Comparison of the efficacy between lidocaine spray plus lidocaine jelly lubrication and lidocaine jelly lubrication alone prior to nasogastric intubation: a prospective double-blind randomized controlled study.

OBJECTIVE: Although a common procedure, nasogastric (NG) intubation is also painful and unsatisfactory. Previous studies showed the benefits of local anesthesia in various forms over lubricant jelly alone, but they are rarely used due to their inconvenience and unavailability. The authors conducted a double-blind randomized controlled study to compare a commercial-available 10% lidocaine spray plus 2% lidocaine jelly lubrication and 2% lidocaine jelly lubrication alone prior to NG intubation. MATERIAL AND METHOD: Patients who fulfilled the indications for NG intubation were randomized to receive either 10% lidocaine spray or placebo (normal saline) spray to the nostril and throat prior to NG intubation. NG tubes lubricated with 2% lidocaine jelly were then inserted by experienced physicians. Physician, who sprayed, inserted the NG tubes and collected the patient's data, did not know the content of the spray, while patients were also blinded against the information of the spray. RESULTS: Sixty patients were included in the present study. Thirty one randomly received lidocaine spray and 29 received placebo spray. There were more female patients in the lidocaine group (65% vs. 28%, p=0.04), but ages, indications for NG intubation, size of NG tube, and physicians' experience in the procedure were similar in both groups. Patients' discomfort after being sprayed was also similar in both groups. However during the NG intubation, the patients in the lidocaine group experienced less pain as measured by visual analog scale (23.6 +/- 16.6 vs. 43.1 +/- 31.4 mm, p=0.005) and less discomfort (30.0 +/- 24.4 vs. 51.4 +/- 30.0 mm, p=0.004) than the placebo group. Ninety-three percent of the patients in the lidocaine group favored the same spray for their next intubations, while 65% of the placebo group did (p = 0.009). In addition, there was more physicians' satisfaction in the lidocaine group as measured by 5-point Likert scale (p=0.041). Likewise, 61% of the physicians favored lidocaine spray compared to 34.5% of the placebo spray (p=0.038). Degree of difficulty, duration of intubation, number of attempts and success rates of NG intubations were as well similar in both groups. No complications were found in the present study. CONCLUSION: 10% lidocaine spray plus 2% lidocaine jelly lubrication was more effective in relieving patients' pain, discomfort, and resulted in higher physicians' satisfaction. There were also no additional side effects as compared to 2% lidocaine jelly lubrication alone. Therefore, it should be recommended for routine application.

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.

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.

Acute fatty liver in pregnancy.

We report woman with a 36 week twin pregnancy who presented with labor pains 8 hours prior to hospitalization. Jaundice was found on clinical examination in the out patient department. After admission for investigation, laboratory tests which demonstrated abnormal bleeding rapidly worsened and the condition of the fetus was worsened. Emergency caesarian section was performed while resuscitating the patient. The twins were delivered with good outcome but their mother's condition worsened and she expired from sepsis on the 32nd day after admission. The differential diagnosis of jaundice in the third trimester pregnancy, treatment, optimization for operation and outcome of acute fatty liver of pregnancy are discussed. Acute fatty liver in pregnancy is a rare but fatal disease for pregnant woman.