Yang-Yuan Chen

Hemoclip-Assisted Polypectomy of Large Duodenal Brunner's Gland Hamartoma

Brunners gland hamartoma, also known as Brunneroma or Brunners gland adenoma, is a rare tumor of the duodenum and an uncommon cause of gastrointestinal bleeding. In symptomatic patients, treatment requires either surgical resection or endoscopic polypectomy. We report a case of upper gastrointestinal bleeding from a pedunculated Brunners gland hamartoma in the duodenal bulb. A new technique using hemoclip-assisted polypectomy is described to remove a large pedunculated Brunners gland hamartoma.

Esophageal intramural hematoma: an unusual complication of endoscopic biopsy.

Esophageal intramural hematoma (EIH) is a rare form of esophageal injury, whichmay be an intermediate ofMalloryWeiss syndrome (mucosal tear) or Boerhaave’s syndrome (transmural rupture). Patientsusuallypresentwith a sudden onset of retrosternal chest pain, back pain, hematemesis, dysphagia, or odynophagia. The disorder can occur spontaneously, or it can be secondary to variceal injection therapy, esophageal dilatation, food impaction, improper swallowing of drug pills, or coagulopathy. We presently report a novel case of EIH caused by endoscopic biopsy and its successful management by endoscopic therapy.

Double-balloon enteroscopic treatment for bleeding jejunal diverticulum

The great impersonators of the classic age of medicine were syphilis and tuberculosis, to which renal cell carcinoma, lymphoma, and systemic lupus erythematosus were added later. With the advent of AIDS, Cytomegalovirus (Greek: cyto, cell; megalo, large) became another important impersonator. Think CMV today whenever you see ulcers, polypoid lesions, strictures, and what appears to be ‘‘itis,’’ be it esophagitis, gastritis, enteritis, colitis, pancreatitis, cholecystitis, or even hepatitis. As for why this elderly man has CMV, it is likely the virus was reactivated because of the immunosuppression caused by the prednisone, perhaps in combination with his advancing age. HIV is another possibility, not always tested for; never make judgments, rather do the test and make the diagnosis. And when obtaining biopsy specimens of an ulcer, remember that the more specimens that are taken, with 6 being the minimum, the greater the chance of diagnosing CMVdand take them from the edge of the ulcer as well as the center; CMV likes vascular endothelium, mucosal epithelium, and connective tissue stromal cells. The intranuclear inclusion body giving the appearance of an owl’s eye is an insensitive but highly specific finding for CMV. Owls’ eyes have an abundance of rods and therefore are capable of remarkable black and white vision. When looking for owl eyes in histologic sections, we should also emulate their behavior to look forward and see clearly, but at the same time remember that most of life’s situations are not black and white, but rather shades of gray. Things may not be what they appear to be at first glance. Lawrence J. Brandt, MD Associate Editor for Focal Points At the Focal Point

Delayed fatal hemorrhage after endoscopic band ligation for gastric Dieulafoy's lesion

Dieulafoy’s lesions are well-known, rare, and diagnostically challenging clinical entities that usually cause massive GI bleeding. We describe a patient who received endoscopic band ligation (EBL) for a bleeding Dieulafoy’s lesion at the gastric cardia. Despite endoscopic follow-up, the patient died from recurrent fatal hemorrhage. To our knowledge, this is the first reported death caused by delayed hemorrhage after EBL for a Dieulafoy’s lesion.

Profound transient thrombocytopenia associated with 90Yttrium microsphere therapy for inoperable hepatoma.

The use of 90Yttrium microspheres to treat unresectable hepatoma is increasing worldwide. Therapeutically, 90Yttrium microspheres show promising increases in survival and tumor response, as well as acceptable toxicities. Here, we report on a 67-year-old man with hepatitis C-related advanced-stage hepatoma. This patient received selective internal radiation therapy (SIRT) using 90Yttrium microspheres (SIR-Spheres®). The patient displayed bone marrow suppression that resulted in a transient yet profound thrombocytopenia. To our knowledge, this is the first case of a hematologic complication as a consequence of the use of commercially available 90Yttrium microsphere devices.

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

AIMnTo evaluate the efficacy of thalidomide in combination with other therapies to treat patients with advanced hepatocellular carcinoma (HCC).nnnMETHODSnWe 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.nnnRESULTSnA 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.nnnCONCLUSIONnThalidomide 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.

Combined capillary hemangioma and angiodysplasia of the ileum: an unusual cause of obscure gastrointestinal bleeding with preoperative localization by double-balloon endoscopy.

Vascular lesions in the small bowel with bleeding complications are usually difficult to diagnose and localize preoperatively. With the increased use of either capsule endoscopy or enteroscopy, there have been more reports of preoperative diagnosis from such lesions. The authors report a rare case of obscure gastrointestinal bleeding from a combined hemangioma and angiodysplasia identified by double-balloon enteroscopy. To the authors knowledge, this is the first report of such combined lesions.

Extravasation of sclerosant after injection of N-butyl-2-cyanoacrylate for a bleeding gastric Dieulafoy lesion

cause she had been passing tarry stools for 2 days. Emergency endoscopy re− vealed an actively spurting Dieulafoy le− sion in the gastric fundus (l Fig. 1). Be− cause of the technical difficulty of apply− ing hemoclips in this case we performed rubber−band ligation, which resulted in immediate hemostasis (l Fig. 2). Twelve hours later, fresh blood reappeared in the nasogastric aspirate. A repeat endoscopy showed active oozing from the base of the ligated area (l Fig. 3). Despite the in− jection of 12 mL of diluted epinephrine, the bleeding persisted. After discussing the situation with the patient she agreed to receive a sclerosant injection, and the bleeding stopped after an injection of a mixture of 0.5 mL of N−butyl−2−cyano− acrylate and lipiodol. The patient com− plained of dull epigastric pain after the injection, and a chest radiograph showed radiopaque material along the left dia− phragm (l Fig. 4). Abdominal computed tomography confirmed that there was ex− travasation of sclerosant along the left subphrenic area (l Fig. 5). The patient was free of any signs of infection and was discharged on day 6 of her hospital day. She remained well over the following 2 years. Endoscopic therapy is now a mainstay of treatment for Dieulafoy lesions. Several authors have documented hemostasis rates for endoscopic band ligation of 80 % ±100 % in case series of patients with Dieulafoy lesions [1, 2]. However, the optimal rescue therapy after failed endoscopic band ligation is not known. In the present case, injection therapy with diluted epinephrine failed to control the bleeding. Hemoclipping or coagulati− on therapy would have been technically difficult. It was believed that repeated band ligation would increase the risk of gastric perforation [3], and so Histoacryl injection was chosen as the last resort be− fore surgery [4]. Despite the successful hemostasis, the complication of injec− tion−site leakage and resultant transient abdominal pain are concerning. This might have been caused by direct pene− tration of the gastric wall by the injection needle. The short−term outcome of scler− osant extravasation in this case and in an− other reported case [5] was good, but it is still not clear what the long−term effects of this complication are.

Evaluation of dose-efficacy of sorafenib and effect of transarterial chemoembolization in hepatocellular carcinoma patients: a retrospective study.

BackgroundTransarterial chemoembolization (TACE) and sorafenib are the therapeutic standard for intermediate and advanced stage hepatocellular carcinoma (HCC) patients respectively. High costs with adverse events (AE) of sorafenib might limit sorafenib dosage, further affecting therapeutic response. To attain greatest benefit, we evaluated the efficacy of different doses and effect of TACE during and after sorafenib discontinuation in patients representing Child-Pugh Classification Class A with venous or extra-hepatic invasion.MethodsA total 156 patients met the criteria and were divided into Groups I (nu2009=u200952) accepting 800xa0mg/day; II (nu2009=u200958) accepting 800xa0mg/day and reduced to 400xa0mg/day owing to AE; and III (nu2009=u200946) accepting 400xa0mg/day. TACE was performed during and after sorafenib discontinuation and therapeutic response bimonthly to four-monthly was rated thereafter.ResultsMedian duration of sorafenib treatment and patients’ survival were 4.00u2009±u20090.45 and 7.50u2009±u20091.44xa0months in all cases; 2.50u2009±u20090.90 and 5.00u2009±u20091.10xa0months in Group I; 5.50u2009±u20091.27 and 16.50u2009±u20091.86xa0months in Group II; 4.00u2009±u20090.94 and 6.50u2009±u20092.49xa0months in Group III. Group II presented the best response and survival benefit (pu2009=u20090.010 and pu2009=u20090.011 respectively). Child-Pugh Classification score 5 (Hazard Ratiou2009=u20090.492, pu2009=u20090.049), absent AE (3.423, pu2009=u20090.015), tumor numbersu2009≤u20093 (0.313, pu2009=u20090.009), sorafenib durationu2009≤u20091xa0cycle (3.694, pu2009=u20090.004), and absent TACE (3.197, pu2009=u20090.008) significantly correlated with patient survival. TACE benefit appeared in separate and total cases during (pu2009=u20090.002, pu2009=u20090.595, pu2009=u20090.074, pu2009=u20090.002 respectively) and after discontinuation of sorafenib administration (pu2009=u20090.001, pu2009=u20090.034, pu2009=u20090.647, pu2009=u20090.001 respectively).ConclusionsLow-dosage sorafenib not only appeared tolerable and lowered economic pressure but also provided satisfactory results. TACE benefited patient’s survival during and after sorafenib discontinuation.

The clinical significance of jejunal diverticular disease diagnosed by double-balloon enteroscopy for obscure gastrointestinal bleeding.

BackgroundJejunal diverticular disease is a rare cause of gastrointestinal bleeding. The reported incidence of this disease is low in the studies of double-balloon enteroscopy.AimThe aim of this study was to evaluate the clinical features and management of jejunal diverticular disease, diagnosed by double-balloon enteroscopy, at our institution.MethodThis was a retrospective study of patients with jejunal diverticular disease conducted from April 2004 to September 2009 at Changhua Christian Hospital. We evaluated the clinical significance of jejunal diverticular disease and the outcome of endoscopic treatment for jejunal diverticular bleeding.ResultsFrom April 2004 to September 2009, a total of 55 patients underwent double-balloon enteroscopy due to obscure gastrointestinal bleeding. Fifteen of these patients were diagnosed with jejunal diverticular disease (8 men and 7 women, mean age 71 years). Four patients were found to have a single diverticulum. Gastrointestinal bleeding was attributed to jejunal diverticular disease in 12 patients. Six patients received endoscopic treatment in order to achieve hemostasis. One patient received emergency surgery due to uncontrolled bleeding.ConclusionsTo our knowledge, this is the first study reporting the clinical significance of jejunal diverticular disease diagnosed by double-balloon enteroscopy. We found that obscure GI bleeding was attributed significantly to jejunal diverticular disease.