Clinical Endoscopy

Gastrointestinal Complication in Transplant Patients: Gun Min Kim, M.D., Dae Young Cheung, M.D., Ph.D. and Jin Il Kim, M.D., Ph.D.; Korean J Gastrointest Endosc 2010;41(2):65-71. Published online August 30, 2010

Abstract PDF: The gastrointestinal tract is one of the major sites for complications after solid organ and hematopoietic stem cell transplantation, and gastrointestinal complications are the principle cause of morbidity and death. The major gastrointestinal complications after transplantation include mucositis, typhlitis, infectious enterocolitis by virus, bacteria or fungus, pseudomembranous colitis, gastric ulcer, graft- versus-host disease, pneumatosis cystoides intestinalis, thrombotic microangiopathy and post-transplantation lymphoproliferative disease. Symptoms and signs of gastrointestinal complications following transplantation are often non-specific and present with varying severity. Moreover, the suppressed immune state often prohibits invasive studies including endoscopy and blurs the serologic and hematologic results. Therefore, it is hard to reach accurate diagnoses even after thorough investigations. Almost all immunosuppressive drugs can lead to gastrointestinal complications and we need proper strategies to minimize their side effects. On the one hand, we can expect better organ and patient survival through the judicious use of a broad range of immunosuppressive drugs; on the other hand, we should try to not ruin survival through proper precautions and early treatment of gastrointestinal complications following successful transplantation. (Korean J Gastrointest Endosc 2010;41:65-71)

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Clinical Characteristics of Bleeding Peptic Ulcer in Elderly Patients: Experience at a Single Secondary Referral Center: Dong Wook Choi, M.D., Sung Joon Lee, M.D., Hee Jung Kim, M.D., Dae Joon Chung, M.D., Myoung Ok Park, M.D., Soo Chul Park, M.D., Dae Hee Choi, M.D. and Chang Don Kang, M.D.; Korean J Gastrointest Endosc 2010;41(2):72-78. Published online August 30, 2010

Abstract PDF: Background
/Aims: Bleeding peptic ulcer in elderly patients is believed to differ from that found in younger patients. The purpose of this study was to evaluate the characteristics of bleeding peptic ulcer in elderly Korean patients.
Methods
We retrospectively evaluated 113 patients who were admitted to an emergency room for peptic ulcer bleeding from January 2006 to August 2008. For each patient, we investigated the clinical manifestations, the treatments and the hospital course.
Results
Peptic ulcer bleeding was more prevalent in elderly patients (n=63) than in younger patients (n=50). The elderly group had a higher incidence of comorbidities such as hypertension, stroke and ischemic heart disease, which might have be attributable to higher usage of aspirin and antiplatelet agents. There were no differences in the chief complaints or laboratory findings. The rate of Helicobacter pylori infection was lower in the elderly patients than that in the younger patients (41.3% vs. 62.0%, respectively, p=0.029). Four elderly patients and one younger patient died while in hospital, with one patient in each group dying due to bleeding.
Conclusions
Peptic ulcer bleeding in elderly patients was associated with higher usage of aspirin and antiplatelet agents. There were no significant differences between the elderly and younger patients for the initial clinical presentation, the hospital course or the mortality due to bleeding. (Korean J Gastrointest Endosc 2010;41:72-78)

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Characteristics of Lesions Misdiagnosed as Obscure Gastrointestinal Bleeding: Hyun Sook Choi, M.D., Jin Oh Kim, M.D., Dong Kyun Kim, M.D., Sung Ran Jeon, M.D., Yoon Ho Jung, M.D.,
Hyun Gun Kim, M.D., Tae Hee Lee, M.D., Won Young Cho, M.D., Wan Jung Kim, M.D., Bong Min Ko, M.D., Moon Sung Lee, M.D., Joo Young Cho,; Korean J Gastrointest Endosc 2010;41(2):79-84. Published online August 30, 2010

Abstract PDF: Background
/Aims: Double balloon enteroscopy (DBE) and capsule endoscopy (CE) are useful for evaluation of obscure gastrointestinal bleeding (OGIB). However, many bleeding sources within reach of conventional upper and lower endoscopes can be missed in patients who have undergone DBE and CE for OGIB. The aim of this study was to determine the incidence and characteristics of OGIB lesions within reach of a conventional endoscope in patients undergoing DBE and CE for the indication of OGIB.
Methods
This retrospective study included 134 patients who were evaluated for OGIB between March 2003 and May 2009 at Soonchunhyang University Hospital.
Results
Of the 134 patients, 76 underwent CE, 28 patients underwent DBE, and 30 underwent both CE and DBE. The incidence of OGIB lesions within reach of a conventional upper and lower endoscopy was 9.7% (n=13) and the mean age of patients was 51 years (range: 20 to 69 years). The most commonly missed lesion was duodenal ulcer (n=8). The other missed lesions were gastric ulcer (n=2), terminal ileal ulcer (n=2) and ileocecal valve ulcer (n=1).
Conclusions
The duodenum should be observed closely in initial upper and lower endoscopy by experienced endoscopists. Performing a second EGD and ileocolonoscopy before DBE and CE may increase the diagnostic yield and improve cost-effectiveness in patients with OGIB. (Korean J Gastrointest Endosc 2010;41: 79-84)

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Two Cases of Eosinophilic Esophagitis Treated with a Proton Pump Inhibitor and a Systemic Steroid: Jeong Rok Lee, M.D., Kyung Ho Song, M.D., Won Joong Jeon, M.D., Sang Jin Lee, M.D., Byung Hyo Cha, M.D., Jin Dong Kim, M.D., Young Nam Kim, M.D. and Chang Won Ha, M.D.*; Korean J Gastrointest Endosc 2010;41(2):85-89. Published online August 30, 2010

Abstract PDF: Eosinophilic esophagitis is a chronic inflammatory disorder characterized by dense eosinophilic infiltration of the esophageal mucosa. As an emerging disease during the last decade, eosinophilic esophagitis has gained increased recognition in both the medical and research communities. The pathogenesis is incompletely understood and food allergies and aeroallergens have been implicated. The most common clinical symptoms in adults are dysphagia and food impaction. We diagnosed two cases as eosinophilic esophagitis and treated them with a proton pump inhibitor and a systemic steroid. We confirmed improvements in clinical presentation and histologic findings and report these cases. (Korean J Gastrointest Endosc 2010;41:85-89)

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A Case of Endoscopic Removal of Hypopharyngeal Papilloma under General Anesthesia with Nasotracheal Intubation: Yoon Ho Jung, M.D., Joo Young Cho, M.D., Dong Kyun Kim, M.D., Young Kwan Cho, M.D., Won Young Cho, M.D., Jin Oh Kim, M.D., Joon Seong Lee, M.D. and So Young Jin, M.D.*; Korean J Gastrointest Endosc 2010;41(2):90-93. Published online August 30, 2010

Abstract PDF: Benign tumors of the hypopharynx are uncommon and papillomas are quite rare. Papillomas grow very slowly and they are well defined, mobile and sometimes pedunculated masses. In order to minimize the patient's discomfort, many endoscopists tend to pass the scope quickly through the throat, without trying to visualize the oral and hypopharyngeal lesion. As for the treatment of hypopharyngeal lesions, cases of endoscopic treatment are rare and any guidelines have not yet been defined. We present here a case of endoscopic removal of a hypopharyngeal papilloma with the patient under general anesthesia and nasotracheal intubation. (Korean J Gastrointest Endosc 2010;41:90-93)

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Metastatic Large Cell Neuroendocrine Carcinoma Combined with Gastric Adenocarcinoma: Kun Hyung Cho, M.D., Young Woon Chang, M.D., Seong Dong Sohn, 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(2):94-97. Published online August 30, 2010

Abstract PDF: A 67 year-old man was admitted due to findings that were suspicious for malignancy on gastroscopy at a primary clinic. We also performed gastroscopy and this showed the presence of a 3 cm sized nodular elevated lesion at the angle of the stomach. A biopsy demonstrated the presence of adenocarcinoma of the stomach. A distal gastrectomy with D2 lymph node dissection was performed and the microscopic features of the resected specimen confirmed the diagnosis of adenocarcinoma of the stomach and also metastatic large cell neuroendocrine carcinoma of lymph nodes of an unknown primary origin. Although double primary gastric adenocarcinoma and gastric neuroendocrine tumor with regional lymph node metastasis has been seldom reported, a double primary carcinoma of gastric adenocarcinoma and metastatic large cell neuroendocrine carcinoma of lymph nodes has seldom been reported. We report on this unusual case along with a review of the relevant medical literature. (Korean J Gastrointest Endosc 2010; 41:94-97)

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Gastric Wall Abscess Caused by a Fish Bone and Treated with Endoscopic Management: Won Jung Jun, M.D., Jong Sun Rew, M.D., Yong Chan Cho, M.D., Du Young Noh, M.D., Sung Kyun Kim, M.D., Hyen Soo Kim, M.D. and Sung Kyu Choi, M.D.; Korean J Gastrointest Endosc 2010;41(2):98-101. Published online August 30, 2010

Abstract PDF: Intramural gastric abscess is a rare condition representing a localized form of suppurative gastritis. According to the extent of the disorder, suppurative gastritis is classified into diffuse and localized types. The diffuse or phlegmonous type is more common and involves the entire stomach with inflammation spreading to all layers from the submucosa. The localized form referred to as "intramural gastric abscess" accounts for 5% to 15% of cases. The pathogenic mechanism includes direct invasion by microorganisms and hematogenous spread from a distant source. Cases are usually diagnosed with a combination of imaging modalities such as ultrasound, computed tomography, endoscopic ultrasound, and esophagogastroduodenoscopy. Herein we report a case of intramural gastric abscess that developed following ingestion of a fish bone. It was successfully treated with endoscopic incision and drainage of pus. (Korean J Gastrointest Endosc 2010;41:98-101)

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Two Cases of Unusual Infectious Peritonitis Mimicking Peritoneal Carcinomatosis of Early Gastric Cancer: Seung Bum Lee, M.D., Ho June Song, M.D., Suk Won Choi, M.D., Hoon Yu, M.D., Jeong Hoon Lee, M.D., Hwoon-Yong Jung, M.D. and Jin-Ho Kim, M.D.; Korean J Gastrointest Endosc 2010;41(2):102-107. Published online August 30, 2010

Abstract PDF: Endoscopic mucosal resection is an organ-saving and minimally invasive treatment modality for early gastric cancer that is mucosa-confined, differentiated, and less than 2 cm in size. On pre-treatment cancer staging work-ups, unusual, benign, infiltrative peritoneal lesions can mimic metastasis of early gastric cancer, and thus lead to loss of an opportunity for the lesion to be properly treated by endoscopy. In the present cases, we report two unusual cases of infectious peritonitis, i.e., tuberculosis and paragonimiasis, which have been occurring sporadically in Korea. The two infectious lesions were confirmed by peritoneal biopsy and the gastric cancers were subsequently removed by endoscopic mucosectomy. These two cases remind us of 1) following indications for endoscopic mucosectomy, 2) the need for peritoneal biopsy for undetermined peritoneal lesions while avoiding laparoscopic gastrectomy, and 3) the coincidental occurrence of unusual infectious peritonitis with gastric cancer in our geographic region. (Korean J Gastrointest Endosc 2010;41:102-107)

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Endoscopic Resection of an Adenocarcinoma Arising from a Sporadic Tubulovillous Adenoma of the Duodenum: Hwa Young Seok, M.D., Jae Myung Cha, M.D., Joung Il Lee, M.D., Kwang Ro Joo, M.D., Hyun Phil Shin, M.D., Sung Won Jung, M.D. and Na Eun Jang, M.D.; Korean J Gastrointest Endosc 2010;41(2):108-112. Published online August 30, 2010

Abstract PDF: Duodenal tumors may pose diagnostic difficulties in asymptomatic young patients because the duodenum may be overlooked during routine upper gastrointestinal endoscopy and because duodenal tumors are rare and present non-specific signs and symptoms. Although adenomas are the most common duodenal tumors, adenocarcinoma arising from sporadic tubulovillous adenoma without familial adenomatous polyposis is an uncommon condition in young patients. In patients with sporadic duodenal adenomas, the prevalence of colorectal adenomas is higher than prevalence for the general population. Herein, we report the case of a 27-year male with adenocarcinoma arising from a sporadic tubulovillous adenoma of the duodenum. The tumor was completely resected by endoscopic resection. Synchronous colon adenoma was also detected and treated by endoscopic mucosal resection. (Korean J Gastrointest Endosc 2010;41:108-112)

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Polyarteritis Nodosa Localized in Small Intestine: A Case Report: Byung Hoon Lim, M.D., Ji Sun Jang, M.D., Jung Won Kim, M.D.*, Se Jin Jang, M.D.^†, Sung Hoon Kim, M.D., Jei So Bang, M.D., Soo Hyun Yang, M.D. and Jong Hoon Byun, M.D.; Korean J Gastrointest Endosc 2010;41(2):113-117. Published online August 30, 2010

Abstract PDF: Polyarteritis nodosa is a systemic necrotizing vasculitis that affects mainly small and medium-sized arteries that involve multiple organs. In addition to the systemic involvement of classical vasculitis, localized vasculitis involves blood vessels within a confined vascular distribution or single organ without clinical evidence of generalized inflammation. Localized vasculitis of the gastrointestinal tract is a rare entity. In particular, a limited involvement of the small bowel is an unusual manifestation of polyarteritis nodosa. In this report, we describe a case of biopsy-proven polyarteritis nodosa presenting as small bowel bleeding without other systemic manifestations. (Korean J Gastrointest Endosc 2010;41:113-117)

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A Case of Rectal Leiomyosarcoma Presenting as a Semipedunculated Polypoid Mass: Sang Heon Lee, M.D., Ji Hyun Kim, M.D., Jeong Ah Seo, M.D., Sung Soo Moon, M.D., Hyoun Gu Kang, M.D. and Sang Young Seol, M.D.; Korean J Gastrointest Endosc 2010;41(2):118-122. Published online August 30, 2010

Abstract PDF: Rectal leiomyosarcoma is an extremely rare disease. Anal bleeding, rectal pain and a sensation of pressure in the anus are the most common symptoms. It tends to form a polypoid intraluminal mass and commonly originates from the muscularis propria, but may arise from the muscularis mucosa, or in the walls of the blood vessels. Characteristically, leiomyosarcoma has very high mitotic activity and is, on immunohistochemical staining, positive for actin and desmin, but negative for c-kit and S-100. We experienced a case of a rectal leiomyosarcoma in a 54 year-old man who presented with anal bleeding. Colonoscopic examination revealed a 4.5 cm-sized semipedunculated polypoid mass at mid-rectum. We confirmed that it was a leiomyosarcoma histologically by endoscopic resection with mechanical snaring. Low anterior resection followed by radiation therapy was performed. We report here on this case with a review of the relevant literature. (Korean J Gastrointest Endosc 2010;41:118-122)

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A Case of Strongyloides Stercoralis Concurrently Invading the Stomach and Colon: Eun Sil Koh, M.D., Sang Bum Kang, M.D., Jeong Hwa Lee, M.D., Dong Soo Lee, M.D., Yeon Soo Kim, M.D., Seung Woo Lee, M.D., Young Yong Ahn, M.D. and Tae Yun Heo, M.D.; Korean J Gastrointest Endosc 2010;41(2):123-127. Published online August 30, 2010

Abstract PDF: Strongyloides stercoralis is a nematode that may involve any segment of the Gl tract or virtually every human organ because of its autoinfection cycle and hyperinfection. It may occur in either immunocompetent or immunocompromised individuals. A 72-year-old woman who had no notable medical history presented with chronic diarrhea and generalized edema and she revealed protein losing eneteropathy. She was diagnosed with Strongyloidiasis infection through EGD and a colonoscopic biopsy specimen at a time when there were rhabditiform larvae present. The patient was treated with albendazole 400 mg/day for three days. At the follow-up three months later, the endoscopic biopsy specimens revealed no evidence of Strongyloidiasis infection and her clinical symptoms had progressively improved. The present case represents a rare report of Strongyloidiasis in a immunocompetent patient diagnosed through EGD and the colonoscopic biopsy specimen concurrently. So, we report on this case along with a review of the relevant literature. (Korean J Gastrointest Endosc 2010;41:123-127)

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