Clinical Endoscopy

Clinical Features of Re-infection of Helicobacter pylori after Successful Eradication: Jai Hwan Kim, M.D., Hyo Joon Yang, M.D., Eun Sun Jang, M.D., Eun Ju Jo, M.D., Hyun Jin Jo, M.D., Jae Young Chun, M.D., Jong Kyung Choi, M.D., Sung Wook Hwang, M.D., Sang Hyub Lee, M.D.*, Young Soo Park, M.D.*, Jin Hyeok Hwang, M.D.*, Jin Wook Kim, M.D.*,; Korean J Gastrointest Endosc 2008;37(3):161-166. Published online September 30, 2008

Abstract PDF: Background
/Aims:Studies on re-infection of Helicobacter pylori are limited. This study was designed to determine if there are clinical features of H. pylori re- infection related to gastroduodenal diseases or histological findings. Methods: From a population of patients that were treated for H. pylori eradication from May 2003 to September 2007, 129 subjects were enrolled. Regimens were PPI-based triple or quadruple agents and follow-up methods were UBT, CLO or histology. Results: A total of 29 subjects experienced a recurrence (within one year, 17 subjects; between one and two years, eight subjects; more than two years, four subjects). Recurrence periods were 2 to 32 months, and the mean period was 12.62± 8.40 months. Among 29 subjects, eight subjects had chronic atrophic gastritis, 14 subjects had a peptic ulcer, five subjects had stomach cancer and two subjects had a MALT lymphoma; there were no statistical differences of the odds ratio between matched diseases. By use of the Updated Sydney System, neither H. pylori colonization density nor neutrophil infiltration nor monocyte infiltration grade in histology was associated with recurrence or re-infection. Conclusions: Neither histological findings nor gastroduodenal diseases was associated with H. pylori re-infection. The re-infection rate in this study was approximately 6.2%. This rate was slightly higher than rates reported in other recent studies in Korea. (Korean J Gastrointest Endosc 2008;37:161-166)

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A Prospective Trial Comparing 4 L-Polyethylene Glycol with 2 L-Polyethylene Glycol Plus Bisacodyl Tablets for Colon Preparation: Min-Jung Kang, M.D., Sung-Ae Jung, M.D., Ji Min Jung, M.D., Hyun Joo Song, M.D., Seong-Eun Kim, M.D., Hye-Kyung Jung, M.D., Ki-Nam Shim, M.D., Kwon Yoo, M.D. and Il-Hwan Moon, M.D.; Korean J Gastrointest Endosc 2008;37(3):167-173. Published online September 30, 2008

Abstract PDF: Background
/Aims: The aim of the study was to prospectively compare low-volume PEG plus 20 mg bisacodyl with the standard 4 L PEG with regards to the adequacy of bowel preparation, patient compliance and the side effects. Methods: From September 2007 to January 2008, 59 patients who had previously undergone screening colonoscopy with 4 L PEG and had been diagnosed with colonic polyps were admitted for polypectomy. The colonoscopists, who were unaware of the preparation that was administered, evaluated the adequacy of the bowel cleansing. Detailed questionnaires were also used to assess patient compliance, the difficulty of bowel preparation, side effects and patient preference. Results: The physician's evaluation of the colon cleansing showed better adequacy with 4 L PEG than with 2 L PEG plus bisacodyl (p＜0.05). There was no difference in patient compliance between the 2 bowel preps. The patients in the 2 L PEG plus bisacodyl group tolerated the bowel preparation more easily than the patients in the 4 L PEG (81.4% vs. 15.3%, respectively). Moreover, the scores of the visual analog scale for the difficulty of bowel preparation were 5.8±2.3 in the 4 L PEG group and 3.2±1.9 in the 2 L PEG plus bisacodyl (p＜0.01). The majority (89.8%) of the patients preferred 2 L PEG plus bisacodyl (p＜0.001). The 2 L PEG plus bisacodyl group revealed less nausea, vomiting and sleep discomfort (p＜0.05), but they had more abdominal pain (p＜0.01). Conclusions: 2 L PEG plus bisacodyl is not as effective as the standard 4 L PEG for colon cleansing. However, 2 L PEG plus bisacodyl can be used for patients who have difficulty drinking a large amount of PEG. (Korean J Gastrointest Endosc 2008;37:167-173)

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Histological Quality of Small Polyps Resected Using Different Electric Currents in a Colonoscopic Polypectomy: Si Hyung Lee, M.D., Byung Ik Jang, M.D., Tae Nyeun Kim, M.D. and Joon Hyuk Choi, M.D.*; Korean J Gastrointest Endosc 2008;37(3):174-178. Published online September 30, 2008

Abstract PDF: Background
/Aims: Most polyps encountered during a colonoscopic polypectomy are small. Thus, accurate evaluation of small polyp histology is important in the decision-making process. The aim of this study was to assess and compare the histological quality of polyps obtained by the use of snare polypectomy with two different electric currents. Methods: Consecutive polyps less than 1 cm were identified and removed by use of either the blend mode (Blended mode, Circon, BC-200) or automatic cutting and coagulation mode (Endocut Q mode, effect 3, 40 watts, ERBE, VAIO-300). An experienced gastrointestinal pathologist evaluated the specimens for cautery damage, margin, architecture, presence of muscularis mucosa and general histological quality. Results: Sixty-six patients (77.2% men; mean age, 60.2±9.2 years) underwent 109 polypectomies (53 using the blended mode and 56 using the Endocut Q mode; mean polyp diameter, 0.87±0.17 mm). Age, gender, location, diameter and the histology of the polyp was not different with the use of both methods. The cautery amount (≥2) with use of the blended mode was not significantly different than with the use of the Endocut mode (50.9% vs. 39.2%, p=0.22). The cautery degree, margin, architecture, presence of muscular mucosa and overall histological quality was not different with the use of both methods. Conclusions: The histological quality of polyps less than 1 cm obtained by use of either the blended mode or Endocut Q mode was not different. (Korean J Gastrointest Endosc 2008;37:174- 178)

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Famotidine versus Pantoprazole for the Prevention of Delayed Bleeding and Healing of Iatrogenic Ulcers after Endoscopic Mucosal Resection: Ho In Hwang, M.D., Chang Hwan Park, M.D., Sang Min Yum, M.D., Seok Lee, M.D., Wan Sik Lee, M.D., Hyun Soo Kim, M.D., Sung Kyu Choi, M.D. and Jong Sun Rew, M.D.; Korean J Gastrointest Endosc 2008;37(3):179-184. Published online September 30, 2008

Abstract PDF: Background
/Aims: Endoscopic mucosal resection (EMR) currently serves as the minimally invasive treatment of choice for early gastric cancer and premalignant lesions of the stomach. There have been few studies addressing whether a proton pump inhibitor or a histamine 2-receptor antagonist is the most effective treatment for iatrogenic ulcers after EMR. We compared the effectiveness of pantoprazole and famotidine in treating iatrogenic ulcers and preventing bleeding after EMR without endoscopic submucosal dissection. Methods: Between March 2006 and April 2007, we retrospectively analyzed the effect of famotidine (40 mg/day) and pantoprazole (40 mg/day) on the healing of iatrogenic ulcers and control of bleeding after EMR. Results: During the study period, 126 patients underwent EMR. Eighty-one received famotidine, and 45 received pantoprazole. The mean duration of drug therapy was 44 days in each group. The stages of ulcers at 1 to 3 months after EMR were mostly scar stage, and there was no specific difference between the groups. Delayed bleeding was seen after EMR in one patient (1.2%) from the famotidine group and in one patient (2.2%) from the pantoprazole group. There were no other major complications after EMR. Conclusions: Famotidine was no different than pantoprazole in its effectiveness toward preventing delayed bleeding and promoting healing of iatrogenic ulcers after EMR. (Korean J Gastrointest Endosc 2008; 37:179-184)

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The Differential Diagnosis and Prognosis of an Ampulla of Vater Cancer with a Grossly Normal Appearance: Ji Bong Jeong, M.D., Yong-Tae Kim, M.D.*, Yong Jin Jung, M.D., Ji Won Kim, M.D., Byung Kwan Kim, M.D., Kook Lae Lee, M.D., Ji Kon Ryu, M.D.* and Yong Bum Yoon, M.D.*; Korean J Gastrointest Endosc 2008;37(3):185-191. Published online September 30, 2008

Abstract PDF: Background
/Aims: The purpose of this study was to determine the clinical parameters for a differential diagnosis between a malignant and benign stricture of the ampulla of Vater with a grossly normal appearance and to evaluate the diagnostic accuracy of the use of an endoscopic biopsy for the prognosis of ampulla of Vater cancers. Methods: Medical records and cholangiograms were retrospectively reviewed. In order to determine the clinical parameters useful for a differential diagnosis, clinical manifestations, laboratory findings and the common bile duct diameter were compared between malignant and benign strictures. The diagnostic accuracy of the use of an endoscopic biopsy and the clinical features of patients with an ampulla of Vater cancer were analyzed. The survival rate after management was also evaluated. Results: Nine patients with a benign stricture and 15 patients with a malignant stricture were included in this study. The levels of serum bilirubin, alkaline phosphatase and alanine aminotransferase were significantly higher in patients with a malignant stricture than in patients with a benign stricture (p＜0.05). Of the patients who underwent surgical management, 93% had stage I or II disease. All of the patients were alive up to a mean follow-up period of 50 months. Conclusions: Liver function tests and the use of an endoscopic biopsy are useful in the differential diagnosis of a stricture of the ampulla of vater with a grossly normal appearance. Cancer patients typically present with an early stage and the prognosis is relatively good. (Korean J Gastrointest Endosc 2008;37:185-191)

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A Patient with Jejunal Mucinous Adenocarcinoma Metastatic to the Stomach Presenting with Submucosal Tumors in the Stomach and Jejunum: Gwang Sil Kim, M.D., Tae Joo Jeon, M.D., Tae-Hoon Oh, M.D., Won Chang Shin, M.D., Won-Choong Choi, M.D., Eunah Shin, M.D.*, Jung Yeon Kim, M.D.* and Hong-Joo Kim, M.D.^†; Korean J Gastrointest Endosc 2008;37(3):192-197. Published online September 30, 2008

Abstract PDF: The small bowel is the least common site for cancer to arise. Only approximately 1% of all gastrointestinal neoplasms arise in the small bowel. Mucinous adenocarcinoma is diagnosed when the amount of extracellular mucin in a tumor is over 50%. Because it is a very rare disease, there is little data available concerning its incidence, most common site of origin, and common sites of metastasis. There are no case reports describing primary mucinous adenocarcinoma of the jejunum in Korea. We report a case of jejunal mucinous adenocarcinoma metastatic to the stomach presenting as a submucosal tumor. (Korean J Gastrointest Endosc 2008;37:192-197)

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A Case of Plummer-Vinson Syndrome in an Elderly Patient: Min Jae Jo, M.D., Tae Nyeun Kim, M.D.*, Sun Taek Choi, M.D., Do Whae Park, M.D., You Min Kim, M.D. and Hye Young Lee, M.D.; Korean J Gastrointest Endosc 2008;37(3):198-202. Published online September 30, 2008

Abstract PDF: Plummer-Vinson syndrome is a complex syndrome characterized by upper esophageal webs, dysphagia, and iron deficiency anemia. This syndrome develops principally in middle-aged women, and only rarely in patients over age 80. We present a case of Plummer-Vinson syndrome occurring in an 82-year-old woman who visited the hospital because of progressive dysphagia. Esophagogram and endoscopic examination showed an upper esophageal web, and laboratory examination revealed iron deficiency anemia. Dysphagia improved after endoscopic balloon dilatation, and iron deficiency anemia improved after iron supplementation. Even Plummer-Vinson syndrome can be improved by sufficient amounts of oral ferrous sulfate and endoscopic balloon dilatation, it is important to identify the cause of iron deficiency anemia and to check for the presence of malignant disease. The common causes of anemia differ between middle-aged and elderly women, and the clinician needs to look for malignancy-induced chronic gastrointestinal tract blood loss and chronic inflammatory diseases. We report a rare case of Plummer- Vinson syndrome in a woman over 80 years of age. (Korean J Gastrointest Endosc 2008;37:198-202)

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A Case of a Localized Abscess in the Neck after Esophagogastroduodenoscopy: Hyun-Jae Woo, M.D., Chang Hoon Bae, M.D., Yong-Dae Kim, M.D. and Si-Youn Song, M.D.; Korean J Gastrointest Endosc 2008;37(3):203-206. Published online September 30, 2008

Abstract PDF: Perforations of the upper gastrointestinal tract are uncommon complications after performing an esophagogastroduodenoscopy (EGD). Perforations after an EGD procedure are likely to occur in the hypopharynx and cervical esophagus, where endoscope passage is anatomically difficult. Life-threatening complications including mediastinitis, a mediastinal abscess, pericarditis and sepsis can develop in most cases of a perforation. However, without such fatal complications, an abscess that is localized at the neck is extremely rare following an esophageal perforation. We experienced a case of a localized abscess in the neck after EGD and successfully treated the abscess without surgical management. We emphasize the importance of early detection for neck space infections caused by EGD-induced injuries. (Korean J Gastrointest Endosc 2008;37:203-206)

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A Case of Duodenal Intramural Hematoma Complicated with Chronic Pancreatitis: Byoung Do Park, M.D., Don Haeng Lee, M.D., Seok Jeong, M.D., Jung Il Lee, M.D., Jin Woo Lee, M.D., Hyung Gil Kim, M.D., Yong Woon Shin, M.D. and Yong Soo Kim, M.D.; Korean J Gastrointest Endosc 2008;37(3):207-211. Published online September 30, 2008

Abstract PDF: The majority of cases of duodenal intramural hematoma occur in children due to blunt abdominal trauma. In adult patients, the etiology of hematoma is quite varied. A hematoma may occur due to the usage of anticoagulants, hemophilia, Henoch-Schonlein purpura, vasculitis, pancreatic disease, endoscopic coagulation of duodenal ulcer bleeding and following an endoscopic retrograde cholangiopancreatogram. A 53-year-old male patient was admitted for hematemesis. The patient was a heavy alcoholic and had a history of chronic pancreatitis, but there was no definite trauma history or other medical illness. In the duodenal second portion, a huge submucosal mass obstructed the lumen with submucosal hemorrhage. As depicted on an abdominal CT and an endoscopic ultrasonogram, chronic pancreatitis and a duodenal submucosal tumor was suspected. On the eighth hospital day, abdominal pain suddenly became worse and peritoneal-irritation signs were observed. Therefore, a surgical procedure was urgently performed. Considering the rarity of its etiology in Korea, we report a case of duodenal intramural hematoma complicated with chronic pancreatitis. (Korean J Gastrointest Endosc 2008;37:207-211)

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Two Cases of Neuroendocrine Carcinomas of the Stomach: Large Cell Carcinoma and Small Cell Carcinoma: Su Jin Oh, M.D., In Hee Kim, M.D., Yu-Jeong Hwang, M.D., Seok Lee, M.D., Seong-Hun Kim, M.D., Sang Wook Kim, M.D., Seung Ok Lee, M.D. and Soo Teik Lee, M.D.; Korean J Gastrointest Endosc 2008;37(3):212-217. Published online September 30, 2008

Abstract PDF: Neuroendocrine carcinoma of the stomach is an uncommon cancer with a high grade malignant behavior and a poor prognosis. The classification of gastric neuroendocrine carcinomas and its biologic characteristics remain controversial. It can be subdivided into the large cell and small cell variants based on its morphological characteristics. The low incidence of this tumor has contributed to the limited knowledge regarding its treatment and prognosis. We report here on two cases of primary neuroendocrine carcinomas of stomach, large cell and small cell carcinomas, respectively, along with a review of the literature. (Korean J Gastrointest Endosc 2008;37:212-217)

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Endoscopic Resection of a Pedunculated Colonic Leiomyoma Resembling a Hyperplastic Polyp: Yong Wan Park, M.D., Young Seok Cho, M.D., Jin Soo Kim, M.D., Hye Sook Son, M.D., Hyung Keun Kim, M.D., Sung Soo Kim, M.D., Hiun Suk Chae, M.D. and Kyu Yong Choi, M.D.; Korean J Gastrointest Endosc 2008;37(3):218-221. Published online September 30, 2008

Abstract PDF: Colonic leiomyoma is a rare condition that accounts for 3% of all gastrointestinal leiomyomas. Many colonic leiomyomas are found incidentally and are sometimes confused with epithelial neoplasms. Most leiomyomas are removed surgically. However, a small peduculated leiomyoma can be removed endoscopically as it has the appearance of an adenomatous polyp. A 54 year-old man underwent a colonoscopic examination due to frequent loose stools. Colonoscopy demonstrated the presence of a small reddish polyp with a short stalk in the sigmoid colon. We performed a successful polypectomy by the use of colonoscopic snare electrocauterization. A pathological examination revealed the presence of a leiomyoma originating in the muscularis mucosa. We report a case of a small peduculated leiomyoma that was removed endoscopically, with a review of the literature. (Korean J Gastrointest Endosc 2008;37:218-221)

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Two Cases of Pneumatosis Coli Associated with Ischemic Colitis: Nu Ri Chon, M.D., Hyojin Park, M.D., Kuen Man Lee, M.D., Hong Sun Yoon, M.D. and Sang Kyum Kim, M.D.*; Korean J Gastrointest Endosc 2008;37(3):222-226. Published online September 30, 2008

Abstract PDF: Pneumatosis coli (PC) is a rare disease that is characterized by multiple, varying-sized cysts at the mucosa or submucosa in the colon and sigmoid colon. About 85% of PC is associated in other gastrointestinal, pulmonary and connective diseases. Ischemic colitis is rarely associated with PC. The symptoms of PC are not specific, and the patients with this malady present with hematochezia, abdominal pain, diarrhea and other symptoms associated with their underlying diseases. Colonoscopy and computed tomography are recommended for making the diagnosis. The underlying diseases should be treated and oxygen therapy, intra-venous antibiotics and/or surgical treatment can be used. The prognosis is generally good, but volvulus, intussusception, intestinal obstruction, bleeding and perforation can occur in 3% of these patients. We experienced two patients who initially presented with hematochezia and they were found to have PC and ischemic colitis according to the colonoscopy exams; these are the first such reported cases in Korea. Both patients were treated conservatively with low-dose oxygen therapy and intra-venous metronidazole. We report here on 2 cases of PC associated with ischemic colitis, and we review the relevant literature. (Korean J Gastrointest Endosc 2008;37:222-226)

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A Case of Protein Loosing Enteropathy Associated with Pseudomembranous Colitis in a Patient with Peritonitis: Gyoun Hong Kwon, M.D., Dong Heo, M.D., Hyun Seung Lee, M.D., Yong Gun Jo, M.D., Bong Jin Kim, M.D., Jee Yeon Kim, M.D. and Yong Mock Bae, M.D.; Korean J Gastrointest Endosc 2008;37(3):227-230. Published online September 30, 2008

Abstract PDF: Pseudomembranous colitis can be induced by the therapeutic or prophylactic use of antibiotics, and antibiotics- induced colitis has become a severe clinical problem. Protein‐loosing enteropathy is associated with an abnormal, excessive loss of serum proteins into the gastrointestinal tract, and this leads to hypoproteinemia, including hypoalbuminemia, edema and diarrhea. We present here a case of protein‐loosing enteropathy that was induced by pseudomembranous colitis, and this was induced by the use of antibiotics. Patients with chronic renal disease and peritonitis show hypoalbuminemia and edema. We experienced a patient who displayed edema, hypoalbuminemia, diarrhea and a fever for several days after the use for antibiotics for treating his peritonitis. We made the diagnosis of protein-loosing enteropathy complicated by psuedomembranous colitis. In a patient with peritonitis, uncontrolled edema and diarrhea, and the patient's hypoalbuminemia is continued, we must consider the possibility that the patient has protein-loosing enteropathy, and we should examine the total protein level and the Ձ1‐antitrypsin clearance. (Korean J Gastrointest Endosc 2008; 37:227-230)

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A Case of Acute Pancreatitis Caused by the Migration of a Feeding Gastrostomy Tube: Sung Kyun Kim, M.D., Chang Hwan Park, M.D., Yong Chan Cho, M.D., Jun Eul Hwang, M.D., Won Jung Jun, M.D., Hyen Soo Kim, M.D., Sung Kyu Choi, M.D. and Jong Sun Rew, M.D.; Korean J Gastrointest Endosc 2008;37(3):231-234. Published online September 30, 2008

Abstract PDF: A feeding gastrostomy tube is used to provide chronic nutritional support for patients who have a swallowing disability. Serious complications associated with feeding gastrostomy are rare. However, dislocation of the gastrostomy tube into the duodenum can lead to serious complications. There have been 7 reports in which the gastrostomy tube used for enteral feeding was associated with acute pancreatitis. But there have been no reports of pancreatitis associated with feeding gastrostomy in Korea. Further, all the reported cases were associated with both pancreatitis and cholangitis secondary to the compression of the major papilla by the percutaneous endoscopic gastrostomy tube. To the best our knowledge, this is the first report of acute pancreatitis, without cholangitis, that was induced by the compression of migrating surgical gastrostomy tube. Herein, we report on a case of a 68-year-old Korean male diagnosed with acute pancreatitis, and this was induced by the migration of a surgical gastrostomy tube. (Korean J Gastrointest Endosc 2008; 37:231-235)

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