Huan-Lin Chen

Abdominal Tuberculosis in Southeastern Taiwan: 20 Years of Experience

BACKGROUND/PURPOSE Abdominal tuberculosis (TB) is a rare manifestation of extrapulmonary TB. This disease entity can be overlooked, and its early diagnosis is difficult because of its variable manifestations and lack of specific symptoms. METHODS The clinical and diagnostic features, treatment, and outcome of patients with abdominal TB at a major hospital in southeastern Taiwan from January 1987 to December 2006 were investigated. RESULTS Twenty-one patients with abdominal TB identified during the 20-year period were included. A predominance of male (13/21, 61.9%) and Taiwanese aborigine (15/21, 71.4%) patients was noted. Middle-aged (30-50 years) patients with alcoholic liver cirrhosis had the highest risk. Common presenting features included abdominal pain (18/21, 85.7%), fever (16/21, 76.2%), ascites (13/21, 61.9%), and weight loss (12/21, 57.3%). The mean time to reach a diagnosis was 48 +/- 10 days. Tuberculous peritonitis was noted in 11 patients, with a high correlation with liver cirrhosis (p = 0.0237, Fishers exact test). The other patients were diagnosed with TB of the gastrointestinal tract (n = 6), urinary tract (n = 2), and pelvis (n = 2). Abdominal sonography and abdominal computed tomography were helpful for diagnosis, by revealing ascites and thickening of the peritoneum. Pulmonary involvement was noted in 11 patients. Most of the patients (16/21, 76.2%) improved with anti-tuberculosis therapy, and five patients died from sepsis and respiratory failure. CONCLUSION Abdominal TB is a rare manifestation of extrapulmonary TB, even in southeastern Taiwan where TB is prevalent. Delay in diagnosis is common and abdominal TB should be included in the differential diagnosis of middle-aged aborigine men with alcoholic liver cirrhosis and peritonitis.

Identification of Ectopic Pancreas in the Ileum by Capsule Endoscopy

Ectopic pancreas, an uncommon submucosal tumor in the gastrointestinal (GI) tract, is histologically similar to normal pancreatic tissue. We present a case of ectopic pancreas in the ileum. A 35-year-old man had intermittent dark bloody stool for 2 months accompanied by epigastric pain and postprandial abdominal fullness. Esophagogastroduodenoscopy and colonoscopy did not reveal any abnormalities. Capsule endoscopy revealed a small red polyp in the ileum. Abdominal computed tomography scan and small bowel barium follow-through study were not of any help. GI bleeding and abdominal discomfort were resolved after the lesion was surgically removed. Pathologic examination demonstrated pancreatic acinar cells and a secretory duct in the ileal submucosa, consistent with ectopic pancreas. Ectopic pancreas in the small intestine may be a rare cause of obscure GI bleeding. Capsule endoscopy seems to be a good, noninvasive tool for identification in the small bowel, particularly when other imaging modalities fail to detect any abnormalities.

Changing Pattern of Ectopic Pancreas: 22 Years of Experience in a Medical Center

BACKGROUND/PURPOSE Ectopic pancreas is usually a silent gastrointestinal malformation. It may become clinically evident when complicated by chronic inflammation or by growth. More ileal ectopic pancreas has been found in recent years in our hospital. We report the clinical manifestation of ectopic pancreas over the past 22 years. METHODS We reviewed the medical records of patients seen between May 1984 and December 2005 at Mackay Memorial Hospital, with a diagnosis of ectopic pancreas, and extracted clinical and histopathology data from the records. RESULTS A total of 39 patients (18 male, 21 female; mean age, 46 years) were diagnosed with ectopic pancreas. Most patients were aged between 30 and 50 years. Only 15 (38%) had symptoms suggestive of ectopic pancreas. These included abdominal pain (n = 9), upper gastrointestinal bleeding (n = 5), and abdominal distension (n = 2). The diagnosis in the other 24 patients was made incidentally, usually during surgery for other conditions. While lesions in the stomach were more likely to be diagnosed because of symptoms (12 of 13), lesions in the small bowel were almost always diagnosed incidentally. Only one of eight in the duodenum, one of 10 in the jejunum, and one of eight in the ileum, were isolated findings. One case of ectopic pancreas was detected by capsule endoscopy. CONCLUSION Ectopic pancreas can be found in various parts of the gastrointestinal tract. The high proportion of ileal ectopic pancreas is unexpected and needs further study.

Trismus and Trigeminal Neuralgia in One Patient with Colon Cancer

A 64-year-old man got trismus and trigeminal neuralgia under the diagnosis of colon cancer with mandibular metastasis after emergency appendectomy and elective hemicolectomy. The patient chose to forgo further surgery and was given only palliative chemotherapy and radiotherapy. He died six months after diagnosis. Metastatic tumors to the oral cavity are relatively uncommon. They are found most commonly in the mandible, and 70% of cases are adenocarcinoma-most commonly from breast and lung, followed by adrenals, kidneys, prostate, thyroid and colon. Mandibular mass is usually the first sign, then soft-tissue swelling, pain and paresthesias. Tissue proof is needed to confirm the diagnosis. The treatment depends on the nature of the primary, the degree of dissemination and the precise location. However, the prognosis is grim, with the mean survival after diagnosis being only about 6-7 months.

Refeeding syndrome in Southeastern Taiwan: Our experience with 11 cases

AIM To present our experience with refeeding syndrome in southeastern Taiwan. METHODS We conducted a retrospective study during a 2-year period at the Mackay Memorial Hospital, Taitung Branch. We enrolled patients with very little or no nutrition intake for more than 10 d, a high risk group of refeeding syndrome, including those suffering from alcohol abuse, cancerous cachexia, chronic malnutrition, and prolonged starvation. RESULTS A total of 11 patients (7 males, 4 females) with nasogastric feeding were included as having refeeding syndrome. Most of them had the symptoms of diarrhea, lethargy, and leg edema. The initial nutritional supplement was found to be relatively high in calories (1355.1 ± 296.2 kcal/d), high in protein (47.3 ± 10.4 gm/d), low in vitamin B1 (2.0 ± 0.5 mg/d), low in potassium (1260.4 ± 297.7 mg/d), and low in phosphorus (660.1 ± 151.8 mg/d). Furthermore, hypophosphatemia (2.4 ± 0.9 mg/dL) was noted during follow-up. Based on the suggestions of a dietician and a gastroenterologist, the clinical disorders of diarrhea, malaise and leg edema were significantly improved. The level of phosphate was also increased (3.3 ± 0.6 mg/dL). CONCLUSION Refeeding syndrome is an overlooked and risky disorder that has some potentially fatal complications. Nasogastric feeding in nursing homes is an important risk factor for patients and deserves greater attention based on the initial results of this study.

Clinical manifestations and risk factors of amebic liver abscess in Southeast Taiwan compared with other regions of Taiwan.

Amebic liver abscess (ALA) had previously been endemic in Taiwan, particularly in the southern region, although its occurrence in the southeastern area was unknown. Thus, we conducted a retrospective study for southeastern Taiwan. We identified 14 patients who were diagnosed with ALA between July of 1995 and July of 2008. These patients were predominantly male and older in age. Most patients lived in rural areas (85.7%). Alcoholism (78.6%) and diabetes (35.7%) were risk factors for ALA. No human immunodeficiency virus (HIV) infections were detected. The most common clinical symptoms were fever (100%) and abdominal pain (100%). Short mean durations of symptoms, high bilirubin levels, and low albumin levels were also noted. Most patients (92.86%) had a single lesion, particularly in the right liver lobe (71.4%). Six patients also had secondary Klebsiella pneumoniae bacterial infections. Clinicians should be aware of the different risk factors in different regions when diagnosing amebic liver abscess in Taiwan.

The genotype distribution of hepatitis C in southeastern Taiwan: Clinical characteristics, racial difference, and therapeutic response

The genotypes of hepatitis C virus (HCV) are associated with the therapeutic response. The racial diversity of Taitung, Taiwan is heterogeneous and a distinguishing feature; how such racial differences influence the genotype distribution and treatment outcome has not been well studied. The objective of this study is to elucidate the HCV genotype distribution in southeastern Taiwan and to analyze the racial differences influencing genotypes and clinical implications. In this retrospective cohort study, we included 343 patients who had been treated with peginterferon‐alpha plus ribavirin. The predominant HCV genotype in the southeastern area was type 1 (43.7%), followed by type 2 (37.0%). The proportion of patients mixed with genotype 1 was lower in indigenous vis‐à‐vis nonindigenous groups (46.1% and 60.2%, p = 0.02). The prevalence of genotype 6 (5.2%) seems higher than in the general population of Taiwan and showed no difference between indigenous and nonindigenous people. The sustained virological response rate was higher in patients without genotype 1, low baseline HCV RNA (≤ 400,000 IU/mL), and in patients who achieved rapid virological response. Racial differences did not influence the therapeutic response. In this retrospective study, the proportion of HCV genotype 6 appeared slightly higher in southeastern areas than in the general population in Taiwan. The prevalence of genotype 1 in indigenous people was statistically lower than in nonindigenous people. Sustained virological response rate did not show any significant difference between indigenous and nonindigenous people in the current study.

MMP-9 -1562 Promoter Polymorphism Associated with Gastric Cancer Risk in Females.

Background/Aims: C to T transition at the matrix metalloproteinase-9 (MMP-9) promoter site -1562 abolishes a binding site of a putative transcription repressor protein to the C allelic promoter. The aim of this study is to elucidate the significance of MMP-9 genotypes in clinicopathological manifestations of gastric cancer. Methodology: We conducted a case-control study based on previously stored peripheral blood samples from 263 gastric cancer patients and 354 controls. MMP-9 genotyping was analyzed by PCR-RFLP method. Stratified analysis, logistic regression and Cox proportional hazards analysis were used to evaluate the associations between polymorphisms and gastric cancer development, invasiveness, and survival. Results: There was significant correlation between female patients with MMP-9 -1562 C/T or T/T genotype and higher risk of gastric cancer (OR=2.12, p=0.02). On stratified analysis, only elderly females with T allele had higher risk of gastric cancer (OR=2.64, p=0.04). On Cox proportional hazards analysis, serosal invasion (adjusted HR=3.47, p<0.001) and lymph node metastasis (adjusted HR=2.31, p=0.003), but not MMP-9 polymorphism, were independent prognostic factors for survival. Conclusions: MMP-9 -1562 promoter polymorphism with T allele may be used as a marker to predict gastric cancer development in female subjects, especially in the elderly.

Ruptured Pancreaticoduodenal Artery Pseudoaneurysm with Chronic Pancreatitis Presenting as Recurrent Upper Gastrointestinal Bleeding

Pancreaticoduodenal artery (PDA) aneurysms are extremely rare, accounting for only 2% of all visceral artery aneurysms [1]. PDA aneurysms may be either pseudoaneurysms— secondary to pancreatitis or trauma—or true aneurysms, mainly due to hemodynamic disorders of vessels, arteriosclerosis, congenital vascular disease, or occlusion or stenosis of the celiac trunk [2–5]. Rupture is the major complication, occurring in two-thirds of reported cases of PDA aneurysm and is fatal in half of the patients in whom it occurs [3]. We report a case of ruptured PDA pseudoaneurysm presenting with recurrent upper gastrointestinal bleeding.

Early endoscopic finding of esophageal thermal injury after having spicy hot pot

We herein present the case of a woman who had esophageal thermal injury after having a spicy hot pot. The patient came to us with complaints of odynophagia, dysphagia, and burning sensation at the throat and upper chest while eating or drinking for 1 day. An upper endoscopy was conducted 1 day after the onset of symptoms, which showed a linear, disrupted bullae‐like lesion with a thin detached membrane. Our report depicts the early endoscopic finding of esophageal thermal injury following the ingestion of hot food. The finding is different from what has been often reported as the “candy‐cane” appearance of esophageal injury, which results from the ingestion of hot liquid.