Usefulness of Gastroscope in Patients with Incomplete Colonoscopy

BACKGROUND/AIMS: Conventional colonoscopy is limited in some patients with several causes, such as fixed angulation, extensive loop or adhesion. Therefore, small-caliber scopes are considered alternatives to unsuccessful conventional colonoscopy. The aim of this study is to evaluate the usefulness of gastroscope in patients with unsuccessful colonoscopy. METHODS: From May 2008 to April 2009, a total of 2,548 colonoscopies were performed in Wonkwang University Hospital. The gastroscope was used subsequently when conventional colonoscopy failed. RESULTS: There were 27 cases (1.06%) of unsuccessful colonoscopy. The causes of failure were assessed as fixed angulation of the sigmoid colon (59.2%, 16/27), excessive looping (14.8%, 4/27), stricture (14.8%, 4/27), sigmoid diverticulosis (7.4%, 2/27), and adhesion of transverse colon (3.7%, 1/27). The average time of intubation to cecum with the gastroscope was 7 minutes and 28 seconds (range, 2 to 20 minutes). With the gastroscope, 77.8% (21/27) were intubated to the cecum. The pain score of gastroscope was reduced, as compared with that of conventional colonoscopy (4.95 vs. 5.94, P<0.001). CONCLUSIONS: Gastroscope would be a useful alternative tool in patients with unsuccessful colonoscopy.

Acral Metastasis in a Patient with Ampullary Carcinoma

Although skin metastasis from a malignant tumor of an internal organ usually occurs at an advanced disease stage, there has been no prior report of a cutaneous acral metastasis from ampullary carcinoma to date. We report a 71-year old male patient with cutaneous metastasis from an ampullary adenocarcinoma. The patient had a history of pylorus preserving pancreaticoduodenectomy for carcinoma of the ampulla of Vater two years prior to presentation. Physical examination revealed ill-defined, painful and hard erythematous nodules at the left thumb and distal phalanx of the right middle finger. The computed tomography scan showed low density masses in the retroperitoneum; the histological examination of a nodule from the right middle finger showed a metastatic adenocarcinoma. This case illustrates that cutaneous metastasis from ampullary carcinoma has a poor prognosis.

Association between Diverticulosis and Colonic Neoplasm in Koreans / 대한소화기학회지

BACKGROUND/AIMS: Although a few published studies have reported on the relationship between diverticulosis and neoplasia in the west, it is not yet examined in Korea. The aim of this study was to determine whether there is an association between diverticulosis and colonic neoplasia. METHODS: We retrospectely analysed the medical records of 3,007 patients (M:F=1.3:1) who underwent colonoscopic examinations from year 2002 to year 2004. Patients who had a history of previous polypectomy, colon resection, or inflammatory bowel diseases were excluded. The size, extent (none, few, or many), and location of diverticuli and polyps were analyzed. RESULTS: Of 2,377 patients, included 57% were male and the mean age was 50.8 year-old. Nine percent of the patient had diverticulosis, 29% had more than one neoplasm, and 6% had advanced neoplasia. Patients with diverticular diseases had higher risks of any neoplasia than those without diverticulum (p=0.03, 37.7% vs. 28.2%). There was no correlation between diverticular diseases and advanced neoplasia. Patients with proximal diverticular diseases had higher risk of any proximal neoplasia than other patients (p<0.01 24.6% vs. 14.3%). Moreover, they had higher risk of proximal advanced neoplasia than others (p=0.01, 4.5% vs. 2%). In addition, comparison of multiple diverticular disease with few or no diverticuli revealed no difference in the risk of any neoplasia. CONCLUSIONS: These data show that the patients with diverticular diseases have more neoplasms than controls without diverticula.

Analysis of Risk Factors Associated with the Severity of Biliary Pancreatitis / 대한소화기내시경학회지

BACKGROUND/AIMS: The aim of the study was to investigate the risk factors for biliary pancreatitis according to severity. METHODS: This study retrospectively reviewed 58 patients who underwent endoscopic retrograde cholangiopancreatography for the management of acute biliary pancreatitis between November 2001 and June 2004. The severity of pancreatitis was classified as severe or mild pancreatitis according to the Glasgow scale. Multiple clinical and radiological factors were analyzed for a relationship with the severity of pancreatitis and coexisting biliary pathology. RESULTS: Ten patients (17%) had severe pancreatitis (the SP group) and the remaining 48 patients (83%) had mild pancreatitis (the MP group). The diameter of the common bile duct CBD) and cystic duct, and the number and the size of gallstones were not significantly different between the two groups of patients. The number of patients without a periampullary diverticulum in the SP group (90.0%) was significantly higher than in the MP group (39.6%). Most of the SP patients (90.0%) had CBD stones (<5 mm) or CBD sludge, but the prevalence of CBD stones (<5 mm) or CBD sludge was lower in the MP group (54.2%, p=0.04). The absence of a periampullary diverticulum was identified as a risk factor according to severity by the use of logistic regression analysis (odds ratio=25; p=0.01). CONCLUSIONS: The development of severe biliary pancreatitis was influenced by risk factors such as a CBD stone less than 5 mm or sludge and the absence of a periampullary diverticulum.

Anisakiasis of the Colon: Report of Two Cases / 대한소화기내시경학회지

Anisakiasis is a rare finding in the colon in comparison with its involvement in the stomach. Also, anisakiasis of the colon is usually incidentally diagnosed during either endoscopy or on operation for intestinal obstruction due to the fact that anisakiasis of the colon does not have typical clinical features. In other words, the diagnosis of colonic anisakiasis is usually made after surgical exploration. We herein report on two cases of anisakiasis of the colon that were treated successfully by colonoscopic removal of the worm without any surgery. A review of the related literature is included.

Primary Duodenal Choriocarcinoma Presenting as Massive Intestinal Bleeding and Metastasis to Brain / 대한소화기학회지

Duodenal choriocarcinoma, either primary or metastatic, is very rare. Early diagnosis and prompt initiation of chemotherapy improve the prognosis of this neoplasm. We herein present, together with the referred literatures, a case of a 47-year-old female patient who visited to our hospital with upper intestinal bleeding. She was diagnosed as duodenal choriocarcinoma by operation. Brain metastasis was found soon after the operation and combination chemotherapy was done.

The Usefulness of Mesalazine Suppositories for the Treatment of Lymphoid Follicular Proctitis / 대한소화기학회지

BACKGROUND/AIMS: Lymphoid follicular proctitis (LFP) is an uncommon inflammatory condition confined to the rectum. Patients with LFP constitute a special group with clinical, endoscopic, and histological features unrelated to other types of inflammatory bowel diseases, and have been reported to be refractory to local steroid and/or oral sulfasalazine therapy. The aim of this study was to clarify whether mesalazine suppositories have a therapeutic effect in LFP. METHODS: The histologic slides of 8 cases indexed in our pathology files as "lymphoid follicular proctitis of the rectal mucosa" from January 2001 to November 2003 were reviewed retrospectively. RESULTS: The most common symptom in the patients with LFP was rectal bleeding. The endoscopic mucosal changes were discontinuous, sparing whole circumferential involvement, and were strictly confined to the rectum. Average period of medication was 12 months. All the symptomatic patients with LFP responded to mesalazine suppository therapy. In addition, these patients did not progress to other disease including ulcerative proctitis or lymphoma. CONCLUSIONS: Mesalazine suppository treatment is a useful therapeutic option for symptomatic patients with LFP.

The Usefulness of Mesalazine Suppositories for the Treatment of Lymphoid Follicular Proctitis / 대한소화기학회지

BACKGROUND/AIMS: Lymphoid follicular proctitis (LFP) is an uncommon inflammatory condition confined to the rectum. Patients with LFP constitute a special group with clinical, endoscopic, and histological features unrelated to other types of inflammatory bowel diseases, and have been reported to be refractory to local steroid and/or oral sulfasalazine therapy. The aim of this study was to clarify whether mesalazine suppositories have a therapeutic effect in LFP. METHODS: The histologic slides of 8 cases indexed in our pathology files as "lymphoid follicular proctitis of the rectal mucosa" from January 2001 to November 2003 were reviewed retrospectively. RESULTS: The most common symptom in the patients with LFP was rectal bleeding. The endoscopic mucosal changes were discontinuous, sparing whole circumferential involvement, and were strictly confined to the rectum. Average period of medication was 12 months. All the symptomatic patients with LFP responded to mesalazine suppository therapy. In addition, these patients did not progress to other disease including ulcerative proctitis or lymphoma. CONCLUSIONS: Mesalazine suppository treatment is a useful therapeutic option for symptomatic patients with LFP.

Diagnostic Use of Endoscopic Ultrasonography in the Evaluation of Common Bile Duct Dilatation / 대한소화기내시경학회지

BACKGROUND/AIMS: The aim of this study was to assess the diagnostic use of endoscopic ultrasonograpy (EUS) in detecting the cause of common bile duct (CBD) dilatation in patients in whom abdominal ultrasonography or abdominal CT scan could not identify the cause of dilatation. METHODS: Thirty-seven patients (23 men, 14 women, mean age 62.2 years) with uncertain causes of CBD dilatation on abdominal sonogram and CT scan between October 1999 and November 2003 were enrolled. All patients were evaluated by EUS and endoscopic retrograde cholangiopancreatography (ERCP). Final diagnosis were determined by ERCP, surgical exploration and clinical follow-up. RESULTS: The following diagnosis were made by EUS: choledocholithiasis in 11 patients, CBD dilatation only in 12, benign stricture of distal CBD in 8, periampullary tumor in 6. The definitive diagnosis of choledocholithiasis (n=11), benign stricture of distal CBD (n=10), ampullary tumor (n= 5) were determined by ERCP with or without sphincterotomy and surgical exploration. EUS provided the accurate explanation for CBD dilatation in 32 of the 37 patients (86%). CONCLUSIONS: When the diagnosis of biliary obstruction remains obscure on abdominal sonography or CT scan, EUS may be useful.

A Case of Swallowing Syncope Caused by Endoscopic Examination / 대한소화기내시경학회지

Swallowing syncope is thought to be induced by an abnormal esophagovagal reflex arc that leads to transient bradyarrhythmia. Bradyarrhythmia in the response to swallowing produce decreased cardiac output and cerebral perfusion which result in loss of consciousness. Dysarrhythmia are common during any procedure which involves the manipulation of upper gastrointestinal tract, such as endoscopy of the esophagus or stomach. Swallowing syncope represents an extreme form of this phenomenon. We report a patient who had bradycardia and fainting episode during endoscopic examination. High degree atrioventricular block was detected in 24 hr Holter monitoring.

Cytoplasmic Domain of Intercellular Adhesion Molecule-1(ICAM-1)is Important for the ICAM-1 Mediated Membrane Projection of Endothelial Cells / 대한해부학회지

Intercellular adhesion molecule-1 (ICAM-1)has been shown to enhance leukocyte adhesion, thereby inducing migration through blood endothelial cells. However, the molecular event during the process of adhesion is largely unknown. To examine the role of ICAM-1 cytoplasmic domain in SDF-1 alpha-induced T lymphocyte migration and adhesion, mutant human ICAM-1 molecules were expressed in COS-7 cell line. COS-7 cells expressing ICAM-1_GFP mutant without alpha-actinin revealed no association with the actin cytoskeleton, while wild-type ICAM-showed clear association with the actin, as observed by confocal microscopy, suggesting that actinin binding motif in the cytoplasmic domain of ICAM-1 is important for the proper localization of ICAM-1 on the cell membrane. However, based on adhesion assay, we found that the cytoplasmic domain of ICAM-1 is not essential for the binding of lymphocytes which were activated by SDF-1alpha. On the other hand, ICAM-1-mediated receptor-ligand clustering event was significantly inhibited in the cells expressing ICAM-1 mutants without alpha-actinin or whole cytoplasmic domain. Taken together, these results suggest that ICAM-1 cytoplasmic domain is not essential for the adhesion but important for the ligand-receptor-mediated membrane projection of endothelial cells before trans-endothelial migration of lymphocytes.

A case of acute pancreatitis caused by hyperparathyroidism / 대한내과학회지

Hypercalcemia due to hyperparathyroidism is a proposed mechanism of pancreatitis. The occurrence of acute pancreatitis caused by hypercalcemia represents a diagnostic clue for hyperparathyroidism. The incidence of acute pancreatitis caused by hyperparathyroidism appears to be decreasing, and it reflects the earlier diagnosis of hyperparathyroidism due to wide spread application of screening method. In a 71-year-old female patient who was admitted to hospital because of acute pancreatitis, hypercalcemia led to the discovery of the parathyroid adenoma. The patient recovered by parathyroidectomy with medical management of hypercalcemia.

A Case of Spontaneous Biloma Complicated with Choledocholithiasis and Chronic Cholecystitis / 대한소화기학회지

A biloma is an encapsulated bile collection outside the biliary tree. Most cases of biloma are caused by iatrogenic injury or trauma. Intrahepatic rupture of the biliary tree due to nontraumatic cause is a rare event. A 68- year-old man was admitted because of abdominal pain and fever. He had no past history of abdominal surgery, instrumentation or trauma. Computed tomography (CT) scan and magnetic resonance cholangiopancreatography (MRCP) demonstrated a large subcapsular fluid collection in the right liver associated with choledocholithiasis and cholecystitis. Biloma was confirmed by sono-guided percutaneous needle aspiration and was drained through a pigtail catheter. After the successful treatment by percutaneous drainage and endoscopic sphincterotomy, the patient recovered. Here, we report an uncommon case of spontaneous biloma formation in association with choledocholithiasis with a review of literatures.

The Effect of Iron Depletion on the Monocytic Adhesion, Differentiation and SR-A Expression / 대한해부학회지

Maintenance of cellular iron homeostasis is a prerequisite for proliferation and differentiation of cells, and is also a central role in the regulation of immune function. Monocyte-macrophages play an important roles in host defense, particularly in the inflammatory process of acute and chronic disease. The reason that an iron is important in these cell is because an iron is indispensable in a generation of hydroxyl radical for bacterium killing. Because of the role of iron in the monocytic THP-1 cell differentiation is not become clear, we investigated whether THP-1 cell can differentiate to macrophage-like cell using of iron and iron chelator which cause iron depletion. The cell differentiation was not able to observe by iron treatment, by the way, the cell adhesion was increased in DFO treated monocyte and cellular pseodopodial extension, change of a nucleus-cytoplasmic ratio were showed in Differential interference contrast (DIC) and Giemsa staining, and it was inhibited by ferric citrate (FC). Increased polystyrene bead phagocytosis by DFO treatment of THP-1 cell were detected through FACS and rhodamine-phallodin staining. The SR-A expression, which was a cell differentiation marker, was increased by DFO treatment of THP-1 cell. These results suggest that iron depletion by DFO can promote THP-1 cell diffentiation into macrophage-like cell, and this may carrying out important role in the immune response.

Effects of Sulphasalazine and Glucocorticoid on the Regulation of CCL20 Gene Expression in the Peripheral Blood Cells of Korean Patients with Ulcerative Colitis / 대한해부학회지

Discovery of Nod2 has brought to light the significance of mononuclear cells as well as epithelial cells in inflammatory bowel disease (IBD) pathogenesis. Similarly, CCL20 is expressed in both mononuclear cells and epithelial cells and is likely to link innate and acquired immunity. We therefore asked whether CCL20 expression is altered in the peripheral blood mononuclear cells (PBMCs) from patients with ulcerative colitis (UC), a major type of IBD in Korea, and is correlated with the disease activity. The expression levels of CCL20 mRNA were significantly high in the PBMCs from the patients with UC. CCL20 protein expression was also up-regulated in the mucosal epithelium in UC but not in normal controls. Interestingly, however, disease activity index (DAI) revealed that untreated UC groups express higher expression levels of CCL20 mRNA than treated UC groups, implying that CCL20 may be a potential target for the anti-inflammatory treatments. In an agreement with this, three months follow up study revealed that the UC patients who were treated with 5-amino salicylic acid (5-ASA) and glucocorticoid showed dramatic decrease in their CCL20 mRNA levels as compared to untreated ones. Moreover, TNF-alpha-or IL-1beta-induced CCL20 secretion in human epithelial HT-29 cells was significantly diminished by the treatment with 5-ASA and/or dexamethasone, suggesting that CCL20 may be one of the central targets of the anti-inflammatory drugs. Collectively, these results suggest that CCL20 expression in UC may be associated with altered immune and inflammatory responses in the blood as well as the intestinal mucosa and further implied a potential for CCL20 as an important diagnostic marker for UC.

The Effect of Itopride, a New Prokinetic, on Acid Reflux Symptoms and Variables in Patients with GERD / 대한소화관운동학회지

BACKGROUND/AIMS: Itopride is a newly developed prokinetic agent enhancing gastric motility through both antidopaminergic and anti-acetylcholinesterase actions. The importance of esophageal motor dysfunction in the pathogenesis of gastro-esophageal reflux disease (GERD) makes it interesting to examine the effect of itopride on esophageal acid exposure. METHODS: The effect of itopride on esophageal 24-hour acid reflux variables was studied in 26 patients with GERD symptoms, pre-entry total acid exposure time (pH<4) of more than 5% and mild esophagitis (Savary-Miller grade I, II) by endoscopy. Ambulatory 24-hour pH monitoring and symptom assessment were performed after treatment with itopride 50 mg or 100 mg t.i.d for 4 weeks by a randomization allocation schedule with an open label. RESULTS: In both itopride groups, total symptom scores were decreased after treatment significantly. Itopride 300 mg was significantly more effective than 150 mg in decreasing the total time and total percent time of intraesophageal pH below 4, and DeMeester score. Consequently, no serious adverse effects were reported after administration in both groups. CONCLUSIONS: Itopride 100 mg t.i.d is effective to decrease pathologic reflux in patients with GERD. Therefore, it has a therapeutic potential for this diseases.

A Case of MALT-lymphoma of the Ampulla of Vater / 대한소화기내시경학회지

Primary gastrointestinal lymphomas originating from the mucosa-associated lymphoid tissue (MALT) have been reported with increasing frequency. The stomach is the most frequent site of MALT lymphoma, and a relationship with Helicobacter pylori infection has been studied. However, primary MALT lymphoma arising from the ampulla of Vater is extremely rare, and its relationship with Helicobacter pylori infection is still obscure. We report here a case of a 71-year-old man with marginal zone B cell lymphoma of MALT with large B cell lymphoma of the ampulla of Vater that was not associated with Helicobacter pylori. A pancreaticoduodenectomy was performed, and the pathologic examination of the resected specimen confirmed the diagnosis. The patient tolerated just one course of systemic chemotherapy, but has been doing well for 18 months after surgery.

Soluble factor from tumor cells induces heme oxygenase-1 by a nitric oxide-independent mechanism in murine peritoneal macrophages

Tumor target-derived soluble secretary factor has been known to influence macrophage activation to induce nitric oxide (NO) production. Since heme oxigenase-1 (HO-1) is induced by a variety of conditions associated with oxidative stress, we questioned whether soluble factor from tumor cells induces HO-1 through NO-dependent mechanism in macrophages. We designated this factor as a tumor-derived macrophage-activating factor (TMAF), because of its ability to activate macrophages to induce iNOS. Although TMAF alone showed modest activity, TMAF in combination with IFN-gamma significantly induced iNOS expression and NO synthesis. Simultaneously, TMAF induced HO-1 and this induction was slightly augmented by IFN-gamma. Surprisingly, however, induction of HO-1 by TMAF was not inhibited by the treatment with the highly selective iNOS inhibitor, 1400 W, indicating that TMAF induces the HO-1 enzyme by a NO-independent mechanism. While rIFN-gamma alone induced iNOS, it had no effect on HO-1 induction by itself. Collectively, the current study reveals that soluble factor from tumor target cells induces HO-1 enzyme in macrophages. However, overall biological significance of this phenomenon remains to be determined.

A Dieulafoy's Lesion of the Rectum Treated by Endoscopic Band Ligation: A case report / 대한소화기내시경학회지

The Dieulafoy's lesion is an unusual cause of gastrointestinal hemorrhage that results from the erosion of abnormally large submucosal artery. The lesion is usually located in the stomach, although it may occur anywhere in the gastrointestinal tract. Lower GI bleeding from Dieulafoy- like lesion of rectum is very rare. We describe one patient with extragastric Dieulafoy's disease, in the rectum. Diagnosis was made by endoscopy. Recently, endoscopy is important in the treatment of Dieulafoy-like lesion of rectum including epinephrine injection and coagulation therapy. We treated with the endoscopic management using ligation technique. We report a case that the 65-year old women had a extragastric Dieulafoy's lesion on the rectum, treated by endoscopic ligation with O-ring.

Endoscopic Band Ligation in Nonvariceal Upper Gastrointestinal Bleeding / 대한소화기내시경학회지

BACKGROUND/AIMS: Endoscopic band ligation (EBL) has now emerged as the method of choice for treatment of esophageal variceal bleeding. However, only small numbers of patients with upper gastrointestinal (UGI) bleeding from non-esophageal varices have been treated in this way. We studied the usefulness of EBL in UGI bleeding without esophageal varices during emergency endoscopy. METHODS: During January 1997 to December 2000, 28 patients (54.7 13.2 years, male:female=22:6) of non-variceal bleeding at upper GI tract were treated by endoscopic ligation, using Stiegmann-Goff clear view band ligation device. Bleeding was identified from gastric Dieulafoy's lesion (n=15), Mallory-Weiss syndrome (n=8), and small ulcer (n=5). RESULTS: Ten of the 28 patients had underlying diseases, including liver cirrhosis (n=5), chronic renal failure (n=2), essential hypertension (n=2), and sepsis (n=1). The Dieulafoy's lesions were mostly located on the fundus and the body. There was active bleeding in 19 (spurting, 8: oozing, 11) and only exposed vessel in 9. EBL was successful in 27 of 28 cases (97%) during admission, and one patient had rebleeding during follow-up period ranging from 6 months to 24 months. CONCLUSIONS: EBL is an available, inexpensive, and easily learned method of treatment for patients with non-variceal gastrointestinal hemorrhage such as Dieulafoy's lesion, Mallory-Weiss syndrome, and small ulcer with active bleeding.