Assessing risk stratification in long-term outcomes of rectal neuroendocrine tumors following endoscopic resection: a multicenter retrospective study.

OBJECTIVES: While endoscopic resection of rectal neuroendocrine tumors (NETs) has significantly increased, long-term data on risk factors for recurrence are still lacking. Our aim is to analyze the long-term outcomes of patients with rectal NETs after endoscopic resection through risk stratification. METHODS: In this multicenter retrospective study, we included patients who underwent endoscopic resection of rectal NETs from 2009 to 2018 and were followed for ≥12 months at five university hospitals. We classified the patients into three risk groups according to the clinicopathological status of the rectal neuroendocrine tumors: low, indeterminate, and high. The high-risk group was defined if the tumors have any of the followings: size ≥ 10 mm, lymphovascular invasion, muscularis propria or deeper invasion, positive resection margins, or mitotic count ≥2/10. RESULTS: A total of 346 patients were included, with 144 (41.6%), 121 (35.0%), and 81 (23.4%) classified into the low-, indeterminate-, and high-risk groups, respectively. Among the high-risk group, seven patients (8.6%) received salvage treatment 28 (27-67) days after the initial endoscopic resection, with no reported extracolonic recurrence. Throughout the follow-up period, 1.1% (4/346) of patients experienced extracolonic recurrences at 56.5 (54-73) months after the initial endoscopic resection. Three of these patients (75%) were in the high-risk group and did not undergo salvage treatment. The risk of extracolonic recurrence was significantly higher in the high-risk group compared to the other groups (p = 0.039). CONCLUSION: Physicians should be concerned about the possibility of metastasis during long-term follow-up of high-risk patients and consider salvage treatment.

Deep learning in negative small-bowel capsule endoscopy improves small-bowel lesion detection and diagnostic yield.

OBJECTIVES: Although several studies have shown the usefulness of artificial intelligence to identify abnormalities in small-bowel capsule endoscopy (SBCE) images, few studies have proven its actual clinical usefulness. Thus, the aim of this study was to examine whether meaningful findings could be obtained when negative SBCE videos were reanalyzed with a deep convolutional neural network (CNN) model. METHODS: Clinical data of patients who received SBCE for suspected small-bowel bleeding at two academic hospitals between February 2018 and July 2020 were retrospectively collected. All SBCE videos read as negative were reanalyzed with the CNN algorithm developed in our previous study. Meaningful findings such as angioectasias and ulcers were finally decided after reviewing CNN-selected images by two gastroenterologists. RESULTS: Among 202 SBCE videos, 103 (51.0%) were read as negative by humans. Meaningful findings were detected in 63 (61.2%) of these 103 videos after reanalyzing them with the CNN model. There were 79 red spots or angioectasias in 40 videos and 66 erosions or ulcers in 35 videos. After reanalysis, the diagnosis was changed for 10 (10.3%) patients who had initially negative SBCE results. During a mean follow-up of 16.5 months, rebleeding occurred in 19 (18.4%) patients. The rebleeding rate was 23.6% (13/55) for patients with meaningful findings and 16.1% (5/31) for patients without meaningful findings (P = 0.411). CONCLUSION: Our CNN algorithm detected meaningful findings in negative SBCE videos that were missed by humans. The use of deep CNN for SBCE image reading is expected to compensate for human error.

Quantitative multiplex real-time polymerase chain reaction assay for the detection of Helicobacter pylori and clarithromycin resistance.

BACKGROUND: Identifying clarithromycin resistance is essential for eradicating Helicobacter pylori (HP). Therefore, we evaluated the performance of Allplex™ H.pylori & ClariR Assay (Allplex™) for diagnosing and detecting clarithromycin resistance in HP. METHODS: Subjects who underwent esophagogastroduodenoscopy between April 2020 and August 2021 at Incheon St. Mary's hospital were enrolled in this study. The diagnostic performances of Allplex™ and dual priming oligonucleotide (DPO)-based multiplex polymerase chain reaction (PCR) were compared with sequencing as the gold standard. RESULTS: A total of 142 gastric biopsy samples were analyzed. Gene sequencing revealed 124 HP infections, 42 A2143G mutations, 2 A2142G mutations, one dual mutation, and no A2142C mutation. DPO-PCR showed 96.0% sensitivity and 100.0% specificity for HP detection; the corresponding rates for Allplex™ were 99.2% and 100.0%. DPO-PCR showed 88.3% sensitivity and 82.0% specificity for A2143G mutation, and Allplex™ showed 97.6% and 96.0%. The Cohen's Kappa coefficient for overall test results was 0.56 for DPO-PCR and 0.95 for Allplex™. CONCLUSION: Allplex™ showed comparable diagnostic performance with direct gene sequencing and non-inferior diagnostic performance to DPO-PCR. Further research is required to confirm whether Allplex™ is an effective diagnostic tool for the eradication of HP.

Association between regular physical activity and lower incidence of colorectal cancer in patients with diabetes mellitus: a nationwide cohort study.

AIM: The aim of this work was to investigate the association between changes in physical activity (PA) status and the development of colorectal cancer (CRC) in patients with diabetes. METHOD: This nationwide population study included 1 439 152 patients with diabetes who underwent a health screening provided by the Korean National Health Insurance Service between January 2009 and December 2012 and a follow-up screening after 2 years. Based on changes in PA status, participants were categorized into four groups: remained inactive, remained active, active-to-inactive and inactive-to-active. RESULTS: During the median follow-up period of 5.2 years, 38 244 new cases of CRC were diagnosed. Compared with the remained inactive group, among the three other groups, the remained active group had the lowest risk of CRC [adjusted hazard ratio (aHR) 0.93; 95% CI 0.90-0.96], followed by the inactive-to-active group (aHR 0.97; 95% CI 0.94-1.00) and active-to-inactive group (aHR 0.99; 95% CI 0.96-1.02), after adjusting for confounding variables (p = 0.0007). This reduction in cancer incidence in the remained active group was observed for both rectal cancer (aHR 0.87, 95% CI 0.79-0.95) and colon cancer (aHR 0.93, 95% CI 0.90-0.97), irrespective of sex. In terms of the intensity and amount of PA, moderate intensity PA was the most effective, and a positive correlation was found between the amount of PA and the reduction in CRC incidence. CONCLUSION: Regular PA was independently associated with a decreased risk of CRC in patients with diabetes. The intensity and amount of physical activity both play a role in reducing the risk.

Convolutional neural network-based object detection model to identify gastrointestinal stromal tumors in endoscopic ultrasound images.

BACKGROUND AND AIM: We aimed to develop a convolutional neural network (CNN)-based object detection model for the discrimination of gastric subepithelial tumors, such as gastrointestinal stromal tumors (GISTs), and leiomyomas, in endoscopic ultrasound (EUS) images. METHODS: We used 376 images from 114 patients with histologically confirmed gastric GIST or leiomyoma to train the EUS-CNN. We constructed the EUS-CNN using an EfficientNet CNN model for feature extraction and a weighted bi-directional feature pyramid network for object detection. We assessed the performance of our EUS-CNN by calculating its accuracy, sensitivity, specificity, and area under receiver operating characteristic curve (AUC) using a validation set of 170 images from 54 patients. Four EUS experts and 15 EUS trainees were asked to judge the same validation dataset, and the diagnostic yields were compared between the EUS-CNN and human assessments. RESULTS: In the per-image analysis, the sensitivity, specificity, accuracy, and AUC of our EUS-CNN were 95.6%, 82.1%, 91.2%, and 0.9234, respectively. In the per-patient analysis, the sensitivity, specificity, accuracy, and AUC for our object detection model were 100.0%, 85.7%, 96.3%, and 0.9929, respectively. The EUS-CNN outperformed human assessment in terms of accuracy, sensitivity, and negative predictive value. CONCLUSIONS: We developed the EUS-CNN system, which demonstrated high diagnostic ability for gastric GIST prediction. This EUS-CNN system can be helpful not only for less-experienced endoscopists but also for experienced ones. Additional EUS image accumulation and prospective studies are required alongside validation in a large multicenter trial.

Improved classification and localization approach to small bowel capsule endoscopy using convolutional neural network.

BACKGROUND: Although great advances in artificial intelligence for interpreting small bowel capsule endoscopy (SBCE) images have been made in recent years, its practical use is still limited. The aim of this study was to develop a more practical convolutional neural network (CNN) algorithm for the automatic detection of various small bowel lesions. METHODS: A total of 7556 images were collected for the training dataset from 526 SBCE videos. Abnormal images were classified into two categories: hemorrhagic lesions (red spot/angioectasia/active bleeding) and ulcerative lesions (erosion/ulcer/stricture). A CNN algorithm based on VGGNet was trained in two different ways: the combined model (hemorrhagic and ulcerative lesions trained separately) and the binary model (all abnormal images trained without discrimination). The detected lesions were visualized using a gradient class activation map (Grad-CAM). The two models were validated using 5,760 independent images taken at two other academic hospitals. RESULTS: Both the combined and binary models acquired high accuracy for lesion detection, and the difference between the two models was not significant (96.83% vs 96.62%, P = 0.122). However, the combined model showed higher sensitivity (97.61% vs 95.07%, P < 0.001) and higher accuracy for individual lesions from the hemorrhagic and ulcerative categories than the binary model. The combined model also revealed more accurate localization of the culprit area on images evaluated by the Grad-CAM. CONCLUSIONS: Diagnostic sensitivity and classification of small bowel lesions using a convolutional neural network are improved by the independent training for hemorrhagic and ulcerative lesions. Grad-CAM is highly effective in localizing the lesions.

Comparison of 7- and 14-Day Eradication Therapy for Helicobacter pylori with First- and Second-Line Regimen: Randomized Clinical Trial.

BACKGROUND: Although Helicobacter pylori is a key cause of gastric cancer development, its eradication rate has been decreasing by standard regimens. For successful eradication, duration of treatment has been issued for overcoming antibiotics resistance. We were to compare the eradication rate of 7-day vs. 14-day treatment in first- and second-line regimens. METHODS: This study was an open-label randomized controlled trial. A total of 369 H. pylori-infected patients were enrolled and assigned either to 7-day or 14-day proton pump inhibitor (PPI)-based standard triple therapy (STT; PPI-clarithromycin-amoxicillin). Bismuth-containing quadruple therapy was used as second-line therapy. Eradication success was defined as a negative 13C-urea breath test. RESULTS: In first-line treatment, eradication rate was 78.5% (106/135) and 78.6% (114/143) in the 7-day and 14-day treatment in per-protocol (PP) analysis (P = 0.805). In intention-to-treat (ITT) analysis, eradication rate was 64.0% (114/178) and 66.0% (126/191), respectively (P = 0.924). There was no significant difference in drug compliance (81.5% vs. 84.3%, P = 0.320). In second-line therapy, eradication rate was not significantly different in both treatments of PP analysis (91.7% [33/36] vs. 100% [45/45], P = 0.084). In the ITT analysis, eradication rate was 79.6% (35/44) and 90.4% (47/52), respectively (P = 0.080). Drug compliances were not significantly different between the two groups (95.5% vs. 98.1%, P = 0.728). CONCLUSION: PPI-based STT for H. pylori is not efficient as a first-line therapy both in 7 days and 14 days in Korea. Although bismuth-containing quadruple therapy for 14 days as a second line therapy tend to show higher eradication rate compared to 7-day therapy, this should be elucidated by further larger scaled studies. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02487511.

Nationwide antibiotic resistance mapping of Helicobacter pylori in Korea: A prospective multicenter study.

INTRODUCTION: The eradication rates for Helicobacter pylori have decreased in Korea although the prevalence of this bacterium has also decreased. Antibiotic resistance is likely to be a crucial factor in H. pylori eradication success, and we therefore mapped these resistance patterns nationwide in Korea. MATERIALS AND METHODS: Five hundred and ninety adult subjects were prospectively enrolled from 2017 to 2018 from 15 centers across six geographic areas of Korea. A total of 580 biopsy tissues had been sampled from these patients during an upper endoscopy and were frozen at -80°C and delivered to a central laboratory. The agar dilution method was used to determine the minimum inhibitory concentration of amoxicillin, clarithromycin, metronidazole, tetracycline, ciprofloxacin, and levofloxacin for each H. pylori isolate. RESULTS: The culture success rate was 60.2% (349/580). Resistance rates against clarithromycin, metronidazole, amoxicillin, tetracycline, levofloxacin, and ciprofloxacin were 17.8%, 29.5%, 9.5%, 0%, 37.0%, and 37.0%, respectively. The geographic distribution of metronidazole and quinolone resistance was highly variable. Some subjects had multiple H. pylori strains in the antrum and body of the stomach and showed a heterogeneous resistance profile between these anatomic areas. The H. pylori multidrug resistance (MDR) rate was 25.2% (88/349) among amoxicillin, clarithromycin, metronidazole, tetracycline, and quinolone and 11.2% (39/349) among four of these major antibiotics except for quinolone. The Seoul and Chungcheong areas showed a relatively lower MDR rate. CONCLUSION: The antibiotic resistance of H. pylori differs by drug and geographic area in Korea. Detailed nationwide antibiotic resistance mapping is needed to develop an effective H. pylori eradication strategy.

Risk factors for peritonitis in patients on continuous ambulatory peritoneal dialysis who undergo colonoscopy: a retrospective multicentre study.

BACKGROUND: Colonoscopy is associated with a risk of peritonitis in patients on peritoneal dialysis. However, no study has yet described the risk factors in play. METHODS: This was a retrospective multicentre study. The medical records of patients on continuous ambulatory peritoneal dialysis (CAPD) who underwent colonoscopy from January 2003 to December 2012 were analysed. We recorded demographic characteristics, colonoscopic factors, use of prophylactic antibiotics, and development of peritonitis. Colonoscopy-related peritonitis was defined as peritonitis developing within 1 week after colonoscopy. Demographic and clinical characteristics were compared between patients who did and those who did not develop peritonitis. RESULTS: During the study period, 236 patients on CAPD underwent colonoscopy, of whom 9 (3.8%) developed peritonitis. The rates of polypectomy/endoscopic mucosal resection were significantly higher in the peritonitis group than in the no peritonitis group (66.7 vs. 23.4%, p = 0.009). Prophylactic antibiotics were prescribed before colonoscopy in 65 patients; none developed peritonitis. No patient who developed peritonitis received prophylactic antibiotics (p = 0.067). CONCLUSIONS: Advanced procedures including polypectomy or endoscopic mucosal resection increase colonoscopy-related peritonitis in patients on CAPD. Randomized controlled trials to investigate whether prophylactic antibiotics are needed to prevent peritonitis in all CAPD patients are warranted.

Transcatheter embolization effectively controls acute lower gastrointestinal bleeding without localizing bleeding site prior to angiography.

BACKGROUND AND AIMS: Colonoscopy is preferred for treatment of lower gastrointestinal bleeding (LGIB). However, several conditions such as poor bowel preparation can cause endoscopic failure, leading to surgery or transcatheter therapy as alternative options. We aimed to assess the efficacy and safety of transcatheter arterial embolization (TAE) for LGIB in patients with endoscopic failure. METHODS: Between January 2005 and June 2015, 93 consecutive patients with acute LGIB underwent visceral angiography at three academic hospitals. Among them, a total of 52 patients were treated with TAE for LGIB and analyzed. Technical success, complications and 30-day rebleeding and mortality after TAE were investigated retrospectively in patients with and without localization of LGIB. RESULTS: Technical success of TAE was achieved in all patients. After TAE, 30-day rebleeding and mortality rate were 27% (14/52) and 29% (15/52), respectively. TAE was performed without localizing bleeding site in 32 of 52 patients (62%). Between patients with and without localized bleeding site, there were no significant differences in 30-day rebleeding rate (25% vs. 28%) and mortality rate (15% vs. 38%). Causes of death were mostly unrelated to bleeding. Only two cases of bowel infarction occurred after TAE in patients without bleeding site localization. Rebleeding could be predicted if the patient received more than six units of packed red blood cell transfusion before TAE in multivariate analysis. CONCLUSIONS: TAE can be an effective treatment for LGIB even without localizing bleeding site.

Effect of Dynamic Position Changes on Adenoma Detection During Colonoscope Withdrawal: A Randomized Controlled Multicenter Trial.

OBJECTIVES: Adequate luminal distension is essential for improving adenoma detection during colonoscope withdrawal. A few crossover studies have reported that dynamic position changes maximize luminal distension and increase adenoma detection rates (ADR). We designed a multicenter, randomized, parallel-group trial to verify the effect of dynamic position changes on colonic adenoma detection. METHODS: This study was conducted at the six hospitals of the Catholic University of Korea. Patients aged 45-80 years who underwent a colonoscopy for the first time were included. In the position change group, the position changes during colonoscope withdrawal were as follows: cecum, ascending colon, and hepatic flexure: left lateral position; transverse colon: supine position; splenic flexure, descending colon, sigmoid colon, and rectum: right lateral position. In the control group, the examinations were performed entirely in the left lateral position during colonoscope withdrawal. The primary outcome measure was the ADR, which was defined as the proportion of patients with ≥1 adenoma. RESULTS: A total of 1,072 patients were randomized into the position change group (536 patients) or the control group (536 patients). The ADR was higher in the position change group than in the control group (42.4 vs. 33.0%, P=0.002). More adenomas were detected per subject in the position change group (0.90 vs. 0.67, P=0.01). Increases in the number of adenomas were observed in examinations of the transverse colon (0.22 vs. 0.13, P=0.016) and the left colon (0.37 vs. 0.27, P=0.045). A significant increase in the ADR was observed for endoscopists with a relatively low detection rate. For endoscopists with a high detection rate, non-significant changes in the ADR were observed. CONCLUSIONS: Dynamic position changes during colonoscope withdrawal increased the ADR.

Irritable bowel syndrome-specific health-related quality of life instrument: development and psychometric evaluation.

BACKGROUND: Health-related quality of life (HRQOL) is an important outcome indicator for chronic disease, and particularly in the absence of biological markers for illness, such as with irritable bowel syndrome (IBS). The aims of this study were to develop and evaluate a new IBS-specific HRQOL instrument (IBS-HR-QOL). METHODS: This methodological study comprised three steps: conceptualization of the IBS-HR-QOL, item extraction and establishment of content validity, and psychometric evaluation of the instrument with 267 IBS patients recruited from four university hospitals. RESULTS: The content validity of the developed IBS-HR-QOL was assessed by 11 experts. Exploratory and confirmatory factor analyses yielded four factors. The criterion and convergent validities of the IBS-HR-QOL were demonstrated using the Short Form-36 and the Hospital Anxiety and Depression Scale, respectively. Known-groups validity was demonstrated using a symptom-severity scale. The internal consistency reliability and test-retest reliability were satisfactory, with a Cronbach's alpha and intraclass correlation coefficient of 0.93 and 0.88, respectively. CONCLUSIONS: The IBS-HR-QOL comprises a total of 16 items. The IBS-HR-QOL demonstrated good psychometric properties. This instrument is easily comprehensible and short, rendering it feasible for use in clinical practice and research.

Expanded therapeutic potential in activity space of next-generation 5-nitroimidazole antimicrobials with broad structural diversity.

Metronidazole and other 5-nitroimidazoles (5-NI) are among the most effective antimicrobials available against many important anaerobic pathogens, but evolving resistance is threatening their long-term clinical utility. The common 5-NIs were developed decades ago, yet little 5-NI drug development has since taken place, leaving the true potential of this important drug class unexplored. Here we report on a unique approach to the modular synthesis of diversified 5-NIs for broad exploration of their antimicrobial potential. Many of the more than 650 synthesized compounds, carrying structurally diverse functional groups, have vastly improved activity against a range of microbes, including the pathogenic protozoa Giardia lamblia and Trichomonas vaginalis, and the bacterial pathogens Helicobacter pylori, Clostridium difficile, and Bacteroides fragilis. Furthermore, they can overcome different forms of drug resistance, and are active and nontoxic in animal infection models. These findings provide impetus to the development of structurally diverse, next-generation 5-NI drugs as agents in the antimicrobial armamentarium, thus ensuring their future viability as primary therapeutic agents against many clinically important infections.

Circumferential submucosal incision prior to endoscopic mucosal resection provides comparable clinical outcomes to submucosal dissection for well-differentiated neuroendocrine tumors of the rectum.

BACKGROUND: Small rectal neuroendocrine tumors (NETs) can be treated with endoscopic resection. Endoscopic submucosal dissection (ESD) has been accepted as a reliable technique, but it is difficult. We evaluated the feasibility and efficacy of precut and endoscopic mucosal resection (CSI-EMR) for rectal NETs compared to ESD. METHODS: Patients with rectal NETs were enrolled consecutively. ESD or CSI-EMR was performed at operator's discretion. Histological and clinical outcomes were measured and compared between the two treatment modalities. RESULTS: Thirty-three patients were enrolled in the study. Seventeen NETs were treated by the ESD method and 16 were treated by CSI-EMR. Both groups had similar mean tumor diameters (ESD 7.53 ± 1.94 vs. CSI-EMR 6.63 ± 1.99 mm; p = 0.197). En bloc resection was achieved in 100 % of ESD group and 87.5 % of CSI-EMR group. Lateral margin involvement occurred in one patient in ESD group and two in CSI-EMR group. The histologically complete resection rate was 88.2 % (15 of 17) in the ESD group and 81.2 % (13 of 16) in CSI-EMR group (p = 0.592). One case of perforation occurred in both groups. Delayed bleeding did not occur. None of the measured outcomes were different between the two groups. Operating time was significant shorter in CSI-EMR group than in ESD group (9.69 vs. 20.12 min, respectively; p value = 0.004). CONCLUSIONS: CSI-EMR results in reliable clinical outcomes for small rectal NETs comparable to those of ESD. CSI-EMR is technically feasible and more time saving.

Long-term outcome of capsule endoscopy in obscure gastrointestinal bleeding: a nationwide analysis.

BACKGROUND AND STUDY AIMS: The clinical impact of video capsule endoscopy (VCE) in patients with obscure gastrointestinal bleeding (OGIB) remains undetermined. The aim of this study was to evaluate the long-term clinical impact of VCE in patients with OGIB using a nationwide registry. PATIENTS AND METHODS: Data from 305 patients who underwent VCE for OGIB from 13 hospitals in Korea between January 2006 and March 2009 were analyzed. Prospectively collected VCE registry data were reviewed, and follow-up data were collected by chart review and telephone interviews with patients. Multivariate regression analyses using hazard ratios (HR) were performed to determine risk factors for rebleeding. RESULTS: Significant findings were detected in 157 patients (51.5%). After VCE, interventional treatment was performed in 36 patients (11.8%). The overall rebleeding rate was 19.0% during a mean (±SD) follow-up of 38.7±26.4 months. Rebleeding rate did not differ by positive VCE results or application of interventional treatment. Multivariate analysis revealed that angiodysplasia (HR 1.82; 95% confidence interval [CI] 1.04-3.20; P=0.037) and duration of OGIB >3 months (HR 1.64; 95%CI 1.10-2.46; P=0.016) were independent prognostic factors associated with rebleeding. In a subgroup analysis of patients taking anticoagulants, patients who discontinued drugs after VCE showed a lower rebleeding rate than those who did not discontinue this therapy (P=0.019). CONCLUSIONS: VCE did not have a significant impact on the long-term outcome of patients with OGIB. Patients with angiodysplasia on VCE or OGIB>3 months need to be closely followed even after interventional treatment. In patients who are taking anticoagulants, discontinuation of drugs is necessary in order to lower the risk of rebleeding.

Prediction and management of recurrent right colon diverticulitis.

PURPOSE: While the incidence of right colonic diverticulitis (RCD) is rare in Western countries, the right colon is the most common site of diverticulitis in Asian countries. However, its recurrent pattern and management were rarely studied. This study was designed to elucidate the pattern of recurrence in RCD. METHODS: Of the 154 patients admitted as right colonic diverticulitis between February 2004 and March 2012, 104 patients were enrolled, prospectively. The recurrence rate, size, multiplicity, location, diagnostic criteria score, and predisposing factors were evaluated based on Hinchey's classification of diverticulitis. RESULTS: There were 104 patients with right colonic diverticulitis in this study, and 20 patients (19.2 %) recurred after medical treatment. When the diverticula were not located in the right colon, the recurrence rate was significantly higher than the diverticula located only in the right colon (p = 0.004). The recurrence rate of diverticulitis for a single diverticulum was significantly lower than that for multiple diverticula (p = 0.02). Of the 20 patients with recurrence, 1 (5 %) patient underwent laparoscopic diverticulectomy due to a misdiagnosis of diverticulitis as appendicitis. The remaining 19 patients (95 %) received nonoperative management and recovered without any sequelae. CONCLUSIONS: The recurrence rate was 19.2 %, and the predisposing factors were the location of diverticula and the multiplicity of primary diverticula. The re-recurrence rate of recurred patients was 26.3 %. The recurred lesions were controlled simply by nonoperative management. Elective surgery was also a treatment option.

Portal hypertensive enteropathy diagnosed by capsule endoscopy in cirrhotic patients: a nationwide multicenter study.

BACKGROUND AND AIM: Due to the limited data on portal hypertensive enteropathy (PHE), the prevalence of and clinical factors related to PHE remain unclear. This study determined the prevalence of PHE using capsule endoscopy (CE) and PHE-related clinical factors. METHODS: This was a retrospective multicenter study using the Capsule Endoscopy Nationwide Database Registry. From 2,879 cases that underwent CE, 45 cirrhosis patients with portal hypertension (PH) were enrolled and divided into PHE (n = 18) and non-PHE (n = 27) groups. From computed tomography (CT) images, six secondary changes due to PH were scored to give a total CT score of 0-6. The main outcome variable was the prevalence of PHE and PHE-related clinical factors. RESULTS: The prevalence of PHE was 40 %. Comparing the PHE and non-PHE groups, the most common findings were angiodysplasias in 55.7 % (vs. 7.4 %, p = 0.001) and varices in 38.9 % (vs. 0 %, p = 0.001). Active bleeding was observed in 16.6 and 3.7 %, respectively, but this difference was not significant. In the univariate analysis, Child-Turcotte-Pugh class C (p = 0.002) and a high CT score (≥3 vs. <3, p = 0.004) were significantly associated with PHE. However, only a high CT score was significant in the multivariate analysis (odds ratio 11.19; 95 % confidence interval, 1.59-infinity; p = 0.040). CONCLUSIONS: The prevalence of PHE was 40 %, and it might be more prevalent in cirrhosis patients with PH who have a high CT score. CE is a useful diagnostic tool for evaluating PHE in cirrhosis patients with PH.

Endoscopic resection yields reliable outcomes for small rectal neuroendocrine tumors.

BACKGROUND AND AIM: We analyzed the characteristics of gastrointestinal neuroendocrine tumors and examined the outcomes and safety of modalities in rectal neuroendocrine tumors. METHODS: Between 2007 and 2011, a total of 91 patients with gastrointestinal neuroendocrine tumors were retrospectively reviewed in terms of the characteristics of tumors. RESULTS: Sixty-six patients had rectal neuroendocrine tumors and underwent endoscopic mucosal resection (EMR, n = 29), endoscopic submucosal dissection (ESD, n = 23), or transanal endoscopic microsurgery (TEM, n = 14). The complete resection rate was higher in the ESD group (82.7%) and in the TEM group (100%) compared to the EMR group (65.5%) (P < 0.046). The complication rate was higher in the ESD group (47.8%) than in the EMR group (18.5%) (P = 0.003). No local tumor recurrence was observed in all patients, regardless of the procedure, during the median follow-up period of 21.5 ± 13.5 months. CONCLUSIONS: ESD achieved a higher complete resection rate than EMR and comparable to TEM. Tumor recurrence was not observed in the endoscopic resection and TEM groups, regardless of the completeness of resection. Small neuroendocrine tumors of the gastrointestinal tract can be managed reliably with both endoscopic resection and TEM.

Eradication of Helicobacter pylori according to 23S ribosomal RNA point mutations associated with clarithromycin resistance.

BACKGROUND: Clarithromycin-resistant Helicobacter pylori is associated with point mutations in the 23S ribosomal RNA (rRNA) gene. METHODS: A total of 1232 patients participated and were divided into 2 control groups and 1 case group. Patients in the APC control group, which consisted of 308 randomly assigned participants, were treated with standard triple therapy, consisting of amoxicillin, rabeprazole, and clarithromycin; 308 participants in the APM control group were treated with amoxicillin, rabeprazole, and metronidazole. For the 616 participants in the case group, a test for point mutations in the 23S rRNA gene of H. pylori was conducted. A total of 218 individuals in the case group received a new tailored therapy regimen, in which amoxicillin, rabeprazole, and clarithromycin were given in the absence of a mutation, whereas clarithromycin was replaced by metronidazole if the mutation was detected. RESULTS: The rate of eradication of H. pylori in the tailored group was 91.2% (176/193), which was significantly higher than that in the APC (75.9% [214/282]; P < .001) and APM (79.1% [219/277]; P < .001) control groups. CONCLUSION: The rate of H. pylori eradication among patients who received tailored therapy on the basis of detection of a clarithromycin resistance mutation by polymerase chain reaction was much higher than the rate among patients who received a standard triple therapy regimen. CLINICAL TRIALS REGISTRATION: NCT0145303.