Intestinal Research

Volume 5(1); June 2007

Original Article

The Effectiveness of Audiovisual Aids Education in Preparing Patients for Colonoscopy: Byung Hoon Min, Dong Kyung Chang, Young Ho Kim, Poong-Lyul Rhee, Jae J. Kim, Jong Chul Rhee; Published online June 30, 2007

Abstract PDF: Background/Aims
The purpose of this study is to investigate how effectively audiovisual aids education can improve patients' bowel preparation and their satisfaction during colonoscopic examination. Methods: The control group consisted of 116 patients and the experimental group consisted of 109 patients. The control group was given the existing test guidebooks and the experimental group was offered audiovisual aids education immediately before the test. After the test, the patients assessed. Results: In regard to the organization and consistency of colonoscopic education, the experimental group showed a statistically significant score (p=0.000). In regard to satisfaction with the colonoscopy, the average score of the control group was 7.50⁑2.02, while that of the experimental group was 8.63⁑1.76 (p=0.000). In regard to bowel preparation, the experimental group showed a statistically meaningful score compared to that of the control group (p=0.002). In terms of examination time comparison, the experimental group returned a statistically meaningful score (p=0.005). In regard to the nurses' task satisfaction, according to the information offered, the experimental group showed a statistically significant score (8.47⁑1.32) compared to the control group (6.49⁑2.23)(p=0.000). Conclusions: The audiovisual aids education enhanced the patients' satisfaction. Therefore these aids are worth incorporating within nursing methods. (Intest Res 2007;5:52-59)

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Case Report

A Case of C1 Esterase Inhibitor Deficiency Presenting as Recurrent Abdominal Pain and Ascites: Byung Hoon Min, Dong Kyung Chang, Young Ho Kim, Poong-Lyul Rhee, Jae J. Kim, Jong Chul Rhee; Published online June 30, 2007

Abstract PDF: C1 esterase inhibitor deficiency is a disorder resulting from a qualitative or functional defect of the C1 esterase inhibitor. It is characterized by recurrent episodes of subcutaneous and submucosal swellings in any part of the skin and the respiratory and gastrointestinal tracts. Gastrointestinal symptoms such as abdominal pain are the dominant symptoms in about 25% of cases and sometimes make this condition misunderstood as surgical emergency, especially when ascites is accompanied. We experienced a case of C1 esterase inhibitor deficiency in a 35-year-old woman presenting with recurrent abdominal pain, ascites, and lower extremities edema. Her symptoms first occurred 8 years ago, and used to spontaneously resolve within 3 days. In laboratory finding, serum C4 and serum C1 esterase inhibitor showed reduced level of 3.2 mg/dL and 5 mg/dL, respectively. After treatment with danazol and tranexamic acid, no more recurrence of symptoms was observed during 2 months of follow-up period. (Intest Res 2007;5:73-76)

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Reviews

Capsule Endoscopy: In Seok Lee, Myung Gyu Choi; Intest Res 2007;5(1):01-05. Published online June 30, 2007

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Balloon Enteroscopy: Bong Min Ko, Moon Sung Lee; Intest Res 2007;5(1):06-12. Published online June 30, 2007

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Current State of Small Bowel Investigation: Practical Use of Double Balloon Enteroscopy: Hyun Joo Jang, Jin Lee; Intest Res 2007;5(1):13-18. Published online June 30, 2007

Abstract PDF: The small intestine has been regarded as the most difficult area of the gastrointestinal tract to investigate by endoscopic view. Capsule endoscopy provided a complete evaluation of the small bowel and has become one of the major approaches in diagnosis of suspected small bowel diseases. However, this technique has several limitations, including its inability to perform conventional endoscopic procedures, taking biopsy specimens, and therapeutic interventions. Another novel method, double balloon enteroscopy, introduced by Yamamoto et al. in 2001, makes it possible to overcome these limitations. Since then, several studies have reported diagnostic and therapeutic outcomes. In this brief review, the authors summarized the current clinical outcomes and practical use of double balloon enteroscopy in suspected small bowel disorders. (Intest Res 2007;5:13-18)

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Original Articles

Usefulness of C-reactive Protein Level before and during Antimycobacterial Therapy in the Differential Diagnosis between Crohn's Disease and Intestinal Tuberculosis: Sang Hyun Park, Suk-Kyun Yang, Seung-Jae Myung, Jeong-Sik Byeon, Byongduk Ye, Seunghyun Kwon, Benjamin Kim, Soon Man Yoon, Mi Young Do, Do Hoon Kim, Sai-Hui Kim, Jin Ho Kim; Intest Res 2007;5(1):19-25. Published online June 30, 2007

Abstract PDF: Background/Aims
Crohn's disease (CD) and intestinal tuberculosis (TB) are chronic inflammatory bowel disorders that are difficult to differentiate. Therefore, a therapeutic trial of antimycobacterial drugs is often used to differentiate CD from TB. This study aimed to evaluate the usefulness of C-reactive protein (CRP) level before or during antimycobacterial therapy to differentiate CD from TB. Methods: A total of 26 CD patients and 52 TB patients who received antimycobacterial therapy at the Asan Medical Center were included. CRP levels before or during antimycobacterial therapy were compared between CD and TB patients. A positive response to antimycobacterial therapy was defined as the decrease of CRP level below 50% of its baseline value. Results: The baseline CRP level was normal in only 1 of 26 CD patients (3.8%), while it was in 26 of 52 TB patients (50%). The rate of positive response to antimycobacterial therapy was significantly different between CD and TB patients whose baseline CRP level was abnormal: 28.0% (7/25) vs 88.5% (23/26) in 2 weeks, 34.8% (8/23) vs 84.6% (22/26) in 4 weeks, and 43.5% (10/23) vs 92.3% (24/26) in 8 weeks of antimycobacterial therapy. The rate of normalization in CRP level was also significantly different between the two groups: 0% (0/25) vs 73.1% (19/26) in 2 weeks, 13.0% (3/23) vs 69.2% (18/26) in 4 weeks, and 8.7% (2/23) vs 80.8% (21/26) in 8 weeks of antimycobacterial therapy. Conclusions: The CRP level before and during antimycobacterial therapy may be used as a supplementary tool in the differential diagnosis between CD and TB patients. (Intest Res 2007;5:19-25)

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Clinical Features of Intestinal Behcet's Disease according to Disease Subtypes: Ji Eun Kim, Dong Soo Han, Hyun Seok Cho, Tae Joon Byun, Tae Yeob Kim, Chang Soo Eun, Yong Cheol Jeon, Joo Hyun Sohn; Intest Res 2007;5(1):26-32. Published online June 30, 2007

Abstract PDF: Background/Aims
Intestinal Behcet's disease can be diagnosed when Behcet's disease patient has intestinal ulcers. The aim of this study was to recognize the clinical features and course of intestinal Behcet's disease according to disease subtypes. Methods: We performed a retrospective chart review of patients who had intestinal lesions associated with Behcet's disease on colonoscopy between March, 2001 and May, 2006. Results: Of the 38 patients (18 men/20 women) enrolled, the mean age at diagnosis was 40.9⁑13.6 years. By Japanese criteria, 18 patients were classified in incomplete type, 8 in suspected type, and 8 in possible type. Four patients had only intestinal lesion without Behcet's manifestation. By International Study Group of Behcet's Disease criteria, 10 were met Behcet's disease, and 15 was suspected as Behcet's disease. Characteristics of intestinal ulcers were aphthous shape and ileocecal location. Five patients were reclassified during clinical course. There was no difference at clinical outcome according to prescribed medications. Conclusions: Not a few of intestinal Behcet's disease patients were difficult to meet the Behcet's disease criteria. Because clinical manifestations of intestinal Behcet's disease patients may be changed, it would be needed to reclassify disease subtypes with long-term follow-up. (Intest Res 2007;5:26-32)

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Clinicopathologic Features and Endoscopic Treatment of Laterally Spreading Tumors of the Colorectum: Cheol Woong Choi, Sun Mi Lee, Tae Oh Kim, Gwang Ha Kim, Jung Heo, Dae Hwan Kang, Geun Am Song, Mong Cho; Intest Res 2007;5(1):33-37. Published online June 30, 2007

Abstract PDF: Background/Aims
Laterally spreading tumors (LSTs) of the colorectum are defined as lesions greater than 10 mm in diameter with a low vertical axis that extend laterally along the luminal wall. We analyzed the clinicopathologic characteristics and endoscopic treatment of LSTs on the colorectum. Methods: The 127 colorectal LSTs were collected from January 2005 through February 2007. Those lesions were analysed according to their endoscopic and pathologic findings. Results: 67 LSTs (52.8%) were more than 20 mm in size. Most common involved sites of LSTs were rectum (32.4%) and ascending colon (25.9%). Most common subtype of LSTs were granular-homogeneous type (G-H) (37%). Histologic types were 76 tubular adenomas (59.8%), 24 tubulovillous adenomas (18.8%), 6 villous adenomas (4.8%) and 21 adenocarcinoma (16.6%). Both nodular mixed type (G-NM) and pseudo-depressed type (NG-PD) contained a carcinomatous component with high frequency as compared with the G-H type. Carcinoma invaded into the submucosa were present in 3 lesions of G-NM type and 6 lesions of NG-PD type. Conclusions: LSTs showed different clinicopathologic characteristics depending on the morphologic classification. G-NM type or NG-PD type had more malignant potential than other types. Endoscopists should select an adequate therapeutic strategy for large LST with careful consideration. (Intest Res 2007;5:33-37)

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Endoscopic Differentiation of Small Bowel Strictures: Hwang Choi, Kyu Yong Choi, Bo In Lee, Min Kuk Kim, Hyun Jung Jung, Jeong Seon Ji, Tae Ho Kim, Jung Hwan Oh, Kang Moon Lee, Sang Woo Kim, Soo Heon Park, Hiun Suk Chae, Myung Gyu Choi, Sok Won Han, In Sik Chung; Intest Res 2007;5(1):38-44. Published online June 30, 2007

Abstract PDF: Background/Aims
The diagnosis of small bowel stricture was made by operation. Capsule endoscopy has been useful for diagnosis of small bowel diseases but has limited value in cases with stricture. Double balloon endoscopy is the useful method to visualize the entire small bowel. The aims of this study are to evaluate the feasibility of double balloon endoscopy and to differentiate the endoscopic findings in patients with small bowel stricture. Methods: Between March 2004 and February 2007, fifteen consecutive patients were referred for the evaluation of small bowel stricture. Small bowel strictures were suspected in small bowel series and CT in eleven patients. Capsule endoscopies were performed in six patients and entrapped in three patients. Double balloon endoscopy (EN-450P5/20, Fujinon, Japan) was performed with midazolam (median 5 mg, range 5-10 mg) and meperidine (median 50 mg, range 50-100 mg). All lesions except one were found within 60 minutes. One patient had been excluded because of false-positive finding of capsule endoscopy. Clinical and endoscopic findings were compared between strictures of Crohn's disease (group I, n=6) and those of other causes (group II, n=8). Results: Double balloon endoscpies were performed with good tolerance without side effect. Age, chief complaints, duration of symptom, and initial hemoglobin and serum albumin levels were not different between two groups. The proportion of male sex was higher in group I than group II (100%, 38%, respectively; p=0.031). The strictures below 0.5 cm in diameter were 83% in group I and 13% in group II (p=0.026). The arrangement of stricture in group I was more eccentric than that in group II (100%, 17%, respectively; p=0.015). The location of stricture, appearance of surrounding mucosa, associated ulcer, and ulcer margin were not different between two groups. Conclusions: Endoscopic differentiation using double balloon endoscopy can be made easily and safely in patients with small bowel stricture. The strictures of small bowel in patients with Crohn's disease were narrower and more eccentric than those in patients with other diseases. (Intest Res 2007;5:38-44)

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Usefulness of Sigmoidoscopy in Pseudomembranous Colitis: Focused on the Comparison with Immunological Assay for C. difficile Toxin and the Role as a Predictive Factor for Clinical Outcome: Jun-Won Chung, Jeong-Sik Byeon, Kwi-Sook Choi, Benjamin Kim, Seunghyun Kwon, Byong Duk Ye, Seung-Jae Myung, Suk-Kyun Yang, Jin-Ho Kim; Intest Res 2007;5(1):45-51. Published online June 30, 2007

Abstract PDF: Background/Aims
Pseudomembranous colitis (PMC) shows a diverse clinical course. The aim of this study is to evaluate the usefulness of sigmoidoscopy in PMC. Methods: Sigmoidoscopic findings and medical records were analyzed in 74 patients with PMC (male：female=38：36, 62⁑16 years). Sigmoidoscopic grades of PMC were classified into mild (n=45) when pseudomembrane covered ＜1/3 of lumen, moderate (n=18) when it covered 1/3-2/3 of lumen, and severe (n=11) when its extent was ＞2/3 of lumen. Results: In comparison to sigmoidoscopy, diagnostic sensitivity of enzyme immunoassay (EIA) for C. difficile toxin A was 29%. EIA sensitivity was 38% in mild, 28% in moderate, 0% in severe sigmoidoscopic grade (p=0.02). Risk factors for severe sigmoidoscopic grade were ileus, nasogastric tube insertion, and serum albumin below 2.3 g/dL. Initial treatment success rate was lower in severe grade (33%) than mild (96%) and moderate grade (83%) (p＜0.01). One year mortality rate was lower in severe grade (17%) than mild (85%) and moderate grade (84%) (p=0.01). Old age and severe sigmoidoscopic grade were risk factors for death. Conclusions: Sigmoidoscopic severity grading may be useful in the prediction of prognosis in PMC patients. Sigmoidoscopy may also be useful in the diagnosis of PMC, especially in patients with severe PMC. (Intest Res 2007;5:45-51)

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Promoter CpG Hypermethylation and Downregulation of Caveolin Expression in Human Colon Cancers: Nam Hoon Kim, Hyo Jong Kim, Sung Gil Chi, Young Soo Moon; Intest Res 2007;5(1):60-72. Published online June 30, 2007

Abstract PDF: Background/Aims
Abnormal reduction of caveolins has been found in many human cancers while its overexpression also correlates with increased metastatic progression of some tumors. To elucidate the possible implication of caveolin abnormality in human colon tumorigenesis, the expression and mutational status of caveolins was explored. Methods: We investigated 11 human colon cancer cell lines, 49 primary carcinoma tissues, and its matched normal colonic tissues. Both mRNA and protein levels of caveolins (cav-1, cav-2) were evaluated by quantitative RT-PCR and immunoblotting. Effect of cav-1 expression on tumor growth was tested using cell counting and colony formation assay. Cav-1 expression was restored in nonexpressing cells, whereas cav-1 expression was inhibited by siRNA-mediated knockdown in expressing cells. Methylation status of 38 CpG sites was evaluated by bisulfite DNA sequencing. Results: Low expression of cav-1 transcript was found in 54.5% of cancer cell lines, whereas 45.5% of those showed strong expression. Expression level of cav-1 protein was very low in majority of cancer cell lines except two cell lines. Approximately 47% and 10% of primary carcinomas exhibited significant reduction and elevation in cav-1 expression, respectively. Cav-2 expression also showed down- and up-regulation in 28% and 3% of primary tumors, respectively. Cav-1 transcript was re-expressed in nonexpressing cells by 5-aza-dC treatment. Restoration of cav-1 inhibited growth of cav-1-negative cells and reduced phospho-Erk level, whereas ectopic overexpression of cav-1 further stimulated cav-1-expressing cells and activated p53 and p21. Conclusions: Caveolin undergoes epigenetic silencing in a considerable proportion of human colon cancers by aberrant promoter CpG hypermethylation. Also, cav-1 acts two opposite functions as a growth suppressor or growth stimulator in colon cancers. (Intest Res 2007;5:60-72)

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Case Reports

A Case of Colonic Perforation following Colonoscopy in Collagenous Colitis: Youn Sun Park, Byung Ik Jang, Tae Nyeun Kim, Jong Ryul Eun, Jae Won Choi, Kyu Hyung Lee, Kyeong Ok Kim, Si Hyung Lee, Mi Jin Kim; Intest Res 2007;5(1):77-80. Published online June 30, 2007

Abstract PDF: Collagenous colitis is a clinicopathological syndrome characterized by: (1) chronic watery diarrhea and crampy abdominal pain and (2) thickened subepithelial collagen band and increased intraepithelial lymphocytes on histology. The mucosa generally appears endoscopically normal, although some nonspecific abnormalities such as patchy erythema, an abnormal vascular pattern or erythema may be found in upto one third of cases. Collagenous colitis is generally regarded as a benign disease and serious complication are uncommon. The frequency of colonic perforation in collagenous coliltis is unknown, but is probably very rare. Only 16 patients, excluding our cases, have so far been reported. We report a case of a 80-year-old woman with collagenous colitis who presented with colonic perforation two days after the colonoscopy. (Intest Res 2007;5:77-80)

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A Case of Cytomegalovirus Colitis Complicated by Perforation after Short-term Steroid Therapy in a Patient with Eosinophilia: Jong Pil Im, Yoon Kyung Jeon, Sang Gyun Kim, Joo Sung Kim, Hyun Chae Jung, In Sung Song; Intest Res 2007;5(1):81-86. Published online June 30, 2007

Abstract PDF: Cytomegalovirus (CMV) infection is a rare event that has been reported mainly in immunocompromised patients who have HIV infection or receive immunosuppressive medication. Although CMV infection is generally asymptomatic in healthy individuals, CMV colitis in immunocompetent host can be potentially severe disease with significant morbidity, especially in older patients. We report a case of CMV colitis complicated by colonic perforation after short term steroid therapy in a patient with eosinophilia who has no evidence of immunosuppression. A high index of suspicion is crucial for early diagnosis of CMV colitis especially in older patients, even though obvious evidence of immunodeficiency is lacking. Colonoscopic examination including multiple biopsies is mandatory for diagnosis of CMV colitis, and antiviral agents should be started once the diagnosis is confirmed. (Intest Res 2007;5:81-86)

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A Case of Multiple Deep Infiltrating Intestinal Endometriosis Presenting as Abdominal Mass: Hyun Seok Cho, Dong Soo Han, Se Woo Park, Tae Jun Byun, Tae Yeob Kim, Chang Soo Eun, Yong Cheol Jeon, Joo Hyun Sohn; Intest Res 2007;5(1):87-91. Published online June 30, 2007

Abstract PDF: Endometriosis is one of the most common benign gynecologic conditions in women of childbearing age. Endometriosis involving the gastrointestinal tract occurs in 5.3-12% of women and the most commonly affected site is the rectum and the sigmoid colon. The reports of intestinal endometriosis in Korea are too few to obtain a rate of occurence, and in these cases, the depth of invasion was limited to the serosa, resulting in no significant symptoms or signs. Intestinal endometriosis can show up as a mass suggestive of malignant neoplasm on imaging studies, which can result in serious errors in diagnosis and treatment. In Korean studies, the masses were solitary, and there was no reported case of multiple endometriosis in the sigmoid colon, ascending and descending colon. We report a case of multiple deep infiltrating intestinal endometriosis presenting as an abdominal mass. (Intest Res 2007;5:87-91)

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Editorials

Is There a Shortcut in Differentiating Crohn's Disease from Intestinal Tuberculosis?: Yong Woo Chung, Dong Soo Han; Intest Res 2007;5(1):92-94. Published online June 30, 2007

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Role of Sigmoidoscopy for Pseudomembranous Colitis: Byung Ik Jang; Intest Res 2007;5(1):95-98. Published online June 30, 2007

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Selected Summary

Brief Summary of Outcomes in Multicenter Studies by KASID: Sang Kil Lee; Intest Res 2007;5(1):99-101. Published online June 30, 2007

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Letterses to the Editor

Is the Prognosis of Ulcerative Colitis Better in Korean Patients?: Intest Res 2007;5(1):102-104. Published online June 30, 2007

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Risk Factor of Ischemic Colitis and Usefulness of High-resolution Ultrasonography: Intest Res 2007;5(1):105-106. Published online June 30, 2007

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Conference Review

Digestive Disease Week 2007: Sun-Young Lee; Intest Res 2007;5(1):107-110. Published online June 30, 2007

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