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Background/Aims: This study aimed to investigate the patterns of preferred endoscopic procedure types and techniques for managing difficult common bile duct (CBD) stones in South Korea. Methods: The Committee of Policy and Quality Management of Korean Pancreatobiliary Association (KPBA) conducted a survey containing 19 questions. Both paper and online surveys were carried out; with the paper survey being conducted during the 2019 Annual Congress of KPBA and the online survey being conducted through Google Forms from April 2020 to February 2021. Results: The response rate was approximately 41.3% (86/208). Sixty-two (73.0%) worked at tertiary hospitals or academic medical centers, and 60 (69.7%) had more than 5 years of endoscopic retrograde cholangiopancreatography experience. The preferred size criteria for large CBD stones were 15 mm (40.6%), 20 mm (31.3%), and 30 mm (4.6%). For managing of large CBD stones, endoscopic papillary large balloon dilation after endoscopic sphincterotomy was the most preferred technique (74.4%). When performing procedures in those with bleeding diathesis, 64 (74.4%) respondents favored endoscopic papillary balloon dilation (EPBD) alone or EPBD with small endoscopic sphincterotomy. Fifty-five respondents (63.9%) preferred the doubleguidewire technique when faced with difficult bile duct cannulation in patients with periampullary diverticulum. In surgically altered anatomies, cap-fitted forward viewing endoscopy (76.7%) and percutaneous transhepatic cholangioscopy (48.8%) were the preferred techniques for Billroth-II anastomosis and total gastrectomy with Roux-en-Y anastomosis, respectively. Conclusions: Most respondents showed unifying trends for the management of difficult CBD stones. The current practice patterns could be used as basic data for clinical quality improvements in the management of difficult CBD stones. [ABSTRACT FROM AUTHOR]

With an aging population, the number of patients with difficulty swallowing due to medical conditions is gradually increasing. In such cases, enteral nutrition is administered through a temporary nasogastric tube. Long-term use of a nasogastric tube leads to various complications and a decreased quality of life. Percutaneous endoscopic gastrostomy (PEG) is the percutaneous placement of a tube into the stomach, aided endoscopically, which may be an alternative to a nasogastric tube when enteral nutritional is required for 4 weeks or more. This paper is the first Korean clinical guideline for PEG. It was developed jointly by the Korean College of Helicobacter and Upper Gastrointestinal Research and led by the Korean Society of Gastrointestinal Endoscopy. These guidelines aimed to provide physicians, including endoscopists, with the indications, use of prophylactic antibiotics, timing of enteric nutrition, tube placement methods, complications, replacement, and tubes removal for PEG based on the currently available clinical evidence. [ABSTRACT FROM AUTHOR]

Current studies have confirmed that liver diseases are closely related to intestinal microorganisms; however, those studies have mainly concentrated on bacteria. Although the proportion of intestinal microorganisms accounted for by colonizing fungi is very small, these fungi do have a significant effect on the homeostasis of the intestinal microecosystem. In this paper, the characteristics of intestinal fungi in patients with chronic liver diseases such as alcoholic liver disease, nonalcoholic fatty liver disease and cirrhosis are summarized, and the effects of intestinal fungi and their metabolites are analyzed and discussed. It is important to realize that not only bacteria but also intestinal fungi play important roles in liver diseases. [ABSTRACT FROM AUTHOR]

Background/Aims To systematically report incidence of PD leakage, pancreatic disruption in pancreatic fluid collection (PFC), pseudocyst and WON from existing studies. Methods We searched from PubMed by use Keywords Incidence and/or PD leakage and/or PD disruption and/or pancreatic pseudocyst and/or WON and/or PFC and searched references cited by the retrieved articles which were relevant with incidence of PD leakage in pancreatic pseudocyst, WON and PFC. Results The 2,553 papers met searching words above. Exclusion criteria were non-English language articles, unavailable full text articles, review articles, case reports, case series with number of cases <10 cases or populations of children. The 1,372 papers were then available for reviewing. Finally, only 52 papers had information of incidence of PD leakage or PD disruption in pseudocyst, WON, or PFC. To ensure true PD leakage or PD disruption, we decided to use only studies that use endoscopic retrograde pancreatography (ERP) for an evaluation of PD leakage. From 52 papers, of 4,110 cases with PFCs, PD leakage and disruption were identified in 1,097 cases (26.7%) and 840 cases (20.44%), respectively. Of 1,532 cases with pseudocyst, 618 cases (40.3%) and 78 cases (5.1%) had PD leakage and disruption, respectively. From 1,463 cases with WON, 308 cases (21.1%) and 382 cases (26.1%) had PD leakage and disruption, respectively. For the rest of 1,115 cases labelled as PFC, information was not enough to classify into either pseudocyst or WON. In patients with pseudocyst and WON, about half of them has either PD leakage or disruption confirmed by ERP. Most PD injury in pseudocyst were PD leakage whereas incidence of PD disruption was slightly higher than leakage in WONs. Conclusions This systematic review reported incidence of PD leakage or disruption in about half of patients with PFC, pseudocyst and WON from published literatures. [ABSTRACT FROM AUTHOR]

A laser endoscopy system was developed in 2012. The system allows blue laser imaging (BLI), BLI-bright, and linked color imaging (LCI) to be performed as modes of narrowband light observation; these modes have been reported to be useful for tumor detection and characterization. Furthermore, an innovative endoscopy system using four-light emitting diode (LED) multilight technology was released in 2016 to 2017 in some areas in which laser endoscopes have not been approved for use, including the United States and Europe. This system enables blue light imaging (this is also known as BLI) and LCI with an LED light source instead of a laser light source. Several reports have shown that these modes have improved tumor detection. In this paper, we review the efficacy of BLI and LCI with laser and LED endoscopes in tumor detection and characterization. [ABSTRACT FROM AUTHOR]

Background/Aims: We aimed to investigate whether the current indications for curative endoscopic resection (ER) of gastric cancer (GC) can be applied to GC caused by adenoma. Additionally, we attempted to identify factors predictive of lesions subsequently found in addition to the expanded indications for ER. Methods: We retrospectively analyzed 342 patients diagnosed with GC caused by adenoma who underwent ER at a single tertiary center between February 2011 and December 2014. The gross whole tumor size was measured using the endoscopically resected specimen. The microscopic whole tumor size was measured using mapping paper. The estimated cancer size was calculated using the microscopic whole tumor size and the square root of the carcinoma component. Results: A gross whole tumor size ≥3 cm, carcinoma component ≥35%, and gross ulceration were predictive of lesions other than the expanded indications for ER. The overall rate of lymph node metastasis was 0.3% (1/327), which only occurred in one patient with a lesion other than the expanded indications (4.5%, 1/22). Conclusions: The current indications for curative ER in GC can be applied to GC caused by adenoma. In cases suspected of having lesions other than the expanded indications, patients should be cautiously selected for ER to reduce the risk of an inappropriate procedure. [ABSTRACT FROM AUTHOR]

Background/Aims: Functional dyspepsia (FD) has long been regarded as a syndrome because its pathophysiology is multifactorial. However, recent reports have provided evidence that changes in the duodenal ecosystem may be the key. This study aimed to identify several gastrointestinal factors and biomarkers associated with FD, specifically changes in the duodenal ecosystem that may be key to understanding its pathophysiology. Methods: In this case-control study, 28 participants (12 with FD and 16 healthy control individuals) were assessed for dietary nutrients, gastrointestinal symptom severity, immunological status of the duodenal mucosa, and microbiome composition from oral, duodenal, and fecal samples. Integrated data were analyzed using immunohistochemistry, real-time polymerase chain reaction, 16S rRNA sequencing, and network analysis. Results: Duodenal mucosal inflammation and impaired expression of tight junction proteins were confirmed in patients with FD. The relative abundance of duodenal Streptococcus (p=0.014) and reductions in stool Butyricicoccus (p=0.047) were confirmed. These changes in the gut microbiota were both correlated with symptom severity. Changes in dietary micronutrients, such as higher intake of valine, were associated with improved intestinal barrier function and microbiota. Conclusions: This study emphasizes the relationships among dietary nutrition, oral and gut microbiota, symptoms of FD, impaired function of the duodenal barrier, and inflammation. Assessing low-grade inflammation or increased permeability in the duodenal mucosa, along with changes in the abundance of stool Butyricicoccus, is anticipated to serve as effective biomarkers for enhancing the objectivity of FD diagnosis and monitoring. [ABSTRACT FROM AUTHOR]

Nucleos(t)ide analogues (NUCs) and interferon have been used for several decades to treat chronic hepatitis B; however, the therapeutic response remains unsatisfactory. Although NUC therapy exhibits potent on-treatment viral suppression, frequent off-therapy virological relapses suggest an indefinite treatment course. Interferon modulates the innate and adaptive antiviral immune responses and thus increases the chance of viral eradication. Interferon therapy has the advantage of a finite duration, absence of drug resistance, and durable posttreatment responses. Therefore, the combination of NUCs and interferon can theoretically facilitate a synergistic therapeutic effect. This paper summarizes the current strategies of various combination therapies into three categories: the simultaneous "dual" strategy, sequential combination "add-on" strategy, and "switch" strategy. Generally, dual therapy exhibits greater on-treatment and off-therapy viral suppression and lower drug resistance compared with NUC monotherapy. Compared with interferon monotherapy, dual therapy has greater on-treatment viral suppression but shows no difference in off-therapy sustained virological responses. Specific add-on or switch strategies provide promising on-treatment efficacy in select patients. Pretreatment or on-treatment quantitative hepatitis B surface antigen and e antigen are predictive for the treatment efficacy of combination therapy. The optimal schedule of combination regimens and individualized therapy remain to be comprehensively evaluated. [ABSTRACT FROM AUTHOR]

Background/Aims: There are no consensus guidelines for patients with acute cholecystitis undergoing percutaneous cholecystostomy who are unfit for interval cholecystectomy. The current study aimed to compare the clinical outcomes of endoscopic gallbladder drainage, i.e. conversion from percutaneous cholecystostomy (including endoscopic transpapillary gallbladder stenting and endoscopic ultrasound-guided gallbladder drainage), and conservative treatment after percutaneous cholecystostomy tube removal. Methods: This retrospective review included patients who underwent percutaneous cholecystostomy for acute cholecystitis between January 2017 and December 2020. Consecutive patients who underwent endoscopic gallbladder drainage or percutaneous cholecystostomy tube removal without interval cholecystectomy were included. Outcome measures included recurrent acute cholecystitis and unplanned readmission due to gallstone-related diseases. Results: During the study period, 238 patients were selected (63 underwent endoscopic gallbladder drainage conversion and 175 underwent conservative treatment). Patients who underwent endoscopic gallbladder drainage conversion had lower rates of recurrent acute cholecystitis (3 [4.76%] vs 31 [17.71%], p=0.012) and unplanned readmission due to gallstone-related diseases (6 [9.52%] vs 40 [22.86%], p=0.022) than those who underwent conservative treatment following percutaneous cholecystostomy tube removal. In the univariate and multivariate analyses, calculus cholecystitis (odds ratio, 13.75; 95% confidence interval, 1.83 to 102.83; p=0.011) and conversion of endoscopic gallbladder drainage (odds ratio, 0.23; 95% confidence interval, 0.06 to 0.78; p=0.019) were significant predictive factors for recurrent acute cholecystitis. Conclusions: Endoscopic gallbladder drainage conversion led to more favorable outcomes than conservative treatment after percutaneous cholecystostomy tube removal. Therefore, endoscopic gallbladder drainage conversion may be considered a promising treatment option for patients undergoing percutaneous cholecystostomy who are at a high surgical risk. [ABSTRACT FROM AUTHOR]

Background/Aims: This study investigated whether the personality traits of endoscopists are associated with the effect of interventions for the improvement of colonoscopy quality. Methods: This prospective, multicenter, single-blind study was performed with 13 endoscopists in three health screening centers over a 12-month period. Quality indicators (QIs), including adenoma detection rate (ADR), polyp detection rate (PDR), and withdrawal time, were measured every 3 months. Consecutive interventions for the improvement of colonoscopy quality were conducted every 3 months, which included the personal notification of QIs, the in-group notification of QIs, and finally a targeted “quality education” session. The personality traits of each endoscopist were evaluated for perfectionism, fear of negative evaluation, and cognitive flexibility after the last QI assessment. Results: A total of 4,095 colonoscopies were evaluated to measure the QIs of the individual endoscopists for 12 months. The mean ADR, PDR, and withdrawal time of the 13 endoscopists were 32.3%, 47.7%, and 394 seconds at baseline and increased to 39.0%, 55.1%, and 430 seconds by the end of the study (p=0.003, p=0.006, and p=0.004, respectively). Among the three interventions, only quality education significantly improved QIs: ADR, 36.0% to 39.0% (odds ratio, 1.28; 95% confidence interval, 1.01 to 1.63). The improvement of ADR and PDR by education was significantly associated with perfectionism (r=0.617, p=0.033 and r=0.635, p=0.027, respectively) and fear of negative evaluation (r=0.704, p=0.011 and r=0.761, p=0.004, respectively). Conclusions: Education can improve colonoscopy quality, and its effect size is associated with an endoscopist’s personal traits such as perfectionism and fear of negative evaluation. [ABSTRACT FROM AUTHOR]

The current standard treatment for muscularis propria-invasive (T2) colorectal cancer is surgical colectomy with lymph node dissection. With the advent of new endoscopic resection techniques, such as endoscopic full-thickness resection or endoscopic intermuscular dissection, T2 colorectal cancer, with metastasis to 20%-25% of the dissected lymph nodes, may be the next candidate for endoscopic resection following submucosal-invasive (T1) colorectal cancer. We present a novel endoscopic treatment strategy for T2 colorectal cancer and suggest further study to establish evidence on oncologic and endoscopic technical safety for its clinical implementation. [ABSTRACT FROM AUTHOR]

Background/Aims: Recent papers have highlighted the role of diet and lifestyle habits in irritable bowel syndrome (IBS), but very few population-based studies have evaluated this association in developing countries. The aim of this study was to evaluate the association between diet and lifestyle habits and IBS. Methods: A food frequency and lifestyle habits questionnaire was used to record the diet and lifestyle habits of 78 IBS subjects and 79 healthy subjects. Cross-tabulation analysis and logistic regression were used to reveal any association among lifestyle habits, eating habits, food consumption frequency, and other associated conditions. Results: The results from logistic regression analysis indicated that IBS was associated with irregular eating (odds ratio [OR], 3.257), physical inactivity (OR, 3.588), and good quality sleep (OR, 0.132). IBS subjects ate fruit (OR, 3.082) vegetables (OR, 3.778), and legumes (OR, 2.111) and drank tea (OR, 2.221) significantly more frequently than the control subjects. After adjusting for age and sex, irregular eating (OR, 3.963), physical inactivity (OR, 6.297), eating vegetables (OR, 7.904), legumes (OR, 2.674), drinking tea (OR, 3.421) and good quality sleep (OR, 0.054) were independent predictors of IBS. Conclusions: This study reveals a possible association between diet and lifestyle habits and IBS. [ABSTRACT FROM AUTHOR]

Background/Aims: Ultrasonography has a low sensitivity for detecting early-stage hepatocellular carcinoma (HCC) in cirrhotic patients. Non-contrast abbreviated magnetic resonance imaging (aMRI) demonstrated a comparable performance to that of magnetic resonance imaging without the risk of contrast media exposure and at a lower cost than that of full diagnostic MRI. We aimed to investigate the cost-effectiveness of non-contrast aMRI for HCC surveillance in cirrhotic patients, using ultrasonography with alpha-fetoprotein (AFP) as a reference. Methods: Cost-utility analysis was performed using a Markov model in Thailand and the United States. Incremental cost-effectiveness ratios were calculated using the total costs and qualityadjusted life years (QALYs) gained in each strategy. Surveillance protocols were considered cost-effective based on a willingness-to-pay value of $4,665 (160,000 Thai Baht) in Thailand and $50,000 in the United States. Results: aMRI was cost-effective in both countries with incremental cost-effectiveness ratios of $3,667/QALY in Thailand and $37,062/QALY in the United States. Patient-level microsimulations showed consistent findings that aMRI was cost-effective in both countries. By probabilistic sensitivity analysis, aMRI was found to be more cost-effective than combined ultrasonography and AFP with a probability of 0.77 in Thailand and 0.98 in the United States. By sensitivity analyses, annual HCC incidence was revealed as the most influential factor affecting cost-effectiveness. The cost-effectiveness of aMRI increased in settings with a higher HCC incidence. At a higher HCC incidence, aMRI would remain cost-effective at a higher aMRI-to-ultrasonography with AFP cost ratio. Conclusions: Compared to ultrasonography with AFP, non-contrast aMRI is a cost-effective strategy for HCC surveillance and may be useful for such surveillance in cirrhotic patients, especially in those with high HCC risks. [ABSTRACT FROM AUTHOR]

The article discusses the relationship between bile acids and gastric intestinal metaplasia (GIM), a precancerous condition that can lead to gastric cancer. Bile acid reflux is a significant cause of GIM, as it exposes the stomach lining to bile acids, which trigger the transformation of normal gastric cells into cells resembling intestinal cells. The article explores the role of GATA4, CDX2, and MUC2 in the activation of GIM and the potential for therapeutic interventions targeting these factors. The findings suggest a potential avenue for precision medicine strategies in the treatment of GIM and gastric cancer. [Extracted from the article]

The International Study Group for Pancreatic Fistula (ISGPF) made the first attempt to standardize the outcome measure of fistulas in the field of pancreatic surgery by publishing the definition and classification of postoperative pancreatic fistulas (POPFs) in 2005. POPFs were determined by any measurable volume of fluid output via an operatively placed drain with amylase activity greater than three times the upper normal serum value. Taking into account more than 10 years of reported experience worldwide, the updated definition published in 2016 by the reconvened International Study Group for Pancreatic Surgery (ISGPS) attempted to overcome the limits of the previous classification. The crucial concept of POPF clinical significance was introduced by eliminating grade A from the fistula scenario. The wider use of interventional procedures has also made it necessary to recode grade C POPFs, which now have clearer boundaries, toward the worst end of the severity scale. Grade B still represents the most prevalent and heterogeneous category of POPFs, both in terms of clinical burden and management. In the near future, further efforts will be required to better stratify grade B POPFs to standardize treatment strategies and compare outcomes among institutions. [ABSTRACT FROM AUTHOR]

Background/Aims: Most guidelines recommend surgical resection of all main duct (MD) and mixed-type (MT) intraductal papillary mucinous neoplasms (IPMNs) in suitable patients. However, there is little evidence regarding the malignancy risk of enhancing mural nodules (EMNs) that are present only in the main pancreatic duct (MPD) in patients with MD- and MT-IPMNs. Therefore, this study aimed to identify the clinical and morphological features associated with malignancy in MD- and MT-IPMNs with EMNs only in the MPD. Methods: We retrospectively enrolled 50 patients with MD- and MT-IPMNs with EMNs only in the MPD on contrast-enhanced magnetic resonance imaging. We evaluated the clinical characteristics and preoperative radiologic imaging results of MPD morphology and EMN size and analyzed the risk factors associated with malignancy. Results: Histological findings of EMNs were low-grade dysplasia (38%), malignant lesions (62%), high-grade dysplasia (34%), and invasive carcinoma (28%). On the receiver operating characteristic curve, the cutoff value of EMN size on magnetic resonance imaging for best predicting malignancy was 5 mm (sensitivity, 93.5%; specificity, 52.6%; area under the curve, 0.753). Multivariate analysis showed that only EMN >5 mm (odds ratio, 27.69; confidence interval, 2.75 to 278.73; p=0.050) was an independent risk factor for malignancy. Conclusions: EMNs of >5 mm are associated with malignancy in patients with MD- and MTIPMNs with EMNs that are present only in the MPD, in accordance with the international consensus guidelines. [ABSTRACT FROM AUTHOR]

Background/Aims Small bowel perforation due to foreign body ingestion is a rare case. Ingested foreign matter is usually released naturally without any problem. However, ingested foreign body can cause serious complications with a very low possibility. Intestinal perforation is the most common complication of foreign body intake. In this paper, we discuss a rare case of perforation in the distal part of the jejunum as a result of swallowing a foreign body in an elderly patient without gastrointestinal disease or previous history of surgery. Methods An 80 year-old women visited our center for abdominal pain. She has no previous history of intestinal problems. The initial vital signs were stable. Physical examination revealed tenderness at the lower abdomen. Laboratory results were as follow: white blood cell 12,310/mm3, hemoglobin 10.4 g/dL, platelet 201,000/mm3, neutrophil count 9,601.8/mm3, creatinine 1.53 mg/dL and C-reactive protein 11.12 mg/dL. On computed tomography, hyperdense linear lesions of about 1.6 cm were seen in the middle small bowel loop of the left lower quadrant, and inflammatory changes were observed around the bowel wall (Fig. 1). Laparoscopic examination revealed a small, sharp fishbone penetrating the small intestinal wall in the distal jejunum, and the lesion was removed by surgery. The patient was discharged 8 days after surgery without any complications. Conclusions The patient experienced bowel perforation at the distal-portion of the jejunum, despite normal bowel physiology with no history of intestinal disease or intraabdominal surgery. Our case shows that intestinal perforation due to foreign body intake should be considered in the differential diagnosis of acute abdominal pain. Appropriate history taking and imaging techniques will help the doctor make the correct diagnosis. Surgery is the best way to identify and treat intestinal perforation caused by the ingestion of foreign bodies. [ABSTRACT FROM AUTHOR]

Background/Aims Based on our earlier study among the elderly in primary care, the prevalence of functional constipation was 13.5% and 20% reported stool frequency <3 per week. In the current study, we aimed to determine predictors of decreased stool frequency among constipated elderly using a hierarchical linear regression model approach. Methods Consecutive elderly (above 65 years old) participants were recruited after informed consent. In addition to questionnaires (Rome III Questionnaire, demographic, diet and physical activity), patients underwent anorectal studies including high resolution anorectal manometry (M-Compass, Medspira), balloon expulsion test, and colonic transit study (Sitzmarks). Using multiple linear regression, association between a lower stool frequency in constipated elderly and independent factors (three hierarchical models i.e., model 1 demographic, model 2 risk factors and model 3 anorectal parameters) was determined with p<0.05 as significant. Results Of 71 elderly screened, 31 (2/3 females) were recruited, 17 had constipation and 14 without. With univariable analysis, those with versus without constipation reported lower stool frequency, longer duration of defecation, more Bristol type 1, 2 & 3 stools, water intake <6 glass per day, and less income per month (all p<0.05) (Table 1). With hierarchical model analysis, significant predictors of less frequent stools in elderly were the use of medications (adjusted B, -3.41; 95% confidence interval [CI], -6.61 to -0.22; p=0.037) in model 1, Bristol type 1, 2 & 3 stools (adjusted B, -5.4; 95% CI, -8.59 to -2.22; p=0.002) and longer duration of defecation (adjusted B -2.82; 95% CI, -5.34 to -0.31) in model 2, and lastly hyposensitivity (adjusted B, 0.19; 95% CI, 0.06 to 0.31) in model 3. Conclusions Among constipated elderly, the use of medications, Bristol type 1, 2 & 3 stools, longer duration of defecation and hyposensitivity predict less frequent stools. [ABSTRACT FROM AUTHOR]

Background/Aims: Low-volume preparations for colonoscopy are gaining attention for their higher acceptability. However, the efficacy and safety of oral sulfate solution (OSS) preparations in patients with ulcerative colitis (UC) has not been well known. Therefore, we aimed to compare OSS and 2-L polyethylene glycol with ascorbic acid (PEG+Asc) for bowel preparation in inactive UC. Methods: A multicenter, randomized, single-blind study was conducted at six tertiary referral hospitals in Korea. Outpatients with UC who had stable disease activity were randomly allocated to the OSS group or the 2-L PEG+Asc group for bowel preparation before colonoscopy. The study outcomes included treatment efficacy, safety, tolerability, and acceptability. Bowel cleansing was assessed using the Boston Bowel Preparation Scale and rated as successful cleansing if the score was ≥6. Patient acceptance and tolerability were assessed using a 4-point ordinal scale. Additionally, disease activity and laboratory data before and after colonoscopy were evaluated to check for safety. Results: The OSS and 2-L PEG+Asc groups included 92 and 93 participants, respectively. No significant between-group difference was noted in successful cleansing (OSS [96.7%] vs 2-L PEG+Asc [97.8%], p=0.64). Moreover, the safety, acceptance, and tolerability were not significantly different (all p>0.05). Furthermore, no significant changes were found in serum electrolytes or disease activity in either group. Conclusions: OSS is effective for colonoscopy cleansing, has acceptable tolerability, and does not affect disease activity; thus, it can be used safely for bowel preparation in patients with inactive UC. [ABSTRACT FROM AUTHOR]

Background/Aims: Among several methods used to prevent endoscopic submucosal dissection (ESD) bleeding, the recently developed hemostatic powder (HP) has few technical limitations and is relatively easy-to-use. This study aimed to analyze the hemostatic effects and mechanisms of two HPs using a porcine upper gastrointestinal hemorrhage model. Methods: We evaluated HPs (Endospray and epidermal growth factor [EGF]-endospray) for adhesion, waterproofing ability, permeability, and absorption in vitro. ESD was performed to induce bleeding ulcers in the porcine stomachs. In a total of three pigs, three bleeding ulcers per animal were generated. Hemostasis and rebleeding were evaluated endoscopically. After 72 hours, the animals were sacrificed, and histologically analyzed. Results: The water absorption of HPs was over 20 times the initial value within 30 minutes. The gelated HPs completely blocked water penetration into the applied site within 5 minutes and strongly adhered to the Petri-dish surface for up to 6 hours. The initial hemostasis rates within 5 minutes were 33.3%, 100.0%, and 66.7%, and the rebleeding rates at 6 to 72 hours after HP application were 33.3%, 16.7%, and 33.3% (control, Endospray, and EGF-endospray groups, respectively). Histological analysis revealed the thickness of the regenerated mucosa (522.1, 514.5, and 680.3 µm) and the submucosal layer (1,510.3, 2,848.2, and 3,062.3 µm) and the number of newly formed blood vessels (15.3, 17.9, and 20.5) in the control, Endospray, and EGFendospray groups, respectively. Conclusions: The endoscopic HPs demonstrated the ability to elicit effective initial hemostasis and the histological ulcer-healing effect of EGF in an animal model of hemorrhagic gastric ulcers. [ABSTRACT FROM AUTHOR]

Background/Aims: In patients with acute nonvariceal upper gastrointestinal bleeding (ANVUGIB), the optimal timing of endoscopy is still a matter of dispute. We conducted a systematic review and meta-analysis to determine the clinical benefit of early endoscopy. Methods: A literature search of the MEDLINE, Embase, and Cochrane databases was conducted to identify publications from inception to March 1, 2022. Eligible studies included observational cohort studies and randomized controlled trials that reported clinical outcomes of endoscopy in patients with ANVUGIB. ANVUGIB patients who underwent endoscopy within 24 hours of admission were considered to have had an early endoscopy. The primary outcome was the mortality rate in ANVUGIB patients who had early or nonearly endoscopy. Results: The final analysis included five randomized controlled studies (RCTs) and 20 observational studies from the 1,206 identified articles. The mortality rate was not significantly reduced among patients who received endoscopy performed within 24 hours, whether in cohort studies nor in RCTs. For subgroup analysis, a higher mortality rate was found only among patients who received very early endoscopy within 12 hours (odds ratio, 1.66; p<0.001, I2 =0) in cohort studies. No significant difference in mortality rates was found among patients at high risk of bleeding who received early versus nonearly endoscopy. Conclusions: Early endoscopy within 24 hours does not appear to significantly reduce the mortality rates of patients with ANVUGIB. Further well-designed studies are warranted to address if very early endoscopy within 12 hours can provide a clinical benefit for patients at high risk of bleeding. [ABSTRACT FROM AUTHOR]

Video capsule endoscopy (VCE) of the small-bowel has been proven to accurately diagnose small-bowel inflammation and to predict future clinical flares among patients with Crohn’s disease (CD). In 2017, the panenteric capsule (PillCam Crohn’s system) was introduced for the first time, enabling a reliable evaluation of the whole small and large intestines. The great advantage of visualization of both parts of the gastrointestinal tract in a feasible and single procedure, holds a significant promise for patients with CD, enabling determination of the disease extent and severity, and potentially optimize disease management. In recent years, applications of machine learning, for VCE have been well studied, demonstrating impressive performance and high accuracy for the detection of various gastrointestinal pathologies, among them inflammatory bowel disease lesions. The use of artificial neural network models has been proven to accurately detect/classify and grade CD lesions, and shorten the VCE reading time, resulting in a less tedious process with a potential to minimize missed diagnosis and better predict clinical outcomes. Nevertheless, prospective, and real-world studies are essential to precisely examine artificial intelligence applications in real-life inflammatory bowel disease practice. [ABSTRACT FROM AUTHOR]

A growing body of evidence has demonstrated an intricate association between inflammatory bowel disease (IBD) and neurodegenerative conditions, expanding beyond previous foci of comorbidities between IBD and mood disorders. These new discoveries stem from an improved understanding of the gut-microbiome-brain axis: specifically, the ability of the intestinal microbiota to modulate inflammation and regulate neuromodulatory compounds. Clinical retrospective studies incorporating large sample sizes and population-based cohorts have demonstrated and confirmed the relevance of IBD and chronic neurodegeneration in clinical medicine. In this review, we expound upon the current knowledge on the gut-microbiome-brain axis, highlighting several plausible mechanisms linking IBD with neurodegeneration. We also summarize the known associations between IBD with Parkinson disease, Alzheimer disease, vascular dementia and ischemic stroke, and multiple sclerosis in a clinical context. Finally, we discuss the implications of an improved understanding of the gut-microbiome-brain axis in preventing, diagnosing, and managing neurodegeneration among IBD and non-IBD patients. [ABSTRACT FROM AUTHOR]

Background/Aims: We aimed to investigate the comfort, safety, and endoscopic visibility during esophagogastroduodenoscopy (EGD) afforded by a modified 4-hour semifluid and 2-hour water (“4+2”) fasting protocol. Methods: In this parallel group, endoscopist-blinded, randomized controlled trial, outpatients undergoing unsedated diagnostic EGD from 10:30 AM to 12:00 PM were randomly assigned to either a “4+2” protocol group or a conventional fasting group. The participants’ comfort during the fasting period and procedure was measured using the visual analog scale, and mucosal visibility was measured by endoscopists using the total visibility score. Satisfaction was defined as a visual analog scale score of ≤3. The primary outcome was the participants’ comfort during fasting. Results: One hundred and six and 108 participants were randomized to the “4+2” protocol and control groups, respectively. Participants’ comfort before EGD was significantly higher in the “4+2” protocol group measured by both the proportion of satisfaction (86.8% vs 63.9%, p=0.002) and the visual analog scale score (median [interquartile range]: 1.0 [1.0–2.0] vs 3.0 [1.0–4.0], p<0.001). The proportion of satisfaction during EGD also significantly improved (59.4% vs 45.4%, p=0.039) in the “4+2” protocol group. The total visibility score was unaffected by the fasting protocol (5.0 [4.0–5.0] vs 4.0 [4.0–5.0], p=0.266). No adverse events were observed during the study. Conclusions: The “4+2” protocol was more comfortable and provided equal mucosal visibility and safety compared with conventional fasting for unsedated EGD. [ABSTRACT FROM AUTHOR]

Background/Aims: We explored whether high sodium intake, assessed by urinary excretion, determines the risk of sarcopenia and nonalcoholic fatty liver disease (NAFLD). Methods: We analyzed 10,036 adult participants with normal kidney function from the Korea National Health and Nutrition Examination Survey (2008–2011). NAFLD was identified using the fatty liver index, and the muscle mass was evaluated using dual X-ray absorptiometry. The dietary sodium intake was estimated using Tanaka’s equation. Results: The mean 24-hour urinary sodium excretion was 144.2±36.1 mmol/day (corresponding to 3.3 g/day Na) in the total population. The 24-hour urinary sodium excretion showed moderate accuracy in predicting NAFLD (area under the receiver operating characteristic, 0.702; 95% confidence interval [CI], 0.692 to 0.712). A cutoff value of 99.96 mmol/day (corresponding to 2.30 g/day Na) for urinary sodium excretion in predicting NAFLD showed 76.1% sensitivity and 56.1% specificity. The results of multiple adjusted models indicated that the participants with the highest urinary sodium excretion had a significantly higher risk of NAFLD (odds ratio, 1.46; 95% CI, 1.27 to 1.66; p<0.001) and sarcopenia (odds ratio, 1.49; 95% CI, 1.28 to 1.73; p<0.001) than those with the lowest urinary sodium excretion. The association between a higher 24-hour urinary sodium excretion and NAFLD was independent of sarcopenia. Conclusions: Participants with a high sodium intake, as assessed by sodium excretion, had a substantial risk of NAFLD and sarcopenia. [ABSTRACT FROM AUTHOR]

Background/Aims: A full colonoscopy is currently required in children and adolescents with colorectal polyps, because of their potential of neoplastic transformation and complications such as intussusception. We aimed to analyze the associations of polyp characteristics in children and adolescents with colorectal polyps. Based on these findings, we also aimed to reevaluate the necessity of conducting a full colonoscopy. Methods: Pediatric patients <18 years of age who had undergone a colonoscopic polypectomy and those with <5 colorectal polyps were included in this multicenter, retrospective study. Baseline clinicodemographics, colonoscopic and histologic findings were investigated. Results: A total of 91 patients were included. Multivariate logistic regression analysis showed that polyp size was the only factor associated with the presence of any polyps located proximal to the splenic flexure (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.28 to 4.28; p=0.007). Furthermore, polyp location proximal to the splenic flexure and sessile morphology were associated with the presence of any adenomatous polyp (OR, 8.51; 95% CI, 1.43 to 68.65; p=0.023; OR, 18.41; 95% CI, 3.45 to 173.81; p=0.002, respectively). Conclusions: In children and adolescents presenting with <5 colorectal polyps, polyp size and the presence of any adenomatous polyp were positively associated with polyp location proximal to the splenic flexure. This finding supports the necessity of a full colonoscopic exam in pediatric patients with colorectal polyps for the detection of polyps before the occurrence of complications such as intussusception or neoplastic transformation. [ABSTRACT FROM AUTHOR]

Background/Aims: Enteroenteric intussusception in Peutz-Jeghers syndrome (EI-PJS) is traditionally treated by surgery. However, enteroscopic treatment is a minimally invasive approach worth attempting. We aimed to develop a risk scoring system to facilitate decision-making in the treatment of EI-PJS. Methods: This was a single-center case-control study, including 80 patients diagnosed with PJS and coexisting intussusception between January 2015 and January 2021 in Air Force Medical Center. We performed logistic regression analysis to identify independent risk factors and allocated different points to each subcategory of risk factors; the total score of individuals ranged from 0 to 9 points. Then, we constructed a risk stratification system based on the possibility of requiring surgery: 0–3 points for “low-risk,” 4–6 points for “moderate-risk,” and 7–9 points for “high-risk.” Results: Sixty-one patients (76.25%) were successfully treated with enteroscopy. Sixteen patients (20.0%) failed enteroscopic treatment and subsequently underwent surgery, and three patients (3.75%) received surgery directly. Abdominal pain, the diameter of the responsible polyp, and the length of intussusception were independent risk factors for predicting the possibility of requiring surgery. According to the risk scoring system, the incidence rates of surgery were 4.44% in the low-risk tier, 30.43% in the moderate-risk tier, and 83.33% in the high-risk tier. From low- to high-risk tiers, the trend of increasing risk was significant (p<0.001). Conclusions: We developed a risk scoring system based on abdominal pain, diameter of the responsible polyps, and length of intussusception. It can preoperatively stratify patients according to the risk of requiring surgery for EI-PJS to facilitate treatment decision-making. [ABSTRACT FROM AUTHOR]

Acute pancreatitis can range from a mild, self-limiting disease requiring no more than supportive care, to severe disease with life-threatening complications. With the goal of providing a recommendation framework for clinicians to manage acute pancreatitis, and to contribute to improvements in national health care, the Korean Pancreatobiliary Association (KPBA) established the Korean guidelines for acute pancreatitis management in 2013. However, many challenging issues exist which often lead to differences in clinical practices. In addition, with newly obtained evidence regarding acute pancreatitis, there have been great changes in recent knowledge and information regarding this disorder. Therefore, the KPBA committee underwent an extensive revision of the guidelines. The revised guidelines were developed using the Delphi method, and the main topics of the guidelines include the following: diagnosis, severity assessment, initial treatment, nutritional support, convalescent treatment, and the treatment of local complications and necrotizing pancreatitis. Specific recommendations are presented, along with the evidence levels and recommendation grades. [ABSTRACT FROM AUTHOR]

The impact of the coronavirus disease 2019 (COVID-19) pandemic has been immense, and it continues to have lasting repercussions. While the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus primarily infects the respiratory system, other organ systems are affected, including the liver. Scientific knowledge on the role of SARS-CoV-2 infection and liver injury has evolved rapidly, with recent data suggesting specific hepatotropism of SARS-CoV-2. Moreover, additional concerns have been raised in regard to long-term liver damage, related to emerging cases of post-COVID-19 cholangiopathy and chronic cholestasis. Great effort has also been focused on studying how specific subpopulations with chronic medical conditions might be disproportionately impacted by COVID-19. One such population includes individuals with chronic liver disease (CLD) and cirrhosis, with an expanding body of research indicating these patients being particularly susceptible to adverse outcomes. In this review, we provide an updated summary on the current pathogenesis and mechanism of liver injury in the setting of SARS-CoV-2 infection, the association between health outcomes and SARS-CoV-2 infection in patients with CLD, and the unique consequences of the COVID-19 pandemic on the routine care of patients with CLD. [ABSTRACT FROM AUTHOR]

Background/Aims In clinical practice, the development of diabetic ketoacidosis (DKA) secondary to acute pancreatitis (AP) is rare. AP precipitates a more severe episode of DKA due to marked depletion of the intravascular volume. The aim of this paper is trying to present the complicated relationship of AP and DKA. Methods The following methods were executed: observation, listening, talks, medical history collection, physical assessment, direct care. Results This 73-year-old female had a past history of hypertension. She presented to emergent department with epigastric discomfort. The laboratory data showed leukocytosis, elevated lipase, hyperbilirubinemia, elevated aminotransferases, hyperglycemia, elevated ketone body. Abdominal computed tomography (CT) revealed AP. She was admitted due to new-onset DKA and AP. After admission, her insulin regimen was continued after resolution of DKA. Aggressive fluid resuscitation with 6-L crystalloid fluid was given. However, progressive dyspnea was noted. Endotracheal intubation was performed on June 5, 2018. Abdominal CT showed acute necrotizing pancreatitis and suspicious multiple focal infarctions in the both lobes of liver. We change antibiotic to Doripenem because of elevated infection parameters. After treatment, the clinical condition improved a lot. After hemodynamic status stabilized, we started diuretic therapy. Abdominal CT was repeated; progression of ascites and misty mesentery was noted. We consulted radiologist for evaluation of drainage. However, high operative risk was informed. Medical treatment was suggested. After diuresis, extubation was performed successfully on June 22, 2018. She recovered well. She was discharged on July 3, 2018. Conclusions DKA may mask a coexisting AP. AP can worsen hypovolemic shock and metabolic derangement in DKA. Aggressive hydration, insulin/dextrose infusion and initiation of a fibrate resulted in correction of acidosis. Continuous to monitor AP complications such as acute respiratory distress syndrome, pancreatic necrosis, infection, and pseudocysts are very important. [ABSTRACT FROM AUTHOR]

Background/Aims There is a lack of studies addressing mortality and causes of death in cohorts of Asian patients with intestinal Behcet disease (BD). This study aimed to assess causes of death in patients with intestinal BD and compare the related factors with mortality in a single center with a retrospective manner. Methods Total 543 patients who diagnosed intestinal BD in Severance Hospital, Yonsei University College of Medicine, Seoul, Korea, between January 1989 and December 2015 were enrolled to this study. Patient's baseline demographic and clinico-laboratory data were collected based on electronic and paper medical records. The baseline characteristics and treatment related outcomes were compared between dead intestinal BD patients and control group (n=115, age, sex and diagnosis periods were matched). All factors with p-value of <0.05 in the univariate analysis were included in a Cox proportional hazards multivariate model. Results Total 57 patients (10.5%) with intestinal BD died during study periods. The median duration of follow-up period was 32.1 months (range, 1 to 280 months). Main causes of death included systemic infection (n=18, 31.6%), malignancy (n=16, 28.1%) and cardiovascular disease (n=14, 24.6%). In multivariate analyses, combined hematologic disease (hazard ratio [HR], 5.016; 95% confidence interval [CI], 2.459 to 10.230), Charlson comorbidity index (HR, 1.485; 95% CI, 1.257 to 1.754), loss of weight (HR, 5.422; 95% CI, 2.368 to 12.416), extraintestinal manifestations at major vessels (HR, 2.211; 95% CI, 1.077 to 4.540) and disease distribution at upper gastrointestinal tract (HR, 3.949; 95% CI, 1.752 to 8.900) were associated with the risk of mortality. Conclusions Main causes of death were systemic infection, malignancy and cardiovascular disease. Combined hematologic disease, Charlson comorbidity index, loss of weight, extra-intestinal manifestations at major vessels and disease distribution at upper gastrointestinal tract were associated with increase of mortality in intestinal BD. [ABSTRACT FROM AUTHOR]

Background/Aims Carotenoids are hydrocarbons which play an important role in photomorphogenesis, photosynthesis, photoprotection, development and defense of plants. Capsanthin is a crystalline red color pigment found as main components of Capsicum annuum fruits during the ripening. Capsanthin is also found in Lilium, Aesculus, Berberis and Asparagus officinalis. Methods Various literature databases have been searched to collect all the information of capsanthin particularly for their anti-cancer potential. Results Chemically capsanthin contains cyclopentane ring, 11 conjugated double bonds and a conjugated keto group. Capsanthin is a powerful antioxidant and anti-tumor activities, attenuates obesity-induced inflammation and raises plasma high-density lipoprotein cholesterol levels. Conclusions The purpose of this work is to collect all the data of beneficial aspects of capsanthin. In this paper, medicinal importance and pharmacological activities of capsanthin are discussed and found that it has significant anti-cancer potential. This work aims to highlight all the literature support of capsanthin in the drug discoveries with special reference to their anti-cancer properties. [ABSTRACT FROM AUTHOR]

Background/Aims We aimed to validate the updated version of Korean stroop test for MHE screening. Methods Liver cirrhosis (LC) patients without history of overt HE were recruited prospectively from 13 centers. All participants completed Korean paper-pencil test (KPPT) and the Korean stroop test. Korean stroop test consisted of two stroop-off states (color and word) and two stroop-on states (inhibition and switching). Four types of "on time+off time"s were analyzed (color-plus-inhibition, color-plus-switching, word-plus-inhibition, and word-plus-switching). MHE was diagnosed when KPPT scores ≥2. Results A total of 119 LC patients and 792 healthy controls were enrolled. The most common etiology of LC was alcohol (62.8%). Mean Model for End Stage Liver Disease (MELD) score of LC patients was 11. Prevalence of MHE was 39.5% by KPPT. Four types of "on time+off time" significantly differed among healthy controls, cirrhosis patients without MHE, and cirrhosis patients with MHE. All types of "on time+off time" showed positive correlation with PHES scores (all p<0.01). The highest area under the curve (AUC) among "on time+off time"s, was for word-plus-inhibition (AUC, 0.699; 95% confidence interval, 0.603 to 0.795; p<0.001) in discrimination of MHE. Ln prothrombin time (international normalized ratio; odds ratio [OR), 197.33; p=0.008) and word-plus-inhibition (OR, 1.012; p=0.011) were significant in multivariate analysis for MHE diagnosis. The cutoff point for the highest Youden's index value was 155 seconds for word-plus-inhibition time with 78.8% of sensitivity and 60.6% of specificity. In the subgroup of patients with MELD score less than 11, on time+off time for word-plus-inhibition was the only prognostic factor in the diagnosis of MHE (OR, 1.008; p=0.037). Conclusions The Korean Stroop Test is simple and valid for screening of MHE. [ABSTRACT FROM AUTHOR]

Background/Aims Pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) is a major concern among procedure-related adverse events. Although several risk factors were identified from previous studies, there was no study for optimal procedure time to prevent post-ERCP pancreatitis (PEP). We reviewed ERCP database to evaluate the association between procedure time and PEP. Methods Database for ERCP procedure between September 2012 and July 2019 at Kyungpook National University Chilgok Hospital was prospectively reviewed. We enrolled patients with naïve papilla who underwent ERCP. Risk factors for PEP was evaluated and decision tree analysis was conducted to evaluate the association between procedure time and the occurrence of PEP. Results We analyzed 896 consecutive patients with naïve papilla. Among them, PEP occurred in 61 patients (6.8%). The times for overall procedure and selective biliary cannulation in patients with PEP were longer than in those without PEP (26.2±11.6 minutes vs 20.2±11.1 minutes, p<0.001 and 12.5±9.0 minutes vs 8.1±6.6 minutes, p<0.001). Decision tree analysis revealed that overall procedure time of less than 20 minutes and selective biliary cannulation time of less than 6 minutes were decisive factors for the reduced risk of PEP with adjust p-value of <0.001 and 0.011, respectively. Conclusions According to our study results, we recommend that the procedure time for selective biliary cannulation might be not exceed 6 minutes to avoid the occurrence of PEP and additional preventive management would be required in case of longer procedure time. [ABSTRACT FROM AUTHOR]

Background/Aims To date, usually, the initial treatment of acute pancreatitis (AP) consists of nil per oral (NPO) regimen and administration of analgesic and abundant intravenous fluids. It is assumed that the benefit without food intake that pancreatic stimulation be enteral feeding may aggravate pancreatic inflammation. However, the validity of such assumptions is pretty much debatable. On the other hand, various studies have revealed that enteral feeding significantly reduced the risk of infection, lowers the need of surgical intervention, and reduces the length of hospital stay. Results from the meta-analysis show that mortality rate is significantly reduced when patients of acute pancreatitis are fed enterally. More importantly, the timing of the start of the start of nutrition, within 48 hours of hospital admission a factor that relate in the reduction of the mortality in patients with severe AP. Methods The prospective randomized control trial is designed in patients with diagnosed mild to moderate pancreatitis. The patients satisfying the inclusion criteria were subjected to early nasogastric tube feeding and were compared with NPO group. Results In the present study, we investigated an alternative approach to reinitiating feeding that was based on hunger, without the remission of abdominal pain or normalization of pancreatic amylase and lipase. Our results demonstrated that early oral refeeding based on this approach significantly decreased the duration of hospitalization. We found mean difference between the groups was 1.65 (p=0.04). Conclusions Based on the finding illustrated above it implies that early enteral feeding could be appropriate strategy for the management of mild to moderate acute pancreatitis in term of reduction of hospital stay and intensity of pain score. [ABSTRACT FROM AUTHOR]

Background/Aims Besifovir dipivoxil maleate (BSV) is an acyclic nucleotide phosphonate with a potent antiviral activity against hepatitis B virus (HBV). An antiviral efficacy of BSV for 48 weeks was shown to be comparable to tenofovir disoproxil fumarate (TDF) with improved renal and bone safety. We evaluated the efficacy and safety of BSV in treatment- naïve chronic hepatitis B patients in 192 weeks follow-up study. Methods After 48 weeks of double-blind comparison of BSV to TDF, patients continued to participate in the open-label BSV study. We evaluated antiviral efficacy and drug safety up to 192 weeks for both BSV continuing group (BSV-BSV) and the group switched from TDF to BSV after 48 weeks (TDF-BSV). The primary endpoint was virological response (HBV DNA <69 IU/mL). Results Among 197 patients who received randomized treatments, 170 for 2nd year, 157 for 3rd year and 152 for 4th entered the open-label phase extensional study. Finally, 150 patients completed 192 weeks of follow-up. The virological response rate over 192 weeks was 92.5% in BSV-BSV while 93.1% in TDF-BSV patients (p=0.90). HBeAg seroconversion and alanine aminotransferase normalization rates were similar between the groups. There were no drug resistant mutations to BSV. Bone mineral density and renal function were well preserved in BSV-BSV while those were once worsened and then recovered after switching therapy in TDF-BSV patients. Conclusions BSV maintained antiviral efficacy over 192 weeks without any resistance. BSV was also effective for those who have switched from TDF to BSV. BSV was safe and well tolerated. [ABSTRACT FROM AUTHOR]

Background/Aims To eliminate hepatitis C virus (HCV) infection by 2030, improving the public knowledge of and accessibility to HCV screening and treatment is essential. The aim of this study was to evaluate the knowledge and testing rate of HCV and the opinions about the inclusion of the HCV test in the Nation Health Examination among the general population of South Korea. Methods A telephone interview survey was conducted by an independent research company using a 16 item-questionnaire (demographic, knowledge on HCV, testing rate and its result, necessity of screening) during May 2019. The sample population consisted of 1,003 Korean adult residents adjusted by age, gender and area according to the standard Korean population in 2019. Results Among the 1,003 participants (498 men and 505 women, mean age of 47.9 years), 56.4% recognized HCV; 44.4% understood HCV is transmittable; and 56.4% thought HCV is curable by medication. Testing for anti-HCV was reported by 91 people (9.1%); among them, 10 people (11.0%) reported a positive result, and eight people were treated. The common reasons for HCV testing were a health check-up (58.5%), a physician's recommendation (11.0%) and elevated liver enzymes (10.7%). The HCV testing rate was significantly low in the young age group with those in their 20s (2.3%), but the people in their 30s and above had a similar testing rate from 9% to 12.9% according to increasing age. The majority (75.1%) agreed to HCV screening by integration into the National Health Examination System. Conclusions The level of knowledge on HCV is suboptimal, and the self-reported testing rate of HCV is less than 10%, but once diagnosed, the treatment rate seems to be high in South Korea. More active campaigns and effective screening are urgently needed. [ABSTRACT FROM AUTHOR]

Background/Aims Hepatoid adenocarcinoma (HAC) is a rare variant characterized by hepatocellular differentiation and poor outcome. Little is known about HAC due to its rarity. We aimed to evaluate the distribution and clinicopathologic spectrum of HAC of the gastrointestinal tract (GIT). Methods Clinicopathologic data of all HAC of GIT (2003-2018) were retrieved and the diagnosis confirmed on histopathology (as per the World Health Organization classification). Results A total of 23 cases were studied. The median age was 55 years (range, 33 to 85 years); male-to-female ratio was 1.3. Sites of primary tumor included: stomach (61%), gallbladder (17%), rectum (13%), gastroesophageal junction (4.5%), and pancreas (4.5%). Serum alfa-fetoprotein levels ranged from 54 to 22,570 ng/mL (median, 1,725 ng/mL). Serum carcinoembryonic antigen was elevated in 13 (58%). Seventy percent of patient had distant metastases at presentation. Median tumor size was 6.5 cm. Radical surgery was possible in five patients; two received prior neoadjuvant chemotherapy. On microscopy, tumor cells were hepatoid in appearance; the proportion of hepatoid cells ranged from 10% to 90%; 25% revealed subnuclear vacuolation reminiscent of fetal enteric-type epithelium. On immunohistochemistry, all tumors showed reactivity for at least two glandular markers (CK20, CDX2, CK19, CK7) and two hepatocytic markers (HepPar1), glypican- 3, AFP and arginase-1. c-erbB2 (0/6) and mismatch repair protein deficiency (0/3) was absent. Adjuvant chemotherapy, palliative chemotherapy, and best supportive care were given in five, 15 and two patients, respectively. Distant metastases were observed in 88% patients; the commonest site was liver (71%). One patient was alive without disease, 17 developed progressive disease while five patients died of disease. Median progression-free survival was 4 months and median overall survival was 6 months. Conclusions HAC is a rare malignancy with a high rate of systemic dissemination and a poor outcome. Accurate diagnosis at an early stage and effective multimodality treatment is the need of the hour. [ABSTRACT FROM AUTHOR]

Background/Aims Cisplatin and 5 fluorouracil (5-FU) based concurrent chemoradiotherapy (CCRT) has become a standard treatment option for patients with unresectable or medically inoperable esophageal cancer. The aim of this study was to assess the acute cardiac toxicity in CCRT for oesophageal cancer patients. Methods From August 2016 to September 2017, 41 patients with histologically proven oesophageal cancer were treated with three dimensional conformal radiotherapy with total dose of 50 Gy with concurrent chemotherapy (cisplatin+5-FU) for 3 weeks. To assess the acute cardiac toxicity, weekly early gastric cancer (ECG) during CCRT and chest X-ray, ECG and Echocardiogram before and after CCRT were done. Results In this study, 14 patients (34%) had no specific ST-T changes and specific ST-T changes. Although 34% were diagnosed as coronary artery disease, only 10 patients (24%) developed chest pain. V30Gy was <40% in all patients (p=0.87175). The mean cardiac dose was less than 26% and EF was reduced after CCRT (p=0.26015). Two patients (5%) developed grade 1 cardiac dysrhythmia during treatment which were transient. All patients had reduction in resting EF by <20% after CCRT (grade 1 cardiac toxicity) but no therapy was required. Fourteen patients (34%) developed grade 1 and grade 2 cardiac ischaemia during and after CCRT which were treatable but no patient developed cardiac/pericardial effusion during and after CCRT treatment. Conclusions In conclusion, CCRT for oesophageal cancer impaired LVF both systolic and diastolic and this impairment was prominent in the high LV-dose group. Cardiac ischaemia which was a treatable stage of radiation induced coronary artery disease was also found. Therefore, all patients in this study were tolerated well to combination of radiotherapy and concurrent chemotherapy without significant side effects. [ABSTRACT FROM AUTHOR]

Background/Aims Compared to surgery, adjuvant TS-1 and XELOX regimen in gastric cancer (GC) has shown survival benefit after D2 gastrectomy. As the elderly population continues to grow, adjuvant chemotherapy (AC) has become important. Clinicians hesitate to offer chemotherapy to elderly patients because of comorbidities and intolerability. This study aims to investigate the efficacy, safety, and compliance of AC with TS-1 and XELOX regimen in patients aged >70 years. Methods We collected data on stage II/III GC patients who underwent D2 gastrectomy followed by AC (TS-1 or XELOX regimen) between January 2013 and December 2018 at Chungnam National University Hospital. They were classified into two groups by age which is over 70 years or not; we analyzed baseline characteristics, adverse events, overall survival (OS), relapse free survival (RFS), rates of regimen completion, and dose reduction. Results There was no significant difference in OS and RFS between both regimens. The TS-1 group had 232 patients (92 elderly). For grade >3 adverse events, elderly patients had more anemia (p=0.029) and lower completion rates (78.4% vs 91.5%, p<0.001) but not dose reduction rates; both OS and RFS were lower (p=0.034 and 0.026) (Fig. 1A and B). The XELOX group had 119 patients (27 elderly). For grade >3 adverse events, elderly patients had more thrombocytopenia (p=0.02); no differences in completion and dose reduction rates; and no differences in OS and RFS (Fig. 1C and D). Conclusions There was no difference in efficacy between the TS-1 and XELOX regimens; both were tolerable in elderly patients. The XELOX group showed no differences in OS and RFS, which were lower in the TS-1 group, possibly due to decreased completion rates. Clinicians should not hesitate to prescribe AC to elderly patients. Furthermore, completing chemotherapy schedule should be important. [ABSTRACT FROM AUTHOR]

Background/Aims The Aim of this study is to evaluate the predictive factors prior to the initiation of biofeedback therapy in patients with dyssynergic defecation or fecal incontinence. Methods We retrospectively reviewed patients who underwent biofeedback therapy at tertiary referral hospital between October 2004 and April 2015 for symptoms of defecatory dysfunction and fecal incontinence. Clinical response was recorded after a course of biofeedback therapy and response rates based on patient opinion (3 points or more satisfaction and two or more times a week increased the number of defecation). Results A total of 238 patients who underwent biofeedback therapy. One hundred sixty- nine (71%) were responder and 69 (29%) were not. Of those who underwent at least four biofeedback sessions, subjective short-term response rates were 113 of 167 (67%) in the constipation group and 27 of 39 (69%) in the FI group, 26 of 29 (89%) in the combination group and 3 of 3 (100%) in the anal pain group. Multivariate analysis was performed for those variables significant in the univariate analysis. The global bowel satisfaction score before biofeedback therapy (odds ratio [OR], 0.718; 95% confidence interval [CI], 0.583 to 0.886; p=0.002), the bowel movement frequency before biofeedback therapy (OR, 0.860; 95% CI, 0.764 to 0.968; p=0.012), rectal volume for constant sensation (OR, 0.989; 95% CI, 0.979 to 1.000; p=0.047), and pelvic floor descent (OR, 0.655; 95% CI, 0.456 to 0.942; p=0.022) were found to be the factors independently associated with good respond to biofeedback therapy. Conclusions Our data show that the higher global bowel satisfaction score, higher bowel movement frequency before biofeedback therapy, higher rectal volume for constant sensation, and higher pelvic floor descent are associated with poor response to biofeedback therapy for patients with dyssynergic defecation or fecal incontinence. [ABSTRACT FROM AUTHOR]

Background/Aims Obesity is an established risk factor of erosive esophagitis and metabolic unhealthiness has been implicated in the pathogenesis of erosive esophagitis. Yet, the risk of erosive esophagitis among obese individuals without obesity-related metabolic unhealthiness, a condition referred to as metabolically healthy obese (MHO), remains unclear. We examined the association between body mass index (BMI) categories and the development of erosive esophagitis in a cohort of metabolically healthy individuals. Methods We conducted a cohort study of 14,725 asymptomatic adults free of erosive esophagitis and metabolic abnormalities, who underwent repeated health check-ups including screening endoscopy. A metabolically healthy state was defined as having no metabolic syndrome components and a homeostasis model assessment of insulin resistance <2.5. The presence of erosive esophagitis was determined using endoscopy. Results During 81,385.2 person-years of follow-up, 1,865 participants developed erosive esophagitis (incidence rate, 22.9 per 1,000 person-years). The multivariable adjusted hazard ratios (95% confidence intervals) for incident erosive esophagitis comparing overweight (BMI, 23.0-24.9 kg/m2) and obese (≥25 kg/m2) with normal-weight participants (18.5-22.9 kg/m2) were 1.12 (1.00-1.25 kg/m2) and 1.29 (1.14-1.47 kg/m2), respectively. In dose-response analyses, increasing BMI also showed positive association with overall and LA-B grade or higher. The association persisted in MHO individuals without central obesity. The association between waist circumference categories and the development of erosive esophagitis was also evident. Conclusions In a large cohort of strictly defined metabolically healthy men and women, the MHO phenotype was associated with an increased incidence of erosive esophagitis, providing evidence that the MHO phenotype is not protective from gastroesophageal reflux disease. [ABSTRACT FROM AUTHOR]

Background/Aims Impedance baseline measurements can be used to evaluate changes in the integrity of the mucosa. Baseline impedance is known to be correlated with transepithelial resistance, which reflects impaired mucosal permeability. Recently, impaired duodenal mucosal integrity associated with increased mucosal permeability and/or low grade inflammation is suggested to be involved in the pathogenesis of functional dyspepsia (FD). The aim of the study was to measure the mucosal impedance values in the duodenum and antrum of patients with FD and compare those values with healthy controls. Methods Eighteen adult patients (male:female, 8:10; mean age, 60 years) referred to Ajou University Hospital for chronically recurrent dyspeptic symptoms, who were finally diagnosed FD based on the Rome IV criteria, and 12 asymptomatic healthy controls (male:female, 2:10; mean age, 60 years) were enrolled in a prospective manner. Mucosal impedance measurement was performed on the duodenal 1st part, distal antrum, and distal esophagus just above EG junction during conventional endoscopy in the fasting state. Results Age and sex ratio did not significantly differ between patients with FD and healthy controls. Mucosal impedance values at D were significantly lower in patients with FD (p=0.012) and in patients with PDS alone (p=0.049), and tended to be lower in patients with EPS alone (p=0.074), compared with healthy controls. Mucosal impedance values at A were significantly lower in patients with FD (p=0.043), and tended to be lower in patients with EPS alone (p=0.073) and in patients with PDS and EPS (p=0.071), compared with healthy controls. Those values did not significantly altered in patients with PDS alone. Mucosal impedance values at E were significantly lower in patients with EPS alone, but did not significantly altered in other groups, compared with healthy controls. Conclusions Mucosal impedance values are significantly decreased on the duodenum and distal antrum in patients with FD, compared with controls. Mucosal impedance values are significantly decreased in the duodenum of the patients with PDS and the distal esophagus of the patients with EPS, and tend to be decreased in the duodenum and distal antrum of the patients with EPS, and the distal antrum of the patients with overlap of PDS and EPS. These alterations may suggest the involvement of altered mucosal permeability in the pathogenesis of FD, requiring further investigation. [ABSTRACT FROM AUTHOR]

Background/Aims Functional dyspepsia (FD) is a common functional gastrointestinal disease which accompanied with alterations in cerebral functional connections. This study aimed to explore the potential of the functional brain network to be utilized for FD diagnosis and purposed to pick out the important consensus features to distinguish FD patients from healthy subjects. Methods Sixty-seven FD patients and 68 healthy subjects were scanned with a 3.0T magnetic resonance imaging scanner. The whole brain was divided into 116 regions according to the automated anatomical labeling atlas. The static correlation was adopted to compute the functional connectivity between each pair of regions to generate the functional brain network, which would be used as the classification feature. After feature filtering with the method of differential region accumulation, a linear kernel support vector machine (SVM) classifier was adopted to do the classification analysis. A leave-one-out cross-validation strategy was used to evaluate the performance of the classifier, and the accuracy, the sensitivity, the specificity, and the area under the receiver operating characteristic curve (AUROC) were applied to quantify the performance of the classifier. Results The accuracy of the SVM classifier could reach up to 0.926 (specificity, 0.912; sensitivity, 0.94; AUROC, 0.969) by using the 65 highest ranked features. The consensus features used to distinguish FD were mainly located within the gastric sensation neuromatrix, the limbic system, and the default mode network. Specifically, the bilateral angular gyrus demonstrated the highest weight in classification (Fig. 1). Conclusions This study illustrated that the resting-state functional brain network had good diagnostic potential for FD. The gastric sensation neuromatrix, limbic system, and default mode network could be used as the classification features to distinguish FD patients from healthy subjects. [ABSTRACT FROM AUTHOR]

Background/Aims Analyze the long-term results of surgical treatment of gastroesophageal reflux disease (GERD) in combination with hiatal hernia (HH). Methods The study included 41 patients aged 24 years to 71 years, 10 men and 31 women. All patients underwent surgical treatment of GERD in combination with HH. Patient complaints, endoscopic and fluoroscopic signs of GERD and HH were evaluated in the range from 1 year to 8 years after surgery. Results The average age of patients at the time of surgery was (47.2±2.4) years. Laparoscopic fundoplication (LFP) was performed on 38 patients (92.7%) according to Toupet with unilateral (13 people) or bilateral (25 people) crurography. Two patients underwent NFP according to Nissen; one patient, esophagofundoraphia with incomplete fundoplication according to Chernousov. In 10 cases, simultaneously with LFP, a laparoscopic cholecystectomy was performed for chronic calculous cholecystitis, in six cases, selective proximal vagotomy was performed for patients with duodenal ulcer, five patients underwent laparoscopic hernioplasty (umbilical hernia, white line hernia). When analyzing the long-term results of surgical treatment in the period (2.8±0.7) years after surgery, HPAI was detected in 22 people. It was also revealed that the presence of gastroesophageal reflux correlated with the age of the patients at the time of surgery (r=0.32, p=0.04), the presence of a fixed HH correlated with the male gender (r=0.3, p=0.04). Axial cardial HPLC was less frequently detected after Toupet LFP combined with bilateral crurography (r=-0.36, p=0.02). Conclusions Thus, post-fundoplication symptoms often occur after surgery at an older age. Toupet LFP with bilateral crurography is associated with better postoperative outcomes. [ABSTRACT FROM AUTHOR]

Background/Aims To assess the efficacy and safety of adalimumab, a recombinant human monoclonal antibody against tumor necrosis factor α (TNF-α), and to explore predictors of response in Korean patients with ulcerative colitis (UC). Methods We conducted a prospective observational multicenter study over 56 weeks in adult patients with moderately to severely active UC. The primary outcomes were rates of clinical response at week 8 and 56. Secondary outcomes were rates of clinical remission, steroid-free remission, and mucosal healing at week 8 and 56. Adalimumab drug levels were checked at week 8 and at loss of response. Results A total of 146 patients were enrolled and included in the analysis. Clinical response rates were 52.1% (76/146) and 37.7% (55/146) at week 8 and 56, respectively. Clinical remission were achieved in 24.0% (35/146) and 21.9% (32/146) of patients at week 8 and 56. Steroid-free remission rates was 21.2% (31/146) at week 56. Mucosal healing rates were 39.0% (57/146) and 30.1% (44/146) at week 8 and 56. Prior use of anti-TNF-α did not affect the primary and secondary outcomes. Adalimumab drug level was significantly higher in patients with clinical response, clinical remission, and mucosal healing at week 8. Clinical response (74.5% vs 38.5%, p<0.001) and mucosal healing (52.7% vs 30.8%, p=0.008) at week 8 were associated with clinical response at week 56. Serious adverse drug reactions were identified in 2.7% (4/146) of patients including one case of pulmonary tuberculosis. Conclusions Adalimumab is safe and effective for induction and maintenance in Korean patients with UC, regardless of prior anti-TNF therapy. A better response to induction therapy can predict a better long-term response. [ABSTRACT FROM AUTHOR]

Background/Aims Although dysbiosis has been reported in Crohn's disease (CD) compared with healthy controls (HC), limited studies have examined the intestinal microbiota composition in relation to prognosis of CD. We aim to analyze difference in microbial communities and relevant metabolic pathways according to the prognosis of CD. Methods We analyzed a cohort of 370 CD and 740 HC fecal samples from 14 centers in Korea, applied a 16S rRNA sequencing approach. We categorized CD patients into three groups as good (CD-G), intermediate (CD-I), and poor (CD-P) prognosis group according to history of using biologics and intestinal resection. The microbial composition, diversity and microbial community function were analyzed. Results Microbiota α-diversity was decreased in within all CD groups vs HC, with more significant reduction in CD-P compared with CD-G and CD-I. β-Diversity indicated different microbial patterns in CD-P compared with CD-G and CD-I. Among microbiota that were differentially abundant between HC and CD groups, 13 genera and 10 species showed difference abundance between CD-G and CD-P groups (Fig. 1). Escherichia coli from proteobacteria phylum and species Producta and genera Lactobacillus and Coprococcus from Firmicutes phylum consistently showed difference between CD-G and CD-P groups after adjusting for confounding clinical variables. In functional profiling, the increased microbial catabolic pathways, pathways related to enterobacterial common antigen and LPS biosynthesis were presented in the CD-P group than the CD-G group. Family Enterobacteriaceae or its species E. coli were the top contributor for these pathways. Conclusions CD prognosis is associated with changes in microbiota composition and decreased diversity. Specific bacteria such as E. coli might not only causally involved in CD progression but also adapted to live in inflammatory environment. [ABSTRACT FROM AUTHOR]