Jeng-Shiann Shin

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.

When to discharge patients with bleeding peptic ulcers : a prospective study of residual risk of rebleeding

BACKGROUND From January 1993 to December 1994, we conducted a prospective study to investigate the evolutionary change of rebleeding risk in bleeding peptic ulcers. To obviate possible confounding factors that would influence decision making for discharge of patients, subjects with coexistent acute illnesses, systemic bleeding disorders, alcoholism, and use of nonsteroidal anti-inflammatory drugs were excluded. METHODS Emergency endoscopies were performed in patients with hematemesis or a melena within 24 hours of admission. Ulcer lesions were divided into six categories according to endoscopic findings. The residual risks of rebleeding of each type of ulcers were calculated for 10 days, and the critical point of acceptable rebleeding risk after discharge was set at 3%. RESULTS Three hundred ninety-two patients with bleeding peptic ulcers completed the study. The ulcers, characterized by clean bases, red or black spots, adherent clots, nonbleeding visible vessels without local therapy, nonbleeding visible vessels with local therapy, and bleeding visible vessels with local therapy took 0, 3, 3, 4, 4, and 3 days, respectively, to decrease rebleeding risk to below the critical point. All episodes of fatal rebleeding (n = 4) occurred within 24 hours after admission. CONCLUSIONS Patients with clean-based ulcers can be discharged in the first day of admission. The optimal duration required for hospitalization of patients with ulcers characterized by nonbleeding visible vessels at initial endoscopy is 4 days. The remaining patients with ulcers marked by other bleeding stigmata may be discharged after a 3-day observation.

The natural history (fading time) of stigmata of recent hemorrhage in peptic ulcer disease

From October 1991 to December 1992, 144 patients with bleeding peptic ulcer and stigmata of recent hemorrhage were included in a study designed to investigate, by means of endoscopic examinations repeated at 2-day intervals, the evolutionary development of stigmata of recent hemorrhage, such as visible vessels, and to determine the time required for each type of stigma to fade. Eighty-five patients underwent endoscopic follow-up until the stigmata had disappeared. A visible vessel takes about 4.1 +/- 2.1 days to disappear, requiring significantly more time than an adherent clot or an old stigma, which take 2.4 +/- 0.8 days and 2.4 +/- 1.3 days, respectively (p < .05). Bleeding does not recur after stigmata disappear. Time required for stigmata to fade is not affected by age, sex, smoking, history of peptic ulcer, ulcer location, severe bleeding, underlying systemic disease, or endoscopic local therapy. While healing, stigmata of recent hemorrhage evolve through a sequence of phases: a visible vessel may or may not appear as an adherent clot and then as a red or black flat spot before disappearing.

Emergency endoscopic nasobiliary drainage for acute calculous suppurative cholangitis and its potential use in chemical dissolution

Abstract Acute suppurative cholangitis is one of the common causes of acute abdomen in Taiwan. Emergency decompression is a life‐saving procedure if patients fail to respond to antibiotic treatment. From July 1988 to June 1991, 224 patients were encountered with concomitant bile duct stones and cholangitis; 40 were brought to the emergency service with shock or mental confusion or responded poorly to antibiotic treatment. The patients consisted of 20 males and 20 females aged 21–81 years (mean age 64 years); 55% had intrahepatic duct stones, 50% had positive blood culture, 38% had undergone previous biliary surgery, 25% had concomitant medical illnesses and 20% presented with mental confusion. Emergent endoscopic nasobiliary drainage (ENBD) was performed within 48 h of each patients arrival in the emergency room. In 3 days all the patients exhibited significant improvement as defined by body temperature, vital signs, white blood cell count, serum bilirubin and alkaline phosphates levels. When their condition had stabilized, 21 patients underwent elective surgery. Six patients received ethylenediaminetetraacetic acid infusion through an ENBD tube. Two of the patients’ stones dissolved completely. Six patients received papillotomy with stone removal. The remaining patients refused further treatment. There was no hospital mortality. It is therefore concluded that ENBD offers an effective treatment for acute calculus suppurative cholangitis and it is a potential route of administration for the chemical dissolution of bile duct stones.

Clinical assessment of the bacterial load of Helicobacter pylori on gastric mucosa by a new multi‐scaled rapid urease test

The present study tests the efficacy of the multi‐scaled urease test (MUT) in detecting Helicobacter pylori infection and determines whether the MUT can predict the bacterial density on histology. A total of 111 sets of gastric specimens were obtained from patients with dyspepsia but without recent bleeding. Two biopsies were taken as closely as possible in each set. One sample was used for the MUT (Hp fast; GI Supply, Camp Hill, PA, USA), while the other was used to determine the histological density of H. pylori by modified Giemsa stain (grade 0–5). The results of MUT were interpreted as negative if the colour was yellow or bright green (reaction score 0) and positive if the colour was green, light blue, or blue (reaction score 1, 2 and 3, respectively). The reaction scores of MUT were recorded sequentially at 15 and 30 min and 1, 4 and 24 h. On the basis of histological confirmation, MUT had a sensitivity of 89.6%, a specificity of 88.2%, a positive predictive value of 94.5% and a negative predictive value of 78.9%. Focusing on specimens with the presence of bacteria under histology, 77 specimens were divided into five subgroups by grades of density of H. pylori (HPD1–5). The reaction scores had become sequentially elevated from 30 min through to 24 h in each subgroup. For subgroups HPD4 and 5, the positive rates of MUT were 70.6 and 66.6%, respectively, as early as 30 min and progressed to 100% within 4 h. In contrast, the positive rate for the HPD1 subgroup was 16.6% at 4 h and increased to only 62.5% at 24 h. In subgroups HPD 2 and 3, the positive rates were less than 30% at 30 min, but became more than 66.6% at 4 h and were 100% at 24 h. The early (i.e. mean value of reaction scores before 4 h) and late (24 h) mean reaction scores disclosed two elevated trends as the density of H. pylori increased (early: 0.2, 0.7, 0.8, 1.5, 1.2; late: 1.4, 2.3, 2.6, 3.0, 3.0; P < 0.05). In conclusion, MUT is a reliable method for the diagnosis of H. pylori infection. It can also indirectly predict the density of H. pylori on histology.

Endoscopic variceal ligation versus conservative treatment for patients with hepatocellular carcinoma and bleeding esophageal varices

BACKGROUND Endoscopic variceal ligation (EVL) is currently a favored treatment for control of bleeding from esophageal varices. However, little is known about the treatment of bleeding varices in hepatocellular carcinoma. METHODS EVL was performed in 16 patients with bleeding esophageal varices due to concomitant hepatocellular carcinoma. Treatment results were compared with those of another 23 patients who were conservatively treated. RESULTS Comparing the two groups, ligation significantly reduced the risk of fatal bleeding (44% vs 70%; P < 0.05). Significantly fewer patients in the ligation group died at the time of the index hemorrhage (11% vs 52%; P < 0.05). Rebleeding occurred in 44% of the ligation group and 73% in the control group (P > 0.05). The mean days of survival were 40 +/- 20 (range, 7 to 103) in the ligation group and 20 +/- 30 (range, 1 to 136) in the control group (P = 0.08). In the absence of portal vein thrombosis, ligation significantly reduced the rebleeding rate (17% vs 50%, P < 0.05) and the mortality rate (0% vs 100%, P < 0.05). CONCLUSION EVL is a good choice for palliation in patients with esophageal variceal bleeding and hepatocellular carcinoma. Aggressive use of EVL may be tried in those patients without portal venous thrombosis.

Choledocholithiasis treated by ethylenediaminetetraacetic acid infusion through an endoscopic nasobiliary catheter.

A 64 year old man was admitted to the National Cheng Kung University Hospital for obstructive jaundice. He had received cholecystectomy 5 years previously. Sonography revealed common bile duct stones. He was treated with endoscopic nasobiliary drainage (ENBD) for 5 days for concomitant cholangitis. The muddy pigment stones disappeared completely after 10 days of infusion of ethylenediaminetetraacetic acid (EDTA) via the ENBD tube. There were no adverse effects, and he was stone‐free 4 months later.

Predictors for Rebleeding of Bleeding Peptic Ulcers Characterized by Flat Spots in Bases

From January 1993 to January 1995, we conducted a prospective study to investigate the natural history and predictors for rebleeding peptic ulcers which were characterized by flat pigmented spots. Emergency endoscopies were performed on 746 patients with hematemesis or melena, or both within 24 hours after admission. The patients with peptic ulcers marked by flat pigmented spots in ulcer bases were enrolled and 14 clinical parameters were recorded for analysis of predictors of rebleeding. Results: Among the 84 patients with flat pigmented spots in initial endoscopy, 3 (3.6%) rebled. All three rebleeding episodes were successfully treated by supportive care and/or therapeutic endoscopy. The overall mortality rate was 0%. The mean time lapse of rebleeding was 3.7±0.6 days. Using Fisher exact test, hypovolemic shock emerged as a significant predictor for rebleeding (p＜0.05). The patients without hypovolemic shock had an extremely low residual risk of rebleeding (1.3%) even on admission; in contrast, subjects with hypovolemic shock faced a 50% rebleeding risk on admission, and it took 4 days to decrease the rebleeding risk to less than 3%. In summary, bleeding ulcers characterized by flat pigmented spots have a low risk of rebleeding and mortality. Hypovolemic shock is a significant predictor of rebleeding in the subpopulation. The patients with flat pigmented spots and stable hemodynamics are candidates for early discharge while patients with the same stigmata and hypovolemic shock should be observed in hospital for at least 4 days.

Fundic Gland Polyposis in Patient without Familial Adenomatosis Coli - A Case Report with Atypical Clinical Presentation and Location

A 22-year-old female with a history of frequent epigastralgia presented with coffee ground emesis. Endoscopy and upper gastrointestinal series revealed gastric ployposis extending from the cardia to the antrum. The largest polyp was more than 4 cm in diameter. Fundic gland polyposis was diagnosed from a polypectomy specimen. Fundic gland polyposis has been previously reported to present with non-specific or no gastrointestinal symptoms and is usually located in the fundus and body, The size of the polyp rarely exceeds 1 cm in diameter. This case demonstrates an unusual presentation with has not been previously reported, (Tzu-Chi Med J 194; 6: 203-208)

Primary infarction of greater omentum: report of a case

A 38-year-old alcoholic male, who had had an appendectomy at 17 years of age, suffered from indolent epigastralgia for 3 days, which rapidly progressed into severe cramping abdominal pain on the right side after a heavy meal with alcohol. His symptoms initially simulated acute cholecystitis but this was later found negative by sonography. Due to progressive abdominal distention, low grade fever, and right upper quadrant pain with peritoneal sign, abdominal CT scan was arranged through a small bowel lesion. The CT scan disclosed a heterogenic wedge-shaped area with intervening fibrous bands and hyperattentulated fatty necrosis over the RUQ. The patient was subsequently operated on, and both the surgical and pathologic findings confirmed primary infarction of greater omentum with torsion. Omental infarction is a rare cause of right-side abdominal pain and occurs at any age sporadically with certain predisposing factors. Clinically, it presents as right-side abdominal pain that simulates acute cholecystitis or appendicitis. Therefore, preoperative diagnosis is not common. Specific findings of abdominal CT scan as shown in this case is a good tool for early diagnosis.