Ligation): Korean J Gastrointest Endosc 1999;19(2):171-177. Published online November 30, 1998

Abstract PDF: Background
/Aims: Eradication of esophagogastric varix is the most important goal of endoscopic variceal treatment. However, the effect of initial ligation numbers with endo-scopic variceal ligation has not been widely studied. The purpose of this retrospective study was to evaluate the effect of initial ligation numbers on the eradication of esophageal varix. Methods: The mean number of sessions to variceal eradication was compared according to initial ligation numbers, and varix grade by the North Italian Endoscopy Club, and the Child-Pugh class in 212 patients. Initial ligation numbers were divided into three groups; more than 11, 6 ∼10, and fewer than 5. Results: Except with grade I, esophageal varix was eradicated earlier in the two groups of more than 6 ligations (p ＜0.01). The mean number of sessions in the group of more than 11 ligations was significantly different from that of the group of 6 ∼10 ligations in grade II patients (p ＜0.05). The mean number of sessions was not significantly different when compared by the Child-Pugh class. Conclusion: It is suggested that patients with more initial ligation numbers may result in earlier eradication of esophageal varix with endoscopic ligation. (Korean J Gastrointest Endosc 19: 171 ∼177, 1999)

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식도암의 심달도 판정에 있어서 내시경적 초음파검사의 유용성 (Role and Limit of Endoscopic Ultrasonography in Staging for Esophageal Cancer ): Korean J Gastrointest Endosc 1999;19(2):178-185. Published online November 30, 1998

Abstract PDF: Background
Despite the technical developments in diagnosis and therapy, esophageal cancer is highly lethal disease and the survival is largely dependent upon the stage of the disease. Preoperative cancer staging is crucial in choosing a therapeutic option as well as in predicting the prognosis of the patients. Staging has been based on computerized tomography (CT) and transabdominal ultrasonography. However CT has a limit in pre-cisely discriminating the depth of invasion or the lymph node metastases. With the devel-opment of endoscopic ultrasonography (EUS) and with its superiority in delineating wall structure and detecting lymph node metastases, its usefulness in staging for esophageal cancer has been cknowledged. In order to evaluate the accuracy of EUS, we compared EUS with pathologic findings in patients with esophageal carcinoma. Methods: From July 1990 to August 1997, 136 patients with esophageal cancer received preoperative cancer staging with EUS. Among them, 48 patients who underwent surgical procedures with the intention of radical resection were included. We compared the EUS and pathologic find-ings and analysed the accuracy of EUS for preoperative staging. Results: The overall accu-racy of EUS for T-staging was 43.8%. Twenty five percents of the patients (12/48) pre-sented high-grade tumor strictures, which precluded the passage of the endoscope. There was no statistical significance according to tumor site, size or gross morphology. However theaccuracy was significantly lower in tumors with ulceration than in tumors without ulceration (35.3% vs 64.3%, p=0.004). Mainly, ulceration in tumors caused significant overstaging of the T-stage. In the assessment of regional lymph node metastasis, the overall accuracy achieved by EUS was 66.6%; the sensitivity was 95.5%, specificity 42.3%, positive predictive value 58.3%, and negative predictive value 91.7%. Tumors with more than 2 lymph nodes rendered more accurate N-staging than tumors with less than 2 lymph nodes. Conclusions: In conclusion, the accuracy of the EUS for preoperative staging of esophageal cancer was not satisfactory, mostly influenced by ulceration in tumors and its resultant inflammatory reactions around the tumors, therefore more systematic study will be needed to establish the precise diagnostic criteria of EUS staging. (Korean J Gastrointest Endosc 19: 178 ∼185, 1999)

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출혈성 소화성 궤양의 장기 재발률 (Long-Term Recurrent Bleeding Rate of Bleeding Peptic Ulcer): Korean J Gastrointest Endosc 1999;19(2):186-192. Published online November 30, 1998

Abstract PDF: Background
/Aims: Bleeding from a peptic ulcer is one of the common and serious complications associated with the rate of reported mortality, which ranges from 5% to 10%. Endoscopic therapy is effective in controlling active bleeding and reducing the emer-gency surgery, the immediate mortality rate and the incidence of early rebleeding. But few recent studies have documented the long-term recurrent bleeding rate after discharge in patients with bleeding peptic ulcers. The aim of this study was to determine the long-term recurrent bleeding rate and factors predisposing to recurrent bleeding. Methods: Eighty-eight patients with bleeding peptic ulcers discharged after medical treatment between Dec. 1990 and Jul. 1992 were included in this study and retrospectively followed up with medical records and telephone interviews. The end point of follow-up was recur-rent hemorrhage, surgery for treatment of ulcer complication, or death. Results: By July 1997, retrospective follow-up was available in 76 patients. Recurrent bleeding occurred in 23 patients (30.3%) with bleeding peptic ulcers and the median follow-up period was 69 months (range, 1 ∼79 months). The estimated cumulative recurrent bleeding rate after 1, 2, 3, 4, 5 and 6 years was 11.8%, 14.5%, 19.9%, 24.2%, 27.2% and 34.2%, respectively. There was no difference between the recurrent bleeding group and the non-recurrent bleed-ing group according to age, sex, prior NSAIDs use, previous history of bleeding or pepticulcer, site of ulcer, stigmata of recent hemorrhage at initial examination, method of treatment and amount of transfusion. Conclusion: Recurrent bleeding occurred in one-third of patients with bleeding peptic ulcers after 6 years of follow-up and one-third of recurrent bleeders rebled within 1 year. The factors predisposing to recurrent bleeding in the long-term follow-up could not be found. Therefore, further studies designed to identify factors predisposing to recurrent bleeding are needed and the evaluation of Helicobacter pylori status in bleeding peptic ulcer is needed because Helicobacter pylori is an important factor of peptic ulcer recurrence. (Korean J Gastrointest Endosc 19: 186 ∼192, 1999)

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메틸렌 블루 색소내시경과 조직학적으로 확인된 장상피화생에서 Helicobacter pylori 양성률에 대한 연구 (The Study of the Positivity of Helicobacter pylori in the Intestinal Metaplasia Detected by Methylene Blue Chromoendoscopy and Histology): Korean J Gastrointest Endosc 1999;19(2):193-199. Published online November 30, 1998

Abstract PDF: Background
/Aims: To assess the relationship between the intestinal metaplasia, Helico-bacter pylori infection, and H. pylori positivity, the difference in the type of intestinal metaplasia according to H. pylori status were examined. Methods: Chromoendoscopy by methylene blue stain method was performed to assess the diagnostic viability for the detection of intestinal metaplasia in subjects who having histologically determined intes-tinal metaplasia. Results: Intestinal metaplasia was found in 35 subjects. Of these, 21subjects (60%) were male and 14 subjects (40%) were female. Of 35 subjects, 26 subjects were H. pylori positive cases (74.3%) and 9 subjects were H. pylori negative cases (25.7%). The mean age of intestinal metaplasia subjects was 51.5 8.9 years. Of these, the mean age of H. pylori positive subjects was 49.5 8.0 years, whereas the mean age of H. pylori negative subjects was 57.2 9.2 years (p ＜0.05). On the type of intestinal metaplasia, 31 subjects showed type I (88.6%) and 4 subjects showed type II (11.4%). There was no statistical difference of intestinal metaplasia type according to H. pylori status. The diagnostic value of methylene blue chromoendoscopy in the diagnosis of intestinal metaplasia had a sensitivity of 82.4%, specificity of 100%, positive predictivevalue of 100% and negative predictive value of 75%. Conclusions: Although a causal relationship between H. pylori infection and the histogenesis of intestinal metaplasia was not proven, it is suggested that H. pylori positive cases lead to an earlier development of intestinal metaplasia than H. pylori negative cases. Therefore, it is important to assess the probability of the development of gastric carcinoma through a follow up study. (Korean J Gastrointest Endosc 19: 193 ∼199, 1999)

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직직장암의 수술전 병기판정을 위한 경직장 초음파단층촬영술의 효용성 (The Efficacy of Endorectal Ultrasonography in the Preoperative Staging of Rectal Cancer): Korean J Gastrointest Endosc 1999;19(2):200-208. Published online November 30, 1998

Abstract PDF: Background
/Aims: The precise preoperative staging of rectal cancer is of great im-portance for the selection of an appropriate treatment. Endorectal ultrasonography (EUS) has been proven as an efficient tool for staging in rectal cancer. Moreover, its technical advancement has been enhancing resolution and applications. We evaluated the accuracy of preoperative staging using EUS in rectal cancer and examined whether staging by EUS was an efficient procedure. Methods: EUS was performed in 79 patients with rectal cancer diagnosed by colonoscopic biopsy from January to December, 1996. Endoscopic examina-tion was used with Olympus, GF-UM20 and Br?l and Kjaer type 2001 Scanner. The staging by EUS was based on UICC classification. Results: Preoperative staging by EUS was equal to pathologic staging in 70.9% (56/79) of cases. Overstaging was found in 17.7% (14/79) and downstaging in 11.4% (9/79). The prediction of lymph node metastases was accurate in 50 of 79 cases (63.3%). Conclusion: EUS seems to be an efficient diagnostic method to assess rectal cancer staging. More accurate imaging and further experience in the interpretation is needed to improve the efficacy of EUS. (Korean J Gas-trointest Endosc 19: 200 ∼208, 1999)

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대장 편평융기형 병변의 분석과 의의 (Clinicopathologic Features of Flat Elevations in the Colon and Their Significance): Korean J Gastrointest Endosc 1999;19(2):209-220. Published online November 30, 1998

Abstract PDF: Background
/Aims: There are two main routes in the growth and development of colo-rectal carcinomas, that is to say, the adenoma-carcinoma sequence and the route described by the de novo theory. The adenoma-carcinoma sequence has been considered a principal route for colorectal carcinomas for a long time, but recently the de novo cancer theory has become a controversial issue, and many authors have claimed that their cases were de novo carcinomas. Since Muto described small “flat elevations ”and emphasized their significance as precursors of colorectal carcinomas, especially of flat colorectal carci-nomas, many flat elevations have been reported. He cautioned that the reported de novo carcinomas could also be carcinomas that developed from small flat adenomas. In addition, no data are available in Korea on the subject of flat elevations. Accordingly, we attempted to analyze flat elevations in the colon and to obtain correlations between their endoscopic and histologic features and their clinical implications. Methods: The authors performed colonoscopic removal of 146 flat elevations from January 1997 to December 1997 at Song-Do Colorectal Hospital in Seoul, Korea. We reviewed and analyzed all those lesions. During colonoscopy, the sizes of the lesions were measured by an endoscopic ruler. Results: The most common age group was the sixth decade. Only one case involved a patient under 30 years old. The male-to-female ratio was 3.2 ：1. The numbers of flat adenomas and flat adenocarcinomas were 68 and 1, respectively. These 69 cases amounted to 47.3% of the flat elevations. The malignancy rate for flat adenomas was 1.4% (1/69). There were no malignancies in flat elevations with diameters below 10 mm. Hyperplasticpolyps and chronic nonspecific inflammation showed 34.9% and 15.8%, respectively. Most of the flat elevations were smaller than 10 mm (98.6%). Recognizable endoscopic features of the flat elevations were redness (47.3%) and depression (15.8%), but 50 cases (34.2%) of the flat elevations had no specific features. Flat elevations smaller than 5 mm had discolorations in 15 cases (14%). The sigmoid colon was the most common site of the flat elevations. The percentage of flat elevations found in the sigmoid colon and the rectum was 70.5%. Hot biopsy was the main treatment for lesions smaller than 5 mm (75.7%), and snare polypectomy was the main treament for lesions from 5 mm to 9 mm. Conclu-sions: Flat elevations were detected without difficulty through careful examination. Nearly half of the flat elevations were flat adenomas. Accordingly, flat elevations may have some clinical significance on the basis of the adenoma-carcinoma sequence, but flat elevations greater than 10 mm should be managed cautiously because of possible malignancy. (Korean J Gastrointest Endosc 19: 209 ∼217, 1999)

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고립성 직장 궤양 증후군의 진단과 치료에 대한 문제점에 관한 검토 (Clinical Pitfalls in the Diagnosis and Treatment of Solitary Rectal Ulcer Syndrome ): Korean J Gastrointest Endosc 1999;19(2):221-234. Published online November 30, 1998

Abstract PDF: Background
/Aim: Solitary rectal ulcer syndrome (SRUS) is a rare disease, but it is encountered in the colorectal field. SRUS is usually associated with defecation disorders such as puborectalis dysfunction, rectal occult or overt prolapse, descending perineum syndrome, and so forth. Without knowledge about SRUS, the lesion could be easily overlooked or misdiagnosed. The histologic characteristics of SRUS are fibromuscular obliteration in the lamina propria and/or misplaced mucin-filled cysts below the muscularis mucosae, this latter condition being commonly referred to as colitis cystica profunda. However, these characteristics, even though they exist, are often missed in the initial biopsy specimens from SRUS patients, leading to misdiagnoses which cause delayed diag-nosis and treatment. In spite of the incomplete histologic indications, a careful and con-scientious clinician, using clinical features and characteristic endoscopic findings, would not misdiagnose SRUS lesions. In other words, the clinical features and endoscopic find-ings are as important as, if not more important than, the histologic findings in the diag-nosis of SURS lesions. Methods: The authors reviewed and analyzed 18 recently experi-enced, biopsy-proven cases of SRUS with emphasis on gross classification and initial pathologic misdiagnoses. Results: The most common age groups were the 5th and the 6th decades with a mean age of 46.5. The male-to-female ratio was 1.6 ：1. The most common symptoms were mucous discharge and defecation difficulty. All lesions involvedthe rectum, and the lower rectum was the most common site. Four diffuse-type lesions showed an extensive involvement up to the sigmoid colon. The most common form of SRUS was the elevated type (44.4%). The ulcerated type accounted for 27.8% of the cases and the flat type, 22.2%. Circumferential involvement of the SRUS was noticed in 3 cases. In 9 cases (50%), pathologic findings missed the characteristics of SRUS and indicated one or a combination of chronic nonspecific inflammation, a chronic ulcer, an inflam-matory polyp, an adenomatous polyp, pseudomembranous colitis, and adenocarcinoma. In three of these cases, a second biopsy was taken with the same results. Based on the clinician' s belief that SRUS was the cause of the lesions, all nine cases were reviewed by the pathologist and a final diagnosis of SRUS was reached. Associated disorders were hemorrhoids, rectoceles, rectal prolapse, perianal fistulas, descending perineum syndrome, and anal fissures. Among them, hemorrhoids and rectoceles were the most common disorders. Four SRUS cases were managed surgically with good results. The surgical treatment was an excision of the lesion itself and/or the correction of the associated disorders. Conclusions: The histologic characteristics of SRUS are the key to diagnosis, but sufficiently large biopsy specimens are necessary in order to obtain the correct diagnosis. However, the clinical features, including symptoms and associated disorders, plus the characteristic endoscopic findings can produce the correct diagnosis even in cases of insufficiently large biopsy samples or incomplete histologic reports. (Korean J Gas-trointest Endosc 19: 221 ∼234, 1999)

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악성 폐쇄성 황달환자에서 코일형 (EndocoilTM) 금속배액관과 플라스틱 배액관의 비교 (Randomised Trial of Coil (EndocoilTM) Stent Versus Plastic Stent in Malignant Biliary Tract Obstruction): Korean J Gastrointest Endosc 1999;19(2):235-241. Published online November 30, 1998

Abstract PDF: Background
/Aims: Endoscopic stent placement has become accepted palliative therapy for malignant biliary tract obstruction (MBTO). The main problem of plastic stent are the clogging or migration. The new self expandable super-elastic metallic coil stent (Endo-coilTM, Instent Inc.) is claimed to allow large lumen and prolong biliary-stent patency. In a prospective randomised trial, we compared the efficacy and frequency of stent dysfunction of EndocoilTMand plastic stent (PercuflexR, Microvasive Co.). Method: Bet-ween Aug. 1994 and Mar. 1995, we assigned 29 patients (21 males and 8 females, mean age 63 years) with unresectable MBTO due to cancer of bile duct (17), pancreas (6) periampullary (3), gallbladder (2) and perichoedochal LN (1). Thirteen of patients under-went EndocoilTMstents (24 Fr) and other 16 patients underwent plastic stents (12 Fr) insertion via transpapillary route. Successful insertion of stents was attained all cases and no serious complication occured. Results: All patients with EndocoilTM stents and 11 (68%) patients with plastic stents were relieved completely from jaundice (T. bilirubon ＜3.0 mg/dl). There was no differences in decreasement of bilirubin between two groups after 7 days and 30 days after stents insertion. Median patency of the stents was significantly prolonged in patients with EndocoilTM stents compared with those with plastic stents(205 days vs 92 days). The stent dysfunction was noted 2 cases (15%) in EndocoilTM due to tumor ingrowth. In contrast, stent dysfunction was occured in 10 cases (62%) of plastic stents due to clogging (7 cases) and migration (3 cases). The patients' overall median survival was not different significantly between two groups (EndocoilTM250 days vs plastic 196 days). Conclusions: Both ndocoilTMand plastic stents offer effective bile drainage in MBTO. However EndocoilTM stents may be more effective for providing longer periods of drainage due to lower frequency of stent dysfuction than plastic stents. (Korean J Gastrointest Endosc 19: 235 ∼241, 1999)

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다발성 베체트 식도 궤양 1 예 (A Case of Multiple Esophageal Ulcerations in Behcet's Disease): Korean J Gastrointest Endosc 1999;19(2):242-248. Published online November 30, 1998

Abstract PDF: Hyung Ju Kim , Soong Lee , Soo In Choi , Sang Hoo Park , Sang Guk Kim , An Soo Jang , Seung Won Yang, , Jeong Pyeong Seo , Hong Bae Park The diagnostic criteria of Behcet' s disease - which requires the presence of recurrent oral ulceration plus any two of recurrent genital ulceration, typical defined eye lesions, typical defined skin lesions or a positive pathergy test - was proposed by the International Study Group for Behcet' s Disease (ISGBD). Intestinal Behcet' s disease most commonly affects the ileocecal region, but esophageal involvement of Behcet' s disease is rare, only 8 cases have previously been reported in Korea. A 23-year old female who had a 10-year history of recurrent oral and genital ulcer and recurrent erythematous skin eruption, was admitted to our hospital because of dysphagia and substernal pain. Endoscopic exami-nation showed multiple small sized ulcers on oral cavity and two diffuse deep ulcers surrounded with irregularly nodular and hyperemic edematous mucosa at distal esophagus. The pathologic finding was subepithelial accumulation of chronic inflammatory cells, especially around the vessels. So she was treated with steroid under the diagnosis of esophageal involvement of Behcet' s disease. She has been followed in improvement status without recurrence. (Korean J Gastrointest Endosc 19: 242 ∼246, 1999)

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내시경적 조직검사로 진단된 위 분선충증 1 예 (A Case of Gastric Strongyloidiasis Diagnosed by Endoscopic Biopsy): Korean J Gastrointest Endosc 1999;19(2):249-253. Published online November 30, 1998

Abstract PDF: Korea Strongyloidiasis is a parasitic disease caused by Strongyloides stercoralis which exists in two forms : the free living and parasitic forms. It exists in warm, moist climate in areas where there is frequent fecal contamination of the soil. After cutaneous invasion by the filariform larvae, petechial hemorrage, pruritus, papular rashes, edema, and urticaria occur. Infection commonly occurs in the proximal intestine of the gastrointestinal (G-I) tract but may extend from the stomach to the anus. Once the worm is established in the small intestine, the physical findings may include epigastric tenderness to palpation. The mucosal biopsy is an inefficient way of making the diagnosis because the worm is found in the biopsy specimen in only 2% of patients. Gastric strongyloidiasis is rare. We experienced a case of gastric strongyloidiasis diagnosed by the endoscopic biopsy and serologic test for parasite specific IgG antibody by micro-ELISA. (Korean J Gastrointest Endosc 19: 249 ∼253, 1999)

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제 4 기 진행성 위암과 제 1 기 신세포암이 (A Case of Synchronous Stage-IV Advanced Gastric Cancer): Korean J Gastrointest Endosc 1999;19(2):254-260. Published online November 30, 1998

Abstract PDF: Multiple primary malignancy is called when two cancers occur independently in one individual. Multiple primary malignancy may be divided into two groups, synchronous or metachronous depending on the interval between their diagnosis. Synchronous cancer is diagnosed simultaneously or within an interval of 6 months and metachronous cancer at interval of more than 6 months. Since Billroth reported the first case of multiple primary malignancy, many cases have been reported partly owing to the advancement of diagnostic procedures and treatment modalities. The incidence of multiple primary malignancy tends to increase and it is fundamental that patients who have been treated for cancer receive a careful follow-up study. Here we report on a case of stage-IV advanced gastric cancer with stage-I renal cell carcinoma which was discovered during the staging procedure of gastric cancer. Both cancers were confirmed histologically and classified as gastric adeno-carcinoma and renal cell carcinoma. (Korean J Gastrointest Endosc 19: 254 ∼258, 1999)

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Helicobacter pylori 감염을 동반한 T 림프구 기원의 원발성 위 림프종 1 예(A Case of Primary Gastric T-cell Lymphoma with Helicobacter pylori Infection): Korean J Gastrointest Endosc 1999;19(2):261-266. Published online November 30, 1998

Abstract PDF: The primary T-cell lymphoma of the stomach is a extremely rare disease, only about 33 cases were described in the literature since 1986. Recent studies have proved a strong relation between Helicobacter pylori infection and several gastric diseases such as peptic ulcer, chronic gastritis, gastric cancer, and lymphoma. We report a case of primary gastric T-cell lymphoma with H. pylori infection in a 63-year-old male who had a history of epigastric fullness for 2 years. Gastroscopy showed a round ulcer of 1cm in size on anterior side of gastric angle. The gastroscopic biopsy revealed diffuse large cell malignant non-Hodgkin' s lymphoma on light microscopic examination, and T-cell immunophenotype with immunohistochemical study. The result of CLOtest was positive. No lymphadeno-pathy was found with chest roentgenogram and computed omography of abdomen and pelvis. Bone marrow examination showed normal finding. (Korean J astrointest Endosc 19: 261 ∼266, 1999)

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간세포암의 십이지장침윤에 의한 상부위장관 출혈 1 예 (A Case of Hepatocellular Carcinoma with Duodenal Invasion and Bleeding): Korean J Gastrointest Endosc 1999;19(2):267-274. Published online November 30, 1998

Abstract PDF: Recent advances in both the diagnosis and treatment of hepatocellular carcinoma have improved the prognosis and changed the clinical significance of the recently increasing distant metastases. Distant metastases found after successful treament of the primary lesions are of great clinical significance for the treatment of hepatocellular carcinoma. The duodenum is a rare site of hematogenous metastases or direct invasion from hepatocellular carcinoma. A 23 year old man was admitted with upper gastrointestinal bleeding. He had been diagnosed with hepatocellular carcinoma and treated by a left lobectomy and chemoembolization. The patient was admittted for 12 months after the treatment of the primary tumor. Endoscopic examination revealed a mass in the duodenal bulb that protruded into the lumen. He died due to massive hematemesis. We report on a rare case of hepatocellular carcinoma with duodenal invasion in a 23-year-old male patient. (Korean J Gastrointest Endosc 19: 267 ∼272, 1999)

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원발성 십이지장 유암종 (Carcinoid tumor) 1 예 (A Case of Primary Duodenal Carcinoid Tumor): Korean J Gastrointest Endosc 1999;19(2):275-280. Published online November 30, 1998

Abstract PDF: Carcinoid tumors are slow growing, rare neoplasms that arise from enterochromaffin cells, with malignant potential. Primary duodenal carcinoid tumors are rare, the reported incidence being 2.0 ∼8.9% of all gastrointestinal carcinoid tumors. Unless the carcinoid syndrome has developed, the non-specificity of the symptoms and physical findings, makes the clinical diagnosis of these tumors difficult. However, with the introduction of large and deep endoscopic biopsies, it is possible to diagnose duodenal carcinoid tumors at an early stage. Usually, local resection is the therapy of choice because of the very slow growth of the lesion and the low incidence of metastasis. Radical surgery is mandatory only in lesions more than 2 cm in diameter, or in the presence of muscular invasion. A 69-year-old female visited our medical department, having had symptoms of upper ab-dominal pain and intermittent melena for 1 week. Endoscopic examination showed 2.5 2.5 cm sized elevated mass lesion with central ulceration in the anterior wall side of the duodenal bulb. Immunohistochemical stains of the biopsy specimen showed that the tumor cells are positive reactivity for NSE (neuron-specific-enolase), chromogranin A, and cyto-keratin. (Korean J Gastrointest Endosc 19: 275 ∼280, 1999)

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TIPS (Transjugular Intrahepatic Portosystemic Shunt)로 치료된 십이지장 정맥류 출혈 (Duodenal Variceal Bleeding Treated with a Transjugular Intrahepatic Portosystemic Shunt): Korean J Gastrointest Endosc 1999;19(2):281-286. Published online November 30, 1998

Abstract PDF: Most cases of upper gastrointestinal bleeding in patients with portal hypertension are caused by esophagogastric varices. Less often, bleeding originates in varices located elsewhere. If ectopic varices are found, the same hemostatic technique tend to be used. However, there is no evidence that such techniques are useful in these cases. Duodenal varices are quite common, although they rarely bleed due to their location deep in the duodenal wall. Consequently, if emergency endoscopy is not conducted, hemorrhage may be wrongfully attributed to coexisting esophagogastric varices in a patient with portal hypertension without active bleeding. Hemorrhage from duodenal varices may be severe and life threatening. We report a patient with portal hypertension and bleeding duodenal varices caused by cirrhosis of the liver. Hemorrhage was subsequently controlled by placement of a transjugular intrahepatic portosystemic shunt. We recommend that in patients with life-threatening hemorrhage from duodenal varices caused by cirrhosis of the liver, transjugular intrahepatic portosystemic shunt (TIPS) be considered in the man-agement. (Korean J Gastrointest Endosc 19: 281 ∼286, 1999)

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내시경으로 진단된 역행성 공장위 중첩증 1 예 (A Case of Retrograde Jejunogastric Intussusception Diagnosed by Endoscopy): Korean J Gastrointest Endosc 1999;19(2):287-294. Published online November 30, 1998

Abstract PDF: Retrograde jejunogastric intussusception defined as a segmental invagination of jejunal loop into stomach through stoma is a rare complication following partial gastric resection. Endoscopy and UGI series is very helpful in the diagnosis of this disease. Although the management of this disease is usually surgical, an endoscopic reduction can alternatively be attempted. If endoscopic reduction was failed, operation should be immediately per-formed in the acute type because of its high mortality. When anatomical reduction is done on due time, the prognosis is fairly good. We report a case of retrograde jejunogastric intussusception with a brief review of the literature. There was a 56 year old male patient who visited the hospital with chief complaints of severe epigastric pain and vomiting. He had subtotal gastrectomy for gastric carcinoma 6 years ago. On emergency endoscopy the type IIa jejunogastric intussusception was found. As the patient was suspected to be incar-cerated, surgical reduction was performed without delay. He was discharged on the 8th admission day. (Korean J Gastrointest Endosc 19: 287 ∼291, 1999)

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수술중 내시경으로 진단된 장출혈을 동반한 공장 결핵 1 예 (A Case of Bleeding Jejunal Tuberculosis Diagnosed with Intraoperative Endoscopy): Korean J Gastrointest Endosc 1999;19(2):295-299. Published online November 30, 1998

Abstract PDF: Tuberculosis is a multi-organ disease. The incidence of pulmonary tuberculosis is declining due to improvement in public health, vaccination and the development of anti-tuberculosis medication, but extrapulmonary tuberculosis has become more common, especially in immuno-compromised individuals, AIDS patients and immigrants to western worlds. Gastrointestinal tuberculosis continues to give rise to diagnostic and therapeutic challenges. The jejunal tuberculosis is uncommon and presents a difficult diagnostic problem. Bleeding jejunal tuberculosis is a very rare source of lower gastrointestinal bleeding. We have recently experienced a case of a jejunal tuberculosis which was proven to be a source of gastrointestinal bleeding by intraoperative endoscopy and was confirmed by surgical exploration. This report summarized our experience and review of literature. (Korean J Gastrointest Endosc 19: 295 ∼299, 1999)

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궤양성 대장염에 동반된 괴저성 농피증 1 예 (Pyoderma Gangrenosum in Ulcerative Colitis): Korean J Gastrointest Endosc 1999;19(2):300-305. Published online November 30, 1998

Abstract PDF: Ulcerative colitis is an inflammatory disorder that affects the rectum and extends proximally to affect a variable extent of the colon. The major symptoms of ulcerative colitis include diarrhea, rectal bleeding, the passage of mucus, and abdominal pain. Ulcer-ative colitis also may be complicated by many local and systemic disorders as extrain-testinal manifestations. Pyoderma gangrenosum is the most severe dermatologic com-plication associated with ulcerative colitis. It is a painful , chronic, ulcerating skin disease of unknown cause. Diagnosis is clinical, there being no accepted histological diagnostic criteria. Conventional therapy is empirical, usually with high dose corticosteroids, but var-ious other agents have been tried with occasional success including topical antibiotics, cyclosporine, disodium cromoglycate, and dapsone. This patient was treated with high dose corticosteroid (prednisolone 1 mg/kg/day) and discharged with clinical improvement. So we report this case with a literature review. (Korean J Gastrointest Endosc 19: 300 ∼305, 1999)

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다량의 수양성 설사후 발생한 아급성 (Subacute Ischemic Colitis Developed after Severe Watery Diarrhea): Korean J Gastrointest Endosc 1999;19(2):306-312. Published online November 30, 1998

Abstract PDF: Ischemic colitis represents most common form of gastrointestinal ischemia, usually developed in elderly or debilitated patient with a variety of underlying medical problems. The presumed etiologies are numerous. It usually presents as an acute abdominal illness with bloody diarrhea. Subacute ischemic colitis in healthy adults develops spontaneously in the absence of major vasculature occlusion, and the original insult precipitating the ischemic event usually cannot be established. Diagnosis is based on the clinical symptom, barium study, colonoscopic and histopathologic findings. Therapy and outcome are depen-dent on the severity of disease. It usually requires only medical management and is asso-ciated a good prognosis. We report a case of subacute ischemic colitis in healthy adults developed after severe watery diarrhea with literatures. (Korean J Gastrointest Endosc 19: 306 ∼310, 1999)

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유두부 주위 게실 환자에서의 파악겸자를 이용한 췌담도의 선택적 삽관술 (Application of Grasp Forceps on Selective Cannulation of Pancreatobiliary Duct in a Patient with Peripapillary Diverticulum ): Korean J Gastrointest Endosc 1999;19(2):313-317. Published online November 30, 1998

Abstract PDF: During endoscopic retrograde cholangiopancreatography (ERCP), cannulation is more difficult in patients with anatomical variations, ampullary stenosis, impacted stone in the papilla, papillary cancer, peripapillary diverticulum, postoperative states such as those after Billroth II or Braun operations. In patients with peripapillary diverticulum, the position of the papilla can be modified by the presence of the diverticulum, rendering the cannu-lation more difficult. In this situation, the success rate of ERCP is lower than that in nor-mal situation. We have, therefore, used a new technique with the application of grasp forceps to expose the duodenal papilla properly during ERCP in a patient whose papilla was located on the edge of a large duodenal diverticulum and the papillary orifice was hidden behind the edge of the diverticulum. (Korean J Gastrointest Endosc 19: 313 ∼317, 1999)

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췌장 가성낭종 내에 완전 삽입된 Pigtail 스텐트의 올가미를 이용한 교정 (Correction of Incidentally Migrated Pigtail Stent in Pancreatic Pseudocyst using Polypectomy Snare): Korean J Gastrointest Endosc 1999;19(2):318-321. Published online November 30, 1998

Abstract PDF: Endoscopic drainage of pancreatic pseudocysts is a new nonsurgical treatment modality. Among the cystogastrostomy and stent related complications, proximal migration of stent is rare and the correction of inserted stent into a pseudocyst is very difficult. We report a correction of an incidentally inserted pigtail stent into pseudocyst using a polypectomy snare. (Korean J Gastrointest Endosc 19: 318 ∼321, 1999)

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용종성종괴모양을 보인 십이지장 팽대부의 (Polypoid Stenosing Papillitis of the Ampulla of Vater): Korean J Gastrointest Endosc 1999;19(2):322-334. Published online November 30, 1998

Abstract PDF: "Stenosing papillitis" is a descriptive term for an anatomic deformity of the Ampulla of Vater due to chronic inflammation and fibrosis, which is characterized by narrowing of the lower end of the bile and pancreatic duct, and by clinical symptoms resembling pancreticobiliary disease. Duodenoscopic finding of "stenosing papillitis" usually shows edema, erythema, and laceration on Ampulla of Vater, but endoscopic finding such as polypoid mass is rare. We recently experienced one case of polypoid stenosing papillitis and report with a review of relevant literatures A 54-year-old man was admitted to our hospital because of chronic right upper abdominal pain for 2 years. Duodenoscopy re-vealed a polypoid mass with erythemaous color change on Ampulla of Vater, which was endoscopically resected by using a polypectomy snare, and pathologic examination showed chronic inflammation and fibrosis. (Korean J Gastrointest Endosc 19: 322 ∼327, 1999)

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