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1.  Applying Novel Nutrient Drink to Clinical Trial of Functional Dyspepsia 
The drink test has been regarded as a surrogate marker of gastric accommodation. The aims of this study were to develop a novel nutrient drink test (NDT) protocol and investigate its potential for application to a clinical trial of functional dyspepsia (FD).
A novel NDT was designed, involving drinking 125 mL of nutrient 4 times at 5-minute intervals or until maximal tolerability. Healthy volunteers and patients with FD rated their symptoms every 5 minutes for 20 minutes in a developmental study. Patients with FD were enrolled in an open trial of itopride for 4 weeks. NDT was performed before and after treatment. Improvement of integrative symptoms score during NDT after treatment for more than 50% compared with baseline was defined as responder.
Total aggregate symptom scores, sum of symptom scores measured during NDT, were higher in FD patients (n = 40, 368.1 ± 245.3) than in controls (n = 19, 215.9 ± 171.2) (P = 0.018) in a developmental study. In an open trial of itopride, symptom scores measured during NDT decreased significantly at all time points after treatment in responders (n = 49), whereas did not in non-responders (n = 25). Total aggregate symptom score for NDT correlated significantly with integrative dyspeptic symptom score, sum of 8 symptom scores of NDI questionnaire, at baseline (r = 0.374, P = 0.001) and after treatment (r = 0.480, P < 0.001).
Our novel NDT can quantify dyspeptic symptoms and reflected therapeutic effects of itopride treatment in a clinical trial of FD patients. This NDT can be used as an effective parameter in clinical trials or drug development programs for assessing effects of novel therapies on postprandial symptoms.
PMCID: PMC4015202  PMID: 24840374
Clinical Trial; Functional dyspepsia; Itopride; Nutrient drink test
2.  Hematologic diseases: High risk of Clostridium difficile associated diarrhea 
AIM: To investigate the incidence and clinical outcome of Clostridium difficile (C. difficile) associated diarrhea (CDAD) in patients with hematologic disease.
METHODS: We retrospectively reviewed the medical records of patients who underwent C. difficile testing in a tertiary hospital in 2011. The incidence and risk factors for CDAD and its clinical course including recurrence and mortality were assessed in patients with hematologic disease and compared with those in patients with nonhematologic disease.
RESULTS: About 320 patients were diagnosed with CDAD (144 patients with hematologic disease; 176 with nonhematologic disease). The incidence of CDAD in patients with hematologic disease was estimated to be 36.7 cases/10000 patient hospital days, which was higher than the 5.4 cases/10000 patient hospital days in patients with nonhematologic disease. Recurrence of CDAD was more frequent in patients with hematologic disease compared to those with nonhematologic disease (18.8% vs 8.5%, P < 0.01), which was associated with higher re-use of causative antibiotics for CDAD. Mortality due to CDAD did not differ between the two groups. Multivariate analysis showed that intravenous immunoglobulin was the only significant factor associated with a lower rate of recurrence of CDAD in patients with hematologic disease.
CONCLUSION: The incidence and recurrence of CDAD was higher in patients with hematologic disease than in those with nonhematologic disease.
PMCID: PMC4047347  PMID: 24914383
Clostridium difficile associated diarrhea; Incidence; Clinical outcome; Patients with hematologic disease; Intravenous immunoglobulin
3.  The Efficacy of Hypnotherapy in the Treatment of Irritable Bowel Syndrome: A Systematic Review and Meta-analysis 
Hypnotherapy is considered as a promising intervention for irritable bowel syndrome (IBS), but the evidence is still limited. The aims of this study were to conduct a systematic review and meta-analysis to estimate the efficacy of hypnotherapy for the treatment of IBS.
A literature search was performed using MEDLINE (PubMed), Embase, PsycINFO and the Cochrane Central Register of Controlled Trials (CENTRAL database). Only randomized controlled trials that compared hypnotherapy with any other conventional treatment or no treatment in patients with IBS were included. Studies had to report outcomes as IBS symptom score or quality of life. The mean change in outcome score was used to pool these outcomes for the meta-analysis. Data were synthesized using the standardized mean difference for continuous data.
Seven randomized controlled trials (6 papers) involving 374 patients with IBS were identified. Performance bias was high in all trials because it was impossible to blind participants and therapists in this type of intervention. The outcomes in this meta-analysis were evaluated at 3 months for short-term effects and at 1 year for long-term effects. The change in abdominal pain score at 3 months was significant in the hypnotherapy group (standardized mean difference, −0.83; 95% CI, −1.65 to −0.01). Three of the 4 trials showed greater improvement in overall gastrointestinal symptoms in the hypnotherapy group.
This study provides clearer evidence that hypnotherapy has beneficial short-term effects in improving gastrointestinal symptoms of patients with IBS.
PMCID: PMC4015203  PMID: 24840368
Gastrointestinal diseases; Hypnosis; Irritable bowel syndrome; Meta-analysis; Review
4.  Estimating the Burden of Irritable Bowel Syndrome: Analysis of a Nationwide Korean Database 
Management of irritable bowel syndrome (IBS) imposes a heavy economic burden. This study was to estimate the epidemiologic features of IBS and to report the IBS burden for the first time in the Korean population.
A cross-sectional study was conducted using the National Health Insurance (NHI) system database, which covers the entire population of Korea. IBS was defined as diagnostic code −10 in adults with any outpatient clinic visits or hospitalization related to IBS. We excluded diseases that mimic IBS symptoms.
A total of 2.42 million (58.2% female) individuals were identified as patients with IBS, yielding an age- and gender-adjusted prevalence of 5.1% in males and 6.9% in females. The prevalence of IBS increased proportionally with age, with higher medical costs in middle-aged patients. Outpatient clinics were visited by 98.6% of IBS patients, and 1.9% were treated upon admission. Of these patients, 87.6% were given a prescription. Co-morbidities that commonly accompanied IBS included upper gastrointestinal (36.1%), respiratory (12.3%), musculoskeletal (8.0%) disease, somatoform (4.3%) and depression/anxiety disorders (3.1%). The NHI costs of IBS, which include the NHI covered cost and beneficiary copayment charges, were estimated to be 155 million USD, which accounts for 0.46% of the total NHI costs for the entire Korean population.
According to the Korean national claims database, about 6% of the Korean population seeks medical care for IBS at least once per year. This high prevalence places a large economic burden on the Korean healthcare system, accounting for 0.46% of overall national medical expenditure.
PMCID: PMC4015204  PMID: 24840377
Epidemiology; Cost of illness; Irritable bowel syndrome; Population
5.  Effect of DA-9701 on gastric emptying in a mouse model: Assessment by 13C-octanoic acid breath test 
AIM: To evaluate the effects of DA-9701 on the gastric emptying of a solid meal using the 13C-octanoic acid breath test in a mouse model.
METHODS: Male C57BL/6 mice aged > 8 wk and with body weights of 20-25 g were used in this study. The solid test meal consisted of 200 mg of egg yolk labeled with 1.5 L/g 13C-octanoic acid. The mice were placed in a 130 mL chamber flushed with air at a flow speed of 200 mL/min. Breath samples were collected for 6 h. The half-emptying time and lag phase were calculated using a modified power exponential model. To assess the reproducibility of the 13C-octanoic acid breath test, the breath test was performed two times at intervals of one week in ten mice without drug treatment. To assess the gastrokinetic effects of DA-9701, the breath test was performed three times in another twelve mice, with a randomized crossover sequence of three drug treatments: DA-9701 3 mg/kg, erythromycin 6 mg/kg, or saline. Each breath test was performed at an interval of one week.
RESULTS: Repeatedly measured half gastric emptying time of ten mice without drug treatment showed 0.856 of the intraclass correlation coefficient for the half gastric emptying time (P = 0.004). The mean cumulative excretion curve for the 13C-octanoic acid breath test showed accelerated gastric emptying after DA-9701 treatment compared with the saline control (P = 0.028). The median half gastric emptying time after the DA-9701 treatment was significantly shorter than after the saline treatment [122.4 min (109.0-137.9 min) vs 134.5 min (128.4-167.0 min), respectively; P = 0.028] and similar to that after the erythromycin treatment [123.3 min (112.9-138.2 min)]. The lag phase, which was defined as the period taken to empty 15% of a meal, was significantly shorter after the DA-9701 treatment than after the saline treatment [48.1 min (44.6-57.1 min) vs 52.6 min (49.45-57.4 min), respectively; P = 0.049].
CONCLUSION: The novel prokinetic agent DA-9701 accelerated gastric emptying, assessed with repeated measurements in the same mouse using the 13C-octanoic acid breath test. Our findings suggest that DA-9701 has therapeutic potential for the treatment of functional dyspepsia.
PMCID: PMC3718907  PMID: 23885150
DA-9701; Gastric emptying; Prokinetic agent; Breath test; Functional dyspepsia
6.  Chronic gastrointestinal symptoms and quality of life in the Korean population 
AIM: To evaluate the prevalence of chronic gastrointestinal symptoms and their impact on health-related quality of life (HRQOL) in the Korean population.
METHODS: A cross-sectional survey, using a reliable and valid Rome II based questionnaire, was performed on randomly selected residents, between 18 and 69 years in age. All respondents were interviewed at their homes or offices by a team of interviewers. The impact of chronic gastrointestinal symptoms on HRQOL was assessed using the Korean version of the 36-item Short-Form general health survey (SF-36).
RESULTS: Of the 1807 eligible subjects, 1417 (78.4%: male 762; female 655) were surveyed. Out of the respondents, 18.6% exhibited at least one chronic gastrointestinal symptom. The prevalence of gastroesophageal reflux disease (GERD), defined as heartburn and/or acid regurgitation experienced at least weekly, was 3.5% (95% CI, 2.6-4.5). The prevalence of uninvestigated dyspepsia, irritable bowel syndrome (IBS) and chronic constipation based on Rome II criteria were 11.7% (95% CI, 10.1-13.5), 2.2% (95% CI, 1.5-3.1), and 2.6% (95% CI, 1.8-3.5) respectively. Compared with subjects without chronic gastrointestinal symptoms (n = 1153), those with GERD (n = 50), uninvestigated dyspepsia (n = 166) and IBS (n = 31) had significantly worse scores on most domains of the SF-36 scales.
CONCLUSION: The prevalence of GERD, uninvestigated dyspepsia and IBS were 3.5%, 11.7% and 2.2% respectively, in the Korean population. The health-related quality of life was significantly impaired in subjects with GERD, uninvestigated dyspepsia and IBS in this community.
PMCID: PMC2766123  PMID: 19009657
Chronic gastrointestinal symptom; Gastroesophageal reflux disease; Dyspepsia; Irritable bowel syndrome; Qaulity of life
7.  Evaluation of esophageal function in patients with esophageal motor abnormalities using multichannel intraluminal impedance esophageal manometry 
AIM: To evaluate the functional aspect of esophageal motility in healthy subjects and in patients who were referred for esophageal function testing using multichannel intraluminal impedance-esophageal manometry (MII-EM), and to assess the clinical utility of MII-EM.
METHODS: From September 2003 to January 2004, we performed the MII-EM on healthy volunteers and all the patients who were referred for esophageal function testing. Each patient received 10 liquid and 10 viscous swallows. We analyzed the results, the impedance and the manometric findings. Some of the subjects had additional ambulatory 24-h pH study performed to diagnose gastroesophageal reflux disease (GERD).
RESULTS: Among 89 studied subjects, the MII-EM findings showed normal esophageal motility in 50 (56.17%), ineffective esophageal motility (IEM) in 17 (19.10%), nutcracker esophagus in 7 (7.86%), achalasia in 4 (4.49%), and scleroderma esophagus in 11 (12.35%) cases. The completeness and the speed of bolus transit were in the order of nutcracker esophagus, normal manometry and IEM. Some of the swallows showing normal manometry and IEM had incomplete transit. In the achalasia and scleroderma esophagus, almost all the swallows had incomplete transit. The body amplitudes were higher for the swallows with complete transit than for the swallows with incomplete transit. There was not a significant difference in the manometric and impedance findings between the subjects with and without GERD.
CONCLUSION: MII-EM is a useful tool in assessing the esophageal function in the patients having esophageal motility abnormality. The primary factors influencing the bolus transit are the amplitude of the esophageal body and normal peristalsis.
PMCID: PMC4088145  PMID: 17072960
Impedance manometry; Esophageal function; Motility; Bolus transit
8.  Development, Translation and Validation of Enhanced Asian Rome III Questionnaires for Diagnosis of Functional Bowel Diseases in Major Asian Languages: A Rome Foundation-Asian Neurogastroenterology and Motility Association Working Team Report 
The development-processes by regional socio-cultural adaptation of an Enhanced Asian Rome III questionnaire (EAR3Q), a cultural adaptation of the Rome III diagnostic questionnaire (R3DQ), and its translation-validation in Asian languages are presented. As English is not the first language for most Asians, translation-validation of EAR3Q is essential. Hence, we aimed to culturally adapt the R3DQ to develop EAR3Q and linguistically validate it to show that the EAR3Q is able to allocate diagnosis according to Rome III criteria.
After EAR3Q was developed by Asian experts by consensus, it was translated into Chinese, Hindi-Telugu, Indonesian, Korean, and Thai, following Rome Foundation guidelines; these were then validated on native subjects (healthy [n = 60], and patients with irritable bowel syndrome [n = 59], functional dyspepsia [n = 53] and functional constipation [n = 61]) diagnosed by clinicians using Rome III criteria, negative alarm features and investigations.
Experts noted words for constipation, bloating, fullness and heartburn, posed difficulty. The English back-translated questionnaires demonstrated concordance with the original EAR3Q. Sensitivity and specificity of the questionnaires were high enough to diagnose respective functional gastrointestinal disorders (gold standard: clinical diagnoses) in most except Korean and Indonesian languages. Questionnaires often uncovered overlapping functional gastrointestinal disorders. Test-retest agreement (kappa) values of the translated questionnaires were high (0.700–1.000) except in Korean (0.300–0.500) and Indonesian (0.100–0.400) languages at the initial and 2-week follow-up visit.
Though Chinese, Hindi and Telugu translations were performed well, Korean and Indonesian versions were not. Questionnaires often uncovered overlapping FGIDs, which were quite common.
PMCID: PMC4288097  PMID: 25537673
Asia; Gastrointestinal diseases; Rome III criteria; Translations; Validation
9.  Preoperative colonoscopy through the colonic stent in patients with colorectal cancer obstruction 
World Journal of Gastroenterology : WJG  2014;20(30):10570-10576.
AIM: To evaluate the feasibility of a preoperative colonoscopy through a self-expendable metallic stent (SEMS) and to identify the factors that affect complete colonoscopy.
METHODS: A total of 48 patients who had SEMS placement because of acute malignant colonic obstruction underwent preoperative colonoscopy. After effective SEMS placement, patients who showed complete resolution of radiological findings and clinical signs of acute colon obstruction underwent a standard bowel preparation. Preoperative colonoscopy was then performed using a standard colonoscope. If the passage of colonoscope was not feasible gastroscope was used. After colonoscopy, cecal intubation time, grade of bowel preparation, tumor location, stent location, presence of synchronous polyps or cancer, damage to colonoscopy and bleeding, and stent migration after colonoscopy were recorded.
RESULTS: Complete evaluation with colonoscope was possible in 30 patients (62.5%). In this group, adenoma was detected in 13 patients (43.3%). The factors that affected complete colonoscopy were also analyzed: Tumor location at an angle; stent placement at an angle; and stent expansion diameter, which affected complete colonoscopy significantly. However in multivariate analysis, stent expansion diameter was the only significant factor that affected complete colonoscopy. Complete evaluation using additional gastroscope was feasible in 42 patients (87.5%).
CONCLUSION: Preoperative colonoscopy through the colonic stent using only conventional colonoscope was unfavorable. The narrow expansion diameter of the stent may predict unfavorable outcome. In such a case, using small caliber scope should be considered and may expect successful outcome.
PMCID: PMC4130868  PMID: 25132777
Colon cancer; Stent; Preoperative colonoscopy; Complete colonoscopy
10.  Association Between Non-erosive Reflux Disease and High Risk of Obstructive Sleep Apnea in Korean Population 
Obstructive sleep apnea is becoming more important in gastroesophageal reflux disease (GERD) patients. This study investigated the prevalence of high risk for obstructive sleep apnea in GERD patients in comparison with that in healthy controls using the Berlin Questionnaire. We also investigated the risk factors for obstructive sleep apnea in GERD patients.
We enrolled 1,007 subjects: 776 healthy controls, 115 individuals with erosive reflux disease, and 116 with non-erosive reflux disease. GERD was diagnosed and classified using endoscopy and a reflux questionnaire. The Berlin Questionnaire was used to evaluate obstructive sleep apnea.
More patients in the GERD group (28.2%) had higher risk for obstructive sleep apnea than healthy controls (20.4%, P = 0.036). More patients with non-erosive disease (32.8%) had higher risk for obstructive sleep apnea (OSA) than patients with erosive disease (20.9%) and controls (20.4%, P = 0.010). On multivariate analysis, non-erosive disease was a high risk factor for obstructive sleep apnea (odds ratio [OR], 1.82; P = 0.011). Age ≥ 55 years (OR, 1.83; P < 0.001) and a high body mass index (≥ 25 kg/m2) (OR, 2.76; P < 0.001) were also identified as risk factors. Nocturnal GERD was related to high risk for OSA in non-erosive disease patients (OR, 2.97; P = 0.019), but not in erosive disease patients.
High risk for OSA is more prevalent in GERD patients than in controls. Non-erosive reflux disease, age ≥ 55, and a high BMI are associated with high risk for OSA.
PMCID: PMC4015211  PMID: 24840371
Gastroesophageal reflux; Esophagitis; Sleep apnea, obstructive
11.  Symptom Characteristics and Psychosomatic Profiles in Different Spectrum of Gastroesophageal Reflux Disease 
Gut and Liver  2013;8(2):165-169.
Gastroesophageal reflux disease (GERD) is diagnosed based on symptoms of heartburn and regurgitation but is a heterogeneous condition which can be subclassified according to endoscopy and esophageal reflux monitoring. The aim of this study was to identify differences in demographic characteristics and reflux symptom patterns among patients with various spectrum of GERD.
Patients having weekly heartburn or acid regurgitation were classified into four pathophysiological subgroups according to endoscopy and pH monitoring: reflux esophagitis (RE), endoscopy-negative reflux disease with pathological reflux (PR+), hypersensitive esophagus (HE), and normal acid exposure with negative symptom association (pH-).
A total of 195 patients were enrolled. The numbers of patients in the subgroups were: RE, 39.0%; PR+, 20.0%; HE, 10.3%; and pH-, 30.8%. Grossly, reflux symptom patterns and relieving/exacerbating factors did not differ between subgroups. Prevalence of extraesophageal syndrome was higher in patients with PR+ than in other groups. Overlapping functional dyspepsia was common in all groups. The SCL-90-R depression score was higher in PR+ patients than in RE patients (p<0.05).
Demographic characteristics and reflux symptom patterns cannot differentiate pH- group from GERD subtypes. Esophageal pH monitoring could be considered for the initial evaluation of GERD in the tertiary referral setting.
PMCID: PMC3964267  PMID: 24672658
Gastroesophageal reflux; Demographic characteristics; Symptom characteristic; Psychosomatic factor; Esophageal reflux monitoring
12.  Long-term pretreatment with proton pump inhibitor and Helicobacter pylori eradication rates 
AIM: To investigate whether proton pump inhibitor (PPI) pretreatment influences Helicobacter pylori eradication rate.
METHODS: We retrospectively reviewed H. pylori-infected patients who were treated with a standard triple regimen (PPI, amoxicillin 1 g, and clarithromycin 500 mg, all twice daily for 7 d). The diagnosis of H. pylori infection and its eradication was assessed with the rapid urease test, histological examination by silver staining, or the 13C-urea breath test. We divided the patients into two groups: one received the standard eradication regimen without PPI pretreatment (Group A), and the other received PPI pretreatment (Group B). The patients in Group B were reclassified into three groups based on the duration of PPI pretreatment: Group B-I (3-14 d), Group B-II (15-55 d), and Group B-III (≥ 56 d).
RESULTS: A total of 1090 patients were analyzed and the overall eradication rate was 80.9%. The cure rate in Group B (81.2%, 420/517) was not significantly different from that in Group A (79.2%, 454/573). The eradication rates in Group B-I, B-II and B-III were 80.1% (117/146), 81.8% (224/274) and 81.4% (79/97), respectively.
CONCLUSION: PPI pretreatment did not affect H. pylori eradication rate, regardless of the medication period.
PMCID: PMC3921530  PMID: 24574779
Proton pump inhibitor; Helicobacter pylori; Urea breath test; Antibiotics; Drug resistance
13.  Learning Curve of Capsule Endoscopy 
Clinical Endoscopy  2013;46(6):633-636.
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.
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.
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.
Experience with approximately 10 cases of CE is appropriate for trainees to attain CE competency.
PMCID: PMC3856264  PMID: 24340256
Capsule endoscopy; Learning curve
14.  Obesity Is Associated With Increasing Esophageal Acid Exposure in Korean Patients With Gastroesophageal Reflux Disease Symptoms 
Obesity is regarded as an important contributor to the increasing occurrence of gastroesophageal reflux disease. The aims of this study were to determine whether obesity is associated with gastroesophageal reflux in patients with gastroesophageal reflux disease and to identify the factors affecting increased acid exposure in obese patients.
We retrospectively analyzed the data of patients who underwent ambulatory 24-hour pH monitoring and esophageal manometry at Seoul St. Mary's Hospital. Obesity was classified according to the Asia-Pacific criteria.
A total of 366 patients were analyzed; 18 were underweight, 152 normal weight, 104 overweight, and 92 obese. Obesity was more frequent in men and younger patients. The percentage time of pH < 4 in the total, upright, and postprandial periods was significantly higher in obese patients than in normal or underweight patients. The DeMeester score was also higher in obese patients. Body mass index correlated positively with reflux parameters. Multivariate analysis showed that being male and obesity were significantly associated with abnormal acid exposure (P < 0.005). The total lower esophageal sphincter length shortened as body mass index increased (P < 0.005). The gastroesophageal pressure gradient increased as body mass index increased (P < 0.05).
Obesity is associated with increasing esophageal acid exposure. The mechanism responsible for the relationship between gastroesophageal reflux disease and obesity may be associated with shortening of the lower esophageal sphincter length and increasing the gastroesophageal pressure gradient.
PMCID: PMC3714412  PMID: 23875101
Esophageal pH monitoring; Gastroesophageal reflux disease; Manometry; Obesity
15.  Extremely High Panesophageal Pressurization in Type II Achalasia 
PMCID: PMC3714421  PMID: 23875110
16.  Anemia after gastrectomy for early gastric cancer: Long-term follow-up observational study 
AIM: To identify the incidence and etiology of anemia after gastrectomy in patients with long-term follow-up after gastrectomy for early gastric cancer.
METHODS: The medical records of those patients with early gastric adenocarcinoma who underwent curative gastrectomy between January 2006 and October 2007 were reviewed. Patients with anemia in the preoperative workup, cancer recurrence, undergoing systemic chemotherapy, with other medical conditions that can cause anemia, or treated during follow up with red cell transfusions or supplements for anemia were excluded. Anemia was defined by World Health Organization criteria (Hb < 12 g/dL in women and < 13 g/dL in men). Iron deficiency was defined as serum ferritin < 20 μg/dL. Vitamin B12 deficiency was defined as serum vitamin B12 < 200 pg/mL. Iron deficiency anemia was defined as anemia with concomitant iron deficiency. Anemia from vitamin B12 deficiency was defined as megaloblastic anemia (mean cell volume > 100 fL) with vitamin B12 deficiency. The profile of anemia over 48 mo of follow-up was analyzed.
RESULTS: One hundred sixty-one patients with gastrectomy for early gastric cancer were analyzed. The incidence of anemia was 24.5% at 3 mo after surgery and increased up to 37.1% at 48 mo after surgery. The incidence of iron deficiency anemia increased during the follow up and became the major cause of anemia at 48 mo after surgery. Anemia of chronic disease and megaloblastic anemia were uncommon. The incidence of anemia in female patients was significantly higher than in male patients at 12 (40.0% vs 22.0%, P = 0.033), 24 (45.0% vs 25.0%, P = 0.023), 36 (55.0% vs 28.0%, P = 0.004), and 48 mo (52.0% vs 31.0%, P = 0.022) after surgery. Patients with total gastrectomy showed significantly higher incidence of anemia than patients with subtotal gastrectomy at 48 mo after surgery (60.7% vs 31.3%, P = 0.008). The incidence of iron deficiency was significantly higher in female patients than in male patients at 6 (35.4% vs 13.3%, P = 0.002), 12 (45.8% vs 16.8%, P < 0.001), 18 (52.1% vs 22.3%, P < 0.001), 24 (60.4% vs 20.9%, P < 0.001), 36 (62.5% vs 29.2%, P < 0.001), and 48 mo (66.7% vs 34.7%, P = 0.001) after surgery.
CONCLUSION: Anemia was frequent after gastrectomy for early gastric cancer, with iron deficiency being the major cause. Evaluation for anemia including iron status should be performed after gastrectomy and appropriate iron replacement should be considered.
PMCID: PMC3496888  PMID: 23155340
Gastrectomy; Stomach neoplasms; Anemia; Iron deficiency; Vitamin B12 deficiency
17.  Comparative study of rendezvous techniques in post-liver transplant biliary stricture 
AIM: To investigate the usefulness of a new rendezvous technique for placing stents using the Kumpe (KMP) catheter in angulated or twisted biliary strictures.
METHODS: The rendezvous technique was performed in patients with a biliary stricture after living donor liver transplantation (LDLT) who required the exchange of percutaneous transhepatic biliary drainage catheters for inside stents. The rendezvous technique was performed using a guidewire in 19 patients (guidewire group) and using a KMP catheter in another 19 (KMP catheter group). We compared the two groups retrospectively.
RESULTS: The baseline characteristics did not differ between the groups. The success rate for placing inside stents was 100% in both groups. A KMP catheter was easier to manipulate than a guidewire. The mean procedure time in the KMP catheter group (1012 s, range: 301-2006 s) was shorter than that in the guidewire group (2037 s, range: 251-6758 s, P = 0.022). The cumulative probabilities corresponding to the procedure time of the two groups were significantly different (P = 0.008). The factors related to procedure time were the rendezvous technique method, the number of inside stents, the operator, and balloon dilation of the stricture (P < 0.05). In a multivariate analysis, the rendezvous technique method was the only significant factor related to procedure time (P = 0.010). The procedural complications observed included one case of mild acute pancreatitis and one case of acute cholangitis in the guidewire group, and two cases of mild acute pancreatitis in the KMP catheter group.
CONCLUSION: The rendezvous technique involving use of the KMP catheter was a fast and safe method for placing inside stents in patients with LDLT biliary stricture that represents a viable alternative to the guidewire rendezvous technique.
PMCID: PMC3491604  PMID: 23139613
Rendezvous; Biliary stricture; Liver transplantation; Endoscopic retrograde cholangiography; Percutaneous transhepatic biliary drainage
18.  Impaired Esophageal Bolus Transit in Patients with Gastroesophageal Reflux Disease and Abnormal Esophageal Acid Exposure 
Gut and Liver  2012;6(4):440-445.
We assessed the bolus transit and motility characteristics in gastroesophageal reflux disease (GERD) patients with abnormal esophageal pH monitoring.
We retrospectively reviewed the combined impedance-esophageal manometry data from consecutive patients who had abnormal acid exposure during 24-hour esophageal pH monitoring. We compared these data to the results from functional heartburn (FH) and asymptomatic volunteers.
The data from 33 GERD patients (mean age of 51 years, 18 males), 14 FH patients (mean age of 51 years, one male), and 20 asymptomatic volunteers (mean age of 27 years, nine males) were analyzed. Ineffective esophageal motility was diagnosed in 10% of the volunteers, 21% of the FH patients, and 15% of the GERD patients. Ineffective contraction was more frequent in GERD and FH patients than in volunteers (16% and 20% vs 6%, respectively; p<0.05). Additionally, 10% of the volunteers, 21% of the FH patients and 36% of the GERD patients had an abnormal bolus transit. Complete bolus transit was less frequent, and bolus transit was slower in GERD patients than in volunteers for liquid (70% vs 85%) and viscous swallows (57% vs 73%). A longer acid clearance time was associated with abnormal bolus transit in the GERD group.
Patients with GERD have mild peristaltic dysfunction and incomplete and slower esophageal bolus transit. These conditions predispose them to prolonged acid contact with the esophagus.
PMCID: PMC3493723  PMID: 23170147
Gastroesophageal reflux; Bolus transit; Impedance
19.  Anorectal Manometric Dysfunctions in Newly Diagnosed, Early-Stage Parkinson's Disease 
Background and Purpose
Anorectal dysmotility is common in advanced Parkinson's disease (PD), but there have been few evaluations in newly diagnosed PD patients.
We conducted anorectal manometric evaluations in 19 newly diagnosed, drug-naïve, early-stage PD patients. All of the PD patients were questioned regarding the presence of anorectal symptoms.
Anorectal manometry was abnormal in 12 of the 19 patients. These abnormalities were more common in patients with more severe anorectal symptoms, as measured using a self-reported scale. However, more than 40% of patients with no or minimal symptoms also exhibited manometric abnormalities.
These results suggest that anorectal dysmotility manifests in many early-stage PD patients, which this represent evidence for the involvement of neuronal structures in such nonmotor manifestations in PD.
PMCID: PMC3469798  PMID: 23091527
Parkinson's disease; anorectal dysfunction; manometry
20.  Recent advances in targeted endoscopic imaging: Early detection of gastrointestinal neoplasms 
Molecular imaging has emerged as a new discipline in gastrointestinal endoscopy. This technology encompasses modalities that can visualize disease-specific morphological or functional tissue changes based on the molecular signature of individual cells. Molecular imaging has several advantages including minimal damage to tissues, repetitive visualization, and utility for conducting quantitative analyses. Advancements in basic science coupled with endoscopy have made early detection of gastrointestinal cancer possible. Molecular imaging during gastrointestinal endoscopy requires the development of safe biomarkers and exogenous probes to detect molecular changes in cells with high specificity anda high signal-to-background ratio. Additionally, a high-resolution endoscope with an accurate wide-field viewing capability must be developed. Targeted endoscopic imaging is expected to improve early diagnosis and individual therapy of gastrointestinal cancer.
PMCID: PMC3309894  PMID: 22442742
Autofluorescence endoscopy; Confocal endomicroscopy; Endoscopy; Molecular imaging; Molecular probes, Near-infrared fluorescence imaging; Targeted endoscopic imaging
21.  Performance and Cost of Disposable Biopsy Forceps in Upper Gastrointestinal Endoscopy: Comparison with Reusable Biopsy Forceps 
Clinical Endoscopy  2012;45(1):62-66.
It is believed that disposable biopsy forceps are more costly than reusable biopsy forceps. In this study, we evaluated performance and cost of disposable forceps versus reusable forceps in esophagogastroduodenoscopic biopsy.
Between October 2009 and July 2010, we enrolled 200 patients undergoing esophagogastroduodenoscopic biopsy at Seoul St. Mary's Hospital. Biopsies were performed with 100 disposable or 5 reusable forceps by random assignment. Seventy-five additional patients were studied to estimate durability of reusable forceps. The assisting nurses estimated the performance of the forceps. The evaluation of costs included purchase prices and reprocessing costs. The adequacy of the sample was estimated according to the diameter of the obtained tissue.
Performance of disposable forceps was estimated as excellent in 97.0%, good in 2.0% and adequate in 1.0%. Reusable forceps were estimated as excellent in 36.0%, good in 36.0%, adequate in 25.1% and inadequate in 2.9%. The performance of reusable forceps declined with the number of uses. The reprocessing cost of reusable forceps for one biopsy session was calculated as ₩8,021. The adequacy of the sample was excellent for both forceps.
Disposable forceps showed excellent performance. Considering the reprocessing costs of reusable forceps, usage of disposable forceps with a low price should be considered.
PMCID: PMC3363127  PMID: 22741133
Endoscopy; Biopsy; Disposable equipment; Costs and cost analysis
22.  Current Advance in Small Bowel Tumors 
Clinical Endoscopy  2011;44(1):13-21.
Small intestinal tumors are difficult challenge to gastroenterologists. The difficulty in making a diagnosis of small intestinal tumor lies in the relative inaccessibility and absence of typical presentation. New endoscopic and radiologic technologies provide clear and fine anatomical visualization of the small bowel and are approved to improve the diagnostic sensitivity and accuracy. Patients at risk of small intestinal tumors might gain a benefit from proper surveillance with this new technology. Minimally invasive therapy is now available with advance of balloon assisted enteroscopy. This review describes the general aspect of the small intestinal tumors, focusing on the new modalities for diagnosis.
PMCID: PMC3363052  PMID: 22741107
Small bowel; Tumor
23.  Health Related Quality of Life in Functional Gastrointestinal Disorders in Asia 
The importance of health-related quality of life (HRQOL) continues to grow, as clinicians and clinical researchers have recognized the impact of the functional gastrointestinal disorders. Limited information is available on the performance of HRQOL questionnaires in Asia. Furthermore, the effect across different cultural settings of functional gastrointestinal disorders on HRQOL has been little studied in Eastern countries. We summarized recent studies on HRQOL in Korean patients with functional gastrointestinal disorders as well as other Asian literatures. Functional gastrointestinal disorders-related symptoms had a great effect on the HRQOL of Korean patients. These results and their considerable prevalence in Korea indicate that functional gastrointestinal disorders have a substantial social impact in this country.
PMCID: PMC3155060  PMID: 21860816
Dyspepsia; Irritable bowel syndrome; Quality of life
24.  Functional Gastrointestinal Disorders Diagnosed by Rome III Questionnaire in Korea 
Rome criteria classifying functional gastrointestinal disorder (FGID) were updated. The aims of this study were to assess the spectra of FGID and to evaluate the applicability of Rome III criteria in Korea.
New patients who visited 2 primary clinics and 2 tertiary care hospitals were consecutively invited to complete questionnaires. These consisted of questionnaires for FGID based on Rome III criteria and symptom checklist-90-revised for somatization, depression and anxiety.
A total of 786 patients was participated. Among them, FGID was observed in 49.7%. In the patients with FGID, functional dyspepsia was most common (46.0%) followed by irritable bowel syndrome (IBS, 40.2%). Functional dyspepsia was most common both in the primary care clinics and tertiary care hospitals. Postprandial distress syndrome was the most common subtype and the frequency of epigastric pain syndrome was low. There were few responders for constipation as Bristol types 1 and 2 and for diarrhea as types 6 and 7 in subtype classification using the Bristol Stool Form Scale. Thereby, unspecified IBS defined by stool form was unexpectedly common in 43.9% of IBS, whereas unspedified IBS defined by Rome III definition was 5.1%. Patients with overlap FGIDs had higher score of anxiety, depression or somatization.
FGIDs were common both in primary care clinics and tertiary care hospitals of Korea. Overlap FGIDs is still common by Rome III criteria, which may limits its wide application.
PMCID: PMC3155064  PMID: 21860820
Classification; Dyspepsia; Gastrointestinal diseases; Irritable bowel syndrome
25.  The Prevalence of Gastrointestinal Symptoms in Patients with Non-Insulin Dependent Diabetes Mellitus 
Gastrointestinal (GI) symptoms are common among patients with non-insulin dependent diabetes mellitus (NIDDM). Our aim was to investigate the frequency of chronic GI symptoms in Korean patients with NIDDM.
A cross-sectional survey, using a reliable and valid questionnaire, was performed in diabetes clinics from seven hospitals of the Catholic University of Korea.
A total of 608 patients (249 males and 359 females, mean age 53.7±10.9 years) were investigated. The frequencies of weekly heartburn and acid regurgitation (esophageal symptoms) were 7.1% (95% confidence interval [CI], 5.0 to 9.2) and 4.4% (95% CI, 2.8 to 6.1), respectively. The frequency of dyspepsia was 13.2% (95% CI, 10.5 to 15.8). The frequencies of constipation and diarrhea were 15.0% (95% CI, 12.2 to 18.0) and 5.3% (95% CI, 3.5 to 7.1), respectively. Nausea and the use of manual maneuvers to facilitate defecation were more prevalent in women than in men. Constipation and fecal incontinence were more common in diabetes patients with long duration (>10 years). Fecal incontinence and using laxatives were more frequent in the complicated diabetes group. Using laxatives was more frequent in the uncontrolled diabetes group.
Two-thirds of diabetic patients experienced GI symptoms. The prevalence of GI symptoms was more common in patients who had diabetic complications and a long duration of diabetes.
PMCID: PMC2784973  PMID: 19949728
Diabetes mellitus, type 2; Prevalence; Signs and symptoms, digestive; Diabetes complications

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