Clinical Endoscopy

Interobserver Variation in the Endoscopic Diagnosis of Gastroesophageal Reflux Disease: Jun Haeng Lee, M.D., Jong-Soo Lee, M.D., Poong-Lyul Rhee, M.D., Hoon Jai Chun, M.D.*, Myung-Gyu Choi, M.D.^†, Young-Tae Bak, M.D.*, Dongkee Kim, M.D.^‡, Kijun Song, M.D.^‡ and Sang In Lee, M.D.^§; Korean J Gastrointest Endosc 2006;33(4):197-203. Published online October 30, 2006

Abstract PDF: Background
/Aims: A diagnosis of gastroesophageal reflux disease (GERD) is based on the typical symptoms, such as acid regurgitation and heartburn. However, there is a very high inter-observer variation in the evaluation of GERD patients. Methods: The endoscopic images of forty-two cases with reflux symptoms (2 still images and 15-second video images per case) were analyzed by 18 experienced endoscopists and 22 trainees. The findings were classified into the following: (1) 6 groups (modified LA classification: 4 LA groups, minimal, and normal), (2) erosinve and non-erosive, and (3) confluent erosive and others. The level of inter-observer variation is expressed as a kappa value. Results: The level of inter-observer agreement of the 18 experienced endoscopists for classifying the patients into 6 groups was fairly low (kappa=0.364). However, when the findings were classified into the 2 groups suggested in the Genval workshop (NERD, A, or B versus C or D), the level of inter- observer agreement increased substantially (kappa=0.710). The kappa value of the 22 trainees for classifying the patients into 6 groups was 0.402. Conclusions: Modified LA classification with minimal change lesions showed a fairly low level of agreement. The problem caused by inter-observer variations decreased significantly when the findings were classified into two groups. (Korean J Gastrointest Endosc 2006;33:197⁣203)

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The Treatment Effect of Savary Bougie Dilation in Benign Esophageal Strictures: Jeong Young Choi, M.D., Jin Hong Kim, M.D., Joon Hyuck Choi, M.D., Kee Myung Lee, M.D., Byung Moo Yoo, M.D., Ki Baik Hahm, M.D. and Sung Won Cho, M.D.; Korean J Gastrointest Endosc 2006;33(4):204-211. Published online October 30, 2006

Abstract PDF: Background
/Aims: Bougie dilatation is generally considered to be effective treatment of benign esophageal stricture. However, sometimes its therapeutic effect was unsatisfactory, or symptom used to recur after treatment. We reviewed our data to evaluate the efficacy of bougie dilation, and examined the factors associated with the bougienation effect. Methods: Fifty-five patients, who were diagnosed with a benign esophageal stricture, underwent bougie dilation, and were followed up for more than 6 months, and were retrospectively analyzed. The treatment effects were graded as 'cure', 'fair', 'poor', and 'no effect'. The factors which influenced the treatment effect were analyzed. Results: For the patients of severe pre- dilatation symptoms, long stricture lesion, and severe endoscopic stricture, the therapeutic effect of bougienation was significantly bad (p=0.002, 0.001, 0.019). Therapeutic effect was higher in patients who were treated with large diameter dilator in the first session (p=0.005), and has stronger relation with the length of stricture than the degree of stricture. In the follow-up period, 45 (81.8%) of 56 patients has achieved cure response. In the cure response group, 30 patients (66.7%) needed one, 5 (11.1%) needed two, 5 (11.1%) needed three, 3 (6.7%) needed four, 1 (2.2%) needed five, and the last one (2.2%) needed six sessions of bougienation. Conclusions: The luminal diameter of the stricture, the length of the stricture and the diameter of the dilator used in the initial session were associated with treatment effect. Bougie dilatation was reconfirmed to be effective treatment modality for benign esophageal stricture. (Korean J Gastrointest Endosc 2006; 33:204⁣211)

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Phase III Clinical Trial of Revaprazan (Revanex^Ⓡ) for Gastritis: Myung-Gyu Choi, M.D., Soo-Heon Park, M.D., Sung-Kook Kim, M.D.*, Rin Chang, M.D.^†, Seok-Reyol Choi, M.D.^‡, Geun-Am Song, M.D.^∥, Ki-Baik Hahm, M.D.^§, Yong-Chan Lee, M.D.^¶, Hyun-Soo Kim, M.D.**, Tae-Nye; Korean J Gastrointest Endosc 2006;33(4):212-219. Published online October 30, 2006

Abstract PDF: Background
/Aims: We performed a randomized, double-blind, phase III, multicenter trial to assess the comparative efficacy and safety of revaprazan, which is a novel acid pump antagonist in comparison with ranitidine for treating patients suffering with acute gastritis and acute aggravation of chronic gastritis. Methods: Five hundred and twelve subjects were randomized to 2 weeks of treatment with either revaprazan 200 mg q.d. or ranitidine 150 mg b.i.d. The primary efficacy parameter was the estimated improvement rate according to endoscopy, and the secondary efficacy parameter was the improvement rate for the subjects' symptoms. Results: The estimated improvement rates at 2 weeks (intention-to-treat analysis) were 79.9% with revaprazan and 60.5% with ranitidine; a significant difference was found between the two groups (p＜0.0001). On the per-protocol analysis, the estimated improvement rates for revaprazan and ranitidine were 79.4% and 60.2%, respectively. There was a significant difference in the estimated improvement rates between the two groups (p＜0.0001). On both analyses, there were no significant differences between the two groups for the improvement rates of the subjects' symptoms. Both drugs were well tolerated. Conclusions: The efficacy of revaprazan was higher than that of ranitidine for the estimated improvement rate according to endoscopy and also for the symptomatological improvement rate, and revaprazan was well tolerated by the subjects suffering with gastritis. (Korean J Gastrointest Endosc 2006;33:212⁣219)

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A Case of Primary Malignant Melanoma of the Esophagus Treated by Esophagectomy: Jin Sun Park, M.D., Sang Jo Choi, M.D., Choong Keun Cha, M.D., Sung Jae Shin, M.D., Ki Myung Lee, M.D., Ki-Baik Hahm, M.D., Ph.D., Jin Hong Kim, M.D., ungsoo Lee, M.D.* and Jae Ho Han, M.D.^†; Korean J Gastrointest Endosc 2006;33(4):220-225. Published online October 30, 2006

Abstract PDF: A primary malignant melanoma of the esophagus is a very rare disease representing approximately 0.1∼.02% of all esophageal neoplasms and 0.5% of all mucosal melanomas. Despite a surgical resection, a primary malignant melanoma of the esophagus has a poor prognosis, mainly due to the fast development of hematogenous and lymphatic metastases. However, a resection of the tumor appears to be the treatment of choice. Local excision does not prolong the survival of patients. After a radical excision, the mean survival time is 7∼12 months and the estimated 5 year survival is 4.2%. However, after a local excision, the average survival time is 9 months and there is no report of a patient who survived more than 1year. We encountered a 55-year-old woman with a primary malignant melanoma of the esophagus, who underwent a radical esophageal resection with a lymph node dissection. We report this case with a review of the relevant literature. (Korean J Gastrointest Endosc 2006;33:220⁣225)

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Development of Early Gastric Cancer 38 Months after the Complete Remission of Helicobacter pylori Associated Gastric MALT Lymphoma: Ji-Yun Jo, M.D., Hwoon-Yong Jung, M.D., Kee Don Choi, M.D., Ho June Song, M.D., Gin Hyug Lee, M.D., Jeong-Sik Byeon, M.D., Seung-Jae Myung, M.D., Suk-Kyun Yang, M.D., Weon-Seon Hong, M.D. and Jin-Ho Kim, M.D.; Korean J Gastrointest Endosc 2006;33(4):226-229. Published online October 30, 2006

Abstract PDF: Helicobacter pylori (H. pylori) has been etiologically linked with primary gastric mucosa-associated lymphoid tissue (MALT) lymphoma and gastric carcinoma; however, synchronous and metachronous development of these two neoplasm is a rare finding. The metachronous development of early gastric cancer following gastric MALT lymphoma is even more exceptional, and less than 10 cases have been reported on the literature. We encountered one case of early gastric cancer which occurred 38 months after the complete remission of H. pylori associated gastric MALT lymphoma. We report here on this case along with a review of the literature. (Korean J Gastrointest Endosc 2006;33:226⁣229)

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Two Cases of Gastric Mucosal Calcinosis: Ju Chun Yeo, M.D., Dong Uk Ju, M.D., Se Young Lee, M.D., Sung Woo Eum, M.D., Jai Hyun Lee, M.D., Se Hwan Kim, M.D., Chang Keun Park, M.D., Seung Yup Lee, M.D., Hyun Soo Kim, M.D. and Mi Jin Koo, M.D.*; Korean J Gastrointest Endosc 2006;33(4):230-234. Published online October 30, 2006

Abstract PDF: Gastric mucosal calcinosis (GMC) is a very rare condition that is characterized by the nodular deposition of calcium salts in the gastric mucosa. It has been associated with renal failure, gastric cancer, ingestion of aluminum- containing antacids and the use of sucralfate in organ transplant patients. The etiology of this condition is uncertain, but several theories have been proposed; the condition is due secondarily to hyperparathyroidism in renal failure and to the alkalinization of the gastric mucosa. We report here on two patients who had long- term use of bismuth and/or aluminum-containing antacids to treat their gastro-esophageal reflux symptoms. The esophagogastroduodenoscopy revealed acute gastritis patterns, and GMC was confirmed histologically with biopsy. When one patient stopped ingesting bismuth-containing antacid solution, the follow-up esophagogastroduodenoscopy and the biopsy revealed a completely improved state. We report here on these interesting cases and we include a brief review of the literature. (Korean J Gastrointest Endosc 2006;33:230⁣234)

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A Case of the Duodenal Bulb Abscess: Jae Il Chung, M.D., Hi Jong Chang, M.D., Sang Hun Lee, M.D., Dong Sik Cho, M.D., Si Woo Kim, M.D., Sung Chul Cha, M.D., Yu Gin Cho, M.D., Yun Chul Seok, M.D., Jin Hoi Ku, M.D.* and Haeng Ji Kang, M.D.^†; Korean J Gastrointest Endosc 2006;33(4):235-238. Published online October 30, 2006

Abstract PDF: Duodenal abscess is a rarely reported disease throughout the entire world. Duodenal abscesses are developed mostly from the complication of duodenal ulcer perforation, and only small percentage of duodenal abscesses are the result of cholecysto-duodenal fistula which was made by gall bladder perforation. We report a 84-year-old male patient who presented to the emergency department with severe anorexia and generalized weakness for 2 weeks. The upper gastrointestinal endoscopy done and revealed a protruding mass at the lesser curvature of the duodenal bulb. As soon as the mass was punched with a biopsy forceps, a large amount of abscess began to pour out into the intestinal lumen. Abdominal CT scan demonstrated the presence of an air-fluid level the in gall bladder and also abscess in the porta hepatitis which was located between the gall bladder and the duodenum. Because the patient refused any surgical intervention, we treated him conservatively with intravenous antibiotics. Patient's symptom of anorexia was slowly resolved, and patient was discharged 10 days later. (Korean J Gastrointest Endosc 2006;33:235⁣238)

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Three Cases of Colonic Anisakiasis: Young Hun Kim, M.D., Woo Bong Choi, M.D., Seung Chan Lee, M.D. and Hyun Woong Choi, M.D.*; Korean J Gastrointest Endosc 2006;33(4):239-243. Published online October 30, 2006

Abstract PDF: Anisakiasis occurs when humans ingest raw or inadequately cooked saltwater fish or squid that is infested with anisakis larvae. The larvae invade the gastrointestinal mucosa and cause abdominal pain, nausea, vomiting and various gastrointestinal lesions. Anisakiasis of the stomach has been reported occasionally but involvement of the small bowel or colon is extremely rare. We report three cases of anisakiasis in the colon with a brief review of the relevant literature. (Korean J Gastrointest Endosc 2006;33:239⁣243)

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A Case of Primary Colonic Lymphoma with Peritoneal Carcinomatosis and Pleural Effusion: Ik Jun Choi, M.D., Mi Youn Park, M.D., Se Na Jang, M.D., Bum June Kwon, M.D., Hae Seong Nam, M.D., Keon Woo Park, M.D., Eun Chul Jang, M.D., Seung Woo Lee, M.D., Yeon Soo Kim, M.D. and Sang Bum Kang, M.D.; Korean J Gastrointest Endosc 2006;33(4):244-247. Published online October 30, 2006

Abstract PDF: Primary gastrointestinal lymphomas are quite rare with the stomach and small bowel being the most frequent site. Colon involvement is observed in only 10∼20% of all gastrointestinal lymphomas. A colonic lymphoma presents with non-specific abdominal pain, weight loss, a change in bowel habits, bleeding, intestinal obstruction, intussusception and a palpable mass. A colonic lymphoma can be indicated using a barium enema, abdominal CT and colonoscopy. The correct diagnosis is obtained by a colonoscopic biopsy. We report a case of primary colonic non-Hodgkin's lymphoma with peritoneal carcinomatosis and a right pleural effusion. (Korean J Gastrointest Endosc 2006;33:244⁣247)

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A Case of Intestinal Lymphangiectasia Improved with Antiplasmin and Octreotide Treatment: Su Kyong Yu, M.D., Jae Myung Choi, M.D., Jun Hwan Yoo, M.D., Duck Kee Kim, M.D., Seung Jae Shin, M.D., Kee Myung Lee, M.D., Beung Moo Yoo, M.D., Ki Baik Hahm, M.D., Jin Hong Kim, M.D. and Jae Ho Han, M.D.*; Korean J Gastrointest Endosc 2006;33(4):248-252. Published online October 30, 2006

Abstract PDF: Intestinal lymphangiectasia is characterized by protein- losing enteropathy, and is diagnosed by a small bowel biopsy demonstrating dilated lymphatics in the mucosa, submucosa and serosa in the absence of coexistent inflammation. We report a case of primary intestinal lymphangiectasia that occurred in a 2-year-6-month-old girl who was treated successfully with antiplasmin and octreotide. Initially, the patient was treated with a lipid restriction diet with medium chain triglyceride oil, but her symptoms were not relieved. This case shows that antiplasmin and octreotide therapy might be useful for treating refractory primary intestinal lymphangiectasia. (Korean J Gastrointest Endosc 2006;33:248⁣252)

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A Case of Ampullary Carcinoma Managed with Endoscopic Snare Ampullectomy: Kyu Chul Lee, M.D.* and Dong Ki Lee, M.D.; Korean J Gastrointest Endosc 2006;33(4):253-256. Published online October 30, 2006

Abstract PDF: The ampullary carcinoma is a rare disease that occurs in approximately 0.2% of all gastrointestinal carcinomas and in 7% of all periampullary carcinomas. The clinical manifestations of ampullary carcinoma are anorexia, nausea, vomiting, jaundice, itching, abdominal pain, diarrhea, etc. When discovered, approximately 80% of cases are operable because of the rare regional invasion of the tumor. The 5-year survival rate after surgery is approximately 35%, but closer to 0% without surgery. Therefore the treatment of choice is surgery (pancreaticoduodenec- tomy, Whipple's operation). However, less invasive procedures are needed for patients in poor general condition, old age, and those who refuse surgery. We report a case of an ampullary carcinoma in which an endoscopic snare ampullectomy was performed as a second option after the patient refused surgery. (Korean J Gastrointest Endosc 2006;33:253⁣256)

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A Case of Pancreatogastric Fistula Associated with Intraductal Papillary Mucinous Neoplasm: Seung Geun Lee, M.D., Il Du Kim, M.D., Hye Jeong Lee, 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., Mong Cho, M.D., Jee Yeon Kim, M.D.* and Suk Kim, M.D.^†; Korean J Gastrointest Endosc 2006;33(4):257-260. Published online October 30, 2006

Abstract PDF: There have been an increasing number of reports of intraductal papillary mucinous neoplasm (IPMN) of the pancreas since its first report by Ohhasi et al. in 1982. However, fistula formation associated with IPMN to other organs is rare. A 79-year -old woman visited our hospital due to diarrhea and dyspepsia for 3 months. Abdominal computed tomography and magnetic resonance imaging revealed IPMN of the pancreas and fistula formation in the stomach. Endoscopic retrograde cholangiography after injecting a dye through the pancreatic duct showed dye flowing out into stomach. An endoscopic biopsy was carried out through the pancreatogastric fistula and this tumor was confirmed to be IPMN. We report a case of pancreatogastric fistula associated with IPMN that was confirmed by histology. (Korean J Gastrointest Endosc 2006;33:257⁣261)

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