Clinical Endoscopy

The Clinical Significance of the Absolute and Relative Classification of the Depth of Invasion for Submucosal Invasive Carcinomas of the Colon: Soo Jung Lee, M.D., Jin Oh Kim, M.D., Soo Hoon Eun, M.D., Hyun Soo Joo, M.D., Yeon Soo Kim, M.D., Hyun Ku Jung, M.D., In Seop Jung, M.D., Bong Min Ko, M.D., Joo Young Cho, M.D., Joon Seong Lee, M.D., Moon Sung Lee, M.D., So Young Jin, M.D., Chan Sup Shim,; Korean J Gastrointest Endosc 2007;35(2):61-67. Published online August 30, 2007

Abstract PDF: Background
/Aims: We investigated the clinical significance of the criteria of the absolute and relative depth of invasion for submucosal invasive colorectal carcinomas. Methods: We analyzed retrospectively the clinicopathological features of 29 submucosal invasive colorectal cancers. The relative depth of submucosal invasion was evaluated by a relative (sm1, 2, 3) classification and the absolute depth of submucosal invasion was measured in micrometers from the lower border of the muscularis mucosa to the deepest cancer gland. Results: All sm1 cancers showed a submucosal layer invasion of less than 1,000μm; invasion was seen between 500μm and 1,000μm. The rate of lymphovascular invasion was higher for sm1c, sm2 and sm3 than for sm1a and sm1b, and the rate of invasion was higher for a level of 500μm or more than for a level of 500μm or less for the depth of submucosal invasion. One of sixteen patients that underwent surgery showed lymph node involvement. For this patient, the relative depth of invasion was sm1c and the absolute depth was 900μm. Conclusions: Endoscopically treated submucosal colorectal cancer needs to be evaluated by the absolute depth in addition to the relative depth. It seems that a submucosal invasive cancer less than 500μm in submucosal depth probably can be treated by endoscopic resection.

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The Significance of Fecal Occult Blood Testing to Screen for Colon Cancer: Jung Hyun Kwon, M.D., Myung Gyu Choi, M.D., Jung Pil Suh, M.D., Jae Hyuck Chang, M.D., Kwan Woo Nam, M.D., Ho Sung Park, M.D., Chang Nyol Paik, M.D., Jae Myung Park, M.D., Yu Kyung Cho, M.D., In Seok Lee, M.D., Sang Woo Kim, M.D. and In Sik Chung, M.D.; Korean J Gastrointest Endosc 2007;35(2):68-73. Published online August 30, 2007

Abstract PDF: Background
/Aims: We investigated the efficacy of the fecal occult blood test (FOBT) as a colon cancer screening tool in a tertiary hospital setting. Methods: This retrospective study analyzed patients who underwent routine check- ups at Kang-Nam St. Mary's Hospital Health Promotion Center from January 2004 to April 2005. All the subjects were encouraged to submit stool for a FOBT, while performing a double contrast barium enema (DCBE) was optional for those who wanted colon examination. Colonoscopy was performed if the FOBT or DCBE results were abnormal or if the patients had bowel symptoms. Results: The FOBT was performed in 8,198 of 10,182 patients (80.5%) who underwent routine check-ups. The overall positive rate of FOBT was 149 of 8,198 (1.8%) and this increased with age (p＜0.05). Colonoscopy and/or DCBE was performed in 33 of 149 patients (22.1%) in the FOBT positive group. Colon cancer and polyp were diagnosed 2 (6.1%) and 7 (21.2%) patients, respectively, in the FOBT positive group, whereas colon cancer and polyp were diagnosed in 3 (0.5%) and 102 (15.7%) patients, respectively, in the FOBT negative group. The sensitivity and specificity of the FOBT for colon cancer was 40% and 95.4%, respectively. Conclusions: Although it had low sensitivity, the FOBT was a useful screening tool for detecting colon cancer in a tertiary hospital setting.

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A Role of Endoscopic Balloon Dilatation after Partial Infundibulotomy in Billroth II Patients: Dae Won Jun, M.D.*, Ho Soon Choi, M.D., Sae Hoon Park, M.D.^†, Hang Lak Lee, M.D., Oh Young Lee, M.D., Byung Chul Yoon, M.D., Joon Soo Hahm, M.D., Min Ho Lee, M.D. and Dong Hoo Lee, M.D.; Korean J Gastrointest Endosc 2007;35(2):74-79. Published online August 30, 2007

Abstract PDF: Background
/Aims: Endoscopic retrograde cholangiopancreatography (ERCP) is difficult to perform in patients with a Billroth II anastomosis due to the anatomical alterations. This study evaluated retrospectively the efficacy and safety of endoscopic balloon dilatation after a partial infundibulotomy with a needle knife in patients who had undergone a Billroth II operation. Methods: Between January 1, 2004 and December 31, 2005, 11 patients, who had undergone a prior Billroth II gastrectomy, underwent ERCP because of a suspicion of pancreatobiliary diseases. Infundibulotomy was performed using a needle knife sphincterotome. After a partial infundibulotomy, a dilation balloon was passed over a prepositioned guidewire and placed in the biliary orifice. Under endoscopic and fluoroscopic control, the balloon was then inflated with diluted contrast over a period of 1 to 2 minutes. Results: A total of 10 patients (7 male and 3 female) were enrolled in this study. Eight had common bile duct stones, 1 bile duct cancer, and 1 pancreatic cancer. The common bile duct was dilated by a balloon. The calculi were removed in 6 patients, and a common bile duct stent was implanted in two cases via endoscopy. No complications such as acute pancreatitis or apparent infections of the biliary tracts were encountered in these cases except for mild fever, temporary high serum levels of aminotransferase and amylase after ERCP in 3 cases. No severe bleeding or perforation occurred in patients undergoing balloon dilatation. Conclusions: An infundibulotomy with balloon dilatation is a valuable alternative to endoscopic sphinterotomy in the treatment of patients with bile duct diseases, who have undergone prior Billroth II gastrectomies.

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The Safety and Effectiveness of Medium Endoscopic Sphincterotomy with Endoscopic Papillary Large Balloon Dilation for Removing Difficult Common Bile Duct Stones: Sun Hae Lee, M.D., Sung Wook Hong, M.D., Young Deok Cho, M.D., Young Koog Cheon, M.D., Sang Gyun Kim, M.D., Jae Young Jang, M.D., Young Seok Kim, M.D., Jong Ho Moon, M.D., Joon Seong Lee, M.D., Moon Sung Lee, M.D., Chan Sup Shim, M.D. and Boo Sung Kim, M.; Korean J Gastrointest Endosc 2007;35(2):80-86. Published online August 30, 2007

Abstract PDF: Background
/Aims: Mechanical lithotripsy is generally used when it is difficult to endoscopically remove common bile duct (CBD) stones. However, this procedure not only requires extensive experience, but it is also time consuming. Medium endoscopic sphincterotomy (medium EST) combined with endoscopic papillary large balloon dilation (EPLBD) is recently being increasingly used; therefore, the aim of this study was to evaluate the safety and effects of medium EST with EPLBD for patients with CBD stones that are difficult to remove. Methods: 41 patients with CBD stones that were difficult to remove by conventional endoscopic methods were enrolled in this study. EPLBD was performed after medium EST. The size of the stones, the procedure time, complications and the total number of sessions needed for stone removal were analyzed. Results: The mean size of the CBD stones was 18.2 ⁑ 7.7 mm, and the mean number of stones was 2.7. Additional mechanical lithotripsy for complete removal was required in 9.7% (4/41) of the patients. Procedure related complications occurred in 7% (3/41): bleeding in 1 case and acute pancreatitis in 2 cases. Conclusions: Medium EST with EPLBD was a safe and effective treatment modality for CBD stones that were difficult to remove. Further prospective randomized studies are needed for comparing the effectiveness and safety between conventional EST and medium EST with EPLBD for removing difficult CBD stones.

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A Case of Epithelioid Type Gastric Gastrointestinal Stromal Tumor with Gastrointestinal Bleeding: Eui Hyung Kim, M.D., Eun Jung Jeon, M.D., Jung Hwan Oh, M.D., Kon Ho Shim, M.D., Hyeug Lee, M.D., Jeong Jo Jeong, M.D. and Sang Wook Choi, M.D.; Korean J Gastrointest Endosc 2007;35(2):87-90. Published online August 30, 2007

Abstract PDF: The stomach is the most frequently noted site (50∼60%) of gastrointestinal stromal tumor. This tumor is categorized into three subtypes (the spindle cell type, the epithelioid type or mixed type) according to the shape of the cells that make up the tumor. We herein report on a case of gastrointestinal stromal tumor with an epithelioid subtype in a 60-year-old male. On admission, the patient presented with epigastric pain and melena. Endoscopy revealed a submucosal tumor with a central ulcer at the gastric body. Gastric wedge resection was performed. The tumor cells showed a rounded shape and positive staining for CD117. Because the epithelioid type gastrointestinal stromal tumor is unusual in Korea, we report here on this case along with a review of the relevant literature.

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One Case of Infectious Mononucleosis Concurrent with Acute Erosive EBV Gastritis: Jai Hyun Lee, M.D., Sung Woo Eum, M.D., Ga Young Kim, M.D., Jae Dae Shin, M.D., Jong Pil Park, M.D., Hyun Soo Kim, M.D., Gun Woo Kim, M.D. and Mi Jin Gu, M.D.*; Korean J Gastrointest Endosc 2007;35(2):91-95. Published online August 30, 2007

Abstract PDF: Infectious mononucleosis is an EBV-induced infection, and this is a self-limiting clinical syndrome with such characteristics as fever, pharyngitis, headache, splenomegaly, hepatomegaly and multiple lymphadenopathy among children and young adults. On the other hand, EBV infection-induced gastrointestinal symptoms like anorexia, nausea, vomiting, dyspepsia, abdominal pain, gastric bleeding and diarrhea are non-specific signs and there is less of a chance of EBV infection being involved with gastrointestinal disease. Especially, the relation of gastric cancer and gastric lymphoma with EBV infection is well defined, but other EBV-related gastrointestinal diseases have rarely been reported. Therefore, we report here on a case of acute erosive EBV gastritis that was diagnosed as EBV-induced infectious mononucleosis, and this was confirmed by esophagogastroduodenoscopy with biopsy.

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A Case of Double Pylorus Accompanied by Duodenal Ulcer: Ji Yeon Lee, M.D., Hyun Jeong Lee, M.D., Jong Sup Lee, M.D., Jin Nam Hyun, M.D., So Mi Kim, M.D., Seok Young Kim, M.D., Won Jun Lee, M.D., Seung Jin Choi, M.D., Il Young Chon, M.D. and Dong Joon Oh, M.D.; Korean J Gastrointest Endosc 2007;35(2):96-99. Published online August 30, 2007

Abstract PDF: Double pylorus is a rare abnormality of the gastrointestinal tract and it presents as two openings between the gastric antrum and the duodenal bulb. The acquired type is more common than the congenital one and this acquired type arises secondary to peptic ulcer disease. A 68-year-old man visited the gastrointestinal clinic and he presented with chronic epigastric pain and dyspepsia. Upper endoscopy showed double pylorus with an accessory channel on the lesser curvature side of the prepyloric antrum and also an active duodenal ulcer. Upon review of the patient's past history and examination, the findings of the upper endoscopy that was done 7 years previously were within the normal limits. The patient was diagnosed as having a double pylorus secondary to duodenal ulcer and he treated conservatively with anti-ulcer therapy. We report here on a case of double pylorus along with the brief review of the literature.

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A Case of Giant Brunner's Gland Adenoma Originating from the Gastric Pylorus Associated with Severe Anemia and Intussusception: Jeong Hwan Cho, M.D., Jin Seok Jang, M.D.*, Chae Ryeong Jang, M.D.*, Seung Uk Lee, M.D.*, Myung Hwan Roh, M.D.*, Sang Young Han, M.D.*, Seok Reyol Choi, M.D.*, Jin Han Cho, M.D.^† and Sook Hee Hong, M.D.^‡; Korean J Gastrointest Endosc 2007;35(2):100-104. Published online August 30, 2007

Abstract PDF: Brunner's gland adenoma is characterized by benign proliferation of the normal Brunner's gland, and is a relatively rare disease that accounts for only 10% of benign duodenal tumors. It is usually found in the bulb and second portion of the duodenum, but is rarely found in the pylorus. The clinical manifestations vary from non-specific upper abdominal symptoms to obstruction, intussusception and gastrointestinal hemorrhage. It is a benign lesion but rarely undergoes malignant transformation. Management of Brunner's gland adenoma involves complete removal of the lesion. We experienced a 43-year-old man who had complained of melena and dyspnea on exertion. An esophagogastroduodenoscopy and computed tomography of the upper gastrointestinal tract demonstrated the presence of a 5.5⁓4.0 cm sized hyperemic and lobulated large mass with hemorrhage that originated from the pylorus and was intussuscepted into the duodenum. Resection of the tumor revealed that it was a Brunner's gland adenoma on a histological examination.

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A Case of Eneropathy-associated T-cell Lymphoma Presenting with Persistent Abdominal Pain and Diarrhea: Tae Gun Moon, M.D., Poong-Lyul Rhee, M.D., Jung Su Ha, M.D., Hoi Jin Kim, M.D., June Sang Lee, M.D., Dong Kyung Chang, M.D., Young Ho Kim, M.D., Jun Haeng Lee, M.D., Jae J. Kim, M.D., Jong Chul Rhee, M.D. and Yong-Heyh Ko, M.D.*; Korean J Gastrointest Endosc 2007;35(2):105-109. Published online August 30, 2007

Abstract PDF: Enteropathy-associated T-cell lymphoma (EATL) is an unusual primary gastrointestinal lymphoma, and it is particularly associated with celiac sprue. These patients typically suffer from abdominal pain, diarrhea and/or weight loss. Primary intestinal T-cell lymphoma without celiac sprue is known to be rare. We report here on a case of EATL that presented with persistent abdominal pain and diarrhea, but this patient was without celiac sprue.

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Acute Cytomegalovirus Proctocolitis Presenting with Massive Lower Gastrointestinal Bleeding: Su Yeon Rhie, M.D., Chang Hwan Choi, M.D., Hyun Woong Lee, M.D., Mi Young Do, M.D., Seong Hyun Lee, M.D., Chae Heo, M.D., Suk Won Kim, M.D., Hyung Joon Kim, M.D., Sae Kyung Chang, M.D., Tae Jin Lee, M.D.* and Hwa Eun Oh, M.D.^†; Korean J Gastrointest Endosc 2007;35(2):110-115. Published online August 30, 2007

Abstract PDF: Cytomegalovirus (CMV) colitis usually affects immunosuppressed patients. However, CMV colitis may also affect patients with a debilitation caused by a severe illness or affect patients that have a specific physiological status (old age, pregnancy). Clinically, patients with CMV colitis most commonly present with abdominal pain, diarrhea, and gastrointestinal bleeding. The diagnosis of CMV colitis usually requires a biopsy of mucosal tissue. The characteristic finding on biopsy reveals CMV inclusion bodies. CMV colitis can be successfully treated with ganciclovir. We report two cases of CMV proctocolitis in elderly patients with chronic diseases that presented with massive lower gastrointestinal bleeding due to multiple rectal ulcerations. A pathological examination showed CMV inclusion bodies. CMV colitis should be considered in the differential diagnosis of patients with massive rectal ulcer bleeding when other causes fail to explain the course of the disease.

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A Case of Pneumoperitoneum, Pneumoretroperitoneum, Pneumomediastinum, and Subcutaneous Emphysema after Endoscopic Submucosal Resection: Chang Jun Shin, M.D., Kyoung Wan You, M.D., Seoung Bong Pyo, M.D., Hyeung Cheul Moon, M.D., Gun Young Hong, M.D., Dong Hyun Oh, M.D., Sang Wook Park, M.D., Yeun Keun Lim, M.D. and Kang Suk Seo, M.D.; Korean J Gastrointest Endosc 2007;35(2):116-120. Published online August 30, 2007

Abstract PDF: Flexible fiberoptic colonoscopy is extensively used for the diagnosis and management of colorectal disease. Many possible complications can occur. The most common and most serious complications are hemorrhage, perforation and respiratory problems. Colonic perforation usually results in a fatal and emergent condition. However, management of iatrogenic colonic perforation has been controversial. The choice between the medical versus the surgical approach has been dependent on the mechanism of the perforation, bowel preparation, location, size of the defect and severity of symptoms. We report here a case where colonic perforation emerged during endoscopic submucosal resection of a rectal tumor. The rectal perforation was accompanied with pneumoperitoneum, subcutaneous emphysema, pneumoretroperitoneum and pneumomediastinum. As the bowel preparation was excellent, intravenous antibiotics and total parenteral nutirition were administered. The patient was treated successfully without any complications.

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A Case of Biliary Stricture Induced by Blunt Abdominal Trauma Treated Endoscopically: Soo Hyun Kim, M.D.*, Don Haeng Lee, M.D.*^†, Seok Jeong, M.D.*, Jung Il Lee, M.D.*, Jin-Woo Lee, M.D.*, Kye Sook Kwon, M.D.*, Hyung Gil Kim, M.D.*, Yong Woon Shin, M.D.* and Young Soo Kim, M.D.*; Korean J Gastrointest Endosc 2007;35(2):121-124. Published online August 30, 2007

Abstract PDF: Traumatic biliary stricture is a secondary occurrence because of bile duct injury induced by trauma or surgery, but the delayed onset of a biliary stricture after blunt abdominal trauma is a rare condition. The patient mainly presents with jaundice after recent trauma. The traumatic biliary stricture is confirmed by complete history taking as well as by the use of endoscopic retrograde cholangiography and abdominal CT. Although surgical management such as bilioenteric anastomosis has been used traditionally for this type of biliary stricture, nonsurgical intervention, especially with balloon dilation or retrograde biliary drainage using duodenoscopy have been recently used and show good treatment outcomes. Herein we report a case of biliary stricture caused by blunt abdominal trauma that was treated endoscopically.

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