Jean-Dean Liu

Investigation of the extent of gastric metaplasia in the duodenal bulb by using methylene blue staining

Background and Aims: The existence of gastric metaplasia (GM) of the duodenal mucosa has been considered to be highly related to the recurrence of duodenal ulcers (DU). The aims of this study are to evaluate the usefulness of methylene blue staining in the detection of GM, and to clarify the relationship between GM and the deformity of the duodenal bulb.

Large Early Gastric Cancers Treated by Endoscopic Submucosal Dissection with an Insulation-tipped Diathermic Knife

It is difficult to remove a large early gastric cancer (> or = 3 cm) in one-piece resection using conventional endoscopic mucosal resection. We tried to use an insulation-tipped (IT) diathermic knife to dissect these lesions. IT-endoscopic submucosal dissection (ESD) was performed in four aging patients with gastric malignancy. All lesions could be removed in one-piece resection by IT-ESD, although three of them exhibited remarkable fibrosis and ulceration. Three cases experienced curative treatment with IT-ESD after the pathologic evaluation, but it was not curative in one case because the pathology showed angiolymphatic invasion. This patient refused additional surgery in consideration of existing major systemic diseases. At 3 months to 1 year of follow-up, endoscopy showed no evidence of residual cancer. IT-ESD is effective in the treatment of large early gastric cancer and is an alternative treatment for early gastric cancer patients who are at risk for major operation.

Predictors of Mortality in Patients with Pyogenic Liver Abscess Requiring Intensive Care

Background: Despite progress in the diagnosis and management of pyogenic liver abscess, the mortality rate remains high in critically ill patients. There have been limited studies on patients with pyogenic liver abscess requiring intensive care. The aim of this study was to assess the risk factors of mortality among patients with pyogenic liver abscess treated in intensive care unit (ICU). Methods: Thirty-five patients with pyogenic liver abscess admitted to ICU, between January 2003 and June 2009, were studied retrospectively. Parameters including general characteristics, clinical presentations, Acute Physiology and Chronic Health Evaluation (APACHE) Ⅱ scores, features of liver abscess and laboratory data were reviewed. The main outcome measure was survival. Univariate and subsequent multivariate logistic regression analyses were performed to assess the risk factors for mortality. The best cut-off for each identified independent risk factor for mortality was then investigated. Results: Univariate analysis implicated APACHE Ⅱ scores on admission, abscess size and gas formation as prognostic factors of mortality. Multivariate analysis showed higher APACHE Ⅱ scores on ICU admission (OR=1.387; 95% CI=1.106-1.739) and size of the liver abscess (OR=2.986; 95% CI=1.060-3.723) as independent prognostic factors for mortality. Finally, APACHE Ⅱ scores≥17 and the diameter of liver abscess≥5 cm were found to be relatively more accurate in predicting mortality in the study population. Conclusion: In patients with pyogenic liver abscess requiring intensive care, APACHE Ⅱ scores≥17 and the diameter of liver abscess≥5 cm were accurate predictors of mortality.

Clinical Experience of Adult Nodular Gastritis

Aim Nodular gastritis is not a common clinical entity. We want to investigate the clinical manifestations of adult nodular gastritis in Taiwanese patients. Methods Patients over 18 years of age with varying degrees of discomfort and who had undergone esophagogastroduodenoscopy (EGD) by an experienced endoscopist at Taipei Medical University Hospital from March 1, 1997 to February 28, 2005, were enrolled. A Campylobacter-like organism (CLO) test was done for identification of Helicobacter pylori (H. pylori) infection. The clinical features of adult nodular gastritis were analyzed in this study. Results A total of 8,137 patients underwent 10,293 EGD examinations during this period, and nodular gastritis was diagnosed in 30 women and 13 men. The incidence of adult nodular gastritis was about 0.5% (43/8137). More female (69.7%) patients were affected. More than 40% of the patients had peptic ulcer disease and more than 80% complained of epigastralgia at presentation. A CLO test was positive in 88.4% of these patients. The gastric antrum was always affected (100%). Pathology always revealed intense inflammation and 60% had lymphoid follicular hyperplasia. Remission of the gastric antral nodularity after eradication of H. pylori was also found. Conclusion Adult nodular gastritis is a rare clinical entity in Taiwan. Careful endoscopic examination may be required. It has a strong association with H. pylori infection. H. pylori eradication may improve nodular gastritis.

Development of multifocal duodenal erosions after anti-Helicobacter pylori triple therapy.

BACKGROUND AND PURPOSE Anti-Helicobacter pylori triple therapy is effective for healing duodenal ulcer (DU) diseases and reducing disease recurrence. However, multifocal duodenal erosions or shallow ulcers may develop after triple therapy. The purpose of this study was to investigate the incidence and outcome of duodenal erosions that developed after triple therapy. METHODS A total of 106 Taiwanese with active DU and with H. pylori infection were enrolled in this study. All patients received anti-H. pylori triple therapy (i.e., 2 weeks of antimicrobial agents combined with treatment for 4 to 6 weeks with acid suppression agents). Follow-up endoscopy was performed immediately after stopping treatment. The incidence of multifocal erosions or shallow ulcers over the bulb and/or second portion of the duodenum was studied. Additional acid suppression agent was given for 4 weeks whenever duodenal erosions or shallow ulcers were found. RESULTS Out of 106 patients, 11 (10.4%) were found to have multifocal duodenal erosions and/or shallow ulcers on the duodenal bulb and/or second portion of the duodenum at the end of treatment. Ten of the 11 patients with newly developed erosions had healed DU in the S1 or S2 stage, and all 11 had successful H. pylori eradication. The duodenal erosions and/or shallow ulcers of these 11 patients were healed after an additional 4 weeks of histamine-2-receptor antagonist therapy. CONCLUSIONS Multifocal duodenal erosions and/or shallow ulcers were noted in around 10% of Taiwanese DU patients who received anti-H. pylori triple therapy. An additional 4 weeks therapy with acid suppression agents healed these lesions.

Relationship of Duodenal Juxtapapillary Diverticula to Biliary Stone Disease

The relationship between duodenal juxtapapillary diverticula (JPD), age, sex and biliary stone disease was still unclear. The aim of this study was to compare the incidence of JPD in different age groups, gender, and among different types of biliary stone diseases. The results of 227 consecutive endoscopic retrograde cholangiopancreatography (ERCP) examinations conducted at the Taipei Medical University Hospital between 1992 and 1999 were retrospectively analyzed. The overall incidence of JPD was 17.6%. A positive correlation was found between age and incidence of JPD. The incidence of JPD in males and females were 18.3% and 17%, respectively. There was no significant correlation between gender and incidence of JPD. Association with JPD was signficantly higher in patients with common bile duct stones (31.1%) than patients with gallbladder (GB) stones (10.2%) or patients without biliary stones (18.8%) (p＜0.05). In conclusion, the incidence of JPD increases with age, but does not related to sex. The association between JPD and biliary stone disease was significant only in patients with CBD stones, but not in patients with GB stones or free of biliary stones.

Dual Infection with Non-Self-Limited Cytomegalovirus and Shigella of the Colon in Non-Immunocompromised Patient: Report of a Case

Cytomegalovirus infections are usually found in immunocompromised persons and rarely present in those who are immunocompetent. We report a case of an elderly man presenting with watery diarrhea, abdominal pain, and fever for one month. Infection of Shigella flexneri was proved by stool culture at first. Clinical symptoms did not improve with antibiotics treatment. In contrast, diffuse abdominal distention and megacolon developed. Then the diagnosis of CMV colitis was made by colonoscopy with mucosal biopsy. Treatment with Ganciclovir (10 mg/kg/day I.V. in 2 divided doses) for 2 weeks resulted in resolution of clinical symptoms with no noticeable side effects. There was no relapse during 6 months follow-up. We report, to our knowledge, the second case of dual infection of the colon with CMV and Shigella in an immunocompetent patient and the first non-self-limited example.