Proposal of a Novel Serological Algorithm Combining FIB-4 and Serum M2BPGi for Advanced Fibrosis in Nonalcoholic Fatty Liver Disease

Background/Aims@#Noninvasive methods have become increasingly critical in the diagnosis of fibrosis in chronic liver diseases. Herein, we compared the diagnostic performance of serum Mac2 binding protein glycosylation isomer (M2BPGi) and other serological panels for fibrosis in patients with nonalcoholic fatty liver disease (NAFLD) and proposed an improved two-step diagnostic algorithm for advanced fibrosis. @*Methods@#We enrolled 231 patients diagnosed with NAFLD who underwent a liver biopsy. We subsequently evaluated the diagnostic performance of serological panels, including serum M2BPGi, a fibrosis index based on four factors (FIB-4), aspartate aminotransferase-to-platelet ratio index (APRI), and NAFLD fibrosis score (NFS), in predicting the stage of liver fibrosis. We then constructed a two-step algorithm to better differentiate advanced fibrosis. @*Results@#The areas under the receiver operating characteristic curves of serum M2BPGi, FIB-4, APRI, and NFS for advanced fibrosis (≥F3) were 0.823, 0.858, 0.779, and 0.827, respectively. To reduce the performance of unnecessary liver biopsy, we propose a two-step algorithm using FIB-4 as an initial diagnostic tool and serum M2BPGi (≥0.6) as an additional diagnostic method for patients classified as intermediate (23%). Using the proposed algorithm, the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were 0.812, 0.814, 0.814, 0.600, and 0.927, respectively. @*Conclusions@#Serum M2BPGi is a simple and effective test for advanced fibrosis in patients with NAFLD. Application of the two-step algorithm based on FIB-4 and M2BPGi proposed here can improve diagnostic performance and reduce unnecessary tests, making diagnosis easily accessible, especially in primary medical centers.

Efficacy and Safety of Fecal Microbiota Transplantation and Prospect of Microbe-based Therapies for Inflammatory Bowel Disease / 대한소화기학회지

The use of 5-ASA, immunomodulators, biologics, and small molecule drugs are the main treatment for inflammatory bowel disease (IBD), however, fecal microbiota transplantation (FMT) is also drawing attention as a treatment to improve intestinal dysbiosis by transplantaing normal human stool into patients with IBD. FMT demonstrates relatively good effects in inducing clinical remission in IBD, but unlike Clostridium difficile infection, multiple FMT can enhance the clinical effect. There are no reports of the long-term effectiveness and safety of FMT conducted in IBD yet, therefore, well-designed, prospective studies will be needed. Gut microbiota can affect inflammatory response, intestinal barrier function, and host metabolism, so microbe-based therapies are likely to be a new treatment option for IBD. The deeper the understanding of microbe products or effectors, the more likely it is to provide personalized therapy in IBD.

The Effect of Anticoagulant in Patients with Cirrhosis Associated with Acute Portal Vein Thrombosis / 대한소화기학회지

The treatment of portal vein thrombosis (PVT) in patients with liver cirrhosis (LC) has been controversial, and it is generally caseand institution-dependent. The occurrence of acute or extensive PVT is critical and requires urgent treatment because it is usually accompanied by symptoms, particularly when total occlusion occurs, causing acute decompensation of liver disease. Even in severe cases, drug selection and treatment duration are determined based on each institution’s experience. Therefore, consistent guidelines for the treatment of patients with LC with PVT are required. Recently, a patient with acute occlusive PVT with LC who showed signs of acute decompensation was treated by administering low molecular weight heparin as anticoagulant therapy. After anticoagulant treatment, the portal vein was almost completely recanalized, and the deteriorated liver function improved. In addition, the patient recovered well and showed no recurrence of PVT for more than a year. Thus, the most recent knowledge regarding the treatment of nonmalignant PVT in LC was reviewed along with a case report.

Helicobacter pylori Eradication Therapy-associated Diarrhea

Eradication of Helicobacter pylori has contributed to the treatment of peptic ulcers and mucosa-associated lymphoid tissue lymphoma. Moreover, it has possibly decreased the prevalence of gastric cancer. However, eradication therapy is associated with various adverse effects, of which diarrhea is the most common. The incidence of diarrhea after eradication treatment varies from 8% to 48%. In particular, the incidence is higher in patients who receive first-line standard triple therapy compared with those who receive second-line therapy. Both antibiotics and proton pump inhibitors, components of eradication therapy, have short-term and long-term impacts on gut microbiota. The alterations of gut microbiota may not recover until 1 year after eradication therapy. Most cases of diarrhea that occur after eradication therapy are antibiotic-associated diarrhea caused by the destruction of the normal gut microbiota. In some cases, Clostridioides difficile-associated diarrhea occurs after eradication therapy. If bloody diarrhea occurs after eradication therapy and the Clostridioides difficile toxin is not detected, antibiotic-associated hemorrhagic colitis associated with Klebsiella oxytoca infection should be suspected. It is crucial to explain the possibility of diarrhea before initiating eradication therapy to increase compliance. Furthermore, probiotics may be administered to reduce diarrhea. If severe diarrhea or symptoms other than the usual antibiotic-associated diarrhea occur during or after eradication therapy, antibiotics should be discontinued. In addition, appropriate tests to determine the cause of diarrhea should be performed. This review summarizes the alteration of the gut microbiota, the causes of diarrhea after Helicobacter pylori eradication therapy, and its management.

Efficacy and Safety of Fecal Microbiota Transplantation and Prospect of Microbe-based Therapies for Inflammatory Bowel Disease / 대한소화기학회지

The use of 5-ASA, immunomodulators, biologics, and small molecule drugs are the main treatment for inflammatory bowel disease (IBD), however, fecal microbiota transplantation (FMT) is also drawing attention as a treatment to improve intestinal dysbiosis by transplantaing normal human stool into patients with IBD. FMT demonstrates relatively good effects in inducing clinical remission in IBD, but unlike Clostridium difficile infection, multiple FMT can enhance the clinical effect. There are no reports of the long-term effectiveness and safety of FMT conducted in IBD yet, therefore, well-designed, prospective studies will be needed. Gut microbiota can affect inflammatory response, intestinal barrier function, and host metabolism, so microbe-based therapies are likely to be a new treatment option for IBD. The deeper the understanding of microbe products or effectors, the more likely it is to provide personalized therapy in IBD.

The Effect of Anticoagulant in Patients with Cirrhosis Associated with Acute Portal Vein Thrombosis / 대한소화기학회지

The treatment of portal vein thrombosis (PVT) in patients with liver cirrhosis (LC) has been controversial, and it is generally caseand institution-dependent. The occurrence of acute or extensive PVT is critical and requires urgent treatment because it is usually accompanied by symptoms, particularly when total occlusion occurs, causing acute decompensation of liver disease. Even in severe cases, drug selection and treatment duration are determined based on each institution’s experience. Therefore, consistent guidelines for the treatment of patients with LC with PVT are required. Recently, a patient with acute occlusive PVT with LC who showed signs of acute decompensation was treated by administering low molecular weight heparin as anticoagulant therapy. After anticoagulant treatment, the portal vein was almost completely recanalized, and the deteriorated liver function improved. In addition, the patient recovered well and showed no recurrence of PVT for more than a year. Thus, the most recent knowledge regarding the treatment of nonmalignant PVT in LC was reviewed along with a case report.

Helicobacter pylori Eradication Therapy-associated Diarrhea

Eradication of Helicobacter pylori has contributed to the treatment of peptic ulcers and mucosa-associated lymphoid tissue lymphoma. Moreover, it has possibly decreased the prevalence of gastric cancer. However, eradication therapy is associated with various adverse effects, of which diarrhea is the most common. The incidence of diarrhea after eradication treatment varies from 8% to 48%. In particular, the incidence is higher in patients who receive first-line standard triple therapy compared with those who receive second-line therapy. Both antibiotics and proton pump inhibitors, components of eradication therapy, have short-term and long-term impacts on gut microbiota. The alterations of gut microbiota may not recover until 1 year after eradication therapy. Most cases of diarrhea that occur after eradication therapy are antibiotic-associated diarrhea caused by the destruction of the normal gut microbiota. In some cases, Clostridioides difficile-associated diarrhea occurs after eradication therapy. If bloody diarrhea occurs after eradication therapy and the Clostridioides difficile toxin is not detected, antibiotic-associated hemorrhagic colitis associated with Klebsiella oxytoca infection should be suspected. It is crucial to explain the possibility of diarrhea before initiating eradication therapy to increase compliance. Furthermore, probiotics may be administered to reduce diarrhea. If severe diarrhea or symptoms other than the usual antibiotic-associated diarrhea occur during or after eradication therapy, antibiotics should be discontinued. In addition, appropriate tests to determine the cause of diarrhea should be performed. This review summarizes the alteration of the gut microbiota, the causes of diarrhea after Helicobacter pylori eradication therapy, and its management.

Clinical outcomes of positive resection margin after endoscopic mucosal resection of early colon cancers

BACKGROUND/AIMS: When determining the subsequent management after endoscopic resection of the early colon cancer (ECC), various factors including the margin status should be considered. This study assessed the subsequent management and outcomes of ECCs according to margin status.METHODS: We examined the data of 223 ECCs treated by endoscopic mucosal resection (EMR) from 215 patients during 2004 to 2014, and all patients were followed-up at least for 2 years.RESULTS: According to histological analyses, the margin statuses of all lesions after EMR were as follows: 138 cases (61.9%) were negative, 65 cases (29.1%) were positive for dysplastic cells on the resection margins, and 20 cases (8.9%) were uncertain. The decision regarding subsequent management was affected not only by pathologic outcomes but also by the endoscopist’s opinion on whether complete resection was obtained. Surgery was preferred if the lesion extended to the submucosa (odds ratio [OR], 25.46; 95% confidence interval [CI], 7.09–91.42), the endoscopic resection was presumed incomplete (OR, 15.55; 95% CI, 4.28–56.56), or the lymph system was invaded (OR, 13.69; 95% CI, 1.76–106.57). Fourteen patients (6.2%) had residual or recurrent malignancies at the site of the previous ECC resection and were significantly associated with presumed incomplete endoscopic resection (OR, 4.59; 95% CI, 1.21–17.39) and submucosal invasion (OR, 5.14; 95% CI, 1.18–22.34).CONCLUSIONS: Subsequent surgery was associated with submucosa invasion, lymphatic invasion, and cancer-positive margins. Presumed completeness of the resection may be helpful for guiding the subsequent management of patients who undergo endoscopic resection of ECC.

Could Transgastric Endoscopic Ultrasound-Guided Aspiration Alone Be Effective for the Treatment of Pancreatic Abscesses?

Drainage of pancreatic abscesses is required for effective control of sepsis. Endoscopic ultrasound (EUS)-guided endoscopic drainage is less invasive than surgery and prevents local complications related to percutaneous drainage. Endoscopic drainage with stent placement in the uncinate process of the pancreas is a technically difficult procedure. We report a case of pancreatic abscess treated by repeated EUS-guided aspiration and intravenous antibiotics without an indwelling drainage catheter or surgical intervention.

Valacyclovir-Induced Neurotoxicity in a Maintenance Hemodialysis Patient

Valacyclovir is an oral antiviral agent used in the treatment of herpesvirus infection. Although neuropsychiatric symptoms may accompany the use of this drug, valacyclovir is increasingly used to treat herpes zoster, as it is more effective when orally administered. This paper reports one case of neurotoxicity of valacyclovir in patients with end stage renal disease who were undergoing maintenance hemodialysis. Valacyclovir can induce life-threatening neurotoxicity, especially in end stage renal disease patients despite the appropriate dose reduction. Furthermore, Valacyclovir-induced neurotoxicity can be effectively managed by intensive hemodialysis.

A Case of Complete Heart Block in a Patient with Myasthenia Gravis Associated with Thymoma / 대한내과학회지

Myasthenia gravis is an autoimmune disorder characterized by antibodies against acetylcholine receptors in skeletal muscle. Myocardial involvement can present as myocarditis, ventricular tachycardia, heart failure and sudden death. However, advanced heart block is a very rare symptom. We report the case of a 69-year-old male who experienced dizziness and ptosis for one-month prior. He was diagnosed with myasthenia gravis and thymoma accompanied by complete atrioventricular block. The dizziness disappeared after implantation of a permanent pacemaker and the advanced heart block was resolved after surgical removal of the thymoma.