Age-adapted Variation in Screening Interval of Fecal Immunochemical Test May Improve its Participation and Colonoscopy Acceptance.

GOALS: We determined appropriate intervals for administering the fecal immunochemical test (FIT) and performance outcomes in an Asian national colorectal cancer (CRC) screening program. BACKGROUND: The optimal interval for FIT in CRC screening is unclear, especially in Asian populations. STUDY: Between January 2009 and December 2015, 13,480 individuals aged 50 years or older with an initial negative FIT result underwent 2 rounds of FIT screening at intervals of 1 (annual group, 5333), 2 (biennial group, 7363), or 3 years (triennial group, 784). Positive rates of FIT, colonoscopy acceptance, colonoscopy findings, and detection rates for CRC and advanced neoplasia were compared according to FIT intervals. RESULTS: The overall positivity rate of FIT in the second screening round was significantly higher in men and in older subjects than in the entire sample. Younger subjects were less likely to undergo annual FIT (36.0% vs. 46.4%, P<0.001). The colonoscopy acceptance rate was decreased in the biennial and triennial groups compared with an annual group among younger subjects (odds ratio, 0.56; 95% confidence interval, 0.33-0.95 for the biennial group vs. odds ratio, 0.19; 95% confidence interval, 0.03-1.37 for the triennial group). Detection rates for CRC and advanced neoplasia in the second round were significantly higher and accompanied by increased FIT screening intervals in older, but not younger subjects. CONCLUSIONS: Age-adapted variation in FIT screening intervals, such as annual screening for elderly subjects and biennial screening for younger subject, may improve FIT participation and colonoscopy acceptance.

Evaluation of scoring systems without endoscopic findings for predicting outcomes in patients with upper gastrointestinal bleeding.

BACKGROUND: Risk scoring systems are used to evaluate patients with upper gastrointestinal bleeding (UGIB). We compared Glasgow-Blatchford score (GBS), modified GBS (mGBS), and Pre-endoscopy Rockall score (Pre-E RS) for immediate application without endoscopic findings in predicting the need of interventions and the 30-day mortality in patients with UGIB. METHODS: Patients who visited the emergency room with UGIB from January 2007 to June 2016 were included. GBS, mGBS, and Pre-E RS were obtained for all patients. The area under the receiver-operating characteristic curves (AUC) was used to assess the accuracy of the scoring systems to determine the need for interventions and 30-day mortality. Also, we investigated the potential cutoff scores for predicting 30-day mortality and the need for interventions. RESULTS: In predicting the need for interventions, GBS (AUC = 0.727) and mGBS (AUC = 0.733) outperformed Pre-E RS (AUC = 0.564, P < 0.0001). In predicting 30-day mortality, Pre-E RS (AUC = 0.929) outperformed GBS (AUC = 0.664, P < 0.0001) and mGBS (AUC = 0.652, P < 0.0001). Based on AUC analyses of sensitivities and specificities, the optimal cutoff mGBS and GBS for the need for interventions was 9 (70.71% sensitivity, 89.35% specificity) and 9 (73.57% sensitivity, 82.90% specificity) respectively, and optimal cutoff Pre-E RS for 30-day mortality was 4 (88.0% sensitivity, 97.52% specificity). CONCLUSIONS: GBS and mGBS are considered to be moderately accurate in making an early decision about the need of interventions in patients with UGIB. Pre-E RS is considered to be highly accurate in early detection of patients at high risk for 30-day mortality without endoscopic findings. In addition, we suggested potential cutoff scores to predict the need of interventions for GBS and mGBS, and 30-day mortality for Pre-E RS. Further studies are needed to confirm the clinical applicability of results.

Successful Endoscopic Hemostasis Is a Protective Factor for Rebleeding and Mortality in Patients with Nonvariceal Upper Gastrointestinal Bleeding.

BACKGROUND: Rebleeding and mortality rates remain high in patients with nonvariceal upper gastrointestinal bleeding. AIM: To identify clinical and endoscopic risk factors for rebleeding and mortality in patients with nonvariceal upper gastrointestinal bleeding. METHODS: This study was performed in patients with nonvariceal upper gastrointestinal bleeding who underwent upper endoscopic procedures between July 2006 and February 2013. Clinical and endoscopic characteristics were compared among patients with and without rebleeding and mortality. Logistic regression analysis was performed to determine independent risk factors for rebleeding and mortality. RESULTS: After excluding 64 patients, data for 689 patients with nonvariceal upper gastrointestinal bleeding were analyzed. Peptic ulcer (62.6 %) was by far the most common source of bleeding. Endoscopic intervention was performed within 24 h in 99.0 % of patients, and successful endoscopic hemostasis was possible in 80.7 % of patients. The 30-day rebleeding rate was 13.1 % (n = 93). Unsuccessful endoscopic hemostasis was found to be the only independent risk factor for rebleeding (odds ratio 79.6; 95 % confidence interval 37.8-167.6; p = 0.000). The overall 30-day mortality rate was 3.2 % (n = 23). Unsuccessful endoscopic hemostasis (odds ratio 4.9; 95 % confidence interval 1.7-13.9; p = 0.003) was also associated with increased 30-day mortality in patients with nonvariceal upper gastrointestinal bleeding. CONCLUSIONS: Successful endoscopic hemostasis is an independent protective factor for both rebleeding and mortality in patients with nonvariceal upper gastrointestinal bleeding.

The Clinical Outcomes of Lower Gastrointestinal Bleeding Are Not Better than Those of Upper Gastrointestinal Bleeding.

The incidence of lower gastrointestinal bleeding (LGIB) is increasing; however, predictors of outcomes for patients with LGIB are not as well defined as those for patients with upper gastrointestinal bleeding (UGIB). The aim of this study was to identify the clinical outcomes and the predictors of poor outcomes for patients with LGIB, compared to outcomes for patients with UGIB. We identified patients with LGIB or UGIB who underwent endoscopic procedures between July 2006 and February 2013. Propensity score matching was used to improve comparability between LGIB and UGIB groups. The clinical outcomes and predictors of 30-day rebleeding and mortality rate were analyzed between the two groups. In total, 601 patients with UGIB (n = 500) or LGIB (n = 101) were included in the study, and 202 patients with UGIB and 101 patients with LGIB were analyzed after 2:1 propensity score matching. The 30-day rebleeding and mortality rates were 9.9% and 4.5% for the UGIB group, and 16.8% and 5.0% for LGIB group, respectively. After logistic regression analysis, the Rockall score (P = 0.013) and C-reactive protein (CRP; P = 0.047) levels were significant predictors of 30-day mortality in patients with LGIB; however, we could not identify any predictors of rebleeding in patients with LGIB. The clinical outcomes for patients with LGIB are not better than clinical outcomes for patients with UGIB. The clinical Rockall score and serum CRP levels may be used to predict 30-day mortality in patients with LGIB.

Development and validation of a risk stratification-based screening model for predicting colorectal advanced neoplasia in Korea.

GOALS: To develop and validate a risk stratification-based screening model for predicting colorectal advanced neoplasia in Korea. BACKGROUND: Colorectal advanced neoplasia is the relevant finding of screening colonoscopy. Risk estimation for advanced neoplasia may be helpful to improve compliance and to develop more cost-effective approaches toward screening. STUDY: We developed Korean Colorectal Screening (KCS) score by optimizing and adjusting Asia-Pacific Colorectal Screening (APCS) score to predict advanced neoplasia in an asymptomatic Korean population who received screening colonoscopies from September 2006 to September 2009. Moreover, we validated the KCS score in another Korean cohort who received screening colonoscopies from October 2009 to February 2011. We also assessed the predictive power and diagnostic performance of both KCS and APCS scores. RESULTS: There were 3561 subjects in the derivation cohort and 1316 subjects in the validation cohort, with a prevalence of advanced neoplasia of 4.7% and 4.3%, respectively. After a multivariate analysis, KCS was developed as 0 to 8 points comprising of age, sex, body mass index, smoking, and family history of CRC. Using KCS scores to stratify the validation cohort, the prevalences of advanced neoplasia in the 3 risk tiers (average, moderate, and high) were 2.0%, 3.7%, and 10.9%, respectively. Moderate-risk and high-risk tiers showed 2.1- and 6.5-fold increased prevalences, respectively, of advanced neoplasia compared with average risk tier. In addition, KCS score showed relatively good discriminative power (ROC=0.681) and higher sensitivity compared with APCS score for the high-risk tier. CONCLUSIONS: KCS score may be clinically simple and useful for assessing advanced neoplasia risk in Korea. However, racial disparity should be considered in risk stratification-based screening in each country.

Predictive Factors for Endoscopic Visibility and Strategies for Pre-endoscopic Prokinetics Use in Patients with Upper Gastrointestinal Bleeding.

BACKGROUND: Although current guideline recommends selective use of pre-endoscopic prokinetics to increase diagnostic yield in upper gastrointestinal bleeding (UGIB) patients, no data to guide the use of these drugs are available. AIMS: We aimed to investigate predictive factors for endoscopic visibility and develop simple and useful strategies for pre-endoscopic prokinetics use in UGIB patients. METHODS: A total of 220 consecutive patients who underwent upper endoscopy for suspicious UGIB were enrolled. Patients were randomly allocated to either a training or a validation set at a 2:1 ratio. Significant parameters on univariate analysis were subsequently tested by a classification and regression tree (CART) analysis. RESULTS: Time to endoscopy and nasogastric aspirate findings were independently related to endoscopic visibility. The CART analysis generated algorithms proposed sequential use of time to endoscopy (≤5.2 vs. >5.2 h) and nasogastric aspirate findings (red blood or coffee rounds vs. clear aspirate) for predicting endoscopic visibility. Prediction of unacceptable visibility in the validation set produced sensitivity, specificity, positive predictive value, and negative predictive value of 75.8, 67.5, 65.8, and 77.1 %, respectively. Accurate prediction for visibility was identified in 52 of 73 patients (71.2 %). CONCLUSIONS: Time to endoscopy and nasogastric aspirate findings were independently related to endoscopic visibility in patients with UGIB. A decision-tree model incorporating these two variables may be useful for selecting UGIB patients who benefit from pre-endoscopic prokinetics use.

Clinicopathological risk factors of early carcinoma in colorectal neoplasias according to Japanese and Western criteria.

BACKGROUND AND AIMS: There are discrepancies in the classification of early carcinoma in colorectal neoplasia between Japanese and Western criteria. However, no studies have investigated the clinicopathological risk factors associated with early carcinoma according to these criteria. METHODOLOGY: We compared the clinicopathological risk factors of early carcinoma with those of dysplasia, and used multivariate analysis to elucidate the independent risk factors associated with early carcinoma. Lesions with severe cytologic or architectural changes confined to the mucosa are classified as carcinoma in Japanese criteria and as high grade dysplasia (HGD) in Western criteria. RESULTS: Pathologically, 625 total patients were diagnosed with low grade dysplasia (n=321), HGD (n=244), intramucosal carcinoma (n=35) or submucosal carcinoma (n=25). In multivariate analysis, age, large lesion size, and non-polypoid appearance were associated with carcinoma in Japanese criteria; however, only large lesion size was associated with carcinoma in Western criteria. The clinicopathological characteristics of intramucosal carcinoma were similar to those of submucosal carcinoma rather than HGD. CONCLUSIONS: The clinicopathological characteristics for early carcinoma were not identical between Japanese and Western criteria. Japanese criteria classifying intramucosal carcinoma as carcinoma rather than HGD may be supported by our findings.

Association of hyper-LDL cholesterolemia with increased risk of colorectal adenoma.

BACKGROUND/AIMS: Previous studies on the association between dyslipidemia and the presence of colorectal adenoma showed conflicting results, and were limited due to small sample sizes, inconsistent definitions of dyslipidemia, or a lack of data on full lipid profiles. The aim of this study was to determine the association between colorectal adenomas and dyslipidemia according to the definition by the National Cholesterol Education Program- Adult Treatment Panel III. METHODOLOGY: We conducted a retrospective, cross-sectional study in subjects who underwent screening colonoscopy and blood tests for full lipid profiles. Serum dyslipidemia profiles were compared between the adenoma group and the control group, and multivariate analysis was performed to identify independent predictors of the presence of colorectal adenomas. RESULTS: Patients with hyper-LDL cholesterolemia were more frequently included in the adenoma group than the control group (46.7% vs. 32.1%, respectively, p=0.023), and hyper-LDL cholesterolemia (OR = 1.954, 95% CI=0.981-3.893, p=0.057) showed a statistical trend for the positive association with the presence of colorectal adenomas by multivariate analysis. Furthermore, proximal colorectal adenomas were more prevalent in the hyper-LDL cholesterolemia group than in the normal LDL cholesterolemia group (p=0.026). CONCLUSIONS: Hyper-LDL cholesterolemia was associated with the presence of colorectal adenomas, especially in the proximal colon.

Osteoporosis is associated with the risk of colorectal adenoma in women.

BACKGROUND: Recently, it was reported that postmenopausal women with lower bone mineral density have an increased risk of colorectal cancer. An association between lower bone mineral density and colorectal cancer suggests that colorectal adenoma, which is a precursor of colorectal cancer, may also be associated with lower bone mineral density. OBJECTIVE: The aim of this study was to determine the association between colorectal adenoma and osteoporosis. DESIGN AND PATIENTS: We conducted a retrospective cross-sectional study between January 2007 and May 2011. Women older than 50 years of age who underwent dual-energy x-ray absorptiometry for bone mineral density and screening colonoscopy at Gangdong Kyung Hee University Hospital in Korea during a routine health checkup were eligible for this study. We performed multivariate analysis adjusted for age, family history of colorectal cancer, alcohol consumption, current smoking, regular aspirin use, exercise, menopause, and postmenopausal hormone use to identify independent predictors for the presence of colorectal adenoma. MAIN OUTCOME MEASURES: The primary outcome measured was the prevalence of colorectal adenoma according to the bone mineral density level. RESULTS: A total of 992 women older than 50 years were assigned to an osteoporosis group (n = 231) or a control group (n = 231) after menopause matching. In univariate analysis, the proportion of colorectal adenoma was significantly higher in the osteoporosis group than in the control group (29.9% vs 20.8%, p = 0.025). Furthermore, osteoporosis (OR = 1.592, 95% CI = 1.004-2.524, p = 0.048) was found to be an independent risk factor for the presence of colorectal adenoma. CONCLUSIONS: Osteoporosis is associated with an increased risk of colorectal adenoma in women older than 50 years.

Use of a low cut-off value for the fecal immunochemical test enables better detection of proximal neoplasia.

BACKGROUND: The advantage of the quantitative fecal immunochemical test (FIT) is the flexibility to set the positivity threshold. However, the diagnostic success of the FIT has not been compared for standard and low cut-off thresholds. AIMS: The purpose of this study was to compare the diagnostic success of FIT for standard and low cut-off thresholds. METHODS: In 2009 and 2010 a standard cut-off threshold (20 µg Hb/g feces) was used as positivity criterion for the FIT; in 2012 a low cut-off (10 µg Hb/g feces) was used. Diagnostic success was compared between the two groups. RESULTS: Of the total of 14,289 participants, 195 (1.4 %) had positive FIT results. Positivity of the FIT was significantly higher in the low cut-off group than in the standard cut-off group (1.8 vs. 1.0 %, p = 0.000). Although detection of advanced neoplasia lesions was comparable, proximal neoplasia was more frequently detected in the low cut-off group (33.3 vs. 20.9 %, p = 0.016). With the low cut-off threshold, 39 (0.7 %) participants were also classified as having positive results, and 18 (46.2 %) of these had colorectal neoplasias. The number of positive results from the FIT was increased by 54.9 %, and detection of advanced neoplasia was increased by 60 % with the low cut-off threshold compared with the standard cut-off. CONCLUSIONS: A low cut-off threshold for the FIT resulted in better detection of proximal neoplasia in population-based screening. These results indicate the cut-off threshold for positive FIT should be properly chosen and adjusted in colorectal cancer screening.

Prediabetes is associated with a high-risk colorectal adenoma.

BACKGROUND: Type 2 diabetes mellitus is associated with an increased risk of colorectal neoplasia. However, association between prediabetes and colorectal adenoma has not been reported. AIMS: The aim of this study was to evaluate the relationship between prediabetes and the presence of colorectal adenomas. METHODS: Consecutive prediabetic subjects who underwent screening colonoscopy were enrolled at Kyung Hee University Hospital in Gangdong, Seoul, Korea, between June 2006 and May 2012. Non-prediabetic subjects were separately pooled from the database of the Center for Health Promotion between January 2012 and May 2012. Prediabetes was defined according to the recommendations of the American Diabetes Association. The prevalence of colorectal adenomas and their characteristics were compared between prediabetic and non-prediabetic groups. RESULTS: The prevalence of colorectal adenoma was higher in prediabetic subjects than in non-prediabetic subjects (39.6 vs. 30.6 %, respectively, p = 0.019). Prediabetic subjects had more multiple and high-risk adenomas than the control group in non-matched analysis (p = 0.000, respectively). In age-matched analysis, the prevalence of multiple and high-risk adenomas were significantly higher in a prediabetic group than those in a control group (44.4 vs. 28.4 %, p = 0.034; 51.9 vs. 34.6 %, p = 0.026, respectively). Furthermore, prediabetes (odds ratio = 2.198; 95 % confidence interval = 1.042-4.637; p = 0.039) was found to be an independent risk factor for a high-risk adenoma by multivariate analysis. CONCLUSIONS: The prevalence of multiple and high-risk colorectal adenomas is significantly higher in the prediabetic subjects than those in the control group. Furthermore, prediabetes was found to be an independent risk factor for a high-risk colorectal adenoma.

Polymorphisms of interferon gamma gene and risk of hepatocellular carcinoma in korean patients with chronic hepatitis B viral infection.

BACKGROUNDS/AIMS: Increasing evidence supports the contribution of the pro-/anti-inflammatory cytokine balance and genetic factors to hepatocellular carcinoma (HCC). Here, we investigated whether genetic interferon gamma polymorphisms were associated with HCC in Korean patients with chronic hepatitis B. METHODOLOGY: We genotyped a single nucleotide polymorphism (SNP, rs2430561, +874A/T) and a microsatellite (rs3138557, (CA)n repeat), located in the first intron of the interferon gamma gene, by direct sequencing and the gene scan method. A population-based case-control study of HCC was conducted and included 170 patients with chronic hepatitis and HCC, and 171 with chronic hepatitis B patients without hepatocellular carcinoma in a Korean population. RESULTS: Genotype and allele distributions of the interferon gamma gene SNP were associated with HCC. The frequencies of the AA genotype and the A allele were significantly increased in hepatocellular carcinoma subjects (p<0.05). Combined analysis using the genotype of rs2430561 and the number of microsatellites revealed that the frequencies of AT-CA12 and TT-CA12 increased significantly in hepatocellular carcinoma subjects (p<0.0001). CONCLUSIONS: Our results suggest that the interferon gamma gene may be a susceptibility gene and a risk factor for HCC in the Korean population.

Association between HLA-G 14-bp insertion/deletion polymorphism and hepatocellular carcinoma in Korean patients with chronic hepatitis B viral infection.

BACKGROUND/AIMS: The aim of this study was to determine whether the major HLA-G gene was associated with hepatocellular carcinoma (HCC). Abnormal HLA-G expression is present in various diseases, such as renal cell carcinoma, asthma and classical Hodgkin's lymphoma. METHODOLOGY: To investigate the possible association with susceptibility to HCC, 181 chronic hepatitis patients and 180 HCC patients were enrolled in this study. The HLA-G 14-bp insertion/deletion polymorphism is located in the 3' untranslated region of the HLA-G gene and was analyzed using polymerase chain reaction. For analysis of genetic data, SNPStats and SPSS 18.0 were used. Logistic regression models were performed to determine the odds ratio, 95% confidence interval, and p value. RESULTS: Allele and genotype frequencies of the HLA-G 14-bp insertion/deletion polymorphism in the hepatitis group had a similar pattern, as compared to those in the HCC group. Furthermore, no differences were observed between patients with and without liver cirrhosis. CONCLUSIONS: These results suggest that the HLA-G 14-bp insertion/deletion polymorphism may not be associated with HCC susceptibility and liver cirrhosis development in the Korean population.

Polymorphisms of interferon gamma gene and risk of hepatocellular carcinoma in Korean patients with chronic hepatitis B viral infection.

BACKGROUNDS/AIMS: Increasing evidence supports the contribution of the pro-/anti-inflammatory cytokine balance and genetic factors to hepatocellular carcinoma (HCC). Here, we investigated whether genetic interferon gamma polymorphisms were associated with HCC in Korean patients with chronic hepatitis B. METHODOLOGY: We genotyped a single nucleotide polymorphism (SNP, rs2430561, +874A/T) and a microsatellite (rs3138557, (CA) (n) repeat), located in the first intron of the interferon gamma gene, by direct sequencing and the gene scan method. A population-based case-control study of HCC was conducted and included 170 patients with chronic hepatitis and HCC, and 171 with chronic hepatitis B patients without hepatocellular carcinoma in a Korean population. RESULTS: Genotype and allele distributions of the interferon gamma gene SNP were associated with HCC. The frequencies of the AA genotype and the A allele were significantly increased in hepatocellular carcinoma subjects (p < 0.05). Combined analysis using the genotype of rs2430561 and the number of microsatellites revealed that the frequencies of AT-CA12, and TT-CA12 increased significantly in hepatocellular carcinoma subjects (p < 0.0001). CONCLUSIONS: Our results suggest that the interferon gamma gene may be a susceptibility gene and a risk factor for HCC in the Korean population.

First-degree relatives of colorectal cancer patients are likely to show advanced colorectal neoplasia despite a negative fecal immunochemical test.

BACKGROUND/AIMS: Fecal immunochemical test (FIT) is an integral component of most colorectal cancer (CRC) screening programs. However, little is known about clinical risk factors associated with advanced colorectal neoplasia (CRN) despite negative FIT results. The aim of this study was to determine the clinical predictors of advanced CRN despite negative FIT results. METHODS: We performed FITs for asymptomatic subjects ≥50 years from January 2009 to December 2010. Patients who underwent colonoscopy for a medical check-up, despite a negative FIT result, were included to evaluate the clinical predictors of advanced CRN based on colonoscopy. RESULTS: During the study period, 373 subjects underwent screening colonoscopy despite their negative FIT results. Among those 373 subjects, 356 (95.4%) did not show any advanced CRNs; however, 17 (4.6%) subjects showed advanced CRNs on their colonoscopies despite negative FIT results. Being a first-degree relative of a CRC patient was significantly associated with advanced CRNs in univariate analysis (p = 0.031). According to multivariate logistic regression analysis, being a first-degree relative of a CRC patient was a significant predictor of advanced CRNs despite negative FIT results (OR 7.33; 95% CI, 0.53-35.08; p = 0.013). CONCLUSION: First-degree relatives of CRC patients are likely to show advanced CRNs despite a negative FIT.

Efficacy of entecavir and adefovir combination therapy for patients with lamivudine- and entecavir-resistant chronic hepatitis B.

BACKGROUND: The optimal treatment of patients with chronic hepatitis B (CHB) who develop resistance to both lamivudine (LMV) and entecavir (ETV) after sequential monotherapy of LMV and ETV remains little known. METHODS: We evaluated the efficacy of entecavir (ETV) plus adefovir dipivoxil (ADV) combination therapy for patients with resistance to LMV and ETV. We reviewed the medical records of 12 patients, and treated all 12 patients with ETV plus ADV combination therapy for at least 18 months. Quantitative hepatitis B virus (HBV) DNA levels, serologic markers, and hepatic panel values were monitored at baseline and 3-month intervals thereafter for 18 months. RESULTS: The baseline mean serum HBV DNA level was 7.26 ± 1.11 log(10) copies/ml. The mean reductions in serum HBV DNA levels from baseline to 3, 6, 9, 12, 15, and 18 months were -1.98 ± 1.03, -2.87 ± 1.02, -3.32 ± 1.10, -3.92 ± 1.30, -4.36 ± 1.22, and -4.57 ± 1.18 log(10) copies/ml, respectively. Complete virological response (HBV DNA of <2 log(10) copies/ml) at 6, 12, and 18 months was observed in 1 (8.3%), 4 (33.3%), and 6 (50.0%) patients, respectively. The 2 patients with baseline HBV DNA of <6 log(10) copies/ml achieved complete virological response at 18 months, while 4 of 10 patients with baseline HBV DNA of ≥6 log(10) copies/ml achieved complete virological response at 18 months. None of the 12 patients experienced virological breakthrough during follow-up. CONCLUSIONS: ETV plus ADV combination therapy effectively reduced serum HBV DNA levels in patients with CHB who developed resistance to both LMV and ETV. Additional long-term studies are needed to assess the effect of long-term treatment with these drugs.

Early use of needle-knife fistulotomy is safe in situations where difficult biliary cannulation is expected.

BACKGROUND AND AIMS: Difficult cannulation is a well known risk for post-ERCP pancreatitis. This study evaluated the outcomes of needle-knife fistulotomy (NKF) used prior to being faced with difficult biliary cannulation. METHODS: Patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) for the purpose of biliary endotherapy between January 2007 and December 2008 were eligible for this study; 218 patients were recruited. Biliary cannulation was performed only by a standard catheter or a pull type papillotome, without wire-guided assistance in all patients. If selective cannulation was not achieved within five cannulation attempts, NKF was performed, and the results were compared with the easy cannulation group that succeeded biliary cannulation within five attempts. RESULTS: Needle-knife fistulotomy (NKF) was performed in 72 (33.0%) of the 218 patients. The total success rate of the ERCP was 98.2% (214/218), and for the NKF group the success rate was 94.4% (68/72). The rate of complications in patients with NKF did not increase compared to patients in the easy cannulation group (P > 0.05): 4.2% (3/72) versus 3.4% (5/146) for acute pancreatitis, 6.9% (5/72) versus 6.8% (10/146) for bleeding, and 1.4% (1/72) versus 0% (0/146) for perforation, respectively. CONCLUSIONS: Our results suggest that the use of NKF for biliary cannulation might be safe and effective. Therefore, in experienced hands, early use of NKF might be recommended.

Performance of the fecal immunochemical test is not decreased by high ambient temperature in the rapid return system.

BACKGROUND: Hemoglobin concentration of fecal immunochemical test may be decreased at high ambient temperature, and fecal samples in FIT may be exposed to high ambient temperature. AIMS: The aim of this study was to determine whether a high ambient temperature on the day of screening may decrease the performance of FITs in population-based screening. METHODS: We performed FITs for asymptomatic participants aged 50 years or older. Fecal hemoglobin concentration, the probability of a positive FIT and a detection rate of colorectal neoplasms were compared between low (<10.0 °C) and high (≥25.0 °C) temperature groups. RESULTS: The FIT results for 8,316 participants were analyzed. The mean log(10) Hb concentration in the low temperature group was significantly higher than those in the high temperature group (0.36 vs. 0.25 ng/ml, p = 0.000). Regression analysis showed that an increase in temperature of 1 °C reduced the probability of a positive FIT by 3.1 %. However, we found no differences between the two groups in the FIT positive rate and detection rate of colorectal neoplasms. In multivariate analysis, high ambient temperature was not a significant risk factor for either the positive FIT result or the detection of colorectal neoplasms. CONCLUSIONS: Potential instability of fecal hemoglobin at high ambient temperatures should be considered; however, its influence on performance of FIT may be attenuated by the short exposure time of fecal samples to high ambient temperature (i.e., rapid return system).

The risk of postpolypectomy bleeding during colonoscopy in patients with early liver cirrhosis.

BACKGROUND: Colonoscopists are often hesitant to perform endoscopic polypectomy in patients with liver cirrhosis (LC) because of the risk for postpolypectomy bleeding (PPB). However, little is known about the risk of PPB in these patients. METHODS: We performed a retrospective study of patients with early LC who underwent colonoscopic polypectomy at a single center between September 2006 and May 2011. We investigated the incidence of immediate PPB (IPPB) and delayed PPB (DPPB) in these patients. In addition, we investigated which LC-related and polyp-related factors were associated with IPPB. RESULTS: Thirty patients with LC were included in our study, and 29 (96.7 %) of them were classified in Child-Pugh class A or B. The mean prothrombin time was 1.27 ± 0.23, and the mean platelet count was 136.77 ± 106.49 × 10(3)/L. A total of 66 polyps in 30 patients were removed. In terms of IPPB, only 2 (3.03 %) of the 66 removed polyps presented with mild oozing and were controlled by hemostatic procedures using hemoclips. DPPB did not occur in any of the patients in the IPPB or the non-IPPB group. Although the IPPB polyp group was too small to detect statistical significance, the IPPB polyps were larger than the non-IPPB polyps (22.5 ± 10.61 vs. 7.22 ± 3.01 mm), and the gross morphology of both IPPB polyps was the pedunculated type. However, LC-related variables such as platelet counts and Child-Pugh scores did not significantly differ between the IPPB and non-IPPB groups. CONCLUSIONS: In patients with early LC, the risk of postpolypectomy bleeding was acceptably low and there was no case with DPPB. Therefore, polypectomy can be performed with caution. IPPB was associated with the size and the gross morphology of the polyps. However, LC-related variables in patients with early LC did not impact IPPB.

Telephone reminder call in addition to mailing notification improved the acceptance rate of colonoscopy in patients with a positive fecal immunochemical test.

BACKGROUND AND AIMS: Colorectal cancer (CRC) screening with a fecal immunochemical test (FIT) reduces CRC mortality; however, the acceptance rate of a colonoscopy in patients with a positive FIT was not high. The aim of this study was therefore to determine whether a telephone reminder call could increase the acceptance rate of colonoscopy in patients with a positive FIT. METHODS: We performed FITs for asymptomatic participants aged 50 years or older. For patients with a positive FIT, a colonoscopy was recommended via mailing notification only (control group) or via a telephone reminder call after mailing notification (intervention group). The calls informed patients about the significance of a positive FIT and encouraged a colonoscopy following positive FITs. RESULTS: The FIT results were positive in 90 of 8,318 patients who received FITs. Fifty patients were advised to receive colonoscopy via mailing notification only, and 40 patients were advised via both a telephone reminder call and a mailing notification. The acceptance rate of colonoscopy was significantly higher in the intervention group than in the control group (p = 0.038). The lesion-detection rate for an advanced neoplasia was also significantly higher in the intervention group than in the control group (p = 0.046). According to multivariate logistic regression analysis, a telephone reminder was a significant determinant of colonoscopy acceptance in patients with a positive FIT (OR 4.33; 95% CI, 1.19-15.75; p = 0.026). CONCLUSIONS: Telephone reminder calls in addition to mailing notification improved the acceptance rate of colonoscopy in patients with a positive FIT.