Clinical Endoscopy

Volume 42(2); February 2011

Conscious Sedation During Gastrointestinal Endoscopy: Midazolam vs Propofol: Ja Seol Koo, M.D. and Jai Hyun Choi, M.D.; Korean J Gastrointest Endosc 2011;42(2):67-73. Published online February 28, 2011

Abstract PDF: Endoscopy is increasingly performed with the patient under conscious sedation in many countries. The majority of patients can be adequately and safely sedated during routine upper endoscopy and colonoscopy with a combination of a benzodiazepine and opioid. Midazolam is a water-soluble benzodiazepine that is characterized by a rapid onset of action and a shorter duration compared with that of the other drugs of the same class. The major side effect of midazolam is respiratory depression, which can be reversed by flumazenil, a benzodiazepine-specific antagonist. Propofol is a lipid-soluble agent that has the advantages of a more rapid onset of action and a shorter recovery time compared to that of midazolam. However, it should be used with caution since it can lead to hypotension and respiratory depression. Propofol can be safely and effectively administered by nonanesthesiology physicians and nurses provided that they have received adequate training. Two models have been proposed for the administration of propofol by endoscopists: nurse-administered propofol sedation (NAPS) and combination propofol (propofol plus other agents) sedation. In order to modify the pharmacological disadvantages of propofol, fospropofol sodium, a water-soluble prodrug of propofol, has recently been developed. In addition, new delivery systems have been devised: patient-controlled sedation and computer-assisted personalized sedation, in which the computer continuously monitors the patient's condition and adjusts the dose of propofol accordingly. Endoscopists must have a thorough understanding of the medications used for endoscopic sedation and they must acquire the skills necessary for the treatment of cardiopulmonary complications. Therefore, it is necessary to develop a practice guideline pertaining to endoscopic sedation and also training programs for physicians and nurses in Korea. (Korean J Gastrointest Endosc 2011;42:67-73)

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Regression of Hyperplastic Gastric Polyp after Helicobacter pylori Eradication: Sang-Ah Lim, M.D., Jae-Won Yun, M.D., Daewoong Yoon, M.D., Wonjae Choi, M.D., Seung Han Kim, M.D., Jung Wan Choe, M.D., Mi-Na Kim, M.D., Eun Joo Kang, M.D., Jong Jae Park, M.D., Moon Kyung Joo, M.D., Beom Jae Lee, M.D., Young-Tae Bak, M.D., Sang Woo Lee,; Korean J Gastrointest Endosc 2011;42(2):74-82. Published online February 28, 2011

Background/Aims: Recent studies have suggested that the eradication of Helicobacter pylori (Hp) may lead to the regression of hyperplastic polyps (HPPs) in the stomach. We evaluated the sizes of HPPs after Hp eradication and we also compared the clinical parameters between the regression and non-regression groups.

Methods: We enrolled 187 patients who had HPPs in the stomach. The polyps were measured by using biopsy forceps, and the endoscopically observed changes of the polyps were assessed by two endoscopists.

Results: Total regression was observed in 68 patients of the eradicated group and in 6 patients in the non-eradicated group (42.5% vs. 22.2%, respectively, p＜0.05). The non regression rate was significantly higher for the non-eradicated group than that for the eradicated group (33% vs. 10%, respectively, p＜0.05). Comparing between the regression and non-regression groups, the incidence of polyps that were smaller than 10 mm in size and sessile was significantly higher in the regression group. Hp eradication was the only significant predictor of regression.

Conclusions: Hp eradication could be a therapeutic option for Hp positive-hyperplastic gastric polyps, and especially for those that are less than 10 mm in size and sessile. (Korean J Gastrointest Endosc 2011;42:74-82)

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Management of Duodenal Perforations after Endoscopic Retrograde Cholangiopancreatography: Jong-Hyun Kim, M.D., Keon-Young Lee, M.D., Seung-Ik Ahn, M.D., Kee Chun Hong, M.D., Seok Jung, M.D.*, Don Haeng Lee, M.D.*, Yun-Mee Choe, M.D., Sun Keun Choi, M.D., Yoon-Seok Hur, M.D., Sei Joong Kim, M.D., Young Up Cho, M.D., Seok-Hwan Shin, M.D. and Kyu; Korean J Gastrointest Endosc 2011;42(2):83-89. Published online February 28, 2011

Abstract PDF

Background/Aims: Surgery has been the mainstay of treatment for duodenal perforations after the introduction of endoscopic retrograde cholangiopancreatography (ERCP). Yet there have recently been arguments that conservative management with or without endoscopic intervention may be possible and safe.

Methods: For the patients who received ERCP at Inha University Hospital from Jan. 2001 to Dec. 2007, we retrospectively analyzed the clinical manifestations, the treatment and the clinical outcomes of the cases with duodenal perforation. Results: Among the 1708 ERCP cases, duodenal perforation occurred in eleven (0.6%) patients. There were two cases of duodenal perforations (type I), four cases of peri-Vaterian injury (type II), two cases of bile duct perforations (type III) and three cases of retroperitoneal perforations (type IV). Six patients (55%) were treated surgically while the others were managed conservatively. Except for one death (9.1%), ten patients fully recovered. Either residual diseases or fluid collections, as seen on CT, were present in the surgically managed patients. The median time interval between ERCP and surgery was 19 hours (range: 8∼30 hours).

Conclusions: To decide on the management of duodenal perforation after ERCP, the presence of residual disease or the leakage of intraluminal contents should be considered along with the type of the perforation. (Korean J Gastrointest Endosc 2011;42:83-89)

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Local Recurrence of EGC after ESD: Sang Hun Lee, M.D., Jin Hwan Jung, M.D., Jun Ho Song, M.D., Jeong Ho Kim, M.D., Dae Young Cheung, M.D., Jin Il Kim, M.D., Soo Heon Park, M.D. and Jae Kwang Kim, M.D.; Korean J Gastrointest Endosc 2011;42(2):90-93. Published online February 28, 2011

Abstract PDF: Endoscopic mucosal resection is not accepted as an alternative to surgery for treating EGC of the undifferentiated histologic type because of the relatively higher probability of lymph node metastasis with the endoscopic procedure. The recently developed endoscopic submucosal dissection (ESD) techniques have made en-bloc resection of large intramucosal or ulcerated lesions feasible, but the procedure's therapeutic indications are limited to EGC without lymph node metastasis. If we could define a subgroup of patients who have undifferentiated EGC with a low-risk of lymph node metastasis, then the application of ESD would be possible instead of surgery. ESD also allows precise histologic assessment of resected specimens and it may prevent residual disease and local recurrence. We report on a case that poorly differentiated adenocarcinoma was curatively removed by ESD, but cancer recurrence was detected in the lamina propria of the post ESD scar without lymph node metastasis or intraluminal lesions three years after the ESD. (Korean J Gastrointest Endosc 2011;42:90-93)

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A Case of Retrograde Jejunogastric Intussusception Following Subtotal Gastrectomy: Ji Hoon Yoon, M.D., Hyuk Yong Kwon, M.D., Myoung Joon Kim, M.D., Min Gu Chon, M.D., Seol Jung Ak, M.D., Seung Keun Park, M.D. and Hee Ug Park, M.D.; Korean J Gastrointest Endosc 2011;42(2):94-97. Published online February 28, 2011

Abstract PDF: Retrograde jejunogastric intussusception is a rare complication following Billroth ll gastric surgery. It is a segmental invagination of a jejunal loop into the stomach through stoma. Clinical manifestations are epigastric pain, vomiting with bile or blood, and a palpable mass in the epigastrium. Gastroscopy and a upper GI (UGI) series are very helpful in the diagnosis of this disease. Although the management of this disease is usually surgical, when endoscopic reduction has failed, surgery should be immediately done because of the high mortality. We present here a case of jejunogastric intussusception that was diagnosed by gastroscopy in a patient with a history of Billroth ll surgery that had been done 6 years prior due to gastric cancer. (Korean J Gastrointest Endosc 2011;42:94-97)

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Endoscopic Treatment of 3 Cases of GIST with High Aggressive Behavior: Young Ju Cho, M.D., Kee Myung Lee, M.D., Kee Myoung Jung, M.D., Sun Gyo Lim, M.D., Jin Hong Kim, M.D., Sung Jae Shin, M.D., Jae Chul Hwang, M.D. and Young Bae Kim, M.D.*; Korean J Gastrointest Endosc 2011;42(2):98-104. Published online February 28, 2011

Abstract PDF: Gastrointestinal stromal tumors (GISTs) are the most common subepithelial tumor of the gastrointestinal tract. They originate from mesenchymal tissue. Because of difficulties in discriminating between benign and malignant GISTs, the treatment modality is selected on the base of tumor size, mitosis count, location, originating layer, and the presence of complications. Regular follow-up, open resection, or laparoscopic operation were considered main treatments for GISTs. Surgical resection is standard treatment for a huge GIST. However, the treatment method is not determined for GISTs of less than 3 cm that show a benign clinical course. Recently, endoscopic treatment was attempted because of recent endoscope developments and associated devices. We report three cases of gastric GISTs with a high risk of aggressive behavior that were successfully treated by endoscopic resection. (Korean J Gastrointest Endosc 2011;42:98-104)

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A Case of Focal Intramural Abscess Due to a Fish Bone Ingestion in a Healthy Middle Aged Woman: Sang Hun Ko, M.D., Gye Sung Lee, M.D.*, Jae I Ko, M.D., Hyng Sik Yun, M.D., Sung Keun Kim, M.D., Sung Ho Kim, M.D., Chan Woo Park, M.D. and Gwan Woo Nam, M.D.*; Korean J Gastrointest Endosc 2011;42(2):105-108. Published online February 28, 2011

Abstract PDF: Gastric wall abscess is a one form of phlegmonous gastritis and there are scare reports on this. Gastric wall abscess is a purulent inflammatory disease and it is commonly caused by a focal injury to the gastric mucosa such as a penetrating trauma from an ingested foreign body or an endoscopic biopsy where by bacterial infection occurs throughout all the layers of the gastric wall. With symptoms such as abdominal pain and fever, making the diagnosis after an operation was possible in the past, but it has recently become possible to make the diagnosis before the operation via esophagogastroduodenoscopy, endoscopic ultrasonography and/or abdominal computed tomography. We recently experienced a case of gastric wall abscess that was associated with a foreign body (presumably a fish bone) in a healthy middle aged woman. By performing generalized esophagogastroduodenoscopy and abdominal computed tomography at a primary medical institution, we made an early diagnosis and treated the patient. Herein, we report on this case and we review the relevant literature. (Korean J Gastrointest Endosc 2011;42:105-108)

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De Novo Submucosal Colorectal Cancer in a 3 mm Sessile Polyp: So My Koo, M.D., Jin Oh Kim, M.D., Hyun Gun Kim, M.D., Tae Hee Lee, M.D., Seong Ran Jeon, M.D., So Young Jin, M.D., and Joon Seong Lee, M.D.; Korean J Gastrointest Endosc 2011;42(2):109-112. Published online February 28, 2011

Abstract PDF: The majority of colorectal carcinomas (95∼100%) are thought to arise from adenomas. Yet colorectal carcinomas may rarely arise de novo. The popular definition of de novo carcinoma is that the lesion should consist exclusively of a carcinoma histologically and contain no adenomatous elements. Without an adenoma-carcinoma sequence, de novo carcinomas have a much higher rate of submucosal invasion, despite their small size. Their speed of growth is thought to be rapid. Some studies have shown that de novo carcinomas might arise as a macroscopically flat or depressed lesion, rather than a protruded one. However, the typical macroscopic findings of de novo carcinomas have not been established. They might be variable macroscopically and include a protruded type. We report a case of de novo colorectal carcinoma that invaded the submucosal layer involving a minute sessile polyp only 3 mm in diameter, which was removed by endoscopic mucosal resection. (Korean J Gastrointest Endosc 2011;42:109-112)

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Early Adenocarcinoma Arising from Traditional Serrated Adenoma in the Colon: Min Kyung Kim, M.D., Jae Myung Cha, M.D., Sung Jig Lim, M.D., Sunyong Kim, M.D., Jung Min Chae, M.D., Uk Jo, M.D., Kwang Ro Joo, M.D. and Joung Il Lee, M.D.; Korean J Gastrointest Endosc 2011;42(2):113-117. Published online February 28, 2011

Abstract PDF: A serrated adenoma is a precursor lesion for some cases of microsatellite unstable colorectal carcinoma (CRC). The serrated neoplasia pathway has been associated with carcinogenesis of serrated adenoma, which is different from the traditional adenoma-carcinoma sequence. The serrated neoplasia pathway accounts for 10∼15% of CRCs, and these tumors typically demonstrate microsatellite instability. Cases of a CRC arising from a serrated adenoma have been rarely identified with the recent recognition of the serrated neoplasia pathway. However, these cases are not frequently reported in Korea, because this concept has only been recently emphasized. We report a case of an early adenocarcinoma arising from a traditional serrated adenoma of the colon, which was diagnosed and treated by a colonoscopic polypectomy. (Korean J Gastrointest Endosc 2011;42:113-117)

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Appendiceal Intussusception Showing Various Shapes During a Colonoscopy: Byeong Uk Kim, M.D., Ja Chung Goo, M.D., Soon Man Yoon, M.D., Hee Bok Chae, M.D., Seon Mee Park, M.D., Sei Jin Youn, M.D. and Ro Hyun Sung, M.D.*; Korean J Gastrointest Endosc 2011;42(2):118-123. Published online February 28, 2011

Abstract PDF: Appendiceal intussusception is a rare disease with variable clinical findings, ranging from acute appendicitis to chronic recurrent abdominal pain or rectal bleeding. Occasionally, it is incidentally discovered with no symptoms. Because a preoperative diagnosis is difficult, it can be diagnosed either after surgery, in the case of acute appendicitis, or after a polypectomy, based on being mistaken for a polyp. During a colonoscopy, an appendiceal intussusception should be suspected if the appendiceal orifice is not observed at the cecum and there is a polypoid lesion at the location where the appendiceal orifice is expected. Treatments are usually determined according to preceding diseases. It is important that the colonoscopist avoid careless endoscopic removal by mistaking the intussusception for a polyp. (Korean J Gastrointest Endosc 2011;42:118-123)

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A Case of Pneumatosis Cystoides Intestinalis in Which Endoscopic Ultrasonography Was Useful for the Diagnosis: Eun Jung Kang, M.D., Jin Oh Kim, M.D., Hyun Gun Kim, M.D., Tae Hee Lee, M.D., Wan Jung Kim, M.D., Sung Gon Jun, M.D., Gang Il Cheon, M.D. and Joon Seong Lee, M.D.; Korean J Gastrointest Endosc 2011;42(2):124-126. Published online February 28, 2011

Abstract PDF: Pneumatosis cystoides intestinalis (PCI) is an uncommon condition in which submucosal or subserosal gas cysts are present within the bowel wall. We report a case of a 37-year-old man with no medical history. He underwent a colonoscopy for screening purposes, which revealed multiple and variably sized submucosal tumors in the ascending colon. Endoscopic ultrasonographic (EUS) finding showed multiple hyperechogenic regions with distal acoustic shadowing within the submucosa of the ascending colon. A computed tomography scan showed multiple air-filled cystic masses in the ascending colon. EUS appears to be effective for the diagnosis of PCI. (Korean J Gastrointest Endosc 2011;42:124-126)

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A Case of a Collision Tumor in the Ampulla of Vater with an Adenocarcinoma and a Large Cell Neuroendocrine Carcinoma: Kang Ju, M.D., Tae Hyo Kim, M.D., Cha Young Kim, M.D., Sang Su Lee, M.D., Hong Jun Kim, M.D., Hyun Jin Kim, M.D., Woon Tae Jung, M.D. and Ok Jae Lee, M.D.; Korean J Gastrointest Endosc 2011;42(2):127-130. Published online February 28, 2011

Abstract PDF: Most tumors affecting Vater's ampulla are adenocarcinomas, but a neuroendocrine carcinoma in the ampulla of Vater is extremely rare. The coexistence of these two tumors has been reported in only a few cases. Here, we report a rare case of a collision tumor of the ampulla of Vater with an adenocarcinoma and a large cell neuroendocrine carcinoma. (Korean J Gastrointest Endosc 2011;42:127-130)

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A Case of Acute Pancreatitis Caused by the Necrotic Tissue of Gallbladder Cancer: Hoe Hoon Chung, M.D., Seok Ho Dong, M.D., Jaejun Sim, M.D., Jae Young Jang, 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 2011;42(2):131-134. Published online February 28, 2011

Abstract PDF: The most common cause of acute pancreatitis is gallstones. However, idiopathic causes comprise about 10 to 15% of all cases of acute pancreatitis. Biliary sludge is thought to be a cause of idiopathic acute pancreatitis and mainly via obstruction of the common bile duct. Cholesterol polyps of the gallbladder, cholesterolosis and hemobilia can be associated with biliary pain. Fragments of the gallbladder polyps and blood clots can lead to acute pancreatitis in a way similar to that of biliary sludge. Yet it has never been reported that the necrotic tissue of gallbladder cancer can lead to acute pancreatitis. Herein, we report on the case of a 52-year-old man with acute pancreatitis that was caused by the necrotic tissue of gallbladder cancer. The necrotic tissue in the bile duct was revealed on endoscopic retrograde cholangiopancreatography (ERCP). The patient was successfully treated by laparoscopic cholecystectomy along with liver segmentectomy. (Korean J Gastrointest Endosc 2011;42:131-135)

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