Comparison of the Cut Direction between Gross Finding, Streoscopic Finding, and Pathologic Mapping of Endoscopic Submucosal Dissection Specimen / 대한소화기학회지

BACKGROUND/AIMS: The correct pathologic review is very important after endoscopic submucosal dissection. The cut direction of specimen should be the right angle of the closest area between the lesion and the lateral margin for the correct pathologic review. The aim of this study was to evaluate the concordance of the gross finding and stereoscopic finding compared to the pathologic mapping in the setting of the cut direction. METHODS: Between December 2008 and May 2009, the objects were 48 specimens in 46 patients who were diagnosed with early gastric cancer and high grade adenoma after endoscopic submucosal dissection. The specimens were stained with hematoxylin and observed by the stereoscopy and analyzed by the image analysis system. The cut direction was divided by an angle of 45 degree based on the oral side of the specimen, and the cut directions of the gross finding, the stereoscopic finding, and the pathologic finding were compared. RESULTS: The concordance of the gross finding in the setting of the cut direction was 68% (33/48), and the kappa value was 0.626, and the concordance of the stereoscopic finding in the setting of the cut direction was 87% (33/48), and the kappa value was 0.874. The accuracy of the gross finding was significantly lower than that of the stereoscopic finding in the setting of the cut direction (p<0.05). CONCLUSIONS: The endoscopist needs the careful observation and close attention in the setting of the cut direction of the specimen by gross finding, and stereoscopic analysis may be a useful tool for decision of the cut direction.

A Case of Meckel's Diverticulum Diagnosed for Recurrent Hematochezia in Old Age / 대한소화기내시경학회지

The small bowel is the most common site of an unknown origin of gastrointestinal bleeding. Meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract in children. The complications from Meckel's diverticulum such as bleeding decrease with age, and so Meckel's diverticular bleeding is very rare in old age patients. The diagnosis of Meckel's diverticulum may be very difficult and especially in old age patients. Capsule endoscopy and double balloon enteroscopy have recently become useful diagnostic tools for assessing diverticular bleeding and small bowel lesions as these techniques can examine the entire small intestine. We report here on a case of Meckel's diverticulum that was detected by capsule endoscopy and double balloon enteroscopy and this was confirmed by surgery in a 76-year-old man with recurrent hematochezia.

A Case of Endoscopic Removal of Hypopharyngeal Papilloma under General Anesthesia with Nasotracheal Intubation / 대한소화기내시경학회지

Benign tumors of the hypopharynx are uncommon and papillomas are quite rare. Papillomas grow very slowly and they are well defined, mobile and sometimes pedunculated masses. In order to minimize the patient's discomfort, many endoscopists tend to pass the scope quickly through the throat, without trying to visualize the oral and hypopharyngeal lesion. As for the treatment of hypopharyngeal lesions, cases of endoscopic treatment are rare and any guidelines have not yet been defined. We present here a case of endoscopic removal of a hypopharyngeal papilloma with the patient under general anesthesia and nasotracheal intubation.

Characteristics of Lesions Misdiagnosed as Obscure Gastrointestinal Bleeding / 대한소화기내시경학회지

BACKGROUND/AIMS: Double balloon enteroscopy (DBE) and capsule endoscopy (CE) are useful for evaluation of obscure gastrointestinal bleeding (OGIB). However, many bleeding sources within reach of conventional upper and lower endoscopes can be missed in patients who have undergone DBE and CE for OGIB. The aim of this study was to determine the incidence and characteristics of OGIB lesions within reach of a conventional endoscope in patients undergoing DBE and CE for the indication of OGIB. METHODS: This retrospective study included 134 patients who were evaluated for OGIB between March 2003 and May 2009 at Soonchunhyang University Hospital. RESULTS: Of the 134 patients, 76 underwent CE, 28 patients underwent DBE, and 30 underwent both CE and DBE. The incidence of OGIB lesions within reach of a conventional upper and lower endoscopy was 9.7% (n=13) and the mean age of patients was 51 years (range: 20 to 69 years). The most commonly missed lesion was duodenal ulcer (n=8). The other missed lesions were gastric ulcer (n=2), terminal ileal ulcer (n=2) and ileocecal valve ulcer (n=1). CONCLUSIONS: The duodenum should be observed closely in initial upper and lower endoscopy by experienced endoscopists. Performing a second EGD and ileocolonoscopy before DBE and CE may increase the diagnostic yield and improve cost-effectiveness in patients with OGIB.

A Case of Jeujunogastric Intussusception Presented with Hematemesis after Distal Gastrectomy / 대한소화기학회지

Adult intussusception represents 5% of all cases of intussusception and accounts for only 1-5% intestinal obstructions. Intussusception is a rare complication after gastric surgery with an incidence estimated at 0.1%. Early diagnosis of the acute onset intussusception is critical because mortality rates increase abruptly with delay in surgical treatment. We present here a case of jejunogastric intussusception diagnosed by gastroscopy in a patient with a history of distal gastrectomy due to early gastric cancer who had experienced hematemesis.

Clinical Availability of Endoscopic Incision and Submucosal Dissection for the Treatment of Gastric Neoplasms

PURPOSE: Endoscopic incision and submucosal dissection (EISD) is a technique that is being implemented for the resection of gastric adenomas and early gastric cancer (EGC). Since EISD requires a high degree of skill and experience, and due to its association with a moderate risk of gastrointestinal bleeding, its use has been limited. The objective of this study is to investigate the clinical benefits of EISD based upon clinical data on the EISD procedure. MATERIALS AND METHODS: This study was conducted at Soonchunhyang University Hospital and it included 179 gastric adenoma and early gastric carcinoma lesions from 164 patients who had undergone an EISD from February 2003 to May 2005. RESULTS: Among the total of 179 lesions, the distributions of EGC and adenomas were 70.3% (126/179) and 23.4% (42/179) respectively. The sizes of lesions were divided into 10 mm or less, 11~20 mm, 21~30 mm and greater than 31 mm and each rates are 10.0% (18/179), 46.3% (83/179), 30% (50/179) and 15.6% (28/ 179). Among 120 cases which could be measured depth of lesion in according to pathologic findings, m1 (0.8%, 1/120), m2 (38.3%, 46/120), m3 (25%, 57/120), sm1 (11.7%, 14/120), sm2 (1.6%, 2/120) were diagnosed as early stages of gastric cancer. The complete resection rate was 85.2% (150/176) and en-bloc resection rate was 96.0% (169/176). Complications as such as perforation and bleeding developed in 4.4%(8/179) and 21.2% (38/ 179), respectively. CONCLUSION: EISD is an effective in the endoscopic treatment for gastric adenoma and early gastric cancers. However, further evaluation of this method and long-term follow-up will be necessary for an evaluation of the recurrence rate after resection of a tumor.

Successful Hemoperfusion in Acute Phenobarbital Intoxication / 대한신장학회잡지

Phenobarbital is long acting barbiturate with low lipid solubility that act as central nervous system depressants and used as anticonvulsant, sedative, hypnotic drug. In acute severe barbiturate intoxication, through CNS depression, coma, respiratory arrest and hypotension may occur, which are the major causes of mortality. Mortality is 3% for blood levels over 80 mg/mL and the lethal dose in adult is estimated as 6 to 10 g. We report a case of phenobarbital intoxication in a 20 years old female, who was successfully treated by emergency hemoperfusion. She was in semicomatous state and had respiratory difficulty on the day of admission. It was estimated that she intakes 1.6 g of phenobarbital. She was treated with mechanical ventilation, urine alkalization and charcoal administration. Hemoperfusion was attempted to remove rapidly phenobarbital from blood. After hemoperfusion the blood phenobarbital level was decreased from 96 mg/mL to 67 mg/mL. On 2nd hospital day, the blood phenobarbital level was 56 mg/mL and she recovered her self respiration and mentality.

A Case of the Ruptured Splenic Artery Aneurysm Treated with Transcatheter Embolization / 대한소화기학회지

Splenic artery aneurysms are the most common visceral artery aneurysms, which are usually found incidentally. The most common complication of splenic artery aneurysms is spontaneous rupture into the peritoneal cavity, which leads to acute peritonitis and shock. Less commonly, it may rupture directly into the stomach, small bowel or pancreatic duct and may present with acute gastrointestinal hemorrhage. We report a rare case of the ruptured splenic artery aneurysm, presenting as acute massive hematochezia which was treated with transcatheter embolization.

The US Findings of Acute Nonperforated and Perforated Appendicitis in Children

PURPOSE: To analyse and interpret different sonographic findings in acute nonperforated and appendicitis. MATERIALS AND METHODS: In 46 cases of acute appendicitis in children(26 girls, 20 boys) proven by surgery, sonographic findings were reviewed retrospectively. The findings of nonperforated and perforated appendicitis were analysed, focusing on the size, shape and echogenicity of the appendix, echo patterns of periappendiceal abscesses, mesenteric lymphadenopathy, and the prevalence of appendicolith. RESULTS: A noncompressible distended appendix was present in 18 of 21 patients with nonperforated appendicitis and in 13 of 25 patients with perforation. In 18 patients with nonperforated appendicitis, the average diameter of distended appendix was 8.6mm;target appearance was noted in 16 patients and loss of echogenic submucosa in two. In 13 patients with perforated appendicitis, the average diameter of appendix was 9.1 mm;target appearance was noted in four patientsand loss of echogenic submucosa in nine. periappendiceal abscesses were present in 21 of 25 cases of perforated appendicitis, and the echogenicity of abscesses was mixed in 12 patients, hypoechogenic in eight, and hyperechogenic in one. Mesenteric lymphadenopathy was present in two of 21 patients with nonperforated appendicitis and in four of 25 with perforation. Appendicolith was detected on sonography in three of 25 patients with perforated appendicitis, but was found in seven patients during surgery. One patients with perforated appendicitis also had right side hydronephrosis. Sonographically false-negative results were obtained in sixcases. CONCLUSION: A sonographic examination was useful to differenciate perforated and nonperforated appendicitis in children. Loss of echogenic submucosa in the distended appendix and periappendiceal abscess formation were important findings in diagnosis of perforated appendicitis.