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Splenic artery pseudoaneurysm (SAP) is a rare condition, occurring from many causes like pancreatitis, peptic ulcer, surgery, abdominal trauma and iatrogenic origins. SAP poses a great challenge to clinicians because it can lead to a variety of symptoms from abdominal pain, nausea, vomiting to massive bleeding into gastrointestinal tracts as well as abdominal cavity. A 43-year-old female who had previously been managed for alcoholic chronic pancreatitis and thrombotic thrombocytopenic purpura was admitted with hematochezia and dizziness. Patient went into shock from bleeding, however, there was no bleeding focus on initial CT scan and gastroduodenoscopy. Shock occurred repeatedly due to the severe blood loss from gastrointestinal tracts. On the 4th day in hospital, duodenal bleeding was suspected on gastrointestinal bleeding scan and bleeding from ampulla of Vater was found on follow-up gastroduodenoscopy. SAP which causes hemosuccus pancreaticus was diagnosed on angiography and it was treated successfully by embolization. Korean J Pancreatobiliary 2015;20(1):46-50

Background Numerous studies have focused on the association between miR-34 family members, which are direct p53 targets, and carcinogenesis of many cancers, including hepatocellular carcinoma (HCC). This study aimed to assess whether polymorphisms in the single-nucleotide polymorphism miR-34b/c T>C (rs4938723) and TP53 Arg72Pro (rs1042522) increase the risk of HCC and influence outcome in patients with HCC. Patients and methods We enrolled 157 HCC patients and 201 cancer-free control subjects from the Korean population. MicroRNA polymorphisms were genotyped using the polymerase chain reaction–restriction fragment length polymorphism (PCR-RFLP) method. Results We found that the miR-34b/c TC + CC frequency was significantly higher in HCC patients than in controls (adjusted odds ratio [AOR]: 1.580; 95% confidence interval [CI]: 1.029–2.426). The miR-34b/c CC-TP53 Arg/Arg combination significantly increased the risk of HCC (AOR: 13.644; 95% CI: 1.451–128.301). The SNPs miR-34b/c T>C and TP53 Arg72Pro(G>C) had no influence on survival of HCC patients. Conclusions Our findings suggest that loss of the T allele in miR-34b/c T>C, and the miR-34b/c CC-TP53 Arg/Arg combination increases the risk of HCC in the Korean population.

Background/Aims: This study assessed the efficacy of a rifaximin plus levofloxacin-based rescue regimen in patients that had failed both triple and quadruple standard regimens for the eradication of Helicobacter pylori. Methods: We treated patients for H. pylori between August 2009 and April 2011. The triple regimen consisted of combined treatment with amoxicillin, clarithromycin, and pantoprazole for 1 week. For failed cases, a quadruple regimen of tetracycline, metronidazole, bismuth dicitrate, and lansoprazole for 1 week was administered. The rescue regimen for persistently refractory cases was rifaximin 200 mg t.i.d., levofloxacin 500 mg q.d., and lansoprazole 15 mg b.i.d. for 1 week. Results: In total, 482 patients were enrolled in this study. The eradication rates associated with the first and second regimens were 58% and 60%, respectively. Forty-seven out of 58 patients who failed with the second-line regimen received rifaximin plus levofloxacin-based third-line therapy. The eradication rate for the third regimen was 65%. The cumulative eradication rates were 58%, 85%, and 96% for each regimen, respectively. Conclusions: A rifaximin plus levofloxacin-based regimen could be an alternative rescue therapy in patients with resistance to both triple and quadruple regimens for the eradication of H. pylori. (Gut Liver 2012;6:452-456)

Background Recent studies have suggested that common genetic polymorphisms alter the processing of microRNA (miRNA) and may be associated with the development and progression of cancer. Patients and methods The association of miRNA polymorphisms with HCC survival was analyzed in 159 HCC patients and 201 controls by the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method. Results The risk of HCC was significantly lower for the miR-499A>G, AG + GG in HCC patients (AOR = 0.603, 95% CI = 0.370–0.984) and hepatitis B virus (HBV)-related HCC patients (AOR = 0.561, 95% CI 0.331–0.950). In addition, the risk of HCC was significantly lower for the miR-149C>T, CT and CT + CC in HCC patients (CT; AOR = 0.542, 95% CI = 0.332–0.886, CT + CC; AOR = 0.536, 95% CI = 0.335–0.858) and HBV-related HCC patients (CT: AOR = 0.510, 95% CI 0.305–0.854, CT + CC: AOR = 0.496, 95% CI 0.302–0.813). The miR-149C>T polymorphism was also associated with survival rate of HCC patients in OKUDA II stage. Conclusions miR-149C>T and miR-499A>G were associated with HBV-related HCC. Further studies on larger populations will need to be conducted to confirm these results.

Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Korea 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏 Hepatic portal venous gas (HPVG), a rare radiologic finding, is associated in some cases with severe or lethal conditions requiring urgent surgical intervention. Computed tomography has recently demonstrated a wider range of clinical conditions associated with HPVG, some of which are benign and do not necessarily require surgery. However, HPVG remains an ominous sign in cases of bowel ischemia or necrosis. We report on a case of massive HPVG caused by a fatal intestinal infarction, which showed rapid disease progression, eventually resulting in death due to septic shock. The HPVG in this case was huge and could therefore be confused with an air-biliarygram. (Intest Res 2011;9:153-157) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

PURPOSE (18)F-fluorodeoxyglucose positron emission tomography/computed tomography ((18)F-FDG PET/CT) scans are frequently performed for the screening or staging of malignant tumors. This study aimed to assess the usefulness of (18)F-FDG PET/CT in detection of gastric cancer recurrence after curative gastrectomy. MATERIALS AND METHODS Eighty nine patients who had undergone curative gastrectomy due to gastric cancer and had (18)F-FDG PET/CT and contrast CT scans within 2 weeks for surveillance in asymptomatic patients (n = 11) or to clarify suspected recurrence (n = 78) were consecutively collected and retrospectively analyzed. They had clinical follow-up for at least 12 months after PET/CT and CT scans. RESULTS Fifteen of the 89 patients (16.9%) were diagnosed with recurrent gastric cancer in 21 organs. Forty one organs showed an increase in FDG uptake, and only 9 of these organs were diagnosed with recurrent gastric cancer by (18)F-FDG PET/CT. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of the (18)F-FDG PET/CT were 42.9%, 59.7%, 29.3%, 78.2%, and 57.3%, respectively. On the CT scan, 18 of 21 recurrent gastric cancers were detected, and 7 cases were in agreement with the (18)F-FDG PET/CT. The sensitivity and specificity of the CT scan were 85.8% and 87.3%, respectively, which are superior to the (18)F-FDG PET/CT. When we diagnosed a recurrence based on either (18)F-FDG PET/CT or CT scans, the sensitivity increased to 95.2% and the specificity decreased to 45.6%, when compared with the contrast CT scan alone. CONCLUSION (18)F-FDG PET/CT is an insufficient diagnostic method in detection of recurrence after curative gastrectomy, and even less accurate than contrast CT scan alone.

Complications associated with an intramural hematoma of the bowel, is a relatively unusual condition. Most intramural hematomas resolve spontaneously with conservative treatment and the patient prognosis is good. However, if the symptoms are not resolved or the condition persists, surgical intervention may be necessary. Here we describe internal incision and drainage by endoscopy for the treatment of an intramural hematoma of the duodenum. A 63-yr-old woman was admitted to the hospital with hematemesis. The esophagogastroduodenoscopy (EGD) showed active ulcer bleeding at the distal portion of duodenal bulb. A total of 10 mL of 0.2% epinephrine and 2 mL of fibrin glue were injected locally. The patient developed diffuse abdominal pain and projectile vomiting three days after the endoscopic treatment. An abdominal computed tomography revealed a very large hematoma at the lateral duodenal wall, approximately 10 x 5 cm in diameter. Follow-up EGD was performed showing complete luminal obstruction at the second portion of the duodenum caused by an intramural hematoma. The patient's condition was not improved with conservative treatment. Therefore, 21 days after admission, endoscopic treatment of the hematoma was attempted. Puncture and incision were performed with an electrical needle knife. Two days after the procedure, the patient was tolerating a soft diet without complaints of abdominal pain or vomiting. The hematoma resolved completely on the follow-up studies.

Background/Aims: Subcellular localization of hepatitis B virus (HBV) core antigen (HBcAg) and HBV surface antigen (HBsAg) is known to be related to the activity of liver disease and the level of HBV replication. The aim of this study was to determine the correlation between histologic activity, viral replication, and the intracellular distributions of HBcAg and HBsAg. Methods: We enrolled 670 patients with chronic hepatitis B who underwent liver biopsy at Bundang CHA hospital between 1997 to 2007. The data from medical records were reviewed retrospectively. Results: The stage of fibrosis was higher (3.31±1.34 vs. 2.43±1.39, mean±SD, p＜0.01) and the grade of necroinflammatory activity was higher (9.39±3.11 vs. 6.13±3.40, p＜0.001) for the cytoplasmic expression of HBcAg (cHBcAg) than for the nuclear expression of HBcAg (nHBcAg). The serum HBV DNA level was 677.30±983.14 pg/mL in cHBcAg, 1274.46±1417.28 pg/mL in nHBcAg, 1121.01±1121.0 pg/mL in c-nHBcAg, and 229.47±678.92 pg/mL in negative (p＜0.001). HBeAg was seropositive in 74.7% of patients with cHBcAg, 90.6% in those with nHBcAg, 90.3% in those with n-cHBcAg, and 55.6% in those with negative (p＜0.001). The histologic stage and grade of hepatitis were not significantly correlated with the subcellular localization of intrahepatic HBsAg (p＞0.05). Conclusions: These observations suggest that the histologic activity of hepatitis is higher and viral replication is lower in cHBcAg positive patients than in those with nHBcAg. (Gut and Liver 2008;2:166173)

Background/Aims: The objective of this study was to document the prevalence rate of occult hepatitis B virus (HBV) in healthy pregnant woman and the possibility of transmission to the foetus. Methods: This study was performed prospectively with 202 healthy pregnant women. HBV-DNA testing was performed using two specific quantitative tests with two independent sets of sera and cord blood. DNA sequencing analysis was carried out to confirm the specificity of polymerase chain reaction (PCR) product of HBV-DNA testing. Results: Eight of 202 (4%) individuals with the TaqMan PCR assay and 23 of 202 (11.4%) with the COBAS Amplicor HBV Monitor test were HBV-DNA positive. Six (3%) individuals were positive with both methods. Sequencing and genotyping analysis of HBV polymerase gene with sera of the 75th subject resulted in genotype C. HBV-DNA testing with four cord blood samples showed that all were HBV-DNA negative. Conclusion: Occult HBV infection shows a difference in prevalence rate depending on the test method but the existence has been confirmed by sequencing analysis. Our results also suggest that vertical transmission through the cord blood is not so high as to be clinical problems and warrants further investigation.

Background/Aims: Colonoscopic perforations have been managed with exploratory laparotomy, and have resulted in some morbidity and mortality. Recently, laparoscopic surgery is commonly performed for this purpose. The aim of this study was to compare the outcomes of several management strategies for iatrogenic colonoscopic perforations. Methods: We retrospectively reviewed the medical records of patients who had been treated for colonoscopic perforation between January 2004 and April 2013 at CHA Bundang Medical Center in Korea. Results: A total of 41 patients with colonoscopic perforation were enrolled. Twenty patients underwent conservative management with a success rate of 90%. Surgical management was performed in 23 patients including two patients who were converted to surgical management after the failure of the initial conservative management. Among 14 patients who underwent surgery at 8 hours after the perforation, there was no considerable difference in adverse outcomes between the laparotomy group and the laparoscopic surgery group. The medical costs and claim rate were 1.45 and 1.87 times greater in the exploratory laparotomy group, respectively. Conclusions: Conservative management of colonoscopic perforation could be an option for patients without overt symptoms of peritonitis or with a small defect size. If surgical management is required, laparoscopic surgery may be considered as the initial procedure even with a delayed diagnosis.

Epithelial-mesenchymal transition (EMT) is an important factor in cancer invasiveness and metastatic progression. During EMT, cancer cells acquire stem cell properties. The role of EMT and stemness in colon cancer has not been fully understood. We aimed to demonstrate the clinical significance of EMT and the stem cell phenotype in colorectal cancer. Two hundred and thirty-one surgically resected colon cancer cases were included in the present study. mRNAs of E-cadherin, TWIST1 and SNAI1 were analyzed by quantitative real-time polymerase chain reaction (qRT-PCR) (n=109). Immunohistochemical staining was performed for six markers (ALDH1, TGF-β1, E-cadherin, β-catenin, TWSIT1 and SNAI1) (n=231). We assessed clinicopathological characteristics according to the expression of the stem cell phenotype and EMT markers. Based on the results of qRT-PCR, TWIST1 and SNAI1 significantly influenced node metastasis (P=0.04 and P=0.02, respectively). High TWIST1 and SNAI1 mRNA expression was associated with poor overall survival according to the univariate analysis (P

The microRNA (miR)-34 family is a direct transcriptional target of tumor-suppressor TP53 and loss of miR-34 function may impair TP53-mediated cell cycle arrest and apoptosis. In the present study, we investigated whether the single nucleotide polymorphisms (SNPs) rs4938723 (T>C) in the promoter region of miR-34b/c and Arg72Pro (G>C) in codon 72 of TP53 are independently or complementarily associated with the risks and clinical outcomes of colorectal cancer (CRC) and whether the combined effect of these SNPs and metabolic risk factors are related to CRC. We evaluated the SNPs in 545 CRC patients and 428 healthy controls using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) and DNA sequence analysis. We found that the GC and GC/CC genotypes of TP53 Arg72Pro were associated with decreased risk of CRC (adjusted OR = 0.727 for GC; OR = 0.735 for GC/CC). The combined genotypes of TT-GC and CC-GG were significantly associated with reduced CRC risk (adjusted OR = 0.628 for TT-GC; OR = 0.381 for CC-GG, respectively). The SNP rs4938723 and diabetes mellitus (DM) together were associated with an increased CRC risk, but the SNP TP53 Arg72Pro CC with DM showed a protective effect against CRC. These findings indicate that rs4938723 in the promoter region of pri-miR-34b/c and the SNP in TP53 codon 72 were related to decreased risk of CRC in the population studied and those metabolic diseases and genetic variants influence each other with regard to CRC susceptibility.

Gastric volvulus occurs when the stomach rotates about its longitudinal axis (organo-axial volvulus), or about an axis joining the lesser and greater curvatures (mesentero-axial volvulus). Primary gastric volvulus, making up one third of cases, occurs when the stabilizing ligaments are too lax as a result of congenital or acquired causes. Secondary gastric volvulus, making up the remainder of cases, occurs in association with a paraesophageal hernia or other congenital or acquired diaphragmatic defects. While gastric volvulus may occur acutely, especially in children, it may not be clinically apparent and discovered incidentally. The authors present a case of chronic organo-axial volvulus of the stomach secondary to left hemidiaphragmatic eventration with a review of the relevant literature.

Background/aims Oxygen free radicals play an important role in acute pancreatitis. Pantoprazole as a proton pump inhibitor (PPI) has pancreatic anti-secretory effect and a pronounced inhibitory reactivity towards hydroxyl radicals. The objective of the study was to investigate the effect of pantoprazole on the course of acute pancreatitis. Methods We conducted a prospective randomized trial involving 40 patients with acute pancreatitis. Patients were divided into two groups. One group received PPI and the other group did not receive PPI. In the PPI group, patients received pantoprazole 40 mg intravenously twice a day for fasting time, and then 40 mg orally twice a day until discharge. Results There were no significant differences in baseline characteristics and laboratory markers between two groups. In the pantoprazole group, mean hospital stay was 7.4 days, time to start oral intake was 69.0 hours, and time to pain relief was 59.7 hours. Acute physiology and chronic health evaluation (APACHE) II score was 3.15 at admission day and 2.35 at discharge. On the other hand, in the non-pantoprazole group, mean hospital stay was 7.6 days, time taken to start oral intake was 71.4 hours, and time taken to pain relief was 61.8 hours. APACHE II score was 4.4 at admission and 2.85 at discharge. However, there were no significant differences between two groups. Conclusions Treatment with pantoprazole did not have influence on the clinical course of acute pancreatitis. But, considering it was a pilot study, large scale prospective trials will be needed.

Colonic lipoma, a very rare form of benign tumor, is typically detected incidentally in asymptomatic patients. The size of lipoma is reported variously from 2 mm to 30 cm, with higher likelihood of symptoms as the size is bigger. Cases with symptom or bigger lesion are surgically resected in principle; endoscopic resection, which has developed recently with groundbreaking advance of endoscopic excision technology, is being used more often but with rare report of success due to high chance of complications such as bowel perforation or bleeding. The authors report here, together with a literature review, our experiences of three cases of giant colonic lipomas showing complete remission after aggressive unroofing technique, at certain intervals, using snare catheter at the origin of the lipoma so that the remaining lipoma could be drained out of the exposed surface spontaneously, in order to reduce complications.

Bleeding from the appendix has been reported very rarely in patients with lower-gastrointestinal-tract bleeding. In general, after a colonoscopic diagnosis of appendiceal bleeding, laparoscopic or surgical appendectomy would be recommended. Two patients with continuous bleeding from the appendix were treated with partial occlusion of the appendiceal orifice by colonoscopic clipping. In neither case was there evidence of further active bleeding over the following 12 months. This is the first report of such a treatment in the English literature.

Background and Aim: Signal transducers and activators of transcription (STAT) behave as signal transducers in the cytoplasm and as transcription factors in the nucleus. In the current study, we analyzed the immunohistochemical staining patterns of gastrectomy tissue specimens. We investigated the expression of STAT3 and STAT5 and estimated the relationship between STAT and cancer prognosis. Methods: One hundred patients who underwent gastrectomy due to gastric adenocarcinoma at Bundang CHA hospital between January 2000 and May 2005 were studied. Immunohistochemistry was carried out using antibodies against STAT3 and STAT5. The interpretation of the immunohistochemical staining was based on the proportion of stained cells in the field: positive, > 10% stained cells; and negative

Nonalcoholic fatty liver disease (NAFLD) is known to be closely associated with various metabolic abnormalities including metabolic syndrome. However, there are few data available on the association of metabolic syndrome with the sonographically fatty liver and normal range of liver function test. The purposes of this study were to find the incidence of ultrasonographic fatty liver with normal range of liver function test and to evaluate the association with metabolic syndrome in apparently healthy Korean adults.We examined 538 men and women, aged 30-80 years, who participated in a health screening test. Among the people with normal ALT level, we compared clinical characteristics and prevalence of metabolic disorders according to the presence of nonalcoholic sonographyally fatty liver, and then they were subdivided into upper normal range and lower normal range of ALT level.Compared to the people without sonographic fatty liver, people with sonographic fatty liver and normal range of ALT level had odds ratios for metabolic syndrome of 4.53, insulin resistance 4.83, hypertension 2.69, dyslipidemia 6.90, and obesity 5.39, respectively. Furthermore, the prevalence of metabolic syndromes and other metabolic disorders were increased in both sonographically fatty liver group or ultrasonographically normal liver group with upper normal range of ALT level compared with lower normal ALT level (p0.01).The nonalcoholic sonographically fatty liver was strongly associated with metabolic syndrome and common metabolic abnormalities even with normal liver function test.

The objective of this study was to document the prevalence rate of occult hepatitis B virus (HBV) in healthy pregnant woman and the possibility of transmission to the foetus.This study was performed prospectively with 202 healthy pregnant women. HBV-DNA testing was performed using two specific quantitative tests with two independent sets of sera and cord blood. DNA sequencing analysis was carried out to confirm the specificity of polymerase chain reaction (PCR) product of HBV-DNA testing.Eight of 202 (4%) individuals with the TaqMan PCR assay and 23 of 202 (11.4%) with the COBAS Amplicor HBV Monitor test were HBV-DNA positive. Six (3%) individuals were positive with both methods. Sequencing and genotyping analysis of HBV polymerase gene with sera of the 75th subject resulted in genotype C. HBV-DNA testing with four cord blood samples showed that all were HBV-DNA negative.Occult HBV infection shows a difference in prevalence rate depending on the test method but the existence has been confirmed by sequencing analysis. Our results also suggest that vertical transmission through the cord blood is not so high as to be clinical problems and warrants further investigation.

We report a rare case of a massive fatal embolism that occurred in the middle of endoscopic retrograde cholangiopancreatography (ERCP) and retrospectively examine the significant causes of the event. The patient was a 50-year old female with an uncertain history of previous abdominal surgery for multiple biliary stones 20 years prior. The patient presented with acute right upper quadrant pain. An abdominal computed tomographic (CT) scan revealed the presence of multiple stones in the common bile duct (CBD) and intra-hepatic duct (IHD) with biliary obstruction, multifocal liver abscesses, and air-biliarygram. Emergency ERCP showed a wide and straight opening of choledochoduodenostomy, which may have been created during a previous surgery, and multiple filling defects in the CBD. With the use of a forward endoscope, mud stones were extracted through the opening of the choledochoduodenostomy. Cardiac arrest suddenly developed during the procedure, and despite immediate resuscitation, the patient died due to a massive systemic air embolism. We reviewed previously reported fatal cases and accessed factors facilitating air embolisms in this case.

Elevated transaminase levels are often detected during pregnancy. Causes are variable and difficult to differentiate. Furthermore, there is no practical guideline for abnormal transaminase levels in pregnancy. The aim of this study was to suggest a strategy for managing elevated transaminase level during pregnancy.One hundred and fifty-five women with elevated transaminase level were included from an antenatal care center between January 1, 2003 and December 31, 2004. Another 221 women with normal transaminase levels were enrolled as control group. We analyzed documented causes, changes in laboratory tests, and pregnancy outcomes.Two groups showed no difference in baseline characteristics except the duration of pregnancy, parity, and albumin level. Of abnormal results, 39.4% occurred between 30 and 40 gestational weeks while 29% occurred between 10 and 20 gestational weeks. Common causes were hyperemesis gravidarum followed by pre-eclampsia, viral hepatitis, and HELLP syndrome. Excluding viral hepatitis, 69 patients showed abnormal results in the first two trimesters and the results were normalized during the follow-up period. AST and ALT levels were 52.9 (+/-49.6) IU/L and 83.3 (+/-77.0) IU/L during the first two trimesters in the patient group. Abnormal results during the third trimester were associated with shorter duration of pregnancy.Elevated transaminase levels up to 3 to 4 times of the upper normal limit during the first two trimesters could be safely observed with careful history taking and hepatitis viral antigen tests. However, abnormal results in the third trimester were associated with a shorter duration of pregnancy and should be managed carefully.

Complicating intramural hematoma is an interesting, relatively unusual condition. Various etiologic factors have been described, with the most common being blunt trauma, anticoagulant therapy, Henoch-Sch nlein purpura and blood dyscrasias. Most intramural hematomas resolve spontaneously with conservative treatment, and the prognosis is good. However, if the abdominal pain or obstruction does not resolve with medical management over seven to ten days, complications such as infarction or peritonitis may occur, and surgical intervention might be required. We report a case of intramural hematoma of duodenum treated with percutaneous drainage and embolization of bleeding focus which was complicated with acute pancreatitis after anticoagulation treatment in a patient with recurrent history of deep vein thrombosis. In addition, we reviewed reports of intramural hematoma of the duodenum and treatment strategies.

Assessment of Health-related quality of life (HRQOL) outcomes in treatment of chronic disease is increasingly important. The objective of this study was to validate a Korean translation of the Liver Disease Quality of Life instrument (LDQOL version 1.0) for use in patients with chronic liver disease.Two native Korean speakers with fluent English translated LDQOL including instructions, items, and response choices. This Korean translation of the LDQOL was administered to 121 patients with chronic liver disease. Cronbach's alpha coefficients were applied to test an internal consistency reliability of disease-specific scales of the LDQOL. MELD and modified CTP scores were calculated for all patients. Associations of MELD and modified CTP scores with severity of liver disease were analyzed with LDQOL.Internal consistency reliability was good (Cronbach's Alpha=0.69-0.94) in liver disease specific scales, except for the quality of social interaction scale (Cronbach's Alpha= 0.56). Mean modified CTP score and MELD score were 6.2+/-1.9 and 9.3+/-5.3, respectively. Both MELD score and modified CTP score showed correlations with most of the scores of liver disease specific scales of LDQOL 1.0, except for the quality of social interaction and sleep scale.The Korean version of the liver disease specific scales of the LDQOL 1.0 is validated and useful for measuring HRQOL in Korean patients with chronic liver disease.

5,10-Methylenetetrahydrofolate reductase (MTHFR), a key enzyme in folate metabolism, plays a major role in the provision of methyl groups for DNA methylation; thymidylate synthase (TS) is a rate-limiting enzyme in the synthesis of dTMP and DNA repair. The clinical role of genetic polymorphisms of MTHFR and that of the TS enhancer region (TSER) were demonstrated in several clinical studies with colorectal, esophageal, gastric and breast cancer. However, there have never been any studies on the association between cholangiocarcinoma (CCC) and genetic polymorphisms of MTHFR and TSER. Therefore, the polymorphism of MTHFR and TSER, which share a common substrate, 5,10-methylenetetrahydrofolate, in CCC was examined, concurrently. The influence of these polymorphisms on plasma homocysteine levels was also investigated.Blood samples were obtained from 47 patients with CCC and 204 healthy control donors. Using polymerase chain reaction and restriction fragment length polymorphism (PCR-RFLP), the C to T transition at position 677 of MTHFR and tandem repeat of 28bp in the enhancer region of TS gene were analyzed. Plasma homocysteine levels were also determined.According to the logistic regression model, a combination of MTHFR 677CC with the TSER 2R(+) genotype had a relative risk of 5.38 (95% CI, 1.23-23.56) of developing CCC compared to MTHFR 677CC with TSER 2R(-) (p = 0.0257). The level of homocysteine was lower in CCC patients than healthy controls without statistical significance (8.27 +/- 4.17 vs. 9.40 +/- 2.57, p = 0.093).Our data suggest a role of MTHFR 677CC with the TSER 2R(+) genotype in increasing the risk of CCC. This study is the first to suggest an association between CCC and the polymorphisms of MTHFR and TSER.

275 Outcome Over 5 Years of Minimally Invasive Treatment of Early Gastric Cancer Beyond Endoscopic Submucosal Dissection Ga Won Song*, Suk Pyo Shin, Weon-Jin Ko, Jun Hwan Yoo, Duk Hwan Kim, Kim Wonhee, Kwang Hyun Ko, Joo Young Cho, Ki Baik Hahm, Sung-Pyo Hong, Pil Won Park, Jun-Hyung Cho Digestive Disease Center, Soonchunhyang University Hospital, Seoul, Korea (the Republic of); Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam-si, Korea (the Republic of) Background/Aims: The aim of this study was to evaluate the long term outcomes of combined endoscopic submucosal dissection (ESD) with laparoscopic lymph node dissection (LLND) and endoscopic full-thickness resection (EFTGR) with laparoscopic regional lymph node dissection (hybrid natural orifice transluminal endoscopic surgery, hybrid NOTES) for early gastric cancer (EGC). Methods: This is a retrospective analysis at a single tertiary referral center. A total of 23 patients with EGC underwent combined ESD with LLND and hybrid NOTES for early gastric cancer beyond endoscopic submucosal dissection between February 2007 and August 2009. Then the patients received periodic endoscopic follow-up and metastatic surveys over 5 years. The main outcome measures were curability (curative or non-curative), recurrent rate, and survival rates. Results: The curative resection rate of all cases was 95.7% (ESD with LLND 90.0% vs. hybrid NOTES 100%, respectively). Incomplete resection was shown in 1 (tumor-positive vertical margin). Histologically, 11 cases were mucosal cancers, and 12 were submucosal cancers. And there were 12 undifferentiated cancers. The median tumor size was 3.4 cm (range, 1.25.7cm) in long diameter. The lymphovascular invasion was found in 3 cases with 1 lymph node metastasis. 5 patients underwent additional gastrectomy because of tumor-positive margins or treatment-related complications. During over 5 year follow-up periods, none showed local recurrence or lymph node metastasis. The 5 year overall survival rates and disease free survival of the patients was100% in both. Conclusion: Combined ESD with LLND and hybrid NOTES showed favorable long term clinical outcomes. They could be utilized as a bridge between ESD and gastrectomy in selected patients with a risk of lymph node metastasis. 276 Incidence and Risk Factors of Metachronous Gastric Cancer After Endoscopic Resection and Successful Helicobacter pylori Eradication: Results From a Large-Scale, Multicenter Cohort Study in Japan Genki Mori*, Takeshi Nakajima, Ichiro Oda, Kiyoshi Asada, Taichi Shimazu, Nobutake Yamamichi, Takao Maekita, Chizu Yokoi, Mitsuhiro Fujishiro, Takuji Gotoda, Masao Ichinose, Toshikazu Ushijima Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan; Division of Epigenomics, National Cancer Center Research Institute, Tokyo, Japan; Epidemiology and Prevention Group, Research Center for Cancer Prevention and Screening, National Cancer Center, Tokyo, Japan; Department of Gastroenterology, University of Tokyo, Tokyo, Japan; Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan; Department of Gastroenterology and Hepatology, National Center for Global Health and Medice, Tokyo, Japan; Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan Introduction: A previous multicenter prospective randomized study from Japan showed that Helicobacter pylori (HP) eradication reduced the development of metachronous gastric cancer (MGC) after endoscopic resection (ER) for early gastric cancer (GC) from 40.5 to 14.1 cases per 1000 person-years. MGC is, however, still detected in a certain rate even after successful HP eradication, few studies have evaluated the incidence and risk factors of MGC. Aims: To clarify the incidence and risk factors of MGC in the cases after ER for early GC with successful HP eradication. Methods: Participants comprised 594 patients (485 men, 109 women; median age, 66 years; range, 36-79 years) who underwent ER for early GC and successful HP eradication in one of three institutions (National Cancer Center Hospital, The University of Tokyo Hospital and Wakayama Medical University Hospital) between 1999 and 2010. Annual endoscopic surveillance was performed after ER. HP infection was diagnosed using the C urea breath test, serology and culture of biopsy samples. Positive results in at least one of these three tests were considered as evidence of HP infection. The status of baseline gastric mucosal atrophy at the time of successful HP eradication was assessed endoscopically according to the Kimura-Takemoto classification. MGC was defined as a GC newly detected at least 1 year after successful HP www.giejournal.org Vol eradication. Results: Median follow-up period after successful HP eradication was 4.5 years (range, 1.0-11.4 years). During the follow-up period, 93 MGCs were detected in 79 patients. Kaplan-Meier analysis showed a linear increase in the cumulative incidence of MGC; the incidence of MGC was 29.9 cases per 1000 person-years (Fig. 1). Multivariate analysis by using Cox proportional hazard modeling revealed that male sex, open-type gastric mucosal atrophy, and multiple GCs before HP eradication were independent risk factors for MGC (Table 1). Conclusion: Careful and continuous surveillance endoscopy for MGC is required even after successful HP eradication, particularly in male patients, those with extensive gastric mucosal atrophy, and multiple GCs before HP eradication. Multivariate analysis for the risk of MGC ume 81, No. 5S : 2015 GASTROINTE Number STINAL E Hazard Ratio

Liver dysfunction and reactivation of hepatitis virus are well-described complications in cancer patients who receive cytotoxic chemotherapy and may result in varying degrees of liver damage. However, there has been just few reports on such complications and on the preemptive use of lamivudine in Korea. The aims of this study were to determine the prevalence of hepatitis B and C virus infection and the incidence of liver dysfunction in patients with malignancies who receive chemotherapy, to determine the reactivation rate of hepatitis B virus (HBV) in those patients, to evaluate the effect of preemptive use of lamivudine in patients with HBV infection.Among 1,477 patients who received chemotherapy due to various malignancies from January 2000 to June 2005, 668 patients with incomplete viral studies or hepatitis related malignancy were excluded. A retrospective study was conducted by reviewing the medical records of remaining 809 patients.The overall prevalence rate of hepatitis B or C virus in patients receiving chemotherapy was 6.55% (53/809). The incidences of liver dysfunction was not significantly different between hepatitis virus positive group and negative group. Reactivation rate of hepatitis B or C virus after chemotherapy was 15% (6/40). In all patients who received lamivudine therapy, aspartate aminotransferase and alanine aminotransferase level were normalized and HBV DNA negativity achieved.The existence of hepatitis virus in patients receiving chemotherapy did not significantly influence the development of severe liver dysfunction, owing probably to the lamivudine therapy. Further prospective studies are required to ascertain the reactivation of hepatitis virus in patients receiving chemotherapy and the need for prophylactic lamivudine therapy in HBV positive patients.

Reactive hemophagocytic syndrome or hemophagocytic lymphohistiocytosis, is characterized by the proliferation of benign histiocytes showing phagocytosis of blood cells in hematopoietic organs including bone marrow, spleen, or lymph nodes, accompanied by fever, hepatosplenomegaly, hepatic dysfunction, pancytopenia, and hypertriglyceridemia. The pathogenesis of reactive hemophagocytic syndrome is unknown. It is often associated with infection, malignant neoplasm, autoimmune disease, drugs and various immunodeficiencies. The prognosis of this syndrome is poor and the causes of death are hemorrhage, infection, or multiorgan failure. We experienced a case of hemophagocytic syndrome with terminal ileal ulcers, not associated with other causes. Thus, we report this case with a review of literatures.

The failure rates of first and second line therapies of Helicobacter pylori (H. pylori) eradication range from 15 to 20%. This study was aimed to evaluate the efficacy and safety of levofloxacin based triple therapy compared with standard triple or quadruple therapy for H. pylori eradication in Korea.We enrolled two hundred and sixty seven patients with presence of H. pylori infection. One hundred and forty-one patients were treated with levofloxacin based triple therapy (LAP; levofloxacin, amoxicillin, proton pump inhibitor; PPI), and 126 patients were treated with standard triple therapy (CAP; clarithromycin, amoxicillin, PPI). We retreated the patients who had failed in H. pylori eradication with standard quadruple second-line therapy (MTPB; metronidazole, tetracycline, PPI, bismuth subcitrate) or levofloxacin based therapy (LAP or LCP; levofloxacin, clarithromycin, PPI).In first line therapy of H. pylori eradication, the eradication rates of levofloxacin based triple therapy and standard triple therapy were 69.8% and 74.0% respectively (p=0.52). In second-line therapy, the eradication rate of levofloxacin based triple therapy and standard quadruple therapy were 62.5% and 40.0% respectively (p=0.34).Levofloxacin based triple therapy is effective as standard regimen to eradicate H. pylori infection and is useful for an alternative rescue therapy as well.

The therapeutic strategies of applying adefovir for treating lamivudine resistant HBV mutants are controversial. Thus, we observed the clinical outcomes after discontinuation of lamivudine to establish the timing to initiate adefovir therapy.Fifty chronic hepatitis B (CHB) patients with lamivudine resistant HBV mutants who had received lamivudine for more than 12 months were included in the study. We investigated the clinical outcomes at 6 months after the end of treatment (EOT). We compared the serial clinical outcomes among respective groups based on serum ALT at the EOT and the clinical characteristics of patients with or without acute exacerbation (AE) and the HBeAg loss. We also investigated the predictive parameters of AE and HBeAg loss.Fifteen patients (30%) had experienced AE at 6 months after the EOT. Four patients received antiviral agents because of their hepatic decompensation. Patients with AE had higher serum ALT values and lower HBV DNA titers at EOT compared with those patients without AE. Serum ALT at the EOT was the predictive parameter of AE. Eight patients (21.6%) had newly developed HBeAg loss at 6 months after EOT. The total bilirubin at EOT was the predictive parameter of HBeAg loss.CHB patients with lamivudine resistant HBV mutants had favorable clinical outcomes at 6 months after EOT. Therefore, we can consider observing the clinical courses after discontinuation of lamivudine and it is not always required to overlap the adefovir for treating lamivudine resistant HBV mutants except for the treatment of patients with a high risk of developing decompensation.

Background: Non-erosive reflux disorder, which represents more than 60% of gastro-esophageal reflux disorders, lacks objective parameters for diagnosis. The purpose of this study was to evaluate the correlation between non-erosive minimal lesions at the lower esophagus and gastro-esophageal reflux disorder. Methods: Patients were asked to answer a symptom questionnaire. The endoscopic findings were either graded by LA classification or recorded as non-erosive minimal lesions. Patients with minimal lesions were treated with rabeprazole or a placebo and responses were evaluated at weeks 1 and 4. Results: In 8 centers, 3454 patients were screened. In patients with heartburn or acid regurgitation as the most bothersome symptom, 23.7% had endoscopy negative reflux disorder, 40.1% showed minimal lesions, and 36.2% had mucosal break esophagitis. Thirty-four percent of patients with minimal lesions and 39.1% of patients with LA 'grade A' mild esophagitis reported typical reflux symptoms as their main symptom. In patients with minimal lesions, medication with rabeprazole reduced symptoms significantly at weeks 1 and 4, but not with the placebo. Conclusion: Patients with non-erosive minimal esophageal lesions had similar reflux symptoms comparable to those with mild erosive reflux esophagitis, and reflux symptoms were improved with a short-term proton pump inhibitor. Thus, non-erosive minimal esophageal lesion constitutes a great part of gastro-esophageal reflux disorder.

Combined hepatocellular-cholangiocarcinoma is a rare form of primary liver cancer, featuring both hepatocellular and biliary epithelial differentiations. An intrahepatic tumor may be considered as a metastatic lesion. It has been suggested in the literature that the likelihood of metastasis in the cirrhotic liver is lower than that in the non-cirrhotic liver. A rare case of combined hepatocellular-cholangiocarcinoma and second primary colon adenocarcinoma in a 67-year-old male patient with liver cirrhosis is presented. Histologically, the intrahepatic mass was composed of a spindle cell sarcomatous component; a hepatocellular carcinoma component; and a cholangiocarcinoma component. There were focal transitional regions among the different components. Immunohistochemically, the cholangiocarcinoma component of the intrahepatic mass showed positive reactions for CK-7 but negative reactions for CK-20. The adenocarcinoma of the colon showed positive reactions for CK-20 but negative reactions for CK-7.

BACKGROUND/AIMS Nonalcoholic fatty liver disease (NAFLD) is known to be closely associated with various metabolic abnormalities including metabolic syndrome. However, there are few data available on the association of metabolic syndrome with the sonographically fatty liver and normal range of liver function test. The purposes of this study were to find the incidence of ultrasonographic fatty liver with normal range of liver function test and to evaluate the association with metabolic syndrome in apparently healthy Korean adults. METHODS We examined 538 men and women, aged 30-80 years, who participated in a health screening test. Among the people with normal ALT level, we compared clinical characteristics and prevalence of metabolic disorders according to the presence of nonalcoholic sonographyally fatty liver, and then they were subdivided into upper normal range and lower normal range of ALT level. RESULTS Compared to the people without sonographic fatty liver, people with sonographic fatty liver and normal range of ALT level had odds ratios for metabolic syndrome of 4.53, insulin resistance 4.83, hypertension 2.69, dyslipidemia 6.90, and obesity 5.39, respectively. Furthermore, the prevalence of metabolic syndromes and other metabolic disorders were increased in both sonographically fatty liver group or ultrasonographically normal liver group with upper normal range of ALT level compared with lower normal ALT level (p

A 17-year-old man was diagnosed as Peutz-Jeghers syndrome (PJS) because of pigmented lip and multiple gastrointestinal polyps. He had anemia and underwent polypectomy on the duodenum and colon. His maternal family members were patients with PJS. His mother used to be screened with endoscopy to remove large polyps. One and half years later, he underwent jejunal segmental resection due to intussusceptions. He underwent endoscopic polypectomy every 2 to 3 years. When he was 23 years old, high-grade dysplasia was found in colonic polyp and his mother underwent partial pancreatectomy due to intraductal papillary mucinous carcinoma. When he was 27 years old, diffuse gastric polyps on the greater curvature of corpus expanded and grew. Therefore, wide endoscopic polypectomy was done. Histological examination revealed focal intramucosal carcinoma and low-grade dysplasia in hamartomatous polyps. We report cases of cancers occurred in first-degree relatives with PJS.

Though efficient acid suppression with proton pump inhibitors (PPIs) remains the mainstay of treatment of gastroesophageal reflux disease (GERD), some of the patients showed refractory response to PPIs, necessitating further intervention. After increasing dose of PPIs and other kinds of pharmacological intervention adopting prokinetics or others, variable endoscopic treatments are introduced for the treatment of these refractory cases. The detailed introduction regarding endoscopic treatment for GERD is forwarded in this review article. Implantation of reabsorbable or synthetic materials in the distal esophagus was tried in vain and is expelled from the market due to limited efficacy and serious complication. Radiofrequency energy delivery (Stretta) and transoral incisionless fundoplication (EsophyX) are actively tried currently.

Background/aims The prevalence of occult HBV infection depends on the prevalence of HBV infection in the general population. Hemodialysis patients are at increased risk for HBV infection. The aim of this study was to determine the prevalence of occult HBV infection in hemodialysis patients. Methods Total of 98 patients undergoing hemodialysis in CHA Bundang Medical Center (Seongnam, Korea) were included. Liver function tests and analysis of HBsAg, anti-HBs, anti-HBc and anti-HCV were performed. HBV DNA testing was conducted by using two specific quantitative methods. Results HBsAg was detected in 4 of 98 patients (4.1%), and they were excluded. Among 94 patients with HBsAg negative and anti-HCV negative, one (1.1%) patient with the TaqMan PCR test and 3 (3.2%) patients with the COBAS Amplicor HBV test were positive for HBV DNA. One patient was positive in both methods. Two patients were positive for both anti-HBs and anti-HBc and one patient was negative for both anti-HBs and anti-HBc. Conclusions The present study showed the prevalence of occult HBV infection in HBsAg negative and anti-HCV negative patients on hemodialysis at our center was 3.2%. Because there is possibility of HBV transmission in HBsAg negative patients on hemodialysis, more attention should be given to prevent HBV transmission.

Obstructive jaundice is very rarely caused by impaction of a pancreatic stone in the papilla. We report here on a case of obstructive jaundice with acute cholangitis that was caused by an impacted pancreatic stone in the papilla in a patient with chronic pancreatitis. A 48-year-old man presented with acute obstructive cholangitis. Abdominal computed tomography with the reconstructed image revealed distal biliary obstruction that was caused by a pancreatic stone in the pancreatic head, and there was also pancreatic ductal dilatation and parenchymal atrophy of the pancreatic body and tail with multiple calcifications. Emergency duodenoscopy revealed an impacted pancreatic stone in the papilla. Precut papillotomy using a needle knife was performed, followed by removal of the pancreatic stone using grasping forceps. After additional sphincterotomy, a large amount of dark-greenish bile juice gushed out. The patient rapidly improved and he has remained well.

목적: ERCP를 이용한 유두 괄약근 절개술은 간외 담관결석 환자에게서 가장 널리 이용되는 치료방법이지만, ERCP가 실패하거나, 위절제술을 받은 경우, 담췌관으로의 접근이 어려운 경우, 환자의 전신상태가 불량한 경우 등에서는 시술하기가 어렵다. 본 연구의 목적은 ERCP를 시행하기 어려운간외 담관 결석을 가진 환자들에게서 PTPBD (percutaenous transhepatic papillary balloon dilatation) 및 폐쇄 풍선 카테터를 이용한 간외 담관 결석 제거술의 안전성 및 유용 유용성을 알아보고자 하였다. 방법: 2001년부터 2010년까지 10년간 간외 담도 결석으로 내원한 509명의 환자 중 PTPBD를 이용하여 간외 담도 결석 제거술을 시행한 17명의 환자를 후향적으로 자료 분석하였다. 모든 환자는 결석을 제거하기 3-4일 전에 PTBD를 시행하였다. 십이지장 유두부를 풍선 확장술로 확장시킨 후, 폐쇄 풍선 카테터(풍선 지름 11.5 mm)를 이용하여 결석을 확장된 유두부를 통해 십이지장 안으로 밀어내어 제거하였다. 크기가 15 mm를 넘는 큰 결석 일부는 부분 쇄석술을 먼저 시행한 후 시술을 시행하였다. 시술결과는 잔류 결석의 유무로 평가하였고, 합병증 및 결석의 크기와 수에 따라서 세부적으로 분석하였다. 결과: 시술을 시행한 17명의 환자들 중 이전에 위절제술을 시행한 환자는 9명, 전신상태가 불량한 환자가 4명, ERCP에 실패한 환자가 4명이었다. 결석의 크기는 직경이 평균 13.6mm (8-25 mm)이었고, 7명은 결석이 1개(41.2%), 5명은 2개 (29.4%), 그리고 남은 5명은 결석이 3개 이상(29.4%)이었다. 17명의 환자 중에 16명(94%)이 잔류 결석 없이 시술에 성공하였다. 이 중 2명의 환자(11.7%)는 시술을 2번 시행하여 성공하였다. 치료에 실패한 1명(6%)의 환자는 랑데뷰 방법을 이용하여 직시 위내시경을 통해 치료에 성공하였다. 시술과연관된 사망 및 합병증의 발생은 없었다. 췌장염의 발생은 없었고, 3명의 환자에게서 경도의 일시적인 아밀라아제 상승소견이 보였다. 결론: 경피 경간 유두부 풍선 확장술 및 폐쇄 풍선 카테터를 이용한 간외 담관 결석 제거술은 ERCP에 부적절하거나 실패한 환자 군에서 안전하고 효과적인 대체 방법으로 이용될 수 있다.