Clinical Endoscopy

Endoscopic Submucosal Dissection for Colorectal Tumors: Sang Un Park, M.D. and Dong Kyung Chang, M.D.; Korean J Gastrointest Endosc 2010;40(3):145-156. Published online March 30, 2010

Abstract PDF: Because screening gastrointestinal endoscopies have been widely performed recently, diagnosis rates of early stage cancer have been increasing rapidly. This trend has also led to advances in therapeutic endoscopy, which is less invasive than surgery. The state-of-the-art technique, endoscopic submucosal dissection (ESD), allows more favorable outcomes than conventional endoscopic mucosal resection (EMR) regarding en-bloc resection of the lesion, irrespective of the size of the lesion. ESD has already been established as the standard therapeutic option for neoplastic lesions in the upper gastrointestinal tract. However, the use of ESD for colorectal lesions is not yet established because of the unique pathological, organ specific characteristics of colonic lesions. Moreover, endoscopists are required to have higher qualifications to perform ESD and tend to cause complications more frequently. Nevertheless, it is obvious that ESD has a therapeutic advantage for certain colonic lesions and enables endoscopists to achieve a higher en-bloc resection rate, resulting in enhanced curability and more accurate histopathological assessment. Recent development of a special colonoscope for ESD and refinement of devices such as surgical knives and traction systems are expected to overcome some limitations of ESD and a standard protocol will be available in the near future. In this review, we will discuss the current status and future prospects of colorectal ESD. (Korean J Gastrointest Endosc 2010;40:145-156)

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Follow-up after Double Balloon Enteroscopy in Patients with Suspected Small Bowel Bleeding: Focused on the Rebleeding Rate: Sun-Jin Boo, 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 2010;40(3):157-163. Published online March 30, 2010

Abstract PDF: Background
/Aims: Double balloon enteroscopy (DBE) is an effective modality for making the diagnosis and managing suspected small bowel bleeding. However, there is limited data on the follow-up results after DBE. The aim of this study was to evaluate the long-term clinical outcome after DBE in patients with suspected small bowel bleeding.
Methods
We retrospectively analyzed the rebleeding rate of 60 consecutive patients (M：F=39：21, age: 13∼85 years) who underwent DBE because of suspected small bowel bleeding at Asan Medical Center during a 3 year period.
Results
The median follow-up period was 552 days. Bleeding sources were detected by DBE in 41 patients. The cumulative rebleeding rate at 6, 12 and 24 months was 22%, 27% and 30%, respectively. There was no significant difference in the cumulative rebleeding rate between the patients with bleeding sources detected by the initial DBE and those without bleeding sources detected by the initial DBE. The cumulative rebleeding rate at 6 and 12 months was significantly higher for the patients with vascular or superficial mucosal lesions than for the patients with tumors or other lesions (p=0.013).
Conclusions
The rebleeding risk after DBE is not low for patients with suspected small bowel bleeding. The rebleeding risk is especially high for patients with vascular or superficial mucosal lesions, and this may necessitate careful follow-up. (Korean J Gastrointest Endosc 2010;40:157-163)

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Risk Factors for Delayed Bleeding after Colonoscopic Polypectomy: Woo Jin Han, M.D., Yoon Jae Kim, M.D., Jung Gon Kim, M.D., Tae Kyung Kim, M.D., Seo Young Lee, M.D., Moon Sook Cho, M.D., Jun Won Chung, M.D., Dong Kyun Park, M.D., Ki Baik Hahm, M.D., Yun Soo Kim, M.D. and Ju Hyun Kim, M.D.; Korean J Gastrointest Endosc 2010;40(3):164-169. Published online March 30, 2010

Abstract PDF: Background
/Aims: The aim of this study was to identify risk factors for delayed bleeding after colonoscopic polypectomy.
Methods
3,530 polypectomies in 1,542 patients were evaluated. Risk factors were identified among patient-related factors (age, sex, comorbidity, anticoagulants, antiplatelets), polyp-related factors (size, shape, location, histology), and procedure-related factors (experience of the endoscopist, sedation, resection method).
Results
Delayed bleeding occurred in 26 lesions (0.7%) of 24 patients (1.6%). Polyp-based multivariate analysis revealed that polyp size greater than 15 mm (OR, 2.882; 95% CI, 1.106 to 7.506; p=0.030) and sedation-free colonoscopy (OR, 2.606; 95% CI, 1.116 to 6.084; p=0.027) were significant risk factors for delayed bleeding after polypectomy. In colonoscopy-based analysis, hypertension increased the risk of delayed bleeding after polypectomy (OR, 2.938; 95% CI, 1.009 to 8.557; p=0.048).
Conclusions
Large polyp size, sedation-free colonoscopy, and hypertension are associated with delayed bleeding after colonoscopic polypectomy. (Korean J Gastrointest Endosc 2010;40:164-169)

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Gastric Candidiasis in an Immunocompromised Host: A Case Report and Review of the Literature: Tae Jin Seo, M.D., Wan Sik Lee, M.D., Kyoung Rok Lee, M.D., Hye Kyong Jeoung, M.D., Hyung Il Kim, M.D., Sung Bum Cho, M.D., Young Eun Joo, M.D. and Jong Sun Rew, M.D.; Korean J Gastrointest Endosc 2010;40(3):170-174. Published online March 30, 2010

Abstract PDF: Candida albicans frequently inhabits the gastrointestinal tract of humans and this can lead to gastrointestinal candidiasis. Candida albicans infection of the gastrointestinal tract in normal or immunocompromised patients invariably involves the esophagus, with the typical finding of mucosal plaques. In contrast, gastric candidiasis is an uncommon phenomenon that usually occurs in immunocompromised hosts, andonly such eight cases have currently been documented in Korea. We report here on an additional case of gastric candidiasis in a 39-year old woman who had undergone craniotomy and chemotherapy for glioblastoma, and we review the medical literature related to this condition. (Korean J Gastrointest Endosc 2010;40:170-174)

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Two Cases of Gastric Marginal Zone B Cell Lymphoma Treated with a Single Agent Chemotherapy: Young Seok Bae, M.D., Kwang Jae Lee, M.D., Dong Wan Kim, M.D., Jun Ho Hong, M.D., Jung Bin Yoon, M.D., Sang Hoon Bae, M.D., Jin Suk Lee, M.D.* and Chul Soo Song, M.D.; Korean J Gastrointest Endosc 2010;40(3):175-180. Published online March 30, 2010

Abstract PDF: Gastric marginal zone B cell lymphoma of the MALT type (MALT lymphoma) is usually accompanied by a Helicobacter pylori (H. pylori) infection. Most gastric MALT lymphomas regress after the eradication of H. pylori. Therefore, H. pylori eradication therapy is an effective first-line treatment for gastric MALT lymphoma. A second-line treatment for patients who fail to respond to eradication therapy, including radiotherapy and chemotherapy, produces a good response and survival rate. We encountered 2 cases of H. pylori eradication-resistant gastric MALT lymphoma, which were treated with cyclophosphamide monotherapy. A complete response was obtained in both cases after a treatment duration of 3 months and remission continued for 15 and 18 months, respectively. Treatment-related toxicity was mild. Oral monochemotherapy might be an alternative, effective and safe treatment modality for patients with gastric MALT lymphoma who are resistant to H. pylori eradication therapy. (Korean J Gastrointest Endosc 2010;40:175-180)

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A Case of Advanced Gastric Adenocarcinoma with Synchronous Gastric Diffuse Large B Cell Lymphoma: Young Jun Lee, M.D., Yoon Jae Kim, M.D., U Seok Choi, M.D., Dong Kyun Park, M.D., Ki Baik Hahm, M.D., Yun Soo Kim, M.D., Ju Hyun Kim, M.D. and Dong Bok Shin, M.D.; Korean J Gastrointest Endosc 2010;40(3):181-185. Published online March 30, 2010

Abstract PDF: Signet ring cell carcinoma is a subtype of adenocarcinoma that is characterized by abundant intracellular mucin accumulation. Diffuse large B-cell lymphoma is the most common histological subtyple of gastrointestinal lymphoma. The gastrointestinal tract is the most frequently involved extranodal site in non-Hodgkin's lymphoma. However, little is known about the coexistence of advanced gastric cancer and gastric diffuse large B cell lymphoma. We report a case of synchronous advanced gastric adenocarcinoma and gastric diffuse large B cell lymphoma in a 62-year-old woman. (Korean J Gastrointest Endosc 2010;40:181-185)

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A Case of Primary Duodenal Adenocarcinoma Treated by Endoscopic Mucosal Resection: Kun Hyung Cho, M.D., Jae Young Jang, M.D., Ji-Yun Kim, M.D., HyunJin Park, M.D., Nam Sook Park, M.D., Jeung Eun Park, M.D., Seong Dong Sohn, M.D. and Yun Hwa Kim, M.D.*; Korean J Gastrointest Endosc 2010;40(3):186-189. Published online March 30, 2010

Abstract PDF: Primary nonampullary duodenal adenocarcinoma is an extremely rare disease. In the past, almost all duodenal adenocarcinomas were detected at an advanced stage. Yet recently, an increased number of case reports of early duodenal adenocarcinoma has coincided with the advances in the field of endoscopy, and there has also been an increased number of case reports of duodenal adenocarcinoma treated by endoscopic mucosal resection. We report here on a case of primary nonampullary duodenal adenocarcinoma that was treated by endoscopic mucosal resection, and there has been no recurrence for over 3 years, as assessed by endoscopic examination. (Korean J Gastrointest Endosc 2010;40:186-189)

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A Giant Lipoma Incidentally Found in Massive Jejunal Diverticular Bleeding: Seung Hye Jung, M.D., Woo Chul Chung, M.D., Kang Moon Lee, M.D., Chang Nyol Paik, M.D., Hyun Jin Kim, M.D., Sung Hoon Jung, M.D., Jae Wuk Kwak, M.D. and Ji Han Jung, M.D.*; Korean J Gastrointest Endosc 2010;40(3):190-194. Published online March 30, 2010

Abstract PDF: Jejunal diverticulosis is a rare malady and it is often asymptomatic. It may lead to chronic non-specific or acute symptoms such as malabsorption, intussusception, obstruction, bleeding, perforation and abscess formation. It usually is seen as an incidental finding on computerized tomography, enteroclysis or during an emergency operation. Since the advent of double balloon enteroscopy and capsule endoscopy, several cases of small bowel diverticulosis with complications have recently been reported. Lipomas are the rare benign tumors of the small intestine with no malignant potential and they are mostly incidentally encountered during investigation of the gastrointestinal tract. We report here on a case of massive small bowel bleeding with jejunal diverticulosis, and a pedunculated elongated lipoma was incidentally found. (Korean J Gastrointest Endosc 2010;40:190-194)

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A Case of Asymptomatic Appendiceal Intussusception by Mucinous Cystadenoma: Won Seo, M.D., Won Cheol Park, M.D., Tae Su Lim, M.D., Dong Baek Kang, M.D., Jung Taek Oh, M.D., Jeong Kyun Lee, M.D., Ki Hoon Kim, M.D.* and Ki Jung Yun, M.D.^†; Korean J Gastrointest Endosc 2010;40(3):195-198. Published online March 30, 2010

Abstract PDF: Appendiceal intussusception has rarely been reported, and this has an incidence of 0.01% when performing appendectomy. It develops due to anatomical or pathological conditions such as polyps, worms, carcinomas, mucoceles or fecaliths. Patients with appendiceal intussusception present with various clinical symptoms from no symptoms to acute or chronic lower abdominal pain like that in appendicitis. Yet making the accurate preoperative diagnosis is sometimes difficult. Advanced colonoscopy has recently made it possible to arrive at the preoperative diagnosis and colonoscopy provides the optimal management of appendiceal intussusceptions that show various clinical symptoms. We report here on a 62- year-old woman who has no clinical symptoms of appendiceal intussusception, and the patient was preoperatively diagnosed by colonoscopy and managed with laparoscopic partial cecectomy. The final diagnosis was mucinous cystadenoma- induced appendiceal intussusception. (Korean J Gastrointest Endosc 2010;40:195- 198)

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A Case of Primary Jejunal Mucinous Adenocarcinoma Diagnosed by Single Balloon Enteroscopy: Youngju Lee, M.D., Jae Young Jang, M.D., Sung Hyung Ha, 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 2010;40(3):199-202. Published online March 30, 2010

Abstract PDF: The small bowel rarely develops neoplasm, and tumor of the small bowel accounts for only 1∼2% of all gastrointestinal neoplasm. Most cases of jejunal and ileal adenocarconoma are of the well or moderately differentiated type. Mucinous adenocarcinoma is diagnosed when the amount of extracellular mucin in a tumor is over 50% and its incidence in the small bowel is very low. A 49-year-old man presented with postprandial abdominal pain and vomiting for the previous 2 months. The abdominal computed tomography scan showed about a 6.5 cm-sized mass at the proximal jejunum. Single balloon enteroscopy was done preoperatively for making the diagnosis and the biopsy showed mucinous adenocarcinoma of the proximal jejunum. Under the diagnosis of primary jejunal cancer. We report here on our case for which a definite diagnosis was made before surgery by performing single balloon enteroscopy, and we review the relevant medical literature. (Korean J Gastrointest Endosc 2010;40:199-202)

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Eosinophilic Colitis Presenting with Bloody Diarrhea: Case Report: Sun Ik Jang, M.D., Hyeung Yeol Park, M.D. and In Sun Jun, M.D.*; Korean J Gastrointest Endosc 2010;40(3):203-208. Published online March 30, 2010

Abstract PDF: Eosinophilic colitis is a chronic inflammatory bowel condition of unknown etiology and a rare subtype of eosinophilic gastrointestinal diseases. It is characterized by gastrointestinal symptoms and increased eosinophil numbers in the intestinal mucosa and absence of other potential causes of gastrointestinal eosinophilia. The clinical presentation is varied and depends on the involved layer of the large intestine. There are no confirmatory laboratory tests, and the morphologic evaluation of biopsies or surgical specimens is required to confirm the diagnosis. A 65-year-old man presented with an 8 day duration of bloody diarrhea and lower abdominal pain. The patient was diagnosed with eosinophilic colitis by histopathological evaluation of biopsies and was further categorized as a nonatopic variant associated with non-IgE-mediated reaction. The patient was successfully treated with systemic corticosteroid for 2 weeks. On follow-up after 9 months, the patient remained well without relapse or new lesions. (Korean J Gastrointest Endosc 2010;40:203-208)

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Removal of a Common Bile Duct Stone Using ERCP without Fluoroscopic Guidance in a Pregnant Woman: So Young Park, M.D., Kyo-Sang Yoo, M.D., Kyeong Min Son, M.D., Kyung-Hun Lee, M.D., Kyung-Rim Huh, M.D., Kyoung Oh Kim, M.D., Cheol Hee Park, M.D. and Jong Hyeok Kim, M.D.; Korean J Gastrointest Endosc 2010;40(3):209-213. Published online March 30, 2010

Abstract PDF: Pregnancy causes alterations in bile compositions and, an increased incidence of cholelithiasis and the complications related to it. This often requires endoscopic interventions such as endoscopic retrograde cholangiopancreatography (ERCP), but the radiation exposure during the ERCP may be harmful to the fetus. We report here on a case of successful ERCP and therapeutic endoscopic intervention without fluoroscopic guidance for a pregnant woman with common bile duct stone that was complicating her biliary pancreatitis. (Korean J Gastrointest Endosc 2010;40:209- 213)

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Successful Endoscopic Papillary Balloon Dilatation for a Patient with Recurrent Sump Syndrome: Ki Shik Shim, M.D., Tae Hyo Kim, M.D., Kyoung Ah Jung, M.D., In Kyu Moon, 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 2010;40(3):214-218. Published online March 30, 2010

Abstract PDF: Sump syndrome is a rare late complication of choledochoenteric anastomosis, and this caused by the accumulation of food debris, choledocholithiasis, bile sludge and cholesterol crystals in the distal common bile duct. This syndrome is characterized by symptoms such as abdominal pain and fever. The treatment modality for this syndrome has been surgery in the past. However, endoscopic treatment such as endoscopic sphinterotomy is currently regarded as the primary therapeutic approach for this condition. We experienced a patient with a history of choledochoduodenostomy and who developed sump syndrome as a complication of the surgery. Endoscopic sphinterotomy was performed for treatment, but this only produced the recurrence of the disease. The recurrent sump syndrome was eventually successfully controlled by performing endoscopic papillary balloon dilatation. (Korean J Gastrointest Endosc 2010;40:214-218)

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