Advances in Digestive Medicine最新文献

This study aimed to compare the effect of long-term continuous entecavir (ETV) compared with tenofovir disoproxil fumarate (TDF) on the reduction of hepatocellular carcinoma (HCC) development in patients with chronic hepatitis B (CHB) related liver cirrhosis. This study recruited patients who had CHB-related liver cirrhosis and received ETV or TDF treatment for more than 6 months. Regular assessments of ultrasonography and alpha-fetoprotein test were arranged every 3 months for HCC detection. Five-year cumulative incidence of HCC and risk factors for HCC development were analyzed. A total of 286 consecutive cirrhotic patients were included, 198 in the ETV group and 88 in the TDF group. During a median follow-up of 57.5 months, 25 (12.6%) patients in the ETV group and 12 (13.6%) patients in the TDF group developed HCC. The 5-year cumulative incidence of HCC was comparable between the ETV and TDF groups (6.57% vs. 9.09%, log-rank p = .242). Multivariate Cox proportional hazard analysis revealed that male, old age, diabetes, and low platelet count were independent risk factors for HCC development. This study observed that long-term ETV or TDF provided comparable preventive effects on HCC development in patients with CHB-related liver cirrhosis.

A 54-year-old lady was hospitalized for pericardial tamponade. An urgent pericardial drainage was performed. She was also noted to have acute kidney injury complicated by severe hyperkalemia of 7.0 mmol/L. The hyperkalemia was corrected with multiple doses of oral sodium polystyrene sulfonate (SPS) as well as a combination of intravenous insulin and dextrose injection, followed by 48 h of continuous renal replacement therapy. After 10 days, she developed fresh rectal bleeding with mild tachycardia. After stabilizing the patient including blood products transfusion, bidirectional gastrointestinal endoscopy was performed. The upper gastrointestinal endoscopy was unremarkable.

Colonoscopy revealed numerous necrotic ulcers involving the cecum (Figure 1A), and clean-based ulcers in the sigmoid colon (Figure 1B). The rest of the colon mucosa was normal. Histology of the colonic biopsies showed fragments of polygonal basophilic crystals with mosaic pattern at the ulcer base (Figure 2A). Colon ischemia was an important differential diagnosis; however, the finding of some of these crystals being surrounded by granulation tissue and inflammatory infiltrate (Figure 2B) supported the diagnosis of SPS-induced colon injury. Pseudomembranous colitis, viral inclusions, crypt distortion, crypt abscess, or granuloma were not seen, making other differential diagnoses, such as infective colitis with ulcers and inflammatory bowel disease, not likely.

SPS is a commonly used cation exchange resin in the management of hyperkalemia. In a large population-level matched cohort study, SPS was found to be associated with higher risk of serious adverse gastrointestinal events.¹ SPS-related adverse gastrointestinal event such as ulcer, necrosis, or perforation, although uncommon, can occur to any segment of the gastrointestinal tract, with colon being the most common site. Irrespective of the location of the injury in the gastrointestinal tract, the mortality rate remained high and was found to be 20.7% in a systemic review.²

The diagnosis of SPS-induced gastrointestinal injury can be accurately made when there is a history of SPS exposure with temporal relationship to the symptom onset, together with histological evidence of SPS crystals in the biopsy sample. Risk factors include chronic kidney disease, uremia, solid organ transplantation and immunosuppressive therapy, postoperative status, hypotension, ileus, and opioid use.³ Clinicians ought to exercise prudence in prescribing SPS, especially in patients who are critically ill with multiple risk factors. In such cases, newer gastrointestinal potassium binder like sodium zirconium cyclosilicate will likely be a safer option.

The authors declare no conflicts of interest.

Informed consent was obtained. Ethics committee approval is not necessary locally as this is a simple case report. Nonetheless, the principles outlined in

Endoscopic polypectomy has become standard in the management of most polyps in the gastrointestinal tract, but bleeding is the most common adverse event. Polypectomy with a cold snare (CSP) has been increasingly utilized in recent years, but further evidence is required to establish its safety of gastric polypectomy. The aim of this study was to compare intraprocedure and postprocedure adverse events in patients who underwent CSP vs conventional hot snare polypectomy (HSP) of gastric polyps. Electronic medical records and endoscopy reports of all patients who underwent gastric polypectomy at the Kaohsiung Chang Gung Memorial Hospital between January 2019 and June 2021 were retrospectively reviewed. Data on patient demographics, polyp characteristics, method of polypectomy, and adverse events were collected. A total of 193 gastric polyps removed from 111 patients were reviewed. The mean age was 58.1 years, and 74.8% were female. Of these, 142 polyps were removed from 78 patients by HSP, compared to 51 polyps removed from 33 patients by CSP. The mean polyp size was 7.9 mm in the HSP group and 7.5 mm in the CSP group (P = .306). Nine patients (11.5%) from HSP group and 5 (15.2%) from CSP group presented with immediate bleeding that were managed by endoscopic treatment (P = .755). There was no serious adverse event, such as delayed bleeding or perforation, occurred in this study. In multivariate logistic regression, only the number of polyps resected >1 was identified as independent risk factor of immediate post-polypectomy bleeding. Therefore, the safety of CSP was non-inferior to HSP and could be an additional option for removal of gastric polyps ≤10 mm.

A 69-year-old woman presented to the emergency department with melena for 3 days. She has a medical history of hepatitis B virus-related cirrhosis. The esophagogastroduodenoscopy showed a gastric varix, GOV-2, with an ulcer on its surface. Histoacryl injection was attempted, but massive bleeding ensued just as the needle touched it. Five milliliters of a 1:1 mixture of N-butyl-2-cyanoacrylate and lipiodol were injected into the varix (1 mm per injection, at the same site). The patient was then transferred to the intensive care unit.

Shortness of breath with frequent dry cough developed 1 day later. The patient was slightly tachycardic at 97 beats per minute, tachypneic at 27 times per minute, and normotensive at 132/54 mmHg, with SpO₂ of 98%. Physical examination showed bilateral clear breath sounds. Laboratory investigations showed a hemoglobin level of 7.1 g/dL, platelet count of 15 × 10³/μL, and D-dimer of 1285.4 ng/ml. Arterial blood gas analysis showed pH 7.436, pCO₂ 34.9 mmHg, pO₂ 120.6 mmHg (under O₂ nasal cannula 3 L/min), and bicarbonate 23.8 mEq/L. The chest X-ray showed branching opacities over left hilum (Figure 1).

What is the diagnosis?

Non-contrast chest computerized tomography showed hyperdense material in the left pulmonary branches (Figure 2), and the diagnosis of acute pulmonary embolism after histoacryl injection was made. The patient was under mechanical ventilation support for total 18 days, with only supportive treatment during this period. She was discharged smoothly without any oxygen support.

Histoacryl injection therapy is effective for the gastric varices. The overall complication rate ranged from 0.5% to 5%,¹ and pulmonary embolism is an unusual but potentially life-threatening one,² especially in patients with large varices requiring large volumes of sclerosant.³ Other contributory factors include the rate of injection and ratio of the constituent components of the sclerosant.³ Although a leak through an arteriovenous pulmonary shunt or an open foramen ovale had been proposed,⁴ there was no such abnormality in our case. Hyperdense segments of the pulmonary arteries with respect to the surrounding vessels are the image features on chest X-ray (the so-called “vascular cast sign”), and a confirmatory non-contrast computerized tomography will be more suitable than a contrasted one in detecting the radio-opaque lipiodol.⁵ All endoscopists should keep this rare complication in mind, and timely recognition—if it occurs, unfortunately—relies on the physician's timely awareness.

The authors declare no conflicts of interest.

According to the institutional review board (IRB), there is no need of IRB approval for an image article in our hospital. A written informed consent was obtained before st

To investigate the impact of early HBV DNA suppression after receiving entecavir (ETV) on treatment response in hepatitis B e antigen (HBeAg) positive chronic hepatitis B (CHB) patients. A total of 140 baseline HBV DNA-matched HBeAg-positive patients receiving ETV were enrolled. Of those 70 patients achieved early virological response at week 24 (VR24 group) and the remaining 70 patients failed to achieve VR24 (non-VR24 group). Factors of serological and virological outcomes were analyzed. Patients with pretherapy alanine aminotransferase (ALT) levels over five times upper limit of normal had a higher HBeAg seroclearance rate (P = .038). The VR24 group had the higher ratio of HBeAg seroclearance and maintained viral suppression within 96 and 144 weeks, respectively (53% and 75%, respectively). The cumulative rates of virological breakthrough (VBT) in the VR24 group and non-VR24 group were 0% and 5.71%, 3.2% and 11.83%, 3.2% and 17.24%, 3.2% and 17.24%, and 3.2% and 21.84% from week 48 to 240, every 48 weeks, respectively (P = .006). In the multivariate analysis, undetectable HBV DNA and age at week 24 were associated with VBT (P = .02 and .006, respectively). Pretherapy ALT levels predicted a higher probability of HBeAg seroclearance. VR24 could be associated with HBeAg seroclearance and maintained viral suppression during therapy. Detectable HBV DNA at week 24 and older age could be predictive factors with an occurrence of VBT in HBeAg-positive CHB patients treated with ETV.

Cholelithiasis is a disease with increasing prevalence over the decades. Gallbladder drainage (GBD) is an alternative choice in critically ill patients who cannot tolerate early surgery for acute cholecystitis. In previous data, early or delayed cholecystectomy (CCY) leads to less recurrent biliary events (RBEs) comparing to using a wait-and-see strategy. We wondered if a subsequent CCY strategy after GBD can benefit patients with high surgical risk. This study aimed to explore the clinical outcome after percutaneous transhepatic GBD and risk factors for RBEs. We studied 180 adult acute cholecystitis patients who received percutaneous transhepatic GBD during index admission between July 2017 and December 2018 in Chung Shan Medical University Hospital and Changhua Christian Hospital after exclusion of patients died during the index admission or lost follow-up within 30 days. We further divided these patients into those who received subsequent CCY within 2 months and those who received no CCY within 2 months. RBEs, mortality, and biliary event-related mortality were compared. Multivariate analysis was applied to find the most important factors of RBE-free survival. There were 8 cases (13.6%) in the subsequent CCY group that experienced recurrent biliary events, whereas 39 cases (32.2%) experienced recurrent biliary events in the no CCY within 2 months group. The proportion and average recurrent biliary events per person were all significantly lower in the subsequent CCY group. Although the overall mortality rate was higher in the group that had no CCY within 2 months (16.5% vs 5.1%), the RBE-related mortality difference was insignificant. The most decisive factor to determine RBE-free survival is whether there was a subsequent CCY or not (HR: 0.485, 95% CI: 0.250-0.941, P = .032). We found that subsequent CCY can decrease further RBEs and improve RBE-free survival in high-risk patients with acute cholecystitis that accepted percutaneous transhepatic GBD initially.

The esophageal hypervigilance and anxiety scale (EHAS) is a valuable cognitive-affective evaluation of visceral sensitivity, which has been demonstrated to associate with gastroesophageal reflux disease (GERD) symptom severity and psychological stress. We aimed to obtain the values for EHAS in the setting of patients who underwent esophagogastroduodenoscopy (EGD) without GERD symptoms and investigate potential clinical factors contributing level of EHAS in symptomatic patients. Patients scheduled EGD with or without GERD symptoms were prospectively enrolled for assessing patient-reported outcomes, including EHAS and GERD questionnaire (GERDQ). Patients without GERD symptoms had GERDQ ≤8 were classified as controls. Potential factors influencing the level of EHAS were identified via generalized linear model. We enrolled 534 patients, aged 20 to 84 years (mean, 52.78), of whom 54.2% were female; 110 had GERD symptoms, and 418 were controls. Patients with GERD symptoms had higher EHAS levels than controls (28.7 vs 10.2, P < .001). On generalized linear model GERDQ scores and female gender positively correlated with EHAS (GERDQ, β = 2.254, P < .001; female, β = 3.828, P = .001). In summary, our study suggests that greater esophageal hypervigilance and anxiety are associated with reflux symptoms burden across the spectrum of GERD, and correlate with female gender too.

Leptomeningeal carcinomatosis (LMC) is a rare but devastating complication of advanced cancer. The reported incidence may be underestimated because of the non-specific clinical presentation and the suboptimal accuracy of the confirmation tests. Despite advances in multidisciplinary care, the prognosis for patients with LMC remains poor. Gastric cancer (GC) ranking 9th in incidence among all kinds of malignancies in Taiwan. We aimed to review our experience with LMC in GC patients at a tertiary referral center to analyze the clinical features and survival outcomes. All patients with a malignant diagnosis of cerebrospinal fluid (CSF) cytology at the National Taiwan University Hospital were reviewed from January 2002 to December 2018. The survival analysis was calculated by the Kaplan-Meier method. Univariate and multivariate Cox proportional hazards regression analysis were used to identify factors associated with survival. We identified 18 patients with a diagnosis of GC-related LMC. LMC occurred in approximately 0.45% of GC patients during this period. Nine (50%) were male, and the median age was 58.5 years old. The most frequent neurological symptom of these patients was altered mental status (72.2%), followed by headache (44.4%) and nausea/vomiting (44.4%). Intracranial hypertension was noted in 87.5% with the mean opening pressure to be 385.3 mmCSF. Intrathecal (IT) chemotherapy was administered to nine patients, principally with methotrexate alone (55.6%). Fourteen patients received CSF drainage by ventriculo-peritoneal shunt or external ventricular drainage via Ommaya reservoir for relieving intracranial hypertension. In the univariate Cox proportional hazards regression analysis, the poor ECOG performance status (>2), absence of other metastases, and absence of CSF drainage were all prognostic factors of poor survival. In conclusion, LMC was a rare manifestation of GC and was associated with an extremely poor survival when the performance status was poor at presentation. CSF drainage may have some impact on the survival duration in selected cases with LMC.

A 56-year-old man with a history of diabetes mellitus poorly controlled recently (HbA1c: 7.5%, <6%) presented with a 3-month history of postprandial epigastric pain, 10-kg weight loss, steatorrhea, tea-colored urine, and clay-colored stool. Physical examination revealed yellowish skin and icteric sclera but no peripheral stigmata of cirrhosis. Laboratory investigation was significant for elevated aspartate aminotransferase (289 IU/L, 8-31 IU/L), alanine aminotransferase (613 IU/L, 0-41 IU/L), alkaline phosphatase (595 U/L, 34-104 U/L), γ-glutamyl transferase (758 U/L, 0-26 U/L), total and direct bilirubin (8.0/6.1 mg/dL, 0.3-1/0.03-0.18 mg/dL), and carbohydrate antigen 19-9 (289 U/mL, <37 U/mL). Contrast-enhanced computed tomography revealed diffuse enlargement of the pancreas (arrow) and dilatation of the common bile duct (CBD) without identifiable stone or a mass lesion (arrowhead; Figure 1A). Endoscopic ultrasound (EUS) demonstrated hyperechoic foci and strands in the enlarged pancreas (arrow) and layer-by-layer whole wall thickening with a hyper-hypo-hyperechoic series (sandwich pattern) of CBD (arrowhead) as well as gallbladder (star; Figure 1B). Magnetic resonance cholangiopancreatography (MRCP) showed dilated CBD with distal tapering near the pancreatic head (arrow; Figure 1C). The diagnosis of autoimmune pancreatitis was confirmed by serologic immunoglobulin G4 (IgG 4) elevation (IgG 4: 2880 mg/dL, 3-201 mg/dL) and favored type I according to nonductal Level 1/Level 2 criteria of international consensus diagnostic criteria.¹ The patient recovered from jaundice and gained weight after treatment of prednisone 40 mg/d for 4 weeks, then taper by 5 mg/wk. The 8-week follow-up EUS demonstrated normalization of pancreatic size (arrow) and CBD morphology (arrowhead; Figure 2).² Autoimmune pancreatitis mimicking pancreatic cancer is a rare cause of obstructive jaundice with an estimated incidence of 1 per 100 000.³ In summary, we demonstrated a case of autoimmune pancreatitis diagnosed by complement image study and elevating serum IgG 4, which achieved successful medical treatment of obstructive jaundice without further invasive procedures.¹

The authors declare no conflicts of interest.

This report was approved by the Research Ethical Committee of Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation (No. CR111-08).