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.

Combining age and HBsAg level predicts post-treatment durability of nucleos(t)ide analogue-induced HBeAg seroconversion.

BACKGROUND AND AIMS: Previous studies have indicated that lamivudine-induced hepatitis B e antigen (HBeAg) seroconversion may not be durable in the Asian population. We investigated the useful predictors of post-treatment hepatitis B virus (HBV) relapse in patients with nucleos(t)ide analogue (NA)-induced HBeAg loss/seroconversion. METHODS: A total of 157 non-cirrhotic patients with NA-induced HBeAg loss/seroconversion (78, lamivudine; 68, entecavir; 11, telbivudine) were retrospectively analyzed. All patients had at least 12 months of post-treatment follow-up and consolidation therapy duration. RESULTS: The cumulative rate of post-treatment HBV relapse at 5 years was 57.1%. Multivariate analysis revealed that age and baseline hepatitis B surface antigen (HBsAg) levels independently predicted post-treatment HBV relapse. The post-treatment HBV relapse rate was significantly higher in patients aged > 40 years than in those < 40 years (P < 0.001). A baseline HBsAg level of 2000 IU/mL was the optimal cut-off value for predicting post-treatment HBV relapse (P = 0.002). The post-treatment HBV relapse risk further increased with the presence of both risk factors (age ≥ 40 years and baseline HBsAg level ≥ 2000 IU/mL; P < 0.001). A prolonged consolidation therapy period of ≥ 18 or 24 months had no positive effect on sustained viral suppression. There was no significant difference in post-treatment HBV relapse rates between patients with lamivudine- and entecavir-induced HBeAg loss/seroconversion during the off-treatment follow-up (P = 0.31). CONCLUSION: The combination of an age of 40 years and a baseline HBsAg level of 2000 IU/mL was a useful marker for predicting post-treatment HBV relapse in patients with NA-induced HBeAg loss/seroconversion.

The role of hepatitis B surface antigen quantification in predicting HBsAg loss and HBV relapse after discontinuation of lamivudine treatment.

BACKGROUND & AIMS: We investigated whether the quantification of hepatitis surface antigen (HBsAg) could predict HBsAg loss or hepatitis B virus (HBV) relapse after stopping lamivudine treatment. METHODS: A total of 188 naive chronic hepatitis B patients (83 HBeAg-positive, 105 HBeAg-negative patients), who were previously treated with lamivudine (treatment duration: 89.3 ± 35.9 weeks, range: 52-243 weeks) but stopped the treatment for at least 12 months were recruited. RESULTS: The cumulative incidence of HBsAg loss and HBV relapse at year 6 after stopping lamivudine treatment was 24% and 65.9% respectively. Cox regression analysis revealed that lower alanine aminotransferase (ALT) at baseline, lower HBsAg levels at the end of treatment, and longer treatment duration were independent predictors for HBsAg loss, and old age, male sex and higher HBsAg levels at the end of treatment were independent predictors for post-treatment HBV relapse. At the end of treatment, the HBsAg cut-off value of 300 IU/ml could predict 55.6% (5/9) HBsAg loss in HBeAg-positive patients. In HBeAg-negative patients, the HBsAg cut-off values of 120 and 200 IU/ml could predict 79.2% (19/24) HBsAg loss and 93.3% (28/30) post-treatment sustained response respectively. Further HBsAg reduction (>0.22 log IU/ml) at month 6 after stopping treatment was an independent predictor for HBsAg loss after adjusting for HBsAg level at the end of treatment. CONCLUSIONS: Serum HBsAg level at the end of treatment is a useful predictor to guide the timing of stopping lamivudine treatment in chronic hepatitis B patients.

High risk of hepatitis B virus reactivation in nucleos(t)ide analogue-induced hepatitis B e antigen seroconverters older than 40 years.

BACKGROUND: A recent study showed that chronic hepatitis B virus (HBV) carriers with nucleos(t)ide analogue (NA)-induced hepatitis B antigen (HBeAg) seroconversion occurring before the age of 30 years have a higher risk of HBV reactivation. AIM: To compare the risk of HBV reactivation and HBeAg seroreversion between patients with spontaneous and NA-induced HBeAg seroconversion. METHODS: A total of 135 and 251 non-cirrhotic patients with NA-induced and spontaneous HBeAg seroconversion, respectively, were analyzed. RESULTS: NA-induced HBeAg seroconverters faced higher risks of HBV reactivation and HBeAg seroreversion than spontaneous HBeAg seroconverters (P < 0.001). In spontaneous HBeAg seroconverters, age at HBeAg seroconversion, sex, HBV DNA levels before HBeAg seroconversion, HBV genotype C, and pre-S deletions were independent predictors of HBV reactivation. In NA-induced HBeAg seroconverters, only age at baseline was an independent predictor of HBV reactivation. To determine whether the difference in the incidence of HBV reactivation or HBeAg seroreversion between two groups was age-specific, we analyzed these patients according to their age at HBeAg seroconversion (20-29, 30-39, and ≥40 years). Our data showed that NA-induced HBeAg seroconversion was an independent predictor of HBV reactivation and HBeAg seroreversion than spontaneous HBeAg seroconversion in patients older than 40 years at HBeAg seroconversion, but not in patients between 20-29 and 30-39 years of age. CONCLUSIONS: NA-induced HBeAg seroconverters are associated with higher risks of HBV reactivation and HBeAg seroreversion compared to spontaneous HBeAg seroconverters, especially in patients who are older than 40 years at HBeAg seroconversion.

Virological response to entecavir reduces the risk of liver disease progression in nucleos(t)ide analogue-experienced HBV-infected patients with prior resistant mutants.

OBJECTIVES: This study investigated the influence of virological response (VR) to entecavir on clinical liver disease progression in nucleos(t)ide analogue (NA)-naive and -experienced patients. METHODS: We investigated 487 chronic hepatitis B patients (323 NA-naive, 164 NA-experienced) treated with entecavir monotherapy for at least 12 months. VR was defined as hepatitis B virus DNA level <300 copies/mL during entecavir therapy. Clinical events were defined as hepatic decompensation, hepatocellular carcinoma (HCC), death and liver transplantation. RESULTS: Of the 487 patients, 49 developed clinical events during entecavir treatment. Of those, 36 developed HCC. For all patients, Cox regression analysis showed that age, baseline cirrhosis, alanine aminotransferase level ≤200 U/L, albumin level and no VR during entecavir treatment were independent predictors for clinical events and HCC development. However, the benefit of VR to entecavir was significant for clinical events and HCC only in NA-experienced patients, but not in NA-naive patients. For the further analysis of the different subgroups of NA-experienced patients, the benefit of VR to entecavir was significant for clinical events or HCC only in patients with prior lamivudine- or adefovir-resistant mutants, but not in NA-experienced patients who had never developed lamivudine- or adefovir-resistant mutants. VR at month 12 (but not early VR at month 6) remained a significant predictor associated with the development of clinical events and HCC in NA-experienced patients. CONCLUSIONS: VR to entecavir was associated with a reduced risk of clinical events and HCC in NA-experienced patients, particularly in those who had prior lamivudine- or adefovir-resistant mutants.

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.

Characteristics of adefovir resistance in patients with or without lamivudine-resistant hepatitis B virus treated with adefovir: a 4-year experience.

BACKGROUND/AIM: We investigated the 4-year incidence and predictors of adefovir resistance in chronic hepatitis B patients with or without lamivudine (LAM)-resistance treated with adefovir dipivoxil with or without short-term LAM overlapping. METHODS: One hundred and two LAM-resistant patients and 79 without LAM resistance (36 naïve and 43 prior LAM exposure) treated with adefovir for >12 months were prospectively examined. RESULTS: Cumulative incidences of adefovir resistance at month 12, 24, 36 and 48 were 3.9, 21.1, 31.8 and 43% respectively in LAM-resistant patients. Cirrhosis was a significant risk factor for adefovir resistance. A similar rate of adefovir resistance was observed for LAM-resistant patients and those with prior LAM exposure without resistance. Regarding LAM-resistant patients, compared with those having hepatitis B virus (HBV) DNA levels <300 copies/ml, patients having HBV DNA levels >10(4) copies/ml at week 24 of therapy had a hazard ratio (HR) of 9.8 for adefovir resistance development, while those without LAM resistance having the same HBV DNA levels at week 48 had a similar HR (9.5). Multidrug-resistant (LAM+adefovir) variants were detected by direct sequencing in three of 35 LAM-resistant patients treated with a switch to adefovir. Two of them had resistant mutations to both drugs on the same viral genome as determined by molecular cloning and sequencing. CONCLUSION: The incidence of adefovir resistance was high in LAM-resistant patients treated with sequential adefovir. High HBV DNA levels at week 24 and 48 of therapy were the strongest predictors for adefovir resistance development in patients with and without LAM resistance respectively.

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.

Hepatitis B virus genotype B results in better immediate, late and sustained responses to peginterferon-alfa in hepatitis-B-e-antigen-positive patients.

BACKGROUND AND AIMS: This study investigated outcome predictors in hepatitis-B-e-antigen (HBeAg)-positive chronic hepatitis B patients treated with peginterferon alfa-2a. METHODS: A total of 88 HBeAg-positive patients receiving peginterferon alfa-2a for 6 months and followed up for at least 24 weeks were prospectively analyzed. Precore and core promoter genes of hepatitis B virus (HBV) were sequenced from the serial serum samples of 88 patients. RESULTS: After 24 weeks of follow up, 38.6% and 28.4% of patients achieved HBeAg clearance and combined response, respectively. Multivariate analysis disclosed that pretreatment HBeAg sample to cut-off (S/Co) ratio ≤ 200, alanine aminotransferase > 200 IU/mL, HBV genotype B and T1846 were independent factors for HBeAg clearance, and HBeAg S/Co ratio ≤ 200 and HBV genotype B were major determinants for combined response. HBeAg S/Co ratio ≤ 10 at week 12 of therapy was the useful factor for treatment response and had a greater power (P = 0.012) to predict HBeAg clearance than HBV DNA. Patients with HBeAg clearance had a higher frequency of A1896 mutation at baseline and during therapy than those without HBeAg clearance, and the frequency of A1896 decreased during treatment. During follow up, delayed HBeAg seroconversion and reactivation of HBV after HBeAg clearance were observed in eight non-responders and 20 patients with HBeAg clearance, respectively. HBV genotype B was a significant factor to predict both responses. CONCLUSIONS: Pretreatment HBeAg S/Co ratio ≤ 200 and HBV genotype B were major determinants for treatment response to peginterferon. Genotype-B-infected patients had higher probability of delayed HBeAg clearance and sustained response. Rapid decrease of HBeAg titer was useful on treatment predictor.

The effects of cefazolin on cirrhotic patients with acute variceal hemorrhage after endoscopic interventions.

BACKGROUND: The American Association for the Study of Liver Diseases (AASLD) guidelines recommend that antibiotic prophylaxis should be instituted in any patient with cirrhosis and gastrointestinal hemorrhage, and that oral norfloxacin, intravenous ciprofloxacin, and ceftriaxone are preferable. However, the antimicrobial spectrum of the first generation of cephalosporins (cefazolin) covers a wide range of bacteria species, including community-acquired strains of Escherichia coli and Klebsiella pneumoniae, but their efficacy as prophylactic antibiotics in cirrhotic patients with acute hemorrhage was seldom warranted in the literature. This study aimed to explore the effects of cefazolin on the outcome of cirrhotic patients with acute variceal hemorrhage after endoscopic interventions. METHODS: A cross-sectional, retrospective chart review study was conducted on cirrhotic patients with acute variceal hemorrhage who underwent endoscopic procedures in a medical center. Cirrhotic patients who did not receive antibiotics were classified as group A (n = 63) while patients who received intravenous cefazolin 1 g q8 h for 2-7 days were classified as group B (n = 50). The end points were the prevention of infection, length of hospital stay, time of rebleeding, and death. RESULTS: A total of 113 patients were studied (male/female: 82/31; age: 56.8 ± 13.5 years). The incidence of infection (including proven infections) and bacteremia were significantly lower in group B patients (38.1% vs. 16.0%, P = 0.010; 17.5% vs. 4.0%, P = 0.026; 9.5% vs. 0%, P = 0.033, respectively). The no prophylactic antibiotics treatment was the independent risk factor. There was no significant difference between the two groups with respect to the source of bleeding, type of endoscopic intervention, length of hospital stay, and mortality. Actuarial probability of remaining free of early rebleeding (<7 days) was P = 0.105 by log-rank test for all cirrhosis patients and P = 0.085 for Child-Pugh class A patients. CONCLUSIONS: The use of cefazolin in cirrhotic patients after endoscopic interventions for acute variceal hemorrhage reduced infections. A trend of actuarial probability of remaining free of early rebleeding (<7 days) was observed, especially in Child-Pugh class A patients. This study may be hampered by the small sample size and more large-scale studies are mandatory.

Evolution of full-length HBV sequences in chronic hepatitis B patients with sequential lamivudine and adefovir dipivoxil resistance.

BACKGROUND & AIMS: The aim of this study was to determine the evolution of full-length hepatitis B virus (HBV) sequences in chronic hepatitis B (CHB) patients with sequential lamivudine (LAM) and adefovir (ADV) resistance. METHODS: The full-length genomes of HBV were sequenced from 11 CHB patients before LAM treatment and at the emergence of LAM- and ADV-resistant HBV. RESULTS: Besides the known LAM-resistant polymerase gene mutations, 10 of 11 patients who had LAM-resistant HBV variants had additional amino acid changes in the reverse transcriptase (RT) domain, and ADV therapy reversed these additional changes to pre-LAM therapy status. Furthermore, new amino acid changes in the RT domain, distinct from the known ADV-resistant HBV variants, were selected at the emergence of ADV resistance in six of 11 patients. Seven patients had amino acid changes within the known T-cell or B-cell epitopes of HBV surface and core antigens at the emergence of LAM and/or ADV resistance. The frequency of pre-S deletions between nucleotide 3037-56 was higher at the emergence of ADV resistance compared with that at the emergence of LAM resistance (7/11 vs. 1/11; p=0.024). Combined LAM-ADV resistance was detected in one of 11 patients. This patient had resistant mutations to both drugs on the same viral genome by molecular cloning (5/24 polymerase gene clones). CONCLUSIONS: In addition to the known LAM- and ADV-resistant mutations accompanying the emergence of LAM and ADV resistance, the changes of nucleotide or amino acid sequences occurred commonly in the HBV surface antigen or RT domain and were scattered along the full-length HBV genomes.

Neither diabetes mellitus nor overweight is a risk factor for hepatocellular carcinoma in a dual HBV and HCV endemic area: community cross-sectional and case-control studies.

OBJECTIVES: Chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are well-known risk factors for hepatocellular carcinoma, and diabetes mellitus (DM) and overweight have also been reported as risk factors for hepatocellular carcinoma (HCC). We tried to elucidate the roles of DM and overweight in HCC development in a dual HBV and HCV endemic area of southern Taiwan. METHODS: In 2004, a community-based comprehensive screening program was conducted in Tainan County. Hepatitis B surface antigen (HBsAg), anti-HCV, alpha-fetoprotein, complete blood counts, triglyceride, cholesterol, and glucose levels were examined. DM was defined as fasting blood sugar >126 mg per 100 ml, and overweight was defined as a body mass index >24 kg m(-2). Subjects with thrombocytopenia (platelet count <150 x 10(9) l(-1)) and elevated alpha-fetoprotein (>20 ng ml(-1)) underwent ultrasonographic screening for HCC. A total of 56,307 adults (>40 years old) participated, and 72 new HCC cases were detected and confirmed. RESULTS: In comparisons of all 72 HCC cases with the other 144 individual age-, sex-, residency-, HBsAg-, and anti-HCV-matched controls, only thrombocytopenia and high alanine transaminase (ALT) levels were shown to be independent risk factors. Neither DM nor overweight was shown to be significant in any of the analyses. CONCLUSIONS: On the basis of the community-based cross-sectional and case-controlled studies, neither DM nor overweight was a risk factor for HCC in a dual HBV and HCV endemic area. However, male gender, age (> or =65 years), HBsAg, anti-HCV, thrombocytopenia, and high ALT levels were independent risk factors for HCC.

Extended lamivudine consolidation therapy in hepatitis B e antigen-positive chronic hepatitis B patients improves sustained hepatitis B e antigen seroconversion.

OBJECTIVES: Longer lamivudine (LAM) consolidation therapy after hepatitis B e antigen (HBeAg) seroconversion has been demonstrated to reduce the cumulative relapse rate. However, the optimal interval of LAM consolidation therapy remains controversial. We evaluated the post-treatment durability of LAM-induced HBeAg seroconversion and the length of LAM consolidation therapy required to maintain sustained HBeAg seroconversion. MATERIAL AND METHODS: This retrospective study included 401 naive HBeAg-positive chronic hepatitis B patients who were treated with LAM 100 mg daily for at least 24 weeks (range 24-258 weeks). Among them, 124 patients who achieved a complete response (HBeAg seroconversion, alanine aminotransferase normalization, hepatitis B virus DNA < 200 copies/ml) at the end of LAM therapy were followed up for at least 48 weeks (range 48-350 weeks). RESULTS: Of the 124 complete responders, 42 (33.87%) achieved a sustained response (persistent response >or= 48 weeks). However, the cumulative relapse rates at 48 and 96 weeks post-treatment were 54.03% and 68.4%, respectively. Multivariate analysis revealed pretreatment age or= 48 weeks (HR 2.44; 95% CI 1.35-4.40; p = 0.003) to be independent factors for predicting a sustained response. CONCLUSIONS: LAM-induced HBeAg seroconversion is not durable in Taiwan. However, a duration of LAM consolidation therapy > 48 weeks may be favorable for maintaining durable HBeAg seroconversion.

Liver stiffness decrease after effective antiviral therapy in patients with chronic hepatitis C: Longitudinal study using FibroScan.

AIM: The aim of the present study was to assess the changes of liver stiffness (LS) and its associated factors in patients with chronic hepatitis C virus infection (HCV) after interferon (IFN)-based therapy. METHODS: Patients with chronic HCV who had previously undergone at least 20 weeks of IFN-based therapy were enrolled. The patients' initial LS measurement was taken at the time of enrollment, and a second LS measurement was made after an interval of at least 38 weeks. LS measurement was carried out with FibroScan, and changes of LS and its associated factors were analyzed. RESULTS: One hundred and forty-four patients, including 95 sustained virological response (SVR) patients and 49 non-sustained virological response (NSVR) patients, were enrolled. There was a significant decrease of LS among SVR patients (median, 0.6; P < 0.001). NSVR patients showed an increase of LS (median, 0.8; P = 0.557). For SVR patients, a high initial LS was the predictive factor of a rapid reduction of LS values. However, advanced fibrosis stage before therapy, higher body mass index (BMI) and longer time remission were predictive factors for slow reduction of LS values. CONCLUSIONS: LS decreases in sustained responders following IFN-based therapy in patients with chronic HCV. Advanced fibrosis, higher BMI, longer time for remission and lower initial LS value are predictive factors for a slow improvement of LS in sustained responders.

Optimal treatment increased survival of hepatocellular carcinoma patients detected with community-based screening.

BACKGROUND AND AIM: The early detection of hepatocellular carcinoma (HCC) and opportunity to select appropriate treatment are important benefits of HCC screening. Our aim in the present study was to investigate the survival rate, prognostic factors and treatment effects in HCC patients of community-based screening. METHODS: Community-based ultrasound (US) screening for HCC in adults with platelet counts (< 150 x 10(3)/mm(3)) and/or alpha fetoprotein (AFP) > 20 ng/mL was conducted in 2002 and 2004. As per the Barcelona Clinic Liver Cancer (BCLC) stage, 90 cases of intermediate or earlier stage HCC were detected and 88 cases had sufficient information for analysis (49 men and 39 women, aged 65.8 +/- 9.6 years). The tumor diameter was mostly less than 5 cm (76.1%). The follow up was continued until June 2008. RESULTS: The 4-year overall survival rate was 46.8%. Old age (> or = 70 years) (P = 0.046), later stage of HCC (intermediate vs earlier) (P = 0.012), low platelet count (< 100 x 10(3)/mm(3)) (P = 0.013) and refusal of modern treatment (P = 0.026) were independent poor prognostic factors. Curative treatment increased survival in patients of all ages. Both curative treatment and transcatheter arterial embolization (TAE) increased survival in cases of intermediate HCC. However, treatment benefits were not found for patients with (very) early stage HCC. CONCLUSIONS: Early detection and prompt treatment of HCC leads to increased survival. For elderly patients this benefit was seen only for early stage cases receiving curative treatment. Differences between treatment types for patients with (very) early stage HCC might emerge with a longer follow-up period.

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 study on sequence variations in pre-S/surface, X and enhancer II/core promoter/precore regions of occult hepatitis B virus in non-B, non-C hepatocellular carcinoma patients in Taiwan.

This study was to investigate the clinical significance and virologic factors of occult hepatitis B virus (HBV) infection in hepatocellular carcinoma (HCC) patients without hepatitis B surface antigen (HBsAg) or anti-hepatitis C virus (non-B, non-C) in Taiwan. Serum HBV DNA (occult HBV) was detected in 90 of 222 non-B, non-C HCC patients and 24 of 300 non-B, non-C controls without HCC. Of 90 occult HBV-infected HCC patients, the sequences of HBV pre-S/surface, X and enhancer II/core promoter/precore genes were analyzed from 40 patients. Direct sequencing of such genes was also performed in 24 non-B, non-C controls without HCC and 40 HBsAg-positive HCC controls. Compared with non-B, non-C controls without HCC, non-B, non-C subjects with HCC had significantly higher prevalence of occult HBV (p < 0.0001). Moreover, M1I and Q2K in pre-S2 gene and G1721A were more common in occult HBV-infected patients with HCC than in those without HCC. Compared with the HBsAg-positive HCC controls, occult HBV-infected HCC patients had higher frequencies of M1I and Q2K in pre-S2 gene, G185R and S210N in surface gene, A36T and A44L in X gene, and G1721A in enhancer II gene, and had lower rates of pre-S deletions and A1762T/G1764A, A1846T, G1896A and G1899A in core promoter/precore genes. Multivariate analysis showed Q2K in pre-S2 gene, G1721A and A1846T were independent factors for occult HBV-infected HCC. Our study suggested that the virological factors of HBV related to HCC were different between occult HBV-infected and HBsAg-positive patients. The G1721A, M1I and Q2K in pre-S2 gene may be useful viral markers for HCC in occult HBV carriers.

Is the Cancer of the Liver Italian Program system an adequate weighting for survival of hepatocellular carcinoma? Evaluation of intrascore prognostic value among 36 subgroups.

BACKGROUND: The Cancer of the Liver Italian Program (CLIP) staging system for hepatocellular carcinoma (HCC) was subdivided into 36 subgroups. We aimed to validate the prognostic value of CLIP scoring. METHODS: This study included 3868 HCC cases treated between 1986 and 2002. Survival and prognostic impact of all subgroups were analysed. RESULTS: In primary CLIP, comparisons of each score showed a significant difference (P<0.001) and exhibited a linear trend (P<0.001). A CLIP score of 0 was used as control group. Portal vein thrombosis, Child-Pugh B, alpha-fetoprotein (AFP) > or =400 ng/ml and multinodular with tumour extension < or =50% of the four subgroups with a CLIP score of 1 exhibited decreasing univariate hazard ratios and 95% confidence intervals, with values of 2.99 (2.05-4.37), 2.39 (2.00-2.86), 1.66 (1.40-1.96) and 1.39 (1.18-1.63) respectively. Homogeneity in the same score was evaluated by comparing subgroup survival curves. For scores 1-5, 83.3% (5/6), 57.1% (16/28), 24.4% (11/45), 3.6% (1/28) and 16.7% (1/6) pairs of survival curves significantly differed, respectively, with decreasing linear trend (P<0.001). CONCLUSION: Different prognostic weighting of four predictive factors caused intrascore heterogeneity. Lower CLIP scores were associated with increased differences in intrascore. In conclusion, the CLIP staging scoring system is a reasonable ordinal scale, but the clinician must be aware of the heterogeneity of mortality risk within a given score.

FibroScan and ultrasonography in the prediction of hepatic fibrosis in patients with chronic viral hepatitis.

BACKGROUND: The aim of this study was to assess the diagnostic performances of liver stiffness measurement (LSM), ultrasonography (US) and their combined use in predicting the extent of hepatic fibrosis. METHODS: Consecutive patients with chronic hepatitis B (HBV) or hepatitis C virus (HCV) infections, with indications for liver biopsy, were prospectively enrolled. LSM was performed on the same day as biopsy. US scores, including assessment of liver surface, liver parenchyma, intrahepatic vessels and spleen index, were used to assess the degree of hepatic fibrosis. The pathological findings were used as a reference standard and diagnostic accuracy was assessed and compared. RESULTS: Three-hundred and twenty patients, including 199 men and 121 women, with a mean age of 50.8 years, were analyzed. There were 214 (66.9%) HCV patients, 88 (27.5%) HBV patients and 18 (5.6%) patients with both HCV and HBV. LSM correlated significantly with the hepatic fibrosis (F) scores, necro-inflammatory activity and US scores in multivariate analysis. The diagnostic accuracy of LSM is significantly superior to US, and equal to combined LSM with US, in the prediction of all HCV-related fibrosis scores. The cut-off value of LSM is 6 kPa for diagnosing F > =1, with a positive predictive value of 91%. Also, the cut-off value is 12 kPa for the prediction of cirrhosis, with a negative predictive value of 94%. CONCLUSIONS: LSM is useful for predicting hepatic fibrosis and excluding cirrhosis. A combination of LSM and US does not improve the accuracy in assessing hepatic fibrosis.

Pancreatic head cancer with distant duodenal metastasis: a case report with rare endoscopic presentations.

Metastasis to the duodenum from a primary cancer is rare, but direct extension from pancreatic cancer is much more common. Here, we present a case of multiple duodenal metastases of pancreatic head cancer in a 77-year-old woman with upper gastrointestinal bleeding. An upper gastrointestinal endoscopic examination revealed multiple elevated reddish nodules on a normal mucosa background that extended from the superior duodenal angle to the duodenal second portion. Echo-guided fine needle aspiration biopsies of the pancreatic head tumor and endoscopic biopsies of the reddish duodenal nodules proved the diagnosis of adenocarcinoma. When such endoscopic morphology is found, especially when the locations are distant from the papillae, metastasis should be considered and multiple biopsies are mandatory.