Eradication Rate Using a First-line Triple Therapy for Helicobacter pylori Infection in Yeongdong, Gangwon Province, Korea

Background/Aims@#The eradication success rate of Helicobacter pylori (H. pylori) infection with a first-line standard triple therapy (STT) has been decreasing in Korea. However, treatment outcomes of H. pylori infection in Yeongdong, Gangwon Province have been scarcely reported. This study aimed to investigate the treatment outcomes of H. pylori infection in a single tertiary care hospital with regional characteristics. @*Materials and Methods@#From July 2018 to June 2019, a total of 592 patients who underwent STT consisting of a proton pump inhibitor, amoxicillin, and clarithromycin for 7 to 14 days as a first-line H. pylori eradication therapy were included. Demographic data and treatment outcomes were retrospectively reviewed using medical records. @*Results@#The median age of 592 patients was 58 years (range 23 to 86) and 329 patients (55.6%) were men. The indication for eradication therapy included chronic atrophic gastritis (57.9%), peptic ulcer disease (19.6%), and gastric neoplasm after endoscopic resection (5.9%). Most patients (92.2%) received a 7-day course of STT. Eradication rate of STT was 64.0% (379/592). Rescue therapy was performed in 146 patients, and the final eradication rate reached 85.6% (507/592). @*Conclusions@#Eradication rate of STT in Yeongdong area of Gangwon Province was unsatisfactory, warranting the consideration of a first-line eradication regimen other than STT.

An Esophageal Squamous Cell Carcinoma with Lymph Node Metastasis Presenting as a Small Subepithelial Tumor

A subepithelial tumor-like esophageal carcinoma is rare. We report a case of an esophageal squamous cell carcinoma with lymph node metastasis presenting as a small subepithelial tumor. A 68-year-old man presented to our hospital complaining of hoarseness since last three months. Endoscopic examination revealed a 1 cm hard and fixed subepithelial tumor with surface erosion in the lower esophagus. A biopsy specimen was obtained using conventional forceps, and histopathological evaluation revealed few atypical squamous epithelial cells. Subsequent EUS demonstrated a homogeneous hypoechoic lesion in the deep mucosal layer. A CT scan of the chest showed a 3 cm mass in the right upper paratracheal area. EUS-guided fine needle biopsy of the lesion led to the diagnosis of squamous cell carcinoma with lymph node metastasis.

Hyperbaric oxygen therapy for pyoderma gangrenosum associated with ulcerative colitis

Pyoderma gangrenosum (PG), an ulcerating skin condition, is rare in patients with ulcerative colitis (UC). We report a case of successful treatment of PG in a patient with UC using hyperbaric oxygen therapy (HBOT). The patient had UC that was in remission following treatment with mesalazine and azathioprine therapy. After visiting an orthopedic clinic, the patient opted for treatment with antibiotics and daily dressing of the ulcerative skin lesions, while azathioprine was discontinued. However, the lesions did not improve. Two months later, the patient visited a dermatologist who diagnosed the lesions as PG, and he was admitted to our unit. Surgical debridement and HBOT were performed by a plastic surgeon in the emergency department. After 3 months of HBOT and topical treatment, the patient's PG completely resolved. His UC was still in remission with mesalazine alone. HBOT may be an effective and safe alternative treatment for PG associated with UC, particularly in patients in whom anti-tumor necrosis factor agents are unnecessary.

A Case of Small Hepatocellular Carcinoma Who Showed Complete Response by Combined Therapy of Transarterial Chemoembolization and Stereotactic Body Radiotherapy

In hepatocellular carcinoma (HCC), surgical resection or local ablation therapy is limited because of severe liver dysfunction or tumor location. Transarterial chemoembolization (TACE) has beed used widely as palliative treatment. Stereotactic Body Radiotherapy (SBRT) is a more recent and effective treatment for early stage HCC. We report a case with small HCC with complete response by TACE combined with SBRT.

Mucosal Incision and Forceps Biopsy for Reliable Tissue Sampling of Gastric Subepithelial Tumors

BACKGROUND/AIMS: The diagnostic efficacy of current tissue sampling techniques for gastric subepithelial tumors (SETs) is limited. Better tissue sampling techniques are needed to improve pathological diagnosis. The aim of this study was to evaluate the safety and efficacy of a new technique, mucosal incision and forceps biopsy, for reliable tissue sampling of gastric SETs. METHODS: This study enrolled 12 consecutive patients who underwent mucosal incision and forceps biopsy of gastric SETs between November 2011 and September 2014 at Gangneung Asan Hospital. The medical records of patients were reviewed retrospectively. The safety and diagnostic yield of this method were evaluated. RESULTS: By performing mucosal incision and forceps biopsy, we were able to provide a definitive histological diagnosis for 11 out of 12 cases. The pathological diagnoses were leiomyoma (3/11), gastrointestinal stromal tumor (GIST; 2/11), lipoma (2/11), schwannoma (1/11), and ectopic pancreas (3/11). In cases of leiomyoma (n=3) and GIST (n=2), tissue samples were of sufficient size to allow immunohistochemical staining. In addition, the mitotic index was evaluated in two cases of GIST. There were no procedure-related complications. CONCLUSIONS: Mucosal incision and forceps biopsy can be used as one of several methods to obtain adequate tissue samples from gastric SETs.

Interrater Reliability among Endoscopists: Diagnosis of Laryngopharyngeal Reflux Based on the Reflux Finding Score Determined by Upper Endoscopy

BACKGROUND/AIMS: Laryngopharyngeal reflux (LPR) is an extraesophageal manifestation of gastroesophageal reflux disease. Endoscopic assessment of LPR is needed for convenient diagnosis and documentation of treatment efficacy. The aim of this study was to investigate the interrater reliability of LPR among endoscopists based on endoscopic laryngeal images. MATERIALS AND METHODS: Nineteen endoscopists participated in this study. Before the test, they completed an intensive education program by an otorhinolaryngologist on the reflux finding score (RFS), which is a validated laryngoscopic assessment of LPR. A total of 100 endoscopic laryngeal images were used for 3 tests of RFS. Cohen's and Fleiss' kappa coefficients were used to determine the degree of interrater agreement in the diagnosis of LPR. RESULTS: In the first test, the mean of Cohen's kappa coefficients for LPR diagnosis between the otorhinolaryngologist and each of the 19 endoscopists was 0.3. In the second test, after additional education, the mean kappa value was 0.32. Fleiss' kappa coefficients for diagnosis of LPR among the 19 endoscopists in the first and second tests were 0.30 and 0.26, respectively. CONCLUSIONS: A short-term education program for endoscopists did not result in an improvement of accuracy in the diagnosis of LPR. Further studies using advanced educational programs for endoscopists are required.

Removal of Anorectal Cancer by Endoscopic Submucosal Dissection / 대한내과학회지

Anorectal cancer is traditionally treated via abdominoperineal resection and/or chemoradiation. Currently, endoscopic submucosal dissection (ESD) is widely used to treat early gastrointestinal epithelial neoplasias. However, the use of ESD to treat lesions of the anal canal raises concerns that do not arise when treating lesions of the stomach and colorectum. Therefore, particular care is needed when treating lesions in the anal area. We recently treated a 75-year-old woman who was scheduled for surgical resection to treat anorectal cancer. The lesion was successfully removed using ESD. This is the first report of the use of ESD to treat anorectal cancer in Korea. Here, we present our case report and review the relevant literature.

An Incidental Finding of a Radiopaque Pill following Cervical Spinal Surgery in a Parkinson's Disease Patient

There are previous reports of the identification of radiopaque medications on abdominal X-rays or computed tomography (CT). We describe an interesting case of the incidental identification of a radiopaque medication on cervical spinal CT following cervical spinal surgery. A sixty seven-year-old male patient with Parkinson's disease (PD) visited our emergency center with a C5-6 dislocation and fracture. Surgery was performed with open reduction and pedicle screw fixation through the posterior approach. No abnormal events occurred during the perioperative period. However, a radiopaque incidental foreign body in front of the C6 vertebrae was found on a cervical spinal CT and X-rays that were performed as routine examinations on postoperative day 3. After 6 hours, we performed gastrofibroscopy (GFS) but were unable to find anything. Therefore, we checked all of his medications related to the neck and check X-ray again. One enteric-coated pill he had taken exhibited strong radiodensity. Although our patient underwent an unnecessary GFS, every spinal surgeon should keep in mind that radiopaque pills can appear similar to spinal instruments on X-ray and CT. In addition, we should also know the associated dysphagia is a possible cause of the delayed passage of medicine in PD with or without cervical osteophytes.

Liver Metastasis of Early Gastric Cancer with Mixed Histology after Endoscopic Submucosal Dissection

The Japanese Classification of Gastric Carcinoma histologically classifies endoscopically resected gastric cancer into differentiated and undifferentiated types according to the presence or absence of tubular structures on histology. The former includes papillary adenocarcinoma and tubular types, and the latter includes poorly differentiated adenocarcinoma, signet ring cell carcinoma and mucinous adenocarcinoma. However, gastric cancer sometimes contains a mixture of differentiated and undifferentiated components, and the clinical outcomes of the histological mixture are unknown, especially following endoscopic resection of early gastric cancer (EGC). This case was within the guideline indications for endoscopic submucosal resection (ESD), although it contained a partly signet ring cell carcinoma component; it recurred after 19 months with multiple lymph node and liver metastases. This case shows that additional surgical resection after ESD should be performed for patients with any mixed signet ring cell component, even in mild or moderately differentiated EGC.

Two Cases of Electrocautery Incision Therapy Using an Insulated-tip Knife for Treatment of Symptomatic Benign Short-segment Colonic Stenosis Following Colonic Resection / 대한소화기학회지

Anastomotic stenosis of the colon is not an uncommon finding; however, its frequency varies from one study to another. Traditionally, postoperative colonic stenosis is managed surgically. However, endoscopic therapy has recently become the preferred treatment modality over traditional surgery. Good short-term success has been achieved with use of endoscopic balloon dilation; however, restenosis may occur over time in 14% to 25% of patients. The current report showed the effectiveness and usefulness of an insulated-tip knife (IT-knife) for electrocautery therapy of a patient with symptomatic anastomotic colonic stenosis.

Colonic Langerhans Cell Histiocytosis Presenting as an Isolated Polyp / 대한내과학회지

A 56-year-old male underwent a screening colonoscopy. An 8-mm sessile polyp was removed from the descending colon using snare polypectomy. Histology showed Langerhans cells and eosinophil infiltration of the submucosa. Immunohistochemical staining was positive for S-100 protein and CD1a antigen, which confirmed the diagnosis of Langerhans-cell histiocytosis. On further workup, there was no evidence of involvement of any other organs. Here, we report a very rare case of colonic Langerhans-cell histiocytosis presenting as an isolated polyp.

Colon Cancer After Acute Diverticulitis Treatment

Diverticulitis is the most common clinical complication of diverticular disease, affecting 10-25% of the patients with diverticula. The prevalences of diverticulitis and colon cancer tend to increase with age and are higher in industrialized countries. Consequently, diverticulitis and colon cancer have been reported to have similar epidemiological characteristics. However, the relationship between these diseases remains controversial, as is the performance of routine colonoscopy after an episode of diverticulitis to exclude colon cancer. Recently, we experienced three cases of colon cancer after treating acute diverticulitis, based on which we suggest the importance of follow-up colonoscopy after acute diverticulitis.

A Case of Gastric Inverted Hyperplastic Polyp Found with Gastritis Cystica Profunda and Early Gastric Cancer

A gastric inverted hyperplastic polyp is a rare type of gastric polyp and is characterized by downward growth of a variety of mucosal components into the submucosa. The polyp consists of columnar cells resembling foveolar epithelium and pyloric gland epithelium and can coexist with gastritis cystica profunda. Frequently, adenocarcinoma can coexist, but the relation is not clear. A 77-year-old male underwent endoscopic submucosal dissection due to early gastric cancer. A gastric inverted hyperplastic polyp was found in the removed specimen and gastric cystica profunda was also found. We report a case of gastric inverted hyperplastic polyp coexisting with gastric cystica profunda and gastric adenocarcinoma.

A Clinical Analysis of Gastrointestinal Stromal Tumors in Small Intestine: Comparison of Bleeding and Non-bleeding Group

BACKGROUND/AIMS: Gastrointestinal stromal tumors (GIST) in the small intestine are rare and can cause bleeding. The study investigated the clinical characteristics of GIST in the small intestine and to determine the factors related to gastrointestinal bleeding. METHODS: We retrospectively evaluated the clinical outcomes of 22 patients with small bowel GIST who were pathologically diagnosed at Gangneung Asan Hospital between March 1997 and August 2012. RESULTS: The median age was 63.5 (38-82) years. Nine patients (40.9%) had gastrointestinal bleeding, five patients (22.7%) had abdominal pain, two patients (9%) had palpable mass. The site of tumor was the duodenum in nine cases (40.9%), jejunum in 7 cases (31.8%), and ileum in six cases (27.3%). Most patients underwent small bowel resection or wedge resection but three patients underwent pancreaticoduodenectomy. Tumor size ranged from 1.6 to 19 cm (median 6.5 cm). The median mitotic rate was 2 (0-50)/50 high power fields (HPF). The median mitotic rate was 2 (0-50)/50 HPF. Five patients (25%) showed recurrence. Gender, aspirin or warfarin use, size and mitotic index of tumor, hospital stay, recurrence and survival were not significantly different between bleeding and non-bleeding group. Bleeding group showed older age, proximal location in small intestine and mucosal ulceration significantly. CONCLUSIONS: Small bowel GISTs with bleeding were marked by older age, mucosal ulceration and location of proximal small bowel (duodenum and jejunum) rather than distal small bowel (ileum).

The Efficacy and Tolerability of Sugared Polyethylene Glycol for Colonoscopy / 대한소화기학회지

BACKGROUND/AIMS: Although polyethylene glycol (PEG) solution is commonly used for colonoscopic bowel preparation because of its safety and effectiveness, its salty taste decreases patient's compliance. The aim of this study was to compare the sugared PEG solution with the standard PEG solution in regard to the quality of bowel preparation and patient's compliance. METHODS: From January through June in 2012, 100 patients who underwent colonoscopy in Gangneung Asan Hospital were prospectively enrolled. They were randomly assigned to receive either standard PEG solution or sugared PEG solution. The quality of bowel preparation was assessed by a doctor's questionnaire and the patient's compliance was assessed by a patient's questionnaire. RESULTS: There was no significant difference in the quality of bowel preparation (4.2+/-2.0 vs. 4.1+/-1.5, p=0.783), and endoscopist's satisfaction score (8.2+/-1.8 vs. 8.5+/-1.3, p=0.253) between two groups. However, The degree of disgust was lower in the sugared PEG group than the standard PEG group (6.4+/-2.3 vs. 3.9+/-2.9, p=0.000). The willingness to repeat same regimen was higher in the sugared PEG group than the standard PEG group (2.0+/-0.6 vs. 2.3+/-0.7, p=0.004). There was no difference in side effects between two groups. CONCLUSIONS: The sugared PEG solution as a bowel preparation method revealed a higher patient's compliance and was effective as the standard PEG solution. When the patient dislike the taste and saltness of the standard PEG solution, the sugared PEG solution will be good alternative method.

Proteomic Analysis of Colonic Mucosal Tissue from Tuberculous and Ulcerative Colitis Patients

Changes in the expression profiles of specific proteins leads to serious human diseases, including colitis. The proteomic changes related to colitis and the differential expression between tuberculous (TC) and ulcerative colitis (UC) in colon tissue from colitis patients has not been defined. We therefore performed a proteomic analysis of human TC and UC mucosal tissue. Total protein was obtained from the colon mucosal tissue of normal, TC, and UC patients, and resolved by 2-dimensional electrophoresis (2-DE). The results were analyzed with PDQuest using silver staining. We used matrix-assisted laser desorption ionization time-of-flight/time-of-flight spectrometry (MALDI TOF/TOF) to identify proteins differentially expressed in TC and UC. Of the over 1,000 proteins isolated, three in TC tissue and two in UC tissue displayed altered expression when compared to normal tissue. Moreover, two proteins were differentially expressed in a comparative analysis between TC and UC. These were identified as mutant beta-actin, alpha-enolase and Charcot-Leyden crystal protein. In particular, the expression of alpha-enolase was significantly greater in TC compared with normal tissue, but decreased in comparison to UC, implying that alpha-enolase may represent a biomarker for differential diagnosis of TC and UC. This study therefore provides a valuable resource for the molecular and diagnostic analysis of human colitis.

A Case of a Mucinous Adenocarcinoma Arising from a Rectal Diverticulum

The occurrence of an adenocarcinoma arising from a rectal diverticulum that causes mechanical ileus is very rare. Recently, we diagnosed a case of a mucinous adenocarcinoma in a rectal diverticulum after an emergent abdominal perineal resection and permanent colostomy by laparotomy. Here, we present a case report and a review of the literature.

A Case of Ischemic Colitis after Bee Venom-induced Anaphylaxis / 대한소화기내시경학회지

Anaphylaxis is a potentially life-threatening allergic reaction, presenting with various clinical symptoms. The most common etiologies of anaphylactic reactions include allergic responses to food, medications, latex, and Hymenoptera stings. In its classic form, anaphylaxis typically involves the cutaneous, respiratory and cardiovascular systems. Gastrointestinal symptoms, including nausea, vomiting, diarrhea and cramping abdominal pain, can occur transiently but mucosal lesions are rarely detected. We recently experienced a case of ischemic colitis presenting with hematochezia after bee venom-induced anaphylactic shock. To the best of our knowledge, this is the first case in Korea. We report the case with a review of the literature.

A Case of Gastrointestinal Bleeding after a Snake Bite / 대한내과학회지

The clinical presentation of snake bites varies greatly. Symptoms range from only bite marks to muscle spasms, paralysis, altered mental status, and muscle weakness. In severe cases, symptoms may include life threatening coagulopathy or gastrointestinal bleeding owing to increased vascular permeability. In this report, the patient presented with massive gastrointestinal bleeding after a snake bite and recovered with conservative treatment.

Diagnosis of a Transverse Colon Penetration and Tube Displacement 4 Months after Percutaneous Radiologic Gastrostomy / 대한소화기내시경학회지

Percutaneous radiologic gastrostomy (PRG) is an enteral nutritional method that can be applied to a patient with dysphagia due to cerebrovascular accident, Parkinsonism, dementia, or head and neck cancer. PRG is a safe and cost-effective method with low morbidity and mortality rates compared with surgical gastrostomy, because it require less sedation and less invasive placement technique. PRG complications include wound infections, peritonitis, tube malfunctions, peristomal leakage, bleeding, ileus, pneumoperitoneum, aspiration pneumonia, and bowel perforation. But, bowel perforation after PRG is rare. We recently experienced a case of transverse colon penetration and tube displacement, which occurred as a PRG complication in a 60-year-old male with a cerebrovascular accident.