Clinical Endoscopy

The Usefulness of the Endoscopic Findings for Predicting Depth of Invasion in Early Gastric Cancer: Yang Hyun Baek, M.D., Hyun Seung Yoo, M.D., Hyun Ah Yoon, M.D., Ja Won Kim, M.D., Jeong Mo Koo, M.D., Young Hoon Kim, M.D., Su Hyun Cho, M.D., Seul Ki Kim, M.D., Jin Seok Jang, M.D., Jong Hun Lee, M.D., Myung Hwan Roh, M.D. and Seok Reyol Choi, M.D.; Korean J Gastrointest Endosc 2007;35(5):297-303. Published online November 30, 2007

Abstract PDF: Background
/Aims: Endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) has been used as a treatment for early gastric cancer (EGC). This study was performed to evaluate the usefulness of the endoscopic findings for diagnosing the depth of invasion in EGC patients. Methods: We retrospectively analyzed the endoscopic findings of 558 EGC patients who were diagnosed after gastrectomy, EMR or ESD at Dong-A University Hospital between 2000 and 2006, and we divided them into two groups (the mucosa group versus the submucosa group). Nine factors were assessed (Type I or IIa: surface color, surface irregularity, the Yamada type and pitting on the apex; Type IIb: surface color, surface irregularity and marginal definiteness: Type IIc or III: ulcer base irregularity, shape of the converging folds, center of the converging folds and marginal elevation). The tumor size and histologic type were assessed for all the EGCs. Results: Ulcer base irregularity (p=0.005), marginal elevation (p=0.001), and the shape of the converging folds (p=0.018) showed significant correlation with the depth of invasion in type IIc or III EGCs. Tumor size (＜2 cm) showed a significant correlation with mucosal invasion for all the EGCs. Conclusions: These results support the usefulness of the endoscopic findings for making the therapeutic decision for performing EMR or ESD through predicting the depth of invasion of EGCs. (Korean J Gastrointest Endosc 2007;35:297-303)

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Endoscopic and Clinical Characteristics of Gastrointestinal Parasite Infections: Won Hyun Lee, M.D., Seung Seok Yoo, M.D., Hyun Jin Kim, M.D., Tae Hyo Kim, M.D. and Ok Jae Lee, M.D.; Korean J Gastrointest Endosc 2007;35(5):304-312. Published online November 30, 2007

Abstract PDF: Background
/Aims: Although the overall infection rate of infection with parasites has decreased, the rate of food- mediated infection with parasites has not declined. This study was conducted to define the various endoscopic and clinical characteristics of gastrointestinal (GI) parasite infections diagnosed endoscopically. Methods: We reviewed retrospectively the medical records including the endoscopic reports of 27 patients with GI parasite infections diagnosed endoscopically at University Hospital from January 1993 through September 2006. Results: Among 27 patients with a GI parasite infection, 66.7% were female and food-mediated parasite infections including anisakiasis accounted for 77.8% of all of the infections. Soil-mediated parasites were still detected. Extremely rare cases of echinostomiasis and diphyllobothriasis were also identified. Abdominal pain was most frequent symptom (48.1%) and even intestinal or biliary obstructions were seen. The most common endoscopic finding was a visible worm, and various findings including the presence of a pseudotumor were observed. The median period from symptom onset to endoscopy was 15 days for anisakiasis with a pseudotumor compared to 1 day for anisakiasis without a pseudotumor. Conclusions: Endoscopy revealed the presence of various GI parasite infections as well as the presence of anisakiasis, a food-mediated parasitic disease. Various clinical and endoscopic features were seen, including GI bleeding, obstruction, and a pseudotumor. Therefore, a thorough endoscopic examination is required promptly together with detailed history taking concerning the consumption of raw fish. (Korean J Gastrointest Endosc 2007;35:304-312)

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Expression of TGF-β, TGF-β Receptor Type II and VEGF in Colorectal Adenomas and Adenocarcinomas: Sang Bum Kang, M.D., Seung Woo Lee, M.D., Yeon Soo Kim, M.D., Soon Woo Nam, M.D., Dong Soo Lee, M.D., Jin Man Kim, M.D.*, Sok Won Han, M.D. and Kyu Yong Choi, M.D.; Korean J Gastrointest Endosc 2007;35(5):313-320. Published online November 30, 2007

Abstract PDF: Background
/Aims: The aim of study was to investigate the expression of TGF-Ղ, TGF-RII and VEGF determined by immunohistochemical analysis with a comparison of the clinicopathological parameters such as tumor size, grade of dysplasia, lymph node metastasis and Dukes' stage in colorectal adenomas and adenocarcinomas, by use of a tissue microarray method. Methods: The expression of TGF-Ղ1, TGF-ՂRII, and VEGF was determined by immunohistochemistry in 20 adenomas and 40 adenocarcinomas. Tissue microarrays consisting of 2 mm cores from corresponding blocks were constructed and stained. Results: In adenomas, the staining intensity of TGF-Ղ, TGF-ՂRII and VEGF was increased in a high-grade dysplasia group of patients as compared a with low-grade dysplasia group of patients, respectively. The staining intensity of TGF-ՂRII was significantly increased in a high-grade dysplasia group of patients than a low-grade dysplasia group of patients (p =0.021). For the adenocarcinomas, the expression and staining intensity of TGF-Ղ1, TGF-ՂRII and VEGF were increased as compared with the adenomas (p＜0.001). However, no significant correlation was observed between the staining intensity of TGF-Ղ, TGF-ՂRII and VEGF and the clinicopathological parameters. Conclusions: The increased expression of TGF-Ղ1, TGF-ՂRII and VEGF in colorectal adenocarcinoma suggests a role for these proteins in colorectal carcinogenesis. Loss of the growth-inhibitory effect of TGF-Ղ may commence in the early stage of colorectal carcinogenesis. (Korean J Gastrointest Endosc 2007;35:313-320)

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A Comparison of the Use of Self-Expanding Metallic Stent Insertion with Emergency Surgery as an Initial Treatment for Obstructive Colorectal Cancer: Jung Pil Suh, M.D., Sang Woo Kim, M.D., Chang Nyol Paik, M.D., Jae Myung Park, M.D.,Yu Kyung Cho, M.D., In Seok Lee, M.D., Myung Gyu Choi, M.D., Kyu Yong Choi, M.D.,In Sik Chung, M.D., Won Kyung Kang, M.D.* and Seong Taek Oh M.D.*; Korean J Gastrointest Endosc 2007;35(5):321-327. Published online November 30, 2007

Abstract PDF: Background
/Aims: Emergency surgery for obstructive colorectal cancer is associated with a high rate of postoperative complications. The objective of this study is to investigate the clinical difference between the use of elective surgery after stent insertion, and the performance of emergency surgery as an initial treatment for colorectal cancer with an intestinal obstruction. Methods: For patients that were admitted from February 2004 to June 2006 for obstructive colorectal cancer, a retrospective analysis on the clinical outcome was performed for a group of patients that received a stent as an initial treatment (stent group) and a group of patients that received emergency surgery as an initial treatment (emergency operation group). Results: Postoperative complications in the stent group included pneumonia and wound infection (9.5%). For the emergency operation group, postoperative complications included sepsis, deep vein thrombosis, wound infection, anastomosis leakage and postoperative bleeding (38.9%). The number of postoperative complications were significantly less in patients in the stent group than for patients in the emergency operation group (p=0.032). The number of a one-staged operation was significantly higher in the stent group compared with the emergency operation group (85.7% vs 55.6%; p=0.039). The number of a stoma created at least once was significantly lower in the stent group (14.3% vs 50%; p=0.017) than in the emergency operation group. Conclusions: As an initial treatment for an obstructive colorectal cancer, the use of stent insertion for primary management should be considered since it can reduce the degree of postoperative complications and the necessity for multi-staged operations. (Korean J Gastrointest Endosc 2007;35:321-327)

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A Case of Esophageal Submucosal Dissection that Developed during Conscious Sedation Endoscopy: Hong Jun You, M.D., Moo In Park, M.D., Kyu Jong Kim, M.D., Won Moon, M.D., Sun Jung Kim, M.D., Sung Woo Yang, M.D., Se Young Park, M.D., Woo Seong Jeon, M.D., Dong Yang Park, M.D., Jun Young Song, M.D. and Seun Ja Park, M.D.; Korean J Gastrointest Endosc 2007;35(5):328-331. Published online November 30, 2007

Abstract PDF: Esophageal submucosal dissection is a rare condition, resulting in the separation of the submucosa and muscle layer by mucosal laceration and bleeding. Possible causes are external trauma, foreign body entrapment, endoscopic instrumentation and even spontaneous dissection. Typical endoscopic findings show a false lumen from the torn mucosa and a muscle layer in the false lumen. Esophagography shows a "double barrelled" appearance. A dissection can be resolved with conservative management. We experienced a case of a submucosal dissection of the esophagus with perforation, an unusual complication of conscious sedation endoscopy. (Korean J Gastrointest Endosc 2007;35:328-331)

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A Case of a Pedunculated Exoluminal Gastrointestinal Stromal Tumor in the Stomach: Young Jin Kim, M.D., Jai Hyun Choi, M.D., Eun Sun Kim, M.D., Dong Hun Lee, M.D., Nark-Soon Park, M.D., Ja Seol Koo, M.D., Sung Woo Jung, M.D., Hyung Joon Yim, M.D., Hong Sik Lee, M.D., Sang Woo Lee, M.D. and Ho Sang Ryu, M.D.; Korean J Gastrointest Endosc 2007;35(5):332-336. Published online November 30, 2007

Abstract PDF: A 49-year-old man visited our hospital with a complaint of a left lower quadrant abdominal mass. Abdominal computed tomography (CT) showed an exophytic tumor attached to the stomach; the marginal region was intensely enhanced as seen on contrast imaging in the delayed phase. The gastric tumor was excised using a laparoscopic procedure. The gastric tumor was removed along with the gastric wall where the tumor was attached to by a pedicle. The external surface of the tumor showed a well-encapsulated appearance and several engorged vessels. Histologically, the tumor cells had a clear or eosinophilic cytoplasm and round nuclei. Four mitotic figures were seen per 50 cells on a high power field. Immunohistochemical staining demonstrated positive expression of c-kit, CD34, and vimentin and negative expression of smooth muscle actin (SMA) and S-100. The final diagnosis was a pedunculated exoluminal gastrointestinal stromal tumor (GIST). (Korean J Gastrointest Endosc 2007;35:332- 336)

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A Case of a Gastric Gastrointestinal Stromal Tumor with a Fistula and Gastrointestinal Bleeding: Jin Ho Lee, M.D., Jung Youn Moon, M.D., Hyun Jung Kim, M.D., Jung Eun Huh, M.D., Jong Ryul Park, M.D., Hye Jung Jang, M.D., Ji Hoon Yoon, M.D., Seung Keun Park, M.D., Hee Ug Park, M.D. and Hye Sook Kim, M.D.*; Korean J Gastrointest Endosc 2007;35(5):337-341. Published online November 30, 2007

Abstract PDF: There has been much debate on the origin, differentiation and prognosis of gastrointestinal stromal tumors (GIST). Based on recent studies, we consider Cajal interstitial cell as the origin of a GIST. The common symptoms of a GIST are abdominal pain, hemorrhage, and the presence of a mass. However, there are few reported cases of a GIST with abscess pockets that communicate with the lumen of the stomach via a fistula. We report a case of a GIST of the stomach presenting with an abscess and a fistula communicating with the lumen of the stomach. An 84-year-old man presented with continuous fever and general weakness. We were able to diagnose the disease by an endoscopic examination, CT scan, biopsy and by cellular immunohistochemical staining. (Korean J Gastrointest Endosc 2007;35:337-341)

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A Case of Multiple Opportunistic Gastrointestinal Infections in a Korean AIDS Patient: Kang Nyeong Lee, M.D., Hang Lak Lee, M.D., Dong Hee Koh, M.D., Sang Pyo Lee, M.D., Young Chul Lee, M.D., Oh Young Lee, M.D., Byung Chul Yoon, M.D., Ho Soon Choi, M.D., Joon Soo Hahm, M.D. and Hyun Ju Bae, M.D.; Korean J Gastrointest Endosc 2007;35(5):342-345. Published online November 30, 2007

Abstract PDF: The number of AIDS patients is currently increasing in Korea, and multiple opportunistic infections, which are due to their immunocompromised state, have become a significant clinical problem. These opportunistic diseases may vary according to the severity of immunosuppression, the mode of transmission, the risk factors, the living environment and treatment; rectal syphilis, perianal condyloma lata and amoebic liver abscess are known to rarely develop in AIDS patients. We report here on a case of a homosexual man who simultaneously presented with an amebic liver abscess, esophageal candidiasis, chronic hepatitis B, rectal syphilis, perianal condyloma lata and asymptomatic neurosyphilis. He was treated with highly active antiretroviral therapy (HARRT) and the appropriate antiviral and antibiotic agents. (Korean J Gastrointest Endosc 2007;35:342-345)

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Intestinal Tuberculosis with a Duodenal Fistula: Eun Bum Park, M.D., Yoon Tae Jeen, M.D., Jae Hong Ahn, M.D., Sang-jun Suh, M.D., Sun Jae Lee, M.D., Nark-Soon Park, M.D., Bora Keum, M.D., Yeon Seok Seo, M.D., Yong Sik Kim, M.D., Hoon Jai Chun, M.D., Hong Sik Lee, M.D., Soon Ho Um, M.D., Sang Woo Lee, M.; Korean J Gastrointest Endosc 2007;35(5):346-350. Published online November 30, 2007

Abstract PDF: Intestinal tuberculosis is a common disease of extrapulmonary tuberculosis. A diagnosis of intestinal tuberculosis is difficult as the symptoms and laboratory findings are not specific for the disease. Intestinal tuberculosis may cause various complications, such as intestinal obstruction, intestinal perforation, intraabdominal abscess, intestinal hemorrhage and fistula formation. A duodenal fistula caused by tuberculosis is an especially rare condition. We experienced a case of intestinal tuberculosis with a duodenal fistula as a complication. The patient was a 25- year-old man that presented with weight loss and diarrhea. Esophagogastroduodenoscopy showed a deep ulcerative lesion on the third portion of the duodenum with a fistula opening. A histological finding revealed granulomatous inflammation with multinucleated giant cells. In addition, the result of a Tb PCR assay was positive. After two months of treatment with the appropriate medication, the symptoms improved and the fistula has closed completely. We report the case with a review of the literature. (Korean J Gastrointest Endosc 2007;35:346-350)

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A Case of Arteriovenous Malformation of the Descending Colon Presenting with Massive Bleeding: Young Kook Shin, M.D., Jin Tae Jung, M.D., Jung Seok Kwon, M.D., Myung Jun Seong, M.D., Han Il Lee, M.D.* and Chang Ho Cho, M.D.^†; Korean J Gastrointest Endosc 2007;35(5):351-354. Published online November 30, 2007

Abstract PDF: Arteriovenous malformation is a rare cause of lower gastrointestinal bleeding in patients younger than 50 years of age and is characterized by recurrent, painless, massive bleeding and chronic anemia without a remarkable prior or family history. The most commonly sites involved are the ascending colon and small bowel. This condition rarely involves the stomach and descending colon. Until recently, there has been only one case report on arteriovenous malformation of the descending colon in Korea. We report a case of a 32 year old male patient who presented with massive lower gastrointestinal bleeding and had been diagnosed with arteriovenous malformation of the descending colon after undergoing colonoscopy and abdomen CT with contrast enhancement. The patient underwent left hemicolectomy because of persistent bleeding despite conservative management. (Korean J Gastrointest Endosc 2007; 35:351-354)

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A Case of a Colonic Giant Lipoma Removed by Endoscopic Resection: Hyun Chul Whang, M.D., Dong Han Im, M.D., Joon Seok Oh, M.D., Hyun Ju Kim, M.D.,Hwa Mock Lee, M.D., Youn Uk Ko, M.D., Won Il Park, M.D., Kwang Jin Kim, M.D., Jin Kwang An, M.D. and Ung Suk Yang, M.D.; Korean J Gastrointest Endosc 2007;35(5):355-358. Published online November 30, 2007

Abstract PDF: A gastrointestinal lipoma, though rare, is a mesencymal tumor of the large bowel, and the second most common benign colonic tumor detected after an adenomatous polyp. The lesion may be asymoptomatic when small and may be detected incidentally, usually during a colonoscopic examination for another purpose. Lipomas of the large bowel that are not causing symptoms probably need no treatment, as malignant transformation has not been documented. If the mass is large, it can cause pain, anal bleeding due to intussusception, bowel obstruction and diarrhea, and thus resection should be considered. Due to the risk of perforation, endoscopic resection of large colonic lipomas has been discouraged. However, large colonic lipomas can be removed safely by endoscopic resection with the use of an endoscopic ultrasonogram and submucosal injection to elevate the lesion. (Korean J Gastrointest Endosc 2007;35:355-358)

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A Case of Pancreatic Arteriovenous Malformation Presenting Upper Gastrointestinal Bleeding: Su Hee Park, M.D., Mi Jeong Kim, M.D., You Sang Ko, M.D., You Jin Lim, M.D., Seung Yong Han, M.D., Hyun Woo Byun, M.D., Min Ho Choi, M.D., Hyun Joo Jang, M.D., Sea Hyub Kye, M.D. and Jin Lee, M.D.; Korean J Gastrointest Endosc 2007;35(5):359-363. Published online November 30, 2007

Abstract PDF: A pancreatic arteriovenous malformation (AVM) is a very rare disease entity that is usually asymptomatic; however, it may present with a massive gastrointestinal hemorrhage. Recent advances in cross-sectional imaging and the widespread availability of angiography have contributed to the diagnosis of this condition. A patient was transferred to our clinic due to unknown origin gastrointestinal bleeding and upper abdominal pain. Double balloon enteroscopy and duodenoscopy revealed a bleeding pancreatico-cholangio-duodenal fistula. We were able to diagnose an arteriovnous malformation with a pancreatico- cholangio-duodenal fistula by the use of angiography and from the post-operative pathological findings. (Korean J Gastrointest Endosc 2007;35:359-363)

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A Case of Choledochocele Associated with Papillary Adenocarcinoma: Dong Hun Lee, M.D., Jae Seon Kim, M.D., Ji Hoon Kim, M.D., Eun Sun Kim, M.D., Young Jin Kim, M.D., Nark-Soon Park, M.D., Sun Jae Lee, M.D., Beom Jae Lee, M.D. and Young-Tae Bak, M.D.; Korean J Gastrointest Endosc 2007;35(5):364-368. Published online November 30, 2007

Abstract PDF: Choledochocele is a rare abnormality that's defined as cystic or diverticular dilatation of the common bile duct, and this protrudes into the duodenal lumen. It may cause abdominal pain, recurrent pancreatitis, obstructive jaundice etc. Although its anatomic form does not meet the criteria of pancreaticobiliary malunion, malignant changes of the choledochocele in relation to pancreaticobiliary reflux may occur. It still is regarded as having a lower malignant potential than any other type of choledochal cyst. Only one case has been currently been reported in Korea. We experienced a case of a 71 year-old woman with upper abdominal pain that was caused by a choledochocele with duodenal ampullary adenocarcinoma. She was successfully treated by surgical excison without severe complications. We report here on this case along with a review of the literature. (Korean J Gastrointest Endosc 2007;35:364-368)

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A Case of a Double Gallbladder with Common Bile Duct Stones: Nark-Soon Park, M.D., Hong Sik Lee, M.D., Ji Hoon Kim, M.D., Dong Hun Lee, M.D., Eun Sun Kim, M.D., Young Jin Kim, M.D., Eun Bum Park, M.D., Jin Nam Kim, M.D., Ja Seol Koo, M.D., Sang Woo Lee, M.D., Jae Hyun Choi, M.D., Chang Duck Kim, M.D. and Ho Sang Ry; Korean J Gastrointest Endosc 2007;35(5):369-372. Published online November 30, 2007

Abstract PDF: A double or bilobed gallbladder is a rare congenital anomaly, occurring at a rate of 1/4,000∼5,000. We encountered a case of a double gallbladder that was diagnosed by an endoscopic retrograde cholangiogram. In view of the paucity of this anomaly, we report the case of a patient with a double gallbladder (Y duplication) accompanied by a common bile duct (CBD) stone. We also discuss the characteristics, classification, embryology and treatment of the double gallbladder. (Korean J Gastrointest Endosc 2007;35:369-372)

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Two Cases of Direct Peroral Cholangioscopy Using an Ultra-Slim Upper Endoscope Endoscopic after Stone Removal: Jong Chan Lee, M.D., Jong Ho Moon, M.D., Bong Min Go, M.D., Hyun Jong Choi, M.D., Hyun Cheol Koo, M.D., Young Koog Cheon, M.D., Young Deok 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 2007;35(5):373-376. Published online November 30, 2007

Abstract PDF: Peroral cholagioscopy is a good procedure that permits direct visualization of the biliary tree and target biopsies of lesions. However, peroral cholangioscopy with a mother- baby system requires two experienced endoscopists, and the procedure remains time consuming and expensive and the apparatus is easily broken. Therefore, an easier technique to get direct visual examination of the biliary tree is needed. Direct peroral cholangioscopy (direct POC) with using an ultra-slim upper endoscope was performed in two patients after endoscopic stone removal for diagnosing their biliary stricture. One patient had wire-guided direct POC performed and the patient was diagnosed benign biliary stricture on the proximal CBD after forcep biopsy. Another patient had overtube-assisted direct POC performed and that patient was found to have a polypoid lesion at the bifurcation. Future advances in endoscope development, as well as specifically designed accessories, are expected to increase its clinical utility. Korean J Gastrointest Endosc 2007;35: 373-377)

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