Advances in Digestive Medicine最新文献

Medication adherence is crucial in inflammatory bowel disease (IBD). This study aimed to evaluate attitudes to medication and the effects of IBD nursing services in a Taiwanese cohort. Sixty four adult patients with IBD were invited to complete a questionnaire at Changhua Christian Hospital between October 2020 and June 2021. All the patients (32 with Crohn's disease and 32 with ulcerative colitis) completed the questionnaire. Regarding medication adherence, most patients were highly or moderately adherent and reported never or sometimes forgetting to take medication (100% for steroids and 90.7% to 91.2% for other medications). Regarding worries about adverse reactions, 38.8%, 40.3%, 12.8%, and 6.1% of patients never or rarely, sometimes, often, and always felt worried about adverse reactions, respectively. Regarding the usefulness of IBD nursing service for disease education, medication education, and scheduling of an outpatient clinic, approximately 10.9% to 12.5% of patients felt useful, and 78.1% felt very useful. Our study showed a higher adherence rate and lower worries about adverse reactions, which may be the effects of IBD nursing service at our institution.

A 48-year-old man with melena was admitted to our hospital for 1 month. The patient denied any history of systemic disease, and had no history of cirrhosis, esophageal varices or thrombocytopenia. He sometimes drinks but did not achieve the criteria of alcoholism (≥20 g daily). Upper endoscopy revealed an ulcerative mass in the gastric body. The patient underwent endoscopic biopsy (Figure 1A). Computed tomography (CT) revealed tumors in the bilateral hepatic lobes without vascular invasion or extra-hepatic metastasis; and the left-lobe tumor directly invaded the stomach (Figure 1B). Laboratory tests showed 5 g/dL hemoglobin, 599 × 10³/μL platelet count, and 2839.04 IU/mL alpha-fetoprotein levels. Hepatitis B surface antigen, HBV DNA and antibodies to hepatitis C virus were negative. Anti-hepatitis B core antibody IgG was positive. Pathological examination of the gastric tumor revealed metastatic HCC (Figure 1C). Immunohistochemical analysis of the tumor tissue showed negative expression for CK7, CK20, and CDX-2, but positive expression for hepatocyte paraffin-1 (Hep par-1) (Figure 1D) and glypican-3 (GPC-3). After the confirmation of metastatic HCC, he received transarterial chemoembolization and lenvatinib therapy but died several months later owing to tumor progression.

The most common extrahepatic metastatic sites are the lungs, bones, and lymph nodes. In contrast, HCC metastases to the gastrointestinal (GI) tract are rare, and the mortality rate is high. After diagnosis of GI metastases, the average remaining lifespan is approximately 7.3 months.¹ Sohn et al. reported the earliest case of HCC metastasis to the GI tract in 1965. The tumor was approximately of 6 cm, and located in the left hepatic lobe with portal vein invasion, and metastasized to the esophagus.² Shiota et al. reported the first case of HCC with stomach invasion in which the tumor was located in both the right and left hepatic lobe.³

A systematic review published by Urhut et al. in 2022 included 192 patients, 87.3% of whom were male.¹ According to the report, the most common GI tract metastases were in the stomach (27.9%) and duodenum (27.9%). Most routes of metastasis were direct invasion and hematogenous metastasis. Therefore, risk factors for HCC with GI tract metastases included growth mode, tumor size, tumor localization, and portal vein invasion. Because of their close anatomical location, tumors located on the right side of the liver are more likely to invade the duodenum, whereas tumors located on the left side of the liver are more likely to invade the stomach.¹ Symptoms of HCC with GI invasion include GI bleeding, anemia, abdominal pain, palpable masses, nausea, and vomiting. Esophagogastroduodenoscopy and abdominal contrast-CT are the most useful diagnostic tools. Histological evidence can help diagnose HCC with GI invasio

Consistent high-quality of papers published in Advances in Digestive Medicine (AIDM) can only be maintained with the cooperation and dedication of a number of expert referees. The Editors would like to thank all those who have donated the hours necessary to review, evaluate and comment on manuscripts; their conscientious efforts have enabled the journal to maintain its tradition of excellence. We are grateful to the following reviewers for their contributions during 2023.

Chang, Chen-Wang

Chang, Chi-Yang

Chang, Li-Chun

Chen, Chieh-Chang

Chen, Chiung-Yu

Chen, Jiann-Hwa

Cheng, Hao-Tsai

Cheng, Pin-Nan

Chien, Hsi-Yuan

Chien, Shih-Chieh

Chiu, Yi-Chun

Chou, Chu-Kuang

Chou, Jen-Wei

Chu, Yin-Yi

Chuah, Seng-Kee

Chung, Chen-Shuan

Hsieh, Yu-Hsi

Hsu, Chao-Wen

Hsu, Chen-Ming

Hsu, Ping-I

Huang, Chung-Feng

Huang, Tien-Yu

Huang, Yi-Hsiang

Hung, Chao-Hung

Hung, Chih-Sheng

Kao, Wei-Yu

Lai, Hsueh-Chou

Le, Puo-Hsien

Lee, I-Cheng

Lee, Pei-Chang

Lee, Teng-Yu

Liang, Chih-Ming

Liao, Szu-Chia

Lin, Chih-Wen

Lin, Ching-Pin

Lin, Yu-Min

Liou, Jyh-Ming

Liu, Chun-Jen

Lu, Po-Wen

Ng, Zi Qin

Peng, Cheng-Yuan

Su, Chien-Wei

Sun, Meng-Shun

Tai, Chi-Ming

Tai, Wei-Chen

Tsai, Tzung-Jiun

Tseng, Cheng-Hao

Tseng, Kuo-Chih

Tseng, Ping-Huei

Tseng, Tai-Chung

Tsou, Yung-Kuan

Tu, Chia-Hung

Wang, Yen-Po

Wong, Ming-Wun

Yang, Hung-Chih

Yang, Sheng-Shun

Yen, Hsu-Heng

Colorectal endoscopic submucosal dissection (ESD) is a highly effective technique for resecting early colorectal neoplasms, and it has now gained recognition as the standard of care.^{1, 2} ESD has demonstrated remarkable success in achieving higher en bloc resection rates, with substantial evidence of its efficacy in Japan and Western countries.^{3, 4} Despite its proven effectiveness, concerns have arisen regarding the relatively higher incidence of perforation during colorectal ESD, particularly within the Taiwanese context. Conducting a comprehensive investigation into the specific risk factors for perforation during ESD procedures in Taiwan to better understand the challenges is crucial.

Yang et al. conducted this retrospective analysis of 161 cases, seeking to provide valuable insights into the management and prevention of ESD-associated perforation within the Taiwanese population.⁵ The study encompassed 161 patients who underwent colorectal ESD at a tertiary medical center in Taiwan between January 2014 and December 2019. Clinical risk factors for perforation during ESD were rigorously analyzed, including age, gender, tumor morphology, tumor size, tumor location, procedure duration, en bloc resection rate, histology, and the presence of submucosal fibrosis. Notably, the study revealed an impressive overall en bloc resection rate of 98.1%. Nevertheless, perforations were observed in 19.3% of the cases, affecting 31 out of the 161 patients. Importantly, it is worth highlighting that all perforations were effectively managed through endoscopic closure using hemoclips and nonsurgical approaches without the necessity for emergency surgery. Furthermore, multivariate analysis identified two independent risk factors for perforation during colorectal ESD. Severe submucosal fibrosis significantly increased the odds of perforation (odds ratio [OR] 3.06; 95% confidence interval [CI]: 1.23–7.59; P = .016), and the location of the lesion in the right colon demonstrated a higher risk of perforation (OR 4.54; 95% CI: 1.31–15.79; P = .017).⁵ In conclusion, this study provides important insights into the risk factors associated with perforation during colorectal ESD. Encouragingly, despite a relatively higher incidence of perforation, all patients in this study experienced favorable outcomes without the need for surgical intervention. The study demonstrates that colorectal ESD in Taiwan is an effective treatment with low rates of major complications.

In recent years, endoscopists in Taiwan have introduced several techniques to enhance colorectal ESD, a historically considered challenging, time-consuming, and high-risk procedure. These new techniques have brought renewed hope and improved outcomes to ESD procedures. First, Chang et al. have developed the Diving, Lifting, and Horizontal dissection technique with the loop–clip traction method,

Recurrence of reflux symptoms following discontinuing proton pump inhibitor therapy is a common problem in the treatment of gastroesophageal reflux disease. We aim (1) to examine the cumulative 12-week incidence of symptom relapse following 8-week proton pump inhibitor therapy in patients with Los Angeles grade A/B erosive esophagitis and (2) to search the risk factors predicting symptom relapse in the treatment of erosive esophagitis. From June 2010 to May 2019, patients with Los Angeles Grade A/B erosive esophagitis receiving esomeprazole therapy (40 mg qd) for 8 weeks followed by complete symptom resolution were included in this study. Subjects received on-demand esomeprazole treatment for 12 weeks and underwent prospective follow-up for reflux symptoms. 12-week cumulative incidence of symptom relapse was assessed, and predictive risk factors for symptom relapse were determined by multivariate analysis. 219 patients with Los Angeles Grade A/B erosive esophagitis who achieved complete symptom resolution following 8-week esomeprazole therapy were enrolled. During the 12-week follow-up period, 110 patients (50.2%) developed symptom relapse. Univariate analysis showed that symptom relapse was significantly associated with advanced age, smoking, and the presence of heartburn (p = .003, .015, and .042, respectively). Multivariate analysis with stepwise logistic regression showed that only advanced age (95% confidence interval [CI]: 1.45–5.15) and smoking (95% CI: 1.30–6.58) were independent factors predicting symptom relapse with odds ratios of 2.74 and 2.92, respectively. The 12-week cumulative incidence of symptom relapse following initial proton pump inhibitor treatment in patients with Los Angeles grade A/B erosive esophagitis is 50.2%. Advanced age and smoking are independent risk factors predicting symptom relapse following treatment in patients with mild erosive esophagitis.

A 75-year-old male was referred for investigation of a painless, erythematous umbilical nodule that had been increasing in size for several months. The lesion was 2.5 cm in diameter, with an irregular border and superficial ulceration (Figure 1A). He had a recent admission for cholangitis secondary to choledocholithiasis but was otherwise feeling well. His past medical history was significant for ischemic heart disease with cardiac stents, and alcohol-related cirrhosis with portal hypertension. Given concern for a primary gastrointestinal malignancy, he proceeded to endoscopy. This demonstrated two small (10–15 mm), superficial antral ulcers (Figure 1B). These were confirmed on biopsy to be poorly differentiated gastric adenocarcinoma. Staging CT chest, abdomen, and pelvis did not show any distant metastases (Figure 2A). A diagnostic laparoscopy was performed and excluded peritoneal disease. The umbilical nodule was excised to assist with staging. Unexpectedly, histology showed that the umbilical nodule was a metastasis from prostate adenocarcinoma. This was confirmed on the immunohistochemistry staining which showed tumor cell expression with prostate-specific antigen and prostate-specific acid phosphatase.

PET (68 PSMA-11) imaging (Figure 2B) confirmed metastatic prostate cancer with disease in mediastinal lymph nodes, axial skeleton, and left lung. His case was discussed in the multidisciplinary meeting. Due to his frailty and co-morbidities, he underwent endoscopic submucosal dissection of the gastric adenocarcinoma. The histopathology showed two foci of poorly differentiated gastric adenocarcinoma (9 and 12 mm) invading the muscularis mucosae (pT1a). There was no lymphovascular invasion and the margins (lateral and deep) were negative. The metastatic prostate cancer was treated with palliative radiotherapy to deposits in T11 and L4, as well as androgen deprivation therapy. Further systemic therapy was not administered due to his co-morbidities. His disease is stable, and the patient continues to live independently 18 months later.

Sister Mary Joseph nodule represents a cutaneous metastasis, most commonly from the gastrointestinal tract. It is uncommon finding, occurring in up to 3% of abdominal and pelvic malignancies.¹ It is extremely rare for prostate cancer to cause a Sister Mary Joseph nodule, with only a few cases reported.² Appearance is variable and clinicians should demonstrate a high index of suspicion to avoid misdiagnosis.^{1, 2} Histological sampling is vital as identification of the primary tumor may be difficult, as demonstrated by this case. Accurate disease staging is necessary for appropriate treatment.

Zi Qin Ng: Study design, data collection and analysis, drafting of manuscript. Adrian Teo: Performed the surgery, and Review of the manuscript. Tim Mitchell: Data collection and analysis, critical review of manuscrip

To investigate the time-trend and endoscopic-pathological characteristics of early-onset gastric carcinoma (EOGC) in Vietnamese patients. All patients who underwent upper gastrointestinal endoscopy at a tertiary hospital during the 2014–2019 period and had pathologically confirmed gastric carcinoma were retrospectively recruited. The demographic data and endoscopic and pathological findings from all patients were recorded and analyzed to compare the EOGC group (i.e., ≤40 years of age) with the older group (>40 years of age). Out of 1668 patients with gastric carcinoma, 151 (9.1%) patients were with EOGC. The time-trend change in the EOGC rate was insignificant during the investigated period (p = .972). The median age of patients with EOGC was 35 (IQR, 32–38). Compared with the older group, EOGC was more likely to present with a female predominance (52.3% vs. 30.7%, p < .001), endoscopically located at the gastric body (34.4% vs. 19.2%, p < .001), presented with a diffuse infiltrative appearance (18.9% vs. 11.7%, p = .011) but were less likely to have superficial gastric cancer morphology (0.0% vs. 4.5%, p = .009). Pathologically, it was more likely to have diffuse type (36.4% vs. 23.9%, p = .001) and poor differentiation (90.6% vs. 62.7%, p < .001). EOGC in Vietnamese individuals is not rare, and its incidence has not significantly changed during the studying period. The majority of EOGC was poorly differentiated carcinoma. This study reported the different endoscopic distribution and appearance of EOGC from gastric carcinoma in older patients requiring attention during endoscopic examination.

The aim of this study was to assess the diagnostic yield and outcomes of intraoperative enteroscopy (IOE) in patients with overt small bowel bleeding in the era of balloon-assisted enteroscopy and capsule endoscopy. We retrospectively reviewed the medical records of patients with small bowel bleeding who underwent IOE from January 2005 to April 2016 in a tertiary medical center. A total of 18 patients with overt small bowel bleeding who underwent a total 18 IOE procedures were included. The mean amount of blood transfusion was 35.7 units (SD, 21.4 units), and 11 patients had hypovolemic shock. The diagnostic yield of the IOE procedures was 94.4% (17/18). The most common pathologic diagnosis was ulcer. The rebleeding rate was 44.4% (8/18), and the overall survival rate was 61.1% (11/18). IOE remains a valuable tool for diagnosing overt small bowel bleeding. The usage of IOE might potentially be limited due to critical clinical conditions in the era of deep enteroscopy. A specific caution should be taken in performing IOE due to the high morbidity of the procedure.

A 50-year-old male presented with sudden onset of upper abdominal pain. He had no infectious or other gastrointestinal symptoms. He had a background of hypertension, hypercholesterolemia and was a heavy smoker. Biochemistry results showed raised white cell count of 28 × 10⁹/L, elevated creatinine of 130 μmol/L, and venous lactate of 4.7 mmol/L.

Computed tomography (CT) of the abdomen demonstrated a hematoma contained within the lesser sac (Figure 1A). Computed tomography angiography (CTA) revealed an abrupt cutoff of the first branch of superior mesenteric artery (SMA) at the site of hemorrhage suggesting dissection with a distal nonocclusive thrombus (Figures 1B and 2). It was possible that the SMA dissection led to the hematoma within the lesser sac and had tamponade itself. Therefore, there was no active hemorrhage on the subsequent CTA. Given that he was hemodynamically stable with no signs of peritonism, he was managed nonoperatively. He was commenced on lifelong antiplatelet therapy. He had a follow-up CTA which was unremarkable. He remained clinically well.

Patients with isolated superior mesenteric artery dissection (ISMAD) are at risk of intestinal ischemia. Patients usually present with intractable abdominal pain. Other symptoms include diarrhea, nausea, and vomiting. Risk factors for ISMAD include atherosclerotic disease, hypertension, and abdominal aortic aneurysm.¹ CTA is the gold standard for diagnosis. Other imaging modalities include ultrasound and magnetic resonance angiography.²

The management of ISMAD consists of initial resuscitation. Patients with no signs of hemodynamic instability or peritonism can be managed nonoperatively.³ Anticoagulation is the mainstay of nonoperative management. A systematic review and meta-analysis reported that the majority of patients were commenced on anticoagulation therapy.⁴ Antiplatelet therapy has also been used in stable ISMAD patients with success.⁵

Operative management options include surgical or endovascular revascularization. Bypass grafting is the most common surgical procedure. Other surgical methods include thrombectomy or ligation of a branch of SMA.⁴

In conclusion, ISMAD is a rare cause of abdominal pain and prompt treatment is vital due to the risk of intestinal ischemia.

The authors declare no conflicts of interest.

According to the Institutional Review Board (IRB), there is no need for IRB approval for an image review article. A written informed consent was obtained from the patient before starting and the authors followed the principles outlined in the WMA Declaration of Helsinki throughout the writing process.

Hepatitis C virus (HCV) is both hepatotropic and lymphotropic in human bodies. Its cytopathic nature leads to a wide category of extrahepatic manifestations. The kidney is one of the target organs/systems that HCV involves. A poor renal function in chronic hepatitis C (CHC) patients may be due to immune complex depositions that causes glomerular or tubulointerstitial injuries. Increasing comorbidities than the general population, such as diabetes, may further compromise renal function. An early interferon-based cohort study in Taiwan has shown that antiviral treatment, regardless of successful viral eradication, may decrease the risk of end-stage renal disease (ESRD).¹ It raised the hope for possible halting or reversal of the deteriorated renal function in CHC patients.

In the current issue by Su et al.,² the authors discussed the short-term change in estimated glomerular filtration rate (eGFR) in CHC patients who were treated with sofosbuvir/velpatasivir. One of the rationality raised by the authors is the safety concern of sofosbuvir-based regimens in patients with chronic kidney disease stage 4 or 5 because of the concern of the overt accumulation and delayed excretion of the metabolite, GS-331007. We now clearly know that its use is very safe in patients whose eGFR was less than 30 mL/min/1.73 m² after the approval of the FDA in 2019. Among ESRD patients, GS-331007 was smoothly removed by regular hemodialysis, which was never detected throughout 1 month to 1 year after the end of sofosbuvir/velpatasivir treatment.³

The authors did not show the overall eGFR change after directly acting antivirals (DAAs) therapy. Rather, they observed an improvement of eGFR in patients with baseline eGFR ≤60 mL/min/1.73 m² but a decreased eGFR in patients with baseline eGFR >60 mL/min/1.73 m². This contradictory result was difficult to explain but have been reported in previous studies.^{4, 5} It should be noted that the MDRD equation may improperly judge a healthy subject with a high eGFR level.⁶ Moreover, a transient decrease in eGFR in patients with extremely high baseline levels shortly after DAA may not indicate deterioration of renal function. As eGFR declines with aging, age per se would be the confounder for the comparison of eGFR change. An ideal way is to compare the slope of coefficient difference of eGFR change between comparators.^{4, 7, 8} Recently, Liu et al. have shown a steeper slope of eGFR decline in patients who failed antiviral therapy compared with those who achieved a sustained virological response (SVR).⁹ Due to the lack of a control group (untreated or treatment failure patients) in the DAA era, another way is to observe the short-term dynamic change in eGFR immediately before and after DAA treatment as in this study. To eluci