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).

Molecular Identification of Biliary Isospora Belli: A Case Report.

This report describes the novel sampling of bile from the biliary endoscopic intervention for the molecular identification of parasite infection.A 63-year-old Vietnamese man underwent travel health examination in our hospital. Physical examination showed that his height was 159 cm and weight was 41 kg. He had a 15-year history of intermittent abdominal pain and frequent episodes of diarrhea. Laboratory tests revealed raised eosinophil count (23%, normal range [NR] 0-5), absolute eosinophil count (1899/µL, NR 50-350), and levels of serum immunoglobulin E (3770 IU/mL, NR < 100), aspartate transaminase (270 U/L, NR 0-37), alanine transaminase (210 U/L, NR 0-40), and total bilirubin (1.8 mg/dL, NR 0.2-1.4); however, the serum alkaline phosphatase level was normal (65 U/L, NR 28-94) and non-reactive result for serum human insufficiency virus antibody.Magnetic resonance cholangiopancreatography revealed diffuse dilatation of the biliary tree; the common hepatic and pancreatic duct diameters increased to 1.86 cm and 0.61 cm, respectively.Endoscopic retrograde cholangiopancreatography was performed and a 10-Fr model plastic biliary stent was inserted and flushed with 20 cc normal saline; thereafter, the bile was collected and sent for DNA sequencing. Isospora belli (IB) infection was identified by a polymerase chain reaction.Trimethoprim-sulfamethoxazole 800 mg q6h was administered for 1 month. Liver enzyme levels normalized and negative for concentration method of ova study. The patient was doing well and weighed 51 kg at the outpatient clinic visit 3 months later.This bile sampling with molecular identification has not been described in the literature. We believe that an acute IB infection through fecal-oral transmission may progress to chronic infection of the hepatobiliary system, leading to biliary obstruction and jaundice.

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.

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.

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.

Novel low-cost endoscopic cap for esophageal foreign objects: a case report.

A 57-year-old man presented to the hospital because of swallowing of a small marble precipitated by a hallucination. He subsequently developed chest discomfort. He had a history of psychiatric problem and an esophageal corrosive injury complicated by stricture of the middle esophagus.This report describes the novel idea of endoscopic intervention for the retrieval of an esophageal foreign body. Its inventiveness and the use of limited resources, by adapting a 30-mm aseptic common tubing into an endoscopic retrieving device, make the method novel. This novel low-cost endoscopic cap (NLCEC) was adapted to 25 mm of the front end of the endoscope, with 5 mm maintained for the soft part to prevent esophageal mucosal injury during the retrieval process. An 8-mm green marble was found impacted in the esophagus 32 cm from the incisors. The use of forced suction allowed for the successful retrieval of the marble within minutes. The patient had an uneventful recovery without any serious complications.This NLCEC may be a viable and safe tool for the endoscopic retrieval of esophageal foreign objects without general anesthesia. This innovative design is beneficial in terms of patient safety, easy preparation, and low cost.

High-level disinfection of gastrointestinal endoscope reprocessing.

High level disinfection (HLD) of the gastrointestinal (GI) endoscope is not simply a slogan, but rather is a form of experimental monitoring-based medicine. By definition, GI endoscopy is a semicritical medical device. Hence, such medical devices require major quality assurance for disinfection. And because many of these items are temperature sensitive, low-temperature chemical methods, such as liquid chemical germicide, must be used rather than steam sterilization. In summarizing guidelines for infection prevention and control for GI endoscopy, there are three important steps that must be highlighted: manual washing, HLD with automated endoscope reprocessor, and drying. Strict adherence to current guidelines is required because compared to any other medical device, the GI endoscope is associated with more outbreaks linked to inadequate cleaning or disinfecting during HLD. Both experimental evaluation on the surveillance bacterial cultures and in-use clinical results have shown that, the monitoring of the stringent processes to prevent and control infection is an essential component of the broader strategy to ensure the delivery of safe endoscopy services, because endoscope reprocessing is a multistep procedure involving numerous factors that can interfere with its efficacy. Based on our years of experience in the surveillance of culture monitoring of endoscopic reprocessing, we aim in this study to carefully describe what details require attention in the GI endoscopy disinfection and to share our experience so that patients can be provided with high quality and safe medical practices. Quality management encompasses all aspects of pre- and post-procedural care including the efficiency of the endoscopy unit and reprocessing area, as well as the endoscopic procedure itself.

The clinical and bacteriological factors for optimal levofloxacin-containing triple therapy in second-line Helicobacter pylori eradication.

Quinolone has the disadvantage of easily acquired drug resistance. It is important to prescribe it wisely for a high eradication rate. The current study aimed to determine the clinical and bacteriological factors for optimal levofloxacin-containing triple therapies in second-line H. pylori eradication. We enrolled a total of 158 H. pylori-infected patients who failed H. pylori eradication using the 7-day standard triple therapy (proton-pump inhibitor [PPI] twice daily, 500 mg clarithromycin twice daily, and 1 g amoxicillin twice daily). They were prescribed with either a 10-day (group A) or 14-day (group B) levofloxacin-containing triple therapy group (levofloxacin 500 mg once daily, amoxicillin 1 g twice daily, and esomeprazole 40 mg twice daily for 10 days) by their clinicians. Follow-up studies to assess treatment responses were carried out 8 weeks later. The eradication rates attained by groups A and B were 73.6% (95% confidence interval [CI]  = 63.9-85.3%) and 90.5% (95% CI = 84.5-98.1%), respectively in the per protocol analysis (P = 0.008 in the per protocol analysis) and 67.1% (95% CI = 56.6-78.5%) and 84.8% (95% CI = 76.8-93.4%), respectively, in the intention-to-treat analysis (P = 0.009). The subgroup analysis revealed that H. pylori eradication rates for group A patients with levofloxacin-susceptible strains were 92.9% (13/14) but it dropped to 12.5% (1/8) when levofloxacin-resistant strains existed. H. pylori was eradicated among all the group B patients with levofloxacin-susceptible strains, but only half of patients with levofloxacin-resistant strains were successfully eradicated. In conclusion, this study confirms the effectiveness of 14-day treatment. Importantly, the results imply that 10-day treatment duration should be optimal if a culture can be performed to confirm the existence of susceptible strains. The duration of H. pylori eradication and levofloxacin resistance were the influencing factors for successful treatment. This study suggests that tailored levofloxacin-containing therapy should be administered only for patients with susceptible strains because it can achieve >90% success rates.

Levofloxacin-containing second-line anti-Helicobacter pylori eradication in Taiwanese real-world practice.

BACKGROUND: Quinolone-containing triple therapy is recommended as an option for non-bismuth containing second-line Helicobacter pylori eradication. Current available Taiwanese reports in the literature used 7-day quinolone-containing triple therapy. As a result, some physicians still prescribe 7-day regimens in real-world practice in Taiwan. This study aimed to further assess the appropriateness of 7-day levofloxacin-containing triple therapy as second-line therapy. METHODS: We enrolled 61 patients who failed H. pylori eradication using the standard triple therapy for 7 days and were prescribed levofloxacin-containing second-line triple therapy (levofloxacin 500 mg once daily, amoxicillin 1 g twice daily, and esomeprazole 40 mg twice daily). Routine follow-up with either endoscopy or urea breath test was done 8 weeks later to assess treatment response. RESULTS: The eradication rates were 78.7% in the intention-to-treat analysis and 81% in the per-protocol analysis. The incidence of adverse events was 6.6%. Drug compliance was 95.1%. Antibiotic resistance showed the following results: Amoxicillin (0%), levofloxacin (23.5%), clarythromycin (35.3%), metronidazole (17.6%), and tetracycline (0%). CONCLUSION: The 7-day levofloxacin-containing triple therapy provides an unacceptable per-protocol report card as the second-line treatment for anti-H. pylori eradication in Taiwan and should be modified by either extending the duration to 10-14 days or seeking other regimens.

Diagnostic pitfall of sebaceous gland metaplasia of the esophagus.

We investigated the sebaceous gland metaplasia (SGM) of the esophagus and clarified the evidence of misdiagnosis and its diagnosis pitfall. Cases of pathologically proven SGM were enrolled in the clinical analysis and reviewed description of endoscope. In the current study, we demonstrated that SGM is very rare esophageal condition with an incidence around 0.00465% and an occurrence rate of 0.41 per year. There were 57.1% of senior endoscopists identified 8 episodes of SGM. In contrast, 7.7% of junior endoscopists identified SGM in only 2 episodes. Moreover, we investigated the difference in endoscopic biopsy attempt rate between the senior and junior endoscopist (P = 0.0001). The senior endoscopists had more motivation to look for SGM than did junior endoscopists (P = 0.01). We concluded that SGM of the esophagus is rare condition that is easily and not recognized in endoscopy studies omitting pathological review.

Baseline and serial liver stiffness measurement in prediction of portal hypertension progression for patients with compensated cirrhosis.

BACKGROUND & AIMS: Liver stiffness measurement (LSM) using transient elastography is useful in prediction of significant portal hypertension (PHT). To evaluate the usefulness of baseline and serial LSM in predicting clinical disease progression (CDP) for patients with compensated hepatic cirrhosis. METHODS: Consecutive patients with compensated cirrhosis and without hepatocellular carcinoma (HCC) were prospectively enrolled. Baseline LSM was assessed at enrolment, then at a 6- to 12-month interval. Esophagogastroduodenoscopy and ultrasonography were performed regularly for surveillance of varices and HCC, while CDP including HCC development and PHT progression was recorded. RESULTS: Two hundred and twenty patients were enrolled. In a median follow-up of 36.9 months, CDP were detected in 49 patients including 30 PHT progression and 19 HCC developments. The cumulative incidence of CDP, PHT progression and HCC development at 3 years was 20.7%, 12.8% and 9.1% respectively. Multivariate analyses showed that baseline LSM was an independent predictor of PHT progression and CDP, however, not of HCC occurrence. The performance of baseline LSM in predicting PHT progression, varices growth/development and hepatic decompensation was 0.744, 0.638 and 0.929. With 17, 12 and 21.1 kPa as the cut-off, the negative predictive value was 92, 94 and 99% respectively. Patients with baseline LSM ≧17 kPa without serial changes had higher risk of PHT progression. CONCLUSION: For patients with compensated cirrhosis, LSM was an independent predictor of PHT progression and CDP, but not of HCC occurrence. Baseline LSM was useful to exclude PHT progression. Patients with baseline and serial LSM ≧17 kPa had higher risk of PHT progression.

Endoscopic biopsy as quality assurance for endoscopic services.

Gastroendoscopy (GS) procedures are not only performed by gastroenterologists (GE) but also by hepatologists (HT) in many countries. Endoscopic biopsy (EBx) remains the gold standard for the investigation and documentation of esophago-gastro-duodenal pathology. EBx is subjectively performed by an endoscopist, and the level of skill and experience of the endoscopist may affect the quality of the endoscopic service. Reasons for this discrepancy included lack of experience practitioners to order EBx when required of GS issues between in GE and HT limit access. Ideally, services should be safe and of high quality. This study assessed the EBx/GS ratio as the endoscopic quality assurance as an index of GS services. This was a cohort study of endoscopists at Kaohsiung Chang Gung Memorial Hospital, a teaching hospital in southern Taiwan. There were 34,570 episodes of EBx in 199,877 GS procedures. The 25 endoscopists were divided into GE (n = 13) and HT (n = 12) groups, and correlation coefficients were calculated over a 14.5-year duration of intervention. The Trimmean of EBx/GS was 19.29% in 14.5 years (34570/199877 with Trimmean 0.2 percentile ratio correlations), and the Pearson correlation coefficient was 0.90229. There were significantly more EBx procedures in the GE group than in the HT group at 1 and 5 years (21.5% vs. 15.1% and 20.9% vs. 17.3%, respectively, P<0.00001). Junior GE attempted significantly more EBx than both the senior GE (24.06% vs. 20.41%, P<0.0001), and junior HT (24.06% vs. 13.2%, P<0.0001). In conclusion, quality assurance for gastrointestinal endoscopy involves numerous aspects of unit management and patient safety. Quality measures used with the EBx/GS ratio may be one of the best ways to ensure the quality of endoscopic procedures in a teaching hospital.

Ten-Day versus 14-Day Levofloxacin-Containing Triple Therapy for Second-Line Anti-Helicobacter pylori Eradication in Taiwan.

Second-line Helicobacter pylori (H. pylori) eradication with fluoroquinolone-containing triple therapy is one of the recommended treatment options, but neither 7-day nor 10-day regimens provide >90% success rates. The current retrospective study aimed to clarify the effects of 10-day and 14-day levofloxacin-containing triple therapies for second-line H. pylori eradication in a Taiwanese cohort and to evaluate the potential clinical factors influencing eradication. A total of 200 patients who failed H. pylori eradication using the standard triple therapy were prescribed with either a 10-day (EAL-10) or a 14-day (EAL-14) levofloxacin-containing triple therapy group (levofloxacin 500 mg once daily, amoxicillin 1 g twice daily, and esomeprazole 40 mg twice daily). Follow-up studies to assess treatment response were carried out 8 weeks later. Eradication rates attained by EAL-10 and EAL-14 were 75.6%; 95% CI = 63.9-85.3% and 92.5%; 95% CI = 84.5-98.1%, P = 0.002 in the per protocol analysis and 68%; 95% CI = 56.6-78.5% and 86%; 95% CI = 76.8-93.4%, P = 0.002 in the intention-to-treat analysis. The duration of H. pylori therapy is the independent risk factor of H. pylori eradication (P = 0.003). In conclusion, 14-day levofloxacin-containing triple therapy can provide a >90% H. pylori eradication rate, but 10-day treatment duration may be suboptimal. The longer duration of H. pylori therapy (14 days) is the independent risk factor.

The effect of systemic antibiotic prophylaxis for cirrhotic patients with peptic ulcer bleeding after endoscopic interventions.

PURPOSE: All previous studies reported the benefit of antibiotic prophylaxis in cirrhotic patients with either a mixture of nonvariceal and variceal bleeding or variceal bleeding alone. Reports on sole peptic ulcers bleeding are lacking. We aimed to assess the effect of antibiotic prophylaxis in cirrhotic patients with peptic ulcer bleeding after endoscopic interventions and the risk factors associated with recurrent bleeding. METHODS: A cross-sectional retrospective chart review study was conducted on 148 cirrhotic patients with acute peptic ulcer hemorrhage who underwent therapeutic endoscopic procedures. Patients who received prophylactic intravenous ceftriaxone were classified as group A (n = 38) and those who did not receive antibiotics were classified as group B (n = 110). The outcomes were prevention of infection, length of hospital stay, time of rebleeding, and death. RESULTS: More patients suffered from recurrent bleeding and infection in group B than those in group A (28.2 vs. 5.3 %; p = 0.003, and 26.4 vs. 10.5 %; p = 0.043, respectively). The risk factors associated with recurrent bleeding were being male (OR = 3.4; p = 0.024), those with advanced stage of cirrhosis with Child-Pugh's class C (OR = 3.8; p < 0.001), and those without antibiotic prophylaxis (OR = 8.9; p = 0.003). The observed 30-day survival was virtually identical for both groups (p = 0.279). CONCLUSIONS: Antibiotic prophylaxis in cirrhotic patients after endoscopic interventions for acute peptic ulcer hemorrhage reduced infections and decreased rebleeding. Male gender, cirrhosis Child-Pugh's class C, and no antibiotic prophylaxis were independent predictors of recurrent bleeding. Further studies should be directed to explore ways to improve the overall outcome of these patients.

Randomized comparison of two non-bismuth-containing second-line rescue therapies for Helicobacter pylori.

BACKGROUND: Classical second-line anti-Helicobacter pylori includes proton-pump inhibitor, tetracycline, metronidazole, and bismuth salts, but alternative therapies are required owing to the restricted availability of the latter. Levofloxacin-containing triple therapy is recommended but is expensive. Besides, quinolone resistance in an endemic tuberculosis infection area like Taiwan is concerned. The low in vitro antibiotic resistance to amoxicillin and tetracycline in Taiwanese H. pylori strains implies that in vivo esomeprazole/amoxicillin/tetracycline (EAT) second-line rescue therapy may be effective. This study compared the efficacy of esomeprazole/amoxicillin/levofloxacin (EAL) and EAT second-line eradication therapies and determines the clinical factors influencing the efficacy of salvage regimens. MATERIALS AND METHODS: One hundred and twenty-eight patients who failed H. pylori eradication using the standard triple therapy for 7 days are randomly assigned to either EAL group (esomeprazole 40 mg twice daily, amoxicillin 1 g twice daily, and levofloxacin 500 mg once daily) for 7 days or EAT group (esomeprazole 40 mg twice daily, amoxicillin 1 g twice daily, tetracycline 500 mg four times daily) for 14 days. Follow-up endoscopy or urea breath test was performed 8 weeks later to assess treatment response. RESULTS: The eradication rates of EAL and EAT groups were 78.1 versus 75.0%, p = .676 (in intention-to-treat analysis) and 80.3 versus 80%, p = .0964 (per-protocol analysis). Both groups exhibited similar drug compliance (95.3 vs 96.9%, p = .952) but more adverse events in the EAT group (6.3 vs 12.5%, p = .225). CONCLUSIONS: Despite low in vitro drug resistances to amoxicillin and tetracycline, the efficacy of 14-day EAT regimens attained an unacceptable report card of 75% eradication rates in intention-to-treat analysis and was not even superior to the 7-day EAL regimen. Drug-drug interaction between combined antibiotics should be considered other than in vivo drug resistances.

Is a biopsy necessary for colon polyps suitable for polypectomy when performing a colonoscopy?

BACKGROUND: The incidence of colorectal cancer is increasing in Taiwan. Adenomatous polyps are known to be precancerous lesions and need to be removed. New techniques like chromendoscopy, magnifying endoscopy, narrow band imaging and magnifying endoscopy with flexible spectral imaging color enhancement may improve the accuracy of identifying precancerous polyps but are not widely available in the real world. This study analyzed the conventional biopsy method in diagnosing early colon cancer and the necessity for subsequent surgery after polypectomy. METHODS: From January 2002 to December 2007, 1027 adenomatous polypoid specimens taken from 720 patients who received polypectomy by conventional white light colonoscopy were studied. The pathologic reports of 26 specimens of early cancer or high grade dysplasia from 25 patients were analyzed. Protruding polyps were classified as pedunculated (o-Ip), subpedunculated (o-Isp) and sessile (o-Is). RESULTS: Fourteen of the 26 specimens were type o-Ip, 10 were type o-Isp, and 2 were type o-Is. The pathologic reports were high grade dysplasia (n = 5), mucosal adenocarcinoma (n = 18) and submucosal adenocarcinoma (n = 3). Among these, 7 lesions from 7 patients received a randomized biopsy instead of immediate polypectomy. Adenoma was reported in 6 of them with only one malignancy detected (false negative rate: 86%). Eight patients received surgery. The mean follow-up period for these patients was 17 months, and none of them had recurrences. CONCLUSIONS: The randomized biopsy method for adenomatous polyps has a high false negative rate for early colon cancer and high grade dysplasia and is therefore not necessary in cases of protruding type polyps which can be removed by polypectomy. An adequate direct polypectomy may completely remove the protruding type of early colon cancer.

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.

Predictors of rebleeding after initial hemostasis with epinephrine injection in high-risk ulcers.

AIM: To identify the predictors of rebleeding after initial hemostasis with epinephrine injection (EI) in patients with high-risk ulcers. METHODS: Recent studies have revealed that endoscopic thermocoagulation, or clips alone or combined with EI are superior to EI alone to arrest ulcer bleeding. However, the reality is that EI monotherapy is still common in clinical practice. From October 2006 to April 2008, high-risk ulcer patients in whom hemorrhage was stopped after EI monotherapy were studied using clinical, laboratory and endoscopic variables. The patients were divided into 2 groups: sustained hemostasis and rebleeding. RESULTS: A total of 175 patients (144, sustained hemostasis; 31, rebleeding) were enrolled. Univariate analysis revealed that older age (≥ 60 years), advanced American Society of Anesthesiology (ASA) status (category III, IV and V), shock, severe anemia (hemoglobin < 80 g/L), EI dose ≥ 12 mL and severe bleeding signs (SBS) including hematemesis or hematochezia were the factors which predicted rebleeding. However, only older age, severe anemia, high EI dose and SBS were independent predictors. Among 31 rebleeding patients, 10 (32.2%) underwent surgical hemostasis, 15 (48.4%) suffered from delayed hemostasis causing major complications and 13 (41.9%) died of these complications. CONCLUSION: Endoscopic EI monotherapy in patients with high-risk ulcers should be avoided. Initial hemostasis with thermocoagulation, clips or additional hemostasis after EI is mandatory for such patients to ensure better hemostatic status and to prevent subsequent rebleeding, surgery, morbidity and mortality.

Esophageal motility differences among aged patients with achalasia: a Taiwan report.

BACKGROUND AND AIM: There are limited reports on esophageal motility pressures in aged patients with achalasia and these are inconclusive. The aim of the present retrospective study was to understand the changes of esophageal motility in aged achalasia patients among the Taiwan population. METHODS: Manometric studies of 49 patients with achalasia had been performed through January 1998 to June 2005. The findings of lower esophageal sphincter (LES) basal and residual pressures and esophageal body contraction amplitudes were calculated and compared between the older and younger patient groups at different age cut-offs. RESULTS: Higher basal LES pressure increased significantly from the cut-off age of 65 years (i.e. patients over 65 had significantly higher basal LES pressure than younger patients: 37.0 +/- 4.19 mmHg vs 30.0 +/- 1.32 mmHg, P = 0.045). With patients > or =70 years old, it was more obvious (46.0 +/- 3.7 mmHg vs 29.6 +/- 1.2 mmHg, P = 0.001). Beginning at the cut-off age of 55, the LES residual pressure was significantly higher in older patients than those who were younger (14.0 +/- 11.06 mmHg vs 11.1 +/- 0.6 mmHg, P = 0.017). LES residual pressure is more significant in the older groups. A linear correlation between age and residual LES pressures (r = 0.383) was found. No differences were found in esophageal contraction pressure. CONCLUSIONS: Older achalasia patients in Taiwan have higher basal LES pressures, with a linear correlation between age and residual LES pressures. Age has no influence on esophageal contraction pressure.

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.