A Black Stomach Cause by Ingestion of Calcium Chloride

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1 P-1 A Black Stomach Cause by Ingestion of Calcium Chloride Seung Sik Park, Chang Mo Moon, Jung Ho Park, Hong Joo Kim, Dong Il Park, Yong Kyun Cho, Chong Il Sohn, Woo Kyu Jeon, Byung Ik Kim, Yoon Sook Jung Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea Introduction: The accidental or suicidal ingestion of corrosives induces severe esophagogastric damage. Although there are some reports of black esophagus in the literature, reports regarding black stomach are very rare. Case Report: A 57-year-old man visited emergency room after swallowing about 150 mg CaCl 2. (Hippopotamus absorbing water ) Vital signs were stable and laboratory findings showed leukocytosis and hypercalcemia (WBC 1410, Ca/P 15.6/5.6). Immediately, N/S irrigation through nasogastric tube was performed and EGD was performed. There were dark colored mucosal changes and ulcerations covered with necrotizing exudate in stomach wall (Fig). After 2days, hypercalcemia was corrected by hydration and pamidronate. The patient s condition was improved and discharged on 11th admission day. CaCl 2 is alkaline substance and the injury mechanism is related to the hygroscopic properties of CaCl 2 granules. When CaCl 2 incorporates with water, it generates an exothermic reaction. Because the stomach content has more water (N/S irrigation, acid and mucus secretion) it seems that the burning was more severe than the esophageal and duodenal burn. Fig. Conclusion: A black stomach is the uncommon endoscopic finding of extensive black discoloration of the gastric mucosa from gastric necrosis. Key Words: Black Stomach, Calcium Chloride, CaCl 2, Ingestion, Corrosive P-2 Comparison of Clinical Outcome of Peptic Ulcer Bleeding according to the Different Etiology: H. pylori Infection or Drug Dae Bum Kim 1, Woo Chul Chung 1, Eun Jung Jeon 2, Chang Nyol Paik 1, Kang-Moon Lee 1 Department of Internal Medicine, The Catholic University of Korea, College of Medicine, 1 St. Vincent Hospital, Suwon, 2 St. Paul Hospital, Seoul, Korea Background: The peptic ulcer has two major etiologies, Helicobacter pylori (H. pylori) and drug (low dose aspirin, antithrombotic agents and nonsteroidal anti-inflammatory drugs (NSAIDs). Its bleeding can be severe, but the severity of bleeding according to the etiology has rarely been reported. We aim to evaluate the clinical outcomes and severities of peptic ulcer bleeding (PUB) according to the etiology. Methods: A consecutive series of patients who had PUB and admitted to the hospital between 2005 and 2011 were retrospectively analyzed. A total of 232 patients were enrolled in this study, and we compared the clinical characteristics and outcomes according to the different etiologies. We also evaluated the severity of PUB using Blatchford score and Rockall score between four groups. Results: In drug group, patients were older (mean age: ± years vs ± years, p<0.01), the duration of admission was longer, (8.52 ± 8.97 days vs ± 2.41 days, p<0.01), the ulcer size was larger (1.24 ± 0.92 cm vs ± 0.51 cm, p<0.01) and transfusion need is higher (3.58 ± 4.95 vs ± 1.98, p=0.01) than H. pylori group. And Blatchford score and Rockall score of drug group are higher than H. pylori group (9.78 ± 3.77 vs ± 3.71, p=0.03 and 4.73 ± 2.21 vs ± 1.54, p<0.01, respectively). The Blatchford and Rockall score of H. pylori with drug group are higher than H. pylori group. The patients in idiopathic group showed larger ulcer and had higher proportion of rebleeding than H. pylori group, however no significant difference is noted in Blatchford and Rockall score between the two groups. Conclusions: Clinically, the PUB seems to be more severe in drug induced group than H. pylori group. And idiopathic group has larger ulcer and reveals rebleeding frequently, but are not severe than H. pylori group. In the drug users, infection of H. pylori might not appear to play an important role in severerity of PUB. Key Words: Peptic ulcer, Gastrointestinal bleeding, Helicobacter pylori, Antithrombotic therapy, Anti-Inflmmatory agent, Non- Steroidal November 23, rd Congress of the Korean Society of Gastrointestinal Endoscopy 173

2 P-3 Belching during Esophagogastroduodenoscopy and Its Association with Gastroesophageal Reflux Disease Ban Seok Lee, Byung Hyo Cha, Young Nam Kim, Won Jung Jeon, Sang Jin Lee, Jin Dong Kim Digestive Disease Center and Department of Internal Medicine, Cheju Halla General Hospital, Jeju, Korea Background: Belching may result from transient lower esophageal sphincter relaxations, therefore, it has been proposed that belching may be a manifestation of gastroesophageal reflux disease (GERD). However, it is still questionable whether belching during esophagogastroduodenoscopy (EGD) is associated with GERD. Aims: To investigate frequency of belching during EGD and its association with GERD. Methods: A retrospective review was performed for the prospectively collected clinical and endoscopic data regarding 120 subjects undergoing EGD from Dec to May in the training hospital in Korea. Participants having gastrointestinal motility disorder, end-stage renal or liver disease, active mucosal lesion in stomach, or malignancy were excluded. Subjects who underwent endoscopic sedation were also excluded. All the detectable belching events were counted during endoscopy. Diagnosis of erosive reflux disease (ERD) and non erosive reflux disease (NERD) was based on endoscopic finding and proton-pump inhibitor (PPI) test, respectively. Results: There were 72 GERD patients (51 ERD and 21 NERD). Belching was more frequent in subjects with GERD than without GERD (6.8 ± 4.6, 1.2 ± 1.6 times, p<.001). After adjusting for other demographic and clinical variables using the logistic regression analysis, belching was still significantly associated with GERD (OR = 2.366, p<.001). In the analysis, the other significant factor besides belching was body-mass index (BMI) (OR = 1.227, p=.003). Subgroup analysis was performed in subjects without ERD. In multivariate analysis, belching and BMI were also significant factors associated with NERD (OR = and 1.223, p=.001 and.041, respectively). The grade of GERD was not significantly correlated with the frequency of belching. Conclusions: Frequent belching during EGD is associated with GERD. Furthermore, it may be useful diagnostic aid for NERD in patients without ERD even before the PPI test. Key Words: GERD, NERD, Belching, Reflux, Esophagitis P-4 Interrater Reliability of Laryngopharyngeal Reflux Findings between Otolaryngologist and Endoscopists -A Pilot Study Yong Sub Lee, Chang Seok Bang, Yun Hyeong Lee, Yeon Soo Kim, Gwang Ho Baik, Dong Joon Kim Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea Background and Aims: Reflux finding score (RFS) is an eight-item index designed to assess laryngopharyngeal reflux disease (LPRD) based on laryngoscopic findings. A score of 7 or above considered to be indicative of LPRD. This is to evaluate interrater reliability of LPR findings between otolaryngologist and endoscopists. Patients and Methods: Between May 2013 and August 2013, a total of 200 endoscopic pictures of larynx were selected for study. All investigators recorded their findings based on RFS. All endoscopists were two times educated on RFS from otolayrngologist before study and in the middle of study. The selected pictures were independently reviewed by one otolaryngologist and four endoscopists. Results: LPRD with 7 or more RFS was diagnosed in 46.5% (93/200) by otolaryngologist. On the first test with 100 pictures, Kappa values on LPRD between otolaryngologist and endoscopists had range from to On the second test with remaining 100 pictures after interim education, Kappa values had range from to Table 1. Interrater Reliability of Laryngopharyngeal Reflux between Otolaryngologist after 2 Hours Education Well-experienc ed endoscopist Less-experienced endoscopists Reviewer A Reviewer B Reviewer C Reviewer D The reflux finding score (RFS) % Agreement Cohen s kappa % Agreement Cohen s kappa % Agreement Cohen s kappa % Agreement Cohen s kappa Subglottic edema Ventricular obliteration Laryngeal erythema Vocal cord edema Diffuse laryngeal edema Posterior commissure Hypertrophy Laryngeal granuloma Thick endolaryngeal mucus Differential diagnosis beween laryngopharyngeal reflux (RFS 7) and normal finding (RFS < 7) 1st test nd test Conclusions: Our results didn't showed that there was substantial agreement on RFS between otolaryngologist and endoscopists. However, effective education on RFS might be expected to improve inter-observer agreement of it. Key Words: Laryngopharyngeal reflux, Reflux finding score, Endoscopy rd Congress of the Korean Society of Gastrointestinal Endoscopy November 23, 2013

3 P-5 Spontaneous Gastric Intramural Hematoma Occurred in a Patient Medicated with Clopidogrel Jung Sun An 1, Ki Joo Kang 1, Sung Woong Jung 1, Seung Yeon Chun 1, Ji Won Park 1, Sung-Eun Kim 1, Ho Suk Kang 1, Sung-Hoon Moon 1, Jong Hyeok Kim 1, Choong Kee Park 1, Dong Seon Park 2 1 Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 2 Department of Internal Medicine, Sam Hospital, Anyang, Korea Introduction: Intramural hematoma of the gastrointestinal tract is a rare disease. So far, there have only been a few reports, especially on hematoma of the stomach wall in particular. Case Report: A 52-year-old man was admitted complaining of abdominal pain and hematemesis. He has received hemodialysis due to glomerulonephritis and was medicated with a clopidogrel. Laboratory tests measured a hemoglobin level was 10.0 g/dl and serum creatinine was 10.9 mg/dl. On endoscopy, a large hematoma (about 10cm-sized) covered with normal mucosa was noted at antrum, anterior wall side and it was soft when compressed by forceps. In the center of lesion, about 2.5 cm-sized, an active ulcer with adherent clot was found (Fig. 1). Abdominal computed tomography revealed an approximately 11 4 cm intramural hematoma in anterior wall of gastric antrum (Fig. 2). He was given conservative treatment with proton pump inhibitors and total parenteral nutrition. 10 days later, on follow-up endoscopy, intramural hematoma was disappeared and large geographic ulcer was noted. P-6 Risk of Rebleeding after Endoscopic Hemostasis Differs according to the Use of Antithrombotic Agents Mi Jin Hong, Sun-Young Lee, Jeong Hwan Kim, In-Kyung Sung, Hyung Seok Park, Chan Sup Shim, Choon Jo Jin Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea Background/Aims: Endoscopic hemostasis is the first-line treatment for upper gastrointestinal bleeding (UGIB). Although several factors are known to be risk factors for rebleeding, little is known about the use of antithrombotics. We tried to verify the risk factors for rebleeding after a successful endoscopic hemostasis according to the use of antithrombotics. Methods: UGIB patients who underwent successful endoscopic hemostasis between August 2005 and September 2012 were included. Rebleeding was diagnosed when the previously treated lesion bled again within 1 month of the initial episode. The risk of rebleeding was analyzed according to the underlying disease(s) and recent medication(s) of the patient, characteristics of the bleeding lesion, and variables related to the initial endoscopic hemostasis. Results: Of 614 UGIB patients who were controlled by endoscopic hemostasis, 138 patients (22.5%) were taking antithrombotics. Rebleeding occurred in 113 patients (18.4%). The risk of rebleeding was higher with aspirin medication (p=0.009) and after a long endoscopic hemostasis (p<0.001). Conclusions: The risk of rebleeding after endoscopic hemostasis for UGIB is higher in patients taking aspirin medication and after a long endoscopic hemostasis. Key Words: Aspirin, Antithrombotics, Endoscopic hemostasis, Rebleeding, Upper gastrointestinal bleeding Fig. 1. Fig. 2. Conclusion: We report the case of spontaneous intramural hematoma in a patient receiving hemodialysis with anticoagulation therapy, successfully managed with a conservative therapy. Key Words: Intramural hematoma, Stomach, Endoscopy November 23, rd Congress of the Korean Society of Gastrointestinal Endoscopy 175

4 P-7 Clinical Characteristics of Upper Gastrointestinal Bleeding after Percutaneous Coronary Intervention: A Single Center Study Ji Myoung Lee, Seon Young Park, Jung Ho Choi, Uh Jin Kim, Sung Wook Lim, Ho Suk Ki, Chung Hwan Jun, Sung Bum Cho, Wan Sik Lee, Chang Hwan Park, Young Eun Joo, Hyun Soo Kim, Sung Kyu Choi, Jong Sun Rew Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea Background and Aims: Percutaneous coronary intervention (PCI) is generally performed as therapeutic procedure and requires more than 1 year of antithrombotic treatment in acute coronary syndrome (ACS). However, we often encounter upper gastrointestinal bleeding (UGIB), a serious complication of antithrombotic therapy. The aim of this study was to investigate the incidence and clinical risk factors of UGIB in Korean patients undergoing PCI. Patients and Methods: A total of 3541 patients undergoing PCI between January 2006 and June 2012 were retrospectively analyzed for risk factors associated with UGIB within a year of PCI. Results: UGIB was occurred in 35 patients (0.98%). The univariate analysis suggested that the following factors were associated with UGIB: history of peptic ulcer disease (PUD), male, age of 65 years (old age), presence of chronic kidney disease (CKD), and the use of anticoagulant. Multivariable logistic regression analysis revealed history of PUD (aor 8.72; 95%CI ; p=0.000), male (aor 3.58; 95%CI: ; p=0.012), old age (aor 3.10; 95%CI: ; p=0.006), presence of CKD (aor 2.76; 95%CI: ; p=0.021), the use of anticoagulant (aor 4.34; 95%CI: ; p=0.003) as independent risk factors of UGIB. Conclusion: History of PUD, male, old age, presence of CKD, and use of anticoagulant were the independent risk factors of UGIB. Key Words: Upper gastrointestinal bleeding, Percutaneous coronary intervention P-8 Clinical Characteristics and Outcomes in Patients with Angiographic Embolization for Upper Gastrointestinal Bleeding Hee Jung Park, Do Hoon Kim, Hyun Lim, Ji Yong Ahn, Kwi-Sook Choi, Jeong Hoon Lee, Kee Don Choi, Ho June Song, Gin Hyug Lee, Hwoon-Yong Jung, Jin-Ho Kim Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Asan Digestive Disease Research Institute, Seoul, Korea Background/Aims: Endoscopic therapy is the first method of choice to treat upper gastrointestinal bleeding (UGIB). Transcatheter angiographic embolization (TAE) is considered as gold standard for endoscopy-refractory patients. We evaluated the clinical characteristics and risk factors in patients undergoing TAE after failed endoscopic hemostasis. Method: Between January 2004 and May 2013, patients who presented with UGIB at Asan Medical center and underwent TAE after failed endoscopic therapy were retrospectively enrolled. Clinical and endoscopic characteristics compared according to major outcome (rebleeding or bleeding-related death). Rebleeding was defined as a new bleeding episode manifested by melena, hematemesis or hematochezia within 30 days from initial bleeding episode. Result: Among 2270 patients with UGIB, 110 patients underwent TAE after one or more of attempts with endoscopic hemostasis. The most common cause of UGIB was malignancy (n=27, 24.5%) and most common bleeding site was stomach (n=49, 44.5%). Rebleeding occurred in 29 patients (26.4%) and bleeding-related death occurred in 25 patients (22.7%) after embolization. Patients with major outcome showed significantly more patients with renal failure, less attempt of hemostasis at initial endoscopy, more number of transfused RBCs, lower levels of hemoglobin and higher Glasgow Blatchford score. In multivariate analysis, attempt of endoscopic hemostasis at initial endoscopy was an independent factor predictive of the major clinical outcome. Conclusion: TAE could be considered as first-line therapy for massive UGI bleeding refractory to endoscopic treatment and is a good alternative to surgery. Aggressive treatment with early endoscopic hemostasis prior to angiographic embolization is essential for a favorable clinical outcome. Key Words: Upper gastrointestinal bleeding, Endoscopic hemostasis, Transcatheter embolization rd Congress of the Korean Society of Gastrointestinal Endoscopy November 23, 2013

5 P-9 Risk Factors and Management for Pyloric Stenosis Occurred after Endoscopic Submucosal Dissection Adjacent to Pylorus Jae Un Lee, Moon Sik Park, So Hee Yun, Shang Hoon Han, Wang Guk Oh, Young Jae Lee, Gum Mo Jung, Ji Woong Kim, Yong Keun Cho, Jin Woong Cho Division of Gastroenterology, Department of Internal Medicine, Presbyterian Medical Center, Seonam University College of Medicine, Jeonju, Korea Background and Aims: Endoscopic submucosal dissection (ESD) has been widely accepted as a curative treatment for gastric neoplasm. Pyloric stenosis is chronic complication that can be caused after ESD. The aim of this study is to clarify the risk factors and management for pyloric stenosis. Method: From January 2004 to August 2013, a total of 112 patients who underwent ESD adjacent to the pylorus were reviewed retrospectively. Pyloric mucosal defect was defined when any resection margin of ESD was involved in pyloric ring. Pyloric stenosis is defined when a 1 cm diameter endoscope could not be passed to duodenum. Result: Among the 112 patients, pyloric stenosis was identified in eight. pyloric stenosis was significantly more frequent in longitudinal diameter of resected specimen ( 5 cm) than the others (<5 cm) (41.7% vs 3% respectively, p<0.001). The incidence of pyloric stenosis in circumferential mucosal defect over 75% of pyloric ring was significant higher than the others (p<0.001). The four of 8 patients with pyloric stenosis had no symptom and the others had gastric outlet obstruction symptoms such as vomiting and dysphagia. Symptomatic four patient underwent endoscopic balloon dilation and the pyloric stenosis were improved. And asymptomatic patients who received conservative management were also successfully treated. Conculsion: The risk factors of pyloric stenosis were the circumferential mucosal defect over 75% of pyloric ring and longitudinal diameter of resected specimen (>5 cm). Although endoscopic balloon dilation was effective treatment for pyloric stenosis, conservative management was also helpful to improve pyloric stenosis in patients who had relatively mild symptoms. Key Words: Pyloric stenosis, Endoscopic submucosal dissection, Endoscopic balloon dilation P-10 A Case of Esophagomediastinal Lymph Node Fistula Treated Tuberculosis Medication and Percutaneous Endoscopic Gastrostomy Jin Ho Jun, Nam Hoon Kim, Ju Hun Paik, Jin Suk Kim, Won Ki Bae, Jeong Wook Kim Department of Internal Medicine, Inje University College of Medicine, Goyang, Korea Background: Tuberculosis related esophagomediastinal Lymph node fistula is rare complication. but in some previous report these condition was improved only several weeks Tuberculosis medication with NPO. Case: We describe a 22-year old man who 2 month ago diagnosed pulmonary tuberculosis and spinal tuberculosis in spite of tuberculosis medication, presented with fever and dysphagia. He had computed tomography and gastroscopy finally diagnosed esophagomediastinal Lymph node fistula. He was treated with continuous tuberculosis medication and total parenteral nutritiion but 3 weeks after the fistula was not closure. In order to avoid surgical procedure we performed percutaneous endoscopic gastrostomy and maintain tuberculosis medication, parenteral nutrition. Eventually 2 month after he was improved esophagomediastinal Lymph node fistula and removed percutaneous endoscopic gastrostomy. Conclusion: Tuberculosis related esophagomediastinal Lymph node fistula was treated tuberculosis medication and percutaneous endoscopic gastrostomy Key Words: Esophago-mediastinal fistula, Tuberculosis, Percutaneous Endoscopic Gastrostomy November 23, rd Congress of the Korean Society of Gastrointestinal Endoscopy 177

6 P-11 Endoscopic Stent Managements for Treatment of Postoperative Complications after Gastric Cancer Surgery Sung-Min Park, Joon-Sung Kim, Byung-Wook Kim, Bo-In Lee, Hwang Choi, Chul-Hyun Lim Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea Background and Aims: Anastomotic leaks and strictures following gastrectomy due to gastric cancer are reported to occur at an incidence of 1-3%. Endosopically placed stents can be used to treat these complications and avoid revisional surgery. The purpose of our study was to investigate the healing rates after endoscopically placed stents for anastomotic complications. Materials and Methods: A retrospective review of patients who received endoscopic stent placement for postoperative complications after gastric cancer surgery at two teaching hospitals of The Catholic University of Korea from January 2008 to July 2013 was performed. Results: A total of 36 patients received 37 endoscopic stent placement for treatment of anastomotic complications. The mean duration of stent placement was 38 days (Table 1). Technical and clinical success was achieved in 100% and 97.2%, each. One patient underwent revisional operation due to unresolved stricture despite endoscopic stent placement. Adverse events included 12 stent migrations and 1 perforation induced by stent migration. No surgery was required for resolution of adverse events. Table 1. Outcome of Endoscopic Stent insertion for Treatment of Postoperative Anastomotic Leak, Stricture, and Fistula Total Leaks Strictures fistula Stents (n) Time between surgery and complication (d) Duration of stent (d) Stent migration (%) Technical success (%) Clinical success (%) Conclusions: Endoscopic stent placement can be safe and effective for the treatment of benign anastomotic complications after gastric cancer. Key Words: Gastric cancer, Endoscopic stent, Complications, Stricture, Leakage P-12 A Case of Duodenal Metastasis from Primary Lung Cancer Eun Young Doo 1, Hang Lak Lee 1, Young Woo Ahn 1, Ki Deok Yoo 1, Hye Jin Tae 1, Jin Ok Kim 1, Kang Nyeong Lee 1, Dae Won Jun 1, Oh Young Lee 1, Byung Chul Yoon 1, Ho Soon Choi 1, Joon Soo Hahm 1, Ki Seok Jang 2 Department of 1 Internal Medicine, 2 Pathology, Hanyang University College of Medicine, Seoul, Korea Introduction: Metastatic carcinoma from primary lung cancer is usually recognized in the brain, liver, adrenal glands, and bone. It is uncommon in the digestive system, and duodenal metastasis is extremely rare. We report the case of a patient with sarcomatoid carcinoma of the lung who had duodenal metastasis. Case Report: A 68-year-old male with dyspnea and pleuritic chest pain was examined at a division of pulmonology. A mass shadow in the lower lobe of the left lung was seen on a chest roentgenogram. He was diagnosed as having a large cell undifferentiated carcinoma after a fine needle aspiration biopsy. No metastasis lesions were detected by chest CT scan. However, there were increased FDG uptake in the third portion of the duodenum as well as the lung on the PET image. Instead of double balloon enteroscopy, push enteroscopy using pediatric colonoscope demonstrated about 1.5 cm sized polypoid mass on the third portion of the duodenum. Endoscopic biopsy showed sarcomatoid carcinoma. He underwent a lower lobectomy of the left lung, duodenectomy and duodenoje- junostomy. The pathologic diagnosis was metastatic sarcomatoid carcinoma originating from the lung. He received chemotherapy including gemcitabine and cisplatin. Conclusion: This case indicates that sarcomatoid carcinoma can spread to duodenum. The histologic assessment is necessary and push enteroscopy using pediatric colonoscope is useful in case of distal duodenal lesions. Key Words: Duodenal metastasis, Lung cancer, Sarcomatoid rd Congress of the Korean Society of Gastrointestinal Endoscopy November 23, 2013

7 P-13 A Case of Gastric Glomus Tumor Diagnosed by Deep Biopsy via Endoscopic Submucosal Dissection Ki Deok Yoo 1, Hang Lak Lee 1, Yong Woo Ahn 1, Eun Young Doo 1, Hye Jin Tae 1, Jin Ok Kim 1, Kang Nyeong Lee 1, Dae Won Jun 1, Oh Young Lee 1, Byung Chul Yoon 1, Ho Soon Choi 1, Joon Soo Hahm 1, Ki Seok Jang 2 Department of 1 Internal Medicine, 2 Pathology, Hanyang University College of Medicine, Seoul, Korea Introduction: Gastric glomus tumors are rare submucosal tumors originated from the glomus cell which means modified smooth muscle cells of the glomus body. We report a case of gastric glomus tumor that mimicked a GIST in a patient who underwent deep biopsy after endoscopic submucosal dissection. Case: A 40-year-old woman visited our hospital for further evaluation of submucosal tumor of posterior wall in low body of stomach which was found during routine endoscopy at other hospital. No specific finding was observed on history, physical examination and laboratory tests. An upper gastrointestinal endoscopy identified approximately 30 mm sized well-demarcated endoluminal elevated lesion at posterior wall in low body of stomach, consistent with a gastric submucosal tumor. Abdominal CT scan revealed about 20 mm sized gastric submucosal tumor at posterior wall in low body of stomach. EUS showed an heterogenous and hypoechoic mass with anechoic spaces and irregular borders, connected with 4th gastric wall layers. The mass was measured as 33 mm 15 mm. We performed a deep biopsy after endoscopic submucosal dissection for histological diagnosis. Microscopic examination showed a cellular and richly vascular tumor, which shows solid growth pattern of tumor cells organized around hemangiopericytomalike vessels. Uniform, benign-looking tumor cells with round nuclei and inconspicuous nucleoli were observed. On immunohistochemistry, tumor cells are positive for smooth muscle actin, caldesmon, and negative for S-100, desmin. The final diagnosis was glomus tumor within the gastric proper muscle layer. Conclusion: Gastric glomus tumor is very rare. To our knowledge, this is the first case of gastric glomus tumor diagnosed by deep biopsy after endoscopic submucosal dissection. Most of the gastric glomus tumors are essentially benign in nature. Endoscopic tissue confirm via deep biopsy could be a good modality for diagnosis of submucosal tumor. Key Words: Glomus tumor, Submucosal tumor, Deep biopsy P-14 A Case of Stomach Cancer Diagnosed by Random Biopsies Taken from Endoscopically Normal Mucosa Sang Hyuk Lee 1, Sung Chul Park 1, Dong Wook Choi 1, Dong Gyu Lee 1, Kyoung Ree Lim 1, Eun Ju Cho 1, Dae Hee Choi 1, Chang Don Kang 1, Sung Joon Lee 1, Kyu-Hyoung Lim 1, Young Joon Ryu 2 Department of 1 Internal Medicine, 2 Pathology, Kangwon National University School of Medicine, Chuncheon, Korea Introduction: Borrmann type IV advanced gastric cancer is diffusely infiltrative carcinoma in which ulceration is usually not a marked feature. Therefore, even experts can miss the diagnosis of it. However, endoscopically normal gastric cancer is very rare. Case Report: A 33 year-old female had presented with abdominal distension and nausea for the past 3 months to the university hospital near her house. Abdominopelvic CT and whole body PET-CT revealed malignant ovarian neoplasm on her left ovary with multiple metastatic lesions to the lung and peritoneal cavity. Esophagogastroduodenoscopy and colonoscopy to find the primary lesions of the malignancy showed no suspicious lesions. She went to another medical center to get second opinion about her malignancy. In that center, several diagnostic examinations were performed including repeated esophagogastroduodenoscopy but they did not find any abnormalities. However, through the biopsy of her left supraclavicular lymph node, the signet ring cell carcinoma was demonstrated. She was diagnosed with metastatic ovarian tumor, but the primary site was still unknown. After that she was transferred to our hospital. Repeated gastroscopy was performed to obtain clues to reveal primary lesions. During the procedure, any suspicious lesions could not be found like the previous gastroscopies. However, several tissues were taken randomly from the mucosa which looked like normal in the body of the stomach. The obtained tissues were demonstrated as signet ring carcinoma. She was diagnosed with the Krukenberg tumor originated from the stomach. She underwent chemotherapy, but passed away after 2 months later. Conclusion: We report a case of gastric signet ring cell carcinoma diagnosed by random biopsies taken from the body of the stomach of which mucosa was endoscopically normal. Key Words: Stomach Cancer, Random Biopsy November 23, rd Congress of the Korean Society of Gastrointestinal Endoscopy 179

8 P-15 A Case of Repeated Biopsy Could Not Reveal Malignancy in Borrmann Type Ⅱ Gastric Cancer Joon Hur, Jae Hyuck Chang, Soo Jeong Kim, Hoon Young Ko, Jong Hwan Lee, Mi Ae Song, Tae Ho Kim, Chang Whan Kim, Sok Won Han Division of Gastroenterology, Department of Internal Medicine, Bucheon St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Bucheon, Korea The endoscopic biopsy is critical to proper diagnosis. However, the result of biopsy may not match the endoscopic findings. If gastric cancer were highly suspected, repeated biopsy would be helpful. We experienced a case of Borrmann type II gastric cancer in which three times repeated biopsy did not reveal malignancy. A 49-year-old male underwent esophagogastroduodenoscopy (EGD) and abdominal computed tomography (CT) due to epigastric pain. They demonstrated 3 cm sized ulcerofungating lesion suspected of Borrmann type II cancer at greater curvature side of lower body. Endoscopic biopsy was performed. The result of biopsy was only benign cells without finding of malignancy. After treatment with proton pump inhibitor (PPI) for three weeks, the second EGD and biopsy was performed. The appearance of gastric ulcer did not change. Malignant cell also was not found. Because the patient refused gastric operation or surgical biopsy, we planned endoscopic ultrasonography (EUS) and CT after three months with PPI treatment. On followed EUS and CT, the ulcerofungating lesion was still noted without definite interval change. EUS showed that the ulcerative lesion invaded muscle layer with focal serosal abutting. The third time biopsy report also did not reveal malignancy. We strongly recommended him surgery because of malignant potentiality. Finally, the surgery was performed. Surgical specimen was proved as moderately differentiated tubular adenocarcinoma in the submucosa, proper muscle, and serosa layer. However, mucosa did not have malignant cell. The mucosa layer was all covered with regenerative epithelium. If gastric mucosa was replaced with regenerative epithelium, repeated endoscopic biopsy cannot reveal malignancy even though gross appearance is suspected Borrmann type II advanced gastric cancer. In case of highly suspected gastric cancer in EGD or EUS, surgery should be recommended. Key Words: Gastric cancer, Borrmann type II, Regenerative Epithelium P-16 A Case of Primary Malignant Melanoma Involving Entire Stomach and Duodenum Chang Seok Lee, Byung Hoon Ji, Joung Boom Hong, Dong Jun Kim, Kyung Won Ko, Dae Hwan Kang, Byung Jun Song Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea Introduction: Gastro-intestinal malignant melanoma is very rare. Clinically, most of cases are associated with metastasis especially from cutaneous sources. Rarer still is primary gastric melanoma involving entire stomach and duodenum. If the patient has no obvious primary cutaneous lesion or other extra intestinal disease, a primary gastric melanoma is suggested. Case Report: An 81-year-old man patient was admitted to the Department of Gastroenterology due to abdominal discomfort for a few days. Upper gastrointestinal endoscopy revealed numerous melanotic polypoid mass in the entire stomach and duodenum. Endoscopic biopsy of these polypoid masses showed malignant melanoma (Fig. 1). Special immunohistochemical stains including HMB45, Melan A, S100 protein were positive. According to a Abdominal CT and whole body PET-CT, multiple liver and bone metastasis were suggested. Fig. 1. Conclusion: Primary Malignant melanoma arising from gastro-intestinal tract is an unusual clinical entity and most of the cases are secondary melanomas metastases from cutaneous sources. We report a rare endoscopic findings of primary malignant melanoma involving entire stomach and duodenum. Key Words: Melanoma, Malignant, Stomach, Duodenum, Endoscopic rd Congress of the Korean Society of Gastrointestinal Endoscopy November 23, 2013

9 P-17 Association between Visceral Obesity and Lymph Node Metastasis in Gastric Cancer Ki Deok Yoo 1, Hang Lak Lee 1, Eun Young Doo 1, Yong Woo Ahn 1, Hye Jin Tae 1, Jin Ok Kim 1, Kang Nyeong Lee 1, Dae Won Jun 1, Oh Young Lee 1, Byung Chul Yoon 1, Ho Soon Choi 1, Joon Soo Hahm 1, Se Woo Park 2 1 Department of Internal Medicine, Hanyang University College of Medicine, Seoul, 2 Division of Gastroenterology, Cheju Halla General Hospital, Jeju, Korea Background & Aims: An association between obesity and unfavorable outcomes for various types of malignancy has been established. However, the relationship between fat distribution and lymph node metastasis has not been well studied. The purpose of this study was to assess the impact of visceral obesity on lymph node metastasis and overall survival in gastric cancer. Patients & Methods: This study reviewed medical records for consecutive patients who underwent radical resection for gastric cancer between 2003 and Metastatic lymph node ratio (MLR) was defined as the number of involved nodes by tumor divided to the total number of resected lymph nodes. Visceral obesity was determined by measuring abdominal fat volume distribution via CT scan and then calculating the percentage of visceral fat (VF%) to total fat area. Results: With MLR as a dependent variable, the following factors were significant in univariate linear regression analysis: depth of invasion (p<0.001), serum total cholesterol (p<0.008), and VF% (p=0.028). MLR significantly decreased with VF% (R = 0.099; R 2 = 0.010). The regression equation of assumed linearity was y = x (β = , p=0.028). Multivariate linear regression showed that depth of invasion (p<0.001), histological differentiation (p=0.037), and VF% (p=0.044) were independent factors related to higher MLR. Conclusions: Although there was no association visceral obesity and overall survival, a higher ratio of visceral fat was associated with a decreased ratio of metastatic lymph nodes. Key Words: Visceral obesity, Lymph node metastasis, Gastric cancer P-18 What Factors Make Difficulties at Endoscopic Staging for Gastric Cancer? Seung Chan Kim, Seong Hwan Kim, Young Sook Park, Yun Ju Jo, Byoung Kwan Son, Young Kwan Jo, Sang Bong Ahn, Ji Hyun Lee Department of Gastroenterology, Eulji University School of Medicine, Eulji Medical Center, Seoul, Korea Background and Aims: Because of health care programs, gastric cancer detected earlier times than past years. But, most endoscopists make difficulties at classifying marginal cancer. We conducted a study to find differences between advanced gastric cancer (AGC) mimicking early gastric cancer(eg C) and AGC mimicking EGC. Patients and Methods: We enrolled 244 patients were operated or performed ESD for gastric cancer between 2004 and AGC mimicking EGCs and 15 EGC mimicking AGCs patients were betw een them. We analyze endoscopic appearance and clinicopathological findings. Results: EGC mimicking AGCs were 10.07% (15/149) of all EGCs at clinicopathological diagnosis an d AGC mimicking EGCs were 11.1% (10/90) of all AGCs. EGC mimicking AGCs were mostly located at lower thirds of stomach (66.7%, 10/15), AGC mimicking EGCs were at center of stomach (50%, 5/ 10). Most of mimicking cancer s size was more than 2.5cm. Mucosal fold changes and clinicopatholo gical findings were needed more analysis. Conclusion: EGC mimicking AGC and AGC mimicking EGC are difficult to classified because of their morphological similarities at endoscopy. Air level and combined mucosal atrophy or metaplasia are also contributed. Key Words: Mimicking, AGC, EGC November 23, rd Congress of the Korean Society of Gastrointestinal Endoscopy 181

10 P-19 Therapeutic Ablation with Argon Plasma Coagulation of Localized Gastric Amyloidosis: A Case Report Jae Hoon Kim, Hyun Soo Kim, Yun Jin Chung, Jae Kwon Jung, Hyang Eun Seo, Dong Wook Lee, Kyung Hwa Yoon, Dong Yeub Eun Department of Internal Medicine, Daegu Fatima Hospital, Daegu, Korea Case: presentation: A 72-year-old man underwent an esophagogastroduodenoscopy procedure for regular checkup. The esophagogastroduodenoscopy showed an about 2cm sized focal area of white friable ulcerative lesion at the greater curvature side of proximal gastric body, suggesting early gastric cancer. A biopsy specimen revealed amyloid deposits in the mucosa, but no evidence of malignancy. Congo red staining showed positive for amyloidal protein and polarizing examination represented apple-green birefringence. Endoscopic ultrasound showed a flat thickening of layer confined to mucosa and muscularis mucosa (MM). And submucosa showed relatively clear layer to MM and muscularis propria layer was absolutely intact. Additional endoscopic biopsy of duodenum and colorectum was normal. And laboratory and radiologic examination, and even bone marrow biopsy were done for excluding systemic amyloidosis and all results were unremarkable. We tried to resect the localized amyloidosis endoscopically, but its central portion wasn t elevated after injection due to fibrosis. So we decided to ablate the lesion with argon plasma coagulation (APC) for therapeutic purpose. No specific side effect was observed, such as bleeding, abdominal pain, infection, and perforation. On the follow up endoscopy at two months after procedure, just only a white scar was seen at that site and biopsy didn t show amyloidosis anymore. Conclusions: Localized gastric amyloidosis is very rare and the ablation therapy with APC is alternative to treat amyloidosis instead of endoscopic resection. We report a case of successful ablation therapy with APC of localized gastric amyloidosis. We need to follow-up continuously. Key Words: Localized gastric amyloidosis, Ablation, Argon plasma coagulation P-20 A Case of Basaloid Squamous Cell Carcinoma of the Esophagus Treated by Endoscopic Submucosal Dissection (ESD) Bo Kyoung Choi 1, Sung Hoon Kim 1, Moon Hyong Lee 1, Chi Hoon Cha 1, Jae Won Seo 1, Su Hyun Yang 1, Ji Sun Jang 1, Yoon Jung Kim 2 Departments of 1 Internal Medicine, 2 Pathology, Veterans Health Service Medical Center, Seoul, Korea Introduction: Basaloid squamous cancer (BSC) is an uncommon variant of squamous cell carcinoma, with its prevalent sites being the hypopharynx, tongue base and larynx. Esophageal BSC is extremely rare, accounting for less than 2% of primary esophageal malignancies. BSC is more aggressive and has a poorer prognosis. Endoscopic resection in patients with esophageal basal squamous carcinoma is limited by the frequent presence of lymph node and distant metastasis. Case Report: A 84-year-old man who underwent ESD due to gastric adenoma was checked by followed-up esophagogastroduodenoscopy (EGD). On the study an approximately 0.6cm sized, slightly elevated nodular mucosal lesion with central erythama at the 34 cm from the upper incisor was found incidentally. Forceps biopsy was done at the lesion, then the biopsy finding showed atypical squamous epithelial proliferation. So, the ESD was performed for diagnostic and therapeutic purposes. Tumor size was cm, and the final diagnosis was basaloid squamous cell carcinoma. The lymphatics, venous and perineural invasion were not identified. Following Chest CT and PET CT scan, there was no lymph node and distant metastasis. So, the patient was planned to be followed up regularly without further treatment. After 6 months later from the procedure, there was no evidence of tumor recurrence. Conclusion: Basaloid squamous cell carcinoma of the esophagus is a rare tumor. Generally, BSC has been reported to have a worse prognosis than SCC of the esophagus because of the higher rates of lymph node and distant metastasis. So, aggressive treatment for esophageal BSC is recommended such as surgery. But, some reports have shown that superficial BSCs of the esophagus has not been associated with lymph node metastatis, then suggested that it might be possible to be treated by endoscopic therapy. So, we reported a case of basaloid squmous cell carcinoma of the esophagus treated by ESD. Key Words: Esophagus, Basaloid squamous cell carcinoma, ESD rd Congress of the Korean Society of Gastrointestinal Endoscopy November 23, 2013

11 P-21 Peripheral Facial Nerve Palsy after Endoscopic Submucosal Dissection Hong Seong Chough, Jun Lee, Young Dae Kim, Chan Guk Park, Man Woo Kim Department of Internal Medicine, Chosun University, Gwangju, Korea Background: Peripheral facial nerve palsy may have a detectable cause (secondary facial nerve palsy) or may be idiopathic without obvious cause(primary or Bell s palsy). Secondary facial nerve palsy is due to various causes and is generally less prevalent than primary facial nerve palsy. Peripheral facial nerve palsy associated extrinsic compression is very rarely reported. This case is first report of peripheral facial nerve palsy after endoscopic submucosal dissection. Case: A 71-year-old man presented for endoscopic submucosal dissection. Medical history was hypertension. Upper endoscopy revealed 30mm sized, slightly elevated, discolored lesion at antrum. We performed endoscopic submucosal dissection for dysplasia at antrum. Time during procedure was 45 minutes. After two days, patients complained of left facial weakness, eyebrow sagging, disappearance of nasolabial fold and drooping at the left corner of mouth. Nerve conduction velocity and blink reflex revealed a peripheral type facial nerve palsy. Possible cause of facial nerve palsy was considered direct compression by pillow and endoscopy mouthpiece band. After conservative treatment, symptoms of facial nerve palsy are subsided. Conclusion: Endoscopic submucosal dissection has become accepted as a standard treatment in selected patients with early gastric cancer and adenoma. Because of increasing endoscopic procedure time, direct compression of left facial nerve could be developed. This case is first report of peripheral facial nerve palsy after endoscopic submucosal dissection. Therefore, the patients treated with endoscopic submucosal dissection should also be well informed of the possible side effect. Key Words: Peripheral facial palsy, Endoscopic submucosal dissection P-22 A Case of Acute Myocardial Infarction Occurred Immediately after Endoscopic Submucosal Dissection Hyung Il Moon, Seung Woo Lee Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea Introduction: Endoscopic mucosal resection (EMR) or Endoscopic submucosal dissection (ESD) have been increasingly used for the treatment of gastric adenoma and early gastric cancer. Cardiopulmonary complications as well as bleeding and perforation can be infrequent but serious complications after ESD. Case: A 70-year-old woman with prior coronary artery disease was admitted to undergo ESD for high grade dysplastic adenoma at stomach. The usual ESD techniques were used. The lesion was successfully removed in 90 minutes. 90 min after ESD, she experienced chest discomfort. The ECG showed elevated ST segments from V1 to V4. Cardiac markers were significantly elevated. 2 hours later, her chest discomfort spontaneously subsided, with normalization of ECG (Fig. 1). Elective coronary angiography was performed which revealed no in stent restenosis and no thrombus. Fig. 1. (A) The ECG showed slightly elevated ST segments from V1 to V4 during the chest discomfort. (B) The ECG showed recovery of elevated ST segments after resolution of chest discomfort. Conclusion: Endoscopists should consider that ESD may possibly be accompanied by unexpected coronary symptom and may change the course of the disease even if the resection itself is successful. Patients such as recent MI should have the procedure performed with electrocardiographic, blood pressure, and pulse-oximetry monitoring. And it would be reasonable to consider injecting only normal saline. Key Words: ESD, Myocardial infarction November 23, rd Congress of the Korean Society of Gastrointestinal Endoscopy 183

12 P-23 A Case of Calcifying Fibrous Tumor of Stomach Body Found Incidentally Back Jin Sung 1, Wang Guk Oh 2, Shang Hoon Han 2, Ji Woong Kim 2, Jin Woong Cho 2 1 Mi Rae Internal Medicine, 2 Division of Gastroenterology, Department of Internal Medicine, Jesus Hospital, Jeonju, Korea Introduction: Calcifying fibrous tumors (CFT) are uncommon, benign mesenchymal tumor. Although around 75% of CFTs originated in the abdominal cavity and the peritoneum, CFT of the tubular gastrointestinal tract is quite rare. Case: A 55 years old female was refered to our department for the management of gastric polyp found incidentally. Initial laboratory findings showed hemoglobin 11.6g/dL, AST 16U/L, ALT 13U/L, γ-gtp 16U/L, glucose 92 mg/dl and creatinine 0.7mg/dL. Endoscopic examination disclosed a mm sized round smooth flat elevation with central depression and blood clot, at the lower body lesser curvature (Fig.). The lesion was ensnared and resected en block using the endoscopic mucosal resection technique and two hemo-clips were attached. Histologically, the tumor was consisted of sparsely cellular sclerosis and thick collagen fibers. There were some lymphocystic aggregation, focal lymphoplasma cell infiltration and calcifications (Fig. 1). Immunohistochemical staining was performed and showed negative for c-kit, CD34, SMA and positive for vimentin (a few). Fig. 1. Conclusion: Although the rare occurrence of CFT in the stomach, we can not exclude from consideration in differential diagnosis of gastric submcosal lesions. Key Words: Calcifying fibrous tumor, Stomach, Gastric polyp P-24 Risk Factor of Metachronous Lesion after Endoscopic Resection in Gastric Adenoma and Gastric Cancer Dae-Seong Myung, Jong-Sun Kim, Sung-Bum Cho, Wan-Sik Lee, Young-Eun Joo Departments of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea Background: Endoscopic resection has been widely accepted as a less invasive treatment for early gastric cancer and adenoma, so endoscopic resection is on the increase. We sought to determine the risk factor of metachronous lesion after endoscopic resection following endoscopic resection in patients with gastric adenoma and gastric cancer. Method: From January 2004 to January 2012, 1,252 patients were treated by endoscopic resection about gastric adenoma and early gastric cancer at Chonnam National University Hwasun Hospital, Jeonnnam, Korea. We excluded from the study those patients with follow-up periods of less than 1 year, patients lost to follow-up, and those who underwent previous gastrectomy and gastrectomy after endoscopic treatment due to complications or incomplete resection. Finally, 773 cases were included. (gastric adenoma: 364 patients, early gastric cancer: 352 patients) Result: Total in 53 patients(6.8%), metachronous lesion was developed. During the follow-up period (mean = months, range = months), synchronous lesion was seen in 147 patients. In univariate analysis, age, sex, smoking, alcohol ingestion, size and shape of lesion, depth of invasion, family history were not correlated to be developed metachronous lesion. But synchronous lesion, histology, location of tumor were correlated to be developed metachronous lesion. In multivariate analysis, synchronous lesion (p<0.001, OR 3.71( )) and advanced histology (p=0.004, OR 2.36( )) were proved to be significantly relevant to metachronous lesion development. Conclusion: Endoscopic resection is safe and effective treatment modality in gastric adenoma and early gastric cancer. Because probability of metachronous lesion is increased, careful follow up is required in patient with advanced histology or synchronous lesion. Key Words: Endoscopic resection, Metachronous lesion, Gastric adenoma, Early gastric cancer, Risk factor rd Congress of the Korean Society of Gastrointestinal Endoscopy November 23, 2013

13 P-25 Early Gastric Cancer with Mixed Differentiated Histology Is a Distinct Type Regarding Outcomes of Endoscopic Resection Choong Nam Shim, Hyun Soo Chung, Jun Chul Park, Hyuk Lee, Sung Kwan Shin, Sang Kil Lee, Yong Chan Lee Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea Background: The precise differential diagnosis of histology between differentiated type and undifferentiated type is critical for deciding proper candidates for endoscopic resection (ER) for early gastric cancer (EGC). However, gastric cancers include a mixture of differentiated and undifferentiated histological types in some cases. The purpose of this study was to evaluate the clinicopathologic features predicting mixed differentiated histological type and the clinical implications of mixed differentiated histology in endoscopically resected EGC in terms of therapeutic outcomes. Methods: A total of 1016 patients with 1039 EGCs underwent ER from January 2007 and June The enrolled lesions were diagnosed as differentiated histologic type from forceps biopsy specimens. They were grouped, according to the occurrence of mixed differentiated type in ER specimen, as pure differentiated (n=1011) or mixed differentiated (n=28). Results: The mixed differentiated histology was diagnosed in 2.7% of enrolled lesions. Younger age, a larger size, mid-third location, submucosal invasion on endosonographic ultrasound, and moderately-differentiated histology of forceps biopsy were significantly associated with the mixed differentiated group compared with the pure differentiated group in univariate analysis. Multivariate analysis revealed that a larger size, mid-third location, and moderately-differentiated histology of forceps biopsy were independent risk factors for mixed differentiated type. The en block resection rate tended to be lower and complete and curative resection rates were significantly lower in the mixed differentiated group. Conclusions: EGC with mixed differentiated histological type changes the therapeutic outcomes. We should consider the possibility of mixed differentiated histology if the lesion shows a larger size, mid-third location, and moderately-differentiated histology on forceps biopsy. Key Words: Early gastric cancer, Histology, Endoscopic resection P-26 Size Discrepancy between Endoscopy and Pathology Is Not Negligible in Endoscopic Resection for Early Gastric Cancer Choong Nam Shim 1, Mi Kyung Song 2, Dae Ryong Kang 2, Hyun Soo Chung 1, Jun Chul Park 1, Hyuk Lee 1, Sung Kwan Shin 1, Sang Kil Lee 1, Yong Chan Lee 1 1 Department of Internal Medicine, Institute of Gastroenterology, 2 Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea Background: Accurate tumor size measurement is critical for selecting proper candidates for endoscopic resection (ER) of early gastric cancer (EGC). However, size discrepancy between endoscopic size and pathologic size often occurs in EGC. The purpose of this study was to assess the clinicopathological characteristics and outcomes of size discrepancy in EGC. Methods: A total of 554 patients with EGC underwent ER. Enrolled lesions were classified into the following three groups according to size discrepancy between endoscopic size and pathologic size; well- estimated (n=223), underestimated (n=140), or overestimated (n=191). The well-estimated group was defined as lesions with a ratio of endoscopic size to pathologic size from 0.7 to 1.3. Results: The overall size discrepancy was 6.3 ± 5.3 mm. Size, location, macroscopic type, T stage on endoscopic ultrasound, pt stage, and histology were significantly different between the three groups. In multivariate analysis, a larger size, mid-third location, flat/depressed type, and undifferentiated histology were independent risk factors for endoscopic size underestimation. A smaller size and mucosal invasion were independent predictive factors for overestimation of endoscopic size. Significantly lower complete resection and curative resection rates were detected in the underestimated group compared with the well-estimated group. There was no significant difference in complete and curative resections between the overestimated group and the well-estimated group. Conclusions: A larger size, mid-third location, flat/depressed type, and undifferentiated histology of EGC carry a high risk for the underestimation of endoscopic size, which changes therapeutic outcomes of ER. There is no benefit to the therapeutic outcomes resulting from the overestimation of size. Key Words: Early gastric cancer, Size, Discrepancy, Endoscopic resection November 23, rd Congress of the Korean Society of Gastrointestinal Endoscopy 185

14 P-27 Risk Factors for Pyloric Stricture after Endoscopic Submucosal Dissection Hyun Jik Lee, Jun Chul Park, Chan Hyuk Park, Eun Hye Kim, Chung Nam Shim, Hyun Soo Jung, Hyuk Lee, Sung Kwan Shin, Sang Kil Lee, Yong Chan Lee Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea Background/Aims: Post-endoscopic resection stricture is one of delayed complication of endoscopic submucosal dissection (ESD). The aim of this study is to evaluate the risk factor of endoscopic dilation for pyloric stricture after ESD in gastric neoplasm. Methods: Retrospectively a total 151 gastric neoplasm at prepylorus and pylorus were treated by ESD between 2007 and 2012 at a single institution. Post-endoscopic resection stricture which could not be passed by endoscope was treated with endoscopic balloon dilation. Results: Eleven patients were received endoscopic balloon dilation (7.2%) for treatment of post-endoscopic resection stricture. All 11 patients were successfully treated by endoscopic balloon dilation. Significant differences between endoscopic balloon dilation non-group and performed group were found in age (67.4±10.3 years vs. 73.6±6.0 years), pretreatment antral deformity (46.4% vs. 81.8%), tumor size (10.8±5.9mm vs. 23.5±17.5mm), the proportion of extension to the whole circumference of the lumen ( 3/4: 90.6% vs. 45.5%, >3/4: 9.4% vs. 54.5%) and tumor location (anterior wall: 33.6% vs. 9.1%, greater curve: 15.7% vs. 54.5%). Multivariate analysis revealed that pretreatment antral deformity (odds ratio [OR]:10.787; 95% confidence interval [CI]: , p=0.031) and circumferential extension of > 3/4 (OR: 1.121; 95% CI: p=0.003) were independent risk factors for post-endoscopic resection stricture. Conclusions: Antral deformity and sub-circumferential resection over 75% of the circumference are independent risk factors for post-endoscopic resection stricture and balloon dilation at prepylorus and pylorus. Key Words: Antral deformity, Endoscopic submucosal dissection (ESD), Stricture, Balloon dilation P-28 Comparison of Oral or Intravenous Proton Pump Inhibitors for the Prevention of Bleeding after ESD Yeoun Su Jung, Kyeong Ok Kim, Jun Suk Park, Sung Bum Kim, Jung Woo Lee, Chan Seo Park, Hyun Hee Chung, Myung Jin Oh, Kook Hyun Kim, Si Hyung Lee, Byung Ik Jang, Tae Nyeun Kim Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea Background/Aims: Endoscopic submucosal dissection (ESD) is widely used as an effective treatment of early gastric cancer or adenoma. For the prevention of post ESD bleeding, intravenous proton pump inhibitor (PPI) has been used. However, the route of administration has not been confirmed. The aim of the present study was to compare the efficacy of intravenous (IV) and oral (PO) PPI administration for the prevention of delayed post ESD bleeding. Aims & Methods: From March 2010 to February 2011, 151 consecutive patients were randomly assigned to receive PO 30mg lansoprazol twice a day for 48 hours and 120mg pantoprazole IV injection for 48 hours. After ESD, all patients underwent follow-up endoscopy after 24 hours and were observed shock, melena, hematemesis and hemoglobin loss up to 60 days after ESD. The frequency of delayed bleeding was compared and risk factor was analyzed. Result: Age, sex and use of anticoagulants were not different between the two groups. Underlying cerebro-cardiovascular disease was more common in PO group (12.3%) than IV group (2.3%)(p=0.019). Delayed bleeding occurred in 2 of 65 patients (3.1%) from PO group and 2 of 87 patients (2.3%) from IV group(p=1.000). The onset of delayed bleeding was 4 days and 20 days after ESD in PO group, 18 hours and 7 days after ESD in IV group. Between two groups, there were no differences in stigma at the follow-up endoscopy and length of hospital stay by multivariate analysis. Oozing or exposed vessels at follow up endoscopy was a risk factor for bleeding (odds ratio=17.5, p=0.022). Conclusion: There was no statistical difference in the delayed bleeding rate, length of hospital stay and complications between PO and IV of the PPI. Bleeding stigma such as oozing and exposed vessels at the follow-up endoscopy was risk factors of delayed bleeding by univariate and multivariate analyses. Oral PPI administration can cost-effectively replace IV PPI for prevention of post-esd bleeding. Key Words: Endoscopic submucosal dissection, Proton pump inhibitor, Bleeding rate rd Congress of the Korean Society of Gastrointestinal Endoscopy November 23, 2013

15 P-29 Clinical Outcomes of Endoscopic Resection in Gastric Neuroendocrine Tumor in Korea: A Nationwide Multicenter Study Jung Ran Choi 1, Da Hyun Jung 1, Jie-Hyun Kim 1, Sang Kil Lee 1, Bora Keum 2, Sung Chul Park 3, Dae Young Cheung 4, Sung Soo Kim 4, Tae Ho Kim 4, Jin Tae Jung 4, Tae Joo Jeon 5, Chan Gyoo Kim 6, Il Hyun Baek 7, Seun Ja Park 8, Byung Ik Jang 9, Jonghoon Lee 10, Chang-Hun Yang 11, Yun Jeong Lim 11, Tae Hee Lee 12, Bong Min Koh 13, Wan Jung Kim 13, Hyunjin Kim 14 Department of Internal Medicine, 1 Yonsei University College of Medicine, Seoul, 2 Korea University Anam Hospital, Seoul, 3 Kangwon National University Hospital, Chuncheon, 4 The Catholic University Hospital, Seoul, 5 Inje University Paik Hospital, Seoul, 6 Center for Gastric Cancer, National Cancer Center, Seoul, 7 Hallym University Hospital, Seoul, 8 Kosin University Gospel Hospital, Busan, 9 Yeungnam University Medical Center, Daegu, 10 Dong-A Medical Center, Busan, 11 Dongguk University Hospital, Goyang, 12 Konyang University Hospital, Daejeon, 13 Soonchunhyang University Hospital, Seoul, 14 Gyeongsang National University Hospital, Jinju, Korea Background/Aims: Gastric neuroendocrine tumor (NET) is a rare disease and active treatment is necessary by setting a right direction. The long-term result of endoscopic resection (ER) is not established yet. We aimed to investigate the safety and efficacy of ER in gastric NET. Methods: From January 2002 to December 2011, 189 patients were diagnosed with gastric NET from 25 institutions. Among them, 75 patients (40%) were treated by ER. Positive margin and lymphovascular invasion were defined as incomplete resection. The clinicopathologic characteristics, therapeutic efficacy and follow-up outcomes were retrospectively evaluated. Results: The proportions of antrum, body, and fundus were 8.1%, 81.1%, and 10.8%, respectively. The mean size of the tumors was 7 ± 5 mm and elevated gross appearance was the most common. Endoscopic mucosal resection (EMR) was performed on 64 (85.3%) lesions and endoscopic submucosal dissection (ESD), 11 (14.7%) lesions, and complete resection rate was 92%. During the follow-up period ranging from 1 to 106 months, local recurrence occurred in 3 patients and systemic recurrence in 1 patient. All the 4 patients had previously received EMR. 3 patients with local recurrence underwent successful repeated EMR. 17 patients with the tumor larger than 1cm were treated by ER. Among them, complete resection rate was 94% with 6% lateral margin positivity. Neither recurrent gastric NET nor metastatic lesions were detected during the follow-up period ranging from 2 to 100 months. Conclusions: ER may be a safe and effective treatment in gastric NETs, and ESD may be superior to EMR for complete resection. According to the results, gastric NETs larger than 1cm showed the good clinical outcomes after ER. However, large-scale and long-term follow-up studies should be conducted. Key Words: Gastric neuroendocrine tumor, Endoscopic resection, Clinical outcomes P-30 Discrepancy between Endoscopic Forcep Biopsy and the Histopathologic Diagnosis after Endoscopic Submucosal Dissection Jung Woo Lee, Si Hyung Lee, Sung Bum Kim, Jun Suk Park, Yeoun Su Jung, Chan Seo Park, Hyun Hee Chung, Myong Jin Oh, Kyeong Ok Kim, Kook Hyun Kim, Byung Ik Jang, Tae Nyeun Kim Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea Backgrounds/Aim: Endoscopic submucosal dissection (ESD) has been known as a method of local treatment for early gastric cancer (EGC) or gastric adenoma. However, there is some discrepancy between the histology of the forceps biopsy and that of the ESD. We compared the results of endoscopic forcep biopsy and the histopathologic diagnosis after performing ESD. Method: We retrospectively reviewed 1049 cases from October 2005 to June 2012 that could be compared the histologic results from the resected specimens by ESD to the tissue obtained by endoscopic biopsy. Results: The discrepancy rate between the histology of the endoscopic biopsy and the resected specimen was 464(44.2%) of 1049 cases. 157(24%) of 654 lesions that showed adenoma on the endoscopic biopsy were diagnosed with gastric cancer after ESD. Of the 32 lesions that showed atypical gland on the endoscopic biopsy, 23(71.8%) were diagnosis with gastric cancer after ESD. 171(97.2%) of 176 cases that showed adenocarcinoma on endoscopic biopsy were diagnosed with gastric cancer after ESD. Conclusion: The discrepancy of the histopathological diagnosis was found between ESD and forcep biopsy. Therefore, It should be removed by endoscopic submucosal dissection if a lesion is suspected to be EGC, although the endoscopic biopsy may reveal adenoma or atypical gland. e Key Words: Endoscopic submucosal dissection, Early gastric cancer, Gastric adenoma November 23, rd Congress of the Korean Society of Gastrointestinal Endoscopy 187

16 P-31 The Efficacy of Postoperative Intravenous Dexamethasone for Pain Relief after Endoscopic Submucosal Dissection Hye Won Lee 1, Hyunsoo Chung 1,2, Jun Chul Park 1,2, Sung Kwan Shin 1,2, Sang Kil Lee 1,2, Young Chan Lee 1,2, Hyuk Lee 1,2 1 Department of Internal Medicine, 2 Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea Background: Endoscopic submucosal dissection (ESD) is the gold standard technique for performing en bloc resection of large superficial tumors in the upper and lower gastrointestinal tract. Very little is known about the management of epigastric pain after ESD for gastric neoplasm. This study aimed to assess the utility and safety of single dose postoperative intravenous dexamethasone for pain relief after the operation. Methods: This was a randomized, double-blind, placebo-controlled trial of intravenous dexamethasone 0.15 mg/kg after ESD for early gastric neoplasm (DEXA group), comparing with a control group receiving placebo saline only (placebo group). Patients completed a questionnaire comprising the present pain intensity and short-form McGill pain (SF-MP) score at immediate postoperative period, 6, 12, 24 hours after ESD. The primary outcomes variable was present pain intensity (PPI) measured at 6 hour after ESD. The secondary outcomes variables included pain medication, McGill pain score, complications, second-look endoscopic finding, and length of stay. Results: Thirty-six patients receiving ESD for early gastric neoplasm participated. The mean value of 6-hour PPI in DEXA group was lower than that of placebo group (1.67±1.03 vs. 2.67±1.03, p=0.006). The total 6-hour SF-MP score, especially in sensory domain, was higher in placebo group than in DEXA group (12.11±4.14 and 9.39±2.75, p=0.026). Tramadol for pain relief was more frequently injected in placebo group than DEXA group (44.4 % vs. 11.1%, p=0.026). No difference of length of stay was noted. The distribution of artificial ulcer patterns on second-look endoscopy performed 48 hours following ESD was similar between the groups. There was no difference in complication including acute or delayed bleeding between two groups. Conclusion: Single dose postoperative intravenous dexamethasone after ESD was effective and safe for epigastric pain relief during postoperative period. Key Words: Endoscopic submucosal dissection, Early gastric cancer, Pain relief, Intravenous dexamethasone, Present pain intensity P-32 Long-Term Follow up Result of No Residual Tumor after ESD in EGC Yong Hwan Kwon, Seong Woo Jeon Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea Background: To evaluate the long term follow up recurrence of early gastric cancer (EGC) in patients with histological discrepancies between biopsy and negative findings at endoscopic submucosal dissection (ESD). Methods: Between January 2007 and December 2010, we ve researched 493 EGC patients data who underwent ESD, retrospectively and included patients who were reported pathological no residual tumor. Results: Finally, 18 patients (1.8%) were reported no residual tumor findings in the ESD resection specimens. The Male:Female ratio was 11:8 and mean age was (33-71) years. Mean tumor size was (16-450) mm2 and mean number of forceps biopsy fragments was 3.37 (2-5). Mean follow-up duration was months and EGC recurrence was seen in 3 cases (15.8%). The compatibility between previous ESD lesion and recurrence lesion, 2 cases were recurred in previous ESD sites. Undifferentiated type was 2 cases, and 1 case was differentiated type. Only one case was different histologic grade compared with previous histology. Conclusions: At the time of negative findings after ESD, we presumed that tumors might have been small enough to be removed by the forceps biopsy. However, the possibility of sampling error or a different location should be considered. Key Words: No residual tumor, Endoscopic resection, EGC rd Congress of the Korean Society of Gastrointestinal Endoscopy November 23, 2013

17 P-33 The Role of Photodynamic Therapy in Patients with Esophageal Squamous Cell Carcinoma Kwung Jun Park 1, Hee Jin Kim 1, Cheol Min Shin 1, Young Soo Park 1, Nayoung Kim 1, Dong Ho Lee 1, Sang Hoon Jeon 2 Department of 1 Internal Medicine, 2 Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea Purpose: Over the past 20 years photodynamic therapy (PDT) has become a viable treatment method for early and developing stages of esophageal cancer. Our study examined the outcome of such cancers by using PDT. The aim of this study was to evaluate the effect of PDT and investigate the survival rate of such patients. Methods and Materials: 25 patients diagnosed as esophageal cancer from May 2003 to January male and 2 female patients had a median age of 68 (range 53-86). All patients were diagnosed as squamous cell carcinoma. PDT with different outputs according to the patient s state was initiated. Therapy response, recurrence rate, survival outcome, and complication of the patients were evaluated. The follow-up period ranged from 5 to 90 months(median 27 months). Results: Four patients were in situ carcinoma, 14 were T1-stage cancer, 6 had recurrent esophageal cancer after previous surgery or chemoradiotherapy and 1 had advanced. The complete response (CR) rate was 60% (15 of 25) in patients who received PDT. The CR rate was statistically higher (p=0.007) for patients who had Tis/T1 lesion (14 of 18; 77%) than for those with recurrent (1 of 6; 16%). There was one patient that had recurrence 12 months after PDT. Overall, the mean survival time was 65 months and the 5-year survival rate was 69%. The mean survival time was statistically higher for patients who had Tis/T1 lesion (80 months) than for those with recurrent (32 months). The mean survival time was significantly longer (p=0.029) for patients with CR (68 months) than for patients with partial response (49 months) after PDT. We experienced seven cases of esophageal stricture (28%) that required dilatation and one case of esophageal perforation (4%) that required operation after PDT. Conclusion: The role of PDT in recurred and advanced esophageal cancer is limited, but PDT might be an effective regimen for early esophageal cancer, with overall favorable survival time, and low recurrence rates. Key Words: Photodynamic therapy, Esophageal cancer P-34 Predictors of LNM in EGC according to Review of Patients Underwent Surgical Treatment-Single Center Experience Chang Seok Lee, Cheol Woong Choi, Dae Hwan Kang, Hyung Wook Kim, Su Bum Park Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea Background: In recent decade, endoscopic submucosal dissection (ESD) has been introduced to treatment of early gastric cancer (EGC). However, the indication for these types of treatment are still based on the Japanese data and no clear consensus has been reached on which type of EGC present a negligible risk for lymph node metastasis (LNM). Actually, LNM rate of EGC have been upto approximately 2-3%. Thus, we analyzed LNM in patients with EGC underwent gastrectomy with lymphadenectomy and identified the predictive clinicopathological factors for LNM on EGC. Methods: We investigated data from 252 patients with EGC underwent gastrectomy with lymphadenectomy between November 2008 and August The association between the clinicopathological factors and the presence of LNM were retrospectively analyzed by univariate and multivariate logistic regression analyses : sex, age, tumor size, type of operation, tumor location, gross type, ulceration, histopathologic grade, Lauren s classification, depth of invasion, lymphatic invasion, vascular invasion, perineural invasion. Results: In univariate analysis, histologic grade (p=0.000), lymphatic invasion (p=0.009), perineural invasion (p=0.033) were significantly correlated with lymph node metastasis. Overall LNM rate for EGC was 5.2% (n=13). Of the 13 lesions with lymph node positive, 2(15.4%) tumors were poorly differentiated intra-mucosal(m) cancers, 3 (23.1%) were signet ring cell M cancers, 1 (7.7%) was well differentiated sub-mucosal (SM) cancer, 5 (38.5%) were poorly differentiated SM cancers, 1 (7.7%) was signet ring cell SM cancer. The lesions within expanded indication of ESD proposed in Japan had no LNM. Conclusion: Based on our cases of single center, we have been able to clarify the risk factors of LNM associated with EGC. Histological type, lymphatic and perineural invasion were independent predictors for LNM in EGC. In addition, there is no LNM for lesion within expanded indication, ESD may be performed carefully. Key Words: EGC, LNM, ESD, Gastrectomy, Indication November 23, rd Congress of the Korean Society of Gastrointestinal Endoscopy 189

18 P-35 Clinical Usefulness of Argon Plasma Coagulation during Endoscopic Submucosal Dissection Eun Young Doo, Hang Lak Lee, Ki Deok Yoo, Yong Woo Ahn, Hye Jin Tae, Jin Ok Kim, Joon Soo Hahm, Byung Chul Yoon, Ho Soon Choi, Oh Young Lee, Dae Won Jun, Kang Nyeong Lee Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea Background: Argon plasma coagulation (APC) is a noncontact technique for tissue coagulation. The aim of this study is to assess the clinical usefulness of APC in case of fibrotic changes encountered during endoscopic submucosal dissection (ESD). Patients & Methods: We retrospectively assessed total of 26 cases performed APC during dissection due to fibrosis. All patients received a focal APC treatment at fibrotic areas during dissection. However, all other areas were removed using normal ESD techniques. The equipment for APC included an argon gas source and a high-frequency generator. After procedure, follow up endoscopic examinations with pinch biopsy was performed every 6 months. Results: We performed total 680 ESD procedure due to early gastric cancer or gastric adenoma between 2008 and Among 680 cases, APC was used due to submucosal fibrosis in 26 cases. Total 23 cases were enrolled in this study except follow up loss cases. The mean age was 64.25± 8.12 years; 22 patients were male and 1 patient was female. Twelve cases were gastric adenoma and eleven cases were gastric cancer. In eleven cases of gastric cancer, nine cases were mucosal cancer and two cases showed submucosal invasion. During follow up, total 4 cases showed a recurrence. One case was adenoma case and three cases were cancer cases. We performed re-esd in three cases, however, lymphatic metastasis was developed in one case. Conclusions: APC coagulation method in fibrotic and scar lesion can be effective and safe procedure, however, careful attention should be needed. Key Words: ESD, Argon plasma coagulation P-36 The Difference between Macroscopic and Pathologic Diameter in Gastric Tumor Resected by Endoscopic Submucosal Dissection Shang Hoon Han 1, So Hee Yun 1, Jae Un Lee 1, Moon Sik Park 1, Wang Guk Oh 1, Young Jae Lee 1, Gum Mo Jung 1, Ji Woong Kim 1, Yong Keun Cho 1, Seol Bong Yoo 2, Myoung Jin Ju 2, Kwang Min Lee 2, Jin Woong Cho 1 Division of Gastroenterology, Department of 1 Internal Medicine, 2 Pathology, Presbyterian Medical Center Seonam University College of Medicine, Jeonju, Korea Background and Aims: We decide whether to perform endoscopic submucosal dissection (ESD) or gastrectomy for early gastric cancer (EGC) by endoscopic examination. We cannot estimate the correct tumor size with naked eye during upper endoscopic examination. And endoscopic size of gastric tumor is different from histologic size of it. The goal of this prospective study is to compare macroscopic and pathologic diameters of gastric tumors resected by ESD. Methods: We prospectively enrolled 34 gastric adenomas (n=25) and adenocarcinomas (n=9) from 31 patients and performed ESD from July 2013 to September Tumor diameters were measured macroscopically by an investigator with a hand ruler just after removal and pathologically by a pathologist on mapping charts after processing specimen. Results: Macroscopic mean diameter of all tumors was ±5.16 mm. Pathologic mean diameter of them was ±7.43 mm. Macroscopic diameters were significantly different from pathologic diameters (p-value <0.001). Pearson's correlation coefficient between macroscopic and pathologic diameters was (p-value <0.001). Pathologic diameters of 7 tumors were larger than macroscopic diameters. Mean of difference in two measurement methods between adenoma and EGC was not significant (p-value >0.05). Conclusions: Endoscopic diameter was different from pathologic diameter. We think that it can do ESD for EGC that cross absolute indication for tumor size. Key Words: ESD, Diameter, Stomach Neoplasms, Estimate rd Congress of the Korean Society of Gastrointestinal Endoscopy November 23, 2013

19 P-37 The Efficacy & Safety of Endoscopic Submucosal Dissection for Gastric Subepithelial Tumors Originated from Muscle Layer So Hee Yun, Moon Sik Park, Jae Un Lee, Shang Hoon Han, Wang Guk Oh, Young Jae Lee, Gum Mo Jung, Ji Woong Kim, Yong Keun Cho, Jin Woong Cho Division of Gastroenterology, Department of Internal Medicine, Presbyterian Medical Center, Seonam University College of Medicine, Jeonju, Korea Background/Aims: The histological diagnosis and the direction of treatment of gastric SETs cannot be only determined based on those endoscopic finding and a standard endoscopic forceps biopsy. Thus, endoscopic submucosal dissection(esd) can be a useful method for treatment as well as diagnosis of SETs, but data about their efficacy and safety are limited in the case of SETs originating from the muscularis propria layer. Therefore, the aims of this study is to investigate the efficacy and safety of ESD for gastric SETs, especially originating from the muscularis propria layer. Methods: Fom January 2004 to June 2013, 72 patients with gastric SETs were treated with ESD. Twenty eight lesions among these were originated from the muscularis propria. The endosonographic reports, pathology and the patients medical records were reviewd retrospectively. Results: The mean age of the patients was 54.5±12.0 years, and sixty percent were female. The mean tumor diameter was 16.3±7.7 mm. The mean procedure time was 34.8±32.2 minutes. The histologic types of muscularis propria origin were composed of GIST 13(46%), leiomyoma 4(14.3%), ectopic pancreas 4(14.3%), schwannoma 1(3.6%), gastritis cystica profunda 1(3.6%), and so forth. The overall rate of complete resection was 70.8%, including the muscularis mucosa and submucosa (84.1%) and the muscularis propria (50%)(p=.002). The complication rate was 12.5%(9/72), composed of bleeding and perforation, but all patients were treated conservatively. The multivariable analysis for the complication incidence showed that origin of the muscularis propria was only significant factor. (95% CI: ,p=.011)The mean duration of follow-up was 22.9±27.8 months. The recurrence rate was 4.2%(3/72) without mortality during this period, and all of recurrence cases were local recurrence. Conculsions: This study shows that ESD for gastric SETs including origin from the muscularis propria is effective and safe method. Key Words: Gastric subepithelial tumor, Endoscopic submucosal dissection, Muscularis propria P-38 Long-Term Outcome after Endoscopic Submucosal Dissection in Patients with Superficial Esophageal Squamous Cell Carcinoma Dong Chan Joo 1, Gwang Ha Kim 1, Do Youn Park 2, Joon Hyung Jhi 1, Geun Am Song 1 Departments of 1 Internal Medicine, 2 Pathology, Pusan National University School of Medicine, Busan, Korea Background/Aims: Superficial esophageal squamous cell carcinoma (SESCC) is being increasingly detected during screening endoscopy. Endoscopic submucosal dissection (ESD) allows en bloc and histologically complete resection of lesions. This study assessed the technical feasibility and long-term outcomes of ESD for SESCCs. Methods: Between January 2005 and August 2012, 27 patients with 28 SESCCs underwent ESD at Pusan National University Hospital. The en bloc and pathologically complete resection rates, complication (perforation and bleeding) rate, incidence of esophageal stricture after ESD, and overall and disease-specific survival rates were evaluated. Results: The en bloc and pathologically complete resection rates were 93% and 83%, respectively. No significant bleeding occurred, and perforation with mediastinal emphysema was observed in 2 (7%) patients. Post-ESD stricture occurred in 2 (7%) patients who had mucosal defects involving more than three-fourths of the esophageal circumference. During a mean follow-up of 23 months, local tumor recurrence was seen in 2 of 4 lesions with pathologically incomplete resection; one was treated by re-esd and the other was treated by surgical esophagectomy. The overall and disease-specific survival rates were 84% and 100%, respectively. Conclusions: ESD seems to be a feasible and effective curative treatment for SESCCs. All patients should be closely followed-up after ESD. Key Words: Esophageal cancer, Squamous cell carcinoma, Endoscopic submucosal dissection, Outcome November 23, rd Congress of the Korean Society of Gastrointestinal Endoscopy 191

20 P-39 A Comparative Study of Transnasal versus Conventional Transoral EGD in PEG Placement and Tube Change Eunkyung Kim, Eunjoon Moon, Jooan Hwang, Seohee Ryu, Minkyung Lim, Sungyo Lim, Sungjae Shin, Keemyung Lee Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea Background and Study Aims: The placement of percutaneous endoscopic gastrostomy (PEG) has become a standard enteral feeding procedure for dysphagic patients with neurological disease or tumors of the head and neck. The aim of this study was to compare transnasal esophagogastroduodenoscopy (EGD) and conventional transoral EGD in PEG placement and tube change. Methods: Between July 2010 and August 2013, 262 patients were performed PEG placement or tube change in our hospital. We conducted a comprehensive retrospective study comparing transnasal and transoral EGD in PEG placement and tube change. Certain parameters, including hemodynamic parameters, pain scale, procedure time and complication rate were compared. Results: There were no significant differences in changes of systolic blood pressure (p=0.378), diastolic blood pressure (p=0.198), heart rate (p= 0.863) and SaO2 (p=0.627)during the procedure between transnasal EGD and transoral EGD in PEG placement. The FLACC pain scale during the procedure was significantly lower (p=0.045) in transnasal EGD compared with transoral EGD in PEG placement. In the comparison of the rate of complications between transnasal EGD and transoral EGD in PEG placement and tube change were not significantly different. Conclusion: No significant differences of hemodynamic parameters, procedure time and complication rate were seen between transnasal EGD and transoral EGD for the PEG placement and tube change. Results show that both methods are tolerable and feasible for PEG placement and tube change. Key Words: Percutaneous endoscopic gastrostomy, Transnasal esophagogastroduodenoscopy P-40 Successful Treatment of Post-Operative Leakage Using OTSC Yong Woo Ahn, Hang Lak Lee, Ki Deok Yoo, Eun Young Doo, Hye Jin Tae, Jin Ok Kim, Joon Soo Hahm, Byung Chul Yoon, Ho Soon Choi, Oh Young Lee, Dae Won Jun, Kang Nyeong Lee Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea Introduction: Nonsurgical methods for postoperative complication such as perforations, fistulas, and anastomotic leakages has been studied by endoscopists. Over-the-scope clips (OTSC) system is a novel methods for such problems. We report two cases which were successfully treated with over-the-scope clips (OTSC) methods for complication after gastrointestinal surgery. Case report Case 1: A 70-year-old male who underwent esophagectomy and esophagogastrostomy due to esophageal cancer 7 year ago was presented with swallowing difficulty. Chest CT and esophagogram revealed gastropulmonary fistula, from below anastomosis site to right upper lobe lung parenchyme. The opening of fistula was closed by OTSC methods without complication. Case 2: A 60-year-old male who underwent total gastrectomy and Roux-en-Y esophagojejunostomy due to stomach cancer at cardia 24 days ago was presented with low abdominal pain. Abdomen CT and esophagogram showed anastomotic leakages from anastomosis site to abdominal cavity. The opening of leakage was closed by OTSC methods without complication. Fig. 1. Conclusion: The OTSC device may offer a nonsurgical approach for closure of gastrointestinal complication like perforations, fistulas, and anastomotic leakages. Key Words: OTSC, Over-The-Scope-Clip, Leakage, Fistula, Post-operative rd Congress of the Korean Society of Gastrointestinal Endoscopy November 23, 2013

21 P-41 Extensive Esophageal and Small Intestinal Ischemia in Scrub Typhus Jeong-Mi Lee, Chang-Yoon Ha, Hyun-Jin Kim, Ok-Jae Lee Department of Internal Medicine, Gyeongsang National University School of Medicine, Jinju, Korea Introduction: Scrub typhus is an infectious disease with Rickettsia tsutsugamushi of variable clinical severity from mild to fatal. Bacterial pneumonia or peripheral vascular collapse is well known complication, however, gastrointestinal (GI) complication, especially ischemia is extremely rare. We experienced a case of esophageal and small intestinal ischemia in a 72-year old woman with scrub typhus. Case Report: A 72-year old woman was admitted because of abdominal pain and diarrhea of 10 days duration. She was taking medicines for diabetes mellitus and hypertension. Her past medical histories were tuberculous pleurisy 20 months earlier and subtotal gastrectomy for advanced gastric cancer 9 years ago. She had vomiting, and general malaise, but no fever. Her body temperature was There was no specific physical finding except severe diffuse abdominal tenderness. Skin lesion including eschar was not found on thorough physical examination. Initial laboratory tests including complete blood count and biochemistry were normal. Contrast enhanced CT of abdomen revealed marked segmental thickening of small intestinal wall with decreased enhancement, edema of entire small bowel, and small amount of ascites. Mesenteric CT angiography did not show vascular abnormality. Extensive mucosal necrosis and diffuse ulcers with dark greenish dirty exudates in the lower esophagus and descending duodenum, and marked edematous and hyperemic gastric mucosa were noted on upper GI endoscopy. Pancytopenia and DIC features developed during conservative management. Serologic test for Orienta tsutsugamushi was positive. After administration of doxycycline, her symptoms, abdominal tenderness, and laboratory findings improved markedly, and esophageal, gastric, and duodenal mucosal lesions improved on following upper GI endoscopy. Conclusion: Although it is extremely rare, GI ischemia should be considered as a serious complication in the patient with scrub typhus. Key Words: Ischemia, Esophagus, Small intestine, Scrub typhus, Complication P-42 Clinical Analysis of Proton Pump Inhibitor- Responsive Esophageal Eosinophilia (PPI-REE) Gak Won Yun, Jie-Hyun Kim, Jae Jun Park, Young Hoon Youn, Hyojin Park Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea Background/Aims: PPI-REE is the newly recognized disease subtype of eosinophilic esophagitis that responds to PPI therapy. As of yet, whether this represents a sub-phenotype of GERD, a sub-phenotype of eosinophilic esophagitis (EoE), or its own distinct entity remains unclear. The aim of this study was to evaluate the clinicopathologic features of PPI-REE. Methods: Five patients with PPI-REE (4 men and 1 women; mean age, 34.6 years) were diagnosed with EoE based on typical symptoms, endoscopic abnormalities and esophageal eosinophilia with 15 eosinophils/high-power field and responding to proton pump inhibitor (PPI). Symptoms and endoscopic and pathological findings at initial observation and follow-up were evaluated. Results: Median follow-up duration was 12 months (2-60 months) and the average endoscopic follow-up period was 2.4 months (2-3 months). Presenting symptoms were dysphagia (3 of the 5 patients), heartburn (3 of the 5 patients), acid regurgitation (2 of the 5 patients) and foreign body sense ( 2 of the 5 patients). All patients have typical endoscopic findings of EoE, linear furrow ( 2 of the 5 patients) and esophageal ring ( 3 of the 5 patients). Three of the 5 patients were accompanied with allergic disorder (1 asthma and 2 allergic rhinitis) and two of the 5 patients were accompanied with reflux esophagitis. Three patients with allergic condition showed prominently increased serum IgE ( > 1000 KIU/L) and positive skin prick test against various allergens. All patients had symptomatic resolution within 4 weeks and histologic resolution within 8 weeks after PPI therapy. But, no one improved typical endoscopic findings. There was no symptomatic recurrence in our follow-up duration. Conclusions: PPI therapy induce rapid resolution of the symptoms and eosinophil counts in patients with PPI-REE. Large scale studies with long-term follow-up are warranted. Key Words: Esophageal eosinophilia, Proton pump inhibitor November 23, rd Congress of the Korean Society of Gastrointestinal Endoscopy 193

22 P-43 A Case of Nonalcoholic Wernicke-Korsakoff Syndrome in Caustic Injury Il Nam Ju, Hyung Il Moon, Kang Yeon Won, Bong Suk Ko, Sung Jin Moon, Myeong Jun Song, Sang Bum Kang, Dong Soo Lee and Seung Woo Lee Depratment of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea Introduction: Wernicke s encephalopathy (WE) is a neuropsychiatric condition generally caused by acute thiamine (vitamin B1) deficiency and classically involves the triad of altered mentation, ataxia and ophthalmoplegia. If WE signs and symptoms are not adequately treated with thiamine supplements, progression to Korsakoff syndrome, a chronic neurological condition characterized by antegrade amnesia, can occur. Case report: A 50-year-old nonalcoholic woman attempted suicide by drinking hydrochloric acid. On a day of admission, endoscopic examination revealed diffuse necrosis with black discoloration through the entire stomach (grade 3B injury) (Figure A) and focal necrosis of duodenum (grade 3A injury). Total parenteral nutrition (TPN) was conducted for 21days and liquid diet was started. But she developed acute disorientation with confusion. Brain MRI showed symmetric high signal intensity in the mamillary bodies in FLAIR image (Figure B). The revision of commercialized TPN products we used, revealed that thiamine was not included. We immediately started thiamine treatment but her anterograde amnesia was not recovered, suggesting Korsakoiff syndrome. A Conclusion: Prophylactic vitamin supplementation including thiamine should be implemented during prolonged TPN. Key Words: Wernicke Encephalopathy, Korsakoff Syndrome B P-44 Relapsed Esophageal Web in Plummer-Vinson Syndrome Kang Yeon Won, Hyung Il Moon, Il Nam Ju, Bong Suk Ko, Dong Soo Lee, Sang Bum Kang, Won Seok Park, Myeong Jun Song, Sung Jin Moon, Seung Woo Lee Department of Internal Medicine, The Catholic University School of Medicine, Daejeon St. Mary's Hospital, Daejeon, Korea Introduction: Plummer-Vinson syndrome is defined by the classic triad of dysphagia, iron-deficiency anemia and esophageal webs. Relapsed esophageal web in Plummer-Vinson syndrome is very rare. We report a case of relapsed esophageal web in Plummer-Vinson syndrome. Case: A 42-year-old female presented with difficulty in swallowing from 3 years. On admission, laboratory data showed WBC 4000/mm 3, Hb 6.0 g/dl, Platelet /mm 3, serum iron 13μg/dl, total iron binding capacity (TIBC) 363 μg/dl, ferritin 1.44 ng/ml. Blood cell morphology was showed microcytic hypochromic anemia. On our hospital upper GI endoscopy, post cricoid esophageal web was seen and the endoscope could not be passed across the cricoid level. Barium swallowing test was shows upper esophageal web. Based on these findings, a diagnosis of Plummer- Vinson syndrome was made. Endoscopic balloon dilatation was performed and iron supplementation was continued. Her symptoms was improved and discharged. Although iron supplement, her anemia was continued because of poor compliance and menorrhagia. One years later, She felt the difficulty of swallowing again. On readmission, investigations revealed microcytic hypochromic anemia with Hb 9.0 g/dl, serum iron 10 μg/dl, total iron binding capacity 339 μg/dl, ferritin 2.3 ng/ml. Endoscopic finding was also upper esophageal web. Based on above finding, a diagnosis of the recurrence of esophageal web in Plummer-Vinson syndrome was made. Endoscopic balloon dilatation was performed again. After dilatation, her symptom of dysphagia was improved. At the time of discharge, We emphasized the importance of consumption of iron supplement to her. Conclusion: Although the pathogenesis of esophageal web in Plummer- Vinson syndrome is unclear, iron-deficiency anemia is the most powerful factor of esophageal web formation in light of our experience. The correction of iron deficiency anemia is very important. Key Words: Plummer-Vinson syndrome, Esophageal web rd Congress of the Korean Society of Gastrointestinal Endoscopy November 23, 2013

23 P-45 Intramural Gastric Emphysema Associated with Superior Mesenteric Artery Syndrome: A Case Report Yu Min Lee 1, Hyun Joo Song 1, Soo Young Na 1, Sun Jin Boo 1, Heung Up Kim 1, Seung Hyoung Kim 2 Department of 1 Internal Medicine, 2 Radiology, Jeju National University School of Medicine, Jeju, Korea Introduction: Gas in the wall of the stomach is rarely reported and could be caused by gastric emphysema or emphysematous gastritis. Gastric emphysema occurs when there is increased intragastric pressure. These patients are generally asymptomatic, and the clinical course is usually benign. Compared with gastric emphysema, emphysematous gastritis is caused by gas-forming microorganisms and has a high mortality rate with a fulminant course. Therefore, early diagnosis and aggressive treatment is important to manage emphysematous gastritis. These two conditions can be distinguished by pathogenesis, clinical manifestations and radiological findings. Case Report: A 24-year-old man was admitted to our emergency room with vomiting, abdominal distension and pain, after he had eaten Korean rice cakes one day before. He was known to have epilepsy and a developmental disorder. Abdominal pelvic computed tomography (CT) scans showed air in the gastric wall and a compressed third segment of the duodenum. On the patient s third day in the hospital, upper endoscopy revealed multiple geographic ulcers with mucosal hemorrhage in the body of the stomach. There was marked dilatation of the second segment of the duodenum with many geographic ulcers and a collapsed third segment. Based on the CT and endoscopic findings along with his clinical symptoms, the patient was diagnosed as having gastric emphysema associated with superior mesenteric artery (SMA) syndrome. The patient improved after the administration of antibiotics, nasogastric decompression and jejunal feeding after 13 days of admission. Conclusion: We report a rare case of gastric emphysema associated with SMA syndrome in a young man. He was managed successfully with medical treatment and nutritional support. Key Words: Emphysema, Superior mesenteric artery syndrome P-46 A Case of Gastric Syphilis Hoon Young Ko, Joon Hur, Soo Jeong Kim, Jong Hwan Lee, Mi Ae Song, Tae Ho Kim, Jae Hyuck Chang, Chang Whan Kim, Sok Won Han Division of Gastroenterology, Department of Internal Medicine, Bucheon St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Bucheon, Korea Introduction: The decreased incidence of gastric syphilis has made its clinical presentation less widely appreciated. The clinical diagnosis of gastric syphilis ranges from a benign ulcer to mimicking an infiltrative carcinoma or lymphoma. Case Report: A 34-year-old woman presented with a 10-day history of epigastric soreness with nausea. The duodenoscopy revealed numerous, 5-15 mm, round, light yellowish colored, erosion or ulcer like lesions from fundus to proximal antrum. Gastric syphilis was confirmed by demonstrating spirochetes in a gastric biopsy specimen by Warthin-Starry siver stain. Fluorescent treponemal antibody-absorption IgM test for syphilis, Treponema pallidum haemagglutination were positive. She was treated with Intramuscular penicillin G. After treatment, her symptoms were improved. Conclusion: We report on a case of gastric syphilis that manifested with multiple gastric erosions or ulcers. It was correctly diagnosed by histopathologic findings and the serologic testing. If unusual gastritis, gastric erosion and gastric ucler are revealed on duodenoscopy, gastric syphilis should be considered in one of diagnosis by clinician. Key Words: Gastric syphilis November 23, rd Congress of the Korean Society of Gastrointestinal Endoscopy 195

24 P-47 Giant Esophageal Squamous Papilloma Chanwoo Jung, SeungKun Park Department of Internal Medicine, Maryknoll Hospital, Busan, Korea Introduction: An esophageal papilloma is a rare benign tumor found in less than 0.04% of endoscopic examinations. Most are small, sessile but some rare cases and presentations of giant esophageal papilloma have been reported in the literature. Case Report: A 77-year old male with history of cerebral infarction presented with epigastric discomfor. Physical examination and lab findings are normal. He went through gastroduodenoscopy. His gastroduodenoscopy showed protruding mass which accounts for about half of the circumference in mid-esophagus (Fig. 1). Lugol solution was applied, there was no areas that are not dyed. Biopsy was performed. Segment of esophageal mass showed polypoid lesion with squamous epithelium which covered the fibrovascular core.(figure) We recommeded operation to the patient because of ambiguity regarding premalignancy. But the patient refused operation. He has been followed up. Fig. 1. P-48 Foreign Bodies in the Upper Gastrointestinal Tract: Endoscopic Diagnosis and Removal Ho Jun Lee, Sung Uk Lim, Chung Hwan Jun, Ho Seok Ki, Seon Young Park, Sung Bum Cho, Wan Sik Lee, Chang Hwan Park, Young Eun Joo, Hyun Soo Kim, Sung Kyu Choi, Jong Sun Rew Department of Internal Medicine, Chonnam National University College of Medicine, Gwanju, Korea Background/Aims: Endoscopy is widely used in diagnosis and management of foreign bodies in upper gastrointestinal tract (UGIT). The aims of this study were to characterize the clinical features associated with foreign bodies in UGIT and to determine the clinical factors for successful endoscopic removal. Methods: We retrospectively reviewed 291 patients with foreign bodies in UGIT who arrived at Chonnam National University Hospital between august 2011 and august Results: Foreign bodies were found in 85.5% (249/291) of the cases during endoscopic procedure. The types were chiefly fish bones (28.1%), coins (13.2%), bones (9.1%) and meats (7.9%). The locations were upper esophagus (58.3%), stomach (19.4%), mid-esophagus (10.7%), and lower esophagus (7.4%). Endoscopic removal was successful in 97.1% (242/249). Impaction time (p=0.002) and diameter (p=0.005) were independent factors to predict the complications for endoscopic removal. Conclusions: Endoscopic removal of foreign bodies in the UGIT is an effective and safe procedure. We should give more attention to remove foreign bodies with long impaction time and large size. Key Words: Foreign body, Upper gastrointestinal tract, Endoscopy Conclusion: A squamous papilloma of the esophagus is a rare benign tumor, usually without characteristic symptoms. Rarely giant esophageal papilloma has been reported. All endoscopists must be aware of this lesion, which must be removed in all patients because of ambiguity regarding premalignancy and differential diagnosis. Key Words: Esophagus, Giant papilloma, Gastroduodenoscopy rd Congress of the Korean Society of Gastrointestinal Endoscopy November 23, 2013

25 P-49 Endoscopic Flushing with Pronase Improves the Quality of a Gastric Biopsy-A Prospective, Randomized, Controlled trial Sun-Young Lee 1, Hye Seung Han 2, Jae Myung Cha 3, Yu Kyung Cho 4, Gwang Ha Kim 5, Il-Kwun Chung 6 Departments of 1 Internal Medicine, 2 Pathology, Konkuk University School of Medicine, Seoul, 3 Department of Internal Medicine, University of Kyunghee College of Medicine, Seoul, 4 Department of Internal Medicine, The Catholic University College of Medicine, Seoul 5 Department of Medicine, Pusan National University School of Medicine, Busan and 6 Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea Background and Aims: Premedication for esophagogatroduodenoscopy (EGD) includes an anti-foaming agent and a mucolytic agent. Pronase, a proteolytic enzyme, is known to improve mucosal visibility during EGD and does not interfere with the CLO test, but little is known about its effects on a gastric biopsy. This study assessed whether endoscopic flushing with pronase improves the quality of a gastric biopsy. Patients and Methods: Consecutive subjects who visited for EGD were randomly assigned to either the control group or pronase group in a prospective setting. The first biopsy of the discolored lesion was performed during endoscopy (if any). Endoscopic flushes with 50 ml of water and simethicone were applied in the control group after the first biopsy, while endoscopic flushes with 50 ml of water, pronase, sodium bicarbonate, and simethicone were applied in the pronase group. The second biopsy was performed 2-3 mm behind the first biopsied site. The thickness of mucus and depth of the specimen were assessed by one pathologist who was unaware of the randomization. Overall diagnostic adequacy, anatomical orientation, and crush artifact were measured to assess the quality of the biopsy. Results: Ten of the 208 subjects were not analyzed due to the lack of a discolored lesion. Relative to the control group, the pronase group showed significantly decreased thickness of mucus (p<0.001), increased depth of biopsy (p<0.001), improved anatomical orientation (p=0.010), and improved overall diagnostic assessment (p=0.011) in the follow-up biopsied specimen after the endoscopic flushing. The crush artifact and hemorrhage did not differ between the groups. Conclusions: Endoscopic flushing with pronase not only improves the depth of a biopsy but also the anatomical orientation and overall diagnostic adequacy. Pronase can be recommended for flushing during EGD to improve the quality of a biopsy. Key Words: Biopsy, Esophagogastrododenoscopy, Mucus, Pronase, Stomach P-50 Cholecystectomy or Gallbladder in Situ after Endoscopic Clearance of Common Bile Duct Stones in Elderly Patients Ji Woong Jang, Yongsoo Cho, Hyun Cheol Koo, Sae Hee Kim, Sung Hee Jung, Yong Sik Kim, Anna Kim Department of Internal Medicine, Eulji University Hospital, Eulji University College of Medicine, Daejeon, Korea Background and Aims: Although cholecystectomy is common practice after endoscopic clearance of CBD stones in patients with cholecystocholedocholithiasis, we often face a difficulty in deciding cholecystectomy in elderly patients with various comorbid conditions. The aim of this study is to evaluate whether cholecystectomy in very elderly patients is justified after endoscopic clearance of CBD stones. Patients and Methods: From January 2011 to December 2012, among 854 patients who underwent ERCP, 120 patients older than 80 years old were initially selected. After excluding patients with previous hepatobiliary surgery including cholecystectomy, previous ERCP, IHD stone, ERBD, and/or patients with follow-up less than 6 months, 32 cholecystocholedocholithiasis patients older than 80 years with follow-up more than 6 months were enrolled. Results: Enrolled patients included 18 men and 14 women, with a median age of 83 years (ranging from years). 2 (6%) patients underwent previous abdominal operation other than hepatobiliary surgery, and periampullary diverticulum was observed in 15 (47%) patients. Precut was used in only 1 (3%) patient.the median follow-up period was 564 days (ranging from 182 to 1482 days). Patients` backgrounds were not significantly different between cholecystectomy group (9/32, 28%) and gallbladder in situ group (23/32, 72%). There was no recurrence of cholecystitis in gallbladder in situ group as well as in cholecystectomy group. The cumulative incidence of CBD stone recurrence was not different between the two groups (3/9 (33%) in cholecystectomy group vs. 6/23 (26%) in gallbladder in situ group, p=0.193). Conclusions: In very elderly patients, preserving the gallbladder does not increase the risk of cholecystitis and CBD stone recurrence after endoscopic treatment of CBD stones. Therefore, cholecystectomy after endoscopic clearance of CBD stones in cholecystocholedocholithiasis patients should not be recommended in very elderly patients. Key Words: Cholecystectomy, CBD stone, ERCP, Elderly November 23, rd Congress of the Korean Society of Gastrointestinal Endoscopy 197

26 P-51 Characteristics of Recurrent CBD Stones and Role of Endoscopic Papillary Large-Balloon Dilation in Preventing Recurrence Jae Hyuck Chang, Tae Ho Kim, Chang Whan Kim, In Seok Lee, Sok Won Han Department of Internal Medicine, The Catholic University of Korea, Seoul, Korea Background: Some common bile duct (CBD) stones recur after endoscopic stone extraction. Little information is available on the characteristics of symptomatic recurrent CBD stones or on ways to prevent recurrence. Methods: Between January 2007 and December 2012, 481 consecutive patients undergoing endoscopic extraction of CBD stones were enrolled. A total of 97 patients consisting of 34 patients with recurrent CBD stones and 63 patients without recurrence who were followed up more than five years were selected. The characteristics of the CBD stones and related clinical information were analyzed retrospectively. Results: The sizes of the CBD stones increased during the recurrences: 10.1 ± 5.2 mm, 13.5 ± 7.3 mm, and 16.8 ± 7.8 mm at the initial presentation, the first recurrence, and the second recurrence, respectively (p=0.016). Among CBD stone recurrences, 50% occurred within 2.3 years, and 80% occurred within 5.3 years. In patients with CBD diameters less than 12 mm, no recurrence was encountered when an endoscopic papillary large-balloon dilation (EPLBD) of 10 mm was performed. In patients with CBD more than 12 mm, recurrences occurred significantly less when the EPLBDs were 10 mm or 12 mm (p=0.036 and 0.025, respectively). Multivariate analysis revealed that EPLBD 10 mm and the CBD diameter were independent factors related to the recurrence of CBD stones (p=0.001 and 0.012, respectively). Conclusion: The sizes of CBD stones increased during recurrences. EPLBD more than 10 mm reduced the recurrence of CBD stones. Key Words: Choledocholithiasis, Common bile duct gallstones, Endoscopic retrograde cholangiopancreatography, Recurrence P-52 Conventional Y Stent versus Niti-S Large Cell D-Type Stent in Bilateral Stent Placement for Advanced Hilar Malignancy Hong Kyu Choi 1, Sung Ill Jang 1, Jeong Sik Yoo 2, Kwang Hoon Lee 2, Jin Hyeok Hwang 3, Dong Ki Lee 1 Department of 1 Internal Medicine, 2 Radiology, Gangnam Severance Hospital, Seoul, 3 Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea Objectives: Endoscopic bilateral drainage for advanced hilar malignancy using metal stents is considered difficult. Various types of self-expandable metallic stents (SEMSs) are available. Niti-S large cell D-type (LCD) biliary stent is uniform, large cell (7 mm) stent with thick nitinol wire (0.178 mm). The purpose of this study is to compare conventional Y with Niti-S large cell D-type (LCD) stent in bilateral stent placement for malignant hilar biliary obstruction. Methods: This is a prospective study of 69 patients with inoperable advanced hilar tumor. We categorized our patients into 2 groups as follows: Group I = patients with conventional bilateral Y-stenting (n=55), Group II = patients with bilateral newly designed Niti-S large cell D-type (LCD) stenting (n=14). The main outcome measurements were technical and functional success, complications, stent patency, revision efficacy. Results: The technical success rates of two groups were 65.5%(36/55) for conventional Y and 78.6% (11/14) for LCD. The functional success rates were 86.1% (31/36) for conventional Y and 90.9% (10/11) for LCD. Complications were observed in six of the 36 (19.4%) for conventional Y and zero of 11 (0%) for LCD. Stent occlusion occurred in 13 of the 36 (36.1%) for conventional Y and in 4 of the 11 (36.4%) for LCD. Stent patency time was 168 days for conventional Y and 146 days for LCD. Reintervention was performed: plastic stent (3/13), percutaneous transhepatic biliary drainage (6/13), metal stent (4/13) in conventional Y and metal stent (4/4) in LCD. Conclusions: LCD stent is equally effective as conventional Y stent in terms of technical and functional success rates, complications, and stent patency, revision efficacy, moreover it has no procedure related complication. Key Words: Conventional Y stent, Niti-S large cell D-type stent, Advanced hilar malignancy, Procedure related complication rd Congress of the Korean Society of Gastrointestinal Endoscopy November 23, 2013

27 P-53 A Case of Ampulla of Vater Cancer Presenting as Recurrent Acute Pancreatitis Min Seok Yoo, Byoung Kwan Son, Ji Hyun Lee, Seung Chan Kim, Young Kwan Jo, Sang Bong Ahn, Seong Hwan Kim, Yun Ju Jo, Young Sook Park Department of Internal Medicine, Eulji General Hospital, Eulji University School of Medicine, Seoul, Korea Introduction: Recurrent acute pancreatitis (RAP) results commonly from alcohol consumption and gallstones. It can occur as a result of any process that prevents free flow of pancreatic juice. In alcoholics, other causative factors of RAP could be overlooked or misdiagnosed. We report a case of RAP caused by ampulla of vater (AOV) cancer which was initially misdiagnosed with alcoholic pancreatitis. Case: A 55-year-old man was admitted because of new-onset jaundice and relapsed epigastric pain. He had been admitted with acute pancreatitis 2 months and 6 months ago. He had consumed 56 g alcohol daily, but he stopped drinking after being diagnosed with RAP due to alcohol 2 month ago. Laboratory studies revealed amylase/lipase 258/182 mg/dl, AST/ALT/ ALP/rGTP 40/86/842/631 mg/dl, total bilirubin 5.9 mg/dl, Triglyceride 163 mg/dl. Abdominal computed tomography (CT) showed more prominent dilatation of main pancreatic duct and common bile duct compared with previous CT. Endoscopic retrograde cholangiopancreatography (ERCP) was performed, showing a nodular lesion less than 1 cm in diameter after endoscopic sphincterectomy and papillary adenocarcinoma was confirmed by biopsy. The patient subsequently underwent a pylorus preserving pancreatoduodenectomy. Conclusion: Anatomical factors including pancreatobilliary tumors can induce obstruction of pancreatic duct and result in RAP. High index of suspicion is important in dealing with RAP with elusive etiologies or unclear imaging findings. Early ERCP can be indicated for making an accurate diagnosis in RAP. Key Words: Acute pancreatitis, Ampulla of Vater cancer P-54 Retroperitoneal Abscess as an Uncommon Complication after Endoscopic Papillectomy Sung Uk Lim, Ho Seok Ki, Chung Hwan Jun, Seon Young Park, Chang Hwan Park, Hyun Soo Kim, Sung Kyu Choi, Jong Sun Rew Departments of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea Introduction: Endoscopic papillectomy is increasingly used in the management of papillary neoplasia since the 1970s. This endoscopic papillectomy has been recognized as a safe and effective alternative to surgical resection. We present here a uncommon case of retroperitoneal abscess after endoscopic papillectomy. Case Report: A 70-year-old man was admitted for endoscopic papillectomy; his esophagogastroduodenography (EGD) and endoscopic ultrasonogram (EUS) showed a 15-mm sized lesion in duodenal major papilla; a tubular adenoma with high grade dysplasia was confirmed on biopsy. He underwent endoscopic papillectomy with endoscopic electroqautery snare. Minor oozing vessel was controlled with an endoclipping, and plastic stent was placed in pancreatic duct. Two days later after the procedure, he had severe abdominal pain and headache. His laboratory findings were amylase 969 U/L, Lipase 923 U/L, white blood cells count 15500/mm 3 (neutrophil : 87.4%) and enhanced abdominal computed tomography (CT) presented an enlargement and heterogenous enhancement of pancreatic head and soft tissue stranding along with pancreas head and duodenal loop. His clinical symptoms and laboratory findings had improved after fasting and antibiotics for 7 days. He was discharged, but readmitted 7 days later because of severe abdominal pain and fever. Abdominal CT demonstrated a fluid collection in infrapancreatic and left anterior pararenal space, but no evidence of pancreatic swelling and dilatation of common bile duct and main pancreatic duct was noted. Surgical incision and drainage of abdominopelvic abscess was performed. His clinical condition subsequently improved and follow-up abdominal CT showed nearly complete improvement of abscess pockets. He was discharged 30 days after readmission. Conclusion: Endoscopic papillectomy is a very safe procedure as first-line therapy for papillary neoplasm. But we should consider that it can also have severe complications related to this therapy. Key Words: Endoscopic papillectomy, Retroperitoneal abscess November 23, rd Congress of the Korean Society of Gastrointestinal Endoscopy 199

28 P-55 Clinical Outcomes of Endoscopic Snare Papillectomy of Duodenal Major Papillary Neoplasm Yong Hun Kim, Sang-Woo Cha, Tae Hoon Lee, Hyun Jong Choi, Soung Won Jung, Jae Young Jang, Jong Ho Moon, Young Deok Cho, Sang-Heum Park, Sun Joo Kim Institute for Digestive Research, Digestive Disease Center, Department of Internal Medicine, Soonchunhyang University, College of Medicine, Seoul, Korea. Background and Aims: The use of endoscopic snare papillectomy (ESP) for the treatment of duodenal major papillary neoplasm was increased. However, concerns about ESP included the risk of incomplete removal. The aim of this study was to evaluate the clinical outcomes of ESP and the effectivity of argon plasma coagulation (APC) for the treatment of residual tissue. Patients and Methods: Among the patients who received ESP for the treatment of duodenal major papillary neoplasm from November 2005 to May 2013, 27 patients were enrolled. These patients were followed for more than 3 months. We retrospectively reviewed the medical records of the patients. Results: Twenty three patients had adenoma, 2 had adenocarcinoma, 1 had carcinoid tumor, and 1 had paraganglioma. Median follow-up periods was 13 months (range : 4-72 months). The overall rate of en bloc resection was 88.9% (24/27). Specimens with margin positivity after ESP were reported in 11 patients (8 lateral margin positivity, 3 lateral and vertical margin positivity). Among the 11 patients with margin positivity, 5 patients received additional treatment (4 APC, 1 hot biopsy and APC) and 6 patients with grossly no residual tissue were followed by close endoscopic surveillance with white light and/or narrow band imaging. Among all patients, local recurrence was detected in 3 patients (11.1%, 3/27), 2 cases occurred in the patient with margin positivity (18.2%, 2/11) and 1 case occurred in the patient with margin negativity (6.3%, 1/16). Two patients with local recurrence were the patients who did not receive additional treatment of lateral margin positivity. There was no local recurrence in the patients who received APC for the treatment of residual tissue. Conclusions: After ESP of duodenal major papillary neoplasm, additional treatment of margin positivity should be considered and close endoscopic surveillance should be performed. APC may be an effective method for the treatment of residual tissue. Key Words: Endoscopic snare papillectomy, Duodenal major papillary neoplasm, Argon plasma coagulation P-56 A Case of Idiopathic Acute Recurrent Pancreatitis Caused by Branch Duct Type IPMN and Ampulla of Vater Adenoma Ki Deok Yoo, Ho Soon Choi, Jin Ok Kim, Hye Jin Tae, Yong Woo Ahn, Eun Young Doo, Kang Nyeong Lee, Hang Lak Lee, Dae Won Jun, Oh Young Lee, Byung Chul Yoon, Joon Soo Hahm Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea Introduction: Acute pancreatitis is an acute inflammatory condition of the pancreas caused by various etiologic factors. When patients experience more than one episode of acute pancreatitis they are diagnosed to acute recurrent pancreatitis (ARP). The causes of acute recurrent pancreatitis is found in most of patients after an initial evaluation. But in the 10-30% of patients in whom the initial evaluation fails to reveal an causes, the patients are diagnosed to idiopathic ARP (IARP). We report a case of idiopathic acute recurrent pancreatitis, in which MRCP and ERCP revealed branch duct type IPMN at pancreatic head portion and ampulla of Vater adenoma. Case: A 77-year-old woman had suffered from idiopathic recurrent pancreatitis 2 times for the past 2 months. Abdominal Ultrasonography and Abdominal CT scan revealed no etiologic factor of recurrent pancreatitis. At the first episode of pancreatitis, MRCP was performed. MRCP showed a branch duct type IPMN at pancreatic head portion. At first, we thought the cause of acute pancreatitis is IPMN at pancreatic head portion. At the second episode of pancreatitis, her symptoms and laboratory findings did not improved despite conservative treatment. We performed a ERCP. ERCP revealed an nodular mucosa of ampulla of Vater and abrupt cutoff sign of distal CBD caused by adenoma of ampulla of Vater. We also performed an brushing cytology and forcep biopsy of ampulla of Vater. The histologic finding of the lesion was tubular adenoma with high grade dysplasia of ampulla of Vater. Although surgical resection was planned, the patient refused the surgical operation. The patient is being followed through the outpatient clinic with conservative treatment. Conclusion: In patients in whom the initial evaluation fail to reveal an causes, endoscopic studies such as EUS, ERCP should be performed to evaluate etiologic factors. Key Words: Recurrent pancreatitis, IPMN, Ampulla of Vater adenoma rd Congress of the Korean Society of Gastrointestinal Endoscopy November 23, 2013

29 P-57 Endoscopic Papillary Balloon Dilation for the Management of Bile Duct Stones in Patients with Billroth-II Gastrectomy Jun Suk Park, Kook Hyun Kim, Yeoun Su Jung, Jung Woo Lee, Seung Bum Kim, Hyun Hee Chung, Chan Seo Park, Myong Jin Oh, Kyeong Ok Kim, Si Hyung Lee, Byung Ik Jang, Tae Nyeun Kim Department of Internal Medicine, College of Medicine, Yeungnam University, Daegu, Korea Background: Endoscopic common bile duct stone removal is relatively difficult in patients with a history of Billroth-II gastrectomy and endoscopic sphincterectomy (ES) with conventional sphincterotome that is frequently used for management of biliary disease may increase complication risk, such as, bleeding and perforation due to the anatomical changes. The aims of this study was to evaluate the safety and effectiveness of endoscopic papillary large balloon dilation (EPLBD) in patients with B- II gastrectomy. Methods: A review of 53 patients who underwent ERCP for treatment of common duct stones in patients with B-II gastrectomy from January 2010 to December 2012 were conducted retrospectively. Hepatobiliary cancer, pancreatic cancer, common bile duct stricture, concomitant pancreatitis was excluded. Results: Of 53 patients, 31 patients were enrolled. The median age was 70.2 ± 7.1 years and male to female ratio was 2.9:1. Patients who underwent ES or EPLBD for management of CBD stones were 16 and 15, retrospectively. Mechanical lithotripsy was performed 7 patients (4 in ES group, 3 in EPLBD group). The median size of balloon was 11.3 ± 1.4 mm (range mm). The median expansive duration of balloon was 33.1 ± 14.0 s (range s). The overall stone removal rate of the 31 patients was 96.8% (30/31). Overall incidence of post-ercp pancreatitis was 0%. Post-ERCP bleeding was occurred 1 patient in EPLBD group. No significant difference in the incidence of post-ercp bleeding was observed between the two groups (p=0.48). Cholangitis was not observed in this study. Conclusion: EPLBD seems to be a effective and safe procedure for CBD stone removal in patients with billroth II gastrectomy. Key Words: ERCP, EPLBD, BII gastrectomy, CBD stone, Cholangitis P-58 Comparison of Nafamostat Mesilate in 24-Hour versus 8-Hour Infusion in the Prevention of Post-ERCP Pancreatitis Byeong Jun Song, Hyung Wook Kim, Cheol Woong Choi, Su Bum Park, Su Jin Kim, Dae Hwan Kang Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea Objective: 24-hour infusion of the protease inhibitor nafamostat mesilate effectively prevents post-ercp pancreatitis (PEP). However, the appropriate duration of administration is unknown. 8-hour infusion compared to 24-hour infusion can respect the patient's wish to avoid hospitalization and provide medical costs saving. We assessed and compared the incidence of PEP as a 8-hour or 24-hour infusion. Methods: From February to August 2013, a total of 214 patients who underwent ERCP were analyzed. Patients were divided into 2 groups: 24- hour infusion with nafamostat mesilate (group A), 8-hour infusion (group B) (107 patients per arm). Serum amylase and lipase levels were checked before ERCP, 4 and 24 hours after ERCP, and when clinically indicated. The incidence of PEP was analyzed. Results: The overall incidence of acute pancreatitis was 5.6% (12/214). There was no significant difference in the incidence of PEP as 24-hour infusion or 8-hour infusion (6.6% vs 4.6% respectively; p=0.768). Also there was no significant difference in the incidence of hyperamylasemia (8.4% vs 6.5%, respectively; p=0.796). Conclusions: Since both nafamostat mesilate infusion protocols had equal incidence of PEP, 8-hour infusion of nafamostat mesilate was also helpful in preventing PEP. Key Words: Nafamostat mesilate, Post-ERCP pancreatitis, Acute pancreatitis November 23, rd Congress of the Korean Society of Gastrointestinal Endoscopy 201

30 P-59 Can the Initial Implementation of Precut Fistulotomy Reduce the Risk of Complications Related to ERCP? Dong Hoon Baek, Dong Uk Kim, Hye Kyung Jeon, Joon Hyung Jhi, Gwang Ha Kim, Geun Am Song Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea Background and Aims: Precut fistulotomy has been considered as a risk factor for ERCP-related complications. However it is still debated whether the risk of complications is due to precut fistulotomy itself or prior repeated procedures. We aimed at assessing the rate of cannulation success and ERCP-related complications after the initial implementation of precut fistulotomy compared to precut fistulotomy performed after a difficult biliary cannulation. Patients and Methods: We conducted a retrospective study from January 2011 to December A total of 152 patients without prior sphincterotomy were enrolled. The patients were classified into two groups: the initial implementation of precut fistulotomy (Group A, n=72) or the late implementation of precut fistulotomy after a difficult biliary cannulation (precut fistulotomy after > 10 cannulation attempts, > 10minutes, and > 3 accidental pancreatic duct cannulations, Group B, n=80). Results: Both groups were comparable, with no statistical differences for age, gender, ERCP indications. There was no statistical difference in the overall success rate of cannulation between group A and B (95.9 vs. 95%, p=0.807). The mean cannulation time of group A was shorter than that of group B (5.7 vs minutes, p<0.001). The overall complication rates for group A and B were 8.3% and 17.5%, respectively. The overall number of patients with post-ercp pancreatitis was 3 in group A compared to 11 in group B (4.1 vs. 13.8%, p=0.041). There were no statistical difference in other complications including perforation and bleeding between group A and B. All complications could be resolved conservatively. Conclusion: The initial implementation of precut fistulotomy may be able to provide high cannulation success rate with significantly less time and reduce post-ercp pancreatitis risk compared to the late implementation of precut fistulotomy. Key Words: Precut fistulotomy, ERCP related complications, Post ERCP pancreatitis P-60 Endoscopic Balloon Dilation Lithotripsy for Difficult Bile Duct Stone: A Pilot Feasibility Study Jin-Seok Park, Jee Young Han, Seok Jeong and Don Haeng Lee Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea Background/Aim: Endoscopic treatment for removal of large or impacted bile duct stones is challenging, and may not be successful. The aim of this study is to evaluate the safety and efficacy of an endoscopic balloon dilation lithotripsy (EBDL) as a novel technique for retrieval of the stones in difficult extrahepatic bile duct stones for which conventional endoscopic treatments failed. Patients and Methods: The patients were included in the indication of EBDL, only if the stones would be confirmed as brown-pigmented stones or recurrent. Balloon dilation was performed using a balloon dilation catheter by the target stones at the common hepatic duct (CHD) or CBD level in 5 cases in order to crush the large and/or impacted stones. Then, the fragmented stones were removed successfully using a basket and/or an extraction balloon catheter. Results: The median diameter of balloon used for EBDL was 13.5 mm (range: mm). Balloon dilation was performed for 60 seconds per session. The median session number of EBDL for crushing the stone was 2 times (range: 1-4 times). The median number of ERCP session for complete stone removal was 3 times (range: 2-5 times) after EBDL. The overall procedure-related complication was 0% (0/5) and the success rate was 100% (5/5). Conclusion: EBDL might be a safe and effective option for treatment of large and impacted extrahepatic bile duct stones refractory to conventional endoscopic treatments. Key Words: Lithotripsy, Biliary Calculi, Removal device, Balloon, Stone removal rd Congress of the Korean Society of Gastrointestinal Endoscopy November 23, 2013

31 P-61 A Case of Biliary Fascioliasis Diagnosed by Endoscopic Retrograde Cholangiopancreatography in Biliary Stage Young Kyeong Seo, Jung Sik Choi, Eun Uk Jung, Sang Hun Lee, Kyoung Sun Ok, Sung Jae Park, Sam Ryong Jee, Youn Jae Lee, Sang Yong Seol Department of Gastroenterology, Inje University College of Medicine, Busan, Korea Introduction: Fascioliasis is a rare endemic zoonotic disease, caused by fasciola hepatica, a liver fluke. Humans can become accidental hosts of this paracite by ingesting contaminated drinking water or plants. There are two disease stages: the hepatic (acute) and biliary (chronic) stages. Case Report: A 39-year-old women with history of chronic hepatitis B presented with intermittent RUQ abdominal pain for several years. On physical examination, no abnormalities were found.initial laboratory findings excluding CA 19-9 were in normal values. CA 19-9 was elevated (13.51 U/ml). Ultrasonography showed irregular wall thickening and luminal narrowing of the common hepatic duct and on MRCP, an irregular filling defect was detected at the common hepatic duct. Endoscopic retrograde cholangiography (ERCP) demonstrated diffuse mild ductal dilatation with about 10mm filling defect at extrahepatic bile duct (EHBD). A needle infundibulotomy and endoscopic papillary balloon dilatation (EPBD) was done with extraction of single fasciola fluke. Endoluminal forcep biopsy was taken for excluding neoplasm. The result suggested biliary intraepithelial neoplasia (low grade). Our patient will be given triclabendazole to eradicate the paracite with double oral doses of 10mg/kg and will be done careful follow-up. Conclusion: The diagnosis of F. hepatica is based on microscopic identification of the characteristic eggs in the feces, duodenal aspirates or biles but enzyme linked immunosorbent assay (ELISA) testing is more rapid and reliable. The infection can be shown more easily by ERCP, during which a filling defect can be identified in the bile duct. Biliary stage of this zoonotic infection can be easily misdiagnosed because symptoms are subclinical, and only intermittent cholangitis may be the prominent sign. This report confirm the diagnostic and therapeutic role of ERCP in patients with bile duct abnormalities caused by biliary fascioliasis. Key Words: Fasciola hepatica, Endemic zoonotic disease, ERCP P-62 The Effect of the Preceding Biopsy on Complete Endoscopic Resection in Rectal Carcinoid Tumor Sang Pyo Lee, In-Kyung Sung, Jeong Hwan Kim, Sun-Young Lee, Hyung Seok Park, Chan Sup Shim Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea Background and Aims: Biopsy of rectal carcinoid tumor is commonly taken before endoscopic resection. However the preceding biopsy can inhibit complete resection by causing blurred tumor border and fibrosis of the tissue. The objective was to investigate the effect of the preceding biopsy on complete endoscopic resection in rectal carcinoid tumor and to see if rectal carcinoid tumors macroscopically can be distinguished by endoscopy. Patients and Methods: We reviewed retrospectively the records of patients with rectal carcinoid tumor who were undergone an endoscopic treatment at Konkuk University Hospital in Seoul, Korea, during a 7-year period from July 2005 to July We investigated the completeness of tumor resection, treatment methods, and characteristics of the patients and tumors. In addition, we checked whether the biopsy was taken or not. Results: A total of 98 rectal carcinoid cases (34 female, mean age 48.0±11.1 years) were included and the resection margin was clear in 57 cases. The preceding biopsy was taken in 26 cases (45.6%) in the clear resection margin group and in 31 cases (75.61%) in the positive margin group. The preceding biopsy was significantly associated with the risk of incomplete tumor resection [OR (95% CI ), p=0.004]. In 95.9% of all cases, the carcinoid tumor could be suspected by macroscopic appearance during initial endoscopy. Conclusions: The preceding biopsy which was performed before endoscopic excision may disturb complete resection of rectal carcinoid tumor. And, in most cases, the carcinoid tumor could be suspected by macroscopic appearance. Therefore the preceding biopsy is not essential and it should be avoided for complete resection of rectal carcinoid tumor. Key Words: Colonic polyps, Colonoscopic Polypectomy, Adenomatous Polyps, Interval Colorectal Cancer, Polypectomy November 23, rd Congress of the Korean Society of Gastrointestinal Endoscopy 203

32 P-63 A Tailored Approach for Endoscopic Treatment of Small Rectal Neuroendocrine Tumor Jun Heo, Min Kyu Jung, Sung Kook Kim, Seong Woo Jeon Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea Background and Aims: Resection of rectal neuroendocrine tumors (NETs) less than 1cm in diameter can be performed using various endoscopic techniques. The aim of our study To evaluate the efficacy of endoscopic submucosal resection with band ligation (ESMR-L) relative to endoscopic mucosal resection (EMR) for rectal NETs according to the characteristics of the tumors. Methods: 82 rectal NETs in 77 patients treated by ESMR-L (n = 48) or EMR (n = 34) between September 2007 and October 2012 were retrospectively analyzed. ESMR-L was used for flat type tumors or tumors with non-lifting sign after submucosal injection. Conventional EMR was used for elevated type tumors or tumors with well-lifting sign after submucosal injection. Results: The pathological complete resection rate was higher in the ESMR-L group (46 lesions, 95.8%) compared with the EMR group (30 lesions, 88.2%); however, this difference was not significant (p=0.226). Overall complication did not differ significantly between the ESMR-L group and the EMR group (p=0.774). There was one case of remnant lesion in the ESMR-L group, which was managed by endoscopic mucosal resection after circumferential pre-cutting (EMR-p), and no recurrence has been detected in either the ESMR-L or EMR groups. Conclusion: ESMR-L and EMR procedures could have a similar excellent complete resection rate, if we select the endoscopic resection technique according to the characteristics of the small rectal NETs. Key Words: Rectal neuroendocrine tumor, EMR, Submucosal injection P-64 Endoscopic Resection for Rectal Neuroendocrine Tumors: A Single Center Experience Byoung Wook Bang, Kye Sook Kwon, Hyung Gil Kim, Yong Woon Shin Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea Introduction: Rectal neuroendocrine tumors are as small as 10 mm or less in about 80% of patients at diagnosis. Several endoscopic methods were used for treatment of small rectal neuroendocrine tumor. The aim of this study was to compare treatment efficacy, safety and procedure time among endoscopic mucosal resection (EMR), endoscopic submucosal resection with band ligation (ESMR-L) and endoscopic submucosal resection (ESD). Methods: Between Janunary 2005 and September 2013, we retrospectively investigated patients who visited at Inha University for endoscopic resection of rectal neuroendocrine tumor. Rate of deep and lateral resection margin, incidence of complications and procedure time were evaluated. Results: Seventy six cases were treated by EMR (n=35), ESMR-L (n=22) or ESD (n=19) respectively. There were no procedure-related complications such as perforation and bleeding in all groups. The rate of positive deep and lateral resection margin was significantly lower in ESMR-L group (deep: 0%, lateral: 0%) than ESD (deep: 47%, lateral: 26%) and EMR groups (deep: 31%, lateral: 17%). The procedure time of EMR (5.3 ± 2.4 min) and ESMR-L (5.3 ± 3.0 min) was significantly shorter comparing to that of ESD (19.3 ± 9.6 min) (p-value=0.000) Conclusions: ESMR-L is a safe, effective and relatively less time-consuming procedure for removal of small rectal neuroendocrine tumor (< 10 mm). Key Words: Endoscopy, Rectum, Neuroendocrine tumor rd Congress of the Korean Society of Gastrointestinal Endoscopy November 23, 2013

33 P-65 A Randomized Controlled Trial Comparing 2 L Polyethylene Glycol Solution Containing Ascorbic Acid with 2 L Polyethylene Glycol Plus Bisacodyl Tablets for Colonoscopy Bowel preparation Sun-Kyung Na, Sung-Ae Jung, Hye-Kyung Song, Hye-Won Yun, Jae-In Ryu, Min-Jin Lee, Eun-Mi Song, Seong-Eun Kim, Ki-Nam Shim, Hye-Kyung Jung, Tae Hun Kim, Kwon Yoo, Il Hwan Moon Department of Internal Medicine, Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea Background: Although polyethylene glycol (PEG) solution is the most widely used as bowel preparation for colonoscopy, it has been associated with poor compliance because of a salty taste and a large amount of fluid. Reduced volume preparations were subsequently developed to improve efficiency. However, there were few studies about relative efficacy and tolerability of these preparations. The aim of this study was to compare 2 L PEG containing ascorbic acid with 2 L PEG plus bisacodyl tablets (10 mg) in regard to quality of bowel preparation and patient compliance. Methods: The patients who needed a repeated colonoscopy for colon polypectomy within three months were enrolled. After a diagnostic colonoscopy with 4 L PEG preparation, they were randomly assigned to receive either 2 L PEG containing ascorbic acid or 2 L PEG plus bisacodyl tablets for colon polypectomy. Overall colon cleansing score was assessed by blinded investigators using a validated four- point scale and patient compliance was assessed by a questionnaire. Results: There were no significant differences in colon cleansing score (p=0.059) and patient compliance (p=0.083) between 2 L PEG containing ascorbic acid and 2 L PEG plus bisacodyl tablets. In addition, colon cleansing score was not statistically different between traditional 4 L PEG preparation and 2 L PEG preparation (p=0.03). However, 2 L PEG preparation showed better compliance than 4 L PEG preparation (p<0.01). There was no difference in side effects and adverse events. Conclusions: There were no significant differences in quality of bowel preparation and patient compliance between two 2 L PEG preparations. Therefore, two 2 L PEG preparations could be good alternatives to 4 L PEG preparation for colon polypectomy performed sequentially. Key Words: Bowel preparation, Colonoscopy, Polyethylene glycol P-66 A Preliminary Comparison between 2 L Ascorbic Acid Mixed PEG and Combination of 1 L Ascorbic Acid Mixed PEG and Bisacodyl Ji Eun Kwon 1, Jong Pil Im 1, Jaeyoung Chun 1, Su Hwan Kim 2, Seong-Joon Koh 2, Ji Won Kim 2, Joo Sung Kim 1, Hyun Chae Jung 1 1 Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, 2 Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul National University College of Medicine, Seoul, Korea Background and Aims: The two-liter of polyethylene glycol (PEG) solution with ascorbic acid (Asc) can provide efficacy similar to that of standard 4-L PEG solution. Also oral bisacodyl (Bis) could reduce the required volume of PEG solution for bowel preparation. This study was aimed to compare the efficacy and patient acceptability of ascorbic acid mixed PEG solution (PEG + Asc) in 2-L versus the combination of 1-L PEG + Asc and Bis for colonoscopy preparation. Patients and Methods: This was a prospective, randomized, single-blind, non-inferiority trial. Participants who were scheduled for colonoscopy were included and randomized to receive either 2-L PEG + Asc only (Group 1) or 1-L PEG + Asc plus 20-mg Bis (group 2). The bowel preparation quality was assessed via endoscopic images by independent blinded investigator. The preparations were rated by the participants for tolerance, compliance, and adverse effects. Results: A total of 84 participants were included in the analysis, 42 in each group. Successful bowel preparation rate was the same in both groups (39/42, 92.9%) There was no statistical difference in patient compliance between two groups. All of the 81 patients who underwent colonoscopy prior to this study did not experience the regimens used in this study. Among them, Thirty-three of 39 patients (84.6%) in group 1 and 25 of 42 patients (59.5%) in group 2 preferred our regimen to previously experienced one. There were no severe adverse effects in both groups. Conclusions: These results, although preliminary, suggest that bowel preparation with bisacodyl and 1-L of ascorbic acid mixed PEG solution is well-tolerated, safe, and effective as 2-L of ascorbic acid mixed PEG solution. Key Words: Colonoscopy, Polyethylene glycol, Ascorbic Acid, Bisacodyl November 23, rd Congress of the Korean Society of Gastrointestinal Endoscopy 205

34 P-67 Four Cases of Acute Hyponatremia in the Use of Picosulfate-Based Preparation in Colonoscopy. Jong Hwan Lee, Chang Whan Kim, Hoon Young Ko, Mi Ae Song, Joon Hur, Soo Jeong Kim, Tae Ho Kim, Jae Hyuck Chang, Sok Won Han Department of Internal Medicine, St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Bucheon, Korea Colonoscopy is the most effective method for diagnosing colonic pathology. Choosing a more comfortable and safer preparation is a important task. Our clinic have used polyethylene glycol based solution, Colyte. But, the major disadvantages of Colyte is the large volume of fluid that patients must drink. Thus, recently we adopted a new preparation, PICOLIGHT (sodium picosulfate-magnesium oxide-citric acid). In two months, we did 216 colonoscopy cases with newly adopted preparation. we introduce 4 cases of acute hyponatremia. 78-year-old female was due to undergo day-care colonoscopy for screening. She took amlodipine and telmisartan for hypertension control. Within 3 hour of her first dose of PICOLIGHT, she complained of generalized motor weakness and involuntary movement. Her biochemistry on casualty revealed hyponatremia of 125 meq/l, 17mEq/L below than her baseline sodium level, 142 meq/l. 63-year-old female was due to undergo day-care colonoscopy for screening. She took lecanidipin for hypertension control. She visted our clinic 2 hour earlier than the scheduled time, with complains of nausea, weakness and dizziness. Her biochemistry on casualty revealed hyponatremia of 128 meq/l, 16mEq/L below than her baseline sodium level, 146 meq/l. 74-year-old female was due to undergo colonoscopy for evaluation of chronic diarrhea. Within 3 hour of her first dose she complained of severe nausea and chilling. Her biochemistry on casualty revealed hyponatremia of 126 meq/l, 15mEq/L below the Her baseline sodium level 141 meq/l. 66-year-old female was due to undergo colonoscopy for screening. She took cinadipine and thiazide. After 10 hour of her first dose she complained of intractable vomitting. Her biochemistryrevealed hyponatremia of 114 meq/l, 25 meq/l below the Her baseline sodium level 139mEq/L. All four patients were recovered by infusion of normal or hypertonic (3%) saline solution. More caustions were needed for prescribing PICOLIGHT, especially in older patients. Key Words: Picosulfate, Hyponatremia, Colonoscopy P-68 A Prospective Randomized Controlled Trial Comparing among Three Bowel Preparations for Colonoscopy: A Preliminary Report Moon Sik Park, So Hee Yun, Jae Un Lee, Shang Hoon Han, Wang Guk Oh, Young Jae Lee, Gum Mo Jung, Yong Keun Cho, Jin Woong Cho, Ji Woong Kim Division of Gastroenterology, Department of Internal Medicine, Presbyterian Medical Center, Seonam University College of Medicine, Jeonju, Korea Background/Aims: There are few data that compare among the three widely used bowel preparations in Korea: conventional 4 L PEG; sodium picosulfate and magnesium citrate(p/mc); and low-volume PEG plus Ascorbic acid(2 L PEG + Asc). The aim of this study is to compare among the three bowel preparations in the efficacy, tolerability, and safety. Methods: Fifty patients undergoing outpatient elective colonoscopy were randomly assigned to one of the three preparations in a single blinded prospective study. The preparations were as follows: Group A(n=17), 4 liters of PEG solution; Group B(n=17), one of 3 sachets of sodium picosulfate; or Group C(n=16), 2 liters of PEG plus ascorbic acid. All colonoscopy images were recorded into computed video files. One Endoscopist blinded to the type of preparation gave a bowel cleansing score using video files. And tolerability and safety were evaluated by a questionnaire immediately before the procedure. Results: Data analysis showed that efficacy in group A was superior to that in group B by Aronchick bowel preparation scale (p=0.011) and Boston bowel preparation scale (p=0.039). There were no significant differences among the three groups in tolerability. But, taste in group B was better than that in group C (p=0.002). The factors associated with safety such as abdominal distension, nausea were not significantly different among the groups. Conclusion: Conventional 4 L PEG is superior to Sodium Picosulfate and Magnesium citrate(p/mc) in colon cleansing efficacy. But, taste is significantly better in Sodium Picosulfate and Magnesium citrate(p/mc) group than Low-volume PEG plus Ascorbic acid (2 L PEG + Asc) group. Key Words: Colon, Preparation, Polyethylene glycol, Picosulfate, Ascorbic acid rd Congress of the Korean Society of Gastrointestinal Endoscopy November 23, 2013

35 P-69 The Miss Rate of Polyps in Colonoscopy and Related Variables: Retrospective Study Han Na Choi 1, Hyun Hee Kim 1, Seok Oh Jang 1, Hyun Sik Hwang 1, San Gu Kwank 2, Jin Tae Jung 1 Department of 1 Internal Medicine, 2 Medical Statistics, The Catholic University of Daegu School of Medicine, Daegu, Korea Background/Aims: The miss rate of colon polyps is known as about 20-25% in literatures. In our hospital, colonoscopiests found out missed polyps more frequently during endoscopic mucosal resection of colon. The aim of the current study is to analyze the miss rate of polyps in these patients and related factors. Methods: Patients who underwent endoscopic mucosal resection for colon polyp in one year and colonoscopy within the previous 6 months were included. For 192 patients, total 1122 polyps were found. The miss rates of polyps was calculated and related variables were analyzed. Results: 130 male and 62 female were included, the ratio of male/female was 2.1%. Mean number of polyps per patient was 5.4±3.9. Age of patients was classified with less than 55 (n=48, 25%), between 55 and 65 (n=71, 37%) and more than 65 (n=72, 38%). 122 of 192 patients had missed polyp(per patient miss rate 63.5%), 332 of 1122 polyps were missed(per polyp miss rate 29.6%). Female was significantly lower than male in miss rate (OR 0.349; 95% confidence interval [CI] ), age of more than 65 was higher in miss rate compared to age of less than 55 (OR 2.569; 95% CI ). Body mass index, procedure taking time, career of colonoscopiest, preparation drug, bowel preparation status, procedure start time(morning, afternoon), number of polyps at first colonoscopy did not affect the miss rate. In polyp character analysis, size of more than 10 mm was lower in the miss rate compared to size of less than 5 mm (OR 0.450; 95% CI ), polyps in the right colon were more frequently missed (OR 1.140; 95% CI ), but histologic charactestics of polyps did not affect the miss rate. Conclusions: Considering of colon polyp resection, the miss rate was significantly higher in male. Also, the age of patients more than 65, polyps with the size less than 5mm or located in right colon, noting that the miss rate of polyps could be high, colonoscopiest should observe carefully. Key Words: Polyp, Miss rate, Colonoscopy, EMR, Related factors P-70 Reoccurrence Rate and Risk factors of Advanced Colorectal Polyps after Endoscopic Removal Hyun Hee Chung, Kyeong Ok Kim, Yeoun Su Jung, Sung Bum Kim, Jun Suk Park, Jung Woo Lee, Chan Seo Park, Myung Jin Oh, KooK Hyun Kim, Si Hyung Lee, Byung Ik Jang, Tae Nyeun Kim Departments of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea Background/Aims: Surveillance of individuals with colon polyps is important for the prevention of colorectal cancer, and its interval is based on the clinical status.the aims of the present study were to assess the long term outcomes and risk factors of the reoccurrenceof advanced colorectal polyps after endoscopic removal. Methods: The medical record of 1510 patients diagnosed colorectal polyps between January 2005 and December 2008 were reviewed retrospectively. The term advanced colorectal polyp describes colorectal polyps greater than 1 cm in diameter and/or villous component and/or severe dysplasia or adenocarcinoma. The frequency and clinical feature of the advanced colorectal neoplasm was assessed and compared with non-advanced polyps. Risk factors of reoccurrenceof advanced colorectal polyp were analyzed. Result: Mean age of the patients was 66±11.3 years and 65.3% of the patients were male. Mean number of initial polyps per patient was 3.0 and advanced polyps were noted in 501 patients (33.2 %). Mean size of advanced colorectal polys was 15.3±8.3 mm and 12.4% of advanced colorectal polyps were located at the right side colon.the duration of colonoscopy follow up was 910.1±791.6days in non advanced colorectal polyp group and 688.2±719.0days in the advanced colorectal polyp group (p<0.05). The frequency of advanced colorectal polyps in previous advanced colorectal polyp group was significantly higher than that in the non-advanced subgroup (19.3% vs 10.9%, p<0.05). The risk factor of reoccurrence of advanced polyp was histologic feature with high grade dysplasia. Conclusion: Advanced colorectal polyp occurred more frequently in patients with the history of advanced colorectal polyp than in patients without history. The surveillance should be performed more strictly in patients with advanced colorectal polyp previously, especially with high grade dysplasia. Key Words: Adenoma, Colonoscopy November 23, rd Congress of the Korean Society of Gastrointestinal Endoscopy 207

36 P-71 Comparison of Clip and Endoloop in Preventing Postpolypectomy Bleeding in Pedunculated Colonic Polyps: Randomized Study Jeong-Seon Ji, Kang-Moon Lee, Seung-Woo Lee, Tae Ho Kim, Young-Seok Cho, Hyung-Keun Kim, Hwang Choi Departments of Internal Medicine, School of Medicine, The Catholic University of Korea, Seoul, Korea Backgroud/Aims: Although endoscopic colonic polypectomy is a standard procedure, the risk of bleeding remains high after resecting pedunculated polyps due to the presence of a large artery in the stalk. Several methods for minimizing the risk of bleeding, including epinephrine injection and use of the endoloop, have been proposed. The effectiveness of the prophylactic clip has not been confirmed. We designed a prospective, randomized study to compare the efficacy of applying the prophylactic clip and endoloop in the prevention of postpolypectomy bleeding in cases of large pedunculated polyps. Methods: A total of 195 patients who have pedunculated colorectal polyps with heads larger than 10 mm and stalks larger than 5 mm in diameter were included. In group A, hemoclips were applied to the base of the stalk, followed by conventional snare polypectomy. In group B, an endoloop was positioned at the base of the stalk before the conventional snare polypectomy. The immediate and delayed bleeding complications were assessed. Results: A total of 98 and 105 polyps were randomized to groups A and B, respectively. Clip application was possible in all the cases in group A. In 7 cases in group B, the placement of the endoloop failed (6.6%). There were 5 cases of bleeding in group A (5.1%) and 6 cases in group B (5.7%) (p=0.847). For the cases in which the endoloop placement was successful, 4 cases of bleeding (4.1%) were observed. One case of delayed bleeding was observed in both groups. The bleeding was successfully controlled with the placement of additional hemoclips or argon plasma coagulation, and no blood transfusions were required. A thick stalk (>10 mm) and failed preventive procedure were related to a greater risk of postpolypectomy bleeding (p=0.006 and p=0.048, respectively). Conclusions: The application of a prophylactic clip is as effective and safe as an endoloop in the prevention of postpolypectomy bleeding in cases of large pedunculated colonic polyps. Key Words: Colonic polyp, Bleeding, Clip P-72 In What Situation, Can We Perform Outpatient Based Endoscopic Mucosal Resection without Serious Concern? Hyung Hun Kim 1, Eun Joo Cho 2, Myung-Gyu Choi 1 1 Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, 2 Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea Background and Aim: In spite of no solid evidence, there seems to be a belief that it is safe to perform out-patient based endoscopic mucosal resection (EMR) for a polyp no more than 10 mm. In the present study, we aimed to calculate the actual possibility of delayed bleeding according to the specific conditnos of risk factors to understand in which condition we can perform out-patient based EMR without serious concern. Method: Between January 2004 and December 2010, 3015 cases of EMR were retrospectively investigated. The risk factors for delayed hemorrhage were analyzed in terms of the patients condition, characteristics of polyp, and procedure. We analyzed the possibility of delayed bleeding after classifying condition of the independent risk factors. Results: The mean (± SD) polyp size was 11.1 ± 6.8 mm and the most common location was sigmoid colon (25.9%). Size of the polyp (95% CI = , p<0.001) and patients with chronic renal failure (95% CI = , p=0.007) were the independent risk factors for delayed bleeding in multivariate analysis. 95% CI for percent of delayed bleeding according to polyp size are as follows: size 10 mm, %; 20 mm size > 10 mm, %; size > 20 mm, %. 95% CI for percent for the risk of immediate bleeding for a polyp 10 mm, was 0.01%-0.56%. 95% CI for percent of incomplete resection was 0.07%-0.49% in polyps 10 mm. Conclusion: As previous research claimed the size of the polyp was imperative risk factor for delayed bleeding. The frequency of delayed bleeding was quiet low in polyps 10 mm, and so did the immediate bleeding. We cautiously concluded that it might be safe to perform out-patient based EMR for polyps 10 mm. Key Words: Colon, Polyp, Endoscopic mucosal resection, Bleeding rd Congress of the Korean Society of Gastrointestinal Endoscopy November 23, 2013

37 P-73 Endoscopic Resection as the First-Line Treatment for Early Colorectal Cancer: Comparison with Surgery Jun Heo, Min Kyu Jung, Sung Kook Kim, Seong Woo Jeon Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea Background: Endoscopic resection has emerged as an alternative therapeutic option for selected cases of early colorectal cancer. However, even now, few data are available on the comparative effectiveness of endoscopic versus surgical resection of early colorectal cancer. The aim of our study was to compare the clinical outcomes in patients with early colorectal cancer who underwent endoscopic resection and those who underwent surgical resection. Methods: We analyzed the data on all patients who were treated with either endoscopic resection or colorectal surgery at single institute from January 2005 to December 2010 retrospectively. In total, 304 lesions in 297 patients with early colorectal cancer were enrolled. Results: After excluding 54 deep submucosal lesions (and/or tumor budding (Grade 2 or 3)), a total of 168 lesions with mucosal/superficial submucosal invasion were treated by endoscopic resection and 70 lesions with mucosal/superficial submucosal invasion were treated by colorectal surgery. In the endoscopic resection group, the en bloc resection rate and the complete resection rate were 91.1% and 91.1% respectively. In the colorectal surgery group, both the en bloc resection rate and the curative resection rate were 100%. However, using Log rank analysis, no significant difference in recurrence rate (including metachronous cancer) during the median follow up period of 26 months (range, 1-96 months) was observed between the two groups (p=0.930). In addition, a similar morbidity rate was observed for endoscopic resection compared with surgery (5.4% versus 5.7%, p=0.760). A significantly shorter hospital stay was observed in the endoscopic resection group than colorectal surgery group (median two days (range, 2-29) vs median 10 days (range, 7-37), p<0.001). Conclusion: We suggest that endoscopic resection, being equally effective but less invasive than surgery, can be the first-line treatment for well selected early colorectal cancer. Key Words: Early CRC, Endoscopic resection, Surgery P-74 Tubular Adenoma within Colonic Diverticulum Ki Seong Lee, Min Jae Yang, Seun Joo Ahn, Sung Jae Shin Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea Introduction: The occurrence of a neoplastic lesion within a colonic diverticulum is rare. Adenocarcinomas within colonic diverticula were reported in some cases. But benign adenomatous neoplasms were reported only three cases on the literature, and had a villous components on the histology. Herein We report a first case of tubular adenoma within colonic diverticulum. Case Report: A 60-year-old male visited in order to remove colonic LST discovered on the health screening. 1.5x1.0cm sized LST was seen within cecal diverticulum. EMR had failed because the tumor did not lift out from the diverticulum after submucosal injection. The patient underwent ileocecectomy. The final histologic diagnosis was tubular adenoma with low grade dysplasia. Fig. (A-C) Endoscopic findings on the adenoma within diverticulum (A) Distant view of the lesion (B) Closed view of the lesion (C) The tumor did not lift out the part of polyp buried inside the diverticulum. (D-E) Gross pathologic specimen (D) 1.5x1.0cm sized adenoma within diverticulum is noted on the cecum base. (E) Cross section of the lesion Conclusion: The diverticular disease and neoplastic lesions of the colon increase with age, their influence on each other. In addition, the entrapment of carcinogens such as inos and COX-2 within diverticula may promote inflammation. It lead to neoplastic change of the colonic mucosa. But reports of adenoma within diverticulm are rare. It is considered difficult to detect of tumor. Therefore, the chance of tumor to be malignant change is relatively high. So we reported the unique case of tubular adenoma with low malignant potential. Key Words: Adenoma, Colon, Diverticulum November 23, rd Congress of the Korean Society of Gastrointestinal Endoscopy 209

38 P-75 Proctitis, Perianal and Perirectal Abscess Caused by Klebsiella Pneumoniae Sung Youn Choi, Eun Haeng Jeong, Woo Shin Jeong, Ki Bae Bang, Seung Sik Park, Dae Sung Lee, Chong Il Sohn, Dong Il Park, Jung Ho Park, Chang Mo Moon, Yoon Suk Jung Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University College of Medicine, Seoul, Korea Introduction: Although Klebsiella pneumoniae is found in the normal flora of the gastrointestinal tract of humans, it can cause invasive infection, especially patients with diabetes mellitus and chronic alcoholics. Case: A 61 year old male with diabetes and a history of alcohol abuse presented with abdominal pain, anal pain, diarrhea and fever for two weeks. Physical examination revealed abdominal tenderness and perianal painful lesion. He underwent sigmoidoscopy and there were multiple ulceration with yellowish exudates at rectum and sigmoid colon (Fig.). The patient was treated with ciprofloxacin and metronidazole. After one week, follow up sigmoidoscopy was perforemd due to sustained fever. The lesions were aggravated and seem like web because of destructive rectal mucosa (Fig). Rectal MRI were performed and it showed perianal and perirectal abscess. He underwent laparoscopic sigmoid colostomy and perirectal abscess incision and drainage. ESBL (+) K. pneumoniae was proven in pus culture. Antibiotics switched to ertapenem. He has improved after surgery and discharged. Fig. Conclusion: K. pneumoniae can cause rapid invasive infection in patients with diabetes and chronic alcoholics. We report a rare case of proctitis and perirectal abscess caused by invasive klbesiella infection. Key Words: Klebsiella pneumoniae, Proctitis, Perirectal abscess P-76 The Analysis of Endoscopic Ultrasonographic (EUS) Finding for Esophageal Subepithelial Lesion (SEL) Chan Seo Park, Si Hyung Lee, Yeoun Su Jung, Jun Suk Park, Sung Bum Kim, Jung Woo Lee, Hyun Hee Chung, Myung Jin Oh, Kook Hyun Kim, Kyeong Ok Kim, Byung Ik Jang, Tae Nyeun Kim Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea Background: The number of endoscopic ultrasonography (EUS) for esophageal subepithelial lesion(sel) is on the increase recently. We reviewed EUS finding for esophageal SEL. Methods: We retrospectively investigated the 230 patients who underwent EUS for esophageal SEL from July 2010 to June We analysed EUS finding, such as size, location, wall layer of origin, echogenic feature and assumptive diagnosis. Results: Mean age was 56.7±11.3 years and male to female ratio was 139 : 91. Among 230 enrolled patients, subepithelial tumor (SET) was observed in 189 (82.2%) patients. Mean size of SET was 8.5±5.0 mm and mean distance from incisor tooth to lesion was 29.2±6.7 cm. The most common origin wall layer of the SET was muscularis mucosa (MM, 59.4%), followed by submucosa (SM, 15.8%) and muscularis propria (MP, 21.1%). 3.7% of SET was indetermined. In echogenicity, 93.7% of SET was hypoechoic and 72.6% of SET was homogeneous. In analysis of primary assumptive diagnosis, 70.5% was leiomyoma, 16.8% was granular cell tumor, 6.8% was gastrointestinal stromal tumor (GIST), 1.6% was cyst and 2.1% was vascular ectasia. The tissue sample by biopsy was checked in only 14.2% (27 cases) and the result was mostly (81.5%) non-specific inflammation. 21 cases (9.1%) of 230 patients revealed extrinsic compression, 61.9% was compressed by vessel or heart, 33.3% was due to spine and one case (4.8%) was bronchus. 20 patients (8.7%) was normal without SEL. 107 patients (46.5%) of enrolled 230 patients repeatedly underwent EUS at least twice but, 79.4% (85/107) of SET was no change in size or shape. Conclusion: In according to our result, esophageal SEL is mostly benign nature and misdiagnosed as extrinsic compression or normal variation easily. Thus, meticulous inspection is essential to distinguish SET and extrinsic compression. EUS is a good modality to examine esophageal SEL but, EUS is limited to accurate diagnosis of SET. The tissue acquisition for accurate diagnosis of SET is important issue. Key Words: Esophagus, EUS, SEL rd Congress of the Korean Society of Gastrointestinal Endoscopy November 23, 2013

39 P-77 EUS Findings and Clinical Features of Esophageal Tuberculosis Presenting as a Subepithelial Lesion: A Report of 4 Cases Joon Hyung Jhi, Gwang Ha Kim, Dong Hoon Baek, Geun Am Song Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea Introduction: When esophageal tuberculosis presents as a subepithelial lesion, conventional endoscopy and computed tomography (CT) are often insufficient to distinguish it from other diseases. We report a case series of four patients with esophageal tuberculosis mimicking a subepithelial lesion, and describe characteristic endoscopic ultrasonography (EUS) findings and clinical features. Case Report: From 2005 to 2012, a total of 1,315 patients underwent EUS for esophageal subepithelial lesions, and of them, 4 were diagnosed as tuberculosis. Histopathological examination on the 4 patients showed caseous necrosis in 2, positive tuberculosis-polymerase chain reaction in 2, and no positive acid fast bacilli stain in any patient. EUS showed heterogenous hypoechoic masses in the esophageal wall in all 4 patients, and all the masses had hyperechoic spots inside. Two patients had intact local wall layers, and the other two patients had interrupted esophageal adventitia, and enlarged mediastinal lymph nodes that was connected with esophageal wall thickening. Three patients had good responses to the anti-tuberculous therapy, and one patient had improved without treatment. The surveillance endoscopy showed a diverticulum in 3, and a superficial depression in 1 on the previous lesion sites. Conclusion: Esophageal tuberculosis should be considered in the differential diagnosis of cases with esophageal subepithelial lesion. In this report, the chief EUS findings include heterogenous hypoechoic masses in the esophageal wall with hyperechoic spots inside, interruption of the esophageal adventitia, and mediastinal lymphadenopathy. EUS evaluation may be helpful to make a correct diagnosis. Key Words: Esophageal tuberculosis, Subepithelial lesion, Endoscopic ultrasonography P-78 Survival Prediction by Area on Endosonography after Definitive Chemoradiotherapy for Locally Advanced Esophageal Cancer Choong Nam Shim 1, Mi Kyung Song 2, Hye Sun Lee 2, Eun Hye Kim 1, Chan Hyuk Park 1, Hyun Jik Lee 1, Hyun Soo Chung 1, Hyuk Lee 1, Sung Kwan Shin 1, Sang Kil Lee 1, Yong Chan Lee 1, Jun Chul Park 1 1 Department of Internal Medicine, Institute of Gastroenterology, 2 Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea Background: Definitive chemoradiotherapy (dcrt) is a reasonable approach for patients with locally advanced esophageal cancer who are not surgical candidates. However, only a few studies showed the prognostic significance of EUS in esophageal cancer patients treated with dcrt. This study was performed to investigate whether EUS assessment of response, particularly tumor area, can be used as a prognostic marker in patients with squamous cell carcinoma (SCC) of the esophagus who received dcrt. Methods: A total of 33 patients received dcrt for locally advanced esophageal cancer with histological confirmation as squamous cell carcinoma. The maximal transverse cross-sectional area of the tumor was measured before and after definitive therapy. The EUS response was defined as a 50% reduction of tumor area after dcrt. Results: EUS assessed non-response in 20 patients (60.6%) and response in 13 patients (39.4%), respectively. EUS responders showed a significant longer median progression-free survival (PFS) than those in the EUS nonresponders (not reached vs months, p=0.005). EUS responders revealed a tendency of longer median overall survival (OS) compared with EUS nonresponders (not reached vs months, p=0.120). In multivariate analysis, EUS response to definitive therapy was the only significant factor associated with PFS (p=0.045), while both EUS response to definitive therapy (p=0.221) and histology of tumor (p=0.196) were tended to significantly related to OS. Conclusions: Reduction of maximal cross-sectional tumor area by EUS correlates with the better prognosis of patients with locally advanced squamous cell carcinoma of the esophagus after dcrt. Key Words: Esophageal cancer, Endosonography, Area, Definitive chemoradiotherapy, Progression-Free survival November 23, rd Congress of the Korean Society of Gastrointestinal Endoscopy 211

40 P-79 Comparison of 22-Gauge Aspiration and 22-Gauge Biopsy Needles in EUS- Guided Subepithelial Tumor Sampling Gwang Ha Kim 1, Yu Kyung Cho 2, Eun Young Kim 3, Hyung Kil Kim 4, Jin Woong Cho 5, Tae Hee Lee 6, Jeong Seop Moon 7, Korean EUS Study Group 1 Department of Internal Medicine, Pusan National University School of Medicine, Busan, 2 Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, 3 Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, 4 Department of Internal Medicine, Inha University School of Medicine, Incheon, 5 Department of Internal Medicine, Presbyterian Medical Center, Jeonju, 6 Institute for Digestive Research, Digestive Disease Center, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, Seoul, 7 Department of Internal Medicine, Inje University College of Medicine, Seoul, Korea Background and Aim: Endoscopic ultrasonography (EUS)- guided fine-needle aspiration (EUS-FNA) may facilitate tissue sampling for the pathological diagnosis of subepithelial tumors (SETs) in the gastrointestinal (GI) tract. However, immunohistochemical analysis is not always feasible with EUS- FNA samples due to the low quality of the aspirated specimen. This study aimed at comparing the 22-gauge (G) EUS-guided fine-needle biopsy (EUS-FNB) and 22G EUS-FNA in the histologic core sampling for the pathologic diagnosis, including immunohistochemical evaluation, in patients with GI SETs. Methods: Twenty-eight patients with GI SETs 2 cm in size were prospectively enrolled at 5 university hospitals in Korea between January and June They were randomized to undergo either EUS-FNB or EUS-FNA. Results: A total of 22 patients were finally analyzed in this study: 10 and 12 patients underwent EUS-FNA and EUS-FNB, respectively. Compared to the EUS-FNA group, the EUS-FNB group had a significantly lower median number of needle passes for obtaining macroscopically optimal core sample (4 vs. 2, p=0.014), higher yield rate of macroscopically and histologically optimal core sample with 3 needle passes (30% vs. 92%, p=0.006; 20% vs. 75%, p=0.010, respectively), and higher diagnostic sufficiency rate (20% vs. 75%, p=0.010). No technical difficulties were encountered in both groups. Conclusion: This study shows that EUS-FNB has a better ability to obtain histological core samples and higher diagnostic sufficiency rate than EUS-FNA and that EUS-FNB is a feasible, safe, and preferable option for obtaining adequate core samples for the histologic diagnosis of GI SETs. Key Words: Subepithelial tumor, Endoscopic ultrasonography, Biopsy P-80 Endoscopic Characteristics of Gastric Schwannoma Distinguished from GIST Hyung Chul Park, Dae Seong Myung, Jong Sun Kim, Seon Young Park, Sung Bum Cho, Wan Sik Lee, Chang Hwan Park, Young Eun Joo, Hyun Soo Kim, Sung Kyu Choi, Jong Sun Rew Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea Background and Aims: Gastric schwannoma is a rare gastrointestinal mesenchymal tumor, which are usually benign. The preoperative diagnosis via endoscopy is a challenging issue due to the difficulty of differentiation from other submucosal tumors. The purpose of this study is to evaluate endoscopic characteristics of gastric schwannoma distinguished from GIST. Patients and Methods: A total of 21 tumors were histologically identified as gastric schwannomas among the patients who underwent surgery with GIST on preoperative examination between January 2005 to june 2013 at our institutions. Additionally, we selected randomly 88 patients who were histologically identified with GIST. Data on endoscopic examinations were collected and analyzed by retrospectively reviewing the medical records. Results: Gastric schwannomas predominantly occurred in older adults with a female predominance (14 women and 7 men; mean ages, 55 years). On endoscopic findings, the most were round shape (85%), covered with normal mucosa (85%) and located on body, GC side (95%) of the stomach. The morphology classified according to the Yamada s classification was common to type I and type II (61% and 33%, respectively). On endoscopic ultrasonographic findings, the most were arising from 4th layer and hypoechogenicity without internal echoic lesion (95%). Compared with GIST, there was significant difference to morphology (p=0.002), tumor location (p=0.000) and internal echogenicity (p=0.004). On endoscopic findings, GISTs showed predominant morphological features of Yamada type II, III and mainly located on cardia/fundus (43.2%) and body, LC side (30.7%). On endoscopic ultrasonographic findings, there were no significant difference between echogenicity, but a presence of internal echoic lesion was predominant in GISTs. Conclusions: Tumor location, morphologic features, presence of internal echoic lesion on endoscopic examinations is useful to distinguish between gastric schwannoma and GIST. Key Words: Schwannoma, GIST, SMT, EUS, Endoscopy rd Congress of the Korean Society of Gastrointestinal Endoscopy November 23, 2013

41 P-81 Role of Endoscopic Ultrasound in Patients with Large Gastric Folds: Predictive Features for Malignancy Hyun Lim, Gin Hyug Lee, Ji Yong Ahn, Jeong Hoon Lee, Kwi-Sook Choi, Do Hoon Kim, Kee Don Choi, Ho June Song, Hwoon-Yong Jung, Jin-Ho Kim Departments of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Asan Digestive Disease Research Institute, Seoul, Korea Background/Aims: Making a differential diagnosis of large gastric folds is a clinical challenge because the etiology is extremely varied, and standard biopsies are often inconclusive. Endoscopic ultrasound (EUS) can help distinguish between malignant and benign causes of large gastric folds because of its ability to visualize the architecture of gastric wall layer. Our study aimed to investigate the EUS features that can predict malignant disease in patients with large gastric folds. Methods: We retrospectively reviewed the EUS features (gastric wall thickness, preservation of five-layered structure, thickened layer, presence of ascites, and presence of lymph nodes enlargement) in patients with large gastric folds. Results: Sixty-five patients (26 benign diseases and 39 malignant diseases) were included. Thicker gastric wall, thickened deep layer, thickened muscularis propria, non-preserved wall layer structure, and lymph node enlargement were significantly more prevalent in patients with malignant disease. In contrast, thickened superficial layer was more common in benign diseases. In analysis of EUS predictive features for malignancy, thickened muscularis propria (OR: 65.81, 95% C.I: , p<0.001) and non-preserved wall layer structure (OR: 28.29, 95% C.I: , p=0.012) were significant EUS features. Conclusions: EUS is a useful tool in assessing patients with large gastric folds. Thickened muscularis propria and non-preserved wall layer structure were significant predictive EUS features for malignant disease. Key Words: Large gastric folds, Endoscopic ultrasound, Malignancy P-82 A Case: NK/T Cell Lymphoma Diagnosed by EUS-FNA So-Yun Nah, Eun-Sun Jung, Byung-Wook Bang, Gye-Sook Kwon, Yong-Woon Shin, Hyung-Kil Kim Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea Introduction: Extranodal natural killer (NK)/T-cell lymphoma of nasal type is a rare disease presenting aggressive clinical course. The primary site of involvement is the nasal cavity and the upper aerodigestive tract, comprising >80% of cases. Less often extranasal areas such as the skin, intestinal tract, and various other organs are also involved. We describe a case of pancreatic NK/T-cell lymphoma diagnosed by endoscopic ultrasound-guided fine needle aspiration biopsy (EUS-FNAB). Case Report: A 22-year-old man presented with a one month history of epigastric discomfort and jaundice. He was diagnosed recurrent pancreatitis at community hospital. Laboratory results showed bicytopenia, cholestatic pattern of abnormal liver function test, and elevated level of amylase and lipase. Abdomen and pelvic computed tomography revealed enlargement and swelling of pancreas (Fig.). Stricture of distal common bile duct accompanying proximal ductal dilatation was noted on endoscopic retrograde cholangiopancreatography (Fig.). Patient underwent EUS-FNAB, and the pathologic examination determined extranodal natural killer (NK)/T-cell lymphoma of nasal type. Fig. Conclusion: This is the first case of intraabdominal extranodal NK/T cell lymphoma diagnosed by EUS guided fine needle aspiration. Key Words: EUS, Pancreas, Lymphoma, Endoscopic ultrasound-guided fine needle aspiration biopsy November 23, rd Congress of the Korean Society of Gastrointestinal Endoscopy 213