Survey-Based Analysis of the Clinical Treatment Status of Irritable Bowel Syndrome in Korea

Background@#The quality-of-life of patients with irritable bowel syndrome is low; incorrect diagnosis/treatment causes economic burden and inappropriate consumption of medical resources. This survey-based study aimed to analyze the current status of irritable bowel syndrome treatment to examine differences in doctors’ perceptions of the disease, and treatment patterns. @*Methods@#From October 2019 to February 2020, the irritable bowel syndrome and Intestinal Function Research Study Group of the Korean Society of Neurogastroenterology and Motility conducted a survey on doctors working in primary, secondary, and tertiary healthcare institutions. The questionnaire included 37 items and was completed anonymously using the NAVER platform (a web-based platform), e-mails, and written forms. @*Results@#A total of 272 doctors responded; respondents reported using the Rome IV diagnostic criteria (amended in 2016) for diagnosing and treating irritable bowel syndrome.Several differences were noted between the primary, secondary, and tertiary physicians’ groups. The rate of colonoscopy was high in tertiary healthcare institutions. During a colonoscopy, the necessity of random biopsy was higher among physicians who worked at tertiary institutions. ‘The patient did not adhere to the diet’ as a reason for ineffectiveness using low-fermentable oligo-, di-, and mono-saccharides, and polyols diet treatment was higher among physicians in primary/secondary institutions, and ‘There are individual differences in terms of effectiveness’ was higher among physicians in tertiary institutions. In irritable bowel syndrome constipation predominant subtype, the use of serotonin type 3 receptor antagonist (ramosetron) and probiotics was higher in primary/secondary institutions, while serotonin type 4 receptor agonist was used more in tertiary institutions. In irritable bowel syndrome diarrhea predominant subtype, the use of antispasmodics was higher in primary/secondary institutions, while the use of serotonin type 3 receptor antagonist (ramosetron) was higher in tertiary institutions. @*Conclusion@#Notable differences were observed between physicians in primary/secondary and tertiary institiutions regarding the rate of colonoscopy, necessity of random biopsy, the reason for the ineffectiveness of low-fermentable oligo-, di-, and mono-saccharides, and polyols diet, and use of drug therapy in irritable bowel syndrome. In South Korea, irritable bowel syndrome is diagnosed and treated according to the Rome IV diagnostic criteria, revised in 2016.

Efficacy of a Restrictive Diet in Irritable Bowel Syndrome: A Systematic Review and Network Meta-analysis / 대한소화기학회지

Background/Aims@#Dietary factors can aggravate the symptoms of irritable bowel syndrome (IBS). Many IBS patients try restrictive diets to relieve their symptoms, but the types of diets with an exacerbating factor are unknown. Therefore, this paper reports the results of a systematic review and network meta-analysis of randomized-controlled trials (RCTs) reviewing the efficacy of food restriction diets in IBS. @*Methods@#The MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov databases were searched until July 21, 2021, to retrieve RCTs assessing the efficacy of restriction diets in adults with IBS. Two independent reviewers performed the eligibility assessment and data abstraction. RCTs that evaluated a restriction diet versus a control diet and assessed the improvement in global IBS symptoms were included. These trials reported a dichotomous assessment of the overall response to therapy. @*Results@#A total of 1,949 citations were identified. After full-text screening, 14 RCTs were considered eligible for the systematic review and network meta-analysis. A starch- and sucrose-reduced diet and a diet with low-fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) showed significantly better results than a usual diet. Symptom flare-ups in patients on a gluten-free diet were also significantly lower than in those on high-gluten diets. @*Conclusions@#These findings showed that the starch- and sucrose-reduced, low FODMAP, and gluten-free diets had superior effects in reducing IBS symptoms. Further studies, including head-to-head trials will be needed to establish the effectiveness of dietary restrictions on IBS symptoms.

Nutritional Impact of Percutaneous Endoscopic Gastrostomy: A Retrospective Single-center Study / 대한소화기학회지

Background/Aims@#Several conditions may cause difficulties with oral feeding. Percutaneous endoscopic gastrostomy (PEG) is commonly performed on patients who require enteral feeding for >2-3 weeks. This study examined the nutritional state of patients who required enteral feeding and underwent PEG to quantify the benefits of the procedure. @*Methods@#This retrospective study included patients who underwent PEG at the Chungnam National University Hospital between January 2013 and December 2018. A gastroenterologist performed all PEG procedures using the pull technique, and all patients were followed up for >3 weeks postoperatively. The BMI and lymphocyte count, along with the levels of hemoglobin, total protein, albumin, total cholesterol, BUN, and creatinine pre-PEG and between 3 weeks and 6 months post-PEG were evaluated. @*Results@#Overall, 151 patients (116 males; mean age 64.92 years) were evaluated. Of these patients, 112 (74.2%), 34 (22.5%), and five (3.3%) underwent PEG tube insertion because of neurological diseases, malignancy, and other conditions, respectively. The BMI and the hemoglobin, total protein, albumin, and total cholesterol levels were significantly higher post-PEG than pre-PEG. @*Conclusions@#These findings highlight the usefulness of PEG in the management of nutritionally poor patients with difficulties in feeding orally.

Intestinal Perforation as a Paradoxical Reaction to Antitubercular Therapy: A Case Report

Paradoxical reactions to tuberculosis (TB) treatment are characterized by an initial improvement of the clinical symptoms followed by clinical or radiological deterioration of existing tuberculous lesions, or by development of new lesions. Intestinal perforation in gastrointestinal TB can occur as a paradoxical reaction to antitubercular therapy. A 55-year-old man visited the outpatient department with lower abdominal pain and weight loss. He was diagnosed with intestinal TB and started antitubercular therapy. After 3 months of antitubercular therapy, a colonoscopy revealed improvement of the disease. Three days after the colonoscopy, the patient visited the emergency room complaining of abdominal pain. Abdominal computed tomography revealed extraluminal air-filled spaces in the pelvic cavity. We diagnosed a small bowel perforation and performed an emergency laparotomy and a right hemicolectomy with small bowel resection. This report describes the case of intestinal perforation presenting as a paradoxical reaction to antitubercular and provides a brief literature review.

Intestinal Perforation as a Paradoxical Reaction to Antitubercular Therapy: A Case Report

Paradoxical reactions to tuberculosis (TB) treatment are characterized by an initial improvement of the clinical symptoms followed by clinical or radiological deterioration of existing tuberculous lesions, or by development of new lesions. Intestinal perforation in gastrointestinal TB can occur as a paradoxical reaction to antitubercular therapy. A 55-year-old man visited the outpatient department with lower abdominal pain and weight loss. He was diagnosed with intestinal TB and started antitubercular therapy. After 3 months of antitubercular therapy, a colonoscopy revealed improvement of the disease. Three days after the colonoscopy, the patient visited the emergency room complaining of abdominal pain. Abdominal computed tomography revealed extraluminal air-filled spaces in the pelvic cavity. We diagnosed a small bowel perforation and performed an emergency laparotomy and a right hemicolectomy with small bowel resection. This report describes the case of intestinal perforation presenting as a paradoxical reaction to antitubercular and provides a brief literature review.

Gastric Schwannoma Mimicking Advanced Gastric Cancer

Gastric schwannoma, a rare mesenchymal tumor originating from the schwann cells of peripheral nerves, rarely occurs in the gastrointestinal tract. It accounts for only 0.2% of all gastric tumors and 2~6% of gastric mesenchymal tumors. Gastric schwannoma is observed as a subepithelial tumor on endoscopy; it is covered with normal mucosa, rendering its preoperative differential diagnosis difficult. An asymptomatic 43-year-old woman visited our hospital after a 7-cm ulcerofungating mass was detected in the lesser curvature of the gastric body on gastroscopy. Abdominal CT revealed multiple enlarged lymph nodes, and ¹⁸F-fluorodeoxyglucose (FDG) PET demonstrated a subtle uptake of FDG, suggestive of advanced gastric cancer. After three failed attempts of endoscopic biopsy, the patient underwent total gastrectomy with lymphadenectomy and was subsequently diagnosed with gastric schwannoma. Herein, we report this case with a literature review.

Percutaneous Endoscopic Gastrostomy Tube Insertion-induced Superior Mesenteric Artery Injury Treated with Angiography / 대한소화기학회지

Percutaneous endoscopic gastrostomy (PEG) is widely used to provide nutritional support for patients with dysphagia and/or disturbed consciousness preventing oral ingestion, and PEG tube placement is a relatively safe and convenient non-surgical procedure performed under local anesthesia. However, the prevention of PEG-insertion-related complications is important. A 64-year-old man with recurrent pneumonia underwent tracheostomy and nasogastric tube placement for nutritional support and opted for PEG tube insertion for long-term nutrition. However, during the insertion procedure, needle puncture had to be attempted twice before successful PEG tube placement was achieved, and a day after the procedure his hemoglobin had fallen and he developed hypotension. Abdominal computed tomography revealed injury to a pancreatic branch of the superior mesenteric artery (SMA) associated with bleeding, hemoperitoneum, and pancreatitis. Transarterial embolization was performed using a microcatheter to treat hemorrhage from the injured branch of the SMA, and the acute pancreatitis was treated using antibiotics and supportive care. The patient was discharged after an uneventful recovery. Clinicians should be mindful of possible pancreatic injury and bleeding after PEG tube insertion. Possible complications, such as visceral injuries or bleeding, should be considered in patients requiring multiple puncture attempts during a PEG procedure.

Ischemic Necrosis of the Gastric Remnant without Splenic Infarction Following Subtotal Gastrectomy

Gastric remnant necrosis after a subtotal gastrectomy is an extremely uncommon complication due to the rich vascular supply of the stomach. Despite its rareness, it must be carefully addressed considering the significant mortality rate associated with this condition. Patients vulnerable to ischemic vascular disease in particular need closer attention and should be treated more cautiously. When gastric remnant necrosis is suspected, an urgent endoscopic examination must be performed. We report a case of gastric remnant necrosis following a subtotal gastrectomy and discuss possible risk factors associated with this complication.

Pneumoretroperitoneum, Pneumomediastinum, Pneumothorax, and Subcutaneous Emphysema after Diagnostic Colonoscopy / 대한소화기학회지

Colonoscopy is a commonly performed endoscopic procedure. Although it is generally considered to be safe, serious complications, such as colorectal perforation, can occur. Most colonic perforations are intraperitoneal and cause pneumoperitoneum with acute abdominal pain as the initial symptom. However, extraperitoneal perforations with pneumoretroperitoneum may happen, albeit rarely, with atypical initial symptoms. We report a rare case of rectosigmoid perforation occurring after diagnostic colonoscopy that developed into pneumoretroperitoneum, pneumomediastinum, pneumothorax, and subcutaneous emphysema, with a change in voice and neck swelling as the initial symptoms. The patient was successfully treated with endoscopic closure of the perforation and conservative management.

Clinical Outcome of Doublet and Triplet Neoadjuvant Chemotherapy for Locally Advanced Gastric Cancer / 대한소화기학회지

BACKGROUND/AIMS: In gastric cancer, the rate of recurrence and metastasis following radical resection is high, necessitating improvement in survival and cure rates. Neoadjuvant chemotherapy (NAC) has potential benefits for locally advanced gastric cancer; however, the surgical benefits and effects on survival are unclear. This study evaluates the effectiveness of NAC in locally advanced gastric cancer and compares clinical outcomes of doublet and triplet regimens. METHODS: We reviewed patient medical records of 383 patients who underwent NAC (n=41) or surgery only (n=342) for treatment of locally advanced gastric cancer. The baseline characteristics and clinical outcomes were compared between the groups. Chemotherapy patients were classified according to regimen, doublet (n=28) and triplet (n=13), and NAC-related clinical response, safety, and toxicity were analyzed. RESULTS: The baseline characteristics did not differ significantly between groups. After NAC, the tumor downstage rate was 51.2% (21/41); however, overall survival (p=0.205) and disease-free survival (p=0.415) were not significantly different between the groups. On subgroup analysis, no significant differences in drug toxicity (p=0.604) or clinical response (p=0.374) were found between outcomes of doublet and triplet chemotherapy regimens. CONCLUSIONS: In patients with locally advanced gastric cancer, NAC showed tolerable drug toxicity and increased tumor downstage, but NAC failed to increase the survival rate, which may be caused by a high D2-lymphadenectomy rate. Therefore, NAC was found to be a therapeutic option for select gastric cancer patients.

A Case of a Small Cell Neuroendocrine Carcinoma in the Ampulla of Vater Incidentally Found on Gastroduodenoscopy

Small cell neuroendocrine carcinoma in the ampulla of Vater is a rare disease and there have only been three cases reported in Korea. In these three cases, the patients had symptoms of abdominal pain and jaundice. A biopsy via endoscopic retrograde cholangiopancreatography confirmed a small cell neuroendocrine carcinoma; thus, each patient underwent surgical treatment. Recently, we experienced a case of small cell neuroendocrine carcinoma in an asymptomatic patient. An ulcerative lesion was identified during screening gastroduodenoscopy. Here, we report this case and review the relevant literature.

Nephrotic Syndrome Related to Early Gastric Cancer

Nephrotic syndrome results in a prolonged, heavy increase in glomerular permeability to proteins. Nephrotic syndrome caused by malignant neoplasms accounts for 7.9% to 10.9%. Nephrotic syndrome can improve following resection of gastric malignancies. However, the relationship between early gastric cancer and nephrotic syndrome has not been elucidated. We report a case of early gastric cancer with nephrotic syndrome that improved after resection of the primary gastric lesion by endoscopic submucosal dissection.

Gastric Perforation Caused by Primary Gastric Diffuse Large B Cell Lymphoma / 대한소화기학회지

Spontaneous gastric perforation is a rare complication of gastric lymphoma that is potentially life threatening since it can progress to sepsis and multi-organ failure. Morbidity also increases due to prolonged hospitalization and delay in initiating chemotherapy. Therefore prompt diagnosis and appropriate treatment is critical to improve prognosis. A 64-year-old man presented to the emergency department with severe abdominal pain. Chest X-ray showed free air below the right diaphragm. Abdominal CT scan also demonstrated free air in the peritoneal cavity with large wall defect in the lesser curvature of gastric lower body. Therefore, the patient underwent emergency operation and primary closure was done. Pathologic specimen obtained during surgery was compatible to diffuse large B cell lymphoma. Fifteen days after primary closure, the patient received subtotal gastrectomy and chemotherapy was initiated after recovery. Patient is currently being followed-up at outpatient department without any particular complications. Herein, we report a rare case of gastric lymphoma that initially presented as peritonitis because of spontaneous gastric perforation.

The Clinical Utility of FDG PET-CT in Evaluation of Bone Marrow Involvement by Lymphoma / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Bone marrow biopsy is a standard method for the evaluation of bone marrow infiltration by lymphoma; however, it is an invasive and painful procedure. Fluorodeoxyglucose positron emission tomography-computed tomography (FDG PET-CT) is a noninvasive imaging technique with the potential to detect bone marrow involvement by lymphoma. MATERIALS AND METHODS: We retrospectively reviewed medical records of lymphoma patients. All patients were examined by FDG PET-CT and iliac crest bone marrow biopsy for initial staging work-up. RESULTS: The study population comprised 94 patients (median age, 60 years; 56 males) with Hodgkin's lymphoma (n=8) or non-Hodgkin's lymphoma (n=86). Maximum standardized uptake values on the iliac crest of patients with lymphoma infiltrated bone marrow were significantly higher than those of patients with intact bone marrow (2.2+/-1.2 g/mL vs. 1.3+/-0.4 g/mL; p=0.001). The calculated values for FDG PET-CT during evaluation of bone marrow involvement were as follows: sensitivity 50%, specificity 96%, positive predictive value 80%, negative predictive value 85%, and positive likelihood ratio (LR+) 11.7. The value of LR+ was 16.0 in patients with aggressive subtypes of non-Hodgkin's lymphoma (NHL). CONCLUSION: FDG PET-CT could not replace bone marrow biopsy due to the low sensitivity of FDG PET-CT for detection of bone marrow infiltration in lymphoma patients. Conversely, FDG PET-CT had high specificity and LR+; therefore, it could be a useful tool for image-guided biopsy for lymphoma staging, especially for aggressive subtypes of NHL. In addition, unilateral bone marrow biopsy could be substituted for bilateral bone marrow biopsy in lymphoma patients with increased FDG uptake on any iliac crest.

Late Postoperative Anterograde Jejunojejunal Intussusception after Total Gastrectomy with Loop Esophagojejunostomy

Anterograde jejunojejunal intussusception after total gastrectomy is a very rare postoperative complication. We report a 54-year-old man with a history of total gastrectomy, uncut Roux-en-Y gastric bypass, and Braun's jejunojejunal anastomosis. An upper gastrointestinal endoscopy revealed a bulky, reddish mass in the efferent loop with congestion, edema, and mucosal bleeding. An emergency computed tomography showed a target-like multilayered wall thickening in the afferent loop and a lamellar structure arranged in a concentric circle. Surgical exploration revealed an anterograde intussusception of the afferent proximal jejunum adjacent to the jejunojejunostomy site. This is a very uncommon occurrence because most intussusceptions after total gastrectomy are of the retrograde type. Moreover, anterograde jejunojejunal intussusception tends to occur in the early postoperative period. We report a case of late postoperative anterograde jejunojejunal intussusception after total gastrectomy with Braun's jejunojejunal anastomosis in a 54-year-old Korean man and review the related literature.

Spontaneous Pneumomediastinum, Pneumothorax, and Subcutaneous Emphysema Complicating H1N1 Virus Infection / 대한내과학회지

Since April 2009, outbreaks of the new influenza A (H1N1) virus have occurred worldwide. The spectrum of disease caused by H1N1 infection ranges from non-febrile, mild upper respiratory tract illness to severe or fatal pneumonia. Rapidly progressive respiratory diseases, such as acute respiratory distress syndrome and renal or multi-organ failure, have accounted for severely affected inpatients. Complex cases involving myocarditis, encephalitis, and myositis have been described. However, pulmonary air-leak syndrome, consisting of spontaneous pneumomediastinal emphysema, pneumothorax, and subcutaneous emphysema complicating pneumonia with the H1N1 virus, has not previously been reported in Korea. Here, we report a case of pulmonary air-leak syndrome complicating H1N1 infection that was resolved with an antiviral agent, high-flow oxygen, and fluid therapy.

Left Transradial Coronary Angiography in a Patient With Dextrocardia

Although dextrocardia occurs rarely, the incidence of coronary artery disease is similar to the general population. Because of unfamiliarity with performing catheterization, transradial coronary angiography has seldom been performed in a patient with dextrocardia. We successfully performed left transradial coronary angiography in a patient with a right side heart using counter-directional torquing of the catheters and mirror-image angiographic angles.

Incidence and prognosis of disseminated intravascular coagulation in patients with severe sepsis or septic shock / 대한내과학회지

BACKGROUND/AIMS: We investigated the incidence and prognosis of disseminated intravascular coagulation (DIC) using DIC scoring system in patients with severe sepsis or septic shock. METHODS: Patients admitted to the intensive care unit (ICU) in a tertiary hospital for severe sepsis or septic shock were enrolled from Mar. 2008 to Feb. 2009. Using the International Society on Thrombosis and Haemostasis (ISTH) criteria, we calculated DIC score at three time points (Day 0, Day 1, and Day 2). RESULTS: Among 111 patients with severe sepsis or septic shock, 89 (severe sepsis, 8; septic shock, 81) were enrolled. Mean DIC score at ICU admission was 3.3+/-1.3 and the incidence of overt DIC (DIC score > or = 5) during the first 48 hours was 33.8% (27/89). Sequential Organ Failure Assessment (SOFA) score was well correlated with DIC score and was higher in patients with overt DIC than in those without. The ICU, hospital and 28-day death rates in patients with overt DIC were 63.0%, 66.7%, and 63.0%, respectively, which were significantly higher than in those without overt DIC. In multivariate analysis, Simplified Acute Physiology Score (SAPS) II was significantly associated with hospital death (p=0.002), and the occurrence of overt DIC showed a borderline significance (p=0.053). CONCLUSIONS: Using the ISTH criteria for DIC, the incidence of overt DIC was 33.8% in patients with severe sepsis or septic shock. The occurrence of overt DIC was associated with a higher organ failure score and hospital outcomes.

Balloon Embolectomy of a Cylindrical Dissected Plaque That Complicated Performing Superficial Femoral Artery Angioplasty

We report here on a case of successfully removing a calcified plaque embolus that complicated performing angioplasty. A 67 year-old woman underwent percutaneous transluminal angioplasty for a stenosis of the right superficial femoral artery (SFA). The angiogram showed a marked stenosis at the mid-portion of SFA and diffuse circular calcification along the atheroma rim was seen on the computed tomographic angiography. Although balloon inflation was attempted on the lesion, it was not fully dilated. After repeated balloon inflations, a radiopaque calcified atheroma was detached from the arterial wall and it migrated proximally along with withdrawing the balloon. The embolus was too extensive to be pulled out through the catheter sheath; therefore, a small balloon was inflated at the distal end of the embolic atheroma to anchor it and the embolus was removed with the balloon and the sheath system via an arteriotomized puncture site. A huge cylindrical atheroma that measured 4 cm in length was successfully removed. The final angiography showed a widened target site without any dye leakage.