Efficacy and Safety of Infliximab Therapy and Predictors of Response in Korean Patients with Crohn's Disease: A Nationwide, Multicenter Study

PURPOSE: Infliximab is currently used for the treatment of active Crohn's disease (CD). We aimed to assess the efficacy and safety of infliximab therapy and to determine the predictors of response in Korean patients with CD. MATERIALS AND METHODS: A total of 317 patients who received at least one infliximab infusion for active luminal CD (n=198) and fistulizing CD (n=86) or both (n=33) were reviewed retrospectively in 29 Korean referral centers. Clinical outcomes of induction and maintenance therapy with infliximab, predictors of response, and adverse events were evaluated. RESULTS: In patients with luminal CD, the rates of clinical response and remission at week 14 were 89.2% and 60.0%, respectively. Male gender and isolated colonic disease were associated with higher remission rates at week 14. In week-14 responders, the probabilities of sustained response and remission were 96.2% and 93.3% at week 30 and 88.0% and 77.0% at week 54, respectively. In patients with fistulizing CD, clinical response and remission were observed in 85.0% and 56.2% of patients, respectively, at week 14. In week-14 responders, the probabilities of sustained response and remission were 94.0% and 97.1%, respectively, at both week 30 and week 54. Thirty-nine patients (12.3%) experienced adverse events related to infliximab. Serious adverse events developed in 19 (6.0%) patients including seven cases of active pulmonary tuberculosis. CONCLUSION: Infliximab induction and maintenance therapy are effective and well tolerable in Korean patients with luminal and fistulizing CD. However, clinicians must be aware of the risk of rare yet critical adverse events.

Clinical features of active tuberculosis that developed during anti-tumor necrosis factor therapy in patients with inflammatory bowel disease

BACKGROUND/AIMS: Anti-tumor necrosis factor (TNF) therapy for active ulcerative colitis (UC) and Crohn's disease (CD) is associated with increased risks of tuberculosis (TB) infection. We analyzed the incidence and clinical features of Korean patients with inflammatory bowel disease (IBD) who developed active TB during anti-TNF therapy. METHODS: Ten cases of active TB developed in patients treated with infliximab (n=592) or adalimumab (n=229) for UC (n=160) or CD (n=661) were reviewed. We analyzed demographics, interval between start of anti-TNF therapy and active TB development, tests for latent TB infection (LTBI), concomitant medications, and the details of diagnosis and treatments for TB. RESULTS: The incidence of active TB was 1.2% (10/821): 1.5% (9/592) and 0.4% (1/229) in patients receiving infliximab and adalimumab, respectively. The median time to the development of active TB after initiation of anti-TNF therapy was three months (range: 2-36). Three patients had past histories of treatment for TB. Positive findings in a TB skin test (TST) and/or interferon gamma releasing assay (IGRA) were observed in three patients, and two of them received anti-TB prophylaxis. Two patients were negative by both TST and IGRA. The most common site of active TB was the lungs, and the active TB was cured in all patients. CONCLUSIONS: Active TB can develop during anti-TNF therapy in IBD patients without LTBI, and even in those with histories of TB treatment or LTBI prophylaxis. Physicians should be aware of the potential for TB development during anti-TNF therapy, especially in countries with a high prevalence of TB.

Role of Small Intestinal Bacterial Overgrowth in Functional Gastrointestinal Disorders

No abstract available.

Alteration of Gut Microbiota and Efficacy of Probiotics in Functional Constipation

No abstract available.

Dermatomyositis associated with hepatitis B virus-related hepatocellular carcinoma

Dermatomyositis is an idiopathic inflammatory myopathy with typical cutaneous manifestations. It has been proposed that dermatomyositis may be caused by autoimmune responses to viral infections. Previous studies have shown an association between dermatomyositis and malignant tumors such as ovarian cancer, lung cancer, and colorectal cancer. However, a chronic hepatitis B virus (HBV) infection associated with dermatomyositis and hepatocellular carcinoma (HCC) has been very rarely reported. Here, we report a rare case of dermatomyositis coinciding with HBV-associated HCC. A 55-year-old male was confirmed to have HCC and dermatomyositis based on proximal muscle weakness, typical skin manifestations, elevated muscle enzyme levels, and muscle biopsy findings. This case suggests that HCC and/or a chronic HBV infection may be factors in the pathogenesis of dermatomyositis through a paraneoplastic mechanism.

Efficacy of Ramosetron in Male Patients With Irritable Bowel Syndrome With Diarrhea (Neurogastroenterol Motil 2011;23:1098-1104)

No abstract available.

A Case of Acute Myocarditis as the Initial Presentation of Crohn's Disease

We experienced a case of acute myocarditis as the initial presentation of Crohn's disease. A 19-year-old woman was admitted with impaired consciousness, shock, and respiratory failure. She had suffered from frequent diarrhea and abdominal pain for several years. Cardiac troponin I and creatine kinase-MB fraction levels were elevated to 5.32 and 16.66 ng/mL, respectively. A 12-lead electrocardiogram showed sinus tachycardia, and a chest radiograph revealed interstitial pulmonary edema. An echocardiogram showed dilated ventricles with akinesia of the basal to apical inferoseptal, anteroseptal, anterior, and inferior left ventricular walls and severely impaired systolic function. Intensive care with inotropic support was effective, and her clinical condition gradually improved. Two weeks later, a colonoscopy revealed ulceration with stenosis in the terminal ileum and multiple aphthous ulcers in the rectum. A biopsy of the rectum revealed non-caseating granulomatous inflammation. She was diagnosed with Crohn's disease presenting with acute myocarditis.

A Case of Undifferentiated Carcinoma with Osteoclast-Like Giant Cells in the Pancreas / 대한내과학회지

Undifferentiated carcinomas with osteoclast-like giant cells are rare pancreatic and periampullary neoplasms that mimic giant cell tumors of bone morphologically. Recently, we experienced an osteoclast-like giant cell tumor arising in the tail of the pancreas. A 76-year-old male was admitted with epigastric discomfort and indigestion. Abdominal computed tomography (CT) and abdominal magnetic resonance imaging (MRI) showed a 3x3-cm mass containing necrotic and hemorrhagic areas in the tail of the pancreas. A distal pancreatectomy and splenectomy were performed. Histological examination showed tumor cell components consisting of mononuclear pleomorphic cells admixed with osteoclastic giant cells. The final diagnosis was undifferentiated carcinoma with osteoclast-like giant cells with ductal adenocarcinoma in the pancreas.

The Frequency and Risk Factors of Colorectal Adenoma in Health-Check-up Subjects in South Korea: Relationship to Abdominal Obesity and Age

BACKGROUND/AIMS: Obesity is associated with the risk of colorectal cancer. However, there is a lack of information about the relationship between obesity and colorectal adenoma. We investigated whether general and abdominal obesity are risk factors for colorectal adenoma. METHODS: Subjects who received health check-ups, including colonoscopy, from April 2006 to September 2007 in Chung-Ang University Hospital were included (n=1,316). The frequency and characteristics of colorectal adenomas were analyzed according to demographic features, past history, blood tests, body mass index, and components of metabolic syndrome. Abdominal obesity was defined as a waist circumference of > or =80 cm in women and > or =90 cm in men. RESULTS: The sex ratio of the subjects was 1.9:1 (male:female) and their age was 47.7+/-10.0 years (mean+/-SD). In univariate analysis, abdominal obesity was significantly associated with the frequency of colorectal adenoma (26.5% "yes" vs 16.9% "no"; p or =100 mg/dL) or fatty liver (p or =60 years; OR, 6.7; 95% CI, 3.5-12.5), and abdominal obesity (OR, 1.5; 95% CI, 1.0-2.2) were independent risk factors for colorectal adenoma (p<0.05). The frequency of multiple adenomas (more than two sites) was also significantly higher in subjects with abdominal obesity. However, the effect of abdominal obesity on the development of colorectal adenoma decreased in elderly people. CONCLUSIONS: Abdominal obesity is an independent risk factor for colorectal adenoma and its multiplicity, especially in younger people in South Korea.

The Changes in Prevalence and the Related Factors of Helicobacter pylori Infection in Korean Health Check-up Subjects during 8 Years / 대한소화기학회지

BACKGROUND/AIMS: The aim of this study was to evaluate the changes in prevalence and the related factors of Helicobacter pylori (H. pylori) infection in Korean health check-up subjects during the period of 8 years. METHODS: Among 89,231 subjects who visited the Health Promotion Centers of Severance hospital or Chung-Ang University hospital from Jan. 1998 through Dec. 2005, a total of 10,553 subjects who received esophagogastroduodenoscopy (EGD) and H. pylori test were enrolled. H. pylori infection was assessed by histologic examination. Changes of the prevalence of H. pylori infection during 8 years, and infection-related factors such as demographic characteristics, body mass index, ABO blood types, endoscopic findings (presence of peptic ulcer diseases), educational level, economic status, smoking habits, and alcohol intake in year 2005 were analyzed. RESULTS: The mean age of 10,553 subjects (7,329 men, 3,224 women) was 49.7+/-10.4 years (range from 17 to 92 years). The prevalence of H. pylori infection at the first, second, third, fourth, fifth, sixth, seventh, and eighth year were 64.7%, 58.1%, 54.2%, 50.4%, 48.9%, 49.5%, 39.6%, and 40.0%, respectively, and these serial decreases in prevalence over 8 years were statistically significant (p<0.001). Regardless of sex, age or EGD findings, the prevalence of H. pylori infection was significantly decreased. In the analysis of the H. pylori infection-related factors in 2005, only age and EGD findings (peptic ulcer diseases) were significant factors. CONCLUSIONS: The prevalence of H. pylori infection was significantly decreased during 8-year period in Korean health check-up subjects. Age and peptic ulcer diseases were the two significant factors related to H. pylori infection in Korea.

The etiology of acute viral hepatitis for the last 3 years at a single institution in Seoul / 대한내과학회지

BACKGROUND/AIMS: Hepatitis A is increasing during the recent years in Korea, and sporadic cases of hepatitis E are not rare. We investigated the etiology of acute viral hepatitis, including 27 cases of coinfection with hepatitis A and E, during the last 3 years. METHODS: Retrospective analysis of one hundred eleven patients with acute viral hepatitis at Chung-Ang University Hospital was done from January 2005 to July 2007. The patients were positive for any one of the following tests: IgM anti-HAV, IgM anti-HBc, HCV RNA and IgM anti-HEV. RESULTS: The proportions of acute viral hepatitis A, B and C were 94.6% (105/111), 4.5% (5/111) and 0.9% (1/111), respectively. Among the patients with hepatitis A, 27 patients (24.3%) were positive for IgM anti-HEV. We analyzed 105 patients with either hepatitis A only or they had coinfection of hepatitis A and E. The mean age, the duration of the hospital stay, the mean levels of serum transaminase, bilirubin and albumin and the protrombin time were similar between the patients with hepatitis A only and those with coinfection of hepatitis A and E. All the patients were discharged without serious complication such as fulminant hepatic failure. The biochemical liver function tests were normalized in all patients within 8 weeks. CONCLUSIONS: The most common etiology of acute viral hepatitis in Koreans was the hepatitis A virus. Patients coinfected with hepatitis A and E were observed. The patients with coinfection of hepatitis A and E showed no significant difference in their clinical features and laboratory parameters, as compared to the patients with hepatitis A only.

A Case of Primary Hepatic Burkitt's Lymphoma / 대한소화기학회지

Burkitt's lymphoma is a rare disease that belongs to the aggressive non-Hodgkin's lymphoma. Herein, we report a case of primary hepatic Burkitt's lymphoma. A 19-year-old man visited the hospital for right upper quadrant pain. He felt fatigue for two months. Physical examination revealed hepatomegaly and no palpable lymph node. He had no fever, weight loss, or night sweating. Laboratory finding showed mild anemia (hemoglobin, 12.4 g/dL), mild elevated transaminase (ALT, 52 IU/L), elevated lactate dehydrogenase (LDH, 437 IU/L), and alkaline phosphatase (ALP, 129 IU/L). The viral marker was positive for HBsAg, HBeAg, anti-HBs, and anti-HBc (IgG), and negative for anti-HBe, anti-HCV, and anti-HIV. CEA, AFP, and CA19-9 levels were within normal ranges. The HBV DNA quantitation was 1.3x10(9) copies/ml. Abdominal-Pelvis CT scan and abdominal MRI finding were compatable with malignant lymphoma. Liver biopsy examination confirmed Burkitt's lymphoma. No metastasis was detected in the thoracic cavity, bone marrow, and spinal fluid. The patient was treated with the combination regimen of cyclophosphamide, doxorubicin, vincristine, prednisone and high dose methotrexate. Cytosine arabinoside and methotrexate were added for CNS prophylaxis by intrathecal installation. Chemotherapy was administered every 3 weeks for fifteen cycles. Serial follow-up CT scan showed a marked decrease in the size of hepatic lesions. Follow-up CT scan and PET-CT scan were perfomed 4 weeks after the final cycle disclosed no definite residual or active lesion confirming the state of complete remission.

Hepatocellular Carcinoma with Metastasis to the Cavernous Sinus of Skull Base Causing Ptosis / 대한소화기학회지

The cavernous sinus of skull base is a extremely rare metastastatic site for hepatocellular carcinoma (HCC). A 51-year-old man was diagnosed with HCC by liver biopsy and palliative radiotherapy on HCC including main portal vein was performed. One month later, he was admitted due to sudden onset ptosis. Neurologic findings were normal except for abnormal movement of right eye, and it raised the possibility of abnormality in the right occulomotor, trochlear and the abducens nerves. Contrast-enhanced CT scan of brain showed a mass with homogeneous enhancement involving the right cavernous sinus. T2-weighted axial MR images demonstrated a homogeneous mass with intermediate signal intensity, and contrast-enhanced axial T1-weighted MR images demonstrated a mass with homogeneous enhancement in the right cavernous sinus. We describe a case of HCC metastasis to the cavernous sinus with symptoms of ptosis and disturbance of right eyeball movement.

A case of superior mesenteric artery thrombosis associated with antiphospholipid syndrome / 대한내과학회지

Antiphospholipid syndrome (APS) has received considerable attention due to its association with a thrombophilic disorder. Thrombotic events associated with this syndrome most often involve the venous system and occasionally the arterial system such as the cerebral, coronary, renal, and retinal arteries. Few reports on mesenteric artery thrombosis associated with APS are documented. We report a case of a 45 year old male diagnosed with superior mesenteric artery thrombosis associated with APS. The patient had symptoms of chronic mesenteric ischemia including postprandial abdominal pain, weight loss and diarrhea, and was positive for lupus anticoagulant antibody. An abdominal CT showed superior mesenteric arterial thrombosis and luminal narrowing. Symptoms were improved after anticoagulant therapy.

Diabetes Mellitus and the Risk of Colorectal Adenoma

BACKGROUND/AIMS: Diabetes mellitus (DM) is associated with an increased incidence of colon cancer. However, the relationship between DM and colorectal adenoma is not definite. In this study, we sought to determine the association between DM and the prevalence of colorectal adenoma. METHODS: We enrolled 606 patients with DM and 606 asymptomatic adults who underwent colonoscopy for routine health evaluations from June 2003 to June 2007. The frequency and characteristics of the colorectal adenomas were analyzed and compared between the two groups. RESULTS: The sex ratio and mean age were 1.67:1 (M:F) and 58.1+/-10.6 years, respectively, in patients with DM, and 1.68:1 and 57.6+/-8.9 years, respectively, in patients without DM, and these values were similar. The frequency of colorectal adenoma was 33.2% for the patients with DM and 32.3% for the patients without DM. The frequency, location, number, size and histopathologic findings of the colorectal adenomas were not different between the two groups. Among the patients with DM, the frequency of colorectal adenoma was 35.7% in the patients treated with oral hypoglycemic agents and 31.4% in the patients treated with insulin. Also, the other characteristics of the colorectal adenomas were not different according to the treatment method. CONCLUSIONS: The frequency and characteristics of colorectal adenomas were not different between the patients with and without DM.

Acute Cytomegalovirus Proctocolitis Presenting with Massive Lower Gastrointestinal Bleeding / 대한소화기내시경학회지

Cytomegalovirus (CMV) colitis usually affects immunosuppressed patients. However, CMV colitis may also affect patients with a debilitation caused by a severe illness or affect patients that have a specific physiological status (old age, pregnancy). Clinically, patients with CMV colitis most commonly present with abdominal pain, diarrhea, and gastrointestinal bleeding. The diagnosis of CMV colitis usually requires a biopsy of mucosal tissue. The characteristic finding on biopsy reveals CMV inclusion bodies. CMV colitis can be successfully treated with ganciclovir. We report two cases of CMV proctocolitis in elderly patients with chronic diseases that presented with massive lower gastrointestinal bleeding due to multiple rectal ulcerations. A pathological examination showed CMV inclusion bodies. CMV colitis should be considered in the differential diagnosis of patients with massive rectal ulcer bleeding when other causes fail to explain the course of the disease.

Acute Cytomegalovirus Proctocolitis Presenting with Massive Lower Gastrointestinal Bleeding / 대한소화기내시경학회지

Cytomegalovirus (CMV) colitis usually affects immunosuppressed patients. However, CMV colitis may also affect patients with a debilitation caused by a severe illness or affect patients that have a specific physiological status (old age, pregnancy). Clinically, patients with CMV colitis most commonly present with abdominal pain, diarrhea, and gastrointestinal bleeding. The diagnosis of CMV colitis usually requires a biopsy of mucosal tissue. The characteristic finding on biopsy reveals CMV inclusion bodies. CMV colitis can be successfully treated with ganciclovir. We report two cases of CMV proctocolitis in elderly patients with chronic diseases that presented with massive lower gastrointestinal bleeding due to multiple rectal ulcerations. A pathological examination showed CMV inclusion bodies. CMV colitis should be considered in the differential diagnosis of patients with massive rectal ulcer bleeding when other causes fail to explain the course of the disease.

Comparison of bacterial infection rate between patients with alcoholic liver cirrhosis and viral liver cirrhosis / 대한내과학회지

BACKGROUND: Some studies have reported that bacterial infection is more common in alcoholic compared to non-alcoholic liver cirrhosis such as viral liver cirrhosis. However, other studies reported no significant differences in the bacterial infection rate between alcoholic and non-alcoholic liver cirrhosis. This study was performed to compare the frequency of bacterial infection between alcoholic and viral liver cirrhosis. METHODS: We analyzed 190 cirrhotic patients (alcoholic 83, viral 107) with 539 hospitalized cases (alcoholic 242, viral 297) who were followed for more than 12 months. RESULTS: During the follow up period, 82 patients (43.2%) presented with bacterial infectionsthat developed in 34 (41.0%) patients with alcoholic liver cirrhosis and 48 (44.9%) patients with viral liver cirrhosis. There was no significant difference in the frequency of bacterial infection including community acquired and nosocomial infection between alcoholic and viral cirrhotic patients regarding the Child-Pugh class, various laboratory parameters and site of infection. Gram-negative and enteric bacterial strains were the most frequently isolated pathogens in both groups. CONCLUSIONS: There was no significant difference in the frequency of infection between patients with alcoholic and viral liver cirrhosis. Further efforts are needed to reduce bacterial infection by gram negative and enteric bacteria in patients with both alcoholic and viral cirrhosis.

Protective effects of mastic in non-steroidal anti-inflammatory drug induced gut damage and bacterial translocation in a rat model / 대한내과학회지

BACKGROUND: NSAIDs induce gut damage and bacterial translocation throughout the entire gastrointestinal tract. The aim of the present study was to examine whether mastic, a natural resinous exudate obtained from the Pistacia lentiscus treetrees, can reduce diclofenac induce gut damage and bacterial translocation in rats. METHODS: 32 SD rats were divided into four groups; a control group, diclofenac group, diclofenac with 0.3 cc/kg mastic group and diclofenac with 1.0 cc/kg mastic group. Mastic oils were administered 3 hours before diclofenac administration (100 mg/kg orally x2 days). Intestinal permeability, enteric aerobic bacterial counts in the distal ileum and cecum, intestinal adhesion, lipid peroxidation of distal ileum, and bacterial translocation to mesenteric lymph nodes, liver, spleen, kidney and heart were measured, respectively RESULTS: Diclofenac caused marked increase in intestinal permeability, enteric bacterial numbers in distal ileum and cecum, intestinal adhesion, lipid peroxidation of the distal ileum, and bacterial translocation to mesenteric lymph nodes, liver, spleen, kidney and heart of which event were reduced with Mostic coadminist. Howere mastic oil showed significant profect effects in 1.0 cc/kg dose. CONCLUSIONS: Mastic was proven to have beneficial effects on preventing NSAID induced gut injury and bacterial translocation in a rat model.

Risk factors for hospital acquired infections in patients with decompensated liver cirrhosis / 대한내과학회지

BACKGROUND: Infection is a frequent complication in patients with chronic liver disease, mainly during the advanced stages. This study was performed to investigate the risk factors for infections in hospitalized patients with decompensated liver cirrhosis. METHODS: We analyzed 108 decompensated hospitalized cirrhotic patients (34 cases with infection and 117 cases without infection) without clinical evidence of infection at the time of admission and during initial 72 hours after admission. RESULTS: Univariate and multivariate analysis revealed that patients who developed an infection were more likely to have a lower serum albumin levels. Gram-negative bacterial strains were detected most frequently, in 13 of the 18 strains isolated. There was no significant difference in etiology of disease, Child-Pugh classification, cirrhotic complications including upper G-I bleeding, hepatocelluar caricnoma, invasive procedure, diabetus mellitus, admission to ICU, duration of admission, survival rate and various parameters related to liver and renal function between patients with infection and without infection. CONCLUSION: The present study indicates that decompensated cirrhotic patient with low serum albumin levels have a higher risk of developing a hospital acquired infection, especially by gram negative bacteria.