• Journal of Gastric Cancer
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• v.23 no.1
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• pp.3-106
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• 2023

Gastric cancer is one of the most common cancers in Korea and the world. Since 2004, this is the 4th gastric cancer guideline published in Korea which is the revised version of previous evidence-based approach in 2018. Current guideline is a collaborative work of the interdisciplinary working group including experts in the field of gastric surgery, gastroenterology, endoscopy, medical oncology, abdominal radiology, pathology, nuclear medicine, radiation oncology and guideline development methodology. Total of 33 key questions were updated or proposed after a collaborative review by the working group and 40 statements were developed according to the systematic review using the MEDLINE, Embase, Cochrane Library and KoreaMed database. The level of evidence and the grading of recommendations were categorized according to the Grading of Recommendations, Assessment, Development and Evaluation proposition. Evidence level, benefit, harm, and clinical applicability was considered as the significant factors for recommendation. The working group reviewed recommendations and discussed for consensus. In the earlier part, general consideration discusses screening, diagnosis and staging of endoscopy, pathology, radiology, and nuclear medicine. Flowchart is depicted with statements which is supported by meta-analysis and references. Since clinical trial and systematic review was not suitable for postoperative oncologic and nutritional follow-up, working group agreed to conduct a nationwide survey investigating the clinical practice of all tertiary or general hospitals in Korea. The purpose of this survey was to provide baseline information on follow up. Herein we present a multidisciplinary-evidence based gastric cancer guideline.

• The Journal of Internal Korean Medicine
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• v.43 no.6
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• pp.1105-1121
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• 2022

Objectives: The purpose of this study is to explore the effectiveness and safety of frequently used clinical herbal medicines (Yijung-tang [Lizhong-tang, LJT], Pyeongwi-san [Pingwei-san, PWS], and Shihosogan-tang [Chaihu Shugan-tang, SST]) in patients with functional dyspepsia (FD) when administered according to herbal medicine and Korean medicine pattern identification. The results of this study will be used to standardize the diagnostic instrument used in Korean medicine and to investigate biomarkers of Korean medicine pattern identification. Methods: This study will be a randomized, assessor-blind, 3-arm, parallel, open-label, multi-center clinical trial. A total of 300 FD participants will be recruited from 3 Korean medical hospitals and assigned to the LJT (n=100), PWS (n=100), and SST (n=100) groups according to FD pattern identification. The patients will take the medication for 8 weeks, 3 times a day, before or between meals. The primary outcome will be total dyspepsia symptom (TDS) and the secondary outcomes will be adequate relief (AR) for dyspepsia, overall treatment effect (OTE), visual analogue scale (VAS), functional dyspepsia-related quality of life (FD-QoL), gastrointestinal symptom score (GIS), and pattern identification questionnaires. For the exploratory outcomes, we will analyze blood and fecal metabolome profiles, microbiota from fecal and saliva samples, single nucleotide polymorphism (SNP), and results of Korean medicine diagnosis device measurements (heart rate variability, and tongue, pulse, and abdominal diagnosis). Conclusions: The results of this study will prove objectivity for Korean medicine pattern identifications, and the effectiveness and safety of herbal medicines for the population with FD.

• Annals of Hepato-Biliary-Pancreatic Surgery
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• v.28 no.2
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• pp.161-202
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• 2024

Backgrounds/Aims: Reported incidence of extrahepatic bile duct cancer is higher in Asians than in Western populations. Korea, in particular, is one of the countries with the highest incidence rates of extrahepatic bile duct cancer in the world. Although research and innovative therapeutic modalities for extrahepatic bile duct cancer are emerging, clinical guidelines are currently unavailable in Korea. The Korean Society of Hepato-Biliary-Pancreatic Surgery in collaboration with related societies (Korean Pancreatic and Biliary Surgery Society, Korean Society of Abdominal Radiology, Korean Society of Medical Oncology, Korean Society of Radiation Oncology, Korean Society of Pathologists, and Korean Society of Nuclear Medicine) decided to establish clinical guideline for extrahepatic bile duct cancer in June 2021. Methods: Contents of the guidelines were developed through subgroup meetings for each key question and a preliminary draft was finalized through a Clinical Guidelines Committee workshop. Results: In November 2021, the finalized draft was presented for public scrutiny during a formal hearing. Conclusions: The extrahepatic guideline committee believed that this guideline could be helpful in the treatment of patients.

• Pediatric Gastroenterology, Hepatology & Nutrition
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• v.1 no.1
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• pp.45-55
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• 1998

Purpose: To make objective standards of small intestinal mucosal changes in cow's milk-sensitive enteropathy (CMSE) we analyzed histological changes of endoscopic duodenal mucosa biopsy specimens from normal children and patients of CMSE. Methods: We review the medical records of patients who had been admitted and diagnosed as CMSE by means of gastrofiberscopic duodenal mucosal biopsy following cow's milk challenge and withdrawal. Thirteen babies with CMSE, ranging from 14 days to 56 days of age, were studied. Five non-CMSE patients were used as control, ranging from 22 days to 72 days of age. The morphometric parameters under study were villous height, crypt zone depth, ratio of villous height to crypt zone depth, total mucosal thickness and length of surface epithelium by using H & E stained specimens under the drawing apparatus attached microscope. In addition, the numbers of lymphocytes in the epithelium and eosinophil cells in the lamina propria and epithelium were measured. Results: In the duodenal mucosal biopsy specimens in CMSE we found partial and subtotal villous atrophy with an increased number of interepithelial lymphocytes. The mean villous height($135{\pm}59\;{\mu}m$), ratio of villous height to crypt zone depth ($0.46{\pm}0.28$), total mucosal thickness ($499{\pm}56\;{\mu}m$), length of surface epithelium of small intestinal mucosa ($889{\pm}231\;{\mu}m$) in CMSE was significantly decreased compared with the control (p<0.05). The mean crypt zone depth ($311{\pm}65\;{\mu}m$) was significantly greater than the control ($188{\pm}24\;{\mu}m$)(p<0.05). Infiltration of interepithelial lymphocytes ($34.1{\pm}10.5$) were significantly greater than the control ($13.6{\pm}3.6$)(p<0.05). The number of eosinophil cells in both lamina propria and epithelium was no significant differences between groups (p>0.05). The small intestinal mucosa in treated CMSE showed much improved enteropathy of villous height, crypt zone depth, interepithelial lymphocytes compared with the control as well as untreated CMSE. Conclusion: Quantitation of mucosal dimensions confirmed the presence of CMSE. It seems to be a limitation in the capacity of crypt cells to compensate for the loss of villous epithelium in CMSE. Specimens obtained by gastrofiberscopic duodenal mucosal biopsy were suitable for morphometric diagnosis of CMSE. Improvement of CMSE also can be confirmed histologically after the therapy of protein hydrolysate.

• Pediatric Gastroenterology, Hepatology & Nutrition
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• v.7 no.1
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• pp.31-39
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• 2004

Purpose: Although acute nonspecific mesenteric lymphadenitis (ANML) is probably common cause of abdominal pain in children, which can be severe enough to be an abdominal emergency, the clinical features of mesenteric lymphadenitis are not clear. Also, a differential diagnosis with acute appendicitis (APPE) is indispensable to avoid serious complications. The clinical features of ANML were determined, and the risk factors for differential diagnosis with APPE were analyzed. Methods: Between November 2000 and May 2001, data from 26 patients (aged 1 to 11 years) with ANML and 21 patients (aged 2 to 13 years) with APPE were reviewed. ANML was defined as a cluster of five or more lymph nodes measuring 10 mm or greater in their longitudinal diameter in the right lower quadrant (RLQ) without an identifiable specific inflammatory process on the ultrasonographic examination. There were risk factors on patient's history, physical examination, and laboratory examination; the location of abdominal pain, abdominal rigidity, rebound tenderness, fever, nocturnal pain, the vomiting intensity, the diarrhea intensity, the symptom duration, and the peripheral blood leukocytes count. Results: Of the 26 ANML patients and 21 APPE patients, abdominal pain was noted on periumbilical (76.9% vs 14.2%), on RLQ (11.5% vs 71.4%), with abdomen rigidity (7.6% vs 80.9%), with rebound tenderness (0.0% vs 76.1%)(p<0.05), in the lower abdomen (11.5% vs 14.2%), and at night (80.8% vs 100.0%) (p>0.05). The clinical symptoms were vomiting (38.4% vs 90.4%), the vomiting intensity ($1.5{\pm}0.7$ [1~3]/day vs $4.5{\pm}2.9$ [1~10]/day), diarrhea (65.3% vs 28.5%) (p<0.05), and fever (61.5% vs 76.2%)(p>0.05). The period to the subsidence of abdominal pain in the ANMA patients was $2.5{\pm}0.5$ (2~3) days. The laboratory data showed a significant difference in the peripheral blood leukocytes count ($8,403{\pm}1,737[5,900{\sim}12,300]/mm^3\;vs\;15,471{\pm}3,749[5,400{\sim}20,800]/mm^3$)(p<0.05). Discriminant analysis between ANML and APPE showed that the independent discriminant factors were a vomiting intensity and the peripheral blood leukocytes count and the discriminant power was 95.7%. Conclusion: The clinical characteristics of ANML were abrupt onset of periumbilical pain without rigidity or rebound tenderness, a mild vomiting intensity, normal peripheral leukocytes count, and relatively short clinical course. If the abdominal pain persist for more than 3 days, and/or the vomiting intensity is more than 3 times/day, and/or the peripheral leukocytes count is over $13,500/mm^3$, abdominal ultrasonography is recommended to rule out APPE.

• Pediatric Gastroenterology, Hepatology & Nutrition
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• v.7 no.1
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• pp.40-47
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• 2004

Purpose: A new classification of gastrointestinal food allergy was published, but the changes of terminology between previously reported terms and the new ones were in a state of disorder. This has resulted in confusion between medical communication and diagnostic and therapeutic approaches. The clinical observations of infants presenting with gastrointestinal cow milk allergy (GI-CMA) were performed, and the changes in the terminology reviewed through the published Korean literature. Methods: Between March 2003 and July 2003, data from 37 consecutive infants with GI-CMA, aged 2 weeks to 15 months, were reviewed. The challenge and elimination test of cow milk, and the endoscopic and histologic findings, were used for the seven subdivisions of GI-CMA according to a new classification on the basis of patients' ages, clinical manifestations and location of gastrointestinal lesions. Results: The 37 patients had a mean age of $5.4{\pm}4.8$ months, with those observed in 26 (70.3%) of patients being below 6 months of age. The seven final diagnoses were; cow milk protein-induced enterocolitis (CMPIE) in 12 (32.4%), cow milk protein proctitis (PROC) in 12 (32.4%), IgE-mediated (IGE) in 6 (16.2%), gastroesophageal reflux-associated cow milk allergy (GERA) in 5 (13.5%) and eosinophilic gastroenterocolitis in 2 (5.4%). CMPIE was revealed as the typical type in 7 (18.9%) and the atypical type in 5 (13.5%), and all of typical CMPIE revealed cow milk protein-induced enteropathy. The mean age at symptom onset was $4.3{\pm}0.8$ months, and for those with typical and atypical CMPIE, and PROC and GERA were $3.8{\pm}4.6$, $10.4{\pm}3.8$, $3.4{\pm}3.9$ and $7.8{\pm}5.7$ months, respectively (p<0.05). The period from onset of symptom to diagnosis was $2.4{\pm}3.3$ (0.5~12) months, with those observed in atypical CMPIE and GERA being over 3months. Although the birth weights in all patients were within the 10~90 percentile range, the body weights on diagnoses were below the 3 percentile in 48.6%; IGE 16.7%, EOS 0%, typical CMPIE 85.7%, atypical CMPIE 60.0%, PROC 25.0% and GERA 100% (p<0.05). Through the review of the Korean literature, 8 case reports and 14 original articles for GI-CMA were found. Conclusion: GI-CMA is not a rare clinical disorder and is subdivided into seven categories on the basis of the patient's age, clinical manifestations and location of the gastrointestinal lesions. The terms for GI-CMA are changing with new classifications, and careful approaches are necessary for medical communications.

• Pediatric Gastroenterology, Hepatology & Nutrition
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• v.6 no.2
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• pp.140-151
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• 2003

Purpose: We tried to evaluate the long term efficacy and positive predictive factors of interferon-alpha treatment in children with chronic hepatitis B. Methods: The study population included 113 children who received interferon therapy between May 1982 and July 2002 (20 years) for chronic hepatitis B in Department of Pediatrics, Yonsei University College of Medicine. Male to female ratio was 2.3 : 1 and the mean age at diagnosis was $11.1{\pm}4.1$ years old. Response to treatment was defined as normalization of alanine aminotransferase (ALT), disappearance of HBeAg and HBV-DNA Eighty two children responded while 32 did not. Interferon-alpha was given intramuscularly for 6 months at a dosage of $3{\times}10^6$ unit, 3 times weekly. In relapsed cases, lamivudine or interferon retreatment was done. Results: Seroconversion rate was 77.0% in terms of HBeAg, 74.3% in terms of HBV-DNA, and 80.5% in terms of ALT normalization after treatment. Seroconversion rate of both HBeAg and HBV-DNA was 72.6%. Analyzed by life table method, the effect of the treatment had been maintained over 10 years after cessation of therapy. Pre-treatment ALT level was the only significant positive predictive factor of response. Eleven cases (13.4%) relapsed, and 2 out of 3 showed response when treated with lamivudine and 1 out of 3 with interferon retreatment. Conclusion: Interferon-alpha showed significant efficacy in the treatment of chronic hepatitis B in our study. Further studies about the effect of interferon therapy on complications of hepatitis such as hepatocarcinoma, cirrhosis are warranted.

• Pediatric Gastroenterology, Hepatology & Nutrition
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• v.12 no.2
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• pp.156-162
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• 2009

Purpose: The aim of this study was to investigate the clinical usefulness of upper gastrointestinal (GI) endoscopy in children with Henoch-Sch$\"{o}$nlein purpura (HSP). Methods: We retrospectively analyzed the clinical, endoscopic, and histopathologic records of children with HSP who had been admitted to the Department of Pediatrics of Gil Hospital and underwent upper GI endoscopy between January 2002 and June 2009. Patients were classified into the following two groups for statistical analysis: duodenal involvement (+) and duodenal involvement (-). Results: Fifty-one children with HSP underwent upper GI endoscopy; the mean age was 7.2${\pm}$2.9 years. The upper GI endoscopy showed abnormalities of the duodenum in 38 cases (74.5%), 22 of which had duodenal ulcers. Among the biopsy specimens obtained from the duodenum of 37 cases, 13 cases (35.1%) had leukocytoclastic vasculitis, neutrophil debri, and/or extravasation of RBCs. Steroid use was more frequent in the duodenal involvement (+) group (86.8%) than the duodenal involvement (-) group (53.8%; p=0.02). The mean length of hospitalization was 13.9${\pm}$8.43 days in the duodenal involvement (+) group and 8.1${\pm}$4.62 days in the duodenal involvement (-) group (p=0.003). The recurrence rate was significantly higher in the duodenal involvement (-) group than the duodenal involvement (+) group (p=0.027), whereas none of the other study parameters, such as the age of onset, renal involvement, and steroid use, led to significantly higher or lower recurrence rates. Conclusion: These results suggest that duodenal involvement can influence the clinical course and prognosis of HSP in children.

• Pediatric Gastroenterology, Hepatology & Nutrition
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• v.2 no.1
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• pp.65-73
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• 1999

Purpose: Regurgitation, vomiting and feeding intolerance are frequent in the neonates. Esophageal function and gastric peristalsis are not fully developed in the neonates, so we should give attention to reduce the incidence of regurgitation and vomiting after feeding. It is necessary to shorten the gastric emptying by change of feeding types and postprandial postures. Gastric emptying time was measured by ultrasound in the neonates to evaluate the effect of feeding types and postprandial postures. Method: We measured gastric antral cross sectional area along the abdominal aorta at the level of the superior mesenteric artery in longitudinal section at NPO state (4 hours after feeding), 0 and every 30 min. after feeding until the value goes below or back to the NPO state. Fifteen neonates were examined in each breast-fed and formula-fed group in supine position. Eighteen and 15 neonates were examined in supine and prone posture after formula feeding, respectively. We used 5 MHz convex prove with Aloka Echo Camera SSD-650. Result: 1) Gastric emptying time of breast-fed infants was $76.0{\pm}20.02$ min. which was significantly shorter than $96.0{\pm}20.28$ min. of formula-fed infants. 2) Gastric emptying time on postprandial prone posture was $85.0{\pm}22.43$ min. which was not significantly different from $96.0{\pm}20.28$ min. on postprandial supine posture. Conclusion: Breast feeding is strongly recommended to the neonates to shorten gastric emptying time. So we can expect to reduce the incidence of regurgitation, vomiting and feeding intolerance. The postprandial posture depends on the traditional trend which is safe and comfortable to the mothers.

• Pediatric Gastroenterology, Hepatology & Nutrition
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• v.8 no.1
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• pp.21-30
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• 2005

Purpose: The aim of this study was to identify the clinical features and natural history of dietary protein induced proctocolitis (DPIPC) and to detect the causative foods of DPIPC, and to evaluate the effect of elimination of the foods on the course of the disease. Methods: Between March 2003 and July 2004, data from 30 consecutive patients with DPIPC who were followed for over 6 months, was reviewed. The diagnostic criterion used for DPIPC was an increase in the number of eosinophils in the lamina propria (${\geq}60per$ 10 high-power fields). In breast feeding mothers, 5 highly allergenic foods were eliminated from the maternal diet for 7 days, namely, allergenic food groups such as dairy products, eggs, nuts and soybean, fish and shellfish, and wheat and buckwheat. We observed the disappearance or appearance of hematochezia after elimination or challenge with the offending foods. Results: Before diagnosis infants were breast-fed (93.3%) or formula-fed (6.7%). Mean age at symptom onset was $11.5{\pm}5.1$ (5~24) weeks, and mean age at diagnosis was $17.8{\pm}9.5$ (8~56) weeks. Duration from symptom onset to diagnosis was $6.3{\pm}6.7$ (0~36) weeks. Mean peripheral blood eosinophil count was $478{\pm}320$ (40~1,790)/$mm^3$ and eosinophilia (> $250/mm^3$) was observedin 90.0% of patients. None of patients were found to have an increased serum IgE level. Of 15 patients that received sigmoidoscopy, nodular hyperplasia with erosion was observed in 93.3%. Of 27 patients whose mother ate the diet eliminated the 5 food groups, hematochezia diappeared in 74.1% of patients. Offending foods were identified as dairy products (37.5%), wheat and buckwheat (27.5%), fish and shellfish (20.0%), nuts and soybean (7.5%) and eggs (7.5%). A free maternal diet without patient's clinical symptoms was achieved at $29.4{\pm}8.7$ (9~44) weeks of patient's age, and a free baby diet without blood in stools was achieved at $37.5{\pm}9.7$ (12~56) weeks of age. Conclusion: DPIPC commonly occurs in exclusively breast-fed babies. Elimination of the above-mentioned 5 hyper-allergenic food groups from the maternal diet for 7days enables the detection of the offending foods. DPIPC is a transient disorder and 96.0% of patients can tolerate the offending foods at 12 months of age.