Kyung Ho Song

Development and Validation of the Korean Rome III Questionnaire for Diagnosis of Functional Gastrointestinal Disorders

Background/Aims A self-report questionnaire is frequently used to measure symptoms reliably and to distinguish patients with functional gastrointestinal disorders (FGIDs) from those with other conditions. We produced and validated a cross-cultural adaptation of the Rome III questionnaire for diagnosis of FGIDs in Korea. Methods The Korean version of the Rome III (Rome III-K) questionnaire was developed through structural translational processes. Subsequently, reliability was measured by a test-retest procedure. Convergent validity was evaluated by comparing self-reported questionnaire data with the subsequent completion of the questionnaire by the physician based on an interview and with the clinical diagnosis. Concurrent validation using the validated Korean version of the Short Form-36 Health Survey (SF-36) was adopted to demonstrate discriminant validity. Results A total of 306 subjects were studied. Test-retest reliability was good, with a median Cronbachs α value of 0.83 (range, 0.71-0.97). The degree of agreement between patient-administered and physician-administered questionnaires to diagnose FGIDs was excellent; the κ index was 0.949 for irritable bowel syndrome, 0.883 for functional dyspepsia and 0.927 for functional heartburn. The physicians clinical diagnosis of functional dyspepsia showed the most marked discrepancy with that based on the self-administered questionnaire. Almost all SF-36 domains were impaired in participants diagnosed with one of these FGIDs according to the Rome III-K. Conclusions We developed the Rome III-K questionnaire though structural translational processes, and it revealed good test-retest reliability and satisfactory construct validity. These results suggest that this instrument will be useful for clinical and research assessments in the Korean population.

Differential diagnosis of left-sided abdominal pain: Primary epiploic appendagitis vs colonic diverticulitis

AIM To investigate the clinical characteristics of left primary epiploic appendagitis and to compare them with those of left colonic diverticulitis. METHODS We retrospectively reviewed the clinical records and radiologic images of the patients who presented with left-sided acute abdominal pain and had computer tomography (CT) performed at the time of presentation showing radiological signs of left primary epiploic appendagitis (PEA) or left acute colonic diverticulitis (ACD) between January 2001 and December 2011. A total of 53 consecutive patients were enrolled and evaluated. We also compared the clinical characteristics, laboratory findings, treatments, and clinical results of left PEA with those of left ACD. RESULTS Twenty-eight patients and twenty-five patients were diagnosed with symptomatic left PEA and ACD, respectively. The patients with left PEA had focal abdominal tenderness on the left lower quadrant (82.1%). On CT examination, most (89.3%) of the patients with left PEA were found to have an oval fatty mass with a hyperattenuated ring sign. In cases of left ACD, the patients presented with a more diffuse abdominal tenderness throughout the left side (52.0% vs 14.3%; P = 0.003). The patients with left ACD had fever and rebound tenderness more often than those with left PEA (40.0% vs 7.1%, P = 0.004; 52.0% vs 14.3%, P = 0.003, respectively). Laboratory abnormalities such as leukocytosis were also more frequently observed in left ACD (52.0% vs 15.4%, P = 0.006). CONCLUSION If patients have left-sided localized abdominal pain without associated symptoms or laboratory abnormalities, clinicians should suspect the diagnosis of PEA and consider a CT scan.

Healing Effects of Rebamipide and Omeprazole in Helicobacter pylori-Positive Gastric Ulcer Patients after Eradication Therapy: A Randomized Double-Blind, Multinational, Multi-Institutional Comparative Study

Background and Aims: A recent placebo-controlled trial showed that rebamipide, which is a mucosal-protective antiulcer agent, promoted gastric ulcer healing without affecting the Helicobacter pylori status. We conducted a randomized, double-blind trial to compare the healing effects of rebamipide and the proton-pump inhibitor omeprazole in H. pylori-positive gastric ulcers after H. pylori eradication therapy. Methods: After completion of 1 week of eradication therapy, 132 patients with H. pylori-positive gastric ulcer were enrolled in 5 Chinese and 4 Korean institutions. Patients were randomly assigned to take either 20 mg of omeprazole (n = 63) or 300 mg of rebamipide (n = 65) daily for 7 weeks. Healing was defined as complete recovery and S1 and S2 stage ulcer according to the Sakita-Miwa classification. Results: Healing rates at 12 weeks were 81.5% (53/65) and 82.5% (52/63) in the rebamipide and omeprazole groups, respectively. There was no significant difference in treatment efficacy, as evidenced by gastric ulcer healing rates (absolute difference –1.0%; 95% confidence interval –10.7 to 8.7; p = 0.88). The H. pylori eradication rate and ulcer healing rate did not differ between the groups, the latter regardless of eradication outcome. Conclusions: Rebamipide is as effective as omeprazole in treating of H. pylori-positive gastric ulcer after eradication therapy.

Acute mediastinitis arising from pancreatic mediastinal fistula in recurrent pancreatitis.

Acute mediastinitis is a fatal disease that usually originates from esophageal perforation and surgical infection. Rare cases of descending necrotizing mediastinitis can occur following oral cavity and pharynx infection or can be a complication of pancreatitis. The most common thoracic complications of pancreatic disease are reactive pleural effusion and pneumonia, while rare complications include thoracic conditions, such as pancreaticopleural fistula with massive pleural effusion or hemothorax and extension of pseudocyst into the mediastinum. There have been no reports of acute mediastinitis originating from pancreatitis in South Korea. In this report, we present the case of a 50-year-old female suffering from acute mediastinitis with pleural effusion arising from recurrent pancreatitis that improved after surgical intervention.

Practical Methods to Assess Chronic Constipation

Defining the pathophysiology of chronic constipation is critical for planning management. After excluding organic diseases, physician should speculate whether the constipated patient has a defecatory disorder or not. Recently, American Gastroenterology Association suggested an updated algorithm in diagnosis of chronic constipation.1 The major change was anorectal manometry and a rectal balloon expulsion test as the initial step which should be considered even before conventional laxative trial especially in patients who are highly suspected as having a defecatory disorder. This change inevitably posed the measurement of colon transit time in the last step of the algorithm and assessment of colonic transit is not recommended as early study any more. What is the rationale of this change? The American Gastroenterology Association medical position statement provided two reasonable issues. First, because near half of patients with defecatory disorders show concomitant slow colonic transit, slow transit time cannot rule out the presence of defecatory disorders and omit anorectal studies. Defecatory disorders are treated with pelvic floor retraining behavioral therapy, namely biofeedback, even if slow colonic transit is concomitant. Second reason is that the administration of laxative is the main initial therapy regardless of colon transit if there is no evidence of defecatory disorders. Normal transit constipation and slow transit constipation are treated similarly. Then, what is the clinical impact of slow colonic transit? We select very exceptional case of refractory chronic constipation as a candidate of surgical treatment according to the colonic transit. Colectomy could be effective in medically refractory constipated patients with slow colonic transit if defecatory disorders are not concomitant. The overall satisfaction rate of surgery was about 86% in a systematic review involving 39 reports and 1423 patients.2 Confirming slow colonic transit and ruling out defecatory disorders are mandatory for the successful outcome. The present study by Park et al3 suggested that the gas volume scoring could be a practical method assessing colonic transit. Even though the authors cannot find a positive correlation of colon transit time and colon gas volume score, they demonstrated that the difference of gas volume existed between slow transit and normal transit, defined as 45 hours (mean value + 1 standard deviation). The difference of gas volume score was small, 5.66% vs 4.15%, and the sensitivity and specificity of the cut-off value to diagnose slow colon transit was disappointing. The failure of presenting valuable cut-off colon gas volume score to differentiate slow colon transit is a big drawback of this study, because there was only small mean difference of colon gas volume score between the groups and this small difference can be easily made by manual processing of gas volume scoring or by confusing small bowel gas as colon gas. Also the range of colon gas volume score largely overlaps each other. Therefore the present outcome has insufficient clinical impact to replace conventional method using radiopaque markers to assess colon transit time. But primary physicians can roughly discriminate slow transit constipation based on this tendency of colon gas on simple x-ray and colon transit. When primary physicians encounter a constipated patient with a relatively larger amount of colon gas on simple abdominal x-ray, they can suspect the patient may have slow colon transit. There are some practical methods to assess constipated patient and this include digital rectal exam and Bristol stool scale. We can consider additional anorectal tests in patients of abnormal digital rectal exam.4 Abnormal digital rectal exam by skillful examiner can practically suspect defecatory disorder. Also Bristol stool scale is a practical indicator of colon transit and this simple illustration can be useful in a clinical setting of discrepancy between the bowel frequency and stool hardness.5 Besides of this physical exam and simple illustration, simple abdominal radiography may give some additional information to primary physician.

Clinical Practice Guidelines for Irritable Bowel Syndrome in Korea, 2017 Revised Edition

In 2011, the Korean Society of Neurogastroenterology and Motility (KSNM) published clinical practice guidelines on the management of irritable bowel syndrome (IBS) based on a systematic review of the literature. The KSNM planned to update the clinical practice guidelines to support primary physicians, reduce the socioeconomic burden of IBS, and reflect advances in the pathophysiology and management of IBS. The present revised version of the guidelines is in continuity with the previous version and targets adults diagnosed with, or suspected to have, IBS. A librarian created a literature search query, and a systematic review was conducted to identify candidate guidelines. Feasible documents were verified based on predetermined inclusion and exclusion criteria. The candidate seed guidelines were fully evaluated by the Guidelines Development Committee using the Appraisal of Guidelines for Research and Evaluation II quality assessment tool. After selecting 7 seed guidelines, the committee prepared evidence summaries to generate data exaction tables. These summaries comprised the 4 main themes of this version of the guidelines: colonoscopy; a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols; probiotics; and rifaximin. To adopt the core recommendations of the guidelines, the Delphi technique (ie, a panel of experts on IBS) was used. To enhance dissemination of the clinical practice guidelines, a Korean version will be made available, and a food calendar for patients with IBS is produced.

Quality of life, patient satisfaction, and disease burden in patients with gastroesophageal reflux disease with or without laryngopharyngeal reflux symptoms

Patients with gastroesophageal reflux disease (GERD) have decreased health‐related quality of life (HRQL). The quality of life in patients with laryngopharyngeal reflux (LPR) symptoms is also significantly impaired. However, the impact of LPR symptoms on HRQL in GERD patients has not been studied.

Septic Shock in Pyogenic Liver Abscess: Clinical Considerations

BACKGROUND/AIMS Pyogenic liver abscess (PLA) is a life-threatening condition, despite advances in diagnostic technology and strategies for treatment. A strong predictor of mortality in this condition is septic shock. This study describes clinical, biochemical, and radiologic features in patients with PLA with or without septic shock, with the intent of describing risk factors for septic shock. METHODS Of 358 patients with PLA enrolled, 30 suffered septic shock and the remaining 328 did not. We reviewed the medical records including etiologies, underlying diseases, laboratory, radiologic and microbiologic findings, methods of treatment and treatment outcomes. RESULTS The case fatality rate was 6.1%. In univariate analysis, the presence of general weakness, mental change, low platelet level, prolonged PT, high BUN level, high creatinine level, low albumin level, high AST level, high CRP level, abscess size >6 cm, the presence of gas-forming abscess, APACHE II score ≥ 20, and the presence of Klebsiella pneumoniae infection were significantly associated with septic shock. Multivariate analysis showed the presence of mental change (p=0.004), gas-form -ing abscess (p=0.012), and K. pneumoniae infection (p=0.027) were independent predictors for septic shock. CONCLUSIONS The presence of mental change, gas-forming abscess, and K. pneumoniae infection were independent predictors for septic shock in patients with PLA.

Seroprevalence of Helicobacter pylori in Korea: A multicenter, nationwide study conducted in 2015 and 2016

The Korean College of Helicobacter and Upper Gastrointestinal Research has studied Helicobacter pylori (H. pylori) prevalence since 1998 and found a dynamic change in its prevalence in Korea. The aim of this study was to determine the recent H. pylori prevalence rate and compare it with that of previous studies according to socioeconomic variables.

A case of hepatocellular carcinoma in the caudate lobe successfully treated by transcatheter arterial chemoembolization using drug-eluting beads

Hepatocellular carcinoma (HCC) in the caudate lobe remains one of the most intricate locations where various treatments tend to pose problems with regard to the optimal approach. Surgical resection has been regarded as the most effective treatment; however, isolated resection of the caudate lobe is strenuous and associated with a high rate of early recurrence. Percutaneous ablation might be technically difficult or impossible to perform due to the deep location of tumors and adjacent large vessels. Treatment with drug-eluting beads (DEB) can potentially enhance the therapeutic efficacy for patients with unresectable HCC by drawing on the slower, more consistent drug delivery process. We described a case of a 62-year-old man with HCC in the caudate lobe who was successfully treated by DEB.