Chen-Ming Hsu

Comparative Study of Conventional Colonoscopy, Chromoendoscopy, and Narrow-Band Imaging Systems in Differential Diagnosis of Neoplastic and Nonneoplastic Colonic Polyps

AIM:To identify the feasibility of the narrow-band imaging (NBI) method compared with that of conventional colonoscopy and chromoendoscopy for distinguishing neoplastic and nonneoplastic colonic polyps.METHOD:This study enrolled consecutive patients who underwent colonoscopy using a conventional colonoscope between January and February 2006 at Chang-Gung Memorial Hospital, Linkou Medical Center, Taiwan. These 78 patients had 110 colorectal polyps. During the procedure, conventional colonoscopy first detected lesions, and then the NBI system was used to examine the capillary networks. Thereafter indigo carmine (0.2%) was sprayed directly on the mucosa surface prior to evaluating the crypts using a conventional colonoscope. The pit patterns were characterized using the classification system proposed by Kudo. Finally, a polypectomy or biopsy was performed for histological diagnosis.RESULTS:Of the 110 colorectal polyps, 65 were adenomas, 40 were hyperplastic polyps, and five were adenocarcinomas. The NBI system and pit patterns for all lesions were analyzed. For differential diagnosis of neoplastic (adenoma and adenocarcinoma) and nonneoplastic (hyperplastic) polyps, the sensitivity of the conventional colonoscope for detecting neoplastic polyps was 82.9%, specificity was 80.0% and diagnostic accuracy was 81.8%, significantly lower than those achieved with the NBI system (sensitivity 95.7%, specificity 87.5%, accuracy 92.7%) and chromoendoscopy (sensitivity 95.7%, specificity 87.5%, accuracy 92.7%). Therefore, no significant difference existed between the NBI system and chromoendoscopy during differential diagnosis of neoplastic and nonneoplastic polyps.CONCLUSION:The NBI system identified morphological details that correlate well with polyp histology by chromoendoscopy.

Magnifying endoscopy with indigo carmine contrast for differential diagnosis of neoplastic and nonneoplastic colonic polyps.

This study describes the feasibility of magnifying colonoscopy with indigo carmine dye contrast to distinguish neoplastic and nonneoplastic colonic polyps. This study sampled consecutive patients undergoing colonoscopy using an Olympus CF240ZI from January to October 2000 at Chang-Gung Memorial Hospital, Lin-Kou Medical Center. This study analyzed a total of 270 polyps. Indigo carmine (0.2%) was sprayed directly on the mucosa surface before observing the crypts using a magnifying colonoscope (1.5×–100×). The pit patterns were described using the classification proposed by Kudo. Finally, polypectomy or biopsy was performed for histological diagnosis. The study identified 155 adenomas, 99 hyperplastic polyps, 9 adenocarcinomas, and 7 other nonneoplastic lesions (harmatoma, inflammatory polyps, and mucosal tag). The pit pattern was analyzed for all lesions. Further classification into neoplastic (adenoma and adenocarcinoma) and nonneoplastic (hyperplastic and others) polyps revealed 156 neoplastic and 14 nonneoplastic polyps among the type III to type V pits and 92 nonneoplastic and 8 neoplastic polyps among the type I and II pits. The sensitivity of type III to type V pits in detecting neoplastic polyps was 95.1%, with a specificity of 86.8% and diagnostic accuracy of 91.9%. The positive likelihood ratio was 7.3, and the negative likelihood ratio was 0.06. Magnifying colonoscopy with indigo carmine dye contrast provides morphological detail that correlates well with polyp histology. Small flat lesions with typical type II pit pattern should have minimal neoplastic risk, thus endoscopic resection is not necessary.

Prospective cohort study comparing sequential organ failure assessment and acute physiology, age, chronic health evaluation III scoring systems for hospital mortality prediction in critically ill cirrhotic patients

The aim of the study was to evaluate the usefulness of sequential organ failure assessment (SOFA) and acute physiology, age, chronic health evaluation III (APACHE III) scoring systems obtained on the first day of intensive care unit (ICU) admission in predicting hospital mortality in critically ill cirrhotic patients. The study enrolled 102 cirrhotic patients consecutively admitted to ICU during a 1‐year period. Twenty‐five demographic, clinical and laboratory variables were analysed as predicators of survival. Information considered necessary to calculate the Child–Pugh, SOFA and APACHE III scores on the first day of ICU admission was also gathered. Overall hospital mortality was 68.6%. Multiple logistic regression analysis revealed that mean arterial pressure, SOFA and APACHE III scores were significantly related to prognosis. Goodness‐of‐fit was good for the SOFA and APACHE III models. Both predictive models displayed a similar degree of the best Youden index (0.68) and overall correctness (84%) of prediction. The SOFA and APACHE III models displayed good areas under the receiver–operating characteristic curve (0.917 ± 0.028 and 0.912 ± 0.029, respectively). Finally, a strong and significant positive correlation exists between SOFA and APACHE III scores for individual patients (r2 = 0.628, p < 0.001). This investigation confirms the grave prognosis for cirrhotic patients admitted to ICU. Both SOFA and APACHE III scores are excellent tools to predict the hospital mortality in critically ill cirrhotic patients. The overall predictive accuracy of SOFA and APACHE III is superior to that of Child–Pugh system. The role of these scoring systems in describing the dynamic aspects of clinical courses and allocating ICU resources needs to be clarified.

Endoscopic Mucosal Resection for Colonic Non-polypoid Neoplasms

BACKGROUND:Colonic neoplastic lesions can be classified morphologically into polypoid and non-polypoid types. Non-polypoid lesions have a higher malignant potential than polypoid lesions. Removing these lesions and obtaining integral specimen for histopathology evaluation during colonoscopy examination is an important task. Endoscopic mucosal resection (EMR) is an alternative to surgery for removing of non-polypoid lesions of the GI tract. This study assessed the safety, efficacy, and clinical outcomes of EMR.PATIENTS AND METHODS:From October 2000 to October 2003 during the routine colonoscopy performed at one medical center, identified 152 non-polypoid colonic neoplasms in 149 patients (92 males, 57 females) were found. The mean patient age was 57.8 ± 15.5 yr (range 32–80 yr). EMR was performed for lesions suspected of being neoplastic tumors via magnification colonoscopy with the indigo carmine dye spray method. The lesions were removed via EMR with pure cutting current after which hemoclips were applied to the resected wounds.RESULTS:The study identified 40 flat type lesions, 106 lateral spreading tumors, and 6 depressed lesions that were completely resected. The mean size of lesions was 19.4 ± 10.3 mm (range 6–60 mm). Histological findings were 4 adenocarcinomas, 59 with high-grade adenoma/dysplasia, and 89 with low-grade adenoma/dysplasia. Two patients experienced bleeding immediately following EMR, while adequate hemostasis was achieved using hemoclips. Neither delayed bleeding nor perforation developed following EMR.CONCLUSION:EMR by using pure cutting current and hemoclip is a useful method for obtaining integral specimen for accurate pathologic assessment. This method provides a safe and minimally invasive technique managing of colonic non-polypoid lesions.

The outcome assessment of double-balloon enteroscopy for diagnosing and managing patients with obscure gastrointestinal bleeding

Diagnosing and treating patients with obscure gastrointestinal bleeding is clinically challenging. Most lesions responsible for the origin of obscure gastrointestinal bleeding are located in the small bowel. Double-balloon enteroscopy is a novel method for exploring the small intestine and has significant therapeutic potential. This study evaluated the value of double-balloon enteroscopy in diagnosing and managing obscure gastrointestinal bleeding. From October 2003 to January 2006, a total of 20 patients (6 men, 14 women; mean age, 55.2 years old) with obscure gastrointestinal bleeding (18 obscure overt bleeding, 2 obscure occult bleeding) were investigated by double-balloon enteroscopy. A total of 29 procedures (15 via oral approach and 14 via rectal approach) were performed. The diagnostic yield, endoscopic therapeutic procedures, complications, and outcome were then assessed.Small bowel lesions potentially responsible for the bleeding were identified in 15 (75%) of 20 patients, including 9 angiodysplasias, 2 gastrointestinal stromal tumors (GISTs), 2 ulcers, 1 jejunal granulation polyp, and 1 Peutz-Jeghers polyposis. Endoscopic treatments including heater probe coagulation, polypectomy, and endoscopic mucosal resection were performed in 11 patients. Two patients with GISTs received surgical intervention. Two patients with angiodysplasias that endoscopic treatment failed underwent laparoscopic resections following tattooing. There were no complications and the procedures were tolerated well. Among the 15 patients who had a lesion identified with subsequent treatment, rebleeding occurred in 3 (20%) patients with angiodysplasias. Of the five patients in whom no definite lesion was detected, rebleeding developed in four (80%). For patients with an identified lesion that was further treated, the rebleeding rate was lower than for those with “persistent” obscure gastrointestinal bleeding (P=0.031). We conclude that double-balloon enteroscopy offers a safe and effective method for diagnosing and managing patients with obscure gastrointestinal bleeding.

Factors that influence cecal intubation rate during colonoscopy in deeply sedated patients.

Background and Aim:  The technical performance of colonoscopy performed in deeply sedated patients differs from that performed without sedation or under minimal to moderate sedation. The aim of this study is to evaluate the factors affecting cecal intubation during colonoscopy performed under deep sedation.

Liver injury is associated with enhanced regulatory T-cell activity in patients with chronic hepatitis B

Summary.  Chronic hepatitis B virus (HBV) infection is associated with impairment of HBV‐specific immune responses. Recently, it has been shown that regulatory T (Treg) cells downregulate HBV‐specific immune responses but their role in chronic hepatitis B is still controversial. We hypothesized that liver injury enhances the influence of Treg cells on HBV‐specific immune responses. The frequency of Treg cell and the in vitro expansion of HBV‐specific CD8+ T cell detected by the tetramer method were investigated in 79 patients with chronic hepatitis B. Thirty‐three healthy volunteers were enrolled to measure the frequency of Treg cell as controls. The results showed that in chronic hepatitis B cases, the frequency of Treg cells in peripheral blood was significantly higher than that in normal volunteers. The higher level of serum transaminase was associated with higher frequency of Treg cells, which both had a linear correlation relationship. HBV‐DNA level, HBe status, age and sex had no statistical association with Treg cell frequency. Furthermore, in patients with higher serum transaminase levels, the expansion of HBV‐specific CD8+ T cells was higher after removal of Treg cells when compared with patients with lower serum transaminase levels. In conclusion, our data indicate a significant association between serum transaminase level and frequency/activity of Treg cells. Based on this observation, we propose that liver‐injury enhances Treg cell frequency/activity in chronic hepatitis B patients.

Double Balloon Enteroscopy–The Last Blind-Point of the Gastrointestinal Tract

Technical challenges have obstructed the diagnosis and treatment of small intestine disease. An innovative form of enteroscopy—the double balloon method—permits visualization of the complete small intestine, to-and-fro examination of an area of interest, and biopsy and endoscopic procedures which are safer, faster, and less painful than earlier methods. From October 2003 to May 2004, a total of 10 patients with obscure gastrointestinal bleeding received 12 enteroscopic examinations, 8 per oral and 4 per rectal examinations, while 2 patients received per oral enteroscopy first and further per rectal procedures 2 days later. Two cases with intestinal submucosal tumors were discovered by per oral enteroscopy, one with a 5-cm SMT with reddish mucosa at the jejunum and another with a 4-cm SMT and surface ulceration, in which the biopsy showed GIST. Both patients received an operation later. Four patients were found to have intestinal angiodysplasia in jejunum(per oral) and one in ileum (per rectal), and after local therapy bleeding stopped. Multiple angiodysplasias were observed in a patient who was operated on for active bleeding from the ileum after Indian ink tattooing. The two patients who received per oral and per rectal procedures did not display definite small intestinal lesions. All patients underwent the procedures satisfactorily without any complications, and the examination times varied from 90 to 360 min. Double balloon enteroscopy permits deep insertion of an endoscope into the small intestine without excessive stretching of the intestinal tract. This method can use either an oral or an anal approach. To-and-fro observation of almost the complete small intestine is possible, as are interventions.

Association of endoscopic ultrasonographic parameters and gastrointestinal stromal tumors (GISTs): can endoscopic ultrasonography be used to screen gastric GISTs for potential malignancy?

ABSTRACT Background: Previous research shows that only 10–30% of gastrointestinal stromal tumors (GISTs) are malignant. Nonetheless, some reports suggest that all of them have some degree of potential for malignancy. Endoscopic ultrasonography (EUS) is a useful technique for differentiation of subepithelial lesions in the gastrointestinal tract. We explored EUS characteristics that might predict the malignancy potential of GISTs. Methods: In this retrospective review of the medical records from 1999 through 2007, patients who had gastric stromal tumors diagnosed prior to surgery using EUS were enrolled. The EUS images, procedure records and tissue histopathology were reviewed. All patients were positive for C-kit. Results: Of the 110 patients enrolled, 57 were males, and 53 were females. Most (67%) of the GISTs were located in the gastric body. The lesion size ranged from 6.3 to 150 mm (mean ± SD: 39.73 ± 22.49 mm). The high-risk GIST group had 19 (17.3%) patients, the intermediate-risk group had 12 (10.9%) patients and the low/very low-risk group had 79 (71.8%) patients. Thirty patients had cystic lesions (27.3%), while six patients had calcification in the lesion (5.5%). Additionally, 27 patients (24.5%) had surface ulceration visible on endoscopy. GISTs at high risk for malignancy were highly associated with lesion size (p<0.0001), cystic change (p=0.015) and surface ulceration (p=0.036) but not with calcification (p=0.667). We also found that mitosis was associated with lesion size (p<0.0001) rather than other parameters. Age was not predictive of malignancy potential (p=0.316). However, tumor size is the only one independent risk factor for malignancy (p ≤ 0.0001). Conclusions: The preliminary results show that large gastric GISTs with cystic change and surface ulceration may associate with a risk of malignancy, warranting more aggressive management. Nevertheless, the tumor size is more important than other factors.

Angiodysplasia and bleeding in the small intestine treated by balloon-assisted enteroscopy

This study aimed to evaluate the outcomes in patients undergoing balloon‐assisted enteroscopy (BAE) with heat probe or argon plasma coagulation and to identify risk factors for recurrent bleeding.