Clinical Endoscopy

Clinical Significance of Endoscopic Ultrasonography in Gastritis Cystica Polyposa: Il-Kwun Chung, M.D., Eun-Joo Kim, M.D., Dae-Joong Kim, M.D.*,Moon-Soo Lee, M.D.^†, Sang-Heum Park, M.D., Hong-Soo Kim, M.D.,Moon-Ho Lee, M.D. and Sun-Joo Kim, M.D.; Korean J Gastrointest Endosc 2001;22(4):195-201. Published online April 30, 2001

Abstract PDF: Background
/Aims: Gastritis cystica polyposa (GCP) is one of multiple cystic lesions in the stomach. Endoscopic ultrasonography (EUS) is the best diagnostic tool to evaluate small gastric cystic lesions at a preoperative state. The aim of this study is to evaluate the endoscopic and typical EUS findings of GCP. Methods: From January 1995 to November 1999, nine cases of GCP were confirmed by endoscopic resection or operation. We analyzed clinical features, endoscopic findings, and EUS findings and compared them with histologic diagnosis. Results: Endoscopic findings of GCP were varied: 3 gastric polyps, 2 submucosal tumors (SMT), 2 flat elevated lesions, 1 hypertrophic gastritis, and 1 small polyp coexisting with gastric cancer. EUS findings were characterized by a mean size of 14.1 mm (9∼26 mm), multiple variable-sized anechoic lesions with intervening hyperechoic structures (8 cases), irregular margins (7), mucosa and submucosal thickening (6), and submucosal invasion by anechoic lesions (5 GCP profunda). In histologic findings, 6 GCP were associated with underlying gastritis only, 2 GCP with gastric tubular adenomas, and 1 GCP with EGC. Conclusions: Endoscopic findings vary enough that endoscopists cannot initially confirm any impressions of GCP. EUS is an effective diagnostic tool to evaluate and differentiate GCP from protruding and elevated gastric lesions, and plays an important role to decide treatment methods for GCP and/or it's associated gastric tumorous lesions.

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Usefulness of Giemsa Staining and Campylobacter-Like Organism (CLO) Test Following Helicobacter pylori Eradication Therapy: Hyo Jung Kim, M.D., Sung Tae Kim, M.D., Sang Woo Lee, M.D., Yoon Tae Jeen, M.D.,Hoon Jai Chun, M.D., Hong Sik Lee, M.D., Chi Wook Song, M.D.,Soon Ho Um, M.D., Jai Hyun Choi, M.D., Chang Duck Kim, M.D.,Ho Sang Ryu, M.D. and Jin Hai Hyun, M.D.; Korean J Gastrointest Endosc 2001;22(4):202-207. Published online April 30, 2001

Abstract PDF: Background
/Aims: Follow-up studies with low sensitivity and specificity make it difficult to predict precisely long-term effect of H. pylori eradication therapy. The aim of this prospective study was to evaluate the usefulness of Giemsa staining and CLO test following eradication therapy. Methods: In this study, H. pylori eradication therapy was done in 99 consecutive peptic ulcer patients and followed at 1, 6, and 12 months. Follow-up diagnosis was performed by Giemsa staining and CLO test using 6 specimens taken from the gastric antrum and midbody. Eradication was considered if the results of the two tests were negative. Results: Overall the results of 63 (64%) patients among 99 patients who followed more than 6 months did not changed including 9 persistent positive, and 54 negative. However, the result of 36 patients changed to 21 positive and 15 negative conversion after 6 months. The estimated sensitivity, specificity, positive predictive value, negative predictive value of the Giemsa staining and CLO test, using PCR and culture as 'gold standard', were 67%, 85%, 82%, 70%, respectively. Conclusions: Sensitivity and specificity of Giemsa staining and CLO test following eradication therapy are lower than other reports. It is suggested that the large, multicenter prospective study is necessary to prove diagnostic accuracy of those follow-up studies. (Korean J Gastrointest Endosc 2001; 22:202⁣207)

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Primary Gastric Small Cell Carcinoma-Pure Type 1 Case: Won Seok Park, M.D., Dong Soo Lee, M.D., Kang Moon Lee, M.D.,Byung Min Ahn, M.D., Yong Ho Choi, M.D., Young Jung Lee, M.D.,Yong Hyun Park, M.D., Eun Hee Lee, M.D.*, Ho Jin Song, M.D.and Doo Ho Park, M.D.; Korean J Gastrointest Endosc 2001;22(4):208-211. Published online April 30, 2001

Abstract PDF: Primary gastric small cell carcinoma is very rare, so that its incidence is about 0.1% of all gastric cancer and it was first reported in 1976. The morphologic and biologic features of primary gastric small cell carcinoma are similar to those of small cell carcinoma of the lung. Gastric small cell carcinomas are pathologically classified as a pure type and a composite type combined with adenocarcinoma and/or squamous cell carcinoma. Because the behavior of this cancer is very aggressive and exclusive, it invade lymphatic and/or vascular lumen, and dose distant metastasis easily. We report the case of a 55-yr-old man who developed pure type primary gastric small cell carcinoma. The patient underwent Billroth-II subtotal gastrectomy and recieved a multiagent chemotherapy. He remains free from tumor recurrence 12 months after surgery. (Korean J Gastrointest Endosc 2001;22:208⁣211)

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Endoscopically Treated Gastritis Cystica Polyposa Found in an Unoperated Stomach: Tae Hoon Oh, M.D., Seung-Jae Myung, M.D., Hwoon-Yong Jung, M.D., Ju Sang Park, M.D.,Suk-Kyun Yang, M.D., Weon-Seon Hong, M.D., Jin Ho Kim, M.D., Gyeong Hoon Kang, M.D.*,Hyun Kwon Ha, M.D.^† and Young Il Min, M.D.; Korean J Gastrointest Endosc 2001;22(4):212-215. Published online April 30, 2001

Abstract PDF: Gastritis cystica polyposa (GCP) which is characterized by polypoid hyperplasia of the gastric mucosa, is known as an uncommon lesion that usually occurs at the gastroenterostomy site, although rarely it can be found in an unoperated stomach. Recently, GCP has been proposed to be a possible precancerous lesion itself. We present a rare case of GCP which presented as a large soft polypoid mass with a stalk in a previously unoperated stomach. A 44-year-old woman was admitted due to further study of large gastric mass. Previously, she had not undergone gastric surgery. Physical examination disclosed nothing abnormal. and laboratory test showed iron deficiency anemia. Endoscopy showed a large soft polypoid mass in gastric fundus and endoscopic ultrasonography showed a homogenous hypoechoic, and multilocular cystic mass with a stalk. We removed it via endoscopic polypectomy and histologic examination of this polypoid specimen showed the features consistent with the diagnosis of GCP. (Korean J Gastrointest Endosc 2001;22:212⁣215)

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A Case of Ampullary Adenoma Resected by Endoscopic Mucosal Resection: Hyun Ju Park, M.D., Myung-Hwan Kim, M.D., Yeon Ho Ju, M.D., Dong Wan Seo, M.D.,Sung Koo Lee, M.D., Ki Rhack Kim, M.D. and Young Il Min, M.D.; Korean J Gastrointest Endosc 2001;22(4):216-219. Published online April 30, 2001

Abstract PDF: Villous adenomas of the ampulla of Vater are rare premalignant tumors that have been reported to occur in 0.04% to 0.12% of postmortem series. Traditionally surgical treatment has been used but it might result in significant morbidity and mortality. This case is a villous adenoma of ampulla of Vater found incidentally, but successfully removed by endoscopic method. After endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasonography (EUS), we resected the tumor of ampulla of Vater endoscopically using endoscopic mucosal resection (EMR) method. The post-procedure course was uneventful. Here we report an ampullary adenoma resected by endoscopic method in a 42-year-old man with villous adenoma of the ampulla of Vater. (Korean J Gastrointest Endosc 2001;22:216⁣219)

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A Case of Peutz-Jeghers Syndrome with Multiple Intussusception and Rectal Adenocarcinoma: Young-Hae Sohn, M.D., Young-Eun Joo, M.D., Kyoung-Won Yoon, M.D.,Sung-Bum Cho, M.D., Hyeong-Rok Kim, M.D.*, Young-Jin Kim, M.D.*,Hyun Soo Kim, M.D. and Sei Jong Kim, M.D.; Korean J Gastrointest Endosc 2001;22(4):220-224. Published online April 30, 2001

Abstract PDF: Peutz-Jeghers syndrome (PJS) is a rare disease of autosomal dominant inheritance, which is characterized by hamartomatous gastrointestinal polyps and mucocutaneous melanin pigmentation. PJS often presents as surgical emergen cies with complications of the polyps, such as intussusception, small bowel obstruction, bleeding and volvulus. Intussusception caused by PJS polyps is often observed in the small bowel, but intussusception which involving small and large bowel concommittantly is not so much. The association between PJS and an increased risk for cancer has been controversial. Recent studies have shown PJS have a increased risk for both gastrointestinal and extraintestinal cancer. We report a case of PJS with rectal adenocarcinoma and multiple intussusceptions involving small and large bowel concommittantly. (Korean J Gastrointest Endosc 2001;22:220⁣224)

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A Case of Ascites by Pseudomembranous Colitis, Initially Diagnosed Malignant Asites: Chang Uck Kim, M.D., Jin Won Cho, M.D., Jin Young Song, M.D.,Do Kyun Jin, M.D., Su Jin Hong, M.D., Sea Hyub Kae, M.D.,Jin Lee, M.D. and Sang Aun Joo, M.D.; Korean J Gastrointest Endosc 2001;22(4):225-228. Published online April 30, 2001

Abstract PDF: Pseudomembranous colitis (PMC) is mostly related with the antibiotics and it presents with diarrhea, abdominal pain, fever, hypoalbuminemia and hypovolemia. In the clinical course of pseudomembranous colitis (PMC), ascites is a rare presentation, and high elevation of carcinoembryonic antigen (CEA) associated with PMC is also a very rare presentation. We experienced a case taken cephalosporin group antibiotics for six weeks and presented with fever, abdominal pain, severe diarrhea, and massive ascites. During evaluation, we found low serum-ascites albumin gradient and high level of CEA in both ascites and plasma. With the impression of hidden malignancy, the special studies were done, but PMC was only found without malignancy. After vancomycin therapy, all symptoms were relieved and CEA level declined. (Korean J Gastrointest Endosc 2001;22:225⁣228)

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A Case of Rectal Bleeding Treated by Endoscopic Band Ligation: Jeong Won Jang, M.D., Hiun Suk Chae, M.D., Je Hyun Shin, M.D., Kang Moon Lee, M.D.,Seong Soo Kim, M.D., Chun Sang Bang, M.D., Jin Il Kim, M.D., Suk Won Han, M.D.,Ki Bum Kim, M.D., Young Ok Kim, M.D., Seon Ahe Yun, M.D., Chang Don Lee, M.D.,Kyu Yong Choi,; Korean J Gastrointest Endosc 2001;22(4):229-232. Published online April 30, 2001

Abstract PDF: Endoscopic band ligation has been a standard therapy in esophageal varix bleeding since it was first introduced in 1980s. However, technical problems have interrupted as a therapeutic management of lower gastrointestinal bleeding. We report a case of successful management of rectal bleeding with endoscopic band ligation in patient with chronic renal failure, who had been managed by hemodialysis since eight months before. Successful control of rectal bleeding was achieved by endoscopic band ligation. Three days later, round and shallow ulcer developed at the ligated site, which was improved at follow-up sigmoidoscopy and bleeding was not observed any more. He was discharged without complications. Herein, we report the band ligation as a useful method in treatment of rectal bleeding. (Korean J Gastrointest Endosc 2001;22:229⁣232)

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Three Case of Acute Pancreatitis Complicating Endoscopic Insertion of the Biliary Stent: Sung Gwon Kim, M.D., Jong Jae Park, M.D., Moon Gi Chung, M.D., Oh Sang Kwon, M.D.,Dong Kyun Park, M.D., Yang Suh Koo, M.D., Sun Suk Kim, M.D., You Kyung Kim, M.D.,Dong Hoon Kang, M.D., Duck Joo Choi, M.D., Hyun Chul Park, M.D. and Ju Hyun Kim, M.D.; Korean J Gastrointest Endosc 2001;22(4):233-238. Published online April 30, 2001

Abstract PDF: Acute pancreatitis is one of the major complications of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST). Various etiology such as mechanical, chemical, hydrostatic, and thermal factor are thought to be involved for this procedure-related pancreatitis. However, acute pancreatitis can occur as a direct complication of endoscopic biliary drainage (EBD). Although the exact mechanism remains unclear, it is postulated that the stent compresses pancreatic ductal orifice and resultant pancreatic outflow obstruction actually provokes pancreatitis. Using the larger stent diameter over 10 Fr and a straight stent rather than curved one, proximal rather than distal bile duct obstruction are risk factors for stent-induced pancreatitis. We report on three cases of acute pancreatitis complicating the EBD with a plastic stent, nasobiliary catheter, and covered-metallic stent respectively. (Korean J Gastrointest Endosc 2001;22:233⁣238)

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Two Cases of Extended Endoscopic Sphincterotomy in Patients with Periampullary Diverticulum ―How do we estimate the upper margin of intramural ampulla in patients with periampullary diverticulum?―: Sang Heum Park, M.D., In Ho Kim, M.D., Eun Joo Kim, M.D.,Il Kwun Chung, M.D., Hong Soo Kim, M.D., Moon Ho Lee, M.D. and Sun Joo Kim, M.D.; Korean J Gastrointest Endosc 2001;22(4):239-244. Published online April 30, 2001

Abstract PDF: Periampullary diverticulum (PAD), which was frequently noticed during endocopic retrograde cholangiopancreatography (ERCP) for examination on patients with pancreaticobiliary diseases, made difficult to cannulate the duct and to perform the endoscopic sphincterotomy (EST). EST was very useful therapeutic modality for pancreaticobiliary disease, but endoscopists are always careful about EST-related complication, especially in patients with PAD. The general principle of EST was not to incise extendedly above the papillary roof, but the following endoscopic findings help to try the extended EST safely above the papillary roof. On the endoscopic examination there was reducible protrusion above papilla by contrast injection or air deflation, which had bile-colored transparency and arborescent capillary network in the usual direction of the bile duct. We have recently experienced 2 cases of extended EST in patients with PAD, who showed the endoscopic findings mentioned above and recovered without bleeding or perforation. (Korean J Gastrointest Endosc 2001;22:239⁣244)

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Primary Malignant Lymphoma of the Ampulla of Vater: Yun Jung Lee, M.D., Jae Hyong Park, M.D., Sung Hoon Moon, M.D., Hea Suk Jang, M.D.,Sung Mok Chai, M.D., Ki Rhack Kim, M.D., Dong Wan Seo, M.D., Sung Koo Lee, M.D.,Myung Hwan Kim, M.D. and Young Il Min, M.D.; Korean J Gastrointest Endosc 2001;22(4):245-249. Published online April 30, 2001

Abstract PDF: The vast majority of ampullary tumors are epithelial in nature and are either adenoma or adenocarcinoma. Rarely lymphoma or mucinous and squamous elements may be found. Primary lymphoma of pancreaticobiliary region are exceedingly rare, and mostly nodal. Recently, we have experienced a 29-year-old woman with primary malignant lymphoma of the ampulla of Vater with recurrent acute pancreatitis and jaundice. On duodenoscopy, bulging ampulla with normal overlying duodenal mucosa was observed. Endoscopic sphincterotomy was done and tumor inside the ampulla was exposed. ERCP showed high grade biliary and pancreatic ductal strictures extending from the papillary orifice, with upstream ductal dilatation, respectively. With endoscopic biopsy alone, the tumor was confirmed as B-cell lymphoma histologically. (Korean J Gastrointest Endosc 2001;22:245⁣249)

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A Case of Primary Sclerosing Cholangitis Localized at Intrahepatic Bile Duct: Woon Hyun Jun, M.D., Ho Soon Choi, M.D., Seok Woo Kang, M.D., Yun Ju Cho, M.D.,Oh Young Lee, M.D., Dong Soo Han, M.D., Yong Chul Jun, M.D., Bung Chul Yoon, M.D.,Joon Soo Hahm, M.D., Min Ho Lee, M.D., Chun Suhk Khee, M.D. and Kyung Nam Park, M.D.; Korean J Gastrointest Endosc 2001;22(4):250-254. Published online April 30, 2001

Abstract PDF: Primary sclerosing cholangitis is a cholestatic liver disease characterized by fibroobliterative inflammation of the entire biliary tree. It is a slowly progressive disease with an undulating course, resulting in biliary cirrhosis. The gold standard for establishing the diagnosis is cholangiographic demonstration of typical diffuse biliary stricturing and beading. We exprienced a case of primary sclerosing cholangitis by Endoscopic retrograde cholangiopancreatography (ERCP) demonstration. ERCP findings revealed multiple luminal narrowing, stricture and beaded dilatation of the intrahepatic duct. We report a case of primary sclerosing cholangitis localizing at intrahepatic bile duct, which is confused with cholangiocarcinoma. (Korean J Gastrointest Endosc 2001; 22:250⁣254)

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