Quality Metrics of a Fecal Immunochemical Test-Based Colorectal Cancer Screening Program in Korea

BACKGROUND/AIMS: Knowledge regarding the quality metrics of fecal immunochemical test (FIT)-based colorectal cancer screening programs is limited. The aim of this study was to investigate the performance and quality metrics of a FIT-based screening program. METHODS: In our screening program, asymptomatic subjects aged ≥50 years underwent an annual FIT, and subjects with positive FIT results underwent a subsequent colonoscopy. The performance of the FIT and colonoscopy was analyzed in individuals with a positive FIT who completed the program between 2009 and 2015 at a university hospital. RESULTS: Among the 51,439 screened participants, 75.1% completed the FIT. The positive rate was 1.1%, and the colonoscopy completion rate in these patients was 68.6%. The positive predictive values of cancer and advanced neoplasia were 5.5% and 19.1%, respectively. The adenoma detection rate in the patients who underwent colonoscopy after a positive FIT was 48.2% (60.0% for men and 33.6% for women). The group with the highest tertile quantitative FIT level showed a significantly higher detection rate of advanced neoplasia than the group with the lowest tertile (odds ratio, 2.6; 95% confidence interval, 1.4 to 5.1; p < 0.001). CONCLUSIONS: The quality metrics used in the United States and Europe may be directly introduced to other countries, including Korea. However, the optimal quality metrics should be established in each country.

High C-reactive protein level is associated with high-risk adenoma

BACKGROUND/AIMS: There is substantial evidence supporting a role of inflammation in the pathogenesis of colorectal cancer; however, little is known about the association between serum C-reactive protein (CRP) and the risk of colorectal adenoma. This study was conducted to investigate the association between serum CRP and colorectal adenoma risk. METHODS: A retrospective cross-sectional study was performed on first-time screening colonoscopies in asymptomatic subjects who also had their serum CRP level measured during a routine health check-up between September 2006 and September 2009 in Korea. Serum CRP level was compared between high-risk and low-risk adenoma groups and independent predictors of high-risk adenoma were analyzed using multivariate regression analysis. RESULTS: Among the 3,309 eligible patients, the high-risk adenoma group had higher serum CRP levels than the low-risk adenoma group (P=0.000). In addition, patients with a high-risk adenoma were more frequently included in the high CRP group than in the low CRP group (8.6% vs. 4.0%, P<0.001). The prevalence of high-risk adenoma was 3.5 times higher in the highest quartile of CRP level (P=0.000) compared with that in the lowest quartile. In logistic regression analysis, a higher quartile CRP level was found to be an independent risk factor for high-risk adenoma (odds ratio, 1.8; 95% confidence interval, 1.3–2.5; P=0.000). CONCLUSIONS: High CRP level is associated with high-risk adenoma in both men and women. Our data may support the association between chronic inflammation and colorectal neoplasia, which warrants further investigation.

Determining the optimal surveillance interval after a colonoscopic polypectomy for the Korean population?

BACKGROUND/AIMS: Western surveillance strategies cannot be directly adapted to the Korean population. The aim of this study was to estimate the risk of metachronous neoplasia and the optimal surveillance interval in the Korean population. METHODS: Clinical and pathological data from index colonoscopy performed between June 2006 and July 2008 and who had surveillance colonoscopies up to May 2015 were compared between low- and high-risk adenoma (LRA and HRA) groups. The 3- and 5-year cumulative risk of metachronous colorectal neoplasia in both groups were compared. RESULTS: Among 895 eligible patients, surveillance colonoscopy was performed in 399 (44.6%). Most (83.3%) patients with LRA had a surveillance colonoscopy within 5 years and 70.2% of patients with HRA had a surveillance colonoscopy within 3 years. The cumulative risk of metachronous advanced adenoma was 3.2% within 5 years in the LRA group and only 1.7% within 3 years in the HRA group. The risk of metachronous neoplasia was similar between the surveillance interval of <5 and ≥5 years in the LRA group; however, it was slightly higher at surveillance interval of ≥3 than <3 years in the HRA group (9.4% vs. 2.4%). In multivariate analysis, age and the ≥3-year surveillance interval were significant independent risk factors for metachronous advanced adenoma (P=0.024 and P=0.030, respectively). CONCLUSIONS: Patients had a surveillance colonoscopy before the recommended guidelines despite a low risk of metachronous neoplasia. However, the risk of metachronous advanced adenoma was increased in elderly patients and those with a ≥3-year surveillance interval.

Small Bowel Perforation Caused by Press-through Package / 대한소화기학회지

With an increased use of the press-through package (PTP) tablet, there has also been an increase in mis-swallowing cases, especially in elderly patients. We report a rare case of PTP-induced small bowel perforation and fistula formation with adjacent small bowel in a healthy elderly patient, who experienced persistent abdominal pain of unknown cause. A 62-year-old healthy man was admitted to our hospital with left abdominal pain that started one month ago. Neither abdominal tenderness nor rebound tenderness was present on physical examination. His vital signs and all other test results were within normal limits. However, a 2.5 cm curved radiopaque material within his thickened small intestine was incidentally detected on an abdominal computed tomography. He underwent laparoscopic small bowel resection, which revealed foreign body in the distal small intestine. Edema, perforation, and adhesions with the surrounding tissues were also noticed in the distal small intestine. Foreign body was turned out to be PTP, and this was considered to be responsible for the small bowel perforation and fistula formation. Precautions regarding PTP usage are necessary to prevent inadvertent PTP ingestion and its related complications, such as perforation, especially in the elderly population.

Cerebral venous thrombosis in a patient with Crohn's disease

Patients with inflammatory bowel disease (IBD) have an elevated risk of venous thromboembolism compared with the general population. The most common sites of venous thromboembolism in IBD patients are the deep veins of the legs, the pulmonary system, and portal and mesenteric veins. However, cerebral venous thrombosis is rarely associated with IBD. This report describes a case of cerebral venous thrombosis in a patient with Crohn's disease. A 17-year-old girl, diagnosed 4 years earlier with Crohn's disease, presented with headache and vomiting. Magnetic resonance imaging of the brain with venography showed venous thrombosis in the cortical veins, superior sagittal sinus, right transverse sinus, and right internal jugular vein. The patient immediately started anticoagulation therapy with intravenous heparin infusion followed by daily oral rivaroxaban 10 mg. Follow-up imaging after 2 weeks showed resolution of the thrombosis, with recanalization of the cortical veins, superior sagittal sinus, right transverse sinus, and right internal jugular vein. She continued rivaroxaban therapy for 6 months, and remained well, without neurologic sequelae. A high level of concern for cerebral venous thrombosis may be important when treating active IBD patients, because anticoagulation treatment can prevent fatal complications.

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.

Life-threatening Duodenal Ulcer Bleeding from a Ruptured Gastroduodenal Artery Aneurysm in a Patient with Neurofibromatosis Type 1 / 대한소화기학회지

Vasculopathy is rarely reported in neurofibromatosis type 1, but when it occurs it primarily involves the aorta and its main branches. Among vasculopathies, aneurysmal dilatation is the most common form. Although several case reports concerning aneurysms or pseudoaneurysms of visceral arteries in neurofibromatosis type 1 patients have been reported, there are no reports describing gastroduodenal artery aneurysms associated with neurofibromatosis type 1. We experienced a case of life-threatening duodenal ulcer bleeding from a ruptured gastroduodenal artery aneurysm associated with neurofibromatosis type 1. We treated our patient by transarterial embolization after initial endoscopic hemostasis. To our knowledge, this is the first reported case of its type. High levels of suspicion and prompt diagnosis are required to select appropriate treatment options for patients with neurofibromatosis type 1 experiencing upper gastrointestinal bleeding. Embolization of the involved arteries should be considered an essential treatment over endoscopic hemostasis alone to achieve complete hemostasis and to prevent rebleeding.

A Case of Cavernous Lymphangioma of the Small Bowel Mesentery / 대한소화기학회지

Lymphangioma is a benign vascular lesion with characteristics of subepithelial tumor which can proliferate in the lymphatic system. Lymphangioma of the small-bowel mesentery is rare, having been reported in less than 2% of all lymphangiomas. Lymphangioma does not require any specific treatment because it is absolutely a benign tumor. However, surgical exploration is rarely required for cases with disease-related symptoms or complications, or for those misdiagnosed as a malignant lesion. We recently experienced a case of mesenteric cavernous lymphangomas in a 53-year-old female who was misdiagnosed as having a liposarcoma. The final diagnosis was confirmed by a pathologic examination of the specimen that was obtained via laparoscopic exploration. Herein, we report a very rare case of mesenteric cavernous lymphangioma along with a brief review of relevant literature.

Anaphylactic Shock Caused by Ingestion of Polyethylene Glycol

Colonoscopy is the current standard method for evaluation of the colon. The diagnostic accuracy and therapeutic safety of colonoscopy depend on the quality of colonic cleansing and preparation. Generally, all these preparations have been demonstrated to be safe for use in healthy individuals without significant comorbid conditions. Based on safety and efficacy concerns, polyethylene glycol (PEG) is most commonly utilized as a bowel preparation solution for colonoscopy. Adverse events in patients receiving PEG are mostly clinically non-significant. However, fatal adverse events rarely have been shown to occur in the few individuals who experience vomiting or aspiration. Anaphylactic shock associated with ingestion of PEG electrolyte solution is an extremely rare fatal complication, and reported mainly in Western countries. Here, we report the first case of anaphylactic shock following the ingestion of PEG solution in Korea.

Fatal Small Bowel Bleeding with very Low Risk Gastrointestinal Stromal Tumor in Jejunum / 이화의대지

Gastrointestinal stromal tumor (GIST) is the most common mesenchymal neoplasm of the gastrointestinal (GI) tract. These tumors are frequently small, asymptomatic and found incidentally. GI bleeding is a common complication of these tumors, but small sized, very low risk GIST rarely complicated with fatal bleeding. In this report, we describe a 42-year-old woman with a jejunal GIST accompanied by severe GI bleeding. She presented with melena and an angiographic embolization was performed for a jejunal mass with bleeding. However, rebleeding was suspected after an angiographic embolization and an emergent segmental resection for the bleeding mass was performed. She was finally diagnosed as a 1.8 cm sized very low risk GIST in jejunum. In conclusion, physician should consider that even very low risk GIST can be the cause of GI bleeding when there is severe bleeding.

A Patient with Duodenal Mucinous Adenocarcinoma Presenting as a Laterally Spreading Tumor

Primary duodenal carcinoma is rare. Duodenal mucinous adenocarcinoma (DMA) is even rarer, and its associated manifestations and typical endoscopic or imaging findings are not well characterized. Herein, we report a case of primary DMA in an asymptomatic 58-year-old man who visited our hospital for a regular health screening. Upper endoscopy revealed an approximately 4-cm lesion in the second portion of the duodenum, but the mass was not visualized on computed tomography. Biopsies revealed a tubular adenoma that was subsequently resected. Frozen biopsies demonstrated DMA with a background of low-grade tubular adenoma for which we performed Roux-en-Y duodenojejunostomy and jejunojejunostomy. To our knowledge, this is the first report of a patient with DMA in Korea.

Association of Gallbladder Polyp with the Risk of Colorectal Adenoma

BACKGROUND/AIMS: Gallbladder polyps and colorectal adenomas share many common risk factors; however, their association has never been studied. The aim of this study was to investigate this association in asymptomatic healthy subjects. METHODS: Consecutive asymptomatic subjects who underwent both screening colonoscopy and abdominal ultrasonography at Kyung Hee University Hospital in Gang Dong between July 2010 and April 2011 were prospectively enrolled. The prevalence of colorectal adenoma was compared between subjects with or without gallbladder polyps. Furthermore, a logistic regression analysis was performed to determine the independent risk factors for colorectal adenoma in these subjects. RESULTS: Of the 581 participants, 55 presented with gallbladder polyps and 526 did not have gallbladder polyps. Participants with gallbladder polyps showed a trend toward a higher prevalence of colorectal adenoma than those without gallbladder polyps (52.7% vs. 39.2%, P=0.051). Although the result was not statistically significant, gallbladder polyps were found to be a possible risk factor for colorectal adenoma (odds ratio=1.796, 95% confidence interval=0.986-3.269, P=0.055), even after adjusting for potential confounding factors. There was no difference observed in colorectal adenoma characteristics between the two groups. CONCLUSIONS: Our results suggest a possible association between gallbladder polyps and colorectal adenomas. Future studies with larger cohorts are warranted to further investigate this matter.

A Case of Toxic Hepatitis by Weight-Loss Herbal Supplement Containing Garcinia cambogia

We report a case of patient with acute toxic hepatitis induced by weight-loss herbal supplement. A patient took natural extract supplement containing Garcinia cambogia for only two days and visited Kyung Hee University Hospital at Gangdong complaining of abdominal discomfort and jaundice. Serum ceruloplasmin level was decreased and hepatic copper levels on liver biopsy specimen were increased. Although, those were mimicking Wilson's disease, pathological findings and clinical manifestations were consistent with drug-induced acute hepatitis. Genetic test was negative for Wilson's disease. After one month of hospitalization, the patient improved and was discharged home in good condition. She was followed up for four months and her symptoms and signs of hepatitis continued to improve steadily with normal liver function tests. Our case emphasizes the importance of taking a caution when taking herbal supplements for the purpose of weight loss. This case also demonstrates the importance of suspicion of medication-related adverse events, even though the duration of taking the materials seems to be too short to affect the patients.

Clinical Characteristics and Outcomes of Diverticulitis by Physician's Specialty

BACKGROUND/AIMS: Several factors affecting the severity and outcomes of diverticulitis have been reported, but there is little research on physician specialty related with this disease. Therefore, we evaluated the clinical characteristics and outcomes of diverticulitis depending on physician's specialty. METHODS: Medical records of 239 patients, who had been hospitalized with first-diagnosed acute colonic diverticulitis at Kyung Hee University Hospital in Gang Dong (Seoul, Korea) from June 2006 to December 2012, were retrospectively analyzed. The patients were classified according to whether they had been managed by gastroenterologists or not. Clinical characteristics and treatment outcomes were compared between two groups. RESULTS: Of these 239 patients, 38 (15.9%) patients were treated by a gastroenterologist and 201 (84.1%) patients by a non-gastroenterologist. Clinical characteristics such as age, gender, body mass index, comorbidity, medication, laboratory results, recurrence and complication were not significantly different between two groups. However, right-sided diverticulitis predominated in the non-gastroenterologist group (79% vs. 91%, P=0.028). From the sub-group analysis of uncomplicated diverticulitis, intravenous antibiotics was used for a shorter period of time by gastroenterologists than non-gastroenterologists (3.3+/-1.9 days vs. 4.4+/-2.8 days, P=0.032). Multivariate logistic regression analysis showed that the 3 day administration of intravenous antibiotics significantly depended on the physician's specialty (odds ratio 7.984, 95% confidence interval 1.990-32.043, P=0.003). CONCLUSIONS: The results suggest that the duration of intravenous antibiotics for treating uncomplicated colonic diverticulitis was shortened by gastroenterology specialists without increasing operation or recurrence.

A Case of Biliary Cast Developed in a Patient with Long-Standing Biliary Sludge

Development of biliary casts is very unusual, especially in patients who have not undergone liver transplantation. Variable causes of biliary cast formation in nonliver transplantation patients have been suggested. However, stasis of bile flow and/or gallbladder hypocontractility is known to eventually result in the promotion of biliary sludge and subsequent cast formation. Here we present one case of biliary cast syndrome, which developed in a nonliver transplant patient who had biliary sludge for a long period of time, providing evidence that long-standing biliary sludge may lead to cast formation.

Preoperative Carbohydrate Antigen 19-9 Levels Can Predict Stage and Survival Rate in Patients with Colorectal Cancer

BACKGROUND/AIMS: The purpose of this study was to determine whether preoperative carbohydrate antigen 19-9 (CA 19-9) levels can predict the stage of diseases or survival rate in patients with resectable colorectal cancer (CRC). METHODS: A total of 247 patients who underwent curative resections at Kyung Hee University Hospital at Gangdong between 2006 and 2011 were enrolled. We investigated the correlations of preoperative serum levels of CA19-9 with clinicopathological features of CRC. Receiver operative curve was constructed for evaluating the efficiency of the serum CA 19-9 levels in the stratifying stage of CRC. Survival analysis was performed with Kaplan-Meire method and log-rank test. Cox regression analysis was used for the multivariate analysis for survival. RESULTS: Abnormal level of serum CA 19-9 (>37 IU/mL) were associated with advanced T stage (P60 U/mL was an independent predictor of survival rate in the patients with TNM stage III CRC.

The Improvement of Nutritional Support with Percutaneous Endoscopic Gastrostomy

BACKGROUND/AIMS: Percutaneous endoscopic gastrostomy (PEG) is the most common method of enteral nutrition for patients who require long term artificial nutrition. PEG has been used as a method of nutritional support; however, improvement of nutritional support via PEG has not yet been reported. In this study, we analyzed the efficacy of nutritional support via PEG. METHODS: We conducted a retrospective analysis of 196 consecutive patients who underwent PEG at Kyung Hee University Hospital in Gang Dong from 2006 to 2012. We analyzed clinical characteristics, the method of nutritional support, and the proportion of intake to establish recommendations for nutritional requirements and the duration needed to reach the level of appropriate nutrition. RESULTS: A total of 196 patients included 130 men and 66 women, and their mean age (standard deviation) was 69.1+/-14.0 years. Compared with caloric and protein supplementation before PEG, 113 kcal (13.8% of baseline) and 4.8 g of protein (17.5% of baseline) could be additionally supplied with PEG (P=0.001, respectively). The number of patients who could take more than 90% of the recommended requirements of caloric and protein supplementation after PEG showed increased caloric and protein intake by 25.4% and 20.2%, respectively, in comparison with those before PEG (P=0.001 and P=0.001, respectively). The mean duration of catch-up for more than 90% of the recommended caloric and protein intake was approximately 11 days. Procedure related complications and early mortality were reported in 8.1% and 0% of patients, respectively. CONCLUSIONS: PEG is an effective and safe nutritional support method for patients who require long term artificial nutrition.

Predicting factors of present hepatitis C virus infection among patients positive for the hepatitis C virus antibody

BACKGROUND/AIMS: To identify the predicting factors of present hepatitis C virus (HCV) infection among patients with positivity for antibodies to HCV (anti-HCV). METHODS: We analyzed patients who showed positive enzyme immunoassay (EIA) results and performed an HCV RNA test as a confirmatory test at Kyung Hee University Hospital at Gangdong from June 2006 to July 2012. The features distinguishing the groups with positive and negative HCV RNA results were reviewed. RESULTS: In total, 490 patients were included. The results of the HCV RNA test were positive and negative in 228 and 262 patients, respectively. The index value of anti-HCV, mean age, platelet counts, total bilirubin, prothrombin time international normalized ratio, albumin and alanine transaminase (ALT) levels differed significantly between the two groups. On multivariable analysis, an index value of anti-HCV >10 [odds ratio (OR)=397.27, P40 IU/L (OR=3.64, P=0.001), and albumin <3.8 g/dL (OR=2.66, P=0.014) were related to present HCV infection. CONCLUSIONS: Although EIA is not a quantitative test, considering the anti-HCV titer with ALT and albumin levels may be helpful in predicting present of HCV infection.

Simultaneous Laparoscopic Cholecystectomy and Endovascular Abdominal Aortic Aneurysm Repair / 대한혈관외과학회지

Concomitant cholelithiasis and abdominal aortic aneurysm (AAA) is not uncommon. Cholecystectomy at the time of aneurysm repair was delayed in patients with asymptomatic cholelithiasis due to the possibility of the graft infection. If a patient is subjected to a high risk of aneurysmal rupture and symptomatic cholelithiasis, the combined cholecystectomy and aneurysm repair should be performed. With the advent of the minimally invasive surgery, minimal invasive approach is widely adopted in patients with cholelithiasis and AAA. We reported one patient who had symptomatic cholelithiasis and AAA, successfully treated with the laparoscopic cholecystectomy and endovascular AAA repair.

A Case of Early Adenocarcinoma at Esophagogastric Junction Treated with Cap-pitted Endoscopic Mucosal Resection / 이화의대지

Surgery is the primary treatment for adenocarcinoma originating from the esophagogastric junction. However, many physicians attempt various endoscopic treatments for the cases of early adenocarcinoma and high-grade dysplasia of esophagogastric junction in order to avoid the high risk of complications associated with surgical resection. Recently, there is an increasing tendency to use endoscopic mucosal resection for the management of early esophageal cancer due to low morbidity and mortality rates. We report here on a case of early adenocarcinoma at esophagogastric junction successfully treated with endoscopic mucosal resection.