Kaka Renaldi

Changing trends in gastrointestinal malignancy in Indonesia: The Jakarta experience

Aims: To identify changing trends in gastrointestinal cancer incidence in Indonesia according to age, gender, histopathology, and cancer location. Methods: We examined retrospectively the demography, cancer location, and pathological characteristics of 295 consecutive gastrointestinal cancer patients admitted to Cipto Mangunkusumo National General Hospital in 2002–2006. We compared these data with data from 343 gastrointestinal cancer patients admitted in 2007–2011. The data were analyzed by chi-square, analysis of variance, Kolmogorov–Smirnov, and Mann–Whitney U tests using SPSS 21.0. Results: The most prevalent gastrointestinal cancers in 2002–2006 and 2007–2011 were colorectal cancer (76.3% and 71.4%), followed by gastric cancer (15.6% and 14.9%), esophageal cancer (7.4% and 7.6%), and duodenal cancer (0.7% and 6.1%).There was an increase in esophageal adenocarcinoma prevalence from 36.4% to 69.2% (p = 0.023). The mean age at diagnosis of esophageal cancer decreased from 53.02 ± 13.12) to 50.43 ± 11.93) years (p = 0.031). The percentage of patients with gastric cancer aged 30–60 years increased from 60.9% to 82.4% (p = 0.018) and the percentage of patients aged > 60 years decreased from 34.8% to 13.7% (p = 0.015). In the histopathological analysis of gastric cancer, the prevalence of adenocarcinoma increased from 58.7% to 78.4% (p = 0.036), whereas the prevalence of signet ring cell carcinoma decreased from 21.7% to 5.9% (p = 0.022). The prevalence of gastric cancer lesions extending to >1 location increased from 2.2% to 27.5% (p = 0.001).The frequency of duodenal cancer among women increased non significantly from 0% to 52.4% (p = 0.261). The demography, histopathology, and location of colorectal cancers did not change between the two periods. Conclusions: Our study shows some changing trends in gastrointestinal malignancy in Indonesia in terms of demography, histopathology, and the location of cancers from 2002–2006 to 2007–2011.

Influence of Fucoidan in Mucus Thickness of Gastric Mucosa in Patients with Chronic Gastritis

Background: Chronic gastritis is commonly found with complains of dyspepsia, which may decrease work productivity. Imbalance between agressive and defensive factors is the cause of chronic gastritis. Therapy is mostly directed to the agressive factors, particularly gastric acid and very few studies are directed on defensive factors. Mucus is the first defense mechanism of gastric mucosa. Fucoidan is a phytopharmaca, which is thought to increase the thickness of gastric mucosa. The objective of this study was to know the thickness of gastric mucosa in patients with chronic gastritis and to evaluate the effect of fucoidan to the gastric mucosa thickness in patients with chronic gastritis. Method: In this double-blinded randomized clinical trial study, 41 patients in the Endoscopy Unit Cipto Mangunkusumo Hospital between October 2009 and October 2010 were enrolled consecutively. Selected patients were divided into 2 groups: a group was given fucoidan and another group was given placebo. Statistical analysis was done using T-test. Results: Of 41 chronic gastritis patients, only 34 patients completed this study. There was difference of mucus thickness of gastric mucosa in patients with chronic gastritis; in the antrum 42.59 µ m (± 8.67) and in the corpus 44.28 µ m (± 9.64). This study also showed that fucoidan administration increased the mucus thickness in the antrum by 7.42 µ m and in the corpus by 7.74 µ m compared to placebo significantly. Conclusion: Fucoidan increased the mucus thickness of gastric mucosa in patients with chronic gastritis. Keywords: mucus thickness, chronic gastritis, fucoidan

Unusual Case of Massive Obscure Gastrointestinal Bleeding: Ectopic Varices in Jejunum Caused by Arteriovenous Malformation

Small bowel ectopic varices is a rare etiology for obscure gastrointestinal bleeding. Ectopic varices in the absence of portal hypertension can be caused by congenital or familial conditions (e.g. malformation of vessel). Bleeding caused by ectopic varices can be massive and life threatening. Single Balloon Enteroscopy (SBE) is one of diagnostic modalities for obscure gastrointestinal bleeding. We report one case of obscure overt gastrointestinal bleeding with sub-acute onset. Previous esophagogastroduodenoscopy and colonoscopy cannot found the source of bleeding. On the enteroscopy we found varices at proximal jejunum with active bleeding during procedure. We applied hemostatic powder to stop the bleeding and proceed to surgery. Surgery was performed by enteroscopy guide. The jejunum section with varices was resected and the pathology confirmed the malformation of arteriovenous. Currently there is no available guideline or randomized study for the treatment of ectopic varices. Treatment options include ligation, sclerotherapy, surgery and interventional radiology. In this patient we choose surgery because of massive gastrointestinal bleeding.

Management of Gastric Motility Disorder

Gastric motility disorder or gastroparesis is an objective slowing of gastrointestinal emptying syndrome, in the absence of mechanical obstruction, with cardinal symptoms such as rapid feeling of fullness, fullness sensation after eating, nausea, vomiting, bloating, and upper abdominal pain. Patients with gastroparesis are at risk of weight loss, malnutrition, and lack of vitamins and minerals, as well as increasing morbidity and mortality. The prevalence and incidence data of gastroparesis do not describe the true reality, because of the complexity of diagnosis. Beside Diabetes mellitus, many other causes should also be considered. Several studies have shown that nausea, vomiting and fullness sensation in abdominal are the most associated symptoms with gastroparesis. A 4-hour solid phase gastric emptying scintigraphy is the diagnostic standard for the slowing of gastric emptying. Lowest effective dose metoclopramide starting with a dose of 3 x 5 mg is the first line for pharmacological therapy. For persistent or refractory gastroparesis with pharmacologic therapy, gastric electrical stimulation (GES) and surgical therapy may be considered. The management should involve relevant medical team by not forget to consider patient comfort.

Prevention and Management of Refeeding Syndrome

Refeeding Syndrome is a syndrome which occurs as a result of food administration in poorly nourished individuals. In this syndrome, there are wide range of biochemical alterations, clinical manifestations, and complications, starting from mild (asymptomatic) to severe (death). This syndrome was initially proposed in 1950s; however, there is still no agreement for its clear definition, causing clinicians to be less aware and tend to overlook this condition. Clinical manifestations which usually appear include electrolyte imbalances (hypophosphatemia, hypokalemia, hyponatremia, hypomagnesemia) and vitamin B1 deficiency. The main principle in management of refeeding syndrome is prevention, where clinicians need to identify this condition in the early stage in high risk individuals, supervision during refeeding, and administration of appropriate diet.

National Consensus on the Use of Sedation Drugs in the Gastrointestinal Endoscopic Procedures

Gastrointestinal endoscopy is rapidly developing and several gastrointestinal endoscopy equipment are available for both diagnostic and therapeutic purposes. Proper sedation is critical in performing endoscopic procedures, both for patients and physicians. This consensus is used as a guideline and not as a legal standard in performing endoscopic services. This consensus explained the definition, indication, contraindication, and complication prevention during sedation. Factors affecting the need of sedation is patient factors, procedure factors, and sedation level. Diagnostic or therapeutic upper gastrointestinal tract endoscopy which not complicated can be performed with minimal sedation or moderate sedation, while deep sedation can be considered for longer and more complex procedures. Furthermore, assessment and selection of sedation was explained, followed by the guide to choose pharmacological sedation and analgesics. Currently, diazepam, midazolam, propofol, fentanyl, and pethidine is the most likely used sedation during gastrointestinal endoscopy, with midazolam as the preferred medication of choice. This consensus also explained the antidote of each drug and the recovery after procedure. This consensus aimed to improve gastrointestinal endoscopic procedure services in Indonesia.

Comparison of Endoscopic Ultrasound (EUS) and Magnetic Resonance Cholangiopancreatography (MRCP) in Diagnosing Cholelithiasis in Acute Biliary Pancreatitis Patients

Aim: To determine how endoscopic ultrasound (EUS) is compared to magnetic resonance cholangiopancreatography (MRCP) in diagnosing cholelithiasis in acute biliary pancreatitis. Method: Five steps of evidence based medicine is conducted, they are: (1) Formulate the clinical question; (2) Search the evidence; (3) Appraise the study; (4) Apply the answer; (5) Assess the outcome. The search term in general is: (“cholelithiasis”) and (“EUS”) and (“MRCP”) and diagnosis. Results: We searched in Pubmed and Cochrane library. We excluded articles that do not focus on answering our clinical question. There is one systematic review that is capable of answering our clinical question. Conclusion: It can generally be concluded from this study that EUS and MRCP are useful techniques in the etiological diagnosis of acute pancreatitis of non-established cause. Endoscopic ultrasonography should be preferred for establishing a possible biliary etiology in patients who have not had a cholecystectomy.

Through-the-scope Polyethylene Balloon Dilations in Benign Corrosive Esophageal Stricture Complicated with Temporomandibular Joint Dislocation

Esophageal dilation is a non-surgical management for anatomic and functional abnormalities causing both benign and malignant esophageal stricture. The basic goals of stricture dilation include safe and efficacious lumenal enlargement plus prevention of restenosis. These could be achieved using through- the-scope (TTS) balloon dilations, ranged in diameter of 4 to 40 mm, they will allow dilation of previously inaccessible strictures in the esophagus, stomach, small bowel, and colon. There are 5,000–15,000 cases of stricture due to ingestion of corrosive substances in United States every year. The following case would demonstrate a 28-year-old male with depressive disorder who attempted a suicide by ingesting corrosive substances two months before admission. Subsequently he started having difficulty in swallowing even soft foods. The complaint was gradually increasing until a month before admission he went through endoscopic examination and a corrosive esophageal stricture found. Hence after, he underwent dilation using Savary bouginage with fluoroscopy and through-the-scope (TTS) balloon dilations. The patient underwent a series of dilation treatment and demonstrated vigorous improvement. Problems raised as the patient was complicated with temporomandibular joint (TMJ) dislocation due to traumatic injury after ingesting corrosive substances. The consideration in management of esophageal stricture with complications will be discussed further in this article. Keywords: esophageal stricture, corrosive substances, dysphagia, temporomandibular joint dislocation, through-the-scope polyethylene balloon dilation