A Case of Allergic Reaction to 0.5% Moxifloxacin Eye Drops

Purpose@#We report a rare case of allergic contact dermatitis after the use of a non-preservative 0.5% moxifloxacin ophthalmic solution.Case summary: A 60-year-old male presented with bacterial corneal ulceration of the right eye. He was treated with 50 mg/mL of fortified cefazolin and 14 mg/mL of tobramycin that were tapered as the corneal lesion improved after 1 month, and 0.5% moxifloxacin application was started. After 2 weeks of moxifloxacin treatment, the patient developed conjunctival injection, lid swelling, redness, and itching in the right eye. An allergic reaction was suspected and moxifloxacin administration was immediately stopped. The symptoms improved after the administration of oral antihistamines, 0.5% loteprednol eye drops, and steroid combination ointment. @*Conclusions@#Patients treated with 0.5% topical moxifloxacin should be monitored for allergic contact dermatitis, even if preservative-free eye drops are used.

ILM Insertion for the Treatment of Macular Hole Associated with Phakic Intraocular Lens Implantation

Purpose@#To report a case of macular hole closure using an internal limiting membrane (ILM) flap following implantation of a posterior chamber phakic implantable contact lens (ICL).Case summary: An 18-year-old female patient presented with visual loss of the left eye after ICL implantation. She had high myopia of -12.5 diopter (spherical equivalent) and a corrected visual acuity of 2/100. The fundus photograph and optical coherence tomography showed a full-thickness macular hole measuring 688 µm in width and 976 µm in length. The ILM around the hole was detached from the retinal surface, which was greater in size than the macular hole. The initial surgical intervention involved vitrectomy, inverted ILM flap placement, and gas tamponade. The decrease in gas volume was associated with a loss of the ILM flap. For hole closure, the remaining ILM flap in the peripheral macula was harvested and inserted in the hole during the second surgery. The silicone oil was used for tamponade. One month after ILM insertion, complete closure of the hole was observed. The visual acuity improved to 20/40 after silicone oil removal. @*Conclusions@#A large full-thickness macular hole developed after ICL implantation in a patient with high myopia. Macular hole surgery using ILM insertion and prolonged tamponade closed the hole and effectively improved the visual acuity.

Biliary Self-Expandable Metal Stent Could Be Recommended as a First Treatment Modality for Immediate Refractory Post-Endoscopic Retrograde Cholangiopancreatography Bleeding

Background/Aims@#Recent reports suggest that the biliary self-expandable metallic stent (SEMS) is highly effective for maintaining hemostasis when endoscopic hemostasis fails in endoscopic retrograde cholangiopancreatography (ERCP)-related bleeding. We compared whether temporary SEMS offers better efficacy than angioembolization for refractory immediate ERCP-related bleeding. @*Methods@#Patients who underwent SEMS placement or underwent angioembolization for bleeding control in refractory immediate ERCP-related bleeding were included in the retrospective analysis. We evaluated the hemostasis success rate, severity of bleeding, change in hemoglobin levels, amount of transfusion, and delay to the start of hemostasis. @*Results@#A total of 27 patients with SEMS and 13 patients who underwent angioembolization were enrolled. More transfusions were needed in the angioembolization group (1.0±1.4 units vs. 2.5±2.0 units; p=0.034). SEMS failure was successfully rescued by angioembolization. The partially covered SEMS (n=23, 85.1%) was generally used, and the median stent-indwelling time was 4 days. The mean delay to the start of angioembolization was 95.2±142.9 (range, 9–491) min. @*Conclusions@#Temporary SEMS had similar results to those of angioembolization (96.3% vs. 92.3%; p=0.588). Immediate SEMS insertion is considered a bridge treatment modality for immediate refractory ERCP-related bleeding. Angioembolization still has a role as rescue therapy when SEMS does not work effectively.

Epidemiology of Urolithiasis with Sex and Working Status Stratification Based on the National Representative Cohort in Republic of Korea

Background@#This study aimed to estimate the annual prevalence and incidence of urolithiasis stratified by work status based on a large nationwide sample. @*Methods@#This study used data from the National Health Insurance Service-National Sample Cohort from 2002 to 2015. The prevalence and incidence of urolithiasis were estimated based on work status and gender stratification. The risk of urolithiasis among workers was calculated using age-standardized incidence ratio with stratification of work type. @*Results@#The prevalence of urolithiasis was significantly higher in workers than in non-workers, especially men, during the follow-up period. The total estimated number of urolithiasis cases was 41,086 and the overall incidence of urolithiasis was 0.3%. The age-standardized incidence ratio of urolithiasis was significantly higher among the total workers (1.14; 95% confidence interval, 1.13–1.16), self-employed workers (1.08; 95% confidence interval, 1.06–1.11), and paid workers (1.19; 95% confidence interval, 1.17–1.21) than among the non-working population. @*Conclusions@#Workers, especially paid workers and men, were vulnerable to urolithiasis. Further studies are required to investigate the effects of working conditions on urolithiasis.

Endoscopic hemostasis using an over-the-scope clip for massive bleeding after percutaneous endoscopic gastrostomy removal: a case report

Percutaneous endoscopic gastrostomy (PEG) is a common method for providing long-term enteral nutrition to patients. PEG tube placement and removal are relatively safe; generally, a PEG tube can be removed using gentle traction, and excessive bleeding is rare. The over-the-scope clip system is a new device that can be used for gastrointestinal hemostasis and for closing gastrointestinal fistulae. In the present case, a 68-year-old male patient had to remove the PEG tube because of persistent leakage around the PEG tube. Although it was gently removed using traction, incessant bleeding continued, with a Rockall score of 5 points, even after hemocoagulation was attempted. An over-the-scope clip device was used to achieve hemostasis and fistula closure.

Difficult Biliary Cannulation from the Perspective of PostEndoscopic Retrograde Cholangiopancreatography Pancreatitis:Identifying the Optimal Timing for the Rescue Cannulation Technique

Background/Aims@#Recently, the European Society of Gastrointestinal Endoscopy (ESGE) proposed criteria for “difficult biliary cannulation” during endoscopic retrograde cholangiopancreatography (ERCP). This study aimed to investigate the clinical relevance of the ESGE criteria from the perspective of post-ERCP pancreatitis (PEP). @*Methods@#An ERCP database was prospectively maintained between November 2014 and December 2015 across six teaching hospitals in South Korea. The ESGE criteria (biliary cannulation time, the number of cannulation attempts, and inadvertent pancreatic duct [PD] manipulation) were recorded in this database as well as other technical factors. Logistic regression analysis was used to identify risk factors for PEP. Then, the PEP prediction model was investigated using decision tree analysis. @*Results@#We analyzed 1,067 consecutive patients with naïve papilla. The overall rate of PEP was 6.6%. Multivariate analysis revealed that female sex (odds ratio [OR], 1.860; 95% confidence interval [CI], 1.124 to 3.078), a selective biliary cannulation duration >5 minutes (OR, 3.282; 95% CI, 1.641 to 6.566), and inadvertent PD manipulation (OR, 2.614; 95% CI, 1.480 to 4.617) were significant factors affecting PEP. Decision tree analysis revealed that biliary cannulation time (χ2 =49.857, p5 minutes, and >5 minutes with inadvertent PD manipulation, respectively. @*Conclusions@#Biliary cannulation time and inadvertent PD manipulation could be relevant indicators of PEP, and 5 minutes might be used as a cutoff value for the implementation of the rescue cannulation technique.

Difficult Biliary Cannulation from the Perspective of PostEndoscopic Retrograde Cholangiopancreatography Pancreatitis:Identifying the Optimal Timing for the Rescue Cannulation Technique

Background/Aims@#Recently, the European Society of Gastrointestinal Endoscopy (ESGE) proposed criteria for “difficult biliary cannulation” during endoscopic retrograde cholangiopancreatography (ERCP). This study aimed to investigate the clinical relevance of the ESGE criteria from the perspective of post-ERCP pancreatitis (PEP). @*Methods@#An ERCP database was prospectively maintained between November 2014 and December 2015 across six teaching hospitals in South Korea. The ESGE criteria (biliary cannulation time, the number of cannulation attempts, and inadvertent pancreatic duct [PD] manipulation) were recorded in this database as well as other technical factors. Logistic regression analysis was used to identify risk factors for PEP. Then, the PEP prediction model was investigated using decision tree analysis. @*Results@#We analyzed 1,067 consecutive patients with naïve papilla. The overall rate of PEP was 6.6%. Multivariate analysis revealed that female sex (odds ratio [OR], 1.860; 95% confidence interval [CI], 1.124 to 3.078), a selective biliary cannulation duration >5 minutes (OR, 3.282; 95% CI, 1.641 to 6.566), and inadvertent PD manipulation (OR, 2.614; 95% CI, 1.480 to 4.617) were significant factors affecting PEP. Decision tree analysis revealed that biliary cannulation time (χ2 =49.857, p5 minutes, and >5 minutes with inadvertent PD manipulation, respectively. @*Conclusions@#Biliary cannulation time and inadvertent PD manipulation could be relevant indicators of PEP, and 5 minutes might be used as a cutoff value for the implementation of the rescue cannulation technique.

Removal of a Large, Intractable Common Bile Duct Stone by Direct Peroral Cholangioscopy Using Upper Gastrointestinal Endoscopy and Polypectomy Snare / 대한소화기학회지

ERCP is the standard treatment for common bile duct stones. On the other hand, 10-15% of cases involve intractable common bile duct stones, which cannot be treated by conventional biliary sphincterotomy with a stone retrieval method. Large bile duct stones are typically managed by mechanical lithotripsy and endoscopic papillary large balloon dilatation. Peroral cholangioscopy techniques can be applied if this technique fails. In the present case, a 67-year-old woman had a large common bile duct stone that could not be retracted using the conventional ERCP stone extraction method. The common bile duct stone was eventually removed by direct peroral upper gastrointestinal endoscopy and a polypectomy snare.

Prognostic Implication of Volumetric Quantitative CT Analysis in Patients with COVID-19: A Multicenter Study in Daegu, Korea

Objective@#Lung segmentation using volumetric quantitative computed tomography (CT) analysis may help predict outcomes of patients with coronavirus disease (COVID-19). The aim of this study was to investigate the relationship between CT volumetric quantitative analysis and prognosis in patients with COVID-19. @*Materials and Methods@#CT images from patients diagnosed with COVID-19 from February 18 to April 15, 2020 were retrospectively analyzed. CT with a negative finding, failure of quantitative analysis, or poor image quality was excluded. CT volumetric quantitative analysis was performed by automated volumetric methods. Patients were stratified into two risk groups according to CURB-65: mild (score of 0–1) and severe (2–5) pneumonia. Outcomes were evaluated according to the critical event-free survival (CEFS). The critical events were defined as mechanical ventilator care, ICU admission, or death.Multivariable Cox proportional hazards analyses were used to evaluate the relationship between the variables and prognosis. @*Results@#Eighty-two patients (mean age, 63.1 ± 14.5 years; 42 females) were included. In the total cohort, male sex (hazard ratio [HR], 9.264; 95% confidence interval [CI], 2.021–42.457; p = 0.004), C-reactive protein (CRP) (HR, 1.080 per mg/dL;95% CI, 1.010–1.156; p = 0.025), and COVID-affected lung proportion (CALP) (HR, 1.067 per percentage; 95% CI, 1.033– 1.101;p < 0.001) were significantly associated with CEFS. CRP (HR, 1.164 per mg/dL; 95% CI, 1.006–1.347; p = 0.041) was independently associated with CEFS in the mild pneumonia group (n = 54). Normally aerated lung proportion (NALP) (HR, 0.872 per percentage; 95% CI, 0.794–0.957; p = 0.004) and NALP volume (NALPV) (HR, 1.002 per mL; 95% CI, 1.000–1.004;p = 0.019) were associated with a lower risk of critical events in the severe pneumonia group (n = 28). @*Conclusion@#CRP in the mild pneumonia group; NALP and NALPV in the severe pneumonia group; and sex, CRP, and CALP in the total cohort were independently associated with CEFS in patients with COVID-19.

Impact of Hospital Volume and the Experience of Endoscopist on Adverse Events Related to Endoscopic Retrograde Cholangiopancreatography:A Prospective Observational Study

Background/Aims@#Few studies have addressed the relationship between the occurrence of adverse events (AEs) in endoscopic retrograde cholangiopancreatography (ERCP) and hospital case volume or endoscopist’s experience with inconsistent results. The aim of our study was to investigate the impact of hospital case volume and endoscopist’s experience on the AEs associated with ERCP and to analyze patient- and procedure-related risk factors for post-ERCP AEs. @*Methods@#From January 2015 to December 2015, we prospectively enrolled patients with naïve papilla who underwent ERCP at six centers. Patient- and procedure-related variables were recorded on data collection sheets at the time of and after ERCP. @*Results@#A total of 1,191 patients (median age, 71 years) were consecutively enrolled. The overall success rate of biliary cannulation was 96.6%. Overall, 244 patients (20.5%) experienced post-ERCP AEs, including pancreatitis (9.0%), bleeding (11.8%), perforation (0.4%), cholangitis (1.2%), and others (0.9%). While post-ERCP pancreatitis (PEP) was more common when the procedure was performed by less experienced endoscopists, bleeding was more common in high-volume centers and by less experienced endoscopists. Multivariate analysis showed that a less experience in ERCP was significantly associated with PEP (odds ratio [OR], 1.630; 95% confidence interval [CI], 1.050 to 2.531; p=0.030) and post-ERCP bleeding (OR, 1.439; 95% CI, 1.003 to 2.062; p=0.048). @*Conclusions@#Our study demonstrated that overall AEs following ERCP were associated with the experience of the endoscopist. To minimize post-ERCP AEs, rigorous training with a sufficient case volume is required, and treatment strategies should be modified according to the endoscopist’s expertise.

Palliative Measures with Ethanol Gallbladder Ablation and Endobiliary Radiofrequency Ablation Followed by Endoscopic Biliary Stent Placement in an Advanced Case of Common Bile Duct Cancer: A Case Report / 대한소화기학회지

Endobiliary radiofrequency ablation (RFA) is a procedure performed widely to induce locoregional tumor control by the transfer of thermal energy to the lesion and subsequent tumor necrosis. A 72-year-old male with a prior history of acute calculous cholangitis and perforated cholecystitis was admitted to the Kyungpook National University Hospital complaining of fever and nausea. He had an indwelling percutaneous transhepatic gallbladder drainage (PTGBD) catheter from the previous episode of perforated cholecystitis. An abdominal CT scan showed marked dilation of both the intrahepatic and extrahepatic bile ducts. Common bile duct cancer was confirmed histologically after an endobiliary biopsy. A surgical resection was considered to be the initial treatment option. During open surgery, multiple metastatic nodules were present in the small bowel mesentery and anterior abdominal wall. Resection of the tumor was not feasible, so endobiliary RFA was performed prior to biliary stenting. Cholecystectomy was required for the removal of the PTGBD catheter, but the surgical procedure could not be performed due to a cystic ductal invasion of the tumor. Instead, chemical ablation of the gallbladder (GB) with pure ethanol was performed to breakdown the GB mucosa. Palliative treatment for a biliary obstruction was achieved successfully using these procedures. In addition, a PTGBD catheter was removed successfully without significant side effects. As a result, an improvement in the patient's quality of life was accomplished.

Effects of bispectral index monitoring as an adjunct to nurse-administered propofol combined sedation during colonoscopy: a randomized clinical trial

BACKGROUND/AIMS: The efficacy of bispectral index (BIS) monitoring during colonoscopic sedation is debated. We aimed to determine whether BIS monitoring was useful for propofol dose titration, and to evaluate differences in sedative administration between expert and inexperienced medical personnel during colonoscopy procedures that required moderate sedation. METHODS: Between February 2012 and August 2013, 280 consecutive patients scheduled to undergo a screening colonoscopy participated in this study and were randomly allocated to the expert or inexperienced endoscopist group. Each group was further divided into either a BIS or a modified Observer's Assessment of Alertness/Sedation Scale (MOAA/S) subgroup. Trained nurses administered combined propofol sedation and monitored sedation using either the BIS or MOAA/S scale. RESULTS: The mean BIS value throughout the procedure was 74.3 +/- 6.7 for all 141 patients in the BIS group. The mean total propofol dose administered in the BIS group was higher than that in the MOAA/S group, independently of the endoscopists' experience level (36.9 +/- 29.6 and 11.3 +/- 20.7, respectively; p < 0.001). The total dose of propofol administered was not significantly different between the inexperienced endoscopist group and the expert endoscopist group, both with and without the use of BIS (p = 0.430 and p = 0.640, respectively). CONCLUSIONS: Compared with monitoring using the MOAA/S score alone, BIS monitoring was not effective for titrating the dose of propofol during colonoscopy, irrespective of colonoscopist experience.

Removal of Choledocholith by Endoscopic Retrograde Cholangiopancreatography in a Situs Invsersus Patient / 대한소화기학회지

Situs inversus is an extremely rare autosomal recessive disease with left-right inversion of internal organs. It carries technical difficulties in diagnostic or therapeutic procedures. There have been a few case reports on stone extraction by ERCP in situs inversus patients. ERCP techniques in situs inversus can be classified into conventional method and mirror image method. In mirror image method, the procedure is performed with the patient in the right lateral decubitus position and the endoscopist on the patient's left side. Until now, there is no consensus about which method is better. Herein, we report an unusual case of choledocholithiasis in a patient with situs inversus who underwent ERCP for stone extraction by both conventional method and mirror image method.

Erratum: A Case of Pneumothorax Following Gastric Endoscopic Submucosal Dissection / 대한내과학회지

The legend of Figure 2 was given incorrectly.

A Case of Pneumothorax Following Gastric Endoscopic Submucosal Dissection / 대한내과학회지

Endoscopic submucosal dissection (ESD) is widely accepted as an alternative treatment to surgical resection for gastric neoplastic lesions. Among the complications of gastric ESD, perforation is usually manifested as a pneumoperitoneum. Here, we report a patient with a right-sided pneumothorax, pneumoperitoneum, and pneumoretroperitoneum as complications of gastric ESD. The patient recovered without further complications using conservative treatment, including endoscopic clipping, nasogastric drainage, and insertion of a chest tube.

Revised Atlanta Classification of Acute Pancreatitis Can Predict Clinical Outcome Better: a Retrospective, Multicenter Study / 대한췌담도학회지

BACKGROUND/AIMS: The 2012 revision of the Atlanta classification of acute pancreatitis (AP) by international consensus has been published and in use. This study investigated and compared clinical outcome of patients with AP stratified according to the 1992 Atlanta classification and revised classification. METHODS: A total of 574 AP patients from six referral hospitals between January 2012 and July 2013 were included. Medical records were reviewed retrospectively. Severity assessment according to both classifications was done. Demographics, organ failure, local complications, length of stay, and clinical outcome were recorded. RESULTS: There were 377 males (65.7%). Median age was 55.4 years. Two most common causes of AP were alcohol (n=238, 41.5%) and gallstone (n=193, 33.6%). According to revised classification, there were mild (n=356, 62%), moderately severe (n=197, 34.3%), and severe AP (n=21, 3.7%). Length of stay showed gradual increment with increase in degrees of severity according to the revised classification (5.9 days in mild AP, 8.3 days in moderately severe AP, and 13 days in severe AP, p<0.001). All the patients with mild and moderately severe AP improved, but all the 11 cases without improvement belonged to severe AP. CONCLUSIONS: The revised classification seems to be a good predictor for clinical outcome of AP.

The Effect of Concomittent Therarpy and Quadruple Therapy for Patients Who Had 23S Ribosomal Ribonucleic Acid Mutated Helicobacter pylori in Daegu and Kyoungpook Area

BACKGROUND/AIMS: Proton pump inhibitor (PPI) and two types of antimicrobial agents, amoxicillin, and clarithromycin have been widely used for the eradication of Helicobacter pylori. However, antibiotic resistant strains has rapidly increased and has emerged as an important factor for eraducation failure. MATERIALS AND METHODS: Patients diagnosed with chronic gastritis, peptic ulcer disease or gastric epithelial neoplasm was examined by H. pylori PCR for mutation at 23S rRNA. Positive H. pylori PCR without 23S rRNA mutation was eradicated by standard triple therapy. Patients with 23S rRNA mutation was eradicated by standard triple therapy or concomittent therapy with amoxicillin, PPI, clarithromycin and metronidazol or quadruple therapy with bismuth, PPI, tetracycline and metronidazol. We evaluated the predictors of eradication failure with regards to 23S rRNA mutation and initial eradication regimen. RESULTS: Nine hundred sixty-one patients were studied. H. pylori PCR was positive in 35.0% of the patients and 23S rRNA mutatation was found in 22.2% of the patients. The eradication rate of H. pylori for the A2143G point mutated group with standard triple therapy was 28.5% and significantly lower than 93.1% of the wild type group and 100% of the concomitant therapy group, 66.6% of one week quadruple group and 100% of two week quadruple group (P<0.005). CONCLUSIONS: When 23S rRNA point mutation was positive, the standard triple therapy was not effective and the eradication rates was only 22.2%. Alternative regimens should be considered when 23S rRNA point mutation is detected, especially when A2143G point mutation is detected because A2143G point mutation is highly related to eradication failure.

Changes in the Eradication Rate of Conventional Triple Therapy for Helicobacter pylori Infection in Korea / 대한소화기학회지

Although, the prevalence of Helicobacter pylori infection in Korea has declined owing to the eradication therapy, recent seroprevalence of H. pylori infection is still reported to be as high as 54.4%. Until now, "standard regimen" for eradication of H. pylori has been conventional triple therapy consisting of proton pump inhibitor, amoxicillin, and clarithromycin. However, with the increase in antibiotic resistance, especially against clarithromycin, the eradication rate of conventional triple therapy has steadily declined during the past 13 years in Korea. Present eradication rate of standard triple therapy is reported to be less than 80%, which is the Maginot line of efficacy for the currently available regimen. Therefore, new first line eradication regimen is needed to enhance the eradication rate of H. pylori infection.

A Double-Blind, Randomized, Active Drug Comparative, Parallel-Group, Multi-Center Clinical Study to Evaluate the Safety and Efficacy of Probiotics (Bacillus licheniformis, Zhengchangsheng(R) capsule) in Patients with Diarrhea

BACKGROUND/AIMS: Bacillus Licheniformis, a probiotic used in the treatment of diarrhea, has been shown to suppress the growth of pathologic bacteria. This study was performed to assess the therapeutic efficacy and safety of Zhengchangsheng(R) (Bacillus Licheniformis) in comparison with another probiotic, Bioflor(R) (Saccharomyces Boulardii) for the treatment of diarrhea. METHODS: Patients with diarrhea (n=158) were randomized to receive Zhengchangsheng(R) or Bioflor(R) for 5 days. The existence or non-existence of formed feces, changes in daily stool frequency, improvement of subjective symptoms, and changes in the severity of diarrhea were compared. RESULTS: Of the 158 full analysis set (FAS) patient population, 151 patients comprised the per protocol (PP) analysis. The rates of recovered to formed feces in the Bacillus and Saccharomyces groups were 91.0% vs. 95.0% in the FAS (P=0.326) and 90.5% vs. 96.1% in the PP analysis (P=0.169), respectively. The mean duration of diarrhea changing to formed feces was 3.15+/-1.10 days in the Bacillus group and 3.22+/-1.01 in the Saccharomyces group (P=0.695, FAS). The frequency of defecation, subjective symptoms, and degree of severe diarrhea were improved in both groups, however, there were no statistically significant differences between the 2 groups. Analysis of the 95% confidence intervals for the differences in the rate of recovery to formed feces between the 2 groups met the criteria for non-inferiority of Bacillus compared to Saccharomyces. No significant adverse events were observed during the study period. CONCLUSIONS: Zhengchangsheng(R) is not inferior to Bioflor(R) in therapeutic efficacy and is a safe and useful therapeutic agent for the treatment of diarrhea.

Two Human Cases of Diphyllobothrium nihonkaiense Infection in Korea

Diphyllobothrium latum and Diphyllobothrium nihonkaiense are the 2 reported main causes of human diphyllobothriasis in the Republic of Korea. However, the differentiation of these 2 species based on morphologic features alone is difficult. The authors used nucleotide sequencing of the mitochondrial cytochrome c oxidase subunit 1 (cox1) gene to diagnose Diphyllobothrium spp. Two patients visited the emergency room at Kyungpook National University Hospital on 3 April and 12 April 2013, respectively, with fragments of parasites found while defecating. The parasites were identified as Diphyllobothrium spp. based on morphologic characteristics, and subsequent cox1 gene sequencing showed 99.9% similarity (1,478/1,480 bp) with D. nihonkaiense. Our findings support the hypothesis that D. nihonkaiense is a dominant species in Korea.