Wai-Wah Ng

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.

Regression of high-grade gastric mucosa-associated lymphoid tissue lymphoma with Helicobacter pylori after triple antibiotic therapy ☆ ☆☆

Mucosa-associated lymphoid tissue (MALT) lymphoma of the stomach has recently been defined as a distinct histopathologic entity, often associated with Helicobacter pylori infection.1,2 High-grade gastric lymphoma is composed of diffuse large cells with abundant cytoplasm, vesicular nuclei, and prominent nucleoli. It is a distinct disease with aggressive clinical features and a poorer prognosis than that of low-grade MALT lymphomas.3,4 Patients with localized high-grade MALT lymphoma are often treated with either surgical resection or chemotherapy with or without radiotherapy.5,6 Although a high success rate in the regression of low-grade B-cell MALT lymphoma by eradication of H pylori has been reported,7-9 the role of this therapeutic option for highgrade lymphoma is still controversial.10 However, there are several reports of complete remission of H pylori–related high-grade lymphoma after cure of the H pylori infection.11-14

Endoscopic injection sclerotherapy versus conservative treatment for patients with unresectable hepatocellular carcinoma and bleeding esophageal varices.

We performed endoscopic injection sclerotherapy (EIS) in the treatment of 37 patients with bleeding esophageal varices due to unresectable hepatocellular carcinoma (HCC). The results were compared with those in another 33 HCC patients treated only conservatively, without EIS, during the same period. A majority of both groups died within 3 weeks after treatment. Comparing the two groups, there was no significant difference in fatal bleeding (66% vs 75%), but significantly fewer of the EIS patients died of the index hemorrhage (43% vs. 83%; p less than 0.01). Also, in the absence of portal vein thrombosis, EIS significantly reduced the risk of fatal bleeding (31% vs. 73%; p less than 0.25). The mean days of survival were 32 +/- 15 (range, 2 to 320) in the EIS group and 10 +/- 14 (range, 2 to 270) in the compared group (p less than 0.001). We conclude that EIS provides temporary control of acute esophageal variceal bleeding in patients with unresectable HCC. The major factors contributing to EIS failure are the lethal propensity of the underlying disease and portal vein thrombosis.

Magnesium citrate–bisacodyl regimen proves better than castor oil for colonoscopic preparation

Background : A clean colon preparation prior to endoscopy or X‐ray examination is essential to obtain an accurate diagnosis. In order to determine which of two easily made preparations is better, this study compares colon cleansing efficacy, patient acceptance and side effects in patients given either a magnesium citrate–bisacodyl or a castor oil regimen prior to colonoscopy.

Endothelin-1 is a candidate mediating intestinal dysmotility in patients with acute pancreatitis.

We studied whether gastrointestinal transit wasdisturbed during acute pancreatitis and attempted toidentify which mechanisms might be involved in acutepancreatitis. Using a noninvasive hydrogen breath test to determine the orocecal transit time, 24patients with the clinical diagnosis of acutepancreatitis were enrolled into the intestinal motilitystudy. Orocecal transit time was measured twice in all patients: once at the acute stage and once atrecovery. Blood was obtained to study amylase, lipase,C-reactive protein, erythrocyte sedimentation rate, andendothelin-1 and nitrate/nitrite levels. Orocecal transit times measured at the acute stage weresignificantly delayed compared with those at recovery(mean values ± SEM, 130.0 ± 9.0 vs 80.8± 7.4 min, P < 0.001). Plasma endothelin-1levels exhibited a positive correlation with orocecal transittimes in the acute stage (r = 0.509, P = 0.011). Thepercentages of altered orocecal transit times alsocorrelated with the percentages of altered plasmaendothelin-1 levels (r = 0.751, P < 0.001). Plasmanitrate/nitrite levels significantly decreased at theacute stage compared with those at recovery (5.25± 0.82 vs 10.20 ± 1.24 μM, P <0.05). We conclude that intestinal transit is delayed in patientswith mild to moderate acute pancreatitis. Elevatedplasma endothelin-1 levels in the acute stage may be onemechanism mediating intestinal dysmotility.

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.

Medical treatment of duodenal ulcer: Acid inhibition or Helicobacter pylori eradication?

To ascertain whether acid inhibition or Helicobacter pylori (HP) colonization is the decisive factor in the healing of duodenal ulcer, we treated 54 patients with famotidine and carried out long‐term follow‐up. Helicobacter pylori colonization was found in 70.4% of patients before treatment. There were no differences in the pre‐treatment characteristics between patients with HP positive or HP negative ulcers. The 4‐week and 8‐week healing rates after famotidine treatment were 72.5% and 82.4% respectively. No difference in HP colonization was found between patients with ulcer healed and those with ulcer not healed (78.4%vs 64.3% at 4th week and 77.3%vs 71.4% at 8th week, P > 0.05). In patients with ulcer healed at 4th week, the intragastric pH was raised significantly and the antral acute inflammation was less severe than those with ulcer not healed. Ulcer recurrence was found in 76.9% of patients within 1 year, but there was no difference in ulcer recurrence between the patients with positive or negative HP colonization at the time of ulcer healing. Our results suggest that duodenal ulcer healing and recurrence are closely related to acid inhibition rather than to HP colonization.

Pseudogastroparesis as a presentation of small-bowel malignancy.

&NA; Establishing the diagnosis of small‐bowel malignancy is sometimes an extremely difficult challenge owing to its non‐specific symptoms. The mainstay of treatment is early recognition, diagnosis and surgical resection. The prognosis depends primarily on the degree of spread and stage at presentation. We present two cases with initially obscure presentations of a small‐bowel tumour. One was a jejunal adenocarcinoma, but an initial upper gastrointestinal and small‐bowel series did not disclose the lesion; the other was a primary ileal lymphoma, first thought to be diabetes mellitus gastroparesis. Therefore, a negative small‐bowel series or presentation of a systemic disease‐associated intestinal pseudo‐obstruction or gastroparesis does not exclude the possibility of a small‐bowel malignancy, if the clinical symptoms are not alleviated after prokinetic medications. The clinicians should further pursue the possibility of an obstructing lesion. Eur J Gastroenterol Hepatol 12:351‐355

Roxatidine versus ranitidine in the short-term management of duodenal ulcer: a randomized, double-blind trial

Abstract Roxatidine is a structurally novel histamine 2 -receptor antagonist. This randomized, double-blind trial compared duodenal ulcer healing rates after 4 and 8 weeks of treatment with a twice-daily regimen of either 75-mg roxatidine (n = 69) or 150-mg ranitidine (n = 70). Endoscopy was performed at 4- and 8-week intervals to assess ulcer healing. Symptom severity scores and side effects were recorded. In the intent-to-treat analysis after 4 weeks, 77.3% of patients were healed with roxatidine and 75.8% were healed with ranitidine; after 8 weeks, the healing rates were 93.9% and 81.8%, respectively. There were no significant differences between groups. In the per-protocol analysis at 4 weeks, 80.3% of patients were healed with roxatidine and 83.1% were healed with ranitidine; after 8 weeks, the healing rates were 95.1% and 88.1%, respectively. There were no significant differences between groups. Both agents effectively suppressed ulcer symptoms. The average number of antacid tablets consumed daily to relieve ulcer pain and compliance rates for trial drugs were similar between groups. Adverse events primarily included a few occurrences of exacerbated pain. We conclude that roxatidine is at least as good as ranitidine for short-term management of duodenal ulcer in terms of ulcer healing and symptom resolution. It also causes few adverse effects.