Effects of probiotics or broccoli supplementation on Helicobacter pylori eradication with standard clarithromycin-based triple therapy

Background/Aims@#The eradication failure rate of standard triple therapy (proton pump inhibitor, clarithromycin, and amoxicillin) for Helicobacter pylori infection has increased owing to antibiotic resistance in Korea. We assessed whether Saccharomyces boulardii probiotic or broccoli sprout extract sulforaphane supplementation could increase the H. pylori eradication rate and/or reduce antibiotic-associated adverse events. @*Methods@#A total of 217 patients with H. pylori-positive chronic gastritis or peptic ulcer disease were recruited. Clarithromycin resistance was assessed in all patients by testing for A2142G and A2143G point mutations in H. pylori 23S rRNA using a dual-priming polymerase chain reaction (PCR) oligonucleotide. Thirty-four patients (17.3%) were clarithromycin-resistant and were excluded from the study. Finally, 183 patients with infections not resistant to clarithromycin were randomly assigned to triple therapy only (group A, n = 61), triple therapy plus probiotics (group B, n = 61), or triple therapy plus sulforaphane (group C, n = 61) groups. CYP2C19 polymorphisms were examined at position G681A of exon 5 and G636A of exon 4 by PCR with restriction fragment length polymorphism (PCR-RFLP) analysis. H. pylori eradication was assessed by 13C-urea breath test 4 weeks after treatment completion. @*Results@#The eradication rates were similar among the groups both in the intention- to-treat (A = 85.2%, B = 89.6%, and C = 81.6%) and per-protocol (A = 89.2%, B = 86.8%, and C = 96.3%) analyses. The frequencies of overall adverse events in the groups also did not differ (A vs. B: p = 0.574; A vs. C: p = 1.000). @*Conclusions@#Probiotic or sulforaphane with triple therapy for H. pylori infection neither increased the eradication rate nor reduced the occurrence of adverse events.

Clarithromycin resistance and female gender affect Helicobacter pylori eradication failure in chronic gastritis

BACKGROUND/AIMS@#The eradication rate of the first-line triple therapy (a proton pump inhibitor, clarithromycin, and amoxicillin) for Helicobacter pylori infection has gradually decreased in Korea. We evaluated whether clinical parameters, clarithromycin resistance, and CYP2C19 genotype can affect the eradication failure.@*METHODS@#A total of 203 patients with H. pylori-positive chronic gastritis were consecutively enrolled. They received clarithromycin-based triple therapy for 7 days. A clarithromycin resistance test was performed by detection of A2142G and A2143G point mutations in H. pylori 23S rRNA. The CYP2C19 genotype was examined for polymorphism G681A of exon 5 and G636A of exon 4 by polymerase chain reaction with restriction fragment length polymorphism. Eradication was assessed by a ¹³C-urea breath test 4 weeks after treatment.@*RESULTS@#Of 203 patients, 190 completed the study. The eradication rate was 64.0% according to intention-to-treat analysis and 68.4% by per-protocol analysis. CYP2C19 genotypes were identified as follows: 75 poor metabolizers, 75 intermediate metabolizers, and 40 rapid metabolizers. Nonetheless, this polymorphism was not significantly associated with eradication failure (p = 0.682). Clarithromycin resistance was detected in 33/190 patients (17.4%), and their eradication rate was zero. Clarithromycin resistance (odds ratio [OR], 19.13; 95% confidence interval [CI], 9.35 to 35.09) and female gender (OR, 1.73; 95% CI, 1.15 to 4.25) were significantly associated with eradication failure. The other clinical parameters such as age, cigarette smoking, alcohol intake, the body mass index, hypertension, and diabetes were not significantly associated with eradication.@*CONCLUSIONS@#Clarithromycin resistance and female gender are factors affecting H. pylori eradication failure in patients with chronic gastritis.

Congenital Jejunal Diverticular Bleeding in a Young Adult

Diverticular bleeding of the small bowel is rare and occurs primarily in adults aged more than 60 years. In younger adults, Meckel's diverticulum, a true diverticulum that congenitally occurs in the distal ileum, is the most common cause of diverticular bleeding of the small bowel. Unlike Meckel's diverticula, other kinds of small bowel diverticula are not congenital and their incidence is related to age. Furthermore, congenital true diverticular bleeding of the jejunum in adults is very rare. We report the case of a 24-year-old man with subepithelial tumor-like lesion accompanied with obscure overt gastrointestinal bleeding. This lesion was initially suspected to be a subepithelial tumor based on radiologic tests and capsule endoscopy. He was finally diagnosed with a congenital true diverticulum in the jejunum with the appearance of a Meckel's diverticulum after surgical resection.

Efficacy of Lactose-free Milk in Korean Adults with Lactose Intolerance / 대한소화기학회지

BACKGROUND/AIMS: Lactose-free milk (LFM) is available for nutrient supply for those with lactose intolerance (LI). However, there are no consistent results of the efficacy of LFM in LI subjects. We aimed to examine the changes of gastrointestinal (GI) symptoms and hydrogen breath test (HBT) values after ingestion of lactose contained milk (LCM) vs. LFM. METHODS: From May 2015 to September 2015, thirty-five healthy adults with history of LCM-induced GI symptoms were recruited at a tertiary hospital. For the diagnosis of LI, HBT with LCM 550 mL (lactose 25 g) was performed every 20 minutes for 3 hours. The test was defined as "positive" when H2 peak exceeded 20 ppm above baseline values (DeltaH2>20 ppm). When the subjects are diagnosed as LI, the second HBT using LFM 550 mL (lactose 0 g) was performed 7 days later. Subjects were asked to complete a questionnaire about the occurrence and severity of GI symptoms. RESULTS: Among a total of 35 subjects, 31 were diagnosed with LI at first visit, and their LCM-related symptoms were abdominal pain (98.6%), borborygmus (96.8%), diarrhea (90.3%), and flatus (87.1%). The DeltaH2 value in subjects taking LCM (103.7+/-66.3 ppm) significantly decreased to 6.3+/-4.9 ppm after ingesting LFM (p<0.0001). There were also significant reduction in total symptom scores and the severity of each symptom when LCM was changed to LFM (p<0.0001). CONCLUSIONS: This is the first report that LFM reduce LCM-related GI symptoms and H2 production in Korean adults. LFM can be an effective alternative for LCM in adults with LI.

Non-Helicobacter pylori, Non-nonsteroidal Anti-inflammatory Drug Peptic Ulcer Disease / 대한소화기학회지

Non-Helicobacter pylori, non-NSAID peptic ulcer disease (PUD), termed idiopathic PUD, is increasing in Korea. Diagnosis is based on exclusion of common causes such as H. pylori infection, infection with other pathogens, surreptitious ulcerogenic drugs, malignancy, and uncommon systemic diseases with upper gastrointestinal manifestations. The clinical course of idiopathic PUD is delayed ulcer healing, higher recurrence, higher re-bleeding after initial ulcer healing, and higher mortality than the other types of PUD. Genetic predisposition, older age, chronic mesenteric ischemia, cigarette smoking, concomitant systemic diseases, and psychological stress are considered risk factors for idiopathic PUD. Diagnosis of idiopathic PUD should systematically explore all possible causes. Management of this disease is to treat underlying disease followed by regular endoscopic surveillance to confirm ulcer healing. Continuous proton pump inhibitor therapy is an option for patients who respond poorly to the standard ulcer regimen.

Polymorphisms in PRKCDBP, a Transcriptional Target of TNF-alpha, Are Associated With Inflammatory Bowel Disease in Korean

BACKGROUND/AIMS: Emerging data indicate that polymorphic sequence variations in the tumor necrosis factor alpha (TNF-alpha) gene may affect its production, and be associated with the risk of inflammatory bowel disease (IBD). PRKCDBP is a putative tumor suppressor gene and a transcriptional target of TNF-alpha. The aim of this case-control study is to explore the possible association of single nucleotide polymorphisms (SNPs) in PRKCDBP with the development of IBD in Koreans. METHODS: Genotyping analysis of four SNPs of PRKCDBP [rs35301211 (G210A), rs11544766 (G237C), rs12294600 (C797T), and rs1051992 (T507C)] was performed on 170 ulcerative colitis (UC),131 Crohn's disease (CD) patients, and 100 unrelated healthy controls using polymerase chain reaction and restriction fragment length polymorphism. RESULTS: Heterozygous configuration of three SNPs (G210A, G237C, and C797T) was very rare in both patients and healthy controls. However, allele frequencies of the T507C SNP showed a significant difference between UC patients and controls (P=0.037). The CC genotype of the T507C SNP was identified in 46.6% (61 of 131) of CD and 49.4% (84 of 170) of UC patients, but only in 33.0% (33 of 100) of healthy controls. Furthermore, CC homozygosity was more prevalent than TC heterozygosity in both CD and UC patients versus controls (P=0.016; gender-adjusted odds ratio [aOR], 2.16; 95% confidence interval [CI], 1.16-4.04 and P=0.009; aOR, 2.09; 95% CI, 1.193.64; respectively) CONCLUSIONS: Our results suggest that the T507C SNP in PRKCDBP, a TNF-alpha-inducible gene, might be associated with susceptibility to IBD (particularly UC) development in Koreans.

A Case of Aortoesophageal Fistula due to Esophageal Cancer Treated with Endovascular Stent Grafting / 대한내과학회지

Hemorrhage into the esophagus due to aortoesophageal communication is very rare but life-threatening with high morbidity and mortality. Because of this, most cases of aortoesophageal fistula are confirmed by autopsy. However, we report herein a case of a 62-year-old male with an aortoesophageal fistula who was successfully treated with endovascular stent-grafting. The patient had undergone esophageal stent insertion due to esophageal cancer and experienced hematemesis and hemodynamic shock due to an aortoesophageal fistula. Emergency endoscopy was unable to identify the source of the hemorrhage due to massive bleeding. Computed tomography of the chest revealed a focal pseudoaneurysm at the descending aorta and diffuse thinning of the esophageal wall, which were treated with endovascular stent-grafting. Although aortoesophageal fistulas are usually fatal, implantation of a covered stent into the esophagus may help prevent massive bleeding, providing valuable time to treat the patient.

A Case of an Esophageal Foreign Body with Iatrogenic Esophageal Perforation Caused by the Gag Reflex / 대한내과학회지

Esophageal foreign bodies are a common clinical problem; they can be removed via endoscopic intervention. However, sharp foreign bodies, such as fish bones, stuck in a physiological or pathological stenosis of the esophagus can sometimes lead to esophageal perforation. This can even lead to fatal complications, such as empyema, mediastinitis, esophago-tracheal fistula, and peritonitis. Consequently, during an endoscopic procedure, special precautions and protective devices are required. Here, we report the case of a 56-year-old woman who presented with an esophageal impacted fish bone with iatrogenic esophageal perforation caused by the gag reflex during endoscopic removal. She was treated successfully with surgery and antibiotics. The case highlights the need for sufficient sedation of the patient and attention by clinicians to achieve successful treatment without complications.

A Case of Primary Gastric Amyloidosis with Fulminant Heart Failure / 대한소화기학회지

A 53-year-old woman was admitted with epigastric discomfort and weakness. Laboratory examination at admission showed mild anemia and proteinuria. Esophagogastroduodenoscopy revealed marked mucosal atrophy, diffuse nodularity and granular appearance with mucosal friability. Biopsy was performed on the antrum and body of the stomach. On the next day, the patient began to complain of severe dyspnea, and hypoxia was present on pulse oximetry. Therefore, emergency echocardiography was conducted and it showed restrictive cardiomyopathy along with thrombus in the left atrium. With time, heart failure was aggravated despite intensive management. The result of gastric biopsy revealed amyloid deposits which stained positively with Congo red. On immunohistochemistry study, kappa and lambda chain were present. In addition, kappa chain was significantly elevated in urine and serum on electrophoresis. Although the patient was finally diagnosed as having primary gastric amyloidosis with restrictive cardiomyopathy, her general condition rapidly deteriorated and died at 12th hospital day. When obscure gastric lesion is encountered, performing gastric biopsy is strongly recommended since it be primary gastric amyloidosis. Herein, we present an unusual case of primary gastric amyloidosis.

The Effects of Broccoli Sprout Extract Containing Sulforaphane on Lipid Peroxidation and Helicobacter pylori Infection in the Gastric Mucosa

BACKGROUND/AIMS: The aims of this study were to investigate whether a broccoli sprout extract containing sulforaphane (BSES) inhibited the Helicobacter pylori infection density and exerted an antioxidative effect on gastric mucosal damage. METHODS: The enrolled subjects were randomized in a double-blinded manner into three groups. Finally, 33 H. pylori (+) BSES treatment subjects (group A), 28 H. pylori (+) placebo subjects (group B), and 28 H. pylori (-) BSES treatment subjects (group C) were studied. H. pylori infection density was indirectly quantified by a 13C-urea breath test (UBT), and the ammonia concentration in gastric juice aspirates was measured through gastroscopic examination. Malondialdehyde (MDA), an oxidative damage biomarker, and reduced glutathione (GSH), an antioxidant biomarker, were measured in the gastric mucosa by an enzyme-linked immunosorbent assay. RESULTS: BSES treatment did not significantly affect the UBT values or ammonia concentration in group A (p=0.634 and p=0.505, respectively). BSES treatment did significantly reduce mucosal MDA concentrations in group A (p<0.05) and group C (p<0.001), whereas the gastric mucosal GSH concentrations did not differ before and after treatment in any of the groups. CONCLUSIONS: BSES did not inhibit the H. pylori infection density. However, BSES prevented lipid peroxidation in the gastric mucosa and may play a cytoprotective role in H. pylori-induced gastritis.

A Case of Simultaneous Primary Gastric and Duodenal Mucosa-Associated Lymphoid Tissue Lymphoma after Therapeutic Endoscopy / 대한내과학회지

Primary gastrointestinal lymphoma is the most common type of extranodal non-Hodgkin's lymphoma. Most cases are defined histologically as mucosa-associated lymphoid tissue (MALT) lymphoma, while low-grade MALT lymphoma affecting the stomach and duodenum simultaneously is rare. In this case report, we describe the case of a 55-year-old female who presented to the gastroenterology clinic at our hospital for management of gastric adenoma and duodenal polyp by endoscopic mucosal resection and polypectomy. The pathology report noted MALT lymphoma with submucosal tubulovillous adenoma and hyperplastic polyps in the stomach and duodenum. She underwent eradication of Helicobacter pylori using proton pump inhibitor-based triple therapy.

Antiplatelet Agent-Related Peptic Ulcer Disease / 대한내과학회지

Antiplatelet therapies have been widely used to prevent cardiovascular diseases. However, antiplatelet agents cause gastrointestinal (GI) damage and are associated with a greater risk of gastroduodenal ulcers and life-threatening ulcer complications. The first step to reduce the GI risk of antiplatelet therapy is to assess whether the patient requires continuous antiplatelet therapy. The second step is to eliminate risk factors that may place the patient at greater GI risk such as Helicobacter pylori infection, NSAID use, steroid ingestion, and smoking. Continuous aspirin therapy plus a powerful proton pump inhibitor (PPI) is the choice of treatment for antiplatelet-related peptic ulcers. The risk of cardiovascular complications and risk of gastric complication using antiplatelet agents should be evaluated individually.

Successful Eradication of Helicobacter pylori Using Modified Quadruple Therapy in Patient with Long-lasting H. pylori-induced Active Gastritis

Helicobacter pylori is a well known major causative agent of chronic gastritis. In general, the inflammation induced by this organism is a chronic active gastritis, which develops into atrophic gastritis. It is well established that atrophic gastritis is one of the major risk factors of intestinal gastric cancer. Thus, severe long-lasting gastritis induced by H. pylori infection is considered for treatment to prevent gastric cancer. We experienced a case of dramatic eradication of H. pylori using a fifth-line salvage therapy in a patient with H. pylori-induced active gastritis during four years of follow-up.

Prediction of Helicobacter pylori Infection Status via Close Observation of Gastric Mucosal Pattern by Standard Endoscopy

BACKGROUND/AIMS: Common endoscopic findings in stomachs with Helicobacter pylori infections include antral nodularity, thickened gastric folds, and visible submucosal vessels. These findings are suggestive but not diagnostic of H. pylori infection. Magnifying endoscopy can reveal more precisely the abnormal mucosal patterns in an H. pylori-infected stomach; however, it requires more training, expertise, and time. We aimed to establish a new classification for predicting H. pylori-infected stomachs by non-magnifying standard endoscopy alone. MATERIALS AND METHODS: A total of 617 participants who underwent gastroscopy were prospectively enrolled from August 2011 to January 2012. We performed a careful close examination of the corpus at the greater curvature maintaining a distance < or =10 mm between the endoscope tip and the mucosal surface. We classified gastric mucosal patterns into four categories: normal regular arrangement of collecting venules (numerous minute red dots), mosaic-like appearance (type A; swollen areae gastricae or snakeskin appearance), diffuse homogenous redness (type B), and mixed pattern (type C; irregular redness with groove) to predict H. pylori infection status. RESULTS: The frequencies of H. pylori infection in patients with a normal regular arrangement of collecting venules pattern and types A, B, and C patterns were 9.4%, 87.7%, 98.1%, and 90.9%, respectively. The sensitivity, specificity, and positive and negative predictive values of all abnormal patterns for prediction of H. pylori infection were 93.3%, 89.1%, 92.3%, and 90.6%, respectively. The overall accuracy was 91.6%. CONCLUSIONS: Careful close observation of the gastric mucosal pattern with standard endoscopy can predict H. pylori infection status.

A Case of Endoscopic Full-Thickness Resection in a Patient with Gastric High-Grade Dysplasia Unsuitable for Endoscopic Submucosal Dissection

Gastric high-grade dysplasia is an important premalignant lesion in gastric epithelial cells and has a high possibility of transforming to adenocarcinoma. Therefore, biopsy-proven high-grade dysplasia should be treated with en bloc resection methods such as endoscopic mucosal resection or endoscopic submucosal dissection (ESD). We report the case of a 63-year-old male patient, diagnosed with gastric high-grade dysplasia at the angle and lesser curvature side of the lower body. The patient was initially treated with ESD, although histopathology subsequently showed horizontal margin involvement. Since the lesion was diffusely edematous and margins were uncertain because of the previous ESD treatment, we chose to treat the patient with laparoscopy-assisted endoscopic full-thickness resection (EFTR). EFTR is a recently developed procedure, which uses both endoscopic and laparoscopic techniques to resect the full-thickness of the tissue. The final pathologic report revealed high-grade dysplasia and a focal intramucosal carcinoma of 0.8x0.7 cm. We conclude that EFTR can be an effective alternative treatment in gastric high-grade dysplasia unsuitable for ESD.

Clinical Outcome of Treatment with Infliximab in Crohn's Disease: A Single-Center Experience / 대한소화기학회지

BACKGROUND/AIMS: Our aim was to assess the long-term data regarding efficacy and safety of infliximab (IFX) treatment for refractory Crohn's disease (CD) patients in our tertiary teaching hospital. METHODS: We have retrospectively analyzed the medical records of 89 CD patients who underwent IFX treatment between March 2003 and February 2011 at Kyung Hee University Hospital (Seoul, Korea). The primary outcome measurements were the rates of initial clinical response (CR) at 10 weeks after the 1st IFX infusion and sustained CR at the end of the follow-up. Overall adverse events related to IFX treatment were also evaluated. RESULTS: The mean (SD) follow-up period of eligible 80 patients was 33.7 (21.9) months. A total of 77 patients (96%) showed initial clinical response, but 8 patients showed loss of response to IFX during the follow-up. Finally, 59 patients (59/77, 76.6%) showed sustained CR at the end of the study. Logistic regression analyses showed that an initial CR at 10 weeks was the independent predictor associated with sustained CR (OR 22.286, 95% CI 2.742-132.717, p=0.001). Overall adverse events reported in 18 patients (18/80, 23.3%), including 3 serious infection (pulmonary tuberculosis and herpes zoster). CONCLUSIONS: Treatment with IFX was efficacious and relatively safe for refractory CD patients in Korea. An initial CR at 10 weeks was significantly associated with sustained CR.

Septic Pylephlebitis as a Rare Complication of Crohn's Disease / 대한소화기학회지

Thrombophlebitis of the portal venous system (PVS) with superimposed bacterial infection (septic pylephlebitis) is an extremely rare complication of Crohn's disease (CD), and therefore diagnosis of septic pylephlebitis is difficult without high clinical suspicion. A 16-year old male patient who was diagnosed with CD 3 months earlier was admitted with recurrent fever and abdominal pain. CD activity had been well controlled with conventional medical treatment during a follow-up period. Abdominal contrast-enhanced computed tomography showed massive thrombosis in the PVS without evidence of intra-abdominal infection, and blood cultures were positive for Streptococcus viridians. There was no evidence of deep vein thrombosis or pulmonary thromboembolism, and all laboratory tests for thrombophilia were normal. Based on these findings, the patient was diagnosed with septic pylephlebitis complicated with CD, and was successfully treated with intravenous antibiotic therapy combined with anticoagulation. This case suggests that early comprehensive evaluation is crucial for immediate diagnosis and proper treatment of septic pylephlebitis in patients with CD who present with fever and abdominal pain of unknown origin, even with stable disease activity and absence of other intra-abdominal infections.

A Case of Aspiration Pneumonia with Acute Respiratory Distress Syndrome Following Aspiration of Polyethylene Glycol Solution Treated by Bronchoalveolar Lavage / 대한내과학회지

Colonoscopy requires adequate cleaning of the entire colon. Polyethylene glycol (PEG) is a popular laxative regimen because of the ease of applicability and optimal bowel preparation results. Although the safety and efficacy of this solution is well established, serious complications from the bowel PEG-cleansing procedure have been reported. Here, we report a case of a 79-year-old male who developed aspiration pneumonia with acute respiratory distress syndrome after administration of PEG by mouth before a scheduled colonoscopy. He was treated successfully with bronchoalveolar lavage and corticosteroids.

A Case of Early Gastric Cancer with Solitary Metastasis to the Pleura

The incidence of early gastric cancer (EGC) has increased to >50% in Korea owing to a higher detection rate caused by rapid advances in diagnostic instrumentation. EGC with distant metastasis has been rarely reported. Here, we report the case of a 76-year-old woman in whom general EGC was initially diagnosed by endoscopy and endoscopic ultrasonography. She subsequently underwent endoscopic submucosal dissection (ESD). Histological examination of the ESD specimen revealed that neoplastic cells were located predominantly in the submucosal layer and submucosal lymphatic channels. Metastatic cancer cells were also found in the pleural effusion. After conducting all analyses, including immunohistochemical staining, we concluded that the patient had primary EGC with pleural metastasis.

Upper Gastrointestinal Hemorrhage from Esophageal Ulcer Caused by Coinfection of Herpes Simplex Virus and Cytomegalovirus in Immunocompromised Patient

Coinfection with herpes simplex virus and cytomegalovirus is a very rare cause of esophageal ulcer and upper gastrointestinal hemorrhage. A 26 year-old male kidney transplant recipient was referred with a complaint of melena. Upper gastrointestinal endoscopy showed a huge esophageal ulcer in the anastomosis site of the esophagogastrostomy. The ulcer occupied about two-thirds of the circumference of the esophageal lumen and an exposed vessel in the ulcer base was noted. Pathologic findings with immunohistochemical stain showed co-infection of herpes simplex virus and cytomegalovirus. He was treated successfully with endoscopic hemostasis and antiviral therapy. We report a case of upper gastrointestinal hemorrhage from esophageal ulcer caused by coinfection of herpes simplex virus and cytomegalovirus.