Intestinal Research

Prevention of Post-operative Recurrence in Crohn's Disease: Hyo Jong Kim; Intest Res 2008;6(1):1-7. Published online June 30, 2008

Abstract PDF: At one year after a first resection in patients with Crohn's disease, up to 80% of patients show endoscopically-determined recurrence of disease, 10-20% have a clinical relapse and 5% have to undergo surgery again. However, there are currently no guidelines for the postoperative maintenance therapy for patients with Crohn's disease, and considerable uncertainty remains as to the efficacy of the various postoperative treatments. New lesions can be visualized endoscopically within weeks to months after performing ileal resection and creating an ileocolonic anastomosis in the neoterminal ileum. The evolution of these lesions mimics the natural history of ileal Crohn's disease at the onset. If we are able to prevent the recurrence of early lesions, then we will probably interrupt the natural course of this disease. Since there is a lag time of months to years between the development of recurrent lesions in the bowel and the recurrence of symptoms, we recommend performing endoscopy of the bowel 6 months after the initial operation to assess the severity of recurrence, and the strategy for further treatment should be based on this assessment. The development of explicit criteria for the appropriateness of various postoperative treatment regimens is needed to aid physicians when they making the clinical decisions in this context. (Intest Res 2008;6:1-7)

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Animal Models of Inflammatory Bowel Disease: Byung Ik Jang; Intest Res 2008;6(1):8-18. Published online June 30, 2008

Abstract PDF: Inflammatory bowel disease (IBD) is a chronic inflammatory disease of unknown etiology that includes two main disease entities-ulcerative colitis and Crohn's disease. Although the pathogenesis of IBD remains unclear, it is widely accepted that genetic, environmental and immunological factors are involved. Animal models of IBD are indispensable for the understanding of the pathogenesis and novel therapeutic applications for IBD. IBD animal models can be divided into several different categories, including models of spontaneous colitis (cotton-top tamarin colitis); inducible forms of colitis (using acetic acid, dextran sulfate sodium and indomethacin); an adoptive transfer model (CD45RB^high transfer model); genetically engineered models (with IL-10 knockout or TCR-Ձ chain knockout mice). However, there is no 'perfect' model for human disease. Investigators must make judicious choices when selecting a model for a particular study. In this review, an overview of the different IBD animal models is provided and the contribution of the models to the current understanding of disease mechanisms is discussed, with the ultimate goal to develop future therapeutic trials. (Intest Res 2008;6:8-18)

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Sonic Hedgehog Expression in Colorectal Neoplasms: Hye Seung Han, Sun-Young Lee, Moo Kyung Seong, Jeong Hwan Kim, In-Kyung Sung, Hyung Seok Park, Choon Jo Jin, Tae Sook Hwang; Intest Res 2008;6(1):19-24. Published online June 30, 2008

Abstract PDF: Background/Aims
Dysregulation of the hedgehog pathway has been implicated in regeneration and carcinogenesis, leading to the expression of the sonic hedgehog (Shh) protein in gastrointestinal neoplasms. The expression of Shh in colon neoplasms and paired normal colonic mucosa was therefore investigated. Methods: Forty-four colon cancers and 73 colon adenomas that were removed by surgical colectomy or colon polypectomy between August 2005 and August 2006 were included. Colorectal neoplasms and the adjacent normal colon tissue were examined by immunohistochemistry using rabbit polyclonal Shh antibody. Results: Expression of Shh was up-regulated in adenomas and adenocarcinomas of the colon compared to normal colon tissues (p＜0.001). The degree of Shh expression was not associated with the size, shape, or, location of the tumor, or as the age and gender of the patient. In normal colonic epithelium, Shh was expressed at the apex of the crypts and in a few basally-located cells. Conclusions: Higher levels of Shh expression in colonic adenoma and adenocarcinoma suggest that Shh is required during epithelial proliferation in the colon. Hedgehog signaling is likely to be associated with early tumorigenesis in colonic neoplasms. (Intest Res 2008;6:19-24)

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Clinical Significance of Screening Colonoscopy in Elderly: A KASID Multi-center Study: Sung Geun Park, Dong Il Park, Young-Ho Kim, Hyun Soo Kim, Won Ho Kim, Tae Il Kim, Hyo Jong Kim, Suk-Kyun Yang, Jeong-Sik Byeon, Moon Sung Lee, Il Kwon Jung, Moon Kwan Chung, Sung-Ae Jung, Yoon Tae Jeen, Jai Hyun Choi, Hwang Choi, Dong Soo Han, Jae Suk Song; Intest Res 2008;6(1):25-30. Published online June 30, 2008

Abstract PDF: Background/Aims
Currently, screening colonscopy is widely performed in the medical field. The initial time of screening is recommended at an age of 50 years, but the age to cease screening is unknown. Accordingly, we have investigated the diagnostic yield of colonoscopy according to indications in the elderly, and we evaluated if screening colonoscopy is useful in the elderly. Methods: We recruited asymptomatic individuals undergoing screening colonoscopy according to age (2830 subjects aged 50-74 years and 111 subjects ≥75 years-old), The colonoscopy findings of the study subjects were compared. In addition, colonoscopy findings of asymptomatic subjects more than 75 years-old were compared with the findings of symptomatic subjects with the same age. Results: The yield for overall neoplasia and advanced adenoma was higher in the group of subjects ≥75 years-old than in the 50-74 years age group (overall adenoma: 49.54% versus 24.98%, p＜0.001; advanced adenoma: 16.2% versus 8.23%, p=0.003). The overall frequency of neoplasms was higher in asymptomatic subjects ≥75 years-old than in symptomatic subjects ≥75 years-old (49.54% versus 28.19%, p＜0.001). Conclusions: The prevalence of advanced adenoma increased with age. Screening colonoscopy was still significantly effective in elderly subjects ≥75 years-old. The lack of a decline in the frequency of adenoma, including advanced adenoma, justifies continuing screening colonoscopy in the elderly. (Intest Res 2008;6:25-30)

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The Usefulness of Double Balloon Enteroscopy for Diagnosis and Treatment of Small Bowel Diseases: Min Ho Choi, Kyung Hae Lee, Je Hyun Ryu, Seung Yong Han, Hyeon Woo Byun, Dong Hee Koh, Hyun Joo Jang, Chang Soo Eun, Sea Hyub Kae, Jin Lee; Intest Res 2008;6(1):31-36. Published online June 30, 2008

Abstract PDF: Background/Aims
Double balloon eneterscopy is a promising endoscopic method to examine the entire small bowel and to conduct therapeutic procedures. This study was performed to evaluate the clinical outcome and usefulness of double balloon enteroscopy. Methods: We enrolled patients with suspected small bowel disease. Double balloon enteroscopy was performed in 61 patients and 89 procedures were undetaken between August 2004 and October 2007 at Hangang Sacred Heart Hospital. Results: Indications for double balloon enteroscopy were obscure gastrointestinal bleeding, chronic abdominal pain or diarrhea and the presence of a suspicious small bowel tumor. Double balloon enteroscopy contributed to the diagnosis of small bowel diseases in 82.0% of patients. In 46 patients (75.4%), specific treatments were influenced by the results of double balloon enteroscopy. There were no significant complications. Conclusions: Double balloon enteroscopy is one of the most useful methods for the diagnosis and treatment of small bowel disease. (Intest Res 2008;6:31-36)

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Diverticulitis: Focused on Clinical Course and Relapse: Kwi-Sook Choi, Jeong-Sik Byeon, Soon Man Yoon, Kyung-Jo Kim, Byong Duk Ye, Seung-Jae Myung, Suk-Kyun Yang, Jin-Ho Kim; Intest Res 2008;6(1):37-44. Published online June 30, 2008

Abstract PDF: Background/Aims
There are a limited number of studies concerning the outcomes of diverticulitis in the Oriental population. We sought to evaluate the clinical features and the long-term outcomes of diverticulitis in Korean patients. Methods: We retrospectively reviewed the clinical courses of 104 patients (59 men, 45 women; median age 48.5 years [range: 24-83 years]) hospitalized for their first episode of diverticulitis between 1989 and 2005. Results: Right-sided diverticulitis was more common (71/104, 68%). However, the proportion of left-sided diverticulitis increased as age increased. Thirty-two patients underwent operations: 30 because of complications and 2 because of presumed appendicitis. Left-sided diverticulitis was an independent risk factor for complications (OR=7.6, p＜ 0.001), and it required surgical treatment more often than right-sided diverticulitis did (61% vs. 17%, p＜0.001). Eighty-five patients were followed for a median of 36 months. Four of the 62 medically treated patients developed recurrence of diverticulitis, with a 3-year cumulative recurrence rate of 4.8%. None of the 4 recurrences showed complications, and all were successfully managed using conservative treatment. No predictive factors for the recurrence of diverticulitis could be determined. Conclusions: The recurrence rate and risk of complications associated with recurrence are low in patients treated conservatively for the first episode of diverticulitis. Therefore, elective surgery to prevent recurrence and complications should be utilized sparingly in patients with diverticulitis. (Intest Res 2008;6:37-44)

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The Effect of 5-Aminosalicylic Acid on Renal Function in Patients with Inflammatory Bowel Disease: Kyeong Ok Kim, Byung Ik Jang, Tae Nyeun Kim, Si Hyung Lee; Intest Res 2008;6(1):45-49. Published online June 30, 2008

Abstract PDF: Background/Aims
An increasing number of case reports indicate the potential nephrotoxicity of 5-aminosalicylic acid (ASA). The aim of this study was to investigate the effect of long-term use of 5-ASA on renal function in patients with inflammatory bowel disease (IBD). Methods: The medical records of 318 patients with IBD that were treated with 5-ASA from 2001 to 2007 at Yeungnam University Hospital were reviewed. Changes in creatinine clearance (CCr), as measured by modification of diet with the renal disease study (MDRD) method, and risk factors were analyzed. Results: One-hundred patients were available for analysis. The male to female ratio was 55：45 and the mean age was 35.89±14.1 years. Fifty-eight patients were diagnosed with Crohn's disease and the other patients were diagnosed with ulcerative colitis. The mean treatment duration with 5-ASA was 2.6±2.5 years and 85 patients were treated with mesalazine and eight patients were treated with sulfasalazine. The mean baseline glomerular filtration rate (GFR) was 112.9±25.3 mL/min. The mean CCr declined to 106.3±28.3 ml/min/m² with an annual decline of 1.44 ml/min/year/m², but there was no statistically significant change in the mean CCr. Changes in the CCr were correlated with the pretreatment CCr. Conclusions: There was no statistically significant change in serum CCr. Although 5-ASA therapy in IBD patients resulted in no meaningful effect on renal function, the annual decline was within the normal range (0.4-1 mL/min/m²). Serial follow-up of GFR has significance. A large prospective study with a longer time is needed to confirm these findings. (Intest Res 2008;6:45-49)

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Diabetes Mellitus and the Risk of Colorectal Adenoma: Sang-Jung Kim, Chang Hwan Choi, Hong Ju Moon, Jang Sik Mun, Hyun Woong Lee, Hyung Joon Kim, Jae Hyuk Do, Sae Kyung Chang; Intest Res 2008;6(1):50-55. Published online June 30, 2008

Abstract PDF: Background/Aims
Diabetes mellitus (DM) is associated with an increased incidence of colon cancer. However, the relationship between DM and colorectal adenoma is not definite. In this study, we sought to determine the association between DM and the prevalence of colorectal adenoma. Methods: We enrolled 606 patients with DM and 606 asymptomatic adults who underwent colonoscopy for routine health evaluations from June 2003 to June 2007. The frequency and characteristics of the colorectal adenomas were analyzed and compared between the two groups. Results: The sex ratio and mean age were 1.67：1 (M：F) and 58.1±10.6 years, respectively, in patients with DM, and 1.68:1 and 57.6±8.9 years, respectively, in patients without DM, and these values were similar. The frequency of colorectal adenoma was 33.2% for the patients with DM and 32.3% for the patients without DM. The frequency, location, number, size and histopathologic findings of the colorectal adenomas were not different between the two groups. Among the patients with DM, the frequency of colorectal adenoma was 35.7% in the patients treated with oral hypoglycemic agents and 31.4% in the patients treated with insulin. Also, the other characteristics of the colorectal adenomas were not different according to the treatment method. Conclusions: The frequency and characteristics of colorectal adenomas were not different between the patients with and without DM. (Intest Res 2008;6:50-55)

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Response to Biofeedback Therapy for Patients with Rectal Hyposensitivity: Kee Wook Jung, Seung-Jae Myung, Jeong-Sik Byeon, In Ja Yoon, Jung Eun Ko, So Young Seo, Soon Man Yoon, Mi Young Do, Do Hoon Kim, Benjamin Kim, Seunghyun Kwon, Byong Duk Ye, Hwoon-Yong Jung, Suk-Kyun Yang, Jin-Ho Kim; Intest Res 2008;6(1):56-69. Published online June 30, 2008

Abstract PDF: Background/Aims
Rectal hyposensitivity (RH) has been treated with conventional biofeedback therapy (BFT), whereas the effectiveness and long term results of this therapy are not known. We aimed to investigate the effectiveness of BFT for patients with RH by conducting a retrospective review of prospectively collected data. Methods: From June 2004 to March 2007, we enrolled those RH patients who underwent BFT. BFT was performed two or three times every week. Six months after BFT, the clinical response was evaluated by subjective and objective parameters. Results: A total of 82 RH patients underwent BFT. Fifty three patients finished BFT and the other 29 patients dropped out during BFT. Thirty six patients (67.9%) showed responsiveness (R) to BFT and 17 (31.5%) showed non-responsiveness (NR). The characteristics between the two groups showed no difference, except for the "desire to defecate" volume (116.1±25.2 in the R group vs. 140.0±43.9 in the NR group, p value ＜0.05) and the rectoanal inhibitory reflex (RAIR) (15.6±0.5 in the R group R vs. 27.6±18.2 in the NR group, p value ＜0.05). The R group showed a shorter colon transit time compared to NR group. At six months after BFT, a total of 20 patients were interviewed; 15 patients answered that they still had responsiveness (75%). Conclusions: The patients with RH showed a similar BFT response to that of the constipated patients. However, the patients with a more hyposensitive rectum and a longer colonic transit showed NR to BFT, suggesting RH is an important factor in BFT responsiveness. (Intest Res 2008;6:56-69)

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A Case of Sigmoidorectal Intussusception after Self-Expandable Colonic Stent Placement: Chang Kyun Lee, Hyo Jong Kim, Jae Young Jang, Seok Ho Dong, Byung-Ho Kim, Young Woon Chang, Rin Chang, Hyoung Jung Kim, Kil Yeon Lee; Intest Res 2008;6(1):70-75. Published online June 30, 2008

Abstract PDF: Self-expandable metallic stents are widely used to relieve acute colorectal obstruction that's secondary to malignancy. They are utilized for both palliation and preoperative decompression prior to colorectal surgery. Although stents have been documented as a relatively safe therapeutic modality, procedure-related complications such as perforation, bleeding, stent reobstruction and migration can occur during or after colonic stent placement. Therefore, clinicians must be aware of the various complications associated with colonic stent placement. We present here a very rare case of sigmoidorectal intussusception that developed after fluoroscopic placement of a self-expandable metallic stent for preoperative decompression of sigmoid colon cancer. We misdiagnosed the intussusception as a distal stent migration on the plain radiography. On the sigmoidoscopic examination to evaluate the unrelieved colonic obstruction, we diagnosed a sigmoidorectal intussusception of the stent-implanted malignant tumor. The patient was successfully treated by laparoscopic partial reduction, followed by a curative anterior resection. This case demonstrates that careful examination must be done in cases of unrelieved colonic obstruction with suspicious stent migration, and intussusception must be considered as a rare complication of self-expandable metallic stent placement in the colon. (Intest Res 2008;6:70-75)

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A Case of Cystic Lymphangioma of Small Bowel Mesentery Presented with Small Bowel Volvulus: Chang Yoon Ha, Ki-Nam Shim, Min Jung Kang, Ji Min Jung, Youn Ju Na, Sung-Ae Jung, Kwon Yoo, Seog Ki Min; Intest Res 2008;6(1):76-79. Published online June 30, 2008

Abstract PDF: A cystic lymphangioma is a rare benign tumor that arises in an organ with a large number of lymphatics. It arises in patients of all ages and has variable presentations. An abdominal cystic lymphangioma most commonly occurs in the intestinal mesentery, with the retroperitoneum being the second location of choice, and it causes abdominal pain, hematochezia, intussusceptions and protein-losing enteropathy. If the cystic lymphangioma presents with symptoms, surgical excision is required for treatment and diagnosis. We report here a case of cystic lymphangioma of the small bowel mesentery that presented with a small bowel volvulus, along with a brief review of the literature. (Intest Res 2008;6:76-79)

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A Case of Pyoderma Gangrenosum Associated with Ulcerative Colitis: Young Wook Yoo, Sung Hee Jung, Yun Jung Lee, Sung Hoon Lee, Sae Hee Kim, Hyang Ie Lee, Hyeon Woong Yang, Anna Kim, Sang Woo Cha, Dong Wook Kang; Intest Res 2008;6(1):80-84. Published online June 30, 2008

Abstract PDF: Ulcerative colitis is associated with various extraintestinal manifestations. Skin lesions can occur in 9-19% of patients with ulcerative colitis. Pyoderma gangrenosum is the most severe dermatologic complication that is associated with ulcerative colitis. It is a painful, chronic ulcerating skin disease of unknown cause. The lesions usually appear on the pretibial area, but may also be found elsewhere. Diagnosis is clinical as there are no accepted histological diagnostic criteria. Systemic steroid therapy remains the treatment of choice in most patients, but various other agents have been used with occasional success including topical antibiotics, cyclosporine and infliximab. We experienced a case of pyoderma gangrenosum that developed on both pretibial areas in a 41-year-old female patient with active ulcerative colitis. The patient was treated with a corticosteroid and sulfasalazine. We report this case with a review of the literature. (Intest Res 2008;6:80-84)

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A Case of Ulcerative Colitis with Prolonged Remission Following Azathioprine-Induced Pancytopenia: Jun Seok Lee, Young Sook Park, Nam In Kim, Yoon Ju Jo, Seung Hwan Kim, Han Hyo Lee, Moon Hee Song, Dae Won Jun; Intest Res 2008;6(1):85-89. Published online June 30, 2008

Abstract PDF: Azathioprine (AZA) is widely used for the treatment of inflammatory bowel disease. Bone marrow suppression is a common side effect with AZA treatment. However, data from AZA trials has indicated that a leukocyte count less than 5,000/mm³ was a good predictor of induction and maintenance of remission. Moreover, there is evidence that eradication of sensitized leukocytes by leukapheresis or bone marrow transplantation improves inflammatory bowel disease. We report a case of a patient who had a chronic relapse of ulcerative colitis requiring the frequent use of systemic steroids, but presented prolonged remission following AZA-induced severe pancytopenia. Also colonoscopy showed accelerated healing of diffuse active ulcers following just recovery from pancytopenia. (Intest Res 2008;6:85-89)

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Brief Summary of Recent Multicenter Studies by KASID: Dong Il Park; Intest Res 2008;6(1):90-92. Published online June 30, 2008

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Five-year Colon Surveillance after Screening Colonoscopy (Gastroenterology 2007;133:1077-1085): Ji Won Kim; Intest Res 2008;6(1):93-94. Published online June 30, 2008

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