Postoperative Clinical Outcomes of Colonic Stent Placement as Bridge-to-surgery vs. Emergency Surgery in Left-sided Malignant Colonic Obstruction / 대한소화기암학회지

Background/Aims@#Colonic stenting as a bridge to elective surgery is an alternative for emergency surgery in patients with acute malignant colonic obstruction. However, since its benefits are uncertain, we aimed to establish whether it has better clinical outcomes. @*Methods@#The patients with acute malignant left-sided colon obstruction enrolled from January 2009 to December 2018 in National Health Insurance Service Ilsan Hospital. The patients were enrolled to undergo colonic stenting as a bridge to elective surgery or emergency surgery. The following oncological outcomes were assessed: incidence of complete remission, disease progression, local recurrence, and systemic recurrence. @*Results@#Out of 40 patients, 33 received self-expanding metallic stent (SEMS) as a bridge-tosurgery, and 7 underwent emergency surgery. More stoma was made in case of emergency surgery with statistical significance (p < 0.001). There were no significant differences in complete remission rate in curable left-sided malignant colonic obstruction between SEMS as a bridgeto-surgery and emergency surgery. Complete remission was achieved for 3 patients (42.9%) in the non-stent group and 27 patients (81.8%) in the stent group. There was no statistically significant difference in oncologic outcomes between the two groups (p = 0.069). According to multi-variate analysis, advanced TNM stage, Adjuvant chemotherapy, and SEMS bridge-tosurgery were significantly associated with disease-free survival. Disease-free survival rate differed significantly between the two groups (p = 0.024). @*Conclusions@#SEMS as a bridge-to-surgery might be an effective strategy and reduce stoma formation in acute malignant left-sided colon obstruction.

Risk for metabolic syndrome in the population with visceral fat area measured by bioelectrical impedance analysis

Background/Aims@#To investigate whether visceral fat area (VFA) measured by bioelectric impedance analysis (BIA) was associated with metabolic syndrome in subjects with and without obesity. @*Methods@#A total 23,202 participants who underwent medical check-ups were assessed. Participants were stratified by body mass index (BMI) and VFA. We evaluated six different groups for metabolic syndrome: Group 1 (normal weight and low VFA), Group 2 (normal weight and high VFA), Group 3 (overweight and low VFA), Group 4 (overweight and high VFA), Group 5 (obesity and low VFA), and Group 6 (obesity and high VFA). @*Results@#Metabolic syndrome traits and metabolic syndrome were significantly more prevalent in the high-VFA (≥ 100 cm2 ) subgroup in each BMI group. Adjusted logistic regression analyses revealed that the odds ratio for metabolic syndrome compared with Group 1 was the highest in Group 6 (24.53; 95% confidence interval [CI], 21.77 to 27.64). Notably, the odds ratio of Group 2 was higher than that of Group 3 (2.92; 95% CI, 2.30 to 3.69 vs. 2.57; 95% CI, 2.23 to 2.97). @*Conclusions@#Our study demonstrates that the combination of BMI assessment and VFA determination by BIA may be a useful method for predicting the risk of metabolic syndrome. The VFA by BIA may be a useful target for interventions to improve metabolic syndrome.

Multidisciplinary and Multisociety Practice Guideline on Reprocessing Flexible Gastrointestinal Endoscopes and Endoscopic Accessories

The area of endoscopic application has been continuously expanded since its introduction in the last century and the frequency of its use also increased stiffly in the last decades. Because gastrointestinal endoscopy is naturally exposed to diseased internal organs and contact with pathogenic materials, endoscopy mediated infection or disease transmission becomes a major concern in this field. Gastrointestinal endoscopy is not for single use and the proper reprocessing process is a critical factor for safe and reliable endoscopy procedures. What needed in these circumstances is a practical guideline for reprocessing the endoscope and its accessories which is feasible in the real clinical field to guarantee acceptable prevention of pathogen transmission. This guideline contains principles and instructions of the reprocessing procedure according to the step by step. And it newly includes general information and updated knowledge about endoscopy-mediated infection and disinfection. Multiple societies and working groups participated to revise; Korean Association for the Study of the Liver, the Korean Society of Infectious Diseases, Korean College of Helicobacter and Upper Gastrointestinal Research, the Korean Society of Gastroenterology, Korean Society of Gastrointestinal Cancer, Korean Association for the Study of Intestinal Diseases, Korean Pancreatobiliary Association, the Korean Society of Gastrointestinal Endoscopy Nurses and Associates and Korean Society of Gastrointestinal Endoscopy. Through this cooperation, we enhanced communication and established a better concordance. We still need more researches in this field and fill up the unproven area. And our guidelines will be renewed accordingly.

A Case of a Bleeding Duodenal Lipoma Successfully Controlled by Endoscopic Resection

This is a case report of successful endoscopic resection (ER) of a bleeding duodenal lipoma. An 85-year-old woman who was diagnosed with asymptomatic subepithelial tumor of the duodenum 3 years ago visited the emergency room with hematemesis and was admitted to our hospital. Emergent esophagogastroduodenoscopy revealed bleeding from an ulcer on the superior aspect of a subepithelial tumor measuring about 20 mm in diameter, at the superior duodenal angle. The ulcer was in the active stage (A1), with a visible vessel. The bleeding was controlled by ER of the tumor using a snare. The final pathological diagnosis was duodenal lipoma with mucosal ulceration. The patient showed no signs of bleeding for 10 days after the procedure; subsequently, she was discharged and followed up for regular checkups.

Covered Self-expandable Metallic Stent Insertion as a Rescue Procedure for Postoperative Leakage after Primary Repair of Perforated Duodenal Ulcer / 대한소화기학회지

Surgery has been the standard treatment for perforated duodenal ulcers, with mostly good results. However, the resolution of postoperative leakage after primary repair of perforated duodenal ulcer remains challenging. There are several choices for re-operation required in persistent leakage from perforated duodenal ulcers. However, many of these choices are complicated surgical procedures requiring prolonged general anesthesia that may increase the chances of morbidity and mortality. Several recent reports have demonstrated postoperative leakage after primary repair of a perforated duodenal ulcer treated with endoscopic insertion using a covered self-expandable metallic stent, with good clinical results. We report a case with postoperative leakage after primary repair of a perforated duodenal ulcer treated using a covered self-expandable metallic stent.

Real World Experience of Telbivudine Versus Entecavir in Patients with Chronic Hepatitis B, Including Long-Term Outcomes after Treatment Modification

PURPOSE: To estimate long-term outcomes after treatment modification in patients with chronic hepatitis B (CHB) treated with entecavir (ETV) and telbivudine (LdT). MATERIALS AND METHODS: The study enrolled 131 nucleos(t)ide analogue (NA)-naïve CHB patients treated with ETV or LdT. During the 3-year study, NA treatment history including the incidence, the type of treatment modification, reasons for the modification, and overall complete virologic response (CVR) rate were retrospectively evaluated using the patients' medical records. RESULTS: Among the 131 patients, 84 and 47 were initially treated with ETV and LdT, respectively. During the course of 3-year study, 82 patients in the ETV group (97.6%) maintained initial treatment whereas only 19 in the LdT group (40.4%). In the LdT group, 26 patients (92.9%) switched to another NA and another NA was added in 2 (7.1%) patients. An assessment of the CVR rate at 3 years, including treatment modification, showed that 89.3% and 95.7% of patients in the ETV and LdT groups, respectively, had undetectable serum hepatitis B virus DNA levels (p=0.329). Among LdT patients with treatment modification, the cumulative incidence rate of a CVR for rescue therapy was significantly higher in the tenofovir than in the ETV group (p=0.009). CONCLUSION: During the 3-year study, there were no significant differences in the CVR between the ETV and LdT groups if appropriate rescue therapy was considered.

Two Cases of Humoral Hypercalcemia of Malignancy in Metastatic Cholangiocarcinoma / Journal of the Korean Cancer Association, 대한암학회지

Humoral hypercalcemia of malignancy (HHM) is rarely associated with cholangiocarcinoma (CC), and represents dismal prognosis. A 63-year-old male was admitted for evaluation of an intrahepatic mass. He was diagnosed with HHM associated with locally advanced CC. As the tumor responded to the concurrent chemoradiotherapy with capecitabine and cisplatin, serum calcium level was normalized. However, according to the disease progression, he suffered recurrence of HHM and he expired approximately one year after initial diagnosis. A 68-year-old male who presented with abdominal pain was diagnosed with metastatic CC. After the eighth cycle of gemcitabine and cisplatin, progression of the disease was found with HHM. He was treated with the best supportive care, until his demise approximately one month after the diagnosis of HHM. We report on two cases of HHM associated with CC that demonstrate strong correlation between hypercalcemia and disease burden.

Recurrent Acute Pericarditis Induced by 5-aminosalicylates in a Patient with Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is an idiopathic chronic inflammation of the intestines. IBD treatment may require anti-inflammatory agents such as sulfasalazine or 5-aminosalicylate (5-ASA) and immunomodulators to control the symptoms. However, these agents have a variety of common adverse effects such as nausea, vomiting, skin rash, leukopenia, thrombocytopenia, and infections. Moreover, rare side effects such as nephrotic syndrome, pneumonitis, and pericarditis can occur. A 21-year-old male was admitted to the hospital due to acute chest pain, fever, and sweating. The patient had a history of Crohn's disease and had been taking mesalazine for 3 weeks. Chest x-ray, echocardiography, and clinical manifestations revealed that the patient had acute pericarditis. However, we did not recognize the relationship between these findings and 5-ASA at that time. Two years later, the patient took 5-ASA again, and similar symptoms occurred, which led us to confirm that he suffered from pericarditis induced by this drug. We report a case of acute recurrent pericarditis that developed after taking 5-ASA for IBD treatment with a review of the literature.

A Case of Miller Fisher Syndrome in a Patient with Systemic Lupus Erythematosus / 대한내과학회지

Neuropsychiatric events are common in patients with systemic lupus erythematosus (SLE). The estimated incidence of neuropsychiatric SLE (NPSLE) is 30 to 40%. However, NPSLE poses a difficult diagnostic challenge because a variety of conditions should be considered in the differential diagnosis, especially when patients present with uncommon or rare NPSLE features. We herein describe a 49-year-old man with SLE who initially presented with diplopia, ptosis, and gait disturbance that had developed 1 week after an upper respiratory tract infection. He was finally diagnosed with Miller Fisher syndrome (a variant of Guillain-Barre syndrome) according to clinical symptoms, anti-GQ1b antibody positivity, and neurological study results. The patient recovered without sequelae with intravenous immunoglobulin therapy. This is the first report to describe a case of Miller Fisher syndrome that developed in a patient with SLE in Korea and suggests that Miller Fisher syndrome should be included as a differential diagnosis of NPSLE.

A Case of Henoch Schonlein Purpura with Gastrointestinal Bleeding Due to Jejunal Ulcer by Capsule Endoscopy / 고신대학교의과대학학술지

Henoch-Schonlein purpura (HSP) is the most common form of systemic vasculitis in children. Palpable purpura, arthralgia, arthritis, abdominal pain and renal involvement are the major clinical manifestations. Gastrointestinal involvement is related with abdominal pain and bleeding. We described a 71 year-old female experienced acute exacerbation of HSP presented with gastrointestinal bleeding. She was hospitalized for hematemesis and diagnosed duodenitis by esophagogastroduonenoscopy (EGD). Duodenitis was improved at EGD checked in 7 days. She still complained of melena and abdominal pain. There were no abnormal findings at sigmoidoscopy. Jejunal ulcer and purpura were diagnosed by capsule endoscopy. Symptoms were relieved after administration of systemic steroid. But she needed renal replacement therapy for 3 months. Small bowel ulcer diagnosed by capsule endoscopy in patients with HSP was rarely described in Korean literature. This case suggests that capsule endoscopy have a role in diagnosis of small bowel ulcer and its severity in HSP with gastrointestinal symptom.

Colchicine Ameliorates High Glucose-Induced ICAM-1 and Fibronectin Expression in Renal Cells via Inhibiting Locally-Produced Angiotensin II / 대한신장학회지

PURPOSE: A previous study has demonstrated that colchicine abrogated intercellular adhesion molecule (ICAM)-1 and fibronectin expression in renal cells exposed to high glucose media, but the underlying mechanism was not clarified. This study was undertaken to elucidate whether it was attributed to the inhibitory effect of colchicine on locally-produced angiotensin II (AII) under diabetic conditions. METHODS: Rat mesangial cells and NRK-52E cells were cultured in media containing 5.6 mM glucose (NG), NG+10(-7) M AII (NG+AII), or 30 mM glucose (HG) with or without 10(-8) M colchicine (Col) and/or 10(-6) M L-158,809, an AII type 1 receptor blocker (ARB). ICAM-1 and fibronectin mRNA and protein expressions were determined by real-time PCR (RT-PCR) and Western blot, respectively. AII levels in conditioned media were determined by ELISA. RESULTS: AII levels in conditioned media were significantly higher in HG-stimulated mesangial cells and NRK-52E cells compared to NG cells (p<0.05). ICAM-1 and fibronectin mRNA and protein expression were significantly increased in renal cells exposed to HG media (p<0.05 or p<0.01), and these increases were significantly ameliorated by colchicine or ARB treatment (p<0.05). Colchicine and ARB also significantly attenuated AII-induced ICAM-1 and fibronectin expression (p<0.05). However, there was no additive inhibitory effect of colchicine and ARB on the increases in ICAM-1 and fibronectin expression. CONCLUSION: Colchicine abrogated increased ICAM-1 and fibronectin expression in renal cells under diabetic conditions, which is partly mediated by inhibiting HG-induced locally-produced AII. These findings provide a new renoprotective mechanism of colchicine in diabetic nephropathy in addition to its impact on leukocyte functions.

Acute Esophageal Necrosis Associated with Esophageal Foreign Body Injury and the Development of Pneumomediastinum

A 74-year-old woman complained of dysphagia and hemoptysis after ingesting a fragment of crab shell while eating crab salted-fermented fish products, and presented dyspnea that had lasted for three days. Computed tomography indicated pneumomediastinum. Laboratory results revealed acute renal failure. The patient experienced respiratory distress and shock over the days following her initial presentation. Upper gastrointestinal endoscopy revealed black pigmentation of the esophageal mucosa from the middle to lower esophagus. Despite intensive care, the patient's condition deteriorated and she died. This is the first case of acute esophageal necrosis associated with esophageal foreign body injury and the development of pneumomediastinum reported in Korea.