The Usefulness of Argon Plasma Coagulation Compared with Endoscopic Submucosal Dissection to Treat Gastric Adenoma / 대한소화기학회지

BACKGROUND/AIMS: To date, the best therapeutic modality for gastric adenoma, especially low-grade adenoma, has not been established. The aim of this study was to assess the usefulness of argon plasma coagulation (APC) in treating gastric adenoma compared with endoscopic submucosal dissection (ESD). METHODS: We included 210 patients with gastric adenoma, who underwent treatment with either APC (97 patients) or ESD (113 patients). The clinical and pathologic characteristics, mean duration of hospital stay, complications, and recurrence rates between the two groups were compared. RESULTS: The mean adenoma size was 0.9 cm and 1.1 cm in the APC group and ESD group, respectively (p<0.001). The mean duration of hospital stay was significantly shorter in the APC group than in the ESD group (1.6 days vs. 5.8 days, p<0.001). Complications did not occur in the APC group. However, one case of perforation (0.9%) and 6 cases of bleeding (5.3%) occurred in the ESD group. The recurrence rates were 15.3% (15/97 patients) in the APC group and 3.5% (4/113 patients) in the ESD group (p=0.003). The proportion of hospitalization was less in the APC group (43.3%, 42/97) than in the ESD group (100.0%, 113/113) (p<0.001). Medical expense was less in the APC group (377,172 won) than in the ESD group (1,430,610 won) (p<0.001). CONCLUSIONS: The findings of this study suggest that APC is a safe treatment method for gastric adenoma without serious complications. However, regular endoscopic follow-up is necessary to detect any residual or recurrent lesions due to the relatively high rate of local recurrence after APC.

Obstructive ileus caused by phlebosclerotic colitis

A 57-year-old man with chronic kidney disease and a history of using numerous herbal medications visited Inje University Ilsan Paik Hospital for abdominal pain and vomiting. An abdominal radiograph showed diffuse small bowel distension containing multiple air-fluid levels and extensive calcifications along the colon. Computed tomography showed colon wall thickening with diffuse calcification along the colonic mesenteric vein and colonic wall. Colonoscopy, performed without bowel preparation, showed bluish edematous mucosa from the transverse to the distal sigmoid colon, with multiple scar changes. At the mid transverse colon, a stricture was noted and the scope could not pass through. A biopsy of the stricture site revealed nonspecific changes. The patient was diagnosed with phlebosclerotic colitis. After the colonoscopy, the obstructive ileus spontaneously resolved, and the patient was discharged without an operation. Currently, after 2 months of follow-up, the patient has remained asymptomatic. Herein, we report the rare case of an obstructive ileus caused by phlebosclerotic colitis with a colon stricture.

Obstructive ileus caused by phlebosclerotic colitis

A 57-year-old man with chronic kidney disease and a history of using numerous herbal medications visited Inje University Ilsan Paik Hospital for abdominal pain and vomiting. An abdominal radiograph showed diffuse small bowel distension containing multiple air-fluid levels and extensive calcifications along the colon. Computed tomography showed colon wall thickening with diffuse calcification along the colonic mesenteric vein and colonic wall. Colonoscopy, performed without bowel preparation, showed bluish edematous mucosa from the transverse to the distal sigmoid colon, with multiple scar changes. At the mid transverse colon, a stricture was noted and the scope could not pass through. A biopsy of the stricture site revealed nonspecific changes. The patient was diagnosed with phlebosclerotic colitis. After the colonoscopy, the obstructive ileus spontaneously resolved, and the patient was discharged without an operation. Currently, after 2 months of follow-up, the patient has remained asymptomatic. Herein, we report the rare case of an obstructive ileus caused by phlebosclerotic colitis with a colon stricture.

Intramural Duodenal Hematoma after Transpancreatic Septotomy during ERCP: A Case Report and Literature Review / 대한췌담도학회지

Transpancreatic septotomy is known to improve the success rate of selective bile duct cannulation in endoscopic retrograde cholangiopancreatography. Recent retrospective study reported that transpancreatic septotomy is more effective and safer than needle knife sphincterotomy. Herein, we report a case of patient with gallstone pancreatitis who suffered from intramural duodenal hematoma after transpancreatic septotomy that caused obstruction of the duodenum and hypovolemic shock. The intramural hematoma improved after conservative management. The rare adverse event such as intramural duodenal hematoma seems to be considered after transpancreatic septotomy, especially when acute pancreatitis is accompanied.

Acute pancreatitis associated with pegylated interferon-alpha-2a therapy in chronic hepatitis C

Chronic hepatitis C virus (HCV) infection is a major cause of liver cirrhosis and hepatocellular carcinoma. Combination therapy of pegylated interferon-alpha (PEG-IFN-α) and ribavirin (RBV) is a current standard treatment for chronic HCV infection in Korea, which has considerable adverse effects. Acute pancreatitis is a rare complication of PEG-IFN-α administration. We report a case of a 62-year-old female who experienced acute pancreatitis after 4 weeks of PEG-IFN-α-2a and RBV combination therapy for chronic HCV infection. The main cause of the acute pancreatitis in this case was probably PEG-IFN-α rather than RBV for several reasons. A few cases have been reported in which acute pancreatitis occurred during treatment with PEG-IFN-α-2b. This is the first report of acute pancreatitis associated with PEG-IFN-α-2a in Korea.

Long-term virological outcome in chronic hepatitis B patients with a partial virological response to entecavir

BACKGROUND/AIMS: The clinical outcome of patients with a partial virological response (PVR) to entecavir (ETV), in particular nucloes(t)ide analogue (NA)-experienced patients, has not been thoroughly investigated. The aim of the present study was to assess long-term outcomes in NA-naive and NA-experienced chronic hepatitis B patients with a PVR to ETV. METHODS: Chronic hepatitis B patients treated with ETV (0.5 mg/day) for at least 1 year were enrolled retrospectively. PVR was defined as a decrease in hepatitis B virus (HBV) DNA titer of more than 2 log10 IU/mL, yet with residual serum HBV DNA, as determined by real time-polymerase chain reaction, at week 48 of ETV therapy. RESULTS: A total of 202 patients (127 NA-naive and 75 NA-experienced, male 70.8%, antigen positive 53.2%, baseline serum HBV DNA 6.2 +/- 1.5 log10 IU/mL) were analyzed. Twenty-eight patients demonstrated a PVR. The PVR was associated with a high serum HBV DNA titer at baseline and at week 24. Virological response (< 60 IU/mL) was achieved in 46.2%, 61.5%, 77.6%, and 85% of patients with PVR at week 72, 96, 144, and 192, respectively. Resistance to antivirals developed in two NA-experienced patients. Failure of virological response (VR) in patients with PVR was associated with high levels of serum HBV DNA at week 48. CONCLUSIONS: Patients with PVR to ETV had favorable long-term virological outcomes. The low serum level of HBV DNA (< 200 IU/mL) at week 48 was associated with subsequent development of a VR in patients with PVR to ETV.

Tenofovir disoproxil fumarate monotherapy for nucleos(t)ide analogue-naive and nucleos(t)ide analogue-experienced chronic hepatitis B patients

BACKGROUND/AIMS: This study investigated the antiviral effects of tenofovir disoproxil fumarate (TDF) monotherapy in nucleos(t)ide analogue (NA)-naive and NA-experienced chronic hepatitis B (CHB) patients. METHODS: CHB patients treated with TDF monotherapy (300 mg/day) for > or =12 weeks between December 2012 and July 2014 at a single center were retrospectively enrolled. Clinical, biochemical, and virological parameters were assessed every 12 weeks. RESULTS: In total, 136 patients (median age 49 years, 96 males, 94 HBeAg positive, and 51 with liver cirrhosis) were included. Sixty-two patients were nucleos(t)ide (NA)-naive, and 74 patients had prior NA therapy (NA-exp group), and 31 patients in the NA-exp group had lamivudine (LAM)-resistance (LAM-R group). The baseline serum hepatitis B virus (HBV) DNA level was 4.9+/-2.3 log IU/mL (mean+/-SD), and was higher in the NA-naive group than in the NA-exp and LAM-R groups (5.9+/-2.0 log IU/mL vs 3.9+/-2.0 log IU/mL vs 4.2+/-1.7 log IU/mL, P<0.01). The complete virological response (CVR) rate at week 48 in the NA-naive group (71.4%) did not differ significantly from those in the NA-exp (71.3%) and LAM-R (66.1%) groups. In multivariate analysis, baseline serum HBV DNA was the only predictive factor for a CVR at week 48 (hazard ratio, 0.809; 95% confidence interval, 0.729-0.898), while the CVR rate did not differ with the NA experience. CONCLUSIONS: TDF monotherapy was effective for CHB treatment irrespective of prior NA treatment or LAM resistance. Baseline serum HBV DNA was the independent predictive factor for a CVR.

Difference in Adenoma Detection Rates according to Colonoscopic Withdrawal Times and the Level of Expertise / 대한소화기학회지

BACKGROUND/AIMS: Adequate screening colonoscopy in the general population decreases the mortality associated with colorectal cancer through detection and removal of adenomatous polyps. Prolonged colonoscopic withdrawal times (>6 min) are reportedly beneficial for adenoma detection rates (ADRs). However, the quality of the endoscopist compared with colonoscopic withdrawal times is not known. The aims of this study were to investigate the difference in ADRs between trainees and experienced examiners. METHODS: A total of 967 consecutive patients who underwent screening colonoscopy in a single University hospital from June 2010 to November 2011 were enrolled in this prospective observational study. Colonoscopy was performed by four experienced staff and seven gastroenterology fellows. RESULTS: Seven gastroenterology fellows performed 633 colonoscopies and four experienced staff performed 334 colonoscopies. The overall detection rates of colorectal adenoma were 31.5% with ADRs of fellows and staff of 29.4% and 35.6%, respectively (p=0.047). Fellows also showed lower advanced ADRs (5.7% vs. 9.9%, p=0.016), and fellows had longer mean withdrawal times than staff (12.4+/-4.9 min vs. 8.2+/-4.1 min, p<0.001). Multivariate analysis showed significantly increased ADRs and advanced ADRs for staff compared with fellows (adjusted OR 2.41, 95% CI 1.70-3.43; adjusted OR 2.55, 95% CI 1.47-4.45, respectively). CONCLUSIONS: ADRs were significantly lower when colonoscopy was performed by trainees, although withdrawal times were longer than those of staff. Our results demonstrated that the quality of colonoscopy, as measured by ADRs, may be improved by experienced examiners.

A Case of Small Cell Neuroendocrine Tumor Occurring at Hilar Bile Duct / 대한소화기학회지

Neuroendocrine tumors of the extrahepatic biliary tree are extremely rare malignancies accounting for 0.2-2.0% of all gastrointestinal carcinoid tumors. Neuroendocrine tumors obstructing the biliary tree are extremely difficult to diagnose preoperatively and nearly impossible to differentiate from cholangiocarcinoma. Statistically, the most common anatomic location in the biliary tree is the common bile duct, followed by the perihilar region. Herein, we present a case of a small cell neuroendocrine carcinoma of the hilum in a 79-year-old man following laparotomy. To our knowledge, this is the first case of small cell type neuroendocrine carcinoma of hilar bile duct reported in Korea.

Risk Factors of Cryptogenic Hepatocellular Carcinoma in Patients with Low Body Mass Index or without Metabolic Syndrome

BACKGROUND/AIMS: Many patients are diagnosed with cryptogenic hepatocellular carcinoma (HCC) without metabolic syndrome (MS). We investigated the risk factors for cryptogenic HCC in patients with a low body mass index (BMI) or without MS. METHODS: Thirty-six patients were diagnosed with cryptogenic HCC over a 10-year period at a tertiary research hospital. Data including BMI score and risk factors for MS were analyzed retrospectively. Patients with fewer than two risk factors for MS (n = 16) were compared with those with two or more risk factors (n = 20). Patients with high BMI (> or = 23 kg/m2, n = 20) were also compared with those with lower BMI (n = 16). RESULTS: Patients with fewer than two risk factors for MS were significantly more likely to smoke and be hepatitis B surface antibodies (anti-HBs)-positive vs. patients with two or more risk factors. However, only smoking was statistically significant on multivariate analysis. Peaks of BMI were observed in two regions. Lower BMI was significantly associated with the presence of anti-HBs compared with high BMI, although this association was not statistically significant on multivariate analysis. CONCLUSIONS: Smoking is a potential risk factor for cryptogenic HCC in patients without MS. Remote hepatitis B virus infection may be a risk factor for cryptogenic HCC in patients without MS or with a low BMI.

CMV Gastric Ulcers Healed by Supportive Therapy / 대한소화기내시경학회지

Cytomegalovirus (CMV) is a potentially important pathogen in an immunocompromised host. CMV infection usually occurs in patients with severe immune deficiency, such as acquired immunodeficiency syndrome, organ transplantation, malignant disease, or immunosuppressive therapy. CMV can cause ulcerations anywhere in the GI tract ranging from the esophagus to the rectum, but the colon is the most susceptible organ in the GI tract. CMV infection rarely occurs but generally causes an asymptomatic or mildly symptomatic acute illness in immunocompetent patients. Some patients with gastrointestinal CMV disease do not require antiviral treatment such as ganciclovir and frequently recover with supportive therapy. Although in immunocompetent patients, antiviral therapy may be needed based on age, chronic illness, or treatment response. We experienced a case of CMV-induced multiple gastric ulcers with severe epigastric pain in an immunocompetent patient who fully recovered with supportive therapy including a proton pump inhibitor.

A Case of Gastric Low-grade MALT Lymphoma Induced by a Helicobacter heilmannii-like Organism / 대한소화기내시경학회지

Helicobacter heilmannii is a Gram negative, long spiral-shaped organism associated with zoonotic infections acquired from primates including cats and dogs. Infection with H. heilmannii leads to gastritis, peptic ulcer disease, gastric adenocarcinoma, and gastric mucosa-associated lymphoid tissue (MALT) lymphoma. We experienced a 54-year-old man with dyspepsia who was diagnosed with primary gastric MALT lymphoma (stage IE1) associated with a H. heilmannii-like organism. Upper gastrointestinal endoscopy revealed only microvascular dilatation and mucosal granularity without elevated or ulcerative lesions at the stomach angle. He was probably infected by a pet dog. The man was treated with eradication therapy for 2 weeks including lansoprazole, amoxicillin, and clarithromycin. Four weeks after eradication of the H. heilmannii-like organism, follow-up endoscopy and pathological biopsy findings showed complete remission of the gastric MALT lymphoma.

A Case of Churg-Strauss Syndrome Manifesting as Colonic Aphthous Ulcers with Granuloma / 대한소화기내시경학회지

Churg-Strauss syndrome is characterized by asthma, peripheral and tissue eosinophilia, extravascular granuloma formation, and vasculitis of multiple organ systems. The gastrointestinal tract may be involved in 20% to 50% of patients, mainly with abdominal pain, diarrhea and GI bleeding. Ulcers in the small and large bowel are an uncommon manifestation, usually detected during laparotomy performed in the setting of bowel perforation. Endoscopically proven segmental colonic aphthous ulcers with typical pathologic findings such as extravascular granuloma formation, eosinophilic infiltration, or vasculitis are a rarer manifestation. We present a patient with Churg-Strauss syndrome and two aphthous ulcers in the sigmoid colon that healed after treatment with high dose steroids and cyclophosphamide.

A Case of Autoimmune Hepatitis Combined with Ulcerative Colitis / 대한내과학회지

Autoimmune hepatitis (AIH), primary sclerosing cholangitis (PSC), and primary biliary cirrhosis (PBC) are the major immune-mediated chronic liver diseases. They are characterized by circulating autoantibodies, hypergammaglobulinemia, unique clinical features, and associations with other autoimmune diseases, such as inflammatory bowel disease and autoimmune thyroiditis. Primary biliary cirrhosis is known to be associated with inflammatory bowel disease, such as ulcerative colitis. On the other hand, autoimmune hepatitis is rarely associated with ulcerative colitis. Here, we report a case diagnosed as autoimmune hepatitis combined with ulcerative colitis on the basis of histological and endoscopic findings.

Ill-defined Granulomas Demonstrated in Ulcers of the Terminal Ileum and Transverse Colon in a Patient with Typhoid Fever / 대한소화기내시경학회지

Typhoid fever, the most serious human salmonellosis, is a systemic infectious disease caused by Salmonella enterica serovar Typhi and is characterized by prolonged fever, bacteremia, and multiplication of the organism within mononuclear phagocytic cells of the liver, spleen, lymph nodes, and Peyer's patches. The characteristic lesion of typhoid fever is an ulceration of the small intestinal lymphoid tissue, particularly the Peyer's patches. The usual histological findings of typhoid ulcer are necrosis and histiocytic proliferation that phagocytizes erythrocytes and degenerated lymphocytes. A granuloma is an unusual histopathological presentation of a typhoid lesion. Even if granulomas have been reported in the bone marrow, liver, and spleen in cases of typhoid fever, granulomas in primary ulcers of the ileum and transverse colon have been reported very rarely. We experienced a case of typhoid fever in which ill-defined granulomas were seen in ulcers of the terminal ileum and transverse colon.

A Case of Autoimmune Hepatitis Following Acute Hepatitis A / 대한소화기학회지

The pathogenesis of autoimmune hepatitis (AIH) is unclear, but viral infections have been proposed as a potential trigger in patients with genetic predisposition. We report a case of AIH following acute hepatitis A (AHA). A 57-year-old woman presented with fatigue and pitting edema for last 3 months. She had been diagnosed as an AHA 15 months ago based on clinical features, biochemical tests and positive HAV IgM antibody at a local clinic. Her biochemical tests was normalized one month after AHA diagnosis, but the serum levels of aminotransferase started to rise four months after AHA diagnosis. Antinuclear antibody was positive at a titer of 1:40, and anti-smooth muscle antibody was also positive. Hypergammaglobulinemia and liver pathology were typical for AIH. The patients had a score of 17 according to the International Autoimmune Hepatitis Group's system. She was given prednisolone and azathioprine and showed complete response to immunosuppressive therapy. The present case is the first report on AIH triggered by AHA in Korea.

A Huge Gastric Bezoar That Was Removed by Endoscopic Combination Therapy with an Argon Plasma and Coca-Cola Injection / 대한소화기내시경학회지

Bezoars are collections or concretions of indigestible foreign material in the gastrointestinal tract. In the past, the most common method for the treatment of bezoar was surgical management. The current treatment methods for bezoars include chemical dissolution and endoscopic lithotripsy using biopsy forceps and, snare, electrohydraulic lithotripsy and laser. Cases of endoscopic fragmentation of gastric bezoars using an argon plasma and dissolution of gastric bezoars with Cola have recently been described, but it took a long time in those cases to remove a bezoar by a single method. Moreover, fragmented, residual bezoar-related complications sometimes occurred. We report here on a case of a 35-year-old man with a 10x8x8 cm sized huge gastric bezoar that was successfully removed by combination therapy using an argon plasma and Coca-Cola injection. Compared with the previous single method, combination therapy using an argon plasma and Coca-Cola injection shortened the procedure time and reduced the complications related to a fragmented, remaining bezoar.

Two Cases of Foreign Body-induced Esophageal Perforation That Were Treated by Endoscopic Clipping and Non-surgical Management / 대한소화기내시경학회지

Perforation of the esophagus is a deadly injury that requires careful management if the patient is to survive. Prompt recognition and proper treatment of esophageal perforation may avert death or minimize complications. Esophageal perforation might be followed by mediastinitis, broncho-esophageal fistula, pneumomediastinum, peritonitis and empyema. Although primary surgical repair is the mainstay of treatment, non-surgical management can be attempted in selected patients. Endoscopic closure of an esophageal perforation with metallic clips and conservative therapy has recently been reported. We describe here two patients with esophageal perforation and pneumomediastinum that were caused by fish bones. One was completely closed by endoscopic clipping and the other was not. Non-surgical management that was made up of parenteral nutrition and antibiotic therapy produced the same successful outcomes in these two cases.

A Case of Psoriasis Induced by Infliximab Treatment for Crohn's Disease / 대한소화기학회지

Infliximab, the monoclonal antibody to tumor necrosis factor, is indicated for refractory luminal and fistulizing Crohn's disease and rheumatoid arthritis. Infliximab treatment has adverse events including infusion reactions, opportunistic infections, and the potential for the event such as reactivation of latent tuberculosis. Cutaneous adverse reactions of TNF-alpha agents include skin rash, urticaria, pruritus, lupus-like eruption, and injection site reactions. Most of all, psoriasis or psoriasiform dermatitis induced by infliximab treatment for Crohn's disease is rarely reported in Korea. We report a case of psoriasis induced by infliximab treatment for Crohn's disease with a review of world literature.

Cytomegalovirus Colitis with Ulcerative Colitis in the Steroid Naive Immunocompetent Patient / 대한소화기내시경학회지

Ulcerative colitis is an idiopathic chronic inflammatory bowel disease that exclusively involves the colon. It is characterized by diffuse mucosal inflammation and a recurrent course of remission and relapse. Factors such as smoking, diet, genetic factors and miocrobial infection have all been suggested as causes of ulcerative colitis. One of the important issues in the treatment of ulcerative colitis is opportunistic infection associated with the usage of corticosteroid and immunosuppresant. In most cases, opportunistic cytomegalovirus infection after treatment with corticosteroid or immunosuppressant worsens the course of ulcerative colitis. However, cytomegalovirus infection is uncommon in immunocompetent patients and it is rare in immunocompetent patients with corticosteroid naive ulcerative colitis. We report here on a case in which an immunocompetent patient was newly diagnosed with ulcerative colitis and cytomegalovirus coinfection simultaneously.