Clinical Endoscopy

Is Routine Second-Look Endoscopy Necessary for All Bleeding Peptic Ulcers?: Eun Ju Lee, M.D., Sang Won Lee, M.D., Tae Dong Kim, M.D., Kook Hyun Kim, M.D.,; Korean J Gastrointest Endosc 2003;26(1):1-7. Published online January 30, 2003

Abstract PDF: Background
/Aims: Second-look endoscopy is generally performed to prevent rebleeding in patients with bleeding peptic ulcers. However, considering recent technologic advances of endoscopic hemostasis and decreasing rate of rebleeding, a small benefit with second-look endoscopy is suggested. Prospective study was carried out to evaluate the efficacy of second-look endoscopic examinations. Methods and Results: One hundred thirty six patients with bleeding from peptic ulcer were included. Emergency endoscopic treatments consisting of the injection of hypertonic saline- epinephrine (HSE), band ligation and/or clipping were performed in patients with Forrest class I-IIb. They were scheduled to receive second-look endoscopy in 48 hours after initial endoscopy. Nine patients (6.6%) received endoscopic retreatment during second-look endoscopy and emergency endoscopic retreatment was required before scheduled endoscopy in six patients (4.4%) because of the evidence of rebleeding. Factors influencing retreatment were Forrest classification of initial endoscopy and methods of hemostasis. None of the patients with Forrest class IIb-III and the patients receiving endoscopic band ligation or clipping on initial endoscopy required retreatment during follow-up endoscopy. Conclusion: Routine second-look endoscopy may not be recommended after initial successful endoscopic treatment of peptic ulcer bleeding, especially in case of Forrest class IIb, IIc or III and in the patients treated with band ligation or clipping. (Korean J Gastrointest Endosc 2003;26:1⁣7)

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Helicobacter pylori Infection and Pathologic Findings in Bile Reflux Gastritis: Jong Pil Im, M.D., Jong In Yang, M.D., Kee Don Choi, M.D., Byeong Gwan Kim, M.D.*,; Korean J Gastrointest Endosc 2003;26(1):8-14. Published online January 30, 2003

Abstract PDF: Backgroud/Aims: The role of Helicobacter pylori in bile reflux gastritis (BRG) is uncertain. We show the role of H. pylori and pathology in BRG. Methods: Thirty seven patients, including 5 patients who had undergone subtotal gastrectomy, were diagnosed with BRG by gastroscopic findings of bile-stained mucosa with hyperemia/ erosions. We measured total bile acid (TBA) concentration and compared the H. pylori positivity between BRG patients and 70 non-BRG patients. We showed how often we could see the pathologic findings of reactive gastritis in BRG and compared the grade of lymphoplasma cell and neutrophil infiltration between H. pylori positive and negative group in BRG. Results: TBA concentration of 10 patients was 7,376.7⁑5,482.6μmol/L. H. pylori positive rate of BRG was 45.9% and that of non-BRG was 70% (p=0.015). The gastric pit elongation and tortuosity were found only in 3 cases with gastric surgery. The grade of lymphoplasma cell and neutrophil infiltration was 2.41⁑0.51 and 1.88⁑0.86 in H. pylori positive BRG and 1.55⁑0.69 and 0.55⁑0.76 in H. pylori negative BRG, respectively (p＜0.001). Conclusions: H. pylori infection in BRG was lower than that in non-BRG. The gastric pit elongation and tortuosity of BRG were not seen often. The lymphoplasma cell and neutrophil infiltration were relatively sparse in H. pylori negative BRG. (Korean J Gastrointest Endosc 2003;26:8⁣14)

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Endoscopic Biliary Drainage Using Soehendra Stent: Joo Ho Lee, M.D., Cheul Woong Choi, M.D., Sang Yong Lee, M.D., Jin Ouk Kang, M.D.,; Korean J Gastrointest Endosc 2003;26(1):15-20. Published online January 30, 2003

Abstract PDF: Background
/Aims: Endoscopic biliary drainage (EBD) has been used effectively as the palliative treatment for malignant biliary obstruction. In high grade strictures, endoscopic stenting can be achieved by dilating devices such as dilating or balloon catheters. Subgroup of malignant biliary obstructions are too stenotic to allow passage of plastic or metal stents. In cases of failure of conventional stenting, we evaluated the efficacy and safety of the 7-Fr Soehendra stent retriever (SSR) used as a dilator. Methods: From January 1999 to September 2001, 14 patients with malignant pancreaticobiliary stirictures (2 pancreatic, 12 biliary) that could not be traversed with plastic or metal stents, underwent stricture dilation with SSR. An endoscopic sphincterotomy was performed and a guide wire was inserted beyond the stricture. Then the SSR was introduced over the guide wire via duodenoscope. Then the stricture was traversed by torquing the SSR clockwise while pushing it. The SSR was removed and then the plastic or metal stents were inserted above the stricture. Results: Of the 14 patients, 13 patients (93%) underwent successful stenting using SSR. Symptom relief was observed in all patients after endoscopic biliary stenting. One patient (7%) went on to percutaneous biliary drainage because we failed to insert the metal stent into the stenotic left hepatic duct after traversing the stricture with SSR. There were no significant complications such as bile duct or duodenal perforation and bleeding. Conclusions: The Soehendra stent retriever is useful and safe for dilation with subsequent stent placement of malignant pancreaticobiliary stirictures resistant to conventional stenting. However, this device may be difficult to pass a tortuous or small-diameter hilar stricture. (Korean J Gastrointest Endosc 2003;26:15⁣20)

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A Case of Congenital Esophageal Stenosis Due to Tracheobronchial Remnants in Adult: Won Seok Jeong, M.D., Yoon Tae Jeen, M.D., Hoon Jai Chun, M.D., Du Rang Kim, M.D.,; Korean J Gastrointest Endosc 2003;26(1):21-25. Published online January 30, 2003

Abstract PDF: Congenital stenosis of the esophagus is a rare form of esophageal stenosis in adults. The main causes of congenital esophageal stenosis are the esophageal web, esophageal stricture due to tracheobronchial remnants, and idiopathic esophageal muscular hypertrophy. Recently we have experienced a 32-year-old male with dysphagia, indigestion, postprandial chest discomfort who was diagnosed as congenital esophageal stenosis due to tracheobronchial remnant. The esophagogram showed stricture of the distal esophagus with secondary proximal dilatation and endoscopic finding revealed marked stenosis on the distal esophagus with normal surrounding mucosa. The esophageal manometric finding showed decreased body peristalsis and incomplete relaxation of the lower esophageal sphincter. The patient was treated by surgical resection of the stenotic segment with end to end anastomosis. We report this rare case of adult type tracheobronchial remnant with analysis of various worldwide report and with brief review of literature. (Korean J Gastrointest Endosc 2003;26:21⁣25)

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A Case of CMV Infection Associated with: Ki Young Choi, M.D.*, Kwang Bum Cho, M.D., Jun Young Hwang, M.D., Woo Jin Jung, M.D.,; Korean J Gastrointest Endosc 2003;26(1):26-30. Published online January 30, 2003

Abstract PDF: Gastrointestinal cytomegalovirus (CMV) disease causes substantial morbidity and mortality in immunocompromised patients, especially in transplant recipients and those who infected with HIV. Although acute infection is generally asymptomatic or produces only non-specific symptoms in the immunocompetent host, acute CMV infection accompanies gastrointestinal ulceration in a small number of patients. The colon is the most common site of the infection, although it may occur in other gastrointestinal tract. CMV infection associated with simultaneous esophageal and colonic ulcers has not been reported in Korea. We report a patient with subarchnoid hemorrhage who had suffered from simultaneous esophageal and colonic ulcers associated with CMV infection which showed characteristic histologic findings of CMV infection. (Korean J Gastrointest Endosc 2003;26:26⁣30)

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Ingestion of a Mouthpiece Fragment during Intravenous: Seung Ryong Lee, M.D., Byoung Sik Mun, M.D., Heok Soo Ahn, M.D. and Seung Ok Lee, M.D.; Korean J Gastrointest Endosc 2003;26(1):31-34. Published online January 30, 2003

Abstract PDF: The demand for intravenous sedated upper gastrointestianl endoscopy is currently increasing steeply. Despite this trend, patient status complication due to this procedure is largerly neglected by most physicians. Recently, in three patients, mouthpiece fragment were left within the patients' body after intravenous sedated upper gastrointestinal endoscopy. They were transferred to our institution for the removal of the fragment. The patients complained of an uneasy sensation from within their body, around their necks and chests. After conducting therapeutic endoscopy, the fragment could be located around the distal part of their esophagus and within their stomach. The fragment were removed successfully by using snare in two patients, and by using forceps in another patient. (Korean J Gastrointest Endosc 2003; 26:31⁣34)

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Henoch-Schönlein Purpura in a Disseminated Tuberculosis Patient: Dae Hyung Jun, M.D., Byung Wook Kim, M.D., Bo In Lee, M.D., Yong Bum Park, M.D.,; Korean J Gastrointest Endosc 2003;26(1):35-38. Published online January 30, 2003

Abstract PDF: Henoch-Schönlein purpura is a systemic leukoclastic vasculitis and involves small vessels resulting in vasculitis. Major pathogenetic mechanism of Henoch-Schönlein purpura has not been still elucidated. Possible causes, however, may be associated with viral infection, bacterial infection, exposure to drugs and toxins, systemic diseases and carcinomas. Henoch-Schönlein purpura rarely develops in patients with tuberculosis, though there have been some reports on the development of this syndrome during antituberculous therapy. A 24-year-old man was admitted to our hospital because of diffuse abdominal pain, lower leg purpura and disseminated tuberculosis involving lung, duodenum, colon and lumbar spine and diagnosed as Henoch-Schönlein purpura with disseminated tuberculosis. Henoch-Schönlein purpura developed before antibuberculous therapy and antituberculous treatment was effective both in disseminated tuberculosis and Henoch-Schönlein purpura. We concluded that disseminated
tuberculosis might be a cause of Henoch-Schönlein purpura. (Korean J Gastrointest Endosc 2003;26:35⁣38)

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A Case of Acute Lower Gastrointestinal Bleeding from the Appendix: Won Seok Jeong, M.D., Yong Dae Kwon, M.D., Du Rang Kim, M.D., Kyoo Nam Hwang, M.D.,; Korean J Gastrointest Endosc 2003;26(1):39-42. Published online January 30, 2003

Abstract PDF: In spite of the recent advances in diagnostic technology in clinical gastroenterology, identifying the cause of acute lower gastrointestinal bleeding is still a challenging task. Hematochezia from the appendiceal bleeding is rare and associated diseases are appendiceal endometriosis, angiodysplasia, arteriovenous malformation, Crohn's disease, appendicitis, carcinoid, lymphoma, diverticulosis, and intussusception of the appendix. We experienced a 31-year-old male with acute lower gastrointestinal bleeding from the appendix. Colonoscopy could demonstrate an active hemorrhage from the orifice of the appendix. Mesenteric arteriography revealed active bleeding from the appendix, which was managed with gelfoam embolization. Next day, appendectomy was done because of recurrent bleeding. Surgically removed appendix could not dislose any abnormal lesion except a small mucosal break. (Korean J Gastrointest Endosc 2003; 26:39⁣42)

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Cystic Lymphangioma of the Colon: Diagnosed by Endoscopic Ultrasonography: Jong-Hyup Lee, M.D., Min-Kyu Chung, M.D., Eun Soo Kim, M.D., Tae-Suk Kim, M.D., Seung-Yup Lee, M.D.,; Korean J Gastrointest Endosc 2003;26(1):43-47. Published online January 30, 2003

Abstract PDF: Lymphangioma occasionally occurs in gastrointestinal tract, small intestine and mesentery. Cystic lymphangioma is a rare cause of colonic submucosal mass. Endoscopic ultrasonography is very valuable in differential diagnosis of colonic submucosal masses. A 61-year old woman visited our hospital due to lower abdominal pain for two months. In the colonoscopic examination, cystic mass which had smooth mucosal surface was noted at the ascending colon. Endoscopic ultrasonography showed anechoic, multicystic mass confined to the submucosa. The underlying muscularis propria was intact. Endoscopic resection, using a ligating device, was performed for histopathologic diagnosis and treatment. On the histopathologic examination, the cystically dilated spaces lined by endothelium and separated by fibrous septa were present in the submucosa. The histological diagnosis was cystic lymphangioma of the colon. (Korean J Gastrointest Endosc 2003;26:43⁣47)

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Localized Giant Pseudopolyposis of the Cecum Associated with Crohn's Disease: Hwan Yeol Kim, M.D., Seung Won Chung, M.D., Young Hun Kim, M.D., Sun Hae Lee, M.D.,; Korean J Gastrointest Endosc 2003;26(1):48-51. Published online January 30, 2003

Abstract PDF: Pseudopolyposis occurs twice as often in ulcerative colitis as in Crohn's disease. Pseudopolypsis is divided into the followings: localized multiple pseudopolyposis, localized giant pseudopolyposis, generalized pseudopolyposis and long finger-like pseudopolyps. The most serious problem is confusion with carcinoma. Indications for operation are intussusception or obstruction, radiological simulation of carcinoma. The pseudopolyp could be managed by careful follow-up with colonoscopy and multiple biopsies. We report a case of localized giant pseudopolyposis of the cecum associated with Crohn's disease, with review of relevant literature. (Korean J Gastrointest Endosc 2003;26:48⁣51)

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A Case of Rectal Varix Bleeding Treated with Endoscopic Variceal Ligation: Kye Won Lee, M.D., Hiun Suk Chae, M.D., Yong Bum Park, M.D., Yun Jeong Lee, M.D.,; Korean J Gastrointest Endosc 2003;26(1):52-55. Published online January 30, 2003

Abstract PDF: Esophagogastric varices are considered to be the most common complication in patients with portal hypertension. Among ectopic varices, rectal varices are infrequent but potentially serious complication. The etiology and pathogenesis of rectal varices remains controversial. Several kinds of treatment have been performed but standard treatment for rectal varices has not been established. Herein we report a case of rectal varix bleeding treated with endoscopic variceal ligation (EVL) and then evaluated by transrectal color doppler ultrasonography. (Korean J Gastrointest Endosc 2003;26:52⁣55)

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A Case of Langerhans Cell Histiocytosis with Sclerosing Cholangitis: Jae Chul Hwang, M.D., Doh Hyun Kim, M.D., Eun Hee Lee, M.D., Jai Hak Jeung, M.D.,; Korean J Gastrointest Endosc 2003;26(1):56-60. Published online January 30, 2003

Abstract PDF: Langerhans cell histiocytosis is a rare disorder with abnormal proliferation of histiocytes. Besides the infiltration of a variety of organs, patients with Langerhans cell histiocytosis can develop sclerosing cholangitis, with bile duct involvement, progressive fibrosis, and cirrhosis. We report a case of Langerhans cell histiocytosis with sclerosing cholangitis. Endoscopic retrograde cholangiopancreatography revealed multiple strictures and dilatations of left intrahepatic and extrahepatic bile duct. Endoscopic biopsy of common bile duct showed diffuse infiltration of histiocytes and eosinophiles in lamina propria. Immunohistochemical stain showed positive reactions for S-100 and CD1a and a negative reaction for cytokeratin in infiltrating histiocytes. (Korean J Gastrointest Endosc 2003;26:56⁣60)

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