Eosinophilic gastroenteritis: clinical experience with 15 patients

AIM

To evaluate the clinic features of eosinophilic gastroenteritis and to examine the diagnosis, treatment, long-term outcome of this disease.

METHODS

Charts with a diagnosis of eosinophilic gastroenteritis from 1984 to 2002 at Mackay Memorial Hospital were reviewed retrospectively. There were 15 patients diagnosed with eosinophilic gastroenteritis. The diagnosis was established in 13 by histologic evaluation of endoscopic biopsy or operative specimen and in 2 by radiologic imaging and the presence of eosinophilic ascites.

RESULTS

All the patients had gastrointestinal symptoms and 12 (80%) had hypereosinophilia (absolute eosinophil count 1,008 to 31,360/cm3). The most common symptoms were abdominal pain and diarrhea. Five of the 15 patients had a history of allergy. Seven patients had involvement of the mucosa, 2 of muscularis, and 6 of subserosa. One with a history of seafood allergy was successfully treated with an elimination diet. Another patient improved spontaneously after fasted for several days. The remaining 13 patients were treated with oral prednisolone, 10 to 40 mg/day initially, which was then tapered. The symptoms in all the patients subsided within two weeks. Eleven of the 15 patients were followed up for more than 12 months (12 to 104 months, mean 48.7), of whom 5 had relapses after discontinuing steroids (13 episodes). Two of these patients required long-term maintenance oral prednisolone (5 to 10 mg/day).

CONCLUSION

Eosinophilic gastroenteritis is a rare condition of unclear etiology characterized by relapses and remissions. Short courses of corticosteroids are the mainstay of treatment, although some patients with relapsing disease require long-term low-dose steroids.

Caffeic acid phenethyl ester induces apoptosis of human pancreatic cancer cells involving caspase and mitochondrial dysfunction

AIMS

This study aimed to investigate the effect of caffeic acid phenethyl ester (CAPE), an active component isolated from honeybee propolis, in inducing apoptosis in human pancreatic cancer cells.

METHODS

Inhibition of viability of BxPC-3 and PANC-1 cell lines induced by CAPE was estimated by a trypan blue dye exclusion test. The type of cell death in BxPC-3 after CAPE treatment was characterized by observation of morphology, sub-G1 DNA content, annexin-V/PI staining, caspase-3 and caspase-7 assay, and DNA agarose gel electrophoresis.

RESULTS

CAPE (10 microg/ml) resulted in marked inhibition of viability of BxPC-3 (80.4 +/- 4.1%) and PANC-1 (74.3 +/- 2.9%) cells. CAPE induced a time-dependent increase in hypodiploid percentage and a significant decrease in mitochondrial transmembrane potential in BxPC-3 cells. It induced morphological changes of typical apoptosis, but no DNA fragmentation was noted by DNA electrophoresis. The inhibition of growth and increased in the proportion of sub-G(1) cells was partially blocked by pretreatment with the pan-caspase inhibitor Z-VAD-fmk (50 microM) in BxPC-3 cells indicating a caspase-related mechanism in CAPE-induced apoptosis. Caspase-3/caspase-7 activity was approximately 2 times greater in CAPE-treated BxPC-3 cells compared with control cells.

CONCLUSIONS

These results suggest that CAPE is a potent apoptosis-inducing agent. Its action is accompanied by mitochondrial dysfunction and activation of caspase-3/caspase-7.

Identification of a novel HLA-A allele, A*1131, in a Taiwanese

Here we report the identification and sequence analysis of a new HLA-A11* variant, A*1131 allele, found in a Taiwanese volunteer bone marrow donor. The novel A*11 variant is identical to A*1125 in exon 2 but differs from A*1125 in exon 3 by one nucleotide substitution at position 527 causing an amino acid change at codon 152 E-->V (GAG-->GTG). In comparison with HLA-A*110101, allele A*1131 has three nucleotide differences in exon 3: 527 C-->T, 538 C-->T and 539 A-->T leading to two amino acid variations at residues 152 A-->V and 156 Q-->L.

Sequence-based typing of a novel HLA-DRB1*04 allele, DRB1*0461, in a Taiwanese volunteer marrow donor

We report here a novel HLA-DRB1 allele, DRB1*0461, discovered in a Taiwanese volunteer marrow donor. The new sequence has nucleotide variation at positions 260 (C-->A) and 261 (C-->G), i.e. codon 58, as compared to DRB1*0408. Nucleotide change caused an amino acid substitution from alanine to glutamic acid. We believe that the gene conversion took place between DRB1*0405 and DRB1*1101 based on sequence homology and gene frequency in population studies. In comparison to DRB1*0405, DRB1*0461 has two amino acid changes at codons 57 and 58. Amino acid residue substitution at position 57 may affect peptide-binding environment at pocket P9 of the antigen-binding groove of the MHC molecule. This would have potential effect in peptide binding as well as in T-cell recognition, which could have clinical significance in bone marrow and organ transplantations.

Detection of a novel HLA-B27 allele, B*2740, in Taiwanese volunteer bone marrow donors by sequence-based typing: curiosity rewarded

We report here a novel HLA-B allele, B*2740, discovered in Taiwanese volunteer marrow donors. The new sequence has nucleotide variation at position 527 (T-->A) as compared to B*2708. The nucleotide change caused an amino acid substitution from valine (V) to glutamic acid (E) at codon 152. Since B*2740 carries sequence confers to HLA-Bw6 public epitope we believe that this novel B*27 allele might have been generated from a gene conversion involving a Bw4-specific allele (probably B*2704) and a Bw6-specific allele.

A novel HLA-B allele, B*5214, detected in a Taiwanese volunteer bone marrow donor using a sequence-based typing method

HLA-B*5214, a novel rare allele of HLA-B*52 variant, was found in a Taiwanese volunteer bone marrow donor by sequence-based typing method. The sequence of B*5214 is identical to that of B*520101 in exon 2 but differs from B*520101 in exon 3 at nucleotide positions 419 A-->T and 435 A-->G. Alteration of these two nucleotides resulted an amino acid substitution at amino acid residue 116 Y-->F ( TAC-->TTC) and a silent exchange at residue 121 K-->K (AAA-->AAG).

Endoscopic findings in a patient with Henoch-Schonlein purpura

Henoch-Schonlein purpura (HSP) is a systemic vasculitis of the small vessels of the skin, joints, GI tract, and kidney. It preferentially affects children but may also occur in adults. We report a 60-year-old man with HSP who presented with colicky abdominal pain, bloody diarrhea, arthralgia, and skin rash. The gastrointestinal tract was viewed by upper endoscopy and colonoscopy. We found characteristic endoscopic findings in the stomach, cecum and sigmoid colon, the combination of which has rarely been demonstrated in one patient. Histologic examination of skin biopsy specimens revealed leukocytoclastic vasculitis with positive staining for IgA in the capillaries. Endoscopy appears to have substantial diagnostic utility in patients suspected of having HSP, especially when abdominal symptoms precede the cutaneous lesions.

Nutrition therapy in esophageal cancer-Consensus statement of the Gastroenterological Society of Taiwan

A number of clinical guidelines on nutrition therapy in cancer patients have been published by national and international societies; however, most of the reviewed data focused on gastrointestinal cancer or non-cancerous abdominal surgery. To collate the corresponding data for esophageal cancer (EC), a consensus panel was convened to aid specialists from different disciplines, who are involved in the clinical nutrition care of EC patients. The literature was searched using MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and the ISI Web of Knowledge. We searched for the best evidence pertaining to nutrition therapy in the case of EC. The panel summarized the findings in 3 sections of this consensus statement, based on which, after the diagnosis of EC, an initial distinction is made between the patients, as follows: (1) Assessment; (2) Therapy in patients with resectable disease; patients receiving chemotherapy or chemoradiotherapy prior to resection, and patients with unresectable disease, requiring chemoradiotherapy or palliative therapy; and (3) Formula. The resulting consensus statement reflects the opinions of a multidisciplinary group of experts, and a review of the current literature, and outlines the essential aspects of nutrition therapy in the case of EC. The statements are: Patients with EC are among one of the highest risk to have malnutrition. Patient generated suggestive global assessment is correlated with performance status and prognosis. Nutrition assessment for patients with EC at the diagnosis, prior to definitive therapy and change of treatment strategy are suggested and the timing interval can be two weeks during the treatment period, and one month while the patient is stable. Patients identified as high risk of malnutrition should be considered for preoperative nutritional support (tube feeding) for at least 7-10 days. Various routes for tube feedings are available after esophagectomy with similar nutrition support benefits. Limited intrathoracic anastomotic leakage postesophagectomy can be managed with intravenous antibiotics and self-expanding metal stent (SEMS) or jejunal tube. Enteral nutrition in patients receiving preoperative chemotherapy or chemoradiation provides benefits of maintaining weight, decreasing toxicity, and preventing treatment interruption. Tube feeding or SEMS can offer nutrition support in patients with unresectable esophageal cancer, but SEMS is not recommended for those with neoadjuvant chemoradiation before surgery. Enteral immunonutrition may preserve lean body mass and attenuates stress response after esophagectomy. Administration of glutamine may decrease the severity of chemotherapy induced mucositis. Enteral immunonutrition achieves greater nutrition status or maintains immune functions during concurrent chemoradiation.

Ultrasonography of splenic abnormalities

AIM

This report gives a comprehensive overview of ultrasonography of splenic abnormalities. Certain ultrasonic features are also discussed with pathologic correlation.

METHODS

We review the typical ultrasonic characteristics of a wide range of splenic lesions, illustrating them with images obtained in our institution from 2000 to 2003. One hundred and three patients (47 men, 56 women), with a mean age of 54 years (range 9-92 years), were found to have an abnormal ultrasonic pattern of spleen.

RESULTS

We describe the ultrasonic features of various splenic lesions such as accessory spleen, splenomegaly, cysts, cavernous hemangiomas, lymphomas, abscesses, metastatic tumors, splenic infarctions, hematomas, and rupture, based on traditional gray-scale and color Doppler sonography.

CONCLUSION

Ultrasound is a widely available, noninvasive, and useful means of diagnosing splenic abnormalities. A combination of ultrasonic characteristics and clinical data may provide an accurate diagnosis. If the US appearance alone is not enough, US may also be used to guide biopsy of suspicious lesions.

Nodular gastritis: an endoscopic indicator of Helicobacter Pylori infection

We prospectively assessed the relationship between nodular gastritis and Helicobacter pylori infection. Of 1409 adults who underwent endoscopy for persistent dyspepsia between June 2004 and August 2005, 41 (2.9%) patients were diagnosed with nodular gastritis (11 [27%] men and 30 [73%] women). The mean age was 45.9 years. A control group of 65 patients without nodular gastritis was also evaluated. The prevalence of H. pylori infection was higher in patients with nodular gastritis than in controls (38/41 [93%] vs. 33/65 [51%]). Of 21 patients treated to eradicate H. pylori, the nodular gastritis pattern resolved or improved in 16 patients on subsequent endoscopy. This study suggests that a nodular pattern of the gastric mucosa on endocscopy is a good indicator for H. pylori infection in adults, with the high positive predictive value of 92.7%.

A novel artificial tissue simulator for endoscopic submucosal resection training - a pilot study

BACKGROUND

We developed a novel artificial simulator for endoscopic submucosal dissection (ESD) as a bridge between instructional videos and animal tissue training and aimed to evaluate the feasibility of using an artificial tissue model in ESD training.

METHODS

Eight gastroenterology fellows from one medical center were enrolled in this ESD training program. Before and after the simulator training, attendees indicated on a 5-point scale the degree of difficulty in performing the following procedures: lesion marking, mucosal pre-cutting, circumferential incision, submucosal dissection, and hemostasis. After the simulator training, the participants completed a questionnaire regarding their opinions on the degree of realism and the feasibility of using this model for training.

RESULTS

After watching an instructional video, attendees felt that the most difficult techniques were submucosal dissection and hemostasis. After using the artificial tissue simulator model, the attendees felt more confident in performing performing lesion marking (p = 0.026) and submucosal dissection (p = 0.037). However, they still felt that hemostasis was the most difficult techniques to master. Overall, the attendees thought the simulator was realistic in simulated lesion marking and its use was feasible for simulated lesion marking and submucosal dissection.

CONCLUSION

Our pilot study shows the feasibility of using a novel artificial tissue in performing ESD and we believe that the artificial tissue simulator acts well as a bridge between instructional videos and animal model training. The model is reusable and inexpensive, and could disseminate the techniques of the ESD more easily and quickly.

The add-on N-acetylcysteine is more effective than dimethicone alone to eliminate mucus during narrow-band imaging endoscopy: a double-blind, randomized controlled trial

OBJECTIVE

Recent studies have shown that pronase can improve mucosal visibility, but this agent is not uniformly available for human use worldwide. This study aimed to assess the efficacy of N-acetylcysteine (NAC), a mucolytic agent, in improving mucus elimination as measured by decreased endoscopic water flushes during narrow-band imaging (NBI) endoscopy.

MATERIAL AND METHODS

A consecutive series of patients scheduled for upper gastrointestinal endoscopy at outpatient clinics were enrolled in this double-blind, randomized controlled trial. The control group drank a preparation of 100 mg dimethicone (5 ml at 20 mg/ml) plus water up to 100 ml, and the NAC group drank 300 mg NAC plus 100 mg dimethicone and water up to 100 ml. During the endoscopy, the endoscopist used as many flushes of water as deemed necessary to produce a satisfactory NBI view of the entire gastric mucosa.

RESULTS

In all, 177 patients with a mean age of 51 years were evaluated in this study. Significantly lesser water was used for flushing during NBI endoscopy for the NAC group than the control group; 40 ml (30-70, 0-120) versus 50 ml (30-100, 0-150) (median (interquartile range, range), p = 0.0095).

CONCLUSIONS

Considering the safety profile of NAC, decreasing the number of water flushes for optimal vision and unavailability of pronase in some areas, the authors suggest the use of add-on NAC to eliminate mucus during NBI endoscopy.

Endoscopic patterns and histopathological features after eradication therapy in Helicobacter pylori-associated nodular gastritis

The endoscopic finding of nodular gastritis (NG) is highly associated with presence of Helicobacter pylori infection. How the endoscopic patterns and histopathology of NG change after eradication of H. pylori is unclear. Twenty-one adults (3 men and 18 women) with H. pylori-associated NG found on endoscopy were enrolled for this study. The histological findings included gastritis activity, bacterial colonization, and lymphoid follicles. Repeat endoscopy for the endoscopic as well as histopathological features of gastric biopsy specimens was performed 2 months later after eradication treatment. H. pylori was successfully eradicated in 19 patients. Endoscopic NG disappeared in 12, improved in 5, and was unchanged in 4. After treatment, there was significant improvement in scores for gastritis activity [P < 0.001, 95% confidence interval (CI) 1.31-1.91], bacterial colonization (P < 0.001, 95% CI 0.71-1.14) and follicular gastritis (P = 0.047, 95% CI 0.04-0.52), primarily among patients whose endoscopic pattern resolved completely. The disappearance of nodularity on endoscopy was accompanied by a decrease in follicular gastritis score.

Caffeic Acid phenethyl ester inhibits epithelial-mesenchymal transition of human pancreatic cancer cells

Background. This study aimed to investigate the effect of propolis component caffeic acid phenethyl ester (CAPE) on epithelial-mesenchymal transition (EMT) of human pancreatic cancer cells and the molecular mechanisms underlying these effects. Methods. The transforming growth factor β (TGF-β-) induced EMT in human pancreatic PANC-1 cancer cells was characterized by observation of morphology and the expression of E-cadherin and vimentin by western blotting. The migration potential was estimated with wound closure assay. The expression of transcriptional factors was measured by quantitative RT-PCR and immunocytochemistry staining. The orthotopic pancreatic cancer xenograft model was used for in vivo assessment. Results. The overexpression of vimentin was attenuated by CAPE, and the alteration in morphology from polygonal to spindle shape was partially reversed by CAPE. Furthermore, CAPE delayed the TGF-β-stimulated migration potential. CAPE treatment did not reduce the expression levels of Smad 2/3, Snail 1, and Zeb 1 but inhibited the expression of transcriptional factor Twist 2. By using an orthotopic pancreatic cancer model, CAPE suppressed the expression of Twist 2 and growth of PANC-1 xenografts without significant toxicity. Conclusion. CAPE could inhibit the orthotopic growth and EMT of pancreatic cancer PANC-1 cells accompanied by downregulation of vimentin and Twist 2 expression.

Detection of a rare Caucasoid HLA-DRB1*0337 in a Taiwanese bone marrow donor using sequence-based typing method

We here describe the identification of HLA-DRB1*0337, using sequence-based typing (SBT) method, in a Taiwanese bone marrow donor intrigued by a casual curiosity on the donor's racial background. On high-resolution sequence-specific primer (SSP) typing we observed misleading reaction patterns due to similarity of DNA sequences in the exon 2 of DRB1*0301, *0317, *0337 and *1139. When encountering rare alleles in HLA typing, it is important to pay extra attentions to avoid pitfalls and shortcomings of SSP typing kits routinely used and bear in mind that constant up-dating of high-resolution SSP typing kits to be able to distinguish newly reported alleles. SBT may be considered as a back-up HLA typing method to confirm rare alleles.

Biloma following repeated transcatheter arterial embolization and complicated by intrahepatic duct stones: a case report

Biloma is an encapsulated bile collection outside the biliary tree due to a bile leak. It is occasionally found following traumatic liver injury or iatrogenic injury to the biliary tract, induced either during an endoscopic or surgical procedure. It is a rare complication of transcatheter arterial embolization (TAE). Although biloma can be shrunk by appropriate aspiration or drainage in majority of cases, we report a case of intrahepatic biloma following repeated TAE for hepatocellular carcinoma (HCC) and complicated by infection and intrahepatic stones. This particular constellation of problems has not been reported before and the intrahepatic stones need to be removed by percutaneous procedure.

Training gastroenterology fellows to perform gastric polypectomy using a novel ex vivo model

AIM

To evaluate the effect of hands-on training of gastroenterology fellows in gastric polypectomy using an ex vivo simulator.

METHODS

Eight gastroenterology fellows at Mackay Memorial Hospital, Taipei were evaluated in gastric polypectomy techniques using a pig stomach with artificial polyps created by a rubber band ligation device. The performance of four second year (year-2) fellows who had undergone one year of clinical training was compared with that of four first year (year-1) fellows both before and after a 4-h workshop using the ex vivo simulator. The workshop allowed for hands-on training in the removal of multiple artificial polyps and the placement of hemoclips at the excision site. Evaluation included observation of technical skills, procedure time, and the fellows' confidence scale.

RESULTS

One week after the workshop, the year-1 fellows were re-evaluated and had significantly improved mean performance scores (from 17.9 ± 1.8 to 22.5 ± 0.7), confidence scale (from 4.5 ± 1.0 to 7.8 ± 0.5) and procedure time (from 615.0 ± 57.4 s to 357.5 ± 85.0 s) compared with their baseline performance. After 4 h of training using the ex vivo simulator, the skills of the year-1 fellows were statistically similar to those of the year-2 fellows.

CONCLUSION

Use of this ex vivo simulator significantly improved the endoscopic gastric polypectomy skills of gastroenterology fellows who had not had previous clinical training in gastric polypectomy.

Identification of a novel HLA-DQB1 allele, DQB1*0326, in a College of American Pathologists 2009 survey specimen

We identified a novel DQB1*0326 allele from a proficiency test sample provided by the College of American Pathologists (CAP) medical society. This novel DQB1 allele was unexpectedly discovered by sequence-based typing method in an attempt to resolve a discrepant typing result between the CAP survey report and our laboratory report. This novel DQB1 allele is most similar to DQB1*030302 and DQB1*0311. DQB1*0326 has a nucleotide substitution resulting an amino acid change when compared with DQB1*030302 (M to L) and it differs from DQB1*0311 by one nucleotide variation causing an amino acid replacement (A to D).

Discovery of HLA-B*480102 in Taiwanese

Human leucocyte antigen (HLA)‐B48, an antigen within 7C CREG (cross‐reacting group) (Steiner et al., 2001) that cross‐reacts frequently with HLA‐B40 (i.e. HLA‐B60 and ‐B61) group of antibodies serologically, can be found in Alaskan Natives (Leffell et al., 2002), Amerindians (Martinez‐Naves et al., 1997), African Americans, Caucasians, and Oriental ethnicities (Mori et al., 1997; Schipper et al., 1997; Cao et al., 2001; Middleton et al., 2004; Hong et al., 2005; Itoh et al., 2005; Lee et al., 2005; Ogata et al., 2007). Sequencing investigations demonstrated that the common allele encoding the B48 antigen is B*4801 (Belich et al., 1992). To date, there are at least 16 WHO recognized B*48 alleles according to the most recent report from the WHO nomenclature committee (Marsh et al., 2005). Here we report a newly discovered allele B*480102, a variant of B*4801, detected in a 55‐year‐old Taiwanese patient of Minan origin (southern China).

Oral glutamine supplement inhibits ascites formation in peritoneal carcinomatosis mouse model

Background. Peritoneal carcinomatosis (PC) accompanied with ascites formation causes several distressing symptoms, resulting in poor quality of life. Methods. Twenty BALB/c nude mice generated by direct orthotopic injection of human pancreatic cancer PANC-1 cells were randomized to receive either a stock laboratory diet or a stock diet supplemented with glutamine. Half of the mice were sacrificed at day 76 to measure the amount of ascitic fluid and pancreatic tumor volume. The remaining mice were subject to survival analysis. Serum albumin levels were estimated every 2 weeks. Results. At day 76, the average amount of ascitic fluid measured in the control group was 1.2 ± 0.3 mL compared to 0.5 ± 0.5 mL from the glutamine-supplemented mice (P = 0.045). The volume of pancreatic tumor was 2.60 ± 0.8 cm(3) in the control group and 1.98 ± 1.3 cm(3) in glutamine-supplemented mice (P = 0.39). The mean survival time of glutamine-supplemented mice was prolonged from 87 ± 4 to 101 ± 2 days (P = 0.0024). Mean serum albumin levels were higher in the glutamine-supplemented group. Conclusions. This preclinical study showed that oral supplementation of glutamine may provide ascites-reducing activity in pancreatic cancer patients with PC, via a cell-mediated immunity-independent mechanism.