Chi-Chieh Yang

Prevalence and risk factors of nonalcoholic fatty liver disease in an adult population of Taiwan : Metabolic significance of nonalcoholic fatty liver disease in nonobese adults

Background The prevalence of nonalcoholic fatty liver disease (NAFLD) is rarely reported in Taiwan. Goals To determine the prevalence and risk factors of NAFLD in an adult population of Taiwan. Study The cross-sectional community study examined 3245 adults in a rural village of Taiwan. The diagnostic criteria for NAFLD included no excessive alcohol intake, no chronic viral hepatitis, no known etiologies of liver disease, and ultrasonography consistent with fatty liver. Results The prevalence of NAFLD was 11.5% (372/3245). The risk factors for NAFLD in the general population were male sex [odds ratio (OR), 1.44; 95% confidence interval (CI), 1.09-1.90], elevated alanine aminotransferase (ALT) (OR, 5.66; 95% CI, 3.99-8.01), obesity (OR, 7.21; 95% CI, 5.29-9.84), fasting plasma glucose ≥126 mg/dL (OR, 2.08; 95% CI, 1.41-3.05), total cholesterol ≥240 mg/dL (OR, 1.50; 95% CI, 1.06-2.13), triglyceride ≥150 mg/dL (OR, 1.76; 95% CI, 1.32-2.35), and hyperuricemia (OR, 1.53; 95% CI, 1.16-2.01). Age ≥65 years was inversely related to NAFLD (OR, 0.53; 95% CI, 0.36-0.77). The only NAFLD risk factors among nonobese subjects were age between 40 and 64 years (OR, 2.35; 95% CI, 1.34-4.11, P=0.003), elevated ALT (OR, 15.45; 95% CI, 8.21-29.09, P<0.001), and triglyceride ≥150 mg/dL (OR, 2.48; 95% CI, 1.42-4.32, P=0.001). In subjects with NAFLD, the prevalence of elevated ALT in the presence of each metabolic risk factor, such as obesity, fasting plasma glucose ≥126 mg/dL, total cholesterol ≥240 mg/dL, triglyceride ≥150 mg/dL, and hyperuricemia, did not differ from that of subjects with normal ALT levels. Conclusions NAFLD is closely associated with elevated ALT, obesity, diabetes mellitus, hypercholesterolemia, hypertriglyceridemia, and hyperuricemia. Among the metabolic disorders, only hypertriglyceridemia was related to NAFLD in nonobese subjects. Serum ALT level was not a good predictor of metabolic significance in subjects with NAFLD.

Long-term outcome of percutaneous transhepatic cholangioscopic lithotomy for hepatolithiasis

OBJECTIVES:Percutaneous transhepatic cholangioscopic lithotomy (PTCSL) for the treatment of hepatolithiasis is particularly suited for those patients who are poor surgical risks or who refuse surgery and those with previous biliary surgery or stones distributed in multiple segments. However, hepatolithiasis is characterized by high rates of treatment failure and recurrence. We examined the long-term results of 245 patients with hepatolithiasis treated by PTCSL.METHODS:This was a retrospective study of 245 patients who underwent PTCSL for hepatolithiasis; the patients were followed for 1–22 yr to evaluate the immediate and long-term results. Sonography was used to search for stone recurrence every year or whenever the patients presented symptoms suggestive of cholangitis. Cholangiography and/or CT were performed to verify recurrence.RESULTS:PTCSL achieved complete clearance of hepatolithiasis in 209 patients (85.3%); the rate of incomplete clearance was higher in patients with intrahepatic duct stricture (29/118, 24.6% vs 7/127, 5.5%; p = 0.002). The rate of major complications was 1.6% (4/245) and included liver laceration (n = 2), intra-abdominal abscess (n = 1), and disruption of the percutaneous transhepatic biliary drainage fistula (n = 1). The overall recurrence rate of hepatolithiasis and/or cholangitis was 63.2%. The absolute rate of stone recurrence was not significantly related to the presence of intrahepatic duct stricture (51/89, 56.2% vs 53/120, 44.4%; p = 0.08), although the median time to recurrence was less in those with stricture (11 vs 18 yr; p = 0.007). In the patients without intrahepatic duct stricture, the rate of complete stone clearance was not related to the presence of dilation (34/38, 89.5% vs 86/89, 96.6%; p = 0.196), but the recurrence rate was higher in those with dilation (20/34, 58.8% vs 33/86, 38.4%; p = 0.042). Among the 209 patients with a successful initial PTCSL, the incidence of recurrent cholangitis or cholangiocarcinoma was significantly higher in those with incompletely removed recurrent hepatolithiasis than in those without coexisting hepatolithiasis (44.3%, 27/61 vs 16.2%, 24/148; p < 0.001 and 6.6%, 4/61 vs 0.7%, 1/148; p = 0.026).CONCLUSIONS:PTCSL is a relatively safe and effective procedure for treating hepatolithiasis. Long-term follow-up is required because the overall recurrence rate of hepatolithiasis and/or cholangitis is high. The rate of complete stone clearance and the median time to stone recurrence are less in the presence of stricture, but the absolute rate of stone recurrence is not significantly related to stricture. In the absence of stricture, the rate of stone recurrence is higher in patients with dilated intrahepatic duct. Complete stone clearance is necessary, because the incidence of recurrent cholangitis or cholangiocarcinoma is higher in patients with incomplete clearance of recurrent hepatolithiasis.

Prevalence and etiology of elevated serum alanine aminotransferase level in an adult population in Taiwan

Background:  The prevalence and etiologies of elevated alanine aminotransferase (ALT) have geographic variations and they are rarely reported in Taiwan. Through a population‐based screening study, the prevalence and etiologies of elevated ALT in an adult population of Taiwan were assessed.

Prevalence and risk factors of gallstone disease in an adult population of Taiwan: an epidemiological survey

Background and Aims:  The aim of this study was to determine the prevalence and risk factors of gallstone disease (GSD) in an adult population of Taiwan through a population‐based screening study.

Double-balloon enteroscopy application in biliary tract disease—its therapeutic and diagnostic functions

BACKGROUND On occasion, it is impossible to perform ERCP with a traditional duodenoscope in patients who have had a Billroth II gastrectomy or hepatojejunostomy, and who now have biliary tract problems. Repeat surgery is not a suitable course of action in these patients. Therefore, finding alternative modalities to resolve these obstructions is of great importance. OBJECTIVE To report successful endoscopic examination and treatment of difficult biliary obstructions by using double-balloon enteroscopy. PATIENTS Five patients. DESIGN Cases series. INTERVENTION Double-balloon enteroscopy (DBE) for biliary tract examination and treatment. RESULTS We report on 5 patients who underwent Billroth II gastrectomy or biliary tract Roux-en-Y surgery and who later had biliary tract obstruction from various causes. We were unable to perform ERCP with traditional duodenoscopy but successfully completed ERCP with DBE. DBE was originally designed to examine the small intestine. The successful biliary tract cannulation rate when using DBE is lower than with duodenoscope. We performed ERCP by using DBE a total of 5 times, with a successful biliary cannulation rate of 60%. We performed a special-method papillotomy in 2 patients. This method entailed inserting an electric sphincterotome through the percutaneous transhepatic cholangiography and drainage (PTCD) route after performing DBE intubation to the ampulla of Vater. We then successfully completed a papillotomy with an electric sphincterotome under DBE guidance. CONCLUSIONS DBE appears to be a promising alternative in the examination and treatment of biliary tract disease in patients after GI operations such as Billroth II gastrectomy and choledochojejunostomy.

Preoperative staging of gastric cancer by endoscopic ultrasound: the prognostic usefulness of ascites detected by endoscopic ultrasound.

Background Endoscopic ultrasound (EUS) is the standard modality in local preoperative staging of gastric cancers and is reputedly able to detect ascites. However, the association between ascites detected by EUS and local tumor staging, peritoneal carcinomatosis, or survival after surgery is not well documented. Goals To assess the accuracy, sensitivity, and specificity of EUS in the preoperative staging and detection of ascites in gastric cancers. We also try to correlate ascites with histologic staging, tumor differentiation, and survival rate of gastric carcinoma after surgery. Study The retrospective analysis was made in 57 consecutive patients with histologically confirmed gastric adenocarcinomas that underwent EUS before surgery. The accuracy of EUS was compared with the final surgical-pathologic findings. We estimated the prognostic usefulness by analyzing the clinicopathologic features of gastric adenocarcinomas and following up their survival rates. Results The overall T staging was 88% accurate by EUS. The accuracy for T staging was as follows: T1, 100%; T2, 33%; T3, 93%; and T4, 100%. About 50% of T2 cases were overstaged. The overall accuracy, sensitivity, and specificity of detecting lymph node metastasis by EUS were 79%, 79%, and 80%, respectively. One of the seven T1 cancers had regional lymph node metastasis, and it was missed by EUS, although the T classification was precisely staged based on finding submucosal invasion. A total of 22 patients (39%) had ascites detected by EUS; both the sensitivity and specificity of EUS in demonstrating ascites were 100% in our study. Ascites was significantly correlated with the depth of tumor invasion (p = 0.036), lymph node metastasis (p = 0.008), and poor cellular differentiation (p = 0.007), but it was not significantly correlated with macroscopic peritoneal carcinomatosis. The survival rate after surgical treatment was poor in those with gastric cancers with lymph node metastasis, ascites, or poorly differentiated tumors (p < 0.05). However, multivariate analysis showed that lymph node metastasis was the only significant prognostic predictor (p = 0.004). Conclusions Endoscopic ultrasound is a valuable diagnostic tool in the local staging of gastric cancers and demonstration of ascites. Although the surgical treatment of gastric cancers with lymph node metastasis, ascites, or poor differentiation had poorer survival rate, only lymph node metastasis was proved to be a significant prognostic predictor in multivariate analysis.

Reappraisal of endosonography of ampullary tumors: Correlation with transabdominal sonography, CT, and MRI

To reappraise the accuracy of transabdominal sonography (US), CT, MRI, and endosonography (EUS) in the diagnosis and staging of ampullary tumors.

Pancreatic tuberculosis with obstructive jaundice--a case report.

Isolated pancreatic tuberculosis (TB) is very rare and its treatment somewhat controversial. We report a case of pancreatic TB diagnosed as pancreatic carcinoma. An 82-yr-old man presented with right upper abdominal pain and obstructive jaundice, without fever or weight loss. Ultrasonography, computed tomography, and endoscopic retrograde cholangiopancreatography showed a mass lesion in the pancreatic head, which caused stricturing of the distal common bile duct and pancreatic duct in the head of the gland. As malignancy was suspected, he underwent a Whipple procedure (pancreaticoduodenectomy). Histological examination of the resection specimen disclosed typical features of tuberculosis in the pancreatic head, lymph nodes, and at the ampulla of Vater. The rest of the abdominal cavity was unremarkable. After receiving antimicrobial therapy for tuberculosis for 6 months, he remains well, without jaundice or a recurrent mass visible by ultrasound.

Reappraisal of percutaneous transhepatic cholangioscopic lithotomy for primary hepatolithiasis

BackgroundA review of the literature pertaining to percutaneous transhepatic cholangioscopic lithotomy (PTCSL) showed that more than 50% of reported patients had undergone earlier biliary surgery.MethodsA retrospective study investigated 74 patients undergoing initial PTCSL for hepatolithiasis who had undergone no prior biliary surgery or manipulation. The patients were followed for 1 to 23 years after PTCSL for effective evaluation of the procedure outcome.ResultsComplete clearance of hepatolithiasis was achieved for 61 (82%) patients. The incomplete clearance rate was higher for patients with intrahepatic duct stricture (11/37 [30%] vs 2/37 [5%]; p < 0.05), although it showed no relation to the actual lobar distribution of hepatolithiasis (left: 7/41 [17%] vs right: 2/11 [18%] vs bilateral: 4/22 [18%]; p < 0.05). The recurrence rate for hepatolithiasis also was higher for patients with intrahepatic duct stricture (18/26 [69%] vs 13/35 [37%]; p < 0.05), but the recurrence rate showed no relation to the lobar distribution of hepatolithiasis (left: 18/34 [53%] vs right: 4/9 [44%] vs bilateral: 9/18 [50%] p > 0.05) or the presence of gallbladder stones (5/12 [42%] vs 26/49 [53%]; p > 0.05). Patients showing the coexistence of retained or recurrent hepatolithiasis demonstrated a higher incidence of recurrent cholangitis (57% [13/23] vs 14% [7/51]; p < 0.01) or cholangiocarcinoma (17% [4/23]) vs 0% [0/51]; p < 0.01).ConclusionsThe findings show that PTCSL is effective for treating primary hepatolithiasis, and that complete stone clearance is mandatory to diminish the sequelae of hepatolithiasis. Intrahepatic duct stricture was the main factor contributing to incomplete clearance and stone recurrence.

Relation of hepatolithiasis to helminthic infestation

Background and Aim:  The relation of helminthic infestation to hepatolithiasis is a subject of dispute. This case–control study was undertaken to evaluate the prevalence of helminthiasis in hepatolithiasis patients and to compare the clinicopathological features of hepatolithiasis between patients with and without helminthiasis.