Clinical Endoscopy

Comparison of Double Balloon Enteroscopy and Capsule Endoscopy for Patients with Suspected Small Bowel Diseases: Hyun Joo Jang, M.D., Cheol Hee Park, M.D., Seung Yong Han, M.D., Hyun Woo Byun, M.D., Min Ho Choi, M.D., Sea Hyub Kae, M.D. and Jin Lee, M.D.; Korean J Gastrointest Endosc 2007;35(6):379-384. Published online December 30, 2007

Abstract PDF: Background
/Aims: Double balloon enteroscopy (DBE) and capsule endoscopy (CE) are two new methods for evaluating small bowel diseases. However, the clinical relevance of these procedures remains to be uncovered. We investigated the diagnostic and therapeutic impact of DBE and CE for patients with suspected small bowel diseases. Methods: We retrospectively reviewed the medical records of 60 patients who were examined by DBE or CE for suspected small bowel diseases between May 2003 and September 2005. The diagnostic yield and therapeutic impact were compared between the two groups. Results: Thirty-five patients were examined by CE and 25 patients were examined by DBE. DBE showed abnormal findings in 20 patients (80%). CE detected abnormal findings in 23 patients (65.7%). The overall diagnostic yield was not different between the two groups (p=0.226). In the DBE group, therapeutic interventions were performed in 18 patients (72%). In the CE group, therapeutic interventions were performed in 7 patients (20%). The overall therapeutic impact showed a significant difference between the two procedures (p<0.001). Conclusions: Although there is no significant difference in the diagnostic yield between the two procedures, DBE appears to have a higher therapeutic yield than CE for patients with suspected small bowel diseases. (Korean J Gastrointest Endosc 2007;35:379-384)

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Analysis of Risk Factors Associated with the Severity of Biliary Pancreatitis: Hyo Jeong Oh, M.D., Tae Hyeon Kim, M.D., Chang Soo Choi, M.D., Ji Hye Kweon, M.D., Pyoung Suk Lim, M.D., Sae Ron Shin, M.D.*, Suck Chei Choi, M.D. and Yong-Ho Nah, M.D.; Korean J Gastrointest Endosc 2007;35(6):385-390. Published online December 30, 2007

Abstract PDF: Background
/Aims: The aim of the study was to investigate the risk factors for biliary pancreatitis according to severity. Methods: This study retrospectively reviewed 58 patients who underwent endoscopic retrograde cholangiopancreatography for the management of acute biliary pancreatitis between November 2001 and June 2004. The severity of pancreatitis was classified as severe or mild pancreatitis according to the Glasgow scale. Multiple clinical and radiological factors were analyzed for a relationship with the severity of pancreatitis and coexisting biliary pathology. Results: Ten patients (17%) had severe pancreatitis (the SP group) and the remaining 48 patients (83%) had mild pancreatitis (the MP group). The diameter of the common bile duct CBD) and cystic duct, and the number and the size of gallstones were not significantly different between the two groups of patients. The number of patients without a periampullary diverticulum in the SP group (90.0%) was significantly higher than in the MP group (39.6%). Most of the SP patients (90.0%) had CBD stones (＜5 mm) or CBD sludge, but the prevalence of CBD stones (＜5 mm) or CBD sludge was lower in the MP group (54.2%, p=0.04). The absence of a periampullary diverticulum was identified as a risk factor according to severity by the use of logistic regression analysis (odds ratio=25; p=0.01). Conclusions: The development of severe biliary pancreatitis was influenced by risk factors such as a CBD stone less than 5 mm or sludge and the absence of a periampullary diverticulum. (Korean J Gastrointest Endosc 2007;35:385-390)

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A Case of Rectal Adenocarcinoid Tumor: Seong Deuk Baek, M.D., Jung Hyun Lee, M.D., Jung Il Seo, M.D., Chang Woo Lee, M.D., Jong Im Lee, M.D.*, Dong Hun Kim, M.D.*, Tae Jung Jang, M.D.* and Jung Ran Kim, M.D.*; Korean J Gastrointest Endosc 2007;35(6):391-394. Published online December 30, 2007

Abstract PDF: An adenocarcinoid is a mixed tumor comprised of both carcinoid and adenocarcinomatous components that is commonly found in the esophagus, stomach, duodenum, small bowel and appendix, and is also rarely found in the large bowel. A 61 year old male visited our institution because of a change in bowel habitus 3 months prior to the time of his visit. Colonoscopic findings revealed a 2×2 cm round smooth surface mass 7 cm from the anal verge, and an endoscopic ultrasonograph revealed a round hypoechoic mass in the submucosal layer. The mass was resected by endoscopic mucosal resection using a cap- fitted endoscope. Pathologic analysis of the mass confirmed that it was a composite tumor comprised of carcinoid and adenocarcinomatous components. To the best of our knowledge, this paper is the first case of rectal adenocarcinoid reported in Korea. (Korean J Gastrointest Endosc 2007; 35:391-394)

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A Case of Gastric Suture Granuloma Suspected of Malignant Submucosal Tumor: In Kyu Moon, M.D., Tae Hyo Kim, M.D., Kyoung Ah Jung, M.D., Jae Min Lee, M.D., Hyun Chin Cho, M.D., Ki Shik Shim, M.D., Hyun Ju Min, M.D., Hyun Jin Kim, M.D., Woon Tae Jung, M.D. and Ok Jae Lee, M.D.; Korean J Gastrointest Endosc 2007;35(6):395-398. Published online December 30, 2007

Abstract PDF: A gastric suture granuloma is an uncommon postsurgical complication. When nonabsorbable sutures are used, the inflammation can persist months after the original procedure with the subsequent formation of an abscess around the sutures surrounded by granulation tissue. Suture granulomas are usually asymptomatic, and have clinical importance as a differential diagnosis of a gastric submucosal tumor. The incidence of suture granuloma is low using absorbable sutures in gastrointestinal anastomosis. We report a case of a 70 year old man diagnosed with a suture granuloma. Approximately 30 years earlier, he underwent primary closure due to gastric ulcer perforation. When a gastroscopy was performed to assess upper abdominal soreness, it revealed a submucosal tumor that indicated a malignancy, which was diagnosed as a suture granuloma after surgery. (Korean J Gastrointest Endosc 2007;35:395-398)

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Retrieval of a Retained Capsule due to Isolated Crohn's Enteritis by Means of Double Balloon Enteroscopy: Kon-Ho Shim, M.D., Soo-Yeon Jung, M.D., Jun-Ho Song, M.D., Hyeug Lee, M.D., Eui-Hyung Kim, M.D., Eun-Jung Jeon, M.D., Jung-Hwan Oh, M.D., Jeong-Jo Jeong, M.D., Hwang Choi, M.D. and Sang-Wook Choi, M.D.; Korean J Gastrointest Endosc 2007;35(6):399-403. Published online December 30, 2007

Abstract PDF: Capsule endoscopy is being increasingly used for investigating GI bleeding of an obscure origin and also the bleeding that's due to Crohn's disease. Capsule endoscopy is a safe procedure with few complications. Complications of capsule endoscopy are capsule retention, incomplete small bowel examination, swallowing disorders and technical complications. However, capsule retention still remains a major concern. Crohn's disease may rarely show its first manifestation as GI bleeding. We present here a case of obscure GI bleeding in which the diagnosis of isolated Crohn's enteritis was made by using wireless CE. The retained capsule at the jejunal stricture of Crohn's disease was successfully retrieved by performing double balloon enteroscopy. (Korean J Gastrointest Endosc 2007;35:399-403)

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A Case of Eosinophilic Esophagogastroenteritis with Transmural Involvement: Jong Dae Kim, M.D., Euyi Hyeog Im, M.D., Jung Ho Lee, M.D., Tae Hee Lee, M.D., Sun Moon Kim, M.D., Young Woo Choi, M.D. and Young Woo Kang, M.D.; Korean J Gastrointest Endosc 2007;35(6):404-409. Published online December 30, 2007

Abstract PDF: Eosinophilic gastroenteritis is an uncommon disorder characterized by eosinophilic inflammation of the gastrointestinal tract that can present with various gastrointestinal manifestations, depending on the specific site of the affected gastrointestinal tract and the specific layer of the affected gastrointestinal wall. The depth of infiltration is the basis for a proposed classification as mucosal, muscular and serosal subtypes. Diagnostic criteria include the demonstration of eosinophilic infiltration of the bowel wall and lack of evidence of extra-intestinal disease. We experienced a 56-year-old woman that presented with postprandial epigastric pain and, 3 weeks later, with low abdominal pain. An abdominal examination showed tenderness and rebound tenderness in the whole abdomen and a hypoactive bowel sound. Endoscopy demonstrated the presence of mild edematous mucosa in the esophagus and stomach. There was eosinophilic infiltration in the esophagus, stomach and duodenum on as determined by a histological examination and muscular layer hypertrophy as determined on an endoscopic ultrasound examination. A CT scan showed wall thickening of the lower esophagus and gastric antrum to the mid-jejunum with mesenteric fat haziness, and a small amount of ascites was seen in the pelvic cavity. Eosinophilia was seen in the serum and from a fluid examination of aspirated fluid determined by culdocentesis. There was no evidence of parasitic infection based on a serum immunoassay and stool examination. The symptoms disappeared with oral prednisolone management and the patient was discharged from the hospital. This case showed continuous involvement from the lower esophagus to the mid-jejunum with transmural eosinophilic infiltration. (Korean J Gastrointest Endosc 2007;35:404-409)

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A Case of Small Bowel Obstruction due to a Mushroom Bezoar: Song Yi Kim, M.D., Jae Woo Kim, M.D., Jin Hon Hong, M.D., Ki Won Jo, M.D., Hong Jun Park, M.D., Il Young Lee, M.D., Chang Jin Yea, M.D., Hyun Soo Kim, M.D.,Soon Koo Baik, M.D. and Mee Yon Cho, M.D.*; Korean J Gastrointest Endosc 2007;35(6):410-414. Published online December 30, 2007

Abstract PDF: A mushroom bezoar is an unusual type of bezoar and a rare cause of small bowel obstruction, with the only cases being previously described in the foreign literature. Common sites of obstruction are the gastric outlet, the terminal ileum as well as segments of pre-existing gastrointestinal stenosis of various etiologies. Predisposing factors include a high fiber intake, inadequate chewing, gastric hyposecretion and hypomotility, and a previous gastrectomy and vagotomy. Computed tomography has the capability of directly showing the bezoar and displaying the resulting small bowel obstruction. We report a case of incomplete small bowel obstruction in a 38-year-old woman, caused by a mushroom bezoar in the terminal ileum. (Korean J Gastrointest Endosc 2007;35:410-414)

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A Case of a Vascular Mass Treated with Double Balloon Enteroscopy: Jae Hong Ahn, M.D., Jai Hyun Choi, M.D., Eun Bum Park, M.D., Sun Jae Lee, M.D., Sang Jun Suh, M.D., Dong Il Kim, M.D., Sung Woo Jung, M.D., Ja Seol Koo, M.D., Hyung Joon Yim, M.D., Hong Sik Lee, M.D. and Sang Woo Lee, M.D.; Korean J Gastrointest Endosc 2007;35(6):415-419. Published online December 30, 2007

Abstract PDF: Obscure gastrointestinal bleeding is defined as an intermittent or continuous loss of blood in which the source has not been identified after an upper endoscopy and colonoscopy. Small bowel bleeding is one of the most common causes of obscure gastrointestinal bleeding and constitutes 2∼10% of all gastrointestinal bleeding. As the small intestine lies in the mid-portion of the intestine and has a long length, it is difficult to diagnose and treat small bowel bleeding using conventional endoscopy. Although the development of wireless capsule endoscopy has increased the diagnosis rate of small bowel disease, the use of capsule endoscopy has some limitations. The use of capsule endoscopy depends on intestinal peristalsis, and while visual diagnosis is possible, obtaining a biopsy or providing treatment is not possible with the use of the procedure. Capsule endoscopy has a few other limitations, such as the lack of air insufflation and the unavailability of rinsing. The use of the new double balloon enteroscopy procedure has advantages over the use of capsule endoscopy. With this method, it is possible to obtain biopsies and it is possible to perform therapeutic procedures, rinsing and air insufflation. We report a case of a vascular mass of the small bowel with recurrent bleeding, which was treated with endoscopic sclerotherapy. (Korean J Gastrointest Endosc 2007;35:415-419)

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An Ampulla of Vater Carcinoid Tumor that Presented with Upper Gastrointestinal Bleeding: Jae Serk Park, M.D., Sung Jo Bang, M.D., Seok Won Jung, M.D., Sung Ho Kwon, M.D., Byung Chul Kim, M.D., Dong Ha Han, M.D., Hyun Soo Kim, M.D., Young Min Kim, M.D.*, Chang Woo Nam, M.D.^† and Do Ha Kim, M.D.; Korean J Gastrointest Endosc 2007;35(6):420-423. Published online December 30, 2007

Abstract PDF: A Carcinoid tumor of the ampulla of Vater is extremely rare, accounting for less than 0.3% of all gastrointestinal carcinoids. Most reported cases have arisen from the gallbladder. An ampullary carcinoid most commonly presents with jaundice or upper abdominal discomfort, and bleeding from the tumor is exceedingly rare. A diagnosis is most frequently made postoperatively due to submucosal spread of the tumor. As the metastatic potential cannot be predicted by tumor size, a Whipple pancreaticoduodenectomy rather than local excision is considered the treatment of choice. We herein report a case of a primary carcinoid tumor located at the ampulla of Vater that presented as gastrointestinal bleeding; the tumor was diagnosed by an endoscopic biopsy after a papillary sphinterotomy. (Korean J Gastrointest Endosc 2007;35:420-423)

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A Case of Peutz-Jeghers Polyp that was Diagnosed using Capsule Endoscoy and the Polyp was Removed by Means of Double Balloon Enteroscopy: Jong Sung Lee, M.D., Won Cheol Jang, M.D., Kyung Sun Ok, M.D., Tae Yeob Jeung, M.D., Jin Gook Huh, M.D., Soo Hyung Ryu, M.D., Jung Hwan Lee, M.D., You Sun Kim, M.D. and Jeong Seop Moon, M.D.; Korean J Gastrointest Endosc 2007;35(6):424-428. Published online December 30, 2007

Abstract PDF: Peutz-Jeghers syndrome is an autosomal dominant hereditary disease that's characterized by hamartomatous polyps of the gastrointestinal tract and mucocutaneous melanin pigmentation. Hamartomatous polyps can arise anywhere in the gastrointestinal tract, but they are most common in the small intestine. The major symptoms of Peutz-Jeghers syndrome are abdominal pain, intussusception and anemia due to gastrointestinal bleeding, which are all caused by harmatomatous polyp. Capsule endoscopy has been reported to have a higher diagnostic yield than small bowel barium radiography for patients with Peutz-Jeghers syndrome and who have small bowel polyp. Small bowel polyp in patients with Peutz-Jeghers syndrome can be resected by double balloon enteroscopy without laparotomy. We report here on a patient with melena that was caused by small bowel polyps, and this was found by using capsule endoscopy. Polyp in the distal ileum was resected by using colonoscopy and the patient was diagnosed as suffering with Peutz-Jeghers syndrome. The other proximal ileum polyp was resected by using double balloon enteroscopy without complication. (Korean J Gastrointest Endosc 2007;35:424-428)

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A Case of Differentiated Mucosal Gastric Cancer with Lymph Node Metastasis Presented as an Intra-abdominal Mass: Jong Pil Im, M.D., Jung Mook Kang, M.D., Hyuk-Joon Lee, M.D.*, Sang Gyun Kim, M.D., Joo Sung Kim, M.D., Hyun Chae Jung, M.D. and In Sung Song, M.D.; Korean J Gastrointest Endosc 2007;35(6):429-434. Published online December 30, 2007

Abstract PDF: In early gastric cancer, the most important prognostic factor is the presence or absence of a lymph node metastasis that is associated with the tumor size, histopathological differentiation, depth of tumor invasion and lympho-vascular invasion. A small sized differentiated mucosal cancer without a lympho-vascular invasion or histological ulceration rarely metastasizes to the lymph node. Herein, we report a case of a lymph node metastasis that is presented as an intra-abdominal mass in a 2.5 cm-sized differentiated mucosal cancer without ulceration or lympho-vascular invasion. (Korean J Gastrointest Endosc 2007;35:429-434)

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A Case of Polypoid Esophageal Carcinosarcoma with Spontaneous Resected Stalk: Seok Woo Kang, M.D.^†, Chel Yoon, M.D.^†, Doo Geun Chai, M.D.^†, Jae Hawn Kim, M.D., Sung Yeun Yang, M.D., Su Kyoung Kwon, M.D. and Soo Im Choi, M.D.*; Korean J Gastrointest Endosc 2007;35(6):435-440. Published online December 30, 2007

Abstract PDF: Carcinosarcomas of the esophagus are rare malignant neoplasms that consist of both carcinomatous and sarcomatous components, which comprise approximately 1∼2% of all esophageal neoplasms. Usually, esophageal carcinosarcomas are the polypoid type, and patients with esophageal carcinosarcoma have progressive dysphagia. The multiplicity in terminology appears to be related to the uncertain histogenesis of these tumors. We report a case of a polypoid esophageal carcinosarcoma with a spontaneous resected stalk in a 45 year-old male patient who presented with progressive dysphagia and weight loss. (Korean J Gastrointest Endosc 2007;35:435-440)

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Hemoclipped Dieulafoy's Lesion in Giant Diverticulum in the 3rd Portion of Duodenum: Mo Se Kim, M.D., Sung Yeun Yang, M.D., Jae Hwan Kim, M.D., Su Kyoung Kwon, M.D., Tae Hee Kim, M.D., Sang Hoon Seol, M.D., Eun Ji Noh, M.D., Doo Gun Chae, M.D.* and Jung Hae Koh, M.D.; Korean J Gastrointest Endosc 2007;35(6):441-444. Published online December 30, 2007

Abstract PDF: A duodenal diverticulum is common in the second portion of the duodenum and can occur at any age. An obstruction, bleeding, perforation, diverticulitis are not an uncommon complicationa of duodenal diverticulum. As a rare complication, bleeding in the duodenal diverticulum may be massive, and duodenal diverticulum is resected primarily as a result of the difficulty in determining the site of bleeding. However, there has been a recent increase in endoscopic diagnosis and the treatment of diverticular bleeding. Band ligation increases the risk of duodenal diverticular perforation because of the thin diverticular wall. An endoscopic hemoclip is a preferable method for endoscopic sclerotherapy. We report a 48- year-old man with a giant duodenal diverticulum that was treated with a hemoclip. The duodenal diverticular perforation was treated effectively with supportive care. (Korean J Gastrointest Endosc 2007;35:441-444)

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Case Series of ERCP and EST with Rotatable Papillotome (Autotome^Ⓡ) in Patients with Billoth II Gastrectomy: Yong Hun Kim, M.D., Chang-Il Kwon, M.D., Dae Young Kim, M.D., Myung Su Son, M.D., Kwang Hyun Ko, M.D., Sung Pyo Hong, M.D., Seong Gyu Hwang, M.D., Pil Won Park, M.D. and Kyu Sung Rim, M.D.; Korean J Gastrointest Endosc 2007;35(6):445-450. Published online December 30, 2007

Abstract PDF: Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST) are the mainstays of the diagnosis and treatment of variable hepatobiliary and pancreatic diseases. The success rate of ERCP and EST in patients who have undergone a Billroth II gastrectomy is lower than in patients with a normal anatomy. Because the view of the ampulla is rotated 180^o in patients with Billroth II, several methods (ex, precut biliary needle-knife papillotome or wire-guided billroth II papillotome) have been used for endoscopic sphincterotomy instead of a pull-type papillotome. Using the recently devised pull-type and rotatable papillotome (Autotome^Ⱂ), we performed successful ERCP and EST in 2 patients with a Billroth II gastrectomy without complications. (Korean J Gastrointest Endosc 2007;35:445-450)

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Endoscopic Papillary Large Balloon Dilatation for Large Biliary Stones in a Hemodialysis Patient: A Case Report: Seung Hyun Cho, M.D., Dong Ki Lee, M.D., Byung Jun Lee, M.D.,Hyun Chul Lim, M.D. and Chan Ik Park, M.D.; Korean J Gastrointest Endosc 2007;35(6):451-456. Published online December 30, 2007

Abstract PDF: In retrieving bile duct stones, full-endoscopic sphincterotomy (EST) with endoscopic mechanical lithotripsy (EML) is considered as a traditional method, and balloon dilation of the papillary sphincter has also been used. Recent studies have reported that mid-EST and endoscopic papillary large balloon dilatation (EPLBD) was as useful as full-EST with EML, without serious complications. In patients with coagulopathy, such as end-stage renal disease, even a small incision of the sphincter could cause profuse bleeding. In such patients, balloon dilation of the sphincter is a preferred technique over EST. A prior Billroth-II operation renders EST more difficult and increases the risk of a complication. In these patients, the use of EPBD is also preferred as well. We report a case of successfully retrieving large bile duct stones by EPLBD without EST, in a patient who had a prior Billroth-II operation, and is undergoing hemodialysis. The patient is free of complications, such as bleeding or acute pancreatitis. (Korean J Gastrointest Endosc 2007;35:451-455)

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