Chronic gastrointestinal symptoms and quality of life in the Korean population

AIM: To evaluate the prevalence of chronic gastroin-testinal symptoms and their impact on health-related quality of life (HRQOL) in the Korean population. METHODS: A cross-sectional survey, using a reliable and valid Rome Ⅱ based questionnaire, was per-formed on randomly selected residents, between 18 and 69 years in age. All respondents were interviewed at their homes or offices by a team of interviewers. The impact of chronic gastrointestinal symptoms on HRQOL was assessed using the Korean version of the 36-item Short-Form general health survey (SF-36). RESULTS: Of the 1807 eligible subjects, 1417 (78.4%: male 762; female 655) were surveyed. Out of the respondents, 18.6% exhibited at least one chronic gastrointestinal symptom. The prevalence of gastro- esophageal reflux disease (GERD), defined as heart- burn and/or acid regurgitation experienced at least weekly, was 3.5% (95% CI, 2.6-4.5). The prevalence of uninvestigated dyspepsia, irritable bowel syndrome (IBS) and chronic constipation based on Rome Ⅱ cri- teria were 11.7% (95% CI, 10.1-13.5), 2.2% (95%CI, 1.5-3.1), and 2.6% (95% CI, 1.8-3.5) respectively. Compared with subjects without chronic gastrointesti- nal symptoms (n = 1153), those with GERD (n = 50), uninvestigated dyspepsia (n = 166) and IBS (n = 31) had signifi cantly worse scores on most domains of the SF-36 scales. CONCLUSION: The prevalence of GERD, uninvesti-gated dyspepsia and IBS were 3.5%, 11.7% and 2.2% respectively, in the Korean population. The health- related quality of life was signifi cantly impaired in sub-jects with GERD, uninvestigated dyspepsia and IBS in this community.

Endoscopic band ligation and endoscopic hemoclip placement for patients with Mallory-Weiss syndrome and active bleeding

AIM: To compare the hemostatic efficacy and safety of two mechanical endoscopic methods: endoscopic band ligation (EBL) and endoscopic hemoclip placement (EHP) in patients with actively bleeding Mallory-Weiss syndrome (MWS). METHODS: A prospective randomized study to compare the efficacy and safety of EHP with EBL was performed from January 2002 to August 2005. Forty-one patients with active bleeding from MWS were treated with EHP (n = 21) or EBL (n = 20). RESULTS: There were no significant differences between groups with respect to clinical and endoscopic characteristics. The mean number of hemoclips applied was 3.2 ± 1.5 and the mean number of bands applied was 1.2 ± 0.4. Primary hemostasis was achieved in all patients. Recurrent bleeding was observed in one patient from the EHP group and two from the EBL group. Patients with recurrent bleeding were treated by the same modality as at randomization and secondary hemostasis was achieved in all. There were no significant differences between the two groups in total transfusion amount or duration of hospital stay. No complications or bleeding-related death resulted. CONCLUSION: EHP and EBL are equally effective and safe for the management of active bleeding in patients with Mallory-Weiss syndrome, even in those with shock or comorbid diseases.

Thalidomide effect in endothelial cell of acute radiation proctitis

AIM: To determine whether thalidomide prevents microvascular injury in acute radiation proctitis in white rats. METHODS: Fourteen female Wistar rats were used: six in the radiation group, six in the thalidomide group, and two in normal controls. The radiation and thalidomide groups were irradiated at the pelvic area using a single 30 Gy exposure. The thalidomide (150 mg/kg) was injected into the peritoneum for 7 d from the day of irradiation. All animals were sacrificed and the rectums were removed on day 8 after irradiation. The microvessels of resected specimens were immunohistochemically stained with thrombomodulin (TM), von Willebrand Factor (vWF), and vascular endothelial growth factor (VEGF). RESULTS: The microscopic scores did not differ significantly between the radiation and thalidomide groups, but both were higher than in the control group. Expression of TM was significantly lower inthe endothelial cells (EC) of the radiation group than in the control and thalidomide groups (P < 0.001). The number of capillaries expressing vWF in the EC was higher in the radiation group (15.3 ± 6.8) than in the control group (3.7 ± 1.7), and the number of capillaries expressing vWF was attenuated by thalidomide (10.8 ± 3.5, P < 0.001). The intensity of VEGF expression in capillaries was greater in the radiation group than in the control group and was also attenuated by thalidomide (P = 0.003). CONCLUSION: The mechanisms of acute radiation- induced proctitis in the rats are related to endothelial cell injury of microvessel, which may be attenuated with thalidomide.

Nonampullary duodenal adenoma:Current understandingof its diagnosis,pathogenesis,and clinical management

Nonampullary duodenal adenomas are relatively common in familial adenomatous polyposis(FAP), but nonampullary sporadic duodenal adenomas(SDAs)are rare. Emerging evidence shows that duodenal adenomas, regardless of their anatomic location and whether they are sporadic or FAP-related, share morphologic and molecular features with colorectal adenomas. The available data suggest that duodenal adenomas develop to duodenal adenocarcinomas via similar mechanisms. The optimal approach for management of duodenal adenomas remains to be determined. The techniques for endoscopic resection of duodenal adenoma include snare polypectomy, endoscopic mucosal resection(EMR), endoscopic submucosal dissection(ESD), and argon plasma coagulation ablation. EMR may facilitate removal of large duodenal polyps. Although several studies have reported cases of successful ESD for duodenal adenomas, the procedure is technically difficult to perform safely because of the anatomical properties of the duodenum. Although current clinical practice recommends endoscopic resection of all large duodenal adenomas in patients with FAP, endoscopic treatment is usually insufficient to guarantee a polypfree duodenum. Surgery is indicated for FAP patients with severe polyposis or nonampullary SDAs or FAPrelated polyps not amenable to endoscopic resection. Further studies are needed to develop newer endoscopic techniques to guide diagnostic and therapeutic decisions for future management of nonampullary duodenal adenomas.

Endoscopic band ligation: Beyond prevention and management of gastroesophageal varices

Endoscopic band ligation (EBL) is the preferred endoscopic technique for the endoscopic treatment of acute esophageal variceal bleeding. EBL has also been used to treat nonvariceal bleeding. Recently, Han et al demonstrated that EBL can be a feasible and safe alternate technique for the management of iatrogenic gastric perforation especially in cases in which closure with endoclips is difficult. EBL is technically simpler to perform than other methods and provides a good view of the lesions under direct pressure and suction from the transparent ligation cap. EBL can be used even if the diameter of the perforation is greater than 10 mm or if there is a severe tangential angle. In this commentary, we discuss the efficacy and safety of EBL for the closure of iatrogenic gastrointestinal perforation. We also discuss the advantages and disadvantages of EBL for the treatment of nonvariceal bleeding.

Which endoscopic treatment is the best for small rectal carcinoid tumors?

The incidence of rectal carcinoids is rising because of the widespread use of screening colonoscopy. Rectal carcinoids detected incidentally are usually in earlier stages at diagnosis. Rectal carcinoids estimated endoscopically as < 10 mm in diameter without atypical features and confined to the submucosal layer can be removed endoscopically. Here, we review the efficacy and safety of various endoscopic treatments for small rectal carcinoid tumors, including conventional polypectomy, endoscopic mucosal resection(EMR),cap-assisted EMR(or aspiration lumpectomy),endoscopic submucosal resection with ligating device,endoscopic submucosal dissection, and transanal endoscopic microsurgery. It is necessary to carefully choose an effective and safe primary resection method for complete histological resection.

Recent advances in photoacoustic endoscopy

Imaging based on photoacoustic effect relies on illuminating with short light pulses absorbed by tissue absorbers, resulting in thermoelastic expansion, giving rise to ultrasonic waves. The ultrasonic waves are then detected by detectors placed around the sample. Photoacoustic endoscopy(PAE) is one of four major implementations of photoacoustic tomography that have been developed recently. The prototype PAE was based on scanning mirror system that deflected both the light and the ultrasound. A recently developed mini-probe was further miniaturized, and enabled simultaneous photoacoustic and ultrasound imaging. This PAE-endoscopic ultrasound(EUS) system can offer high-resolution vasculature information in the gastrointestinal(GI) tract and display differences between optical and mechanical contrast compared with single-mode EUS. However, PAE for endoscopic GI imaging is still at the preclinical stage. In this commentary, we describe the technological improvements in PAE for possible clinical application in endoscopic GI imaging. In addition, we discuss thetechnical details of the ultrasonic transducer incorporated into the photoacoustic endoscopic probe.

A case of Clostridium difficile infection complicated by acute respiratory distress syndrome treated with fecal microbiota transplantation

Acute respiratory distress syndrome is a life-threatening disorder caused mainly by pneumonia.Clostridium difficile infection(CDI)is a common nosocomial diarrheal disease.Disruption of normal intestinal flora by antibiotics is the main risk factor for CDI.The use of broadspectrum antibiotics for serious medical conditions can make it difficult to treat CDI complicated by acute respiratory distress syndrome.Fecal microbiota transplantation is a highly effective treatment in patients with refractory CDI.Here we report on a patient with refractory CDI and acute respiratory distress syndrome caused by pneumonia who was treated with fecal microbiota transplantation.

Is percutaneous endoscopic gastrostomy tube placement safe in patients with ventriculoperitoneal shunts?

AIM:To investigate whether percutaneous endoscopic gastrostomy (PEG) tube placement is safe in patients with ventriculoperitoneal (VP) shunts.METHODS: This was a retrospective study of all patients undergoing PEG insertion at our institution between June 1999 and June 2006. Post-PEG complications were compared between two groups according to the presence or absence of VP shunts. VP shunt infection rates, the interval between PEG placement and VP shunt catheter insertion, and long-term follow-up were also investigated.RESULTS: Fifty-five patients qualified for the study. Seven patients (12.7%) had pre-existing VP shunts. All patients received prophylactic antibiotics. The complication rate did not differ between VP shunt patients undergoing PEG (PEG/VP group) and non-VP shunt patients undergoing PEG (control group) [1 (14.3%) vs 6 (12.5%), P=1.000]. All patients in the PEG/VP group had undergone VP shunt insertion prior to PEG placement. The mean interval between VP shunt insertion and PEG placement was 308.7 d (range, 65-831 d). The mean follow-up duration in the PEG/VP group was 6.4 mo (range, 1-15 mo). There were no VP shunt infections, although one patient in the PEG/VP group developed a minor peristomal infection during follow-up.CONCLUSION: Complications following PEG placement in patients with VP shunts were infrequent in this study.

A squamous metaplasia in a gastric ulcer scar of the antrum

An 81-year-old man presented with epigastric pain and weight loss for one month. He had a past history of pulmonary tuberculosis, 10 years ago. We performed a gastroscopy, which showed a linear depressed whitish gastric ulcer scar (0.8 cm in length) in the posterior wall of the prepyloric antrum. The result of biopsy was reported as squamous epithelium. Immunohistochemical staining using an antibody to high molecular weight cytokeratin (HMC) revealed positive staining in the squamous epithelium. Two years later, the lesion was followed up. The lesion remained at same site endoscopically, but no squamous epithelium could be seen microscopically.

Boerhaave's syndrome during bowel preparation with polyethylene glycol in a patient with postpolypectomy bleeding

Boerhaave's syndrome is spontaneous rupture of the esophagus,a rare condition with high mortality that occurs most often after forceful vomiting.Polyethylene glycol(PEG) solution is the most common preparation used for colonoscopy.Since large volumes have to be ingested,PEG may induce severe vomiting or retching.However,Boerhaave's syndrome has rarely been reported as a potential problem related to PEG solution.We report a case of spontaneous esophageal rupture due to violent vomiting during bowel preparation with PEG solution in a patient with postpolypectomy bleeding.

Prolapse gastropathy syndrome may be a predictor of pathologic acid reflux

AIM: To assess the occurrence of gastric acid reflux into the esophagus in endoscopically confirmed prolapse gastropathy syndrome (PGS). METHODS: Using ambulatory esophageal pH measurement (BRAVOTM wireless esophageal pH monitoring system), twenty-six patients with PGS were compared with twenty-one patients with erosive esophagitis (EE) as controls. We assessed several reflux parameters, including the percentage of total time at pH < 4, and the DeMeester score. RESULTS: There were no statistical differences between the PGS group and the EE group as to mean age, sex ratio and pH recording time. The EE group showed more severe reflux than the PGS group, as evaluated in terms of the longest duration of reflux, the number of reflux episodes, the number of reflux episodes lasting > 5 min, the total time with pH < 4 during acid reflux episodes, and the DeMeester score, but none of these parameters showed statistically significant difference. Although 53.8% (14/26) ofthe PGS group and 76.2% (16/21) of the EE group demonstrated pathologic acid reflux (DeMeester score > 14.72), there was no statistically significant difference between the two groups in the incidence of pathologic acid reflux (P = 0.11). CONCLUSION: There was no statistically significant difference in pathologic acid reflux between the PGS and EE group. These data suggest that endoscopically diagnosed PGS might be a predictor of pathologic acid reflux.

Extraction and clipping repair of a chicken bone penetrating the gastric wall

We report a case of gastric penetration caused by accidental ingestion of a chicken bone in a 42-year old woman with a partially wearing denture. Three days ago, she accidentally swallowed several lumps of poorly-chewed chicken. Physical examination disclosed mild tenderness in the periumbilical area. Abdominal Computed tomography (CT) showed a suspicious penetration or perforation of the stomach wall measuring about 3 cm, by a linear radiopaque material at the lesser curvature of the antrum. The end of a chicken bone was very close to but did not penetrate the liver. Endoscopic examination revealed a chicken bone that penetrated into the prepyloric antrum. The penetrating chicken bone was removed with grasping forceps. Five endoscopic clips were applied immediately at the removal site and the periumbilical pain resolved promptly. After removal of the chicken bone, the patient was treated with conservative care for three days, after which she was completely asymptomatic and discharged without complication. To treat gastric penetration by a foreign body, endoclipping can be a useful method in patients with no signs or symptoms of peritoneal irritation.

Colonic lipoma covered by hyperplastic epithelium: Case report

Colonic lipomas are submucosal nonepithelial tumors covered by intact or eroded mucosa. In rare cases, alterations in the mucosa covering a lipoma include hyperplasia, adenoma, atrophy, ulceration, and necrosis. Here, we report a case of a colonic lipoma covered by hyperplastic epithelium in a 68-year-old woman. Based on the colonoscopy findings, a snare polypectomy was performed for a presumptive diagnosis of an epithelial lesion; however, the histological examination revealed a colonic submucosal lipoma with overlying hyperplastic epithelium.

Recent advances in targeted endoscopic imaging:Early detection of gastrointestinal neoplasms

Molecular imaging has emerged as a new discipline in gastrointestinal endoscopy.This technology encompasses modalities that can visualize disease-specific morphological or functional tissue changes based on the molecular signature of individual cells.Molecular imaging has several advantages including minimal damage to tissues,repetitive visualization,and utility for conducting quantitative analyses.Advancements in basic science coupled with endoscopy have made early detection of gastrointestinal cancer possible.Molecular imaging during gastrointestinal endoscopy requires thedevelopment of safe biomarkers and exogenous probes to detect molecular changes in cells with high specificity anda high signal-to-background ratio.Additionally,a high-resolution endoscope with an accurate wide-field viewing capability must be developed.Targeted endoscopic imaging is expected to improve early diagnosis and individual therapy of gastrointestinal cancer.

Impact of statin intensity on adverse cardiac and cerebrovascular events in older adult patients with myocardial infarction

BACKGROUND There is insufficient evidence regarding the effect of high-intensity statin therapy in older adults.This study aimed to investigate the effects of high-intensity statin treatment on the clinical outcomes in older adults with myocardial infarc-tion(MI).METHODS Consecutive patients with MI aged at least 75 years were analyzed retrospectively.The primary endpoint was major adverse cardiac and cerebrovascular events(MACCE),defined as a composite of all-cause death,MI,rehospitalization due to un-stable angina,repeat revascularization,and ischemic stroke.The high-intensity group was compared to the low-to-moderate in-tensity group in the propensity score-matched cohort.RESULTS Average age of total 546 patients was 81 years.Among them,84%of patients underwent percutaneous coronary in-tervention.The unadjusted seven-year MACCE rate differed by statin intensity(high-intensity statin group:38%,moderate-intensity statin group:42%,low-intensity statin group:56%,and no-statin group:61%,P=0.004).However,among these groups,many baseline characteristics were significantly different.Among the 74 propensity score-matched pairs,which lacked any significant differences in all baseline characteristics,the high-intensity group had a significantly lower rate of MACCE than the low-to-moderate intensity group(37%vs.53%,P=0.047).Follow-up low-density lipoprotein cholesterol levels were significantly lower in the high-intensity group than that in the low-to-moderate intensity group(69.4±16.0 mg/dL vs.77.9±25.9 mg/dL,P=0.026).CONCLUSIONS In older adult patients with MI,the use of high-intensity statin caused significantly less occurrence of MACCE in comparison to that in low-to-moderate intensity for up to seven years of follow-up.

A randomized, prospective, two-center comparison of sirolimus-eluting stent and zotarolimus-eluting stent in acute ST-elevation myocardial infarction： The SEZE trial

Background The zotarolimus-eluting stent has shown larger in-stent late lumen loss compared to sirolimus-eluting stents in previous studies. However, this has not been thoroughly evaluated in ST elevation myocardial infarction. Methods This was a prospective, randomized, controlled trial evaluating angiographic outcomes in patients presenting with ST elevation myocardial infarction, treated with zotarolimus-eluting stents or sirolimus-eluting stents. From March 2007 to February 2009, 122 patients were randomized to zotarolimus-eluting stents or sirolimus-eluting stents in a 1：1 fashion. The primary endpoint was 9-month in-stent late lumen loss confirmed by coronary angiography, and secondary endpoints were percent diameter stenosis, binary restenosis rate, major adverse cardiac events （a composite of cardiac death, non-fatal myocardial infarction, and target vessel revascularization）, and late-acquired incomplete stent apposition. Results Angiographic in-stent late lumen loss was significantly higher in the zotarolimus-eluting stent group compared to the sirolimus-eluting stent group （（0.49±0.65） mm vs. （0.10±0.46） mm, P=0.001）. Percent diameter stenosis at 9-month follow-up was also larger in the zotarolimus-eluting stent group （（30.0±17.9）% vs. （17.6±14.0）%, P 〈0.001）. In-segment analysis showed similar findings. There were no significant differences in binary restenosis rate, major adverse cardiac events, and late-acquired incomplete stent apposition. Conclusions Compared to sirolimus-eluting stents, the zotarolimus-eluting stent is associated with significantly higher in-stent late lumen loss at 9-month angiographic follow-up in the treatment of ST elevation myocardial infarction. Although there was no significant difference in 1-year clinical outcomes, the clinical implication of increased late lumen loss should be further studied.

Gene editing particle system as a therapeutic approach for drug-resistant colorectal cancer

The epidermal growth factor receptor(EGFR)pathway plays an important role in the progression of colorectal cancer(CRC).Anti-EGFR drugs based on antibodies have been widely used for treating CRC through inducing the cell death pathway.However,the majority of CRC patients will inevitably develop drug-resistance during anti-EGFR drug treatment,which is mainly caused by a point mutation in the KRAS oncogene.We developed a nanoliposomal(NL)particle containing the Cas9 protein and a single-guide RNA(sgRNA)complex(Cas9-RNP),for genomic editing of the KRAS mutation.The NL particle is composed of bio-compatible lipid compounds that can effectively encapsulate Cas9-RNP.By modifying the NL particle to include the appropriate antibody,it can specifically recognize EGFR expressing CRC and effectively deliver the gene-editing complexes.The conditions of NL treatment were optimized using a KRAS mutated CRC in vivo mouse model.Mice with KRAS-mutated CRC showed drug resistance against cetuximab,a therapeutic antibody drug.After treating the mice with the KRAS gene-editing NL particles,the implanted tumors showed a dramatic decrease in size.Our results demonstrated that this genomic editing complex has great potential as a therapeutic carrier system for the treatment of drug-resistant cancer caused by a point mutation.