Technical issues and new devices of ESD of early gastric cancer.

Endoscopic submucosal dissection (ESD) is a highly refined technique compared to conventional endoscopic mucosal resection. It enables complete resection of early gastric cancer (EGC) which has no possibility of lymph node metastasis. Indication for ESD of EGC generally entails early gastric cancer confined to the mucosa with well differentiated histology, though there are clinically suitable expanded criteria. As ESD requires specific skill and expertise, endoscopists need to be familiarized with basic methods and the use of special devices. The essence of the technique is to dissect the submucosal layer with direct vision and maintain the cutting plane above the underlying proper muscle layer. Although there are some differences in the detailed technical aspect, the cardinal method of ESD is now well established and standardized. Furthermore, research and development of new ESD devices that render more efficient, safe ESD are still in progress to improve the overall result of ESD on early gastric cancer.

[Crohn's disease presenting with erythema nodosum as an early sign: a case report].

Erythema nodosum is the most common form of septal panniculitis and the most frequent skin manifestation associated with inflammatory bowel disease, affecting up to 15% of Crohn's disease patients. Since the development of erythema nodosum is closely related with a variety of disorders and condition, it can serve as an important early sign of systemic disease. Here, we present the occurrence of erythema nodosum as an early sign of Cronh's disease in a 16-year-old woman.

Analysis of factors related to lymph node metastasis in undifferentiated early gastric cancer.

BACKGROUND/AIMS: This study was conducted to analyze the factors related to lymph node metastasis in undifferentiated early gastric cancer and to investigate whether endoscopic resection can be performed. METHODS: Three hundred sixty-two early gastric cancer patients who were diagnosed with undifferentiated early gastric cancer and underwent surgery were divided into groups depending on their age, sex, location of tumor, macroscopic findings, presence of an ulcer, histological type, tumor size, depth of invasion, and lymphatic involvement, and the correlations between clinicopathological characteristics and lymph node metastasis were analyzed. RESULTS: Lymph node metastasis was detected in 31 (8.5%) of the 362 patients. Univariate analysis revealed correlations between lymph node metastasis and various factors ranging from patient age, location of tumor, presence of an ulcer, and depth of invasion to lymphatic involvement. However, in multivariate analysis, presence of an ulcer and lymphatic involvement were found to be independent risk factors. After selecting and analyzing only patients with intramucosal early gastric cancer, we found that lymphatic involvement was the only independent risk factor. CONCLUSIONS: Though presence of an ulcer is an independent predictive factor for lymph node metastasis before operation in patients with undifferentiated early gastric cancer, caution is required in the interpretation. In addition, clinicopathological characteristics such as histological type and tumor size did not have a significant effect on lymph node metastasis. Therefore, we found that the evidence was insufficient to select endoscopic resection even when there is a small lesion, and we believe that the decision on the use of endoscopic resection for patients with undifferentiated early gastric cancer should be made more carefully when there is an ulcer.

Effective administration method of intravenous proton pump inhibitor: a novel testing using a BRAVO catheterless pH monitoring system.

BACKGROUND/AIMS: This study investigated the use of the BRAVO catheterless pH monitoring system to determine the effective administration method of intravenous proton pump inhibitor and the effectiveness of 80 mg pantoprazole per day on the regulation of gastric acid. METHODS: A total of 32 patients who underwent endoscopic resection were randomly assigned to the repeated bolus injections group (40 mg dose, twice per day) and continuous infusion group (mixed with 5% glucose, continuous infusion of 80 mg per day). Then, pantoprazole was administered and intragastric pH was measured for 48 hours through a BRAVO capsule. The length of time until the intragastric pH reached 4 and 6 after administration was measured, as well as the mean/median pH for 48 hours and the fraction times (%) of pH >4 and >6 for 48 hours. The factors affecting intragastric pH were also analyzed. RESULTS: There were no complications due to the attachment of the BRAVO capsule. No significant differences according to administration methods were found in all factors. Only Helicobacter pylori had significant effect on the fraction times (%) of pH >4 and >6 for 48 hours (p<0.05). CONCLUSIONS: The effects of intravenous proton pump inhibitor were similar between the administration methods. Therefore, the repeated bolus injection method, which is relatively simple, is a good choice. Regarding the dose of intravenous pantoprazole, which is used after successful endoscopic hemostasis, 80 mg would be sufficient. We hope that this study encourages the use of the BRAVO catheterless pH monitoring system.

Triple synchronous primary cancers of rectum, thyroid, and uterine cervix detected during the workup for hematochezia.

Multiple primary cancers are defined as multiple occurrences of malignant neoplasm of different histologic origin in the same individual. The synchronous occurrence of triple distinct cancers in the same patient is very rare. Herein, we report an extremely rare case of synchronous triple primary cancers of the rectum, thyroid gland and uterine cervix; all were detected during the work-up for hematochezia. To the best of our knowledge, this is the first such report in the medical literature.

[Effect of combination pretreatment of polyethylene glycol solution and magnesium hydroxide for colonoscopy].

BACKGROUND/AIMS: This study was designed to compare the efficacy and patient tolerance between standard bowel preparation using 4 liters of polyethylene glycol (PEG) solution and 4 liters of PEG preceded by the osmotic laxative, magnesium hydroxide in constipation and non-constipation group. METHODS: 173 outpatient colonoscopy, except for three patients who were not taking magnesium, were divided into constipation and non-constipation group. Then, the patients were randomly assigned to receive 4-liter of PEG solution or 4-liter of PEG plus magnesium hydroxide. The quality of bowel preparation was assessed using Ottawa scale, and satisfaction score was assessed using questionnaires. Solid stool, cecal intubation time, compliance, and side effects were assessed. RESULTS: Non-constipation group showed no significant differences between two groups. In constipation group, 4-liter PEG solution plus magnesium hydroxide induced the more effective colonic preparation (Ottawa scale 2.47+/-0.99 vs. 5.92+/-2.39, p<0.05), and less solid stool (0.67+/-0.72 vs. 1.38+/-0.65, p<0.05) compared with 4-liter PEG solution. CONCLUSIONS: Bowel preparation with magnesium hydroxide and 4 liters of PEG solution might reduce solid stool in constipation group, but could not improve preparation quality.

Ischemic colitis after mesotherapy combined with anti-obesity medications.

Mesotherapy and anti-obesity medications are gradually gaining worldwide popularity for purposes of body contouring and weight loss. Their adverse effects are various, but there is a tendency to disregard them. Ischemic colitis is one of the most common diseases associated with non-obstructive blood vessel disorders. However, there have been no case reports about the adverse effects resulting from mesotherapy only or in combination with anti-obesity medications. We report on an interesting case of ischemic colitis after mesotherapy combined with anti-obesity medications in a 39-year-old female who had no risk factors.

[A case of idiopathic pancreatitis in a patient with Crohn's disease].

Pancreatitis has been occasionally associated with Crohn's disease (CD). A definite etiology of pancreatitis can be identified in most patients, but a very small proportion remain idiopathic. We report a case of idiopathic pancreatitis resolved along with the clinical improvement of CD in a 25-year-old man. He presented with abdominal pain and diarrhea for 8 years. Ileocolonoscopy and enteroclysis showed multiple, longitudinal ulcers and strictures at the ileojejunum. The laboratory findings showed elevated serum amylase (951 IU/L) and lipase (326 IU/L) without positive autoantibodies. Esophagogastroduodenoscopy, enhanced pancreatic CT, and MRCP showed no abnormalities at ampulla of Vater, pancrease, and pancreaticobiliary duct. With the treatment with antibiotics, 5-aminosalicylic acid, steroid, and azathioprine, as a whole, decreasing pattern and intermittent fine coordinated fluctuation of the levels of amylase and lipase along with the decrease of Crohn's disease activity index (CDAI) and the CRP levels were observed. Then, three months after the start of the treatment, normalization of the pancreatic enzymes was observed, and there was recurrent elevation of pancreatic engyme during 12 months maintenance therapy. This report supports the concept of an association between idiopathic pancreatitis and CD, based on a significant and close relation between the levels of serum amylase and lipase, and CDAI.

Congenital absence of the splenic artery and splenic vein accompanied with a duodenal ulcer and deformity.

Congenital absence of the splenic artery is a very rare condition. To the best of our knowledge, congenital absence of the splenic artery accompanied with absence of the splenic vein has not been reported. We report a case of the absence of the splenic artery and vein in a 61-year-old woman who presented with postprandial epigastric discomfort. Upper gastrointestinal endoscopy showed a dilated, pulsatile vessel in the fundus and duodenal stenosis. An abdominal computed tomography (CT) scan revealed absence of the splenic vein with a tortuously engorged gastroepiploic vein. Three-dimensional CT demonstrated the tortuously dilated left gastric artery and the left gastroepiploic artery with non-visualization of the splenic artery. After administration of a proton pump inhibitor, abdominal symptoms resolved without any recurrence of symptoms during 6 mo of follow-up.

Ambulatory 24-hour pharyngeal pH monitoring in healthy Korean volunteers.

Pharyngeal pH monitoring is the standard diagnostic approach for laryngopharyngeal reflux (LPR). However, the normal values for Asian populations are still unknown. We evaluated the results of ambulatory 24-h pharyngeal pH monitoring in healthy volunteers to determine the normal reference values in the Korean population. Thirty healthy subjects underwent ambulatory 24-h pharyngeal pH monitoring with glass electrodes positioned 1 cm above the upper esophageal sphincter and 5 cm above the lower esophageal sphincter, based on esophageal manometry after upper gastrointestinal endoscopy. LPR occurred in about one half of the healthy volunteers without any significant association with age, gender and body mass index. Pharyngeal acid reflux occurred mainly in the upright position. At the 95th and 90th percentile, after the exclusion of mealtimes, the upper limits of normal (ULN) for pharyngeal acid exposure were 0.41% and 0.18%. The ULNs for the number of pharyngeal acid events were 12.8 and 5.0. The corresponding ULNs for the esophagus were 5.1% and 3.8% and 62.7 and 32.6. The findings of this study help establish the reference standards for LPR in Korean patients.

Hemorrhagic Meckel's diverticulum in an older woman diagnosed by repeated angiographies.

Meckel's diverticulum is a remnant of the vitelline duct and a congenital anomaly of the gastrointestinal tract. Hemorrhage from a Meckel's diverticulum is common in children but extremely rare in adults over 50 years of age. Very few cases have been reported to date and all prior cases were in men. Meckel's diverticulum is commonly overlooked as a possible cause of a lower gastrointestinal hemorrhage in adults. Here, we present the rare case of a 58-year-old woman with massive hemorrhage from a Meckel's diverticulum that was diagnosed by repeated emergency angiographies and treated with elective laparoscopic surgery.

Normal 24-hour Ambulatory Esophageal pH Values in Koreans.

BACKGROUND/AIMS: Twenty-four-hour ambulatory esophageal pH monitoring is considered the gold standard for diagnosing gastroesophageal reflux disease. The aim of this study was to quantify normal distal esophageal acid parameters in healthy Koreans. METHODS: Thirty healthy adults who were not on medication and were free from gastrointestinal symptoms were analyzed. Ambulatory esophageal acid (pH <4) exposure parameters were recorded at 5 cm above the lower esophageal sphincter. RESULTS: The 95th percentiles for reflux parameters assessed in the distal esophagus were as follows: percentage of total time with pH <4, 5.10%; percentage of upright time with pH <4, 7.88%; percentage of supine time with pH <4, 4.00%; number of reflux episodes, 62.7; number of reflux episodes with pH <4 for >5 minutes, 5.3; and the longest single acid-exposure episode, 21.3 minutes. CONCLUSIONS: Physiological gastroesophageal reflux occurs frequently in healthy Koreans. These data provide a reference range that could be utilized in studies involving Korean subjects.

[A case of ischemic colitis presenting as bloody diarrhea after normal saline enema].

Ischemic colitis is a frequent disorder of large bowel in elderly persons or in debilitated patients with a variable underlying medical problems. Ischemic colitis may result from alterations in the systemic circulation or anatomic or functional changes in the local mesenteric vasculature. In most cases, no specific cause for the ischemic colitis is identified. Cases of ischemic colitis after enema for bowel cleansing have been rarely reported, but there has been no case report after normal saline enema. We report a case of ischemic colitis in a 72-year old patient with well-controlled hypertension, presenting as bloody diarrhea which developed after normal saline enema for preoperative bowel cleansing.

[A case of giant colonic lipoma showing spontaneous resolution after endoscopic partial resection].

Generally, colon lipoma is mildly symptomatic or asymptomatic. However, sometimes it may present with symptoms, such as pain, constipation, obstruction, or bleeding and may be the leading point for intussusception, particularly in large size (>20 mm). Giant colon lipoma may warrant the removal to exclude confusion with other lesions that have a malignant potential and to control symptoms. Currently, surgical resection should be considered for giant lipoma more than 20 mm in diameter due to the high risk of perforation or bleeding, especially when the lesion is broadly-based. We report here a case of spontaneous resolution acquired after endoscopic partial resection for the symptomatic giant colon lipoma with broad-base requiring surgery.

Gastrointestinal stromal tumor of appendix incidentally diagnosed by appendiceal hemorrhage.

Gastrointestinal stromal tumor is rare, which arises from the mesenchymal tissues in the gastrointestinal tract, and it is extremely rare in the appendix. Only a few cases have been found in this location to date. Although the annual incidence of lower gastrointestinal bleeding has been increasing, bleeding related to the appendix is quite rare. We herein present a very rare case of gastrointestinal stromal tumor incidentally found by appendiceal hemorrhage.

[A case of Cowden's disease associated with breast cancer].

Cowden's disease, also known as various hamartomatous malformations of multiple organs, is a rare autosomal dominant disorder. The most important feature of Cowden's disease is its frequent association with malignant neoplasm, particularly in the breast and thyroid gland. Cowden's disease with malignant neoplasms is quite rare in Korea so far. We report a case of Cowden's disease associated with breast cancer in a 41-year-old female who underwent routine health cheek-up.

A prospective analysis of low-grade gastric malt lymphoma after Helicobacter pylori eradication.

BACKGROUND: Primary gastric low-grade B-cell lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) is known to be successfully treated with anti-Helicobacter pylori (H. pylori) therapy alone. However, there are few reports on long-term results after eradication therapy. The aims of this study were to analyze the rate and the interval to reach complete remission (CR), and to assess the rate and the factors affecting recurrence of MALT lymphoma. MATERIALS AND METHODS: Between 1996 and 2003, a total of 90 H. pylori-infected patients with low-grade MALT lymphoma were included in this study. For initial staging, endoscopic ultrasonography, chest-abdomen-pelvis CT scans, and bone marrow examination were taken. All patients were made to take anti-H. pylori therapy for 14 days. Tumoral response was assessed by endoscopy every 3 months till CR and every 6 months after achieving CR. RESULTS: Among 90 treated patients, 85 (94.4%) reached CR. The median interval to CR was 3 months (range, 1-24). Seventy-nine (92.9%) patients were in CR at 12 months. Median follow-up period after CR was 45 months (range 15-109). Among 77 patients who were followed-up after CR, 8 (10.4%) patients were proved with recurrence of MALT lymphoma. Cumulative recurrence rate was 2.7, 11.5, and 12.2% at 1, 2, and 3 years. The presence of H. pylori was only a significant risk factor affecting recurrence. CONCLUSIONS: The status of H. pylori is the most important risk factor affecting recurrence. Therefore, adequate eradication regimen and accurate regular evaluation for H. pylori status are needed during follow up of primary gastric low-grade B-cell MALT lymphoma.