Meta-Analytic Bayesian Model For Differentiating Intestinal Tuberculosis from Crohn's Disease.

OBJECTIVES: Distinguishing intestinal tuberculosis (ITB) from Crohn's disease (CD) is difficult, although studies have reported clinical, endoscopic, imaging, and laboratory findings that help to differentiate these two diseases. We aimed to produce estimates of the predictive power of these findings and construct a comprehensive model to predict the probability of ITB vs. CD. METHODS: A systematic literature search for studies differentiating ITB from CD was conducted in MEDLINE, PUBMED, and EMBASE from inception until September 2015. Fifty-five distinct meta-analyses were performed to estimate the odds ratio of each predictive finding. Estimates with a significant difference between CD and ITB and low to moderate heterogeneity (I2<50%) were incorporated into a Bayesian prediction model incorporating the local pretest probability. RESULTS: Thirty-eight studies comprising 2,117 CD and 1,589 ITB patients were included in the analyses. Findings in the model that significantly favored CD included male gender, hematochezia, perianal disease, intestinal obstruction, and extraintestinal manifestations; endoscopic findings of longitudinal ulcers, cobblestone appearance, luminal stricture, mucosal bridge, and rectal involvement; pathological findings of focally enhanced colitis; and computed tomographic enterography (CTE) findings of asymmetrical wall thickening, intestinal wall stratification, comb sign, and fibrofatty proliferation. Findings that significantly favored ITB included fever, night sweats, lung involvement, and ascites; endoscopic findings of transverse ulcers, patulous ileocecal valve, and cecal involvement; pathological findings of confluent or submucosal granulomas, lymphocyte cuffing, and ulcers lined by histiocytes; a CTE finding of short segmental involvement; and a positive interferon-γ release assay. The model was validated by gender, clinical manifestations, endoscopic, and pathological findings in 49 patients (27 CD, 22 ITB). The sensitivity, specificity, and accuracy for diagnosis of ITB were 90.9%, 92.6%, and 91.8%, respectively. CONCLUSIONS: A Bayesian model based on the meta-analytic results is presented to estimate the probability of ITB and CD calibrated to local prevalence. This model can be applied to patients using a publicly available web application.

Asia Pacific Consensus Statements on Crohn's disease. Part 1: Definition, diagnosis, and epidemiology: (Asia Pacific Crohn's Disease Consensus--Part 1).

Inflammatory bowel disease (IBD) was previously thought to be rare in Asia, but emerging data indicate rising incidence and prevalence of IBD in the region. The Asia Pacific Working Group on Inflammatory Bowel Disease was established in Cebu, Philippines, at the Asia Pacific Digestive Week conference in 2006 under the auspices of the Asian Pacific Association of Gastroenterology with the goal of developing best management practices, coordinating research, and raising awareness of IBD in the region. The consensus group previously published recommendations for the diagnosis and management of ulcerative colitis with specific relevance to the Asia-Pacific region. The present consensus statements were developed following a similar process to address the epidemiology, diagnosis, and management of Crohn's disease. The goals of these statements are to pool the pertinent literature specifically highlighting relevant data and conditions in the Asia-Pacific region relating to the economy, health systems, background infectious diseases, differential diagnoses, and treatment availability. It does not intend to be all comprehensive and future revisions are likely to be required in this ever-changing field.

Asia-Pacific consensus statements on Crohn's disease. Part 2: Management.

The Asia Pacific Working Group on Inflammatory Bowel Disease was established in Cebu, Philippines, at the Asia Pacific Digestive Week conference in 2006 under the auspices of the Asian Pacific Association of Gastroenterology (APAGE) with the goal of developing best management practices, coordinating research and raising awareness of IBD in the region. The consensus group previously published recommendations for the diagnosis and management of ulcerative colitis (UC) with specific relevance to the Asia-Pacific region. The present consensus statements were developed following a similar process to address the epidemiology, diagnosis and management of Crohn's disease (CD). The goals of these statements are to pool the pertinent literature specifically highlighting relevant data and conditions in the Asia-Pacific region relating to the economy, health systems, background infectious diseases, differential diagnoses and treatment availability. It does not intend to be all-comprehensive and future revisions are likely to be required in this ever-changing field.

Early Course of Inflammatory Bowel Disease in a Population-Based Inception Cohort Study From 8 Countries in Asia and Australia.

BACKGROUND & AIMS: The incidence of inflammatory bowel disease (IBD) is increasing in Asia, but little is known about disease progression in this region. The Asia-Pacific Crohn's and Colitis Epidemiology Study was initiated in 2011, enrolling subjects from 8 countries in Asia (China, Hong Kong, Indonesia, Sri Lanka, Macau, Malaysia, Singapore, and Thailand) and Australia. We present data from this ongoing study. METHODS: We collected data on 413 patients diagnosed with IBD (222 with ulcerative colitis [UC], 181 with Crohn's disease [CD], 10 with IBD unclassified; median age, 37 y) from 2011 through 2013. We analyzed the disease course and severity and mortality. Risks for medical and surgical therapies were assessed using Kaplan-Meier analysis. RESULTS: The cumulative probability that CD would change from inflammatory to stricturing or penetrating disease was 19.6%. The cumulative probabilities for use of immunosuppressants or anti-tumor necrosis factor agents were 58.9% and 12.0% for patients with CD, and 12.7% and 0.9% for patients with UC, respectively. Perianal CD was associated with an increased risk of anti-tumor necrosis factor therapy within 1 year of its diagnosis (hazard ratio, 2.97; 95% confidence interval, 1.09-8.09). The cumulative probabilities for surgery 1 year after diagnosis were 9.1% for patients with CD and 0.9% for patients with UC. Patients with CD and penetrating disease had a 7-fold increase for risk of surgery, compared with patients with inflammatory disease (hazard ratio, 7.67; 95% confidence interval, 3.93-14.96). The overall mortality for patients with IBD was 0.7%. CONCLUSIONS: In a prospective population-based study, we found that the early course of disease in patients with IBD in Asia was comparable with that of the West. Patients with CD frequently progress to complicated disease and have accelerated use of immunosuppressants. Few patients with early stage UC undergo surgery in Asia. Increasing our understanding of IBD progression in different populations can help optimize therapy and improve outcomes.

Environmental risk factors in inflammatory bowel disease: a population-based case-control study in Asia-Pacific.

OBJECTIVE: The rising incidence of inflammatory bowel disease in Asia supports the importance of environmental risk factors in disease aetiology. This prospective population-based case-control study in Asia-Pacific examined risk factors prior to patients developing IBD. DESIGN: 442 incident cases (186 Crohn's disease (CD); 256 UC; 374 Asians) diagnosed between 2011 and 2013 from eight countries in Asia and Australia and 940 controls (frequency-matched by sex, age and geographical location; 789 Asians) completed an environmental factor questionnaire at diagnosis. Unconditional logistic regression models were used to estimate adjusted ORs (aOR) and 95% CIs. RESULTS: In multivariate model, being breast fed >12 months (aOR 0.10; 95% CI 0.04 to 0.30), antibiotic use (aOR 0.19; 0.07 to 0.52), having dogs (aOR 0.54; 0.35 to 0.83), daily tea consumption (aOR 0.62; 0.43 to 0.91) and daily physical activity (aOR 0.58; 0.35 to 0.96) decreased the odds for CD in Asians. In UC, being breast fed >12 months (aOR 0.16; 0.08 to 0.31), antibiotic use (aOR 0.48; 0.27 to 0.87), daily tea (aOR 0.63; 0.46 to 0.86) or coffee consumption (aOR 0.51; 0.36 to 0.72), presence of hot water tap (aOR 0.65; 0.46 to 0.91) and flush toilet in childhood (aOR 0.71; 0.51 to 0.98) were protective for UC development whereas ex-smoking (aOR 2.02; 1.22 to 3.35) increased the risk of UC. CONCLUSIONS: This first population-based study of IBD risk factors in Asia-Pacific supports the importance of childhood immunological, hygiene and dietary factors in the development of IBD, suggesting that markers of altered intestinal microbiota may modulate risk of IBD later in life.

Intestinal capillariasis in the 21st century: clinical presentations and role of endoscopy and imaging.

BACKGROUND: Intestinal capillariasis is one of the common causes of malabsorption in the East. Reports emphasizing the roles of clinical, endoscopic and radiologic findings of intestinal capillariasis are limited. METHODS: Retrospective review of medical records of 26 patients diagnosed with intestinal capillariasis at Siriraj Hospital, Bangkok, Thailand between 2001- 2013. RESULTS: Clinical manifestations were chronic watery diarrhea (93%), chronic abdominal pain (70%), significant weight loss (92%), hypoalbuminemia (100%; 85% lower than 2.0 g/dL), and anemia (50%). The median duration of symptoms was 5.5 months (1-60 months). Parasites were found in stool in 15 patients (57%). In patients whose stool tests were initially negative, parasites were discovered in tissue biopsy from endoscopy in 1 from 10 esophagogastroduodenoscopies (EGD), 0 from 7 colonoscopies, 3 from 5 push enteroscopies, and 3 from 5 balloon-assisted enteroscopies (BAE). Endoscopic findings included scalloping appearance, mucosal cracking, and redness of mucosa. These endoscopic findings affected mostly at jejunum and proximal ileum. They were similar to celiac disease except duodenal involvement which is uncommon in capillariasis. Three patients underwent video capsule endoscopy (VCE) and typical abnormal findings were observed in all patients. Small bowel barium study showed fold thickening, fold effacement, and increased luminal fluid in 80% of patients, mainly seen at distal jejunum and ileum. CT findings were long segment wall thickening, enhanced wall, and fold effacement. Treatment with either albendazole or ivermectin cured all patients with most responding within 2 months. CONCLUSIONS: In endemic area, intestinal capillariasis should be considered if patients develop chronic watery diarrhea accompanied by significant weight loss and severe hypoalbuminemia. Stool examination had quite low sensitivities in making diagnosis in our study. Deep enteroscopy with biopsy guided by imaging or VCE may improve diagnostic yield. Empirical therapy may also be justifiable due to the very good response rate and less side effects.

Incidence and phenotype of inflammatory bowel disease based on results from the Asia-pacific Crohn's and colitis epidemiology study.

BACKGROUND & AIMS: Inflammatory bowel diseases (IBD) are becoming more common in Asia, but epidemiologic data are lacking. The Asia-Pacific Crohn's and Colitis Epidemiology Study aimed to determine the incidence and phenotype of IBD in 8 countries across Asia and in Australia. METHODS: We performed a prospective, population-based study of IBD incidence in predefined catchment areas, collecting data for 1 year, starting on April 1, 2011. New cases were ascertained from multiple overlapping sources and entered into a Web-based database. Cases were confirmed using standard criteria. Local endoscopy, pathology, and pharmacy records were searched to ensure completeness of case capture. RESULTS: We identified 419 new cases of IBD (232 of ulcerative colitis [UC], 166 of Crohn's disease [CD], and 21 IBD-undetermined). The crude annual overall incidence values per 100,000 individuals were 1.37 for IBD in Asia (95% confidence interval: 1.25-1.51; 0.76 for UC, 0.54 for CD, and 0.07 for IBD-undetermined) and 23.67 in Australia (95% confidence interval: 18.46-29.85; 7.33 for UC, 14.00 for CD, and 2.33 for IBD-undetermined). China had the highest incidence of IBD in Asia (3.44 per 100,000 individuals). The ratios of UC to CD were 2.0 in Asia and 0.5 in Australia. Median time from symptom onset to diagnosis was 5.5 months (interquartile range, 1.4-15 months). Complicated CD (stricturing, penetrating, or perianal disease) was more common in Asia than Australia (52% vs 24%; P = .001), and a family history of IBD was less common in Asia (3% vs 17%; P < .001). CONCLUSIONS: We performed a large-scale population-based study and found that although the incidence of IBD varies throughout Asia, it is still lower than in the West. IBD can be as severe or more severe in Asia than in the West. The emergence of IBD in Asia will result in the need for specific health care resources, and offers a unique opportunity to study etiologic factors in developing nations.

Yield, etiologies and outcomes of capsule endoscopy in Thai patients with obscure gastrointestinal bleeding.

AIM: To investigate the yield, etiologies and impact of capsule endoscopy (CE) in Thai patients with obscure gastrointestinal bleeding (OGIB). METHODS: The present study is a retrospective cohort study. All patients with OGIB who underwent CE in Siriraj Hospital, Bangkok, Thailand during 2005-2009 were included in the study. All the patients' medical records and results of the CE videos were reviewed. CE findings were classified as significant, suspicious/equivocal and negative. Sites of the lesions were located to duodenum, jejunum, jejunoileum, ileum and diffuse lesions by the localization device of the CE. Impact of CE on the patients' management was defined by any investigation or treatment given to the patients that was more than an iron supplement or blood transfusion. Patients' outcomes (rebleeding, persistent bleeding, anemia or requirement of blood transfusion) were collected from chart reviews and direct phone interviews with the patients. RESULTS: Overall, there were 103 patients with OGIB included in the study. Mean age of the patients was 64 ± 16 years (range 9-88 years) and 57 patients (55%) were male. Types of OGIB were overt in 80 (78%) and occult in 23 patients (22%). The median time interval of CE after onset of OGIB was 10 d (range 1-180 d). The median time of follow-up was 19 mo (range 1-54 mo). Capsules reached caecum in 77 patients (74%) and capsule retention was found in 1 patient (1%). The diagnostic yield of CE revealed significant lesions in 37 patients (36%), suspicious/equivocal lesions in 15 patients (15%) and 51 patients (49%) had negative CE result. Among the significant lesions, the bleeding etiologies were small bowel ulcers in 44%, angiodysplasia in 27%, small bowel tumor in 13%, miscellaneous in 8% and active bleeding without identifiable causes in 8%. Patients with small bowel ulcers were significantly associated with the use of non-steroidal anti-inflammatory drugs (48%, P = 0.034), while patients with small bowel tumors were more commonly female (86%, P = 0.043) compared to the other etiologies. The rate of rebleeding, persistent bleeding or anemia in patients with positive, equivocal and negative CE results were 5%, 0% and 18%, respectively (P = 0.078). All the 9 patients with rebleeding after negative CE were subsequently found to be from hematologic disorders (4), colonic diverticulosis (2), colonic Dieulafoy's (1), hemorrhoid (1) and hemosuccus pancreaticus (1). Results of CE had a positive impact on the patients' management in 35% of the patients whose results were positive, but none on the patients whose results were equivocal or negative CE (P < 0.001). CONCLUSION: In Thai OGIB patients, CE had low yield and small bowel ulcer was most common. Positive CE impacted managements and outcomes. Negative CE caused low rebleeding.

Viability of Lactobacillus casei strain Shirota (LcS) from feces of Thai healthy subjects regularly taking milk product containing LcS.

OBJECTIVE: To demonstrate the recovery of Lactobacillus casei strain Shirota (LcS) from feces of Thai subjects who regularly took LcS containing milk product for 1 week and demonstrate the disappearance of LcS after stopped taking milk product. MATERIAL AND METHOD: First fecal samples were collected from 20 healthy adults at 10 days after they abstained from all lactobacillus containing milk products. Second specimens taken after the subjects ingested LcS containing milk product for 7 days and third specimens at 7 days after they stopped taking LcS containing milk product. All the fecal specimens were culture for LcS using LLV-FOS culture medium and enumeration of LcS was calculated. All stool samples were also tested for the presence of LcS by using nested PCR to confirm the presence of LcS obtained from culture method. RESULTS: Both culture and nested PCR method showed that all the stools samples obtained from subjects prior to the administration of LcS containing milk product were devoid of LcS, except for 3 specimens which showed weakly positive test for PCR. At 7 days after ingesting LcS containing milk product, all stool specimens were positive for LcS on both culture and PCR method. At 7 days after stopped taking LcS containing milk product, 1/19 specimens were positive from culture and 6/ 19 specimens were positive for PCR method. CONCLUSION: LcS could survive in the gastrointestinal tract of Thai subjects and could be recovered from the feces after ingestion.

Acute hemorrhagic rectal ulcer syndrome: the first case series from Thailand.

The term "Acute hemorrhagic rectal ulcer syndrome (AHRUS)" has been denoted as a pathological entity that consists of lower gastrointestinal bleeding with unique clinical features. The common setting can be found in elderly patients who were hospitalized with multiple comorbidities. The typical location is around the dentate line. The predominant feature of these ulcers is profuse and painless rectal bleeding. Currently, this condition has not been established worldwide and it has never been reported in Thailand. The authors reported nine cases of AHRUS. These cases were reviewed from the records of endoscopic procedures which were performed at Siriraj Endoscopy Center between September-December 2006. All underwent complete colonoscopy to evaluate endoscopic appearances. Histopathologic findings were thoroughly reviewed. The characteristics of the ulcers are multiple, round or oval shape located just above the dentate line, with/without evidence of bleeding stigmata. Histopathologic features included superficial necrosis, erosions with acute inflammatory cell infiltration and evidence of recent hemorrhage, all of which were confined to the mucosal layer. No organisms were discovered from the lesions. In conclusion, this is the first review of AHRUS which is an uncommon cause of hematochezia in Thailand. Although this clinical entity is not well established in Western countries, the rising incidence of AHRUS in Asia warrants further investigation into its pathogenesis, treatment and prevention.

Genetic polymorphism of low-density lipoprotein receptor did not affect treatment outcome of chronic hepatitis C genotype 3.

BACKGROUND: The low-density lipoprotein receptor (LDL-R) has been proposed to function as a receptor for the hepatitis C virus (HCV) entry. Polymorphism of LDL-R gene may influence the clearance of virus and response to treatment. This study was conducted to evaluate the association of LDL-R gene polymorphism and the response to antiviral treatment in patients with chronic HCV infection. MATERIAL AND METHOD: A total of 112 naïve patients with HCV genotype 3 were enrolled in the study. All patients were treated with a combination of pegylated interferon and ribavirin for 24 weeks. Polymerase chain reaction combined with restriction fragment length polymorphism was used to detect the polymorphism at the LDL-R gene intron 11 loci, including intron1, intron 3.1, intron 3.2, intron 4, intron 6, exon 8, intron 11, intron 13, intron 14 and 3'UTR-2 SNPs in intron 16 region. Comparisons of genotype and allele frequency between responders and nonresponders were analyzed. RESULTS: Patients had a mean age of 54 years and 43% were male. Mean HCVRNA viral load and alanine aminotransferase level were 6.3 log, IU/mL and 100 IU/L, respectively. Sustained virological response, relapse and no response were documented in 68.7%, 17.9% and 13.4%, respectively. Baseline characteristics including age, sex, body weight, aminotransferase levels and HCV RNA viral load were similar between responders and nonresponders. No statistical difference was found for either genotype distribution or allele frequency among responders and nonresponders. CONCLUSION: This study did not provide the evidence for a role of LDL-R polymorphism the response to antiviral treatment in patients with HCV genotype 3. This indicates that a genetic component via the LDL-R may not control HCV treatment outcome in HCV genotype 3

Epidemiology of suspected Clostridium difficile-associated hospital-acquired diarrhea in hospitalized patients at Siriraj Hospital.

BACKGROUND: Clostridium difficile-associated disease (CDAD) is an important cause of hospital-acquired diarrhea. OBJECTIVE: To determine the prevalence, risk factors, diagnosis, treatments and outcomes of the patients with CDAD in hospitalized patients at Siriraj Hospital. MATERIAL AND METHOD: The medical records of hospitalized patients aged older than 14 years who developed hospital-acquired diarrhea and their stool samples were sent for detection of C. difficile toxins from March to June 2008 were reviewed. Risk factors of CDAD were identified by reviewing medical records of CDAD patients (case group) and patients who had hospital-acquired diarrhea without C. difficile toxins (control group). The patients in the control group were matched with the case group in terms of gender and age. RESULTS: Three hundred and twenty three stool samples obtained from 255 adult hospitalized patients were sent to microbiology laboratory for detection of C. difficile toxins. The prevalence of CDAD in suspected C. difficile-associated hospital-acquired diarrhea was 12.3% (95% CI 8.5% to 17.6%). Univariate analysis showed that antibiotic use (> or =2 agents), proton pump inhibitor (PPI) use, hematologic malignancy, receiving chemotherapy or immunosuppressive agents were associated with CDAD. Multivariate analysis revealed that only antibiotic use (> or =2 agents), PPI use and hematologic malignancy were independent risk factors associated with CDAD. Nasogastric intubation was observed to be associated with CDAD as a protective factor from both univariate and multivariate analyses. Diagnosis of CDAD in most of the patients was made by a presence of C. difficile toxin in their stool samples. Response rate to metronidazole was 74.5%. The recurrence rate of CDAD was 3.2%. The mortality rate due to CDAD was 3.2%. CONCLUSION: CDAD is not uncommon in the patients with hospital-acquired diarrhea especially in those who have hematologic malignancy, receive multiple antibiotics or receive PPI. Metronidazole is an acceptable treatment for CDAD. The recurrence rate of CDAD and mortality rate due to CDAD are low.

Prospective evaluation of gastrointestinal lesions by bidirectional endoscopy in patients with iron deficiency anemia.

BACKGROUND: Occult bleeding from the gastrointestinal (GI) lesions is a common cause of iron deficiency anemia (IDA). The information concerning the prevalence and the appropriate strategy for evaluation of IDA in Thai patients is scanty. OBJECTIVE: Prospectively evaluate Thai patients with IDA for GI lesions using bidirectional endoscopy MATERIAL AND METHOD: Consecutive patients with IDA were investigated by esophagogastroduodenoscopy (EGD) and colonoscopy. Significant GI lesions were identified. Clinical data and results of the fecal occult blood testing (FOBT) were collected to determine factors associated with the presence of GI lesions. RESULTS: One hundred three patients were included in this study and the mean age was 63.6 +/- 15.2 years old. Significant GI lesions were detected in 58 patients (56%), 43% by EGD, 25% by colonoscopy. Twelve patients (12%) had dual lesions identified from both EGD and colonoscopy The most common lesions were peptic ulcers (22%) and colonic carcinoma (13%). Anti-platelets use and positive FOBT were associated with the significant GI lesions with odds ratios of 2.37 (95% CI 1.05-5.36, p = 0.036) and 2.83 (95% CI 1.05-7.68, p = 0.038), respectively FOBT had sensitivity, specificity, positive predictive value, and negative predictive value for significant GI lesions at 81%, 40%, 68%, and 66%, respectively. Site-specific symptoms correctly guided the route of endoscopy in 60-80% of the patients. CONCLUSION: EGD resulted in a better yield than colonoscopy and was the preferred route of initial endoscopy unless there was suggestive site-specific symptom. Bidirectional endoscopy was finally required in most patients unless a cancerous lesion was detected by the initial endoscopy.

Erythrocyte sedimentation rate and C-reactive protein for the prediction of severity of acute pancreatitis.

OBJECTIVES: To investigate the performance of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) for predicting severe acute pancreatitis (AP). METHODS: Fifty patients with AP were prospectively enrolled. Erythrocyte sedimentation rate and CRP were measured at admission and every 12 hours for 48 hours after admission. RESULTS: The patients' mean age was 50 ± 2.2 years, 64% were male, and 30% developed severe AP. Patients with severe AP had higher levels of ESR (77 ± 4.7 vs 50 ± 4.8 mm/h; P = 0.002) and CRP (218 ± 30.7 vs 97 ± 12.1 mg/L; P <0.001) at 36 hours after admission compared with those with mild AP. Erythrocyte sedimentation rates of 60 mm/h or greater predict severe AP at 36 hours with a sensitivity, specificity, and positive and negative predictive values of 86%, 57%, and 48% and 90%, whereas CRP of 150 mg/L or greater provided the results of 86%, 87%, and 75% and 93%, respectively. Elevation of either ESR or CRP at 24 hours increased the sensitivity and negative predictive value to 100%, and elevation of both ESR and CRP increased the specificity and PPV to 100%. CONCLUSIONS: Erythrocyte sedimentation rate can predict severe AP with a slightly inferior performance to CRP. Combined ESR and CRP at 24 hours can predict severe AP accurately.

The Asia-Pacific consensus on ulcerative colitis.

Inflammatory bowel disease (IBD) is increasing in many parts of the Asia-Pacific region. There is a need to improve the awareness of IBD and develop diagnostic and management recommendations relevant to the region. This evidence-based consensus focuses on the definition, epidemiology and management of ulcerative colitis (UC) in Asia. A multi-disciplinary group developed the consensus statements, reviewed the relevant literature, and voted on them anonymously using the Delphi method. The finalized statements were reviewed to determine the level of consensus, evidence quality and strength of recommendation. Infectious colitis must be excluded prior to diagnosing UC. Typical histology and macroscopic extent of the disease seen in the West is found in the Asia-Pacific region. Ulcerative colitis is increasing in many parts of Asia with gender distribution and age of diagnosis similar to the West. Extra-intestinal manifestations including primary sclerosing cholangitis are rarer than in the West. Clinical stratification of disease severity guides management. In Japan, leukocytapheresis is a treatment option. Access to biologic agents remains limited due to high cost and concern over opportunistic infections. The high endemic rates of hepatitis B virus infection require stringent screening before initiating immune-suppressive agents. Vaccination and prophylactic therapies should be initiated on a case-by-case basis and in accordance with local practice. Colorectal cancer complicates chronic colitis. A recent increase in UC is reported in the Asia-Pacific region. These consensus statements aim to improve the recognition of UC and assist clinicians in its management with particular relevance to the region.

Changing of the etiology of acute pancreatitis after using a systematic search.

BACKGROUND: Alcohol and gallstone are the 2 most common etiologies of acute pancreatitis (AP). In Thailand, alcohol has been believed to be the leading etiology of AP. However, a thorough and systematic search may discover real etiology of AP. MATERIAL AND METHOD: During 2006 to 2007, seventy-eight patients with AP were prospectively searched for the etiology by: 1. Performing liver chemistry tests and transabdominal ultrasonography (US) for gallstone in every case; 2. Measuring serum triglyceride and calcium in every case; 3. Investigating definite drugs use or other identified etiology; 4. Asking about the amount of alcohol ingestion (amount > 80 g/day for > 5 years was required for alcoholic AP; 5. Performing CT scan (if age > 40 years) and EUS if no etiology was identified. Results were compared with the retrospective data from medical records of 66 AP patients during 2003-2005. RESULTS: Of the 78 patients, the etiologies were alcohol in 32 (41%), gallstones in 29 (37%), miscellaneous in 13 (17%) and idiopathic AP in 4 patients (5%). When compared with the retrospective data of the 66 patients over the past 3 years, the etiologies were alcohol 53%, gallstone 22%, miscellaneous 11% and idiopathic 14%. Among the 45 patients of the study period (58%) who consumed alcohol more than the defined threshold for alcoholic AP, 13 (29%) were found to have other explainable causes of AP, i.e gallstones in 10, hypertriglyceridemia in 2 and AIDS cholangiopathy in 1 patient. CONCLUSION: Alcohol was probably over-diagnosed as a leading etiology of AP in the past. A systematic search of the etiologies lowered the frequency of alcoholic and idiopathic AP but discovered more patients with gallstone pancreatitis. One-fourth of AP patients who were heavy drinkers had other explainable etiologies of AP.

Natural course of abdominal pain in chronic pancreatitis with intermittent (type A) pain after conservative treatment.

BACKGROUND: Abdominal pain in chronic pancreatitis (CP) is difficult to treat and appropriate choice of treatment is controversial. It has been suggested that patients with CP particularly from alcohol (ACP) with intermittent attack of abdominal pain (type A pain) should be managed conservatively because pain relief will be achieved in most cases. However, data of the efficacy of this strategy is scanty and conflicting and whether this strategy is effective or feasible in idiopathic CP (ICP) is unclear. MATERIAL AND METHOD: Data of all patients with CP with type A pain, who were followed-up and managed conservatively during 2004-2008 were analyzed. Pain relief was defined by the absence of abdominal pain for more than 1 year RESULTS: Twenty-two patients were followed-up with a median duration of 31 months (range 5-96 months). The etiology of CP was alcoholic (ACP) in 12 (56%), early-onset idiopathic (E-ICP) in 5 (22%) and late-onset idiopathic (L-ICP) in 5 (22%). Alcohol abstinence was successful in every ACP patient. Overall, 18 patients (82%) had pain relief with a median duration of 39 months (range 16-167 months) from the onset of pain or 14 months (range 11-57 months) from the time of diagnosis of CP. Pain relief was achieved at a higher level mainly in ACP (100%) and L-ICP (80%) but was only 40% in E-ICP Median duration from onset until pain relief were 28 months (range 16-167 months) for ACP, 36 months (range 16-39 months) for L-ICP and 120 months (range 42-120 months) for E-ICP. The difference was statistically significant between L-ICP and E-ICP (p = 0.036), but not between ACP and E-ICP (p = 0.13) and between ACP and L-ICP (p = 0.80). Median duration from the time of diagnosis of CP until pain relief was only 14 months forACP 13 months for L-ICP but was 52 months for E-ICP. None of the patients required narcotics, endoscopic therapy or surgery. CONCLUSION: Conservative management was feasible and effective in most patients with CP and type A pain, particularly ACP after alcohol abstinence, and L-ICP Conservative treatment was not effective in E-ICP.

Clinical utility of lens culinaris agglutinin-reactive alpha-fetoprotein in the diagnosis of hepatocellular carcinoma: evaluation in a Thai referral population.

BACKGROUND AND OBJECTIVE: There is no established clinical role for the lens culinaris agglutinin-reactive fraction of alpha-fetoprotein (AFP-L3%) in the management of the Thai hepatocellular carcinoma (HCC) patient population. The aim of this prospective study was to evaluate clinical utility and performance characteristics of AFP-L3% for the diagnosis of HCC in Thai referral patients. MATERIAL AND METHOD: Sixty-one histologically proven HCC patients and 35 patients with other liver cancers were included for analysis. RESULTS: The HCC population was comprised of 50 males and 11 females, with a mean age of 48.8 years. According to the Okuda system, three were classed as stage I, thirty-five belonged to stages II, and six were classified in stage III. An AFP-L3% a cut-off value of > 15% yielded a sensitivity of 82% (95% confidence interval [CI], 74-88%), specificity of 71% (95% CI, 58-82%), positive predictive value of 83% (95% CI, 75-90), and negative predictive value of 69% (95% CI, 56-80) for the diagnosis of HCC. In HCC patients with AFP of < 200 ng/ml, an AFP-L3% at a cut-off value of > 15% not only maintained high sensitivity of 83% and good specificity of 71% but also increased negative predictive value to 86% for the diagnosis of HCC. CONCLUSION: AFP-L3% provides high sensitivity but with lower sensitivity in the diagnosis of HCC than total AFP in individuals with symptomatic liver mass. However, considering its high negative predictive value in patients with AFP < 200 ng/ml, AFP-L3% might be useful as an adjunctive marker, in combination with AFP, to exclude the presence of HCC.

Antibody response to an eight-site intradermal rabies vaccination in patients infected with Human Immunodeficiency Virus.

OBJECTIVE: To investigate the rabies virus neutralizing antibody response in HIV-1-infected patients with CD4+ cell count 200 cells/microL after post-exposure prophylaxis using an eight-site intradermal rabies vaccination regimen. METHODS: In a prospective cohort study, 27 HIV-1 infected patients were recruited, none of which had a history of rabies vaccination. All patients provided informed consent and were separated into two groups according to their CD4+ cell count (patients with CD4+ counts of 200 cells/microL). All patients received Purified Chick Embryo Cell rabies Vaccine (PCECV) using a modified eight-site regimen in which 0.1 mL of vaccine was injected intradermally on each of days 0, 3, 7, 14, and 30 (8-8-8-8-8). CD4+ cell counts, HIV-1 viral load and rabies virus neutralizing antibody (RVNAb) concentrations as determined by the Rapid Fluorescent Focus Inhibition Test (RFFIT) were evaluated on blood samples taken on days 0, 3, 7, 14, 30, 90, 180 and 365 after vaccination. RESULTS: Of the 27 patients included in the study, 18 patients (67%) had CD4+ cell counts of >200 cells/microL and 9 patients (33%) had CD4+ counts of or=0.5 IU/mL). There was no statistically significant difference in RVNAb concentrations between the two groups on days 3, 7, 14, 30, 90, 180 and 365 after vaccination. CONCLUSION: PCECV is immunogenic in HIV-1-infected patients with CD4+ cell counts below 200 cells/microL when administered in a modified eight-site intradermal PEP regimen.

Upper gastrointestinal bleeding etiology score for predicting variceal and non-variceal bleeding.

AIM: To identify clinical parameters, and develop an Upper Gastrointesinal Bleeding (UGIB) Etiology Score for predicting the types of UGIB and validate the score. METHODS: Patients with UGIB who underwent endoscopy within 72 h were enrolled. Clinical and basic laboratory parameters were prospectively collected. Predictive factors for the types of UGIB were identified by univariate and multivariate analyses and were used to generate the UGIB Etiology Score. The best cutoff of the score was defined from the receiver operating curve and prospectively validated in another set of patients with UGIB. RESULTS: Among 261 patients with UGIB, 47 (18%) had variceal and 214 (82%) had non-variceal bleeding. Univariate analysis identified 27 distinct parameters significantly associated with the types of UGIB. Logistic regression analysis identified only 3 independent factors for predicting variceal bleeding; previous diagnosis of cirrhosis or signs of chronic liver disease (OR 22.4, 95% CI 8.3-60.4, P < 0.001), red vomitus (OR 4.6, 95% CI 1.8-11.9, P = 0.02), and red nasogastric (NG) aspirate (OR 3.3, 95% CI 1.3-8.3, P = 0.011). The UGIB Etiology Score was calculated from (3.1 x previous diagnosis of cirrhosis or signs of chronic liver disease) + (1.5 x red vomitus) + (1.2 x red NG aspirate), when 1 and 0 are used for the presence and absence of each factor, respectively. Using a cutoff > or = 3.1, the sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) in predicting variceal bleeding were 85%, 81%, 82%, 50%, and 96%, respectively. The score was prospectively validated in another set of 195 UGIB cases (46 variceal and 149 non-variceal bleeding). The PPV and NPV of a score > or = 3.1 for variceal bleeding were 79% and 97%, respectively. CONCLUSION: The UGIB Etiology Score, composed of 3 parameters, using a cutoff > or = 3.1 accurately predicted variceal bleeding and may help to guide the choice of initial therapy for UGIB before endoscopy.