Rescue endoscopic bleeding control for nonvariceal upper gastrointestinal hemorrhage using clipping and detachable snaring.

Nonvariceal upper gastrointestinal (UGI) bleeding recurs after appropriate endoscopic therapy in 10 % - 15 % of cases. The mortality rate can be as high as 25 % when bleeding recurs, but there is no consensus about the best modality for endoscopic re-treatment. The aim of this study was to evaluate clipping and detachable snaring (CDS) for rescue endoscopic control of nonvariceal UGI hemorrhage. We report a case series of seven patients from a Korean tertiary center who underwent endoscopic hemostasis using the combined method of detachable snares with hemoclips. The success rate of endoscopic hemostasis with CDS was 86 %: six of the seven patients who had experienced primary endoscopic treatment failure or recurrent bleeding after endoscopic hemostasis were treated successfully. In conclusion, rescue endoscopic bleeding control by means of CDS is an option for controlling nonvariceal UGI bleeding when no other method of endoscopic treatment for recurrent bleeding and primary hemostatic failure is possible.

The efficacy of i-SCAN for detecting reflux esophagitis: a prospective randomized controlled trial.

New imaging technologies have been applied in endoscopy to improve the detection and differentiation of subtle mucosal changes using a digital contrast method. Among them, i-SCAN technology is the most recently developed image-enhancing technology. We investigated whether i-SCAN could improve the detection rate of reflux esophagitis. Interobserver agreement between endoscopists was compared with conventional white light (WL) endoscopic examination. We performed a prospective randomized controlled trial. A consecutive series of 514 subjects that underwent an esophagogastroduodenoscopy for health inspection were enrolled and randomized into the i-SCAN group (n = 246) and WL group (n = 268). An esophagogastroduodenoscopy with video recording was used for detecting reflux esophagitis, and reflux esophagitis were categorized by the modified Los Angeles (LA) classification. The total number of reflux esophagitis identified by WL and i-SCAN was 58 (21.7%) and 74 (30.1%), respectively. The diagnostic yield of reflux esophagitis was significantly higher (P = 0.034) in the i-SCAN group (30.1%) as compared to the WL group (21.6%). Using the modified LA classification, the detection rate of minimal changes was significantly higher (P = 0.017) in the i-SCAN group (11.8%) as compared to the WL group (5.6%), but the detection rates of LA-A and LA-B were not significantly different between the two groups (P = 0.897 and P = 0.311, respectively). After comparison of the interobserver agreement using randomly selected video clips, the i-SCAN group showed better agreement than the WL group (Kappa value, 0.793 vs. 0.473). Compared to WL endoscopy, applying i-SCAN in daily practice can improve the diagnostic yield of reflux esophagitis by detecting more minimal changes in the squamo-columnar junction of the esophagus and can improve the interobserver agreement of the modified Los Angeles classification.

Comparison of transnasal small-caliber vs. peroral conventional esophagogastroduodenoscopy for evaluating varices in unsedated cirrhotic patients.

BACKGROUND AND STUDY AIMS: We aimed to evaluate the accuracy of transnasal small-caliber esophagogastroduodenoscopy (TNSC-EGD) compared with peroral conventional EGD (POC-EGD) for evaluating varices in unsedated patients with liver cirrhosis. The success rate, safety, endoscopist satisfaction, and patient tolerability of TNSC-EGD were also addressed. PATIENTS AND METHODS: One hundred patients with liver cirrhosis participated in this randomized crossover trial, and 84 subjects completed both procedures. Of the 84 patients, 28 had marked bleeding diathesis (platelet count ≤ 50000/mm (3) and/or prothrombin time ≥ 1.7 INR). Endoscopists and patients answered questionnaires using a 100-mm visual analog scale about, respectively, their satisfaction and their tolerance of the procedure. RESULTS: The success rate of TNSC-EGD was comparable to that of POC-EGD (96% vs. 99%). Nasal mucosal hemorrhages induced by TNSC-EGD occurred in 5 patients (6%), but were easily controlled. Compared to the POC-EGD reference test, diagnostic accuracies of TNSC-EGD for detecting esophageal varices, gastric varices, and red color signs were 98%, 98%, and 96%, respectively. Concordance rates on grading esophageal varices and gastric varices were excellent at 93% (κ = 0.85) and 96% (κ = 0.87). Endoscopist satisfaction was not significantly different between TNSC-EGD and POC-EGD, whereas patient tolerance of TNSC-EGD was significantly greater than that of POC-EGD (79.0 ± 14.4 vs. 69.5 ± 16.1; P = 0.001). CONCLUSION: TNSC-EGD without sedation was found to be feasible, safe, and accurate for evaluating esophageal varices, gastric varices, and red color signs in patients with cirrhosis - even in those with marked bleeding diathesis. Furthermore, it was significantly better tolerated by patients, without altering endoscopist satisfaction. Our findings indicate that TNSC-EGD without sedation might be viewed as a potential alternative to POC-EGD for evaluation of varices.

Decompression and interspinous dynamic stabilization using the locker for lumbar canal stenosis associated with low-grade degenerative spondylolisthesis.

BACKGROUND: Decompression and spinal fusion have been generally recommended for spinal stenosis associated with low-grade degenerative spondylolisthesis (DS), although this is still controversial. The purpose of the present study is to analyze the clinical and radiological outcomes of interspinous dynamic stabilization using the Locker (WINNOVA co, Seoul, Korea) for lumbar canal stenosis with grade I DS. METHODS: The authors performed a retrospective review of 23 consecutive patients who underwent single level decompression and the Locker application for lumbar canal stenosis with grade I DS and were followed up for at least 2 years. Excluded were those with DS grade II or higher and DS combined with foraminal disc herniation/stenosis. The mean age of patients at the time of surgery was 62.1 years (range: 45-81 years). RESULTS: There were no complications in the perioperative period. At a mean follow-up duration of 28.3 months (range: 24-32 months), visual analogue scale scores for back pain, leg pain, and Oswestry disability index had decreased significantly; from 4.6, 7.2, and 38.5% to 2.4, 2.6, and 15.3%, respectively. Clinical success was achieved in 87% of the patients. The mean percentage of slippage did not change significantly. The mean sagittal rotation angle significantly decreased from 9.7 to 6.5 degrees (p=0.01). One patient (4.3%) underwent secondary fusion surgery due to persistent pain. CONCLUSIONS: Decompression and interspinous dynamic stabilization using the Locker yielded favorable clinical and radiological outcomes for lumbar canal stenosis with grade I DS and could be an alternative for spinal fusion. However, further long-term follow-up studies are necessary.

Effect of drug-eluting metal stents in benign esophageal stricture: an in vivo animal study.

BACKGROUND AND STUDY AIMS: The aim of this study in canines was to investigate the effectiveness and safety of self-expandable metal stents, which were coated with paclitaxel to minimize the tissue response. MATERIALS AND METHODS: 14 dogs (5-10 kg) were randomly allocated to two groups. Drug-eluting stents (DES, n = 7) or nondrug-eluting stents (non-DES, n = 7) were endoscopically inserted and fixed in the esophagus of healthy dogs. Every 2 weeks, for a maximum period of 8 weeks, an endoscopic examination was performed to evaluate the status of stent insertion, the grade of tissue hyperplasia, and mucosal change at both ends of the stent. RESULTS: One case of stent migration was observed after 4 weeks in the non-DES group. In this group, tissue reaction and hyperplasia remained for more than 4 weeks after stent insertion. By contrast, an endoscopic examination of the surrounding esophageal mucosa in the DES group showed very little tissue reaction, and the stent was easily separated from the esophageal tissue. CONCLUSION: Although further studies are required to confirm our results, we suggest that these newly designed DES may provide an alternative tool to manage refractory benign esophageal stricture.

Relationship of wheezing to the severity of obstruction in asthma.

Ninety-three asthmatic patients were examined on 320 occasions for wheezing and peak expiratory flow rate (PEFR). The presence of a wheeze (either reported by the patient or found on examination) was associated with a significantly lower PEFR. Expiratory wheezing was usually accompanied by inspiratory wheezing; this biphasic wheezing was associated with a lower PEFR than only expiratory wheezing. Loudness and the high pitch of wheezing were associated with more severe obstruction. Most expiratory wheezing lasted throughout the entire expiration. Expiratory or inspiratory wheezing of high pitch, moderate to severe intensity, and spanning the entire phase of the breath was associated with a lower PEFR than wheezing without these characteristics. Although characterization of wheezing has a general relationship to the severity of airway obstruction, an objective measurement of expiratory flow rate is necessary for the evaluation of each patient's condition.

Evaluation of the severity of asthma: patients versus physicians.

It is clear that accurate assessment of the severity of asthma requires a measurement of airway obstruction, such as peak expiratory flow rate. In this study, physicians were quite inaccurate in estimating the peak expiratory flow rate by examining patients, whereas the patients themselves were far more accurate in guessing the measurement. In addition, they were able to tell whether the peak expiratory flow rate was better, the same or worse from day to day. Patients' symptoms are important indices of the severity of airway obstruction which should be exploited in management.

Aerosol beclomethasone in patients with steroid-responsive chronic obstructive pulmonary disease.

Some patients with chronic obstructive pulmonary disease have favorable responses to treatment with oral corticosteroids with increase in one-second forced expiratory volume of 30 percent or more above the baseline. The benefit of long-term steroid therapy may be outweighed by the side effects. Twelve patients who had previously demonstrated a response to oral corticosteroids were studied in a double-blind randomized crossover trial comparing prednisone (30 mg daily) with beclomethasone (metered-dose inhaler, 16 puffs daily) for two weeks each with a two-week washout period between the two regimens. Those who were taking prednisone tapered the dose to 5 mg daily and those taking beclomethasone discontinued it for two weeks before the beginning of the study. History, physical examination, and pulmonary function were monitored. The mean one-second forced expiratory volume increased from 0.65 to 1.00 liter after prednisone therapy and it increased from 0.63 to 0.81 liter after aerosol beclomethasone (difference significant, p less than 0.01 by paired t test). Only five of 12 patients had an increase in one-second forced expiratory volume with steroid aerosol, an increase that was at least 50 percent that achieved by prednisone. In most patients with steroid-responsive chronic obstructive pulmonary disease, aerosol beclomethasone is not an adequate substitute for oral steroids.

Bronchodilator response to oral aminophylline and terbutaline versus aerosol albuterol in patients with chronic obstructive pulmonary disease.

Bronchodilator efficacy of oral administration of aminophylline (400 mg) and terbutaline sulfate (5 mg) was compared with inhalation of three puffs of albuterol sulfate in 17 patients with stable chronic obstructive pulmonary disease in a double-blind crossover study. Two hours after either form of therapy, the patients were treated again with three puffs of albuterol. Forced expiratory volume in one second (FEV1) increased significantly more from the baseline value after albuterol aerosol than after oral medication at 30, 60, and 120 minutes (paired t test, p less than 0.01). After three puffs of albuterol at 120 minutes, FEV1 increased to similar values an hour later on both days in 14 of 17 patients. Thirteen patients complained of side effects during oral therapy and none during aerosol therapy. Maximum bronchodilatation was achieved by albuterol aerosol in 14 of 17 patients, and addition of oral therapy produced no further increase of flow rate in these patients. Bronchodilator aerosol is the logical choice for treatment of chronic obstructive pulmonary disease because it is more effective than oral therapy and because it is free from side effects.

Clinical validation of the Helikit: a 13C urea breath test used for the diagnosis of Helicobacter pylori infection.

OBJECTIVE: To assess the clinical performance of the Helikit, a 13C urea breath test, in the diagnosis of Helicobacter pylori infection. METHODS: A total of 205 participants were assessed in Canada and Korea for H. pylori infection status by endoscopy, or a combination of IgG ELISA and CLO test, as well as by the Helikit. The Helikit contains 75 mg of 13C urea as well as citric acid, flavor enhancers and stabilizers in a single plastic cup. The powder is dissolved in 75 mL of water for oral administration. No extra mixing or dilution steps are required. RESULTS: Using the biopsy-derived data as the gold standard the Helikit displayed a clinical sensitivity of 93.5% (95% confidence interval 88.5 to 98.5%) and a clinical specificity of 97.3% (94.3 to 100%). An overall diagnostic efficiency of 95.6% (92.8 to 98.4%) was obtained. No statistically significant difference in the performance characteristics was found between Korea and Canada. No significant adverse events were noted. CONCLUSIONS: The Helikit offers an easy, safe and accurate approach to the diagnosis of H. pylori infection.

Diversity of core promoter mutations in immune clearance phase of chronic HBV infection.

BACKGROUND/AIMS: Transcription of HBV (hepatitis B virus) pre-core and pre-genomic mRNAs is controlled by core promoter. Therefore, mutations in the core promoter region might change the activity of liver diseases through an altered transcriptional level of the mRNA. The present study was carried out to determine the diversity of HBV core promoter sequences in chronic HBV carriers. METHODS: DNA sequences in the core promoter region were determined after cloning the PCR product. Two groups of chronic HBV carriers with HBeAg, including five cases of asymptomatic carriers (ASCs, 21 clones) and eight with chronic hepatitis (CH, 50 clones) were studied. RESULTS: Mutations in the core promoter were found in three out of the ASCs (11 clones), and in all eight cases in the CH group (48 clones). While mutations at nucleotide 1762 (A-->T) and 1764(G-->A) were not found in ASC, mutations at the same positions were found in all the cases of CH group (40 clones) (P=0.003). Diverse patterns of mutations in the core promoter were observed in each patient in the CH group. CONCLUSIONS: Further studies are needed to determine whether the diversity of HBV core promoter mutations has clinical significance such as the seroconversion of HBeAg to anti-HBe.

Colonoscopic diagnosis of whipworm infection.

Trichuriasis is an intestinal infection found in human beings which is caused by Trichuris trichiura, more commonly known as whipworm because of its whip-like appearance. It is characterized by the invasion of the colonic mucosa by the adult Trichuris and produces minor inflammatory changes at the sites of localization. It is prevalent throughout the world, especially in tropical areas. Its diagnosis is usually made by identification of the typical eggs in the stool; adult whipworm is rarely seen during colonoscopy. Colonoscopy can directly diagnose trichuriasis, confirming the threadlike form of worms with an attenuated end. The worms can be overlooked, particularly if colon preparation is imperfect. Attenuated whip-like ends of whipworms, which are embedded in the colonic mucosa, were removed with biopsy forceps. We report on 5 cases of whipworm infection that were diagnosed on total colonoscopy.

Mechanism of UV light-induced photorelaxation in isolated rat aorta.

Isolated rat thoracic aorta which is pharmacologically precontracted by phenylephrine induces photorelaxation when exposed to long wave length UV-light. The aim of the present study was to characterize the mechanism of UV-light induced by photorelaxation in the rat aorta. 1. UV light relaxed both endothelium-intact and -denuded rat aortic rings contracted by phenylephrine. The magnitude of relaxation on UV light was dependent on the exposure time and slightly greatly in endothelium-denuded rings than in endothelium-intact preparations. 2. L-NAME (10 nM-100 uM) but not D-NAME completely inhibited the photorelaxation in a concentration dependent manner. 3. The UV-induced relaxation was inhibited by methylene blue (1 -100 uM), and verapamil (100 nM), and removal of extracellular Ca2+. In contrast, UV-light induced photorelaxation was potentiated by N(w)-nitro-Larginine (L-NOARG) treatment. 4. In immunocytochemical analysis of UV-light induced iNOS and eNOS expression in rat aortas, at which expression levels were increased in a time-dependent manner on UV-irradiation in aortic endothelium and smooth muscle, respectively. These results suggest that UV light-induced photorelaxation may be due to nitric oxide from exogenously administered L-arginine as well as endogenous nitric oxide donors such as amino acid and arginine derivatives. Additional suggestion is that UV light stimulates the expression of nitric oxide synthases, and its activity for nitric oxide generation is dependent on cytosolic Ca2+ originated from extracellular space.