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We present an interesting case of acute acalculous cholecystitis which was diagnosed as cystic duct cancer after endoscopic ultrasonography (EUS). A 63-year-old man visited to an emergency room (ER) because of right upper quadrant (RUQ) abdominal pain. The patient had fever up to 38.2℃ and tenderness at RUQ abdomen. The Murphy’s sign was positive. Laboratory tests showed elevated white blood cell count and abnormal liver function test. The computed tomography scan revealed a distended gallbladder with inflammation without gallstone. Emergent gallbladder drainage was performed at ER. The cholecystogram via percutaneous tube and EUS revealed hypoechoic intraluminal mass at cystic duct. Laparoscopic cholecystectomy was performed at first, and the frozen pathologic examination revealed adenocarcinoma in the cystic duct. The extended cholecystectomy was performed after a month and there was no residual tumor in the liver bed and lymph nodes. The final staging of GBC was revealed as pT2N0M0.

Endoscopic ultrasound (EUS)-guided tissue acquisition of pancreatic solid tumor requires a strict recommendation for its proper use in clinical practice because of its technical difficulty and invasiveness. The Korean Society of Gastrointestinal Endoscopy (KSGE) appointed a task force to draft clinical practice guidelines for EUS-guided tissue acquisition of pancreatic solid tumor. The strength of recommendation and the level of evidence for each statement were graded according to the Minds Handbook for Clinical Practice Guideline Development 2014. The committee, comprising a development panel of 16 endosonographers and an expert on guideline development methodology, developed 12 evidence-based recommendations in eight categories intended to help physicians make evidence-based clinical judgments with regard to the diagnosis of pancreatic solid tumor. This clinical practice guideline discusses EUS-guided sampling in pancreatic solid tumor and makes recommendations on circumstances that warrant its use, technical issues related to maximizing the diagnostic yield (e.g., needle type, needle diameter, adequate number of needle passes, sample obtaining techniques, and methods of specimen processing), adverse events of EUS-guided tissue acquisition, and learning-related issues. This guideline was reviewed by external experts and suggests best practices recommended based on the evidence available at the time of preparation. This guideline may not be applicable for all clinical situations and should be interpreted in light of specific situations and the availability of resources. It will be revised as necessary to cover progress and changes in technology and evidence from clinical practice. (Gut Liver 2021;15:354-374)

The Korean Society of Gastrointestinal Endoscopy (KSGE) developed a gastrointestinal (GI) endoscopy board in 1995 and related regulations. Although the KSGE has acquired many specialists since then, the education and training aims and guidelines were insufficient. During GI fellowship training, obtaining sufficient exposure to some types of endoscopic procedures is difficult. Fellows should acquire endoscopic skills through supervised endoscopic procedures during GI fellowship training. Thus, the KSGE requires training guidelines for fellowships that allow fellows to perform independent endoscopic procedures without supervision. This document is intended to provide principles that the Committee of Education and Training of the KSGE can use to develop practical guidelines for granting privileges to perform accurate GI endoscopy safely. The KSGE will improve the quality of GI endoscopy by providing guidelines for fellowships and supervisors.

The risk of hepatocellular carcinoma (HCC) is not completely eliminated in chronic hepatitis C (CHC) patients even after viral eradication. There are few studies in predicting the development of HCC using biomarker in CHC patients with sustained virologic response (SVR). We evaluated the role of the aspartate aminotransferase-to-platelet ratio index (APRI) and fibrosis-4 index (FIB-4) in predicting HCC development in 295 patients with SVR after interferon therapy. The annual incidence of HCC was 0.55% (95% confidence interval: 0.31-0.96). It was higher in patients with a pretreatment APRI ≥2.0 than in those with an APRI2.0 (1.82% versus 0.17%

4020 Background: In the TeloVac study, GV1001 with Gemcitabine/capecitabine (G/C) did not show increased overall survival (OS) than G/C in patients (pts) with advanced pancreatic ductal adenocarcinoma (PDA). But cytokine examination suggested high serum eotaxin level may predict improved survivals in pts received GV1001 with G/C. This phase III trial was designed to assess the efficacy of GV1001 with G/C for previous untreated eotaxin-high Korean pts with advanced PDA. Methods: Eligible pts with histologically proven locally advanced and metastatic PDA (except peritoneal carcinomatosis), age > 18 years, and ECOG PS 0–2 were recruited. Pts were randomly assigned (1:1) to receive either G/C or G/C with GV1001 (G/C/GV). All pts receiving G/C/GV were with high serum eotaxin level (≥81.02 ng/mL), and the pts receiving G/C were randomly assigned again (1:1) to eotaxin-high and eotaxin-low pts. Study was designed according to Korean MFDS guidance for approval of clinical trial. G/C treatment included G (1000 mg/m2, 30 min IVF, D 1, 8, & 15) and C (830 mg/m2 BID for 21 days per month (m). G/C/GV treatment included an intradermal injection of GM-CSF (75 μg) and GV1001 (0.56 mg; D 1, 3, & 5, once on week 2–4, & 6, then monthly thereafter) from the start of G/C. The primary endpoint was OS. The secondary endpoints included time to progression (TTP), objective response rate, and safety. Survival data was analyzed using the copula graphic estimate method under dependent censoring. The response was independently assessed per RECIST v1.1. Under the one-sided significance level of 2.5% and to achieve the power of 80% of the statistical significance with the median OS difference from 7.9 to 14.9 m (HR = 0.53), 85 events and 118 registrations needed. Considering 20% drop-outs, 148 registrations were required. Results: Between Nov 2015 and Apr 2020, of 511 pts screened in 16 centers, eotaxin-high pts were identified as 34.7% (174 / 502 pts). 148 pts randomly assigned to G/C/GV (n = 75; all eotaxine-high) and G/C (n = 73; 37 eotaxine-high, 36 eotaxine-low). Median OS was significantly improved in the G/C/GV group with 11.3m [95% CI 8.6-14.0] than G/C group with 7.5 m [95% CI 5.1-10.0] (p = 0.021). Also, median TTP was significantly improved in the G/C/GV group (7.3 m [95% CI 5.0-9.7]) than in the G/C group (4.5 m [95% CI 3.2-5.8], p = 0.021). In other secondary endpoints, no statistical significance was confirmed between the two groups. Grade 3-4 treatment-emergent adverse events were reported in 49 pts (73.13%) vs. 58 pts (77.33%) in the G/C and G/C/GV group, without significant differences (p = 0.562). Conclusions: G/C/GV treatments significantly extend OS and TTP in advanced PDA than G/C, and specific safety-related issues had not been found. GV1001 should be considered as one of the options in PDA pts with high serum eotaxin levels. Clinical trial information: NCT02854072.

Some recent studies have found regression of liver cirrhosis after antiviral therapy in patients with hepatitis C virus (HCV)-related liver cirrhosis, but there have been no reports of complete regression of esophageal varices after interferon/peg-interferon and ribavirin combination therapy. We describe two cases of complete regression of esophageal varices and splenomegaly after interferon-alpha and ribavirin combination therapy in patients with HCV-related liver cirrhosis. Esophageal varices and splenomegaly regressed after 3 and 8 years of sustained virologic responses in cases 1 and 2, respectively. To our knowledge, this is the first study demonstrating that complications of liver cirrhosis, such as esophageal varices and splenomegaly, can regress after antiviral therapy in patients with HCV-related liver cirrhosis.

Background/Aims: On previous study, the H. pylori eradication rate by triple therapy was 68.2 % in Jeju. We perform thisstudy to estimate the eradication rate of quadruple therapy fo rthe treatment failure group of the triple therapy.Methods: From January 1, 2005 to August 31, 2007, We investigated the medical record for adult patient received quadrupletherapy including proton pump inhibitor (PPI), bismuth, tetracycline, metronidazole because of failed OAC triple therapy. Wecollected data and compared the eradication rate for sex, age,p lace of residence, kind of PPI, and treatment periods.Results: Total 105 patient was enrolled (M:F=60:45, Mean age±SD 58.0±12.5). The overall eradication rate was 79.0%. Therewere no significant difference of eradication rate in differen tgroup of sex, place of residence, age, PPI, duration of treatemnt.Conclusions: The H. pylori eradication rate of quadruple therapy was 79.0% in Jeju island. We could not found any significantfactor influencing to quadruple therapy.

Azathioprine (AZA) is widely used to maintain clinical remission of Crohn’s disease. AZA is also important as a steroidsparingagent in steroid-dependent and active Crohn’s disease. Bone marrow suppression is common adverse effect ofAZA. We report a case of a 16-year-old male patient who was diagnosed as Crohn’s disease with involvement of terminalileum and colon; he experienced clinical and endoscopic remission of Crohn’s disease following improvement of AZAinduced life-threatening myelosuppression and pancreatitis.

27 year old woman visited ER due to severe epigastric pain who underwent laparoscopic pylorus preserving pancreaticoduodenectomy due to solid pseudopapillary tumor 3 years ago. CT scan showed loculated fluid collection in the perihepatic space. The fluid collection was punctured using a curvilinear echoendoscope followed by the placement of two 7-Fr double pigtail plastic stents across the liver. There were no early or delayed complications and the procedure was effective in relieving pain. Follow-up CT scan after 8 weeks showed completely resolved fluid collection. EUS guided drainage can be a feasible way to resolve the symptom in patient with fluid collection after pancreatic resection.

Roux-en-Y gastric bypass (RYGB) is the most common bariatric surgery. The performance of ERCP in bariatric RYGB is challenging due to the long Roux limb. We herein compared the indications and technical outcomes of ERCP via percutaneous gastrostomy (GERCP) and double balloon enteroscopy (DBERCP) for patients with prior bariatric RYGB anatomy.Between December 2005 and November 2011, consecutive ERCP patients who had undergone RYGB were identified using a prospectively maintained electronic ERCP database. Medical records were abstracted for ERCP indications and outcomes. In most cases, the gastrostomy was done by either laparoscopic or open surgery and allowed to mature at least 1 month before performing ERCP. The choice of route for ERCP was at discretion of managing physician.Forty-four patients (F = 42) with GERCP and 28 patients (F = 26) with DBERCP were identified. The mean age was younger in GERCP than DBERCP (44.8 vs. 56.1, p0.001). GERCP patients were more likely to have suspected sphincter of Oddi dysfunction (77 %) as the primary indication whereas DBERCP was suspected CBD stone (57 %). The mean total number of sessions/patient in GERCP and DBERCP was 1.7 ± 1.0 and 1.1 ± 0.4, respectively (p = 0.004). GERCP access to the major papilla was successful in all but two (97 %), whereas duct cannulation and interventions were successful in all. In DBERCP, the success rate of accessing major papilla, cannulation and therapeutic intervention was 78, 63, 56 %, respectively. There was one (3.1 %) post-ERCP pancreatitis in DBERCP. Complications occurred in 11 GERCP procedures (14.5 %) and 10 were related to the gastrostomy. This was significantly higher than that of DBERCP (p = 0.022).GERCP is more effective than DBERCP in gaining access to the pancreatobiliary tree in patients with RYGB, but it is hindered by the gastrostomy maturation delay and a higher morbidity. Technical improvements in each method are needed.

A perirectal abscess is a relatively common disease entity that occurs as a postsurgical complication or as a result of various medical conditions. Endoscopic ultrasound (EUS)-guided drainage was recently described as a promising alternative treatment. Previous reports have recommended placement of a drainage catheter through the anus for irrigation, which is inconvenient to the patient and carries a risk of accidental dislodgement. We report four cases of perirectal abscess that were successfully treated with only one or two 7 F double pigtail plastic stent placements and without a drainage catheter for irrigation.

OBJECTIVES The aims of this study were to evaluate whether serum pancreatic enzyme levels could be used to aid screening for chronic pancreatitis (CP). METHODS 170 healthy volunteers were screened and prospectively enrolled in the control group. 150 patients who were diagnosed with calcific CP were enrolled in the patient group by retrospective review. Serum amylase and lipase levels were compared between the 2 groups. RESULTS The mean values ± SD of the control group were compared with those of the patient group for serum amylase level (48.1 ± 13.2 vs 34.8 ± 17.2 U/L, P < 0.001) and serum lipase level (26.4 ± 11.3 vs 16.3 ± 11.2 U/L, P < 0.001). On the receiver operating characteristic curve analysis for amylase level, area under the curve was 0.740 (95% confidence interval), and sensitivity and specificity were 38.7% and 94.1%, respectively, with a cutoff value of 27.5 U/L. On the receiver operating characteristic curve analysis for lipase level, area under the curve was 0.748 (95% confidence interval), and sensitivity and specificity were 33.3% and 95.9%, respectively, with a cutoff value of 10.5 U/L. CONCLUSIONS Our results suggest that low serum pancreatic enzyme levels can be used to aid in detection of CP.

Background/Aims Pancreatic duct calcifications are common in chronic pancreatitis. Secretin (SEC) stimulates pancreas duct cells to secrete bicarbonate-rich fluid. SEC may aid fragmentation and facilitate excretion of pulverized pancreatic stones during extracorporeal shock wave lithotripsy (ESWL). The aim was to evaluate the effect of SEC administered during ESWL on clearance of main pancreatic stone (MPDS) at endoscopic retrograde cholangiopancreatography (ERCP). Methods Between Jan. 2003 and Sept. 2010, patients with MPDS who were treated with ESWL and ERCP were identified retrospectively. The number and diameter of calcifications were assessed at pre-ESWL images. Before 2006, ESWL was performed without SEC stimulation. From 2007, 16 μg of SEC was administered IV near the beginning of ESWL at the discretion of the managing physician. Clearance of the pancreatic duct was assessed with ERCP after ESWL. Results A total of 233 consecutive cases (SEC group: 71, no SEC group: 162) were tallied. Overall there were 310 ESWLs and 332 ERCPs in the 233 cases. On univariate analysis, the use of SEC showed significantly higher rate of complete MPDS clearance (63% vs. 46%, p = 0.021) after first ESWL/ERCP. The number of repeat sessions of ESWL/ERCP was similar between the two groups (SEC vs. No SEC, ESWL/ERCP: 1.27 vs. 1.36/1.34 vs. 1.46). Independent predictors of complete/nearly complete stone clearance included the use of SEC ( p = 0.005), pre-ESWL pancreatic stent ( p = 0.001). Conclusions Secretin during ESWL appears to aid clearance of MPDS in chronic calcific pancreatitis. Further prospective randomized studies would be of interest.

Although esophageal perforation due to foreign body is uncommon, it is a lethal problem that requires careful management because of severe complications such as mediaslinilis, empyema, tracheobronchial fistula and retroperitoneal abscess. A 77-year-old man suddenly developed right upper quadrant pain after eating fish (Chromis notata) in the morning the day before admission. Upper endoscopy revealed a 4 cm-sized fishbone impaction and it was removed by a biopsy forcep. Esophageal perforation was found at the middle esophagus. Chest computed tomography showed pneumomediastinum in the left paraaortic area, paraesophageal area, and retrothyroid area. The patient was treated with total parenteral nutrition and broad spectrum intravenous antibiotics. On the seventh day of admission, he was completely recovered and esophagogram showed no leakage of contrast dye. We report an esophageal perforation and pneumomediastinum by a fishbone (Chromis notata) impaction as popular local dish in Jeju island, which was treated successfully with conservative management.

Objectives Tumor growth factor beta (TGF-beta) is an immunosuppressive cytokine and has been implicated in a variety of disease processes, including those in autoimmune disease. Tumor growth factor beta is also involved in fibrosis by regulating matrix metalloproteinases (MMPs) and the tissue inhibitor of MP (TIMP). The purpose of this study was to compare the expression patterns of TGF-beta1, MMP-2, and TIMP-2 between autoimmune chronic pancreatitis (AIP) and alcoholic chronic pancreatitis (ACP) by immunohistochemical staining of pancreatic tissue specimens. Methods Pancreatic tissue specimens were obtained from 16 of 57 patients who had a diagnosis of AIP at the Asan Medical Center. Pancreatic tissue specimens of ACP were obtained from 10 patients who were surgically treated. Immunohistochemical staining was performed with antibodies specific for TGF-beta1, MMP-2, and TIMP-2. Results The degree of immunohistochemical staining for TGF-beta1 was significantly weaker in AIP than in ACP in the pancreatic ductal epithelial and mononuclear cells (P = 0.029 and P = 0.018, respectively). Conclusions This finding suggests that there may be a defect in the function of regulatory T (Treg) cells, which normally prevents autoimmune disease progression via a suppressor mechanism. Further studies are needed to identify the type of regulatory T cell involved in this process.

Serum immunoglobulin G (IgG) and/or IgG4 elevation is one of the notable characteristics of autoimmune chronic pancreatitis (AIP). The purpose of this study was to compare the sensitivity and specificity of IgG with those of IgG4 in the diagnosis of AIP.From December 2005 to March 2006, patients who were diagnosed as having ordinary chronic pancreatitis of a certain cause (n = 67) and pancreatic cancer (n = 76) in Asan Medical Center were enrolled. The IgG and IgG4 levels of these patients were compared with those of 35 AIP patients diagnosed in Asan Medical Center.The percentage of patients with serum IgG level more than 1800 mg/dL was 10.4% (7/67), 2.6% (2/76), and 54.3% (19/35) in patients with ordinary chronic pancreatitis, pancreatic cancer, and AIP, respectively. As for serum IgG4 levels more than 135 mg/dL, it was 11.9% (8/67), 1.3% (1/76), and 73.3% (22/30), respectively. The specificity of IgG at 1800 mg/dL and IgG4 at 135 mg/dL was both 93.7%. The serum IgG4 showed high specificity (98.7%) in differentiating AIP from pancreatic cancer. The IgG4 level at 141 mg/dL was determined as the most optimal cutoff value with resulting sensitivity and specificity of 73.3% and 95.1%, respectively (area under the curve, 0.816), whereas for IgG, it was determined as 1770 mg/dL, with sensitivity and specificity of 57.1% and 93.7% (area under the curve, 0.788).The sensitivity of serum IgG4 tended to be higher than that of IgG in the diagnosis of AIP. The IgG4 showed high specificity in the differential diagnosis of AIP from pancreatic cancer. Serum IgG4 should be included in the diagnostic workup for AIP.

Behçet's disease is a chronic, relapsing, systemic inflammatory disease characterized by recurrent oral and genital ulcers, skin lesions, and ocular lesions. Gastrointestinal tract is occasionally involved in Behçet's disease, and the typical gastrointestinal lesions are punched-out, discrete mucosal ulcerations. Corticosteroids, 5-aminosalicylic acid derivatives, thalidomide, and immunomodulators have been used to treat Behçet's disease. Some patients with gastrointestinal Behçet's disease undergo surgical management because of the refractoriness to these medical measures or complications, such as perforation and bleeding. Even after successful surgery, postoperative complications, such as poor healing of the anastomosis site and postoperative ulcer recurrence, are so common that repeated operations are frequently required. However, there have been few reports addressing the most effective way to reduce and treat postoperative complications and recurrences. We describe a patient with Behçet's disease involving the distal ileum, who was treated with infliximab as rescue therapy of an unhealed anastomosis site and early recurrent ulcers after a distal ileocecectomy because of persistent bleeding. Abdominal pain from recurrent ulcers improved by the fifth day after the infliximab infusion and almost disappeared by the second week. An ileocolonoscopy performed 15 days after the infliximab infusion showed near complete healing of the recurrent ulcers. This report suggests that infliximab may be an effective novel therapy for the management of early postoperative complications and recurrences in gastrointestinal Behçet's disease.

Recent studies suggest that liver cirrhosis is reversible after administering oral nucleos(t)ide analogue therapy to patients with hepatitis B virus (HBV) infection. However, few studies have addressed whether esophageal varices can regress after such therapy. We report a case of complete regression of esophageal varices during entecavir therapy in patients with HBV-related liver cirrhosis, suggesting that complications of liver cirrhosis such as esophageal varices can regress after the long-term suppression of HBV replication.

Gallbladder (GB) cancer is asymptomatic in nature, making diagnosis and treatment difficult. The lymph node status is the strongest predictor of long-term survival for patients with GB cancer, and a complete removal of regional lymph nodes is important for patients undergoing radical resection of GB cancer. Unfortunately, lymph node metastases are common in the early stages of GB cancer. However, there have only been a few cases describing the symptoms or complications of metastatic lymph nodes in patients with GB cancer. Although hemoperitoneum caused by metastatic lymph nodes can occur with several cancers, it is very rare. To the best of our knowledge, hemoperitoneum from spontaneous ruptures of metastatic lymph nodes with GB cancer has not yet been reported. Herein, we describe such a case in a patient newly diagnosed with GB cancer.

This study compared the efficacy of DA-9601 (Dong-A ST Co., Seoul, Korea) and its new formulation, DA-5204 (Dong-A ST Co.), for treating erosive gastritis. This phase III, randomized, multicenter, double-blind, non-inferiority trial randomly assigned 434 patients with endoscopically proven gastric mucosal erosions into two groups: DA-9601 3 times daily or DA-5,204 twice daily for 2 weeks. The final analysis included 421 patients (DA-5204, 209; DA-9601, 212). The primary endpoint (rate of effective gastric erosion healing) and secondary endpoints (cure rate of endoscopic erosion and gastrointestinal [GI] symptom relief) were assessed using endoscopy after the treatment. Drug-related adverse events (AEs), including GI symptoms, were also compared. At week 2, gastric healing rates with DA-5204 and DA-9601 were 42.1% (88/209) and 42.5% (90/212), respectively. The difference between the groups was −0.4% (95% confidence interval, −9.8% to 9.1%), which was above the non-inferiority margin of −14%. The cure rate of gastric erosion in both groups was 37.3%. The improvement rates of GI symptoms with DA-5204 and DA-9601 were 40.4% and 40.8%, respectively. There were no statistically significant differences between the two groups in both secondary endpoints. AEs were reported in 18 (8.4%) patients in the DA-5204 group and 19 (8.8%) in the DA-9601 group. Rates of AE were not different between the two groups. No serious AE or adverse drug reaction (ADR) occurred. These results demonstrate the non-inferiority of DA-5204 compared to DA-9601. DA-5204 is as effective as DA-9601 in the treatment of erosive gastritis. Registered randomized clinical trial at ClinicalTrials.gov (NCT02282670), Graphical Abstract

Bhupesh Pokhrel,1 Eun Kwang Choi,1 Omer Khalid,2 Kumar Sandrasegaran,3 Evan L Fogel,1 Lee McHenry,1 Stuart Sherman,1 James Watkins,1 Gregory A Cote,1 Henry A Pitt,4 Nicholas J Zyromski,4 Beth Juliar,1 Glen A Lehman11Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, 2Department of Gastroenterology, St Louis University School of Medicine, St Louis, MO, 3Department of Radiology, 4Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USABackground: A preliminary study has shown increased pancreatic fat in patients with idiopathic pancreatitis and sphincter of Oddi dysfunction. In this study, we aimed to determine if an increased quantity of pancreatic fat is an independent risk factor for pancreatitis post-endoscopic retrograde cholangiopancreatography (ERCP).Methods: In this case control study, we retrospectively reviewed a local radiological and ERCP database to identify patients who had had abdominal magnetic resonance imaging (MRI) followed by ERCP no more than 60 days later between September 2003 and January 2011. Percentage of fat was determined by recording signal intensity in the in-phase (Sin) and out-of-phase (Sout) T1-weighted gradient sequences, and calculation of the fat fraction as (Sin - Sout)/(Sin) × 2 by an abdominal radiologist blinded to clinical history. Controls matched for age, gender, and other pancreatobiliary disease were selected from a group with no post-ERCP pancreatitis (before fat content of the pancreas was analyzed).Results: Forty-seven patients were enrolled. Compared with controls, subjects with post-ERCP pancreatitis were similar in terms of age (41.4 years versus 41.1 years), gender (21.2% versus 20.2% males), pancreatobiliary disease characteristics, and most ERCP techniques. Measurements of pancreatic head, body, and tail fat and body mass index were similar in patients and controls.Conclusion: Increased pancreatic fat on MRI criteria is not an independent predictor of post-ERCP pancreatitis.Keywords: magnetic resonance imaging, obesity, pancreatic fat, post-ERCP pancreatitis, sphincter of Oddi dysfunction

It has been hypothesized that naturally occurring mutations in HBV may play a role in the pathogenesis of HBV-related disease. We determined the molecular characteristics of naturally occurring HBV isolates and performed a functional analysis of full-length hepatitis B virus quasispecies from a patient with chronic hepatitis B. The 10 HBV clones isolated were identified as HBV genotype B4 and subtype adw. In most clones, amino acid substitutions and nucleotide changes occurred in a specific region of the core protein, X protein and in the core promoter. In the core protein, cI3L, cL60M, and cI97L were detected in 8 of 10 clones and cP130T was detected in all 10 clones. In the X protein, xI127M was detected in 5 clones. In the basal core promoter, the A1762T/G1764A mutation was found only in 1 clone. An 11-bp nucleotide insertion between nucleotides 1772 and 1773, was found in 2 clones. Six clones that were replication-competent exhibited variation in the level of replicating capacity in vitro even though the average genetic distance between the HBV clones was only 0.5% (range: 0.3–0.7%). Among the replication-competent 6 clones, 5 clones showed higher replication competency compared with clone B9 (reference clone used in this study) in Huh7 cells. However, 4 clones showed lower replication competency compared with clone B9 in HepG2 cells. In conclusion, the HBV virus exhibits genetic variation in the form of quasispecies with different mutation patterns, and these quasispecies may be recognized by distinct viral replication patterns even in patients with subtle genetic mutation.

Objective: In vitro studies showed that mutations in the basal core promoter (BCP) or precore (PC) region restore the replication inefficiency of the lamivudine-resistant mutant. The aim of this study was to clarify the effect of molecular characteristics on the antiviral response to adefovir in patients with lamivudine-resistant chronic hepatitis B (CHB). Methods: Sixty-six lamivudine-resistant patients who were treated with adefovir monotherapy were studied. Sequences of BCP, PC region and reverse transcriptase were determined before adefovir therapy. In patients with virologic breakthrough, reverse transcriptase sequencing was performed. Results: The cumulative probabilities of virologic response were 23.3, 46, 52.7 and 59.5% at years 1, 2, 3 and 4, respectively. PC mutation, the absence of compensatory mutations (rtL80I/V or rtV173L), and a decrease in serum hepatitis B virus (HBV) DNA by 3 log or greater at 6 months were independent predictors of virologic response. The cumulative probabilities of virologic breakthrough were 0, 12.9, 30.7 and 44.5% at years 1, 2, 3 and 4, respectively. BCP mutation and a less than 3 log decrease in serum HBV DNA at 6 months were 2 independent risk factors for virologic breakthrough. Conclusion: Response to adefovir depends on mutation patterns in the BCP, PC region and reverse transcriptase, and on-treatment decreases in serum HBV DNA in lamivudine-resistant CHB patients.

Backgrounds/Aims: The hepatitis C virus (HCV) genotype affects clinical outcomes of HCV infection, in terms of the response to antiviral therapy and progression of chronic liver diseases, and shows geographic differences in distribution. The aim of this study was to elucidate the HCV genotypes in patients with chronic HCV infection in Jeju, which is an island off the Korean peninsula. Methods: The study population consisted of 162 patients with anti-HCV antibodies and HCV-RNA. HCV genotypes were determined using genotype specific primers. Results: HCV genotype 2a predominated (62.3%), followed by genotype 1b (34.0%) and 2b (3.7%). The prevalence of genotypes differed significantly with age, with HCV genotypes 1 and 2 being more frequent in older and younger subjects (P=0.035), respectively. HCV-RNA levels were higher in patients with genotype 1 than in those with genotype 2 (P=0.001). HCV genotype was not significantly related to sex, clinical diagnosis and potential risk factors. Conclusions: HCV genotype 2a is most common in Jeju, followed by genotype 1b. Our results suggest that the distribution of the HCV genotype differs between regions in Korea. (Korean J Hepatol 2008;14:28-35)

Autoimmune chronic pancreatitis (AIP) is a clinically attractive entity because of its dramatic response to steroid therapy. But the long-term results after steroid therapy have not been reported yet in Korea. The purpose of this study was to assess the long-term results and prognosis after steroid therapy in patients with AIP.We retrospectively analyzed the clinical, radiologic, and laboratory features and evaluated clinical outcomes in 19 patients with AIP who have been treated with oral corticosteroid. All patients were initially treated with prednisolone (30-40 mg/d) for 1 or 2 months. After the confirmation of clinical improvement in radiologic imaging and laboratory findings, the daily dose of prednisolone was then gradually tapered by 5-10 mg per month to the maintenance dose (2.5-7.5 mg/d).All the patients showed normalization or marked improvement in symptoms, laboratory and imaging findings after steroid therapy. There were 4 cases (21%) of recurrence during the mean follow-up period of 27 months. All the patients with recurrence responded to oral steroid again. Among the 10 patients with diabetes mellitus, seven patients were able to stop or reduce the medication for diabetes after completion of steroid therapy. The biliary stents were additionally inserted in 10 patients who showed distal common bile duct stricture and obstructive jaundice. The accompanying autoimmune diseases were also improved with oral corticosteroid.Steroid therapy is very effective for AIP and is also effective in the cases of recurrence. A definitive protocol of steroid therapy for AIP should be established in the future.

Objectives: Autoimmune chronic pancreatitis (AIP) is a very attractive disease to clinicians in terms of its dramatic response to the oral steroid therapy in contrast to ordinary chronic pancreatitis. In the year 2002, the Japan Pancreas Society published the diagnostic criteria of AIP, and many clinicians around the world use these criteria for its diagnosis. The purpose of this study was to evaluate whether the Japanese criteria for the diagnosis of AIP are adequate or not. Methods: We retrospectively analyzed the clinical, radiologic, laboratory, and histologic features of 31 patients with AIP who have been successfully treated with oral corticosteroid. All the enrolled patients showed normalization or marked improvement in symptoms, laboratory, and imaging findings after steroid treatment. Results: The mean patients' age was 56 years (range, 32-78 years) and comprised 25 males and 6 females. Seven patients who responded to the steroid did not satisfy the Japanese imaging criterion because the extent of irregular narrowing was less than one third of the entire length of main pancreatic duct. Among these 7 patients, 1 patient did not meet the laboratory and histopathologic criteria as well. Another 2 patients fulfilled the Japanese imaging criterion only and showed normal IgG level, negative results of autoantibody measurements, and nondiagnostic pancreatic histopathology. Taken together, 9 (29%) of the 31 patients did not meet the Japanese diagnostic criteria for AIP, yet responded to the steroid. Conclusions: Clinicians may miss a substantial portion of AIP patients who may benefit from steroid therapy when the diagnosis is confined to those who satisfy the criteria proposed by the Japan Pancreas Society. It is necessary to convene a worldwide consensus to develop an improved diagnostic criteria for AIP.

Bile duct injury is the most serious complication of cholecystectomy. The aim of this study was to evaluate the outcome of endoscopic treatment in bile duct injury after cholecystectomy.We reviewed the results of endoscopic treatments in the patients diagnosed as bile duct injury after cholecystectomy on cholangiographic examinations, retrospectively. Endoscopic treatment included insertion of nasobiliary drainage catheter or plastic stent after endoscopic sphicterotomy.A total of twenty-two patients (9 male, 13 female; median age of 59 years) with bile duct injury were included. Endoscopic treatment was successfully performed in 12 of 13 patients with bile leak only. In patients with both bile leak and stricture, endoscopic treatment was successful in 2 of 3 patients. In 6 patients with complete obstruction of bile duct, endoscopic treatment failed and surgical approach was needed. In our series, transpapillary endoscopic treatment was not successful when proximal bile duct above the injured site was not visualized by endoscopic retrograde cholangiopancreatography (ERCP) and surgery was performed in all cases. Overall success rate of endoscopic treatment in 22 patients with bile duct injury was 64% (14/22). There was no complication associated with endoscopic treatment.ERCP is useful for the treatment of bile leakage after cholecystectomy and can be used for the treatment prior to surgery. Surgical intervention is needed in case of endoscopic treatment failure.

Treatment of pancreatic duct stones by extracorporeal shockwave lithotripsy (ESWL) serves as a nonsurgical treatment modality in patients with stones that are located in upstream of the strictures or in patients with impacted stones. We present the results of ESWL in endoscopically unretrievable pancreatic duct stones in the past 2 years.Between January 2002 and December 2003, 58 patients with chronic pancreatitis were treated by ESWL for pancreatic duct stones. ESWL was performed with an electrohydraulic lithotripter ultrasound focusing system.The mean number of shockwave treatments was 2.5, and the patients received 4,578 (1,527-10,155) shockwave discharges with a mean energy of 15.8 kV. Fragmentations of the stones were achieved in 54 patients (93.2%), and complete clearance of the stones were noticed in 27 patients (46.6%). Fragmentation of stones equal or less than 3 mm in diameter was associated with successful removal of stones (p0.05). Complete relief of pain occurred in 32 patients (55.2%). The procedures were well tolerated and no patient had significant complications such as acute pancreatitis.ESWL is an effective and a safe procedure for endoscopically unretrievable main pancreatic duct stones. ESWL combined with endoscopic therapy can increase the success rate of nonsurgical removal of pancreatic duct stones in patients with chronic pancreatitis.

Hepatic sinusoidal dilatation is a rare benign vascular disorder characterized by focal dilatation of the sinusoidal spaces. In most cases, the underlying etiology is unclear but it may be related to the impairment of venous outflow or sinusoidal infiltration by diverse causes. Diagnosing hepatic sinusoidal dilatation based soley on imaging study is not easy since there are no pathognomonic radiologic findings indicative of this condition. Recently, the authors experience two cases of hepatic sinusoidal infiltration. The first patient was a 53-year-old man detected to have multiple hepatic nodules on ultrasonography (US) during a routine medical check-up. The second patient was an 82-year-old woman with abdominal discomfort who was referred from local clinic with high suspicion of hepatic metastases on US. In both cases, CT scan demonstrated multiple nodules with rim enhancement on arterial phase that became iso-dense to adjacent liver parenchyma on delayed phase. On MRI, these nodules showed rim enhancem ent on arterial phase, had high signal intensity on T2 weighted images, and became iso-intense with partial defect on hepatobiliary phase. Because imaging studies could not exclude the presence of hepatic metastases, liver biopsy was performed and it demonstrated hepatic sinusoidal dilatation with well preserved reticulin fiber without any evidence of malignancy. Herein, we report two cases of idiopathic hepatic sinusoidal dilatation mimicking hepatic metastases. (Korean J Gastroenterol 2014;64:239-245)

F-FDG uptake of primary lesions (98.6% vs. 28.0%, P＜0.001) and lymph nodes (50.0% vs. 6.0%, P＜0.001), and higher standardized uptake value max of primary lesions (7.65±3.51 vs. 4.82±2.18, P=0.012). Among 65 patients who underwent gastrectomy, PET-CT positive lesions were found in patients with tumor size greater than 3 cm (86.4% vs. 9.5%, P＜0.001), lesions detected by stomach CT (90.9% vs. 9.5%, P＜0.001) and PET-CT lymph node positive lesions (4.8% vs. 31.8%, P=0.025). Among 31 patients with EGC, elevated types (type I and IIa) showed no difference of positive 18

Background/Aims: The point mutations in 23S rRNA gene accounts for the majority of the clarithromycin resistance of Helicobacter pylori. This study aimed to investigate the association between the clarithromycin-resistance of H. pylori and the failure of primary H. pylori eradication therapy in Jeju Island. Methods: Between April 2011 and October 2012, 6,937 patients underwent endoscopy, and H. pylori infection was evaluated in 2,287 patients (33.0%). Total of 110 patients with H. pylori infection were treated with proton pump inhibitor (PPI)-based triple therapy. The result of eradication was evaluated with urea breath test, histology and PCR which were conducted 4 weeks from the last dose of medicine. Results: The patients who had point mutations were 33 (26.0%). A2142G and A2143G mutations were observed in 10 patients (7.9%) and 23 patients (18.1%). Among 110 patients treated with PPI-based triple therapy, the success rate of the eradication therapy was 52.7% (58/110) and 70.7% (58/82) by intention-to-treat and per-protocol analysis, respectively. Fifteen of the 24 patients who failed the eradication therapy showed point mutations; 1 patient (4.2%) showed A2142G mutation and 14 patients (58.3%) showed A2143G mutation. Patients with A2143G mutation H. pylori showed higher failure rate of 87.5%. Patients with A2142G mutation H. pylori showed similar failure rate compared to those of the patients with wild type H. pylori. Conclusions: In Jeju Island, the frequency of 23S rRNA point mutations is similar (26.0%) with other regions of Korea (15.8-31.3%). A2143G mutation is associated with the failure of H. pylori eradication. (Korean J Gastroenterol 2013;61:252-258)

대장암은 선종-암 속발 이론에 따라서 용종의 조기 발견 중요성이 Background/Aims: Colorectal cancer is the third most common cancer and the fourth leading cause of cancer death in Korea. Colonoscopic screening with removal of adenomas is an effective strategy for reducing the incidence and mortality of colorectal cancer. This study was conducted to investigate predictable factors of early colorectal cancer (ECC) in patients with advanced adenoma (AA), tumor in situ (Tis), and submucosal (SM) cancer diagnosed after colonoscopic polypectomy. Methods: Between August 2003 and June 2012, a total of 1,001 patients who underwent colonoscopic polypectomy in Jeju National University Hospital were enrolled in this study. Results: Patients were classified into four groups; non-AA, AA, Tis, and SM cancer. Compared to the AA group, the ECC group (n=50) had large adenoma size (12.2±5.9 mm vs. 15.3±6.5 mm, P 15 mm (odds ratio [OR], 4.49; 95% confidence interval [CI] 2.408.38), distal location (OR, 2.59; 95% CI, 1.33-5.05), and diabetes mellitus (OR, 2.10; 95% CI, 1.07-4.43) were significantly associated with ECC. Of the 12 patients with SM cancer, 5 underwent additional operations and had no remnant carcinoma. Conclusions: Predictable factors of ECC after colonoscopic polypectomy may be adenoma size >15 mm, distal location and diabetes mellitus. (Intest Res 2013;11:169-177)

Pancreatic duct stones are a common complication during the natural course of chronic pancreatitis and often contribute to additional pain and pancreatitis. Abdominal pain, one of the major symptoms of chronic pancreatitis, is believed to be caused in part by obstruction of the pancreatic duct system (by stones or strictures) resulting in increasing intraductal pressure and parenchymal ischemia. Pancreatic stones can be managed by surgery, endoscopy, or extracorporeal shock wave lithotripsy. In this review, updated management of pancreatic duct stones is discussed.