Prognostic impact of hepatitis B or C on intrahepatic cholangiocarcinoma

BACKGROUND/AIMS

Intrahepatic cholangiocarcinoma (ICC) is the second-most common primary liver malignancy, arising from the peripheral intrahepatic bile duct epithelium. Hepatitis B virus (HBV) or hepatitis C virus (HCV) may be involved in the development of ICC. We explored the prognostic value of hepatitis virus infection, as well as other prognostic factors affecting survival in patients with ICC.

METHODS

A retrospective chart review was performed for patients diagnosed with ICC between August 2005 and December 2018 at Konkuk University Medical Center. We identified a total of 131 patients with ICC. Overall survival rates of patients with and without hepatitis were determined. Univariate and multivariate analyses were used to estimate factors influencing survival outcomes.

RESULTS

A total of 17.6% (23/131) of patients were positive for HBV or HCV. Hepatitis B positive ICC patients were significantly younger with higher albumin and higher α-fetoprotein than those without hepatitis viral infections. The median survival of hepatitis-positive and hepatitis-negative groups was 280 and 213 days, respectively. Survival rates were not significantly different between the two groups (p = 0.279). Multivariate analyses indicated that lower serum carbohydrate antigen 19-9 (CA 19-9) (p < 0.001), lower T stage (p = 0.042), the absence of lymph-node metastasis (p = 0.043), and receiving curative surgery (p = 0.033) were independent predictors of better outcomes.

CONCLUSION

While hepatitis influenced a number of clinical features in ICC patients, it did not affect survival rate. Prognostic factors influencing survival outcomes with ICC were CA 19-9 level, T stage, the presence of lymph node metastasis, and curative surgery.

ABC Classification Is Less Useful for Older Koreans Born before 1960

Background/Aims

In the ABC classification system, group A consists of seronegative subjects without gastric corpus atrophy. This study aimed to determine the prevalence and characteristics of pseudo group A subjects.

Methods

Group A subjects were identified among consecutive Korean adults who underwent a serum anti-Helicobacter pylori immunoglobulin G (IgG) test and pepsinogen (PG) assay on the day of endoscopy. Past infection was defined as the presence of either eradication history or endoscopic findings suggesting past infection (i.e., gastric xanthoma, metaplastic gastritis, or advanced atrophy >closed-type 1).

Results

Among 2,620 group A subjects, 448 (17.1%) had eradication history, and 133 (5.1%) showed endoscopic findings suggesting past infection. Older age (odds ratio [OR], 1.148; 95% confidence interval [CI], 1.067 to 1.236) and earlier year of birth (OR, 1.086; 95% CI, 1.009 to 1.168) were independent risk factors for classification into pseudo group A, with cutoff points at 50.5 years and birth year of 1959.5, respectively. Positive H. pylori test findings were found in 22 subjects (3.1%) among the 715 subjects who underwent the urea breath test or Giemsa staining on the same day. Current infection was positively correlated with PG I and PG II levels (p<0.001) but not with age, anti-H. pylori IgG titer, or classification into pseudo group A.

Conclusions

Among the group A subjects, 22.2% had past infection. The risk was higher in subjects older than 50 years, especially those born before 1960. Furthermore, current infection was found in 3.1% of the subjects and was correlated with increased gastric secretory ability.

Effect of Preceding Biopsy on the Results of Endoscopic Submucosal Dissection for Colorectal Laterally Spreading Tumor

BACKGROUND

Forceps biopsies are usually performed before endoscopic submucosal dissection (ESD) for colonic laterally spreading tumors (LSTs). However, preceding biopsy is commonly believed to possibly inhibit complete tumor resection by causing blurring of tumor borders and tissue fibrosis.

AIMS

The aims were to investigate whether the preceding biopsy of colorectal LST affects the complete endoscopic tumor resection and increases the risk of complications.

METHODS

We retrospectively reviewed the medical records of patients with colorectal LSTs who underwent ESD at our center during an 8-year period. Patients were divided into two groups according to whether they underwent biopsy of the tumor before ESD. In addition, the characteristics of patients and tumors, including the completeness of tumor resection, were investigated.

RESULTS

Of 288 patients (174 men) enrolled in this study, 194 (67.4%, preceding biopsy group) underwent biopsies before ESD, whereas 94 (32.6%, no biopsy group) did not. There were no significant differences in age, sex, comorbidity, medication history, tumor location, and final pathologic result between both groups. Tumor size was larger (p = 0.002) and LST-G tumor was more common (p = 0.003) in the preceding biopsy group than in the no biopsy group. No significant difference was seen in ESD outcomes, including procedure time, hospitalization period, incidence of complications, en bloc resection rate, resection margin status, and incidence of surgical operation, between both groups.

CONCLUSIONS

Biopsy of LST is commonly performed before endoscopic resection. Contrary to popular belief, it does not increase the incomplete tumor resection rate and incidence of complications.

TRIAL REGISTRATION

KCT0002321.

Usefulness of Carbohydrate Antigen 19-9 Test in Healthy People and Necessity of Medical Follow-up in Individuals with Elevated Carbohydrate Antigen 19-9 Level

Background

Carbohydrate antigen 19-9 (CA 19-9) is a tumor marker whose level is elevated in many types of cancers and other benign conditions. CA 19-9 levels are frequently found to be elevated in individuals during general health examinations. This study aimed to investigate the clinical characteristics of such individuals and to determine the need for medical follow-up.

Methods

We investigated individuals who underwent a health inspection, including a serum CA 19-9 test, at our center. Their CA 19-9 levels, age, sex, body mass index (BMI), and personal and past histories were investigated. Additionally, subgroup analyses were performed for those who underwent follow-up study for the elevated CA 19-9 levels.

Results

Of 58,498 subjects, 581 (1.0%) had elevated CA 19-9 levels. Multivariate analyses revealed that older age, female sex, lower BMI, and diabetes were independent predisposing factors for elevated CA 19-9 level. A subgroup analysis revealed that the causative conditions were identified in 129 of 351 subjects (36.8%). Among them, the causative conditions in 31 subjects (8.8%, including four cases of cancer and 15 of benign tumors) were not detected at the initial check-up and were found during the follow-up period.

Conclusion

The use of CA 19-9 as a marker for cancer in healthy individuals is inappropriate. However, medical follow-up in individuals with elevated CA 19-9 levels may be useful because some causative diseases may be detected during follow-up.

[Identification of Nodular Gastritis among Patients Diagnosed with Lymphofollicular Gastritis on a Gastric Biopsied Specimen]

Background/Aims

Nodular gastritis (NG) is a well-known endoscopic finding observed in patients with a Helicobacter pylori infection, which may lead to invasive gastric cancer. Lymphofollicular gastritis consists of lymphoid follicles or lymphoid cell aggregates, and is common in children. The aim of this study was to identify patients with NG from those in whom gastric biopsied specimens showed lymphoid follicles and lymphoid cell aggregates.

Methods

Subjects, whose gastric biopsy specimens showed lymphoid follicles or lymphoid cell aggregates, were included in this study. The inclusion criterion was that they underwent a serum pepsinogen assay on the day of upper gastrointestinal endoscopy. NG was diagnosed if the endoscopy findings revealed regular-sized, multiple, colorless subepithelial nodules.

Results

Among 108 subjects who showed lymphoid follicles or lymphoid cell aggregates, 13 (12.0%) revealed NG on endoscopy, and all these subjects showed positive Giemsa staining. Patients diagnosed with NG were younger (p=0.012) and showed a female predominance (p=0.001) compared to those without NG. The mean serum pepsinogen levels were higher (p=0.001) and lymphoid follicle-dominant subjects were more common (p<0.001) in the NG subjects than in those without NG. Logistic regression analysis revealed a younger age (p=0.041) and female gender (p=0.002) to be significant independent risk factors for NG.

Conclusions

NG should be distinguished from lymphofollicular gastritis because only 12% of patients showing gastric biopsy findings of lymphoid follicles and lymphoid cell aggregates demonstrated NG on endoscopy. NG is an endoscopic finding that is more common in women and in the younger population, irrespective of the biopsy findings and gastric secretory ability.

The histologic detection of Helicobacter pylori in seropositive subjects is affected by pathology and secretory ability of the stomach

BACKGROUND

Helicobacter pylori is unevenly distributed in hypochlorhydric environments. The study aim was to elucidate the risk factors for a negative Giemsa staining finding in seropositive subjects by measuring the secretory ability of the stomach.

METHODS

Subjects aged over 18 years were included consecutively after endoscopic biopsy at gastric lesions with color or structural changes. Blood was sampled for the serum pepsinogen (PG) assay and H. pylori serology test. After excluding the subjects with past H. pylori eradication, the risk factors for a negative Giemsa staining finding in seropositive subjects were analyzed.

RESULTS

Among 872 included subjects, a discrepancy between the serum anti-H. pylori IgG and Giemsa staining findings was found in 158 (18.1%) subjects, including 145 Giemsa-negative, seropositive subjects. Gastric adenocarcinoma/adenoma (OR = 11.090, 95% CI = 3.490-35.236) and low serum PG II level (OR = 0.931, 95% CI = 0.899-0.963) were the independent risk factors for a negative Giemsa staining finding in seropositive subjects. The cutoff value of serum PG II level was 7.45 ng/mL (area under curve [AUC] = 0.904, 95% CI = 0.881-0.927). Follow-up studies of Giemsa staining at different sites of the stomach revealed that 75% of the Giemsa-negative seropositive subjects with adenocarcinoma are positive, whereas none of those with low serum PG II level of <7.45 ng/mL revealed positive findings.

CONCLUSIONS

The risk of a negative Giemsa staining finding in seropositive subjects is increased in gastric adenocarcinoma/adenoma specimens and in subjects with a diminished gastric secretory ability with low serum PG II level of <7.45 ng/mL. A false-negative Giemsa staining finding is common in subjects with adenocarcinoma, and therefore, additional biopsies at different sites should be performed in these subjects.

Aggressive intravenous hydration with lactated Ringer's solution for prevention of post-ERCP pancreatitis: a prospective randomized multicenter clinical trial

BACKGROUND AND STUDY AIMS : The present study aimed to determine the type of intravenous hydration that is best suited to reducing the incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis.

PATIENTS AND METHODS

In a prospective randomized multicenter trial, average-to-high risk patients who underwent first-time ERCP were randomly assigned to three groups (1:1:1) who received: aggressive intravenous hydration (3 mL/kg/h during ERCP, a 20-mL/kg bolus and 3 mL/kg/h for 8 hours after ERCP) with either lactated Ringer's solution (LRS) or normal saline solution (NSS), or standard intravenous hydration with LRS (1.5 mL/kg/h during and for 8 hours after ERCP). The primary end point was post-ERCP pancreatitis (PEP).

RESULTS

395 patients were enrolled, and 385 completed the protocols. The three groups showed no significant differences in demographic characteristics. There was a significant difference in the intention-to-treat (ITT) PEP rate between the aggressive LRS group (3.0 %, 95 % confidence interval [CI] 0.1 % - 5.9 %; 4 /132), the aggressive NSS group (6.7 %, 95 %CI 2.5 % - 10.9 %; 9 /134) and the standard LRS group (11.6 %, 95 %CI 6.1 % - 17.2 %; 15 /129; P = 0.03). In the two-group comparisons, the ITT PEP rate was significantly lower for the aggressive LRS group than for the standard LRS group (relative risk [RR] 0.26, 95 %CI 0.08 - 0.76; P = 0.008). There was no significant difference in the ITT PEP rate between the aggressive NSS group and the standard LRS group (RR 0.57, 95 %CI 0.26 - 1.27; P = 0.17).

CONCLUSION

Aggressive hydration with LRS is the best approach to intravenous hydration for the prevention of PEP in average-to-high risk patients.

Efficacy and safety of flumazenil injection for the reversal of midazolam sedation after elective outpatient endoscopy

OBJECTIVE

Midazolam sedation during elective endoscopy is widely performed and flumazenil is frequently administered after endoscopy to reverse sedation in clinical practice. This study aimed to investigate the safety and efficacy of flumazenil injections after elective endoscopy under midazolam sedation.

METHODS

Participants who underwent an upper endoscopy under midazolam sedation were randomly divided into two groups. In group I, flumazenil was administered i.v. 10 min after the patient's transfer to the recovery room, and no antidote was injected in group II. The time of stay in the recovery room and adverse events were reviewed through the nursing records. We asked the patients about their pain and degree of satisfaction according to a visual analogue scale (VAS), their memory of the procedure, mental status and the presence of uncomfortable symptoms on the day of the procedure and the day afterwards.

RESULTS

The length of stay in recovery was significantly shorter in group I than in group II. No significant differences were found in the number of patients with pain (VAS ≥1), adverse events and discomfort between the two groups. Additionally, there were no differences in the patients' memory of the procedure, satisfaction with sedation, willingness to repeat the endoscopy and mental status.

CONCLUSIONS

The time in the recovery room after flumazenil administration was significantly shortened, and the use of the drug did not increase the risk of adverse events or discomfort. The use of flumazenil for reversing midazolam sedation seems to be safe and effective.

Endoscopic Submucosal Dissection of Early Gastric Cancer in Patients with Liver Cirrhosis

BACKGROUND AND OBJECTIVES

Endoscopic submucosal dissection (ESD) has become widely accepted method for treating early gastric cancer (EGC), but little is known about its role in patients with liver cirrhosis (LC). The aims of this study were to evaluate the outcomes of ESD in treating EGC in patients with LC.

METHODS

The multicenter retrospective study identified 43 patients with chronic hepatitis B (CHB)-related cirrhosis undergoing ESD for treating EGC. The patients (LC group) were subdivided into two groups based on their Child-Pugh classification (CP-class): 32 with CP-class A (LC-A) and 11 with CP-class B (LC-B). The patients were compared to 47 non-cirrhotic CHB patients who underwent ESD (CHB group). Eight patients had a past history of hepatocellular carcinoma (HCC) prior to ESD, but no patients had viable HCC when ESD was performed.

RESULTS

Procedural outcomes (en bloc, lateral/basal margins resection) and post-procedural complications (bleeding or perforation) did not differ significantly between the LC and CHB groups or between the LC-A and LC-B groups. No patients experienced worsening of the Child-Pugh score 1 month after ESD compared with the baseline score. During a median observation period of 66 months, the recurrence rates of gastric cancers were similar between the LC and CHB groups (5-year recurrence rates: 2.4 vs. 2.3%, p = 0.925), and all recurrent gastric cancers were completely resected by additional ESD. The overall mortality rate was increased in the LC group (5-year mortality rates: 17.9 vs. 5.7%, p = 0.034), and 8 of 10 deaths were attributed to liver-related diseases (such as HCC, complications of portal hypertension, hepatic failure).

CONCLUSIONS

ESD is feasible in patients with EGC and comorbid LC, even those with CP-class B cirrhosis. Their prognosis depends on LC-related diseases and not recurrent EGC.

Factors impacting patient cooperation during elective gastroscopy

BACKGROUND/AIMS

Some people have difficulty tolerating upper endoscopy. The cause of and risk factors for this are not well known. The aim of this study was to investigate the factors involved in poor cooperation during screening upper endoscopy.

METHODS

A total of 4,422 subjects who underwent a health inspection with upper endoscopy carried out by a single experienced endoscopist were included. We retrospectively investigated subjects' self-reporting questionnaires and medical records, including endoscopic and histologic findings. The examinees' cooperation and the completeness of endoscopic examination were evaluated based on the operator's subjective judgment.

RESULTS

Examinee cooperation during the endoscopic procedure was poor in 358 out of 4,422 subjects (8.1%). Of the subjects with poor cooperation, the endoscopic examination was incomplete in 36 subjects (10.1%). Multivariate analysis revealed that young age (< 40 years), female sex, high body mass index (≥ 25), hiatal hernia, and procedural sedation using midazolam were independent risk factors for poor cooperation.

CONCLUSIONS

Cooperation during screening upper endoscopy was poor in a considerable number of examinees. Endoscopists must keep in mind that examinee cooperation is more likely to be poor in the young, obese people, women, patients with hiatal hernias, and those who receive procedural sedation.

A randomized controlled trial of prophylactic antibiotics in the prevention of electrocoagulation syndrome after colorectal endoscopic submucosal dissection

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is currently commonly performed, but colorectal ESD has a substantial risk of adverse events, including post-ESD electrocoagulation syndrome (PEECS). We investigated whether the use of prophylactic antibiotics can reduce the occurrence of PEECS.

METHODS

Patients who underwent colorectal ESD were randomly assigned to 1 of 2 treatment regimens. Ampicillin and/or sulbactam mixed with normal saline solution was administered 1 hour before ESD in group 1 then additionally injected every 8 hours twice more. In group 2, normal saline solution without antibiotics was administered following the same schedule. We investigated the characteristics of the patients and tumors, the incidence of PEECS, laboratory findings, and the visual analog scale (VAS) score for abdominal pain measured on the morning after ESD.

RESULTS

A total of 100 cases (50 per group) were finally analyzed, and 97 tumors were successfully resected en bloc. The number of patients having C-reactive protein (CRP) levels ≥1 mg/dL and the number of patients having VAS scores for abdominal pain ≥1 were greater in group 2 than in group 1 (P = .008 and .023, respectively). The incidence of PEECS in group 2 also was higher than that in group 1 (1 and 8 in groups 1 and 2, respectively; P = .031).

CONCLUSIONS

The prophylactic use of ampicillin and/or sulbactam in colorectal ESD is associated with reduced risk of PEECS, decreased CRP levels, and decreased abdominal pain. The use of prophylactic antibiotics in colorectal ESD may be an effective tool for reducing the risk of PEECS. (Clinical trial registration number: KCT0001102.).

Factors Related to Upper Gastrointestinal Symptom Generation in 2275 Helicobacter pylori Seroprevalent Adults

BACKGROUND AND AIM

Upper gastrointestinal (UGI) symptoms are common; however, the role of Helicobacter pylori and gastric corpus atrophy in the generation of these symptoms is controversial. The aim of this study was to determine the risk factors for UGI symptoms in adults in an endemic area of H. pylori infection.

METHODS

Korean adults who completed questionnaires on the day of serum anti-H. pylori IgG and pepsinogen (PG) assays before UGI endoscopy were included. Gastric corpus atrophy was based on the criteria of a serum PG I/II ratio <3.0 and a PG I <70 ng/ml.

RESULTS

Of the 2275 included subjects, 723 (31.8%) had at least one UGI symptom. A total of 374 (16.4%) subjects had multiple symptoms without significant correlations between the symptoms (λ < 0.2). The H. pylori serology assay was positive in 1382 (60.7%) subjects, and gastric corpus atrophy was present in 291 (12.8%). Neither H. pylori seropositivity (p = 0.077) nor gastric corpus atrophy (p = 0.138) was related to the presence of UGI symptoms. Female gender and smoking were independent risk factors for heartburn and upper abdominal pain (all p < 0.001). Furthermore, female gender was the only independent risk factor for multiple UGI symptoms (p < 0.001), globus sensation (p < 0.001), early satiety (p < 0.001), epigastric soreness (p = 0.001), and chest discomfort (p = 0.003).

CONCLUSIONS

In an H. pylori seroprevalent population, female gender is the most common risk factor followed by smoking for UGI symptom generation. Neither H. pylori seropositivity nor gastric corpus atrophy is an independent risk factor for UGI symptom generation.

Differences in Prevalence of Lymphovascular Invasion among Early Gastric Cancers between Korea and Japan

BACKGROUND/AIMS

The presence of invasion is a diagnostic criterion of early gastric cancer (EGC) in Korea, whereas diagnosis in Japan is based on enlarged nuclei and prominent nucleoli. Moreover, the depth of invasion is the location of cancer cell infiltration in Korea, whereas it is the location of lymphovascular invasion (LVI) or cancer cell infiltration in Japan. We evaluated the characteristics of EGC with LVI to uncover the effects of different diagnostic criteria.

METHODS

Consecutive T1-stage EGC patients who underwent complete resection were included after endoscopic or surgical resection. The presence of LVI was evaluated.

RESULTS

LVI was present in 112 of 1,089 T1-stage EGC patients. LVI was associated with depth of invasion (p<0.001) and age (p=0.017). The prevalence of LVI in mucosal cancer was significantly higher in Korea (p<0.001), whereas that of submucosal cancer was higher in Japan (p=0.024). For mucosal EGC types, LVI was positively correlated with diagnostic criteria applied in Korea (p=0.017). For submucosal EGC types, LVI was positively correlated with Japanese criteria (p=0.001) and old age (p=0.045).

CONCLUSIONS

The higher prevalence of LVI for mucosal EGC in Korea and for submucosal EGC in Japan indicates that different diagnostic criteria should be considered when reading publications from other countries.

Link between Serum Pepsinogen Concentrations and Upper Gastrointestinal Endoscopic Findings

The serum pepsinogen (PG) assay findings are correlated with the status of Helicobacter pylori infection, but there are controversies on the link with upper gastrointestinal (UGI) endoscopic findings. The aim of this study was to determine the significance of a serum PG assay for correlating with endoscopic findings in H. pylori-seroprevalent adult population. Korean adults who visited for a health check-up were included consecutively. Subjects after gastrectomy or H. pylori eradication were excluded. After completing the serum PG assay and anti-H. pylori immunoglobulin G (IgG) titer on the same day of UGI endoscopy, subjects with equivocal serology test finding or gastric neoplasm were excluded. Of the 4,830 included subjects, 3,116 (64.5%) were seropositive for H. pylori. Seropositive finding was related to high serum PG I (P < 0.001) and PG II (P < 0.001) concentrations, low PG I/II ratio (P < 0.001), old age (P < 0.001), and male gender (P = 0.006). After adjusting age and gender, the serum PG I and II concentrations were positively correlated with the presence of nodular gastritis (NG) (all P = 0.003). The serum PG I was positively correlated with gastric ulcer (P = 0.003), and it was correlated with duodenal ulcer in seropositive subjects (P = 0.008). The PG I/II ratio was positively correlated with erosive esophagitis, while it was inversely related to chronic atrophic gastritis and metaplastic gastritis (all P < 0.001). Our findings suggest that the serum PG assay finding correlates well with the UGI endoscopic finding. A higher serum PG concentration in subjects with NG and peptic ulcer disease suggests that endoscopic findings reflect gastric secreting ability.

The outcome of endoscopic management of bile leakage after hepatobiliary surgery

BACKGROUND/AIMS

Despite improvements in surgical techniques and postoperative patient care, bile leakage can occur after hepatobiliary surgery and may lead to serious complications. The aim of this retrospective study was to evaluate the efficacy of endoscopic treatment of bile leakage after hepatobiliary surgery.

METHODS

The medical records of 20 patients who underwent endoscopic retrograde cholangiopancreatography because of bile leakage after hepatobiliary surgery from August 2009 to September 2014 were reviewed retrospectively. Endoscopic treatment included insertion of an endoscopic retrograde biliary drainage stent after endoscopic sphincterotomy.

RESULTS

Most cases of bile leakage presented as percutaneous bile drainage through a Jackson-Pratt bag (75%), followed by abdominal pain (20%). The sites of bile leaks were the cystic duct stump in 10 patients, intrahepatic ducts in five, liver beds in three, common hepatic duct in one, and common bile duct in one. Of the three cases of bile leakage combined with bile duct stricture, one patient had severe bile duct obstruction, and the others had mild strictures. Five cases of bile leakage also exhibited common bile duct stones. Concerning endoscopic modalities, endoscopic therapy for bile leakage was successful in 19 patients (95%). One patient experienced endoscopic failure because of an operation-induced bile duct deformity. One patient developed guidewire-induced microperforation during cannulation, which recovered with conservative treatment. One patient developed recurrent bile leakage, which required additional biliary stenting with sphincterotomy.

CONCLUSIONS

The endoscopic approach should be considered a first-line modality for the diagnosis and treatment of bile leakage after hepatobiliary surgery.

Risk Factors for the Presence of Symptoms in Peptic Ulcer Disease

BACKGROUND/AIMS

Peptic ulcer disease (PUD) is a common condition, but is difficult to detect in asymptomatic individuals. We aimed to investigate the prevalence of symptomatic and asymptomatic PUD during screening endoscopy and to identify risk factors for the presence of symptoms in patients with PUD.

METHODS

We investigated subjects who underwent a health inspection, including endoscopy of the upper gastrointestinal (GI) tract and a serum anti-Helicobacter pylori IgG assay, and who completed a self-report questionnaire about their symptoms.

RESULTS

Of the 12,852 subjects included in the study, 124 (1.0%) had symptomatic PUD and 309 (2.4%) had asymptomatic PUD. Old age, current smoking, and H. pylori infection were independent risk factors for symptomatic and asymptomatic PUD. Use of non-steroidal anti-inflammatory drugs (NSAIDs) was an independent risk factor only for symptomatic PUD (p=0.040). Compared to subjects with asymptomatic PUD, subjects with symptomatic PUD were more likely to have active-stage ulcers (p=0.002) and to drink more heavily (p=0.005).

CONCLUSIONS

Use of NSAIDs is a risk factor for symptomatic PUD, but not for asymptomatic PUD. Excessive alcohol consumption and active-stage ulcers in patients with PUD are related to the presence of gastroduodenal symptoms.

Microsatellite Instability of Gastric and Colorectal Cancers as a Predictor of Synchronous Gastric or Colorectal Neoplasms

BACKGROUND/AIMS

Microsatellite instability (MSI) plays a crucial role in gastrointestinal carcinogenesis. The aim of this study was to clarify whether MSI is a useful marker for predicting synchronous gastric and colorectal neoplasms.

METHODS

Consecutive patients who underwent both esophagogastroduodenoscopy and colonoscopy before the resection of gastric or colorectal cancers were included. MSI was analyzed using two mononucleotide and three dinucleotide markers.

RESULTS

In total, 434 gastric cancers (372 microsatellite stability [MSS], 21 low incidence of MSI [MSI-L], and 41 high incidence of MSI [MSI-H]) and 162 colorectal cancers (138 MSS, 9 MSI-L, and 15 MSI-H) were included. Patients with MSI gastric cancer had a higher prevalence of synchronous colorectal cancer, colorectal adenoma, and gastric adenoma than those with MSS gastric cancers (4.8% vs 0.5%, p=0.023; 11.3% vs 3.2%, p=0.011; 3.2% vs 1.2%, p=0.00, respectively). The prevalence of synchronous colorectal adenomas was highest in MSI-L gastric cancers (19.0%), compared with MSI-H (7.3%) or MSS (3.2%) gastric cancers (p=0.002). In addition, there were no significant differences in the prevalence rates of synchronous colorectal adenoma among the MSI-H (13.3%), MSI-L (11.1%), and MSS (12.3%) colorectal cancers (p=0.987).

CONCLUSIONS

The presence of MSI in gastric cancer may be a predictor of synchronous gastric and colorectal neoplasms, whereas MSI in colorectal cancer is not a predictor of synchronous colorectal adenoma.

The Clinical Features and Predisposing Factors of Asymptomatic Erosive Esophagitis

BACKGROUND

Asymptomatic erosive esophagitis (AEE) is considered an erosive esophagitis without the typical reflux symptoms, but the clinical course and significance of AEE is still unclear.

AIM

We investigated the prevalence and predisposing factors of AEE, and tried to determine its clinical features and significance.

METHODS

Subjects, who had at least two health inspections (upper endoscopy, self-reporting questionnaire, and serum Helicobacter pylori IgG antibody test) at our center, were enrolled. The questionnaire included typical reflux symptoms, previous medical history, underlying disease, smoking, alcohol intake, and medication history. Based on the results of follow-up study, the changes in endoscopic findings and reflux symptoms were also investigated.

RESULTS

Of the 2961 patients visiting our clinic, 568 (19.2 %) were diagnosed with AEE. Age over 50 years, male sex, a body mass index over 25, current smoking, heavy drinking, negativity for H. pylori infection, and hiatal hernia were independent predisposing factors for AEE (p = 0.020, p < 0.001, p < 0.001, p = 0.013, p = 0.003, p < 0.001, p = 0.038, respectively). Within the follow-up period (mean 25 ± 9.5 months), reflux symptoms developed in 30 subjects (7.9 %), and current smoking was the only risk factor for the development of AEE symptoms (p = 0.015). On the follow-up endoscopy, erosive esophagitis disappeared in nearly half of the subjects with AEE (174, 45.6 %).

CONCLUSIONS

AEE is common, but many cases of AEE may be spontaneously cured without treatment. Although symptom development is rare, quitting smoking may be helpful as a prevention strategy.

CLINICAL TRIAL REGISTRATION NUMBER

KCT0001716.

Does 2 L Polyethylene Glycol Plus Ascorbic Acid Increase the Risk of Renal Impairment Compared to 4 L Polyethylene Glycol?

BACKGROUND

The use of polyethylene glycol (PEG)-based solutions is the gold standard for bowel preparation. However, PEG use might be associated with the risk of acute kidney injury.

AIMS

We aimed to compare the safety of 2 L PEG plus ascorbic acid (AA) versus 4 L PEG.

METHODS

Health examinees that underwent colonoscopy and blood tests on the same day at our center were included in this retrospective study. All subjects were prescribed either 2 L PEG plus AA or 4 L PEG for the bowel preparation prior to the colonoscopy. The incidences of electrolyte imbalance and renal impairment after colonic preparation were investigated. Renal impairment was determined if the subject's estimated glomerular filtration rate was measured less than 60 mL/min/1.73 m².

RESULTS

Of the 29,789 cases, 14,790 received 2 L PEG plus AA (group A) and 14,999 received 4 L PEG (group B) for colonic preparation. Renal impairment occurred more commonly in group A (n = 467, 3.2 %) than in group B (n = 189, 1.3 %). Electrolyte changes such as hypernatremia and hyperkalemia were more common in group A than group B, whereas hyponatremia, hypokalemia, and hypophosphatemia were more common in group B than group A. Old age, male sex, and the use of 2 L PEG plus AA were independent risk factors for renal impairment.

CONCLUSIONS

The evidence strongly suggests that acute kidney injury is more likely to occur when 2 L PEG plus AA is used for the bowel preparation than when 4 L PEG is used.

CLINICAL TRIAL REGISTRATION NUMBER

KCT0001703.

Does the antibody production ability affect the serum anti-Helicobacter pylori IgG titer?

AIM: To investigate the relationship between serum titers of anti-Helicobacter pylori (H. pylori) immunoglobulin G (IgG) and hepatitis B virus surface antibody (HBsAb).

METHODS: Korean adults were included whose samples had positive Giemsa staining on endoscopic biopsy and were studied in the hepatitis B virus surface antigen (HBsAg)/HBsAb serologic assay, pepsinogen (PG) assay, and H. pylori serologic test on the same day. Subjects were excluded if they were positive for HBsAg, had a recent history of medication, or had other medical condition(s). We analyzed the effects of the following factors on serum titers of HBsAb and the anti-H. pylori IgG: Age, density of H. pylori infiltration in biopsy samples, serum concentrations of PG I and PG II, PG I/II ratio, and white blood cell count.

RESULTS: Of 111 included subjects, 74 (66.7%) exhibited a positive HBsAb finding. The serum anti-H. pylori IgG titer did not correlate with the serum HBsAb titer (P = 0.185); however, it correlated with the degree of H. pylori infiltration on gastric biopsy (P < 0.001) and serum PG II concentration (P = 0.042). According to the density of H. pylori infiltration on gastric biopsy, subjects could be subdivided into those with a marked (median: 3.95, range 0.82-4.00) (P = 0.458), moderate (median: 3.37, range 1.86-4.00), and mild H. pylori infiltrations (median: 2.39, range 0.36-4.00) (P < 0.001). Subjects with a marked H. pylori infiltration on gastric biopsy had the highest serological titer, whereas in subjects with moderate and mild H. pylori infiltrations titers were correspondingly lower (P < 0.001). After the successful eradication, significant decreases of the degree of H. pylori infiltration (P < 0.001), serum anti-H. pylori IgG titer (P < 0.001), and serum concentrations of PG I (P = 0.028) and PG II (P = 0.028) were observed.

CONCLUSION: The anti-H. pylori IgG assay can be used to estimate the burden of bacteria in immunocompetent hosts with H. pylori infection, regardless of the HBsAb titer after HBV vaccination.

The clinical course of asymptomatic esophageal candidiasis incidentally diagnosed in general health inspection

OBJECTIVE

Esophageal candidiasis mostly occurs in the immunocompromised host. However, it may also affect healthy people and is frequently asymptomatic. The clinical significance of asymptomatic esophageal candidiasis (AEC) is still unclear. The aims of the study were to investigate the prevalence of AEC during health inspection and to identify its predisposing factors and clinical significance.

MATERIALS AND METHODS

A total of 49,497 subjects who underwent a health inspection that included upper endoscopy were enrolled. We retrospectively reviewed the subject's self-reporting questionnaires, medical records and endoscopic findings. We considered "long-term" follow-up to be >6 months with at least one more follow-up endoscopy.

RESULTS

One hundred and seventy (0.4%) subjects were endoscopically diagnosed as esophageal candidiasis and 141 subjects were AEC. Multivariate analysis revealed that old age (≥60 years) was an independent risk factor for AEC (OR, 1.862, p = 0.005). The number of subjects with long-term follow-up was 79 (195.3 person-years). Among these, AEC of 64 subjects (81.0%) had disappeared on the follow-up endoscopy and was not recurrent. The other 15 subjects had AEC diagnosed more than once on the follow-up endoscopy, and 5 of them were spontaneously healed during the follow-up period. The remaining 10 subjects whose candidiasis was sustained up to the last endoscopy did not complain of symptoms during the follow-up period, and their endoscopic findings did not worsen.

CONCLUSIONS

AEC is rare and old age is the only risk factor. AEC does not require medical care because it is a self-limited disease.

Endoscopic wire-guided papillectomy versus conventional papillectomy for ampullary tumors: A prospective comparative pilot study

BACKGROUND AND AIM

A major concern about endoscopic snare papillectomy (ESP) is the risk of procedure-related pancreatitis. To maintain pancreatic duct access for stent placement after ESP, wire-guided ESP (WP) was introduced. The aim of the study was to compare post-procedure pancreatitis rates, the success rate of pancreatic stent insertion, and complete resection rates between WP and conventional ESP (CP) procedures.

METHODS

This was a multi-center, prospective, randomized pilot study. Forty-five patients with ampullary tumors were randomly assigned to a WP group (n = 22) or a CP group (n = 23). In the WP group, a guidewire was placed in the pancreatic duct prior to ESP. A 5-Fr pancreatic stent was passed over the guidewire and placed across the pancreatic duct orifice.

RESULTS

Complete resection was achieved in 20 patients (91%) in the WP group and 18 patients (78%) in the CP group (P = 0.414). A pancreatic stent was placed successfully in all patients in the WP group but in only 15 patients (65%) in the CP group (P = 0.004). Post-papillectomy pancreatitis occurred in four (18%) patients in the WP and three (13%) patients in the CP groups (P = 0.960). In the CP group, three of eight (37.5%) patients without stents developed pancreatitis compared with zero of 15 patients with stents (P = 0.032).

CONCLUSIONS

The WP method is a useful technique used to insert a pancreatic stent after ESP, compared with CP. However, there was no significant difference in the post-procedure pancreatitis or complete resection rates between the two methods.

Photodynamic Therapy in Patients with Advanced Hilar Cholangiocarcinoma: Percutaneous Cholangioscopic Versus Peroral Transpapillary Approach

OBJECTIVE

This study aimed to compare the clinical outcomes of patients with advanced hilar cholangiocarcinoma (CC) who underwent photodynamic therapy (PDT) with either percutaneous transhepatic cholangioscopy (PTCS) or endoscopic retrograde cholangiopancreatography (ERCP).

BACKGROUND DATA

PDT has been proposed as a promising therapy for treatment of unresectable hilar CC that is resistant to conventional standard treatment. However, few studies have compared the delivery methods of PDT in unresectable hilar CC patients.

METHODS

Thirty-seven adult patients with advanced hilar CC were included in this study. Twenty-four patients treated with PTCS-directed PDT and 13 patients treated with ERCP-directed PDT were analyzed retrospectively.

RESULTS

The PTCS- and ERCP-directed PDT groups were comparable with respect to age, gender, health status, pretreatment bilirubin levels, Bismuth type, and hilar CC stage. The length of hospital stay differed significantly (p < 0.001) between the two groups, with a median hospital stay of 37 days (range, 13-77 days) in the ERCP-directed PDT group versus 63 days (range, 23-125 days) in the PTCS-directed group. PTCS-directed PDT patients demonstrated an overall survival similar to that of ERCP-directed PDT patients, with a median survival of 11.6 versus 9.5 months, respectively (p = 0.96). Only lower pre-PDT bilirubin levels (p = 0.002) were a significant predictor of improved survival in all patients who underwent PDT, as determined by multivariate analysis. Median metal stent patency was similar between the groups [PTCS-directed PDT group (n = 8), 6.2 months; ERCP-directed PDT group (n = 7), 7.2 months; p = 0.642]. Survival after PTCS- or ERCP-directed PDT was not statistically different in patients with advanced hilar CC.

CONCLUSIONS

Lower pre-PDT bilirubin levels were associated with longer survival in all patients.

Efficacy and Safety of Balloon-Occluded Retrograde Transvenous Obliteration with Sodium Tetradecyl Sulfate Liquid Sclerotherapy

OBJECTIVE

To evaluate the efficacy and safety of balloon-occluded retrograde transvenous obliteration (BRTO) with sodium tetradecyl sulfate (STS) liquid sclerotherapy of gastric varices.

MATERIALS AND METHODS

Between February 2012 and August 2014, STS liquid sclerotherapy was performed in 17 consecutive patients (male:female = 8:9; mean age 58.6 years, range 44-86 years) with gastric varices. Retrograde venography was performed after occlusion of the gastrorenal shunt using a balloon catheter and embolization of collateral draining veins using coils or gelfoam pledgets, to evaluate the anatomy of the gastric varices. We prepared 2% liquid STS by mixing 3% STS and contrast media in a ratio of 2:1. A 2% STS solution was injected into the gastric varices until minimal filling of the afferent portal vein branch was observed (mean 19.9 mL, range 6-33 mL). Patients were followed up using computed tomography (CT) or endoscopy.

RESULTS

Technical success was achieved in 16 of 17 patients (94.1%). The procedure failed in one patient because the shunt could not be occluded due to the large diameter of gastrorenal shunt. Complete obliteration of gastric varices was observed in 15 of 16 patients (93.8%) with follow-up CT or endoscopy. There was no rebleeding after the procedure. There was no procedure-related mortality.

CONCLUSION

BRTO using STS liquid can be a safe and useful treatment option in patients with gastric varices.

Development of Biliary and Enteral Stents by the Korean Gastrointestinal Endoscopists

Stenting in the gastrointestinal tract is a common procedure used for palliation of obstruction in the enteral and biliary tract. Today, stenting of malignant and benign strictures is performed at almost every major tertiary hospital in Korea. Moreover, Korea has become a major global supplier of cutting edge technology in the field of self-expanding metal stents. However, the history of stenting in Korea is relatively short and was far behind that of other nations such as Japan and Germany. The authors are humbled and gratified to have been able to observe the development and application of these stents in Korea, first hand. In this article, the authors review the overall history of stenting with a specific focus on the development of stenting in Korea. The development of esophageal, gastroduodenal, biliary, and colonic stents in Korea are reviewed in this article from a chronological and historical point of view, and a personal account of some of the significant moments of stent development in Korea are described.

Is endoscopic papillary large balloon dilation safe for treating large CBD stones?

In recent years, endoscopic papillary large balloon dilation (EPLBD) with endoscopic sphincterotomy (EST) has been shown to be an effective technique for the removal of large or difficult common bile duct (CBD) stones, as an alternative to EST. Reviewing the literature published since 2003, it is understood that EPLBD has fewer associated overall complications than EST. Bleeding occurred less frequently with EPLBD than with EST. There was no significant difference in postendoscopic retrograde cholangiopancreatography pancreatitis or perforation. Recent accumulated results of EPLBD with or even without EST suggest that it is a safe and effective procedure for the removal of large or difficult bile duct stones without any additional risk of severe adverse events, when performed under appropriate guidelines. Since use of a larger balloon can tear the sphincter as well as the bile duct, possibly resulting in bleeding and perforation, a balloon size that is equal to or smaller in diameter than the diameter of the native distal bile duct is recommended. The maximum transverse diameter of the stone and the balloon-stone diameter ratio have a tendency to affect the success or failure of complete removal of stones by large balloon dilation to prevent adverse effects such as perforation and bleeding. One should take into account the size of the native bile duct, the size and burden of stones, the presence of stricture of distal bile duct, and the presence of the papilla in or adjacent to a diverticulum. Even though the results of EPLBD indicate that it is a relatively safe procedure in patients with common duct stones with a dilated CBD, the recommended guidelines should be followed strictly for the prevention of major adverse events such as bleeding and perforation.

Prognostic Value of FDG-PET/CT Total Lesion Glycolysis for Patients with Resectable Distal Bile Duct Adenocarcinoma

AIM

We investigated the prognostic value of clinicopathological factors in patients with a distal bile duct adenocarcinoma after curative resection.

PATIENTS AND METHODS

This retrospective study included 25 patients who underwent (18)F-fluorodeoxyglucose positron-emission tomography/computed tomography (FDG-PET/CT) before surgery. The maximum standardized uptake value (SUVmax), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) were measured using FDG-PET/CT. FDG-PET/CT parameters and other clinicopathological factors were assessed to evaluate survival.

RESULTS

Univariate survival analysis showed that high TLG, high MTV, and high SUVmax were significant prognostic predictors for poor overall survival. For progression-free survival, high TLG and large tumor size were significant predictors for a poor prognosis. After multivariate survival analysis, only high TLG was an independent prognostic predictor for poor overall survival (p=0.025).

CONCLUSION

Preoperative assessment of TLG by FDG-PET/CT might be a useful prognostic predictor in patients with a distal bile duct adenocarcinoma after curative resection.

Case of Fitz-Hugh-Curtis syndrome in male without presentation of sexually transmitted disease

Fitz-Hugh-Curtis syndrome is a type of perihepatitis that causes liver capsular infection without infecting the hepatic parenchyma or pelvis. Fitz-Hugh-Curtis syndrome is known to occur commonly in women of childbearing age who do not use oral contraceptives and have sexual partners older than 25 years of age. However, the syndrome has been reported to occur rarely in males. The clinical symptoms are right upper quadrant pain and tenderness, and pleuritic right sided chest pain. The clinical presentation is similar in male and female. We experienced a case of Fitz-Hugh-Curtis syndrome in a 60-year-old man with the chief complaint of right upper quadrant abdominal pain. Despite a previous history of gonorrhea, we have also described our experiences of improved symptoms and recovery with allopathic medicines and have thereby reported the present case with a literature review.

Risk factors for incomplete polyp resection during colonoscopic polypectomy

Background/Aims

Colonoscopic polypectomy is highly efficient in preventing colorectal cancer, but polyps may not always be completely removed. Improved knowledge of the risk factors for incomplete polyp resection after polypectomy may decrease the cancer risk and additional costs. The aim of this study was to investigate the conditions that can cause incomplete polyp resection (IPR) after colonoscopic polypectomy.

Methods

A total of 12,970 polyps that were removed by colonoscopic polypectomy were investigated. Among them, we identified 228 cases with a positive resection margin and 228 controls with a clear resection margin that were matched for age, gender, and polyp size. We investigated the location, morphology, and histological type of the polyps and evaluated the skills of the endoscopist and assisting nurse.

Results

Multivariate analysis revealed that the polyps, which were located in the proximal part of the colon and rectum, were at significant risk of IPR. Histologically, an advanced polyp and an inexperienced assistant were also independent risk factors for IPR.

Conclusions

Polypectomy should be performed more carefully for polyps suspected to be cancerous and polyps located in the proximal part of the colon or rectum. A systematic training program for inexperienced assistants may be needed to decrease the risk of IPR.

Comparison of dexmedetomidine with on-demand midazolam versus midazolam alone for procedural sedation during endoscopic submucosal dissection of gastric tumor

OBJECTIVE

Endoscopic submucosal dissection (ESD) is commonly performed as a treatment for gastric neoplasms. However, sedation with midazolam (MDZ) often does not reach satisfactory sedation levels during the procedure and the drug may suppress respiration and blood pressure. This study aimed to investigate the safety and efficacy of dexmedetomidine (DEX) with on-demand MDZ (the DEX group) in comparison with MDZ alone (the MDZ group) as a sedative during ESD of gastric neoplasms.

METHODS

Eighty patients undergoing ESD for gastric tumor were randomly assigned to one of two treatment regimens (40 patients in each). We investigated the depth of sedation by using a Modified Observers Assessment Alertness/Sedation score, the number of patients' reactions interfering with the procedure, sedation related-adverse events and the degree of satisfaction of patients and doctors.

RESULTS

There was no statistically significant difference between the two groups regarding their age, gender, body mass index, American Society of Anesthesiologists physical status classification and the characteristics of the tumor. Appropriate sedation rate and the degree of satisfaction of the doctors were significantly higher in the DEX group than in the MDZ group. Patients' reactions interfering with the procedure were more numerous in the MDZ group than in the DEX group. There was no significant difference in adverse events between the two groups.

CONCLUSIONS

DEX with on-demand MDZ for sedation during gastric ESD is as safe as MDZ alone and the sedation effect of DEX with MDZ is superior to that of MDZ alone.

Effect of submucosal fibrosis on endoscopic submucosal dissection of colorectal tumors: pathologic review of 173 cases

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is now commonly performed as a treatment for colorectal tumors. However, little is known about the relationship between submucosal fibrosis and the outcome of the colonic ESD procedure. The aims of this study were to investigate the relationship between the degree of submucosal fibrosis in colorectal tumors and the outcomes of ESD for these tumors and to evaluate the risk factors for submucosal fibrosis.

METHODS

We retrospectively reviewed the records of patients with colorectal adenoma or carcinoma who had undergone an ESD, during a four-year period from January 2010 to December 2013. The resected specimens were histologically examined after Masson's trichrome staining, and the severity of the submucosal fibrosis was classified as no fibrosis (F0), mild fibrosis (F1), or severe fibrosis (F2).

RESULTS

Among a total of 173 cases (106 male, mean age 65.0 ± 10.2 years; F0 33, F1 78, F2 62) enrolled, 46 incidences of complications (perforation 19, post-coagulation syndrome 21, bleeding 6) had developed. Multivariate analysis revealed that F2 fibrosis was significantly associated with the development of complications. Submucosal invasion and large tumor size (≥ 30 mm) were identified as independent predictors of F2 fibrosis.

CONCLUSION

Severe fibrosis is the most powerful risk factor for complications and can interfere with en bloc resections. The possibility of submucosal fibrosis should be considered, and the procedure should be cautiously performed in cases where the tumor diameter is greater than 30 mm and when submucosal cancer is suspected.

The effect of emotional stress and depression on the prevalence of digestive diseases

Background/Aims

Epidemiological data indicate that emotional stress and depression might influence the development of gastrointestianl disorders and cancers, but the relationship between the two is still unclear. The aim was to investigate the effect of stress/depression on the prevalence of digestive diseases. In addition, we tried to identify whether stress and depression are risk factors for these diseases.

Methods

A total of 23 698 subjects who underwent a medical check-up including upper and lower endoscopy were enrolled. By review -ing the subject’s self-reporting questionnaire and endoscopic findings, we investigated the digestive diseases, including functional dyspepsia (FD), irritable bowel syndrome (IBS), reflux esophagitis, peptic ulcer disease, and adenoma and carcinoma of the stomach and colon. Stress and depression scores were measured by the Brief Encounter Psychosocial Instrument and Beck’s Depression Inventory, respectively (Korean version).

Results

Stress and depression were related to FD, IBS, and reflux esophagitis. Depression was also linked to peptic ulcer disease and adenoma/carcinoma of the colon and stomach. Multivariate analysis revealed that stress and depression were independent risk factors for FD (OR, 1.713 and 1.984; P < 0.001) and IBS (OR, 1.730 and 3.508; P < 0.001). In addition, depression was an independent risk factor for gastric adenoma/carcinoma (OR, 4.543; P < 0.001).

Conclusions

Stress and depression are related to various digestive diseases, and they may be predisposing factors for FD and IBS. Depression may also be a cause of gastric cancer. Psychological evaluation of gastroenterology patients may be necessary, but more study is needed.

Correlation between Helicobacter pylori infection, IgE hypersensitivity, and allergic disease in Korean adults

BACKGROUND

The correlation between allergic disease and Helicobacter pylori infection is still controversial in endemic areas. The aim of this study was to determine whether H. pylori infection is related to allergic disease and/or immunoglobulin E (IgE) hypersensitivity in Korean adults.

MATERIALS AND METHODS

Consecutive Korean adults who visited our center for a routine checkup were enrolled. All subjects completed a questionnaire that was designed to ascertain their medical history pertaining to physician-diagnosed allergic disease, allergy treatments, and H. pylori eradication therapy. Blood was sampled for serum anti-H. pylori IgG antibody. IgE hypersensitivity was measured using a commercially available ImmunoCAP(®) Phadiatop (Phadia AB, Uppsala, Sweden).

RESULTS

Of the 3376 Korean adults who were enrolled, 62 did not answer to the questionnaires adequately and were thus excluded. The proportion of noninfected subjects (p < .001) and the prevalence of IgE-related allergic disease (p < .001) were both highest among those aged <40 years, while the prevalence of non-IgE-related allergic disease was highest among those aged ≥70 years (p < .001). Logistic regression analysis revealed that being younger than 40 years was significantly related to the absence of H. pylori infection (OR = 2.507, 95% CI = 1.621-3.878, p < .001).

CONCLUSIONS

The statuses of H. pylori infection, IgE hypersensitivity, and allergic diseases differ with age group, there being a higher prevalence of IgE-related allergic disease and a lower H. pylori infection rate among young adults. The hygiene hypothesis might explain these findings in young Koreans, due to the rapid development and improvements in sanitation in Korea.

Colonic lymphangiomatosis resolved after excisional biopsy

Lymphangioma is an uncommon malformation of the lymphatic system that involves a benign proliferation of the lymphatics, with no established treatment method. Multiple colonic lymphangioma, or colonic lymphangiomatosis, is an extremely rare condition. We report a case of colonic lymphangiomatosis that was detected during a colonoscopic examination conducted as part of a general health check-up. The lesion completely resolved after excisional biopsy.

Prevalence and clinical features of coagulation syndrome after endoscopic submucosal dissection for colorectal neoplasms

BACKGROUND AND OBJECTIVES

There are several published studies examining the major complications (bleeding and perforation) of colon endoscopic submucosal dissection (ESD). However, little is known about the other complications, such as post-ESD coagulation syndrome (CS). The aims of this study were to evaluate the prevalence and the clinical features of CS after colon ESD.

METHODS

There were 183 cases treated with ESD for either a colorectal laterally spreading tumor or a polypoid mass in Konkuk University Medical Center. There were 151 cases enrolled in this study after excluding patients with perforation, bleeding, nonlifting sign, or nonneoplastic lesions. Patients with a fever above 37.7 °C, abdominal pain, and localized tenderness after ESD without macro- or microperforation, regardless of the symptoms of peritoneal irritation, were deemed as showing post-colon ESD CS.

RESULTS

There were 151 cases enrolled in this study, and 13 patients (8.6 %) showed CS after colorectal ESD. There were no differences in the demographic and endoscopic characteristics between the patients with CS and those without CS. The mean hospitalization stay was 3.0 ± 0.3 days longer in the CS (+) group (6.9 ± 1.9 days) than that in the CS (-) group (3.9 ± 1.6 days) (p = 0.001). All patients with CS were treated with conservative, nonsurgical management, such as fasting and intravenous antibiotics.

CONCLUSIONS

The rate of post-ESD CS was less than 9 % in this study. Although CS occurred, all of the patients with CS showed a favorable progression within 1 week.

G protein β3 subunit polymorphism and long-term prognosis of functional dyspepsia

Background/Aims

A link between G protein β3 (GNB3) polymorphism and functional dyspepsia (FD) has been suggested. The aim of this study was to determine the role of GNB3 polymorphism in the long-term prognosis of FD in Koreans.

Methods

FD patients and normal healthy controls were recruited from patients who visited our center between December 2006 and June 2007. All of the subjects completed Rome III questionnaires before undergoing upper gastrointestinal endoscopy and colonoscopy. Genomic DNA was extracted for GNB3 genotyping. After 5 years, the subjects were reevaluated using the same questionnaires.

Results

GNB3 825T carrier status was significantly related to FD in Koreans (p=0.04). After 5 years, 61.0% of the initial FD patients and 12.2% of the initial normal subjects were diagnosed with FD (odds ratio [OR], 11.7; 95% confidence interval [CI], 4.3 to 31.1; p<0.001). Regardless of the GNB3 genotype (p=0.798), female sex was strongly correlated with FD after 5 years (OR, 3.3; 95% CI, 1.2 to 9.1; p=0.017).

Conclusions

The T allele of GNB3 is linked to FD in Koreans but does not predict long-term prognosis. Female sex is related to a higher prevalence of FD after 5 years.

Long-term outcome of photodynamic therapy with systemic chemotherapy compared to photodynamic therapy alone in patients with advanced hilar cholangiocarcinoma

Background/Aims

Patients with cholangiocarcinoma usually present at an advanced stage, and more than 50% of cases are not resectable at the time of diagnosis. Recently, photodynamic therapy (PDT) has been proposed as a palliative and neoadjuvant modality. We evaluated whether combination of PDT and chemotherapy is more effective than PDT alone.

Methods

In total, 161 patients with cholangiocarcinoma diagnosed between February 1999 and September 2009 were evaluated. Sixteen patients were treated with PDT and chemotherapy (group A), and 58 were treated with PDT (group B).

Results

The median survival was 538 days (95% confidence interval [CI], 475.3 to 600.7) in group A and 334 days (95% CI, 252.5 to 415.5) in group B (p=0.05). Lymph node metastasis status, serum bilirubin of pretreatment, tumor node metastasis stage, treatment method (PDT with chemotherapy vs PDT alone), time to PDT and the number of PDT sessions were prognostic factors with statistical significance in the univariate analysis. A multivariate analysis showed that PDT with chemotherapy and more than two sessions of PDT were significant independent predictors of longer survival in advanced cholangiocarcinoma (hazard ratio [HR], 2.23; 95% CI, 1.18 to 4.20; p=0.013 vs HR, 1.79; 95% CI, 1.044 to 3.083; p=0.034).

Conclusions

PDT with chemotherapy results in longer survival than PDT alone.

Rebleeding after initial endoscopic hemostasis in peptic ulcer disease

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 whether the use of antithrombotics affects rebleeding rate after a successful endoscopic hemostasis for peptic ulcer disease (PUD). UGIB patients who underwent successful endoscopic hemostasis were included. Rebleeding was diagnosed when the previously treated lesion bled again within 30 days of the initial episode. Of 522 UGIB patients with PUD, rebleeding occurred in 93 patients (17.8%). The rate of rebleeding was higher with aspirin medication (P=0.006) and after a long endoscopic hemostasis (P<0.001). Of all significant variables, procedure time longer than 13.5 min was related to the rate of rebleeding (OR, 2.899; 95% CI, 1.768-4.754; P<0.001) on the logistic regression analysis. The rate of rebleeding after endoscopic hemostasis for PUD is higher in the patients after a long endoscopic hemostasis. Endoscopic hemostasis longer than 13.5 min is related to rebleeding after a successful endoscopic hemostasis for PUD.

Combining the serum pepsinogen level and Helicobacter pylori antibody test for predicting the histology of gastric neoplasm

OBJECTIVE

To determine whether the combination test of serum pepsinogen (PG) levels and Helicobacter pylori (H. pylori) antibody was effective for predicting the incidence and histology of gastric neoplasms.

METHODS

This study included asymptomatic Korean adults who underwent esophagogastroduodenoscopy with blood tests for PG levels and H. pylori immunoglobulin G antibody test on the same day. Participants with extragastric malignancy, history of H. pylori eradication or gastric neoplasms, or recent antacid medication were excluded. Gastric atrophy was defined as a serum PG I/II ratio ≤3.0 and PG I ≤70 ng/mL. The participants were classified into four groups according to the presence (+) or absence (-) of gastric atrophy and H. pylori infection.

RESULTS

Of the 3328 included participants, 17 were incidentally diagnosed as having either gastric adenoma or carcinoma. The incidence of gastric neoplasm was highest in the gastric atrophy (+)/H. pylori (-) group (4.17%; OR 25.8, P = 0.009), but the neoplasm exhibited the least advanced histology. The gastric atrophy (-)/H. pylori (-) group exhibited the lowest incidence of gastric neoplasm (0.17%) but the most advanced histology.

CONCLUSION

A combination of serum PG levels and H. pylori antibody test is useful for detecting gastric neoplasms based on the slow gastric carcinogenesis pathway progressing from gastric adenoma to Lauren's intestinal-type gastric cancer, but not for those with advanced histology such as Lauren's diffuse-type gastric cancer.

The effect of preceding biopsy on complete endoscopic resection in rectal carcinoid tumor

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 of the study was to investigate the effect of preceding biopsy on complete endoscopic resection in rectal carcinoid tumor. It was also determined if rectal carcinoid tumors can be macroscopically distinguished by endoscopy. We reviewed retrospectively the records of patients with rectal carcinoid tumor who had undergone an endoscopic treatment at our hospital, during a 7-yr period. The resection margin was clear in 57 of 98 cases. The preceding biopsy was taken in 57 cases and the biopsy was significantly associated with the risk of incomplete tumor resection (OR, 3.696; 95% CI, 1.528-8.938, P = 0.004). In 95.9% of the cases, it was possible to suspect a carcinoid tumor by macroscopic appearance during initial endoscopy. The preceding biopsy may disturb complete resection of rectal carcinoid tumor. In most cases, the carcinoid tumor could be suspected by macroscopic appearance. Therefore the preceding biopsy is not essential, and it may be avoided for the complete resection.

Recurrence of gastroesophageal reflux disease correlated with a short dinner-to-bedtime interval

BACKGROUND AND AIM

Gastroesophageal reflux disease (GERD) can be classified into erosive reflux disease (ERD) and nonerosive gastroesophageal reflux disease (NERD). We aimed to compare the recurrence rates of ERD and NERD and determine the risk factors related to the recurrence.

METHODS

This prospective study comprised 337 consecutive adults who completed questionnaires on their GERD symptoms, height, weight, sleeping position, dinner time, and bedtime. During upper gastrointestinal endoscopy, the presence of a hiatal hernia and mucosal breaks in the low esophagus, esophageal length (the distance between the Z-line and the incisors), and the esophageal length-to-height ratio were recorded. Recurrence was diagnosed when the patient required additional proton pump inhibitor medication after initial recovery with 4-8 weeks of treatment.

RESULTS

Recurrence was experienced by 47 (26.0%) of 181 GERD patients. The recurrence rate did not differ between the 48 ERD (27.1%) and 133 NERD (25.6%) patients (P = 0.849). Of the various factors studied, recurrence was found to be correlated with a dinner-to-bedtime interval of less than 3 h (P = 0.002), globus sensation (P = 0.031), and old age (P = 0.047). Logistic regression analysis revealed that a short interval between dinner and bedtime was the only factor significantly related to the recurrence (P = 0.002).

CONCLUSION

Both ERD and NERD patients who sleep within 3 h after eating have a higher risk of GERD recurrence. Our findings highlight the impact of a short dinner-to-bedtime interval on the recurrence of GERD (ClinicalTrials.gov ID: KCT0000134).

Low prevalence of microsatellite instability in interval gastric cancers

BACKGROUND AND AIM

Esophagogastroduodenoscopy (EGD) is recommended at 2-year intervals in countries with a high prevalence of gastric cancer. The aim of this study was to determine whether interval gastric cancers that develop within 2 years of a previous complete screening are associated with microsatellite instability (MSI).

METHODS

Newly diagnosed gastric cancer patients who had undergone gastrectomy were included. Of these 459 patients, 177 were classified as interval gastric cancer since they were diagnosed within 2 years of a previous EGD. Noninterval gastric cancer patients were subclassified into 65 patients who underwent previous EGD between the past 2 and 10 years and 217 patients without EGD during the last 10 years. Analysis for MSI was conducted using two mononucleotide and three dinucleotide markers.

RESULTS

MSI was found more frequently in noninterval gastric cancers than in interval gastric cancers (p = 0.009). Interval gastric cancers were associated with a higher prevalence of early gastric cancer (p = 0.006), smaller size (p < 0.001), and lower TNM stages (p = 0.006). On logistic regression analysis, noninterval gastric cancers were related to MSI (p = 0.010) and larger size (≥4 cm) (p = 0.009). Subjects with interval gastric cancer showed better survival than those with noninterval gastric cancer (p = 0.006).

CONCLUSIONS

During a 2-year screening interval, noninterval gastric cancers tend to be larger, more advanced, and associated with MSI. Biannual EGD screening is effective for detecting small gastric cancers at an early stage, but is not useful in detecting gastric cancers with MSI.

Clinical feasibility of a new through-the-scope fully covered esophageal self-expandable metallic stent: an in vivo animal study

BACKGROUND

Most delivery devices used for esophageal stents for obstructing esophageal cancer have a diameter of 5-8 mm, a size that is too large to pass through the endoscopic working channel. The conventional esophageal stent requires multiple endoscopic procedures for implantation. The purpose of the present study was to evaluate the clinical feasibility of a newly developed fully covered, self-expanding, through-the-scope (TTS) esophageal stent in a porcine model.

METHODS

Eight mini pigs were used. Each animal underwent placement of a fully covered TTS stent (Hanarostent® Esophagus TTS) and the upper part of the stent was fixed by suturing with nylon. Fluoroscopy was carried out every week to assess migration of the stent. Follow-up endoscopy was done every month for 3 months to evaluate the status of the membrane, stent mesh, grade of tissue hyperplasia, and mucosal changes at both ends of the stent.

RESULTS

All stents were successfully and easily deployed, and were placed without any distortion in the stent or without rupture of the membrane. In two cases, stent migration was observed after 8 weeks. No case of membrane disruption, stent mesh disruption or tissue hyperplasia at either end of the stent was found at the completion of the study.

CONCLUSION

Our findings indicate that the new fully covered self-expanding TTS esophageal stent is easy and simple to implant, and no significant distortion of mesh or disruption of membrane was observed.

Elevated hemoglobin A1c levels are associated with worse survival in advanced pancreatic cancer patients with diabetes

Background/Aims

Pre-existing diabetes mellitus (DM) has been identified as an adverse prognostic variable associated with increased mortality in various cancers. Although DM and hyperglycemia are considered risk factors for pancreatic cancer (PC), antidiabetic treatments for patients with advanced PC have been overlooked. This study aimed to evaluate the impact of hemoglobin A1c (HbA1c) levels on PC survival.

Methods

We retrospectively reviewed the medical records of first-diagnosed patients with advanced PC who were admitted to Konkuk University Medical Center from 2005 to 2011.

Results

A total of 127 patients were enrolled, and there were 111 deaths (87.4%) within the 7-year observational period. The most common etiology was disease progression (n=108). DM before PC diagnosis was observed in 65 patients (51.1%), including 28 patients with new-onset DM. The overall median survival times in patients with and without DM were 198 and 263 days, respectively (p=0.091). Survival time according to HbA1c was significantly different between the <7.0% and ≥7.0% groups (362 and 144 days, respectively; p=0.038). In the HbA1c ≥7.0% group, the median overall survival time was 273 days for the metformin group and 145 days for the nonmetformin oral agent group; however, there was no significant difference between the two groups (p=0.058).

Conclusions

A high HbA1c level may be associated with worse survival in patients with advanced PC with DM. Antidiabetic treatment, metformin in particular, was associated with an improved outcome.

What is the next step for gastric atypical epithelium on histological findings of endoscopic forceps biopsy?

BACKGROUND

Gastric atypical epithelium on endoscopic biopsy is borderline lesions between benign and malignant. Definitive management of this lesion remains debatable.

AIMS

We aimed to analyze the final histological diagnosis for atypical epithelium on endoscopic biopsy and to examine the discrepancy rate between the final histological diagnosis and the initial endoscopic assessment.

METHODS

This retrospective study finally enrolled 24 cases proven atypical epithelium on initial histology of an endoscopic biopsy. Of 24 cases, endoscopic submucosal dissection (n = 22), operation (n = 1) and follow-up biopsy without endoscopic submucosal dissection (n = 1) were performed.

RESULTS

Of the 24 cases, early gastric cancer (n = 15, 62%) and adenoma (n = 7, 30%) lesions were finally diagnosed in 22 cases. Age, sex, endoscopic results and number of biopsy did not significantly influence the result of final outcome. Between the initial endoscopic assessment and the final histological diagnosis, 12 cases (50%) showed a concordant diagnosis, but eight (33%) and four cases (17%) showed upgraded and downgraded diagnoses, respectively.

CONCLUSIONS

Of atypical epithelium cases, the rate of malignant and premalignant lesions was 92% and it was difficult to distinguish between malignant and benign lesions using the initial endoscopic findings. Therefore, endoscopic submucosal dissection can be considered in patients with atypical epithelium on endoscopic biopsy.

Clinical role of contrast-enhanced harmonic endoscopic ultrasound in differentiating solid lesions of the pancreas: a single-center experience in Korea

Background/Aims

The differential diagnosis of pancreatic solid lesions remains challenging. The aim of this study was to investigate the accuracy of contrast-enhanced harmonic endoscopic ultrasound (CEH-EUS) in differentiating pancreatic cancer from benign lesions.

Methods

We prospectively evaluated 37 patients with pancreatic solid lesions. After intravenous injection of a contrast agent (SonoVue), CEH-EUS was performed using a radial echoendoscope. Pancreatic solid lesions were classified into three vascular patterns (hyperintense, isointense, and hypointense) on the basis of CEH-EUS imaging, and these patterns were compared to the histological diagnosis.

Results

The lesions were hypervascular (n=6), isovascular (n=3), or hypovascular (n=28). Histological diagnosis was confirmed by EUS-FNA in 26 patients (22 adenocarcinomas, two focal pancreatitis, one pancreatic neuroendocrine tumor [NET], and one pancreatic tuberculosis); by surgery in 10 patients (four adenocarcinomas, three pancreatic NETs, two invasive intraductal papillary mucinous neoplasms, and one acinar cell carcinoma); and by both methods in one patient. Among pancreatic carcinomas, 28 out of 30 lesions (93%) had persistent hypovascular signals in the early and late phase, which indicates a sensitivity and diagnostic accuracy of 93% and 92%, respectively for the diagnosis of pancreatic cancer.

Conclusions

CEH-EUS was useful for characterization of pancreatic solid masses with high sensitivity and accuracy.