Seohyun Lee

The diagnostic value of a digital rectal examination compared with high-resolution anorectal manometry in patients with chronic constipation and fecal incontinence.

Objectives:Digital rectal examination (DRE) is a simple clinical method to diagnose anorectal disorders. High-resolution antorectal manometry (HRAM) based on a spatiotemporal plot is expected to promote improved diagnostic accuracy. However, there are no reports comparing the effectiveness of DRE and HRAM. The aim of our study was therefore to evaluate the diagnostic value of DRE compared with HRAM.Methods:A total of 309 consecutive patients with chronic constipation (n=268) or fecal incontinence (n=41) who underwent a standardized DRE, HRAM, and balloon expulsion test were enrolled in this study. The diagnostic yield of DRE compared with HRAM was determined, and agreement between DRE and HRAM data was evaluated.Results:Of the constipated patients, 207 (77.2%) were diagnosed with dyssynergia using HRAM. The sensitivity, specificity, and positive predictive value of DRE in the diagnosis of dyssynergia were 93.2%, 58.7%, and 91.0%, respectively, and moderate agreement was seen between the two modalities (κ-coefficient =0.542, P<0.001). In patients with fecal incontinence, there was moderate agreement in terms of anal squeeze pressure between the two modalities (κ-coefficient =0.418, P=0.006); however, there was poor agreement for anal resting tone (κ-coefficient =0.079, P=0.368).Conclusions:DRE shows high sensitivity and positive predictive value in detecting dyssynergia compared with HRAM, and could therefore be used as a bedside screening test for the diagnosis of this disorder. Further studies are warranted to evaluate the correlation between DRE and HRAM in assessing anal sphincter pressure.

Validity and Reliability of CAT and Dyspnea-12 in Bronchiectasis and Tuberculous Destroyed Lung

Background The objective of this study was to assess the validity and reliability of the Korean version of chronic obstructive pulmonary disease assessment test (CAT) and Dyspnea-12 Questionnaire for patients with bronchiectasis or tuberculous destroyed lung. Methods For 62 bronchiectasis patients and 37 tuberculous destroyed lung patients, 3 questionnaires including St. Georges Respiratory Questionnaires (SGRQ), CAT, and Dyspnea-12 were obtained, in addition to spirometric measurements. To assess the validity of CAT and Dyspnea-12, correlation with SGRQ was evaluated. To assess the reliability of CAT and Dyspnea-12, Cronbachs α coefficient was calculated. Results The mean ages of the patients were 60.7±8.3 years in bronchiectasis and 64.4±9.3 years in tuberculous destroyed lung. 46.8% and 54.1% were male, respectively. The SGRQ score was correlated with the score of the Korean version of CAT (r=0.72, p<0.0001) and Dyspnea-12 (r=0.67, p<0.0001) in bronchiectasis patients. The SGRQ score was correlated with the score of CAT (r=0.86, p<0.0001) and Dyspnea-12 (r=0.80, p<0.0001) in tuberculous destroyed lung patients. The Cronbachs α coefficient for the CAT and Dyspnea-12 were 0.84 and 0.90 in bronchiectasis, and 0.88 and 0.94 in tuberculous destroyed lung, respectively. Conclusion We found that Korean version of CAT and Dyspnea-12 are valid and reliable in patients with tuberculous destroyed lung and bronchiectasis.

The risk of colorectal cancer in inflammatory bowel disease: a hospital-based cohort study from Korea

Abstract Objective. Limited data are available on the incidence and risk factors of colorectal cancer (CRC) in Asian patients with inflammatory bowel disease (IBD). Material and methods. Information on 5212 Korean patients with IBD (2414 with Crohn’s disease [CD] and 2798 with ulcerative colitis [UC]) was retrieved from the IBD registry of Asan Medical Center. Data on CRC incidence for the entire Korean population were derived from the Korean Statistical Information Service. Results. During 39,951 person-years of follow-up (17,679 for CD and 22,272 for UC), 30 patients (12 with CD and 18 with UC) developed CRC. The standardized incidence ratio (SIR) of CRC was 6.0 (95% confidence interval [CI], 3.10–10.48) for CD and 1.68 (95% CI, 1.00–2.66) for UC; it was 9.69 (95% CI, 5.01–16.93) for CD with colonic involvement and 4.31 (95% CI, 2.46–7.00) for extensive UC. The SIR was also increased in patients diagnosed with IBD at younger than 30 years old. CRC location was the low rectum in 11 of 12 CD patients (91.7%). The cumulative probability of rectal cancer was higher in CD patients with a perianal fistula than in those without a perianal fistula (p = 0.02). Conclusions. A high prevalence of perianal fistulas in Korean CD patients may be the cause of the predominance of low rectal cancer in this population and the higher SIR of CRC in Koreans than in Westerners. In contrast, the SIR of CRC in Korean UC patients may be similar to that in Western UC patients.

Short- and Long-Term Outcomes of Acute Severe Ulcerative Colitis in Korea: The 1999-2005 Cohort.

Background:No previous studies have evaluated the long-term outcomes of acute severe ulcerative colitis (ASUC) in non-Caucasian populations. The purposes of this study were to evaluate the short- and long-term outcomes of Korean patients with ASUC. Methods:We retrospectively analyzed 99 Korean patients with ASUC who satisfied the criteria given by Truelove and Witts between 1999 and 2005. The short-term outcome parameter was the colectomy rate during index hospitalization, and the long-term outcome parameters were the rates of colectomy and rehospitalization after discharge from index hospitalization. Results:During index hospitalization, 16 of 99 patients (16.2%) underwent colectomy: 6 of 71 responders (8.5%) to intravenous steroids on day 3 versus 10 of 28 nonresponders (35.7%), as assessed using the Oxford index (P = 0.002). Among 83 patients who avoided colectomy during index hospitalization, 13 patients (15.7%) underwent colectomy during the median follow-up period of 10.6 years. The cumulative probability of colectomy tended to be lower in complete responders on day 7 of intravenous steroid therapy (CR7) than in others: 3.7% versus 13.9% at 5 years and 7.6% versus 18.2% at 10 years (P = 0.100). The cumulative probability of rehospitalization was significantly lower in CR7 than in other patients: 20.5% versus 37.5% at 5 years and 31.4% versus 48.2% at 10 years (P = 0.043). Conclusions:Assessing the degree of response to intravenous steroids helps predict the short- and long-term outcomes in patients with ASUC. Korean patients with ASUC may have better clinical courses than Caucasians, as indicated by the lower colectomy rate.

Appendectomy and the clinical course of ulcerative colitis: A retrospective cohort study and a nested case–control study from Korea

Appendectomy protects against the development of ulcerative colitis (UC). However, the relationship between appendectomy and the clinical course of UC is complex, and could be impacted by a number of variables. The aim of this study was to compare the clinical course of UC between appendectomized patients and nonappendectomized patients in Korea.

The Clinical Usefulness of Endoscopic Ultrasound-Guided Fine Needle Aspiration and Biopsy for Rectal and Perirectal Lesions

Background/Aims Endoscopic ultrasound-guided fine needle aspiration and/or biopsy (EUS-FNA/B) have been used to diagnose subepithelial tumors (SETs) and extraluminal lesions in the gastrointestinal tract. Our group previously reported the usefulness of EUS-FNA/B for rectal and perirectal lesions. This study reports our expanded experience with EUS-FNA/B for rectal and perirectal lesions in terms of diagnostic accuracy and safety. We also included our new experience with EUS-FNB using the recently introduced ProCore needle. Methods From April 2009 to March 2014, EUS-FNA/B for rectal and perirectal lesions was performed in 30 consecutive patients. We evaluated EUS-FNA/B performance by comparing histological diagnoses with final results. We also investigated factors affecting diagnostic accuracy. Results Among 10 patients with SETs, EUS-FNA/B specimen results revealed a gastrointestinal stromal tumor in 4 patients and malignant lymphoma in 1 patient. The diagnostic accuracy of EUS-FNA/B was 50% for SETs (5/10). Among 20 patients with non-SET lesions, 8 patients were diagnosed with malignant disease and 7 were diagnosed with benign disease based on both EUS-FNA/B and the final results. The diagnostic accuracy of EUS-FNA/B for non-SET lesions was 75% (15/20). The size of lesions was the only factor related to diagnostic accuracy (P=0.027). Two complications of mild fever and asymptomatic pneumoperitoneum occurred after EUS-FNA/B. Conclusions The overall diagnostic accuracy of EUS-FNA/B for rectal and perirectal lesions was 67% (20/30). EUS-FNA/B is a clinically useful method for cytological and histological diagnoses of rectal and perirectal lesions.

Clinical Features and Prognosis of Resectable Primary Colorectal Signet-Ring Cell Carcinoma

Background/Aims We attempted to investigate the prognosis of signet-ring cell carcinoma (SRC) patients who underwent curative surgery by comparing them with age-, sex-, and stage-matched non-mucinous adenocarcinoma (NMAC) patients. Methods Between January 2003 and December 2011, 19 patients with primary SRC of the colorectum underwent curative surgery. Four SRC patients under the age of 40 were excluded, and the clinicopathological data of 15 patients (7 men; median age, 56 years) were reviewed and compared with the data of 75 NMAC patients matched by age, sex, and pathologic stage. Results The median follow-up duration was 30.1 months for the SRC group and 43.7 months for the NMAC group (P=0.141). Involvement of the left side of the colon (73.3% vs. 26.7%, P=0.003) and infiltrative lesions such as Borrmann types 3 and 4 (85.7% vs. 24.0%, P=0.001) were more common in the SRC group than in the NMAC group. The five-year overall survival rate was significantly lower for patients with SRC than for those with NMAC (46.0% vs. 88.7%, hazard ratio, 6.99; 95% confidence interval, 2.33-20.95, P=0.001). Conclusions Patients with even resectable primary colorectal SRC had a poorer prognosis than age-, sex-, and stage-matched colorectal NMAC patients.

A Patient-Based Nomogram for Predicting Overall Survival after Radiofrequency Ablation for Hepatocellular Carcinoma

PURPOSE To develop a prognostic nomogram based on specific patient and tumor factors capable of estimating individual survival outcomes after radiofrequency (RF) ablation as a primary therapy for hepatocellular carcinoma (HCC). MATERIALS AND METHODS This retrospective study included 893 patients who were initially treated with curative RF ablation for HCC; patients were temporally divided into derivation (n = 607) and validation (n = 286) cohorts. A multivariate Cox proportional hazards model for overall survival was developed and validated. The discriminatory accuracy of the model was compared with the preexisting Cancer of the Liver Italian Program (CLIP) system and the Tokyo score previously proposed for percutaneous therapy for HCC by analyzing receiver operating characteristic (ROC) curves. RESULTS A nomogram was generated for 3-year survival, incorporating largest tumor diameter and number of tumors, serum albumin and creatinine, platelet count, prothrombin time, and serum α-fetoprotein on a logarithmic scale. It had good calibration and discrimination abilities with a C-index of 0.74. The validation results also showed that the nomogram performed well in terms of goodness-of-fit and discrimination (C-index, 0.72). Analysis of ROC curves in the validation cohort indicated that the model had better predictive power than CLIP and Tokyo scores (C-indexes, 0.54 and 0.66, respectively). CONCLUSIONS This prognostic tool quantifying per-patient expected survival after RF ablation can be used in daily clinical decision making with regard to patients with HCC deemed suitable for radical ablation and is probably more reliable than existing guidelines.

Single Balloon Enteroscopy-Assisted Endoscopic Retrograde Cholangiopancreatography in Patients Who Underwent a Gastrectomy with Roux-en-Y Anastomosis: Six Cases from a Single Center

Patients with altered anatomy such as a Roux-en-Y anastomosis often present with various pancreaticobiliary problems requiring therapeutic intervention. However, a conventional endoscopic approach to the papilla is very difficult owing to the long afferent limb and acute angle of a Roux-en-Y anastomosis. Balloon-assisted enteroscopy can be used for endoscopic retrograde cholangiopancreatography (ERCP) in patients with altered anatomy. We experienced six cases of Roux-en-Y anastomosis with biliary problems, and attempted ERCP using single balloon enteroscopy (SBE). SBE insertion followed by replacement with a conventional endoscope was attempted in five of six patients. The papilla was successfully approached using SBE in all cases. However, therapeutic intervention was completed in only three cases because of poor maneuverability caused by postoperative adhesion. We conclude that in patients with Roux-en-Y anastomosis, the ampulla can be readily accessed with SBE, but longer dedicated accessories are necessary to improve this therapeutic intervention.

Temporal trends in the misdiagnosis rates between Crohn’s disease and intestinal tuberculosis

AIM To investigate the temporal trends in the misdiagnosis rate between Crohn’s disease (CD) and intestinal tuberculosis (ITB) in South Korea. METHODS We retrospectively reviewed the medical records of patients managed for CD or ITB at Asan Medical Center, a tertiary referral hospital, Seoul, Korea between 1996 and 2014. The temporal trends in the misdiagnosis rates between the two diseases were analyzed. The demographic and clinical characteristics were compared between CD patients who were initially misdiagnosed as ITB (final CD group) and vice versa (final ITB group). Final diagnostic criteria for ITB and medication for CD before definite diagnosis of TB were also analyzed in final ITB group. RESULTS In total, 2760 patients were managed for CD and 772 patients for ITB between 1996 and 2014. As well, 494 of the 2760 CD patients (17.9%) were initially misdiagnosed as ITB and 83 of the 772 ITB patients (10.8%) as CD. The temporal trend in misdiagnosing CD as ITB showed a decrease (OR = 0.89, 95%CI: 0.87-0.91, P < 0.001), whereas the temporal trend in misdiagnosing ITB as CD showed an increase (OR = 1.06, 95%CI: 1.01-1.11, P = 0.013). Age at diagnosis, presenting symptoms, and proportion of patients with active/past perianal fistula and active/inactive pulmonary tuberculosis (TB) were significantly different between final CD group and final ITB group. Forty patients (48.2%) in final ITB group were diagnosed by favorable response to empirical anti-TB treatment. Seventeen patients (20.5%) in final ITB group had inappropriately received corticosteroids and/or thiopurines due to misdiagnosis as CD. However, there were no mortalities in both groups. CONCLUSION Cases of CD misdiagnosed as ITB have been decreasing, whereas cases of ITB misdiagnosed as CD have been increasing over the past two decades.