The efficacy of limited endoscopic sphincterotomy plus endoscopic papillary large balloon dilation for removal of large bile duct stones.

BACKGROUND: The removal of large bile duct stones (> 15 mm) by conventional endoscopic sphincterotomy (EST) and endoscopic papillary balloon dilation (EPBD) can be challenging, requiring mechanical lithotripsy (ML) in addition to EST or EPBD. The primary complication of ML is basket and stone impaction, which can lead to complications such as pancreatitis and cholangitis. The present study aims to investigate the efficacy of limited EST plus endoscopic papillary large balloon dilation (EST-EPLBD) for large bile duct stone extraction with an extent of cutting < 1/2 the length of the papillary mound. METHODS: We enrolled 185 patients with ≥15 mm bile duct stones who received EST, EPLBD and limited EST-EPLBD treatment from January 1, 2010 to February 28, 2018, at Kaohsiung Chang Gung Memorial Hospital (Kaohsiung, Taiwan). All patients were categorized into three groups: EST group (n = 31), EPLBD group (n = 96), and limited EST-EPLBD group (n = 58). The primary outcome variables were the success rate of complete stone removal and complications. RESULTS: The limited EST-EPLBD group exhibited a higher success rate of the first-session treatment compared with the EST and EPLBD groups (98.3% vs. 83.9% vs. 86.5%; P = 0.032) but required a longer procedure time (32 (12-61) min vs. 23.5 (17-68) min vs. 25.0 (14-60) min; P = 0.001). The need for ML during the procedure was 4 (12.9%) in the EST group, 10 (10.4%) in the EPLBD group and 2 (3.4%) in the limited EST-EPLBD group. Post-procedure bleeding in the EST group was more common than that in the limited EST-EPLBD group (9.7% vs. 0%; P = 0.038). Furthermore, dilated bile duct was the only risk factor for bile duct stone recurrence in the limited EST-EPLBD group. CONCLUSIONS: Limited EST-EPLBD exhibits a higher success rate but requires marginally longer procedure time for the first-session treatment. Furthermore, dilated bile duct is the only risk factor for bile duct stone recurrence in patients undergoing limited EST-EPLBD.

Limited precut sphincterotomy combined with endoscopic papillary balloon dilation for common bile duct stone removal in patients with difficult biliary cannulation.

BACKGROUND: Difficult biliary cannulation in endoscopic retrograde cholangiopancreatography (ERCP) can result in failure of common bile duct (CBD) stone removal and pancreatitis. The present study aimed to report the efficacy and safety of limited precut sphincterotomy (PS) combined with endoscopic papillary balloon dilation (EPBD) for CBD stone removal in patients with difficult biliary cannulation, and the complications associated with this combined procedure. METHODS: A total of 3305 patients underwent ERCP in our hospital between October 2009 and September 2014 and 258 were diagnosed with difficult biliary cannulation. Of these 258 patients, 58 underwent limited PS combined with EPBD for CBD stone removal, and these 58 patients were included in this retrospective study. RESULTS: The overall success rate was 94.8 % (55/58), and the success rate for single-session removal was 87.9 % (51/58). The mean procedure time was 41 ± 11.48 min (range, 20-72 min). Mechanical lithotripsy was needed in 10.3 % (6/58) of patients. Procedure-related complications included bleeding in 3.4 % (2/58), pancreatitis in 8.6 % (5/58) and biliary tract infection (BTI) in 1.7 % (1/58) of patients. CONCLUSIONS: The therapeutic outcome of limited PS combined with EPBD for CBD stone removal in patients with difficult biliary cannulation was good with an acceptable complication rate. It could be an alternative to PS and "early" limited PS should be used for prompt identification of the bile duct. Limited PS combined with EPBD is safe and effective for CBD stone removal in patients with difficult biliary cannulation.

Clinical Impact of Gadoxetic Acid-Enhanced Magnetic Resonance Imaging on Hepatoma Management: A Prospective Study.

BACKGROUND: For patients with hepatocellular carcinoma (HCC), gadoxetic acid-enhanced magnetic resonance imaging (EOB-MRI) improved the diagnosis, migrated Barcelona Clinic Liver Cancer (BCLC) stage, and changed therapeutic decision in retrospective analysis. AIM: This prospective study was to evaluate the clinical impact of EOB-MRI on HCC management. METHODS: From September 2012 to February 2014, consecutive patients with suspicion of HCC in BCLC early stage by multidetector computed tomography or dynamic MRI with non-specific gadolinium, well liver function reserve, and admitted for resection evaluation were enrolled prospectively. Additional EOB-MRI was performed. The HCC diagnosis, BCLC staging, and treatment decision were obtained in a liver cancer conference. EOB-MRI impact on HCC management was analyzed. RESULTS: One hundred and three patients including 68 with typical and 35 with atypical HCC nodules in dynamic imaging studies were enrolled. EOB-MRI characterized 3 (4.4 %) benign and 33 (94.3 %) HCC for patients with typical and atypical HCC nodules, respectively. For 90 HCC patients, additional EOB-MRI changed BCLC stage in 25 (27.8 %) and treatment decision in 17 (18.9 %) patients. There were 66 patients with 78 resected nodules including 65 HCCs, 4 intrahepatic cholangiocarcinomas, and 9 benign nodules. Dynamic study and EOB-MRI detected and characterized 69 and 77 nodules, respectively. The sensitivity and accuracy in HCC diagnosis were 98.5 and 85.7 % for EOB-MRI, which were better than those of dynamic study (p < 0.001). CONCLUSIONS: Additional EOB-MRI improved HCC diagnosis in sensitivity, accuracy but not specificity. It changed BCLC staging and treatment decision in 27.8 and 18.9 % of early-stage HCC patients.

Predicting risk factors for rebleeding, infections, mortality following peptic ulcer bleeding in patients with cirrhosis and the impact of antibiotics prophylaxis at different clinical stages of the disease.

BACKGROUND: Infections in cirrhotic patients with upper gastrointestinal bleeding are a common event causing severe complication and mortality. This study aimed to identify risk factors that may predict rebleeding, bacterial infections, and the impact of antibiotic prophylaxis on mortality at different stages of cirrhosis following acute peptic ulcer bleeding (PUB). METHODS: A hospital-based retrospective cohort study was conducted on 235 cirrhotic patients with acute peptic ulcer hemorrhage who underwent therapeutic endoscopic procedures between January 2008 and January 2014 (n = 235); of these, 88 patients received prophylactic intravenous ceftriaxone (antibiotic group) and 147 patients did not (nil-antibiotic group). The recorded outcomes were length of hospital stay, bacterial infection, rebleeding, and in-hospital mortality. RESULTS: Forty-eight (20.4%) patients experienced ulcer rebleeding and 46 (19.6%) developed bacterial infections. More patients suffered from infection and recurrent bleeding in the nil-antibiotic group than the antibiotic group (25.2% vs. 10.2%, p = 0.005 and 30.6% vs. 3.4%; p < 0.001, respectively). The predictive risk factors for rebleeding were the Rockall score (p = 0.004), units of blood transfusion (p = 0.031), and no antibiotic prophylaxis (p <0.001); for bacterial infections, they were the Child-Pugh score (p = 0.003), active alcoholism (p = 0.035), and no antibiotic prophylaxis (p = 0.009). Overall, 40 (17%) patients died during hospitalization. The Rockall score and rebleeding were predictive factors for in-hospital mortality. In subgroup analysis, survival was significantly reduced in decompensated patients (p = 0.034). CONCLUSIONS: This study suggests that antibiotic prophylaxis after endoscopic hemostasis for acute PUB prevented infections and reduced rebleeding events in cirrhotic patients. Antibiotic prophylaxis improved survival among decompensated cohort following PUB. The Rockall score and rebleeding were predictive risk factors for in-hospital mortality.

Endoscopic papillary balloon dilation for removal of bile duct stones: evaluation of outcomes and complications in 298 patients.

BACKGROUND: Endoscopic papillary balloon dilation (EPBD) is a therapeutic procedure for extraction of bile duct stones. GOALS: To evaluate the therapeutic outcomes, postoperative complications, and associated risk factors of EPBD in patients with bile duct stones. STUDY: A total of 298 patients with bile duct stones were treated with EPBD. Their immediate outcomes were assessed and they were followed up for late complications. The modified Cotton criteria were used to determine the incidence of post-EPBD pancreatitis. RESULTS: Complete removal of bile duct stones was achieved in 273 patients (91.6%). Removal was successful in 94.6% of stones ≤ 1 cm and 82.9% of stones >1 cm (P=0.001). Thirty patients (10.1%) had acute pancreatitis after EPBD with bile duct stone extraction, including 20 women (P=0.044), 20 patients under 60 years old (P=0.003) and 19 who received contrast medium injection to the pancreas (P=0.016). Symptomatic bile duct stones recurred in 12 patients (4%) 1 to 65 months after EPBD. The duration of balloon dilation was >3 minutes in 11 of these 12 patients (P=0.025) and all recurrent stones were brown and black pigment stones. CONCLUSIONS: EPBD is an effective and safe treatment for bile duct stone removal. Small bile duct stones (≤ 1 cm) can easily be extracted by EPBD. Contrast medium injection to the pancreas, female sex, and age under 60 years were significant risk factors for post-EPBD pancreatitis. Balloon dilatation duration >3 minutes was the only risk factor for recurrent symptomatic bile duct stones.

Congenital anomaly of low insertion of cystic duct: endoscopic retrograde cholangiopancreatography findings and clinical significance.

BACKGROUND/AIM: Low insertion of cystic duct (LICD) may be problematic during cholecystectomy. This study was performed retrospectively to assess the prevalence of LICD and identify the risk factors of stone recurrence between LICD and non-LICD (NLICD) after removal of stones. METHODS: Between January 1999 and November 2005, 3546 patients received endoscopic retrograde cholangiopancreatography examination for suspicion of biliary tract diseases. The age and sex-matched group with NLICD was enrolled to compare the clinical differences with LICD group. LICD was defined as "the orifice level of the cystic duct being below the low third of the extrahepatic duct." Recurrence was defined as "patients suffering from cholangitis or biliary stones 1 year later after the first intervention." RESULTS: Of the enrolled 3546 patients (male/female=1821/1725), 191 (5.4%) had LICD. Excluding cases of malignancy, nonbiliary stones, and incomplete data, 122 LICD patients were available. Periampullary diverticula and positive bacterial culture from bile were less common in the LICD group than the NLICD group (P=0.045; P<0.001, respectively). Lower recurrent rate of common bile duct (CBD) stones in the recurrent cases were found in the LICD group compared with the NLICD group (P=0.024; P=0.039, respectively). Univariate analysis revealed that LICD [odds ratio (OR)=0.284; P=0.032] and CBD stones (OR=4.496; P=0.006) were significantly correlated to stone recurrence. CONCLUSIONS: Our study clearly demonstrated the prevalence (5.4%) of LICD in cases with suspicion of biliary tract disease based on endoscopic retrograde cholangiopancreatography. Notably, the strongest predictors, NLICD and CBD stones, appeared to result in the higher stone recurrence.

Surveillance culture of endoscope to monitor the quality of high-level disinfection of gastrointestinal reprocessing.

BACKGROUND/AIMS: Inadequate reprocessing of endoscopes or endoscopic accessories may result in iatrogenic infection and present a risk to public health. The aim of this study is to utilize microbiological cultures of endoscopes to assess the adequacy of standard reprocessing procedures. METHODOLOGY: A prospective study to randomly cultures of endoscopes and colonoscopies immediately after the completion of the decontamination cycle monthly. The samples were obtained by flushing 50 ml sterile distilled water to the internal channel and collected into a sterile container. These samples were incubated at 37 degrees C and examined for bacterial growth. RESULTS: A total of 49 cultures were obtained from June to December in year 2005. Three out of 7 were culture positive in the first month initially, but after prolonged the soaking duration to 25 minutes, the subsequent cultures were reduced to 1 positive sample only. The positive culture rate was 18.4% (9/49), and 44.4% (4/9) in Monoflora culture and 55.6% (5/9) in Multi-flora. Upper endoscopes decontaminated by automated endoscopic washing machine labeled as number 5 was found persistently culture positive with varied organisms despite vigorous manual cleaning and prolonged disinfectant soaking duration. At repair, the relief valve in the automated endoscopes washing machine was damaged and disconnected. After repair, subsequent cultures were negative. CONCLUSIONS: Endoscopy culturing is a useful method to assess the effectiveness of standard reprocessing procedures. Servicing of automated endoscope washer regularly is mandatory to minimize cross infection and quality assurance.

A comparison between non-sedation and general endotracheal anesthesia for retrograde endoscopic common bile duct stone removal: A tertiary center experience.

BACKGROUND: Conscious sedation is not routinely administered for therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in many countries. The aim of our retrospective study was to compare the safety and rate of success and complications during common bile duct (CBD) stone extraction using ERCPs performed with no-sedation (NS) or under general endotracheal anesthesia (GET). METHODS: The medical records of all patients who underwent ERCP for biliary stone extraction between January 2010 and September 2013 were reviewed, and patients classified to the NS and GET groups. The primary outcomes were the rate of success of complete stone removal and rate of complications, including post-ERCP pancreatitis (PEP), perforation, bleeding, pneumonia, and mortality within 30 days post-ERCP. Operative time was recorded for analysis. RESULTS: During the study period, 630 patients underwent ERCP, 402 with NS and 105 with GET. Among the 402 patients in the NS group, 37 (9.2%) could not complete the procedure due to an inability to tolerate the procedure. The success rate of complete stone extraction was higher among patients in the GET group than the NS group (94.3% versus 75.6%, respectively; p < 0.001). The rate of contrast injection into the pancreatic duct was higher for the NS than GET group (24.9% versus 15.2%, respectively; p = 0.008). Although non-significant, there was a higher incidence of post-ERCP pancreatitis (PEP) in the NS than in the GET group (10.4% versus 5.7%, respectively; p = 0.105), while the incidence of pneumonia was higher for the GET group. Biliary pancreatitis, contrast injection into the pancreatic duct and an operation time ≥30 min were independent risks factors for PEP. CONCLUSIONS: ERCP under GET is effective for CBD stone removal, but with slightly higher pneumonia rate after the procedure than non-sedated ERCP.

Model for end-stage liver disease (MELD) score for predicting late esophageal varices rebleeding in cirrhotic patients.

BACKGROUND/AIMS: Esophageal varices bleeding is a fatal complication of portal hypertension. The model for end-stage liver disease (MELD) has been used as a tool to predict mortality risk in cirrhotic patients. It is currently unknown if MELD score can be applied to predicting late esophageal varices rebleeding. The predictive ability of the MELD score for short-term esophageal varices rebleeding was studied. METHODOLOGY: Ninety-five cirrhotic patients with esophageal varices bleeding were enrolled with a follow up period of at least 3 months. All patients had undergone a successful hemostasis at admission. Initial admission MELD score and 3-months MELD were obtained to observe their correlation with the late esophageal varices rebleeding. RESULTS: MELD score of 13 and 16 are the mean MELD score of the admission and 3-months respectively in the rebleeding group. The correlation between initial admission MELD score and late stage data showed a positive linear regression in the rebleeding patients (p=0.001, r=0.773) but not in the non-rebleeding group. CONCLUSIONS: The MELD score is a good predictor of short term esophageal varices rebleeding rate. At least 2 MELD score data is needed to evaluate the possibilities of rebleeding

Pseudoachalasia in a patient after truncal vagotomy surgery successfully treated by subsequent pneumatic dilations.

Pseudoachalasia is a difficult condition for the clinician to differentiate from idiopathic achalasia even by manometry, radiological studies or endoscopy. Its etiology is usually associated with tumors. In most cases, the diagnosis is made after surgical explorations. The proposed pathogenesis of the disease is considered as mechanical obstruction of the distal esophagus or infiltration of the malignancy that affects the inhibitory neurons of the meyenteric plexus in the majority of cases. Surgery has been reported as a cause of pseudoachalasia. We report a 70-year-old man who suffered from deglutination disorder caused by pseudo-achalasia after truncal vagotomy. The patient was symptom-free after a nine-year follow-up and complete recovery of esophageal motility status from pseudoachalasia after pneumatic dilations. We also reviewed the literature of pseudoachalasia.

A Randomized Control Trial Comparing 2 Levofloxacin-Containing Second-Line Therapies for Helicobacter pylori Eradication.

Summary of Trial Design.Lengthy exposure to quinolone-containing triple therapy in Helicobacter pylori eradication leads to the development of drug resistance. Sequential therapy with a quinolone and metronidazole -containing regimen appears to be an effective treatment option. This randomized controlled trial aimed to compare the efficacy of 5-plus 5 days' levofloxacin and metronidazole-containing sequential therapy (EALM) with that of 10-day levofloxacin-containing triple therapy (EAL) in second-line H pylori eradication treatment.One hundred and sixty-four patients who had failed the H pylori eradication attempts using the standard triple therapy (proton pump inhibitor bid, clarithromycin 500 mg bid, amoxicillin 1 g bid × 7 days) were randomly assigned to either an EALM therapy group (n = 82; esomeprazole 40 mg bid and amoxicillin 1 g bid for 5 days, followed by esomeprazole 40 mg bid, levofloxacin 500 mg qd, and metronidazole 500 mg tid, for 5 days) or a 10-day EAL therapy group (n = 82; levofloxacin 500 mg qd, amoxicillin 1 g bid, and esomeprazole 40 mg bid). One patient was lost to follow-up in each group. Follow-up for H pylori status was performed 4 to 8 weeks later.Eradication rates for the EALM and EAL groups were 90.2% (74/82, 95% confidence interval [CI] = 83.7%-96.8%) and 80.5% (66/82, 95% CI = 71.7%-89.2%, P = 0.077) in the intention-to-treat analysis; and 91.4% (74/81, 95% CI = 85.1%-97.6%) and 81.5% (66/81, 95% CI = 72.8%-90.1%, P = 0.067) in the per-protocol analysis. The adverse events for the EALM and EAL groups were 23.5% versus 11.1%, P = 0.038 but were all very mild and were well tolerated except for 1 patient with poor compliance. The compliances were 98.8% and 100%, respectively, between the 2 groups. An antibiotic resistance to levofloxacin was the clinical factor influencing the efficacy of H. pylori eradication therapy in the EAL group, and dual resistance to levofloxacin and metronidazole in the EALM group.Levofloxacin and metronidazole-containing sequential therapy achieved a >90% eradication rate as a second-line H pylori therapy. Dual antibiotic resistance to levofloxacin and metronidazole was the clinical factor influencing the efficacy of H pylori eradication therapy in the sequential therapy (ClinicalTrials.gov number: NCT02596620).

Endoscopic findings and management of dengue patients with upper gastrointestinal bleeding.

There are 100 million cases of dengue infection, 500,000 cases of dengue hemorrhagic fever, and 25,000 deaths annually due to dengue worldwide. Gastrointestinal bleeding is the most common type of severe hemorrhage in dengue fever. However, there are no reports about the clinical applications of endoscopic therapy for upper gastrointestinal bleeding (UGI) in dengue patients. From June 17, 2002 to January 30, 2003, 1,156 patients with confirmed dengue virus infection were treated at Kaohsiung Chang Gung Memorial Hospital in Taiwan. We analyzed those patients who had received endoscopic therapy for UGI. The characteristic endoscopic findings, therapeutic courses, and amount of blood component transfused were collected from their charts for statistical analysis. Among the 1,156 dengue patients, 97 (8.4%) had complications of UGI bleeding during hospitalization. The endoscopic findings included hemorrhagic (and/or erosive) gastritis in 67% of the patients, gastric ulcer in 57.7%, duodenal ulcer in 26.8%, and esophageal ulcer in 3.1%. Of the 73 patients with peptic ulcer, 42 (57.5%) met the endoscopic criteria (recent hemorrhage) for endoscopic hemostasis therapy. Peptic ulcer patients with recent hemorrhage required more transfusions with packed red blood cells (P = 0.002) and fresh frozen plasma (P = 0.05) than those without recent hemorrhage. Among these 42 patients with recent hemorrhage, endoscopic injection therapy was conducted in 15 patients (group A). The other 27 patients (group B) did not receive endoscopic therapy. After endoscopy, patients in group A required more transfusions with packed red blood cells (P = 0.03) and fresh frozen plasma (P = 0.014) than did patients in group B. There were no significant differences between groups A and B in duration of hospital stay and amounts of transfused platelet concentrate after endoscopy. Medical treatment with blood transfusion is the mainstay of management of UGI bleeding in dengue patients. Patients having peptic ulcer with recent hemorrhage require more transfusions with packed red blood cells and fresh frozen plasma for management of UGI bleeding than those without recent hemorrhage. However, when peptic ulcer with recent hemorrhage is encountered during the endoscopic procedure, endoscopic injection therapy is not an effective adjuvant treatment of hemostasis in dengue patients with UGI bleeding.

Short report: Abnormal liver function in scrub typhus.

Scrub typhus is one kind of rickettsial disease and may cause fever, cough, and skin rashes in infected humans. Regarding liver involvement, it was uncommon to be reported in previous medical literature from Western countries. This study observes the relationship between scrub typhus and liver function. From January 1998 to August 2003 in Kaohsiung Chang Gung Memorial Hospital in Taiwan, we observed 30 patients with scrub typhus, and 29 of them had liver function abnormality. In these patients, we found 89.3% with elevated aspartate aminotransferase (AST) levels, 91.7% with elevated alanine aminotransferase (ALT) levels, 84.2% with elevated alkaline phosphatase (ALP) levels, and 38.5% with elevated total bilirubin levels. In our study, there is a close relationship between scrub typhus and impaired liver function tests. Therefore, if patients are found with fever of unknown origin and abnormal liver function, we should take scrub typhus into consideration.

Upper gastrointestinal carcinoid tumors incidentally found by endoscopic examinations.

AIM: This study shares Asian clinical experiences of carcinoid tumors that originated in the upper gastrointestinal tract. METHODS: From May 1987 to June 2002, we had found only 13 cases of histologically confirmed carcinoid tumors in the upper gastrointestinal tract by endoscopic examinations. There were eight males and five females. The mean age was 53.16+/-20.51 years that ranged from 26 to 82 years. Each of their clinical presentations, locations, tumor morphology, and size and the treatment outcome were analyzed and discussed. RESULTS: One patient had a polypoid lesion at the lower esophagus, nine were stomach lesions and three located at the duodenum. All patients with polypoid and submucosal tumor types were of small size (<1.7 cm) and all patients survived after simple excision or polypectomy. Four of the five patients in tumor mass forms died and the tumors were more than 2.0 cm in size. CONCLUSION: Carcinoid tumors rarely originated from the upper gastrointestinal tract and are usually found accidentally after endoscopic study. Bigger size (more than 2 cm) tumor masses may indicate a more severe disease and poor prognosis.

Comparison of treatment outcomes of endoscope-guided pneumatic dilation and laparoscopic Heller myotomy.

The debate on which is the better choice between laparoscopic Heller myotomy (LHM) and endoscopic pneumatic dilation (PD) for esophageal achalasia has been ongoing for decades. This study aims to compare the results of endoscope-guided PD and LHM in 42 patients with achalasia between May 1996 and August 2011. Twenty-one patients who had received PD and 21 who had received LHM were enrolled. The cumulative remission rate was analyzed using the Kaplan-Meier method with the assessment of symptom scores between grades before and after PD or LHM done at 6 weeks, 6 months, 1 year, and then every year thereafter. Possible confounding factors related to the remissions were analyzed by Cox's proportional hazard model. For PD, the cumulative remission rates were 81.0% (1 year), 76.2% (2), 66.7% (3), 61.9% (4), and 47.6% (5). For LHM, the cumulative remission rates were 90.5% every year from the 1(st) to the 5(th). The LHM patients had significantly better remission rates than the PD patients (p = 0.033, by log-rank test). The LHM group had a longer hospital stay than the PD group [median (interquartile range): 8 (6.5-10) days vs. 3 (2-3) days, p < 0.001) and had more reflux complications (52.4% vs. 19.0%, p = 0.024). No perforation occurred in either group. In conclusion, the 5-year cumulative effectiveness of LHM is better than that of PD despite the association of LHM with more reflux events (52.4%).

Seven-Day Nonbismuth Containing Quadruple Therapy Could Achieve a Grade "A" Success Rate for First-Line Helicobacter pylori Eradication.

This prospective study was to assess the efficacy of nonbismuth containing quadruple therapy as first-line H. pylori treatment and to determine the clinical factors influencing patient outcome. We enrolled 200 H. pylori-infected naïve patients. They were prescribed either a 7-day nonbismuth containing quadruple therapy group (EACM, esomeprazole 40 mg twice daily, amoxicillin 1 g twice daily, metronidazole 500 mg twice daily, and clarithromycin 500 mg twice daily) or a 7-day standard triple therapy group (EAC, esomeprazole 40 mg twice daily, amoxicillin 1 g twice daily, and clarithromycin 500 mg twice daily). Follow-up studies to assess treatment responses were carried out 8 weeks later. The eradication rates attained by EACM and EAC groups were 95.6% (95% confidence interval [CI] = 89.4%-98.3%) and 79.3% (95% CI = 70%-86.4%) in the per-protocol analysis (P < 0.001) and 88% (95% CI = 80.2%-93.0%) and 73% (95% I = 63.6%-80.3%) in the intention-to-treat analysis (P = 0.007). Clarithromycin resistance, metronidazole resistance, and dual clarithromycin and metronidazole resistances were the clinical factors influencing H. pylori eradication in EACM group. Clarithromycin resistance and dual clarithromycin and metronidazole resistances were the influential factor for EAC treatment. In conclusion, the results suggest that 7-day nonbismuth containing quadruple therapy could achieve a grade "A" report card for first-line H. pylori treatment.

Endoscopic Management of Foreign Bodies in the Upper Gastrointestinal Tract of Adults.

BACKGROUND: Foreign object ingestion and food bolus impaction are a common clinical problem. We report our clinical experiences in endoscopic management for adults, foreign body ingestion, and food bolus impaction. METHOD: A retrospective chart review study was conducted on adult patients with foreign body ingestion and food bolus impaction between January 2011 and November 2014. Patients with incomplete medical records were excluded. RESULTS: A total of 198 patients (226 incidents) were included in the study (male/female: 1.54/1; age 57 ± 16 years). Among them, 168 foreign bodies were found successfully (74.3%). 75.6% of the foreign bodies were located in the esophagus. Food bolus impaction was most common (41.6%). 93.5% of foreign bodies in current study cohort were successfully extracted and 5 patients required surgical interventions. Comparisons between symptomatic and asymptomatic patients revealed that locations of foreign bodies in the pharynx and esophagus were the significant relevant factors (P < 0.001). Shorter time taken to initiate endoscopic interventions increased detection rate (289.75 ± 465.94 versus 471.06 ± 659.93 minutes, P = 0.028). CONCLUSION: Endoscopic management is a safe and highly effective procedure in extracting foreign body ingestion and food bolus impaction. Prompt endoscopic interventions can increase the chance of successful foreign bodies' detection.

Five-year sequential changes in secondary antibiotic resistance of Helicobacter pylori in Taiwan.

AIM: To determine changes in the antibiotic resistance of Helicobacter pylori (H. pylori) in southern Taiwan after failure of first-line standard triple therapy. METHODS: We analyzed 137 H. pylori-infected isolates from patients who experienced eradication failure after standard first-line triple therapy from January 2010 to December 2014. The H. pylori strains were tested for susceptibility to amoxicillin, clarithromycin, levofloxacin, metronidazole and tetracycline using the E-test method. The minimal inhibitory concentration (MIC) was determined by the agar dilution test. MIC values of ≥ 0.5, ≥ 1, ≥ 1, ≥ 4 and ≥ 8 mg/L were considered to be the resistance breakpoints for amoxicillin, clarithromycin, levofloxacin, tetracycline and metronidazole, respectively. RESULTS: A high resistance rate was found for clarithromycin (65%-75%) and metronidazole (30%-40%) among patients who failed first-line standard therapy. The resistance levels to amoxicillin and tetracycline remained very low; however, levofloxacin resistance was as high as 37.5% in 2010 but did not increase any further during the past 5 years. The rates of resistance to these antibiotics did not show a statistically significant upward or downward trend. CONCLUSION: Antibiotic resistance of H. pylori remains a problem for the effective eradication of this pathogen and its associated diseases in Taiwan. High clarithromycin resistance indicated that this antibiotic should not be prescribed as a second-line H. pylori eradication therapy. Moreover, levofloxacin-based second-line therapy should be used cautiously, and the local resistance rates should be carefully monitored.

Dengue fever with acute acalculous cholecystitis.

Dengue fever (DF) with acute acalculous cholecystitis is rarely reported. To investigate the incidence, treatment, and prognosis of acute acalculous cholecystitis in DF patients, we retrospectively studied 10 patients with DF and acute acalculous cholecystitis. From October 2001 to July 2002, 131 patients were diagnosed with DF. Ten of 131 DF patients (7.63%) had complications of acute acalculous cholecystitis. Two patients underwent cholecystectomy and one underwent percutaneous transhepatic gallbladder drainage due to poor resolution of acute acalculous cholecystitis. We found acute acalculous cholecystitis in a small proportion of patients with DF. In our experience, closely monitoring vital signs to avoid shock and correct thrombocytopenia to avoid bleeding could be adequate for most patients. In some cases, surgical treatment may be needed for DF fever patients with complications of diffuse peritonitis.

Sequential changes of serum aminotransferase levels in patients with severe acute respiratory syndrome.

Severe acute respiratory syndrome (SARS) is a newly emerging infectious disease. To describe the hepatic injury caused by this disease, we report the sequential changes of serum transaminase in probable SARS patients during a hospital outbreak in southern Taiwan. From April to June, 2003, 52 probable SARS patients were hospitalized. Serial serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels were retrospectively analyzed and hepatitis B surface antigen (HBsAg) was also evaluated to correlate with the progression of this disease. Fifty-three percent of the patients had abnormal liver function during hospitalization. More than 70% of abnormal transaminase levels were mildly elevated. Most elevated levels were noted during the second week after onset of fever. Neither transaminase elevation nor HBsAg was related to the prognosis of SARS, and only advanced age was an independent predictor of poor outcome. Our study suggested that coronavirus causing SARS might induce liver damage.