Jui-Hsiang Tang

Caustic ingestion in adults: The role of endoscopic classification in predicting outcome

BackgroundThe ingestion of caustic substances induces an extensive spectrum of injuries to the aerodigestive tract which include extensive necrosis and perforation of the esophagus and stomach. The gold standard of safely assessing depth, extent of injury, and appropriate therapeutic regimen is esophagogastroduodenoscopy (EGD). The objective of this study was to report our clinical experience and to evaluate the role of a 6-point EGD classification system of injury in predicting outcomes in adult patients diagnosed with caustic agent ingestion.MethodsThe study was a retrospective medical chart review from 273 patients admitted to the Chang Gung Memorial Hospital in Tao-Yuan, Taiwan between June 1999 and July 2006 for treatment of caustic ingestion. The patients underwent EGD within 24 hours of admission and mucosal damage was graded using Zagars modified endoscopic classification scheme. After treatment, patients were followed in the outpatient clinic for a minimum of 6 months.ResultsA total of 273 patients were included for analysis. Grade 3b injury was the most common caustic injury (n = 82, 30.03%), followed by grade 2b injuries (n = 62, 22.71%). Stricture was the most common complication (n = 66, 24.18%), followed by aspiration pneumonia (n = 31, 11.36%), and respiratory failure (n = 21, 7.69%). Compared to grade 3a mucosal injury, grade 3b mucosal injuries were at greater risk of prolonged hospital stay (odds ratio [OR]: 2.44; 95% confidence interval [CI]: 1.25–4.80), ICU admission (OR: 10.82; 95% CI: 2.05–200.39), and gastrointestinal (OR: 4.15; 95% CI: 1.55–13.29) and systemic complications (OR: 4.07; 95% CI: 1.81–14.07).ConclusionIn patients with caustic ingestion, EGD should be performed within 12 to 24 hours and categorized according to a 6-point scale. Patients with grade 3b burns identified on endoscopy have high rates of morbidity. The 6-point scale is useful for predicting immediate and long-term complications, and guiding appropriate therapy.

Endoscopic management of Dieulafoy lesions in acute nonvariceal upper gastrointestinal bleeding

Dieulafoy lesion is an unusual but important cause of upper gastrointestinal bleeding. The study retrospectively reviewed 29 patients (2.1%) with Dieulafoy lesions of 1393 acute nonvariceal upper gastrointestinal bleeding episodes from October 1999 to May 2001. Nineteen patients (66%) were male and the median age was 62 years (range, 19 to 86 years). Two patients underwent emergent surgery after endoscopic diagnosis. The other patients were allocated to four therapeutic endoscopic groups: group I, epinephrine injection (11 patients); group II, epinephrine injection plus heater probe coagulation (10 patients); group III, histoacryl injection (4 patients); and group IV, hemoclipping (2 patients). Initial treatment failure ocurred in three patients (all in group I) and they received surgery, hemoclipping, or band ligation as salvage therapy, respectively. Among those who achieved initial hemostasis, recurrent bleeding developed in two patients (all in group I) and was successfully controlled by endoscopic injection plus thermal therapy. No complication was noted after endoscopic treatment. Group II had a significantly higher successful hemostasis rate than group I (100 vs 54%; P = 0.02). One patient in the therapeutic endoscopy groups died during admission, for a mortality rate of 3.7%. Patients were followed up from 6 to 36 months and no further bleeding was noted. The results suggest that epinephrine injection plus heater probe coagulation was significantly superior to epinephrine injection alone in achieving hemostasis. Histoacryl injection, hemoclipping, and endoscopic band ligation were safe and effective alternate therapies.

Frequency and Risk Factors for Barrett’s Esophagus in Taiwanese Patients: A Prospective Study in a Tertiary Referral Center

BackgroundThere is a paucity of epidemiologic data concerning Barrett’s esophagus (BE) in Taiwan.AimThis study aimed to investigate the frequency of and risk factors for BE in self-referred Taiwanese patients undergoing diagnostic endoscopy.MethodsA total of 736 consecutive patients undergoing upper endoscopy for a variety of gastro-intestinal symptoms from February to October 2007 were evaluated. A standard questionnaire was used to record the clinical characteristics and patient symptoms. Gastro-esophageal reflux disease (GERD) was diagnosed using the Montreal definition, while the Los Angeles Classification and Prague Circumferential and Maximal Criteria were used to assess erosive esophagitis and BE, respectively. Four-quadrant biopsies were taken from endoscopically suspected esophageal metaplastic mucosa every 2xa0cm for histologic evaluation. Eight variables were tested using a logistic regression model to identify risk factors for BE in GERD patients.ResultsGERD was diagnosed in 344 patients, with typical esophageal symptoms noted in 255, reflux chest pain syndrome in 107, and extra-esophageal syndrome in 51, while 27 were asymptomatic. The mean age of the GERD patients was 49.8xa0years and 55.5% of them were male. Thirty-six percent (123 of 344) demonstrated erosive esophagitis and 95% were classified as having Los Angeles grade A or B disease. BE was diagnosed in 13 patients (3.8% of GERD patients), three of whom had dysplastic mucosa. In the final analysis model, hiatal hernia (odds ratio [OR]xa0=xa04.7, 95% confidence interval [CI]xa0=xa01.3–17.7, Pxa0=xa00.02) and GERD durationxa0>5xa0years (ORxa0=xa04.2, 95% CIxa0=xa01.2–4.8, Pxa0=xa00.03) were independent risk factors for the development of BE.ConclusionThere is a 3.8% frequency of BE in Taiwanese GERD patients. Hiatal hernia and prolonged GERD duration are significant risk factors.

Endoscopic Diagnosis of Helicobacter pylori Infection by Rapid Urease Test in Bleeding Peptic Ulcers : A Prospective Case-Control Study

Goal To assess the efficacy of rapid urease test (RUT) in patients with bleeding ulcers, as well as the effects of visible blood in the stomach and short-term (<24u2009h) use of standard-dose proton pump inhibitor (PPI) on RUT sensitivity. Background The sensitivity of RUT in the diagnosis of Helicobacter pylori in upper gastrointestinal bleeding has been reported with conflicting results. Study This was a prospective case-control study evaluating 324 consecutive patients with bleeding peptic ulcers (study group) and 164 with uncomplicated ulcers (control group). The presence of H. pylori infection was determined by both RUT and histology. Prevalence of H. pylori infection and the RUT sensitivity in diagnosing the bacteria between study and control groups were conducted. Results The prevalence of H. pylori infection in those with bleeding ulcers was significantly lower than that of controls (53.7% vs. 65.2%, P=0.015). The false-negative rate of RUT in the study group was significantly greater than that of the control group (16.7% vs. 5.6%, P=0.006), whereas the sensitivity rates in the study group with or without gastric blood were significantly lower than those of the controls (79.6% vs. 94.4%, P=0.005; 84.8% vs. 94.4%, P=0.019). There was no significant difference in RUT sensitivity between study group with or without visible gastric blood (P=0.41). The RUT sensitivity rate was also not significantly different between those treated with PPI and those without in patients with bleeding ulcers (82.7% vs. 85.7%, P=0.67). Conclusions This study shows that the sensitivity of RUT in patients with bleeding ulcers is reduced. The presence of blood in the stomach and the short-term use of standard-dose PPI do not affect the RUT sensitivity in bleeding ulcers.

Predictors of Rebleeding and Mortality in Patients with High-Risk Bleeding Peptic Ulcers

Background and AimPatients with bleeding ulcers can have recurrent bleeding and mortality after endoscopic therapy. Risk stratification is important in the management of the initial patient triage. The aim of this study is to identify the clinical and laboratory risk factors for recurrent bleeding and mortality.MethodsA prospective study was conducted in 390 consecutive patients with bleeding peptic ulcers and high-risk endoscopic stigmata, e.g., active bleeding, a non-bleeding visible vessel, adherent blood clot, and hemorrhagic dot. We tested 13 available variables for association with recurrent bleeding and 15 were tested for association with mortality. A logistic regression model was used to identify individual correlates associated with these adverse outcomes.ResultsBleeding recurred in 46 patients (11.8%) within 3xa0days and 21 patients (5.4%) had in-hospital mortality. In the full-factor analysis model, the incidence of recurrent bleeding was significantly higher in five of the 13 investigated variables and mortality was significantly higher in two of the 15 variables. In the final analysis model, significant risk factors for recurrent bleeding within 3xa0days, with adjusted odds ratios (OR), were in-hospital bleeding (OR 3.3), initial hemoglobin level <10xa0g/dl (OR 3.3) and ulcer ≥2xa0cm (OR 2.0). In-hospital bleeding was the only independent risk factor for mortality (OR 8.3).ConclusionThe study emphasizes the role of ulcer size, anemia and in-hospital bleeding as the determining high-risk predictors for adverse outcomes for bleeding peptic ulcers.

Outcomes of bleeding peptic ulcers: a prospective study.

Background and Aim:u2002 Bleeding peptic ulcers can be due to Helicobacter pylori (H.u2003pylori) infection, use of non‐steroidal anti‐inflammatory drugs (NSAIDs), or idiopathic causes. The aim of this prospective study was to identify the clinical outcomes of bleeding peptic ulcers related to different causes.

Endoscopic retrograde cholangiography in the diagnosis and treatment of mucobilia.

Objective. Some biliary neoplasms secrete copious mucin into bile ducts, yet the management of mucobilia is not well known. The objective of this study was to analyze 16 patients with copious mucin in the biliary tract stressing the diagnostic and therapeutic aspects of endoscopic retrograde cholangiography (ERC). Material and methods. Sixteen patients with mucobilia were found among 5635 cases of ERC from October 1999 to October 2006 in our institution. Diagnostic and therapeutic ERC as well as clinical features were retrospectively analyzed. Results. Mucin had a greater impact than the neoplasm itself on the cholangiogram and clinical presentation. ERC failed to show the tumors but a disproportionate or aneurysmal dilatation of the segmental or lobar duct correlated with the tumor-bearing duct was evident. Endoscopic managements included clearance of intraductal mucin and/or endoscopic nasobiliary drainage (ENBD). Three patients were excluded from outcome assessment because of non-specific symptoms or spontaneously subsiding jaundice. Among the 13 patients eligible for assessment, subjective improvement in symptoms and/or a decrease in jaundice along with subsiding cholangitis following ERC was observed in 5 of the 7 patients that underwent both clearance of intraductal mucin and ENBD (ENBD function was poor in all 7 patients), in 1 patient who underwent only clearance of intraductal mucin, and in 3 of the 5 patients who underwent only ENBD. The three patients with progressive jaundice, despite endoscopic management, had advanced disease. Conclusions. ERC revealed the tumor-bearing duct but not the extent of the disease in most of the patients with mucobilia. When mucobilia is encountered during ERC, the management should include clearance of as much intraductal mucin as possible. ENBD is frequently obstructed by mucin and may be helpful only in selected cases.

Double-balloon enteroscopy for ERCP in patients with Billroth II anatomy: results of a large series of papillary large-balloon dilation for biliary stone removal.

Background and study aims: Data on double-balloon enteroscopy (DBE)-assisted endoscopic retrograde cholangiopancreatogrphy (ERCP) in patients with Billroth II gastrectomy and the use of endoscopic papillary large-balloon dilation (EPLBD) for the removal of common bile duct stones in Billroth II anatomy are limited. The aims of the study were to evaluate the success of DBE-assisted ERCP in patients with Billroth II gastrectomy and examine the efficacy of EPLBD (u200a≥u200a10u200amm) for the removal of common bile duct stones. Patients and methods: A total of 77 patients with Billroth II gastrectomy in whom standard ERCP had failed underwent DBE-assisted ERCP. DBE success was defined as visualizing the papilla and ERCP success as completing the intended intervention. The clinical results of EPLBD for the removal of common bile duct stones were analyzed. Results: DBE was successful in 73 of 77 patients (95u200a%), and ERCP success was achieved in 67 of these 73 (92u200a%). Therefore, the rate of successful DBE-assisted ERCP was 87u200a% (67 of a total of 77 patients). The reasons for ERCP failure (nu200a=u200a10) included tumor obstruction (nu200a=u200a2), adhesion obstruction (nu200a=u200a2), failed cannulation (nu200a=u200a3), failed stone removal (nu200a=u200a2), and bowel perforation (nu200a=u200a1). Overall DBE-assisted ERCP complications occurred in 5 of 77 patients (6.5u200a%). A total of 48 patients (34 male, mean age 75.5 years) with common bile duct stones underwent EPLBD. Complete stone removal in the first session was accomplished in 36 patients (75u200a%); mechanical lithotripsy was required in 1 patient. EPLBD-related mild perforation occurred in 2 patients (4u200a%). No acute pancreatitis occurred. Conclusions: DBE permits therapeutic ERCP in patients who have a difficult Billroth II gastrectomy with a high success rate and acceptable complication rates. EPLBD is effective and safe for the removal of common bile duct stones in patients with Billroth II anatomy.

Residual Gastric Volume After Bowel Preparation With Polyethylene Glycol for Elective Colonoscopy: A Prospective Observational Study

Goal: To examine the residual gastric volume (RGV) in colonoscopy after bowel preparations with 3-L polyethylene glycol (PEG). Background: Obstacles to high-volume bowel preparation by anesthesia providers resulting from concerns over aspiration risk are common during colonoscopy. Study: Prospective measurements of RGV were performed in patients undergoing esophagogastroduodenoscopy (EGD) and morning colonoscopy with split-dose PEG preparation, patients undergoing EGD and afternoon colonoscopy with same-day PEG preparation, and patients undergoing EGD alone under moderate conscious sedation. Colonoscopy patients were allowed to ingest clear liquids until 2 hours before the procedure. Patients undergoing EGD alone were instructed to eat/drink nothing after midnight. Results: There were 860 evaluated patients, including 330 in the split-dose preparation group, 100 in the same-day preparation group, and 430 in the EGD-only group. Baseline demographics and disease/medication factors were similar. The mean RGV in patients receiving the same-day preparation (35.4 mL or 0.56 mL/kg) was significantly higher than that in patients receiving the split-dose preparation (28.5 mL or 0.45 mL/kg) and in patients undergoing EGD alone (22.8 mL or 0.36 mL/kg) (P=0.023 and P<0.0001, respectively). Within the bowel-preparation groups, patients with fasting times of 2 to 3 hours had similar RGV compared with patients who had fasting times >3 hours. The shape of the distribution and the range of RGV among the 3 study groups were similar. No aspiration occurred in any group. Conclusions: PEG bowel preparations increase RGV mildly, but seem to have no clinical significance. These results support the current fasting guidelines for colonoscopy.

Choledochal cyst with malignancy: magnetic resonance imaging and magnetic resonance cholangiopancreatographic features in two cases.

Choledochal cyst is an uncommon congenital malformation most frequently seen in Asian females [1–5]. Irwin and Morison first reported a case of choledochal cyst with underlying cancerous change in 1944 [6]. The risk of developing carcinoma in the cyst has been reported to be between 4% and 28% [4, 5, 7–9]. There have been a few reports on the imaging findings of biliary malignancy occurring in choledochal cysts in which most of the published images were performed with computed tomography (CT) and/or ultrasonography [9–13]. Magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography (MRCP) features of choledochal cyst associated with malignancy have rarely been reported [14]. This report illustrates the MRCP and endoscopic retrograde cholangiopancreatography appearances of cholangiocarcinoma in a choledochal cyst and the MRI features of tumor invasion to adjacent organs.