High incidence of clopidogrel-associated gastrointestinal bleeding in patients with previous peptic ulcer disease.

BACKGROUND: In average-risk patients, the new anti-platelet agent, clopidogrel, causes less upper gastrointestinal adverse events than aspirin. However, there are no safety data on the use of clopidogrel in high-risk patients. AIM: To evaluate the safety of clopidogrel in patients with peptic ulcer disease in a retrospective cohort longitudinal study. METHODS: During the period from January 2000 to May 2002, 70 patients who were prescribed clopidogrel (75 mg/day) for a previous history of non-aspirin-related peptic ulcer disease or a history of aspirin-related gastrointestinal complications (dyspepsia or peptic ulcer) were recruited. The occurrence of ulcer complications (bleeding/perforation/obstruction) was the primary end-point. RESULTS: After a median follow-up of 1 year, nine patients (12%) developed gastrointestinal bleeding and one had a perforated peptic ulcer. Clopidogrel-associated gastrointestinal bleeding was significantly more common in patients with a history of gastrointestinal bleeding than in those without (22% vs. 0%; P = 0.007; odds ratio, 1.3; 95% confidence interval, 1.1-1.5). CONCLUSIONS: Clopidogrel is associated with a high incidence of upper gastrointestinal bleeding in high-risk patients. A previous history of gastrointestinal bleeding appears to be a predictor of adverse gastrointestinal events.

Sequential intravenous/oral antibiotic vs. continuous intravenous antibiotic in the treatment of pyogenic liver abscess.

AIM: Pyogenic liver abscesses result in substantial morbidity and mortality. Antimicrobial regimens using sequential intravenous/oral therapy may reduce the length of hospital stay. In this retrospective analysis, the efficacy of continuous intravenous antibiotic therapy (group I) vs. sequential intravenous/oral antibiotic therapy (group II) was studied in patients with pyogenic liver abscess. METHODS: One hundred and twelve consecutive patients (55 in group I and 57 in group II) with pyogenic liver abscess were analysed. Clinical response, length of hospital stay and relapse rates were examined. RESULTS: Group II had a significantly shorter duration of intravenous antibiotic treatment (3.2 weeks vs. 5.9 weeks, P < 0.01) and a shorter length of hospital stay (28 days vs. 42 days, P < 0.01) when compared to group I. Oral antibiotics were prescribed for a median duration of 2.9 weeks in group II after discharge. No relapse occurred within 6 weeks after the completion of treatment in both groups. The cost of therapy was significantly lower in group II than in group I by 33%. CONCLUSIONS: A sequential intravenous/oral antibiotic regime is a safe and effective treatment for pyogenic liver abscess. This reduces the cost of therapy and the length of hospital stay.

A Chinese patient with non-HFE-linked iron overload.

The gene for hemochromatosis (HFE) was recently identified and contains two missense mutations: C282Y and H63D. The C282Y mutation is found homozygous in approximately 85% to 90% of patients of Northern European ancestry with hereditary hemochromatosis. There are no previous reports with results of genetic testing in Chinese patients with regard to iron overload. In this case report, we describe a Chinese woman with marked hepatic iron overload that was nonfamilial, with unusual biopsy findings, in whom neither the C282Y nor the H63D mutations in HFE were found.

Esophageal variceal ligation by reloading with inexpensive hemorrhoidal O-ring--is an overtube necessary?

The overtube is the major cause for severe complications during endoscopic variceal ligation with a single-shot ligator. This retrospective study was designed to examine the necessity of the placement of an overtube during elective endoscopic variceal ligation. Thirty-one sessions in 18 patients were analyzed. An overtube was inserted using an over-the-scope technique in 11 sessions (group 1) but was omitted in 20 sessions (group II). The complications, technical difficulties, and operating time were analyzed. Child's grading, the size of the esophageal varices, and the number of rubber bands deployed were comparable in both groups. There was a significantly longer operating time (p < 0.01) and more oropharyngeal injury (p = 0.03) in group I than in group II. Mid esophageal injury, which was associated with resistance in withdrawing the gastroscope from the overtube, occurred in 55% of sessions in group I but in 0% of session in group II. In conclusion, the use of an overtube is associated with more complications, and it can be omitted during elective endoscopic variceal ligation.

High alpha-fetoprotein level in HCV-related nodular liver cell dysplasia.

The diagnosis of hepatocellular carcinoma is generally made in patients with a mass lesion in the cirrhotic liver if the alpha-fetoprotein level is >1,000 ng/L. Other causes of elevation of alpha-fetoprotein to this extreme degree include nonseminomatous germ cell tumor and hepatic metastasis. However, it is extremely rare for benign hepatic lesions to cause alpha-fetoprotein of > 1,000 ng/ml. We report a Chinese patient with spontaneous normalization of alpha-fetoprotein with an initial value > 10,000 ng/ml due to nodular dysplasia complicating hepatitis C-related liver cirrhosis. The alpha-fetoprotein was secreted from the dysplastic liver cells.

Cytomegalovirus colitis in individuals without apparent cause of immunodeficiency.

Cytomegalovirus infection is usually reported in immunocompromised patients. In this study, apparently immunocompetent patients with cytomegaloviral colitis were reviewed. Records with a diagnosis of cytomegaloviral colitis from January 1989 to June 1996 were retrieved for analysis. Ten patients were included (median age 70 yr). The major presenting symptoms were diarrhea and hematochezia. Ulceration was the main macroscopic finding. Rectal bleeding was mostly self-limiting. Three patients developed local complications (rectovaginal fistula in two; rectal stricture in one). In the two patients with rectovaginal fistula, lymphocytes subsets and proliferative response were entirely normal. In the other patient, low B lymphocyte count and low response to mitogen were demonstrated. However, the immunoglobulins were not suppressed and rectal biopsies revealed noncaseating granulomas, suggesting activated cell-mediated immunity. In conclusion, a high index of suspicion is crucial for early diagnosis of cytomegaloviral colitis in patients with bloody diarrhea, even though obvious evidence of immunodeficiency is lacking.

Effect of simethicone on the accuracy of the rapid urease test.

OBJECTIVE: Simethicone, which is a principal ingredient in the defoaming agent used during gastroscopy, can inhibit the growth of Helicobacter pylori (MIC, 64-128 mg/l). This prospective study was designed to evaluate the in vivo and in vitro effects of simethicone on the accuracy of the rapid urease test (RUT). METHODS: In the in vivo study, three sets of gastric biopsies (two from the antrum, and one from the corpus) were taken from 75 patients. The first set was examined histologically, and the second set was used for the RUT (pre-simethicone RUT). Then, 25 ml simethicone (1200 mg/l) was introduced into the stomach for a contact time of 1 min. A third set of gastric biopsies was taken for the RUT (post-simethicone RUT). In the in vitro clinical study, 41 patients were recruited. The first set of gastric biopsies was used for the RUT (pre-incubation RUT). The second set was incubated in 1 ml of simethicone for 5 min before being used for the RUT (post-incubation RUT). In the spectrophotometric study, urease activity before and after incubation in simethicone for 5 min was quantified in 12 patients by measuring the absorbance at 560 nm. RESULTS: Reading at 15 min, the concordance rate between the pre-simethicone and post-simethicone RUT was 98%. In the in vitro clinical study, the concordance rate between the pre-incubation and post-incubation RUT was 97%. The spectophotometric study showed a significant reduction of 43% in urease activity after incubation in simethicone. CONCLUSION: The application of a defoaming agent containing simethicone does not affect the accuracy of the RUT. However, simethicone modestly suppresses urea hydrolysis.