Siu-Yin Wong

High incidence of clopidogrel-associated gastrointestinal bleeding in patients with previous peptic ulcer disease

Background:  In average‐risk patients, the new anti‐platelet agent, clopidogrel, causes less upper gastrointestinal adverse events than aspirin. However, there are no safety data on the use of clopidogrel in high‐risk patients.

Gastrointestinal bleeding in patients receiving a combination of aspirin, clopidogrel, and enoxaparin in acute coronary syndrome.

BACKGROUND:The combination of aspirin, clopidogrel, and enoxaparin (combination therapy) is the standard treatment for acute coronary syndrome but is associated with gastrointestinal bleeding. However, information in this area is scarce.AIM:This retrospective study aimed to determine the incidence of upper gastrointestinal bleeding in a real-life situation. The effect of proton pump inhibitor (PPI) treatment was also analyzed.METHOD:From January 2002 to December 2006, all patients receiving combination therapy were analyzed. The end point was the occurrence of upper gastrointestinal bleeding during combination therapy or within 7 days of stopping enoxaparin.RESULTS:The patient group consisted of 666 patients (age 72.1 ± 12.6 yr). Gastrointestinal bleeding occurred in 18 (2.7%) patients. The overall hospital mortality was 4.1% (27 patients). A cardiac event was the major cause (N = 24, 3.6%). Only one patient died of massive gastrointestinal bleeding (0.15%). Multiple logistic regression analysis demonstrated that previous peptic ulcer, cardiogenic shock, and the lack of PPI coprescription were significant risk factors for gastrointestinal bleeding. The age-adjusted odds ratio (95% confidence interval) for gastrointestinal bleeding was 5.07 (1.31–16.58) for previous peptic ulcer, 21.41 (2.56–146.68) for cardiogenic shock, and 0.068 (0.010–0.272) for the coprescription with a PPI.CONCLUSION:In real life, the incidence of gastrointestinal bleeding associated with the combination of aspirin, clopidogrel, and enoxaparin therapy was estimated to be 2.7%. Previous peptic ulcer disease or cardiogenic shock were significant independent risk factors. Coprescription with a PPI can significantly reduce the risk.

Upper Gastrointestinal Bleeding in Patients with Aspirin and Clopidogrel Co-Therapy

Introduction: The major complication of aspirin and clopidogrel (A+C) co-therapy is upper gastrointestinal bleeding (UGIB). However, data are unavailable for real-life situations. Furthermore, the treatment effect of antisecretory agents is unknown. Aim: This cohort study aimed to determine the occurrence of UGIB. The treatment effect of H2-receptor antagonist (H2RA) and proton pump inhibitor (PPI) was also analyzed. Method: The records of 987 consecutive patients on A+C co-therapy between January 2001 and September 2006 were analyzed. The follow-up ended on the dates of a first occurrence of UGIB, stopping A+C co-therapy, a change in the antisecretory class, death, or March 2007. Results: After a follow-up of 5.8 ± 6.5 months, UGIB occurred in 39 (4.0%) patients. PPI, H2RA and control were prescribed in 213, 287 and 487 patients respectively. After adjustment for age, dose of aspirin, previous UGIB and duration of treatment, the risk was marginally reduced by H2RA (OR = 0.43, 95% CI 0.18–0.91, p = 0.04) and significantly reduced by PPI (OR = 0.04, 95% CI 0.002–0.21, p = 0.002), as compared to control. Conclusion: The occurrence of UGIB associated with A+C co-therapy for a median of 5.8 months was 4.0%. Co-prescription with PPI was associated with a lower risk.

Cytomegalovirus colitis in individuals without apparent cause of immunodeficiency.

Cytomegalovirus infection is usually reported inimmunocompromised patients. In this study, apparentlyimmunocompetent patients with cytomegaloviral colitiswere reviewed. Records with a diagnosis ofcytomegaloviral colitis from January 1989 to June 1996 wereretrieved for analysis. Ten patients were included(median age 70 yr). The major presenting symptoms werediarrhea and hematochezia. Ulceration was the mainmacroscopic finding. Rectal bleeding was mostlyself-limiting. Three patients developed localcomplications (rectovaginal fistula in two; rectalstricture in one). In the two patients with rectovaginalfistula, lymphocytes subsets and proliferative response wereentirely normal. In the other patient, low B lymphocytecount and low response to mitogen were demonstrated.However, the immunoglobulins were not suppressed and rectal biopsies revealed noncaseatinggranulomas, suggesting activated cell-mediated immunity.In conclusion, a high index of suspicion is crucial forearly diagnosis of cytomegaloviral colitis in patients with bloody diarrhea, even though obviousevidence of immunodeficiency is lacking.

Sequential intravenous/oral antibiotic vs. continuous intravenous antibiotic in the treatment of pyogenic liver abscess.

Aim : Pyogenic liver abscesses result in substantial morbidity and mortality. Antimicrobial regimens using sequential intravenous/oral therapy may reduce the length of hospital stay. In this retrospective analysis, the efficacy of continuous intravenous antibiotic therapy (group I) vs. sequential intravenous/oral antibiotic therapy (group II) was studied in patients with pyogenic liver abscess.

Repeated intestinal perforation caused by an incomplete form of Behçet's syndrome.

Abstract Behçets disease, as initially described, is a triad of recurrent oral and genital ulcers and relapsing uveitis. The incomplete form, in which there is no ocular involvement, has been described in Japan and Korea, but this is not commonly recognized in the southern Chinese. We reported herein a rare case of repeated intestinal perforations caused by an incomplete form of Behçets syndrome in a southern Chinese man.

Skip colonic ulceration in typhoid ileo-colitis

Abstract: Colonic skip lesions are typically described in Crohns colitis, but this phenomenon has been recognized in ulcerative colitis (skipped appendiceal involvement), Behcets colitis, cytomegaloviral colitis, and even in Aeromonas hydrophilia and Histoplasma capsulatum infection. However, skip lesions in typhoid ileo-colitis have not been reported in the English-language literature. We report herein a patient with skip ulcers due to typhoid fever.

Effect of simethicone on the accuracy of the rapid urease test

Objective Simethicone, which is a principal ingredient in the defoaming agent used during gastroscopy, can inhibit the growth of Helicobacter pylori (MIC, 64–128 mg/l). This prospective study was designed to evaluate the in vivo and in vitro effects of simethicone on the accuracy of the rapid urease test (RUT). Methods In the in vivo study, three sets of gastric biopsies (two from the antrum, and one from the corpus) were taken from 75 patients. The first set was examined histologically, and the second set was used for the RUT (pre-simethicone RUT). Then, 25 ml simethicone (1200 mg/l) was introduced into the stomach for a contact time of 1 min. A third set of gastric biopsies was taken for the RUT (post-simethicone RUT). In the in vitro clinical study, 41 patients were recruited. The first set of gastric biopsies was used for the RUT (pre-incubation RUT). The second set was incubated in 1 ml of simethicone for 5 min before being used for the RUT (post-incubation RUT). In the spectrophotometric study, urease activity before and after incubation in simethicone for 5 min was quantified in 12 patients by measuring the absorbance at 560 nm. Results Reading at 15 min, the concordance rate between the pre-simethicone and post-simethicone RUT was 98%. In the in vitro clinical study, the concordance rate between the pre-incubation and post-incubation RUT was 97%. The spectophotometric study showed a significant reduction of 43% in urease activity after incubation in simethicone. Conclusion The application of a defoaming agent containing simethicone does not affect the accuracy of the RUT. However, simethicone modestly suppresses urea hydrolysis.

Prolonged storage of frozen unbuffered rapid urease test.

Unbuffered rapid urease test (RUT) is an accurate, rapid, and inexpensive method of detecting Helicobacter pylori. However, it is generally recommended to prepare the reagent daily. This prospective study was undertaken to evaluate the shelf-life of our unbuffered RUT at −20°C. Two sets of antral biopsies (X2) and body biopsies (X1) were taken from all patients. They were subjected to histologic examination and RUT stored at −20°C. We studied 303 patients. One hundred seventy-nine (59%) were infected as defined by histologic examination. The reagent was classified according to the storage time (group I, 0–30 days [n = 109]; group II, 31–60 days [n = 63]; group III, 61–90 days [n = 80]; and group IV, &tgr;91 days [n = 51]). There was an excellent agreement between the histologic examination and the RUT of the four groups (kappa coefficient: group I, 0.88; group II, 0.80; group III, 0.87; group IV, 0.88). The sensitivity of our RUT in groups I, II, III, and IV were 92%, 92%, 91%, and 89%, respectively. The corresponding specificity were 97%, 88%, 97%, and 100%. Our RUT remains highly sensitive and specific when it is stored at −20°C for 4 months.

Esophageal variceal ligation by reloading with inexpensive hemorrhoidal O-ring--is an overtube necessary?

The overtube is the major cause for severe complications during endoscopic variceal ligation with a single-shot ligator. This retrospective study was designed to examine the necessity of the placement of an overtube during elective endoscopic variceal ligation. Thirty-one sessions in 18 patients were analyzed. An overtube was inserted using an over-the-scope technique in 11 sessions (group 1) but was omitted in 20 sessions (group II). The complications, technical difficulties, and operating time were analyzed. Childs grading, the size of the esophageal varices, and the number of rubber bands deployed were comparable in both groups. There was a significantly longer operating time (p < 0.01) and more oropharyngeal injury (p = 0.03) in group I than in group II. Mid esophageal injury, which was associated with resistance in withdrawing the gastroscope from the overtube, occurred in 55% of sessions in group I but in 0% of session in group II. In conclusion, the use of an overtube is associated with more complications, and it can be omitted during elective endoscopic variceal ligation.