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Background/Aims: Colonoscopic polypectomy is the best diagnostic and therapeutic tool to detect and prevent colorectal neoplasms. However, previous studies have reported that 17% to 28% of colorectal polyps are missed during colonoscopy. We investigated the miss rate of neoplastic polyps and the factors associated with missed polyps from quality-adjusted consecutive colonoscopies.Methods: We reviewed the medical records of patients who were found to have colorectal polyps at a medical examination center of the Kangbuk Samsung Hospital between March 2012 and February 2013. Patients who were referred to a single tertiary academic medical center and underwent colonoscopic polypectomy on the same day were enrolled in our study. The odds ratios (ORs) associated with polyp-related and patient-related factors were evaluated using logistic regression analyses.Results: A total of 463 patients and 1,294 neoplastic polyps were analyzed. The miss rates for adenomas, advanced adenomas, and carcinomas were 24.1% (312/1,294), 1.2% (15/1,294), and 0% (0/1,294), respectively. Flat/sessile-shaped adenomas (adjusted OR, 3.62; 95% confidence interval [CI], 2.40–5.46) and smaller adenomas (adjusted OR, 5.63; 95% CI, 2.84– 11.15 for ≤5 mm; adjusted OR, 3.18; 95% CI, 1.60–6.30 for 6–9 mm, respectively) were more frequently missed than pedunculated/sub-pedunculated adenomas and larger adenomas. In patients with 2 or more polyps compared with only one detected (adjusted OR, 2.37; 95% CI, 1.55–3.61 for 2–4 polyps; adjusted OR, 11.52; 95% CI, 4.61–28.79 for ≥5 polyps, respectively) during the first endoscopy, the risk of missing an additional polyp was significantly higher.Conclusions: One-quarter of neoplastic polyps was missed during colonoscopy. We encourage endoscopists to detect smaller and flat or sessile polyps by using the optimal withdrawal technique.

Klebsiella pneumoniae (K. pneumoniae) can at times cause invasive infections, especially in patients with diabetes mellitus and a history of alcohol abuse. A 61-year-old man with diabetes mellitus and a history of alcohol abuse presented with abdominal and anal pain for two weeks. After admission, he underwent sigmoidoscopy, which revealed multiple ulcerations with yellowish exudate in the rectum and sigmoid colon. The patient was treated with ciprofloxacin and metronidazole. After one week, follow up sigmoidoscopy was performed owing to sustained fever and diarrhea. The lesions were aggravated and seemed webbed in appearance because of damage to the rectal mucosa. Abdominal computed tomography and rectal magnetic resonance imaging were performed, and showed a perianal and perirectal abscess. The patient underwent laparoscopic sigmoid colostomy and perirectal abscess incision and drainage. Extended-spectrum beta-lactamase-producing K. pneumoniae was identified in pus culture. The antibiotics were switched to ertapenem. He improved after surgery and was discharged. K. pneumoniae can cause rapid invasive infection in patients with diabetes and a history of alcohol abuse. We report the first rare case of proctitis and perianal abscess caused by invasive K. pneumoniae infection.

OBJECTIVE There is dissociation between insulin resistance, overweight/obesity, and fatty liver as risk factors for type 2 diabetes, suggesting that different mechanisms are involved. Our aim was to 1) quantify risk of incident diabetes at follow-up with different combinations of these risk factors at baseline and 2) determine whether each is an independent risk factor for diabetes. RESEARCH DESIGN AND METHODS We examined 12,853 subjects without diabetes from a South Korean occupational cohort, and insulin resistance (IR) (homeostasis model assessment-IR ≥75th centile, ≥2.0), fatty liver (defined by standard ultrasound criteria), and overweight/obesity (BMI ≥25 kg/m2) identified at baseline. Odds ratios (ORs) and 95% confidence intervals (CIs) for incident diabetes at 5-year follow-up were estimated using logistic regression. RESULTS We identified 223 incident cases of diabetes from which 26 subjects had none of the three risk factors, 37 had one, 56 had two, and 104 had three. In the fully adjusted model, the OR and CI for diabetes were 3.92 (2.86–5.37) for IR, 1.62 (1.17–2.24) for overweight/obesity, and 2.42 (1.74–3.36) for fatty liver. The OR for the presence of all three factors in a fully adjusted model was 14.13 (8.99–22.21). CONCLUSIONS The clustering of IR, overweight/obesity, and fatty liver is common and markedly increases the odds of developing type 2 diabetes, but these factors also have effects independently of each other and of confounding factors. The data suggest that treatment for each factor is needed to decrease risk of type 2 diabetes.

Without significant coronary artery stenosis, ischemic electrocardiographic change including ST segment elevation, segmental wall motion abnormality and elevated serum cardiac-specific markers (creatine kinase-MB, Troponin-T) may develop after central nervous system injuries such as subarachnoid, intracranial or subdural hemorrhage. Misdiagnosing these patients as acute myocardial infarction may result in catastrophic outcomes. By reporting a case of a 55-year old female with subarachnoid hemorrhage mimicking acute ST elevation myocardial infarction, we hope to underline that careful attention of neurologic abnormality is critical in making better prognosis.

Background/Aims: Inpatient status can cause inadequate bowel preparation. The majority of previous studies regarding bowel preparation have focused on comparing the effects of different purgative regimens in outpatients. However, data on bowel preparation for inpatients are lacking. The aim of this study was to investigate whether bisacodyl plus polyethylene glycol (PEG) can improve bowel preparation in hospitalized patients. Methods: A prospective, randomized and observer-blind study was performed. A total of 196 hospitalized patients undergoing colonoscopy were randomized to receive 4 L PEG (PEG only group) or 4 L PEG＋bisacodyl 10 mg (bisacodyl added group). The adequacy of bowel preparation was scored using the Ottawa bowel preparation scale. Results: One hundred and eighty-three subjects completed the study; 96 in the bisacodyl added group and 87 in the PEG only group. There were no significant differences between the bisacodyl added group and the PEG only group with respect to the score of bowel cleansing (3.59±2.81 vs. 3.82±3.03, p=0.607), quality of bowel cleansing (adequate preparation 89.6% vs. 85.1%, p=0.380), and overall adverse events (66.7% vs. 52.9%, p=0.057). However, a larger proportion of patients in the PEG only group were able to ingest the entire solution as prescribed than in the bisacodyl added group (98.9% vs. 75.0%, p＜0.001). Conclusions: In hospitalized patients, the quality of bowel preparation did not differ depending on whether bisacodyl is added or not. In addition, patient compliance based on consumption of cleansing agent was better in the PEG only group. (Korean J Gastroenterol 2014;64:268-277)

목적: 대장내시경 시행 시 작은 폴립이나 종양 같은 점막의 병변을 발견하는 데 있어 대장점막의 자세한 관찰이 무엇보다 중요하며 이를 위해 적절한 장정결이 필수적이다. 이번 연구의 목적은 대장내시경 전처치로 PEG 용액을 사용하고 검사 전일 맑은 유동식만을 먹게 한 그룹과 식이제한을 하지 않은 그룹에 있어서 장정결도와 장정결제의 내약성, 부작용 발생 여부에 차이가 있는지 알아보고자 하는데 있다. 대상 및 방법: 이번 연구는 무작위배정, 단일 맹검 전향적 연구로 총 330명의 환자를 대상으로 검사 전일 2 L의 PEG 용액과 맑은 유동식이를 복용한 그룹 1과 검사 전일 2 L의 PEG 용액과 제한하지 않은 일반 식이를 복용한 그룹 2로 무작위 배정하였다. 결과: 162명의 환자가 그룹 1로, 168명의 환자가 그룹 2로 배정되었으며, 두 그룹 사이에 만족스러운 대장정결을 보인 환자 수의 차이는 관찰되지 않았다(80.2%, 78.6%, P=0.707). 그룹 1의 환자들에서 맑은 유동식이를 적어도 2회 이상 지킨 환자들에 대한 순응도는 50%밖에 되지 않았고, 하루 2-3회 맑은 유동식을 복용한 그룹 1A에서 0-1회밖에 복용하지 않은 그룹 1B보다 만족스러운 대장정결을 보인 환자 수가 더 많았지만 그 차이는 미약하였다(74.1%, 86.4%, P=0.048). PEG 용액에 대한 내약성은 두 그룹 간에 차이가 없었고(P=0.573), 전처치로 인한 부작용 발생 여부에도 두 그룹 간에 차이가 없었다(P=0.686). 결론: 대장내시경을 위한 장정결에 있어서 검사 전일 맑은 유동식을 복용하는 것은 식이제한을 하지 않는 것에 비하여 효과와 장정결제에 대한 내약성, 부작용 발생에 있어서 차이가 없었다. 만일 맑은 유동식을 권고하는 전처치를 시행할 경우 환자의 맑은 유동식의 횟수에 대한 순응도가 무엇보다 중요하여 이를 향상시킬 수 있는 방법을 찾아야 한다.

Congenital anomalies or normal variants of the pancreatic duct are in most cases asymptomatic and are found incidentally while conducting imaging studies (such as a MRCP and a CT scan) for other reasons. The frequency of pancreatic duct variants has been reported to be about 9% of the general population; the most common type is a bifid configuration of the major and minor pancreatic ducts. Though most patients with pancreatic duct variants do not have any symptoms, a small number may develop jaundice or gallstones. By reporting the case of a patient with a variant pancreatic duct who developed acute pancreatitis after undergoing screening endoscopy and biopsy, this study aims to warn of the possible risks of screening endoscopy or biopsy in the second portion of the duodenum. (Korean J Med 2012;82:709-712)