Endoscopic Treatment of Gallstone Diseases / 대한소화기내시경학회지

Gallstone diseases include gallbladder stones, extrahepatic bile duct stones and intrahepatic duct stones. In the past, the main treatment modality was a surgical operation. With the development of endoscopic treatment, the main treatment modality is shifting towards endoscopic treatment. After the development of endoscopic sphincterotomy, endoscopic stone removal using a basket or balloon has been the major treatment modality for extrahepatic bile duct stones. For huge extrahepatic bile duct stones, mechanical or laser lithotripsy are used as ancillary equipment. Direct peroral cholangioscopic methods using a slim endoscopy or a Spyglass system now being rapidly developed instead of the "mother and baby" scope. If extrahapatic bile duct stones fail to be removed with peroral endoscopic treatment, then the stones can be treated via a percutaneous route (a percutaneous transhepatic route or a percutaneous transabdominal route). For intrahepatic duct stones, the location of stones, the site and degree of bile duct stricture and the existence of parenchymal atrophy are important factors to decide the treatment modality. The treatment modality is usually decided on according to the Tsunoda classification. Gallbladder stones usually need cholecystectomy because of recurrence. Endoscopic treatment is an indication for treating inoperable calculous cholecystitis patients. Endoscopic treatment for gallstone disesae will continue to rapidly develop in the future to the benefit of both the patients and endoscopists.

The Clinical Effect of Supplementary Argon Plasma Coagulation after Endoscopic Mucosal Piecemeal Resection of a Gastric Adenoma and Carcinoma / 대한소화기내시경학회지

BACKGROUND/AIMS: This study was designed to determine the effect of supplementary argon plasma coagulation (APC) after piecemeal resection of a gastric adenoma or an intramucosal adenocarcinoma. METHODS: Cases of 62 lesions of 56 consecutive patients with either a gastric adenoma or carcinoma were retrospectively reviewed at the Ajou University Medical Center. APC was performed after an endoscopic complete resection using the piecemeal method of endoscopic mucosal resection (EMR) for patients in the EMR-APC group. For patients in the EMR group, APC was not performed. RESULTS: There was no significant difference in the recurrence rate of the cancers for both groups (9.7%, for the EMR group, 6.5% for the EMR-APC group). The recurrence rate of a low grade dysplasia was 6.7% (EMR group) and 6.3% (EMR-APC group) (p=1.000), the recurrence rate for a high grade dysplasia was 11.1% (EMR group) and 25.0% (EMR-APC group) (p=1.000), and the recurrence rate for an intramucosal adenocarcinoma was 14.3% (EMR group) and 0% (EMR-APC group) (p=0.389). The recurrence rates of lesions in which the lesion size was less than 20 mm and over 20 mm for each group were 6.7% and 9.1% (EMR group) (p=1.000) versus 12.5% and 0% (EMR-APC group) (p=0.520). There was also no significant statistical difference in the recurrence rates for both groups according to the location and macroscopic type of lesion. CONCLUSIONS: Supplementary treatment with APC could not significantly reduce the recurrence rate after complete piecemeal resection determined macroscopically. A large- scale and prospective study is necessary to elucidate the clinical significance of supplementary APC for gastric neoplasm treatment.

A Case of Salmonella Liver Abscess / 대한소화기학회지

Liver abscess can be caused by bacterial, parasitic, or fungal infection. Amebic abscesses are more common, but pyogenic abscesses account for three quarters of hepatic abscess in developed countries. Most common pathogens of the pyogenic liver abscess are Escherichia coli, Klebsiella pneumoniae, Bacteroides, Enterococci, Streptococci, and Staphylococci. However, liver abscess caused by Salmonella species has rarely been reported. We experienced a case of Salmonella liver abscess which improved after antibiotic therapy and percutaneous drainage. The patient was 52 years-old man who had an episode of intermittent fever, chills and epigastric pain for 2 weeks. He was diagnosed as liver cirrhosis eight years ago and diabetes three years ago. Salmonella group D, non-typhi was cultured from blood and pus from the liver respectively at the same time. With percutaneous drainage and susceptible antibiotic therapy, liver abscess decreased in size with improvements in fever and abdominal pain.

Comparison of Patients' Satisfaction for Transnasal or Transoral Endoscopy in Unsedated Patients / 대한소화기내시경학회지

BACKGROUND/AIMS: The aim of this study was to compare the patient's satisfaction and tolerance of transnasal (TN) and transoral (TO) endoscopy prospectively. METHODS: 120 patients were assigned to undergo TN (age: 49.5, M : F=65 : 55) or TO (age: 47.4, M : F=63 : 57) endoscopy according to their wishes. RESULTS: The patients' satisfaction was higher in the TN group than in the TO group (8.45 vs. 4.95, p <0.05). The degree of choking sensation, nausea, and throat soreness was lower in the TN group than the TO group. There was no difference in endoscopists' satisfaction between the two groups. The duration for TN was longer than for TO. Epistaxis and nasal pain were the common complications in the TN group. All complications were mild and were relieved spontaneously. An endoscopic examination could be completed in all patients in the TO group. In the TN group, examination failure was quite common in the early phase but the incidence decreased with increasing experience. It took the experience of at least 20 cases for the endoscopist to adapt to the TN route. CONCLUSIONS: TN endoscopy is believed to be a comfortable and safe procedure for improving the patients' satisfaction and for reducing the level of inconvenience.

N-utyl--yanoacrylate (Histoacryl) in the Treatment of Esophageal Variceal Bleeding: Comparison with Band Ligation / 대한간학회지

BACKGROUND/AIMS: Endoscopic sclerotherapy and band ligation have been well documented beneficial therapeutic options of esophageal variceal bleeding. But acute variceal bleeding is refractory to sclerotherapy in upto one-hird of patients, and rebleeding occurs in 30% to 50%. Recently alternative endoscopic modality, N-utyl--yanoacrylate (Histoacryl) injection is performed in intravariceal sclerotherapy but its efficacy and safty are not clearly established. We evaluated the efficacy of Histoacryl on esophageal variceal bleeding and compared with that of endoscopic band ligation in the present study. MATERIALS/METHODS: From March 1994 to March 1998, ninety seven patients with endoscopically documented esophageal variceal bleeding were enrolled. Histoacryl injection (Histoacryl group, n=33) or endoscopic band ligation (EVL group, n=64) was done for esophageal variceal bleeding. We evaluated the rebleeding rate and in-ospital mortality in both groups. RESULTS: Baseline characteristics were similar but active bleeding on first endoscopic session was significantly higher in Histoacryl group (Histoacryl group; 90.7%, EVL group; 26.6%, p=0.002). Successful hemostasis was done at 87.9% in Histoacryl group, 95.3% in EVL group (not significant). There were no significant differences on early rebleeding rate (18.2% vs 23.4%), late rebleeding rate (39.4% vs 37.5%) and in-ospital mortality (24.2% vs 15.6%) between Histoacryl group and EVL group. There were no technique-elated fatal complications at Histoacryl injection group. CONCLUSION: Therapeutic efficacy of Histoacryl injection was similar to the endoscopic band ligation in patients with esophageal varix bleeding in terms of hemostasis and rebleeding. Histoacryl is effective therapeutic option for esophageal variceal bleeding as well as gastric variceal bleeding.

Peroral Intubation of a Self-expanding Coil Stent for Palliation of Unresectable Gastric Cancer with Antral Obstruction / 대한소화기내시경학회지

BACKGROUND: Peroral intubation of a self-expanding metal stent is usually difficult in malignant antral obstruction in patients with unresectable gastric cancer, due to the curved gastroduodenal structure. METHODS: The delivery catheter of a self-expanding nickel-titanium coil stent was modified, which was originally used in obstructive esophagocardial cancer. Peroral intubation of the coil stent was attempted in patients suffering from intractable vomiting due to unresectable gastric cancer with antral obstruction. RESULTS: Fifteen of 18 patients (83.3%) were successfully managed without immediate complications such as stent migration, serious bleeding, bowel perforation, and procedure- related mortality. One patient, who failed the peroral intubation, was managed by percutaneous intubation of the coil stent via the route of percutaneous endoscopic gastrostomy. After insertion of the coil stent, food ingestion and symptomatic improvement of vomiting was achieved in 15 (93.8%) of 16 patients. The mean survival time was 3.7 months (range, 1-10 months). No delayed stent migration and occlusion by tumor overgrowth occurred. Stent occlusion by food materials occurred in one patient during the follow-up period, which was corrected by endoscopic flushing. CONCLUSION: These results suggest that peroral intubation of a self-expanding coil stent is a safe and effective palliation for unresectable gastric cancer with antral obstruction.

Two Cases of CMV Esophagitis and Proctitis / 대한소화기내시경학회지

Gastrointestinal cytomegalovirus (CMV) disease most frequently occurs in adults with immune deficiency due to acquired immune deficiency syndrome (AIDS), organ trans- plantation, cancer chemotherapy, and steroid therapy. Because the number of patients with immune deficiency has increased in recent years in Korea and CMV is one of the most common infecting complications in these settings, the number of patients with CMV disease is also increasing. Most cases of CMV disease are due to reactivation of a latent virus. The pathogenesis of this intestinal disease is vascular endothelial involvement with subsequent ischemic mucosal injury. An endoscopy usually reveals large, well defined ulcers greater than 3 cm. Deep longitudinal serpiginous ulcers represent a coalescence of adjoining smaller ulcers. CMV infection produces a characteristic cytomegalic cell containing a intranuclear inclusion, which is sometimes surrounded by a clear halo ("owl's eye"). The presence of cytomegalic cells on mucosal biopsy specimens stained with hematoxylin and eosin has been considered the golden standard for establishing the diagnosis of CMV gastrointestinal disease. Immunohistochemistry with monoclonal antibody to CMV antigens and in situ hybridization for CMV DNA are useful in the diagnosis. We report 2 cases of CMV esophagitis and proctitis which showed characteristic endoscopic and histologic findings of the CMV infection.

Endoscopic Application of Modified Gianturco Z Biliary Stent / 대한소화기내시경학회지

Palliative treatment of malignant biliary obstructions represent the principal indications of endoscopic or percutaneous transhepatic implantation of endoprostheses. Many kinds of biliary stents have been used to maintain patency of the bile ducts obstructed by benign or malignant strictures. However, the biliary stent in current use, has a tendency to become blocked. In order to maintain a long-term stent patency before clogging, biliary stents with large diameters are needed and some kinds of expandable metal stents are proposed. The Hanaro stent (Sooho medi-tech Co. LTD, Seoul, Korea) is a modified Gianturco Z biliary stent, made of 0,01-inch stainless steel wire with a zigzag pattern. It has a spiral, cylindrical configuration and is 10 mm in expanded diameter. It hes been used only with the percutaneous transhepatic technique. In this article, we describe a new method for endoscopic retrograde placement of a modified Gianturco Z biliary stent. This report describes our experience on endoscopic application of a modified Gianturco Z biliary stent in a patient with malignant obstruction of the distal common bile duct.

A Case of Biliary Papillomatosis which Underwent Curative Resection / 대한소화기내시경학회지

Biliary Papillomatosis is an extremely rare pathologic entity. Only about 40 cases of intrahepatic or diffuse intra- and extrahepatic papillomatosis have been described since the first report in 1959 by Caroli. Although this is a histologically benign lesion, its course is unfavaurable because of its tendency to extend to the entire biliary tract, high recurrence rate following local excision and the probability of progression to malignancy. We described herein a case of biliary papillomatosis associated with diffuse bile duct dilatation. The patient, a 59-year-old male, was admitted to our hospital because of right upper abdominal pain and weight loss. Cholangiogram revealed multiple round filling defects in common hepatic duct with intrahepatic bile duct dilatation. The patient underwent Whipple's operation with right lobectomy. Grossly, multiple small pin-head sized polypoid masses were seen in common bile duct, common hepatic duct and right intrahepatic duct. Microscapically, papillary epithelial hyperplasia with moderate cellular atypia was seen and there was no evidence of stromal invasion. He is healthy with a follow-up for 7 months.

Two Cases of Villous Adenoma of the Common Bile Duct: Endoscopic Diagnosis and Treatment / 대한소화기내시경학회지

Villous adenomas of the common bile duct are rare and accordingly it is difficult to render a firm preoperative diagnosis. They are the unusual cause of bile duct obstruction and can mimic malignant extrahepatic biliary tumors or stones. Until recently, only a few cases had been reported in the medical literature. Although some authors advocate open surgical excision, especially with recurrence or carcinomatous change, an endoscopic resection of a distal common bile duct adenoma is a viable alternative for those patients considered poor surgical risks. We present two cases of villous adenoma of the common bile duct diagnosed by an endoscopic biopsy and endoscopically resected, with review of the relevant literature on the subject.

Two Cases of Anomalous Termination of the Common Bile Duct and the Pancreatic Duct into the Duodenal Bulb / 대한소화기내시경학회지

Many examples of congenital anomalies of the pancreatobiliary ductal system are now being found due to the development of new diagnostic techniques. Recently, despite the improvement in diagnosis and management of pancreatobiliary lesions, a lack of knowledge and understanding of these variations is undoubtedly responsible for many problems in medical and surgical management. In particular, drainage of the common bile duct and pancreatic duct at sites other than the second portion of the duodenum is an anatomieal curiosity. We report two cases in this study, of anomalous termination of the common bile duct and the pancreatic duct into the duodenal bulb, diagnosed by an ERCP and a gastroscopy.

A Study on the Calcium-Binding Protein in Gallbladder Bile / 대한내과학회지

OBJECTIVES: Calcium salts are usually present in the center of all types of gallstones, including pure cholesterol stones. It has been postulated that precipitation of calcium salts might act as a nidus for gallstone formation. Our goal was to determine whether a calcium-binding protein was present in bile and whether this protein has any calcium-binding properties. METHODS: Calcium-binding moiety was obtained by addition of CaC12 into the gallbladder bile. Calcium-binding protein was identified by SDS-PAGE (sodium dodecyl sulfate-polyacrylamide gel electrophoresis). The capacity to bind calcium was confirmed by autoradiography with 45Ca++. RESULTS: We identified a protein(M.W.

Distinct Expressions of TGF-a among Chronic Hepatitis, Liver Cirrhosis, and Hepatocellular Carcinoma / 대한간학회지

BACKGROUND/AIMS: Transforming growth factor-a(TGF-a) is a polypeptide cytokine related to cell proliferation and transformation. TGF-a binds to EGF receptor and stimulating DNA synthesis in liver cell. The hepatitis B virus (HBV) by itself is also believed to play a role in the hepatic carcinogenesis. Recently, it was reported that TGF-a and HBV were synergistic in action with rapid appearance of hepatocelluar carcinoma in bitransgenic mice. Although TGF- a is thought to play an important role in hepatocarcinogenesis, its expression during the natural history of HBV hepatitis was poorly understood. This investigation was performed to elucidate the dynamic changes and istinct immunohistochemical staining patterns in the course of chronic HBV hepatitis with specific reference to hepatocelluar carcinoma and to explain the role of TGF-a in the pathogenesis of hepatocelluar carcinoma. MATERIALS/METHODS: Employing TGF-a monoclonal antibody, signal detection was carried out by peroxidase-conjugated streptavidin in deparaffinized liver tissue sections taken from HBsAg positive patients. All of the liver tissue sections were proven HBV DNA positive by in situ hybridization. Immunohistochemical staining was performed in the tissue sections obtained from four normal controls, six from patients with chronic persistent hepatitis, five with chronic active hepatitis, eight with liver cirrhosis and eleven with hepatocellular carcinoma. RESULTS: The patterns of TGF-a immunoreactivity were cytoplasmic-grain types in normal controls and chronic persistent hepatitis, honeycomb types in chronic active hepatitis, occasional cytoplasmic-flooding types in liver cirrhosis, and cytoplasmic-grape types in hepatocellular carcinoma. A Shapiro-Wilk W test for frequency table analysis for the expression of TGF-a in these different disease groups was statistically significant. CONCLUSION: These data suggest that step-wise distinct expression of TGF-a enhancement in HBV associated chranic liver diseases which eventually resulted in the development of hepatocellular carcinoma were conceivably due to dysregulation of liver cell cycles by both HBV and TGF-a during the persistent repetition of cell cycles.

Centrilobular Distribution of Ethylnitrosourea-Induced Hepatocellular Foci in the Mouse / 대한간학회지

BACKGROUND/AIMS: Hepatocytes on the hepatic lobule mipate from portal zone to centrilobular mea as the DNA synthesis within it. And also, the xenobiotic reactions reveal characteristic differences associated with zone specific metabolism in the liver acinus. In this study, the zonal distribution of ethylnitrosourea (ENU)-induced hepatic precancerous lesion was stereologically investigated. METHODS: Nine B6C3F1 mices were given I.p. injection of ENU (60 ug/pn body weight) when the pups were 15 days old prior to sacrifices at 8 weeks of life. All the 150 consecutive sections, 3 p m in thickness, were stained with hematoxylin and eosin and identified the basophilic precancerous lesions with 80-165 p m diameter in equatorial plane by the Zeiss microprojector. And then the distances from the center of selected foci to terminal hepatic vein or portal vein branches were estimated under the microscopic fields. As a control group, the same estimations were performed from the random points by the appointments of random digit table. RESULTS: Mean distance between ENU-induced 52 hepatocellular foci and the nearest terminal hepytic vein was 181.15+112.39 p m (Mean+ SD), but that of randomly selected 104 points was 291.73+157.98pm (Mean+5D) (Students t-test, p<0.0005). Substantially, 52.7% of ENU-induced 52 hepatocellular foci were within 300 p m from the terminal hepatic vein, but randomly selected 104 points were only 50.9% (Shapiro Wilk W test, w=0.819857, p=0.048038). Mean distance from ENU-induced 52 foci to portal vein was 398.85+149.98pm (Mean+SD), but that from the randomly selected 104 points was 315.87+145.79 pm (Mean+SD)(Students t-test, p<0.0005). CONCLUSION: Stereologically, ENU-induced mice liver cell foci distribute non-randomly to Zone III, centrilobular zone of mouse hepatic acini where promote invasion toward terminal hepatic veins.

Two Cases of Mucinous Ductal Ectasia of the Pancreas which Showed Characteristic Pancreatoscopic Findings / 대한소화기내시경학회지

We report two cases of mucinous ductal ectasia of the pancreas which showed characteristic pancreatoscopic findings. They also showed characteristic duodenoscopic findings such as patulous ampullary orifice and mucus leakage from the papilla, and underlying pathology was hyperplasia in one case and adenoma in the other case, The insertions of pancreatoscope into the main pancreatic duct were easy without previous sphincterotomy and whitish frog egg-like mucosa was noted in one case and finger-like papillary projection was noted in the other case.

Simultaneous Measurement of Choledochal and Pancreatic Sphincter Motility ; Comparative Study of Manometric Parameters / 대한소화기내시경학회지

If manometric profiles of sphincter of Oddi(SO) measured from the pancreatic duct and the bild duct are essentially equal, then measurement of manometric profiles from only one duct would be adequate in evaluating SO dysfunction. We report a series of 9 patients whom we evaluate with SO manometry. Cannulation of both the biliary sphincter segment and pancreatic sphincter segment was archived consecutively in one session and we compared the manometric parameters of choledochal sphincter from those of pancreatic sphincter. 1) In 7 out of 9 patients(78%), normal manometric finding of SO were seen in both choledochal and pancreatic sphincters. However, in 2 out of 9 cases(22%) abnormal manometric findings were noted in only one sphincter segment. Elevation of basal pressure(n = l) and increased retrograde propagation(n = 1) were found in the pancreatic sphincter segment alone. 2) Tbe mean intraductal pressure in the pancreatic duct was significantly greater(12.6+/- 5.8mmHg) than that of common bile duct(3.8+/- 3.3mmHg)(p<0.01). However, basal pressure, amplitude, frequency and propagation sequence in the phasic contraction of SO were not different significantly between choledochal and pancreatic sphincter segment. In conclusion, SO manometry of both the pancreatic and bile duct is needed if complete manometric information is desired. Selective cannulation of common bile duct and pancreatic duct during SO manometry is necessary in order to diagnose segmental 50 dysfunction.

Tumor Marker Study of Pure Pancreatic Juice in Patient with Pancreatic Diaeases / 대한소화기내시경학회지

Several reports have described the usefulness of tumor markers detected in pancreatic juice for diagnosis of pancreatic cancer. We performed this study to evaluate the usefulness of tumor markers in pure pancreatic juice collected by duodenoscopic cannulation of pancreatic duct before and after injection of secretin. From April 1993 to July 1995, 8 cases of pancreatic cancer, 5 cases of benign pancreatic lesions, and 5 cases of benign biliary diseases without pancreatic lesion were involved. CEA and CA 19-9 immunoreactivity were measured by radioimmunoassay. Concentrations of CA 19-9 in pure pancreatic juice were significantly higher in patients with pancreatic cancer(median value; 3582, range 88.4-10410 IU/ml) than in control patients(median value 231, range 30.4-682 IU/ml)(p0.05). There was no significant correlation between levels of CA19-9, CEA in pancreatic juice and those levels in serum. The amounts of juice collected by duodenoscopic cannulation in patients with pancreatic cancer were 1.5+/- 0.9ml during 5 minutes before infusion of secretin, 11.3+/- 3.9ml, 10.8+/- 4.0ml, 10.6+/- 4.0ml in 5 minute interval after infusion of secretin. These results indicated that measurement of CA19-9 in pure pancreatic juice may be used as a marker for pancreatic cancer. Adequate amount of pancreatic juice was collected by duodenoscopic cannulation for evaluation of tumor marker, enzyme studies and cytology.

The Clinical Characteristics of 16 Patients with Sphincter of Oddi Dyskinesia / 대한소화기내시경학회지

We evaluated the clinical characteristics of patients with SO dyskinesia(n=16) who were confirmed by ERCP manometry during past 5 years. They were 14 male and 2 female and mean age was 52-year-old(range, 32-75). According to the criteria suggested by Hogan and Geenen, 13 patients were classified into biliary type and 3 patients into pancreatic type. Among the patients with biliary type(n=13), 12 patients fulfilled the criteria for group II dysfunction of SO and 1 patient for group III. Among the patients with pancreatic type(n=3), all fulfilled the criteria for group II. The manometric abnormalities were increased basal pressure(n=4), tachyoddia(n=7), increased retrograde propagation(n=3), tachyoddia and increased retrograde propagation(n=l), and tachyoddia and increased basal pressure(n=l). As treatment, 12 patients received conventional endoscopic sphincterotomy and 3 patients received endoscopic pancreatic sphincterotomy in addition to conventional endoscopic sphincterotomy. Satisfactory results (complete absence or marked reduction of pain) were obtained in 13(87%) out of 15 patients by endoscopic treatment. In conclusion, SO dyskinesia is not so common disease and the detection of patients with SO dyskinesia may increase by frequent application of ERCP manometry.

Choledochal Cyst and Anomalous Union of Pancreaticobiliary Duct in the Adult / 대한소화기내시경학회지

Background/Aims: Choledochal cyst is a congenital dilatation of extra- or intrahepatic bile duct. Recently, anomalous union of pancreaticobiliary duct(AUPBD) is supposed to be one of the major causes of choledochal cyst. The aims of this study are to assess the association ratio of AUPBD in choledochal cyst and whether the AUPBD in choledochal cyst have a clinical significance. Methods: The study subjects were 35 adult patients who were diagnosed by ERCP in Asan Medical Center from August, l990 to July, 1995. We have classified the type of choledochal cyst and AUPBD according to Todani and Kimura, respectively.

Application of Peroral Cholangioscopy in Biliary Diseases / 대한소화기내시경학회지

Retrograde transpapillary cholangioscopy can be safely performed by use of a mother-baby-scope system after endoscopic sphincterotomy. Improved endoscopes are now available and may lead to a better acceptance of this technique. Cholangioscopy is complementary to cholangiography for differential diagnosis of various types of bile duct lesions. From march 1992 to September 1994, we performed 15 cases of peroral cholangioscopy for evaluation of bile duct lesions. Indications of peroral cholangioscopy were 6 cases of benign biliary diseases and 9 cases of malignant biliary diseases. In benign diseases, two cases of extrahepatic bile duct stones, 1 case of intrahepatic duct stone with stricture, 2 cases of benign elevated lesions of bile duct and 1 case of occluded expandable metallic stent were involved. In malignant diseases, 7 cases of primary bile duct cancer, 2 cases of hepatocellular carcinoma with bile duct invasion were involved. By use of peroral cholangioscopy with biopsy, differential diagnosis of bile duct lesion was possible. As a complication, severe abdominal pain and hypotension was developed in one case during the procedure and in another case, cholangitis was developed after the procedure. In conclusion, peroral cholangioscopy is a safe and useful procedure in various types of biliary diseases especially in the differential diagnosis of malignancy.