Heng-Cheng Chu

Spontaneous intracranial hemorrhage in cirrhotic patients.

OBJECTIVE The major characteristics of spontaneous intracranial hemorrhage (SICH) in cirrhotic patients have not been completely defined. Cirrhotic patients with SICH were thus analyzed in an effort to better understand the risk factors for SICH and predict patient outcomes. PATIENTS AND METHODS From 1997 to 2006, 4515 hospitalized cirrhotic patients were recruited, with a focus on 36 cirrhotic patients with SICH who had no history of cerebral vascular accidents, head injuries, or cerebral arteriovenous malformations. The patient characteristics, severity of cirrhosis, location of the hematoma, and prognosis were analyzed. RESULTS Of the patients, 78% were males, 72% consumed alcohol, and 81% had a mild-to-moderate degree of cirrhosis. The overall incidence of SICH was related to the etiology of cirrhosis as follows: virus-related cirrhosis (0.3%), alcohol-related cirrhosis (1.9%), and combined virus- and alcohol-related cirrhosis (3%). The outcome of patients with SICH was associated with the size of the hematoma (P<0.005), the initial Glasgow Coma Scale score (P<0.05), the Child-Pugh classification (P=0.05), and the serum total bilirubin level (P<0.05). CONCLUSION SICH occurs primarily in young males with mild-to-moderate alcoholic cirrhosis of the liver. The etiology of cirrhosis is related to the incidence of SICH, but not to the patient outcome. The severity of liver cirrhosis is associated with patient outcome, but not the incidence of SICH.

Hepatitis C Virus Core Protein Down-Regulates p21Waf1/Cip1 and Inhibits Curcumin-Induced Apoptosis through MicroRNA-345 Targeting in Human Hepatoma Cells

Background Hepatitis C virus (HCV) has been reported to regulate cellular microRNAs. The HCV core protein is considered to be a potential oncoprotein in HCV-related hepatocellular carcinoma, but HCV core-modulated cellular microRNAs are unknown. The HCV core protein regulates p21Waf1/Cip1 expression. However, the mechanism of HCV core-associated p21Waf1/Cip1 regulation remains to be further clarified. Therefore, we attempted to determine whether HCV core-modulated cellular microRNAs play an important role in regulating p21Waf1/Cip1 expression in human hepatoma cells. Methods Cellular microRNA profiling was investigated in core-overexpressing hepatoma cells using TaqMan low density array. Array data were further confirmed by TaqMan real-time qPCR for single microRNA in core-overexpressing and full-length HCV replicon-expressing cells. The target gene of microRNA was examined by reporter assay. The gene expression was determined by real-time qPCR and Western blotting. Apoptosis was examined by annexin V-FITC apoptosis assay. Cell cycle analysis was performed by propidium iodide staining. Cell proliferation was analyzed by MTT assay. Results HCV core protein up- or down-regulated some cellular microRNAs in Huh7 cells. HCV core-induced microRNA-345 suppressed p21Waf1/Cip1 gene expression through targeting its 3′ untranslated region in human hepatoma cells. Moreover, the core protein inhibited curcumin-induced apoptosis through p21Waf1/Cip1-targeting microRNA-345 in Huh7 cells. Conclusion and Significance HCV core protein enhances the expression of microRNA-345 which then down-regulates p21Waf1/Cip1 expression. It is the first time that HCV core protein has ever been shown to suppress p21Waf1/Cip1 gene expression through miR-345 targeting.

Preliminary experience with gemcitabine and cisplatin adjuvant chemotherapy after liver transplantation for hepatocellular carcinoma

AIM Liver transplantation (LT) criteria for treatment of hepatocellular carcinoma (HCC) were refined to improved survival and disease-free rates. Adjuvant chemotherapy might eliminate disseminated tumor cells after removal of the primary liver cancer and thereby benefit LT recipients. Our purpose was to evaluate the effect of an adjuvant chemotherapy (gemcitabine and cisplatin) on outcome of patients treated with LT for HCC. METHODS Of the 99 patients who underwent liver transplantation from October 2001 through February 2006, there were 58 with HCC. Nine patients with extra-hepatic metastasis and four who died for noncancer-related reasons were excluded. Three groups (total n=45) were compared: Group A (n=15) met the Milan criteria and did not receive study chemotherapy, Group B (n=13) did not fit the Milan criteria and did not receive chemotherapy, and Group C (n=17) did not fit the Milan criteria and received gemcitabine and cisplatin. RESULTS The chemotherapy regimen was well tolerated. Leukopenia, the need for granulocyte colony-stimulating factor treatment, or both occurred in four patients. The disease-specific survival rates were better for groups A and C than for group B (p=0.02) and the disease-free survival rates were also better for groups A and C than for group B (p=0.01). CONCLUSIONS Systemic gemcitabine and cisplatin may improve disease-specific and disease-free survival in HCC patients who do not meet the Milan criteria after LT.

Aggressive hepatic resection for patients with pyogenic liver abscess and APACHE II score ≥15

BACKGROUND Most liver abscesses resolve after antimicrobial therapy or percutaneous tube drainage (PD). The aim of this study was to evaluate the results of hepatic resection (HR) for patients with pyogenic liver abscesses and an Acute Physiology and Chronic Health Evaluation II (APACHE II) score > or =15. METHODS We compared the clinical outcomes of 81 patients with APACHE II scores > or =15 undergoing PD and/or HR. RESULTS The failure rate (3 of 65) and double-treatment rate (32 of 65) in the PD group were significantly higher than in the HR group (3 of 35 vs 0 of 35; P = .0002). The mortality rate in the PD group was significantly higher than the other 2 groups (14 of 46 vs 2 of 19 and 1 of 16; P = .038). The length of hospital stay was significantly shorter and antibiotic use less in the HR group than in the PD group (P < .05). CONCLUSIONS Aggressive HR for patients with liver abscesses and APACHE II scores > or =15 produced better clinical outcomes.

Acute pulmonary embolism as the first manifestation of hepatocellular carcinoma complicated with tumor thrombi in the inferior vena cava: Surgery or not?

Acute pulmonary embolism as the first manifestation of hepatocellular carcinoma (HCC) complicated with tumor thrombi in the inferior vena cava (IVC) and right atrium is rare [1]. These patients usually die within a short period because of pulmonary embolism, heart failure, or cancer progression [2]. Here, we describe a 57-year-old man who had HCC complicated with tumor thrombi and pulmonary embolism. He was initially unwilling to undergo surgery but agreed to the surgery after developing a tumor thrombus of the right atrium followed within 24 hr by acute respiratory failure. He died from complications arising from surgery. We reviewed published reports of 14 patients who had HCC and pulmonary embolism. The 1-year survival rate was higher for patients who underwent surgery (40%) than for patients who did not undergo surgery (0%). Therefore, hepatic resection and removal of tumor thrombi should be considered to prolong the patient’s life span.

Carbon dioxide insufflation does not reduce pain scores during colonoscope insertion in unsedated patients: a randomized, controlled trial.

BACKGROUND CO(2) is rapidly absorbed from the colon and eliminated via the lung. Insufflation of CO(2) instead of air during colonoscopy can reduce distention-induced pain. OBJECTIVE This study aimed to evaluate the effects of CO(2) insufflation on pain during intubation and extubation and to identify predictors of pain and discomfort during colonoscope insertion. DESIGN Prospective, randomized, controlled trial. SETTING Single tertiary medical center in Taiwan. PATIENTS A total of 193 patients enrolled from September 2010 through June 2011. INTERVENTIONS Colonoscope insertion with either air or CO(2) insufflation. CO(2) was used for extubation in both groups. MAIN OUTCOME MEASUREMENTS The main outcome measurement was pain, recorded on a 10-point visual analog scale (VAS) for left-sided colonoscope insertion and right-sided colonoscope insertion and at 1, 3, 6, and 24 hours post-procedure. Colonoscope cecal intubation time and extubation time, completeness of intubation, and loop formation were also assessed. RESULTS CO(2) insufflation during colonoscope intubation was used in 98 patients and air in 97 patients. The mean pain scores during intubation were low (2-3) for patients undergoing air insufflation and were not reduced further in patients receiving CO(2). A mean pain score of 0 was reported by both groups for all postprocedure time points. Multivariate analysis identified sex, loop formation of the sigmoid colon, time to reach the transverse colon, and requested sedation as factors that significantly affect VAS pain scores. LIMITATIONS This study was limited in scope to a single medical center with experienced endoscopists. CONCLUSIONS We detected no significant benefit to the use of CO(2) insufflation compared with air insufflation during intubation for colonoscopy performed by experienced colonoscopists. The absence of postprocedure pain in both groups supports previous observations that CO(2) insufflation during extubation is effective in reducing postprocedure pain. Female sex and loop formation were identified as key factors influencing pain scores on colonoscope insertion. ( CLINICAL TRIAL REGISTRATION NUMBER TSGHIRB-099-05-081.).

Modified mallampati classification as a clinical predictor of peroral esophagogastroduodenoscopy tolerance

BackgroundUnsedated esophagogastroduodenoscopy (EGD) is simpler and safer than sedated EGD; however, approximately 40% of patients cannot tolerate it. Early identification of patients likely to poorly tolerate unsedated EGD is valuable for improving compliance. The modified Mallampati classification (MMC) has been used to evaluate difficult tracheal intubation and laryngoscope insertion. We tried to assess the efficacy of MMC to predict the tolerance of EGD in unsedated patients.MethodsTwo hundred patients who underwent an unsedated diagnostic EGD were recruited. They were stratified according to the view of the oropharynx as either MMC class I + II (good view) or class III + IV (poor view). EGD tolerance was assessed in three ways: gag reflex by endoscopist assessment, patient satisfaction by interview, and the degree of change in vital signs.ResultsMMC was significantly correlated to gag reflex (P < 0.001), patient satisfaction (P = 0.028), and a change of vital signs (P = 0.024). Patients in the poor view group had a 3.87-fold increased risk of gag reflex (P < 0.001), a 1.78-fold increased risk of unsatisfaction (P = 0.067), and a 1.96-fold increased risk of a change in vital signs (P = 0.025) compared to those in the good view group.ConclusionsMMC appears to be a clinically useful predictor of EGD tolerance. Patients with poor view of oropharynx by MMC criteria may be candidates for sedated or transnasal EGD.

Pure hepatoid adenocarcinoma of the stomach with spleen and lymph-node metastases

The authors report a rare case of hepatoid adenocarcinoma of the stomach, presenting initially with spleen and lymph node metastases.

Xanthogranulomatous panniculitis after spillage of gallstones during laparoscopic cholecystectomy mimics intra-abdominal malignancy.

Spillage of gallstones into the peritoneal cavity during laparoscopic cholecystectomy (LC) occurs frequently and may be associated with complications. Most of these complications present late after the original procedure, and many have clinical pictures that are not related to biliary etiology, which can confound and delay adequate management. Our patient presented with an intra-abdominal firm heterogeneous mass lesion. Imaging studies showed obvious abdominal wall invasion, and CA-125 level was elevated. Thus, malignancy could not be excluded. Final operative pathology revealed xanthogranulomatous inflammation. Complications of LC should be considered for patients with intra-abdominal abscess or mass lesion if there is a history of LC, regardless of time interval.

Peginterferon alfa-2a plus ribavirin for hemophilic patients with chronic hepatitis C virus infection in Taiwan

BACKGROUND/PURPOSE Chronic hepatitis C virus (HCV) infection is a major cause of morbidity and mortality in patients with hemophilia. However, the efficacy and safety of pegylated interferon (PEG-IFN) plus ribavirin (RBV) for hemophilic patients with chronic HCV infection in Taiwan are still unknown. The aim of this study is to report the efficacy and safety of PEG-IFN plus RBV in a single center in Taiwan. METHODS In an open-label single-treatment one-arm cohort study, 12 hemophilic patients with elevated alanine aminotransferase level more than two times the upper limit of normal for more than 3 months received 180 μg/week of PEG-IFN-α-2a plus RBV 1000-1200 mg/day at a cut-off value of 75 kg. The duration of treatment was 48 weeks for patients with HCV Genotype 1/4 infection and 24 weeks for patients with HCV Genotype 2/3 infection. Efficacy of therapy was expressed as sustained virological response (SVR). RESULTS Eight patients achieved SVR (66.7%). The SVR rates were 57%, 100%, 100%, and 0% for patients with HCV Genotypes 1, 2, 3, and 4 infection, respectively. Adverse events (AEs) developed in 10 patients (83.3%). Severe thrombocytopenia developed in one patient. However, the patient did not suffer from severe bleeding. CONCLUSION Our study shows that the SVR rates are similar in hemophilic and nonhemophilic patients with chronic HCV infection who receive PEG-IFN-α-2a plus RBV in Taiwan. The rate of AEs also resembled other studies in nonhemophilic patients in Taiwan. No patient suffered from severe bleeding. However, large-scale, well-conducted studies are still needed to verify the treatment efficacy and safety.