Nonpharmacologic Treatment of Chronic Constipation.

Functional constipation is a common clinical diagnosis that affects approximately 14% of the world's population. Non-pharmacological therapies often represent the initial steps in management and may include lifestyle adjustments or changes such as physical activity and diet. Pharmacological options have been used when the non-pharmacological approach has been ineffective. Biofeedback therapy, surgery, sacral nerve stimulation, botulinum toxin injection, and vibrating capsules can be considered in scenarios where the laxatives are ineffective. Biofeedback therapy is highly effective and safe in treating dyssynergic defecation, which affects more than half of patients with chronic constipation. This paper overviews non-pharmacological therapies for functional constipation.

Predicting Responsiveness to Biofeedback Therapy Using High-resolution Anorectal Manometry With Integrated Pressurized Volume.

Background/Aims: Biofeedback therapy is widely used to treat patients with chronic constipation, especially those with dyssynergic defecation. Yet, the utility of high-resolution manometry with novel parameters in the prediction of biofeedback response has not been reported. Thus, we constructed a model for predicting biofeedback therapy responders by applying the concept of integrated pressurized volume in patients undergoing high-resolution anorectal manometry. Methods: Seventy-one female patients (age: 48-68 years) with dyssynergic defecation who underwent initial high-resolution anorectal manometry and subsequent biofeedback therapy were enrolled. The manometry profiles were used to calculate the 3-dimensional integrated pressurized volumes by multiplying the distance, time, and amplitude during simulated evacuation. Partial least squares regression was performed to generate a predictive model for responders to biofeedback therapy by using the integrated pressurized volume parameters. Results: Fifty-five (77.5%) patients responded to biofeedback therapy. The responders and non-responders did not show significant differences in the conventional manometric parameters. The partial least squares regression model used a linear combination of eight integrated pressurized volume parameters and generated an area under the curve of 0.84 (95% confidence interval: 0.76-0.95, P < 0.01), with 85.5% sensitivity and 62.1% specificity. Conclusions: Integrated pressurized volume parameters were better than conventional parameters in predicting the responsiveness to biofeedback therapy, and the combination of these parameters and partial least squares regression was particularly promising. Integrated pressurized volume parameters can more effectively explain the physiology of the anorectal canal compared with conventional parameters.

Timing of endoscopy in patients with upper gastrointestinal bleeding.

The optimal timing of endoscopy in patients with acute upper gastrointestinal bleeding (UGIB) remains controversial. In this study, we investigated the clinical outcomes of urgent endoscopy in patients with UGIB compared with elective endoscopy. From January 2016 to December 2018, consecutive patients who visited the emergency department and underwent endoscopy for clinical manifestations of acute UGIB, including variceal bleeding, were eligible. Urgent endoscopy (within 6 h) and elective endoscopy (after 6 h) were defined as the time taken to perform endoscopy after presentation to the emergency department. The primary outcome was mortality rate within 30 days. A total of 572 patients were included in the analysis. Urgent endoscopy was performed in 490 patients (85.7%). The 30-day mortality rate did not differ between the urgent and elective endoscopy groups (5.3% and 6.1%, p = 0.791). There was no difference regarding the recurrent bleeding rate, total amount of transfusion, or length of hospital between the groups. In multivariate analysis, age and the amount of transfusion were associated with mortality. Urgent endoscopy was not associated with a lower 30-day mortality rate compared with elective endoscopy in patients with acute UGIB.

Efficacy of Twice a Day Bismuth Quadruple Therapy for Second-Line Treatment of Helicobacter pylori Infection.

Bismuth quadruple therapy (BQT) is an effective treatment for Helicobacter pylori infection. However, frequent dosing schedules of BQT regimen often compromise drug adherence and may affect treatment outcomes. This retrospective study aimed to investigate the efficacy of twice-daily BQT compared to that of four times a day therapy. From August 2018 to November 2020, adult patients who failed first-line standard triple therapy and underwent BQT were eligible. Patients were categorized into two groups according to dosing schedule: (i) the BQT group (n = 213) who received standard BQT administered four times a day; and (ii) the BQTb group (n = 141) who received proton pump inhibitor, bismuth 600 mg, metronidazole 500 mg, and tetracycline 1 g twice a day. The eradication rate did not differ between the BQT (92.5%) and the BQTb groups (90.1%) (p = 0.441). Adherence and adverse event rate were similar between the two groups. Multivariate analysis showed that current smoking was associated with eradication failure; however, dosing frequency was not associated with the efficacy of eradication therapy. This study suggested that twice a day BQT is as effective as four times a day therapy for second-line treatment of H. pylori infection.

Selected nasogastric lavage in patients with nonvariceal upper gastrointestinal bleeding.

BACKGROUND: Risk stratification before endoscopy is crucial for proper management of patients suspected as having upper gastrointestinal bleeding (UGIB). There is no consensus regarding the role of nasogastric lavage for risk stratification. In this study, we investigated the usefulness of nasogastric lavage to identify patients with UGIB requiring endoscopic examination. METHODS: From January 2017 to December 2018, patients who visited the emergency department with a clinical suspicion of UGIB and who underwent nasogastric lavage before endoscopy were eligible. Patients with esophagogastric variceal bleeding were excluded. The added predictive ability of nasogastric lavage to the Glasgow-Blatchford score (GBS) was estimated using category-free net reclassification improvement and integrated discrimination improvement. RESULTS: Data for 487 patients with nonvariceal UGIB were analyzed. The nasogastric aspirate was bloody in 67 patients (13.8 %), coffee-ground in 227 patients (46.6 %), and clear in 193 patients (39.6 %). The gross appearance of the nasogastric aspirate was associated with the presence of UGIB. Model comparisons showed that addition of nasogastric lavage findings to the GBS improved the performance of the model to predict the presence of UGIB. Subgroup analysis showed that nasogastric lavage improved the performance of the prediction model in patients with the GBS ≤ 11, whereas no additive value was found when the GBS was greater than 11. CONCLUSIONS: Nasogastric lavage is useful for predicting the presence of UGIB in a subgroup of patients, while its clinical utility is limited in high-risk patients with a GBS of 12 or more.

Prophylactic clip application for large pedunculated polyps before snare polypectomy may decrease immediate postpolypectomy bleeding.

BACKGROUND: Although prophylactic clip application before polypectomy may prevent postpolypectomy bleeding (PPB), the usefulness of prophylactic clipping in the treatment of large pedunculated polyps is controversial in some prospective randomized studies. This study was conducted to evaluate the efficacy of prophylactic clip application and to investigate the predictors of PPB in large pedunculated colorectal polyps. METHODS: A total of 137 pedunculated polyps (size ≥1 cm) in 116 patients were prospectively included and randomized into group A (with clipping) and group B (without clipping), and resected. The occurrences of immediate PPB (graded 1-4) and delayed PPB were compared. RESULTS: Sixty-seven polyps were allocated in group A and 70 polyps in group B. In both groups, the median polyp diameter was 15 mm (P = 0.173) and the median stalk diameter was 3 mm (P = 0.362). Twenty-eight (20.4%) immediate PPB episodes in 137 polyps occurred, 6 (9.0%) in group A and 22 (31.4%) in group B (P = 0.001). However, the occurrence of delayed PPB was not different between the groups (P = 0.943). Prophylactic clip application decreased the occurrence of immediate PPB (odds ratio 0.215, 95% confidence interval 0.081-0.571). Moreover, polyp size ≥20 mm and stalk diameter ≥ 4 mm increased the risk of immediate PPB. CONCLUSIONS: Clip application before polypectomy of ≥1 cm pedunculated polyps is effective in decreasing the occurrence of immediate PPB. Thus, clip application should be considered before performing snare polypectomy, especially for large polyps with a thick stalk. TRIAL REGISTRATION: This research was studied a prospective maneuver and enrolled in a registry of clinical trials run by United States National Library of Medicine at the National Institutes of Health (ClinicalTrials.gov Protocol Registration and Results system ID: NCT01437631). This study was registered on September 19, 2011.

Full-dose sofosbuvir plus low-dose ribavirin for hepatitis C virus genotype 2-infected patients on hemodialysis.

BACKGROUND/AIMS: New direct-acting antivirals have shown surprising success in the treatment of hepatitis C, not only in the general population, but also in difficult-to-treat cohorts. However, there is still limited data regarding direct-acting antivirals, including sofosbuvir (SOF), in the context of hemodialysis. The aim of this study was to investigate the safety and outcome of administering full-dose SOF (400 mg/day) plus low-dose ribavirin (RBV, 100 to 200 mg/day) in hemodialysis patients with hepatitis C virus (HCV) genotype 2 (GT2) infection. METHODS: Patients with chronic HCV GT2 infection and end-stage renal disease on maintenance hemodialysis treated with full-dose SOF plus low-dose RBV were retrospectively identified from a database of patients with HCV GT2 who were treated in Konkuk University Chungju Hospital between February 2017 and February 2018. Medical records were reviewed for demographics, medical history, laboratory data, and radiologic and electrocardiographic findings. RESULTS: All nine patients completed a full course of 12 weeks of treatment with a full-dose SOF plus low-dose RBV regimen. Two had compensated cirrhosis. Seven patients were treatment-naïve, and two had a relapse following previous interferon-based therapy. All patients had a sustained viral response at 12 weeks post-treatment. There was no discontinuation of treatment because of side effects. CONCLUSION: In hemodialysis patients with HCV GT2 infection, the full-dose SOF plus low-dose RBV regimen appears to be safe and well tolerated, and yields high rates of sustained virologic response.

Comparison of Bowel Cleansing Efficacy, Safety, Bowel Movement Kinetics, and Patient Tolerability of Same-Day and Split-Dose Bowel Preparation Using 4 L of Polyethylene Glycol: A Prospective Randomized Study.

BACKGROUND: Split-dose bowel preparation is recommended for morning colonoscopy, although a same-day dose regimen is an alternative for afternoon colonoscopy. Same-day preparation for morning colonoscopy has rarely been evaluated. OBJECTIVE: We compared the bowel cleansing efficacy, bowel movement kinetics, safety profile, and patient tolerability of split-dose and same-day preparation using 4-L polyethylene glycol. DESIGN: This was a prospective, randomized, assessor-blinded study. SETTINGS: This study was performed at a tertiary center in Korea. PATIENTS: Study subjects were randomly assigned to the same-day or split-dose groups. For the same-day dose group, 4 L of polyethylene glycol were ingested on the day of colonoscopy starting at 5:00 AM for morning colonoscopy or 7:00 AM for afternoon colonoscopy. In the split-dose group, 2 L of polyethylene glycol were ingested at 9:00 PM the day before colonoscopy, and the remaining 2 L from 7:00 AM for morning colonoscopy or from 10:00 AM for afternoon colonoscopy. Colonoscopy was performed from 10:00 AM. MAIN OUTCOME MEASURES: The efficacy of bowel cleansing was evaluated using the Boston bowel preparation scale. The participants completed questionnaires asking about adverse events, bowel movement kinetics, and tolerability of the preparation before colonoscopy. RESULTS: A total of 339 subjects were included (same-day dose = 172; split dose = 167). One subject in each group did not undergo colonoscopy. The rate of successful cleansing did not differ between the groups (same-day dose = 98.8% vs split dose = 98.2%; p = 0.681). There were no instances of hemodynamic instability or aspiration in either group. Tolerability, including overall satisfaction and willingness to reuse, were comparable between the groups. LIMITATIONS: This was a single-center study. CONCLUSIONS: The bowel cleansing efficacy, safety profile, and tolerability of same-day dosing with polyethylene glycol were comparable with those of split dose. Therefore, same-day dosing with 4 L of polyethylene glycol is a feasible bowel preparation method. See Video Abstract at http://links.lww.com/DCR/B44. COMPARACIÓN DE LA EFICACIA DE LA LIMPIEZA INTESTINAL, LA SEGURIDAD, LA CINÉTICA DEL MOVIMIENTO INTESTINAL Y LA TOLERABILIDAD DEL PACIENTE DE LA PREPARACIÓN INTESTINAL EN EL MISMO DÍA Y EN DOSIS DIVIDIDAS UTILIZANDO 4 L DE POLIETILENGLICOL: UN ESTUDIO PROSPECTIVO ALEATORIZADO: Se recomienda la preparación del intestino en dosis divididas para la colonoscopia de la mañana, aunque un régimen de una sola dosis el mismo día es una alternativa para la colonoscopia en la tarde. La preparación de una sola dosis el mismo día para la colonoscopia matutina rara vez se ha evaluado.Comparamos la eficacia de la limpieza intestinal, la cinética del movimiento intestinal, el perfil de seguridad y la tolerabilidad del paciente de la dosis dividida y la preparación el mismo día utilizando 4 L de polietilenglicol.Este fue un estudio prospectivo, aleatorizado, cegado por el evaluador.Este estudio se realizó en un centro terciario en Corea.Los sujetos del estudio fueron asignados aleatoriamente a el grupo de una dosis en el mismo día o al grupo de dosis dividida. Para el grupo de dosis del mismo día, se ingirieron 4 L de polietilenglicol el día de la colonoscopia a partir de las 5 a.m. para la colonoscopia de la mañana o las 7 a.m. para la colonoscopia de la tarde. En el grupo de dosis dividida, se ingirieron 2 L de polietilenglicol a las 9 p.m. el día anterior a la colonoscopia, y los otros 2 L restantes a partir de las 7 a.m. para la colonoscopia de la mañana o desde las 10 a.m. para la colonoscopia de la tarde. La colonoscopia se realizó a partir de las 10 a.m.La eficacia de la limpieza intestinal se evaluó mediante la escala de preparación intestinal de Boston. Los participantes completaron cuestionarios preguntando sobre los eventos adversos, la cinética del movimiento intestinal y la tolerabilidad de la preparación antes de la colonoscopia.Se incluyeron un total de 339 sujetos (dosis el mismo día, 172; dosis dividida, 167). Un sujeto en cada grupo no se sometió a colonoscopia. La tasa de limpieza exitosa no difirió entre los grupos (dosis el mismo día, 98.8% versus dosis dividida, 98.2%; p = 0.681). No hubo casos de inestabilidad hemodinámica o aspiración en ninguno de los grupos. La tolerabilidad, incluida la satisfacción general y la voluntad de reutilización, fueron comparables entre los grupos.Este fue un estudio de centro único.La eficacia de la limpieza intestinal, el perfil de seguridad y la tolerabilidad de la dosificación en el mismo día con polietilenglicol fueron comparables con los de la dosis dividida. Por lo tanto, la dosificación en el mismo día con 4 L de polietilenglicol es un método factible de preparación intestinal. Vea el video del resumen en http://links.lww.com/DCR/B44.

Long-term Clinical Outcomes and Risk of Peritoneal Seeding after Endoscopic Submucosal Dissection for Early Gastric Cancer: A Focus on Perforation during the Procedure.

Background/Aims: The risk of peritoneal seeding following perforation after endoscopic resection in patients with early gastric cancer is unclear. The purpose of this study was to investigate long-term clinical outcomes including peritoneal seeding and overall survival rate following gastric perforation during endoscopic submucosal dissection (ESD). Methods: Between January 2002 and March 2015, 556 patients were diagnosed with early gastric cancer and underwent ESD. Among them, 34 patients (6.1%) experienced gastric perforation during ESD. Clinicopathological data of these patients were reviewed to determine the clinical outcome and evidence of peritoneal seeding. Results: Among 34 patients with perforation, macroperforations occurred during ESD in 17 cases (50%), and microperforation was identified in the remaining 17 cases (50%). All patients except one who underwent emergency surgery due to severe panperitonitis were managed successfully by endoscopic clipping (n=27) or conservative medical treatment (n=6). No evidence of peritoneal seeding after perforation associated with ESD was found in our cohort. Cumulative survival rates did not differ between the perforation and non-perforation groups (p=0.691). Furthermore, mortality was not associated with perforation. In addition, multivariate analysis showed that tumor size and achievement of curative resection were related to cancer recurrence. Perforation was not associated with cancer recurrence and survival. Conclusions: Perforation associated with ESD does not lead to worse clinical outcomes such as peritoneal seeding or cumulative survival rate. Therefore, periodic follow-up might be possible if curative resection was achieved even if perforation occurred during ESD.

A risk-scoring model for the prediction of delayed bleeding after colorectal endoscopic submucosal dissection.

BACKGROUND AND AIMS: Delayed bleeding is an important adverse event after colorectal endoscopic submucosal dissection (ESD). We aimed to investigate the incidence and risk factors of delayed bleeding after colorectal ESD and to develop a risk-scoring model for predicting delayed bleeding. METHODS: This retrospective study was performed at 5 centers. The derivation and validation cohorts comprised 1189 patients from 1 center and 415 patients from the other 4 centers. We investigated the incidence and risk factors of delayed bleeding. Then, we developed a risk-scoring model for predicting delayed bleeding by using the data of the derivation cohort. We validated the scoring system in the validation cohort. RESULTS: Delayed bleeding occurred in 34 patients (2.9%) in the derivation cohort. In multivariate analysis, the risk factors of delayed bleeding were tumor location in the rectosigmoid colon (odds ratio [OR], 6.49; 95% confidence interval [CI], 1.96-21.42; P = .002), large tumor (≥30 mm) (OR, 2.10; 95% CI, 1.01-4.40; P = .048), and use of antiplatelet agents except for aspirin alone (OR, 4.04; 95% CI, 1.44-11.30; P = .008). These 3 factors were incorporated into a risk-scoring model for prediction of delayed bleeding. As the score based on this system increased, the incidence of delayed bleeding increased in the validation cohort. CONCLUSION: The risk-scoring model incorporating tumor location, tumor size, and use of antiplatelet agents can quantitatively predict the risk of delayed bleeding after colorectal ESD.

New Metrics in High-Resolution and High-Definition Anorectal Manometry.

PURPOSE OF REVIEW: To review recently published diagnostic methods that use high-resolution (HR-) or high-definition- (HD-) anorectal manometry (ARM) techniques. RECENT FINDINGS: The integrated pressurized volume (IPV) is a new measure based on spatiotemporal plots obtained from HR-ARM. The IPV may be clinically useful for improving the prediction of abnormal balloon expulsion test in patients with constipation and for discriminating patients with anorectal disorders from asymptomatic controls. Combination of IPV parameters was superior to conventional manometric parameters in predicting the responsiveness to biofeedback therapy. Moreover, several novel parameters including the HR-ARM resting integral, HR-ARM squeeze profile, and anorectal asymmetry index may each be useful as predictive factors for identifying patients with fecal incontinence. HR- and HD-ARM are increasingly performed worldwide for evaluation of anorectal function. Here, we describe new metrics whose clinical significance has not been fully established. Further standardization and validation of these metrics could provide clinically important new information and could help improve our understanding of the pathophysiology of anorectal disorders.

Clinical outcomes of colorectal endoscopic submucosal dissection and risk factors associated with piecemeal resection.

BACKGROUND/AIMS: We aimed to investigate the factors associated with piecemeal resection of colorectal neoplasia (CRN), in spite of endoscopic submucosal dissection (ESD). MATERIALS AND METHODS: We analyzed the retrospective data for colorectal ESD cases from January 2005 to April 2014. We also reviewed the piecemeal endoscopic mucosal resection (EMR) for CRNs ≥20 mm, performed over the same period. RESULTS: En bloc resection was possible in 648 (85.7%) of 756 lesions in 740 patients. Multivariate analysis showed that hybrid ESD (odds ratio (OR), 29.07; 95% confidence interval (CI), 15.46-54.65; p<0.01) and mild or severe submucosal fibrosis (OR, 3.62; 95% CI, 1.94-6.76; p<0.01) were independently associated with piecemeal ESD. The en bloc ESD group showed higher histologic complete resection rate than the piecemeal ESD group (80.4% vs. 56.5%; p<0.01), and the piecemeal ESD group showed higher recurrence rate than in the en bloc ESD group (5.6% [4/72] vs. 0.7% [3/450]; p<0.01). Overall recurrence rate was 1.3% (7/522). CONCLUSION: Hybrid ESD and submucosal fibrosis are independently associated with piecemeal ESD. Piecemeal ESD cases recurred more frequently than en bloc ESD cases.

Validation of same-day bowel preparation regimen using 4L polyethylene glycol: Comparison of morning and afternoon colonoscopy.

A split-dose regimen is the recommended method of bowel preparation for colonoscopy. However, for colonoscopy performed in the afternoon, same-day preparation is recommended rather than a split-dose regimen. No study has compared the efficacy of same-day bowel-cleansing for morning colonoscopy (MC) and afternoon colonoscopy (AC). The aims of this study were to evaluate the bowel-cleansing efficacy, adverse events, and patient tolerability of same-day bowel preparation for colonoscopy using 4L polyethylene glycol (PEG).The medical records of consecutive patients who underwent colonoscopy at our healthcare center over 3 months were retrospectively reviewed. Colonoscopy was performed between 10:00 and 16:00. Study subjects were assigned to the MC or AC group according to their colonoscopy start time (MC group, before 12:00; AC group, after 12:00). Study subjects were instructed to drink 500-mL PEG every 15 minutes. In the MC group, bowel cleansing was started at 05:00 and finished at 07:00. For the AC group, 2L PEG was consumed from 07:00, and the remaining 2L PEG was started 3 hours before colonoscopy. The composite safety profile included vital signs, laboratory test results, and questionnaire findings. Laboratory testing of subjects and completion of the questionnaire were performed before colonoscopy. The questionnaire asked about adverse events and tolerability of the bowel cleansing regimen. Bowel-cleansing efficacy was assessed using the Boston bowel preparation scale (BBPS). Bowel-cleansing efficacy, tolerability, and safety profile were compared between the 2 groups.Two hundred and ninety-one subjects were included (MC group, 169; AC group, 122).The BBPS did not differ between the 2 groups (7.3 ±â€Š0.8 vs. 7.3 ±â€Š0.8, P = .68). There were no instances of electrolyte imbalance or hemodynamic instability in either group. The tolerability of the bowel-cleansing regimen did not differ between the 2 groups (P = .59).The bowel-cleansing efficacy, safety profile, and patient tolerability of MC and AC were comparable. A same-day dose of 4L PEG is a feasible bowel preparation method.

Relation of Enteric α-Synuclein to Gastrointestinal Dysfunction in Patients With Parkinson's Disease and in Neurologically Intact Subjects.

BACKGROUND/AIMS: α-Synucleinopathy in the brain is the neuropathological hallmark of Parkinson's disease (PD). However, the functional impact of α-synucleinopathy in the enteric nervous system remains unknown. We aim to evaluate the association between gastrointestinal (GI) dysfunction and α-synuclein (αSYN) pathology in the stomach and colon of PD patients and controls, as well as to investigate the association between the αSYN pathology in GI tract and future PD risk. METHODS: A total of 35 PD patients and 52 neurologically intact subjects were enrolled in this study. Endoscopic biopsies were performed, and then immunohistochemical staining for αSYN was performed. All subjects completed the validated Rome III questionnaire for the assessment of GI symptoms. The association between GI symptoms and the αSYN pathology in GI mucosa was evaluated. Incident PD cases were assessed during a median follow-up of 46 months. RESULTS: The proportion of self-reported constipation and functional constipation through the Rome III questionnaire was significantly higher in PD patients than in controls (P ＜ 0.001 and P = 0.015). However, no significant association was found between the αSYN pathology in the stomach and colon mucosa and constipation, as well as other GI symptoms including dyspepsia symptoms and abdominal discomfort or pain, regardless of the presence or absence of clinical PD (P ＞ 0.05). No incident PD cases were diagnosed during study period. CONCLUSIONS: Our present study suggests that the deposition of αSYN in the mucosal enteric nervous system may not be reflected by functional impairment of the affected segment of the gut.

Clinical characteristics and long-term prognosis of elderly onset ulcerative colitis.

BACKGROUND AND AIM: The aim of this study was to investigate the clinical characteristics and prognosis of patients with elderly onset ulcerative colitis (EOUC), a new growing subgroup of UC. METHODS: This study retrospectively analyzed 3060 South Korean UC patients diagnosed between 1977 and 2014. The clinical characteristics and prognosis of EOUC, defined as UC in those aged ≥ 60 years at diagnosis, were compared with those of non-EOUC (NEOUC). RESULTS: Among the 3060 patients, 226 were diagnosed with EOUC (7.4%, median age at diagnosis 65.9 years [interquartile range, 62.9-68.7 years], 58.4% male). The frequency of EOUC increased from 3.9% in the interval 1977-1999 to 9.7% in the interval 2008-2014 (P < 0.001). There were more ex-smokers in the EOUC than in the NEOUC group (44.2% vs 19.9%, P < 0.001). In the EOUC group, extensive colitis at diagnosis, and the maximum extent thereof, was less than in the NEOUC group (13.7% vs 22.6%, P = 0.002, and 34.5% vs 42.5%, P = 0.011, respectively). The 10-year cumulative colectomy rate was significantly higher in the EOUC than in the NEOUC group (12.6% vs 7.7%, P = 0.015). UC-related and all-cause mortality were higher in the EOUC than in the NEOUC group (3.5% vs 0.6%, P < 0.001, and 12.4% vs 1.8%, P < 0.001, respectively). CONCLUSION: Elderly onset ulcerative colitis patients are likely to exhibit distinct features both at diagnosis and during follow-up. It is necessary to pay more attention to, and to conduct further studies on, this particular group of patients.

Assessment of factors associated with smoking cessation at diagnosis or during follow-up of Crohn's disease.

BACKGROUND AND AIM: Smoking cessation is known to improve the course of Crohn's disease (CD). However, the factors associated with smoking cessation after CD diagnosis have not been well established. METHODS: Clinical characteristics and change in smoking status were evaluated in 445 current smokers at the time of CD diagnosis. Patients were classified into three subgroups based on their final smoking status and time of smoking cessation: non-quitters, quitters at diagnosis, and quitters during follow-up. RESULTS: The overall smoking cessation rate was 55.7% (248 of 445 patients). The diagnosis of CD was the main reason for quitting (41.5%, 103 of 248 patients). Smoking cessation at the time of CD diagnosis was associated with intestinal resection within 3 months from CD diagnosis (odds ratio [OR] 2.355, 95% confidence interval [CI] 1.348-4.116, P = 0.003), light smoking (OR 2.041, 95% CI 1.157-3.602, P = 0.014), and initiation of smoking before 18 years of age (OR 0.570, 95% CI 0.327-0.994, P = 0.047). Light smoking (OR 1.762, 95% CI 1.019-3.144, P = 0.043) and initiation of smoking before 18 years (OR 0.588, 95% CI 0.381-0.908, P = 0.017) were also associated with overall smoking cessation. CONCLUSION: Quitters after CD diagnosis, including quitters at diagnosis and quitters during follow-up, had features distinct from those of non-quitters. Given the motivation at CD diagnosis, a detailed history of smoking habits should be taken and all current smokers should be encouraged to quit smoking at the time of CD diagnosis.

Local recurrence and subsequent endoscopic treatment after endoscopic piecemeal mucosal resection with or without precutting in the colorectum.

BACKGROUND/AIMS: Precutting before endoscopic piecemeal mucosal resection (EPMR) may increase colorectal polyp resection effectiveness. We aimed to identify risk factors for recurrence after conventional EPMR (CEPMR) and precut EPMR (PEPMR) and investigated endoscopic treatment outcomes for recurrent cases. METHODS: The medical records of patients with colorectal polyps treated by EPMR were analyzed. Patients without follow-up surveillance colonoscopies were excluded. RESULTS: Among 359 lesions, the local recurrence rate on the first surveillance colonoscopy was 5.8% (18/312) and 6.4% (3/47) after CEPMR and PEPMR, respectively. Among lesions without recurrence at the first surveillance colonoscopy, the rates of late recurrence on subsequent surveillance colonoscopy were 3.9% (6/152) and 0% after CEPMR and PEPMR, respectively. Larger tumor size was the only independent risk factor for recurrence (odds ratio, 7.93; 95% confidence interval, 1.95-32.30; P<0.001). Endoscopic treatment was performed for all 27 recurrences. A combination of ≥2 endoscopic treatment modalities was used in 19 of 27 recurrences (70.4%). Surveillance colonoscopies were performed in 20 of 27 recurrences after endoscopic treatment. One (5.0%) had a re-recurrence and was treated by surgical resection because recurrence occurred at the appendiceal orifice. Nineteen of 20 lesions (95.0%) could be cured endoscopically, although 3 of the 19 showed second or third recurrences and were treated by repeat endoscopic resection. CONCLUSIONS: The local recurrence rates after CEPMR and PEPMR were similar. Larger tumor size was an independent risk factor for local recurrence after EPMR. Endoscopic treatment of recurrences resulted in high cure rates, although combination methods were necessary in many cases.

Efficacy of Precut Endoscopic Mucosal Resection for Treatment of Rectal Neuroendocrine Tumors.

BACKGROUND/AIMS: Endoscopic resection is the first-line treatment for rectal neuroendocrine tumors (NETs) measuring <1 cm and those between 1 and 2 cm in size. However, conventional endoscopic resection cannot achieve complete resection in all cases. We aimed to analyze clinical outcomes of precut endoscopic mucosal resection (EMR-P) used for the management of rectal NET. METHODS: EMR-P was used to treat rectal NET in 72 patients at a single tertiary center between 2011 and 2015. Both, circumferential precutting and EMR were performed with the same snare device in all patients. Demographics, procedural details, and histopathological features were reviewed for all cases. RESULTS: Mean size of the tumor measured endoscopically was 6.8±2.8 mm. En bloc and complete resection was achieved in 71 (98.6%) and 67 patients (93.1%), respectively. The mean time required for resection was 9.0±5.6 min. Immediate and delayed bleeding developed in six (8.3%) and 4 patients (5.6%), respectively. Immediate bleeding observed during EMR-P was associated with the risk of delayed bleeding. CONCLUSIONS: Both, the en bloc and complete resection rates of EMR-P in the treatment of rectal NETs using the same snare for precutting and EMR were noted to be high. The procedure was short and safe. EMR-P may be a good treatment choice for the management of rectal NETs.

Elevated C-reactive protein level during clinical remission can predict poor outcomes in patients with Crohn's disease.

Intestinal inflammation and mucosal damage in Crohn's disease (CD) are believed to progress even during clinical remission. We investigated the long-term prognosis of CD patients in clinical remission according to serum C-reactive protein (CRP) levels. This study included 339 CD patients in clinical remission (Crohn's disease activity index < 150) for more than 6 months between January 2008 and December 2010. Clinical outcomes were compared between patients with normal and elevated CRP levels during clinical remission. During clinical remission, 150 patients had normal CRP consistently and 189 had elevated CRP at least once. During follow-up (median, 7.9 years [interquartile range, 6.8-8.0]), the Kaplan-Meier analysis with the log-rank test showed that normal CRP group had a longer CD-related hospitalization-free survival (P = 0.007) and a longer CD-related intestinal resection-free survival (P = 0.046) than elevated CRP group. In multivariate analysis, elevated CRP was significantly and independently associated with an increased risk of subsequent CD-related hospitalization (adjusted hazard ratio [aHR] 1.787, 95% confidence interval [CI]: 1.245-2.565, P = 0.002) and of subsequent CD-related intestinal resection (aHR 1.726, 95% CI: 1.003-2.969, P = 0.049). The most common reason for CD-related hospitalization was penetrating complications (35.6%). Even when CD patients are in clinical remission, elevated CRP is significantly associated with subsequent CD-related hospitalization and CD-related intestinal resection during follow-up. CD patients in clinical remission but elevated CRP should receive more careful attention and timely interventions to improve long-term outcomes.