Clinical Endoscopy

Postpolypectomy Colonoscopy Surveillance: Hyun Soo Kim, M.D.; Korean J Gastrointest Endosc 2009;39(5):257-264. Published online November 30, 2009

Abstract PDF: Colonoscopy and polypectomy are increasingly being used as the most effective interventions for preventing colorectal cancer (CRC), which has resulted in a growing cohort of patients who require postpolypectomy surveillance (PPS). The goal of PPS is to prevent the development of significant metachronous adenomas and CRCs. The surveillance interval depends on an accurate assessment of the individual patient's risk of developing subsequent colonic neoplasm. The newly developed consensus guidelines (CG) emphasize the concept of 'risk stratification' and these guidelines are more user-friendly than the previous ones, thus eliminate conflicting recommendations that are a barrier to physicians using the guideline. Despite the development of CGs, many specialists and non-specialists overutilize colonoscopy for PPS, which causes an ineffective large burden of cost and it strains already limited resources. The safest and most cost-effective approach by colonoscopists to preventing CRC is to maximize the effectiveness of colonoscopy for clearing the colon and then follow the recommended intervals between procedures, including extended intervals for the low-risk cohorts. Educating colonoscopists and the widespread implementation of continuous quality improvement programs are required to bridge the gap between the guidelines and their clinical application. (Korean J Gastrointest Endosc 2009;39:257-264)

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A Prospective Comparison of Sulfate Free Polyethylene Glycol versus Sodium Phosphate Solution for Precolonoscopic Bowel Preparation: Jin Gook Huh, M.D., You Sun Kim, M.D., Jong Hyeok Park, M.D., Kyung Sun Ok, M.D., Won Cheol Jang, M.D., Tae Yeob Jeong, M.D., Soo Hyung Ryu, M.D., Jung Hwan Lee, M.D. and Jeong Seop Moon, M.D.; Korean J Gastrointest Endosc 2009;39(5):265-270. Published online November 30, 2009

Abstract PDF: Background
/Aims: Polyethylene glycol (PEG) solution is commonly used for precolonoscopic preparation because of its safety and effectiveness. Sulfate free PEG (SF-PEG) solution was developed to reduce the salty taste by removing the sodium sulfate. The aim of this study was to compare the efficacy and patient compliance of SF-PEG and sodium phosphate (NaP) solutions for preparing the bowel before colonoscopy.
Methods
From February through April in 2007, 534 patients who underwent colonoscopy were prospectively enrolled. The efficacy of bowel cleansing was assessed by a doctor's questionnaire and the patient's compliance was assessed by a patient's questionnaire.
Results
There was no significant difference between the groups for the "stools and fluids" assessment of bowel cleansing (2.07 vs. 2.14, respectively, p=0.149). However, SF-PEG was more effective on the "air bubbles" assessment (1.34 vs. 1.71, respectively, p＜0.001) and the overall assessment (0.72 vs. 0.91, respectively, p=0.010) than NaP. The patients preferred SF-PEG rather than NaP for "Taste" (1.34 vs. 2.25, respectively, p=0.148). However, the patients significantly preferred NaP rather than SF-PEG for "Quantity" (2.46 vs. 1.18, respectively, p＜0.001).
Conclusions
The SF-PEG solution showed more effectiveness for bowel cleansing as compared to the NaP solution. SF-PEG tastes better than NaP, but patients are still required to consume 4 liters for the standard preparing regimen. (Korean J Gastrointest Endosc 2009;39:265-270)

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The Clinical Efficacy of Uisng a Soehendra Stent Retriever for Endoscopic Biliary Drainage in Malignant Biliary Obstruction: Pyo Jun Kim, M.D., Dae Hwan Kang, M.D., Hyung Wook Kim, M.D., Cheol Woong Choi, M.D., Ki Tae Yoon, M.D., Yong Wook Kim, M.D. and Mong Cho, M.D.; Korean J Gastrointest Endosc 2009;39(5):271-275. Published online November 30, 2009

Abstract PDF: Background
/Aims: Endoscopic biliary drainage is widely used for the palliative treatment of malignant biliary obstruction. For the advanced stricture, the general treatments such as a dilating or balloon catheter can not fully expand a duct. The authors used a Soehendra Stent Retriever for these cases, and we evaluated the value of using this instrument for treating these patients.
Methods
From July 2006 to Jun 2008, we studied 12 patients with mailignant biliary obstruction (Klatskin's tumor=10, Gall bladder cancer=2) and who were failed at having a stent inserted with such general treatment such as using a dilating or balloon catheter (M：F=7：5, age=69.1 years old). For the bilateral biliary drainage of the duct, the "stent in stent" method was used and 12 patients were treated with a Soehendra Stent Retriever with clockwise rotation, as well as going forward to expand the target area of the intrahepatic bile duct obstruction and insert a metal stent.
Results
Ten patients among the 12 who were treated by a Soehendra Stent Retriever achieved successful insertion of a stent (technical success, 83.3%), and all 12 patients showed improvement of their jaundice.
Conclusions
To insert bilateral stents for the advanced malignant biliary obstruction, expanding the strictured area with a Soehendra Stent Retriever can improve the success of inserting a stent. (Korean J Gastrointest Endosc 2009; 39:271-275)

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A Case of Blue Rubber Bleb Nevus Syndrome: Yun Suk Yang, M.D., Chang Goo Lee, M.D., Sang Jun Park, M.D., Jung Hyun Kim, M.D., Sang Eok Kim, M.D., Kwang Hee Lee, M.D., Ki Yong Kim, M.D. and Jin Woo Yun, M.D.; Korean J Gastrointest Endosc 2009;39(5):276-279. Published online November 30, 2009

Abstract PDF: Blue rubber bleb nevus syndrome is a rare disorder that's characterized by multiple venous malformations of the skin and gastrointestinal tract, and these lesions usually cause episodes of occult gastrointestinal hemorrhage and iron deficiency anemia. We report here on a case of a 57-year-old woman who presented with intermittent melena and multiple cutaneous venous malformations. The endoscopic and radiologic examinations show multiple bluish polypoid venous malformations on the gastrointestinal tract, retroperitoneum, liver, mediastinum and lung. We were able to diagnose her as suffering from blue rubber bleb nevus syndrome and we treated her with iron supplementation for anemia. We report this case along with a brief review of the relevant literature. (Korean J Gastrointest Endosc 2009;39:276-279)

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A Case of Idiopathic Chronic Ulcerative Enteritis Presenting with Septic Shock: Go Heun Kim, M.D., Sung-Ae Jung, M.D., Hyun Joo Song, M.D., Seong-Eun Kim, M.D., Ki-Nam Shim, M.D., Kwon Yoo, M.D., Kwang-Ho Kim, M.D.* and Woon Sup Han, M.D.^†; Korean J Gastrointest Endosc 2009;39(5):280-284. Published online November 30, 2009

Abstract PDF: Idiopathic chronic ulcerative enteritis (ICUE) is a rare disease with a mortality rate exceeding 75%, which manifests as an ulceration of the small bowel in the absence of a recognizable cause. It is diagnosed by biopsy. A 31-year-old man who had a 10-year history of recurrent episodes of abdominal pain was admitted with a 10-day occurrence of abdominal pain and fever. Upper endoscopy showed multiple active ulcers from duodenal second to distal portion. Colonoscopy revealed diffuse ulcerations at the terminal ileum. Colonic findings were normal. The patient was treated with intravenous antibiotics, systemic steroids, and total parenteral nutrition in the intensive care unit. Ten days after admission, the patient fell into shock due to massive hematochezia and underwent an emergency surgical resection, which revealed Meckel's diverticulum. Bleeding was uncontrolled and the following day surgical resection and intraoperative endoscopy of the highly involved jejunum revealed severe ulcerative bleeding. Microscopic examination revealed ulcerations with pseudopolyps and granulation tissue and no evidence of vasculitis, suggestive of ICUE. (Korean J Gastrointest Endosc 2009;39:280-284)

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Adenocarcinoma and Tuberculous Lymphadenitis on the Same Site of the Sigmoid Colon: A Case Report and Literature Review: Sung Ho Ryu, M.D., Woon Geon Shin, M.D., Seung Min Lee, M.D., So Yeon Park, M.D., Sung Jun Kim, M.D., Jong Jin Yoo, M.D., Seoung Jin Cho, M.D.* and Hak Yang Kim, M.D.; Korean J Gastrointest Endosc 2009;39(5):285-290. Published online November 30, 2009

Abstract PDF: Inflammatory bowel disease can progress to colon cancer. However, there is not much of a causal relationship between intestinal tuberculosis and colon cancer. There have been a few case reports of intestinal tuberculosis in association with colon cancer. We experienced a 59-year-old man who had the collision-like pathology of adenocarcinoma and tuberculous lymphadenitis on the sigmoid colon. He visitied our hospital because of abdominal pain and hematochezia. Colonoscopy showed a mass on the sigmoid colon that was causing luminal obstruction. Therefore, sigmoidectomy was performed and the resected specimen revealed a collision-like appearance; the mass was composed of adenocarcinoma invading the proper muscle layer and caseating granuloma in the serosa and lymph nodes. We report here on a case of collision-like pathology that was composed of adenocarcinoma and tuberculosis on the sigmoid colon, and we review the relevant literature. (Korean J Gastrointest Endosc 2009;39:285-290)

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A Bezoar That Caused Afferent Loop Syndrome and Pancreatitis: Hyuk Soon Choi, M.D., Chang Duck Kim, M.D., Hyun Seok Kang, M.D., Seok Bae Yoon, M.D., Yoon Tae Jeen, M.D., Hoon Jai Chun, M.D., Soon Ho Um, M.D. and Ho Sang Ryu, M.D.; Korean J Gastrointest Endosc 2009;39(5):291-295. Published online November 30, 2009

Abstract PDF: Bezoars are conglomerates of nondigestible matter in the gastrointestinal tract that may or may not be accompanied by gastrointestinal manifestations. Bezoars develop in patients with previous gastric surgery or in those patients with delayed gastric emptying that is due to gastroparesis caused by hypothyroidism or diabetes mellitus. Small bowel obstruction due to a gastric bezoar is rare, but it can lead to severe complications such as intestinal perforation, compression necrosis etc. A female patient came to our department complaining of upper abdominal pain and she was diagnosed as having a bezoar that was causing afferent loop syndrome and pancreatitis. We attempted to manage the patient by inserting a nasogastric tube, performing gastrofibroscopy and implementing percutaneous transhepatic biliary drainage, but the patient's condition worsened and deteriorated into a septic condition. An operation was planned, but the patient showed improvement owing to the migration of the bezoar. Herein, we report on a case of afferent loop syndrome due to bezoar and this was complicated by acute pancreatitis. (Korean J Gastrointest Endosc 2009;39:291-295)

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Iatrogenic Esophageal Submucosal Dissection: A Case Report: Suk Ho Hong, M.D., Bong Roung Kim, M.D., Sun Hee Beom, M.D., Jae Myung Lee, M.D., Sung Du Kim, M.D., You Hyun Jang, M.D. and Hyuk Jung Kim, M.D.*; Korean J Gastrointest Endosc 2009;39(5):296-299. Published online November 30, 2009

Abstract PDF: Nasogastric tube insertion is a routine clinical procedure for nutritional support, gastric aspiration and decompression. Although it is generally a safe procedure, complication rates range from 0.3∼8%. Submucosal esophageal dissection is a rare disorder caused by mucosal tearing and bleeding between the mucosal and muscular layers of the esophagus, leading to their separation. We report a case of submucosal esophageal dissection secondary to the accidental iatrogenic intramural insertion of a nasogastric tube. (Korean J Gastrointest Endosc 2009;39: 296-299)

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Successful Treatment of Gastric Hamartomatous Polyp with Hemorrhage by Endoscopic Mucosal Resection: Jung Min Lee, M.D., Ji Hoon Baek, M.D., Hye Mi Kang, M.D., Byeng Do Min, M.D., Sang Hoon Park, M.D., Ji Woong Kim, M.D., Jin Woong Cho, M.D. and Myoung Jin Ju, M.D.*; Korean J Gastrointest Endosc 2009;39(5):300-303. Published online November 30, 2009

Abstract PDF: Hamartomatous polyp is an uncommon lesion. Most of the gastric hamartomatous polyps occur in patients in their 40s because of polyposis coli. Gastric hamartomaotus polyps are usually asymptomatic, but they occasionally manifest with hematemesis or anemia. If they are congenital, then sessile polyps in children should be observed with some measurable frequency. However, many reports have revealed that if the polyp size is big and the risk of rebleeding is high, then ESD or surgical resection can be used to completely remove them. An inverted gastric hamartomatous polyp may have an early gastric cancer component. We report here on an unusual polyp in a 14-years male who presented with hematemesis. Those were about two 3 cm sized large polyps at the proximal antrum and mid body of the stomach, respectively. The polyps were successfully removed by an endoscopic mucosal resection and the lesions were diagnosed as gastric harmatomas. (Korean J Gastrointest Endosc 2009;39:300-303)

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A Case of Blue Rubber Bleb Nevus Syndrome Treated by Endoscopic Band Ligation and Endoscopic Polypectomy: Sun Youn Bae, M.D., Jin Yong Kim, M.D., Won Kyung Yun, M.D., Ho Jung Chung, M.D., Mi Yeon Kim, M.D., Mi Rae Lee, M.D. and Ji Won Hwang, M.D.; Korean J Gastrointest Endosc 2009;39(5):304-307. Published online November 30, 2009

Abstract PDF: Blue rubber bleb nevus syndrome (BRBNS) is a rare disorder that is characterized by multiple cutaneous vascular malformations in the skin and gastrointestinal tract and is associated with intestinal hemorrhage and iron deficiency anemia. This syndrome may induce severe or fatal bleeding; however, the causes of this syndrome are unknown. We report here a case of BRBNS that was diagnosed in a 20-year-old male with chronic anemia and a past history of surgery due to cutaneous hemangioma on the shoulder and thigh. One purplish hemangioma on the stomach and multiple bluish hemangiomas on the colon were noted on the endoscopic examination. We successfully treated the GI hemangioma with endoscopic band ligation and endoscopic polypectomy. (Korean J Gastrointest Endosc 2009;39:304-307)

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Endoscopic Polypectomy of Primary Rectal Mature Teratoma: A Case Report: Jongha Park, M.D., Jeong-Sik Byeon, M.D., Jeong-Hyeon Jo, M.D.*, Kyung-Jo Kim, M.D., Byong Duk Ye, M.D., Seung-Jae Myung, M.D., Suk-Kyun Yang, M.D. and Jin-Ho Kim, M.D.; Korean J Gastrointest Endosc 2009;39(5):308-312. Published online November 30, 2009

Abstract PDF: Teratoma is a type of benign germ cell tumor that often contains several different types of tissue such as hair, muscle and bone, and these tissues arise from the three germinal layers. It occurs most often in the tailbones of children, the ovaries of women and the testicles of men. Primary rectal teratoma is extremely rare. We report here on a case of a 49-year-old woman with a primary rectal teratoma, and this was incidentally found during routine health screening. The rectal teratoma was a 15 mm-sized pedunculated polyp with a short stalk at the rectum, about 15 cm from anal verge as seen on CT colonography. On sigmoidoscopy and EUS, a fat and calcium containing well-defined polypoid lesion was noted in the upper rectum, with a narrow stalk attached to the colonic wall. The tumor was successfully excised by endoscopic polypectomy in order to obtain the histologic diagnosis and administer the proper treatment. (Korean J Gastrointest Endosc 2009;39:308-312)

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A Case of Eosinophilic Gastritis with Delayed Gastric Emptying: Sun Youn Bae, M.D., Hyuk Lee, M.D., Ho Jung Chung, M.D., Mi Yeon Kim, M.D. and Mi Rae Lee, M.D.; Korean J Gastrointest Endosc 2009;39(5):313-318. Published online November 30, 2009

Abstract PDF: Eosinophilic gastritis is a rare disease that is characterized by eosinophilic infiltration of the bowl wall tissue, and the presentation of symptoms varies depending on the affected site. It is likely that eosinophil-active cytokines play important roles in this disease. A 22-year old man presented with abdominal pain and vomiting. Endoscopic gastric biopsy revealed eosinophilic infiltration, and the serum level of Interleukin (IL)-5 was increased. Gastric emptying was moderately delayed in this patient. The patient was treated with steroid and he showed dramatic clinical improvement with disappearance of the eosinophilic infiltration of the gastric mucosa, normalization of the serum level of IL-5 and improvement of the gastric emptying time. There has been few case reports of eosinophilic gastritis that have described the change of the serum level of cytokines and the gastric emptying. We report here on a case of eosinophilic gastritis and the patient showed elevated serum level of cytokines and delayed gastric emptying. The patient improved after being treated with steroid. (Korean J Gastrointest Endosc 2009; 39:313-318)

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A Case of Intrahepatic Choledochal Web That Was Diagnosed by Percutaneous Transhepatic Cholangioscopy and It Was Treated with Balloon Dilatation: Review of the Korean Cases: Hyeong Il Kim, M.D.*, Seung Ok Lee, M.D.*^,†, Young Wook Jeong, M.D.*, Seong Hun Kim, M.D.*^,†, In Hee Kim, M.D.*^,†, Sang Wook Kim, M.D.*^,†, Dae Ghon Kim, M.D.*^,†and Soo; Korean J Gastrointest Endosc 2009;39(5):319-323. Published online November 30, 2009

Abstract PDF: Choledochal web is an extremely rare disease and it is frequently associated with bile duct stone that causes biliary obstruction and cholangitis. Most cases of choledochal web have been found incidentally during a surgical procedure or on autopsy because of its rare incidence and the absence of specific clinical manifestations. Yet making an early diagnosis has become feasible with the development of radiologic studies. All twelve cases of choledochal web, reported in Korea, were located in the extrahepatic duct, and were diagnosed with an operation, endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography. We report here on a case of intrahepatic choledochal web that was well visualized by percutaneous transhepatic choledochoscopy and it was treated with balloon dilatation. (Korean J Gastrointest Endosc 2009;39:319-323)

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A Case of Duodenobiliary Fistula Caused by a Metal Stent in a Patient with Hepatocellular Carcinoma: Seok Bae Yoon, M.D., Hong Sik Lee, M.D., Hyuk Soon Choi, M.D., Hye Jin Cho, M.D., Tae Jung Yun, M.D., Jin Nam Kim, M.D., Ik Yoon, M.D. and Chang Duck Kim, M.D.; Korean J Gastrointest Endosc 2009;39(5):324-327. Published online November 30, 2009

Abstract PDF: Biliary drainage can improve the quality of life in a patient with obstructive jaundice caused by malignancy. Biliary metal stent insertion is a very useful method because it drains the bile physiologically and patients have little discomfort with the procedure. It has a few complications such as restenosis, liver perforation, bowel perforation, fistula formation and stent dislocation. Perforation and fistula formation are caused by pressure due to the self expanding characteristics of the metal stent. We report here on a case of duodenobiliary fistula that was caused by a biliary metal stent in a patient suffering with hepatocellula carcinoma, and we also include a review of the relevant literature. (Korean J Gastrointest Endosc 2009; 39:324-327)

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