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Background/aims: Fexuprazan, a novel potassium-competitive acid blocker, was developed for treating acidrelated disorders. Pharmacokinetic and pharmacodynamic properties of fexuprazan, unlike those of proton pump inhibitors, are independent of food effect. This study aims to evaluate differences in efficacy and safety of fexuprazan in patients with erosive esophagitis (EE) according to the timing of dosing., Methods: In this multicenter, open-label noninferiority study, patients who had typical reflux symptoms with endoscopically confirmed EE were randomized 1:1 to receive fexuprazan 40 mg daily 30 minutes before or after meal. Treatment was completed after 2 weeks or 4 weeks when healing was endoscopically confirmed. The primary endpoint was the proportion of patients with healed EE confirmed by endoscopy up to week 4. Safety endpoints included treatmentemergent adverse events (TEAEs)., Results: In the prior-to-meal group (n = 89) and after-meal group (n = 86), 4-week EE healing rates were 98.77% and 100.00% (difference, 0.01%; 95% CI, -0.01% to 0.04%) and 2-week EE healing rates were 95.77% and 97.14% (difference, 0.01%; 95% CI, -0.05% to 0.07%), respectively. TEAEs were 9.78% and 8.70% in the prior-to-meal group and the after-meal group, respectively., Conclusions: Non-inferiority analysis revealed that taking fexuprazan after meal was non-inferior to taking fexuprazan before meals in patients with EE. The frequency of adverse events was similar between the 2 study groups. The drug is safe and effective for healing EE regardless of the timing of dosing.

The diagnostic value of ileoscopy is not well established, and its routine practice is controversial. We aimed to investigate the diagnostic value of biopsy for macroscopically abnormal lesions in the terminal ileum and to identify the association between endoscopic indications and findings and the presence of significant disease. This retrospective study included 551 patients who underwent biopsy of abnormal lesions in the terminal ileum (TI) during colonoscopy between February 2000 and June 2019. Biopsy results were analyzed in relation to the endoscopic indications and gross findings. Significant disease was defined as a case in which a specific disease was suspected or confirmed by the biopsy results, requiring additional examination or treatment. Among the 551 biopsies from macroscopically abnormal lesions in the TI, 44 (8.0%) had significant diseases. The frequency of significant disease was high in patients with clinically suspected inflammatory bowel disease (IBD) (50.0%), anemia (31.6%), right lower quadrant (RLQ) pain (28.6%), and radiological abnormalities in the TI (27.5%). The frequency of Crohn's disease (CD) was high in patients with clinically suspected IBD. A concurrent abnormality in the ileocecal valve (ICV) (14.3%) and the presence of an ulcer (14.2%), mass, or polyp (25.4%) correlated with a high incidence of significant disease, particularly CD. In cases of suspected IBD, anemia, RLQ pain, and radiologic abnormalities in the TI, there is a high possibility of significant disease. Ulcers, masses, polyps, and concurrent abnormalities in the ICV were also associated with significant disease.

Background: Many patients with ulcerative colitis (UC) gain weight after treatment. However, the clinical significance of weight gain in these patients remains unclear. This study aimed to evaluate body weight changes after treatment in patients newly diagnosed with moderate-to-severe UC and their effects on patients' prognosis., Methods: The change in weight between diagnosis and 1 year after treatment in 212 patients enrolled in the MOSAIK cohort (mean age, 40 years; males, 60%) was analyzed. Significant weight gain was defined as a weight increase of ≥ 5% from the baseline at 1 year. Factors associated with significant weight gain and the effect of significant weight gain on the risk of major adverse outcomes (clinical relapse, hospitalization, and new use of steroids or biologics) during a follow-up period of 20 months were evaluated., Results: Mean weight gain at 1 year was 1.7 ± 4.2 kg. The proportion of overweight/obese patients increased by 9.0% from 37.9% to 46.9%. Thirty-two percent had significant weight gain; extensive colitis at diagnosis was the only factor associated with significant weight gain (odds ratio 6.5, 95% confidence interval 1.4-31.0, p = 0.006). In multivariable analysis, significant weight gain was not associated with the risk of major adverse outcomes. Weight loss symptoms at diagnosis were associated with an increased risk for new steroid use after 1 year., Conclusions: Approximately one-third of patients with moderate-to-severe UC had significant weight gain after 1 year of treatment. However, significant weight gain was not associated with the patient's prognosis., (© 2023. The Author(s).)

Background/aims: Fexuprazan is a novel potassium-competitive acid blocker that could be of benefit to patients with gastric mucosal injury. The aim of this study was to assess the 2-week efficacy and safety of fexuprazan in patients with acute or chronic gastritis., Methods: In this study, 327 patients with acute or chronic gastritis who had one or more gastric erosions on endoscopy and subjective symptoms were randomized into three groups receiving fexuprazan 20 mg once a day (q.d.), fexuprazan 10 mg twice a day (b.i.d.), or placebo for 2 weeks. The posttreatment assessments were the primary endpoint (erosion improvement rate), secondary endpoints (cure rates of erosion and edema and improvement rates of redness, hemorrhage, and subjective symptoms), and drug-related adverse events., Results: Among the patients, 57.8% (59/102), 65.7% (67/102), and 40.6% (39/96) showed erosion improvement 2 weeks after receiving fexuprazan 20 mg q.d., fexuprazan 10 mg b.i.d., and placebo, respectively. Both fexuprazan 20 mg q.d. and 10 mg b.i.d. showed superior efficacy to the placebo (p=0.017 and p<0.001, respectively). Likewise, both fexuprazan 20 mg q.d. and 10 mg b.i.d. also showed higher erosion healing rates than the placebo (p=0.033 and p=0.010, respectively). No difference was noted in the edema healing rate and the improvement rates for redness, hemorrhage, and subjective symptoms between the fexuprazan and placebo groups. No significant difference was noted in the incidence of adverse drug reactions., Conclusions: Fexuprazan 20 mg q.d. and 10 mg b.i.d. for 2 weeks showed therapeutic efficacy superior to that of placebo in patients with acute or chronic gastritis (ClinicalTrials.gov identifier NCT04341454).

Background/aims: Gastroesophageal reflux disease (GERD) is a common chronic gastrointestinal disorder that typically requires long-term maintenance therapy. However, little is known about patient preferences and satisfaction and real-world prescription patterns regarding maintenance therapy for GERD., Methods: This observational, cross-sectional, multicenter study involved patients from 18 referral hospitals in Korea. We surveyed patients who had been prescribed proton pump inhibitors (PPIs) for GERD for at least 90 days with a minimum follow-up duration of 1 year. The main outcome was overall patient satisfaction with different maintenance therapy modalities., Results: A total of 197 patients were enrolled. Overall patient satisfaction, patient preferences, and GERD health-related quality of life scores did not significantly differ among the maintenance therapy modality groups. However, the on-demand therapy group experienced a significantly longer disease duration than the continuous therapy group. The continuous therapy group demonstrated a lower level of awareness of potential adverse effects associated with PPIs than the on-demand therapy group but received higher doses of PPIs than the on-demand therapy group. The prescribed doses of PPIs also varied based on the phenotype of GERD, with higher doses prescribed for non-erosive reflux disease than erosive reflux disease., Conclusion: Although overall patient satisfaction did not significantly differ among the different PPI maintenance therapy modality groups, awareness of potential adverse effects was significantly different between the on-demand and continuous therapy groups.

Background/aims: It remains unclear which maintenance treatment modality is most appropriate for mild gastroesophageal reflux disease (GERD). We aimed to compare on-demand treatment with continuous treatment using a proton pump inhibitor (PPI) in the maintenance treatment for patients with non-erosive GERD or mild erosive esophagitis., Methods: Patients whose GERD symptoms improved after 4 weeks of standard dose PPI treatment were prospectively enrolled at 25 hospitals. Subsequently, the enrolled patients were randomly assigned to either an on-demand or a continuous maintenance treatment group, and followed in an 8-week interval for up to 24 weeks., Results: A total of 304 patients were randomized to maintenance treatment (continuous, n = 151 vs on-demand, n = 153). The primary outcome, the overall proportion of unwillingness to continue the assigned maintenance treatment modality, failed to confirm the non-inferiority of on-demand treatment (45.9%) compared to continuous treatment (36.1%). Compared with the on-demand group, the GERD symptom and health-related quality of life scores significantly more improved and the overall satisfaction score was significantly higher in the continuous treatment group, particularly at week 8 and week 16 of maintenance treatment. Work impairment scores were not different in the 2 groups, but the prescription cost was less in the on-demand group. Serum gastrin levels significantly elevated in the continuous treatment group, but not in the on-demand group., Conclusions: Continuous treatment seems to be more appropriate for the initial maintenance treatment of non-erosive GERD or mild erosive esophagitis than on-demand treatment. Stepping down to on-demand treatment needs to be considered after a sufficient period of continuous treatment.

Background/aims: The prospective Crohn's Disease Clinical Network and Cohort Study is a nationwide multicenter cohort study of patients with Crohn's disease (CD) in Korea, aiming to prospectively investigate the clinical features and long-term prognosis associated with CD., Methods: Patients diagnosed with CD between January 2009 and September 2019 were prospectively enrolled. They were divided into two cohorts according to the year of diagnosis: cohort 1 (diagnosed between 2009 and 2011) versus cohort 2 (between 2012 and 2019)., Results: A total of 1,175 patients were included, and the median follow-up duration was 68 months (interquartile range, 39.0 to 91.0 months). The treatment-free durations for thiopurines (p<0.001) and anti-tumor necrosis factor agents (p=0.018) of cohort 2 were shorter than those of cohort 1. Among 887 patients with B1 behavior at diagnosis, 149 patients (16.8%) progressed to either B2 or B3 behavior during follow-up. Early use of thiopurine was associated with a reduced risk of behavioral progression (adjusted hazard ratio [aHR], 0.69; 95% confidence interval [CI], 0.50 to 0.90), and family history of inflammatory bowel disease was associated with an increased risk of behavioral progression (aHR, 2.29; 95% CI, 1.16 to 4.50). One hundred forty-one patients (12.0%) underwent intestinal resection, and the intestinal resection-free survival time was significantly longer in cohort 2 than in cohort 1 (p=0.003). The early use of thiopurines (aHR, 0.35; 95% CI, 0.23 to 0.51) was independently associated with a reduced risk of intestinal resection., Conclusions: The prognosis of CD in Korea appears to have improved over time, as evidenced by the decreasing intestinal resection rate. Early use of thiopurines was associated with an improved prognosis represented by a reduced risk of intestinal resection.

Background/aims: Narrow band imaging provides an accurate diagnosis of colonic polyps. However, these diagnostic modalities are not used as standard endoscopic tools in most institutions. This study aims to investigate whether the chicken skin mucosa (CSM) surrounding the colon polyp yields additional information about colorectal polyps, including histological differentiation of neoplastic and non-neoplastic polyps, under conventional white light colonoscopy., Methods: This study prospectively observed 173 patients who underwent endoscopic polypectomy and reviewed the clinical data and pathologic reports of 313 polyps from a university hospital. Two endoscopists each performed colonoscopy and polypectomy and assessed the CSM. The association between CSM surrounding colorectal polyps and histology was analyzed., Results: The majority (91.3%) of CSM-positive polyps were neoplastic (sensitivity, 37.90%; specificity, 86.15%; p&lt;0.001). In logistic regression, the neoplastic polyps were associated with positive CSM (adjusted odds ratio [OR], 3.51; 95% confidence interval [CI], 1.45 to 9.25; p=0.007), protruded polyps (adjusted OR, 4.85; 95% CI, 1.65 to 17.23; p=0.008), and neoplastic histology-associated pit pattern (pit III, IV, and V) (adjusted OR, 10.14; 95% CI, 4.85 to 22.12; p=0.000). Furthermore, advanced adenomas were associated with positive CSM (adjusted OR, 5.64; 95% CI, 1.77 to 20.28; p=0.005), protruded polyps (adjusted OR, 3.30; 95% CI, 1.15 to 9.74; p= 0.026), and ≥10 cm polyp size (adjusted OR, 18.56; 95% CI, 3.89 to 147.01; p=0.001)., Conclusions: Neoplastic and advanced polyps were associated with CSM-positive polyps. These findings suggest that CSM is a useful marker in differentiating neoplastic polyps and advanced polyps under conventional white colonoscopy.

Introduction: Low-volume bowel preparation has been developed to increase patient compliance. We compared 1 L of polyethylene glycol/ascorbic acid (PEG/Asc) and oral sodium sulfate (OSS) with respect to bowel preparation efficacy, compliance, and safety., Methods: A multicenter, prospective, randomized, single-blinded, non-inferiority trial was conducted in 3 hospitals. Patients were randomized to receive a bowel-cleansing agent. Bowel-cleansing efficacy was evaluated using the Boston Bowel Preparation Scale (BBPS). Satisfaction, feeling, taste of the bowel cleanser, and adverse events after taking the bowel cleanser were investigated through a questionnaire. Additionally, blood samples were analyzed before and after bowel cleansing., Results: In total, 172 patients were analyzed (85 with 1 L PEG/Asc and 87 with OSS), and the mean BBPS scores were comparable between agents. The 1L PEG/Asc group tended to have a higher BBPS score in the right colon (2.22 vs 2.02; P = .08). The compliance of 1 L of PEG/Asc was comparable to that of OSS. Patients taking 1 L PEG/Asc reported greater thirst and dizziness (P = .04 and P = .047, respectively) than the OSS cohort. On the other hand, gastrointestinal symptoms such as vomiting and abdominal distension were more common in the OSS group, without statistical significance. In terms of laboratory adverse events, elevation of serum creatinine was found in both groups after taking the bowel cleansing agent (P < .001 for the 1L PEG/Asc group; P = .04 for the OSS group). However, most of the increased values were within the normal ranges., Discussion: The 1L PEG/Asc treatment was comparable to OSS in terms of bowel preparation efficacy, compliance, and safety., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background/aims: Symptom-based subtyping of functional dyspepsia (FD) is used to segregate patients into groups with homogenous pathophysiological mechanisms. This study examined whether subtyping could reflect the duodenal and gastric microinflammation in FD patients., Methods: Twenty-one FD patients without Helicobacter pylori infection were recruited. An endoscopic biopsy was performed in the duodenum 2nd portion, stomach antrum, and body. The eosinophil and mast cell counts per high-power field (×40) were investigated by H&E and c-kit staining, respectively. The degree of inflammatory cell infiltration, atrophy, and intestinal metaplasia was also determined by H&E staining in the stomach. The baseline characteristics and eosinophil and mast cell infiltrations were compared among the three groups (epigastric pain syndrome, postprandial distress syndrome, and overlap)., Results: According to the symptom assessment, seven subjects were classified into the epigastric pain syndrome group, 10 into the postprandial syndrome group, and four into the overlap group. The baseline variables were similar in the three groups. Eosinophil infiltration was more prominent in the duodenum than in the stomach. In contrast, mast cell infiltration was similar in the duodenum and stomach. The eosinophil counts in the duodenum were similar in the three groups. The eosinophil counts in the stomach and mast cell counts in the duodenum and stomach were also similar in the three groups., Conclusions: Duodenal eosinophil infiltration was prominent in FD patients, but the eosinophil counts were similar regardless of the symptom-based subtypes of FD. Hence, the current symptom-based subtyping of FD does not reflect duodenal eosinophil and mast cell infiltration.

Background and Aim: No inception cohort study has ever evaluated the early course of moderate-to-severe ulcerative colitis (UC) within 1 year of diagnosis in the non-Caucasian population. We aimed to investigate the early clinical course of moderate-to-severe UC patients in terms of remission, relapse, UC-related hospitalizations, colectomy, mortality, and overall use of medications., Methods: In the MOSAIK inception cohort, which is an ongoing multicenter, prospective, hospital-based, observational cohort, 354 patients with moderate-to-severe UC were followed up for 1 year. Main outcomes of UC and predictive factors for medication use over the course of 1 year were evaluated., Result: Among 354 patients, 276 (78.0%) patients were followed up for 1 year. The rates of remission, relapse, UC-related hospitalizations, and proximal disease extension were 95.3%, 39.6%, 15.2%, and 12.3%, respectively. Systemic corticosteroids, thiopurines, and biologics were administered to 61.2%, 30.4%, and 10.5% of patients, respectively, throughout 1 year. One year after, 58.2% patients experienced remission or mild endoscopic activity. Overall disease courses did not show much difference according to moderate or severe disease activity at baseline. In addition, no colectomy and mortality were observed for 1 year. Predictive factors for medication use included disease severity, disease extent, endoscopic severity, and presence of periappendiceal inflammation at baseline for corticosteroid, disease extent and initial corticosteroid use for thiopurine, and only initial corticosteroid use for biologics., Conclusion: Korean patients with moderate-to-severe UC may have more favorable early outcomes than Western patients. However, outcomes of them need to be further looked into for a longer time., (© 2021 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Familial adenomatous polyposis (FAP) is a hereditary disease characterized by the development of numerous colorectal adenomas in young adults. Metformin, an oral diabetic drug, has been shown to have antineoplastic effects and a favorable safety profile. We performed a randomized, double-blind, controlled trial to evaluate the efficacy of metformin on the regression of colorectal and duodenal adenoma in patients with FAP. Thirty-four FAP patients were randomly assigned in a 1:2:2 ratio to receive placebo, 500 mg metformin, or 1,500 mg metformin per day orally for 7 months. The number and size of polyps and the global polyp burden were evaluated before and after the intervention. This study was terminated early based on the results of the interim analysis. No significant differences were determined in the percentage change of colorectal and duodenal polyp number over the course of treatment among the three treatment arms ( P = 0.627 and P = 1.000, respectively). We found no significant differences in the percentage change of colorectal or duodenal polyp size among the three groups ( P = 0.214 and P = 0.803, respectively). The overall polyp burdens of the colorectum and duodenum were not significantly changed by metformin treatment at either dosage. Colon polyps removed from the metformin-treated patients showed significantly lower mTOR signal (p-S6) expression than those from patients in the placebo arm. In conclusion, 7 months of treatment with 500 mg or 1,500 mg metformin did not reduce the mean number or size of polyps in the colorectum or duodenum in FAP patients (ClinicalTrials.gov ID: NCT01725490). PREVENTION RELEVANCE: A 7-month metformin treatment (500 mg or 1,500 mg) did not reduce the number or size of polyps in the colorectum or duodenum of FAP patients as compared to placebo. These results do not support the use of metformin to promote regression of intestinal adenomas in FAP patients., (©2021 American Association for Cancer Research.)

Background and Aim: The few studies concerning the association between sleep disorders and functional dyspepsia (FD) have yielded inconsistent results. We compared the prevalence of sleep disorders in patients with FD and healthy controls, and evaluated whether FD was independently associated with sleep disorders, and the risk factors for sleep disorders in patients with FD., Methods: This prospective, multicenter, cross-sectional study was conducted from August 2014 to December 2017 at 12 hospitals in South Korea. The inclusion criterion was the presence of FD (for ≥18 years) according to the Rome III criteria. Healthy controls were recruited from among patients who visited the Health Examination Center for check-ups., Results: In total, 526 subjects were prospectively enrolled in this study (201 with FD and 325 healthy controls). The prevalence of sleep disorders was significantly higher among the patients with FD than among the healthy controls (41.8% vs 18.8%, P = 0.000). In a multivariate analysis, FD (odds ratio [OR] = 1.851; 95% confidence interval [CI] 1.194-2.870; P = 0.006), female sex (OR = 1.672; 95% CI 1.063-2.628; P = 0.026), and anxiety (OR = 3.325; 95% CI 2.140-5.166; P = 0.000) were independent risk factors for sleep disorders in the overall cohorts. In patients with FD only, low body mass index, heartburn, and anxiety were independent risk factors for sleep disorders in a further multivariate analysis., Conclusion: Sleep disorders were common in patients with FD. FD was significantly associated with sleep disorders in our patient population, irrespective of the presence of heartburn or psychiatric disorders., (© 2020 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background: The personality traits of endoscopists have been suggested to affect the adenoma detection rate (ADR). We thus evaluated the relationship between endoscopists' personality traits and the ADR during colonoscopy using the Minnesota Multiphasic Personality Inventory-2 (MMPI-2)., Methods: In total, 1230 patients (asymptomatic and aged 50-80 years) who underwent screening or surveillance (≥ 5 years) colonoscopy were recruited from 13 university hospitals by 20 endoscopists between September 2015 and December 2017. We retrospectively measured the ADR, polyp detection rate (PDR), and number of adenomas per colonoscopy (APC). All 20 endoscopists completed all 567 true/false MMPI-2 items., Results: The overall mean colonoscopy withdrawal time, PDR, ADR, and APC were 7.3 ± 2.8 min, 55%, 45.3%, and 0.97 ± 1.58, respectively. No significant difference was observed in the MMPI-2 clinical scales (e.g., hypochondriasis and psychasthenia), content scales (e.g., obsessiveness and type A character), or supplementary scales (e.g., dominance and social responsibility) between the high ADR group (ADR ≥45%, n = 10) and the low ADR group (ADR < 45%, n = 10). In multivariate logistic regression analysis, the ADR was associated significantly with patient age and sex. The ADR was related significantly to endoscopists' colonoscopy experience and the per-minute increase in the colonoscopy withdrawal time (OR 1.21, 95% CI 1.06-1.38, p = 0.005). In a logistic regression analysis adjusted for patient factors, the ADR was associated significantly with ego strength (OR 1.04, 95% CI 1.00-1.09, p = 0.044), as measured by the MMPI-2., Conclusions: With the exception of ego strength, the endoscopists' personality traits were not associated with adenoma or polyp detection.

Background/aims: This study compared the efficacy, compliance, and safety of bowel preparation between sodium picosulfate with magnesium citrate (SPMC) and oral sulfate solution (OSS)., Methods: A prospective randomized multicenter study was performed. Split preparation methods were performed in both groups; the SPMC group, 2 sachets on the day before, and 1 sachet on the day of the procedure, the OSS group, half of the OSS with 1 L of water on both the day before and the day of the procedure. The adenoma detection rate (ADR), adequacy of bowel preparation using the Boston Bowel Preparation Scale (BBPS) score, patient satisfaction on a visual analog scale (VAS), and safety were compared between the 2 groups., Results: This study analyzed 229 patients (121 in the SPMC group and 108 in the OSS group). ADR showed no differences between 2 groups (51.7% vs. 41.7%, P> 0.05). The mean total BBPS score (7.95 vs. 8.11, P> 0.05) and adequate bowel preparation rate (94.9% vs. 96.3%, P> 0.05) were similar between the 2 groups. The mean VAS score for taste (7.62 vs. 6.87, P=0.006) was significantly higher in the SPMC group than in the OSS group. There were no significant differences in any other safety variables between the 2 groups except nausea symptom (36.1% vs. 20.3%, P=0.008)., Conclusions: Bowel preparation for colonoscopy using low volume OSS and SPMC yielded similar ADRs and levels of efficacy. SPMC had higher levels of satisfaction for taste and feeling than did OSS.

Background: Tegoprazan is a novel potassium-competitive acid blocker that has a fast onset of action and can control gastric pH for a prolonged period, which could offer clinical benefit in acid-related disorders., Aim: To confirm the non-inferiority of tegoprazan to esomeprazole in patients with erosive oesophagitis (EE)., Methods: In this multicentre, randomised, double-blind, parallel-group comparison study, 302 Korean patients with endoscopically confirmed EE (Los Angeles Classification Grades A-D) were randomly allocated to either tegoprazan (50 or 100 mg) or esomeprazole (40 mg) treatment groups for 4 or 8 weeks. The primary endpoint was the cumulative proportion of patients with healed EE confirmed by endoscopy up to 8 weeks from treatment initiation. Symptoms, safety and tolerability were also assessed., Results: The cumulative healing rates at week 8 were 98.9% (91/92), 98.9% (90/91) and 98.9% (87/88) for tegoprazan 50 mg, tegoprazan 100 mg and esomeprazole 40 mg, respectively. Both doses of tegoprazan were non-inferior to esomeprazole 40 mg. The incidence of adverse events was comparable among the groups, and tegoprazan was well-tolerated., Conclusion: Once daily administration of tegoprazan 50 or 100 mg showed non-inferior efficacy in healing EE and tolerability to that of esomeprazole 40 mg., (© 2019 The Authors. Alimentary Pharmacology & Therapeutics Published by John Wiley & Sons Ltd.)

Background/aims: The aims of the present study were to determine the frequency of interval colorectal cancers (CRCs) after surveillance colonoscopy and to compare the clinicopathologic features and survival outcomes with those of non-interval CRCs., Methods: From January 2003 to December 2013, 66,016 follow-up colonoscopies for 38,412 patients performed within recommended time were reviewed retrospectively based on data from 11 tertiary hospitals in South Korea. To compare clinicopathologic features and survival rates for interval CRC, 106 patients with non-interval CRC matched in age and gender were included., Results: Among the 66,016 colonoscopies performed within the surveillance period, 63 cases (63/66,016) of interval CRC were detected, and 53 were finally included in the analysis. The mean age was 69.9±8.8 years, and the male to female ratio was 1.94:1. Although the occurrence rate of cancer in the right side colon was higher than that of non-interval CRC, interval CRCs were predominantly left sided. Other clinicopathologic features and overall survival were not significantly different between the two groups. Missed lesion was suspected to be the most common cause (29 cases, 54.7%)., Conclusions: The frequency of interval CRC among patients who had undergone a surveillance colonoscopy was 0.095%. While sharing some similar clinical features and survival outcomes, interval CRCs in Korea developed more often in males and on the left side in contrast to results from Western studies.

Background and Aim: The role of screening or diagnostic colonoscopy to detect advanced neoplasia in young cohorts of age < 50 is unclear. This study compared the risk of colorectal neoplasia in a young age cohort against that in 50-54s screening cohort., Methods: A multi-center retrospective study was conducted at 14 university hospitals to compare the detection rates of neoplasia and advanced neoplasia in screening or diagnostic colonoscopy in the young cohort of < 50s against those in screening colonoscopy in the 50-54s cohort., Results: Among 10 477 eligible subjects, 9765 subjects were enrolled after excluding 712 subjects. Advanced neoplasia detection rates in the young screening cohort was significantly lower than that in the 50-54s screening cohort (5.9% vs 9.3%, P < 0.001). Compared with 50-54s screening cohort, the risk of advanced neoplasia was significantly reduced by 23%, 53%, and 54% in the 45-49s, 40-44s, and 20-39s screening cohorts, respectively. The detection rates of advanced neoplasia in the young diagnostic cohort was 5.0%, which was much lower than 11.8% in 50-54s screening cohort (P < 0.001). Compared with the 50-54s screening cohort, the risk of advanced neoplasia was significantly reduced by 50%, 66%, and 71% in the 45-49s, 40-44s, and 20-39s diagnostic cohorts, respectively., Conclusions: Colonoscopy to detect advanced neoplasia in young adults aged < 50 years should be reconsidered as their risk of advanced neoplasia on screening or diagnostic colonoscopy was much lower than those of 50-54s screening cohort; however, colonoscopy screening may be justified for high-risk 45-49s cohorts., (© 2017 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background and Aim: The present study evaluated the clinical characteristics of Korean patients with Crohn's disease (CD) according to their age at diagnosis in a nationwide multicenter cohort study., Methods: A total of 1224 patients diagnosed with CD between 1982 and 2008 in 32 hospitals were included, and age at diagnosis was categorized as ≤ 16 (G1), 17-40 (G2), 41-59 (G3) and ≥ 60 (G4) years old. The baseline characteristics, medication, and intestinal resection were compared according to the age at diagnosis., Results: The number of patients in each age group was 155 (G1; 12.7%), 919 (G2; 75.1%), 120 (G3; 9.8%), and 30 (G4; 2.5%). The frequencies of ileocolonic disease in the late adult onset and elderly onset groups were lower than those in the other groups (P < 0.001). The cumulative probabilities of thiopurine and anti-tumor necrosis factor use in late adult onset and elderly onset groups were significantly reduced compared with those of the other groups (P < 0.01). However, the risk of the first intestinal resection was not different among the age groups. The ileal location (hazard ratio [HR]: 1.59; 95% confidence interval [CI]: 1.11-2.27), complicated behavior (HR: 3.35; 95% CI: 2.63-4.27), and early thiopurine use (HR: 0.27; 95% CI: 0.17-0.43) were associated with the first intestinal resection, whereas the age at diagnosis was not a risk factor., Conclusions: Elderly onset CD may be related to favorable outcomes in Korea. Thus, the heterogeneity of this disease should be considered when developing a tailored strategy for the treatment of CD., (© 2017 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background and Aim: Patients with gastroesophageal reflux disease (GERD) have decreased health-related quality of life (HRQL). The quality of life in patients with laryngopharyngeal reflux (LPR) symptoms is also significantly impaired. However, the impact of LPR symptoms on HRQL in GERD patients has not been studied., Methods: A nationwide, random-sample, and face-to-face survey of 300 Korean patients with GERD was conducted from January to March 2013. Gastroesophageal reflux symptoms were assessed using the Rome III questionnaire, LPR symptoms using the reflux symptom index, and HRQL using the EuroQol five dimensions (EQ-5D) questionnaire. A structured questionnaire on patient satisfaction, sickness-related absences, and health-related work productivity was also used., Results: Among the 300 patients with GERD, 150 had LPR symptoms. The mean EQ-5D index was lower in patients with GERD and LPR symptoms than in those without LPR (0.88 vs 0.91, P = 0.002). A linear regression model showed that the severity of LPR symptoms was related to decreased HRQL and was independent of age, marital status, body mass index, or household income. The overall satisfaction rate regarding treatment was lower in patients with GERD and LPR (40.0% vs 69.1%, P = 0.040). GERD patients with LPR symptoms reported greater sickness-related absent hours per week (0.36 vs 0.02 h, P = 0.016) and greater percentages of overall work impairment than those without LPR (31.1% vs 20.8%, P < 0.001)., Conclusions: Gastroesophageal reflux disease patients with LPR symptoms have a poorer HRQL, a lower satisfaction rate, and a greater disease burden than those without LPR., (© 2017 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Interval colorectal cancer (I-CRC) is defined as a CRC diagnosed within 60 months after a negative colonoscopy, taking into account that 5 years is the "mean sojourn time." It is important to prevent the development of interval cancer. The development of interval colon cancer is associated with female sex, old age, family history of CRC, comorbidities, diverticulosis, and the skill of the endoscopist. During carcinogenesis, sessile serrated adenomas/polyps (SSA/Ps) share many genomic and colonic site characteristics with I-CRCs. The clinical and biological features of I-CRC should be elucidated to prevent the development of interval colon cancer.

Background and Aims: The diagnosis of gastric intestinal metaplasia (IM) is currently performed by histologic assessment of multiple endoscopic biopsies, methylene blue chromoendoscopy, or narrow-band imaging with magnification. However, practical and readily available methods are lacking. We assessed the diagnostic accuracy and reproducibility of acetic acid chromoendoscopy (AAC) for determining the extent of gastric IM., Methods: One hundred twenty-six participants were enrolled. The participants underwent screening EGD with 1.5% acetic acid instillation for the detection of acetowhite reaction. Subsequently, targeted biopsies were performed at the 5 standard intra-gastric locations of the updated Sydney system. The accuracy of AAC was calculated using the histology results as a reference. Two endoscopists, each of whom was blinded to the other's result, determined the presence or absence of acetowhite reaction., Results: The overall diagnostic accuracy of AAC was 89.0%, and the sensitivity and specificity were 77.6% and 94.4%, respectively. The specificity for the gastric body was >94%. The proportion of extensive IM, a strong risk factor for gastric cancer, increased from 0.9% to 18.1% when AAC was used instead of conventional EGD alone (P < .001). Endoscopically determined atrophy had a negative effect on the diagnosis of AAC (odds ratio, 3.012; 95% confidence interval, 1.625-5.583). There was substantial inter- and intra-observer agreement., Conclusions: AAC is a valid and reproducible tool for determining the extent of gastric IM and may serve as a practical method of identifying populations at high risk of gastric cancer. (Clinical trial registration number: NCT01499576.)., (Copyright © 2017. Published by Elsevier Inc.)

Background/aims: The aim of this study was to compare the clinical features and outcomes of ulcerative colitis (UC) according to the age of onset in Korea., Methods: A total of 1,141 patients who were diagnosed with UC between July 1987 and November 2013 at 11 tertiary hospitals were enrolled. The baseline disease characteristic and disease state at onset, treatment during the disease course were retrospectively reviewed among patients with young-onset (YO, < 20 years) and adult-onset (AO, ≥ 20 years). Severe outcome was defined as use of intravenous (IV) steroids, infliximab, immunosuppressant, or UC-related operation., Results: There were 55 YO patients (mean age, 17.8 ± 2.4) and 1,086 AO patients (mean age, 43.0 ± 13.6). High Mayo scores (7.7 ± 3.0 vs. 5.6 ± 2.7, p = 0.000), extensive UC (52.7% vs. 25.8%, p = 0.000) and IV steroid (41.8% vs. 18.0%, p = 0.000), immunosuppressant (47.3% vs. 26.9%, p = 0.002), and infliximab (20.0% vs. 7.2%, p = 0.001) use were more frequent in the YO than in the AO group. According to multivariate analysis, severe outcomes were related to YO disease (hazard ratio [HR], 2.18; 95% confidence interval [CI], 1.27 to 3.71), body mass index < 23 kg/m 2 (HR, 1.46; 95% CI, 1.07 to 2.00), severe (HR, 2.29; 95% CI, 1.36 to 3.38), and moderate (HR, 2.48; 95% CI, 1.67 to 3.67) disease, extensive UC (HR, 2.90; 95% CI, 1.79 to 4.69), UC-related admission (HR, 63.89; 95% CI, 20.41 to 200.02), and oral steroid use (HR, 0.51; 95% CI, 0.39 to 0.67)., Conclusions: UC with YO presented with more advanced clinical features at onset and more severe outcomes than the AO. YO cases require careful management and intense treatment strategies., Competing Interests: No potential conflict of interest relevant to this article was reported.

Objectives: With advances in diagnostic endoscopy, the detection of rectal neuroendocrine tumors (NETs) has increased. However, clinical outcomes, especially after endoscopic treatment, are still unclear. The aim of this study was to determine the long-term clinical outcomes of endoscopically resected rectal NETs according to the pathologic status after initial resection., Methods: In this large, multicenter, retrospective cohort study, we analyzed the medical records of patients who underwent endoscopic resection of rectal NETs and were followed for ≥24 months at 16 university hospitals. The outcomes of interest were local or distant recurrence and metachronous lesions., Results: On the pathologic assessment of 407 patients, the resection margin status was positive in 76 (18.7%) and indeterminate in 72 (17.7%) patients. Patients whose rectal NETs were diagnosed or suspected as NETs before resection showed a much higher complete resection rate than those whose tumors were resected as polyps and then diagnosed (P<0.001). Fourteen patients received salvage treatment at 1.9±2.8 months after initial treatment. During a median follow-up period of 45.0 months, local recurrence occurred in 3 (0.74%) patients, but there was no recurrence in the lymph nodes or distant organs. Metachronous rectal NETs were diagnosed in 3 (0.74%) patients. According to the pathologic status after initial resection, local recurrence and metachronous lesions occurred in 1 (0.4%) and 2 (0.8%) patients, respectively, in the pathologic tumor-free group, whereas they occurred in 2 (1.4%) and 1 (0.7%) patients, respectively, in the indeterminate group., Conclusions: Considering the long-term prognosis including that for recurrences or metachronous lesions, endoscopic resection is an efficient and a safe modality for the treatment of rectal NETs. This treatment may result in favorable clinical outcomes in patients with tumors of indeterminate pathology, as well as in pathologic tumor-free cases after initial resection.

Objectives: A differential diagnosis between intestinal tuberculosis (ITB) and Crohn's disease (CD) is challenging. The aim of this study was to investigate the clinical, endoscopic, and histological features and to create a predictive score model for differentiating CD and ITB., Methods: In total, 261 patients, 99 with ITB and 162 with CD, were recruited from seven tertiary centers from 2005 to 2013 and reviewed retrospectively. For the creation of a validated model, parameters were selected by univariate logistic regression and receiver operating characteristic curve analyses. Then, the prediction model was established on the basis of β-coefficients of the multivariate logistic regression. For the validation of the model, the same regression equation was tested on the other group., Results: Age, diarrhea, ring-shaped ulcer, longitudinal ulcer, sigmoid involvement, suspicious radiological pulmonary tuberculosis, and gender were selected as the factors for a seven-marker model. In the seven-marker model of the validation data set, the sensitivity, specificity, positive predictive value, and negative predictive value with a cutoff level of 0.35 were 98.0, 92.4, 88.9, and 98.6, respectively., Conclusions: The seven-marker model seems to be highly reliable for differentiating between ITB and CD and could be conveniently used by clinicians to obtain results.

Background: The efficacy of proton-pump inhibitor-amoxicillin-clarithromycin therapy for H. pylori eradication has decreased over time., Objective: We assessed the trend of H. pylori eradication rates over the last 10 years and the relationship between the eradication rates and the amount of macrolide antibiotic use in a country with a high prevalence of H. pylori infection., Methods: This vast nationwide multicenter study was conducted with 34,139 adults treated for H. pylori infection from January 2001 to December 2010. The defined daily dose per km(2) (DSD) of macrolide antibiotics was calculated (n = 141,019) using the Health Insurance Review & Assessment data base from 2008 to 2010 in the two cities which had the lowest (Jeju city) or highest (Chuncheon city) eradication rate., Results: The eradication rates of proton-pump inhibitor-amoxicillin-clarithromycin therapy ranged 84.9-87.5% from 2001 to 2007, and those of 2008 to 2010 ranged 80.0-81.4% with a decreasing trend (p < 0.0001). The decreasing trend of eradication rates for the overall first-line therapy was observed only in three of the seven geographic areas in Korea (p < 0.0001). The DSD of macrolide antibiotics was significantly higher in Jeju than Cheunchon city (0.85 vs 0.52, p < 0.0001)., Conclusions: H. pylori eradication rates with clarithromycin-containing triple therapy in Korea showed a decreasing trend over the past 10 years, although the trend varied among geographic areas. This difference may be associated with the amount of macrolide antibiotic use., (© 2015 John Wiley & Sons Ltd.)

Background/aims: Pyogenic liver abscess (PLA) is a life-threatening condition, despite advances in diagnostic technology and strategies for treatment. A strong predictor of mortality in this condition is septic shock. This study describes clinical, biochemical, and radiologic features in patients with PLA with or without septic shock, with the intent of describing risk factors for septic shock., Methods: Of 358 patients with PLA enrolled, 30 suffered septic shock and the remaining 328 did not. We reviewed the medical records including etiologies, underlying diseases, laboratory, radiologic and microbiologic findings, methods of treatment and treatment outcomes., Results: The case fatality rate was 6.1%. In univariate analysis, the presence of general weakness, mental change, low platelet level, prolonged PT, high BUN level, high creatinine level, low albumin level, high AST level, high CRP level, abscess size >6 cm, the presence of gas-forming abscess, APACHE II score ≥ 20, and the presence of Klebsiella pneumoniae infection were significantly associated with septic shock. Multivariate analysis showed the presence of mental change (p=0.004), gas-form -ing abscess (p=0.012), and K. pneumoniae infection (p=0.027) were independent predictors for septic shock., Conclusions: The presence of mental change, gas-forming abscess, and K. pneumoniae infection were independent predictors for septic shock in patients with PLA.

Background/aims: The effect of proton pump inhibitors (PPI) in Asian functional dyspepsia (FD) patients has not been well established as in Westerncountries. DA-9701, a novel prokinetic agent, stimulates gastric emptying and modulates visceral hypersensitivity in vivo and in human studies. This study was conducted to compare the efficacy of DA-9701 with a conventional PPI in mono or combination therapy in patients with FD., Methods: In this double-blind, randomized, non-inferiority trial, 389 patients diagnosed with FD using Rome III criteria were allocated among3 groups: 30-mg DA-9701 t.i.d (means 3 times a day), 40-mg pantoprazole, and 30-mg DA-9701 t.i.d + 40-mg pantoprazole. Theprimary efficacy end-point was a global assessment of the patient binary response or response on a 5-Likert scale after 4 weeks., Results: The global symptomatic improvement was 60.5% in the DA-9701 group, 65.6% in the pantoprazole group, and 63.5% in the DA-9701 + pantoprazole group using a 5-Likert scale at week 4 with no significant difference among 3 groups (P = 0.685). Symptomimprovement measured by binary outcome was significantly achieved in each of the 3 groups, but not different among groups.Patients in all treatment groups reported significant improvement in the response rate and symptoms according to FD subtypes anddyspepsia-related quality of life (P < 0.001), but there were no significant differences among the 3 groups., Conclusions: DA-9701 improves global and individual symptoms and increases dyspepsia-specific quality of life in patients with FD. The efficacyof DA-9701 monotherapy is comparable with pantoprazole and there is no additive effect with combination of DA-9701 andpantoprazole in patients with FD.

Background/aims: To determine the incidence and clinical characteristics of tuberculosis (TB) medication-associated Clostridium difficile infection., Methods: This multicenter study included patients from eight tertiary hospitals enrolled from 2008 to 2013. A retrospective analysis was conducted to identify the clinical features of C. difficile infection in patients who received TB medication., Results: C. difficile infection developed in 54 of the 19,080 patients prescribed TB medication, representing a total incidence of infection of 2.83 cases per 1,000 adults. Fifty-one of the 54 patients (94.4%) were treated with rifampin. The patients were usually treated with oral metronidazole, which produced improvement in 47 of the 54 patients (87%). Twenty-three patients clinically improved with continuous rifampin therapy for C. difficile infection. There were no significant differences in improvement between patients treated continuously (n=21) and patients in whom treatment was discontinued (n=26)., Conclusions: The incidence of C. difficile infection after TB medication was not low considering the relatively low TB medication dosage compared to other antibiotics. It may not be always necessary to discontinue TB medication. Instead, decisions concerning discontinuation of TB medication should be based on TB status.

Background/aims: Gastric pathology and Helicobacter pylori (H. pylori) infection among Asian patients with Crohn's disease (CD) are still unclear. We evaluated gastric histologic features and frequency of H. pylori infection in Korean patients with CD., Methods: Among 492 patients with CD receiving upper gastrointestinal (GI) endoscopic evaluation in 19 Korean hospitals, we evaluated the endoscopic findings and gastric histopathologic features of 47 patients for our study. Histopathologic classification was performed using gastric biopsy tissues, and H. pylori infection was determined using the rapid urease test and histology., Results: There were 36 men (76.6%), and the median age of patients at the time of upper GI endoscopy was 23.8 years (range, 14.2-60.5). For CD phenotype, ileocolonic disease was observed in 38 patients (80.9%), and non-stricturing, non-penetrating disease in 31 patients (66.0%). Twenty-eight patients (59.6%) complained of upper GI symptoms. Erosive gastritis was the most common gross gastric feature (66.0%). Histopathologically, H. pylori-negative chronic active gastritis (38.3%) was the most frequent finding. H. pylori testing was positive in 11 patients (23.4%), and gastric noncaseating granulomata were detected in 4 patients (8.5%). Gastric noncaseating granuloma showed a statistically significant association with perianal abscess/fistula (P=0.0496)., Conclusions: H. pylori-negative chronic active gastritis appears to be frequent among Korean patients with CD. The frequency of H. pylori infection was comparable with previous studies. An association with perianal complications suggests a prognostic value for gastric noncaseating granuloma in patients with CD.

Background/aims: Pediatric inflammatory bowel disease (IBD) has been increasing worldwide. The characteristics of pediatric-onset IBD have mainly been reported in Western countries. We investigated the clinical characteristics of pediatric IBD in Korea and compared these with the data from the 5-year European multicenter study of children with new-onset IBD (EUROKIDS registry)., Methods: Children who were diagnosed with IBD between July 1987 and January 2012 were investigated at five Korean university hospitals. Their clinical characteristics were retrospectively evaluated by medical record review. The results were compared with the EUROKIDS data., Results: A total of 30 children with Crohn's disease (CD) and 33 children with ulcerative colitis (UC) were enrolled. In comparison with the EUROKIDS group, Korean pediatric IBD patients showed a male predominance (86.7% vs 59.2%, p=0.002 in CD; 75.8% vs 50%, p=0.003 in UC). Korean pediatric CD patients had a higher prevalence of terminal ileal disease (36.7% vs 16.3%, p=0.004) and perianal disease (33.3% vs 8.2%, p<0.001) than patients in the EUROKIDS group. Korean pediatric UC patients had a higher prevalence of proctitis than patients in the EUROKIDS group., Conclusions: Our results suggest that the characteristics of Korean pediatric IBD patients and European pediatric IBD patients may be different.

Background/aims: We investigated whether sodium picosulfate with magnesium citrate (SPMC) plus bisacodyl compares favorably with conventional polyethylene glycol (PEG) with respect to bowel cleansing adequacy, compliance, and safety., Methods: We performed a multicenter, prospective, single-blinded study in outpatients undergoing daytime colonoscopies. Patients were randomized into a split preparation SPMC/bisacodyl group and a conventional split PEG group. We compared preparation adequacy using the Boston bowel preparation scale (BBPS), ease of use using a modified Likert scale (LS), compliance/satisfaction level using a visual analogue scale (VAS), and safety by monitoring adverse events during the colonoscopy between the two groups., Results: A total of 365 patients were evaluated by intention to treat (ITT) analysis, and 319 were evaluated by per protocol (PP) population analysis (153 for SPMC/bisacodyl, 166 for PEG). The mean total BBPS score was not different between the two groups in both the ITT and PP analyses (p>0.05). The mean VAS score for satisfaction and LS score for the ease of use were higher in the SPMC/bisacodyl group (p<0.001). The adverse event rate was lower in the SPMC/bisacodyl group than in the PEG group (p<0.05)., Conclusions: The SPMC/bisacodyl treatment was comparable to conventional PEG with respect to bowel preparation adequacy and superior with respect to compliance, satisfaction, and safety.

Background: Probiotics can be beneficial in irritable bowel syndrome (IBS). Mosapride citrate, a selective 5-HT4 receptor agonist, stimulates gastrointestinal motility. We investigated the efficacy of combination therapy with probiotics and mosapride for non-diarrheal-type IBS., Methods: Two hundred and eighty-five IBS patients were randomly assigned to either a combination of probiotics (Bacillus subtilis and Streptococcus faecium) and mosapride at one of four different doses or a placebo for 4 weeks. The primary outcome was the proportion of patients experiencing adequate relief (AR) of global IBS symptoms at week 4. The secondary outcomes included subject's global assessment (SGA) of IBS symptom relief, individual symptoms, stool parameters, and IBS-quality of life., Key Results: The proportion of AR at week 4 was significantly higher in all treatment groups compared to the placebo group (53.7% in group 1, 55.0% in group 2, 55.2% in group 3, 53.6% in group 4 [the highest dose], and 35.1% in placebo group, respectively, p < 0.05). The proportion of patients reporting 'completely or considerably relieved' in the SGA was higher in the treatment groups than in the placebo group. The abdominal pain/discomfort score in the treatment group 4 was more prominently improved compared with that of the placebo group. In patients with constipation-predominant IBS, the improvements in stool frequency and consistency were significantly higher in the treatment groups 4 and 1, respectively, than those in the placebo group., Conclusions & Inferences: Combination therapy with probiotics and mosapride is effective for relief of symptoms in patients with non-diarrheal-type IBS. The study has been registered in the US National Library of Medicine (http://www.clinicaltrials.gov, NCT01505777)., (© 2015 John Wiley & Sons Ltd.)

The objective of this study was to conduct a meta-analysis to determine risk factors that may facilitate patient selection for radical resections or additional resections after a polypectomy. Eligible articles were identified by searches of PUBMED, Cochrane Library and Korean Medical Database using the terms (early colorectal carcinoma [ECC], lymph node metastasis [LNM], colectomy, endoscopic resection). Thirteen cohort studies of 7,066 ECC patients who only underwent radical surgery have been analysed. There was a significant risk of LNM when they had submucosal invasion (≥ SM2 or ≥ 1,000 µm) (odds Ratio [OR], 3.00; 95% confidence interval [CI], 1.36-6.62, P = 0.007). Moreover, it has been found that vascular invasion (OR, 2.70; 95% CI, 1.95-3.74; P < 0.001), lymphatic invasion (OR, 6.91; 95% CI, 5.40-8.85; P < 0.001), poorly differentiated carcinomas (OR, 8.27; 95% CI, 4.67-14.66; P < 0.001) and tumor budding (OR, 4.59; 95% CI, 3.44-6.13; P < 0.001) were significantly associated with LNM. Furthermore, another analysis was carried out on eight cohort studies of 310 patients who underwent additional surgeries after an endoscopic resection. The major factors identified in these studies include lymphovascular invasion on polypectomy specimens (OR, 5.47; 95% CI, 2.46-12.17; P < 0.001) and poorly or moderately differentiated carcinomas (OR, 4.07; 95% CI, 1.08-15.33; P = 0.04). For ECC patients with ≥ SM2 or ≥ 1,000 µm submucosal invasion, vascular invasion, lymphatic invasion, poorly differentiated carcinomas or tumor budding, it is deemed that a more extensive resection accompanied by a lymph node dissection is necessary. Even if the lesion is completely removed by an endoscopic resection, an additional surgical resection should be considered in patients with poorly or moderately differentiated carcinomas or lymphovascular invasion.

Background: Patients with Crohn's disease (CD) are frequently exposed to diagnostic radiation, mainly as a result of abdominopelvic computed tomography (APCT) examinations. However, there are limited data on the impact of APCT on clinical management in this population., Aim: To investigate clinical predictors of urgent findings on APCT in patients with CD who presented to the emergency department (ED)., Methods: A retrospective study was performed among patients with CD presenting to 11 EDs with a gastrointestinal complaint. The primary outcome, OPAN (obstruction, perforation, abscess, or non-CD-related urgent findings), included new or worsening CD-related urgent findings or non-CD-related urgent findings that required urgent or emergency treatment. Variables with P < 0.1 in univariate analyses were included in a multivariable logistic regression model., Results: Of the 266 APCTs performed, 103 (38.7 %) had OPAN and 113 (42.5 %) required changes in treatment plan. Stricturing or penetrating disease (odds ratio [OR] 2.72, 95 % confidence interval [CI] 1.21-6.13), heart rate >100 beats/min (OR 2.33, 95 % CI 1.10-4.93), leukocyte count >10,000/mm(3) (OR 4.38, 95 % CI 2.10-9.13), and CRP >2.5 mg/dL (OR 3.11, 95 % CI 1.23-7.86) were identified as the independent predictors of OPAN, whereas biologic agent use (OR 0.37; 95 % CI 0.15-0.90) was identified as the negative predictor in patients with CD., Conclusions: Only 39 % of the APCTs performed in the ED among patients with CD showed urgent findings. Stricturing or penetrating disease, tachycardia, leukocytosis, and high CRP level were predictors of urgent CT findings, while biologic agent use was a negative predictor. To reduce unnecessary radiation exposure, the selection process for CD patients referred for APCT must be improved.

Background/aims: It is well-known that patients with chronic liver disease commonly have nutritional deficiency. In the present study, we investigated the differences in malnutrition risk between patients with liver cirrhosis and viral hepatitis carrier., Methods: Patients with chronic liver disease who have been hospitalized at Konyang University Hospital from May 2012 to April 2013 were analyzed retrospectively. The malnutrition risk was divided into three categories (low, intermediate, and high) according to Konyang University Hospital Malnutrition Screening, which include BMI, serum albumin, total lymphocyte count (TLC), hemoglobin, weight change, appetite, and dysphagia, within 24 hours of hospitalization., Results: Among a total of 460 patients, 313 had liver cirrhosis (LC), and 147 were viral hepatitis carriers. Age (p<0.001), serum albumin level (p<0.001), TLC (p=0.011), hemoglobin (p<0.001) and serum cholesterol level (p=0.005) were significant different between the two groups. However, there were no difference in height, weight, and BMI. The malnutrition risk of the patients with viral hepatitis carrier was significantly lower than that of the patients with LC (p<0.001). In addition, among 313 patients with LC, malnutrition risk of the patients with Child-Pugh class A (n=150) was significantly lower than that of the patients with class B (n=90) or C (n=73) (p<0.001)., Conclusions: Viral hepatitis carrier group had significantly lower malnutrition risk than LC group. The risk of malnutrition in Child-Pugh class A group was significantly lower than that in class B or C group.

Endoscopic submucosal dissection (ESD) is a widely accepted treatment for early gastric and esophageal cancer. Compared to endoscopic mucosal resection, ESD has the advantage of enabling en bloc removal of tumors regardless of their size. However, ESD can result in a large artificial ulcer, which may lead to a considerable deformity. Circumferential mucosal defects of more than three-fourths the esophageal circumference, long longitudinal mucosal defects (>30 mm), and lesions in the upper esophagus are significant risk factors for the development of post-ESD strictures of the esophagus. In the stomach, a circumferential mucosal defects more than three-fourths in extent and longitudinal mucosal defects >5 cm are risk factors of post-ESD stricture. If scheduled early, regular endoscopic balloon dilation is effective in controlling and preventing post-ESD stricture. Moreover, intralesional steroid injections or oral steroids can achieve remission of dysphagia or reduce the need for repeated endoscopic balloon dilation. However, further study is needed to improve the prevention of stricture formation.

Background/aims: There have been few population-based studies on the prevalences of gastroesophageal reflux disease (GERD) and dyspepsia using Rome III criteria in Asian countries., Methods: A population-based, cross-sectional study was conducted by telephone interviews of 5,000 Koreans between the ages of 20-69 years. Gastrointestinal symptoms were assessed by a translated Korean version of Rome III criteria. Uninvestigated dyspepsia (UID) was defined by symptom criteria of Rome III. GERD was defined by troublesome heartburn and/or acid regurgitation occurring at least once a week. The EQ5D assessment tool was used for the evaluation of quality of life., Results: The prevalences of UID, postprandial distress syndrome (PDS), and epigastric pain syndrome (EPS) were 7.7, 5.6, and 4.2 %, respectively. Overlap between PDS and EPS was found in 27.1 % (104/384) of subjects with UID. There were no significant differences in demographic variables between patients with PDS and EPS. The prevalence of GERD was 7.1 %. Overlap between GERD and UID was found in 50.0 % of GERD patients. The EQ5D index of patients without either UID or GERD was 0.92 ± 0.07, and those of patients with only UID, with only GERD, and with both UID and GERD were 0.88 ± 0.09, 0.88 ± 0.11, and 0.84 ± 0.15, respectively., Conclusions: GERD and UID based on Rome III criteria were prevalent and significantly affected the quality of life in Korea. In Korean patients with UID, there was considerable overlap and there were no significant differences in demographic variables between PDS and EPS.

Background/aims: Several recent studies have reported that the early use of infliximab (IFX) improves the prognosis of Crohn's disease (CD). However, no data are available from Asian populations, as the forementioned studies have all been conducted in Western countries. The aim of the current study was to evaluate the impact of early use of IFX on the prognosis of Korean patients with CD., Methods: Patients with a diagnosis of CD established between July 1987 and January 2012 were investigated in 12 university hospitals in Korea. Because insurance coverage for IFX treatment began in August 2005, patients were assigned to either of 2 groups based on diagnosis date. The first group included patients diagnosed from July 1987 to December 2005, and the second from January 2006 to January 2012. We compared the cumulative probabilities of operation and reoperation between the two groups using the Kaplan-Meier method and a log-rank test., Results: Of the 721 patients investigated, 443 (61.4%) comprized the second group. Although the cumulative probabilities of immunosuppressant (P<0.001) and IFX use (P<0.001) after diagnosis were significantly higher in the second group, there were no significant differences in cumulative probabilities of operation (P=0.905) or reoperation (P=0.418) between two groups., Conclusions: The early use of IFX did not reduce CD-related surgery requirements in Korean patients with CD. These study results suggest that the early use of IFX may have little impact on the clinical outcome of CD in Korean patients in the setting of a conventional step-up algorithm.

Functional dyspepsia is one of the most common gastrointestinal disorders encountered in clinical practice. Functional dyspepsia is currently defined by Rome III criteria as the chronic dyspeptic symptoms (postprandial fullness, early satiety, epigastric pain or burning) in the absence of underling structural or metabolic disease that readily explain the symptoms. According to the Rome III consensus, functional dyspepsia can be subdivided into postprandial distress syndrome (PDS) and epigastric pain syndrome (EPS). Although the Rome III criteria have been published more than 8 years ago, not much effort has been put into validating these criteria and direct scientific evidence supporting the validity of the subdividing functional dyspepsia into PDS and EPS are lacking. This article is intended to review the validity of the Rome III criteria on the subdivisions of functional dyspepsia, i.e. PDS and EPS. The impact of sleep disorder, Helicobacter pylori-associated dyspepsia, and the emerging drug therapies in functional dyspepsia will also be discussed in this article.

Esophageal thermal injury caused by food has been reported to occur mostly after drinking hot liquid food, and is known to produce alternating white and red linear mucosal bands. In addition, thermal injury caused by ingestion of hot solid foods is documented to be a cause of esophageal ulcers or pseudomembranes. From January 2006 to August 2012, five patients with suspected esophageal thermal injury underwent esophagogastroduodenoscopy with biopsy. A "candy-cane" appearance was observed in one case, pseudomembrane was observed in two cases, an esophageal ulcer was observed in one case, and a friable and edematous mucosa was noted in one case. We believe that the endoscopic findings of esophageal thermal injury depend on the following factors: causative materials, amount of food consumed, exposure period, and time to endoscopy after the incident. Therefore, physicians who encounter patients with suspected esophageal thermal injury should carefully take the patient's history considering these factors.

Background/aims: Infliximab was approved for the treatment of ulcerative colitis (UC) in 2006 and has recently been used as rescue therapy in steroid-refractory UC. The aim of this study was to investigate the differences of medication use and prognosis in UC patients according to the periods of diagnosis., Methods: From 1987 to 2012, a total of 1,422 patients with UC were retrospectively reviewed in 12 hospitals. The study population was divided into two groups according to the periods of diagnosis as follows; group A: 1987-2005, group B: 2006-2012. Analyzed variables were compared by using chi-square test and logistic regression analysis., Results: Mean age of the subjects was 42.2 years, and the mean follow-up period was 4.7 years. In univariate analysis, the use of infliximab in group B was significantly higher than group A (4.5% vs. 7.6%, p=0.016), and UC-related hospitalization (45.8% vs. 40.1%, p=0.031) and UC-related surgery (6.4% vs. 3.5%, p=0.010) in group B was significantly lower than that of group A. The use of oral steroid in surgery group was significantly higher than non-surgery group in multivariate analysis (OR 1.85, 95% CI 1.03-3.30, p=0.039)., Conclusions: Infliximab might play an important role for the treatment of steroid-refractory UC. Well-designed prospective trials based on the efficacy and safety of infliximab are required in the future.

Background/aims: The recently developed double balloon enteroscopy (DBE) may be useful to evaluate small bowel lesions in patients with suspected Crohn’s disease (CD). We investigated the findings of DBE, small bowel follow-through and abdominal CT in patients with suspected CD who could not be diagnosed with CD using conventional colonoscopy., Methodology: Thirty patients (27 males, mean age 32.7±9.27 years) with suspected CD were consecutively enrolled in this study. The main symptoms were abdominal pain, chronic diarrhea, weight loss, obscure bleeding, or anemia. These patients were enrolled from May 2006 to January 2007 at 10 tertiary medical centers participating in the Korean Association for the Study of Intestinal Diseases., Results: The DBE demonstrated definite CD in 24 patients (80.0%) and suspected findings of CD in six patients. The pathology results obtained by endoscopic biopsies revealed a granuloma in six patients (23.1%). The DBE identified additional findings not detected by radiology studies in 24 patients (80%) although the small bowel followthrough and the abdominal CT revealed the abnormal findings (73.1% and 64%)., Conclusions: DBE may be a promising alternative and useful technique for patients with suspected CD. DBE provides biopsy sampling and more detailed information than radiology studies.

Various adverse events have been reported during combination therapy with pegylated (PEG)-interferon-α and ribavirin, although opportunistic infections, especially cryptococcal meningitis, are very rare. A 61-year-old woman complained of headaches and a fever during treatment of a chronic hepatitis C virus (HCV) infection. She had been treated for 7 months. Her headaches were refractory to analgesics, and she developed subtle nuchal rigidity. The cerebral spinal fluid (CSF) revealed a white blood cell count of 205/mm(3), 51 mg/dL protein, 35 mg/dL glucose, and negative Cryptococcus antigen. The CSF culture resulted in no growth. Five days later, the CSF was positive for Cryptococcus antigen. We administered amphotericin B and flucytosine, followed by fluconazole. Approximately 2 months later, she was discharged. For the first time, we report a case of cryptococcal meningitis during the treatment of chronic HCV with PEG-interferon-α and ribavirin.

Dyspepsia refers to group of commonly occurring upper gastrointestinal symptoms. The majority of patients with dyspepsia suffer from functional (nonulcer) dyspepsia. Although there is a lack of epidemiological data from population-based or patient cohort studies in Korea, the current understanding of this condition has been updated using data from various recent research studies, which have facilitated the development of clinical guidelines for functional dyspepsia. According to a survey using the Rome III criteria, more than 40% of respondents who visited primary clinics and tertiary hospitals were defined as having functional dyspepsia, most of who were within a subgroup of patients with postprandial distress syndrome. In addition, a population-based cross-sectional survey revealed considerable overlap between functional dyspepsia and other functional gastrointestinal disorders, including gastroesophageal reflux disease (especially nonerosive reflux disease) and irritable bowel syndrome. In contrast to the results of Western trials, there is insufficient evidence to recommend a Helicobacter pylori test-and-treat strategy as an initial management approach to functional dyspepsia in Korea, suggesting the need for early endoscopic evaluation. Additional studies are necessary to adjust the cutoff age for implementation of immediate endoscopic evaluation of patients without alarm symptoms. Considering the prevalence of H. pylori infection and the limited efficacy of symptomatic relief after its eradication, further well-qualified studies in Korea are warranted.

Background and Aim: Although differences in genetic susceptibility and the clinical features of Crohn's disease (CD) have been reported between Asian and Caucasian patients, the disease course and predictors of CD in Asians remains poorly defined. The study therefore aimed to investigate factors predictive of the clinical outcomes of patients with CD in a Korean population., Methods: This retrospective multicenter cohort study included 728 Korean CD patients from 13 university hospitals. The first CD-related surgery or need for immunosuppressive or biological agents were regarded as the clinical outcomes of interest., Results: A total of 126 (17.3%) CD patients underwent CD-related surgery, while 473 (65.0%) and 196 (26.9%) were prescribed thiopurine drugs and infliximab, respectively. Multivariate Cox regression analysis identified current (hazard ratio [HR] = 1.86; P = 0.018) and former smoking habits (HR = 1.78; P = 0.049), stricturing (HR = 2.24; P < 0.001), and penetrating disease behavior at diagnosis (HR = 3.07; P < 0.001) as independent predictors associated with the first CD-related surgery. With respect to immunosuppressive and biological agents, younger age (< 40 years) (HR = 2.17; P < 0.001 and HR = 2.10; P = 0.006, respectively), ileal involvement (HR = 1.36; P = 0.035 and HR = 2.17; P = 0.006, respectively), and perianal disease (HR = 1.42; P = 0.001 and HR = 1.38; P = 0.038, respectively) at diagnosis were significant predictors for the need of these medications., Conclusions: In Korean patients with CD, stricturing, penetrating disease behavior, and smoking habits at the time of diagnosis are independent predictors for CD-related surgery. It was also identified that younger age (< 40 years), ileal involvement, and perianal disease at diagnosis are predictive of a need for immunosuppressive or biological agents., (© 2013 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd.)

Objective: We evaluated the effect of acute hypergravity (HG) on the immune response in a murine model of allergic asthma., Material and Methods: Twenty-eight BALB/c mice were used. Group A (control group, n = 7) mice were sensitized and challenged with normal saline. Group B (control HG exposure group, n = 7) mice were sensitized, challenged with saline, and exposed to acute HG (+10 Gz) for 4 hours. Group C (asthma group, n = 7) mice were challenged with intraperitoneal and intranasal ovalbumin (OVA) to induce asthma. Group D (asthma HG exposure group, n = 7) mice were exposed to HG for 4 hours after the induction of asthma. We estimated the total and OVA-specific serum IgE, serum titers of various cytokines, and the number of eosinophils, neutrophils, and lymphocytes in bronchoalveolar lavage (BAL) fluid. Histopathology of the lung was also evaluated., Results: The serum level of interleukin (IL)-5 was significantly higher in Group D (12.9 ±4.9 pg/ml) compared to that in Group C (4.7 ±6.5 pg/ml, p = 0.017). In BAL fluid, the number of neutrophils was significantly increased in Group D compared to Group C (p = 0.014). Group D demonstrated a higher infiltration of inflammatory cells (9973.8 ±1642.7 cells/mm(2)) compared to Group C (7666.3 ±586.5 cells/mm(2), p = 0.017). This tendency of increase in infiltration was not significant in non-asthmatic animals (Group A: 4488.8 ±176.1 cells/mm(2) vs. Group B: 4946.3 ±513.7 cells/mm(2), p > 0.05)., Conclusions: Acute HG exacerbated the allergic response by increasing serum IL-5 levels and promoting pulmonary infiltration of inflammatory cells.

Background/aims: Antispasmodics such as octylonium are widely used to manage irritable bowel syndrome (IBS) symptoms. However, the efficacy and safety of another antispasmodic, tiropramide, remain uncertain. We aimed to evaluate the efficacy and safety of tiropramide compared with octylonium in patients with IBS., Methods: In this multicenter, randomized, non-inferiority trial, 287 patients with IBS (143 receiving tiropramide and 144 octylonium) were randomly allocated to either tiropramide 100 mg or octylonium 20 mg t.i.d (means 3 times a day) for 4 weeks. Primary endpoint was the mean change of abdominal pain from baseline assessed by visual analogue scales (VAS) score after 4 weeks of treatment. Secondary endpoints were the changes in abdominal pain from baseline at week 2 and in abdominal discomfort at weeks 2 and 4, using VAS scores, patient-reported symptom improvement including stool frequency and consistency, using symptom diaries, IBS-quality of life (IBS-QoL), and depression and anxiety, at week 4., Results: The VAS scores of abdominal pain at week 4, were significantly decreased in both tiropramide and octylonium groups, but the change from baseline did not differ between the 2 groups (difference,-0.26 mm; 95% CI,-4.33-3.82; P = 0.901). Abdominal pain and discomfort assessed using VAS scores, diaries, and IBS-QoL were also improved by both treatments, and the changes from baseline did not differ. The incidence of adverse events was similar in the 2 groups, and no severe adverse events involving either drug were observed., Conclusions: Tiropramide is as effective as octylonium in managing abdominal pain in IBS, with a similar safety profile.