Differential Diagnosis of Colorectal Polyps with Narrow Band Imaging Colonoscopy without Magnification / 대한소화기학회지

BACKGROUND/AIMS: Narrow band imaging (NBI) endoscopy can be used for gross differentiation between the types of colonic polyps. This study was conducted as a retrospective study for estimation of the interobserver and intra-observer agreement of the pit pattern of the mucosal surface and the accuracy of histology prediction. METHODS: A total of 159 patients underwent complete colonoscopy and 219 polyps examined by NBI endoscopy without magnification were assessed. Interobserver and intra-observer agreement were calculated by investigators in each group for determination of the surface pattern and prediction of histology based on the modified Kudo's classification using intraclass correlation coefficient. RESULTS: Interobserver agreement for the surface pit pattern and prediction of polyp type was 0.84 and 0.73 in experienced endoscopists, and 0.86 and 0.62 in trainees, respectively. Intra-observer agreement for the surface pit patterns and prediction of polyp type was 0.81, 0.83, 0.85, 0.83, 0.56, 0.84, 0.51, 0.83, and 0.71; and 0.71, 0.70, 0.82, 0.54, 0.72, 0.37, 0.51, 0.34, and 0.30, respectively. The diagnostic accuracy for prediction of polyp type was 69.4% for experienced endoscopists and 72.9% for trainees. CONCLUSIONS: NBI endoscopy without magnification showed fairly good inter and intra-observer agreement for the pit pattern of the mucosal surface and the accuracy of histology prediction; however, it had some limitation for differentiation of colon polyp histologic type. Training and experience with NBI is needed for improvement of accuracy.

How Should Azathioprine Be Dosed in Crohn's Disease? A Novel Strategy of Maximum Dose-titration Based on the Lower Limit of Leukocyte Count and Tolerability / 대한소화기학회지

BACKGROUND/AIMS: Although general guidelines have suggested weight-based dosing of azathioprine (AZA, 2.5 mg/kg/day) for Crohn's disease (CD), a substantial number of patients develop bone marrow suppression. The aim of this study was to evaluate the maximum dose of AZA not based on weight but titrated according to the lower limit of leukocyte count for maintaining remission in patients with CD. METHODS: Among a total of seventy-eight patients with CD, who had been followed-up at Kosin University Gospel Hospital (Busan, Korea) from 2010 to 2011, those treated with the maximum dose of AZA meeting both drug-tolerability and leukocytes count of more than 4,000/mm3 for steroid-free maintaining remission were enrolled. The titrated maximum AZA dose and its relationship with weight were evaluated. RESULTS: A total of 42 patients (male, 32 patients; mean age, 31 years) were enrolled. The maximum dose of AZA was 49.1 mg/day. The dose per weight was 0.87 mg/kg/day and negatively correlated with body weight (gamma=-0.51, p=0.01) and BMI (gamma=-0.33, p=0.034). AZA dose per weight in the below 40 years old group was significantly higher than that in the above 40 years old group (p=0.039). CONCLUSIONS: Dose decision of AZA based only on weight could put the patients to inappropriately low or high dose resulting in need of additional therapy or serious side effect, respectively. Therefore, the maximum dose-titration based on the lower limit of leukocyte count and tolerability is a novel and a valuable strategy in deciding the dose of thiopurines.

[Bacteria isolated from surgical infections and its susceptibilities to antimicrobial agents--special references to bacteria isolated between April 2009 and March 2010].

Bacteria isolated from surgical infections during the period from April 2009 to March 2010 were investigated in a multicenter study in Japan, and the following results were obtained. In this series, 671 strains including 16 strains of Candida spp. were isolated from 174 (79.1%) of 220 patients with surgical infections. Four hundred and eleven strains were isolated from primary infections, and 244 strains were isolated from surgical site infection. From primary infections, anaerobic Gram-negative bacteria were predominant, followed by aerobic Gram-negative bacteria, while from surgical site infection aerobic Gram-positive bacteria were predominant, followed by anaerobic Gram-negative bacteria. Among aerobic Gram-positive bacteria, the isolation rate of Enterococcus spp. was highest, followed by Streptococcus spp., and Staphylococcus spp. in this order, from primary infections, while Enterococcus spp. was highest, followed by Staphylococcus spp. from surgical site infection. Among aerobic Gram-negative bacteria, Escherichia coli was the most predominantly isolated from primary infections, followed by Klebsiella pneumoniae, Enterobacter cloacae and Pseudomonas aeruginosa, in this order, and from surgical site infection, E. coli was most predominantly isolated, followed by P. aeruginosa and E. cloacae. Among anaerobic Gram-positive bacteria, the isolation rate of Eggerthella lenta was the highest from primary infections, followed by Parvimonas micra, Streptococcus constellatus and Finegoldia magna, and from surgical site infection, E. lenta was most predominantly isolated. Among anaerobic Gram-negative bacteria, the isolation rate of Bilophila wadsworthia was the highest from primary infections, followed by Bacteroides fragilis, Bacteroides ovatus and Bacteroides thetaiotaomicron, and from surgical site infection, B. fragilis was most predominantly isolated, followed by B. ovatus, B. wadsworthia and B. thetaiotaomicron, in this order. In this series, we noticed no vancomycin-resistant Gram-positive cocci, nor multidrug-resistant P. aeruginosa. We should carefully follow up B. wadsworthia which was resistant to various antibiotics, and also Bacteroides spp. which was resistant to many beta-lactam antibiotics.

Successful Treatment of an Iatrogenic Giant Femoral Artery Pseudoaneurysm With Percutaneous Thrombin Injection

A femoral artery pseudoaneurysm (FAP) is one of the most troublesome complications following invasive procedures related to the femoral arterial access. Post-procedure FAP rarely occurs; however, its occurrence tends to increase with the more frequently antiplatelet agents, anticoagulants, and larger-sized catheter used for interventional procedures. Traditionally, surgical repair has been considered as the standard treatment modality for FAP; however, less invasive methods currently exist such as blind manual or ultrasound-guided compression repair (UGCR) as well as percutaneous thrombin injection, both of which have replaced the need for surgery. We report a case of a giant pseudoaneurysm in a femoral artery, which had developed as a complication of stenting in a patient with carotid artery stenosis and ischemic heart disease, and was subsequently successfully treated using percutaneous thrombin injection.

Three Cases of Endoscopic Mucosal Resection of Rectal Carcinoid Tumor by Band Ligation and the Snare Resection Technique / 대한소화기내시경학회지

Many reports have shown that endoscopic polypectomy or endoscopic mucosal resection can successfully remove tumor less than 1.0 cm in size. However, most carcinoid tumors in the rectum occur in the submucosal layer so that the entire tumor cannot be completely removed via endoscopic polypectomy or endoscopic mucosal resection. Endoscopic mucosal resection can also cause perforation of the intestinal wall and bleeding. Due to these reasons, instead of these two conventional methods, endoscopic mucosal resection using a ligation device is currently being used for the treatment of rectal carcinoid tumor. Recent studies that used this method have reported that endoscopic mucosal resection of rectal carcinoid tumor by band ligation and the snare resection technique is safe with minimal complications and this is quite useful to completely remove rectal carcinoid tumor.

Three Cases of Endoscopic Hemostasis of Gastric Ulcer Bleeding from an Exposed Blood Vessel with Using Histoacryl (N-Butyl-2-Cyanoacrylate) / 대한소화기내시경학회지

Upper gastrointestinal bleeding is a primary and emergency complication of peptic ulcer. Injection of Histoacryl (N-butyl-2-cyanoacrylate) is an effective endoscopic hemostasis procedure to treat peptic ulcer bleeding. However, Histoacryl injection is not a widely used method because of its various and sometimes severe complications. Therefore, the use of Histocaryl should be considered as a second line treatment modality to achieve therapeutic endoscopic hemostasis when the conventional treatment modalities fail or the patient has a high risk of needing operative therapy. Three patients, who had gastric ulcer bleeding from an exposed blood vessel, were each treated by an injection of Histoacryl diluted with Lipiodol at a dilution ratio of 1:1. All 3 procedures were successfully accomplished without any complications.