Fa Yauh Lee

Endoscopic variceal ligation versus propranolol in prophylaxis of first variceal bleeding in patients with cirrhosis

Background and Aim:  To compare the efficacy and safety of endoscopic variceal ligation (EVL) with propranolol in prophylaxis on the rate of first esophageal variceal bleeding in patients with cirrhosis.

Clinical courses and predictors for rebleeding in patients with peptic ulcers and non-bleeding visible vessels: a prospective study.

Detailed characterisation of non-bleeding visible vessels in terms of colour, size evolution, and time of rebleeding is important in determining the natural history of these lesions. The colour and size of non-bleeding visible vessels were observed endoscopically every day for three days and then every other day until rebleeding or flattening of visible vessels occurred in 140 patients. Rebleeding happened in 61 (44%) patients. Of them, 59 (97%) rebled within 72 hours. Flattening of visible vessels happened in 79 (56%) patients and 77 of 79 (98%) had flattening of visible vessels within 72 hours. Rebleeding rate increased with increasing length of exposed vessels (r = 0.96, p < 0.001). Coffee ground fluid or blood retention in the stomach and ulcer size > or = 2.0 cm were independent predictors for rebleeding using multivariate analysis. It is suggested that patients with non-bleeding visible vessels and independent predictors for rebleeding may need early aggressive treatment.

Natural history of bleeding peptic ulcers with a tightly adherent blood clot: a prospective observation

BACKGROUND The natural history of a bleeding peptic ulcer with a tightly adherent blood clot remains uncertain. Controversy exists concerning removal of such blood clots at the bleeding ulcer base. This article presents the natural history of a bleeding peptic ulcer with a tightly adherent clot and defines the characteristics of those requiring aggressive management. METHODS Clinical parameters were analyzed to determine the independent predictors of rebleeding in these patients. One hundred one patients with bleeding peptic ulcers and tightly adherent blood clots were enrolled during a period of 12 months. RESULTS Twenty-five patients (25%) rebled within 1 month. With a multivariate analysis, we found comorbid illness (odds ratio, 3.41), shock (odds ratio, 3.65), and initial hemoglobin at or below 10 gm/dL (odds ratio, 2.99) to be independent predictors of rebleeding. CONCLUSIONS Most patients with a tightly adherent clot in an ulcer have an uneventful course. However, endoscopic therapy may prove to be beneficial in the subset of patients with independent predictors of rebleeding.

Therapeutic endoscopy for Dieulafoy's disease

Dieulafoys disease is an underdiagnosed cause of massive upper gastrointestinal bleeding. The mortality rate is extremely high and the diagnosis is usually made at autopsy. Operation has been deemed the treatment of choice for Dieulafoys disease in the past decades. Here, however, we report successful therapeutic endoscopy in eight cases of Dieulafoys disease in a period of 20 months. Six patients (75%) were in shock before therapy. Six received heat-probe thermocoagulation, one received pure alcohol (99.8%) injection and one received hypertonic glucose solution (50%) injection. No perforation or recurrent hemorrhage occurred in the following period of 11.2 +/- 3.4 months (SEM) in six patients. The other two died of unrelated illness. In the near future, therapeutic endoscopy may replace surgery in the management of Dieulafoys disease.

Relationships between the severity of cirrhosis and haemodynamic values in patients with cirrhosis

Abstract The relationship between the severity of cirrhosis and systemic and hepatic haemodynamic values was evaluated in 193 patients with cirrhosis, most of whom were diagnosed with post‐necrotic cirrhosis. It was found that the hepatic venous pressure gradient and cardiac output in Pughs A patients (13.6 ± 4.8 mmHg and 6.2 ± 1.6 L/min, mean ± s.d.) were significantly lower than in both Pughs B (16.8 ± 4.3 mmHg and 7.3 ± 2.1 L/min) and Pughs C (18.8 ± 5.5 mmHg and 7.4 ± 2.3 L/min) patients (P < 0.01), respectively. In contrast, the systemic vascular resistance in Pughs A patients (1232 ± 369 dyn/s per cm5) was significantly higher than in both Pughs B (1016 ± 345 dyn/s per cm5) and Pughs C (935 ± 234 dyn/s per cm5) patients (P < 0.01), respectively. Additionally, not only was there a positive correlation found between Pughs score and cardiac output and hepatic venous pressure gradient, but a negative correlation was found between Pughs score and systemic vascular resistance. It was also confirmed that the degree of portal hypertension and the hyperdynamic circulation were more severe in patients with ascites than in those without ascites. However, there were no statistically significant differences in hepatic venous pressure gradient among patients with F1, F2 and F3 esophageal varices (15.7 ± 4.0, 17.0 ± 4.8 and 18.0 ± 4.8 mmHg, respectively). It is concluded that in those patients with cirrhosis, the severity of cirrhosis is closely related to the degree of the hyperkinetic circulatory state and portal hypertension.

Clinical significance of serum type-III procollagen aminopropeptide in hepatitis B virus-related liver diseases

Serum type-III procollagen aminopropeptide (PIIIP) has been considered a marker of hepatic fibrogenesis. In an attempt to evaluate the clinical significance of serum PIIIP in patients with hepatitis B virus (HBV)-related liver diseases, the levels of the peptide were measured in 66 healthy adults and 200 patients with HBV-related liver diseases. As compared with the healthy adults (12.3 +/- 3.1 ng/ml), the serum PIIIP levels were significantly elevated in patients with acute hepatitis (17.4 +/- 6.6 ng/ml), chronic persistent hepatitis (18.3 +/- 4.9 ng/ml), and inactive liver cirrhosis (22.1 +/- 7.1 ng/ml). The PIIIP levels in patients with chronic active hepatitis (CAH) (33.9 +/- 23.1 ng/ml) were the highest among HBV-related liver diseases and had a tendency to increase with the severity of CAH. Of the liver-diseased patients with serum PIIIP levels greater than 30 ng/ml, 91% had a recent episode of severe hepatocellular damage, whereas 56% of patients with greatly elevated serum liver aminotransferase levels had no associated high increase in serum PIIIP levels. Thus, we suggest that fibrogenesis in HBV-related liver diseases is initiated by severe hepatocellular damage, but liver damage can also take place without prominent hepatic fibrogenesis. Serum PIIIP may be a serum marker to predict the active fibrogenesis of HBV-related liver diseases.

Inverse association between hepatitis B virus infection and fatty liver disease: a large-scale study in populations seeking for check-up.

Background Although many studies have attempted to clarify the association between hepatitis B virus (HBV) infection and fatty liver disease, no prior studies have emphasized the relationship of HBV and fatty liver regarding different demographics of age and body mass index (BMI). Aim To investigate the correlation of HBV and fatty liver in the different demographics of age and BMI. Methods We enrolled consecutive subjects who had received health check-up services at the Taipei Veterans General Hospital from 2002 to 2009 and ultrasonography was used to diagnose fatty liver according to the practice guidelines of the American Gastroenterological Association. Results Among the 33,439 subjects enrolled in this study, fatty liver was diagnosed in 43.9% of the population and 38.9% of patients with chronic HBV infection. Multivariate analysis showed that BMI, age, waist circumference, systolic blood pressure, fasting glucose, cholesterol, alanine aminotransferase (ALT) levels, and platelet counts were positively associated, while hepatitis B surface antigen (HBsAg) positivity was inversely associated with fatty liver, especially for subjects with BMI>22.4 kg/m2 and age>50 years. On the contrary, HBV infection was positively correlated with the presence of elevated serum ALT levels in subjects with fatty liver disease regardless of their age and BMI. Conclusions Metabolic factors are important determinants for the prevalence of fatty liver. Patients with HBV infection were inversely associated with fatty liver disease than the general population, especially in older and obese patients. Furthermore, metabolic factors and HBV infection were associated with elevated serum ALT levels in fatty liver disease.

Updated thresholds for serum alanine aminotransferase level in a large-scale population study composed of 34 346 subjects

The sensitivity of current upper limit of normal (ULN) of serum alanine aminotransferase (ALT) levels for detecting chronic liver disease has been challenged recently.

Comparison of the model for end-stage liver disease (MELD), MELD-Na and MELDNa for outcome prediction in patients with acute decompensated hepatitis

BACKGROUND AND AIM The model for end-stage liver disease (MELD) is used to predict the outcome of patients with cirrhosis. Incorporation of serum sodium (Na) into MELD may further increase its prognostic ability. Two Na-containing MELD models, MELD-Na and MELDNa, were proposed to enhance the prognostic ability. This study compared the predictive accuracy of these models for acute decompensated hepatitis. METHODS We investigated the outcome of 182 patients with acute decompensated hepatitis. RESULTS Twenty (11%) patients died at 3 months. The MELD-Na and MELDNa both had significantly higher area under the receiver operating characteristic curve (AUC) in comparison to MELD (MELD-Na: 0.908, MELDNa: 0.895, MELD: 0.823, p=0.004 and 0.001, respectively). Among 96 patients without specific antiviral treatment, the MELD-Na and MELDNa consistently had significantly higher AUC than the MELD (MELD-Na: 0.901, MELDNa: 0.882, MELD: 0.810, p=0.008 and 0.004, respectively). Three independent indicators, pre-existing cirrhosis (odds ratio [OR]: 5.67, 95% confidence interval [CI]: 1.72-18.7), serum albumin<3.7 g/dL (OR: 5.68, 95% CI: 1.18-27.03) and serum sodium (Na)<138 mequiv./L (OR: 10.0, 95% CI: 2.08-47.62), were associated with 3-month mortality. CONCLUSION MELD-Na and MELDNa provide better prognostic accuracy than the MELD for patients with acute decompensated hepatitis. The adequacy of liver reserve determines the outcome of these patients.

Cancer risk in patients with pyogenic liver abscess: a nationwide cohort study

There has been no large‐scale population‐based study on the relationship between pyogenic liver abscesses (PLA) and subsequent cancer risk.