Rebleeding after Initial Endoscopic Hemostasis in Peptic Ulcer Disease

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

G Protein beta3 Subunit Polymorphism and Long-Term Prognosis of Functional Dyspepsia

BACKGROUND/AIMS: A link between G protein beta3 (GNB3) polymorphism and functional dyspepsia (FD) has been suggested. The aim of this study was to determine the role of GNB3 polymorphism in the long-term prognosis of FD in Koreans. METHODS: FD patients and normal healthy controls were recruited from patients who visited our center between December 2006 and June 2007. All of the subjects completed Rome III questionnaires before undergoing upper gastrointestinal endoscopy and colonoscopy. Genomic DNA was extracted for GNB3 genotyping. After 5 years, the subjects were reevaluated using the same questionnaires. RESULTS: GNB3 825T carrier status was significantly related to FD in Koreans (p=0.04). After 5 years, 61.0% of the initial FD patients and 12.2% of the initial normal subjects were diagnosed with FD (odds ratio [OR], 11.7; 95% confidence interval [CI], 4.3 to 31.1; p<0.001). Regardless of the GNB3 genotype (p=0.798), female sex was strongly correlated with FD after 5 years (OR, 3.3; 95% CI, 1.2 to 9.1; p=0.017). CONCLUSIONS: The T allele of GNB3 is linked to FD in Koreans but does not predict long-term prognosis. Female sex is related to a higher prevalence of FD after 5 years.

Early Gastric Cancer-Like Advanced Gastric Cancer versus Advanced Gastric Cancer-Like Early Gastric Cancer

BACKGROUND/AIMS: Improvements in the endoscopic evaluation and management of gastric cancer have made it possible to determine the depth of invasion during endoscopic examination. The aim of this study was to elucidate the differences between early gastric cancer (EGC) that resembles advanced gastric cancer (AGC) and AGC that resembles EGC. METHODS: We retrieved cases of EGC-like AGC and AGC-like EGC from consecutive gastric cancers that had been completely resected. The endoscopic diagnoses and clinicopathological findings were analyzed. RESULTS: AGC-like EGCs were located mainly in the distal part of the stomach, whereas EGC-like AGCs were located mainly in the proximal part of the stomach (p<0.001). Sixty percent of AGC-like EGCs were moderately differentiated adenocarcinomas, while 64% of EGC-like AGCs were poorly differentiated adenocarcinomas (p=0.015). According to Lauren's classification, 68% of AGC-like EGCs were intestinal type, whereas 71% of EGC-like AGCs were diffuse type (p=0.020). CONCLUSIONS: AGC-like EGCs predominate in the distal part of the stomach, while EGC-like AGCs predominate in the proximal part. When evaluating the depth of a gastric cancer, care should be taken not to underestimate measurements in proximal gastric cancers since they tend to be poorly-differentiated adenocarcinomas, in Lauren's diffuse type, and invade deeper than their endoscopic appearance might suggest.

Changing Trends of Serum Pepsinogen I/II Ratio in Asymptomatic Subjects

BACKGROUND/AIMS: Gastric atrophy can be diagnosed by serum pesinogen I/II ratio. The aim of this study was to investigate whether the changes of serum pepsinogen I/II ratio can be predicted by gastroscopy. MATERIALS AND METHODS: Sixty healthy subjects who underwent screening for serum pepsinogen I/II levels, serum Helicobacter pylori (H. pylori) antibody, and gastroscopy for two sequential years were included. Endoscopic findings were classified into four different categories according to the degree of chronic atrophic gastritis; none, mild, moderate, and severe. Changes of the serum pepsinogen I/II ratio, body mass index, H. pylori antibody, and endoscopic findings were analyzed after a year. RESULTS: The serum pepsinogen I/II ratio showed a tendency to decrease after a year in subjects with H. pylori infection (P=0.013) and those with moderate to severe atrophic gastritis (P=0.004), whereas it increased in subjects without H. pylori infection and those with none to mild atrophic gastritis. On multivariate analysis, the degree of atrophic gastritis was the only factor that was related to the changing trends of the serum pepsinogen I/II ratio (odds ratio=5.385, P=0.023). CONCLUSIONS: The degree of atrophic gastritis on endoscopic findings can predict the changes of the serum pepsinogen I/II ratio after a year. Regardless of the current status of H. pylori infection, the serum pepsinogen I/II ratio decreases after a year in subjects with moderate to severe atrophic gastritis.

Recurrence of Colorectal Neoplasm Cannot Be Predicted by Sonic Hedgehog Expression in the Normal Colonic Tissue

BACKGROUND/AIMS: The expression of sonic hedgehog (Shh) in the colon cancer cell has been implicated in colorectal carcinogenesis. However, the association between Shh expression in the normal colonic mucosa and the recurrence of colorectal neoplasm after tumor resection has not been well documented. The aim of the study was to determine the association between Shh expression in the normal colonic mucosa and in the recurrence of colorectal neoplasm. METHODS: Fifty-five patients who underwent a long-term follow-up colonoscopy after the colorectal neoplasm resection were included. At the time of the tumor resection, Shh expression in the normal colonic mucosa was examined. The association between Shh expression in the normal colonic mucosa and the recurrence of colorectal neoplasm was analyzed. RESULTS: In total, 97 colorectal neoplasms were detected among 41 subjects after a mean follow-up period of 63 weeks (range 27-254 weeks). Of 55 subjects, 26 (47.3%) exhibited positive Shh expression in the normal colonic tissue, and the recurrence rate did not differ with the degree of Shh expression (P=0.238). The degree of Shh expression was not associated with the number (P=0.389), size (P=0.928), location (P=0.410), pathologic types (P=0.127), or time of recurrence (P=0.711) of the recurred colorectal neoplasm. CONCLUSIONS: Most colorectal neoplasm patients show recurrence after the resection and exhibit Shh expression in the normal colonic tissue. The degree of Shh expression in the normal colonic mucosa does not predict the recurrence of colorectal neoplasm.

Relationship between Positron Emission Tomography Uptake and Macroscopic Findings of Colorectal Cancer

BACKGROUND/AIMS: The semiquantitative parameter "standard uptake value" (SUV) of 18Fluorodeoxyglucose (FDG) positron-emission tomography (PET) provides important additional information about colorectal cancer. In general, colorectal cancers exhibit different growth patterns with different clinicopathological characteristics. The aim of this study was to elucidate the link between the macroscopic appearance of colorectal cancers and maximum SUV (SUVmax) FDG uptakes. METHODS: We analyzed 347 patients with colorectal cancer who underwent PET scanning before treatment. The SUVmax of colorectal cancer was analyzed by examining PET images. The macroscopic appearance of each colorectal cancer was classified into three major types: ulcerofungating (n=223), ulceroinfiltrating (n=44), and fungating (n=78). Two cases that were difficult to classify were excluded from the study. RESULTS: The SUVmax was higher in colorectal cancers with an ulcerofungating appearance (12.19+/-5.84, mean+/-standard deviation) and ulceroinfiltrating appearance (11.66+/-5.63) than in those with a fungating appearance (9.58+/-6.67; P=0.005) (ulcerofungating and ulceroinfiltrative vs. fungating, P<0.001). A smaller tumor size (P<0.001) were significantly related to the fungating colorectal cancer. Four out of six colorectal cancers that did not show FDG uptake were the fungating type. CONCLUSIONS: Colorectal cancers with a fungating appearance exhibit a lower SUVmax, shallower invasion and smaller tumor size. Our results indicate that colorectal cancers with a fungating appearance would be less prominent on PET scan than those with an ulcerofungating or ulceroinfiltrating appearance, and thus require more attention.

Cytomegalovirus Infection-related Spontaneous Intestinal Perforation and Aorto-enteric Fistula after Abdominal Aortic Aneurysmal Repair / 대한소화기학회지

Gastrointestinal complications (GI) after thoracoabdominal aortic repair can be classified as biliary disease, heptic dysfunction, pancreatitis, GI bleeding, peptic ulcer disease, bowel ischemia, paralytic ileus, and aortoenteric fistula. Theses complications are associated with high post operative morbidity and mortality. Most of the aortoenteric fistulae after thoracoabdominal aortic surgery are found at the duodenum, near the surgical site. These rare complications are caused by an indirect communication with abdominal aorta that originated from an aneursymal formation ruptured into the duodenum. Such aorto-duodenal fistula formation is considered as a result of inflammatory change from secondary infection near the surgical instruments. Herein, we report two cases of massive upper GI bleeding from aorto-duodenal fistulae and spontaneous lower GI perforation related to cytomegalovirus infection after abdominal aortic aneurysmal repair operations.

Cytomegalovirus Infection-related Spontaneous Intestinal Perforation and Aorto-enteric Fistula after Abdominal Aortic Aneurysmal Repair / 대한소화기학회지

Gastrointestinal complications (GI) after thoracoabdominal aortic repair can be classified as biliary disease, heptic dysfunction, pancreatitis, GI bleeding, peptic ulcer disease, bowel ischemia, paralytic ileus, and aortoenteric fistula. Theses complications are associated with high post operative morbidity and mortality. Most of the aortoenteric fistulae after thoracoabdominal aortic surgery are found at the duodenum, near the surgical site. These rare complications are caused by an indirect communication with abdominal aorta that originated from an aneursymal formation ruptured into the duodenum. Such aorto-duodenal fistula formation is considered as a result of inflammatory change from secondary infection near the surgical instruments. Herein, we report two cases of massive upper GI bleeding from aorto-duodenal fistulae and spontaneous lower GI perforation related to cytomegalovirus infection after abdominal aortic aneurysmal repair operations.

Cecal Polypoid Arteriovenous Malformations Removed by Endoscopic Biopsy

Colonic arteriovenous malformation (AVM) is one of the causes of lower gastrointestinal bleeding. Unlike small vascular ectasia or angiodysplasia, colonic AVM tends to be solitary, large in size, and identified endoscopically as flat or elevated bright red lesion. Herein, we report a case of non-solitary and small cecal AVMs which were removed by endoscopic biopsy. A 66-yr-old woman was referred for routine gastrointestinal cancer screening. She was suffering from diabetes, hypertension, end-stage renal disease, and anemia of chronic disease. On colonoscopic finding, three semi-pedunculated polyps, less than 5 mm in size, were noticed near to the appendiceal orifice. Since the lesions revealed normal-looking epithelium with converging folds on the cecal base, lesions were diagnosed as inflammatory polyps on gross finding. Three biopsies were taken from each lesion. Bleeding from the biopsied site ceased spontaneously. Histopathologic evaluation demonstrated intramucosal hemorrhage and dilated submucosal vessels which were consistent with polypoid colonic AVMs.

Presence of Iron in Colorectal Adenomas and Adenocarcinomas

BACKGROUND/AIMS: Iron overload reportedly increases the risk of colorectal neoplasms, but the distribution of tissue iron in a colorectal neoplasm remains controversial. In this study, we attempted to determine the significance of tissue iron in colorectal adenomas and adenocarcinomas. METHODS: This study investigated 138 colorectal neoplasms (54 adenocarcinomas, 25 adenomas with high-grade dysplasia, and 59 adenomas with low-grade dysplasia) that were removed by surgical or endoscopic resection in Konkuk University Hospital between August 2005 and August 2006. Adjacent normal colon tissues and colorectal neoplasms were stained with Perls' Prussian blue to reveal ferric compounds. RESULTS: Positive Perls' staining was evident in 35.2% (19/54) of the adenocarcinomas and 22.6% (19/84) of the adenomas, and in only 2.2% (3/138) of the samples of adjacent normal colon tissue (p<0.001). Iron appears to reside exclusively in the stroma and outside the gland, rather than in the epithelial cells. Iron expression was strong in larger (p=0.004) and pedunculated (p<0.001) adenomas, and in all types of adenocarcinomas regardless of their size, shape, and location. CONCLUSIONS: The frequent presence of iron in the stroma of large adenomas, pedunculated adenomas, and adenocarcinomas indicates that iron deposition is a secondary phenomenon to intralesional hemorrhage rather than a consequence of epithelial-cell carcinogenesis.

Sonic Hedgehog Expression in Colorectal Neoplasms

BACKGROUND/AIMS: Dysregulation of the hedgehog pathway has been implicated in regeneration and carcinogenesis, leading to the expression of the sonic hedgehog (Shh) protein in gastrointestinal neoplasms. The expression of Shh in colon neoplasms and paired normal colonic mucosa was therefore investigated. METHODS: Forty-four colon cancers and 73 colon adenomas that were removed by surgical colectomy or colon polypectomy between August 2005 and August 2006 were included. Colorectal neoplasms and the adjacent normal colon tissue were examined by immunohistochemistry using rabbit polyclonal Shh antibody. RESULTS: Expression of Shh was up-regulated in adenomas and adenocarcinomas of the colon compared to normal colon tissues (p<0.001). The degree of Shh expression was not associated with the size, shape, or, location of the tumor, or as the age and gender of the patient. In normal colonic epithelium, Shh was expressed at the apex of the crypts and in a few basally-located cells. CONCLUSIONS: Higher levels of Shh expression in colonic adenoma and adenocarcinoma suggest that Shh is required during epithelial proliferation in the colon. Hedgehog signaling is likely to be associated with early tumorigenesis in colonic neoplasms.

Irritable Bowel Syndrome Is More Common in Women Regardless of the Menstrual Phase: A Rome II-based Survey

Functional gastrointestinal disorders are more common in women in relation to the fluctuations of female sex hormones. We tried to know the gender-related differences in the prevalence of irritable bowel syndrome and gastrointestinal symptoms according to the menstrual phase. A total of 253 women before menopause and 252 men below age 50 were examined by a gastroenterologist after completing the questionnaire. Blood tests, endoscopic procedures, and imaging studies were done, if needed. Women were subclassified into three groups according to their menst- ruation period; menstrual phase, proliferative phase, and secretory phase. Finally, 179 men and 193 women were analyzed. Irritable bowel syndrome was more frequently noticed in women than in men (p=0.01). The diarrhea-dominant type was more common in men, while constipation-dominant or alternating types were more common in women (p<0.001). Of 193 women, there was no significant difference in their gastrointestinal symptoms according to their menstrual phase. Regardless of the menstrual phase, gastrointestinal symptoms are more frequent in women. Physicians should consider different symptomatic manifestations between men and women should be considered when evaluating functional gastrointestinal disorders.

Plasma Adiponectin and Insulin Resistance in Korean Type 2 Diabetes Mellitus

Insulin resistance, which implies impairment of insulin signaling in the target tissues, is a common cause of type 2 diabetes. Adipose tissue plays an important role in insulin resistance through the dysregulated production and secretion of adipose-derived proteins, including tumor necrosis factor-alpha, plasminogen activator inhibitor-1, leptin, resistin, angiotensinogen, and adiponectin. Adiponectin was estimated to be a protective adipocytokine against atherosclerosis, and also to have an anti-inflammatory effect. In this study, the relationship between fasting plasma adiponectin concentration and adiposity, body composition, insulin sensitivity (ITT, HOMAIR, QUICK), lipid profile, fasting insulin concentration were examined in Korean type 2 diabetes. The difference in the adiponectin concentrations was also examined in diabetic and non-diabetic subjects, with adjustment for gender, age and body mass index. 102 type 2 diabetics and 50 controls were examined. After a 12-h overnight fast, all subjects underwent a 75gram oral glucose tolerance test. Baseline blood samples were drawn for the determinations of fasting plasma glucose, insulin, adiponectin, total cholesterol, triglyceride, LDL-cholesterol, and HDL-cholesterol. The body composition was estimated using a bioelectric impedance analyzer (Inbody 2.0). The insulin sensitivity was estimated using the insulin tolerance test (ITT), HOMAIR and QUICK methods. In the diabetic group, the fasting adiponectin concentrations were significantly lower in men than in women. They were negatively correlated with BMI (r=-0.453), hip circumference (r=-0.341), fasting glucose concentrations (r=-0.277) and HOMAIR (r=-0.233). In addition, they were positively correlated with systolic blood pressure (r=0.321) and HDL-cholesterol (r= 0.291). The systolic blood pressure and HDL-cholesterol were found to be independent variables, from a multiple logistic regression analysis, which influenced the adiponectin concentration. Compared with the non-diabetic group, the adiponectin concentrations were significantly lower in the diabetic group, with the exception of obese males. In conclusion, the plasma adiponectin concentrations were closely related to the insulin resistance parameters in Korean type 2 diabetic patients.

A Case of Primary Iliopsoas Abscess Presented as Femoral Neuropathy in a Hemodialysis Patient / 대한신장학회잡지

Primary iliopsoas abscess is a rare but potentially serious condition. The diagnosis is frequently delayed due to its variable and nonspecific features and occult clinical course. The delayed diagnosis and treatment of iliopsoas abscess is the major poor prognostic factor. We report a rare case of primary iliopsoas abscess that presented as a femoral neuropathy in a patient on hemodialysis. A 49-year-old man with end stage renal disease was admitted due to pain in the left inguinal area, and weakness and hypoesthesia of left lower leg. Left iliopsoas abscess was confirmed by CT and MRI. Left femoral neuropathy was diagnosed with electrodiagnostic study. Iliopsoas abscess with femoral neuropathy was completely treated with CT-guided aspiration, antibiotics and prolonged physical therapy of hip and knee joints. To our knowledge, this is the first case report of primary iliopsoas abscess presented as a femoral neuropathy in a patient on hemodialysis in Korea.

Agranulocytosis Induced by Vancomycin in an ESRD Patient on CAPD

Agranulocytosis is a rare adverse effect associated with prolonged vancomycin therapy, and is potentially serious, especially in end stage renal disease (ESRD) patients. We describe a continuous ambulatory peritoneal dialysis (CAPD) patient that developed vancomycin-induced agranulocytosis during treatment for methicillin-resistant Staphylococcus aureus (MRSA) -associated external cuff infection and pneumonia. The agranulocytosis was rapidly resolved by granulocyte colony-stimulating factor (G-CSF) therapy and by the discontinuation of vancomycin.

The Changes of Serologic Markers in Pneumoconiosis of Coal Workers / 결핵

BACKGROUND: Pneumoconiosis is a parenchymal lung disease that results from the accumulation of coal dust in the lungs and the consequent tissue reaction. To evaluate the role of various personal factors in pneumoconosis and the significance of some serologic markers for assessing the disease activity related to pneumoconiosis, the Rheumatoid Factor(RF), α1-AT, C-Reactive Protein(CRT), ceruloplasmin and fibrinogen levels were measured. METHOD: All the patients were males, 45-76 years old, and the mean duration of coal dust exposure was 23.2 years. 51 patients were classified as having Simple Pneumoconiosis (SP), 59 had Progressive Massive Fibrosis (PMF). Fifty eight men with ages ranging from 26-70 years wer used as normal controls. The serum RF and CRT were titrated using an Autochemistry analyzer (HITACHI 7150 : Japan) and the α1-AT and ceruloplasmin levels were measured using a Nephelometer (Behring Nephelometer : Germany) and the fibrinogen levels were estimated by using and Autoanalyzer for hematologic coagulation. RESULT: There was a higher RF level in the SP, and PMF groups than in the control groups but there was no statistical difference. The CRP, α1-AT, and ceruloplasmin levels were also higher in the SP, and PMF groups. However, the fibrinogen concentration was within the normal ranges in both the SP and PMF groups. CONCLUSION: The CWP (Ed note : Define CWP) patients had significantly higher CRP, α1-AT, and ceruloplasmin levels compared to the control group. It is believed that these serologic changes could be used as a marker of the disease activity.

A Case Report of the Primary Lung Lymphoma / 결핵

The primary lymphoma in the lung is very rare. Most of the primary pulmonary lymphomas, which represent 3-4 % of extra-nodal lymphomas, are low-grade B-cell lymphoma. The low-grade B-cell lymphomas progress slowly and the prognosis of these are more favorable than that of the nodal lymphomas. However, high-grade forms progress rapidly with more severe course. The diagnosis of primary pulmonary lymphomas generally relies on the histopathologic findings of lung specimens obtained by surgical excision of the lesions or open-lung biopsy. Recently, less aggressive biopsies(transbronchial, transthoracic) and/or immunocyto -chemical, immunochemical and gene rearrangement studies on materials obtained by bronchoalveolar lavage have been used occasionally. The treatment of the primary pulmonary lymphomas has not been precisely codified. Several clinical data suggest that limited surgery or non -aggressive chemotherapy can provide long-term survival in patients with such slowly developing neoplasm, and demonstrated the need for the development of noninvasive diagnostic methods. In this study, we report a case of high-grade B-cell lymphoma of the lung which was treated with combination chemotherapy.

A Case of a Bezoar Found in a Normal Duodenal Bulb / 대한소화기내시경학회지

A 50-year-old man who had suffered from chronic indigestion complained of upper abdominal pain and vomiting which had persisted for 4 days. Consequently, he had eaten two persimmons before sleeping detected each day for five days. An irregular multinodular villous filling defect was in the duodenal bulb on, the UGI series, which had its location and changed its position. It was difficult to differentiate a papillary gastric polyp or villous tumor from the duodenal bezoar, but the patient's history of having eaten persimmons was helpful. The endoscopic and pathologic study confirmed a phytobezoar which was located in the normal duodenal bulb. Subsequently we are reporting this case having reviewed the related literature of the phytobezoar which was found in the normal duodenal bulb.

A Case of Hydrogen Peroxide Enema Induced Chemical Colitis

Hydrogen peroxide solution is commonly used for irrigating and cleaning wounds. When it is applied to tissues, catalase causes its rapid molecular degeneration with the release of oxygen bubbles. We present case report illustrating two hazards ; chemical colitis and oxygen embolus. A 29-year-old previously healthy woman presented to the bloody diarrhea and anal pain after hydrogen peroxide enema. In the colonoscopic examination, severe mucosal edema and ulceration with bleeding was noted from anus to sigmoid colon. With use of anal endosonography, multiple high level echo were noted in the internal and external anal sphincter of the upper anal canal. Microscopically, mononuclear cells were infiltrated in lamina propria and congestion. She had treatment with IV fluid, IV antibiotics and NPO. At 3rd hospital day, anal pain was disappeared. Bloody stool was disappeared next day. At 8th hospital day, mucosal edema and ulceration were disappeared on colonoscopic examination. Recovery was full and the patient was discharged at nine days after the episode.

Histopathological Features of H.pyloriinduced Gastritis and Improvement of Gastritis after Eradication of H.pylori / 대한내과학회지

OBJECTIVES: This study was designed to investigate the distribution of Helicobacter pylori(HP), the relationship between HP colonization and gastritis scores graded according to the Sydney system, epithelial damage, and lymphoid follicles, and to assess the effect of eradication of HP infection on the different histological parameters. METHODS: Gastritis scores, epithelial damage, and lymphoid follicles were assessed in gastric antral, body, and fundic biopsy specimens before and 4 weeks after antiHP triple therapy in 32 patients with HP-related gastritis. RESULTS: The mean initial scores of all histological parameters were higher in the antrum compared with the body and fundus. A significant, positive correlation was noted between HP score and the score for inflammation, for activity, and for mucus depletion. After eradication of HP infection, significant improvement in activity, chronic inflammation, and mucus depletion was detected in responders with a successful HP eradication ; the activity return to normal in follow-up, and chronic inflammation and mucus depletion was decreased significally in severity in responders(p<0.05). No significant reduction in severity of gastritis and mucus depletion was detected in the non-responders with persistent HP infection following anti-HP triple therapy. CONCLUSIONS: The eradication of HP results in a rapid, significant histopathological improvement in the gastritis scores and epithelial damage in gastric mucosa.