Ki Nam Shim

Appendiceal orifice inflammation as a skip lesion in ulcerative colitis: an analysis in relation to medical therapy and disease extent☆☆☆

BACKGROUND Although several reports have claimed that the appendix can be involved as a skip lesion in ulcerative colitis, they do not exclude the possibility that this skip lesion occurs as a result of medical therapy. Also, little is known about the relation between the presence of appendiceal orifice inflammation and the extent of the disease. METHODS The presence of appendiceal orifice inflammation was prospectively assessed both endoscopically and histologically in 94 patients with active ulcerative colitis, the extent of whose disease had not been beyond the hepatic flexure. To evaluate the effect of prior medical therapy on the prevalence of appendiceal orifice inflammation, all cases were divided into two groups. Group A consisted of 66 patients who had been treated before inclusion; group B was composed of 28 patients newly diagnosed at inclusion. RESULTS Appendiceal orifice inflammation was diagnosed in 24 (26%) of 94 patients with active subtotal ulcerative colitis, with no statistical difference observed between group A (23%) and group B (32%). In all 94 patients, the frequency of appendiceal orifice inflammation decreased significantly as the extent of disease increased, i.e., 37% in proctitis (n = 49), 17% in left-sided colitis (n = 36), and 0% in extensive colitis (n = 9) (p < 0.05). CONCLUSIONS Appendiceal orifice inflammation as a skip lesion of ulcerative colitis is not rare, is more frequently observed in patients with less extensive disease, and is not the result of patchy improvement due to medical therapy.

Detection of Helicobacter pylori DNA in Human Biliary Tree and Its Association with Hepatolithiasis

Recently, several authors have reported that Helicobacter pylori DNA has been found in human bile. The aim of this study is to investigate the presence of H. pylori in the biliary tree of Koreans, including the bile, biliary epithelium, and gallstones. This study analyzed intrahepatic bile, bile duct tissue, and gallstones from 43 patients with hepatobiliary disease (PTCS group), gallbladder bile and tissue from 23 patients with gallbladder disease (CCT group), and eight patients without hepatobiliary disease (control group). H. pylori was examined by PCR with two different primers. PCR was positive in 4/43 (9.3%) by 26 kDa protein antigen primer and in 5/43 (11.6%) by urease A gene primer in bile from the PTCS group. However, in intrahepatic duct tissue, PCR was positive in only one case. PCR of gallbladder bile, tissue, and intrahepatic duct stones was negative. Upon intrahepatic bile analysis, the pH was significantly lower in PCR-positive than in negative cases (P < 0.05). In conclusion, H. pylori DNA may be present in the bile when there are certain environmental changes, such as lowered pH; however, H. pylori does not colonize the bile duct epithelium. We could find no pathogenetic role for H. pylori in the formation of hepatolithiasis.

Antibiotic-Associated Diarrhea: Candidate Organisms other than Clostridium Difficile

Backgraound/Aims The direct toxic effects of antibiotics on the intestine can alter digestive functions and cause pathogenic bacterial overgrowth leading to antibiotic-associated diarrhea (AAD). Clostridium Difficile (C. Difficile) is widely known to be responsible for 10~20% of AAD cases. However, Klebsiella oxytoca, Clostridium perfringens, Staphylococcus aureus, and Candida species might also contribute to AAD. Methods We prospectively analyzed the organisms in stool and colon tissue cultures with a C. Difficile toxin A assay in patients with AAD between May and December 2005. In addition, we performed the C. Difficile toxin A assays using an enzyme-linked fluorescent assay technique. Patients were enrolled who had diarrhea with more than three stools per day for at least 2 days after the initiation of antibiotic treatment for up to 6~8 weeks after antibiotic discontinuation. Results Among 38 patients (mean age 59±18 years, M:F=18:20), the organism isolation rates were 28.9% (11/38) for stool culture, 18.4% (7/38) for colon tissue cultures and 13.2% (5/38) for the C. Difficile toxin A assay. The overall rate of identification of organisms was 50.0% (19/38). Of the five patients that had a positive result by the C. Difficile toxin A assay, two had no organism isolated by the stool or colon tissue culture. The organisms isolated from the stool cultures were C. Difficile (4), Klebsiella pneumoniae (K. pneumoniae) (3), Candida species (3), and Staphylococcus aureus (1). C. Difficile (4) and K. pneumoniae (3) were isolated from the colon tissue culture. Conclusions For C. Difficile negative AAD patients, K. pneumoniae, Candida species, and Staphylococcus aureus were found to be potential causative organisms.

The Clinical Meaning of Benign Colon Uptake in 18 F-FDG PET: Comparison with Colonoscopic Findings

Background/Aims Benign colon 18F-fluorodeoxyglucose (FDG) uptake is frequently observed in asymptomatic individuals. Aims of this study were to investigate the benign colon uptake by whole body FDG-positron emission tomography (PET) in asymptomatic adults and to correlate those results with colonoscopic and histologic findings. Methods Among 3,540 subjects who had undergone FDG-PET, 43 subjects who were diagnosed to have benign colon uptake in FDG-PET and underwent colonoscopy were retrospectively reviewed. Subjects were classified as diffuse or focal groups based on their FDG uptake patterns. PET results were analyzed together with colonoscopic and histologic findings. Results Forty-three subjects showed benign colon uptake in FDG-PET; 28 of them were shown as the diffuse group, while other 15 subjects were classified as the focal group. Five subjects among those showed diffuse uptake were diagnosed as adenoma. Seven among 15 subjects who showed focal uptake were diagnosed as adenocarcinoma (n=2), adenoma (n=3), or non-neoplastic polyp (n=2). Positive predictive values were 25% in the diffuse group and 47% in the focal group. Conclusions We recommend that patients showing benign FDG uptake in the colon should be further evaluated by colonoscopy, especially for patients with focal FDG uptake.

The Usefulness of Capsule Endoscopy for Small Bowel Tumors

Video capsule endoscopy (VCE) has expanded the range of endoscopic examination of the small bowel. The clinical application of VCE is mainly for obscure gastrointestinal bleeding (OGIB) and small bowel tumor is one of the clinically significant diagnoses of VCE, often requiring subsequent invasive interventions. Small bowel tumors are detected with a frequency of around 4% with VCE in indications of OGIB, iron deficiency anemia, unexplained abdominal pain, and others. Protruding mass with bleeding, mucosal disruption, irregular surface, discolored area, and white villi are suggested as the VCE findings of small bowel tumor. Device assisted enteroscopy (DAE), computed tomography enteroclysis/enterography and magnetic resonance enteroclysis/enterography also have clinical value in small bowel examination and tumor detection, and they can be used with VCE, sequentially or complementarily. Familial adenomatous polyposis, Peutz-Jeghers syndrome, melanoma, lymphoma, and neuroendocrine tumor with hepatic metastasis are the high risk groups for small bowel tumors, and surveillance programs for small bowel tumors are needed. VCE and radiological imaging have value in screening, and in selected cases, DAE can provide more accurate diagnosis and endoscopic treatment. This review describes the usefulness and clinical impact of VCE on small bowel tumors.

Dietary Habit and Helicobacter pylori Infection in Early Gastric Cancer Patient.

PURPOSE Helicobacter pylori (H. pylori) is now generally accepted to be strongly associated with the development of gastric cancer, as well as intakes of some salted foods, charred foods, etc. To evaluate the association among dietary habits, H. pylori infection, and early gastric cancer in Koreans, a hospital based case-control study was conducted. MATERIAL AND METHOD A total of 268 persons participated in this case-control study. Sixty nine patients were newly diagnosed as an early gastric cancer (EGC) at the Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, Seoul, Korea. One hundred ninety-nine subjects with no symptoms who visited the Health Promotion Center for their general checkups were selected as the controls. All subjects were examined for H. pylori infection, biochemical blood test the life style, and dietary habit were interviewed by a trained dietition with semi-quantitative food frequency question naire (FFQ) and adaptive salt concentration were taste evaluated. RESULTS H. pylori seropositivity was observed in 88.4% in cases, as compared with 74.9% in controls (OR=2.5, 95% CI: 1.1-5.7). The adaptive salt concentration was associated with early gastric cancer risk (chi-squir=50.8, p<0.001). The analysis of food intake frequency demonstrated that early gastric cancer risk was reduced by the intake of clear soups, raw vegetables, fruits and juices, beef with vegetables and soybean curds. On the other hand, high intake of salt-fermented fish and kimchi elevated the risk of early gastric cancer. CONCLUSION These results suggest that some dietary factors and H. pylori infection have a significant association with the development of early gastric cancer.

⁎4482 Usefulness of polymerase chain reaction for the differential diagnosis of intestinal tuberculosis and crohn's disease.

Background & Aim: The definite diagnosis of intestinal tuberculosis (I-TB) is made by histological evidence of caseating granulomas or acid-fast bacilli, or growth of M. tuberculosis on culture of biopsy specimens. It is often difficult, however, to differentiate I-TB from Crohns disease (CD) when all of the three tests were negative. The aim of this study was to evaluate the usefulness of M. tuberculosis complex-polymerase chain reaction (TBCPCR) for the differential diagnosis of I-TB and CD. Methods: We obtained biopsy specimens from 32 patients with I-TB and 29 patients with CD. Ziehl-Neelsen stain, M. tuberculosis culture and TBC-PCR were carried out in all patients. TBC-PCR was also performed with normal colonic specimens obtained from 22 patients with colonic polyps as the control. TBCPCR was done with DNA extracted from the paraffin-embedded tissues in all cases. Four pairs of oligonucleotide primers (Bioneer, Korea) were used for the nested PCR at the two different sites of IS6110 insertion element of M. tuberculosis complex. Results: The TBC-PCR gave positive results in 23 (72%) of 32 patients with I-TB, 3 (10%) of 29 patients with CD, and 3 (14%) of 22 normal controls, yielding a sensitivity of the TBC-PCR on biopsy specimens of 72% and a specificity of 88%. In patients with I-TB, the sensitivity of culture, acid-fast bacilli stain and caseating granulomas were 44%, 25% and 9%, respectively. When all of these three tests were combined, the sensitivity rose to 63%. In addition, among the 12 I-TB patients with the negative result in all of the three conventional tests, 8 (67%) were PCR-positive. Therefore when the result of TBC-PCR was combined with that of histological examination and culture, the sensitivity became higher upto 88%. The positive rate of TBC-PCR was 100% in patients showing caseating granulomas or acid-fast bacilli on histological examination, and 64% in culture-positive patients. Conclusions: TBC-PCR is a very sensitive method for the diagnosis of I-TB. Therefore, combining of TBC-PCR with conventional methods might be helpful in differentiating I-TB from CD.