Clinical Endoscopy

Quality Control for Upper Gastrointestinal Endoscopy: Jae Myung Park, M.D.; Korean J Gastrointest Endosc 2010;40(6):343-346. Published online June 30, 2010

Abstract PDF: Upper gastrointestinal endoscopy is the most common procedure in the field of gastroenterology. Controlling the quality of endoscopy is quite important because gastric cancer is the most prevalent cancer in Korea. For each endoscopic procedure, the indicators of quality control can be considered for 3 time periods: the preprocedure, intraprocedure and postprocedure periods. The common issues during preprocedure include the proper indications, the patient's consent for the procedure, the patient's clinical status and the risk assessment, and the steps to reduce the risk. The common issues during intraprocedure include all the technical aspects of the procedure, including completion of the examination and any of the therapeutic maneuvers. The postprocedure activities include providing instructions to the patient, documentation of the procedure, recognition and documentation of complications, follow-up of the pathologic conditions and assessing the patient's satisfaction. Regular monitoring the quality of endoscopy can raise the level of performing endoscopic procedures.(Korean J Gastrointest Endosc 2010;40:343-346)

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Clinical Characteristics of Gastrointestinal Carcinoid Tumors: Myoung Hee Lee, M.D., Sung Jae Shin, M.D., Su Jin Jeon, M.D., Sun-Gyo Lim, M.D., Yoon Chul Lee, M.D., Jae Chul Hwang, M.D., Kee Myung Lee, M.D., Kwang Jae Lee, M.D. and Jin Hong Kim, M.D.; Korean J Gastrointest Endosc 2010;40(6):347-351. Published online June 30, 2010

Abstract PDF: Background
/Aims: Various factors have been reported that can predict the clinical course and outcome of patients with gastrointestinal (GI) carcinoid tumors. We analyzed the clinical characteristics of GI carcinoid tumors and the factors associated with metastasis.
Methods
We retrospectively analyzed the clinical manifestations, treatment modalities and prognosis of 83 patients with GI carcinoid tumors.
Results
The mean age of the patients was 48 years old. The locations of the carcinoid tumors were rectum (n=60), stomach (n=12), duodenum (n=6), appendix (n=4) and colon (n=1). The most common symptom was non-specific (n=65, 79.5%), and the mean tumor size was 11.2 mm. The main treatment modality was endoscopic resection (n=66, 79.5%). Nine patients showed metastasis, and all of their tumors were larger than 2 cm. Univariate analysis revealed that size, ulceration and invasion of the proper muscle layer were significant factors associated with metastasis. Tumor size (p=0.001) was the only independent factor on multivariate analysis.
Conclusions
The diagnosis of small sized, asymptomatic GI carcinoid tumors has increased and endoscopic treatment was a useful modality. Tumor size was a predictive factor for metastasis. (Korean J Gastrointest Endosc 2010;40:347-351)

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Changes in Indications and Diagnostic Rates of Capsule Endoscopy in a Single Center: Tae Hee Lee, M.D., Jin-Oh Kim, M.D., Hyun Gun Kim, M.D., Hyun Sook Choi, M.D., Wan Jung Kim, M.D., Young Kwan Cho, M.D., Won Young Cho, M.D., Bong Min Ko, M.D., Joo Young Cho, M.D., Joon Seong Lee, M.D. and Moon Sung Lee, M.D.; Korean J Gastrointest Endosc 2010;40(6):352-356. Published online June 30, 2010

Abstract PDF: Background
/Aims: The aim of this study was to investigate changes with time in indications for capsule endoscopy examinations (CEs) and diagnostic rates.
Methods
We retrospectively reviewed medical records of 425 CEs (417 patients), which were done for several different indications between March 2003 and May 2009. Indications, bowel cleansing, complete CEs, and diagnostic rates were compared between the first half (2003∼2005) and the second half (2006∼2009) of the study period.
Results
Overt bleeding and occult bleeding, respectively, accounted for 31% and 5.8% in the first half; and 45.4% and 12.4% in the second half. The differences were significant (p＜0.05). Other indications were significantly decreased in the second half compared to the first half (29.6% and 7.7% respectively). Bowel cleansing was considered "adequate" in 48% in the first half vs. 61.6% in the second half (p＜0.05). No significant difference was found in complete CE rates. There was a significant difference in diagnostic rates between the first half and the second half (23.8% and 43.9%, respectively).
Conclusions
Cumulative experience and knowledge with CEs has led to an increased number of CEs for obscure bleeding and a decreased number of CEs for other indications in which the role of CEs was unclear. Improved diagnostic rates of CEs were accompanied by these changes in CEs indications. (Korean J Gastrointest Endosc 2010;40:352-356)

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A Case of Aortoesophageal Fistula Complicated by a Stent for Benign Esophageal Stricture: Ja Won Kim, M.D., Sung Jo Bang, M.D., Do Ha Kim, M.D., Hee Chul Jung, M.D., Ssang Yong Oh, M.D., Sang Jin Lee, M.D., Ji Eun Lee, M.D. and Jeong Hoon Lee, M.D.; Korean J Gastrointest Endosc 2010;40(6):357-360. Published online June 30, 2010

Abstract PDF: Self-expandable metallic stents (SEMS) are widely used for the palliative treatment of malignant strictures of the gastrointestinal tract. Recently, several studies tested whether a SEMS is an effective and safe option for benign esophageal stricture. 　Serious complications such as hemorrhage, compression of the bronchus, bronchoesophageal fistula, and esophageal rupture were infrequently encountered as complications of esophageal stent placement. Aortoesophageal fistula is extremely rare as a complication of esophageal SEMS insertion; only seven cases have been reported worldwide. We now report a case of an 80-year old female with aortoesophageal fistula after placement of a SEMS for an esophageal stricture. (Korean J Gastrointest Endosc 2010;40:357-360)

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Cowden's Disease Detected by Gastric Polyposis during Endoscopy in a Routine Check Up: A Case Report: Ji Eun Yi, M.D., Dae Hyeon Cho, M.D., Jae Gon Woo, M.D., Oh Un Kwon, M.D., Kyoung Won Jung, M.D., Chang Wook Jung, M.D., Gil Jong Yoo, M.D. and Sang Goon Sim, M.D.; Korean J Gastrointest Endosc 2010;40(6):361-365. Published online June 30, 2010

Abstract PDF: Cowden's disease, a rare autosomal dominant disorder characterized by benign hamartomatous overgrowth of various tissues, increases the risk of cancer of the thyroid, breast, endometrium, prostate, and possibly other organs. Generally, germline mutations in the coding sequence for PTEN are found in 80% of patients with Cowden's disease. Here we report a rare case of incidentally discovered gastric polyposis during esophagogastroscopy for medical screening in a patient with a history of surgery for breast and thyroid cancer. Identifyng the mutation in the PTEN gene to a diagnosis of Cowden's disease. (Korean J Gastrointest Endosc 2010;40:361-365)

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An Intramural Gastric Hematoma after Epinephrine Injection for Gastric Ulcer Bleeding in Patient with Liver Cirrhosis: Hyeong Cheol Cheong, M.D., Tae Hyeon Kim, M.D., Jin Soo Chung, M.D., Tae Hyun Kim, M.D., Bong Jun Yang, M.D., Hyo Jung Oh, M.D. and Yong Woo Sohn, M.D.; Korean J Gastrointest Endosc 2010;40(6):366-369. Published online June 30, 2010

Abstract PDF: Intramural hematoma of the gastrointestinal tract is an uncommon occurrence with the majority being localized to the esophagus or duodenum. Hematoma of the gastric wall is very rare, and has been reported most commonly in association with coagulopathy, trauma, hematologic disease, and therapeutic endoscopy. Here we describe a case of intramural gastric hematoma after epinephrine injection therapy for a gastric ulcer with underlying liver cirrhosis that was successfully managed with conservative therapy. (Korean J Gastrointest Endosc 2010;40:366-369)

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A Huge Gastric Bezoar That Was Removed by Endoscopic Combination Therapy with an Argon Plasma and Coca-Cola Injection: Jung Hoon Kim, M.D., Won Ki Bae, M.D., Hyoung Don Lee, M.D., Jung Bok Park, M.D., Nam-Hoon Kim, M.D., Kyung-Ah Kim, M.D., June Sung Lee, M.D. and Young Soo Moon, M.D.; Korean J Gastrointest Endosc 2010;40(6):370-373. Published online June 30, 2010

Abstract PDF: Bezoars are collections or concretions of indigestible foreign material in the gastrointestinal tract. In the past, the most common method for the treatment of bezoar was surgical management. The current treatment methods for bezoars include chemical dissolution and endoscopic lithotripsy using biopsy forceps and, snare, electrohydraulic lithotripsy and laser. Cases of endoscopic fragmentation of gastric bezoars using an argon plasma and dissolution of gastric bezoars with Cola have recently been described, but it took a long time in those cases to remove a bezoar by a single method. Moreover, fragmented, residual bezoar-related complications sometimes occurred. We report here on a case of a 35-year-old man with a 10×8×8 cm sized huge gastric bezoar that was successfully removed by combination therapy using an argon plasma and Coca-Cola injection. Compared with the previous single method, combination therapy using an argon plasma and Coca-Cola injection shortened the procedure time and reduced the complications related to a fragmented, remaining bezoar. (Korean J Gastrointest Endosc 2010; 40:370-373)

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Systemic Sarcoidosis Associated with Early Gastric Cancer: Kyung-Hun Lee, M.D., Kyoung-Oh Kim, M.D., Yu Jin Kim, M.D., Jae Hyung Lee, M.D., Kwang Pyo Son, M.D.,Kyung Rim Huh, M.D., Cheol Hee Park, M.D. and Jong Hyeok Kim, M.D.; Korean J Gastrointest Endosc 2010;40(6):374-377. Published online June 30, 2010

Abstract PDF: For a potentially malignant lymphadenopathy, it is clinically important to distinguish between metastasis of a primary tumor and a benign lesion such as systemic sarcoidosis or sarcoid reaction. We describe here a case of systemic sarcoidosis that was associated with early gastric cancer. A patient was found to have early gastric cancer (EGC) during routine clinical examination. The chest radiography demonstrated bilateral hilar lymphadenopathy and further examination showed that he had multiple lymphadenopathies. We diagnosed systemic sarcoidosis with EGC because of the elevated serum ACE-I, the chest CT findings and the pathological analysis. We performed endoscopic submucosal dissection (ESD) for EGC, and there was no local recurrence and distant metastasis for eighteen months. These findings suggest that the possibility of systemic sarcoidosis should be considered in cases with established malignancy and multiple lymphadenopathies. (Korean J Gastrointest Endosc 2010;40:374-377)

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A Case of Pneumatosis Intestinalis in a Chordoma Patient with Tetraplegia: Hye Min Yang, M.D.*, Yun Jeong Lim, M.D., Yong Seok Lee, M.D.^† and Jin Ho Lee, M.D.; Korean J Gastrointest Endosc 2010;40(6):378-381. Published online June 30, 2010

Abstract PDF: Pneumatosis cystoides intestinalis (PCI) is an uncommon clinical condition of undetermined etiology that is characterized by multiple subserosal or submucosal gas-filled cysts. PCI may be associated with gastrointestinal, pulmonary or connective vascular diseases. The clinical manifestations are non-specific. PCI is diagnosed by plain X-ray or CT of the abdomen. The clinical course and prognosis are usually good. Complications such as intestinal obstruction, intussusceptions and bowel perforation can occur in rare cases. Here we report a case of PCI in a chordoma patient with tetraplegia who complained of abdominal distension. The patient was diagnosed by plain X-ray which showed bubbles in the small bowel. The abdominal distension and the bubbles were markedly improved by conservative treatment. (Korean J Gastrointest Endosc 2010;40:378-381)

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A Case of Rectal Implantation Cysts at an Anastomosis Site after Laparoscopic Low Anterior Resection for a Rectal Cancer: Hee Sun Lee, M.D., Geun Am Song, M.D., In Hye Hwang, M.D., Yang Seon Yi, M.D., Kyung Hwa Shin, M.D., Bo Kyung Choi, M.D., Gwang Ha Kim, M.D. and Do Youn Park, M.D.*; Korean J Gastrointest Endosc 2010;40(6):382-386. Published online June 30, 2010

Abstract PDF: Rectal implantation cysts can be caused by continued growth in the submucosa of traumatically misplaced columnar epithelium during previous surgery. Cases of implantation cyst occurring at the site of anastomosis have rarely been reported. Rectal implantation cysts occurring at an anastomosis site after a low anterior resection for rectal cancer need to be distinguished from locally recurrent rectal cancer. Here we present a case of rectal implantation cysts in a patient with rectal cancer who underwent laparoscopic low anterior resection 9 months previously. The diagnosis was made according to the characteristic image findings of endoscopic ultrasonography and enodsocopic ultrasonography-guided fine needle aspiration. This is the first case report of rectal implantation cyst in Korea. (Korean J Gastrointest Endosc 2010;40:382-386)

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A Case of Splenic Pseudoaneurysmal Rupture Misrecognized as Bleeding from Gastric Submucosal Tumor: Kwang Jae Lee, M.D., Tae Yeong Lee, M.D., Young Seok Bae, M.D., Dong Wan Kim, M.D., Jung Bin Yoon, M.D., Sang Hoon Bae, M.D., Dong Hyun Kim, M.D. and Seok Reyol Choi, M.D.*; Korean J Gastrointest Endosc 2010;40(6):387-390. Published online June 30, 2010

Abstract PDF: Splenic arterial pseudoaneurysm is an uncommon life-threatening complication of acute and chronic pancreatitis. Pseudoaneurysm can lead to massive bleeding into the abdominal cavity and the retroperitoneum. Less commonly, it may rupture directly into the stomach, small bowel or pancreatic duct and may present as an acute gastrointestinal hemorrhage. It can be diagnosed by various imaging modalities including computerized tomography, ultrasound and angiography. Percutaneous transvascular embolization of the pseudoaneurysm is one of the alternative treatment methods. Here we present a case of splenic arterial pseudoaneurysmal rupture misrecognized as bleeding from a gastric submucosal tumor in patient with hematemesis. We also review the literature. (Korean J Gastrointest Endosc 2010;40:387-390)

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A Case of Ampullary Adenomyoma Associated with Dilatations of Pancreatic and Biliary Ducts: Byung Uk Lee, M.D., Jei So Bang, M.D., Soo Hyun Yang, M.D., Ji Ho Kim, M.D., Jong Hoon Byun, M.D., Won Keun Si, M.D., Moon Hyung Lee, M.D. and Bo Kyoung Choi, M.D.; Korean J Gastrointest Endosc 2010;40(6):391-395. Published online June 30, 2010

Abstract PDF: Adenomyoma is a nonneoplastic lesion that can be found anywhere in the gastrointestinal tract, but it's rarely found in the ampulla of Vater. To the best of our knowledge, it is a benign lesion, but most cases are misdiagnosed as carcinoma or adenoma by a preoperative endoscopic or radiologic procedure, and this leads to unnecessarily extensive surgical resection. We report here on a case of ampulla of Vater adenomyoma that resulted in biliary and pancreatic duct dilatation. The tumor was diagnosed by endoscopic papillectomy. (Korean J Gastrointest Endosc 2010;40:391-395)

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A Case of Tubular Adenoma of the Common Hepatic Duct Accompanied with Gallbladder Carcinoma: Jun Ho Choi, M.D., Tae Hoon Lee, M.D., Sang-Heum Park, M.D., Yun Suk Shim, M.D., Chang Kyun Lee, M.D., Suck-Ho Lee, M.D., Sun-Joo Kim, M.D. and Hyun-Deuk Cho, M.D.*; Korean J Gastrointest Endosc 2010;40(6):396-400. Published online June 30, 2010

Abstract PDF: Biliary adenoma is rarely found in the biliary tract, and there are currently few reported cases of tubular adenoma. Biliary adenoma most often occurs on the duodenal ampulla and the next most common site is on the common bile duct. Because the clinical signs, symptoms and the laboratory findings of these lesions may be similar to malignant biliary diseases, it is difficult to differentiate benign biliary adenoma from malignancy. Therefore, the diagnosis of these tumors tends to be delayed and physicians usually make the pathologic confirmation after a surgical operation. We experienced a case of the simultaneous occurrence of tubular adenoma of the common hepatic duct and gallbladder carcinoma, and all this was diagnosed and treated with common hepatic duct resection and a Roux-en-Y hepaticojejunostomy operation. To the best of our knowledge, this is the first report of biliary tubular adenoma accompanied with gallbladder carcinoma arising from tubulovillous adenoma. (Korean J Gastrointest Endosc 2010;40:396-400)

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