The prevalence of colorectal neoplasia in patients with gastric cancer: a Korean Association for the Study of Intestinal Disease (KASID) Study.

GOALS: The goal of this study was to determine the prevalence of colorectal neoplasia, using colonoscopy surveillance, in a cohort of patients with gastric cancers. BACKGROUND: The association between gastric cancer and colorectal cancer has been conflicting. STUDY: A total of 543 patients (males, 362; females, 181) with gastric cancer were matched with 2 persons from the population without a diagnosis of gastric cancer as confirmed by endoscopy according to age (+/-2 y), sex, date of colonoscopy examination (+/-2 wk), and endoscopist. Main Outcome was the prevalence of colorectal neoplasia diagnosed by colonoscopy. RESULTS: A significantly higher colorectal cancer prevalence was found in the gastric cancer group, that is, 19 of 543 (3.5%) versus 14 of 1086 (1.3%; P<0.001). The odds of developing colorectal cancer were higher in the presence of gastric cancer (odds ratios, 3.46; 95% confidence interval: 1.51-7.91). Four of the 119 (3.4%) gastric cancer patients below 50 years of age had colorectal cancer in contrast with no cases in the matched controls. The prevalence of colorectal adenoma was higher in the gastric cancer group, with a prevalence of 215 in 543 (39.6%) versus 311 in 1086 (28.6%; P<0.001). The risk of adenoma was also greater among gastric cancer patients (odds ratios, 1.76; 95% confidence interval: 1.34-2.25). CONCLUSIONS: Our data reveal a higher prevalence and risk of colorectal cancer in patients diagnosed with gastric cancer, particularly in patients below 50 years of age. Additional studies are needed to explore the geographical differences in the association between gastric cancer and colon cancer.

Clinical features and treatment outcomes of upper gastrointestinal bleeding in patients with cirrhosis.

With recent progress in treatment modalities, mortality from upper gastrointestinal (UGI) bleeding has decreased appreciably. The aim of this study was to establish how UGI bleeds are managed in Korean patients with cirrhosis and to evaluate treatment outcomes. A total of 479 episodes of acute UGI bleeding in 464 patients with cirrhosis were included during a six-month period at nine tertiary medical centers. Treatment outcomes were assessed by failure to control bleeding, rebleeding and mortality. The source of bleeding was esophagogastric varices in 77.7% of patients, nonvariceal lesions in 15.9%, and undefined in 6.5%. For control of bleeding, endoscopic and pharmacologic treatments were used in 74.7% and 81.9% of patients, respectively. Variceal ligation was a major technique for endoscopic treatment (90%), and terlipressin and somatostatin were the main pharmacologic agents used (96.4%). Initial hemostasis was achieved in 86.8% of cases, but rebleeding occurred in 3.8% and 16.8% of cases within five days and six weeks of hemorrhage, respectively. Five-day and six-week mortality were 11.3% and 25.9%, respectively. Survival of patients with variceal bleeding seems to be remarkably improved than previous reports, which may suggest the advances in hemostatic methods for control of variceal hemorrhage.

Abdominal obesity is an independent risk factor for erosive esophagitis in a Korean population.

BACKGROUND: The relationship between obesity and gastroesophageal reflux disease (GERD) is controversial. The aim of the present study was to investigate the potential roles of body mass index (BMI) and waist circumference on GERD in a Korean population. METHODS: A total of 2457 subjects who visited the Kangbuk Samsung Hospital medical screening center for esophagogastroduodenoscopy from September 2004 to April 2005 were enrolled. All participants were given a questionnaire to determine reflux symptoms. Abdominal obesity was defined as a waist circumference > or =80 cm in women and > or =90 cm in men. RESULTS: The proportion of subjects in each BMI group was 68.9%, 28.7% and 2.4% for BMI <25, 25-30 and >30, respectively. The prevalence of abdominal obesity was 24.2%. The prevalence of reflux symptoms was 8.2%. Neither BMI nor abdominal obesity was significantly associated with reflux symptoms after adjustment. The prevalence of erosive esophagitis was 6.6%. There was a clear dose-response relationship between prevalence of erosive esophagitis and BMI (5.6%, 8.1% and 15.5% for BMI <25, 25-30 and >30, respectively, P = 0.002). Abdominal obesity was also associated with erosive esophagitis (odds ratio, 2.3; 95% confidence interval, 1.6-3.1). However, only the association between abdominal obesity and erosive esophagitis remained strong after adjustments. CONCLUSIONS: Abdominal obesity rather than BMI is an independent risk factor for erosive esophagitis in the Korean population.

Factors affecting the technical difficulty of colonoscopy.

BACKGROUND/AIMS: Colonoscopy is a standard diagnostic tool for screening and surveillance of diseases affecting the colon. Colonoscopy may be painful for patients and difficult for the endoscopist. The aim of this study was to identify the factors affecting the technical difficulty of a colonoscopic examination and to predict potential difficult patients who will undergo colonoscopy. METHODOLOGY: A total of 646 outpatients were consecutively included in this study. Patient's age and gender, body mass index (BMI), prior surgical history, and the duration and symptoms of irritable bowel syndrome (IBS) were recorded before the procedure. The quality of bowel preparation, the difficulty of examination reported by the colonoscopist, the degree of patient pain, the degree of pain as reported by an observer, cecal intubation time andcolonoscopic findings were assessed after the procedure. RESULTS: We evaluated the difficulty of colonoscopy by cecal intubation time. Advanced age (>50 years), female gender, low BMI (< or = 23 Kg/m2), poor bowel preparation, prior surgical history, patient pain and the presence of IBS were associated with prolonged cecal intubation time. A multivariate logistic regression analysis demonstrated that advanced age, female gender, low BMI, poor bowel preparation and patient pain were independent factors related to prolonged cecal intubation time. CONCLUSIONS: In patients with advanced age, female gender and low BMI, information that colonoscopy may be difficult and painful should be provided. If a colonoscopy is not absolutely indicated, barium enema or CT colonography may be performed as alternative diagnostic modalities.

Clinical significance of small colorectal adenoma less than 10 mm: the KASID study.

BACKGROUND/AIMS: Polypectomy is the current modality of choice to prevent benign colorectal adenoma from progressing to an invasive cancer. However, in cases of small colorectal adenoma, it remains unclear as to whether polypectomy is actually an effective treatment modality. We evaluated the clinical significance of polypectomy in cases of small colorectal adenomas, measuring less than 10 mm. METHODOLOGY: All colonoscopies were performed at 11 Korean tertiary medical centers, between July 2003 and March 2004. A total of 5996 colorectal adenomas were detected and divided into 5 groups according to their size (Group 1; 1-5 mm, Group 2; 6-7 mm, Group 3; 8-9 mm, Group 4; 10-19 mm, Group 5; more than 20 mm). The term 'advanced adenoma' refers here to tubular adenomas with diameters of at least 10 mm, or to tubulovillous, villous, or high-grade dysplasia, irrespective of size. 'Cancer' here is defined as the invasion of malignant cells beyond the muscularis mucosa. RESULTS: As the sizes of the adenomas increased, the prevalence of advanced adenoma was also observed to increase. In Groups 2 and 3, the prevalence of tubulovillous or villous adenoma were higher than was expected (5.2% and 6.6%, p < 0.001). Interestingly enough, in Group 2, the prevalence of cancer was at least as high as in Group 4 (0.7% vs. 0.5%, p < 0.001). CONCLUSIONS: In cases of small colorectal adenomas, measuring between 6 and 9 mm, the prevalence of cancer was at least as high as that seen in the cases of colorectal adenomas measuring between 10 and 19 mm. Therefore, small colorectal adenomas measuring between 6 and 9 mm should not be ignored, in order to decrease the prevalence of colorectal cancer.

[The survey for the actual condition of drug medication and development of health care cost associated with toxic liver injury in Korean: a multicenter study for the detection and the development of nationwide reporting system of toxic liver injury].

BACKGROUNDS AND AIMS: In Korea, interests in health and health care costs have been increased along with the increase of mean survival rate and income level. The aim of this study is to investigate the actual condition of drug medication and burden of health care cost. METHODS: A total of 1,434 subjects in four tertiary medical centers were enrolled in this study. The questionnaires were obtained between March 2005 and September 2005. Based on this information, the actual condition of drug medication and health care cost were analyzed. RESULTS: The mean age of the subjects was 55.0+/-11.4 years (16-87 years). The male and female ratio was 1.74:1. The subjects with drug medication except for doctor's prescription are presently 26.6% and were 40.9% in the past. Traditional medicine (39.6%) and health food (29.9%) are more frequently used than herbal medicine (5.8%) and medical supplies (4.2%) now. In the past, herbal medicine (14.6%) was more frequently used compared with the present. The side effects of drug medication were developed in 90 subjects (7.5%). The total mean health care costs were 895,000 Won/year, the herbal medicine, 834,000 Won/year, the health food, 950,000 Won/year, and the traditional medicine, 324,000 Won/year. CONCLUSIONS: In this study, the subjects with other drug medications without doctor's prescription were as high as ever. The frequency of the use of the herbal medicine was decreased. However, the frequency for the use of the health food and traditional medicine have relatively increased. The side effects and additional large amounts of health care costs were occurred.

Influence of overweight and obesity on upper endoscopic findings.

BACKGROUND: In previous studies, increasing body mass index (BMI, kg/m(2)) was related to chronic gastrointestinal symptoms, such as frequent vomiting, upper abdominal pain, bloating and diarrhea. However, there have been no reports about the relationship between increasing BMI and abnormal upper endoscopic findings such as gastritis or ulcer. METHODS: The study group consisted of 27 319 individuals who underwent medical checkup at a healthcare center from 1 January to 31 December 2003. The following classification of BMI was applied. (i) underweight; BMI < 18.5; (ii) normal weight; 18.5 or= 30.0. The subjects were grouped according to the findings of upper endoscopy as follows: group 1, those with erosive gastritis, gastric ulcers (benign and malignant) and duodenal ulcers; group 2, those with reflux esophagitis; and group 3, those with findings of upper endoscopy other than group 1 and group 2. RESULTS: The prevalence of obesity and overweight was 2.2% and 30.5%, respectively. By multivariate analyses, overweight (OR 1.31, 95% CI; 1.22-1.40, P = 0.000) and obesity (OR 1.40, 95% CI; 1.14-1.72, P = 0.001) were significant contributors of group 1. Overweight (OR 1.61, 95% CI; 1.42-1.83, P = 0.000) and obesity (OR 2.23, 95% CI; 1.59-3.11, P = 0.000) were also significant contributors of group 2. CONCLUSIONS: In the general population, increasing BMI was associated with abnormal upper endoscopic findings, such as erosive gastritis, gastric ulcer, duodenal ulcer and reflux esophagitis. Clarification of the cause-and-effect relationships and the mechanisms of these associations require further investigation.

The association between increased alanine aminotransferase activity and metabolic factors in nonalcoholic fatty liver disease.

Nonalcoholic fatty liver disease (NAFLD) has been associated with metabolic disorders, including central obesity, dyslipidema, hypertension, and hyperglycemia. Metabolic syndrome, obesity, and insulin resistance are major risk factors in the pathogenesis of NAFLD. The aim of this study was to identify the relative contribution of the metabolic syndrome, obesity, and insulin resistance to alanine aminotransferase (ALT) activity in NAFLD. A total of 3091 subjects diagnosed with fatty liver by ultrasonography were enrolled. All components of metabolic syndrome criteria, anthropometric parameters, fasting insulin levels, high-sensitivity C-reactive protein (hs-CRP) as an inflammation marker, and ALT were measured in each subject. Homeostasis model assessment--insulin resistance (HOMA-IR) as a measure of insulin resistance and body mass index (BMI) as a measure of obesity were calculated. The prevalence of increased ALT levels (>40 IU/L) was 26.7%. Increased ALT activity was significantly associated with the following characteristics: male sex, young age, increased triglycerides, fasting glucose, fasting insulin, HOMA-IR, hs-CRP, waist circumference, BMI and diastolic blood pressure, and decreased high-density lipoprotein cholesterol (HDL-C). According to the increase in the number of metabolic syndrome components, BMI, HOMA-IR, and hs-CRP, the prevalence and odds ratio for having increased ALT activity were significantly increased. Central obesity, raised triglycerides, reduced HDL-C, and raised fasting glucose were strongly associated with increased ALT activity. In conclusion, a number of metabolic syndrome components, obesity, insulin resistance, and hs-CRP, are strong predictors of increased ALT activity in NAFLD. Central obesity, raised triglycerides, reduced HDL-C, and raised fasting glucose are metabolic syndrome components that contributed to increased ALT activity.

Significance of endoscopy in asymptomatic premenopausal women with iron deficiency anemia.

There is, currently, no consensus with regard to the role of endoscopy in the etiologic investigation of asymptomatic pemenopausal women suffering from iron deficiency anemia (IDA). We conducted a retrospective case-control study to evaluate the contribution of esophagogastroduodenoscopy (EGD) and colonoscopy to the etiologic diagnosis of a group of asymptomatic premenopausal women suffering from IDA. One hundred eight consecutive asymptomatic premenopausal women who fulfilled our entry criteria were included in our patient group between January 1998 and December 2004. One hundred thirty-five age-matched asymptomatic premenopausal women without anemia who had undergone EGD and colonoscopy for medical checkups were included in the control group. Clinically relevant lesions were detected in 7 of 108 (6.5%) of the patients and in 8 of 135 (5.9%) of the controls. There were no differences with regard to the frequency of clinically relevant lesions between the two groups (P > 0.05). Concomitant upper and lower GI lesions were not detected in any patients. In the upper GI tract, the only lesion found to be potentially causative of IDA anemia was a severe erosive gastritis, which was found in both the patient and the control groups. A source consistent with chronic bleeding was detected in the lower GI tract in 6 (5.6%) of the patients and 7 (5.2%) of the controls. Bleeding hemorrhoids represented the most frequently detected lesions in both the patient and control groups. Only one case of colon cancer was detected in the patient group. As IDA in the premenopausal women could not be attributed consistently to GI blood loss in this study, prospective studies should be conducted to validate our findings and to identify which subgroup of asymptomatic premenopausal women would benefit from a diagnostic endoscopic evaluation.

[Is gastric cancer a new indication for surveillance colonoscopy? Colon cancer is increased in gastric cancer patients].

BACKGROUND/AIMS: It has been reported that the risk of gastric polyp is increased in various colonic polyposis syndromes or in series of patients with sporadic colonic polyps. However, there are only a few large case controlled studies of colon cancer incidence in gastric cancer patients who underwent colonoscopy. The aims of this study were to determine the incidence of colorectal neoplasm and to evaluate the necessity of colonoscopic surveillance in patients with gastric cancer. METHODS: We performed colonoscopy in 105 patients with gastric cancer who agreed to undergo colonoscopy before or after 6 months from gastric resection between January 2002 and December 2004 in Kangbuk Samsung hospital. As a control group, 269 consecutive, age and sex matched patients without gastric neoplasm on gastroscopy who underwent colonoscopy within 6 months for the evaluation of various gastrointestinal symptoms during the year 2004 were included. Endoscopic reports and pathological results were reviewed retrospectively. RESULTS: In the patient group, adenomatous polyps were diagnosed in 24/105 patients (22.9%) and colorectal adenocarcinoma in 10/105 patients (9.5%). In the control group, adenomatous polyps were diagnosed in 78/269 patients (29.0%) and colorectal adenocarcinoma in 2/269 patients (0.7%). The incidence of colorectal adenocarcinoma between the patient group and control group showed significant differences (odds ratio 11.04, p=0.003). CONCLUSIONS: The risk of colorectal adenocarcinoma increases significantly in patients with gastric cancer. We suggest that the patients with gastric cancer might carry a high risk for colorectal cancer whom require surveillance colonoscopy.

[Levofloxacin-azithromycin combined triple therapy for Helicobacter pylori eradication].

BACKGROUND/AIMS: Antibiotic resistance and poor compliance are the main causes of Helicobacter pylori (H. pylori) eradication failure. This study evaluated the eradication rate, tolerability, and compliance of levofloxacin- azithromycin combined triple therapy for H. pylori eradication. METHODS: 1) First-line eradication: A total of 78 H. pylori-positive patients were enrolled. Seventeen military men in Armed Forces Capital Hospital were treated with 7 days of levofloxacin-azithromycin combined triple therapy (omeprazole 20 mg bid, levofloxacin 500 mg od, and azithromycin 500 mg od), and 61 patients in Kangbuk Samsung Hospital were treated with standard PPI-based triple therapy (omeprazole 20 mg bid, amoxicillin 1.0 g bid, and clarithromycin 500 mg bid) for 7 days. 2) Second-line eradication: A consecutive series of 59 patients who failed H. pylori eradication with standard PPI-based triple therapy in Kangbuk Samsung Hospital were randomized to two groups. Thirty patients were retreated with 7 days of bismuth-based quadruple therapy (omeprazole 20 mg bid, bismuth 120 mg qid, metronidazole 500 mg tid, and tetracycline 500 mg qid), and remaining 29 patients were retreated with levofloxacin-azithromycin combined triple therapy. Patient's compliance and tolerability were evaluated at the end of treatment. The status of H. pylori infection was assessed 8 weeks later then. The successful eradication of H. pylori was defined as negative results from histology and CLO test, or 13C-urea breath test. RESULTS: First-line eradication rate of levofloxacin-azithromycin triple therapy was lower than that of standard PPI-based triple therapy, but there was no statistically significant difference (70.6% vs. 80.3%, p=0.390). Second-line eradication rate of levofloxacin-azithromycin combined triple therapy was significantly lower than that of bismuth-based quadruple therapy (ITT/PP 65.5%/73.1% vs. 90%/90%, p<0.0001). The compliances of all patients were more than 85%. Two of patients with levofloxacin-azithromycin combined triple therapy complained self-limiting side effects (mild dizziness; mild insomnia with general weakness). CONCLUSIONS: Levofloxacin-azithromycin combined triple therapy should not be recommended as the first-line or second-line H. pylori eradication regimen in Korea.

Relationship between serum uric acid concentration and insulin resistance and metabolic syndrome.

BACKGROUND: Associations between hyperuricemia, cardiovascular diseases and diabetes have been reported, but few of the studies have been conducted in the Korean population. The present study examined a Korean adult population with respect to the relationships between serum uric acid concentrations and hypertension, insulin resistance, and the risk factors of metabolic syndrome. METHODS AND RESULTS: A total of 53,477 subjects were divided into 4 groups according to serum uric acid quartiles. The incidence of hypertension in all subjects was higher in the first quartile than in the third plus fourth quartile (odds ratio (OR) 1.192, p < 0.001). Homeostasis model assessment index was found to be associated with serum uric acid concentration in all subjects (OR 1.193, p < 0.001), and the serum uric acid concentration was positively correlated with the risk factors of metabolic syndrome. In addition, the number of metabolic syndrome variables increased as serum uric acid concentration increased. CONCLUSIONS: Serum uric acid concentration was found to be independently correlated with hypertension, insulin resistance and the risk factors of metabolic syndrome. In addition, even those with a serum uric acid concentration in the normal range showed an increased risk of metabolic syndrome as serum uric acid concentration increased.

Development of Korean standard brain templates.

We developed age, gender and ethnic specific brain templates based on MR and Positron-Emission Tomography (PET) images of Korean normal volunteers. Seventy-eight normal right-handed volunteers (M/F=49/29) underwent 3D T1-weighted SPGR MR and F-18-FDG PET scans. For the generation of standard templates, an optimal target brain that has the average global hemispheric shape was selected for each gender. MR images were then spatially normalized by linear transformation to the target brains, and normalization parameters were reapplied to PET images. Subjects were subdivided into 2 groups for each gender: the young/midlife (<55 yr) and the elderly groups. Young and elderly MRI/PET templates were composed by averaging the spatially normalized images. Korean templates showed different shapes and sizes (mean length, width, and height of the brains were 16.5, 14.3 and 12.1 cm for man, and 15.6, 13.5 and 11.4 cm for woman) from the template based on Caucasian (18.3, 14.2, and 13.3 cm). MRI and PET templates developed in this study will provide the framework for more accurate stereotactic standardization and anatomical localization.