Clinical Endoscopy

A Remote Educational System in Medicine Using Digital Video Transfer System: Joon Soo Hahm, M.D., Shuji Shimizu, M.D.^∥, Naoki Nakashima, M.D.^∥, Yil Sik Hyun, M.D., Ho Soon Choi, M.D., Yong Ko, M.D.*, Kyeong Geun Lee, M.D.^†, Sun Il Kim, M.D.^‡, Tae Eun Kim^§, Ji Won Yun^§; Korean J Gastrointest Endosc 2006;32(3):161-167. Published online March 30, 2006

Abstract PDF: Background
/Aims: Telemedicine has opened the door to a wide range of learning experience to the doctors and students working and studying at various remote locations. However, there are limitations to this technology, such as the lack of any approved international standards of ethics. The aim of our study was to establish a telemedical education system using the Digital Video Transfer System (DVTS) on the high-speed network. Methods: The Asia Pacific Information Infrastructure (APII) link was used to connect Korea with Japan, and the Korea Advanced Research Network (KOREN) was used to connect Busan with Seoul. Teleconferencing and video streaming between Hanyang University Hospital in Seoul and Kyushu University Hospital in Japan were realized using DVTS over the Ipv4 network. Results: Four endoscopic surgeries and two endoscopic procedures were successfully transmitted between Seoul and Kyushu, while concomitant teleconferences were taking place between the two cities throughout the operations. An adequate bandwidth of 60 Mbps was kept for two-line transmissions. The quality of transmitted video image showed no frame loss with a rate of 30 images per second. The sound was also clear, and the time delay was less than 0.3 sec. Conclusions: We have established an international medical network with high-quality video transmission over Internet medium and this was easy to perform, reliable and economical. (Korean J Gastrointest Endosc 2006;32:161⁣167)

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The Usefulness of Positional Change in Endoscopic Hemostasis for Bleeding Dieulafoy's Lesion: Jae Hak Lee, M.D., Suck Ho Lee, M.D., Won Yeop Bae, M.D., Jeong Hoon Park, M.D., Do Hyun Park, M.D., Il Kwun Chung, M.D., Sang Heum Park, M.D. and Sun Joo Kim, M.D.; Korean J Gastrointest Endosc 2006;32(3):168-172. Published online March 30, 2006

Abstract PDF: Background
/Aims: Dieulafoy's lesion is a rare cause of massive upper gastrointestinal bleeding, most commonly in the proximal stomach. Although the mechanical hemostatic method has been widely used, it is difficult to access for complete application. This study evaluated the utility of a positional change in patients with a bleeding Dieulafoy's lesion. Methods: Between January 2003 and March 2004, 15 patients with a bleeding Dieulafoy's lesion were randomly assigned to either a positional change group (right decubitus or supine, n=7) or a left decubitus group (n=8). The demographic characteristics, endoscopic variables, and clinical outcomes were analyzed. Results: The patients' characteristics at entry were similar in both groups. Initial hemostasis was achieved in all patients. Recurrent bleeding developed in only one patients in the left decubitus group. The mean procedure time was significantly shorter in the positional change group than in the left decubitus group (4.5⁑3.4 min vs. 7.4⁑5.2 min, p＜0.05). The ineffective hemoclip number (respectively, 0.3⁑0.1 vs. 1.4⁑1.2, p＜0.05) was significantly different in the two groups. No major procedure-related complications occurred in the positional change group. Conclusions: Endoscopic hemostasis with a positional change is an effective and safe method for treating in a bleeding Dieulafoy's lesion. (Korean J Gastrointest Endosc 2006; 32:168⁣172)

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Efficacy of Oral Sodium Phosphate Preparation for Capsule Endoscopy: Jun Hwan Wi, M.D., Jin Oh Kim, M.D., In Seop Jung, M.D., Ji Hyun Lee, M.D., Hyun Jung Kim, M.D., Bong Min Ko, M.D., Joo Young Cho, M.D., Joon Seong Lee, M.D., Moon Sung Lee, M.D., Chan Sup Shim, M.D. and Boo Sung Kim, M.D.; Korean J Gastrointest Endosc 2006;32(3):173-178. Published online March 30, 2006

Abstract PDF: Background
/Aims: Capsule endoscopy is an effective diagnostic tool for detecting small bowel disease. However, the method of bowel preparation for capsule endoscopy has not been standardized. The aim of this study was to evaluate the efficacy of oral sodium phosphate as a preparation for capsule endoscopy. Methods: A total of 129 cases who underwent capsule endoscopy from Mar. 2003 to Sep. 2004 were analyzed retrospectively. Eighty- eight cases were prepared with sennosides (Alaxyl^Ⱂ) and 41 cases were prepared with sodium phosphate. The intestinal mucosa was defined as being unclean if the intestinal content, food materials, and bubbles covered more than 25% of the mucosal surface. Using a stopwatch, the exact time of the unclean image was recorded. The percentage of the unclean image for the small intestinal transit time (SITT) was calculated as an objective score. Small bowel cleansing was considered 'adequate' if the objective score was ＜10% and 'inadequate' if the objective score was 10% or greater. Results: 35 cases (40%) showed an adequate image in the sennosides and simethicone group and 26 cases (63%) showed an adequate image in the sodium phosphate and simethicone group. The adequacy rate was significantly higher in the sodium phosphate group than in the sennosides group (p＜0.05). Conclusions: Capsule endoscopy prepared by sodium phosphate and simethicone produced a better visual image than sennosides and simethicone. (Korean J Gastrointest Endosc 2006;32:173⁣178)

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The Characteristics of Colonic Adenoma Detected by ¹⁸F-FDG-PET: Yoo-Kyung Cho, M.D., Sung-Ae Jung, M.D., Su-Jung Baik, M.D., Chang-Bae Lee, M.D., Sung-Eun Kim, M.D., Tae-Hun Kim, M.D., Moon-Sun Bae, M.D.*, Ki-Nam Shim, M.D. and Kwon Yoo, M.D.; Korean J Gastrointest Endosc 2006;32(3):179-183. Published online March 30, 2006

Abstract PDF: Background
/Aims: FDG-PET is widely used for the evaluation of cancer patients. FDG-PET is usually employed for a staging of colorectal cancer and for the early detection of postoperative recurrence of cancer. Areas of focal uptake that suggest colonic lesions, including benign adenoma, may be seen on an FDG-PET image. This study evaluated the characteristics of colonic adenoma as detected by FDG-PET. Methods: 60 subjects (M/F: 30：30, mean age: 55⁑11) who underwent both PET study and colonoscopy were enrolled and their data were retrospectively analyzed. Results: A total of 50 lesions of colonic adenoma (3∼35 mm) were found in 17 subjects by colonoscopy. Compared with the colonoscopic findings, FDG- PET had a positive predictive value of 52.9% and a negative predictable value of 81.4%. The positive rate increased with the size of the colonic adenoma (15 mm, 100.0%; ≥10 mm, 82.4%; ＜5 mm, 0.0%) and with the protruded type of polyp (sessile, 25.0%; subpedunculated, 47.7%; pedunculated, 90.9%). Conclusions: FDG-PET positive colonic lesions should raise a concern for not only possible malignancy, but also for the large sized or malignant transforming colonic adenoma. (Korean J Gastrointest Endosc 2006;32:179⁣183)

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Endoscopic Sphincterotomy Plus Endoscopic Papillary Large Balloon Dilatation for Large Bile Duct Stones: Seoung Joon Hwang, M.D., Young Gyun Kim, M.D., Kyu Chul Lee, M.D., Myung Kwan Ji, M.D.*, Hyun Soo Kim, M.D.*, Soon Goo Baik, M.D.*, Kuen Man Lee, M.D., Jin Hyuck Chang, M.D., Min Su Kim, M.D., Yong Han Paik, M.D., Se Joon Lee, M.D., Hyo Jin Park, M.D., Kw; Korean J Gastrointest Endosc 2006;32(3):184-189. Published online March 30, 2006

Abstract PDF: Background
/Aims: The extraction of large common bile duct (CBD) stones after an endoscopic sphincterotomy (EST) is successful in 80∼90% of cases but it often requires a prolonged time and repeated trials. This study investigated the utility of a combined endoscopic papillary large balloon dilatation (EPLBD) and a mid-incision of an EST (m-EST) method for the removal of large CBD stones. Methods: Thirty patients with large CBD stones were enrolled in this study. EPLBD was carried out using the one-step inflation of a 15∼18 mm diameter balloon after m-EST. Results: The maximum stone diameter was 21.62±5.38 mm. Twelve patients had more than 4 stones, 7 patients had 2 stones, and the remainder had a single large stone. Complete ductal clearance was achieved in all patients. After the procedure, the serum amylase and/or lipase levels were elevated in 3 patients (13.3%). However, there was no episode of true pancreatitis. Minor bleeding was encountered in only one patient (3.3%), and was easily controlled by an endoscopic epinephrine injection. The procedure was carried out safely in 6 patients with periampullary diverticulum. No perforation or mortality was encountered. Conclusions: Combined EPLBD and m-EST is a safe and effective method, and may be a good alternative treatment for removing large CBD stones. (Korean J Gastrointest Endosc 2006;32:184⁣189)

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Esophageal Ulcer by Thermal Injury from Steamed Egg: Sun Moon Kim, M.D., Seung Hyun Jung, M.D., Young Moon Kim, M.D., Hoon Sup Koo, M.D., Tae Hee Lee, M.D., Eui Hyeog Im, M.D., Kyu Chan Huh, M.D., Bum Kyeong Kim, M.D.*, Young Woo Choi, M.D. and Young Woo Kang, M.D.; Korean J Gastrointest Endosc 2006;32(3):190-193. Published online March 30, 2006

Abstract PDF: The common causes of esophageal ulcers include severe reflux esophagitis, carcinomas, pill-induced esophagitis, viral diseases, caustic injury, foreign bodies and radiation injury. In rare cases, they can also be caused by Crohn's disease, Behcet's disease, syphilis and idiopathic causes. A thermal injury caused by the ingestion of hot food has not been reported to be a cause of esophageal ulcers. We report an alcoholic who developed an esophageal ulcer and odynophagia after ingesting part of an extremely hot steamed egg with a review of the few available reports regarding such injuries. We suggest that the ingestion of extremely hot food should also be considered a cause of esophageal ulcers. (Korean J Gastrointest Endosc 2006; 32:190⁣193)

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A Case of Gastric CD56+ Extranodal NK/T-cell Lymphoma, Nasal Type: Hee Jung Oh, M.D., Ki-Nam Shim, M.D., Ji Hyun Song, M.D., Hyun Joo Song, M.D., Kum Hei Ryu, M.D., Chang Bai Lee, M.D., Tae Hun Kim, M.D., Sung-Ae Jung, M.D., Kwon Yoo, M.D., Il-Hwan Moon, M.D. and Shi Nae Lee, M.D.*; Korean J Gastrointest Endosc 2006;32(3):194-199. Published online March 30, 2006

Abstract PDF: A NK/T cell lymphoma is highly aggressive lymphoma of a putative NK-cell origin with a predominant extranodal presentation and a rapidly fatal course. CD56 has been reported to be the most reliable marker for a NK/T cell lymphoma. A NK/T cell lymphoma is strongly associated with the Epstein-Barr virus. We report a case of an aggressive NK/T cell lymphoma presenting as a gastric ulcer. A 52-year-old female patient presented with hematochezia and fever. The endoscopic finding showed a gastric ulcer with a recent bleeding stigma. Histologically, the gastric biopsy showed a diffuse infiltration of small or medium sized lymphoma cells with an angiocentric growth pattern and necrosis. The lymphoma cells were CD56⁢, CD3⁢, CD20⁣, which are consistent with a NK/T cell lymphoma. Unfortunately, the patient was discharged without treatment. We report this case with a review of the relevant literature. (Korean J Gastrointest Endosc 2006;32:194⁣199)

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A Case of Carcinoid Tumors of the Stomach and Duodenum Treated by Endoscopy: Yoon-Jung Kim, M.D., Kyu-Jong Kim, M.D., Lee Chun Park, M.D., Ji Hun Roh, M.D., Dae Gwan Im, M.D., Nam Young Park, M.D., Won Moon, M.D., Moo In Park, M.D., Seun Ja Park, M.D. and Bong Kwon Cheon, M.D.*; Korean J Gastrointest Endosc 2006;32(3):200-204. Published online March 30, 2006

Abstract PDF: A carcinoid tumor is a slow growing, rare neoplasm arising from enterochromaffin cells with a malignant potential. A primary carcinoid tumor of the stomach and duodenum is uncommon. However, their prevalence has been increasing due to the widespread use of endoscopy. Recently, the use of endoscopic resection for the treatment of small carcinoid tumors is gradually increasing. To our knowledge, this is the first case report of synchronous carcinoid tumors in the stomach and duodenum. We report a case of small, multiple carcinoid tumors of the stomach and duodenum in a 58-year-old man that was endoscopically removed with a snare. (Korean J Gastrointest Endosc 2006;32:200⁣204)

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A Case of Duodenal Gastrointestinal Stromal Tumor Mimicking Isolated Duodenal Varix: Tae Woo Kim, M.D., Min Soo Kim, M.D., Jeong Won Jang, M.D., In Seok Lee, M.D., Si Hyun Bae, M.D., Jong Young Choi, M.D., Myung-Gyu Choi, M.D., Seung Kew Yoon, M.D. and In-Sik Chung, M.D.; Korean J Gastrointest Endosc 2006;32(3):205-209. Published online March 30, 2006

Abstract PDF: Gastrointestinal stromal tumors (GIST) are generally located in the stomach and small intestine, and they present most with commonly abdominal pain. However, the duodenum is an unusual location and is commonly associated with gastrointestinal bleeding. A 51-year-old female was admitted for a 15-day history of melena and malaise. A cystic mucosal lesion featuring an isolated duodenal varix was observed by gastroduodenoscopy. Abdominal CT revealed a tortuous vascular structure at the posterior wall of the duodenum. Endoscopic Histoacryl injection therapy at the cystic mucosal lesion and a duodenal segmental resection were performed. The procedure was successful. Microscopic observation revealed GIST. We report a case of a duodenal GIST mimicking an isolated duodenal varix. (Korean J Gastrointest Endosc 2006;32:205⁣209)

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Two Cases of Successful Clipping Closure of Iatrogenic Duodenal Perforation Occurred during Endoscopic Procedure: Young Jae Lee, M.D., Sin Un Lee, M.D., In O Sun, M.D., Jin Hwa Choi, M.D., Hea Un Choi, M.D., Eun Young Ko, M.D., In Suk Seo, M.D., Young Keun Cho, M.D., Seung Min Park, M.D., Yang Ho Kim, M.D., Jin Woong Cho, M.D. and Yong Ung Lee, M.D.; Korean J Gastrointest Endosc 2006;32(3):210-214. Published online March 30, 2006

Abstract PDF: The risk of complications associated with endoscopic procedures, including bleeding and perforation, tends to increase due to the magnification of the therapeutic endoscopic spectrum. In cases of duodenal perforation, surgical closure is the treatment of choice; however, there have been some cases in which the nonsurgical treatment of an iatrogenic duodenal perforation during an endoscopic procedure was effected via endoscopic clipping closure. Here, we report two cases of successful endoscopic clipping closure of an iatrogenic duodenal perforation occur ring during a duodenoscopy insertion for ERCP and endoscopic mucosal resection for the treatment of duodenal adenoma. (Korean J Gastrointest Endosc 2006;32:210⁣214)

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A Case of Superior Mesenteric Artery Syndrome Treated by Laparoscopic Surgery: Ji-Sung Chun, M.D., Woo-Chul Chung, M.D., Seong-Su Hwang, M.D.*, Hyun-Min Cho, M.D.^†, Kang-Moon Lee, M.D., Bo-In Lee, M.D., Su-Yeon Lee, M.D., Ji-Won An, M.D., U-Im Chang, M.D., Jin-Mo Yang, M.D., Kyu-Yong Choi, M.D. and In-Sik Chung, M.D.; Korean J Gastrointest Endosc 2006;32(3):215-220. Published online March 30, 2006

Abstract PDF: Superior mesenteric artery (SMA) syndrome is a symptom complex resulting from compression of third portion of duodenum by the root of the small bowel mesentery at the level of the SMA. This syndrome can occur as an acute illness but more commonly it appears as chronic condition. Identification of this syndrome can be a diagnostic dilemma and it is frequently made by exclusion. In our patient, rapid weight loss, nausea and bile stained vomiting were present. Ultrasound and MR-angiography were performed for measuring the angle and the distance between the SMA and the aorta. We confirmed the diagnosis via the reduced aorto-mesenteric angle and distance and the patient was then treated by laparoscopic surgery. After lysis of the ligament of Treitz, the patient's symptom were improved. This syndrome must be considered as one of the causes of upper gastrointestinal obstruction. (Korean J Gastrointest Endosc 2006;32:215⁣220)

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A Case of Partial Intestinal Obstruction due to Ascaris lumbricoides: Won Yong Shin, M.D., Han Hyo Lee, M.D., Young Hye Byun, M.D., Jeong Seon Kim, M.D., Eun Young Lee, M.D., Seong Hwan Kim, M.D., Moon Hee Song, M.D., Yun Ju Jo, M.D., Young Sook Park, M.D. and Dong Hoon Kim, M.D.*; Korean J Gastrointest Endosc 2006;32(3):221-225. Published online March 30, 2006

Abstract PDF: Ascaris lumbricoides (A. lumbricoides) is the largest and most common human intestinal helminth in the world. However, the prevalence of ascariasis has, in recent years, been very low in Korea. The majority of patients infected with A. lumbricoides are asymptomatic. However, sometimes these infections may give rise to intestinal obstructions or pancreatobiliary disease, via retrograde migration through the ampulla of Vater. Intestinal obstruction associated with A. lumbricoides is a complication that is frequently observed in children living in endemic areas. However, no cases of A. lumbricoides-associated intestinal obstruction have been reported in Korea since 1967. In this report, we describe the case of a 78-year-old man, who presented with sustained nausea and postprandial vomiting, and was diagnosed with a partial intestinal obstruction due to A. lumbricoides after undergoing an esophagogastroduodenoscopy. (Korean J Gastrointest Endosc 2006;32:221⁣225)

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A Case of Colonic Intussusception Caused by Cystic Lymphangioma of the Colon: Jung Hyun Lee, M.D., Sang Yong Lee, M.D., Joo Ho Lee, M.D., Hyo Jin Jung, M.D., Tae Oh Kim, M.D., Gwang Ha Kim, M.D., Jeong Heo, M.D., Dae Hwan Kang, M.D., Geun Am Song, M.D. and Mong Cho, M.D.; Korean J Gastrointest Endosc 2006;32(3):226-230. Published online March 30, 2006

Abstract PDF: Lymphangioma is a benign tumor that is commonly found in children. Many lymphangiomas are congenital malfor- mations of the lymphatic system and they are considered to be lymphatic hamartomas. Lymphangiomas usually occur in the head, neck and axillary region, and they rarely occur in the gastrointestinal tract. Cystic lymphangioma is a rare cause of colonic submucosal masses. Lymphangioma of the colon has recently been diagnosed more frequently by performing colonoscopy and endoscopic ultrasonography. However, only a few cases of colonic intussusception due to lymphangioma have been reported in the literature. We experienced a case of intussusception that was caused by cystic lymphangioma of the colon, and we report here on the findings. (Korean J Gastrointest Endosc 2006;32:226⁣230)

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A Case of Clonorchiasis Presenting with Acute Pancreatitis and Cholangitis: Ki Sung Lee, M.D., Kyung Ho Kim, M.D., So Young Park, M.D., Chi Jun Park, M.D., Ja Young Lee, M.D., Myoung Kuk Jang, M.D., Joon Yong Park, M.D., Jin Heon Lee, M.D., Hak Yang Kim, M.D. and Jae Young Yoo, M.D.; Korean J Gastrointest Endosc 2006;32(3):231-234. Published online March 30, 2006

Abstract PDF: Clonorchiasis is a parasitic disease that is often found in Japan, Korea, China, Hong Kong as well as in countries in Southeast Asia. The disease is caused by the ingestion of infected raw freshwater fish. The clinical manifestations depend on the number of flukes in a patient, the period of infestation, and the complications. In patients with a heavy infestation, extrahepatic bile duct, the gallbladder and even the pancreas are involved. We experienced a 62-year-old man who had a history of ingestion of raw freshwater fish and presented with acute pancreatitis and cholangitis. The pancreaticobiliary-associated clonorchiasis was successfully treated with endoscopic sphincterotomy, and praziquantel. (Korean J Gastrointest Endosc 2006;32:231⁣234)

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A Case of Mucin-hypersecreting Gallbladder Papillary Carcinoma Manifested as Obstructive Jaundice: Ji Hoon Jung, M.D., Myung-Hwan Kim, M.D., Sang Su Lee, M.D., Chang Hee Jung, M.D., Ji Young Lee, M.D., Dong Wan Seo, M.D., Sung Goo Lee, M.D. and Gyung Yeop Gong, M.D.*; Korean J Gastrointest Endosc 2006;32(3):235-237. Published online March 30, 2006

Abstract PDF: Biliary papillomatosis (BP) is a rare disease that is classified as either the mucin-hypersecreting type or nonmucin-secreting type. Typical papillomas of the biliary tree mainly involve intrahepatic bile ducts or both intra- and extrahepatic bile ducts. The isolated involvement of the extrahepatic bile duct is rare, and there is no report of BP confined to the gallbladder in Korea. We report a case of a 50-year-old man who developed obstructive jaundice due to hypersecreted mucin from papillomas of the gallbladder. (Korean J Gastrointest Endosc 2006;32:235⁣238)

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