Clinical Endoscopy

Technique, Management and Complications of Percutaneous Endoscopic Gastrostomy: Yun Jeong Lim, M.D. and Chang Heon Yang, M.D.; Korean J Gastrointest Endosc 2009;39(3):119-124. Published online September 30, 2009

Abstract PDF: Percutaneous endoscopic gastrostomy (PEG) is a widely used method for introducing a gastrostomy tube endoscopically to enable enteral feeding in patients who are unable to eat but have a normally functioning gut. The endsopist trained in the techniques for enteral access should be equally acquired the knowledge for monitoring patients and managing the complications arising from the initial gastrostomy procedure. Optimal endoscopic technique, proper monitor, early recognition of impending complication and quick management are important because most of these patients are elderly, debilitated, and chronically ill. In this review, general information about insertion and management of PEG was described based on the our experience of PEG and review of literatures. (Korean J Gastrointest Endosc 2009;39:119-124)

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The Clinical Significance of Extraluminal Compressions According to the Site of the Stomach: Yong Wuk Kim, M.D., Gwang Ha Kim, M.D., Dong Uk Kim, M.D., Il Du Kim, M.D., Kyung Sik Jung, M.D., Woo Jin Jung, M.D., Cheol Woong Choi, M.D., Dae Hwan Kang, M.D. and Geun Am Song, M.D.; Korean J Gastrointest Endosc 2009;39(3):125-130. Published online September 30, 2009

Abstract PDF: Background
/Aims: It can be difficult to differentiate an extraluminal compression from a true submucosal tumor (SMT) in the stomach. The best method for differentiating an extraluminal compression from a true SMT is endoscopic ultrasonography (EUS). Extragastric compression is frequently observed, but its clinical significance has rarely been reported on. We evaluated the clinical findings of extraluminal compression according to the site of the stomach.
Methods
Ninety-one patients were diagnosed by EUS as having extragastric compressions from January 2006 to July 2008. Abdominal sonography or computed tomography was performed in some cases.
Results
The causes of normal structures (64 cases) were the vessels, spleen, intestine, gallbladder, liver, mesentery, pancreas and kidney. The causes of pathologic lesions (27 cases) were hepatic cyst, distended gallbladder with sludge, splenic cyst, hepatic hemangioma, polycystic hepatic and renal disease, pancreatic cyst, renal cyst, calcified lymph node and hepatocelluar carcinoma. The great curvature of the fundus was the most frequent site of extraluminal compressions. The lesions in the anterior wall of the body showed a higher frequency of pathologic lesions than did those lesions in other sites.
Conclusions
EUS is useful for finding the causes of extragastric compression. Careful evaluation is needed because many lesions in the anterior wall of the body of the stomach were due to pathologic causes. (Korean J Gastrointest Endosc 2009;39:125-130)

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Eradication Rates of Bismuth-based Quadruple Therapy as a Second-line Treatment for Helicobacter pylori Infection: Jung Hwan Oh, M.D., Tae Ho Kim, M.D., Dae Young Cheung, M.D., Jae Myung Park, M.D., Jae Kwang Kim, M.D., Sang Wook Choi, M.D., Suk Won Han, M.D. and In Sik Chung, M.D.; Korean J Gastrointest Endosc 2009;39(3):131-135. Published online September 30, 2009

Abstract PDF: Background
/Aims: There has been a substantial decline in Helicobacter pylori (H. pylori) cure rates with standard triple therapy in recent years. Therefore, great emphasis has been placed on second line treatment for its successful eradication. The aim of this study was to evaluate the efficacy of bismuth based quadruple therapy as a second line treatment for H. pylori infection.
Methods
From January 2001 to December 2007, the hospital records of 215 patients who failed to the standard triple therapy were reviewed retrospectively. The patients were treated with bismuth based quadruple therapy (PPI, bismuth 120 mg qid, metronidazole 500 mg tid, and tetracycline 500 mg qid). The successful eradication of H. pylori was defined as negative result from histology, CLO test or ¹³C-urea breath test.
Results
Eradication rates by intention-to-treat (ITT) and per-protocol (PP) analyses with quadruple therapy were 64% (137/215) and, 91% (137/151) respectively. The eradication rates were not significantly different according to diseases, duration of treatment, area and proton pump inhibitors. The PP eradication rates for the years from 2001 to 2007 were not significantly different.
Conclusions
The bismuth based quadruple therapy is still effective as the second line treatment for the eradication of H. pylori. (Korean J Gastrointest Endosc 2009; 39:131-135)

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The Efficacy and Safety of Endoscopic Submucosal Dissection in Colorectal Neoplasms: Single Center Study: Hye Jin Seo, M.D., Kwang Bum Cho, M.D., Seok Guen Lee, M.D., Hong Seok Lee, M.D., Eun Soo Kim, M.D., Byoung Kuk Jang, M.D., Kyung Sik Park, M.D., Woo Jin Chung, M.D. and Jae Seok Hwang, M.D.; Korean J Gastrointest Endosc 2009;39(3):136-142. Published online September 30, 2009

Abstract PDF: Background
/Aims: Endoscopic submucosal dissection (ESD) is not commonly used in the colorectal area because of technical difficulty and due to the characteristics of the organ. We therefore wanted to determine the efficacy and safety of endoscopic submucosal dissection in colorectal neoplasms.
Methods
Colorectal tumor lesions resected by ESD in a single medical center were analyzed retrospectively.
Results
A total of 47 patients were treated for 50 lesions. Mean age was 64.3±9.8 (43∼85) years. Laterally spreading tumors were the most common type (44, 88%) followed by Is+IIa type tumors (6, 12%). The en bloc resection rate was 76% and the complete resection rate was 74%. The mean procedure time was 81.1±44.7 (20∼180) minutes. The mean size of resected specimen was 26.9±10.4 (10∼50) mm. The histological diagnosis determined that 24 lesions (48%) were tubular adenoma, 18 lesions (36%) were intramucosal cancer, 7 lesions (14%) were sm1 cancer and 1 lesion (2%) was over sm2 cancer. Bleeding occurred in 6 (12%) and perforations in 13 (26%) of the patients and all were treated successfully by endoscopic or conservative treatment. The concordance rate of pre and post ESD pathological diagnosis was only 47%.
Conclusions
ESD is a feasible technique for treating superficial colorectal tumors with a high complete resection rate, minor invasiveness, and a high safety rate. In addition, ESD might be useful in establishing the complete pathological evaluation of colorectal epithelial neoplasm. (Korean J Gastrointest Endosc 2009;39:136-142)

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Combination Therapy Using Multi-biliary Endoprostheses and Oral Ursodeoxycholic Acid for Difficult, Large and Multiple Bile Duct Stones: Tae Hoon Lee, M.D., Sang-Heum Park, M.D., Yun Suk Shim, M.D., Sae Hwan Lee, M.D., Chang Kyun Lee, M.D., Il-Kwun Chung, M.D., Hong Soo Kim, M.D. and Sun-Joo Kim, M.D.; Korean J Gastrointest Endosc 2009;39(3):143-148. Published online September 30, 2009

Abstract PDF: Background
/Aims: Large common bile duct (CBD) stones accompanied by risk factors can be difficult to extract using conventional techniques. This study investigates the efficacy of combination therapy using multiple double pigtail stents and ursodeoxycholic acid (UDCA).
Methods
A total of 895 patients underwent the attempted removal of CBD stones. Multiple double pigtail stents (7 Fr or 10 Fr) were inserted into the CBD over a guidewire. The stents remained in place until endoscopic removal during a second attempt. All patients received oral UDCA (600 mg/day) during the follow-up.
Results
In 21 patients (2.34%), complete clearance was not achieved by the conventional method. Large, multiple stones, the presence of periampullary diverticulum, stricture of the distal CBD, and severe cardiopulmonary disease were observed as limiting factors for the successful removal of CBD stones. Complete endoscopic clearance was achieved in 12 patients (57.1%), and there was a statistically significant reduction in stone size (mean 4.60±2.45 mm, p=0.002). The mean duration of stenting and administration of medicine was 73.9 days. There was no immediate complication related to the procedure.
Conclusions
Our results suggest that combination therapy using pigtail stents and UDCA may be an easy and effective method for removal of difficult CBD stones. (Korean J Gastrointest Endosc 2009;39:143-148)

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Management of Occluded Biliary Uncovered Metal Stents: Covered Self Expandable Metallic Stent vs. Uncovered Self Expandable Metallic Stent: Kyung Sik Jung, M.D., Woo Jin Jung, M.D., Dong Uk Kim, M.D., Cheul Woong Choi, M.D. and Dae Hwan Kang, M.D.; Korean J Gastrointest Endosc 2009;39(3):149-153. Published online September 30, 2009

Abstract PDF: Background
/Aims: Unresectable malignant biliary obstruction has usually been treated by placement of a self-expandable metallic stent (SEMS). One of the major complications of SEMS is occlusion of the stent by the ingrowth and overgrowth of tumor. The optimal management of an occluded SEMS is still an unresolved problem. We performed this study to evaluate the usefulness of placing a second stent with using an uncovered SEMS or a covered SEMS in patients with stent occlusion.
Methods
From January 2006 to December 2007, a total of 163 patients were treated with the placement of an uncovered SEMS for treating malignant biliary obstruction, except for the cases with Klatskin's tumor. Thirty four patients were occluded and they underwent a second SEMS insertion. All the patients with an occluded uncovered SEMS were managed with placement of a covered SEMS or an uncovered SEMS by ERCP.
Results
The median patent duration after intervention was 98 days (range: 8∼300 days) after the second covered SEMS insertion, and the median patent duration after intervention was 90 days (range: 10∼643 days) after the second uncovered SEMS insertion. No significant difference in the patent period was observed between the covered SEMS group and the uncovered SEMS group (P=0.832).
Conclusions
The covered SEMS group and the uncovered SEMS group had similar patent periods for the management of occluded uncovered metal stents. (Korean J Gastrointest Endosc 2009;39:149-153)

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A Case of an Esophageal Bronchogenic Cyst Presenting with Dysphagia: Hee Jung Lee, M.D., Hee Seok Moon, M.D., Jae Kyu Sung, M.D., Hyun Yong Jeong, M.D., Hyun Jung Lee, M.D.* and Dae Young Kang, M.D.*; Korean J Gastrointest Endosc 2009;39(3):154-157. Published online September 30, 2009

Abstract PDF: Bronchogenic cysts are rare congenital anomalies that are formed due to abnormal budding of the endodermal foregut during embryogenesis. These cysts are found at various sites because the location of the cyst depends on the embryological state of the abnormal budding. Submucosal tumors (SMTs) of the esophagus that originate from the submucosa or the intramural layer account for less than 1% of all esophageal neoplasms, and bronchial cysts of the esophagus usually present as a type of SMT or as external compression. We report here on an interesting case of bronchogenic cyst presenting with dysphagia in an adult. (Korean J Gastrointest Endosc 2009;39:154-157)

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Dieulafoy's Lesion Coexisting with Early Gastric Cancer: Yong Soo Ahn, M.D., Hyeuk Park, M.D., Young Jun Hwang, M.D., Hong Myong Jung, M.D., Jang Sik Mun, M.D., Bo Hyun Myoung, M.D., Do Hyun Kim, M.D. and Ho Dong Kim, M.D.; Korean J Gastrointest Endosc 2009;39(3):158-161. Published online September 30, 2009

Abstract PDF: Dieulafoy's lesion is an uncommon cause of gastrointestinal (GI) bleeding, but can be associated with massive, life-threatening GI bleeding. This lesion is an isolated protruding vessel of the submucosal artery associated with a small mucosal defect and normal surrounding mucosa. Although this lesion can occur throughout the GI tract (esophagus, stomach, duodenum, colon, rectum, etc), it has been rarely reported elsewhere than the stomach. Especially, there have been no reports of Dieulafoy lesion coexistent with early gastric cancer in Korea. We report the successful application of endoscopic hemoclipping for the treatment of a very rare Dieulafoy lesion coexistent with early gastric cancer. (Korean J Gastrointest Endosc 2009;39:158-161)

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A Case of Gastric Adenocarcinoma Mimicking a Gastrointestinal Stromal Tumor: Sung Youn Choi, M.D., Seung Hun Jang, M.D., Jae Hoon Min, M.D., Tae Wan Kim, M.D., Ji Ae Lee, M.D., Sun Jeoung Byun, M.D. and Byoung Kwon Ghim, M.D.*; Korean J Gastrointest Endosc 2009;39(3):162-165. Published online September 30, 2009

Abstract PDF: Gastric adenocarcinoma is the second most common cause of cancer death worldwide, but there are some geographical differences in its incidence. Gastointestinal stromal tumor (GIST) is an uncommon disease with a wide spectrum of aggressive behavior. These two tumors have a distinct pathogenesis. GIST is frequently identified as an incidental lesion found by routine endoscopy or in resection specimens that are removed for other reasons. We report a case of a gastric adenocarcinoma mimicking GIST in a 79-year-old woman. GIST was suggested by endoscopic ultrasonography and computed tomography scanning, but gastric adenocarcinoma was confirmed by gastroduodenoscopic biopsy. We performed a subtotal gastrectomy with Billroth I, lymph node dissection and transverse colon segmentectomy, and a 15.0×7.5×5.5 cm-sized gastric tumor was confirmed pathologically. Immunohistochemistry was positive for carcinoembryonic antigen and focal weakly positive for cytokeratin7 and cytokeratin20. (Korean J Gastrointest Endosc 2009;39:162-165)

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A Case of Dieulafoy-like Lesion with Massive Bleeding at Ileocecal Valve Following Acute Infectious Colitis in a Pediatric Patient: Jae Seung Soh, M.D., Seong Hun Kim, M.D., Yoon Jae Lee, M.D., In Hee Kim, M.D., Sang Wook Kim, M.D., Seung Ok Lee, M.D., Dae Ghon Kim, M.D. and Soo Teik Lee, M.D.; Korean J Gastrointest Endosc 2009;39(3):166-168. Published online September 30, 2009

Abstract PDF: The common causes of lower gastrointestinal bleeding in children are intussusception, rectal juvenile polyp, chronic inflammatory colitis and Meckel's diverticulum. Bleeding from Dieulafoy's ulcer at the lower gastrointestinal tract is rare, but this often occurs in the rectum. So far, there has been no report that a Dieulafoy lesion in the ileocecal valve might be formed after acute colitis in a pediatric patient. In this case report, a Dieulafoy-like lesion at the ileocecal valve caused lower gastrointestinal bleeding in an asymptomatic 14-year-old woman. A careful history taking and medical examination are mandatory to identify the bleeding focus in the GI tract and this can be treated by endoscopy. (Korean J Gastrointest Endosc 2009;39:166-168)

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Acute Hyponatremic Encephalopathy after Ingestion of Polyethylene Glycol Solution before Colonoscopy: Chae Heo, M.D., Hyoung Chul Oh, M.D., Jeong Wook Kim, M.D. and Jae Gyu Kim, M.D.; Korean J Gastrointest Endosc 2009;39(3):169-171. Published online September 30, 2009

Abstract PDF: Preparation for colonoscopy involves a thorough cleansing of the large bowel. Cleansing is performed using several methods, including ingestion of 4 liters of polyethylene glycol solution. However, these methods can induce hyponatremia by various mechanisms. Severe or rapidly progressing hyponatremia can result in the swelling of the brain, and the symptoms of hyponatremia are mainly neurological. Recently, we encountered a 41-year-old woman who developed acute hyponatremia with encephalopathy after undergoing bowel preparation for colonoscopy. She presented with general weakness, nausea, headache, agitation, delusions, and slurred speech one day after the ingestion of polyethylene glycol solution. Her serum sodium level was very low (110 to 115 mEq/L). Her symptoms pertaining to hyponatremia continued to persist for more than 2 days despite continuous intravenous administration of hypertonic saline for the correction of hyponatremia. (Korean J Gastrointest Endosc 2009;39:169-171)

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A Case of Lymphangiomatosis Arising in the Colon: Bum Suk Son, M.D., Chang Kyun Lee, M.D., Duk Su Kim, M.D., Yong Sub Lee, M.D., Suck-Ho Lee, M.D., Il-Kwun Chung, M.D., Sun-Joo Kim, M.D. and Ji Hye Lee, M.D.*; Korean J Gastrointest Endosc 2009;39(3):172-175. Published online September 30, 2009

Abstract PDF: Lymphangioma is a benign vascular lesion that shows the characteristics of subepithelial tumor, which can proliferate in the lymphatic system. Only a few cases of multiple lymphangimas of the colon, the so called "colonic lymphanigomatosis", have been currently reported on the medical literature. Because lymphangioma is absolutely a benign tumor, it does not require any specific treatment, except for rare disease-related symptoms or complications such as anemia, intussusception and protein-losing enteropathy. Endoscopic resection for this tumor has sometimes been performed for both diagnostic and therapeutic purposes. We recently experienced a case of multiple colonic lymphangomas that arose in the ascending colon of a 46-year-old male patient and these lesions were found during performance of colonoscopy. The final diagnosis was confirmed by a pathologic examination of the specimen that was obtained via endoscopic resection. Follow-up colonoscopy at 1 year after the initial examination showed complete resolution of the previously noted lesions without any specific treatment. We report here on a very rare case of colonic lymphangiomatosis along with a brief review of the relevant literature. (Korean J Gastrointest Endosc 2009;39:172-175)

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Cytomegalovirus Colitis in an Immunocompetent Patient with Henoch-SchoҨnlein Purpura: Jung Yoon Yoon, M.D., Sung-Ae Jung, M.D., Hyun Joo Song, M.D., Min-Jung Kang, M.D., Seong-Eun Kim, M.D., Ki-Nam Shim, M.D., Kwon Yoo, M.D. and Dong Eun Song, M.D.*; Korean J Gastrointest Endosc 2009;39(3):176-180. Published online September 30, 2009

Abstract PDF: Most cases of cytomegalovirus (CMV) colitis occur in adults with severe immuno- deficiency. There have been a few reports involving immunocompetent patients. CMV colitis may occur after colonic mucosal injury in immunocompetent patients. Henoch-SchoҨnlein purpura (HSP) is a common systemic vasculitis in childhood. Diagnostic criteria include palpable purpura with at least one other manifestation; abdominal pain, IgA deposition, arthritis or arthralgia, or renal involvement. To best of our knowledge, we describe the first case of CMV colitis in an immunocompetent patient with preceding HSP. A 38-year-old man presented with a 1-day history of abdominal pain, diarrhea and vomiting. Two-years previously, he underwent a right hemicolectomy due to intussusception. Over a 1-month period, palpable purpura was evident on both arms and legs. Colonoscopy revealed multiple, linear geographic ulcerations at an anastomosis opening site with huge ulceration at the small bowel, which was covered with white exudates. Colonoscopic biopsy showed CMV inclusion bodies and skin biopsy revealed leukocytoclastic vasculitis. The patient was successfully treated with gancyclovir and prednisolone. (Korean J Gastrointest Endosc 2009;39:176-180)

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A Case of Phytobezoar in the Common Bile Duct Following Percutaneous Transhepatic Papillary Large Balloon Dilatation: Byong Ryol Lim, M.D., Tae Hyo Kim, M.D., Min Ki Shin, M.D., Kang Ju, M.D., Chang Yoon Ha, M.D., Hyun Ju Min, M.D., Woon Tae Jung, M.D. and Ok Jae Lee, M.D.; Korean J Gastrointest Endosc 2009;39(3):181-184. Published online September 30, 2009

Abstract PDF: Biliary bezoar is a rare event that can cause cholangitis and pancreatitis. Biliary bezoar occurs infrequently by food material reflux and bile stasis following choledochoenterostomy, choledochoduodenal fistula, endoscopic sphincterotomy, duodenal diverticula, and because of suture remnants. We describe a phytobezoar in the common bile duct following percutaneous transhepatic large balloon papillary dilatation, which was successfully removed using an endoscopic procedure. (Korean J Gastrointest Endosc 2009;39:181-184)

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