Hyun Il Seo

Impact of Nonalcoholic Fatty Liver Disease on Insulin Resistance in Relation to HbA1c Levels in Nondiabetic Subjects

OBJECTIVES:A cross-sectional analysis was conducted in healthy, nondiabetic Korean adults to assess the prevalence of nonalcoholic fatty liver disease (NAFLD), to compare the prevalence of NAFLD across different glycemic ranges as assessed by glycosylated hemoglobin (HbA1c), and to examine the impact of NAFLD on insulin resistance in relation to HbA1c levels.METHODS:After rigorous exclusion criteria, the final number of subjects who participated in a comprehensive health status checkup program was 99,969. All subjects were classified into four categories with respect to HbA1c level (≤4.9, 5.0–5.4, 5.5–5.9, and 6.0–6.4%). We estimated the odds ratio (OR) for prevalence of NAFLD according to the categorized level of HbA1C and evaluated the association of NAFLD with the homeostatic model assessment of insulin resistance (HOMA-IR) in relation to the HbA1c level.RESULTS:Twenty-eight percent (n=28,130, 40.2% of the men, 10.3% of the women) of the study subjects had NAFLD. Men had a 5.83-fold (95% confidence interval 5.63–6.05) increased risk for having NAFLD than did women. The risk for NAFLD increased with increasing level of HbA1c (OR 1.44, 2.62, and 7.18) when compared with the lowest quartile (HbA1C≤4.9%). HOMA-IR increased in the NAFLD subjects as the level of HbA1c increased. The magnitude of association of HOMA-IR with HbA1c level was greater in NAFLD subjects than in non-NAFLD subjects (P<0.001 for interaction). These associations were consistent even after adjustment for body mass index and other metabolic components.CONCLUSIONS:NAFLD had an association with HbA1c level and insulin resistance in nondiabetic individuals, and these associations were independent of obesity and other metabolic components.

Which metabolic syndrome criteria best predict the presence of non-alcoholic fatty liver disease?

AIMS To know which MS criteria best predict the presence of NAFLD and the prevalences of metabolic syndrome (MS) and non-alcoholic fatty liver disease (NAFLD) diagnosed ultrasonographically among pre-diabetic and diabetic subjects based on three different MS criteria (IDF, ATP III, WHO). METHODS Subjects were screened and those with a fasting serum glucose level ≥100 mg/dL were further tested with a 75 g oral glucose tolerance test. And those who were newly diagnosed as having pre-diabetes or diabetes were evaluated for MS and NAFLD. We compared the risk ratios of NAFLD among three MS criteria using multivariate and multiple logistic regression analyses. RESULTS A total of 1365 subjects (977 males, mean age 48.4±9.5 years) were analyzed. The WHO criteria produced the highest prevalence of MS in both the pre-diabetic (49.8%) and diabetic (58.9%) groups. The IDF criteria produced the highest odds ratio for NAFLD in both pre-diabetic (3.89 [95% CI 2.75-5.51]) and diabetic (5.53 [95% CI 3.21-9.52]) groups. CONCLUSIONS The prevalence of MS depends on the set of diagnostic criteria used. IDF criteria best predicts the presence of NAFLD. The presence of NAFLD should be considered as a component of the diagnostic criteria for MS.

The Effect of Infliximab on Patients with Ulcerative Colitis in Korea

Background/Aims Infliximab was introduced recently as a rescue therapy for ulcerative colitis (UC) patients refractory to conventional treatments such as therapy with 5-amiono salicylic acids (5-ASA), immune modulators, and corticosteroids. However, there is insufficient data about its efficacy and safety in Korea. Methods From 7 tertiary referral hospitals, 33 patients who were treated with infliximab for moderate to severe (Mayo score 6-12) UC refractory to conventional treatment were recruited to this study. Clinical remission was defined as a total Mayo score of 2 or lower and every subscore less than 2. Partial response was defined as a decrease of Mayo score at least 3 points from baseline. Results Twenty-three patients (69.7%) showed clinical remission and 29 patients (87.8%) showed partial response in the observation period. When the remission and non-remission groups were compared in univariate analysis, only a higher total Mayo score at base line (11.0±0.9 vs. 9.9±1.5; P=0.04) was related to remission. The remission maintenance rate decreased with time in the Kaplan-Meier analysis. Two patients experienced re-remission after the first remission followed by aggravation during infliximab treatment. Three patients stopped infliximab treatment owing to adverse events including rhabdomyolysis, pneumonia, and fever of unknown origin. Conclusions If there is no choice except surgery for UC patients refractory to conventional treatment, infliximab is an effective and relatively safe treatment option for these patients in Korea.

Electrolyte changes after bowel preparation for colonoscopy: A randomized controlled multicenter trial

AIM To investigate the electrolyte changes between 2-L polyethylene glycol with ascorbic acid 20 g (PEG-Asc) and 4-L PEG solutions. METHODS From August 2012 to February 2013, a total of 226 patients were enrolled at four tertiary hospitals. All patients were randomly allocated to a PEG-Asc group or a 4-L PEG. Before colonoscopy, patients completed a questionnaire to assess bowel preparation-related symptoms, satisfaction, and willingness. Endoscopists assessed the bowel preparation using the Boston Bowel Preparation Scale (BBPS). In addition, blood tests, including serum electrolytes, serum osmolarity, and urine osmolarity were evaluated both before and after the procedure. RESULTS A total of 226 patients were analyzed. BBPS scores were similar and the adequate bowel preparation rate (BBPS ≥ 6) was not different between the two groups (PEG-Asc vs 4-L PEG, 73.2% vs 76.3%, P = 0.760). Bowel preparation-related symptoms also were not different between the two groups. The taste of PEG-Asc was better (41.1% vs 16.7%, P < 0.001), and the willingness to undergo repeated bowel preparation was higher in the PEG-Asc group (73.2% vs 59.3%, P = 0.027) than in 4-L PEG. There were no significant changes in serum electrolytes in either group. CONCLUSION In this multicenter trial, bowel preparation with PEG-Asc was better than 4-L PEG in terms of patient satisfaction, with similar degrees of bowel preparation and electrolyte changes.

A Case of Gastric Inverted Hyperplastic Polyp Found with Gastritis Cystica Profunda and Early Gastric Cancer

A gastric inverted hyperplastic polyp is a rare type of gastric polyp and is characterized by downward growth of a variety of mucosal components into the submucosa. The polyp consists of columnar cells resembling foveolar epithelium and pyloric gland epithelium and can coexist with gastritis cystica profunda. Frequently, adenocarcinoma can coexist, but the relation is not clear. A 77-year-old male underwent endoscopic submucosal dissection due to early gastric cancer. A gastric inverted hyperplastic polyp was found in the removed specimen and gastric cystica profunda was also found. We report a case of gastric inverted hyperplastic polyp coexisting with gastric cystica profunda and gastric adenocarcinoma.

Comparison of the efficacy of disinfectants in automated endoscope reprocessors for colonoscopes: tertiary amine compound (Sencron2?) versus ortho-phthalaldehyde (Cidex?OPA)

Background/Aims To prevent the transmission of pathogens by endoscopes, following established reprocessing guidelines is critical. An ideal reprocessing step is simple, fast, and inexpensive. Here, we evaluated and compared the efficacy and safety of two disinfectants, a tertiary amine compound (TAC) and ortho-phthalaldehyde (OPA). Methods A total of 100 colonoscopes were randomly reprocessed using two same automated endoscope reprocessors, according to disinfectant. The exposure time was 10 minutes for 0.55% OPA (Cidex® OPA, Johnson & Johnson) and 5 minutes for 4% TAC (Sencron2®, Bab Gencel Pharma & Chemical Ind. Co.). Three culture samples were obtained from each colonoscope after reprocessing. Results A total of nine samples were positive among the 300 culture samples. The positive culture rate was not statistically different between the two groups (4% for OPA and 2% for TAC, P=0.501). There were no incidents related to safety during the study period. Conclusions TAC was non-inferior in terms of reprocessing efficacy to OPA and was safe to use. Therefore, TAC seems to be a good alternative disinfectant with a relatively short exposure time and is also less expensive than OPA.

Hyperbaric oxygen therapy for pyoderma gangrenosum associated with ulcerative colitis

Pyoderma gangrenosum (PG), an ulcerating skin condition, is rare in patients with ulcerative colitis (UC). We report a case of successful treatment of PG in a patient with UC using hyperbaric oxygen therapy (HBOT). The patient had UC that was in remission following treatment with mesalazine and azathioprine therapy. After visiting an orthopedic clinic, the patient opted for treatment with antibiotics and daily dressing of the ulcerative skin lesions, while azathioprine was discontinued. However, the lesions did not improve. Two months later, the patient visited a dermatologist who diagnosed the lesions as PG, and he was admitted to our unit. Surgical debridement and HBOT were performed by a plastic surgeon in the emergency department. After 3 months of HBOT and topical treatment, the patients PG completely resolved. His UC was still in remission with mesalazine alone. HBOT may be an effective and safe alternative treatment for PG associated with UC, particularly in patients in whom anti-tumor necrosis factor agents are unnecessary.

Mucosal Incision and Forceps Biopsy for Reliable Tissue Sampling of Gastric Subepithelial Tumors

Background/Aims The diagnostic efficacy of current tissue sampling techniques for gastric subepithelial tumors (SETs) is limited. Better tissue sampling techniques are needed to improve pathological diagnosis. The aim of this study was to evaluate the safety and efficacy of a new technique, mucosal incision and forceps biopsy, for reliable tissue sampling of gastric SETs. Methods This study enrolled 12 consecutive patients who underwent mucosal incision and forceps biopsy of gastric SETs between November 2011 and September 2014 at Gangneung Asan Hospital. The medical records of patients were reviewed retrospectively. The safety and diagnostic yield of this method were evaluated. Results By performing mucosal incision and forceps biopsy, we were able to provide a definitive histological diagnosis for 11 out of 12 cases. The pathological diagnoses were leiomyoma (3/11), gastrointestinal stromal tumor (GIST; 2/11), lipoma (2/11), schwannoma (1/11), and ectopic pancreas (3/11). In cases of leiomyoma (n=3) and GIST (n=2), tissue samples were of sufficient size to allow immunohistochemical staining. In addition, the mitotic index was evaluated in two cases of GIST. There were no procedure-related complications. Conclusions Mucosal incision and forceps biopsy can be used as one of several methods to obtain adequate tissue samples from gastric SETs.

Randomized clinical trial comparing fixed-time split dosing and split dosing of oral Picosulfate regimen for bowel preparation

AIM To compare the efficacy of fixed-time split dose and split dose of an oral sodium picosulfate for bowel preparation. METHODS This is study was prospective, randomized controlled study performed at a single Institution (2013-058). A total of 204 subjects were assigned to receive one of two sodium picosulfate regimens (i.e., fixed-time split or split) prior to colonoscopy. Main outcome measurements were bowel preparation quality and subject tolerability. RESULTS There was no statistical difference between the fixed-time split dose regimen group and the split dose regimen group (Ottawa score mean 2.57 ± 1.91 vs 2.80 ± 2.51, P = 0.457). Cecal intubation time and physician’s satisfaction of inspection were not significantly different between the two groups (P = 0.428, P = 0.489). On subgroup analysis, for afternoon procedures, the fixed-time split dose regimen was equally effective as compared with the split dose regimen (Ottawa score mean 2.56 ± 1.78 vs 2.59 ± 2.27, P = 0.932). There was no difference in tolerability or compliance between the two groups. Nausea was 21.2% in the fixed-time split dose group and 14.3% in the split dose group (P = 0.136). Vomiting was 7.1% and 2.9% (P = 0.164), abdominal discomfort 7.1% and 4.8% (P = 0.484), dizziness 1% and 4.8% (P = 0.113), cold sweating 1% and 0% (P = 0.302) and palpitation 0% and 1% (P = 0.330), respectively. Sleep disturbance was two (2%) patients in the fixed-time split dose group and zero (0%) patient in the split dose preparation (P = 0.143) group. CONCLUSION A fixed-time split dose regimen with sodium picosulfate is not inferior to a split dose regimen for bowel preparation and equally effective for afternoon colonoscopy.

Predisposing Factors of Ischemic Colitis: Data from 14 Years of Experience in a Single Center

Background and Aims While several case reports on ischemic colitis (IC) suggest the presence of predisposing causative factors, a few studies have investigated the predisposing factors in IC. This study aimed to identify the characteristics of patients with IC, particularly focusing on the predisposing factors. Methods We conducted a single-center, retrospective analysis of 159 patients with IC. Clinical characteristics, laboratory data, endoscopic findings, and medical records were reviewed. Data were compared between groups of patients defined according to the predisposing factors. The predisposing factors are defined as temporary states or episodic events occurring within a week before the development of IC such as colonoscopy, enema, use of laxatives, heavy drinking, pancreatitis, shock, and burn. Results Compared to the group of patients without predisposing factors of IC, the group of patients with predisposing factors was characterized by a relatively higher prevalence of male sex (56.9% versus 33.3%, p = 0.005), younger age (60.9 ± 15.4 versus 67.2 ± 13.4 years, p = 0.010), lower incidence of hypertension (43.1% versus 60.2%, p = 0.044), and fewer risk factors (1.24 ± 1.18 versus 1.82 ± 1.22, p = 0.005). Conclusions Among men with predisposing factors, IC may develop even at a relatively younger age and in the absence of multiple risk factors, suggesting that predisposing factors may be involved in the pathogenesis of IC.