Clinical Efficacy and Safety of Endoscopic Treatment of Gastrointestinal Stromal Tumors in the Stomach

Background/Aims@#Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors in the stomach. We evaluated the clinical outcomes of endoscopic treatment for gastric GISTs. @*Methods@#This is a single center, retrospective study that enrolled 135 cases of gastric subepithelial tumors (SETs) resected by endoscopic procedures and confirmed as GISTs by histopathology from March 2005 to July 2019. The immediate and long-term clinical outcomes were analyzed retrospectively. @*Results@#The mean patient age was 57.9 years, and the mean tumor size was 2.1 cm. Of the tumors, 43.0% were located in the body, followed by the fundus (26.7%) and cardia (17.0%). Most tumors (85.2%) were resected by endoscopic submucosal dissection, followed by endoscopic mucosal resection (6.7%), submucosal tunneling endoscopic resection (5.9%), and endoscopic full-thickness resection (2.2%). Macroperforation occurred in 4.4% and microperforation in 6.7% of the cases. The R0 resection rate was 15.6%. However, the rate of complete resection by the endoscopic view was 90.4%, of which 54.8% of cases were in the very-low-risk group, followed by the low-risk group (28.1%), intermediate-risk group (11.9%), and high-risk group (5.2%). During 36.5 months of follow-up, recurrence was found in four (3.4%) of the 118 patients who were monitored for more than 6 months (low-risk group, 1/37 [2.7%]; intermediate-risk group, 2/11 [18.2%]; high-risk group, 1/6 [16.7%]). @*Conclusions@#Endoscopic treatment of a GIST appears to be a feasible procedure in selected cases. However, additional surgery should be considered if the pathologic results correspond to intermediate- or high-risk groups.

Primary Esophageal Mucosa-associated Lymphoid Tissue Lymphoma: A Rare Case Report and Review of Other Published Data

The gastrointestinal tract is the most common extranodal site for lymphomas, and mucosa-associated lymphoid tissue lymphoma is the second most common histological lymphoma subtype. However, primary esophageal mucosa-associated lymphoid tissue lymphomas are extremely rare. Few such cases are documented, and the reports demonstrate inconsistent diagnostic and therapeutic strategies. Herein, a 54-year-old man was referred to our hospital for treatment of dysphagia. Esophagogastroduodenoscopy revealed a large, horseshoe-shaped subepithelial mass in the upper esophagus. Endoscopic ultrasonography and computed tomography revealed that the mass was well-demarcated and confined to the muscularis mucosa, with no abnormalities in other organs or lymph nodes. The mass was presumptively diagnosed as benign, and the patient underwent endoscopic mucosal dissection for pathological confirmation and symptom relief. Pathological examination of the dissection specimen revealed that it was a primary esophageal mucosa-associated lymphoid tissue lymphoma. As the patient had an elevated immunoglobulin G level and Helicobacter pylori infection, we administered adjuvant eradication therapy. The patient remains under surveillance and is free of lymphoma recurrence 36 months postoperatively. This case report demonstrates that endoscopic resection and H. pylori eradication are effective treatment strategies for early-stage esophageal mucosa-associated lymphoid tissue lymphoma.

Safe and appropriate use of laxatives for colonoscopy

Appropriate bowel preparation is essential for effective colonoscopy. Inadequate use of bowel preparation solutions reduces patient compliance, makes the detection of lesions such as adenoma difficult, and increases the risk of complication such as perforation. Current Concepts: A 4-L polyethylene glycol (PEG) solution can be safely used for bowel preparation, even in most individuals with underlying diseases. However, it requires a high preparation-volume intake and has poor patient compliance due to its unpleasant taste. Therefore, a 2- or 1- L sulfate-free, PEG-based laxative was developed to, reduce the amount of PEG and improve the taste. Furthermore, simethicon-containing laxative formulation was developed to eliminate gas bubbles. In addition, oral bowel preparation solutions with enema agents and prokinetics were used to improve bowel preparation, but no improvement was observed. Various alternative laxatives are available; however, PEG-based bowel preparation solutions are still recommended in most cases due to their stability. Discussion and Conclusion: Although a 4-L PEG solutions recommended for bowel preparation in most cases, several laxatives have been introduced to overcome its disadvantages. The laxative agent must be selected according to each patient’s specific characteristics. Moreover, the method of taking bowel preparation solutions and additional bowel preparation medications must be carefully chosen. In addition, patient education via various methods, such as using a smartphone, when taking a bowel preparation agent may help improve bowel preparation quality.

Safe and appropriate use of laxatives for colonoscopy

Appropriate bowel preparation is essential for effective colonoscopy. Inadequate use of bowel preparation solutions reduces patient compliance, makes the detection of lesions such as adenoma difficult, and increases the risk of complication such as perforation. Current Concepts: A 4-L polyethylene glycol (PEG) solution can be safely used for bowel preparation, even in most individuals with underlying diseases. However, it requires a high preparation-volume intake and has poor patient compliance due to its unpleasant taste. Therefore, a 2- or 1- L sulfate-free, PEG-based laxative was developed to, reduce the amount of PEG and improve the taste. Furthermore, simethicon-containing laxative formulation was developed to eliminate gas bubbles. In addition, oral bowel preparation solutions with enema agents and prokinetics were used to improve bowel preparation, but no improvement was observed. Various alternative laxatives are available; however, PEG-based bowel preparation solutions are still recommended in most cases due to their stability. Discussion and Conclusion: Although a 4-L PEG solutions recommended for bowel preparation in most cases, several laxatives have been introduced to overcome its disadvantages. The laxative agent must be selected according to each patient’s specific characteristics. Moreover, the method of taking bowel preparation solutions and additional bowel preparation medications must be carefully chosen. In addition, patient education via various methods, such as using a smartphone, when taking a bowel preparation agent may help improve bowel preparation quality.

Clinicopathological Features of Small Bowel Tumors Diagnosed by Video Capsule Endoscopy and Balloon-Assisted Enteroscopy: A Single Center Experience

Background/Aims@#Small bowel malignancies often present a diagnostic challenge due to their relative rarity and nonspecific clinical symptoms. However, technical developments in endoscopic instruments, including video capsule endoscopy (VCE) and enteroscopy, have allowed for the visualization of the entire small bowel. This study aimed to investigate the clinicopathological features of small bowel malignant tumors diagnosed by VCE and double-balloon enteroscopy (DBE) in a single tertiary center. @*Methods@#We retrospectively analyzed VCE and DBE findings from Korea University Guro Hospital from January 2010 through September 2018. @*Results@#A total of 510 VCE and 126 DBE examinations were performed in 478 patients. Small bowel malignancies were diagnosed in 28 patients (15 males; mean age, 61.0 years; range, 42 to 81 years). Among them, 8 had lymphoma, 8 had primary adenocarcinoma, 7 had gastrointestinal stromal tumor (GIST) and 5 had metastatic cancer. Abdominal pain and obstructive symptoms were the most common findings in metastatic cancers (4/5, 80%). On the other hand, obscure gastrointestinal bleeding was the most common symptom of GIST (6/7, 85.7%) and adenocarcinoma (3/8, 37.5%). @*Conclusions@#Approximately 6% of the patients who underwent either VCE or DBE were diagnosed with small bowel malignancy. These findings demonstrated the different clinical characteristics among small bowel malignancies and merit further study.

A prospective randomized clinical study evaluating the efficacy and compliance of oral sulfate solution and 2-L ascorbic acid plus polyethylene glycol

Oral sulfate solution (OSS) is an emerging cleansing agent for bowel preparation. However, data comparing OSS to other conventional bowel preparations in Asian patients are limited. Therefore, the objective of this study was to compare the efficacy and tolerability of OSS to ascorbic acid plus polyethylene glycol (AA + PEG) in Asian patients. Methods: This was a prospective, randomized, parallel, investigator-blind study performed in two university hospitals in Korea. Bowel preparation efficacy was evaluated using both the Ottawa Bowel Preparation Scale (OBPS) and Boston Bowel Preparation Scale (BBPS). Results: Among 173 patients, 86 received OSS while 87 received AA + PEG for bowel preparation. Total OBPS score was 2.80 ± 2.48 in the OSS group and 4.49 ± 3.08 in the AA + PEG group, indicating significantly (p < 0.001) better efficacy with OSS. Total BBPS was higher in the OSS group (7.43 ± 1.49 vs. 6.51 ± 1.76, p < 0.001), indicating superior bowel preparation quality with OSS. Preparation-related adverse events were generally acceptable. Patients receiving OSS had more nausea (1.92 ± 0.94 vs. 1.54 ± 0.76, p = 0.004) and abdominal cramping (1.45 ± 0.78 vs. 1.17 ± 0.51, p = 0.006) than those receiving AA + PEG. However, overall satisfaction and taste were similar between the two groups. Conclusions: OSS had a non-inferior bowel cleansing efficacy than AA + PEG regardless of colon segment.

Change in Size of Gastric Hyperplastic Polyps after Helicobacter pylori Eradication: A Prospective Study

BACKGROUND/AIMS: Helicobacter pylori (H. pylori) eradication is known to be effective for reducing the size of gastric hyperplastic polyps (HPPs). This study investigated the change in size of gastric HPPs after H. pylori eradication.MATERIALS AND METHODS: This was a prospective study that enrolled 25 H. pylori-positive patients diagnosed as having HPPs at Korea University Guro Hospital between July 2015 and July 2016. If the patient wanted to receive eradication therapy, medication was given. If the patients refused eradication, only clinical follow-up was performed. All patients were subsequently followed up with endoscopic examination to determine any change in polyp size.RESULTS: Eighteen of the 25 H. pylori-positive patients diagnosed as having HPPs were given an eradication regimen, and 17 were confirmed to have achieved successful eradication. Twelve (70.8%) of the 17 patients in the eradication group showed ≥50% reduction in size, while two (25.0%) of the eight patients in the non-eradication group showed 50% reduction. The polyp regression rate was significantly higher in the eradication group (P=0.03). A multivariate analysis revealed that H. pylori eradication (OR, 40.047; 95% CI, 1.112~1442.767; P=0.044) and female sex (OR, 12.947; 95% CI, 1.038~161.503; P=0.047) were significant predictive factors of HPP regression.CONCLUSIONS: H. pylori eradication is an effective therapeutic modality for gastric HPP regression.

Can More Aggressive Treatment Improve Prognosis in Patients with Hepatocellular Carcinoma? A Direct Comparison of the Hong Kong Liver Cancer and Barcelona Clinic Liver Cancer Algorithms

BACKGROUND/AIMS: In addition to the globally endorsed Barcelona Clinic Liver Cancer (BCLC) staging system, other algorithms or staging systems have been developed, including the Hong Kong Liver Cancer (HKLC) staging system. This study aimed to validate the HKLC staging system relative to the BCLC staging system for predicting survival for hepatocellular carcinoma (HCC) patients in Korea. METHODS: From 2004 to 2013, 2,571 patients newly diagnosed with HCC were consecutively enrolled at three Korea University medical centers. RESULTS: Both staging systems differentiated survival well (p < 0.001). However, 1-year and 3-year survival were predicted better using the HKLC system than the BCLC system (area under the receiver operating characteristic curve: 0.869 vs 0.856 for 1 year, p=0.002; 0.841 vs 0.827 for 3 years, p=0.010). In hypothetical survival curves, the HKLC system exhibited better median overall survival than the BCLC system (33.1 months vs 19.2 months). In evaluations of prognosis according to either BCLC or HKLC treatment guidelines, risk of death was reduced in the group following only HKLC guidelines compared with the group following only BCLC guidelines (hazard ratio, 0.601; 95% confidence interval, 0.443 to 0.816; p=0.001). CONCLUSIONS: Although both staging systems predicted and discriminated HCC prognoses well, the HKLC system showed more encouraging survival benefits than the BCLC system.

Foods Inducing Typical Gastroesophageal Reflux Disease Symptoms in Korea

BACKGROUND/AIMS: Several specific foods are known to precipitate gastroesophageal reflux disease (GERD) symptoms and GERD patients are usually advised to avoid such foods. However, foods consumed daily are quite variable according to regions, cultures, etc. This study was done to elucidate the food items which induce typical GERD symptoms in Korean patients. METHODS: One hundred and twenty-six Korean patients with weekly typical GERD symptoms were asked to mark all food items that induced typical GERD symptoms from a list containing 152 typical foods consumed daily in Korea. All patients underwent upper gastrointestinal endoscopy followed by 24-hour ambulatory esophageal pH monitoring. The definition of “GERD” was if either of the 2 studies revealed evidence of GERD, and “possible GERD” if both studies were negative. RESULTS: One hundred and twenty-six cases (51 GERD and 75 possible GERD) were enrolled. In 19 (37.3%) of 51 GERD cases and in 17 (22.7%) of 75 possible GERD cases, foods inducing typical GERD symptoms were identified. In the GERD group (n = 19), frequent symptom-inducers were hot spicy stews, rice cakes, ramen noodles, fried foods, and topokki. In the possible GERD group (n = 17), frequent symptom-inducers were hot spicy stews, fried foods, doughnuts, breads, ramen noodles, coffee, pizza, topokki, rice cakes, champon noodles, and hotdogs. CONCLUSIONS: In one-third of GERD patients, foods inducing typical symptoms were identified. Hot spicy stews, rice cakes, ramen noodles, fried foods, and topokki were the foods frequently inducing typical symptoms in Korea. The list of foods frequently inducing typical GERD symptoms needs to be modified based on their own local experiences.

Education and Training Guidelines for the Board of the Korean Society of Gastrointestinal Endoscopy

The Korean Society of Gastrointestinal Endoscopy (KSGE) developed a gastrointestinal (GI) endoscopy board in 1995 and related regulations. Although the KSGE has acquired many specialists since then, the education and training aims and guidelines were insufficient. During GI fellowship training, obtaining sufficient exposure to some types of endoscopic procedures is difficult. Fellows should acquire endoscopic skills through supervised endoscopic procedures during GI fellowship training. Thus, the KSGE requires training guidelines for fellowships that allow fellows to perform independent endoscopic procedures without supervision. This document is intended to provide principles that the Committee of Education and Training of the KSGE can use to develop practical guidelines for granting privileges to perform accurate GI endoscopy safely. The KSGE will improve the quality of GI endoscopy by providing guidelines for fellowships and supervisors.

Fecal Microbiota Transplantation as a Treatment of Recurrent Clostridium difficile Infection: Where Are We Now and Where Are We Heading? / 대한소화기학회지

No abstract available.

What Is the Mean Procedure Time to Optimize Colonoscopy?

No abstract available.

Inverted Hyperplastic Polyp in Stomach: A Case Report and Literature Review / 대한소화기학회지

An inverted hyperplastic polyp (IHP) found in stomach is rare and characterized by downward growth of hyperplastic mucosal component into the submucosa. Because of such characteristic, IHP can be misdiagnosed as subepithelial tumor or malignant tumor. In fact, adenocarcinoma was reported to have coexisted with gastric IHP in several previous reports. Because only 18 cases on gastric IHP have been reported in English and Korean literature until now, pathogenesis and clinical features of gastric IHP and correlation with adenocarcinoma have not been clearly established. Herein, we report a case of gastric IHP which was initially misdiagnosed as gastrointestinal stromal tumor and resected using endoscopic submucosal dissection. Literature review of previously published case reports on gastric IHP is also presented.

Panenteritis as an Initial Presentation of Systemic Lupus Erythematosus / 대한소화기학회지

Lupus enteritis is a rare, severe complication of systemic lupus erythematosus (SLE), needing prompt diagnosis and proper management. However, SLE rarely presents as lupus enteritis at the time of initial diagnosis. Thus, delayed diagnosis and misdiagnosis are common. We report a case of a 25-year-old woman with lupus panenteritis. The patient had multiple hospitalizations for abdominal pain, nausea, and diarrhea, initially without any other symptoms suggestive of SLE, but was later observed to have malar rash and oral ulcers. Laboratory investigations were compatible with SLE, including positive antinuclear antibody (1:320) with speckled pattern. CT revealed diffuse hypodense submucosal thickening of the stomach, the entire small bowel, colon, appendix, and rectum. Treatment with high-dose corticosteroids followed by maintenance therapy with mycophenolate mofetil, hydroxychloroquine, and azathioprine resulted in clinical improvement. Diagnosis of lupus enteritis requires a high index of suspicion given the low incidence and nonspecific clinical findings.

Intra-ampullary Adenocarcinoma Presenting as Recurrent Pancreatitis / 대한췌담도학회지

Advances in imaging modalities have provided useful information in diagnosing ampullary lesions such as adenoma and adenocarcinoma. Endoscopic retrograde cholangiopancreaticography (ERCP) have a role in the diagnosis of unexposed intra-ampullarylesion. We report an interesting case of adenocarinoma of the ampulla of Vater presenting as idiopathic recurrent pancreatitis. A 56 years old woman was referred due to idiopathic recurrent pancreatitis for 2 years. She presented abdominal pain and upper abdominal tenderness. Magnetic resonance cholangiopancreaticography (MRCP) revealed minimal bile and pancreatic ductal dilatation without obstruction. Subsequent ERCP revealed a small polypoid lesion which was exposed after endoscopic sphincterotomy. Endoscopic biopsy showed papillary adenoma with low grade dysplasia. Additional endoscopic papillectomy was performed. Endoscopic biopsy done 3 months later showed papillary adenoma with high grade dysplasia. Pylorus preserving pancreatoduodenectomy was done and final pathology was well differentiated adenocarcinoma. The patient was recovered well but received adjuvant chemotherapy due to metastatic lymph nodes.

Astaxanthin Inhibits Proliferation of Human Gastric Cancer Cell Lines by Interrupting Cell Cycle Progression

BACKGROUND/AIMS: Astaxanthin is a carotenoid pigment that has antioxidant, antitumoral, and anti-inflammatory properties. In this in vitro study, we investigated the mechanism of anticancer effects of astaxanthin in gastric carcinoma cell lines. METHODS: The human gastric adenocarcinoma cell lines AGS, KATO-III, MKN-45, and SNU-1 were treated with various concentrations of astaxanthin. A cell viability test, cell cycle analysis, and immunoblotting were performed. RESULTS: The viability of each cancer cell line was suppressed by astaxanthin in a dose-dependent manner with significantly decreased proliferation in KATO-III and SNU-1 cells. Astaxanthin increased the number of cells in the G0/G1 phase but reduced the proportion of S phase KATO-III and SNU-1 cells. Phosphorylated extracellular signal-regulated kinase (ERK) was decreased in an inverse dose-dependent correlation with astaxanthin concentration, and the expression of p27(kip-1) increased the KATO-III and SNU-1 cell lines in an astaxanthin dose-dependent manner. CONCLUSIONS: Astaxanthin inhibits proliferation by interrupting cell cycle progression in KATO-III and SNU-1 gastric cancer cells. This may be caused by the inhibition of the phosphorylation of ERK and the enhanced expression of p27(kip-1).

The Influence of Alcoholic Liver Disease on Serum PIVKA-II Levels in Patients without Hepatocellular Carcinoma

BACKGROUND/AIMS: Prothrombin induced by vitamin K deficiency or antagonist II (PIVKA-II) is a widely used diagnostic marker for hepatocellular carcinoma (HCC). We evaluated the correlation between alcoholic liver disease (ALD) and serum PIVKA-II levels in chronic liver disease (CLD) patients. METHODS: We retrospectively reviewed the medical records of 2,528 CLD patients without HCC. Among these patients, 76 exhibited serum high PIVKA-II levels of >125 mAU/mL (group 1). We categorized 76 control patients matched by age, sex, and the presence of liver cirrhosis from the remaining patients who were negative for serum PIVKA-II (group 2). RESULTS: Group 1 revealed increased antibiotic usage (23.7% vs 2.6%, p<0.001) and incidence of ALD (60.5% vs 14.5%, p<0.001) as well as elevated aspartate aminotransferase (52.5 IU/L vs 30.5 IU/L, p=0.025) and gamma glutamyl transpeptidase (67.5 IU/L vs 36.5 IU/L, p=0.005) levels compared with group 2. Further, group 1 was significantly associated with a worse Child-Pugh class than group 2. In the multivariate analysis, ALD (odds ratio [OR], 7.151; p<0.001) and antibiotic usage (OR, 5.846; p<0.001) were significantly associated with positive PIVKA-II levels. CONCLUSIONS: Our study suggests that ALD and antibiotics usage may be confounding factors when interpreting high serum PIVKA-II levels in patients without HCC. Therefore, serum PIVKA-II levels in patients with ALD or in patients administered antibiotics should be interpreted with caution.

The Influence of Alcoholic Liver Disease on Serum PIVKA-II Levels in Patients without Hepatocellular Carcinoma

BACKGROUND/AIMS: Prothrombin induced by vitamin K deficiency or antagonist II (PIVKA-II) is a widely used diagnostic marker for hepatocellular carcinoma (HCC). We evaluated the correlation between alcoholic liver disease (ALD) and serum PIVKA-II levels in chronic liver disease (CLD) patients. METHODS: We retrospectively reviewed the medical records of 2,528 CLD patients without HCC. Among these patients, 76 exhibited serum high PIVKA-II levels of >125 mAU/mL (group 1). We categorized 76 control patients matched by age, sex, and the presence of liver cirrhosis from the remaining patients who were negative for serum PIVKA-II (group 2). RESULTS: Group 1 revealed increased antibiotic usage (23.7% vs 2.6%, p<0.001) and incidence of ALD (60.5% vs 14.5%, p<0.001) as well as elevated aspartate aminotransferase (52.5 IU/L vs 30.5 IU/L, p=0.025) and gamma glutamyl transpeptidase (67.5 IU/L vs 36.5 IU/L, p=0.005) levels compared with group 2. Further, group 1 was significantly associated with a worse Child-Pugh class than group 2. In the multivariate analysis, ALD (odds ratio [OR], 7.151; p<0.001) and antibiotic usage (OR, 5.846; p<0.001) were significantly associated with positive PIVKA-II levels. CONCLUSIONS: Our study suggests that ALD and antibiotics usage may be confounding factors when interpreting high serum PIVKA-II levels in patients without HCC. Therefore, serum PIVKA-II levels in patients with ALD or in patients administered antibiotics should be interpreted with caution.

Small Bowel Metastatic Cancer Observed With Double Balloon Enteroscopy in a Patient With a Past History of Multiple Cancers

Small bowel tumors are very rare and generally malignant. As a result of the anatomical location and nonspecific manifestations of small bowel tumors, they are very difficult to diagnose. Balloon-assisted enteroscopy is a relatively noninvasive method compared to surgical resection, and allows for real-time observation, tissue confirmation with biopsy, and interventional procedures. Here, we report the case of a 69-year-old woman with a small bowel metastatic carcinoma observed with double balloon enteroscopy (DBE). She had a history of multiple cancers including ovarian cancer, bladder cancer, and breast cancer. The antegrade DBE procedure was performed before surgery for biopsy tissue confirmation. The patient underwent small bowel resection, and the final diagnosis was the same as that determined by preoperative biopsy. The final diagnosis was metastatic small bowel cancer originating from a cancer of the breast. This is the first detailed report of the preoperative diagnosis of small intestinal metastatic breast cancer by DBE.

The Effect of Oral Cola Ingestion for Endoscopic Inspection of Remnant Stomach: Randomized Case Control Study

BACKGROUND/AIMS: Nasogastric administration of cola for dissolution of phytobezoar was reported but the mechanism is not well understood. We aimed to evaluate the efficacy of cola ingestion for upper gastrointestinal endoscopy in patients who have had distal gastrectomy. MATERIALS AND METHODS: Patients were enrolled from July 2007 to October 2007 and all previously received subtotal gastrectomy. We conducted a randomized case-control study which the patients were randomly assigned to two groups. Group A had preparation with cola and group B had no preparation. Cola preparation group ingested about 1,500 mL of cola between 7 PM to 10 PM in the evening before the procedure. Two examiners who were blinded to the type of preparation performed the endoscopy. We assessed the degree of food residue and bile reflux by Japanese classification. RESULTS: A total of 70 patients were included. The comparison of clinical and laboratory characteristics between the two groups showed no statistically significant difference. During endoscopy, food residue was less found in group A than B, but without statistically significance (group A=12.1%, group B=21.6%, P=0.087). However, bile reflux was significantly less found in group A than B (group A=36.4%, group B=67.6%, P=0.015). Multivariate analysis, cola preparation significantly reduced food residue (OR, 0.032; P=0.001) and bile reflux (OR, 0.102; P=0.001). CONCLUSIONS: Preparation with cola in the evening before endoscopic examination may provide a good quality of preparation in patient with remnant stomach after distal gastrectomy.