Yun Jeong Lim

Capsule endoscopy in small bowel tumors: A multicenter Korean study

Background and Aim:  Capsule endoscopy (CE) has proven to be highly effective at detecting small bowel lesions in a variety of clinical conditions, but studies concerning the practical impact of CE on small bowel tumors are still scarce, especially in the Asian population. The aim of this study was to evaluate the diagnostic and therapeutic impact of CE in the field of small bowel tumors.

Rescue strategies against non-steroidal anti-inflammatory drug-induced gastroduodenal damage

Non‐steroidal anti‐inflammatory drugs (NSAIDs) are the most commonly prescribed drugs worldwide, which attests to their efficacy as analgesic, antipyretic and anti‐inflammatory agents as well as anticancer drugs. However, NSAID use also carries a risk of major gastroduodenal events, including symptomatic ulcers and their serious complications that can lead to fatal outcomes. The development of “coxibs” (selective cyclooxygenase‐2 [COX‐2] inhibitors) offered similar efficacy with reduced toxicity, but this promise of gastroduodenal safety has only partially been fulfilled, and is now dented with associated risks of cardiovascular or intestinal complications. Recent advances in basic science and biotechnology have given insights into molecular mechanisms of NSAID‐induced gastroduodenal damage beyond COX‐2 inhibition. The emergence of newer kinds of NSAIDs should alleviate gastroduodenal toxicity without compromising innate drug efficacy. In this review, novel strategies for avoiding NSAID‐associated gastroduodenal damage will be described.

Visceral Abdominal Obesity Is Associated With an Increased Risk of Irritable Bowel Syndrome

Objectives:There are several studies considering obesity as the risk factor for various lower gastrointestinal symptoms. But the relationship between visceral abdominal obesity and the incidence of irritable bowel syndrome (IBS) is not studied yet. The aim of this study was to investigate the association between visceral adipose tissue (VAT) and the risk of IBS.Methods:This is a case–control study comparing the VAT area between subjects with IBS (IBS group) and controls without IBS (non IBS group), who underwent abdomen computerized tomography (CT) for routine health checkup from January 2012 to August 2013 in a health promotion center. A telephone survey was retrospectively conducted to diagnose IBS by Rome III criteria. The association between IBS and abdominal obesity was evaluated by measuring VAT, subcutaneous adipose tissue (SAT), VAT/SAT ratio, body mass index (BMI) and waist circumference (WC).Results:The prevalence of IBS was 19.9% (67/336) among all enrolled subjects. In the univariate analysis, VAT area, VAT/SAT ratio, waist circumference, the presence of reflux esophagitis and the ratio of females were significantly higher in the IBS group than in the non IBS group. However, a higher BMI or a higher SAT area is not associated with an increased risk of IBS. In the multivariate analysis, a higher VAT area (odds ratio (OR)=9.42, 95% confidence interval (CI): 2.90–30.64, highest tertile vs. lowest tertile, P=0.001), VAT/SAT ratio (OR=10.15, 95% CI: 3.05–33.58, highest tertile vs. lowest tertile, P=0.001) and waist circumference (OR=7.81, 95% CI: 2.13–28.66, highest tertile vs. lowest tertile, P=0.002) were independently associated with a risk of IBS. Only in the IBS-D group, not in the IBS-C, visceral adiposity was associated with an increased risk of IBS.Conclusions:Visceral adiposity measured by VAT, VAT/SAT, and waist circumference is associated with an increased risk of IBS, especially of IBS-D. However, neither SAT nor BMI are associated with an increased risk of IBS.

Prevalence and risk factors of esophageal candidiasis in healthy individuals: a single center experience in Korea.

Purpose Esophageal candidiasis (EC) is the most frequent opportunistic fungal infection in immunocompromised host. However, we have found EC in healthy individuals through esophagogastroduodenoscopy (EGD). The aim of this study was to determine the prevalence and risk factors for EC in healthy individuals. Materials and Methods We retrospectively reviewed the medical records of 281 patients who had been incidentally diagnosed with EC. We also conducted age and sex matched case control study to identify the risk factor for EC. Results The prevalence of EC was 0.32% (281/88125). The most common coexisting EGD finding was reflux esophagitis (49/281, 17.4%). An antifungal agent was prescribed in about half of EC, 139 cases (49.5%). Follow-up EGD was undertaken in 83 cases (29.5%) and 20 cases of candidiasis was persistently found. Case control study revealed EC were more often found in user of antibiotics (p=0.015), corticosteroids (p=0.002) and herb medication (p=0.006) as well as heavy drinking (p<0.001). Conclusion The prevalence of EC was 0.32% (281/88125) in Korea. Use of antibiotics, corticosteroids and herb as well as heavy drinking were significant risk factors for EC in healthy individuals.

Recent Advances in NSAIDs-Induced Enteropathy Therapeutics: New Options, New Challenges

The injurious effects of NSAIDs on the small intestine were not fully appreciated until the widespread use of capsule endoscopy. It is estimated that over two-thirds of regular NSAID users develop injury in the small intestinal injuries and that these injuries are more common than gastroduodenal mucosal injuries. Recently, chronic low-dose aspirin consumption was found to be associated with injury to the lower gut and to be a significant contributing factor in small bowel ulceration, hemorrhage, and strictures. The ability of aspirin and NSAIDs to inhibit the activities of cyclooxygenase (COX) contributes to the cytotoxicity of these drugs in the gastrointestinal tract. However, many studies found that, in the small intestine, COX-independent mechanisms are the main contributors to NSAID cytotoxicity. Bile and Gram-negative bacteria are important factors in the pathogenesis of NSAID enteropathy. Here, we focus on a promising strategy to prevent NSAID-induced small intestine injury. Selective COX-2 inhibitors, prostaglandin derivatives, mucoprotective drugs, phosphatidylcholine-NSAIDs, and probiotics have potential protective effects on NSAID enteropathy.

Adjuncts to colonic cleansing before colonoscopy

Pre-procedural cleansing of the bowel can maximize the effectiveness and efficiency of colonoscopy. Yet, efficacy of the current gold standard colonic preparation method - high-volume oral administration of purgative agents 12-24 h prior to the procedure - is limited by several factors, such as patient compliance (due to poor palatability and inconvenience of the dosing regimen) and risks of complications (due to drug interactions or intolerance). Attempts to resolve these limitations have included providing adjunctive agents and methods to promote the colonic cleansing ability of the principal purgative agent, with the aim of lessening unpleasant side effects (such as bloating) and reducing the large ingested volume requirement. Several promising adjunctive agents are bisacodyl, magnesium citrate, senna, simethicone, metoclopramide, and prokinetics, and each are being investigated for their potential. This review provides an up to date summary of the reported investigations into the potencies and weaknesses of the key adjuncts currently being applied in clinic as supplements to the traditional bowel preparation agents. While the comparative analysis of these adjuncts showed that no single agent or method has yet achieved the goal of completely overcoming the limitations of the current gold standard preparation method, they at least provide endoscopists with an array of alternatives to help improve the suboptimal efficacy of the main cleansing solutions when used alone. To aid in this clinical endeavor, a subjective grade was assigned to each adjunct to indicate its practical value. In addition, the systematic review of the currently available agents and methods provides insight into the features of each that may be overcome or exploited to create novel drugs and strategies that may become adopted as effective bowel cleansing adjuncts or alternatives.

A case of hepatic portal venous gas as a complication of endoscopic balloon dilatation.

The development of hepatic portal venous gas (HPVG) is rare but it might be associated with serious disease and poor clinical outcome. Recently, several iatrogenic causes of HPVG have been reported. HPVG as a complication of endoscopic balloon dilatation is a previously unreported event. We experienced a case of HPVG after endoscopic balloon dilatation in a 31 yr-old man with pyloric stricture due to corrosive acids ingestion. The patient was treated conservatively with fluid resuscitation, antibiotics and Levin tube with natural drainage. Five days later, the follow-up CT scan showed spontaneous resolution of HPVG. This case reminded us the clinical importance and management strategy of HPVG. We report here a case of iatrogenic HPVG with a review of relevant literature.

Learning Curve of Capsule Endoscopy

Background/Aims Capsule endoscopy (CE) has become an important tool for the diagnosis of small bowel disease. Although CE does not require the skill of endoscope insertion, the images should be interpreted by a person with experience in assessing images of the gastrointestinal mucosa. This investigation aimed to document the number of cases needed by trainees to gain the necessary experience for CE competency. Methods Fifteen cases were distributed to 12 trainees with no previous experience of CE during their gastroenterology training as clinical fellows. Twelve trainees and an expert were asked to read CE images from one patient each week for 15 weeks. The diagnosis was reported using five categories (no abnormalities detected, small bowel erosion or ulcer, small bowel tumor, Crohn disease, and active small bowel bleeding with no identifiable source). We then examined, using the κ coefficient, how the degree of mean agreements between the trainees and the expert changed as the training progressed each week. Results The agreement rate of CE diagnosis increased as the frequencies of interpretation increased. Most of the mean κ coefficients were >0.60 and >0.80 after week 9 and 11, respectively. Conclusions Experience with approximately 10 cases of CE is appropriate for trainees to attain CE competency.

Risk Factor Analysis for Development of Asymptomatic Carotid Stenosis in Koreans

Many risk factors for atherosclerosis have been proposed to identify high risk individuals. We conducted a retrospective study to determine the risk factors for development of carotid stenosis (CS) in Koreans. Database of 2,805 subjects who underwent a check up of carotid artery for health examination were analyzed. Stenosis (%) of common carotid artery or proximal internal carotid artery was examined with ultrasonography. Subjects were divided into 2 groups (Group I; CS <10%, Group II; CS ≥30%). We compared demographic, laboratory and clinical data between 2 groups to determine the risk factors of CS. One hundred ninety seven subjects (7.0%) were categorized as Group II. At age- and sex-adjusted multivariate analysis, diabetes mellitus, hypertension, cerebrovascular disease, ischemic heart disease, hyperlipidemia, aspirin medication, current smoking, fasting glucose, total cholesterol, low density lipoprotein-cholesterol (LDL-C) and leukocyte count were significant risk factors of CS. At stepwise logistic regression analysis, age, hypertension, hyperlipidemia, LDL-C and leukocyte count were independent risk factors. At subgroup analysis by smoking, age and leukocyte count were independent risk factors in smoker and age and hypertension in nonsmoker.

Long-Term Outcomes of NSAID-Induced Small Intestinal Injury Assessed by Capsule Endoscopy in Korea: A Nationwide Multicenter Retrospective Study

Background/Aims We evaluated the long-term outcome and clinical course of patients of nonsteroidal anti-inflammatory drug (NSAID)-induced small intestinal injury by performing capsule endoscopy (CE). Methods A multicenter retrospective study was conducted using data collected from the CE nationwide database registry, which has been established since 2002. Results A total of 140 patients (87 males; mean age, 60.6±14.8 years) from the CE nationwide database registry (n=2,885) were diagnosed with NSAID-induced small intestinal injury and enrolled in our study. Forty-nine patients (35.0%) presented with a history of aspirin use and an additional 49 (35.0%) were taking NSAIDs without aspirin. The most prominent findings after performing CE were multiple ulcerations (n=82, 58.6%) and erosions or aphthae (n=32, 22.9%). During the follow-up period (mean, 15.9±19.0 months; range, 0 to 106 months), NSAID-induced small intestinal injury only recurred in six patients (4.3%). Older age and hypertension were positive predictive factors for recurrence. Conclusions These results suggest that the recurrence of NSAID-induced small bowel injury was not frequent in the presence of conservative treatment. Therefore, the initial diagnosis using CE and the medication history are important.