The Prevalence and Clinical Features of Non-responsive Gastroesophageal Reflux Disease to Practical Proton Pump Inhibitor Dose in Korea: A Multicenter Study / 대한소화기학회지

BACKGROUND/AIMS: In Korea, there are no available multicenter data concerning the prevalence of or diagnostic approaches for non-responsive gastroesophageal reflux disease (GERD) which does not respond to practical dose of proton pump inhibitor (PPI) in Korea. The purpose of this study is to evaluate the prevalence and the symptom pattern of non-responsive GERD. METHODS: A total of 12 hospitals who were members of a Korean GERD research group joined this study. We used the composite score (CS) as a reflux symptom scale which is a standardized questionnaire based on the frequency and severity of typical symptoms of GERD. We defined "non-responsive GERD" as follows: a subject with the erosive reflux disease (ERD) whose CS was not decreased by at least 50% after standard-dose PPIs for 8 weeks or a subject with non-erosive reflux disease (NERD) whose CS was not decreased by at least 50% after half-dose PPIs for 4 weeks. RESULTS: A total of 234 subjects were analyzed. Among them, 87 and 147 were confirmed to have ERD and NERD, respectively. The prevalence of non-responsive GERD was 26.9% (63/234). The rates of non-responsive GERD were not different between the ERD and NERD groups (25.3% vs. 27.9%, respectively, p=0.664). There were no differences between the non-responsive GERD and responsive GERD groups for sex (p=0.659), age (p=0.134), or BMI (p=0.209). However, the initial CS for epigastric pain and fullness were higher in the non-responsive GERD group (p=0.044, p=0.014, respectively). CONCLUSIONS: In conclusion, this multicenter Korean study showed that the rate of non-responsive GERD was substantially high up to 26%. In addition, the patients with the non-responsive GERD frequently showed dyspeptic symptoms such as epigastric pain and fullness.

Esophageal Squamous Cell Carcinoma Patients Have an Increased Risk of Coexisting Colorectal Neoplasms

BACKGROUND/AIMS: Esophageal squamous cell carcinoma (ESCC) and colorectal neoplasms (CRNs) share risk factors. We aimed to investigate whether the CRN risk is increased in ESCC patients. METHODS: ESCC patients who underwent a colonoscopy within 1 year of diagnosis were retrospectively analyzed. Patients were matched 1:3 by age, gender, and body mass index to asymptomatic controls. CRN was defined as the histological confirmation of adenoma or adenocarcinoma. Advanced CRN was defined as any of the following: > or =3 adenomas, high-grade dysplasia, villous features, tumor > or =1 cm, or adenocarcinoma. The risk factors for both CRN and advanced CRN were evaluated by univariate and multivariate analyses. RESULTS: Sixty ESCC patients were compared with 180 controls. The ESCC group had significantly higher numbers of CRNs (odds ratio [OR], 2.311; 95% confidence interval [CI], 1.265 to 4.220; p=0.006) and advanced CRNs (OR, 2.317; 95% CI, 1.185 to 4.530; p=0.013). Significant risk factors for both CRN and advanced CRN by multivariate analysis included ESCC (OR, 2.157, 95% CI, 1.106 to 4.070, p=0.024; and OR, 2.157, 95% CI, 1.045 to 4.454, p=0.038, respectively) and older age (OR, 1.068, 95% CI, 1.032 to 1.106, p<0.001; and OR, 1.065, 95% CI, 1.024 to 1.109, p=0.002, respectively). CONCLUSIONS: The rates of CRN and advanced CRN are significantly increased in ESCC. Colonos-copy should be considered at ESCC diagnosis.

Is the Impedance Baseline Helpful in the Evaluation of Globus Patients?

BACKGROUND/AIMS: Gastroesophageal reflux disease (GERD) has been suggested to be responsible for 23-68% of globus cases. The impedance baseline (IB) acquired by 24-hour multichannel intraluminal impedance monitoring has been proven to represent esophageal mucosal integrity. We aimed to investigate whether the IB is helpful for evaluating globus patients. METHODS: Twenty-four-hour multichannel intraluminal impedance pH tracings (MII-pH) were evaluated in globus patients. Differences in the IB between the acid reflux, non-acid reflux, and no reflux groups were analyzed. Receiver operating characteristic (ROC) curves were obtained to determine the optimal measurement point from the lower esophageal sphincter (LES). RESULTS: A total of 62 patients were analyzed. MII-pH showed that acid reflux, non-acid reflux, and no reflux were present in 13, 5, and 44 patients, respectively. The acid reflux group had a significantly lower IB than the other groups at a location 3 cm from the LES. ROC curve analysis revealed that placement at a position 3 cm from the LES resulted in moderate diagnostic accuracy (area under the curve = 0.88). When we set 2500 Omega as the cut-off value for acid reflux at a position 3 cm from the LES, the additional diagnostic yield for acid reflux was increased by 19.4% compared with that obtained by MII-pH. CONCLUSIONS: IB is complementary to pH findings enabling identification of a subset of patients with co-existing acid reflux. Catheter placement at a location 3 cm from the LES and a cut-off value of 2500 Omega may be reasonable criteria for estimating acid reflux.

Retraction Notice to "Endoscopic Resection for Rectal Carcinoid Tumors: Comparision of Polypectomy and Endoscopic Submucosal Resection with Band Ligation"

This retracts the below mentioned article upon the authors' request.

Feasibility of Planned Endoscopic Submucosal Dissection with Snaring for Gastric Adenoma Compared with Standard Endoscopic Submucosal Dissection

BACKGROUND/AIMS: Planned endoscopic submucosal dissection with snaring (ESD-S) is thought to shorten operating time spent on submucosal dissection, but may lead to uncertainty of en bloc resection or to a possible increase in tumor-positive margins. The purpose of the present study is to investigate the feasibility of ESD-S as a planned procedure for gastric adenoma. MATERIALS AND METHODS: The medical records of 99 patients who underwent ESD-S or ESD for gastric adenoma between May 2011 and May 2012 were retrospectively reviewed. We analyzed the differences between the ESD-S and the ESD groups, focusing on rates of en bloc resection and pathologic complete resection, mean operation time, and complications. RESULTS: The mean operation time was significantly lower in the ESD-S group than in the ESD group (19.9+/-11.2 vs. 33.8+/-19.9, P=0.012). Cases with an operation time under 30 minutes were more frequent in the ESD-S group (88.9% vs. 48.1%, OR=8.615, 95% CI=2.949~25.168). There were no significant differences in en bloc resection, histologic complete resection, or complication rates between the two groups. CONCLUSIONS: ESD-S has a time advantage over ESD with a comparable compete resection rate. ESD-S can be considered a planned method for available early gastric adenoma.

Analysis of Risk Factors for Early Tube Exchange in Percutaneous Endoscopic Gastrostomy

BACKGROUND/AIMS: Percutaneous endoscopic gastrostomy (PEG) is a widely-performed procedure for patients undergoing enteral feeding. Due to frequent complications, careful management after the PEG is required. In this study, we investigated the risk factors associated with early exchange of PEG tube. MATERIALS AND METHODS: We did a retrospective survey of 72 patients who received a PEG between January 2009 and April 2014. All patients underwent a tube exchange or removal after the first PEG. Patients who had an exchange within 6 months were defined as 'early exchange' group and the others, as 'late exchange' group. We analyzed the relationship between early exchange and pre-PEG status. RESULTS: Mean age of patients was 67.5+/-18.3 years. The most frequent mental status and performance status before the first procedure, was 'alert' (n=48, 66.7%) and Eastern Cooperative Oncology Group (ECOG) score was 4 (n=28, 39.8%). Mean BMI was 20.2+/-3.7 kg/m2 and the majority of PEG cause was cerebrovascular accidents (n=23, 31.9%). Many patients had a tube exchange (or removal) because of tube dysfunction (n=32, 44.4%). The 'early exchange' group showed a lower BMI than 'late exchange' group (19.7+/-3.57 kg/m2 vs. 22.4+/-3.87 kg/m2, P value 0.009). 'Underweight' (BMI less than 18.5 kg/m2) group was more frequently observed in 'early exchange' group. There was no significant difference in pre-PEG status and post-PEG complication between the 2 groups. CONCLUSIONS: A lower BMI was associated with early exchange of PEG. Health providers should pay attention to the nutritional status of PEG patients.

The Relationship between Gastroesophageal Reflux Disease and Chronic Periodontitis

BACKGROUND/AIMS: The most common cause of chronic periodontitis is poor oral hygiene. Gastroesophageal reflux disease (GERD) enhances the proximal migration of gastric contents and may cause poor oral hygiene. We hypothesized that GERD may increase thse risk of chronic periodontitis and investigated this potential relationship. METHODS: A retrospective cross-sectional study was conducted in outpatients between January 1, 2010, and April 30, 2012. GERD was defined as being present based on at least two of the following criteria: etiologic agent(s), identifiable signs and symptoms, and consistent anatomic alterations. A total of 280 patients with chronic periodontitis and 280 controls were analyzed. Information regarding patient demographics and other potential confounding factors for chronic periodontitis were collected through individual medical records. RESULTS: GERD was revealed to be independently associated with an increased incidence of chronic periodontitis (odds ratio [OR], 2.883; 95% confidence interval [CI], 1.775 to 4.682). The other three variables of dental caries (OR, 1.531; 95% CI, 1.042 to 2.249), tobacco use (OR, 2.335; 95% CI, 1.461 to 3.730), and history of medication (calcium channel blocker, cyclosporine, or phenytoin) (OR, 2.114; 95% CI, 1.160 to 3.854) were also determined to be independent risk factors. CONCLUSIONS: The present study supported our hypothesis that GERD can be a risk factor for chronic periodontitis.

Observer Variability in Gastric Neoplasm Assessment Using the Vessel Plus Surface Classification for Magnifying Endoscopy with Narrow Band Imaging

BACKGROUND/AIMS: Recent studies have demonstrated that magnifying endoscopy with narrow band imaging (ME-NBI) facilitates differentiation of early gastric cancer from gastric adenoma using vessel plus surface (VS) classification. This study estimated the interobserver and intraobserver agreement of endoscopists using the Yao VS classification system for the gastric mucosal surface. METHODS: We retrospectively reviewed patients who underwent endoscopic submucosal dissection or endoscopic mucosal resection, and selected cases in which preoperative ME-NBI was conducted. Before testing endoscopists, a 20-minute training module was given. Static ME-NBI images (n=47 cases) were presented to seven endoscopists (two experts and five trainees) who were asked to assess the images in 20 seconds using the Yao VS classification system. After 2 weeks, the endoscopists were asked to analyze the images again. The kappa statistic was calculated for intraobserver and interobserver variability. RESULTS: The mean kappa for intraobserver agreement was 0.69 (experts, 0.74; trainees, 0.64). The mean kappa for interobserver agreement was 0.42 (experts, 0.49; trainees, 0.40). CONCLUSIONS: We obtained reliable results as assessed by observer variability, with only brief training on VS classification. The VS classification appears to provide an objective assessment of ME-NBI for trainees who are not familiar with ME-NBI.

Utilizing Intrabolus Pressure and Esophagogastric Junction Pressure to Predict Transit in Patients With Dysphagia

BACKGROUND/AIMS: High-resolution manometry (HRM), with a greatly increased number of recording sites and decreased spacing between sites, allows evaluation of the dynamic simultaneous relationship between intrabolus pressure (IBP) and esophagogastric junction (EGJ) relaxation pressure. We hypothesized that bolus transit may occur when IBP overcomes integrated relaxation pressure (IRP) and analyzed the relationships between peristalsis pattern and the discrepancy between IBP and IRP in patients with dysphagia. METHODS: Twenty-two dysphagia patients with normal EGJ relaxation were examined with a 36-channel HRM assembly. Each of the 10 examinations was performed with 20 and 30 mmHg pressure topography isobaric contours, and findings were categorized based on the Chicago classification. We analyzed the relationships between peristalsis pattern and the discrepancy between IBP and IRP. RESULTS: Twenty-two patients were classified by the Chicago classification: 1 patient with normal EGJ relaxation and normal peristalsis, 8 patients with intermittent hypotensive peristalsis and 13 patients with frequent hypotensive peristalsis. A total of 220 individual swallows were analyzed. There were no statistically significant relationships between peristalsis pattern and the discrepancy between IBP and IRP on the 20 or 30 mmHg isobaric contours. CONCLUSIONS: Peristalsis pattern was not associated with bolus transit in patients with dysphagia. However, further controlled studies are needed to evaluate the relationship between bolus transit and peristalsis pattern using HRM with impedance.

Extremely High Panesophageal Pressurization in Type II Achalasia

No abstract available.

Characteristics of Clinical Features between Isolated Left Side Ischemic Colitis and Non-Isolated Left Side Ischemic Colitis / 고신대학교의과대학학술지

OBJECTIVES: Compared with all other patterns, isolated right colon ischemia has been found to be more associated with coronary artery disease and a poor prognosis. However, there has been no research on comparing isolated left side ischemic colitis (ILIC) and non-ILIC with vascular assessment. The aim of the present study was to evaluate the clinical and laboratory findings between these two different forms of ischemic colitis (IC). METHODS: We retrospectively investigated differences in clinical features, course, and mesenteric vascular (superior mesenteric artery, SMA; inferior mesenteric artery, IMA) findings between ILIC and non-ILIC patients who were hospitalized at Kosin University Gospel Hospital from 2004 to 2010. RESULTS: Our study population comprised 221 patients, all of whom met our entry criteria of biopsy-proven or -compatible IC. Of the 221 patients, 46 (20.8%) had non-ILIC. Congestive heart failure and hypercholesterolemia were more frequently observed in the non-ILIC group (P = 0.003 and P = 0.020, respectively). SMA atherosclerosis and SMA stenosis were more frequently observed in the non-ILIC group (P = 0.006 and P = 0.001, respectively). Recovery periods were longer in the non-ILIC group (P = 0.039), and mortality was lower in the ILIC group (6.9% vs. 17.3%, P = 0.026). CONCLUSIONS: ILIC has favorable outcomes compared with non-ILIC. Furthermore, non-ILIC showed a close relationship with SMA atherosclerosis and SMA stenosis, which should be investigated carefully in the clinical field.

Four Endoscopic Predictors of Carcinoma as a Final Diagnosis after Endoscopic Resection of Forceps Biopsy-proven Gastric Adenomas

BACKGROUND/AIMS: Previous studies have reported that the frequency of re-diagnosing as carcinoma after endoscopic resection of gastric adenoma ranges between 6% and 47%. Therefore, specific endoscopic findings have been used to predict re-diagnosing as carcinoma after endoscopic resection of gastric adenoma at our center. We evaluated whether there is a use for these indicators for predicting carcinoma as a final diagnosis in forceps biopsy-proven adenomas. MATERIALS AND METHODS: We investigated 378 tissue samples from 308 patients. Classification of specimens as adenoma and carcinoma was based on postresection specimen. Endoscopic findings were reviewed for tumor location, size, gross appearance, surface nodularity, central concavity, surface color, and presence of ulcers. These variables were analyzed and compared between the adenoma group (275 cases) and the carcinoma group (103 cases), assigned based on post-resection diagnosis. RESULTS: The mean patient age was 61, and 227 of the patients were male. The mean lesion diameter was 14.9+/-8.1 mm in the adenoma group and 17.9+/-9.3 mm in the carcinoma group. A lesion size of 15 mm or greater, depressed appearance, surface nodularity, central concavity, and presence of high-grade dysplasia were all independently associated with re-diagnosing as carcinoma after endoscopic resection. CONCLUSIONS: Lesion size of 15 mm or greater, depressed-type appearance, central concavity, and nodular surface are feasible predictors of carcinoma as a final diagnosis in forceps biopsy-proven adenomas. Physicians need to recommend immediate endoscopic resection for forceps biopsy-proven adenomas with these four independent features so as not to miss the optimal window for treatment.

Four Endoscopic Predictors of Carcinoma as a Final Diagnosis after Endoscopic Resection of Forceps Biopsy-proven Gastric Adenomas

BACKGROUND/AIMS: Previous studies have reported that the frequency of re-diagnosing as carcinoma after endoscopic resection of gastric adenoma ranges between 6% and 47%. Therefore, specific endoscopic findings have been used to predict re-diagnosing as carcinoma after endoscopic resection of gastric adenoma at our center. We evaluated whether there is a use for these indicators for predicting carcinoma as a final diagnosis in forceps biopsy-proven adenomas. MATERIALS AND METHODS: We investigated 378 tissue samples from 308 patients. Classification of specimens as adenoma and carcinoma was based on postresection specimen. Endoscopic findings were reviewed for tumor location, size, gross appearance, surface nodularity, central concavity, surface color, and presence of ulcers. These variables were analyzed and compared between the adenoma group (275 cases) and the carcinoma group (103 cases), assigned based on post-resection diagnosis. RESULTS: The mean patient age was 61, and 227 of the patients were male. The mean lesion diameter was 14.9+/-8.1 mm in the adenoma group and 17.9+/-9.3 mm in the carcinoma group. A lesion size of 15 mm or greater, depressed appearance, surface nodularity, central concavity, and presence of high-grade dysplasia were all independently associated with re-diagnosing as carcinoma after endoscopic resection. CONCLUSIONS: Lesion size of 15 mm or greater, depressed-type appearance, central concavity, and nodular surface are feasible predictors of carcinoma as a final diagnosis in forceps biopsy-proven adenomas. Physicians need to recommend immediate endoscopic resection for forceps biopsy-proven adenomas with these four independent features so as not to miss the optimal window for treatment.

A Rare Case of Free Bowel Perforation Associated with Infliximab Treatment for Stricturing Crohn's Disease / 대한소화기학회지

Crohn's disease is characterized by chronic transmural inflammation of the bowel and is associated with serious complications, such as bowel strictures, abscesses, fistula formation, and perforation. As neither medical nor surgical therapy provides a cure for Crohn's disease, the primary goals of therapy are to induce and maintain remission and prevent complications. As a biologic agent, infliximab, a monoclonal antibody to tumor necrosis factor, is indicated for refractory luminal and fistulizing Crohn's disease that does not respond to other medical therapies or surgery. Infliximab has proven to be very effective for inducing and maintaining remission in Crohn's disease; however, infliximab treatment has several potential complications. Here, we report a case of free perforation following a therapeutic response after an initial dose of infliximab for Crohn's disease. This is the first case report describing a free perforation in a Crohn's disease patient after an initial dose of infliximab.

Submucosal Tumor-like Early-stage Mucinous Gastric Carcinoma: A Case Study / 대한소화기학회지

Mucinous gastric carcinoma (MGC) is an unusual histologic subtype, and early detection of MGC is very rare. Early-stage MGC appears as an elevated lesion resembling a submucosal tumor (SMT) due to abundant mucin pools in the submucosa or mucosa. We report a rare case of SMT-like early-stage MGC. Tumor type was predicted preoperatively based on characteristic endoscopic findings, in which an SMT-like mass was observed at the gastric fundus. The tumor was covered by nearly normal mucosa, but with an opening allowing for the passage of copious mucus discharge. A total gastrectomy with Roux-en-Y esophagojejunostomy was subsequently performed. Histopathology of the tumor revealed early-stage (lamina propria) mucinous adenocarcinoma.

Helicobacter pylori Infection and Metabolic Disease / 대한내과학회지

The topic of the extragastric manifestations of Helicobacter pylori infection continues to capture the attention of many researchers all over the world. There are, in fact, several studies concerning obesity, diabetes mellitus, cardiovascular diseases, lung diseases, hematologic diseases, eye and skin diseases, hepatobiliary diseases, and neurological disorders. Among them, obesity and related disorders are hot spots in modern society. Here, we review the results of the studies about the relationship between Helicobacter pylori infection and obesity related diseases.

Reinterpretation of Follow-Up, High-Resolution Manometry for Esophageal Motility Disorders Based on the Updated Chicago Classification

The aim of this study was to assess changes between primary classification of esophageal motility disease and follow-up classification by high resolution manometry (HRM) and to determine whether previously classified diseases could be recategorized according to the updated Chicago Classification published in 2011. We reviewed individual medical records and HRM findings twice for each of 13 subjects. We analyzed primary and follow-up HRM findings based on the original Chicago Classification. We then reclassified the same HRM findings according to the updated Chicago Classification. This case series revealed the variable course of esophageal motility disorders; some patients experienced improvement, whereas others experienced worsening symptoms. Four cases were reclassified from variant achalasia to peristaltic abnormality, one case from diffuse esophageal spasm to type II achalasia and one case from peristaltic abnormality to variant achalasia. Four unclassified findings were recategorized as variant achalasia. In conclusion, esophageal motility disorders are variable and may not be best conceptualized as an independent group. Original classifications can be recategorized according to the updated Chicago Classification system. More research is needed on this topic.

Successful Endoscopic Mucosal Resection of a Low Esophageal Carcinoid Tumor

Esophageal carcinoid tumors remain some of the rarest of all carcinoid tumors, with only several cases previously reported in the literature. The endoscopic mucosal resection of selected carcinoid tumors has been shown to be a valid, safe, and effective method of treatment. Endoscopic ultrasonography is the technique of choice to select patients eligible for endoscopic resection. Here, we report successful endoscopic mucosal resection of a low esophageal carcinoid tumor and review the relevant literature. The present case is the first reported case of esophageal carcinoid tumor in Korea.

What Have We Accomplished in Endoscopic Image Analysis for Atrophic Gastritis?

Identifying precancerous conditions such as atrophic gastritis and intestinal metaplasia (IM) has a crucial role in detecting high risk patients for gastric cancer. White light imaging (WLI) is a basic tool for diagnosing these premalignant conditions, however its low accuracy and high variability has been a serious problem in diagnosing these premalignant conditions. Several noble imaging technologies, such as magnifying endoscopy, narrow band imaging, autofluorescence imaging, and confocal laser endomicroscopy, provids us with chances of overcoming the limitations of conventional WLI. Autofluorescence images help us understand the extent of atrophic gastritis with vivid colors. Magnifying endoscopy with narrow band imaging shows microsurface structure and micrvascular architecture and is able to identify the degree of intestinal metaplasia by the presence of "light blue crest" sign. Confocal laser endomicroscopy produces reliable images of goblet cells that can replace biopsy. Usefulness of the new endoscopic imaging techniques for predicting gastric cancer development needs to be validated in clinical practice. Currently, it would be practical to apply magnifying endoscopy with narrow band imaging sequentially after white light endoscopy for identifying the presence of IM and atrophic gastritis.

Endoscopic Resection for Rectal Carcinoid Tumors: Comparision of Polypectomy and Endoscopic Submucosal Resection with Band Ligation

BACKGROUND/AIMS: Rectal carcinoid tumors, at diagnosis, are as small as 10 mm or less in about 80% of patients. These tumors are generally removed by endoscopic resection. The aim of this study was to compare treatment efficacy and safety between endoscopic submucosal resection with band ligation (ESMR-L) and conventional polypectomy. METHODS: Between January 2005 and September 2010, a total of 88 patients, who visited at Busan Paik Hospital and Kosin University Gospel Hospital for endoscopic resection of rectal carcinoid, were reviewed, retrospectively. RESULTS: Thirty-three cases were treated by ESMR-L, and 55 cases by conventional polypectomy. There were no significant difference in the size of tumor between ESMR-L group and polypectomy group (6.02+/-2.36 vs. 6.49+/-3.24 mm, p=0.474). The rate of positive resection margin was significantly lower in ESMR-L group (2/33, 6.1%) than in polypectomy group (19/55, 34.5%; p=0.002). The rate of positive vertical resection margin, among others, was markedly lower in ESMR-L group (1/33, 3.0%) compared to polypectomy group (19/55, 34.5%; p<0.001). CONCLUSIONS: ESMR-L, rather than conventional polypectomy, is a useful treatment option for removal of rectal carcinoid tumors less than 10 mm in diameter.