Yung-Chih Lai

Portal blood flow in acute hepatitis with and without ascites: a non-invasive measurement using an ultrasonic Doppler.

Abstract To evaluate the role of portal blood flow in severe acute hepatitis leading to the formation of ascites, we studied the portal blood flow of 30 patients with severe acute hepatitis (20 without ascites and 10 with ascites), 20 patients with mild acute hepatitis and 20 healthy normal volunteers using duplex sonography. The portal blood flow of patients with severe acute hepatitis and ascites (421 ± 94 mL/min) was lower than that of the volunteers (725 ± 131 mL/min), the mild acute hepatitis (658 ± 148 mL/min), and the severe acute hepatitis (633 ± 108mL/min) without ascites (P < 0.001). The congestion index of severe acute hepatitis and ascites (0.16 ± 0.04 cm · s) was higher than that of the volunteers (0.09 ± 0.03 cm · s, P < 0.001), the mild acute hepatitis (0.09 ± 0.02 cm · s, P < 0.001), and the severe acute hepatitis (0.12 ± 0.04 cm · s, P < 0.02) without ascites. Portal blood flow was negatively correlated with prolonged prothrombin time (P < 0.001) and serum total bilirubin level (P= 0.002) and congestion index was positively correlated with heart rate (P= 0.006), prolonged prothrombin time (P < 0.001). and serum total bilirubin level (P= 0.001). Our study shows that in severe acute hepatitis, portal blood flow was reduced in patients with ascites. The non‐invasive ultrasonic Doppler is a safe and helpful method in the clinical evaluation of portal hypertension in severe acute hepatitis.

Prospective study of abdominal ultrasonography before laparoscopic cholecystectomy.

To investigate the role of abdominal ultrasonography (US) in predicting possible difficulties during laparoscopic cholecystectomy, we performed preoperative US evaluation prospectively in 82 consecutive patients. We correlated our predictions of “easy” and “difficult” with difficulties experienced at operation in surgery. The binary outcomes were analyzed by taking both easy category of US and surgical operation as positive results and both difficult category as negative results. We obtained satisfactory sensitivity (93.8%), accuracy (81.4%), and positive predictive value (84.7%), but low specificity (35.3%) and negative predictive value (60%). The highly positive results were the result of careful US examination. The low specificity and negative predictive value were attributed to the fact that most surgically difficult cases were due to adhesions around the gallbladder, difficult indeed to detect at US. We conclude that thorough abdominal US examination before laparoscopic cholecystectomy is useful in preoperative evaluation of patients undergoing laparoscopic cholecystectomy, even if it not infrequently fails to predict the surgically difficult cases mainly due to adhesions around the gallbladder.

Eosinophilic Esophagitis: Report of a Case

Eosinophilic esophagitis (EoE) is a rare disorder characterized by symptoms of esophageal dysfunction and marked eosinophilic infiltration of esophageal mucosa. We present a 40-year-old male who suffered from progressive dysphagia with solid food and mild chest pain for 1 month. Upper endoscopy revealed diffuse concentric rings, longitudinal furrows and adherent white exudates. Laboratory data showed elevated total IgE but without peripheral blood eosinophilia. Histopathology of the biopsy specimen of the esophageal mucosa showed prominent intraepithelial eosinophilic infiltration (＞15/HPF). Under the diagnosis of eosinophilic esophagitis, the symptoms were non-responsive to proton pump inhibitor therapy, oral steroids were prescribed and the dysphagia improved gradually. EoE is a distinct cause of dysphagia and food impaction in adults. Our present case highlights the clinical and endoscopic features, histopathological criteria and response to medical treatment.

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.

Argon Plasma Coagulation with Lower Energies for Hemorrhagic Radiation Proctitis: Report of a Case

Radiation proctopathy (RP) is a troublesome complication of radiotherapy for pelvic malignancies and its incidence is around 5%-7.5%. We present a 79-year-old man who began passing fresh blood from his rectum after prostate cancer radiotherapy before admission to the hospital. Colonoscopy revealed friable rectal mucosa oozing blood. Under the diagnosis of hemorrhagic radiation proctitis, the patient was underwent two sessions of argon plasma coagulation (APC) at a power setting of 30 W and 1.5 L/min flow rate; bleeding stopped after treatment. For 13 months after the first APC treatment, the patient was in good condition and without recurrent rectal bleeding. Review of the literature for the treatment of PR bleeding showed that endoscopic treatment modalities are superior to medical therapy alone or surgical intervention. In 1991, Grund and Farin et al. first performed APC with a flexible endoscope. Compared to other endoscopic treatments, APC has the advantages of effectiveness, ease of use, cost effectiveness, safety, and fewer complications over other treatment modalities. The power setting for APC ranges from 25 to 60 W and the argon flow rate is 0.6 to 2 L/min; these settings effectively control the PR bleeding. The reports show that use of less power (a median of 30 W) instead of higher power produces the best results. We discuss the various power settings for APC based on clinical application.

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.

Effects of Different Antibiotics in the Treatment of Cirrhotic Patients with Culture-Negative Neutrocytic Ascites or Spontaneous Bacterial Peritonitis

Ascitic infection is a major cause of morbidity and mortality in liver cirrhosis patients. Many reports suggest that at least 5 days of third generation cephalosporin is better than a conventional first generation cephalosporin or amoxicillin plus an aminoglycoside for treating ascitic infections. We retrospectively reviewed 54 patients with culture-negative neutrocytic ascites (CNNA) or spontaneous bacterial peritonitis (SBP) who were treated with an intravenous first generation cephalosporin plus short-term gentamicin, or a second or third generation cephalosporin. Thirteen patients with CNNA (group A) were treated with an intravenous first generation cephalosporin plus short-term gentamicin intravenous drip (regimen Ⅰ). Another 18 CNNA patients (group B) were treated with an intravenous second or third generation cephalosporin monotherapy (regimen Ⅱ). Seven patients with SBP (group C) were treated with regimen Ⅰ and 16 patients with SBP (group D) were treated with regimen Ⅱ. Three and 16 patients with shock on admission were treated with regimen Ⅰ or Ⅱ respectively. We compared the success rates of these two regimens in CNNA and SBP groups. The successful treatment rates were 92.3% (12/13), 67.7% (12/18), 57.1% (4/7) and 37.5% (6/16) for groups A, B, C, D, respectively. The difference in success rates between regimen Ⅰ and regimen Ⅱ in the CNNA group or SBP group was not statistically significantly. However, the success rates for antibiotics given to non-septic shock patients and septic shock patients were significantly different (non-septic shock: 32/35 vs. septic shock: 2/19, p＜0.05,) A first generation cephalosporin plus short-term gentamicin has good effect to treat CNNA patients not in shock. But it should be used cautiously to prevent acute renal failure in cirrhosis patients. Broader spectrum antibiotics should be used in patients with shock or any clinical deterioration.

Multiple Hepatic Angiomyolipomas: Report of a Case

Hepatic angiomyolipoma is an uncommon benign mesenchymal neoplasm with a high content of fat cells, variable proportions of smooth muscle fibers and blood vessels. We present a rare case of multiple hepatic angiomyolipomas. A 50-year-old lady had gall stones related right upper quadrant abdominal pain as well as multiple bright liver tumors. Patient underwent laparoscopic cholecystectomy and diagnostic liver wedge biopsy. Histologic findings of liver tumors showed fat cells, blood vessels and epitheloid smooth-muscle cells. The epitheloid smooth-muscle cells were positive for HMB-45 staining. Intensive studies did not show any renal angiomyolipoma and tuberous sclerosis. The abdominal pain had been improved after cholecystectomy. Our patient had also iron deficiency anemia. Upper endoscopy, colonoscopy and small intestinal series did not show any evidence of intestinal blood loss. Her hemoglobin did not respond to iron-supplement therapy. Iron malabsorption might be the cause of iron deficiency anemia.

Mesenteric Hemangiopericytoma Presenting as Acute Abdomen: Report of a Case

Hemangiopericytoma is an uncommon neoplasm arising from the pericyte of Zimmerman. This tumor is commonly found on the extremities, retroperitoneum, and nasopharynx. Hemangiopericytoma is found with local recurrence more often than distant metastasis. We report a 42 year-old man who developed mesenteric hemangiopericytoma 8 years after the resection and subsequent radiation therapy for the tumor at nasal cavity. This patient suffered from acute abdominal pain with peritoneal sign. The computed tomography showed a mesenteric tumor with superior mesenteric vein thrombosis and edematous intestine. The laparotomy revealed a large mesentery tumor compressing the root of mesentery to cause mesenteric ischemia. Histology confirms the diagnosis of hemangiopericytoma. Tracing back his history, we speculated that this patient had a hemangiopericytoma, arising from mesentery and presenting with acute symptoms.

C^13 Urea Breath Test Combined with Symptomatology is Helpful in Deciding Which Dyspeptic Patients Need Endoscopy to Rule in Peptic Ulcer

Knowing when to give endoscopy to a primary dyspeptic patient is a difficult decision for any gastroenterologist. We decided to address the problem by testing for Helicobacter pylon and analyzing patients symptoms. Within one-year period, 117 consecutive dyspeptic outpatients underwent endoscopy. Of these patients, all had symptom duration longer than one month, had no sinister symptoms (anemia, body weight loss and gastrointestinal bleeding), never had previous endoscopy, had no gastric surgery, nor had ingestion of antibiotics or non-steroid anti-inflammatory drugs two weeks prior to enrollment, and were free of hepatobiliary disease by abdominal sonography. Urea breath test (UBT) with only a 15-minute collection interval was done to each patient and a questionnaire about dyspeptic symptoms was also answered. Patients were divided into three groups according to the results of UBT and endoscopy; UBT negative patients (n=44), UBT positive with no ulcer patients (n=37) and UBT positive with ulcer or scar present patients (n=36). In UBT negative patients, they were more younger and they had no evidence of peptic ulcer disease endoscopically. In UBT positive patients, patients with peptic ulcer disease had statistically signficant difference than those without peptic ulcer disease in that they had more regular attack of pain before meal and at midnight, and their pain can be relieved by eating. We conclude that the 15-minute UBT in association with symptoms analysis is helpful in deciding which dyspeptic patients need to be given endoscopy.