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Background and Aim: In addition to index colonoscopy findings, demographic parameters including age are associated with the risk of metachronous advanced colorectal neoplasia. Here, we aimed to develop a risk scoring model for predicting advanced colorectal neoplasia (ACRN) during surveillance using a combination of clinical factors and index colonoscopy findings., Methods: Patients who underwent the removal of one or more adenomas and surveillance colonoscopy were included. A risk scoring model for ACRN was developed using the Cox proportional hazard model. Surveillance interval was determined as a time point exceeding 4% of the cumulative ACRN incidence in each risk group., Results: Of 9591 participants, 4725 and 4866 were randomly allocated to the derivation and validation cohorts, respectively. Age, abdominal obesity, advanced adenoma, and ≥ 3 adenomas at index colonoscopy were identified as risk factors for metachronous ACRN. Based on the regression coefficients, point scores were assigned as follows: age, 1 point (per 1 year); abdominal obesity, 10 points; advanced adenoma, 10 points; and ≥ 3 adenomas, 15 points. Patients were classified into high-risk (≥ 80 points), moderate-risk (50-79 points), and low-risk (30-49 points) groups. In the validation cohort, the high-risk and moderate-risk groups showed a higher risk of ACRN than the low-risk group (hazard ratio [95% confidence interval]: 7.11 [4.10-12.32] and 1.58 [1.09-2.30], respectively). Two-, 4-, and 5-year surveillance intervals were recommended for the high-risk, moderate-risk, and low-risk groups, respectively., Conclusions: Our proposed model may facilitate effective risk stratification of ACRN during surveillance and the determination of appropriate surveillance intervals., (© 2020 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background and Aim: Sarcopenia has been suggested to be associated with chronic inflammation and insulin resistance. This study aimed to evaluate whether low muscle mass is associated with the incidence and recurrence of advanced colorectal adenoma., Methods: We conducted a cohort study including 14 701 participants who underwent first-time screening colonoscopy between 2003 and 2012 and follow-up colonoscopy until 2017. Skeletal muscle mass was measured using a bioelectrical impedance analyzer and divided by body weight to calculate the skeletal muscle mass index (SMI)., Results: During a median 47 (interquartile range, 35-58) months of follow-up, overall and advanced adenoma developed in 2988 (20.3%) and 207 (1.41%) participants, respectively. In multivariate analysis using models adjusted for baseline adenoma risk, lifestyle factors, markers for insulin resistance and chronic inflammation, and metabolic syndrome, decreasing SMI quartiles were associated with increased risk of occurrence of advanced adenoma and overall adenoma. The adjusted hazard ratios (95% confidence intervals) comparing SMI quartiles 3, 2, and 1 to quartile 4 were 1.57 (1.03-2.41), 1.22 (0.78-1.92), and 1.77 (1.13-2.76), respectively, for advanced adenoma (P for trend = 0.049) and 1.05 (0.95-1.17), 1.09 (0.98-1.21), and 1.26 (1.13-1.41), respectively, for overall adenoma (P for trend < 0.001)., Conclusions: In this large cohort with long-term colonoscopy follow-up, low relative muscle mass was associated with increased risk of occurrence of advanced adenoma and overall adenoma at follow-up colonoscopy, independent of metabolic and inflammatory markers. Timely and thorough surveillance colonoscopy may be emphasized in such populations., (© 2020 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background and Aims: Serrated polyp detection rate (SDR) is a potential quality indicator for preventing colorectal cancer associated with the serrated pathway. Using clinically significant SDR (CSSDR) has been suggested based on clinically significant serrated polyp's ability to be colorectal cancer precursors. Correlations between CSSDR and simpler SDRs, other than proximal SDR, have not yet been studied. We aimed to investigate which simpler SDR indicator is most relevant to CSSDR or adenoma detection rate (ADR) and provide benchmark data., Methods: We analyzed 26 627 colonoscopies performed by 30 endoscopists. Clinically significant serrated polyps were defined as any sessile serrated adenoma/polyp or traditional serrated adenoma, hyperplastic polyps ≥ 5 mm in the proximal colon, or hyperplastic polyps ≥ 10 mm anywhere in the colon. Correlation of CSSDR and ADR with other simple SDRs, SDR-pathology (sessile serrated adenoma/polyp or traditional serrated adenoma), SDR-size (≥ 10 mm), and SDR-location (proximal location) was analyzed using Pearson's correlation test and Steiger's z-test., Results: The CSSDR was 1.7% to 13.2% (mean = 6.1%). The correlation coefficient of CSSDR/SDR-size was 0.91 (P < 0.01), which was higher than that of CSSDR/SDR-location (0.64, P < 0.01) (0.91 vs 0.61, P < 0.01). The correlation coefficient of ADR/CSSDR and ADR/SDR-location was 0.41 (P < 0.01) and 0.81 (P < 0.01), respectively. For ADR ≥ 25%, endoscopists' median screening CSSDR was 5.4%, while SDR-location and SDR-size were 10.9% and 2.2%, respectively., Conclusion: Large SDR could be a simple proxy for CSSDR, in addition to proximal SDR. Large SDR and proximal SDR benchmarks of 2.2% and 10.9% may guide adequate serrated polyp detection with uniform definitions and simpler calculations., (© 2020 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background and Aim: Abdominal obesity, measured using waist circumference (WC), is associated with the colorectal neoplasia (CRN) risk. We examined whether WC is associated with the CRN risk even in normal-weight individuals., Methods: A cross-sectional study was performed on asymptomatic normal-weight (body mass index 18.5-23 kg/m 2 ) individuals who underwent colonoscopy as health checkups., Results: Of 63 057 examinees, 30 498 were men (mean age, 41.1 years) and 32 559 were women (mean age, 41.7 years). The prevalence of overall CRN in WC quartiles 1, 2, 3, and 4 was 14.2%, 15.5%, 15.5%, and 18.7%, respectively, in men and 7.4%, 8.9%, 9.4%, and 11.5%, respectively, in women. The prevalence of advanced CRN (ACRN) in WC quartiles 1, 2, 3, and 4 was 1.5%, 1.3%, 1.6%, and 2.1%, respectively, in men and 1.0%, 1.3%, 1.2%, and 1.3%, respectively, in women. Among men, the overall CRN risk in quartile 4 (> 82 cm) was higher than that in quartiles 1, 2, and 3 (adjusted odds ratio, OR [95% confidence interval, CI], 1.22 [1.11-1.34], 1.12 [1.05-1.23], and 1.18 [1.07-1.29], respectively); the ACRN risk in quartile 4 was also higher than that in quartiles 1, 2, and 3 (adjusted OR [95% CI], 1.41 [1.09-1.81], 1.56 [1.19-2.03], and 1.50 [1.16-1.94], respectively). Among women, the overall CRN risk in quartile 4 (> 77 cm) was higher than that in quartiles 1 and 3; the ACRN risk was not different among all groups., Conclusions: Even with a normal weight, a large WC was associated with the CRN risk, especially with the ACRN risk in men., (© 2019 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background and Aim: PBK-1701TC is a novel sulfate tablet-based that contains 320 mg of simethicone and delivers 90% of the salt and water delivered by oral sulfate solution (OSS) preparation. This study evaluated the efficacy, safety, and tolerability of PBK-1701TC compared with OSS in bowel preparation for colonoscopy., Methods: This randomized, multicenter, phase 3 non-inferiority trial included adults aged 19 years or older with a body mass index of 19-30 kg/m 2 undergoing colonoscopy at five university hospitals in Korea. The primary efficacy endpoint was successful bowel-cleansing rate, defined as Harefield Cleansing Scale grade A or B as evaluated by blinded central readers. Secondary endpoints included the presence of residual air bubbles. Adverse events and laboratory evaluations were monitored to assess safety. Tolerability was assessed via participant interview., Results: Overall, 235 participants were randomized, and 224 were included in the per-protocol analysis (PBK, 112; OSS, 112). Successful bowel cleansing was achieved for 95.5% (107/112) in the PBK group, which was non-inferior to the OSS group (98.2%, 110/112) with a difference of -2.7% (one sided 97.5% confidence limit, -8.1%). The participants in the PBK group had fewer intraluminal bubbles (0.9% vs 81.3%, P < 0.001) and reported a lower incidence of nausea and vomiting, with better acceptance, taste, and willingness to repeat the regimen than those in the OSS group (all P < 0.05)., Conclusion: The novel sulfate tablet, PBK-1701TC, was non-inferior to OSS with respect to bowel-cleansing efficacy and exhibited better safety and tolerability in adults undergoing colonoscopy., (© 2019 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background and Aim: Obesity and metabolic syndrome are well-known risk factors for the development of metachronous colorectal neoplasia (CRN). However, data on the risks of metachronous CRN among subgroups according to obesity and metabolic status are scarce. Therefore, we aimed to compare the risk of metachronous CRN among men with different obesity and metabolic status., Methods: In total, 8059 asymptomatic men who underwent ≥ 1 adenoma removal between 2010 and 2014 and follow-up colonoscopic surveillance until 2017 were categorized into four groups according to obesity and metabolic status: metabolically healthy non-obese (MHNO), metabolically healthy obese (MHO), metabolically unhealthy non-obese (MUNO), and metabolically unhealthy obese (MUO)., Results: Of the 8059 men, 2389 (29.6%), 351 (4.4%), 1986 (24.6%), and 3333 (41.4%) subjects were assigned to the MHNO, MHO, MUNO, and MUO groups, respectively. The mean surveillance interval was 3.5 ± 1.4 years. Compared to the MHNO group, the risk of metachronous advanced CRN was significantly increased in the MUO group (adjusted hazard ratio [HR] = 1.50; 95% confidence interval [CI]: 1.02-2.19), but not in the MHO and MUNO groups, while the risk of metachronous overall CRN significantly increased in the MUNO (adjusted HR = 1.12; 95% CI: 1.01-1.24) and MUO groups (adjusted HR = 1.17; 95% CI: 1.07-1.29), but not in the MHO group., Conclusions: Men who had both obesity and poor metabolic health were found to be at an increased risk of metachronous advanced CRN, suggesting that MUO men may need to undergo more intensive surveillance colonoscopy after polypectomy., (© 2019 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background and Aim: A biosimilar of infliximab, CT-P13 (Remsima®) has the potential to reduce treatment costs and enhance access to biological therapy for inflammatory bowel disease (IBD) patients. However, long-term clinical data on its use for IBD treatment are currently sparse. We aimed to investigate the long-term efficacy and safety of CT-P13 therapy in a large, real-life IBD cohort., Methods: A total of 368 IBD patients (227 with Crohn's disease [CD] and 141 with ulcerative colitis [UC]) treated with CT-P13 at 16 referral hospitals in Korea between July 2012 and December 2017 were retrospectively analyzed., Results: The cumulative retention rates at years 1, 3, and 5 were 86.1%, 68.5%, and 58.7% and 69.7%, 46.0%, and 26.7% in anti-tumor necrosis factor (TNF)-naïve CD and UC patients, respectively. The clinical response and remission rates at week 14 and at years 1, 3, and 5 were 94.3%, 92.7%, 76.8%, and 17.6% and 78.6%, 82.4%, 72.2%, and 17.6% in anti-TNF-naïve CD and 85.6%, 80.0%, 55.2%, and 6.7% and 42.6%, 59.8%, 44.2%, and 6.7% in anti-TNF-naïve UC patients, respectively. Among patients who switched from the biologic originator to CT-P13, the cumulative retention rates at years 1, 3, and 5 were 88.5%, 66.1%, and 44.8% in CD, and 73.9%, 42.5%, and 42.5% in UC patients, respectively. Significant improvements in disease activity scores were accompanied by marked reductions in inflammatory marker levels, and no unexpected adverse events including death or malignancy occurred during the study period., Conclusions: Long-term treatment with CT-P13 is effective in inducing and maintaining disease improvement and is well-tolerated in patients with IBD. CT-P13 may be a promising treatment option for IBD., (© 2019 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

The Asia-Pacific Working Group on Inflammatory Bowel Disease was established in Cebu, Philippines, under the auspices of the Asia-Pacific Association of Gastroenterology with the goal of improving inflammatory bowel disease care in Asia. This consensus is carried out in collaboration with Asian Organization for Crohn's and Colitis. With biologic agents and biosimilars becoming more established, it is necessary to conduct a review on existing literature and establish a consensus on when and how to introduce biologic agents and biosimilars in conjunction with conventional treatments for ulcerative colitis and Crohn's disease in Asia. These statements also address how pharmacogenetics influences the treatments of ulcerative colitis and Crohn's disease and provides guidance on response monitoring and strategies to restore loss of response. Finally, the review includes statements on how to manage treatment alongside possible hepatitis B and tuberculosis infections, both common in Asia. These statements have been prepared and voted upon by members of inflammatory bowel disease workgroup employing the modified Delphi process. These statements do not intend to be all-encompassing, and future revisions are likely as new data continue to emerge., (© 2019 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background and Aim: Little is known regarding the exact burden of inflammatory bowel disease (IBD) in Asian countries because previous epidemiologic studies were hospital based. We aimed to develop and validate an operational definition of IBD cases from health insurance claims data and to examine the epidemiological features of IBD in Korea., Methods: We analyzed stratified sample data from the Korean Health Insurance Review and Assessment (2010-2016) database using 12 different definitions and applied the best definition to the entire (2007-2016) dataset., Results: The definition that combined the International Classification of Disease 10th revision code with IBD-specific medications had the best performance characteristics among the 12 tested definitions. During the 8-year study period, IBD prevalence increased from 25 345 in 2009 to 47 444 in 2016. Over that period, the prevalence of Crohn's disease increased 1.9-fold (from 16.0/100 000 in 2009 to 29.6/100 000 in 2016) and that of ulcerative colitis increased 1.6-fold (from 41.4/100 000 in 2009 to 66.0/100 000 in 2016). Similarly, the estimated incidence of Crohn's disease also increased 1.2-fold (from 2.4 to 2.9 per 100 000) and that of ulcerative colitis rose 1.3-fold (from 4.0 to 5.3 per 100 000). During the study period, the predominant increase in IBD incidence was among younger individuals, especially those aged < 30 years., Conclusion: Patients with IBD can be accurately identified using Korean insurance claims data by combining information regarding the International Classification of Disease 10th revision codes and the IBD medications used. The prevalence of IBD continues to increase, with an apparent shift toward younger (< 30 years) age groups., (© 2018 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background and Aim: There are no established guidelines on screening strategies for persons with a family history of colorectal cancer (CRC) in Korea. We aimed to evaluate the age-specific risk of colorectal neoplasia according to family history of CRC., Methods: Participants who underwent screening colonoscopy were included. Age-specific prevalence of non-advanced adenoma (NAA) and advanced colorectal neoplasia (ACRN) was calculated according to family history of CRC., Results: Among 35 997 participants, 1339 (3.7%) had a family history of CRC in first-degree relatives. A family history of CRC was an independent risk factor for NAA (adjusted odds ratio [AOR] 1.33, 95% confidence interval [CI] 1.16-1.52). In the subgroup analysis by age, family history of CRC was a risk factor for NAA in the 50-59 and ≥ 60 years groups (AOR [95% CI]: 1.42 [1.04-1.91] and 2.33 [1.34-4.09], respectively), but not in the 30-39 and 40-49 years groups. In the curve of age-specific prevalence of NAA, the gap of the prevalence between the family history and non-family history groups began to widen after the mid-50s. In cases of ACRN, a family history of CRC was not a risk factor in the entire age group (AOR 1.16, 95% CI 0.75-1.70). In the curve of age-specific prevalence of ACRN, however, the gap of the prevalence between the family history and non-family history groups began to widen after the early 60s., Conclusion: Although a family history of CRC is a risk factor for NAA, it may affect NAA development from the mid-50s and ACRN development from the early 60s., (© 2018 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background and Aim: The relationship between a family history of colorectal cancer (CRC) and the risk of metachronous colorectal neoplasia (CRN) following polypectomy remains unknown. We aimed to compare the risk of metachronous CRN according to CRC family history in groups of patients aged < 50 and ≥ 50 years., Methods: We studied patients who underwent ≥ 1 adenoma removal between 2010 and 2014 and follow-up surveillance colonoscopic examinations until 2017., Results: Among the 9866 patients studied, 544 (5.5%) had ≥ 1 first-degree relatives (FDRs) affected by CRC. In patients aged < 50 years (n = 7787), as compared with having no family history of CRC, a positive family history in any FDR (hazard ratio [HR] 1.37, 95% confidence interval [CI] 1.16-1.62), a father (HR 1.35, 95% CI 1.09-1.68), or a mother (HR 1.32, 95% CI 1.005-1.74) was associated with an increased risk of metachronous CRN after adjusting for confounding factors. However, in patients aged ≥ 50 years (n = 2079), there was no significant association between having an FDR with CRC and the risk of metachronous CRN. For metachronous advanced CRN, the association between its risk and family history of CRC was not observed in either the < 50 years or ≥ 50 years of age group., Conclusions: Having an FDR with CRC at a young age (< 50 years) appears to be closely related to the risk of metachronous CRN. However, considering that the risk of metachronous advanced CRN did not depend on CRC family history, the interval of post-polypectomy surveillance colonoscopy may not need to be adjusted depending on CRC family history., (© 2018 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background and Aim: Active smoking is well known to be a risk factor for colorectal neoplasia (CRN). However, it remains unclear whether passive smoking is also related to the risk of CRN. This study investigated the effect of passive smoking on the risk of CRN in never, former, and current smokers., Methods: A cross-sectional study was performed on asymptomatic examinees who underwent colonoscopy as part of a health check-up., Results: Of 136 707 participants, 33 052 (24.2%) were never passive smokers, and 103 655 (75.8%) were ever passive smokers. The mean age of the study population was 41.0 years. The proportion of never, former, and current smokers was 56.9%, 21.4%, and 24.8%, respectively, and the proportion of overall CRN and advanced CRN (ACRN) was 15.4% and 1.7%, respectively. Ever passive smoke exposure was associated with an increased risk of overall CRN in never smokers (adjusted odds ratio [AOR] 1.08; 95% confidence interval [CI] 1.02-1.13) and former smokers (AOR 1.08; 95% CI 1.00-1.17) but not in current smokers (AOR 1.02; 95% CI 0.94-1.11). Additionally, it significantly increased the risk of ACRN among never smokers (AOR 1.17; 95% CI 1.01-1.35) and tended to increase the risk of ACRN among former smokers (AOR 1.26; 95% CI 0.99-1.61). Moreover, the risk of CRN increased with increasing frequency and duration of passive smoking in never and former smokers., Conclusions: Passive smoking was an independent risk factor for CRN in never and former smokers. Never and former smokers who are highly exposed to passive smoke as well as current smokers should be given priority for colonoscopy., (© 2017 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background and Aim: Low activity of natural killer (NK) cells is known to be associated with higher risk of cancer, especially with poor prognosis and the presence of colorectal cancer (CRC). We investigated whether NK cells activity differs between subjects with and without colorectal neoplasia (CRN)., Methods: A cross-sectional study was performed on 1818 asymptomatic examinees aged ≥ 30 years who underwent NK cell activity test (which quantitates the amount of interferon-γ secreted into the plasma by NK cells) and a colonoscopy as part of a health checkup., Results: The mean age of the study population was 41.4 years. The proportion of overall CRN and advanced CRN was 13.5% (n = 246) and 0.7% (n = 13), respectively. Only one subject was diagnosed with CRC. The median level of NK cell activity was lower in subjects with CRN than in those without CRN (1205 vs 1515 pg/mL, P = 0.009). It was also lower in subjects with non-advanced CRN than in those without CRN (1221 vs 1515 pg/mL; P = 0.036). Moreover, it was lower in subjects with advanced CRN than in those with non-advanced CRN (480 vs 1221 pg/mL; P = 0.028). Subjects with low levels of NK cell activity (< 250 pg/mL) had a higher prevalence of overall CRN (19.0% vs 12.9%, P = 0.024) and advanced CRN (3.4% vs 0.4%, P = 0.001) than those who demonstrated higher level (≥ 250 pg/mL)., Conclusions: Natural killer cell activity seemed to decrease along with CRC progression toward the later stages in the adenoma-carcinoma sequence. Its activity may be depressed in relation to progression of neoplasia, even at precancerous stage., (© 2017 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background and Aim: A family history of colorectal cancer (CRC) is an important risk factor for CRC, but more detailed data are needed to prepare effective screening guidelines. We aimed to evaluate the risk of colorectal neoplasia (CRN) among individuals with different relatives affected by CRC (the first-degree relatives [FDRs] or the second-degree relatives or the first cousins) and to assess the effects of family histories according to age groups (30-39, 40-49, and ≥ 50 years)., Methods: A cross-sectional study was performed on 98 562 asymptomatic examinees aged ≥ 30 years who underwent colonoscopy as part of a health checkup., Results: Mean age of the study population was 41.4 years, and the prevalence of CRN was 15.7%. Participants with ≥ 1 FDRs and ≥ 2 FDRs affected by CRC had a higher risk of CRN than those with no family history of CRC, while those with ≥ 1 second-degree relatives or first cousins affected did not. In the 30-39 and 40-49 years age groups, a family history of CRC in parents was a risk factor for CRN and advanced CRN, but not in siblings. By contrast, in the ≥ 50 age group, participants with affected siblings (reference group) had a significantly higher risk for advanced CRN than those with affected parents (adjusted odds ratio; 95% confidence interval: 0.39; 0.16-0.94 in father and 0.43; 0.18-0.995 in mother)., Conclusions: The risk of CRN can be different according to the types of family members affected, and the impact of such family histories can be different according to age., (© 2017 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Because anti-tumor necrosis factor (anti-TNF) therapy has become increasingly popular in many Asian countries, the risk of developing active tuberculosis (TB) among anti-TNF users may raise serious health problems in this region. Thus, the Asian Organization for Crohn's and Colitis and the Asian Pacific Association of Gastroenterology have developed a set of consensus statements about risk assessment, detection, and prevention of latent TB infection and management of active TB infection in patients with inflammatory bowel disease (IBD) receiving anti-TNF treatment. Twenty-three consensus statements were initially drafted and then discussed by the committee members. The quality of evidence and the strength of recommendations were assessed by using the Grading of Recommendations Assessment, Development, and Evaluation methodology. Web-based consensus voting was performed by 211 IBD specialists from nine Asian countries concerning each statement. A consensus statement was accepted if at least 75% of the participants agreed. Part 1 of the statements comprised two parts: (i) risk of TB infection during anti-TNF therapy and (ii) screening for TB infection prior to commencing anti-TNF therapy. These consensus statements will help clinicians optimize patient outcomes by reducing the morbidity and mortality related to TB infections in patients with IBD receiving anti-TNF treatment., (© 2017 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Because anti-tumor necrosis factor (anti-TNF) therapy has become increasingly popular in many Asian countries, the risk of developing active tuberculosis (TB) among anti-TNF users may raise serious health problems in this region. Thus, the Asian Organization for Crohn's and Colitis and the Asia Pacific Association of Gastroenterology have developed a set of consensus statements about risk assessment, detection and prevention of latent TB infection, and management of active TB infection in patients with inflammatory bowel disease (IBD) receiving anti-TNF treatment. Twenty-three consensus statements were initially drafted and then discussed by the committee members. The quality of evidence and the strength of recommendations were assessed by using the Grading of Recommendations Assessment, Development, and Evaluation methodology. Web-based consensus voting was performed by 211 IBD specialists from nine Asian countries concerning each statement. A consensus statement was accepted if at least 75% of the participants agreed. Part 2 of the statements comprised three parts: (3) management of latent TB in preparation for anti-TNF therapy, (4) monitoring during anti-TNF therapy, and (5) management of an active TB infection after anti-TNF therapy. These consensus statements will help clinicians optimize patient outcomes by reducing the morbidity and mortality related to TB infections in patients with IBD receiving anti-TNF treatment., (© 2017 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background and Aim: An elevated alanine aminotransferase (ALT) is frequently observed in subjects with metabolic syndrome, which is associated with the risk of colorectal adenoma (CRA). However, the relationship between ALT and CRA remains unclear. Therefore, we aimed to investigate whether high serum ALT is associated with the risk of CRA in a metabolically healthy population., Methods: We conducted this cross-sectional study in 27,717 asymptomatic Korean adults who underwent a health checkup. Subjects were categorized as adenoma-free, hyperplastic polyp, low-risk adenoma, or high-risk adenoma. High-risk adenoma was defined as three or more adenomas, any adenoma ≥ 10 mm, or adenoma with high-grade dysplasia or villous features., Results: Among all participants, 10.3% and 1.5% of cases were categorized as low-risk and high-risk adenoma, respectively. In multivariate analyses adjusting for age, sex, body mass index, smoking habits, alcohol intake, regular exercise, aspirin and analgesics use, family history of colon cancer, education level, fatty liver, high-sensitivity C reactive protein, homeostasis model assessment of insulin resistance, total cholesterol, and triglyceride, an increase in ALT was positively associated with the prevalence of low-risk and high-risk adenoma (P for trend = 0.029 and 0.027, respectively). The highest quartile group of ALT level showed a significantly increased prevalence in low-risk (odds ratio, 1.17) and high-risk adenoma (odds ratio, 1.48) groups compared with the lowest quartile group. This phenomenon persisted in the subgroup analysis in men, but not in women., Conclusions: In the asymptomatic healthy population, high serum ALT is significantly associated with the risk of CRA., (© 2016 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background and Aims: Little is known about how to include adults < 50 years in colonoscopy screening. This study aimed to derive a risk-scoring model incorporating laboratory indicators for metabolic risks to predict advanced colorectal neoplasia (ACN) in asymptomatic Korean adults both younger and older than 50 years., Methods: In this cross-sectional study, 70 812 consecutive adult recipients of a screening colonoscopy in a single health check-up center in Korea between 2003 and 2012 were enrolled. A risk score model was developed using multiple logistic regression model and internally validated., Results: Overall prevalence of ACN was 1.4% (956/70 812). A 15-point score model was developed to comprise age, sex, family history of colorectal cancer, smoking, body mass index, serum levels of fasting glucose, low-density lipoprotein cholesterol, and carcinoembryonic antigen. Based on the score, the validation cohort could be categorized into five risk groups (low, borderline, moderate, high, and very high) with an ACN prevalence of 0.7%, 1.3%, 2.7%, 6.6%, and 13.2%, respectively. Compared with the borderline risk group, the low-risk group showed a 50.3% reduced risk of ACN. Meanwhile, the moderate, high, and very high risk groups showed 2, 5, and 10-fold increased risk of ACN. The score showed significantly superior discriminative power than the Asian-Pacific colorectal screening score (P = 0.003)., Conclusions: Our scoring model based on both clinical and laboratory risk factors is useful for the prediction of ACN. This score may be used to include adults < 50 years in colonoscopy screening., (© 2016 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background and Aim: Although it is known that metformin can reduce risk of colorectal cancer, it is unclear whether it protects against colorectal adenoma., Methods: This study conducted a systematic literature search on MEDLINE, EMBASE, and the Cochrane Library using the primary keywords "colorectal," "colon," "rectal," "rectum," "adenoma," "polyp," "neoplasia," "neoplasm," "metformin," and "diabetes." Studies were included if they evaluated the association between metformin use and colorectal adenoma and reported odds ratios (ORs) or provided data from which these could be estimated., Results: Ten studies and a total of 8726 patients were evaluated. Across all studies, a median of 32.1% (range: 15.2-53.0%) of patients taking metformin also had adenoma; a median of 43.5% (range: 20.5-59.6%) of those not taking metformin had adenoma. In our meta-analysis, metformin use reduced the risk of adenoma (pooled OR = 0.76, 95% confidence interval [CI] = 0.63-0.92, I 2  = 60%). Upon subgroup analyses, metformin use tended to reduce risk of adenoma in a high-risk population consisting of patients with a history of colorectal neoplasia (CRN) (pooled OR = 0.61, 95% CI = 0.34-1.10, I 2  = 79%). In addition, metformin reduced the risk of adenoma in a high-risk population consisting of patients with diabetes mellitus (pooled OR = 0.75, 95% CI = 0.62-0.91, I 2  = 57%)., Conclusion: Metformin use seemed to be associated with a reduced risk of colorectal adenoma, especially in high-risk populations consisting of patients with diabetes mellitus or a history of CRN, although statistical power was not achieved in patients with a history of CRN., (© 2016 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background and Aim: There is controversy about the surveillance interval after colonoscopy when 5-10 adenomas have been found on index colonoscopy. This study aimed to investigate the risk of colorectal neoplasm (CRN) according to the number of adenomas at index colonoscopy., Methods: A retrospective, multicenter study was conducted at 10 university hospitals in Korea. We included 1394 patients with ≥ 3 adenomas at index colonoscopy. The risk of advanced CRN was compared according to the number of adenomas (intermediate risk group, 3-4 small adenomas or at least one ≥ 10 mm, and high risk group, ≥ 5 small adenomas or ≥ 3 at least one ≥ 10 mm)., Results: Overall, 164 (11.8%) developed an advanced CRN after a mean of 4.0 years from baseline colonoscopy. The 3-year and 5-year risk of advanced CRN was 2.1% (95% CI 2.09-2.11) and 14.4% (95% CI 14.36-14.44) in intermediate risk group and 3.2% (95% CI 3.19-3.21) and 23.3% (95% CI 19.15-19.25) in high risk group (P = 0.01). Having ≥ 5 adenomas (OR = 1.57, 95% CI 1.11-2.23, P = 0.01) detected at index colonoscopy was a significant risk factor for developing advanced CRN., Conclusions: Although risk of advanced CRN in patients with 5-10 adenomas was significantly higher than that in patients with 3-4 adenomas, the cumulative risk at 3 years was low at 3.2%. Thus, we suggest that a 3-year surveillance interval might be appropriate for the patients with 5-10 adenomas, and further prospective studies are needed to investigate whether more intensive surveillance is needed in this group., (© 2016 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background: General obesity and abdominal obesity is an established risk factor of gastroesophageal reflux disease (GERD). However, the influence of weight or waist change on improvement of GERD is unclear. Our aim was to investigate if weight loss or waist reduction improves GERD symptoms and esophagitis., Methods: A retrospective longitudinal study of 15 295 subjects who underwent gastroscopy for a health checkup and reported GERD symptoms between 2011 and 2013, and repeated a checkup until 2014 was conducted. The improvement of GERD symptoms and esophagitis according to weight loss (≥-2, -0.5 to -2 kg/m 2 in body mass index [BMI]), waist reduction (≥-5, -0.1 to -0.5 cm) and baseline BMI/waist circumference (WC) categories was assessed using logistic regression., Key Results: Weight loss or waist reduction was associated with improvement in GERD symptoms only in subjects with general or abdominal obesity. Among subjects with general obesity (BMI ≥25 kg/m 2 ) and decreased ≥2 kg/m 2 in BMI, the adjusted odds ratio (OR) of improvement in GERD symptoms was 2.34 (95% confidence interval [CI] 1.70-2.83). Among subjects with abdominal obesity (WC ≥90 cm) and decreased ≥5 cm in WC, the corresponding OR was 2.16 (95% CI 1.56-2.90). There was no association between weight loss or waist reduction and improvement in esophagitis., Conclusions & Inferences: Weight loss or waist reduction was associated with improvement in GERD symptoms only in subjects with general or abdominal obesity. Weight loss or waist reduction will be an important treatment option in obese patients., (© 2016 John Wiley & Sons Ltd.)

Background and Aim: To guide selection of optimal screening strategies for advanced colorectal neoplasia (ACRN), we evaluated the screening performances of sigmoidoscopy, fecal immunochemical test (FIT), and the Asia-Pacific Colorectal Screening (APCS) system, as well as combinations of these techniques., Methods: We reviewed the records of participants who had undergone a colonoscopy and FIT as part of a comprehensive health-screening program. Results of sigmoidoscopy were estimated from lesions under colonoscopic examination. The screening strategies were classified as sigmoidoscopy-based, FIT-based, and APCS-based. The sensitivity and reduction of number needed to colonoscope (NNScope) of each screening strategy were assessed., Results: Of 23 023 participants, 398 (1.7%) had ACRN. To predict the presence of ACRN, sigmoidoscopy was the most effective method (odds ratio [OR]: 22.96, 95% confidence interval [CI]: 18.26-29.07), followed by FIT (OR: 7.18, 95% CI: 5.28-9.68) and APCS (high risk [≥4] OR: 2.59, 95% CI: 1.87-3.58; moderate risk [2-3] OR: 1.66, 95% CI: 1.28-2.17). Regarding sigmoidoscopy-based strategies, "sigmoidoscopy positive alone" and "sigmoidoscopy positive or APCS ≥4" were optimal strategies (reduction of NNScope: 79-86%; sensitivity: 73-78%). In the case of FIT-based strategies, "FIT positive or APCS ≥4" was the optimal strategy (reduction of NNScope: 72%; sensitivity: 37%). With regard to the APCS system only, "APCS ≥2" and "APCS ≥4" were recommended as sensitivity-preferred and reduction in NNScope-preferred strategies, respectively., Conclusions: The performance in ACRN prediction differs among screening methods (sigmoidoscopy, FIT, and APCS). Among the various single or combined screening strategies, several specific strategies can be chosen depending on medical resources, financial budgets, and screenee preference., (© 2016 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background and Aim: The number of patients with >10 adenomas is relatively small, and few studies have investigated the risk of colorectal neoplasm (CRN) in these patients. Thus, we aimed to investigate the risk of developing CRN in patients with >10 adenomas and to compare their risk with that of patients with 3-10 adenomas., Methods: A retrospective multicenter cohort study that included 214 patients with >10 adenomas on index colonoscopy performed between January 2009 and December 2011, and underwent follow-up colonoscopy until December 2015 was conducted. The risk of developing advanced CRN (cancer or advanced adenoma with a diameter of ≥10 mm or with a villous component, or high-grade dysplasia) was investigated and compared with that in patients with 3-10 adenomas (n = 975)., Results: Among the 214 patients with >10 adenomas, the mean age was 62.9 years and the mean number of adenomas on index colonoscopy was 14.2. Overall, 57 patients (26.6%) developed an advanced CRN after a mean of 4.3 years from baseline colonoscopy. The respective 3- and 5-year cumulative risks of advanced CRN were 6.8% (95% confidence interval [CI] 2.9-10.7) and 28.7% (95% CI 20.8-36.5), higher than those in the group with 3-10 adenomas (n = 975, P = 0.001). Having >10 adenomas on index colonoscopy was an independent risk factor for developing advanced CRN (odds ratio 2.25, 95% CI 1.49-3.38)., Conclusions: The risk of developing advanced CRN in patients with >10 adenomas was high and statistically higher than that in patients with 3-10 adenomas. Further prospective studies are needed to investigate whether a more intensive surveillance is needed in this group., (© 2016 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background and Aim: The present study aimed to evaluate the non-inferiority of low-volume oral sulfate solution (OSS) to 4-L polyethylene glycol (PEG) solutions administered in a split-dose regimen as bowel preparation for colonoscopy. The safety and tolerability were also compared between the two regimens., Methods: In this prospective, randomized, single-blind, active-control, parallel group, and non-inferiority trial, consecutive outpatients and health checkup recipients aged 19-65 years undergoing elective colonoscopy were enrolled to receive OSS or 4-L PEG in a split-dose regimen. The quality of bowel preparation was evaluated using the Boston Bowel Preparation Scale. The occurrence of any adverse events, acceptance, compliance, and satisfaction during bowel preparation were evaluated by participant interviews., Results: Overall, 210 participants were randomized, and 199 were administered by the study agents. Adequate bowel preparation was achieved in 98.0% (97/99) of the OSS group, which was non-inferior to the PEG group (96%; 96/100) with a difference of +2.8% (95% confidence interval; -2.8, +6.8). There were no differences in the incidence of adverse events except for abdominal pain, which was more frequent in the OSS (7.1%, 7/99) than in the PEG (1.0%, 1/100; P = 0.035) group. Acceptance, compliance, and satisfaction were significantly higher in the OSS than in the PEG group (all P < 0.05)., Conclusions: Split-dose OSS was non-inferior to split-dose 4-L PEG with regard to bowel preparation efficacy before colonoscopy in adult outpatients or screening colonoscopy recipients aged ≤65 years with acceptable safety and superior tolerability., (© 2016 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background: Although statin use has been reported to reduce the risk of colorectal cancer beyond its cholesterol-lowering effects, the benefit of statins against colorectal adenoma has not been fully clarified. We aimed to investigate the association between statin use and the risk of colorectal adenoma., Methods: We conducted a systematic literature search on MEDLINE, EMBASE, and the Cochrane Library using the primary keywords "adenoma," "polyp," "colorectal," "colon," "rectal," "rectum," "neoplasia," "neoplasm," "statin," "3-hydroxy-3-methylglutaryl-coenzyme A," and "HMG-CoA." Studies were included if they evaluated the association between statin use and adenoma and reported relative risks (RRs) or odds ratios or provided data for estimation. Pooled estimates were calculated using the random-effects model., Results: Six studies including 13 239 patients were analyzed. The median proportion of patients with any adenoma was 29.7% (range, 20.9-38.4%) in patients taking statins and 31.2% (range, 19.6-63.4%) in patients not taking statins across included studies. The median proportion of patients with advanced adenoma in those taking statins was 7.7% (range, 3.1-27.2%), whereas that in patients not taking statins was 11.3% (range, 3.5-32.4%). On meta-analysis, statin use did not significantly affect the risk of any adenoma (pooled RR = 0.901; 95% confidence interval [CI], 0.735-1.104); however, it was associated with a lower risk of advanced adenoma (pooled RR = 0.833; 95% CI, 0.750-0.925)., Conclusions: Statin use seems to be associated with a reduced risk of advanced adenoma, but not any adenoma. Statins may prevent neoplastic progression of adenomas rather than the development of adenomas., (© 2016 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background and Aim: Although smoking and alcohol has been linked to an increased risk of colorectal neoplasm (CRN), large-scale studies to identify dose-dependent relationship between amount of smoking and alcohol consumption and risk of CRN are rare. We aimed to investigate the risk for CRN according to the amount of smoking and alcohol intake in a large sample of Korean adults., Methods: A cross-sectional study was performed on 31,714 examinees aged ≥30 years undergoing their first colonoscopy as part of routine preventive health care between 2010 and 2011. Never smokers were compared with six groups of smokers according to smoking amount, and individuals with alcohol intake of ≤ 6.25 g ethanol per day were compared with three groups according to alcohol amount., Results: In adjusted models, the risk of overall CRN increased with increasing amount of smoking (P for trend < 0.001). The adjusted odds ratios for overall CRN comparing never smokers with six smoker groups according to smoking amount (≤2.50, 2.51-5.60, 5.61-9.00, 9.01-13.00, 13.01-19.50, and ≥19.51 pack-years) were 1.02, 1.19, 1.35, 1.53, 1.63, and 2.03, respectively. In addition, the risk of both non-advanced and advanced CRN increased with increasing amount of smoking (both P for trend < 0.001). However, the amount of alcohol consumption was not correlated with the risk of CRN., Conclusions: The prevalence of CRN was associated with increasing amount of smoking in a dose-response manner, whereas it was not associated with the amount of alcohol consumption. Our study suggests that smoking amount as well as smoking status should be considered for CRN risk stratification., (© 2015 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background and Aim: Advanced adenoma (> 10 mm in diameter, villous structure, or high-grade dysplasia) in young patients may have different characteristics and prognosis compared with those in older patients. We aimed to compare the incidence of colorectal neoplasms in young patients with older patients after removing high-risk adenoma (advance adenoma or ≥ 3 adenomas)., Methods: A retrospective, multicenter study was conducted at 13 university hospitals in Korea. The 1479 patients who removed high-risk adenoma at index colonoscopy and followed by surveillance colonoscopy ≥ 2.5 years after were included. The cumulative incidence of overall and advanced colorectal neoplasms was compared according to the age groups (group 1: < 50 years, group 2: 50-70 years, and group 3: ≥ 70 years)., Results: The prevalence of advance adenoma detected at index colonoscopy was significantly higher in group 1 than in groups 2 and 3 (85.4%, 78.1%, and 77.2%, respectively; P = 0.035). The 5 years cumulative incidence of overall and advanced colorectal neoplasms were 61.9%, 67.9%, and 74.7% (P < 0.001), and 11.7%, 17.9%, and 27.1% (P = 0.001) in groups 1, 2, and 3, respectively. In multivariate analysis, age > 70 years was a significant risk factor for developing overall (hazard ratio [HR] 1.41, 95% confidence interval [CI] 1.12-1.82, P = 0.004) and advanced colorectal neoplasms (HR = 2.56, 95% CI 1.43-4.59, P = 0.002)., Conclusion: The cumulative incidence of overall and advanced colorectal neoplasms was significantly higher in older patients than in young patient groups. Age was a significant risk factor for developing colorectal neoplasms after removing high-risk adenoma., (© 2015 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd.)

Background and Aim: The biosimilar of infliximab, CT-P13, has recently been shown to be equivalent to infliximab in both efficacy and safety in the treatment of rheumatologic diseases. However, no data are available with respect to the drug's efficacy in patients with inflammatory bowel disease (IBD). We aimed to assess the efficacy and safety of CT-P13 in IBD patients, Methods: This was a retrospective multicenter study including both anti-tumor necrosis factor (TNF) naïve patients and patients who switched from the biologic originator to CT-P13., Results: In anti-TNF naïve Crohn's disease (CD) patients (n = 32), clinical response and remission rates were 90.6% and 68.8% at week 2, 90.6% and 84.4% at week 8, 95.5% and 77.3% at week 30, and 87.5% and 75.0% at week 54, respectively. In anti-TNF naïve ulcerative colitis (UC) patients (n = 42), clinical response and remission rates were 76.2% and 19.0% at week 2, 81.0% and 38.1% at week 8, 91.3% and 47.8% at week 30, and 100% and 50.0% at week 54, respectively, while mucosal healing rates were 58.3% at week 8, 66.7% at week 30, and 66.7% at week 54. The efficacy of CT-P13 was maintained in 92.6% (25/27) of CD patients and in 66.7% (6/9) of UC patients after switching from its originator. Adverse events related to CT-P13 occurred in 11.8% of UC patients., Conclusions: CT-P13 appears to have comparable efficacy, safety, and interchangeability with its originator in the treatment of IBD. Further prospective studies with long-term follow-up periods will be needed to confirm the biosimilarity of CT-P13., (© 2015 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd.)

Background and Aim: Prior studies have reported 2-L polyethylene glycol (PEG) plus ascorbic acid (PEG + Asc) is an effective alternative to standard 4-L PEG for bowel preparation before colonoscopy, but they are limited because of some confounders. Therefore, we compared the efficacy, patient compliance, satisfaction, and safety of 2-L PEG + Asc versus 4-L PEG for bowel cleansing in optimal preparation strategies., Methods: In this prospective, randomized, single-blind trial, consenting outpatients were randomly assigned to one of two arms. All colonoscopies were scheduled in the morning and cleansing solutions were administered as a split-dose regimen. Bowel-cleansing efficacy in three different segments was measured on a five-point scale with four-point overall grading. Patients' opinions of the preparation regimens were obtained by questionnaire., Results: There was no significant difference between the 2-L PEG + Asc (159/163; 97.5%) and 4-L PEG (162/164; 98.8%) with respect to the overall success of bowel cleansing (mean difference = -1.3 [-4.1-∞]). Patient compliance, acceptability, and satisfaction were better in the 2-L PEG + Asc arm than the 4-L PEG arm (P < 0.05). Additionally, the incidence of side effects was lower in the 2-L PEG + Asc than the 4-L PEG (overall, 57.7% vs 73.2%, P < 0.05). However, no significant difference was seen in patients' rating of taste., Conclusions: In an optimal preparation setting, 2-L PEG + Asc has equal efficacy as a bowel cleanser prior to colonoscopy as 4-L PEG, with the advantages of better patient compliance, satisfaction, and safety.

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

Background/aims: Infliximab is currently used for the treatment of moderate-to-severe ulcerative colitis (UC) with an inadequate response to conventional agents. The efficacy and safety of infliximab in Korean patients with UC were assessed., Methods: This was a retrospective multicenter study including all adult patients who received at least one infliximab infusion for UC. Short- and long-term clinical outcomes and adverse events of infliximab therapy were evaluated, and predictors of response were identified., Results: A total of 134 UC patients were included. The indications for infliximab therapy were acute severe UC in 28%, steroid-dependency in 38%, and steroid-refractoriness in 33%, respectively. The rates of clinical response and remission were 87% and 45% at week 8. In multivariate analysis, we found significant predictors of clinical remission at week 8: immunomodulator-naïve (odds ratio [OR] = 4.89, 95% confidence interval [CI]: 1.44-16.66, P = 0.01), hemoglobin ≥ 11.5 g/dL (OR = 4.47, 95% CI: 1.48-13.45, P = 0.008), C-reactive protein ≥ 3 mg/dL (OR = 4.77, 95% CI: 1.43-15.94, P = 0.01), and response at week 2 (OR = 20.54, 95% CI: 2.40-175.71, P = 0.006). Long-term clinical response and remission rates were 71% and 52%, respectively, and mucosal healing was the only factor influencing long-term response. Adverse events related to infliximab occurred in 15% of patients, and most of them were mild and transient., Conclusions: Infliximab is effective and safe in the treatment of active UC in Korea. No history of previous immunomodulator use and high baseline C-reactive protein are independent predictors of good response., (© 2013 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd.)

Background and Aim: There have been no trials comparing the prophylactic effect of oral quinolone and intravenous cephalosporin antibiotics and elucidating the predictive factors for the occurrence of bacterial infections in cirrhotic patients with gastrointestinal bleeding in Asian-Pacific region., Methods: One hundred and thirteen patients with advanced liver cirrhosis and active gastrointestinal hemorrhage were enrolled in our study. The patients were randomly allocated into either the oral ciprofloxacin group (n = 50, 500 mg every 12 h) or the intravenous ceftriaxone group (n = 63, 2.0 g per day for 7 days)., Results: Proven or possible infections were significantly more frequent in the patients in the oral ciprofloxacin group (34.0%) than the intravenous ceftriaxone group (14.3%, P = 0.002). The intestinal permeability index (IPI, mean [SD]) measured the day after admission was significantly higher in the patients with proven or possible infections (1.45 [0.96]) compared with the no infection group (0.46 [0.48], P <0.01). By multivariate analysis, oral ciprofloxacin prophylaxis and higher IPI at the time of inclusion were independent and significant predictors for proven or possible infections. By receiver operating characteristic curve analysis, the best cutoff value of IPI for the prediction of the occurrence of bacterial infection was 0.62%., Conclusions: The frequency of proven or possible infections was significantly lower in the intravenous ceftriaxone group compared with the oral ciprofloxacin group. The IPI measured the day after admission is a good clinical parameter predicting the occurrence of infection in these patients., (© 2011 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd.)

Background and Aim: There have been no reports comparing the therapeutic results of adefovir (ADV) and entecavir (ETV) rescue therapy for patients with lamivudine (LAM)-resistant chronic hepatitis B (CHB). We aimed to compare the cumulative efficacy and resistance of ETV 1.0 mg monotherapy, ADV monotherapy and ADV add-on LAM combination therapy in LAM-refractory patients., Methods: One hundred and four patients were included in the following three treatment groups; group 1 (n = 24), LAM was switched to ETV (1.0 mg once a day); group 2 (n = 44), LAM was switched to ADV (10 mg once a day); and group 3 (n = 36), ADV was added to LAM (10 mg once a day)., Results: After 6 months of rescue treatment, alanine aminotransferase normalization was observed in 75.0%, 65.9% and 74.3% of patients receiving ETV monotherapy, ADV monotherapy and ADV add-on therapy, respectively. A significantly higher log(10)HBV-DNA drop at 6 months occurred in the ADV add-on group compared with the ETV group. The rate of HBV-DNA polymerase chain reaction undetectability (<300 copies/mL) 6 months after initiation of ETV monotherapy, ADV monotherapy and ADV add-on therapy was 33.3%, 27.3% and 68.6%, respectively (P = 0.003). The cumulative HBeAg seroconversion rate was significantly higher in ADV add-on/ADV monotherapy groups compared with the ETV monotherapy group (P = 0.022). Viral breakthrough and genotypic resistance were detected in six (25.0%) and six (13.6%) patients in the ETV and ADV monotherapy groups, whereas no cases of genotypic resistance were detected in ADV add-on group 24 months after initiation of antiviral treatment (P < 0.01)., Conclusion: Adefovir add-on treatment in patients with LAM-resistant CHB suppresses HBV replication more effectively than ETV or ADV monotherapy. Additionally, no genotypic resistance was detected in the ADV add-on group.

Background and Aims: The purpose of the present study was to determine the clinical characteristics of subjects with gallbladder polyps and cholelithiasis compared with those with gallbladder polyps only., Methods: Between August 1999 and December 2005, 176 subjects with gallbladder polyps and cholelithiasis (study group) by transabdominal ultrasonography performed during a medical check-up at our institution were recruited and compared with a control group of 185 subjects who had gallbladder polyps only., Results: No significant difference in the mean interval change (delta) of polyp size during the follow-up period between the study and control groups (0.85 +/- 1.39 mm vs 0.84 +/- 1.58 mm, respectively, P = 0.927) was noted. A significantly higher proportion (9/176 [5.1%]) of examinees in the study group had attacks of acute cholecystitis compared with the control group (1/185 [0.5%], P < 0.01). By multivariate logistic regression analysis, gallbladder wall thickening on initial ultrasonography (odds ratio, 13.7; 95% confidence interval, 1.1-178.0; P = 0.046) and the interval increase in the size of the gallbladder polyps (odds ratio, 14.7; 95% confidence interval, 1.7-126.9; P = 0.014) were independent risk factors for cholecystectomy. No gallbladder cancer occurred during the follow-up period., Conclusions: There was no significant difference in delta polyp size between the examinees with gallbladder polyps and cholelithiasis and those with gallbladder polyps only. Hence, a small proportion of subjects with gallbladder polyps and cholelithiasis, such as those with thickened gallbladder walls and an interval increase in the size of the gallbladder polyps are candidates for prophylactic cholecytectomy.

Background and Aims: Metabolic syndrome and insulin resistance are associated with a higher risk of colon cancer. Non-alcoholic fatty liver disease (NAFLD) is regarded as a manifestation of metabolic syndrome in the liver. This investigation was initiated to determine whether NAFLD has a relationship to colorectal adenomatous polyps., Methods: We examined the 2917 participants who underwent a routine colonoscopy at Kangbuk Samsung Hospital in 2007. We divided the 2917 subjects into the adenomatous polyp group (n = 556) and the normal group (n = 2361). Anthropometric measurements, biochemical tests for liver and metabolic function, and abdominal ultrasonographs were assessed., Results: The prevalence of NAFLD was 41.5% in the adenomatous polyp group and 30.2% in the control group. By multiple logistic regression analysis, NAFLD was found to be associated with an increased risk of colorectal adenomatous polyps (odds ratio, 1.28; 95% confidence interval, 1.03-1.60). An increased risk for NAFLD was more evident in patients with a greater number of adenomatous polyps., Conclusion: NAFLD was associated with colorectal adenomatous polyps. Further studies are needed to confirm whether NAFLD is a predictor for the development of colorectal adenomatous polyps and cancer.

Background: We aimed to explore the predictive ability of preoperative carbohydrate antigen 19-9 (CA19-9) and carcinoembryonic antigen (CEA) levels for assessing tumor resectability (R0 resection) in patients with pancreatic adenocarcinoma., Methods: The present study included 72 patients who had been treated surgically for potentially resectable pancreatic adenocarcinoma and 42 patients who had been treated surgically for palliation (bypass surgery) at our institution. Pancreatic adenocarcinoma was histologically confirmed by pathological examination of the resected specimen or, if unresected, by intraoperative biopsy., Results: For resectable disease, the mean and median values of CA19-9 were significantly lower than for R1/2 or unresectable disease. The best cut-off points for CEA, CA19-9, and tumor size to predict resectability were 2.47 ng/mL, 92.77 U/mL and 11.85 cm(3), respectively. A CA19-9 > or = 92.77 U/mL and both tumor markers no less than the cut-off levels predicted the possibility of R1/2 or unresectability with 90.6% and 88.6% accuracy, respectively. However, either tumor marker or both tumor markers less than the cut-off levels predicted the probability of R0 resection only with 27.1% and 40.6% accuracy, respectively. The independent contributing factors to resectability (R0 resection) by multivariate regression analysis were a CA 19-9 < 92.77 U/mL, a tumor size < 11.85 cm(3), and a less advanced AJCC stage., Conclusion: The present study demonstrates that preoperative serum CA19-9 and CEA levels can be used for the prediction of resectability (R0 resection) in patients with pancreatic adenocarcinoma, which may enable a simple and cost-effective exclusion of such patients who are unlikely to benefit from surgery.

Background and Study Aims: A prepackaged low residue one-day diet (breakfast, lunch and dinner) has been recently developed to improve patient tolerance for bowel preparation prior to colonoscopy. The aims of this study were to evaluate the efficacy and tolerability of bowel preparation protocols based on a low residue diet and 4L polyethylene glycol (PEG) solution, and to compare these new options with the traditional liquid diet and the PEG 4L lavage., Methods: A total of 214 patients (mean age: 54.1 years; 120 male, 94 female) from four university hospitals were included in the analysis. Patients were randomized to receive a clear liquid diet and the PEG 4L regimen (106 patients) or the low residue test meals and the PEG 4L regimen (TM-PEG 4L, 108 patients). The colon cleansing efficacy of the different preparations was rated using the Ottawa bowel preparation scale., Results: No significant differences were observed between the treatment groups according to the Ottawa cleansing scale findings (PEG 4L: 2.97 vs TM-PEG 4L: 2.46, P = 0.063). The overall tolerability was higher in the TM-PEG 4L group than in the PEG 4L group (P = 0.036). No difference was found when the two groups were compared with regard to adverse events (P = 0.599)., Conclusions: A prepackaged low residue one-day diet provided cleansing efficacy similar to that of a clear liquid diet and offered the benefit of improved tolerability compared to the conventional PEG 4L regimen.

Background and Aim: Our study aimed to evaluate the therapeutic results of endoscopic N-butyl-2-cyanoacrylate injection (EBC) and balloon-occluded retrograde transvenous obliteration (BRTO) in patients with gastric variceal hemorrhage (GVH) and/or high-risk gastric varices (GV)., Methods: Twenty-seven patients with GVH and/or high-risk GV (>or= 5 mm in diameter, those with red spots, and a Child-Pugh grading of B or C liver cirrhosis) who were treated with either EBC or BRTO from April 2005 to December 2007 were included in our study., Results: EBC or BRTO was initially used for the treatment of GVH in 14 and 13 patients, respectively. Technical success was achieved in all 14 patients (100%) initially treated with EBC, and 10 of 13 patients (76.9%) initially treated with BRTO. Significant rebleeding occurred in 10 patients (71.4%) of the EBC group, and two patients (15.4%) of BRTO group (P < 0.01). Five of six patients (83.3%) treated with rescue BRTO due to rebleeding after initial EBC achieved technical success, and all six patients who were treated with rescue BRTO had no rebleeding during the median follow up of 17 (range: 2-37) months. The cumulative survival rate of the EBC with the BRTO rescue group/BRTO group was significantly higher than the EBC group., Conclusion: The therapeutic efficacies of EBC and BRTO for the treatment of active GVH and/or high-risk GV appeared to be similar. However, EBC might be associated with a higher rebleeding rate than BRTO. BRTO could be an effective rescue treatment for patients with GVH after initial treatment of EBC.

Background: The relationship between obesity and gastroesophageal reflux disease (GERD) is controversial. The aim of the present study was to investigate the potential roles of body mass index (BMI) and waist circumference on GERD in a Korean population., Methods: A total of 2457 subjects who visited the Kangbuk Samsung Hospital medical screening center for esophagogastroduodenoscopy from September 2004 to April 2005 were enrolled. All participants were given a questionnaire to determine reflux symptoms. Abdominal obesity was defined as a waist circumference > or =80 cm in women and > or =90 cm in men., Results: The proportion of subjects in each BMI group was 68.9%, 28.7% and 2.4% for BMI <25, 25-30 and >30, respectively. The prevalence of abdominal obesity was 24.2%. The prevalence of reflux symptoms was 8.2%. Neither BMI nor abdominal obesity was significantly associated with reflux symptoms after adjustment. The prevalence of erosive esophagitis was 6.6%. There was a clear dose-response relationship between prevalence of erosive esophagitis and BMI (5.6%, 8.1% and 15.5% for BMI <25, 25-30 and >30, respectively, P = 0.002). Abdominal obesity was also associated with erosive esophagitis (odds ratio, 2.3; 95% confidence interval, 1.6-3.1). However, only the association between abdominal obesity and erosive esophagitis remained strong after adjustments., Conclusions: Abdominal obesity rather than BMI is an independent risk factor for erosive esophagitis in the Korean population.

Background: In previous studies, increasing body mass index (BMI, kg/m(2)) was related to chronic gastrointestinal symptoms, such as frequent vomiting, upper abdominal pain, bloating and diarrhea. However, there have been no reports about the relationship between increasing BMI and abnormal upper endoscopic findings such as gastritis or ulcer., Methods: The study group consisted of 27 319 individuals who underwent medical checkup at a healthcare center from 1 January to 31 December 2003. The following classification of BMI was applied. (i) underweight; BMI < 18.5; (ii) normal weight; 18.5 or= 30.0. The subjects were grouped according to the findings of upper endoscopy as follows: group 1, those with erosive gastritis, gastric ulcers (benign and malignant) and duodenal ulcers; group 2, those with reflux esophagitis; and group 3, those with findings of upper endoscopy other than group 1 and group 2., Results: The prevalence of obesity and overweight was 2.2% and 30.5%, respectively. By multivariate analyses, overweight (OR 1.31, 95% CI; 1.22-1.40, P = 0.000) and obesity (OR 1.40, 95% CI; 1.14-1.72, P = 0.001) were significant contributors of group 1. Overweight (OR 1.61, 95% CI; 1.42-1.83, P = 0.000) and obesity (OR 2.23, 95% CI; 1.59-3.11, P = 0.000) were also significant contributors of group 2., Conclusions: In the general population, increasing BMI was associated with abnormal upper endoscopic findings, such as erosive gastritis, gastric ulcer, duodenal ulcer and reflux esophagitis. Clarification of the cause-and-effect relationships and the mechanisms of these associations require further investigation.

Background: We sought to evaluate the diagnostic use of multidetector computed tomography (MDCT) cholangiography with multiplanar reformation (MPR) for the assessment of patients with biliary obstruction., Methods: MDCT cholangiography with the MPR technique was performed in 58 patients who were thought to have biliary obstruction. No cholangiographic contrast agent was administered. MRCP in 24 patients, Endoscopic retrograde cholangiopancreatography (ERCP) in 46 patients and percutaneous transhepatic cholangiography (PTC) in 24 patients were performed. Eighteen patients underwent biopsy or surgery. The findings on MDCT cholangiography were compared with those of MRCP, ERCP, PTC, biopsy or surgery., Results: The findings of MDCT cholangiography were as follows: choledocholithiasis (n = 34, 56.7%), malignant stricture (n = 14, 23.3%), benign stricture (n = 1, 1.7%), and cholelithiasis (n = 11, 18.3%). A small common bile duct (CBD) stone in one patient could not be detected on MDCT cholangiography. One patient with a small stone in distal CBD detected on MDCT cholangiography had no stone on ERCP. Two patients with initial diagnoses of CBD stones by MDCT cholangiography were disclosed to have malignant bile duct stricture by reference examination. The sensitivity and specificity of MDCT cholangiography for the diagnosis of bile duct stones were 96.9% and 96.2%, respectively. The sensitivity and specificity of MDCT cholangiography for the diagnosis of bile duct stricture were 85.7% and 100%, respectively. The overall accuracy of MDCT cholangiography for the diagnoses of the causes of biliary obstruction was 89.8%., Conclusion: MDCT cholangiography with the MPR technique is a fast and non-invasive technique with relatively high sensitivity and specificity for the diagnoses of the causes of biliary obstruction.

Background and Aim: Differences in the prevalence of non-alcoholic fatty liver disease (NAFLD) between Eastern and Western populations are primarily attributable to differences in definitions and biased population selection. Thus, the aim of the present study was to accurately determine the actual prevalence of NAFLD by sonography and to characterize the risk factors for NAFLD., Methods: The present cross-sectional study was performed with data obtained from 6,648 subjects, all of whom were older than 20 years of age (3,530 men and 3,118 women). The term 'non-drinker' was applied to men who consumed less than 30 g alcohol/day and to women who consumed less than 20 g alcohol/day. Non-alcoholic fatty liver disease was defined as a sonographically detected fatty liver in the absence of viral hepatitis in a non-drinker., Results: Of the 1,613 subjects who were diagnosed with sonographic fatty liver, 1,240 were non-drinkers and had no viral hepatitis. Overall, the unadjusted and age-adjusted prevalences of NAFLD were 18.7% (23% in men, 13.7% in women) and 16.1% (21.6% in men, 11.2% in women), respectively. Multivariate analysis revealed that several risk factors were profoundly associated with the prevalence of NAFLD, including obesity, insulin resistance, hyperlipidemia and hyperglycemia in both genders, as well as age, menopausal status and estrogen medication in women only., Conclusions: These results demonstrate that the prevalence of NAFLD in Korean adults, according to sonographic surveys, is comparable to that seen in more developed countries. From the perspective of increasing obesity, the high prevalence rates noted in the study may herald an increased burden of chronic liver disease in the Korean population.

Background and Aim: Although insulin resistance is often considered the link between obesity and non-alcoholic fatty liver disease (NAFLD), the role of insulin resistance, independent of obesity, as a NAFLD risk factor in non-obese men has been less well established. Systemic inflammation may be accompanied by insulin resistance in healthy subjects. The goal of the present study was to examine if insulin resistance and systemic inflammatory markers are independent predictors of NAFLD in non-obese men., Methods: The authors conducted a cross-sectional survey of 120 patients with NAFLD and 240 controls matched by age and body mass index. Controls had no evidence of alcohol abuse, hepatitis B or C, obesity, or previous history of diabetes, fasting hyperglycemia or hypertension. Diagnosis of NAFLD was based on an elevated alanine aminotransferase level and sonographic evidence of a fatty liver. Insulin resistance was determined using a homeostasis model assessment (HOMA-IR)., Results: The age-adjusted risk of developing NAFLD was strongly associated with the elevated levels in measurements of uric acid, fasting blood sugar, triglycerides, apolipoprotein B, C-reactive protein (CRP) and HOMA-IR, and decreased levels of high density lipoprotein cholesterol and apolipoprotein A-I. Multivariate analysis based on univariate analysis indicated that an increase in CRP (odds ratio [OR] = 1.37; 95% confidence interval [CI]: 1.06-1.77) per 1 SD (1.48 mg/L) and HOMA-IR (OR = 2.28; 95% CI: 1.67-3.11) per 1 SD (0.63) were independent risk factors for NAFLD., Conclusion: Insulin resistance and systemic inflammatory response are of key importance for inducing NAFLD, particularly in apparently healthy non-obese men.