Jyh-Jou Chen

Role of Helicobacter pylori in cirrhotic patients with peptic ulcer. A serological study.

Helicobacter pylori was found to be a promoter factor of peptic ulcer that has an incidence higher in patients with hepatic cirrhosis. To clarify the role betweenH. pylori and peptic ulcer in patients with hepatic cirrhosis, a serological test (ELISA test, HEL-p, AMRAD, Australia), was used to measure the presence ofH. pylori of patients with hepatic cirrhosis. Within two years, 108 cirrhotic patients who had received a panendoscopic examination were enrolled in this study. There were 79 males and 27 females with a mean age of 53.2 years. Sixty-four cases had positive serum HBsAg and 44 had negative serum. The results showed that the prevalence ofHelicobacter pylori in cirrhosis was 43.5% (47/108). There was no difference of HEL-p-positive rate between peptic ulcer and normal gastroduodenal mucosa (45.2% vs 46.1%,P>0.05). According to this study, there appears to be no relation between peptic ulcer andH. pylori in patients with hepatic cirrhosis. The etiology of peptic ulcer in cirrhotic patients need further study.

Septic Acute Cholecystitis

BACKGROUND Bacteremia occurs frequently in cholangitis, but the incidence of bacteremia in acute cholecystitis has not previously been examined. METHODS Seventy-eight cases (46 men and 32 women; mean age, 63 +/- 10 years) of acute cholecystitis with positive blood cultures were analyzed for clinical manifestation, bacteriology, and what consequences ensued. Seventy-eight non-bacteremic cholecystitis patients, matched for age and sex, served as the control group. RESULTS The prevalence of bacteremia in acute cholecystitis was 7.65% (78 of 1020). A single microorganism was isolated from the blood and bile in 87.2% and 27.3%, respectively. The commonest organisms were Escherichia coli and Klebsiella pneumoniae. The source of bacteremia could be identified from the infected bile in 80% of cases. Compared with the non-bacteremia group, significant increases in liver biochemical test results (aspartate and alanine aminotransferases and bilirubin, and so forth), more complications (acute renal failure and septic shock), and higher mortality (9.0%) were found in the bacteremic group. CONCLUSION Acute cholecystitis is not often complicated by bacteremia, but when bacteremia is present, morbidity and death more consistently ensue.

Sequential invasions of pancreatic pseudocysts in pancreatic tail, hepatic left lobe, caudate lobe, and spleen

A 66-year-old male patient without a history of risk factors for pancreatitis suffered from pancreatitis and developed pseudocyst. During the course of treatment and follow-up, the pseudocyst was found to have migrated through the pancreatic tail, left hepatic lobe, caudate lobe, and spleen on abdominal sonography and computed tomography scan. Finally, emergent laparotomy was done for splenic abscess and removal of infected pseudocyst in the spleen and lesser sac of the abdomen. The patient made a full recovery after operation.

Endoscopic injection sclerotherapy with 1.5% Sotradecol for bleeding cardiac varices

The authors retrospectively studied the efficacy of endoscopic injection sclerotherapy (EIS) with 1.5% Sotradecol (STD) in patients with bleeding cardiac varices (CV). Case histories of 27 patients with large, isolated, bleeding CVs were reviewed. Case records of another 27 patients with isolated esophageal varices (EV), matched for age, sex, and year EIS was performed, were selected from a computer data bank as controls. Using a small volume (2-4 ml) of injection per vessel, the rate of immediate control of bleeding was 66.7% (18 of 27) in the CV group and 70.4% (19 of 27) in the EV group. The early rebleeding rate was higher for patients in the EV group (48.1%, 13 of 27) than for those in the CV group (18.5%, 5 of 27) (p = 0.0209). On the other hand, it was more difficult to control the rebleeding from CV (p = 0.00494). In terms of mortality, there was no statistically significant difference between the CV and EV groups (33.3 versus 29.6%) within 1 week after EIS, but the 1-month post-EIS mortality rate was significantly higher (p = 0.0278) in the CV group (18 of 27, 66.7%) than in the EV group (10 of 27, 37.0%). Among those in the CV group who died of late complications within 1 month after EIS, three died of recurrent hemorrhage, five of infection, and one of viscus perforation. In the EV group, only two patients died of infection. Thus, it was concluded that EIS with small volumes (2-4 ml) of 1.5% STD was equally effective in controlling immediate bleeding from CV and EV. However, it was more difficult to control early rebleeding from CV, and the mortality and complications within 1 month after EIS were significantly higher in patients with CV. These observations are currently under careful study and evaluation.

Famotidine versus omeprazole, in combination with amoxycillin and tinidazole, for eradication of Helicobacter pylori infection.

Background Eradication regimens combining two antibiotics with a proton pump inhibitor have been studied intensively. In contrast, only a few studies have focused on the possible role of H2-receptor antagonists in eradication therapy. The mechanism involved in the synergy between antibiotics and proton pump inhibitors is still controversial. Objectives To compare the results of two triple-therapy regimens, different only in the antisecretory drugs used, in patients with Helicobacter pylori infection, and to assess the impact of primary resistance to metronidazole on treatment outcome. Methods A total of 120 patients with peptic ulcer and non-ulcer dyspepsia were randomly assigned to a 2-week course of either: famotidine 40 mg twice a day, amoxycillin 1 g twice a day and tinidazole 500 mg twice a day (FAT group; n = 60); or omeprazole 20 mg twice a day, amoxycillin 1 g twice a day and tinidazole 500 mg twice a day (OAT group; n = 60). Upper endoscopy was performed prior to treatment and at least 4 weeks after completion of treatment and discontinuation of the antisecretory therapy. H. pylori status was assessed by a biopsy urease test, histology and culture. Results In the intention-to-treat analysis, eradication of H. pylori was achieved in 48 of the 60 patients (80%; 95% confidence interval: 70–90%) in the FAT group, compared to 50 of the 60 patients (83.3%; 95% confidence interval: 74–93%) in the OAT group. In the per protocol analysis, eradication therapy was achieved in 48 out of 53 patients (90.6%; 95% confidence interval: 83–98%) treated with FAT and 50 out of 57 patients (87.7%; 95% confidence interval: 79–96%) treated with OAT (not significant). The primary metronidazole resistance was present in 28.8% of strains. Overall, per protocol eradication rates in strains resistant and susceptible to metronidazole were 83.3% and 91.3% respectively (P > 0.05). Conclusions Two-week courses of either high-dose famotidine or omeprazole, both combined with amoxycillin and tinidazole, are equally effective for eradication of H. pylori infection. In a 2-week triple therapy, metronidazole resistance has no significant impact on eradication rates.

Various sonographic patterns of smooth muscle tumors of the gastrointestinal tract: a comparison with computed tomography.

To evaluate the sonographic patterns of smooth muscle tumors of the gastrointestinal tract, we analyzed 25 patients with histologically confirmed smooth muscle tumors. Sonography revealed no abdominal mass in seven patients (sonogram‐negative), and abdominal masses in 18 patients (sonogram‐positive). The mean size of tumors in the sonogram‐negative group (4.5 +/‐ 1.5 cm) was smaller than that in the sonogram‐positive group (11.4 +/‐ 3.5 cm). We classified the various sonograms into three patterns. Comparing the sonograms with the computed tomographic pictures of each pattern, we theorized that the different patterns on sonograms may be caused by tumor necroses of different sizes with or without gas in the necrotic cavity. For the necrotic tumors, the size of the necrotic area did not correspond to the size of the tumor. However, the tumors with necroses were significantly larger than those without necroses. A central necrosis was found in cases exhibiting both leiomyosarcoma and leiomyoma. On comparing the sonogram‐positive and sonogram‐negative groups, we found that the size and location of a tumor may affect the detection rate of that tumor by sonography.

Gallbladder Volume in Patients with Common Hepatic Duct Dilatation: An Evaluation of Courvoisier's Sign Using Ultrasonography

To evaluate the usefulness of Courvoisiers sign in ultrasonography, gallbladder size in patients with common hepatic duct dilatation was measured using the ellipsoid method during ultrasonographic examination. During a 6-month period 24 patients with malignant obstructions (6 with carcinoma of the ampulla of Vater, 9 with pancreatic head tumors, 5 with carcinoma of the bile duct, and 4 with malignant lymphadenopathy), 50 patients with calculous obstructions, and a group of 50 normal control patients were examined in this study. Gallbladder volumes were larger in patients with biliary tract dilatation (88.8 +/- 6.8 ml) than in the control group (34.3 +/- 2.8 ml) (p < 0.01). Although the duration and total serum bilirubin level were higher in patients with malignant obstructions, the gallbladder volumes were the same in these two groups (93.0 +/- 11.3 ml versus 86.7 +/- 8.5 ml). A linear relationship was found between gallbladder volume and total serum bilirubin in patients with malignant biliary obstructions (r = 0.6, p < 0.001) and in patients with calculous biliary obstructions without gallbladder stones (r = 0.68, p < 0.001). We hypothesized that the gallbladder volume is irrelevant in differentiating the nature of the biliary tract dilatation and that the gallbladder size is dependent on the degree of biliary obstruction when the gallbladder is not afflicted by fibrosis.

The Clinical Manifestations of Gastric Ulcer Patients with Fungal Colonization

To examine the clinical significance of gastric ulcer with fungal colonization, we retrospectively reviewed 103 cases in the past 8 years. There were 84 males and 19 females with mean age of 58.5 years (26-81 years). The symptoms were the same as those of classical peptic ulcer. However, 38.8% of them presented upper gastrointestinal bleeding. The endoscopy revealed that 43.7% of the ulcers were greater than 2 cm in size and 24.3% showed an appearence of malignant ulcer. The ulcers were most of ten localized at angle and antrum. Thirty five percent of patients had other combined disorders at the time of diagnosis. Seventy-two percent of ulcers achieved good healing and symptomatic improvement after conventional anti-ulcer treatment without antifungal agents. This study revealed that the fungal colonization of gastric ulcer occurred frequently in aged patients or in patients with large ulcers, 38.8% of whom preseneted upper gastrointestinal bleeding. The clinical symptoms and treatment were same as those of ordinary peptic ulcer. The routine treatment using antifungal agents needs further study.