Improvement of adenoma detection rate by two computer-aided colonic polyp detection systems in high adenoma detectors: a randomized multicenter trial

BACKGROUND

This study aimed to evaluate the benefits of a self-developed computer-aided polyp detection system (SD-CADe) and a commercial system (CM-CADe) for high adenoma detectors compared with white-light endoscopy (WLE) as a control.

METHODS

Average-risk 50-75-year-old individuals who underwent screening colonoscopy at five referral centers were randomized to SD-CADe, CM-CADe, or WLE groups (1:1:1 ratio). Trainees and staff with an adenoma detection rate (ADR) of ≥35% were recruited. The primary outcome was ADR. Secondary outcomes were the proximal adenoma detection rate (pADR), advanced adenoma detection rate (AADR), and the number of adenomas, proximal adenomas, and advanced adenomas per colonoscopy (APC, pAPC, and AAPC, respectively).

RESULTS

The study enrolled 1200 participants. The ADR in the control, CM-CADe, and SD-CADe groups was 38.3%, 50.0%, and 54.8%, respectively. The pADR was 23.0%, 32.3%, and 38.8%, respectively. AADR was 6.0%, 10.3%, and 9.5%, respectively. After adjustment, the ADR and pADR in both intervention groups were significantly higher than in controls (all P<0.05). The APC in the control, CM-CADe, and SD-CADe groups was 0.66, 1.04, and 1.16, respectively. The pAPC was 0.33, 0.53, and 0.64, respectively, and the AAPC was 0.07, 0.12, and 0.10, respectively. Both CADe systems showed significantly higher APC and pAPC than WLE. AADR and AAPC were improved in both CADe groups versus control, although the differences were not statistically significant.

CONCLUSION

Even in high adenoma detectors, CADe significantly improved ADR and APC. The AADR tended to be higher with both systems, and this may enhance colorectal cancer prevention.

Texture and color enhancement imaging (TXI) plus endocuff vision versus TXI alone for colorectal adenoma detection: a randomized controlled trial

BACKGROUND AND AIMS

Increasing the adenoma detection rate (ADR) helps reduce the risk of post-colonoscopy colorectal cancer. Texture and Color Enhancement Imaging (TXI) improves ADR by enhancing the brightness and contrast of endoscopic images. Endocuff Vision (ECV) is a mucosal exposure device that helps flatten the colonic folds. The benefit of combining TXI with ECV has not been studied previously. Thus, we aimed to compare the ADR between using TXI combined with ECV and TXI alone.

METHODS

We conducted a prospective randomized controlled trial recruiting patients aged ≥ 40 years who underwent colonoscopy for colorectal cancer screening or gastrointestinal symptoms. The participants were randomized in a 1:1 ratio into the TXI with ECV (TXI + ECV) and the TXI groups. Experienced endoscopists with ≥ 40% ADR performed all colonoscopies. The primary outcome was ADR.

RESULTS

We had 189 and 192 patients in the TXI + ECV and TXI groups, respectively. The baseline characteristics of both groups were comparable. The ADR was significantly higher in the TXI + ECV group than in the TXI group (65.6% vs. 52.1%, P = 0.007). Adenoma per colonoscopy (APC) was significantly greater in the TXI + ECV group than in the TXI group (1.6 vs. 1.2, P = 0.021), prominently proximal (1.0 vs. 0.7, P = 0.031), non-pedunculated (1.4 vs. 1.1, P = 0.035), and diminutive (1.3 vs. 1, P = 0.045) adenomas. Serrated lesion detection rate, insertion time, and withdrawal time did not differ between the groups.

CONCLUSION

Adding ECV to TXI significantly improves ADR and APC compared to using TXI alone.

TRIAL REGISTRATION

Thai Clinical Trials Registry TCTR20220507004.

Linked color imaging, mucosal exposure device, their combination, and standard colonoscopy for adenoma detection: a randomized trial

BACKGROUND AND AIMS

By different mechanisms, image-enhancement techniques (linked color imaging [LCI]) and mucosal exposure devices (Endocuff-assisted colonoscopy [EAC]) can improve the adenoma detection rate (ADR) during screening colonoscopy. The impact of the combination of the 2 techniques has never been studied. This study aimed to compare the ADR between the combination of LCI and EAC (LCI+EAC), LCI alone, EAC alone, and standard high-definition (HD) colonoscopy.

METHODS

This prospective randomized controlled trial included participants who underwent screening colonoscopy. Participants were randomized to LCI+EAC, LCI, EAC, and standard HD colonoscopy. All colonoscopies were performed by endoscopists with a recorded ADR ≥35%. The primary outcome was the ADR. Secondary outcomes were proximal ADR (pADR) and the mean number of adenomas per colonoscopy (APC).

RESULTS

One thousand participants were included in the study. The LCI+EAC group provided the highest ADR and pADR. The ADRs in the LCI+EAC, LCI, EAC, and standard HD colonoscopy groups were 57.2%, 52.8%, 51.6%, and 47.6%, respectively, with pADRs of 38.4%, 34.8%, 33.6%, and 28.0%, respectively. The mean numbers of APC were 1.28, 1.20, 1.16, and .89, respectively. After a multiple comparison adjustment, a significant difference in pADR was only observed between the LCI+EAC and standard HD colonoscopy groups (difference, 10.3 percentage points; 95% confidence interval, .02%-17.4%; P = .05). The incidence rate ratios of the adenoma numbers were significantly higher in the LCI+EAC (1.43), LCI (1.34), and EAC (1.30) groups relative to the standard HD colonoscopy group (.89) (P < .009 for all comparisons).

CONCLUSIONS

The combination of LCI and EAC can significantly improve the detection of pADR and APC but not ADR by high-ADR performers. (Clinical trial registration number: TCTR20190319001.).

Usefulness of mean number of adenomas per positive screenee for identifying meticulous endoscopists among those who achieve acceptable adenoma detection rates

BACKGROUND

Adenoma detection rate (ADR) is a quality indicator for colonoscopy. However, many missed adenomas have subsequently been identified after colonoscopies performed by endoscopists with ADR ≥ 25 %. Adenomas per positive participant (APP; mean number of adenomas detected by an endoscopist among screenees with positive findings) correlates well inversely with adenoma miss rate. This study aimed to evaluate whether APP added additional information on the detection rate for advanced adenomas (AADR) and proximal adenomas (pADR) and among endoscopists with acceptable ADRs (≥ 25 %).

METHODS

A total of 47 endoscopists performed 7339 screening colonoscopies that were retrospectively reviewed. Using a cutoff APP value of 2.0, endoscopist performance was classified as high or low APP. Endoscopist ADRs were also classified as acceptable (25 % - 29 %), high standard (30 % - 39 %) and aspirational (≥ 40 %). Generalized linear models were used to assess the relationship between AADR or pADR, and ADR and APP, after adjusting for potential confounders.

RESULTS

After adjusting for endoscopist performance and patient characteristics, endoscopists with high APP had a significant 2.1 percentage point increase in AADR (95 %CI 0.3 to 3.9; P = 0.02) and a 2.1 percentage point increase in pADR (95 %CI - 0.8 to 5.1; P = 0.15) compared to endoscopists with low APP. In total, 11 (24 %), 18 (38 %), and 18 (38 %) endoscopists were classified as having acceptable, high standard, and aspirational ADRs, respectively. APP values higher than the cutoff were found in 18 %, 44 %, and 72 % of endoscopists with acceptable, high standard, and aspirational ADRs, respectively (P = 0.02).

CONCLUSION

APP is helpful for identifying more meticulous endoscopists who can detect a greater number of advanced adenomas. Endoscopists who achieved an only acceptable ADR had the lowest APP.

Overweight as an Additional Risk Factor for Colorectal Neoplasia in Lean Population

Background:

Overweight in Thailand is not as common as in Western countries. We sought to evaluate overweight as the additional risk factor that can increase the prediction of colorectal neoplasia (CRN) detection in Thais apart from the Asia-Pacific Colorectal Screening (APCS) score.

Methods:

We prospectively enrolled asymptomatic 338 subjects who underwent screening colonoscopy between November 2016 and September 2017. All risk factors according to APCS, BMI and the presence of metabolic syndrome were collected. Overweight was defined as BMI ≥23 kg/m². By APCS score, subjects were categorized into 1) high-risk and 2) average-risk. Using the combination of APCS score and overweight, subjects were stratified into 4 groups; high-risk with overweight (G1), average-risk with overweight (G2), high-risk with normal weight (G3) average-risk and with normal weight (G4). Logistic regression analysis was used to estimate the risk of detecting CRN.

Results:

The prevalence of CRN in the high-risk subjects was higher than that of in the average-risk subjects (49%vs.32%; OR, 2.00; 95%CI, 1.17-3.41). After adjustment for APCS risk factors and metabolic syndrome, overweight significantly increased the risk of detecting CRN (OR, 2.52; 95%CI, 1.57-4.05). Among the 4 groups, the detection rates of CRN were significantly different (G1=64%, G2=40%, G3=32% and G4=21%, p<0.01). The relative risk of detecting CRN increased when G1 (OR 6.49; 95%CI, 2.87-14.67), and G2 (2.42; 1.39-4.21) were compared with G4.

Conclusions:

In addition to the APCS score, overweight is an independent risk factor for detecting CRN. In Thai population, combining overweight and APCS score may be useful to improve the prediction for CRN.

Impact of Fecal Hb Levels on Advanced Neoplasia Detection and the Diagnostic Miss Rate For Colorectal Cancer Screening in High-Risk vs. Average-Risk Subjects: a Multi-Center Study

Objectives:

The Asia-Pacific Colorectal Screening (APCS) scoring system was developed to identify high-risk subjects for advanced neoplasia. However, the appropriate fecal immunochemical test (FIT) cutoff for high-risk population may be different from that of average-risk population. We aimed to evaluate the FIT performance at different cutoffs in high-risk subjects undergoing colorectal cancer (CRC) screening.

Methods:

We prospectively enrolled asymptomatic subjects aged 50–75 years. Using the APCS score, subjects were stratified into either the average-risk or high-risk groups. All subjects were tested with one-time quantitative FIT and underwent colonoscopy. We compared the FIT performance for advanced neoplasia between two groups using different cutoffs (5 (FIT5), 10 (FIT10), 20 (FIT20), 30 (FIT30), and 40 (FIT40) μg Hb/g feces).

Results:

Overall, 1,713 subjects were recruited, and 1,222 (71.3%) and 491 (28.7%) were classified as average-risk and high-risk, respectively. Advanced neoplasia was detected in 90 (7.4%) of the average-risk subjects and 65 (13.2%) of the high-risk subjects. In the high-risk group, by decreasing the cutoff from FIT40 to FIT5, the sensitivity increased by 33.8 percentage points with decreased specificity by 11 percentage points. In the average-risk group, the sensitivity increased by 20 percentage points with decreased specificity by 9.6 percentage points. At the lowest cutoff (FIT5), the number of needed colonoscopies to find one advanced neoplasia was 2.8 and 6.1 for the high-risk and average-risk groups, respectively.

Conclusions:

Using an appropriate FIT cutoff for CRC screening in high-risk subjects could improve CRC screening performance and reduce the unnecessary colonoscopies. To maintain high sensitivity and specificity for advanced neoplasia, the optimal cutoff FIT in the high-risk subjects should be lower than that in the average-risk subjects.

The Optimal Cut-Off Level of The Fecal Immunochemical Test For Colorectal Cancer Screening in a Country with Limited Colonoscopy Resources: A Multi-Center Study from Thailand

Background:

Selecting the cut-off point for the fecal immunochemical test (FIT) for colorectal cancer (CRC) screening programs is of prime importance. The balance between the test performance for detecting advanced neoplasia and the available colonoscopy resources should be considered. We aimed to identify the optimal cut-off of FIT for advanced neoplasia in order to minimize colonoscopy burden.

Methods:

We conducted a multi-center study in 6 hospitals from diverse regions of Thailand. Asymptomatic participants, aged 50-75 years, were tested with one-time quantitative FIT (OC-SENSOR, Eiken Chemical Co.,Ltd., Tokyo, Japan) and all participants underwent colonoscopy. We assessed test performance in detecting advanced neoplasia (advanced adenoma and CRC) and measured the burden of colonoscopy with different cut-offs [25 (FIT25), 50 (FIT50), 100 (FIT100), 150 (FIT150), and 200 (FIT200)ng/ml].

Results:

Among 1,479 participants, advanced neoplasia and CRC were found in 137 (9.3%) and 14 (0.9%), respectively. From FIT25 to FIT200, the positivity rate decreased from 18% to 4.9%. For advanced neoplasia, an increased cut-off decreased sensitivity from 42.3% to 16.8% but increased specificity from 84.2% to 96.3%. The increased cut-off increased the positive predictive value (PPV) from 21.5% to 31.5%. However, all cut-off points provided a high negative predictive value (NPV) (>90%). For CRC, the miss rate for FIT25 to FIT 150 was the same (n=3, 21%), whereas that with FIT200 increased to 35% (n=5).

Conclusions:

In a country with limited-colonoscopy resources, using FIT150 may be preferred because it offers both high PPV and NPV for advanced neoplasia detection. It could also decrease colonoscopy workload, while maintaining a CRC miss rate similar to those with lower cut-offs.

Serum microRNA-34a is potential biomarker for inflammation in nonalcoholic fatty liver disease

Background

MicroRNA-34a (miR-34a) contributes to liver injury through an apoptosis pathway.

Objective

To determine the correlation between serum miR-34a and liver inflammation as assessed by nonalcoholic fatty liver disease (NAFLD) activity score (NAS).

Method

We included a cross-selectional study of 50 patients with NAFLD in this observational study and confirmed diagnosis by liver biopsy, with NAS grading. A control group comprised 23 healthy individuals without chronic liver disease. Serum miR-34a was assayed using a real-time quantitative PCR (Applied Biosystems).

Result

The mean age of NAFLD patients was 46.0 ± 13.7 years, and 52% were female. Metabolic syndrome was found in 76%. Liver histopathology showed that 54% of patients had NAS ≥4 and significant fibrosis (≥2) was found in 22%. Serum levels of miR-34a were significantly correlated with NAS (r = 0.39, P = 0.005), and the degree of steatosis (r = 0.28, P = 0.049), ballooning (r = 0.30, P = 0.034), and fibrosis (r = 0.39, P = 0.005). Serum miR-34a in patients with NAS ≥4 was significantly higher than in those with NAS <4 (P = 0.011) and controls (P < 0.001). There was no significant correlation between serum miR-34a and other variables. The area under receiver operating characteristic curve for serum miR-34a comparing patients with NAS ≥4 and with NAS <4 was 0.67 (95% CI 0.52, 0.82).

Conclusion

Serum level of miR-34a has a significant fair to good correlation with NAS and may serve as a biomarker of liver inflammation and fibrosis in patients with NAFLD.

Kinetics of serum HBsAg and intrahepatic cccDNA during pegylated interferon therapy in patients with HBeAg-positive and HBeAg-negative chronic hepatitis B

This study was aimed at comparing clinical applicability of serum HBsAg quantification in relation to intrahepatic covalently closed-circular DNA (cccDNA) in patients with HBeAg-positive and HBeAg-negative chronic hepatitis B (CHB) treated with pegylated interferon (PEG-IFN) monotherapy for 48 weeks. Overall, 32 and 36 patients with HBeAg-positive and HBeAg-negative CHB, respectively were recruited. Paired liver biopsies at baseline and end of therapy were analyzed for cccDNA. Virological response (VR) at 48 weeks post-treatment was defined as HBeAg clearance (for HBeAg-positive CHB) and HBV DNA <2,000 IU/ml (for both groups). The results demonstrated that baseline levels of all viral markers were higher in the HBeAg-positive group than the HBeAg-negative group. Baseline HBsAg correlated with cccDNA in the HBeAg-positive group (r = 0.452, P = 0.009) but not in the HBeAg-negative group (r = 0.018, P = 0.919). However, the magnitude of cccDNA and HBsAg decline at end of treatment was not different between groups. The reduction of HBsAg showed a positive correlation with cccDNA decline in HBeAg-positive and HBeAg-negative CHB (r = 0.544, P = 0.001 and r = 0.364, P = 0.029, respectively). Overall, responders had more decline in cccDNA and HBsAg levels compared with non-responders. Patients with serum HBsAg decline of >1.0 log₁₀ IU/ml during treatment archived VR and HBsAg clearance of 80% and 30%, respectively. In conclusion, serum HBsAg represented a better surrogate marker of intrahepatic cccDNA in patients with HBeAg-positive CHB compared to those with HBeAg-negative CHB. On-treatment, HBsAg reduction of 1.0 log₁₀ IU/mL was associated with a high probability of subsequent VR and HBsAg clearance in patients receiving PEG-IFN therapy. J. Med. Virol. 89:130-138, 2017. © 2016 Wiley Periodicals, Inc.

A randomized clinical trial of peginterferon alpha-2b with or without entecavir in patients with HBeAg-negative chronic hepatitis B: Role of host and viral factors associated with treatment response

Combining peginterferon (PEG-IFN) and a potent nucleoside/nucleotide analogue might improve treatment response in patients with chronic hepatitis B (CHB). The aims of this study were to compare the efficacy of PEG-IFN alpha-2b with or without entecavir in HBeAg-negative CHB and to investigate predictors of response. A total of 126 treatment-naïve patients were randomly assigned to receive monotherapy (n = 63) or combination therapy (n = 63) for 48 weeks. Virological response (VR) was defined as HBV DNA level <2000 IU/mL at week 96. Baseline factors including polymorphisms in the IFNL3 (rs12979860) and HLA-DPA1 (rs3077) genes and on-treatment viral kinetics were determined. At week 48, rates of undetectable HBV DNA were lower in the monotherapy than combination groups, but rates of HBsAg clearance and decline were comparable. At week 96, there was no difference between the corresponding groups regarding virological response (41.3% vs 38.1%, P = 0.856), HBsAg clearance (9.5% vs 4.8%, P = 0.491) and HBsAg decline. Baseline HBsAg level [odds ratio (OR): 3.14 (1.34-7.69), P = 0.012] and rs3077 polymorphism [OR: 2.78 (1.27-6.11), P = 0.011] were independent predictors of response. Patients carried GG genotype of rs3077 with low baseline HBV (<1000 IU/mL) had high probability of achieving VR (76.5%) and HBsAg clearance (29.4%). None of the patients without decrease in HBsAg combined with <2 log10 HBV DNA decline at week 12 achieved a virological response. In conclusion, the combination therapy lead to greater on-treatment HBV DNA suppression but did not improve virological response and HBsAg clearance/decline over monotherapy. Host and viral factors could help optimize decision-making at baseline and during PEG-IFN-based therapy.

HEPATIC LYMPHOMA AND SPLENIC ASPERGILLOSIS MIMICKING HEPATOSPLENIC ABSCESSES FROM MELIOIDOSIS IN THAILAND

We report here a case of hepatic lymphoma and splenic aspergillosis in an elderly patient with diabetes mellitus, exhibiting hepatosplenic abscesses mimicking melioidosis. Immunohistochemistry confirmed the diagnosis of a diffuse hepatic large B-cell lymphoma. Biopsy of the spleen revealed a clump of fungus with a slender shape and dichotomous branching, morphologically consistent with aspergillosis. Hepatosplenic abscesses are a common presentation in melioidosis, but this case reveals this assumption can lead to misdiagnosis. Histological and microbiological confirmation are required, especially in patients with hepatosplenic lesions.

Diagnostic values of dual focus narrow band imaging and probe-based confocal laser endomicroscopy in FAP-related duodenal adenoma

BACKGROUND AND STUDY AIMS

Familial adenomatous polyposis (FAP) is associated with an increased risk of development of periampullary and nonampullary adenoma. Either routine biopsy or endoscopic removal of the lesion is generally required to identify the presence of adenoma. Because the risk of tissue sampling from the ampulla is high and nonampullary polyps are sometimes numerous, resection of all the lesions is time-consuming. This study aimed to evaluate the diagnostic values of duodenal adenoma by dual focus NBI (dNBI) and probe-based confocal endomicroscopy (pCLE) in FAP patients.

PATIENTS AND METHODS

The authors conducted a diagnostic study in a single tertiary-care referral center. Surveillance esophagogastroduodenoscopy with dNBI and pCLE was performed on 26 patients with FAP for real-time adenoma diagnosis by two different endoscopists; one used dNBI and the other pCLE. Histology from the matched lesion was used as the gold standard.

RESULTS

A total of 55 matched biopsies (25 ampullas, 30 nonampullas) were performed. The sensitivity, specificity, post predictive value (PPV), negative predictive value (NPV), and accuracy of dNBI vs. pCLE from all duodenal lesions were 96.9 % vs. 93.8 %, 78.3 % vs. 81 %, 86.1 % vs. 88.2 %, 94.7 vs. 89.5 %, and 92.4 % vs. 88.6 %, respectively.

CONCLUSIONS

For surveillance of periampullary and nonampullary adenoma in patients with FAP, the real-time readings provided a high degree of diagnostic value when histology was used as the gold standard. (

CLINICAL TRIAL REGISTRATION NUMBER

NCT02162173).

Helicobacter pylori Infection in Thailand: A Nationwide Study of the CagA Phenotype

Background

The risk to develop gastric cancer in Thailand is relatively low among Asian countries. In addition, the age-standardized incidence rate (ASR) of gastric cancer in Thailand varies with geographical distribution; the ASR in the North region is 3.5 times higher than that in the South region. We hypothesized that the prevalence of H. pylori infection and diversity of CagA phenotype contributes to the variety of gastric cancer risk in various regions of Thailand.

Methods

We conducted a nationwide survey within Thailand. We determined H. pylori infection prevalence by detecting H. pylori, using histochemical and immunohistochemical methods. The anti-CagA antibody and anti-East-Asian type CagA antibody (α-EAS Ab), which showed high accuracy in several East Asian countries, were used to determine CagA phenotype.

Results

Among 1,546 patients from four regions, including 17 provinces, the overall prevalence of H. pylori infection was 45.9% (710/1,546). Mirroring the prevalence of H. pylori infection, histological scores were the lowest in the South region. Of the 710 H. pylori-positive patients, 93.2% (662) were immunoreactive with the anti-CagA antibody. CagA-negative strain prevalence in the South region was significantly higher than that in other regions (17.9%; 5/28; p < 0.05). Overall, only 77 patients (11.6%) were immunoreactive with the α-EAS Ab. There were no differences in the α-EAS Ab immunoreactive rate across geographical regions.

Conclusions

This is the first study using immunohistochemistry to confirm H. pylori infections across different regions in Thailand. The prevalence of East-Asian type CagA H. pylori in Thailand was low. The low incidence of gastric cancer in Thailand may be attributed to the low prevalence of precancerous lesions. The low incidence of gastric cancer in the South region might be associated with the lower prevalence of H. pylori infection, precancerous lesions, and CagA-positive H. pylori strains, compared with that in the other regions.

A combination of clinical risk stratification and fecal immunochemical test results to prioritize colonoscopy screening in asymptomatic participants

BACKGROUND

Stool-based colonoscopy is the preferred strategy for colorectal cancer (CRC) screening. The Asia-Pacific Colorectal Screening System (APCS) score also is helpful in stratifying the risk for advanced neoplasia in the asymptomatic population. The combination of the fecal immunochemical test (FIT) result and clinical risk stratification may be more helpful in stratifying the risk.

OBJECTIVE

To evaluate the value of the combination of FIT and APCS scores in stratifying asymptomatic participants for colonoscopy.

DESIGN

Cross-sectional study.

SETTING

University hospital.

PATIENTS

A total of 948 asymptomatic participants eligible for screening colonoscopy.

INTERVENTIONS

FIT, APCS score evaluation, screening colonoscopy.

MAIN OUTCOME MEASUREMENTS

The prevalence of colorectal neoplasia in 4 different groups of participants according to FIT and APCS score evaluations.

RESULTS

The prevalence of non-advanced and advanced neoplasia in the 4 groups (high risk with positive FIT result, high risk with negative FIT result, moderate risk with positive FIT result, and moderate risk with negative FIT result) was 44% versus 36.9%, 30.1% versus 11.6%, 27.1% versus 12%, and 22.6% versus 6.4%, respectively (P < .001). Participants with both high-risk scores and positive FIT results had a significantly higher detection rate of advanced neoplasia (6.15-fold, 95% confidence interval, 3.72-10.17) compared with the other 3 groups. Seven cancers were discovered; 4 were in the high-risk with positive FIT result group.

LIMITATIONS

Hospital-based study.

CONCLUSION

In countries with limited resources, participants with positive FIT results and high-risk scores by APCS should be given priority for colonoscopy because this group is most likely to have advanced neoplasia. However, this strategy needs to be confirmed for its cost-effectiveness in a large, population-based study. (

CLINICAL TRIAL REGISTRATION NUMBER

TCTR20140228001.).

Forward-viewing radial-array echoendoscope for staging of colon cancer beyond the rectum

AIM: To evaluate feasibility of the novel forward-viewing radial-array echoendoscope for staging of colon cancer beyond rectum as the first series.

METHODS: A retrospective study with prospectively entered database. From March 2012 to February 2013, a total of 21 patients (11 men) (mean age 64.2 years) with colon cancer beyond the rectum were recruited. The novel forward-viewing radial-array echoendoscope was used for ultrasonographic staging of colon cancer beyond rectum. Ultrasonographic T and N staging were recorded when surgical pathology was used as a gold standard.

RESULTS: The mean time to reach the lesion and the mean time to complete the procedure were 3.5 and 7.1 min, respectively. The echoendoscope passed through the lesions in 13 patients (61.9%) and reached the cecum in 10 of 13 patients (76.9%). No adverse events were found. The lesions were located in the cecum (n = 2), ascending colon (n = 1), transverse colon (n = 2), descending colon (n = 2), and sigmoid colon (n = 14). The accuracy rate for T1 (n = 3), T2 (n = 4), T3 (n = 13) and T4 (n = 1) were 100%, 60.0%, 84.6% and 100%, respectively. The overall accuracy rates for the T and N staging of colon cancer were 81.0% and 52.4%, respectively. The accuracy rates among traversable lesions (n = 13) and obstructive lesions (n = 8) were 61.5% and 100%, respectively. Endoscopic ultrasound and computed tomography had overall accuracy rates of 81.0% and 68.4%, respectively.

CONCLUSION: The echoendoscope is a feasible staging tool for colon cancer beyond rectum. However, accuracy of the echoendoscope needs to be verified by larger systematic studies.

Asymptomatic primary rectal neuroendocrine carcinoma presented as a large pelvic mass

A 55-year-old healthy Thai man presented with incidental finding of a well-circumscribed, 5.8×5.4 cm mass in the right side of the pelvic cavity with heterogeneous density by a CT scan performed for trauma. No other distant lesion was detected. The pathology from pelvic mass showed poorly differentiated neuroendocrine carcinoma (NEC). A submucosal mass of 10 cm from the anal verge was found at colonoscopy, and a biopsy showed the same histopathology as in the pelvic mass. Final diagnosis was poorly differentiated primary rectal NEC with metastasis to the right iliac node (by CT scan). Carboplatin and etoposide were given for six cycles and tumour size was decreased.

Post liver transplantation lymphoproliferative disorder mimics recurrence of hepatocellular carcinoma

We report a case of Epstein-Barr virus (EBV)-related postliver transplantation lymphoproliferative disorder (PTLD) in a patient with post liver transplant which initially presented in a CT scan image mimicking recurrence of hepatocellular carcinoma. Histopathology showed atypical plasma cell-like infiltration, and immunohistochemistry confirmed diagnosis of EBV-associated diffuse large B-cell lymphoma. Typical imaging from dynamic phases contrast CT scan might not accurately diagnose recurrent HCC in postorthotropic liver transplantation. Liver biopsy should be performed for accurate diagnosis and proper treatment.

A non-progressive signet patient with ring cell gastric adenocarcinoma who survived for 6 years without treatment

An elderly Thai woman had presented with dyspepsia and reflux symptoms since 6 years. Oesophagogastroduodenoscopy showed a large gastric ulcer with a histopathological diagnosis of signet ring cell carcinoma. The test for Helicobacter pylori was positive and it was successfully eradicated. An abdominal CT scan showed the irregularly thick antral wall along with non-specific subcentimeter lymph nodes which was compatible with at least stage IA. Her serum carcinoembryonic antigen level was within normal range. She refused any surgical treatment and preferred to take her own medications. To date, 6 years after her first diagnosis, the second oesophagogastroduodenoscopy was performed and showed a large gastric ulcer at the incisura extending to the gastric antrum. The histopathological result of the ulcer confirmed the presence of poorly differentiated adenocarcinoma with signet ring cell. She remains healthy and refused to have a follow-up disease staging or additional treatment.

Flexible spectral imaging color enhancement plus probe-based confocal laser endomicroscopy for gastric intestinal metaplasia detection

BACKGROUND AND AIM

Probe-based confocal laser endomicroscope (pCLE) has been applied for the early detection and confirmation of many gastrointestinal neoplasms; however, its use in gastric intestinal metaplasia (GIM) detection has not yet been validated. The objective of this study was to assess the diagnostic yield of magnifying flexible spectral imaging color enhancement (ME-FICE) plus pCLE for GIM detection.

METHODS

Sixty patients with previous histology confirmed as GIM underwent a surveillance EGD. Standard and 100× ME-FICE were used as a screening mode to depict GIM by light-blue crest, large long crest, and villous pattern criteria. Then, pCLE was followed to confirm the presence of GIM. In each patient, two biopsies were obtained from one positive area, and the other two were taken from the negative area. All specimens were interpreted by a clinically blinded pathologist. The reading results by ME-FICE and by ME-FICE plus pCLE were assessed for sensitivity, specificity, positive predictive value, negative predictive value (NPV), false-positive rate, false-negative rate, and accuracy.

RESULTS

Of the 59 areas suspicious for GIM in 45 patients, 44 areas were confirmed as GIM by histology. The overall criteria from ME-FICE plus pCLE provided the highest sensitivity, specificity, positive predictive value, NPV, and accuracy at 96%, 90%, 86%, 97%, and 92%, respectively. There were two false-negatives (4%) and seven false-positives (10%). No early gastric cancer was detected in any.

CONCLUSION

Combining ME-FICE with pCLE provides high sensitivity and NPV for GIM detection. The prompt histology reading by this technique may avoid unnecessary biopsy (Clinical trial registration number: NCT01489397).

Case report: severe CMV colitis in a patient with follicular lymphoma after chemotherapy

BACKGROUND

Cytomegalovirus (CMV) can infect immuno-compromised host, especially in HIV and bone marrow transplantation patients. CMV colitis was reported after receiving chemotherapy in a solid tumor and aggressive Non-Hodgkin's lymphoma, but not yet in indolent lymphoma patients.

CASE REPORT

In the present report, a 64-year-old woman was re-admitted with watery diarrhea after eight cycles of chemotherapy for Follicular lymphoma. She had hyponatremia, hypokalemia, and hypocalcemia, which were the consequences of severe diarrhea. After two weeks of continuous diarrhea, she was set for colonoscopy, which showed multiple ulcers along the colon. Pathological results were found to be consistent with CMV colitis. Her diarrhea symptom improved after receiving ganciclovir.

CONCLUSION

CMV colitis could occur in indolent lymphoma patients who receive R-CVP regimen (rituximab, cyclophosphamide, vincristine, and prednisolone). Patients exhibiting severe and prolonged diarrhea should be investigated for definite diagnosis in order to receive proper treatment.

Diagnostic role of serum glypican-3 in differentiating hepatocellular carcinoma from non-malignant chronic liver disease and other liver cancers

BACKGROUND AND AIMS

The role of glypican-3 (GPC3), a novel serum marker, in differentiating hepatocellular carcinoma (HCC) from non-malignant chronic liver disease and other malignant space-occupying lesions in the liver is largely unknown. The aims of this study were to evaluate its diagnostic role and clinical correlations in patients with HCC.

METHODS

Six groups were studied which included 40 healthy subjects, 50 patients with chronic hepatitis (CH), 50 patients with liver cirrhosis (LC), 100 patients with HCC, 50 patients with intrahepatic cholangiocarcinoma (ICC) and 50 patients with metastatic carcinoma (MCA). Serum GPC3 levels were measured by using a sandwich enzyme-linked immunosorbent assay method.

RESULTS

Fifty-three percent of HCC patients had elevated serum GPC3 levels with values ranging 35.5-7826.6 ng/mL. The serum marker was undetectable in other groups except one patient (2%) with LC and another patient (2%) with MCA. In most cases of HCC, elevated GPC3 values did not correlate with alpha-fetoprotein (AFP) levels. Detectable GPC3 was significantly correlated with the presence of viral hepatitis markers but was not correlated with tumor size and stage of HCC. Serum GPC3 was superior to AFP in detecting small HCC (56.3% and 31.3%, respectively). A combination of serum GPC3 and AFP yielded an improved sensitivity for detecting small HCC to 75%.

CONCLUSION

Serum GPC3 is highly specific for detecting HCC. The combined use of serum GPC3 and AFP provides a potentially promising tool to better differentiate HCC from benign liver disorders, as well as from other liver cancers.

Favorable outcome of orthotopic liver transplantation in very high-risk situations

BACKGROUND

Favorable outcomes of marginal liver grafts depends on optimal perioperative control and good recipient parameters. The aim of this study was to assess the results of marginal liver grafts associated with prolonged ischemic times and high-risk recipients.

METHODS

We retrospectively reviewed data from patients who underwent orthotopic liver transplantation between 2001 and 2005. The patients were divided into two groups: group 1 received marginal liver grafts with ischemia times >or= 12 hours and recipient United Network for Organ Sharing (UNOS) status 1, 2A, and 2B. Patients who had marginal liver grafts with ischemic times less than 12 hours and/or better UNOS status were classified as group 2. We compared initial graft function as well as patient and graft survivals at 1 year between the two groups.

RESULTS

Among 31 patients who were reviewed, four were excluded because of incomplete data and 24/27 received marginal liver grafts. Seven patients were classified into group 1, and 17 into group 2. The initial poor function rate was 85.7% (6/7 patients) and 76.47% (13/17 patients) in groups 1 and 2, respectively. The 1-year survival rate in group 1 was 85.7% (6/7 patients) and 94.12% (16/17 patients) in group 2.

CONCLUSION

Marginal liver grafts can be used with favorable outcomes even in high-risk situations, such as prolonged ischemia times and high-risk recipients.

Asymptomatic bilateral giant adrenal myelolipomas: case report and review of literature

OBJECTIVE

To describe an unusual case of bilateral giant adrenal masses caused by a primary adrenal myelolipoma.

METHODS

We present the clinical, laboratory, and pathologic findings in a 32-year-old man with bilateral adrenal masses. The previous reports of bilateral myelolipomas also were reviewed.

RESULTS

During a routine examination, a 32-year-old Thai man was found to have an asymptomatic abdominal mass. A computed tomographic scan of the abdomen disclosed bilateral adrenal masses; the one on the left was approximately 27 by 24 by 12 cm, and the one on the right side was 9 by 5 by 5 cm. The computed tomographic scan characteristics showed that both masses consisted mainly of low-density tissues (-30 to -90 Hounsfield units), suggestive of fatty component. An endocrinologic evaluation revealed no evidence of adrenal cortical or medullary functional abnormalities. Bilateral adrenalectomy was performed because of the large size of the lesions and the inability to rule out malignant involvement.

CONCLUSION

Myelolipoma is a relatively rare benign tumor of the adrenal glands composed of adipose cells and mature hematopoietic elements. Most such lesions are small, asymptomatic, and unilateral; giant or bilateral myelolipomas are quite rare. To our knowledge, our current case may represent the largest bilateral lesions in the literature.

Visceral fat and insulin resistance as predictors of non-alcoholic steatohepatitis

AIM

To examine whether visceral fat is associated with non-alcoholic steatohepatitis (NASH), to assess for parameters associated with visceral adiposity and to investigate for factors associated with fibrotic severity in NASH.

METHODS

Thirty NASH and 30 control subjects underwent biochemical tests, anthropometric assessment, bioelectrical impedance, dual energy X-ray absorptiometry and abdominal fat study by CT scan. Liver biopsies were graded according to the Brunt criteria.

RESULTS

NASH subjects had elevated blood pressure, body mass index, waist circumference and waist-to-hip ratio. A greater number of diabetes mellitus, impaired glucose tolerance test and HOMA-IR > 3.5 were found in NASH patients. HOMA-IR > 2.8 (OR 20.98, 95% CI 3.22-136.62; P < 0.001) and visceral fat area > 158 cm(2) (OR 18.55, 95% CI 1.60-214.67; P = 0.019) were independent predictors for NASH. Advanced stage of NASH was found in 15 (50%) patients. HOMA-IR > 3.5 (OR 23.12, 95% CI 2.00-266.23; P = 0.012) and grading of portal inflammation (OR 7.15, 95% CI 1.63-31.20; P = 0.009) were determined as independent risk factors for advanced stage of NASH.

CONCLUSION

Obesity (especially central obesity) and metabolic syndrome are common in Thai NASH. Insulin resistance and elevated visceral fat are risk factors for the presence of NASH. The advanced stage of the disease is related to insulin resistance.

Serum LINE-1 hypomethylation as a potential prognostic marker for hepatocellular carcinoma

BACKGROUND

We investigated the clinical implications of global hypomethylation, one of the most consistent epigenetic changes in cancer, in the sera of patients with hepatocellular carcinoma (HCC).

METHODS

Combined bisulfite restriction analysis PCR was used to assess the methylation status of LINE-1 repetitive sequences in genomic DNA derived from sera of 85 patients with HCC, 73 patients with cirrhosis, 20 healthy carriers of hepatitis B virus (HBV) and 30 healthy controls.

RESULTS

Serum genome hypomethylation, the percentage of unmethylated LINE-1, was significantly increased in patients with HCC (P<0.001). The levels of serum LINE-1 hypomethylation at initial presentation correlated significantly with the presence of HBsAg, large tumor sizes, and advanced tumor stages classified by the CLIP score. Multivariate analyses showed that serum LINE-1 hypomethylation was a significant and independent prognostic factor of overall survival.

CONCLUSION

Serum LINE-1 hypomethylation may serve as a prognostic marker for patients with HCC.

Adrenal hemorrhage as the first presentation of hepatocellular carcinoma

We report a 67-year-old man who presented with sudden onset of pain in the left flank in association with anemia and hypotension. Imaging studies revealed hepatocellular carcinoma (HCC) at the right lobe of the liver with bilateral adrenal metastases and recent hemorrhage in the left adrenal gland. His serology for hepatitis C was positive. Abdominal exploration with left adrenalectomy was performed. The postoperative course of the patient was uneventful and three cycles of transarterial chemoembolization (TACE) were administered. His general condition gradually deteriorated, and he died 6 months after surgery. Spontaneous massive AH due to metastatic HCC is unusual. Considering the high incidence of HCC in Asia, clinicians should be aware of this atypical and fatal presentation.

Histological variants of colorectal adenocarcinoma and clinicomorphological association

OBJECTIVE

Besides TNM staging system, some special histological features of colonic carcinomas are associated with variable clinicopathological parameters. The objective was to provide new information of correlation between various histomorphological parameters together with available clinical data and each special feature

MATERIAL AND METHOD

A retrospective study of 162 materials collected from subjects with first diagnosed as adenocarcinoma of colorectum in King Chulalongkorn Memorial Hospital over a period of 2 years from 2002 to 2003.

RESULT

One hundred and forty-seven cases of prominent cribiform feature are related to patient age (p = 0.025) and infiltrative margin (p = 0.006). Thirty-two cases with mucinous component are associated with patient age (p = 0.009) and tumor depth (p = 0.015). Thirteen cases with signet ring cell morphology are correlated with nodal and distant organ metastasis (p = 0.023 and p = 0.020, respectively) as well as angiolymphatic invasion (p = 0.015). In addition the size of signet ring cell containing carcinomas is also related to location (p = 0.036). It is larger in proximal site and smaller in distal counterpart. The authors did not find any statistical significance in 9 cases of medullary carcinoma. Notably, our 33 cases showed biphasic or triphasic feature.

CONCLUSION

Each distinct histological variant of colorectal adenocarcinoma is associated with some different clinicopathological variables,' mostly effecting clinical outcome. Pathologists should be concerned with special histological subtypes of colorectal adeonocarcinomas and communicate with physicians for proper management.

Inflammatory bowel disease in Thai children: presentations and outcomes of treatment

Inflammatory bowel disease (IBD) is characterized by idiopathic chronic intestinal inflammation, due to abnormalities in gastrointestinal immunoregulation. Pediatric IBD has been rarely reported in Thailand. We describe eight children, five girls and three boys, who were diagnosed with IBD at Ramathibodi Hospital during 1999-2005 and had a follow-up of more than one year. Four cases had Crohn's disease (CD) and four cases had ulcerative colitis (UC). The ages at diagnosis ranged from 3.5 to 15.5 years. Diagnosis of IBD was delayed for more than 12 months in five patients. Five out of eight patients had early onset of disease, before 6 years of age. The manifestations included chronic diarrhea, abdominal pain, rectal bleeding and perianal lesions. The common extraintestinal manifestations were oral ulcer, anemia, weight loss and failure to thrive. Most patients had moderate to severe diseases and ileocolic fistula developed in one patient with CD. The disease was controlled with 5-aminosalicylic acid and corticosteroid in most patients. Four patients required additional therapy with azathioprine. Infliximab was used in two patients who were chronically steroid-dependent CD, one also had persistent ileocolic fistula and both patients responded well. During the follow-up period ranging from 1.1 to 5.8 years, three patients remained growth retardation; all had early onset of disease before 6 years of age, long duration of symptoms of more than 3 years before diagnosis and had multiple relapses. It is concluded that there is an increasing number of IBD in Thai children during the recent years. Most patients had moderate to severe diseases. Early onset of disease, delay in diagnosis and treatment are responsible for more complications, particularly persistent growth impairment. Early recognition of IBD and treatment are essential for a satisfactory long-term outcome.

Anti-inflammatory effects of Aloe vera on leukocyte-endothelium interaction in the gastric microcirculation of Helicobacter pylori-infected rats

This research was aimed to investigate anti-inflammatory effects of Aloe vera on leukocyte-endothelium in the gastric microcirculation of Helicobacter pylori (H. pylori)-infected rats. Thirty-six male Sprague-Dawley rats were divided into 3 groups: control, H. pylori-infected, and A. vera-treated group (200 mg/kg b.w., twice daily). H. pylori-inoculation was induced in the rats by the administration of H. pylori solution. Intravital fluorescence videomicroscopy was used to examine leukocyte adhesion in postcapillary venules on the posterior surface of stomach area on different periods after administration of A. vera. Serum tumor necrosis factor-alpha (TNF-alpha) level was measured in blood collected at the end of experiment by using ELISA technique. The results showed that in H. pylori-infected group on day 8, the leukocyte adhesion was 13.40+/-1.00 cells/100 microm vessel length and the TNF-alpha was 76.76+/-23.18 pg/ml, which increased significantly (p < 0.05), compared with the control group (leukocyte adhesion(control) = 2.54+/-0.6 cells/100 microm vessel length and TNF-alpha(control) = 9.92+/-2.62 pg/ml). Treatment with A. vera reduced the leukocyte adhesion (5.5+/-0.5 cells/100 microm vessel length), and TNF-alpha (26.31+/-6.38 pg/ml) significantly (p < 0.05). In conclusion, H. pylori enhanced leukocyte-endothelium interaction in the posterior stomach area markedly. This enhancement in leukocyte-endothelium interaction could be improved by the treatment of A. vera, associated with reduction in TNF-alpha level.

A retrospective study of colonic polyps in King Chulalongkorn Memorial Hospital

To evaluate and classify polyps from colon in Thai patients, the authors retrospectively analyzed the 776 polyps from 696 subjects in King Chulalongkorn Memorial Hospital during the past five-year period from 1999 to 2003. All colonic polyps were included in the study. There were 461 (59%) male and 315 (410%) female with the mean age of 51 years. Non-neoplastic and neoplastic polyps were documented 50% each. Hyperplastic polyp was the most frequent diagnosis (39%), followed by tubular adenoma (36%). According to neoplastic polyp, 8%, 3%, and 14% cases were identified as high-grade dysplastic change, intramucosal carcinoma, and invasive carcinoma, respectively.

A Novel Germline Mutation, 1793delG, of the MEN1 Gene Underlying Multiple Endocrine Neoplasia Type 1

Pulmonary carcinoids are rare neuroendocrine tumors which comprise 1-2% of all lung tumors. They usually occur sporadically; however, their association with multiple endocrine neoplasia type 1 (MEN1) syndrome has been documented. We report a case of a Thai woman with a pulmonary carcinoid tumor and a null cell pituitary tumor. Her family history was unremarkable for any MEN-related lesions. Genetic testing revealed a novel deletion mutation at exon 10 (1793delG) of the MEN1 gene, resulting in a stop codon 26 amino acids downstream. This mutation is predicted to cause a loss of the second nuclear localization signal of the menin protein.

A germline mutation in a Thai family with familial multiple endocrine neoplasia type 1

Multiple endocrine neoplasia type 1, caused by the mutation in the MEN1 gene, is an autosomal dominant disorder with over 95% penetrance characterized by hyperparathyroidism, pancreatic endocrine tumor and pituitary tumor. The authors performed a molecular analysis to identify a mutation in a Thai man with MEN1. He was found to be heterozygous for IVS6 + 1G to A. Two of his three children were also found to carry this mutation. The newly available genetic test for patients with MEN1 in Thailand makes it possible to accurately DNA-based diagnose clinically suspected individuals and their presymptomatic members, which has important therapeutic impacts on them.

Unusual manifestations of gastric inflammatory fibroid polyp in a child

AIM: Inflammatory fibroid polyp (IFP) is a rare benign lesion that may occur throughout the digestive tract. IFP is more commonly found in the antrum of the stomach in particular. It mostly affects adults at the average age of 60 years. These polyps are able to cause abdominal pain, gastrointestinal bleeding, intestinal obstruction or intussusception. In this paper we report a case of gastric IFP with unusual presenting features.

METHODS: A child with gastric IFP was described and the literature was reviewed.

RESULTS: A 4-year-old girl presented with fever for 2 months, arthralgia of knees and ankles, iron deficiency anemia, and hypoalbuminemia. Her stool examination was positive for occult blood. The upper gastrointestinal study demonstrated a large lobulated mass at the upper part of gastric body. Partial gastrectomy en bloc with this 5 cm × 8 cm mass was subsequently performed. Pathological examination was consistent with IFP. Following the mass excision, her fever abruptly declined and disappeared together with anemia and arthralgia. She remained asymptomatic and the abdominal ultrasonography performed at the 24-month follow-up demonstrated no recurrence of the tumor.

CONCLUSION: The etiopathogenesis of IFP still remains unclear. The presence of IFP throughout the gastrointestinal tract and its variable clinical appearances make it difficult to diagnose. The inflammatory symptoms found in this patient support the hypothesis of inflammatory benign lesions of IFP.

Gastrointestinal manifestations of cow's milk protein allergy during the first year of life

BACKGROUND

Cow's milk protein sensitive enteropathy (CMPSE) is a common condition in the first year of life. Clinically CMPSE usually presents with symptoms like vomiting, chronic diarrhea, mucous bloody diarrhea and hematemesis. More unusual symptoms associated with CMPSE are infantile colic, gastroesophageal reflux and chronic constipation. The objective of this study was to assess the gastrointestinal manifestations and allergic march in CMPSE patients.

METHOD

The authors reviewed the records of 10 CMPSE patients observed by the Gastrointestinal Unit at King Chulalongkorn Memorial Hospital from 1997-2001 including patient characteristics, laboratory investigations, endoscopy and follow-up outcome.

RESULTS

Of 10 CMPSE patients, the median age of CMPSE onset was 3.5 months. The gastrointestinal manifestations were hematemesis (n = 6), mucous bloody diarrhea (n = 3) and chronic watery diarrhea (n = 2). Exclusively breast-fed infants seemed to have more delayed onset of symptoms than those who were not. Anemia (n = 3), high serum IgE (n = 4) and positive skin prick test for cow's milk (n = 5) were found. Neither peripheral eosinophilia nor hypoalbuminemia was found. Endoscopy revealed acute and chronic gastritis. Treatment was successful by changing to soy or extensive hydrolysate formula with mean duration of cow's milk intolerance of 24 months. In 2-year follow-up, three of ten patients who had high serum IgE level developed allergic rhinitis and eczema.

CONCLUSION

CMPSE can be manifested in various symptoms. Exclusive breast feeding for more than 4 months can postpone the onset of CMPSE. Serum IgE or specific IgE level to cow's milk protein may identify the atopic career of CMPSE individuals.

Effectiveness of ranitidine bismuth citrate based triple therapy for treating Helicobacter pylori

OBJECTIVE

To determine the efficacy, safety and tolerance of a one week regimen of RBC, clarithromycin, and amoxicillin for H. pylori eradication in Thai patients.

MATERIAL AND METHOD

Patients who were undergoing endoscopy for dyspeptic symptoms. On the day of endoscopy, three biopsies were taken for H. pylori diagnosis. The patients who had the presence of H. pylori infection by positive from rapid urease test or histologic examination were invited to take part in an open, prospective study. Patients received a combination of RBC 400 mg, clarithromycin 500 mg, and amoxicillin 1 g twice daily for 7 days. Repeated endoscopy was performed to evaluate H. pylori eradication at least 1 month after the end of treatment. Clinical symptoms, side effects and compliance were assessed by interview during the study and at follow-up.

RESULTS

Thirty nine patients with H. pylori infection were included. Male and female rates was 27:12 with a mean age of 42.8 +/- 11.4 years (range 21-68). There was a 89.74 per cent eradication rate by intent-to-treat and 94.59 per cent by per-protocol analysis. There were no serious adverse events during the study. Two patients (5.13%) stopped the medication because of side effects. Two patients had failure to eradication after complete treatment. Subjective improvement of the clinical symptoms was found in 92.3 per cent.

CONCLUSION

One week's regimen of RBC, clarithromycin, and amoxicillin triple therapy resulted in a relatively high efficacy, safety and tolerance for H. pylori eradication in Thai patients.

Duodenal Helicobacter pylori associated duodenal ulcer depend on gastric Helicobacter pylori status

Gastric Helicobacter pylori (H. pylon) plays an important role in the pathogenesis of duodenal ulcer (DU), although not all H. pylori infected persons will develop disease. Duodenal H. pylori was supposed to be one of the factors related with DU. The aim of this study was to investigate whether H. pylori in the duodenum of patients with DU plays a critical role in the pathogenesis of DU regarding the gastric H. pylori status. Furthermore, it was to determine the prevalence of duodenal H. pylori infection in Thailand. Ninety three patients were included in the study. They underwent gastroscopic evaluation for dyspeptic symptoms and none of them had previous H. pylori eradication therapy. An upper gastrointestinal endoscopy was performed and two specimens were collected each form the antrum, midcorpus and duodenal bulb in order to diagnose H. pylori infection. The gold standard for H. pylori detection is a positive specimen culture or polymerase chain reaction (PCR) assay for the vac A gene or positive urease test plus H. pylori seen in the pathology. Ninety three dyspeptic patients (43 males and 50 females; mean age 48.2 years; range 22 to 79 years) were included in the study. Duodenal H. pylori was detected in 31/93 (33.33%) patients which included 15 (48.38%) patients with duodenal ulcer, 2 (6.45%) patients with gastric ulcer and 14 (45.16%) patients with NUD. Five of thirty one (16.21%) patients with duodenal H. pylori infection had negative gastric H. pylori. These five patients included 1 with DU, 1 with DU and 3 with NUD. Duodenal H. pylori was associated with DU dependent of the presence of gastric H. pylori (p<0.05) and there was no association between duodenal H. pylori with negative gastric H. pylori and duodenal ulcer (p>0.05). Duodenal H. pylori is associated with duodenal ulcer dependent on the presence of gastric H. pylori. These results suggest that transmission of gastric H. pylori to the duodenum was prerequisited for the formation of DU.

Necrotizing ileitis caused by cytomegalovirus in patient with systemic lupus erythematosus: case report

We report a systemic lupus erythematosus (SLE) patient with necrotizing ileitis diagnosed at a tertially care centre in Thailand. The patient was surgically explored because peritonitis was suspected and segmental gangrenous and perforation of the terminal iliem were found. The pathological finding was necrotizing ileitis with appearance of cytomegalic intranuclear inclusion body. The presence of cytomegalovirus (CMV) infection in tissue was confirmed by CMV-DNA detection using polymerase chain reaction and ELISA probe hybridization method. The hemoculture and peritoneal fluid culture results revealed no pathogenic organisms. Postoperatively, the clinical course of the patient deteriorated and she developed hypotension. Vasopressive drugs were administered without clinical improvement. She expired on day 5 postoperation. Regarding CMV infection, the organism involves the small bowel in only 4.3 per cent of all CMV infections of the gastrointestinal tract. Isolated cases of ileal perforation due to CMV infection have never been reported in a SLE patient. Thus, chronic right lower abdominal pain, fever with or without diarrhea in immunocompromised patients should cause clinicians to consider CMV ileitis in the differential diagnosis. Immediate surgical resection and prompt antiviral therapy lead to successful treatment.

Malignant duodenal stromal tumor: the first case report in Thailand and review of the literature

The authors presented a middle aged Thai patient with malignant duodenal stromal tumor identified at a tertially care centre in Thailand. The patient presented with obscure gastrointestinal bleeding and the small bowel endoscopy revealed a bleeding tumor mass at the fouth part of the duodenum. The patient underwent segmental duodenectomy with end to end anstosomis. The histopathology of the tumor composed of interlacing bundles of spindle cells with oval to elongated pleomorphic nuclei and eosinophilic cytoplasm. The immunohistochemistrical study confirmed the diagnosis of malignant stromal tumor with smooth muscle differentiation. The computer tomography scan (CT scan) of the abdomen showed no evidence of metastasis. Postoperatively, the patient's clinical condition showed continuous improvement without further gastrointestinal bleeding. The patient has remained healthy up to present (six months of follow-up). A high level of suspicion to detect this malignant tumor especially in a patient presenting with obscure gastrointestinal bleeding and effective surgical treatment allow better clinical outcome in this rare and fatal malignancy.