APDW 2018 E‐poster Exhibitions – Lower GI

Background and Aim: Inflammatory bowel disease (IBD) is an idiopathic disease caused by a dysregulated immune response to intestinal microbes in an individual with a genetic predisposition. Therefore, alleviation of inflammation is very important to treat IBD. Mesenchymal stem cells (MSCs) have been highlighted as new candidates for treating autoimmune disease based on their immunomodulatory properties. In this study, we investigated the anti-inflammatory mechanism and therapeutic effects of adipose tissue-derived MSCs (ASCs) using THP-1 macrophages and dextran sodium sulfate (DSS)-induced mice with chronic colitis. Methods: Human adipose tissue (AT) from three healthy donors (age, 24–38 years) was obtained from Wonju Severance Christian Hospital (Wonju, Korea). Chronic colitis model was induced by DSS. Macrophage differentiation of THP-1 was induced with 100 nM of phorbol ester 12-O-tetradecanoylphorbol13-acetate (TPA, Sigma) for 2 days and was co-cultured with or without ASCs in transwell plates (Corning, Lowell, MA, USA) while treating with 1 mg/mL lipopolysaccharide (LPS, Sigma). Results: LPS-treated THP-1 cells expressed mRNA of CD11b, an M1 macrophage marker, at day 2. However, THP-1 co-cultured with ASCs expressed mRNA of CD206, CD68, CCL18, legumain, and IL-10, markers of M2 macrophages. In THP-1 cells co-cultured with ASCs, precursor (pro)-IL-1b, Cox-2, and NLRP3 increased dramatically compared to LPS-treated THP-1 cells. Secretion of IL-1b and IL-18 was significantly inhibited by ASCs, but PGE2 production was highly increased in co-culture conditions of THP-1 and ASCs. IL-18 secretion was inhibited by PGE2 treatment, and PGE2 inhibited inflammasome complex (ASC/Cas-1/NLRP3) formation in THP-1 cells. In the DSS-induced chronic colitis model, ASCs ameliorated colitis by decreasing the total number of macrophages and the M1 macrophage population. Conclusion: Our results suggest that ASCs can suppress the inflammatory response by controlling the macrophage population, and ASCs may be therapeutically useful for the treatment of IBD.

Background and Aim: Oregonin, a major diarylheptanoid derivative isolated from Alnus japonica, exerts anti-inflammatory effects. However, little is known about the effect of oregonin in intestinal inflammation. Methods: The current study investigated the potential of oregonin for clinical applications in the treatment of inflammatory bowel disease (IBD) and elucidated its underlying molecular mechanisms. We investigated the anti-inflammatory effect of oregonin in tumor necrosis factor-α (TNF-α)stimulated human intestinal epithelium HT-29 cells. In addition, we also determined the protective effect of oregonin against disruption of the intestinal barrier in tert-butyl hydroperoxide (t-BH)-stimulated human intestinal epithelium Caco-2 cells. Results: Oregonin suppressed the expression of cyclooxygenase-2 (COX-2) and intercellular adhesion molecule-1 (ICAM-1) and inhibited nuclear factor kB activation in TNF-α-stimulated HT-29 cells. Oregonin increased heme oxygenase-1 (HO-1) expression through the ERK1/2 and JNK-dependent signaling pathway, which contributed to the oregonin-mediated suppression of COX-2 expression in TNF-α-stimulated HT-29 cells. Moreover, oregonin induced AMP-activated protein kinase (AMPK) activation. Knockdown of AMPK abolished the induction of HO-1 protein by oregonin and suppression of oregoninmediated ICAM-1 and COX-2 expressions in TNF-α-stimulated HT-29 cells. Oregonin prevented the t-BH-induced increase in monolayer permeability by inhibiting the reduction in zonula occludens-1 and occludin expressions in Caco-2 cells. Targeting HO-1 by siRNA transfection attenuated the oregonin-mediated prevention of loss of tight junction proteins and increase in permeability. Conclusion: Our findings suggest that oregonin can be a potential candidate to treat IBD by preventing mucosal inflammation and barrier disruption, although further in vivo studies using experimental colitis models should be undertaken. Keywords: oregonin, inflammation, barrier disruption, intestinal epithelial cells Background and Aim: Metastasis is a critical modulator for the high mortality and poor prognosis of colorectal cancer (CRC). MicroRNAs (miRNAs) are significant regulators of metastasis that act by modulating their target genes. In this study, we aimed to investigate the expression and the potential mechanisms of miR-124 and miR-154 in CRC. Methods: Quantitative real-time polymerase chain reaction (qRT-PCR) was used to miR-124, miR-154, and TRAF6 expressions in both CRC cancer cell lines and human CRC tissues. The mechanistic functions of miR-124 and miR-154 were tested by proliferation, transwell migration and invasion, and flow cytometry assay in vitro. Predicted miR-124 and miR-154 target gene, TRAF6, was tested by dual-luciferase activity assay, qRT-PCR, and western blot analysis. Results: We found that TRAF6 significantly was upregulated in CRC tissues and cell lines. The expression of TRAF6 was positively correlated with clinical advanced stage and lymph node metastasis. Moreover, a luciferase assay revealed that miR-124 and miR-154 directly targeted 3 0 -UTR TRAF6. Overexpression of miR-124 or miR-154 inhibited CRC cell proliferation, migration, and invasion abilities. Whereas overexpression of anti-miR-124 or anti-miR-154 inversely regulated its suppressive effects compared with control group. Furthermore, miR-124 or miR-154 suppressed not only expression of TRAF6 mRNA and protein but also p-AKT, cyclin D1, and p-p65 expressions in CRC cells. In clinical specimens, miR-124 or miR-154 was significantly downregulated in CRC tissues and negatively correlated with TRAF6 mRNA expression, respectively. Conclusion: These results suggest that miR-124 and miR-154 function as a tumor-suppressor in CRC and that their suppressive effects mediate proliferation, migration, and invasion. Our results suggest that miR-124 and 154 might be an important target for the treatment of CRC proliferation, migration, and metastasis. Background and Aim: SOX2 has a key role in the maintenance of pluripotent and stem cells, and high SOX2 expression is associated with a poor prognosis of colorectal cancer (CRC). We investigated the role of SOX2 on cancer stem cell (CSC) of CRC, using CRC cell lines SW480 and SW620. In addition, we examined microRNA29a (miR29a) that reduces histone deacetylase 4 (HDAC4) and SOX2 expression level and regulates cancer stem cells. Methods: mRNA expression and CSC markers were compared between SW480 and SW620, using mRNA microarray and real-time PCR, respectively. In these cell lines, overexpression and knockdown of SOX2 were done using transfection of GFP-SOX2, pcDNA-SOX2 and shSOX2, and SOX2 RNAi, and we used miR29a mimic and inhibitor. After overexpression or knockdown, beta-catenin and mTOR pathway were examined by western blot, and CSC markers were evaluated with real-time PCR and flow cytometry analysis. Results: SOX2 expression of SW620 was significantly higher than SW480. These cell lines showed different expressions of CSC markers, including Lgr5, CD133, CD44, CD166, SOX2, BMI1, EphB2, CD24, and DCLK1. Overexpression and knockdown of SOX2 induced the change of beta-catenin and mTOR signal in different ways between SW480 and SW620 cells. In addition, overexpression of SOX2 increased dormant CSC markers, and SOX2 knockdown leaded to increased active CSC markers. miR29a inhibited HDAC4 and confirmed that SOX2 was degraded by acetylation of SOX2. Conclusion: SOX2 through miR29a, HDAC4 pathway have important role in regulation of CSC of CRC, especially between dormant and active CSC. Keywords: cancer stem cell, colorectal cancer, cancer stem cell, SOX2, HDAC4 Background and Aim: The purpose of this study was to determine possible effects and mechanisms of electroacupuncture (EA) via chronically implanted electrodes at ST36 on TNBS-induced colonic inflammation. Methods: Colitis in rats was induced by intrarectal administration of 2,4,6-trinitrobenzenesulfonic acid (TNBS). The rats were treated with sham-EA, EA1 (EA using parameters of 25 Hz, 2 s on, 3 s off, 0.5 ms, 4.0 mA) or EA2 (EA using parameters of 5 Hz, 10 s on, 90 s off, 0.5 ms, 4.0 mA) for 3 weeks. A control group (received rectal injection of saline) was also followed for 3 weeks. Disease activity index (DAI), macroscopic and microscopic lesions, plasma levels of inflammatory cytokines , and myeloperoxidase (MPO) activity of colonic tissues were assessed. The autonomic function was assessed by the spectral analysis of the heart rate variability (HRV) derived from the electrocardiogram. Results: (i) The vagal activity was significantly increased with acute EA1 and EA2 both during and after 30-min EA; (ii) DAI in the TNBStreated rats was significantly decreased by EA1 and EA2 compared to the sham-EA group (P < 0.05 and P < 0.01, respectively), and EA2 was more effective than EA1 (P < 0.05); (iii) the macroscopic score was 6.43 ± 0.61 in the sham-EA group and reduced to 4.86 ± 0.14 with EA1 (P < 0.05) and 4.0 ± 0.22 with EA2 (P < 0.001); EA2 was more effective than EA1 (P = 0.017). The similar result was found in the histological score. (iv) The plasma levels of TNF-α, IL-1β, and IL-6 were all significantly decreased with EA1 and EA2 compared to the sham-EA group; (v) autonomically, both chronic EA1 and EA2 significantly increased vagal activity and decreased sympathetic activity in comparison with sham-EA group. Conclusion: Chronic EA using chronically implanted electrodes improves colonic inflammation in TNBS-treated rats by inhibiting pro-inflammatory cytokines via the autonomic mechanism. Keywords: inflammatory bowel disease, electrical acupuncture, inflammatory cytokines OE-0670 (PE-0494) High-fat diet induced-gut microbiota dysbiosis accelerates intestinal adenoma-adenocarcinoma sequence via activation of MCP-1/CCR2 axis Authors: TIANYU LIU; ZIXUAN GUO; HAILONG CAO; BANGMAO WANG Affiliation: Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China Background and Aim: High-fat diet (HFD) is one of the important risk factors for colorectal cancer (CRC). Dysbiosis is associated with intestinal carcinogenesis, and little is known about the crosstalk between HFD and gut microbiota in intestinal carcinogenesis. We investigated the effects of HFD on the composition of gut microbiota and tumor development. Methods: Four-week-old Apc min/+ mice were randomly divided into two groups: HFD group (60% fat content) and control group (regular diet). Fecal pellets and cecal contents were collected for microbiota 16S rRNA sequencing and short-chain fatty acids (SCFAs) analysis. A cocktail of antibiotics was administered with HFD for microbiota depletion to investigate the effect of crosstalk between the HFD and the gut microbiota. Parameters of intestinal tumor development, cell proliferation, cell apoptosis, inflammation, and monocyte chemoattractant protein-1 (MCP-1)/CC chemokine receptor 2 (CCR2) signaling axis were also determined. Intestinal tumor associated macrophages (TAMs) were measured by immunofluorescence double staining. Fecal microbiota transplantation (FMT) was used in another batch of Apc min/+ mice to determine the causality between HFD-induced dysbiosis and carcinogenesis. In addition, according to the colonoscopy data, we evaluated the effect of HFD on intestinal tumor development and examined the expression levels of MCP-1, CCR2, and M2 TAMs in tumor tissue. Results: Administration of HFD increased the number and malignancy of intestinal tumors in Apc min/+ mice, while these effects can be inhibited by antibiotics cocktail. Promotion of intestinal tumor formation was accompanied by increased tumor cell proliferation and decreased apoptosis. Moreover, HFD administration altered and simplified the composition of gut microbiota, with increased opportunistic pathogens and decreased SCFAs producing bacteria. Concomitantly, SCFAs concentrations in cecal contents of HFD group were decreased comparing with control group. The alteration of gut microbiota was correlated with activation of MCP-1/CCR2 axis that recruit and polarize M2 TAMs. Interestingly, the transfer of fecal microbiota from HFD-fed mice also increased the tumor multiplicity, activated the MCP-1/CCR2 signaling axis, and promoted carcinogenesis. By analyzing clinical data, we also found that HFD was closely related to advanced colorectal neoplasia. Immunohistochemistry results showed that the expression levels of MCP-1, CCR2, and M2 TAMs polarization in tumor tissues of HFD patients were significantly higher than those in regular diet. Background and Aim: The aim of this study is to investigate microbial changes and host response in colon occurring in rats of different sex and age following a high-fat diet (HFD), in 6-week-old (young age) and 2year-old (old age) Fisher-344 rats of either sex. Methods: After feeding rats (n = 4-6 per group) with HFD for 8 weeks, fecal microbiome was analyzed with 16S rRNA metagenome sequencing. We performed hematoxylin and eosin (H&E) staining, immunohistochemistry (IHC) for Ki67, and ELISA or western blot (for myeloperoxidase, COX2, caspase-1, and cyclin D1) to evaluate the fat proportion in colon muscle layers and the levels of inflammation and cell proliferation in colon mucosa. Correlations between microbial factors and the Ki67 index were analyzed with statistical methods. Results: The HFD induced a decreased species richness of microbiota (Chao1) and increased Firmicutes/Bacteroidetes ratio only in aged rats, not in young rats. Sex differences in the alteration by HFD were observed in the microbiome of aged rats, for example, A. muciniphila and Desulfovibrio spp. Histological inflammation and cell proliferation of colon mucosa (Ki67) were significantly increased by HFD even in young rats, with more severity of cell proliferation in aged males. The HFD-induced decrease of species richness and the increase of some species (Desulfovibrio spp. and Clostridium lavalense), which produce carcinogenic compounds, was significantly correlated with Ki67 index. In colon mucosa, the concentration of myeloperoxidase increased by HFD only in males, not in females. Conclusion: In conclusion, the results suggest a link between HFD-induced gut dysbiosis (particularly the low species richness and high abundance ratios of Desulfovibrio spp. and C. lavalense) and cell proliferation of colon mucosa (indicated by Ki67 IHC). Sex differences influence on the response of gut microbiome to HFD particularly in old age, and this might be linked to the sex differences of inflammation in the colon mucosa.
Keywords: aging, high-fat diet, gut microbiota, rats, Ki67 Background and Aim: High-fat diet, which leads to an increased level of intestinal deoxycholic acid (DCA), is a major environmental factor in the development of colorectal cancer (CRC). High-fat diet can destroy the intestinal mucosal barrier. However, evidence relating to bile acids, mucosal barrier, and intestinal tumorigenesis is limited. Methods: The barrier function and expression of inflammatory cytokines of DCA in colorectal tumor cells (Caco-2 and IMCE cells) were examined by TEER values and realtime PCR. Apc min/+ mice were distributed into two groups: control group and DCA group received 0.2% DCA in drinking water. After 12 weeks, mice were sacrificed for the pathological evaluation. FITC-D was used to detect intestinal permeability. The intestinal barrier function was identified by real-time PCR, immunohistochemistry, and immunofluorescence. Results: DCA disrupted cell monolayer integrity and promoted the pro-inflammatory cytokines production in Caco-2 and IMCE cells. DCA administration increased the number and size of intestinal adenomas and promoted adenoma-adenocarcinoma sequence in Apc min/+ mice. DCA induced the activation of NLRP3 inflammasomes, increased the production of inflammatory cytokines and led to intestinal low grade inflammation. A reduction of tight junction protein zonula occludens 1 (ZO-1) and the number of intestinal cells including goblet and Paneth cells were also observed after DCA treatment. Moreover, DCA significantly reduced the level of secretory immunoglobulin A and promoted the polarization of M2 macrophages in the intestine of Apc min/+ mice. Conclusion: DCA in- Background and Aim: Lactobacillus rhamnosus GG (LGG) plays a more and more important significant role in the treatment of constipation. However, the exact mechanism remains unclear. 5-Hydroxytryptamine 4 receptor (5-HT4R) is a critical receptor that related to the motility of intestine; activation of 5-HT4R could cause the release of mucin in goblet cells; in this study, we aimed to find whether LGG could modulate the defecation function in mice colon and the possible mechanism. Methods: Male C57BL/6 adult mice were randomly divided into 3 groups: MRS group (n = 10), tegasromide group (n = 15), and LGG group (n = 15). Gavage of MRS broth, distilled water solution of tegasromide, and LGG supernatant was respectively given to these 3 groups of mice for 7 days. Defecation parameters including number of pellets in 2 h, fecal weight, fecal dry weight, fecal water content, and gastrointestinal transit time (GITT) were detected. PAS staining was used to evaluate goblet cells number in mice colon. The mRNA and protein levels of 5-HT4R and mucin 2 (MUC2) were detected by real-time PCR and western blotting. Results: Weight and general situation of all mice have no significant difference. The number of defecation pellets in 2 h, fecal weight, fecal dry weight, and fecal water content in the tegasromide group and LGG group are increased than in MRS group. PAS staining shows that the average number of goblet-positive cells in the colon in tegasromide group and LGG group are increased compared with MRS group. The mRNA and protein levels of 5-HT4R and MUC2 were increased in tegasromide group and LGG group compared with MRS group. Conclusion: LGG supernatant can upregulate 5-HT4R expression and MUC2 production and promote defecation function in mice. This study indicates that goblet cells can become a promising target in improving colon function and provide new window for prevention and treatment for constipation. Keywords: LGG, 5-HT4R, defecation function Background and Aim: To investigate the role of cytokeratin 8 (CK8) on the change of intercellular permeability of intestinal epithelial cells induced by corticotropin releasing factor (CRF). Methods: The expression levels of CRFR1 and CRFR2 on the HT29 cell surface were determined by immunofluorescence. After treatment with 100-nM CRF for 72 h, the translocation of FITC-labelled dextran was measured in a transwell chamber; the structural changes of tight junctions were observed under transmission electron microscopy; the expression levels of CK8 and tight junction proteins ZO-1 and occludin were detected by immunoblotting. The activity of PKC kinase was detected by ELISA. Furthermore, the effects of CRF on intestinal epithelial permeability were examined in CK8-silenced HT29 cells, which were constructed by shRNA interference. Results: CRF treatment increased FITC-labelled dextran permeability (P < 0.05), caused the opening of tight junctions, and induced increased fluorescence intensity of CK8. The expression levels of occludin and ZO-1 were downregulated (all P < 0.05). PKC kinase activity decreased at 1 h after CRF treatment (P < 0.05). CRF-induced increased permeability and downregulation of occludin were not blocked by CK8 silencing (all P > 0.05). Nevertheless, CK8 silencing blocked the effects of CRF regarding the decrease in the expression levels of ZO-1 and increase in PKC kinase activity (all P < 0.05). Conclusion: CK8 may increase of intestinal epithelial permeability induced by CR, inhibiting the activity of PKC kinase, and there may be other signaling pathways involved. Keywords: intestinal epithelial permeability, cytokeratin 8, corticotropinreleasing factor, tight junction protein, PKC Background and Aim: Nerolidol, a naturally occurring sesquiterpene is predominantly synthesized in plants and responsible for the host defense as well as providing aroma. In many experimental studies, it has been shown to confer beneficial effects by mitigating oxidative stress and inflammation. Therefore, in the present study, we evaluated the effect of nerolidol in acetic acid-induced rat model of colitis Methods: Nerolidol (50 mg/kg/day) was administered for either 3 days before or 30 min after IBD for 7 days. The body weight, macroscopic, and microscopic analysis of the colon of nerolidol-treated IBD rats and that of control rats were performed on days 0, 2, 4, and 7. Results: Nerolidol was found to significantly improve IBD-induced reduction in mean body weight and mean macroscopic and microscopic ulcer scores. Nerolidol also reduced the MPO activity, a marker of inflammation mediating neutrophil adhesion and levels of MDA, a marker of lipid peroxidation concomitant to improved GSH activity. Furthermore, the levels of calprotectin and levels of pro-inflammatory cytokines such as IL-1, IL-6, IL-23, and TNF-α were also reduced significantly (P > 0.05) by nerolidol. Conclusion: The findings demonstrate that nerolidol improved mean macroscopic and microscopic ulcer scores, inhibited inflammation and oxidative stress, and mitigated the reduction in body weight in the IBD rats. Given the safety and efficacy of nerolidol, it could be a promising agent of natural origin in prevention and treatment of colitis. However, further studies are required to translate these findings clinically.
Keywords: nerolidol, inflammation, oxidative stress, acetic acid, colitis Background and Aim: Acute severe lower gastrointestinal bleeding (LGIB) is a rare complication in Crohn's disease, which is a therapeutic challenge due to variety of clinical manifestations and extents of disease. We aimed to compare the characteristics of the first bleeding and re-bleeding episodes in patients with Crohn's disease. Methods: Between January 2012 and November 2015, 30 patients of severe LGIB of Crohn's disease were retrospectively investigated. Acute LGIB was defined as acute massive rectal bleeding requiring 2 packs of blood transfusion within at least 24 h or a sudden decrease in hemoglobin level below 9 g/dL. Results: Mean age at the time of bleeding was 38.4 ± 10.9 years. Mean duration from diagnosis of Crohn's disease to the first bleeding episode was 66.9 ± 63.7 months. Mean serum levels of hemoglobin and C-reactive protein were 8.6 ± 1.8 g/dL and 7.1 ± 7.9 mg/dL, respectively, and 19 (63.3%) patients had moderate-to-severe Crohn's disease. The bleeding focus was identified in 56.7% of patients, by colonoscopy (46.7%). The bleeding lesion was an ulcer in 81.3% of the cases and left colon in 56.2%. The treatment of acute severe LGIB accounted for 50% of the medical treatments using systemic corticosteroids. The maintenance treatment were 16 (53.4%) using azathioprine and 4 (13.3%) using infliximab, respectively.
In moderate-to-severe Crohn's disease, re-bleeding episodes occurred more frequently than first bleeding episode but not statistically significant (P = 0.082). However, utilization of the total parenteral nutrition was statistically significantly higher in the re-bleeding episode group than in the first bleeding group (45.0% vs 90.0%, P = 0.048). Conclusion: Acute severe LGIB in Crohn's disease is usually considered to be a conservative treatment with systemic corticosteroids, azathioprine, and infliximab. However, operative treatment may be needed for poorly controlled bleeding, and further studies including prevalence and re-bleeding risk factors are needed. Keywords: Crohn's disease, lower gastrointestinal bleeding, infliximab, conservative treatment Background and Aim: Fecal calprotectin (Fcal) and fecal immunochemical test (FIT) are known to be a useful predictor in endoscopic activity evaluation in ulcerative colitis (UC) patients. The aim of this study is to confirm the correlation between endoscopic activity and the two tests and to evaluate the difference between the two tests. Methods: A total of 174 results, obtained in simultaneous examination with endoscopy and two tests, were retrospectively evaluated for 127 patients with UC. The efficacy of two tests for endoscopic activity evaluation was compared. Endoscopic activity were assessed using Ulcerative Colitis Endoscopic Index of Severity (UCEIS) or Mayo Endoscopic Subscore (MES). Results: Both Fcal and FIT results were significantly correlated with MES and UCEIS (P < 0.001 and P < 0.001). But Fcal showed a more accurate statistical correlation than FIT in both MES (r = 0.678 versus 0.635) and UCEIS (r = 711 versus 0.657). In the complete mucosal healing state, the sensitivity of FIT was more higher than that of Fcal (sensitivity to MES 0; FIT 98% versus Fcal 70%, sensitivity to UCEIS 0 or 1; FIT 95% versus Fcal 80%) but lower in specificity (specificity to MES 0; FIT 37% versus Fcal 81%, specificity to UCEIS 0 or 1; FIT 37% versus Fcal 83%). Conclusion: Both Fcal and FIT were well correlated with endoscopic activity in UC patients, but Fcal was more correlated with endoscopic activity. FIT was more sensitive to predict complete mucosal healing, but the specificity of Fcal was higher than that of FIT. Keywords: ulcerative colitis, endoscopic activity, fecal calprotectin, fecal immunochemical test Background and Aim: Negative fecal calprotectin (Fcal) is known to be associated with complete mucosal healing in ulcerative colitis (UC). The aim of this study is to investigate the factors associated with positive Fcal in UC patients with complete mucosal healing (cMH) and clinical course in these patients. Methods: A total of 51 UC patients with cMH confirmed by endoscopy (Mayo Endoscopic Subscore 0) were retrospectively. Fcal was examined on the day of endoscopy, and other tests (fecal immunochemical test; FIT, WBC, hemoglobin, CRP, ESR, and albumin) were evaluated.
Results: The cut-off value for Fcal in this study was set at 170 ug/g based on the result of a receiver operating characteristics curve analysis (area under curve, 0.863; sensitivity, 0.748; specificity, 0.804) to predict cMH. Among the 51 patients, 11 patients (29.4%) with cMH were positive Fcal. In univariate analysis, factors associated with positive Fcal in UC patients with cMH were old age ≥ 50 (OR 4.444, P = 0.047), anemia (OR 10.278, P = 0.006), elevated ESR (OR 9.917, P = 0.003), and positive FIT (OR 48.60, P = 0.012). In multivariate analysis, only elevated ESR (OR 5.250, P = 0.011) was significantly related with positive Fcal in UC patients with cMH. Among these patients, only one patient had worsening clinical course 3 months later. Conclusion: Positive Fcal in UC patients with cMH was significantly associated with elevated ESR, and most of them had good clinical course. Keywords: ulcerative colitis, fecal calprotectin, mucosal healing Background and Aim: Nuclear factor kappa B (NF-κB) activation and endoplasmic reticulum (ER) stress signaling play significant roles in the pathogenesis of inflammatory bowel disease (IBD). Thus, we evaluated whether new therapeutic probiotics have anti-colitic effects, and we investigated their mechanisms related to NF-κB and ER-stress pathways. Methods: Luciferase, nitric oxide (NO), and cytokine assays using HT-29 or RAW264.7 cells were conducted. Mouse colitis was induced using dextran sulfate sodium (DSS) and confirmed by disease activity index and histology. Macrophages and T-cell subsets in isolated peritoneal cavity cells (PCCs) and splenocytes were analyzed by flow cytometry. Gene expression and cytokine profiles were determined using RT-PCR. Results: Lactobacillus acidophilus (LA1) and Pediococcus pentosaceus inhibited NO production in RAW264.7 cells, but only LA1 inhibited TNF-α and induced IL-10 expression. LA1 increased the lifespan of DSS-treated mice and attenuated the severity of colitis by inducing M2 macrophages in PCCs and Th2 and Treg cells in splenocytes. The restoration of goblet cells in the colon was accompanied by the induction of IL-10 expression and the suppression of pro-inflammatory cytokines. Additionally, we found that LA1 exerts an anticolitic effect by improving ER stress in HT-29 cells as well as in vivo. Conclusion: We showed that LA1 selectively interferes with ER stress and suppresses NF-κB activation. Our findings suggest that LA1 can be used as a potent immunomodulator in IBD treatment, and the regulation of ER stress may have significant implications in treating IBD. Keywords: endoplasmic reticulum stress, inflammatory bowel disease, Lactobacillus Acidophilus, nuclear factor kappa B, probiotics Background and Aim: Lactobacillus plantarum (LP3) has been identified as a probiotic bacterium owing to its role as an antioxidant and for the maintenance of the intestinal permeability. The ability of LP3 to survive in the human gastrointestinal tract makes it possible to deliver vehicles for therapeutic compounds or proteins in vivo. The aim of this study was to investigate anti-colitic effects of LP3 and its mechanism as new therapeutic probiotics for the treatment of inflammatory bowel diseases (IBD). Methods: In vivo study was performed using mice with 2.5% (w/v) dextran sodium sulfate (DSS)-induced colitis model. Mice were randomly divided into three groups: control, DSS-treated group, and a group with a DSS treatment followed by the oral administration of LP3 (10 8 cells). Mice in the third group were gavaged with LP3 daily for 7 days following the administration of DSS for 7 days. All mice were sacrificed at day 14. An analysis of macrophages and T-cell subsets was performed with harvested peritoneal cavity cells (PCCs) and splenocytes using a flow cytometric assay. The gene expression and the cytokine profiles were measured using quantitative reverse transcriptase polymerase chain reaction. Results: The administration of LP3 effectively increased the lifespan of mice that suffered from the acute colitis and attenuated the disease activity. The increased induction of M2 macrophages in PCCs, type 2 helper T cells, and regulatory T cells (Treg) in splenocytes and the restoration of goblet cells in the colon were accompanied with the induction of IL-10 and suppression of pro-inflammatory cytokines. Conclusion: We showed that LP3 has anti-inflammatory effects with positive regulation of Treg as well as the induction of IL-10 expression. These findings suggest that LP3 can be used as a potent immunomodulator for IBD in the way that it regulates the number of Treg, which has significant implications in IBD. Keywords: Lactobacillus plantarum, inflammatory bowel diseases, regulatory T cells, IL-10, probiotics Background and Aim: High-density lipoprotein-cholesterol (HDL-C) may play a key role in immune responses, but its association with inflammatory bowel diseases (IBD) remains unclear. We conducted a nationwide population-based study to investigate the effect of HDL-C on the development of IBD. Methods: We conducted a retrospective study using claims data from the National Healthcare Insurance service in Korea. All subjects who received medical checkups at least 3 times between 2009 and 2012 were included and followed up until 2015. Serum HDL-C levels were collected, and the variability in HDL-C levels was measured by variability independent of mean (VIM). Patients who developed IBD including Crohn's disease (CD) and ulcerative colitis (UC) were identified during the followup. Results: During the follow-up, CD was newly detected in 32 (0.003%), 42 (0.004%), 54 (0.005%), and 66 (0.007%) cases from highest to lowest HDL-C quartile groups, respectively. The incidence rate ratio of CD (per 100,000 person-years) was 1.34, 1.69, 2.26, and 2.74, respectively. The risk of UC was not associated with HDL-C or HDL-C VIM. The lowest HDL-C quartile group showed a 3.30-fold increased risk of CD compared to the highest HDL-C quartile group (95% confidence interval [CI], 2.13-5.11). The highest HDL-C VIM quartile group had a 3.25fold increased risk of CD compared to the lowest HDL-C VIM quartile group (95% CI, 2.03-5.18). Considering mean values and variation in HDL-C levels together, a group with the lowest HDL-C and the highest HDL-C VIM showed a 3.00-fold increased risk of CD compared to a group with higher quartile (2nd to 4th) of HDL-C levels and lower quartile (1st to 3rd) of HDL-C VIM (95% CI, 2.02-4.46). Conclusion: Patients with low serum levels and high variation of HDL-C had increased risk of CD but not UC. Background and Aim: Lymphoid follicular proctitis (LFP), also known as nodular proctitis, is an uncommon inflammatory condition confined to the rectal mucosa and its pathogenesis is unknown. LFP is often considered as a form of ulcerative colitis, but it's a distinct entity with clinical, endoscopic, and histological features unrelated to other type of inflammatory bowel disease. In patients with LFP, intermittent rectal bleeding associated with defecation is the major presenting symptoms. We report a case of LFP in patient with rectal bleeding. Methods: A 50-year-old male visited our clinic with intermittent rectal bleeding with stool, without diarrhea, fever, weight loss, or other general symptoms. His past medical history and family history were unremarkable. The laboratory blood tests including a white blood cell count, hemoglobin, platelet, alanine aminotransferase, and aspartate transaminase were within normal limit. A viral marker for hepatitis B and a serologic investigation for the immunocompromised state (HIV antibody) were all negative. The rapid plasma reagin (RPR) test for syphilis is non-reactive. Results: Sigmoidoscopy showed the rectal mucosa to be finely granular pattern without erosion or ulceration, and no abnormal findings above the rectum (Fig. 1a). Histopathological examination revealed marked lymphoid follicular hyperplasia without crypt abscess or granuloma, and neutrophils, eosinophils and plasma cells are scant or absent (Fig. 1b). It was diagnosed as an LFP. The patient improved after using mesalazine suppository. Conclusion: LFP should be included in the differential diagnosis of proctitis, and mesalazine suppository may be useful for symptomatic patients with LFP. Keywords: follicular proctitis, rectal bleeding, endoscopy, mesalazine  Background and Aim: There is limited data regarding the impact of treatment for IBD on the BMD status. Therefore, this study aimed to identify the change of BMD in patients with IBD after treatment including 5aminosalicylic acid, thiopurine, and anti-TNF agents. Methods: The cases were retrieved from 442 patients who were diagnosed with IBD in a single university hospital. Of those, 119 patients (CD 84, UC 35) had the followup BMD with at least 1-year interval. The associations between BMD, BMI, and disease activity parameters including CDAI, Mayo score, hemoglobin (Hb), C-reactive protein (CRP), serum albumin were evaluated as Pearson correlation analysis and partial correlation. BMD was measured as Z score and low BMD was defined as less than À1. Results: In enrolled 84 patients with inactive CD, the baseline mean of BMD Z score at the lumbar spine and femur neck were À0.44 ± 1.36, À0.13 ± 1.28. The follow-up mean of BMD Z score at the lumbar spine and femur neck were À0.47 ± 1.21 (P = 0.512), À0.18 ± 1.17 (P = 0.304). In enrolled 35 patients with inactive UC, the baseline mean of BMD Z score were À0.20 ± 1.04, À0.11 ± 1.06. The follow-up mean of BMD Z score at the lumbar spine and femur neck were À0.26 ± 1.05 (P = 0.145), À0.08 ± 1.06 (P = 0.633). The proportion of low BMD patients of CD and UC at the baseline were 30 (35.7%), 11 (30.6%); the number of low BMD patients with CD and UC at the disease-controlled status were 31 (36.9%, P = 0.873) and 9 (25%, P = 0.599), respectively. Only in the low BMD group of CD, the BMD of femur neck was correlated with BMI, Hb, CRP, and albumin (0.517: P = 0.003, 0.423: P = 0.02, À0.394: P = 0.031, 0.378: P = 0.039). However, there was no correlation with disease activity parameter and BMD status in partial correlation, using BMI as control variable. Conclusion: There is no correlation with the improvement of disease and BMD status after treatment in patients with IBD. However, in low BMD group of CD, treatment itself could improve the status of BMD of femur neck. Keywords: bone mineral density, ulcerative colitis, Crohn's disease Background and Aim: Ulcerative colitis (UC) is a chronic inflammatory bowel disease of unknown etiology and is a lifelong disease repeating clinical improvement and aggravation. Endoscopic severity assessment is very important, because the severity assessment is related to the prognosis of the UC patient. Colonoscopy is able to identify the entire field but is accompanied by complication, and the preparation process is difficult. The aim of this study is to evaluate the endoscopic tool to assess severity of ulcerative colitis during follow up UC patients. Methods: The subjects were 183 UC patients who were diagnosed and followed up at Chosun University Hospital from January 2013 to December 2017. Among them, 101 patients with follow-up colonoscopy were enrolled and retrospectively evaluated for endoscopic severity. The severity is assessed by colonoscopy alone; inspector determines endoscopic severity of follow up UC patients from rectosigmoid and proximal colon. The scale of endoscopic severity is endoscopic Mayo score and Ulcerative Colitis Endoscopic Index Scale (UCEIS). Results: Of the 101 patients, 40 has lesions limited to the rectosigmoid colon (39%). The average of endoscopic Mayo score of the entire colon is 1.21, and in case of rectosigmoid, the colon is 1.07. The average of UCEIS of the entire colon is 2.24, and in case of rectosigmoid, the colon is 1.94. The agreement endoscopic Mayo score between each site is observed with a kappa value of 0.83 (P = 0.00), and the agreement of UCEIS between each site is observed with a kappa value of 0.840 (P = 0.00). Conclusion: There is a very high level of agreement between the entire colon severity and the rectosigmoid colon severity in followed UC patients. Sigmoidoscopy is a good modality for evaluating the endoscopic severity of followed UC patients, considering complication and high cost. Keywords: ulcerative colitis, endoscopic activity, sigmoidoscopy Background and Aim: Inflammatory bowel disease (IBD) is known to be caused by a genetic predisposition involving multiple genes; however, there is growing evidence that abnormal interaction with environmental, particularly epigenetic, factors can have a significant contribution during the development of IBD. Although many studies, particularly genomewide association studies (GWAS), have been performed to identify the genetic changes underlying the pathogenesis of Crohn's disease (CD), the role of epigenetic changes in the development of complications arising from CD is poorly understood. Methods: We employed an unbiased approach to define DNA methylation alteration in CD patients using the HumanMethylation450K BeadChip platform. We validated the methylation levels of 19 genes that showed hypermethylation in CD patients compared with normal control. Technical validation was performed using quantitative MSP analysis. We performed functional implication of hypermethylated genes in CD analyzed by gene network. Results: Compared to normal controls, the majority of differential DNA methylation in CD patient samples was in the promoter, intergenic, and gene body regions. The DNA methylation profile in CD revealed 134 probes (23 hypermethylated and 111 hypomethylated probes) that were differentially methylated. We validated the methylation levels of 19 genes that showed hypermethylation in CD patients compared with normal control. MSP analysis showed that the Fragile Histidine Triad (FHIT) genes were hypermethylated in a disease-specific manner. Gene network analysis of the hypermethylated candidates suggested putative molecular interactions relevant to IBD pathology. Conclusion: Our DNA methylation profile identifies newly hypermethylated genes in CD, as well as the gene network associated with disease development, which can provide direction for future research in the diagnosis/prognosis or therapeutic treatments for CD. Keywords: genome-wide analysis, DNA methylation, inflammatory mucosa, Crohn's disease Background and Aim: Gemella morbillorum, a microaerophilic Grampositive coccus, is a natural inhabitant of the human oropharyngeal, gastrointestinal, and urogenital flora. Dental diseases and cardiac diseases are reported as background diseases, but there are few reports, and it is speculated that other infectious diseases are caused by other chronic diseases and immunocompromised patients. There are case reports of septicemia caused by Gemella morbillorum after treatment with anti-TNF-α antibody in patients with purulent perspiratory inflammation, which is suggested as one risk factor. Methods: A 39-yearold man diagnosed with Crohn's disease (CD) started on anti-TNF therapy with infliximab (5 mg/ kg/body) in 2008. Due to refractory anal fistula, therapy was changed on infliximab (10 mg/kg/body) in 2013. There was no problem in particular; he was in hospital treatment outpatient. Although on January 2, 2016, the patient was admitted to Hokkaido University Hospital with a high fever of 39 degrees. And once diagnosis sepsis, but there was nothing that could be an infection lesion with CT. There was also no finding that doubted the exacerbation of CD. Day 1: we started antibacterial therapy with cefmetazole (CFM). Day 3: Gemella species was detected from the result of the blood culture, and after the antibiotic was changed to amoxicillin (ABPC), the symptoms were improved, and the fever was lowered. Dental examination, cardiac ultrasound examination, and colonoscopy were performed during hospitalization, but there were no findings that could cause sepsis in particular. After changing to the appropriate antibiotic therapy, the patient was discharged with good passage on January 17. Results: There is no history of dental diseases and heart diseases in this case, and anti-TNF-α antibody therapy is assumed to be an incentive. Conclusion: Even though it is a rare complication, it should be recognized as a risk of severe sepsis because of its impact on life quality. Keywords: Crohn's disease, sepsis, anti-TNF-antibody therapy, Gemella morbillorum, antibacterial therapy Background and Aim: Anemia is characterized by low hemoglobin levels due to a variety of causes. Anemia is known to be the main symptom of inflammatory bowel disease (IBD). Although anemia may occur in patients with IBD, it is unclear whether the incidence of IBD increases in anemic patients compared to the general population. The aim of this study was to assess the incidence of IBD in patients with anemia according to hemoglobin concentration. Methods: We conducted a nationwide, population-based study using claims data from the National Healthcare Insurance Service (NHIS)-National Health Screening Cohort in Korea. We included people aged 20 years or older between 2010 and 2012 (n = 2,148,417). Anemia was defined using World Health Organization criteria. We compared patients with anemia to persons without anemia matched by age, sex, and body mass index (BMI). We identified patients who were newly diagnosed with IBD that met both of ICD-10 codes ( Background and Aim: The pro-angiogenic cysteine-rich protein 61 (Cyr61) is a novel pro-inflammatory factor. Whether Cyr61 is involved in the development of inflammatory bowel disease (IBD) remains unknown. The purpose of this study is to investigate the expression of Cyr61 in patients with IBD. Methods: We achieved the colonic mucosa from 23 patients with IBD who had undergone colonoscopy. We measured the expression of Cyr61 and inflammatory markers in the biopsy specimens using the real-time PCR, and we determined the expression of Cyr61 in LPS-treated colonic epithelial cells (CaCo-2 and HCT 116). Results: The mean age of enrolled patients was 31.7 years, and 11 patients (47.8%) had ulcerative colitis and 12 patients (52.2%) had Crohn's disease. Expression of Cyr61 in the inflamed mucosa was 2.5 times higher than that of the non-inflamed mucosa (P = 0.002, Fig. 1). Expression of TNF-α, IL-6, and TLR-4 increased significantly in inflamed mucosa than that of the non-inflamed mucosa (all P < 0.05). Time-dependent increase in Cyr61 expression was observed in CaCo-2 and HCT 116 after the treatment with LPS. Also, the relationship between C-reactive protein and Cyr61 showed statistic significance (P = 0.027). Conclusion: Our results reveal a novel mechanism between Cyr61 and inflammatory bowel disease. We suggest the role of Cyr61 in therapies targeting Cyr61 in patients with IBD. Keywords: Cyr61, inflammatory bowel disease, biomarker  Methods: A 19-year-old woman visited the emergency department with complaint of diarrhea and ulcers in lower leg. She was admitted to another hospital with diarrhea 3 months ago. She was diagnosed with infectious colitis and treated with antibiotics, but the diarrhea was continued. Her ankle pain and swelling started after discharge, and it got worse. The ulcers located in pretibial areas, with the size of 2 to 15 cm and in oval shape with necrotic and hemorrhagic sloping edges oozing with pus. On examination, she was tachycardic. Results: CT with thromboembolism protocol was performed; pulmonary thromboembolisms (PTEs) and deep vein thrombosis (DVTs) were detected. The patient underwent colonoscopy that demonstrated continuous erythematous, nodular, easy friability, and ulcerated mucosa throughout the colon, sparing the terminal ileum. Biopsies revealed severe active inflammatory changes and chronic inflammation with cryptitis and crypt distortion but no granuloma or vasculitis. We diagnosed UC based on colonoscopic finding and histopathologic reports. Skin lesion was diagnosed as pyoderma gangrenosum. The patient was started on antibiotics and intravenous methylprednisolone 30 mg daily. Tacrolimus ointment was applied for PG, and unfractionated heparin was infused for PTEs and DVTs at first and changed to low molecular weight heparin later. Background and Aim: Pyostomatitis vegetans (PV) is a rare kind of stomatitis characterized by multiple miliary pustules that primarily affect the labial gingiva as well as the buccal and labial mucosa. Although the pathogenesis of PV remains unclear, it is now recognized as a rare oral manifestation of ulcerative colitis (UC) and Crohn's disease (CD). PV is more common in UC and considered as a specific marker of disease activity in UC. Treatment is aimed at controlling underlying inflammatory bowel disease (IBD). Systemic steroids are usually used for these patients. Anti-neutrophilic agents, such as dapsone, have also been effective, especially in relapsing case. Methods: A 37-year-old Korean woman came to our clinic for evaluation of oral ulceration of 10-month duration. At the time of development of oral lesion, she had hematochezia and mucoid stool, and sigmoidoscopy at other hospital showed ulcerative proctitis. She received prednisone and 5-aminosalicylate. Remission of proctitis was achieved, but oral lesions were not improved. Results: A physical examination showed multiple white or yellowish, friable micropustules with an erythematous and edematous mucosal base on labial and buccal mucosae, as well as ulcerations and hemorrhagic crusting. Complete blood counts showed peripheral eosinophilia (10.5%), and C-reactive protein was 4.17 mg/dL (normal range, < 0.47 mg/dL). Biopsy specimen showed intra-epithelial microabscesses and a dense mixed infiltrate of inflammatory cells consisting of neutrophils, eosinophils, and lymphocytes in the lamina propria. Histological findings were consistent with the diagnosis of PV. Remission of oral lesions was not achieved in spite of systemic steroids therapy. Oral lesions were gradually improved after adalimumab was introduced. Conclusion: Our case confirms previously reported good experience with biologics in the management of PV associated with IBD. In cases of PV without response to systemic steroids therapy, biologics may be considered to induce remission of oral lesions. Keywords: ulcerative colitis, pyostomatitis vegetans, biologics Background and Aim: In patient with inflammatory bowel disease (IBD), anemia is one of the common complication. Iron supplementation is the most effective therapy IBD in patients with anemia; however, it could cause some adverse events. In era of anti-TNF (tumor necrosis factor) agents, there was no definite treatment evidence of oral iron supplements. Therefore, we aimed to analyze the effect of oral iron supplements in IBD patient treated with anti-TNF agents. Methods: We retrospectively reviewed the medical records of 37 patients with ulcerative colitis (UC) and 42 patients with Crohn's disease (CD) who started anti-TNF treatment between January 2000 and December 2014. We analyzed the effect of iron supplement on hemoglobin changes as well as IBD recurrence. The definition of moderate anemia was defined as less than hemoglobin 10. Data from the year of anti-TNF initiation (year 0) and the following year (year 1) were compared. Results: Among 79 patients, 27 patients (34.2%) started anti-TNF agents and iron supplement simultaneously, and 52 patients (65.8%) only received anti-TNF agents. The prevalence of anemia and hemoglobin, hematocrit, CRP, and ESR levels were significantly improved compared with before treatment. Hemoglobin change was all significantly elevated regardless of iron supplement (anti-TNF agent + iron: from 9.8 to 11.7, P = 0.004; anti-TNF agent: from 11.9 to 13.3, P < 0.001). In IBD patients with moderate anemia, improvement of anemia was more prominent in iron supplement group (anti-TNF agent + iron: from 8.5 to 11.4, P = 0.001; anti-TNF agent: from 9.3 to 11.4, P = 0.081). Conclusion: Anti-TNF agent provided clinically meaningful improvements in hemoglobin, CBC, CRP, and ESR. In patients requiring anti-TNF agent treatment, anemia could be improved without iron supplementation. However, in patients with moderate anemia, iron supplementation may be helpful. Keywords: inflammatory bowel disease, anti-TNF agents, iron, anemia, supplement The patients with IBD showed significantly lower serum pyridoxine levels and significantly higher homocysteine levels than controls. The frequencies of binucleated cells (BNCs) with MNi, nucleoplasmic bridges (NPBs), and nuclear buds (Nbuds) were 8.5 (5.8-13.5), 1.0 (0.0-1.9), and 5.4 (4.3-7.4) for the IBD group, and 5.9 (4.8-7.7), 0.2 (0.0-1.0), and 3.5 (2.9-5.4) for the control group (P = 0.011, P = 0.010, and P = 0.002), respectively. Background and Aim: The altered intestinal microbial profiles have been known to be associated with colorectal cancer as well as inflammatory bowel diseases. To determine the role of the commensal bacteria in the development of colitis-associated cancer (CAC), we investigated the effects of intestinal microbial change through antibiotics administration on colon tumorigenesis in the azoxymethane (AOM)-dextran sodium sulfate (DSS)-induced murine CAC model. Methods: CAC was induced in the C57BL/6 mice by injection of 10 mg/kg AOM followed by two rounds of 2% DSS exposure to elicit colitis. Four antibiotics combination (vancomycin, ampicillin, neomycin, and metronidazole) or each individual antibiotic were administered for 2 weeks prior to and throughout the duration of AOM/DSS administration. After sacrifice of the mice, colonic inflammation, proliferation, and tumorigenesis were evaluated. To characterize the change of intestinal microbiota, high throughput Illumina MiSeq sequencing for sequential feces was performed. Results: Antibiotics treatment, regardless of cocktail or individual, decreased AOM/DSS-induced tumor numbers, mean tumor size, histologic colitis and dysplasia scores, and pro-inflammatory and proliferatory cytokine expressions compared to AOM/DSS group without antibiotics treatment. Individual antibiotic treatment induced variable tumor burdens and degree of colitis, ranging between those of antibiotics cocktail-treated group and antibiotics nontreated group. Metagenomic sequencing analysis demonstrated that different antibiotics treatments generated different intestinal bacterial communities from each other. There was a positive correlation between the number of tumors and number of operational taxonomic units. The relative abundances of Proteobacteria and Tenericutes phylum were positively related to tumor burden, while sum of the relative abundances of Firmicutes and Bacteroidetes phylum, especially that of Clostridia class were negatively related to tumor burden. Conclusion: The change of intestinal microbiota through antibiotics administration attenuates colon tumorigenesis. Ecological interactions of the gut microbial community, rather than individual bacterial population, play an important role in the development of CAC. Keywords: microbiota, colitis-associated cancer, azoxymethane-dextran sodium sulfate, tumorigenesis Background and Aim: The risk of colorectal carcinoma (CRC) is increased in patients with Crohn's disease (CD). Patients with severe inflammation and those with longer duration of diagnosis were more likely to develop colorectal carcinoma (CRC). The prevalence of cancer was higher in inflammatory bowel disease (IBD) patients with (0.78%) than without stricture (0.11%). Methods: We report a case of a 52-year-old Indian gentleman who was diagnosed with perianal CD. Following treatment with sulfasalazine for 2 years, he defaulted follow up but reported a history of remaining asymptomatic for 30 years. He was admitted to the hospital for weight loss and deep vein thrombosis; he was also malnourished with anemia. Colonoscopy proved difficult: because of altered rectosigmoid anatomy and severe stricturing disease, evaluation was only up to the descending colon despite changing to a thinner calibre gastroscope. Limited histology showed active colitis with inflammation. CT colonography revealed multiple stenotic colonic segments with wall thickening. Results: Using Baar's proposed prediction risk model to assess his CRC risk-taking into account his age and duration of CD-he scores 15 points and has a probability of developing CRC 0.1% in the next year. Limited studies show that incidence of dysplasia/cancer in IBD patients who underwent surgery for stricturing disease is 1.2-3%. Conversely, prevalence of CRC after colectomy is < 3%. We postulate that his multiple strictures confer an even higher risk for occurrence of colonic adenocarcinoma. Where endoscopic surveillance for malignancy is challenging, there may be benefit in offering prophylactic surgical resection-the patient was however not keen for this. Background and Aim: There is a lack of data about the usefulness of neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), and fecal calprotectin (FC) in IBD. We aimed to investigate the clinical significance of NLR, PLR, and FC in IBD. Methods: We retrospectively analyzed 58 patients with IBD and 116 age-and sex-matched healthy subjects who underwent endoscopy and laboratory tests including inflammatory biomarkers. NLR and PLR were compared between IBD and healthy controls, and correlations between these indexes including FC and clinical/endoscopic activity were analyzed. Results: Receiver operating characteristic analysis was performed, which revealed a sensitivity of 70.7% and specificity of 73.3% when a cut-off of 1.798 was used for NLR (AUC, 0.802). For identifying IBD, the optimal cut-off of 139.86 for PLR had a sensitivity of 58.6% and specificity of 63.8% (AUC, 0.696). The positive correlations between NLR and CRP were observed only in IBD (r = 0.348; P = 0.008). PLR was positively correlated with ESR (r = 0.377; P = 0.004), CRP (r = 0.587; P < 0.001), and FC (r = 0.278; P = 0.034) in IBD. FC and endoscopic score were moderately correlated (r = 0.694; P = 0.026) in CD and weakly correlated (r = 0.381; P = 0.008) in UC. In IBD, correlations of NLR and PLR with endoscopic score were not statistically significant. FC > 200 μg/g (OR, 29.1, P = 0.035) and steroid use at the time of FC testing (OR, 40.3, P = 0.022) were independently associated with moderate to severe endoscopic activity. Conclusion: Although NLR and PLR are biomarkers for differentiating IBD, they are not useful indicators for reflecting the intestinal mucosal conditions in IBD. FC may be a useful inflammatory biomarker for determining the intestinal mucosal activity. Keywords: inflammatory bowel disease, neutrophil to lymphocyte ratio, platelet to lymphocyte ratio; fecal calprotectin Background and Aim: The trabecular bone score (TBS), a recently developed diagnostic tool, is a novel, grey-level texture measurement that can provide quantified information on trabecular microarchitecture. In the literature, TBS has been reported to be useful in predicting risk for fragility fracture, independent of area bone mineral density (BMD). However, studies regarding the usefulness of TBS in ulcerative colitis was rarely published. We aim to analyze whether TBS is associated with clinical features and outcomes in patients with UC. Methods Background and Aim: The aim of this study was to assess whether the incidence of inflammatory bowel disease are increased in patients with COPD compared to general population of South Korea. Methods: This nationwide, population-based study performed using data from the National Healthcare Insurance service in Korea. We included patients who were diagnosed with COPD according to ICD-10 code (J43.x and J44.x) from 2010 to 2014 and were prescribed one or more COPD medications at least twice per year. We compared COPD patients with non-COPD controls matched by age and sex with a ratio of 1:5. Cases with newly diagnosed IBD that meet both of ICD-10 codes (K50 for Crohn's disease [CD] and K51 for ulcerative colitis [UC]) and V code for rare intractable disease (V130 for CD and V131 for UC) were identified. The cumulative incidence probability of IBD was estimated. Results: During the mean follow up of 3.9 years, incidence rate of CD was 2.58 per 1,000 person-years, compared to 1.61 per 1,000 person-years among non-COPD controls (hazard ratio [HR], 1.61; 95% confidence interval [CI], 1.35-1.90; P < 0.001). Incidence rate of UC was 8.0 per 1,000 person-years, compared to 6.1 per 1,000 person-years among non-COPD controls (HR, 1.31; 95% CI, 1.19-1.44; P < 0.001). Analyzing the risk of IBD according to severity of COPD, the incidence rate of IBD was higher with increasing severity of COPD. Conclusion: The risk of IBD increased in the patients with COPD of South Korea. These results are suggestive of an association between COPD and IBD. Keywords: chronic obstructive pulmonary disease, inflammatory bowel disease Background and Aim: The aims of this study were to determine the epidemiological, sociological, clinical features and the effect of treatment in inflammatory bowel disease (IBD) patients. We also aimed to create a database related to this group of patients for the future studies. Methods: This study includes IBD patients who were diagnosed and followed up at Ondokuz MayÄ±s University Faculty of Medicine. The files of these patients were scanned retrospectively to investigate the demographic features and the clinical, endoscopic, and laboratory findings. We recorded the patients' disease activity index correlation. Ulcerative colitis (UC) and Crohn's Disease (CD) patients were compared to find out if there are significant differences in terms of these characteristics. Results: In our study, 150 patients were included (99 UC, 51 CD). In the patients whom followed, the UC/CD ratio was 2/1. The parasitos infestation history and allergic disease in CD was more than UC (P < 0.05). The duration between the onset of complaints and the diagnosis of CD was longer than in UC patients (P < 0.05). The rate of having surgery related with the disease was more in CH (P < 0.05). The rate of having surgery related with the disease was more in CD (P < 0.05). The frequency of anemia patients was 39.4% in UC and 53.1 % in CD. While proctosigmoiditis was observed mostly in the UK patients, terminal ileitis was the most frequent one in CD. The anti-TNF treatment ratio was 22.3% in UC and 43.1 in CD. Conclusion: We believe that this study will provide a database on the epidemiological characteristics and treatment responses of the increasing prevalence of inflammatory bowel disease in Turkey.
Keywords: ulcerative colitis, Crohn's disease, epidemiology Background and Aim: 5-aminosalicylic acid, corticosteroids, thiopurine, and anti-tumor necrosis factor (TNF)-α agents were effective in treating inflammatory bowel disease (IBD). We assessed the trend of prescribing these medications and their associated outcomes in Taiwan IBD patients.
Methods: A nationwide cohort study of 3806 subjects with IBD, diagnosed and registered as a catastrophic illness from 2001 to 2015, was conducted.
Results: Among these patients, 919 (24.1%) patients were diagnosed with CD and 2887 (75.9%) with UC. From 2001 to 2015, we found all these medications prescribed more often gradually. Higher dosage 5aminosalicylic acid decreased the risk of hospitalization (HR = 0.6) and operation (HR = 0.5). Thiopurine was associated with increased risk of hospitalization (HR = 2.3 in low dosage group, HR = 2.1 in high dosage group) but not affected operation risk. Higher dosage thiopurine increased the risk of tuberculosis (HR = 3.6) reactivation. Anti-TNF-α agent was associated with increased risk of hospitalization (HR = 4.0, in low dosage group, HR = 3.3, in high dosage group). Higher dosage anti-TNF-α agent increased the associated risk of operation (HR = 2.9), hepatitis B (HR: 4.3), and tuberculosis (HR: 5.1) reactivation. Corticosteroid was associated with increased risk of hospitalization (HR = 2.1, in low dosage group, HR = 3.5, in high dosage group) and risk of colostomy and ileostomy. High dosage corticosteroid also increased the risk of hepatitis B (HR = 2.8) and tuberculosis (HR: 2.8) reactivation. Conclusion: 5-aminosalicylic acid usage decreased the associated risk of hospitalization and operation for IBD patients, whereas thiopurine, corticosteroid, and anti-TNF-α agent were associated with increased risk of hepatitis B and TB reactivation, as well as the risk of hospitalization. No significant of increased risk of malignancy from all these medications usage observed in this cohort. Keywords: inflammatory bowel disease, 5-aminosalicylic acid, corticosteroids, thiopurine, anti-tumor necrosis factor agents Background and Aim: The biosimilar of infliximab, CT-P13 (Remsima®) has potential to reduce treatment costs and enhance access to biological therapy for patients with inflammatory bowel disease (IBD). However, the long-term efficacy and safety of CT-P13 in IBD patients remains unclear. Therefore, we aimed to evaluate the long-term clinical outcomes of moderate-to-severe IBD patients who are receiving CT-P13 treatment. Background and Aim: Golimumab (GLM) was approved for the treatment of ulcerative colitis (UC) in 2013. While the other anti-TNF available drugs (infliximab and adalimumab) have validated algorithms concerning prescription and therapeutic drug monitoring (TDM), little is known about GLM. So far, there is no consensus on a possible therapeutic level or cut-off associated with clinical response, remission, or any other outcome measure such as endoscopic healing in UC for GLM. Therefore, we aim to explore the pharmacodynamic change of GLM in UC patients. Methods: We used two kinds of methods for measuring the GLM level: one as in house method; the other with the IDKmonitor® Golimumab drug level ELISA kit (Immundiagnostik AG, Bensheim, Germany). After obtaining the informed consent, the serum was sampling at specific time points after the GLM injection. The dosage and schedule of GLM treatment was 200 mg (week 0), 100 mg (week 2), 50 mg (week 6) for the induction. Followed by 50 mg every 4 weeks as the maintenance therapy. Results: A total of 11 UC patients who received GLM treatment were enrolled in this study with 24 trough level measured. The mean disease duration was 5.4 years. Their mean age was 37.5 years old. Male was still predominant in this cohort (73%). All of them received the combination therapy (91.7% thiopurine, 8.3% methotrexate). The correlation between the in house method and commercial kit was good (r 2 = 0.932, P < 0.0001). The mean trough level was 3.32 ug/mL for induction phase and 0.66 ug/mL for maintenance therapy, respectively. Conclusion: Our results demonstrated that the in house method results correlated with the commercial kit. Our patients had lower trough level of GLM in maintenance phase than previous reports. Better understanding of these parameters could lead to improved patient care with GLM. Keywords: inflammatory bowel disease, golimumab Background and Aim: The risk of venous thromboembolism (VTE) is triple among inflammatory bowel disease (IBD) patients relative to general person. Although several consensus statements about VTE have been proposed, acute arterial events among IBD patients were less focused. Extraintestinal manifestations of ulcerative colitis (UC) is common; however, few reports described immune thrombocytopenia (ITP). Hence, we report an 81-year-old patient with UC complicating acute cerebral infarction after he stopped cyclosporine for ITP. Methods: The patient was diagnosed UC for 10 years with oral sulfasalazine and achieved remission of symptoms. The patient had ITP for 1 year according to bone marrow examination which presented with platelet counts decreased to 4 × 10 9 /L. Cyclosporine (50 mg bid) was prescribed as a maintenance therapy, and the platelet count was maintained in normal range. However, the patient stopped cyclosporine himself about 1 month ago. The patient admitted to hospital again due to hematochezia and diarrhea about 20 days ago. His medical history was complex, including hypertension, pulmonary emphysema, and diabetes. Laboratory tests showed that the patient's platelet count was normal. Cyclosporine was applied again after consulted hematologist. Colonoscopy presented severe extensive lesions and confirmed UC by biopsy. Results: We started treatment with dexamethasone (8 mg/day) combined mesalazine (3 g/day). Defecation reduced to four times that day. Stool examination showed red blood cells negative but occult blood test positive. Unexpectedly, the patient developed paralysis and speaking problems. Brain CT scan showed multi-ischemic infarcts. Neurologists proposed careful monitor and intensive treatment in ICU. Unfortunately, he died of respiratory failure which caused by aspiration pneumonia. Conclusion: UC accompanying ITP developed cerebral infarction is rare. ITP might be related to UC. IBD patients are at high risk for thrombotic complications, which mean a decisive factor of morbidity and mortality, and we should pay more attention on acute arterial events. Keywords: ulcerative colitis, immune thrombocytopenia, acute cerebral infarction EP-0053 (PE-0548) Retrospective case series of cytomegalovirus colitis in inflammatory bowel disease patients Authors: XINMEI ZHANG; ZHENYU ZHANG Affiliation: Department of Gastroenterology, Nanjing First Hospital Nanjing Medical University, Nanjing, China Background and Aim: Concurrent cytomegalovirus (CMV) infection colitis is concerned as an exacerbating factor in patients with inflammatory bowel disease (IBD). We evaluate the clinical features of CMV colitis in hospitalized IBD patients. Methods: A retrospective study was performed involving IBD patients with CMV colitis hospitalized in Nanjing First Hospital from January 1, 2012, through December 31, 2017. The patients' demographic data, clinical features, endoscopic and pathologic findings, treatment regimens, and outcome were analyzed. Results: Seven patients were identified with CMV colitis, including five ulcerative colitis (UC) patients and two Crohn's disease (CD) patients. CMV colitis was diagnosed as being positive for CMV on immunohistochemical staining in colonic tissue. Of all the UC patients, 80% had disease exacerbation marked by fever and aggravated abdominal symptoms, while CD patients didn't show this trend. Atypical appearances, such as wide mucosal defect, longitudinal ulceration, cobblestone-like appearance, irregular ulceration, and punchedout ulceration, were observed in UC CMV colitis patients. High-dose corticosteroids exposure was noted in 71.4% patients. Ganciclovir treatment which was given to five patients (four UC and one CD) made UC patients achieve clinical improvement, while didn't show overall benefit for CD patient. Conclusion: Compared to CD patients, UC patients appear to have closer relationship between CMV infection and disease exacerbation. High-dose corticosteroids exposure is a risk factor for CMV infection. Antiviral treatment is recommended especially for UC CMV colitis. Keywords: inflammatory bowel disease, Crohn's disease, ulcerative colitis, cytomegalovirus colitis EP-0077 (PE-0549) Gastro-resistant, prolonged release mesalazine preparation, inducedneutropenia in patients with IBD Authors: AISHA KHALID; MOHAMMED AL-ANSARI Affiliation: Department of Gastroenterology, Ballarat Base Hospital, Melbourne, Victoria, Australia Background and Aim: 5-Aminosalicylates have proven role in the management of inflammatory bowel disease. The availability mesalazine (like Mezavant Pentasa and Salofalk) preparations have enabled us to control the disease symptoms at wider level with minimal side effects than sulphasalazine. Methods: We have collected the data from Ballarat Base Hospital, a regional hospital in Victoria, with ethics committee approval. Results: Here is a case report of 81 male diagnosed with ulcerative colitis and was coomenced on newest preparation of mesalazine and after 3 months use of it, presented in ER with severe illness, lethary, and found to be in severe neutropenia. Nil significant past history. Drug was discontinued, and short course of G-CSF was given and neutropenia resolved in 2 weeks. Conclusion: Our patient showed the pattern of mesalazine-induced neutropenia but showed quick recovery after discontinuation of the drug and short course of G-CSF. We advised regular blood count checkup with its use. Keywords: neutropenia, ulcerative colitis, mesalazine Background and Aim: Cumulative surgery rate and postoperative relapse of intestinal Behcet's disease have been reported to be high. This study aimed to establish a scoring system based on follow-up endoscopic findings that can predict intestinal Behcet's disease recurrence after surgery. Methods: Fifty-four patients with intestinal Behcet's disease patients who underwent surgery due to bowel complications and underwent follow-up colonoscopy were retrospectively investigated. Their clinical data including colonoscopic findings were retrieved. Classification and Regression Tree analysis was used to develop an appropriate model of endoscopic classification that can explain the post-surgical recurrence of intestinal Behcet's disease most accurately based on the following classification: e0 -no lesions; e1-< 20-mm sized solitary ulcer; e2-20-mm sized solitary ulcer; and e3-multiple ulcers regardless of size. Results: Clinical relapse occurred in 37 patients (61.52%). Among 38 patients with colonoscopic recurrence, only 29 cases had clinically relapsed. Multivariate analysis identified higher DAIBD at colonoscopy (HR = 1.013, 95% CI, 1.005-1.021, P = 0.002) and colonoscopic recurrence (HR = 2.829, 95% CI, 1.223-6.545, P = 0.015) as independent risk factors for clinical relapse of intestinal Behcet's disease. Endoscopic findings were classified into four groups, and multivariate analysis showed that the endoscopic score was an independent risk factor of clinical relapse (P = 0.012). The risk of clinical relapse was higher in the e3 colonoscopy group compared to the e0 group (HR = 6.284, 95% CI, 2.036-19.391, P = 0.001 Affiliation: [1]Department of Internal Medicine-GI/Hepatology, Akita City Hospital, and [2]Department of Internal Medicine-GI/Hepatology, Nakadori General Hospital, Akita, Japan Background and Aim: No previous study has incorporated a plant-based diet in the induction phase of treatment for severe ulcerative colitis (UC). The aim of this study was to investigate the remission rate for infliximab combined with a plant-based diet as first-line (IPF) therapy for moderateto-severe to severe UC. Methods: This was a prospective single-group trial conducted at two tertiary hospitals. In 2012, infliximab became available for the treatment of UC in Japan. Moderate-to-severe to severe UC were candidates for the study. Severity was judged based on the Truelove & Witts criteria. Patients were admitted and given standard induction therapy with infliximab (5 mg/kg at 0, 2, and 6 weeks). Additionally, they received a plant-based diet, namely, a lacto-ovo-semi-vegetarian diet (30 kcal/kg standard body weight/day). The primary end-point was remission, defined as the disappearance of bloody stool at week 6 after initiation of study therapy. Improvement without disappearance of bloody stool was regarded as therapeutic response. Indication for surgery before completion of study therapy was regarded as therapeutic failure. This research was approved by an ethics committee. Results: IPF therapy was administered in 15 cases (male/female 8/7: 11 relapse cases, 2 initial episode cases, and 2 chronic continuous cases: 11 extensive colitis, 4 left-sided colitis: 10 severe, 5 moderate-to-severe). Median age was 37 years with a range from 18 to 78 years. Median disease duration was 36 months with a range from 4 to 336 months. Clinical remission, therapeutic response, and therapeutic failure were seen in 11, 2, and 2 cases, respectively. The remission rate was 73% in both intention to treat and per protocol analyses. The rate of therapeutic failure was 13%. Conclusion: IPF therapy induced remission at week 6 in 11 of 15 (73%) moderate-to-severe to severe UC patients. This is far better than the outcomes reported in the literature. Keywords: ulcerative colitis, infliximab, plant-based diet, remission, inflammatory bowel disease Background and Aim: It is unclear if vedolizumab has different risk of enteric infections such as clostridium difficile associated diarrhea (CDAD) compared to anti-TNF agents. We aim to study the risk of CDAD among vedolizumab and anti-TNF treated patients with inflammatory bowel disease (IBD). Methods: Retrospective review of case records was conducted for all IBD patients treated with vedolizumab and anti-TNF therapies at Singapore General Hospital from March 2010 to March 2018. Baseline characteristic, treatment duration with biologics, incidence of CDAD, and its associated risk factors (recent hospitalization within 3 months, antibiotics, steroid, immunomodulator, or proton pump inhibitor use within 4 weeks) were collected. Risk of CDAD was compared using Fisher exact test. Results: One hundred nine patients (vedolizumab: 23; anti-TNF: 86) were included. There was no significant difference in CDAD incidence between both groups, vedolizumab (1/23, 0.043%) vs anti-TNF (5/86, 0.058%), P = 0.63 (Table 1). The single case of CDAD in the vedolizumab cohort was receiving prednisolone and proton pump inhibitor at the time of diagnosis. For the 5 cases of CDAD from the anti-TNF cohort, majority (4/ 5, 80%) had minimum 1 risk factor, and 3/5 (60%) had minimum 2 risk factors. All patients were treated successfully with no recurrence reported over a median follow-up period of 16.7 months (IQR 12.5-39.5). Conclusion: While our study has observed comparable incidence of CDAD among IBD patients who were treated with vedolizumab or anti-TNF therapies, they were confounded by additional risk factors. Larger studies will be required to confirm this observation. Keywords: CDAD incidence, IBD, vedolizumab vs anti-TNF, enteric infections, CDAD recurrence CDAD table   Table 1. Cases of CDAD in both cohorts.
APDW 2018 E-poster Exhibitions -Lower GI OE-0145 (PE-0553) Ulcerative colitis in a Bangladeshi child: Case report Authors: SHIREEN AHMED; NAZMUL HOQUE; ATIA SAEED Affiliation: Department of Gastroenterology, Birdem General Hospital, Dhaka, Bangladesh Background and Aim: Ulcerative colitis (UC) is a chronic idiopathic inflammatory disorder of colon. The incidence of pediatric-onset UC is uncommon in tropics and subtropics but roughly 15% to 20%, in most North American and European regions. We describe a case of pediatric ulcerative colitis with successful treatment. Methods: A 4-year-old girl who presented with passage of loose bloody stool, abdominal pain, and mild arthralgia along with significant weight loss. Her height was 95 cm and weight was 13 kg. Diagnosis was confirmed by colonoscopy and biopsy. Treatment was thereafter started with parenteral steroid initially then oral steroid and mesalamine. The patient is now on remission and is on regular follow up. Results: Ulcerative colitis (UC) is a multifactorial disease characterized by remission and relapse. The hallmark symptoms are chronicity (> 2-3 weeks), abdominal cramping, diarrhea, and bloody stool. About 10% of patients present with features of severe colitis. Childhood-onset UC is extensive in 60% to 80% of cases, twice as often as in adults. Children also have unique age-related considerations, such as growth, puberty, nutrition, and bone mineral density accretion during adolescence, as well as differing psychosocial needs and development. With medical management, most children are in remission within 3 months; however, 5-10% continues to have symptoms unresponsive to the treatment beyond 6 months. Conclusion: UC is rare in Bangladesh, especially in children. Several conditions like infective colitis, allergic colitis, Meckel's diverticulitis, Crohn's disease, etc. may mimic the features of UC. So if a child presents with recurrent bloody diarrhea, UC should be considered as differential diagnosis. Keywords: Bangladeshi child, ulcerative colitis , especially resection of ileocecal valve (ICV) increased the odds of SIBO. Methane positive on breath test was inversely associated with SIBO in IBD patients (OR = 0.72; 95% CI 0.11-4.51) compared to controls. Treatment with immunotherapy and disease activity was not associated with SIBO in CD patients. Conclusion: Prevalence of SIBO is significantly increased in IBD patients and more than 9-fold when compared controls. Prior surgery, presence of fibrostenosing disease, combined small and large bowel disease but not disease activity, and use of immunosuppression and methane positivity on breath test were associated with SIBO in IBD patients. Keywords: bacterial overgrowth, inflammatory bowel disease, breath tests, ulcerative colitis, Crohn's disease Background and Aim: Inflammatory bowel disease (IBD) patients are vulnerable to micronutrient deficiencies due to diarrhea-related gastrointestinal loss and lack of dietary intake from anorexia related to disease activity. However, there is still limited number of studies on the incidence and risk factors of micronutrient deficiency. Methods: We retrospectively analyzed 105 IBD patients who underwent micronutrient examination including folate, vitamin B12, 25-OH-vitamin D, ferritin from March 2016 to March 2017. In addition, all of these patients had follow-up blood tests 6 months later at single tertiary university hospital. Results: In the deficiency group, 76 (72.4%) patients had a deficiency in one of the four micronutrients (folate, vitamin B12, 25-OH-vitamin D, and ferritin), and 29 (27.6%) were in the non-deficient group. Deficiency group showed significantly higher rate of young age (mean ± standard deviation [SD], 38.7 ± 14.5 vs 54.4 ± 15.0; P < 0.001), incidence of deficiency in Crohn's disease (CD) (CD, ulcerative colitis [UC], and intestinal Behcet's disease [BD]; 78.9% vs 14.5% vs 6.6%; P < 0.001), use of azathioprine (35.5% vs 10.3%; P = 0.011) and anti-TNF agents (50.0% vs 20.7%; P = 0.006) compared with non-deficient group. On the multivariate analysis, CD (Hazard ratio [HR], 3.600; 95% confidence interval [CI], 1.057-12.253; P = 0.040) and intestinal BD (HR, 15.469; 95% CI, 1.081-221.359; P = 0.044) were determined to be significant independent factors for micronutrient deficiency compared with UC. Conclusion: In conclusion, the incidence of micronutrient deficiency is high (72.4%), and CD and intestinal BD were associated with higher risk of deficiency than UC. Therefore, in IBD patients, especially the patients with CD and intestinal BD, need more attention in micronutrition. Keywords: IBD, micronutrient deficiency Background and Aim: To analyze the clinical and demographic profile of ulcerative colitis patients who required surgical intervention. Methods: Data of 60 patients studied between the year 2011 and 2018 with ulcerative colitis (UC) operated by restorative proctocolectomy and ileo pouch anal anastomosis (IPPA) were analyzed. The hematological, biochemical investigation along with endoscopic evaluation was done. The clinical course of patients was studied to estimate the average time required for surgical intervention. Results: The mean age of the patients who underwent surgical intervention was 32.3 ± 7.8 years, out of which 40.6% were females and 59.4% were males, average duration of disease was 25.56 ± 5.4 months. The number of acute episodes before operation was 4.53 ± 1.12; follow up was done for 42 months. Out of 60 patients, 63% had hemoglobin < 10 g/dL with a mean value of 9 Background and Aim: In inflammatory bowel diseases (IBD), the involvement of food antigens in immune responses remains unclear. The objective of this study was to assess the prevalence and clinical significance of food specific immunoglobulin G (IgG) and E (IgE) antibodies in patients with IBD. Methods: We enrolled a total of 101 IBD patients, including 32 ulcerative colitis (UC), 69 Crohn's disease (CD), and 50 healthy controls (HC). Serum IgG antibodies against 14 unique food allergens were measured by semi-quantitative enzyme linked immunosorbent assay (ELISA). Serum IgE antibodies against 10 food allergens were detected by western blotting (WB). Results: Food sIgG antibodies were detected in 53.1% of UC patients, 91.3% of CD patients, and 42% of HC. CD patients showed the significantly higher IgG antibodies prevalence than UC groups and healthy controls (CD vs HC, P = 0.000; CD vs UC, P = 0.000). However, there was no significance between UC and HC groups (P = 0.324). The number of IgG-positive foods was significantly larger in CD patients than in UC or HC patients (CD vs HC, P = 0.000; CD vs UC, P = 0.008). The top five prevalent food allergens which caused positive sIgG antibodies in IBD patients were tomato (77.5%), corn (68.8%), egg (61.3%), rice (57.5%), soybean (38.7%). IBD-related surgery was suggested as a risk factor (IBDrelated surgery: OR = 10.910, P = 0.014). Anti-food IgE antibodies prevalence were not different among CD (57.1%), UC (65.2%) patients, and controls (60%) (CD vs HC, P = 0.868; UC vs HC, P = 0.686). Conclusion: High prevalence of serum food sIgG may be related to incidence of CD. sIgG antibodies may potentially be utilized to guide diets for CD patients. Keywords: inflammatory bowel diseases, food antigens, food specific immunoglobulin G Background and Aim: Recent murine studies have highlighted the pro-inflammatory role of retinoic acid (RA) in sustaining inflammation. However, there is limited human data. We investigated the in vivo and in vitro role of RA in modulating mucosal inflammation in inflammatory bowel disease (IBD). Methods: This cross-sectional study included controls, steroid naïve ulcerative colitis (UC), and Crohn's disease (CD) patients. Mucosal biopsies and blood were evaluated for RA levels and immunophenotypic profiles (CD4, CD8, MAIT, γδ T cells). In healthy volunteers, we assessed the effect of RA on CD4 T-cell responses differentiated in the presence and absence of inflammatory conditions. Results: Twenty-nine UC patients, 13 CD patients, and 15 healthy controls were included. IBD patients had an increased tissue (UC: 3.4 vs 0.8 ng/mL; P < 0.0001, CD: 3.5 vs 0.8 ng/mL; P < 0.0001) and serum (UC: 1.4 vs 0.7 ng/mL; P < 0.05, CD: 1.7 vs 0.7 ng/mL; P < 0.01) RA levels than controls. Active UC had higher tissue RA levels than patients in remission (4.0 vs 2.5 ng/mL; P < 0.01). This effect was accompanied by significantly increased   Background and Aim: The global trend indicating rising incidence of inflammatory bowel disease in newly industrialized countries like the Philippines will add up to the major health problem of tuberculosis disease burden. Addressing this looming concern requires adequate data to develop good clinical practice for better delivery of health care. Availability of clinical information will help clinicians develop comprehensive approach in dealing with possible coexistence of Crohn's disease and intestinal tuberculosis. Methods: We present a case of 33-year-old, male, Filipino diagnosed with Crohn's disease with coexisting intestinal tuberculosis.
Results: Judicious approach to distinguish Crohn's disease from intestinal tuberculosis is the initial step for management. Treatment of intestinal tuberculosis must take precedence over Crohn's disease. Treatment with intestinal tuberculosis follows the basic principle of treatment with pulmonary tuberculosis employing a 6-to 9-month regimen. In cases of complications, like stricture formation leading to obstruction and perforation, surgical intervention must be considered. Conclusion: A thorough clinical evaluation, including comprehensive history and complete physical examination in addition to endoscopic, histopathologic, and biochemical investigations must be seek out prior to any attempts to start definite treatment. Ensure to rule out other diseases especially infectious etiology, most particularly intestinal tuberculosis because medications use to treat Crohn's disease has the potential to induce flare of tuberculosis leading to complications. Compendium of scientific information and clinical data will help clinicians to develop strategies and clinical pathways to address possible dilemma due to close association of these two diseases.
Keywords: inflammatory bowel disease, Crohn's disease, intestinal tuberculosis Background and Aim: Biotherapy has been recently advanced as an indication and maintenance therapy for inflammatory bowel disease such as ulcerative colitis (UC). Golimumab (GLM), which was an anti-tumor necrosis factor alpha, was approved to use for patients with UC as an indication and maintenance therapy in Japanese insurance system in addition to infliximab (IFX) and adalimumab (ADA). However, we sometimes experience the patients with secondary failure of biotherapy. We present the case of a patient with an extensive and steroid-dependent ulcerative colitis, who received a maintenance therapy of infliximab and azathioprine after failure of maintenance therapy using GLM. Methods: This was a case report. Results: This case report is a 46-year-old woman. Her past medical history is uterine myoma. She had been diagnosed with UC at the age of 26 and was in remission maintained by oral administration of 5-aminosalicylic acid (5-ASA). She experienced several cycles of relapse and remission. Steroid and leukocytapheresis (LCAP) therapy were received during repeated relapses. One and a half year ago, she got worse to severe UC and received an induction therapy of corticosteroid (PSL 40 mg/day). Although clinical remission was achieved, the attempt to taper corticosteroids was unsuccessful, it means that it has become steroid-dependent UC. Therefore, GLM was used as a maintenance therapy. Then, she was success to get free from steroid. After 10 months with this treatment, the patient was admitted to the hospital with severe condition of UC (UCAI score; 15). Steroid therapy (PSL40 mg/day) was used as an induction therapy. Then, IFX (5 mg/kg) concomitant with azathioprine (50 mg/day) was used as a maintenance therapy. She remains in clinical remission. Conclusion: Switching biotherapy and adding AZA was an important treatment option for UC patients after secondary failure of biotherapy. In the near future, new type of bioagents are desired to be available in Japan. Keywords: infliximab, golimumab, ulcerative colitis, steroid-dependent UC In a following subgroup analysis based on types of IBS, acetic acids, propionic acids, and butyric acids were found significantly higher in IBS-D patients than in IBS-C patients in one study. We also analyzed the fecal SCFAs of IBS patients receiving treatments. Patients who were receiving antibiotics and probiotics, SCFAs changed insignificantly, and those who were receiving low FODMAP diets, acetic acids and butyric acids declined significantly. Conclusion: There were differences of fecal SCFAs between IBS patients and health controls. It implied that some fecal SCFAs might be a helpful indicator for diagnosing IBS from healthy people as well as monitoring IBS treatment effectiveness to some extent. Solid and certain conclusions need more studies.
Keywords: irritable bowel syndrome, short-chain fatty acids, meta-analysis Alteration of SCFAs  (20,40,60, and 80 mmHg) and lower pain and volume thresholds compared to the control mice (all P < 0.05). Colonic PAR-2 expression (P = 0.03) as well as fecal serine protease activity (P = 0.02) and intestinal mast cell counts (P < 0.001) were elevated in PI-IBS compared to the control mice. Decreased colonic TJ proteins expression, increased lactulose/mannitol ratio (P = 0.001), and elevated colonic Th1/Th2 cytokine ratio (P = 0.001) were observed in PI-IBS compared to the control mice. Administration of PAR-2 agonist in control mice demonstrated similar changes observed in PI-IBS mice, while PAR-2 antagonist normalized intestinal hyper-permeability (P = 0.001) led a trend towards decreased Th1/Th2 ratio (P = 0.07) and reduced visceral hypersensitivity (decreased AWR scores and higher pain and volume thresholds) in PI-IBS mice. Background and Aim: Irritable bowel syndrome (IBS) is the most common functional gastrointestinal disorder. The prevalence of IBS in various Asian countries (ROME III) is 5-10%. (i) To estimate the prevalence and predictors of clinical irritable bowel syndrome by ROME IV, ROME III, and Asian criteria. (ii) To measure the agreement between ROME IV, ROME III, and Asian criteria. Methods: It was a cross-sectional questionnaire-based study done on 552 medical students (138 students per batch × 4 batches) who gave their consent for the study were included. Filled up questionnaires were collected and chi-square test was applied. Results: Among IBS subtypes 43.9%, 29.8%, 18.1%, and 9.4% were mixed, constipation predominant, diarrhea-predominant, and unclassified. Prevalence increases with increasing age and higher MBBS batch using Rome III (P = 0.012, 0.027) and Asian criteria (P = 0.002, 0.017) but not with ROME IV (P = 0.23, 0.40). IBS was found to have an association with mode of delivery, physical activity, BMI, coffee, dairy products, carbonated beverages, sleep duration, analgesic, and antibiotics intake. Cohen's kappa coefficient (κ) were 0.699, 0.367, and 0.213, between ROME III and Asian, ROME IV and ROME III, and ROME IV and Asian criteria. Conclusion: Prevalence of clinical IBS according to ROME IV, ROME III, and Asian criteria were 5.8%, 19%, 30.4%, respectively (Fig. 1). More specifically, ROME IV-positive IBS was mainly a subgroup of ROME III-positive IBS with more serious symptoms. Keywords: IBS, ROME IV, ROME III, Asian, prevalence IBS prevalence and severity distribution Only FC affected total disease-specific scores of KDQOL-SF-24 (P < 0.001). All three GERD, IBS, and FC affected total physical scores of KDQOL-SF-24 (all P < 0.03), but none affected total mental scores of KDQOL-SF-24 (all P > 0.4). On the disease-specific domains of KDQOL-SF-24, GERD affected symptoms and sleep (both P < 0.005), FC affected social support and patient satisfaction (both P < 0.03), and both GERD and FC affected effects and burden of kidney diseases (all P < 0.03). On the physical domains of KDQOL-SF-24, FC affected general health perception (P < 0.001), both IBS and FC affected physical functioning (both P < 0.03), and both GERD and IBS affected pain (both P < 0.03). On the mental domains of KDQOL-SF-24, GERD affected emotion (P = 0.001) and FC affected energy or fatigue (P = 0.049). Conclusion: FC is very common among patients with CKD and affected especially the disease-specific component of KDQOL-SF-24. GERD and IBS are less common than FC and GERD affected more domains of KDQOL-SF-24 than IBS. lesser score more distress) and Relationship Dynamics Scale (RDS; a measure of conflict; higher score more conflicts) were outcome measures of marital quality. Hospital Anxiety Depression Scale (HADS) and Quality of Life (EQ-5D-5L and EQ-VAS) were also evaluated outcomes. Multivariate analysis was used to determine associations between factors and outcomes. Results: Of 68 participants (mean age 37.8), 56% were IBS, 32.4% were FD, and 12% overlap of two. Factors associated with distressed relationship were wife income, height, weight, anxiety, and QOL. Factors associated with marital conflicts included education (P = 0.009), wife income (P = 0.02), height (P = 0.02), and number of children (P = 0.05). Factors associated with anxiety included age (P = 0.04), duration of current marriage (P = 0.01), and number of marriages (P = 0.03) and with depression, age, and duration of marriage (both P = 0.01). QOL was affected by marital conflicts (P = 0.01) not others. Of 150 controls without FGIDs (mean age 34.0 ± 9.4 years), there were no identifiable factors associated with distressed relationship (all P > 0.05), but with marital conflicts, husband income was significant factor (P < 0.001 Background and Aim: Irritable bowel syndrome (IBS) is one of the most common functional gastrointestinal diseases with high prevalence all over the world and its pathogenesis is not fully explained. Serotonin transporter (SERT) is a transmembrane transport protein which reuptakes excessive 5hydroxytryptamine to terminate its physiological effects, and the aberrant expression of SERT has been demonstrated to closely associate with IBS etiology. Probiotics have been proved by substantial evidence to play an important role in IBS management. Saccharomyces boulardii is a commonly used fungal probiotics in clinical practice, and it has been reported to be efficacious in relieving IBS symptoms; however, the precise mechanism remains unclear. The aim of the study is to explore the effects of Saccharomyces boulardii on the expression of SERT in intestinal epithelium and provide new evidence to the mechanisms of fungal probiotics relieving IBS. Methods: Human colonic epithelial cells HT-29 and Caco-2 and C57BL/6 mice were treated with different concentrations of Saccharomyces boulardii supernatants (SbS), and the Sabauraud Dextrose Broth was utilized as control group. SERT mRNA levels and SERT protein levels in HT-29 cells, Caco-2 cells, and mice intestinal tissues were detected by real-time-PCR and western blotting. Results: SERT mRNA levels in HT-29 and Caco-2 cells treated with SbS for 24 h were higher than that in control groups. Likewise, the expression of SERT protein in both cells was also upregulated in comparison to the control, tendency of which was similar to that of the corresponding mRNA. In addition, SbS can significantly upregulate SERT mRNA and protein level in mice intestinal tissues after being treated for 1 week. Background and Aim: Diverticular bleeding generally occurs in middleaged or elderly patients and patients taking anticoagulant or antiplatelet agents. If it occurs at a relatively young age without risk factors, the possibility of other diseases should be considered. We report the case of a 17year-old adolescent who finally diagnosed with gastric heterotopia after surgery. Methods: This was a case report. Results: A 17-year-old adolescent visited our clinic with abdominal pain and hematochezia after undergoing colonoscopy in another hospital. The patient was diagnosed as diverticular bleeding and referred to our hospital. Emergency colonoscopy was performed. Cecal diverticular bleeding was diagnosed, and successful hemostasis with clipping was performed. The patient was discharged 3 days after hemostasis without events. Six months later, he visited the outpatient clinic and complained of sustained right lower abdominal discomfort and an episode of hematochezia 1 month before the visit. Colon study was performed to determine the distribution of the colon diverticulum. There was a diverticulum and an external compression in the cecum, and no other diverticulum was found in the colon. Three weeks after the colon study, the patient visited the hospital and complained of aggravated right lower abdominal pain. Abdominopelvic CT showed thickening of the ascending and transverse colon, suggesting nonspecific colitis and multiple lymph nodes of less than 1 cm in size in the ileocolic chain, suggesting reactive lymph nodes. On the basis of the sustained right lower abdominal pain and discomfort and repeated findings of hematochezia, anemia, and abnormal findings on both CT and colon study, we recommended surgery, and laparoscopic ileocecal resection was performed. After pathological examination, congenital diverticulum with gastric heterotopia in the cecum and cecal perforation was diagnosed. Conclusion: In a case of hematochezia, even in younger patients, a complete colonoscopy should be performed, and one should be aware of the occurrence of rare diseases such as gastric heterotopia. Keywords: hematochezia, diverticular bleeding, gastric heterotopia Background and Aim: Disseminated tuberculosis (TB) results from the lymphohematogenous spread of mycobacterium tuberculosis and typically do not present in people with intact immune system. Gastrointestinal TB is 7-10% in all of extrapulmonary cases. Involvement of rectum and anal canal is uncommon and massive transfusion requiring lower GI bleeding is rare. Methods: We report a case of a previously healthy 49-year-old Filipino who presented with altered mental status, low grade fever, and cough. Work-up revealed TB meningitis and pulmonary tuberculosis. During this admission, he developed massive hematochezia requiring multiple blood transfusions. On colonoscopy, clean-based rectal ulcers were noted, and biopsies showed TB PCR positivity. Anti-Koch's treatment with dexamethasone was started; however, patient developed drug-induced liver injury, and re-challenge was done to continue treatment with resolution of bleeding noted. Patient was sent home after physical therapy and completion of treatment for pneumonia and pressure ulcers. Results: In patients treated for intestinal TB, it is expected that there will be a complete resolution of the lesions, detectable by endoscopy or by imaging, following therapy. Conclusion: Massive bleeding from ulcers in any part of the gastrointestinal system should therefore be included in differential diagnoses for disseminated TB especially in endemic areas, where the burden of disease is high and even immunocompetent hosts can be affected. High index of suspicion is warranted in order to institute early treatment for this potentially life-threatening condition. Keywords: disseminated tuberculosis, immunocompetence, massive GI bleeding, GI TB, rectal ulcers Background and Aim: Multiple myeloma is a neoplasm of plasma cells which produce monoclonal immunoglobulin, sometimes is combined with amyloidosis that resulted from the deposition of amyloid proteins in body tissues and lead to organ dysfunction. We report a case that has lower gastrointestinal tract hemorrhage as a primary manifestation of multiple myeloma accompanied with gut amyloidosis. Methods: A 61-year-old man reported a 5-month history of abdominal pain, bloody diarrhea, and a weight loss of 10 kg. Colonoscopy showed multiple colonic ulcers appearing indistinguishable among enterophthisis, ulcerative colitis, and ischemic colitis, while his laboratory test supported none of them. Pathological findings only suggested non-specific chronic inflammation. On his back and chest wall, there were patches of dark brown rashes with slight itch throughout the course of his disease. A 6-week diagnostic treatment of mesalazine 1 g tid po was carried out and the abdominal pain and hematochezia got partly remission, but colonic ulcers gave no improvement. Afterwards, the patient developed community-acquired pneumonia and heart failure. Moreover, the anemia was aggravating. We conducted bone marrow aspiration and found neoplastic plasma cell proliferation.
Monoclonal immunoglobulin was also detectable in his blood, leading to the diagnosis of multiple myeloma. Re-examination of his colonic biopsies revealed positive by Congo red staining. Results: The patient is now receiving an appropriate chemotherapy for multiple myeloma, yet still under our follow up. Conclusion: Hematochezia is a common complaint of patients. In those with unexplained mucosal lesions, gastrointestinal amyloidosis should be suspected, and staining of biopsies from lesions by Congo red is recommended. Subsequent etiologic evaluation would be helpful to make optimal medical decisions. Keywords: hemorrhage, multiple myeloma, monoclonal immunoglobulin, amyloidosis Background and Aim: Colonic angiodysplasia (AGD) is a common cause of gastrointestinal bleeding. However, the characteristics and actual prevalence of patients with colonic AGD is limited. We determined the clinical features and risk factors for bleeding of colonic AGD in a Taiwanese population. Methods: From February 2007 to December 2016, 16,760 colonoscopies were performed at Tri-Service General Hospital. Eighty-four patients were diagnosed with AGD. We conducted a retrospective study by analyzing the medical records of these 84 patients. The clinical features and endoscopic findings were evaluated thoroughly. Furthermore, we distinguished colonic AGD into bleeding and non-bleeding types and identified the risk factors for actively bleeding colonic AGD. Results: In our study, the prevalence of colonic AGD is 0.5% in all patients receiving colonoscopy. Among those 84 patients with colonic AGD, we found that the percentage of them increased with age. In all, 53.6% of patients with colonic AGD were older than 70 years old. More than half of the patients had hypertensive cardiovascular disease (53.6%), and the AGD lesions were predominantly in the left-sided colon (34.5%). We analyzed several factors to identify those associated with bleeding colonic AGD. The results indicated that age (P = 0.014) and chronic kidney disease (P = 0.033) were significant factors associated with bleeding lesions. In addition, hypertensive cardiovascular disease and type 2 diabetes mellitus also were associated with bleeding tendencies. Conclusion: Angiodysplastic lesions in Taiwanese patients were left-sided colon predominant. Old age and chronic kidney disease were independent risk factors associated with bleeding colonic angiodysplasia. Keywords: colonic angiodysplasia, bleeding, risk factor Background and Aim: Patients with colonic diverticular disease may develop diverticular bleeding in 3% to 15% of cases. Early rebleeding is defined as within 30 days after hemostasis, and late rebleeding is defined as that occurring after 30 days. We examined the association between rebleeding (early and late) and various factors including patients' background and initial management. Methods: We performed a retrospective study of patients with colonic diverticular bleeding from August 1, 2011, through March 31, 2017, at our hospital and related institutions. Using the hospital registry, we divided 205 patients into three groups: early, late, and no rebleeding. We analyzed that the association between rebleeding and various factors including patients' background factors: age, gender, past history, medication, hospital length of stay, presence or absence of blood transfusion, and post-hospitalization course. Results: There were 46 patients in the early rebleeding group, 30 cases in the late rebleeding group, and 129 cases without rebleeding group. As risk factors of early rebleeding, liver disease complications tended to be higher in univariate analysis (P = 0.06) and significantly higher in multivariate analysis (odds ratio 6.8, P = 0.02). Meanwhile, as risk factors of late rebleeding, cerebrovascular accidents were significantly higher in univariate analysis (P = 0.001) as well as in multivariate analysis (odds ratio 6.8, P = 0.02). In addition, blood transfusion was performed more frequently in early rebleeding group than in late rebleeding group (P = 0.003). There were no significant differences of average hospital length of stay among three groups: 12 days in the early rebleeding group; 11 days in the late rebleeding group, and 9.2 days in the no rebleeding group. Conclusion: In the current study, hepatic disease was considered as an independent risk factor of early rebleeding, and cerebrovascular accident was considered as an independent risk factor of late rebleeding. Keywords: colonic diverticular bleeding, rebleeding, risk factor Background and Aim: Endoscopic band ligation (EBL) has been performed to achieve hemostasis for colonic diverticular bleeding as well as endoscopic clipping. But the direct comparison between EBL and endoscopic clipping is few reported. Methods: We retrospectively analyzed 37 patients who underwent EBL or endoscopic clipping for colonic diverticular bleeding from January 2015 to February 2018 on the basis of singlecenter experience in Japan. Results: Of the 37 patients, 17 (45.9%) were treated with EBL. The success rates of hemostasis were 94.1% in EBL group and 100.0% in clipping group, respectively. No significant differences in time required for detection of bleeding diverticulum (14.4 ± 1.9 min vs 13.5 ± 2.0 min, P = 0.76), time for hemostasis (22.5 ± 3.5 min vs 19.8 ± 3.3 min, P = 0.59), and total procedure time (36.8 ± 4.4 min vs 34.9 ± 4.5 min, P = 0.77) were observed between the two groups. The short-term rebleeding rate within 30 days was significantly lower in EBL group (0.0% vs 25.0%, P = 0.009), but the long-term rebleeding rate over 1 year did not differ significantly between the two groups (45.5% vs 35.3%, P = 0.59). As for complications, perforation occurred in neither group, and fever developed 1 of EBL group and 2 of clipping group, respectively. Conclusion: EBL for colonic diverticular bleeding is safe and efficacious as well as endoscopic clipping. EBL significantly decreased the short-term rebleeding rate, but the long-term rebleeding rate was comparable.
Keywords: endoscopic band ligation, colonic diverticular bleeding Patient characteristics and results  HD) were included, with a 1:2 match for chronic kidney disease without hemodialysis (CKD-non HD) and a control group. The end-points were lower GI bleeding, angiodysplasia bleeding, and bleeding-related mortality. Results: From January 1, 2000, to December 31, 2012, 574 hemodialysis patients were enrolled, and both 1148 patients with CKD-non HD and the control were identified by a 1:2 match. The cumulative incidence of lower GI bleeding was 12.9% in hemodialysis patients, 3.6% in the CKD-non HD group, and 2.8% in the control group. The cumulative incidence of angiodysplasia bleeding was 1.1%, 0.1%, 0.1% in these three groups. In multivariate analysis for lower GI bleeding, hemodialysis (Hazard ratio [HR] 29.09), chronic kidney disease (HR 6.61), male (HR 3.14), and extreme old age (age ≥ 85, HR 15.74) were independent risk factors for lower GI bleeding. The bleeding-related mortality rates were 2.4%, 1.1%, and 0% in these three groups, P < 0.05. Conclusion: Hemodialysis was the most important risk factor for lower GI bleeding, angiodysplasia bleeding, and bleeding-related mortality. Keywords: hemodialysis, chronic kidney disease, lower gastrointestinal bleeding, angiodysplasia Background and Aim: The long-term effect of gut microbiota and subsequent metabolic profiles in colectomy patients is limited. We evaluated and compared long-term effects of metabolic profiles and microbiota status in early colorectal cancer (CRC) patients receiving curative colectomy to the controls. Methods: In this cross-sectional study, we analyzed metabolic syndrome (MS) occurrence in 165 patients after curative partial colectomy with right hemicolectomy (RH) or low anterior resection (LAR) and 333 age-sex matched controls. Fecal samples from some of those with RH, LAR, and controls were analyzed by next-generation sequencing method.
Results: MS occurrences were significantly higher in patients after RH, but not LAR, when compared with the controls over the long-term (> 5 years) follow up (P = 0.020) ( Table 1). Compared with control group, RH group showed lower bacterial diversity (P = 0.007), whereas LAR group showed significantly higher bacterial diversity at the genera level (P = 0.016). Compared with the control group, the principal component analysis revealed significant differences in bacterial genera abundance after RH and LAR (P < 0.001). Firmicutes to Bacteroidetes ratio was significantly lower in the RH group than the control group (22.0% versus 49.4%, P < 0.05). Conclusion: Early CRC patients after RH but not LAR had a higher occurrence of MS than the controls during long-term follow up. In parallel with the metabolic profile, gut microbial diversity also significantly decreased after RH. This study suggests that patients after curative RH due to CRC should receive not only standard surveillance including colonoscopy but also standard regular metabolic screening. Keywords: metabolic syndrome, gut microbiota, colorectal cancer, right hemicolectomy Background and Aim: The role of gut microbiome in the etiology of colorectal cancer (CRC) is emerging, and the type of microbiota patterns in South Asian populations has not been studied. Hence, we set out to study the gut microbiota patterns in patients with CRC, diabetes (DM), and healthy individuals to find the specific gut microbiota patterns associated with CRC. Methods: The relative abundance of 45 types of gut microbiota was determined in stool samples in patients with CRC (n = 24), DM (n = 20), and healthy individuals (n = 44), using a PCR array. Data were analyzed using a specific software for analysis. Results: Bacteroides fragilis was expressed 23.88-fold higher in patients with CRC, and 77.09-fold higher in patients with DM when compared to healthy individuals. Aeromonas species were the predominant microbes, in patients with DM (226.64-fold higher), followed by Enterococcus faesium (183.1-fold higher), Shigella dysentriae and Streptococcus agalactiae compared to healthy individuals. Akkermansia muciniphila, Bacteroides vulgatus, and Bacteroides thetaiotaomicron were 5.87, 2.12, and 8.03-fold higher in CRC patients, while expression of most bacterial species of the genus Enterobacteriaceae were lower (Fig. 1). Conclusion: Bacteria of the genus Enterobacteriaceae were most abundant type of gut bacteria patients with DM, while their abundance was lower in patients with CRC. Bacteroides fragilis was equally highly expressed in patients with DM and CRC. Since DM is known to be a risk factor for the development of CRC, the role of Bacteroides fragilis in the pathogenesis of CRC should be further investigated.
Keywords: colorectal cancer, gut microbiota, Sri Lanka  Background and Aim: The gut microbiota plays a vital role in intestinal carcinogenesis. Evidence indicates that the decrease of butyrate-producing bacteria can be found in patients with colorectal cancer (CRC). However, little is known about the effect of butyrate-producing bacteria supplementation on intestinal carcinogenesis. In this study, we aimed to investigate the antitumor effects and mechanisms of Clostridium butyricum (one of butyrate-producing bacteria) on the composition of intestinal microbiota and cancer progression. Methods: High-fat diet-fed Apc min/+ mice were gavaged with Clostridium butyricum at a dose of 2 × 10 9 cfu/0.2 mL 3 times a week for 12 weeks. Mice with high-fat diet and basal diet were used as high-fat diet controls and untreated controls, respectively. At the 12th week of the experiment, fresh feces were collected for microbiota illumina sequencing analysis, and ileocecal feces were used for short-chain fatty acids (SCFAs) analysis. Parameters of intestinal tumor development, cell proliferation and apoptosis, and Wnt signaling pathway were also determined. The human colon cancer cell lines Caco-2 and HCT116 were used to further verify the antitumor effect of Clostridium butyricum. Results: Clostridium butyricum significantly prevented high-fat diet-induced intestinal tumorigenesis in Apc min/+ mice compared with these fed a single highfat diet. Clostridium butyricum increased ileocecal concentrations of shortchain fatty acids and activated GPR43 and GPR109A in Apc min/+ mice.
Additionally, Clostridium butyricum inhibited proliferation and promoted apoptosis in intestinal tumor cells. Moreover, Clostridium butyricum ameliorated deteriorative composition of intestinal microbiota, which increased probiotics including SCFA-producing bacteria and decreased CRC-related bacteria. At the molecular level, Clostridium butyricum inhibited the tumor-associated Wnt/β-catenin signaling pathway. Conclusion: Supplementation of butyrate-producing bacteria suppressed intestinal carcinogenesis through modulating intestinal microbiota and Wnt pathway. These findings broaden our understanding for the butyrate-producing bacteria supplement in the prevention and treatment of CRC. Keywords: producing-butyrate bacteria, intestinal carcinogenesis, gut microbiota, high-fat diet, Apc min/+ mouse  Fig. 1). 002 showed significantly higher sporulation than 014 and 046 at 72 h (002: 47.14% vs 014: 7.341%, P < 0.0001). 002 showed a significantly higher germination than others at 0 h and 48 h (At 0 h, 002: 5.615% vs others: 0%, P < 0.02). Results of animal experiment are in progress. Conclusion: Ribotypes 002 had high toxin production as 014 and 027 and high sporulation and germination rates, which may contribute to high mortality of 002 in Hong Kong.
Keywords: Clostridioides difficile, sporulation and germination, clostridioides difficile infection, toxin production, ribotypes   (Fig. 1). A higher abundance of Akkermansia and Alistipes and lower abundance of Prevotella were detected in CIPO patients compared with controls. Principal component analyses indicated slight difference in bacterial composition between the 2 groups. In the subgroup analysis among CIPO patients based on active symptoms, transition zone, and small bowel involvement at enrollment, no significant difference was observed. Conclusion: CIPO is associated with a rich and diverse fecal microbiome with higher abundance of Akkermansia and Alistipes but lower abundance of Prevotella. Future studies are warranted to elucidate the meaning of this microbiome change in CIPO.
Keywords: intestinal pseudo-obstruction, colon, chronic, fecal microbiome Background and Aim: Stress is one vital etiology of irritable bowel syndrome (IBS), which is well known for perturb the microbiome and exacerbate IBS-associated symptoms. Changes in the microbiota and its metabolites affect the IBS pathophysiology. We investigated the alterations and correlations of the gut microbiome and metabolism in response to stress due to colorectal distention combined with restraint stress (CDR) administration in rats. Methods: CDR stress was used to induce IBS-like symptoms in rats. Metagenomic sequencing of the 16S rRNA gene was used to characterize the ileocecal intestinal contents microbiome. UPLC-MS/MS assaying of small molecules was used to characterize the metabolomes of the ileocecal intestinal contents. Results: IBS group significantly decreased in the species diversity compared to controls; no significant differences were observed in the mean community richness. The gut of IBS group was depleted of some potentially beneficial bacteria, such as Christensenellaceae, Bacteroides sp., and Ruminococcaceae but were enriched in some bacterial taxa containing opportunistic pathogens. The differences in the metabolite profiles significantly changed. Tryptamine and L-phenylalanine were the primary differentially excreted metabolites identified, and phenylalanine, tyrosine, and tryptophan biosynthesis was the major metabolic pathway induced by stress. Several altered gut bacterial taxa exhibited potential interactions with stress-induced IBS through their associations with altered metabolism indicators, such as the positive correlation between Tryptamine and Prevotella and the negative between L-phenylalanine and Oscillibacter. Background and Aim: Despite well-known benefits of technology-based support programs, technology-based colon cancer support programs for Asian Americans have rarely been developed and used. The purpose of this study was to present the challenges in developing a culturally tailored technology-based colon cancer support program for Asian Americans (TCOLS) using computers and mobile devices. Methods: The TCOLS has been developed based on the Bandura's Theory of Behavioral Change.
To develop the program, the Ruby on Rails framework and the Xen hypervisor were used. The TCOL was developed to include social media sites, 10 educational modules, and 20 online resources. During the development process, the challenges that the research team met were recorded, and weekly research team meetings were held to discuss and resolve the challenges. The written records were analyzed using a content analysis. Results: First, the use of multiple languages raised several practical challenges including the inaccuracy of Google translator. Second, security issues related to computer servers were raised because the research team did not have a control of computer servers located in the central IT office. Third, the use of the existing electronic data collection system was a challenge to use multiple language versions. Fourth, technological literacy of research team members was another challenge to consider. Finally, adoption of culture-specific mobile apps was a challenge to incorporate in the program (e.g. WeChat, Line, Kakaotalk). Conclusion: There exist several challenges that need to be considered in future development of a technology-based support program for colon cancer that is tailored to a specific cultural group.
Keywords: colon cancer, support program, technology, issues, languages Background and Aim: Colorectal endoscopic submucosal dissection (ESD) has been widely spread due to technical and equipment development. However, there are cases where maneuverability is poor. We evaluated the efficacy of balloon-assisted endoscope (BAE) for colorectal ESD with poor endoscopic maneuverability before and after adoption. Methods: We confirmed maneuverability preoperatively in all 400 cases of colorectal ESD performed at Showa University Fujigaoka Hospital from April 2011 to April 2018. Eighty-three subjects of deep colon cases were judged as poor maneuverability and included. Fifty-four cases in the BAE group using a balloon-assisted endoscope (group B) and 29 cases in the conventional group (group C) not using it were retrospectively compared. We used a single balloon-assisted endoscope (ST-CB 1; Olympus, Tokyo, Japan) for BAE. Tumor size, resected specimen size, procedure duration, dissection speed, en bloc resection rate, histology, and associated complications were compared between groups. Results: Lesion localization (cecum, ascending/transvers, descending) was (22/32) in group B and (15/ 14) in group C, respectively. The mean tumor size (29 mm), tumor invasiveness, fibrosis, perforation, and postoperative bleeding did not differ between the two groups. Two groups showed similar percentages of en bloc resection (97.8% vs 97.9%), but there was statistically significant difference between the two groups in R0 resection (96.3% vs 82.8%; P = 0.048). In group B, compared with group C, procedure duration tended to be shorter (67.9 min vs 80 min), dissection speed tended to be earlier (19.6 mm 2 /min vs 17.4 mm 2 /min). Conclusion: In cases of colorectal ESD with poor maneuverability, BAE contributed to shortening of resection time and improvement of R0 resection rate. This study with BAE suggests the possibility of contributing to the further spread of colorectal ESD. Keywords: endoscopic submucosal dissection, colorectal ESD, colorectal tumor, balloon endoscope, balloon-assisted endoscope Background and Aim: Non-alcoholic fatty liver disease (NAFLD) is associated with risks for developing colorectal adenoma, which is related to various metabolic factors. However, studies on the risks of developing colorectal adenoma according to the severity of NAFLD are limited. This study aimed to evaluate the association between advanced fibrosis in NAFLD and the risk for colorectal adenoma. Methods: We retrospectively analyzed the data of 6,332 adults who underwent abdominal ultrasound and first-time colonoscopy on the same day in a health screening program at Yeungnam University Hospital from September 2009 to June 2017. NAFLD was diagnosed using abdominal ultrasound. We evaluated the presence of advanced fibrosis in NAFLD using various non-invasive score, which also analyzed the detection rate of colorectal adenoma according to the presence of advanced fibrosis in the subjects with NAFLD. Results: The subjects with NAFLD had a higher prevalence of colorectal adenoma, advanced adenoma, and multiple adenomas. In the multivariate analysis adjusting for demographic and metabolic factors, NAFLD was an independent risk factor for colorectal adenoma (adjusted odds ratio [OR], 1.15; 95% confidence interval [CI], 1.02-1.30), advanced adenoma (adjusted OR, 1.50; 95% CI, 1.12-2.01), and multiple adenomas (adjusted OR, 1.32; 95% CI, 1.01-1.73). When NAFLD was further stratified based on the stage of fibrosis using the non-invasive score models, the subjects with NAFLD and advanced fibrosis had a significantly higher risk for colorectal adenoma, advanced adenoma, and multiple adenomas than those with NAFLD without advanced fibrosis. Conclusion: NAFLD with advanced fibrosis is an independent risk factor for colorectal adenoma compared with NAFLD without advanced fibrosis. Keywords: liver fibrosis, non-alcoholic fatty liver disease, colorectal adenoma Background and Aim: International guideline recommends performing a colonoscopy after an episode of acute diverticulitis. The aim of this study was to assess the colonoscopy results and its clinical significance in patients with acute diverticulitis on CT scan. Methods: From January 2006 to December 2016, medical records of patients with acute diverticulitis diagnosed on CT scan who underwent complete colonoscopy within 1 year of diagnosis were reviewed retrospectively. Patient's characteristics, CT findings, and colonoscopy results were reviewed. Analyses for prevalence and factors associated with advanced colorectal neoplasia (ACN) were also performed. Results: Among the 235 patients with acute diverticulitis diagnosed on CT scan, 77 patients without exclusion criteria were finally included. The mean age was 49.7 ± 15.3 years, and 51 (66.2%) patients were men. The lesion was in the right colon in 68 (88.3%) patients, and all the lesions were shown as bowel wall thickening on CT scan. Fluid collection was noted in 11 (14.3%) patients, abscess in 3 (3.9%) patients, and lymphadenopathy in 7 (9.1%) patients on CT scan; 97.4% of the patients were improved with conservative treatment. Mean interval from diagnosis to colonoscopy was 40.2 ± 56.4 days. Adenomatous polyps were found in 19 (24.7%) patients; among them, 5 (6.5%) patients had advanced adenoma. Colorectal adenocarcinoma was found in 4 (5.2%) patients, and all of them were over 70 years old. The prevalence of advanced colorectal neoplasia was higher in patients over 60 years and admitted for longer than 10 days. On multivariate analysis, age over 60 years was identified as independent risk factor for ACN. Conclusion: Colonoscopy detected ACN in 11.7% patients with acute diverticulitis. Because patients over 60 years have a higher risk of ACN, follow-up colonoscopy is needed after the diagnosis of acute diverticulitis. Keywords: colonoscopy, colonic diverticulitis, colorectal neoplasia Background and Aim: Accumulating data indicates that certain microRNAs (miRNAs or miRs) are differently expressed in the samples of tumors and paired non-tumorous samples taken from the same patients with colorectal tumors. We previously reported to clarify the relationship between the expression of the miRNAs and the endoscopic morphological appearance of the colorectal tumors. Methods: We analyzed miRNAs (miR-143, -145, -7, -21, -34a) of 162 tubular or tubulovillous adenoma or tubular early cancer, or 75 tubular type 2 advanced cancer, 26 familial adenomatous polyposis (FAP), 15 ulcerative colitis associated tumor (UCAT), and 9 sessile serrated adenoma/polyp (SSA/P). Moreover, we classified adenomas and early cancer in endoscopic morphological appearance. At last, we tried to clarify the relationship between the expression of the miRNAs and the colorectal tumor development. Results: The expression levels of miR-143, -145, and -34a were reduced in most of the polypoid and FAP tumors compared with those in the flat elevated, UCAT, SSA/ P ones. In type 2 cancers, the miRNA expression profile was similar to that of the polypoid and FAP tumors. The expression levels of miR-7 and -21 were upregulated in non-granular type of laterally spreading tumor, UCAT, SSA/P compared with those in polypoid and FAP tumors. Conclusion: These findings indicated that the expression of onco-related miRNAs was closely associated with the development and endoscopic appearance of colorectal tumors. Keywords: microRNA, colorectal tumor development, adenoma carcinoma sequence, de novo type pathway, inflammatory colonic carcinogenesis EE-0156 (PE-0607) Alcohol consumption is associated with the risk of developing colorectal neoplasia: Propensity score matching analysis Authors: YOUNG JOO YANG; CHANG SEOK BANG; GWANG HO BAIK Affiliation: Department of Internal Medicine-GI/Hepatology, Chuncheon Sacred Heart Hospital, Chuncheon, Republic of Korea Background and Aim: Despite the well-known association between alcohol consumption and the development of colorectal neoplasm (CRN), the cumulative effect of alcohol consumption on the development of CRN has not been thoroughly elucidated to date. Methods: We retrospectively identified 1,448 patients who underwent index and subsequent surveillance colonoscopy during the study period. The association between significant alcohol consumption (males > 30 g/day, females > 20 g/day) and the cumulative occurrence of overall and advanced CRN at the time of surveillance colonoscopy was analyzed using propensity score matching (PSM) analysis. Results: In the PSM analysis with 210 matched-pairs, the cumulative rate of overall CRN at 5 years after index colonoscopy was higher in the significant alcohol consumption group than in the control group (40% vs 27.6%, P = 0.004). Significant alcohol consumption (adjusted hazard ratio [aHR]: 1.86, 95% CI: 1.28-2.70, P = 0.001) was associated with the occurrence of overall CRN at surveillance colonoscopy. In subgroup analyses based on the risk categories of index colonoscopic findings, significant alcohol consumption was associated with the overall CRN occurrence at the time of surveillance colonoscopy in the normal (aHR: 1.90, 95% CI: 1.16-3.13, P = 0.01) and low-risk groups (aHR: 2.13, 95% CI: 0.98-4.62, P = 0.06). However, there was no association between significant alcohol consumption and the development of advanced CRN on surveillance colonoscopy. Conclusion: Significant alcohol consumption is associated with the risk of overall CRN occurrence, especially in patients in the normal or low-risk categories at index colonoscopy. Alcohol consumption habits should be reflected in the determination of optimized time intervals for surveillance colonoscopy. Keywords: alcohol drinking, propensity score, colorectal neoplasm Background and Aim: Patients diagnosed with gastric cancer have a higher prevalence and increased risk of colorectal cancer. But few studies have investigated the risk of colorectal cancer or adenoma in patients with early gastric cancer or gastric adenoma. The purpose of this study is to investigate the prevalence of colorectal adenoma or cancer in patient with gastric adenoma and early gastric cancer. Methods: We performed a prospective study. From January 2015 to December 2016, 110 patients who had treated stomach ESD due to early gastric cancer or adenoma were enrolled. Healthy age-and sex-matched controls were enrolled from general screening population. Demographic factors and colonoscopic findings of the cases and the controls were collected, and prevalence and risk factor of colorectal adenoma and cancer of both groups are analyzed. Results: Data from 110 patient in the gastric neoplasm group (93 with gastric adenoma, 17 early gastric cancer) and 110 healthy control group participants were included in the statistical analysis. The presence of gastric adenoma or early gastric cancer was an independent risk factor for colorectal adenoma (OR = 4.4312, 95% CI = 2.7159-7.2301). The presence of gastric adenoma or early gastric cancer was an independent risk factor for colorectal high risk adenoma (OR = 5.0980, 95% CI = 1.9995-12.9986). There was no statistical relation between gastric adenoma or early gastric cancer and colorectal cancer (P = 0.0948). Conclusion: The risk of colorectal adenoma and high risk colorectal adenoma increased significantly in patients with gastric adenoma and early gastric cancer. Therefore, we suggest that colonoscopic surveillance should be strictly considered in patient with gastric adenoma and early gastric cancer. Background and Aim: Rarely, actinomycosis can mask malignant diseases. We report a case of colonic diffuse large B cell lymphoma (DLBCL) which was misdiagnosed as abdominal actinomycosis. Methods: A 76year-old woman presented with right flank pain and weight loss. Abdominal CT (Fig. 1) and colonoscopy (Fig. 2) revealed huge ascending colon mass. Although initial impression was malignancy, colonoscopic biopsy revealed no malignant cells, but sulfar granule and filamentous organism (Fig. 3) suggested actinomycosis. Results: We administered intravenous penicillin G under the impression of abdominal actinomycosis. But her condition deteriorated rapidly, and follow-up CT showed markedly increased colon mass and new multiple nodular lesions around ascending colon. We performed sono-guided percutaneous biopsy of nodular lesion.
Pathologic result was DLBCL. The patient was scheduled for chemotherapy but expired due to cancer progression. Conclusion: Diagnosis of gastrointestinal infiltrating tumors is often difficult because superficial biopsy rarely provide confirmative diagnosis. This case shows the difficulty of correct diagnosis of lymphoma due to the concomitant actinomycosis.
Deep biopsy or surgery must be considered in case of actinomycosis with no response to antimicrobial therapy. Keywords: lymphoma, actinomycosis   Background and Aim: The study was conducted to investigate the risk for colorectal neoplasia after colonoscopic resection of sessile serrated adenoma/polyps. Methods: Among the patients who underwent colonoscopy at the University of Korea Ansan Hospital between January 2012 and December 2015, a total of 147 patients with any serrated adenoma/polyp were enrolled in our study. Baseline characteristics and findings on initial and surveillance colonoscopy were extracted retrospectively. The incidence and risk factors of any colorectal neoplasia at the time of surveillance colonoscopy were evaluated. Results: In the 147 patients with any serrated adenoma/polyp, 3 (2%) with traditional serrated adenoma at index colonoscopy were excluded. Among 144 with sessile serrated adenoma/ polyp (SSA/P), male was 89 (61.8%), and mean age was 57.1 years (range 21-85). At index colonoscopies of 144 patients, 166 SSA/P were resected, and 266 other colorectal neoplasms such as tubular adenoma, tubulovillous adenoma, and cancer were detected. Among them, 30 (20.8%) patients underwent surveillance colonoscopy until September 2016. The mean interval between surveillance colonoscopy and initial colonoscopy was 19.6 months (range, 6.2-37.9 months). Cumulative incidence rate for any neoplasm on surveillance colonoscopy was 53.3% (n = 16), with a rate of 6.7% (n = 2) for advanced neoplasm. In univariate analysis between the two groups according to the metachronous colorectal adenomas, the risk factor was not found, although male was more prevalent (61.9% vs 33.3%, P = 0.151). Conclusion: The results reveal that SSA/P is associated with increased risk of metachronous colorectal neoplasm although significant risk factor of them is not found. Therefore, the short interval of surveillance colonoscopy can be considered in the patients with SSA/P on screening colonoscopy. Keywords: sessile serrated adenoma, colonoscopy, colorectal neoplasia Background and Aim: Little is known about the long-term outcomes of endoscopically resected rectal neuroendocrine tumors (NETs). The present study aimed to investigate treatment strategies determining additional treatment after endoscopic resection (ER) of rectal NETs and long-term outcomes of endoscopically resected rectal NETs. Methods: We analyzed medical records of patients who underwent ER for rectal NETs from January 2005 to December 2016. The clinicopathological characteristics of these lesions were analyzed and long-term outcomes were evaluated. Results: A total of 322 patients were studied. The complete and curative resection rates were 76.4% and 55.9%, respectively. Rectal NETs initially resected as polyps and treated with conventional EMR were observed more frequently in the non-curative group (P = 0.041 and P = 0.012, respectively). After ER, only 44 of the 142 patients (31.0%) who did not meet the criteria for curative resection received additional salvage treatment. In multivariate analysis, lesions diagnosed via biopsies (OR, 0.096; P = 0.002) or suspected as NETs initially (OR, 0.04; P = 0.001) were less likely to undergo additional treatment. Positive lymphovascular invasion (OR 61.971; P < 0.001), positive (OR 75.993; P < 0.001), or indeterminate (OR 13.203; P = 0.001) resection margins were more likely to undergo additional treatment. Although lymph node metastasis was found in 6 patients, none experienced local or metastatic tumor recurrence during the median follow up of 40.49 months. Conclusion: Long-term outcomes after ER for rectal NETs were excellent. The prognosis showed favorable outcomes regardless of whether patients receive additional salvage treatments. Keywords: rectal neuroendocrine tumor, endoscopic resection, additional treatment, outcome Background and Aim: Uterine abscess is a rare condition with an incidence of 0.5 % amidst gynecologic patients and 13.6% in elderly gynaecologic patients. The commonest cause of uterine abscesses are malignant gynecological tumors. Methods: A 70-year-old lady presented to the emergency department (ED) with colicky abdominal pain for 5 months, loose stools, and weight loss of 4 kg. She was febrile (37.9°C) and had lower abdominal tenderness. Hemoglobin was 9.9 g/dL. A computed tomograph of thorax, abdomen and pelvis demonstrated a loculated rim enhancing collection in the uterine fundus and left adnexa region measuring 8.2 cm × 8.8 cm × 7.6 cm and focal circumferential enhancing wall thickening involving the rectosigmoid colon measuring 4 cm × 5 cm × 3.7 cm. Results: The uterine collection was percutaneously drained; the aspirate yielded frank pus which grew Streptococcus viridans and Pseudomonas aeruginosa. A colonoscopy was performed which showed a circumferential mass at the rectosigmoid junction that measured 10 cm. Histopathology showed adenocarcinoma. Laparotomy was then performed which revealed a rectosigmoid mass which had invaded the posterior wall of the uterus and small bowel loops. An anterior resection with total abdominal hysterectomy and bilateral salphingo-oophorectomy with small bowel resection was performed. Two out of 20 lymph nodes had tumor metastasis (Staging: pT4b, N1b, M0). The proximal and distal resection margins were tumorfree. Conclusion: This case highlights the importance of maintaining a high index of suspicion of colorectal malignancy in extracolonic abscesses associated with Strepcococcus viridans. Keywords: rectosigmoid adenocarcinoma, Streptococcus viridans abscess, uterine abscess Background and Aim: Most colon cancers occurs via the adenoma-carcinoma sequence. Some colon cancers bypass this sequence and directly appears from normal tissues. We investigated the endoscopic and clinicopathologic features of early colon cancers originating de novo. Methods: In an academic hospital, 292 pathologic specimens of early colon cancers taken by endoscopic removal or surgical resection from 252 patients were reviewed retrospectively. De novo colon cancer was defined as early colon cancers without adjacent adenoma. Results: Mean lesion size of 17 (4%) de novo cancers from 16 patients (mean age 60 ± 9 years, male n = 10) was 1.24 ± 0.55 cm. Most lesions were located in the left colon; rectum 6 (35.3%), sigmoid colon 5 (29.4%), descending colon 4 (23.5%), and transverse colon 2 (11.7%). Elevated type was common: Is/ Isp 5/2 (41.2%), IIa (+IIc) 3/2 (29.4%), IIc (+IIa) 3/1 (23.5%), and laterally spreading tumor 1 (5.8%). Central erosions or ulcers were seen in 6 (35.3%). Submucosal and lymphvascular invasion showed in 10 (58.8%) and 4 (23.5%), respectively. The appendix mucinous cyst is a relatively rare disease, in which the mucus is stored in the lumen of the appendix and is expanded like a cyst. Depending on the case, it may shift to peritoneal pseudomyxoma. It is not only due to the rupture of cysts but also pathological differences. In overseas reports, LAMN is classified into two types by pathologic histology. In one type it is said that there is a high risk of peritoneal pseudomyxoma, and there are reports that tumor reduction surgery and hyperthermic intraperitoneal chemotherapy should be performed in that case. Keywords: LAMN, appendix cyst, pseudomyxoma peritonei  (FOBT) is conducted every year for adults over 50 years, and an additional colonoscopy or barium enema is selected in the individuals with positive FOBT. However, the adherence of the additional examination was lower than expected. Therefore, we aimed to investigate the impact of the adherence to the additional examination on clinical outcomes in the NCSP. Methods: The study population was adults aged 50 years or older that were participated in the NCSP from 2007 to 2015. Data were obtained from the Korea National Health Insurance Corporation database, which were linked with the Central Cancer Registration and National Statistical Office. The main outcomes were the detection of CRC and the proportion of local, regional, and metastatic lesions. Results: After the wash-out period from January 2007 to December 2008, a total of 319,998 were FOBT-positive cases in the National Cancer Screening Program between January 2009 and December 2010. Among the study subjects (n = 184,103) excluding subjects that met the exclusion criteria, 82,300 (44.7%) were compliant to additional examination and 101,803 (55.3%) were not. The overall CRC incidence was 2.6% in the non-compliance and 6.6% in the compliance group. Of these, regional lesions were 80.6% in the non-compliance and 85.3% in the compliance group, while the metastatic lesions were 19.4% in the non-compliance and 14.7% in the compliance. Additionally, the overall mortality and cancer-specific mortality within 5 years were lower in the compliance group than the non-compliance. Conclusion: According to the compliance with the additional examination after positive FOBT, the proportion of localized lesions among the diagnosed CRC was higher in the compliance group than the non-compliance. In addition, the 5-year mortality was lower in the compliance group than the non-compliance. Background and Aim: Emerging publications about cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) for colorectal peritoneal metastases show encouraging outcomes. Simultaneous liver resection could offer a chance of cure to selected patients with liver and peritoneal metastases. Methods: We reported a patient with colorectal liver and peritoneal metastases that was managed with hepatectomy, CRS, and HIPEC to maximize the chance of survival. Results: A 45-year-old gentleman had laparoscopic right hemicolectomy for obstructing carcinoma of ascending colon in 2015. In view of bilobar liver metastases, palliative chemotherapy of XELOX and bevacizumab were given. He was referred to our center for consideration of liver resection in 2017. PET scan showed another metachronous carcinoma of rectum with liver metastases at left lobe and segment 5. In the multidisciplinary meeting, the plan was robotic total mesorectal resection (TME) followed by left hepatectomy. Robotic TME and loop ileostomy were performed uneventfully. Two months later, at the time of elective hepatectomy, diagnostic laparoscopy revealed peritoneal deposits at right flank peritoneum and around the ileostomy. Intraoperative frozen section confirmed metastatic adenocarcinoma; thus, hepatectomy was abandoned. Subsequent PET-CT scan showed static liver metastases 1 month later; therefore, synchronous CRS, HIPEC, closure of ileostomy, and hepatectomy were performed 3 months after rectal resection. Intraoperatively, the peritoneal cancer index was 7. Left lateral sectionectomy, wedge resection of segment 5, peritonectomy, closure of ileostomy, and HIPEC were performed, with complete cytoreduction (CC-0). Post-operatively, he recovered well apart from postoperative ileus. The patient remained disease free for 6 months. His latest PET scan showed small volumes of recurrent liver and peritoneal disease. He declined third line chemotherapy as he was asymptomatic. Conclusion: CRS/HIPEC and hepatectomy could be considered in highly selected patients with colorectal metastases with minimal postoperative morbidities when compared with systemic chemotherapy or biologics. Keywords: colorectal neoplasms, perintoneal neoplasms, liver neoplasms, cytoreductive surgical procedures, antineoplastic agents Background and Aim: Screening for the early detection of colon cancer is of great significance for improving the patient survival. The purpose of this study was to explore the potential of circulating microRNAs (miRNAs) as a biomarker for colon cancer and to explore whether it can differentiate benign adenomas from colon cancer and normal people. Methods: The difference of miRNAs expression in 3 pairs of colon cancer and normal human plasma samples was investigated by microarray. After comparing the differential miRNAs expression profile with our group previous results of miRNAs chip expression differences in colon cancer tissue, we chose three miRNAs (miR-150, miR-519d, and miR-519e) to be further verified in colon and normal human plasma specimens. The correlation between their expression and clinicopathological factors was discussed. Finally, miR-519d and miR-150 were selected to investigate the expression and diagnostic significance in 90 specimens including normal persons, benign adenomas, and colon cancer. Results: Compared with normal people, the expression of miR-519e in colon cancer was not changed, while both miR-150 and miR-519d downregulated. miR-150 and miR-519d expressions were closely related to differentiation and lymphatic metastasis. Low expression levels of miR-150 and miR-519d can distinguish normal human, benign adenomas, and colon cancer from each other, and the combined detection resulted in higher AUC. Conclusion: Two kinds of circulating miRNAs are identified to separate normal people, benign adenomas, and colon cancer, which has the potential as biomarkers for early colon cancer.
Keywords: circulating miRNAs, colon cancer Background and Aim: The risk of colorectal neoplasia associated with family history of non-advanced adenoma (non-AA) is unknown. We determined the prevalence of colorectal neoplasm in subjects who have first-degree relatives (FDR) with non-AA compared to individuals who do not have FDR with adenomas. Methods: In this blinded, cross-sectional study, consecutive patients with newly diagnosed non-AA were identified from our colonoscopy database. FDRs of patients with non-AA age 40-70 years were invited for a colonoscopy (known as exposed FDRs). Our controls (known as unexposed FRDs) were FDRs aged 40-70 years of individuals who had received a normal screening colonoscopy. FDRs with a FH of colorectal cancer were excluded. The primary outcome was rate of AA. Secondary outcomes included rates of non-AA and all colorectal adenomas.
Results: Six hundred twenty-seven consecutive patients with newly diagnosed non-AA were recruited. A total of 414 FDRs from 414 effected families underwent colonoscopy. These 414 exposed FDRs were age and sexmatched with 1 unexposed FDRs each; 414 unexposed FDR from 414 families participated in a colonoscopy. Baseline characteristics were comparable between exposed and unexposed FDRs. Prevalence of AA was 3.9% in exposed Background and Aim: A 70-year-old man was referred for the evaluation of an appendiceal mass that was incidentally detected on CT. He denied any symptoms, vital signs were normal, and physical examination revealed no abdominal or rebound tenderness. A nontender palpable nodule measuring 10 mm in size was observed on the right thigh. Laboratory tests showed normal. Eosinophilia was not detected. CT showed the mass measured approximately 27 mm in length with segmental enhancement and luminal obliteration in the proximal appendix. Additionally, a right retroperitoneal serpiginous opacity with surrounding fat infiltration was observed near the appendix. He underwent a colonoscopy; however, no abnormal mucosal lesion was identified. Methods: We re-evaluated the patient's history and discovered that he occasionally consumed raw fish, frogs, and snakes from stream water. He underwent IgG antibody testing, and the results were positive for clonorchiasis and sparganosis. The patient refused surgery and was treated with praziquantel. However, follow-up CT showed persistence of the appendiceal mass. He underwent appendectomy with dissection of retroperitoneal fat, which was clinically suspicious for a migration tract. Additionally, we excised the nodule on his right thigh. Results: Histopathological examination of the resected appendix and the migration tract revealed chronic nonspecific inflammation and calcospherules with granulomatous inflammation, respectively, and resected thigh nodule showed an abscess with granulomatous inflammation and perivascular lymphoplasmacytic inflammation suggesting a parasite migration tract. Conclusion: Sparganosis is diagnosed based on the identification of larva in tissues. However, in the absence of larvae, the diagnosis can be confirmed based on histopathological findings of chronic granulomatous inflammation with central necrosis and calcospherules, and a positive ELISA test for Sparganum with a relevant history of Sparganum transmission. Treatment involves the surgical resection of larvae. Although praziquantel is useful in patients in whom surgical treatment is unavailable or those with multi-site infection, medical treatment shows high recurrence rates and unfavorable outcomes. Keywords: Sparganosis Background and Aim: Eosinophilic gastroenteritis (EGE) is an inflammatory disorder characterized by eosinophilic infiltration of the gastrointestinal tract without any known cause. It is a rare disease, and symptoms and endoscopic findings can be non-specific. Peripheral blood eosinophilia may be mild or absent. Radiologic findings often show non-specific bowel wall thickening in the mucosal disease and ascites in the serosal disease. However, rectal involvement has rarely been reported. Methods: Here, we report EGE with prominent rectal involvement. Results: An 18-yearold woman presented with abdominal pain and diarrhea for 3 weeks. Initial laboratory findings showed elevated white blood cell counts (26,480/μL) and serum eosinophil count (18,986/μL). Abdominopelvic computed tomography showed diffuse bowel wall edema from the esophagus to the rectum and mild ascites. Upper and lower endoscopy showed no significant mucosal change. Random mucosal biopsies were performed from the esophagus to the rectum, which revealed significant eosinophil infiltration with cluster and degranulation in each segment, especially in the rectum (Fig. 1). There was no other cause of eosinophilia, and the serologic tests for parasitic infection and autoimmune disease showed negative results. Based on these findings, the patient was finally diagnosed with EGE and was administered oral corticosteroid on an outpatient basis. After 2 weeks, the patient showed significant improvement in symptoms, and steroid dose was successfully tapered over 2 months. During the 10-month follow-up period, the patient continued to be stable without recurrence. Conclusion: We report a patient who was diagnosed with EGE with remarkable rectal involvement and successfully treated with oral steroid. Keywords: eosinophilic gastroenteritis, eosinophil, ascites, corticosteroid  Background and Aim: The incidence of right-sided diverticulitis is much higher in Asians compared to Caucasians. The aim of this study was to determine and compare the outcome of right colonic diverticulitis with those of left-sided disease. Methods: Retrospective review of patients admitted with diverticulitis from 2004 to 2014 to a tertiary referral unit. Patient demographics, Hinchey classification, need for emergency surgery, and perioperative outcome were analysed and compared. Results: In total 360 patients presented with diverticulitis, of which 260 (72%) were right-sided disease. The mean age was 61 years, 159 (44.2%) patients were male; 201 (55.8%) were female. All patients complained of abdominal pain while leukocytosis and fever were present in 73% and 36% of patients, respectively. The mean hospital stay was 9.4 days. The majority of patients (93%) were Hinchey grade I and II. There was no significant difference in sex, Hinchey class, or the need for emergency surgery between the 2 groups. One hundred patients (28%) underwent emergency surgery. Sixty-seven (25.7%) right-sided patients required emergency surgery; however, 54 (81%) of these were based on a presumptive clinical diagnosis of acute appendicitis. Postoperative morbidity was significantly higher in left-sided diverticulitis (70.6% vs 29.4%, P = 0.001). There was no significant difference in operative mortality. Conclusion: Right-sided diverticulitis is an important clinical diagnosis in the Asian population. Clinical presentation can often mimic acute appendicitis. When emergency surgery is required, right-sided diverticulitis is associated with a lower operative morbidity compared to left-sided disease. Keywords: diverticulitis, colonic Background and Aim: Dasatinib is a tyrosine kinase inhibitor used for secondary treatment for chronic myeloid leukemia (CML) and acute lymphoblastic leukemia (ALL) patients who are imatinib-intolerant or -resistant. One of the adverse events of dasatinib is hemorrhagic colitis. Cases of dasatinib-induced hemorrhagic colitis have been rarely reported. Severe bleeding is one of the rare complications. The aim of this study is to evaluate the clinical characteristics of dasatinib-induced colitis. Methods: This retrospective analysis of prospectively collected data was performed using information from the endoscopy, clinical records, and pathology database system of Seoul St. Mary's Hospital. Consecutive patients on dasatinib who underwent colonoscopy between January 2012 and June 2018 were enrolled. Results: Of the 624 patients who were treated with dasatinib during the study period, 148 patients underwent colonoscopy. Forty-five cases showed abnormal features. Excluding other diseases such as CMV colitis, PMC, GVHD, a total of 7 patients were diagnosed with dasatinib-induced colitis (15.5%). The mean age was 55 years. Two patients were male (28.5%). Five patients were CML and 2 were ALL Ph(+). The median time was 4 months from the dasatinib initiation to the time of colono/sigmoidoscopy (range from 3 months to 3 years). Endoscopic findings were various (angiodysplasia, inflammatory polyps, ulcers, erythema, edema, mucosal bleeding). In 4 cases with bleeding, hemorrhage improved after discontinuation of dasatinib, but re-bleeding was observed in all patients when the dasatinib was used again in a reduced dose. Only in cases without active bleeding, there was no problem in maintaining or reducing the dose of dasatinib related to re-bleeding. Conclusion: Dasatinib-induced hemorrhagic colitis is not uncommon. When bleeding occurs, cessation of dasatinib is the only effective treatment to prevent re-bleeding. Further study is needed for screening and diagnosis criteria for hemorrhagic colitis. Keywords: dasatinib, hemorrhage, colitis Background and Aim: Neutropenic enterocolitis or typhlitis, a life-threatening necrotizing enterocolitis occurring primarily in neutropenic patients post chemotherapy. Reporting severe complications will help in unifying a general approach to this condition. Methods: We report a case of a 23year-old, male, with B cell acute lymphoblastic leukemia, who had re-induction chemotherapy and developed fever, diarrhea, and right lower quadrant pain mimicking appendicitis. Computed tomography scan revealed thickened cecal walls and matted terminal ileum with reactive appendiceal inflammation. Patient was diagnosed as typhlitis and treated conservatively by placing him on nothing per orem, decompression, and parenteral nutrition. Clostridium difficile and other infectious causes were ruled out. Supportive transfusion, G-CSF injections, and IV antibiotics were given with note of resolution of symptoms. Repeat imaging after 1 week showed resolution of bowel edema with normal looking appendix. Patient was discharged and was able to continue his chemotherapy. Results: More common in adults with hematologic malignancies as well as other immunosuppressive causes, this condition is now well recognized as an important cause of morbidity and mortality. Conclusion: Given the need for use of systemic chemotherapy, patients are at risk for this potentially lethal complication and that timely diagnosis and recognition is needed to curtail its high mortality rate. Keywords: typhlitis, neutropenic enterocolitis, febrile neutropenia Background and Aim: Diverticulosis is a disease that results from complex interactions among the aging process, multiple environmental factors, and genetic predisposition. Despite epidemiologic evidence of genetic risk factors, no attempt has been made to identify genes that confer susceptibility to colonic diverticulosis. Methods: We performed the first genomewide association study (GWAS) on susceptibility to diverticulosis in a Korean population. A GWAS was conducted among 7,948 healthy individuals; among these cases, the test set comprised 893 cases and 1,075 controls, and the replication set comprised 346 cases and 305 controls. Diverticulosis was diagnosed by colonoscopy during comprehensive medical checkups, and single-nucleotide polymorphisms (SNPs) related to diverticulosis were detected with the Affymetrix Axiom ™ KORV1.1-96 Array.
Results: In total, 9 SNPs were identified in three SNP aggregates in the test set (P < 10 À3 , within 200 kb) after adjusting for sex. All the SNPs were replicated in the replication set (P < 0.05). Three SNPs were near the WNT4 gene, four SNPs were near the RHOU gene, and two SNPs were in the OAS1/3 genes. The top SNP associated with right-sided colonic diverticulosis was rs22538787, located near the WNT4 gene (combined set, P value = 3.128 × 10 À6 , odds ratio = 1.415 [95% confidence interval: 1.223-1.637]). Conclusion: We found 9 novel SNP alleles associated with colonic diverticulosis that implicated three gene loci: the WNT4, RHOU, and OAS1/3 genes, as being involved in the underlying genetic susceptibility to right-sided diverticulosis. Our results could provide new genetic insights into the development of diverticulosis in Asian populations. Keywords: polymorphism, diverticulosis, genome-wide association study, single nucleotide Background and Aim: Mesenteric inflammatory veno-occlusive disease (MIVOD) is very rare cause of ischemic bowel diseases, which is affecting the veins of bowel and mesentery. It is important to differentiate from other disease such as mesenteric venous thrombosis, and systemic disease. We describe a 76-year-old male who presented with sign of bowel obstruction and required surgical resection. Methods: We report a case in a 76-year-old Asian male who rapidly progress the symptom of abdominal pain and bloody stool. Computed tomography showed edema of distal descending colon with mild ascites. Colonoscopy revealed edematous and erythematous mucosa from the distal descending colon to the sigmoid colon. Initial clinical impression was that of type 4 colon cancer, lymphoma, recurrence of phlebo sclerosing colitis, or ischemic colitis. Colon biopsy specimens showed any pathology. After 43 days of treatment and total parental nutrition, repeated CT scan and colonoscopy finding were exacervate to previous examinations and that last colonoscopy couldn't be completed because of severe edematous. Also 3 times of biopsies revealed only focal active colitis of uncertain etiology. Faced with his persistent abdominal pain and weight loss without any precise diagnosis, surgical consultation was obtained. Results: The diagnosis of MIVOD was made after histopathological surgical specimens. Our patient completely recovered and no recurrence during the follow-up period more than over 13 months.
Conclusion: MIVOD is difficult to diagnosis at the early stage because it needs pathohistological findings in the submucosal lesion. Therefore, distinguish from other disease such as thrombostatics, systemic disease, inflammatory bowel disease, and vasculitis is important. We present a case of MIVOD leading to ischemic colitis. MIVOD, in spite of its rarity, should be considered as a differential diagnosis of unexplained severe abdominal pain with edematous colon. After common pathological causing was excluded, physician has to bear in mind the surgical resection. Keywords: MIVOD, ischemic colitis Background and Aim: CT colonography (CTC) using Barium Sulfate Oral Suspension makes it possible to alleviate pretreatment and contributes to alleviating discomfort in colon examination. However, colonoscopy (CS) on the same day has been considered difficult due to the use of barium sulfate. We therefore validated whether same-day CS can be performed after CTC with barium sulfate fecal tagging. Methods: Of the 7508 patients who underwent CTC with barium sulfate fecal tagging between June 2016 and March 2018, a total of 111 patients who also underwent sameday CS were investigated. The physician performing CS endoscopically examined and classified the status of residual barium as "good," feasible to perform total CS without problems; "satisfactory," feasible to perform total CS without issues even with the presence of barium; "poor," feasibility of total CS after multiple washings to clear the large amount of residual barium; or "unsatisfactory," infeasibility of completing total CS due to excessive residual barium. Results: Among the 111 patients who underwent same-day CS, CS did not pass through due to constriction in 8 patients, and the procedure was withdrawn by the endoscopist due to a lesion in 22 patients. Of the 81 patients who underwent total CS, the status of residual barium was determined as good in 46 patients, satisfactory in 20 patients, poor in 4 patients, and unsatisfactory in 11 patients. Excellent CS observation was feasible up to the cecum in 80% of these patients. Half of the unsatisfactory status reached the sigmoid colon, and it became difficult to implement CS with barium residuals. Endoscope failure did not occur after CS in any patients. Conclusion: CS can be performed even after CTC with barium sulfate fecal tagging. However, some patients require endoscopic washing of barium for detailed observation, indicating that the procedure should be limited to histological tissue collection or verification of treatment method. Keywords: CT colonography, barium sulfate oral suspension Background and Aim: Malignant atrophic papulosis (MAP), otherwise known as Degos disease, is a rare and progressive arterial mesenterial vascular occlusive disease. It is mainly manifested in the skin, gastrointestinal tract, and nervous system which associated with a poor prognosis. We report a case of malignant atrophic papule presenting with the skin lesion, abdominal pain, and diarrhea as the main clinical manifestations to illustrate the clinical course, endoscopy findings, and diagnosis. Methods: A 37year-old man was admitted to our hospital with generalized abdominal pain and diarrhea. The patient had presented initially with multiple skin lesions 4 years earlier and arthralgia 1 year earlier. Abdominal computed tomography (CT) revealed evidence of ileocolonic inflammation. Colonoscopy revealed multiple distal ileal and colonic ulcers with a diameter of 0.5 cm to 0.7 cm, central depression, slight uplift of surrounding mucosa with hyperemia, and edema. Treatment with topical corticosteroids was initiated without benefit. Histopathologic examination of a skin punch biopsy specimen revealed focal lichenoid dermatitis with hyperkeratosis, thickened basement membrane, superficial and deep perivascular chronic inflammation, hemosiderin deposition, and increased dermal mucin. Degos disease was diagnosed. During the hospitalization, the patient developed slow speech, incomplete motor aphasia, atrophy of the left temporal muscle, left opening of the mouth, left side facial hypoesthesia. Head CT revealed an abnormality, and the diagnoses of meningiencephalitis, right frontal, and temporal subdural effusion were considered. Results: Two weeks later, the patient developed small intestinal perforation, continuous high fever, and lethargy died on the 20th day of hospitalization. Conclusion: This case illustrates a rare disease which is a combination of neurological and gastrointestinal manifestation with a skin rash that manifests with porcelain white scars suggests systemic MAP. Many medications have been tried but are mostly without success, and the treatment for systemic disease is supportive. The morbidity and mortality of MAP depend upon the extent of disease involvement.
Keywords: malignant atrophic papule, ileocolonic inflammation, colonoscopy, rash, meningiencephalitis Background and Aim: A 55-year-old Chinese lady with myasthenia gravis and metastatic malignant thymoma with previous thymectomy presented with a 3-week history of diarrhea. Stool microbiological studies were negative. She continued to have severe diarrhea despite empirical treatment with antibiotics and anti-diarrheal agents. Stool fat globule tests were normal. Serum Immunoglobulin A (Good Syndrome was a differential) and chromogranin A levels were normal. Methods: Her colonoscopy revealed erythema in the ascending and descending colon. Biopsies showed an increase in apoptosis. Her gastroscope showed corpus gastritis, and biopsies revealed acute inflammation. A capsule endoscopy done was normal. It was discussed with the pathologist and with her history; the possibility of thymoma-associated multi-organ autoimmunity (TAMA) was raised. A repeat colonoscopy performed 1 month later showed an endoscopically normal colon. Repeat biopsies showed apoptotic colonopathy with increased apoptotic bodies in the crypts compared to previous biopsies, and features were consistent with TAMA. Immunohistochemical staining for Cytomegalovirus was negative. Results: However, she developed a severe pneumonia. A decision was made after discussion with neurology to give intravenous immunoglobulin (IVIG) and intravenous steroids. A splenic biopsy was done to exclude lymphoproliferative diseases as splenic deposits were noted on a computed tomography scan. Histology showed an epithelial tumor, with features consistent with a metastatic thymoma. She was continued on steroids with resolution of her diarrhea. Conclusion: She was a diagnostic challenge as histology of her colonic biopsies were subtle and non-specific till the suspicion of TAMA was brought up. Also, there is no well-defined treatment for the management of this TAMA which presents with intractable diarrhea. In our case, we started her on immunosuppression despite her pneumonia as her TAMA-associated diarrhea was severe and there were also concerns of a myasthenia gravis flare. Keywords: Diarrhea Background and Aim: We aimed to assess the anorectal function and colonic transit time in elderly patients with and without functional constipation (FC) in Kelantan, Malaysia. Methods: Patients aged > 65 years completed a ROME III screening questionnaire for functional constipation and subsequently underwent HRAM using the Mcompass ™ portable system (Medspira, MN, USA), balloon expulsion test (BET), and colonic transit study (CTS) with Sitzmarks® radio-opaque markers (Konsyl, MD, USA). Data were then analysed using SPSS version 20.0 (SPSS, Chicago, IL). Results: Eighteen patients (mean age 67 years, 83% female gender, 89% Malay ethnicity) were recruited into this ongoing study. Eight patients (44%) had FC. The medians (IQR) for the mean anal resting pressure, mean anal squeeze pressure, and mean squeeze duration were 42 mmHg (33), 93.5 mmHg (42), and 10 s (15). The medians (IQR) of the rectal balloon volume for different sensory thresholds were first sensation 20 mL (10); desire 50 mL (33); urgency 110 mL (75); and pain 130 mL (80). The median duration (IQR) for BET is 10 s (22). One patient (5.6%) had rectal hyposensitivity. Three patients (16.7%) had prolonged BET; while another three (16.7%) had delayed colonic transit, with the markers predominantly accumulated in the rectosigmoid area. Six patients (33%) had dyssynergic defecation, of which 50% were type 2 dyssynergia. Comparison of demographic, HRAM, BET, and CTS characteristics between elderly patients with and without FC is summarized in Table 1. Conclusion: No difference in anorectal function and colonic transit time was observed from this interim analysis. Keywords: functional constipation, elderly, high-resolution manometry Comparison of characteristics Background and Aim: Systemic lupus erythematosus is a chronic inflammatory disease commonly present with musculoskeletal, skin, renal, or hematological manifestations. Involvement of the intestinal tract is recognized but a rare occurrence. Chronic diarrhea is a very rare presentation of SLE.
Methods: A 28-year-old Sri Lankan lady with autoimmune thyroiditis taking thyroxine presented with diarrhea for 4 weeks with LOA, LOW, vomiting, and abdominal pain. Examination only revealed lower abdominal tenderness. Results: Her thyroid profile was normal. Stool examination, serum calcium, LDH, protein, albumin, urine examination, liver, and renal panels were within normal range. Mantoux and Quantiferron GOLD tests were negative. Ileocolonoscopy, enteroscopy, OGD, and biopsies were unremarkable. Laparascopy and peritoneal biopsies were also normal. CECT abdomen showed thickened small bowel loops and mild ascites. Peritoneal fluid analysis revealed exudative ascites with WBC 185 (L-55%), RBC 3440/mm 2 . Her ESR was 25, CRP 3.3 mg/dL, ANF highly positive (> 1/ 100), anti U1 RNP positive and complement levels were low (C3: 28.4 [90-180], C4: 4.8 [10-40] mg/dL) but dsDNA, anti-smith, and anticardiolipin antibodies were negative. Her initial FBC and blood picture were normal but later in the course of the disease had leucopenia (2.2*10 9 ). Depending on those, she was diagnosed as having SLE and started on steroids and hydroxycloroquine. Her diarrhea and vomiting improved, and ascites disappeared with treatment. Conclusion: Our patient fulfilled the 2012 SLICC criteria as she had two clinical criteria, serositis (ascites) and leucopenia and two immunologic criteria, positive ANA and low complement levels. In addition to that, there were other supportive evidences such as high ESR with normal CRP, positive U1RNP. It was concluded that if a common cause for chronic diarrhea is not identified, rare presentations of common diseases such as SLE should be considered as in this case. Background and Aim: Gastrointestinal histoplasmosis (GIH) is an uncommon disease with myriad of manifestations. We report a series of cases of gastrointestinal histoplasmosis including two of esophageal involvement from a tertiary center in North India. Methods: Retrospective analysis of patients with primary symptomatic GIH admitted in tertiary care center in last 1 year was done. Data regarding mode of presentation, clinical and imaging findings, endoscopic and histological findings were retrieved. Risk factors for primary GIH were assessed. Results: Six patients with symptomatic GIH were identified. Mean age of patients was 43 ± 13.08 years.
Half of the patients were male. The clinical features included abdominal pain (83%), weight loss (83%), fever (66%), diarrhea (33%), and dysphagia (33%). None of the patient presented with intestinal obstruction. Colonic was involved in 67% of patients, and 33% of patients had esophageal involvement. The diagnosis was established by using histology and PAS staining which showed multiple intracellular as well as extracellular small organisms with peripheral halo. Risk factors for GIH were identified and were HIV with low CD4 counts (143 and 125 cells/mm 3 ) in two patients, primary gastrointestinal lymphoma, disseminated tuberculosis with severe malnutrition, isolated CD4 lymphocytopenia (16 cells/mm 3 ) and diabetes mellitus. All patients were given amphotericin B followed by itraconazole. All patients responded to treatment and in 4 cases mucosal healing was also documented. Conclusion: GIH is not uncommon even in countries endemic with tuberculosis like India. Early diagnosis and differentiation from tuberculosis and Crohn's disease will help in institution of prompt treatment which is associated with good outcome. Keywords: gastrointestinal, esophagus, colon, HIV, diabetes