Effect of gut microbiome on minor complications after a colonoscopy

Background/Aims@#Minor complications that might occur after colonoscopy, including abdominal discomfort, bloating, diarrhea, and constipation, could a barrier for patients to undergo a screening colonoscopy. In this study, we aimed to identify the effect of gut microbial diversity and composition on minor complications after colonoscopy. @*Methods@#A total of 24 healthy subjects provided their stools before bowel preparation and on the 7th and 28th day after colonoscopy. On the 7th day after colonoscopy, the presence of minor complications was investigated using a questionnaire. We divided patients into 2 groups, the no complication group and complications group. The fecal microbial diversity, distribution, and composition were then compared between the groups. @*Results@#Five of the 24 subjects reported that they had undergone minor complications after colonoscopy. Most of the symptoms were mild and self-limited, but 1 patient needed medication. Interestingly, the Firmicutes/Bacteroidetes ratio of the initial stool samples before bowel preparation in the complication group was significantly higher than that in no complication group. After bowel preparation, the Firmicutes/Bacteroidetes ratio of the complication group decreased, but not in the no complication group. The microbial diversity of the no complication group decreased after bowel preparation, but not in the complication group. @*Conclusions@#The gut microbial composition and diversity before and after bowel preparation could be considered as one of the causes of minor complications after colonoscopy. Further studies are needed to delineate the role of gut microbiota in the occurrence of minor complications after colonoscopy.

Effect of gut microbiome on minor complications after a colonoscopy

Background/Aims@#Minor complications that might occur after colonoscopy, including abdominal discomfort, bloating, diarrhea, and constipation, could a barrier for patients to undergo a screening colonoscopy. In this study, we aimed to identify the effect of gut microbial diversity and composition on minor complications after colonoscopy. @*Methods@#A total of 24 healthy subjects provided their stools before bowel preparation and on the 7th and 28th day after colonoscopy. On the 7th day after colonoscopy, the presence of minor complications was investigated using a questionnaire. We divided patients into 2 groups, the no complication group and complications group. The fecal microbial diversity, distribution, and composition were then compared between the groups. @*Results@#Five of the 24 subjects reported that they had undergone minor complications after colonoscopy. Most of the symptoms were mild and self-limited, but 1 patient needed medication. Interestingly, the Firmicutes/Bacteroidetes ratio of the initial stool samples before bowel preparation in the complication group was significantly higher than that in no complication group. After bowel preparation, the Firmicutes/Bacteroidetes ratio of the complication group decreased, but not in the no complication group. The microbial diversity of the no complication group decreased after bowel preparation, but not in the complication group. @*Conclusions@#The gut microbial composition and diversity before and after bowel preparation could be considered as one of the causes of minor complications after colonoscopy. Further studies are needed to delineate the role of gut microbiota in the occurrence of minor complications after colonoscopy.

Mosapride Improves Lower Esophageal Sphincter and Esophageal Body Function in Patients With Minor Disorders of Esophageal Peristalsis

Background/Aims@#High-resolution manometry (HRM) has broadened the awareness of minor esophageal peristaltic disorders. However, the treatments for these minor disorders are limited and the role of prokinetics has been controversial. This study evaluates the effect of mosapride in patients with minor peristaltic disorders. @*Methods@#This study prospectively enrolled 21 patients with esophageal symptoms who were diagnosed with minor peristaltic disorders by gastroscopy and HRM using the Chicago classification version 3.0. Patients received mosapride 30 mg daily for 2 weeks. Symptoms were assessed using the abbreviated World Health Organization quality of life scale (WHOQOL-BREF) and a HRM study was performed before and after 2 weeks of treatment. @*Results@#HRM metrics of lower esophageal sphincter (LES) respiratory mean pressure (median 14.6 mmHg vs 17.3 mmHg; interquartile range [IQR] 8.7-22.5 mmHg vs 12.5-25.9 mmHg; P = 0.004) and distal contractile integral (median 343.8 mmHg·sec·cm vs 698.1 mmHg·sec·cm; IQR 286.5-795.9 mmHg·sec·cm vs 361.0-1127.6 mmHg·sec·cm; P = 0.048) were significantly increased after treatment. Complete response (≥ 80.0%), satisfactory response (≥ 50.0%), partial response (< 50.0%), and refractory response rates were 19.0%, 52.4%, 14.3%, and 14.3%, respectively. However, there was no statistical difference in all WHOQOL-BREF scores before and after treatment. Univariate analysis showed LES respiratory mean pressure (P = 0.036) was associated with symptom improvement (complete + satisfactory group). However, no statistical difference was found in other factors after multivariate analysis. @*Conclusions@#Mosapride improved esophageal symptoms and significantly increased LES respiratory mean pressure and distal contractile integral. Therefore, mosapride could enhance LES and esophageal body contraction pressures in patients with minor peristaltic disorders.

Efficacy and Safety of Etomidate in Comparison with Propofol or Midazolam as Sedative for Upper Gastrointestinal Endoscopy

Background/Aims@#In this study, we compared the efficacy and safety of etomidate with those of propofol or midazolam for the maintenance of sedation during endoscopy. @*Methods@#The study enrolled patients who underwent sedative endoscopy in our hospital and divided them into three groups. Patients in each group were administered midazolam as induction therapy and were subsequently administered either midazolam (M + M group), propofol (M + P group), or etomidate (M + E group) as maintenance medication. The primary outcome was overall cardiovascular and respiratory adverse events. @*Results@#In total, 105 patients who underwent sedative endoscopic examination were enrolled. The outcomes related to the procedure and sedation were not significantly different among the groups. Overall cardiovascular and respiratory adverse events were observed in 9 patients (25.7%) in the M + M group, 8 patients (23.5%) in the M + P group, and 10 patients (27.8%) in the M + E group. The logistic regression analysis revealed that etomidate use was not an independent risk factor for overall cardiovascular and respiratory adverse events. @*Conclusions@#The outcomes following the use of etomidate for maintenance after induction with midazolam for sedation in upper gastrointestinal endoscopy were not inferior to those following midazolam or propofol use from the perspectives of safety and efficacy.

Effect of Sending Educational Video Clips via Smartphone Mobile Messenger on Bowel Preparation before Colonoscopy

BACKGROUND/AIM: We aimed to evaluate the efficacy of sending educational video clips via smartphone mobile messenger (SMM) on enhancing bowel preparation before colonoscopy. METHODS: This was a prospective, endoscopist-blinded, randomized controlled study. Patients in the SMM group received two video clips sent via SMM that explained the diet and regimen for bowel preparation, whereas those in the control group did not receive any video clips. We compared the quality of bowel preparation between the two groups, which was assessed by an endoscopist using the Ottawa scale. RESULTS: Between August and November 2014, 140 patients in the SMM group and 141 patients in the control group underwent colonoscopic examination. The total Ottawa score of the SMM group was significantly lower than that of the control group (5.47±1.74 vs. 5.97±1.78, p=0.018). These results were particularly prominent in the younger age group; the total Ottawa score of patents in the SMM group aged <40 years was significantly lower than that of patients in the control group aged <40 years (5.10±1.55 vs. 6.22±2.33, p=0.034). CONCLUSIONS: We demonstrated that sending educational video clips via SMM could result in better bowel preparation, especially in the younger age group.

Risk of Delayed Bleeding after a Colorectal Endoscopic Mucosal Resection without Prophylactic Clipping: Single Center, Observational Study / 대한소화기학회지

BACKGROUND/AIMS: Bleeding is one of the major complications of a colorectal polypectomy. The aim of this study was to identify the risk of delayed bleeding, particularly after a colorectal endoscopic mucosal resection (EMR) without prophylactic clipping.METHODS: Between April 2014 and August 2014, patients who underwent colorectal EMR (≥6 mm and < 2 cm) without prophylactic clipping were included. This study evaluated the incidence of delayed bleeding and the associated factors after colorectal EMR without prophylactic clipping.RESULTS: A total of 717 colorectal polyps (≥6 mm and < 2 cm) of 243 patients resected by colorectal EMR in the study period were evaluated. The mean age of the patients was 63 years; 165 patients were men and 78 patients were women. The mean polyp size removed by colorectal EMR was 9.0 mm (range 6.0–19.0), and the number of polyps larger than 1 cm was 212 (29.6%). Delayed bleeding after colorectal EMR occurred in 12 polyps (1.7%) in eight patients (3.3%), and there were no significant risk factors affecting delayed bleeding.CONCLUSIONS: This study identified that the incidence of delayed bleeding on colorectal polyps (≥6 mm and < 2 cm) after EMR without prophylactic clipping was 3.3%, but no significant risk factors affecting delayed bleeding were found.

Is stool frequency associated with the richness and community composition of gut microbiota?

BACKGROUND/AIMS: Recently, a number of studies have reported that the gut microbiota could contribute to human conditions, including obesity, inflammation, cancer development, and behavior. We hypothesized that the composition and distribution of gut microbiota are different according to stool frequency, and attempted to identify the association between gut microbiota and stool frequency. METHODS: We collected fecal samples from healthy individuals divided into 3 groups according to stool frequency: group 1, a small number of defecation (≤2 times/wk); group 2, normal defecation (1 time/day or 1 time/2 day); and group 3, a large number of defecation (≥2–3 times/day). We evaluated the composition and distribution of the gut microbiota in each group via 16S rRNA-based taxonomic profiling of the fecal samples. RESULTS: Fecal samples were collected from a total of 60 individuals (31 men and 29 women, aged 34.1±5.88 years), and each group comprised 20 individuals. The microbial richness of group 1 was significantly higher than that of group 3 and tended to decrease with increasing number of defecation (P<0.05). The biological community composition was fairly different according to the number of defecation, and Bacteroidetes to Firmicutes ratio was higher in group 1 than in the other groups. Moreover, we found specific strains at the family and genus levels in groups 1 and 3. CONCLUSIONS: Bacteroidetes to Firmicutes ratio and the abundance of Bifidobacterium were different according to the stool frequency, and specific bacteria were identified in the subjects with large and small numbers of defecation, respectively. These findings suggest that stool frequency might be associated with the richness and community composition of the gut microbiota.

Insulin Resistance Is Associated with Early Gastric Cancer: A Prospective Multicenter Case Control Study

BACKGROUND/AIMS: Recently, increased body weight has been found to be associated with an increasing risk of several cancers, including gastric cancer. The true pathogenic role of hyperglycemia in the development of gastric cancer remains unclear as hyperglycemia and its associated conditions may work as carcinogenic factors. The goal of this study was to clarify the factors associated with early gastric cancer and evaluate a homeostasis model assessment of the insulin resistance (HOMA-IR) index, fasting glucose, and lipid profile as predictors of early gastric cancer. METHODS: A total of 63 patients with early gastric cancer between November 2012 and March 2013 were included. Preoperative serum lipid profile levels and serum fasting glucose were examined prospectively in patients with early gastric cancer. The same number of controls were evaluated and matched to the early gastric cancer group for age and gender. We performed multivariate logistic regression analysis to identify independent risk factors for early gastric cancer. RESULTS: Univariate analysis showed that risk for early gastric cancer was associated with diastolic blood pressure (BP), total cholesterol, fasting glucose, and HOMA-IR. In the multivariate-adjusted model, higher total cholesterol, fasting glucose, body mass index, and diastolic BP were strongly associated with an increased risk of early gastric cancer. CONCLUSIONS: Hyperglycemia, a lower high-density lipoprotein cholesterol level, and a low HOMA-IR level appear to be associated with early gastric cancer risk.

A Incidentally Diagnosed Duodenal Subepithelial Mass: Gangliocytic Paraganglioma Treated by Endoscopic Mucosal Resection

Gangliocytic paraganglioma is a very rare tumor that is usually located in the duodenum. It is characterized by benign behavior and favorable outcomes; however, it sometimes shows regional lymph node metastasis. The clinical management of gangliocytic paraganglioma has not yet been standardized. A 36-year-old Korean man visited Kosin University Gospel Hospital for the management of a duodenal subepithelial mass that was detected incidentally. Endoscopic mucosal resection was performed without any adverse events. Pathological examination of the resected specimen revealed gangliocytic paraganglioma. The patient has remained in good health during the 6 months of follow-up after the procedure.

Is It More Effective to Prescribe a Proton Pump Inhibitor Separately before a Meal for the Eradication of Helicobacter pylori?

BACKGROUND/AIMS: The current standard regimen for the treatment of Helicobacter pylori infection is a combination of a proton pump inhibitor (PPI), amoxicillin, and clarithromycin. The aim of this study was to determine the effectiveness of PPIs taken separately before a meal for the treatment of H. pylori infection. MATERIALS AND METHODS: This retrospective study included 160 patients who were tested positive for rapid urease in Kosin Unversity Gospel Hospital between January 2008 and December 2012. The patients were divided into two groups (n=80 in each group) based on the method of administration of the H. pylori triple therapy. Group A took a PPI before a meal and amoxicillin and clarithromycin after a meal. Group B took all three medications together after a meal. The 13C-urea breath test was performed after 4 weeks to assess the eradication of H. pylori. RESULTS: H. pylori was eradicated in 58/80 (72.5%) patients in group A and 60/80 (75.0%) patients in group B, with no significant difference between the groups (P=0.719). Adverse effects occurred in 4 patients of group A and 7 patients of group B (5.0% and 8.8%, respectively); however, the difference between the groups was not significant (P=0.232). CONCLUSIONS: Administration of all medicines at once after a meal may be the better prescription for treatment, considering patient convenience and improved likelihood of compliance.

Gastric Cancer Recurrence in 12 Years after Surgical Resection / 대한소화기학회지

Recurrence of gastric cancer after 10 years of surgical resection is highly rare. There are limited data on the surveillance of patients with gastric cancer after 10 years from gastrectomy. A 50-year-old man presented to the gastroenterology clinic at our hospital for the management of abnormal findings on a routine colonoscopic exam. He had undergone gastrectomy for advanced gastric cancer 12 years ago. At presentation, colonoscopic examination revealed asymmetrically edematous and hyperemic mucosal change with luminal narrowing on transverse colon. Abdominal computed tomography showed no evidence of distant metastasis, except for focal bowel wall thickening on transverse colon. He underwent a laparoscopic right-hemicolectomy, and the resected specimen revealed a recurrent and metastatic lesion. We report a case of recurrence of gastric cancer after 10 years from surgical resection with relevant literature review.

Gastric Microbiota and Gastric Cancer

The stomach had been recognized as an organ where many bacteria cannot survive due to the presence of gastric acid. However, a number of bacteria have been detected after the discovery of Helicobacter pylori with recent advances in nucleotide sequencing techniques and bioinformatics. These include Proteobacteria, Firmicutes, Bacteroidetes, Actinobacteria and Fusobacteria. Several animal studies suggested that the imbalance of gastric microbiotas could be associated with the development of gastric cancer. Changes in the composition of the gastric microbiota may increase the production of N-nitroso compounds, which is known to be a carcinogen. Further studies on the actual function and proteomics of gastric microbiota could be beneficial for prevention, early diagnosis, and new treatment strategies of gastric cancer.

Trends in Helicobacter pylori eradication rates by first-line triple therapy and related factors in eradication therapy

BACKGROUND/AIMS: Trends in successful eradication of Helicobacter pylori using first-line triple therapy, consisting of a proton pump inhibitor, amoxicillin, and clarithromycin, have been understudied. We evaluated H. pylori eradication rates at a single center over the last 10 years and identified risk factors related to eradication failure. METHODS: This study included 1,413 patients who were diagnosed with H. pylori infection and received 7 days of triple therapy between January 2003 and December 2012. We investigated H. pylori eradication rates retrospectively with respect to the year of therapy, as well as demographic and clinical factors. H. pylori eradication was confirmed by a 13C-urea breath test or a rapid urease test at least 4 weeks after the completion of triple therapy. RESULTS: The overall H. pylori eradication rate was 84.9%. Annual eradication rates from 2003 to 2012 were 93.5%, 80.0%, 87.2%, 88.5%, 92.0%, 88.3%, 85.7%, 84.1%, 83.7%, and 78.8%, respectively, by per-protocol analysis. The eradication rate with first-line triple therapy decreased during the last 10 years (p = 0.015). Multivariate analysis showed that female gender (odds ratio [OR], 1.69; 95% confidence interval [CI], 1.12 to 2.55) and smoking (OR, 1.61; 95% CI, 1.05 to 2.47) were associated with the failure of H. pylori eradication therapy. CONCLUSIONS: The efficacy of first-line triple therapy for H. pylori infection has decreased over the last 10 years, suggesting an increase in antibiotic-resistant H. pylori strains. Thus, other first-line therapies may be necessary for H. pylori eradication in the near future.

Efficacy and Safety of FOLFIRI after Failure of FOLFOX-4 in Advanced Gastric Cancer / 대한소화기학회지

BACKGROUND/AIMS: The purpose of this study was to investigate the efficacy and safety of irinotecan based FOLFIRI chemotherapy as a second-line treatment after failure of FOLFOX-4 chemotherapy in patients with advanced gastric cancer. METHODS: Fifty-two patients who were pathologically diagnosed with unresectable gastric cancer and received FOLFIRI chemotherapy after failure of FOLFOX-4 chemotherapy between September 2005 and February 2012 were enrolled in this study. Data were collected by retrospectively reviewing the medical records. The response to chemotherapy was assessed every 3 cycles by World Health Organization criteria and long term survival was analyzed. The toxicities were evaluated for every course of chemotherapy according to National Cancer Institution (NCI) toxicity criteria version 3.0. RESULTS: Median age of the patients was 57 years. Median overall survival (OS) and time to progression (TTP) were 7.8 and 5 months, respectively. The number of patients showing complete remission, partial remission, stable disease, and progressive disease were 0 (0.0%), 9 (17.3%), 30 (57.7%), and 13 (25.0%), respectively. The overall response rate was 17.3%. During a total of 345 cycles, anemia worse than NCI toxicity grade 3 occurred in 2.9%, leukopenia in 20.3%, neutropenia in 12.2%, and thrombocytopenia in 1.5%. Patients with less organ involvement by metastasis, less than 34 U/mL of CA 19-9 and good responsiveness to third cycle of second line chemotherapy were associated with longer OS and TTP. CONCLUSIONS: FOLFIRI chemotherapy has a modest efficacy with acceptable toxicities in patients with advanced gastric cancer as a second-line treatment. Further well-controlled studies are needed to elucidate the efficacy of FOLFIRI chemotherapy as second-line treatment in patients with advanced stomach cancer.

A Case of Intestinal Tuberculosis with Perianal Fistula Diagnosed after 30 Years / 대한소화기학회지

Tuberculosis can occur anywhere in the gastrointestinal tract. However, anorectal tuberculosis has rarely been reported. A 46-years-old male presented with abdominal pain and perianal discharge of 30 years' duration. The patient had received operations for anal fistula and inflammation three times. Although he had been taking mesalazine for the past three years after being diagnosed with Crohn's disease, his symptoms persisted. Colonoscopy performed at our hospital revealed cicatricial change of ileocecal valve and diffuse ulcer scar with mild luminal narrowing of the ascending, transverse, and descending colon without active lesions. Multiple large irregular active ulcers were observed in the distal sigmoid and proximal rectum. An anal fistula opening with much yellowish discharge and background ulcer scar was observed in the anal canal. However, cobble-stone appearance and pseudopolyposis were not present. Therefore, we clinically diagnosed him as having intestinal tuberculosis with anal fistula and prescribed antituberculosis medications. Follow-up colonoscopy performed 3 months later showed much improved multiple large irregular ulcers in the distal sigmoid colon and proximal rectum along with completely resolved anal fistula without evidence of pus discharge.

A Case of Medullary Thyroid Carcinoma with de novo V804M RET Germline Mutation

Many cases of RET proto-oncogene mutations of hereditary medullary thyroid carcinoma (MTC) have been reported in Korea. However, MTC with V804M RET proto-oncogene germline mutations have not been reported in Korea. A 33-yr-old man was diagnosed with a 0.7-cm sized thyroid nodule. Laboratory testing revealed serum calcitonin was elevated. The patient underwent total thyroidectomy with central compartment neck dissection for the thyroid tumor. RET gene analysis was performed in both the index patient and his family. There were no V804M RET mutation and abnormal laboratory findings within his family except the index patient. Therefore, this patient was a de novo V804M RET germline mutation.

A Case of Endobronchial Actinomycosis with a Broncholith cured by Cryotherapy through a Flexible Bronchoscope / 고신대학교의과대학학술지

We report the case of a 53-year-old man who presented with obstructive pneumonitis and broncholithiasis. We attempted to remove the broncholith with forceps through a flexible endoscope, but the potential for bleeding due to partial synechia did not allow this. We succeeded in removing it with cryotherapy. The histopathological diagnosis was thoracic actinomycosis associated with broncholithiasis. Endobronchial actinomycosis with a broncholith is very rare. We successfully treated a patient with endobronchial actinomycosis with a broncholith by administering short-term antibiotics after broncholithectomy via cryotherapy through a flexible bronchoscope.

A Case of Localized Castleman's Disease in a Patient with Rheumatoid Arthritis

Castleman's disease is an atypical lymphoproliferative disorder of unknown origin. It has three histologic types (hyaline vascular, plasma-cell, and mixed) and two clinical types (localized and multicentric). Some systemic diseases may be accompanied with Castleman's disease, but it is unclear if Castleman's disease is relevant to rheumatoid arthritis. We experienced a case of Castleman's disease suffering from rheumatoid arthritis. A 25-year-old female with rheumatoid arthritis was referred to our hospital with a palpable mass lesion in the left upper arm. Excisional biopsy of the mass and arthroscopic synovectomy were performed, and the histological finding was compatible with hyaline-vascular type of Castleman's disease. Herein, we report this case along with brief review of relevant literature.

The Combination Therapy with Peg-interferon Alfa and Ribavirin for Chronic Hepatitis C in Korea as an Initial Treatment / 고신대학교의과대학학술지

OBJECTIVES: The combination therapy with peginterferon and ribavirin has been used to treat chronic hepatitis C for several years in Korea but there is a few report about the results of the treatment. We evaluated safety and efficacy of the combination therapy with Peg-interferon and ribavirin and analyzed factors that may affect treatment. METHODS: Total 72 untreated chronic hepatitis C patients were administered pegylated interferon alfa-2a (180microg/week) or alfa-2b (1.5microg/kg/week) and ribavirin (800 mg/day in genotype 2, 1000-1200 mg/day in genotype 1). Duration of the treatment was 24 weeks in genotype 2 and 48 weeks in genotype 1. Response of the treatment was evaluated by rapid virologic response (RVR), early virologic response (EVR), end treatment virologic response (ETR), sustained virologic response (SVR) and adverse event. RESULTS: The RVR, EVR, ETR, SVR were 61.8%, 82.5%, 88.9% and 80.5% retrospectively. The SVR of genotype 1 was 63.4% and non-genotype 1 was 96.7%. Genotype (Odds ratio: 14.92) was an independent predictor of the SVR. Leukocytopenia, flu-like symptoms, itching, rash and anemia were common adverse events of the combination therapy and if then we reduced dose and there was one case of cessation. CONCLUSIONS: The combination therapy with Peg-interferon and ribavirin shows efficacy to the Korean patients with chronic hepatitis C as an initial treatment. Genotypes 2 and 3 were more likely to have a sustained virologic response.

A Case of Thyrotoxic Periodic Paralysis Associated with Transient Thyrotoxicosis / 고신대학교의과대학학술지

Thyrotoxic periodic paralysis is an acute muscle weakness of the limbs associated with hypokalemia. It can occur with any form of thyrotoxicosis. Thyrotoxic periodic paralysis associated with transient thyrotoxicosis due to thyroiditis is very rare. We experienced a case of thyrotoxic periodic paralysis associated with transient thyrotoxicosis. A 39-yr-old man was referred to our hospital because of paralysis of upper and lower extremity. The laboratory results were hypokalemia and mild thyrotoxicosis. A thyroid scan with Tc-99m revealed decreased uptake in the thyroid area compatible with destructive thyroiditis. The paralytic attack did not recur after the patient recovered to euthyroid state.