Clinical Endoscopy

Gastrointestinal Lymphoma: Sang Gyun Kim, M.D.; Korean J Gastrointest Endosc 2010;41(1):1-4. Published online July 31, 2010

Abstract PDF: Gastrointestinal lymphoma is the leading cause of extranodal lymphoma. Gastric lymphoma is very common in patients with gastrointestinal lymphoma, and diffuse large B-cell lymphoma and marginal zone B-cell lymphoma of the mucosa- associated lymphoid tissue (MALT) are the most common histological types. Helicobacter pylori (H. pylori) has been implicated in the pathogenesis of MALT lymphoma, and eradication of H. pylori has successfully resulted in the remission of MALT lymphoma. In the cases of H. pylori-negative MALT lymphoma or advanced gastric lymphoma, radiation therapy and/or chemotherapy can be used to treat the disease and achieve remission. (Korean J Gastrointest Endosc 2010;41:1-4)

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Recent Eradication Rates of First-line Triple Regimens for H. pylori Infection: Na Young Paek, M.D.*, Yun Jeong Lim, M.D., Jong Ho Lee, M.D., Ji Hun Kang, M.D., Jeong Bae Park, M.D. and Jin Ho Lee, M.D.; Korean J Gastrointest Endosc 2010;41(1):5-9. Published online July 31, 2010

Abstract PDF: Background
/Aims: Decreasing trend of eradication rate of H. pylori using first-line triple regimens (proton pump inhibitor, amoxicillin, clarithromycin) has been issued. Longer therapies may become more popular if there are better results. Recent eradication rate should be examined and proper recommendation should be timely done according to the result.
Methods
We examined recent eradication rates of first-line triple regimens and compared eradication rate according to the duration of this first-line therapy for H. pylori infection. The 976 patients received first-line triple therapy at the single center from November, 2005 to October, 2009 were retrospectively analyzed. Urea breath test was done at four to six weeks after completion of eradication therapy.
Results
Overall eradication rate of triple regimen by intention to treat analysis was 80.4% (785/976). One week eradication rate has decreasing trend and below 73.3% during recent 2 years. Eradication rate in 2 weeks group (83.3%, 165/198) was significantly higher than 1 week group (73.3%, 198/270) from November, 2007 to October, 2009 (p＜0.01).
Conclusions
Our results showed that 2 weeks triple regimen should be preferred as first-line therapy for H. pylori eradication. (Korean J Gastrointest Endosc 2010; 41:5-9)

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A Clinical Usefulness of Premedication with Hyoscine N-butyl Bromide in Colonoscopy: Eun Ok Kim, M.D., Suck-Ho Lee, M.D., Duk Su Kim, M.D., Chang Kyun Lee, M.D., Tae Hoon Lee, M.D., Il-Kwun Chung, M.D., Sang-Heum Park, M.D. and Sun-Joo Kim, M.D.; Korean J Gastrointest Endosc 2010;41(1):10-15. Published online July 31, 2010

Abstract PDF: Background
/Aims: We conducted a prospective, randomized, double-blinded, placebo-controlled trial to investigate the effect of hyoscine-N-butyl bromide during colonoscopy.
Methods
A total of 133 patients undergoing colonoscopy were randomized to receive either 20 mg of hyoscine-N-butyl bromide (n=70) or normal saline solution (n=63) via intramuscular injection as premedication.
Results
The mean cecal intubation time and withdrawal time in the hyoscine- N-butyl bromide group were significantly shorter than those of the control group (5.26±2.78 min vs. 6.74±4.89 min; p=0.032, 5.42±1.54 min vs. 6.18±2.54 min; p=0.038, each). The spasm grade in the hyoscine-N-butyl bromide group was significantly lower than that of the control group (p＜0.001). No significant differences were found in the polyp detection rate (15.7% vs. 28.6%; p=0.073) and adenoma detection rate (10.0% vs. 15.9%; p=0.311). Difficulty of colonoscopy for the endoscopists and nurses (p=0.853; p=0.732), the patient's comfort (p=0.891) and the patient's willingness to repeat colonoscopy (85.7% vs. 82.5%; p=0.932) were also similar in both groups.
Conclusions
Premedication with intramuscularly administered hyoscine-N-butyl bromide do not demonstrate any additional benefits except reducing the colonoscopy insertion time. (Korean J Gastrointest Endosc 2010;41:10-15)

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A Case of Incidentally Found Primary Esophageal Bezoar in a Patient with Situs Inversus Totalis: Yong Chan Cho, M.D., Won Jung Jun, M.D., Hyung Il Kim, M.D., Sung Kyun Kim, M.D., Hyen Soo Kim, M.D., Sung Kyu Choi, M.D. and Jong Sun Rew, M.D.; Korean J Gastrointest Endosc 2010;41(1):16-20. Published online July 31, 2010

Abstract PDF: Situs inversus totalis (SIT) is very rare autosomal recessive condition, and patients with SIT have complete mirror image reversal of the thoracic and abdominal viscera. There have been no case reports of esophageal bezoar in a patient with situs inversus totalis. Bezoars are retained concretions of indigestible foreign material, including food material, vegetable material and hair, and they are usually founded in the stomach, small intestine and rectum. Esophageal bezoars are very rare, but they are known to occur in patients with anatomical defects or esophageal motility disorders. The treatment of esophageal bezoar is usually based on endoscopic fragmentation and extraction, dissolution with papain, cellulose, pancreatic enzyme and/or Coca cola. We report here on a case of an endoscopically treated primary esophageal bezoar in a patient with situs inversus totalis, and the patient experienced no complications from the treatment. (Korean J Gastrointest Endosc 2010;41:16-20)

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Malignant Transformation of Gastric Gastrointestinal Stromal Tumor in 44 Months Observational Period: A Case Report: Choong Heon Ryu, M.D., Ji Hyun Kim, M.D., Kwan Sik Park, M.D., Hyo Rim Seo, M.D., Yun Jung Choi, M.D., Seoung In Ha, M.D., Yoon Jung Kim, M.D. and Sang Young Seol, M.D.; Korean J Gastrointest Endosc 2010;41(1):21-25. Published online July 31, 2010

Abstract PDF: Gastrointestinal stromal tumor is a common type of gastrointestinal mesenchymal tumor. Depending on the patient's age, compliance and health status, and the level of suspicion of malignancy, tumors ≤3 cm in size are typically monitored annually by endoscopic ultrasonography. The examination interval can be extended if no size change is noted on consecutive examinations. We report here on a 44-year-old female who presented with abdominal discomfort and displayed no size change of her gastrointestinal stromal tumor on three consecutive endoscopies over a 44- month interval. The patient was diagnosed with malignant gastrointestinal stromal tumor on the basis of the evident ulceration seen on esophagogastroduodenoscopy and the inhomogenous echo noted on the endoscopic ultrasonography and the pathologic findings by gastric wedge resection. (Korean J Gastrointest Endosc 2010;41:21-25)

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A Case of Duodenal Gastrointestinal Stromal Tumor Mimicking a Vascular Neoplasm: Jung Kyung Yang, M.D., Yong Seok Kim, M.D., Hoon Sup Koo, M.D., Kwang Il Kim, M.D., Sun Moon Kim, M.D., Euyi Hyeog Im, M.D., Kyu Chan Huh, M.D. and Sang Eok Lee, M.D.*; Korean J Gastrointest Endosc 2010;41(1):26-30. Published online July 31, 2010

Abstract PDF: Gastrointestinal stromal tumors (GIST) are the most common mesenchymal neoplasm of the gastrointestinal tract. They are preferentially located in the stomach and small intestine. However, the duodenum is an unusual location for GIST. Here we present a case of a 67-year-old woman with a GIST of the 3rd portion of duodenum mimicking vascular neoplasm as an obscure acute gastrointestinal bleeding. The upper gastrointestinal endoscopy and colonoscopy failed to find the lesion. Finally, a large protruded lesion with ulcer was found at the 3rd portion of duodenum using a colonoscope through the oral approach. A spurting bleeding was developed during hypertonic saline epinephrine injection for treatment of oozing bleeding at the margin of the ulcer. Abdominal 3D CT-angiography showed a round and hypervascular structure at the posterior wall of duodenum. A wedge resection of the third portion of the duodenum was performed. Microscopic findings revealed GIST. (Korean J Gastrointest Endosc 2010;41:26-30)

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A Case of Successful Embolization with Superselection by Endoscopic Hemoclipping for Pseudoaneurysmal Bleeding in a Patient with Pylorus Preserving Pancreaticoduodenectomy: Yong Hun Kim, M.D., Chang-Il Kwon, M.D., Sae Kyung Joo, M.D., Won Hee Kim, M.D., Hong Gern Bin, M.D., Man Deuk Kim, M.D. and Seong Gyu Hwang, M.D.; Korean J Gastrointest Endosc 2010;41(1):31-35. Published online July 31, 2010

Abstract PDF: Arterial bleeding after pancreaticoduodenectomy is a very serious complication with high mortality. Therefore, early diagnosis and treatment is essential. In particular, early detection and immediate embolization can be effectively used for the delayed massive bleeding that occurs from a pseudoaneurysmal rupture. However, sometimes intermittent bleeding or a vessel spasm can cause the bleeding focus to remain unidentified in spite of repeated angiography. We experienced a case of successful embolization with superselection by endoscopic hemoclipping in a patient who underwent pylorus preserving pancreaticoduodenectomy, and the patient's bleeding focus was not found after repeated angiography. Endoscopic hemoclip application can be useful for localizing a pseudoaneurysmal rupture in patients with pancreaticoduodenectomy. (Korean J Gastrointest Endosc 2010;41:31-35)

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A Case of Hamartomatous Polyp without Peutz-Jeghers Syndrome Arising from Appendix: Wee Sik Sohn, M.D., Ju Sang Park, M.D., Ji Eun Kim, M.D., Bong Hwan Kim, M.D., Seung Hee Yoo, M.D. and Eun Mee Han, M.D.*; Korean J Gastrointest Endosc 2010;41(1):36-40. Published online July 31, 2010

Abstract PDF: Peutz-Jeghers syndrome is a familial syndrome consisting of mucocutaneous pigmentation and gastrointestinal polyposis and appears to be inherited as a single pleiotropic autosomal dominant gene with variable and incomplete penetrance. Cases of hamartomatous polyps of the Peutz-Jeghers type without Peutz-Jeghers syndrome have only rarely been reported. Moreover, only one case of a Peutz-Jeghers polyp at the appendix has been reported; it was resected by appendectomy. We report here on a case of a 45 year old man who had a hamartomatous polyp of the Peutz-Jeghers type arising from the appendix. The polyp was successfully removed by endoscopic polypectomy. To our knowledge, this is the first case of a hamartomatous polyp of the Peutz-Jeghers type that originated from the appendix and that was resected endoscopically. (Korean J Gastrointest Endosc 2010;41:36-40)

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A Case of Esophageal Lymphoepithelioma-like Carcinoma: Sunha Bahng, M.D., Jun Haeng Lee, M.D., Eun Kyoung Kim, M.D., Sung Bum Park, M.D., Silvia Park, M.D. and Kyoung Mee Kim, M.D.*; Korean J Gastrointest Endosc 2010;41(1):41-44. Published online July 31, 2010

Abstract PDF: Lymphoepithelioma-like carcinoma (LELC) of the esophagus is an extremely rare tumor and the prognosis is favorable. We present here a case an esophageal LELC that showed no definite progression for 5 years. An esophageal tumor was found during screening endoscopy for a 72-year-old asymptomatic Korean woman. At first the histology showed no abnormal findings. No treatment was done for the lesion. Five years later, a follow-up endoscopy showed the same tumor in the esophagus. The size and shape of the esophageal tumor seemed unchanged during the follow-up. The lesion was a round elevated lesion that measured approximately 2.5 cm in the lower esophagus. The covering mucosa looked smooth, but there were erosions on top of the tumor. Biopsy showed an undifferentiated carcinoma associated with a dense lymphocytic and plasma cell infiltration, which are typical findings of LELC. (Korean J Gastrointest Endosc 2010;41:41-44)

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Three Cases of Endoscopic Mucosal Resection of Rectal Carcinoid Tumor by Band Ligation and the Snare Resection Technique: Young Hwa Jo, M.D., Ji Hun Roh, M.D., Dong Young Goo, M.D., Jae Hoon Yoo, M.D., Ki Soo Kim, M.D., Young Min Shin, M.D., Sung Hoon Kim, M.D. and Ji Eun Park, M.D.; Korean J Gastrointest Endosc 2010;41(1):45-51. Published online July 31, 2010

Abstract PDF: Many reports have shown that endoscopic polypectomy or endoscopic mucosal resection can successfully remove tumor less than 1.0 cm in size. However, most carcinoid tumors in the rectum occur in the submucosal layer so that the entire tumor cannot be completely removed via endoscopic polypectomy or endoscopic mucosal resection. Endoscopic mucosal resection can also cause perforation of the intestinal wall and bleeding. Due to these reasons, instead of these two conventional methods, endoscopic mucosal resection using a ligation device is currently being used for the treatment of rectal carcinoid tumor. Recent studies that used this method have reported that endoscopic mucosal resection of rectal carcinoid tumor by band ligation and the snare resection technique is safe with minimal complications and this is quite useful to completely remove rectal carcinoid tumor. (Korean J Gastrointest Endosc 2010;41:45-51)

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Three Cases of Appendicitis Diagnosed by Colonoscopy in Patients with Atypical Presentations: Seong Dong Sohn, M.D., Young Woon Chang, M.D., Kun Hyung Cho, M.D., Young Hwangbo, M.D., Jaejun Shim, M.D., Jae Young Jang, M.D., Hyo Jong Kim, M.D. and Byung Ho Kim, M.D.; Korean J Gastrointest Endosc 2010;41(1):52-55. Published online July 31, 2010

Abstract PDF: The diagnostic considerations are broad for patients who clinically present with obscure abdominal pain. Acute appendicitis can be diagnosed according to the clinical signs and symptoms, yet this can often be extremely challenging. Difficulties particularly arise when the presentation is atypical. Investigations that may help include laboratory tests, non-invasive imaging and laparoscopy. We experienced 3 cases of acute appendicitis that were diagnosed by colonoscopy. The colonoscopy revealed a bulging of the appendix into the cecal lumen. The mucosa was erythematous and edematous with pus draining from the appendiceal orifice. These findings were suggestive of appendicitis, which was confirmed after surgical appendectomy. In our experience, making the colonoscopic diagnosis of appendicitis might be helpful for patients with atypical symptoms, but colonoscopy should not be used for the diagnosis in the beginning if appendicitis is initially suspected. (Korean J Gastrointest Endosc 2010;41:52-55)

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A Case of Simple Ulcer of the Terminal Ileum Successfully Treated by Monoclonal Antibody to Tumor Necrosis Factor-Ձ (Infliximab): Seok Jong Lee, M.D., Woo Chul Chung, M.D., Kang Moon Lee, M.D., You Suk Oh, M.D., Eun Jung Kim, M.D., Kang Hyun Choi, M.D. and Chang Nyol Paik, M.D.; Korean J Gastrointest Endosc 2010;41(1):56-60. Published online July 31, 2010

Abstract PDF: Nonspecific and idiopathic ulcer of the small bowel or colon is a rare condition, and it is the so called "simple ulcer" when the patients do not have systemic symptoms of Behcet's syndrome. Differentiation of simple ulcer from intestinal Behcet's disease according to the endoscopic and pathologic findings is often impossible and the clinical course of the 2 maladies is similar. A 51-year-old man presented with low abdominal pain, and colonoscopy revealed a huge deep ulceration with an entero-enteric fistula in the terminal ileum. He was diagnosed with simple ulcer without the constitutional symptoms of Behcet's syndrome. He was refractory to conventional therapy with corticosteroids and antibiotics, and so he required surgical resection. Monoclonal antibody against tumor necrosis factor-Ձ (Infliximab) was administered at 0, 2 and 6 weeks. His symptoms were relieved after the therapy and the ulceration had completely resolved after 1 year. He was entirely asymptomatic at the 36 month follow up. (Korean J Gastrointest Endosc 2010;41:56-60)

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A Case of Lymphoid Polyp in the Ampulla of Vater Associated with Tubulopapillary Adenoma: Ji Ho Kim, M.D., Jei So Bang, M.D., Jong Hoon Byun, M.D., Su Hyun Yang, M.D., Sung Hoon Kim, M.D., Ji Sun Jang, M.D. and Yoon Jung Kim, M.D.*; Korean J Gastrointest Endosc 2010;41(1):61-64. Published online July 31, 2010

Abstract PDF: Lymphoid polyp is a very rare disease that commonly occurs in the rectum. It is a benign, focal or diffuse lesion that typically occurs where clusters of lymphoid follicles are present. The polyp is composed of well differentiated lymphoid tissue. It can generally be differentiated from malignant lymphoma by the proliferation of normal lymphoid tissue, which has a prominent follicular pattern and a clearly defined germinal center. There have been only a few reports of lymphoid polyps of the rectum, and there have been no reports of lymphoid polyp in the ampulla of Vater. We experienced a case of lymphoid polyp in the ampulla of Vater associated with tubulopapillary adenoma, and the patient first presented with jaundice, weight loss and general weakness. (Korean J Gastrointest Endosc 2010;41:61-64)

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