Y. T. Jeen

Risk Factors for Immediate Postpolypectomy Bleeding of the Colon: A Multicenter Study

OBJECTIVES:The aims of this prospective study were to document the incidence of colon immediate postpolypectomy bleeding (IPPB) according to grade, and to identify potential risk factors of IPPB in patients who have received complete colonoscopy and polypectomy because of a colorectal polyp.METHODS:This was a prospective, cross-sectional study of 5,152 patients treated at 11 tertiary medical centers between July 2003 and July 2004. Patient-related, polyp-related, and procedure-related variables were evaluated as potential risk factors for IPPB. IPPB was defined as a bleeding occurring during the procedure and was graded as G1–G4. Risk factors associated with IPPB were analyzed by univariate and multivariate logistic regression analysis.RESULTS:A total of 9,336 colonic polyps were removed in 5,152 patients, and 262 (2.8%) colorectal polyps in 215 patients presented with IPPB. Polyp-based multivariate analysis revealed that old age (≥65 yr), comorbid cardiovascular or chronic renal disease, anticoagulant use, polyp size greater than 1 cm, gross morphology of polyps such as pedunculated polyp or laterally spreading tumor, poorer bowel preparation, cutting mode of the electrosurgical current, and the inadvertent cutting of a polyp before current application were significant risk factors for IPPB.CONCLUSION:Nine factors have been found to be associated with IPPB and polypectomy should be undertaken with caution under these conditions.

Prevalence of endoscopic reflux esophagitis among Koreans

Background and Aim: Although reflux esophagitis is believed to be common in the Western population, very few epidemiologic data on reflux esophagitis in Koreans are available. The aims of this study were to evaluate the prevalence of endoscopic reflux esophagitis in patients who came for a physical check‐up at Korea University Hospital, and to study the relationship between various factors relevant to reflux disease.

Inconsistent association of esophageal symptoms, psychometric abnormalities and dysmotility.

Abstract OBJECTIVES: The aim of this study was to characterize the psychometric profiles of symptomatic patients with abnormal esophageal motility and symptomatic patients with normal manometric findings compared to asymptomatic controls. METHODS: A total of 113 patients with abnormal esophageal motility (7 achalasia, 8 diffuse esophageal spasm, 27 nutcracker esophagus, 37 hypertensive lower esophageal sphincter, 21 hypotensive peristalsis, 13 failed peristalsis), 23 symptomatic controls with similar esophageal symptoms but normal manometry, and 27 asymptomatic controls were enrolled. Validated questionnaires assessing depression (Beck Depression Inventory), anxiety (Spielberger State Anxiety Inventory or Trait Anxiety Inventory), and somatization (Psychosomatic Symptom Checklist) were administered to all subjects. RESULTS: Patients with both esophageal symptoms and either hypertensive lower esophageal sphincter, nutcracker esophagus, or hypotensive contractions exhibited increased somatization, acute anxiety, or depression compared to asymptomatic controls but not compared to symptomatic controls. On the other hand, the psychometric profiles of patients with achalasia and diffuse esophageal spasm were strikingly normal. Among esophageal symptoms, chest pain was closely correlated with psychometric abnormalities. CONCLUSIONS: The esophageal symptoms of patients with abnormal esophageal motility may relate to the underlying psychological abnormalities, independent of manometric abnormalities.

Biliary papillary hyperplasia with clonorchiasis resembling cholangiocarcinoma.

Infection by the liver fluke Clonorchis sinensis is very common in the Far East. It causes low grade inflammatory changes and proliferation in the biliary tree. Initially there is desquamation of the biliary epithelium, followed by hyperplasia and adenomatous proliferation. Cholangiocarcinomas are potential long term complications. We present a case of biliary papillary hyperplasia with clonorchiasis resembling cholangiocarcinoma in a 69-yr-old Korean man. Early recognition of biliary hyperplasia and treatment of Clonorchis sinensis is important to prevent development of cholangiocarcinoma, especially in the Far East.

The effect of the respiratory cycle on liver stiffness values as measured by transient elastography

Summary.u2002 The findings of several studies suggest that liver stiffness values can be affected by the degree of intrahepatic congestion respiration influence intrahepatic blood volume and may affect liver stiffness. We evaluated the influence of respiration on liver stiffness. Transient elastography (TE) was performed at the end of inspiration and at the end of expiration in patients with chronic liver disease. The median values obtained during the inspiration set and during the expiration set were defined as inspiratory and expiratory liver stiffness, respectively. A total of 123 patients with chronic liver disease were enrolled (mean age 49u2003years; 64.2% men). Liver cirrhosis coexisted in 29 patients (23.6%). Expiratory liver stiffness was significantly higher than inspiratory liver stiffness (8.7 vs 7.9u2003kPa, Pu2003=u20030.001), while the expiratory interquartile range/median ratio (IQR ratio) did not differ from the inspiratory IQR ratio. Expiratory liver stiffness was significantly higher than inspiratory liver stiffness in 49 (39.8%) patients (HE group), expiratory liver stiffness was significantly lower than inspiratory stiffness in 15 (12.2%) patients, and there was no difference in 59 (48.0%) patients. Liver cirrhosis was more frequent in those who had a lower liver stiffness reading in expiration, and only the absence of liver cirrhosis was significantly associated with a higher reading in expiration in multivariate analysis. In conclusion, liver stiffness was significantly elevated during expiration especially in patients without liver cirrhosis. The effect of respiration should be kept in mind during TE readings.

New approach to radial expansive force measurement of self expandable esophageal metal stents

The accurate measurement of radial expansive force is crucial for optimal design and implantation of self expandable esophageal metal stents. In the present study, a new method of measurement under experimental conditions simulating actual stent implantation has been developed. This method offers precise and reproducible measurements and can be applied to a wide variety of stent types. In particular, the method enables one to measure expansive pressure as well as the true radial expansive force up to the radial compression ratio of 72%, covering the range of compression often encountered in a partially obstructed lumen. The test results for various kinds of metal stents are presented and compared. Based on these results, three important points of observation critical in explaining and predicting the expansion characteristics of stents have been reported. Further understanding and characterization of these findings will be necessary for developing new stents with outstanding clinical efficacy.

Anaphylactic shock-induced ischemic proctocolitis following bee stings: first case report

for hematochezia following resuscitation from a hypotensive shock. The history revealed that while working outdoors, the patient had been attacked by a swarm of bees and received multiple stings, rendering him unconscious. Following initial recovery at the local hospital, he developed hematochezia and was referred to us. On examination at admission, the patient was alert and not pale, and his vital signs were stable. He denied any previous allergic history related to drugs or other substances, and he was not taking any medication. There was no notable family history. Pain and tenderness were elicited in the periumbilical region but without rebound tenderness. Digital rectal examination revealed bloody and mucoid discharge. The initial laboratory results showed leukocytosis and mild elevation of serum aminotransferases without anemia. Abdominopelvic computed tomography (CT) disclosed edematous wall thickening in the rectosigmoid and cecal regions. Electrocardiography did not show any sign of cardiac arrhythmia. On sigmoidoscopy, the rectal mucosa was hemorrhagic and greatly swollen with narrowing of the lumen, whitish exudates, and intermittent, deep ulcerations (● Fig. 1a). This presentation persisted as the scopewas advanced and then relatively normal mucosa was seen at 25 cm from the anal vergewith a sharply distinct margin (● Fig. 1b). Total colonoscopy carried out the next day revealed cecal pathology with similar findings (● Fig. 1c). Following administration of empirical antibiotics, bowel rest, and copious intravenous hydration, the abdominal pain subsided and the hematochezia ceased. The patient resumed his normal diet 11 days after admission. Pathologic examination verified the diagnosis of ischemic colitis. Followup total colonoscopy before discharge revealed much improvement (● Fig. 1d– f), and a later endoscopic review examination revealed minimal changes in the colonic mucosa with no evidence of stricture or other deformities. Ischemic colitis is the most commonmanifestation of mesenteric ischemia [1], and a few cases of acute ischemic colitis of unusual etiology have been reported [2– 5]. Our patient’s young age and otherwise apparently healthy constitution with no notable medical history are suggestive of low probability of atherosclerotic change and susceptibility to any kind of bowel ischemia. Our patient therefore exemplifies a rare instance of anaphylactic shock caused by bee stings leading to ischemic colitis, and is the only case of its kind to be reported to date.

Splenic infarction after cyanoacrylate injection for fundal varices

to hepatitis B infection, who had undergone regular endoscopic variceal therapy for fundal varices, was admitted for secondary prophylaxis. The laboratory findings were unremarkable apart from a low platelet count (34 × 103/μL) and prolonged prothrombin time (17.7 s, international normalized ratio [INR] 1.46, 59%). Endoscopic examination revealed small esophageal varices and large fundal varices with the red color sign. Two injections of 2mL of N-butyl-2-cyanoacrylate (Histoacryl; B. Braun, Tuttlingen, Germany) diluted with Lipiodol (Guerbet, Aulnay Sous Bois, France) were administered into the fundal varices. The patient had undergone multiple sessions of endoscopic injection therapy in the past with no occurrence of complications. However, 2 days after the last endoscopic cyanoacrylate therapy, he developed abdominal pain and fever, and his white blood cell (WBC) count rose to 14 × 103/μL. Abdominal computed tomographic (CT) angiography revealed remnants of cyanoacrylate in the splenic vein with nonenhancing splenic parenchyma, suggestive of cyanoacrylate-induced splenic infarction (● Fig. 1). Intravenous antibiotics were immediately initiated along with supportive management. Both the abdominal pain and fever gradually subsided and the WBC count normalized. The patient was discharged on day 20 in the hospital without any further complications or symptoms. A follow-up CT showed persistent, large, hypoattenuated lesions in the spleen, but the patient remained asymptomatic during the 9 months’ follow-up in the outpatient department (● Fig. 2). Endoscopic injection of cyanoacrylate is generally considered to be the usual treatment for gastric varices, but complications such as fever, deep ulceration, chest pain, andvascular occlusion can occur. Although splenic infarction after administration of cyanoacrylate is rare, it has been reported tooccurwhen largevolumesof cyanoacrylate are injected rapidly. This is because of the consequent splenic venous occlusion [1]. With adequate supportive management the splenic infarct can be left in situ. Its clinical course may be self-limiting and the patient may not require surgical treatment, such as splenectomy [2].

Candida esophagitis complicated by esophageal stricture.

department of gastroenterology with dysphagia accompanied by odynophagia without weight loss. The patient was immunocompetent and her only medication was synthyroid, which she had been taking for the past 15 years due to hypothyroidism. The patient said that she had her first recurrent episodes of odynophagia 7 years previously and recalled that endoscopic examination at that time had revealed severe candida esophagitis. Her symptoms improved after taking medication for 1 month. She was without symptoms for a couple of years, but about 5 years prior to the current presentation, she began to experience dysphagia from time to time when taking pills or swallowing meat, and these episodes had become more frequent and had worsened during the past year. The patient visited a gastroenterologist and underwent endoscopy, which revealed narrowing of the esophagus and whitish plaques scattered throughout the mucosa. The endoscopy performed at our hospital also revealed esophageal luminal narrowing at 23 cm from the central incisor, with irregular mucosa and multiple ulcers and whitish exudates (● Fig. 1). The scope (GIF-H260, Olympus, Japan) could not pass beyond the stricture. Multiple biopsies were taken and revealed fungal infection, consistent with candidiasis, with ulcer and pseudoepitheliomatous hyperplasia. The patient was prescribed fluconazole and at follow-up endoscopy 6 weeks later the esophageal stenosis and mucosal lesion had improved. However, the lumen was still not wide enough for the GIFH260 to pass and only the GIF-Q260, which has a smaller caliber, could pass through the stricture site (● Fig. 2). During the follow-up at the outpatient department, endoscopy was performed again because the patient complained of gradual worsening of dysphagiawith solid foods. Endoscopic examination showed more stenotic lumen through which even the GIF-Q260 could not pass (● Fig. 3). Barium esophagogram demonstrated narrowing deformity with an irregular base in the upper and mid-esophagus; the distal esophagus was normal (● Fig. 4). Our case demonstrates the importance of proper and timely management of candida esophagitis, as inadequate and delayed treatment can result in esophageal stricture that can become debilitating.

Successful hybrid NOTES resection of early gastric cancer in a patient with concomitant advanced colon cancer

scopic surgery) is currently of greatest interest to endoscopists and laparoscopic surgeons [1–3]. Early gastric cancer (EGC) is generally managed with endoscopic submucosal resection (ESD) if indicated. We present a case of EGC removed by hybrid NOTES, with a concomitant colon cancer resected via laparoscopic colectomy. A 62-year-old man was diagnosed with simultaneous gastric and colonic cancer. The gastric cancer was an EGC in the form of a moderately differentiated adenocarcinoma on the upper body; the mass in the ascending colon was also moderately differentiated adenocarcinoma (● Fig. 1). Computed tomography and positron emission tomography showed no definite evidence of metastasis. Although total gastrectomy with right colectomy was the treatment of choice, the patient was concerned about his expected quality of life after the surgical resection. ESD of the EGC was also considered, but this was not suitable even on the basis of an expanded indication [4]. We therefore decided to perform hybrid NOTES for gastric adenocarcinoma and laparoscopy-assisted colectomy. After successful removal of the colon cancer by the colorectal surgeon (J. K.) using a standardized laparoscopic technique, the endoscopist (B. K.) used an improved insulated-tip (IT2) knife and endoscopic papillotome to cut around the EGC for a fullthickness incision. The stomach was artificially perforated and collapsed, and a surgeon (S. S. P.) helped by holding back the shrunken stomach. The lesion was cut around for about two-thirds of the total diameter, and laparoscopic removal was completed via a wedge resection with stapling (● Fig. 2). Pathologically, the gastric lesionwas a poorly differentiated tubular adenocarcinoma (type IIb + IIc) invading the lamina propria. The colon cancer was diagnosed as a moderately differentiated adenocarcinomawith three positive lymph nodes. The resection margins of both cancers were free of carcinoma. Endoscopic follow-up and a CT scan taken after 4 months revealed no distinct recurrence of either lesion. Current NOTES researchers who still have access to only a handful of pre-existing equipment without any innovative new devices will benefit from the possibility of performing hybrid NOTES. In an institution with an experienced laparoscopic surgeon and also a skillful endoscopist, hybrid NOTES is a reasonable choice for patients requiring organ preservation. It will also function as a crucial makeshift bridge for crossing over to authentic NOTES in the near future.