Yu-Pin Ho

Adrenal insufficiency in patients with cirrhosis, severe sepsis and septic shock.

Patients with cirrhosis are susceptible to bacterial infection, which can result in circulatory dysfunction, renal failure, hepatic encephalopathy, and a decreased survival rate. Severe sepsis is frequently associated with adrenal insufficiency, which may lead to hemodynamic instabity and a poor prognosis. We evaluated adrenal function using short corticotropin stimulation test (SST) in 101 critically ill patients with cirrhosis and severe sepsis. Adrenal insufficiency occurred in 51.48% of patients. The patients with adrenal insufficiency had a higher hospital mortality rate when compared with those with normal adrenal function (80.76% vs. 36.7%, P < .001). The cumulative rates of survival at 90 days were 15.3% and 63.2% for the adrenal insufficiency and normal adrenal function groups, respectively (P < .0001). The hospital survivors had a higher cortisol response to corticotropin (16.2 ± 8.0 vs. 8.5 ± 5.9 μg/dL, P < .001). The cortisol response to corticotropin was inversely correlated with various disease severity, Model for End‐Stage Liver Disease, and Child–Pugh scores. Acute physiology, age, chronic health evaluation III score, and cortisol increment were independent factors to predict hospital mortality. Mean arterial pressure on the day of SST was lower in patients with adrenal insufficiency (60 ± 14 vs. 74.5 ± 13 mm Hg, P < .001), and a higher proportion of these patients required vasopressors (73% vs. 24.48%, P < .001). Mean arterial pressure, serum bilirubin, vasopressor dependency, and bacteremia were independent factors that predicted adrenal insufficiency. In conclusion, adrenal insufficiency is common in critically ill patients with cirrhosis and severe sepsis. It is related to functional liver reserve and disease severity and is associated with hemodynamic instability, renal dysfunction, and increased mortality. (HEPATOLOGY 2006;43:673–681.)

Organ system failure scoring system can predict hospital mortality in critically ill cirrhotic patients.

Goals This study was conducted to assess and compare the accuracy of Child-Pugh classification and organ system failure (OSF) scores, obtained on the first day of ICU admission, in predicting the hospital mortality in critically ill cirrhotic patients. Background Cirrhotic patients admitted to the medical intensive care unit (ICU) are associated with high mortality rates. The prognosis of critically ill cirrhotic patients is determined by the extent of hepatic and extrahepatic organ dysfunction. Study A total of 111 patients diagnosed with liver cirrhosis were admitted to medical ICU from July 2001 to June 2002. Information considered necessary to compute the Child-Pugh and OSF scores on the first day of ICU admission was prospectively collected. Results The overall hospital mortality rate was 64.9%. Liver disease was most commonly attributed to hepatitis B viral infection. The OSF scores demonstrate a good fit using the Hosmer and Lemeshow goodness-of-fit test. Meanwhile, by using the areas under receiver operating characteristic (AUROC) curve, the OSF scores demonstrated an excellent discriminative power (AUROC 0.901), whereas the performance of Child-Pugh scores is clearly poorer (AUROC 0.748). Conclusion This investigation confirms that the prognosis for cirrhotic patients admitted to ICU is grave. The OSF score is a simple, reproducible, and easily applied tool with excellent prognostic abilities that can provide objective information for patients families and physicians and supplement the clinical judgment of prognosis.

Endoscopic management of Dieulafoy lesions in acute nonvariceal upper gastrointestinal bleeding

Dieulafoy lesion is an unusual but important cause of upper gastrointestinal bleeding. The study retrospectively reviewed 29 patients (2.1%) with Dieulafoy lesions of 1393 acute nonvariceal upper gastrointestinal bleeding episodes from October 1999 to May 2001. Nineteen patients (66%) were male and the median age was 62 years (range, 19 to 86 years). Two patients underwent emergent surgery after endoscopic diagnosis. The other patients were allocated to four therapeutic endoscopic groups: group I, epinephrine injection (11 patients); group II, epinephrine injection plus heater probe coagulation (10 patients); group III, histoacryl injection (4 patients); and group IV, hemoclipping (2 patients). Initial treatment failure ocurred in three patients (all in group I) and they received surgery, hemoclipping, or band ligation as salvage therapy, respectively. Among those who achieved initial hemostasis, recurrent bleeding developed in two patients (all in group I) and was successfully controlled by endoscopic injection plus thermal therapy. No complication was noted after endoscopic treatment. Group II had a significantly higher successful hemostasis rate than group I (100 vs 54%; P = 0.02). One patient in the therapeutic endoscopy groups died during admission, for a mortality rate of 3.7%. Patients were followed up from 6 to 36 months and no further bleeding was noted. The results suggest that epinephrine injection plus heater probe coagulation was significantly superior to epinephrine injection alone in achieving hemostasis. Histoacryl injection, hemoclipping, and endoscopic band ligation were safe and effective alternate therapies.

Extracorporal liver support with molecular adsorbents recirculating system in patients with hepatitis B-associated fulminant hepatic failure.

Hepatitis B virus (HBV) infection is the most prevalent cause of fulminant hepatic failure (FHF) in the Far East. HBV‐associated FHF is characterised by rapidly progressive end organ dysfunction/failure and a very poor prognosis.

The clinical characteristics and manifestations of cytomegalovirus esophagitis

Esophagitis is the second most common gastrointestinal manifestation of cytomegalovirus (CMV) infection after colitis. CMV esophagitis has been reported in patients who have undergone transplantation, are on long-term renal dialysis, or who have the human immunodeficiency virus infection. This study aimed to investigate the clinical characteristics and manifestations of CMV esophagitis in patients who underwent diagnostic endoscopy. A total of 16 patients with histologically proven CMV infection were identified from 1539 patients with esophageal ulcers and analyzed retrospectively (January 2006 to December 2013). Patients personal data (age, smoking, and alcohol consumption), underlying systemic diseases (diabetes mellitus, end-stage renal disease, and chronic obstructive pulmonary disease), malignancy, indication for esophagogastroduodenoscopy, endoscopic characteristics, and diagnostic methods (pathological or serological findings) were collected for further analysis. Among the patients with CMV esophagitis, the mean age was 59.94 years (range, 23-84 years). The maleu2009:u2009female ratio was 1.67:1. Odynophagia and epigastralgia were common symptoms. Of the 16 patients, 3 (18.75%) were infected with the human immunodeficiency virus and 9 (56.25%) had an underlying malignancy, including lung cancer (6 patients), esophageal cancer (2 patients), gastric cancer (1 patient), ampulla of Vater cancer (1 patient), and lymphoma (1 patient). Six of the 9 patients (66.7%) with malignancy had been administered concurrent chemoradiotherapy (CCRT). In this study, patients with malignancy who had been administered CCRT were at increased risk for CMV esophagitis, which had not been reported before in the literature. CMV esophagitis should be considered as a potential treatment-related complication of CCRT.

Increased regulatory T cells in patients with liver cirrhosis correlated with hyperbilirubinemia and predict bacterial complications.

Patients with liver cirrhosis (LC) were regarded as immunocompromised status with high incidence of bacterial infection. Regulatory T cell (Treg cell) is known as an immune suppressor and also plays an important role in patients with sepsis. This paper aims to study the role of Treg cells in patients with liver cirrhosis and their correlations to bacterial complications.

Accuracy of immunochemical fecal occult blood test for detecting colorectal neoplasms in individuals undergoing health check-ups

In Taiwan, the prevalence of colorectal cancer has been increasing in recent decades. As a result, the fecal occult blood test (FOBT) has been advocated and widely used for colorectal cancer screening in areas with limited colonoscopy capacity. The goal of this study was to analyze the sensitivity of a single immunochemical FOBT (I‐FOBT) and correlate it with the results of colonoscopy for detecting colorectal neoplasia in the asymptomatic Taiwanese population.

Spontaneously significant pneumoretroperitoneum misinterpreted as herniated intervertebral disc: an unusual presentation of perforation of ascending colon cancer.

Colon cancer is a common neoplasm and is the third most common cause of neoplasm-induced death in Taiwan (1). Approximately 15.22 individuals per million population die of colon cancer annually in Taiwan (1). Most patients with colon cancer present with abdominal pain, weight loss, altered bowel habits, chronic blood loss, or acute bleeding. Furthermore, a few studies have demonstrated that colon cancer can present with symptoms and signs of colon perforation (2–8). The incidence of colon cancer presenting with perforation is about 2.1–9.5% of total cases (3–5, 7, 8). Most patients with perforated colon cancer exhibit symptoms and signs of peritonitis owing to intraperitoneal perforation. Rarely, such patients present with retroperitoneal perforation (6, 9–11). Abdominal symptoms in retroperitoneal perforation may be minimal, and diagnosis is often delayed or missed because of unusual symptoms and signs. This investigation describes a case of ascending colon cancer with spontaneous retroperitoneal perforation, presenting initially with symptoms mimicking sciatica caused by pneumoretroperitoneum and retroperitoneal abscess.

Recurrent bleeding of colonic diverticular hemorrhage after endoscopic treatment: Clinical experience of an endoscopic center

Diverticular bleeding is one of the most common etiologies of lower GI bleeding. Endoscopy is a useful tool in both diagnosis and therapeutic management. The endoscopic hemostatic methods included epinephrine injection, thermal coagulation, clipping or combination of them. The aim of this study was to evaluate the outcome of different type of hemostasis.

Clinical Characteristics and Manifestation of Herpes Esophagitis: One Single-center Experience in Taiwan

AbstractWe aimed to investigate the clinical characteristics of patients with herpes esophagitis (HE) based on endoscopic typing.Herpes simplex virus infection in the gastrointestinal tract primarily affects the esophagus. However, little is known about the presentation, endoscopic findings, and outcomes of HE.From 2003 to 2013, 47 patients with HE were identified histologically from among 1843 patients with esophageal ulcers. Personal data, underlying disease, esophagogastroduodenoscopy indication, endoscopic characteristics, pathological findings, laboratory data, and outcomes were collected. Endoscopic findings were classified into 3 types based on gross appearance and were correlated with clinical presentation.The mean age of patients was 62.04u200a±u200a14.76 years, and most patients were men (39/47, 83%). The most common symptoms were odynophagia/dysphagia (20/47, 42.6%). Whereas 25 patients (53.2%) were diagnosed with malignancy, it was related to human immunodeficiency virus in only 1 patient (2.1%). HE was classified into 3 types based on endoscopic images: type I (nu200a=u200a19), type II (nu200a=u200a10), and type III (nu200a=u200a18). The majority of patients with HE type III had sepsis (72%) and obvious leukocytosis than the other 2 types (Pu200a=u200a0.03). The overall mortality rate was 6.4% (3/47), and most of the patients who died (66.7% [2/3]) belonged to the endoscopic classification type III group. Clinical parameters were analyzed for the risk of poor outcome. Postchemotherapy and/or radiotherapy were associated with 30-day mortality after appearance of HE (Pu200a<u200a0.05).Herpes esophagitis primarily affects men and patients with malignancy or sepsis. However, the disease is usually self-limiting, and HE-related mortality is low. Relationship between severity of endoscopic findings and patients’ outcome remains questionable. Further prospective study is needed.