Shue-Shian Chiou

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.

Randomized Comparison of Two Non-Bismuth-Containing Second-line Rescue Therapies for Helicobacter pylori

Background:  Classical second‐line anti‐Helicobacter pylori includes proton‐pump inhibitor, tetracycline, metronidazole, and bismuth salts, but alternative therapies are required owing to the restricted availability of the latter. Levofloxacin‐containing triple therapy is recommended but is expensive. Besides, quinolone resistance in an endemic tuberculosis infection area like Taiwan is concerned. The low in vitro antibiotic resistance to amoxicillin and tetracycline in Taiwanese H. pylori strains implies that in vivo esomeprazole/amoxicillin/tetracycline (EAT) second‐line rescue therapy may be effective. This study compared the efficacy of esomeprazole/amoxicillin/levofloxacin (EAL) and EAT second‐line eradication therapies and determines the clinical factors influencing the efficacy of salvage regimens.

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.

The Clinical and Bacteriological Factors for Optimal Levofloxacin-Containing Triple Therapy in Second-Line Helicobacter pylori Eradication

Quinolone has the disadvantage of easily acquired drug resistance. It is important to prescribe it wisely for a high eradication rate. The current study aimed to determine the clinical and bacteriological factors for optimal levofloxacin-containing triple therapies in second-line H. pylori eradication. We enrolled a total of 158 H. pylori-infected patients who failed H. pylori eradication using the 7-day standard triple therapy (proton-pump inhibitor [PPI] twice daily, 500 mg clarithromycin twice daily, and 1 g amoxicillin twice daily). They were prescribed with either a 10-day (group A) or 14-day (group B) levofloxacin-containing triple therapy group (levofloxacin 500 mg once daily, amoxicillin 1 g twice daily, and esomeprazole 40 mg twice daily for 10 days) by their clinicians. Follow-up studies to assess treatment responses were carried out 8 weeks later. The eradication rates attained by groups A and B were 73.6% (95% confidence interval [CI] = 63.9–85.3%) and 90.5% (95% CI = 84.5–98.1%), respectively in the per protocol analysis (P = 0.008 in the per protocol analysis) and 67.1% (95% CI = 56.6–78.5%) and 84.8% (95% CI = 76.8–93.4%), respectively, in the intention-to-treat analysis (P = 0.009). The subgroup analysis revealed that H. pylori eradication rates for group A patients with levofloxacin-susceptible strains were 92.9% (13/14) but it dropped to 12.5% (1/8) when levofloxacin-resistant strains existed. H. pylori was eradicated among all the group B patients with levofloxacin-susceptible strains, but only half of patients with levofloxacin-resistant strains were successfully eradicated. In conclusion, this study confirms the effectiveness of 14-day treatment. Importantly, the results imply that 10-day treatment duration should be optimal if a culture can be performed to confirm the existence of susceptible strains. The duration of H. pylori eradication and levofloxacin resistance were the influencing factors for successful treatment. This study suggests that tailored levofloxacin-containing therapy should be administered only for patients with susceptible strains because it can achieve >90% success rates.

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.

Baseline and serial liver stiffness measurement in prediction of portal hypertension progression for patients with compensated cirrhosis

Liver stiffness measurement (LSM) using transient elastography is useful in prediction of significant portal hypertension (PHT). To evaluate the usefulness of baseline and serial LSM in predicting clinical disease progression (CDP) for patients with compensated hepatic cirrhosis.

Risk factors influencing the outcome of peptic ulcer bleeding in end stage renal diseases after initial endoscopic haemostasis

Background and Aims:  Patients suffering from peptic ulcer (PU) bleeding who have end‐stage renal disease (ESRD) may encounter more adverse outcomes. The primary objective is to investigate the risk factors that influence the outcomes of ESRD and chronic kidney disease (CKD) patients with PU bleeding after successful initial endoscopic haemostasis.

Ten-Day versus 14-Day Levofloxacin-Containing Triple Therapy for Second-Line Anti-Helicobacter pylori Eradication in Taiwan.

Second-line Helicobacter pylori (H. pylori) eradication with fluoroquinolone-containing triple therapy is one of the recommended treatment options, but neither 7-day nor 10-day regimens provide >90% success rates. The current retrospective study aimed to clarify the effects of 10-day and 14-day levofloxacin-containing triple therapies for second-line H. pylori eradication in a Taiwanese cohort and to evaluate the potential clinical factors influencing eradication. A total of 200 patients who failed H. pylori eradication using the standard triple therapy were prescribed with either a 10-day (EAL-10) or a 14-day (EAL-14) levofloxacin-containing triple therapy group (levofloxacin 500 mg once daily, amoxicillin 1 g twice daily, and esomeprazole 40 mg twice daily). Follow-up studies to assess treatment response were carried out 8 weeks later. Eradication rates attained by EAL-10 and EAL-14 were 75.6%; 95% CI = 63.9–85.3% and 92.5%; 95% CI = 84.5–98.1%, P = 0.002 in the per protocol analysis and 68%; 95% CI = 56.6–78.5% and 86%; 95% CI = 76.8–93.4%, P = 0.002 in the intention-to-treat analysis. The duration of H. pylori therapy is the independent risk factor of H. pylori eradication (P = 0.003). In conclusion, 14-day levofloxacin-containing triple therapy can provide a >90% H. pylori eradication rate, but 10-day treatment duration may be suboptimal. The longer duration of H. pylori therapy (14 days) is the independent risk factor.

Seven-Day Nonbismuth Containing Quadruple Therapy Could Achieve a Grade “A” Success Rate for First-Line Helicobacter pylori Eradication

This prospective study was to assess the efficacy of nonbismuth containing quadruple therapy as first-line H. pylori treatment and to determine the clinical factors influencing patient outcome. We enrolled 200 H. pylori-infected naïve patients. They were prescribed either a 7-day nonbismuth containing quadruple therapy group (EACM, esomeprazole 40 mg twice daily, amoxicillin 1 g twice daily, metronidazole 500 mg twice daily, and clarithromycin 500 mg twice daily) or a 7-day standard triple therapy group (EAC, esomeprazole 40 mg twice daily, amoxicillin 1 g twice daily, and clarithromycin 500 mg twice daily). Follow-up studies to assess treatment responses were carried out 8 weeks later. The eradication rates attained by EACM and EAC groups were 95.6% (95% confidence interval [CI] = 89.4%–98.3%) and 79.3% (95% CI = 70%–86.4%) in the per-protocol analysis (P < 0.001) and 88% (95% CI = 80.2%–93.0%) and 73% (95% I = 63.6%–80.3%) in the intention-to-treat analysis (P = 0.007). Clarithromycin resistance, metronidazole resistance, and dual clarithromycin and metronidazole resistances were the clinical factors influencing H. pylori eradication in EACM group. Clarithromycin resistance and dual clarithromycin and metronidazole resistances were the influential factor for EAC treatment. In conclusion, the results suggest that 7-day nonbismuth containing quadruple therapy could achieve a grade “A” report card for first-line H. pylori treatment.