Investigation of Skip Lesion at the Appendiceal Orifice in Ulcerative Colitis

BACKGROUND: Generally ulcerative colitis has a character that has a continuous pathological lesion from the rectum toward the cecum. Ulcerative appendicitis with a skipped appendiceal orifice lesion, which is unusual in ulcerative colitis, has been infrequently reported, and its clinical characteristics have not been identified. PURPOSE: This study was carried out to evaluate the incidence rate and the clinical characteristics of ulcerative appendicitis. METHODS: One hundred consecutive patients with ulcerative colitis who had been treated from Jan. 1997 to Aug. 1998 at Song-Do Colorectal Hospital were used for the study. Data evaluated included age, sex, involved site, clinical type, clinical severity of the disease, and endoscopic severity of the disease. RESULTS: Nineteen (19%) of the 100 patients had skipped lesions around the appendiceal orifice; the other 81 did not. There were no significant differences between these two groups with respect to the age and the sex distributions, the involved site, the clinical type, and the clinical severity. There was a correlation between the endoscopic grades, based on the Riley classification, of the lesions at the rectum and at the appendiceal orifice. Seven patients (36.8%) of the 19 patients with appendiceal orifice lesions showed an extended lesion from the appendiceal orifice to the cecum. CONCLUSIONS: We suggest that appendiceal lesions in ulcerative colitis are not infrequent. Even though no significant differences in the clinical characteristics of ulcerative colitis with ulcerative appendicitis, compared with those of ulcerative colitis without ulcerative appendicitis, were found, we suggest that more profound study of ulcerative appendicitis probably contribute to understand the pathophysiology of ulcerative colitis.

Clinicopathologic Features of Flat Elevations in the Colon and Their Significance / 대한소화기내시경학회지

BACKGROUND AND AIMS: There are two main routes in the growth and development of colo-rectal carcinomas, that is to say, the adenoma-carcinoma sequence and the route described by the de novo theory. The adenoma-carcinoma sequence has been considered a principal route for colorectal carcinomas for a long time, but recently the de novo cancer theory has become a controversial issue, and many authors have claimed that their cases were de novo carcinomas. Since Muto described small "flat elevations" and emphasized their significance as precursors of colorectal carcinomas, especially of flat colorectal carci-nomas, many flat elevations have been reported. He cautioned that the reported de novo carcinomas could also be carcinomas that developed from small flat adenomas. In addition, no data are available in Korea on the subject of flat elevations. Accordingly, we attempted to analyze flat elevations in the colon and to obtain correlations between their endoscopic and histologic features and their clinical implications. METHODS: The authors performed colonoscopic removal of 146 flat elevations from January 1997 to December 1997 at Song-Do Colorectal Hospital in Seoul, Korea. We reviewed and analyzed all those lesions. During colonoscopy, the sizes of the lesions were measured by an endoscopic ruler. RESULTS: The most common age group was the sixth decade. Only one case involved a patient under 30 years old. The male-to-female ratio was 3.2 : 1. The numbers of flat adenomas and flat adenocarcinomas were 68 and 1, respectively. These 69 cases amounted to 47.3% of the flat elevations. The malignancy rate for flat adenomas was 1.4% (1/69). There were no malignancies in flat elevations with diameters below 10 mm. Hyperplasticpolyps and chronic nonspecific inflammation showed 34.9% and 15.8%, respectively. Most of the flat elevations were smaller than 10 mm (98.6%). Recognizable endoscopic features of the flat elevations were redness (47.3%) and depression (15.8%), but 50 cases (34.2%) of the flat elevations had no specific features. Flat elevations smaller than 5 mm had discolorations in 15 cases (14%). The sigmoid colon was the most common site of the flat elevations. The percentage of flat elevations found in the sigmoid colon and the rectum was 70.5%. Hot biopsy was the main treatment for lesions smaller than 5 mm (75.7%), and snare polypectomy was the main treament for lesions from 5 mm to 9 mm. CONCLUSIONS: Flat elevations were detected without difficulty through careful examination. Nearly half of the flat elevations were flat adenomas. Accordingly, flat elevations may have some clinical significance on the basis of the adenoma-carcinoma sequence, but flat elevations greater than 10 mm should be managed cautiously because of possible malignancy.

Clinical Pitfalls in the Diagnosis and Treatment of Solitary Rectal Ulcer Syndrome / 대한소화기내시경학회지

BACKGROUND AND AIM: Solitary rectal ulcer syndrome (SRUS) is a rare disease, but it is encountered in the colorectal field. SRUS is usually associated with defecation disorders such as puborectalis dysfunction, rectal occult or overt prolapse, descending perineum syndrome, and so forth. Without knowledge about SRUS, the lesion could be easily overlooked or misdiagnosed. The histologic characteristics of SRUS are fibromuscular obliteration in the lamina propria and/or misplaced mucin-filled cysts below the muscularis mucosae, this latter condition being commonly referred to as colitis cystica profunda. However, these characteristics, even though they exist, are often missed in the initial biopsy specimens from SRUS patients, leading to misdiagnoses which cause delayed diag-nosis and treatment. In spite of the incomplete histologic indications, a careful and con-scientious clinician, using clinical features and characteristic endoscopic findings, would not misdiagnose SRUS lesions. In other words, the clinical features and endoscopic find-ings are as important as, if not more important than, the histologic findings in the diag-nosis of SURS lesions. METHODS: The authors reviewed and analyzed 18 recently experi-enced, biopsy-proven cases of SRUS with emphasis on gross classification and initial pathologic misdiagnoses. RESULTS: The most common age groups were the 5th and the 6th decades with a mean age of 46.5. The male-to-female ratio was 1.6 : 1. The most common symptoms were mucous discharge and defecation difficulty. All lesions involvedthe rectum, and the lower rectum was the most common site. Four diffuse-type lesions showed an extensive involvement up to the sigmoid colon. The most common form of SRUS was the elevated type (44.4%). The ulcerated type accounted for 27.8% of the cases and the flat type, 22.2%. Circumferential involvement of the SRUS was noticed in 3 cases. In 9 cases (50%), pathologic findings missed the characteristics of SRUS and indicated one or a combination of chronic nonspecific inflammation, a chronic ulcer, an inflam-matory polyp, an adenomatous polyp, pseudomembranous colitis, and adenocarcinoma. In three of these cases, a second biopsy was taken with the same results. Based on the clinician' s belief that SRUS was the cause of the lesions, all nine cases were reviewed by the pathologist and a final diagnosis of SRUS was reached. Associated disorders were hemorrhoids, rectoceles, rectal prolapse, perianal fistulas, descending perineum syndrome, and anal fissures. Among them, hemorrhoids and rectoceles were the most common disorders. Four SRUS cases were managed surgically with good results. The surgical treatment was an excision of the lesion itself and/or the correction of the associated disorders. CONCLUSIONS: The histologic characteristics of SRUS are the key to diagnosis, but sufficiently large biopsy specimens are necessary in order to obtain the correct diagnosis. However, the clinical features, including symptoms and associated disorders, plus the characteristic endoscopic findings can produce the correct diagnosis even in cases of insufficiently large biopsy samples or incomplete histologic reports.

Depressed-Type Early Colorectal Cancer / 대한소화기내시경학회지

BACKGROUND AND AIM: While detection and removal of polyps on the basis of the adenoma-carcinoma sequence has been a principal procedure for endoscopists, a new type of early colorectal cancer has been recognized and has become a hot issue. This new ailment is a depressed-type early colorectal cancer, which has the characteristics of rapid growth and early invasion of the submucosa. Though once considered to be mere conjecture, many researchers claim that this cancer is a de novo carcinoma despite of its rare occurrence. Recently, 4 depressed-type neoplastic lesions were presented, which signifies the importance of recognizing that this type of cancer exists and is characterized by rapid growth and early invasion of the submucosa. METHODS: The 4 recently experienced depressed neoplastic lesions were reviewed and analyzed with respect to their endoscopic and clinicopathologic characteristics. The sizes of the lesions were measured in the fully inflated state of the bowel by using an endoscopic ruler. RESULTS: The sites of predilection were the descending and sigmoid colon. All of the lesions were under 10 mm, with 75% being below 5 mm. The largest lesion was an 8-mm, well-differentiated mucosal carcinoma. The overall malignancy rate was 25%. Light redness was observed in all patients. Distortion with air transformation of the mucosal fold was also recognized in all the patients. The main treatment was endoscopic mucosal resection, which amounted to 50%. CONCLUSIONS: Depressed colorectal neoplasms are real. They can be determined by their characteristic endoscopic features, such as light redness and distortion with air transformation of the mucosal fold. Because of their characteristics of rapid growth and early invasion of the submucosa, it is important to detect and manage them in an early stage, when their sizes are below 10 mm.

Submucosal Invasive Cancer in the Colon / 대한소화기내시경학회지

BACKGROUND AND AIMS: A superficially invasive cancer in the colon is considered a candidate for an endoscopic resection. Therefore, detecting a superficially invasive cancer and differentiating it from a massively invasive cancer is an important key in selecting proper treatment. In order to accomplish this purpose, exact knowledge of the characteristics of submucosal invasive cancers is required. In this study, attempts to define those endoscopic features and draw guidelines for treatment were made. METHODS: Recently, 23 submucosal invasive cancers were experienced. All of them were detected by an endoscopic examination, and were treated by endoscopic therapy and/or surgical resection. These cancers were reviewed and analyzed with emphasis on size, configuration, differentiation, and treatment. RESULTS: The most common sizes ranged from 10 mm to 19 mm (47.8%). There were two minute lesions below 5 mm. The most common type of lesions was sessile (43.5%). Most lesions showed redness and 60.9% showed hardness. Many cases had characteristic features such as nodules (47.8%), bleeding easily upon touch (39.1%), erosion (39.1%), and white spots (34.8%). Other characteristic features were expanded figures, depressions, and mucosal convergence. Moderately-differentiated adenocarcinomas were predominant (8/15, 53.3%), and there were four polypoid cancers (4/17, 23.5%). In 43.5% of the lesions, only endoscopic treatment was enough. Forty-four percent of all patients treated endoscopically needed additional surgical resections because of uncertainty with respect to complete excision of the cancer and/or a poorly-differentiated adenocarcinoma with lymphatic invasion. There was no lymph node metastasis in any of the patients who underwent surgical resections, and three of them had no residual tumors, as the endoscopic treatment had completely excised the cancer. CONCLUSIONS: Accurate information on submucosal invasive cancers and recognition of the endoscopic characteristics of submucosal invasive cancers are necessary for their detection and management in an early stage. Moreover, it is possible to differentiate superficially invasive cancers from massively invasive ones by their characteristic features. Therefore, in selected patients with superficially invasive cancers, surgical resections can be avoided.

Diagnosis and Treatment of Depressed Colorectal Neoplastic Lesion

PURPOSE: Depressed colorectal cancer is a newly recognized colorectal cancer. It has the characteristics of rapid growth and early invasion of the submucosa. Accordingly, recognition of that lesion is important. However, it is still rarely detected in Korea. This study was designed to evaluate the characteristics of depressed colorectal neoplastic lesions. METHODS: We experienced 22 cases of depressed neoplastic lesions from January 1997 to December 1998. All of them were detected by performing colonoscopy. Among them, 6 were early colorectal cancers. The twenty-two cases accounted for 1.3% of all neoplastic lesions but advanced colorectal cancers encountered during the same period, and the six accounted for 6.6% of all early colorectal cancers during that period. We reviewed and analyzed those 22 lesions with respect to their clinicopathologic characteristics, especially size and histology. RESULTS: The most common age group was the 6th decade. The male-to-female ratio was 2.7 to 1. The predilection of sites were the descending colon, the transverse colon, and the sigmoid colon in that order. The most common size was 3~4 mm, 9 lesions (40.9%) and the next was 5~6 mm, 7 lesions (31.8%). Twenty lesions (90.9%) were 8 mm or smaller in size. The overall malignancy rate was 27.3% (6/22), comprising 9.1% (2/22) for mucosal cancers, and 18.2% (4/22) for submucosal ones. The two lesions which were larger than 10 mm were submucosal cancers. Endoscopic mucosal resection (EMR) was the most common type of treatment, accounting for 59.1%. Two submucosal cancers and one mucosal cancer were operated on without any endoscopic treatment. That one mucosal cancer had initially been suspected of being a submucosal one upon endoscopic examination. There were neither complications nor recurrences during the average 10-month follow-up. CONCLUSIONS: The target for detecting and treating depressed colorectal cancer should be lesions below 10 mm in size, and the treatment of choice should be EMR.

Clinical Analysis of Ulcerative Colitis

Ulcerative colitis is increasing now in Korea, and the diagnosis has become relatively easy because sigmoidoscopy and colonoscopy are frequently used. However, the result of treatment is not satisfactory because the relapse rate is very high. Hence, the aim of treatment is to put this disease into remission as soon as possible and to keep it in remission. The authors reviewed 80 confirmed ulcerative colitis cases which were treated from Feb. 1997 to Sep. 1997 at Song Do Colorectal Hospital. The results are as follows: 1) The male to female ratio for these 80 cases was 41:39, and the most prevalent age group was the 4th decade. 2) The most common clinical symptoms were anal bleeding in 77 cases(96%), diarrhea in 68 cases(85%), and abdominal pain in 21 cases(26%). 3) The extension of the disease were the proctitis in 47 cases(59%), the left - side colitis in 28 cases(35%), the total colitis in 4 cases(5%), and the atypical colitis in 1 case(1.3%). 4) The duration of the disease was below 6 month in 30 cases, 6 months to 1 year in 35 cases, and 1~5 years in 11 cases, and over 5 years in 4 cases. 5) Clinical types were the one-attack-only type(18 cases), the relapsing-remitting type(60 cases), the chronic continuous type(1 case), and the acute fulminating type(1 case). 6) In the 28 cases of left side colitis, the average time to remission depended on the medication was 18 days for a 5-ASA 5-ASA suppository, 14.5 days for a 5-ASA oral steroid, and 8.3 days for a 5-ASA budesonide enema. Thus, a budesonide enema is the most effective medication for obtaining remission. 7) The most commonly suspected predisposing factors for relapse were cessation of medication(58 cases), mental stress(18 cases), physical stress(15 cases), and inadequate diet(8 cases). As indicated above, ulcerative colitis is increasing now in Korea, and the rectum is the most commonly involved site for this disease. Relapsing-remitting ulcerative colitis is the most frequently occurring type. Almost all cases were easily put into remission within 4 weeks, but relapse frequently occurred. Suspected predisposing factors, such as mental stress, physical stress, and inadequate diet, should be avoided in order to prevent relapse, and medication, such as 5-aminosalicylic acid, should be continued to maintain remission.

Intraoperative Muscular Injection of Tarasyn(R) for Postoperative Hemorrhoidectomy Pain Management

The pain after a hemorrhoidectomy is widely feared by many patients who are mostly still treated with oral/intramuscular narcotics to control their pain postoperatively. In an effort to decrease posthemorrhoidectomy pain by applying newer methods of analgesia, a prospective trial was conducted to investigate the postoperative analgesic effect of Tarasyn(R) (ketorolac tromethamine) injected into the internal sphincter muscle at the time of the hemorrhoidectomy. Tarasyn(R) is a nonsteroidal anti-inflammatory drug introduced for intramuscular injection to control postoperative pain. It's action is peripheral. Therefore, it seems appropriate to inject it directly into the anal sphincter muscles when these are exposed during anorectal procedures. A total loading dose of 60 mg(2 cc, 30 mg/ml) of ketorolac was used intraoperatively. It was injected intramuscularly locally after completion of hemorrhoidectomy. Postoperative pain after a hemorrhoidectomy can be safely controlled in a patient by using newer methods of pain control, including supplemental use of the nonsteroidal analgesic ketorolac, which allows early release of the patient, the day of surgery by diminishing the postoperative pain in our study group. Another important advantage of a local injection of ketorolac was the elimination of urinary retention.

Ischemic Colitis

Ischemic colitis is an uncommon disease in Korea, but nowadays, the incidence of this disease is increasing in Korea. The reason is that the number of old patients is increasing and colonoscopic diagnosis is performed more frequently. It is especially important to differentiate it from other inflammatory bowel disease, such as infectious colitis, ulcerative colitis, Crohn's disease, and drug-induced colitis, because ischemic colitis is similar to other inflammatory bowel disease in symptoms and colonoscopic findings. However, the authors were able to differentiate ischemic colitis from other inflammatory bowel disease by close examination of a patient's history, microscopic examination and culture studies of the bacteria in the stool, and close observation of the changes in the colonoscopic findings with time. We experienced six cases of ischemic colitis and report them along with a brief review of the literature.

Fecal Soiling Manometric findings and treatment

BACKGROUND: Fecal continence is maintained by complex coordination of the sphincter mechanism and the anorectal sensation. Although most patients with fecal incontinence have a dysfunction of anal sphincter, fecal soiling seems to be related with a change in the anorectal sensation. PURPOSE: This study was done to evaluate the manometric findings and the methods of treatment for patients with fecal soiling. METHODS: The manometric findings from 25 patients with fecal soiling were compared with those from 22 normal controls. The patients were treated with biofeedback and with bulking agent. RESULTS: All the patients affected by fecal soiling were male except for one. There were no differences in the mean maximal resting pressure (MRP), and the mean maximal squeezing pressure (MSP) between the patients and the controls. The mean sphincter length and the mean length of the high pressure zone (HPZ) of the patients were significantly longer (50.5 vs. 55.6 mm and 28.2 vs. 31.3 mm, respectively; p<0.05 student t-test) than those of the controls. The minimal sensory volume (MSV) was significantly larger in the patient group, with a mean of 24.2 ml vs. 17.8 ml, than in the control group (p<0.05). The mean volume necessary to induce the recto-anal inhibitory reflex (RR) was 47.1 ml for the control group and 32.6 ml for the patient group (p<0.05). In the longitudinal profile of the anal sphincter, the HPZ was shifted proximally and the pressure peak was broader in the fecal soiling group. Of the 14 patients treated with biofeedback, 11 responded well. CONCLUSION: Almost all of the patients affected by fecal soiling were men. The MRP and the MSP of the patients with fecal soiling were not lower than those of the normal controls. The sphincter length was longer in the patients with soiling than in the controls(p<0.05). However, for the fecal soiling group the distribution of the pressure along the anal canal was different in the sense that the HPZ was shifted proximally and the pressure peak was broader. The changes in the MSV and the RR suggest that there may be a defect in the anorectal sensation. The patients responded well to the combined use of biofeedback and a bulking agent.

Tubulovillous and Villous Adenomas of the Colon and Rectum - Endoscopic Characteristics and Management / 대한소화기내시경학회지

BACKGROUND/AIMS: A villous tumor, histologically villous or tubulovillous adenoma, is a clinical challenge because of its higher potential for malignancy and higher recurrence rate. However, information and experience with these tumors in the Korean people is still lacking. For that reason, we designed this study to review and analyze the colonoscopic features, the potential for malignancy, and the treatiment with respect to the confirmation of guidelines for the accurate diagnosis and reasonable management of such tumors in the Korean population. MATERIALS AND METHODS: We performed 753 polypectomies, including 4 transanal excisions and several bowel resections, from January 1996 to May 1997 at Song-Do Colorectal Hospital in Seoul, Among them, 447 cases (59.4%) were adenomas, comprising 405 (53.8%) tubular adenomas, 31 (4.1%) tubulovillous adenomas, and 11 (1.5%) villous adenomas. We analyzed the 42 (5.6%) tubulovillous and villous adenomas.

Clinical Study of External Thrombotic Hemorrhoids-A study of the changes in

An external thrombotic hemorrhoid is a very painful disease with a high incidence rate. The chief complaints encountered by the surgeon are protrusion and pain. However, because the spontaneous healing rate is very high, there is no consensus on whether conservative management or surgery is a more effective treatment policy. In an attempt to resolve this problem, we performed a clinical analysis of fifty patients with external thrombotic hemorrhoids who were treated by conservative management at Song-Do Colorectal Hospital from October 1996 to December 1996. We recorded the time required for the protrusion and the pain to disappear and performed manometry to check the sphincter pressure and tissue pathology to determine the pathogenesis of the external thrombotic hemorrhoid. The results are as follows: 1) Based on pathology, the cause of the external thrombotic hemorrhoids was venous thrombosis due to venous stasis, not a hematoma due to venous rupture. 2) Manometry showed that the resting sphincter pressure and the squeezing sphincter pressure for the patients with external thrombotic hemorrhoids was higher than those of the control group, which was the reason for the venous stasis. In conclusion, because an external thrombotic hemorrhoid is just a thrombosis due to venous stasis, the thrombosis can be improved by using methods such as a warm sitz bath and analgesics to decrease the sphincter pressure. Hence, conservative management should be the preferred treatment in almost all cases.

Surgical Managements of Anal Stricture

Anal stricture is a mechanical narrowing of the anal canal due to contracture of the epithelial lining which has been supplanted by fibrous connective tissue. We reviewed 82 patients with anal strictures who were admitted at Song-Do Colorectal Hospital from Jan. 1994 to Dec. 1996. The etiology of the strictures were injection therapy with necrotizing agent in 62 patients(78%), secondary to hemorrhoid and fistular operations in 13 patients(17%), and other causes in 7 patients(8.5%). The degree of anal stricture was mild in 40 patients, moderate in 33 patients, and severe in 9 patients. The operation methods used to treat the anal strictures were infernal sphincterotomy in 27 patients, local advancement flap in 42 patients, and rotational flap in 13 patients; the selection of the operation method was based on the cause, severity and level of the stricture. During the local advancement or rotational flap operation, a concurrent internal sphincterotomy was also employed in selected patients who had a fibrotic muscular component contributing to the stricture. We preferred to use a sliding skin graft in the advancement flap operation and a C-flap in rotational flap operation. According to a follow-up study with an average follow-up of 20 months, 24 of the 27 patients with mild stricture, 19 of the 24 patients with moderate stricture, and 7 of the 8 patients with severe stricture had good results, and remained 3 patients with mild stricture, 5 patient with moderate stricture, and 1 patient with severe stricture had fair results. Mild anal strictures were effectively treated by sphincterotomy or one or two sliding skin grafts, moderate to severe anal strictures with diaphragmatic type were treated by anorectoplasty, and moderate to severe low anal stoictures with annular type were effectively treated by two or three sliding skin grafts. Based on these results, sliding skin grafts should be effective in most cases of moderate to severe anal canal stricture, although occasionally a rotational flap may be indicated in cases of severe lack of the anoderm.