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Ascaris lumbricoides causes one of the most common soil-transmitted helminthiases globally. The worms mostly infect the human small intestine and elicit negligible or nonspecific symptoms, but there are reports of extraintestinal ectopic ascariasis. We describe a rare case of biliary ascariasis mistaken for biliary stent in a 72-year-old female patient with a history of liver resection. She visited our outpatient clinic complaining of right upper quadrant pain and fever for the past week. She had previously undergone left lateral sectionectomy for recurrent biliary and intrahepatic duct stones 2 years ago. Besides mildly elevated gamma-glutamyl transferase levels, her liver function tests were normal. Magnetic resonance cholangiopancreatography revealed a linear filling defect closely resembling an internal stent from the common bile duct to the right intrahepatic bile duct. A live female A. lumbricoides adult worm was removed by endoscopic retrograde cholangiopancreatography (ERCP). Despite a significant decrease of the ascariasis prevalence in Korea, cases of biliary ascariasis are still occasionally reported. In this study, a additional case of biliary ascariasis, which was radiologically misdiagnosed as the biliary stent, was described in a hepatic resection patient by the worm recovery with ERCP in Korea.

Pancreatic acinar cell carcinoma (ACC) is a rare neoplasm accounting less than 1% of malignant pancreatic tumors. A 47-year-old male patient visited the emergency room with epigastric pain. Computed tomography or magnetic resonance imaging revealed a 4.7-cm heterogeneously enhanced solid and cystic mass with internal necrosis located in the head of the pancreas. Radiological diagnosis was borderline malignancy such as neuroendocrine tumor or solid pseudopapillary neoplasm. Two months later, the necrotic mass in the pancreas head had grown up to 11 cm, compressing the duodenum, superior mesenteric vein, and proximal transverse colon. Pylorus preserving pancreatoduodenectomy with segmental resection of transverse colon was performed. Histopathological examination revealed that the tumor was pancreatic ACC. The patient recovered without any complication and was doing well without recurrence for 12 months after surgery.

Background In this study, we sought to evaluate whether systemic propentofylline (PPF) has antiallodynic effects in a rat model of postoperative pain, and to assess the mechanism involved. Methods After plantar incision, rats were intraperitoneally injected with various doses of PPF to evaluate its antiallodynic effect. To investigate the involved mechanism, rats were intraperitoneally injected with yohimbine, dexmedetomidine, prazosin, naloxone, atropine or mecamylamine, following the incision of the rat hind paws, and then PPF was administered intraperitoneally. The mechanical withdrawal threshold (MWT) was evaluated using von Frey filaments at various time points and serum levels of tumor necrosis factor (TNF)-α, interleukin (IL)-1β, and IL-6 were measured to determine the inflammatory response level. Results MWT was significantly increased after intraperitoneal injection of 30 mg/kg of PPF when compared with the control group. Injection of PPF and yohimbine, atropine or mecamylamine showed significant decreases in the MWT, while injection of PPF and dexmedetomidine showed a significant increase. Systemic administration of PPF inhibited the post-incisional increase in serum level of TNF-α and IL-1β. Conclusions Systemic administration of PPF following surgery presented antiallodynic effects in a rat model of postoperative pain. The antiallodynic effects against mechanical allodynia could be mediated by α-adrenergic and cholinergic receptors.

Background/Aims: The adverse events associated with endoscopic retrograde cholangiopancreatography (ERCP) in end-stage renal disease (ESRD) patients undergoing hemodialysis (HD) have not been sufficiently evaluated. This study aimed to review the morbidity and mortality associated with ERCP in ESRD patients on HD using a systematic review and pooled analysis. Methods: A systematic review and pooled analysis were conducted on studies that evaluated the clinical outcomes of ERCP in patients on HD. Random-effect model meta-analyses with subgroup analyses were conducted. The methodological quality of the included publications was evaluated using the risk of bias assessment tool for nonrandomized studies. The publication bias was assessed. Results: A total of 239 studies were identified, and 12 studies comprising 7921 HD patients were included in the analysis. The pooled estimated frequency of bleeding associated with ERCP in HD patients was 5.8% (460/7921). In the subgroup analysis of seven comparative studies, the ERCP-related bleeding rate was significantly higher in HD patients than in non-HD patients (5.5% (414/7544) vs. 1.5% (6734/456,833), OR 3.84; 95% CI 4.26–25.5; p < 0.001). The pooled frequency of post-ERCP pancreatitis was 8.3%. The pooled frequency of bowel perforation was 0.3%. The pooled estimated mortality associated with ERCP was 7.1% The publication bias was minimal. Conclusion: This pooled analysis showed that ERCP-related morbidity and mortality are higher in HD patients than in non-dialysis patients.

(1) Background: The AJCC Cancer Staging Manual, Eighth Edition, subdivided T2 GBC into T2a and T2b. However, there still exist a lack of evidence on the prognostic significance of tumor location. The aim of the present study was to examine the existing evidence to determine the prognostic significance of tumor location of T2 gallbladder cancer (GBC) and to evaluate the optimal surgical extent according to tumor location. (2) Methods: We searched for relevant literature published in the electronic databases PubMed, MEDLINE, Web of Science, Cochrane Library, and Embase before September 2020 using search terms related to gallbladder, cancer, and stage. Data were weighted and pooled using random-effects modeling. (3) Results: Seven studies were deemed eligible for inclusion, representing a cohort of 1789 cases of resected T2 GBC. The overall survival for T2b tumor was significantly worse than that for T2a tumor (HR, 2.141; 95% confidence interval (CI), 1.140 to 4.023; I2 = 71.4%; Pchi2 = 0.007). The rate of lymph node metastasis was lower in the T2a group (26.6%) than in the T2b group (36.6%) (OR, 2.164; 95% CI, 1.309 to 3.575). There was no evidence of a survival difference between the patients who underwent extended cholecystectomy and simple cholecystectomy in T2a GBC (OR, 0.802; 95% CI, 0.618 to 1.042) and T2b GBC (OR, 0.820; 95% CI, 0.620 to 1.083). (4) Conclusions: Hepatic side tumor was a significant poor prognostic factor in T2 GBC. Extended cholecystectomy and simple cholecystectomy showed comparable survival outcomes in T2 GBC, and additional large-scale prospective studies are warranted to establish evidence-based treatment guidelines for T2 GBC.

Desmoid fibromatosis is a rare benign tumor, but due to its rarity and diverse clinical course, treatment guidelines have not been established. However, since a good prognosis can be expected, an accurate diagnosis and appropriate treatment are required. We describe a rare case of desmoid fibromatosis on young female that presented as huge abdominal mass.A 28-year-old female with left upper abdominal pain 1 month ago was referred.Abdominal computed tomography and magnetic resonance imaging revealed a heterogeneous soft tissue mass approximately 29 × 17 cm in size in the left abdomen with abdominal wall invasion and pathological fracture in costochondral junction of the left 8th to 10th ribs.Surgical resection was performed.33 × 23 × 6 cm sized tumorous mass showed proliferation of bland fibromatosis and myofibroblast with nuclear β-catenin expression on pathological examination. Desmoid fibromatosis arising from intra-abdominal soft tissue with ribs and pericardium invasion was diagnosed.The mainstay of treatment of symptomatic desmoid fibromatosis is surgical resection, and in the case of abdominal tumor, it can be more dangerous when it invades adjacent organ. We report a case that required additionally multidisciplinary approach for surgery and postoperative treatment of huge abdominal desmoid tumor which infiltrate bone and pericardium beyond abdominal cavity.

The objective of our study was to develop a decision tree model for the early prediction of the severity of acute pancreatitis (AP) using clinical and radiologic scoring systems.For this retrospective study, 192 patients with AP who underwent CT 72 hours or less after symptom onset were divided into two cohorts: a training cohort (n = 115) and a validation cohort (n = 77). Univariate analysis was performed to identify significant parameters for the prediction of severe AP in the training cohort. For early prediction of disease severity, a classification tree analysis (CTA) model was constructed using significant scoring systems shown by univariate analysis. To assess the diagnostic performance of the model, we compared the area under the ROC curve (AUC) with each selected single parameter. We also evaluated the diagnostic performance in the validation cohort.The Acute Physiology and Chronic Health Evaluation (APACHE)-II score, bedside index for severity in acute pancreatitis (BISAP) score, extrapancreatic inflammation on CT (EPIC) score, and Balthazar grade were included in the CTA model. In the training cohort, our CTA model showed a trend of a higher AUC (0.853) than the AUC of each single parameter (APACHE-II score, 0.835; BISAP score, 0.842; EPIC score, 0.739; Balthazar grade, 0.700) (all, p0.0125) while achieving specificity (100%) higher than and accuracy (94.8%) comparable to each single parameter (both, p0.0125). In the validation cohort, the CTA model achieved diagnostic performance similar to the training cohort with an AUC of 0.833.Our CTA model consisted of clinical (i.e., APACHE-II and BISAP scores) and radiologic (i.e., Balthazar grade and EPIC score) scoring systems and may be useful for the early prediction of the severity of AP and identification of high-risk patients who require close surveillance.

We evaluated the diagnostic performance of ultrasonography (US) plus superb microvascular imaging (SMI) compared with conventional US alone for diagnosing acute cholecystitis. We included 54 patients with suspected biliary disease. The SMI pixel count showing flow signal was measured in the region of interest of the gallbladder bed of the liver. Two radiologists independently evaluated imaging features and rated five-point diagnostic likelihood level before versus after the additional SMI using the cutoff SMI pixel count. The SMI pixel count was significantly higher in acute than in non-acute cholecystitis (169.84 vs. 27.48, p < 0.001). The optimal SMI cutoff pixel count for predicting acute cholecystitis obtained by receiver operating characteristic curve was 56.67(82.8% sensitivity, 92.0% specificity). The area under the curve value was significantly higher after the additional SMI than before (0.798-0.863 vs. 0.701-0.736, p < 0.05). US plus SMI could objectively improve diagnostic performance compared with conventional US for acute cholecystitis.

Background Recently, despite the high prevalence of fatigue in patients, there is a lack of research on the quality of life (QoL) in unexplained fatigue patients, indicating that they are not properly diagnosed and treated. The aim of this study was to compare fatigue severity and QoL between patients with explained and unexplained fatigue. Methods The study consisted of 200 Korean adults who complained of fatigue without underlying disease. Fatigue Severity Scale, Short Form Health Survey-36 version 2 (SF-36v2), and Beck Depression Inventory-II (BDI-II) self-questionnaires were administered. Participants were dichotomized to two groups, namely, patients with unexplained or explained fatigue, sorted according to laboratory examination results. The chi-square test, t-test, and Wilcoxon rank-sum test were used, and analysis of covariance was calculated after adjusting for age, sex, body mass index, smoking status, and physical component summary (PCS) of SF-36v2 or BDI-II. Results PCS of SF-36v2 between the two groups showed significant difference. Compared to patients with explained fatigue, those with unexplained fatigue showed lower physical component scores of QoL. Conclusion QoL of patients with unexplained fatigue could largely diminish than those with explained fatigue. The primary clinician should be aware of poor QoL in patients with unexplained fatigue to identify who is in need of more attention and intervention.

The development of common bile duct (CBD) stones after laparoscopic cholecystectomy (LC) could be a stressful event for surgeons and patients. The purpose of this study was to investigate the risk factors for and the time of occurrence of CBD stones, which are detected at a certain period after LC in patients who have no history of having CBD stone before operation. A total of 1938 patients who underwent LC for benign gallbladder lesion were retrospectively analyzed. The patients were categorized into two groups according to the development of CBD stones at least 6 months after LC (case group, control group). The risk factors for and the time of development of CBD stones after LC were evaluated. In a univariate analysis, the significant factors for the development of CBD stones were old age, acute cholecystitis, the presence of periampullary diverticulum, and the presence of gall bladder stones sized

Purpose To determine the prevalence of and investigate the risk factors for gallbladder (GB) polypoid lesions in a healthy population. Materials and methods A total of 23827 subjects who underwent abdominal ultrasonography in conjunction with health screening examinations were retrospectively analyzed. The prevalence of risk factors for GB polypoid lesions were evaluated. In addition, risk factors according to the number of polypoid lesions and the presence of stones with polypoid lesions were investigated. To analyze these risk factors, a control group was established with a 1:2 ratio matched for age and sex. Results The prevalence of GB polypoid lesions was identified as 9.96%. On multivariate analysis, chronic hepatitis B infection (CHB) and the presence of metabolic syndrome (MS) were risk factors for GB polypoid lesions. CHB and MS were also significant independent risk factors for multiple GB polypoid lesions when compared with solitary GB polypoid lesions. In addition, gastric Helicobacter pylori infection and MS were significant risk factors for GB polypoid lesions with stones when compared with GB polypoid lesions without stones. Conclusion The prevalence of GB polypoid lesions in a healthy Korean population was 9.96%. Patients with CHB and MS need to be carefully examined for such lesions.

Whether the etiology of potential small-bowel bleeding depends on the age and gender of the patient is not yet fully understood.A total of 1953 patients who underwent video capsule endoscopy (VCE) to evaluate potential small-bowel bleeding and were registered in the Capsule Endoscopy Nationwide Database Registry from 2003 to 2014 were eligible for this study. VCE findings and the etiology of small-bowel bleeding were analyzed by age and gender.The diagnostic yield of VCE was 48.4% (95% CI: 46.2%-50.6%) and the diagnosis rate of etiology of potential small-bowel bleeding was 61.4% (95% CI: 59.2%-63.6%). The etiology of potential small-bowel bleeding depends on the age and gender of the patient. Crohn's disease and small-bowel diverticular diseases were more prevalent etiology of potential small-bowel bleeding in the young adults group ( 40 years) whereas angiodysplasia was revealed to be a most common etiology in elderly group (≥ 60 years), reaching statistical significance (The etiology of potential small-bowel bleeding depends on the age of the patient. Thus, an individualized lesion-specific diagnostic approach based on age might be needed for patients with potential small-bowel bleeding.

Background Procollagen type I N-terminal propeptide (PINP) is one of the most clinically useful bone formation biomarkers. Therefore, the purpose of this study was to independently evaluate the performance of automated total PINP assay and established age- and gender-specific reference intervals for PINP in healthy Korean population. Methods The imprecision, linearity, and detection capability of Elecsys total PINP assay was determined and reference interval was established using 599 serums from Korean population with normal bone mineral densities based on bone densitometry. Age groups were divided into 20s, 30s, 40s, 50s, 60s and over. Results Elecsys total PINP had excellent performance in imprecision, linearity, and detection capability. When partitioning age groups in Korean male and female populations, there was significant difference in total PINP between different age groups. In male populations, PINP level was decreased with increasing age, then it remained steady after middle-age. In female populations, there was a decreasing tendency similar to that in the male population with a sharp increase in the 50 to 59 age group. Conclusions Elecsys total PINP assay showed precise and reliable performance in our study. We established age-related PINP reference intervals for Korean male and female population with normal bone mineral densities.

Background/aims Acute pancreatitis is a common complication of endoscopic retrograde cholangiopancreatography (ERCP). Combination therapy w ith ora l udenafil and aceclofenac may reduce the occurrence of post-ERCP pancreatitis by targeting different pathophysiological mechanisms. We investigated whether combining udenafil and aceclofenac reduced the rates of post-ERCP pancreatitis. Methods A prospective, randomized, double-blind, placebo-controlled, multicenter study was conducted in four academic medical centers. Between January 2012 and June 2013, a total of 216 patients who underwent ERCP were analyzed for the occurrence of post-ERCP pancreatitis. Patients were determined to be at high risk for pancreatitis based on validated patient and procedure-related risk factors. Results Demographic features, indications for ERCP, and therapeutic procedures were similar in each group. There were no significant differences in the rate (15.8% [17/107] vs. 16.5% [18/109], p = 0.901) and severity of post-ERCP pancreatitis between the udenafil/aceclofenac and placebo groups. One patient in each group developed severe pancreatitis. Multivariate analyses indicated that suspected dysfunction of the sphincter of Oddi and endoscopic papillary balloon dilation without sphincterotomy were associated with post-ERCP pancreatitis. Conclusions Combination therapy with udenafil and aceclofenac is not effective for the prevention of post-ERCP pancreatitis.

Background and Aim Endoscopic retrograde cholangiopancreatography (ERCP) has been increasingly performed in the elderly patients, yet little is known concerning objective criteria of safety. This study aimed to determine the potential predictors for the procedure-related outcomes. Methods Two hundred eighty-one patients older than 70 years who were indicated for ERCP (group A [n = 195], 70–79 years of age; group B [n = 86], ≥ 80 years of age) were prospectively enrolled and analyzed for the development of serious adverse events related to ERCP. Results ERCP was not performed in six patients at high risk for the procedure. There were significant differences between group A and B in Duke Activity Status Index (DASI) (23.1 vs 14.9, P

Biliary decompression with antibiotic therapy is the mainstay treatment for acute cholangitis with bacteremia. A few studies have been conducted to investigate the optimal duration and route of antibiotic therapy in biliary tract infection with bacteremia. Patients with acute cholangitis with bacteremia who achieved successful biliary drainage were randomly assigned to an early oral antibiotic switch group (group A, n = 29) and a conventional intravenous antibiotics group (group B, n = 30). Patients were discharged when they were afebrile over 2 days after oral antibiotic switch and showed consecutive improvement in the laboratory index. They were followed up and assessed at 30 days after diagnosis to evaluate the eradication of bacteria, recurrence of acute cholangitis, and 30-day mortality rate. There were no statistically significant differences between the two groups in baseline characteristics, clinical and laboratory index, severity of acute cholangitis, bacteria isolated from blood cultures, and clinical outcomes. The rate of eradication of bacteria was 93.1 % in group A and 93.3 % in group B, respectively (p = 0.97). Using non-inferiority tests, the rate of eradication of bacteria in group A was not inferior to that in group B (95 % CI −0.13 to 0.14, p = 0.97). There was no statistically significant difference in the recurrence of acute cholangitis and a 30-day mortality rate between the two groups. Early switch to oral antibiotic therapy following adequate biliary drainage for treatment of acute cholangitis with bacteremia was not inferior to conventional 10-day intravenous antibiotic therapy.

Objectives We aimed to determine the prevalence of cholesterol gallstones, the compositional changes of gallstones and its predisposing factors in Korea with this single-center study. Methods Data of 365 patients who underwent cholecystectomy for cholecystolithiasis from July 2008 to September 2011 were reviewed. Based on the compositional analysis of the gallstones, patients were assigned to either cholesterol gallstone group or pigment gallstone group. The characteristics of the patients and the gallstones were summarized and compared. Results After eight patients with mixed gallstones were excluded, 357 patients were enrolled in the study, including cholesterol gallstones in 175 (49.0%) and pigment gallstones in 182 (51.0%). The number of patients with cholecystolithiasis increased but the prevalence of cholesterol gallstone decreased with age. Compared with the pigment gallstone group, the cholesterol gallstone group was associated with young age (

Capsule endoscopy (CE) is considered as a noninvasive and reliable diagnostic tool of examining the entire small bowel. CE has been performed frequently at many medical centers in South Korea; however, there is no evidence-based CE guideline for adequate diagnostic approaches. To provide accurate information and suggest correct testing approaches for small bowel disease, the guideline on CE was developed by the Korean Gut Image Study Group, a part of the Korean Society of Gastrointestinal Endoscopy. Operation teams for developing the guideline were organized into four areas: obscure gastrointestinal bleeding, small bowel preparation, Crohn's disease, and small bowel tumor. A total of 20 key questions were selected. In preparing this guideline, MEDLINE, Cochrane library, KMbase, KISS, and KoreaMed literature searches were performed. After writing a draft of the guideline, opinions from various experts were reflected before approving the final document. The guideline should be regarded as recommendations only to gastroenterologists in providing care to their patients. These are not absolute rules and should not be construed as establishing a legal standard of care. Although further revision may be necessary as new data appear, this guideline is expected to play a role for adequate diagnostic approaches of various small bowel diseases.

We experienced a case of acute myocarditis as the initial presentation of Crohn's disease. A 19-year-old woman was admitted with impaired consciousness, shock, and respiratory failure. She had suffered from frequent diarrhea and abdominal pain for several years. Cardiac troponin I and creatine kinase-MB fraction levels were elevated to 5.32 and 16.66 ng/mL, respectively. A 12-lead electrocardiogram showed sinus tachycardia, and a chest radiograph revealed interstitial pulmonary edema. An echocardiogram showed dilated ventricles with akinesia of the basal to apical inferoseptal, anteroseptal, anterior, and inferior left ventricular walls and severely impaired systolic function. Intensive care with inotropic support was effective, and her clinical condition gradually improved. Two weeks later, a colonoscopy revealed ulceration with stenosis in the terminal ileum and multiple aphthous ulcers in the rectum. A biopsy of the rectum revealed non-caseating granulomatous inflammation. She was diagnosed with Crohn's disease presenting with acute myocarditis.

Light chain deposition disease (LCDD) is a rare disorder associated with a clonal proliferation of plasma cells, which synthesize abnormal monoclonal immunoglobulin light chains. LCDD is characterized by systemic deposition of light chains in various organs, with the kidneys being most commonly affected. There have been few reports of isolated LCDD. We report a rare case of LCDD limited to a duodenal polyp. A 63-yr-old man visited our hospital for health screening without symptoms in 2009. On gastrofiberscopy, a duodenal polyp was observed. The biopsy showed diffuse infiltration by atypical plasma cells, which were positive for kappa-type light chains by immunohistochemistry. While the patient refused further management, we could find no evidence of recurrence until 2 yr after the initial diagnosis. It has been reported that isolated LCDD has relatively good prognosis compared to systemic LCDD. However, treatment for this disease has not been established yet.

Background Udenafil, a phosphodiesterase-5 inhibitor, may decrease sphincter of Oddi tone and allow efficient cannulation. Objective To determine whether prophylactic udenafil reduces the rates of occurrence of post-ERCP pancreatitis. Design Prospective, randomized, double-blind, placebo-controlled, multicenter study. Setting Three academic medical centers. Patients From November 2008 to November 2010, a total of 278 patients who underwent ERCP were analyzed. Intervention ERCP. Main Outcome Measurement Rate of post-ERCP pancreatitis. Results Demographic features, indications for ERCP, and therapeutic procedures were similar in each group. The overall rate of pancreatitis was 7.9% (22/278). There was no significant difference in the rate (8.0% [11/137] vs 7.8% [11/141], P = .944) and severity of post-ERCP pancreatitis between the udenafil and placebo groups. Severe pancreatitis developed in 1 patient in the placebo group. On both univariate and multivariate analyses, age 40 years or younger, suspected sphincter of Oddi dysfunction, complete pancreatic duct opacification, and failed cannulation were associated with post-ERCP pancreatitis. Only mild udenafil-related complications occurred, including flushing (n = 3) and headache (n = 3). Limitations Unselected patient group, overestimation of the rate of pancreatitis in the placebo group. Conclusion Udenafil was not effective for prevention of post-ERCP pancreatitis in this study. (Clinical trial registration number: KCT0000021.)

Background and Aim: Capsule endoscopy (CE) has proven to be highly effective at detecting small bowel lesions in a variety of clinical conditions, but studies concerning the practical impact of CE on small bowel tumors are still scarce, especially in the Asian population. The aim of this study was to evaluate the diagnostic and therapeutic impact of CE in the field of small bowel tumors. Methods: CE records consecutively pooled from the beginning of use of CE in Korea, October 2001 until April 2008, in 14 centers throughout Korea were reviewed. Clinical information and CE video images of small bowel tumors were analyzed. Results: A total of 1332 cases undergoing CE were reviewed with all clinical indications. Small bowel tumors were diagnosed with CE in 57 (4.3%) of 1332 patients. The tumors were malignant in 33 cases, and included three adenocarcinomas, eight lymphomas, 20 gastrointestinal stromal tumors, and two metastatic cancers. The most frequent indications for CE in malignant tumors were obscure gastrointestinal bleeding, followed by abdominal pain and weight loss. Thirty of 57 tumors were identified exclusively by CE (diagnostic impact = 30/57), and they were smaller in size (mean, range: 14.3 mm, 2–35 mm) compared to the other tumors detected in radiological studies (48.7 mm, 10–110 mm). Seven patients underwent surgical resection (therapeutic impact = 7/57). Conclusion: CE effectively identifies small bowel tumors that are undetectable by conventional radiological studies (diagnostic impact = 52.6%) and can critically change the therapeutic course (therapeutic impact = 12.3%).

Endoscopic retrograde cholangiopancreatography (ERCP) has been increasingly performed in the elderly patients, yet little is known concerning objective criteria of safety. This study aimed to determine the potential predictors for the procedure-related outcomes.Two hundred eighty-one patients older than 70 years who were indicated for ERCP (group A [n = 195], 70-79 years of age; group B [n = 86], ≥ 80 years of age) were prospectively enrolled and analyzed for the development of serious adverse events related to ERCP.ERCP was not performed in six patients at high risk for the procedure. There were significant differences between group A and B in Duke Activity Status Index (DASI) (23.1 vs 14.9, P 0.01) and Eastern Cooperative Oncology Group performance status (3 and 4, 49/195 vs 33/86, P 0.05). Major ERCP-related complications (hypotension, severe bradycardia, hypoxia, myocardial infarction, cerebral infarction) occurred in five patients from group B and three from group A. Post-ERCP pancreatitis occurred in one patient from group A and bleeding in one from group B. In univariate analysis, old age (≥ 80 years), American Society of Anesthesiologists score ≥ 3, and DASI 10 were statistically significant predictors for overall serious events related to ERCP. In the multivariate analysis, DASI 10 (only manage to ambulate) was independent predictor for overall serious events related to ERCP.DASI score is useful predictor for the feasibility assessment of safe ERCP in the elderly patients.

We aimed to determine the prevalence of cholesterol gallstones, the compositional changes of gallstones and its predisposing factors in Korea with this single-center study.Data of 365 patients who underwent cholecystectomy for cholecystolithiasis from July 2008 to September 2011 were reviewed. Based on the compositional analysis of the gallstones, patients were assigned to either cholesterol gallstone group or pigment gallstone group. The characteristics of the patients and the gallstones were summarized and compared.After eight patients with mixed gallstones were excluded, 357 patients were enrolled in the study, including cholesterol gallstones in 175 (49.0%) and pigment gallstones in 182 (51.0%). The number of patients with cholecystolithiasis increased but the prevalence of cholesterol gallstone decreased with age. Compared with the pigment gallstone group, the cholesterol gallstone group was associated with young age (50 years), female gender, obesity (body mass index ≥ 25 kg/m²) and the absence of chronic liver diseases.The relative prevalence of cholesterol gallstones in Korea has been stationary so far, but may change in the future since cholesterol gallstones are increasingly prevalent in the young generation.

The preparation for video capsule endoscopy (VCE) of the bowel suggested by manufacturers of capsule endoscopy systems consists only of a clear liquid diet and an 8-hour fast. While there is evidence for a benefit from bowel preparation for VCE, so far there is no domestic consensus on the preparation regimen in Korea. Therefore, we performed this study to recommend guidelines for bowel preparation before VCE. The guidelines on VCE were developed by the Korean Gut Image Study Group, part of the Korean Society of Gastrointestinal Endoscopy. Four key questions were selected. According to our guidelines, bowel preparation with polyethylene glycol (PEG) solution enhances small bowel visualization quality (SBVQ) and diagnostic yield (DY), but it has no effect on cecal completion rate (CR). Bowel preparation with 2 L of PEG solution is similar to that with 4 L of PEG in terms of the SBVQ, DY, and CR of VCE. Bowel preparation with fasting or PEG solution combined with simethicone enhances the SBVQ, but it does not affect the CR of VCE. Bowel preparation with prokinetics does not enhance the SBVQ, DY, or CR of VCE.

Background: Entecavir (ETV) has potent antiviral activity against hepatitis B virus (HBV), and the emergence of drug resistance is rare in nucleoside-naive patients. Resistance requires simultaneous appearance of three mutations which account for the very low resistance profile of ETV. We experienced one case of genotypic ETV resistance with viral rebound during ETV treatment of nucleoside-naive patients with chronic hepatitis B (CHB). Case: A 50-year-old HBV e antigen-positive man received ETV 0.5 mg/day for 120 weeks. The level of HBV DNA was 9.0 log10 copies/ml at baseline, declined to a nadir of 2.7 at week 60 and then rebounded to 6.0 at week 108 and 7.5 at week 120. The serum alanine aminotransferase level did not increase during ETV treatment. The ETV resistance-related substitution (T184A) and lamivudine resistance-related substitutions (L180M and M204V) were detected by sequence analysis at week 96. Conclusions: The three substitutions associated with ETV and lamivudine resistance developed simultaneously without complete suppression in a nucleoside-naive CHB patient after extended therapy. In spite of the extremely rare chance of viral mutation during ETV treatment, treatment-naive patients with high pretreatment viral loads and detectable HBV DNA during treatment should be carefully monitored or undergo targeted surveillance for resistance.

A 68-year-old woman presented with yellowish discharge oozing from a fistula opening in the upper epigastric area that had persisted for one month prior to her visit. The patient had undergone a left lateral segmentectomy of the liver ten years prior for treatment of intrahepatic duct (IHD) stones. An abdominal computed tomography (CT) scan showed focal stricture and proximal dilatation of remnant IHD and a 1 cm-sized rim-enhancing lesion located under the surgical bed of the abdominal wall surrounding the dilated remnant IHD. Despite conservative management including nasobiliary drainage, no further improvement was anticipated. Partial hepatectomy and fistulectomy were performed for pathologic diagnosis and treatment of the enhancing lesion. Histopathology revealed adenocarcinoma. In this case, cholangiocarcinoma might have arisen in association with IHD stones and then developed a choledocho-cutaneous fistula as a clinical manifestation.

We report a rare case of hypereosinophilic syndrome (HES) presenting with intractable gastric ulcers. A 71-year-old man was admitted with epigastric pain. Initial endoscopic findings revealed multiple, active gastric ulcers in the gastric antrum. He underwent Helicobacter pylori (H pylori) eradication therapy followed by proton pump inhibitor (PPI) therapy. However, follow-up endoscopy at 4, 6, 10 and 14 mo revealed persistent multiple gastric ulcers without significant improvement. The proportion of his eosinophil count increased to 43% (total count: 7903/mm(3)). Abdominal-pelvic and chest computed tomography scans showed multiple small nodules in the liver and both lungs. The endoscopic biopsy specimen taken from the gastric antrum revealed prominent eosinophilic infiltration, and the liver biopsy specimen also showed eosinophilic infiltration in the portal tract and sinusoid. A bone marrow biopsy disclosed eosinophilic hyperplasia as well as increased cellularity of 70%. The patient was finally diagnosed with HES involving the stomach, liver, lung, and bone marrow. When gastric ulcers do not improve despite H pylori eradication and prolonged PPI therapy, infiltrative gastric disorders such as HES should be considered.

The inflammatory response during pancreatitis regulates necrotic and apoptotic rates of parenchymal cells. Neutrophil depletion by use of anti-polymorphonuclear serum (anti-PMN) increases apoptosis in experimental pancreatitis but the mechanism has not been determined. Our study was designed to investigate signaling mechanisms in pancreatic parenchymal cells regulating death responses with neutrophil depletion. Rats were neutrophil depleted with anti-PMN treatment. Then cerulein pancreatitis was induced, followed by measurements of apoptosis signaling pathways. There was greater activation of executioner caspases-3 in the pancreas with anti-PMN treatment compared with control. There were no differences between these groups of animals in mitochondrial cytochrome c release or in activities of initiator caspase-8 and -9. However, there was greater activation of caspase-2 with anti-PMN treatment during cerulein pancreatitis. The upstream regulation of caspases-2 includes p53, which was increased; the p53 negative regulator, Mdm2, was decreased by anti-PMN treatment during cerulein pancreatitis. In vitro experiments using isolated pancreatic acinar cells a pharmacological inhibitor of Mdm2 increased caspase-2/-3 activities, and an inhibitor of p53 decreased these activities during cholecystokinin-8 treatment. Furthermore, experiments using the AR42J cell line Mdm2 small interfering RNA (siRNA) increased caspase-2/-3 activities, and p53 siRNA decreased these activities during cholecystokinin-8 treatment. These results suggest that during acute pancreatitis the inflammatory response inhibits apoptosis. The mechanism of this inhibition involves caspase-2 and its upstream regulation by p53 and Mdm2. Because previous findings indicate that promotion of apoptosis decreases necrosis and severity of pancreatitis, these results suggest that strategies to inhibit Mdm2 or activate p53 will have beneficial effects for treatment of pancreatitis.

Obesity is associated with the risk of colorectal cancer. However, there is a lack of information about the relationship between obesity and colorectal adenoma. We investigated whether general and abdominal obesity are risk factors for colorectal adenoma.Subjects who received health check-ups, including colonoscopy, from April 2006 to September 2007 in Chung-Ang University Hospital were included (n=1,316). The frequency and characteristics of colorectal adenomas were analyzed according to demographic features, past history, blood tests, body mass index, and components of metabolic syndrome. Abdominal obesity was defined as a waist circumference of/=80 cm in women and/=90 cm in men.The sex ratio of the subjects was 1.9:1 (male:female) and their age was 47.7+/-10.0 years (mean+/-SD). In univariate analysis, abdominal obesity was significantly associated with the frequency of colorectal adenoma (26.5% "yes" vs 16.9% "no"; p0.001). The frequency of colorectal adenoma was significantly higher among males, older patients, current smokers, and subjects with fasting hyperglycemia (/=100 mg/dL) or fatty liver (p0.05). Multivariate analysis identified that male sex (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.0-2.2), old age (age/=60 years; OR, 6.7; 95% CI, 3.5-12.5), and abdominal obesity (OR, 1.5; 95% CI, 1.0-2.2) were independent risk factors for colorectal adenoma (p0.05). The frequency of multiple adenomas (more than two sites) was also significantly higher in subjects with abdominal obesity. However, the effect of abdominal obesity on the development of colorectal adenoma decreased in elderly people.Abdominal obesity is an independent risk factor for colorectal adenoma and its multiplicity, especially in younger people in South Korea.

Background/Aims The ability to visualize the small bowel mucosa by capsule endoscopy is limited. Moreover, studies involving small-bowel preparation with purgative drugs have failed to establish which preparations produce better images and higher diagnostic yields. The aim of this study was to evaluate the efficacies and diagnostic yields of different bowel preparations. Methods A cohort of 134 patients with suspected small bowel disease was randomly assigned to 3 groups. Patients in group A (n=44) fasted for 12 h before being administered an M2A capsule (Given Imaging, Yoqneam, Israel). Patients in group B (n=45) were asked to drink two doses of 45 mL of sodium phosphate (NaP) with water during the afternoon and evening on the day before the procedure and to drink at least 2 L of water thereafter. Patients in group C (n=45) drank 2 L of a polyethylene glycol (PEG) lavage solution the evening before the procedure. Results Overall cleansing of the small bowel was adequate in 43% of patients in group A, 77% of those in group B, and 56% of those in group C (group A vs group B, p=0.001). Diagnoses for obscure gastrointestinal bleeding were established in 9 patients (39%) in group A, 16 patients (69%) in group B, and 14 patients (50%) in group C. No significant difference in diagnostic yield was observed between groups. Conclusions Bowel preparation with NaP for capsule endoscopy improved small-bowel mucosal visualization when compared to 12-h overnight fasting.

The aim of this study was to evaluate the changes in prevalence and the related factors of Helicobacter pylori (H. pylori) infection in Korean health check-up subjects during the period of 8 years.Among 89,231 subjects who visited the Health Promotion Centers of Severance hospital or Chung-Ang University hospital from Jan. 1998 through Dec. 2005, a total of 10,553 subjects who received esophagogastroduodenoscopy (EGD) and H. pylori test were enrolled. H. pylori infection was assessed by histologic examination. Changes of the prevalence of H. pylori infection during 8 years, and infection-related factors such as demographic characteristics, body mass index, ABO blood types, endoscopic findings (presence of peptic ulcer diseases), educational level, economic status, smoking habits, and alcohol intake in year 2005 were analyzed.The mean age of 10,553 subjects (7,329 men, 3,224 women) was 49.7+/-10.4 years (range from 17 to 92 years). The prevalence of H. pylori infection at the first, second, third, fourth, fifth, sixth, seventh, and eighth year were 64.7%, 58.1%, 54.2%, 50.4%, 48.9%, 49.5%, 39.6%, and 40.0%, respectively, and these serial decreases in prevalence over 8 years were statistically significant (p0.001). Regardless of sex, age or EGD findings, the prevalence of H. pylori infection was significantly decreased. In the analysis of the H. pylori infection-related factors in 2005, only age and EGD findings (peptic ulcer diseases) were significant factors.The prevalence of H. pylori infection was significantly decreased during 8-year period in Korean health check-up subjects. Age and peptic ulcer diseases were the two significant factors related to H. pylori infection in Korea.

The cavernous sinus of skull base is a extremely rare metastastatic site for hepatocellular carcinoma (HCC). A 51-year-old man was diagnosed with HCC by liver biopsy and palliative radiotherapy on HCC including main portal vein was performed. One month later, he was admitted due to sudden onset ptosis. Neurologic findings were normal except for abnormal movement of right eye, and it raised the possibility of abnormality in the right occulomotor, trochlear and the abducens nerves. Contrast-enhanced CT scan of brain showed a mass with homogeneous enhancement involving the right cavernous sinus. T2-weighted axial MR images demonstrated a homogeneous mass with intermediate signal intensity, and contrast-enhanced axial T1-weighted MR images demonstrated a mass with homogeneous enhancement in the right cavernous sinus. We describe a case of HCC metastasis to the cavernous sinus with symptoms of ptosis and disturbance of right eyeball movement.

Burkitt's lymphoma is a rare disease that belongs to the aggressive non-Hodgkin's lymphoma. Herein, we report a case of primary hepatic Burkitt's lymphoma. A 19-year-old man visited the hospital for right upper quadrant pain. He felt fatigue for two months. Physical examination revealed hepatomegaly and no palpable lymph node. He had no fever, weight loss, or night sweating. Laboratory finding showed mild anemia (hemoglobin, 12.4 g/dL), mild elevated transaminase (ALT, 52 IU/L), elevated lactate dehydrogenase (LDH, 437 IU/L), and alkaline phosphatase (ALP, 129 IU/L). The viral marker was positive for HBsAg, HBeAg, anti-HBs, and anti-HBc (IgG), and negative for anti-HBe, anti-HCV, and anti-HIV. CEA, AFP, and CA19-9 levels were within normal ranges. The HBV DNA quantitation was 1.3 x 10(9) copies/ml. Abdominal-Pelvis CT scan and abdominal MRI finding were compatible with malignant lymphoma. Liver biopsy examination confirmed Burkitt's lymphoma. No metastasis was detected in the thoracic cavity, bone marrow, and spinal fluid. The patient was treated with the combination regimen of cyclophosphamide, doxorubicin, vincristine, prednisone and high dose methotrexate. Cytosine arabinoside and methotrexate were added for CNS prophylaxis by intrathecal installation. Chemotherapy was administered every 3 weeks for fifteen cycles. Serial follow-up CT scan showed a marked decrease in the size of hepatic lesions. Follow-up CT scan and PET-CT scan were performed 4 weeks after the final cycle disclosed no definite residual or active lesion confirming the state of complete remission.

Capsule endoscopy can detect lesions associated with Crohn's disease in the small bowel that go unrecognized by conventional radiologic imaging. The aim of this study was to assess the value of capsule endoscopy in the classification of patients with Crohn's disease. This study was carried out on 52 patients with known Crohn's disease. Small bowel follow-through findings were compared with capsule endoscopic findings. All patients were classified according to the extent of the disease: small bowel-colon type, small bowel type, or colon type. Seventeen patients who were reported as being normal showed evidence of small bowel Crohn's disease according to capsule endoscopy. Differences were observed between the small bowel follow-through and the capsule endoscopy classification (kappa=0.54). Treatment was changed based on the results of wireless capsule endoscopy in 15 patients.

NSAIDs induce gut damage throughout the entire gastrointestinal tract and bacterial translocation. The aim of this study was to examine if administration of glutamine was able to prevent the NSAID-induced gut damages and bacterial translocation in the animal models.Rats were utilized into 5 groups; control group, diclofenac group, and diclofenac with glutamine 0.8, 1.6, and 3.2 g/kg/day group. The animals with glutamine were fed with L-glutamine for 4 days before diclofenac administration. Gut injury was induced by administration of a single dose of diclofenac (80 mg/kg orally). Intestinal permeability (24 hour urinary excretion of phenolsulfonphthalein), enteric aerobic bacterial counts, serum biochemical profiles and bacterial translocation to mesenteric lymph nodes, liver and spleen were measured.Diclofenac caused the increase in intestinal permeability, enteric bacterial count, enteric protein and albumin loss and bacterial translocation. Administration of glutamine reduced the increase in intestinal permeability, protein losing enteropathy, enteric bacterial overgrowth and bacterial translocation induced by diclofenac.Glutamine may have beneficial effects on NSAID-induced gut damage and bacterial translocation.

In order to identify microsatellite instability (MSI), the test based on the polymerase chain reaction (PCR) can be used. However, PCR is not routinely performed in all hospital laboratories. Recently, immunohistochemistry (IHC) for MLH1 and MSH2 proteins has been reported as a rapid and useful method for MSI. However, the efficacy of IHC in the detection of the MSI has not been well established. The aim of this study was to evaluate the usefulness of IHC in the detection of the MSI by comparing it with the test results using PCR in colorectal cancer (CRC).Paraffin-embedded normal and tumor tissues from seventy-five patients who underwent surgical resection of CRC were used. Abnormal expression of MLH1 and MSH2 protein was determined by IHC using MLH1 and MSH2 antibodies. Normal and tumor DNAs were obtained from thirty CRC tissues that showed abnormal expression of MLH1 and MSH2 proteins by IHC. The MSI status was confirmed by PCR using five markers.Thirty tumors showed abnormal expression of MLH1 and MSH2 proteins by IHC, but only three tumors out of them were confirmed to have MSI by PCR.This result suggests that IHC with MLH1 and MSH2 antibodies does not seem to be a useful method to identify MSI in CRC, therefore PCR is required for detection of the MSI.

Background/Aims Capsule endoscopy (CE) is widely used. However, CE has limitations including incomplete examination, inadequate bowel preparation, and retention. The aim of this study was to estimate the indications for and detection, completion, and retention rates of small intestine CE based on the 10-year data from the Korean Capsule Endoscopy Registry. Methods Twenty-four hospitals participated in this study. Clinical information, such as reasons for CE, method and quality of bowel preparation, and incomplete examination and capsule retention rates, was collected and analyzed. Results A total of 2,914 CEs were registered. The most common reason for CE was obscure gastrointestinal bleeding (59%). Significant lesions were detected in 66% of cases. Positive CE diagnosis occurred in 63% of cases. The preparation method did not significantly affect the quality of bowel preparation for CE. The overall incomplete rate was 33%, and was high in the elderly and those with poor bowel preparation. Capsule retention was 3% and high in patients with small bowel tumors and Crohn's disease and in children under 10 years of age. Conclusions CE is a valuable technique; while the overall detection rate is high, incompletion and retention rates are also relatively high. CE should be carefully considered in the elderly and children less than 10 years of age, as well as in patients with small bowel tumors and Crohn's disease.

Ovarian metastases represent about 3-5% of all ovarian malignancies. Most of these tumors originate in the digestive tract and cholangiocarcinoma rarely involves the ovary. A 60-year-old woman was admitted for the investigation of abdominal distension that had lasted 1 week. One and a half years prior, the patient had undergone choledochal cyst excision, Roux-en Y hepaticojejunostomy and cholecystectomy. Computed tomography scans of the abdomen revealed a papillary mass in the remnant distal common bile duct and enlargement of both ovaries with a huge amount of ascites. An explorative laparotomy disclosed no peritoneal seeding with resectable cholangiocarcinoma and bilateral ovarian mass. Pylorus-preserving pancreatoduodenectomy and bilateral salphingo-oophorectomy with hysterectomy were performed. Histologically, it was a well-differentiated adenocarcinoma and all surgical margins were free of tumor. Both ovarian masses were consistent with metastatic adenocarcinoma from the common bile duct. The patient received six cycles of postoperative adjuvant systemic chemotherapy, dying after 10 months due to pulmonary embolism.