Predictive Factors Correlated with Successful Early Endoscopic Removal of Pancreaticolithiasis in Chronic Pancreatitis after Extracorporeal Shock Wave Lithotripsy

BACKGROUND

The treatment of chronic pancreatitis (CP) and symptomatic pancreatic duct (PD) calculi often involves techniques like endoscopic retrograde cholangiopancreatography (ERCP), extracorporeal shock wave lithotripsy (ESWL), or a combination of both. However, identifying predictive factors for the successful removal of these calculi remains variable. This study aimed to determine the factors predicting successful ESWL and endoscopic removal in CP and PD calculi patients.

METHODS

We examined data from CP patients who underwent complete PD calculi removal via ESWL combined with ERCP between July 2012 and 2022, and assessed baseline characteristics, imaging findings, and treatment details. Patients were categorized into early- and late-endoscopic complete removal groups (EER and LER groups, respectively).

RESULTS

Of the 27 patients analyzed, 74.1% were male with an average age of 44 ± 9.6 years. EER was achieved in 74% of the patients. Patients in the EER group exhibited smaller PD calculi diameter (8.5 vs. 19 mm, p = 0.012) and lower calculus density (964.6 vs. 1313.3 HU, p = 0.041) compared to the LER group. Notably, PD stricture and the rate of PD stent insertion were not different between the groups. A calculus density threshold of 1300 HU on non-contrast CT demonstrated 71% sensitivity and 80% specificity in predicting EER.

CONCLUSIONS

Smaller and low-density PD calculi may serve as predictors for successful EER, potentially aiding in the management of CP patients with PD calculi.

Role of oral iron supplementation for anemia secondary to acute nonvariceal upper gastrointestinal bleeding: a randomized controlled trial

BACKGROUND AND AIM

Although acute upper gastrointestinal bleeding (UGIB) can lead to anemia, evidence regarding the effects of oral iron supplementation on UGIB-induced anemia following discharge remains lacking. The present study aimed to investigate the effects of oral iron supplementation on hemoglobin response and iron storage in patients with anemia secondary to nonvariceal UGIB.

METHODS

This randomized controlled trial included 151 patients with nonvariceal UGIB who had anemia at discharge. Patients were assigned to a 1:1 block in which they were either administered 6 weeks of 600 mg/d oral ferrous fumarate (treatment group, n = 77) or treated without iron supplementation (control group, n = 74). The primary outcome was composite hemoglobin response (hemoglobin elevation greater than 2 g/dL or no anemia at the end of treatment [EOT]).

RESULTS

The proportion of patients achieving composite hemoglobin response was greater in the treatment group than in the control group (72.7% vs 45.9%; adjusted risk ratio [RR], 2.980; P = 0.004). At EOT, the percentage change in the hemoglobin level (34.2 ± 24.8% vs 19.4 ± 19.9%; adjusted coefficient, 11.543; P < 0.001) was significantly higher in the treatment group than in the control group; however, the proportions of patients with a serum ferritin level <30 μg/L and a transferrin saturation <16% were lower in the treatment group (all P < 0.05). No significant differences in treatment-associated adverse effects and adherence rates were observed between the groups.

CONCLUSION

Oral iron supplementation exerts beneficial effects on anemia and iron storage following nonvariceal UGIB without significantly impacting rates of adverse effects or adherence.

Clinical Outcomes of the Endoscopic Step-Up Approach with or without Radiology-Guided Percutaneous Drainage for Symptomatic Walled-Off Pancreatic Necrosis

Background and objectives: Symptomatic walled-off pancreatic necrosis is a serious local complication of acute necrotising pancreatitis. The endoscopic step-up approach is the standard treatment for symptomatic walled-off pancreatic necrosis; however, adjunctive radiologic percutaneous drainage for this condition is controversial. This study compared the clinical and radiologic resolution of walled-off pancreatic necrosis achieved with the endoscopic step-up approach with or without radiology-guided percutaneous drainage. Material and Methods: This retrospective, single-centre cohort study enrolled patients with symptomatic walled-off pancreatic necrosis who underwent endoscopic transmural drainage (ETD) followed by directed endoscopic necrosectomy (DEN) with or without radiology-guided drainage. A total of 34 patients (endoscopic approach, n = 22; combined modality approach, n = 12) underwent the endoscopic step-up approach (ETD followed by DEN). Baseline characteristics, clinical success, and resolution of necrosis were compared between groups. Results: All patients achieved symptom resolution from walled-off pancreatic necrosis. The mean patient age was 58.4 years, and 21 (61.8%) were men. Following treatment with the endoscopic approach and combined modality approach, clinical success was achieved in 90.9% of patients within 11.5 days, and 66.7% of patients within 16.5 days, respectively. Both length of hospital stay (55 days vs. 71 days; p = 0.071) and time to complete radiologic resolution were shorter (93 days vs. 124 days; p = 0.23) in the endoscopic approach group. Conclusion: Both the endoscopic step-up approach and the CMD approach resulted in a favourably high clinical resolution rates in patients with symptomatic WON. However, clinical success rates seemed to be higher, and the length of hospital stay tended to be shorter in the endoscopic approach than in the CMD approach, as well as the significantly shorter necrosectomy time in each procedure was observed. Of note, these findings might be from some inherited differences in baseline characteristics of the patients between the two groups, and a randomized controlled trial with a larger sample size to verify these results is warranted.

Postoperative outcomes of resectable periampullary cancer accompanied by obstructive jaundice with and without preoperative endoscopic biliary drainage

BACKGROUND

Preoperative biliary drainage (PBD) is useful in resectable periampullary cancer with obstructive jaundice. Whether it is better than direct surgery (DS) in terms of postoperative complications and mortality is controversial.

METHODS

All cases of successful pancreaticoduodenectomy (PD) in patients with periampullary cancer with obstructive jaundice performed between January 2016 and January 2021 were retrospectively reviewed. Endoscopic PBD was performed; data pertaining to serum bilirubin level, procedural technique, and duration before surgery were obtained. The incidence of postoperative complications and survival rate were compared between the PBD and DS group.

RESULTS

A total of 104 patients (PBD, n = 58; DS, n = 46) underwent curative PD. The mean age was 63.8 ± 10 years and 53 (51%) were male. Age, body mass index (BMI), sex, Eastern Cooperative Oncology Group status, presence of comorbid disease, initial laboratory results, and pathological diagnoses were not significantly different between the two groups. The incidence of postoperative complications was 58.6% in the PBD group while 73.9% in the DS group (relative risk [RR] 1.26, 95% confidence interval [CI] 0.92, 1.73, p=0.155) and the difference was not significant except in bile leakage (RR 8.83, 95% CI 1.26, 61.79, p = 0.021) and intraoperative bleeding (RR 3.97, 95% CI 0.88, 17.85, p = 0.049) which were higher in the DS group. The one-year survival rate was slightly less in the DS group but the difference was not statistically significant. The independent predictors for death within 1-year were intraoperative bleeding and preoperative total bilirubin > 14.6 mg/dL.

CONCLUSIONS

PBD in resectable malignant distal biliary obstruction showed no benefit in terms of 1-year survival over DS approach. But it demonstrated the benefit of lower risks of intraoperative bleeding, and bile leakage. Additionally, the level of pre-operative bilirubin level of over 14.6 mg/dL and having intraoperative bleeding were associated with a lower 1-year survival in such patients. Overall, PBD may be not necessary for all resectable periampullary cancer patients, but there might be a role in those with severely jaundice (>14.6 mg/dL), as it helps lower risk of intraoperative bleeding, and might lead to a better survival outcome.

Optical diagnosis by near-focus versus normal-focus narrow band imaging colonoscopy in colorectal polyps based on combined NICE and WASP classification: a randomized controlled trial

Background/Aims

Narrow Band Imaging (NBI) International Colorectal Endoscopic (NICE) and Workgroup Serrated Polyps and Polyposis (WASP) classifications were developed for optical diagnosis of neoplastic and sessile serrated polyps, respectively. Near-focus NBI with NICE combined with WASP criteria for optical diagnosis of colonic polyps has not yet been evaluated. We aimed to compare the accuracy of near-focus NBI (group A) with normal-focus NBI (group B) in real-time optical diagnosis of colorectal polyps using combined NICE and WASP criteria.

Methods

Among 362 patients, 118 with 227 polyps were recruited. Groups A and B included 62 patients with 130 polyps (three lost polyps) and 56 patients with 106 polyps (six lost polyps), respectively. Optical diagnoses were compared with pathological reports.

Results

The accuracy of optical diagnosis of neoplastic polyps in groups A and B was not significantly different (76% vs. 71%, p=0.52). WASP criteria provided all false positive diagnoses of sessile polyps as serrated polyps in 31 (16.2%) patients.

Conclusions

Near-focus NBI was not superior to normal-focus NBI in optical diagnostics of neoplastic polyps using NICE criteria. In our study, WASP classification yielded all false positives in the diagnosis of sessile serrated adenomas/polyps. Routine real-life optical diagnosis of polyps is still unadvisable.

Diagnostic performance of endoscopic ultrasound-guided tissue acquisition by EUS-FNA versus EUS-FNB for solid pancreatic mass without ROSE: a retrospective study

BACKGROUND

Endoscopic ultrasound-guided tissue acquisition (EUS-TA) is an established diagnostic procedure for solid pancreatic mass. However, the diagnostic yield between fine-needle aspiration (FNA) and fine-needle biopsy (FNB) remains unclear. We aimed to evaluate and compare the diagnostic yields between FNA and FNB using conventional FNA and Franseen needles of the same size 22-gauge needle, in patients with solid pancreatic mass who underwent EUS-TA without rapid onsite cytopathology evaluation (ROSE).

METHODS

All cases of EUS-TA by FNA or FNB for solid pancreatic mass between January 2017 and October 2020 in a single-centre university hospital were retrospectively reviewed. All procedures were performed without an onsite cytologist. Before the endoscopist finished the procedure, macroscopic onsite evaluation (MOSE) was confirmed. The diagnostic yield and the average number of needle passes between FNB and FNA were then compared.

RESULTS

A total of 151 patients (FNA, n = 77; FNB, n = 74) with solid pancreatic mass detected by cross-sectional imaging underwent EUS-TA. The mean age was 62.3 ± 12.8 years, with 88 (58.3%) males. Age, sex, mass location, tumour size and disease stage from imaging were not significantly different between the two groups. The diagnostic performance was higher in EUS-FNB (94.6%) than in EUS-FNA (89.6%). The mean number of needle passes was clearly fewer in FNB than in FNA (2.8 vs. 3.8, p < 0.001). The total procedure time was shorter in FNB (34.7 min) than in FNA (41 min). The adverse event rate between FNB and FNA was not significantly different.

CONCLUSIONS

The diagnostic yield of solid pancreatic mass was higher in FNB using the Franseen needle than in FNA using the conventional FNA needle in a centre where ROSE is unavailable, without serious adverse event. In addition, FNB had fewer needle passes and shorter total procedure time.

Comparison of Clinical Outcomes Between Surgical Gastrostomy and Percutaneous Endoscopic Gastrostomy with Introducer Technique in Patients with Upper Aerodigestive Malignancies: A Single-Center Analysis

BACKGROUND

Conventional percutaneous endoscopic gastrostomy (PEG) in patients with upper aerodigestive malignancies inevitably carries a risk of stomal metastasis that could be avoided by the direct insertion of the gastrostomy tube through the abdomen. This study compared the efficacy and safety between surgical gastrostomy (SG) and Introducer PEG in patients with upper aerodigestive malignancies.

METHODS

We retrospectively reviewed patients with upper aerodigestive malignancies undergoing SG or Introducer PEG. Procedure data, postprocedural clinical outcomes and 30-day mortality were assessed.

RESULTS

In total, 99 patients were feasible to analysis: 53 were in the SG group, and 46 were in the Introducer PEG group. The SG group had a higher incidence of (in-hospital) major complications [28.3% VS 4.3%, p = 0.002], a longer procedure duration [52.02 ± 21.30 VS 21.46 ± 8.22 min, p < 0.001], higher pain scores at 24 h [median (interquartile range, IQR); 5(3-8) VS 1(0-5), p < 0.001] and longer length of hospitalization (LOH) [median (IQR); 5(4-6) days VS 3(2-4) days, p < 0.001)]. In-hospital (3.8% VS 0%, p = 0.493) and 30-day mortality (17.0% VS 13.0%, p = 0.586) were not different between the two groups. In univariate analysis, high BMI, anemia (hemoglobin <11 g/dL), normal nutritional status (serum albumin >3 g/dL) and procedural type were found to be predicting factors for complications. Procedural type (Introducer PEG) was an independent factor for major complications in multivariate analysis [OR = 0.12, 95% CI 0.02-0.61, p= 0.011].

CONCLUSIONS

In patients with upper aerodigestive malignancies, Introducer PEG was associated with lower rate of (in-hospital) major complications, faster operative time, lower pain scores and shorter LOH.

CLINICAL TRIALS REGISTRY NUMBER

TCTR20181220004.

Biliary Fascioliasis in Chronic Calcific Pancreatitis Presenting with Ascending Cholangitis and Biliary Stricture

Biliary fascioliasis is a rare infection of the hepatobiliary system. In human, it is known to present with two main phases; acute phase (hepatic phase) presenting with abdominal pain or abnormal liver biochemistry then chronic phase (biliary phase) presenting with biliary obstruction or cholangitis. Optimal treatment of biliary fascioliasis consists of endoscopic retrograde cholangiography with removal of the parasite and single oral dose of triclabendazole. We report a rare case of biliary fascioliasis in chronic calcified pancreatitis who presented with ascending cholangitis and biliary stricture. A 63-years-old Thai man was referred to our hospital for treatment of clinical symptoms severe cholangitis. Magnetic resonance cholangiopancreatography showed evidence of distal common bile duct stricture associated with chronic calcific pancreatitis. ERCP was performed, that found a few amorphous filling defects in the common bile duct and distal biliary stricture. After removal of the foreign body of what seems to be a fluke parasite followed with single oral dose triclabendazole thereafter, the clinical symptom was improved dramatically.

Mucinous cystic neoplasm of the liver with extrahepatic growth presenting with ascending cholangitis diagnosed by endoscopic ultrasound features: a case report

Background

Mucinous cystic neoplasm of the liver with extrahepatic growth is a rare benign epithelial neoplasm of the biliary system that presents with a mass effect or is incidentally found on imaging. The tumor affects mostly the common hepatic duct, which is difficult to diagnose preoperatively by radiology, endoscopy, or cystic fluid analysis. Endoscopic ultrasound is a noninvasive tool for the evaluation of features of a cystic lesion and the extent of disease. Optimal treatment is complete tumor resection.

Case presentation

A 27-year-old Thai woman was referred to our hospital for investigation and treatment of clinical symptoms of obstructive jaundice and ascending cholangitis, as well as an unknown cause of obstruction. Multiple investigations were performed, including endoscopic retrograde cholangiography and magnetic resonance imaging. Endoscopic ultrasound showed a multiloculated cystic lesion with internal septations without communication to the bile duct, which helped to support a diagnosis of mucinous cystic neoplasm. Eventually, the pathological diagnosis made was mucinous cystic neoplasm of the bile duct. A follow-up clinical examination with imaging at 6 months revealed that the patient was asymptomatic and without recurrence.

Conclusions

We report a rare case of a patient with a large mucinous cystic neoplasm of the liver with extrahepatic growth causing biliary obstruction, which was diagnosed on the basis of endoscopic ultrasound features. Following definitive diagnosis, treatment with complete surgical resection using a multidisciplinary approach was successful.

An Uncommon Cause of Small Bowel Bleeding from Appendiceal Carcinoma

Massive hematochezia caused by a small bowel lesion is a rare entity. Currently, video capsule endoscopy and balloon-assisted enteroscopy are effective in identifying the source of small intestine bleeding. Herein, we report a case of small bowel bleeding caused by a nonmucinous appendiceal adenocarcinoma with ileal invasion which was detected by video capsule endoscopy and single-balloon endoscopy. Despite the advanced disease stage with hepatic and peritoneal metastases, as of September 2016 the patient has had 8 years' disease-free survival after surgical resection and chemotherapy.

Influence of Body Position on Anorectal Manometric Assessment in Functional Constipation

OBJECTIVE

To date, there have been no studies to evaluate the influence of posture on anorectal manometric measurements in patients with functional constipation. The present study aimed to compare differences in anorectal manometric measurements in constipated patients when performing the test in the lying and sitting positions.

MATERIAL AND METHOD

Anorectal manometry with a conventional solid state manometric catheter was performed in 30 constipated patients in both the lying and sitting positions. Anorectal manometric variables at rest and during attempted defecation with empty rectum were assessed in both positions. A colonic transit study using Sitzmarks radiopaque markers and a 50-mL water-filled balloon expulsion test was also performed in all patients. Patients exhibiting an abnormal manometric pattern of defecation in either the sitting or lying position proceeded to a simulated defecation test. The anorectal pressure parameters of resting and during attempted defecation of the both positions were compared.

RESULTS

The resting rectal pressure, maximum rectal straining pressure, and defecation index during attempted defecation were significantly higher in the sitting position than the lying position. A dyssynergic manometric pattern during attempted defecation with empty rectum was seen in 46% of the patients in the lying position, not significantly different from the 56% in the seated position (p = 0.58). Most patients (71%) who exhibited manometric dyssynergia with an empty rectum could relax their anal sphincter during the simulated defecation test. Only six (20%) constipated patients had abnormal dyssynergic anal sphincter contraction confirmed by a simulated defecation test.

CONCLUSION

Body position affects the results of manometric measurements related to the defecation mechanism.

Comparing cost-effectiveness between endoscopic ultrasound and endoscopic retrograde cholangiopancreatography in diagnosis of common bile duct stone in patients with predefined risks: A study from a developing country

Background and Objectives:

Endoscopic ultrasound (EUS) achieves results comparable to endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis of common bile duct (CBD) stone, but studies from the western have shown EUS to be less expensive in patients with intermediate risk for CBD stones. The aim of this study was to compare the costs of EUS and ERCP in the diagnosis of CBD stones in a developing country.

Materials and Methods:

A prospective study was done with 141 patients with suspected CBD stones, categorized as having high or intermediate risk for CBD stone. All underwent EUS, and the high-risk patients had ERCP after the EUS. For intermediate-risk patients, an ERCP was done at the discretion of the attending physician. The CBD stone was confirmed by ERCP in patients who underwent both EUS and ERCP. Patients who received EUS only were followed up every 3 months for 1 year. The false negative rate in patients with EUS and ERCP was estimated in the clinical follow-up.

Result:

One hundred and forty-one patients (141: 83 females, 58 males) with a mean age ± standard deviation (SD) of 55.71 ±18.68 years were recruited. Ninety-four (94) patients underwent both EUS and ERCP. ERCP confirmed the diagnosis in 83 of 85 patients (97.6%) with CBD stone detected by EUS. Forty-seven (47) patients with a negative EUS and no ERCP done were symptom-free during the follow-up. The overall sensitivity, specificity, positive predictive value, and negative predictive value of EUS were 97.6%, 80%, 97.6%, and 80% respectively. An EUS-based strategy for high-risk patients was 15% more expensive than an ERCP-based strategy, but the EUS-based strategy reduced the cost to 37.78% less than the ERCP-based strategy in intermediate-risk patients. The EUS-based strategy was cost-saving when the CBD stone prevalence was less than 52.5%.

Conclusion:

EUS is safer and less costly than ERCP for CBD stone diagnosis in patients with intermediate risk.

i-Scan detection of minimal change esophagitis in dyspeptic patients with or without Gastroesophageal Reflux disease

Background

The association of minimal change esophagitis (MCE) with GERD is controversial. i-Scan endoscopy (SE) provides high resolution and modulation of images that may improve minimal change lesion (MCL) detection. We aimed to assess the efficacy of SE in detecting MCL in dyspeptic patients with GERD compared with patients without GERD by GerdQ or by endoscopy with 24-h pH monitoring (PHM) and in normal volunteers.

Methods

This is a cohort study conducted at a tertiary center. All dyspeptic patients were prospectively recruited. All patients completed a validated Thai version of GerdQ and then underwent endoscopy. Forty normal volunteers as a control group were recruited for endoscopy. The distal esophagus was examined by high definition endoscopy and SE sequentially. All had PHM done. GERD was diagnosed by Los Angeles classification A-D and/or by a positive PHM. MCE was diagnosed when MCL or combination of MCL was present.

Results

Of 174 patients, 144 completed the study protocol. After the exclusion of 6 patients, 138 remained for analysis. Overlapping GERD symptoms were found in 44.2 % and 26.8 % had confirmed GERD. Group A was comprised of 61 patients with a positive GerdQ and 77 patients in group B had a negative GerdQ. Twenty-four in group A, 28 in group B and 7 in the control group had MCE that was not significantly different. MCE in GERD was significantly higher (51.45 %) than in non-GERD (32.7 %) (p = 0.047) and in the control group (20.58 %) (p = 0.007). The sensitivity, specificity, positive predictive value, and negative predictive value of SE were 51.35 %, 67.33 %, 36.54 % and 79.06 %, respectively.

Conclusion

In dyspeptic patients, SE detected more MCE in GERD than in non-GERD patients and in the control group.

Trial registration

ClinicalTrials.gov number NCT01742377

Endoscopic ultrasound-guided biliary intervention in patients with surgically altered anatomy

AIM

To evaluate the efficacy of endoscopic ultrasound guided biliary drainage (EUS-BD) in patients with surgically altered anatomies.

METHODS

We performed a search of the MEDLINE database for studies published between 2001 to July 2014 reporting on EUS-BD in patients with surgically altered anatomy using the terms "EUS drainage" and "altered anatomy". All relevant articles were accessed in full text. A manual search of the reference lists of relevant retrieved articles was also performed. Only full-text English papers were included. Data regarding age, gender, diagnosis, method of EUS-BD and intervention, type of altered anatomy, technical success, clinical success, and complications were extracted and collected. Anatomic alterations were categorized as: group 1, Billroth I; group 2, Billroth II; group 4, Roux-en-Y with gastric bypass; and group 3, all other types.

RESULTS

Twenty three articles identified in the literature search, three reports were from the same group with different numbers of cases. In total, 101 cases of EUS-BD in patients with altered anatomy were identified. Twenty-seven cases had no information and were excluded. Seventy four cases were included for analysis. Data of EUS-BD in patients categorized as group 1, 2 and 4 were limited with 2, 3 and 6 cases with EUS-BD done respectively. Thirty four cases with EUS-BD were reported in group 3. The pooled technical success, clinical success, and complication rates of all reports with available data were 89.18%, 91.07% and 17.5%, respectively. The results are similar to the reported outcomes of EUS-BD in general, however, with limited data of EUS-BD in patients with altered anatomy rendered it difficult to draw a firm conclusion.

CONCLUSION

EUS-BD may be an option for patients with altered anatomy after a failed endoscopic-retrograde-cholangiography in centers with expertise in EUS-BD procedures in a research setting.

Normal Solid Gastric Emptying Values Measured by Scintigraphy Using Asian-style Meal:A Multicenter Study in Healthy Volunteers

BACKGROUND/AIMS

To report gastric emptying scintigraphy, normal values should be established for a specific protocol. The aim of this study was to provide normal gastric emptying values and determine factors affecting gastric emptying using Asian rice-based meal in healthy volunteers.

METHODS

One hundred and ninety-two healthy volunteers were included at 7 tertiary care centers across Thailand. Gastric emptying scintigraphy was acquired in 45 degree left anterior oblique view immediately after ingestion of a 267 kcal steamed-rice with technetium-99m labeled-microwaved egg meal with 100 mL water for up to 4 hours.

RESULTS

One hundred and eighty-nine volunteers (99 females, age 43 ± 14 years) completed the study. The medians (5-95th percentiles) of lag time, gastric emptying half time (GE T1/2) and percent gastric retentions at 2 and 4 hours for all volunteers were 18.6 (0.5-39.1) minutes, 68.7 (45.1-107.8) minutes, 16.3% (2.7-49.8%) and 1.1% (0.2-8.8%), respectively. Female volunteers had significantly slower gastric emptying compared to male (GE T1/2, 74 [48-115] minutes vs. 63 (41-96) minutes; P < 0.05). Female volunteers who were in luteal phase of menstrual cycle had significantly slower gastric emptying compared to those in follicular phase or menopausal status (GE T1/2, 85 [66-102] mintes vs. 69 [50-120] minutes or 72 [47-109] minutes, P < 0.05). All of smoking volunteers were male. Smoker male volunteers had significantly faster gastric emptying compared to non-smoker males (GE T1/2, 56 [44-80] minutes vs. 67 [44-100] minutes, P < 0.05). Age, body mass index and alcohol consumption habits did not affect gastric emptying values.

CONCLUSIONS

A steamed-rice with microwaved egg meal was well tolerated by healthy volunteers. Gender, menstrual status and smoking status were found to affect solid gastric emptying.

EUS-FNA for pancreatic cyst lesion, today and tomorrow in the Kingdom of Thailand

Unlike endoscopic retrograde cholangiopancreatography (ERCP) service, endoscopic ultrasonography (EUS) service in Thailand is at its elementary state. Currently, there are only 11 hospitals in Thailand carrying out EUS whereas there are more than 50 hospitals carrying out ERCP. This is a multicenter questionnaire survey that obtained information on EUS practice for pancreatic cysts. Of those 11 hospitals, only three hospitals provided enough number of patients with pancreatic cysts undergoing EUS. There were many differences in endosonographers opinions regarding specific information in the pancreatic cyst. In addition, the threshold to carry out and not to carry out fine needle aspiration are varies.

The value of Carlsson-dent questionnaire in diagnosis of gastroesophageal reflux disease in area with low prevalence of gastroesophageal reflux disease

Background/Aims

Symptom-based diagnosis for gastroesophageal reflux disease (GERD) has been accepted in the population with high prevalence. Carlsson-Dent questionnaire (CDQ) is a standardized symptom-based diagnosis tool for GERD. The value of this tool in the population with low prevalence is unknown. The aim of this study was to determine CDQ performance for diagnosis of GERD in Thai population with low prevalence versus endoscopy or 24 hour pH monitoring.

Methods

Patients with dyspepsia by Rome II criteria were recruited. All patients completed a Thai version of CDQ and underwent endoscopic examination. Those without esophagitis or peptic ulcer and positive CDQ score took pH monitoring.

Results

One hundred patients (68 female) with mean age ± SD of 45.6 ± 12.4 years were recruited. Six with Los Angeles grade A esophagitis had negative CDQ score. In 44 with positive CDQ score, 3 had Los Angeles grade B esophagitis and 41 had pH monitoring done with 8 having positive test. The GERD diagnosis by CDQ was confirmed in 11 of 44 patients (25%). CDQ detected 11 out of 17 GERD detected by endoscopy and pH monitoring and the sensitivity of CDQ was 64%.

Conclusions

CDQ diagnosed more GERD in Thai population with low prevalence compared with endoscopy and pH monitoring. This may be due to some patients with functional heartburn were picked up by CDQ and some patients with GERD were not detected by endoscopy and pH monitoring.

Endoscopic stenting versus surgical bypass in advanced malignant distal bile duct obstruction: cost-effectiveness analysis

OBJECTIVE

Palliative treatment of obstructive jaundice from advanced tumour of the distal bile duct is controversial. The aim of this study was to compare the clinical outcomes and costs between endoscopic stent insertion and surgery.

METHODS

The clinical data for 116 patients treated with either endoscopic plastic stenting (65 patients) or surgical bypass (51 patients) were reviewed and analysed.

RESULTS

No significant difference was found between the two groups in terms of the length of hospital stay, survival time, cost, effectiveness, and early complications. However, late complications were significantly more common in the stenting group (p = 0.007). Jaundice recurred in 15 stented patients at a median time of 3 months due to stent blockage, and one surgical patient had recurrent jaundice from anastomosis stricture. Late gastric outlet obstruction occurred in one of 36 surgical patients who did not undergo prophylactic gastroenterostomy and one of 65 stented patients developed this complication.

CONCLUSION

Both techniques are equally effective in biliary drainage, but stenting has a higher rate of recurrent jaundice. We recommend surgery for patients with low surgical risks and endoscopic stent in those with a short life expectancy or those unfit for surgery.

The possible diagnostic role of endoscopic ultrasound in patients with dyspepsia

BACKGROUND

Dyspepsia is common in clinical practice with frequent relapses and often requires multiple investigations to assess intraluminal and extraluminal etiologies. Endoscopic ultrasound (EUS) has the potential of serving both purposes in a single setting.

MATERIAL AND METHOD

Patients with dyspepsia who underwent EUS in four-year period were retrospectively reviewed. Diagnostic findings of US, final diagnoses were noted and compared with the reference standards.

RESULTS

131 patients with a mean age +/- SD of 50 +/- 12.7 years were included. The common diagnoses were non-ulcer dyspepsia in 56%, symptomatic gallstone (GS) in 22.9%. EUS detected two GS missed by transabdominal ultrasound (TUS). EUS missed one GS documented by surgery. EUS detected seven cases of ERCP-proven CBD stones undetected by TUS and had a sensitivity, specificity, positive predictive value and negative predictive value for CBD stones of 87.5%, 91.7%, 87.5%, and 91.7% respectively.

CONCLUSION

EUS is a potential investigation for the management of dyspepsia.

Low and high doses of rabeprazole vs. omeprazole for cure of Helicobacter pylori infection

BACKGROUND

Low-dose rabeprazole-based triple therapy was effective for Helicobacter pylori eradication in a few Japanese studies.

AIM

To compare the effectiveness of 1-week low-dose and high-dose rabeprazole-based triple therapy with those of omeprazole.

METHODS

One hundred and sixty-two H. pylori-infected dyspeptic patients were randomized to receive twice daily for 1 week either rabeprazole 10 mg (R10), rabeprazole 20 mg (R20) or omeprazole 20 mg (O) in combination with amoxicillin 1,000 mg (A) and clarithromycin 500 mg (C). H. pylori status assessment was by the CLO test and histology at entry and by the 13C-urea breath test at 4-6 weeks after cessation of therapy.

RESULTS

H. pylori eradication rates in intention-to-treat groups were 85%, 96% and 83% for R10AC, R20AC and OAC, respectively. Eradication rates in per protocol groups were 86%, 96% and 90% for R10AC, R20AC and OAC, respectively. On an intention-to-treat analysis, the R20AC group had a significantly higher eradication rate than did R10AC or OAC (P < 0.05). However, the higher eradication rate with R20AC did not reach statistical significance in the per protocol analysis. Drug intolerance was found in three OAC patients.

CONCLUSION

High-dose rabeprazole-based triple therapy is more effective than its low-dose equivalent or omeprazole in eradicating H. pylori infection.

Preoperative education improves quality of patient care for endoscopic retrograde cholangiopancreatography

The goal of this study was to evaluate the effect of preoperative education on patient satisfaction and cooperation during an endoscopic retrograde cholangiopancreatography (ERCP) procedure. Risk reduction was also studied in terms of decreased meperidine administration. Subjects were preoperatively educated by the endoscopy nurse regarding the ERCP procedure and how to communicate with the nurse during the procedure. Forty-five patients with a mean age of 58 years participated in the study. Effective patient cooperation was achieved. All subjects were satisfied with the educational process and the ERCP team. These findings suggest preoperative education is a cost-effective intervention in enhance patient cooperation and patient satisfaction for patients undergoing ERCP.

Findings and benefit of liver biopsies in 46 patients infected with human immunodeficiency virus

AIMS

The aim of this work is to evaluate the role of liver biopsy and to determine the histological findings in patients infected with the human immunodeficiency virus (HIV) who have abnormal liver function tests (LFT).

METHODS

We performed a percutaneous liver biopsy in 46 HIV-seropositive patients with abnormal LFT. Parts of biopsied tissue were used for bacterial and fungal culture and the rest was processed for histological examination including special staining.

RESULTS

Of these 46 patients, 41 patients were males and five were females. The median age was 31+/-6 years. Mycobacterium tuberculosis was the most common histological finding (15 cases). Of 15 tuberculosis patients, 11 (73.3%) had lymphadenopathy and positive acid-fast bacilli (AFB) in node aspiration or biopsy. The other findings included AFB-negative granuloma (eight cases), histoplasmosis (six cases), cryptococcosis (six cases), penicillosis (four cases), viral hepatitis: hepatitis C virus (HCV; one case), hepatitis B virus and HCV infection (one case), fatty liver (two cases), drug-induced hepatitis (one case) and non-specific changes (five cases). There were double infections in three patients. We were able to demonstrate opportunistic infections in 41 cases (89.3%).

CONCLUSIONS

Mycobacterium tuberculosis was the most common histological finding in HIV patients with abnormal LFT in Thailand. Liver biopsy was a useful procedure in evaluating abnormal LFT in HIV patients.

Sphincter of Oddi manometry in various biliary diseases: a report in 20 Thai patients

This is the first report of sphincter of Oddi manometry study in 20 Thai patients with various biliary diseases. The yield of abnormal SOM in 3 of 17 in our study was low and was comparable to other reports. The successful rate of 85 per cent and complication rate were acceptable. Careful clinical assessment is mandatory before SOM study in order to gain the best benefit and minimize the risk of SOM.

Liver involvement in murine typhus

Liver involvement was retrospectively evaluated in 137 patients with murine typhus. Fifteen (10.9%) were jaundiced. One patient had been subjected to cholecystectomy after misdiagnosis of acute cholecystitis. Serum aminotransferase levels were abnormal in 48/52 measurements, and there were elevations of > 5-fold in 14 patients. Liver biopsies and/or necropsies from four jaundiced patients showed portal tract and sinusoidal infiltrates, cloudy swelling/and necrosis of the hepatocytes and occasional pseudogranuloma formation. There were striking mitoses even in the early stage, suggesting rapid hepatocellular regeneration. Haemolytic diseases (G6PD deficiency or haemoglobinopathies), alcoholism, and a second infection probably also contributed to the pathogenesis of jaundice in murine typhus. This rickettsiosis should be included among differential diagnoses of acute hepatitis in patients exposed to areas endemic for Rickettsia typhi.

Biliary stent: a report of experience in 25 Thai patients

Biliary stent insertion was done in 25 patients. Eighteen were successful, 14 by endoscopic method and 4 by combined endoscopic percutaneous method. Twelve with malignant diseases and 4 with benign diseases had satisfactory drainage. Failed stent insertion occurred in 7 cases. Stent malfunction was found in 30 per cent and occlusion was the most common problem. Complications occurred in 32 per cent and most were mild. The 4 per cent mortality of the procedure is acceptable. Biliary stent should be considered as an alternative or as an adjunctive treatment to surgery.

Endoscopic removal of stone in patients with retained common bile duct stone and T-tube after cholecystectomy. Is it justified?

Fifteen patients with retained common bile duct (CBD) stones and T-tube and twenty patients with CBD stones without T-tube had stones removed by endoscopic method. The result of endoscopic sphincterotomy, stone extraction, stone clearance and complication in patients with T-tube was similar to the results in patients without T-tube. The presence of T-tube did not create much difficulty in stone removal and the successful rate of 86.6 per cent (13/15) was satisfactory. Endoscopic removal of retained stones in patients with T-tube is recommended when retrieval via T-tube is not available since the later has fewer reported complications with very low mortality compared to the endoscopic technique.

Liquid meal emptying in non-ulcer dyspepsia: a study in 22 Thai patients

Twenty-four patients with non-ulcer dyspepsia (NUD) were recruited for gastric emptying study of liquid meal before and after 1 week's treatment with domperidone (80 mg in 19, 40 mg in 2, dropout 1 and excluded 2). Delayed gastric emptying was found in 8 of 22 (36.36%). Clinical improvement was found in 11 patients after treatment. Gastric emptying improvement was found in 3 patients (2 without clinical improvement). No correlation was found between the clinical and gastric emptying improvement. (Fisher exact test p greater than 0.25). Impaired liquid emptying is common in NUD and domperidone improved clinical symptoms in 50 per cent of NUD in this study.

The magnitude of nocturnal acid suppression by ranitidine 300 mg given at 18.00 hours

Ranitidine 300 mg given at 18.00 hours in 5 patients with CVA resulted in 99.5 per cent acid suppression for 12 hours. Intragastric pH of 4 or greater was obtained in only 58 per cent of the 12-hour period. An early evening dose of ranitidine is probably more effective and dosage reduction may be applicable for the healing of duodenal ulcers. However, ranitidine as given in this study is probably not adequate for stress ulcer prophylaxis.

Tetracycline-induced esophageal ulcer: a condition that probably more common than it appears to be

Ten cases of tetracycline derivatives related drug induced esophageal ulceration were described. Five cases were due to minocycline and another five were due to doxycycline. Recumbent posture after drug ingestion was one of the predisposing factors. Odynophagia was the main symptom but may not be the presenting symptom. The diagnosis was easily confirmed by endoscopy. Single-contrast barium study was not sensitive for the demonstration of the esophageal ulcers. The recommended treatment includes cessation of the offending drug and symptomatic treatment. All recovered without any sequela within 3 to 11 days. The most important measure to prevent this condition is to instruct patients to take drugs in the upright position with at least 100 ml of water.

Medication-induced esophageal injury: report of 17 cases with endoscopic documentation

We report on medication-induced esophageal injury (MIEI) in 17 patients (six male, 11 female) seen from October 1986 to May 1990. The mean age of patients was 27.3 (SD = 5.7) yr; mean duration of drug ingestion prior to the occurrence of symptoms 10.2 (SD = 11.5) days, and mean duration of symptoms before seeking medical attention 4.6 (SD = 3.8) days. Symptoms subsided after treatment, with a mean of 6 (SD = 2.5) days. Symptoms included odynophagia (in 17), chest pain (six), epigastric pain (three), and retrosternal pain (one). Symptoms occurred after the drug was stopped in three. MIEI was caused by doxycycline (seven), minocycline (five), Pantozyme (one), cloxacillin (one), unknown (two), and dicloxacillin + Danzen (one). Reclining after drug ingestion was the predominant risk factor. Endoscopy showed most ulcers to be multiple and at midesophagus. Barium swallows done in two patients were negative. There is no previous report of Pantozyme (pancreatic enzyme), Danzen (serratio-peptidase), cloxacillin, and dicloxacillin causing MIEI.

Gastrointestinal lesions in patients over 40 years of age with iron deficiency anemia and hookworm infection

A prospective study of 41 patients (24 male and 17 female) aged over 40 years with iron deficiency anemia and hookworm infection was performed by endoscopy and barium enema to determine the incidence of GI lesions. Alcohol ingestion, smoking, abdominal pain, anorexia, loss in weight, bowel habit change, analgesic consumption and stool occult blood test were analyzed for their positive predictive value of GI lesions. The mean age of the patients was 62.8 years (SD = 10.1). The mean hemoglobin was 5.99 gm.% (SD = 1.9). Twenty patients (48.8%) had GI lesions. The lesions included 10 erosive gastritis, 1 erosive duodenitis, 5 gastric ulcers, 2 duodenal ulcers, 1 carcinoma of stomach and 1 carcinoma of colon. Gastric ulcer, duodenal ulcer and carcinoma were regarded as significant lesions. Abdominal pain was found in 16 of the 20 patients with GI lesions and 8 of the 21 without GI lesion (Chi square with Yate's correction, x2 = 5.78 p = 0.02). Four of the 17 patients without pain had GI lesions but only one of these 4 (5.8%) had gastric ulcer. Abdominal pain had an 80% sensitivity and 62% specificity for the positive prediction of GI lesions based on the above findings. GI investigation is recommended for all patients with abdominal pain. In those without pain, treatment of hookworm and iron therapy with follow-up may be justified.

Pneumatic dilatation for achalasia of the esophagus: report of three patients treated with self-constructed pneumatic bags using the endoscopic technique

Three patients with achalasia of the esophagus treated with pneumatic bag dilatation were reported. The preliminary result is encouraging. To what extent the difference in the type of bags and technical variations contributed to the ultimate outcome of the treatment is not known. The endoscopically aided pneumatic dilatation was found to be safe and simple.