Joong Ho Bae

The Miss Rate for Colorectal Adenoma Determined by Quality-Adjusted, Back-to-Back Colonoscopies.

Background/Aims Colonoscopy is considered to be the gold standard for detecting adenomatous polyps. Polyps are missed during colonoscopic examination at a rate that varies from 6% to 27%. The adenoma miss rate affects colonoscopic surveillance intervals and procedural quality. We aimed to assess the adenoma miss rate and the variables affecting the rate using same-day, quality-adjusted, back-to-back colonoscopies. Methods This prospective study was performed at a single institution and included 149 patients. Two consecutive same-day colonoscopies were performed by two experienced endoscopists. The adenoma miss rates and variables affecting the missed adenomas, including polyp characteristics and procedure times, were evaluated. Results The miss rates of polyps, adenomas, and advanced adenomas were 16.8%, 17%, and 5.4%, respectively. The smaller polyps and increased number of polyps detected during the first colonoscopy were more likely to be missed. A longer insertion time during the colonoscopy was correlated with an increased adenoma detection rate. Conclusions There was a significant miss rate in the detection of colonic adenomas even in quality-adjusted, back-to-back colonoscopies. The adenoma miss rate can be reduced with a sufficient observation time during colonoscopic insertion. The development of specific technological methods to reduce the adenoma miss rate is necessary.

Adult-onset Still's Disease with Disseminated Intravascular Coagulation and Multiple Organ Dysfunctions Dramatically Treated with Cyclosporine A

Severe systemic manifestations of adult onset Stills disease (AOSD) are often fatal and occasionally related to hemophagocytic syndrome (HS). We describe the case of a 49-yr-old woman with AOSD presenting with non-remitting high fever, confusion, jaundice, hepatosplenomegaly, serositis, azotemia, pancytopenia, coagulopathy with disseminated intravascular coagulation (DIC), hyperferritinemia, acute acalculous cholecystitis and ileocolitis noted in computed tomographic images. The patient had a history of herpes zoster developed prior to the admission, but there is no history of diarrhea or abdominal pain. Although bone marrow examination was not performed due to hemorrhagic diathesis, we suspected AOSD-associated HS on the basis of clinical course without detectable infectious agents in cultures or serologic studies. Intravenous immunoglobulin, pulse methylprednisolone, oral cyclosporine A (CsA) and ceftriaxone brought about transient improvement of fever and confusion, but the disease progressed. After increasing CsA dose, all previously mentioned abnormalities disappeared rapidly. Accordingly, we believe that DIC and multiple organ dysfunctions might have been the complications of HS but not that of sepsis, and that CsA can be used as a first-line therapy in case of life-threatening situations.

A fatal case of hepatitis B virus (HBV) reactivation during long-term, very-low-dose steroid treatment in an inactive HBV carrier

Hepatitis B virus (HBV) may be reactivated after chemotherapy or immunosuppressive therapy, and therefore administration of antiviral agents before such treatment is recommended. Most reported cases of reactivation are associated with high doses of immunosuppressive agents or combination therapy. We present a case of a previously inactive HBV carrier with an acute severe flare-up during a long-term, very-low-dose (2.5 mg/day) steroid treatment for rheumatoid arthritis. We suggest that even a minimal dose of single-regimen oral steroid can cause reactivation of indolent, inactive HBV.

Graduated injection needles and snares for polypectomy are useful for measuring colorectal polyp size

BACKGROUND Accurate measurement of polyp size during colonoscopy is important; however, visual estimation of polyp size is inaccurate, and it is cumbersome to use additional accessories to measure polyp size whenever polyps are detected. AIMS To evaluate the accuracy and usefulness of graduated devices that can also be used for polypectomy. METHODS The ends of the outer sheath of the injection needles and snares were marked at intervals of 5mm (total 30mm). Four endoscopists measured 53 polyps of 36 patients in the following manner: visual estimation, estimation with biopsy forceps, and measurement with graduated devices. Actual size of all polyps measured through a calliper was used as reference standard. RESULTS The difference between actual size and size measured by visual estimation was statistically significant (1.27mm, P<0.001), whilst the differences between actual size and size measured by biopsy forceps (0.06mm, P=1.00) or graduated devices (0.15mm, P=0.620) were not. The linear correlation between the estimates and the actual sizes showed that the graduated device gave the largest positive linear correlation (0.986, P<0.001) of the three measurement methods tested. CONCLUSIONS The graduated devices are efficient methods when measuring polyp size and performing polypectomy in a single step.

Glass dust esophagitis: an unusual cause of chest pain

H Y n H A 29-year-old man who had worked as a glass grinder for 6 months presented with 2 days of chest pain that began after drinking a glass of water at his workplace. The pain was worsened by the intake of both food and liquids. Physical examination, chest radiography, and electrocardiography findings all were normal. Hematologic examination was normal except for mild eosinophilia (white blood count 7900/mm; eosinophils, 8.4%). EGD revealed fine whitish granular elevations with mucosal erythema scattered throughout the entire esophagus (A and B). Pathologic examination of esophageal biopsy specimens showed diffuse surface epithelial erosion associated with active inflammatory infiltrates including eosinophils (C, H&E, orig. mag. 40). On higher power view, numerous tiny fragments of refractile foreign body–like material were present over the surface squamous epithelium with occasional impaction into the erosive foci (D, H&E, orig. mag. 200). Considering his d