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Background/Aims@#It remains unclear which maintenance treatment modality is most appropriate for mild gastroesophageal reflux disease (GERD).We aimed to compare on-demand treatment with continuous treatment using a proton pump inhibitor (PPI) in the maintenance treatment for patients with non-erosive GERD or mild erosive esophagitis. @*Methods@#Patients whose GERD symptoms improved after 4 weeks of standard dose PPI treatment were prospectively enrolled at 25 hospitals.Subsequently, the enrolled patients were randomly assigned to either an on-demand or a continuous maintenance treatment group, and followed in an 8-week interval for up to 24 weeks. @*Results@#A total of 304 patients were randomized to maintenance treatment (continuous, n = 151 vs on-demand, n = 153). The primary outcome, the overall proportion of unwillingness to continue the assigned maintenance treatment modality, failed to confirm the noninferiority of on-demand treatment (45.9%) compared to continuous treatment (36.1%). Compared with the on-demand group, the GERD symptom and health-related quality of life scores significantly more improved and the overall satisfaction score was significantly higher in the continuous treatment group, particularly at week 8 and week 16 of maintenance treatment. Work impairment scores were not different in the 2 groups, but the prescription cost was less in the on-demand group. Serum gastrin levels significantly elevated in the continuous treatment group, but not in the on-demand group. @*Conclusions@#Continuous treatment seems to be more appropriate for the initial maintenance treatment of non-erosive GERD or mild erosive esophagitis than on-demand treatment. Stepping down to on-demand treatment needs to be considered after a sufficient period of continuous treatment.
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Background/Aims@#Gastroesophageal reflux disease (GERD) is a common chronic gastrointestinal disorder that typically requires long-term maintenance therapy. However, little is known about patient preferences and satisfaction and real-world prescription patterns regarding maintenance therapy for GERD. @*Methods@#This observational, cross-sectional, multicenter study involved patients from 18 referral hospitals in Korea. We surveyed patients who had been prescribed proton pump inhibitors (PPIs) for GERD for at least 90 days with a minimum follow-up duration of 1 year. The main outcome was overall patient satisfaction with different maintenance therapy modalities. @*Results@#A total of 197 patients were enrolled. Overall patient satisfaction, patient preferences, and GERD health-related quality of life scores did not significantly differ among the maintenance therapy modality groups. However, the on-demand therapy group experienced a significantly longer disease duration than the continuous therapy group. The continuous therapy group demonstrated a lower level of awareness of potential adverse effects associated with PPIs than the on-demand therapy group but received higher doses of PPIs than the on-demand therapy group. The prescribed doses of PPIs also varied based on the phenotype of GERD, with higher doses prescribed for non-erosive reflux disease than erosive reflux disease. @*Conclusion@#Although overall patient satisfaction did not significantly differ among the different PPI maintenance therapy modality groups, awareness of potential adverse effects was significantly different between the on-demand and continuous therapy groups.
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In recent years, significant translational research advances have been made in the upper gastrointestinal (GI) research field. Endoscopic evaluation is a reasonable option for acquiring upper GI tissue for research purposes because it has minimal risk and can be applied to unresectable gastric cancer. The optimal number of biopsy samples and sample storage is crucial and might influence results. Furthermore, the methods for sample acquisition can be applied differently according to the research purpose; however, there have been few reports on methods for sample collection from endoscopic biopsies. In this review, we suggested a protocol for collecting study samples for upper GI research, including microbiome, DNA, RNA, protein, single-cell RNA sequencing, and organoid culture, through a comprehensive literature review. For microbiome analysis, one or two pieces of biopsied material obtained using standard endoscopic forceps may be sufficient. Additionally, 5 mL of gastric fluid and 3–4 mL of saliva is recommended for microbiome analyses. At least one gastric biopsy tissue is necessary for most DNA or RNA analyses, while proteomics analysis may require at least 2–3 biopsy tissues. Single cell-RNA sequencing requires at least 3–5 tissues and additional 1–2 tissues, if possible. For successful organoid culture, multiple sampling is necessary to improve the quality of specimens.
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A primary extranodal B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) is a distinct clinical-pathological entity that develops in diverse anatomic locations. However, colorectal involvement is rare. The authors encountered a case of a MALT lymphoma of the rectum in a 69-year-old woman who complained of up to 3 kg weight loss during 3 months. A colonoscopy demonstrated a 1.0×1.0 cm sized subepithelial tumor (SET) at the lower rectum. The patient underwent an endoscopic mucosal resection with ligation for the SET. Pathological analysis revealed marked small to medium-sized lymphocytic infiltration. Immunohistochemistry revealed neoplastic cells positive for CD20 and bcl-2. A polymerase chain reaction detected immunoglobulin H gene rearrangement. Finally, rectal MALT lymphoma was diagnosed. Computed tomography and positron emission tomography scans showed that there was no lymph node metastasis or other organ involvement. A bone marrow biopsy was found to be negative for any neoplastic process. Therefore, the Ann Arbor stage was IeB. Helicobacter pylori (H. pylori) was not detected in the gastric biopsy specimens. Thus far, she has had no relapse since the endoscopic resection. The incidence of rectal MALT is very rare, and treatment is unclear. This paper reports a case of rectal MALT lymphoma treated successfully with only an endoscopic resection.
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Background/Aims@#Prokinetics can be used for treating patients with gastroesophageal reflux disease (GERD), who exhibit suboptimal response to proton pump inhibitor (PPI) treatment. We conducted a systematic review to assess the potential benefits of combination treatment with PPI plus prokinetics in GERD. @*Methods@#We searched PubMed, the Cochrane Library, and EMBASE for publications regarding randomized controlled trials comparing combination treatment of PPI plus prokinetics to PPI monotherapy with respect to global symptom improvement in GERD (until February 2020). The primary outcome was an absence or global symptom improvement in GERD. Adverse events and quality of life (QoL) scores were evaluated as secondary outcomes using a random effects model. Quality of evidence was rated using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). @*Results@#This meta-analysis included 16 studies involving 1446 participants (719 in the PPI plus prokinetics group and 727 in the PPI monotherapy group). The PPI plus prokinetics treatment resulted in a significant reduction in global symptoms of GERD regardless of the prokinetic type, refractoriness, and ethnicity. Additionally, treatment with PPI plus prokinetics for at least 4 weeks was found to be more beneficial than PPI monotherapy with respect to global symptom improvement. However, the QoL scores were not improved with PPI plus prokinetics treatment. Adverse events observed in response to PPI plus prokinetics treatment did not differ from those observed with PPI monotherapy. @*Conclusions@#Combination of prokinetics with PPI treatment is more effective than PPI alone in GERD patients. Further high-quality trials with large sample sizes are needed to verify the effects based on prokinetic type.
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Background/Aims@#The use of endoscopic submucosal dissection (ESD) for treating undifferentiated-type early gastric cancer is controversial. The objective of this study was to perform a meta-analysis to compare the long-term outcomes of ESD and surgery for undifferentiated-type early gastric cancer. @*Methods@#The PubMed, Cochrane Library, and EMBASE databases were used to search for relevant studies comparing ESD and surgery for undifferentiated-type early gastric cancer. The methodological quality of the included publications was evaluated using the Risk of Bias Assessment tool for Nonrandomized Studies. The rates of overall survival, recurrence, adverse event, and complete resection were determined. Odds ratios (ORs) and 95% confidence intervals (CIs) were also evaluated. @*Results@#This meta-analysis enrolled five studies with 429 and 1,236 participants undergoing ESD and surgery, respectively. No significant difference was found in the overall survival rate between the ESD and surgery groups (OR, 2.29; 95% CI, 0.98–5.36; p=0.06). However, ESD was associated with a higher recurrence rate and a lower complete resection rate. The adverse event rate was similar between the two groups. @*Conclusions@#ESD with meticulous surveillance esophagogastroduodenoscopy may be as effective and safe as surgery in patients with undifferentiated-type early gastric cancer. Further large-scale, randomized, controlled studies from additional regions are required to confirm these findings.
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Background/Aims@#Prokinetics can be used for treating patients with gastroesophageal reflux disease (GERD), who exhibit suboptimal response to proton pump inhibitor (PPI) treatment. We conducted a systematic review to assess the potential benefits of combination treatment with PPI plus prokinetics in GERD. @*Methods@#We searched PubMed, the Cochrane Library, and EMBASE for publications regarding randomized controlled trials comparing combination treatment of PPI plus prokinetics to PPI monotherapy with respect to global symptom improvement in GERD (until February 2020). The primary outcome was an absence or global symptom improvement in GERD. Adverse events and quality of life (QoL) scores were evaluated as secondary outcomes using a random effects model. Quality of evidence was rated using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). @*Results@#This meta-analysis included 16 studies involving 1446 participants (719 in the PPI plus prokinetics group and 727 in the PPI monotherapy group). The PPI plus prokinetics treatment resulted in a significant reduction in global symptoms of GERD regardless of the prokinetic type, refractoriness, and ethnicity. Additionally, treatment with PPI plus prokinetics for at least 4 weeks was found to be more beneficial than PPI monotherapy with respect to global symptom improvement. However, the QoL scores were not improved with PPI plus prokinetics treatment. Adverse events observed in response to PPI plus prokinetics treatment did not differ from those observed with PPI monotherapy. @*Conclusions@#Combination of prokinetics with PPI treatment is more effective than PPI alone in GERD patients. Further high-quality trials with large sample sizes are needed to verify the effects based on prokinetic type.
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Background/Aims@#The use of endoscopic submucosal dissection (ESD) for treating undifferentiated-type early gastric cancer is controversial. The objective of this study was to perform a meta-analysis to compare the long-term outcomes of ESD and surgery for undifferentiated-type early gastric cancer. @*Methods@#The PubMed, Cochrane Library, and EMBASE databases were used to search for relevant studies comparing ESD and surgery for undifferentiated-type early gastric cancer. The methodological quality of the included publications was evaluated using the Risk of Bias Assessment tool for Nonrandomized Studies. The rates of overall survival, recurrence, adverse event, and complete resection were determined. Odds ratios (ORs) and 95% confidence intervals (CIs) were also evaluated. @*Results@#This meta-analysis enrolled five studies with 429 and 1,236 participants undergoing ESD and surgery, respectively. No significant difference was found in the overall survival rate between the ESD and surgery groups (OR, 2.29; 95% CI, 0.98–5.36; p=0.06). However, ESD was associated with a higher recurrence rate and a lower complete resection rate. The adverse event rate was similar between the two groups. @*Conclusions@#ESD with meticulous surveillance esophagogastroduodenoscopy may be as effective and safe as surgery in patients with undifferentiated-type early gastric cancer. Further large-scale, randomized, controlled studies from additional regions are required to confirm these findings.
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Background/Aims@#For systematic screening protocol for the stomach (SSS), 22 gastroscopy images are considered sufficient to avoid blind spots during gastroscopy. The aim of this study was to investigate the relationship between the number of gastroscopy images taken during the gastroscopy procedure and the detection rate of clinically significant gastric lesions (CSGLs). @*Materials and Methods@#We retrospectively reviewed the data obtained from a cohort of consecutive subjects at a health promotion center. The primary outcome measure was the detection rate of CSGLs per endoscopist, according to the number of gastroscopy images. We also analyzed whether all the CSGLs were detected via SSS. @*Results@#The mean number of gastroscopy images obtained by eight endoscopists was 27.6±10.5 in 2,912 subjects without CSGLs and without biopsies. Among the 5,970 subjects who underwent gastroscopy by the eight endoscopists, 712 CSGLs were detected in 551 subjects. Fifty-six CSGLs (7.9%) in 55 subjects (10.0%) were not detected during the SSS. Photo-endoscopists who took more images achieved a higher detection rate of CSGLs than those who took fewer images (adjusted OR 2.07, 95% CI 1.41~3.05; P<0.0001). @*Conclusions@#The modified SSS, which included 22 SSS images, the fundus, and the saddle area, detected significantly more CSGLs. This modified SSS should be validated with further prospective studies.
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Background/Aims@#Predicting histological ulceration in early gastric cancer (EGC) during endoscopic examination is crucial for endoscopists deciding on the treatment modality. The aim of this study was to investigate the endoscopic factors that can predict histological ulcerations in EGCs. @*Methods@#We retrospectively analyzed patients who underwent endoscopic submucosal dissection (ESD) for EGC. Clinical features and endoscopic characteristics of EGC such as location, histological differentiation, longest diameter, tumor morphology, mucosal break, converging fold, color change, and surface irregularity were reviewed. Histological ulceration was defined based on ESD specimens. @*Results@#A total of 633 EGC lesions from 613 patients were included and histological ulcerations were found in 90 lesions (14.2%). Presence of converging folds, tumor morphology, and color changes on endoscopic examination were related to histological ulceration in the univariate analysis and converging folds along with color changes were statistically significant factors in the multivariate analysis. Kaplan–Meier analysis showed that patients with histological ulcerations in EGCs tended to have higher marginal recurrence rates. @*Conclusions@#Mucosal breaks are not equivalent to histological ulcerations. Rather, the existence of converging folds and color changes during endoscopic examination suggest histological ulcerations. Endoscopists should consider these factors when they decide the treatment modality for EGCs.
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BACKGROUND/AIMS: The risk of peritoneal seeding following perforation after endoscopic resection in patients with early gastric cancer is unclear. The purpose of this study was to investigate long-term clinical outcomes including peritoneal seeding and overall survival rate following gastric perforation during endoscopic submucosal dissection (ESD). METHODS: Between January 2002 and March 2015, 556 patients were diagnosed with early gastric cancer and underwent ESD. Among them, 34 patients (6.1%) experienced gastric perforation during ESD. Clinicopathological data of these patients were reviewed to determine the clinical outcome and evidence of peritoneal seeding. RESULTS: Among 34 patients with perforation, macroperforations occurred during ESD in 17 cases (50%), and microperforation was identified in the remaining 17 cases (50%). All patients except one who underwent emergency surgery due to severe panperitonitis were managed successfully by endoscopic clipping (n=27) or conservative medical treatment (n=6). No evidence of peritoneal seeding after perforation associated with ESD was found in our cohort. Cumulative survival rates did not differ between the perforation and non-perforation groups (p=0.691). Furthermore, mortality was not associated with perforation. In addition, multivariate analysis showed that tumor size and achievement of curative resection were related to cancer recurrence. Perforation was not associated with cancer recurrence and survival. CONCLUSIONS: Perforation associated with ESD does not lead to worse clinical outcomes such as peritoneal seeding or cumulative survival rate. Therefore, periodic follow-up might be possible if curative resection was achieved even if perforation occurred during ESD.
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Humans , Cohort Studies , Emergencies , Follow-Up Studies , Mortality , Multivariate Analysis , Recurrence , Stomach Neoplasms , Survival RateABSTRACT
Accurate diagnosis of Helicobacter pylori (H. pylori) infection is mandatory for the effective management of many gastroduodenal diseases. Currently, various diagnostic methods are available for detecting these infections, and the choice of method should take into account the clinical condition, accessibility, advantage, disadvantage, as well as cost-effectiveness. The diagnostic methods are divided into invasive (endoscopic-based) and non-invasive methods. Non-invasive methods included urea breath test, stool antigen test, serology, and molecular methods. Invasive methods included endoscopic imaging, rapid urease test, histology, culture, and molecular methods. In this article, we provide a review of the currently available options and recent advances of various diagnostic methods.
Subject(s)
Breath Tests , Diagnosis , Helicobacter pylori , Helicobacter , Methods , Urea , UreaseABSTRACT
BACKGROUND/AIMS: Esophageal eosinophilia occurs in many conditions, including eosinophilic esophagitis (EoE) and proton pump inhibitor-responsive esophageal eosinophilia (PPI-REE), which have been increasingly recognized in Western countries. There have been only a few reports in Korea. Here, we evaluated the clinical and endoscopic characteristics of patients with esophageal eosinophilia from our experience. METHODS: Nineteen patients were diagnosed with esophageal eosinophilia based on typical symptoms, endoscopic features, esophageal eosinophilia with ≥15 eosinophils/high power field, and response to medication by PPI. Symptoms, endoscopic and pathological findings were evaluated. RESULTS: Of the 19 patients, 2 patients were diagnosed with EoE, 7 patients were diagnosed with PPI-REE, and 10 patients were undetermined due to loss to follow-up. Among these 19 patients, dysphagia was present in 11, and heartburn, dyspepsia and reflux in 8. Sixteen patients had common endoscopic features, such as longitudinal furrows, concentric rings, strictures, and white plaques; however, 3 patients had normal findings. Nine patients underwent endoscopy at the time of follow-up. Two patients had complete resolution, and 3 had partial resolution. However, 4 patients showed no endoscopic changes. All patients showed symptom improvements. CONCLUSIONS: The clinical and endoscopic characteristics of both groups in Korea were undistinguishable. However, after treatment, endoscopic findings were different between the two groups. Large-scale studies are warranted to confirm our findings.
Subject(s)
Humans , Constriction, Pathologic , Deglutition Disorders , Dyspepsia , Endoscopy , Eosinophilia , Eosinophilic Esophagitis , Esophagus , Follow-Up Studies , Heartburn , Korea , Proton Pump Inhibitors , Proton PumpsABSTRACT
BACKGROUND/AIMS: Postoperative ileus (POI) is characterized by impaired propulsive function of the gastrointestinal tract after surgery. Although inflammation is considered to be an important pathogenesis of POI, significant data are lacking. We aim to correlate the recovery time of postoperative dysmotility with that of inflammation and mucosal permeability. METHODS: An experimental POI model of guinea pig was used. Contractile activity of the circular muscle of the stomach, jejunum, ileum, and proximal colon was measured through a tissue bath study. Inflammatory cells were counted, and the expression of calprotectin and tryptase were analyzed. The expression of protease-activated receptor 2 (PAR-2), claudin-1, and claudin-2 were analyzed with immunofluorescence. RESULTS: The small bowel and colon showed decreased contractile amplitude in the POI groups compared to control. In contrast to the colon, the contractile amplitude of the small bowel significantly recovered in the POI group at 6 hours after the operation compared to the control group. Inflammation was highly significant in the POI groups compared to the control and sham groups, especially in the colon. Immunofluorescence showed increased PAR-2 expression in the POI groups compared to sham. The decreased claudin-1 expression and increased claudin-2 expression may suggest increased mucosal permeability of the small bowel and colon in the POI groups. CONCLUSIONS: Increased inflammation and mucosal permeability may play an important role in the differential recovery stages in POI. These data may provide further insights into the pathophysiology and potential new therapeutic prospects of POI.
Subject(s)
Animals , Baths , Claudin-1 , Claudin-2 , Colon , Fluorescent Antibody Technique , Gastrointestinal Tract , Guinea Pigs , Guinea , Ileum , Ileus , Inflammation , Jejunum , Leukocyte L1 Antigen Complex , Permeability , Receptor, PAR-2 , Stomach , TryptasesABSTRACT
Dysphagia is one of the common symptoms that are encountered in clinical practice. However, dysphagia is still crucial and must be thoroughly investigated because it may be a key symptom of several malignancies. There are two types of dysphagia, oropharyngeal and esophageal dysphagia. Esophageal dysphagia can be caused by esophageal neuromuscular motility disorder, various inflammatory disorders, and also extrinsic or intrinsic structural lesions such as esophageal cancer. This article focuses on malignant esophageal dysphagia, including its causes, risk factors, clinical symptoms, and management.
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Humans , Deglutition Disorders , Esophageal Neoplasms , Gastrointestinal Neoplasms , Risk FactorsABSTRACT
Functional dyspepsia (FD) and irritable bowel syndrome (IBS) are common gastrointestinal (GI) diseases; however, there is frequent overlap between FD and IBS patients. Emerging evidence links the activation of corticotropin releasing factor (CRF) receptors with stress-related alterations of gastric and colonic motor function. Therefore, we investigated the effect of peripheral CRF peptide and water avoidance stress (WAS) on upper and lower GI transit in guinea pigs. Dosages 1, 3, and 10 µg/kg of CRF were injected intraperitoneally (IP) in fasted guinea pigs 30 minutes prior to the intragastric administration of charcoal mix to measure upper GI transit. Colonic transits in non-fasted guinea pigs were assessed by fecal pellet output assay after above IP CRF doses. Blockade of CRF receptors by Astressin, and its effect on GI transit was also analyzed. Guinea pigs were subjected to WAS to measure gastrocolonic transit in different sets of experiments. Dose 10 µg/kg of CRF significantly inhibited upper GI transit. In contrast, there was dose dependent acceleration of the colonic transit. Remarkably, pretreatment of astressin significantly reverses the effect of CRF peptide on GI transit. WAS significantly increase colonic transit, but failed to accelerate upper GI transit. Peripheral CRF peptide significantly suppressed upper GI transit and accelerated colon transit, while central CRF involved WAS stimulated only colonic transit. Therefore, peripheral CRF could be utilized to establish the animal model of overlap syndrome.
Subject(s)
Animals , Humans , Acceleration , Charcoal , Colon , Corticotropin-Releasing Hormone , Dyspepsia , Guinea Pigs , Guinea , Irritable Bowel Syndrome , Models, Animal , Receptors, Corticotropin-Releasing Hormone , WaterABSTRACT
Gastric adenoma (dysplasia) is a precancerous lesion. Therefore, managements of gastric adenomas are important for preventing the development of gastric cancers and for detecting gastric cancers at earlier stages. The Vienna classification divides gastric adenomas into two categories: high-grade dysplasia and low-grade dysplasia. Generally, endoscopic resection is performed for adenoma with high-grade dysplasia due to the coexistence of carcinoma and the potential of progression to carcinomas. However, the treatments of adenoma with low-grade dysplasia remain controversial. Currently two treatment strategies for the low-grade type have been suggested; First is the ‘wait and see’ strategy; Second is endoscopic treatment (e.g., endoscopic mucosal resection, endoscopic submucosal dissection, or argon plasma coagulation). In this review, we discuss the current optimal strategies for endoscopic management of gastric adenoma.
Subject(s)
Adenoma , Argon , Classification , Plasma , Stomach NeoplasmsABSTRACT
Cytomegalovirus (CMV) colitis is common among immunocompromised patients, and often diagnosed by pathologic confirmation because it is associated with a diverse spectrum of clinical and endoscopic features. However, Crohn's disease has no definitive diagnostic criteria, but longitudinal ulcers and cobble stone appearance are accepted as typical endoscopic features of Crohn's disease. An 83 year-old male with a history of radiotherapy for hypopharyngeal cancer visited our hospital with a complaint of melena for 1 week. His colonoscopic exam showed multiple longitudinal ulcers along the entire colon. Most of the ulcers were longer than 4 cm, these endoscopic findings were suspected as typical endoscopic features of Crohn's disease. Pathologic reports revealed multiple inclusion bodies with CMV on immunohistochemistry. He was finally diagnosed as having CMV colitis, and received a 3 week-course of intravenous ganciclovir. A colonoscopic follow-up showed complete healing of the multiple longitudinal ulcers, and he is doing well now without further treatment.