Genotoxicity in Patients on Long-term Proton Pump Inhibitor Therapy in Korea: A Nested Case-control, Prospective, Pilot Study

Background/Aims@#Although proton pump inhibitors (PPIs) remain a mainstay for the suppression of gastric acid secretion, long-term PPI use is associated with side effects. However, the genotoxicity associated with long-term PPI use is unclear. @*Materials and Methods@#This prospective observational pilot study enrolled patients who had been on PPIs for >1 year and healthy controls from July 2015 to August 2016. The subjects completed self-report questionnaires pertaining to their drug and medical history, and only those with no medical history and a ≥2-year wash-out period (for drugs other than PPIs) were included. We collected peripheral-blood lymphocytes from long-term PPI users and healthy controls and analyzed the genotoxicity by using the cytokinesis-block micronucleus cytome assay; we also determined the fasting serum levels of pyridoxine, folate, cobalamin, and homocysteine. @*Results@#Ten long-term PPI users and 40 healthy control subjects were enrolled. The median serum pyridoxine, folate, cobalamin, and homocysteine levels were not significantly different between the groups. The median frequencies of micronuclei (MNi), nucleoplasmic bridges (NPBs), and nuclear buds (Nbuds) per 1,000 binucleated cells, in long-term PPI users and healthy controls, were 30.3 and 16.3 (P<0.005), 2.5 and 1.8 (P<0.005), and 9.3 and 5.0 (P<0.005), respectively. Even after adjustment for confounding factors, the OR of the MNi, NPBs, and Nbuds for long-term PPI users compared with healthy control subjects were 14.1 (P<0.001), 2.0 (P=0.001), and 1.3 (P=0.3), respectively. @*Conclusions@#Long-term PPI use was significantly associated with an increased risk of genotoxicity after adjustment for age, sex, body mass index, medical history, drug history, and the serum levels of vitamins.

Strongyloidiasis Presenting as Yellowish Nodules in Colonoscopy of an Immunocompetent Patient

Strongyloides stercoralis is endemic to tropical and subtropical regions, and infections are usually asymptomatic. However, immunocompromised patients, such as those receiving immunosuppressive therapy, high-dose steroids, or chemotherapy, can develop fatal hyperinfections. An 84-year-old man without any symptoms was diagnosed with strongyloidiasis during a regular screening colonoscopy. His medical history only involved a gastric endoscopic submucosal dissection for early gastric cancer 6 months previously. Few cases have been published about asymptomatic strongyloidiasis diagnosed in an immunocompetent host via endoscopic mucosal resection with characteristic colonoscopic findings. We report a case of colon-involved asymptomatic strongyloidiasis with specific colonic findings of yellowish-white nodules. This finding may be an important marker of S. stercoralis infection, which could prevent hyperinfections.

Primary epiploic appendagitis: compared with diverticulitis and focused on obesity and recurrence

BACKGROUND/AIMS: There is limited data to compare the clinical characteristics and recurrence rates between left-sided primary epiploic appendagitis (PEA) versus left-sided acute colonic diverticulitis (ACD), and right-sided PEA versus right-sided ACD, respectively.METHODS: We retrospectively reviewed the medical records and radiologic images of the patients who presented with left-sided or right-sided acute abdominal pain and had computer tomography performed at the time of presentation showing radiological signs of PEA or ACD between January 2004 and December 2014. We compared the clinical characteristics of left PEA versus left ACD and right PEA versus right ACD, respectively.RESULTS: Fifty-six patients (left:right = 27:29) and 308 patients (left:right = 24:284) were diagnosed with symptomatic PEA and ACD, respectively. Left-sided PEA were statistically significantly younger (50.2 ± 15.4 years vs. 62.1 ± 15.8 years, P= 0.009), more obese (body mass index [BMI]: 26.3 ± 2.9 kg/m² vs. 22.3 ± 3.1 kg/m² , P< 0.001), and had more tendencies with normal or mildly elevated high-sensitivity C-reactive protein (hsCRP) (1.2 ± 1.3 mg/dL vs. 8.4 ± 7.9 mg/dL, P< 0.001) than patients with left-sided ACD. The discriminative function of age, BMI and CRP between left-sided PEA versus left-sided ACD was 0.71 (cutoff: age ≤ 59 years, sensitivity of 66.7%, specificity of 77.8%), 0.84 (cutoff: BMI > 24.5 kg/m² , sensitivity of 80.0%, specificity of 80.0%) and 0.80 (cutoff: CRP < 1.8 mg/dL, sensitivity of 72.2%, specificity of 85.7%).CONCLUSIONS: If patients with left lower quadrant abdominal pain are less than 60 years, obese (BMI > 24.5 kg/m² ) with or without normal to mild elevated CRP levels (CRP < 1.8 mg/dL), it might be necessary for clinicians to suspect the diagnosis of PEA rather than ACD.

The Efficacy of Rebamipide or Ecabet Sodium Supplementation for Helicobacter pylori Eradication Therapy Compared with Quadruple (Concomitant) Regimen / 대한소화기학회지

BACKGROUND/AIMS: Although some previous studies reported that a treatment combined with mucoprotective agent could improve the eradication rate in dual or triple therapy, there are other reports that question the efficacy of combining these drugs in concomitant therapy (CoCTx). The aim of this study was to investigate the effects of rebamipide or ecabet on the Helicobacter pylori (H. pylori) eradication combined with CoCTx. METHODS: We retrospectively reviewed the medical records of 277 patients with proven H. pylori infection. They were assigned to one of 3 regimens for 10 days, twice daily: (a) CoCTx (n=118): lansoprazole 30 mg, amoxicillin 1 g, metronidazole 500 mg, and clarithromycin 500 mg; (b) CoCTx+rebamipide (100 mg) (n=85); (c) CoCTx+ecabet (1 g) (n=74). RESULTS: The baseline characteristics were not significantly different. H. pylori eradication rates were 82.2% (97/118) in CoCTx, 90.6% (77/85) in CoCTx+rebamipide, and 89.2% (66/74) in CoCTx+ecabet (p=0.17), which were statistically insignificant. Overall adverse events were more frequently reported in the CoCTx+rebamipide (50.6%. 43/85) and CoCTx+ecabet (44.6%, 33/74) groups than in the CoCTx (32.2%, 38/118) (p = 0.03) group. Drug compliances were not different between three groups (CoCTx: 95.8%, 113/118; CoCT+rebamipide: 92.9%, 79/85; CoCTx+ecabet 98.6%,73/74) (p=0.209). Multivariate analysis showed that the risk of eradication failure was significantly increased with decreased drug compliance (odds ratio 3.52, 95% confidence interval 1.00–12.32; p=0.05). CONCLUSIONS: Addition of these mucoprotective agent was not superior to CoCTx alone for eradicating H. pylori infection with frequent adverse events. Rather, drug compliance is the most related factor affecting the eradication rate. Our data suggest the importance of drug compliance over the drugs used.

Esophageal Endoscopic Vacuum Therapy with Enteral Feeding Using a Sengstaken-Blakemore Tube

Early diagnosis followed by primary repair is the best treatment for spontaneous esophageal perforation. However, the appropriate management of esophageal leakage after surgical repair is still controversial. Recently, the successful adaptation of vacuum-assisted closure therapy, which is well established for the treatment of chronic surface wounds, has been demonstrated for esophageal perforation or leakage. Conservative treatment methods require long-term fasting with total parenteral nutrition or enteral feeding through invasive procedures, such as percutaneous endoscopic gastrostomy or a feeding jejunostomy. We report 2 cases of esophageal leakage after primary repair treated by endoscopic vacuum therapy with continuous enteral feeding using a Sengstaken-Blakemore tube.

Personalized Urination Activity Recognition Based on a Recurrent Neural Network Using Smart Band / 대한배뇨장애요실금학회지

PURPOSE: Though it is very important obtaining exact data about patients’ voiding patterns for managing voiding dysfunction, actual practice is very difficult and cumbersome. In this study, data about urination time and interval measured by smart band device on patients’ wrist were collected and analyzed to resolve the clinical arguments about the efficacy of voiding diary. By developing a smart band based algorithm for recognition of complex and serial pattern of motion, this study aimed to explore the feasibility of measurement the urination time and intervals for voiding dysfunction management. METHODS: We designed a device capable of recognizing urination time and intervals based on specific postures of the patient and consistent changes in posture. These motion data were obtained by a smart band worn on the wrist. An algorithm that recognizes the repetitive and common 3-step behavior for urination (forward movement, urination, backward movement) was devised based on the movement and tilt angle data collected from a 3-axis accelerometer. The sequence of body movements during voiding has consistent temporal characteristics, so we used a recurrent neural network and long short-term memory based framework to analyze the sequential data and to recognize urination time. Real-time data were acquired from the smart band, and for data corresponding to a certain duration, the value of the signals was calculated and then compared with the set analysis model to calculate the time of urination. A comparative study was conducted between real voiding and device-detected voiding to assess the performance of the proposed recognition technology. RESULTS: The accuracy of the algorithm was calculated based on clinical guidelines established by urologists. The accuracy of this detecting device was high (up to 94.2%), proving the robustness of the proposed algorithm. CONCLUSIONS: This urination behavior recognition technology showed high accuracy and could be applied in clinical settings to characterize patients’ voiding patterns. As wearable devices are developed and generalized, algorithms detecting consistent sequential body movement patterns reflecting specific physiologic behavior might be a new methodology for studying human physiologic behavior.

Esophageal Endoscopic Vacuum Therapy with Enteral Feeding Using a Sengstaken-Blakemore Tube / 대한흉부외과학회지

Early diagnosis followed by primary repair is the best treatment for spontaneous esophageal perforation. However, the appropriate management of esophageal leakage after surgical repair is still controversial. Recently, the successful adaptation of vacuum-assisted closure therapy, which is well established for the treatment of chronic surface wounds, has been demonstrated for esophageal perforation or leakage. Conservative treatment methods require long-term fasting with total parenteral nutrition or enteral feeding through invasive procedures, such as percutaneous endoscopic gastrostomy or a feeding jejunostomy. We report 2 cases of esophageal leakage after primary repair treated by endoscopic vacuum therapy with continuous enteral feeding using a Sengstaken-Blakemore tube.

Artificial Intelligence and the Future of Internal Medicine Physicians / 대한내과학회지

Artificial intelligence (AI) is now very closely related to the work of internal medicine physicians. Internal medicine physicians must actively cope with and study the weak AI that affects them. Active use of weak AI can result in a reduced frequency of medical accidents and improved work efficiency. However, the form of medical consultation designed to treat patients based on behavior and guidelines of simply looking for symptoms and prescribing medications will ultimately disappear. As the age of self-care has begun, directors of local internal medicine clinics may expand their business to include AI-based chronic diseases and healthcare service companies to treat chronic diseases.

Endoscopic Treatment of Diverse Complications Caused by Laparoscopic Adjustable Gastric Banding: A Study in Eastern Asia

BACKGROUND/AIMS: The use of laparoscopic adjustable gastric banding (LAGB) is increasing proportionally with the obesity epidemic. However, some postoperative complications have been highlighted as major problems associated with LAGB. There is no consensus concerning the endoscopic management of these adverse events. The aim of this study was to retrospectively review the feasibility and effectiveness of endoscopic treatment for LAGB complications. METHODS: We retrospectively evaluated 352 patients who underwent LAGB between 2011 and 2015. LAGB-associated complications developed in 26 patients (7.4%). This study involved six patients (1.7%) who received endoscopic treatment. RESULTS: Types of LAGB-induced complications in our series included intragastric migration (n=3), gastric leaks (n=2), and gastric fistulas (n=1). The endoscopic treatment of these complications was successful in four of the six patients. Endoscopic band removal was successful in two patients. All gastric leaks were successfully closed via an endoscopic procedure. In two cases (intragastric migration and gastric fistula), endoscopic treatment was not sufficient, and surgery was performed. CONCLUSIONS: Endoscopic procedures afforded acceptable treatment of band migration and gastric leaks after LAGB. However, the results were poor in patients with gastric fistula.

Development of Personalized Urination Recognition Technology Using Smart Bands / 대한배뇨장애요실금학회지

PURPOSE: This study collected and analyzed activity data sensed through smart bands worn by patients in order to resolve the clinical issues posed by using voiding charts. By developing a smart band-based algorithm for recognizing urination activity in patients, this study aimed to explore the feasibility of urination monitoring systems. METHODS: This study aimed to develop an algorithm that recognizes urination based on a patient's posture and changes in posture. Motion data was obtained from a smart band on the arm. An algorithm that recognizes the 3 stages of urination (forward movement, urination, backward movement) was developed based on data collected from a 3-axis accelerometer and from tilt angle data. Real-time data were acquired from the smart band, and for data corresponding to a certain duration, the absolute value of the signals was calculated and then compared with the set threshold value to determine the occurrence of vibration signals. In feature extraction, the most essential information describing each pattern was identified after analyzing the characteristics of the data. The results of the feature extraction process were sorted using a classifier to detect urination. RESULTS: An experiment was carried out to assess the performance of the recognition technology proposed in this study. The final accuracy of the algorithm was calculated based on clinical guidelines for urologists. The experiment showed a high average accuracy of 90.4%, proving the robustness of the proposed algorithm. CONCLUSIONS: The proposed urination recognition technology draws on acceleration data and tilt angle data collected via a smart band; these data were then analyzed using a classifier after comparative analyses with standardized feature patterns.

Risk Factors for Metachronous Recurrence after Endoscopic Submucosal Dissection of Early Gastric Cancer

Although endoscopic submucosal dissection (ESD) is widely accepted as a curative treatment method for early gastric cancer (EGC) worldwide, metachronous recurrence often occurs after ESD for EGC. However, there are insufficient data about the role of Helicobacter pylori (H. pylori) infection and other risk factors for recurrence. We aimed to compare the metachronous lesion in the H. pylori persistent group and the eradicated group, and to identify risk factors for metachronous lesion. We retrospectively analyzed 782 patients who underwent ESD between January 2008 and December 2013. We excluded patients with dysplasia or patients who were not tested for H. pylori infection. One hundred eighty-five patients were enrolled. We studied risk factors for recurrence, and used survival analysis to test. There were 24 patients with metachronous recurrence after ESD for EGC among the group. The incidence of metachronous gastric lesions after ESD for EGC developed more in the over 70-year-old group (P = 0.025) and more in the H. pylori persistent group (P = 0.008). In conclusion, H. pylori infection and old age are independent risk factors for metachronous gastric lesions after ESD in EGC.

Drug-induced eosinophilic pneumonia in a patient with Crohn's disease: diagnosis and treatment using fraction of exhaled nitric oxide

Oral 5-aminosalicylic acid agents (mesalazine and sulfasalazine) and azathioprine are the mainstays of treatment for inflammatory bowel disease. Reports of pulmonary toxicity induced by oral 5-aminosalicylic acid agents or azathioprine in patients with inflammatory bowel disease are very rare; to date, only 38 cases have been reported worldwide. We, herein, report a case involving a 26-year-old man who was diagnosed with eosinophilic pneumonia after using mesalazine and azathioprine for the treatment of Crohn's disease and recovered after treatment. We also found that the fraction of exhaled nitric oxide level was elevated in this patient. After treatment, the fraction of exhaled nitric oxide level decreased and the symptoms improved. The present case shows that fraction of exhaled nitric oxide is related to the disease activity and treatment effectiveness of druginduced eosinophilic pneumonia.

Mediastinal Tuberculous Lymphadenitis Diagnosed by Endosonographic Fine Needle Aspiration / 대한소화기학회지

Isolated mediastinal tuberculous lymphadenitis is clinically rare. Its clinical presentation may mimic an esophageal submucosal tumor by extrinsic compression. A 26-year-old woman was referred to our hospital for an esophageal subepithelial tumor. A 15×10 mm sized subepithelial lesion was found 30 cm from the upper incisors on esophagogastroduodenoscopy. We diagnosed the lesion as a submucosal tumor, and performed endoscopic ultrasonography-guided fine needle aspiration for a pathologic diagnosis. The histologic examination revealed granulomatous inflammation consistent with tuberculosis. We suggest that the use of endoscopic ultrasonography and fine needle aspiration may be helpful in making an early diagnosis and planning for an optimal treatment.

Usefulness of endoscopic resection using the band ligation method for rectal neuroendocrine tumors

BACKGROUND/AIMS: Rectal neuroendocrine tumors (NETs) are among the most common of gastrointestinal NETs. Due to recent advances in endoscopy, various methods of complete endoscopic resection have been introduced for small (≤10 mm) rectal NETs. However, there is a debate about the optimal treatment for rectal NETs. In our study, we aimed to evaluate the efficacy and feasibility of endoscopic resection using pneumoband and elastic band (ER-BL) for rectal NETs smaller than 10 mm in diameter. METHODS: A total of 55 patients who were diagnosed with rectal NET from January 2004 to December 2011 at Gil Medical Center were analyzed retrospectively. Sixteen patients underwent ER-BL. For comparison, 39 patients underwent conventional endoscopic mucosal resection (EMR). RESULTS: There was a markedly lower deep margin positive rate for ER-BL than for conventional EMR (6% [1/16] vs. 46% [18/39], P=0.029). Four patients who underwent conventional EMR experienced perforation or bleeding. However, they recovered within a few days. On the other hand, patients whounderwent endoscopic resection using a pneumoband did not experience any complications. In multivariate analysis, ER-BL (P=0.021) was independently associated with complete resection. CONCLUSIONS: ER-BL is an effective endoscopic treatment with regards to deep margin resection for rectal NET smaller than 10 mm.

Clinicopathologic Similarities of the Main and Minor Lesions of Synchronous Multiple Early Gastric Cancer

The detection rate of early gastric cancer (EGC) is increasing due to improvements in diagnostic methods, but synchronous multiple EGC (SMEGC) remains a major problem. Therefore, we investigated the characteristics of and the correlation between the main and minor lesions of SMEGC. We retrospectively reviewed the medical records of patients with EGC between April 2008 and May 2013. The main lesion was defined as the one with the greatest invasion depth. If lesions had the same invasion depth, the tumor diameter was used to define the main lesion. Of 963 patients who had treatment for EGC, 37 patients with SMEGC were analyzed. The main and minor lesions showed a significant positive correlation of size (r = 0.533, P = 0.001). The main and minor lesions of SMEGC showed the same vertical and horizontal locations at 70.3% and 64.9%, respectively (P = 0.002 and P = 0.002). Macroscopic types were identical in 67.6% (P < 0.001), and 32.4% had identical macroscopic type and location. The main and minor lesions had identical characteristics of invasion depth, presence of lymphovascular invasion (LVI), and differentiation in 78.4%, 83.8%, and 83.8%, respectively. Differentiation, LVI, and invasion depth (microscopic characteristics) were simultaneously the same in 62.2%. The location, macroscopic type, and 3 microscopic characteristics were matched in 27%. The main and minor lesions of SMEGC have similar clinicopathologic characteristics. Therefore, the possibility of SMEGC should not be neglected in cases of EGC, considering an understanding of the characteristics and association of lesions.

Proposal on the Establishment of Telemedicine Guidelines for Korea / 대한의료정보학회지

OBJECTIVES: An official guideline must be prepared for legalizing the doctor-patient telemedicine system based on the evaluations of the ongoing telemedicine demonstration project performed by the Korean government. In this study, critical items of the Korean telemedicine guideline are suggested based on the guidelines of developed countries. METHODS: To investigate the telemedicine guidelines of developed countries, a keyword of 'telemedicine guidelines' was used for Google search to find out US, Australian, and Japanese guidelines. The common items included in two or more of the followings were screened: US Core Operational Guidelines for Telehealth Services Involving Provider-Patient Interactions, the Australian New South Wales (NSW) Agency for Clinical Innovation Guidelines for the use of Telehealth for Clinical and Non Clinical Settings in NSW, and the Japanese Guidelines for the practice of home telemedicine. RESULTS: A total of 22 common items of the following four domains, which could be used for the Korean guideline were screened: the common features in overall considerations (6 items), the common features in clinical considerations (6 items), the common features in technical considerations (5 items), and the common features in privacy considerations (5 items). These 22 items were suggested as the critical items of the Korean telemedicine guideline. CONCLUSIONS: The screened 22 items of the telemedicine guideline must be further organized for details. Additional studies and professional opinions on the telemedicine cases and on the guidelines of developed countries are required to establish the Korean guideline in the near future.

A Case of Gastric Ulcer Bleeding by Direct Connection to the Splenic Artery

Gastric ulcer bleeding is commonly encountered in emergency situations for gastroenterologist. Usually depth of gastric ulcer does not exceed the muscle layer. We report a case of a 67-year-old male with massive gastric ulcer bleeding caused by direct connection to the splenic artery. Bleeding control was not effectively performed by endoscopy due to massive bleeding with unstable vital sign. Angiography for embolization was performed. Active extravasation of contrast agents at the splenic artery stenosis was noted on splenic arteriogram. Bleeding stopped after embolization with histoacryl and lipiodol was successfully performed. After 1 month, complete ulcer healing was confirmed by follow up endoscopy. There was no evidence of invasive disease on biopsy.

Ten Day Concomitant Therapy Is Superior to Ten Day Sequential Therapy for Helicobacter pylori Eradication / 대한소화기학회지

BACKGROUND/AIMS: Because the efficacy of standard triple therapy for Helicobacter pylori eradication has declined, new regimens such as sequential therapy (ST) and concomitant therapy (CoCTx) have been introduced. The aim of this study was to compare the efficacy of 10-day ST and 10-day CoCTx for H. pylori eradication. METHODS: We retrospectively reviewed the medical records of 316 patients with proven H. pylori infection. They were assigned to one of 2 regimens; ST (n=191) consisted of, lansoprazole 30 mg and amoxicillin 1 g for 5 days followed by lansoprazole 30 mg, metronidazole 500 mg, and clarithromycin 500 mg for 5 days, and CoCTx (n=125) consisted of lansoprazole 30 mg, amoxicillin 1 g, metronidazole 500 mg, and clarithromycin 500 mg for 10 days. All drugs were administered twice a day. Bacterial eradication was checked by using a 13C-urea breath test at least 4 weeks after completion of treatment. RESULTS: The mean age and male to female ratio was 51.74 and 1.03, respectively. Baseline characteristics were not different in both groups. Ten day CoCTx group (94.4%, 118/125) showed better eradication rate than ST group (82.2%, 157/191) (p=0.002). Drug compliances were not statistically different between the two groups (p=0.19). Side effects were more frequently reported in the CoCTx group than in the ST group (p=0.03). CONCLUSIONS: Ten-day CoCTx was superior to ST in terms of eradicating H. pylori infection. Although the CoCTx producing more side effects than ST, CoCTx can be thought to be a promising alternative to ST as a treatment regimen for H. pylori eradication.

Prevalence and Predictive Factors of Malignant Potential in Resected Gastric Subepithelial Tumors

BACKGROUND/AIMS: EUS is a useful method to differentiate malignant from benign gastric subepithelial tumors (SETs) and to determine resection. However, this results in unnecessary resections of benign gastric SETs. The aim of our study is 1. to investigate clinical factors that may predict malignancy in gastric SET and 2. to determine how many of them have malignant potential in resected gastric SETs. MATERIALS AND METHODS: We retrospectively identified 111 patients who underwent pathologic confirmation for gastric SETs by surgical (104/111, 93.6%) and endoscopic resection between February 2003 and April 2012 and analyzed the clinical, EUS findings and final pathologic diagnosis for these patients. RESULTS: The diagnostic accuracy of EUS for SETs was 58.6% (51/87) and the rate of resection for benign SETs was 31.5% (35/111). In multivariate analysis, old age (> or =65), as well as tumor size (> or =2 cm) and location (upper or middle) were significant predictive factors for malignant potential of gastric SETs. CONCLUSIONS: One-third of endoscopic and surgical resections are performed for benign SETs. Patient's age, tumor size, and location should be considered before resection of gastric SETs. In addition, more accurate tools for histologic confirmation should be developed in order to avoid unnecessary resection.

Intestinal Capillariasis Diagnosed by Endoscopic Biopsy

Many new parasitic infections have emerged in Korea, with >35 new species appearing since the 1980s. Among them, Capillaria species are unique for contributing to morbidity in many countries as well as in Korea. Since the first reported case of a 41-year-old male patient diagnosed with intestinal capillariasis in 1991, a total of six cases have been reported thus far. In this case report, we present another imported case of intestinal capillariasis in Korea, in which a 42-year-old male patient presented with intractable diarrhea and weight loss. The diagnosis was confirmed by biopsy of the ileum. The pathognomonic radiographic presentation of a ribbon-like appearance in a small bowel series was crucial in raising an early suspicion of capillariasis and in deciding to perform diagnostic biopsy.