"MURAL" model to predict bleeding from mural-based lesions in potential small bowel bleeding may improve diagnostic capability and decrease cost.

In potential small bowel bleeding, video capsule endoscopy (VCE) is excellent to detect mucosal lesions, while mural-based lesions are better detected by computed tomography enterography (CTE). A predictive tool to identify mural-based lesions should guide selecting investigations. In this retrospective study, we developed and validated the "MURAL" model based on logistic regression to predicts bleeding from mural-based lesions. Cost-effectiveness analysis comparing diagnostic strategy among VCE, CTE, and MURAL model was performed. Of 296 patients, 196 and 100 patients were randomly included in the derivative and validation cohorts, respectively. The MURAL model comprises 5 parameters: age, presence of atherosclerosis, chronic kidney disease, antiplatelet use, and serum albumin level. The area under the receiver operating characteristic curve was 0.778 and 0.821 for the derivative and validation cohorts, respectively. At a cutoff value of 24.2%, the model identified mural-based lesions with 70% sensitivity and 83% specificity in the validation cohort. Cost-effectiveness analysis revealed that application of the MURAL model demonstrated a comparable missed lesion rate but had a lower missed tumor rate, and lower cost compared to VCE strategy. The model for predicting mural-based lesions provide some guidance in investigative decision-making, which may improve diagnostic efficiency and reduce costs.

Negative Video Capsule Endoscopy Had a High Negative Predictive Value for Small Bowel Lesions, but Diagnostic Capability May Be Lower in Young Patients with Overt Bleeding.

Background: Patients with potential small bowel bleeding (PSBB) who have negative results of video capsule endoscopy (VCE), clinical course, rate of rebleeding, and missed lesions with their predictors are essential for further management decision. Methods: This retrospective study included patients presenting with PSBB who had negative VCE findings between January 2008 and December 2016. All patients had to have at least two years of follow-up data to be included. Patients with <2 years of follow-up in their medical record were interviewed by telephone to determine if any unrecorded rebleeding episodes occurred. Results: One hundred forty-two patients were included. The mean age was 60.9 years, and 52.8% were male. Eighty-one patients presented with overt bleeding. The median duration of follow-up was 5.08 years. During the follow-up period, 30 patients experienced rebleeding. The cumulative rate of rebleeding at 1, 2, and 5 years was 10.0%, 14.3%, and 22.4%, respectively. Multivariate analysis showed nonsteroidal anti-inflammatory drugs (NSAIDs) and presentation of overt bleeding to be independent predictors of rebleeding. There were only nine small bowel lesions (6.3%) missed by VCE. These nine patients, compared with others, were significantly younger and tended to present with overt bleeding. Conclusion: Rebleeding was not uncommon in PSBB after negative VCE; however, the rate of missing small bowel lesions was low. Nonetheless, further investigations may be considered in young patients who present with overt bleeding.

Temporal trend in the natural history of ulcerative colitis in a country with a low incidence of ulcerative colitis from 2000 through 2018.

BACKGROUND/AIMS: The incidence of ulcerative colitis (UC) in Thailand (crude incidence rate of 0.28 per 100,000 persons) is much lower than in the West. The burden of UC varies in different populations. The aim of this study was to evaluate the natural history of UC over the two decades in Bangkok, Thailand. METHODS: This retrospective study included patients who were diagnosed with UC between 2000 and 2018 in 2 university hospitals. To evaluate changes in the disease course, we stratified patients into 2000-2009 cohort and 2010-2018 cohort. The cumulative probability of endoscopic healing, UC-related hospitalization and colectomy was estimated using the Kaplan-Meier method. RESULTS: A total of 291 UC patients were followed for total of 2,228 person-years. Comparison between 2 cohorts, there were no differences in disease pattern and severity whereas an increase in the combination use of oral and topical mesalamine and the early use of thiopurine was observed. Only 1% of patients for each cohort required biologic agent at 5 years. The rate of achieving mucosal healing increased from 15% to 46% at 3 years (P< 0.01). The rate of UC-related hospitalization decreased from 30% to 21% at 5 years (P< 0.05). The rate of colectomy decreased from 6% to 2% at 5 years (P< 0.05). CONCLUSIONS: The natural history of UC in a low incidence country was less aggressive than the West. Over the past two decades, the rates of UC-related hospitalization and colectomy have been decreasing which were similar to the West.

Temporal trend of disease recognition, treatment paradigm, and clinical outcomes of Crohn disease in Thailand from 2000 through 2017: Is early use of thiopurines beneficial?

The prevalence of Crohn disease (CD) is increasing in Asia, but data from Southeast Asian population are scarce.The databases of 2 university-based national tertiary referral centers located in Bangkok, Thailand, were retrospectively reviewed for adult patients diagnosed with CD during January 2000 to December 2017. Disease characteristics, diagnosis, treatment, and outcomes were described and compared between the 2000 to 2009 cohort (cohort A) and the 2010 to 2017 cohort (cohort B).One hundred eighty-two patients (mean age: 46.4 years, 50% male) with 993 patient-years of follow-up were included. Thirteen percent had a history of intestinal resection, but were not diagnosed until disease recurrence. Another 6% were diagnosed at the time of first surgery. There was no improvement in diagnostic proficiency between cohorts. Mesalamine, corticosteroids, thiopurines, and biologics were prescribed in 75.8%, 81.3%, 84.6%, and 13.7% of patients, respectively (P > .05 between cohorts). Notably, thiopurines were started earlier in cohort B. Median time to the start of thiopurines was 6.2 and 1.65 months in cohort A and B, respectively (P < .01). However, the cumulative 5-year rates of disease behavior progression (P = .43), hospitalization (P = .14), and bowel surgery (P = .29) were not significantly different between cohorts. Subgroup analysis including only patients who required thiopurines showed the early use of thiopurines to be associated with lower risk of intestinal surgery after diagnosis (hazard ratio: 0.30, 95% confidence interval: 0.11-0.85).Early disease recognition and early introduction of immunomodulators may prevent long-term complications and reduce unnecessary surgery in CD.

Efficacy and safety of nortriptyline in functional dyspepsia in Asians: A randomized double-blind placebo-controlled trial.

BACKGROUND AND AIM: Current treatments of functional dyspepsia (FD) are unsatisfied. Tricyclic antidepressants alter visceral hypersensitivity and brain-gut interaction. We assessed the efficacy and safety of nortriptyline in patients with FD. METHODS: Patients diagnosed with FD according to Rome III criteria who failed to respond to proton pump inhibitor and prokinetic treatment were randomly assigned to either once daily 10-mg nortriptyline or placebo. The primary endpoint was the rate of responders defined as > 50% reduction in dyspepsia symptom score after 8 weeks of treatment. The secondary endpoints were improvement in quality of life as assessed by 36-Item Short Form Health Survey score and safety. RESULTS: Sixty-one patients (nortriptyline 28 and placebo 33) were enrolled. Dyspepsia symptom score and duration of symptoms were balanced at entry between both groups. Eight and seven patients in nortriptyline and placebo groups were lost to follow up. Seven patients withdrew due to mild adverse events (nortriptyline 1 and placebo 6). Overall, 19 with nortriptyline and 20 with placebo completed the study. Patients receiving nortriptyline did not achieve higher response rate than those in placebo in both intention-to-treat (53.6% vs 57.6%, P = 0.75) and per-protocol (76.5% vs 73.7%, P = 1.00) analyses. Nortriptyline did not provide improvement in quality of life. The mean difference was 3.8 (P = 0.36) and 0.88 (P = 0.86) by intention-to-treat and 2.9 (P = 0.57) and 3.5 (P = 0.57) by per-protocol analyses in physical and mental component, respectively. All adverse events were minor and similar in both groups. CONCLUSION: Nortriptyline was not superior to placebo in management of patients with FD.

Impact of Fecal Hb Levels on Advanced Neoplasia Detection and the Diagnostic Miss Rate For Colorectal Cancer Screening in High-Risk vs. Average-Risk Subjects: a Multi-Center Study.

OBJECTIVES: The Asia-Pacific Colorectal Screening (APCS) scoring system was developed to identify high-risk subjects for advanced neoplasia. However, the appropriate fecal immunochemical test (FIT) cutoff for high-risk population may be different from that of average-risk population. We aimed to evaluate the FIT performance at different cutoffs in high-risk subjects undergoing colorectal cancer (CRC) screening. METHODS: We prospectively enrolled asymptomatic subjects aged 50-75 years. Using the APCS score, subjects were stratified into either the average-risk or high-risk groups. All subjects were tested with one-time quantitative FIT and underwent colonoscopy. We compared the FIT performance for advanced neoplasia between two groups using different cutoffs (5 (FIT5), 10 (FIT10), 20 (FIT20), 30 (FIT30), and 40 (FIT40) µg Hb/g feces). RESULTS: Overall, 1,713 subjects were recruited, and 1,222 (71.3%) and 491 (28.7%) were classified as average-risk and high-risk, respectively. Advanced neoplasia was detected in 90 (7.4%) of the average-risk subjects and 65 (13.2%) of the high-risk subjects. In the high-risk group, by decreasing the cutoff from FIT40 to FIT5, the sensitivity increased by 33.8 percentage points with decreased specificity by 11 percentage points. In the average-risk group, the sensitivity increased by 20 percentage points with decreased specificity by 9.6 percentage points. At the lowest cutoff (FIT5), the number of needed colonoscopies to find one advanced neoplasia was 2.8 and 6.1 for the high-risk and average-risk groups, respectively. CONCLUSIONS: Using an appropriate FIT cutoff for CRC screening in high-risk subjects could improve CRC screening performance and reduce the unnecessary colonoscopies. To maintain high sensitivity and specificity for advanced neoplasia, the optimal cutoff FIT in the high-risk subjects should be lower than that in the average-risk subjects.

Severity, Treatment, and Outcome of Acute Pancreatitis in Thailand: The First Comprehensive Review Using Revised Atlanta Classification.

Background. Severity and outcome of acute pancreatitis (AP) in Thailand are unknown. Methods. A retrospective study of 250 patients with AP during 2011-2014 was performed. Severity, treatment, and outcome were evaluated. Severity was classified by revised Atlanta classification. Results. The mean age was 58 years and 56% were men. Etiologies were gallstones (45%), alcohol (16%), postendoscopic retrograde cholangiopancreatography (14%), and idiopathic (15%). Overall, 72%, 16%, and 12% of patients had mild, moderately severe, and severe AP, respectively. Two major types of initial intravenous fluid were normal saline (64%) and Ringer's lactate solution (RLS, 28%). Enteral nutrition was given in 77% of patients with severe AP, median duration 48 hours, and via a nasogastric tube in 67% of patients. Necrotizing pancreatitis (NP) developed in 7% of patients, and 29% of them developed infection (median 17 days). The median length of stay was 6, 9, and 13 days, and the mortality rate was 1%, 3%, and 42% in mild, moderately severe, and severe AP, respectively. The overall mortality rate was 6%. Conclusion. The severity of AP in Thailand was mild, moderately severe, and severe in 72%, 16%, and 12% of patients, respectively. NP was not prevalent. Mortality was high in severe AP. Most treatments complied with standard guidelines except the underuse of RLS.

The Optimal Cut-Off Level of The Fecal Immunochemical Test For Colorectal Cancer Screening in a Country with Limited Colonoscopy Resources: A Multi-Center Study from Thailand

Background: Selecting the cut-off point for the fecal immunochemical test (FIT) for colorectal cancer (CRC) screening programs is of prime importance. The balance between the test performance for detecting advanced neoplasia and the available colonoscopy resources should be considered. We aimed to identify the optimal cut-off of FIT for advanced neoplasia in order to minimize colonoscopy burden. Methods: We conducted a multi-center study in 6 hospitals from diverse regions of Thailand. Asymptomatic participants, aged 50-75 years, were tested with one-time quantitative FIT (OC-SENSOR, Eiken Chemical Co.,Ltd., Tokyo, Japan) and all participants underwent colonoscopy. We assessed test performance in detecting advanced neoplasia (advanced adenoma and CRC) and measured the burden of colonoscopy with different cut-offs [25 (FIT25), 50 (FIT50), 100 (FIT100), 150 (FIT150), and 200 (FIT200)ng/ml]. Results: Among 1,479 participants, advanced neoplasia and CRC were found in 137 (9.3%) and 14 (0.9%), respectively. From FIT25 to FIT200, the positivity rate decreased from 18% to 4.9%. For advanced neoplasia, an increased cut-off decreased sensitivity from 42.3% to 16.8% but increased specificity from 84.2% to 96.3%. The increased cut-off increased the positive predictive value (PPV) from 21.5% to 31.5%. However, all cut-off points provided a high negative predictive value (NPV) (>90%). For CRC, the miss rate for FIT25 to FIT 150 was the same (n=3, 21%), whereas that with FIT200 increased to 35% (n=5). Conclusions: In a country with limited-colonoscopy resources, using FIT150 may be preferred because it offers both high PPV and NPV for advanced neoplasia detection. It could also decrease colonoscopy workload, while maintaining a CRC miss rate similar to those with lower cut-offs.

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.

A Prospective Blinded Comparison of Video Capsule Endoscopy Versus Computed Tomography Enterography in Potential Small Bowel Bleeding: Clinical Utility of Computed Tomography Enterography.

GOALS: To compare the efficacy of video capsule endoscopy (VCE) with computed tomography enterography (CTE) in potential small bowel (SB) bleeding, and to identify factors predictive of a high diagnostic yield for CTE. BACKGROUND: In potential SB bleeding, CTE potentially detects some lesions missed by VCE, but few data have determined its clinical utility. STUDY: Consecutive patients with potential SB bleeding were prospectively enrolled. All underwent VCE and CTE within a 1-week interval. Definitive diagnoses were made by surgery or enteroscopy, except when a strategy of VCE and conservative management was suitable. The diagnostic yields and sensitivities of each investigation were measured. RESULTS: Fifty-two patients were recruited (41 with overt and 11 with occult bleeding); 36 received a definitive diagnosis. The diagnostic yields and sensitivities of VCE and CTE were 59.6% and 30.8% (P=0.004), and 72.2% and 44.4% (P=0.052), respectively. The combined sensitivity of VCE and CTE (88.9%) was significantly greater than VCE (P=0.03) or CTE (P<0.01) alone. VCE was better for ulcers, enteritis, and angiodysplasia, whereas CTE was better for tumors and Meckel diverticula. Age below 40 years and severe bleeding were associated with a higher diagnostic yield for CTE [odds ratios (95% confidence interval)=7.3 (1.04-51.4), P=0.046 and 6.1 (1.4-25.5), P=0.014, respectively]. CONCLUSIONS: Both investigations complement each other in the diagnosis of potential SB bleeding. CTE should be considered when VCE is negative. Age below 40 years and severe bleeding were independent predictors of a higher diagnostic yield for CTE.

Current understanding of the neuropathophysiology of pain in chronic pancreatitis.

Chronic pancreatitis (CP) is a chronic inflammatory disease of the pancreas. The main symptom of patients with CP is chronic and severe abdominal pain. However, the pathophysiology of pain in CP remains obscure. Traditionally, researchers believed that the pain was caused by anatomical changes in pancreatic structure. However, treatment outcomes based on such beliefs are considered unsatisfactory. The emerging explanations of pain in CP are trending toward neurobiological theories. This article aims to review current evidence regarding the neuropathophysiology of pain in CP and its potential implications for the development of new treatments for pain in CP.

γ-Glutamyl Transferase Testing, Change of Its Designation on the Laboratory Request Form, and Resulting Ratio of Inappropriate to Appropriate Use.

OBJECTIVES: To determine the effect of a modified request form on the total use of γ-glutamyl transferase (GGT) usage and the ratio of inappropriate testing. METHODS: We modified a test request form by moving GGT from the "Liver profile" to the "Other" section. The criteria for appropriate GGT ordering were developed based on literature review and then validated by expert consensus. To determine the appropriateness of GGT requests, we reviewed the medical records of patients for whom GGT testing was requested, before and after the change in the request form. RESULTS: The total number of GGT tests performed was reduced from 81,020 tests before the change to 35,816 tests after the change (a 44.2% reduction). Of the 349 patients whose records we examined, GGT testing was ordered for 169 patients before the change in the form and for 180 patients after the change. The percentage of inappropriate GGT ordering was nonsignificantly reduced (from 85.8% to 81.7%; P =.30). CONCLUSIONS: The change in the classification of GGT testing on the laboratory request form was associated with a reduction in total test usage and nonsignificantly associated with a reduction in the proportion of inappropriate testing. Hence, we strongly recommend that physicians be given feedback and education concerning clinical indication.

Repeat upper gastrointestinal endoscopy in patients with functional dyspepsia: yield, findings, and predictors of positive findings.

Background. No guideline on repeat esophagogastroduodenoscopy (EGD) in functional dyspepsia (FD) exists. This study aimed to define yield, findings, and predictors of positive findings on repeat EGD in FD. Methods. FD patients who underwent at least 2 EGDs during October 2005 to November 2011 were enrolled and reviewed. Yield and findings were analyzed and univariate and multivariate analyses were performed to identify predictors of positive repeat EGD. Results. The median time to repeat EGD was 34 months. Among 146 patients, 115 patients (79%) had negative and 31 (21%) had positive repeat EGD, including erosive gastritis (13.0%), peptic ulcer (7.5%), reflux esophagitis (1.4%), and Barrett's esophagus (0.7%). Four independent predictors of positive repeat EGD were smoking (HR 3.88, 95% CI 1.31-11.51, P = 0.015), hypertension (HR 2.96, 95% CI 1.38-6.36, P = 0.050), history of malignancies (HR 3.65, 95% CI 1.16-11.46, P = 0.027), and antiplatelets or NSAIDs used within 4 weeks (HR 4.10, 95% CI 1.13-14.90, P = 0.032), while alarm features or failure to treatment did not predict positive repeat EGD. Conclusion. Yield of repeat EGD in FD was substantially low, all findings were acid-related disorders, and there was no malignancy. Smoking, hypertension, history of malignancies, and antiplatelets/NSAIDs use associated with positive repeat EGD.

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.

Interaction between physicians and pharmaceutical representatives, an insight from Thailand.

BACKGROUND: Evidence from Western countries has shown that informal relationships between the pharmaceutical industry and physicians could have some effect on physicians' prescribing behavior Many countries have, therefore, developed conflict-of-interest policies to mitigate the effects of such interactions. Interactions between pharmaceutical representatives and physicians, one among those relationships, have never been systematically studied in Thailand. OBJECTIVE: To measure, for the first time, interaction between pharmaceutical industry representatives and resident physicians in Thailand and to assess physicians' attitudes toward this interaction, and factors which determined their frequency. MATERIAL AND METHOD: The authors surveyed 970 residentphysicians in May 2009 at a university hospital in Thailand using 3-page anonymous, self-administered questionnaire and analyzed their responses. RESULTS: Overall response rate was 71.6%. Three-fourth of trainees had weekly conversations with pharmaceutical representatives. Nearly 90% of physicians receive at least one gift per month. Residents in one of the specialties with the highest prescribing costs were most likely to have such interaction with an adjusted odds ratio (OR) of 7.91 (4.61-13.58)for having conversations and 5.18 (3.28-8.17) for receiving non-educational gifts. Those residents who perceived that it is impolite to decline gifts were more likely to accept non-educational gifts: adjusted OR of 1.68 (1.04-2.71). CONCLUSION: Frequency of interaction could have only been a marker for level of exposure, not a genuine influence on physicians' prescribing behavior Nevertheless, given that resident physicians in Thailand have frequent interaction with pharmaceutical industry representatives, guidance on managing conflict-of-interest should be included in medical training.

Maldigestion from pancreatic exocrine insufficiency.

Pancreatic exocrine insufficiency (PEI) is one of the long-term consequences of chronic pancreatitis (CP). Majority of patients with PEI were undiagnosed or undertreated. Inadequately treated or subclinical severe PEI causes malnutrition and may pose the patients at risk of premature atherosclerosis and cardiovascular events. Indication of pancreatic enzyme replacement therapy (PERT) is patients with severe PEI, as indicated by the presence of steatorrhea, diarrhea, weight loss, fecal fat > 7 g/day, (13) C-mixed triglyceride breath test < 29%, fecal elastase < 100 ug/g stool, imaging or endoscopic findings of pancreatic ductal dilatation or calculi, and eight endosonographic criteria of CP. The mainstay treatment of PEI is PERT. Dietary fat restriction is unnecessary. PERT with lipase > 40,000 U per meal is recommended. Enteric-coating may be preferred to conventional enzymes because of the availability of high-dose preparations and no need of acid suppression co-therapy. Administration of enzymes with meals is proven to be the most effective regimen. Response to PERT should be measured by the improvement of patients' symptoms, nutritional status, and, in selected cases, by fecal fat or (13) C-mixed triglyceride breath test. Patients unresponsive to PERT should be checked for compliance, increase the dose of lipase to 90,000 units/meal or co-therapy with proton pump inhibitor. In patient with previous gastrointestinal surgery that may interfere enzyme-food mixing, opening the capsules and administering the enzyme granules with meals. Finally, search for small intestinal bacterial overgrowth syndrome and other causes of small bowel malabsorption.

Diagnosis and localization of insulinoma in Thai patients: performance of endoscopic ultrasonography compared to computed tomography and magnetic resonance imaging.

BACKGROUND: Endoscopic ultrasonography (EUS) has now been accepted as the most sensitive method to localize insulinoma. However the data in Thai patients is lacking and the diagnostic performances of EUS comparing to computed tomography (CT) and magnetic resonance imaging (MRI) is unknown. MATERIAL AND METHOD: Retrospective analysis of 19 patients with recurrent hypoglycemia suggestive of insulinoma who underwent EUS, CT and MRI for tumor localization during 2007 to 2012. Surgical pathology or long-term follow-up was used as gold standard. RESULTS: There were 14 patients with 15 insulinoma lesions and 5 patients without insulinoma (2 nesidioblastosis and 3 without lesion). EUS, CTand MRI were performed in 19, 11 and 10 patients, respectively. EUS could detect insulinoma with sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of 93%, 80%, 93% and 80%, respectively. The corresponding performances for CT were 78%, 100%, 100%, 50% and MRI were 71%, 33%, 71%, 33%, respectively. In patients with positive CT subsequent EUS did not change diagnosis. However, EUS was able to detect insulinoma in 50% of patients with negative CT On the other hand, in patients with positive MRI, EUS changed and corrected the diagnosis of MRI in 29% and was able to detect insulinoma in 67% of patients with negative MRI. EUS, CT and MRI correctly localized insulinoma in 87%, 67% and 57%, respectively. The most common incorrect localization was between pancreatic body and tail. CONCLUSION: EUS has the best diagnostic performance in detection and localization of insulinoma. CT is less sensitive but very specific, therefore positive CT may preclude the need of EUS. MRI, however is less sensitive and specific than CT. Either positive or negative MRI may require further EUS.

Mucosal-type eosinophilic gastroenteritis in Thailand: 12-year retrospective study.

OBJECTIVE: To evaluate the clinical features and natural course of disease among patients with mucosal-type eosinophilic gastroenteritis in Thailand. MATERIAL AND METHOD: The present study was conducted by retrospectively searching for the ICD-10 code for eosinophilic gastroenteritis (EGE) among medical records for the period 2001-2012. Clinical and pathological specimens were reviewed using the same diagnostic criteria. Appropriate tests were conducted to exclude other secondary causes of EGE. All patients had to have either received empirical treatment for parasitic infections or were tested for parasites in the stool. After the diagnosis had been established, each patient received 30-40 mg/day of oral prednisoloneforfour weeks, which was tapered down as clinical status improved. All patients were followed up by monitoring clinical symptoms and relevant laboratory findings. Patients who did not maintain follow-up appointments were contacted by telephone and asked about their clinical symptoms. RESULTS: Seventeen patients with a diagnosis of mucosal-type E (6 male, 11 female, M:F ratio 1:1.83) were found. Mean age at the time of presentation was 52.5 +/- 13.04 years. Four patients (23.5%) had either allergic or atopic conditions. Chronic diarrhea and weight loss were the most common initial presentation in 16 patients (94.1%). Microscopically and macroscopically, bloody diarrhea was observed in 13 cases (76.5%). Four patients were found to have protein-losing enteropathy. Peripheral eosinophilia was found in 10 patients (58.8%) with absolute eosinophil counts between 744 and 23,550 cells/mm3. Eight of these had an absolute eosinophil count in the hypereosinophilic range (> 1,500 cells/mm3). All patients treated with prednisolone treatment showed symptomatic improvement within four weeks. One patient's symptom resolved spontaneously, without treatment. Thirteen patients relapsed during the tapering-off of prednisolone. Seven patients showed complete remission. Three patients subsequently developed cancer (lung, breast, and bladder) after EGE was diagnosed. CONCLUSION: EGE, although uncommon, is present in Thailand, where parasitic infections continue to be a significant public-health problem.

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.

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.