Anticoagulant-induced intramural intestinal hematoma: report of three cases and literature review.

Spontaneous intestinal hematoma is a rare complication of anticoagulant therapy. The authors reported three cases of intramural and submucosal small bowel hematoma resulting from warfarin administration. The first patient presented with abdominal pain, had intramural hematoma at jejunum, the most common site of intramural small bowel hematoma. Another patient who had submucosal duodenal hematoma presented with massive upper gastrointestinal bleeding, a rare manifestation of small bowel hematoma. The third patient presented with intramural ileal hematoma that caused abdominal pain and palpable mass after a short period of warfarin therapy. Typical findings on abdominal computerized tomography yielded the diagnosis. All patients rapidly improved after conservative treatment. The history of anticoagulant use with prolonged INR value in patients presented with abdominal pain should alert physicians to search for this entity. It is extremely important to recognize this syndrome in order to avoid an unnecessary operation since the outcome is usually excellent after conservative treatment.

Incidence of Helicobacter pylori recurrent infection and associated factors in Thailand.

OBJECTIVE: To determine the incidence of H. pylori recurrent infection after successful eradication in 4-year follow-up study, and to evaluate the influencing factors for re-infection. MATERIAL AND METHOD: Thirty-seven patients (age range 20-74 years; average 49.06 +/- 14.03 years) were recruited of which 64.9% were females. The H. pylori infection was proved to be successfully eradicated in all patients. Annually, urea breath test (UBT) was assessed to determine H. pylori status after eradication. Age, sex, eating habit, water drinking, number of children, and treatment regimens against H. pylori were recorded A breath test was also performed on the patient's spouse. RESULTS: The H. pylori recurrence occurred in 5/37 (13.51%) of patients observed There were two patients in the first year, one patient each in the second, third, and fourth year The cumulative re-infection rate was 5.41% at 1-year 8.11% at 2-year 10.81% at 3-year and 13.51% at 4-year H. pylori infection of spouse was also frequent (80%). Even if the spouse was infected, 88.89% of patients will remain uninfected after 4-years of H. pylori eradication. No influencing factor for infection recurrence was detected. CONCLUSIONS: The risk of re-infection after H. pylori eradication was low in Thai patients after 4-year follow up. Annual re-infection rate was 3.38%. No dependent factors were associated with a recurrence.

Efficacy of clarithromycin-based triple therapy for treating Helicobacter pylori in Thai non-ulcer dyspeptic patients with clarithromycin-resistant strains.

BACKGROUND: Antibiotic resistance of H. pylori is problematic because it reduces the efficacy of eradication therapy. The objective of the present study was to assess the eradication rates of triple therapy against clarithromycin-sensitive and clarithromycin-resistant strains of H. pylori in Thai non-ulcer dyspeptic patients. MATERIAL AND METHOD: Patients who underwent upper gastrointestinal endoscopy at King Chulalongkorn Memorial Hospital between September 2002 and December 2003 were included. The patients who had positive urease test and culture were enrolled for antimicrobial resistance. Isolates were considered resistant when the MIC was more than 1 mcg/ml for clarithromycin. The patients received a combination of pantoprazole 40 mg BID, clarithromycin MR 1 gm OD, and amoxicillin 1 gm BID, for 7 days. Urea [14C] breath test was performed for evaluation of H. pylori eradication at least 1 month after treatment. RESULTS: Of the 470 patients, H. pylori were identified by positive rapid urease test in 282 patients (69.0%). Of these, cultures for H. pylori were achieved in 113 patients (54.6%) and E-tests for clarithromycin were successfully placed in 69 isolations. There were 29 males and 40 females, mean age was 38.7 +/- 13.3 years. Primary H. pylori resistance to clarithromycin was observed in 16 of 69 patients (23.2%). The eradication rates were 90.6% (48/53) and 56.3% (9/16) in patients with clarithromycin sensitive and clarithromycin resistant H. pylori strains, respectively (p = 0.002). CONCLUSION: The authors reported a high rate of clarithromycin resistant H.pylori isolates in Thailand. Pretreatment resistance to clarithromycin has a significant impact on treatment failure with clarithromycin-based regimen.

Lack of effect of Helicobacter pylori on symptom improvement with a prokinetic medication, cisapride, in patients with non-ulcer dyspepsia.

OBJECTIVE: This study was undertaken to determine whether H. pylori infection has an effect on the improvement of dyspeptic symptoms in response to a prokinetic agent, cisapride, in patients with non-ulcer dyspepsia (NUD). MATERIAL AND METHOD: 35 NUD patients (16 M, 19 F) who had no underlying medical condition and negative upper endoscopy were included in the present study. Each patient received a 2-wk treatment of cisapride (Prepulsid, 10 mg, tid ac). H. pylori infection was determined using a rapid urease test (CLO test). Gastric emptying (GE) scintigraphy and dyspeptic symptom scores were evaluated before and at the end of the treatment. GE was evaluated in 22 healthy volunteers as normal controls. RESULTS: Half time (T1/2) GE of NUD patients was 90.9 +/- 28 min which was significantly longer than controls (77.6 +/- 14 min; p < 0.05) and was shortened to 73.6 +/- 22 min (p < 0.0001) at the end of the treatment. Cisapride significantly improved total dyspeptic symptom scores [7 (2-18) to 3 (0-11), p < 0.0001]. The symptom score improvement was not affected by H. pylori infection [H. pylori positive: 6 (2-18) to 2.5 (0-9), p < 0.0001; H. pylori negative: 9 (4-16) to 3 (0-11), p < 0.0001] or GE status [delayed GE: 10 (5-16) to 3 (15), p < 0.05; non delayed GE: 6 (2-18) to 2 (0-11); p < 0.0001]. CONCLUSIONS: Cisapride improves dyspeptic symptoms regardless of H. pylori and GE status. These results suggest that gastric emptying and H. pylori infection are not essential to determine prior to prescribing a prokinetic agent, cisapride, in patients with NUD.

Experience on endoscopic retrograde cholangiopancreatography at tertiary referral center in Thailand: risks and complications.

BACKGROUND: Several complications from ERCP have been described, including pancreatitis, hemorrhage, perforation, and cholangitis. The actual incidences and risk factors in Thailand have never been analyzed. MATERIAL AND METHOD: The authors retrospectively reviewed the outcome of ERCP at Chulalongkorn University Hospital between September 2000 and December 2002. Potential risk factors were statistically assessed. RESULTS: The incidence of post-ERCP pancreatitis, hemorrhage, perforation and cholangitis was 3.6%, 2.1%, 1.2% and 6%, respectively. Risk factors of pancreatitis were the suspected diagnosis of sphincter of Oddi dysfunction and pancreatic interventions, especially through minor papilla. Prophylactic pancreatic duct stent prior to precut sphincterotomy may reduce the incidence of pancreatitis. Hemorrhage was associated with duodenal diverticulum. The incidence of cholangitis was higher in biliary duct dilation and cholangiocarcinoma, especially hilar involvement. CONCLUSION: Incidence of these complications was comparable to international series with similar risk factors. Cholangitis developed more frequently probably due to a higher incidence of cholangiocarcinoma.

Gastrointestinal and hepatobiliary manifestations in systemic lupus erythematosus.

OBJECTIVE: To report GI and Hepatobiliary manifestations in SLE from Chulalongkorn Hospital in the year 2000. MATERIAL AND METHOD: A retrospective study of SLE patients in the Rheumatological Clinic, Medical Department, Chulalongkorn University. RESULTS: A total 225 SLE patients were found being mainly female (93.3%). The mean age was 32.13 +/- 11.65 years and they almost all lived in the central part of Thailand (79.1%). At diagnosis, the majority of SLE cases are active vital organ (72.1%), kidney and central nervous system are the main organ of involvement. GI and hepatobiliary manifestations were found in 32.89% but did not lead to SLE diagnosis. The duration between SLE diagnosis and first GI and hepatobiliary manifestations is 4.6 +/- 4.4 years. The 3 common manifestations are abnormal liver function test, diarrhea and abdominal pain, with the prevalance rate of 34, 17 and 11% respectively. CONCLUSION: GI and hepatobiliary manifestations of SLE patients in Chulalongkorn Hospital were found in 32.89% but were not specific and could be found in any part of the alimentary tract. The 3 common manifestations were abnormal liver function tests, diarrhea and abdominal pain which were not specific enough to diagnose SLE.

The prevalence of nonalcoholic steatohepatitis in Thai patients with non-HBV, non-HCV chronic hepatitis.

This study aimed to determine the prevalence of nonalcoholic steatohepatitis in Thai patients with non-HBV, non-HCVchronic hepatitis. The clinical and laboratory findings associated with non alcoholic steatohepatitis were discussed. Forty-six patients with negative markers for viral hepatitis B and viral hepatitis C and no history of alcohol consumption or consumption less than 20 grams of ethanol per day were recruited. The informed consent for liver biopsy and blood collecting to identify the etiology of chronic hepatitis was performed. Most patients (76.1%) exhibited fatty metamorphosis of the liver which included steatosis (21.8%) as well as steatohepatitis (54.3%). Eleven of 46 patients (23.9%) were classified as cryptogenic chronic hepatitis. There were statistically significant differences between the fatty metamorphosis group and the cryptogenic chronic hepatitis group with regard to the fasting blood sugar, serum alkaline phosphatase, serum ferritin and histologically necroinflammatory grading score (p < 0.05). Between the steatosis group and the steatohe-patitis group, body mass index (BMI) was the only factor showing statistically significant difference (p = 0.02). Eight from 25 NASH-patients had diabetes mellitus (32.0%) and the AST to ALT ratio in this group was 0.6. The histopathological assessment for inflammation and fibrosis by using Knodell score, the fibrosis score which equal or higher than 3 was found in 20.0% of NASH-patients. CONCLUSION: The prevalence of NASH-patients in Thai patients, with non HBV, non HCV chronic hepatitis was 76.1%, while the liver biopsy can add the diagnostic yield especially in the group of unexplained chronic hepatitis with obesity, diabetes mellitus and dyslipidemia.

Clinical indications of patients with colorectal neoplasm who underwent colonoscopy at King Chulalongkorn Memorial Hospital (presentations of colorectal neoplasm from colonoscopy database).

Even though colorectal cancer in Thailand is not the number one leading cause of death, the incidence of this malignancy is not ignorable. Unfortunately, the majority of patients are diagnosed at a very late stage because of no screening protocol for a high risk group. The authors retrospectively reviewed clinical presentations of patients with colorectal neoplasm who underwent colonoscopy at King Chulalongkorn Memorial Hospital during the two-year period from September 2000 to December 2002. There were 107 patients with colorectal polyps and 48 patients with colorectal cancer. According to frequency of indications: anemia, bowel habit change, and abnormal radiography were presented in patients with colorectal polyps and cancers. There were more right sided colorectal polyps than rectosigmoid polyps. In addition, rectosigmoid cancer was detected less often than right sided colonic cancer. Half of the patients with rectosigmoid cancer presented with hematochezia compared to right sided colonic cancer. Total colonic examination is required if a colonic neoplasm is suspected.

Results of emergency gastroscopy for acute upper gastrointestinal bleeding outside official hours at King Chulalongkorn Memorial Hospital.

This study was to evaluate the epidemiological characteristics, etiology and therapeutic outcome of active upper gastrointestinal bleeding in patients who underwent emergency gastroscopy outside official hours at the Gastroenterology Unit, King Chulalongkorn Memorial Hospital. From January to December 2002, 103 emergency gastroscopies were performed in 99 patients. There were 66 men and 33 women (mean age 55.4 years, range 22-98 years). Causes of bleeding were esophageal varices (29/99; 29.3%), gastric ulcer (25/99; 25.3%), duodenal ulcer (9/99; 9.1%), gastric varices (9/99; 9.1%) and miscellaneous (12/99; 12.1%). Etiology of bleeding was uncertain in 10.1 per cent of the cases. Therapeutic modalities for variceal bleeding were banding (78.6%), sclerotherapy (10.7%) and glue injection (10.7%). Endoscopic therapies for patients with non variceal bleeding were: epinephrine injection with bipolar coaptation (48.1%), epinephrine injection only (11.1%), bipolar coaptation alone (7.4%), heater probe (7.4%), epinephrine injection combined with heater probe (11.1%), epinephrine injection with bipolar coaptation and hemoclipping (7.4%), hemoclipping (3.7%), epinephrine injection with hemoclipping (3.7%). Initial hemostasis was achieved in 91.2 per cent of the patients (91/99). Recurrent bleeding within 72 hours developed in 9.1 per cent of patients (9/99). Of these, eight patients (88.9%) underwent re-endoscopy and bleeding was stopped in 62.5 per cent (5/8). And 2.0 per cent of patients (2/99) had to go for emergency surgery after failed therapeutic endoscopy. Overall mortality was 15.2 per cent (15/99). In conclusion, emergency gastroscopy can offer not only diagnostic but also therapeutic modality for patients with acute upper gastrointestinal bleeding. Endoscopic therapy is effective for both initial hemostasis and recurrent bleeding.

Result of orthotopic liver transplantation at King Chulalongkorn Memorial Hospital: the first series from Thailand.

Liver transplantation is one of the best treatments for advanced liver disease since it can prolong the patient's survival. In Thailand, the first liver transplantation was performed in 1987 at King Chulalongkorn Memorial Hospital. Up till now the authors have transplanted the most in Thailand, having done more than 30 cases. From 1997 to 2002, there were 20 cases of liver transplantation and this is the result presented. The authors classified the patients into 2 groups, according to primary indications for transplantation. Patients with cirrhosis were included in group I and patients with hepatocellular carcinoma were included in group II. The one year survival in group I and II was 64 per cent and 29 per cent respectively. Mortality rate in the cirrhotic group was high during the first 3 months post transplant. The reason for a high mortality rate in the hepatocellular carcinoma group may be secondary to the advanced stage of cancer and the poor condition of the patients. However, the acute rejection rate in the present series of 25 per cent is relatively low compared to other series and this may need further study. The one year survival rate in patients who received a new liver from 1997 to 1999 compared to 2000-2002 was 33 per cent and 54 per cent respectively. This showed an improvement in the result of liver transplantation in Thailand. In conclusion, this report showed a satisfactory result of liver transplantation. The main problem with liver transplantation in Thailand is that potential donors do not understand the problems which leads to few donors. There is also a shortage of skilled personnel, budget, and the appropriate instruments.

Pattern of drug resistant Helicobacter pylori in dyspeptic patients in Thailand.

Emergence of drug resistant Helicobacter pylori (H. pylori) has occurred in various countries and could compromise the efficacy of current treatment regimens. The aim of the study was to identify the pattern of antibiotic resistant H. pylori in Thailand and evaluate various factors associated with drug resistance. Between June 2001 and December 2002, a total of 560 dyspeptic patients who underwent upper gastrointestinal endoscopy at King Chulalongkorn Memorial Hospital were included in this study. Antral gastric biopsies were obtained for H. pylori cultures and susceptibility tests using Epsilometer test (E-test). The value of antibiotic resistant breakpoints were amoxicillin 0.5 microg/ml, clarithromycin 1.0 microg/ml, metronidazole 8 microg/ml, and tetracycline 4 microg/ml, respectively. H. pylori were detected in 315 patients using the rapid urease test (56.25%). Cultures for H. pylori were positive in 172 patients. E-test for all four antibiotics was successfully placed in 79 isolations. The prevalence of antibiotic resistant H. pylori were amoxicillin 13.9 per cent (11/79), clarithromycin 19.0 per cent (15/79), metronidazole 30.4 per cent (24/79), tetracycline 5.1 per cent (4/79), and multi-drugs 16.5 per cent (13/79), respectively. However, age, sex, or endoscopic findings did not differ between the patients with H. pylori resistant strains and sensitive strains. The emergence of antibiotic and multi-drug resistant H. pylori in Thailand were relatively high and these could compromise the efficacy of current treatment regimens. The factors associated with drug resistant H. pylori could not be demonstrated in the present study. Further study in a larger number of patients might be necessary to identify factors associated with resistant H. pylori.