Clinical Outcomes of Transcatheter Arterial Embolization after Failed Endoscopic Intervention for Acute Non-Variceal Bleeding Associated with Benign Upper Gastrointestinal Diseases

Background/Aims@#Transcatheter arterial embolization (TAE) is useful for management of uncontrolled upper gastrointestinal (UGI) bleeding. We investigated clinical outcomes of TAE for non-variceal bleeding from benign UGI diseases uncontrolled with endoscopic intervention. @*Methods@#This retrospective study performed between 2017 and 2021 across four South Korean hospitals. Ninety-two patients (72 men, 20 women) who underwent angiography were included after the failure of endoscopic intervention for benign UGI disease- induced acute non-variceal bleeding. We investigated the factors associated with endoscopic hemostasis failure, the technical success rate of TAE, and post-TAE 30-day rebleeding and mortality rates. @*Results@#The stomach (52/92, 56.5%) and duodenum (40/92, 43.5%) were the most common sites of bleeding. Failure of endoscopic procedures was attributable to peptic ulcer disease (81/92, 88.0%), followed by pseudo-aneurysm (5/92, 5.4%), and angiodysplasia (2/92, 2.2%). Massive bleeding that interfered with optimal visualization of the endoscopic field was the most common indication for TAE both in the stomach (22/52, 42.3%) and duodenum (14/40, 35.0%). Targeted TAE, empirical TAE, and exclusive arteriography were performed in 77 (83.7%), nine (9.8%), and six patients (6.5%), respectively. The technical success rate, the post-TAE 30-day rebleeding rate, and the overall mortality rate were 100%, 22.1%, and 5.8%, respectively. On multivariate analysis, coagulopathy (OR, 5.66; 95% CI, 1.71~18.74; P=0.005) and empirical embolization (OR, 5.71; 95% CI, 1.14~28.65; P=0.034) were independent risk factors for post-TAE 30-day rebleeding episodes. @*Conclusions@#TAE may be useful for acute non-variceal UGI bleeding. Targeted embolization and correction of coagulopathy can improve clinical outcomes.

Roles of Sex Hormones and Gender in the Gut Microbiota

The distribution of gut microbiota varies according to age (childhood, puberty, pregnancy, menopause, and old age) and sex. Gut microbiota are known to contribute to gastrointestinal (GI) diseases such as irritable bowel syndrome, inflammatory bowel disease, and colon cancer; however, the exact etiology remains elusive. Recently, sex and gender differences in GI diseases and their relation to gut microbiota has been suggested. Furthermore, the metabolism of estrogen and androgen was reported to be related to the gut microbiome. As gut microbiome is involved in the excretion and circulation process of sex hormones, the concept of “microgenderome” indicating the role of sex hormone on the gut microbiota has been suggested. However, further research is needed for this concept to be universally accepted. In this review, we summarize sex- and gender-differences in gut microbiota and the interplay of microbiota and GI diseases, focusing on sex hormones. We also describe the metabolic role of the microbiota in this regard. Finally, current subjects, such as medication including probiotics, are briefly discussed.

Roles of Sex Hormones and Gender in the Gut Microbiota

The distribution of gut microbiota varies according to age (childhood, puberty, pregnancy, menopause, and old age) and sex. Gut microbiota are known to contribute to gastrointestinal (GI) diseases such as irritable bowel syndrome, inflammatory bowel disease, and colon cancer; however, the exact etiology remains elusive. Recently, sex and gender differences in GI diseases and their relation to gut microbiota has been suggested. Furthermore, the metabolism of estrogen and androgen was reported to be related to the gut microbiome. As gut microbiome is involved in the excretion and circulation process of sex hormones, the concept of “microgenderome” indicating the role of sex hormone on the gut microbiota has been suggested. However, further research is needed for this concept to be universally accepted. In this review, we summarize sex- and gender-differences in gut microbiota and the interplay of microbiota and GI diseases, focusing on sex hormones. We also describe the metabolic role of the microbiota in this regard. Finally, current subjects, such as medication including probiotics, are briefly discussed.

Changes in Cecal Microbiota and Short-chain Fatty Acid During Lifespan of the Rat

Background/Aims@#The gut microbiota regulates intestinal immune homeostasis through host-microbiota interactions. Multiple factors affect the gut microbiota, including age, sex, diet, and use of drugs. In addition, information on gut microbiota differs depending on the samples.The aim of this study is to investigate whether changes in cecal microbiota depend on aging. @*Methods@#Gut microbiota in cecal contents of 6-, 31-, and 74-week-old and 2-year-old male Fischer-344 rats (corresponding to 5-, 30-, 60-, and 80-year-old humans in terms of age) were analyzed using 16S ribosomal RNA metagenome sequencing and phylogenetic investigation of communities by reconstruction of unobserved states (PICRUSt) based on the Kyoto Encyclopedia of Genes and Genomes orthology.Moreover, short-chain fatty acid (SCFA) level in cecum and inflammation related factors were measured using real-time quantitative polymerase chain reaction and enzyme linked immunosorbent assay. @*Results@#Alpha and beta diversity did not change significantly with age. At the family level, Lachnospiraceae and Ruminococcaceae, which produce SCFAs, showed significant change in 31-week-old rats: Lachnospiraceae significantly increased at 31 weeks of age, compared to other age groups, while Ruminococcaceae decreased. Butyrate levels in cecum were significantly increased in 31-week-old rats, and the expression of inflammation related genes was increased followed aging. Especially, EU622775_s and EU622773_s, which were highly abundance species in 31-week-old rats, showed significant relationship with butyrate concentration. Enzymes required for producing butyrate—acetyl-CoA transferase, butyryl-CoA dehydrogenase, and butyrate kinase—were not predicted by PICRUSt. @*Conclusions@#Major bacterial taxa in the cecal lumen, such as Lachnospiraceae, well-known SCFAs-producing family, changed in 31-week-old rats.Moreover, unknown species EU622775_s and EU622773_s showed strong association with cecal butyrate level at 31 weeks of age.

Significance of Helicobacter pylori Eradication on Atrophic Gastritis and Intestinal Metaplasia

There has been an accumulation of data regarding the chemopreventive effects of Helicobacter pylori (H. pylori) eradication. However, it remains unclear how H. pylori infection causes gastric cancer (GC) and how H. pylori eradication can prevent GC. Atrophic gastritis (AG) and intestinal metaplasia (IM) are known as precancerous lesions which mainly lead to intestinal-type GC but to some extent, can also lead to diffuse-type GC. The most important mechanism of AG/IM is H. pylori-induced chronic gastritis. Thus, the reversibility of AG and IM by H. pylori eradication therapy is very important in the prevention of GC. There have been many studies providing data supporting the improvement of AG by the eradication of H. pylori to some extent. In contrast, IM has been regarded as “the point of no return.” However, more recent studies have implied the improvement of IM after eradication, suggesting the importance of early eradication therapy in reversible histological status. In this review, we focused on the reversibility of AG and IM by H. pylori eradication and tried to investigate the predicting factors for the improvement of AG and IM including age, sex, smoking, and diet, as well as H. pylori infection.

Ischemic Colitis Associated with Low-volume Oral Sulfate Solution for Bowel Preparation / 대한소화기학회지

Ischemic colitis resulting from bowel preparation for colonoscopy is extremely rare, with only a small number of cases with polyethylene glycol having been reported. Here, we present a patient with ischemic colitis after administration of a low-volume oral sulfate solution (OSS). A 49-year-old female without any significant medical history experienced abdominal pain, vomiting, and hematochezia after ingestion of OSS. She complained of severe abdominal pain during colonoscopy, and diffuse edema, hyperemia, friability, and shallow erosions were present on the transverse, descending, and sigmoid colons. A mucosal biopsy revealed mixed lymphoid inflammatory cell infiltration with de-epithelialization, whereas an abdominal CT scan showed submucosal edema on the transverse colon. A diagnosis of ischemic colitis was made. The patient recovered with fluid and antibiotic therapy without significant sequelae. Although OSS is a clinically validated and generally safe bowel preparation agent, ischemic colitis is a rare complication that should be considered.

Eradication Rates of 10-day Sequential Therapy for Helicobacter pylori: Results of an 8-year Prospective Study Conducted at a Tertiary Korean Hospital / 대한소화기학회지

BACKGROUND/AIMS: The Helicobacter pylori (H. pylori) eradication rate of standard triple therapy is unsatisfactory in Korea, and sequential therapy (SQT) has been suggested to be a practical first-line alternative regimen. The aim of this prospective study was to document changes in annual eradication rates of SQT. METHODS: A total of 983 H. pylori-positive subjects were enrolled from 2010 to 2018 and their data were subjected to intention-to-treat (ITT) and per-protocol (PP) analysis. All subjects received 10-day sequential therapy consisting of 40 mg esomeprazole and 1 g amoxicillin b.i.d for 5 days followed by 40 mg esomeprazole b.i.d, 500 mg clarithromycin b.i.d and 500 mg metronidazole t.i.d for 5 days. The 13C-urea breath test, rapid urease test (CLO test®), and histology were used to confirm eradication. Compliance and side effects were also investigated. RESULTS: ITT and PP eradication rates of SQT were 69.9% (687 of 983) and 87.1% (657 of 754), respectively. The annual eradication rate of ITT remained consistent over the 8-year study period (p for trend=0.167), whereas PP analysis showed the eradication rate increased (p for trend=0.042). The overall adverse event rate for SQT was 41.7% (410 subjects). CONCLUSIONS: Despite high antibiotic resistance rates in Korea, the eradication rate of SQT did not decrease over the 8-year study period.

The Effect of Microbiota on Colon Carcinogenesis

Although genetic background is known to contribute to colon carcinogenesis, the exact etiology of the disease remains elusive. The organ’s extensive interaction with microbes necessitated research on the role of microbiota on development of colon cancer. In this review, we summarized the defense mechanism of colon from foreign organism, and germ-free animal models that have been employed to elucidate microbial effect. We also comprehensively discussed the metabolic property of microbiota such as butyrate production, facilitation of heme toxicity, bile acid transformation, and nitrate reduction that has been shown to contribute to the development of the tumor. Finally, up-to-date subjects such as the effect of age and gender on microbiota are briefly discussed.

Comparative Analysis of Ileal and Cecal Microbiota in Aged Rats

BACKGROUND: Gut microbiota contributes to intestinal and immune homeostasis through host-microbiota interactions. Distribution of the gut microbiota differs according to the location in the gastrointestinal tract. Although the microbiota properties change with age, evidence for the regional difference of gut microbiota has been restricted to the young. The aim of this study is to compare the gut microbiota between terminal ileum and cecum of old rats. METHODS: We analyzed gut microbiome of luminal contents from ileum and cecum of 74-week-old and 2-year-old rats (corresponding to 60-year and 80-year-old of human age) by metagenome sequencing of 16S rRNA. RESULTS: Inter-individual variation (beta diversity) of microbiota was higher in ileum than in cecum. Conversely, alpha diversity of microbiota composition was higher in cecum than in ileum. Lactobacillaceae were more abundant in ileum compared to cecum while Ruminococcaceae and Lachnospiraceae were more enriched in cecum. The proportions of Deltaproteobacteria were increased in cecal microbiota of 2-year-old rats compared to 74-week-old rats. CONCLUSIONS: Major regional distinctions of microbiota between ileum and cecum of old rats appear consistent with those of young rats. Age-related alterations of gut microbiota in old rats seem to occur in minor compositions.

Clinical Response of Rifaximin Treatment in Patients with Abdominal Bloating / 대한소화기학회지

BACKGROUND/AIMS: Abdominal bloating is a troublesome complaint due to insufficient understanding of the pathophysiology. The aim of this study was to evaluate the efficacy of rifaximin in reducing bloating associated with functional gastrointestinal disorders (FGIDs). METHODS: A total of 63 patients were treated with rifaximin for FGIDs with bloating or gas-related symptoms between 2007 and 2013 at Seoul National University Bundang Hospital. Rifaximin was administered at a dose between 800 mg/day and 1,200 mg/day for 5 to 14 days. The proportion of patients who had adequate relief of global FGID symptoms and FGID-related bloating was retrospectively assessed. The response was recorded when the symptoms were reduced by at least 50% at the follow-up after treatment cessation. RESULTS: The mean age was 56.8±14.2 years; 49.2% were females. According to Rome III criteria, 20.6% (13/63) had irritable bowel syndrome (IBS) with constipation, 9.5% (6/63) had IBS with diarrhea, 4.8% (3/63) had mixed IBS, 23.8% (15/63) had functional dyspepsia, and 12.7% (8/63) had functional bloating. Of the 51 subjects who were followed-up, 30 (58.8%) had adequate relief of global FGID symptoms and 26 (51.0%) experienced improvement of abdominal bloating after rifaximin treatment. The proportion of female was slightly higher in non-response group than in the response group (60.0% vs. 34.6%, p=0.069). Otherwise, there was no difference between the two groups. CONCLUSIONS: Despite the limitations of this retrospective study, our data confirms that rifaximin may be beneficial for abdominal bloating. Further prospective clinical trial with a larger cohort is needed.

Reversibility of Atrophic Gastritis and Intestinal Metaplasia by Eradication of Helicobacter pylori / 대한소화기학회지

Although there are many guidelines recommending Helicobacter pylori (H. pylori) eradication therapy for atrophic gastritis (AG) and intestinal metaplasia (IM), there have been contradictory reports regarding the reversibility of precancerous lesions such as AG and IM after eradication of H. pylori. There have been many reports that have shown AG seems to improve upon eradication of H. pylori to some extent. In contrast, IM has been regarded as ‘the point of no return’ according to previous reports. However, as recent studies have suggested the improvement of intestinal metaplasia as well, early eradication therapy for reversible histological status is important and necessary for the prevention of gastric cancer. In this review, we focused on the progress of gastritis resulting in AG and IM mainly by H. pylori, the relationship of AG and IM with gastric cancer, the subtype of IM, and the reversibility of AG and IM by eradication of H. pylori. Finally, we introduced the recent extension of indications for H. pylori eradication with coverage by medical insurance, which was published by the Korean Ministry of Health and Welfare in January 2018.

Dynamic Changes in Helicobacter pylori Status Following Gastric Cancer Surgery

BACKGROUND/AIMS: Helicobacter pylori eradication is recommended in patients with early gastric cancer. However, the possibility of spontaneous regression raises a question for clinicians about the need for “retesting” postoperative H. pylori status. METHODS: Patients who underwent curative gastrectomy at Seoul National University Bundang Hospital and had a positive H. pylori status without eradication therapy at the time of gastric cancer diagnosis were prospectively enrolled in this study. H. pylori status and atrophic gastritis (AG) and intestinal metaplasia (IM) histologic status were assessed pre- and postoperatively. RESULTS: One hundred forty patients (mean age, 59.0 years; 60.7% male) underwent subtotal gastrectomy with B-I (65.0%), B-II (27.1%), Roux-en-Y (4.3%), jejunal interposition (0.7%), or proximal gastrectomy (4.3%). Preoperative presence of AG (62.9%) and IM (72.9%) was confirmed. The mean period between surgery and the last endoscopic follow-up was 38.0±25.6 months. Of the 140 patients, 80 (57.1%) were found to be persistently positive for H. pylori, and 60 (42.9%) showed spontaneous negative conversion at least once during follow-up. Of these 60 patients, eight (13.3%) showed more complex postoperative dynamic changes between negative and positive results. The spontaneous negative conversion group showed a trend of having more postoperative IM compared to the persistent H. pylori group. CONCLUSIONS: A high percentage of spontaneous regression and complex dynamic changes in H. pylori status were observed after partial gastrectomy, especially in individuals with postoperative histological IM. It is better to consider postoperative eradication therapy after retesting for H. pylori.

Comparison between Resectable Helicobacter pylori-Negative and -Positive Gastric Cancers

BACKGROUND/AIMS: Controversy exists regarding the characteristics of Helicobacter pylori infection-negative gastric cancer (HPIN-GC). The aim of this study was to evaluate clinicopathologic features of HPIN-GC compared to H. pylori infection-positive gastric cancer (HPIP-GC) using a comprehensive analysis that included genetic and environmental factors. METHODS: H. pylori infection status of 705 resectable gastric cancer patients was determined by the rapid urease test, testing for anti-H. pylori antibodies, histologic analysis and culture of gastric cancer tissue samples, and history of H. pylori eradication. HPIN-GC was defined as gastric cancer that was negative for H. pylori infection based on all five methods and that had no evidence of atrophy in histology or serology. RESULTS: The prevalence of HPIN-GC was 4% (28/705). No significant differences with respect to age, sex, smoking, drinking, family history of gastric cancer or obesity were observed between the two groups. HPIN-GC tumors were marginally more likely to involve the cardia (14.3% for HPIN-GC vs 5.3% for HPIP-GC, p=0.068). The Lauren classification, histology, and TNM stage did not differ according to H. pylori infection status. Microsatellite instability was not different between the two groups, but p53 overexpression in HPIN-GC was marginally higher than in HPIP-GC (56.0% for HPIN-GC vs 37.0% for HPIP-GC, p=0.055). CONCLUSIONS: The prevalence of HPIN-GC was extremely low, and its clinicopathologic characteristics were similar to HPIP-GC.

Clinical Characteristics and Outcomes of Septic Acute Kidney Injury in Critically Ill Patients / 대한신장학회지

PURPOSE: This study was to determine the clinical characteristics and outcomes of critically ill patients with septic acute kidney injury (AKI). METHODS: We retrospectively collected data of patients with AKI who were > or =18 years of age and admitted to the intensive care unit (ICU) for > or =24 hours from April 2007 to December 2009, and compared the clinical characteristics and outcomes of patients with and without sepsis. RESULTS: Of the 1,075 patients, 333 had AKI, as defined by the RIFLE criteria, and 134 of them had AKI with sepsis. Septic AKI had significantly higher SAPS II and SOFA scores, and required more mechanical ventilation and vasoactive drugs than non-septic AKI. Patients with septic AKI progressed more to the failure category of the RIFLE criteria. Patients with septic AKI had higher in-hospital mortality and required more RRT, compared to patients with non-septic AKI. Amongst survivors, patients with septic AKI were more likely to recover renal function. A higher SAPS II score and a greater requirement for vasoactive drugs and renal replacement therapy were independently associated with increased in-hospital mortality in septic AKI. CONCLUSION: Patients with septic AKI have a higher burden of illness with an increased risk of death, but renal function recovers better in survivors of septic AKI.

A Case of Peritonitis Induced by Small Bowel Calcification and Microperforation: Sustained Secondary Hyperparathyroidism in a Patient with Continuous Peritoneal Dialysis / 대한신장학회지

Secondary hyperparathyroidism is a common complication of chronic kidney disease and known to be associated with soft tissue calcification affecting patients' morbidity and mortality. However few cases of intestinal calcification related to secondary hyperparathyroidism have been reported. Herein we report a case of peritonitis complicating small intestinal perforation in a patient who had undergone peritoneal dialysis and had sustained hyperparathyroidism. Diffuse calcifications and perforations in small intestine were identified in abdomino-pelvic CT scan as well as in resected small intestine. Because of relapsing microperforation and resultant intra-abdominal abscess, the patient has been in fasting status depending on total parenteral nutrition for over 8 months after surgery.

Hemophagocytic Syndrome in a Patient with Acute Tubulointerstitial Nephritis Secondary to Hepatitis A Virus Infection

Hepatitis A virus (HAV) infection is generally a self-limited disease, but the infection in adults can be serious, to be often complicated by acute kidney injury (AKI) and rarely by virus-associated hemophagocytic syndrome (VAHS). Our patient, a 48-yr-old man, was diagnosed with HAV infection complicated by dialysis-dependent AKI. His kidney biopsy showed acute tubulointerstitial nephritis with massive infiltration of activated macrophages and T cells, and he progressively demonstrated features of VAHS. With hemodialysis and steroid treatment, he was successfully recovered.

Supernumerary Parathyroid Gland Diagnosed with Contrast-enhanced MDCT after Total Parathyroidectomy / 대한신장학회지

We report a case of a 25-year old man with chronic kidney disease with secondary hyperparathyroidism who had persistent elevation of serum parathyroid hormone level after the immediate total parathyroidectomy and autotransplantation. To localize supernumerary (ectopic) parathyroid gland, we checked Tc-99m MIBI scintigraphy, MDCT and PET-CT. Contrast-enhanced MDCT showed a small strong enhancing lesion over left bracheocephalic vein, and PET-CT showed multiple brown tumors. We removed the supernumerary parathyroid gland and got a rapid drop of parathyroid hormone level.

Peritonitis due to Aspergillus niger in Two Continuous Ambulatory Peritoneal Dialysis Patients / 대한신장학회지

Aspergillus peritonitis is a rare but serious cause of peritonitis in continuous ambulatory peritoneal dialysis (CAPD) patients. We report 2 cases of peritonitis caused by Aspergillus niger in CAPD which were treated successfully with voriconazole and caspofungin, respectively, and catheter removal. Both patients initially received amphotericin B; however, they were not cured with the agent. We briefly discuss the proper selection of antifungal agent and the treatment duration. Previously reported cases of the CAPD peritonitis caused by A. Niger are also reviewed in this article.

A Case of Postrenal Acute Kidney Injury Complicating Retroperitoneal Fibrosis Associated with Autoimmune Pancreatitis / 대한신장학회지

Autoimmune pancreatitis is a recently established clinicopathologic entity often associated with various types of other autoimmune diseases. We report a case of postrenal acute kidney injury (AKI) due to retroperitoneal fibrosis associated with autoimmune pancreatitis. The seventy one year old male patient was admitted because of oliguria and lower extremity edema. He had been diagnosed to have autoimmune pancreatitis and retroperitoneal fibrosis by increased serum IgG and IgG4 level with the presence of rim like attenuation around pancreas and the retroperitoneal fibrosing mass in abdominal CT scan 1 year ago but was lost to follow up. Magnetic resonance cholangiopancretogram and follow up abdominal CT scan showed progressed retroperitoneal fibrosis with newly developed bilateral hydronephrosis and atrophied left kidney despite partial improvement in pancreatitis. Because of progressively rising serum creatinine and oliguria, percutaneous nephrostomy in right kidney was performed. Steroid treatment was initiated with insertion of double J catheter at right ureter and renal function gradually returned. We report here a rare case of postrenal AKI developed in unilateral functioning kidney complicated by combined retroperitoneal fibrosis and autoimmune pancreatitis.