Risk factors influencing the outcome of peptic ulcer bleeding in end stage renal diseases after initial endoscopic haemostasis.

Background and Aims: Patients suffering from peptic ulcer (PU) bleeding who have end-stage renal disease (ESRD) may encounter more adverse outcomes. The primary objective is to investigate the risk factors that influence the outcomes of ESRD and chronic kidney disease (CKD) patients with PU bleeding after successful initial endoscopic haemostasis. Methods: A total of 540 patients with PU bleeding after initial endoscopic haemostasis in a tertiary hospital were investigated retrospectively. They were sorted into three groups after randomised age-matched adjustment: ESRD group (n = 90), CKD group (n = 90) and control group (n = 360). Main outcome measurements were rebleeding, requirement for blood transfusion and surgery, length of hospital stay and mortality. Results: The rebleeding rates were 43% for the ESRD group vs. 21% for the CKD group vs. 12% for the control group (overall p = < 0.001). Multivariate analysis showed the predictors of rebleeding were ESRD, time to endoscope, and non-high-dose proton-pump inhibitors (PPI) users. The risk factors for bleeding-related mortality were presence of moderate degree of CKD and ESRD group, time to endoscope, and Rockall score. All-cause mortality was related to presence of moderate degree of CKD and ESRD group, platelet count, time to endoscope, Rockall score and length of hospital stay. Conclusions: ESRD patients who suffered from PU bleeding were at risk of excessive rebleeding and mortality with frequent occurrence of delayed rebleeding. This study suggests that early endoscopy for initial haemostasis and high-dose intravenous PPI are associated with the reduction of rebleeding risk especially in patients with high Rockall scores.

The role of barium esophagogram measurements in assessing achalasia patients after endoscope-guided pneumatic dilation.

Only a few studies have been performed comparing subjective symptom improvements with objective improvement in esophageal emptying after pneumatic dilation (PD), and discrepancy existed. We evaluated whether esophagogram measurements adds to the traditional subjective symptoms scores in assessing achalasia patients after PD. We enrolled 32 new patients with achalasia who received endoscope-guided PD treatment between January 1998 and June 2004. Postdilation investigations were performed by using esophageal emptying on esophagogram prospectively in a blinded manner, along with symptom scores before and after PD at the initial investigation, 6 weeks later, and every 1 year thereafter. Our results showed that seven patients who noted complete relief showed less than 50% improvement in barium column height and esophageal diameter. There was no linear correlation between the degree of patient symptom improvement and esophageal emptying measured by esophagogram (r = 0.181, P = 0.322). A trend of association existed in the relationship between clinical remissions and initial post-PD esophageal emptying improvement (P = 0.067). In summary, the association between the post-PD symptom score improvement and degrees of esophageal emptying may be hampered by the small sample size in the current study. An additional objective parameter like esophagogram to the subjective symptom scores may be more optimal in assessing clinical remissions.

Replication of hepatitis B virus in first-degree relatives of patients with hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) may occur in family clusters. No genetic mechanism has been identified as responsible for this familial tendency. We suspected that a longer hepatitis B virus (HBV) replication phase might be the reason for a higher risk of HCC in families with this disease. We performed liver biochemical tests, test for viral hepatitis markers and hepatitis B e antigen (HBeAg), and liver ultrasonography in relatives of patients with HCC. A total of 1,885 first-degree relatives from 688 families participated in this study. Seven hundred fifty-two relatives were found to be carriers of hepatitis B surface antigen (HBsAg) and 675 of them were tested for HBeAg. The prevalence of HBeAg was 27.4% in relatives of those with HCC and 20% in asymptomatic HBsAg carriers. The HBeAg prevalence rate was higher in relatives of those with HCC > or = 40 years old than in asymptomatic HBsAg carriers. Moreover, HBeAg was more likely to persist in men than in women > or = 40 years old. We conclude that families with HCC showed a prolonged HBV replication phase that may be one of the cofactors for a familial tendency for HCC.

Sequential invasions of pancreatic pseudocysts in pancreatic tail, hepatic left lobe, caudate lobe, and spleen.

A 66-year-old male patient without a history of risk factors for pancreatitis suffered from pancreatitis and developed pseudocyst. During the course of treatment and follow-up, the pseudocyst was found to have migrated through the pancreatic tail, left hepatic lobe, caudate lobe, and spleen on abdominal sonography and computed tomography scan. Finally, emergent laparotomy was done for splenic abscess and removal of infected pseudocyst in the spleen and lesser sac of the abdomen. The patient made a full recovery after operation.

Excess mortality from hepatocellular carcinoma in an HCV-endemic township of an HBV-endemic country (Taiwan).

Taiwan is an endemic area of hepatitis B virus (HBV). All previous studies have concluded that HBV is the major cause of hepatocellular carcinoma (HCC) in Taiwan. An HBV- and hepatitis C virus (HCV)-endemic township, Tzukuan, in southern Taiwan has been identified with the prevalence of 24% for HB surface antigen (HBsAg) and 37% for anti-HCV antibodies. To elucidate the aetiology of HCC and impact of HCV in this township, we conducted a case-control study and compared HBV-related liver cancer mortality in Tzukuan and Taiwan as a whole. Based on cancer registration datasets of 2 medical centres from 1991 to 1995, we recruited 18 male and 9 female HCC cases from the study township. Their mean age (+/- standard deviation) was 60.3 (+/- 7.3) years. Randomly sampled from a community-based survey, 4 age- (+/- 2 years) and sex-matched residents were selected as community controls for each HCC case. The HBsAg carrier rate was 40.7% in cases and 25.0% in controls (P = 0.1). Anti-HCV positive rate was 88.9% in cases and 53.7% in controls (P = 0.008). Age-adjusted liver cancer mortality in Tzukuan (36.5 per 10(5)) was significantly higher than that of Taiwan as a whole (20 per 10(5)). Based on the HBsAg-positive rate among HCC patients (40.7% in Tzukuan and 77.4-86.6% in Taiwan), the estimated HBV-related liver cancer mortality was similar in Tzukuan (14.9 per 10(5)) and Taiwan (15.8-17.3 per 10(5)). We concluded that HCV was the major risk factor for excess liver cancer mortality in this HCV-endemic township of the HBV-endemic country.

Liver abscess in patients with cirrhosis of the liver: a 12-year experience.

PURPOSE: Liver abscess is rare in patients with cirrhosis of the liver. The aim of this retrospective study was to investigate the incidence, clinical presentation, causal pathogens, and outcome of liver abscess in cirrhotic patients. METHODS: We collected 21 liver abscess specimens (from 14 male patients and 7 female patients; Child A: B: C, 4: 7: 10) from 22,731 admissions of 6450 cirrhotic patients, from 1986 through 1998. RESULTS: The common clinical symptoms and signs included fever, chills, and abdominal tenderness. The major predisposing factors were biliary tract disease (52%) and diabetes mellitus (48%). The diagnosis rate with abdominal ultrasonography was 79%. Gram-negative aerobes were the predominant pathogens (Klebsiella pneumoniae, 66.7%; Escherichia coli, 23.8%), and occurred in 80% and 69% of blood and pus cultures, respectively, while 38% of cases showed polymicrobial pathogens. The location of the abscess was predominantly in the right lobe (71.4%), and 47.6% of patients had multiple abscesses. Six patients died (all with Child C cirrhosis). The overall mortality rate was 28.6% (6/21). CONCLUSIONS: The incidence of liver abscess in the cirrhotic patients was low, at 0.09% (21/22,731 admissions). The clinical presentations and pathogens were not different from those in noncirrhotic patients, except that in our cirrhotic patients, there was no significant difference in mortality between those with monomicrobial and those with polymicrobial abscess: nor was there a significant difference in mortality between those with single and those with multiple abscesses. The Child C patients were the high-risk group.

Famotidine versus omeprazole, in combination with amoxycillin and tinidazole, for eradication of Helicobacter pylori infection.

BACKGROUND: Eradication regimens combining two antibiotics with a proton pump inhibitor have been studied intensively. In contrast, only a few studies have focused on the possible role of H2-receptor antagonists in eradication therapy. The mechanism involved in the synergy between antibiotics and proton pump inhibitors is still controversial. OBJECTIVES: To compare the results of two triple-therapy regimens, different only in the antisecretory drugs used, in patients with Helicobacter pylori infection, and to assess the impact of primary resistance to metronidazole on treatment outcome. METHODS: A total of 120 patients with peptic ulcer and non-ulcer dyspepsia were randomly assigned to a 2-week course of either: famotidine 40 mg twice a day, amoxycillin 1 g twice a day and tinidazole 500 mg twice a day (FAT group; n = 60); or omeprazole 20 mg twice a day, amoxycillin 1 g twice a day and tinidazole 500 mg twice a day (OAT group; n = 60). Upper endoscopy was performed prior to treatment and at least 4 weeks after completion of treatment and discontinuation of the antisecretory therapy. H. pylori status was assessed by a biopsy urease test, histology and culture. RESULTS: In the intention-to-treat analysis, eradication of H. pylori was achieved in 48 of the 60 patients (80%; 95% confidence interval: 70-90%) in the FAT group, compared to 50 of the 60 patients (83.3%; 95% confidence interval: 74-93%) in the OAT group. In the per protocol analysis, eradication therapy was achieved in 48 out of 53 patients (90.6%; 95% confidence interval: 83-98%) treated with FAT and 50 out of 57 patients (87.7%; 95% confidence interval: 79-96%) treated with OAT (not significant). The primary metronidazole resistance was present in 28.8% of strains. Overall, per protocol eradication rates in strains resistant and susceptible to metronidazole were 83.3% and 91.3% respectively (P > 0.05). CONCLUSIONS: Two-week courses of either high-dose famotidine or omeprazole, both combined with amoxycillin and tinidazole, are equally effective for eradication of H. pylori infection. In a 2-week triple therapy, metronidazole resistance has no significant impact on eradication rates.

Ileal aberrant pancreas induces intussusception and gastrointestinal bleeding in an adult woman--case report.

Aberrant pancreas is a congenital anomaly. In surgical series, its incidence varied from 0.2 to 0.8%. About 70% of aberrant pancreas occur in the gastrointestinal tract. Eighty percent of them locate in the stomach and duodenum, and only 0.2% in the ileum. We report on a 25-year-old woman with ileal aberrant pancreas who suffered from ileal intussusception and recurrent gastrointestinal bleeding. The diagnosis was confirmed by surgery and histology. She is symptom-free after surgery.

Dieulafoy's lesion of the jejunum.

Dieulafoy's lesion is a rare vascular anomaly but a potentially life-threatening disease. This lesion can also be found in the small intestine, which can be diagnosed only by angiography. However, the angiography may be normal when the bleeding is inactive. We report a case of jejunal Dieulafoy's lesion with a repeated attack of massive gastrointestinal bleeding with a normal initial angiography. The pathological examination found an unusual picture as a dilated submucosal vessel protruded like a submucosal tumor.

Albumin gradient and portal vein velocity in severe viral hepatitis patients complicated with ascites.

BACKGROUND/AIMS: To ascertain the mechanism of development of ascites and the hemodynamic change of portal system, 28 patients who had an episode of severe viral hepatitis with and without spontaneous bacterial peritonitis were studied. METHODOLOGY: By means of a non-invasive duplex system, the relationships between the albumin gradient of serum-ascites and the portal vein velocity were assessed in 10 patients with spontaneous bacterial peritonitis and 18 patients without spontaneous bacterial peritonitis. RESULTS: In the group of patients with severe form of hepatitis but without spontaneous bacterial peritonitis, there is a significant positive linear correlation between the level of serum albumin and the albumin gradient of serum-ascites (P < 0.001). However, a receded linear correlation was found between the serum albumin and the portal vein velocity (P < 0.02), and between the albumin gradient of serum-ascites and the portal vein velocity (P < 0.027) with Spearman linear correlation analysis. CONCLUSIONS: The present study suggests that hypoalbuminemia may be related to impairment of synthesis function in severe hepatitis itself, but not to the intraabdominal shifting of protein. Decreased portal vein velocity may be the first presenting sign in patients with severe form hepatitis complicating simple ascites. Yet this relationship will be masked and complicated once spontaneous bacterial peritonitis occurs.

Endoscopic and image features in primary gastro-intestinal lymphoma: a 7-year experience.

BACKGROUND/AIM: Primary gastro-intestinal lymphoma (PGIL) has various presentations in the gastrointestinal tract. Between 1987 and 1993, we examined 90 cases, using radiography, sonography and/or endoscopy, in an attempt to characterize the lesions of PGIL. MATERIALS AND METHODS: Patients suffering from PGIL lesions were investigated with the combined modalities of radiology. Sonography and endoscopy. The data was reviewed retrospectively. All cases were proven by tissue histology obtained by biopsy or surgical resection. RESULTS: We characterized seven growth patterns of PGIL: ulceration, infiltration, stricture, obstruction, erosion-like lesion, new growth (divided into 3 sub-groups: nodule, polypoid and mass) and perforation. Ulcerative lesion was found to be predominant in stomach (80.5%, P < 0.001) and duodenum (71.4%, P< 0.01) comparing with small (19.2%) and large (43.8%) bowel. The positive rate of gastric biopsy using endoscopy was 86% (31/36 biopsy cases). New growth pattern was the second main feature in PGIL, and one of the new growths, namely the mass, was predominant feature in terminal ileum (71.4%, P<0.001) and colon (62.5%, P < 0.001) when compared with stomach. Ulceration was a more frequent lesion in gastric and duodenal lymphoma. Cecal and terminal ileal lymphomas were mainly presented as new growth lesions, following the mass pattern. CONCLUSIONS: Radiographic, sonographic, and endoscopic studies showed different patterns in PGIL. A combination of these modalities was recommended in the evaluation of various lesions of PGIL.

Risk factors associated with fulminant amebic colitis.

Amebic colitis is associated with serious complications and a high fatality rate if it progresses to its fulminant form. The purpose of this retrospective study was to determine the risk factors associated with fulminant amebic colitis. From February 1978 to February 1993, 60 adults were diagnosed with intestinal amebiasis at Chang Gung Memorial Hospital. Sixteen patients with massive bloody diarrhea, persistent systemic toxicity or signs of peritonitis were classified as having fulminant colitis, five of whom progressed to fulminant colitis after admission to the hospital. Forty-four patients with good responses to amebicides and without complications were classified as having moderate colitis. There was no amebiasis-related mortality among patients with moderate colitis. In contrast, five patients with fulminant colitis died. Early diagnosis and surgical treatment significantly decreased mortality when compared with conservative treatment. Significant factors associated with the development of fulminant intestinal amebiasis in univariate analyses were being male, age over 60 years, having an associated liver abscess, progressive abdominal pain, signs of peritonitis, leukocytosis, hyponatremia, hypokalemia and hypoalbuminemia. Only the factors of being over 60 years of age and hypokalemia were important in multivariate analyses. We conclude that early and extensive surgical treatment is mandatory for patients with typical presentations of fulminant amebic colitis on admission to the hospital, such as progression to peritonitis, persistent systemic toxemia and explosive bloody diarrhea. For other patients, especially the elderly and those with low serum potassium levels, close monitoring and observation for signs of fulminant colitis is important.

A modified TNM-based Japan Integrated Score combined with AFP level may serve as a better staging system for early-stage predominant hepatocellular carcinoma patients.

BACKGROUND: Combinations of Child-Pugh classification and Liver Cancer Study Group of Japan/Tumor-Node-Metastasis (LCSGJ/TNM) have been reported as Japan Integrated Staging (JIS). We previously modified the 6th AJCC/TNM to serve as a better staging system than the 5th and 6th AJCC/TNM. AIMS: To develop a modified TNM-based JIS to predict the survival of hepatocellular carcinoma (HCC) patients more accurately. METHODS: 3764 HCC patients were enrolled from 1986 to 2002 (2882 patients from 1986 to 2000 and 882 patients from 2001 to 2002). We compared the performance of original JIS, modified TNM-based JIS, modified TNM-based JIS combined alpha-fetoprotein (AFP), BCLC, and CLIP. Lower Akaike information criteria (AIC) values indicated better discriminatory abilities. RESULTS: AIC value was lowest in CLIP during all periods. However, during 2001-2002, when early-stage HCC patients were predominant, AIC value was lowest when modified TNM-based JIS combined AFP was used. CONCLUSION: The CLIP system provided the best prognostic stratification in the present cohort of HCC patients who were mainly at late stages. However, early detection of HCCs has become more common in Taiwan in recent years, which has led to the predominance of early-stage HCC patients. Therefore, modified TNM-based JIS combined AFP may now be the most applicable system in recent years.

Long-term effect of interferon alpha-2b plus ribavirin therapy on incidence of hepatocellular carcinoma in patients with hepatitis C virus-related cirrhosis.

We assessed the efficacy of interferon (IFN) alpha-2b plus ribavirin therapy in patients with hepatitis C virus (HCV)-related cirrhosis, and elucidated the risk factors for the development of hepatocellular carcinoma (HCC) to determine whether these therapies might reduce the incidence of HCC. One hundred and thirty-two HCV-cirrhotic patients receiving IFN alpha-2b (3 or 5 MU thrice weekly) and oral ribavirin (1,000-1,200 mg/day) for 24 or 48 weeks were analysed. Cumulative incidence of HCC was estimated by the Kaplan-Meier method. The prognostic relevance of clinical variables and HCC occurrence was evaluated by univariate analysis with the log-rank test and by multivariate Cox's regression analysis. A total of 116 patients completed the treatment and 73 (55%) achieved a sustained virological response (SVR). Stepwise logistic regression analysis showed that nongenotype 1b (P < 0.001) and low viral load (P = 0.018) were independent variables of SVR. During a median follow-up period of 37 (12-63) months, HCC developed in 11 patients with non-SVR and five with SVR (P = 0.0178), whereas there was no difference between those with transient biochemical response and nonresponse (P = 0.5970). The Kaplan-Meier method also showed that old age (>or=60 years) (P = 0.0034) and genotype 1b (P = 0.0104) were associated with HCC occurrence. Using Cox's regression analysis, non-SVR (odds ratio = 3.521, P = 0.036), male (odds ratio = 6.269, P = 0.011) and old age (odds ratio = 3.076, P = 0.049) were independent significant risk factors contributing to HCC development. Our results suggest that achieving SVR by IFN alpha-2b plus ribavirin therapy may decrease the incidence of HCC in patients with HCV-related cirrhosis.

Sonographic features of retroperitoneal neurilemoma.

Seven cases of retroperitoneal neurilemoma confirmed by histology had an ultrasound examination. There were 5 women and 2 men with a mean age of 55. Most of the cases (5/7) had a palpable mass clinically. Of the 7 cases, 4 had a mass with cystic degeneration and internal echoes on sonogram, consistent with the macroscopic findings of tumors. The internal echoes represented blood clots and residual tissue (or septa) in cyst. Of the remaining 3 cases, one showed a confluent lobulated mass, the second had a solitary homogeneous mass with small cysts, and the third one, which was the smallest (4 cm x 4 cm x 6 cm), had a hypoechoic and homogeneous pattern. The sonograms of all 7 cases were consistent with the macroscopic features of the tumors. The sonographic pattern of tumor parenchyma is either homogenously hyperechoic or hypoechoic. Because of the cystic degeneration, hemorrhage, and residual tissue of retroperitoneal neurilemoma, the sonographic pattern was variable.

Endoscopic and radiological features of intramural esophageal dissection.

A 41-year-old woman was admitted to our hospital complaining of chest pain, dysphagia, and odynophagia after an upper respiratory tract infection and nasogastric tube insertion. An upper endoscopy showed a large submucosal bulge along the posterior wall from the upper esophagus with mucosal tears and bridge formation, extending down to the lower esophagus. A barium esophagogram revealed a "double-barreled" esophagus, and chest computed tomography (CT) scan showed eccentric thickening of the esophageal wall. The diagnosis of intramural esophageal dissection (IED) was made and the patient was managed conservatively with nothing by mouth and intravenous hydration. The clinical course was uneventful; the patient was discharged later and up to the time of writing has been completely asymptomatic, with normal swallowing function.

Use of sonography in the evaluation of the gastroesophageal junction.

To demonstrate the gastroesophageal junction with a real-time, transabdominal sonography through the window of left lobe of liver, the normal sonographic pattern and the thickness of the wall of abdominal esophagus were determined. The detection rate of the normal pattern in 30 control subjects was 93%, the normal thickness of the wall being 3.8 +/- 1.2 mm (range 2 mm to 5 mm). In 7 patients with severe acute esophageal inflammation, the thickness was 7.6 +/- 2.1 mm (range 5 mm to 10 mm). In 6 patients with an invading lesion in the gastroesophageal junction due to malignancy, the thickness of the wall was more than 10 mm in each case. This preliminary study indicates that the sonographic detection of gastroesophageal junction through the liver window can be included in routine abdominal sonography. An increased thickness of the wall needs further study to find the cause of the thickening.

Endoscopic ultrasonographic classification of gastric aberrant pancreas.

BACKGROUND: Gastric aberrant pancreas (GAP) can be demonstrated by its characteristic patterns on endoscopic ultrasonography (EUS). We tried to classify the EUS figures of GAP to provide a useful EUS pattern for diagnosing this disease. METHODS: Among 68 cases of GAP suspected by EUS, 13 patients who were proven to have GAP by histology from surgical specimens (4 cases), mucosectomy (6 cases), and biopsy (3 cases) were enrolled. EUS was performed under a standard procedure using an Olympus EU-M3 machine with a 7.5/12 MHz inter-changeable transducer. The essential histological finding of GAP is pancreatic tissue in specimens. RESULTS: Among 13 patients with GAP (size from 0.7 to 1.6 cm in diameter), 11 tumors were located in the antrum, and 2 were located at the lower body. All 13 tumors arose from the third layer of the gastric wall with an echogenicity higher than the fourth hypoechoic layer. We classified EUS figures of these 13 GAP into 3 types based on the change of the muscular (fourth) layer below the tumor: Type 1 (6 cases), the fourth layer is intact and has a normal thickness; Type 2 (4 cases), the fourth layer has thickened; and Type 3 (3 cases), the fourth layer has thickened, and there are some hyperechoic densities (tubular-like structures) within the fourth layer. Mucosectomy was performed without any complication in 6 cases (four type 1 and two type 2). CONCLUSION: EUS figures of our 13 cases of GAP were classified into 3 types which will be helpful in the EUS diagnosis of GAP and can provide information on selecting patients for mucosectomy.

Hepatic parenchymal calcifications--differentiation from intrahepatic stones.

Intrahepatic hyperechoic lesions with acoustic shadows could be stones or nonspecific calcifications. To verify this, 9 patients with hepatic parenchymal calcifications were compared with 40 patients with intrahepatic stones. A set of criteria are proposed for the diagnosis of intrahepatic stones: (A) dilated intrahepatic duct; (B) pneumobilia; or (C) 2 or more of the following: (1) common hepatic duct more than 6 mm in diameter, (2) multiple lesions in one lobe, (3) left lobe involvement, and (4) elevated serum alkaline phosphatase. The sensitivity, specificity, and overall accuracy were 97.5%, 88.9%, and 95.9, respectively. The criteria help in the selection of patients for evaluation of intrahepatic stones.