In memory of Vikit Viranuvatti, father of Thai gastroenterology.

Vikit Viranuvatti was a pioneer of modern medicine and the virtual father of gastroenterology in Thailand. His achievements, especially in tropical liver diseases, were recognized worldwide. He published more than 219 articles and several international book chapters dealing with liver cancer, amoebiasis, hepatic abscess, hepatitis as well as topics in medical education.

Effect of botulinum toxin injection for achalasia in Thai patients.

BACKGROUND: Achalasia is a disorder of the esophagus. The lower esophageal sphincter fails to relax and increases the loss of body peristalsis. It is an uncommon disease worldwide. Data regarding its treatment are derived mostly from North America and European countries. Few data regarding this treatment were available in Asia and no data about using botulinum toxin injection for this disease was available in Thailand. OBJECTIVE: To evaluate the efficacy of botulinum toxin in achalasia in Thai patients. MATERIAL AND METHOD: Eleven achalasia adult Thai patients with a mean age of 56.5 +/- 16.9 were studied. There are nine females and two males. The duration of symptom before treatment was 27.5 +/- 34.5 months. All patients receiving botulinum toxin injection at Siriraj hospital between 2001 and 2006 were retrospectively reviewed. Pretreatment of baseline lower esophageal sphincter, symptom score and body weight were compared. Time to second botulinum toxin injection or the need to receive treatment for recurrence was recorded to evaluate the time of recurrence. Adverse events from this procedure were collected. RESULTS: Eleven patients were involved in this study. One patient that received 40 units of botulinum toxin showed no response after a six months follow up. The other ten patients received botulinum toxin 80 units for each session and were enrolled in this study. All ten patients demonstrated good response to the first botulinum toxin injection and subsequent injections. Four patients received only one session of botulinum toxin injection during study period. Meanwhile, five patients received two sessions and only one patient required four sessions. Symptom score of all ten patients improved significantly compared with pretreatment score (7.3 +/- 1.3 for pretreatment and 0.4 +/- 0.5, 0.9 +/- 0.7 and 1.6 +/- 1.3 after 2 weeks, 3 months and 6 months, respectively). Body weight increased significantly when compared with pretreatment (47.7 +/- 6.5 Kg for pretreatment and 49.2 +/- 5.8, 50.5 +/- 6.4, and 50.7 +/- 5.8 Kg after 2 weeks, 3 months, and 6 months, respectively). Previous treatments prior botulinum toxin injection do not seem to influence the effect of this treatment. Mean time of recurrence is 444 +/- 132 days (270-718 days). Minor adverse events such as chest pain and reflux symptoms were seen in this therapy. CONCLUSION: Botulinum toxin injection in Thai achalasia patients is an effective, simple, and safe treatment. These results showed the similar outcomes as in Caucasian patients.

Blastocystis hominis infection in irritable bowel syndrome patients.

Irritable bowel syndrome (IBS) is a functional bowel disorder in which abdominal pain is associated with a defect or a change in bowel habits. Subtle inflammation, especially after infectious enteritis, has been sometimes suspected as one mechanism of pathogenesis. This research was performed (1) to evaluate the prevalence of parasitic infections and (2) the possible association of IBS and parasitic infections. Fifty-nine IBS patients were recruited using symptom-based criteria (Rome Criteria II) with an absence of intestinal parasitic infection by direct smear method. Stool samples of individual patients were examined using 7 methods, ie examination for stool occult blood, simple saline smear method, formalin-ether technique, culture for Blastocystis hominis, modified trichrome stain, modified Ziehl-Neelsen method, and trichrome stain for parasitic and bacterial infections. Of the 59 patients, stool samples of 13 patients (22.1%) were positive for parasites. These were B. hominis (13.6%), Strongyloides stercoralis larvae (1.7%), Giardia lamblia cysts (1.7%), and non-pathogenic protozoa, ie Endolimax nana cysts (5.1%). The prevalence rate of parasitic infections in the control group (20%) was not statistically different from the patients. There was no statistical difference between B. hominis infection in IBS patients and control was found in this study (p = 0.87). In the IBS group, B. hominis infection predominated (13.6%), while other parasitic infections were found in 8.5%. The culture method for B. hominis is more sensitive than the direct (simple) stool smear method, which is the routine diagnostic method in most laboratories. These results were also found in control group.

Predictive factors for synchronous common bile duct stone in patients with symptomatic cholelithiasis.

BACKGROUND: Laparoscopic cholecystectomy (LC) has become the treatment of choice for patients with symptomatic cholelithiasis. About 8-15 per cent of patients with symptomatic gallstones may bear associated common bile duct (CBD) stones, The management of choledocholithiasis in the laparoscopic era remain debatable. Although pre-operative endoscopic cholangiopancreatography (ERCP) is available and highly accurate in the detection of CBD stones, its routine use is controversial because of its inherent disadvantages. OBJECTIVE: The aim of this retrospective study was to generate an effective predictive model for bile duct stones detection by pre-operative ERCP. METHOD: Twelve pre-operative clinical, biochemical and sonographic variables from 206 consecutive patients who underwent pre-operative ERCP with LC for gallstones with/without CBD stones from October 1998 to December 2000 were retrospectively analysed RESULTS: 143 of the 206 patients with gallstones were found to have CBD stones. The mean age was 61 (20-93) yr old, and 55.9 per cent were female. Multivariate analysis showed a high predictive value for the presence of CBD stones in patients aged > or = 55 yr old (Odd radio (OR) 1.03, 95% confidence interval (95% CI) 1.01-1.05), jaundice (OR 2.7, 95% CI 1.7-4.8), elevated alkaline phosphatase (OR 1.002, 95% CI 1.000-1.005), CBD dilatation on ultrasound (OR 3.8, 95% CI 1.8-8) and CBD stone on ultrasound. CONCLUSION: The important clinical presentations and investigating could allow more appropriate use of pre-operative ERCP in patients who have symptomatic gallstones with a suspected CBD stone prior to cholecystectomy.

Pancreolauryl test in patients with chronic pancreatitis.

Pancreolauryl test was studied in 17 subjects; four were normal, eleven were patients with chronic pancreatitis, and two were subjects with other gastrointestinal disorders. The pancreolauryl test was performed in urine and serum. Patients with chronic pancreatitis who had positive stool fat had a positive pancreolauryl test at 100% in both urine and serum, while those with negative stool fat had positive results of pancreolauryl test at 28.57% in urine and 60% in serum. However, the test gave 75% positive results in normal serum, but it was 100% negative in urine. Therefore, the cut off point for pancreolauryl test at 4.5 ตg/ml may not be suitable for Thai patients. The false positive of this test in serum may be caused by hemolysis. Pancreolauryl test in urine may be useful to help in diagnosing chronic pancreatitis in which morphological abnormality cannot be found.

Intestinal parasitic infections in HIV and non-HIV infected patients with chronic diarrhea in Thailand.

Chronic diarrhea is a common problem in AIDS patients, and enteric parasites are re-cognized as important causes. This study determined the prevalence of parasitic infections in HIV infected patients with chronic diarrhea. Ninety-one patients with AIDS who presented with chronic diarrhea and 103 patients who were HIV negative were enrolled in the study. Detection of stool parasites was made by microscopy of simple smear, formalin-ether concentration method, modified acid-fast and modified trichrome staining techniques. Species identification of microsporidia spores was made by transmission electron microscopy (TEM). Cases in which serial fecal examinations were negative were subjected to gastroduodenoscopy and/or colonoscopy. Parasitic infections were found in 51 (56%) AIDS patients with chronic diarrhea and in 18 (17%) non-HIV cases (p < 0.001). Microsporidia and Cryptosporidium parvum were the most common parasites found in HIV infected patients and were also significantly more prevalent than in non-HIV infected cases [29% vs 0% for microsporidia, (p < 0.001), and 25% vs 1% for C. parvum, (p < 0.001)]. Species identification of microsporidia spores in 26 patients using TEM revealed Enterocytozoon bieneusi in 19 cases. This study indicated that microsporidia and C. parvum are important pathogenic causes of chronic diarrhea in AIDS patients in Thailand.

Causes and clinical courses of chronic diarrhoea in Siriraj Hospital.

Background : Chronic diarrhoea remains a major gastroenterological problem in Thailand Data regarding investigation, diagnosis and treatment of chronic diarrhoea varies from one country to another. Socio-economic status including sanitation and hygiene may also affect etiology and the clinical course of disease. There data may be misleading for practitioners facing the problem in Thailand. To date, few studies on chronic diarrhoea in Thailand are available. Objectives : To find the causes and clinical courses of chronic diarrhoea. To determine the frequency of various causes. Finally, to see if simple guidelines can be developed to help investigators in Thailand reach a final diagnosis. Methods : Thirty-four in-patients with chronic diarrhoea at Siriraj Hospital were worked up using a systematic scheme for evaluation of chronic diarrhoea by prospective study. Close follow-ups were monitored for an average period of six months. Results : Among the 34 cases, a definite diagnosis was reached in 21 cases (62%) : parasitic infestation seven cases (33%), carcinoma of colon four cases (19%), lymphoma there cases (14%), radiation proctitis two cases (9%), malabsorption and/or maldigestion two cases (9%), tuberculous peritonitis one cases (5%) hyperthyroidism one case (5%) and villous adenoma one case (5%). Conclusion : Our study suggests that a simple investigation using complete blood count, stool examination, and especially concentration methods and sigmoidoscopy in all patients can usually find in up to 38 per cent, while further investigations can detect causes in up to 62 per cent. Of the 13 patients for whom no definite diagnosis was reached, spontaneous remission of chronic diarrhoea was found in four cases (31%).

Efficacy of colloidal bismuth subcitrate vs. cimetidine for treatment of helicobacter pylori positive non-ulcer dyspepsia.

We report an open trial study to determine the role of Helicobacter pylori (HP) in patients with non-ulcer dyspepsia (NUD) and to determine the effect of two drugs (colloidal bismuth subcitrate, CBS and cimetidine) on HP. Our study consisted of 48 patients, 30 received CBS two tablets twice daily and 18 received cimetidine 400 mg twice daily. The result of HP suppression detected by rapid urease test was 66.7% and 86.7% for CBS group after receiving the drug for 4 and 8 weeks respectively, for cimetidine only 11.1% urease test negative during the same period. Follow up urease test 19.2% of patients treated by CBS remained negative but none in the cimetidine group. AII patients felt better during treatment irrespective to status of HP. Our conclusion is that there is no correlation between HP status and NUD symptoms. To evaluate this relationship, further study must be done. To date there is no strong evidence to recommend HP eradication in HP associated NUP patients.

Prevalence of Hepatitis B Virus, Hepatitis C virus and human immune deficiency virus in cirrhotic patients undergoing sclerotherapy for esophageal varices at Siriraj Hospital.

116 sera from cirrhotic patients were tested for HbsAg, Anti-HCV and Anti-HIV to assess the prevalence and determine risk factors of virus acquisition. Forty-two patients (36.21%) were positive for HbsAg, thirty patients (25.86%) were positive for Anti-HCV, five patients positive both HbsAg and Anti-HCV and only one patient (0.86%) was positive for Anti-HCV. There is no statistically different between risk factors (IVDU, prostitute, units of blood transfusion) and positity of viral markers, but alcohol seems to be less in HbsAg positive patients (p < 0.0001). For HIV the prevalrnce is comparable to general populations there is no need for routine Anti-HIV examination in cirrhotic patients with bleeding esophageal varices, but universal precaution is still the rule.