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.

Gastrointestinal lymphoma in Thailand: a clinicopathologic analysis of 120 cases at Siriraj Hospital according to WHO classification.

Clinicopathologic information of gastrointestinal (GI) lymphoma in Southeast Asia is lacking. A retrospective analysis of 120 cases of GI lymphoma in Thailand diagnosed at Siriraj Hospital based on WHO classification was performed. All were non-Hodgkin lymphoma (NHL). The peak age was in the sixth and seventh decades; a slight male preponderance was observed. Sites of involvement included stomach (49.2%), intestine (46.7%), and multiple sites (4.2%). There were 104 cases of primary GI lymphoma (86.7%) and 16 cases of secondary GI lymphoma (13.3%). Presenting GI symptoms were more common in the former; while superficial lymphadenopathy and fever were more common in the latter. Mass lesions were observed in both groups (72.1% vs 56.3%). Localized and advanced diseases were found in 68.3% and 31.7% of primary GI lymphomas, respectively. The most common type of lymphoma in both groups was diffuse large B-cell lymphoma. Lymphoepithelial lesions (LEL) were not significantly different between the two groups (58.2% vs 42.9%), but Helicobacterpylori infection was significantly associated with primary gastric lymphoma (p < 0.0001). The treatment of choice for localized primary GI lymphoma is controversial. Complete surgical resection may increase the chance of complete remission, but mortality and relapse rates might be higher than those observed with combination chemotherapy alone. GI lymphomas in Thailand are mostly primary B-cell NHL. LEL is not indicative of primary GI lymphoma, but H. pylori infection is closely associated with primary gastric lymphoma. A prospective study to determine the treatment of choice for localized GI lymphoma is needed.

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.

Manometric tests of anorectal function in healthy adult Thai subjects.

BACKGROUND AND OBJECTIVES: Diseases of the distal gastrointestinal tract are becoming more common among Thai people especially in the elderly. Manometry is a new and useful technique in the diagnosis and management of anorectal disorders. This cross-sectional study aimed to measure anorectal manometric parameters in normal Thai subjects. MATERIAL AND METHOD: Thirty healthy Thai subjects (17 males and 13 females) were studied. They completed a questionnaire assessing their bowel function. A water-perfused manometric system with non-pull-through technique was used to monitor pressure in the rectum and anus. All subjects were asked to squeeze the anal sphincters, bear down, then blow up a party balloon. Rectal sensation and recto-anal inhibitory reflex were also assessed by intermittent phasic balloon distention. Simulated defecation or balloon expulsion test was also performed. RESULT: The study revealed the following anorectal manometric parameters. The mean with standard deviation of the resting, squeezed, and sustained squeezed pressures were 55.4 +/- 15.3, 170.3 +/- 81.7 and 109.3 +/- 54.4 mm Hg respectively. Men had a longer anal sphincter (p = 0.01) and higher squeezed, and sustained squeezed pressures (p < 0. 001) compared to women, while their resting sphincter pressures were similar. Threshold volumes for rectal sensation and desire to defecate were not different among male and female subjects, but the threshold for urgency to defecate was higher in men. The study yielded normal anorectal manometric parameters in Thai subjects. Some parameters vary with gender. It is difficult to compare these normal ranges in Thai subjects to those in Caucasians, as the number of subjects is rather small and the details of instruments and techniques always vary from lab to lab. The manometric findings in these Thai subjects create more understanding in anorectal physiology and can be used as a guideline for the investigation of anorectal function in a symptomatic Thai population in a motility clinic.

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.