The association between coronary artery calcification and colorectal adenoma

BACKGROUND/AIMS

Both colorectal neoplasm and coronary artery disease are prevalent diseases worldwide and share several risk factors. The aim of this study was to investigate the association between coronary artery calcification and prevalence of colorectal adenoma.

METHODOLOGY

We retrospectively evaluated 3,092 subjects who underwent colonoscopy and coronary artery calcium computed tomography (CT) on the same day or within a 3-month interval, during routine check-ups between January 2006 and June 2009 at the Center for Health Promotion of the Samsung Medical Center. Multivariate logistic regression analysis was used to calculate adjusted odds ratios (ORs).

RESULTS

Colorectal adenomas were detected in 1,067 (34.5%) of the 3,092 subjects, including 536 (41.0%) individuals with and 531 (29.7%) without coronary calcification (p<0.001). Multiple logistic regression analysis showed that the presence of coronary artery calcification (OR=1.346; 95% confidence interval [CI]=1.122-1.614), age ≥50 years (OR=1.516; 95% CI=1.256-1.829), waist circumference of 90-99cm (OR=1.364; 95% CI=1.008-1.844) and current smoker (OR=1.266; 95% CI=1.045-1.534) were associated with the prevalence of colorectal adenoma.

CONCLUSIONS

The prevalence of colorectal adenoma is significantly higher in patients with coronary artery calcification. Our results support positive relationship between coronary artery disease and colorectal adenoma.

Feasibility and efficacy of argon plasma coagulation for early esophageal squamous cell neoplasia

We present 19 cases in which argon plasma coagulation (APC) was used as curative initial treatment for 5 low-grade esophageal squamous intraepithelial neoplasias (ESINs), 12 high-grade ESINs, and 2 early esophageal squamous cell carcinomas (ESCCs). Complete response was defined as the absence of tumor from any biopsy taken from the ablated lesion. At follow-up endoscopy 2 - 4 months after APC, 94.7 % of patients had achieved complete response in a single treatment session. Only one patient with high-grade ESIN showed local recurrence. This patient underwent additional APC and showed complete response at 12 months after initial APC. At the 12-month follow-up endoscopy, again 94.7 % had a complete response. The exception was one patient with local recurrence, who underwent additional APC. After the 12-month follow-up endoscopy, no patient showed local recurrence during a median follow-up of 22 months. No stricture requiring endoscopic dilation occurred after the procedure. This study suggests that APC is a feasible and effective treatment modality for ESIN and early ESCC.

Interpretation of overall colonic transit in defecation disorders in males and females

BACKGROUND

There is little information regarding gender-specific measurements of colonic transit and anorectal function in patients with defecation disorders (DD). To compare overall colonic transit by gender in DD.

METHODS

In 407 patients with constipation due to DD diagnosed by a single gastroenterologist (1994-2012), DD was characterized by anorectal manometry, balloon expulsion test, and colonic transit by scintigraphy. The primary endpoint was overall colonic transit (geometric center, GC) at 24 h (GC24). Effects of gender in DD on colonic transit, and comparison with transit in 208 healthy controls were assessed by Mann-Whitney rank sum test. Secondary endpoints were maximum anal resting (ARP) and squeeze (ASP) pressures. We also tested association of the physiological endpoints among DD females by pregnancy history and among DD patients by colectomy history.

KEY RESULTS

The DD patients were 67 males (M) and 340 females (F). Significant differences by gender in DD patients were observed in GC24 (median: M: 2.2; F: 1.8; P = 0.01), ARP (median: M: 87.8 mmHg; F: 82.4 mmHg; P = 0.04), and ASP (median: M: 182.4 mmHg; F: 128.7 mmHg; P < 0.001). GC24 was slower in DD compared with same-gender healthy controls. GC24 did not differ among DD females by pregnancy history. Anorectal functions and upper GI transit did not differ among DD patients by colectomy history.

CONCLUSIONS & INFERENCES

Patients with DD have slower colonic transit compared with gender-matched controls. Among DD patients, males have higher ARP and ASP, and females have slower colonic transit. Although the clinical significance of these differences may be unclear, findings suggest that interpretation of these tests in suspected DD should be based on same-gender control data.

Gastric extremely well-differentiated intestinal-type adenocarcinoma: a challenging lesion to achieve complete endoscopic resection

Extremely well-differentiated tubular adenocarcinomas (EWDAs) of the stomach are characterized by surface maturation and their mimicking of intestinal metaplasia. Endoscopically, intramucosal EWDAs are frequently ill defined with indistinct borders due to the pallor of the neoplastic mucosa and the lack of contrast against the background atrophic and metaplastic mucosa. We evaluated the effectiveness of endoscopic resection for EWDAs after endoscopic submucosal dissection (ESD). Among 872 patients with early gastric cancer, 17 EWDAs were identified (1.9 %). Endoscopically, the flat or depressed type was significantly more common among EWDAs (88.2 %) than among early gastric cancers of other histologies (37.8 %; P < 0.01). The discrepancy between endoscopically estimated tumor size and tumor size as confirmed in pathology reports was significantly greater among EWDAs (18.4 ± 22.0  mm) than among others (5.8 ± 7.5  mm). Involvement of the lateral resection margin was more common (29.4 % vs. 2.5 %; P < 0.05), and complete resection was achieved less often in EWDAs (47.1 % vs. 80.4 %; P = 0.01) compared to the others. EWDAs are associated with higher rates of incomplete resection after ESD, especially along the lateral margins. Pathologists should alert endoscopists when this diagnosis is made, with its associated risks; and endoscopists should pay particular attention to the extent of these tumors during resection.

How do we interpret an elevated carbohydrate antigen 19-9 level in asymptomatic subjects?

AIM

This prospective cohort study aimed to evaluate the etiology of elevated CA 19-9 levels and to present appropriate guidelines for the asymptomatic patients.

METHODS

Between January 2004 and March 2007, we enrolled consecutive asymptomatic patients who had elevated CA 19-9 levels >37 U/mL. To evaluate the etiology, the CA 19-9 level was rechecked and further studies were carried out. If the CA 19-9 level decreased to the normal range, or if it showed a decreasing trend, then it was monitored annually. Yet, if the CA 19-9 level showed an increasing trend, then the level was monitored at intervals of 1, 3, and 6 months until no evidence of malignancy was proven.

RESULTS

Of the 62,976 patients, 501 (0.8%) subjects showed an elevated CA 19-9 level. This prospective analysis was conducted on 353 subjects (70.5%) who were followed up for at least 6 months. Ten patients (2.8%) were diagnosed with malignancies. There were 97 patients (27.5%) with benign diseases and 246 patients (69.7%) were deemed non-specific.

CONCLUSIONS

CA 19-9 should not be used as a screening tool. In the case of a persistently elevated CA 19-9 level, further work-up for determining the etiology should be done.

Inhibition of cell proliferation and invasion in a human colon cancer cell line by 5-aminosalicylic acid

BACKGROUND

5-Aminosalicylic acid lacks the well-known side effects associated with the long-term use of non-steroidal anti-inflammatory drugs. We investigated anti-carcinogenic mechanisms of 5-aminosalicylic acid on a colon cancer cell line.

METHODS

MTT analysis was performed for various colon cancer cell lines. The expression of NF-kappaB and metalloproteinases was examined in either HT-29 cells treated with IL-1beta and/or 5-aminosalicylic acid. Matrigel assay was used to evaluate invasive potential of HT-29 cells. Analysis of a cDNA microarray containing 8700 genes was performed to identify the alteration of gene expression in response to treatment to 5-aminosalicylic acid.

RESULTS

The use of MTT analysis showed that 5-aminosalicylic acid suppressed the growth of HT-29 cells. The activity of NF-kappaB was also decreased by combined-treatment with IL-1beta and 5-aminosalicylic acid. The use of an ELISA and zymography demonstrated that MMP-2 and MMP-9 enzyme activity were decreased in HT-29 cells by treatment with various concentration of 5-aminosalicylic acid. A matrigel analysis demonstrated that 5-aminosalicylic acid treatment on HT-29 significantly inhibited the invasiveness of the cells. In cDNA microarray, 163 genes following 5-aminosalicylic acid exposure showed altered expression.

CONCLUSIONS

This study indicated that 5-aminosalicylic acid suppresses the growth of human colon cancer cells and is able to inhibit MMPs expression via NF-kappaB mediated cell signals and invasiveness.

Clinical outcomes of endoscopic submucosal dissection (ESD) for treating early gastric cancer: comparison with endoscopic mucosal resection after circumferential precutting (EMR-P)

BACKGROUND

To achieve en bloc resection for large lesions, endoscopic mucosal resection after circumferential precutting and endoscopic submucosal dissection techniques have been developed.

AIM

To compare endoscopic submucosal dissection with endoscopic mucosal resection after circumferential precutting in terms of the clinical efficacy and safety.

PATIENTS AND METHODS

346 consecutive patients underwent their first endoscopic mucosal resection after circumferential precutting (103 patients) or endoscopic submucosal dissection (243 patients) for early gastric cancer and their clinical outcomes were compared.

RESULTS

For early gastric cancer >or=20mm endoscopic submucosal dissection group demonstrated significantly higher en bloc resection and en bloc plus R0 resection rate compared with endoscopic mucosal resection after circumferential precutting group. For early gastric cancer with size of 10-19 mm, endoscopic submucosal dissection group also showed significantly higher en bloc resection rate. For early gastric cancer <20mm, however, en bloc plus R0 resection rate for endoscopic mucosal resection after circumferential precutting group was comparable to that for endoscopic submucosal dissection group. In case of R0 resection of intramucosal differentiated cancer, neither group showed local recurrence during the median 29 and 17 months of follow-up. Two groups did not show significant difference in the bleeding or perforation rates.

CONCLUSION

For early gastric cancer <20mm endoscopic mucosal resection after circumferential precutting may be considered as an alternative choice to endoscopic submucosal dissection. However, for early gastric cancer >or=20mm endoscopic submucosal dissection should be considered as the first choice for treating early gastric cancer.

Comparison of a novel teeth-protecting mouthpiece with a traditional device in preventing endoscopy-related complications involving teeth or temporomandibular joint: a multicenter randomized trial

BACKGROUND AND STUDY AIMS

After upper endoscopy, patients have complained of symptoms involving teeth or the temporomandibular joint; however, these endoscopy-related complications are usually ignored with few attempts to prevent them. The aim of this study was to identify the incidence of endoscopy-related complications involving teeth or temporomandibular joint, and to compare the effectiveness of a newly developed teeth-protecting mouthpiece (TPM) with a traditional mouthpiece (the MB-142) in preventing these complications.

PATIENTS AND METHODS

872 patients from 28 centers, who were undergoing their first upper endoscopy, were randomly assigned to TPM and MB-142 groups. At 3 - 4 days after the procedure, the occurrence of endoscopy-related complications involving the teeth or the temporomandibular joint was investigated using a structured questionnaire. Finally 865 patients (TPM group, n = 423; MB-142, n = 442) responded to this questionnaire and were included in the analysis.

RESULTS

Overall, the incidence of complications was significantly lower in the TPM than in the MB-142 group (0.9% vs. 3.2%). With stratification according to sedation status, in nonsedated patients no significant difference was found between the two groups (0.7% vs. 0.9%). In sedated patients, however, the TPM group showed a significantly lower incidence of complication than the MB-142 group (1.7% vs. 11.6%). Clinically serious problems such as a tooth fracture or a loose tooth occurred only in sedated patients in the MB-142 group.

CONCLUSIONS

The TPM showed an advantage over the MB-142 mouthpiece for preventing endoscopy-related complications involving teeth or the temporomandibular joint.

Response rate and predictors of response in a short-term empirical trial of high-dose rabeprazole in patients with globus

BACKGROUND

Although the aetiology of globus (the sensation of a lump in the throat) remains unclear, gastro-oesophageal reflux disease is associated with globus. A short-term trial with a high-dose proton pump inhibitor has been shown to be a sensitive tool for diagnosing gastro-oesophageal reflux disease.

AIM

To see whether patients with globus symptom responded to short-term high-dose rabeprazole trial and assess predictors of symptom response.

METHODS

Sixty-four patients with globus symptom were analysed. Patients received rabeprazole 20 mg b.d. for 14 days. Patients completed a daily diary assessing the severity and frequency of globus.

RESULTS

Forty-one patients (64%) were diagnosed clinically with gastro-oesophageal reflux disease. Based on the pH testing and endoscopy, the prevalence of gastro-oesophageal reflux disease was 22% (14 of 64). The globus symptom score was significantly higher in patients with gastro-oesophageal reflux disease compared with patients without gastro-oesophageal reflux disease (P = 0.004). Two patients (3%) had complete resolution and 22 (34%) had more than a 50% improvement in the globus symptom score. Endoscopic findings (P = 0.714), pathological acid exposure on pH testing (P = 0.741) or baseline gastro-oesophageal reflux disease symptoms (P = 0.606) were not associated with improvement of globus symptom.

CONCLUSION

While gastro-oesophageal reflux disease may be an aggravating factor in patients with globus, it does not appear to be the sole cause of globus symptom.

Prognostic indicators of gastric carcinoma confined to the muscularis propria

AIMS

Gastric carcinoma confined to the muscularis propria (MPGC) is considered an intermediate-stage carcinoma. A method of discriminating between more favourable and less favourable prognostic groups of this entity is critically needed in dealing with this heterogeneous disease. The aim of this study was to examine the correlation between survival of patients with MPGC and its various clinicopathological parameters.

METHODS AND RESULTS

Various clinicopathological parameters were studied in 171 tissue samples including: macroscopic appearance, size, age, sex, stage, invasion depth, Lauren and Ming classifications, extent, lymphatic emboli and nodal metastasis. Tumours macroscopically resembling early gastric cancers, younger patient age, absence of lymphatic tumour emboli and lower stage were significantly associated with better prognosis of MPGC by univariate analysis. Tumours macroscopically resembling early gastric cancers, younger patient age and Lauren's diffuse type were significantly associated with a better prognosis of MPGC by multivariate analysis.

CONCLUSIONS

These indicators are practical parameters for predicting patient prognosis in clinical practice. The description of these parameters should be carefully noted in the final report and pathologists should evaluate the macroscopic appearance of MPGC.

Clinical significance of pre-S mutations in patients with genotype C hepatitis B virus infection

We investigated the overall and site-specific prevalence of pre-S mutations and its clinical significance in patients with genotype C hepatitis B virus (HBV) infection. Three hundred subjects were included: 50 asymptomatic carriers (AC), 87 chronic hepatitis (CH), 91 liver cirrhosis (LC) and 72 hepatocellular carcinoma (HCC). Pre-S mutations were determined by nucleotide sequence analysis. Possible correlations between pre-S mutations and clinical/virological parameters were examined. Pre-S mutations were detected in 82 cases (27.3%); it was more frequently found in HCC (43.1%) and LC (35.2%) group than in the CH (20.7%) and AC (2.0%) group. Pre-S2 deletion was the most commonly found mutation (10.7%), followed by pre-S2 start codon mutation (9.7%), pre-S1-S2 deletion (3.0%) and both pre-S2 deletion and start codon mutation (2.7%). Pre-S2 deletion and pre-S2 start codon mutation were more frequently detected in advanced diseases (LC and HCC). Pre-S mutations were associated with older age and higher rates of positive HBV DNA (>/=0.5 pg/mL). Advanced disease and positive HBV DNA were shown to be independent predictors of pre-S mutations by logistic regression analysis. These findings suggest that pre-S mutations, especially pre-S2 deletions and pre-S2 start codon mutations, are common in patients with genotype C HBV infection and are associated with advanced liver disease and active viral replication.

Primary NK-/T-cell lymphoma of the gastrointestinal tract: clinical characteristics and endoscopic findings

BACKGROUND AND STUDY AIMS

Primary NK-/T-cell lymphoma of the gastrointestinal tract is a very rare disease with a poor prognosis. The aim of this study was to determine the clinical and endoscopic characteristics of patients with primary gastrointestinal NK-/T-cell lymphoma.

PATIENTS AND METHODS

The clinical features of 14 patients with primary gastrointestinal NK-/T-cell lymphoma and the endoscopic findings in 11 of these patients were reviewed. Their median age was 42 years (range 23-78) at the time of diagnosis.

RESULTS

The initial presenting symptoms of primary gastrointestinal NK-/T-cell lymphoma were gastrointestinal bleeding (n = 6, 42%), abdominal pain (n = 4, 29%), and epigastric soreness (n = 4, 29%). The disease was at an advanced stage at the time of diagnosis: stage II in 5 patients (36%); stage III in 4 (28%); and stage IV in 5 (36%). Initial treatment was with chemotherapy (n = 8, 57%) or surgical resection (n = 5, 36%). The median survival for all patients was 9 months. On endoscopy in 11 patients, the anatomic location of the primary lesion was found to be: stomach, n = 3 (27%); esophagus, n = 2 (18%); duodenum, n = 1 (9%); and the ileocolonic area, n = 5 (46%). These lesions were ulceroinfiltrative in 4 cases (36%), ulcerative in 3 cases (27%), superficial/erosive in 3 cases (27%), and infiltrative in 1 case (9%). No prominent fungating mass was seen in any patient.

CONCLUSIONS

Primary gastrointestinal NK-/T-cell lymphoma was endoscopically characterized by superficial/erosive, ulcerative, or ulceroinfiltrative lesions without fungating mass. The most common presenting symptom was gastrointestinal bleeding. Despite aggressive treatments, the prognosis was very poor.

Nonsurgical treatment of abdominal or pelvic abscess in consecutive patients with Crohn's disease

BACKGROUND

There is little agreement about the efficacy of nonsurgical treatment for abscess associated with Crohn's disease. Furthermore, there is no study on characteristics of abscess or patient that nonsurgical treatment could be worth trying as initial treatment.

AIMS

To evaluate the outcome of nonsurgical treatment in Crohn's disease-related abscess and identify factor leading to failure of nonsurgical treatment of this complication.

PATIENTS

Twenty-four patients, who consecutively admitted for Crohn's disease-related abscess to our institution during a 7-year period, underwent nonsurgical treatment as initial therapy.

METHODS

Outcome data such as recurrence and intractability, and clinical features were retrospectively analysed. Univariate analysis with patient-related factors and abscess-related factors was performed for risk factor identification.

RESULTS

Median follow-up period was 47.5 months. Of the eligible patients, 19 patients were treated medically and 5 patients underwent percutaneous catheter drainage with medical treatment. Overall success rate of nonsurgical treatment in our centre was 66.7%. The cumulative recurrence rate at 7 months was 12.5%. All recurrences occurred within 7 months from complete resolution on follow-up imaging. Univariate analysis showed that the significant factors which lead to failure of nonsurgical treatment were presence of associated fistula and concurrent steroid use (P=0.019 and P=0.019, respectively).

CONCLUSION

Nonsurgical treatment can be considered as initial treatment modality for the Crohn's disease-related abscess without concurrent steroid therapy or relevant fistula.

Non-surgical management of microperforation induced by EMR of the stomach

BACKGROUND

Perforation and bleeding are major complications associated with gastric endoscopic mucosal resection. Evident perforation during endoscopic mucosal resection can be managed by endoscopic clipping. However, management of microperforation is not well established.

PATIENT AND METHOD

From January 2002 to June 2004, 109 early gastric cancers and 300 adenomas were treated with endoscopic mucosal resection. Iatrogenic perforations occurred in 4.16% (n=17) patients. Following exclusion of four evident perforations, microperforation was observed in 3.18% (n=13) patients. The clinical features of microperforation in patients were retrospectively reviewed.

RESULTS

In a total of 13 microperforation cases, 2 patients were managed surgically. The remaining patients successfully recovered without surgical management. In the case of 11 patients without surgery, 7 experienced abdominal pain, which required analgesics, 2 patients experienced mild discomfort and 2 patients experienced no symptoms. A body temperature above 37.5 degrees C was observed in 9.1% (n=1) patients and leucocytosis above 9000 microL-1 was in 72.7% (n=8) patients. The mean duration of nasogastric tube drainage was 2.36+/-1.03 days, of fasting 4.18+/-1.17 days, of intravenous antibiotics 5.55+/-1.44 days and of hospitalisation 7.45+/-1.04 days.

CONCLUSION

Microperforation induced by gastric endoscopic mucosal resection can be managed successfully using a non-surgical approach including fasting, nasogastric tube drainage and intravenous antibiotics.

Enteroendocrine cell counts correlate with visceral hypersensitivity in patients with diarrhoea-predominant irritable bowel syndrome

The objective of this study was to determine whether or not the number of enteroendocrine cells (ECs) in the gut is related to visceral hypersensitivity in patients with diarrhoea-predominant irritable bowel syndrome (D-IBS). Twenty-five subjects with D-IBS (mean, 43.1 years; 16 women, nine men) were recruited into our study, along with 13 healthy controls (mean, 40.7 years; nine women, four men). Maximally tolerable pressures were evaluated via barostat testing, and the levels of ECs were immunohistochemically identified and quantified via image analysis. The numbers of ECs between the D-IBS subjects and the controls were not significantly different in the terminal ileum, ascending colon and rectum. However, the maximally tolerable pressures determined in the D-IBS subjects were significantly lower than those of the control subjects (P < 0.01), and we detected a significant relationship between the maximally tolerable pressures and the numbers of ECs in the rectum (r = -0.37, P < 0.01). Rectal sensitivity was enhanced to a greater degree in D-IBS patients exhibiting an elevated level of rectal ECs. This study provides some evidence to suggest that ECs play an important role in visceral hypersensitivity.

Enteroendocrine cell counts correlate with visceral hypersensitivity in patients with diarrhoea-predominant irritable bowel syndrome

The objective of this study was to determine whether or not the number of enteroendocrine cells (ECs) in the gut is related to visceral hypersensitivity in patients with diarrhoea-predominant irritable bowel syndrome (D-IBS). Twenty-five subjects with D-IBS (mean, 43.1 years; 16 women, nine men) were recruited into our study, along with 13 healthy controls (mean, 40.7 years; nine women, four men). Maximally tolerable pressures were evaluated via barostat testing, and the levels of ECs were immunohistochemically identified and quantified via image analysis. The numbers of ECs between the D-IBS subjects and the controls were not significantly different in the terminal ileum, ascending colon and rectum. However, the maximally tolerable pressures determined in the D-IBS subjects were significantly lower than those of the control subjects (P < 0.01), and we detected a significant relationship between the maximally tolerable pressures and the numbers of ECs in the rectum (r = -0.37, P < 0.01). Rectal sensitivity was enhanced to a greater degree in D-IBS patients exhibiting an elevated level of rectal ECs. This study provides some evidence to suggest that ECs play an important role in visceral hypersensitivity.

Primary colon lymphoma in Korea: a KASID (Korean Association for the Study of Intestinal Diseases) Study

Although almost all primary colorectal lymphomas are of B-cell lineage in Western countries, primary colorectal T-cell lymphomas are not uncommon in the East. The aim of this study was to review the clinical characteristics and treatment outcomes of primary colorectal lymphomas, with special emphasis on the differences between T-cell and B-cell lymphomas. Ninety-five cases of primary colorectal lymphomas that satisfied Dawson's criteria were identified from the clinical databases of 13 university hospitals in Korea. The mean age at the time of presentation was 51.1 years and the male:female ratio was 64:31. The clinical information, including endoscopic and histological characteristics, was retrospectively analyzed. Of the primary colorectal lymphomas, 78 cases (82.1%) were of B-lineage and 17 cases (17.9%) were of T-cell lineage. Patients with T-cell lymphomas presented at a younger age than patients with B-cell lymphomas (42.8 vs 52.9 years, respectively; P = 0.016). The most common presenting symptom was abdominal pain (87.1%) for B-cell lymphomas, whereas hematochezia or night fever was more common for T-cell lymphomas (52.9% and 35.3%, respectively). The most common endoscopic type was fungating mass (54.0%) for B-cell lymphomas and ulcerative/ulcero-infiltrative lesions (80.0%) for T-cell lymphomas. Intussusception was more common in B-cell lymphomas than in T-cell lymphomas (30.8% vs 5.9%, respectively; P = 0.035), but perforation was more common in T-cell lymphomas than in B-cell lymphomas (23.5% vs 3.8%, respectively; P = 0.005). The prognosis was significantly worse for T-cell lymphomas than for B-cell lymphomas (P = 0.002). Primary colorectal T-cell lymphomas are characterized by multifocal ulcerative lesions in relatively young patients, a high rate of hematochezia, fever, or perforation, and a poor prognosis even for cases of localized disease.

Does this patient have oesophageal motility abnormality or pathological acid reflux?

BACKGROUND AND AIMS

The diagnostic values of particular symptoms centred on oesophagus, among patients with suspected oesophageal motility abnormality or pathological acid exposure, are not yet fully understood. The aim of this study was to determine the predictive accuracy of these symptoms in diagnosis of oesophageal motility disorder or pathological acid exposure. PATIENTS AND METHODS.: A total of 462 patients who had undergone conventional oesophageal manometry and ambulatory 24-h pH monitoring to investigate a clinical suspicion of oesophageal motility disorder and pathological acid exposure were enrolled in this study. According to their principal complaints, the patients were divided into the dysphagia category, the non-cardiac chest pain category, the gastrooesophageal reflux disease-related symptom category and the extraoesophageal symptom category.

RESULTS

Two hundred and two (44%) out of 462 patients yielded abnormal findings on manometry and/or pH monitoring. Dysphagia was associated with a likelihood ratio (LR) of 2.11 [95% confidence interval (CI), 1.02-4.00)] in patients exhibiting a combination of oesophageal motility abnormality and pathological acid exposure. During oesophageal manometry, the dysphagia substantially increased the likelihood of classic achalasia (LR, 6.24; 95% CI, 3.32-8.78) and diffuse oesophageal spasm (LR, 3.58; 95% CI, 1.03-7.12). When the patients with dysphagia were divided into two groups according to the severity of their symptoms, classic achalasia was significantly frequent in patients with severe dysphagia (P = 0.016). On the other hand, non-cardiac chest pain was the clinical factor that reduced the likelihood of classic achalasia (LR, 0.22; 95% CI, 0.04-0.93). The distribution of pathological acid exposure was significantly frequent between the groups of patients with and without gastrooesophageal reflux disease-related symptom (P = 0.011).

CONCLUSION

A small number of oesophageal symptoms are helpful in predicting the likelihood of abnormal findings on oesophageal tests among patients with a clinical suspicion of oesophageal motility disorder and pathological acid exposure. The most useful finding is a severe dysphagia, which is likely to have classic achalasia.

The role of follow-up endoscopy after total gastrectomy for gastric cancer

BACKGROUND

Follow-up endoscopy after total gastrectomy for gastric cancer is commonly performed without there being any definite evidence of clinical relevance. Therefore, we investigated the role of the upper endoscopic examinations after total gastrectomy for gastric cancer.

METHODS

The medical records of 212 early gastric cancer (EGC) patients and 622 advanced gastric cancer (AGC) patients who underwent follow-up endoscopic examination after total gastrectomy between 1994 and 2001 were reviewed.

RESULTS

Two of 212 EGC patients and 233 of 622 AGC patients revealed tumour recurrence at all sites. All the endoscopically accessible local tumour recurrences (n=24) were found in the AGC group. Anastomosis site stenosis was detected in 72 of 834 patients.

CONCLUSION

Follow-up endoscopy after total gastrectomy for gastric cancer is useful in detecting complications and tumour recurrence. However, this procedure has a limited role in the clinical management and overall survival for patients with recurrent gastric adenocarcinoma.

Characteristics of submucosal gastric carcinoma with lymph node metastatic disease

AIM

To study the correlation between lymph node metastatic disease and various pathological parameters. Lymph node metastasis is the most important factor in determining the prognosis of patients with early gastric cancer and is significantly associated with the submucosal invasion of neoplastic cells. However, the depth of submucosal layer as well as the depth of submucosal tumour invasion varies among different cases.

METHODS AND RESULTS

We studied various pathological parameters including the macroscopic appearance, location, size, area, differentiation, invasion depth, vascularity and fibrosis of submucosal gastric carcinomas (SMGC), using 248 age- and sex-matched tissue samples. The presence of lymphatic emboli, a larger area, greater size, a non-flat gross type and an increased vascularity of the tumour were significantly associated with node-positive SMGC. Among the three depth-related parameters, the ocular scale measurement, the sm3 method and the sm2 method, only the ocular scale measurement showed a significant correlation with node-positive SMGC. Using multivariate analysis, the incidence of lymph node metastasis increased in the lymphatic tumour emboli and in the tumours that invaded more than half of the submucosal layer.

CONCLUSIONS

These histological indicators seem to be a feasible and easy way to predict lymph node metastatic disease from limited surgery specimens. Pathologists should carefully investigate the lymphatic invasion of tumour cells and measure the invasion depth of the tumour.

Characteristics of submucosal gastric carcinoma with lymph node metastatic disease

AIM

To study the correlation between lymph node metastatic disease and various pathological parameters. Lymph node metastasis is the most important factor in determining the prognosis of patients with early gastric cancer and is significantly associated with the submucosal invasion of neoplastic cells. However, the depth of submucosal layer as well as the depth of submucosal tumour invasion varies among different cases.

METHODS AND RESULTS

We studied various pathological parameters including the macroscopic appearance, location, size, area, differentiation, invasion depth, vascularity and fibrosis of submucosal gastric carcinomas (SMGC), using 248 age- and sex-matched tissue samples. The presence of lymphatic emboli, a larger area, greater size, a non-flat gross type and an increased vascularity of the tumour were significantly associated with node-positive SMGC. Among the three depth-related parameters, the ocular scale measurement, the sm3 method and the sm2 method, only the ocular scale measurement showed a significant correlation with node-positive SMGC. Using multivariate analysis, the incidence of lymph node metastasis increased in the lymphatic tumour emboli and in the tumours that invaded more than half of the submucosal layer.

CONCLUSIONS

These histological indicators seem to be a feasible and easy way to predict lymph node metastatic disease from limited surgery specimens. Pathologists should carefully investigate the lymphatic invasion of tumour cells and measure the invasion depth of the tumour.

Characteristics of intramucosal gastric carcinoma with lymph node metastatic disease

AIM

Recent trends in treatment strategy for early gastric cancer (EGC) are towards minimal surgical procedures, such as endoscopic mucosal resection and laparoscopic partial resection. There is a possibility of incomplete removal of regional lymph nodes in minimal procedures, which may subsequently decrease the chance of a cure. Therefore, it is essential to be able to predict lymph node status and to make careful selection of candidates for mucosal resection.

METHODS AND RESULTS

We studied the relationship between lymph node status and various pathological parameters including macroscopic appearance, location, size, differentiation, presence of ulceration, vascularity, presence of gastritis cystica profunda-like glandular proliferation, disruption of the muscularis mucosae and invasion into the muscularis mucosae, using age- and sex-matched samples of 40 node-positive and 80 node-negative tumours to define the characteristics of intramucosal EGCs. Histological differentiation (P < 0.001), increased submucosal vascularity (P < 0.05), breakdown of the muscularis mucosae (P < 0.05), and invasion of tumour cells into the muscularis mucosae (P < 0.05) were correlated with the lymph node status of intramucosal gastric carcinoma. Furthermore, diffuse type histology (P < 0.001) and deep invasion into the muscularis mucosae (P < 0.05) were indicators of node-positive intramucosal EGCs.

CONCLUSIONS

These histological indicators are easily accessible and seem to predict lymph node metastatic disease in limited surgical specimens. Patients should be carefully selected despite the recent trend toward less invasive resection of EGCs, especially for those apparently confined to the mucosa.

Characteristics of intramucosal gastric carcinoma with lymph node metastatic disease

AIM

Recent trends in treatment strategy for early gastric cancer (EGC) are towards minimal surgical procedures, such as endoscopic mucosal resection and laparoscopic partial resection. There is a possibility of incomplete removal of regional lymph nodes in minimal procedures, which may subsequently decrease the chance of a cure. Therefore, it is essential to be able to predict lymph node status and to make careful selection of candidates for mucosal resection.

METHODS AND RESULTS

We studied the relationship between lymph node status and various pathological parameters including macroscopic appearance, location, size, differentiation, presence of ulceration, vascularity, presence of gastritis cystica profunda-like glandular proliferation, disruption of the muscularis mucosae and invasion into the muscularis mucosae, using age- and sex-matched samples of 40 node-positive and 80 node-negative tumours to define the characteristics of intramucosal EGCs. Histological differentiation (P < 0.001), increased submucosal vascularity (P < 0.05), breakdown of the muscularis mucosae (P < 0.05), and invasion of tumour cells into the muscularis mucosae (P < 0.05) were correlated with the lymph node status of intramucosal gastric carcinoma. Furthermore, diffuse type histology (P < 0.001) and deep invasion into the muscularis mucosae (P < 0.05) were indicators of node-positive intramucosal EGCs.

CONCLUSIONS

These histological indicators are easily accessible and seem to predict lymph node metastatic disease in limited surgical specimens. Patients should be carefully selected despite the recent trend toward less invasive resection of EGCs, especially for those apparently confined to the mucosa.

Outcomes in patients with hepatopulmonary syndrome undergoing liver transplantation

Hepatopulmonary syndrome (HPS) is a condition of significant hypoxia due to intrapulmonary shunting (IPS) in patients with advanced liver disease. Reversibility of HPS after liver transplantation (LT) has been suggested, but the results of LT for HPS remain poorly defined. We studied 78 patients with decompensated liver disease who underwent LT after a preoperative evaluation including contrast echocardiography. We compared the baseline characteristics and outcomes after LT in patients with HPS (n = 13) with those of patients without HPS (n = 65, controls). Before LT, prolongation of prothrombin time was more severe and an advanced Child-Pugh class were more frequent among HPS, patients compared with controls (INR 2.5 +/- 0.8 vs 1.9 +/- 0.7, P = .01; Child-Pugh class A:B:C = 0%:31%:69% vs 14%:65%:21%, P < .01). After LT, no significant differences were observed between the two groups in: clinical outcomes, duration of endotracheal intubation (4.5 +/- 7.7 vs 4.4 +/- 15.0 days), duration of intensive care unit stay (12.0 +/- 8.7 vs 14.4 +/- 19.4 days), duration of total hospital stay (40.0 +/- 33.5 vs 39.8 +/- 23.0), rate of pulmonary complications (7.7% vs 9.2%), or 3-month survival rates (92.3% vs 86.1%). These findings suggest that the presence of HPS does not significantly affect LT outcomes in patients with decompensated liver disease.

Overexpression of Id-1 is significantly associated with tumour angiogenesis in human pancreas cancers

It has been suggested that Id-1 has a critical role in the tumour progression and aggressiveness of several human cancers. However, the clinicopathological and biological significance of Id-1 overexpression remains unclear in human primary cancer. To investigate the association between Id-1 expression and cell proliferation or tumour angiogenesis, we examined the cell cycle kinetic indices (the proliferation and apoptotic indices, PI and AI) and intratumoral microvessel density (MVD) in 65 human pancreatic cancers. We also investigated the relationship between its expression and various clinicopathological factors to determine the clinical significance of Id-1 overexpression. Out of a total 65 cases, 32 (49.3%) showed overexpression of Id-1 vs normal tissues. Id-1 expression was found to be significantly associated with MVD (P=0.002). In further analysis of subgroups with higher and lower Id-1 expression, tumours with higher Id-1 expression (scores 4 and 5) showed significantly higher MVD than tumours with lower expression of Id-1 (scores 2 and 3) (111.18+/-57.14 vs 64.13+/-28.19, P<0.001). However, no significant association was found between Id-1 overexpression and patient survival rate. No significant association was also found between Id-1 expression and cell cycle kinetic indices (PI or AI) in pancreatic cancer. Moreover, the overexpression of Id-1 protein was not correlated with any significant clinicopathologic factors. These findings indicate that Id-1 overexpression is closely related with tumour angiogenesis and a higher density of intratumoral vessel, but that it is not associated with a poorer prognosis of survival or a higher cell proliferative potential in human pancreatic cancer.

Colonoscopic manifestations of typhoid fever with lower gastrointestinal bleeding

BACKGROUND

Intestinal bleeding in patients with typhoid fever usually occurs in the ileum. However, endoscopic findings in such patients are not well established. We examined the colonoscopic manifestations of intestinal lesions with bleeding in patients with typhoid fever.

PATIENTS AND METHODS

The colonoscopic findings of seven patients who presented with haematochezia due to typhoid fever were reviewed retrospectively. Typhoid fever was diagnosed when the Salmonella typhi was isolated or when the Widal test showed strongly positive reactions.

RESULTS

Clinical data and colonoscopic findings were reviewed in seven patients (four men and three women with an average age of 42 years). The most commonly involved area was the terminal ileum (100%), followed by the ileocecal valve (57%), the ascending colon (43%), and the transverse colon (29%). Left colon was intact in all cases. The most common colonoscopic finding was multiple variable-sized punched-out ulcers with slightly elevated margin, as found in five patients. In two patients, only several oedematous hyperaemic mucosal patches with haemorrhagic spots or shallow erosions were seen. Active bleeding was noticed only in one patient, who received endoscopic haemostasis twice. The remaining six patients were treated by conservative treatment including antibiotic therapy. There was no complication during or after the colonoscopic examination.

CONCLUSIONS

Intestinal bleeding in typhoid fever usually occurs from the ulcers in the ileum or proximal colon, and the most common colonoscopic manifestations are multiple variable-sized punched-out ulcerations.

Colonoscopic manifestations of typhoid fever with lower gastrointestinal bleeding

BACKGROUND

Intestinal bleeding in patients with typhoid fever usually occurs in the ileum. However, endoscopic findings in such patients are not well established. We examined the colonoscopic manifestations of intestinal lesions with bleeding in patients with typhoid fever.

PATIENTS AND METHODS

The colonoscopic findings of seven patients who presented with haematochezia due to typhoid fever were reviewed retrospectively. Typhoid fever was diagnosed when the Salmonella typhi was isolated or when the Widal test showed strongly positive reactions.

RESULTS

Clinical data and colonoscopic findings were reviewed in seven patients (four men and three women with an average age of 42 years). The most commonly involved area was the terminal ileum (100%), followed by the ileocecal valve (57%), the ascending colon (43%), and the transverse colon (29%). Left colon was intact in all cases. The most common colonoscopic finding was multiple variable-sized punched-out ulcers with slightly elevated margin, as found in five patients. In two patients, only several oedematous hyperaemic mucosal patches with haemorrhagic spots or shallow erosions were seen. Active bleeding was noticed only in one patient, who received endoscopic haemostasis twice. The remaining six patients were treated by conservative treatment including antibiotic therapy. There was no complication during or after the colonoscopic examination.

CONCLUSIONS

Intestinal bleeding in typhoid fever usually occurs from the ulcers in the ileum or proximal colon, and the most common colonoscopic manifestations are multiple variable-sized punched-out ulcerations.

Increased risk of peristomal wound infection after percutaneous endoscopic gastrostomy in patients with diabetes mellitus

BACKGROUND

Results of prospective studies on the effect of prophylactic antibiotics before percutaneous endoscopic gastrostomy are conflicting. Factors for increased risk of peristomal wound infection have not been clearly identified.

AIM

To evaluate the incidence of complications of percutaneous endoscopic gastrostomy and to determine the predictors of wound infection.

PATIENTS AND METHODS

Percutaneous endoscopic gastrostomy was performed on 134 patients in different disease groups between January 1996 and June 2000. Medical records were carefully reviewed for demographic data, indications for percutaneous endoscopic gastrostomy, use of prophylactic antibiotics, complications and comorbid conditions predisposing to wound infection.

RESULTS

Of 134 patients, 22 (16.4%) developed complications after percutaneous endoscopic gastrostomy Wound infection, the most common complication, occurred in 19 patients (14.2%) and Pseudomonas aeruginosa was the most frequently isolated microorganism. In univariate analysis, non-malignant disease and diabetes mellitus were significantly associated with peristomal wound infection after percutaneous endoscopic gastrostomy. In multivariate analysis, only diabetes mellitus was an independent risk factor for the development of peristomal wound infection after percutaneous endoscopic gastrostomy (p = 0.035)

CONCLUSIONS

Patients with diabetes mellitus have a higher risk of peristomal wound infection after percutaneous endoscopic gastrostomy.

Long-term stress and Helicobacter pylori infection independently induce gastric mucosal lesions in C57BL/6 mice

BACKGROUND

Long-term psychological stresses may have a role in the pathogenesis of peptic ulcer. However, the interaction between stress and Helicobacter pylori infection in the development of peptic ulcer is not established. The aim of this study was to elucidate the roles of long-term stress and H. pylori infection in the development of gastric mucosal lesions in mice.

METHODS

The Sydney strain (SS1) of H. pylori was inoculated into the stomach of C57BL/J6 mice. Twelve weeks later, mice with or without H. pylori infection were exposed to long-term repeated water-immersion-restraint stress (WIRS) for 12 h per day, 3 times per week, for 8 weeks. Gastric mucosal lesions were evaluated both macroscopically (ulcer index) and microscopically (Updated Sydney System).

RESULTS

The long-term WIRS induced mild inflammation, oedema, interstitial haemorrhage and superficial erosions in the stomach of mice both with and without H. pylori infection. The degree of mucosal inflammation or atrophy in H. pylori-infected mice was not influenced by the stress. In the mice without H. pylori infection, the ulcer index of the stressed mice was greater than that of non-stressed mice (1.66 +/- 0.39 versus 0.17 +/- 0.08, P = 0.007). In the mice with H. pylori infection, the ulcer index (mean +/- s(x)) of the stressed mice was also greater than that of non-stressed mice (2.31 +/- 0.59 versus 0.64 +/- 0.22, P = 0.027).

CONCLUSIONS

The present study showed that long-term stress can induce gastric mucosal inflammation and erosions, and this effect may occur independently of H. pylori infection.

Inducible nitric oxide synthase (iNOS) immunoreactivity and its relationship to cell proliferation, apoptosis, angiogenesis, clinicopathologic characteristics, and patient survival in pancreatic cancer

BACKGROUND

The clinicopathological and biological significance of the expression of iNOS in pancreatic cancer remains unclear. The goal of this study was to determine the possible roles and clinical significance of iNOS expression in pancreatic cancer.

METHODS

Seventy-two pancreatic adenocarcinoma tissue specimens were obtained by surgical resection. We investigated the immunohistochemical expression of iNOS in 72 patients with pancreatic cancer with respect to variable clinicopathological characteristics, proliferation activity (assessed by Ki-67 expression), apoptosis (assessed by TUNEL stain), and microvessel density (assessed by CD34 expression; angiogenesis).

RESULTS

Immunohistochemical investigations demonstrated immunolabeling of tumor cells with anti-iNOS antibody. Positivity for iNOS was observed in 48/72 (66.7%). The expression of iNOS protein did not correlate with age, bilirubin, tumor marker, location, size, AJCC stage, differentiation, distant metastasis, or patient survival. No significant association was found between iNOS expression and proliferation or microvessel density in pancreatic cancer. Apoptotic index (AI) of positive iNOS expressions were significantly higher than negative expression (p < 0.001).

CONCLUSION

Inducible nitric oxide synthase (iNOS) is expressed by human pancreatic cancer, and its presence is positively correlated with apoptosis of cancer cells that could provide the basis for the development of therapeutic strategies in human pancreatic cancer.

Efficacy of low-dose clarithromycin triple therapy and tinidazole-containing triple therapy for Helicobacter pylori eradication

BACKGROUND

Proton pump inhibitor-based triple therapies are recommended as the first-line treatment for Helicobacter pylori eradication.

AIM

To evaluate the efficacies of low-dose clarithromycin triple therapy and tinidazole-containing triple therapy in a metronidazole resistance prevalent area and to compare the efficacies with standard triple therapy.

METHODS

In a randomized, multicentre, prospective study, a total of 352 patients with duodenal ulcer or non-ulcer dyspepsia were randomly divided into three groups according to the administered regimen: OAC250 group (omeprazole, 20 mg, amoxicillin, 1000 mg, and clarithromycin, 250 mg), OAC500 group (omeprazole, 20 mg, amoxicillin, 1000 mg, and clarithromycin, 500 mg) and OTC group (omeprazole, 20 mg, tinidazole, 500 mg, and clarithromycin, 500 mg). The three groups received each regimen twice daily for 7 days. Upper gastrointestinal endoscopy was performed before and 4 weeks after treatment. H. pylori status was determined by rapid urease test and 13C urea breath test.

RESULTS

The eradication rates in the OAC250, OAC500 and OTC groups were 76.2%, 65.7% and 64.8% (95% confidence interval: 67.9-84.4%, 56.7-74.8% and 55.7-73.9%), respectively, by intention-to-treat analysis (P=0.149) and 92.8%, 87.2% and 84.1% (95% confidence interval: 84.4-97.3%, 77.9-93.8% and 73.9-91.2%), respectively, by per protocol analysis (P=0.088). All regimens were well tolerated and compliance was excellent.

CONCLUSIONS

Both low-dose clarithromycin triple therapy and tinidazole-containing triple therapy are effective and safe regimens for H. pylori eradication.

The effect of sildenafil on lower esophageal sphincter and body motility in normal male adults

OBJECTIVE

Sildenafil relaxes smooth muscle by blocking type 5 phosphodiesterase, which destroys nitric oxide-stimulated cyclic guanosine monophosphate. The aim of this study is to investigate the change of lower esophageal sphincter (LES) and body motility with the lapse of time after sildenafil infusion in normal male adults.

METHODS

After basal esophageal manometry in eight healthy male adult volunteers, we infused a 50-mg tablet of sildenafil dissolved in water in the stomach through the manometry catheter and observed the changes of LES and body motility with the lapse of time. We randomized the study population into two groups, and esophageal manometry was repeated in LES and body sequence in four volunteers and in body and LES sequence in the other four volunteers immediately after sildenafil infusion.

RESULTS

LES resting pressure significantly decreased after sildenafil infusion. The body peristaltic amplitude gradually decreased and eventually disappeared, and the latency increased significantly after sildenafil infusion in both the proximal and distal esophagus.

CONCLUSIONS

These data support that nitric oxide mediates LES relaxation and the timing of esophageal peristalsis. In the future, sildenafil can be tried in some esophageal motor disorders, which have defects in nitric oxide neuromuscular communication.

Interaction between cyclooxygenase-2 and inducible nitric oxide synthase in gastric cancer

BACKGROUND

Chronic expression of cylcooygenase-2 (COX-2) and inducible nitric oxide synthase (iNOS) may play an important role in gastric carcinogenesis. Thus, the purpose of our study was to assess the expression of COX-2 and iNOS messenger RNA (mRNA) in gastric cancer and to investigate the correlation between the expression of COX-2 and iNOS mRNA in these patients.

STUDY

Twenty-three gastric carcinoma specimens and accompanying adjacent specimens were obtained from surgical resection. The expression of COX-2 and iNOS were examined by comparative reverse transcription polymerase chain reaction.

RESULTS

Cylcooygenase-2 and iNOS mRNA were significantly higher in gastric cancer tissues than in adjacent normal tissues. There was significant correlation between the levels of COX-2 and iNOS mRNA in carcinoma tissues. However, there was no significant correlation between the level of COX-2 or iNOS mRNA expression and several clinicopathologic parameters in these patients.

CONCLUSION

The expression of COX-2 and iNOS may be one of the factors that contribute to gastric carcinogenesis.

Role of autonomic dysfunction in patients with functional dyspepsia

BACKGROUND

The role of autonomic dysfunction in patients with functional dyspepsia is not completely understood.

AIMS

1. to prospectively assess abnormalities of autonomic function in patients with functional dyspepsia, 2. to assess whether autonomic dysfunction in these patients is associated with a. visceral hypersensitivity or b. delayed gastric emptying or c. severity of dyspeptic symptoms.

PATIENTS

A series of 28 patients with functional dyspepsia and 14 healthy volunteers without gastrointestinal symptoms were studied.

METHODS

All patients and controls were submitted to a battery of five standard cardiovascular autonomic reflex tests, dyspeptic questionnaire, gastric barostat tests and gastric emptying tests.

RESULTS

1. Autonomic function tests showed that both sympathetic and parasympathetic scores of dyspeptic patients were significantly higher than in controls; 2. visceral hypersensitivity was confirmed in dyspeptics in response to proximal gastric distension, demonstrating lower pain threshold; 3. delayed gastric emptying occurred more frequently in patients with functional dyspepsia than in controls; 4. epigastric pain and epigastric burning were significantly more prevalent in patients with definite evidence of autonomic dysfunction; 5. No significant association was found between presence of autonomic dysfunction and presence of visceral hypersensitivity or presence of delayed gastric emptying in patients with functional dyspepsia.

CONCLUSIONS

We concluded that a possible role of autonomic dysfunction in eliciting dyspeptic symptoms could not be determined from alterations in visceral hypersensitivity or delayed gastric emptying. Autonomic dysfunction might not be the major explanation for symptoms associated with functional dyspepsia.

The clinical significance of common bile-duct dilatation in patients without biliary symptoms or causative lesions on ultrasonography

BACKGROUND AND STUDY AIMS

Although abdominal ultrasonography (US) is a good initial screening method for detection of biliary tract disease, we sometimes encounter patients who only have findings of dilatation of the common bile duct (CBD) on US, without specific biliary symptoms or jaundice. This study aimed to evaluate the causes and clinical significance of dilatation of the CBD in patients without biliary symptoms, jaundice, or causative lesions at US.

PATIENTS AND METHODS

A total of 77 patients who had no biliary symptoms and whose internal CBD diameter was more than 7 mm, without definite causative lesions on US, were enrolled. Of these, 49 underwent endoscopic retrograde cholangiopancreatography (ERCP) and 28 underwent follow-up US or computed tomography (CT) instead of ERCP. We excluded patients whose bilirubin level had increased beyond the upper normal level or who had previous history of upper abdominal surgery including cholecystectomy.

RESULTS

The ERCP findings were as follows: no lesion in 20 patients (40.8%), juxtapapillary duodenal diverticulum (JDD) in 11 (22.5%), benign stricture in ten (20.4%), distal CBD mass in two (4.1%), choledochal cyst in two (4.1%), anomalous union of the pancreaticobiliary duct (AUPBD) in two (4.1%), and choledochal cyst with AUPBD in two (4.1%). There were no differences in age or in alkaline phosphatase or gamma-glutamyl transpeptidase (GGT) levels between the patients who had causative lesions revealed at ERCP and those who did not. Among the 28 patients who did not undergo ERCP, 12 had returned to normal and eight had no change in CBD diameter on follow-up US. Among eight patients who underwent CT, there were four with normal findings, one with JDD, and three with suspected choledochal cysts.

CONCLUSIONS

We detected a significant number of causative biliary tract lesions in asymptomatic adults with dilatation of the CBD on routine abdominal US; no laboratory or demographic parameters were useful for discrimination. Further diagnostic study will be helpful for the early diagnosis of biliary tract disease in such patients.

Risk factors suggesting malignant transformation of gastric adenoma: univariate and multivariate analysis

BACKGROUND AND STUDY AIMS

Since gastric adenomas are precancerous lesions, polypectomy is necessary. However, there have been no reports suggesting factors capable of predicting malignant transformation of gastric adenomas removed by endoscopic snare polypectomy (ESP) or endoscopic mucosal resection (EMR) in Korea, a country in which gastric cancer is a major problem. The aim of this paper was to elucidate the risk factors suggesting malignant transformation of gastric adenomas removed by ESP or EMR at our center.

PATIENTS AND METHODS

Between November 1994 and June 1999, 118 gastric adenomas diagnosed on the basis of endoscopy and histological examinations of the forceps biopsy specimens obtained were treated by ESP or EMR at our department. Factors capable of predicting malignancy were searched for in the endoscopy reports, still photographs, and histopathological findings.

RESULTS

Eight of the 118 adenomas ultimately proved to have malignant foci. In the univariate analysis, four of the variables studied--location, histological type, surface redness, and degree of dysplasia--had a statistically significant relationship with malignant transformation. In the multivariate analysis, only the degree of dysplasia had a statistically significant relationship with malignant transformation.

CONCLUSIONS

These results suggest that a diagnosis of high-grade dysplasia in forceps biopsy material should be considered an absolute indication for ESP or EMR.

Clinical significance of enlarged perihepatic lymph nodes in chronic hepatitis B

GOALS

To evaluate the clinical significance of enlarged perihepatic lymph nodes in patients with chronic hepatitis B.

BACKGROUND

Enlargement of perihepatic lymph node is a common finding during ultrasonography in patients with chronic hepatitis. Its relation with liver histology and viremia was reported in chronic hepatitis C, but little has been known about its clinical significance in chronic hepatitis B.

STUDY

We evaluated the clinical significance of perihepatic lymphadenopathy in chronic hepatitis B. In 50 patients with biopsy-proven chronic hepatitis B and 15 healthy controls, the perihepatic lymph node volume was evaluated by ultrasonography and its possible correlation with biochemical tests, hepatitis activity index, and hepatitis B viremia was investigated.

RESULTS

Perihepatic lymph node was detected in 48 of 50 patients with chronic hepatitis B (volume = 3.4 +/- 2.4 mL) and in two of 15 controls (0.4 mL and 0.6 mL). In chronic hepatitis B, lymph node volume showed a significant correlation with serum aspartate transaminase (r = 0.66), alanine transaminase (r = 0.63), gamma-glutamyl-transpeptidase (r = 0.53), histologic activity index (r = 0.59), and necroinflammatory score (r = 0.59; p < 0.05 for all), but not with fibrosis score and serum hepatitis B viremia.

CONCLUSIONS

Enlarged perihepatic lymph nodes in chronic hepatitis B can be a good indicator for histologic and biochemical inflammatory activity of the liver, but not for viremia.

Lipiodol accumulation in focal peliosis hepatis with sinusoidal dilatation

Peliosis hepatis is a rare benign condition that is histologically characterized by multiple cystic blood-filled spaces in the liver. Although the cause is unknown, the condition occurs in association with several diseases or medications. We report a patient who was found to have a lesion with lipiodol accumulation in the liver 2 months after its intraarterial injection. The lesion was diagnosed and treated as a small hepatocellular carcinoma. However, subsequent right hepatic lobectomy and histologic examination confirmed the diagnosis of focal peliosis hepatis.

Inducible nitric oxide synthase expression in gastroduodenal diseases infected with Helicobacter pylori

BACKGROUND

Nitric oxide (NO) is synthesized enzymatically from L-arginine by NO synthase, which is measured by inducible NO synthase (iNOS). Helicobacter pylori (H. pylori) infection produces a state of chronic immunostimulation in the gastric epithelium. Infection with cagA+ H. pylori has greater degree of gastric inflammation and epithelial cell damage. Therefore, we compared the levels of iNOS in patients with H. pylori infection in relation to cagA status and H. pylori-related disease.

MATERIALS AND METHODS

One hundred and seven patients, including 51 patients with gastric cancer, 12 patients with gastric ulcer, 18 patients with duodenal ulcer and 26 patients with chronic gastritis, were enrolled in this study. Biopsies from the antrum and body were obtained for histologic examination, culture and reverse transcriptionase-PCR (RT-PCR) for detection of iNOS gene expression. The presence of H. pylori was confirmed by Giemsa staining or culture and the gene expression of cagA in H. pylori isolates was confirmed by PCR.

RESULTS

H. pylori infection was detected in 70.1% (75/107) and cagA was detected in 84.8% (28/33). iNOS expression was detected in 49.5% (53/107) and there was no significant difference in iNOS expression according to H. pylori infection nor the cagA status in the gastroduodenal diseases. However, iNOS expression was more frequently detected in gastric cancer than the other H. pylori-related diseases (64.7% vs. 35.7%, p <.05).

CONCLUSION

Although NO was thought be involved in the gastric carcinogenesis, the level of NO production was not related to H. pylori infection or cagA status.

The analysis of resectability and survival in pancreatic cancer patients with vascular invasion

One of the major limitations of curative resection in patients with pancreatic cancer is local tumor extension to the mesenteric vessels. Thus, the purposes of our study were to assess the clinical value of contrast-enhanced spiral computed tomography (CT) in predicting the resectability and survival of patients with pancreatic cancer with suspicious vascular invasion and to assess the influence of curative resection on the survival of these patients. We enrolled 40 patients with pancreatic cancer who were suspected of having an involvement of the adjacent large vessels and who subsequently underwent operation with curative intent in the study. Resectability and survival were correlated with CT findings such as segment length, degree of encasement, and type and number of vessels involved. The survival rate was compared between the curative and palliative resection groups, and survival rate was compared between the resected and unresected groups. Of the 40 patients with adenocarcinoma of the pancreas, 14 had curative resections and 26 had palliative resections. The probability of curative resection was higher in patients with segment lengths less than 2 cm, as compared with segment lengths more than 2 cm. However, there was no difference in survival between the two groups. There were no differences in resectability and survival according to the degree of encasement and type and number of vessels involved. There was no difference in survival between the curative and palliative resection groups. There was no difference in survival between the resected and unresected groups. A survival benefit was not achieved by curative resection in patients with pancreatic cancer with vascular invasion. Therefore, it would be better to avoid aggressive surgery in patients with pancreatic cancer with vascular invasion.

The properties of carbachol-activated nonselective cation channels at the single channel level in guinea pig gastric myocytes

We investigated the properties of carbachol (CCh)-activated nonselective cation channels (NSC(CCh)) at the single channel level in the gastric myocytes of guinea pigs using a magnified whole-cell mode or an outside-out mode. The channel activity (NPo) recorded in a magnified whole-cell mode increased with depolarization (from -120 to -20 mV) and had the half activation potential of -81 mV under the symmetrical 140 mM Cs+ condition. The single channel conductance depended upon the extracellular monovalent cations with the order of Cs+ (35 pS) > Na+ (25 pS) > Li+ (21 pS). The channel activities markedly diminished or disappeared when external Cs+ was replaced with Na+ or N-methyl-D-glucamate (NMDG+). With Cs+ and Na+ as external cations, the channel showed a monotonic increase in NPo with the increased mole fraction of Cs+ over Na+, and it had an intermediate conductance value in solution containing 67% Cs+ with 33% Na+. These data suggested that the extracellular monovalent cations regulate the whole-cell current of NSC(CCh) by modulating both the open state probability and the unitary conductance, and there is one binding site for the extracellular cations within the pore.

An increased rectal maximum tolerable volume and long anal canal are associated with poor short-term response to biofeedback therapy for patients with anismus with decreased bowel frequency and normal colonic transit time

PURPOSE

Biofeedback is an effective therapy for a majority of patients with anismus. However, a significant proportion of patients still failed to respond to biofeedback, and little has been known about the factors that predict response to biofeedback. We evaluated the factors associated with poor response to biofeedback.

METHODS

Biofeedback therapy was offered to 45 patients with anismus with decreased bowel frequency (less than three times per week) and normal colonic transit time. Any differences in demographics, symptoms, and parameters of anorectal physiologic tests were sought between responders (in whom bowel frequency increased up to three times or more per week after biofeedback) and nonresponders (in whom bowel frequency remained less than three times per week).

RESULTS

Thirty-one patients (68.9 percent) responded to biofeedback and 14 patients (31.1 percent) did not. Anal canal length was longer in nonresponders than in responders (4.53 +/- 0.5 vs. 4.08 +/- 0.56 cm; P = 0.02), and rectal maximum tolerable volume was larger in nonresponders than in responders. (361 +/- 87 vs. 302 +/- 69 ml; P = 0.02). Anal canal length and rectal maximum tolerable volume showed significant differences between responders and nonresponders on multivariate analysis (P = 0.027 and P = 0.034, respectively).

CONCLUSIONS

This study showed that a long anal canal and increased rectal maximum tolerable volume are associated with poor short-term response to biofeedback for patients with anismus with decreased bowel frequency and normal colonic transit time.

Incidence and prevalence of ulcerative colitis in the Songpa-Kangdong District, Seoul, Korea, 1986-1997

BACKGROUND AND AIMS

Ulcerative colitis (UC) is regarded as a rare disease in developing countries, but accurate data are generally lacking. We performed the present study to evaluate the incidence and prevalence of UC in Korea.

METHODS

A retrospective study was performed from 1986 to 1997 in the Songpa-Kangdong district of Seoul, Korea. To recruit UC patients as completely as possible, multiple information sources including all medical facilities in the study area and three referral centres located nearby, but outside the study area were used. The incidence and prevalence rates were adjusted using the 1997 Korean population statistics.

RESULTS

During the study period, a total of 94 incident cases were identified, for an adjusted mean annual incidence rate of 0.68 per 100,000 inhabitants. On 31 December 1997, 91 patients with UC lived in the study area, giving an adjusted prevalence rate of 7.57 per 100,000 inhabitants. By using the Poisson regression analysis, the annual incidence rate increased significantly from 0.20 per 100,000 inhabitants in 1986-1988 to 1.23 per 100,000 inhabitants in 1995-1997 (P < 0.005). Patient age at diagnosis, the interval from onset of symptoms to diagnosis, and the disease extent at diagnosis were fairly constant throughout the study period.

CONCLUSIONS

The incidence and prevalence of UC in our study area are still low compared with those of Western countries, but the incidence rate is steadily increasing.

Hypotonic swelling increases L-type calcium current in smooth muscle cells of the human stomach

The purpose of the present study was to characterize the Ca2+ channels in smooth muscle cells from human stomach and to examine the effects of osmotic swelling on the channel activity. Ca2+ channel current with either Ca2+ or Ba2+ as charge carrier was recorded from freshly isolated smooth muscle cells using the conventional whole-cell patch clamp technique. The degree of cell swelling as a result of hypotonic challenge was monitored using a video image analysis system. The changes in intracellular Ca2+ concentration ([Ca2+]i) were measured by microfluorimetry. The pharmacological and voltage activation profile suggests a typical dihydropyridine-sensitive L-type Ca2+ current. Cell swelling, induced by hypotonic challenge, enhanced the amplitude of currents through L-type Ca2+ channels without significant effects on steady-state voltage dependency. After treatment with the L-type Ca2+ channel agonist Bay K 8644 (0.1-2 microM), no further significant increase in calcium channel current or corresponding [Ca2+]i transients were provoked by the swelling. The above results demonstrated that the presence of L-type Ca2+ current in smooth muscle cells of the human stomach and the augmentation of the current are closely associated with the volume increase resulting from hypotonic swelling.

Evaluation of individual symptoms cannot predict presence of gastric hypersensitivity in functional dyspepsia

Recently, the concept of gastric hypersensitivity was introduced as an important factor in the pathophysiology of functional dyspepsia (FD), but it is unclear which symptoms can predict the presence of gastric hypersensitivity. Therefore, we evaluated the relationship between common symptoms of FD and various parameters measured by gastric barostat in FD patients. Gastric barostat tests were performed in 64 FD patients and 20 healthy control subjects without gastrointestinal symptoms. Individual symptoms such as early satiety, postprandial fullness, sense of delayed emptying, nausea, vomiting, and epigastric soreness were collected and graded as mild to severe. Basal tone, gastric compliance, and postprandial receptive relaxation were similar in controls and patients, the threshold of abdominal discomfort was lower in FD patients than in controls (8.9 +/- 3.6 mm Hg and 14.5 +/- 3.7 mm Hg, respectively, P < 0.05). However, there were no significant differences in the threshold of abdominal discomfort according to the severity of individual symptoms. In conclusion, a simple evaluation of individual symptoms could not predict the presence of gastric hypersensitivity.

Muscarinic receptors controlling the carbachol-activated nonselective cationic current in guinea pig gastric smooth muscle cells

Muscarinic receptor subtypes controlling the nonselective cationic current in response to carbachol (ICCh) were studied in circular smooth muscle cells of the guinea pig gastric antrum using putative muscarinic agonists and antagonists. Both oxotremorine-M (an M2-selective agonist) and CCh dose-dependently activated the cationic current with EC50 values of 0.21 +/- 0.01 microm and 0.97 +/- 0.06 microM, respectively. In contrast, pilocarpine and McN-A 343 (an M1-selective and a putative M4 agonist) were weak partial agonists. In response to 10/microM CCh, 4-DAMP, methoctramine and pirenzepine dose-dependently inhibited ICCh and had IC50 values of 1.91 +/- 0.2 nM, 0.46 +/- 0.07 microM and 8.33 +/- 0.4 microM, respectively. 4-DAMP, methoctramine and pirenzepine shifted the concentration-response curves of ICCh to the right without significantly reducing the maximal current. Values of the apparent dissociation constant pA2 obtained from Schild plot analysis were 9.24, 7.72 and 6.62 for 4-DAMP, methoctramine and pirenzepine, respectively. Also, pertussis toxin completely blocked ICCh generation. These results suggest that the M2-subtype plays a crucial role in the activation of the ICCh, and a block of the M3-subtype reduces the sensitivity of the M2-mediated response with no significant reduction of maximum response.

The etiologic role of gastric hypersensitivity in functional dyspepsia in Korea

To evaluate the role of gastric hypersensitivity and the relationship between gastric hypersensitivity and delayed gastric emptying in Korean functional dyspepsia (FD) patients, the authors performed gastric barostat and gastric emptying scintigraphy in 64 FD patients and compared these results with those of control subjects. Basal tones and gastric compliance were similar in control subjects and patients. However, threshold of abdominal discomfort was lower in FD patients than in control subjects (8.9 +/- 3.6 mmHg and 14.5 +/- 3.7 mmHg respectively; p < 0.05). Twenty-four of 64 patients (37.5%) experienced abdominal discomfort at a pressure less than 7 mmHg above minimal distending pressure (corresponding to the 95th percentile of normal values). Half time of solid-phase gastric emptying in patients and control subjects was not significantly different. Twenty-three of 64 patients (35.9%) had delayed gastric emptying compared with control subjects (normal ranges were mean +/- two standard deviations in control subjects). Thresholds of abdominal discomfort were not significantly different in patients with and without delayed gastric emptying (9.3 +/- 4.0 mL/mmHg vs. 8.6 +/- 3.3 mL/mmHg). There were also no significant differences in the proportion of patients with delayed gastric emptying between patients with and without gastric hypersensitivity. In conclusion, gastric hypersensitivity plays an important role in FD, and the presence of gastric hypersensitivity was not related to the presence of delayed gastric emptying.

Lack of association of Helicobacter pylori infection with gastric hypersensitivity or delayed gastric emptying in functional dyspepsia

OBJECTIVE

We evaluated the relationship between Helicobacter pylori (H. pylori) infection and gastric sensitivity to distention or gastric emptying rate to define the role of H. pylori in the pathogenesis of functional dyspepsia.

METHODS

Gastric barostat, gastric emptying scintigraphy, and 13C urea breath test were performed in 34 consecutive patients with functional dyspepsia.

RESULTS

Between H. pylori-positive and -negative patients with functional dyspepsia, there were no significant differences in basal tone (57.2 +/- 15.0 ml vs 66.8 +/- 18.3 ml), compliance (41.0 +/- 11.2 ml/mm Hg vs 38.2 +/- 11.8 ml/mm Hg), threshold of first sense (3.6 +/- 2.7 mm Hg vs 2.3 +/- 1.5 mm Hg), threshold of abdominal discomfort (9.4 +/- 4.0 mm Hg vs 7.3 +/- 1.9 mm Hg), and postprandial receptive relaxation (115.4 +/- 89.7 ml vs 99.0 +/- 88.7 ml), measured by gastric barostat. Half gastric emptying time (88.6 +/- 24.5 min vs 91.4 +/- 21.6 min) and retention rate at 120 min (32.8 +/- 17.8% vs 41.9 +/- 20.1%) were also similar between the two groups.

CONCLUSION

H. pylori infection was not associated with gastric hypersensitivity to distention or delayed gastric emptying.

Role of hyperinsulinemia and glucose intolerance in the pathogenesis of nonalcoholic fatty liver in patients with normal body weight

OBJECTIVES

The pathogenesis of nonalcoholic fatty liver in non-obese persons is poorly understood. We aimed to elucidate whether hyperinsulinemia and glucose intolerance are associated with development of fatty liver in patients with normal body weight.

METHODS

Forty-seven patients with fatty liver were divided into non-obese (n = 25) and obese groups (n = 22) according to age adjusted body mass index. Inclusion criteria were as follows: (1) elevated transaminase levels during more than 3 months of follow up period, (2) no detectable HBsAg or anti-HCV in the serum, (3) alcohol consumption less than 40 gm/week, (4) no use of potential hepatotoxic drugs within 3 months and (4) sonographic evidence of fatty liver(moderate to severe degree). Baseline insulin levels and oral glucose tolerance test using 75gm of glucose were performed and the results were compared in each group of patients.

RESULTS

Mean baseline insulin levels were elevated in both groups above the reference value, 9.3 +/- 3.5 microU/L in non-obese group and 9.9 +/- 3.5 microU/L in obese group (p = 0.26). Seventeen of non-obese patients (68%) had elevated basal insulin level and 16 of obese patients (73%) had elevated basal insulin level (p = 0.39). In oral glucose tolerance test, there was no difference in glucose level between non-obese and obese groups from O minute to 180 minutes (p > 0.05). Eleven patients from the non-obese group (44%) and 8 patients from the obese group (36%) had either impaired glucose tolerance or diabetes (p = 0.29).

CONCLUSION

Our data suggest that hyperinsulinemia and glucose intolerance may play a role in the pathogenesis of fatty liver in patients with normal body weight as well as in patients with obesity.