Academy of Medicine, Singapore clinical guideline on endoscopic surveillance and management of gastric premalignant lesions.

Gastric cancer (GC) has a good prognosis, if detected at an early stage. The intestinal subtype of GC follows a stepwise progression to carcinoma, which is treatable with early detection and intervention using high-quality endoscopy. Premalignant lesions and gastric epithelial polyps are commonly encountered in clinical practice. Surveillance of patients with premalignant gastric lesions may aid in early diagnosis of GC, and thus improve chances of survival. An expert professional workgroup was formed to summarise the current evidence and provide recommendations on the management of patients with gastric premalignant lesions in Singapore. Twenty-five recommendations were made to address screening and surveillance, strategies for detection and management of gastric premalignant lesions, management of gastric epithelial polyps, and pathological reporting of gastric premalignant lesions.

Clinical guidance on endoscopic management of colonic polyps in Singapore.

Colonoscopy with endoscopic resection of detected colonic adenomas interrupts the adenoma-carcinoma sequence and reduces the incidence of colorectal cancer and cancer-related mortality. In the past decade, there have been significant developments in instruments and techniques for endoscopic polypectomy. Guidelines have been formulated by various professional bodies in Europe, Japan and the United States, but some of the recommendations differ between the various bodies. An expert professional workgroup under the auspices of the Academy of Medicine, Singapore, was set up to provide guidance on the endoscopic management of colonic polyps in Singapore. A total of 23 recommendations addressed the following issues: accurate description and diagnostic evaluation of detected polyps; techniques to reduce the risk of post-polypectomy bleeding and delayed perforation; the role of specific endoscopic resection techniques; the histopathological criteria for defining endoscopic cure; and the role of surveillance colonoscopy following curative resection.

Chapter of Gastroenterologists professional guidance for management of patients with liver disease in Singapore during the COVID-19 pandemic.

In this paper, we aim to provide professional guidance to clinicians who are managing patients with chronic liver disease during the current coronavirus disease 2019 (COVID-19) pandemic in Singapore. We reviewed and summarised the available relevant published data on liver disease in COVID-19 and the advisory statements that were issued by major professional bodies, such as the American Association for the Study of Liver Diseases and European Association for the Study of the Liver, contextualising the recommendations to our local situation.

Chapter of Gastroenterologists professional guidance on risk mitigation for gastrointestinal endoscopy during COVID-19 pandemic in Singapore.

In this paper, we aimed to provide professional guidance to practising gastrointestinal (GI) endoscopists for the safe conduct of GI endoscopy procedures during the current coronavirus disease 2019 (COVID-19) pandemic and future outbreaks of similar severe respiratory tract infections in Singapore. It draws on the lessons learnt during the severe acute respiratory syndrome (SARS) epidemic and available published data concerning the COVID-19 pandemic. It addresses measures before, during and after endoscopy that must be considered for both non-infected and infected patients, and provides recommendations for practical implementation.

EUS-FNA of the left adrenal gland is safe and useful.

INTRODUCTION: There are limited data on the use of endosonography-guided fine-needle aspiration (EUS-FNA) to determine the nature of left adrenal lesions. We described our experience in performing EUS-FNA of left adrenal lesions. CLINICAL PICTURE: During a 20-week period, data on consecutive patients who underwent EUS with or without EUS-FNA were prospectively captured. Patients with a left adrenal mass and who underwent EUS-FNA formed our study population. TREATMENT: EUS-FNA. OUTCOME: A total of 119 consecutive patients underwent diagnostic EUS +/- FNA, during which the left adrenal gland was routinely examined. Twelve of these patients underwent EUS as part of lung cancer staging and among these 12 lung cancer patients, 2 had left adrenal masses detected by computed tomography (CT). EUS detected left adrenal nodules in 2 other patients which were not visualised by CT. The overall prevalence of a left adrenal mass was 3.4%; in the subgroup with confirmed lung cancer, the prevalence was 33.3%. All 4 patients were male, with a mean age of 76.3 years (range, 67 to 87). The mean size of the left adrenal lesion was 30.4 mm (range, 9 to 84.8). EUS-FNA of the left adrenal lesions was performed under Doppler guidance. The mean number of needle passes was 2 (range, 1 to 4). A cellular aspirate was obtained in all patients. No procedural complications occurred. Metastatic non-small cell lung cancer was diagnosed in 2 patients, including a lesion missed on CT. For the other 2 cases, EUS-FNA revealed benign adrenal cells. CONCLUSIONS: EUS-FNA appears safe and useful for the evaluation of left adrenal masses.

In patients referred for investigation because computed tomography suggests thickened gastric folds, endoscopic ultrasound is superfluous if gastroscopy is normal.

BACKGROUND AND OBJECTIVE: Endoscopic ultrasound (EUS) is often requested in patients in whom computed tomography (CT) shows gastric wall thickening. It is unclear if EUS is useful if upper endoscopy is normal. The aim of this study was to prospectively compare the yield of upper endoscopy and EUS for this indication. METHODS: All patients referred for endoscopic ultrasound because of thickened gastric folds on CT from May 2001 and June 2003 were included. A single physician, questioned, examined, and performed upper endoscopy followed by EUS in all patients. Data were recorded prospectively. The main outcome measures were: upper endoscopy and EUS findings and predictors of abnormal EUS. RESULTS: Sixty-nine patients were enrolled. The average age was 57.9, 49% were male, 51% were asymptomatic, 57% had normal upper endoscopy, and 70% had normal EUS. If upper endoscopy was abnormal, EUS was abnormal in 70% of cases (95% CI 62%-78%). If upper endoscopy was normal, the EUS was normal in 100% of cases (95% CI 92%-100%). Multivariate analysis revealed that neither age, gender, presence of abdominal symptoms nor alarm symptoms predicted abnormal EUS. CONCLUSIONS: When CT shows gastric wall thickening: (a) Nnormal upper endoscopy is strongly associated with normal EUS; (b) abnormal upper endoscopy is associated with abnormal EUS in 70% of cases; (c) clinical variables such as age, sex, and the presence of symptoms do not predict or increase the likelihood of abnormal EUS. Therefore, in patients with thickened gastric wall on CT, upper endoscopy should be used to select patients for EUS.

An audit of the outcome of long-term biliary stenting in the treatment of common bile duct stones in a general hospital.

BACKGROUND: This study audited the clinical outcome of a cohort of patients with choledocholithiasis treated with long-term biliary stenting in order to determine the feasibility of this practice. METHODS: Over 2 years, 83 patients with symptomatic choledocholithiasis were treated with long-term stenting because they either refused further treatments or were medically unfit for further procedures after the initial endoscopic retrograde cholangiopancreatography (ERCP). Recurrence of clinical events, need for stent change, morbidity, and mortality were analyzed. As a secondary analysis, published data on long-term biliary stenting were reviewed. RESULTS: ERCP and biliary stenting were successful in all cases with no complications. The mean follow-up was 19 months (1-103 months). The median number of ERCPs performed was 1 (1-4). The mean duration of stent patency was 12.4 months (1-54.8 months). A total of 28 clinical events (cholangitis, 71%) occurred in 24 patients during follow-up, for a late complication rate of 33.7%. ERCP was repeated and the stents changed on 15 occasions in 11 asymptomatic patients with abnormal liver function tests detected on routine follow-up. No biliary-related mortality occurred. Review of published data revealed a mean late complication rate of 22.4% (0%-64%), a biliary-related mortality rate of 3.5% (0%-21.1%), and a nonbiliary-related mortality rate of 20.8% (0%-60.3%). CONCLUSIONS: Long-term biliary stenting is a feasible option for patients who decline or are medically unfit for further elective endoscopic or surgical procedures. Close follow-up is mandatory to detect and treat late complications.

Helicobacter pylori eradication versus prokinetics in the treatment of functional dyspepsia: a randomized, double-blind study.

BACKGROUND: This randomized, double-blind study compared the efficacy of Helicobacter pylori eradication against prokinetics in H. pylori-infected functional dyspepsia patients. METHODS: Patients with moderately severe or severe dyspepsia fulfilling the Rome II criteria were randomized to either H. pylori eradication for 1 week and 6 weeks of placebo prokinetics or 6 weeks of prokinetics and placebo H. pylori eradication in the first week. Symptoms were assessed at baseline and at 6 and 12 months using the Glasgow Dyspepsia Severity Score (GDSS). Global response to treatment was assessed at 12 months. RESULTS: Altogether 130 patients were enrolled (H. pylori eradication, 71; prokinetics, 59). The mean baseline GDSS was 9.3 for the H. pylori eradication group and 8.9 for the prokinetic group. At 6 months, the score was 3.6 and 4.1, respectively, and it remained at 3.5 and 3.8, respectively, at 12 months. With H. pylori eradication, 31.0% had complete symptom resolution (GDSS 0 or 1) at 12 months compared with 23.7% with prokinetics (a nonsignificant difference). At 12 months, global symptomatic improvement was seen in 62.0% of the H. pylori eradication group compared with 67.8% of the prokinetics group. CONCLUSIONS: Both H. pylori eradication and prokinetic therapy resulted in symptom improvement in two-thirds of dyspeptic patients at 1 year. More patients tended to achieve complete symptom relief with H. pylori eradication.

A comparison of the clinical, demographic and psychiatric profiles among patients with erosive and non-erosive reflux disease in a multi-ethnic Asian country.

AIM: To examine the clinical spectrum of gastroesophageal reflux disease (GERD) and compare erosive (ERD) with non-erosive (NERD) in terms of clinical, demographic and psychiatric profiles. METHODS: Patients with reflux symptoms were enrolled and stratified to NERD and ERD after endoscopy (LA classification). Patients with ERD presenting with dyspepsia were included. Patients on proton pump inhibitors (PPI) or H2 receptor antagonists before endoscopy were excluded. Demographic data, Helicobacter pylori (H pylori) status and presence of minor psychiatric morbidity (based on General Health Questionnaire-28) were analyzed. RESULTS: Among 690 patients screened, 533 were eligible for analysis (male to female ratio: 3:2; Chinese: 75.4%; Malay: 9.8%; Indian: 14.8%). Clinical spectrum of GERD: N: 40.5%; A: 46%; B: 9.2%; C: 2.1%; D: 0.6%; Barrett's esophagus: 1.7%. Compared to patients with NERD, patients with ERD were significantly older (45 vs 39.4 years), more likely to be male (64.4% vs 53.7%), tended to smoke (19.6% vs 9.7%), less likely to have minor psychiatric morbidity (26.4 vs 46.7%) and were more likely to respond to PPI (79.7 vs 66.8%). There was also a trend towards a higher BMI (24.5 vs 23.5). Race, alcohol consumption and H pylori status were not significant. On multivariate analysis, age and presence of minor psychiatric morbidity remained with significant differences. CONCLUSION: The majority of patients who have typical symptoms of GERD have NERD or mild erosive reflux disease. Compared to patients with erosive reflux disease, patients with NERD were younger and had a higher prevalence of minor psychiatric morbidity.

Epinephrine injection therapy versus a combination of epinephrine injection and endoscopic hemoclip in the treatment of bleeding ulcers.

AIM: To assess the efficacy of hemoclip application in combination with epinephrine injection in the treatment of bleeding peptic ulcers and to compare the clinical outcomes between patients treated with such a combination therapy and those treated with epinephrine injection alone. METHODS: A total of 293 patients (211 males, 82 females) underwent endoscopic therapy for bleeding peptic ulcers. Of these, 202 patients (152 males, 50 females) received epinephrine injection therapy while 91 patients (59 males, 32 females) received combination therapy. The choice of endoscopic therapy was made by the endoscopist. Hemostatic rates, rebleeding rates, need for emergency surgery and 30-d mortality were the outcome measures studied. RESULTS: Patients who received combination therapy were significantly older (mean age 66+/-16 years, range 24-90 years) and more suffered from chronic renal failure compared to those who received epinephrine injection therapy alone (mean age 61+/-17 years, range 21-89 years). Failure to achieve permanent hemostasis was 4% in the group who received epinephrine injection alone and 11% in the group who received combination therapy. When the differences in age and renal function between the two treatment groups were taken into account by multivariate analysis, the rates of initial hemostasis, rebleeding rates, need for surgery and 30-d mortality for both treatment options were not significantly different. CONCLUSION: Combination therapy of epinephrine injection with endoscopic hemoclip application is an effective method of achieving hemostasis in bleeding peptic ulcer diseases. However, superiority of combination therapy over epinephrine injection alone, could not be demonstrated.

Clinical profile of primary sclerosing cholangitis in Singapore.

BACKGROUND AND AIM: Primary sclerosing cholangitis (PSC) is a rare chronic disease in Singapore and its epidemiological profile has not been described previously. The present study aimed to define the demographic and clinical profile of patients with PSC in Singapore. METHODS: The case records of patients with PSC seen at Changi General Hospital were analyzed in terms of demographic profile, clinical presentation, clinical course, treatment and complications. RESULTS: Ten cases of PSC were diagnosed over a 10-year period. The male:female ratio was 9:1. The median age of diagnosis was 49.5 years (mean: 50.9 years; range: 35-63 years). With regards to clinical presentation, seven patients had hepatobiliary sepsis, two patients had asymptomatic liver biochemistry abnormalities while one patient had cholestatic jaundice. Prevalence rate of perinuclear antineutrophil cytoplasmic antibody (pANCA) was 20%. Symptomatic inflammatory bowel disease (IBD) was diagnosed in 20% of PSC cases. Eight patients (80%) had intrahepatic ductal involvement while two patients (20%) had combined intrahepatic and extrahepatic ductal involvement on endoscopic retrograde cholangiopancreatography (ERCP). The prevalence rate of recurrent cholangitis was 30% while that of recurrent liver abscess, cirrhosis and common bile duct stricture were all 10%. The mean duration of follow up was 6.6 years with one death from liver failure. CONCLUSION: The clinical profile of patients with PSC in Singapore appears to differ with other published data, with a greater number presenting with hepatobiliary sepsis and less frequent association with IBD and pANCA. It is hypothesized that this may be related to differences in environmental triggers and genetic susceptibility.

Seroreactivity to 19.5-kDa antigen in combination with absence of seroreactivity to 35-kDa antigen is associated with an increased risk of gastric adenocarcinoma.

BACKGROUND: Only a minority of those infected with Helicobacter pylori will develop gastric cancer. Stratification of H. pylori strains based on carcinogenic potential will provide a basis for selective surveillance and eradication therapy. We studied the anti-H. pylori antibody profile in Asian patients with gastric adenocarcinoma to identify any H. pylori antigen that may be associated with an increased or decreased risk of gastric carcinoma. PATIENTS AND METHODS: A case-control study comparing the seroprevalence of antibodies with various H. pylori antigens in Singaporeans with gastric adenocarcinoma and the normal Singaporean population was carried out using both conventional immunoglobulin (Ig) G enzyme-linked immunosorbent assay (ELISA) and Western blot immunoassay. RESULTS: The seroprevalence among 44 gastric adenocarcinoma cases (70.5% males, mean age 66.7 +/- 13.5 years) and 261 controls (49.8% males, mean age 61.5 +/- 4.1 years) was 90.9% vs. 50.2% by IgG ELISA. In the H. pylori-positive male population, those suffering from gastric adenocarcinoma had significantly lower seroreactivity to the 35-kDa antigen compared with asymptomatic controls (p =.0198, OR = 3.79, 95% CI 1.24-11.61). Seropositivity to the 19.5 kDa antigen was also found to be associated with the presence of gastric adenocarcinoma in Singaporean males (p =.022, OR = 4.17, 95% CI 1.22-14.28). A 'high-risk' phenotype consisting of absence of a band at 35-kDa in combination with the presence of a band at 19.5-kDa was significantly associated with the presence of gastric adenocarcinoma (p =.002, OR = 3.7, 95% CI 1.6-8.6). CONCLUSIONS: Stratification of H. pylori strains based on their potential for carcinogenesis, such as those strains that are seropositive for the 19.5 kDa antigen and seronegative for the 35-kDa antigen, may provide a basis for selective eradication of H. pylori infection and future vaccine development.