Clinical Endoscopy

Education and Training Guidelines for the Board of the Korean Society of Gastrointestinal Endoscopy: Kee Myung Lee, M.D., Seok Reyol Choi, M.D.*, Byung Ik Jang, M.D.^†, Seong Hwan Kim, M.D.^‡, Chang Don Kang, M.D.^§, Young Dae Kim, M.D.^∥, Jeong Youp Park, M.D.^¶ and Il-Kwun Ch; Korean J Gastrointest Endosc 2011;42(4):207-214. Published online April 28, 2011

Abstract PDF: The Korean Society of Gastrointestinal Endoscopy (KSGE) developed regulations and a gastrointestinal endoscopy board in 1995. Although the KSGE has acquired many specialists since then, the education and training aims and guidelines were insufficient. Although endoscopic examinations are supervised by a specialist during a GI fellowship, some types of GI endoscopic examinations and treatments are difficult to obtain exposure. Fellows should acquire endoscopic skills through repeated independent endoscopic examinations after a GI fellowship. Thus, the KSGE requires training guidelines for fellowships that allow fellows to perform endoscopic examinations without a supervisor. This document is intended to provide the principles that the Committee of Education and Training of KSGE can use to develop practical guidelines for granting privileges to perform accurate GI endoscopy safely. KSGE will contribute to improving the quality of GI endoscopy by providing guidelines for fellowships and supervisors. (Korean J Gastrointest Endosc 2011;42:207-214)

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Efficacy and Safety of Albis^Ⓡ in Acute and Chronic Patients with Gastritis: A Double-blind, Placebo-controlled, Randomized Multi-center Study: Hae Won Han, M.D., Myung-Gyu Choi, M.D., Sang Young Seol, M.D.*, Dong Ho Lee, M.D.^†, Hwoon-Yong Jung, M.D.^‡, Tae Nyeun Kim, M.D.^§, Suck Chei Choi, M.D.^∥ and Hyen Soo Kim, M.D.^¶; Korean J Gastrointest Endosc 2011;42(4):215-221. Published online April 28, 2011

Abstract PDF: Background
/Aims: Albis^Ⱂ is a newly developed drug comprised of ranitidine, bismuth and sucralfate. The aim of the study was to prove non-inferiority of Albis^Ⱂ compared to Stillen^Ⱂ for treating erosive gastritis.
Methods
This study was a randomized, double-blind, multi-center trial. The primary endpoint was 2 weeks of treatment.
Results
Of the 229 patients in the intention-to-treat (ITT) population, 87 from the Albis^Ⱂ, and 96 from the Stillen^Ⱂ group were included in the per protocol (PP) analysis. The endoscopic improvement rate was not different between the Albis^Ⱂ group and the control in both the PP (42.5%, 39.6%) and ITT (35.3%, 34.5%) populations. The endoscopic cure of erosion was also not different in the Albis^Ⱂ group than that in the control group in both the PP (32.3%, 31.3%) and ITT (27.6%, 27.4%) populations. The endoscopic improvement rate for hemorrhage, edema, and erythema were also not different between the two groups in both the PP and ITT populations. No statistically significant differences were observed for adverse events between the two groups.
Conclusions
Half of the approved dose of Albis^Ⱂ for peptic ulcers has non-inferiority compared to Stillen^Ⱂ for treating erosive gastritis. A low dosage of Albis^Ⱂ is cost efficient and safe. (Korean J Gastrointest Endosc 2011;42:215-221)

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Treatment Outcomes after Endoscopic Submucosal Dissection of Large Superficial Rectosigmoid Colon Tumors: Jin-Sung Koh, M.D., Jong-Jae Park, M.D., Wonho Jung, M.D., Joon Young Lee, M.D., Sang-Ah Lim, M.D., Minjung Kwon, M.D., Hyejin Noh, M.D., Moon Kyung Joo, M.D., Beom Jae Lee, M.D., Ji Hoon Kim, M.D., Jong Eun Yeon, M.D., Jae Seon Kim, M.D., Kwan Soo Byun,; Korean J Gastrointest Endosc 2011;42(4):222-227. Published online April 28, 2011

Abstract PDF: Background
/Aims: Endoscopic submucosal dissection (ESD) of a colorectal tumor is technically difficult. This study aimed to analyze the clinical outcomes of superficial large rectosigmoid tumors after ESD.
Methods
Medical records of 15 patients with large rectosigmoid tumors (more than 30 mm), in which ESD performed, were reviewed retrospectively.
Results
The mean tumor size was 42.5±14.3 mm (range, 30∼78 mm). A histological examination revealed a well-differentiated adenocarcinoma in five cases (33.3%), adenoma with high-grade dysplasia in six cases (40%), and low-grade dysplasia in four cases (26.7%). The mean procedural time was 90.5±60.7 min (range, 22∼246 min). The en bloc resection rate was 86.7%, and the complete resection rate 100%. The lateral resection margin was positive in four cases (26.6%), but no cases with a positive vertical margin were observed. Bleeding occurred in three cases (20%), and all were treated successfully using endoscopic measures. Perforations occurred in three cases (20%); two cases were treated by clipping and the other by a laparotomy.
Conclusions
ESD is a treatment option for superficial large rectosigmoid tumors. Further studies with larger cases and a longer term follow-up are needed to establish the efficacy and safety of ESD for colorectal tumors. (Korean J Gastrointest Endosc 2011;42:222-227)

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A Case of a Pharyngeal Impacted Fish Bone Foreign Body Detected by Finger Palpation: Heung Up Kim, M.D., Hyung Joo Song, M.D., Eun Kwang Choi, M.D., Yoo-Kyung Cho, M.D. and Byung-Cheol Song, M.D.; Korean J Gastrointest Endosc 2011;42(4):228-231. Published online April 28, 2011

Abstract PDF: Emergent endoscopy is needed in cases of a fish bone foreign body in the upper gastrointestinal tract. A fish bone foreign body is common in the oral cavity and pharynx and has a high rate of complications because of the characteristic shape. A diagnosis is very difficult when the foreign body penetrates and impacts the surrounding tissue. Computed tomography is useful for the diagnosis; however, direct removal would be impossible if the foreign body was not localized during endoscopy. If the foreign body is anchored to the oral cavity and pharynx, finger palpation is useful to find the impacted fish bone. We report here on a case of an endoscopically missed pharyngeal impacted fish bone foreign body that was finally detected by finger palpation and successfully removed by rescue endoscopy. (Korean J Gastrointest Endosc 2011;42:228-231)

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A Case of Gastric Bezoar Treated with a Distal Attachment Device: Kwang Pyo Jang, M.D., Jun Lee, M.D., Il Goo Park, M.D., Yu Mi Byeon, M.D., Chol Jin Park, M.D., Young Dae Kim, M.D., Chan Guk Park, M.D. and Man Woo Kim, M.D.; Korean J Gastrointest Endosc 2011;42(4):232-235. Published online April 28, 2011

Abstract PDF: Bezoars are collection of indigestible materials in the gastrointestinal tract. Many endoscopic techniques for removal of bezoars have been reported recently, but these methods need much equipment. We treated a gastric bezoar with a distal attachment device easily available for an endoscope. A 74-year-old man with a history of diabetes mellitus was admitted to hospital with hematemesis. On the second endoscopic examination, a gastric bezoar (6×4×4 cm) was detected in the stomach. Then, using a distal attachment device, we injected Coca-Cola directly into the bezoar by an injector. With tension force, the bezoar was easily broken due to the impulse of the distal attachment device. The endoscopic technique used in our case can be easily performed and has fewer complications compared to those of other techniques. Therefore, we report here on this new treatment modality that uses a distal attachment device. (Korean J Gastrointest Endosc 2011;42:232-235)

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A Case of Neuroendocrine Carcinoma Presenting as a Subepithelial Tumor Diagnosed by ESD: Dae Hyun Baek, M.D., Seong Hwan Kim, M.D., Jun Young Jung, M.D., Byoung Kwan Son, M.D., Yunju Jo, M.D., Young Sook Park, M.D. and Won Mi Lee, M.D.*; Korean J Gastrointest Endosc 2011;42(4):236-240. Published online April 28, 2011

Abstract PDF: A gastric neuroendocrine carcinoma is very rare, and the histological diagnosis is very difficult. These carcinomas result in a poor prognosis because they are preceded by severe lymphovascular invasion and early metastasis. In particular, it is difficult to distinguish between adenocarcinoma and neuroendocrine carcinoma by endoscopy when no specific symptoms are present (e.g., dyspepsia, nausea). According to published articles in Korea, most cases were diagnosed as adenocarcinoma initially; however, they were confirmed postoperatively as neuroendocrine carcinoma based on a histological examination using immunohistochemical staining. A case of a 55-year-old man, who had an incidental finding of a subepithelial tumor during his health check-up, was recommended for an endoscopic submucosal dissection (ESD). But the patient was lost to follow-up for 4 years. When he was examined again, the size of the tumor had increased from the previous exam. He underwent ESD and was diagnosed with a well-differentiated neuroendocrine carcinoma. (Korean J Gastrointest Endosc 2011;42:236-240)

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Gastric Mucosal Hemorrhage in a Patient with Idiopathic Thrombocytopenic Purpura: Do Hyung Kim, M.D., Chang-Il Kwon, M.D., Jun Gu Chung, M.D., Woong Park, M.D., Yong Hun Kim, M.D., Haeyoon Kang, M.D.*, Kwang Hyun Ko, M.D. and Doyeun Oh, M.D.; Korean J Gastrointest Endosc 2011;42(4):241-244. Published online April 28, 2011

Abstract PDF: Idiopathic thrombocytopenic purpura (ITP) is an autoimmune condition in which antibodies react against platelets and cause platelet destruction and bleeding that rarely results in gastrointestinal bleeding. Even though it is still controversial, a recent study suggested that Helicobacter pylori is one of the causes of ITP, and that eradication of H. pylori may be helpful for improving platelet count. We report a case of isolated gastric mucosal hemorrhage not related to H. pylori infection in a patient with ITP. A gastric mucosal biopsy revealed mild lamina proprial edema and extravasated red blood cells but no evidence of vasculitis or inflammatory cell infiltration. Thrombocytopenia can lead to a gastric mucosal hemorrhage not related to an H. pylori infection when treating patients with ITP. (Korean J Gastrointest Endosc 2011;42:241-244)

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A Case of a Pancreaticogastric Fistula Following Acute Pancreatitis: Jae Sung Youn, M.D., Hyeuk Park, M.D., Min Geun Lee, M.D., Woo Jong Kim, M.D., Jang Sik Mun, M.D., Bo Hyun Myoung, M.D., Do Hyun Kim, M.D. and Ho Dong Kim, M.D.; Korean J Gastrointest Endosc 2011;42(4):245-249. Published online April 28, 2011

Abstract PDF: A pancreatic fistula (PF) is an abnormal connection between the pancreas and adjacent or distant organs, structures, or spaces resulting from leakage of pancreatic secretions from disrupted pancreatic ducts. A PF is a rare complication that occurs during a acute and chronic pancreatitis or after traumatic or surgical disruption of the pancreatic duct. PFs are frequently classified as internal or external depending upon whether they communicate with an internal organ or the skin. Pancreatico-colonic fistulas are the most common, whereas pancreatico-gastric fistulas are the rarest. We report a rare case of a pancreatico-gastric fistula complicated by acute pancreatitis. (Korean J Gastrointest Endosc 2011;42:245-249)

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Inflammatory Pseudotumor Causing Small Bowel Obstruction in a Patient with AIDS: Hyun Soo Kim, M.D., Jae Myung Cha, M.D., Joung Il Lee, M.D., Kwang Ro Joo, M.D., Hyun Joon Jung, M.D., Chi Hoon Lee, M.D., Sung-Jig Lim, M.D.* and Ki Yong Na, M.D.*; Korean J Gastrointest Endosc 2011;42(4):250-254. Published online April 28, 2011

Abstract PDF: Small bowel obstructions are most commonly caused by adhesions, hernias, neoplasms or inflammatory stricture. Inflammatory pseudotumors are an uncommon cause of small bowel obstruction, even in a patient with acquired immunodeficiency syndrome (AIDS). We have experienced a case of small bowel obstruction caused by an inflammatory pseudotumor in a 38-year old male with AIDS. Abdominal computed tomography showed small bowel obstruction due to jejunal annular wall thickening. Surgical laparotomy showed a non-specific granulomatous inflammatory mass that could not fulfill any diagnostic criteria for a specific disease. This report describes our findings of small bowel obstruction due to an inflammatory pseudotumor and discusses the differential diagnosis of inflammatory pseudotumor in AIDS patients. (Korean J Gastrointest Endosc 2011;42:250-254)

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A Case of Ischemic Colitis Results from the Bleeding on Gastric Dieulafoy Lesions: Jun Seok Park, M.D., Jin Oh Kim, M.D., Hyun Gun Kim, M.D., Tae Hee Lee, M.D., Sung Wook Hong, M.D., Sung Gon Jun, M.D., Seong Ran Jeon, M.D. and Wan Jung Kim, M.D.; Korean J Gastrointest Endosc 2011;42(4):255-258. Published online April 28, 2011

Abstract PDF: Ischemic colitis is the most common ischemic injury of the gastrointestinal tract. It can result from ischemia caused by compromised blood flow to the mesenteric arteries. Colonic ischemia may be precipitated by several conditions, although a cause is not clearly identified in most cases. A 63-year-old man was admitted because of loss of consciousness with melena. After endoscopic bleeding control of Dieulafoy lesions of the stomach, hematochezia occurred during the in-hospital care period. A sigmoidoscopy and computed tomography scan were conducted to evaluate the hematochezia, and ischemic colitis was diagnosed. Here, we report a case of ischemic colitis associated with massive upper gastrointestinal bleeding. (Korean J Gastrointest Endosc 2011;42:255-258)

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Heterotopic Pancreas of the Jejunum Identified by Capsule Endoscopy: Si Eun Kong, M.D., Chang Nyol Paik, M.D., Eun Jung Kim, M.D., Hyung Jin Kim, M.D.*, Ji Han Jung, M.D.^†, Woo Chul Chung, M.D., Kang Moon Lee, M.D. and Jin Mo Yang, M.D.; Korean J Gastrointest Endosc 2011;42(4):259-262. Published online April 28, 2011

Abstract PDF: Heterotopic pancreas is an uncommon condition that commonly occurs in the gastrointestinal tract such as the stomach and small bowel. It is defined as the presence of pancreatic tissue outside its usual location and lacking anatomical and vascular continuity with the pancreas. A heterotopic pancreas is usually found incidentally and is mostly silent; however, it rarely causes abdominal pain, weight loss, bleeding, or ileus. A 49-year-old male presented with intermittent abdominal pain for 4 weeks. We report a case with submucosal features of a jejunal heterotopic pancreas with the aid of capsule endoscopy and a histological confirmation through a single port laparoscopic segmental jejunectomy. (Korean J Gastrointest Endosc 2011;42:259-262)

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A Case of Capillary Hemangioma in the Jejunum Detected by Single Balloon Enteroscopy in a Patient with Anemia: Jun-Hyung Cho, M.D., Jae Young Jang, M.D., Chang Hyun Cho, M.D., Jaejun Shim, M.D., Seok Ho Dong, M.D., Hyo Jong Kim, M.D., Byung-Ho Kim, M.D. and Young Woon Chang, M.D.; Korean J Gastrointest Endosc 2011;42(4):263-267. Published online April 28, 2011

Abstract PDF: Hemangiomas are uncommon benign vascular tumors that account for up to 10% of all small bowel tumors. The jejunum is the most common location, and gastrointestinal bleeding is a frequent clinical presentation. Histologically, hemangiomas are classified as cavernous, capillary, or mixed types. Capillary hemangiomas are dense collections of capillaries usually with a hyperplastic endothelium. There have been a few cases of small bowel capillary hemangioma revealed by capsule endoscopy and confirmed after surgical resection. But preoperative detection of hemangiomas in the small intestine has not been reported, as far as we know, associated with the use of balloon-assisted enteroscopy. This report describes a 44-year-old male with a small bowel mass considered to be a cause of severe iron deficiency anemia. In this case, we performed capsule endoscopy and single balloon enteroscopy to examine the lesion. The patient then underwent a segmental resection of the jejunum, which confirmed the presence of a capillary hemangioma with surface ulceration. (Korean J Gastrointest Endosc 2011;42: 263-267)

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A Case of Malignant Intraductal Papillary Mucinous Neoplasm of the Pancreas with Duodenal Adenocarcinoma: Kyoung Suk Park, M.D., Jae Hee Cho, M.D., Tae Woon Park, M.D., Geun Jun Ko, M.D., Myoung Lyeol Woo, M.D., Jin Ho Jeong, M.D.* and Hwa Eun Oh, M.D.^†; Korean J Gastrointest Endosc 2011;42(4):268-273. Published online April 28, 2011

Abstract PDF: Intraductal papillary mucinous neoplasm of the pancreas (IPMN) is a precancerous lesion with a well-described adenocarcinoma sequence. The rate of progression of IPMN appears to be very slow; however, patients with IPMN may be at increased risk for extrapancreatic malignancies. A 55-year-old female was diagnosed with IPMN of the pancreas and a duodenal polyp in 2004. After an approximate 3 year loss to follow-up, she was readmitted for managing abdominal pain and underwent Whipple's operation. Herein, we report a case of a patient with malignant IPMN accompanied by duodenal adenocarcinoma arising from a duodenal polyp. (Korean J Gastrointest Endosc 2011;42:268-273)

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