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Volume 40(2); February 2010
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Prevention and Management of Gastroesophageal Variceal Hemorrhage
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Soung Won Jeong, M.D., Joo Young Cho, M.D., Sung Jae Shin, M.D.*, Moon Young Kim, M.D.†, Byung Seok Lee, M.D.‡, Tae Hee Lee, M.D.§, Jae Young Jang, M.D., Yeon Seok Seo, M.D.∥, Hoon Jai Chu
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Korean J Gastrointest Endosc 2010;40(2):71-83. Published online February 27, 2010
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Abstract
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- Gastroesophageal variceal hemorrhage involving increased portal pressure is the most common fatal complication of liver cirrhosis. Gastroesophageal varices are present in approximately 50% of patients with liver cirrhosis. Although acute variceal hemorrhage-related mortality has decreased significantly over the last decade, it still is at least 20% at 6 weeks after variceal bleeding even with optimal management. In patients with medium and large varices that have not bled but have a high risk of hemorrhage, nonselective Ղ-blockers or endoscopic variceal ligation may be recommended for the prevention of first variceal hemorrhage. Acute variceal hemorrhage requires intravascular volume support and blood transfusions with vasoconstrictive agents and prophylactic antibiotics. Endoscopic variceal ligation and nonselective Ղ-blockers are standard secondary prophylaxis therapies for variceal bleeding. Patients whose hepatic venous pressure gradient decreases to ＜12 mmHg or at least 20% from baseline levels after treatment with nonselective Ղ-blockers can reduce the probability of recurrent variceal hemorrhage. In gastric fundal varices, endoscopic variceal obturation using cyanoacrylate is preferred. For failures of medical therapy, a transjugular intrahepatic portosystemic shunt or surgically created shunts are salvage procedures. (Korean J Gastrointest Endosc 2010;40:71-83)
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Young Aged Colorectal Cancer Patients: Do They Have a Bad Prognosis?
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Young Taek Kim, M.D., Hang Rak Lee, M.D., Oh Young Lee, M.D., Byung Chul Yoon, M.D., Ho Soon Choi, M.D., Joon Soo Hahm, M.D., You Hern Ahn, M.D., Dong Chan Kim, M.D., Hyung Tae Kim, M.D., Ji Yiung Yoon, M.D., Sa Il Kim, M.D., Seung Sam Bak, M.D.* and Jin
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Korean J Gastrointest Endosc 2010;40(2):84-89. Published online February 27, 2010
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Abstract
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- Background
/Aims: Many previously published articles have reported poor outcomes for young patients with colorectal cancer as compared to that of older patients with colorectal cancer. However, these studies have tended to be small and have various biases. This study was retrospectively designed to determine the clinical course and survival rate of young patient with colorectal cancer.
Methods
All the patients who underwent surgery for colorectal cancer at Hanyang University Hospital between 1995 and 2001 were identified. These patients were assigned to two age groups: the 45 years old and below 45 years old group (123 patients) and the group over the age of 45 (421 patients).
Results
The size of the tumor mass was significantly larger in the young group. There were no significant differences between the two groups for the stage at the time of diagnosis, the differentiation, the degree of lymph node involvement, the cancer location and the gross finding. The median cancer specific survival time was worse for the old group as compared with that of the young group. Age, differentiation, lymph node involvement and the Duke stage were the significant prognostic factors on univariate analysis. Age and the Duke stage were the independent prognostic factors that were significantly correlated with survival on the multivariate analysis using the Cox proportional hazard model.
Conclusions
Contrary to prior reports, younger patients with colorectal cancer appear to have a better survival rate than that of older patients with colorectal cancer. (Korean J Gastrointest Endosc 2010;40:84-89)
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The Efficacy of Diagnostic and Therapeutic Laparoscopic Lymph Node Dissection after Endoscopic Submucosal Dissection in Early Gastric Cancer
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Yong Hun Kim, M.D., Joo Young Cho, M.D., Won Young Cho, M.D., Young Kwan Cho, M.D., Tae Hee Lee, M.D., Hyun Gun Kim, M.D., Jin Oh Kim, M.D., Joon Seong Lee, M.D., Yong Jin Kim, M.D.* and So Young Jin, M.D.†
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Korean J Gastrointest Endosc 2010;40(2):90-96. Published online February 27, 2010
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Abstract
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- Background
/Aims: Lymph node metastasis is infrequently found in patients with early gastric cancer (EGC) following surgery. Accurate evaluation of lymph node status is very important in determining the appropriate treatment for patients with EGC. The efficacy of diagnostic and therapeutic laparoscopic lymph node dissection after endoscopic submucosal dissection in patients with EGC at high risk for lymph node metastasis was evaluated.
Methods
Among patients with EGC who underwent endoscopic submucosal dissection between November 2006 and February 2009, 9 patients with undifferentiated adenocarcinoma, submucosal cancer, immunohistochemically-positive cytoplasmic staining for vascular endothelial growth factor, lymphovascular invasion, a high lymphatic microvessel density, or high microvessel density were selected. All patients underwent laparoscopic lymph node dissection for determination of lymph node status. The local IRB approved the study.
Results
All of the dissected lymph nodes were free of cancer cells in all of the patients. During 16 months of follow-up, no patients had evidence of tumor recurrence.
Conclusions
Laparoscopic lymph node dissection after endoscopic submucosal dissection is useful to assess lymph node status and may help guide further treatment for patients with EGC at high risk for lymph node metastasis. (Korean J Gastrointest Endosc 2010;40:90-96)
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Two Cases of Adrenal Cysts Assessed by Endoscopic Ultrasound-Guided Fine Needle Aspiration for Diagnostic and Therapeutic Purposes
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Hyung Hun Kim, M.D., Jung Hwan Lee, M.D., Sang Ryul Lee, M.D., Su-Yeon Lee, M.D., Young Il Park, M.D., Soo Hyung Ryu, M.D., You Sun Kim, M.D. and Jeong Seop Moon, M.D.
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Korean J Gastrointest Endosc 2010;40(2):97-101. Published online February 27, 2010
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Abstract
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- Adrenal cyst is a rare disease and its incidence rate is about 0.06∼0.18%. Many cases of adrenal cysts are diagnosed incidentally. Surgical excision is generally performed to rule out malignancy when an adrenal cyst is detected. However, a reviewing the overall cases revealed that only 7% of adrenal cysts were malignant or potentially malignant. Thus, it has been suggested to observe an asymptomatic simple benign cyst after aspiration. From this point of view, it is necessary to perform a functional hormonal test and fine needle aspiration cytology for investigating the nature of adrenal cysts. Adrenal cyst drainage can be performed when surgical resection is not indicated. Computed tomography or ultrasonography guided percutaneous aspiration and drainage has been performed, but linear endoscopic ultrasound has not yet been used for this purpose. We have performed endoscopic ultrasound guided fine needle aspiration of adrenal cysts for cytologic and hormonal examination and endoscopic ultrasound guided adrenal cyst drainage, and we report here on our experiences with this technique. (Korean J Gastrointest Endosc 2010;40:97-101)
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A Case of Gastric, Duodenal and Colonic Metastases from Adenocarcinoma of the Lung
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Sang Youn Hwang, M.D., Dong Won Ahn, M.D., Woong Jae Yun, M.D.*, Ji Bong Jeong, M.D., Won Kim, M.D., Yong Jin Jung, M.D., Byeong Gwan Kim, M.D. and Kook Lae Lee, M.D.
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Korean J Gastrointest Endosc 2010;40(2):102-106. Published online February 27, 2010
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Abstract
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- Gastrointestinal metastasis of primary lung carcinoma is very rare, although this is found in about 4.7∼14% of cases at autopsy. An 81-year-old man was admitted with masses in the lung, adrenal gland, bladder and colon on his CT scans. We suspected metastases of an unknown origin and we carried out EGD and colonoscopy to differentiate the primary origin of the metastases. The examination revealed a submucosal tumor-like mass with central erosion on the gastric antrum and colonic splenic flexure, and polypoid lesions with a central fissure on the second portion of the duodenum. All the endoscopic forcep biopsies showed poorly differentiated adenocarcinoma without evidence of foci of the preinvasive surface glandular lesions. Immunochemical analysis of the tumor cells showed positivity for thyroid transcription factor-1 and cytokeratin 7, and negativity for cytokeratin 20 and caudal-related homeobox 2. Therefore, we diagnosed this case as multiple gastrointestinal metastases of primary lung cancer. This is first case of gastric, duodenal and colonic metastases from adenocarcinoma of the lung in the medical literature. (Korean J Gastrointest Endosc 2010;40:102-106)
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Intramural Hematoma of the Esophagus after Endoscopic Pinch Biopsy and Endoscopic Band Ligation
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Jae Nam Yang, M.D., Yun Jeong Lim, M.D., Ji Hun Kang, M.D., Hyoun Woo Kang, M.D., Jun Kyu Lee, M.D., Yong Seok Lee, M.D.*, Jong Sun Choi, M.D.† and Jin Ho Lee, M.D.
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Korean J Gastrointest Endosc 2010;40(2):107-110. Published online February 27, 2010
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Abstract
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- Esophageal intramural hematoma (EIH) is an uncommon clinical entity among the acute esophageal injuries, and EIH predominantly occurs in middle-aged women. The pathogenesis of EIH has not been clarified, yet this. Seems to occur within the submucosal layer of the esophagus after dissection of the mucosa. EIH may occur spontaneously or secondary to trauma. Patients usually complain of a sudden onset of severe retrosternal chest pain, hematemesis, back pain or dysphagia. Most EIHs show improvement through conservative management, including fasting and intravenous hydration, and this usually completely recovers within a period of 2∼3 weeks. We report here on a case that EIH occurred after endoscopic pinch biopsy and endoscopic band ligation and this EIH was exacerbated in a patient who was taking long-term aspirin medication. (Korean J Gastrointest Endosc 2010;40: 107-110)
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Post-extubation Negative Pressure Pulmonary Edema Complicating ESD under General Anesthesia
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Ji Hye Kweon, M.D.†, Tae Hyeon Kim, M.D., Hyo Jeong Oh, M.D., Eun Young Cho, M.D.†, Jin Soo Chung, M.D., Hyeong Cheol Cheong, M.D. and Yong Son, M.D.*
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Korean J Gastrointest Endosc 2010;40(2):111-115. Published online February 27, 2010
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Abstract
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- Negative pressure pulmonary edema is a recognized complication of airway obstruction, particularly after endotracheal extubation. The application of oxygen therapy and continuous positive airway pressure with the administration of diuretics under a rapid diagnosis usually clears pulmonary edema. We report a case of 61-year-old man who developed negative pressure pulmonary edema following extubation after an endoscopic submucosal dissection under general anesthesia. (Korean J Gastrointest Endosc 2010;40:111-115)
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A Case of Malignant Duodenocolic Fistula Treated with Covered Metallic Stents
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Jeong Ah Kim, M.D., Chang Whan Kim, M.D., Chang Hoon Lim, M.D., Seok Ju Lee, M.D., Dong Hoon Ko, M.D., Tae Ho Kim, M.D., Sok Won Han, M.D. and Hiun Suk Chae, M.D.
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Korean J Gastrointest Endosc 2010;40(2):116-120. Published online February 27, 2010
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Abstract
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- Malignant duodenocolic fistula is a rare complication of colon cancer, and this usually develops as the right-side colon cancer that invades the duodenal bulb. The fistula often results in watery diarrhea, weight loss and feculent vomiting. A barium enema or duodenography have been the most useful diagnostic procedures, and the fistula is directly confirmed by an endoscopic examination. Curative resection is not possible in many cases due to metastasis or local invasion, so a palliative operation can be performed to relieve symptoms, but it cannot completely prevent the vomiting or diarrhea. Seven Korean cases of malignant duodenocolic fistula have been previously reported on, and an operation was performed in six cases. We report here on a case of duodenocolic fistula with intestinal obstruction that arouse from a right-side colon cancer, and this was successfully managed by placing covered metallic stents at the duodenum and hepatic flexure. (Korean J Gastrointest Endosc 2010;40:116-120)
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The Identification of Superior Mesenteric Artery Syndrome Established by Endoscopic Ultrasound in a Patient with Severe Gastroptosis
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Sung Jun Kim, M.D., Woo Chul Chung, M.D., Sung Hoon Jung, M.D., Jae Wuk Kwak, M.D., Myung Hyun Lee, M.D., Chang Nyol Paik, M.D. and Kang-Moon Lee, M.D.
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Korean J Gastrointest Endosc 2010;40(2):121-125. Published online February 27, 2010
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Abstract
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- Superior mesenteric artery (SMA) syndrome is caused by compression of the transverse part of the duodenum between the SMA and the aorta, where the distance between these vessels decreases with loss of mesenteric fat. It occurs most frequently in patients with rapid weight loss. Conventionally, the diagnosis is established by digital fluoroscopy and contrast-enhanced spiral computed tomography (CT). A 17-year old woman was admitted via the emergency department with postprandial fullness, nausea, and bile stained vomiting. The initial radiological examination revealed severe gastroptosis. Fluoroscopic evaluation after barium swallowing failed due to a markedly distended stomach. The diagnosis of SMA syndrome was made by endoscopic ultrasound (EUS) using a mini-probe. EUS findings were in good agreement with the CT angiogram. A conservative trial was attempted, but symptoms remained refractory. Surgery was an alternative option and we treated the patient successfully with laparoscopic duodeno-jejunostomy. (Korean J Gastrointest Endosc 2010;40:121-125)
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A Case of Cronkhite-Canada Syndrome Conducted with Capsule Endoscopy of Small Intestine
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Wan Park, M.D., Woo Kyu Jeon, M.D., Jae Eun Lee, M.D., Won Suk Choi, M.D., Mi Hae Seo, M.D., Min Yong Yoon, M.D., Chang Seok Song, M.D. and Dong Hun Kim, M.D.*
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Korean J Gastrointest Endosc 2010;40(2):126-129. Published online February 27, 2010
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Abstract
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- Cronkhite-Canada syndrome is a very rare syndrome. This non-familial hamartomatous polyposis syndrome is characterized by multiple polyps on the entire gastrointestinal tract, nail dystrophy, skin pigmentation and systemic alopecia. The courses of this syndrome could be classified into five types according to clinical symptoms; diarrhea, taste disturbance, xerostomia, abdominal pain and alopecia. Cronkhite-Canada syndrome has a high mortality rate up to 45∼60% due to nutritional absorption disturbance, hypoalbuminemia, recurrent infection, sepsis, heart failure and gastrointestinal bleeding. A pathogenesis of Cronkhite-Canada syndrome is still unknown, and only conservative treatment is available. We diagnosed a 55 years-old female with Cronkhite-Canada syndrome based on the clinical symptoms of nail change, taste disturbance and alopecia, and the histologic finding of polyps in the entire gastrointestinal tract; these polyps were found in the stomach, small intestine and large intestine via capsule endoscopy. We report on this case and we review the relevant medical literature. (Korean J Gastrointest Endosc 2010;40:126-129)
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A Case of Non-occlusive Ischemic Colitis of the Right Colon after Percutaneous Coronary Intervention
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Sung Ryoun Lim, M.D., Hyun Soo Kim, M.D., Ho Seong Ryu, M.D., Jun Ho Cho, M.D., Seon Young Park, M.D., Young Eun Joo, M.D., Sung Kyu Choi, M.D. and Jong Sun Rew, M.D.
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Korean J Gastrointest Endosc 2010;40(2):130-134. Published online February 27, 2010
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- Ischemic colitis is the most common form of gastrointestinal ischemic injury. Indeed, many medical conditions and medications can cause reduced blood flow to the colon. The splenic flexure, descending colon, and sigmoid colon are most commonly affected. Involvement of only the right colon is an infrequent occurrence. Ischemic colitis of the right colon usually is associated with low flow states. Given the high morbidity and mortality of this disorder, early diagnosis and aggressive management is critical. Ischemic colitis associated with heart disease, such as congestive heart failure, myocardial infarction, arrhythmias, aortic valve disease, and atherosclerotic cardiovascular disease, is usually due to low cardiac output, or to disease states resulting in dehydration, or to the splanchnic vasoconstrictive effect of some medications. Here we present a case of nonocclusive ischemic colitis of the right colon after percutaneous coronary intervention for unstable angina. The colitis was successfully treated with conservative management. (Korean J Gastrointest Endosc 2010;40:130-134)
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Inflammatory Cloacogenic Polyp Mimicking Anorectal Malignancy
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Hea Jung Sung, M.D., Jin Il Kim, M.D., Chan Joon Kim, M.D., Jin Min Park, M.D., Seok In Hong, M.D., Dae Young Cheung, M.D., Soo-Heon Park, M.D. and Jae Kwang Kim, M.D.
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Korean J Gastrointest Endosc 2010;40(2):135-138. Published online February 27, 2010
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Abstract
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- Inflammatory cloacogenic polyp is a polypoid protruding lesion arising from the transitional zone of the anorectal junction. It has a distinctive endoscopic, histological appearance, but it may macroscopically resemble anorectal malignancy. It is important to beware of the possibility of adenoma and malignancy when finding lesions at the anorectal junction. The management of inflammatory cloacogenic polyp is endoscopic or surgical excision. We report here on a 62 year old man who had an anorectal polyp. The initial impression was hemorrhoid or anorectal malignancy. He underwent surgical intervention, and the histology showed inflammatory cloacogenic polyp. (Korean J Gastrointest Endosc 2010;40: 135-138)
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A Case of Successful Endoscopic Treatment for Acute Recurrent Pancreatitis Due to Pancreas Divisum with Santorinicele Masquerading as Drug Induced Pancreatitis
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Yun Suk Shim, M.D., Tae Hoon Lee, M.D., Jun Ho Choi, M.D., Sang Pil Kim, M.D., Sae Hwan Lee, M.D., Il Kwun Chung, M.D., Sang Heum Park, M.D. and Sun Joo Kim, M.D.
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Korean J Gastrointest Endosc 2010;40(2):139-143. Published online February 27, 2010
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- There are various causes of acute pancreatitis, and accurately determining the etiology is pivotal for selecting appropriate management. Other hidden causes, such as congenital anomaly, should be considered in patients with recurrent abdominal pain or unexplained recurrent pancreatitis. A santorinicele is a focal cystic dilatation of the terminal dorsal pancreatic duct, and this is usually associated with pancreas divisum and it is a risk factor for acute pancreatitis due to the accompanying relative stenosis of the minor papilla. We present here the case of a patient who was treated for acute pancreatitis that was presumably was caused by either Rifampin or Brucellosis, and the patient recovered with conservative management. However, we eventually diagnosed pancreas divisum with santorinicele by performing MRCP and ERCP after the pancreatitis had relapsed. We report here on a case of successful endoscopic treatment for pancreas divisum with santorinicele as a cause of recurrent pancreatitis, and this was initially confused with drug or infection related pancreatitis. (Korean J Gastrointest Endosc 2009; 40:139-143)
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