Recent trends in the epidemiology and clinical outcomes of inflammatory bowel disease in South Korea,2010-2018

BACKGROUND Inflammatory bowel disease(IBD)was previously regarded as a Western disease;however,its incidence is increasing in the East.The epidemiology of IBD in Asia differs significantly from the patterns in the West.AIM To comprehensively investigate the epidemiology of IBD in South Korea,inclu-ding its incidence,prevalence,medication trends,and outcomes.METHODS We analyzed claims data from the Health Insurance Review and Assessment Service and Rare and Intractable Diseases(RIDs),operated by the National Health Insurance Service of South Korea.Patients with IBD were identified based on the International Classification of Diseases,Tenth Revision,and RID diagnostic codes for Crohn’s disease(CD)and ulcerative colitis(UC)from 2010 to 2018.RESULTS In total,14498 and 31409 patients were newly diagnosed with CD and UC,respectively,between 2010 and 2018.The annual average incidence of CD was 3.11 cases per 105 person-years,and that of UC was 6.74 cases per 10^(5) person-years.Since 2014,the incidence rate of CD has been stable,while that of UC has steadily increased,shifting the peak age group from 50-year-olds in 2010 to 20-year-olds in 2018.The CD and UC prevalence increased consistently over the study period;the use of 5-aminosali-cylates and corticosteroids gradually decreased,while that of immunomodulators and biologics steadily increased in both CD and UC.The clinical outcomes of IBD,such as hospitalization and surgery,decreased during the study period.CONCLUSION The CD incidence has been stable since 2014,but that of UC has increased with a shift to a younger age at peak incidence between 2010 and 2018.IBD clinical outcomes improved over time,with increased use of immunomodu-lators and biologics.

Long-term outcome in patients with obscure gastrointestinal bleeding after negative capsule endoscopy

AIM:To investigate long-term outcome in obscure gastrointestinal bleeding(OGIB) after negative capsule endoscopy(CE) and identify risk factors for rebleeding.METHODS:A total of 113 consecutive patients underwent CE for OGIB from May 2003 to June 2010 at Seoul National University Hospital.Ninety-five patients(84.1%) with a subsequent follow-up after CE of at least 6 mo were enrolled in this study.Follow-up data were obtained from the patients' medical records.The CE images were reviewed by two board-certified gastroenterologists and consensus diagnosis was used in all cases.The primary outcome measure was the detection of rebleeding after CE,and factors associated with rebleeding were evaluated using multivariate analysis.RESULTS:Of the 95 enrolled patients(median age 61 years,range 17-85 years),62 patients(65.3%) were male.The median duration of follow-up was 23.7 mo(range 6.0-89.4 mo).Seventy-three patients(76.8%) underwent CE for obscure-overt bleeding.Complete examination of the small bowel was achieved in 77 cases(81.1%).Significant lesions were found in 38 patients(40.0%).The overall rebleeding rate was 28.4%.The rebleeding rate was higher in patients with positive CE(36.8%) than in those with negative CE(22.8%).However,there was no significant difference in cumulative rebleeding rates between the two groups(log rank test;P = 0.205).Anticoagulation after CE examination was an independent risk factor for rebleeding(hazard ratio,5.019;95%CI,1.560-16.145;P = 0.007),regardless of CE results.CONCLUSION:Patients with OGIB and negative CE have a potential risk of rebleeding.Therefore,close observation is required and alternative modalities should be considered in suspicious cases.

Histologic characteristics of gastric polyps in Korea: Emphasis on discrepancy between endoscopic forceps biopsy and endoscopic mucosal resection specimen

AIM： To investigate histological characteristics of gastric polyps in the Korean population. METHODS： We reviewed endoscopic photographs and medical records of patients with gastric polyps who underwent endoscopic mucosal resection from April 1996 through February 2003. RESULTS： A total of 85 gastric polyps from 74 patients were reviewed, Male-to-female ratio was 1：1,96, Mean age was 59.9 =1：10,8 years. Multiple polyps were observed in 10,8%, Gastric polyps occurred most frequently in the antrum （58.8%）, Pathological results on resected specimens were as follows： tubular adenoma 45.9%, hyperplastic polyp 31.8%, inflammatory polyp 9.4%, hamartoma 3.5%, fundic gland polyp 2.4%, tubulovillous adenoma 2.4%, adenocarcinoma 2.4%, dysplasia 1.1%, and mucosal pseudolipomatosis 1.1%. Discrepancy rate between endoscopic biopsy and pathology of resected specimens was 27.1%. There was no relationship between the size of the polyp and concordance rate. CONCLUSION： There is considerable discrepancy in histologic findings between endoscopic forceps biopsy and resected specimens. Approaches to review of the histology of an entire polyp should be performed, especially when an adenoma is suspected.

Proton pump inhibitors as a risk factor for recurrence of Clostridium-difficile-associated diarrhea

AIM:To investigate the risk factors for Clostridiumdifficile-associated diarrhea(CDAD)recurrence,and its relationship with proton pump inhibitors(PPIs). METHODS:Retrospective data of 125 consecutive hospitalized patients diagnosed with CDAD between January 2006 and December 2007 were collected by medical chart review.Collected data included patient characteristics at baseline,underlying medical disease, antibiotic history before receiving a diagnosis of CDAD, duration of hospital stay,severity of CDAD,concurrenttreatment with PPIs,laboratory parameters,response to CDAD therapy,and recurrence of disease within 90 d of successful treatment.Various clinical and laboratory parameters were compared in patients in whom CDAD did or did not recur. RESULTS:Of the 125 patients(mean age,67.6± 13.9 years)that developed CDAD,98(78.4%)did not experience recurrence(non-recurrent group)and 27 (21.6%)experienced one or more recurrences(recurrent group).Prior to the development of CDAD,96% of the 125 patients were prescribed antibiotics,and 56(44.8%)of the patients received PPIs.Age older than 65 years(P=0.021),feeding via nasogastric tube(NGT)(P=0.045),low serum albumin level(P =0.025),and concurrent use of PPIs(P=0.014) were found to be risk factors for CDAD recurrence by univariate analysis.However,sex,length of hospital stay,duration and type of antibiotics used,severity of disease,leukocyte count and C-reactive protein(CRP) were not associated with risk of CDAD recurrence.On multivariate analysis,the important risk factors were advanced age(>65 years,adjusted OR:1.32,95% CI:1.12-3.87,P=0.031),low serum albumin level(< 2.5 g/dL,adjusted OR:1.85,95%CI:1.35-4.91,P= 0.028),and concurrent use of PPIs(adjusted OR:3.48, 95%CI:1.64-7.69,P=0.016). CONCLUSION:Advanced age,serum albumin level< 2.5 g/dL,and concomitant use of PPIs were found to be significant risk factors for CDAD recurrence.

Clinical and endoscopic characteristics of drug-induced esophagitis

AIM: To investigate clinical, endoscopic and pathological characteristics of drug-induced esophagitis.

Discrepancies between primary physician practice and treatment guidelines for Helicobacterpylori infection in Korea

AIM： To evaluate the attitude of primary care physicians in the diagnosis and treatment of Helicobacter pylori （fl pylori） infection. METHODS： Primary care physicians in the Seoul metropolitan area answered self-administered questionnaire from January to March 2003. RESULTS： One hundred and eight doctors responded to the questionnaire. The most frequent reasons for testing H pylori infection were gastric and duodenal ulcers （93.5% and 88.9%, respectively）. For patients with Hplori positive dyspepsia, 28.7% of doctors always tried to eradicate the worm and 34.4% treated selectively. A large proportion （28.7%） of primary care physicians treated H pylori on a patient＇s request basis. Only 9.3% of primary care physicians always conducted follow-up testing after treating H pylori infection. When H pylori was not cleared by the first treatment, 40.7% of doctors reused the same regimen, 16.7% changed to another triple regimen and 25% to a quadruple regimen. CONCLUSION： It has been well documented that the issuance of guidelines alone has little impact on practice. Communication between primary care physicians and gastroenterologists in the form of continuous medical education is required.

Role of ascites adenosine deaminase in differentiating between tuberculous peritonitis and peritoneal carcinomatosis

AIM： To investigate the usefulness of tumor markers and adenosine deaminase in differentiating between tuberculous peritonitis （TBP） and peritoneal carcinoma- tosis （PC）. METHODS： A retrospective analysis of data was per- formed on consecutive patients who underwent perito- neoscopic and abdominal computed tomography （CT） evaluations. Among 75 patients at the Seoul National University Hospital from January 2000 to June 2010 who underwent both tests, 27 patients （36.0%） and 25 patients （33.3%） were diagnosed with TBP and PC, re- spectively. Diagnosis was confirmed by peritoneoscopic biopsy. RESULTS： Serum c-reactive protein （7.88：1：6.62 mg/ dL vs 3.12 ＋ 2.69 mg/dL, P = 0.01）, ascites adenos- ine deaminase （66.76：1：32.09 IU/L vs 13.89 ：l： 8.95 IU/L, P 〈 0.01）, ascites lymphocyte proportion （67.77 ：1： 23.41% vs 48.36 ＋ 18.78%, P 〈 0.01）, and serum- ascites albumin gradient （0.72 ＋ 0.49 g/dL vs 1.05 ＋ 0.50 g/dL, P = 0.03） were significantly different be- tween the two groups. Among tumor markers, serum and ascites carcinoembryonic antigen, serum carbohy- drate antigen 19-9 showed significant difference be- tween two groups. Abdominal CT examinations showed that smooth involvement of the parietal peritoneum was more common in the TBP group （77.8% vs 40.7%） whereas nodular involvement was more common in the PC group （14.8% vs 40.7%, P = 0.04）. From receiver operating characteristic （ROC） curves ascites adeno- sines deaminase （ADA） showed better discriminative capability than tumor markers. An ADA cut-off level of 21 IU/L was found to yield the best results of differ- ential diagnosis; sensitivity, specificity, positive predic- tive value, and negative predictive value were 92.0%, 85.0%, 88.5% and 89.5%, respectively. CONCLUSION： Besides clinical and radiologic findings, ascitic fluid ADA measurement is helpful in the differen- tial diagnosis of TBP and PC.

Restraint stress induces and exacerbates intestinal inflammation in interleukin-10 deficient mice

AIM:To investigate the effects of restraint stress on chronic colitis in interleukin(IL)-10 deficient(IL-10^(-/-))mice.METHODS:The first experiment compared the effect of restraint stress on the development of intestinal inflammation in wild-type and IL-10^(-/-) mice.Both wildtype and IL-10^(-/-) mice were physically restrained in a well-ventilated,50 cm3 conical polypropylene tube for2 h per day for three consecutive days.The second experiment was performed to assess the effect of restraint stress on exacerbation of colitis induced by piroxicam in IL-10^(-/-) mice.The IL-10^(-/-) mice were exposed to restraint stress for 2 h per day for 3consecutive days,and then treated with piroxicam for4 d at a dose of 200 ppm administered in the rodent chow.RESULTS:In the first experiment,none of the wildtype mice with or without restraint stress showed clinical and histopathological abnormality in the gut.However,IL-10^(-/-) mice exposed to restraint stress exhibited histologically significant intestinal inflammation as compared to those without restraint stress.In the second experiment,restraint stress significantly reduced body weight and increased the severity of intestinal inflammation assessed by histopathologic grading in IL-10^(-/-) mice.Colonic IL12p40 mRNA expression was strongly increased in mice exposed to restraint stress.CONCLUSION:This novel animal model could be useful in future study of psychological stress in the pathogenesis of inflammatory bowel disease.

Fatty liver is an independent risk factor for gallbladder polyps

BACKGROUND Gallbladder polyps(GBPs)are known to be associated with obesity and metabolic diseases.However,to date,the relationship between GBPs and abnormal body fat distribution,such as fatty liver,visceral obesity,or sarcopenia,has not yet been established.AIM To evaluate whether GBPs are associated with fatty liver,visceral obesity,or sarcopenia.METHODS We retrospectively reviewed the medical records of subjects who underwent various laboratory tests,body composition measurement with a non-invasive body composition analyzer,and abdominal ultrasonography during health checkups.A total of 1405 subjects with GBPs were compared with 2810 age-and sex-matched controls.RESULTS The mean age of the subjects was 46.8±11.7 years,and 63.8%were male.According to multiple logistic regression analysis,the presence of fatty liver[odds ratio(OR)1.413;95%confidence interval(CI)1.218-1.638;P<0.001]was an independent risk factor for GBP,together with low levels of alanine aminotransferase(OR 0.993;95%CI 0.989-0.996;P<0.001).Additionally,fatty liver showed both independent(OR 1.629;95%CI,1.335-1.988;P<0.001)and dosedependent(moderate to severe fatty liver;OR 2.137;95%CI,1.662-2.749;P<0.001)relationship with large GBPs(≥5 mm).The presence of sarcopenia and high visceral fat area were not significantly associated with GBPs.CONCLUSION Fatty liver was found to be closely associated with GBPs irrespective of sarcopenia and visceral obesity.

Comparison between uncovered and covered self-expandable metal stent placement in malignant duodenal obstruction

AIM:To compare the clinical outcomes of uncovered and covered self-expandable metal stent placements in patients with malignant duodenal obstruction.METHODS:A total of 67 patients were retrospectivelyenrolled from January 2003 to June 2013.All patients had symptomatic obstruction characterized by nausea,vomiting,reduced oral intake,and weight loss.The exclusion criteria included asymptomatic duodenal obstruction,perforation or peritonitis,concomitant small bowel obstruction,or duodenal obstruction caused by benign strictures.The technical and clinical success rate,complication rate,and stent patency were compared according to the placement of uncovered(n = 38) or covered(n = 29) stents.RESULTS:The technical and clinical success rates did not differ between the uncovered and covered stent groups(100% vs 96.6% and 89.5% vs 82.8%).There were no differences in the overall complication rates between the uncovered and covered stent groups(31.6% vs 41.4%).However,stent migration occurred more frequently with covered than uncovered stents [20.7%(6/29) vs 0%(0/38),P < 0.05].Moreover,the overall cumulative median duration of stent patency was longer in uncovered than in covered stents [251 d(95%CI:149.8 d-352.2 d) vs 139 d(95%CI:45.5 d-232.5 d),P < 0.05 by log-rank test] The overall cumulative median survival period was not different between the uncovered stent(70 d) and covered stent groups(60 d).CONCLUSION:Uncovered stents may be preferable in malignant duodenal obstruction because of their greater resistance to stent migration and longer stent patency than covered stents.

Stress and sleep quality in doctors working on-call shifts are associated with functional gastrointestinal disorders

To investigate the role of sleep quality and psychosocial problems as predictors of functional gastrointestinal disorders (FGIDs) in doctors that work 24 hour-on-call shifts.METHODSIn this cross-sectional observation study, using the Rome III Questionnaire and Pittsburgh Sleep Quality Index (PSQI), we analyzed 170 doctors with 24 hour-on-call shifts.RESULTSAmong the participants that had experienced a 24 hour-on-call shift within the last 6 mo, 48 (28.2%) had FGIDs. Overall prevalence of irritable bowel syndrome (IBS) and functional dyspepsia (FD) were 16.5% and 17.1%, respectively, with 5.3% exhibiting both. Sleep scores (PSQI) (8.79 ± 2.71 vs 7.30 ± 3.43, P = 0.008), the presence of serious psychosocial alarm (83.3% vs 56.6%, P = 0.004), and the proportion of doctors who experienced over two months of recent on-call work (81.2% vs 68.9%, P = 0.044) were significantly different between individuals with or without FGIDs. Multivariate analysis revealed that presenting serious psychosocial alarm was an independent risk factor for prevalence of FD (OR = 5.47, 95%CI: 1.06-28.15, P = 0.042) and poor sleep quality (PSQI ≥ 6) was a predictor of IBS (OR = 4.17, 95%CI: 1.92-19.02, P = 0.016).CONCLUSIONPhysicians should recognize the role of sleep impairment and psychological stress in the development of FGIDs and a comprehensive approach should be considered to manage patients with FGIDs.

Effect of gastric acid suppressants and prokinetics on peritoneal dialysis-related peritonitis

AIM: To investigate the effect of gastric acid suppressants and prokinetics on peritonitis development in peritoneal dialysis(PD) patients.METHODS: This was a single-center, retrospective study. The medical records of 398 PD patients were collected from January 2000 to September 2012 and analyzed to compare patients with at least one episode of peritonitis(peritonitis group, group A) to patients who never had peritonitis(no peritonitis group, group B). All peritonitis episodes were analyzed to compare peritonitis caused by enteric organisms and peritonitis caused by non-enteric organisms.RESULTS: Among the 120 patients who met the inclusion criteria, 61 patients had at least one episode ofperitonitis and 59 patients never experienced peritonitis. Twenty-four of 61 patients(39.3%) in group A and 15 of 59 patients(25.4%) in group B used gastric acid suppressants. Only the use of H2-blocker(H2B) was associated with an increased risk of PD-related peritonitis; the use of proton pump inhibitors, other antacids, and prokinetics was not found to be a significant risk factor for PD-related peritonitis. A total of 81 episodes of peritonitis were divided into enteric peritonitis(EP) or non-enteric peritonitis, depending on the causative organism, and gastric acid suppressants and prokinetics did not increase the risk of EP in PD patients.CONCLUSION: The use of H2B showed a trend for an increased risk of overall PD-related peritonitis, although further studies are required to clarify the effects of drugs on PD-related peritonitis.