Recent advances in the management of difficult bile-duct stones: a focus on single-operator cholangioscopy-guided lithotripsy

The most effective and the standard treatment for bile duct stones (BDSs) is endoscopic retrograde cholangiopancreatography (ERCP). However, in 10% to 15% of patients with BDSs, the stones cannot be removed by conventional ERCP, which involves endoscopic sphincterotomy followed by balloon or basket extraction. Additional techniques or devices are often necessary to remove these difficult bileduct stones, including endoscopic papillary large balloon dilatation to make a larger papillary opening and/or mechanical lithotripsy to fragment the stones. Advances in cholangioscopy have made possible electrohydraulic or laser lithotripsy under direct cholangioscopic visualization during ERCP. Cholangioscopy-guided lithotripsy could be another good option in the armamentarium of techniques for removing difficult BDSs. Here we review endoscopic techniques based on single-operator cholangioscopy for the management of difficult BDSs.

Predictors of Malignancy in “Pure” Branch-Duct Intraductal Papillary Mucinous Neoplasm of the Pancreas without Enhancing Mural Nodules on CT Imaging: A Nationwide Multicenter Study

BACKGROUND/AIMS: Presence of enhanced mural nodules, which can be visualized using computed tomography (CT), is one of high-risk stigmata in branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs). Conversely, the absence of enhanced mural nodules on preoperative imaging does not exclude malignant risk. The present study aimed to investigate other morphological features as predictors of malignancy in “pure” BD-IPMNs without enhanced mural nodules on CT. METHODS: This retrospective study included 180 patients with surgically confirmed “pure” BD-IPMNs of the pancreas and no enhanced mural nodules on preoperative CT. The study was conducted at 15 tertiary referral centers throughout South Korea. Univariate and multivariate analyses were used to identify significant predictors of malignancy. RESULTS: BD-IPMNs with low-grade (n=84) or moderate-grade (n=76) dysplasia were classified as benign; those with high-grade dysplasia (n=8) or invasive carcinoma (n=12) were classified as malignant. The multivariate analysis revealed that cyst size ≥30 mm (odds ratio, 8.6; p=0.001) and main pancreatic duct diameter ≥5 mm (odds ratio, 4.1; p=0.01) were independent risk factors for malignancy in “pure” BD-IPMNs without enhanced mural nodules on CT. Endoscopic ultrasound detected enhanced mural nodules (6/82) that had been missed on CT, and two IPMNs with enhanced mural nodules were malignant. CONCLUSIONS: In patients with “pure” BD-IPMNs who have no enhanced mural nodules on CT, cyst size ≥30 mm and main pancreatic duct diameter ≥5 mm may be associated with malignancy.

Chemotherapy for Small Cell Carcinoma of Gallbladder: A Case Report / 대한췌담도학회지

Small cell carcinoma (SCC) of the gallbladder is a rare disease. It is an aggressive tumor that tends to metastasis early and is associated with poor prognosis. Median overall survival is reported to be approximately 13 months. Metastatic disease has a worse prognosis, and median overall survival is reported to be approximately 4 months. A 65-year-old male patient was diagnosed with the SCC of the gallbladder and was treated with cisplatin/etoposide chemotherapy followed by radiation therapy. Here, we describe the case of the SCC of the gallbladder who survived more than 3 years followed by the review of the literatures on this disease.

A Double-Layered Covered Biliary Metal Stent for the Management of Unresectable Malignant Biliary Obstruction: A Multicenter Feasibility Study

BACKGROUND/AIMS: The covered self-expandable metal stent (CMS) was developed to prevent tumor ingrowth-induced stent occlusion during the treatment of malignant biliary obstruction. However, complications such as cholecystitis, pancreatitis, and stent migration can occur after the endoscopic insertion of CMSs. The aim of the present study was to assess the efficacy and safety of a double-layered CMS (DCMS) for the management of malignant bile duct obstruction. METHODS: DCMSs were endoscopically introduced into 59 patients with unresectable malignant extrahepatic biliary obstruction at four tertiary referral centers, and the patient medical records were retrospectively reviewed. RESULTS: Both the technical and functional success rates were 100%. Procedure-related complications including pancreatitis, cholangitis, stent migration, and liver abscess occurred in five patients (8.5%). The median follow-up period was 265 days (range, 31 to 752 days). Cumulative stent patency rates were 68.2% and 40.8% at 6 and 12 months, respectively. At the final follow-up, the rate of stent occlusion was 33.9% (20/59), and the median stent patency period was 276 days (range, 2 to 706 days). CONCLUSIONS: The clinical outcomes of DCMSs were comparable to the outcomes previously reported for CMSs with respect to stent patency period and complication rates.

Room for Quality Improvement in Endoscopist-Directed Sedation: Results from the First Nationwide Survey in Korea

BACKGROUND/AIMS: This study sought to characterize the current sedation practices of Korean endoscopists in real-world settings. METHODS: All active members of the Korean Society of Gastrointestinal Endoscopy were invited to complete an anonymous 35-item questionnaire. RESULTS: The overall response rate was 22.7% (1,332/5,860). Propofol-based sedation was the dominant method used in both elective esophagogastroduodenoscopy (55.6%) and colonoscopy (52.6%). The mean satisfaction score for propofol-based sedation was significantly higher than that for standard sedation in both examinations (all p<0.001). The use of propofol was supervised exclusively by endoscopists (98.6%). Endoscopists practicing in nonacademic settings, gastroenterologists, or endoscopists with <10 years of endoscopic practice were more likely to use propofol than were their counterparts (all p<0.001). In total, 27.3% of all respondents performed sedation practices without having undergone sedation training, and 27.4% did so without any formal sedation protocols. The choice of propofol as the dominant sedation method was the only significant predictor of endoscopist experience with serious sedation-related adverse events (odds ratio, 1.854; 95% confidence interval, 1.414 to 2.432). CONCLUSIONS: Endoscopist-directed propofol administration is the predominant sedation method used in Korea. This survey strongly suggests that there is much room for quality improvement regarding sedation training and patient vigilance in endoscopist-directed sedation.

Efficacy of Magnesium Trihydrate of Ursodeoxycholic Acid and Chenodeoxycholic Acid for Gallstone Dissolution: A Prospective Multicenter Trial

BACKGROUND/AIMS: Cholecystectomy is necessary for the treatment of symptomatic or complicated gallbladder (GB) stones, but oral litholysis with bile acids is an attractive alternative therapeutic option for asymptomatic or mildly symptomatic patients. This study was conducted to evaluate the efficacy of magnesium trihydrate of ursodeoxycholic acid (UDCA) and chenodeoxycholic acid (CDCA) on gallstone dissolution and to investigate improvements in gallstone-related symptoms. METHODS: A prospective, multicenter, phase 4 clinical study to determine the efficacy of orally administered magnesium trihydrate of UDCA and CDCA was performed from January 2011 to June 2013. The inclusion criteria were GB stone diameter or =50%, radiolucency on plain X-ray, and asymptomatic/mildly symptomatic patients. The patients were prescribed one capsule of magnesium trihydrate of UDCA and CDCA at breakfast and two capsules at bedtime for 6 months. The dissolution rate, response rate, and change in symptom score were evaluated. RESULTS: A total of 237 subjects were enrolled, and 195 subjects completed the treatment. The dissolution rate was 45.1% and the response rate was 47.2% (92/195) after 6 months of administration of magnesium trihydrate of UDCA and CDCA. Only the stone diameter was significantly associated with the response rate. Both the symptom score and the number of patients with symptoms significantly decreased regardless of stone dissolution. Adverse events necessitating discontinuation of the drug, surgery, or endoscopic management occurred in 2.5% (6/237) of patients. CONCLUSIONS: Magnesium trihydrate of UDCA and CDCA is a well-tolerated bile acid that showed similar efficacy for gallstone dissolution and improvement of gallstone-related symptoms as that shown in previous studies.

Recent Advances in the Management of Recurrent Bile Duct Stones / 대한소화기학회지

Approximately 3-15% of patients who have undergone removal of bile duct stones with endoscopic sphincterotomy have recurrence of stones which often presents as acute cholangitis. Despite better understanding on the factors and mechanisms underlying the recurrence of bile duct stones achieved during the past few decades, endoscopic removal still remains the mainstay of management for recurrent bile duct stones. Recently investigated and suggested management of recurrent bile duct stones are highlighted in this review.

Polymorphisms in PRKCDBP, a Transcriptional Target of TNF-alpha, Are Associated With Inflammatory Bowel Disease in Korean

BACKGROUND/AIMS: Emerging data indicate that polymorphic sequence variations in the tumor necrosis factor alpha (TNF-alpha) gene may affect its production, and be associated with the risk of inflammatory bowel disease (IBD). PRKCDBP is a putative tumor suppressor gene and a transcriptional target of TNF-alpha. The aim of this case-control study is to explore the possible association of single nucleotide polymorphisms (SNPs) in PRKCDBP with the development of IBD in Koreans. METHODS: Genotyping analysis of four SNPs of PRKCDBP [rs35301211 (G210A), rs11544766 (G237C), rs12294600 (C797T), and rs1051992 (T507C)] was performed on 170 ulcerative colitis (UC),131 Crohn's disease (CD) patients, and 100 unrelated healthy controls using polymerase chain reaction and restriction fragment length polymorphism. RESULTS: Heterozygous configuration of three SNPs (G210A, G237C, and C797T) was very rare in both patients and healthy controls. However, allele frequencies of the T507C SNP showed a significant difference between UC patients and controls (P=0.037). The CC genotype of the T507C SNP was identified in 46.6% (61 of 131) of CD and 49.4% (84 of 170) of UC patients, but only in 33.0% (33 of 100) of healthy controls. Furthermore, CC homozygosity was more prevalent than TC heterozygosity in both CD and UC patients versus controls (P=0.016; gender-adjusted odds ratio [aOR], 2.16; 95% confidence interval [CI], 1.16-4.04 and P=0.009; aOR, 2.09; 95% CI, 1.193.64; respectively) CONCLUSIONS: Our results suggest that the T507C SNP in PRKCDBP, a TNF-alpha-inducible gene, might be associated with susceptibility to IBD (particularly UC) development in Koreans.

Highlights from the 50th Seminar of the Korean Society of Gastrointestinal Endoscopy

The July issue of Clinical Endoscopy deals with selected articles covering the state-of-the-art lectures delivered during the 50th seminar of the Korean Society of Gastrointestinal Endoscopy (KSGE) on March 30, 2014, highlighting educational contents pertaining to either diagnostic or therapeutic gastrointestinal (GI) endoscopy, which contain fundamental and essential points in GI endoscopy. KSGE is very proud of its seminar, which has been presented twice a year for the last 25 years, and hosted more than 3,500 participants at the current meeting. KSGE seminar is positioned as one of premier state-of-the-art seminars for endoscopy, covering topics for novice endoscopists and advanced experts, as well as diagnostic and therapeutic endoscopy. The 50th KSGE seminar consists of more than 20 sessions, including a single special lecture, concurrent sessions for GI endoscopy nurses, and sessions exploring new technologies. Nine articles were selected from these prestigious lectures, and invited for publication in this special issue. This introductory review, prepared by the editors of Clinical Endoscopy, highlights core contents divided into four sessions: upper GI tract, lower GI tract, pancreatobiliary system, and other specialized topic sessions, including live demonstrations and hands-on courses.

Successful Eradication of Helicobacter pylori Using Modified Quadruple Therapy in Patient with Long-lasting H. pylori-induced Active Gastritis

Helicobacter pylori is a well known major causative agent of chronic gastritis. In general, the inflammation induced by this organism is a chronic active gastritis, which develops into atrophic gastritis. It is well established that atrophic gastritis is one of the major risk factors of intestinal gastric cancer. Thus, severe long-lasting gastritis induced by H. pylori infection is considered for treatment to prevent gastric cancer. We experienced a case of dramatic eradication of H. pylori using a fifth-line salvage therapy in a patient with H. pylori-induced active gastritis during four years of follow-up.

First-line Treatment for Chronic Pancreatitis with Stones: Extracorporeal Shock Wave Lithotripsy? / 대한소화기학회지

No abstract available.

Highlights of International Digestive Endoscopy Network 2013

Rapid advances in the technology of gastrointestinal endoscopy as well as the evolution of science have made it necessary for us to continue update in either various endoscopic techniques or state of art lectures relevant to endoscopy. International Digestive Endoscopy Network (IDEN) 2013 was held in conjunction with Korea-Japan Joint Symposium on Gastrointestinal Endoscopy (KJSGE) during June 8 to 9, 2013 at Seoul, Korea. Two days of impressive scientific program dealt with a wide variety of basic concerns from upper gastrointestine (GI), lower GI, pancreaticobiliary endoscopy to advanced knowledge including endoscopic submucosal dissection forum. IDEN seems to be an excellent opportunity to exchange advanced information of the latest issues on endoscopy with experts from around the world. In this special issue of Clinical Endoscopy, we prepared state of art review articles from contributing authors and the current highlights will skillfully deal with very hot spots of each KJSGE, upper GI, lower GI, and pancreaticobiliary sessions by associated editors of Clinical Endoscopy.

Highlights of the 48th Seminar of Korean Society of Gastrointestinal Endoscopy

This special May issue of Clinical Endoscopy discusses the tutorial contents dealing with either the diagnostic or therapeutic gastrointestinal (GI) endoscopy that contain very fundamental and essential points in this filed. The seminar of Korean Society of Gastrointestinal Endoscopy (KSGE) had positioned as one of prime educational seminars covering the very beginner to advanced experts of GI endoscopy. Besides of four rooms allocated for each lecture, two additional rooms were open for either live demonstration or hands-on course, covering totally 20 sessions including one special lecture. Among these prestigious lectures, 12 lectures were selected for the current review articles in this special issue of Clinical Endoscopy journal. Basic course for beginner to advanced tips to expert were all covered in this seminar. This introductory review prepared by four associated editors of Clinical Endoscopy contained core contents divided into four sessions-upper gut, lower gut, pancreaticobiliary, and specialized topic session part-to enhance understandings not covered by enlisted review articles in this issue.

A Case of Early Gastric Cancer with Solitary Metastasis to the Pleura

The incidence of early gastric cancer (EGC) has increased to >50% in Korea owing to a higher detection rate caused by rapid advances in diagnostic instrumentation. EGC with distant metastasis has been rarely reported. Here, we report the case of a 76-year-old woman in whom general EGC was initially diagnosed by endoscopy and endoscopic ultrasonography. She subsequently underwent endoscopic submucosal dissection (ESD). Histological examination of the ESD specimen revealed that neoplastic cells were located predominantly in the submucosal layer and submucosal lymphatic channels. Metastatic cancer cells were also found in the pleural effusion. After conducting all analyses, including immunohistochemical staining, we concluded that the patient had primary EGC with pleural metastasis.

Septic Pylephlebitis as a Rare Complication of Crohn's Disease / 대한소화기학회지

Thrombophlebitis of the portal venous system (PVS) with superimposed bacterial infection (septic pylephlebitis) is an extremely rare complication of Crohn's disease (CD), and therefore diagnosis of septic pylephlebitis is difficult without high clinical suspicion. A 16-year old male patient who was diagnosed with CD 3 months earlier was admitted with recurrent fever and abdominal pain. CD activity had been well controlled with conventional medical treatment during a follow-up period. Abdominal contrast-enhanced computed tomography showed massive thrombosis in the PVS without evidence of intra-abdominal infection, and blood cultures were positive for Streptococcus viridians. There was no evidence of deep vein thrombosis or pulmonary thromboembolism, and all laboratory tests for thrombophilia were normal. Based on these findings, the patient was diagnosed with septic pylephlebitis complicated with CD, and was successfully treated with intravenous antibiotic therapy combined with anticoagulation. This case suggests that early comprehensive evaluation is crucial for immediate diagnosis and proper treatment of septic pylephlebitis in patients with CD who present with fever and abdominal pain of unknown origin, even with stable disease activity and absence of other intra-abdominal infections.

Tips for Successful Endoscopic Retrograde Cholangiopancreatography in Patients with Billroth II Gastrectomy

No abstract available.

International Digestive Endoscopy Network 2012: A Patchwork of Networks for the Future

This special September issue of Clinical Endoscopy will discuss various aspects of diagnostic and therapeutic advancement of gastrointestinal (GI) endoscopy, explaining what is new in digestive endoscopy and why international network should be organized. We proposed an integrated model of international conference based on the putative occurrence of Digestive Endoscopy Networks. In International Digestive Endoscopy Network (IDEN) 2012, role of endoscopy in gastroesophageal reflux disease and Barrett's esophagus, endoscopy beyond submucosa, endoscopic treatment for stricture and leakage in upper GI, how to estimate the invasion depth of early GI cancers, colonoscopy in inflammatory bowel disease (IBD), a look into the bowel beyond colon in IBD, management of complications in therapeutic colonoscopy, revival of endoscopic papllirary balloon dilation, evaluation and tissue acquisition for indeterminate biliopancreatic stricture, updates in the evaluation of pancreatic cystic lesions, issues for tailored endoscopic submucosal dissection (ESD), endoluminal stents, management of upper GI bleeding, endoscopic management of frustrating situations, small bowel exploration, colorectal ESD, valuable tips for frustrating situations in colonoscopy, choosing the right stents for endoscopic stenting of biliary strictures, advanced techniques for pancreaticobiliary visualization, endoscopic ultrasound-guided biliopancreatic drainage, and how we can overcome the obstacles were deeply touched. We hope that IDEN 2012, as the very prestigious endoscopy networks, served as an opportunity to gain some clues for further understanding of endoscopic technologies and to enhance up-and-coming knowledge and their clinical implications from selected 25 peer reviewed articles and 112 invited lectures.

Drug Rash with Eosinophilia and Systemic Symptoms Syndrome in a Patient on Sulfasalazine for Ulcerative Colitis

Drug rash with eosinophilia and systemic symptoms (DRESS) is a life-threatening systemic drug reaction characterized by fever, rash, hematological abnormalities, lymphadenopathy, and multiple internal organ involvement. Unfortunately, a long latency period as well as clinicians' unawareness of the disease entity often results in a delay of prompt diagnosis and treatment in clinical practice. A search of the literature revealed only few reports on DRESS in patients with inflammatory bowel diseases. The pathogenesis of the disease is not clearly understood, although several possible mechanisms, such as drug detoxification, slow acetylation, and reactivation of human herpes viruses, have been proposed in its development. Here, we present a rare case of DRESS associated with viral reactivation and defects in drug metabolism in a 22-year-old man who had been on sulfasalazine for 6 weeks to treat ulcerative colitis.

Efficacy of Infliximab Rescue Therapy in Hospitalized Patients with Steroid-Refractory Ulcerative Colitis: Single Center Experience

BACKGROUND/AIMS: In hospitalized patients with acute steroid-refractory UC, infliximab has been demonstrated to be one of the medical rescue therapies to avoid colectomy. We report the result of a retrospective observational study to find the efficacy and safety of infliximab as a rescue therapy in our hospital. METHODS: Between January 2007 and January 2010, 9 hospitalized patients with steroid-refractory UC were selected to receive three infusions of infliximab (5 mg/kg), at weeks 0, 2, and 6. Efficacy of treatment was evaluated at 8 weeks after the first infliximab infusion and at the end of follow-up period. Adverse events related to infliximab rescue therapy were also collected. RESULTS: Seven patients (77.8%) had completed 3 infusions of infliximab and achieved clinical response at 8 weeks after the first infliximab infusion. Clinical remission rate and the rate of mucosal healing at 8 weeks were 57.1% (4/7) and 71.4% (5/7), respectively. They were followed up for median time of 24.9 months (19.5-53.6 months). One patient underwent emergency colectomy at weeks 2, due to colon perforation, while another patient had discontinued infliximab treatment at weeks 4, because of Clostridium difficile-associated colitis. Finally, colectomy was avoided in 77.8% (7/9) of cases. There was no mortality. CONCLUSIONS: Rescue therapy with infliximab has sustained clinical benefit in 88.9% of our hospitalized patients with acute steroid-refractory UC. Future prospective and long-term follow-up trials with a large number of patients are needed to confirm the efficacy and safety of the treatment.

Highlights of Pancreatobiliary Endoscopy in International Digestive Endoscopy Network 2012: How Much Has It Advanced?

The pancreatobiliary organ is composed of one of the most complicated structures and complex physiological functions among other digestive organs in our body. This is why endoscopic procedure in pancreaticobiliary system requires rather complicated techniques. In International Digestive Endoscopy Network (IDEN) 2012, many interesting pancreatobiliay endoscopy related topics were presented. Basic procedures like endoscopic papillary balloon dilation (EPBD), advanced techniques like endoscopic necrosectomy, prevention and management of post-ERCP pancreatitis, and spyglass system are reviewed in this highlight summary.