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2.  Benign Colorectal Stricture: An Answer to the Balloon or Stent Question? 
Gut and Liver  2015;9(1):3-4.
doi:10.5009/gnl14448
PMCID: PMC4282847  PMID: 25547085
3.  Diagnosis and Management of High Risk Group for Gastric Cancer 
Gut and Liver  2015;9(1):5-17.
Gastric cancer is associated with high morbidity and mortality worldwide. To reduce the socioeconomic burden related to gastric cancer, it is very important to identify and manage high risk group for gastric cancer. In this review, we describe the general risk factors for gastric cancer and define high risk group for gastric cancer. We discuss strategies for the effective management of patients for the prevention and early detection of gastric cancer. Atrophic gastritis (AG) and intestinal metaplasia (IM) are the most significant risk factors for gastric cancer. Therefore, the accurate selection of individuals with AG and IM may be a key strategy for the prevention and/or early detection of gastric cancer. Although endoscopic evaluation using enhanced technologies such as narrow band imaging-magnification, the serum pepsinogen test, Helicobacter pylori serology, and trefoil factor 3 have been evaluated, a gold standard method to accurately select individuals with AG and IM has not emerged. In terms of managing patients at high risk of gastric cancer, it remains uncertain whether H. pylori eradication reverses and/or prevents the progression of AG and IM. Although endoscopic surveillance in high risk patients is expected to be beneficial, further prospective studies in large populations are needed to determine the optimal surveillance interval.
doi:10.5009/gnl14118
PMCID: PMC4282848  PMID: 25547086
Stomach neoplasms; Risk factors; Risk management
4.  Long-Term Outcomes and Dynamics of Mutants Associated with Lamivudine-Adefovir Rescue Therapy in Patients with Lamivudine-Resistant Chronic Hepatitis B 
Gut and Liver  2015;9(1):103-108.
Background/Aims
To investigate the association between the baseline profiles and dynamics of hepatitis B virus (HBV) DNA polymerase gene mutations and the long-term virological response of lamivudine (LAM)-adefovir (ADV) combination therapy in patients with LAM-resistant chronic hepatitis B.
Methods
Seventy-five patients who received LAM-ADV combination therapy for more than 12 months were analyzed. Restriction fragment mass polymorphism assays were used to detect and monitor the dynamics of LAM- and ADV-resistant mutations.
Results
The median duration of LAM-ADV combination therapy was 26 months (range, 12 to 58 months). The baseline mutation profiles, rtM204I (p=0.992), rtM204I/V (p=0.177), and rtL180M (p=0.051), were not correlated with the cumulative virological response, and the baseline HBV DNA level (p=0.032) was the only independent predictive factor for cumulative virological response. Tests for LAM- and ADV-resistant mutations were performed in 12 suboptimal responders in weeks 48 and 96. The population of rtM204 mutants persisted or increased in 8 of 12 patients, and rtA181T mutants newly emerged as a minor population in four patients until 96 weeks. Nevertheless, the viral loads progressively decreased during rescue therapy, and these dynamics did not correlate with virological response.
Conclusions
The baseline profile and dynamics of LAM-resistant mutations during LAM-ADV combination therapy are not associated with a virological response.
doi:10.5009/gnl14018
PMCID: PMC4282849  PMID: 25287170
Hepatitis B virus; Lamivudine resistance; Restriction fragment mass polymorphism; Mutation
5.  Feasibility of Cap-Assisted Endoscopic Retrograde Cholangiopancreatography in Patients with Altered Gastrointestinal Anatomy 
Gut and Liver  2015;9(1):109-112.
Background/Aims
Endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging in patients with altered gastrointestinal (GI) anatomy. We evaluated the feasibility of cap-assisted ERCP in patients with altered GI anatomy.
Methods
The outcome of ERCP procedures (n=136) was analyzed in 78 patients with Billroth II (B-II) gastrectomy (n=72), Roux-en-Y total gastrectomy (n=4), and hepaticoduodenostomy (n=2). The intubation rate for reaching the papilla of Vater (POV), deep biliary cannulation rate, therapeutic interventions and procedure-related complications were analyzed. All of the procedures were conducted using a cap-fitted forward-viewing endoscope.
Results
The rate of access to the POV was 97.1% (132/136). In cases with successful access, selective biliary cannulation was achieved in 98.5% (130/132) of the patients. The successful biliary cannulation rates were 100% (125/125) for B-II gastrectomy, 50% (2/4) for Roux-en-Y gastrectomy and 100% (3/3) for hepaticoduodenostomy. After selective biliary cannulation, therapeutic interventions, including stone extraction (n=57), sphincterotomy (n=54), stent placement (n=37), nasobiliary drainage (n=20), endoscopic papillary balloon dilatation (n=7) and mechanical lithotripsy (n=15), were performed successfully. The procedure-related complication rate was 8.8% (12/136), including immediate bleeding (5.9%, 8/136), pancreatitis (2.2%, 3/136), and perforation (0.7%, 1/136). There were no procedure-related deaths.
Conclusions
Cap-assisted ERCP is efficient and safe in patients with altered GI anatomy.
doi:10.5009/gnl13447
PMCID: PMC4282850  PMID: 25167794
Cholangiopancreatography; endoscopic retrograde; Cap; Billroth II gastrectomy
6.  Characteristic Findings of Endoscopic Retrograde Cholangiopancreatography in Autoimmune Pancreatitis 
Gut and Liver  2015;9(1):113-117.
Background/Aims
Diffuse or segmental irregular narrowing of the main pancreatic duct (MPD), as observed by endoscopic retrograde cholangiopancreatography (ERCP), is a characteristic feature of autoimmune pancreatitis (AIP).
Methods
ERCP findings were retrospectively examined in 40 patients with AIP in whom irregular narrowing of the MPD was detected near the orifice. The MPD opening sign was defined as the MPD within 1.5 cm from the orifice being maintained. The distal common bile duct (CBD) sign was defined as the distal CBD within 1.5 cm from the orifice being maintained. Endoscopic findings of a swollen major papilla and histological findings of specimens obtained from the major papilla were examined in 26 and 21 patients, respectively.
Results
The MPD opening sign was detected in 26 of the 40 patients (65%). The distal CBD sign was detected in 25 of the 32 patients (78%), which showed stenosis of the lower bile duct. The patients who showed the MPD opening sign frequently showed the distal CBD sign (p=0.018). Lymphoplasmacytic infiltration, but not dense fibrosis, was histologically detected in biopsy specimens obtained from the major papilla.
Conclusions
On ERCP, the MPD and CBD adjacent to the major papilla are frequently maintained in patients with AIP involving the pancreatic head. These signs are useful for diagnosing AIP on ERCP.
doi:10.5009/gnl13473
PMCID: PMC4282851  PMID: 25167792
Pancreatitis; chronic; Cholangitis; sclerosing
8.  Current and Emerging Biologics for Ulcerative Colitis 
Gut and Liver  2015;9(1):18-27.
Conventional medical treatment for ulcerative colitis can have limited efficacy or severe adverse reactions requiring additional treatment or colectomy. Hence, different biological agents that target specific immunological pathways are being investigated for treating ulcerative colitis. Anti-tumor necrosis factor (TNF) agents were the first biologics to be used for treating inflammatory bowel disease. For example, infliximab and adalimumab, which are anti-TNF agents, are being used for treating ulcerative colitis. Recently, golimumab, another anti-TNF agent, and vedolizumab, an anti-adhesion therapy, have been approved for ulcerative colitis by the U.S. Food and Drug Administration. In addition, new medications such as tofacitinib, a Janus kinase inhibitor, and etrolizumab, another anti-adhesion therapy, are emerging as therapeutic agents. Therefore, there is a need for further studies to select appropriate patient groups for these biologics and to improve the outcomes of ulcerative colitis treatment through appropriate medical usage.
doi:10.5009/gnl14226
PMCID: PMC4282853  PMID: 25547087
Biological therapies; Ulcerative colitis
9.  Celiac Disease: A Disorder Emerging from Antiquity, Its Evolving Classification and Risk, and Potential New Treatment Paradigms 
Gut and Liver  2015;9(1):28-37.
Celiac disease is a chronic genetically based gluten-sensitive immune-mediated enteropathic process primarily affecting the small intestinal mucosa. The disorder classically presents with diarrhea and weight loss; however, more recently, it has been characterized by subclinical occult or latent disease associated with few or no intestinal symptoms. Diagnosis depends on the detection of typical histopathological biopsy changes followed by a gluten-free diet response. A broad range of clinical disorders may mimic celiac disease, along with a wide range of drugs and other therapeutic agents. Recent and intriguing archeological data, largely from the Gobleki Tepe region of the Fertile Crescent, indicate that celiac disease probably emerged as humans transitioned from hunter-gatherer groups to societies dependent on agriculture to secure a stable food supply. Longitudinal studies performed over several decades have suggested that changes in the prevalence of the disease, even apparent epidemic disease, may be due to superimposed or novel environmental factors that may precipitate its appearance. Recent therapeutic approaches are being explored that may supplement, rather than replace, gluten-free diet therapy and permit more nutritional options for future management.
doi:10.5009/gnl14288
PMCID: PMC4282854  PMID: 25547088
Celiac disease; Celiac disease history; Occult and latent celiac disease; Sprue-like intestinal disease; Celiac disease therapy
10.  Safety of Gastroenterologist-Guided Sedation with Propofol for Upper Gastrointestinal Therapeutic Endoscopy in Elderly Patients Compared with Younger Patients 
Gut and Liver  2015;9(1):38-42.
Background/Aims
Propofol sedation for elderly patients during time-consuming endoscopic procedures is controversial. Therefore, we investigated the safety of using propofol in elderly patients during upper gastrointestinal therapeutic endoscopy.
Methods
The medical records of 160 patients who underwent therapeutic endoscopic procedures under gastroenterologist-guided propofol sedation at a single institution were retrospectively reviewed. The subjects were divided into two groups: a younger group, patients <75 years old; and an elderly group, patients ≥75 years old. The two groups were compared with respect to the therapeutic regimen, circulatory dynamics, and presence/absence of discontinuation of propofol treatment.
Results
Although the number of patients with liver dysfunction was higher in the elderly group, there were no other significant differences in the baseline characteristics, including the American Society of Anesthesiologists classification, between the elderly and younger groups. The average maintenance rate of continuous propofol infusion was lower in the elderly patients. No statistically significant differences were found in the occurrence of adverse events between the elderly and younger groups. None of the patients returned to a resedated state after the initial recovery from sedation.
Conclusions
Gastroenterologist-guided propofol sedation in elderly patients can be safely achieved in the same manner as that in younger patients, even for time-consuming upper gastrointestinal therapeutic endoscopic procedures.
doi:10.5009/gnl13368
PMCID: PMC4282855  PMID: 25170057
Elderly patient; Propofol; Safety; Sedation; Upper gastrointestinal therapeutic endoscopy
11.  Second-Look Endoscopy after Gastric Endoscopic Submucosal Dissection for Reducing Delayed Postoperative Bleeding 
Gut and Liver  2015;9(1):43-51.
Background/Aims
This stuy evaluated the role of a second-look endoscopy after gastric endoscopic submucosal dissection in patients without signs of bleeding.
Methods
Between March 2011 and March 2012, 407 patients with gastric neoplasms who underwent endoscopic submucosal dissection for 445 lesions were retrospectively reviewed. After the patients had undergone endoscopic submucosal dissection, they were allocated to two groups (with or without second-look endoscopy) according to the following endoscopy. The postoperative bleeding risk of the lesions was not considered when allocating the patients.
Results
The delayed postoperative bleeding rates did not differ between the two groups (with vs without second-look endoscopy, 3.0% vs 2.1%; p=0.546). However, a tumor in the upper-third of the stomach (odds ratio [OR], 5.353; 95% confidence interval [CI], 1.075 to 26.650) and specimen size greater than 40 mm (OR, 4.794; 95% CI, 1.307 to 17.588) were both independent risk factors for delayed postoperative bleeding. Additionally, second-look endoscopy was not related to reduced delayed postoperative bleeding. However, delayed postoperative bleeding in the patients who did not undergo a second-look endoscopy occurred significantly earlier than that in patients who underwent a second-look endoscopy (4.5 and 14.0 days, respectively, p=0.022).
Conclusions
A routine second-look endoscopy after gastric endoscopic submucosal dissection is not necessary for all patients.
doi:10.5009/gnl13252
PMCID: PMC4282856  PMID: 25170062
Second-look endoscopy; Endoscopic submucosal dissection; Bleeding; Delayed bleeding; Hemostasis
12.  Is a Second-Look Endoscopy Necessary after Endoscopic Submucosal Dissection for Gastric Neoplasm? 
Gut and Liver  2015;9(1):52-58.
Background/Aims
Second-look endoscopy is performed to check for the possibility of post-endoscopic submucosal dissection (ESD) bleeding and to perform prophylactic hemostasis in most hospitals; however, there is little evidence about the efficacy of second-look endoscopy. We investigated whether second-look endoscopy after ESD is useful in the prevention of post-ESD bleeding.
Methods
A total of 550 lesions with gastric epithelial neoplasms in 502 patients (372 men and 130 women) were treated with ESD between August 18, 2009 and August 18, 2010. After the exclusion of three lesions of post-ESD bleeding within 24 hours, 547 lesions (335 early gastric cancers and 212 gastric adenomas) were included for the final analysis.
Results
The occurrence rate of delayed post-ESD bleeding was not significantly different between the second-look group and the no second-look group (1% vs 2.5%, p>0.05). The only predictor of delayed bleeding was tumor size, regardless of second-look endoscopy after ESD (22.8±9.87 vs 15.1±10.47, p<0.05). There was no difference between the prophylactic hemostasis and nonprophylactic hemostasis groups, including the occurrence rate of delayed bleeding. In the second-look group with prophylactic hemostasis, the hospital stay was more prolonged than in the second-look group without prophylactic hemostasis, but there was no significant difference (p=0.08).
Conclusions
Second-look endoscopy to prevent delayed bleeding after ESD provides no significant medical benefits.
doi:10.5009/gnl13422
PMCID: PMC4282857  PMID: 25071070
Second-look endoscopy; Endoscopic submucosal dissection; Delayed bleeding; Prophylactic hemostasis
13.  Endoscopic Resection for Synchronous Esophageal Squamous Cell Carcinoma and Gastric Adenocarcinoma in Early Stage Is a Possible Alternative to Surgery 
Gut and Liver  2015;9(1):59-65.
Background/Aims
We investigated the clinical outcomes according to the method of treatment in synchronous esophageal and gastric cancer.
Methods
Synchronous esophageal squamous cell carcinoma and gastric adenocarcinoma were diagnosed in 79 patients between 1996 and 2010. We divided the patients into four groups according to treatment; Group 1 received surgical resection for both cancers or surgery for gastric cancer with chemoradiotherapy for esophageal cancer (n=27); Group 2 was treated by endoscopic resection with or without additional treatment (n=14); Group 3 received chemoradiotherapy only (n=18); and Group 4 received supportive care only (n=20).
Results
The median survival times in groups 1 and 2 were 86 and 60 months, respectively. The recurrence rate and mortality were 23% and 48%, respectively, in group 1 and 21% and 4%, respectively, in group 2. The median survival time was 12 months in group 3 and 9 months in group 4. Multivariate analysis showed that age (p<0.001) and treatment group (p=0.019) were significantly associated with death. Compared with group 1, treatment in the intensive care unit (p=0.003), loss of body weight (p=0.042), and decrease in hemoglobin (p=0.033) were worse in group 1.
Conclusions
Endoscopic resection for synchronous esophageal and gastric cancer could be considered as a possible alternative to surgery for early-stage cancer.
doi:10.5009/gnl13255
PMCID: PMC4282858  PMID: 25170061
Synchronous; Esophageal neoplasms; Stomach neoplasms
14.  Risk Factors for Incomplete Polyp Resection during Colonoscopic Polypectomy 
Gut and Liver  2015;9(1):66-72.
Background/Aims
Colonoscopic polypectomy is highly efficient in preventing colorectal cancer, but polyps may not always be completely removed. Improved knowledge of the risk factors for incomplete polyp resection after polypectomy may decrease the cancer risk and additional costs. The aim of this study was to investigate the conditions that can cause incomplete polyp resection (IPR) after colonoscopic polypectomy.
Methods
A total of 12,970 polyps that were removed by colonoscopic polypectomy were investigated. Among them, we identified 228 cases with a positive resection margin and 228 controls with a clear resection margin that were matched for age, gender, and polyp size. We investigated the location, morphology, and histological type of the polyps and evaluated the skills of the endoscopist and assisting nurse.
Results
Multivariate analysis revealed that the polyps, which were located in the proximal part of the colon and rectum, were at significant risk of IPR. Histologically, an advanced polyp and an inexperienced assistant were also independent risk factors for IPR.
Conclusions
Polypectomy should be performed more carefully for polyps suspected to be cancerous and polyps located in the proximal part of the colon or rectum. A systematic training program for inexperienced assistants may be needed to decrease the risk of IPR.
doi:10.5009/gnl13330
PMCID: PMC4282859  PMID: 25170059
Colonic polyps; Colonoscopic polypectomy; Adenomatous polyps; Interval colorectal cancer; Polypectomy
15.  Clinical Efficacy of Endoscopic Treatment for Benign Colorectal Stricture: Balloon Dilatation versus Stenting 
Gut and Liver  2015;9(1):73-79.
Background/Aims
There has been a lack of research comparing balloon dilatation and self-expandable metal stent (SEMS) placement to determine which is better for long-term clinical outcomes in patients with benign colorectal strictures. We aimed to compare the clinical efficacy and complication rates of balloon dilatation and SEMS placement for benign colorectal strictures from a variety of causes.
Methods
Between January 1999 and January 2012, a total of 43 consecutive patients who underwent endoscopic treatment for benign colorectal stricture (balloon only in 29 patients, SEMS only in seven patients, and both procedures in seven patients) were retrospectively reviewed.
Results
Thirty-six patients underwent endoscopic balloon dilatation, representing 65 individual sessions, and 14 patients received a total of 17 SEMS placements. The initial clinical success rates were similar in both groups (balloon vs SEMS, 89.1% vs 87.5%). Although the reobstruction rates were similar in both groups (balloon vs SEMS, 54.4% vs. 57.1%), the duration of patency was significantly longer in the balloon dilatation group compared with the SEMS group (65.5±13.3 months vs. 2.0±0.6 months, p=0.031).
Conclusions
Endoscopic balloon dilatation is safe and effective as an initial treatment for benign colorectal stricture and as an alternative treatment for recurrent strictures.
doi:10.5009/gnl13326
PMCID: PMC4282860  PMID: 25170060
Benign stricture; Colorectal stricture; Balloon dilatation; Self-expandable metal stent
16.  Usefulness of C-Reactive Protein as a Disease Activity Marker in Crohn’s Disease according to the Location of Disease 
Gut and Liver  2015;9(1):80-86.
Background/Aims
C-reactive protein (CRP) is a serologic activity marker in Crohn’s disease (CD), but it may be less useful in evaluating CD activity in ileal CD patients. We aimed to investigate the usefulness of CRP as a disease activity marker in CD according to disease location.
Methods
Korean CD patients in a single hospital were evaluated. Factors associated with elevated CRP concentration at the time of diagnosis of CD and the association between the physician’s prediction regarding upcoming surgery and the sites of the lesions directly related to surgery were analyzed.
Results
Of 435 CD patients, 25.7%, 6.9%, and 67.4% had ileal, colonic, and ileocolonic CD, respectively. Multivariate analysis revealed that an elevated erythrocyte sedimentation rate, reduced serum albumin, CD activity index (CDAI) >220, and ileocolonic/colonic location were associated with an elevated CRP level and that the CRP level was significantly correlated with the CDAI in all CD patients (γ=0.466, p<0.01). However, the correlation coefficient was dependent on the location, with values of 0.395, 0.456, and 0.527 in patients with an ileal, ileocolonic, and colonic disease location, respectively. Surgery for ileal lesions was less predictable than surgery for ileocolonic or colonic lesions during follow-up.
Conclusions
CRP is less useful as a disease activity marker in patients with ileal CD than those with ileocolonic or colonic CD.
doi:10.5009/gnl13424
PMCID: PMC4282861  PMID: 25170056
Crohn disease; C-reactive protein; Inflammation
17.  Effect of Short-Term Partial Enteral Nutrition on the Treatment of Younger Patients with Severe Crohn’s Disease 
Gut and Liver  2015;9(1):87-93.
Background/Aims
To analyze the effect of short-term supportive temporary partial enteral nutrition therapy for treating severe pediatric Crohn’s disease (CD).
Methods
We conducted a prospective, open-label study in pediatric patients with CD (n=78) from January 2007 to December 2011. The CD patients were divided into three groups according to disease severity (mild, moderate, and severe). Seventeen patients with severe CD received short-term partial enteral nutrition (SPEN) in addition to their general diet for 4 weeks after the induction of remission with medical treatment. This SPEN group was further divided into two groups by age (<13 years, ≥13 years). Nutritional parameters and Pediatric Crohn’s Disease Activity Index scores were analyzed at the initial enrollment and following 1 year of treatment for all groups.
Results
Nutritional status improved substantially after 1 year of treatment in the severe CD group. Nutritional status in the SPEN group improved considerably more than that in the non-SPEN group. Additionally, the <13-year-old group demonstrated better nutritional status improvement than the ≥13-year-old group.
Conclusions
SPEN may be effective in pediatric patients with severe CD for improving nutritional status and moderating disease severity.
doi:10.5009/gnl13345
PMCID: PMC4282862  PMID: 25170058
Crohn disease; Younger age; Partial enteral nutrition; Disease activity; Nutritional status
18.  Predictive Factors of Palliative Radiotherapy Response and Survival in Patients with Spinal Metastases from Hepatocellular Carcinoma 
Gut and Liver  2015;9(1):94-102.
Background/Aims
Spinal metastases often severely limit the quality of life by causing severe pain and neurological deficits. The purpose of this study was to evaluate the palliative effect of radiotherapy (RT) for spinal metastases from hepatocellular carcinoma (HCC) and to identify factors predictive of survival in HCC patients with spinal metastases who received RT.
Methods
A retrospective analysis was performed on 192 patients with spinal metastases from HCC who received RT.
Results
Of 192 patients with spinal metastases from HCC, an overall pain response to palliative RT occurred in 187 patients (97.4%), with a complete pain response (CR) in 41 patients (21.4%) and a partial response in 151 patients (78.6%). A higher biologically effective dose (BED) and more advanced RT techniques were identified as predictive factors for a CR. The 1- and 2-year overall survival (OS) rates were 18.1% and 6.3%, respectively, and the median survival time was 4.5 months. A long OS was associated with good performance status, controlled primary HCC, absence of extrahepatic metastases, and a higher BED.
Conclusions
RT provided effective palliation for patients with painful spinal metastases from HCC. Our results provide information regarding pain control, survival outcomes, and predictive factors for the prognosis of HCC patients with spinal metastases treated with RT.
doi:10.5009/gnl14009
PMCID: PMC4282863  PMID: 25071067
Carcinoma; hepatocellular; Spinal metastases; Radiotherapy; Pain response; Predictive factors
19.  Pathogenesis and Management of Serrated Polyps: Current Status and Future Directions 
Gut and Liver  2014;8(6):582-589.
Hyperplastic or serrated polyps were once believed to have little to no clinical significance. A subset of these polyps are now considered to be precursors to colorectal cancers (CRC) in the serrated pathway that may account for at least 15% of all tumors. The serrated pathway is distinct from the two other CRC pathways and involves an epigenetic hypermethylation mechanism of CpG islands within promoter regions of tumor suppressor genes. This process results in the formation of CpG island methylator phenotype tumors. Serrated polyps are divided into hyperplastic polyps, sessile serrated adenomas/polyps (SSA/Ps), and traditional serrated adenomas (TSAs). The SSA/P and the TSA have the potential for dysplasia and subsequent malignant transformation. The SSA/Ps are more common and are more likely to be flat than TSAs. Their flat morphology may make them difficult to detect and thus explain the variation in detection rates among endoscopists. Challenges for endoscopists also include the difficulty in pathological interpretation as well surveillance of these lesions. Furthermore, serrated polyps may be inadequately resected by endoscopists. Thus, it is not surprising that the serrated pathway has been linked with interval cancers. This review will provide the physician or clinician with the knowledge to manage patients with serrated polyps.
doi:10.5009/gnl14248
PMCID: PMC4215442  PMID: 25368744
Serrated; Hyperplastic; Sessile serrated adenoma/polyp; Hypermethylation; Serrated polyposis syndrome
20.  An Overview of Eosinophilic Esophagitis 
Gut and Liver  2014;8(6):590-597.
Eosinophilic esophagitis (EoE) is a chronic, immune/antigen-mediated esophageal disease affecting both children and adults. The condition is characterized by an eosinophilic infiltration of the esophageal epithelium. Symptoms of esophageal dysfunction include dysphagia, food impaction and symptoms mimicking gastroesophageal reflux disease. Endoscopic examination typically reveals mucosal fragility, ring or corrugated mucosa, longitudinal furrows, whitish plaques or a small caliber esophagus. Histologic findings of >15 eosinophils per high-power field is the diagnostic hallmark of EoE. An elimination diet, topical corticosteroids or endoscopic dilation for fibrostenotic disease serve as effective therapeutic option.
doi:10.5009/gnl14081
PMCID: PMC4215443  PMID: 25368745
Eosinophilic esophagitis; Gastroesophageal reflux; High-power field
21.  Current Status of Endoscopic Papillectomy for Ampullary Tumors 
Gut and Liver  2014;8(6):598-604.
Detection of tumors of the ampulla of Vater, including ampullary adenoma, has been improved by routine screening endoscopic procedures and imaging modalities. Endoscopic resection by endoscopic papillectomy is rapidly replacing classic surgical resection and is a less invasive procedure. Endoscopic resection can have a role not only in the final histopathologic diagnosis but also as a definite therapeutic option. However, the indications for endoscopic resection are not fully established, and endoscopic procedures are not standardized. Significant complications, including severe pancreatitis, intractable bleeding and duodenal perforation, are rare but can occur, especially in less experienced hands. Severe pancreatitis is the most feared complication, but it can be prevented by pancreatic duct stent insertion in most cases. However, in some cases, pancreatic stenting can be challenging after resection. Incomplete resections are sometimes performed to avoid complications. Endoscopic surveillance is also important for identifying and managing remnant adenomatous tissue or recurrent lesions. Further technical development is needed to expand the indications for this procedure, minimize complications and ensure a high success rate.
doi:10.5009/gnl14099
PMCID: PMC4215444  PMID: 25368746
Ampullary tumor; Ampullary adenoma; Endoscopic resection; Endoscopic papillectomy
22.  The Efficacy of Moxifloxacin-Containing Triple Therapy after Standard Triple, Sequential, or Concomitant Therapy Failure for Helicobacter pylori Eradication in Korea 
Gut and Liver  2014;8(6):605-611.
Background/Aims
Retreatment after initial treatment failure for Helicobacter pylori is very challenging. The purpose of this study was to evaluate the efficacies of moxifloxacin-containing triple and bismuth-containing quadruple therapy.
Methods
A total of 151 patients, who failed initial H. pylori treatment, were included in this retrospective cohort study. The initial regimens were standard triple, sequential, or concomitant therapy, and the efficacies of the two following second-line treatments were evaluated: 7-day moxifloxacin-containing triple therapy (rabeprazole 20 mg twice a day, amoxicillin 1,000 mg twice a day, and moxifloxacin 400 mg once daily) and 7-day bismuth-containing quadruple therapy (rabeprazole 20 mg twice a day, tetracycline 500 mg 4 times a day, metronidazole 500 mg 3 times a day, and tripotassium dicitrate bismuthate 300 mg 4 times a day).
Results
The overall eradication rates after moxifloxacin-containing triple therapy and bismuth-containing quadruple therapy were 69/110 (62.7%) and 32/41 (78%), respectively. Comparison of the two regimens was performed in the patients who failed standard triple therapy, and the results revealed eradication rates of 14/28 (50%) and 32/41 (78%), respectively (p=0.015). The frequency of noncompliance was not different between the two groups, and there were fewer adverse effects in the moxifloxacin-containing triple therapy group (2.8% vs 7.3%, p=0.204 and 25.7% vs 43.9%, p=0.031, respectively).
Conclusions
Moxifloxacin-containing triple therapy, a recommended second-line treatment for initial concomitant or sequential therapy failure, had insufficient efficacy.
doi:10.5009/gnl13303
PMCID: PMC4215445  PMID: 25368747
Anti-bacterial agents; Helicobacter pylori; Moxifloxacin; Salvage therapy
23.  Long-Term Outcome after Endoscopic Submucosal Dissection in Patients with Superficial Esophageal Squamous Cell Carcinoma: A Single-Center Study 
Gut and Liver  2014;8(6):612-618.
Background/Aims
Superficial esophageal squamous cell carcinoma (SESCC) is being increasingly detected during screening endoscopy. Endoscopic submucosal dissection (ESD) allows for en bloc and histologically complete resection of lesions. This study assessed the technical feasibility and long-term outcomes of ESD for SESCCs.
Methods
Between January 2005 and August 2012, 27 patients with 28 SESCCs underwent ESD at Pusan National University Hospital. The en bloc and pathologically complete resection rates, complication (perforation and bleeding) rate, incidence of esophageal stricture after ESD, and overall and disease-specific survival rates were evaluated.
Results
The en bloc and pathologically complete resection rates were 93% and 83%, respectively. No significant bleeding occurred, and perforation with mediastinal emphysema was observed in two patients (7%). Post-ESD stricture occurred in two patients (7%) who had mucosal defects involving more than three-fourths of the esophageal circumference. During a mean follow-up of 23 months, local tumor recurrence was seen in two of four lesions with pathologically incomplete resection; one was treated by re-ESD, and the other was treated by surgical esophagectomy. The 5-year overall and disease-specific survival rates were 84% and 100%, respectively.
Conclusions
ESD seems to be a feasible, effective curative treatment for SESCCs. All patients should be closely followed after ESD.
doi:10.5009/gnl13130
PMCID: PMC4215446  PMID: 25368748
Esophageal neoplasms; Squamous cell carcinoma; Endoscopic submucosal dissection; Outcome
24.  The Feasibility of Using Simulated Targets in the Stomachs of Live Pigs for Full Endoscopic Submucosal Dissection Training 
Gut and Liver  2014;8(6):619-624.
Background/Aims
In endoscopic submucosal dissection (ESD) training, only a flat target lesion can usually be simulated in the normal mucosa. This study aimed to evaluate the feasibility of simulated targets in the stomachs of live pigs for complete training.
Methods
Six trained endoscopists with hands-on experience with ex vivo, isolated pig stomachs were enrolled in this pilot study. An endoscopic banding device was used to create a polyp that was snared, leaving an ulcerated lesion. This simulated target model was used to perform ESD in pigs. The en bloc resection rate, procedure time, complications, quality of resection, and participants’ opinions on the simulated targets were compared with the conventional model.
Results
En bloc resections were achieved in all six simulated targets and six conventional models. The mean size of the resected specimens was 32.2 mm (range, 20 to 39 mm) in the simulated target group and 23.5 mm (range, 11 to 40 mm) in the conventional group. The target model had a high quality of resection and had a high satisfaction rate for margin identification and correct peripheral marking.
Conclusions
Good identification of the lesion and ease of periphery marking in the target model may improve resection quality.
doi:10.5009/gnl13327
PMCID: PMC4215447  PMID: 25368749
Animals models; Gastroscopy; Gastric mucosa; Dissection; Swine; Competency-based education
25.  Importance of the Time Interval between Bowel Preparation and Colonoscopy in Determining the Quality of Bowel Preparation for Full-Dose Polyethylene Glycol Preparation 
Gut and Liver  2014;8(6):625-631.
Background/Aims
The quality of bowel preparation (QBP) is the important factor in performing a successful colonoscopy. Several factors influencing QBP have been reported; however, some factors, such as the optimal preparation-to-colonoscopy time interval, remain controversial. This study aimed to determine the factors influencing QBP and the optimal time interval for full-dose polyethylene glycol (PEG) preparation.
Methods
A total of 165 patients who underwent colonoscopy from June 2012 to August 2012 were prospectively evaluated. The QBP was assessed using the Ottawa Bowel Preparation Scale (Ottawa) score according to several factors influencing the QBP were analyzed.
Results
Colonoscopies with a time interval of 5 to 6 hours had the best Ottawa score in all parts of the colon. Patients with time intervals of 6 hours or less had the better QBP than those with time intervals of more than 6 hours (p=0.046). In the multivariate analysis, the time interval (odds ratio, 1.897; 95% confidence interval, 1.006 to 3.577; p=0.048) was the only significant contributor to a satisfactory bowel preparation.
Conclusions
The optimal time was 5 to 6 hours for the full-dose PEG method, and the time interval was the only significant contributor to a satisfactory bowel preparation.
doi:10.5009/gnl13228
PMCID: PMC4215448  PMID: 25368750
Quality of bowel preparation; Colonoscopy; Time interval

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