Clinical Endoscopy

Korean Society of Gastrointestinal Endoscopy (KSGE) Guidelines for Credentialing and Granting Previleges for Capsule Endoscopy: Gut Image Study Group: Yun Jeong Lim, M.D., Jeong Seop Moon, M.D.*, Dong Kyung Chang, M.D.^†, Byung Ik Jang, M.D.^‡, Hoon Jai Chun, M.D.^§ and Myung-Gyu Choi, M.D.^∥; Korean J Gastrointest Endosc 2008;37(6):393-402. Published online December 30, 2008

Abstract PDF: Capsule endoscope is self-contained videoendoscopy device that transmit images of the gastrointestinal tract to an external receiver. Capsule endoscopy has become a very important tool for diagnosing of small bowel disorders. Upcoming capsule endoscopy techniques for the investigation of esophageal, stomach, and colon may render it promising technique for these organs as well. This document is intended to provide the principles by which credentialing organizations may create practical guidelines for granting privileges to perform capsule endoscopy. KSGE recommends that the use of capsule endoscopy be limited to practitioners already competent and privileged to perform standard upper and lower endoscopy and who have extensive experience viewing gastrointestinal mucosa. KSGE recommends additional specific training in capsule endoscopy as well as review of the 20 procedures to verify competence. KSGE also admitted formal fellowship training having a familiarity with the hardware and software systems and interpretation of the at least 10 cases under the supervision of professor in capsule endoscopy during GI fellowship. (Korean J Gastrointest Endosc 2008;37:393-402)

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The Efficacy of Cimetropium Bromide as a Premedication before Esophagogastroduodenoscopy: Jue Yong Lee, M.D., Sung Jung Kim, M.D., Chang Soon Choi, M.D., Young Mook Kim, M.D., Hyun Joo Jeong, M.D., Jung Eun Lee, M.D., Gwang Ho Baik, M.D., Jin Bong Kim, M.D. and Dong Joon Kim, M.D.; Korean J Gastrointest Endosc 2008;37(6):403-408. Published online December 30, 2008

Abstract PDF: Background/Aims: Cimetropium bromide has been used widely as a premedication for endoscopy; however, there are no subjective data pertaining to the effects of cimetropum bromide as a premedication. Thus, the current study was undertaken to compare the effects of cimetropum bromide with placebo as a premedication for esophagogastroduodenoscopy (EGD). Methods: Two hundred ninety-nine consecutive outpatients who had undergone EGD were enrolled in this study. Thirty minutes before EGD, the patients were randomly given an intramuscular injection of cimetropium bromide (5 mg) or saline using a placebo-controlled, double-blind, randomized technique. Immediately after EGD, all the patients and endoscopists were requested to fill out the questionnaire form. Results: One-hundred patients were injected with cimetropium bromide and 150 patients were injected with placebo. There was no statistically significant difference in the degree of residual gastric secretions, the peristaltic activity detected by endoscopists, and the comfort experienced by the patients in each study group. Conclusions: The intramuscular injection of cimetropium bromide (5 mg) as a premedication for EGD was not significantly superior to placebo, at least with respect to subjective parameters, in spite of its broad use. (Korean J Gastrointest Endosc 2008;37:403-408)

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Non-surgical Treatment with Endoscopic Clipping in a Patient with Boerhaave's Syndrome: Yun-Kyung Kim, M.D., Chang Nyol Paik, M.D., U-Im Chang, M.D., Sung Hoon Jung, M.D., Jeong Rok Lee, M.D., Woo Chul Chung, M.D., Kang-Moon Lee, M.D. and Jin-Mo Yang, M.D.; Korean J Gastrointest Endosc 2008;37(6):409-412. Published online December 30, 2008

Abstract PDF: Boerhaave's syndrome is difficult to diagnosis because of the esophageal rupture, which is caused by nausea and vomiting, and Boerhaave's syndrome is known to have a high mortality rate. The mortality increases with a delayed diagnosis; therefore, an early diagnosis and surgical treatment are critical for a good prognosis. Yet some recent cases have shown that non-surgical treatments are successful in some classified patient groups. These groups should be considered according to their symptoms and their laboratory and radiological findings. Sepsis and multi-organ failure should be continuously checked for to see if they occurred and/or progressed. We report here on a 51 year old woman who had Boerhaave's syndrome, and this was caused by heavy drinking, nausea and vomiting, and she improved with just non-surgical treatment such as fasting, antibiotics and endoscopic clipping. (Korean J Gastrointest Endosc 2008;37:409-412)

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A Case of Double Primary Cancer of the Esophagus and Duodenum that Induced Hematemesis: Young Ho Kim, M.D., Chan Hee Seo, M.D. and Moo Yeol Lee, M.D.; Korean J Gastrointest Endosc 2008;37(6):413-418. Published online December 30, 2008

Abstract PDF: The occurrence of double primary cancer of the esophagus and duodenum is considered to be very rare. Moreover, it is difficult to manage this type of double cancer because esophageal cancer has a biologic tendency towards early metastasis. Yet the development of endoscopy such as endoscopic ultrasonography (EUS), the new diagnostic imaging modalities such as PET/CT and advanced pathologic interpretation can lead to an early diagnosis of these multiple primary neoplasms. Appropriate intervention with various therapeutic tools then becomes possible, so these multiple primary neoplasms are not currently obstinate problems. We experienced one patient with double primary cancer; we simultaneously found esophageal cancer and duodenal cancer via endoscopy, and we wanted to treat them with chemo- radiation therapy and endoscopic submucosal dissection, but we failed to persuade the patient to accept the treatment. (Korean J Gastrointest Endosc 2008;37:413-418)

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A Case of Borrmann Typer 4 Cancer that was Suspected to be Eosinophiic Gastritis: Hyun Ho Choi, M.D., Chang Nyol Paik, M.D., U-Im Chang, M.D., Sung Hoon Jung, M.D., Jeong Rok Lee, M.D., Woo Chul Chung, M.D., Kang-Moon Lee, M.D. and Jin-Mo Yang, M.D.; Korean J Gastrointest Endosc 2008;37(6):419-423. Published online December 30, 2008

Abstract PDF: Borrmann type 4 gastric is a malignant disease that shows enlarged gastric folds, and this is easily mistaken as a mucosal flare or as inflammation because a third of these patients show normal mucosa without mucosal defects and the lesion diffusively infiltrates into the submucosal area. Endoscopic ultrasonography is an effective tool for making the differential diagnosis of gastric subepithelial lesion and hypertrophic gastric fold when endoscopy is not suitable to use. Eosinophilic gastritis is a benign lesion with enlarged gastric folds and it shows pathologic eosinophil infiltration in the walls of the stomach. We report here on a case that was suspected to be Borrmann type 4 advanced gastric cancer according to the endoscopic ultrasonography and this was confirmed by abdominal operation. Otherwise, this condition would have been mistaken for eosinophilic gastritis. (Korean J Gastrointest Endosc 2008;37:419-423)

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A Case of Photodynamic Therapy after Endoscopic Submucosal Dissection for the Treatment of Early Gastric Cancer that Mimicked Submucosal Tumor: Woo Seok Choi, M.D., Jong-Jae Park, M.D., Bum Jae Lee, M.D., Jain Park, M.D., Sung-Ho Kim, M.D., Eunhye Lim, M.D., Jae Seon Kim, M.D. and Young-Tae Bak, M.D.; Korean J Gastrointest Endosc 2008;37(6):424-428. Published online December 30, 2008

Abstract PDF: Several cases of photodynamic therapy (PDT) for the curative treatment of early gastric cancer have recently been reported. However, PDT has been performed in only limited cases because it is impossible to determine the pathologic subtype or stage of the malignant lesion after the procedure. Nevertheless, PDT combined with endoscopic submucosal dissection (ESD) is expected to enhance the accuracy of the pathologic assessment and enable more effective, safe treatment for early gastric cancer. Furthermore, PDT may exert a complementary and synergetic effect on ESD for the atypical forms of early gastric cancer. From this background, we report here on a case of early gastric cancer that mimicked submucosal tumor, and this was removed by ESD, and then this was followed by adjuvant PDT. The patient had a high risk for operation due to his old age and comorbidity. After the procedure, he achieved complete remission and he is currently under follow up: he is without recurrence of tumor one year after ESD. (Korean J Gastrointest Endosc 2008;37:424-428)

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A Case of Endoscopic Temporary Stent Insertion to Treat a Pyloric Stenosis Caused by Endoscopic Submucosal Dissection for Early Gastric Cancer: Won Woo Lee, M.D., Jong-Jae Park, M.D., Cho Rong Oh, M.D., Seung Joo Nam, M.D., Key Hyeon Kim, M.D., Jin Ki Hwang, M.D., Jae Seon Kim, M.D. and Young-Tae Bak, M.D.; Korean J Gastrointest Endosc 2008;37(6):429-432. Published online December 30, 2008

Abstract PDF: Circumferential resection by performing endoscopic submucosal dissection (ESD) in the antrum can cause pyloric stenosis. Treatment with balloon dilation usually requires repeated sessions and this may cause bleeding or perforation. There are several studies regarding the treatment of benign pyloric stenosis by the temporary placement of self-expandable metallic stent (SEMS), but these studies did not include any case of pyloric stenosis caused by ESD for treating early gastric cancer (EGC). We experience a case of a man who had EGC encircling the antrum. After ESD, pyloric stenosis occurred and so a SEMS was applied. Eight weeks later, the stent was removed without complications. Stent insertion for benign pyloric stenosis has not been accepted as a standard therapeutic modality. However, continuous dilation of a stenotic lesion can be expected without major complications, except for migration. Therefore, temporary stent insertion can be considered as an alternative treatment option for benign pyloric stenosis. Further study on the long term outcome of this procedure is needed. (Korean J Gastrointest Endosc 2008;37:429-432)

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A Case of Duodenal Fistula Caused by Intra-abdominal Tuberculous Lymphadenopathy during Anti-tuberculous Medication: Kyong Rok Lee, M.D., Kang Seok Seo, M.D., Jun Ho Cheo, M.D., Sang Cheol Choi, M.D., Kang Kim, M.D., Youn Gun Yim, M.D., Gun Young Hong, M.D. and Sang Wook Park, M.D.; Korean J Gastrointest Endosc 2008;37(6):433-437. Published online December 30, 2008

Abstract PDF: Recently, the proportion of extrapulmonary tuberculosis in patients has increased in Korea. Though intestinal tuberculosis in not infrequent, a duodenal fistula caused by tuberculosis is a rare condition. A 29-year-old man was admitted to the Department of Internal Medicine because of fever and weight loss. The patient was a doctor participating in a resident fellowship. The patient was diagnosed with intra-abdominal tuberculous lymphadenopathy and was given anti-tuberculous medication. One month after the administration of medication, the patient showed symptoms and signs of duodenal obstruction because of marked duodenal wall edema and a deep ulcer on the second portion of the duodenum. A computerized tomogram and duodenography revealed the formation of a fistula at the second portion of the duodenum and the presence of abscess-forming tuberculous lymphadenopathy. The use of continuous anti- tuberculous medication resulted in the improvement of the clinical symptoms, with complete healing of the duodenal fistula and tuberculous lymphadenitis. This case suggests that transient clinical worsening in intra-abdominal tuberculous lymphadenitis may occur during an early period of anti- tuberculous medication. (Korean J Gastrointest Endosc 2008;37:433-437)

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A Case of a Jejunal Dieulafoy's Lesion Mimicking a Submucosal Tumor: Hae Won Jeong, M.D., Jin Yong Kim, M.D., Sang Jung Kim, M.D., Tae Hoon Jang, M.D., Won Seok Choi, M.D. and Ji In Lee, M.D.; Korean J Gastrointest Endosc 2008;37(6):438-442. Published online December 30, 2008

Abstract PDF: Dieulafoy's lesion is a rare cause of severe gastrointestinal bleeding. In most cases, Dieulafoy's lesion is typically found in the stomach within 6 cm from the gastroesophageal junction, but the presence of lesions has also been described throughout the gastrointestinal tract. A jejunal Dieulafoy's lesion is extremely rare, and only a few cases have been reported in the Korean population. We experienced a case of a jejunal dieulafoy's lesion mimicking a submucosal tumor that presented with massive gastrointestinal bleeding. The lesion was diagnosed by the use of double balloon enteroscopy and was then confirmed by a pathological examination of the surgical specimen. (Korean J Gastrointest Endosc 2008;37:438-442)

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A Case of Crohn's Disease Isolated to the Appendix, Presented with Weight Loss: Ki Sung Cho, M.D., Jin Woong Cho, M.D., Gum Mo Jung, M.D., Young Jae Lee, M.D., Ji Woong Kim, M.D., Myoung Jin Cho, M.D., Ji Hun Kang, M.D. and Mi Na Oh, M.D.; Korean J Gastrointest Endosc 2008;37(6):443-446. Published online December 30, 2008

Abstract PDF: Granulomatous appendicitis is a rare condition that accounts for less than 0.1∼0.2% of all the cases of appendicitis. The great majority of cases are subacute or recurrent appendicitis and they are treated with interval appendectomy. The remaining causes include Yersinia infection, foreign body reaction, infection by mycobacteria, fungi or parasites, and Crohn's disease isolated to the appendix. Crohn's disease isolated to the appendix has several characteristics such as slow progression, a low recurrence rate and a good prognosis. Crohn's disease isolated to the appendix has recently been called "Idiopathic Granulomatous Appendicitis", and some authors have tried to distinguish it from Crohn's disease involving the appendix. We experienced a case of isolated appendiceal Crohn's disease in a 39-year-old woman and we report on it here along with a review of relevant literature. (Korean J Gastrointest Endosc 2008;37:443-446)

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A Case of Crohn's Disease with an Initial Presentation of Granulomatous Appendicitis: Jae Myung Cha, M.D., Joung Il Lee, 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(6):447-452. Published online December 30, 2008

Abstract PDF: Crohn's disease is a condition of chronic inflammation that potentially involves any location the in gastrointestinal tract; however, Crohn's disease with the primary lesion confined to just the appendix is very rare through out the world. Physicians may not be able the clinically differentiate Crohn's disease confined to the appendix from acute appendicitis, and it may not be distinguishable from granulomatous appendicitis of other causes, according to the histopathology. Therefore, clinical follow-up for assessing additional manifestations and sometimes further investigations are the only means of differentiating between granulomatous appendicitis of other causes and early Crohn's disease of the appendix. We experienced 26- year-old man who underwent ileocecectomy for a presumed diagnosis of an acute appendicitis, which pathologically resulted in a granulomatous appendicitis. The cause of the granulomatous appendicitis might have been Crohn's disease because the patient subsequently developed other manifestations of Crohn's disease, according to the follow-up colonoscopy findings. (Korean J Gastrointest Endosc 2008;37:447-452)

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Development of Two Cases of Acute Colitis after Soap Enemas: Yong Jin Park, M.D., Koon Hee Han, M.D., Young Don Kim, M.D., Woo Jin Jeong, M.D., Gil Hyun Kang, M.D.* and Gab Jin Cheon, M.D.; Korean J Gastrointest Endosc 2008;37(6):453-458. Published online December 30, 2008

Abstract PDF: Acute diarrhea is caused by many situations such as infections, drugs, autoimmune diseases, immunodeficiency, ischemia and toxins. In addition, enema induced-colitis also causes acute diarrhea. Damage to the colon has been reported after exposure to a number of rectally administered agents, the better known of which are soaps and detergents used as cleansing enemas. Soap enemas cause corrosive colitis due to the saponification reaction as well as toxic materials. We report two cases of acute colitis induced by soap enemas administered in preparation for cesarean sections. (Korean J Gastrointest Endosc 2008; 37:453-458)

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A Case of an Anomalous Opening of the Common Bile Duct and Pancreatic Duct into the Duodenal Bulb, and the Patient Presented with Acute Cholangitis and Recurrent Duodenal Ulcer: Myoung Jin Cho, M.D., Mi Na Oh, M.D., Hoon Ki Baek, M.D., Ki Sung Cho, M.D., Ji Hun Kang, M.D., Young Jae Lee, M.D., Ji Woong Kim, M.D. and Jin Woong Cho, M.D.; Korean J Gastrointest Endosc 2008;37(6):459-464. Published online December 30, 2008

Abstract PDF: There are various congenital anomalies of the biliary system, but an ectopic opening of the common bile duct into the duodenal bulb is an extremely rare finding. Despite the recent improvement in the diagnosis and management of pancreatobiliary lesions, the general lack of knowledge and understanding about these variations is undoubtedly responsible for many of the problems that occur during the medical and surgical management of these lesions. We report here on a case of a 65-year-old man who had an ectopic opening of the common bile duct into the duodenal bulb, and this cause acute cholangitis with bile duct sludge, and also recurrent duodenal ulcer. In this case, we used abdomen CT, MRCP, duodenoscopy, EUS and ERCP for making the diagnosis. The cholangitis and duodenal ulcer was improved with medical therapy, and the patient was discharged without any surgical procedure. We report here on this unusual case and we include a review of the relevant medical literature. (Korean J Gastrointest Endosc 2008;37:459-463)

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