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Background/aims Constipation is a common gastrointestinal problem in the elderly. Because of the limitations of life style modifications and the comorbidity, laxative use is also very common. Therefore, this study reviews the latest literature on the effect and safety of laxative in the elderly. Methods A systematic review of randomized controlled trials investigating the effectiveness and safety of laxatives for constipation in elderly patients over 65 years old were performed using the following databases: PubMed, EMBASE, and the Cochrane Library. Results Twenty-three randomized controlled trials were included in this review. Among the selected studies, 9 studies compared laxative with placebo and 5 studies compared laxatives of the same type. Four studies compared different types of laxatives or compared combination agents. Five studies compared novel medications such as prucalopride, lubiprostone, and elobixibat with placebo. Psyllium, calcium polycarbophil, lactulose syrup, lactitol, polyethylene glycol, magnesium hydroxide, stimulant laxative with or without fiber, and other medications were more effective than placebo in elderly constipation patients in short-term. Generally, the frequency and severity of adverse effects of laxative were similar between the arms of studies. Conclusions Bulk laxative, osmotic laxative, stimulant laxative with or without fiber, and other medications can be used in elderly patients in short-term within 3 months with reasonable safety. However, the quality of included studies was not high and most of studies was conducted in a small number of patients. Among these laxatives, polyethylene glycol seems to be safe and effective in long-term use of about 6 months in elderly patients.

Background/Aims: There are no definite guidelines for the management of gastric lesions diagnosed as indefinite for dysplasia (IND) by endoscopic forceps biopsy (EFB). Therefore, this study aimed to evaluate the clinical outcomes of gastric IND and predictive factors for gastric neoplasm.Methods: This study included 457 patients with a first diagnosis of gastric IND by EFB between January 2005 and December 2013. Patient characteristics and endoscopic and pathological data were reviewed and compared.Results: Of the 457 gastric IND patients, 128 (28%) were diagnosed with invasive carcinoma, 21 (4.6%) with high-grade dysplasia, 31 (6.8%) with low-grade dysplasia, and 277 (60.6%) as negative for dysplasia. Of lesions observed, 180 (39.4%) showed upgraded histology. Multivariate analysis revealed that surface erythema (odds ratio [OR], 2.804; 95% confidence interval [CI], 1.741 to 4.516), spontaneous bleeding (OR, 2.618; 95% CI, 1.298 to 5.279), lesion size ≥ 1 cm (OR, 5.762; 95% CI, 3.459 to 9.597), and depressed morphology (OR, 2.183; 95% CI, 1.155 to 4.124) were significant risk factors for high-grade dysplasia or adenocarcinoma. The ORs associated with 2 and ≥ 3 risk factors were 7.131 and 34.86, respectively.Conclusions: Precautions should be taken in the management of gastric IND patients, especially when risk factors, including surface erythema, spontaneous bleeding, lesion size ≥ 1 cm, and depressed morphology are present. Considering the combined effect of the presence of multiple risk factors on the incidence of high-grade dysplasia or adenocarcinoma, endoscopic resection should be recommended if a gastric IND patient has at two or more of these factors.

Background/Aims This study was conducted to clarify the sustained virological response (SVR) prediction ability of baseline and treatment-related factors in patients with chronic hepatitis C virus (HCV) infection. Methods This retrospective study collected data at four tertiary referral hospitals between June 2004 and July 2012. Out of 476 patients, 330 treatment-naïve patients with chronic HCV infection were recruited. Pegylated interferon α-2a/- 2b plus ribavirin was administered for either 24 or 48 weeks depending on the HCV genotype. The baseline and treatment-related predictive factors of SVR were evaluated by analyzing data measured before treatment (i.e., baseline) and during treatment. Results SVR rates for genotypes 1 and 2 were 63% (97/154) and 79.5% (140/176), respectively (p = 0.001). Multivariate analysis for baseline factors revealed that young age (p = 0.009), genotype 2 (p = 0.001), HCV RNA level of < 800,000 IU/mL (p < 0.001), and a baseline platelet count of > 150 × 103 /µL (p < 0.001) were significant SVR predictors, regardless of the genotype. In particular, predictive accuracy for achievement of SVR was 87.3% for a baseline platelet count of > 150 × 103 /µL. In multivariate analysis for treatment-related factors, SVR was associated with achievement of a rapid virological response (RVR; p < 0.001), treatment adherence of ≥ 80/80/80 (p < 0.001). Conclusions Young age, genotype 2, low HCV RNA level, RVR, and treatment adherence were significantly associated with SVR. In addition, platelet count was an independent predictive factor for SVR. Therefore, platelet count could be used to develop individualized treatment regimens and to optimize treatment outcomes in patients with chronic HCV infection.

Gastroesophageal reflux disease (GERD) is a condition in which gastric contents regurgitate into the esophagus or beyond, resulting in either troublesome symptoms or complications. GERD is heterogeneous in terms of varied manifestations, test findings, and treatment responsiveness. GERD diagnosis can be established with symptomatology, pathology, or physiology. Recently the Lyon consensus defined the "proven GERD" with concrete evidence for reflux, including advanced grade erosive esophagitis (Los Angeles classification grades C and or D esophagitis), long-segment Barrett's mucosa or peptic strictures on endoscopy or distal esophageal acid exposure time > 6% on 24-hour ambulatory pH-impedance monitoring. However, some Asian researchers have different opinions on whether the same standards should be applied to the Asian population. The prevalence of GERD is increasing in Asia. The present evidence-based guidelines were developed using a systematic review and meta-analysis approach. In GERD with typical symptoms, a proton pump inhibitor test can be recommended as a sensitive, cost-effective, and practical test for GERD diagnosis. Based on a meta-analysis of 19 estimated acid-exposure time values in Asians, the reference range upper limit for esophageal acid exposure time was 3.2% (95% confidence interval, 2.7-3.9%) in the Asian countries. Esophageal manometry and novel impedance measurements, including mucosal impedance and a post-reflux swallow-induced peristaltic wave, are promising in discrimination of GERD among different reflux phenotypes, thus increasing its diagnostic yield. We also propose a long-term strategy of evidence-based GERD treatment with proton pump inhibitors and other drugs.

Introduction: Signet ring cell carcinoma (SRC) is a poorly differentiated cancer of the stomach. Recent studies imply that early gastric SRC can be well managed by endoscopic resection. Unfortunately, unlike differentiated cancers, the endoscopic features of early gastric SRC have not been well studied. This study evaluated the endoscopic features of early gastric SRC, as well as the risk factors for submucosal (SM) invasion. Method: The medical records of patients from 7 tertiary hospitals (Daejeon and Chungcheong province) were reviewed to examine endoscopic findings and clinical data. These patients underwent surgery or endoscopic resection between January 2011 and December 2016 and were divided into 2 groups (derivation group and validation group) in order to develop and validate an endoscopic scoring system for SM invasion. Results: In total, 331 patients (129 in the derivation group and 202 in the validation group) were enrolled in this study. In the derivation group, the risk factors for SM invasion, namely, fold convergence, nodular mucosal change, and deep depression, were identified by logistic regression analysis (ORs 3.4, 5.9, and 6.0, p < 0.05). A depth-prediction score was created by assigning 1 point for fold convergence and 2 points for other factors. When validation lesions of 0.5 point or more were diagnosed as SM invasion, the sensitivity and specificity were 76.8–78.6% and 61.6–74.7% respectively. Conclusion: Fold convergence, nodular mucosal change, and deep depression are risk factors for SM invasion in early gastric SRC. Our depth-prediction scoring system may be useful for differentiating SM cancers.

Background/Aims Our study aims to characterize esophageal motor function; evaluate the relationships among esophagogastroduodenoscopy (EGD), high-resolution manometry (HRM), and 24-hour esophageal multichannel intraluminal impedance monitoring combined with pH-metry (MII-pH); and elucidate the determinants of esophageal symptom perception in South Koreans with systemic sclerosis (SSc). Methods We reviewed prospectively collected HRM (n = 46), EGD (n = 41), and MII-pH (n = 37) data from 46 consecutive patients with SSc (42 females; mean age 50.1 years) who underwent esophageal tests between June 2013 and September 2018. Results The most common HRM diagnosis was normal (39.1%), followed by ineffective esophageal motility (23.9%) and absent contractility (21.7%). Erosive esophagitis was observed in 12.2% of total SSc patients, with a higher frequency in patients with absent contractility than those with normal motility (44.5% vs 0.0%, P = 0.01). Pathologic acid exposure was observed in 6 patients (20.0%) and positive symptom association in 18 patients (60.0%) in MII-pH tests of symptomatic patients. The proportion of SSc patients with esophageal symptoms not explained by reflux or mucosal or motor esophageal abnormalities was 33.0%. Conclusions Esophageal involvement among South Koreans with SSc was characterized by heterogeneous motility patterns, with a higher prevalence of normal motility and lower prevalence of erosive esophagitis. Reflux hypersensitivity or functional heartburn might be partly attributed to the perception of esophageal symptoms in SSc patients who have neither gastroesophageal reflux disease nor esophageal dysmotility. (J Neurogastroenterol Motil 2020;26:477-485)

Background Spontaneous bacterial peritonitis (SBP) is one of the severe complications of liver cirrhosis. Early detection of high-risk patients is essential for prognostic improvement. The aim of this study is to investigate the predictive factors related to in-hospital mortality in patients with SBP. Methods This was a retrospective study of 233 SBP patients (181 males, 52 females) who were admitted to four tertiary referral hospitals between August 2002 and February 2013. The patients' laboratory and radiologic data were obtained from medical records. The Child-Turcotte-Pugh (CTP) score and model for end-stage liver disease sodium model (MELD-Na) scores were calculated using the laboratory data recorded at the time of the SBP episode. Results The causes of liver cirrhosis were hepatitis B (44.6%), alcohol (43.8%), hepatitis C (6.0%), and cryptogenic cirrhosis (5.6%). The mean MELD-Na and CTP scores were 27.1 and 10.7, respectively. Thirty-one of the patients (13.3%) died from SBP in hospital. Multivariate analysis revealed that maximum creatinine level during treatment was a statistically significant factor for in-hospital mortality (P = 0.005). The prognostic accuracy of the maximum creatinine level during treatment was 78.0% (P < 0.001). The optimal cutoff point for the maximum serum creatinine was 2 mg/dL (P < 0.001). Conclusion The follow-up creatinine level during treatment is an important predictive factor of in-hospital mortality in cirrhotic patients with SBP. Patients with SBP and a serum creatinine level during treatment of ≥ 2.0 mg/dL might have a high risk of in-hospital mortality., Graphical Abstract

Submucosal injection for endoscopic mucosal resection (EMR) may effect performing the prophylactic argon plasma coagulation (APC) of non-bleeding visible vessels on ulcer crater.The purpose of this study was to evaluate the clinical features of visible vessels in iatrogenic ulcers over time after prophylactic APC in colonic EMR.This study was designed as a prospective study. Between August and November 2013, a total of 40 patients who were admitted underwent prophylactic APC for non-bleeding visible vessels after colonic EMR. After confirming whether visible vessels were completely coagulated or not, the number of visible vessels in ulcers was counted over a specific time period, e.g. 1, 3, 5, or 7 min.The mean number of visible vessels was significantly higher at 5 min (0.85 ± 1.14) after EMR with prophylactic APC compared to 1 and 3 min (1 min: 0.28 ± 0.60, P0.001; 3 min: 0.65 ± 0.87, P = 0.02) and there was no significant difference between 5 and 7 min (P = 0.31). Multivariate analysis showed that the size of the iatrogenic ulcer after EMR was associated with the occurrence of visible vessels (ulcer size1 vs. ≤0.5 cm: OR 27.32, 95% CI 2.86-infinity).A 5-min observation of the ulcer may be advantageous for the assessment of visible vessels after performing colonic EMR with prophylactic APC, and large (1 cm) iatrogenic ulcers were associated with the occurrence of visible vessels after colonic EMR.

Submucosal injection with indigo carmine mixed solution can improve the delineation of colorectal neoplasia during endoscopic mucosal resection (EMR). Thus, the aim of this study was to evaluate the efficacy of submucosal injection with indigo carmine mixed solution during EMR of colorectal neoplasia. This was a prospective, randomized, controlled study of a total of 212 neoplastic colon polyps (5–20 mm) subjected to EMR in a single tertiary university hospital. The patients were randomized into two groups according to whether or not indigo carmine mixed solution was used, and the complete resection rate (CRR) after EMR was evaluated. A total of 212 neoplastic polyps (normal saline group, 115; indigo carmine group, 97) were successfully removed by EMR. There was no significant difference in the CRR (92.8 vs. 89.6%, p = 0.414) or macroscopic delineation (86.0 vs. 93.8%, p = 0.118) between the two groups. In a separate analysis of sessile serrated adenomas/polyps (SSAs/Ps), macroscopic delineation was better in the indigo carmine group than the normal saline group (87.5 vs. 53.8%), albeit not significantly (p = 0.103). In univariate analyses, the CRR was significantly related to polyp location, polyp morphology, macroscopic delineation, and pathologic findings. In a multiple logistic regression analysis, macroscopic delineation (odds ratio (OR), 7.616, p = 0.001) and polyp pathology (OR, 8.621; p

New or missed gastric cancer rates after negative endoscopy are high. However, the clinicopathologic characteristics of missed or interval early gastric cancer (EGC) are not well known. The aim of this study was to evaluate clinicopathologic and endoscopic characteristics of missed or interval EGC after negative endoscopy. We retrospectively analyzed 1,055 patients with EGC confirmed by endoscopic resection or surgery between June 2006 and July 2013. Referred patients with diagnosed or suspected gastric neoplasms were excluded (n = 771). Interval EGC was defined as gastric cancer diagnosed within 2 years of negative endoscopy. Clinicopathologic characteristics of patients with initially detected and interval EGC and risk factors for interval EGC were investigated. Of 284 patients, 52 had interval EGC (18.3 %; mean age 65.4 years; average interval between diagnosis and previous endoscopy, 12.6 months). Tumors were significantly smaller (1.3 vs. 1.8 cm, P

Acute esophageal necrosis (AEN) is a serious disease which can causes gastrointestinal bleeding and death. Although black color change is not essential factor of organ necrosis, AEN is also known as “black esophagus.” Because of its rarity, there are limited studies regarding risk factors of

Brunner's gland hamartoma is a rare benign small bowel neoplasm and most lesions are small and asymptomatic. However, large hamartoma-related obstructive symptoms and hemorrhage related to tumor ulceration manifest as hematemesis or melena. The exact pathogenesis if these lesions is not well known, but they are thought to be frequently associated with Helicobacter pylori infections and chronic pancreatitis. We report the case of a 45-year-old man who presented with melena due to a large pedunculated Brunner's gland hamartoma arising from the pylorus. It was successfully removed by endoscopic mucosal resection with piecemeal technique because of too large tumor size for application of a conventional snare.

Concurrent cerebral and coronary artery embolization is a theoretically possible, but extremely rare complication of an atrial myxoma. We present a paitent with a left atrial mass (a probable myxoma) who presented with concurrent cerebral and myocardial infarctions due to emboli of tumor origin. An 84-year-old woman presented with an acute cerebral infarction of the middle cerebral artery territory. Several hours after admission, she complained of chest pain consistent with a myocardial infarction. Transthoracic and transesophageal echocardiographic studies revealed the presence of a large, mobile, heteroechoic mass with a few daughter nodules in the left atrium, compatible with a myxoma. Coronary angiography disclosed subtotal occlusion of the ramus intermedius branch and visible tumor vascularization adjacent to the right coronary artery. With medical treatment, including anticoagulation, the patient was stabilized and had an uneventful clinical course for the ensuing 6 months since discharge. (Korean Circ J 2008;38:622-626)

Submitted 20 December 2007, Accepted 3 April 2008 Correspondence : Eun Ju Choo, M.D. Department of Internal Medicine, Soon Chun Hyang University Bucheon Hospital, 1174 Jung-dong, Wonmi-gu, Bucheon-si, Gyeonggi-do, 420-767, Korea Tel : +82-32-621-5202, Fax : +82-32-621-5016 E-mail : mdchoo@schbc.ac.kr 말라리아는 다양한 형태의 임상적 증상과 합병증을 동 반할 수 있고, 특히 열대열 말라리아(Plasmodium falciparum)일수록 비장과 관련된 중증합병증으로 자발적 비 장파열, 비장혈종, 비장거대증 등이 있다(5). 국내에서 유행 하는 삼일열 말라리아는 그동안 가벼운 임상 경과가 특징 이었으나 최근 비장침범을 하는 중증례들의 보고가 증가하 고 있다(6-10). 이에, 저자들은 국내의 토착형 말라리아 감 염환자에서 합병된 비장파열 1예와 비장경색 1예의 경험을 문헌고찰과 함께 보고한다.

The pathogenic mechanism of focal segmental glomerulosclerosis (FSGS) and aplastic anemia are associated with immunologic events which lead to glomerular cell injury or hematopoietic cell destruction. We present an extremely rare case of FSGS with aplastic anemia in a 30-yr-old woman. The laboratory examination showed hemoglobin 7.2 g/dL, white blood count of 4,200/ microL, platelet count 70,900/microL. Proteinuria (2+, 3.6 g/day) and microscopic hematuria were detected in urinalysis. The diagnosis of FSGS and aplastic anemia were confirmed by renal and bone marrow biopsy. She was treated with immunosuppressive therapy of prednisone 60 mg/day orally for 8 weeks and cyclosporine A 15 mg/kg/day orally. She responded with gradually improving her clinical manifestation and increasing peripheral blood cell counts. Prednisone was maintained at the adequate doses with tapering after 8 weeks and cyclosporine was given to achieve trough serum levels of 100-200 ng/mL. At review ten month after diagnosis and initial therapy, the patient was feeling well and her blood cell counts increased to near normal (Hb 9.5 g/dL, Hct 32%, WBC 8,300/microL, platelet 123,000/microL) and renal function maintains stable with normal range proteinuria (0.25 g/day).