Stress, but not Helicobacter pylori, is associated with peptic ulcer disease in a Thai population.

The purpose of this study was to clarify the relation between psychological and other risk factors, notably helicobacter pylori (H. pylori) infection, in contributing to the occurrence of peptic ulcer (PU) disease. A retrospective case-control study was conducted at Siriraj Hospital, Bangkok from March to December 2000. Seventy endoscopically diagnosed patients with new PU or peptic perforation were compared with 70 patients with other diseases as well as blood donors control matched for age and sex. Historical risk factors, H. pylori Immunoglobulin G antibody (H. pylori IgG Ab), stress (Perceived Stress Questionnaire) and hostility (MMPI Hostility Scale) were assessed. Data were analyzed using logistic regression analysis. The results showed that PU was associated with chronic stress (aOR 2.9, p = 0.01; 95% CI, 1.3-6.5) and family history of PU (aOR 2.4, p < 0.03; 95% CI, 1.1-5.1), with an interaction effect between stress and irregular mealtimes (aOR 4.8, p = 0.01; 95% CI, 1.3-16.9). The incidence rate of H. pylori infection in PU patients was similar to the control group (61.4% and 50.0%, respectively, OR 1.2). The authors conclude that stress and family history, not H. pylori infection, are important risk factors for PU in this population. This finding supports previous studies in Thailand, showing a high prevalence of H. pylori in the population but a low association with PU, in contrast to developed countries. It remains to be seen whether the impact of a family history is due to genetic factors or shared life-style patterns.

Antibodies to neutrophil cytoplasma in patients with ulcerative colitis and their first-degree relatives in Thailand.

BACKGROUND: The prevalence of perinuclear antineutrophil cytoplasmic antibodies (p-ANCA) does not significantly vary in ethnically diverse populations. The prevalence of p-ANCA is high in ulcerative colitis and primary sclerosing cholangitis. While the prevalence of ulcerative colitis in Asian populations is low, it is interesting to know the prevalence of p-ANCA in such a population. METHODS: Sera from 33 cases of ulcerative colitis diagnosed during the last 10 years at the diarrhea clinic, Division of Gastroenterology, Siriraj Hospital, were prospectively compared with case controls consisting of 15 cases of diarrhea from non-inflammatory bowel diseases and 25 non-diarrheic patients. Indirect immunofluorescence assay was used to detect p-ANCA in all the sera. RESULTS: Positive p-ANCA tests were found in 13 of the 33 patients with ulcerative colitis and in one of the 40 controls. Sensitivity of the test was 39.4% and the specificity was 97.5%. The one patient with positive p-ANCA in the control group was the patient with irritable bowel syndrome. Of the 13 p-ANCA-positive ulcerative colitis patients, two cases were found to have proctosigmoiditis, seven cases had left-sided colitis, and four cases had pancolitis. Perinuclear antineutrophil cytoplasmic antibodies was one of the 22 cases of first-degree relatives of ulcerative colitis patients (22 relatives from 12 index ulcerative colitis cases). There was no correlation between the positivity of p-ANCA and disease activity, and extent of the disease. CONCLUSION: The prevalence of p-ANCA in Thai patients with ulcerative colitis (39.4%) is lower than that in the Western population. Although the prevalence of p-ANCA is low in the Thai population, it should serve as a useful tool in diagnosing ulcerative colitis in this part of the world where the disease is uncommon and difficult to diagnose. The negativity of p-ANCA in almost all first-degree relatives of Thai ulcerative colitis patients should be further elucidated.

Ulcerative colitis in Thailand: a clinical study and long term follow-up.

UNLABELLED: Ulcerative colitis (UC) is uncommon in Thailand. Few reports have been published and confirmation of the diagnosis was difficult. To make a firm diagnosis of UC in Thailand, long-term follow-up and demonstration of chronic and relapsing clinical courses should help to confirm the existence of UC in Thailand. OBJECTIVE: To review the demographic data, clinical presentation and clinical courses of the diagnosed UC cases in Thailand. MATERIAL AND METHOD: Diagnosed UC patients who were followed-up for longer than 3 months at the Diarrhea Clinic, Siriraj Hospital between 1988-2000 were included. RESULTS: Forty cases of UC were followed-up. The duration of follow-up ranged from 3-75 months (mean 27 months). Male to female ratio was 19:21 and age of onset varied from 13-77 years (mean 37.7 years). Extents of the disease was left-sided colitis in 58 per cent, left and right-sided colitis in 8 per cent, pancolitis in 21 per cent, proctosigmoiditis in 13 per cent and ileal involvement in 8 per cent. At presentation, the disease was mild in 28 per cent, moderate in 60 per cent, severe in 13 per cent and fulminant in 2. Clinical presentations were diarrhea in 97.5 per cent, lower GI bleeding in 17.5 per cent, abdominal pain in 50 per cent, fever in 27.5 per cent, weight loss in 62.5 per cent and extraintestinal manifestations in 20 per cent. Diagnoses were made in all cases by sigmoidoscopy plus barium enema or colonoscopy and biopsies were taken in all cases. Histologic findings supported the diagnoses in 69 per cent of cases. Seventy per cent responded to sulfasalazine or 5-ASA with or without corticosteroid, but in 30 per cent, azathioprine was added for a period during the treatment. Clinical courses of the diseases were chronic intermittent with remission and relapse in 44 per cent, chronic continuous activity without remission in 27 per cent, single episode without relapse in 27 per cent and acute fulminating course in 6 per cent. One patient died from fulminant pancolitis with colonic perforation. There was no colonic cancer in our cases throughout the follow-up period. CONCLUSIONS: UC is very uncommon in Thailand. Firm diagnosis of UC can be made through long-term follow-up and demonstration of chronic and relapsing clinical courses. The disease severity and extent of disease involvement was slightly different from that in Western countries. Incidence of extraintestinal manifestation was 20 per cent. Most cases responded to sulfasalazine, 5-ASA or corticosteroids.

Prevention of duodenal ulcer relapse with omeprazole 20 mg daily: a randomized double-blind, placebo-controlled study.

We report the first double-blind, placebo-controlled study that assesses the efficacy and safety of omeprazole 20 mg daily in the maintenance treatment of duodenal ulcer. For the healing phase, 128 patients with endoscopically proven active duodenal ulcer and a history of three or more relapses during the 2 years prior to the study were treated until healing with omeprazole 40 mg daily for 2 and up to 8 weeks. One hundred and twenty-three patients whose ulcers were healed were randomized to receive omeprazole 20 mg daily (n = 60) or placebo (n = 63) for 12 months as maintenance treatment. Patients were interviewed at 3, 6, 9 and 12 months, and endoscopy was performed at 3, 6 and 12 months and whenever symptoms recurred. The healing rates of the 124 patients completing the healing phase were 84, 98 and 100% at 2, 4 and 8 weeks, respectively. During the maintenance phase, eight and four patients discontinued treatment from the omeprazole and placebo groups, respectively. The proportion of patients in remission in the omeprazole group and placebo group after 12 months were 94 and 9% respectively (life table estimates, P < 0.0001). No significant clinical or laboratory changes were observed in patients on therapy with omeprazole. Patients with a history of frequent relapses thus continued to have a very high relapse rate without prophylactic treatment. Omeprazole 20 mg daily was effective and safe in maintaining such patients in remission.

Effects of cigarette smoking on duodenal ulcer healing and relapse rate.

104 duodenal ulcer patients were classified into non-smokers (76) and smokers (28). Their age range was between 14-72 years. They were randomly treated with cimetidine (28 non-smokers and 8 smokers), colloidal bismuth (27 non-smokers and 10 smokers) and sucralfate (21 non-smokers and 10 smokers). Follow-up endoscopic examination at 4, 6 and 8 weeks showed that overall healing rates were better in the non-smokers than in the smokers (64.5% against 46.4% at 4 weeks and 92.1% against 67.8% at 6 weeks) and almost all ulcers had healed at the end of 8 weeks (100% in non-smokers and 96.4% in smokers). Among non-smokers, there were no statistically significant differences in the healing rates by any medication at any period of time. Among smokers, colloidal bismuth had significant better healing rate at 6 weeks over cimetidine and sucralfate. (p = 0.04 and p = 0.041 respectively). Overall relapse rates were higher among smokers (32.1%) than non-smokers (10.5%). Of the 3 medications, sucralfate had the lowest relapse rate in both smokers (20%) and non-smokers (9.5%), while colloidal bismuth had the highest relapse rates (40% for smokers and 11.1% for non-smokers).

Comparison study between fasting total serum bile acid and post prandial bile acid in hepatic diseases: a preliminary study.

Fasting bile acid, two-hour post prandial bile acid and other liver function tests (Bili, AST, ALT, ALB, Glob, ALP) were measured in 22 normal and 28 liver diseased patients. In normal volunteers, the mean value of fasting total serum bile acid (FTBA) and postprandial serum bile acid (PTBA) were 3.08 mumole/L (S.D. 1.65) range 0.21-6.26 mumol/L, and 8.07 mumole/L (S.D. 2.99) range 4.06-15.65 mumole/L. Comparison between FTBA, PTBA and other liver function tests in various liver diseases from this study the PTBA was not statistically significant superior to FTBA. Therefore, it is not necessary to do the PTBA at this time until more data is available.

Gastric acid secretion in Thai patients with particular reference to the characteristics differentiating types of gastric and duodenal ulcer.

Acid secretion in both basal and stimulated states (using augmented histalog test) was studied in 31 normal control patients, 64 duodenal ulcer patients and 101 gastric ulcer patients. Having had the result of acid output study, the 64 DU patients could be classified according to their acid secretion results as 35 DU type I or Normosecretor (54.7%) and 29 DU type II or Hypersecretor (45.3%). For the GU patients which were classified according to the sites of lesions as GU type I (GU above angulus), GU type II (GU associated with DU) and GU type III (GU below the angulus). Their acid output study showed that the GU type I had a rather low BAO and a high MAO close to that of the Normosecretor, but the GU type II and III had their BAO and MAO significantly higher than that of the normal control and close to that of the Hypersecretor. Comparison of acid secretion in this study group to other racial groups showed that the Thai population had acid secretion patterns close to other Asian populations, except that the Chinese in Singapore had a higher proportion of Normosecretor (69.0%) than Hypersecretor (31%). The MAO of the Asian population was found to be lower than that of Europeans.

Amoebic liver abscess in Thailand, clinical analysis of 418 cases.

From 1975 to 1983, 418 cases of amoebic liver abscess were admitted to the Department of Medicine, Siriraj Hospital without definite increase or decrease in the overall incidence and without seasonal preponderance. The age range was 16-81 yrs and mean age 42.4 yrs. Male to female ratio was 5:1. Pertinent clinical features were pain, fever and hepatomegaly with predominant involvement of the right lobe. Principal treatment consisted of needle aspiration combined with amoebicidal drugs, i.e. metronidazole, tinidazole and ornidazole. The efficacy of each was similar. Surgical drainage was required in only 2.1 per cent of uncomplicated cases and mortality rate was 0.7 per cent. Ruptures into pleural, pericardial and peritoneal cavity were found in 15.4 per cent and secondary infection in 11.9 per cent. Mortality rate of cases with complication was 7.14 per cent. Length of hospital stay was 12.8 days for the uncomplicated cases and 24.1 days for cases with complications (excluding the nonsurvivals).

Helicobacter pylori and peptic ulcer diseases: prevalence and association with antral gastritis in 210 patients.

Evidence is accumulating that Helicobacter pylori infection plays a major contributory role in peptic ulcer disease [Duodenal Ulcer (DU) and Gastric ulcer (GU)] and non-ulcer dyspepsia (NUD). We, therefore, studied prospectively 210 consecutive patients with upper gastrointestinal symptoms (62 DU, 38 GU and 110 NUD) to determine the prevalence of H. pylori infection and to investigate their association with histological gastritis. Using endoscopic biopsy of the gastric antrum for diagnosing H. pylori infection by Campylobacter-like Organism (CLO) test, histology or bacteriology, the overall prevalence of H. pylori was 63.3 per cent. When H. pylori infection was related to diagnosis, DU had the highest prevalence rate of H. pylori infection (66%), GU and NUD were less frequently associated with H. pylori infection (55% and 44% respectively). We found a close association between H. pylori infection and histologically antral gastritis, in that 72.7, 61.7, and 62.6 per cent of the DU, GU and NUD patients with antral gastritis (respectively) had H. pylori infection. In contrast, none of these patients seen with normal antrum had H. pylori infection. We also found that the prevalence of H. pylori in our patient series was not age related. Of the three procedures used to demonstrate H. pylori, the CLO test and histological staining method gave the highest yields of 84.9 and 79.6 per cent respectively, and bacteriology in only 44.3 per cent, we conclude that the prevalence of H. pylori infection in Thai patients with upper gastrointestinal symptoms is high. H. pylori infection commonly occurs in the patients with antral gastritis, suggesting a possible etiologic role for the bacterium in the histologic lesion.

Peritoneoscopic findings in 203 patients with Opisthorchis viverrini infection.

A study was conducted to determine the value of peritoneoscopy in the diagnosis of opisthorchiasis. Peritoneoscopic findings in 203 proven cases of Opisthorchis viverrini infection are presented. The authors found that cholangiocarcinoma is frequently encountered in patients presenting with prolonged jaundice and hepatomegaly as well as with the peritoneoscopic findings of dilated superficial intrahepatic bile ducts, a bile-stained liver surface and a markedly enlarged gallbladder.

Peritoneoscopy in the diagnosis of liver abscess. Experience with 108 cases during a 10-year period.

Among 4569 cases of peritoneoscopy performed in a period of 10 years (1972-1981), 108 patients with liver abscesses were encountered. The diagnosis of hepatic abscess was made on the basis of gross liver inspection and confirmed or disproved by needle puncture biopsy, histopathologic study, or surgery. Peritoneoscopy is a valuable procedure for the diagnosis of liver abscess. Liver aspiration under direct vision during peritoneoscopy yields more dependable material for the diagnosis of liver abscess than blind liver aspiration. Moreover, during peritoneoscopy one can choose more accurately the site for the insertion of the aspirating needle.

Spontaneous rupture of primary hepatoma: report of 63 cases with particular reference to the pathogenesis and rationale treatment by hepatic artery ligation.

Of 508 cases of primary liver cancer admitted during 1970-1978, 63 cases had spontaneous rupture of carcinomatous nodules. The association with cirrhosis among noncomplicated cases was 65% and 93% in cases with the rupture (P less than 0.001). In most instances, the presenting symptoms were not dramatic and could be indistinguishable from other uncomplicated carcinoma of the liver. Sixteen patients were treated conservatively and all died. The other ten patients who presumably bled due to coagulation defect were also given conservative treatment and the mortality rate was only 60%. Hepatic artery ligation was employed in 26 cases with 54% mortality but bleeding stopped in 92%, as compared with other conventional surgical measures such as packing, suture, and cauterization to control hemorrhage with 90% mortality rate. There is ample evidence that hepatic venous obstruction due to the tumor invasion and portal hypertension due to the pre-existing cirrhosis play important roles in the pathogenesis of spontaneous rupture of the tumor. Hepatic artery ligation is a rationale treatment because it not only cuts off blood supply to the tumor nodule which is almost exclusively nourished by arterial blood, but also reduces the degree of portal hypertension in cirrhosis.

Inaccuracies in measurement of conjugated and unconjugated bilirubin in bile with ethyl anthranilate diazo and solvent-partition methods.

A criticial evaluation was made of the ethyl anthranilate diazo and two solvent-partition methods for the determination of conjugated and unconjugated bilirubin in human and rat bile. The ethyl anthranilate diazo reagent, which reacts only with conjugated bilirubin in serum, also diazotized a variable proportion of unconjugated bilirubin in bile and thus overestimated the concentration of monoconjugates. With the Weber-Schalm and modified Folsch solvent-partition methods applied to human or rat bile, 4--9% of added 14C-labelled unconjugated bilirubin partitioned with the conjugated bilirubin in the upper phase, and 4--9% of added 14C-labelled conjugated bilirubin partitioned into the lower phase. With dog bile, the spill-over of 14C-labelled bilirubin into the lower phase was 9--11%. Analysis of azopigments from the Weber-Schalm partition confirmed that over two-thirds of the bilirubin in the lower phase represents monoconjugates, principally the less-polar monoxylosides and monoglucosides. These solvent-partition methods thus overestimate the concentration of unconjugated bilirubin in bile.

Measurement of conjugated and unconjugated bilirubin in bile. II. A new thin-layer chromatographic method.

A new thin-layer chromatographic (TLC) method is described for measurement of conjugated (CB) and unconjugated (UCB) bilirubin in bile. Bile is streaked on a silica-gel plate and developed with chloroform. Bilirubin in the mobile UCB band and stationary CB band is quantitated by diazotization from the scraped gel with p-iodoaniline reagent. Both CB and UCB in bile yielded identical azopigment absorbance. There was no contamination of the UBC band with either CB or oxidative derivatives of bilirubin, and over 98 per cent added 14C-UBC migrated with the mobile band. Recoveries from TLC averaged 98.2 +/- 4.3 per cent of the applied pigment, duplicated agreed within 10 per cent, and the method accurately detected the enzymatic and alkaline hydrolysis of CB to UCB. Concentrations of UCB in nine samples of normal human gallbladder bile were found to be less than 1.9 mg./dl. and never exceeded 1.2 per cent of the total bilirubin.