Choledochal varices bleeding: A case report.

Choledochal varices are a rare cause of hemobilia associated with chronic portal vein thrombosis. We present a case of chronic portal vein thrombosis complicated with bleeding from choledochal varices. The presentation, clinical manifestations and management are described.

Endosonographic surveillance of small gastrointestinal tumors originating from muscularis propria.

INTRODUCTION: Submucosal tumors (SMT) are not uncommonly found during upper endoscopy. Management for small SMT originating from muscularis propria (MP) is controversial. Data regarding regular endoscopic ultrasound (EUS) surveillance is scarce. We report our experience in using EUS to monitor these tumors. METHODS: Patients with SMT originated from MP as confirmed by EUS were recruited. The maximal diameter, echo pattern, presence of cystic spaces and regularity of extra-luminal margin were documented. Patients with large tumors (maximal diameter > 3 cm), heterogeneous echo pattern, presence of cystic spaces or irregular extra-luminal margin were offered surgery in view of malignant risk. Patients with small tumor and benign EUS features were offered regular EUS surveillance or surgery if they wished. The progress of those patients who underwent EUS surveillance were studied. RESULTS: From January 2002 to December 2007, there were 93 patients with SMT originating from MP. Forty-nine patients had a small tumor and benign EUS features. Only two of these patients chose surgery. The histopathological results were low risk gastrointestinal stromal tumor (GIST) in both patients. Twenty-three patients elected to undergo regular EUS surveillance for a mean period of 17.3 months (range 6-42 months). Three patients (13.0%) showed interval increase in tumor size. There was no change in other EUS features. Surgery was performed in these 3 patients. Histological examination revealed schwannoma in 2 patients and low risk GIST in 1 patient. CONCLUSION: It remains unclear whether EUS surveillance for small tumors originating from MP in the upper gastrointestinal tract is useful.

Correlation of serum biomarkers with clinical severity and mucosal inflammation in Chinese ulcerative colitis patients.

OBJECTIVE: Serum biomarkers are commonly used for diagnosing and monitoring the disease activity of ulcerative colitis (UC) patients. However, their role in predicting active mucosal inflammation on Chinese patients is unknown. Our aim was to determine the sensitivity and correlation of these biomarkers with clinical severity and mucosal inflammation. METHODS: Patients who had been newly diagnosed or who had developed a clinical relapse were identified. Active mucosal inflammation was confirmed by colonoscopy and histology. Those patients who had routine serum biomarkers (C-reactive protein [CRP], erythrocyte sedimentation rate [ESR], white cell count, hemoglobin, platelet count and albumin) checked within 14 days of the index colonoscopy were recruited for a retrospective analysis. The disease severity was graded clinically and the positive rate of each marker was determined. The correlation of these markers with the clinical severity and extent of colitis were assessed by the Mann-Whitney U-test or the Kruskal-Wallis test. For the categorical variable, chi(2) or the Fisher's exact test were adopted. RESULTS: From January 2001 to December 2006, 49 Chinese UC patients fulfilled the inclusion criteria. There were 78 acute mucosal inflammatory episodes (24 at diagnosis and 54 clinical relapses). Abnormal CRP, ESR, white cell count, hemoglobin, platelet count and albumin occurred in 42.3%, 55.1%, 23.1%, 21.8%, 32.1% and 25.6% of these mucosal inflammatory episodes, respectively. For the severity of the clinical disease, all serum biomarkers demonstrated a good correlation with the severity grading. On the other hand, the serum biomarkers correlated well with endoscopic extensive colitis but not with proctitis or left-sided colitis. CONCLUSION: Routine serum biomarkers are not sensitive in predicting mucosal inflammation. However, they are helpful in identifying patients with extensive colitis or clinically severe disease.

Refractory celiac disease: an unusual disease in a Chinese patient.

Celiac disease (CD) is an autoimmune disease characterized by mucosal inflammation and villous atrophy of the small bowel upon exposure to ingested gluten. Although common in developed countries, it is extremely rare in the Chinese population. Refractory celiac disease (RCD) is a rare complication of CD with poor prognosis. Patients may die of severe malabsorption or development of enteropathy-associated T-cell lymphoma. We report a case of RCD in a Chinese woman who required steroid therapy in addition to a gluten-free diet to induce disease remission. The possibility of CD in Chinese patients should not be overlooked.

Current utilization and performance status of endoscopic ultrasound in a community hospital.

OBJECTIVE: Endoscopic ultrasound (EUS) is an essential tool for cancer staging and investigating gastrointestinal diseases. Although it is not a widespread skill, as its expanded indications became much more advanced so did its popularity and hospital acceptance. We aimed to study the utilization and indications of upper EUS in a Hong Kong community hospital. The secondary aim was to assess our accuracy in staging of esophageal and gastric cancer and in evaluating submucosal tumors. METHODS: All patients who had undergone upper EUS in Tuen Mun Hospital from January 2002 to December 2006 were recruited. Their background data, indications, radiological investigations, upper endoscopy and operation records and histopathologic results were retrieved for analysis. The accuracy of EUS in esophageal cancer staging, gastric cancer staging and evaluating submucosal tumors was assessed by comparing surgical and histopathologic findings. RESULTS: A total of 645 upper EUS examinations were performed and there has been a steady increase in EUS utilization in our hospital. The most common indications were evaluating submucosal tumors and staging esophageal and gastric cancer. The accuracy of T and N staging of esophageal cancer was 71.2 and 79.7%, respectively and for gastric cancer was 64.0 and 74.7%, respectively. Endoscopic ultrasound was 70% accurate in identifying lesions arising from the submucosal layer and 100% accurate in identifying lesions from the muscularis propria. CONCLUSION: Endoscopic ultrasound is an accurate method and its demand is increasing. The performance in a community hospital can be further improved and its utilization should expand to other indications.

Pyogenic liver abscess: clinical profile, microbiological characteristics, and management in a Hong Kong hospital.

BACKGROUND AND PURPOSE: Pyogenic liver abscess (PLA) is a major hepatobiliary infection with a significant mortality rate of 10% to 25%. Over the past 2 decades, there have been significant developments in the management of this disease. This study describes the demographic, clinical, and microbiological features, management, and poor prognostic factors of PLA in Hong Kong. METHODS: All patients with PLA admitted to the Tuen Mun Hospital, Hong Kong, from July 1998 to June 2004 were included. The medical records of eligible patients were reviewed to obtain demographic, clinical, laboratory, microbiological, and radiological data. Management strategies and factors associated with mortality were studied. RESULTS: 111 patients were included. Fever, chills, and right upper quadrant pain were the most common presenting symptoms. Low albumin level, elevated alkaline phosphatase, and leukocytosis were the most common laboratory features. Klebsiella spp. was the most common etiological agent detected in cultures of blood and abscess aspirates. Fifty two percent of these isolates were Klebsiella pneumoniae. Fifty three percent of PLA cases were cryptogenic in origin and 22.5% had underlying biliary pathology. The mortality rate was 11.7%. By multiple logistic regression analysis, hepato-pancreatico-biliary malignancy (p=0.001), requirement for open surgery (p=0.01), and significant delay in diagnosis (p=0.019) were independent risk factors associated with in-hospital mortality. CONCLUSION: Although advances in imaging and therapeutic modalities have lead to substantial improvement of outcomes, patients with underlying malignancy and those requiring open surgery in particular are at significant risk of mortality. Delay in diagnosis can result in a fatal outcome. A high index of suspicion with prompt institution of treatment is the cornerstone of successful treatment for patients with PLA.

Epidemiology and clinical characteristics of ulcerative colitis in Chinese population: experience from a single center in Hong Kong.

BACKGROUND AND AIM: Rising incidence and prevalence of ulcerative colitis (UC) had been observed in Asian countries. We conducted a study in an Asian center, aiming to describe the epidemiology and clinical characteristics of UC in local Chinese population. METHODS: This is a retrospective analysis of patients with diagnosis of UC in our hospital from June 1990 to December 2006. The diagnosis of UC has to satisfy the internationally accepted criteria. All patients were Chinese residents in a well-defined catchment area. Clinical and epidemiological data were obtained from medical records and patient interviews. RESULTS: Seventy-three Chinese UC patients had been managed in our hospital. The hospital-based prevalence had risen by three times over a 10-year period, but no definite rising incidence can be demonstrated. The mean age at diagnosis was 40.6 years and the median duration of disease is 72 months. In our patient cohort, 38.4% had ulcerative proctitis and 26% had left-sided UC, whereas 35.6% had extensive UC at presentation. The majority presented with mild (39.7%) or moderate (30.2%) disease activity, but 27.4% presented with severe disease. Two patients (2.7%) present with fulminant disease with one of them developed toxic megacolon. Extra-gastrointestinal manifestations occurred in 13.7%. During the follow-up period, most patients (86.3%) were in disease remission. Four patients (5.5%) underwent colectomy, four patients (5.5%) died, and two patients (2.7%) were lost to follow up. CONCLUSION: The prevalence but not the incidence of UC is rising in Chinese population. It usually affects young patients and a substantial proportion of patients presented with severe and fulminant disease. The disease activity of most Chinese patients can be controlled with medical treatment, though a small proportion of patients need surgery or have fatal outcome.

Prevalence of colorectal neoplasm among patients with newly diagnosed coronary artery disease.

CONTEXT: Colorectal neoplasm and coronary artery disease (CAD) share similar risk factors, and their co-occurrence may be associated. OBJECTIVES: To investigate the prevalence of colorectal neoplasm in patients with CAD in a cross-sectional study and to identify the predisposing factors for the association of the 2 diseases. DESIGN, SETTING, AND PARTICIPANTS: Patients in Hong Kong, China, were recruited for screening colonoscopy after undergoing coronary angiography for suspected CAD during November 2004 to June 2006. Presence of CAD (n = 206) was defined as at least 50% diameter stenosis in any 1 of the major coronary arteries; otherwise, patients were considered CAD-negative (n = 208). An age- and sex-matched control group was recruited from the general population (n = 207). Patients were excluded for use of aspirin or statins, personal history of colonic disease, or colonoscopy in the past 10 years. MAIN OUTCOME MEASURES: The prevalence of colorectal neoplasm in CAD-positive, CAD-negative, and general population participants was determined. Bivariate logistic regression was performed to study the association between colorectal neoplasm and CAD and to identify risk factors for the association of the 2 diseases after adjusting for age and sex. RESULTS: The prevalence of colorectal neoplasm in the CAD-positive, CAD-negative, and general population groups was 34.0%, 18.8%, and 20.8% (P < .001 by chi2 test), prevalence of advanced lesions was 18.4%, 8.7%, and 5.8% (P < .001), and prevalence of cancer was 4.4%, 0.5%, and 1.4% (P = .02), respectively. Fifty percent of the cancers in CAD-positive participants were early stage. After adjusting for age and sex, an association still existed between colorectal neoplasm and presence of CAD (odds ratio [OR], 1.88; 95% confidence interval [CI], 1.25-2.70; P = .002) and between advanced lesions and presence of CAD (OR, 2.51; 95% CI, 1.43-4.35; P = .001). The metabolic syndrome (OR, 5.99; 95% CI, 1.43-27.94; P = .02) and history of smoking (OR, 4.74; 95% CI, 1.38-18.92; P = .02) were independent factors for the association of advanced colonic lesions and CAD. CONCLUSIONS: In this study population undergoing coronary angiography, the prevalence of colorectal neoplasm was greater in patients with CAD. The association between the presence of advanced colonic lesions and CAD was stronger in persons with the metabolic syndrome and a history of smoking.

Fulminant ulcerative colitis associated with steroid-resistant minimal change disease and psoriasis: a case report.

A 43-year-old Chinese patient with a history of psoriasis developed fulminant ulcerative colitis after immunosuppressive therapy for steroid-resistant minimal change disease was stopped. Minimal change disease in association with inflammatory bowel disease is a rare condition. We here report a case showing an association between ulcerative colitis, minimal change disease, and psoriasis. The possible pathological link between 3 diseases is discussed.

Chinese tea consumption and lower risk of Helicobacter infection.

BACKGROUND: Our first study had shown that Chinese tea has anti-Helicobacter activity. The present study investigated the relationship between patients'Helicobacter status and the history of Chinese tea consumption. METHODS: Chinese patients who had their first upper endoscopy were recruited. Before the procedure, patients completed questionnaires about their current Chinese tea consumption habits and those when they were around 10-25 years old. This information was used to calculate the tea consumption indices (TCI). Gastric biopsies (two from the antrum and two from the corpus) were taken for histological examination for Helicobacter. RESULTS: Eighty patients were recruited. Eight patients were rejected because of either an incomplete questionnaire, absence of gastric biopsy or a suspected history of treatment for Helicobacter infection. Of the 72 patients, 42 (58.3%) were Helicobacter positive. The age, sex ratio and indications for endoscopy were similar in both Helicobacter-positive and -negative groups. Classifying patients using either current, past or total TCI, patients with high tea consumption had significantly lower Helicobacter infection rate than those with low tea consumption (45% compared to 74%, 42% compared to 67% and 40% compared to 83%, respectively). Helicobacter-negative patients had higher overall TCI than Helicobacter-positive patients (28.2:17.3). When current and previous histories were analyzed separately, Helicobacter-negative patients also had a trend towards higher TCI currently (16.6:11.0) and in their 20s (11.6:6.1). CONCLUSIONS: There is a significant inverse relationship between Chinese tea consumption and Helicobacter infection. Chinese tea consumption may decrease the chance of Helicobacter infection.