Outcomes of the Conventional versus Pocket-Creation Method for Endoscopic Submucosal Dissection of Gastric Body Tumors Using a Dual Knife: A Retrospective Study

Background/Aims@#Various endoscopic submucosal dissection (ESD) methods for gastric tumors have been tried. However, no studies have yet compared results according to the ESD method for gastric body tumors using a dual knife. The objective of this study was to compare outcomes of two ESD methods for gastric body tumors: the pocket-creation method and conventional method. @*Methods@#Patients who underwent ESD for a gastric body tumor were retrospectively reviewed.Patients were divided into two groups according to the ESD method: the conventional method (group I) and pocket-creation method (group II). Characteristics of patients and tumors, hospitalization period, incidence of complications, resection margin status, incidence of surgical operation, procedure time, and laboratory findings were investigated. @*Results@#Of the total of 100 patients, 52 belonged to group I and 48 to group II. All tumors were successfully resected en bloc. Resection margin involvement was found in six (11.5%) of group I and six (12.5%) of group II. Complications were observed in seven (13.5%; major complication five, minor two) of group I and eight (16.7%; major two, minor six) of group II. There were no significant differences in ESD outcomes such as hospitalization period, incidence of complications, resection margin status, incidence of surgical operation, procedure time, or inflammatory response after ESD between the two groups. @*Conclusions@#Both methods are suitable for treating gastric body tumors with adequate treatment success rates and comparable complication rates.

Diagnostic Accuracy of Fecal Calprotectin for the Detection of Small Bowel Crohn’s Disease through Capsule Endoscopy: An Updated Meta-Analysis and Systematic Review

Background/Aims@#The diagnosis of small bowel Crohn’s disease with negative ileocolonoscopic findings has been challenging. Fecal calprotectin (FC) has been used to detect colonic inflammation, but its efficacy for detecting small bowel inflammation is less established. We performed an updated meta-analysis to evaluate the diagnostic accuracy of FC to detect active small bowel inflammation observed during capsule endoscopy. @*Methods@#We conducted a systematic literature search for studies that evaluated the correlation between small bowel inflammation and FC in patients with suspected/established Crohn’s disease. We calculated the pooled sensitivity, specificity, and diagnostic odds ratios (DORs) and constructed hierarchical summary receiver operating characteristic curves for FC cutoffs of 50, 100, and 200 µg/g. @*Results@#Fourteen studies were eligible for the final analysis. The DORs of all FC cutoffs were significant. The highest DOR was observed at 100 µg/g (sensitivity, 0.73; specificity, 0.73; and DOR, 7.89) and was suggested as the optimal diagnostic cutoff. If we analyzed only studies that included patients with suspected Crohn’s disease, the DOR was 8.96. If we analyzed only studies that included patients with a Lewis score ≥135 as a diagnostic criterion for active disease, the DOR was 10.90. @*Conclusions@#FC has significant diagnostic accuracy for detecting small bowel inflammation, and an FC cutoff of 100 µg/g can be used as a tool to screen for small bowel Crohn’s disease.

Diagnostic Accuracy of Fecal Calprotectin for the Detection of Small Bowel Crohn’s Disease through Capsule Endoscopy: An Updated Meta-Analysis and Systematic Review

Background/Aims@#The diagnosis of small bowel Crohn’s disease with negative ileocolonoscopic findings has been challenging. Fecal calprotectin (FC) has been used to detect colonic inflammation, but its efficacy for detecting small bowel inflammation is less established. We performed an updated meta-analysis to evaluate the diagnostic accuracy of FC to detect active small bowel inflammation observed during capsule endoscopy. @*Methods@#We conducted a systematic literature search for studies that evaluated the correlation between small bowel inflammation and FC in patients with suspected/established Crohn’s disease. We calculated the pooled sensitivity, specificity, and diagnostic odds ratios (DORs) and constructed hierarchical summary receiver operating characteristic curves for FC cutoffs of 50, 100, and 200 µg/g. @*Results@#Fourteen studies were eligible for the final analysis. The DORs of all FC cutoffs were significant. The highest DOR was observed at 100 µg/g (sensitivity, 0.73; specificity, 0.73; and DOR, 7.89) and was suggested as the optimal diagnostic cutoff. If we analyzed only studies that included patients with suspected Crohn’s disease, the DOR was 8.96. If we analyzed only studies that included patients with a Lewis score ≥135 as a diagnostic criterion for active disease, the DOR was 10.90. @*Conclusions@#FC has significant diagnostic accuracy for detecting small bowel inflammation, and an FC cutoff of 100 µg/g can be used as a tool to screen for small bowel Crohn’s disease.

Atorvastatin Induces FXR and CYP7A1 Activation as a Result of the Sequential Action of PPARγ/PGC-1α/HNF-4α in Hep3B Cells / 대한소화기학회지

Background/Aims@#PPARγ, farnesoid X receptor (FXR) and CYP7A1 are associated with solubility of bile. This study was performed to understand a mechanism and interactions of statin-induced PPARγ, PGC-1α and HNF-4α related to the statin-induced activation of FXR and CYP7A1, and verify whether the mevalonate pathway is involved in the mechanism. @*Methods@#MTT assays were performed using cultured human Hep3B cells to determine the effect of atorvastatin on the cell proliferation. Expression levels of indicated proteins were measured using Western blotting assays by inhibiting the protein expression or not. @*Results@#Atorvastatin increased expression of PPARγ, PGC-1α, HNF-4α, FXR, and CYP7A1 in Hep3B cells. PPARγ ligand of troglitazone upregulated the expression of PGC-1α, HNF-4α, FXR, and CYP7A1 in Hep3B cells. Silencing of PPARγ, PGC1α, and HNF4α using respective siRNA demonstrated that atorvastatin-induced FXR and CYP7A1 activation required sequential action of PPARγ /PGC-1α/HNF-4α. The silencing of PPARγ completely inhibited atorvastatin-induced PGC-1α expression, and the PGC1α silencing partially inhibited atorvastatin-induced PPARγ expression. The inhibition of HNF4α did not affect atorvastatin-induced PPARγ expression, but partially inhibited atorvastatin-induced PGC-1α expression. Besides, mevalonate completely reversed the effect of atorvastatin on PPARγ, PGC-1α, HNF-4α, FXR, and CYP7A1. @*Conclusions@#Atorvastatin induces FXR and CYP7A1 activation as a result of sequential action of PPARγ/PGC-1α/HNF-4α in human hepatocytes. We propose that atorvastatin enhances solubility of cholesterol in bile by simultaneously activating of FXR and CYP7A1.

Inflammatory Pseudotumor of the Spleen Associated with Autoimmune Thyroiditis / 대한내과학회지

Inflammatory pseudotumor is a benign disease entity, which is histologically composed of inflammatory cells and fibrotic stroma. It is mainly found in the respiratory tract, but it has also been reported in the liver, central nervous system, soft tissues, urological system, and gastrointestinal tract. It is extremely rare in the spleen and there have been no cases of splenic inflammatory pseudotumor associated with autoimmune thyroiditis in Korea. The pathogenesis or etiology is unknown, but hypotheses include infection, autoimmunity, and parenchymal necrosis with hemorrhage. Because inflammatory pseudotumor may mimic malignant tumors on radiologic findings, pathologic confirmation is necessary to distinguish it from lymphoproliferative disorders of the spleen and other malignant tumors. We report a case of inflammatory pseudotumor of the spleen associated with autoimmune thyroiditis in a patient who complained of periumbilical pain.

Ischemic Gastritis Improved by Supportive Care

Acute extensive ischemic gastritis is an extremely rare disease because the stomach has an abundant submucosal vascular plexus with a dual blood supply from the pancreaticoduodenal and gastroduodenal arteries. Smoking, hypertension, and atherosclerotic vascular diseases can be major risk factors for ischemic gastritis. Acute gastric ischemia presents as an acute abdomen with diarrhea or hematemesis that rapidly progresses to acute peritonitis, irreversible septic shock, and death if untreated. We report a case of acute extensive ischemic gastritis combined with tetraplegia due to cervical myelopathy and extensive atherosclerotic changes of the celiac trunk and abdominal aorta.

Simvastatin Induces Apoptosis and Suppresses Insulin-Like Growth Factor 1 Receptor in Bile Duct Cancer Cells

BACKGROUND/AIMS: Statins act as antineoplastic agents through the inhibition of cell proliferation. This study sought to demonstrate the effects of statins on extrahepatic bile duct cancer cell apoptosis and to document the changes in protein expression involved in tumor growth and suppression. METHODS: Human extrahepatic bile duct cancer cells were cultured. 3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assays were performed to determine the effect of statins on cell proliferation. Apoptosis was measured by a cell death detection enzyme-linked immunosorbent assay and caspase-3 activity assay, and flow cytometry was used to determine the percentage of cells in each phase of the cell cycle. The protein expression of Bax, Bcl-2, insulin-like growth factor 1 (IGF-1) receptor, extracellular signal-regulated kinase 1/2 (ERK1/2), and Akt was measured by Western blot analysis. RESULTS: Simvastatin suppressed cell proliferation by inducing G1 phase cell cycle arrest in bile duct cancer cells. Furthermore, it induced apoptosis via caspase-3 activation, downregulated the expression of the Bcl-2 protein, and enhanced the expression of the Bax protein. Moreover, simvastatin suppressed the expression of the IGF-1 receptor and IGF-1-induced ERK/Akt activation. CONCLUSIONS: Simvastatin induces apoptosis in bile duct cancer cells, which suggests that it could be an antineoplastic agent for bile duct cancer.

Familial Mediterranean Fever With Complete Symptomatic Remission During Pregnancy

Familial Mediterranean fever (FMF) is an inherited autosomal recessive disorder, ethnically restricted and commonly found among populations surrounding the Mediterranean Sea. FMF is the most prevalent autoinflammatory disease; is characterized by recurrent, self-limited episodes of fever with serositis; and is caused by Mediterranean fever gene (MEFV) mutations on chromosome 16. We describe a case of adult-onset FMF with complete symptomatic remission during pregnancy, without the use of colchicine. A 25-year-old woman had presented with periodic fever, abdominal pain, and vomiting since she was 21. Her abdominal computed tomography scan showed intestinal nonrotation. She underwent exploratory laparotomy and appendectomy for her symptoms 1 year prior. She had a symptom-free pregnancy period, but abdominal pain and fever recurred after delivery. Mutation analysis of the MEFV gene revealed two point mutations (p.Leu110Pro and p.Glu148Gln). We report an adult female patient with FMF in Korea with complete symptomatic remission during pregnancy.

A Case of Acute Cholecystitis Caused by Stenotrophomonas maltophilia Bacteremia / 대한췌담도학회지

Stenotrophomonas maltophilia is an ubiquitous aerobic Gram-negative bacillus. Hospitalization and prior antibiotic therapy are risk factors for S. maltophilia infection. This organism is isolated with increasing frequency from hospitalized patients and may cause therapeutic problems because of its intrinsic resistance to common antibiotics and the immunodeficiency status of the affected host. S. maltophilia has been reported to be commonly associated with pneumonia and urinary tract infection. However, biliary infection caused by S. maltophilia is very rare. Herein, we report on a case of acute cholecystitis that developed secondary to S. maltophilia bacteremia in a patient with hepatitis-B related liver cirrhosis and gallbladder stone.

The Iatrogenic Complications of Colonoscopic Polypectomy: A Multicenter Retrospective Study

BACKGROUND/AIMS: Colonoscopic polypectomy is an effective tool for the treatment of colonic polyps. With the recent widespread use of colonoscopic polypectomy, there is a growing concern about iatrogenic complications, such as bleeding and perforation. The aim of this study is to analyze the clinical presentation and management of complications during colonoscopic polypectomy. METHODS: We retrospectively reviewed the medical records of colonoscopic examinations performed at 5 hospitals of Hallym University Medical Center between June 2005 and June 2008. RESULTS: A total of 26,773 colonoscopies and 4,123 colonoscopic polypectomy were performed. The overall rate of complication was 1.04% (43/4,123). Perforation occurred in 0.19% (8/4,123) of cases, and bleeding occurred in 0.85% (35/4,123) of cases. Perforation occurred in 0.05% of snare polypectomies, 1.09% of endoscopic mucosal resections (EMR), and 7.14% of endoscopic submucosal dissections (ESD). Bleeding occurred in 0.8% of snare polypectomies, 1.09% of EMRs, and 3.57% of ESDs. The complication rate of ESDs was higher than in EMRs and snare polypectomies (P<0.001). Endoscopic clippings were performed in 25% of perforation and 66.7% of bleeding cases. Medical treatment was successful in 75% of perforation and 100% of bleeding cases. CONCLUSIONS: Colonoscopic polypectomy is a safe procedure for the treatment of colonic polyps, but rarely, serious complications occur. Compared to a snare polypectomy or an EMR, the complication of an ESD occurs more frequently. Endoscopic treatment and further conservative management seems to be appropriate in most cases with complication.

Giant Brunner's Gland Adenoma of the Proximal Jejunum Presenting as Iron Deficiency Anemia and Mimicking Intussusceptions

Brunner's gland adenoma is a rare benign proliferative lesion developing most commonly in the posterior wall of the duodenum. It is usually small in size and asymptomatic. Depending on its size or location, however, the clinical manifestations of this tumor may be variable from nonspecific symptoms to gastrointestinal bleeding or obstruction. Brunner's gland adenoma in the proximal jejunum is extremely rare. We report a very rare case of giant Brunner's gland adenoma developing in the proximal jejunum which presented as iron deficiency anemia and mimicked intussusceptions on radiologic studies.

Comparison of the Eradication Rate between 1- and 2-Week Bismuth-Containing Quadruple Rescue Therapies for Helicobacter pylori Eradication

BACKGROUND/AIMS: First-line therapies against Helicobacter pylori, including proton pump inhibitors (PPIs) plus two antibiotics, may fail in up to 20% of patients. 'Rescue' therapy is usually needed for patients who failed the first-line treatment. This study evaluated the eradication rate of bismuth-containing quadruple rescue therapy over a 1- or 2-week period. METHODS: We prospectively investigated 169 patients with a persistent H. pylori infection after the first-line triple therapy, which was administered from October 2008 to March 2010. The patients were randomized to receive a 1- or 2-week quadruple rescue therapy (pantoprazole 40 mg b.i.d., tripotassium dicitrate bismuthate 300 mg q.i.d., metronidazole 500 mg t.i.d., and tetracycline 500 mg q.i.d.). After the 'rescue' therapy, the eradication rate, compliance, and adverse events were evaluated. RESULTS: The 1-week group achieved 83.5% (71/85) and 87.7% (71/81) eradication rates in the intention to treat (ITT) and per-protocol (PP) analyses, respectively. The 2-week group obtained 87.7% (72/84) and 88.9% (72/81) eradication rate in the ITT and PP analyses, respectively. There was no significant difference in the eradication rate, patient compliance or rate of adverse events between the two groups. CONCLUSIONS: One-week bismuth-containing quadruple therapy can be as effective as a 2-week therapy after the failure of the first-line eradication therapy.

Familial Mediterranean Fever: The First Adult Case in Korea

Familial Mediterranean fever (FMF) is known to be a genetic disorder that prevalent among populations surrounding the Mediterranean Sea. Since Mediterranean fever gene (MEFV) was discovered at 1997, some cases have been reported in countries not related or close to this area like Japan. In addition it has been generally accepted that the clinical onset of FMF begins before 20 yr of age in most patients. Onset of the disease at an older age may occur but is rare. Adult-onset FMF may be a form of disease with distinct clinical, demographic and molecular characteristics. We describe a case of adult-onset FMF confirmed by DNA analysis of the MEFV gene in a Korean patient. A 32-yr-old man, who has no family history of FMF, presented with periodic fever, abdominal pain and vomiting. Though several various tests were thoroughly performed to evaluate the cause of his symptoms, there was no evidence of infectious, autoimmune or neoplastic diseases. Several gene analysis of periodic fever syndrome was finally performed and two point mutations (p.Leu110Pro, p.Glu148Gln) were identified. We confirmed the first adult case of FMF through detection of MEFV gene mutations in Korea and describe his clinical characteristics.

Familial Mediterranean Fever: The First Adult Case in Korea

Familial Mediterranean fever (FMF) is known to be a genetic disorder that prevalent among populations surrounding the Mediterranean Sea. Since Mediterranean fever gene (MEFV) was discovered at 1997, some cases have been reported in countries not related or close to this area like Japan. In addition it has been generally accepted that the clinical onset of FMF begins before 20 yr of age in most patients. Onset of the disease at an older age may occur but is rare. Adult-onset FMF may be a form of disease with distinct clinical, demographic and molecular characteristics. We describe a case of adult-onset FMF confirmed by DNA analysis of the MEFV gene in a Korean patient. A 32-yr-old man, who has no family history of FMF, presented with periodic fever, abdominal pain and vomiting. Though several various tests were thoroughly performed to evaluate the cause of his symptoms, there was no evidence of infectious, autoimmune or neoplastic diseases. Several gene analysis of periodic fever syndrome was finally performed and two point mutations (p.Leu110Pro, p.Glu148Gln) were identified. We confirmed the first adult case of FMF through detection of MEFV gene mutations in Korea and describe his clinical characteristics.

Spontaneous Biloma Caused by Pancreatic Cancer and Treated by Endoscopic Biliary Stenting / 대한소화기내시경학회지

Biloma is a rare disorder, and is defined as an abnormal extrahepatic or intrahepatic collection of bile within a defined capsular space. The common causes of biloma are iatrogenic and trauma. Spontaneous biloma, especially caused by pancreatic cancer, is very rare. An 86-year-old man was admitted with abdominal pain and fever. The patient denied a history of abdominal surgery, endoscopic retrograde cholangiography, or trauma. Abdominal computed tomography demonstrated a huge collection of fluid in the left lobe of the liver, dilatation of the intra and proximal common bile duct, and a heterogeneous enhancing mass in the pancreatic head portion. Percutaneous drainage under ultrasound guidance was performed, and the fluid analysis was compatible with biloma. A plastic stent was endoscopically inserted into the common bile duct to treat continuous drainage of the fluid despite percutaneous drainage. We report a case of biloma developed spontaneously in a patient with pancreatic cancer and successfully treated by endoscopic biliary stenting.

A Case of Pneumatosis Cystoids Intestinalis with Polymyositis / 대한소화기학회지

Pneumatosis cystoides intestinalis (PCI), characterized by presence of intramural gas cyst in the intestinal wall is associated with various medical condition. Polymyosistis, however, is rarely associated with PCI. Few cases are reported in the world, and none has not been reported previously in Korea. A 67-year-old woman with polymyositis developed mild abdominal pain and abdominal distension during treatment with steroid and azathioprine. Radiographic findings including CT scan showed intraperitoneal free gas and intramural air, compatible with PCI. The patient's symptom and clinical findings improved after the treatment with antibiotics and high-dose oxygen therapy.

A Case of Pneumatosis Cystoids Intestinalis with Polymyositis / 대한소화기학회지

Pneumatosis cystoides intestinalis (PCI), characterized by presence of intramural gas cyst in the intestinal wall is associated with various medical condition. Polymyosistis, however, is rarely associated with PCI. Few cases are reported in the world, and none has not been reported previously in Korea. A 67-year-old woman with polymyositis developed mild abdominal pain and abdominal distension during treatment with steroid and azathioprine. Radiographic findings including CT scan showed intraperitoneal free gas and intramural air, compatible with PCI. The patient's symptom and clinical findings improved after the treatment with antibiotics and high-dose oxygen therapy.

A Case of Hemosuccus Pancreaticus Mistaken for Hemobilia / 대한소화기내시경학회지

Hemosuccus pancreaticus is a rare cause of chronic and intermittent chronic gastrointestinal hemorrhage, and this condition cannot be easily detected by endoscopy. We report here on a 51-year-old woman with obstructive jaundice and a history of acute pancreatitis and chronic alcoholism. Abdominal computed tomography showed a dilated distal common bile duct. We performed endoscopic retrograde cholangiopancreatography to decompress the bile duct and we found a blood clot on the orifice of the ampulla of Vater. Hemobilia with massive bleeding was seen during the examination. Angiography for controlling the hemorrhage showed the pseudoaneurysm of the pancreaticoduodenal artery. Angiographic embolization was successful for controlling the arterial hemorrhage. The patient remained symptom-free and he was discharged without complications.

The Usefulness of Double Balloon Enteroscopy for Diagnosis and Treatment of Small Bowel Diseases

BACKGROUND/AIMS: Double balloon eneterscopy is a promising endoscopic method to examine the entire small bowel and to conduct therapeutic procedures. This study was performed to evaluate the clinical outcome and usefulness of double balloon enteroscopy. METHODS: We enrolled patients with suspected small bowel disease. Double balloon enteroscopy was performed in 61 patients and 89 procedures were undetaken between August 2004 and October 2007 at Hangang Sacred Heart Hospital. RESULTS: Indications for double balloon enteroscopy were obscure gastrointestinal bleeding, chronic abdominal pain or diarrhea and the presence of a suspicious small bowel tumor. Double balloon enteroscopy contributed to the diagnosis of small bowel diseases in 82.0% of patients. In 46 patients (75.4%), specific treatments were influenced by the results of double balloon enteroscopy. There were no significant complications. CONCLUSIONS: Double balloon enteroscopy is one of the most useful methods for the diagnosis and treatment of small bowel disease.

A Case of Brunner's Gland Hyperplasia of the Duodenal Second Portion with Annular Stricture Causing an Induced Obstruction / 대한소화기내시경학회지

Brunner's gland hyperplasia is a tumor arising from the Brunner's gland and the lesions account for 10.6% of benign duodenal tumors. These lesions are usually asymptomatic and detected incidentally by endoscopy or by a UGI barium study. In the case of severe and atypical forms, these lesions cause bleeding, intestinal obstruction or intussuception. However, Brunner's gland hyperplasia causing an annular duodenal stricture and subsequent intestinal obstruction has been rarely reported. We report here a very rare case of Brunner's gland hyperplasia presenting as an annular stricture and obstruction.