There is limited evidence of a natural course of an upper gastrointestinal (UGI)-subepithelial lesion (SEL) of 2 cm or less in size. This study aims to determine the natural course of UGI-SELs and find the risk factors of the endoscopic and endoscopic ultrasonography (EUS) findings associated with an increase in size. The medical records of 2539 patients with UGI-SELs between 2004 and 2016 were reviewed retrospectively. A total of 672 SELs of 2 cm or less in size were analyzed through EUS and followed up for at least 36 months. The mean follow-up duration was 68 months (range: 36–190 months), and 97 SELs (14.4%) showed an increase in size with a mean increase rate of 1.2 mm/year. Initial size (aOR 1.03, 95% confidence interval (CI) 1.01–1.06), an endoscopic finding of a hemorrhagic spot (aOR 3.13, 95% CI 1.14–8.60), and an EUS finding of a lesion in the fourth layer (aOR 1.87, 95% CI (1.21–2.88) were related to an increase in size. An endoscopic finding of translucidity (aOR 0.28, 95% CI (0.10–0.76) and an EUS finding of calcification (aOR 0.30, 95% CI 0.09–0.95) were inversely related to an increase in size. There was no death related to UGI-SELs during the follow-up. While most UGI-SELs of 2 cm or less in size showed no significant size change and favorable prognosis, an individualized follow-up strategy needs to be considered in case of the presence of hemorrhagic spots and lesions in the fourth layer.

Objective: Silibinin is a flavonoid with antihepatotoxic properties, and exhibits pleiotropic anticancer effects. However, the molecular mechanisms responsible for its anticancer actions in pancreatic cancer cells, and the effects on such cells and normal pancreatic cells, remain unclear. The objective of this study was to determine the effect of silibinin on human pancreatic cancer cells and normal ductal cells. Methods: Human pancreatic cancer cells (MIA PaCa-2 and PANC-1) and normal ductal cells (hTERT-HPNE) were cultured with 0-400 μM silibinin for 48 h. Thereafter, the proliferation, invasion, apoptosis, and signaling pathways of the pancreatic cells were evaluated. Results: Silibinin significantly inhibited the proliferation, invasion, and spheroid formation of human pancreatic cancer cells in vitro in a dosedependent manner (p<0.05). It also induced apoptosis in a dose-dependent manner. Western blot analysis showed that silibinin downregulated extracellular signaling-regulated kinase (ERK) and serine/threonine protein kinase (AKT) in human pancreatic cancer cells. It also upregulated microtubule associated protein 1 light chain 3 β (LC3B) and cleaved caspase-3 via c-Jun N-terminal kinases (JNK) signaling. On the other hand, silibinin increased the mRNA and protein levels of c-Jun, Twist-related protein 1, and Snail. It also decreased exogenous p53 levels, but increased endogenous c-Jun protein levels in human pancreatic cancer cells. However, silibinin did not affect cell viability and endogenous c-Jun levels in pancreatic normal ductal cells. It increased exogenous p53 levels, but decreased stemness-related gene expression in pancreatic normal ductal cells. Silibinin increased Ki-67 levels in pancreatic cancer cells, but decreased them in pancreatic normal ductal cells. Conclusion: Silibinin not only exerted anticancer effects by inhibiting AKTERK and JNK signaling, but also upregulated cancer stemness-related genes in human pancreatic cancer cells. These results suggest that silibinin should be used as a therapeutic agent for human pancreatic cancer with caution.

Background/Aims Delayed gastric emptying (GE) is associated with high morbidity and mortality in subjects with diabetes. The aim of this study is to investigate associations between GE time and the major cardiovascular events (coronary heart diseases and ischemic stroke) in diabetic subjects with upper gastrointestinal (UGI) symptoms. Methods Among 259 subjects with chronic UGI symptoms who underwent gastric emptying study (GES) over 13 years, 122 diabetic subjects without gastric surgery and/or rapid GE were enrolled in this study. We also gathered data about baseline demographics, clinical characteristics, estimated GE half-time (GE T-1/2) and incidence of cardiovascular events following GES. Results The mean age of subjects was 64.0 +/- 17.4 years. There were 86 women and 104 subjects with type 2 diabetes. There were 52 (42.6%) subjects with normal GE, 50 (41.0.%) subjects with mild delayed GE, and 20 (16.4%) subjects with marked delayed GE. During follow-up (median, 207 weeks), cardiovascular events occurred in 7 (13.5%) subjects with normal GE, 4 (8.0%) subjects with mild delayed GE and 7 (35.0%) subjects with marked GE (P = 0.015). Univariate analysis showed that GE T-1/2 was significantly associated with incidence of cardiovascular events (crude OR, 1.74; 95% CI, 1.12-2.69; P = 0.014). In a multivariate model, association between GE T-1/2 and incidence of cardiovascular events remained statistically significant after adjustment for baseline characteristics and comorbidities (adjusted OR, 1.94; 95% CI, 1.21-3.12; P = 0.006). Conclusion A delay of GE was associated with an increased incidence of cardiovascular events in diabetic subjects with chronic UGI symptoms.

Chlorogenic acid (CA) is a phenolic compound purified from coffee, fruits and their associated beverages, which possess various biological properties, such as antioxidant and anticarcinogenic activities. The present study evaluated the effects of CA on lipopolysaccharide (LPS)‑induced inflammation in RAW264.7 cells and the associated intracellular signaling pathways using reverse transcription‑quantitative polymerase chain reaction, western blotting and enzyme‑linked immunosorbent assays. CA pretreatment inhibited LPS‑induced expression of inducible nitric oxide synthase (iNOS), nitric oxide (NO) and pro‑inflammatory mediators including interleukin (IL)‑6, tumor necrosis factor‑α (TNF‑α), macrophage inflammatory protein‑2 (MIP‑2) and IL‑1β in RAW264.7 cells. In addition, phosphorylation of Janus kinase 2/signal transducer and activator of transcription 3 (JAK2/STAT3) with LPS was inhibited by CA pretreatment. CA and STAT3 inhibitor (STAT3i) pretreatment inhibited LPS‑induced nuclear translocation of phosphorylated STAT3. In addition, STAT3i inhibited the LPS‑induced expression of iNOS, NO and IL‑1β similar to the results of CA pretreatment. By contrast, STAT3i did not inhibit the LPS‑induced increase in IL‑6, TNF‑α and MIP‑2 expression. These results indicate that CA may suppress LPS‑induced NO and IL‑1β expression by inhibiting JAK2/STAT3 activation in RAW264.7 cells.

Chlorogenic acid (CA) is a phenolic compound purified from coffee, fruits and their associated beverages, which possess various biological properties, such as antioxidant and anticarcinogenic activities. The present study evaluated the effects of CA on lipopolysaccharide (LPS)-induced inflammation in RAW264.7 cells and the associated intracellular signaling pathways using reverse transcription-quantitative polymerase chain reaction, western blotting and enzyme-linked immunosorbent assays. CA pretreatment inhibited LPS-induced expression of inducible nitric oxide synthase (iNOS), nitric oxide (NO) and pro‐inflammatory mediators including interleukin (IL)‐6, tumor necrosis factor-α (TNF-α), macrophage inflammatory protein-2 (MIP-2) and IL-1β in RAW264.7 cells. In addition, phosphorylation of Janus kinase 2/signal transducer and activator of transcription 3 (JAK2/STAT3) with LPS was inhibited by CA pretreatment. CA and STAT3 inhibitor (STAT3i) pretreatment inhibited LPS-induced nuclear translocation of phosphorylated STAT3. In addition, STAT3i inhibited the LPS-induced expression of iNOS, NO and IL-1β similar to the results of CA pretreatment. By contrast, STAT3i did not inhibit the LPS-induced increase in IL-6, TNF-α and MIP-2 expression. These results indicate that CA may suppress LPS-induced NO and IL-1β expression by inhibiting JAK2/STAT3 activation in RAW264.7 cells. Introduction Naturally occurring dietary compounds derived from medicinal plants serve important roles against inflammation and cancer (1-3). Coffee, the most commonly consumed beverage worldwide, is a rich source of dietary phenolic phytochemicals (4). Epidemiological studies have indicated that the dietary intake of coffee lowers the risk of developing cardiovascular disorders, diabetes, Parkinson's disease and cancer of the colon, liver, breast, prostate and endometrium (5-7). Chlorogenic acid (CA) is one of the most abundant phenolic phytochemicals purified from various plants, fruits and beverages, such as coffee. Previous in vitro and in vivo studies have reported that CA demonstrates significant anti‐inflammatory, antioxidative and anticarcinogenic effects (8-10). This suggests that the use of CA may be a useful strategy for the treatment and/or control of inflammation and cancer. However, the underlying molecular mechanisms and targets responsible for the health benefits of CA remain unknown. Although the pathogenesis of inflammatory bowel disease (IBD) has not yet been elucidated, the currently accepted pathogenic scenario suggests that IBD may occur as a result of dysregulated innate and adaptive immune responses against the commensal gut flora, thus generating an excessive production of pro‐inflammatory mediators (11). As part of the dysregulated immune response, macrophages serve a major role in IBD (12-14). Lipopolysaccharide (LPS), a component of Gram-negative bacterial cell walls, is involved in the barrier function of the intestinal epithelium and activates the immune system, leading to the production of pro‐inflammatory mediators, including nitric oxide (NO), enzymes including interleukin-1-receptor-associated kinases or interleukin-receptor-associated kinases (IRAKs), inflammatory cytokines, chemokines and adhesion molecules (15,16). The production of pro‐inflammatory mediators induced by LPS has been implicated in the activation of a number of signaling pathways involving the phosphorylation of Janus kinase/signal transducer and activator of transcription (JAK/STAT), mitogen-activated protein kinases (MAPKs) and nuclear factor-κB (NF-κB). Among LPS-induced signaling pathways, the JAK/STAT pathway is crucial for the expression Chlorogenic acid suppresses lipopolysaccharide‐induced nitric oxide and interleukin‐1β expression by inhibiting JAK2/STAT3 activation in RAW264.7 cells SANG-HUN KIM, SUN-YOUNG PARK, YOUNG-LAN PARK, DAE-SEONG MYUNG, JONG-SUN REW and YOUNG-EUN JOO Department of Internal Medicine, Chonnam National University Medical School, Dong-Ku, Gwangju 501-757, Republic of Korea Received August 4, 2016; Accepted August 3, 2017 DOI: 10.3892/mmr.2017.7686 Correspondence to: Professor Young-Eun Joo, Department of Internal Medicine, Chonnam National University Medical School, 8, Hak-Dong, Dong-Ku, Gwangju 501-757, Republic of Korea E-mail: yejoo@chonnam.ac.kr

Several studies have demonstrated a correlation between the expression of early growth response gene-1 (EGR-1) and the progression of gastric cancers at advanced stages. However, the effects of EGR-1 expression on human gastric cancer progression, particularly on precancerous lesions, have not been investigated. In this study, we evaluate EGR-1 expression levels in target mucosa from patients with early gastric cancer and precancerous lesions, and assess whether EGR-1 expression affects the oncogenic phenotypes of human gastric cancer cells. EGR-1 protein levels were measured in tissues from subjects with normal mucosa (n=6), low-grade dysplasia (n=6), high-grade dysplasia (n=4) and adenocarcinoma (n=3) using enzyme-linked immunosorbent assay and immunohistochemistry analyses. We also investigated the role of EGR-1 in tumor cell behavior by transiently expressing a dominant active EGR-1 variant in cultured cells. A positive correlation was observed between EGR-1 expression and gastric carcinogenesis (P=0.016). Furthermore, there was an increase in nuclear and cytoplasmic expression of EGR-1 in accordance with the histological grade (P for trends=0.003 and 0.003, respectively), and a positive association between the sum of the nuclear and cytoplasmic EGR-1 expression values and the histological grade (P=0.003). In addition, transient overexpression of EGR-1 enhanced cell proliferation, stimulated cell migration, and promoted the phosphorylation of p38 MAPK and AKT in gastric cancer cells in vitro. Our findings demonstrate that EGR-1 may contribute to the early stages of gastric carcinogenesis via the alteration of tumor cell behaviors.

BACKGROUND/AIMS:Intraductal ultrasonography (IDUS) has been performed as an adjunct to endoscopic retrograde cholangiography (ERC) during radiocontrast cholangiography (RC). Radiation exposure during RC poses a health risk to both patients and examiners. We evaluated the feasibility of IDUS without RC in various extrahepatic biliary diseases.METHODS:IDUS was performed with the insertion of an IDUS probe from the papilla of Vater to the confluent portion of the common hepatic duct without fluoroscopy. The technical success rate and procedure-related complications were evaluated retrospectively.RESULTS:Wire-guided IDUS without RC was performed in 105 patients. The mean age was 66.5 years, and 50 (47.6%) were male. The IDUS diagnoses included choledocholithiasis (73, 69.5%), benign biliary stricture (11, 10.5%), choledocholithiasis with biliary pancreatitis (9, 8.6%), bile duct cancer (5, 4.8%), pancreatic cancer (1, 0.9%), and others (6, 5.7%). After IDUS, 66 (62.8%) underwent stone removal, 19 (18.1%) underwent biliary drainage, and 7 (6.6%) underwent brush cytology and biopsy. No significant complications such as perforation or severe pancreatitis occurred.CONCLUSIONS:IDUS without RC was a feasible and safe approach in patients with various extrahepatic biliary diseases. We anticipate a potentially important role of IDUS in various ERC procedures because it lacks the hazards of RC.

BACKGROUND/AIMS:Dieulafoy lesions (DLs) are a rare but significant cause of upper gastrointestinal bleeding. We aimed to define the clinical significance of rebleeding and identify the predictors of rebleeding and mortality in upper gastrointestinal Dieulafoy lesions (UGIDLs).METHODS:Patients diagnosed with UGIDLs between January 2004 and June 2013 were retrospectively evaluated. Multivariate logistic regression analyses were performed to define the predictors of rebleeding and mortality in patients with UGIDLs.RESULTS:The study group consisted of 81 male and 36 female patients. Primary hemostasis was achieved in 115 out of 117 patients (98.3%) with various endoscopic therapies. Rebleeding occurred in 10 patients (8.5%). The mortality rate was significantly higher in patients with rebleeding than in those without rebleeding (30.0% vs. 4.7%, p=0.020). Multivariate logistic regression analysis revealed that kidney disease (p=0.006) and infection (p=0.005) were significant predictors of rebleeding in UGIDLs and that kidney disease (p=0.004) and platelet count (p=0.013) were significant predictors of mortality.CONCLUSIONS:Rebleeding has an important prognostic significance in patients with UGIDLs. Kidney disease and infection are major predictors of rebleeding and mortality in patients with UGIDLs.

OBJECTIVE:The incidence of nonsteroidal anti-inflammatory drugs (NSAIDs)-induced enteropathy is currently increasing. However, the predictors of small bowel bleeding (SBB) associated with NSAIDs are unknown. This study aimed to assess the risk factors of SBB in chronic NSAIDs users.METHODS:We retrospectively compared the medical records of 147 patients receiving NSAIDs in a tertiary-care setting (31 with SBB and 116 without previous bleeding events) and analyzed the predictors of SBB.RESULTS:In total, 31 patients underwent video capsule endoscopy to detect SBB, 74.2% of whom showed the evidence of SBB. Non-invasive treatment was performed in 90.3% of the patients. Multivariate logistic regression analysis revealed that the presence of coronary artery disease [adjusted odds ratio (aOR) 12.43, 95% confidence interval (CI) 1.19-130.34, P = 0.04], use of thienopyridine (aOR 16.93, 95% CI 3.78-75.72, P < 0.001) and prior use of rebamipide (aOR 0.31, 95% CI 0.12-0.82, P = 0.02) were independently associated with SBB in NSAIDs users.CONCLUSIONS:Coronary artery disease and co-use of thienopyridine were associated with SBB in NSAIDs users. The patients with coronary artery disease co-using thienopyridine need to be monitored for the occurrence of SBB when they were prescribed with NSAIDs.

Background/Aims: Intraductal US (IDUS) is an examination of the bile duct by using a thin-caliber ultrasonic probe, yielding real-time, high-quality cross-sectional images. We prospectively evaluated the feasibility and safety of IDUS-directed stone removal without radiocontrast cholangiography (RC) in naive patients with common bile duct (CBD) stones.Methods: A total of 38 naive patients with suspected CBD stones (<20 mm) were enrolled in this study. If IDUS showed CBD stones, we performed endoscopic sphincterotomy and removed the identified CBD stones without RC. The primary outcome was success rate of CBD stone removal without RC. The secondary outcomes were conversion rate to conventional ERCP with RC, fluoroscopy time, clinical responses, and adverse events.Results: IDUS was successfully performed in all enrolled patients (38/38, 100%). No echogenic material was observed in 3 patients (1 Mirizzi syndrome, 2 spontaneous passages of CBD stones). After endoscopic sphincterotomy, IDUS-directed stone removal was successfully performed without RC in 26 patients (74.3%) in the first session. In the 9 patients, after deployment of plastic stents, IDUS-directed stone removal was successfully completed without RC in a second session. There was no conversion to conventional ERCP with RC. Median fluoroscopy time was 10 seconds. There were no immediate and delayed adverse events related to the IDUS-directed stone removal. However, asymptomatic hyperamylasemia developed in 3 patients (7.9%), who recovered without adverse events.Conclusions: IDUS-directed stone removal without RC is feasible and safe for patients with CBD stones. We anticipate a potentially important role of IDUS in the field of various therapeutic interventions.

Leptin, which is encoded by the obese gene, is a multifunctional neuroendocrine peptide that regulates appetite, bone formation, reproductive function and angiogenesis. The aims of the present study were to investigate the expression of leptin in 80 patients with colorectal cancer (CRC) and to determine the effects of leptin on the malignant properties of CRC cells. We evaluated the expression of leptin in tissues of 80 patients with CRC. Suspension cultures were used to isolate CRC stem cells following pretreatment with leptin. We analyzed the effects of leptin on the adhesion and invasive capacities of CRC cell lines. The effects of leptin on JAK and ERK activation were examined using western blotting. Leptin expression was associated with CRC progression and increased the number and size of spheroid formation by CRC cell lines. Leptin enhanced cell invasion and adhesion and activated JAK and ERK signaling in the CRC cell lines. The present study demonstrated that leptin influences the growth and survival of CRC stem cells and regulates adhesion and invasion of colorectal carcinoma through activation of the JAK and ERK signaling pathways.

Whether a Wait-and-See or Choleretic Therapy Is Effective in Acalculous Gallbladder Following Removal of Biliary Stones? Tae Hoon Lee, Hyun Jong Choi, Joung-Ho Han, Yong Seok Kim, Seok Jeong, Sung Hee Park, Yun Nah Lee, Jong Ho Moon, Seonmee Park, Young Woo Choi, Don Haeng Lee, Sang-Heum Park, Sun-Joo Kim Department of Internal Medicine, Soonchunhyang University School of Medicine, Cheonan, Department of Internal Medicine, Soonchunhyang University School of Medicine, Bucheon, Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Department of Internal Medicine, Konyang University School of Medicine, Daejeon, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea

Figure 1.Prevalence (in %) of the 5 most common gastric histopathologic findings in 575,895 controls (left columns) and 3,040 patients with gastroparesis (right columns).Significant odds ratios (with 95% confidence intervals) are depicted on top of the columns; n.s.

BACKGROUND/AIMS:Epigallocatechin-3-gallate (EGCG), the primary catechin in green tea, has anti-inflammatory and anti-oxidative properties. The aim of the current study was to characterize the impact of EGCG on lipopolysaccharide (LPS)-induced innate signaling in bone marrow-derived macrophages (BMMs) isolated from ICR mice.METHODS:The effect of EGCG on LPS-induced pro-inflammatory gene expression and nuclear factor-κB (NF-κB) and mitogen-activated protein kinase (MAPK) signaling was examined using reverse transcription-polymerase chain reaction, Western blotting, immunofluorescence, and the electrophoretic mobility shift assay.RESULTS:EGCG inhibited accumulation of LPS-induced IL-12p40, IL-6, MCP-1, ICAM-1, and VCAM-1 mRNA in BMMs. EGCG blocked LPS-induced IκBα degradation and RelA nuclear translocation. EGCG blocked the DNA-binding activity of NF-κB. LPS-induced phosphorylation of ERK1/2, JNK, and p38 was inhibited by EGCG. U0126 (an inhibitor of MEK-1/2) suppressed the LPS-induced IL-12p40, IL-6, MCP-1, ICAM-1, and VCAM-1 mRNA accumulation in BMMs.CONCLUSIONS:These results indicate that EGCG may prevent LPS-induced pro-inflammatory gene expression through blocking NF-κB and MAPK signaling pathways in BMMs.

BACKGROUND/AIMS:Gastroesophageal reflux (GER) has been implicated in the pathogenesis of chronic cough. The aims of this study were to evaluate the diagnostic usefulness of multichannel intraluminal impedance combined with pH monitoring (MII/pH monitoring) in patients with suspected symptoms of gastroesophageal reflux disease (GERD) and to assess the correlation between GER symptoms and reflux nature.METHODS:Seventy patients with suspected symptoms of GERD (such as heartburn, acid regurgitation, non-cardiac chest pain, globus and chronic cough) were enrolled. All patients were asked to discontinue medications that would influence esophageal motor function and gastric acid secretion at least one week ago. All subjects underwent MII/pH monitoring.RESULTS:Forty-five patients (64.3%) were diagnosed with GERD. Among these patients, eleven patients (15.7%) had pathologic acid reflux by pH data and thirty-four patients (48.6%) had pathologic bolus exposure by impedance. Subjects with chronic cough had a higher DeMeester score (p=0.009), percentage of acid exposure time (p=0.007), acid bolus exposure % time (p=0.027), distal acid reflux episodes (p=0.015) and proximal acid reflux episodes (p=0.030) than subjects without chronic cough.CONCLUSIONS:The results of this study showed that the impedance monitoring enhanced diagnostic sensitivity than pH-monitoring alone by 48.6%. In addition, reflux episodes at the distal and proximal esophagus were noted to be important factors associated with chronic cough.

MMP-1, EGF, and IL-1B gene polymorphism can be associated with gastric carcinogenesis. However, no study has yet confirmed the definitive role of these gene polymorphisms in gastric cancer risk. The 194 gastric cancer patients, 94 gastric adenoma patients, and 182 controls were used in this study. The SNP of the MMP-1 promoter, EGF, and IL-1B-31 were analyzed by PCR-RFLP and sequencing. The genotype frequency was compared between cases and controls, and a univariate and multivariate analysis were performed to determine the significant risk factors associated with gastric adenoma and adenocarcinoma. The frequency of 1G/2G genotypes in the MMP-1 promoter was similar to those in controls (p=0.734). The frequency of A/G genotypes in the EGF was similar to those in controls (p=0.239). The frequency of C/T genotypes in the IL-1B-31 was similar to those in controls (p=0.239). According to univariate analysis, male sex (p ＜0.0001), old age (≥60, p＜0.0001), atrophy (pepsinogen I/II ≤3, p＜0.0001), and G/G genotype of EGF (p=0.034) were significant risk factors associated with gastric adenoma and carcinoma. However, male sex (p=0.002), old age (p＜0.0001), and atrophy (p＜0.0001) were the only significant risk factors associated with gastric adenoma and carcinoma according to the multivariate analysis. In conclusion, the SNP of the MMP-1 promoter, EGF, and IL-1B-31 did not correlate with the risk of gastric adenoma and adenocarcinoma. Sex, age, and atrophy were the significant risk factors of gastric cancer.