Advances in Digestive Medicine最新文献

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).

Melanosis coli, a dark brown discoloration of the colonic mucosa, is associated with chronic use of anthraquinone laxatives (senna). In addition, Aloe Vera¹ and Rhubarb,² used in traditional alternative medicine in Taiwan, are also implicated as the causes of melanosis coli. The term “melanosis,” however, may be misleading, since the pigment responsible for the discoloration is not the deposition of melanin but of lipofuscin in macrophages in the colonic lamina propria. Anthroquinone laxatives induce apoptosis of colon epithelium cells, which are ingested by adjacent macrophages within the mucosa. Those macrophages migrate to the lamina propria and convert the apoptotic cells into lipofuscin with lysozyme. Interestingly, adenomas have impaired absorption of apoptotic debris into the macrophages³ and thus stand out in the dark mucosa of the melanosis coli as a “pigmentation sparring sign.”

Whether melanosis coli increases the risk of colon adenoma and adenocarcinoma is controversial. An early prospective case-control study by Siegers et al suggested anthraquinone laxative abuse was associated with a relative risk of 3.04 (95% confidence interval [CI]: 1.18–4.90) for colorectal cancer.⁴ Most recent case-control studies, however, showed that melanosis coli was associated with increased detection of adenomas but not adenocarcinomas. Kassim et al found that patients with melanosis coli were more likely to have both hyperplastic polyp and low-grade adenoma, but not adenocarcinoma.⁵ Liu et al found that melanosis coli was associated with higher detection rates of low-grade adenoma (odds ratio [OR] = 1.54; 95% CI: 1.06–2.23; P < .05) but similar detection of high-grade adenomas or adenocarcinomas.⁶ Blackett et al showed patients with melanosis were more likely to have an adenoma ≤5 mm (OR = 1.62; 95% CI: 1.04–2.51; P = .03) but not adenomas 6 to 9 mm or ≥10 mm.⁷ Abu Baker et al even reported that melanosis coli was associated with less diagnosis of adenocarcinoma than controls (0.3% vs 3.9%; P < .001).⁸ Katsumata et al conducted a case-control study in Japan and performed a meta-analysis of five studies at the same time. They concluded that although hyperplastic polyps and adenomas were more frequently detected in patients with melanosis coli, the risk of colorectal cancer was not increased.⁹

There are two plausible explanations for the association between melanosis coli and increased detection of adenomas: either melanosis coli promotes the development of adenoma or it facilitates the detection of adenoma. The lack of association between melanosis coli and adenocarcinoma lends support to the latter assumption, as, in accordance with the theory of the colorectal adenoma-carcinoma sequence, increased d

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 2022.

Chang, Chen-Wang

Chang, Li-Chun

Chang, Tien-En

Chang, Wei-Yuan

Chen, Chieh-Chang

Chen, Chiung-Yu

Chen, Jiann-Hwa

Chen, Kuan-Chih

Chen, Peng-Jen

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Kawamura, Junichiro

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Tsou, Yung-Kuan

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Wu, Keng-Liang

Wu, Pei-Shan

Yadegar, Abbas

Yang, Hung-Chih

Yang, Tsung-Chieh

Yen, Hsu-Heng

Yu, Ming-Lung

A 61-year-old woman with underlying disease of hypertension, type II diabetes mellitus, and newly diagnosed lung adenocarcinoma visited our outpatient department because of general fatigue with body weight loss for 2 months. Panendoscopy for anemia showed a patch-like lesion at the great curvature of the middle body (Figure 1A, arrows). Using narrow band image, there was no significant irregular vascularity, but with clear demarcation of the lesion (Figure 1B, arrows).

What is your impression for this patient?

1.  Gastric cancer

2.  Gastric intestinal stromal tumor

3.  Gastric metastasis

4.  Erosive gastritis

Pathology of tissue biopsy revealed gastric mucosa infiltrated by angulated atypical glands composed of cells with large and hyperchromatic nuclei (Figure 2A, arrow). The immunohistochemical stain demonstrated strong positive for cytokeratin (CK), cytokeratin 7 (CK7) and thyroid transcription factor-1 (TTF-1) (Figure 2B), and negative for cytomegalovirus (CMV), and cytokeratin 20 (CK20). It was diagnosed to be a lung cancer with gastric metastasis.

The incidence of lung cancer is the highest in the global world.¹ However, the gastrointestinal metastasis with mucosal invasion is rare, and has extremely variable morphology. Therefore, a cauliflower-like patch should be a differential diagnosis of gastric metastasis.

The authors declare no conflicts of interest.

The study complies with current ethical considerations, and an informed consent was signed by the patient.