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.

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.

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.

Evaluating the Efficacy of Fecal Immunochemical Test, Fecal Calprotectin, and Serum C-Reactive Protein in Diagnosing Patients With Chronic Lower Gastrointestinal Symptoms.

INTRODUCTION: Accurate early detection of ileocolonic lesions in patients with chronic lower gastrointestinal symptoms (LGISs) is often difficult due to the rarity of early-stage alarm signs. This study assesses the effectiveness of noninvasive blood and stool biomarkers in diagnosing ileocolonic lesions in patients with chronic LGISs undergoing colonoscopy. METHODS: We conducted a prospective study between April 2020 and July 2022 involving patients with LGISs lasting a month or more. Before colonoscopy, we gathered clinical data, blood samples for C-reactive protein (CRP) and stool samples for fecal immunochemical test (FIT) and fecal calprotectin (FC) analysis. RESULTS: Of 922 participants analyzed (average age 62 years, 37% male), 130 (14.1%) had significant colonoscopy findings, including cancer, advanced adenoma, and inflammatory conditions. Test effectiveness showed an area under the curve of 0.630 for alarm features, 0.643 for CRP, 0.781 for FIT, and 0.667 for FC. Combining stool tests with alarm features improved diagnostic precision. Those without alarm features had a high negative predictive value of 0.97 with low threshold FIT and FC, missing minimal significant lesions, and no cancer. For patients with alarm features, dual high-cutoff test positivity showed a positive predictive value of 0.67. Adding CRP to fecal tests did not enhance accuracy. DISCUSSION: FIT and FC are valuable in evaluating LGISs. Negative results at low cutoffs can delay colonoscopy in limited resource settings while positive results at dual high cutoffs substantiate the need for the procedure.

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.

Diffuse type autoimmune pancreatitis: the first case report in Thailand.

BACKGROUND: Autoimmune pancreatitis (AIP) is a recently-recognized form of pancreatitis mimicking pancreatic cancer (PaC) but treatable with corticosteroid. There is one report of focal-type AIP in Thailand. Here we presented the first case report of diffuse-type AIP. CASE REPORT: A 76-year-old man presented with 10-day obstructive jaundice. Computed tomography (CT) showed obstructive jaundice from diffusely swollen pancreas, which had a characteristic capsule-like rim non-enhancement pattern of AIP. Serum immunoglobulin G4 (IgG4) was elevated of 468 mg/dL. Endoscopic ultrasound-guided fine needle aspiration demonstrated no PaC. Prednisolone 40 mg/day was started. Jaundice disappeared in 2 weeks and follow-up CT demonstrated normalization of swollen pancreas. CONCLUSION: Diffuse-type AIP does exist in Thailand. Recognition of this condition is critical to avoid misdiagnosis of PaC or unnecessary surgery.

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.

Repeated endoscopic ultrasound guided fine needle aspiration (EUS-FNA) improved diagnostic yield of inconclusive initial cytology for suspected pancreatic cancer and unknown intra-abdominal lymphadenopathy.

BACKGROUND: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is considered as an effective technique to obtain cytology specimens for definite diagnosis of the patients who were suspected of having pancreatic cancer and unknown intra-abdominal lymphadenopathy. The value of repeated EUS-FNA in these patients who had inconclusive first EUS-FNA cytology is not well established. OBJECTIVE: To determine the yield of repeated EUS-FNA in obtaining a definite diagnosis in patients with clinically suspect for pancreatic cancer and unknown intra-abdominal lymphadenopathy including the reasons for which initial EUS-FNA failed. MATERIAL AND METHOD: The authors retrospectively reviewed the EUS database of Siriraj endoscopy center from January 2007 to May 2011, to identify all patients who underwent repeated EUS-FNA for high index suspicion of pancreatic cancer and unknown intra-abdominal lymphadenopathy. The inconclusive results of the first EUS-FNA, the factors associated with non-diagnosed versus diagnosed cytology results were compared. RESULTS: A total of 478 EUS- FNA were performed in our institution. Fifteen patients (6M, 9F), mean age of 57 +/- 11.8 years (30-72 years) had repeated EUS-FNA done for the evaluation of possible malignant diseases. Eight of these patients presented with pancreatic masses and the other seven patients had unknown intra-abdominal lymphadenopathy. The second EUS-FNA diagnosed and was truly benign in 4 patients. Repeated EUS-FNA facilitated determination of the true status of the disease in 13 of 15 patients which 9 of whom were malignancy. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of repeated EUS-FNA for both inconclusive pancreatic masses and unknown intra-abdominal lymphadenopathy were 90%, 100%, 100%, 80% and 92.8% respectively. CONCLUSION: Repeated EUS-FNA for inconclusive initial cytology of patients with suspected pancreatic cancer and unknown intra-abdominal lymphadenopathy provided a very high yield for definite tissue diagnosis and should be recommended.

Clinical characteristics, endosonographic findings and etiologies of gastroduodenal subepithelial lesions: a Thai referral single center study.

OBJECTIVE: The present study was undertaken to evaluate the demographic data, endoscopic ultrasonography (EUS) characteristics of the sub-epithelial lesions, pathology results, complications and long-term follow-up of the patients whom referred for EUS evaluation at Siriraj Hospital. MATERIAL AND METHOD: From January 2008-June 2011, a total of 61 cases was referred for EUS evaluation due to subepithelial lesions. The endoscopic reports, pathology results and the patients' medical records were reviewed. The present study was approved by Siriraj Institutional Review Board. RESULTS: A total of 61 patients were referred for evaluation of subepithelial lesions, 6 of them were excluded. Thus, 55 cases were analyzed. The mean age was 57.7 +/- 13.8 years (27-87 years). Sixty seven percent were female. Only one-third of the patients had symptoms. The provisional diagnosis of the sub-epithelial lesions, regarding only clinical and endosonographic characteristics were GIST neuroendocrine tumor (NET), pancreatic rest, lipoma, granular cell tumor and others (70.9%, 9.1%, 9.1%, 3.6%, 3.6% and 3.6% respectively). All the lesions were diagnosed as GIST originating from either the forth layer (97.4%) or the second layer (2.6%) of gastric or duodenal wall. Fine needle aspiration (FNA) was performed in 13 patients (23.6%). The positive predictive value, negative predictive value and accuracy of diagnosis of GIST made by endosonographers based on only endosonographic characteristics were 85, 100 and 86% (95% CI: 62.4%-94.4%) respectively. CONCLUSION: Most of the subepithelial lesions which were referred for EUS evaluation at Siriraj Hospital were GISTs. The diagnosis of GISTcan be accurately made by using the EUS based on only endosonographic characteristics. FNA should be done for the large sized GIST. For small sized GIST (< 3 cm), FNA might not be beneficial but a 1year interval follow-up with EUS is recommended.

"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.

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.

Efficacy of disposable needles versus angiocath needles for therapeutic abdominal paracentesis.

BACKGROUND: Disposable needle and angiocath needle are the two most commonly used needles for therapeutic abdominal paracentesis. The present study aims to compare the efficacy and complication rate between disposable needles and angiocath needles for therapeutic abdominal paracentesis. MATERIAL AND METHOD: The present study was an open-labelled study of patients indicated for therapeutic abdominal paracentesis at Siriraj Hospital during June to December 2009. Patients were assigned by physicians to either the disposable needle group (disposable needle No.18 used) or the angiocath group (angiocath needle No.16 used). Efficacy and complications were compared. RESULTS: A total of 100 patients were assigned to the disposable group, and 100 patients to the angiocath group. The disposable needle group had higher success rate by single attempt (97% vs. 84%, p = 0.006) and less failure (0 vs. 6%, p = 0.013). However the ascites flow rate in the angiocath group was significantly greater (mean 67.1 vs. 53.1 ml/min, p = 0.012). Complications were fewer in the disposable needle group, particularly of abdominal wall hematoma (1% vs. 8%, p = 0.035). Traumatic tapping also occurred less often in the disposable needle group but was not statistically significant (3% vs. 9%, p = 0.134). CONCLUSION: Compared with angiocath needles, disposable needles used for therapeutic abdominal paracentesis demonstrated higher success rate, fewer complications but slightly slower flow rate.

Pancreatic panniculitis: a cutaneous presentation as an initial clue to the diagnosis of pancreatic cancer.

BACKGROUND: Pancreatic panniculitis is a rare complication of pancreatic diseases, including pancreatic carcinoma. It is clinically manifested by erythematous subcutaneous nodules typically located on the legs which can occur before or at the onset of pancreatic disease. CASE REPORT: An 81-year-old woman presented with painful subcutaneous nodules at both shins, recurrent epigastric pain, anorexia and significant weight loss. Physical examination revealed mild pallor, palpable epigastric mass and multiple tender erythematous subcutaneous nodules discrete to both lower extremities. The skin biopsy showed lobular panniculitis with marked subcutaneous fat necrosis and ghost adipocytes compatible with pancreatic panniculitis that was an important clue for further investigations. Elevations of serum amylase and serum lipase were then noted. Computed tomography of the abdomen revealed pancreatic cancer with duodenal involvement and multiple liver metastases. CONCLUSION: Pancreatic panniculitis is associated with pancreatic cancer and represents an important clue to the diagnosis.

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

Can we predict final outcome of internal medicine residents with in-training evaluation.

OBJECTIVE: To assess the predictive value of in-training evaluation for determining future success in the internal medicine board certifying examination. MATERIAL AND METHOD: Ninety-seven internal medicine residents from Faculty of Medicine Siriraj Hospital who undertake the Thai Board examination during the academic year 2006-2008 were enrolled. Correlation between the scores during internal medicine rotation and final scores in board examination were then examined. RESULTS: Significant positive linear correlation was found between scores from both written and clinical parts of board certifying examination and scores from the first-year summative written and clinical examinations and also the second-year formative written examination (r = 0.43-0.68, p < 0.001). Monthly evaluation by attending staffs was less well correlated (r = 0.29-0.36) and the evaluation by nurses or medical students demonstrated inverse relationship (r = -0.2, p = 0.27 and r = -0.13, p = 0.48). CONCLUSION: Some methods of in-training evaluation can predict successful outcome of board certifying examination. Multisource assessments cannot well extrapolate some aspects of professional competences and qualities.

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.