Frustration Still Exists

No abstract available.

What Matters in Colonoscopy?

No abstract available.

Effect of a Probiotic Preparation (VSL#3) in Patients with Mild to Moderate Ulcerative Colitis / 대한소화기학회지

BACKGROUND/AIMS: Ulcerative colitis (UC) is a chronic disease that characteristically has a relapsing and remitting course. Probiotics might possibly induce remission in the treatment of active UC. Aims of our study were to assess the efficacy of VSL#3 on clinical response and colonic tissue cytokine concentration changes in patients with active UC. METHODS: Twenty-four eligible patients with mild to moderate UC received open-label VSL#3 4 sachets daily in 2 divided doses for 8 weeks. The disease activity pre- and post-VSL#3 therapy was assessed by ulcerative colitis disease activity score and colonic tissue cytokine profiling done at baseline and at week 8. RESULTS: Twenty-four patients (mean age, 43.7 years; range, 20-70 years; male/female, 15/9) were enrolled and 2 patients did not have the final endoscopic assessment. A total of 22 patients were analyzed. Intent to treat analysis demonstrated remission in 45.8% of subjects (n=11); partial response in 20.8% (n=5); no change or worse in 25.0% (n=6) of subjects. The mean ulcerative colitis disease activity index (UCDAI) scores decreased from 7.09+/-1.81 to 1.45+/-1.29 in patients with a remission (p<0.001). The mean endoscopic scores had also significantly decreased from 1.91+/-0.54 to 0.63+/-0.50 in patients with a remission (p<0.001). The concentrations of colonic cytokines did not change significantly during treatment in patients with a remission. CONCLUSIONS: Our study demonstrated that VSL#3 is effective in achieving clinical responses and remissions in patients with mild-to moderately active UC, further supporting the potential role in UC therapy.

Delayed Postpolypectomy Bleeding

No abstract available.

An Incidental Asymptomatic Dieulafoy's Lesion in the Colon: A Case Report

A Dieulafoy's lesion is an uncommon, but important, cause of gastrointestinal bleeding. It is associated with massive, life-threatening hemorrhage and is typically difficult to diagnose. Although originally described in the stomach and rarely found below the proximal stomach, identical lesions have been reported in other gastrointestinal organs, including the duodenum, jejunum, colon, and rectum. Most cases occur with bleeding in the gastrointestinal tract. However, we present an incidental asymptomatic Dieulafoy's lesion in the colon, which was treated successfully by using an endoscopic hemoclipping technique.

Clinical Characteristics of Amebic Colitis as Diagnosed by using Colonoscopic Findings

PURPOSE: Nowadays, with improvements in hygiene and in the sewage system, the prevalence of amebic colitis in Korea is declining. However, amebic colitis still occurs every year. We investigated the clinical features of current patients with amebic colitis and compared the results with those for a past endemic period in Korea. METHODS: From June 2000 to June 2005, 10 patients were diagnosed in the Digestive endoscopy center of Song Do colorectal hospital as having amebic colitis. We evaluated their medical histories, clinical characteristics, and colonoscopic findings. RESULTS: The male-to-female ratio was 1.5 : 1. The mean age was 38.4+/-11.4 years. The mean diagnostic period from occurrence of symptoms to diagnosis was 20.4+/-17.5 days. The clinical symptoms of amebic colitis were diarrhea (80%), bloody stool (70%), mucoid stool (60%), abdominal pain (50%), fever, weight loss, nausea, and fatigue. Seven patients (70%) had a history of travel, and six of those seven patients had taken trips abroad. The foreign areas of travel included India (50%), Indonesia (28.6%), and Japan (16.7%). The diagnostic methods were colonoscopic biopsies to detect trophozoites of Entameba histolytica (90%) and serologic tests for the anti-ameba antibody (10%). The most common colonic locations of the lesions were the cecum (80%) and the rectum (80%). Another was the ascending colon (30%); pan-colonic involvement was also seen (10%). CONCLUSIONS: In the past, the cause of amebic colitis in Korea was poor hygiene. Nowadays, however, travel to amebiasis-endemic areas may be the most important cause. Therefore, the travel history of diarrheal patients is an important diagnostic factor in cases of amebic colitis and a differential diagnosis factor in cases of inflammatory bowel disease.

Difficult Polypectomy

No abstract available.

Difference between Genders in Patients with Obstructive Defecation: Analysis of 1,513 Defecograms

PURPOSE: The aims of this study were to find the difference in frequency between genders and to determine the correlation between age-related disease and other diseases in obstructive defecation. METHODS: A consecutive series of 1,513 patients (343 males, 1,170 females) with obstructive defecation who undertook defecography and/or cinedefecography during 1 year period was analyzed. RESULTS: The causes of obstructive defecation in males showed as spastic pelvic floor syndrome (SPFS) (48.3%), rectal prolapse (RP) (31.4%), descending perineum syndrome (DPS) (25.9%), enterocele or sigmoidocele (7.6%), and rectocele (7%). However, in females, the causes were rectocele (83.8%), DPS (49.2%), RP (37.6%), SPFS (32.5 %), and enterocele or sigmoidocele (11.2%). The SPFS was negatively correlated with enterocele or sigmoidocele, DPS, RP in both genders, but SPFS had no statistical correlation with rectocele. DPS was correlated with RP in both genders and with enterocele or sigmoidocele in females, but no statistical correlation was seen in males. The size of the rectocele showed a slight correlation with age in females (r=0.102, P=0.01). Age was correlated with rectal prolapse in females; however, it showed a negative correlation with SPFS in females. CONCLUSIONS: The frequency of diseases causing obstructive defecation is different between genders. Age may not play a role in aggrevating the diseases causing obstructive defecation. Further pathophysiologic study of gender differences in patients with obstructive defecation is needed.

Current Trend of Inflammatory Bowel Disease

PURPOSE: Inflammatory bowel disease (IBD) has steadily increased, according to westernized life style, popular use of colonoscopy, and development of pathology and diagnostic radiology. However, there is no avaliable data about epidemiology of IBD in Korea. Even though our data is not a standard of IBD patients in Korea, it is possible to understand the trend of IBD. METHODS: From Jan. 1995 to Dec. 2000, cases of ulcerative colitis (UC), Crohn's disease (CD), and indeterminate colitis (ID) were evaluated retrospectively. Annual incidence of IBD at our hospital was calculated with using new IBD patients/new out-patients. To compare the incidence of CD with that of intestinal tuberculosis (TB), intestinal TB cases from Jan. 1997 to Dec. 2000 were evaluated. RESULTS: Total number of IBD patients was 651: UC (480, 73.7%), CD (149, 22.9%) and ID (22, 3.4%) in order of frequency. Male was more prevalent than female (1.2:1), especially in CD (2.5:1). However, there was no difference of sex in UC. Mean age was 37.9 ( 14.1) years old, ranging from 11 to 79. CD patients (25.1 9.4) were younger than UC (41.9 13.0). Incidence of IBD out of new out-patients increased annually:0.30% (53 cases) in 1995, 0.31% (67 cases) in 1996, 0.37% (99 cases) in 1997, 0.38% (100 cases) in 1998, 0.54% (158 cases) in 1999 and 0.58% (174 cases) in 2000. The most common types of UC and CD were proctitis (52.3%) and ileocolic type (59.7%), respectively. Incidence of CD was more prevalent than that of intestinal TB (2.5:1). CONCLUSION: About 0.5% of new out-patients had IBD and the number of patients of IBD increased annually. CD patients were younger than those of UC and male was predominant. The number of patients with CD exceeded that of intestinal TB patients.

Analysis of Factors Influencing Secondary Bleeding after Hemorrhoidectomy

PURPOSE: Secondary bleeding is an inevitable and a troublesome complication of hemorrhoidectomy. This study analyzed the factors related to secondary bleeding after hemorrhoidectomy. METHODS: A total of 14,062 patients received a hemorrhoidectomy from Apr. 1999 to Apr. 2001. A retrospective study of 83 patients with secondary bleeding was done. At first, the doctors were divided into two groups. In one group, each doctor had performed more than 500 hemorrhoidectomies; in the other groups, each doctor had performed less than 500 hemorrhoidectomies. The incidence of secondary bleeding of the two groups was compared. Then, 155 patients without secondary bleeding were randomly selected as a control group. Clinical aspects and laboratory data were compared with those of the bleeding group. RESULTS: The total incidence of secondary bleeding was 0.6%. The incidence for the group with experienced doctors was 0.5%, that for the other group was 1.3%. When bleeding patients were compared with the control group, the proportion of patients who received a blood transfusion within 1 week before operation was 12.1% in the bleeding group and 2.6% in the control group. The postoperative WBC count was increased more in the bleeding group. The percentage treated with metronidazole was 12% compared with 25.3% in the control group. The incidences of bleeding according to operation sites were 19.6% in the right anterior, 12.2% in the left lateral, 10.9% in the right posterior, and 8.4% in the posterior portion. CONCLUSIONS: Secondary bleeding after a hemorrhoidectomy is more prevalent with less experienced doctors, recent history of blood transfusion, less use of metronidazole, and specific location of the hemorrhoid, such as the right anterior and the left lateral site of the hemorrhoid pile.

Clinical Significance of Depressed-Type Colorectal Neoplasms Based on Growth and Development

A route of colorectal cancer development other than the adenoma-carcinoma sequence has recently become an issue due to the discovery of depressed-type early colorectal cancers. Moreover, the fact that some polyp-like cancers actually originate from depressed-type lesions has become obvious. Despite the protruding shapes of depressed-type early colorectal cancers, they probably have biological characteristics, which are different from those of the usual polyp lesions. We undertook this study to evaluate the clinical significance of depressed-type colorectal neoplasms. The authors recently experienced 87 cases of depressed-type colorectal neoplasms. Using Kudo's classification, we classified these 87 cases into three types based on their growth patterns, type IIc, type IIa + IIc, and type Is + IIc, and then analyzed these types on the basis of size, type, and submucosal invasion rate. The submucosal invasion rate of cancers of type IIa + IIc was significantly higher than that of type IIc (p < 0.05), and the rate for cancers of types IIa + IIc and Is + IIc together was significantly higher than that of type IIc (p < 0.05). However, no significant difference was found between the rates of types IIa + IIc and Is + IIc. In conclusion, the IIa + IIc and Is + IIc sub-types of depressed-type colorectal neoplasms, individually and together, have higher rates of submucosal invasion than type IIc lesions. Accordingly, type IIa + IIc and type Is + IIc must be differentiated from the usual polyps and should be managed cautiously, despite their protruding shapes.

Reply / 대한소화기내시경학회지

No abstract available.

Perineal Rectosigmoidectomy with Levatoroplasty for Rectal Prolapse Early functional outcome

PURPOSE: This study was designed to analyze the short-term clinical and functional outcomes of perineal rectosigmoidectomy with levatoroplasty for complete rectal prolapse. METHODS: The data were prospectively collected and consisted of the clinical data, the functional status before and after surgery, the operation record, and the postoperative course. The functional status was evaluated by using Wexner's constipation score (0-30), Wexner's incontinence score (0-20), anorectal manometry, and pudendal nerve terminal motor latency. Follow-up was performed at 3-6 months after the operation by using both a standardized questionnaire completed in the outpatient clinic or telephone interview (n=23) and an anorectal physiology test (n=7). RESULTS: During a one-year period, 23 patients (male=10) underwent perineal rectosigmoidectomy with levatoroplasty for complete rectal prolapse. The median duration of the operations was 88 minutes. The median length of postoperative hospital stay was 6 days. There was one urinary tract infection and no mortalities. The constipation score was significantly decreased after the operation (9.8 vs 3.8; P<0.001), and constipation was improved in 90 percent (19/21) of the cases. The incontinence score was significantly decreased after surgery (mean preop.=11.6, postop.=3.7; P<0.001) and incontinence was improved in 17 of 21 patients with impaired continence (81 percent). Anal sphincter function was not improved but rectal reservoir capacity was significantly decreased after surgery (rectal urgent volume (45.7 cc vs 37.1 cc; P=0.045), maximal tolerable volume (120 cc vs 85.7; P=0.011). Most patients (83 percent) felt that the operation had improved their symptoms. The major reasons for dissatisfaction after surgery were frequent defecation, fecal soiling, persistent or aggravated fecal incontinence, and recurrence. One patient had a complete recurrence (4.3 percent), and another patient had a mucosal prolapse which was treated. CONCLUSIONS: Perineal rectosigmoidectomy with levatoroplasty for complete rectal prolapse is a safe technique with acceptable short-term functional results; however, it is not recommended for rectal prolapse patients with diarrhea-predominant irritable bowel syndrome.

Clinical Aspects and Surgical Methods in Perianal Hidradenitis Suppurativa

PURPOSE: Hidradenitis suppurativa is a chronic suppurative and cicatricial inflammatory disease involving apocrine gland- bearing areas including the axilla, groin, and anogenital regions. Recurrence after surgery is not rare, and there is much debate about operative methods. This study analyzed the clinical characteristics and the relationship between different surgical methods and recurrences of perianal hidradenitis suppurativa. METHODS: A retrospective study of 20 patients with perianal hidradenitis suppurativa was done. The clinical characteristics were examined. The patients were divided into several groups (acute, chronic regional, chronic extensive) according to lesion status; then, different operative methods and recurrence rates were compared. RESULTS: All of the patients were male smokers. The mean age of onset was 28.4 years. The mean duration of disease was 10 years. The total number of operations, including incision and drainage, was 29 cases. Only 4 patients were overweight or obese. The most common symptom was pus discharge (52%). The recurrence rate after final surgery was 30.0%. After incision and drainage in the acute group, 7 of 8 cases (87.5%) recurred. In the chronic regional group, 5 of 9 cases (55.6%) experienced recurrence after excision and primary repair. After excision and healing by secondary intention, 1 of 7 cases (14.3%) had recurrence. In the case of one unroofing and marsupialization, there was no recurrence. In the chronic extensive group, 1 recurrence was noted in 4 unroofings and marsupializations. CONCLUSIONS: In the case of abscess, proper incision and drainage is needed, but further definitive surgery must be done. In the case of chronic disease, if the lesions are regional, excision and healing by secondary intention is more ideal for decreasing the recurrence rate. If the lesions are extensive, unroofing and marsupialization is recom-mended.

Passage Pattern of the Colon during Colonoscopy Based on the 'Axis-Maintaining and Bowel-Shortening Method'

PURPOSE:During colonoscopy, smooth insertion of the colonoscope is an important basic procedure. However, it is not necessarily easy. An understanding of the passage patterns of the colon is helpful for colonoscopy. In this study, the authors aimed to contribute information that could be useful to effect a smooth and effective introduction of the colonoscope. METHODS:The authors performed 7,560 colonoscopies from May 2000 to December 2000. All cases were performed without using sedatives or analgesics. Out of those 7,560 cases, 2,289 cases, which were performed by one colonoscopist, were selected, excluding those with incomplete colonoscopy, those with a history of bowel resection, those with poor bowel preparation, those with advanced disease, such as inflammatory bowel disease, cancer, etc., and those with conditions that could markedly affect colonoscopy. Those 2,289 cases were classified as 4 patterns according to the passage patterns through the colon during colonoscopy:pattern A, passage is possible using right torque and pull-back; pattern B, bowel-shortening is possible at the peak point of the sigmoid colon; pattern C, bowel-shortening is possible at the transverse colon because of a markedly redundant sigmoid colon; and pattern D, pattern is difficult to specify. Those 2,289 cases were also analyzed regarding age. As to age, they were divided into two groups, those under the 6th decade and those of the 6th decade or older. RESULTS:The most common pattern was pattern A, comprising 71.3%; next was pattern B, 19.7%. There was no significant difference in distribution of the passage patterns between the two age groups (P>0.05). CONCLUSIONS:Ninety-one percent (91%) of the cases were patterns A and B. An understanding of the passage patterns will be helpful for smooth insertion of the colonoscope. The 'axis-maintaining and bowel-shortening method' is a useful and effective approach to colonoscopy.

Significance of Subclassification of Depressed-Type Early Colorectal Cancer Based on Growth and Development

PURPOSE:Recently it became obvious that some early cancers which appeared to be polyp lesions had actually originated from depressed-type lesions. The aim of this study was to clarify both the characteristics of depressed- type early colorectal cancers compared with protruded- or flat-type ones and the significance of a subclassification of depressed-type early cancers. METHODS:The authors experienced 248 early colorectal cancers from 1996 to 2000. We classified those cancers into protruded, flat, and depressed types based on growth and development. Further, we used Kudo's classification to subclassify the depressed-type cancers into three sub-types, IIc, IIa+IIc, and Is+IIc. We analyzed the 248 cases with emphasis on size, type, sub-type, and submucosal cancer (sm) rate. RESULTS:The sm rate of the depressed cancers was 81.8% (18/22) and was significantly higher than those of the protruded (30.5%) or the flat (38.5%) types (P<0.05). The sm rate of the depressed lesions not larger than 10 mm was 70% (7/10) and that of the lesions from 11 mm to 20 mm was 91.7% (11/12); there were no depressed cancers larger than 20 mm in diameter. The sm rate of the type IIa+IIc plus type Is+IIc lesions was higher than that of type IIc lesions (93.3%, 14/15 vs. 57.1%, 4/7). Endoscopic resection was done in 74.2% of all early colorectal cancers. CONCLUSIONS:The sm rate of depressed-type early colorectal cancers was 82%, and no depressed cancers were larger than 20 mm in diameter, suggesting that by the time a depressed-type cancers had become larger than 20 mm in size, it had already progressed into an advanced cancer. Thus, it is very important to detect depressed-type cancers in an early stage. Moreover, it is imperative to differentiate type IIa+IIc and type Is+IIc from polyp lesions and to manage them cautiously because their sm rate is higher than that for type IIc lesions.

A Case of Granular Cell Tumor in the Perianal Region

Since granular cell tumor was first described by Abrikossoff in 1926, it has been known as a rare disease. The histogenesis of this tumor is still controversial, but the origin is thought to be from a Schwann cell. About one third of the tumors occur in the tongue, and uncommonly in the perianal region. We report a case of granular cell tumor that developed in the perianal region. The tumor grew slowly for 5 years and was removed by a local excision. This tumor showed positive staining with neuron-specific enolase (NSE).

Depth of Submucosal Invasion for Submucosally Invasive Cancer / 대한소화기내시경학회지

No abstract available

Topical Glyceryl Trinitrate (GTN) Versus Conservative Treatment (CT) in Chronic Anal Fissure: Prospective and Randomized Study

PURPOSE: This study was designed to compare the effect of treatment using glyceryl trinitrate (GTN) ointment with that of conservative treatment (CT) on chronic anal fissure. METHODS: As a preliminary study, maximal resting pressures of the anal canal were checked in 13 patients having chronic anal fissure before and 10 minutes after application of 0.2% GTN ointment. As the study groups, 59 patients having chronic anal fissure were randomly allocated to the GTN and the placebo groups. All the patients in both groups were given oral analgesics, sedatives, and bulk-forming agents. They had applied 0.2% GTN ointment or a placebo ointment three times a day to their perianal skin. Maximal resting pressures of the anal canal were checked at the beginning and at the endpoint of the treatment period which continued for 6 weeks. If there was complete healing of the fissure in the middle of the treatment, the treatment was stopped. Sixteen patients were lost during the study. RESULTS: Among the rest, 22 and 21 patients were included in the GTN group and the placebo group, respectively. The maximal resting pressure decreased significantly in all groups (p0.05). CONCLUSION: The effect of GTN on the symptomatic relief and results of treatment in patients having chronic anal fissure is not superior to that of conservative treatment.

Delayed Bleeding in a Colonoscopic Polypectomy: An experience with 5,236 polypectomies

PURPOSE: Delayed hemorrhage rarely happens after a colonoscopic polypectomy, ranging from 0.2 to 1.8% in frequency. Although its occurrence is unpredictable and it may be serious in some cases, scanty data on its causes, characteristics, and effective management exist in Korea. This study was conducted to provide such data, especially data on the characteristics of delayed hemorrhage and its effective management. METHODS: From 1997 to 1999, one endoscopist at Song-Do Colorectal Hospital performed 5236 polypectomies on 2511 patients. Delayed hemorrhage occurred after 9 of those polypectomies, for a bleeding incidence rate of 0.17% (9/5236). The authors reviewed those 9 incidence of delayed hemorrhage, which involved 9 patients and 9 lesions, with emphasis on the characteristics of the bleeding and the treatment. RESULTS: The mean age of the 9 patients was 50 years, and the male-to-female ratio was 8: 1. The sigmoid colon was involved in 4 of those patients (44.4%), and the right-sided colon was involved in another 4 of those patients. Lesions smaller than 11 mm were either sessile or flat-elevated and accounted for 6 of the 9 lesions (66.7%). The remaning lesions, which were larger than 10 mm, were either pedunculated or semipedunculated. Three (3) of the 9 patients (33.3%) experienced bleeding on day 1, the most common bleeding day. Another 5 patients (55.6%) experienced bleeding during the next 4 days (days 2 to 5). The last patient experienced bleeding on day 9, the latest bleeding day. A snare polypectomy had been performed on 7 of the 9 patients (77.8%), and a hot biopsy had been performed on the other 2 (22.2%). All delayed bleeding was treated by using hemoclips; additional epinephrine injection was used in 55.6% of the cases and an additional detachable snare in 22.2%. Rebleeding was noticed the day following the initial treatment of bleeding in one case and was managed by using hemoclips. CONCLUSIONS: The first 5 days after a colonoscopic polypectomy are crucial, and caution is required during the next 5 days. Thorough knowledge about preventing and managing bleeding is essential.