Clinical Endoscopy

Diagnostic Tips for Making the Diagnosis of Inflammatory Bowel Disease: Dong Soo Han, M.D.; Korean J Gastrointest Endosc 2009;38(4):181-187. Published online April 30, 2009

Abstract PDF: The incidence and prevalence of inflammatory bowel disease (IBD) in Korea and Asian countries is rapidly rising. There are no specific diagnostic tools for this malady and the diagnosis of IBD is based on the clinical, radiologic, endoscopic, pathologic findings. Endoscopy plays an important role for the diagnosis, follow-up, cancer surveillance and therapeutic interventions for IBD. This article reviews the utility of endoscopy for making the diagnosis of IBD and the key points of observation during the endoscopic procedures. (Korean J Gastrointest Endosc 2009;38:181-187)

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Comparison of Endoscopic Forcep Biopsy and the Histopathologic Diagnosis after Endoscopic Submucosal Dissection: Young Dae Kim, M.D., Joo Young Cho, M.D., In Seop Jung, M.D., Bong Min Koh, M.D., Su Jin Hong, M.D., Chang Beom Ryu, M.D., Jin Oh Kim, M.D., Joon Seong Lee, M.D., Moon Sung Lee, M.D., So Young Jin, M.D.*, Chan Sup Shim, M.D. and Boo Sung Kim, M.D.; Korean J Gastrointest Endosc 2009;38(4):188-192. Published online April 30, 2009

Abstract PDF: Background
/Aims: The discrepancy of the histopathological diagnosis between endoscopic forcep biopsy, surgery and endoscopic mucosal resection (EMR), has been reported on in a previous study. We compared the results of endoscopic forcep biopsy and the histopathologic diagnosis after performing endoscopic submucosal dissection (ESD). Methods: We retrospectively reviewed 434 lesions for which we were able to compare the post-ESD histopathologic results with the endoscopic biopsy. Results: 1) Of the 14 lesions that showed chronic gastritis or atypia by endoscopic biopsy, 9 were diagnosed with carcinoma in situ or adenocarcinoma after ESD. 2) fifty one of 141 lesions that showed low grade dysplasia on the endoscopic biopsy were diagnosed with carcinoma in situ or adenocarcinoma after ESD. 3) Of the 60 lesions that showed high grade dysplasia on the endoscopic biopsy, 46 were diagnosis with carcinoma in situ or adenocarcinoma after ESD. Conclusions: The discrepancy of the histopathological diagnosis was found between ESD and forcep biopsy. In light of these results, if a lesion that is suspected to be EGC, although it is not diagnosed by endoscopic biopsy, then it should be confirmed by ESD. (Korean J Gastrointest Endosc 2009;38:188-192)

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The Usefulness of Applying an Additional Clip When Using a Double-layered Pyloric Stent to Treat Gastric Outlet Obstruction: Woo Jin Jung, M.D., Dae Hwan Kang, M.D., Cheol Woong Choi, M.D., Hyung Wook Kim, M.D., Gwang Ha Kim, M.D., Jeong Heo, M.D., Geun Am Song, M.D., Mong Cho, M.D., Kyung Sik Jung, M.D., Yong Wuk Kim, M.D., Dong Uk Kim, M.D., Pyo Jun Kim, M.D. and Il Du Kim, M; Korean J Gastrointest Endosc 2009;38(4):193-198. Published online April 30, 2009

Abstract PDF: Background
/Aims: It has been reported the placement of a double-layered pyloric combination stent can overcome the disadvantage of the increased ingrowth observed for an uncovered stent and the increased migration for a covered stent. But this did not satisfactorily prevent stent migration and it caused stent migration more frequently than with using the uncovered stent. This study evaluated the usefulness of applying a clip in an effort to reduce stent migration. Methods: Fifteen patients with malignant gastric outlet obstruction were treated with endoscopic placement of a double-layered combination pyloric stent. Three endoscopic clips were then applied to fix the proximal end of the enteral stent to the gastric or duodenal mucosa. The clinical efficacy and especially the rate of migration were analyzed. Results: The technical and clinical success rate was 100% (15/15) and 93.3% (14/15), respectively. No stent migration was observed in any of the patients. Three patients (20%) experienced complications such as stent collapse. The median stent patency period was 83.4 days. Conclusions: Endoscopic clipping for enteral stent placement is effective for preventing stent migration in patients with malignant gastric outlet obstruction. (Korean J Gastrointest Endosc 2009;38:193-198)

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Risk Factors Predicting the Development of Complication after Foreign Body Ingestion: Sung Hoon Jung, M.D., Chang Nyol Paik, M.D., Kang Moon Lee, M.D., Woo Chul Chung, M.D., Jeong Rok Lee, M.D., U-Im Chang, M.D. and Jin Mo Yang, M.D.; Korean J Gastrointest Endosc 2009;38(4):199-204. Published online April 30, 2009

Abstract PDF: Background
/Aims: Complications related to foreign body ingestion are uncommon, and especially a food bolus, but some ingested foreign bodies are associated with severe and life threatening morbidity. The aim of this study is determine the predictive risk factors for complications resulting from foreign body ingestion in patients who are without gastrointestinal tract obstruction. Methods: We retrospectively analyzed the data of 147 patients who were diagnosed with a foreign body in the GI tract without obstruction between Jan. 2000 to Aug. 2008. Results: Animal bone fragment and coin were the most common type of foreign bodies in adults and children, respectively. Multivariate analysis showed age (p=0.019), the duration of impaction (p=0.013) and the location of the impacted foreign body (p=0.011) were significant independent risk factors associated with the development of complications. Especially, the most important risk factor for children was the location of the impacted foreign body and for adults it was the duration of impaction. Conclusions: Old age, a longer duration of impaction and impaction at the upper esophageal sphincter or upper esophagus are important predictive factors of complication after foreign body ingestion in patients without gastrointestinal tract obstruction. For cases with these factors, more intensive awareness by the physician should be adapted. (Korean J Gastrointest Endosc 2009;38:199-204)

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A Deep Neck Infection Due to Esophageal Perforation That Was Caused by Upper Gastrointestinal Endoscopy: Sung Gon Shim, M.D., Hang Rak Lee, M.D., Kang Nyeong Lee, M.D., Oh Young Lee, M.D., Byung Chul Yoon, M.D., Ho Soon Choi, M.D., Joon Soo Hahm, M.D. and Kyung Tae, M.D.*; Korean J Gastrointest Endosc 2009;38(4):205-209. Published online April 30, 2009

Abstract PDF: Diagnostic upper gastrointestinal endoscopy is a very commonly performed procedure. Physicians use it as a safe diagnostic tool to evaluate patients with a wide range of problems and complaints, but it can cause several complications in few cases. Esophageal perforation is a rare complication of upper gastrointestinal endoscopy, but it is associated with a relatively high mortality rate. Surgical management is required in most such cases. However, medical treatment can be considered for selected patients who are without a large perforation or systemic effects such as sepsis. Deep neck abscess can develop in patients who have had difficult intubations, and this may be related to retropharyngeal trauma or unapparent perforations. We experienced a case of deep neck infection due to an esophageal perforation that developed as a complication of diagnostic upper gastrointestinal endoscopy, and we successfully treated this patient with incision and drainage. (Korean J Gastrointest Endosc 2009;38:205-209)

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A Case of Esophageal Pyogenic Granuloma: Hyun Sun Cho, M.D., Eun Sun Jung, M.D.*, Yune Jung Lee, M.D., Chul Hyun Lim, M.D., Woong-Ryong Jung, M.D., Hye Young Sung, M.D., Jae Myung Park, M.D. and Myung-Gyu Choi, M.D.; Korean J Gastrointest Endosc 2009;38(4):210-213. Published online April 30, 2009

Abstract PDF: Pyogenic granulomas (PGs) are rare benign lobular capillary hemangiomas that occur on the skin or mucosa. The most common sites of PG occurrence are the skin, lip, face and finger. This entity is extremely rare in the alimentary tract, with the exception of the oral cavity. We describe here a 72-year-old man who presented with dysphagia due to the presence of a pyogenic granuloma. The tumor was located in the mid-esophagus and it was treated with endoscopic submucosal dissection. PG is considered a lesion of reactive origin that may develop in response to trauma, infection, pregnancy, angiogenic factors or hormones. Gastrointestinal PG need to be treated because it is a rare cause of gastrointestinal hemorrhage, and it is hard to differentiate from tumorous conditions such as Kaposi's sarcoma. (Korean J Gastrointest Endosc 2009;38:210-213)

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A Case of Giant Gastric Lipoma Showing Upper Gastrointestinal Bleeding: Hee Seok Moon, M.D., Jae Kyu Sung, M.D., Hyun Yong Jeong, M.D. and Dae Young Kang, M.D.*; Korean J Gastrointest Endosc 2009;38(4):214-217. Published online April 30, 2009

Abstract PDF: Gastric lipoma is a typical benign submucosal tumor that is usually asymptomatic and it is generally detected incidentally when performing upper GI endoscopy. However, depending on its size and location, an atypical gastrointestinal lipoma can cause abdominal pain, diarrhea, constipation, intestinal obstruction, intussuception and life-threatening gastrointestinal bleeding. This tumor is diagnosed and differentiated from other malignant and submucosal tumors on the basis of its characteristic findings at endoscopy and on computed tomography, magnetic resonance imaging and endoscopic ultrasonography. We report here on the case of a 58-year-old female with epigastric discomfort and melena; a 4.5×4 cm ulcero-fungating mass was detected on the anterior wall of the gastric antrum. Surgical subtotal gastrectomy was performed and the lesion was diagnosed as gastric lipoma. (Korean J Gastrointest Endosc 2009;38:214-217)

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Three Cases of Endoscopic Hemostasis of Gastric Ulcer Bleeding from an Exposed Blood Vessel with Using Histoacryl (N-Butyl-2-Cyanoacrylate): Yong Wan Sung, M.D., Ji Hun Roh, M.D., Young Hwa Jo, M.D., Dong Young Gu, M.D., Jae Hoon Yoo, M.D., Jun Mo Youn, M.D., Sung Hoon Kim, M.D. and Young Min Shin, M.D.; Korean J Gastrointest Endosc 2009;38(4):218-223. Published online April 30, 2009

Abstract PDF: Upper gastrointestinal bleeding is a primary and emergency complication of peptic ulcer. Injection of Histoacryl (N-butyl-2-cyanoacrylate) is an effective endoscopic hemostasis procedure to treat peptic ulcer bleeding. However, Histoacryl injection is not a widely used method because of its various and sometimes severe complications. Therefore, the use of Histocaryl should be considered as a second line treatment modality to achieve therapeutic endoscopic hemostasis when the conventional treatment modalities fail or the patient has a high risk of needing operative therapy. Three patients, who had gastric ulcer bleeding from an exposed blood vessel, were each treated by an injection of Histoacryl diluted with Lipiodol at a dilution ratio of 1：1. All 3 procedures were successfully accomplished without any complications. (Korean J Gastrointest Endosc 2009;38:218-223)

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Gastric Inflammatory Fibroid Polyp Resected by Endoscopic Submucosal Dissection: Hyeon Seong Kim, M.D., Jin Il Kim, M.D., Myoung Beom Koh, M.D., Chee Ho Noh, M.D., Se Min Lee, M.D., Dae Young Cheung, M.D., Soo-Heon Park, M.D. and Jae Kwang Kim, M.D.; Korean J Gastrointest Endosc 2009;38(4):224-228. Published online April 30, 2009

Abstract PDF: Inflammatory fibroid polyp (IFP) is a rare benign fibroproliferative disease that arises from the submucosal layer of the gastrointestinal tract. Surgical resection has been performed in most cases and the application of endoscopic resection is rare. Endoscopic submucosal dissection (ESD), which was recently introduced, enables en-bloc resection of a tumor regardless of the tumor size and location. Since IFP is benign, ESD can be very useful for both the diagnosis and treatment of a large-sized IFP. A 45-year-old woman was referred for the management of a gastric mass. Esophagogastroduodenoscopy showed a round submucosal mass with a central bulging at the gastric body. Endoscopic ultrasonography showed a 3.5×3.0 cm-sized hypoechoic mass in the third layer of the stomach. The tumor was removed by ESD with using a hook knife for complete en-bloc resection. The pathologic finding was compatible with the diagnosis of IFP. We report here on a case of IFP that presented as a gastric submucosal tumor and it was treated by the ESD method. (Korean J Gastrointest Endosc 2009;38:224-228)

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Colonic Carcinoma and Tubular Adenoma with High Grade Dysplasia Resembling Submucosal Tumor: Eun Ran Kim, M.D., Dong Kyung Chang, M.D., Kyoung-Mee Kim, M.D.*, Jin Yong Kim, M.D., Young-Ho Kim, M.D., Jae Jun Kim, M.D. and Jong Chul Rhee, M.D.; Korean J Gastrointest Endosc 2009;38(4):229-233. Published online April 30, 2009

Abstract PDF: Colorectal carcinoma arises from the epithelium of the colorectal mucosa, and so it displays various macroscopic appearances with abnormal mucosal changes. But submucosal tumor-like colorectal carcinoma is very rare. We report here on two such cases along with a review of the relevant literature. The first case was submucosal tumor-like colorectal carcinoma that was initially diagnosed as rectal submucosal tumor, but the follow-up endoscopic exam revealed ulceroinfiltrative type adenocarcinoma. The second case was an endoscopically determined polypoid lesion combined with submucosal tumor, but it was found to be tubular adenoma with high grade dysplasia combined with a mucin pool collection in the submucosa after surgical resection. (Korean J Gastrointest Endosc 2009;38:229- 233)

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A Case of Acute Appendicitis Diagnosed by Colonoscopy: Eun Young Kim, M.D., 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. and Woo Young Hew, M.D.; Korean J Gastrointest Endosc 2009;38(4):234-236. Published online April 30, 2009

Abstract PDF: Most patients with acute appendicitis have typical symptoms and physical examination findings, yet some patients may have an atypical clinical presentation that is indistinguishable from other alternative conditions that are included in the differential diagnosis. The clinical role of colonoscopy for the diagnosis of acute appendicitis in these patients has not been investigated. Here, we describe the case of a 44-year-old man with acute appendicitis that was diagnosed with colonoscopy, which was performed 8 days after the development of abdominal pain, and colonoscopy demonstrated the frank pus drainage from the appendiceal orifice. An emergency laparoscopic partial cecectomy with an appendectomy was performed based on the colonoscopy findings. The microscopic findings were consistent with an acute suppurative appendicitis with periappendiceal adhesions, dense fibrosis and inflamed granulation tissue. This case highlights that timely colonoscopy may be helpful for the confirmation or exclusion of appendicitis when the clinical presentation is atypical. (Korean J Gastrointest Endosc 2009;38:234-236)

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A Case of Invasive Candidal Colitis in a Neutropenic Patient: Se Hyung Lee, M.D., Yun Ho Kong, M.D., Koon Hee Han, M.D., Young Don Kim, M.D., Woo Jin Jeong, M.D., Dae Woon Eom, M.D.*, Ji Hoon Kim, M.D.^† and Gab Jin Cheon, M.D.; Korean J Gastrointest Endosc 2009;38(4):237-241. Published online April 30, 2009

Abstract PDF: The candida species are considered as resident microflora in healthy persons. Yet in immunocompromised patients, candida can cause opportunistic invasive fungal infections. A 67-year-old woman presented to the hospital with abdominal pain and diarrhea. On admission, the laboratory studies revealed profound neutropenia, and the abdominal computed tomography showed thickened walls of the ascending colon and terminal ileum. The patient's fever and clinical symptoms continued for 5 days in spite of the empirical antibiotic therapy. We performed colonoscopy and obtained biopsy specimens at the ulcer lesions of the ascending colon and terminal ileum. The histology showed that candida hyphae had invaded to the lamina propria of the colonic mucosa. After antifungal treatment, her clinical symptoms subsided and the follow-up colonoscopic findings showed improvement. Therefore, we suggest that invasive candidal colitis should be considered in the differential diagnosis of neutropenic enterocolitis. (Korean J Gastrointest Endosc 2009;38:237-241)

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A Case of a Pancreatic Intraductal Papillary Mucinous Neoplasm Forming Multiple Fistulas and Manifesting as Duodenal Ulcer Bleeding: Hearn Kook Kim, M.D., Jae Woo Kim, M.D., Myeong Hun Chae, M.D., Jin Hyung Lee, M.D., Hyun Soo Kim, M.D., Soon Koo Baik, M.D., Mee Yon Cho, M.D.* and Seung Whan Cha, M.D.^†; Korean J Gastrointest Endosc 2009;38(4):242-245. Published online April 30, 2009

Abstract PDF: An intraductal papillary mucinous neoplasm (IPMN) of the pancreas is an uncommon tumor characterized by the production of mucin in the pancreatic duct that occasionally involves the formation of fistulas with surrounding organs, including the stomach, duodenum and common bile duct. The mechanism underlying the formation of such fistulas is direct invasion by a tumor or a combination of high pressure in the main pancreatic duct and inflammatory stimulation. A 73-year-old man was referred to our hospital due to the presence of a gastric ulcer detected on screening gastroscopy. Endoscopic findings showed the presence of a whitish thick mucin coated ulcerative lesion that appeared as a perforation or fistula opening. Abdominal computed tomography and magnetic resonance cholangiopancreatography demonstrated the presence of an IPMN of the pancreas and multiple fistula formation with the neighboring organs. An endoscopic biopsy was carried out to obtain pancreatic tumor tissue through the pancreatogastric fistula and the mass was confirmed as a mucinous adenocarcinoma. To the best of our knowledge, this is the first case of an IPMN associated with a pancreatojejunal fistula and duodenal ulcer bleeding due to fistula formation. (Korean J Gastrointest Endosc 2009;38:242-246)

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