Search

OBJECTIVES Some neoplastic lesions remain undetected on colonoscopy. To date, no studies have investigated whether combining cap-assisted colonoscopy with chromoendoscopy increases the adenoma detection rate (ADR). This study aimed to compare cap-assisted chromoendoscopy (CAP/CHROMO) with standard colonoscopy (SC) with respect to their efficacy in detecting adenomas. METHODS This prospective, multicenter, randomized controlled trial included asymptomatic subjects aged 45-75 years who underwent colonoscopy for the first time at 14 university hospitals. Subjects were randomized to either the CAP/CHROMO group (with 0.09% indigo carmine spraying using a cap-mounted catheter at the tip of the colonoscope) or the SC group. All polyps were resected, but only histologically confirmed neoplastic lesions were considered for analysis. The primary outcome was ADR, defined as the proportion of subjects with at least 1 adenoma. RESULTS A total of 1,905 subjects were randomized to the CAP/CHROMO (n = 948) or SC (n = 957) group at 14 centers. Subjects' demographic characteristics were similar between both groups. The CAP/CHROMO group had significantly higher ADR than the SC group (54.4% vs 44.9%, P < 0.001). Significantly, more subjects with at least 1 proximal colon adenoma were identified by CAP/CHROMO (38.6%) than by SC (31.2%) (P = 0.001). The proximal serrated polyp detection rate by CAP/CHROMO was significantly higher in the female subgroup vs SC. However, advanced ADR was not different between the CAP/CHROMO and SC groups (9.3% vs 7.6%, P = 0.180). DISCUSSION CAP/CHROMO markedly improved the ADR and enhanced the detection of proximal adenoma. CAP/CHROMO is feasible for routine application and will allow for a more effective surveillance program.

Background/aims Inflammatory bowel disease (IBD) is associated with the occurrence of venous thromboembolism (VTE). However, to date, there have been few studies on the risk of VTE in Asian IBD patients. We aimed to estimate the incidence of VTE in Asian IBD patients and to determine if IBD is related to increased VTE risk. Methods We performed a population-based cohort study between 2004 and 2015 using Korean National Health Insurance data. IBD and VTE were defined by ICD-10 codes. Incidence rates of VTE were calculated among patients with IBD and among age- and sex-matched controls. Hazard ratios were estimated using Cox regression with adjustment for multiple variables. We performed additional analyses stratifying by age, sex, Charlson comorbidity index (CCI) score, and disease type. Results Among the 45,037 patients with IBD (IBD cohort) and 133,019 matched controls (non-IBD cohort) included in our analysis, 411 IBD patients and 641 controls developed VTE. The IBD cohort had a higher incidence rate ratio and risk of VTE than the non-IBD cohort (incidence rate ratio: 1.92 and hazard ratio: 1.93). Older age, female sex, higher CCI scores, cardiovascular disease, chronic kidney disease, use of steroids, and hospitalization were significant risk factors for VTE in patients with IBD. Conclusions The IBD patients in this study were approximately two times more likely to develop VTE than the non-IBD individuals. Our findings support the need for thromboprophylaxis in Asian IBD patients with various factors that further increase the risk of VTE.

Background/aim Although microRNAs (miRNAs) are known to influence messenger RNA post-transcriptional control and contribute to human tumorigenesis, little is known about the differences in miRNA expression between primary and recurrent epithelial ovarian cancer (EOC). The purpose of this study was to assess the differential miRNA expression between primary and recurrent EOC and to investigate whether miR-196b could regulate the expression of the Homeobox A9 (HOXA9) gene, and thus affect the invasiveness of cancer cells in recurrent EOC. Materials and methods Microarrays were used to generate the expression profiles of 6658 miRNAs from samples of 10 patients with EOC. miRNA expression patterns were compared between primary and recurrent EOC. Aberrantly expressed miRNA, associated genes, and invasion activities were validated by a luciferase assay and an in vitro invasion assay. Results miRNA microarray analysis identified 33 overexpressed miRNAs (including miR-196b) and 18 under expressed miRNAs in recurrent EOC from 6658 human miRNAs. HOXA9 expression was inversely correlated with miR-196b levels in recurrent EOC. We noted that miR-196b induced ovarian cancer cell invasiveness in recurrent EOC by an in vitro invasion assay. Conclusion Overexpression of miR-196b may contribute to invasion activities in recurrent EOC by regulating the HOXA9 gene. Moreover, miR-196b can be a potential biomarker in recurrent EOC.

Introduction Use of colonoscopy or the fecal immunochemical test (FIT) for colorectal cancer (CRC) prevention is supported by previous studies. However, there is little specific evidence regarding comparative effectiveness of colonoscopy or FIT for reducing CRC risk. In this study, we compared the association of CRC risk with colonoscopy and FIT using a nationwide database. Methods This population-based case-control study used colonoscopy and FIT claims data from the Korean National Health Insurance System from 2002 to 2013. Data were analyzed from 61,221 patients with newly diagnosed CRC (case group) and 306,099 individuals without CRC (control group). Multivariable logistic regression models were used to evaluate the association between CRC and colonoscopy or FIT. Results Colonoscopy was associated with a reduced subsequent CRC risk (adjusted odds ratio [OR] 0.29). Stronger associations were found between colonoscopy and distal CRC, compared with proximal CRC (0.24 vs 0.47). In an analysis stratified by sex, the association was weaker in female subjects compared with male subjects (0.33 vs 0.27). Any FIT exposure was associated with CRC risk with an OR of 0.74; this association was stronger for distal cancer. As the frequency of cumulative FIT assessments increased (from 1 to ≥5), the OR of FIT exposure for CRC gradually decreased from 0.81 to 0.45. Discussion The association of colonoscopy or FIT with reduced CRC risk was stronger for distal CRC than for proximal CRC. FIT showed less CRC risk reduction than colonoscopy. However, as the frequency of cumulative FIT assessments increased, the association with CRC prevention became stronger.

Background : /Aims: There are no established guidelines for bowel preparation formulation for bowel cleansing, nor is there an optimal method of dealing with inadequate bowel cleansing. This study investigated bowel preparation formulation preferences and responses to bowel preparation situations using surveys. Methods : : The study surveyed 221 Korean lower gastrointestinal endoscopists from January to March 2015 and assessed their responses. Results : : The analysis indicated that 2-L polyethylene glycol (PEG) plus ascorbic acid (Asc) was the preferred method (76.5%) and most responders expressed satisfaction with the formulation in both potency and safety. To address poor bowel preparation on the day of colonoscopy, the majority of physicians chose to order ingestion of additional preparations and proceed with the colonoscopy as scheduled (56.6%). In addition, concerns about renal safety and electrolyte stability were raised regarding oral sodium phosphate. Conclusion : s: This study found that 2-L PEG+Asc was preferred for potency and safety, and that Korean endoscopists preferred to proceed with colonoscopy in poor bowel preparation situations rather than choose an alternate diagnostic modality. (Korean J Gastroenterol 2016;68:70-76)

Background/Aims We evaluated whether colonic transit time (CTT) can predict the degree of bowel preparation in patients with chronic constipation undergoing scheduled colonoscopy in order to assist in the development of better bowel preparation strategies for these patients. Methods We analyzed the records of 160 patients with chronic constipation from March 2007 to November 2012. We enrolled patients who had undergone a CTT test followed by colonoscopy. We defined patients with a CTT ≥30 hours as the slow transit time (STT) group, and patients with a CTT 30 hours were at risk for inadequate bowel preparation. CTT measured prior to colonoscopy could be useful for developing individualized strategies for bowel preparation in patients with slow CTT, as these patients are likely to have inadequate bowel preparation.

Summary Objectives The aim of this study was to assess characteristics and predictive factors of complementary and alternative medicine (CAM) use for patients with inflammatory bowel disease (IBD) in Korea. Design Prospective, questionnaire based study for patients with IBD in Korea. Setting Six university hospitals and one primary IBD clinic. Main outcome measure Overall characteristics and predictors of CAM use were compared between CAM users and non-users. Results During the study period, 366 patients with IBD (ulcerative colitis=228, Crohn's disease=138) completed the full questionnaire; 29.5% ( n =108) reported CAM use and 70.5% ( n =258) reported no CAM use after diagnosis of IBD. In total, 64.0% were male, the mean patient age was 42.3±15.5 years, and the mean duration of IBD was 5.5±5.8 years. Using logistic regression analysis, university education ( p =0.040), higher income levels ( p =0.009), and longer duration of IBD ( p =0.003) were found to be independent predictors of CAM use. Among CAM users, 65% of CAM was attained within 2 years of IBD diagnosis and only 28.7% discussed CAM use with their physician. Furthermore, 13.9% of CAM users discontinued conventional IBD therapy while using CAM. Conclusions The overall use of CAM in Korea was comparable with those in the West. Physicians should be aware of the high prevalence of CAM use by patients with IBD, especially among those with higher education levels, higher income levels, and longer IBD duration. Furthermore, physicians should ask about CAM use, and help their IBD patients make a more informed choice about CAM use.

Background/Aims We compared the cirrhosis-prediction accuracy of an ultrasonographic scoring system (USSS) combining six representative sonographic indices with that of liver stiffness measurement (LSM) by transient elastography, and prospectively investigated the correlation between the USSS score and LSM in predicting cirrhosis. Methods Two hundred and thirty patients with chronic liver diseases (187 men, 43 women; age, 50.4±9.5 y, mean±SD) were enrolled in this prospective study. The USSS produces a combined score for nodularity of the liver surface and edge, parenchyma echogenicity, presence of right-lobe atrophy, spleen size, splenic vein diameter, and abnormality of the hepatic vein waveform. The correlations of the USSS score and LSM with that of a pathological liver biopsy (METAVIR scoring system: F0-F4) were evaluated. Results The mean USSS score and LSM were 7.2 and 38.0 kPa, respectively, in patients with histologically overt cirrhosis (F4, P=0.017) and 4.3 and 22.1 kPa in patients with fibrotic change without overt cirrhosis (F0-F3) (P=0.025). The areas under the receiver operating characteristic (ROC) curves of the USSS score and LSM for F4 patients were 0.849 and 0.729, respectively. On the basis of ROC curves, criteria of USSS ≥6: LSM ≥17.4 had a sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 89.2%:77.6%, 69.4%:61.4%, 86.5%:83.7%, 74.6%:51.9% and 0.83:0.73, respectively, in predicting F4. Conclusions The results indicate that this USSS has comparable efficacy to LSM in the diagnosis of cirrhosis.

Background : /Aims: In Korea, there are no available multicenter data concerning the prevalence of or diagnostic approaches for non-responsive gastroesophageal reflux disease (GERD) which does not respond to practical dose of proton pump inhibitor (PPI) in Korea. The purpose of this study is to evaluate the prevalence and the symptom pattern of non-responsive GERD. Methods : : A total of 12 hospitals who were members of a Korean GERD research group joined this study. We used the composite score (CS) as a reflux symptom scale which is a standardized questionnaire based on the frequency and severity of typical symptoms of GERD. We defined "non-responsive GERD" as follows: a subject with the erosive reflux disease (ERD) whose CS was not decreased by at least 50% after standard-dose PPIs for 8 weeks or a subject with non-erosive reflux disease (NERD) whose CS was not decreased by at least 50% after half-dose PPIs for 4 weeks. Results : : A total of 234 subjects were analyzed. Among them, 87 and 147 were confirmed to have ERD and NERD, respectively. The prevalence of non-responsive GERD was 26.9% (63/234). The rates of non-responsive GERD were not different between the ERD and NERD groups (25.3% vs. 27.9%, respectively, p=0.664). There were no differences between the non-responsive GERD and responsive GERD groups for sex (p=0.659), age (p=0.134), or BMI (p=0.209). However, the initial CS for epigastric pain and fullness were higher in the non-responsive GERD group (p=0.044, p=0.014, respectively). Conclusion : s: In conclusion, this multicenter Korean study showed that the rate of non-responsive GERD was substantially high up to 26%. In addition, the patients with the non-responsive GERD frequently showed dyspeptic symptoms such as epigastric pain and fullness. (Korean J Gastroenterol 2016;68:16-22)

The measurement of the hepatic venous pressure gradient (HVPG) for the estimation of portal hypertension (PH) in cirrhosis has some limitations, including its invasiveness. Hepatic vein arrival time (HVAT), as assessed by microbubble contrast-enhanced ultrasonography (CEUS), is negatively correlated with the histological grade of liver fibrosis because of the associated hemodynamic abnormalities. Anatomical and pathophysiological changes in liver microcirculation are the initial events leading to PH. However, the direct relationship between HVAT and PH has not been evaluated. The present study measured both HVPG and HVAT in 71 consecutive patients with compensated cirrhosis and analyzed the relationship between the two parameters (i.e., the derivation set). Results were validated in 35 compensated patients with cirrhosis at another medical center (i.e., the validation set). The derivation set had HVPG and HVAT values of 11.4 ± 5.0 mmHg (mean ± standard deviation; range, 2-23) and 14.1 ± 3.4 seconds (range, 8.4-24.2), respectively; there was a statistically significant negative correlation between HVPG and HVAT (r(2) = 0.545; P < 0.001). The area under the receiver operating characteristic curve (AUROC) was 0.973 for clinically significant PH (CSPH; HVPG, ≥ 10 mmHg), and the sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratios for CSPH for an HVAT cut-off value of 14 seconds were 92.7%, 86.7%, 90.5%, 89.7%, 6.95, and 0.08, respectively. In addition, a shorter HVAT was associated with worse Child-Pugh score (P < 0.001) and esophageal varices (P = 0.018). In the validation set, there was also a significant negative correlation between HVAT and HVPG (r(2) = 0.538; P < 0.001), and AUROC = 0.953 for CSPH. HVAT was significantly correlated with PH. These results indicate that measuring HVAT is useful for the noninvasive prediction of CSPH in patients with compensated cirrhosis.

Background Although high sodium intake is associated with obesity and hypertension, few studies have investigated the relationship between sodium intake and non-alcoholic fatty liver disease (NAFLD). We evaluated the association between sodium intake assessed by estimated 24-h urinary sodium excretion and NAFLD in healthy Koreans. Methods We analyzed data from 27,433 participants in the Korea National Health and Nutrition Examination Surveys (2008–2010). The total amount of sodium excretion in 24-h urine was estimated using Tanaka’s equations from spot urine specimens. Subjects were defined as having NAFLD when they had high scores in previously validated NAFLD prediction models such as the hepatic steatosis index (HSI) and fatty liver index (FLI). BARD scores and FIB-4 were used to define advanced fibrosis in subjects with NAFLD. Results The participants were classified into three groups according to estimated 24-h urinary excretion tertiles. The prevalence of NAFLD as assessed by both FLI and HSI was significantly higher in the highest estimated 24-h urinary sodium excretion tertile group. Even after adjustment for confounding factors including body fat and hypertension, the association between higher estimated 24-h urinary sodium excretion and NAFLD remained significant (Odds ratios (OR) 1.39, 95% confidence interval (CI) 1.26–1.55, in HSI; OR 1.75, CI 1.39–2.20, in FLI, both P < 0.001). Further, subjects with hepatic fibrosis as assessed by BARD score and FIB-4 in NAFLD patients had higher estimated 24-h urinary sodium values. Conclusions High sodium intake was independently associated with an increased risk of NAFLD and advanced liver fibrosis.

The clinical impact and complications of hepatogenous diabetes (HD) on cirrhosis have not been elucidated. This study aimed to evaluate the relationship of HD with portal hypertension (PHT) and variceal hemorrhage and to assess the prevalence of HD. From July 2007 to December 2009, 75-g oral glucose tolerance test and insulin resistance (IR) were evaluated for 195 consecutive cirrhotic liver patients (M:F = 164:1, 53.0 ± 10.2 years) who had no history of diabetes mellitus. IR was calculated using the homeostasis model of assessment-insulin resistance (HOMA-IR) formula. Endoscopy for varices, hepatic venous pressure gradient (HVPG), and serologic tests were also conducted. HD was observed in 55.4 % (108/194) of the patients. Among them, 62.0 % required OGTT for diagnosis because they did not show an abnormal fasting plasma glucose level. The presence of HD showed a significant correlation with high Child–Pugh’s score, variceal hemorrhage, and HVPG (p = 0.004, 0.002, and 0.019, respectively). In multivariate analysis, Child–Pugh’s score (OR 1.43, 95 % CI 1.005–2.038) and HVPG (OR 1.15, 95 % CI 1.003–2.547) had significant relationships with HD. Patients with recent variceal hemorrhages (within 6 months) exhibited significantly higher glucose levels at 120 min in OGTT compared to patients without hemorrhages (p = 0.042). However, there was no difference in fasting glucose levels. The 120-min glucose level and HOMA-IR score were significantly and linearly correlated with HVPG (r 2 = 0.189, p

Background In experimental models, bone marrow-derived mesenchymal stem cells (BM-MSCs) have the capacity to differentiate into hepatocytes and exhibit antifibrotic effects. However, there have been no studies in humans with alcoholic cirrhosis. Aim The aim of this study was to elucidate the antifibrotic effect of BM-MSCs in patients with alcoholic cirrhosis, as a phase II clinical trial. Methods Twelve patients (11 males, 1 female) with baseline biopsy-proven alcoholic cirrhosis who had been alcohol free for at least 6 months were enrolled. BM-MSCs were isolated from each patient's BM and amplified for 1 month, and 5 × 107 cells were then injected twice, at weeks 4 and 8, through the hepatic artery. One patient was withdrawn because of ingestion of alcohol. Finally, 11 patients completed the follow-up biopsy and laboratory tests at 12 weeks after the second injection. The primary outcome was improvement in the patients’ histological features. Results According to the Laennec fibrosis system, histological improvement was observed in 6 of 11 patients (54.5%). The Child-Pugh score improved in ten patients (90.9%) and the levels of transforming growth factor-β1, type 1 collagen and α-smooth muscle actin significantly decreased (as assessed by real-time reverse transcriptase polymerase chain reaction) after BM-MSCs therapy (P

Summary Background/Aims The aim of this study was to investigate the relationship between microsatellite instability (MSI) and clinicopathologic features including multiplicity in early stage gastric neoplasias (ESGN). Methods From November 2004 until September 2009, 372 patients with consecutive resected gastric neoplasias were retrospectively enrolled. The gastric neoplasias were composed of 117 advanced gastric cancers (AGCs) and 255 ESGNs including 31 gastric dysplasias (including low and high grade dysplasia) and 224 early gastric cancers (EGCs). Results Based on microsatellite markers, high MSI (MSI-H) was observed in 61 cases (16.4%) and low MSI (MSI-L) in 14 cases (3.8%) of 372 cases. There was a positive correlation between the presence of MSI-H and progression of gastric adenoma to gastric tumor. We compared ESGNs with microsatellite stable (MSS; 223 cases, 87.5%) and ESGNs with MSI-H (24 cases, 9.4%). The ESGNs with MSI-H were only associated with older age and female gender. There were no association with Helicobacter pylori infection, intestinal metaplasia, and distal location in contrast with EGCs with MSI-H. Furthermore, multiplicity of ESGNs was not associated with MSI status. Conclusions The clinicopatholgic features of MSI-H phenotype were different according to the progression of gastric neoplasias from ESGNs to AGCs. ESGNs with MSI-H were only associated with old age, female sex. In addition ESGNs with MSI-H were not associated with an increased risk of multifocal tumors.

Although endoscopic submucosal dissection (ESD)-induced ulcers heal faster and recur less often than non-iatrogenic gastric ulcers, the optimal dosage and duration of proton pump inhibitor treatment for ESD-induced ulcers remain unclear.To evaluate the efficacy of half-dose rabeprazole on endoscopic submucosal dissection-induced ulcer compared with standard dose rabeprazole.The study was a prospective randomized controlled double-blind trial at a single tertiary hospital. A total of 80 patients who underwent ESD for gastric neoplasia were enrolled. Of these patients, 10 were not followed to completion. Final analysis included the remaining 70 patients. Rabeprazole 20 or 10 mg, depending on randomization, was given orally for 4 weeks after ESD.Of the 70 patients, 45 (64 %) were men, and the median age was 65.2 ± 9.7 years. The mean ESD-induced ulcer area was 673 mm(2). No significant differences in ulcer area reduction ratio (p = 0.49) or ulcer-related symptoms (p = 0.91) were observed between the two groups at 4 weeks after ESD.For ESD-induced ulcers, treatment with 10 mg of rabeprazole daily produces a similar outcome as 20 mg of rabeprazole with regard to healing efficacy and symptom resolution.

Further histological subclassification of cirrhosis may be useful because of heterogeneity of severity within cirrhosis. We aimed to determine the relationship between histological subclassification and clinical stage of cirrhosis as well as grade of portal hypertension.One hundred-twenty-three biopsy-proven cirrhosis patients, whose clinical stage of cirrhosis and hepatic venous pressure gradient (HVPG) could be estimated, were included in this prospective study. Histology of cirrhosis was blindly subclassified using the Laennec fibrosis scoring system semi-quantitatively without knowledge of the clinical stage or the HVPG results. The Laennec system subclassifies cirrhosis as mild - thin septa, moderate - at least two broad septa, and severe - at least one very broad septum or many minute nodules. Clinical stages were determined by the presence or absence of varices, ascites, and variceal hemorrhage. Biological and laboratory data were also collected.Alcohol intake was the most common cause of cirrhosis in this cohort (87, 70.7%). Histology of cirrhosis subclassified using the Laennec scoring system significantly correlated with both the clinical stage of cirrhosis (p0.001) and HVPG (mild: 8.1 ± 2.6 mm Hg, moderate: 12.4 ± 3.3mm Hg, severe: 16.3 ± 4.0 mm Hg, p0.001). With higher grades of histological subclassification of cirrhosis, increased frequency in both severe portal hypertension (HVPG ≥ 12 mm Hg) and episodes of variceal hemorrhage were observed (p0.001).Histological subclassification of cirrhosis by the Laennec fibrosis scoring system is tightly correlated with both the clinical stage of cirrhosis and grade of portal hypertension. This suggests that cirrhosis should be subclassified into different stages according to its histological severity.

To evaluate the clinical characteristics of nonvariceal upper gastrointestinal hemorrhage (NGIH) in patients with chronic kidney disease (CKD).From 2003 to 2010, a total of 72 CKD patients (male n = 52, 72.2%; female n = 20, 27.8%) who had undergone endoscopic treatments for NGIH were retrospectively identified. Clinical findings, endoscopic features, prognosis, rebleeding risk factors, and mortality-related factors were evaluated. The characteristics of the patients and rebleeding-related data were recorded for the following variables: gender, age, alcohol use and smoking history, past hemorrhage history, endoscopic findings (the cause, location, and size of the hemorrhage and the hemorrhagic state), therapeutic options for endoscopy, endoscopist experience, clinical outcomes, and mortality.The average size of the hemorrhagic site was 13.7 ± 10.2 mm, and the most common hemorrhagic site in the stomach was the antrum (n = 21, 43.8%). The most frequent method of hemostasis was combination therapy (n = 32, 44.4%). The incidence of rebleeding was 37.5% (n = 27), and 16.7% (n = 12) of patients expired due to hemorrhage. In a multivariate analysis of the risk factors for rebleeding, alcoholism (OR = 11.19, P = 0.02), the experience of endoscopists (OR = 0.56, P = 0.03), and combination endoscopic therapy (OR = 0.06, P = 0.01) compared with monotherapy were significantly related to rebleeding after endoscopic therapy. In a risk analysis of mortality after endoscopic therapy, only rebleeding was related to mortality (OR = 7.1, P = 0.02).Intensive combined endoscopic treatments by experienced endoscopists are necessary for the treatment of NGIH in patients with CKD, especially when a patient is an alcoholic.

Technological Assistance of Cap-Assisted Chromoendoscopy Enhances the Detection Rates of Both Colorectal Adenoma and Proximal Serrated Polyp in an Average-Risk Screening Population: Preliminary Results of a Multi-Center Randomized Controlled Trial Hyun-Soo Kim*, Hong Jun Park, Chan Sik Won, Hyo Keun Jeon, Dongil Park, Jae Myung Cha, Seun-Ja Park, Hwang Choi, Jeong Eun Shin, Chang Soo Eun, Jin-Oh Kim, Hyun Gun Kim, Seong-Eun Kim, Cheol Hee Park, Tae Il Kim, Sung Noh Hong, Dong-Hoon Yang, Byung Chang Kim, Byungho Nam Yonsei Univ. Wonju College of Medicine, Wonju, Republic of Korea; Sungkyunkwan University College of Medicine, Seoul, Republic of Korea; KyungHee University College of Medicine, Hanam, Republic of Korea; Kosin University College of Medicine, Busan, Republic of Korea; The Catholic University of Korea College of Medicine, Incheon, Republic of Korea; Dankook University College of Medicine, Cheonan, Republic of Korea; Hanyang University College of Medicine, Guri, Republic of Korea; Soonchunhyang University College of Medicine, Seoul, Republic of Korea; Ewha Womans University School of Medicine, Seoul, Republic of Korea; Hallym University College of Medicine, Anyang, Republic of Korea; Yonsei University College of Medicine, Seoul, Republic of Korea; Konkuk University School of Medicine, Seoul, Republic of Korea; University of Ulsan College of Medicine, Seoul, Republic of Korea; National Cancer Center, Goyang, Republic of Korea Background/Aim: There is growing evidence that a transparent cap or chromoendoscopy improve detection of colorectal polyps. However, the combined method of these two technologies has not been proven for colorectal polyp or adenoma detection rate. In this multicenter prospective randomized trial, we examined whether cap-assisted chromoendoscopy (CAP-ACE) enhances colorectal adenoma detection rate especially in the proximal colon. Methods: From March 2010 to October 2011, 1,202 asymptomatic average-risk subjects who underwent the first screening colonoscopy in an age of 45 to 75 were enrolled at 14 hospitals. Eighteen expert colonoscopists (more than 5,000 procedures) have performed procedures. Subjects were randomly allocated to CAP-ACE group and regular colonoscopy (RC) group. We prospectively compared insertion and withdrawal time, polyp detection rate (PDR), adenoma detection rate (ADR), and proximal serrated polyp detection rate (PSPDR) between the two groups. Results: A total of 1,202 subjects were enrolled; 598 CAP-ACEs and 604 RCs were performed. Overall PDR and ADR were 60.3% and 47.6%. A total of 52 advanced lesions were found including 16 tubulovillous adenomas, 2 villous adenomas, 13 high grade dysplasias, 11 intramucosal cancers and 10 invasive cancers. The time to cecal intubation (4.8 vs. 4.8 min, p 0.902) was not different between the groups but withdrawal time was prolonged in CAP-ACE group for indigocarmine solution spray and suction (10.5 vs. 8.7 min, p 0.001). Compared to RC, CAP-ACE did increase PDR (65.9% vs. 54.8%, p 0.001) and ADR (51.8% vs. 45.5%, p 0.033) significantly. In particular, this technological assistance of CAP-ACE even in experts significantly enhanced the proximal adenoma detection rate (34.8% vs. 28.8%, p 0.030) as well as PSPDR (10.5% vs. 6.1%, p 0.006). However, advanced lesions (CAPACE 26/598 (4.3%) vs. RC 26/604 (4.3%), p 0.99) including cancers were equally found between groups. Conclusion: Technological assistance of CAP-ACE enhances not only PDR but also ADR, especially in the proximal colon. These results suggest that CAP-ACE technology provide a potential solution for overcoming the limited effectiveness of colonoscopy in the proximal colon and should be considered as the preferred, high standard colorectal cancer screening method for the average-risk screening population.

Surveillance Strategy After Endoscopic Submucosal Dissection for Early Gastric Cancer: A Multicenter Study by Osaka University ESD Study Group Motohiko Kato, Tsutomu Nishida, Katsumi Yamamoto, Shinji Kitamura, Takeshi Nakamura, Akihiro Nishihara, Naoki Kawai, Shinichiro Zushi, Masato Komori, Kazuo Kinoshita, Tomoki Michida, Takuya Yamada, Shusaku Tsutsui, Masahiko Tsujii, Norio Hayashi Graduate School of Medicine, Department of Gastroenterology and Hepatology, Osaka University, Suita, Japan; Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Japan; Department of Gastroenterology, Sakai Municipal Hospital, Sakai, Japan; Department of Gastroenterology, Kansai Rosai Hospital, Amagasaki, Japan; Department of Gastroenterology, Minoh City Hospital, Minoh, Japan; Department of Gastroenterology, Osaka Police Hospital, Osaka, Japan; Department of Gastroenterology, Ikeda Municipal Hospital, Ikeda, Japan; Department of Gastroenterology, Osaka Rosai Hospital, Sakai, Japan; Department of Gastroenterology, Sumitomo Hospital, Osaka, Japan; Endoscopy Center, Osaka Koseinenkin Hospital, Osaka, Japan Background and Aim: Endoscopic submucosal dissection (ESD) has been accepted as a treatment for early gastric cancer (EGC). However, it is known that the patient after endoscopic treatment of EGC is at risk of synchronous and metachronous multiple cancers, even though initial lesion is completely resected, and there is not enough evidence concerning surveillance strategy after ESD for EGC. The aim of this multicenter study is to clarify the surveillance strategy after ESD by assessing the incidence of multiple cancers during follow-up. Methods: This is a multicenter retrospective study from 6 institutes. From March 2003 to November 2010, of total 1567 consecutive cases with gastric neoplasm performed ESD at these 6 institute, 1041 cases were diagnosed as EGC after ESD and were included in this study. Cumulative incident rates of gastric cancer after initial ESD were calculated using the Kaplan-Meier methods. Results: In 1041 cases, multiple cancers were detected in 101 cases and incident rate was 9.7% in the median follow-up period of 28.3 months. The cumulative incident rates of gastric cancer were 7.4% at 1 year, 9.5% at 2 years, and 11.5% at 3 years, respectively. The cumulative incident rates curve showed an inflection point at 1.7 months, after that those increased constantly about 2% per year. Median and 90 percentile of duration between initial ESD and cancer incidence were 22.9 and 36.0 months, respectively. There were no significant differences in institute, patients’ background, and characteristics of initial lesion between cases with and without multiple cancers. All lesions detected during follow-up were successfully treated by re-ESD except 2 cases of mucosal cancers where ESD was not applicable because of undifferentiated histological type. Conclusion: These results suggested multiple cancers detected within 3 months after initial ESD for EGC were overlooked synchronous cancers in the pre-ESD survey. Metachronous lesions were detected with low but constant frequency during follow up. Our recommendation is that initial endoscopic surveillance should be performed within 3-6 months after ESD to check up synchronous lesions and scheduled endoscopic surveillance should be performed annually for at least 3 years. 1174 Randomized Controlled Trial of Conventional vs. Jumbo Forceps Biopsy for the Diagnostic Accuracy of Gastric Neoplasia Before Endoscopic Submucosal Dissection Hyun-Soo Kim, Hyo Keun Jeon, Jae Woo Kim, Hong Jun Park, so Yeon Park, Bo RA Kim, Chan Sik Won, Mee-Yon Cho Internal medicine, Yonsei Univ. Wonju College of Medicine, Wonju, Republic of Korea; Pathology, Yonsei Univ. Wonju College of Medicine, Wonju, Republic of Korea Aim: An endoscopic forceps biopsy carries the risk of missing the neoplastic foci within a gastric neoplastic lesion and underestimating the grade of neoplasia because only a small portion of the lesion is sampled using this technique. The aim of this prospective study was to compare the diagnostic accuracy of gastric neoplasia before endoscopic submucosal dissection (ESD) between conventional forceps and jumbo forceps. Patients and Methods: Between May 2009 and November 2010, 162 gastric neoplastic lesions (adenomas or early gastric cancers without ulcer) from 148 patients were randomized to two groups, conventional forceps (7 mm) and jumbo forceps (8 mm), and four specimens were obtained from each lesion. Each pathologic result of the four endoscopic biopsied specimens between the two groups was compared with that of ESD specimens. Results: Of the 148 patients, 123 (76.9%) were, men; median age was 64.66 10 years. Twenty-nine gastric neoplastic lesions in 26 patients were excluded because ESD was not performed or because pathologic result was inappropriate. Finally, 66 gastric neoplastic lesions in 60 patients and 65 gastric neoplastic lesions in 62 patients were allocated to conventional group and jumbo group. A total of 131 ESD specimens in 122 patients were analyzed. The pathological diagnoses of ESD specimens were as follows: 47 (35.9%) adenomas with low grade dysplasia, 20 (15.3%) adenomas with high grade dysplasia, and 63 (48.1%) adenocarcinomas. The mean diameter of the biopsy specimens were 2.48 0.53mm with conventional group, 2.89 0.60mm with jumbo group. Thus, significantly larger biopsy specimens were obtained by jumbo forceps than conventional forceps(p 0.001). The rates of concordance from the first to all four endoscopic forceps biopsy specimens and the ESD specimens were 66.7%, 72.7%, 74.2% and 80.3% in conventional forceps group and 72.3%, 76.9%, 81.5% and 84.6% in jumbo forceps group (p 0.483, p 0.580, p 0.315, p 0.517), respectively. The concordance rate was not associated with location of gastric neoplastic lesions or with experience of endoscopists (p 0.05). There were no variables found to be significantly associated with rates of concordance in multivariate analysis. Conclusions: Obtaining 4 endoscopic biopsy specimens rather than only one before ESD improved diagnostic accuracy by about 15%. Despite of bigger specimen size, however, jumbo forceps was not proven to be superior to the conventional forceps for better diagnostic accuracy of gastric neoplasia.

2. To assess whether the acute response to oral propranolol predicts the long-term response to these drugs. Methods: Thirty-eight patients with cirrhosis and HVPG ≥12mmHg were included. The HVPG was measured at baseline and 90 minutes after an oral dose of 80mg propranolol. Following randomisation, 17 patients received propranolol (mean dose 122.4mg/day) and 21 carvedilol (mean dose 14.0mg/day) titrated according to pulse and blood pressure response. After 12 weeks, HVPG-measurements were repeated. Results: Acute HVPG-response to propranolol was significant −19.3±12.8% (p < 0.01). Long-term treatment with propranolol and carvedilol decreased HVPG −12.5±16.7% (p < 0.01) and −18.7±16.7% (p < 0.01), respectively, with no significant difference between the two treatment-regimens (p = 0.26). The frequency of long-term responders (HVPG decrease ≥20% or to

Background/Aims: The blunted ventricular systolic and diastolic contractile responses to physical and pharmacological stress in cirrhosis are termed cirrhotic cardiomyopathy (CCM). CCM has been known to involve multiple defects in the β-adrenergic signaling pathway. The aim of this study was to determine whether cirrhotic patients have blunted cardiac responses to catecholamine stimulation through dobutamine stress echocardiography (DSE). Methods: Seventy-one cirrhotic patients with normal left ventricular (LV) chamber size and ejection fraction were enrolled. The LV systolic and diastolic functions were evaluated by two-dimensional and Doppler echocardiography at rest and during peak dobutamine infusion (40 μg/kg/min). An abnormal response was defined as a decrease of less than 10% in LV end-diastolic volume, a decrease of less than 20% in end-systolic volume, and an increase of less than 10% in LV ejection fraction (EF) at peak dobutamine infusion, based on previously used criteria. The early/late diastolic flow (E/A) ratio and diastolic parameters were also measured. Results: A blunted LV response to dobutamine was observed in 18 of 71 cirrhotic patients (25.4%). The baseline EF was significantly higher in 18 patients with a blunted DSE response than that of those with a normal DSE response (P

Primary hyperparathyroidism is caused mainly by a parathyroid adenoma or hyperplasia, and is characterized by hypercalcemia and hypophosphatemia induced by an increased level of parathyroid hormone (PTH). Patients with primary hyperparathyroidism are usually as ymptomatic and the disease is most often detected incidentally. However, patients can present with symptoms of renal stones, peptic ulcer disease, muscle weakness, depression, constipation, and pancreatitis. In addition, it has been reported that choletithiasis can be combined with primary hyperparathyroidism. We report a case of a 49-year-old man with primary hyperparathyroidism accompanied with chronic cholecystitis caused by a gallbladder (GB) stone. The chief complaint was nausea, poor oral intake, abdominal pain, and weight loss. Abdominal sonography was performed and chronic cholecystitis with a GB stone was diagnosed. The serum calcium level was 18.5 mg/dL and the intact parathyroid hormone level was 1,777 pg/mL. A parathyroid mass was detected by neck-computed tomography, neck ultrasonography and a 99m Tc-Tetrofosmin parathyroid scan. The parathyroid mass was removed and the mass was confirmed as a parathyroid adenoma. Cholecystectomy was performed and the diagnosis of chronic cholecystitis was confirmed. After the surgical procedure, the symptoms improved and the calcium level was normalized. (J Kor Endocr Soc 22:470~474, 2007)