Risk of Peptic Ulcer Bleeding Associated with Helicobacter pylori Infection, Nonsteroidal Anti-inflammatory Drugs, and Low-dose Aspirin Therapy in Peptic Ulcer Disease: A Case-control Study

BACKGROUND/AIMS: The association between Helicobacter pylori infection and nonsteroidal anti-inflammatory drugs (NSAIDs) or low-dose aspirin therapy as a risk factor for peptic ulcer bleeding (PUB) remains unclear. This study investigated the risk of PUB associated with H. pylori infection and NSAID or low-dose aspirin therapy in patients with PUD. MATERIALS AND METHODS: This case-control study investigated 340 patients with PUB between 2012 and 2016. The control group comprised age and sex-matched patients with endoscopically documented non-bleeding ulcers. Using logistic regression analysis, the adjusted odds ratio (AOR) was calculated for the risk of PUB. RESULTS: Of the patients investigated, 57.9% in the study group and 51.8% in the control group were diagnosed with H. pylori infection (P=0.106). Logistic regression analysis showed synergistic interaction between H. pylori infection and low-dose aspirin therapy. Multivariate analysis showed that low-dose aspirin (AOR 3.92, P < 0.001), NSAIDs (AOR 2.98, P=0.001), warfarin (AOR 14.57, P=0.011), gastric ulcer (compared with duodenal ulcer) (AOR 1.65, P=0.01), and smoking (AOR 1.97, P=0.004) increased the risk of PUB compared with the risk of PUD. CONCLUSIONS: Both NSAIDs and aspirin are independent risk factors for bleeding in patients with PUD. Additionally, low-dose aspirin therapy concomitant with H. pylori infection produced a synergistic effect. Therefore, H. pylori eradication may be crucial in aspirin users. Moreover, a proton pump inhibitor should be prescribed in patients with a history of bleeding ulcers who need long-term NSAID treatment.

Predictors for the need for endoscopic therapy in patients with presumed acute upper gastrointestinal bleeding

BACKGROUND/AIMS@#Selecting patients with an urgent need for endoscopic hemostasis is difficult based only on simple parameters of presumed acute upper gastrointestinal bleeding. This study assessed easily applicable factors to predict cases in need of urgent endoscopic hemostasis due to acute upper gastrointestinal bleeding.@*METHODS@#The consecutively included patients were divided into the endoscopic hemostasis and nonendoscopic hemostasis groups. We reviewed the enrolled patients’ medical records and analyzed various variables and parameters for acute upper gastrointestinal bleeding outcomes such as demographic factors, comorbidities, symptoms, signs, laboratory findings, rebleeding rate, and mortality to evaluate simple predictive factors for endoscopic treatment.@*RESULTS@#A total of 613 patients were analyzed, including 329 patients in the endoscopic hemostasis and 284 patients in the non-endoscopic hemostasis groups. In the multivariate analysis, a bloody nasogastric lavage (adjusted odds ratio [AOR], 6.786; 95% confidence interval [CI], 3.990 to 11.543; p < 0.0001) and a hemoglobin level less than 8.6 g/dL (AOR, 1.768; 95% CI, 1.028 to 3.039; p = 0.039) were independent predictors for endoscopic hemostasis. Significant differences in the morbidity rates of endoscopic hemostasis were detected between the group with no predictive factors and the group with one or more predictive factors (OR, 2.677; 95% CI, 1.920 to 3.733; p < 0.0001).@*CONCLUSIONS@#A bloody nasogastric lavage and hemoglobin < 8.6 g/dL were independent predictors of endoscopic hemostasis in patients with acute upper gastrointestinal bleeding.

Phylogenetic Analyses of HBV Pre-S/S Genes in Mother-Child Pairs with Long-Term Infection by Presumed Vertical Transmission

Vertical transmission from mother to child, the main route of chronic hepatitis B virus (HBV) infection in the East Asia, is considered one of the most important predictors for the response to antiviral therapies as well as its complications such as cirrhosis and hepatocellular carcinoma. Therefore, it is critical in both etiologic and prognostic aspects to confirm whether or not chronic HBV infection is acquired vertically. This study investigated whether mother-to-child infection could be proved by the phylogenetic analyses of HBV pre-S/S genes ever since several decades have elapsed in mother-child pairs with presumed vertical transmission. The pre-S and S regions of HBVs were compared and analyzed phylogenetically in a total of 36 adults (18 mother-child pairs) with chronic HBV infection. All of the isolates of HBV were genotype C and serotype adr. The divergence between mothers and offsprings was 0 to 1.5%. Phylogenetic trees revealed that 17 of 18 pairs (94%) with presumed vertical transmission were grouped into the same cluster. Vertical transmission from mother to child could be strongly suggested even in adults with a history of several decades of HBV infection using the phylogenetic analyses of pre-S and S genes.

The Simple Predictors of Pseudomembranous Colitis in Patients with Hospital-Acquired Diarrhea: A Prospective Observational Study

BACKGROUND/AIMS: As the incidence rate of and mortality from pseudomembranous colitis (PMC) are increasing worldwide, it is important to study the simple predictive risk factors for PMC among patients with hospital-acquired diarrhea (HAD). This study focused on identifying the clinical risk factors that can easily predict PMC. METHODS: The presumed HAD patients were prospectively recruited at the Hallym University Kangdong Sacred Heart Hospital. RESULTS: Age of 70 and older (adjusted odds ratio [OR], 1.76; 95% confidence interval [CI], 1.12 to 0.75), use of proton pump inhibitors (adjusted OR, 4.07; 95% CI, 2.512 to 6.57), use of cephalosporins (adjusted OR, 2.99; 95% CI, 1.82 to 4.94), and underlying cancer (adjusted OR, 1.72; 95% CI, 1.04 to 2.82) were independent risk factors for PMC in the multivariate logistic regression analysis. The prevalence of PMC was very low in the patients with HAD who exhibited no risk factors. CONCLUSIONS: The risk factors for PMC in patients with HAD included cephalosporin use, proton pump inhibitor use, old age, and cancer. Considering the strongly negative predictive values of these risk factors, endoscopic evaluation can be delayed in patients with HAD without risk of developing PMC.

Helicobacter pylori-related Peptic Ulcer Disease / 대한내과학회지

Although the worldwide prevalence of Helicobacter pylori (H. pylori) infection has decreased, peptic ulcer disease (PUD) remains prevalent due to increased usage of non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin. In recent years, the prevalence of H. pylori infection in PUD cases and the distribution of PUD have changed in Korea. The incidence of idiopathic H. pylori-negative ulcers has increased, and research is needed to determine the cause of these idiopathic ulcers. The eradication of H. pylori infection decreases PUD recurrence, and plays a crucial role in the treatment of PUD. The H. pylori test-and-treat strategy is beneficial for patients starting NSAIDs and long-term aspirin users with a history of bleeding ulcers. Although the H. pylori eradication rate is declining steadily due to antibiotic resistance, especially to clarithromycin, current guidelines still recommend standard triple therapy, including a proton pump inhibitor, amoxicillin, and clarithromycin, as a first-line therapy. Recently, various treatment regimens, including sequential or concomitant therapies, have been developed in an attempt to overcome the low eradication rate observed with standard triple therapy. The aim of this article is to review recent trends in H. pylori-related PUD, focusing on epidemiology and treatment strategies.

A Case of Clostridium Liver Abscess with Sepsis / 대한소화기학회지

Clostridial septicemia usually occurrs in patients with immunocompromised diseases such as diabetes and malignancy. Clostridial liver abscess is very rare but highly fatal. We experienced a case of Clostridial septicemia due to liver abscess in a 73-year-old man. He was presented with fever and chills. On admission, abdominal CT scan showed about 35 mm sized hypoattenuated lesion with multiple central air-bubbles. After the diagnosis of liver abscess, the patient underwent prompt empirical antimicrobial therapy and percutaneous drainage. In spite of early therapy, the patient had gone into shock and death.

The Iatrogenic Complications of Colonoscopic Polypectomy: A Multicenter Retrospective Study

BACKGROUND/AIMS: Colonoscopic polypectomy is an effective tool for the treatment of colonic polyps. With the recent widespread use of colonoscopic polypectomy, there is a growing concern about iatrogenic complications, such as bleeding and perforation. The aim of this study is to analyze the clinical presentation and management of complications during colonoscopic polypectomy. METHODS: We retrospectively reviewed the medical records of colonoscopic examinations performed at 5 hospitals of Hallym University Medical Center between June 2005 and June 2008. RESULTS: A total of 26,773 colonoscopies and 4,123 colonoscopic polypectomy were performed. The overall rate of complication was 1.04% (43/4,123). Perforation occurred in 0.19% (8/4,123) of cases, and bleeding occurred in 0.85% (35/4,123) of cases. Perforation occurred in 0.05% of snare polypectomies, 1.09% of endoscopic mucosal resections (EMR), and 7.14% of endoscopic submucosal dissections (ESD). Bleeding occurred in 0.8% of snare polypectomies, 1.09% of EMRs, and 3.57% of ESDs. The complication rate of ESDs was higher than in EMRs and snare polypectomies (P<0.001). Endoscopic clippings were performed in 25% of perforation and 66.7% of bleeding cases. Medical treatment was successful in 75% of perforation and 100% of bleeding cases. CONCLUSIONS: Colonoscopic polypectomy is a safe procedure for the treatment of colonic polyps, but rarely, serious complications occur. Compared to a snare polypectomy or an EMR, the complication of an ESD occurs more frequently. Endoscopic treatment and further conservative management seems to be appropriate in most cases with complication.

The COX-2-1195AA Genotype Is Associated with Diffuse-Type Gastric Cancer in Korea

BACKGROUND/AIMS: The potential role of the cyclooxygenase (COX)-2 polymorphism has been reported in relation to the risk of gastrointestinal tract malignancies. Therefore, we investigated whether COX-2 polymorphisms are associated with the risk of gastric cancer (GC) in Korea, one of the areas with a high prevalence of this condition. METHODS: We evaluated the genotypic frequencies of COX-2-765 and -1195 in 100 peptic ulcer patients, 100 GC patients, and 100 healthy controls. The polymorphisms of the COX-2-765 and -1195 genes were analyzed by polymerase chain reaction and restriction fragment length polymorphisms. RESULTS: The frequencies of the COX-2-1195 GG, GA, and AA genotype were 20%, 60%, and 20% in intestinal-type GC and 8%, 48%, and 44% in diffuse-type GC, respectively (p=0.021). There were no significant differences in the frequency of COX-2-765 genotypes between intestinal-type GC and diffuse-type GC (p=0.603). Age- and sex-adjusted logistic regression analysis showed that the COX-2-1195 AA genotype was the independent risk factor of diffuse-type GC compared with the COX-2-1195 GG genotype (p=0.041; odds ratio, 6.22; 95% confidence interval, 1.077 to 35.870). CONCLUSIONS: The COX-2-1195 AA genotype may render subjects more susceptible to diffuse-type GC.

Comparison of the Eradication Rate between 1- and 2-Week Bismuth-Containing Quadruple Rescue Therapies for Helicobacter pylori Eradication

BACKGROUND/AIMS: First-line therapies against Helicobacter pylori, including proton pump inhibitors (PPIs) plus two antibiotics, may fail in up to 20% of patients. 'Rescue' therapy is usually needed for patients who failed the first-line treatment. This study evaluated the eradication rate of bismuth-containing quadruple rescue therapy over a 1- or 2-week period. METHODS: We prospectively investigated 169 patients with a persistent H. pylori infection after the first-line triple therapy, which was administered from October 2008 to March 2010. The patients were randomized to receive a 1- or 2-week quadruple rescue therapy (pantoprazole 40 mg b.i.d., tripotassium dicitrate bismuthate 300 mg q.i.d., metronidazole 500 mg t.i.d., and tetracycline 500 mg q.i.d.). After the 'rescue' therapy, the eradication rate, compliance, and adverse events were evaluated. RESULTS: The 1-week group achieved 83.5% (71/85) and 87.7% (71/81) eradication rates in the intention to treat (ITT) and per-protocol (PP) analyses, respectively. The 2-week group obtained 87.7% (72/84) and 88.9% (72/81) eradication rate in the ITT and PP analyses, respectively. There was no significant difference in the eradication rate, patient compliance or rate of adverse events between the two groups. CONCLUSIONS: One-week bismuth-containing quadruple therapy can be as effective as a 2-week therapy after the failure of the first-line eradication therapy.

A case of pedunculated hepatic hemangioma mimicking submucosal tumor of the stomach / 대한간학회지

Hepatic hemangioma is the most common benign tumor of the liver. Most such hemangiomas are small, asymptomatic, and have an excellent prognosis. Giant hepatic hemangioma has been reported in the literature, but the exophytic and pedunculated forms of hepatic hemangioma are rare. A 56-year-old woman was referred to our hospital under the suspicion of having a gastric submucosal tumor. Abdominal computer tomography (CT) scans showed a pedunculated mass from the left lateral segment of the liver into the gastric fundus, exhibiting the atypical CT findings of hepatic hemangioma. We therefore decided to perform laparoscopic resection based on the symptoms, relatively large diameter, inability to exclude malignancy, and risk of rupture of the exophytic lesion. The pathology indicated it to be a cavernous hemangioma of the liver. Herein we report a case of pedunculated hepatic hemangioma mimicking a submucosal tumor of the stomach due to extrinsic compression of the gastric fundus.

The Comparison between 6th and 7th International Union Against Cancer/American Joint Committee on Cancer Classification for Survival Prognosis of Gastric Cancer / 대한소화기학회지

BACKGROUND/AIMS: The tumor-node-metastasis (TNM) staging is an useful system to assess the prognosis of any solid cancer. As new TNM staging classification of 7th stomach cancer was revised in 2009, we evaluated the prognostic predictability of the 7th International Union Against Cancer/American Joint Committee on Cancer (UICC/AJCC) TNM classification compared to 6th UICC/AJCC TNM classification in gastric cancer. METHODS: From January 2000 to December 2009, 5-year survival rates of 266 patients with gastric cancer were calculated by the 6th and 7th UICC/AJCC TNM classification. RESULTS: Using the 7th UICC/AJCC TNM classification, there was no significant difference in the 5-year cumulative survival rates (5 YSR) between stage IIA and IIB, IIB and IIIA, and IIIA and IIIB (70% vs. 71%, p=0.530; 71% vs. 80%, p=0.703; 80% vs. 75%, p=0.576, respectively) though significant differences of the survival rates were observed among stages of 6th edition. Using T stage of 7th edition, 5 YSR was not different between T2 and T3 (86% vs. 82%, p=0.655). Using N stage of 7th edition, 5 YSR were not different between N1 and N2, N3a and N3b (79% vs. 81%, p=0.506; 41% vs. 17%, p=0.895, respectively). CONCLUSIONS: The 7th UICC/AJCC TNM classification had poor prognostic predictability in gastric cancer compared to the 6th edition.

The Simple Predictive Factors of Emergency Endoscopy for Non-variceal Acute Upper Gastrointestinal Bleeding

BACKGROUND/AIMS: Although endoscopy is an important diagnostic method for acute upper gastrointestinal bleeding (AUGIB), the guideline of emergency endoscopy for AUGIB is not yet established. This study was performed to assess the predictive factors of emergency endoscopy for non-variceal AUGIB. MATERIALS AND METHODS: From June 2006 to December 2008, the medical records of 283 patients with non-variceal AUGIB treated in Kangdong Sacred Heart Hospital were retrospectively analyzed. Patients were divided into two groups: emergency endoscopic procedure group or non-procedure group. We compared the factors for predicting the necessity of emergency endoscopic hemostasis. RESULTS: Among 283 patients, 194 were in the emergency endoscopic procedure group and 89 were in the non-procedure group. No significant differences in age, co-morbidities, drug history, and chief complaints were observed. After adjustment of several factors including syncope, systolic blood pressure, nasogastric (NG) tube irrigation and digital rectal examination findings, hemoglobin decline of more than 2 g/dL after 6 hours, prothrombin time, BUN and BUN/creatinine ratio that showed significant differences between the two groups, bloody NG aspiration was the only significant predictive factor (hazard ratio 13.69: P<0.001). CONCLUSIONS: Bloody NG aspiration was a simple factor for predicting emergent endoscopic procedure in non-variceal AUGIB patients.

A Case of Acute Pancreatitis due to Afferent Loop Syndrome with Internal Hernia / 대한소화기학회지

Acute pancreatitis and afferent loop syndrome (ALS) have similar symptoms and physical findings. Accurate early diagnosis is essential, as the management of acute pancreatitis is predominantly conservative whereas ALS usually requires surgery. We experienced one case of pancreatitis due to ALS with internal hernia. Laboratory findings of patient showed elevated serum amylase, lipase and WBC count. One day after admission, diagnosis was modified as acute pancreatitis caused by ALS on computed tomography. Patient was managed with surgical treatment and operation finding revealed ALS due to internal hernia. He was recovered well after surgical treatment and discharged without significant sequelae.

A Case of a Cytomegalovirus Colitis Related Rectal Stricture Treated by Endoscopic Balloon Dilation / 대한소화기내시경학회지

Cytomegalovirus (CMV) colitis is a common opportunistic infection in immunocompromised patients. Affected individuals present with abdominal pain, diarrhea, or hematochezia. Complications of CMV colitis can include massive bleeding, toxic megacolon, bowel perforation and, rarely, colon stricture. A 69-year-old woman who had no specific past history was admitted to the orthopedic department for pelvic bone fracture with right iliac artery rupture caused by a traffic accident. She was successfully managed with emergency transarterial coil embolization. After 2 weeks, she developed hematochezia and recurrent abdominal pain. Colonoscopy showed a huge, deep ulcer in the rectosigmoid colon. Biopsy and immunohistochemical staining revealed giant cells with intracellular inclusion bodies that were positive for CMV antigen. She received antiviral treatment after which her symptoms improved. On follow-up colonoscopy 3 months later, we found a tight luminal narrowing in the rectum. We did a repeat endoscopic balloon dilation in this patient and she experienced improvement.

Prevalence of IgG anti-HAV in patients with chronic hepatitis B and in the general healthy population in Korea / 대한간학회지

BACKGROUND/AIMS: Few studies have investigated hepatitis A virus (HAV) seroepidemiology in Koreans with chronic liver disease (CLD). This study compared the prevalence of IgG anti-HAV between the general healthy population and patients with hepatitis B virus-related CLD (HBV-CLD), with the aim of identifying predictors of HAV prior exposure. METHODS: In total, 1,319 patients were recruited between June 2008 and April 2010. All patients were tested for IgG anti-HAV, hepatitis B surface antigen (HBsAg), and antibodies to hepatitis C virus. The patients were divided into the general healthy population group and the HBV-CLD group based on the presence of HBsAg. The seroprevalence of IgG anti-HAV was compared between these two groups. RESULTS: The age-standardized seroprevalence rates of IgG anti-HAV in the general healthy population and patients with HBV-CLD were 52.5% and 49.1%, respectively. The age-stratified IgG anti-HAV seroprevalence rates for ages or =60 years were 14.3%, 11.2%, 45.5%, 90.5%, 97.6% and 98.3%, respectively, in the general healthy population, and 0%, 9.8%, 46.3%, 91.1%, 97.7%, and 100% in the HBV-CLD group. In multivariate analysis, age ( or =60 years: OR=1060.5, 95% CI=142.233-7907.964, P<0.001) and advanced status of HBV-CLD (OR=19.180, 95% CI=4.550-80.856, P<0.001) were independent predictors of HAV prior exposure. CONCLUSIONS: The seroprevalence of IgG anti-HAV did not differ significantly between the general-healthy-population and HBV-CLD groups. An HAV vaccination strategy might be warranted in people younger than 35 years, especially in patients with HBV-CLD.

Adenocarcinoma and Tuberculous Lymphadenitis on the Same Site of the Sigmoid Colon: A Case Report and Literature Review / 대한소화기내시경학회지

Inflammatory bowel disease can progress to colon cancer. However, there is not much of a causal relationship between intestinal tuberculosis and colon cancer. There have been a few case reports of intestinal tuberculosis in association with colon cancer. We experienced a 59-year-old man who had the collision-like pathology of adenocarcinoma and tuberculous lymphadenitis on the sigmoid colon. He visitied our hospital because of abdominal pain and hematochezia. Colonoscopy showed a mass on the sigmoid colon that was causing luminal obstruction. Therefore, sigmoidectomy was performed and the resected specimen revealed a collision-like appearance; the mass was composed of adenocarcinoma invading the proper muscle layer and caseating granuloma in the serosa and lymph nodes. We report here on a case of collision-like pathology that was composed of adenocarcinoma and tuberculosis on the sigmoid colon, and we review the relevant literature.

Helicobacter pylori Infection and Peptic Ulcer Disease in Patients with Liver Cirrhosis

BACKGROUND/AIMS: We investigated the prevalence and relationship of peptic ulcer disease and Helicobacter pylori infection to liver cirrhosis. METHODS: We examined 288 patients with liver cirrhosis, 322 patients with non-ulcer dyspepsia, and 339 patients with peptic ulcer disease. Rapid urease test and Wright-Giemsa staining were used for diagnosis of H. pylori infection. RESULTS: The prevalence of peptic ulcer disease in patients with cirrhosis was 24.3%. The prevalence of peptic ulcer disease in patients with cirrhosis divided into Child-Pugh classes A, B, and C was 22.3%, 21.0%, and 31.3%, respectively (p>0.05). The prevalence of H. pylori infection in the patients with cirrhosis, non-ulcer dyspepsia, and peptic ulcer without chronic liver disease were 35.1%, 62.4%, and 73.7%, respectively (p0.05). The prevalence of H. pylori infection in patients with hepatitis virus-related liver cirrhosis and in the patients with alcohol-related liver cirrhosis was 42.5% and 22.0%, respectively (p<0.001). The prevalence of H. pylori infection in patients with Child-Pugh classes A, B, and C liver cirrhosis was 51.5%, 30.5%, and 20.0%, respectively (p<0.001). CONCLUSIONS: Factors other than H. pylori may be involved in the pathogenesis of peptic ulcer disease in the setting of liver cirrhosis.

Arteriovenous Malformation Causing Ileocecal Variceal Bleeding in Liver Cirrhosis: Case Report and Review of the Literature

Varices that occur at sites other than the esophagogastric area are termed ectopic varices. An ileal varix is a very rare cause of lower gastrointestinal bleeding. Although ileal varices are generally associated with prior intra-abdominal surgery and adhesions, an arteriovenous malformation (AVM) in the ileocecal area can cause ileal varices and bleeding in patients with portal hypertension who have not received previous intra-abdominal surgery, which is due to an intestinal or colonic AVM dilating the collateral veins and further aggravating portal hypertension. Surgical treatment should be considered in patients with massive ectopic variceal bleeding. We report a case of massive ileocecal variceal bleeding associated with an AVM that occurred in a patient with alcoholic liver cirrhosis.

A case of intussusception by appendiceal mucocele / 대한내과학회지

Intussusception of the appendix is not only extremely rare but also presents with symptoms similar to appendicitis. Therefore, preoperative diagnosis is unusual. On the other hand, appendiceal mucocele refers to obstructive dilatation of the appendiceal lumen caused by mucus. It has been reported in 0.2~0.3% of appendectomy specimens. A 22-year-old woman visited the Emergency Department because of right lower abdominal tenderness with hematochezia. Abdominal CT scan revealed a target sign in the right lower quadrant area that was suggestive of intussusception. The patient underwent emergency surgical reduction of the intussusception and appendectomy. The pathology showed an appendiceal mucocele.

A Case of Duodenal Intramural Hematoma and Hemoperitoneum after Therapeutic Endoscopy in a Patient with Chronic Renal Failure / 대한소화기내시경학회지

Duodenal intramural hematoma is mostly caused by blunt abdominal trauma. It is also less commonly reported as a complication of anticoagulation therapy or as a blood dyscrasia, and as a complication of diagnostic/ therapeutic endoscopy. The presentation of these patients is abdominal pain, vomiting, fever and hematochezia, and this is rarely accompanied with intestinal obstruction, severe pancreatitis and acute peritonitis as its complications. The diagnosis is made clear by performing abdominal ultrasonography and abdominal computed tomography. We reported here on one case of intramural duodenal hematoma and hemoperitoneum after performing endoscopic hemostasis in a chronic renal failure patient who was on maintenance hemodialysis.