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Objective. The long-term efficacy of azathioprine (AZA) in steroid-dependent ulcerative colitis (UC) is still unclear. We aimed to evaluate the efficacy of AZA in patients with steroid-dependent UC. Material and methods. We retrospectively reviewed die medical records of 106 patients with steroid-dependent UC who were administered AZA. Three-year outcomes of AZA therapy were evaluated. The outcome of the treatment was defined as (1) success, indicating induction and maintenance of remission throughout the study period (complete success) or remission followed by infrequent and short relapses (partial success); or (2) failure, indicating the absence of remission, frequent or prolonged relapses, infliximab administration, or colectomy. Results. Of the 106 patients, 73 (68.9%) continued on AZA for >6 months (AZA therapy group) and 33 (31.1%) discontinued AZA within 6 months due to intolerance (AZA intolerance group, n = 20), colectomy (n = 6), or follow-up loss (n = 7). Three-year outcomes for 106 patients were success in 54.7% (complete success, 35.8%; partial success, 18.9%), failure in 32.1% (frequent or prolonged relapses, 12.3%; infliximab administration, 5.6%; colectomy, 14.2%), and follow-up loss or death in 13.2%. The success rate increased to 71.2% (complete success, 46.6%; partial success, 24.7%) when the analysis was confined to the 73 patients who continued AZA for > 6 months. The 3-year success rate was higher in the AZA therapy group (71.2%) than the AZA intolerance group (25.0%) (p < 0.001). Conclusions. AZA is an effective treatment for steroid-dependent UC. The efficacy of AZA is well sustained over 3 years. [ABSTRACT FROM AUTHOR]

Background and Aim Chronic constipation is frequently seen in women who have undergone hysterectomy or delivery. However, reports regarding anorectal physiologic features in those patients are rare. Patients with constipation associated with either radical hysterectomy or vaginal delivery were analyzed in order to clarify the anorectal physiologic features and the effectiveness of biofeedback therapy. Methods Of the constipated patients, a hysterectomy group ( n = 40), delivery group ( n = 41), and a control group ( n = 89), who had no history of either surgery or delivery before developing functional constipation were included. Their anorectal physiological tests and the effectiveness of biofeedback therapy were investigated. Results The volume of desire to defecate was greater in the hysterectomy group than in the control group (86.5 ± 55.0 mL vs 62.9 ± 33.7 mL; P = 0.03), and more than 240 mL of maximal volume of toleration was more frequently noted in the hysterectomy group (32.5%) than in the delivery group (14.6%) and control group (13.5%) ( P = 0.02).The failure of balloon expulsion was more frequently noted in the delivery group (44.0%) than in the hysterectomy group (15.0%) and control group (25.0%) ( P = 0.01). The defecation satisfaction score was significantly increased after biofeedback therapy in the hysterectomy group (2.0 ± 2.7 vs 7.8 ± 1.5, P < 0.001), the delivery group (1.6 ± 2.1 vs 6.7 ± 2.0, P < 0.001), and the control group (2.5 ± 2.7 vs 6.9 ± 2.1, P < 0.001). Conclusions Rectal hyposensitivity could have been the characteristic mechanism in the hysterectomy group, whereas dyssynergic defecation could have been the cause in the delivery group. Biofeedback therapy was effective for both groups. [ABSTRACT FROM AUTHOR]

Background and Aims Although capsule endoscopy ( CE) is widely used as a first-line diagnostic modality for obscure gastrointestinal bleeding ( OGIB), the rebleeding rate after negative CE varies according to different studies. We tried to elucidate the outcomes after negative CE for OGIB and to determine the risk factors associated with rebleeding. Methods We retrospectively reviewed data from 125 patients who had received CE for OGIB. Results Pill Cam SB capsules were used for 92 patients (73.6%) and SB2 capsules for the other 33 (26.4%). The complete visualization of the small bowel was achieved in 93 patients (74.4%). Of the 63 patients (50.4%) who showed negative CE results, 60 patients did not receive any further specific treatment for OGIB, and were analyzed for the rebleeding rate and risk factors for rebleeding. Of the 60 patients, rebleeding episodes were observed in 16 patients (26.7%), and the cumulative rebleeding rates after 6, 12, 24, and 36 months were 12.4%, 14.3%, 28.7%, and 35.9%, respectively. Substantial rebleeding events were observed with similar frequency both after negative CE without subsequent treatment (26.7%) and after positive CE without specific treatment (21.2%) ( P = 0.496). Conclusions Considerable rebleeding episodes were observed after negative CE result for OGIB. Further complementary diagnostic work-ups and close follow-up are needed to be considered for patients with OGIB and negative CE results. [ABSTRACT FROM AUTHOR]

Background: Early and accurate detection of adenomatous colonic polyps is a major concern in the prevention of colon cancer. Near-infrared fluorescence (NIRF) imaging with optical probes targeting specific peptides enables the noninvasive visualization and characterization of lesions. Matrix metalloproteinases (MMPs) are known to play an important role in tumorigenesis and tumor progression.Aim: To investigate the effectiveness of NIRF imaging, with a novel MMP-activatable probe based on a polymeric nanoparticle platform, in the colon cancer models.Methods: We used an azoxymethane (AOM)-induced mouse colon cancer model resembling human sporadic colon cancer and an MMP-positive xenograft tumor model. MMP expression was evaluated by Western blotting, real-time PCR, and immunohistochemical staining. NIRF imaging was performed with a novel MMP-activatable probe, an MMP-inactivatable probe, and saline. In addition, we observed the change of NIRF signal intensity after intratumoral administration of an MMP-inhibitor.Results: Multiple tumors with various sizes developed in AOM-treated mouse colons, progressing from adenomas to adenocarcinomas, with MMP expression progressively increasing in the normal-adenoma-adenocarcinoma sequence. In mice injected with the MMP-activatable probe, the NIRF signal also increased in this sequence and was highly correlated with MMP expression (p < 0.001). Tumor-background-ratios (TBR) of adenocarcinoma to adjacent normal mucosa by a novel probe were significantly higher than that of adenoma (p < 0.001). In both the AOM and xenograft models, NIRF signals of tumors decreased after treatment with an MMP-inhibitor.Conclusions: NIRF imaging using a polymeric nanoparticle-based probe may be useful for detecting early stage disease and for assessing treatment response. [ABSTRACT FROM AUTHOR]

Background: Small bowel tumors are relatively rare, and their confirmative diagnosis before surgery is not easy.Aims: This study was performed to investigate the clinical characteristics of patients with small bowel tumors who received double-balloon enteroscopy (DBE). Secondary end points were to evaluate the usefulness and safety of DBE for the diagnosis of patients with suspected SB tumors derived from other previous procedures.Methods: We retrospectively analyzed consecutive DBE examinations to explore the small intestine in eight university hospitals over a 5-year period.Results: A total of 877 DBE examinations (per oral 487, per anal 390) were performed in 645 patients (405 males, mean age 48.2 years). Small bowel tumors were diagnosed in 112 patients (17.4%), of which 38 patients had benign polyps, 29 had gastrointestinal stromal tumors/leiomyomata, 18 had lymphomas, 14 had adenocarcinomas, five had metastatic or invasive cancers, five had lipomas, and three patients had cystic tumors. The main reasons for DBE among patients with small bowel tumors were obscure gastrointestinal bleeding (OGIB, 40.2%) followed by abnormal imaging study (25.2%). The concordance rate of diagnoses based on DBE with diagnoses based on small bowel follow-through, CT, and capsule endoscopy among patients with small bowel tumors was 68.9% (42/61), 75.3% (70/93), and 78.3% (18/23), respectively. Therapeutic plans were changed due to the DBE results in 64.2% of patients with small bowel tumors.Conclusions: Approximately one-sixth of patients who received DBE had small bowel tumors, and the most common reason for DBE among patients with small bowel tumors was OGIB. DBE is a useful method for the confirmative diagnosis of small bowel tumors and has a good clinical impact on therapeutic plans and short-term clinical results. [ABSTRACT FROM AUTHOR]

Background and Aims: Researchers have not clearly described the clinical and pathogenetic features of hypoganglionosis and adult-onset Hirschsprung's disease, which cause pseudo-obstruction or intractable constipation. We conducted this study to explore these features of hypoganglionosis and adult-onset Hirschsprung's disease in Korean patients.Methods: We enrolled 24 patients pathologically confirmed as having hypoganglionosis and 11 as having adult-onset Hirschsprung's disease. We recruited 26 subjects who had undergone operation for nonobstructive colon cancer and 45 healthy volunteers as controls. We described their clinical features, investigated ganglion cells and interstitial cells of Cajal (ICC), and analyzed RET, EDNRB, EDN3, and SOX10 genes.Results: We classified hypoganglionosis patients into two groups: type I (focal type, n = 13), with focally narrowed transition zone (TZ); and type II (diffuse type, n = 11), without transition zone. Hypoganglionosis patients had significantly fewer ganglion cells than the controls, and those cells were scarcer in the transition zone than in the proximal dilated area (P < 0.05). The ICC numbers in both diseases were significantly lower than in controls; however, they were similar between transition zone and the proximal dilated area in hypoganglionosis. In adult-onset Hirschsprung's disease, two significant intronic RET polymorphic variants, IVS14-24G>A and IVS19+47T>C, were significantly associated with adult-onset Hirschsprung's disease (P = 0.0122 and 0.0295, respectively), but not with hypoganglionosis.Conclusions: Hypoganglionosis and adult-onset Hirschsprung's disease have different pathophysiologic characteristics, although their clinical presentations are similar. We suggest that there are two subgroups of hypoganglionosis: those with or without a focally narrowed transition zone with a profoundly diminished number of ganglion cells. [ABSTRACT FROM AUTHOR]

Objective. Constipation in patients with mild spinal cord disease is not well investigated yet. We aimed to investigate anorectal function and the effect of biofeedback therapy in constipated patients with mild spinal cord diseases. Material and methods. A total of 14 constipated patients with myelopathy and 32 with radiculopathy were enrolled retrospectively. All patients were able to walk independently. The control group comprised of 100 constipated patients without any neurologic problem. Colonic transit time and the presence of dyssynergia were assessed before biofeedback therapy. All patients answered structured questionnaires on constipation, before and after biofeedback therapy. Results. The mean rectosigmoid colonic transit time of the myelopathy group was significantly delayed (myelopathy, 18.6 ± 14.6 h; radiculopathy, 12.8 ± 11.9 h; control, 9.6 ± 11.2 h; p = 0.032). Delay in total colonic transit time was more frequent in the myelopathy group (myelopathy, 57.1%; radiculopathy, 23.3%; control, 18.5%; p = 0.004). On anorectal manometry, the squeezing pressure of the anal sphincter was decreased in the myelopathy group (myelopathy, 132.3 ± 73.3 mmHg; radiculopathy, 179.9 ± 86.1 mmHg; control 200.4 ± 82.4 mmHg; p < 0.05). The success rate of biofeedback therapy was lower in the myelopathy group (28.6% for myelopathy vs. 62.0% for control group; p = 0.034). The response rate to biofeedback therapy was similar between radiculopathy and control group (62.5% for radiculopathy vs. 62.0% for control group; p = 1.000). Conclusions. In constipation associated with mild myelopathy, delayed colonic transit and dyssynergic defecation were major pathophysiologic abnormalities and biofeedback was less effective compared with control group. However, in the radiculopathy group, biofeedback was as effective as in the control group. [ABSTRACT FROM AUTHOR]

Objective. Recent studies have suggested that the clinical characteristics and genetic background of Crohn's disease (CD) patients differ between Asian and Caucasian individuals. However, the clinical features and course of CD in Asian patients remain unclear. Therefore, we investigated the clinical features and long-term prognosis of CD in a Korean population. Material and methods. We retrospectively analyzed 278 Korean patients with CD first diagnosed at the Asan Medical Center between March 1991 and February 2007. Results. The male-to-female ratio was 2.2:1 and the median age at diagnosis was 23 years. The median duration of follow-up was 71 months (range, 1–210 months). At diagnosis, 187 patients (67.3%) had disease in both small bowel and colon, 68 (24.4%) had isolated small bowel disease, and 23 (8.3%) had isolated colonic disease. The number of patients with stricturing or penetrating behavior as defined by the Montreal classification increased from 87 (31.3%) at diagnosis to 141 (50.7%) at final evaluation. One hundred and thirty patients (46.8%) experienced perianal fistulas before and/or after diagnosis of CD. A total of 71 patients (25.5%) underwent intestinal resection and the cumulative probability of intestinal resection after 1, 5, and 10 years was 15.5%, 25.0%, and 32.8%, respectively. Conclusions. Korean CD patients differed from Western patients in gender distribution, disease location, and perianal fistula occurrence. Korean CD patients may also have better clinical courses than Western patients, as indicated by the lower intestinal resection rate. [ABSTRACT FROM AUTHOR]

Abstract: Germline mutations within the adenomatous polyposis coli (APC) gene are associated with familial adenomatous polyposis (FAP), an autosomal dominant disease predisposing individuals to colorectal cancer. Identification of APC mutations has important implications for genetic counseling and management of FAP patients. We examined the APC mutation status of 10 Korean FAP patients by polymerase chain reaction–direct sequencing method and found six APC mutations, including three novel mutations. Testing for MUTYH mutation was done for FAP patients in whom no mutation in the APC gene was identified. Three novel mutations (c.1654_1663delTCTTGGCGAG, c.3709C>T, and c.6092_6094delinsTT) and three previously reported mutations (c.3631_3632delAT, c.4438C>T, and c.4612_4613delGA) were detected. The MUTYH mutation was not detected in any of the four FAP patients without an APC mutation. This finding of three novel mutations in a group of Korean FAP patients broadens the spectrum of APC mutations. [Copyright &y& Elsevier]

Objective. Capsule endoscopy (CE) is a novel investigation for the diagnosis of small-bowel disease but its interpretation is highly subjective. We studied the inter-observer agreement and accuracy of the interpretation of CE findings based on capsule endoscopy structured terminology (CEST). Material and methods. Fifty-six CE video clips were collected from eight university hospitals in South Korea and were independently reviewed by 13 gastroenterology experts and 10 trainees. All investigators recorded their findings based on CEST. To determine the accuracy of individual viewers, we defined the ‘gold standard’ as a joint review by four experts. Results. The 56 CE video clips included five normal cases, 19 cases of protruding lesions, 21 cases of depressed lesions, three cases of flat lesions, one case of abnormal mucosa, six cases with blood in the lumen, and one case of stenotic lumen. The overall mean accuracies for the experts and trainees were 74.3% ± 22.6% and 61.7% ± 25.4%, respectively. The overall accuracy for the trainee group was significantly lower than that for the expert group ( P < 0.001), especially in normal, tumor, venous structure, and ulcer cases. The accuracies of the two groups varied with the CE findings. The accuracies were higher in cases with more prominent intraluminal changes (e.g. active small-bowel bleeding, ulcer, tumor, stenotic lumen). In contrast, subtle mucosal lesions, such as erosion, angioectasia, and diverticulum, had lower accuracies. The mean kappa values for the experts and trainees were 0.61 (range 0.39–0.97) and 0.46 (range 0.17–0.66), respectively. Conclusions. Our results showed that there was substantial agreement between experts and moderate agreement between trainees. In order to achieve higher accuracies and better inter-observer agreement, we need not only more experience with CE but also consensus regarding CEST terminology. [ABSTRACT FROM AUTHOR]

Background: Although the diagnostic and therapeutic values of double balloon endoscopy (DBE) have been investigated, the subjective tolerability to DBE has not been assessed. We aimed to evaluate patients' tolerability to DBE.Methods: We prospectively enrolled patients who underwent DBE. For the comparison of tolerability to DBE with that to esophagogastroduodenoscopy (EGD) and colonoscopy, those who had not undergone EGD nor colonoscopy were excluded. A total of 52 patients were included. All procedures were performed under conscious sedation with midazolam with or without pethidine. Patients' tolerability to DBE, EGD, and colonoscopy was assessed through an interview with a questionnaire using a 10-point Likert scale.Results: A total of 36 patients underwent both antegrade DBE and EGD under conscious sedation. The level of abdominal pain during procedures, the level of post-procedural abdominal discomfort, and the proportion of patients with persistent abdominal discomfort until the next morning were higher in antegrade DBE. However, when analyzed in 16 patients who had good quality of sedation, the differences in the level of abdominal pain during procedures and the persistent abdominal discomfort until the next morning disappeared. A total of 23 patients underwent both retrograde DBE and colonoscopy under conscious sedation. Tolerability parameters were not different between retrograde DBE and colonoscopy. Serious complications, including hemodynamic instability, did not occur during all procedures.Conclusion: Patients tolerated DBE well. DBE may be performed as comfortably as EGD and colonoscopy if the quality of sedation is good enough. [ABSTRACT FROM AUTHOR]

Background: There is no consensus regarding the degree of healing of endoscopic submucosal dissection (ESD)-induced ulcers and the optimal duration of proton pump inhibitor (PPI) treatment.Aim: To evaluate the degree of healing and the factors associated with healing of ESD-induced ulcers after PPI therapy for 4 weeks.Methods: Fifty-six patients who underwent complete ESD for adenoma or early gastric cancer were enrolled. All patients underwent follow-up endoscopy to evaluate the degree of ulcer healing after pantoprazole therapy (40 mg per day) for 4 weeks. We evaluated change in size of ESD-induced ulcers between baseline and 4 weeks, and correlated relevant factors with degree of healing of small and large ulcers.Results: At follow-up, 28 (50%) patients had large ulcers (area > 10 mm(2)). Ulcer size at 4 weeks was closely correlated with initial ulcer size (P < 0.001) and abruptly increased when initial ulcer size was larger than 4 cm. Comorbidity, procedure time, and initial specimen size were significantly associated with healing rate, but multivariate analysis showed that initial ulcer size was the only significant parameter (P < 0.015).Conclusions: Healing degree of ESD-induced ulcers at 4 weeks is dependent on initial ulcer size, indicating that duration of treatment with PPI should be dependent on initial ulcer size. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Backgrounds: It is not clear when and how frequently surveillance endoscopy should be performed after colorectal endoscopic submucosal dissection (ESD). We aimed to suggest a surveillance endoscopy strategy by investigating the cumulative local recurrence rates and identifying risk factors for local recurrence after colorectal ESD. Methods: We reviewed the medical records of 770 patients who underwent colorectal ESD for 778 lesions at our institution from 2005 to 2016. We investigated the cumulative local recurrence rates and risk factors for local recurrence. Results: Local recurrence developed in 12 (1.5%) of 778 lesions during the follow-up period of 37.4 ± 31.7 months. The one-, three-, and five-year cumulative local recurrence rates were 0.4%, 1.7%, and 2.2%, respectively. The risk factors for local recurrence were piecemeal resection (odds ratio (OR) 3.948, 95% confidence interval (CI) 1.164–13.385; p = 0.028) and histological incomplete resection (OR 8.713, 95% CI 2.588–29.334; p < 0.001). Local recurrence tended to develop frequently after ESD of early cancers. Conclusions: Short-term surveillance endoscopy should be recommended after piecemeal ESD, histological incomplete resection, and ESD of early colorectal cancers. Surveillance endoscopy with longer intervals can be suggested after en bloc ESD with the histological complete resection of benign colorectal tumors. [ABSTRACT FROM AUTHOR]

OBJECTIVES: The aims of this prospective study were to document the incidence of colon immediate postpolypectomy bleeding (IPPB) according to grade, and to identify potential risk factors of IPPB in patients who have received complete colonoscopy and polypectomy because of a colorectal polyp. METHODS: This was a prospective, cross-sectional study of 5,152 patients treated at 11 tertiary medical centers between July 2003 and July 2004. Patient-related, polyp-related, and procedure-related variables were evaluated as potential risk factors for IPPB. IPPB was defined as a bleeding occurring during the procedure and was graded as G1–G4. Risk factors associated with IPPB were analyzed by univariate and multivariate logistic regression analysis. RESULTS: A total of 9,336 colonic polyps were removed in 5,152 patients, and 262 (2.8%) colorectal polyps in 215 patients presented with IPPB. Polyp-based multivariate analysis revealed that old age (≥65 yr), comorbid cardiovascular or chronic renal disease, anticoagulant use, polyp size greater than 1 cm, gross morphology of polyps such as pedunculated polyp or laterally spreading tumor, poorer bowel preparation, cutting mode of the electrosurgical current, and the inadvertent cutting of a polyp before current application were significant risk factors for IPPB. CONCLUSION: Nine factors have been found to be associated with IPPB and polypectomy should be undertaken with caution under these conditions. [ABSTRACT FROM AUTHOR]

Colorectal cancer (CRC) is the second‐leading cause of cancer‐related mortality worldwide, which may be effectively reduced by early screening. Colon cancer secreted protein‐2 (CCSP‐2) is a promising blood marker for CRC. An electric‐field effect colorectal sensor (E‐FECS), an ion‐sensitive field‐effect transistor under dual gate operation with nanostructure is developed, to quantify CCSP‐2 directly from patient blood samples. The sensing performance of the E‐FECS is verified in 7 controls and 7 CRC samples, and it is clinically validated on 30 controls, 30 advanced adenomas, and 81 CRC cases. The concentration of CCSP‐2 is significantly higher in plasma samples from CRC and advanced adenoma compared with controls (both P < 0.001). Sensitivity and specificity for CRC versus controls are 44.4% and 86.7%, respectively (AUC of 0.67), and 43.3% and 86.7%, respectively, for advanced adenomas (AUC of 0.67). CCSP‐2 detects a greater number of CRC cases than carcinoembryonic antigen does (45.6% vs 24.1%), and the combination of the two markers detects an even greater number of cases (53.2%). The E‐FECS system successfully detects CCSP‐2 in a wide range of samples including early stage cancers and advanced adenoma. CCSP‐2 has potential for use as a blood‐based biomarker for CRC. [ABSTRACT FROM AUTHOR]

Background: We aimed to evaluate the role of fecal calprotectin (FC) as a noninvasive marker for the disease activity of ulcerative colitis (UC) in a Korean cohort.Methods: A total of 181 fecal samples were collected from 181 consecutive UC patients between April 2015 and September 2016. FC levels were measured using the Quantum Blue® Calprotectin rapid test. The laboratory test results, partial Mayo Score (pMS), and colonoscopic imaging findings at FC level measurement were retrospectively reviewed. The Mayo endoscopic subscore (MES) and UC endoscopic index of severity (UCEIS) were graded by 2 certified endoscopists after training with 50 other cases.Results: The FC levels were significantly correlated with pMS (Spearman correlation coefficient r = 0.428, p < 0.001), MES (r = 0.304, p < 0.001), UCEIS (r = 0.430, p < 0.001), and CRP (r = 0.379, p < 0.001). FC levels exhibited a significantly better correlation with UCEIS than with MES (Meng's z = - 2.457, p = 0.01). The FC cut-off level of 187.0 mg/kg indicated complete mucosal healing (MES = 0; UCEIS =0) with a sensitivity and specificity of 0.857 and 0.891, respectively (area under the curve, 0.883; 95% confidence interval, 0.772-1.000).Conclusion: The FC level is significantly correlated with the clinical disease activity index, endoscopic indices, and serum inflammatory biomarkers in a Korean UC cohort. FC is highly predictive of complete mucosal healing in UC. UCEIS exhibits a stronger correlation with the FC level, as compared to MES. Thus, FC could be used as a reliable noninvasive indicator for evaluating disease activity and mucosal healing in UC. [ABSTRACT FROM AUTHOR]