Clinical Endoscopy

Clinical Findings of Upper Gastrointestinal Bleeding and Risk Factors for Early Rebleeding in Patients with Bleeding Peptic Ulcers: Hyeon Yong Park, M.D., Jin Wook Hur, M.D., Paul Choi, M.D., Nam Young Park, M.D., Jee Yeon Kim, M.D., Dong Wan Kim, M.D., Jee Young Lee, M.D., Ki Hwan Kim, M.D., Moo In Park, M.D., Seun Ja Park, M.D. and Ja Young Koo, M.D.; Korean J Gastrointest Endosc 2003;27(2):57-63. Published online August 30, 2003

Abstract PDF: Background
/Aims: Upper gastrointestinal (UGI) bleeding may have serious complications. Endoscopic therapy is effective in the hemostasis of active bleeding. We analysed the causes of UGI bleeding and evaluated risk factors and rate of rebleeding in patients with bleeding peptic ulcer. Methods: Records from 326 patients admitted with upper gastrointestinal bleeding between January 1998 and December 2002 were reviewed. We retrospectively analyzed clinical findings and rebleeding risk factors of peptic ulcers. Results: Common causes of UGI bleeding were esophageal varix (38.0%), peptic ulcer (36.9%), Mallory-Weiss tear (13.8%), stomach cancer (6.4%). Early rebleeding of bleeding peptic ulcer after hemostasis occurred in 23 cases (19.2%). On the basis of univariate analysis, significant predictive factors for early rebleeding were old age (＞65) (p=0.034), size of ulcer (＞2 cm) (p=0.002), number of ulcer (＞1) (p=0.059). In multivariate analysis, old age (odds ratio, OR=2.3), size of ulcer (OR=3.3), number of ulcer (OR=2.6) were independent risk factors of rebleeding. Conclusions: Common causes of UGI bleeding are esophageal varix, peptic ulcer, Mallory-Weiss tear. Predictive risk factors for early rebleeding in bleeding peptic ulcer may be old age, size of ulcer and number of ulcer. (Korean J Gastrointest Endosc 2003;27:57⁣63)

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A Comparative Study on the Efficacy of Covered Metal Stent and Plastic Stent in Malignant Biliary Obstruction: Jun Hwan Kim, M.D., Byung Ik Jang, M.D., Tae Nyeun Kim, M.D. and Moon Kwan Chung, M.D.; Korean J Gastrointest Endosc 2003;27(2):64-69. Published online August 30, 2003

Abstract PDF: Background
/Aims: Insertion of self-expanding metallic stents (SEMS) has become an established option for the palliation of malignant biliary obstruction (MBO). However, stent occlusion by tumor ingrowth is still an unsolved problem. To overcome this problem, membrane-covered SEMSs have been developed. The purpose of this study was to compare the effectiveness of membrane-covered SEMS versus plastic stent in the treatment of MBO. Methods: Between Jan 2001 and Jul 2002, 57 patients with unresectable MBO who initially had plastic stents inserted were randomized to receive either plastic stent and membrane-covered SEMSs after initial plastic stent failure. Results: Placement of either plastic stents or membrane- covered SEMs was successful in all patients. Mean patency duration of stents were significantly longer in membrane- covered SEMS group (189 days) than in plastic stent group (82 days) (p=0.01). The causes of stent failure were occlusion in 10 cases and migration in 1 case in membrane- covered SEMS group. Of these occluded 10 cases, tumor ingrowth was noted in 7, tumor overgrowth in 2, and biliary incrustation in 1. Conclusions: Membrane-covered SEMS has a longer patency than plastic stent. However, new membrane covering material is needed to prevent tumor ingrowth more effectively. (Korean J Gastrointest Endosc 2003;27:64⁣69)

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A Case of Multiple Gastric Carcinoids Associated with Chronic Atrophic Gastritis and Hypergastrinemia: Myoung Kuk Jang, M.D., Gin Hyug Lee, M.D., Sung Sook Lee, M.D., Chan Sun Park, M.D., Jeong Sik Byeon, M.D., Yun Jung Lee, M.D., Seung Jae Myung, M.D., Hwoon Yong Jung, M.D., Suk Kyun Yang, M.D., Weon Seon Hong, M.D., Jin Ho Kim, M.D., Young Il Min, M.D. a; Korean J Gastrointest Endosc 2003;27(2):70-75. Published online August 30, 2003

Abstract PDF: Gastric carcinoid tumors are so rare that they constitute less than 1% of total primary gastric tumors. They are classified into 3 types: (1) gastric carcionoid associated with chronic atrophic gastritis (type I), (2) gastric carcinoids associated with Zollinger-Ellison syndrome (ZES) or multiple endocrine neoplasm (MEN) type 1 (type II), and (3) sporadic gastric carcinoid (type III). A 55-year-old man underwent a medical check-up. Five polypoid masses were incidentally detected in the cardia, fundus and midbody whose size ranged from 0.5 cm to 1.6 cm in diameter. Tumor cells were strongly positive for cytokeratin, synaptophysin and chromogranin staining. Biopsies from the body and fundus showed severe atrophy. Fasting serum gastrin level was highly increased, 1,098 pg/mL. There was, however, no evidence of the presence of ZES or MEN type 1. The patient underwent total gastrectomy for complete resection and has remained free of any complications with normal serum gastrin level. (Korean J Gastrointest Endosc 2003;27:70⁣75)

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A Case of Duodenal Involvement in Waldenström's Macroglobulinemia: Jae Suk Park, M.D., Ji Seup Kim, M.D., Yong Wuk Kim, M.D., Jung Choi, M.D., Ji Hye Seok, M.D., Jung Ho Park, M.D., Soo Chan Bae, M.D., Seung Keun Park, M.D., Ph.D., Hee Ug Park, M.D. and Hye Sook Kim, M.D.*; Korean J Gastrointest Endosc 2003;27(2):76-79. Published online August 30, 2003

Abstract PDF: Waldenström's macroglobulinemia is a disorder of malignant proliferation of plasmacytoid lymphocytes and monoclonal immunoglobulin M. However, the patients occasionally present with malabsorption and diarrhea due to deposition of extracellular periodic acid-Schiff positive homogenous eosinophilic, amorphorous, and proteinaceous materials in the villi and/or lamina propria of the duodenum. We report a 62-year-old man who, despite involvement of the duodenal mucosa, presented only with fatigue, dypnea on exertion, and anemia. Characteristic duodenoscopic and pathologic findings of this patient are described. (Korean J Gastrointest Endosc 2003;27:76⁣79)

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Migration of Pyloric Self-Expanding Metallic Stent to the Esophagus: Young Gyun Kim, M.D., Jun Pyo Chung, M.D., Seung Hyun Cho, M.D., Seoung Joon Hwang, M.D., Dok Yong Lee, M.D., Sang Won Ji, M.D., Yong-Han Paik, M.D., Se Joon Lee, M.D., Byung Soo Moon, M.D., Kwan Sik Lee, M.D., Sang In Lee, M.D. and Jin Kyung Kang, M.D.; Korean J Gastrointest Endosc 2003;27(2):80-83. Published online August 30, 2003

Abstract PDF: Self-expandable metallic stent (SEMS) has been reported to provide effective treatment alternatives with minimal morbidity for patients with malignant gastroduodenal obstruction. Limitations of SEMSs are stent occlusion due to tumor ingrowth or overgrowth and stent migration. Migrated stents may remain in the stomach or travel distally. To our knowledge, however, migration of pyloric SEMS to the esophagus has not been reported. We experienced such a case in a 65-year-old woman who had undergone a gastrojejunostomy and choledochojejunostomy due to unresectable pancreatic head cancer. Pyloric SEMSs (Niti-S Pyloric Bare Stent, 18⁓60 mm, Taewoong Medical, Korea) were deployed at the obstructed efferent and afferent loops. After severe vomiting, a pyloric SEMS placed at the afferent loop migrated into the esophagus, which caused severe chest pain and intractable hiccup. It was removed endoscopically. This case illustrates that pyloric SEMS can migrate to the esophagus through the lower esophageal sphincter. (Korean J Gastrointest Endosc 2003;27:80⁣83)

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A Case of Abdominal Actinomycosis Mimicking Colon Carcinoma: Jeong Eun Shin, M.D., Sung-Ae Jung, M.D., Seong-Eun Kim, M.D., Su Jung Baik, M.D., Hee Jung Oh, M.D., You Kyoung Cho, M.D., Seung Yon Baek, M.D.*, Kwon Yoo, M.D. and Il-Hwan Moon, M.D.; Korean J Gastrointest Endosc 2003;27(2):84-87. Published online August 30, 2003

Abstract PDF: Actinomycosis is a chronic suppurative and granulomatous-disease caused by Actinomycosis israelli. Clinical presentation of the abdominal form of actinomycosis is nonspecific-pain, fever, leukocytosis, increased erythrocyte sedimentation rate, a sensation of abdominal mass and a formation of fistula. In addition, abdominal actinomycosis may mimic a carcinoma, diverticular abscess, inflammatory bowel disease, and tuberculosis. Most of abdominal actinomycosis develops after trauma, appendicitis, diverticulitis or gastrointestinal perforation. We report a case of abdominal actinomycosis preoperatively mimicking as colon carcinoma, which had no predisposing factors. (Korean J Gastrointest Endosc 2003;27:84⁣87)

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A Case of Granular Cell Tumor in the Rectum: Dong Hee Kim, M.D., Young-Ho Kim, M.D., Nam Hee Kwon, M.D., Bong Geun Song, M.D., Jae Hong Jung, M.D., Min Hyung Kim, M.D., Poong-Lyul Rhee, M.D., Jae J. Kim, M.D. and Jong Chul Rhee, M.D.; Korean J Gastrointest Endosc 2003;27(2):88-91. Published online August 30, 2003

Abstract PDF: Granular cell tumor (GCT), first described by Abrikossoff in 1926, is relatively uncommon, usually benign and solitary neoplasm. The most frequently involved organs include the tongue, skin, breast, and digestive tract. Until now, less than 200 cases of GCTs of the digestive tract have been reported in the esophagus, and less than 50 cases in the large intestine, stomach, biliary tract in the world. Only less than 20 cases of GCT of the rectum have been reported in the world. It is believed that there have been no reported cases of GCT of the rectum in Korea. Recently, the incidence of granular cell tumor has been slowly rising since endoscopy has been used more commonly as a diagnostic tool. We report a case of granular cell tumor in the rectum in a 49-year-old male patient, which was confirmed by microscopic examination after colonoscopic polypectomy. (Korean J Gastrointest Endosc 2003;27:88⁣91)

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A Case of Isolated Rectal Tuberculosis: Jung Wook Hur, M.D.; Korean J Gastrointest Endosc 2003;27(2):92-95. Published online August 30, 2003

Abstract PDF: Isolated rectal tuberculosis is defined as focal lesions of the rectum in the absence of demonstrable lesions in the small and large bowel, and it is a very rare form of intestinal tuberculosis. Common presenting features are rectal bleeding, diarrhea, constipation, tenesmus, and constitutional symptoms. Of them, rectal bleeding is the most common symptom. There are ulcerative, hypertrophic and combined types in the colonoscopic classification. Ulcerative type is the most common findings. The size of the ulcers are variable. The margins of the ulcer are irregular, swollen, erythematous and nodular. The base is covered with whitish to yellowish exudates and shows a granular appearance. For diagnosis of rectal tuberculosis it is important to obtain specimens at more than 6 regions in the base and margins of the ulcer. Important histologc findings are granuloma and demonstration of acid fast bacilli. I report a case of isolated rectal tuberculosis confirmed by colonoscopic study and histology. (Korean J Gastrointest Endosc 2003;27:92⁣95)

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Common Bile Duct Varices: MR Cholangiography and MR Angiography Demonstration: Jin Tae Park, M.D., Myung-Hwan Kim, M.D., Moon Hee Song, M.D., Jung Joon Choi, M.D., Tae Hoon Lee, M.D., Eun Hee Ko, M.D., Won Jang Kim, M.D., Dong Ryoul Oh, M.D., Sang Soo Lee, M.D., Dong Wan Seo, M.D., Sung Koo Lee, M.D. and Young Il Min, M.D.; Korean J Gastrointest Endosc 2003;27(2):96-99. Published online August 30, 2003

Abstract PDF: Extrahepatic obstruction of the portal vein, resulting in portal hypertension, may cause extensive collateral circulation at the porta hepatis. These collateral veins may compress and narrow the common bile duct, sometimes causing obstructive jaundice. Until recently, ERCP and percutaneous angiography have been used to diagnose choledochal varix. Now, MR cholangiography is replacing the diagnostic role of ERCP. This imaging has the advantage of obtaining angiography at the same time. We present a 62-year-old male patient, in whom choledochal varix accompanying choledocholithiasis, was diagnosed by MR cholangiography and contrast-enhanced MR angiography. (Korean J Gastrointest Endosc 2003;27:96⁣99)

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A Case of Common Bile Duct Web Presenting with Obstructive Jaundice without Choledocholithiasis: Young Nam Kim, M.D., In Sung Moon, M.D., Seung Ki Jeong, M.D., Duck Soo Woo, M.D., Jeong Woo Park, M.D., Eun Ki Paik, M.D., Yeon Suk Kim, M.D., Dong Kyun Park, M.D., Duck Joo Choi, M.D., Yu Kyung Kim, M.D., Sun Suk Kim, M.D., Oh Sang Kwon, M.D., Moon Gi C; Korean J Gastrointest Endosc 2003;27(2):100-104. Published online August 30, 2003

Abstract PDF: Biliary web is an extremely rare disease. It has been reported about 40 cases worldwide and 7 cases in Korea. Most cases have been incidentally found at operation or autopsy because of its rare incidence and absence of specific clinical manifestations. On cholangiography, billiary web typically appears as slit like or shelf like radiolucent narrowing. We experienced a case of biliary web of the common bile duct with obstructive jaundice that was diagnosed by endoscopic retrograde cholangiopancreatography and treated by surgery in a 65 year-old male who complained of right upper quadrant pain for 4 days. We report a case of biliary web of the common bile duct with obstructive jaundice with a review of the literature. (Korean J Gastrointest Endosc 2003;27:100⁣104)

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