Patients with inflammatory bowel disease (IBD) are at increased risk for developing colorectal cancer (CRC), although the overall incidence of IBD-associated CRC has been diminishing in recent decades in western countries. As demonstrated in previous studies, the risk of CRC in IBD increases with longer duration, extent of colitis, a familial history of CRC, coexistent primary sclerosing cholangitis, and the degree of inflammation. The pathogenesis of CRC in IBD is poorly understood. Similar to sporadic CRC, IBD-associated CRC is a consequence of sequential episodes of genomic alteration. Multiple inter-related pathways, including immune response by mucosal inflammatory mediators, oxidative stress, and intestinal microbiota, are also involved the pathogenesis of IBD-associated CRC. Continuing colonic inflammation appears to be a factor in the development of CRC; therefore, anti-inflammatory agents such as 5-aminosalicylate compounds and immune modulators have been considered as potential chemopreventive agents. Colonoscopic surveillance is widely accepted as being effective in reducing the risk of IBD-associated CRC, although no clear evidence has confirmed that surveillance colonoscopy prolongs survival in patients with extensive colitis. The traditional recommendation has been quadrantic random biopsies throughout the entire colon; however, several guidelines now have endorsed chromoendoscopy with a target biopsy because of increasing diagnostic yields and reduced workloads for endoscopists and pathologists. New technologies such as narrow band imaging, confocal endomicroscopy, and autofluorescence imaging have not yet been confirmed as surveillance strategies in IBD.
Inflammatory bowel disease; Colorectal cancer; Pathogenesis; Chemoprevention; Surveillance
AIM: To investigate whether composite yogurt with acacia dietary fiber and Bifidobacterium lactis (B. lactis) has additive effects in irritable bowel syndrome (IBS).
METHODS: A total of 130 patients were randomly allocated to consume, twice daily for 8 wk, either the composite yogurt or the control product. The composite yogurt contained acacia dietary fiber and high-dose B. lactis together with two classic yogurt starter cultures. Patients were evaluated using the visual analog scale via a structured questionnaire administered at baseline and after treatment.
RESULTS: Improvements in bowel habit satisfaction and overall IBS symptoms from baseline were significantly higher in the test group than in the control group (27.16 vs 15.51, P = 0.010, 64.2 ± 17.0 vs 50.4 ± 20.5, P < 0.001; respectively). In constipation-predominant IBS, improvement in overall IBS symptoms was significantly higher in the test group than in the control group (72.4 ± 18.4 vs 50.0 ± 21.8, P < 0.001). In patients with diarrhea-predominant IBS, improvement in bowel habit satisfaction from baseline was significantly higher in the test group than in the control group (32.90 vs 7.81, P = 0.006).
CONCLUSION: Our data suggest that composite yogurt enriched with acacia fiber and B. lactis has greater therapeutic effects in patients with IBS than standard yogurt.
Acacia dietary fiber; Bifidobacterium lactis; Irritable bowel syndrome; Probiotics; Yogurt
Colorectal endoscopic submucosal dissection (ESD) is not yet fully popularized in Korea, but is increasing steadily. The outcomes of colorectal ESD in Korea are comparable to those in Japan and other countries. ESD-related complication rates are decreasing as experiences accumulate. Particularly for rectal laterally spreading tumors, ESD is becoming more prevalent than transanal endoscopic microsurgery. Standard indication, qualified training system, and full medical insurance coverage should be established for the procedure to become popular in the long run.
Colonic neoplasms; Endoscopy; Insurance, health, reimbursement
The objective of this article is to report improvement of nutritional status by protein supplements in the patient with protein-losing enteropathy. The patient was a female whose age was 25 and underwent medical treatment of Crohn's disease, an inflammatory bowl disease, after diagnosis of cryptogenic multifocal ulcerous enteritis. The weight was 33.3 kg (68% of IBW) in the severe underweight and suffered from ascites and subcutaneous edema with hypoalbuminemia (1.3 g/dL) at the time of hospitalization. The patient consumed food restrictively due to abdominal discomfort. Despite various attempts of oral feeding, the levels of calorie and protein intake fell into 40-50% of the required amount, which was 800-900 kcal/d (24-27 kcal/kg/d) for calorie and 34 g/d (1 g/kg/d) for protein. It was planned to supplement the patient with caloric supplementation (40-50 kcal/kg) and protein supplementation (2.5 g/kg) to increase body weight and improve hypoproteinemia. It was also planned to increase the level of protein intake slowly to target 55 g/d in about 2 weeks starting from 10 g/d and monitored kidney load with high protein supplementation. The weight loss was 1.0 kg when the patient was discharged from the hospital (hospitalization periods of 4 weeks), however, serum albumin was improved from 1.3 g/dL to 2.5 g/dL and there was no abdominal discomfort. She kept supplement of protein at 55 g/d for 5 months after the discharge from the hospital and kept it at 35 g/d for about 2 months and then 25 g/d. The body weight increased gradually from 32.3 kg (65% of IBW) to 44.0 kg (89% of IBW) by 36% for the period of F/u and serum albumin was kept above 2.8 g/dL without intravenous injection of albumin. The performance status was improved from 4 points of 'very tired' to 2 points of 'a little tired' out of 5-point scale measurement and the use of diuretic stopped from the time of 4th month after the discharge from the hospital owing to improvement in edema and ascites. During this period, the results of blood test such as BUN, Cr, and electrolytes were within the normal range. In conclusion, hypoproteinemia
and weight loss were improved by increasing protein intake through utilization of protein supplements in protein-losing enteropathy.
Protein-losing enteropathy; Hypoalbuminemia; Inflammatory bowel diseases; Protein supplements; Nutrition status
Video capsule endoscopy (CE) can provide a negative result despite the presence of clinically significant small-bowel lesions. We therefore performed a prospective study to elucidate whether repeated back-to-back CE increases the diagnostic yield over a single CE in patients with obscure gastrointestinal bleeding (OGIB).
Sixteen patients with OGIB were prospectively enrolled and underwent back-to-back CE investigation with a 24-hour interval. All CE videos were interpreted by two experienced readers at a maximum 15 frames/second in a random order.
The diagnostic yield of the single CE was 37.5% for the first CE, 43.8% for the second CE, and 62.5% for the back-to-back CE. The overall mean lesion-detection rates of the first and second CEs were 42.2% and 64.6%, respectively. The bowel preparation status of the second CE was improved in 37.5% and unchanged in 62.5% of cases as compared with that of the first CE.
These results indicate that back-to-back CE may increase the diagnostic yield and lesion-detection rate over a single CE in patients with OGIB. Therefore, if the first CE is not diagnostic in a patient with OGIB, repeat back-to-back CE may be considered as a candidate for further workup.
Capsule endoscopy; Diagnostic yield; Obscure gastrointestinal bleeding
AIM: To determine the prevalence and risk factors of work-related musculoskeletal disorders in gastrointestinal endoscopists in Korea.
METHODS: A survey of musculoskeletal symptoms, using a self-administered questionnaire, was conducted on 55 endoscopists practicing in general hospitals or health promotion centers.
RESULTS: Forty-nine (89.1%) endoscopists reported musculoskeletal pain on at least one anatomic location and 37 (67.3%) endoscopists complained of pain at rest. Twenty-six (47.3%) endoscopists had severe musculoskeletal pain defined as a visual analogue score greater than 5.5. Factors related to the development of severe pain were (1) standing position during upper endoscopy, (2) specific posture/habit during endoscopic procedures, and (3) multiple symptomatic areas. Finger pain was more common in beginners, whereas shoulder pain was more common in experienced endoscopists. Sixteen percent of symptomatic endoscopists have modified their practice or reduced the number of endoscopic examinations. Only a few symptomatic endoscopists had sought professional consultation with related specialists.
CONCLUSION: The prevalence of musculoskeletal pain in endoscopists is very high. The location of pain was different between beginners and experienced endoscopists. Measures for the prevention and adequate management of endoscopy-related musculoskeletal symptoms are necessary.
Endoscopy; Endoscopist; Musculoskeletal symptom
Endoscopic submucosal dissection (ESD) is a widely accepted treatment for early gastric and esophageal cancer. Compared to endoscopic mucosal resection, ESD has the advantage of enabling en bloc removal of tumors regardless of their size. However, ESD can result in a large artificial ulcer, which may lead to a considerable deformity. Circumferential mucosal defects of more than three-fourths the esophageal circumference, long longitudinal mucosal defects (>30 mm), and lesions in the upper esophagus are significant risk factors for the development of post-ESD strictures of the esophagus. In the stomach, a circumferential mucosal defects more than three-fourths in extent and longitudinal mucosal defects >5 cm are risk factors of post-ESD stricture. If scheduled early, regular endoscopic balloon dilation is effective in controlling and preventing post-ESD stricture. Moreover, intralesional steroid injections or oral steroids can achieve remission of dysphagia or reduce the need for repeated endoscopic balloon dilation. However, further study is needed to improve the prevention of stricture formation.
Stricture; Esophagus; Stomach; Endoscopic submucosal dissection
A diagnosis of acute diverticulitis is based on computed tomography (CT). Colonoscopy is commonly performed after the acute event to exclude other diagnoses. This study aimed to determine whether colonoscopy is necessary and what additional information is gained from a colonoscopy after acute diverticulitis.
Acute diverticulitis was diagnosed by clinical criteria and characteristic CT findings. We analyzed the number of patients in whom colorectal cancers were diagnosed and other incidental findings of polyps and other diseases.
A total of 177 patients were analyzed retrospectively. The mean age was 43.3±15.3 years (range, 13-82 years) and 97 patients (54.8%) were male. Sixty-one patients had undergone a colonoscopy within 1 year of the acute attack. Advanced adenomatous lesions and colonic malignancy were not detected. Nineteen patients (31.1%) had ≥1 polyp and 11 patients (18.0%) had an adenomatous polyp. No new or different diagnosis was made after colonoscopy. None of the 116 patients who did not undergo colonoscopy within a year after acute diverticulitis had a diagnosis of colorectal cancer registered with the Korea Central Cancer Registry.
Routine colonoscopy yields little benefit in patients with acute diverticulitis diagnosed by typical clinical symptoms and CT. The current practice of a colonoscopy after acute diverticulitis needs to be reevaluated.
Knowledge of the risk factors associated with adverse outcomes after percutaneous endoscopic gastrostomy (PEG) may be helpful for developing PEG recommendations. The purpose of this study was to identify the clinical risk factors associated with adverse clinical outcomes after PEG, especially regarding the use of proton pump inhibitors (PPIs).
We retrospectively reviewed the data from PEG patients at seven university hospitals between June 2006 and January 2012. All patients were followed up through February 2012 after PEG, and the clinical risk factors for adverse clinical outcomes after PEG were analyzed.
Data from 1,021 PEG patients were analyzed. PPI users were more frequently included in the complication group than the noncomplication group (p=0.040). PEG-related complications (p=0.040) and mortality (p=0.003) were more frequent in the PPI group than in the control group. In the subgroup analysis of complicated PEG cases, infectious complications were more frequently found in the PPI group than in the control group (35.8% vs 27.8%). After adjustment for multiple possible confounding factors, PPI users (odds ratio, 1.531; 95% confidence interval, 1.017 to 2.305) and diabetic patients had increased mortality after PEG.
PPI use may be associated with adverse outcomes in patients with PEG; however, further prospective studies investigating this issue are warranted.
Percutaneous endoscopic gastrostomy; Proton pump inhibitors; Mortality; Complication; Risk factors
Plasminogen activator inhibitor-1 (PAI-1) is important for tumor growth, Invasion, and metastasis. In this study, we investigated the relationship between plasma levels of PAI-1 and colorectal adenomas.
We reviewed the medical records of 3,136 subjects who underwent colonoscopy as a screening exam. The subjects were classified into a case group with adenomas (n=990) and a control group (n=2,146). Plasma PAI-1 levels were categorized into three groups based on tertile.
The plasma levels of PAI-1 were significantly higher in adenoma cases than in controls (p=0.023). The prevalence of colorectal adenomas increased significantly with increasing levels of PAI-1 (p=0.038). In the adenoma group, advanced pathologic features, size, and number of adenomas did not differ among the three groups based on tertiles for plasma PAI-1 levels. Using multivariate analysis, we found that plasma level of PAI-1 was not associated with the risk of colorectal adenomas (p=0.675). Adjusted odds ratios for colorectal adenomas according to increasing plasma levels of PAI-1 were 0.980 (95% confidence interval [CI], 0.768 to 1.251) for the second-highest plasma level and 1.091 (95% CI, 0.898 to 1.326) for the highest level, compared with the lowest levels.
These results suggest that elevated plasma PAI-1 levels are not associated with the risk of colorectal neoplasms.
Plasminogen activator inhibitor 1; Colorectal neoplasms
Information on the impact of cecal insertion time on colorectal neoplasm detection is limited. Our objective was to determine the association between cecal insertion time and colorectal neoplasm detection rate in colonoscopy screening.
We performed a cross-sectional study of 12,679 consecutive subjects aged 40–79 years undergoing screening colonoscopy in routine health check-ups at the Center for Health Promotion of the Samsung Medical Center from December 2007 to June 2009. Fixed effects logistic regression conditioning on colonoscopist was used to eliminate confounding due to differences in technical ability and other characteristics across colonoscopists.
The mean cecal insertion time was 5.9 (SD, 4.4 minutes). We identified 4,249 (33.5%) participants with colorectal neoplasms, of whom 1,956 had small single adenomas (<5 mm), 595 had medium single adenomas (5–9 mm), and 1,699 had multiple adenomas or advanced colorectal neoplasms. The overall rates of colorectal neoplasm detection by quartiles of cecal insertion time were 36.8%, 33.4%, 32.7%, and 31.0%, respectively (p trend <0.001).The odds for small single colorectal adenoma detection was 16% lower (adjusted OR 0.84; 95% CI 0.71 to 0.99) in the fourth compared to the first quartile of insertion time (p trend 0.005). Insertion time was not associated with the detection rate of single adenomas ≥5 mm, multiple adenomas or advanced colorectal neoplasms.
Shorter insertion times were associated with increased rates of detection of small colorectal adenomas <5 mm. Cecal insertion time may be clinically relevant as missed small colorectal adenomas may progress to more advanced lesions.
Cecal insertion time; Colorectal neoplasm; Screening colonoscopy
The aberrant methylation of CpG islands in the promoter is associated with colorectal cancer (CRC) carcinogenesis. In our previous study, the promoter of alcohol dehydrogenase, iron containing, 1 (ADHFE1) was most highly methylated in CRC compared to normal colorectal mucosa. In this study, we examined the expression and function of the ADHFE1 in CRC.
We examined the promoter methylation and mRNA expression of ADHFE1 with 5-aza-2′-deoxycytidine (5-Aza-2-dC) in 12 CRC cell lines, 124 paired CRC and adjacent normal mucosa, and 59 advanced adenomas. To confirm methylation of ADHFE1, we performed bisulfite genomic sequencing in 3 CRC cell lines, 6 paired CRC and adjacent normal mucosa. ADHFE1 protein expression was studied using western blot and immunohistochemistry, respectively in the 36 and 243 paired CRC and adjacent normal tissue. We transfected the DLD-1 with pcDNA3.1 vector containing ADHFE1 and examined the expression of differentiation marker, such as ALP, CEA and Cdx2. We examined the ADHFE1 expression at distinct developmental stages in mouse embryos.
The ADHFE1 promoter was hypermethylated in all CRC cell lines, 81.8% in CRCs, and 84.7% in advanced adenomas, with reciprocal change by 5-Aza-2-dC. The expression of ADHFE1 mRNA was down-regulated in all CRC cell lines and 96.3% in CRC tissues. The expression of ADHFE1 protein was down-regulated in 91.7% of CRC tissues. In the immunohistochemistry, normal epithelial cells at the crypt top showed very strong ADHFE1 expression, whereas they were much weaker at the crypt base. In CRC, the good differentiation was significantly associated with high ADHFE1 expression. The activity of differentiation marker, such as ALP and CEA, was higher in pcDNA3.1-ADHFE1 transfected CRC cells with consistent correlation with ADHFE1 protein than control. In mouse embryos, ADHFE1 in the large intestine was the first detected at E15.5. At E18.5, ADHFE1 was predominantly expressed in the top of the mature crypt epithelium.
It showed that the hypermethylation of ADHFE1 promoter in CRC is concordance with down-regulation of ADHFE1 mRNA and ADHFE1 protein. ADHFE1 has an important role of differentiation in CRC, as well as normal colorectal mucosa and embryonic developmental processes.
ADHFE1; Promoter methylation; Colorectal cancer; Differentiation
Capsule endoscopy (CE) is considered as a noninvasive and reliable diagnostic tool of examining the entire small bowel. CE has been performed frequently at many medical centers in South Korea; however, there is no evidence-based CE guideline for adequate diagnostic approaches. To provide accurate information and suggest correct testing approaches for small bowel disease, the guideline on CE was developed by the Korean Gut Image Study Group, a part of the Korean Society of Gastrointestinal Endoscopy. Operation teams for developing the guideline were organized into four areas: obscure gastrointestinal bleeding, small bowel preparation, Crohn's disease, and small bowel tumor. A total of 20 key questions were selected. In preparing this guideline, MEDLINE, Cochrane library, KMbase, KISS, and KoreaMed literature searches were performed. After writing a draft of the guideline, opinions from various experts were reflected before approving the final document. The guideline should be regarded as recommendations only to gastroenterologists in providing care to their patients. These are not absolute rules and should not be construed as establishing a legal standard of care. Although further revision may be necessary as new data appear, this guideline is expected to play a role for adequate diagnostic approaches of various small bowel diseases.
Capsule endoscopy; Small bowel disease; Guideline
We evaluated the risk factors for late complications and functional outcome after total proctocolectomy (TPC) with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC).
Pre- and postoperative clinical status and follow-up data were obtained for 55 patients who underwent TPC with IPAA between 1999 and 2010. The median follow-up duration was 4.17 years. Late complications were defined as those that appeared at least one month after surgery. For a functional assessment, telephone interviews were conducted using the Global Assessment of Functioning Scale. Twenty-eight patients completed the interview.
Late complications were found in 20 cases (36.3%), comprising pouchitis (n = 8), bowel obstruction (n = 5), ileitis (n = 3), pouch associated fistula (n = 2), and intra-abdominal infection (n = 2). The preoperative serum albumin level for patients with late complications was lower than for patients without (2.4 ± 0.5 vs. 2.9 ± 0.7, P = 0.04). Functional outcomes were not significantly associated with clinical characteristics, follow-up duration, operation indication, or late complications.
This study demonstrated that a low preoperative albumin level could be a risk factor for late complications of TPC with IPAA. Preoperative nutritional support, especially albumin, could reduce late complications. Functional outcomes are not related to late complications.
Ulcerative colitis; Proctocolectomy; Complications
Colorectal carcinoma (CRC) with CpG island methylator phenotype (CIMP) is recognized as a distinct subgroup of CRC, and CIMP status affects prognosis and response to chemotherapy. Identification of CIMP status in CRC is important for proper patient management. In Eastern countries, however, the clinicopathologic and molecular characteristics and prognosis of CRCs with CIMP are still unclear.
A total of 245 patients who underwent their first surgical resection for sporadic CRC were enrolled and CIMP status of the CRCs was determined using the quantitative MethyLight assay. The clinicopathologic and molecular characteristics were reviewed and compared according to CIMP status. In addition, the three-year recurrence-free survival (RFS) of 124 patients with stage II or stage III CRC was analyzed in order to assess the effectiveness of fluoropyrimidine-based adjuvant chemotherapy with respect to CIMP status.
CIMP-high CRCs were identified in 34 cases (13.9%), and were significantly associated with proximal tumor location, poorly differentiated carcinoma, mucinous histology, and high frequencies of BRAF mutation, MGMT methylation, and MSI-high compared to CIMP-low/negative carcinomas. For patients with stage II or III CIMP-low/negative CRCs, no significant difference was found in RFS between those undergoing surgery alone and those receiving surgery with fluoropyrimidine-based adjuvant chemotherapy. However, for patients with CIMP-high CRCs, patients undergoing surgery with fluoropyrimidine-based adjuvant chemotherapy (n = 17; three-year RFS: 100%) showed significantly better RFS than patients treated with surgery alone (n = 7; three-year RFS: 71.4%) (P = 0.022).
Our results suggest that selected patients with CIMP-high CRC may benefit from fluoropyrimidine-based adjuvant chemotherapy with longer RFS. Further large scale-studies are required to confirm our results.
Propofol induced sedation with bispectral index (BIS) monitoring has been reported to lead to higher satisfaction in patients and endoscopists during endoscopic submucosal dissection (ESD) procedures. There are no data, however, regarding the efficacy of midazolam and meperidine (M/M) induced sedation with BIS monitoring during ESD. The purpose of this study was to evaluate whether M/M induced sedation with BIS monitoring could improve satisfaction and reduce the dose of M/M required during ESD.
Between September 2009 and January 2010, 56 patients were prospectively enrolled and randomly assigned to a BIS group (n=28) and a non-BIS group (n=28). Patient and endoscopist satisfaction scores were assessed using the visual analog scale (0 to 100) following the ESD.
The mean satisfaction scores did not significantly differ between the BIS and non-BIS groups (92.3±16.3 vs 93.3±15.5, p=0.53) or endoscopists (83.1±15.4 vs 80.0±16.7, p=0.52). Although the mean meperidine dose did not differ (62.5±27.6 vs 51.0±17.3, p=0.18) between the two groups, the mean dose of midazolam in the non-BIS group was lower than in the BIS group (6.8±2.0 vs 5.4±2.1, p=0.01).
BIS monitoring during ESD did not increase the satisfaction of endoscopists or patients and did not lead to an M/M dose reduction. These results demonstrate that BIS monitoring provides no additional benefit to M/M induced sedation during ESD.
Bispectral index monitoring; Satisfaction; Midazolam; Endoscopic submucosal dissection
Although controversial, probiotics and dietary fiber are commonly used for patients with irritable bowel syndrome (IBS). We evaluated the effects of multistrain probiotics on the symptoms of IBS to determine whether the addition of dietary fi ber had an additive effect on constipation-predominant IBS.
A total of 142 participants who met the Rome III criteria were recruited and randomized into a control group or a test group. Participants in the control group received multistrain probiotic fermented milk with Streptococcus thermophilus, Lactobacillus acidophilus and Bifidobacterium infantis; the participants in the test group received the same probiotic fermented milk mixed with dietary fi ber such as sea tangle extracts, radish extracts and glasswort extracts. The patients were treated for four weeks.
Most of the symptoms of IBS, with the exception of fl atulence, stool consistency, and frequency of defecation, signifi cantly improved in both groups. In the analysis of IBS subtypes, especially constipation-predominant IBS, the frequency and duration of defecation and straining at stool were improved more in the test group than in the control group.
Dietary fiber had additive benefits for the symptoms of constipation, especially in constipation-predominant IBS.
Constipation; Dietary fiber; Irritable bowel syndrome; Probiotic fermented milk
The incidence of gastroesophageal reflux disease (GERD) is increasing in Korea. The aim of this study was to evaluate the relationship between GERD symptoms and dietary factors in Korea.
From January 2007 to April 2008, 162 subjects were enrolled (81 in GERD group and 81 in control group). They were asked to complete the questionnaires about GERD symptoms and dietary habits. The symptom severity score was recorded by visual analogue scale.
Subjects with overweight or obesity had an increased risk for GERD (OR, 2.52; 95% CI, 1.18-5.39). Irregular dietary intake was one of the risk factors for GERD (OR, 2.33; 95% CI, 1.11-4.89). Acid regurgitation was the most suffering (2.85 ± 2.95 by visual analogue scale) and frequent reflux-related symptom (57.5%) in GERD. Noodles (OR, 1.22; 95% CI, 1.12-1.34), spicy foods (OR, 1.09; 95% CI, 1.02-1.16), fatty meals (OR, 1.20; 95% CI, 1.09-1.33), sweets (OR, 1.42; 95% CI, 1.00-2.02), alcohol (OR, 1.16; 95% CI, 1.03-1.31), breads (OR, 1.17; 95% CI, 1.01-1.34), carbonated drinks (OR, 1.69; 95% CI, 1.04-2.74) and caffeinated drinks (OR,1.41; 95% CI, 1.15-1.73) were associated with symptom aggravation in GERD. Among the investigated noodles, ramen (instant noodle) caused reflux-related symptoms most frequently (52.4%).
We found that noodles, spicy foods, fatty meals, sweets, alcohol, breads, carbonated drinks and caffeinated drinks were associated with reflux-related symptoms.
Diet; Food habits; Gastroesophageal reflux disease; Symptom
Only a few reports have examined informed consent for gastrointestinal endoscopy in Korea. The aim of this study was to evaluate the appropriateness of the informed consent procedure in Korea.
A total of 209 patients who underwent endoscopy were asked to answer a self-administered structured questionnaire on the informed consent procedure for gastrointestinal endoscopy.
One hundred thirteen patients completed questionnaires and were enrolled. In the survey, 91.2% answered that they understood the procedure, and the degree of understanding decreased with age; 85.8% were informed of the risks of the procedure, and the proportion was higher for inpatients and for those receiving therapeutic endoscopy or endoscopic retrograde cholangiopancreatography; 60.2% were informed of alternative methods, and the proportion was higher in older patients; 76.1% had the opportunity to ask questions during the informed consent procedure, and the proportion was higher in inpatients. The understanding of the risks of the endoscopic procedure was better in the younger and more highly educated groups. About 80% had sedation before endoscopy, and only 56% were informed of the risks of sedation during endoscopy.
The current informed consent process may be reasonably acceptable and understandable to the patients. However, the understanding of the risks of endoscopy was insufficient especially in the cases of older, poorly educated patients and outpatients. The information about alternatives, the opportunity to ask for additional information, and the information about the risks of sedation during endoscopy were also insufficient in the current consent process.
Informed consent; Consent forms; Endoscopy
Although gastric hyperplastic polyps are usually considered as benign lesions, a low risk of carcinomatous conversion is currently recognized. We aimed to identify the characteristics of hyperplastic polyps undergoing neoplastic transformation.
A total of 269 gastric hyperplastic polyps from 216 patients removed by endoscopic polypectomy (EP) or surgical resection were enrolled in this study, and their endoscopic pictures and pathology slides were reviewed.
Neoplastic transformation was detected on forceps biopsy specimen in 11 cases. However, the pathology findings from the EP or surgical specimen revealed neoplastic transformation in 14 cases (5.2%; 4 with dysplasia and 10 with adenocarcinoma). No significant difference was found between hyperplastic polyps with and without neoplastic transformation in age, sex, location, number of polyps or gross appearance. However, neoplastic transformations were more frequently found in gastric hyperplastic polyps >1 cm than in polyps ≤1 cm (12 of 143; 8.4% vs. 2 of 126; 1.6%) (p=0.013).
Neoplastic transformations were more frequently found in gastric hyperplastic polyps >1 cm. Therefore, EP should be considered for gastric hyperplastic polyps >1 cm for the accurate diagnosis and definitive treatment.
Hyperplastic polyp; Neoplastic transformation; Endoscopic polypectomy
The prevalence of gastric cancer associated with Lynch syndrome (LS) is highly variable, and the underlying histologic pathway or molecular mechanisms remain unclear. From 1995 to 2012, 15 patients had been treated for both gastric and colonic adenocarcinomas and diagnosed as LS. In all cases, pathologic review, immunohistochemical analysis for mismatch-repair proteins, and microsatellite instability (MSI) tests were performed. To confirm LS, germline mutation tests and multiplex ligation-dependent probe amplification were performed. All gastric and colonic carcinomas were MSI-high and lost expressions of MLH1/PMS2 in 11 (73%) cases and MSH2/MSH6 in 4 (27%) cases. Remarkably, in a patient with LS and germline mutation of MLH1 gene, pyloric gland adenoma (PGA) transformed to adenocarcinoma during follow-up. In 2 additional cases, PGA was found adjacent to advanced gastric cancers. All PGAs in LS patients were MSI-high and lost expression of mismatch-repair proteins (MLH1/PMS2 in 2 cases and MSH2/MSH6 in 1 case), whereas none of the 14 sporadic PGAs was MSI-high or had lost expression of mismatch-repair proteins. On the basis of these observations, although very rare, we suggest the possibility that PGA may be a precursor lesion to gastric adenocarcinoma in LS and that the mismatch-repair deficient pathway of carcinogenesis is involved early in the gastric carcinogenesis pathway.
gastric; pyloric gland adenoma; carcinoma; precursor; Lynch syndrome