The Miss Rate for Colorectal Adenoma Determined by Quality-Adjusted, Back-to-Back Colonoscopies

BACKGROUND/AIMS: Colonoscopy is considered to be the gold standard for detecting adenomatous polyps. Polyps are missed during colonoscopic examination at a rate that varies from 6% to 27%. The adenoma miss rate affects colonoscopic surveillance intervals and procedural quality. We aimed to assess the adenoma miss rate and the variables affecting the rate using same-day, quality-adjusted, back-to-back colonoscopies. METHODS: This prospective study was performed at a single institution and included 149 patients. Two consecutive same-day colonoscopies were performed by two experienced endoscopists. The adenoma miss rates and variables affecting the missed adenomas, including polyp characteristics and procedure times, were evaluated. RESULTS: The miss rates of polyps, adenomas, and advanced adenomas were 16.8%, 17%, and 5.4%, respectively. The smaller polyps and increased number of polyps detected during the first colonoscopy were more likely to be missed. A longer insertion time during the colonoscopy was correlated with an increased adenoma detection rate. CONCLUSIONS: There was a significant miss rate in the detection of colonic adenomas even in quality-adjusted, back-to-back colonoscopies. The adenoma miss rate can be reduced with a sufficient observation time during colonoscopic insertion. The development of specific technological methods to reduce the adenoma miss rate is necessary.

Clinicopathologic Characteristics of Superficial Gastric Cancer Diagnosed at Primary Health Care Institutions in 2011 / 대한소화기학회지

BACKGROUND/AIMS: Stomach cancer is prevalent in Korea. The purpose of this study was to evaluate the characteristics of superficial gastric cancers detected at SOK Sokpeynhan Internal Medical Network, the nationwide primary health care institutions. METHODS: We prospectively analysed the clinicopathologic and endoscopic characteristics of 218 superficial gastric cancer patients diagnosed using gastric endoscopy at SOK network from January 2011 through December 2011. RESULTS: The mean age was 58.5 years old and male to female ratio was 1.7 : 1. Asymptomatic patients were most common (45.0%). The macroscopic classification revealed that simple types (63.8%) were more common than complex types (36.2%). The most common type was IIc (28.4%) and other types were as follows; IIb (16.1%), IIb+IIc (13.3%), IIa (10.6%), III (9.2%), IIa+IIc (7.3%), IIc+IIa (6.0%), IIc+IIb (5.0%). The most commonly involved sites were the body (53.1%) and greater curvature (32.6%) of the stomach. The size of lesion was less than 1 cm (69.3%) and less than 5 mm (33.5%) in diameter. The most common pathologic type was tubular adenocarcinoma (75.7%). Helicobacter pylori infection rate was 50.2%. Fifty five percent of the cases were diagnosed via endoscopy of National Health Insurance Corporation screenings. CONCLUSIONS: Superficial gastric cancers in 2011 at primary health care SOK network were different from those of previous reports. Type IIc was most common but type IIb was more prevalent and the body and greater curvature of the stomach were the most commonly involved sites. Therefore, careful observation of the proximal gastric mucosa and mucosal color change is needed.

Simple Tests to Predict Hepatic Fibrosis in Nonalcoholic Chronic Liver Diseases

BACKGROUND/AIMS: Several simple tests for hepatic fibrosis employ indirect markers. However, the efficacy of using direct and indirect serum markers to predict significant fibrosis in clinical practice is inconclusive. We analyzed the efficacy of a previously reported indirect marker of hepatic fibrosis - the aspartate aminotransferase to platelet ratio index (APRI) - in patients with nonalcoholic chronic liver diseases (CLDs). METHODS: A total of 134 patients who underwent a percutaneous liver biopsy with a final diagnosis of chronic hepatitis B (n=93), chronic hepatitis C (n=18), or nonalcoholic fatty liver disease (n=23) were enrolled. A single-blinded pathologist staged fibrosis from F0 to F4 according to the METAVIR system, with significant hepatic fibrosis defined as a METAVIR fibrosis score of > or =2. RESULTS: The mean area under the receiver operating characteristic curve (AUROC) of APRI for predicting significant fibrosis in nonalcoholic CLDs was 0.84 [95% confidence interval (CI), 0.78-0.91]. APRI yielded the highest mean AUROC in the patients with chronic hepatitis B (0.85; 95% CI, 0.771-0.926). The positive predictive value of APRI > or =1.5 for predicting significant fibrosis was 89%. The negative predictive value of APRI <0.5 for excluding significant fibrosis was 80%. CONCLUSIONS: APRI might be a simple and noninvasive index for predicting significant fibrosis in nonalcoholic CLDs.

Non-endoscopic Predictors of Large Esophageal Varices in Patients with Liver Cirrhosis / 대한소화기학회지

BACKGROUND/AIMS: The aim of this study was to identify non-endoscopic predictors for the presence of large esophageal varices in Korean patients with liver cirrhosis. METHODS: Among 736 patients with liver cirrhosis newly diagnosed between the year 2001 and 2005, 245 patients (171 men and 74 women, mean age of 51.9 years) fulfilled the inclusion criteria and underwent EGD as screening tests for esophageal varices. Fifteen variables were analysed to identify the presence of large esophageal varices. RESULTS: Esophageal varices were noted in 186 patients (75.9%) and large varices in 55 patients (22.4%), while 59 patients (24.1%) had no varices at the time of initial diagnosis of cirrhosis. The causes of liver cirrhosis were viral hepatitis (41.2%), chronic alcoholism (42.4%), viral hepatitis/alcoholism (9.8%), and others (6.6%). Fifty-one percent, 35.1% and 13.9% of the patients belonged to Child-Pugh class A, B, and C, respectively. Variables associated with the presence of large esophageal varices on univariate analysis were the presence of ascites, splenomegaly (long-axis > or =12 cm by ultrasound measure), alcoholism, Child-Pugh class, platelet count, prothrombin time, and albumin. On multivariate analysis, alcohol, splenomegaly, and ascites were significantly associated with the presence of large esophageal varices. If the patients have two of them, sensitivity and negative predictive value were 80% and 91.7%, respectively. Patients without all three factors had no large esophageal varices. CONCLUSIONS: These results suggest that patients who have at least two among ascites, splenomegaly, and alcoholism would have an increased risk of having large esophageal varices.

Endoscopic Retrieval of a Proximally Migrated Stent in the Dorsal Duct of Pancreas Divisum / 대한소화기내시경학회지

Endoscopic treatment of chronic pancreatitis by stent insertion is an accepted procedure, but various complications can be induced, including proximal migration of the stent. Many techniques are used to retrieve proximally migrated, pancreatic stents. We here report a case of a proximally migrated stent into the dorsal duct of a pancreas divisum, which was retrieved endoscopically by using a mini-snare. A 39-year-old female patient had chronic pancreatitis with divisum. A stent was inserted into the dorsal duct to relieve the chronic pain. After two months, sudden epigastric pain developed due to proximal migration of the stent. The pancreatic stent was retrieved successfully with one endoscopic attempt using a mini-snare. The epigastric pain resolved after retrieval of the stent. Our observation is that pancreatic stent migration may cause severe abdominal pain and that endoscopic retrieval is possible.

Follow-up result of endoscopic mucosal resection for gastric adenoma and early gastric cancer / 대한내과학회지

BACKGROUND: Endoscopic mucosal resection (EMR) is now widely accepted as a useful treatment method for gastric adenoma and early gastric cancer (EGC) because of its minimal invasiveness and satisfactory post-procedure results. The purpose of this study is to define the follow-up results and usefulness of EMR. METHODS: We analyzed 54 cases from June 2000 through September 2004. Endoscopy with histological examination was carried out every 3 months for 1 year after EMR. RESULTS: The patients consisted of 42 men and 12 women, and the mean age was 60 years old. The histological results were 42 gastric adenoma and 12 EGC cases. There were 9 cases that had the histological diagnosis changes after EMR. Complete resections was performed for 48 cases and the en block resections were 33 of 34 cases (97%) and piecemeal resections were done in 15 of 20 cases (75%). Recurrence was seen in 4 cases (7.1%), and the mean recurrence period was 7 months. There were 3 gastric adenomas of 42 cases (7.1%), one case of EGC of 12 cases (8.3%), one en block resection of 34 cases (2.9%) and three piecemeal resections of 20 cases (15%). CONCLUSIONS: EMR is a safe and useful treatment method for gastric adenoma and EGC. However, EMR has some limitations that EGC may have lymph node metastases or multiple tumors. So, periodic follow-up is very important. As we acquire more clinical experience, EMR may be accepted as the standard treatment method for gastric adenoma and EGC.

A Case of Adenosquamous Carcinoma of the Papilla of Vater / 대한소화기학회지

Adenosquamous carcinoma of the papilla of Vater is a rare tumor and only a few cases have been reported so far. Here, we report a case of adenosquamous carcinoma in a 76-year-old male who presented with jaundice and right upper quadrant abdominal pain. Ultrasonography and enhanced abdominal CT scans showed dilated common bile duct (CBD) and intrahepatic bile duct (IHD) with a suspicious obstructing mass in distal CBD. On endoscopy, obstructing and ulcerated mass was noted on the papilla of Vater. Histopathological inspection of the biopsied specimens from mass showed adenosquamous cell carcinoma of the papilla of Vater. Since the patient refused operation, we inserted a self-expandable metallic stent in distal CBD. This is the first case report on adenosquamous carcinoma of the papilla of Vater in Korea.

A Case of Colon Cancer Associated with Crohn's Disease / 대한소화기학회지

Colon cancer is the most serious intestinal complication in patients with Crohn's disease. Although an association between Crohn's disease and colon cancer has not been clearly defined, a number of studies in western countries reported an increased rate of colon cancer in patients with Crohn's disease. In Korea, Crohn's disease is rare when compared to western countries, and only a single case of colon cancer associated with Crohn's disease has been reported. We recently experienced a 66-year-old women with colon cancer associated with Crohn's disease.

Localized Esophageal Ulcerations after CyberKnife Treatment for Metastatic Hepatic Tumor of Colon Cancer / 대한소화기학회지

CyberKnife is an image-guided robotic system designed for stereotactic radiosurgery. It uses the combination of robotics and image guidance to deliver concentrated and accurate beams of radiation to intracranial and extracranial targets. Although the frameless nature of the CyberKnife allows tumors in the chest and abdomen to be treated as well, complications associated with CyberKnife treatment have not been established yet due to its short clinical experience. We describe a case of localized esophageal ulcerations after CyberKnife treatment for metastatic hepatic tumor of colon cancer.

Association of Hepatic Iron Deposition and Serum Iron Indices with Hepatic Inflammation and Fibrosis Stage in Nonalcoholic Fatty Liver Disease / 대한소화기학회지

BACKGROUND/AIMS: Nonalcoholic steatohepatitis can develop from nonalcoholic fatty liver and progress to severe liver disease such as cirrhosis. The mechanism determining the progression from fatty liver to steatohepatitis is unknown. Iron is suspected to enhance hepatic damage associated with nonalcoholic fatty liver disease (NAFLD). The aims of this study were to evaluate the relationship of serum iron indices and hepatic iron deposition with hepatic fibrosis or inflammation, and to assess whether the increased hepatic iron deposition is an independent predictor of progression to liver injury. METHODS: The biochemical and histopathological data of thirty-nine patients with NAFLD were analyzed. Liver biopsy findings were graded according to the method described by Brunt, et al. Hepatic iron concentration was available in 29 of 39 patients. RESULTS: The mean hepatic iron concentration and hepatic iron indices were 1,349+/-1,188 microgram/g dry weight and 0.9+/-0.7 microgram/g/age. Serum ferritin and body mass indices were associated with hepatic inflammation (p=0.001, p=0.006) and fibrosis (p=0.005, p=0.013). Hepatic iron concentration and hepatic iron index were not associated with hepatic inflammation and fibrosis. Multivariate analysis did not identify serum ferritin or body mass index as an independent predictor of liver injury. CONCLUSIONS: Hepatic iron deposition shows no association with the degree of hepatic inflammation or fibrosis. Hepatic iron is not an independent predictor of hepatic injury in patients with NAFLD.

A Case of Acute Cholecystitis Secondary to Hemobilia after Percutaneous Liver Biopsy / 대한소화기학회지

Percutaneous liver biopsy is well established for the diagnosis and follow-up of many liver diseases. Although it is rather safe, major complications, such as bleeding into the peritoneal or thoracic cavity, hemobilia, enteric perforation and intrahepatic hematoma, have been reported related to the procedure. Recently, incidence of such major complications has been decreased since the introduction of ultrasonography-guided liver biopsy. We report a case of 59-year-old female patient with acute cholecystitis secondary to hemobilia 2 days after ultrasonography-guided percutaneous liver biopsy.

A Case of Giant Pedunculated Submucosal Lipoma Causing Intussusception of the Colon / 대한소화기내시경학회지

Intussusception is a relatively common cause of intestinal obstruction in children. However, it is quite uncommon in adults, representing < or =1% of intestinal obstructions in this patient population. Colonic lipoma is rare, usually small, and occurs mainly in the right colon, particularly in the cecum. They often occur in elderly women. Intermittent episodes of intussusception are not uncommon in patients with colonic lipoma but they are usually caused by larger pedunculated lipomas. Almost all gastrointestinal lipomas are submucosal or subserosal, and most are asymptomatic, even though they can cause abdominal pain, bowel obstruction, and gastrointestinal bleeding. Colonic lipoma with a dramatic presentation requiring urgent surgery is rare. Symptomatic lipomas or complicated cases require surgical or endoscopical intervention. We report a case of symptomatic giant pedunculated colonic lipoma causing intussusception requiring surgical intervention, with a successful recovery after surgery.

Macro-aspartate Aminotransferase in a Patient with Chronic Hepatitis C / 대한소화기학회지

Macroenzymes are normal enzymes complexed with an immunoglobulin (usually IgG, rarely IgA or IgM). A number of macroenzymes have been reported in the literature. Among them, macro-AST has been detected in diseases such as acute and chronic hepatitis, various malignancies and autoimmune diseases, but usually not associated with any specific disease. We report a case of elevated AST activity in serum due to marco-AST formation in a female with chronic hepatitis C which was confirmed by AST isoenzyme electrophoresis. To our knowledge, this is the first report of macro-AST occurred in chronic hepatitis patient in Korea.

A Case of Retroperitoneal Schwannoma of the Vagus Nerve / 대한소화기학회지

Schwannomas are benign nerve sheath tumors that originate from any anatomical site. Most schwannomas occur in the head, neck or limbs, but rarely occur in the retroperitoneal space. Furthermore, the schwannoma originating from the vagus nerve of retroperitoneal space is much rare. We experienced a case of retroperitoneal schwannoma of the vagus nerve. A 34-year-old male was refered to our hospital for the evaluation of abdominal mass on ultrasonography. Endoscopic examination revealed submucosal tumor-like lesion on high body of the stomach. Computed tomography (CT) revealed that the stomach was compressed by a solid tumor in the retroperitoneum. On exploratory laparotomy, this mass turned out to be a baseball sized mass in the retroperitoneal space. The mass was excised in an encapsulated state. Histological examination with immunohistochemical stains revealed a schwannoma of the vagus nerve.

A Case of Hemolytic Uremic Syndrome with Hemorrhagic Colitis due to Escherichia coli O111 Infection / 대한소화기학회지

Shiga toxin producing E. coli (STEC) may cause severe hemorrhagic colitis followed by hemolytic uremic syndrome (HUS). In Korea, there had been a few case reports of HUS by STEC, mostly due to O157 serotype. The reports of HUS caused by STEC non-O157 serotype were rare. We report a sporadic case of HUS associated with hemorrhagic colitis. A 51-year-old woman was admitted to our hospital due to intractable abdominal pain and bloody diarrhea. Three days after admission, azotemia and microangiopathic hemolysis developed. E. coli, serotype O111 was identified. Conservative management with plasmapheresis resulted in a complete recovery.

A Case of Spontaneous Perforation of the Common Bile Duct Associated with Cholangitis / 대한소화기학회지

Spontaneous perforation of the common bile duct (CBD) is a rare event in adults. Most cases of CBD perforation are iatrogenic after invasive procedures such as endoscopic retrograde cholangiopancreatography (ERCP) or cholecystectomy. We report a case of an 81-year-old woman who presented with severe right upper abdominal pain, fever, and chills. Abdominal CT showed multiple gallbladder and CBD stones and loculated fluid collection in the inferoposterior portion of the stomach. ERCP showed the leakage of contrast media into the peritoneal cavity from the CBD. We performed endoscopic sphincterotomy (EST) and endoscopic nasobiliary drainage (ENBD) to decompress the CBD instead of emergent surgical intervention. One week later, cholangiography via ENBD tube revealed that there was no more leakage of the contrast media from the CBD. We performed cholecystectomy, removal of the CBD stones after exploration of the CBD, and T tube insertion. The perforated site of the CBD was closed and there was no more fluid collection in the inferoposterior portion of the stomach. Medical treatment including endoscopic procedures was useful for healing of the perforated CBD.

Importance of Age and Other Risk Factors in NSAID-induced Gastropathy / 대한소화기학회지

BACKGROUND/AIMS: It is clinically important to analyze the risk factors of NSAID-induced gastropathy because there could be no symptoms. Age is the most important risk factor according to previous reports. The aim of this study was to find risk factors of NSAID-induced gastropathy and to confirm the association between NSAID-induced gastropathy and age. METHODS: We retrospectively assessed 300 patients who conducted an upper gastroscopy during the course of chronic NSAID treatment. RESULTS: Median age of patients group is 51.4 +/- 12.2 years. In multivariate analysis, age and ulcer history are two significant risk factors. Median age is 46.7 +/- 10.7 years for the patients with nonspecific gastroscopic finding, 53.0 +/- 12.5 for those with erosion, 57.6 +/- 10.0 for those with ulcer, and 63.2 +/- 8.9 for those with hemorrhage. The proportion of ulcer patients is as follows: 6% in the patients of under 40 years old, 14.9% in patients of the 40s, 20% in patients of the 50s, 30.9% in patients of the 60s, 33.3% in patients over 70 years. The proportion of nonspecific findings is 62.2% in patients of the 40s, 37.8% in patients of the 50s, and 29% in patients over 60 years. CONCLUSIONS: Age is the most important risk factor of the NSAID-induced gastrointestinal mucosal injury. A larger randomized prospective control study will be required in the future for more conclusive results.

Clinical Characteristics of Acute Toxic Liver Injury / 대한간학회지

BACKGROUND/AIMS: Recently, acute toxic liver injury has been reported to be the most common cause of acute hepatitis. The frequency and clinical manifestations of acute toxic liver injury was evaluated. METHODS: The medical records of 68 patients demonstrating clinically significant acute toxic liver injury were retrospectively reviewed. Patients with mild biochemical abnormalities were excluded. RESULTS: The annual percentage of toxic liver injury ranged from 50% to 90% among acute hepatitis groups. Among the causes, prescribed drugs (group D) accounted for 55%, herbs or plant products (group H) for 42% and both accounted for 3%. Antibiotics and anti-inflammatory drugs were the most common agents (78%) among group D. The mean age of the patients was 43 and 70% of patients were female. Of the population, common symptoms were jaundice, weakness, fatigue, and nausea. Initial ALT and AST levels were 847 +/- 879 and 664 +/- 625 IU/L, and initial total bilirubin was 7.5 +/- 8.1 mg/dL. Acute toxic liver injury occurred after a mean of 32 days after first exposure. Liver injury resolved within a mean of 32 days. Hepatocellular, mixed, and cholestatic type was 45.2%, 32.3%, 22.5%, respectively. CONCLUSIONS: Recently, acute toxic liver injury has been the most common cause of acute hepatitis in Korea. Prescribed drugs and herbs or plant products are equally important etiologic agents of toxic liver injury. However, etiologic difference may not affect clinical courses or outcomes. A nationwide investigation of the hepatotoxicity of drugs, herbs or other plant products is required.

The Recurrence Rate of Colon Polyp after Polypectomy and the Interval of Surveillance Colonoscopy: Predictors of Early Development of Advanced Polyp / 대한소화기학회지

BACKGROUND/AIMS: Surveillance of individuals with colon polyps is important for the prevention of colon cancer, and its interval is based on the clinical status. Our aims were to determine the recurrence rate of advanced polyp after polypectomy and estimate the adequate interval of surveillance colonoscopy as well as the risk factors of recurrence in Korea. METHODS: Ninety-seven patients who underwent follow-up colonoscopy after initial colonoscopic polypectomy were retrospectively studied. All polyps were endoscopically removed with electrocautery. RESUTLS: Mean number of initial polyps were 2.2 and advanced polyps were observed in 40% of the patients. The cumulative recurrence rate of colon polyp was 13.8% within 1 year, and 60% within 3 years, while that of advanced polyps was 2.5% and 31% within 1 and 3 years, respectively. The significant difference was noted according to the initial polyp number in both overall and advanced polyp recurrence rate. The age at the diagnosis of colon polyps was a significant factor only in overall polyp recurrence rate. Patients who initially had one polyp showed 15% of advanced polyp recurrence within 3 years. CONCLUSIONS: Recurrence of advanced polyp is very rare within one year after polypectomy. Patients with single polyp have low risk and thus, their surveillance may be delayed beyond the standard 3 years. When surveillance colonoscopy is to be performed for the patients with 2 or more polyps, initial polyp number and age should be considered.

Value of Peracetic Acid (SCOTELIN(R)) for Endoscope Disinfection / 대한소화기내시경학회지

BACKGROUND/AIMS: Two percent glutaradehyde has been the reference disinfectant for high-level disinfection, but often requires long period of exposure up to 45 minutes. The aims of this study were to evaluate the effectiveness of a new endoscope disinfectant that uses 0.2% peracetic acid, and to compare the culture-positive rate in each different endoscopes and washers used. MEHTODS: Three endoscopes and two washers that differed in purchase year were used. They were cleansed manually and disinfected with peracetic acid for 10 minutes. A total of 86 gastroduodenal endoscopic sessions were included in the study. RESULTS: Overall culture-positive rate was 37.2%, majority of which came from washings of biopsy channel. There was a significant difference in culture-positive rate according to the machine used. Culture positive rate was 11.4% in recently purchased endoscope and washer used. Of the 28 Helicobactor pylori positive cases, there was one Helicobactor pylori DNA PCR positive case, but no Helicobactor pylori was found. CONCLUSIONS: When new endoscope and washer is used, peracetic acid is effective as a disinfectant. Significant difference in culture rate according to the different machine used might come from the aging effect and difference of cleansing power of the washer.