Tien-Chien Tu

Comparison of invasive and noninvasive tests for detecting Helicobacter pylori infection in bleeding peptic ulcers

BACKGROUND Eradication of Helicobacter pylori infection has been shown to prevent recurrent bleeding from peptic ulcers. However, the detection rate for H pylori infection seems to be underestimated in this group of patients and has been scarcely investigated. METHODS Eighty patients with bleeding peptic ulcer were studied for evidence of H pylori infection. Seventy-seven of these patients were enrolled as having H pylori infection after any one of the following 3 tests were positive: culture, histologic study, or any 2 of rapid urease test (CLO test), carbon 13-labeled urea breath test (UBT), and serologic examination. Fresh blood or blood-containing material in the gastric antrum was noted by panendoscopy in 22 patients (group A). In the remaining 55 cases there was no blood in the antrum (group B). RESULTS The sensitivities of the CLO test, bacterial culture, histologic study, 13C-labeled UBT, and immunoglobulin G serologic test were 45.5%, 36.4%, 77.2%, 95.4%, and 100% in group A, respectively, and 70.9%, 40.0%, 70.9%, 92.7%, and 96.4%, respectively, in group B. There was a statistically significant difference between the sensitivities found for CLO test and 13C-labeled UBT (p < 0.05). Of these 5 tests, only the sensitivity of the CLO test showed a statistically significant difference between groups A and B (p < 0.05). A delayed positive CLO test result was recorded in 13 patients (3 in group A, 10 in group B). CONCLUSION Noninvasive tests seemed to be more sensitive than invasive tests in detecting H pylori infection in patients with bleeding peptic ulcers. Blood in the antrum might reduce the sensitivity of the CLO test but have no effect on the other tests. The CLO test should be observed for more than 24 hours because of the possibility of a delayed positive result in some patients with bleeding peptic ulcers.

Clinical application of Carlsson's questionnaire to predict erosive GERD among healthy Chinese

Background:  Gastroesophageal reflux disease (GERD) is a common gastrointestinal disease, yet there is no definitive gold standard to describe and diagnose it.

Negative CLOtest pellet can be reused

BACKGROUND The CLOtest is based on the production of ammonia from urea in the presence of urease. In theory, substrate that has not been consumed in a negative test can be reused. METHODS We collected negative CLOtest pellets after their first use and stored them at room temperature. Whenever a CLOtest was needed during endoscopy, two biopsy specimens were taken from the antrum. One specimen was tested with a new CLOtest and the other with one that had been used previously. Time to color change was observed in paired tests. RESULTS We used 216 previously used CLOtest pellets with biopsy specimens obtained from 317 patients. Of the paired tests, 204 matched positive and 108 tested negative. Only 5 paired tests had discrepant results. Three had positive results only with a new CLOtest, and 2 were positive only with the reused test. In positive paired tests, there was significant linear correlation in log-transformed color change time between reused and new tests (p < 0.001). Ninety-two percent of previously used pellets were reused fewer than three times before they yielded a positive color change; the interval to this occurrence ranged from 2 to 15 days. Compared with the new CLOtest, the sensitivity of the reused CLOtest was 98. 6% and the specificity was 98.2%. CONCLUSIONS A negative CLOtest kept at room temperature can be reused within a short period of time, in circumstances in which there are environmental and economic considerations to be taken into account.

Gastritis cystica polyposa in an unoperated stomach

Gastritis cystica polyposa is relatively rare and characterized by polypoid hyperplasia and cystic dilatation of the gastric glands in stomach. Most cases are related to previous gastric surgeries, but a few cases have been reported in unoperated stomachs. We present a 34‐year‐old man who had anemic symptoms with melena and exertional dyspnea for 3 weeks. He denied any surgical history. An esophagogastroduodenoscopy revealed diffuse giant folds extending from the lower to the upper body of the stomach with nodularity and no obvious bleeding site. A pathologic diagnosis of a punch biopsy specimen from the giant folds revealed only moderately active chronic inflammation with a high Helicobacter pylori density. After serial studies, the patient received a whole layer gastric biopsy during a laparoscopy. Gastritis cystica polyposa was diagnosed on the pathology report. Our present case highlights the rare clinical and endoscopic condition of gastritis cystica polyposa in an unoperated stomach.

Cold snare polypectomy versus cold forceps biopsy in endoscopic treatment of colonic small and diminutive polyps - the effectiveness and safety in real world

The practice of colonoscopy is used to reduce the risk of colonic malignancy. Complete removal of polyps is required to prevent tumor recurrence and the development of potential interval cancers. However, it is difficult to completely remove the polyp that is more than 4 mm in size through cold forceps biopsy. Polypectomy with a cold snare has been increasingly utilized in recent years, which provides a chance of complete removal of the polyp. This study compares the effectiveness and safety between cold snare polypectomy (CSP) and cold forceps biopsy (CFB) in diminutive or small sessile polyp removal. Between August 2015 and June 2016, 164 consecutive patients with colorectal polyps <10 mm in size were enrolled into either the CSP or CFB group. Demographic data, the duration of colonoscopy withdrawal time, adverse events, and pathological reports were recorded. The primary outcome is complete polyp eradication histologically. The secondary outcomes include rates of adverse events and time taken for the procedures. Of 164 patients, 84 patients were in CSP group and 80 patients in CFB group. The CSP group comprised elder patients (P = 0.042), most of who were male (P = 0.359). There was no significant difference of indications for colonoscopy. The mean withdrawal time was significantly longer in the CSP group (12.5 ± 6.90 minutes vs 9.14 ± 5.45 minutes; P < 0.01). The mean polyp size was bigger in the CSP group (5.05 ± 2.72 mm vs 3.84 ± 1.52 mm, P < 0.05). Eighty‐nine (84.7%) adenomas, 13 (12.4%) hyperplastic polyps, and three other polyps (2.9%) were resected in the CSP group. No high‐grade dysplasia or malignancy was found. Pathological examination showed that 54 polyps were completely removed in CSP group. Thirteen polyps were not removed completely, and 38 polyps could not be surveyed due to tissue destruction during the procedure. In the CFB group, no polyps could be identified with complete removal. The complete histological polyp eradication rate is higher in the CSP group (51.4% vs 0%, P < 0.01). Under operators discretion, 23 cases with 31 hemoclips were applied for bleeding prevention in the CSP group and only one in the CFB group. However, no further treatment requirement or delayed bleeding event was found in both groups. CSP is an effective method in small or diminutive polyps compared with CFB, and its safety is not inferior to CFB. Given these results and the high prevalence of such polyps, CSP is advocated as an alternate treatment.

Association between Gastroesophageal Flap Valve and Erosive Esophagitis

Objectives: Gastroesophageal flap valve (GEFV) can be divided into a four-grade system and this system can well predict the prevalence of gastroesophageal reflux disease (GERD). We tried to use this GEFV grading system to examine the correlation of GEFV to erosive esophagitis. Methods: We enrolled 398 individuals that underwent one-day self-paid health examination, including esoph agogastroduodenoscopy (EGD) in 3-month period. GEFV grade I and Ⅱ were considered normal, whereas grade Ⅲ and Ⅳ were abnormal. We compared and analyzed the correlation of sex, body mass index (BMI) and GEFV grading with erosive esophagitis. Results: There were 37 subjects being diagnosed as abnormal gastroesophageal flap valve (37/398, 9.3%). 18 of them (18/37, 48.6%) had erosive esophagitis also. The remaining 361 subjects were diagnosed as normal flap valve (361/398, 90.7%) and 53 subjects were diagnosed as erosive esophagitis (53/361, 14.7%). Abnormal gastroesophageal flap valve subjects had higher chance to had erosive esophagitis (Odds Ratio=7.51, 95% CI=3.53-15.98). Males had higher prevalence of erosive esophagitis (Odds Ratio=3.74, 95% CI=1.90-7.38) and the prevalence of erosive esophagitis was 17.8%. Age and BMI did not increase the risk of esophagitis remarkably in the initial analyses (P=0.15 and 0.2) Conclusion: Male gender and subject, who have abnormal gastroesophageal flap valve, are prone to develop erosive esophagitis. Age and BMI do not increase the risk of esophagitis remarkably.

Identification of Factors That Impact on Patient Satisfaction of Unsedated Upper Gastrointestinal Endoscopy

This study is designed to validate clinical predictors to patient satisfaction and tolerance for unsedated upper GI endoscopy in Taiwanese patients. Patients who underwent diagnostic upper GI endoscopy at Cathay General Hospital, in Taipei, Taiwan from September 2005 to December 2005 were enrolled. A questionnaire was filled by patient after endoscopic procedure. The clinical predictors for patient satisfaction were analyzed in this study. A total of 3,087 patients underwent endoscopic examinations during this period. A satisfactory endoscopy procedure included the male gender (OR=1.75), advanced age (OR=1.03), procedure time in the morning (OR=1.58), presence of assistant (OR=1.67), previous experience (OR=2.16) for upper endoscopy. Unsedated upper GI endoscopy is a feasible, acceptable, and cost-effective alternative to sedated procedure. It is our suggestion that patients with the above characteristics had merit in selecting unsedated procedure.

An Unusual Image of Acinar Cell Carcinoma of Pancreas: Report of a Case

Acinar cell carcinomas (ACCs) are uncommon tumors of the exocrine pancreas, constituting 1% to 2% of all pancreatic neoplasms. They are more common during the 5th through the 7th decades of life. ACCs are defined as carcinomas exhibiting pancreatic enzyme production by neoplastic cells. These tumors have highly characteristic histological features reflecting their acinar derivation. Typically they present as a sizable pancreatic mass with a well-defined enhancing capsule and internal calcification on the image of computed tomography. We report an ACC of pancreas in a 79-year-old female who presented with a 3-cm gastric submucosal mass and a history of anemia initially. The external compression from pancreas exhibited typical acinar morphology. The thickness of peritoneal membrane showed ”omental cake” appearance. Immunohistochemical studies demonstrated strong positive reactivity for cytokeratin, polyclonal CEA and antitrypsin. A complete workup identified a primary pancreatic tumor.

Clinical Application of Edrophonium Provocative Test in Esophageal Manometry

Unexplained chest pain nowadays has become the leading reason for patients being referred for esophageal manometry. Some drugs are recently used as provocative agents to increase the diagnostic rate during this test and edrophonium chloride is the most common among them. Nevertheless, this provocative test has seldom been applied in Chinese patients. Therefore, we studied 158 consecutive patients with chest pain (group A) and 53 patients with other esophageal symptoms (group B) by using edrophonium as a provocative agent for inducing esophageal chest pain. Each of these patients received 80 μg/kg intravenous bolus dose of edrophonium preceded by saline infusions. Esophageal contractile pressures and contractile duration of upper middle and lower portions were measured before and after drug injection in response to ten 5 mL wet swallows. We found that chest pain was reproduced in only 8 patients and they were all in the group A. Besides, edrophonium increased esophageal pressure signficantly in all three monitored portions of esophageal body but increased contractile duration only in the middle and distal portions. We also found the adverse effects of this agent in such dose were mild and tolerable. In conclusion, edrophonium is relativly safe as a provocative agent and can diagnose chest pain of esophageal origin in small population of Chinese patients.