Clinical Endoscopy

Eosinophilic Esophagitis: Yun Ju Jo, M.D.; Korean J Gastrointest Endosc 2009;39(6):329-337. Published online December 30, 2009

Abstract PDF: Eosinophilic esophagitis, as a new emerging disease during the last decade, is a clinicopathologic disorder of the esophagus, and it is characterized by dense esophageal eosinophilic infiltrations and typical esophageal symptoms. These patients usually present with dysphagia, food impaction or refractory reflux symptoms, and biopsy of the esophagus shows more than 15 eosinophils per high-power field. The typical findings on endoscopy are linear furrows, ringed esophagus, mucosal nodularities, whitish plaques and/or stricture. It is essential to exclude the known causes of tissue eosinophilia such as gastroesophageal reflux disease, eosinophilic gastroenteritis, infections, drug, hypersensitivity, Crohn's disease or malignancy. The majority of these patients have an atopy or allergic disorders, so other causes of eosinphilia should be evaluated. The therapeutic options include acid suppression, steroids, dietary modification, endoscopic dilatation, etc. Eosinophilic esopahgitis has recently been reported in Korea. Future schematic studies about this new disease are needed. (Korean J Gastrointest Endosc 2009;39:329-337)

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Endoscopic Polypectomy of Small Intestinal Peutz-Jeghers Polyps with Double Balloon Enteroscopy: Mi-Young Kim, M.D., Jeong-Sik Byeon, M.D., Kee Don Choi, M.D., Byong Duk Ye, M.D., Dong-Hoon Yang, M.D., Soon Man Yoon, M.D., Kyung-Jo Kim, M.D., Seung-Jae Myung, M.D., Suk-Kyun Yang, M.D. and Jin-Ho Kim, M.D.; Korean J Gastrointest Endosc 2009;39(6):338-345. Published online December 30, 2009

Abstract PDF: Background
/Aims: Small intestinal polyps in patients with Peutz-Jeghers (PJ) syndrome cause therapeutic difficulties because of the necessity for repeated laparotomy. We evaluated the short-term outcomes and long-term usefulness of double balloon enteroscopy (DBE) polypectomy for treating small intestinal PJ polyps.
Methods
We retrospectively reviewed 10 patients with PJ syndrome (M：F=7：3, mean age 22.7 years) and whose small intestinal polyps were resected with DBE between January 2005 and July 2008. We analyzed their clinical, endoscopic and pathologic features, the short-term outcomes and the long-term follow-up results.
Results
Among 10 patients, 2 complained hematochezia and 2 presented with intussusceptions. DBE polypectomy was performed by the oral route in 4 patients, by the anal route in 1 and by both routes in 5 without significant complications, except for only one perforation. The polyps were 0.5∼6 cm in size and most of them were pedunculated. The histopathology revealed hamartomatous polyps in most cases. Follow-up small bowel series was performed in 6 of 10 patients, and 3 showed remnant polyps. Two of them underwent repeated DBE polypectomy without significant complications.
Conclusions
We suggest that DBE polypectomy is a useful treatment for PJ small intestinal polyps because of the good short-term outcome and the effectiveness of repeated polypectomy for the remnant or recurrent polyps. (Korean J Gastrointest Endosc 2009;39:338-345)

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Usefulness of Capsule Endoscopy in Children with Suspected Small Bowel Disease: Hae Jin Park, M.D., So Yeon Lee, M.D., Jae Sung Ko, M.D. and Jeong Kee Seo, M.D.; Korean J Gastrointest Endosc 2009;39(6):346-351. Published online December 30, 2009

Abstract PDF: Background
/Aims: The aim of our study is to investigate the diagnostic value and safety of capsule endoscopy (CE) in the pediatric patients with small bowel (SB) disease.
Methods
We retrospectively reviewed the records of 29 children (mean age: 11.8 year) who underwent CE at Seoul National University Children's Hospital between November 2004 and April 2009.
Results
Six (20%) of the total 29 patients could not swallow the capsule (mean age: 10.5 years), so the capsule was endoscopically placed into the stomach of these 6 patients. The CE examination for the entire SB was finished in 89.6% of the patients. The indications for CE studies were obscure gastrointestinal bleeding (OGIB) or anemia in 14 patients, intestinal polyposis in 8, abdominal pain in 4 and Crohn's disease in 3. The diagnostic yield of CE was 35.7% for OGIB or anemia, 37.5% for intestinal polyposis, 25% for abdominal pain and 33.3% for Crohn's disease. One patient had capsule retention during our CE investigations.
Conclusions
CE is a safe and valuable tool for the detection of SB Crohn's disease, the focus of OGIB and the presence of SB polyps in pediatric patients. (Korean J Gastrointest Endosc 2009;39:346-351)

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A Case of Lymphoepithelial Cyst in the Lower Esophagus: Jung Soo Lee, M.D., Dong Wook Lee, M.D., Dong Yeub Eun, M.D., Sang Man Park, M.D., Seung Min Shin, M.D., Young Dae Park, M.D., Hyun Soo Kim, M.D. and Mi Jin Gu, M.D.*; Korean J Gastrointest Endosc 2009;39(6):352-354. Published online December 30, 2009

Abstract PDF: Lymphoepithelial cyst is a rare benign cystic tumor that is composed of a squamous epithelial cyst surrounded by lymphoid tissue, and this type of cyst is histologically similar to the branchial cleft cysts of the lateral neck. It is most often found in the head and neck and it is only rarely found in the pancreas, mediastinum and hypopharynx. Lymphoepithelial cysts of the esophagus have been described in Japan by Kataoka and Asami. We report here on a case of esophageal lymphoepithelial cyst that was removed endoscopically without serious complications. (Korean J Gastrointest Endosc 2009;39:352-354)

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Distal Esophageal Perforation Caused by Press-Through-Pack Ingestion: Yong Sung Kim, M.D. and Dong Seop Song, M.D.*; Korean J Gastrointest Endosc 2009;39(6):355-358. Published online December 30, 2009

Abstract PDF: A 60-year-old man presented with epigastric pain. The patient had no history of foreign body ingestion and had no symptoms of dysphagia or odynophagia. Chest computed tomography scan showed an esophageal perforation with unknown etiology and an emergency operation for thoracic cavity irrigation and drainage was undertaken, followed by fasting and conservative treatment. Two weeks later, a follow-up chest computed tomography scan revealed a suspicious foreign body in the distal esophagus. Endoscopy revealed a press-through-pack (PTP) that had caused an esophageal perforation. Despite extraction of the PTP and antibiotic administration, the patient died. The present case is important since PTP is commonly used in Korea. (Korean J Gastrointest Endosc 2009;39:355-358)

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Two Cases of Boerhaave's Syndrome Treated by Endoscopic Hemoclipping: Hyun Jeong Jang, M.D., Tae Hyo Kim, M.D., Chang Min Lee, 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(6):359-363. Published online December 30, 2009

Abstract PDF: Boerhaave's syndrome is a spontaneous esophageal perforation due to severe nausea and vomiting after hyperphagia or drinking, and it is not due to trauma, medical instrumentation or a foreign body. Untreated esophageal perforation is associated with high mortality, and the traditional treatment has been surgical drainage and primary repair of the perforation. However, non-surgical primary repair with an endoscopic procedure has recently been attempted in some selected patients with a small sized perforation, limited contamination of the mediastinum and no evidence of sepsis. We report here on 2 patients with Boerhaave's syndrome and who were successfully treated via primary repair with endoscopic hemoclips, and we review the other cases of the Boerhaave's syndrome that were treated with a endoscopic procedure. (Korean J Gastrointest Endosc 2009;39: 359-363)

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A Case of Esophageal Gastrointestinal Stromal Tumor Treated by Endoscopic Submucosal Dissection following an Initial Mucosectomy Using a Transparent Cap: Sun Hee Ko, M.D., Chang-Whan Kim, M.D., Soo-Yeon Jung, M.D., Chang Hoon Lim, M.D., Jeong Ah Kim, M.D., Tae Ho Kim, M.D., Sok Won Han, M.D. and Jean A Kim, M.D.*; Korean J Gastrointest Endosc 2009;39(6):364-368. Published online December 30, 2009

Abstract PDF: Gastrointestinal stromal tumor (GIST) is the most common mesenchymal neoplasm of the gastrointestinal (GI) tract, but the lesion occurs rarely in the esophagus. Although only 10∼30% of GISTs are malignant at the time of diagnosis, many reports show that it is difficult to predict the prognosis and underlying potential of non-malignant ones. Thus, the surgical removal of GISTs is even being proposed as a standard treatment. Recently the endoscopic removal of submucosal tumors of the GI tract is being done in popular, but it has been still considered as both difficult and risky to resect a tumor originating from the muscularis propria layer using the endoscopic methods. Herein, we report a case of an incidentally found submucosal tumor originating from the muscularis propria treated with an endoscopic submucosal dissection method which was performed after a preceding mucosectomy using a transparent cap. The mass turned out to be an esophageal GIST. (Korean J Gastrointest Endosc 2009;39:364-368)

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A Case of Endoscopic Stenting for Anastomotic Leakage after Total Gastrectomy: Ja In Park, M.D., Jong Jae Park, M.D., Joo Yeon Oh, M.D., Won Woo Lee, M.D., Hye Jin Cho, M.D., Jae Young Moon, M.D., Jae Seon Kim, M.D. and Young Tae Bak, M.D.; Korean J Gastrointest Endosc 2009;39(6):369-373. Published online December 30, 2009

Abstract PDF: Anastomotic leakage after gastrectomy has significant morbidity and mortality, and the mortality rate has been reported to be over 60%. There have been very few reports concerning endoscopic stenting for the management of anastomotic leakage. Successful treatment of anastomotic leakage with covered self-expanding metallic stents (stent) has recently been reported. A 62-year-old man with melena was diagnosed with advanced gastric cancer and he underwent total gastrectomy. At the 3rd day after surgery, anastomotic leakage was found by an upper gastrointestinal series (UGI). He underwent laparoscopic primary repair on the 5th day after surgery. The leakage resumed thereafter. At the 12th day after the primary repair, the leakage was successfully managed by stent insertion and the patient improved thereafter. At the 11th week after stent insertion, the stent was removed without complications and the leakage was completely closed. At 1 year after stent removal, no stricture has been found on the anastomosis site. We report here on a case of anastomotic leakage after gastrectomy, and this was completely managed by stent insertion. (Korean J Gastrointest Endosc 2009;39:369-373)

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Two Cases of Pseudomelanosis Duodeni Associated with Systemic Diseases and Oral Iron Supplementation: Kyoung-Hwan Lee, M.D., Tae Hoon Lee, M.D., Yun Suk Shim, M.D., Jun-Ho Choi, M.D., Il-Kwun Chung, M.D., Sang-Heum Park, M.D., Sun-Joo Kim, M.D. and Mee-Hye Oh, M.D.*; Korean J Gastrointest Endosc 2009;39(6):374-378. Published online December 30, 2009

Abstract PDF: Pseudomelanosis duodeni is a rare benign condition that manifests endoscopically as diffuse, small brownish-black spots in the duodenal mucosa, and the histochemical findings show an accumulation of hemosiderin pigment in the duodenal villi's lamina propria. This condition produces no specific symptoms, and it may be reversible. The cause and natural history of the pigmentation have not been clarified, although it is associated with a variety of systemic illnesses and medications. We describe two cases of pseudomelanosis duodeni and the patients had histories of diabetes mellitus, hypertension, chronic renal insufficiency and specific medications. We also review the relevant medical literature on this rare condition. (Korean J Gastrointest Endosc 2009;39:374-378)

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Multiple Gastrointestinal Drug Induced Ulcers Associated with Aspirin and Non-steroidal Anti-inflammatory Drugs: A Case Report and Review of the Literature: Hyun Jin Kim, M.D., Woo Chul Chung, M.D., Kang Moon Lee, M.D., Chang Nyol Paik, M.D., Seung Hye Jung, M.D., Jin Dong Kim, M.D., Sung Hoon Jung, M.D. and Jae Wuk Kwak, M.D.; Korean J Gastrointest Endosc 2009;39(6):379-383. Published online December 30, 2009

Abstract PDF: Aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) are widely prescribed drugs, and they are known to be responsible for many cases of gastroduodenal ulcerations by inhibiting prostaglandin synthesis via blocking the cyclo-oxygenase production. Colonic side effects of these drugs are rare, but they are increasingly being reported to be due to the popularization of colonoscopy and the new formulations of drugs such as enteric coated pills or slow release pills. There is currently no consensus for making the clinical diagnosis and administering the proper therapy for drug-induced colonopathy in Korea. We experienced the patient who had multiple colonic ulcers after ingesting large amounts of aspirin and NSAIDs. In near future, we hope to determine the clinical and endoscopic features of drug associated colon injury. (Korean J Gastrointest Endosc 2009;39:379-383)

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A Case of Salmonella Infection in the Terminal Ileum That Was Initially Misdiagnosed as Lymphoma: Myeong Hun Chae, M.D., Moon Young Kim, M.D., Jin Hyung Lee, M.D., Yong Hwan Kwon, M.D., So Yeon Park, M.D., Mee Yon Cho, M.D.*, Yo Sep Chong, M.D.* and Seung Whan Cha, M.D.^†; Korean J Gastrointest Endosc 2009;39(6):384-388. Published online December 30, 2009

Abstract PDF: Salmonella usually invades the Peyer's patch of the terminal ileum or ascending colon. A 55-year old female was referred to our hospital for general weakness and sustained fever. On the abdominal contrast computed tomography (CT) scan, we found symmetric circular hypertrophy of the intestinal wall and multiple hypertrophied lymph nodes in the terminal ileum. The positron emission tomography computed tomography (PET-CT) scan showed skipped areas of wall thickening and intense fluorodeoxyglucose (FDG) uptake in the terminal ileum and the ileocecal valve with adjacent lymphadenopathies. On the colonoscopy, multiple mass forming variable-sized ulcers on the terminal ileum were found, so a biopsy specimen and the colonic luminal fluid were obtained, and we made a diagnosis of lymphoma. However, the blood and colonic luminal fluid culture for Salmonella paratyphi-A was reported as positive, and therefore we corrected the diagnosis to Salmonella infection. We report here on a case of Salmonella infection in the terminal ileum, which looked like malignant lymphoma on the baseline radiologic image studies, including the CT and PET-CT. (Korean J Gastrointest Endosc 2009;39:384-388)

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A Case of Hemosuccus Pancreaticus Mistaken for Hemobilia: Seung Hwa Lee, M.D., Dong Hee Koh, M.D., Seon Wook Park, M.D., Ji Youn Kim, M.D., Young Wook Kim, M.D., Hyun Joo Jang, M.D., Sea Hyub Kae, M.D. and Jin Lee, M.D.; Korean J Gastrointest Endosc 2009;39(6):389-392. Published online December 30, 2009

Abstract PDF: Hemosuccus pancreaticus is a rare cause of chronic and intermittent chronic gastrointestinal hemorrhage, and this condition cannot be easily detected by endoscopy. We report here on a 51-year-old woman with obstructive jaundice and a history of acute pancreatitis and chronic alcoholism. Abdominal computed tomography showed a dilated distal common bile duct. We performed endoscopic retrograde cholangiopancreatography to decompress the bile duct and we found a blood clot on the orifice of the ampulla of Vater. Hemobilia with massive bleeding was seen during the examination. Angiography for controlling the hemorrhage showed the pseudoaneurysm of the pancreaticoduodenal artery. Angiographic embolization was successful for controlling the arterial hemorrhage. The patient remained symptom-free and he was discharged without complications. (Korean J Gastrointest Endosc 2009;39:389-392)

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A Case of a Submucosal Ganglioneuroma of the Ampulla of Vater That Was Treated by Endoscopic Resection: Hye Jin Cho, M.D., Jae Seon Kim, M.D., Tae Jung Yun, M.D., Seok Bae Yoon, M.D., Hyun-Seok Kang, M.D., Jae Young Moon, M.D., Jong-Jae Park, M.D. and Young-Tae Bak, M.D.; Korean J Gastrointest Endosc 2009;39(6):393-397. Published online December 30, 2009

Abstract PDF: Submucosal tumors in the gastrointestinal tract are covered with a mucous membrane such as the surrounding tissue. Therefore, the use of endoscopic biopsy to diagnose submucosal tumors is not as effective as that for epithelial tumors. Although imaging tools such as ultrasonography or computed tomography have made great advances, it is still difficult to diagnose submucosal tumors before resection. The surgical resection of tumors is the most accurate diagnostic method, yet less invasive endoscopic resection has been preferred in recent years. We report herein on a rare case of ganglionueroma arising from the Ampulla of Vater and this lesion was incidentally found during performance of routine esohagogastroduodenoscopy. The lesion was diagnosed as a ganglioneuroma, and it was successfully removed through endoscopic resection. (Korean J Gastrointest Endosc 2009;39: 393-397)

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