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.

Evaluation of Helicobacter pylori stool antigen test in Thai patients with upper gastrointestinal bleeding.

OBJECTIVE: Stool antigen test was evaluated in comparison with other diagnostic tests for the diagnosis of H. pylori infection in Thai patients presented with upper gastrointestinal bleeding. MATERIAL AND METHOD: Fifty-six patients were enrolled and fecal specimen was obtained from 34 patients. The presence of H. pylori was considered if the culture was positive or at lease two of the other diagnostic tests (urea breath test, serology, rapid urease test or histology) were positive. Stool antigen test was performed by using commercially available monoclonal enzyme immunoassay (Amplified IDEIA HpStAR, Dako, Denmark). RESULTS: Of the 56patients, 35 (62.5%0) were considered H. pylori infected, while in 34patients tested by stool antigen test, 22 (64.71%) were infected. The prevalence of H. pylori infection as determined by each test is considered low (47.06% from stool antigen test; 42.50%from UBT, 65.85%from serology; 51.78%0from RUT- and 46.34% from histology). The sensitivity/specificity/accuracy (%) of stool antigen test was 69.56/100/ 79.41 compared to 73.91/100/85 of UBT 79.17/52.94/68.29 of serology, 80/95.23/85.71 of RUT and 82.61/ 100/90.24 of histology, respectively. CONCLUSION: In summary, the results of this study reveal that the prevalence of H. pylori was relatively low in upper gastrointestinal bleeding patients. Yielding a low sensitivity and accuracy, the stool antigen test is therefore not reliable for the diagnosis of H. pylori infection in patients with upper gastrointestinal bleeding.

14-day quadruple therapy with ranitidine bismuth citrate after Helicobacter pylori treatment failure in Thailand.

BACKGROUND: A quadruple therapy with a proton pump inhibitor, bismuth, metronidazole and tetracycline is recommended as a second line therapy after Helicobacter pylori treatment failure. OBJECTIVE: To evaluate the efficacy of 14-day ranitidine bismuth citrate (RBC) base quadruple therapy after H. pylori treatment failure in Thai patients. METHOD AND MATERIAL: Between June 2003-May 2005, thirty-four patients who were H. pylori positive after first line (Omeprazole, Amoxicillin, Clarithromycin or Metronidazole) treatment failure received 14-day quadruple therapy with RBC (400 mg bid), Rabeprazole (20 mg bid), Metronidazole (500 mg tid) and Tetracycline (500 mg qid). Four weeks after completion of treatment, eradication was confirmed with 14C-urea breath test. RESULTS: There were 18 males (52.9%) and 16 females (47.1%) with a mean age of 47.3 +/- 14.6 years. Four patients dropped out due to side effects. Per-protocol eradication rate was 86.7% and the intention-to-treat eradication rate was 76.5%. Adverse effects were found in 38.2% with a bitter taste, nausea, and dizziness. The mean age in the treatment failure group was younger than that in the successful group (35.3 +/- 13.9 vs 51.1 +/- 13.9 years, p = 0.046, 95%CI, 0.3-31.5%). The abdominal symptoms were improved after eradication (82.4%). CONCLUSION: The 14-day quadruple therapy with ranitidine bismuth citrate is effective and well tolerated for the patients who failed with the Helicobacterpylori treatment. The patients with older age may receive a more favorable outcome of the treatment.

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.

Endoscopic management of pancreatic cancer.

Endoscopic treatment of pancreatic malignancy can be considered as an alternative treatment option in inoperable patients. Endoscopic retrograde cholangio-pancreatography (ERCP) plays a key role, allowing diagnosis, collection of cytologic, biopsy specimens, and insertion of biliary and pancreatic stents. A major problem is the patency of plastic stents that will eventually clog on average after 3 to 4 months. Self-expandable metallic stents have longer patency, but they can also become occluded by tumor ingrowth or overgrowth. Furthermore, metallic stents are much more expensive and their uses may be considered in patients with longer life expectancy. ERCP can be performed on an outpatient basis in selected patients, reducing costs related to hospitalization. A team approach is mandatory to obtain the best results.

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.

Prediction of UGIB event in NSAID users: a model development.

The purpose of this study was to create a predicting tool for UGIB event in NSAID users. The patients of this case-control study were NSAID users who had received NSAIDs for at least 3 days and were gastroscoped The patients with a history of gastrointestinal varices, gastrointestinal cancer, chronic renal failure, coagulopathy, or Mallory-Weiss tear were excluded. The data was collected between July 2001 and January 2002 by patient interviewing and medical record reviewing. One hundred and fifty four NSAID users were identified (89 in the UGIB group, 65 in the non-bleeding group). Most patients were elderly (mean age +/- SD: 60.9 +/- 12.6 years). Age and the number of current NSAID users were significantly higher in UGIB patients than in non-bleeding patients (p < 0.05 and p < 0.01, respectively). The number of antiulceration drug users in non-bleeding patients was higher than in UGIB patients (p < 0. 01). An equation for prediction of UGIB probability in NSAID users was generated by using enter logistic regression. The best model of predicting the risk of UGIB event in NSAID users was logit (UGIB) = 0.33 + 2.09 Multiple NSAID use + 1.43 H. pylori infection + 0.34 Current NSAID use + 0.12 (Age x Sex) - 8.53 Sex - 2.41 Antiulceration drugs - 0. 000048 Age. The model had 80.2% of the overall rate of correct classification. The positive and negative predictive values were 80.8% and 78.9% respectively. The probability of UGIB = e((logit(UGIB)) /1 + e(logit(UGlB)). If the value of the probability of UGIB is more than 0. 5, the patient has a high risk of UGIB. Multiple NSAID use is the strongest factor that affects the probability of UGIB in NSAID users. H. pylori infection is another strong risk factor of NSAID-related UGIB. Antiulceration drug usage reduced the risk of UGIB in this group of patients. The developed model can be used as a guide for pharmacotherapeutic planning in clinical practices.

Effect of Helicobacter pylori infection and NSAIDs on the risk of peptic ulcer bleeding.

Peptic ulcer bleeding remains an important emergency situation with a high incidence and carries significant morbidity and mortality. Current evidence suggests that H. pylori and NSAIDs increase the risk of peptic ulcer bleeding and these two factors seem to act independently. Testing for, and cure of, H. pylori infection is recommended in patients prior to the initiation of NSAID therapy and in those who are currently receiving NSAIDs and have a history of peptic ulcer bleeding. For patients who present with peptic ulcer bleeding but require NSAIDs long-term, H. pylori eradication therapy should be considered, followed by continuous proton pump inhibitor prophylaxis to prevent re-bleeding, regardless of which kind of NSAID (nonselective NSAID/coxib) is being prescribed. The success of eradication should always be confirmed because of the risk of peptic ulcer recurrences and bleeding complication.

Result of wireless capsule endoscopy in patients with suspected small bowel disease: the first series from Thailand.

BACKGROUND AND AIMS: Capsule endoscopy (CE) is a promising diagnostic tool for patients with obscure gastrointestinal bleeding. Only a few papers have reported data from Asian countries. This retrospective study aimed to demonstrate result of capsule endoscopy in patients with suspected small bowel disease as the first series from Thailand. METHOD: Twenty-one patients who underwent wireless capsule endoscopy between July 2003 and June 2004 at King Chulalongkorn Memorial Hospital were retrospectively reviewed in the present study. The indications for capsule endoscopy were overt obscure gastro-intestinal bleeding (n= 12), occult obscure gastro-intestinal bleeding (n=5), chronic recurrent abdominal pain (n=3) and chronic diarrhea (n=1). Diagnoses according to findings of capsule endoscopy were classifield into definite, suspicious and negative finding. RESULTS: The mean age of the 21 patients (10 men and 11 women) was 46 (standard deviation, 18.57) years. Of those 17 obscure gastrointestinal bleeding patients, there were positive findings in 11 from 17 patients (65%). Four patients (24%), 3 with tumor and another with AVM, were classified as definite results. Seven patients (41%), 6 with angioectasia and another with a small ulcer, were classified as suspicious because there was no demonstrated active bleeding lesion and no other clinical supportive evidence. Of these 3 patients with recurrent abdominal pain, one patient (33%) with terminal ileum lymphoid hyperplasia was classified as definite result because of clinical improvement after treatment of the lesion. Another case of chronic diarrhea yielded a negative result. CONCLUSION: Wireless capsule endoscopy is a safe and useful mode of investigation for the diagnosis of obscure gastrointestinal bleeding in Thailand. There is not so much difference in capsule endoscopy results between Western and Asian series.

Clinical and virological differences between hepatitis B virus genotypes B and C: a case-control study.

OBJECTIVE: The pathogenic significance of hepatitis B virus (HBV) genotypes is undefined. The aim of this study was to elucidate the differences in clinical and virologicalfeatures between HBV genotypes B and C by conducting a case-control study in Thai patients who were chronically infected with the virus. PATIENTS AND METHOD: HBV genotyping was assessed by polymerase chain reaction (PCR) and restriction fragment length polymorphism (RFLP) method in stored sera of 470 patients with chronic hepatitis B. Among these, 65 patients with HBV genotype B were enrolled and matched individually to those with HBV genotype C according to sex, age, and distribution of liver disease which included asymptomatic carrier, chronic hepatitis, cirrhosis and hepatocellular carcinoma. RESULTS: Serum alanine aminotransferase (ALT) was significantly higher in patients with genotype C than those with genotype B. Hepatitis B e antigen (HBeAg) was significantly more frequent in genotype C than genotype B patients (50.8 and 30.8%, respectively, p=0.03), but the levels of HBV DNA were comparable between them. Among patients who were positive for HBeAg, the mean age of genotype C patients tended to be older than genotype B patients. CONCLUSION: The present study demonstrated that patients with HBV genotype C had a significantly higher rate of HBeAg, experienced delayed HBeAg seroconversion and exhibited more severe liver disease compared to those with genotype B.

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.

Comparison of clinical features and survival of patients with hepatitis B- and hepatitis C-associated hepatocellular carcinoma in Thailand.

Hepatitis B virus (HBV) and hepatitis C virus (HCV) are leading causes hepatocellular carcinoma (HCC) worldwide. The aim of this study was to determine whether differences do exist between HBV- and HCV-associated HCC in terms of clinical, pathologic features and prognosis among Thai patients. The authors retrospectively reviewed the clinical data of 188 patients with pathologically proven HCC, who were admitted to Chulalongkorn Hospital between January 1997 and December 1999. Of these cases, there were 105 patients (55.9%) with hepatitis B surface antigen (HbsAg) positive, 19 patients (10.1%) with anti-HCV positive, and 2 patients (1.0%) with both markers positive. The authors found that the mean age of patients with HBsAg positive was significantly lower than that of anti-HCV positive (49.2 +/- 12.7 and 58.3 +/- 8.9 years, respectively, p = 0.003). In contrast, the mean serum alpha-fetoprotein level of HBsAg positive group was significantly higher than that of anti-HCV positive group (48,583.6 +/- 109,494.1 and 2,022.7 +/- 4,869.1 IU/ml, respectively, p = 0.001). However, there was no difference between the two groups in terms of the severity of underlying liver disease, tumor histology and morphology, clinical staging, and the overall survival rate of the patients. The authors concluded that, among Thai populations, the majority of clinical features and survival of HBV-associated HCC did not differ from those with HCV-associated HCC.

Clinical spectrum of hepatic tuberculosis: comparison between immunocompetent and immunocompromised hosts.

BACKGROUND: Hepatic tuberculosis has been reported in normal and immunocompromised hosts. However, no published comparisons between these two groups of subjects with hepatic tuberculosis have been found. The aim of this study was to compare the clinical manifestations, biochemical tests, radiologic features and pathological findings of hepatic tuberculosis in immunocompromised and immunocompetent patients. METHOD: The authors reviewed retrospectively 20 patients with hepatic tuberculosis admitted between January 1993 and October 2000 to Chulalongkorn University Hospital, Thailand. There were 12 immunocompromised patients (10 HIV-infected males, 1 systemic lupus erythematosus (SLE) male, 1 SLE female) and 8 immunocompetent patients (6 males, 2 females). The clinical manifestations, biochemical tests, radiologic features and pathological findings were compared between these 2 groups. The diagnosis of Mycobacterium tuberculosis (M. tb) was the combination of a demonstrated organism in hemo- or specimen culture, histopathology (positive acid fast bacilli) and rapid identification of M. tb from nested polymerase chain reaction (nPCR) assay based on amplification of the IS 6110 insertion sequences. RESULTS: The clinical features were similar in both groups with fever, weight loss and hepatomegaly as the main manifestations. The biochemical findings were also similar but the alkaline phosphatase (ALP) was significantly higher in the immunocompromised group (p < 0.001). Hepatomegaly and diffuse increased echogenicity were common in both groups. Ascitis and calcifications were found more commonly in the immunocompetent subjects, although the differences were not statistically significant. Non-caseating granuloma without detection of acid fast bacilli was a common finding in both groups. The nested PCR assay increased the sensitivity from 49 per cent to 86 per cent compared to the regular PCR assay but specificity was 100 per cent in both techniques. The mortality was significantly higher in immunocompetent patients (p < 0.05) due to the extreme age and severe coexisting diseases. CONCLUSION: Fever, weight loss, hepatomegaly, disproportionate elevation of ALP and reverse A/G ratio were common in hepatic tuberculosis. A disproportionate elevation of ALP was significantly higher in the immunocompromised hosts. Nested PCR assay showed good sensitivity and specificity in the diagnosis of this disease.

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.

D-xylose absorption in non-chronic diarrhea AIDS patients with the wasting syndrome.

OBJECTIVE: To compare the intestinal absorptive capacity, permeability function and duodenal histopathology in human immunodeficiency virus (HIV) patients with or without wasting syndrome who had not suffered from chronic diarrhea. METHOD: Adult HIV patients who attended Chulalongkorn Hospital were included. The subjects were classified into wasting and non-wasting groups (group I and group II). 25 g oral D-xylose test, oral phenolsulfonephthalein test and duodenal histopathology were performed. RESULTS: Of thirty-two HIV patients, aged between 25-50 years enrolled, there were 18 and 14 patients in group I and group II, respectively. In both groups, the baseline data, permeability function and histopathology were similar. Intestinal absorptive capacity was statistically different, i.e. 5-hour urine D-xylose was 3.96 +/- 2.81 g and 5.95 +/- 2.47 g in group I and group II respectively (p < 0.05). CONCLUSION: This study demonstrated that D-xylose absorption was decreased in non-diarrheal, wasting HIV infected patients. Abnormal absorptive capacity is a common phenomenon found in HIV patients with wasting syndrome as determined by standard 25 g oral D-xylose test.

Serum hyaluronan: a marker of liver fibrosis in patients with chronic liver disease.

The aim of this study was to evaluate the clinical significance of serum hyaluronan (HA) as a marker of liver fibrosis in patients with chronic liver disease. Serum HA was measured by an ELISA-based method in 28 patients with chronic hepatitis (CH), 43 patients with liver cirrhosis (LC), 57 patients with hepatocellular carcinoma (HCC) and 60 healthy controls. Mean serum HA concentration in patients with LC was 1,376.80 +/- 2,568.85 ng/ml which was significantly higher than those in patients with CH, HCC and the controls (575.93 +/- 732.58, and 426.36 +/- 687.33, and 117.86 +/- 311.11 ng/ml, respectively). Based on a ROC curve analysis, a cut-off point of 354 ng/ml discriminated between LC and other groups with a sensitivity, specificity and accuracy of 82.4%, 78.2%, and 80.2%, respectively. Mean HA concentrations were correlated with the degree of liver fibrosis, but not the grade of necroinflammatory activity. In patients with LC, the mean serum HA level was significantly increased in the Child C group (3,977.96 +/- 4,906.21 ng/ml) in comparison with the Child B and A groups (1,002.63 +/- 448.55, and 537.90 +/- 424.16 ng/ml, respectively). We conclude that serum HA concentrations reflect the extent of liver fibrosis and severity of cirrhosis. Thus, serum HA can be a diagnostic marker of liver fibrosis and cirrhosis in patients with chronic liver disease.

Caffeine clearance in patients with hepatocellular carcinoma after transcatheter oily chemoembolization treatment.

BACKGROUND: Hepatocellular carcinoma (HCC) is a common neoplasm worldwide, particularly in Asia, with a grave prognosis. Transcatheter Oily Chemoembolization (TOCE) is now universally accepted as the method of choice for the treatment of inoperable HCC. The purpose ofthis study was to evaluate caffeine clearance, a quantitative liver function assessment, in HCC patients before and after treatment with TOCE. METHOD: Both conventional liver function test (LFT) and caffeine clearance were evaluated in twelve patients. Each patient took a 3.5 mg/kg single oral dose of caffeine solution before TOCE, 1 day and 5 weeks after treatment. Blood samples were subsequently collected at 0.5, 1.5, 3, 5, 10 and 24 hours after each dose of caffeine administration and assayed for serum caffeine level by the HPLC technique. Clearance (Cl) was calculated using the equation of Cl = Kel x Vd (Kel = elimination rate constant, Vd = volume of distribution) and half-life was determined using pharmacokinetic analysis. RESULTS: The mean caffeine clearance 1 day after TOCE (0.51 +/- 0.096) and 5 weeks after TOCE treatment (0.43 +/- 0.07) was significantly reduced compared with the mean caffeine clearance before treatment (0.79 . 0.2 ml/min x kg) with the p = 0.06 and p = 0.03, respectively. No significant changes (p > 0.05) in most conventional LFT were observed 5 weeks after treatment. CONCLUSIONS: In the present study, the authors found that caffeine clearance was reduced after TOCE in patients with HCC inspite of no changes in conventional LFT. Thus, the determination of caffeine clearance can serve as a useful parameter for the assessment of hepatic functional reserve in HCC patients post TOCE treatment.

Feasibility and complications of endoscopic biliary drainage in patients with malignant biliary obstruction at King Chulalongkorn Memorial Hospital.

Currently the best curative therapy for primary malignant biliary tumor is surgery. Unfortunately, many patients present at a very late stage and only palliative biliary drainage is possible. Usually nonsurgical palliative biliary drainage means either percutaneous or endoscopic approach. In this series, the authors reported the rate of technical success and immediate complications in patients with malignant biliary obstruction who underwent endoscopic biliary drainage. From endoscopic retrograde cholangiopancreatography (ERCP) database between September 2000 and October 2001, there were 273 ERCP performed for obstructive jaundice. Of these, 50 patients with malignant tumor underwent 80 procedures for endoscopic biliary drainage. The patients were divided into three groups according to the cholangiographic findings and clinical diagnoses. Patients with carcinoma of the pancreatic head were categorized as group I (n=10). Group II (n=20) and III (n=20) were patients with extrahepatic cholangiocarcinoma and hilar cholangiocarcinoma respectively. All patients received either plastic or metallic endoprothesis placement for biliary drainage. All patients except two in group I had successful endoscopic treatment. Complications in group I, II and III were 15.4 per cent, 14.3 per cent and 53.1 per cent respectively. Only one patient in group II developed significant hypotension during the procedure. Another complication was defined as post procedure cholangitis. In conclusion endoscopic biliary drainage was technically feasible in 97.5 per cent of patients who had malignant biliary obstruction. In patients with hilar tumor the incidence of post procedure cholangitis was high (53.1%). Improvement in technique, avoiding unnecessary contrast injection, and draining the obstructed bile duct after injecting the contrast may improve the outcome and decrease the rate of post procedure cholangitis in these patients.

Duodenal Helicobacter pylori associated duodenal ulcer depend on gastric Helicobacter pylori status.

Gastric Helicobacter pylori (H. pylon) plays an important role in the pathogenesis of duodenal ulcer (DU), although not all H. pylori infected persons will develop disease. Duodenal H. pylori was supposed to be one of the factors related with DU. The aim of this study was to investigate whether H. pylori in the duodenum of patients with DU plays a critical role in the pathogenesis of DU regarding the gastric H. pylori status. Furthermore, it was to determine the prevalence of duodenal H. pylori infection in Thailand. Ninety three patients were included in the study. They underwent gastroscopic evaluation for dyspeptic symptoms and none of them had previous H. pylori eradication therapy. An upper gastrointestinal endoscopy was performed and two specimens were collected each form the antrum, midcorpus and duodenal bulb in order to diagnose H. pylori infection. The gold standard for H. pylori detection is a positive specimen culture or polymerase chain reaction (PCR) assay for the vac A gene or positive urease test plus H. pylori seen in the pathology. Ninety three dyspeptic patients (43 males and 50 females; mean age 48.2 years; range 22 to 79 years) were included in the study. Duodenal H. pylori was detected in 31/93 (33.33%) patients which included 15 (48.38%) patients with duodenal ulcer, 2 (6.45%) patients with gastric ulcer and 14 (45.16%) patients with NUD. Five of thirty one (16.21%) patients with duodenal H. pylori infection had negative gastric H. pylori. These five patients included 1 with DU, 1 with DU and 3 with NUD. Duodenal H. pylori was associated with DU dependent of the presence of gastric H. pylori (p<0.05) and there was no association between duodenal H. pylori with negative gastric H. pylori and duodenal ulcer (p>0.05). Duodenal H. pylori is associated with duodenal ulcer dependent on the presence of gastric H. pylori. These results suggest that transmission of gastric H. pylori to the duodenum was prerequisited for the formation of DU.