Ching-Wei Chang

Difference between CKD-EPI and MDRD equations in calculating glomerular filtration rate in patients with cirrhosis

AIM To evaluate the difference between the performance of the (CKD-EPI) and Modification of Diet in Renal Disease (MDRD) equations in cirrhotic patients. METHODS From Jan 2004 to Oct 2008, 4127 cirrhotic patients were reviewed. Patients with incomplete data with respect to renal function were excluded; thus, a total of 3791 patients were included in the study. The glomerular filtration rate (GFR) was estimated by the 4-variable MDRD (MDRD-4), 6-variable MDRD (MDRD-6), and CKD-EPI equations. RESULTS When serum creatinine was 0.7-6.8 mg/dL and 0.6-5.3 mg/dL in men and women, respectively, a significantly lower GFR was estimated by the MDRD-6 than by the CKD-EPI. Similar GFRs were calculated by both equations when creatinine was > 6.9 mg/dL and > 5.4 mg/dL in men and women, respectively. In predicting in-hospital mortality, estimated GFR obtained by the MDRD-6 showed better accuracy [81.72%; 95% confidence interval (CI), 0.94-0.95] than that obtained by the MDRD-4 (80.22%; 95%CI, 0.96-0.97), CKD-EPI (79.93%; 95%CI, 0.96-0.96), and creatinine (77.50%; 95%CI, 2.27-2.63). CONCLUSION GFR calculated by the 6-variable MDRD equation may be closer to the true GFR than that calculated by the CKD-EPI equation.

Simulating a target lesion for endoscopic submucosal dissection training in an ex vivo pig model

BACKGROUND Currently, there is no training model that simulates the target lesion encountered during endoscopic submucosal dissection. OBJECTIVE To develop a novel method simulating a target lesion for endoscopic submucosal dissection. DESIGN Training program with the use of an ex vivo porcine stomach model. SETTING Clinical skills training center. INTERVENTION A pseudopolyp was created by using an esophageal variceal ligation device to simulate a protruding (0-Ip) lesion, and the pseudopolyp was transected with a snare cautery to simulate a depressed (0-IIc) lesion. MAIN OUTCOME MEASUREMENTS Evaluate the histological depth of the target lesions and resected specimens. RESULTS Histological findings of the simulated targets showed artificial ulcerative or polypoid lesions involving the muscularis mucosa or superficial submucosa. The resected specimen was limited to the submucosal layer, and no perforation was noted. LIMITATIONS Pilot study in an ex vivo porcine stomach model. CONCLUSION The most important advantage of the model is to simulate realistic target lesions like those encountered in clinical practice in endoscopic submucosal dissection training. It allows trainees to practice how to make proper markings, delineate adequate safety margins, and properly manage different subtypes of early gastric cancer.

Acquired Hyperplastic Gastric Polyps After Treatment of Ulcer

BACKGROUND/PURPOSE Healing of gastric ulcers requires repair by epithelial migration and proliferation. We have found a small proportion of patients with acquired hyperplastic polyps at the healed ulcer site. The aim of this study was to identify clinical characteristics that might be associated with the development of hyper-plastic polyps at the site of healed gastric ulcers. METHODS This was a retrospective review of 86 patients with gastric ulcers from April 2006 to September 2008. After initial endoscopy, the patients were all treated with proton pomp inhibitors, after which a second endoscopy was performed. Demographic data, polyp characteristics (endoscopic and histological), Helicobacter pylori status, and duration of treatment were analyzed. RESULTS A total of 24 hyperplastic gastric polyps were found in 18 patients; all at the site of the healed ulcer (20 in the antrum and 4 in the corpus). The mean size of the ulcers prior to treatment was 14.5 +/- 9.1 mm. Hyperplastic gastric polyps were more likely to occur at the site of ulcers larger than 10 mm (odds ratio = 9.57, 95% confidence interval =2.50-36.65). Age, sex, H. pylori status, ulcer location and duration of treatment did not differ significantly between patients with and without polyps. CONCLUSION Hyperplastic polyps that develop after healing of gastric ulcers are likely to be extensive mucosal injury. A gastric ulcer larger than 10 mm is associated with a significantly increased risk of hyperplastic polyps.

Unusual presentation of desmoid tumor in the small intestine: a case report

Desmoid tumor originating from the small intestine is extremely rare. We report a 50-year-old man who presented with the sudden onset of severe abdominal pain. Computerized tomography (CT) demonstrated a huge homogeneous tumor in the lower abdomen that appeared to be in continuity with the distal ileum. The mass adherent to the ileum was resected and proved to be a desmoid tumor. The patient has remained recurrence free on follow-up.

A Palpable Mass in a Young Man With Chronic Lower Abdominal Pain

Question: A 28-yearold man complained of 2 months of intermittent, dull, lower abdominal pain, abdominal fullness, and weight loss. He denied fever, diaphoresis, or constipation. On examination, he seemed to be uncomfortable, but his vital signs were normal. There were no oral ulcers lesions or lymphadenopathy. The abdomen was slightly distended with active bowel sounds in the lower quadrants. On palpation, there was lower abdominal tenderness without guarding or rebound. A tender mass was palpable in the right iliac fossa. Digital rectal examination yielded brown stool that tested negative for blood. The white blood cell count was 10,600/mm3 with 71% neutrophils. Results of a biochemistry panel and coagulation tests were within noral limits. Tests for Epstein-Barr virus and HIV were negative. Chest and plain abdominal radiographs were normal. Abdominal ultrasonography demonstrated marked circumferential bowel wall hickening in the terminal ileum with a hypoechoic echopattern and aneurysmal dilatation (Figure A). A small bowel barium study hypoechoic chopattern and aneurysmal dilatation (Figure A; left panel: transverse view, right panel: longitudinal view). A small bowel barium study revealed neurysmal dilatation of the distal ileum with an irregular, ulcerated mucosal surface (Figure B, arrowheads) and distal luminal narrowing without bstruction (Figure B, arrows). Abdominal computed tomography showed a homogenous submucosal tumor involving a long segment of the erminal ileum (Figure C). A bulky tumor involving the cecum and terminal ileum was excised (Figure D), followed by end-to-end anastomosis. See the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Lactobacillus casei Variety rhamnosus Probiotic Preventively Attenuates 5-Fluorouracil/Oxaliplatin-Induced Intestinal Injury in a Syngeneic Colorectal Cancer Model

Adjuvant 5-fluorouracil (5-FU)-based chemotherapy, including FOLFOX (5-FU, leucovorin, and oxaliplatin), is recommended for colorectal cancer. However, intestinal mucositis remains a common adverse effect for which no effective preventive strategies are available. To develop a convenient and novel way to alleviate mucositis, we investigated the effect of Lactobacillus casei variety rhamnosus (Lcr35) on FOLFOX-induced mucosal injury. BALB/c mice subcutaneously injected with syngeneic CT26 colorectal adenocarcinoma cells were orally administered Lcr35 daily before, during, and after 5-day injection of FOLFOX regimen, for 14 days. The following methods were used: diarrhea score for toxicity, ELISA for cytokine production, histopathology for intestinal injury, immunohistochemistry for apoptosis/proliferation and regulatory proteins, RT-PCR for cytokine mRNA expression, and DNA sequencing for fecal gut microbiota. FOLFOX administration to colorectal cancer-bearing mice significantly inhibited tumor growth and the accompanying marked diarrhea and intestinal injury histologically characterized by the shortening of villi and destruction of intestinal crypts. Preventive administration of Lcr35 dose-dependently reduced the severity of diarrhea and intestinal mucositis without affecting the anti-tumor effect of FOLFOX. The numbers of apoptotic, NF-κB-, and BAX-activated cells increased after FOLFOX, and these responses were mitigated by Lcr35. TNF-α and IL-6 upregulation by FOLFOX treatment was attenuated by Lcr35. The fecal gut microbiota composition of Firmicutes and Bacteroidetes disturbed by FOLFOX was significantly reversed by Lcr35 toward a preferential profile. In conclusion, the oral probiotic Lcr35 prevented FOLFOX-induced intestinal mucositis in colorectal cancer-bearing mice. The putative mechanism might involve modulation of gut microbiota and proinflammatory responses with suppression of intrinsic apoptosis in intestinal injury.

RIFLE Classification on Admission and Respiratory Failure Predict ICU Mortality in Critically Ill Cirrhotic Patients with Acute Kidney Injury

BACKGROUND: It is difficult to define acute kidney injury (AKI) in cirrhotic patients. A modified diagnostic criterion, defined as an increase in serum creatinine of more than 26.4 μmol/L (0.3 mg/dL) or by 50% from baseline, has recently been suggested for diagnosing AKI in cirrhotic patients.METHODS: This study aimed to evaluate the predictive value of organ scoring systems in critically ill cirrhotic patients with AKI. Cirrhotic patients who were admitted to the intensive care unit (ICU) were enrolled in the present study. The baseline renal function and laboratory results on admission were recorded. The ICU mortality were al so noted.RESULTS: In total, 217 cirrhotic patients (mean age ± years) with 164 survivors and 53 non-survivors who were admitted to ICU were enrolled. The overall ICU mortality and six-month mortality rate were 24.4% and 48.4 %, respectively. According to the RIFLE classification. 155 patients were diagnosed as Non-AKI and 16, 8 and 14 patients were diagnosed as RIFLE-R. RIFLE-I, and RIFLE-F, respectively. Multiple logistic regression analysis demonstrated both RIFLE classification on admission (P=0.001) and respiratory failure with mechanical ventilator dependency were significant predictors of ICU mortality (P=0.021). Cumulative survival rates in ICU differed significantly for Non-AKI vs. RIFLE-R, RIFLE-I, and RIFLE-F (P=0.001) and for RIFLE-R vs. RIFLE-I and RIFLE-F (P=0.04).CONCLUSION: Among several organ scoring systems, RIFLE classification on admission and respiratory failure with mechanical ventilator dependency predict ICU mortality in critically ill cirrhotic patients with AKI.

Cautious application of the hepatorenal syndrome criteria to critically ill patients with cirrhosis

To the Editor: In clinical practice, differential diagnosis of the main phenotypes of acute kidney injury (AKI) may be difficult in patients with cirrhosis because the precipitating factors as well as the clinical presentation may be very similar. Nevertheless, an algorithm to aid the process of differential diagnosis has been suggested based mainly on the more recent diagnostic criteria for hepatorenal syndrome (HRS) (1, 2). However, the practitioner should be cautious when applying these criteria to critically ill patients with cirrhosis. From August 2010 to April 2012, 181 critically ill patients with cirrhosis and ascites were retrospectively reviewed. After excluding patients with end-stage renal disease (7 cases), patients without previous renal function data (17 cases) and patients without urinalysis or renal echo data (2 cases), 155 patients were enrolled for analysis. We included 109 cases in the AKI group according to a modified diagnostic criterion, defined as an increase in the serum creatinine level of >26.4 lmol/L (0.3 mg/dl) or an increase by 50% from baseline (3) (Table 1). Of the patients with AKI, 38.5% (42 cases) had urinary tract infections (UTIs) and 62.4% (68 cases) were classified with renal parenchymal disease (RPCD) [according to HRS criteria: proteinuria >500 mg/day, microhaematuria (>50 red blood cell per high-power field) and/or abnormal renal ultrasonography]. After excluding patients with serum creatinine <1.5 mg/dl (36 cases), presence of RPCD (51 cases), improvement in serum creatinine level after

Gender-specific association of the interleukin 18 gene with symptomatic gallstone disease.

Symptomatic gallstone disease (SGSD) induced several inflammatory responses and affected extrahepatic bile ducts. Although the pathology and environmental risk factors of gallstone disease are well documented, immune or inflammatory responses in SGSD development are still inconclusive. Interleukin 18 (IL18) is a pro‐inflammatory cytokine that plays an important role in immune, infectious, and inflammatory diseases because of the induction of interferon‐γ. In this study, we investigated whether polymorphisms of the IL18 gene were associated with SGSD susceptibility.