Yeon Ji Kim

The usefulness of fecal calprotectin in assessing inflammatory bowel disease activity

Background/Aims Fecal calprotectin (FC) is known to correlate with disease activity and can be used as a predictor for relapse or treatment response in inflammatory bowel disease (IBD). We evaluated the usefulness of FC as a biomarker for disease activity in patients with IBD using both enzyme-linked immunosorbent assay (ELISA) and a quantitative point-of-care test (QPOCT). Methods Fecal samples and medical records were collected from consecutive patients with IBD. FC levels were measured by both ELISA and QPOCT and patient medical records were reviewed for clinical, laboratory, and endoscopic data. Results Ninety-three patients with IBD were enrolled, 55 with ulcerative colitis (UC) and 38 with Crohn’s disease (CD). The mean FC-ELISA levels were 906.3 ± 1,484.9 μg/g in UC and 1,054.1 ± 1,252.5 μg/g in CD. There was a strong correlation between FC-ELISA level and clinical activity indices (p < 0.05). FC-ELISA level was significantly lower in patients with mucosal healing (MH) compared to those without MH in UC (85.5 ± 55.6 μg/g vs. 1,503.7 ± 2,129.9 μg/g, p = 0.005). The results from the QPOCT corresponded well to those from ELISA. A cutoff value of 201.3 μg/g for FC-ELISA and 150.5 μg/g for FC-QPOCT predicted endoscopic inflammation (Mayo endoscopic subscore ≥ 1) in UC with a sensitivity of 81.8% and 85.8%, respectively, and a specificity of 100% for both. Conclusions FC was strongly associated with disease activity indices, serologic markers, and endoscopic activity in patients with IBD. QPOCT can be used more conveniently than ELISA to assess FC in clinical practice.

Positive Glucose Breath Tests in Patients with Hysterectomy, Gastrectomy, and Cholecystectomy

Background/Aims This study aimed to investigate the prevalence and characteristics of small intestinal bacterial overgrowth (SIBO) in patients undergoing abdominal surgeries, such as gastrectomy, cholecystectomy, and hysterectomy. Methods One hundred seventy-one patients with surgery (50 hysterectomy, 14 gastrectomy, and 107 cholecystectomy), 665 patients with functional gastrointestinal disease (FGID) and 30 healthy controls undergoing a hydrogen (H2)-methane (CH4) glucose breath test (GBT) were reviewed. Results GBT positivity (+) was significantly different among the surgical patients (43.9%), FGID patients (31.9%), and controls (13.3%) (p<0.01). With respect to the patients, 65 (38.0%), four (2.3%), and six (3.5%) surgical patients and 150 (22.6%), 30 (4.5%), and 32 (4.8%) FGID patients were in the GBT (H2)+, (CH4)+ and (mixed)+ groups, respectively (p<0.01). The gastrectomy group had a significantly increased preference in GBT+ (71.4% vs 42.0% or 41.1%, respectively) and GBT (H2)+ (64.3% vs 32.0% or 37.4%, respectively) compared with the hysterectomy or cholecystectomy groups (p<0.01). During GBT, the total H2 was significantly increased in the gastrectomy group compared with the other groups. Conclusions SIBO producing H2 is common in abdominal surgical patients. Different features for GBT+ may be a result of the types of abdominal surgery.

Analysis of factors influencing survival in patients with severe acute pancreatitis

Abstract Objective: Acute pancreatitis (AP) ranges from a mild and self-limiting disease to a fulminant illness with significant morbidity and mortality. Severe acute pancreatitis (SAP) is defined as persistent organ failure lasting for 48 h. We aimed to determine the factors that predict survival and mortality in patients with SAP. Methods: We reviewed a consecutive series of patients who were admitted with acute pancreatitis between January 2003 and January 2013. A total of 1213 cases involving 660 patients were evaluated, and 68 cases with SAP were selected for the study. Patients were graded based on the Computer Tomography Severity Index (CTSI), the bedside index for severity (BISAP), and Ranson’s criteria. Results: The frequency of SAP was 5.6% (68/1213 cases). Among these patients, 17 died due to pancreatitis-induced causes. We compared several factors between the survivor (n = 51) and non-survivor (n = 17) groups. On multivariate analysis, there were significant differences in the incidence of diabetes mellitus (p = .04), Ranson score (p = .03), bacteremia (p = .05) and body mass index (BMI) (p = .02) between the survivor and non-survivor groups. Conclusions: Bacteremia, high Ranson score, DM, and lower BMI were closely associated with mortality in patients with SAP. When patients with SAP show evidence of bacteremia or diabetes, aggressive treatment is necessary. For the prediction of disease mortality, the Ranson score might be a useful tool in SAP.

Education and imaging. Gastrointestinal: a cecal lipoma covered by adenomatous epithelium.

A 71-year-old man underwent a screening colonoscopy conducted by his primary physician. The colonoscopy showed a subpedunculated polyp, 18 mm in diameter, in the cecum (Figure 1a). A biopsy specimen showed a tubular adenoma. The patients’ past history included hypertension. He had a family history of colon cancer, and was referred to our hospital for management of the colonic adenoma. Endoscopic mucosal resection (EMR) was performed using an inject-and-cut technique, and the polyp was resected en bloc. The resected specimen was a round, subpedunculated polyp with a tubular and gyrus-like Kudo classification pit pattern (Figure 1b) and yellowish, greasy material at the cut surface (Figure 1c). Histology confirmed the submucosal proliferation of typical fatty cells with a lining mucosa, which was circumferentially involved by the tubular adenoma (Figure 2). Lipomas of the gastrointestinal tract are rare, and were first described by Bauer in 1757. Colonic lipomas are uncommon fatty neoplasms, with a reported incidence ranging between 0.2% and 4.4%. The most common sites of colonic lipomas are the cecum, ascending colon, and sigmoid colon. A lipoma smaller than 2 cm rarely causes symptoms. However, patients may present with diarrhea, constipation, hemorrhage, and abdominal pain, especially when the lipoma is 2–3 cm in diameter. The common endoscopic picture is a smooth, slightly yellow, spherical polyp, usually sessile and rarely pedunculated, with intact overlying mucosa. In rare cases, alterations in the mucosa covering a lipoma include hyperplasia, atrophy, ulceration, and necrosis. The association of lipoma and adenoma has been reported only rarely. One case was a very small adenomatous polyp on a colonic lipoma in the distal transverse colon; another was a large, surgically resected lipoma with a lining mucosa that was almost completely ulcerated, except at the base, which was circumferentially involved by hyperplastic epithelium with a villous adenomatous morphology. It is not clear whether the co-occurrence of these entities was coincidental or correlated. The current case showed a lipoma covered completely by adenomatous tissue. Although most lipomas are incidental findings and require no treatment, a small subgroup requires surgical intervention, including those with suspected malignancy, symptomatic lipomas, surgical emergencies such as intussusception and obstruction with ulceration and bleeding, and, very rarely, massive hemorrhage. Lipomas with diameters of < 2 cm can be safely removed endoscopically, whereas larger lesions should be removed by segmental resection. In the present case, the polyp was initially diagnosed as a tubular adenoma and resected endoscopically. The resected specimen showed a submucosal lipoma with a lining mucosa that was circumferentially involved by adenomatous morphology. Although the colonic lipoma may have no clinical significance, the overlying mucosa, like the rest of the colonic mucosa, is subject to any pathological process. The patient has been followed closely and has shown no recurrence.

The characteristics of small intestinal bacterial overgrowth in patients with gallstone diseases: Gallstone diseases and SIBO

Small intestinal bacterial overgrowth (SIBO) might be prevalent in gallstone disease, including cases involving cholecystectomy and gallstones. The study aimed to investigate the prevalence and characteristics of SIBO in patients with gallstone disease.

The association between a positive lactulose methane breath test and rectocele in constipated patients

OBJECTIVES Rectocele with constipation might be related to methane (CH4) producing intestinal bacteria. We investigated the breath CH4 levels and the clinical characteristics of colorectal motility in constipated patients with rectocele. METHODS A database of consecutive female outpatients was reviewed for the evaluation of constipation according to the Rome III criteria. The patients underwent the lactulose CH4 breath test (LMBT), colon marker study, anorectal manometry, defecography and bowel symptom questionnaire. The profiles of the lactulose breath test (LBT) in 33 patients with rectocele (with size ≥ 2 cm) and 26 patients with functional constipation (FC) were compared with the breath test results of 30 healthy control subjects. RESULTS The mean size of rectocele was 3.52 ± 1.06 cm. The rate of a positive LMBT (LMBT+) was significantly higher in patients with rectocele (33.3%) than in those with FC (23.1%) or healthy controls (6.7%) (p = 0.04). Breath CH4 concentration was positively correlated with rectosigmoid colon transit time in rectocele patients (γ = 0.481, p < 0.01). A maximum high pressure zone pressure > 155 mmHg was a significant independent factor of LMBT+ in rectocele patients (OR = 8.93, 95% CI = 1.14-71.4, p = 0.04). CONCLUSIONS LMBT+ might be expected in constipated patients with rectocele. Moreover, increased rectosigmoid colonic transit or high anorectal pressure might be associated with CH4 breath levels. Breath CH4 could be an important therapeutic target for managing constipated patients with rectocele.

Gastrointestinal: A cecal lipoma covered by adenomatous epithelium

A 71-year-old man underwent a screening colonoscopy conducted by his primary physician. The colonoscopy showed a subpedunculated polyp, 18 mm in diameter, in the cecum (Figure 1a). A biopsy specimen showed a tubular adenoma. The patients’ past history included hypertension. He had a family history of colon cancer, and was referred to our hospital for management of the colonic adenoma. Endoscopic mucosal resection (EMR) was performed using an inject-and-cut technique, and the polyp was resected en bloc. The resected specimen was a round, subpedunculated polyp with a tubular and gyrus-like Kudo classification pit pattern (Figure 1b) and yellowish, greasy material at the cut surface (Figure 1c). Histology confirmed the submucosal proliferation of typical fatty cells with a lining mucosa, which was circumferentially involved by the tubular adenoma (Figure 2). Lipomas of the gastrointestinal tract are rare, and were first described by Bauer in 1757. Colonic lipomas are uncommon fatty neoplasms, with a reported incidence ranging between 0.2% and 4.4%. The most common sites of colonic lipomas are the cecum, ascending colon, and sigmoid colon. A lipoma smaller than 2 cm rarely causes symptoms. However, patients may present with diarrhea, constipation, hemorrhage, and abdominal pain, especially when the lipoma is 2–3 cm in diameter. The common endoscopic picture is a smooth, slightly yellow, spherical polyp, usually sessile and rarely pedunculated, with intact overlying mucosa. In rare cases, alterations in the mucosa covering a lipoma include hyperplasia, atrophy, ulceration, and necrosis. The association of lipoma and adenoma has been reported only rarely. One case was a very small adenomatous polyp on a colonic lipoma in the distal transverse colon; another was a large, surgically resected lipoma with a lining mucosa that was almost completely ulcerated, except at the base, which was circumferentially involved by hyperplastic epithelium with a villous adenomatous morphology. It is not clear whether the co-occurrence of these entities was coincidental or correlated. The current case showed a lipoma covered completely by adenomatous tissue. Although most lipomas are incidental findings and require no treatment, a small subgroup requires surgical intervention, including those with suspected malignancy, symptomatic lipomas, surgical emergencies such as intussusception and obstruction with ulceration and bleeding, and, very rarely, massive hemorrhage. Lipomas with diameters of < 2 cm can be safely removed endoscopically, whereas larger lesions should be removed by segmental resection. In the present case, the polyp was initially diagnosed as a tubular adenoma and resected endoscopically. The resected specimen showed a submucosal lipoma with a lining mucosa that was circumferentially involved by adenomatous morphology. Although the colonic lipoma may have no clinical significance, the overlying mucosa, like the rest of the colonic mucosa, is subject to any pathological process. The patient has been followed closely and has shown no recurrence.

Gastrointestinal: A cecal lipoma covered by adenomatous epithelium: Education and Imaging

A 71-year-old man underwent a screening colonoscopy conducted by his primary physician. The colonoscopy showed a subpedunculated polyp, 18 mm in diameter, in the cecum (Figure 1a). A biopsy specimen showed a tubular adenoma. The patients’ past history included hypertension. He had a family history of colon cancer, and was referred to our hospital for management of the colonic adenoma. Endoscopic mucosal resection (EMR) was performed using an inject-and-cut technique, and the polyp was resected en bloc. The resected specimen was a round, subpedunculated polyp with a tubular and gyrus-like Kudo classification pit pattern (Figure 1b) and yellowish, greasy material at the cut surface (Figure 1c). Histology confirmed the submucosal proliferation of typical fatty cells with a lining mucosa, which was circumferentially involved by the tubular adenoma (Figure 2). Lipomas of the gastrointestinal tract are rare, and were first described by Bauer in 1757. Colonic lipomas are uncommon fatty neoplasms, with a reported incidence ranging between 0.2% and 4.4%. The most common sites of colonic lipomas are the cecum, ascending colon, and sigmoid colon. A lipoma smaller than 2 cm rarely causes symptoms. However, patients may present with diarrhea, constipation, hemorrhage, and abdominal pain, especially when the lipoma is 2–3 cm in diameter. The common endoscopic picture is a smooth, slightly yellow, spherical polyp, usually sessile and rarely pedunculated, with intact overlying mucosa. In rare cases, alterations in the mucosa covering a lipoma include hyperplasia, atrophy, ulceration, and necrosis. The association of lipoma and adenoma has been reported only rarely. One case was a very small adenomatous polyp on a colonic lipoma in the distal transverse colon; another was a large, surgically resected lipoma with a lining mucosa that was almost completely ulcerated, except at the base, which was circumferentially involved by hyperplastic epithelium with a villous adenomatous morphology. It is not clear whether the co-occurrence of these entities was coincidental or correlated. The current case showed a lipoma covered completely by adenomatous tissue. Although most lipomas are incidental findings and require no treatment, a small subgroup requires surgical intervention, including those with suspected malignancy, symptomatic lipomas, surgical emergencies such as intussusception and obstruction with ulceration and bleeding, and, very rarely, massive hemorrhage. Lipomas with diameters of < 2 cm can be safely removed endoscopically, whereas larger lesions should be removed by segmental resection. In the present case, the polyp was initially diagnosed as a tubular adenoma and resected endoscopically. The resected specimen showed a submucosal lipoma with a lining mucosa that was circumferentially involved by adenomatous morphology. Although the colonic lipoma may have no clinical significance, the overlying mucosa, like the rest of the colonic mucosa, is subject to any pathological process. The patient has been followed closely and has shown no recurrence.