A Randomized, Double-Blind, Active-Control, Noninferiority, Multicenter, Phase 4 Study to Evaluate the Efficacy and Safety of Esomeprazole/Sodium Bicarbonate 20/800 mg in Patients with Nonerosive Gastroesophageal Reflux Disease

Background/Aims@#Efficacy of proton pump inhibitors is limited in patients with nonerosive reflux disease (NERD). The aim of this study was to comparatively evaluate the efficacy and safety of esomeprazole with sodium bicarbonate and esomeprazole alone. @*Methods@#This was a multicenter, randomized, double-blind, active-controlled, noninferiority comparative study. A total of 379 patients with NERD were randomly allocated to receive either EsoduoⓇ/sup> (esomeprazole 20 mg with sodium bicarbonate 800 mg) or NexiumⓇ/sup> (esomeprazole 20 mg) once daily for 4 weeks from January 2019 to December 2019. The patients had a history of heartburn for at least 2 days in the week before randomization as well as in the last 3 months and no esophageal mucosal breaks on endoscopy. The primary endpoint was a complete cure of heartburn at week 4. The secondary and exploratory endpoints as well as the safety profiles were compared in the groups at weeks 2 and 4. @*Results@#A total of 355 patients completed the study (180 in the EsoduoⓇ/sup> group and 175 in the NexiumⓇ/sup> group). The proportions of patients without heartburn in the entire 4th week of treatment were not different between the two groups (33.33% in the EsoduoⓇ/sup> group and 35% in the NexiumⓇ/sup> group, p=0.737). There were no significant differences in most of the secondary and exploratory endpoints as well as the safety profiles. @*Conclusions@#EsoduoⓇ/sup> is as effective and safe as NexiumⓇ/sup> for managing typical symptoms in patients with NERD (ClinicalTrial.gov identifier: NCT03928470).

Changes in the seroprevalence of IgG anti-hepatitis A virus between 2001 and 2013: experience at a single center in Korea

BACKGROUND/AIMS: The incidence of symptomatic hepatitis A reportedly increased among 20- to 40-year-old Korean during the late 2000s. Vaccination against hepatitis A was commenced in the late 1990s and was extended to children aged <10 years. In the present study we analyzed the changes in the seroprevalence of IgG anti-hepatitis A virus (HAV) over the past 13 years. METHODS: Overall, 4903 subjects who visited our hospital between January 2001 and December 2013 were studied. The seroprevalence of IgG anti-HAV was analyzed according to age and sex. In addition, the seroprevalence of IgG anti-HAV was compared among 12 age groups and among the following time periods: early 2000s (2001-2003), mid-to-late 2000s (2006-2008), and early 2010s (2011-2013). The chi-square test for trend was used for statistical analysis. RESULTS: The seroprevalence of IgG anti-HAV did not differ significantly between the sexes. Furthermore, compared to the seroprevalence of IgG anti-HAV in the early 2000s and mid-to-late 2000s, that in the early 2010s was markedly increased among individuals aged 1-14 years and decreased among those aged 25-44 years (P<0.01). We also found that the seroprevalence of IgG anti-HAV in individuals aged 25-44 years in the early 2010s was lower than that in the early 2000s and mid-to-late 2000s. CONCLUSIONS: The number of symptomatic HAV infection cases in Korea is decreasing, but the seroprevalence of IgG anti-HAV is low in the active population.

A Case of Isolated Small Intestinal Wall Calcification on Patient with Continuous Ambulatory Peritoneal Dialysis / 대한소화기학회지

The metastatic calcification is defined as the deposition of calcium salt in normal tissue with an abnormal serum biochemical environment, such as chronic kidney disease, hyperparathyroidism, and hypercalcemia related with malignancy. Although the metastatic calcification can develop in any organs and tissues, presenting its symptoms and complications are rare. Thus a few cases have been reported. This case shows the metastatic calcification of the small intestine without any peritoneal and mesenteric vascular calcification which was early diagnosed by computed tomography and mesenteric angiography in a patient with abdominal pain, receiving continuous ambulatory peritoneal dialysis due to end stage renal disease. The clinician should early consider the metastatic calcification as differential diagnosis when unidentified calcifications are noted in simple abdominal X-ray such as in the present case, and promptly confirm it by using appropriate diagnostic tests in order to prevent its complications and progression.

Xanthogranulomatous Inflammation in Terminal Ileum Presenting as an Appendiceal Mass: Case Report and Review of the Literature

Xanthogranulomatous inflammation (XGI) is a rare benign inflammatory disease characterized by aggregation of lipid-laden foamy macrophages. This disease entity has been described in various organs but most commonly in the kidney and gallbladder. The occurrence of this disease in the lower gastrointestinal tract is extremely rare. Its clinical importance is that it can be misdiagnosed as an infiltrative cancer. In this case report, a 52-year-old male complained of right lower quadrant abdominal pain for a period of 3 months. Abdominal computed tomography revealed appendiceal mass and colonoscopy revealed multiple erythematous nodular lesions in the terminal ileum and appendiceal orifice, mimicking appendiceal cancer. Right hemicolectomy was done and the pathological specimen revealed XGI of the terminal ileum. To our knowledge, this is the first case of XGI in terminal ileum presenting as abdominal pain and the appendiceal mass on radiologic findings.

A Case of Adenocarcinoma of the Transverse Colon with Humoral Hypercalcemia of Malignancy

Hypercalcemia is a common electrolyte imbalance in patients with malignancy. Approximately 80% of hypercalcemia is associated with humoral hypercalcemia of malignancy (HHM), but occurs rarely in colorectal carcinomas. A 72-year-old man was admitted with abdominal pain and bowel habit change. Colonoscopy showed a malignant tumor in the transverse colon. Laboratory data showed an elevated serum calcium level (11.6 mg/dL) and elevated parathyroid hormone-related peptide level (12.2 pmol/L). Histology showed poorly differentiated adenocarcinoma. We infused intravenous normal saline, furosemide and pamidronate. The serum calcium level was subsequently normalized. However, the patient died from cancer progression 10 days later. With a review of the relevant literature, we report a case of adenocarcinoma of the transverse colon with HHM.

A Case of Acquired Zonal Aganglionosis in Adult

A chronic intestinal pseudo-obstruction is a rare disorder and a severe digestive syndrome. It is characterized by deranged gut propulsive motility that resembles a mechanical obstruction, but no obstructive process is present. An intestinal pseudo-obstruction may be classified as acute or chronic; the chronic form may also be classified as idiopathic or secondary to a variety of diseases. Treatment of intestinal pseudo-obstruction involves nutritional, pharmacological, and surgical therapies. Surgery should be limited to patients who are refractory to medical therapy and show a deteriorating course. Despite available medical and surgical interventions, the outcome remains poor. Here, we describe a case of a 54-year-old female with chronic constipation and abdominal distension, who was subsequently found to have segmental aganglionosis. The patient was treated with a subtotal colectomy and ileosigmoidostomy without sequelae.

A fatal case of hepatitis B virus (HBV) reactivation during long-term, very-low-dose steroid treatment in an inactive HBV carrier

Hepatitis B virus (HBV) may be reactivated after chemotherapy or immunosuppressive therapy, and therefore administration of antiviral agents before such treatment is recommended. Most reported cases of reactivation are associated with high doses of immunosuppressive agents or combination therapy. We present a case of a previously inactive HBV carrier with an acute severe flare-up during a long-term, very-low-dose (2.5 mg/day) steroid treatment for rheumatoid arthritis. We suggest that even a minimal dose of single-regimen oral steroid can cause reactivation of indolent, inactive HBV.

Esophageal Sinus Formation due to Cyanoacrylate Injection for Esophageal Variceal Ligation-induced Ulcer Bleeding in a Cirrhotic Patient / 대한소화기학회지

Intravariceal injection of N-butyl-2-cyanoacrylate is widely used for the hemostasis of bleeding gastric varices, but not routinely for esophageal variceal hemorrhage because of various complications such as pyrexia, bacteremia, deep ulceration, and pulmonary embolization. We report a rare case of esophageal sinus formation after cyanoacrylate obliteration therapy for uncontrolled bleeding from post-endoscopic variceal ligation (EVL) ulcer. A 50-year-old man with alcoholic liver cirrhosis presented with hematemesis. Emergent esophagogastroscopy revealed bleeding from large esophageal varices with ruptured erosion, and bleeding was initially controlled by EVL, but rebleeding from the post-EVL ulcer occurred at 17th day later. Although we tried again EVL and the injections of 5% ethanolamine oleate at paraesophageal varices, bleeding was not controlled. Therefore, we administered 1 mL cyanoacrylate diluted with lipiodol and bleeding was controlled. Three months after the endoscopic therapy, follow-up endoscopy showed medium to large-sized esophageal varices and sinus at lower esophagus. Barium esophagography revealed an outpouching in esophageal wall and endoscopic ultrasonography demonstrated an ostium with sinus. It is noteworthy that esophageal sinus can be developed as a rare late complication of endoscopic cyanoacrylate obliteration therapy.

A Case of Warfarin-Induced Intramural Hematoma Diagnosed by Double-Balloon Enteroscopy

Although bleeding is a major complication of oral anticoagulant therapy, warfarin-induced spontaneous intramural hematoma of the small bowel is a very rare complication. The clinical features of spontaneous intramural hematoma vary from mild abdominal pain to panperitonitis due to bowel perforation. Because spontaneous intramural hematoma can proceed to a life threatening situation, early diagnosis is of vital importance. Although there are a number of radiologic diagnostic tools available including abdominal ultrasonography and computed tomography, confirmation of the diagnosis through direct visualization of the involved bowel mucosa is very helpful. Direct confirmation of warfarin-induced spontaneous intramural hematoma of the small bowel is possible using double-balloon enteroscopy. We report a case of warfarin-induced spontaneous intramural hematoma with a review of the relevant literature.

A Case of Synchronous Double Primary Cancer of Gastric Adenocarcinoma and Diffuse Large B Cell Lymphoma / 대한소화기학회지

The simultaneous occurrence of primary gastric lymphoma and adenocarcinoma is rarely reported. We here report a case of synchronous double primary tumor of advanced gastric cancer and diffuse large B cell lymphoma. A 65-year-old woman underwent an esophagogastroduodenoscopy for the evaluation of abdominal discomfort of two months' duration. The endoscopic examination showed an ulcerating tumor in the gastric antrum and thickened folds in the fundus and the microscopic examination revealed an adenocarcinoma in the antrum and a diffuse large B-cell lymphoma in the fundus. She has had total gastrectomy and CHOP chemotherapy with rituximab. Since the cases of synchronous double primary gastric tumors have been increased on the recent medical advances, when a gastric tumor is detected for the endoscopic examination, an endoscopist has to make every endeavor not to miss another tumor in the stomach.

A Case of Mucinous Gastric Adenocarcinoma Mimicking Submucosal Tumor / 대한소화기학회지

A gastric carcinoma with the endoscopic features resembling a submucosal tumor (SMT) is rare, and reportedly accounting for 0.1% to 0.63% of all resected gastric carcinomas in Japan. A diagnosis of a SMT-like gastric carcinoma is often difficult as the tumors are almost entirely covered with normal mucosa. Furthermore mucinous gastric adenocarcinoma is uncommon histologic subtype of gastric cancer. These tumors are detected mostly in an advanced stage and rarely in an early stage. Early mucinous gastric adenocarcinoma is characterized as an elevated lesion resembling SMT due to abundant mucin pools in the submucosa. Here we report one case of SMT-like mucinous gastric adenocarcinoma, diagnosed by the usual endoscopic biopsy and treated with surgery.

A Case of Methicillin-Resistant Staphylococcal Enterocolitis with Subsequent Development of Lymphocytic Colitis

Staphylococcus aureus (S. aureus) is occasionally a normal inhabitant of the gastrointestinal tract, and rarely considered a cause of enterocolitis. Methicillin-resistant Staphylococcal enterocolitis may cause persistent diarrhea leading to severe complications and even death, without appropriate treatment. Lymphocytic colitis (LC), a subtype of microscopic colitis, is a relatively common cause of chronic watery diarrhea. We report the case of a 73-year-old woman with profuse watery diarrhea caused by methicillin-resistant S. aureus. Soon after treatment of her enterocolitis with vancomycin the patient's general condition and symptoms improved, although the diarrhea persisted. Through colonoscopic biopsy and immunohistochemical staining, overt LC was diagnosed, and prompt therapy with budesonide was initiated.

A Case of Colonic Intussusception Occurring after Colonoscopic Polypectomy / 대한소화기내시경학회지

Intestinal intussusception in adults is a rare disease. Most of the cases of adult intussusception are secondary to a definable lesion, and so surgical treatment generally needed. Intussusception that occurs after colonoscopic polypectomy is apparently a rare malady. A 77-year old man undergoing colonoscopic polypectomy was diagnosed as having colonic intussusception at the hepatic flexure. As there was no clinical improvement with conservative treatment, he underwent segmental resection of the ascending and transverse colon. Pathologic examination revealed that the colonoscopic polypectomy site was a leading point of the intussusception.

A Case of Segmental Colitis Associated with Diverticular Disease / 대한소화기학회지

Segmental colitis associated with diverticular disease (SCAD) is a colonic inflammatory disorder with localized non-granulomatous inflammation at sigmoid colon, and associated with colonic diverticulosis. SCAD is an apparently uncommon disorder in Western. We experienced a rare case of SCAD in a 46-year-old woman who visited the hospital due to abdominal discomfort. Colonoscopic examination showed multiple sigmoid diverticula in association with a segment length colitis. Colonoscopic biopsies of the sigmoid colon demonstrated cryptitis and crypt abscess along with chronic inflammatory cells infiltration. The biopsies of the rectum was histologically normal. The patient was given the diagnosis of SCAD and treated with oral mesalamine. This is the first case of SCAD reported in Korea.

A Case of Pleural Effusion Associated with Acute Hepatitis A / 대한소화기학회지

Hepatitis A virus (HAV) infection is common in developing countries, including Korea. It can be accompanied by extrahepatic complications such as renal failure, arthritis, and vasculitis. Pleural effusion is a very rare complication of HAV infection, which has been reported usually in children, and has benign clinical courses. Here we report a case of pleural effusion with ascites which occurred in an adult hepatitis A patient. A 26-year-old-woman presented generalized myalgia and fever and was diagnosed as acute hepatitis A. Despite of the improvement of laboratory findings, fever and cough persisted. Pleural effusion newly appeared on the serial chest radiologic images. After the fever settled down, the pleural effusion resolved spontaneously at 13th day of admission.

Fulminant Hepatic Failure with Hepatitis B Virus Reactivation after Rituximab Treatment in a Patient with Resolved Hepatitis B / 대한소화기학회지

It is well known that the reactivation of hepatitis B virus (HBV) may occur as an acute hepatitis after chemotherapy or immunosuppressive therapy. Although most of these cases have been reported in HBsAg-positive patients, there have been a few reports of HBV reactivation in HBsAg-negative patients. There have been concerns for the need to screen the reactivation as well as anti-viral prophylaxis in HBsAg-negative patients with possible HBV occult infection who are planning to undergo chemotherapy or immunosuppressive therapy. Rituximab, an anti-CD20 monoclonal antibody, is effective in the treatment of non-Hodgkin's lymphoma. However, rituximab can affect the immunity against HBV, consequently increasing viral replication. In fact, there have been reports of HBV reactivation after treatment with rituximab. Here, we report a case of HBV reactivation following rituximab plus systemic chemotherapy in diffuse large B cell lymphoma patient who was HBsAg negative, anti-HBs positive, and anti-HBc positive, ultimately leading to treatment-unresponsive fulminant hepatic failure.

Comparison of various noninvasive serum markers of liver fibrosis in chronic viral liver disease / 대한간학회지

BACKGROUND/AIMS: The aim of this study was to determine the clinical performances of noninvasive serum markers for the prediction of liver fibrosis in chronic viral liver diseases. METHODS: We analyzed a total of 225 patients with chronic viral liver diseases (180 with hepatitis B virus, 43 with hepatitis C virus, and 2 with hepatitis B+C virus) who underwent a liver biopsy procedure at the Hanyang University Guri Hospital between March 2002 and February 2007. Serum was also obtained at the time of liver biopsy. Liver fibrosis was staged according to the scoring system proposed by the Korean Study Group for the Pathology of Digestive Diseases. Various noninvasive serum markers were evaluated, including the aspartate aminotransferase (AST)/alanine aminotransferase (ALT) ratio (AAR), age-platelet (AP) index, AST/platelet ratio index (APRI), cirrhosis discriminant score (CDS), platelet count, hyaluronic acid (HA), and type IV collagen. RESULTS: There were 17, 40, 61, 74, and 33 patients at stages F0, F1, F2, F3, and F4, respectively. The overall diagnostic accuracies of each marker, as determined by the area under receiver operating characteristics curves, were APRI=0.822, CDS=0.776, platelet count=0.773, AP index=0.756, HA=0.749, type IV collagen=0.718, and AAR=0.642 for predicting significant fibrosis (> or =F2); and CDS=0.835, platelet count=0.795, AP index=0.794, HA=0.766, AAR=0.711, type IV collagen=0.697, and APRI=0.691 for predicting extensive fibrosis (> or =F3). CONCLUSIONS: All noninvasive serum markers evaluated in this study were useful for predicting significant or extensive liver fibrosis in chronic viral liver diseases. In particular, APRI was most useful for the prediction of significant fibrosis, and CDS was most useful for the prediction of extensive fibrosis.

The Incidence of Minor Complications and Patients' Time Requirements for Colonoscopy / 대한소화기내시경학회지

BACKGROUND/AIMS: Colonoscopy is an important method to screen for colorectal neoplasm and it is known to be a relatively safe procedure. Yet various minor complications, such as abdominal pain or discomfort, may result from colonoscopy or from additional colonoscopic procedures. In this study, we estimated the incidence of minor complications, the related risk factors and the total time requirement for colonoscopy. METHODS: We conducted a prospective analysis from 201 patients who visited Hanyang University Guri Hospital for colonoscopy during February to April, 2008. On the first day after colonoscopy, we asked the patients about the length of personal time devoted to the colonoscopy, such as the time taken for bowel preparation. We contacted all the patients by telephone 3 days after colonoscopy and we asked about any minor complications after colonoscopy, what was the most difficult part of the procedure and the time it took to get back to normal activity. RESULTS: Minor complications occurred in 66 patients (32.8%), of which abdominal discomfort was the most common complaint (74.2%). The incidence of minor complications was increased significantly in proportion to the procedure time (p<0.0001). Bowel preparation was the most difficult part of the procedure for patients (88.0%). The mean duration of colonoscopy was 20 minutes, while the entire time allotted for colonoscopy from bowel preparation to arriving home was an average of 8.24 hours. The mean recovery time to normal activity was 19.02 hours. CONCLUSIONS: Minor complications are relatively common when undergoing colonoscopy, and the duration of the procedure is significantly related to the incidence of minor complications. The majority of patients have difficulty with bowel preparation, so further studies concerning the development of a comfortable and effective preparation method are needed.

Comparison of the Effectiveness of Interventional Endoscopy in Bleeding Peptic Ulcer Disease according to the Timing of Endoscopy

BACKGROUND/AIMS: The optimal timing for interventional endoscopy in bleeding peptic ulcer disease is controversial. This study compared the outcomes between early endoscopy and delayed endoscopy in patients with bleeding peptic ulcer disease. METHODS: We conducted a prospective analysis of data from 90 patients with bleeding peptic ulcer disease who visited the emergency room between May 2006 and September 2007. Patients were categorized into two groups: the early-endoscopy group (admitted during the daytime or at night with prompt endoscopic management) and the delayed-endoscopy group (admitted at night or during weekends, with endoscopic management delayed until the next day). We compared the clinical outcomes of endoscopy between the two groups. RESULTS: There were 49 patients in the early-endoscopy group and 41 patients in the delayed-endoscopy group. Patient demographics, clinical characteristics, bleeding control modality, and Rockall score did not differ between the two groups. There were also no significant differences between the early- and delayed-endoscopy groups in the re-bleeding rate (3/49 vs 5/41, p=0.313), the duration of hospital stay (10.7 vs 9.3 days, p=0.437), and the total amount of blood transfused (3.4 vs 2.7 units, p=0.240). CONCLUSIONS: The effectiveness of interventional endoscopy for patients with bleeding peptic ulcer disease is not significantly affected by the timing of endoscopy.

The Colonoscopic Withdrawal Time is Correlated with the Rate of Detecting Polyps When Performing Colonoscopy / 대한소화기내시경학회지

BACKGROUND/AIMS: The colonoscopic withdrawal time has been proposed as a quality indicator for colonoscopy, and this is based on the recent evidence that the Colon withdrawal time is associated with adenoma detection rate. In this study, we examined the difference of the polyp detection rates between practicing endoscopists, and we analysed certain factors that might lead to such differences, and particularly the colonoscopic withdrawal time. METHODS: We retrospectively evaluated the colonoscopic procedures that were performed by 7 second-year GI fellows at Hanyang University Guri Hospital. A total of 1,515 colonoscopies were assessed for the polyp detection rate, the insertion time, the withdrawal time, bowel preparation, the size of the detected polyps and the location of polyps. RESULTS: The median withdrawal time for the case with no polyps removed was 3.6 to 7.1 minutes. There was a strong positive correlation between the colonoscopic withdrawal times and the polyp detection rates (p<0.001). Furthermore, a longer withdrawal time resulted in discovering a higher percentage of small polyps. On comparing groups, the group of colonoscopists with a withdrawal time longer than 6 minutes had a higher rate of detecting polyps (30.7% vs 18.4%, p<0.001). CONCLUSIONS: There is wide range of polyp detection rates among practicing colonoscopists and there is strong positive correlation between the colonoscopic withdrawal times and the rate of detecting polyps. A long enough withdrawal time, perhaps 7 minutes, is needed to raise the rate of detecting polyps during colonoscopy.