Chiung Yu Chen

Splenic infarction after histoacryl injection for bleeding gastric varices

Gastric varix bleeding is a serious but relatively common complication in cirrhotic patients. Treatment is difficult not only because of the gastric intertwining venous network but also its isolated location in the cardia and fundus. The disappointing results with sclerosing agents in this situation have led to the introduction of tissue adhesive injection. A 93% success rate for initial hemostasis was achieved with N-butyl cyanoacrylate injection.1 The reported complications of this treatment include injection site ulcers, fever, chest pain, and thrombosis of the portal venous system.2 Splenic infarction as a complication had not been reported.

Spontaneous rupture of hepatocellular carcinoma : a review of 141 Taiwanese cases and comparison with nonrupture cases

We reviewed the records and statistics of 560 patients hospitalized with hepatocellular carcinoma (HCC) over a 5-year period. One hundred and forty-one patients (26%) had spontaneous rupture of their HCCs. Different characteristics of the rupture (R) and nonrupture (NR) groups were compared; there were statistically significant differences (p < 0.05) in the size of the tumor (R, 9.83 +/- 4.36 cm, and NR, 7.67 +/- 4.01 cm; p < 0.0001), and the minimal thickness of peritumor liver parenchyma (R, 0.03 +/- 0.20 cm, and NR, 0.30 +/- 0.70 cm; p < 0.001), the presence of the ¿hump sign¿ (R, 87.8%, and NR, 45.7%; p < 0.0001), and the minimal thickness of peritumor liver parenchyma (R, 0.03 +/- 0.20 cm, and NR, 0.30 +/- 0.70 cm; p < 0.001). The percentage of left-lobe tumors was significantly higher in the rupture group than in the nonrupture group (p < 0.05). In addition, the Child-Pughs score and serum transaminase levels were higher, and the prothrombin times more prolonged, in the rupture group. Factors that were not statistically significant included sex, age, etiology of cirrhosis, platelet count, portal vein thrombosis, and the presence of a varix. Multivariate logistic regression analysis indicated that the tumor size, the presence of a hump sign, and the Pughs score correlated the best with HCC rupture (p < 0.05). Ninety-four patients from the rupture group died during hospitalization. The mortality rate was 66.7%. We conclude that (a) spontaneous rupture of HCC is a likely sequel of progressive expansion of tumor that finally protrudes outside the liver surface and hemorrhages, (b) left-lobe tumor presents a higher risk of rupture, and (c) portal hypertension does not play a major role in the pathogenesis of tumor rupture.

Randomised clinical trial: comparison of two everolimus dosing schedules in patients with advanced hepatocellular carcinoma

Deregulation of mammalian target of rapamycin (mTOR) signalling is common in human hepatocellular carcinoma (HCC).

The Role of Bacterial Virulence and Host Factors in Patients with Escherichia coli Bacteremia Who Have Acute Cholangitis or Upper Urinary Tract Infection

We studied the pathogenic role of host and Escherichia coli virulence factors in the development of E. coli bacteremia in patients with acute cholangitis (AC) or upper urinary tract infection (UTI). Isolates recovered from 75 adult patients consecutively admitted to the hospital with E. coli bacteremia caused by AC (n=24) or upper UTI (n=51) were evaluated, as were 30 fecal strains isolated from healthy control individuals. Virulence genes of E. coli were detected by polymerase chain reaction analysis, including papG genes (classes I-III), sfa/foc, fimH, afa, hlyA, cnf1, and iutA. Our results show that biliary tract obstruction and urinary tract obstruction are important host factors for the development of E. coli bacteremia in patients with AC and upper UTI, respectively. With regard to E. coli virulence factors, the papG class II gene might play a more important role in the development of E. coli bacteremia in patients with upper UTI than in those with AC.

Gas in Hepatic Veins: A Rare and Critical Presentation of Emphysematous Pyelonephritis

Although emphysematous pyelonephritis has been recognized for more than a hundred years, the actual etiology is still unknown. Glucose fermentation has been implicated as a mechanism of gas formation. We report a case of emphysematous pyelonephritis in which real-time ultrasonography demonstrated intravascular gas bubbles originating in the involved kidney, and passing into the inferior vena cava and hepatic veins. Gas from the affected kidney was analyzed by chromatography; the result showed hydrogen 10.5%, carbon dioxide 39%, nitrogen 49.6% and oxygen 0.8%. The clinical presentation and the results of gas analysis implicate a critical condition that bacteria proliferated rapidly by mixed acid fermentation of glucose. Additionally, the finding of gas production and transportation could explain the previous hypothesis of gas transport. In this critical situation immediate drainage with medical intervention is indicated to treat this life threatening condition.

Expression of oncogene products HER2/Neu and Ras and fibrosis-related growth factors bFGF, TGF-beta, and PDGF in bile from biliary malignancies and inflammatory disorders.

The expression of several growth factors and K-ras gene mutation in bile were studied to better understand the pathogenesis and improve early diagnosis of bile duct cancers. Bile samples were collected from 12 cholangiocarcinomas (CLC), 10 ampullary cancers (APC), 3 gallbladder cancers (GBC), 7 pancreatic cancers (PNC), 9 biliary tract infection (BTI), 8 biliary stone disease (ST), and 5 normal controls (NC). The highest mean value of TGF-β in bile was in patients with BTI; the mean levels of bFGF and PDGF were highest in CLC, and patients with APC and CLC had higher expression of HER2/Neu than other groups. In bile, a K-ras gene codon 12 mutation was found in 5 of 6 (83%) cases of CLC by the PCR-RFLP method. The results suggest overexpression of bFGF, PDGF, and HER2/Neu and the presence of K-ras mutation are important for carcinogenesis of bile duct cancers, and detection of the above abnormalities in bile is helpful for early diagnosis.

A Clinical Study of 130 Patients with Biliary Tract Cancers and Periampullary Tumors

A retrospective review of 130 patients with peripheral-type cholangiocarcinomas (PTCC), hilar-type cholangiocarcinomas (HTCC), extrahepatic cholangiocarcinomas (EHCC), gallbladder cancers (GBCA), and periampullary cancers (PACA), seen at National Cheng Kung University Hospital and Tainan Municipal Hospital from June 1987 to July 1993 was performed. There were 47 (36%) HTCC, 32 (25%) PACA, 24 (19%) PTCC, 17 (13%) GBCA, and 10 (8%) EHCC patients. The distribution is completely different from that reported in western countries. These cancers mainly occur in elderly patients. HTCC and GBCA were predominantly noted in female patients. Biliary cancers in Taiwan were not related to liver fluke infestation, inflammatory bowel disease or hepatitis B virus infection. However, a close association with biliary lithiasis was found. The incidence of gallstones was 67, 39, 20, 29 and 19% for PTCC, HTCC, EHCC, GBCA and PACA, respectively. The most common presentation for PTCC and GBCA was abdominal pain, or jaundice for HTCC, EHCC and PACA. These symptoms correlate well with the location of the tumors. Among serum tumor markers, the elevation of CA19-9 was most frequent, occurring in 86% of the patients while CA125 and CEA occurred in 47% and 30% of the patients, respectively. During the course of disease, infection developed in 61% of the patients and was the main cause of death in 25%. Biliary tract infection and sepsis were the two leading manifestations and occurred in 49% and 32% of the patients, respectively. Overall survival was poor except in patients whose tumor could be completely resected.

Diagnostic role of biliary pancreatic elastase for cholangiocarcinoma in patients with cholestasis

BACKGROUND A wide array of proteins is secreted into the bile and may be associated with biliary tract diseases. We attempted to discover novel biomarker in bile for cholangiocarcinoma. METHODS Bile was collected from patients with bile duct obstruction. Proteins were separated by 2-dimensional electrophoresis and identified by mass spectrometry. Levels of mRNA and protein expression of the candidate biomarker were analyzed by real-time PCR and Western blotting, respectively, whereas enzyme activity was measured by a kinetic method. The diagnostic efficacy was assessed by receiver operating characteristic (ROC) curve analysis. RESULTS Pancreatic elastase (PE) 3B was identified as a biomarker for cholangiocarcinoma. The mRNA of PE 3B was up-regulated in cancerous tissues, compared to non-cancerous tissues. The protein expression and enzyme activity of PE in bile were increased in patients with cholangiocarcinoma, compared to gallstone patients. Biliary amylase activity was used to correct the presence of pancreaticobiliary reflux. Significantly higher PE/amylase ratios in bile were found in patients with cholangiocarcinoma (0.214+/-0.045) than those with gallstone (0.023+/-0.005, p<0.001). The area under the ROC curve of the ratio was 0.877 (95% CI: 0.765 to 0.988). Using 0.065 as a cutoff value, the ratio distinguished malignant from benign causes of biliary obstruction with a sensitivity of 82% and a specificity of 89%. CONCLUSION PE in bile is a biomarker for cholangiocarcinoma and the combination measurement of PE and amylase enhances diagnostic efficacy.

Increasing incidence and lifetime risk of inflammatory bowel disease in Taiwan: a nationwide study in a low-endemic area 1998-2010.

Background:The incidence of inflammatory bowel disease is increasing worldwide, but data of epidemiological trends from low-endemic area are limited. As one of the low-endemic countries, we describe the trends of this disease in Taiwan over time. Methods:This study was based on data obtained from the Catastrophic Illnesses Registration in the National Health Insurance Research Database, which covers more than 98% of the people in Taiwan. Every certificate of catastrophic illness must be approved by 2 expert gastroenterologists. Thirteen years (1998–2010) of data were analyzed for the trends of Crohns disease (CD) and ulcerative colitis (UC). Results:A total of 2915 incident cases (1818 men and 1097 women) were identified, including 2357 cases of UC and 558 cases of CD. The mean annual incidence rates were 0.80 for UC and 0.19 for CD per 100,000 inhabitants, with lifetime risks for those 20 to 79 years of age of 0.066% and 0.013%, respectively. The mean annual prevalence was 4.59 for UC and 1.05 for CD per 100,000 inhabitants. Poisson regression showed significantly increased trends during the observation period for both diseases, with a men/women ratio of 1.50 in UC and 2.14 in CD (P < 0.01). The mean age of individuals at diagnosis was higher for UC as compared with CD (44.7 versus 37.9, P < 0.001). Conclusions:Inflammatory bowel diseases are still relatively uncommon in Taiwan, but the incidence and prevalence rates are increasing.

Biliary sludge and pigment stone formation in bile duct-ligated guinea pigs

We studied the effects of bile stasis in aguinea pig model of pigment gallstone. The common bileducts of guinea pigs were partially ligated, and theguinea pigs killed one or two weeks later. Biliary sludge or stones were examined with the Fouriertransform infrared spectroscopy and the scanningelectromicroscopy. The bile was analyzed for pH, freecalcium, bile acids and bilirubin fractions, and the activities of both bacterial and endogenousbeta-glucuronidase. After bile duct ligation, calciumbilirubinate precipitates or stones formed in all exceptone of the animals studied. The bile pH and the proportion of unconjugated bilirubin rose afterbile duct ligation, with a concomitant fall of bilirubinmonoglucuronide. The activity of bacterialbeta-glucuronidase decreased after ligation, while the activity of endogenous beta-glucuronidase roseat week 2. Our results imply that precipitation ofcalcium bilirubinate in this animal model was induced byan increased bile pH and the nonenzymatic hydrolysis of conjugated bilirubin.