A rare cause of acute upper gastrointestinal bleeding.

Acute upper gastrointestinal bleeding (AUGB) remains a common indication for admissions and is associated with significant morbidity and mortality. Peptic ulcer diseases and varices are the commonest lesions identified during endoscopy. However, endoscopists need to be aware of the rare causes of AUGB, as missing such lesions can potentially be fatal. Rare causes can be missed if they are not looked for systematically during endoscopy. We report a case of AUGB secondary to bullous pemphigoid involving the esophagus in an elderly gentleman presenting with significant blood loss from hematemesis. A review of the English literatures on bullous pemphigoid involvements of the esophagus was carried out and the underlying pathogenesis and management are discussed.

A randomized, placebo-controlled trial of thymosin-alpha1 and lymphoblastoid interferon for HBeAg-positive chronic hepatitis B.

Combination therapy between two immunomodulators used for treatment of chronic hepatitis B was explored based on reported therapeutic efficacy of interferon-alpha, and thymosin-alpha1 as monotherapeutic agents to determine if combination therapy was superior to interferon alone. This double-blinded, randomized, placebo-controlled trial compares the addition of thymosin-alpha1, 1.6 microg taken three times per week (combination therapy) or thymosin placebo (monotherapy) to lymphoblastoid interferon (Wellferon), 5 million international units (MIU) taken three times per week, for 24 weeks. Entry criteria included positive hepatitis B e antigen (HBeAg); alanine aminotransferease (ALT) > or = 1.5 x upper normal limit, but < or = 10 x upper normal limit; positive HBV DNA; absence of cirrhosis; treatment naivety and no co-morbid factors. A total of 98 HBeAg-positive patients were recruited, of which 48 were randomized to combination therapy and 50 to monotherapy. The primary endpoint was the loss of HBeAg at 72 weeks. The secondary endpoints were HBeAg seroconversion, normalization of ALT, loss of HBV DNA and improvement in histology. The HBeAg loss was 45.8% and 28.0% for combination therapy and monotherapy, respectively (difference, 17.8%; 95% CI -1.2%-35.3%, P = 0.067). There was a trend towards HBeAg loss when using combination therapy. There were also no statistically significant differences between the different therapies with respect to the secondary endpoints of HBeAg seroconversion, changes in histology, normalization of ALT or loss of HBV DNA. In conclusion, this trial showed a 17.8% improvement in HBeAg loss rates using combination therapy over interferon monotherapy. This could clinically indicate a potential important difference that would need confirmation in subsequent trials.

Human immunodeficiency virus and endoscopy: Experience of a general hospital in Singapore.

INTRODUCTION: As the human immunodeficiency virus (HIV) pandemic continues, demand on the endoscopic services will also increase. The aim of the present study was to characterize the characteristics and endoscopic findings of HIV-infected Asian patients. METHODS: Patients with HIV/AIDS who had endoscopy from January 1997 to September 2002 were identified and retrospectively reviewed. RESULTS: There were 125 patients (male, 111; mean age: 43.2 +/- 11 years; mean CD4 count 63 +/- 85/mm(3), range, 1-342/mm(3)) who underwent 181 procedures (upper gastrointestinal endoscopy [UGIE], n = 141; lower gastrointestinal endoscopy [LGIE], n = 40). The median time from diagnosis to endoscopy was 240 days (-660 to 4680 days). For UGIE the main findings were candidiasis, 23.1%; cytomegalovirus esophagitis/ulcers, 11.2%; duodenal ulcers, 8.4%; gastric ulcers, 7.0%; portal-hypertensive-related changes, 6.3%; idiopathic esophageal ulcers, 3.5%; herpes simplex esophagitis/ulcers, 3.5%; and tuberculosis, 2.1%. The CD4 counts were significantly lower in those with opportunistic infections (P = 0.004) but there was no difference between significant and non-significant findings (P = 0.191). For LGIE 35% had endoscopic colitis, 80% of which were non-specific. Significant findings were ileal tuberculosis, n = 3; colon cancer, n = 1; and colonic fistula, n = 1. Ten patients had undergone 16 procedures (UGIE, n = 13; LGIE, n = 3) prior to the diagnosis of HIV/AIDS. They were all male Chinese patients, with positive contact with commercial sex workers (CSW) and had lymphopenia at time of endoscopy. The median time from endoscopy to diagnosis was 180 days (range, 1-660 days). There were no significant differences in age (P = 0.512) and CD4 count at diagnosis (P = 0.066) between patients who had endoscopy before and after diagnosis of HIV/AIDS. Four procedures led to the suspicion of HIV. CONCLUSIONS: Endoscopic findings of symptomatic HIV Asian patients are comparable to those of the West. Universal precautions should always be exercised in all procedures to avoid transmission of disease.