Miss rate of colorectal neoplastic polyps and risk factors for missed polyps in consecutive colonoscopies

BACKGROUND/AIMS: Colonoscopic polypectomy is the best diagnostic and therapeutic tool to detect and prevent colorectal neoplasms. However, previous studies have reported that 17% to 28% of colorectal polyps are missed during colonoscopy. We investigated the miss rate of neoplastic polyps and the factors associated with missed polyps from quality-adjusted consecutive colonoscopies. METHODS: We reviewed the medical records of patients who were found to have colorectal polyps at a medical examination center of the Kangbuk Samsung Hospital between March 2012 and February 2013. Patients who were referred to a single tertiary academic medical center and underwent colonoscopic polypectomy on the same day were enrolled in our study. The odds ratios (ORs) associated with polyp-related and patient-related factors were evaluated using logistic regression analyses. RESULTS: A total of 463 patients and 1,294 neoplastic polyps were analyzed. The miss rates for adenomas, advanced adenomas, and carcinomas were 24.1% (312/1,294), 1.2% (15/1,294), and 0% (0/1,294), respectively. Flat/sessile-shaped adenomas (adjusted OR, 3.62; 95% confidence interval [CI], 2.40–5.46) and smaller adenomas (adjusted OR, 5.63; 95% CI, 2.84– 11.15 for ≤5 mm; adjusted OR, 3.18; 95% CI, 1.60–6.30 for 6–9 mm, respectively) were more frequently missed than pedunculated/sub-pedunculated adenomas and larger adenomas. In patients with 2 or more polyps compared with only one detected (adjusted OR, 2.37; 95% CI, 1.55–3.61 for 2–4 polyps; adjusted OR, 11.52; 95% CI, 4.61–28.79 for ≥5 polyps, respectively) during the first endoscopy, the risk of missing an additional polyp was significantly higher. CONCLUSIONS: One-quarter of neoplastic polyps was missed during colonoscopy. We encourage endoscopists to detect smaller and flat or sessile polyps by using the optimal withdrawal technique.

Perianal Abscess and Proctitis by Klebsiella pneumoniae

Klebsiella pneumoniae (K. pneumoniae) can at times cause invasive infections, especially in patients with diabetes mellitus and a history of alcohol abuse. A 61-year-old man with diabetes mellitus and a history of alcohol abuse presented with abdominal and anal pain for two weeks. After admission, he underwent sigmoidoscopy, which revealed multiple ulcerations with yellowish exudate in the rectum and sigmoid colon. The patient was treated with ciprofloxacin and metronidazole. After one week, follow up sigmoidoscopy was performed owing to sustained fever and diarrhea. The lesions were aggravated and seemed webbed in appearance because of damage to the rectal mucosa. Abdominal computed tomography and rectal magnetic resonance imaging were performed, and showed a perianal and perirectal abscess. The patient underwent laparoscopic sigmoid colostomy and perirectal abscess incision and drainage. Extended-spectrum beta-lactamase-producing K. pneumoniae was identified in pus culture. The antibiotics were switched to ertapenem. He improved after surgery and was discharged. K. pneumoniae can cause rapid invasive infection in patients with diabetes and a history of alcohol abuse. We report the first rare case of proctitis and perianal abscess caused by invasive K. pneumoniae infection.

Efficacy of Bisacodyl Given as Part of a Polyethylene Glycol-based Bowel Preparation Prior to Colonoscopy in Hospitalized Patients: A Prospective Ramdomized Trial / 대한소화기학회지

BACKGROUND/AIMS: Inpatient status can cause inadequate bowel preparation. The majority of previous studies regarding bowel preparation have focused on comparing the effects of different purgative regimens in outpatients. However, data on bowel preparation for inpatients are lacking. The aim of this study was to investigate whether bisacodyl plus polyethylene glycol (PEG) can improve bowel preparation in hospitalized patients. METHODS: A prospective, randomized and observer-blind study was performed. A total of 196 hospitalized patients undergoing colonoscopy were randomized to receive 4 L PEG (PEG only group) or 4 L PEG+bisacodyl 10 mg (bisacodyl added group). The adequacy of bowel preparation was scored using the Ottawa bowel preparation scale. RESULTS: One hundred and eighty-three subjects completed the study; 96 in the bisacodyl added group and 87 in the PEG only group. There were no significant differences between the bisacodyl added group and the PEG only group with respect to the score of bowel cleansing (3.59+/-2.81 vs. 3.82+/-3.03, p=0.607), quality of bowel cleansing (adequate preparation 89.6% vs. 85.1%, p=0.380), and overall adverse events (66.7% vs. 52.9%, p=0.057). However, a larger proportion of patients in the PEG only group were able to ingest the entire solution as prescribed than in the bisacodyl added group (98.9% vs. 75.0%, p<0.001). CONCLUSIONS: In hospitalized patients, the quality of bowel preparation did not differ depending on whether bisacodyl is added or not. In addition, patient compliance based on consumption of cleansing agent was better in the PEG only group.

A Case of Acute Pancreatitis after Endoscopic Biopsy in Congenital Pancreatic Duct Anomalies / 대한내과학회지

Congenital anomalies or normal variants of the pancreatic duct are in most cases asymptomatic and are found incidentally while conducting imaging studies (such as a MRCP and a CT scan) for other reasons. The frequency of pancreatic duct variants has been reported to be about 9% of the general population; the most common type is a bifid configuration of the major and minor pancreatic ducts. Though most patients with pancreatic duct variants do not have any symptoms, a small number may develop jaundice or gallstones. By reporting the case of a patient with a variant pancreatic duct who developed acute pancreatitis after undergoing screening endoscopy and biopsy, this study aims to warn of the possible risks of screening endoscopy or biopsy in the second portion of the duodenum.

Subarachnoid Hemorrhage Misdiagnosed as an Acute ST Elevation Myocardial Infarction

Without significant coronary artery stenosis, ischemic electrocardiographic change including ST segment elevation, segmental wall motion abnormality and elevated serum cardiac-specific markers (creatine kinase-MB, Troponin-T) may develop after central nervous system injuries such as subarachnoid, intracranial or subdural hemorrhage. Misdiagnosing these patients as acute myocardial infarction may result in catastrophic outcomes. By reporting a case of a 55-year old female with subarachnoid hemorrhage mimicking acute ST elevation myocardial infarction, we hope to underline that careful attention of neurologic abnormality is critical in making better prognosis.

Comparison of Bowel Preparation Quality between Clear-liquid Diet and No Diet Restriction

BACKGROUND/AIMS: Adequate bowel preparation is essential for full visualization of colonic mucosa because detection of small polyps and neoplasms depends on the quality of bowel cleansing. The aims of this study were to compare the efficacy, tolerability of preparation and side effect between two groups: clear-liquid diet with polyethylene glycol (PEG) solution versus no diet restriction with PEG solution. METHODS: This was a randomized single-blind prospective study. A total of 330 patients were randomly assigned to receive either 2 L PEG solution with a clear-liquid diet on the day before colonoscopy and another 2 L PEG solution on the day of the procedure (group 1) or 2 L PEG solution with a general diet on the day before colonoscopy and another 2 L PEG solution on the day of the procedure (group 2). RESULTS: 162 patients were assigned to group 1 and 168 patients to group 2. The satisfactory quality of bowel preparation was not significantly different between the two groups (80.2%, 78.6%, P=0.707). Patient's compliance of the clear-liquid diet in group 1 was 50%. The satisfactory quality of bowel preparation was weakly better when the clear-liquid diet was given 2 or 3 times a day (group 1A) than 0 or once a day (group 1B) (74.1%, 86.4%, P=0.048). The tolerability of the PEG solution and side effects of preparation were not significantly different in the two groups (P=0.573, 0.686). CONCLUSIONS: Bowel preparation with no diet restriction and split-dose PEG solution was similar to preparation with a clear-liquid diet in efficacy, tolerability and side effect. Therefore, the use of the clear-liquid diet protocol should improve patient's compliance.

A Case of Bain Abscess caused by Mycobacterium intracellurare / 감염과화학요법

Mycobacterium avium intracellulare complex (MAC) usually causes an opportunistic pulmonary infection in immunocompromised hosts who have underlying structural lung disease. Central nervous system infection due to MAC is very rare even in an immunocompromised host. Most previous reports of central nervous system infection due to MAC have been meningoencephalitis in patients infected with human immunodeficiency virus (HIV). Only four cases of brain abscess due to MAC have been reported worldwide. We report a case of brain abscess due to MAC in a non-HIV patient. Although drugs used for treatment of MAC have limited central nervous penetration, an azithromycin-based anti-tuberculous therapy after surgical drainage of the abscess showed improvement. To the best of our knowledge, this is the first reported case of MAC brain abscess in the Korean literature.

The relationship between the ApoB/ApoA-I ratio and non-alcoholic fatty liver disease in prediabetic patients / 대한내과학회지

BACKGROUND/AIMS: The apolipoprotein B/A-I ratio (ApoB/A-I) is a powerful clinical indicator of atherosclerosis. Although numerous reports have shown the effect of non-alcoholic fatty liver disease (NAFLD) on cardiovascular disease, few reports have examined the relationship between NAFLD and the ApoB/A-I ratio. The aim of the study was to determine the association between NAFLD and the ApoB/A-I ratio in prediabetic patients. METHODS: This cross-sectional study was performed with data obtained from 701 patients (mean age, 47.9+/-9.6 years) diagnosed with prediabetes. Serum lipid profiles including lipoprotein, apolipoprotein, and calculated ApoB/A-I ratio as well as metabolic syndrome parameters such as fasting glucose and insulin were measured in each subject. RESULTS: Among the 701 patients, 340 (48%) had NAFLD. The number of male patients was 490 (NAFLD+, 276; and NAFLD-, 214). The odds ratios for the prevalence of NAFLD increased according to the quartiles of the ApoB/A-I ratio (1.886, 2.245, and 2.587) (p<0.001). CONCLUSIONS: The prevalence of NAFLD correlated with high ApoB/A-I ratio, suggesting that NAFLD increases the risk for atherosclerosis progression in male prediabetic patients.