Chi-Liang Cheng

Caustic ingestion in adults: The role of endoscopic classification in predicting outcome

BackgroundThe ingestion of caustic substances induces an extensive spectrum of injuries to the aerodigestive tract which include extensive necrosis and perforation of the esophagus and stomach. The gold standard of safely assessing depth, extent of injury, and appropriate therapeutic regimen is esophagogastroduodenoscopy (EGD). The objective of this study was to report our clinical experience and to evaluate the role of a 6-point EGD classification system of injury in predicting outcomes in adult patients diagnosed with caustic agent ingestion.MethodsThe study was a retrospective medical chart review from 273 patients admitted to the Chang Gung Memorial Hospital in Tao-Yuan, Taiwan between June 1999 and July 2006 for treatment of caustic ingestion. The patients underwent EGD within 24 hours of admission and mucosal damage was graded using Zagars modified endoscopic classification scheme. After treatment, patients were followed in the outpatient clinic for a minimum of 6 months.ResultsA total of 273 patients were included for analysis. Grade 3b injury was the most common caustic injury (n = 82, 30.03%), followed by grade 2b injuries (n = 62, 22.71%). Stricture was the most common complication (n = 66, 24.18%), followed by aspiration pneumonia (n = 31, 11.36%), and respiratory failure (n = 21, 7.69%). Compared to grade 3a mucosal injury, grade 3b mucosal injuries were at greater risk of prolonged hospital stay (odds ratio [OR]: 2.44; 95% confidence interval [CI]: 1.25–4.80), ICU admission (OR: 10.82; 95% CI: 2.05–200.39), and gastrointestinal (OR: 4.15; 95% CI: 1.55–13.29) and systemic complications (OR: 4.07; 95% CI: 1.81–14.07).ConclusionIn patients with caustic ingestion, EGD should be performed within 12 to 24 hours and categorized according to a 6-point scale. Patients with grade 3b burns identified on endoscopy have high rates of morbidity. The 6-point scale is useful for predicting immediate and long-term complications, and guiding appropriate therapy.

Endoscopic management of Dieulafoy lesions in acute nonvariceal upper gastrointestinal bleeding

Dieulafoy lesion is an unusual but important cause of upper gastrointestinal bleeding. The study retrospectively reviewed 29 patients (2.1%) with Dieulafoy lesions of 1393 acute nonvariceal upper gastrointestinal bleeding episodes from October 1999 to May 2001. Nineteen patients (66%) were male and the median age was 62 years (range, 19 to 86 years). Two patients underwent emergent surgery after endoscopic diagnosis. The other patients were allocated to four therapeutic endoscopic groups: group I, epinephrine injection (11 patients); group II, epinephrine injection plus heater probe coagulation (10 patients); group III, histoacryl injection (4 patients); and group IV, hemoclipping (2 patients). Initial treatment failure ocurred in three patients (all in group I) and they received surgery, hemoclipping, or band ligation as salvage therapy, respectively. Among those who achieved initial hemostasis, recurrent bleeding developed in two patients (all in group I) and was successfully controlled by endoscopic injection plus thermal therapy. No complication was noted after endoscopic treatment. Group II had a significantly higher successful hemostasis rate than group I (100 vs 54%; P = 0.02). One patient in the therapeutic endoscopy groups died during admission, for a mortality rate of 3.7%. Patients were followed up from 6 to 36 months and no further bleeding was noted. The results suggest that epinephrine injection plus heater probe coagulation was significantly superior to epinephrine injection alone in achieving hemostasis. Histoacryl injection, hemoclipping, and endoscopic band ligation were safe and effective alternate therapies.

Endoscopic Diagnosis of Helicobacter pylori Infection by Rapid Urease Test in Bleeding Peptic Ulcers : A Prospective Case-Control Study

Goal To assess the efficacy of rapid urease test (RUT) in patients with bleeding ulcers, as well as the effects of visible blood in the stomach and short-term (<24 h) use of standard-dose proton pump inhibitor (PPI) on RUT sensitivity. Background The sensitivity of RUT in the diagnosis of Helicobacter pylori in upper gastrointestinal bleeding has been reported with conflicting results. Study This was a prospective case-control study evaluating 324 consecutive patients with bleeding peptic ulcers (study group) and 164 with uncomplicated ulcers (control group). The presence of H. pylori infection was determined by both RUT and histology. Prevalence of H. pylori infection and the RUT sensitivity in diagnosing the bacteria between study and control groups were conducted. Results The prevalence of H. pylori infection in those with bleeding ulcers was significantly lower than that of controls (53.7% vs. 65.2%, P=0.015). The false-negative rate of RUT in the study group was significantly greater than that of the control group (16.7% vs. 5.6%, P=0.006), whereas the sensitivity rates in the study group with or without gastric blood were significantly lower than those of the controls (79.6% vs. 94.4%, P=0.005; 84.8% vs. 94.4%, P=0.019). There was no significant difference in RUT sensitivity between study group with or without visible gastric blood (P=0.41). The RUT sensitivity rate was also not significantly different between those treated with PPI and those without in patients with bleeding ulcers (82.7% vs. 85.7%, P=0.67). Conclusions This study shows that the sensitivity of RUT in patients with bleeding ulcers is reduced. The presence of blood in the stomach and the short-term use of standard-dose PPI do not affect the RUT sensitivity in bleeding ulcers.

Outcomes of bleeding peptic ulcers: a prospective study.

Background and Aim:  Bleeding peptic ulcers can be due to Helicobacter pylori (H. pylori) infection, use of non‐steroidal anti‐inflammatory drugs (NSAIDs), or idiopathic causes. The aim of this prospective study was to identify the clinical outcomes of bleeding peptic ulcers related to different causes.

Impact of Bowel Preparation with Low-Volume (2-Liter) and Intermediate-Volume (3-Liter) Polyethylene Glycol on Colonoscopy Quality: A Prospective Observational Study.

Background/Aims: Two-liter polyethylene glycol (PEG) is the most commonly used bowel-cleansing regimen in Taiwan, but its efficacy is unsatisfactory. The aim of this study was to compare 2-liter and 3-liter PEG in terms of their impact on colonoscopy quality among an average-risk population. Methods: Two-liter PEG was provided between August 2012 and May 2013, while 3-liter PEG was provided between June 2013 and March 2014. A split-dose regimen was provided for morning colonoscopy and a same-day regimen was provided for afternoon colonoscopy. The level of bowel cleansing was prospectively scored. Results: A total of 407 consecutive subjects completed the 2-liter regimen, and another 407 consecutive subjects completed the 3-liter regimen. The 3-liter group had a significantly higher rate of excellent or good preparations, equivalent to a Boston bowel preparation scale of ≥7, than the 2-liter group (90 vs. 73%, p < 0.0001). More subjects in the 3-liter preparation group compared with the 2-liter group had overall adenoma (70 vs. 54%, p < 0.0001), proximal adenoma (47 vs. 35%, p = 0.0006), sessile serrated adenoma (28 vs. 6%, p < 0.0001), and advanced adenoma (21 vs. 9%, p < 0.0001). Conclusions: Three-liter PEG provided better cleansing quality and higher adenoma detection rate than 2-liter PEG.

Residual Gastric Volume After Bowel Preparation With Polyethylene Glycol for Elective Colonoscopy: A Prospective Observational Study

Goal: To examine the residual gastric volume (RGV) in colonoscopy after bowel preparations with 3-L polyethylene glycol (PEG). Background: Obstacles to high-volume bowel preparation by anesthesia providers resulting from concerns over aspiration risk are common during colonoscopy. Study: Prospective measurements of RGV were performed in patients undergoing esophagogastroduodenoscopy (EGD) and morning colonoscopy with split-dose PEG preparation, patients undergoing EGD and afternoon colonoscopy with same-day PEG preparation, and patients undergoing EGD alone under moderate conscious sedation. Colonoscopy patients were allowed to ingest clear liquids until 2 hours before the procedure. Patients undergoing EGD alone were instructed to eat/drink nothing after midnight. Results: There were 860 evaluated patients, including 330 in the split-dose preparation group, 100 in the same-day preparation group, and 430 in the EGD-only group. Baseline demographics and disease/medication factors were similar. The mean RGV in patients receiving the same-day preparation (35.4 mL or 0.56 mL/kg) was significantly higher than that in patients receiving the split-dose preparation (28.5 mL or 0.45 mL/kg) and in patients undergoing EGD alone (22.8 mL or 0.36 mL/kg) (P=0.023 and P<0.0001, respectively). Within the bowel-preparation groups, patients with fasting times of 2 to 3 hours had similar RGV compared with patients who had fasting times >3 hours. The shape of the distribution and the range of RGV among the 3 study groups were similar. No aspiration occurred in any group. Conclusions: PEG bowel preparations increase RGV mildly, but seem to have no clinical significance. These results support the current fasting guidelines for colonoscopy.

Paired comparison of procedural sequence in same-day bidirectional endoscopy with moderate sedation and carbon dioxide insufflation: A prospective observational study

Background/Aims: Same-day bidirectional endoscopy (BDE) is a commonly performed procedure, but the optimal sequence of the procedure with carbon dioxide insufflation is not well established. In this study, we investigated the optimal sequence for same-day BDE without polypectomy under moderate sedation and carbon dioxide insufflation in terms of sedation doses and colonoscopy performance. Patients and Methods: We performed a prospective observational study of 63 asymptomatic patients who were admitted for physical check-ups. A colonoscopy-esophagogastroduodenoscopy (EGD) examination was performed first and then an EGD-colonoscopy examination was performed within 1.5 years. Results: The total procedure time, procedure complexity, bowel preparation quality, cecal intubation time, colon polyp detection rate, and adverse events were similar between the two study groups. The total doses of fentanyl and midazolam were significantly higher for the colonoscopy-EGD group than that for the EGD-colonoscopy group (70.8 ± 9.6 μg vs. 56.6 ± 9.2 μg and 6.1 ± 1.3 mg vs. 4.6 ± 1.1 mg, P < 0.0001 and P < 0.0001, respectively). The recovery time to discharge was significantly longer for the colonoscopy-EGD group compared to the EGD-colonoscopy group (38.5 ± 3.9 min vs. 31.9 ± 3.2 min, P < 0.001, respectively). Conclusions: EGD-colonoscopy is the optimal sequence for same-day BDE. In this order, the procedures are better tolerated, the sedation doses are reduced, and the recovery time is shorter.

Optimal procedural sequence for same-day bidirectional endoscopy with moderate sedation: A prospective randomized study

Same‐day bidirectional endoscopy (BDE) is a commonly performed procedure, but the optimal sequence for the procedure with moderate conscious sedation is not well established. This study investigated the optimal sequence for same‐day BDE under moderate conscious sedation and carbon dioxide insufflation in terms of sedation doses, patient discomfort, and colonoscopy performance.