Scipedia: Collection of Advances in Digestive Medicine

Massive post-polypectomy hemorrhage: Successful tulip-bundle technique with endoloop for hemostasis

Scipedia content — Mon, 15 May 2017 12:55:06 +0200

Colonoscopic polypectomy is a common procedure for removing colonic polyps to prevent subsequent development of colon cancer. Hemorrhage is the most common complication following polypectomy, with a reported rate of 0.3% to 6.0%. The risk increases to 12.5% when the size of the polyp stalk exceeds 1 cm. The most commonly used endoscopic preventive techniques, such as injection therapy, prophylactic use of endoclip, or endoloop, were found to decrease the rate of post-polypectomy hemorrhage, and repeated use of these techniques is useful for controlling bleeding. Here, we reported a case of a 65-year-old man with refractory post-polypectomy hemorrhage for a 2-cm adenomatous polyp. Application of an endoloop using the tulip-bundle technique achieved successful hemostasis. To our knowledge, this is the first report of this technique being used to treat refractory acute post-polypectomy hemorrhage.

Medical utilization by liver cancer patients under the National Health Insurance program in Taiwan: A population-based cross-sectional study

Scipedia content — Mon, 15 May 2017 12:55:00 +0200

Taiwan implemented a comprehensive and universal National Health Insurance (NHI) program to cover all inhabitants. This study aimed to assess the medical utilization by liver cancer patients under the NHI. This retrospective cross-sectional study used a sampled NHI research database, which contained 1 million beneficiaries. The claims of liver cancer patients in 2009 were analyzed. The other beneficiaries without liver cancer who used medical services in 2009 served as the control patients. Among the 2335 identified liver cancer patients, 2178 (93.3%) patients used outpatient services and 1193 (51.1%) patients used inpatient services. Liver cancer accounted for 1.8% of the NHI’s total cost. The cost per visit was United States dollars (US$)59.30 for outpatient care and US$2070.30 for inpatient care. The annual cost per patient was US$4746.60, US$1951.00 were for outpatient care and US$2795.60 for inpatient care. Patients who were female, in their 60s, had a lower income, and lived in southern Taiwan had a higher cost per patient (p

Pravastatin inhibits tumor growth through elevating the levels of apolipoprotein A1

Scipedia content — Mon, 15 May 2017 12:54:53 +0200

Statins are a class of drugs used to lower cholesterol levels, accompanying increased high-density lipoprotein (HDL) levels. Previous studies have suggested that statins can inhibit inflammation, and also reduce tumor proliferation. We therefore hypothesized that pravastatin, a member of the statins, mediating the inhibitory functions in tumor growth may be associated with the upregulated HDL constituent, apolipoprotein A1 (ApoA1). Pravastatin-induced inhibition in tumor proliferation in vitro and in xenografts was investigated. Reduced ApoA1 expressions were detected in the tumor regions in specimens from tumor patients as well in xenografts using Western Blotting. Moreover, ApoA1 was administered to inhibit tumor proliferation, and pravastatin was given to enhance the chemotherapeutic efficacy of doxorubicin (DOX). We found a significant statistical reduction of ApoA1 in the tumor regions of specimens from gastric cancer and colorectal cancer patients. MKN45 cells proliferation was inhibited by 18% under the growing medium containing pravastatin. ApoA1 levels were elevated in liver Clone 9 cells administered pravastatin, but not in MKN45 cells. In vitro studies revealed that ApoA1 can reduce MKN45 tumor proliferation. Moreover, the tumor volume was significantly reduced in in vivo xenografts after the administration of pravastatin. Combined treatments of pravastatin with DOX significantly minimized the size of tumors, leading to a better therapeutic efficacy. This study demonstrated that pravastatin elevated ApoA1, an HDL major constituent with anti-inflammatory characteristics, which displayed strong adversary associations with tumor developments and growth. Increasing the amounts of ApoA1 by pravastatin coupled with DOX may improve the therapeutic efficacy for cancer treatment.

Reticulocyte production index as a predictor of clinically significant anemia in chronic hepatitis C patients receiving pegylated interferon combination therapy

Scipedia content — Mon, 15 May 2017 12:54:47 +0200

This work was conducted to study the relationship of reticulocyte production index to clinically significant anemia in chronic hepatitis C patients receiving pegylated interferon combination therapy. A total of 69 chronic hepatitis C patients receiving pegylated interferon combination therapy were included. Clinically significant anemia was defined as a hemoglobin level of 60 years [odds ratio (OR), 2.94, 95% confidence interval (CI), 1.09–7.93], pretreatment hemoglobin level

Unexpected and unintentional fish bone ingestion causing acute abdomen and uncommon small intestinal perforation

Scipedia content — Mon, 15 May 2017 12:54:43 +0200

Perforation of the mesenteric small bowel is an uncommon cause of acute abdomen in the emergency department. Early diagnosis is difficult owing to unspecific clinical presentations. The most common causes of perforation are tumor, trauma, Crohns disease, ischemia, and foreign body ingestion. Currently, computed tomography (CT) is often the initial modality used to assess patients with acute abdomen, and the excellent anatomic details it provides, including segmental bowel wall thickening, mesenteric air bubbles, and fatty infiltration, may help the clinician to diagnose earlier and with greater ease. Here, we present a case of acute abdomen diagnosed as small bowel perforation due to unintentional fish bone ingestion using multidetector CT. The multiplanar reconstruction images from multidetector CT helped locate the perforation site before surgical intervention.

The clinical efficacy and safety of EUS-FNA for diagnosis of mediastinal and abdominal solid tumors – A single center experience

Scipedia content — Mon, 15 May 2017 12:54:36 +0200

Many tumors are small and located around the gastrointestinal (GI) tract, and they are difficult to obtain tissue from for pathological diagnosis by the guidance of conventional methods (sonography or computed tomography. The aim of this study was to analyze the efficacy and benefit of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in the clinical diagnosis of solid tumors in the mediastinum and abdomen. Data from 233 patients with solid tumors on or around the GI tract were reviewed. They had received successful EUS-FNA without on-site cytopathology study. The lesions were classified according to the anatomic location as pancreatic tumors (Group A, n = 91), mediastinal tumors (including lymph nodes) (Group B, n = 38), abdominal tumors (including lymph nodes) (Group C, n = 49), focal transmural thickening of the GI tract (Group D, n = 6), and submucosal tumors of the GI tract (Group E, n = 49). The accuracies of pathological diagnosis of malignancy were 79.2%, 76.9%, 93.2%, and 80% for Groups A–D, respectively. The overall accuracy for malignancy was 82.9%. For the submucosal tumors of the GI tract in Group E, FNA cytopathology provided evidence of specific diagnosis all were GI stromal tumor in 47% of the cases, 14% were diagnosed as suspicious (most were of a spindle cell tumor nature), and 39% were considered negative of tumor or non-diagnostic. There were three episodes (1.3%) of complication (GI bleeding, n = 1, septic fever, n = 1, gallbladder puncture, n = 1) which occurred among all patients in this study, and all of them were treated appropriately, with no occurrence of life-threatening events. EUS-FNA appears to be a very useful tool for obtaining tissue diagnosis for lesions that are inaccessible by the conventional methods and was shown to be a safe and effective technique in the hands of experienced operators. Pathological diagnosis can be obtained for the guidance of clinical management to avoid the more invasive ways, such as surgery or mediastinal scope.

Young man with chronic anemia

Scipedia content — Mon, 15 May 2017 12:54:30 +0200

Advanced hepatocellular carcinoma treated by a combination of sorafenib and radiotherapy

Scipedia content — Mon, 15 May 2017 12:54:24 +0200

Advanced hepatocellular carcinoma has a poor therapeutic outcome and treatment options are limited. Sorafenib, an orally active multikinase inhibitor, is the only systemic drug that has been shown to provide survival benefits in randomized control studies. However, the gains in survival are modest and new treatment strategies are needed. We report here the case of a patient with advanced hepatocellular carcinoma who had an impressive response to a combination of sorafenib and radiotherapy. The treatment was well tolerated with no unexpected toxicities. Post-treatment imaging showed a satisfactory partial response with regression of the tumor by more than 50%.

Early endoscopic finding of esophageal thermal injury after having spicy hot pot

Scipedia content — Mon, 15 May 2017 12:54:18 +0200

We herein present the case of a woman who had esophageal thermal injury after having a spicy hot pot. The patient came to us with complaints of odynophagia, dysphagia, and burning sensation at the throat and upper chest while eating or drinking for 1 day. An upper endoscopy was conducted 1 day after the onset of symptoms, which showed a linear, disrupted bullae-like lesion with a thin detached membrane. Our report depicts the early endoscopic finding of esophageal thermal injury following the ingestion of hot food. The finding is different from what has been often reported as the “candy-cane” appearance of esophageal injury, which results from the ingestion of hot liquid.

Analysis of ascitic fluid lactoferrin levels in the diagnosis of spontaneous bacterial peritonitis after systemic antibiotic treatment

Scipedia content — Mon, 15 May 2017 12:54:14 +0200

Spontaneous bacterial peritonitis (SBP) is one of the most frequent complications of liver cirrhosis. Ascitic fluid lactoferrin has been proved to be a good diagnostic tool for SBP. However, lactoferrin in ascites may be checked after antibiotic treatment in these patients. Our study aims to assess the utility of ascitic fluid lactoferrin levels for the diagnosis of SBP after antibiotic treatment. Twenty-two ascites samples were collected from patients with cirrhosis. Samples were examined for bacterial culture, lactoferrin concentration, and polymorphonuclear leukocyte count. Clinical symptoms and indications for ascitic paracentesis were obtained from medical records. The diagnosis of SBP was based on an elevated ascitic fluid polymorphonuclear leukocyte count of ≥250 cells/mm3 . Four (18.1%) samples fulfilled the diagnostic criteria for SBP. Three ascites samples showed a positive result for bacterial culture. Patients who received antibiotics for treatment of SBP constituted Group B (n = 9), whereas those who did not receive any antibiotics comprised Group A (n = 9). Lactoferrin concentration was significantly elevated (mean: 261.69 ± 145.5 ng/mL) in the three cases with a positive bacterial culture compared to those without SBP, in both Group A (mean: 19.64 ± 6.32 ng/mL, p = 0.002) and Group B (mean: 23.64 ± 9.53 ng/mL, p = 0.001). After systemic antibiotic treatment, elevated lactoferrin levels in the ascites of cirrhotic patients appear to be a promising predictor for the presence of SBP having positive ascitic bacterial culture.

Multipolar radiofrequency ablation with non-touch technique for hepatocellular carcinoma ≤ 3 cm: A preliminary report

Scipedia content — Mon, 15 May 2017 12:54:09 +0200

Conventional monopolar radiofrequency ablation (RFA) bears the risks of incomplete ablation and tumor seeding. This study aimed to evaluate the effectiveness and safety of multipolar RFA with non-touch technique for hepatocellular carcinoma (HCC) ≤ 3 cm. Fifteen cirrhotic patients (9 men, 6 women, age 51–83 years, mean 64.4 years, Child-Pugh score: A = 10 and B = 5) with 17 HCCs of ≤ 3 cm (mean: 26 mm), which were diagnosed based on typical radiologic findings were enrolled. Two or three Celon Prosurge Bipolar electrodes with 3-cm active tip were deployed with non-touch technique via percutaneous approach under ultrasound guidance. Complete ablation was achieved in all 17 lesions. This is defined as no enhanced part around the ablated index tumors according to dynamic computed tomography or magnetic resonance imaging at least 1 month after ablation. No local tumor progression was detected at follow-up (range, 3–21.5 months, mean, 10 months). No track seeding was observed. There was one distant recurrence 15.4 months after ablation. One patient had procedure-related biliary stricture and died of pneumonia 3.5 months after tumor ablation. Multipolar RFA with non-touch technique is an effective method to achieve complete tumor ablation and an adequate safety margin. This method has low complication rate and bears minimal risk of tumor seeding.

Delayed healing of gastric ulcer is associated with downregulation of connexin 32 in the gastric mucosa

Scipedia content — Mon, 15 May 2017 12:53:59 +0200

Most benign gastric ulcers are healed through suppression of gastric acid by a proton pump inhibitor (PPI). Despite prolonged use of a PPI, some gastric ulcers still do not heal. The primary goal of this study is to investigate the relationship between the expression of connexin 32 (Cx32), a major gap junction protein expressed in the gastric mucosa, and the healing response of gastric ulcers. Patients with endoscopically verified gastric ulcer were treated with a standard dose of PPI for 12 weeks. Histological studies were performed to exclude malignancy. In total, 10 patients having endoscopically verified gastric ulcers with delayed healing at the end of the PPI course were included in this study. The control group consisted of 11 patients with gastric ulcers that healed normally. The expression of Cx32 in the gastric mucosa of the ulcer margin was analyzed by immunoblotting. Patients with gastric ulcer showing delayed healing had significantly reduced Cx32 expression in the gastric mucosa compared with the patients in whom the ulcers healed normally (i.e., controls). Age, sex, presence of duodenal ulcers, location and size of gastric ulcer, ulcer staging, Helicobacter pylori infection, use of nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin, smoking, and alcohol consumption were similar in both the control and delayed healing groups. H. pylori infection, use of NSAIDs, smoking, and alcohol consumption all had no significant impacts on the expression of Cx32. Age and expression of Cx32 were not correlated. Downregulation of Cx32 in the gastric mucosa of the ulcer margin may predict delayed healing in patients with gastric ulcer following acid-suppression therapy.

Barretts esophagus and risk of esophageal adenocarcinoma: A retrospective analysis

Scipedia content — Mon, 15 May 2017 12:53:54 +0200

Barretts esophagus (BE) is the most common cause or precursor of esophageal adenocarcinoma (EAC), a condition with a poor prognosis. This study aimed to investigate the clinical characteristics and risk of EAC in patients with BE. From January 2001 to December 2012, a total of 425 patients with histologically proven BE were identified and analyzed retrospectively. Patients' personal data (smoking, alcohol consumption), underlying systemic disease data (diabetes mellitus and hypertension), endoscopic findings (hiatal hernia, peptic ulcer, endoscopically suspected esophageal metaplasia, severity of reflux esophagitis, rapid urease test), and pathological findings (degree of dysplasia, Helicobacter pylori infection) were collected for further analysis. In this retrospective study, 15 patients were diagnosed with EAC. Only one patient was found to have EAC during endoscopic surveillance for BE. The majority of patients (14/15 patients) suffered alarm symptoms and were diagnosed to have BE and EAC concurrently. Meanwhile, EAC is already relatively at an advanced stage. The mean age for diagnosis of EAC in a patient with BE was 67.67 ± 9.92 years old. All patients were male. From a total of 15 patients, 33.3% (5 patients) demonstrated erosive esophagitis under endoscopy and 60% (3 of 5 patients) of these were classified as Los Angeles grade C or D disease. Our study found that BE-associated EAC mostly occurred in older men. In the group with BE-associated EAC, the majority of patients were discovered due to alarm symptoms, at the same time as esophageal adenocarcinoma had already developed. Further prospective study is needed to stratify the risk of disease progression in BE patients.

Evolution of esophageal function testing in achalasia: Linking new technology to treatment outcome

Scipedia content — Mon, 15 May 2017 12:53:50 +0200

A rare presentation of clinically intractable hypertension: Pancreatic paraganglioma

Scipedia content — Mon, 15 May 2017 12:53:45 +0200

Paraganglioma is a rare extra-adrenal pheochromocytoma which originates from chromaffin cells within the ganglia of the sympathetic trunk and of the celiac, renal, suprarenal, and hypogastric plexuses. Pancreatic paragangliomas are rarer still. And even then, paragangliomas are mostly reported to be nonfunctional. We report a case of a 64-year-old woman with underlying disease of hypertension who presented with biliary colic. Contrast-enhanced computer tomography showed an enhancing mass in the uncinate process of the pancreas. Pylorus-sparing Whipple procedure was performed for complete tumor excision. Hypertensive crisis developed after Whipple, which improved after continuous intravenous nicardipine infusion. Pathology revealed a paraganglioma. A 24-h catecholamine urine test showed increased norepinephrine and vanillylmandelic acid level. Functional paraganglioma was diagnosed.

Recurrent abdominal pain after an episode of acute diverticulitis

Scipedia content — Mon, 15 May 2017 12:53:39 +0200

Endoscopic balloon-based radiofrequency ablation for long-segment early esophageal squamous cell neoplasia

Scipedia content — Mon, 15 May 2017 12:53:34 +0200

Esophageal cancer is a common and highly lethal disease. In the Asia-Pacific region, esophageal squamous cell neoplasias are the major forms of the disease. Recent advances in endoscopic therapy enable curative treatment of early esophageal squamous cell neoplasias, however, the technique is complicated and requires a high level of expertise, especially for those with long-segment lesions. Endoscopic radiofrequency ablation is a rapidly evolving treatment modality and has been shown to have good efficacy and safety for the treatment of dysplasia in cases of Barrett’s esophagus. Theoretically, it can also be used to treat squamous dysplasia. We report a case of a 48-year-old man with an 8-cm-long circumferential squamous high-grade dysplasia over the esophagus (from 21 cm to 29 cm below the incisor) that was treated successfully and safely with balloon-based radiofrequency ablation. The procedure took only around 30 minutes to complete. There were no major adverse events during and after the procedure. In addition, we examined the histology of the esophageal coagulum, which showed an extensive cauterization effect with focal dysplasia within the ablated epithelium. Follow-up endoscopy at 1 month, 3 months, and 6 months showed no residual lesion, and biopsies also confirmed complete remission.

Analgesic effect of premedication with meperidine in patients undergoing colonoscopy without sedation

Scipedia content — Mon, 15 May 2017 12:53:30 +0200

Colonoscopy is a standard and useful examination in the diagnosis of colorectal diseases, however, it usually causes pain to patients. Some patients receive narcotic drugs, e.g., meperidine, for pain relief if a colonoscopy is carried out without sedation. Whether the administration of such analgesic drugs to patients without sedation facilitates the performance of the colonoscopy or reduces pain remains to be elucidated. The aim of this study was to evaluate the analgesic effect of meperidine as premedication for patients undergoing a colonoscopy without sedation. A total of 217 patients (109 men, 108 women) undergoing a diagnostic colonoscopy without sedation were analyzed prospectively. The procedures were carried out by three experienced endoscopists in a medical center. The patients could opt to receive analgesic drugs, with 25 mg of meperidine being given intramuscularly prior to the procedure if requested by either the doctor or patient. The colonoscopic examination was performed by one person using the short-axis method. Questionnaires to evaluate abdominal pain during or after colonoscopy without sedation were collected and analyzed for patients who used meperidine as premedication (Group A) and for those who did not receive meperidine (Group B). Abdominal pain was evaluated using a visual analog scale from 0 to 10. The cecal intubation rate, total insertion time, and the patients willingness to receive another colonoscopy in the future if needed were also analyzed. In both groups, the cecal intubation rate was more than 99% with no significant difference between groups. The mean ± standard deviation insertion time was 7.14 ± 5.45 minutes in Group A and 6.24 ± 4.24 minutes in Group B (p = 0.309). The visual analog pain score was 3.54 ± 3.13 in Group A and 2.46 ± 2.75 in Group B (p = 0.009). After adjusting for age and sex, the pain score was 3.51 ± 3.21 in Group A (p = 0.055). Multivariate analysis showed that female sex and the individual endoscopist performing the colonoscopy were associated with abdominal pain during the examination. In our study, premedication with meperidine or no premedication was not associated with a reduction in abdominal pain during colonoscopy without sedation. The insertion time and cecal intubation rate showed no difference between patients with or without additional analgesic drugs prior to the procedure. However, as self-selection bias could not be ruled out, further randomized, placebo-controlled trials are needed to confirm our findings.

Clinical factors associated with the survival of patients with intrahepatic cholangiocarcinoma

Scipedia content — Mon, 15 May 2017 12:53:21 +0200

Intrahepatic cholangiocellular carcinoma (ICC) is an uncommon but lethal cancer. The aim of this study is to assess the factors affecting the survival of ICC patients and to evaluate the benefit of these factors when various therapeutic modalities are used. Between October 2007 and June 2012, 66 ICC cases among 2255 liver cancer patients were identified by pathology and divided into two groups: Group I (surgery group, n = 17) and Group II (nonsurgery group, n = 49). Group II was further divided into Group IIa (those receiving palliative treatment, n = 19) and Group IIb (no treatment received, n = 30). Factors affecting patient survival over the study period were assessed (3- and 6-month results were reported) and therapeutic benefits identified within each of the groups were evaluated. Of the 66 patients identified (male/female = 36/30), 10.6% (7/66) were in the early stages of illness. Overall, the mean patient survival duration was 3.50 ± 0.92 months (1.69–5.31 months). The mean survival duration of Group I patients was 10.50 ± 2.84 months (4.94–16.06 months). The mean survival duration of Group II patients was 3.50 ± 0.65 months (2.24–4.76 months) with Group IIa patients surviving on average 9.50 ± 3.27 months (3.10–15.90 months) and Group IIb patients surviving on average 1.50 ± 0.12 months (1.26–1.74 months). Better survival outcomes were observed in the groups receiving treatment, Group I and Group IIa, than in Group Iib, which did not receive treatment [9.50 ± 1.73 months (6.12–12.89 months) vs. 1.50 ± 0.12 months (1.26–1.74 months), p

IL28B polymorphism and early anemia predict the rapid null response in genotype-1 chronic hepatitis C with dual therapy

Scipedia content — Mon, 15 May 2017 12:53:15 +0200

Rapid null response (rNR), defined as less than one log decline of Hepatitis C virus (HCV-RNA) at Week 4 of treatment with pegylated interferon-α and ribavirin (PegIFN/RBV), is highly correlated with treatment failure in patients with chronic hepatitis C (CHC), genotype-1 (GT-1). In this study, we investigate the possible predictors of rNR. We retrospectively analyzed a cohort of 199 GT-1 CHC naive patients who had been treated with a dual therapy of PegIFN/RBV. Clinical parameters and genotypes of rs12979860, the single nucleotide polymorphisms (SNPs) of interleukin-28B (IL28B ) were analyzed for their relationship with rNR. Of the patients analyzed, 41.7% did not exhibit a rapid virological response (RVR). Only 13.1% of patients who experienced a rNR showed an RVR. The treatment failure rate was 36.2%. High baseline viral load (OR: 5.74, p = 0.028), nonrapid virological response (non-RVR, OR: 4.32, p = 0.004) and rNR (OR: 51.82, p