Shun-Sheng Wu

Dietary habits and right-sided colonic diverticulosis

PURPOSE: In Asian populations, there is a high prevalence of right-sided colonic diverticulosis, the cause of which is uncertain. It is suspected that dietary habits may interact with a congenital predilection to cause this condition. To evaluate the relationship between long-term dietary habits and the prevalence of right-sided diverticulosis in the general population, we performed a retrospective case-control study. METHODS: We reviewed the records of 3,105 screening colonoscopies performed on healthy, asymptomatic adults. All cases of right-sided diverticulosis were selected, and a similar number of gender-matched and age-matched controls with negative colonoscopies were randomly sampled from the same cohort. All case and control subjects were interviewed by a single-blinded nurse to establish their dietary habits during the past decade, in addition to other demographic characteristics. Based on consumption frequency, they were assigned to one of three diet classes for each of three food categories of interest: meat, vegetable, and fruit products. Staple foods such as rice were not included. Odds ratios were then calculated using multivariate conditional logistic regression and tests for trend were performed. RESULTS: A total of 86 cases of right-sided diverticulosis were included, whereas 106 controls were randomly selected. There was a marked association between meat consumption frequency and right-sided diverticulosis, with a trendP value of <0.01 and an odds ratio of 24.81 between the most and least frequent consumers of meat products. Conclusions: The prevalence of right-sided diverticulosis is strongly positively associated with past meat consumption frequency. There is no association with vegetable or fruit consumption frequency, laxative use, supplemental fiber intake, smoking, or family history.

Ascitic fluid carcinoembryonic antigen and alkaline phosphatase levels for the differentiation of primary from secondary bacterial peritonitis with intestinal perforation

BACKGROUND/AIMS In cirrhotic patients, spontaneous bacterial peritonitis (SBP) may be difficult to distinguish from secondary peritonitis with occult intestinal perforation; Runyons criteria (based on ascitic fluid glucose, protein and lactate dehydrogenase levels) are sensitive but not specific. Ascitic fluid carcinoembryonic antigen (CEA) and alkaline phosphatase (AP) are potential markers for secondary peritonitis. METHODS Ascitic fluid CEA and AP levels were prospectively compared among three subject groups--cirrhotic patients with sterile ascites, cirrhotic patients with SBP, and patients (cirrhotic and non-cirrhotic) with perforation-related secondary peritonitis. RESULTS The secondary peritonitis group (n = 38 including 11 cirrhotic patients) had significantly higher mean CEA and AP levels than the SBP (n = 34) and sterile ascites patients (n = 63). Of secondary peritonitis patients, 92% fulfilled predetermined criteria (either CEA >5 ng/ml or AP >240 units/l) versus only 12% of SBP patients; sensitivity was 92% and specificity 88% for differentiating secondary peritonitis from SBP. Runyons criteria had a sensitivity of 97% and specificity of 56%. Stratification of secondary peritonitis patients by the presence or absence of cirrhosis did not alter our results. CONCLUSIONS Ascitic fluid CEA or AP elevations appear to be sensitive and specific markers for perforation-related secondary peritonitis in cirrhotic as well as non-cirrhotic patients.

CASE REPORT: Isolated gastric tuberculosis of the cardia

Background: Isolated gastric tuberculosis is extremely rare, especially in the subcardiac region, where the low pH, high motility and absence of lymphoid tissue result in an unfavourable environment for the development of tuberculous lesions.

Pyogenic liver abscess and colorectal neoplasia: A case series

Background: Colorectal neoplasia is occasionally associated with hepatic abscess. To identify cases, we retrospectively analyzed the medical records of all patients admitted to our hospital for liver abscess from 2004 to 2008. Methods: Underlying disease was actively sought for all patients. Cases with obvious causes, such as biliary tract obstruction and immunocompromising conditions, were excluded. Results: Out of 211 cases of liver abscess included, 12 were found to be associated with colorectal neoplasia. None of these 12 cases had gastrointestinal symptoms. The stool occult blood test was positive in only 3 cases. There were 3 cases of focal adenocarcinoma in tubulovillous adenoma and the remaining 9 cases all had adenomatous polyps. Complete cure was achieved in all cases. Conclusions: When managing patients with liver abscess, colorectal neoplasia should be considered as a possible associated underlying condition.

Thalidomide-based multidisciplinary treatment for patients with advanced hepatocellular carcinoma: A retrospective analysis

AIM To evaluate the efficacy of thalidomide in combination with other therapies to treat patients with advanced hepatocellular carcinoma (HCC). METHODS We performed a retrospective analysis of all patients with HCC who were treated with thalidomide for at least two months. The medical records of patients with HCC who were treated at our institution between April 2003 and March 2008 were reviewed. Image studies performed before and after treatment, tumor response, overall survival, and the decrease in α-fetoprotein (AFP) levels were evaluated. RESULTS A total of 53 patients with HCC received either 100 or 200 mg/d of thalidomide. The patient population consisted of 9 women and 44 men with a median age of 61 years. Thirty patients (56.6%) were classified as Child-Pugh A, and 12 patients (22.6%) were classified as Child-Pugh B. Twenty-six patients had portal vein thrombosis (49.1%), and 25 patients had extrahepatic metastasis (47.1%). The median duration of thalidomide treatment was 6.0 mo. Six of the 53 patients achieved a confirmed response (11.3%), one achieved a complete response (1.9%) and 5 achieved a partial response (9.4%). The disease control rate (CR + PR + SD) was 28.3% (95% CI: 17.8-42.4), and the median overall survival rate was 10.5 mo. The 1- and 2-year survival rates were 45% and 20%, respectively. Only one complete response patient showed an improved overall survival rate of 66.8 mo. Sixteen patients (30.2%) showed more than a 50% decrease in their serum AFP levels from baseline, indicating a better response rate (31.3%), disease control rate (43.8%), and overall survival time (20.7 mo). The therapy was well tolerated, and no significant toxicities were observed. CONCLUSION Thalidomide was found to be safe for advanced HCC patients, demonstrating anti-tumor activity including response, survival, and AFP decreases of greater than 50% from baseline.

Hepatobiliary and pancreatic: Gallbladder perforation

A man, aged 72 years, was evaluated in the emergency service because of altered consciousness. He was known to have hypertension and prostate cancer and had been taking tramadol for bony metastases. No focal neurological signs were found. He had a pulse rate of 118 per minute, a blood pressure of 100/70 and a temperature of 37.2 ° C. His white cell count was at the upper limit of normal (10.6 × 10 9 /L) and his platelet count was mildly depressed (98 × 10 9 /L). His plasma urea and creatinine were elevated and he had minor changes in liver function tests. Investigations included an ultrasound study of the upper abdomen (Fig. 1). This showed a defect in the gallbladder wall (arrows) and pericholecystic fluid (F). A computed tomography scan of his abdomen showed perforation of the gallbladder in the region of the fundus with a fluid collection around the perforation (Fig. 2). The patient was treated by percutaneous drainage of the gallbladder and subsequently had a cholecystectomy. The diagnosis was that of acalculus cholecystitis with perforation. The major clinical setting for acalculus cholecystitis is in patients recovering from major surgery, trauma or burns. Other predisposing factors include vascular disease, vasculitis, bone marrow transplantation and AIDS. In contrast to gallstone cholecystitis, men are more likely to be affected than women. Initially, right upper quadrant pain and tenderness are absent in the majority of patients. In general, acalculus cholecystitis has a more fulminant course than gallstone cholecystitis. Furthermore, the diagnosis is often delayed, particularly in the postoperative setting. Because of this, up to 50% of patients have gallbladder gangrene or perforation at the time of surgery. In relation to management, the traditional approach has been urgent laparotomy and cholecystectomy. However, more recent therapeutic options include percutaneous drainage and perhaps endoscopic drainage via a nasobiliary catheter introduced into the gallbladder with help from a guide-wire. Mortality rates from acalculus cholecystitis are 10% or greater, substantially higher than for gallstone cholecystitis.

Advantageous effect of telbivudine on renal function in patients with chronic hepatitis B infection

In central Taiwan, little is known about the different long‐term effects on renal function of the variant nucleoside analogs for chronic hepatitis B (CHB) patients. We aimed to compare the effects of long‐term use of different nucleoside analogs on renal function at a single medical center. We analyzed patients who fulfilled the criteria of the Bureau of National Health Insurance and received nucleoside analogs between October 1, 2003 and April 30, 2011. Patients were divided into three groups depending on the type of drug administered, which included lamivudine (LAM), entecavir (ETV), and telbivudine (LdT). We excluded CHB patients who received prophylaxis because of chemotherapy and those who underwent bone marrow or liver transplantation. The values of renal function at baseline before treatment and at one year after therapy were analyzed. A total of 307 patients were recruited, including 76 patients who were treated with LAM, 200 patients who were treated with ETV, and 31 patients who were treated with LdT. The initial estimated glomerular filtration rate (eGFR) (T0), as computed by the Modification of Diet in Renal Disease (MDRD) formula and expressed as mL min−1 1.73 m−2, was 86.56 ± 25.30 for LAM, 106.07 ± 36.91 for ETV, and 117.23 ± 42.70 for LdT. The mean change in eGFR (∆eGFR: T12‐T0) at one year after treatment (T12) from baseline (T0) was −3.55 ± 19.13 for LAM, −3.53 ± 22.85 for ETV, and 9.54 ± 29.93 for LdT. For all patients, the ∆eGFR was significantly different between the LdT group and the other two groups (P = 0.006), especially in the subgroups who had eGFR lower than 90 mL min−1 1.73 m−2 (P = 0.001). The type of nucleoside analog was independently associated with ∆eGFR (OR, 4.41; P < 0.001). Renal function improved in CHB patients who received LdT for 1 year compared with those who received LAM or ETV, especially in patients who had eGFR of less than 90 mL min−11.73 m−2.

Rapid virological response assessment by Abbott RealTime hepatitis C virus assay for predicting sustained virological responses in patients with hepatitis C virus genotype 1 treated with pegylated-interferon and ribavirin

The lower limits of virus detection of hepatitis C virus (HCV) RNA detection assays are continuously improving. We aimed to assess the utility of more precise definition of 4th week viral load [rapid virological response (RVR)] in predicting sustained virological response (SVR) in HCV genotype 1 patients treated with pegylated‐interferon (PEG‐IFN) and ribavirin. Clinical data of treatment‐naïve HCV genotype 1 patients were retrospectively collected from 2009 to 2014. Patients were grouped according to 4th week viral load as follows: undetectable (n = 90) and detectable but not quantifiable (< 12 IU/mL, n = 27). All patients received PEG‐IFNα‐2a or ‐2b and ribavirin for 24 weeks. Serum HCV RNA levels were measured by Abbott RealTime (ART; Abbott Molecular, Abbott Park, IL, USA) HCV assay. SVR was 95.5% and 63% in the undetectable group and < 12 IU/mL group of 4th week viral load, respectively. The between‐group difference in SVR was significant (p < 0.001). We determined 4th week viral load was independently associated with SVR (odds ratio = 19.28; p = 0.002) and a good predictor of SVR [area under the curve (AUC) = 0.775; p = 0.001]. ART HCV assays had a stronger SVR predictive value in HCV genotype 1 patients, indicating that only the undetectable group of 4th week viral load patients measured by ART HCV assay should be considered for shorter treatment time (24 weeks) with PEG‐IFN and ribavirin.

Massive post-polypectomy hemorrhage: Successful tulip-bundle technique with endoloop for hemostasis

Colonoscopic polypectomy is a common procedure for removing colonic polyps to prevent subsequent development of colon cancer. Hemorrhage is the most common complication following polypectomy, with a reported rate of 0.3% to 6.0%. The risk increases to 12.5% when the size of the polyp stalk exceeds 1 cm. The most commonly used endoscopic preventive techniques, such as injection therapy, prophylactic use of endoclip, or endoloop, were found to decrease the rate of post‐polypectomy hemorrhage, and repeated use of these techniques is useful for controlling bleeding. Here, we reported a case of a 65‐year‐old man with refractory post‐polypectomy hemorrhage for a 2‐cm adenomatous polyp. Application of an endoloop using the tulip‐bundle technique achieved successful hemostasis. To our knowledge, this is the first report of this technique being used to treat refractory acute post‐polypectomy hemorrhage.

Endoscopic Papillectomy for Tumors of the Major Duodenal Papilla: A Retrospective Analysis in a Medical Center

Papillary tumors are rare in clinical practice, but they can cause complications including jaundice and pancreatitis. Current treatments for papillary tumors include surgical treatment and endoscopic papillectomy. We retrospectively reviewed seven patients who underwent an endoscopic papillectomy in a medical center. The histology after papillectomy revealed benign tumors (5/7) and malignant tumors (2/7). Of the two patients with malignance, one underwent operation and the other one revealed free section margin in histology after papillectomy. No recurrent tumor was found during the follow-up period for the patients who received complete endoscopic papillectomy. In addition, two patients had bleeding events, and one had cholangitis after the procedure. Here, we also performed a literature review for the indication, diagnosis, complications and surveillance of the procedure.