Rk Hsu

Endoscopy-based triage significantly reduces hospitalization rates and costs of treating upper GI bleeding: a randomized controlled trial.

BACKGROUND Many patients with upper gastrointestinal (GI) bleeding have a benign outcome and could receive less intensive and costly care if accurately identified. We sought to determine whether early endoscopy performed shortly after admission in the emergency department could significantly reduce the health care use and costs of caring for patients with nonvariceal upper GI bleeding without adversely affecting the clinical outcome. METHODS All eligible patients with upper GI bleeding and stable vital signs were randomized after admission to undergo endoscopy in 1 to 2 days (control) or early endoscopy in the emergency department. Patients with low-risk findings on early endoscopy were discharged directly from the emergency department. Clinical outcomes and costs were prospectively assessed for 30 days. RESULTS We randomized 110 consecutive stable patients with nonvariceal upper GI bleeding during the 12-month study period. The baseline demographic features, endoscopic findings, and the clinical outcomes were no different between the two groups. However the findings of the early endoscopy allowed us to immediately discharge 26 of 56 (46%) patients randomized to that group. No patient discharged from the emergency department suffered an adverse outcome. The hospital stay (median of 1 day [interquartile range of 0 to 3 days] vs. 2 days [interquartile range of 2 to 3 days], p = 0.0001) and the cost of care (

Therapeutic ERCP in the management of pancreatitis in children

2068 [interquartile range of

Are self-expanding metal mesh stents useful in the treatment of benign esophageal stenoses and fistulas? An experience of four cases

928 to

Crohn's disease in the Chinese population

3960] versus

Anti-neutrophil cytoplasmic antibodies (ANCA) and inflammatory bowel diseases in Chinese

3662 [interquartile range of

Reproducible demonstration of blood flow at duodenal ulcer margins by endoscopic reflectance spectrophotometry

2473 to

Endoscopic assessment of blood flow in duodenal ulcers

7280], p = 0.00006) were significantly less for the early endoscopy group. CONCLUSIONS Early endoscopy performed shortly after admission in the emergency department safely triaged 46% of patients with nonvariceal upper GI bleeding to outpatient care, which significantly reduced hospital stay and costs.

Pancreatitis caused by common bile duct stones in a 3-year-old boy with prior surgery for a choledochal cyst

BACKGROUND The use of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) is increasing in the management of pancreatobiliary diseases in children. METHODS Over a 32-month period, we performed 34 ERCP procedures for the treatment of pancreatitis in 22 children at two university hospitals. Demographics and clinical data and ERCP findings were documented. Clinical status was assessed 6 months before the first ERCP and 6 months after the last ERCP, according to general condition, severity and frequency of pain, and health care encounters (emergency department visits, clinic visits, and hospital admissions related to the pancreatitis). RESULTS Mean age of the patients was 10.7 years (range 1.5 to 17 years). Abdominal pain was the main presenting symptoms with hyperamylasemia and hyperlipasemia. Clinical diagnoses included acute pancreatitis (6), recurrent pancreatitis (5), and chronic pancreatitis (11). The mean follow-up was 16.4 months. Nine patients had sphincter manometry, with abnormal results leading to biliary sphincterotomy in 4. Fifteen patients underwent a total of 23 therapeutic ERCP procedures unrelated to sphincter dysfunction. There were 2 complications of 34 procedures (6%), both being mild pancreatitis after sphincter manometry. There were no deaths. There was a significant reduction in frequency (p < 0.01) and severity of pain (p < 0.01) after intervention. Patients without pancreatographic changes of chronic pancreatitis had the most marked clinical improvement (p < 0.05). In those with ductal changes of chronic pancreatitis, clinical improvement was not predicted by the extent of ductal changes. There was a significant decrease in health care encounters (p < 0.05) and improvement in general condition (p < 0.01) after endoscopic therapy, especially in those with a normal pancreatogram. CONCLUSIONS Therapeutic ERCP is safe in pediatric patients with pancreatitis. Significant clinical improvement is achieved in patients with biliary or pancreatic stone disease. Prospective studies with long-term follow-up are needed to determine the impact of endoscopic therapy in patients with chronic pancreatitis and sphincter of Oddi dysfunction.

Should we rely on rapid urease test or routine staining for the accurate diagnosis of helicobacter pylori

OBJECTIVE: The aim of this study was to review the long-term results of treating benign esophageal fistula and stenosis using self-expanding metal stents. METHODS: We treated four patients using covered mesh or coiled stents. We removed the stents electively in two patients (one endoscopically and one during planned partial esophagectomy) and unexpectedly in one patient who developed bleeding. One stent migrated and required laparotomy for removal. RESULTS: Placement of self-expanding metal stents successfully sealed the benign fistula in two patients and reestablished swallowing in two other patients with complicated achalasia. Two patients were swallowing normally on long-term follow-up, one died of the underlying disease, and one required gastrostomy. CONCLUSION: Temporary use of self-expanding metal stents as a feasible option for treating benign esophageal stenosis and fistula in patients who have failed other conventional treatments.

Mucin Secreting Cholangiocarcinoma Associated with Clonorchiasis

PURPOSE: Crohns disease was extremely rare among Chinese. We reviewed all cases diagnosed as having Crohns disease during a five-year period. METHODS: A diagnosis of Crohns disease was made only if all of the following criteria were fulfilled: 1) clinical symptom(s) and sign(s) compatible with chronic inflammatory bowel disease; 2) exclusion of intestinal infection by repeated stool cultures; 3) macroscopic features of small and/or large intestinal inflammation with skip lesion, stricture, and fistula formation; 4) histologic features of Crohns disease,i.e., focal lymphoid aggregate, focal cryptitis, and granuloma formation; 5) clinical response to conventional therapy for inflammatory bowel disease. RESULTS: Fifteen ethnic Chinese patients were diagnosed as having Crohns disease in this period. All patients had colitis, whereas small intestine inflammation was documented in only 47 percent of patients. Extraintestinal manifestations were uncommon except for arthropathy: ankylosing spondylitis (2), sacroiliitis (1), juvenile rheumatoid arthritis (1), and colitic arthritis (1). The majority of our patients responded to medical therapy. Surgery was undertaken in 33 percent of patients. CONCLUSION: Although there is a general increased incidence of Crohns disease in the Western world, we too are beginning to see more cases in the Far East. Nevertheless, gastrointestinal infection with bacteria and/or parasites should still be carefully excluded in these countries.