Safety of Sedated Therapeutic Endoscopic Retrograde Cholangiopancreatography in Patients Older than 70 Years Old

Objectives : The purpose of this study was to compare the safety and efficacy of midazolam sedated Endoscopic retrograde cholangiopancreatography (ERCP) with unsedated ERCP in patients 70 years of ages and older. Methods : Seventy elderly patients 70 years of age or older who underwent ERCP were divided into two groups: midazolam sedated group (n=43) and unsedated group (n=27). Procedure time, success rate, complications related with ERCP procedure, satisfaction score were analyzed between two groups. Results : Mean procedure time was 20.6 minutes for sedated group and 21.0 minutes for unsedated group (P=0.88). Success rate was 87.5% for sedated group and 100% for unsedated group (P=0.07). Incidence of complications from ERCP procedure showed no significant differences between the sedated and unsedated groups (P=0.10). There was no mortality in both groups related to the sedation or post-ERCP complication. Compared to the unsedated procedure, the sedated ERCP procedure was associated with higher patient satisfaction (P<0.001) and better repeat compliance (P=0.004). Conclusion : There was no significant difference in success rate and complications at sedated and unsedated ERCP in patients 70 years of age and older. Unsedated ERCP showed 66.6% satisfaction score compared to sedated ERCP.ope

Myasthenia Crisis Induced by Pegylated-Interferon in Patient With Chronic Hepatitis C: A Case Report.

Myasthenia gravis is occasionally associated with thymoma that needs surgical resection and may progress to severe respiratory failure. We experienced a rare case of myasthenia crisis during antiviral therapy for chronic hepatitis C, in whom mediastinal thymoma was discovered and successfully managed with surgical thymectomy and meticulous medical care.A 47-year-old-male patient complained of sudden diplopia 1 week after stopping 11-week administration of pegylated-interferon and ribavirin for chronic hepatitis C. Ophthalmologic examinations revealed ptosis on the right eyelid and restricted right eye movement. Myasthenia gravis was confirmed by positive repetitive nerve stimulation test and positive serum antiacetylcholine receptor antibody test, and mediastinal thymoma was found on chest CT scan. The ocular myasthenia gravis progressed to respiratory failure even after discontinuing antiviral treatment but eventually recovered with thymectomy, anticholinesterase administration, steroid pulse therapy, and prolonged ventilator care. We describe the clinical features of this life-threatening complication of interferon treatment along with previous myasthenia crisis cases by interferon for chronic hepatitis C.In patients with chronic hepatitis C who is going to receive interferon-based antiviral treatment, physicians need to keep in mind the potential life-threatening manifestations of myasthenia gravis before and during antiviral treatment especially when patients complain of muscular weakness and easy fatigability.ope

Ischemic colitis during interferon-ribavirin therapy for chronic hepatitis C: a case report

Ischemic colitis is a rare complication of interferon administration. Only 9 cases in 6 reports have been described to-date. This report describes a case of ischemic colitis during pegylated interferon and ribavirin treatment for chronic hepatitis C, and includes a review of the relevant literature. A 48-year-old woman was treated with pegylated interferon α-2a and ribavirin for chronic hepatitis C, genotype Ib. After 19 wk of treatment, the patient complained of severe afebrile abdominal pain with hematochezia. Vital signs were stable and serum white blood cell count was within the normal range. Abdominal computed tomography showed diffuse colonic wall thickening from the splenic flexure to the proximal sigmoid colon, which is the most vulnerable area for the development of ischemic colitis. Colonoscopy revealed an acute mucosal hyperemic change, with edema and ulcerations extending from the proximal descending colon to the sigmoid colon. Colonic mucosal biopsy revealed acute exudative colitis. Polymerase chain reaction and culture for Mycobacterium tuberculosis were negative and the cultures for cytomegalovirus, Salmonella and Shigella species were negative. After discontinuation of interferon and ribavirin therapy, abdominal pain and hematochezia subsided and, following colonoscopy showed improvement of the mucosal ulcerations. Ischemic colitis cases during interferon therapy in patients with chronic hepatitis C reported so far have all involved the descending colon. Ischemic colitis is a rarely encountered complication of interferon administration in patients with chronic hepatitis C and should be considered when a patient complains of abdominal pain and hematochezia.ope

A case of obstructive jaundice caused by tuberculous lymphadenitis: a literature review

Obstructive jaundice caused by tuberculous lymphadenitis is a rare manifestation of tuberculosis (TB), with 15 cases having been reported in Korea. We experienced a case of obstructive jaundice caused by pericholedochal tuberculous lymphadenitis in a 30-year-old man. The patient's initial serum total bilirubin level was 21.1 mg/dL. Abdominal computed tomography revealed narrowing of the bile duct by a conglomerated soft-tissue mass involving the main portal vein. Abrupt obstruction of the common bile duct was observed on cholangiography. Pathologic analysis of a ultrasonography-guided biopsy sample revealed chronic granulomatous inflammation, and an endoscopic examination revealed esophageal varices and active duodenal ulceration, the pathology of which was chronic noncaseating granulomatous inflammation. Hepaticojejunostomy was performed and pathologic analysis of the conglomerated soft-tissue mass revealed chronic granulomatous inflammation with caseation of the lymph nodes. Tuberculous lymphadenitis should be considered in patients presenting with obstructive jaundice in an endemic area.ope

Prevalence of and Risk Factors for Diseases in Korean Americans and Native Koreans Undergoing Health Checkup

BACKGROUND: Korean Americans constitute the fifth largest subgroup in the Asian American population. Despite their increasing population, research and guidelines regarding their health status assessment and disease screening are lacking. This study aimed to compare the prevalence of diseases in Korean Americans and native Koreans to determine the risk factors and guidelines for disease screening. METHODS: Patients who visited the Gangnam Severance Hospital from February 2010 to May 2015 for a health checkup were enrolled in this study. Baseline characteristics, laboratory data, and the organs (stomach, colon, thyroid, brain, prostate, lung, liver, kidney, pancreas, adrenal gland, and heart) of patients were examined. Data regarding patients' dietary patterns were also obtained. Overall, 1,514 Korean Americans (group 1) and 1,514 native Koreans (group 2) were enrolled. RESULTS: The following diseases were more prevalent in group 1 than in group 2: reflux esophagitis (12.9% vs. 10%), gastric ulcer (3.0% vs. 5.5%), colorectal polyp (37.7% vs. 28.7%), hemorrhoids (32.2% vs. 29.9%), and benign prostatic hyperplasia (30.2% vs. 14.3%). Although not statistically significant, coronary artery disease has a high prevalence rate of >20% in both groups. Dietary patterns were not significant between the two groups. CONCLUSION: This study showed that the prevalence of several diseases in Korean Americans differed from that observed in native Koreans. Therefore, a foundation for setting up new guidelines for disease screening among Korean Americans is established.ope

Decreased S100B expression in chronic liver diseases

BACKGROUND/AIMS: Hepatic innervation in liver diseases is not fully understood. We here evaluated S100B expression as a marker of hepatic nerves in patients with various chronic liver diseases, topographically and semi-quantitatively. METHODS: Liver specimens were obtained from 70 subjects (three controls, and 32 chronic hepatitis B, 14 chronic hepatitis C, 14 liver cirrhosis, and seven hepatocellular carcinoma patients). The hepatic nerve density was calculated based on immunohistochemical staining of S100B protein in the portal tracts and hepatic lobules. S100B mRNA levels were semi-quantitatively assessed as the S100B/glyceraldehyde 3-phosphate dehydrogenase (GAPDH) mRNA ratio. RESULTS: The densities of the hepatic nerves in portal tracts of chronic liver diseases were not significantly different from those of normal controls but the hepatic nerve densities in lobular areas of liver cirrhosis were significantly decreased (p = 0.025). Compared to the control, the S100B/GAPDH mRNA ratio was significantly decreased in chronic liver diseases (p = 0.006) and most decreased in chronic hepatitis C patients (p = 0.023). In chronic liver diseases, The S100B/GAPDH mRNA ratio tended to decrease as the fibrosis score > 0 (p = 0.453) but the overall correlation between the S100B/GAPDH mRNA ratio and fibrosis score was not statistically significant (r = 0.061, p = 0.657). CONCLUSIONS: Hepatic innervation is decreased in cirrhotic regenerating nodules compared to the control group and seems to decrease in early stages of fibrosis progression. Further studies are needed to clarify the association between changes of hepatic innervation and chronic liver disease progression.ope

Association between skeletal muscle attenuation and gastroesophageal reflux disease: A health check-up cohort study

Sarcopenia is defined as skeletal muscle attenuation and has an association with metabolic syndrome. Metabolic syndrome, which includes obesity, is one of known predictive factors for gastroesophageal reflux disease (GERD). This study aimed to elucidate the association between sarcopenia and GERD. We retrospectively reviewed electronic medical records of 8,218 patients who were performed an upper gastrointestinal endoscopy at check-up center of the Gangnam Severance Hospital. GERD was diagnosed by endoscopic findings. Erosive reflux disease (ERD) included Barrett's esophagus and reflux esophagitis, with the exception of minimal change esophagitis. Sarcopenia was defined by appendicular skeletal muscle (skeletal muscle in the upper and lower limbs). Sarcopenic obesity was defined as the presence of both sarcopenia and obesity. Associations between sarcopenia and GERD, as well as between sarcopenic obesity and ERD, were analyzed. A total of 3,414 patients were diagnosed with GERD, and 574 (16.8%) had sarcopenia. Sarcopenia was independent predictive factor for GERD (odds ratio [OR] = 1.170, 95% confidence interval [CI]: 1.016-1.346, P = 0.029). In addition, male sex, smoking, alcohol, and diet, including sweets and fatty food, had a significant association with GERD. A total of 1,423 (17.3%) of 8,218 patients were diagnosed with ERD, and 302 (21.2%) had sarcopenia. Male sex, smoking, and fatty food consumption had a significant association with ERD. Moreover, sarcopenia (OR = 1.215, 95% CI: 1.019-1.449, P = 0.030), obesity (OR = 1.343, 95% CI: 1.163-1.552, P < 0.001), and sarcopenic obesity (OR = 1.406, 95% CI: 1.195-1.654, P < 0.001) were independent predictive factors for ERD. Sarcopenia is associated with GERD, and sarcopenic obesity may be predictive factor for ERD.ope

Comparison of the effectiveness of Martin's equation, Friedewald's equation, and a Novel equation in low-density lipoprotein cholesterol estimation

Low-density-lipoprotein cholesterol (LDL-C) is the main target in atherosclerotic cardiovascular disease (ASCVD). We aimed to validate and compare a new LDL-C estimation equation with other well-known equations. 177,111 samples were analysed from two contemporary population-based cohorts comprising asymptomatic Korean adults who underwent medical examinations. Performances of the Friedewald (FLDL), Martin (MLDL), and Sampson (SLDL) equations in estimating direct LDL-C by homogenous assay were assessed by measures of concordance (R2, RMSE, and mean absolute difference). Analyses were performed according to various triglyceride (TG) and/or LDL-C strata. Secondary analyses were conducted within dyslipidaemia populations of each database. MLDL was superior or at least similar to other equations regardless of TG/LDL-C, in both the general and dyslipidaemia populations (RMSE = 11.45/9.20 mg/dL; R2 = 0.88/0.91; vs FLDL: RMSE = 13.66/10.42 mg/dL; R2 = 0.82/0.89; vs SLDL: RMSE = 12.36/9.39 mg/dL; R2 = 0.85/0.91, per Gangnam Severance Hospital Check-up/Korea Initiatives on Coronary Artery Calcification data). MLDL had a slight advantage over SLDL with the lowest MADs across the full spectrum of TG levels, whether divided into severe hyper/non-hyper to moderate hypertriglyceridaemia samples or stratified by 100-mg/dL TG intervals, even up to TG values of 500-600 mg/dL. MLDL may be a readily adoptable and cost-effective alternative to direct LDL-C measurement, irrespective of dyslipidaemia status. In populations with relatively high prevalence of mild-to-moderate hypertriglyceridaemia, Martin's equation may be optimal for LDL-C and ASCVD risk estimation.ope

Relative fat mass at baseline and its early change may be a predictor of incident nonalcoholic fatty liver disease

The relationship between changes in body components and the risk of nonalcoholic fatty liver disease (NAFLD) is not fully understood. We investigated the effects of body components and subsequent changes on incident NAFLD at follow-up ultrasound scanning in a longitudinal cohort. We included 9967 participants without NAFLD at baseline who underwent serial health examinations. Sex-specific, weight-adjusted skeletal muscle index (SMI_Wt) was used. Mean follow-up duration was 48.5 ± 33.5 months. NAFLD developed in 2395 participants (24.0%). Body composition was measured using bioelectrical impedance analysis. The following baseline body components were significantly associated with incident NAFLD: the lowest and middle SMI_Wt tertiles in the normal-weight group (adjusted hazard ratio [aHR] = 2.20 and 1.54, respectively), and fat percentage in the normal-weight (aHR = 1.12), overweight (aHR = 1.05), and obese groups (aHR = 1.03) (all P < 0.05). Among 5,033 participants who underwent ≥ 3 health examinations, SMI_Wt increase between the first and second examinations was an independent protective factor against incident NAFLD in non-obese groups (P < 0.05). Increased fat percentage was an independent risk factor for incident NAFLD in all weight categories (P < 0.05). High fat mass at baseline may be a better predictor of incident NAFLD than muscle mass. Reciprocal changes in fat and muscle mass during the first year of follow-up predicted incident NAFLD in non-obese groups.ope

Triglyceride Glucose-Waist Circumference (TyG-WC) Is a Reliable Marker to Predict Non-Alcoholic Fatty Liver Disease

The triglyceride and glucose index (TyG index), a marker of insulin resistance, is positively associated with NAFLD. Modified TyG indices, combining body composition markers including body-mass index (BMI) or waist circumference (WC) with the TyG index, are reported to enhance predictability of insulin resistance. This study aimed to compare the usefulness of modified TyG indices for predicting NAFLD with the TyG index and fatty liver index (FLI). This cross-sectional study included 12,757 Korean adults. The TyG index and FLI were calculated using established formulas, and TyG-BMI and TyG-WC were calculated as TyG × BMI and TyG × WC, respectively. All measures were divided into quartiles. NAFLD severity (grade 0-3) was compared using ANOVA by quartiles of each index. Odds ratios (ORs) and 95% confidence intervals (CIs) for NAFLD were calculated using a multiple logistic regression analysis. ROC and AUROC analyses were performed to compare the predictability of NAFLD using WC, BMI, TyG, TyG-BMI, TyG-WC, and FLI. A higher TyG index, TyG-BMI, TyG-WC, and FLI were associated with a higher grade of NAFLD. ORs (CIs) for NAFLD increased in all indices, especially in TyG-WC (39.251 (31.304-49.215)) and FLI (38.937 (31.145-48.678)). AUROC was 0.848 (0.840-0.855) for TyG-WC and 0.850 (0.842-0.857) for FLI. TyG-WC is a reliable indicator for the presence of NAFLD in Korean adults.ope