Tseng-Nip Tam

Injection sclerotherapy preceded by esophageal tamponade versus immediate sclerotherapy in arresting active variceal bleeding: a prospective randomized trial

To investigate whether Sengstaken-Blakemore tube tamponade is needed before emergency sclerotherapy, 60 patients with active esophageal variceal bleeding were randomized to receive either immediate injection sclerotherapy (group A) or sclerotherapy preceded by balloon tamponade (group B). Three patients in group A (10%) were completely inaccessible to sclerotherapy. Initial success in stopping bleeding at 24 hours after sclerotherapy was 76% in group A and 81% in group B (p = 0.89). Re-bleeding rate was 27% in group A versus 50% in group B (p = 0.11). Blood requirement was significantly less in group A (3.7 +/- 2.5 units vs. 6.2 +/- 3.2 units, p less than 0.01). Major complications were also significantly less frequently encountered in group A than in group B (14% vs. 39%, p less than 0.05). In-hospital mortality was 24% in group A and 42% in group B (p = 0.14). We conclude that the efficacy of immediate sclerotherapy is comparable to that of delayed sclerotherapy preceded by balloon tamponade. Additionally, significantly less blood requirement and fewer complications were noted in the immediate sclerotherapy group. Thus, emergency sclerotherapy without prior balloon tamponade is feasible and recommended in most patients with acute esophageal variceal hemorrhage.

Colonic mucosal changes in patients with liver cirrhosis

BACKGROUND Portal colopathy has been reported in patients with cirrhosis of the liver. The aim of this study is to evaluate colonic mucosal changes and their clinical significance. METHOD Seventy-five cirrhotic patients with anemia and hemoccult-positive stool and 75 control subjects underwent endoscopic examinations of lower gastrointestinal tract. RESULT Colonic ectasiae were found to be significantly more common in the 75 cirrhotic patients (80% with hepatitis B or C infection) than control subjects (84% vs 0, p < 0.0001). The lesions in 63 cirrhotic patients were found throughout the entire colon. They included colonic telangiectasiae or angiodysplastic-like lesions in 56 (89%) patients, red spots in 14 (22%), features suggesting mild chronic colitis in 8 (13%), and midrectal colorectal varices in 10 (16%). Pathologic findings in patients with telangiectasiae or angiodysplastic-like lesions showed dilation of vessels (7 of 9 patients) and edema of mucosa (6 of 9 patients). There was no correlation between the severity of cirrhosis, grade of esophageal varices, and the presence of colonic ectasiae. CONCLUSIONS Our observations demonstrate that colonic mucosal changes commonly occur in cirrhotic patients with viral hepatitis. The risk of intermittent hemorrhage from colonic ectasiae should be considered in cirrhotic patients with anemia but without evidence of upper gastrointestinal bleeding. These characteristic lesions may represent a spectrum of portal in hypertensive intestinal vasculopathy.

Comparison of lansoprazole and omeprazole in the short‐term management of duodenal ulcers in Taiwan

Lansoprazole is a novel H +/K + ‐ATPase inhibitor which exhibits a very potent and long‐acting suppression of acid secretion. The object of this randomized, controlled trial was to compare duodenal ulcer healing rates after 4 weeks of treatment with a once‐daily regimen of either 30 mg lansoprazole or 20 mg omeprazole. Of a total of 111 patients 57 received lansoprazole, whereas 54 received omeprazole. In intention‐to‐treat analysis at 4 weeks, 89.5% patients showed ulcer healing following treatment with lansoprazole compared with 83.3% of patients treated with omeprazole. Per protocol analysis indicated that 96.1% of patients treated with lansoprazole showed ulcer healing, compared with 93.6% of patients treated with omeprazole (NS). Age, smoking or ulcer size did not affect the ulcer healing rate. Both agents could effectively and quickly resolve ulcer symptoms. The Helicobacter pylori clearance was seen in 36 (73.5%) patients in the lansoprazole group and in 40 (80%) patients in the omeprazole group after four weeks of treatment (NS). In addition, both agents led to hypergastrinaemia, by approximately 1.6 fold. Adverse side effects included a few occurrences of reversible skin rash and constipation. It is concluded that lansoprazole elicits an adequate healing response and resolves symptoms of duodenal ulcer as well as omeprazole. Furthermore, lansoprazole is well tolerated with a few adverse side effects.

Treatment of severe peptic ulcer haemorrhage with the heat probe

From September to December 1986, 30 cases of persistent upper gastrointestinal bleeding were collected and treated, via the endoscope, with a heat probe. All cases had either gastric or duodenal ulcers. Ten cases were in shock. After treatment, all bleeding episodes initially stopped, but six cases (20%) re‐bled. Five cases received repeat heat probe therapy and did not re‐bleed thereafter. Thus the ultimate success rate was 96.7% (29/30). Twenty of 21 ulcers (94.3%) were found to be healed with scars 2 months after therapy. During therapy and the follow‐up period, only one complication occurred and this was a mild aspiration pneumonia. The heat probe is an ideal haemostatic device for severe non‐variceal upper gastrointestinal bleeding.

The Correlation of Clinical Activities to Serum Interleukin-6 Concentration in Patients with Ulcerative Colitis

Interleukin-6 (IL-6) production is significantly increased in mononuclear leukocytes from both active ulcerative colitis (UC) and Crohns disease (CD). The aim of the present study was to examine the correlation between the clinical activities and IL-6 levels in patients with UC. The serum concentrations of IL-6 were evaluated in 32 patients with UC with respect to the clinical performance, endoscopic findings and laboratory data. Serum samples were also obtained from 32 healthy subjects with matched sex and age as controls. The serum concentrations of IL-6 were measured by using commercial enzyme-linked immunosorbent assay (ELISA). C-reactive protein (CRP) and erythrocyte sediment rate (ESR) were also measured. The serum concentration of IL-6was significantly increased in UC patients than the controls (4.5±11vs o.57±0.2pg/ml, p＜0.0001). The diagnostic cut-off value was 0.88 pg/ml which could distinguish the patient groups from the normal controls (sensitivity 78%, specificity 100%). The serum concentrations of IL-6 in UC patients with endoscopic appearance of grade Ⅰ, Ⅱand Ⅲ were significantly different (p=0.0002). In conchusion, the serum concentrations of IL-6 in patients with UC is useful to assess disease activities.

Clinical Experiences of Splenic Artery Aneurysm

Splenic artery aneurysms are the third most common intra-abdominal aneurysms. They are important vascular diseases because rupture of the splenic artery aneurysms is a clinical emergency and results in catastrophic hemorrhage and high mortality rate. The records of patients with documented splenic artery aneurysms diagnosed between 1985 and 1998 were reviewed. Seven were men and 2 women. Ages ranged from 31 to 85 years (mean 58.8 years). Three patients presenting with acute abdomen and shock were proved to have ruptured splenic artery aneurysms. Another 3 patients had nonspecific epigastric or left upper quadrant abdominal discomfort. Splenic artery aneurysms were impressed by a ring calcification on plain abdominal radiograph in 3 patients and by a cystic lesion on ultrasonogram in 5 patients. Further imaging studies including Doppler ultrasonography, contrast-enhanced abdominal computed tomography, magnetic resonance angiography, and celiac angiography may be required to confirm the diagnosis. The diameter of the aneurysms ranged from 0.6 to 13 cm (mean 4.2 cm). The size of the ruptured aneurysms ranged from 2 to 5 cm (mean 3.5 cm). All of the splenic artery aneurysms located at the distal third of the splenic artery. Three patients with ruptured splenic artery aneurysms had emergent surgery. Splenectomy and aneurysmectomy were performed in these patients. Profound shock resulted in one mortality. Another two patients receiving elective surgery had uneventful course. No rupture or other complications of the aneurysms occurred in the four patients not undergoing surgery in the period of follow-up (15-160 months). This study demonstrated that splenic artery aneurysm is an uncommon, but clinically important disease. It requires alertness of physicians and radiologists to make a diagnosis. Appropriate management must be applied according to the individualized conditions of the patients.

Management of Obstructive Jaundice by Nasobiliary Drainage

The nasobiliary drainage (NBD) was applied transpapillary via duodenoscope to 25 patients with obstructive jaundice. The success rate was 84%. Four patients with complete obstruction of lower bile duct were technical failure. Sixty seven percent of patients could maintain adequate drainage and finally received definite or palliative management. In all cases of obstructive jaundice with adequate drainage, the average daily volume of bile output was around 200-300 ml in benign diseases and 400-600 ml in malignant diseases. The serum bilirubin levels decreased in 50% of cases within one week and continued to decrease in the late period. No change or increase in serum bilirubin level was noted in the 7 cases with inadequate bile drainage. After NBD, 9 patients had transient hyperamylasemia, 3 patients had sore throat; 2 patients had secondary infection; 3 patients had obstruction of NBD and 1 patient had dislodgment of catheter. In 95.7% of cases, the first bile culture yielded growth of bacteria but only two of them were identical with blood culture. The nasobiliary drainage is a safe procedure and provides another effective approach to relieve obstructive jaundice. We also found that the serum bilirubin level and daily volume of bile drained might reflect the response of adequate drainage.