Clinical Endoscopy

Pharmacological Therapy in Patients with Bleeding Peptic Ulcers: Jin Il Kim, M.D.; Korean J Gastrointest Endosc 2009;38(5):247-253. Published online May 30, 2009

Abstract PDF: The aim of pharmacological therapy in peptic ulcer disease is to increase the intragastric pH level above 6. The use of a proton pump inhibitor (PPI), a powerful gastric acid secretion inhibitor, has been proven as effective not only to control bleeding but also to reduce the rate of rebleeding. Maintainence of the intragastric pH level above 6 by the administration of a PPI prevents hemolysis caused by acid or pepsin and thereby promotes aggregation of platelets. Intragastric acid suppression can be achieved more effectively with continuous intravenous infusion of a PPI after intravenous bolus injection. However, oral administration of a PPI shows rapid onset, long duration of action and sufficient bioavailability. Therefore, both administration routes and pharmacologic properties of the drugs should be taken into account to gain the proper level of acid suppression above pH 6. Combination therapy with the use of endoscopic hemostatic treatment and intravenous PPI administration is known to result in the best outcome for peptic ulcer bleeding. In previous studies from South Korea, the use of combination therapy has also showed the best hemostaic outcome. However, pharmacological therapy with PPI alone can elevate and maintain intragastric pH above 6.0 and can result in hemostasis as similar to endoscopic hemostasis. (Korean J Gastrointest Endosc 2009;38:247-253)

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Analysis of the Risk Factors That Affect Esophageal Transit Delay When Performing Wireless Capsule Endoscopy: Donghoi Kim, M.D., Kyung-Jo Kim, M.D., Dong Jun Yoo, M.D., Soon Man Yoon, M.D., Byong Duk Ye, M.D., Jeong-Sik Byeon, M.D., Seung-Jae Myung, M.D., Suk-Kyun Yang, M.D., Jin-Ho Kim, M.D. and Eun Jin Rho, M.D.*; Korean J Gastrointest Endosc 2009;38(5):254-259. Published online May 30, 2009

Abstract PDF: Background
/Aims: Capsule endoscopy has become an excellent diagnostic tool for various small bowel diseases. However, some cases of delayed passage of the capsule in the esophagus without obstruction have been reported. The aims of this study were to analyze the risk factors associated with esophageal transit delay.
Methods
From Nov. 2002 to July. 2008, 141 patients underwent capsule endoscopy. Among them, 3 patients were excluded. The 138 patients were divided into two groups (the delayed esophageal transit time (DETT) group, and the normal esophageal transit time (NETT) group), and we compared their characteristics, including age, gender, the reason for examination, the total transit time and the rate of an incomplete examination.
Results
DETT occurred in 7 patients (5.1%). The mean age (61.14±20.70 vs. 44.01±17.37, respectively, p=0.02) was higher in the DETT groups. No statistically increased risk was found for gender and the indications for the procedure. The DETT group showed a higher rate of incomplete examination than did the NETT group (7/7 vs. 41/131, respectively, p=0.001).
Conclusions
Even though delayed esophageal transit on capsule endoscopy is not a serious complication, it could lead to an incomplete examination. Therefore, checking the chest X-rays after swallowing the capsule can be helpful to notice delayed esophageal transit earlier in the procedure. (Korean J Gastrointest Endosc 2009;38:254-259)

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A Prospective Randomized Trial Comparing Preference of Sulfate Free Polyethylene Glycol with Standard Polyethylene Glycol: Jun Seok Lee, M.D., Young Sook Park, M.D., Nam In Kim, M.D., Yun Ju Jo, M.D., Seong Hwan Kim, M.D., Moon Hee Song, M.D. and Dae Won Jun, M.D.; Korean J Gastrointest Endosc 2009;38(5):260-265. Published online May 30, 2009

Abstract PDF: Background
/Aims: The standard polyethylene glycol (PEG) solution for colonic cleansing has a salty taste and a large volume of it is required, which can cause failure for the patient to ingest the required dosage. This has been a limitation for its usage. Sulfate free PEG (SF-PEG) has a less salty taste due to removal of the sodium sulfate, but the published studies in western countries about the preference and the degree of patient's satisfaction with these two solutions has shown conflicting results. The object of this study was to compare SF-PEG with PEG solution in regard to preference, the degree of patient's satisfaction and the adverse effects in Korean patients. We also attempted to determine whether these factors were associated with preference.
Methods
Ninety-four patients scheduled for colonoscopy were given one liter of both solutions (SF-PEG and PEG) and then the patients were allowed to select either of the two solutions for the further two liters intake under informed consent. Before colonoscopy, the preferred solution, the degree of patient's satisfaction, the adverse effects and other information were recorded by questionnaire.
Results
Fifty-nine patients among the 94 patients (63%) preferred the SF-PEG solution (p＜0.05). Especially, the young patients under the age of 35 preferred the SF-PEG solution (83% vs 58%; p=0.045), and patients who had already experienced colonoscopy with PEG solution tended to prefer the SF-PEG (54% vs 78%; p=0.054).
Conclusions
Korean patients preferred the SF-PEG over PEG, and especially young aged patients and the patients who had already taken the PEG solution. Similar results were obtained for both solutions concerning the adverse effects, cleansing quality and compliance, and the degree of satisfaction was not much improved, which was probably due to the same large volume of fluid that is required for colon cleaning. (Korean J Gastrointest Endosc 2009;38:260-265)

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A Case of Subcutaneous Emphysema Following Percutaneous Endoscopic Gastrostomy: Gwang Il Seo, M.D., Jeong Rok Lee, M.D., Woo Chul Chung, M.D., Ju Huyn Oak, M.D., Jin Dong Kim, M.D., Chang Nyol Paik, M.D., Kang-Moon Lee, M.D. and Jin Mo Yang, M.D.; Korean J Gastrointest Endosc 2009;38(5):266-269. Published online May 30, 2009

Abstract PDF: Percutaneous endoscopic gastrostomy (PEG) has widely accepted for providing safe, long-term enteral nutrition for patients with swallowing disabilities. Though safe and technically simple, this procedure is often associated with some complications, such as wound infection, bleeding, stroma leaks and tube transposition. Major complications are rare and these include aspiration pneumonia, perforations, peritonitis and necrotizing fasciitis. We report here on a patient who developed extensive subcutaneous emphysema with hemoperitoneum and peritonitis following PEG. Medical treatment without removal of the PEG led to resolution of the emphysema and the peritonitis and successful PEG feeding. (Korean J Gastrointest Endosc 2009;38:266-269)

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A Case of Colon Cancer Coexisting with Colonic Tuberculosis and This Presented as Bowel Perforation: Chi Hun Kim, M.D., Hye Seung Han, M.D.*, Jeong Hwan Kim, M.D., Byeong Kuk Kim, M.D. and Seong Hwang Jang, M.D.^†; Korean J Gastrointest Endosc 2009;38(5):270-274. Published online May 30, 2009

Abstract PDF: Tuberculosis can involve any part of the body and there are case reports of tuberculosis coexisting with malignancy in most body organs. However, cases of intestinal tuberculosis associated with colon cancer have rarely reported. Inflammatory bowel diseases can progress to malignant diseases due to mucosal dysplastic change. Similarly, intestinal tuberculosis can cause chronic inflammation, but the exact relationship between intestinal tuberculosis and colon cancer is currently obscure. A 71-year-old woman visited our hospital because of abrupt right lower abdominal pain that progressed to rebound tenderness and abdominal rigidity. Abdominal computed tomography showed a polypoid mass in the cecum and a distended terminal ileum. Right hemicolectomy was performed and the surgical specimen revealed extremely well differentiated adenocarcinoma combined with intestinal tuberculosis and bowel perforation in the cecum. We report here on a rare case of colon cancer coexisting with colonic tuberculosis and this presented as bowel perforation. We also include a review of the relevant literature. (Korean J Gastrointest Endosc 2009;38:270-274)

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A Case of Narrow Opened Priampullary Diverticular Bleeding with Diagnostic Difficulty: Jin Nam Kim, M.D., Hong Sik Lee, M.D., Jae Hong Ahn, M.D., Seung Young Kim, M.D., Dong Il Kim, M.D., Sang Woo Lee, M.D. and Jae Hyun Choi, M.D.; Korean J Gastrointest Endosc 2009;38(5):275-378. Published online May 30, 2009

Abstract PDF: A duodenal diverticulum is most common in the medial aspect of the second portion of the duodenum and rarely causes symptoms. An obstruction, bleeding, perforation, jaundice and pancreatitis are uncommon complications of a duodenal diverticulum. Bleeding from the periampullary diverticulum should be considered in the diagnosis of a patient who presents with upper gastrointestinal bleeding of unknown origin. The second portion of the duodenum is sometimes difficult to observe entirely from the tangent line with the use of a forward-viewing endoscope. The diagnosis and treatment of periampullary diverticular bleeding may be achieved more easily by use of a side-viewing endoscope. We report here a case of narrow opened periampullary diverticular bleeding diagnosed by the use of a side-viewing endoscope with difficulty. (Korean J Gastrointest Endosc 2009; 38:275-278)

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A Case of Cytomegalovirus and Pseudomembranous Colitis in an Immunocompetent Adult: Seong Yeol Ryu, M.D., Kwi Hyun Bae, M.D. and Byoung Kuk Jang, M.D.; Korean J Gastrointest Endosc 2009;38(5):279-283. Published online May 30, 2009

Abstract PDF: Cytomegalovirus (CMV) colitis is a rare event that has been described mainly in immunocompromised patients who are on immunosuppressive medication or they have HIV infection. CMV colitis manifesting in an immunocompetent host is exceedingly rare, but this has occasionally been described in pregnant patients and patients with chronic renal failure. Pseudomembranous colitis (PMC) is known to develop with long-term antibiotic administration and it is caused by the abnormal overgrowth of toxin-producing Clostridium difficile that colonize the large bowel. Appropriate diagnostic testing and early treatment may avert morbidity and mortality. A case of the simultaneous occurrence of cytomegalovirus and Clostridium difficile colitis in an immunocompetent adult has not yet been reported in the Koran medical literature. We report here on a case of the simultaneous occurrence of cytomegalovirus and Clostridium diffiicle colitis in an immunocompetent Korean adult. (Korean J Gastrointest Endosc 2009;38:279-283) Key Words:

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Xanthogranulomatous Inflammation Presenting as a Submucosal Mass of the Stomach: Min Kyoung Park, M.D., Hong Jun Yang, M.D., Chang Hoon Lim, M.D., Tae Ho Kim, M.D., Chang Whan Kim, M.D., Jean A Kim, M.D.^†, Wook Kim, M.D.* and Sok Won Han, M.D.; Korean J Gastrointest Endosc 2009;38(5):284-287. Published online May 30, 2009

Abstract PDF: Xanthogranulomatous inflammation is a rare chronic inflammatory condition that is characterized by aggregation of lipid-laden foamy macrophages (xanthoma cells). Although the precise pathogenesis of xanthogranulomatous inflammation is not well understood, various mechanisms have been proposed, including chronic recurrent infection, the presence of gallstones, immunologic disorders and defective lipid transport. This disease entity is well recognized in the kidney and gallbladder, yet involvement of the gastrointestinal tract is extremely rare and the involvement of both the stomach and colon has never been reported on. A coexisting malignancy rarely has been reported in a patient with xanthogranulomatous inflammation. This might present as an inflammatory mass-like lesion with infiltration to the surrounding tissues, and so this often mimics advanced cancer. Therefore, a surgical operation together with careful pathological evaluation is required for making the precise diagnosis. We herein report on a case of xanthogranulomatous inflammation that presented as a submucosal mass in the stomach which was a huge irregular mass involving transverse colon. (Korean J Gastrointest Endosc 2009;38:284-287)

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Endoscopic Submucosal Dissection of Early Gastric Cancer That Occurred in a Patient with Chronic Myelogenous Leukemia: Young Hwangbo, M.D., Jae Young Jang, M.D., Jaejun Shim, M.D., Seok Ho Dong, M.D., Hyo Jong Kim, M.D., Byung Ho Kim, M.D., Young Woon Chang, M.D. and Rin Chang, M.D.; Korean J Gastrointest Endosc 2009;38(5):288-293. Published online May 30, 2009

Abstract PDF: Synchronous double malignancies of early gastric cancer and chronic myelogenous leukemia (CML) are very rare. There are few reports regarding the effect of the CML or imatinib on stomach cancer, and it is difficult to make a decision for the proper timing of treatment for early gastric cancer (EGC) in a patient with CML. A 56-year-old man was diagnosed with early gastric cancer. During the evaluation of his disease, he was also diagnosed as having Philadelphia chromosome positive chronic myleogenous leukemia. He started to take 400 mg of imatinib per day. Two weeks later, he underwent endoscopic submucosal dissection (ESD) for the early gastric cancer. Although there was a bleeding complication, complete resection was successfully performed. ESD is an effective treatment modality for EGC in CML patients, but physicians should keep a watchful eye for bleeding complications after the procedure. Further studies and more experience are needed to determine the proper timing of treatment for these patients. (Korean J Gastrointest Endosc 2009;38:288-293)

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A Case of a Gastric Glomus Tumor with a Positive Cushion Sign: Mi Ra Kim, M.D., Gwang Ha Kim, M.D., Geun Am Song, M.D., Jae Hoon Cheong, M.D., Do Youn Park, M.D.*, Mi Hyun Kim, M.D., Seon Kyeong Kim, M.D. and Seong Hoon Yoon, M.D.; Korean J Gastrointest Endosc 2009;38(5):294-298. Published online May 30, 2009

Abstract PDF: Glomus tumors are commonly observed in the dermis or subcutis but are only rarely found in the stomach. A 52-year-old woman presented with an incidental finding of a submucosal tumor that showed a positive cushion sign in the stomach. Endoscopic ultrasonography (EUS) showed a 1.8×1.0 cm sized well-circumscribed homogenous hypoechoic tumor with side halos in the fourth sonographic layer of the gastric wall. Contrast enhanced abdominal computerized tomography (CT) demonstrated high enhancement of the tumor with the same level of enhancement as the portal vein for the arterial phase, with persistence of enhancement in the portal phase. For treatment, laparascopic wedge resection was performed. Histological findings of a biopsy specimen were compatible with a glomus tumor. Although it is difficult to diagnose a glomus tumor preoperatively, these characteristic findings determined with the use of EUS and CT seem to be useful to distinguish a glomus tumor from other tumors that arise from the third or fourth sonographic layer of the gastric wall. (Korean J Gastrointest Endosc 2009;38:294-298)

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Common Bile Duct Obstruction Caused by Tumor Thrombus after Trans-arterial Chemoembolization in a Hepatocellular Carcinoma Patient: Hoon Choi, M.D., Suk Bae Kim, M.D., Ki Chul Shin, M.D., Hyun Duk Shin, M.D., Se Young Yun, M.D., Jung Eun Shin, M.D., Hong Ja Kim, M.D. and Il Han Song, M.D.; Korean J Gastrointest Endosc 2009;38(5):299-302. Published online May 30, 2009

Abstract PDF: The jaundice in hepatocellular carcinoma patient can be found when the tumor progresses or hepatic function deteriorates. Rarely, it can be occurred when the bile duct is obstructed. The main reason of obstructive jaundice in hepatocellular carcinoma is bile duct invasion of tumor, tumor thrombus, blood clot of hemobilia and direct bile compression by tumor or metastatic lymph node. Although the tumor thrombi among them is difficult to think, prompt diagnosis and treatment should be done because the symptom and prognosis can be improved by removal of the tumor thrombus. We experienced a case of hepatocellular carcinoma patient associated with obstructive jaundice caused by tumor thrombus after transarterial chemoembolization (TACE). The tumor thrombus was removed by endoscopic retrograde cholangiopancreatography (ERCP) and confirmed as degenerated hepatocellular carcinoma cell. (Korean J Gastrointest Endosc 2009;38:299-302)

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A Case of Synchronous Primary Cancer: Small Cell Carcinoma in the Common Bile Duct and Adenocarcinoma in the Stomachs: Yong Dae Kwon, M.D., Chang Duck Kim, M.D., Yong Sik Kim, M.D., Yoon Tae Jeen, M.D., Hoon Jai Chun, M.D., Soon Ho Um, M.D., Ho Sang Ryu, M.D. and Yang Seok Chae, M.D.*; Korean J Gastrointest Endosc 2009;38(5):303-308. Published online May 30, 2009

Abstract PDF: Primary small cell carcinoma occasionally occurs in the gastrointestinal tract; however, primary small cell carcinoma is extremely rare in common bile duct (CBD). Moreover, synchronous advanced gastric cancer has not been reported in the medical literature. We herein report on a case of synchronous primary cancer in the CBD and stomach. A 51-year-old male was admitted because of painless jaundice. Abdominal CT and ERCP showed an exophytic mass that obscured the mid-CBD and there was also intrahepatic duct dilatation. In addition, a large ulcerofungating mass was seen at the lesser curvature of the mid-body on gastrofiberscopy. The biopsy specimen obtained from ulcer was confirmed to be poorly differentiated adenocarcinoma. Explorative laparotomy was performed to remove CBD mass and gastrectomy, however, the surgery was stopped after just biopsy because of the invasion of tumor to the portal vein and difficulty in diseection. Small cell carcinoma was diagnosed from the surgical biopsy specimen by immunohistochemical stains. The tumor cells were strongly positive for neuroendocrine markers such as CD56 and synaptophysin. The patient received chemotherapy with irinotecan and cisplatin. (Korean J Gastrointest Endosc 2009; 38:303-308)

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