Advances in Digestive Medicine最新文献

A 33-year-old male presented with a 14-day history of anal pain, mucus discharge and the sensation of incomplete evacuation after defecation. The patient's past medical history was significant for HIV infection, for which he was under treatment with elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate (Stilbild®) daily. In addition, the patient was referred for unprotected anal intercourse 5 weeks prior to the onset of the symptoms.

The physical exam was significant for a perianal ulcer (Figure 1). On anoscopy of the anal canal, there was extensive inflammation of the anal mucosa. A three-dimensional (3D) endoanal ultrasound was also performed and did not show any evidence of any anal or perianal abscess. Bilateral inguinal lymph nodes were not enlarged. Furthermore, an anal ulcer swab was taken. Both Treponema pallidum hemagglutination assay (TPHA; index 15.4, positive: >1.1) and Venereal Disease Research Laboratory test (VDRL) were positive. The sample was processed with the use of polymerase chain reaction (PCR), which identified a Treponema pallidum infection. Primary perianal syphilis is often presented as a solitary, firm red papulae on the genital area which may progress to an ulcer with a well-defined margin and an indurated base. Patient received benzathine penicillin G 2.4 × 10⁶ units in one intramuscular injection. The lesion was resolved within 5 weeks.

Worldwide, syphilis is considered a re-emerging public health problem.¹ Symptoms, such as anal pain, pus at the anal canal, signs of systematic involvement, and tenesmus should make clinicians suspicious of an anal sexually transmitted infection (STI). Men who have sex with men (MSM) have usually more sexual partners than heterosexual men, while they tend to have more simultaneous partners.² Moreover, in the last decades, HIV is no longer perceived to be a fatal disease, due to the fact that antiretroviral therapy suppresses effectively, there is a decrease on the use of condoms.² In addition, the administration of pre-exposure prophylaxis (PrEP) encourages unprotected intercourse among HIV-uninfected individuals (with low prevalence of syphilis), increasing the risk of contracting syphilis from people living with HIV (with a higher prevalence of syphilis).²

The differential diagnosis of a perianal ulcer also includes perianal tuberculosis (Tb). Perianal Tb is a rare form of extrapulmonary tuberculosis and can be the initial manifestation of Tb.³ Both Ziehl-Neelsen staining and culture, in addition to histopathological examination, are essential for achieving the correct diagnosis and to start the appropriate treatment.

Herpes simplex virus (HSV) infection should also be considered in the presence of perianal lesions.⁴ HSV type 2 is the most common cause of genital and perianal ulce

This 49-year-old male, a victim of chronic hepatitis B-related liver cirrhosis, visited our emergency department due to hematemesis and tarry stool passage. Hypovolemic shock and severe anemia (Hb 4.8 mg/dL) were noted on arrival. After fluid resuscitation and blood transfusion, urgent esophagogastroduodenoscopy revealed no varices in the esophagus and cardiac portion of the stomach; however, some blood was retained at the proximal duodenum. After the scope was pushed down to the distal 2nd portion of the duodenum, convoluted tumorous lesions (Figure 1) with an erosion were noticed distal to ampulla vater. First, what is your diagnosis? Second, what will be your next step?

Ectopic duodenal varices at the second portion were diagnosed by endoscopy. It was confirmed by computed tomography (Figure 2), which revealed enhanced engorged vessels at the wall of second portion duodenum. The bleeding episode was successfully controlled by endoscopic injection sclerotherapy with histoacryl glue and somatostatin intravenous infusion.

Ectopic varices are defined as dilated portosystemic collateral veins located in unusual sites other than the gastroesophageal region and constitute 1% to 5% of all variceal bleeds.¹ These lesions could locate in different sites, including the duodenum, small bowel, rectum, anastomotic site, and stoma with high interobserver variability in their distribution.² In a large study of 173 patients from Japan, Watanabe et al.³ mentioned that the duodenum (32.9%) is the second most common site, and 82.5% of them are located in descending part. Currently, there are no clear guidelines on the management of ectopic varices. Endoscopic treatment, including endoscopic injection sclerotherapy and endoscopic variceal ligation, was the most frequent modality for acute duodenal variceal bleeding, and interventional radiology therapy such as transjugular intrahepatic portosystemic shunt or surgery could be used as rescue therapy. The successful rate of endoscopic treatment alone for acute duodenal variceal bleeding is 73.3%. However, 53.3% patients experience rebleeding within 1 year.⁴

Each author contributed to the manuscript. Wei-Chih Su: Conceptualization, Writing—original draft. Chia-Chi Wang: Conceptualization, Writing—review & editing, Jiann-Hwa Chen: Supervision, Writing—review & editing.

The authors declare no conflicts of interest.

The case report was approved by the Institutional Review Board (11-CR-105) of Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation.

A 41-year-old man presented with intermittent epigastric fullness for several weeks. Mild hyperbilirubinemia was incidentally discovered when he was young, but he was not further examined. For a few weeks, the patient felt right upper quadrant (RUQ) fullness, which was exacerbated after meals. The physical examination indicated mild RUQ tenderness without Murphy's sign. Hepatitis and jaundice were noted. Computed tomography of the abdomen revealed biliary tract dilatation at the distal common bile duct (Figure 1A). Endoscopic retrograde cholangiopancreatography (ERCP) revealed a bulging lesion at the roof of the major duodenal papilla, which first protruded and then flattened and sunken (Figure 1B,C).

What is the diagnosis?

Choledochocele was diagnosed by cholangiogram (Figure 2A) and an endoscopic sphincterotomy (Figure 2B) was performed. Choledochal cyst is a rare congenital biliary cystic disease whose etiology is still unknown. The choledochocele is characterized by cystic dilatation at the pancreaticobiliary junction and protrusion to the duodenum and is subdivided into Types A and B by Sarris and Tsang in 1989.¹ Type A choledochocele is cystic dilatation of bile duct in ampulla and is located proximal to orifice of ampulla. Type B choledochocele is located distal to orifice of ampulla and is diverticula of common channel in ampulla. The duodenal duplication cyst was congenital malformations, which was mimic as choledochocele. Endoscopic ultrasonography or abdominal magnetic resonance cholangiopancreatography can help to distinguish duodenal duplication cyst from a choledochocele. In choledochocele, cholangiogram showed contrast medium accumulation in the bulge at the end of the common bile duct, which may not be present in a duplication cyst.² ERCP is used for the management of cholangitis, obstructive jaundice, or biliary malignancy.

Complete excision of the cyst is the standard treatment. Surgical procedures are chosen according to subtype and endoscopic sphincterotomy or transduodenal complete cyst excision is used for choledochocele management. After the choledochal cyst is removed, the remnant biliary tract may still develop a malignancy. The incidence of remaining biliary malignant transformation after cyst excision was 4.3%, and malignant tumors of the intrahepatic, hilar, or extrahepatic bile duct may occur over time.³

The authors declare no conflicts of interest.

The study participant provided informed consent and this report was approved by the Institutional Review Board of China Medical University Hospital at Taichung (No. CMUH111-REC1-136).

Nonalcoholic fatty liver disease (NAFLD) is the most common liver disease affecting one-fourth population globally. It is also anticipated to be the major cause of liver-related morbidity and transplantation worldwide in the future decades.¹ Of note the Asia-Pacific has a tremendous burden because of the rapid Westernization of the region and the racial characteristics.^2-4 Currently, NAFLD represents a clinical field possessing several unmet needs. The major one is currently no reliable biomarker for disease severity, disease course, or outcome measurement. Therefore, a reliable and confident biomarker for the purposes deserves exploration. The effort  is no doubt more challenging than for viral hepatitis infection.

Cheng et al. presented the study results of the correlation of Mac-2 binding protein glycosylation isomer (M2BPGi) serum level with the other documented noninvasive biomarkers or panels in a single-center retrospective NAFLD database.⁵ M2BPGi has been vigorously studied as a marker for fibrosis in chronic hepatitis B virus infection, chronic hepatitis C virus infection, nonalcoholic steatohepatitis, and even hepatocellular carcinoma.^6-9 The cross-sectional study measured the serum levels of the recently-identified glycosylation isoform of Mac-2 binding protein in both NAFLD and healthy controls. The results showed that the serum levels of M2BPGi were significantly correlated with the levels of AST to platelet ratio index, fibrosis 4 score (FIB-4), and NAFLD fibrosis score, respectively. The M2BPGi levels were significantly higher in females and had an incremental increase with age in both NAFLD patients and the healthy controls. In addition, the M2BPGi level was significantly higher in those intermediate or high risk for advanced fibrosis (defined as FIB-4 level ≥ 1.45) than their low-risk counterparts (FIB-4 level < 1.45). The results thus provided a piece of work addressing the noninvasive fibrosis assessment for the complex metabolic liver disorder.

Generally, the degree of liver fibrosis is the major determinant and the significant predictor of long-term outcomes in patients with NAFLD. There is a higher risk of mortality associated with a higher stage of fibrosis in NAFLD.^{10, 11} Moreover, the risk of liver-related mortality increased on an exponential rather than linear scale with an increase in fibrosis stage.¹² Liver biopsy remains an expensive and invasive procedure associated with potential complications, sampling error, and interobserver variability. Besides imaging- and elastography-based methods, several serum-based panels have been developed for the noninvasive approach to disease severity. Recently, the easy-to-access FIB-4 method has been validated in providing an accurate prediction of liver fibrosis and liver-related events. The algorithm has been adapted by

Colorectal cancer (CRC) ranks as the third most common cancer worldwide and the second leading cause of cancer-related deaths.¹ Timely CRC screening has been proven to reduce both CRC mortality and incidence.^2-4 Colonoscopy, a critical component of both stool-based and scope-based screening approaches, has a vital role in detecting and removing either cancerous or precancerous neoplasms. By doing so, it helps shield individuals from advanced CRC. Nonetheless, it is important to recognize that the protection offered by colonoscopy is not perfect. Post-colonoscopy CRC may still develop in some cases, highlighting the need for ongoing improvements in colonoscopy quality and adherence to screening guidelines.^{5, 6}

An audit on the quality of colonoscopy is a valuable practice that can help guarantee the effectiveness and safety of the procedure. Key quality indicators for colonoscopy include adequate bowel preparation, cecal intubation rate, withdrawal time, and adenoma detection rate. By assessing and monitoring key quality indicators, medical professionals can identify areas for improvement, implement necessary changes, and ensure that patients receive the highest standard of care during colonoscopy procedures.^{7, 8}

High-quality bowel preparation plays a crucial role in ensuring optimal outcomes during colonoscopy procedures. Inadequate bowel preparation is associated with lower rates of detecting neoplastic polyps, higher rates of incomplete procedures, and the need for more frequent repeat procedures. It is concerning that previous studies have indicated that up to 25% of colonoscopies have inadequate bowel preparation. This highlights the importance of conducting evaluations to assess the quality of bowel preparation and identify areas for improvement.⁹

Diet restriction and the use of appropriate cleansing agents are key steps in achieving optimal bowel preparation for colonoscopy. Low-residue diet (LRD) and clear liquid diet (CLD) are commonly used for bowel preparation. LRD allows the consumption of select low-fiber foods while excluding high-fiber foods, whereas CLD limits intake to clear liquids only. A meta-analysis of nine randomized controlled trials (RCTs) compared the two diets and found that LRD was associated with higher patient satisfaction, better tolerance, and more frequent consumption of bowel laxatives. However, there were no significant differences in terms of adequate bowel preparation or adenoma detection rate between the two groups.¹⁰ While the majority of academic societies recommend LRD for bowel preparation,^{9, 11} the decision between LRD and CLD should be based on individual needs and made in consultation with healthcare professionals.

The duration of diet restriction can pose challenges to bowel preparation as it may require signifi

Hepatocellular carcinoma (HCC) is the sixth most prevalent cancer in the world.¹ Hepatitis B virus (HBV) or hepatitis C virus (HCV) infection are the major causes of HCC in Taiwan.² Among the current available treatment modalities, transarterial chemoembolization (TACE) is recommended for patients with the Barcelona Clinics Liver Cancer (BCLC) stage B HCC, which include patients who have Child-Pugh grade A or B liver functional reserve and have large, multifocal tumors, but without extra-hepatic spread, vascular invasion, nor cancer-related symptoms.³ Nevertheless, the application of TACE is not limited to BCLC stage B HCC in the clinical practice.⁴ Hence, the outcomes of patients with HCC who undergo TACE are quite diverse due to the heterogenous demographic characteristics, tumor burden, as well as liver functional reserve. It has been reported that the overall survival (OS) of patients with HCC after TACE varied from 2.5 years up to 4 years in the different studies with different inclusion criteria.⁵

However, TACE is regarded as a non-curative treatment modality for HCC.⁶ Tumor progression or recurrence after TACE are common and several courses of TACE might be needed to achieve a better tumor control.⁷ Nevertheless, each TACE procedure not only induces extensive tumor necrosis but also causes deterioration of liver function. Consequently, HCC patients who have an underlying impaired liver function or clinically significant portal hypertension bear a higher risk of developing liver failure or mortality after TACE.^{4, 8} Moreover, Sieghart et al. proposed an Assessment for Retreatment with TACE (ART) score which enrolled an increase of serum aspartate aminotransferase (AST) level >25%, an increase of Child-Pugh score from baseline, and absence of radiological response after the initial TACE treatment, could predict the prognoses of HCC patients after the second course of TACE.⁹ Adhoute and colleagues further constructed an ABCR score which was composed of BCLC stage and serum alpha-fetoprotein levels at baseline, change in Child-Pugh score from baseline, and the radiological response after the initial course of TACE.¹⁰ In this study, HCC patients who had an ABCR score ≥4 prior to the second TACE had a median OS of only 4.6 months in the training cohort and 7.5 months in the validation cohort, respectively, if they underwent subsequent TACE treatment. Taken together, it indicates that ongoing hepatic necroinflammation and the deterioration of liver functional reserve after TACE is critical in determining the outcomes of HCC patients. Patients who have impaired liver function after initial TACE are not recommended to undergo further TACE.

Stronger Neo-Minophagen C (SNMC; Minophagen Pharmaceutica

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.