Clinical Endoscopy

The Current Status of Endoscopic Submucosal Dissection: Joo Young Cho, M.D. and Won Young Cho, M.D.; Korean J Gastrointest Endosc 2008;37(5):317-320. Published online November 30, 2008

Abstract PDF: Endoscopic Submucosal Dissection (ESD) is curative treatment for early gastrointestinal neoplasia, and this procedure does not involve open surgery. Significant advances of the techniques and instruments for ESD have been made and many medical institutes have the facilities to perform ESD. This article reviews the current status of ESD in Korea. (Korean J Gastrointest Endosc 2008;37: 317-320)

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A Clinical Analysis of Patients with Active Small Bowel Bleeding as Detected on Double Balloon Enteroscopy: Tae Hee Lee, M.D., Jin Oh Kim, M.D., Soo Hoon Eun, M.D., Bong Min Ko, M.D., Joo Young Cho, M.D., Joon Seong Lee, M.D., So Young Jin, M.D., Moon Sung Lee, M.D., Chan Sup Shim, M.D. and Boo Sung Kim, M.D.; Korean J Gastrointest Endosc 2008;37(5):321-327. Published online November 30, 2008

Abstract PDF: Background/Aims: There are few studies that have evaluated active small bowel bleeding. The aim of this study was to evaluate patients with active small bowel bleeding that had been considered as obscure gastrointestinal bleeding an was confirmed by the use of double balloon enteroscopy (DBE). Methods: We retrospectively reviewed the medical records of 12 patients with active small bowel bleeding as detected on DBE from January 2005 to September 2007. Results: The mean patient age was 63 years (age range, 45∼80 years) and the patients consisted of seven men and five women. The mean hemoglobin level at admission was 7.6 g/dL (range, 5.8∼9.0 g/dL). The mean transfusion volume was 4.4 pints (range, 0∼7 pints). Angiodysplasia was the most common cause of bleeding (n=6, 50%), followed by small bowel tumors (n=4, 33%). Other causes included diverticula and a nonspecific ulcer. The most common location of bleeding was the jejunum. Diagnostic yields of capsule endoscopy, a ^99mTc RBC scan, an abdomen CT scan, angiography and a small bowel series were 40%, 33%, 25%, 0% and 0%, respectively. Endoscopic treatment was performed successfully in eight patients (67%). Conclusions: The most common etiology for active small bowel bleeding is angiodysplasia followed by a small bowel tumor. Other diagnostic methods for the small bowel showed low diagnostic yields. Further investigation of active small bowel bleeding is needed to confirm our results. (Korean J Gastrointest Endosc 2008;37:321-327)

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Endoscopic Ultrasonography-guided Tru-Cut Biopsy for Differential Diagnosis in the Gastrointestinal Mesenchymal Neoplasm: Hyoun Woo Kang, M.D., Joo Sung Kim, M.D., Sang Gyun Kim, M.D., Hae Yeon Kang, M.D., Hyun Chae Jung, M.D. and In Sung Song, M.D.; Korean J Gastrointest Endosc 2008;37(5):328-334. Published online November 30, 2008

Abstract PDF: Background/Aims: Risk assessment by mitotic count in the gastrointestinal stromal tumor (GIST), the most common mesenchymal neoplasm, is important. EUS-guided fine- needle aspiration cannot obtain sufficient tissue for determination of mitotic count, but An EUS-guided Tru-Cut biopsy (EUS-TCB) can. The aim of this study was to evaluate clinical role of EUS-TCB in differential diagnosis of mesenchymal neoplasm and risk assessment of GIST. Methods: We prospectively enrolled 18 patients who were diagnosed with submucosal hypoechoic tumors, 2∼5 cm, in the muscular layer by EUS in Seoul National University Hospital from November, 2005, to July, 2007. The rates of adequate biopsy and possibility of risk assessment were evaluated. Results: EUS-TCB was performed in 16 patients. The median tumor size was 2.7 cm, and adequate diagnosis was possible in 8 patients. Tumor size in the adequate specimen group was larger than in the inadequate group (p=0.021). The number of needle passes was higher in the adequate specimen group (p=0.012). Risk assessment by mitotic count was possible in only one case. Conclusions: EUS-TCB in the diagnosis and risk assessment of GIST was inadequate, in part because of insufficient operator experience and small tumors. Development of a new instrument is needed to obtain sufficient tissue. (Korean J Gastrointest Endosc 2008;37:328-334)

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A Case of Esophageal Tuberculosis as the Cause of a Fever of an Unknown Origin: Jae Myung Cha, M.D., Joung Il Lee, M.D., Jae Won Choe, M.D., Kwang Ro Joo, M.D., Sung Won Jung, M.D., Hyun Phil Shin, M.D. and Woo Young Hew, M.D.; Korean J Gastrointest Endosc 2008;37(5):335-338. Published online November 30, 2008

Abstract PDF: Fever of an unknown origin (FUO) means a fever that does not resolve spontaneously, and the cause remains elusive after an extensive diagnostic workup. The most common cause of FUO is infectious disease, and the most common infectious cause documented in Korea is tuberculosis, and particularly extrapulmonary or miliary tuberculosis. Among the extrapulmonary tuberculosis, esophageal tuberculosis is a very rare form of adult tuberculosis, and even in Korea with its high prevalence of tuberculosis. Esophageal tuberculosis can present as systemic symptoms such as weight loss, fever, chills and general weakness, or as local symptoms such as chest pain, dysphagia, cough and hematemesis. However, it can present as a prolonged fever of an unknown origin without any other symptoms. In this report, we describe a patient with esophageal tuberculosis, and the patient presented with a fever of unknown origin for 1 month. The patient was diagnosed by esophagogastroduodenoscopy with biopsy and he responded well to antituberculosis therapy. (Korean J Gastrointest Endosc 2008;37:335-338)

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A Case of an Esophageal Schwannoma with Intense FDG Uptake as Detected on PET-CT: Seong Hoon Yoon, M.D., Gwang Ha Kim, M.D., Do Youn Park, M.D.*, Ho Seok Lee, M.D.^†, Jung Ho Bae, M.D., Jin Hyun Park, M.D., Su Bum Park, M.D. and Geun Am Song, M.D.; Korean J Gastrointest Endosc 2008;37(5):339-343. Published online November 30, 2008

Abstract PDF: An esophageal schwannoma originating in a schwann cell of a neuron presents as a type of submucosal tumor. An esophageal schwannoma is extremely rare, with only 30 reported cases. It is usually a benign tumor. However, three cases with malignant findings and one case with local recurrence have been reported. Reviews of previous reports indicate that benign schwannomas are usually located in the upper esophagus and occur in middle aged- women. An esophageal schwannoma is usually asymptomatic but sometimes causes dysphagia as an initial symptom and dyspnea by trachea compression. The differentiation of a schwannoma from the other submucosal tumors is very difficult on a preoperative examination with the use of esophagoscopy, endoscopic ultrasound and computed tomography. A definite diagnosis of the tumor requires a histological examination and immunohistochemical staining. Positive immunostaining for s-100 protein supports the schwann cell origin of the tumor. We report a case of an esophageal schwannoma with intense FDG uptake as detected on PET-CT. (Korean J Gastrointest Endosc 2008;37:339-343)

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Spontaneous Resolving of Cytomegalovirus Associated Gastritis after Conservative Treatment in Immunocompetent Patients: A Report of Two Cases: Jaehoon Lee, M.D., Suck Chei Choi, M.D., Chang Soo Choi, M.D. and Tae Hyeon Kim, M.D.; Korean J Gastrointest Endosc 2008;37(5):344-348. Published online November 30, 2008

Abstract PDF: Cytomegalovirus (CMV) disease is an important cause of morbidity and mortality in an immunocompromised host. Patients with AIDS, organ transplantion and chemotherapy for malignant disease are susceptible to CMV diseases. CMV disease rarely occurs in an immunocompetent host. The gastrointestinal tract is one of target organs for CMV infection. Immunocompetent patients with gastrointestinal CMV disease frequently recover with supportive therapy. If immunosuppressive therapy is stopped, patients infected with CMV can be spontaneously cured. However, as the prognosis of CMV infection in immunocompromised patients is usually poor, the administration of an antiviral agent is recommended for treatment. We report two cases of gastric CMV in immonocompetent patients who completely recovered with supportive treatment without antiviral therapy. (Korean J Gastrointest Endosc 2008;37:344-348)

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A Case of a Myxoid Variant of a Pedunculated Extraluminal Gastrointestinal Stromal Tumor (GIST) in the Stomach: Jae Myung Cha, M.D., Joung Il Lee, M.D., Jae Won Choe, M.D., Kwang Ro Joo, M.D., Sung Won Jung, M.D., Hyun Phil Shin, M.D., Woo Young Hew, M.D. and Sung Il Choi, M.D.*; Korean J Gastrointest Endosc 2008;37(5):349-354. Published online November 30, 2008

Abstract PDF: Gastointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. They are frequently identified as incidental lesions found by routine endoscopy or in resection specimens that are removed for other reasons. The macroscopic morphology of GISTs may be classified as the intraluminal type, extraluminal type, mixed type and intramural type. The extraluminal type is the second most frequent tumor encountered, but a GIST pedunculated externally from the stomach is very rare. In addition, the myxoid epithelioid variant, which is characterized by an unusually myxoid stroma and epithelioid histology, is also a rare distinct subtype of a GIST that is closely correlated with negative immunoreactivity for c-kit. We report a case of a myxoid epithelioid variant of a pedunculated extraluminal GIST in a 62-year-old man that presented with an abdominal mass. (Korean J Gastrointest Endosc 2008;37:349-354)

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Two Cases of Asymptomatic Pneumoperitoneum after Argon Plasma Coagulation Treatment: Sang Pil Kim, M.D., Suck-Ho Lee, M.D., Jun Young Lee, M.D., Jin Woo Park, M.D., Ji-Young Park, M.D., Chang Kyun Lee, M.D., Il-Kwun Chung, M.D. and Sun-Joo Kim, M.D.; Korean J Gastrointest Endosc 2008;37(5):355-359. Published online November 30, 2008

Abstract PDF: Argon Plasma Coagulation (APC), a new endoscopic hemostatic method of non-contact electrocoagulation, is widely used for ablation of Barrett's esophagus, residual tissue after polypectomy, palliation of malignancy and hemostasis of radiation proctopathy, bleeding peptic ulcers, prevention of esophageal varices. Although a safe and effective procedure, if used inappropriately, side effects such as failure of hemostasis, perforation, asymptomatic submucosal emphysema, and pneumoperitoneum can occur. Perforations progressing to peritonitis require surgery, but a pneumoperitoneum can recover with conservative treatment. Therefore, clinicians should distinguish these two different cases. There are no domestic cases of asymptomatic pneumoperitoneum caused by APC. In two cases treated by endoscopic submucosal dissection of polypectomy and early gastric cancer, asymptomatic pneumoperitoneum occurred after argon plasma coagulation treatment. We present these two cases of asymptomatic pneumoperitoneum treated successfully by conservative treatment without complications. (Korean J Gastrointest Endosc 2008;37:355-359)

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A Case of Synchronous Double Primary Cancer : Gastric Carcinoid and Early Gastric Cancer: Sun Jung Kim, M.D., Seun Ja Park, M.D., Hong Jun You, M.D., Woo Seoung Jeon, M.D., Sung Eun Kim, M.D., Won Moon, M.D., Kyu Jong Kim, M.D. and Moo In Park, M.D.; Korean J Gastrointest Endosc 2008;37(5):360-363. Published online November 30, 2008

Abstract PDF: An association of carcinoid tumors with another primary neoplasm has been reported in 17∼53% of cases, with an especially high incidence of adenocarcinomas. However, simultaneous association of a gastric carcinoid tumor with a gastric adenocarcinoma as a synchronous double primary cancer is extremely rare. We report a case of a synchronous double primary cancer associated with a gastric carcinoid and early gastric cancer in a 63-year-old male patient. (Korean J Gastrointest Endosc 2008;37:360- 363)

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A Case of a Meckel's Diverticular Bleeding Diagnosed by the Use of Double Balloon Enteroscopy: Woo Young Heo, M.D., Jae Myung Cha, M.D., Sung Won Jung, M.D., Hyun Phil Shin, M.D., Jae Won Choe, M.D., Kang Ro Joo, M.D., Joung Il Lee, M.D. and Jong Beom Park, M.D.*; Korean J Gastrointest Endosc 2008;37(5):364-368. Published online November 30, 2008

Abstract PDF: Meckel's diverticulum is one of the most common congenital anomalies, and its incidence is about 2% in the population. Most of the cases are asymptomatic and only 5% of cases are symptomatic with complications, including bleeding, intestinal obstruction, inflammation and perforation. Bleeding from a Meckel's diverticulum is usually painless and is sometimes massive. Recently, the use of double balloon enteroscopy has allowed improved access in patients with obscure gastrointestinal bleeding; however, a case of bleeding from a Meckel's diverticulum treated with double balloon enteroscopy hs rarely been reported. Double balloon enteroscopy can diagnose a Meckel's diverticulum without difficulty as the lesion is usually located at the distal ileum, and the method provides endoscopic hemostasis for the bleeding. Therefore, double balloon enteroscopy might be a useful diagnostic and therapeutic modality for bleeding from a Meckel's diverticulum. We experienced a case of bleeding from a Meckel's diverticulum that was detected and was treated by the use of double-balloon enteroscopy in a 47-year-old man with recurrent episodes of melena. (Korean J Gastrointest Endosc 2008;37:364-368)

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A Case of Colon Cancer Coexisting with Colonic Tuberculosis: Jae Myung Cha, M.D., Joung Il Lee, M.D., Jae Won Choe, M.D., Kwang Ro Joo, M.D.,Sung Won Jung, M.D., Hyun Phil Shin, M.D., Woo Young Hew, M.D. and Suk-Hwan Lee, M.D.*; Korean J Gastrointest Endosc 2008;37(5):369-373. Published online November 30, 2008

Abstract PDF: Patients with chronic inflammatory bowel disease have a potential risk for developing colorectal cancer. Simultaneous occurrence of tuberculosis and colon cancer at the same segment of the colon has been reported; however, there is little causal relationship between the two disorders. The occurrence of tuberculosis and an adenocarcinoma at the same segment of the colon may lead to a histological misdiagnosis of either lesion. Furthermore, it may be difficult to determine the correct radiological cancer staging before surgery, as tuberculous lymphadenitis may be misinterpreted as a lymph node metastasis of colon cancer. We report here a rare case of colon cancer coexisting with colonic tuberculosis at the same segment of the colon. In addition, we review the clinical characteristics of reported patients with similar conditions following a computerized search of KoreaMed and PubMed. (Korean J Gastrointest Endosc 2008;37:369-373)

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Three Cases of Colonic Pseudolipomatosis Induced by Endoscope Disinfectant: Jun Young Lee, M.D., Yong Sung Kim, M.D., Young Woo Sohn, M.D., Yong Reol Oh, M.D.,Jung Hyun Park, M.D., Hui Jung Kim, M.D., Weon Cheol Han, M.D.* and Byoung Kwan Son, M.D.^†; Korean J Gastrointest Endosc 2008;37(5):374-379. Published online November 30, 2008

Abstract PDF: Colonic pseudolipomatosis is a benign condition that is caused by mechanical trauma during an endoscopic procedure or by disinfectant colitis. It is characterized by empty vacuoles that are similar to the adipocyte in the lamina propria on histology and whitish plaques that are seen endoscopy. The prevalence of pseudolipomatosis is relatively low due to the lack of clinical experience and there have been no Korean reports about colonic pseudolipomatosis with the typical endoscopic findings. We report here on three cases of colonic pseudolipomatosis that was caused by endoscope disinfectant (paracetic acid). Typical whitish plaques were observed during the colonoscopic procedures in all 3 cases. In one case, whitish plaques appeared before our eyes immediately after the sudden appearance of whitish foamy fluid when the water button was depressed. H&E stain revealed empty vacuoles in the lamina propria and immunohistochemical staining showed no expression of CD31, CD34 and s-100. There were no symptoms related to these lesions in our cases. (Korean J Gastrointest Endosc 2008;37:374-379)

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A Case of Benign Colonic Stricture Treated by Therapeutic Balloon Dilatation in Ulcerative Colitis: Jun Young Lee, M.D., Suck-Ho Lee, M.D., Sang Pil Kim, M.D., Jin Woo Park, M.D., Chang Kyun Lee, M.D., Ji-Young Park, M.D., Il-Kwun Chung, M.D. and Sun-Joo Kim, M.D.; Korean J Gastrointest Endosc 2008;37(5):380-383. Published online November 30, 2008

Abstract PDF: Ulcerative colitis produces repeated improvements and relapses of chronic colonic inflammation. Complications of the disease can include bleeding, toxic megacolon, colon cancer, or colon stricture. While colonic strictures are common in Crohn's disease, this complication rarely appears in ulcerative colitis cases. Unlike in Crohn's disease, where strictures are commonly treated by endoscopic balloon dilatation, surgical management is the basis for treatment of strictures in ulcerative colitis because malignant strictures are common and because the stricture region is generally wide. We report the case of a patient who presented with decreased stool caliber while undergoing treatment for ulcerative colitis. We performed therapeutic balloon dilatation in this patient with a benign stricture caused by ulcerative colitis and experienced improvement of symptoms. (Korean J Gastrointest Endosc 2008;37: 380-383)

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A Case of Pancreatic Dual Wirsung Ducts in a Patient with von Hippel-Lindau Disease: Hye Soo Kim, M.D., Byung Hoon Han, M.D., Sun Jung Kim, M.D., Jee Sook Lee, M.D., Sae Jin Park, M.D., Sang Uk Lee, M.D., Bang Hur, M.D.* and Jung Hyun Kim, M.D.^†; Korean J Gastrointest Endosc 2008;37(5):384-388. Published online November 30, 2008

Abstract PDF: Rare autosomal dominant disorders associated with various tumors and cysts, and several kinds of pancreatic lesions have been described in patients with von Hippel- Lindau (VHL) disease, but there have been few studies concerned with the variations of the pancreatic duct. We experienced a case of pancreatic dual Wirsung ducts in a patient with VHL disease. Computed tomography scans showed that multiple cysts had nearly completely replaced the pancreas, there was a solid tumor on the uncinate process of the pancreas and a left renal mass suggested renal cell carcinoma. ERCP shows that the Santorini duct and Wirsung duct were fused in a normal fashion, and another Wirsung duct had shrub-like branches that are commonly seen in pancreatic divisum. (Korean J Gastrointest Endosc 2008;37:384-388)

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A Spontaneous Pneumobilia Observed after Severe Vomiting in a Patient with CBD Stone: Se Jin Kim, M.D., Kyoung Hoon Rhee, M.D.*, Joon Ho Wang, M.D., Jae Dong Lee, M.D., Dong Chun Seol, M.D., Seung Chan Kim, M.D. and Won Hak Kim, M.D.; Korean J Gastrointest Endosc 2008;37(5):389-392. Published online November 30, 2008

Abstract PDF: Pneumobilia almost always indicates an abnormal communication between the biliary and gastrointestinal systems. Air may occasionally enter the biliary tract in a retrograde fashion through the papilla. Transient incompetence of the sphincter of Oddi, which is produced by the passage of small biliary stones, is one rare mechanism that can explain pneumobilia. We present here a case of spontaneous pneumobilia after sphincter disruption that was presumably caused by the passage of biliary stone. A 37-year-old woman visited our hospital with the symptom of right upper quadrant pain. The pain subsided after she had an episode of severe vomiting. Plain abdominal radiography revealed that air filled the branches of the hepatic ducts, and the common bile duct had a large filling defect. We also include a review of the related literature. (Korean J Gastrointest Endosc 2008;37:389-392)

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