Rationale:Small bowel diaphragm disease (SBDD) is a rare case, caused by long-term administration of nonsteroidal anti-inflammatory drugs (NSAIDs). The circumferential diaphragm in the lumen of small bowel causing mechanical obstruction is the characteristic finding.Patient concerns:A 74-year-old male was transferred to Pusan National University Yangsan Hospital (PNUYH) due to abdominal pain lasting for 2 months. He was treated in the local medical center (LMC) with Levin tube insertion and Nil Per Os (NPO) but showed no improvement.Diagnosis:According to abdomen-pelvis computed tomography (CT) result, small bowel obstruction due to the adhesion band was identified, showing dilatation of the small bowel with abrupt narrowing of the ileum.Interventions:Laparoscopic exploration was done but failed to find an adhesion band. An investigation of the whole small bowel was done with mini-laparotomy. At the transitional zone, the intraluminal air could not pass so the segmental resection of small bowel including the transitional zone and end-to-end anastomosis was done.Outcomes:After surgery, every laboratory finding recovered to the normal range in 4 days, but the patient's ileus lasted for 8 days. The patient's symptoms were relieved after defecation, he was discharged on postoperative day 10.Lessons:For patients who show mechanical obstruction without an operation history but with long-term administration of NSAIDs, the clinicians should suspect small bowel diaphragm disease.

Background and aims: Survival data in patients with hepatitis C virus (HCV) associated hepatocellular carcinoma (HCC) treated with direct acting antivirals (DAAs) are limited.Survival rates were compared between patients with HCV-related HCC who were untreated for HCV and who treated with DAA.Method: From 2010 to 2019, a total of 469 patients who were monoinfected with HCV-related HCC was categorized into patients untreated for HCV and patients treated with DAA.Multivariable Cox regression with HCV treatment status as a time-varying covariate was used to determine mortality risk.Results: There were 95 untreated group and 94 DAA group.Of DAA group, 42 was active HCC state ( patients without viable HCC).Baseline characteristics between untreated group and DAA with active HCC were balanced except genotype.Sustained virologic response rate was 88.2% by per protocol analysis in DAA treated patients.After time-varying adjustment for DAA treatment initiation compared with untreated patients, patients with DAA had significantly higher 5-year overall survival (76.7% vs. 22.4%, p < 0.001).Multivariate Cox regression showed that survival was significantly improved in patients with DAA treatment ( p < 0.001), patients who were treated with curative treatment (0.034) and with history of interferon exposure ( p = 0.045).Conclusion: In this study, patients in HCV related HCV who treated DAA achieved 88.2% of SVR and showed significant improvement of survival compared with patients untreated with DAA.

Eosinophilic colitis is a rare disease that is characterized by eosinophilic infiltration in the colon wall in symptomatic patients. Thus far, the epidemiology and pathophysiology of eosinophilic colitis have not been well defined, but the hypersensitivity response is likely to play a role in its pathogenesis. The clinical presentation of eosinophilic colitis is usually nonspecific and depends on the layer of the intestinal wall affected by the eosinophilic infiltrate. Eosinophilic colitis is diagnosed generally by exclusion, i.e., after all other causes of eosinophilic infiltration have been excluded. Although there is no consensus over its diagnostic criteria, the laboratory results and radiology and endoscopy findings can provide important diagnostic evidence. This paper reports a case of eosinophilic colitis presenting as subepithelial tumor-like lesions in a 41-year-old man with the chief complaints of abdominal pain and loose stools. The patient had no diseases and no food or drug allergies in his medical history. In general, the endoscopic findings of eosinophilic colitis can vary from a normal mucosa to frank ulcerations. In this case, however, endoscopy revealed subepithelial tumor-like lesions. The colon biopsy showed eosinophilic infiltration in the lamina propria. The patient was treated with steroids, and his symptoms regressed with no signs of relapse.

Differentiating Crohn's disease (CD) from intestinal tuberculosis (TB) is a challenge. In patients suspected of having CD or intestinal TB compounded with active pulmonary TB in its early stages, clinicians often lean towards a diagnosis of intestinal TB. A 14-year-old female patient was admitted with symptoms of abdominal pain and diarrhea with hematochezia. Colonoscopy revealed a stricture of the ileocecal valve and scattered longitudinal ulcers. Initial chest radiography showed consolidation in the left lower lobe of the lung. Chest CT revealed branching nodular opacities and consolidation. The TB PCR of the bronchial washing fluid was positive. The patient was diagnosed with pulmonary and intestinal TB. The colonoscopy findings favored CD. Despite this, anti-tubercular therapy was initiated based on the radiology findings and PCR test. After treatment with anti-tubercular therapy, the patient's diarrhea and abdominal pain worsened despite the improvement observed on her chest radiography. Follow-up colonoscopy revealed aggravation of her ulcers. The patient was diagnosed with CD and treated with prednisolone and mesalazine. Her clinical condition improved, and follow-up colonoscopy showed significant improvement of the ulcers. This case highlights the need for caution in diagnosis and suggests that clinicians consider reevaluation in similar cases.

A rare gastric mucosal lesion characterized by Russell body-containing plasma cell infiltration is termed as Russell body gastritis. This lesion is highly suggested to be correlated with Helicobacter pylori-induced chronic gastritis, and often misdiagnosed as mucosa-associated lymphoid tissue lymphoma, signet ring cell carcinoma, plasmacytoma, or xanthoma. However, Russell body gastritis is easily discriminated by its polyclonal immunoreaction to immunoglobulin light chains contrary to monoclonal immunoreaction of neoplastic disease. We report here a case of Russell body gastritis associated with H. pylori infection, which disappeared after H. pylori eradication.

Analgesics, known to be hepatotoxic drugs, are frequently prescribed to patients with liver cirrhosis who are prone to drug-induced liver injury. No guidelines are available regarding the prescription of analgesics in these patients. Therefore, we aimed to evaluate the prescription pattern of most frequently used analgesics in patients with cirrhosis. We assessed the prescription pattern of acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) in patients with liver cirrhosis registered in Health Insurance Review Assessment Service database between January 1, 2012 and December 31, 2012. A total of 125,505 patients with liver cirrhosis were registered from January 1, 2012 to December 31, 2012. Of that group, 50,798 (40.5%) patients claimed reimbursement for at least one prescription for acetaminophen or NSAIDs during the one year follow-up period. Overall, NSAIDs (82.7%) were more prescribed than acetaminophen (64.5%). NSAIDs were more prescribed than acetaminophen even in decompensated cirrhosis compared with compensated cirrhosis (71.5% vs. 68.8%, P value<0.001). There was a marked difference in prescription preference between acetaminophen and NSAIDs among physicians. Internists more frequently prescribed acetaminophen than NSAIDs compared to other physicians (50.9% vs. 76.2%, P < 0.001). Gastroenterologists more frequently prescribed acetaminophen over NSAIDs compared to other internists (80.9% vs. 51.2%, P < 0.001). Analgesics were prescribed in 40.5% of patients with cirrhosis. NSAIDs were more frequently prescribed although they should be avoided. The prescription pattern of analgesics were different significantly among physicians in patients with liver cirrhosis. The harmful effects of NSAIDs in patients with cirrhosis should be reminded to all physicians prescribing analgesics.

The Korean Journal of Helicobacter and Upper Gastrointestinal Research is an Open-Access Journal. All articles are distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. CASE REPORT ISSN 1738-3331, http://dx.doi.org/10.7704/kjhugr.2016.16.2.107 The Korean Journal of Helicobacter and Upper Gastrointestinal Research, 2016;16(2):107-110

AimThe aim of this study was to investigate the effect of yttrium-90 radioembolization on the outcome of Asian patients with early to advanced stage hepatocellular carcinoma (HCC).MethodsSixty-two patients were screened and 50 patients (80.6%) were eligible. Response was evaluated using the Response Evaluation Criteria in Solid Tumors (RECIST), and overall survival was estimated using the Kaplan-Meier method.ResultsThe Barcelona Clinic Liver Cancer (BCLC) stage was A in 40% of patients, B in 24%, and C in 36%; 66% of patients had hepatitis B virus infections. According to RECIST criteria, partial responses occurred in 40% of patients, and stable disease was achieved in 46%. Tumor response was significantly associated with BCLC stage (P=0.003). The median overall time to progression was 5.8months (range, 0.9-46.1months). Follow-up treatments after radioembolization were carried out in 31 patients due to remnant HCC (n=18) or HCC progression (n=13). The median overall survival was 40.9months (95% confidence interval, 10.2-71.6months). Treatment was tolerable except for one lung toxicity and two hepatic toxicities.ConclusionYttrium-90 radioembolization appears to be well tolerated and effective in Asian patients with BCLC stage A-C HCC. Follow-up treatments after radioembolization can be safely provided.

The bone is a common site for metastasis in hepatocellular carcinoma (HCC). However, bone marrow metastasis from HCC is rarely reported, and its frequency is unclear. Here we report a rare case of bone marrow metastasis that presented as bicytopenia originating from HCC without bone metastasis. A 58-year-old man was admitted for investigation of a liver mass with extensive lymph node enlargement that was detected when examining his general weakness and weight loss. Laboratory findings revealed anemia, thrombocytopenia, mild elevated liver enzymes, normal prothrombin time percentage and high levels of tumor markers (α-fetoprotein and des-γ-carboxyprothrombin). Abdominal computed tomography showed multiple enhanced masses in the liver and multiple enlarged lymph nodes in the abdomen. A bone marrow biopsy revealed only a few normal hematopoietic cells and abundant tumor cells. Despite its rarity, bone marrow metastasis should always be suspected in HCC patients even if accompanied by cirrhosis.

Immunoglobulin G4 (IgG4)-related disease (IgG4RD) is a relatively recently recognized entity that is histopathologically characterized by an extensive infiltration of lymphocytes and IgG4-positive plasma cells with dense fibrosis. IgG4RD is now known to affect any organ system, and a few cases of gastrointestinal lesions have also been reported. However, solitary IgG4RD of the stomach is still very rare. Furthermore, as it can mimic malignant conditions, it is important to recognize this disease to avoid unnecessary surgery. Herein, we present a case of IgG4RD presenting as an isolated subepithelial mass in the stomach.

Aims: Hepatitis C virus (HCV) is the second most prevalent causeof chronic hepatitis and related morbidity in Korea. A novel combinationtherapy of daclatasvir (NS5A replication complex inhibitor) andasunaprevir (NS3 protease inhibitor) has shown promising results forgenotype 1b chronic hepatitis C. But the response rates have been Table 1. Prevalence of amino acids substitutions for the resistance to NS5Ainhibitor. presented so differently according to NS5A polymorphisms and prevalenceof drug-resistant variants before treatment is not well knownyet in the Koran population.Methods: To detect HCV variants resistant to NS5A inhibitor in patientswith genotype 1b chronic hepatitis C and investigate clinical featureswith or without drug-resistant variants, amplification and direct sequencingof the HCV NS5A region was carried out on the 427 genotype1b chronic hepatitis C patients from multi-center cohort, whohad not received direct-acting antivirals before.Results: Amino-acid substitutions for resistance (L31 and/or Y93) weredetected in 51 of the 427 (11.4 %) patients, and Y93 (8.7 %) predominatedover L31 (2.9 %). However, baseline clinical characteristics andresponse to previous interferon based treatment were not differentaccording to the existence of drug-resistant variants.Conclusions: Mutations associated with resistance to NS5A inhibitorwere not uncommon in our study population. But drug-resistant variantsdid not affect clinical features. So it would be important tomonitor the baseline variants before the combination therapy of daclatasvirand asunaprevir for genotype 1b chronic hepatitis C.

Subepithelial tumors (SETs) in the gastrointestinal tract are often incidentally found during endoscopic examinations. Although the utility and safety of endoscopic resection (ER) of SETs in the esophagus and stomach have been described, data about the ER of duodenal SETs remain scant. Therefore, we aimed to investigate the clinical outcomes associated with the ER of duodenal SETs and to assess possible predictive factors for incomplete resection.

Background/Aims: Determining the depth of tumor invasion and the presence of regional lymph node metastasis is important in deciding therapeutic strategies.We aimed to evaluate the diagnostic accuracy of EUS in detecting the depth of tumor invasion and regional lymph node metastasis.Materials and Methods: A total of 141 consecutive patients underwent preoperative evaluation using EUS, CT, and PET CT from November 2005 to June 2009 in Pusan National University Hospital.We reviewed the patients' medical records and compared EUS and pathologic findings.Results: A total of 59 patients were included in the final analysis.The overall accuracy of EUS in predicting the correct T stage was 79.7% (95% CI, 66.8∼88.6%).EUS accurately predicted T stage in 93.2% (95% CI, 82.7∼97.8%) of T1 tumors, 79.7% (95% CI, 66.8∼88.6%) of T2 tumors, and 86.4% (95% CI, 74.5∼93.6%) of T3 tumors.Overall, EUS accurately predicted N stage in 83.1% of cases.EUS correctly predicted N stage in 91.4% of N0 tumors and 70.8% of N1 tumors.Conclusions: Overall accuracy of EUS for the T and N staging of esophageal cancer was high.Thus, EUS is a useful diagnostic modality in determining the initial stage of esophageal cancer.(

With an increasing number of patients with hepatocellular carcinoma (HCC) undergoing liver transplantation (LT), tumor recurrence remains the main limiting factor for long-term survival. Although sorafenib is available for advanced HCC, there is still a lack of data on the use of sorafenib for treatment of recurrent HCC after LT. Here, we report on four cases of the use of sorafenib for treatment of recurrent HCC after LT. The median time of recurrence from LT was 4 months (range, 1-16 months). Two of the four evaluated patients showed stable disease, which was the best response and the duration of stabilization was 11 months and 5 months, respectively. One patient also experienced stable disease and remained in stable disease without sorafenib therapy for 29 months and the total duration of stabilization was 38 months. The remaining patient showed partial response but stopped treatment due to radiological tumor progression during treatment. Although all cases were high risk group for recurrence such as above Milan criteria, vascular invasion and tumor biology, clinical outcomes showed some good results. Therefore, sorafenib may be an acceptable treatment option for recurrent HCC after LT.

Background: Gastric epithelial dysplasia (GED) can be morphologically categorized into adenomatous and foveolar types. To date, there have been few studies on the clinical characteristics of GEDs according to the morphologic types. Therefore, we here aimed to elucidate the clinicopathologic characteristics of patients with GED and the long-term follow-up results after endoscopic resection according to the morphologic characteristics of GEDs.Methods: A total of 357 patients who underwent endoscopic resection for GEDs at Pusan National University Hospital between January 2008 and December 2009 were included in the study. GEDs were morphologically categorized into adenomatous, foveolar, and hybrid types on histologic examination. The clinicopathologic characteristics of patients with GEDs and outcomes of endoscopic resection were analyzed.Results: Patients with GED were divided into 3 groups: adenomatous (n = 167, 46.8%), foveolar (n = 103, 28.9%), and hybrid (n = 87, 24.3%) types. Compared to the adenomatous type, foveolar type lesions were more frequently located in the antrum/pylorus, flat/depressed lesions, and normal/reddish in color; and showed more frequent high-grade dysplasia. During the follow-up period (median, 37.3 months), the overall incidence of synchronous and metachronous lesions was 20.8% and 20.1%, respectively; of these, the incidence of synchronous and metachronous gastric cancer was 8.7% and 5.4%, respectively. There were no significant differences in the incidence of synchronous and metachronous lesions according to morphologic types.Conclusion: GEDs appear to have different clinicopathologic characteristics according to morphologic types. Irrespective of the morphology, synchronous and metachronous gastric cancers are commonly found after endoscopic resection of GEDs. Therefore, close follow-up surveillance after endoscopic resection of GEDs should be performed for all patients.

Multiple therapeutic modalities are available for hepatocellular carcinoma (HCC) treatment. We aimed to evaluate the trends for HCC treatment in Korea. Recent trends and patterns in treatment modalities were assessed in HCC patients who first registered for the Health Insurance Review Assessment Service between 2008 and 2012. From 2009 to 2012, 57,690 patients were diagnosed with HCC. Transcatheter arterial chemoembolization (TACE) was the most common treatment modality for initial treatment. Curative treatment modalities like hepatic resection, liver transplantation, and local ablation therapy increased gradually. The 3 most common treatment modalities (hepatic resection, local ablation therapy, TACE) used after initial treatment in 2009 were studied. Following initial hepatic resection, 44.5% of patients required re-treatment. TACE was the most common modality (in 48.3% of cases), while 15.0% of patients received local ablation therapy. After local ablation therapy, 55.4% of patients were re-treated, wherein 45.0% of patients received TACE and 31.5% received local ablation therapy. Following initial TACE, 73.9% patients were re-treated, most commonly with TACE (57.7%) followed by local ablation therapy (12.8%). While there were no significant differences between the initial and re-treatment modalities, various multiple treatments followed the initial treatment. The treatment modalities were interchangeable.