Endoscopic Intranasal Marsupialization of the Isolated Mucocele in the Inferior Orbit.

ABSTRACT: Isolated intraorbital mucocele without anatomical communication between the sinus and orbital cavity, and all orbital walls are intact is rare. It may lead to many orbital symptoms including proptosis, diplopia, orbital pain. Traditionally, many cases of typical paranasal sinus mucocele are successfully treated with endoscopic marsupialization. Most of the isolated intraorbital mucoceles were treated with complete removal of the mucocele via an external approach. However, there are many disadvantages of the external approach, and a case of isolated intraorbital mucocele in medial orbit treated by endoscopic intranasal marsupialization was reported. Here, the authors report a case of isolated orbital mucocele in inferior orbit treated by endoscopic intranasal marsupialization.

Oltipraz therapy in patients with liver fibrosis or cirrhosis: a randomized, double-blind, placebo-controlled phase II trial.

OBJECTIVES: Oltipraz, a cancer chemopreventive agent, has an anticirrhotic effect in animals. A phase II trial was designed to investigate the preliminary efficacy of oltipraz therapy in liver fibrosis or cirrhosis. METHOD: Of 83 patients who were randomized to receive placebo, oltipraz 60 mg bid or oltipraz 90 mg qd for 24 weeks, 68 completed the study without any major protocol violation. Pre- and post-treatment liver biopsies, and blood fibrosis markers were assessed. KEY FINDINGS: Twenty-four weeks of oltipraz treatment showed no significant differences in the proportions of patients showing an improvement in histological outcomes, including Ishak fibrosis score. In the oltipraz 60 mg bid group, there was a trend of decreases in hepatic collagen area and plasma transforming growth factor-ß1 (TGF-ß1, a blood fibrosis marker) levels from baseline to week 24. In the per-protocol population (n = 68), decreases in plasma TGF-ß1 correlated with those in the Ishak fibrosis score, suggesting that circulating TGF-ß1 serves a possible indicator for fibrosis treatment. CONCLUSIONS: No significant differences in liver histological outcomes were seen among the three treatment groups in this 24-week pilot study. Our finding indicates an association between TGF-ß1 repression and improvement in the histological index of fibrosis.

Bismuth-containing quadruple therapy as second-line treatment for Helicobacter pylori infection: effect of treatment duration and antibiotic resistance on the eradication rate in Korea.

BACKGROUND: The eradication rate of first-line Helicobacter pylori treatment is only 70-85% and has been decreasing due to the increase in antibiotic resistance. The aim of this study was to evaluate the efficacy of bismuth-containing quadruple therapy as second-line treatment for H. pylori infection based on treatment duration. METHODS: We prospectively enrolled 227 patients that were found to have persistent H. pylori infection after first-line proton-pump inhibitor-clarithromycin-amoxicillin triple therapy. Patients were randomized to 1-week (112 patients) and 2-week (115 patients) quadruple therapy with tripotassium dicitrate bismuthate 300 mg q.i.d., metronidazole 500 mg t.i.d., and tetracycline 500 mg q.i.d. and esomeprazole 20 mg b.i.d. The eradication rate, drug compliance, and adverse events were compared based on treatment duration. RESULTS: The eradication rates were 72/112 (64.3%, 95% CI: 0.504-0.830) and 71/92 (77.2%, 0.440-0.749) with 1-week group, and 95/115 (82.6%, 1.165-2.449) an 88/94 (93.6%, 1.213-5.113) with 2-week group by intention-to-treat therapy (p = .002) and per-protocol analysis (p = .001), respectively. The adverse events increased as the treatment durations increased from 7 to 14 days (20.0 and 42.5%, respectively, p < .001). However, there was no significant difference in the patient compliance or the rate of major adverse events between the 1- and 2-week groups (6.3 and 12.5%, respectively, p = .133). CONCLUSION: Two-week bismuth-containing quadruple therapy was more effective than the 1-week treatment, and should be considered for second-line treatment in Korea.

Endoscopic pancreatic sphincterotomy: indications and complications.

BACKGROUND/AIMS: Although a few recent studies have reported the effectiveness of endoscopic pancreatic sphincterotomy (EPST), none has compared physicians' skills and complications resulting from the procedure. Thus, we examined the indications, complications, and safety of EPST performed by a single physician at a single center. METHODS: Among 2,313 patients who underwent endoscopic retrograde cholangiopancreatography between January 1996 and March 2008, 46 patients who underwent EPST were included in this retrospective study. We examined the indications, complications, safety, and effectiveness of EPST, as well as the need for a pancreatic drainage procedure and the concomitant application of EPST and endoscopic sphincterotomy (EST). RESULTS: Diagnostic indications for EPST were chronic pancreatitis (26 cases), pancreatic divisum (4 cases), and pancreatic cancer (8 cases). Therapeutic indications for EPST were removal of a pancreaticolith (10 cases), stent insertion for pancreatic duct stenosis (9 cases), nasopancreatic drainage (7 cases), and treatment of sphincter of Oddi dysfunction (1 case). The success rate of EPST was 95.7% (44/46). Acute complications of EPST included five cases (10.9%) of pancreatitis and one of cholangitis (2.2%). EPST with EST did not reduce biliary complications. Endoscopic pancreatic drainage procedures following EPST did not reduce pancreatic complications. CONCLUSIONS: EPST showed a low incidence of complications and a high rate of treatment success; thus, EPST is a relatively safe procedure that can be used to treat pancreatic diseases. Pancreatic drainage procedures and additional EST following EPST did not reduce the incidence of procedure-related complications.

[Is end stage renal disease a poor prognosis factor of ischemic colitis?].

BACKGROUND/AIMS: In general, ischemic colitis has a very good prognosis. However, there are a lot of controversies in relation to the prognostic factors. The aim of this study was to evaluate risk factors of severe ischemic colitis. METHODS: A retrospective study was undertaken of patients with ischemic colitis hospitalized at the Hanyang University Hospital during the interval 2004-2006. Patients were divided into two groups: those with mild course and those with severe course which led to operation, systemic inflammatory response syndrome, or death. RESULTS: A total of 41 cases (M/F=13/28, mean age=63.8 years) of biopsy proven ischemic colitis were included, of which 31 (75.6%) had a mild course and 10 (24.4%) a severe course. Coexisting medical diseases of patients were hypertension (n=24), diabetes (n=14), end-stage renal disease (n=11), cardiovascular disease (n=5), and malignancy (n=5). Male (p=0.049), alcoholics (p=0.025), end-stage renal disease (p=0.013), LDH (p=0.002), CRP (p=0.014), and peritoneal irritation sign (p=0.001) were the significant risk factors of severe ischemic colitis in univariate analysis. In multivariate logistic regression analysis, end-stage renal disease (p=0.026) was the only significant risk factor of severe ischemic colitis. CONCLUSIONS: Careful attention must be paid to end-stage renal disease patients having ischemic colitis.

Significance of colonoscope length in cecal insertion time.

BACKGROUND: According to a previous study, a longer insertion time was associated with inadequate bowel cleansing, advanced age, constipation, surgical history, sex, and a low body mass index. However, there are only a few studies on the association between cecal insertion time and colonoscope length (long vs intermediate). OBJECTIVE: To assess the association of colonoscope length and cecal insertion time. DESIGN: Prospective comparative trial, with systematic assignment to colonoscope length. PATIENTS: A total of 998 colonoscopic examinations were performed by a single endoscopist, who used video colonoscopes. MAIN OUTCOME MEASUREMENTS: Cecal insertion times and their potential covariates. RESULTS: The mean (+/-SEM) age was 49.06 +/- 0.4 years, 61% were men, and the mean (+/-SEM) body mass index was 24.17 +/- 2.96. The mean (+/-SEM) cecal insertion time was 4.68 +/- 0.09 minutes. Multivariate regression analysis demonstrated that sex (female, P = .000), colonoscope length (long, P = .000), increasing age (P = .000), percentage of body fat (P = .006), and inadequate bowel cleansing (P = .002) were independent factors associated with a longer insertion time. LIMITATIONS: All procedures were performed by only one gastroenterologist, so the individual characteristics of colonoscopic procedures could be affected by a consequent bias. CONCLUSIONS: This large, cross-sectional study identified colonoscope length as a useful factor that affected cecal insertion time.

Association between GERD-related erosive esophagitis and obesity.

BACKGROUND AND OBJECTIVES: To date, many studies have reported on the association of obesity with gastroesophageal reflux disease (GERD), although none of these have been systematic. In light of this, we conducted this study to examine the association of obesity and GERD. SUBJECTS AND METHODS: A total of 3363 patients underwent gastroscopy at Hanyang University Health Promotion Center. Among these patients, we prospectively examined patients who were diagnosed with GERD-related erosive esophagitis on endoscopy. RESULTS: Multivariate analysis showed that the significant risk factors were waist-to-hip ratio (WHR), hiatal hernia, body mass index (BMI), and smoking. As compared with patients who had a WHR less than 0.8, the multivariate odds ratio for erosive esophagitis were 4.055 for a WHR more than 1.0 and 2.316 for a WHR of 0.8 to 1.0. As compared with patients who had a BMI of 20 to 22.5, the multivariate odds ratio for erosive esophagitis was 3.308 (95% confidence interval, 1.792 to 6.107) for a BMI greater than 30. CONCLUSIONS: Obesity, especially abdominal obesity, was the significant risk factor for erosive esophagitis.

Prevalence of gastroesophageal reflux disease symptoms and uninvestigated dyspepsia in Korea: a population-based study.

Various reports on the prevalence of gastroesophageal reflux disease (GERD) and uninvestigated dyspepsia have been conducted in Western countries. We sought to determine the frequency of GERD symptoms and uninvestigated dyspepsia in Korea. Telephone interviews were conducted with 1,044 individuals. Of all subjects, 7.1% reported that GERD symptoms were present at least once a week, and 3.8% at least twice a week. The prevalence of heartburn according to educational level and acid regurgitation according to age was significantly different (P < 0.05). The prevalence of uninvestigated dyspepsia was reported as 12.2%. Dyspepsia was divided into subgroups of 34% ulcer-like, 56% dysmotility-like, and 10% nonspecific. The occurrence of dyspepsia did not vary according to age, gender, educational level and household income. As frequency of GERD symptoms increased, quality of life significantly decreased. We concluded that GERD symptoms and uninvestigated dyspepsia were prevalent in Korea. The prevalence was similar to that of other Asian countries.

[p53 Codon 72 and 16-bp duplication polymorphisms of gastric cancer in Koreans].

BACKGROUND/AIMS: p53 gene plays an important role in cell cycle control in response to DNA damage which may increase the probability of mutations leading to carcinogenesis. The role of p53 gene polymorphisms [codon 72 (exon 4) and 16-bp duplication (intron 3)] as potential markers indicating cancer risk remains inconclusive, and the data on gastric cancer are very limited. The aim of this study was to assess the role of p53 gene polymorphisms in the risk of gastric cancer and in the determination of genetic susceptibility to gastric cancer in Koreans. METHODS: We analysed p53 genotypes using a polymerase chain reaction-based restriction fragment length polymorphism assay in a population-based case-control study in 120 gastric cancer patients and 145 cancer-free controls in Koreans. RESULTS: There was no specific genotype of p53 gene polymorphism in the gastric cancer patients compared to cancer-free controls. In p53 codon 72 and 16-bp duplication polymorphisms, the frequency and distribution of genotypes showed no statistical significance (p=0.7125 and p=0.1659). There was no difference in genotype by histologic subtypes, location of lesion, and age. However, the genotypic distribution in the patient subgroups with a history of heavy cigarette smoking of p53 16-bp duplication polymorphism were significantly different from those of cancer-free controls (p=0.0079). CONCLUSIONS: The p53 codon 72 and 16-bp duplication polymorphisms were not associated with the increased risk of gastric cancer and did not seem to contribute to gastric cancer susceptibility among Koreans. It is possible that p53 16-bp duplication polymorphism modulates the risk of smoking-induced gastric cancer development in Koreans. In order to clarify the associations between specific genotypes and gastric cancer risk, the evaluations of these polymorphisms in other ethnic backgrounds with larger number of patients would be needed.

[A case of Crohn's disease presenting with free perforation and portal venous gas].

Crohn's disease is characterized by its chronic course and transmural inflammation of gastrointestinal tract. The accompanying fibrous reaction and adhesion to adjacent viscera appears to limit the complication of free perforation. The true incidence of free bowel perforation is difficult to assess, however, the anticipated occurrence rate is 1-2% during the course of illness. Moreover, portal venous gas is also an uncommon event in the natural history of Crohn's disease. Portal venous gas occurs when intraluminal gas from the gastrointestinal tract or gas-forming bacteria enters the portal venous circulation. The finding of portal venous gas associated with Crohn's disease does not always mandate surgical intervention. We experienced a case of Crohn's disease presenting with free perforation and portal venous gas. The literatures on the cases with perforation and portal venous gas associated with Crohn's disease were reviewed.

[Association between insulin, insulin resistance, and gallstone disease in Korean general population].

BACKGROUND/AIMS: Diabetes is one of the risk factors of gallstone diseases. Many studies found a positive association between insulin and gallstones in individuals with diabetes. However, this association is unclear in non-diabetes. So we conducted a case-control study for the evaluation of the association between gallstone diseases and fasting serum insulin level, insulin resistance in non-diabetic Korean general population. METHODS: This study was a prospective case-control study on 118 Korean subjects which included clinical examination, abdominal ultrasound, and blood chemistries. Serum fasting insulin level were determined by radioimmunoassay and concentrations of cholesterol, glucose, and triglycerides by standard enzymatic colorimetric methods. Insulin resistance was determined by the homeostasis model assessment (HOMA-IR). Body mass index (BMI), percentage of body fat, and waist hip ratio were also measured. RESULTS: We studied 118 subjects with no clinical evidence of diabetes mellitus and serum glucose <126 mg/dL. Compared with controls (n=89), cases (n=29) had higher levels of serum insulin, glucose, triglyceride levels, and BMI. In t-test and chi-square test for variables, the association between gallstone disease and serum insulin, HOMA-IR index, and BMI were statistically significant (p<0.05). In multiple logistic regression analysis, gallstone disease risk increased with the level of serum insulin (p=0.024, odds ratio=1.376) and HOMA-IR index (p=0.013, odds ratio=2.006). CONCLUSIONS: We suggest that hyperinsulinemia and insulin resistance could be associated with gallstone formation in individuals without clinical diagnosis of diabetes mellitus and with normal serum glucose level.

Role of computed tomographic colonoscopy of postoperative surveillance in patient with gastric cancer.

AIM: To examine the diagnostic yield of colorectal neoplasia at computed tomographic colonoscopy (CTC) as well as the feasibility of contrast enhanced CTC in patients with gastric cancer. METHODS: To examine the incidence of colon polyp we selected postoperative 188 gastric cancer patients, which we refer to as the 'colon polyp survey group'. To examine the feasibility of CTC for early detection of colon cancer or advanced colon adenoma, we selected 47 gastric cancer patients (M:F 29:18, mean age 53.8 years), which we call the 'CT colonoscopy group'. All the 47 patients underwent successive CTC and colonoscopy on the same day. RESULTS: Totally 109 colon polyps were observed from 59 out of 188 gastric cancer patients, the incidence rate of colon polyps in gastric cancer patients being 31.4%. The sensitivity of CTC in detecting individuals with at least 1 lesion of any size was 57.1%, the specificity was 72.7%, the positive predictive value was 47.1%, and the negative predictive value was 71.9%. When the cutoff size was decreased to 6 mm, the sensitivity and specificity were 80.0% and 92.9%, respectively, with positive and negative predictive values of 57.1% and 97.5%, respectively. Only one patient was classified as false negative by virtual colonoscopy. CONCLUSION: The diagnostic yield of colorectal polyp was 31.4% in patients with gastric cancer, and contrast enhanced CTC is an acceptable tool for the detection of synchronous colorectal advanced adenoma and postoperative surveillance of gastric cancer patients.

[Comparison of model for end-stage liver disease score with discriminant function and child-Turcotte-Pugh scores for predicting short-term mortality in Korean patients with alcoholic hepatitis].

BACKGROUND/AIMS: Alcoholic hepatitis is an acute or acute-on-chronic inflammatory syndrome associated with significant morbidity and mortality. Traditionally, Maddrey discriminant function (DF) score and Child-Turcott-Pugh (CTP) score have been used for stratifying the prognosis of alcoholic hepatitis. Recently, the model for end-stage liver disease (MELD) score has been applied to alcoholic hepatitis and some investigators consider MELD score as a better prognostic indicator for severe alcoholic hepatitis. Therefore, this analysis was aimed to compare MELD score with DF and CTP scores for predicting the short-term mortality in Korean patients with alcoholic hepatitis. METHODS: The medical records of patients hospitalized with alcoholic hepatitis between January 1, 1999 and December 31, 2004 at Hanyang University Guri-Hospital were analyzed retrospectively. RESULTS: Of the 138 medical records reviewed, 74 cases fulfilled the inclusion criteria (61 males and 13 females; mean age 47.1 years). Twelve patients (16.2%) died within 90 days after admission. Univariate analysis demonstrated that variables such as ascites, hepatic encephalopathy, splenomegaly, international normalized ratio, CTP, and DF scores were significantly correlated with increased 90-day mortality while MELD score was not. According to the multivariate analysis, only CTP score was statistically significant (p=0.012) while DF and MELD scores were not significant for predicting 90-day mortality. The survival analysis with Cox regression test showed higher DF and CTP scores, but not MELD score, significantly increased the risk of in-hospital mortality. CONCLUSIONS: This study demonstrates that DF and CTP scores are independent predictors of short-term mortality in patients with alcoholic hepatitis.

[Abdominal obesity, insulin resistance, and the risk of colonic adenoma].

BACKGROUND/AIMS: Abdominal obesity and hyperinsulinemia or insulin resistance are of interest in connection with colon carcinogenesis. We conducted a prospective case controlled study for the evaluation of relationship between abdominal obesity, insulin resistance, and colorectal adenoma. METHODS: Fifty patients with colorectal adenoma and fifty healthy subjects were included in this study. Total colonoscopic examinations were performed in all the subjects. Fasting blood sugar (FBS), insulin, homeostasis model assessment (HOMA-IR), triglyceride (TG), cholesterol (CROL), BMI (body mass index), WHR (waist hip ratio), percent body fat (PBF) and obesity degree (OD) were measured. HOMA-IR was considered to represent insulin resistance. Diabetic patients were excluded from this study. RESULTS: There were no differences in sex, serum insulin, FBS, HOMA-IR, TG, CROL between adenoma and control group. Subjects with high BMI, WHR, percent body fat, and obesity were more likely to have colonic adenoma. Multiple logistic regression analysis after adjusting confounding factors, had revealed that WHR was the most important independent risk factor for colon adenoma. CONCLUSIONS: Abdominal obesity was most closely related to colonic adenoma. However, insulin resistance was not related to colonic adenoma. A larger case controlled study is needed.

Prevalence of irritable bowel syndrome in Korea: population-based survey using the Rome II criteria.

BACKGROUND: Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder in the West. But information on the prevalence of IBS in Asia is still lacking, especially in Korea. Therefore, the aims of the present study were to estimate the prevalence of IBS in the general population of Korea and also to investigate characteristics of IBS and health-care-seeking behavior of IBS patients. METHODS: Telephone interview survey was conducted by Gallup, Korea using a validated questionnaire based on the Rome II criteria. The response rate of the telephone interview survey was 25.2% (n = 1066, 535 male and 531 female responders). A random sample of gender and age (between 18 and 60 years), based on a per capita ratio was obtained. RESULTS: Among 1066 subjects, the prevalence of IBS was 6.6% (70 subjects; 7.1%, male; 6.0%, female). The difference in IBS prevalence by gender was not significant. The prevalence was higher among those in their 20s (P = 0.036). Among 70 subjects with IBS, 10/20 IBS subjects sought health care due to abdominal pain. Among the risk factors of IBS, marital status had a significant difference; the following risk factors are arranged in descending order: age (odds ratio [OR]: 1.38, 95% confidence interval [CI]: 0.85-2.25), alcohol intake (OR: 1.38, 95%CI: 0.81-2.35), gender (OR: 1.19, 95%CI: 0.73-1.94), demographics (OR: 1.09, 95%CI: 0.53-2.25), income (OR: 0.88, 95%CI: 0.54-1.45), education level (OR: 0.81, 95%CI: 0.46-1.40), smoking (OR: 0.64, 95%CI: 0.37-1.12), and marital status (OR: 0.59, 95%CI: 0.35-0.99). CONCLUSIONS: The prevalence of IBS in the Korean population is 6.6%, and the male:female ratio is similar. Also, IBS is more frequent in younger subjects. Irritable bowel syndrome subjects visited a physician mostly due to abdominal pain.

[Obstructive jaundice due to biliary cast syndrome followed by orthotopic liver transplantation].

Biliary complication occurs in 6-34% of all liver transplant patients. Although bile leaks and strictures are relatively common, other biliary complications such as T-tube leak, choledocholithiasis, and biliary cast syndrome can also be observed. The biliary cast syndrome describes the presence of casts causing obstruction with its resultant sequelae of biliary infection, hepatocyte damage secondary to bile stasis and ductal damage, all contributing to cholangiopathy. Because the exact timing of cast formation after orthotopic liver transplantation is not consistent, it is difficult to define the true incidence of biliary cast syndrome without long-term follow-up data. Proposed etiological mechanisms include acute cellular rejection, prolongation of cold ischemic time, infection, biliary drainage tubes, and biliary obstruction. The diagnosis of biliary cast syndrome is usually confirmed by endoscopic retrograde cholangiopancreatography. There have been few published articles about biliary casts in Korea. Herein, we report a case of biliary cast syndrome followed by orthotopic liver transplantation.

A population-based study on bowel habits in a Korean community: prevalence of functional constipation and self-reported constipation.

Most studies of bowel habits have been conducted in Western countries. This study was conducted to estimate the epidemiology of constipation and the discrepancy between self-reported constipation and bowel habits in Koreans. Telephone interviews regarding bowel habits were conducted with a total of 1029 individuals in Korea, 15 years of age or older. Subjects were given a questionnaire which asked about bowel symptoms, sociodemographic associations, laxative use, and physician visits. Of all subjects 95.6% had a defecation frequency of between three per week and three per day. The prevalence was 16.5% for self-reported constipation, 9.2% for functional constipation (FC), and 3.9% for constipation-predominant irritable bowel syndrome (IBS-C). Of subjects' self-reporting constipation, proportions of FC and IBS-C were 21.8% and 23.5%, respectively. Of subjects excluding self-reported constipation, the proportion of FC was 6.8%. Prevalences of self-reported constipation and IBS-C were higher in females than in males (P < 0.001). Of subjects' self-reporting constipation, 8.2% used laxatives. We conclude that constipation is a common problem in the general Korean population.

[A case of optic neuritis associated with Crohn's disease].

In Crohn's disease, neurologic complications such as cerebrovascular accident, headache, peripheral neuropathy have been reported sporadically. The pathogenesis of these neurologic complications is still unknown and controversial. We experienced a 22-year-old man, with Crohn's disease accompanied by optic neuritis. Loss of visual acuity was developed during the worsening course of enterocutaneous fistula. After high dose steroid treatment, his visual acuity and neurologic symptoms improved immediately.

Food intolerance and skin prick test in treated and untreated irritable bowel syndrome.

AIM: To correlate the clinical features of treated and untreated patients with irritable bowel syndrome (IBS) to the results of skin prick test (SPT) for food and inhalant allergens. METHODS: We recruited 105 subjects to form three different target groups: treated group (n=44) undergoing treatment for IBS, untreated group (n=31) meeting the Rome II criteria without treatment for IBS, control group (n=30) with no IBS symptoms. RESULTS: SPT results were different among the three groups in which SPT was positive in 17 (38.6%) treated patients, in 5 (16.1%) untreated patients and in 1 (3.3%) control (P<0.01). The number of positive SPTs was greater in the IBS group than in the control group (P<0.001). The number of positive food SPTs was higher in the treated IBS group than in the untreated IBS group (P=0.03). CONCLUSION: Positive food SPT is higher in IBS patients than in controls.