Chia-Long Lee

Comparison of invasive and noninvasive tests for detecting Helicobacter pylori infection in bleeding peptic ulcers

BACKGROUND Eradication of Helicobacter pylori infection has been shown to prevent recurrent bleeding from peptic ulcers. However, the detection rate for H pylori infection seems to be underestimated in this group of patients and has been scarcely investigated. METHODS Eighty patients with bleeding peptic ulcer were studied for evidence of H pylori infection. Seventy-seven of these patients were enrolled as having H pylori infection after any one of the following 3 tests were positive: culture, histologic study, or any 2 of rapid urease test (CLO test), carbon 13-labeled urea breath test (UBT), and serologic examination. Fresh blood or blood-containing material in the gastric antrum was noted by panendoscopy in 22 patients (group A). In the remaining 55 cases there was no blood in the antrum (group B). RESULTS The sensitivities of the CLO test, bacterial culture, histologic study, 13C-labeled UBT, and immunoglobulin G serologic test were 45.5%, 36.4%, 77.2%, 95.4%, and 100% in group A, respectively, and 70.9%, 40.0%, 70.9%, 92.7%, and 96.4%, respectively, in group B. There was a statistically significant difference between the sensitivities found for CLO test and 13C-labeled UBT (p < 0.05). Of these 5 tests, only the sensitivity of the CLO test showed a statistically significant difference between groups A and B (p < 0.05). A delayed positive CLO test result was recorded in 13 patients (3 in group A, 10 in group B). CONCLUSION Noninvasive tests seemed to be more sensitive than invasive tests in detecting H pylori infection in patients with bleeding peptic ulcers. Blood in the antrum might reduce the sensitivity of the CLO test but have no effect on the other tests. The CLO test should be observed for more than 24 hours because of the possibility of a delayed positive result in some patients with bleeding peptic ulcers.

Clinical application of Carlsson's questionnaire to predict erosive GERD among healthy Chinese

Background:  Gastroesophageal reflux disease (GERD) is a common gastrointestinal disease, yet there is no definitive gold standard to describe and diagnose it.

Negative CLOtest pellet can be reused

BACKGROUND The CLOtest is based on the production of ammonia from urea in the presence of urease. In theory, substrate that has not been consumed in a negative test can be reused. METHODS We collected negative CLOtest pellets after their first use and stored them at room temperature. Whenever a CLOtest was needed during endoscopy, two biopsy specimens were taken from the antrum. One specimen was tested with a new CLOtest and the other with one that had been used previously. Time to color change was observed in paired tests. RESULTS We used 216 previously used CLOtest pellets with biopsy specimens obtained from 317 patients. Of the paired tests, 204 matched positive and 108 tested negative. Only 5 paired tests had discrepant results. Three had positive results only with a new CLOtest, and 2 were positive only with the reused test. In positive paired tests, there was significant linear correlation in log-transformed color change time between reused and new tests (p < 0.001). Ninety-two percent of previously used pellets were reused fewer than three times before they yielded a positive color change; the interval to this occurrence ranged from 2 to 15 days. Compared with the new CLOtest, the sensitivity of the reused CLOtest was 98. 6% and the specificity was 98.2%. CONCLUSIONS A negative CLOtest kept at room temperature can be reused within a short period of time, in circumstances in which there are environmental and economic considerations to be taken into account.

Cold snare polypectomy versus cold forceps biopsy in endoscopic treatment of colonic small and diminutive polyps - the effectiveness and safety in real world

The practice of colonoscopy is used to reduce the risk of colonic malignancy. Complete removal of polyps is required to prevent tumor recurrence and the development of potential interval cancers. However, it is difficult to completely remove the polyp that is more than 4 mm in size through cold forceps biopsy. Polypectomy with a cold snare has been increasingly utilized in recent years, which provides a chance of complete removal of the polyp. This study compares the effectiveness and safety between cold snare polypectomy (CSP) and cold forceps biopsy (CFB) in diminutive or small sessile polyp removal. Between August 2015 and June 2016, 164 consecutive patients with colorectal polyps <10 mm in size were enrolled into either the CSP or CFB group. Demographic data, the duration of colonoscopy withdrawal time, adverse events, and pathological reports were recorded. The primary outcome is complete polyp eradication histologically. The secondary outcomes include rates of adverse events and time taken for the procedures. Of 164 patients, 84 patients were in CSP group and 80 patients in CFB group. The CSP group comprised elder patients (P = 0.042), most of who were male (P = 0.359). There was no significant difference of indications for colonoscopy. The mean withdrawal time was significantly longer in the CSP group (12.5 ± 6.90 minutes vs 9.14 ± 5.45 minutes; P < 0.01). The mean polyp size was bigger in the CSP group (5.05 ± 2.72 mm vs 3.84 ± 1.52 mm, P < 0.05). Eighty‐nine (84.7%) adenomas, 13 (12.4%) hyperplastic polyps, and three other polyps (2.9%) were resected in the CSP group. No high‐grade dysplasia or malignancy was found. Pathological examination showed that 54 polyps were completely removed in CSP group. Thirteen polyps were not removed completely, and 38 polyps could not be surveyed due to tissue destruction during the procedure. In the CFB group, no polyps could be identified with complete removal. The complete histological polyp eradication rate is higher in the CSP group (51.4% vs 0%, P < 0.01). Under operators discretion, 23 cases with 31 hemoclips were applied for bleeding prevention in the CSP group and only one in the CFB group. However, no further treatment requirement or delayed bleeding event was found in both groups. CSP is an effective method in small or diminutive polyps compared with CFB, and its safety is not inferior to CFB. Given these results and the high prevalence of such polyps, CSP is advocated as an alternate treatment.

The Diagnosis of Small Intestine Diseases by Wireless Capsule Endoscopy: A Multi Center Experience in Taiwan

Backgrounds: 5% of gastrointestinal (GI) bleeding cannot be accurately detected by bi-directional endoscopy. Wireless capsule endoscopy (CE) was introduced into medical diagnosis since 2000. This study is a multicenter experience of CE to detect the small intestinal diseases in Taiwan.Materials and Methods: The retrospective study was completed by questionnaires. 176 patients underwent wireless capsule endoscopy in eight medical centers in Taiwan. The indications of CE were obscure GI tract bleeding (n=137, 77.8%), anemia (n=18, 10.2%), abdominal pain (n=18, 10.2%), inflammatory bowel disease history (n=2, 1.1%), and gastric carcinoid history (n=1, 0.6%). The study by questionnaires analyzed the pathologic findings, total completion rate, complications of CE and outcomes of patients.Results: The examination completion rate of CE was 66.9% (115/172) and diagnostic yield rate was 90.1% (155/172). Angiodysplasia was the most diagnosed disease (47.7%, 82/172) and followed by small intestinal polyps, tumors or submucosa tumors (36%, 62/172), small intestinal ulcers or erosions (22.1%, 38/172), lymphangiectasia (14.0%, 24/172). 20 patients received surgical treatments (11 with angiodysplasia, 9 with polyps or tumors) and 18 patients received double-balloon enteroscopic examination after CE. Three capsules (1.74%) retained in small and large intestine more than two weeks and removed by surgical treatment.Conclusions: This multicenter cases analysis presented similar results as Westerns reports. Wireless capsule endoscopy is a non-invasive, effect and safe examination and can be used as first line tool to diagnose small intestinal diseases.

Effects of Different Antibiotics in the Treatment of Cirrhotic Patients with Culture-Negative Neutrocytic Ascites or Spontaneous Bacterial Peritonitis

Ascitic infection is a major cause of morbidity and mortality in liver cirrhosis patients. Many reports suggest that at least 5 days of third generation cephalosporin is better than a conventional first generation cephalosporin or amoxicillin plus an aminoglycoside for treating ascitic infections. We retrospectively reviewed 54 patients with culture-negative neutrocytic ascites (CNNA) or spontaneous bacterial peritonitis (SBP) who were treated with an intravenous first generation cephalosporin plus short-term gentamicin, or a second or third generation cephalosporin. Thirteen patients with CNNA (group A) were treated with an intravenous first generation cephalosporin plus short-term gentamicin intravenous drip (regimen Ⅰ). Another 18 CNNA patients (group B) were treated with an intravenous second or third generation cephalosporin monotherapy (regimen Ⅱ). Seven patients with SBP (group C) were treated with regimen Ⅰ and 16 patients with SBP (group D) were treated with regimen Ⅱ. Three and 16 patients with shock on admission were treated with regimen Ⅰ or Ⅱ respectively. We compared the success rates of these two regimens in CNNA and SBP groups. The successful treatment rates were 92.3% (12/13), 67.7% (12/18), 57.1% (4/7) and 37.5% (6/16) for groups A, B, C, D, respectively. The difference in success rates between regimen Ⅰ and regimen Ⅱ in the CNNA group or SBP group was not statistically significantly. However, the success rates for antibiotics given to non-septic shock patients and septic shock patients were significantly different (non-septic shock: 32/35 vs. septic shock: 2/19, p＜0.05,) A first generation cephalosporin plus short-term gentamicin has good effect to treat CNNA patients not in shock. But it should be used cautiously to prevent acute renal failure in cirrhosis patients. Broader spectrum antibiotics should be used in patients with shock or any clinical deterioration.

Clinical Application of Edrophonium Provocative Test in Esophageal Manometry

Unexplained chest pain nowadays has become the leading reason for patients being referred for esophageal manometry. Some drugs are recently used as provocative agents to increase the diagnostic rate during this test and edrophonium chloride is the most common among them. Nevertheless, this provocative test has seldom been applied in Chinese patients. Therefore, we studied 158 consecutive patients with chest pain (group A) and 53 patients with other esophageal symptoms (group B) by using edrophonium as a provocative agent for inducing esophageal chest pain. Each of these patients received 80 μg/kg intravenous bolus dose of edrophonium preceded by saline infusions. Esophageal contractile pressures and contractile duration of upper middle and lower portions were measured before and after drug injection in response to ten 5 mL wet swallows. We found that chest pain was reproduced in only 8 patients and they were all in the group A. Besides, edrophonium increased esophageal pressure signficantly in all three monitored portions of esophageal body but increased contractile duration only in the middle and distal portions. We also found the adverse effects of this agent in such dose were mild and tolerable. In conclusion, edrophonium is relativly safe as a provocative agent and can diagnose chest pain of esophageal origin in small population of Chinese patients.

C^13 Urea Breath Test Combined with Symptomatology is Helpful in Deciding Which Dyspeptic Patients Need Endoscopy to Rule in Peptic Ulcer

Knowing when to give endoscopy to a primary dyspeptic patient is a difficult decision for any gastroenterologist. We decided to address the problem by testing for Helicobacter pylon and analyzing patients symptoms. Within one-year period, 117 consecutive dyspeptic outpatients underwent endoscopy. Of these patients, all had symptom duration longer than one month, had no sinister symptoms (anemia, body weight loss and gastrointestinal bleeding), never had previous endoscopy, had no gastric surgery, nor had ingestion of antibiotics or non-steroid anti-inflammatory drugs two weeks prior to enrollment, and were free of hepatobiliary disease by abdominal sonography. Urea breath test (UBT) with only a 15-minute collection interval was done to each patient and a questionnaire about dyspeptic symptoms was also answered. Patients were divided into three groups according to the results of UBT and endoscopy; UBT negative patients (n=44), UBT positive with no ulcer patients (n=37) and UBT positive with ulcer or scar present patients (n=36). In UBT negative patients, they were more younger and they had no evidence of peptic ulcer disease endoscopically. In UBT positive patients, patients with peptic ulcer disease had statistically signficant difference than those without peptic ulcer disease in that they had more regular attack of pain before meal and at midnight, and their pain can be relieved by eating. We conclude that the 15-minute UBT in association with symptoms analysis is helpful in deciding which dyspeptic patients need to be given endoscopy.