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Abstract Objectives To determine the risk factors for mortality in Korean patients with rheumatoid arthritis (RA)-associated interstitial lung disease (ILD) in comparison to patients with RA but without ILD (RA-nonILD). Methods Data were extracted from a single-centre prospective cohort of RA patients with a chest computed tomography scan at an academic referral hospital in Korea. Patients with RA-ILD enroled between May 2017 and August 2022 were selected, and those without ILD were selected as comparators. The mortality rate was calculated, and the causes of each death were investigated. We used Cox proportional hazard regression with Firth’s penalised likelihood method to identify the risk factors for mortality in patients with RA-ILD. Results A total of 615 RA patients were included: 200 with ILD and 415 without ILD. In the RA-ILD group, there were 15 deaths over 540.1 person-years (PYs), resulting in mortality rate of 2.78/100 PYs. No deaths were reported in the RA-nonILD group during the 1669.9 PYs. The primary causes of death were infection (nine cases) and lung cancer (five cases), with only one death attributed to ILD aggravation. High RA activity (adjusted HR 1.87, CI 1.16–3.10), baseline diffusing capacity for carbon monoxide (DLCO)

Background/Aims: Tegoprazan is a novel potassium-competitive acid blocker that has beneficial effects on acid-related disorders such as gastroesophageal reflux and peptic ulcer diseases. This study aimed to validate the effect of tegoprazan on endoscopic submucosal dissection (ESD)-induced artificial ulcers. Methods : Patients from 16 centers in Korea who underwent ESD for gastric neoplasia were enrolled. After ESD, pantoprazole was administered intravenously for 48 hours. The patients were randomly allocated to either the tegoprazan or esomeprazole group. Tegoprazan 50 mg or esomeprazole 40 mg were administered for 4 weeks, after which gastroscopic evaluation was performed. If the artificial ulcer had not healed, the same dose of tegoprazan or esomeprazole was administered for an additional 4 weeks, and a gastroscopic evaluation was performed. Results : One hundred sixty patients were enrolled in this study. The healing rates of artificial ulcers at 4 weeks were 30.3% (23/76) and 22.1% (15/68) in the tegoprazan and esomeprazole groups, respectively (p=0.006). At 8 weeks after ESD, the cumulative ulcer healing rates were 73.7% (56/76) and 77.9% (53/68) in the tegoprazan and esomeprazole groups, respectively (p=0.210). Delayed bleeding occurred in two patients in the tegoprazan group (2.6%) and in one patient in the esomeprazole group (1.5%). Other adverse events were negligible in both groups. Conclusion : s: Tegoprazan showed similar effects on post-ESD artificial ulcer healing in comparison with esomeprazole.

Background/Aims: H2 receptor antagonists (H2RA) have been used to treat gastritis by inhibiting gastric acid. Proton pump inhibitors (PPIs) are more potent acid suppressants than H2RA. However, the efficacy and safety of low-dose PPI for treating gastritis remain unclear. The aim was to investigate the efficacy and safety of low-dose PPI for treating gastritis. Methods: A double-blind, noninferiority, multicenter, phase 3 clinical trial randomly assigned 476 patients with endoscopic erosive gastritis to a group using esomeprazole 10 mg (DW1903) daily and a group using famotidine 20 mg (DW1903R1) daily for 2 weeks. The full-analysis set included 319 patients (DW1903, n=159; DW1903R1, n=160) and the per-protocol set included 298 patients (DW1903, n=147; DW1903R1, n=151). The primary endpoint (erosion improvement rate) and secondary endpoint (erosion and edema cure rates, improvement rates of hemorrhage, erythema, and symptoms) were assessed after the treatment. Adverse events were compared. Results: According to the full-analysis set, the erosion improvement rates in the DW1903 and DW1903R1 groups were 59.8% and 58.8%, respectively. According to the per-protocol analysis, the erosion improvement rates in the DW1903 and DW1903R1 groups were 61.9% and 59.6%, respectively. Secondary endpoints were not significantly different between two groups except that the hemorrhagic improvement rate was higher in DW1903 with statistical tendency. The number of adverse events were not statistically different. Conclusions: DW1903 of a low-dose PPI was not inferior to DW1903R1 of H2RA. Thus, lowdose PPI can be a novel option for treating gastritis (ClinicalTrials.gov Identifier: NCT05163756).

The azygos venous system is a crucial conduit of the posterior thorax and potentially vital collateral pathway. However, it is often overlooked clinically and radiologically. This pictorial essay reviews the normal azygos venous anatomy and CT findings of congenital variations and structural changes associated with acquired pathologies.

Abstract Background Proton-pump inhibitors (PPIs) are the most effective drugs for treating acid-related disorders. However, once-daily dosing with conventional PPIs fail to fully control acid secretion over 24 h. This study aimed to compare the efficacy and safety of HIP1601 (dual delayed-release esomeprazole) and HGP1705 (delayed-release esomeprazole) in patients with erosive esophagitis (EE). Methods We enrolled 213 patients with EE randomized in a 1:1 ratio to receive 40 mg HIP1601 (n = 107) or HGP1705 (n = 106) once daily for 4 or 8 weeks. The primary endpoint was the EE healing rate, confirmed by endoscopy up to week 8. GERD-related symptoms and treatment-emergent adverse events were compared between both groups. Results By week 8, the estimated healing rates of EE were 97.8% and 96.8% in the HIP1601 and HGP1705 groups, respectively, with a 95% confidence interval of -4.7 to 7.2. After 4 or 8 weeks of treatment, the EE healing rate at week 4, complete resolution rate of symptoms, time to sustained resolution of symptoms, and number of rescue medications used were similar in both groups. The proportion of heartburn- and acid regurgitation-free nights by week 4 were higher in the HIP1601 group compared to the HGP1705 group, but the difference did not reach clinical significance (87.7% vs. 85.8%, P = 0.514, 87.5% vs. 85.8%, P = 0.774). The number of adverse events did not differ significantly between the two groups. Conclusions The efficacy and safety of HIP1601 40 mg were comparable to those of HGP1705 40 mg for the treatment of EE and symptomatic improvement of GERD. Trial registration NCT04080726 ( https://classic.clinicaltrials.gov/ct2/show/NCT04080726 ), registration date: 25/10/2018.

Background: Atrial fibrillation (AF) patients are at high risk of stroke with ∼90% clots originating from the left atrial appendage (LAA). Clinical understanding of blood-flow based parameters and their potential association with stroke for AF patients remains poorly understood. We hypothesize that slow blood-flow either in the LA or the LAA could lead to the formation of blood clots and is associated with stroke for AF patients. Methods: We retrospectively collected cardiac CT images of paroxysmal AF patients and dichotomized them based on clinical event of previous embolic event into stroke and non-stroke groups. After image segmentation to obtain 3D LA geometry, patient-specific blood-flow analysis was performed to model LA hemodynamics. In terms of geometry, we calculated area of the pulmonary veins (PVs), mitral valve, LA and LAA, orifice area of LAA and volumes of LA and LAA and classified LAA morphologies. For hemodynamic assessment, we quantified blood flow velocity, wall shear stress (WSS, blood-friction on LA wall), oscillatory shear index (OSI, directional change of WSS) and endothelial cell activation potential (ECAP, ratio of OSI and WSS quantifying slow and oscillatory flow) in the LA as well as the LAA. Statistical analysis was performed to compare the parameters between the groups. Results: Twenty-seven patients were included in the stroke and 28 in the non-stroke group. Examining geometrical parameters, area of left inferior PV was found to be significantly higher in the stroke group as compared to non-stroke group (p = 0.026). In terms of hemodynamics, stroke group had significantly lower blood velocity (p = 0.027), WSS (p = 0.018) and higher ECAP (p = 0.032) in the LAA as compared to non-stroke group. However, LAA morphologic type did not differ between the two groups. This suggests that stroke patients had significantly slow and oscillatory circulating blood-flow in the LAA, which might expose it to potential thrombogenesis. Conclusion: Slow flow in the LAA alone was associated with stroke in this paroxysmal AF cohort. Patient-specific blood-flow analysis can potentially identify such hemodynamic conditions, aiding in clinical stroke risk stratification of AF patients.

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

Background/Aims: Efficacy of proton pump inhibitors is limited in patients with nonerosive reflux disease (NERD). The aim of this study was to comparatively evaluate the efficacy and safety of esomeprazole with sodium bicarbonate and esomeprazole alone. Methods: This was a multicenter, randomized, double-blind, active-controlled, noninferiority comparative study. A total of 379 patients with NERD were randomly allocated to receive either EsoduoⓇ (esomeprazole 20 mg with sodium bicarbonate 800 mg) or NexiumⓇ (esomeprazole 20 mg) once daily for 4 weeks from January 2019 to December 2019. The patients had a history of heartburn for at least 2 days in the week before randomization as well as in the last 3 months and no esophageal mucosal breaks on endoscopy. The primary endpoint was a complete cure of heartburn at week 4. The secondary and exploratory endpoints as well as the safety profiles were compared in the groups at weeks 2 and 4. Results: A total of 355 patients completed the study (180 in the EsoduoⓇ group and 175 in the NexiumⓇ group). The proportions of patients without heartburn in the entire 4th week of treatment were not different between the two groups (33.33% in the EsoduoⓇ group and 35% in the NexiumⓇ group, p=0.737). There were no significant differences in most of the secondary and exploratory endpoints as well as the safety profiles. Conclusions: EsoduoⓇ is as effective and safe as NexiumⓇ for managing typical symptoms in patients with NERD (ClinicalTrial.gov identifier: NCT03928470).

Abstract Background To introduce a prospective cohort for rheumatoid arthritis (RA) patients with interstitial lung disease (ILD) and to identify their clinical features in comparison with RA patients without ILD. Methods Using a multidisciplinary collaborative approach, a single-center cohort for RA patients with ILD (RA-ILD) was established in May 2017, and enrolment data from May 2017 to March 2021 were used to compare the clinical features of RA patients without ILD (RA-non ILD). Multivariable logistic regression analysis was used to identify factors associated with ILD in RA patients. Results Among 148 RA-ILD and 410 RA-non ILD patients, participants in the RA-ILD group were older (65.8 ± 9.9 vs. 58.0 ± 10.4 years, P

Abstract Background Endoscopic submucosal dissection (ESD) can provide a high en bloc resection rate and has been widely applied as curative treatment for early colorectal cancer (ECC). However, surgical treatment is occasionally required, and reports on the long-term prognosis of ESD are insufficient. This study aimed to investigate the long-term outcomes of ECC removal by ESD, including local recurrence and metastasis. Methods This multicenter study was conducted retrospectively on 450 consecutive patients with ECC who were treated with ESD between November 2003 and December 2013. Clinical, pathological, and endoscopic data were collected to determine tumor depth, resection margin, lymphovascular invasion, and recurrence. Results The median follow-up period was 53.8 (12–138 months). The en bloc resection rate was 85.3% (384) and in intramucosal cancer being 84.1% and in superficial submucosal invasion (SM1) cancer being 89.8% (p = 0.158). The curative resection rate was 76.0% (n = 342), and there was no statistical difference between the two groups (77.3% vs. 71.4%, p = 0.231). The overall recurrence free survival rate (RFS) was 98.7% (444/450). In patients with curative resection, there was no statistically significant difference in RFS according to invasion depth (intramucosal: 99.3% vs. SM1: 97.1%, p = 0.248). Conclusions Patients with curatively resected ECC treated with ESD showed favorable long-term outcomes. Curatively resected SM1 cancer has a RFS similar to that of intramucosal cancer.

To provide high-quality training to residents in a rapidly changing medical environment, it is very important to improve the annual training curriculum centered on competency and ensure that training hospitals maintain an environment suitable for training. The Korean Society of Radiology (KSR) has been steadily improving the training system and has suggested the improvement of the training system by strengthening the competency-based evaluation and faculty development. Currently, KSR was selected for the second annual training curriculum systematization construction project in July 2021, and developed entrustable professional activities, core competencies, and assessment guidelines required by the construction project. Therefore, the development process and assessment guidelines will be introduced to residents and the faculty.

A training dataset that is limited to a specific endoscope model can overfit artificial intelligence (AI) to its unique image characteristics. The performance of the AI may degrade in images of different endoscope model. The domain adaptation algorithm, i.e., the cycle-consistent adversarial network (cycleGAN), can transform the image characteristics into AI-friendly styles. We attempted to confirm the performance degradation of AIs in images of various endoscope models and aimed to improve them using cycleGAN transformation. Two AI models were developed from data of esophagogastroduodenoscopies collected retrospectively over 5 years: one for identifying the endoscope models, Olympus CV-260SL, CV-290 (Olympus, Tokyo, Japan), and PENTAX EPK-i (PENTAX Medical, Tokyo, Japan), and the other for recognizing the esophagogastric junction (EGJ). The AIs were trained using 45,683 standardized images from 1,498 cases and validated on 624 separate cases. Between the two endoscope manufacturers, there was a difference in image characteristics that could be distinguished without error by AI. The accuracy of the AI in recognizing gastroesophageal junction was >0.979 in the same endoscope-examined validation dataset as the training dataset. However, they deteriorated in datasets from different endoscopes. Cycle-consistent adversarial network can successfully convert image characteristics to ameliorate the AI performance. The improvements were statistically significant and greater in datasets from different endoscope manufacturers [original → AI-trained style, increased area under the receiver operating characteristic (ROC) curve, P-value: CV-260SL → CV-290, 0.0056, P = 0.0106; CV-260SL → EPK-i, 0.0182, P = 0.0158; CV-290 → CV-260SL, 0.0134, P < 0.0001; CV-290 → EPK-i, 0.0299, P = 0.0001; EPK-i → CV-260SL, 0.0215, P = 0.0024; and EPK-i → CV-290, 0.0616, P < 0.0001]. In conclusion, cycleGAN can transform the diverse image characteristics of endoscope models into an AI-trained style to improve the detection performance of AI.

Background MUC5B variant rs35705950 is the common and most significant risk variant for rheumatoid arthritis-interstitial lung disease (RA-ILD) in Western populations. However, little is known about its significant association with RA-ILD in Asian populations. We here investigate the association of rs35705950 with Korean patients with RA-ILD.Methods In this cross-sectional study, we genotyped rs35705950 in 2444 patients with RA. Among them, 683 patients with RA who have chest CT were divided into RA-ILD and RA-noILD. RA-ILD was classified as usual interstitial pneumonia (UIP) and other than UIP. The associations of rs35705950 with RA-ILD and its subtype were analysed using multivariable regression adjusted for age at RA diagnosis. Meta-analysis of a previously reported Japanese dataset and Korean dataset obtained for this study was conducted.Results The minor allele (T) frequency of rs35705950 was 0.37%, 1.43% and 2.38% in 2444 patients with RA, 105 patients with RA-ILD and 63 patients with UIP, respectively. Genotypic association of rs35705950 with RA-ILD was insignificant (OR 2.49, 95% CI 0.64 to 9.69, p=0.187), but showed significant association with UIP (OR 4.90, 95% CI 1.23 to 19.59, p=0.024) compared with RA-noILD. In meta-analysis (123 UIP and 878 RA-noILD) combining our data with previously reported Japanese data, this variant was found to be significantly associated with UIP (OR 3.51, 95% CI 1.19 to 10.37, p=0.023).Conclusion MUC5B variant rs35705950 is a rare but significant risk factor for Asian patients with RA-ILD with UIP, suggesting a sharing of the genetic background between Asian and Western populations.

Advanced esophageal cancer is known to have a poor prognosis. The early detection of esophageal neoplasms, including esophageal dysplasia and early esophageal cancer, is highly important for the accurate treatment of the disease. However, esophageal dysplasia and early esophageal cancer are usually subtle and can be easily missed. In addition to the early detection, proper pretreatment evaluation of the depth of invasion of esophageal cancer is very important for curative treatment. The progression of non-invasive diagnosis via image-enhanced endoscopy techniques has been shown to aid the early detection and estimate the depth of invasion of early esophageal cancer and, as a result, may provide additional opportunities for curative treatment. Here, we review the advancement of image-enhanced endoscopy-related technologies and their role in the early identification of esophageal neoplasms.

Background/Aims: Some cases of gastric low-grade dysplasia (LGD) and high-grade dysplasia (HGD) on forceps biopsy (FB) are diagnosed as gastric cancer (GC) after endoscopic resection (ER). This study aims to evaluate the clinical outcomes of ER for gastric LGD and HGD on pretreatment FB and to identify the factors that predict pathologic upstaging to GC. Methods: Patients who underwent ER for LGD and HGD on pretreatment FB from March 2005 to February 2018 in 14 hospitals in South Korea were enrolled, and the patients’ medical records were reviewed retrospectively. Results: This study included 2,150 cases of LGD and 1,534 cases of HGD diagnosed by pretreatment FB. In total, 589 of 2,150 LGDs (27.4%) were diagnosed as GC after ER. Helicobacter pylori infection, smoking history, tumor location in the lower third of the stomach, tumor size >10 mm, depressed lesion, and ulceration significantly predicted GC. A total of 1,115 out of 1,534 HGDs (72.7%) were diagnosed with GC after ER. Previous history of GC, H. pylori infection, smoking history, tumor location in the lower third of the stomach, tumor size >10 mm, depressed lesion, and ulceration were significantly associated with GC. As the number of risk factors predicting GC increased in both LGD and HGD on pretreatment FB, the rate of upstaging to GC after ER increased. Conclusions: A substantial proportion of LGDs and HGDs on pretreatment FB were diagnosed as GC after ER. Accurate ER procedures such as endoscopic submucosal dissection should be recommended in cases of LGD and HGD with factors predicting pathologic upstaging to GC.

Background/Aims Frequent bleeding after endoscopic resection (ER) has been reported in patients with end-stage renal disease (ESRD). We aimed to evaluate the association and clinical significance of bleeding with ER in ESRD patients on dialysis. Methods Between February 2008 and December 2018, 7,571 patients, including 47 ESRD patients on dialysis who underwent ER for gastric neoplasia, were enrolled. A total of 47 ESRD patients on dialysis were propensity score-matched 1:10 to 470 non-ESRD patients, to adjust for between-group differences in variables such as age, sex, comorbidities, anticoagulation use, tumor characteristics, and ER method. Matching was performed using an optimal matching algorithm. For the matched data, clustered comparisons were performed using the generalized estimating equation method. Medical records were retrospectively reviewed. Frequency and outcomes of post-ER bleeding were evaluated. Results Bleeding was more frequent in the ESRD with dialysis group than in the non-ESRD group. ESRD with dialysis conferred a significant risk of post-ER bleeding (odds ratio, 6.1; 95% confidence interval, 2.7–13.6; p

Background/Aims: The proper handling of antithrombotics is critical, and this study aimed to assess guideline adherence in the management of antithrombotics before and after endoscopy. Methods: A survey questionnaire was developed. The respondents’ demographic information was included, and the questionnaire was divided into the first section for forceps biopsy, the second for polypectomy, and the third for endoscopic submucosal dissection (ESD) in which aspirin, clopidogrel, combination therapy (aspirin and clopidogrel), warfarin, and direct oral anticoagulants (apixaban) were prescribed to imaginary patients. Results: A total of 415 endoscopists completed this survey (response rate of 6.2%, 415/6,673). The percentage of respondents who chose to proceed with biopsy for patients taking aspirin, those taking clopidogrel, those under combination therapy, those taking warfarin, and those taking apixaban was 89.4%, 74.2%, 61.0%, 38.6%, and 50.4%, respectively. Most respondents answered that they would discontinue aspirin, clopidogrel, and a combination of both drugs for 5 days before polypectomy or ESD (69.4%/76.9%, 83.6%/83.9%, and 53.3%/65.8%, respectively). The answers indicated that warfarin should be discontinued with heparin bridge therapy in high thromboembolic risk patients (polypectomy 70.1%, ESD 73.5%). Regarding apixaban use in polypectomy and ESD, 63.9% and 58.1% of respondents, respectively, chose answers consistent with the guidelines. Conclusions: The gap between the guidelines and clinical practice in the management of antithrombotics before and after endoscopy is considerable and should be addressed via educational strategies.

Background/Aims The purpose of this study was to investigate the risk factors and long-term clinical outcomes of non-curative resection (NCR) in a large-scale patient population. Methods We retrospectively analyzed the clinical data of 3,094 patients who underwent endoscopic submucosal dissection (ESD) of early gastric cancer from March 2005 to March 2018 at 13 institutions in Korea. We analyzed the risk factors for NCR and the survival between patients with curative resection and those with NCR with no additional treatment. Results The NCR rate was 21.4% (661/3,094). In multivariate regression analysis, the risk factors affecting NCR with ESD were old age, undifferentiated tumor, tumor location in the upper body, tumor size ≥2 cm, and presence of an ulcer. In Cox proportional hazard regression analysis, tumor size ≥2 cm, submucosal invasion, positive horizontal margin, and lymphovascular invasion were risk factors for local recurrence. In Kaplan-Meier analysis, there was no statistically significant difference in the overall survival between the two groups (log-rank p=0.788). However, disease-specific survival was significantly lower in the NCR group (log-rank p=0.038). Conclusions Clinicians should be aware of the risk factors for NCR and local recurrence after ESD for early gastric cancer, and should consider providing additional treatment after NCR.

Background/Aims Irsogladine maleate, an enhancer of gastric mucosal protective factors, has demonstrated its efficacy for various gastric mucosal injuries. The aim of this study was to evaluate the efficacy and safety of irsogladine for prevention of nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin-induced peptic ulcer and gastritis. Methods In this multicenter, randomized, double-blind, exploratory clinical trial, 100 patients over 50 years of age who needed continuous NSAIDs or aspirin for more than 8 weeks were randomly assigned to either test group (irsogladine maleate 2 mg, twice daily, 39 patients for full analysis) or placebo group (37 patients for full analysis). Primary outcomes were incidence of peptic ulcer and ratio of modified Lanza score (MLS) 2 to 4. Secondary outcome was the number of acute erosions confirmed by endoscopy at 8 weeks. Adverse effects were also compared. Results There were no significant differences in gastric protective effects between test and placebo groups. However, two cases of peptic ulcer in the placebo group but none in the test group were observed. These two cases of peptic ulcer were Helicobacter pylori-negative. In addition, H. pylori-negative group showed significant changes in MLS score (p = 0.0247) and edema score (p = 0.0154) after the treatment compared to those before treatment in the test group. There was no significant difference in adverse events between the two groups. Conclusions The efficacy of irsogladine maleate was found in H. pylori-negative group, suggesting its potential as a protective agent against NSAIDs or aspirin-induced peptic ulcer and gastritis.

Background/Aims Epithelial-mesenchymal transition (EMT) is a developmental process, wherein the epithelial cells show reduced intercellular adhesions and acquire migratory fibroblastic properties. EMT is associated with downregulation in epithelial marker expression, abnormal translocation of E-cadherin, and upregulation in mesenchymal marker expression. Here, we investigated the immunohistochemical (IHC) expression of EMT markers in early gastric cancer (EGC) between cancer and noncancer tissues. Methods Tissue samples were prospectively obtained from 19 patients with EGC that underwent endoscopic submucosal dissection (ESD). We compared the expression level of transforming growth factor (TGF)-β, vascular endothelial growth factor (VEGF), E-cadherin, α-smooth muscle actin (α-SMA), and vimentin between cancer and noncancer tissues using IHC. Among the 19 patients, 15 patients had follow-up biopsy at 3 months after ESD for EGC. Results Cancer tissues presented higher values of EMT mesenchymal markers (α-SMA/vimentin/TGF-β/VEGF) than the noncancerous tissues (p

Background/Aims Helicobacter pylori (H. pylori) infection is one of the etiologies of functional dyspepsia (FD). The aim of this study was to compare the efficacy of H. pylori eradication therapy and motilitone monotherapy in patients with FD. Materials and Methods We prospectively performed a multicenter randomized double-blind study between August 2014 and June 2017. FD patients with H. pylori infection randomly received either the standard triple therapy or motilitone. Global and individual symptom improvements, and changes in quality of life score were assessed. Results We failed to enroll as many candidates as we had planned. A study to evaluate the efficacy of medications in FD patients according to the Rome III criteria is difficult to perform in Korea because of the early medication therapy at local hospitals and reluctance to discontinue digestive medications. Of the 35 patients enrolled, 30 (18 in the H. pylori eradication group and 12 in the motilitone group) completed the trial. The success rate of H. pylori eradication was 44.4% (8/18). The symptom improvement rate using the 7-point Likert scale at week 12 was 66.7% (12/18) in the H. pylori eradication group and 91.7% (11/12) in the motilitone group (P=0.193). At week 12, the symptom improvement rate was not significantly different between the patients with successful eradication (87.5%, 7/8) and those in the motilitone group (91.7%, 11/12; P=1.000). Conclusions Eradication therapy could be an effective treatment for H. pylori-positive FD. However, our results should be cautiously interpreted, as we failed to recruit the intended number of subjects.

Background/Aims: The predictive factors of functional dyspepsia (FD) remain controversial. Therefore, we sought to investigate symptom responses in FD patients after Helicobacter pylori (H. pylori) eradication and used predictive factor analysis to identify significant factors of FD resolution at one-year after commencing eradication therapy. Methods: This prospective, multi-center clinical trial was performed on 65 FD patients that met Rome III criteria and had H. pylori infection. Symptom responses and factors that predicted poor response were determined by analysis one year after commencing H. pylori eradication therapy. Results: A total of 63 patients completed the one-year follow-up. When an eradication success group (n=60) and an eradication failure group (n=3) were compared with respect to FD response rate at one year, results were as follows; complete response 73.3% and 0.0%, satisfactory response 1.7% and 0.0%, partial response 10.0% and 33.3%, and refractory response 15.0% and 66.7%, respectively (p=0.013). Univariate analysis showed persistent H. pylori infection (p=0.021), female gender (p=0.025), and medication for FD during the study period (p=0.013) were associated with poor FD response at one year. However, age, smoking, alcohol consumption, and underlying disease were not found to affect response. Finally, multivariate analysis showed that female gender (OR, 4.70; 95% CI, 1.17-18.88) was the sole independent risk factor of poor FD response at one year after commencing H. pylori eradication therapy. Conclusions: Female gender was found to predict poor response in FD patients despite H. pylori eradication. Furthermore, successful H. pylori eradication appears to be associated with FD improvement, but the number of non-eradicated patients was too small to conclude.

Using data from the real world to solve clinical questions that cannot be answered using data from clinical trials is attracting more attention. Clinical outcomes for patients with esophageal cancer in a real-world setting might be different from data in randomized controlled trials. This study aimed to provide real world data on treatment and prognosis in Korean patients with esophageal cancer. This retrospective cancer cohort included newly diagnosed cases of esophageal cancer at 19 tertiary hospitals between January 1, 2005 and December 31, 2017. Cancer staging was defined according to the 7th edition of the American Joint Committee on Cancer criteria. We identified 6,354 patients with newly diagnosed esophageal cancer (mean age: 64.9 ± 9.0 years, 96.9% squamous cell carcinoma). The proportion of early esophageal cancer increased from 24.7% in 2005 to 37.2% in 2015 (p

AimThe functional lumen imaging probe (FLIP) is a recently developed technique to evaluate the esophagogastric junction (EGJ) distensibility. Unlike timed barium esophagogram (TBE) and high-resolution manometry (HRM), FLIP can be used during peroral endoscopic myotomy (POEM). The aim of this study was to evaluate the association of intraoperative FLIP parameters with clinical outcomes as recorded in a single-center database and to investigate a systematic review of literatures.MethodsWe reviewed consecutive patients diagnosed with achalasia and scheduled for POEM between June 2016 and March 2019 in our tertiary referral hospital. All patients underwent intraoperative FLIP assessment during POEM. The final FLIP measurements were compared between the patients with good and poor clinical response. We comprehensively reviewed studies evaluating whether intraoperative FLIP measurements reflected clinical outcomes.ResultsWe evaluated 23 patients with achalasia who underwent intraoperative FLIP before and after POEM. Two exhibited poor clinical responses after 3 months (Eckardt scores = 3). The final distensibility index (DI) did not differ significantly between good and poor responders (5.01 [4.52] vs. 4.91 [3.63-6.20] mm2/mmHg at a balloon distension of 50-mL, median [IQR], P = 0.853). The final DI did not differ significantly between post-POEM reflux esophagitis and non-reflux esophagitis groups (6.20 [5.15] vs. 4.23 [1.79] mm2/mmHg at a balloon distension of 50-mL, median [IQR], P = 0.075).ConclusionsA systematic review of both prospective and retrospective studies including our data indicated that the final intraoperative FLIP measurements did not differ significantly between good and poor responders. Further study with more patients is necessary to explore whether FLIP can predict short- and long-term clinical responses.

Background/AimsWe evaluated whether manometric subtype is associated with treatment outcome in patients with achalasia treated by peroral endoscopic myotomy (POEM).Methods : High-resolution manometry data and Eckardt scores were collected from 83 cases at two tertiary referral centers where POEM is performed. Manometric tracings were classified according to the three Chicago subtypes.Results : Among the 83 cases, 48 type I, 24 type II, and 11 type III achalasia cases were identified. No difference was found in pre-POEM Eckardt score, basal lower esophageal sphincter (LES) pressure, or integrated relaxation pressure (IRP) among the type I, type II, and type III groups. All three patient groups showed a significant improvement in post-POEM Eckardt score (6.1±2.1 to 1.5±1.5, p=0.001; 6.8±2.2 to 1.2±0.9, p=0.001; 6.6±2.0 to 1.6±1.4, p=0.011), LES pressure (26.1±13.8 to 15.4±6.8, p=0.018; 32.3±19.0 to 19.2±10.4, p=0.003; 36.8±19.2 to 17.5±9.7, p=0.041), and 4s IRP (21.5±11.7 to 12.0±8.7, p=0.007; 24.5±14.8 to 12.0±7.6, p=0.002; 24.0±15.7 to 11.8±7.1, p=0.019) at a median follow-up of 16 months.Conclusion : sPOEM resulted in a good clinical outcome for all manometric subtypes.

The cases of non-curative endoscopic resection (NCR) of early gastric cancer have increased due to the widespread use of endoscopic submucosal dissection (ESD). NCR is associated with augmenting chances of local recurrence and lymph node metastasis (LNM). Therefore, some additional treatment strategies after NCR are needed. Treatment strategies for NCR should be determined by considering the risk of residual tumor or local recurrence and LNM. Additional surgical treatment such as gastrectomy and lymph node dissection are recommended in patients who have high-risk of LNM. Close observation without additional treatment is considered for selected patients with a less possibility of local recurrence or LNM. Also it may be suggested if there is no or less benefit from surgery in elderly patients or patients with underlying diseases. Additional endoscopic procedures including ESD, endoscopic mucosal resection or argon coagulation therapy are suggested alternatively for highly selected patients not at risk of LNM based on the absolute or expanded criteria of ESD.

Background/AimsThe resistance rate of Helicobacter pylori is gradually increasing. We aimed to evaluate the efficacy of levofloxacin-based third-line H. pylori eradication in peptic ulcer disease.Methods : Between 2002 and 2014, 110 patients in 14 medical centers received levofloxacin-based third-line H. pylori eradication therapy for peptic ulcer disease. Of these, 88 were included in the study; 21 were excluded because of lack of follow-up and one was excluded for poor compliance. Their eradication rates, treatment regimens and durations, and types of peptic ulcers were analyzed.Results : The overall eradiation rate was 71.6%. The adherence rate was 80.0%. All except one received a proton-pump inhibitor, amoxicillin, and levofloxacin. One received a proton-pump inhibitor, amoxicillin, levofloxacin, and clarithromycin, and the eradication was successful. Thirty-one were administered the therapy for 7 days, 25 for 10 days, and 32 for 14 days. No significant differences were observed in the eradication rates between the three groups (7-days, 80.6% vs 10-days, 64.0% vs 14-days, 68.8%, p=0.353). Additionally, no differences were found in the eradiation rates according to the type of peptic ulcer (gastric ulcer, 73.2% vs duodenal/gastroduodenal ulcer, 68.8%, p=0.655).Conclusion : sLevofloxacin-based third-line H. pylori eradication showed efficacy similar to that of previously reported first/second-line therapies.

Background/Aims Long-term use of aspirin can be a risk factor of peptic ulcer diseases. The aim of this study was to evaluate the efficacy of Albis (Daewoong Pharmaceutical Co., Ltd.) for the prevention of gastric mucosal injury caused by aspirin. Methods Aspirin users were enrolled and randomized into the Albis or placebo group. Screening and follow-up endoscopy were performed for modified Lanza scores (MLSs). Primary outcome was measured by the incidence rate of peptic ulcer, and secondary outcomes were measured by the incidence rate of gastritis, improvement in MLS and subjective symptoms. Results In total, 81 aspirin users were randomized, 43 in the Albis group and 38 in the placebo group. There was no incidence of peptic ulcer in both groups. The incidence of gastritis was significantly higher in the placebo group (44.4% vs. 10.0%, p=0.003); however, the scores of mucosal edema, hyperemia and hemorrhage were not statistically different between the two groups (p>0.05). The frequency of subjective symptoms were more improved in the Albis group than in the placebo group (p=0.023). Conclusions The incidence of gastritis was lower in the group that received low-dose aspirin and Albis. The development of peptic ulcer due to long-term use of aspirin might be prevented with concomitant use of Albis.

Background/Aims: Despite the efficacy of proton pump inhibitor (PPI) treatment, a considerable number of patients with non-erosive reflux disease (NERD) are resistant to treatment with a PPI at the standard dose. In these patients, doubling the dose of PPI is one of the potential therapeutic strategies. However, only few studies support this therapeutic strategy. The aim of this study was to assess the efficacy and safety of 40 mg esomeprazole once daily in patients with persistent symptoms of NERD despite standard daily PPI therapy. Materials and Methods: A total of 92 patients with NERD who had persistent symptoms of NERD despite standard dose (half dose) of PPI for more than 4 weeks, were enrolled in this multicenter (eight centers) open-label study. Efficacy and safety of a daily dose of 40 mg esomeprazole were evaluated after 4 weeks in all the patients. Results: The sum score of two symptoms (heartburn and regurgitation) decreased significantly from 72.51 to 32.55 after 4 weeks of treatment (P＜0.001). The percentage of patients with ≥50% improvement in symptom score (heartburn＋acid regurgitation), during the study period was 66.7%. Patients with severe symptoms at baseline had significantly higher symptom improvement rate in comparison to patients who had milder symptoms. Adverse effects related to the treatment were reported by 3 (3.3%) patients. Conclusions: Esomeprazole 40 mg once daily is an effective and safe strategy to treat NERD patients with persistent symptoms despite standard daily PPI therapy.

Objectives: To provide a comprehensive review of radiological clinical practice guidelines (CPGs) and to establish their characteristics and impact in the field of radiology. Material and Methods: A MEDLINE search was performed for CPGs in which at least half of the authors were from the radiology or imaging department. The following information was extracted from each CPG: year of publication, journal, provider, number of authors, number of pages, number of references, collaboration, country of origin, radiological subspecialty, imaging modality used, topic, source of funding, and number and pattern of citations. Results: In total, 120 radiological CPGs published between July 2006 and June 2016 were identified. One hundred nine (90.8%) radiological CPGs were published in radiology journals, 96 (80.0%) were provided by the scientific community, 108 (90.0%) were collaborative studies, 64 (53.3%) originated from the United States, 36 (30.0%) were concerned with the field of vascular/interventional radiology, 38 (31.7%) used combined imaging techniques, 52 (43.3%) were focused on interpretation and management, and 118 (98.4%) were not funded. Radiological CPGs included a median of 8 authors, 9 pages, and 49 references. The median number of citations and annual citations were 18 (range, 0–540) and 3.5 (range, 0–75.6), respectively. Conclusion: Our study presents several interesting insights into the characteristics and impact of radiological CPGs.

Background/AimsTo investigate the effects of esomeprazole and rebamipide combination therapy on symptomatic improvement in patients with reflux esophagitis.Methods : A total of 501 patients with reflux esophagitis were randomized into one of the following two treatment regimens: 40 mg esomeprazole plus 300 mg rebamipide daily (combination therapy group) or 40 mg esomeprazole daily (monotherapy group). We used a symptom questionnaire that evaluated heartburn, acid regurgitation, and four upper gastrointestinal symptoms. The primary efficacy end point was the mean decrease in the total symptom score.Results : The mean decreases in the total symptom score at 4 weeks were estimated to be −18.1±13.8 in the combination therapy group and −15.1±11.9 in the monotherapy group (p=0.011). Changes in reflux symptoms from baseline after 4 weeks of treatment were −8.4±6.6 in the combination therapy group and −6.8±5.9 in the monotherapy group (p=0.009).Conclusion : sOver a 4-week treatment course, esomeprazole and rebamipide combination therapy was more effective in decreasing the symptoms of reflux esophagitis than esomeprazole monotherapy.

Background : /Aims: This study evaluated the eradication rate of levofloxacin-containing rescue therapy by treatment duration in patients in whom previous first- and second-line treatment failed.Methods : : Fifty-five patients with persistent Helicobacter pylori infection after first-line therapy and second-line therapy were studied in a single referral academic center. We compared the eradication rates by the treatment duration of third-line therapy.Results : : Of 55 patients, 12 (21.8%) received rescue therapy for seven days, 24 (43.6%) received rescue therapy for 10 days, and 19 (34.5%) received rescue therapy for 14 days. The eradication rates of therapy with levofloxacin were 65.5% in the 55 enrolled patients and 73.5% in the 49 patients who underwent follow-up testing. In cases where follow-up testing was performed, the eradication rate of 7-day therapy was 58.3%, of 10-day 68.2%, and of 14-day therapy 93.3%. Eradication rate of 14-day therapy was higher than 7-day (p=0.06) and 10-day (p=0.108), but chance could not be ruled out in the difference among groups.Conclusion : s: This study showed somewhat increasing of H. pylori eradication rate by extending the duration of levofloxacin-containing rescue therapy to 14 days. (Korean J Gastroenterol 2016;68:260-264)

Background/AimsThe purpose of this study is to investigate the recurrence rate of peptic ulcer disease (PUD) over a long follow-up period with PUD patients without Helicobacter pylori.Methods : We retrospectively reviewed patients diagnosed with PUD on endoscopy and divided them into two groups: a H. pylori-negative group (HP-negative group), and a group of patients with untreated H. pylori (HP noneradicated group). We compared the recurrence rates of PUD in these two groups and analyzed the factors that affected ulcer recurrence.Results : Total of nine hospitals in Korea participated, and a total of 1,761 patients were retrospectively reviewed. The HP-negative group included 553 patients, and the HP noneradicated group included 372 patients. The 5-year cumulative probabilities of PUD recurrence were 36.4% in the HP-negative group and 43.8% in the HP noneradicated group (p=0.113). The factors that were found to affect recurrence in the HP-negative group were elder, male, and comorbid chronic kidney disease.Conclusion : sThe 5-year cumulative probability of PUD recurrence without H. pylori infection after a long-term follow-up was 36.4% and the factors that affected recurrence were elder, male, and comorbid chronic kidney disease.

Background/AimsEradication of Helicobacter pylori infection with standard triple therapy (TT) has declined primarily because of increased antibiotic resistance. Sequential therapy (ST) has been suggested as an alternative to TT for the first-line treatment of H. pylori. The purpose of this study was to compare the efficacy of ST with TT.Methods : This was a multicenter, randomized open-label trial performed at nine centers in Korea. Patients with H. pylori infection were randomly assigned to receive either 7 day TT or 10 day ST. Eradication rates, drug compliance, and adverse events were compared among the two regimens.Results : A total of 601 patients were enrolled between March 2011 and September 2014. The intention-to-treat eradication rates were 70.8% for TT and 82.4% for ST (p=0.001). The corresponding per protocol eradication rates were 76.9% and 88.8% for TT and ST, respectively (p=0.000). There were no statistically significant differences between the two regimens with respect to drug compliance and adverse events.Conclusion : sST achieved better eradication rates than TT as a first-line therapy for H. pylori eradication in Korea.

BACKGROUND:Little is known about the correlation between microbiological yield and radiographic activity, on chest computed tomography (CT), in suspected pulmonary tuberculosis (PTB) cases, despite CT being widely used, clinically. METHODS:We used multicenter retrospective data, obtained from medical records, focusing on the diagnostic performance for definite PTB. We categorized patients into four groups, by radiographic activity: definitely active, probably active, indeterminate activity, and probably inactive. RESULTS:Of the 650 patients included, 316 had culture-confirmed PTB; 190 (29.2%), 323 (49.7%), 70 (10.8%), and 67 (10.3%) were classified into the definitely active, probably active, indeterminate activity, and probably inactive groups, respectively. The corresponding observed culture rates for CT radiographic activity were 61.6%, 60.7%, 4.3% and 0%, respectively. When not only culture rates but TB-PCR and histological results were taken into consideration as definite PTB, it showed 66.6%, 67.2%, 14.3%, and 0% of each CT radiographic activity, respectively. Regarding the diagnostic performance for definite PTB, radiographic activity displayed high sensitivity (97.1%, 95% confidence interval (CI), 94.6-98.5) and negative predictive values (92.7%, 95% CI, 86.6-96.2), considered definitely and probably active PTB. Apart from PTB, other etiologies, according to radiographic activity, were predominantly respiratory infections such as bacterial pneumonia and non-tuberculous mycobacterial infection. CONCLUSIONS:Radiographic activity showed good diagnostic performance, and can be used easily in clinical practice. However, clinicians should consider other possibilities, because radiologic images do not confirm microbiological PTB.

Background/AimsPneumoperitoneum is recognized as a benign and self-limiting finding after the insertion of a percutaneous endoscopic gastrostomy (PEG) tube, while complicated pneumoperitoneum is rarely reported. The aim of this study was to reappraise pneumoperitoneum following PEG.MethodsWe retrospectively reviewed 193 patients who underwent PEG from May 2008 to May 2014. All patients had a follow-up upright chest or simple abdominal radiograph after PEG. Pneumoperitoneum was quantified by measuring the height of the air column under the diaphragm and graded as small (4 cm). Clinically significant signs were defined as fever, abdominal tenderness or leukocytosis occurring after PEG insertion.ResultsOf the 193 study patients, 9 (4.6%) had a pneumoperitoneum visualized by radiographic imaging, graded as small in 5 patients, moderate in 2 patients and large in 2 patients. Clinically significant signs were observed in 5 (55.5%) patients with fever reported in 4 patients, abdominal tenderness in 4 patients and leukocytosis in 4 patients. The time to resolution of free air was 2-18 days. Two patients (22.2%) with moderate or large pneumoperitoneum after PEG died from either pneumonia or septic shock.ConclusionsThe clinical course of pneumoperitoneum after PEG is not always benign and self-limiting. These findings suggest that clinicians should not neglect a moderate or large pneumoperitoneum, particularly in patients who have an altered mental status or received antibiotics, since peritoneal irritation cannot be observed under these circumstances.

Amyloidosis is characterized by the abnormal deposition of extracellular amyloid fibrils. Cases involving amyloid light-chain amyloidosis in the small intestine have been reported infrequently in Korea. Here, we report a case of localized light chain protein amyloidosis in the small intestine. Esophagogastroduodenoscopy, push enteroscopy, and capsule endoscopy revealed submucosal tumor-like lesions, multiple shallow ulcers, and several erosions in the distal duodenum and jejunum. An endoscopic biopsy established the diagnosis of amyloidosis. In through an immunohistochemical analysis, the presence of lambda light chain protein was detected. The patient had no evidence of an underlying clonal plasma cell disorder or additional organ involvement. Therefore, we concluded that the patient had localized amyloidosis of the small intestine.

Background/AimsColorectal cancer (CRC) develops from colonic adenomas. Type 2 diabetes mellitus (DM) is associated with a higher risk of CRC and metformin decreases CRC risk. However, it is not certain if metformin affects the development of colorectal polyps and adenomas. This study aimed to elucidate if metforminaffects the incidence of colonic polyps and adenomas in patients with type 2 DM.MethodsOf 12,186 patients with type 2 DM, 3,775 underwent colonoscopy between May 2001 and March 2013. This study enrolled 3,105 of these patients, and divided them in two groups: 912 patients with metformin use and 2,193 patients without metformin use. Patient clinical characteristics, polyp and adenoma detection rate in the two groups were analyzed retrospectively.ResultsThe Colorectal polyp detection rate was lower in the metformin group than in the non-meformin group (39.4% vs. 62.4%, P

OBJECTIVES: Handwashing is the most fundamental way to prevent the spread of infectious diseases. Correct handwashing can prevent 50 to 70% of water-infections and foodborne-infections. We report the results of a fact-finding study on general handwashing attitude and practice in the Republic of Korea by analyzing habits and awareness among adults and students (grades 4 to 12) based on the 2006 to 2014 National Handwashing Surveys and observational surveys. METHODS: The awareness survey was performed by telephone interviews with adults and students in 16 municipalities and provinces sampled by quota for region, sex and age. The observational survey was performed in subway, railway, and other public restrooms in seven municipalities selected through systematic sampling. RESULTS: Adults and students washed their hands with soap/sanitizer an average of 6.6 and 5.2 times daily, respectively, in 2014, an increase and decrease compared to 2006 (4.8) and 2013 (6.8). Their average daily handwashing frequency in 2014, 9.8 and 8.3, was higher than in 2006 (7.6), but lower than in 2013 (10.3).The percentage of participants handwashing with soap after using the restroom (29.5%) has been increasing since 2009, but remain slower than in other countries (42% to 49%). The percentages of participants handwashing with water in 2014, 2013, and 2011 were 57.5%, 72.6%, and 71.4%, respectively. CONCLUSIONS: Handwashing with soap is an important national public health issue, and national projects promoting it should be given high priority. Research support is necessary to provide scientific evidence of the importance of handwashing with soap and to develop and implement evidence-based policies.

Helicobacter pylori infection, a common infection in many countries, is related to the clinical course of upper gastrointestinal diseases. Gastroesophageal reflux disease (GERD) is a common esophageal disease in Western countries and its prevalence is increasing in Asian countries. The pathophysiology of GERD is multifactorial. Although no single factor has been isolated as the cause of GERD, a negative association between the prevalence of H. pylori and the severity of GERD, including Barrett’s esophagus, has been demonstrated in epidemiological studies. The high prevalence of H. pylori infection affects the incidence of GERD in Asian countries. In the subjects with East Asian CagA-positive strains, acid injury may be minimized by hypochlorhydria from pangastritis and gastric atrophy. Additionally, host genetic factors may affect the development of GERD. The interactions between genetic factors and the virulence of H. pylori infection may be the reason for the low prevalence of GERD in Asian countries. H. pylori eradication is not considered pivotal in GERD exacerbation based on evidence from Western studies. A recent meta-analysis demonstrated that eradication therapy of H. pylori was related to a higher risk of developing de novo GERD in Asian studies. H. pylori infection remains an inconclusive and important issue in GERD in Asian countries.

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. [ABSTRACT FROM AUTHOR]

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 noninferiority 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. [ABSTRACT FROM AUTHOR]