Factors affecting the technical difficulty of colonoscopy.

BACKGROUND/AIMS: Colonoscopy is a standard diagnostic tool for screening and surveillance of diseases affecting the colon. Colonoscopy may be painful for patients and difficult for the endoscopist. The aim of this study was to identify the factors affecting the technical difficulty of a colonoscopic examination and to predict potential difficult patients who will undergo colonoscopy. METHODOLOGY: A total of 646 outpatients were consecutively included in this study. Patient's age and gender, body mass index (BMI), prior surgical history, and the duration and symptoms of irritable bowel syndrome (IBS) were recorded before the procedure. The quality of bowel preparation, the difficulty of examination reported by the colonoscopist, the degree of patient pain, the degree of pain as reported by an observer, cecal intubation time andcolonoscopic findings were assessed after the procedure. RESULTS: We evaluated the difficulty of colonoscopy by cecal intubation time. Advanced age (>50 years), female gender, low BMI (< or = 23 Kg/m2), poor bowel preparation, prior surgical history, patient pain and the presence of IBS were associated with prolonged cecal intubation time. A multivariate logistic regression analysis demonstrated that advanced age, female gender, low BMI, poor bowel preparation and patient pain were independent factors related to prolonged cecal intubation time. CONCLUSIONS: In patients with advanced age, female gender and low BMI, information that colonoscopy may be difficult and painful should be provided. If a colonoscopy is not absolutely indicated, barium enema or CT colonography may be performed as alternative diagnostic modalities.

The effect of probiotics on Helicobacter pylori eradication.

BACKGROUND/AIMS: Conflicting results have been reported on the effect of a variety of probiotic strains on Helicobacter pylori (HP) eradication. In this study, we evaluated the outcome of a probiotic strain composed of bacillus subtilis and Streptococcus faecium on HP eradication. METHODOLOGY: We recruited 352 HP infected patients who were randomized into a triple-plus-probiotics group or a triple-only group; the participants received 1 week of PPI-based triple therapy with or without probiotics supplements. For the triple-plus-probiotics group, probiotics was continued for 8 weeks. All patients in the two groups were evaluated for 4 weeks after completion of therapy. RESULTS: Using the intention to treat analysis, evaluation of the triple-plus-probiotics group showed a higher eradication rate than the triple-only group (83.5% vs. 73.3%, p=0.027). Diarrhea and overall side effects were more common in the triple-only group (p<0.05). CONCLUSIONS: Supplementation with probiotic strains, composed of Bacillus subtilis and Streptococcus faecium, were shown to improve drug compliance, reduce side effects and enhance the intention-to-treat eradication rate of HP.

The association between increased alanine aminotransferase activity and metabolic factors in nonalcoholic fatty liver disease.

Nonalcoholic fatty liver disease (NAFLD) has been associated with metabolic disorders, including central obesity, dyslipidema, hypertension, and hyperglycemia. Metabolic syndrome, obesity, and insulin resistance are major risk factors in the pathogenesis of NAFLD. The aim of this study was to identify the relative contribution of the metabolic syndrome, obesity, and insulin resistance to alanine aminotransferase (ALT) activity in NAFLD. A total of 3091 subjects diagnosed with fatty liver by ultrasonography were enrolled. All components of metabolic syndrome criteria, anthropometric parameters, fasting insulin levels, high-sensitivity C-reactive protein (hs-CRP) as an inflammation marker, and ALT were measured in each subject. Homeostasis model assessment--insulin resistance (HOMA-IR) as a measure of insulin resistance and body mass index (BMI) as a measure of obesity were calculated. The prevalence of increased ALT levels (>40 IU/L) was 26.7%. Increased ALT activity was significantly associated with the following characteristics: male sex, young age, increased triglycerides, fasting glucose, fasting insulin, HOMA-IR, hs-CRP, waist circumference, BMI and diastolic blood pressure, and decreased high-density lipoprotein cholesterol (HDL-C). According to the increase in the number of metabolic syndrome components, BMI, HOMA-IR, and hs-CRP, the prevalence and odds ratio for having increased ALT activity were significantly increased. Central obesity, raised triglycerides, reduced HDL-C, and raised fasting glucose were strongly associated with increased ALT activity. In conclusion, a number of metabolic syndrome components, obesity, insulin resistance, and hs-CRP, are strong predictors of increased ALT activity in NAFLD. Central obesity, raised triglycerides, reduced HDL-C, and raised fasting glucose are metabolic syndrome components that contributed to increased ALT activity.

[Bamboo joint-like appearance of stomach in Korean patients with Crohn's disease].

BACKGROUND/AIMS: Bamboo joint-like (BJL) appearance is an endoscopic finding characterized by swollen longitudinal folds transversed by erosive fissures or linear furrows on the lesser curvature side of gastric body and cardia. It has been reported to be associated with Crohn's disease (CD). This study was aimed to evaluate the incidence of BJL appearance in Korean patients with CD. METHODS: From January to December in 2005, we performed esophagogastroduodenoscopy (EGD) in patients diagnosed as CD and ulcerative colitis (UC) in our hospital. Non-inflammatory bowel disease (IBD) subjects with upper gastrointestinal symptoms who underwent EGD were consecutively enrolled during the same period. One endoscopist performed all the endoscopic examinations to avoid inter-observer variation. A dye-spraying technique with 0.4% indigocarmine was used to allow the detection of subtle changes during the endoscopic examination. RESULTS: A total of 21 patients with CD (mean age+/-SD, 40+/-15 yr; M/F, 13/8), 28 patients with UC (42+/-15 yr; 21/7), and 685 non-IBD subjects (49+/-14 yr; 354/331) were enrolled. EGD findings in CD patients were gastric erosions (11/21), chronic superficial gastritis (5/21), chronic atrophic gastritis (1/21), duodenal erosions or ulcers (2/21), and normal (2/21). Incidence of BJL appearance was significantly higher in patients with CD (47.6%, 10/21) than others (UC, 3.6%, 1/28; non-IBD, 0.1%, 1/685) (p< 0.0001). Among patients with CD, incidence of BJL appearance was not significantly different according to the sex, status of H. pylori infection, Vienna classification for phenotype, medications or EGD findings. CONCLUSIONS: BJL appearance on the gastric body and cardia can be a diagnostic clue to CD.

[Levofloxacin-azithromycin combined triple therapy for Helicobacter pylori eradication].

BACKGROUND/AIMS: Antibiotic resistance and poor compliance are the main causes of Helicobacter pylori (H. pylori) eradication failure. This study evaluated the eradication rate, tolerability, and compliance of levofloxacin- azithromycin combined triple therapy for H. pylori eradication. METHODS: 1) First-line eradication: A total of 78 H. pylori-positive patients were enrolled. Seventeen military men in Armed Forces Capital Hospital were treated with 7 days of levofloxacin-azithromycin combined triple therapy (omeprazole 20 mg bid, levofloxacin 500 mg od, and azithromycin 500 mg od), and 61 patients in Kangbuk Samsung Hospital were treated with standard PPI-based triple therapy (omeprazole 20 mg bid, amoxicillin 1.0 g bid, and clarithromycin 500 mg bid) for 7 days. 2) Second-line eradication: A consecutive series of 59 patients who failed H. pylori eradication with standard PPI-based triple therapy in Kangbuk Samsung Hospital were randomized to two groups. Thirty patients were retreated with 7 days of bismuth-based quadruple therapy (omeprazole 20 mg bid, bismuth 120 mg qid, metronidazole 500 mg tid, and tetracycline 500 mg qid), and remaining 29 patients were retreated with levofloxacin-azithromycin combined triple therapy. Patient's compliance and tolerability were evaluated at the end of treatment. The status of H. pylori infection was assessed 8 weeks later then. The successful eradication of H. pylori was defined as negative results from histology and CLO test, or 13C-urea breath test. RESULTS: First-line eradication rate of levofloxacin-azithromycin triple therapy was lower than that of standard PPI-based triple therapy, but there was no statistically significant difference (70.6% vs. 80.3%, p=0.390). Second-line eradication rate of levofloxacin-azithromycin combined triple therapy was significantly lower than that of bismuth-based quadruple therapy (ITT/PP 65.5%/73.1% vs. 90%/90%, p<0.0001). The compliances of all patients were more than 85%. Two of patients with levofloxacin-azithromycin combined triple therapy complained self-limiting side effects (mild dizziness; mild insomnia with general weakness). CONCLUSIONS: Levofloxacin-azithromycin combined triple therapy should not be recommended as the first-line or second-line H. pylori eradication regimen in Korea.

[Is gastric cancer a new indication for surveillance colonoscopy? Colon cancer is increased in gastric cancer patients].

BACKGROUND/AIMS: It has been reported that the risk of gastric polyp is increased in various colonic polyposis syndromes or in series of patients with sporadic colonic polyps. However, there are only a few large case controlled studies of colon cancer incidence in gastric cancer patients who underwent colonoscopy. The aims of this study were to determine the incidence of colorectal neoplasm and to evaluate the necessity of colonoscopic surveillance in patients with gastric cancer. METHODS: We performed colonoscopy in 105 patients with gastric cancer who agreed to undergo colonoscopy before or after 6 months from gastric resection between January 2002 and December 2004 in Kangbuk Samsung hospital. As a control group, 269 consecutive, age and sex matched patients without gastric neoplasm on gastroscopy who underwent colonoscopy within 6 months for the evaluation of various gastrointestinal symptoms during the year 2004 were included. Endoscopic reports and pathological results were reviewed retrospectively. RESULTS: In the patient group, adenomatous polyps were diagnosed in 24/105 patients (22.9%) and colorectal adenocarcinoma in 10/105 patients (9.5%). In the control group, adenomatous polyps were diagnosed in 78/269 patients (29.0%) and colorectal adenocarcinoma in 2/269 patients (0.7%). The incidence of colorectal adenocarcinoma between the patient group and control group showed significant differences (odds ratio 11.04, p=0.003). CONCLUSIONS: The risk of colorectal adenocarcinoma increases significantly in patients with gastric cancer. We suggest that the patients with gastric cancer might carry a high risk for colorectal cancer whom require surveillance colonoscopy.

[The relationship between serum adiponectin level and serum alanine aminotransferase elevation in Korean male with nonalcoholic fatty liver disease].

BACKGROUND/AIMS: Nonalcoholic fatty liver disease (NAFLD) comprises a large part of chronic liver diseases. Recently it was reported that adipokines are closely associated with the common risk factors for NAFLD, such as obesity, diabetes, dyslipidemia, and insulin resistance. We aimed to evaluate the changes in serum adiponectin, resistin and leptin concentrations related to alanine aminotransferase (ALT) elevations in Korean men with NAFLD. METHODS: We studies 38 men who were diagnosed with fatty liver by abdominal ultrasonography. None had a history of excessive alcohol consumption, autoimmune hepatitis, inherited or metabolic liver disease or viral hepatitis. The subjects were divided into two groups. One group had normal levels of ALT (n=28) and the other had increased ALT (n=10). We compared anthropometrical parameters, biochemical items and serum adipokine levels between these two groups. RESULTS: Serum adiponectin levels were lower in the increased ALT group than in the normal ALT group (3.89 +/- 1.77 vs 7.01 +/- 2.54 microgram/dL, P=0.001). But there were no significant differences in serum leptin and resistin levels between two groups (4.02 +/- 2.04 vs 3.26 +/- 1.41 ng/mL, p=0.245, 80.14 +/- 14.8 vs 80.5 +/- 11.34 ng/mL, P=0.937, respectively). Multiple linear regression analyses demonstrated that the serum adiponectin level is inversely correlated with serum ALT level and that the serum aspartate aminotransferase (AST) level is positively correlated with the serum ALT level. CONCLUSIONS: Our study shows that hypoadiponectinemia is associated with an ALT elevation in patients with NAFLD. Adiponectin may play an indirect role in the development of NAFLD.

Clinical significance of distal colon polyps for the prediction of an advanced proximal neoplasm: the KASID prospective multicenter study.

BACKGROUND/AIMS: The possibility of proximal lesion without distal polyps is a weak point of sigmoidoscopic colon cancer screening, but the clinical significance of distal findings for advanced proximal neoplasm (APN) is uncertain. The aim of this study was to assess the significance of a distal finding as a predictor of APN. MATERIALS AND METHODS: Asymptomatic patients > or =50 years old were enrolled from among patients who underwent polypectomy at 11 tertiary medical centers during the Korean Association for the Study of Intestinal Disease prospective study conducted between July 2003 and March 2004. Polyps located distal to the splenic flexure were defined as distal polyps. An advanced neoplasm was defined as a polyp of > or =10 mm in size, and/or with villous features, and/or with high-grade dysplasia, or invasive cancer. Age, gender, and distal polyp size, appearance, and histology were analyzed as risk factors of APN. The sensitivity and positive predictive value of distal polyps for APN were calculated. RESULTS: Data from 826 patients were analyzed. Mean patient age was 60.1 years (range 50-86), and 71.3% were men. APN was found in 98 patients, and 45 (45.9%) patients had no distal polyps. Risk factors of APN were a male gender, distal polyp size, and an advanced distal neoplasm. Sensitivities of a distal polyp of > or =10 mm and of an advanced distal neoplasm for APN were both 38.8% with positive predictive values of 13.3 and 14.4%, respectively. CONCLUSIONS: Although distal colon findings were found to be helpful for predicting APN in asymptomatic patients aged > or =50 years, APN without distal polyps requires careful consideration.

HER-2/neu overexpression is an independent prognostic factor in colorectal cancer.

BACKGROUND AND AIMS: The HER-2/neu protein is intimately involved with normal cell proliferation and tissue growth, as it is extensively homologous and is related to the epidermal growth factor receptor. This phenomenon has been most intensively studied in the context of breast carcinoma, in which its amplification and overexpression correlate with the overall course of disease and poor prognoses, and also constitute a predictive factor of poor response to chemotherapy and endocrine therapy. In this study, we investigated the relationships between the expression of HER-2/neu and the clinicopathological characteristics of colorectal cancer, including survival. This study was performed with a view toward the future introduction of Herceptin therapy for colorectal cancer patients. PATIENTS AND METHODS: HER-2/neu overexpression and gene amplification were examined via semiquantitative standardized immunohistochemical staining and fluorescence in situ hybridization (FISH) in 137 colorectal cancer patients who underwent curative surgery at the Kangbuk Samsung Hospital. RESULTS: Sixty-five (47.4%) out of 137 patients were determined by immunohistochemistry to have overexpressed HER-2/neu protein. HER-2/neu gene amplification was detected in two patients by FISH. Tumors with HER-2/neu overexpression showed higher postoperative recurrence rate (39.3% vs 14.6%, p=0.013). Tumors with HER-2/neu overexpression were associated with poor 3-year (70.8% vs 83.7%) and 5-year survival rates (55.1% vs 78.3%, p<0.05). Advanced TNM stage, postoperative recurrence, and overexpression of HER-2/neu were found to be independently related to survival by multivariate analysis. CONCLUSION: HER-2/neu overexpression may constitute an independent prognostic factor in colorectal cancer patients, and patients exhibiting HER-2/neu overexpression might constitute potential candidates for a new adjuvant therapy which involves the use of humanized monoclonal antibodies.

Abdominal obesity is an independent risk factor for erosive esophagitis in a Korean population.

BACKGROUND: The relationship between obesity and gastroesophageal reflux disease (GERD) is controversial. The aim of the present study was to investigate the potential roles of body mass index (BMI) and waist circumference on GERD in a Korean population. METHODS: A total of 2457 subjects who visited the Kangbuk Samsung Hospital medical screening center for esophagogastroduodenoscopy from September 2004 to April 2005 were enrolled. All participants were given a questionnaire to determine reflux symptoms. Abdominal obesity was defined as a waist circumference > or =80 cm in women and > or =90 cm in men. RESULTS: The proportion of subjects in each BMI group was 68.9%, 28.7% and 2.4% for BMI <25, 25-30 and >30, respectively. The prevalence of abdominal obesity was 24.2%. The prevalence of reflux symptoms was 8.2%. Neither BMI nor abdominal obesity was significantly associated with reflux symptoms after adjustment. The prevalence of erosive esophagitis was 6.6%. There was a clear dose-response relationship between prevalence of erosive esophagitis and BMI (5.6%, 8.1% and 15.5% for BMI <25, 25-30 and >30, respectively, P = 0.002). Abdominal obesity was also associated with erosive esophagitis (odds ratio, 2.3; 95% confidence interval, 1.6-3.1). However, only the association between abdominal obesity and erosive esophagitis remained strong after adjustments. CONCLUSIONS: Abdominal obesity rather than BMI is an independent risk factor for erosive esophagitis in the Korean population.