Clinical Endoscopy

The Diagnostic Accuracy of Endoscopic Ultrasonography for the Preoperative Staging of Gastric Cancer: the Risk of Overstaging and Understaging: Bo Hyun Kim, M.D., Dong Ho Lee, M.D.*, Hae Yeon Kang, M.D., Seong Joon Koh, M.D., Ki Young Yang, M.D., Jeong Hoon Lee, M.D., Kwang Hyuck Lee, M.D.*, Young Soo Park, M.D.*, Jin-Hyeok Hwang, M.D.*, Jin-Wook Kim, M.D.*, Sook Hyang Jung, M.D.*, Nayoung Kim, M; Korean J Gastrointest Endosc 2006;33(5):263-270. Published online November 30, 2006

Abstract PDF: Background
/Aims: The preoperative staging of gastric cancer facilitates the planning of therapy. Preoperative endoscopic ultrasonography is a useful procedure for the staging of gastric cancer, but sometimes there can be problems with overstaging and understaging. Methods: Endoscopic ultrasonography was performed preoperatively on 171 patients with gastric cancer. The results of endoscopic ultrasonography were compared with the postoperative histological staging. Results: The overall accuracy of endoscopic ultrasonography for the determination of the T stage was 65.5%, the overall accuracy was 74.4%, 51.7% and 38.9% for determining the T1, T2 and T3 staging, respectively. Endoscopic ultrasonography had an accuracy of 67.3% for determining the absence of lymph node metastasis. In univariate analysis, the diagnostic accuracy was lower for infiltrative type and gastric cancer with microinvasion significantly. Multivariate analysis showed overstaging occurred for gastric cancers with concomitant ulcer, inflammation or submucosal fibrosis (p=0.004) and that understaging occurred for gastric cancers with infiltrative type or microinvasion (p=0.029, p＜0.001). Conclusions: Endoscopic ultrasonography is a valuable diagnostic tool for most gastric cancers with some exceptions due to the overstaging and understaging. Gastric cancers with concomitant ulcer, inflammation or submucosal fibrosis may contribute to overstaging. By contrast, gastric cancers with infiltrative type or microinvasion may result in understaging. (Korean J Gastrointest Endosc 2006;33:263⁣270)

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The Expression of TGF-β1 in Patients with Chronic Atrophic Gastritis: Kyu-Jong Kim, M.D., Gin Hyug Lee, M.D., Hwoon-Yong Jung, M.D., Seong Soo Hong, M.D., Jin-Yong Jeong, Ph.D., Sun-Mi Lee, B.S., Won-Hee Nam, B.S., Jeong-Sik Byeon, M.D., Seung-Jae Myung, M.D., Suk-Kyun Yang, M.D., Weon-Seon Hong, M.D., Jin-Ho Kim, M.D., You; Korean J Gastrointest Endosc 2006;33(5):271-277. Published online November 30, 2006

Abstract PDF: Background
/Aims: Mucosal atrophy is defined as the loss of appropriate glands in the gastric mucosa; such a finding suggests that this malady is associated with an excessive ratio of apoptotic cells to proliferating epithelial cells. However, exactly why the genesis and progression of the atrophic changes takes place in the gastric mucosa of some, but not all of the subjects infected with H. pylori, is seldom described. TGF-β1 (transforming growth factor-β1) is a potent growth inhibitor in epithelial tissues, and it also induces apoptosis of epithelial cells. We evaluated its role in the pathogenesis of atrophic gastritis by analyzing the expression of TGF-β1. Methods: The subjects were 14 patients with chronic atrophic gastritis and 43 patients with chronic gastritis. The exclusion criteria were as follows; those patients who had a previous history of gastrectomy, PPI, H. pylori eradication, NSAIDs, stomach cancer and/or a severe bleeding tendency. Biopsy specimens were obtained from the antrum, angle and body of the stomach, respectively and we performed RT-PCR for determining the expression of TGF-β1 mRNA with using an additional angle specimen. Results: The clinical parameters were similar in both groups. The rate of H. pylori infection was also similar in both groups. The TGF-β1 levels were significantly higher for the chronic atrophic gastritis group than for the chronic gastritis group. Conclusions: The results that the TGF-β1 levels are significantly higher in the chronic atrophic gastritis group suggest that TGF-β1 is associated with the development of atrophic gastritis. The apoptotic process induced by TGF-β1 may be linked to the development of atrophic gastritis. (Korean J Gastrointest Endosc 2006;33:271-277)

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Clinical and Colonoscopic Characteristics of Primary Signet Ring Cell Carcinoma in Colorectum: Sung Hee Pyo, M.D., Jeong-Sik Byeon, M.D., Seung-Jae Myung, M.D., Suk-Kyun Yang, M.D., Hyung Joon Lee, M.D., Seung Il Pyo, M.D., Jin-Ho Kim, M.D., Jin Cheon Kim, M.D.* and Se Jin Jang, M.D.^†; Korean J Gastrointest Endosc 2006;33(5):278-284. Published online November 30, 2006

Abstract PDF: Background
/Aims: A primary signet ring cell carcinoma (SRCC) in the colorectum is unusual. This study evaluated the clinical and colonoscopic characteristics of primary colorectal SRCC. Methods: Twenty-eight patients diagnosed with a primary colorectal SRCC and 100 patients diagnosed with a primary colorectal nonmucinous adenocarcinoma were enrolled in this study. The medical records and colonoscopic findings were reviewed. Results: The mean age was younger in the SRCC patients than in the nonmucinous adenocarcinoma patients (47.3±15.5 years vs. 60.3±10.4 years, p＜0.001). In SRCC, hematochezia was less frequent while abdominal pain was more common (p＜0.001). Duke stages A or B was rare in SRCC (4/28, 14.3% vs. 58/100, 58.0%, p＜0.001). The colonoscopic features of Borrmann type 4 was more common in SRCC (10/28, 35.7% vs. 3/100, 3.0%, p＜0.001). The occurrence of a tumor in the right colon was more frequent in SRCC (17/28, 60.7% vs. 20/100, 20.0%, p＜0.001). The diagnostic yield of the first colonoscopic biopsy was lower in the SRCC patients (85.7% vs. 98.0%, p=0.021). Conclusions: Primary colorectal SRCC appears to occur in younger patients compared with nonmucinous adenocarcinoma. A more advanced stage and an infiltrative lesion such as Borrmann type 4 appears to be common and the diagnostic yield of a colonoscopic biopsy tends to be low in primary colorectal SRCC. (Korean J Gastrointest Endosc 2006;33:278⁣284)

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A Case of Primary Follicular Lymphoma Arising in the Rectum: Bo Sung Kwon, M.D., Chang Duck Kim, M.D., Jae Youn Park, M.D., Moon Kyung Joo, M.D., Jin Su Jang, M.D., Jin Nam Kim, M.D., Seung Young Kim, M.D., Bora Keum, M.D., Youn Suk Seo, M.D., Yong Sik Kim, M.D., Yoon Tae Jeen, M.D., Hoon Jai Chun, M.D., Soon Ho Um; Korean J Gastrointest Endosc 2006;33(5):285-288. Published online November 30, 2006

Abstract PDF: Follicular lymphoma (FL) is one of the most common non-Hodgkin's lymphomas in the United States, but it is relatively rare in Asia. FL typically arises in lymph nodes together with spleen, liver, and bone marrow involvement. So, primary extra-nodal FL without peripheral nodal involvement is rare. Histologically, it shows nodular aggregates of lymphoma cells and positivity for CD 10, CD 20 and bcl-2. Not only the stage, but also the grade is associated with the survival rate. Grade 3 FL presents a worse prognosis than does grade 1 and 2 FL and this should be treated with an anthracycline based CHOP regimen. We report here on a case of primary follicular lymphoma arising in the rectum; this was observed in a 58-year-old woman who complained of anorexia, dyspepsia and diarrhea. (Korean J Gastrointest Endosc 2006; 33:285⁣288)

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A Case of Huge Gastric Angiodysplasia Treated with Argon Plasma Coagulation: Sung-Jin Moon, M.D., Jin Il Kim, M.D., Jae Kyu Chung, M.D., Min Kuk Kim, M.D., Dae Young Cheung, M.D., Se Hyun Cho, M.D., Soo-Heon Park, M.D., Joon-Yeol Han, M.D., Jae Kwang Kim, M.D. and Kyu Yong Choi, M.D.; Korean J Gastrointest Endosc 2006;33(5):289-293. Published online November 30, 2006

Abstract PDF: Gastric angiodysplasia is an uncommon cause of upper gastrointestinal blood loss that may occur in the stomach or duodenum, and is responsible for up to 1∼6% of upper gastrointestinal bleeding. In contrast to colonic angioectasia, gastric lesions are more common in young individuals and originate from developmental causes. On an endoscopic examination, the lesions typically show a spider-shape or coral reef-like pattern of dilated and tortuous vessels and measure approximately 2 to 10 mm in diameter. We encountered a case of huge gastric angiodysplasia that presented with overt bleeding and anemia and was successfully treated with argon plasma coagulation. (Korean J Gastrointest Endosc 2006;33: 289⁣293)

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A Case of Doudenal Diaphragm in an Adult Treated with Endoscopic Membranotomy using Insulated Tip Electrosurgical Knife: Bum Jun Kwon, M.D., Chang-Whan Kim, M.D., Tae Ho Kim, M.D., Yeon Soo Lim, M.D.*, Jung Sun Pack, M.D., Keun Jong Cho, M.D., Jin Il Kim, M.D., Soo-Heon Park, M.D., Hiun Suk Chae, M.D., Jae Kwang Kim, M.D., Sok Won Han, M.D. and Kyu-Yong Choi, M.D.; Korean J Gastrointest Endosc 2006;33(5):294-297. Published online November 30, 2006

Abstract PDF: A duodenal diaphragm is rare congenital anomaly among the duodenal obstructions. Its symptoms and signs usually appear from birth if the obstruction is complete. However, a diagnosis may be delayed until the patient reaches adulthood in cases of an incomplete obstruction. Treatment of an adult duodenal diaphragm is usually surgical. To our knowledge, there are few reports of the endoscopic treatment of an adult duodenal diaphragm but none in Korea. We report a duodenal diaphragm in a 26- year-old female with epigastric pain, who was treated with an endoscopic membranotomy using an insulated tip knife. (Korean J Gastrointest Endosc 2006;33:294⁣297)

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Upper Gastrointestinal Bleeding due to Direct Invasion of Hepatocellular Carcinoma to the Duodenum: Kyoung Ah Jung, M.D., Hyun Jin Kim, M.D., Sun Pil Choi, M.D., Jong Ha, M.D., Byong Ryol Lim, M.D., Tae Hyo Kim, M.D. and Ok Jae Lee, M.D.; Korean J Gastrointest Endosc 2006;33(5):298-302. Published online November 30, 2006

Abstract PDF: Although a metastasis to the gastrointestinal tract (GI) is rare in patients with hepatocellular carcinoma (HCC), it can occur by hematogenous or lymphatic spread, or by direct invasion of a tumor. A 61-year old woman who had a progressing large primary liver cancer presented with upper gastrointestinal (UGI) bleeding. UGI endoscopy showed a large duodenal submucosal tumor-like mass with a central ulcer and adherent blood clots. Endoscopic biopsy and coagulation using argon plasma probe were performed. The microscopic examination revealed a HCC. We report this unusual case of HCC with direct invasion of the duodenum. (Korean J Gastrointest Endosc 2006;33:298⁣302)

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A Case of Acute Ischemic Enteritis Caused by Polyarteritis Nodosa: Kyung-Hwan Lee, M.D., Jae Myung Park, M.D., Song Wook Chun, M.D., Chang Nyol Paik, M.D., Jung Hwan Oh, M.D., Yu Kyung Cho, M.D., In Seok Lee, M.D., Sang Woo Kim, M.D., Myung-Gyu Choi, M.D. and In-Sik Chung, M.D.; Korean J Gastrointest Endosc 2006;33(5):303-306. Published online November 30, 2006

Abstract PDF: Polyarteritis nodosa is a systemic necrotizing vasculitis of the small- and medium-sized arteries with gastrointestinal involvement in more than 50% of cases at some time during the course of the disease. The gastrointestinal manifestations can be diverse and include abdominal pain, nausea and vomiting, ulceration, hemorrhage, occlusion and perforation. Gut involvement is a serious prognostic factor. A 65-year-old man was referred to our department suffering from epigastric pain. A push enteroscopy revealed ischemic enteritis at the proximal small bowel and the CT scan showed a large dilation of the small bowel. His condition deteriorated rapidly and an exploratory laparotomy and total resection of the small bowel was performed. We report a rare case in which the push enteroscopy revealed acute ischemic enteritis of the small bowel and where the pathology specimen showed transmural necrosis of the involved small bowel due to vessel occlusion caused by polyarteritis nodosa. (Korean J Gastrointest Endosc 2006;33:303⁣306)

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A Case of Protein Losing Enteropathy Caused by Primary Intestinal Lymphangiectasia: Se Young Lee, M.D., Ju Chun Yeo, M.D., Young Deuk Youn, M.D., Sae Rom Kim, M.D., Young Lan Kwon, M.D., Hyon Uk Ryu, M.D., Jun Chul Kim, M.D., Myung Kwon Lee, M.D., Chang Keun Park, M.D. and Sang Mun Lee, M.D.; Korean J Gastrointest Endosc 2006;33(5):307-312. Published online November 30, 2006

Abstract PDF: Primary intestinal lymphangiectasia is a rare congenital cause of protein losing enteropathy that is characterized by chronic diarrhea, generalized edema, ascites, hypoproteinemia, hypoalbuminemia, and lymphopenia. We encountered an 18-year-old woman who suffered from longstanding diarrhea and progressive leg edema. The laboratory findings showed the typical features of this disorder. The presence of enteric protein loss was documented with the 24 hour fecal clearance of α₁-antitrypsin and ^99mTc human serum albumin scintigraphy. A duodenoscopy and biopsy showed scattered white spots and markedly dilated lymphatics in the tips of the villi, respectively. The patient's clinical symptoms improved after placing her on a high protein and low fat diet with medium chain triglyceride supplements. (Korean J Gastrointest Endosc 2006;33:307⁣312)

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A Case of Polypoid Arteriovenous Malformation Treated by Polypectomy with Detachable Snare: Ji Min Jung, M.D., Ki-Nam Shim, M.D., Moon Young Choi, M.D., Hyun Joo Song, M.D., Kum Hei Ryu, M.D., Hye Jung Yeom, M.D., Tae Hun Kim, M.D., Sung-Ae Jung, M.D., Kwon Yoo, M.D., Il Hwan Moon, M.D. and Si Nae Lee, M.D.*; Korean J Gastrointest Endosc 2006;33(5):313-317. Published online November 30, 2006

Abstract PDF: Arteriovenous malformations are degenerative lesions of the gastrointestinal tract that occur with a frequency that increases with increasing age. Although the bleeding caused by arteriovenous malformations is typically chronic, slow, intermittent and recurrent, 15% of patients with arteriovenous malformations present with massive bleeding. Any part of the gastrointestinal tract can be involved and arteriovenous malformations usually appear on endoscopy as either flat or elevated discrete bright red mucosal lesions. There are a few cases of colonic arteriovenous venous malformations with a polypoid appearance with some of their endoscopic treatments resulting in profuse bleeding from the remnant stalk. We encountered a case of a polypoid arteriovenous malformation in the colon of a 69-year-old patient with active gastrointestinal bleeding. The patient was treated successfully by an endoscopic polypectomy with a detachable snare. (Korean J Gastrointest Endosc 2006;33:313⁣317)

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A Case of Condyloma Acuminatum Treated by Argon Plasma Coagulation: Hyon Uk Ryu, M.D., Se Young Lee, M.D., Young Deuk Youn, M.D., Ju Chun Yeo, M.D., Sae Rom Kim, M.D., Young Lan Kwon, M.D., Jun Chul Kim, M.D., Byung Jun Kang, M.D., Chang Keun Park, M.D., Sang Mun Lee, M.D. and Mi Jin Gu, M.D.*; Korean J Gastrointest Endosc 2006;33(5):318-321. Published online November 30, 2006

Abstract PDF: Condyloma acuminatum (CA) is a common sexually transmitted disease caused by the human papillomavirus. In gastrointestinal practice, we generally encounter this disease in the anal canal but rarely in the rectum during a colonoscopy. There are many therapeutic options for CA including chemical or physical destruction, immunological therapy, or a surgical excision. All these procedures have some degree of limitations such as limited clearance rate, high recurrence rate, long duration of therapy, bleeding, release of potentially infectious aerosols, scarring etc. With argon plasma coagulation (APC), which is more available than lasers in gastrointestinal practice, a high frequency current flows through the argon plasma to the tissue, allowing well-controlled superficial tissue destruction without any direct contact between the probe and the tissue. We present a case of anal CA that was treated successfully with APC during a colonoscopy with no recurrence during the follow up. (Korean J Gastrointest Endosc 2006;33:318⁣321)

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Percutaneous Transhepatic Gallbladder Stenting for Acute Cholecystitis after Palliative Metallic Biliary Stenting: Hwal Suk Cho, M.D., Sun Mi Lee, M.D., Chan Won Park, M.D., Ji Young Kim, M.D., Do Hoon Kim, M.D., Kee Tae Park, M.D., Tae Oh Kim, M.D., Jeong Heo, M.D., Gwang Ha Kim, M.D., Dae Hwan Kang, M.D., Geun Am Song, M.D. and Mong Cho, M.D.; Korean J Gastrointest Endosc 2006;33(5):322-325. Published online November 30, 2006

Abstract PDF: Metallic biliary stenting to relieve a malignant biliary obstruction can cause a cystic duct obstruction and acute cholecystitis. Percutaneous transhepatic cholecystostomy is often performed in patients with a limited life expectancy but can have a significant impact on the quality of life. Percutaneous transhepatic gallbladder stenting (PTGS) was performed across the cystic duct via the cholecystostomy tube tract to allow the removal of the cholecystostomy tube. The patient remained asymptomatic for 7 months after PTGS. In conclusion, PTGS across the cystic duct may be considered a treatment option in selected patients who develop acute cholecystitis after palliative metallic biliary stenting. (Korean J Gastrointest Endosc 2006;33: 322⁣325)

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A Case of Pancreatic Endocrine and Exocrine Tumor with MEN Type I: Oh Wan Kwon, M.D., Ho Soon Choi, M.D., Jee Hyun Kim, M.D., Won Moon, M.D., Jung Mi Kim, M.D., Dong Hee Koh, M.D., Hang Rak Lee, M.D., Oh Young Lee, M.D., Byung Chul Youn, M.D., Joon Soo Ham, M.D., Dong Hoo Lee, M.D., Min Ho Lee, M.D. and Choon Suhk Kee, M; Korean J Gastrointest Endosc 2006;33(5):326-331. Published online November 30, 2006

Abstract PDF: An acinar cell carcinoma of the exocrine pancreas is a rare tumor with reported a incidence of 1% to 2% of pancreatic carcinomas. Cases of acinar cell carcinomas with amphicrine features have been reported in recent decades. However, there are no reports of two simultaneous pancreatic masses: an endocrine tumor and, an exocrine tumor. We encountered a 59-year-old female patient presenting with abdominal pain and melena. The acinar cell carcinoma was a 1⁓1 cm-sized round solid mass in the head of the pancreas. The islet tumor was a 2.5⁓1.5 cm-sized round mass in the body of the pancreas. The endocrine tumor was nonfunctioning. Melena resulted from the hemosuccus pancreaticus due to a ductal invasion of the acinar cell carcinoma. The patient had a parathyroid adenoma with hyperparathyroidism. Therefore, both the islet tumor and parathyroid adenoma with hyperparathyroidism were strongly suggestive of a MEN I. (Korean J Gastrointest Endosc 2006;33:326⁣332)

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