Chia-Hsien Wu

Refeeding syndrome in Southeastern Taiwan: Our experience with 11 cases

AIM To present our experience with refeeding syndrome in southeastern Taiwan. METHODS We conducted a retrospective study during a 2-year period at the Mackay Memorial Hospital, Taitung Branch. We enrolled patients with very little or no nutrition intake for more than 10 d, a high risk group of refeeding syndrome, including those suffering from alcohol abuse, cancerous cachexia, chronic malnutrition, and prolonged starvation. RESULTS A total of 11 patients (7 males, 4 females) with nasogastric feeding were included as having refeeding syndrome. Most of them had the symptoms of diarrhea, lethargy, and leg edema. The initial nutritional supplement was found to be relatively high in calories (1355.1 ± 296.2 kcal/d), high in protein (47.3 ± 10.4 gm/d), low in vitamin B1 (2.0 ± 0.5 mg/d), low in potassium (1260.4 ± 297.7 mg/d), and low in phosphorus (660.1 ± 151.8 mg/d). Furthermore, hypophosphatemia (2.4 ± 0.9 mg/dL) was noted during follow-up. Based on the suggestions of a dietician and a gastroenterologist, the clinical disorders of diarrhea, malaise and leg edema were significantly improved. The level of phosphate was also increased (3.3 ± 0.6 mg/dL). CONCLUSION Refeeding syndrome is an overlooked and risky disorder that has some potentially fatal complications. Nasogastric feeding in nursing homes is an important risk factor for patients and deserves greater attention based on the initial results of this study.

Clinical manifestations and risk factors of amebic liver abscess in Southeast Taiwan compared with other regions of Taiwan.

Amebic liver abscess (ALA) had previously been endemic in Taiwan, particularly in the southern region, although its occurrence in the southeastern area was unknown. Thus, we conducted a retrospective study for southeastern Taiwan. We identified 14 patients who were diagnosed with ALA between July of 1995 and July of 2008. These patients were predominantly male and older in age. Most patients lived in rural areas (85.7%). Alcoholism (78.6%) and diabetes (35.7%) were risk factors for ALA. No human immunodeficiency virus (HIV) infections were detected. The most common clinical symptoms were fever (100%) and abdominal pain (100%). Short mean durations of symptoms, high bilirubin levels, and low albumin levels were also noted. Most patients (92.86%) had a single lesion, particularly in the right liver lobe (71.4%). Six patients also had secondary Klebsiella pneumoniae bacterial infections. Clinicians should be aware of the different risk factors in different regions when diagnosing amebic liver abscess in Taiwan.

Signet-ring type adenocarcinoma arising from a tiny gastric polyp.

When I read this case, I thought it nicely illustrated how modern-day therapies are sometimes like a double-edged sword, an expression used for anything that can simultaneously help and hinder. Here we have the iatric cessation of recurrent massive bleeding by the injection of microcoils, but at the price of probably ischemic ulceration: the double-edged sword of cessation of blood flow was on one edge therapeutic, but on the other edge, contributed to the ultimate demise of the patient. Gastric ischemia is uncommon, but more likely to occur in a postoperative operated stomach when collateral pathways of circulation have been compromised during the resection. Lawrence J. Brandt, MD Associate Editor for Focal Points At the Focal Point

The genotype distribution of hepatitis C in southeastern Taiwan: Clinical characteristics, racial difference, and therapeutic response

The genotypes of hepatitis C virus (HCV) are associated with the therapeutic response. The racial diversity of Taitung, Taiwan is heterogeneous and a distinguishing feature; how such racial differences influence the genotype distribution and treatment outcome has not been well studied. The objective of this study is to elucidate the HCV genotype distribution in southeastern Taiwan and to analyze the racial differences influencing genotypes and clinical implications. In this retrospective cohort study, we included 343 patients who had been treated with peginterferon‐alpha plus ribavirin. The predominant HCV genotype in the southeastern area was type 1 (43.7%), followed by type 2 (37.0%). The proportion of patients mixed with genotype 1 was lower in indigenous vis‐à‐vis nonindigenous groups (46.1% and 60.2%, p = 0.02). The prevalence of genotype 6 (5.2%) seems higher than in the general population of Taiwan and showed no difference between indigenous and nonindigenous people. The sustained virological response rate was higher in patients without genotype 1, low baseline HCV RNA (≤ 400,000 IU/mL), and in patients who achieved rapid virological response. Racial differences did not influence the therapeutic response. In this retrospective study, the proportion of HCV genotype 6 appeared slightly higher in southeastern areas than in the general population in Taiwan. The prevalence of genotype 1 in indigenous people was statistically lower than in nonindigenous people. Sustained virological response rate did not show any significant difference between indigenous and nonindigenous people in the current study.

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

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.

A case of massive lower gastrointestinal bleeding from a rectal Dieulafoy lesion

A Dieulafoy lesion is an uncommon and sometimes life‐threatening cause of gastrointestinal hemorrhage. Typically, it presents as a tiny mucosal defect with an exposed protruding artery with normal surrounding mucosa. An 84‐year‐old woman developed sudden massive hematochezia and had an unstable hemodynamic status. The source of bleeding was found to be an exposed vessel in the rectum without surrounding ulceration. The patient was treated successfully with an epinephrine injection given endoscopically, followed by hemostatic clipping.

Genotype distribution and treatment response among incarcerated drug-dependent patients with chronic hepatitis C infection

The prevalence of hepatitis C virus (HCV) infection is disproportionately high among prisoners, especially among those who are drug-dependent. However, current screening and treatment recommendations are inconsistent for this population, and appropriate care is not reliably provided. To address these problems, the present study aimed to identify unique characteristics and clinical manifestations of incarcerated patients with HCV infection. We included incarcerated patients who received treatment with pegylated-interferon combined with ribavirin at Mackay Memorial Hospital in Taitung and were serving sentences at either the Taiyuan Skill Training Institute or the Yanwan Training Institute. HCV genotypes 1 (41.4%), 3 (25.9%), and 6 (24.1%) were the most prevalent in the incarcerated patients. During the study period, we analyzed treatment response among 58 incarcerated patients and compared obtained results with treatment response among 52 patients who were living in the community. Higher sustained virological response rate was observed among patients with incarceration and HCV genotype other than 1. The odds ratios (corresponding 95% confidence intervals) for incarceration and genotype 1 were 2.75 (1.06–7.11) and 0.37 (0.14–0.99), respectively. Better treatment compliance among incarcerated patients might partially explain these results. The results of this study suggest that treatment of prisoners with HCV infection is feasible and effective. More appropriate and timely methods are needed to prevent HCV transmission among injection drug users inside prisons.

Application of chronic liver failure-sequential organ failure assessment score for the predication of mortality after esophageal variceal hemorrhage post endoscopic ligation

Background Esophageal variceal hemorrhage (EVH) is one of the high mortality complications in cirrhotic patients. Endoscopic variceal ligation (EVL) is currently the standard therapy for EVH. However, some patients have expired during hospitalization or survived shortly after management. Aim To evaluate hospital and 6-week mortality by receiver operating characteristic (ROC) curve of chronic liver failure-sequential organ failure assessment (CLIF-SOFA) score compared to a model for end-stage liver disease (MELD) score and Child–Turcotte–Pugh (CTP) class. Methods We retrospectively collected 714 cirrhotic patients with EVH post EVL between July 2010 and June 2016 at Taitung MacKay Memorial Hospital, Taiwan. CLIF-SOFA score, MELD score, and CTP class were calculated for all patients admitted. Results Among the 714 patients, the overall hospital and 6-week mortality rates were 6.9% (49/715) and 13.1% (94/715) respectively. For predicting hospital death, area under receiver operating characteristic curve (AUROC) values of CLIF-SOFA score, MELD score, and CTP class were 0.964, 0.876, and 0.846. For predicting 6-week death, AUROC values of CLIF-SOFA score, MELD score, and CTP class were 0.943, 0.817, and 0.834. CLIF-SOFA score had higher AUROC value with statistical significance under pairwise comparison than did MELD score and CTP class in prediction of not only hospital but also 6-week mortality. The history of hepatocellular carcinoma was the risk factor for 6-week mortality. For patients with hepatocellular carcinoma the cut-point of CLIF-SOFA score was 5.5 for 6-week mortality and 6.5 for hospital mortality on admission. For patients without hepatocellular carcinoma, the cut-point of CLIF-SOFA score was 6.5 for both 6-week and hospital mortality. Conclusion CLIF-SOFA score predicted post-EVL prognosis well. For patients without hepatocellular carcinoma, CLIF-SOFA score ≥6 suggests higher 6-week mortality and CLIF-SOFA score ≥7 suggests higher hospital mortality. For patients with hepatocellular carcinoma, CLIF-SOFA score ≥7 suggests higher 6-week and hospital mortality.

Nutritional Influences on Age-Related Frailty

Frailty and malnutrition are both highly prevalent in the older populations. Frailty has multifactorial origin, and is regarded as a fundamental risk factor for deteriorating health status and disability in elder people. It is estimated that prevalence rates for frailty and pre-frail reach as high as 27% and 51%, respectively. The nutritional deficiency is a key to the development of frailty, and interventions focused on the nutrition can prevent the transition of frailty into disability. The critical role of micronutrients in this context suggests the need to improve the quality of food eaten by elder people, not just the quantity. This review aims at summarizing the recent literature on the nutritional links to frailty, frailty components and frailty-related parameters such as low muscle strength and low walking speed, and implications for strategies to prevent or delay frailty in older age.

Endoscopic-ultrasound-guided cystogastrostomy for walled-off necrosis of the pancreas

Walled-off necrosis of the pancreas is defined as a mature, encapsulated collection of pancreatic and/or peripancreatic necrosis that has developed a well-defined inflammatory wall. It usually occurs > 4 weeks after onset of necrotizing pancreatitis [1]. Minimally invasive techniques are thought to induce less physiological stress as compared with open surgical necrosectomy [2]. We report one case of successful drainage of walled-off necrosis of the pancreas by endoscopic transluminal drainage. This was a 52-year-old man who had just been admitted for acute necrotizing pancreatitis. Abdominal computed tomography (CT) showed extensive abscess formation in the retroperitoneum complicated with ascites (Figure 1, left). He received CT-guided percutaneous drainage and the drainage catheter was removed because of poor function. Endoscopic retrograde pancreatography revealed a tortuous pancreatic duct, which communicated with the peripancreatic abscess cavity. Thus, a pancreatic duct stent was inserted. However, the following abdominal CT 3 months later still showed a large walled-off pancreatic necrosis (Figure 1, right upper). We performed endoscopic ultrasound (EUS) puncture from the stomach to the walled-