Tissue Plasminogen Activator and Plasminogen Activator Inhibitor Type 1 Gene Polymorphism in Patients with Gastric Ulcer Complicated with Bleeding

Tissue plasminogen activator (t-PA) and plasminogen activator inhibitor type 1 (PAI-1) may be involved in the pathogenesis of peptic ulcers through suppression of fibrinolysis. This study was designed to investigate associations of t-PA and PAI-1 genes with clinical features of the patients with bleeding gastric ulcers. Eighty-four patients with peptic ulcers and 100 controls were studied between January 1998 and April 2000. We used polymerase chain reaction and endonuclease digestion to genotype for 4G/5G polymorphism in the promoter region of the PAI-1 gene and the Alurepeat insertion/deletion (I/D) polymorphism in intron h of the t-PA gene. Various clinical features, including lesion site, bleeding event, recurrence of ulcer, and rebleeding, were assessed using a multiple logistic regression model. The genotype distributions of both the t-PA and PAI-1 genes did not differ between the patient and control groups. The occurrence of the I/D or D/D genotype of t-PA was significantly higher in cases of duodenal ulcer (adjusted OR=4.39, 95% CI=1.12-17.21). When a dominant effect (i.e., 4G/4G or 4G/5G versus 5G/5G) of the 4G allele was assumed, the PAI-1 4G/4G genotype was independently associated with rebleeding after hemostasis (adjusted OR=5.07, 95% CI=1.03-24.87). Our data suggest that t-PA gene polymorphism is associated with duodenal ulcers, and that the PAI-1 gene may be a risk factor leading to recurrent bleeding after initial hemostasis.

Secondary Achalasia by Eosinophilic Esophagitis / 대한소화기내시경학회지

Idiopathic eosinophilic esophagitis is a part of disorders that comprise eosinophilic gastroenteritis, a condition characterized by eosinophilic infiltration of the gastrointestinal tract. Its clinical feature depends on the type of layer and location involved. A 56-year-old man presented with dysphagia and abdominal pain. Endoscopic ultrsonography and esophageal manometry showed definite smooth muscle hypertrophy of the esophagus and vigorous achalasia like motility disturbance. We report a case of eosinophilic eosphagitis that resolved by steroid treatment, with a review of relevant literatures.

Helicobacter pylori and Telomerase Activity in Intestinal Metaplasia of the Stomach

BACKGROUND: Helicobacter pylori (H. pylori) has been considered a definitive carcinogen in gastric cancer. Telomerase is activated in gastric cancer and some premalignant gastric lesions, including intestinal metaplasia (IM). In this study, we evaluated the relationships of both H. pylori infection and telomerase activity with endoscopic and histologic features in IM. The effects of H. pylori eradication on endoscopic, histologic and biochemical changes were evaluated. METHODS: Endoscopic biopsies were obtained from 43 patients with IM for rapid urease, histologic and telomerase tests. The endoscopic and histologic features, H. pylori infection and telomerase were assessed. After H. pylori eradication, 15 patients were re-evaluated and compared after 4 months. RESULTS: Thirty-four (79.1%) patients were infected with H. pylori. The incidence of H. pylori infection was borderline correlated to the severity of IM (p=0.076). Telomerase was elevated in eight (18.6%) patients. Telomerase tends to be high in subtype III and endoscopic grade III of IM. After H. pylori eradication, endoscopic extent (p=0.039) and histologic severity (p=0.074) showed improvements, and telomerase decreased significantly (p=0.0001). CONCLUSION: Our data suggest that telomerase is associated with the severity and extent of IM and that H. pylori eradication improves the endoscopic and histologic features in IM, and decreases telomerase activity. H. pylori eradication can be considered one of the methods to prevent gastric cancer in patients with H. pylori-infected IM. Further long-term and large-scaled study will be needed.

A Case of Giant Cavernous Hemangioma of Transverse Colon Associated with Hematochezia / 대한소화기내시경학회지

Gastrointestinal hemangiomas are not common and congenital lesion. Intestinal bleeding is the most common symptom of it. Hemangiomas were classified with capillary, cavernous and mixed type. Cavernous hemangioma is most common. Colonic cavernous hemangioma is rare and are usually arising in the sigmoid colon or/and rectum. Transverse colonic cavernous hemangioma are very rare. Gastrointestinal hemangioma is commonly developed in childhood and in young adults. Fifty eight-year-old man who complained of hematochezia was admitted. Physical examination was unremarkable. Stool occult blood was positive. Abdominal computerized tomography show normal finding. Colonoscopic examination showed giant and bluish-purple colored vascular malformation, 15 cm in length with tough bleeding, on the transverse colon. The patient underwent segmental resection of transverse colon for confirmatory diagnosis and treatment. The final pathologic diagnosis of the resection lesion was cavernous hemangioma of the transverse colon. We report a case of giant hemangioma of the transverse colon associated with hematochezia, with review of relevant literature.

Endoscopic features and clinicopathological relationship of colonic lymphoid hyperplasia / 대한내과학회지

BACKGROUND: There have been known a few endoscopic studies of colonic lymphoid hyperplasia. The various findings of colonic lymphoid nodules may nevertheless cause confusion with other endoscopic diagnosis and their clinicopathologic significance have not been well known until now. The aims of this study were to classify the colonic lymphoid hyperplasia accordings to the colonoscopic findings and to reveal the clinicopathological relationship. METHODS: From January 1998 to December 2000, 35 cases of colon lymphoid hyperplasia were selected in this study, the patients who had any other colon diseases were excluded in initial study group. We evaluated the endoscopic features of colonic lymphoid hyperplasia and analyzed their clinicopathologic relationships. RESULTS: Colonic lymphoid hyperplasia was endoscopically classified as follows: 18 Polyps, 7 Target lesions, 5 Verrucous lesions, 5 Erosions. The rectum and cecum were most frequently involved. The histological grades of colonic lymphoid hyperplasia were divided into grade I (19 cases), grade II (13 cases), graded III (3 cases) according to degree of lymphatic follicle and lymphocyte infiltration to interstitial tissue. The severity of histologic grades had a tendency to increment in verrucous or erosive lesion comparing with polyp or target lesion, but they had no significant relation with other endoscopic or clinical features. CONCLUSION: Colonic lymphoid hyperplasia can be classified endoscopically into four types. Verrucous or erosive lesion might be considered as more severe colonic lymphoid hyperplasia. Further prospective and long-term studies are needed to confirm clinicopathologic significance of various endoscopic features.

Comparative, Controlled Study of Cisapride Tartrate and Domperidone Maleate in Patients with Non-erosive reflux disease (Multicenter Study) / 대한소화관운동학회지

BACKGROUNDS/AIMS: The therapeutic requirements of patients with non-erosive reflux disease (NERD) are similar to those with erosive esophagitis. The pharmacological action mechanism of prokinetics is quite different; domperidone is a peripheral dopamine D2-antagonist and cisapride is a HT4-agonist. This study was performed to evaluate the therapeutic effect of these two different prokinetics in patients with NERD. METHODS: 178 patients, with heartburn and/or regurgitation, without reflux esophagitis were enrolled and divided into 2 groups by randomization code. In this prospective multicenter trial, 178 patients (93 patients in cisapride group, 85 patients in domperidone group) received 10 mg of cisapride three times a day or 10 mg of domperidone three time a day for 2 or 4 weeks. Symptom assessment was performed in each patients before treatments, 2 and 4 weeks after treatment. RESULTS: Of the 133 patients available for final analysis, 65 were allocated to the cisapride group and 68 to the domperidone group. After 2 weeks treatment, heartburn was reduced in 81.1% of cisapride group, 56.7% of domperidone group (p < 0.05) and regurgitation was reduced in 89.7% of cisapride group, 77.7% of domperidone group. After 4 weeks treatment, heartburn was reduced in 94.3% of cisapride group, 88.7% of domperidone group and this difference was not significant. The proportion of adverse events in cisapride group was 9.4% and was 5.5% in domperidone group. CONCLUSIONS: Cisapride tartrate was more effective in relieving heartburn in NERD patients than domperidone maleate after 2 week treatment. However, this superior effect dose not persist longer than 2 weeks.

A Case of Nonsurgical Treatment in Boerhaave's Syndrome Concomitantly Developed with Acute Pancreatitis / 대한소화기내시경학회지

Spontaneous rupture of the esophagus is an uncommon disease which was first reported by Boerhaave in 1724. This esophageal rupture usually occurs during nausea or vomiting, with incoordinate esophageal contraction. Early diagnosis and prompt surgical repair are critical for survival; however late recognition of esophageal rupture is not unusual. In recent years, a variety of nonsurgical approaches have been proposed, particularily in the case of delayed diagnosis. We have experienced one case of Boerhaave's syndrome concomitantly developed with acute pancreatitis which was successfully treated by nonsurgical measures including endoscopic clipping, antibiotics and hyperalimentation. We review the choice of treatment method in delayed diagnosed Boerhaave's syndrome.

A Case of Rectal Dieulafoy's Lesion Treated by Endoscopic Band Ligation / 대한소화기내시경학회지

The variety of endoscopic therapy for the treatment of bleeding Dieulafoy's lesion of the rectum, such as electrocoagulation, clipping, epinephrine and sclerosant injection, reduced the necessity of surgical intervention. Recently, endoscopic band ligation was introduced with favorable results for the hemostasis of rectal lesions. This type of therapy is appropriate for areas of bleeding within otherwise non-fibrotic tissue, such as Dieulafoy's lesion, Mallory- Weiss tear and vascular malformations. We report a case of successful management with endoscopic band ligation in a patient with rectal bleeding from Dieulafoy's lesion.

A Case of Primary Jejunal Malignant Lymphoma Associated with Nodular Lymphoid Hyperplasia / 대한소화기내시경학회지

Nodular lymphoid hyperplasia is a reaction of the intestinal lymphatic tissue to specific inflammatory stimuli and may be probably of no clinical significance, but it may evolve to primary gastrointestinal lymphoma in more severe cases. Recently, several cases of nodular lymphoid hyperplasia complicated by primary gastrointestinal lymphoma have been reported, and which suggested that nodular lymphoid hyperplasia could not be considered as simple benign colon disease any more. We also experienced a case of primary jejunal malignant lymphoma associated with nodular lymphoid hyperplasia, and report this case with a brief review of relevant literatures.

Two Cases of Extended Endoscopic Sphincterotomy in Patients with Periampullary Diverticulum -How do we estimate the upper margin of intramural ampulla in patients with periampullary diverticulum?- / 대한소화기내시경학회지

Periampullary diverticulum (PAD), which was frequently noticed during endocopic retrograde cholangiopancreatography (ERCP) for examination on patients with pancreaticobiliary diseases, made difficult to cannulate the duct and to perform the endoscopic sphincterotomy (EST). EST was very useful therapeutic modality for pancreaticobiliary disease, but endoscopists are always careful about EST-related complication, especially in patients with PAD. The general principle of EST was not to incise extendedly above the papillary roof, but the following endoscopic findings help to try the extended EST safely above the papillary roof. On the endoscopic examination there was reducible protrusion above papilla by contrast injection or air deflation, which had bile-colored transparency and arborescent capillary network in the usual direction of the bile duct. We have recently experienced 2 cases of extended EST in patients with PAD, who showed the endoscopic findings mentioned above and recovered without bleeding or perforation.

A Case Report of Esophageal and Ileocecal Valve Involvement in Behcet's Disease / 대한소화기내시경학회지

Behcet's disease characterized by recurrent oral and genital ulceration and ocular inflammation has been recognized as a multi-system disorder with numerous manifestations including gastrointestinal tract. Terminal ileum and cecum are the most frequently involved portions of the gastrointestinal tract in Behcet's disease and esophageal involvement is very uncommon. We experienced a case of Behcet's disease involved esophageal and ileocecal region which had been diagnosed by endoscopy. A 20-year-old male was admitted by dysphagia and substernal discomfort. There was a history of recurrent aphthous stomatitis and genital ulcers. The large geographic ulcers surrounded with edematous mucosa were found at mid esophagus and the huge ulcer with exudate was noted on ileocecal valve area in endoscopic examination. The microscopic finding of endoscopic biopsy showed chronic nonspecific inflammation with necrotic inflammatory exudate. Pathergy test was positive. So he was diagnosed as Behcet's disease, and his symptoms and signs were resolved after steroid treatment.

Antibiotics Associated Hemorrhagic Colitis: A report of two cases / 대한소화기내시경학회지

Antibiotics related colitis is a well recognized disease entity which in its severest form may result in pseudomembranous colitis, whereas in another form, acute hemorrhagic colitis without pseudomembrane, related to the use of penicillin-type antibiotics is rarely reported. The clinical features of hemorrhagic colitis associated with antibiotics was characterized that the bloody diarrhea, often with abdominal cramping pain begins 2~7 days after starting the antibiotics and rapidly recovered after its withdrawal. Pathogenesis of this disease is not entirely clear. It has been believed that right-sided hemorrhagic colitis is one of the main forms of colitis associated with antibiotics, especially ampicillin derivatives or cephalosporin, but recent reports presented left-sided colitis. We experienced 2 cases of hemorrhagic colitis developed on the left colon after the introduction of quinolone.

What is the best method to diagnose Helicobacter infection in bleeding peptic ulcers?: a prospective trial

BACKGROUND: It has been debated which diagnostic test should be preferred for the diagnosis of Helicobacter pylori (HP) in patients with peptic ulcer diseases. Several limitations are reported in bleeding peptic ulcers because of intragastric blood and possibility of changed numbers of organisms by medication. This study was designed to find out the best method for diagnosis of HP infection, in aspect of deciding the times of detection and the specific tests in bleeding peptic ulcers. METHODS: We prospectively examined histology, rapid urease test (CLO test), urea breath test (13C-UBT) and serology in HP diagnostics in 32 patients with bleeding peptic ulcers to detect HP infection. Each test was performed two times (four methods at first 24 hours and former three methods at 7th day after initial therapeutic endoscopy). We evaluated the sensitivity of each test, compared the two-times results and evaluated the effect of these tests to an outcome of endoscopic hemostasis. RESULTS: Diagnostic sensitivities of histology, CLO test, 13C-UBT and serology are 75%, 67.8%, 100% and 100% at first endoscopy, and 71.4%, 78.5%, 89.3% at 7th day endoscopy, respectively. Histologic study and CLO test had diagnostic limitation at emergent first endoscopy contrary to UBT (p < 0.01). Histologic study, CLO test and UBT have limitations at 7th day endoscopy. Only 3 patients (9.4%) rebled with subsequent complete endoscopic hemostasis and all diagnostic tests at initial endoscopy did not influence the outcome of hemostasis. CONCLUSION: First day histologic and CLO tests are inadequate methods in detecting HP infection in patients with bleeding peptic ulcers. 7-day histologic, CLO test and UBT have a low sensitivity. First-day UBT can be a standard test to diagnose HP infection in patients with bleeding peptic ulcers.

Clinical Significance of Endoscopic Ultrasonography in Gastritis Cystica Polyposa / 대한소화기내시경학회지

No abstract available

Steroid-resistant Ulcerative Colitis in Acute Exacervation Phase Remitted by Cyclosporine and Azathioprine: A case report / 대한소화기내시경학회지

Ulcerative colitis is chronic inflammatory disease of bowel without definite cause. Standard therapy of ulcerative colitis consists of aminosalicylates and glucocorticoid. In recent years, the effectiveness of cyclosporine in inflammatory bowel disease has been reported. Cyclosporine is useful in inducing remission in patients with acute exacervation phase who do not achieve remission with an intensive intravenous steroid therapy. We report a case of steroid-resistnat ulcerative colitis, treated with cyclosporine in 45-year-old man. Remission was not achieved with treatment of sulfasalazine and intensive intravenous glucocorticoid therapy for 10 days. We administered cyclosporine parenterally in dose of 4 mg/kg/day for 10 days. He improved dramatically without significant side effects of drug and avoided colectomy. He was discharged with oral cyclosporine and azathioprine and has been followed up outpatients department remained in clinically remission. Cyclosporine seems to be an effective treatment for patients with steroid-resistnat severe ulcerative colitis in whom colectomy seems inevitable.

Change of Clinical Patterns and Significance of Endoscopy in Gastric Outlet Obstruction / 대한소화기내시경학회지

BACKGROUND/AIMS: The causes of gastric outlet obstruction (GOO) have changed from peptic ulcer disease (PUD) to malignant diseases in recent years. The aims of this study are to determine the relative incidence of malignany and other causative diseases, and to consider therapeutic and diagnostic usefulness of endoscopy. METHODS: 95 patients with GOO who diagnosed by radiologic and endoscopic examination or surgery were reviewed by causative diseases, clinical features, endoscopic findings and outcome of treatment. RESULTS: 1) The mean age was 57.5 years (M:F=2.4:1). 2) The causative diseases were gastric or duodenal malignancy (56.8%), complication of PUD (39.2%), and biliary and pancreatic disease (4.2%). 3) Malignancy was diagnosed by upper gastrointestinal (UGI) endoscopy in 95.8%; obstruction by complication of PUD was detected by endoscopy in 100%. 4) The most common endoscopic type of malignancy was Borrman type 3 (84.8%) and the most common benign lesions were duodenal or pyloric ulcer (94.5%). 5) The managements of malignancy were operation (53.5%), endoscopic stenting (18.5%), and conservative treatment (38.8%). The complications of PUD were treated by anti-ulcer medication (85.3%), endoscopic dilatation (4.8%) and operation (13.6%). CONCLUSIONS: The main causes of GOO are changed to malignancy in recent 5 years. Endoscopy is useful to detect the various causes of GOO, and necessary procedure to decide the method of their management.

Change of Clinical Patterns and Significance of Endoscopy in Gastric Outlet Obstruction / 대한소화기내시경학회지

BACKGROUND/AIMS: The causes of gastric outlet obstruction (GOO) have changed from peptic ulcer disease (PUD) to malignant diseases in recent years. The aims of this study are to determine the relative incidence of malignany and other causative diseases, and to consider therapeutic and diagnostic usefulness of endoscopy. METHODS: 95 patients with GOO who diagnosed by radiologic and endoscopic examination or surgery were reviewed by causative diseases, clinical features, endoscopic findings and outcome of treatment. RESULTS: 1) The mean age was 57.5 years (M:F=2.4:1). 2) The causative diseases were gastric or duodenal malignancy (56.8%), complication of PUD (39.2%), and biliary and pancreatic disease (4.2%). 3) Malignancy was diagnosed by upper gastrointestinal (UGI) endoscopy in 95.8%; obstruction by complication of PUD was detected by endoscopy in 100%. 4) The most common endoscopic type of malignancy was Borrman type 3 (84.8%) and the most common benign lesions were duodenal or pyloric ulcer (94.5%). 5) The managements of malignancy were operation (53.5%), endoscopic stenting (18.5%), and conservative treatment (38.8%). The complications of PUD were treated by anti-ulcer medication (85.3%), endoscopic dilatation (4.8%) and operation (13.6%). CONCLUSIONS: The main causes of GOO are changed to malignancy in recent 5 years. Endoscopy is useful to detect the various causes of GOO, and necessary procedure to decide the method of their management.

Clinical Usefulness of Combination Therapy with Endoscopic Incision Using Needle-Knife Papillotome and Local Injection of Steroid for the Treatment of Benign Esophageal Anastomotic Stricture / 대한소화기내시경학회지

BACKGROUND/AIMS: The endoscopic incision for the treatment of benign esophageal anastomotic stricture (BEAS) was uncommonly reported because of the frequent recurrence of stricture. Intralesional steroid injection has been shown to be effective in prevention of recurrence, so we have performed the combination therapy with endoscopic incision and intralesional steroid injection. METHODS: Fourteen patients with BEAS were treated with endoscopic radial cuts using needle-knife papillotome together with intralesional injection of triamcinolone. The mean age of the 14 patients was 58.1 and mean follow-up days was 205.8 (65~439). RESULTS: The onset of BEAS were 135.6+/-73.0 days and significantly early in patients with distorted stapling (p=0.012). After treatment the diameter of stricture was significantly increased (p=0.001) and the dysphagia was improved above 2 degrees. Initial dilatation was successfully done in one session and there was 10 cases of mild bleeding. The stricture recurrence was developed in 4 cases (30.7%), which showed tendency in long length of stricture (p=0.12) and significance in distorted stapling (p=0.007). CONCLUSIONS: The combination therapy with endoscopic incision and steroid injection may be useful method for the treatment of BEAS, but further long-term follow-up and comparative study were needed.

A Case of Metastatic Malignant Melanoma in Stomach / 대한소화기내시경학회지

Malignant melanomas are common metastatic lesions in the gastrointestinal tract. There are some descriptions for endoscopic findings but few reports on the endoscopic ultrasonographic findings of metastatic malignant melanomas in the stomach. A 67-year-old woman was admitted due to indigestion persisting for 1 month. She had a 3x4 cm sized black pigmented skin lesion on her left foot. An abdominal ultrasonography and CT scan revealed multiple variable sized round lesions in the liver, suggesting metastatic lesions. An endoscopy revealed multiple, elevated lesions with central ulcerations and a star shaped black pigmentation around the ulcer mound on the antrum of the stomach, as well as huge ulcers with black pigmented bases on the upper body. An endoscopic ultrasonography determined that the depths of the elevated lesions on the antrum were 1imited to the mucosal layer and that huge ulcers on the upper body were invading the serosa simultaneously. The skin lesion was diagnosed as a malignant melanoma and the stomach lesion were also confirmed to be metastatic malignant melanomas. The case of malignant melanomas that metastased to the stomach and had unusual endoscopic ultrasonographic findings is herein reported.

The Clinical Usefulness of Esophagogastreduodenoscopy in Neonates and Infants / 대한소화기내시경학회지

BACKGROUND/AIMS: Endoscopic examination of upper gastrointestinal tract disease in infancy and childhood was introduced 2 decades ago. However, clinical indication, premedication, endoscopic features, and practical problems have been infrequently reported in neonate and infants, Therefore, the usef'ulness and problems of endoscopy in these pediatric patients was evaluated. METHODS: Twelve pediatric patients who underwent endos-copic examination which involved a choledochoscope, bronchoscope, and gastrofibroscope included 8 neonates and 4 infants who suffered from gastrointestinal symptoms. Drugs for premedication were chloral hydrate, diazepam, midazolam and ketamine in single or combined administration. RESULTS: Clinical manifestations were hematemesis (67%), melena (42%), vomiting (8%), weight loss (8%), fever (8%) and irritability (8%). Indica-tions for endoscopic examination were upper gastrointestinal Weeding (67%), upper gastrointestinal obstruction (8%), acute drug intoxication (8%), foreign bodies in the stomach (8%) and evaluation for varix (8%). Endo-scopic findings revealed a gastric ulcer (48%), acute gastric mucosal lesion (8/<), external compression on the duodenum (8%), a gastric foreign body (8%), acute esophago-gastritis (8%) and esophageal and gastric varix (8%). Therapeutic endoscopy was performed in 2 patients, One case of hypoxia occurred during diagnostic endoscopy. CONCLUSIONS: Endoseopic examination of the upper gastrointestinal tract is a useful and safe proce-dure to detect diseases in neonates and infants if it is done by experienced endocopists and in the circumstances of adequate premedication.