The use of gabexate mesylate and ulinastatin for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis.

BACKGROUND/AIMS: Acute pancreatitis is a common complication of endoscopic retrograde cholangiopancreatography (ERCP). Only a few pharmacologic agents have been shown to have potential efficacy for the prophylactic treatment of post-ERCP pancreatitis (PEP). The aim of this study was to determine whether prophylactic gabexate and ulinastatin can decrease the incidence of PEP. METHODS: From January 2005 to April 2010, 1,679 patients undergoing ERCP treatment were consecutively enrolled in the study. After selective exclusion, a total of 1,480 patients were included in the analysis. The patients were separated into 3 groups according to the prophylactic administration of gabexate (593 patients), ulinastatin (229 patients), or saline solution (658 patients) and analyzed retrospectively. The primary outcome measurements were the incidence of pancreatitis and hyperamylasemia. RESULTS: PEP occurred in 21 of the 593 (3.5%) patients who received gabexate, 16 of the 229 (7.0%) patients who received ulinastatin, and 48 of the 658 (7.3%) patients who received a saline solution. The incidence of PEP was significantly different between the gabexate and ulinastatin or saline solution groups (p<0.05). CONCLUSIONS: Gabexate prophylaxis is effective in preventing PEP. However, there is no difference in the beneficial effects of the prophylactic administration of ulinastatin and a saline solution.

Long-term treatment outcomes of clevudine in antiviral-naive patients with chronic hepatitis B.

AIM: To evaluate the treatment outcomes of clevudine compared with entecavir in antiviral-naive patients with chronic hepatitis B (CHB). METHODS: We retrospectively analyzed the clinical data of CHB patients treated with clevudine 30 mg/d and compared their clinical outcomes with patients treated with entecavir 0.5 mg/d. The biochemical response, as assessed by serum alanine aminotransferase (ALT) activity, virologic response, as assessed by serum hepatitis B virus DNA (HBV DNA) titer, serologic response, as assessed by hepatitis B e antigen (HBeAg) status, and virologic breakthrough with genotypic mutations were assessed. RESULTS: Two-hundred and fifty-four patients [clevudine (n = 118) vs entecavir (n = 136)] were enrolled. In clevudine-treated patients, the cumulative rates of serum ALT normalization were 83.9% at week 48 and 91.5% at week 96 (80.9% and 91.2% in the entecavir group, respectively), the mean titer changes in serum HBV DNA were -6.03 and -6.55 log(10) copies/mL (-6.35 and -6.86 log(10) copies/mL, respectively, in the entecavir group), and the cumulative non-detection rates of serum HBV DNA were 72.6% and 83.1% (74.4% and 83.8%, respectively, in the entecavir group). These results were similar to those of entecavir-treated patients. The cumulative rates of HBeAg seroconversion were 21.8% at week 48 and 25.0% at week 96 in patients treated with clevudine, which was similar to patients treated with entecavir (22.8% and 27.7%, respectively). The virologic breakthrough in the clevudine group occurred in 9 (7.6%) patients at weeks 48 and 15 (12.7%) patients at week 96, which primarily corresponded to genotypic mutations of rtM204I and/or rtL180M. There was no virologic breakthrough in the entecavir group. CONCLUSION: In antiviral-naive CHB patients, long-term treatment outcomes of clevudine were not inferior to those of entecavir, except for virologic breakthrough.

Virological response to adefovir monotherapy and the risk of adefovir resistance.

AIM: To evaluate virological response to adefovir (ADV) monotherapy and emergence of ADV-resistant mutations in lamivudine (LAM)-resistant chronic hepatitis B patients. METHODS: Seventy-seven patients with documented LAM resistance who were treated with 10 mg/d ADV for > 96 wk were analyzed for ADV resistance. RESULTS: At week 48 and 96, eight (10%) and 14 (18%) of 77 LAM-resistant patients developed the ADV-resistant strain (rtA181V/T and/or rtN236T mutations), respectively. Hepatitis B virus (HBV) DNA levels during therapy were significantly higher in patients who developed ADV resistance than in those who did not. Incidence of ADV resistance at week 96 was 11%, 8% and 6% among patients with complete virological response (HBV DNA level < 60 IU/mL); 0%, 5% and 19% among patients with partial virological response (HBV DNA level ≥ 60 to 2000 IU/mL); and 32%, 34% and 33% among patients with inadequate virological response (HBV DNA levels > 2000 IU/mL) at week 12, week 24 and week 48, respectively. HBV DNA levels > 2000 IU/mL at week 24 showed best performance characteristics in predicting ADV resistance. CONCLUSION: Development of ADV resistance mutations was associated with HBV DNA levels, which could identify patients with LAM resistance who are likely to respond to ADV monotherapy.

Efficacy of initial treatment with clevudine in naive patients with chronic hepatitis B.

BACKGROUND/AIMS: Clevudine, a pyrimidine nucleoside analogue, has potent antiviral effects in patients with chronic viral hepatitis B (CHB). We report the efficacy of initial treatment with clevudine in naïve patients with CHB living in Daejeon and Chungcheong Province, South Korea. METHODS: One hundred five adults with CHB were administered 30 mg of clevudine per day for an average of 51 weeks. We evaluated viral markers and liver biochemistry retrospectively every 3 months. RESULTS: Alanine aminotransferase (ALT), aspartate aminotransferase (AST), and hepatitis B virus (HBV) DNA before the treatment were 184 ± 188 IU/L, 150 ± 138 IU/L, and 7.1 ± 1.2 log copies/mL, respectively. Undetectable rates (< 60 IU/mL) of DNA were 36.2%, 68.9%, 83.6%, 76.2%, and 75.8% at 12, 24, 36, 48, and 60 weeks, respectively. Seroconversion rates were 9.1%, 13.6%, 24.6%, 26.5%, and 26.1% and ALT normalization rates were 64.5%, 78.1%, 87.9%, 90.0% at 12, 24, 36, and 48 weeks, respectively. Six patients (5.7%) had a viral breakthrough. CONCLUSIONS: Clevudine is a useful drug in the initial treatment of patients with CHB, with a potent antiviral effect and low incidence of viral breakthrough.

A case of phlegmonous gastritis associated with marked gastric distension.

Phlegmonous gastritis is an acute and severe infectious disease that is occasionally fatal if the diagnosis is delayed. Alcohol consumption, an immunocompromised state (e.g., due to HIV infection, rheumatoid arthritis, diabetes mellitus, or adult T-cell lymphoma), and mucosal injury of the stomach are reported to be predisposing factors. The main treatments for phlegmonous gastritis are antibiotics administration or surgery. In this case, the patient's stomach was markedly distended due to long-lasting gastric-outlet obstruction, which is thought to be the predisposing factor for phlegmonous gastritis. We inserted a metal stent at the obstructed site palliatively due to strong refusal by the patient for surgery. The patient recovered after stenting and antibiotic therapy.

Pancreatic pseudocyst filled with semisolid lipids mimicking solid mass on endoscopic ultrasound.

Pancreatic pseudocysts, which account for 70%-90% of pancreatic cystic lesions, characteristically are non-epithelially lined cystic cavities that are contiguous with the pancreas. Pancreatic pseudocysts can be caused by acute, chronic or traumatic pancreatitis and should be differentiated from other pancreatic diseases with cystic appearances, especially cystic neoplasms. We report a unique case of a pancreatic pseudocyst filled with semisolid lipids, which appeared by endoscopic ultrasound as a solid mass, and was therefore resected.

Evaluation of esophageal varices on liver computed tomography: receiver operating characteristic analyses of the performance of radiologists and endoscopists.

BACKGROUND AND AIM: Recent liver multi-detector row computed tomography (MDCT) always covers the distal esophagus with an excellent image quality. The aim of this study was to compare the performance of faculty abdominal radiologists with those of radiology residents and endoscopists for the detection of esophageal varices and high-risk esophageal varices on liver MDCT. METHODS: A total of 104 cirrhotic patients that had undergone liver MDCT 4 weeks or less before an upper endoscopy were evaluated. Two faculty abdominal radiologists, two radiology residents, and two endoscopists independently interpreted all of the CT images to detect the presence of esophageal varices and high-risk (grade 2 or 3) esophageal varices. With endoscopic grading as the reference standard, their performances were compared by using receiver operating characteristic (ROC) curve analysis. RESULTS: The areas under the ROC curves for the detection of esophageal varices indicated better performance of the abdominal radiologists (A(z) = 0.868), compared with the radiology residents (A(z) = 0.798) (P = 0.007) and endoscopists (A(z) = 0.784) (P = 0.006). For the detection of high-risk esophageal varices, however, the performance of the abdominal radiologists (A(z) = 0.914) was similar to those of radiology residents (A(z) = 0.900) and endoscopists (A(z) = 0.907) (each P > 0.05). CONCLUSIONS: Experienced readers have a better ability to detect esophageal varices on liver MDCT, but had no higher performance to evaluate high-risk esophageal varices. As the accuracy of detecting high-risk esophageal varices with clinical relevance on liver MDCT is excellent, even by endoscopists, the evaluation of esophageal varices from a recent liver MDCT may be useful to avoid the use of low-yield endoscopy.

[Antiviral efficacy of lamivudine/adefovir combination therapy in chronic hepatitis b patients with resistance to lamivudine and adefovir consecutively].

BACKGROUND/AIMS: The aim of this study was to elucidate the antiviral efficacy of lamivudine (LMV)-adefovir (ADV) combination therapy in chronic hepatitis B patients who showed resistance to LMV and ADV consecutively. METHODS: A retrospective review was performed in eighteen patients with chronic hepatitis B who developed virologic breakthroughs during LMV-ADV sequential mono-therapy and treated with LMV-ADV combination therapy. RESULTS: The median duration of follow up was 17 months (range, 6-27) after the start of LMV-ADV combination therapy. Mean HBV DNA level in log10 IU/mL was 6.08+/-0.95, 4.05+/-1.66, 3.17+/-1.58, 3.18+/-2.16, and 2.35+/-1.52 at 0, 3, 6, 12, and 24 months, respectively. Sixteen patients (88.9%) showed HBV DNA reduction below detection limit (<20,000 IU/mL). HBeAg seroconversion was observed in one patient (7.1%) after 8 months of combination therapy. Virologic breakthrough occurred in only one patient after 21 months of combination therapy. Viral rebound occurred in two patients at 12 months and 14 months of combination therapy. Normalization of serum ALT was achieved in twelve patients (66.7%). Primary non-response was observed in two cases (11.1%). CONCLUSIONS: LMV-ADV combination treatment was effective in 88.9% of patients with resistance to LMV and ADV in a short-term follow up. It may be applied as a bridge therapy until another effective antiviral regimen becomes available.

A Case of Obstructive Jaundice Caused by Paradoxical Reaction during Antituberculous Chemotherapy for Abdominal Tuberculosis.

Abdominal tuberculosis is not a rare disease, but obstructive jaundice caused by tuberculosis (tuberculous lymphadenitis, tuberculous enlargement of the head of pancreas, and/or tuberculous stricture of the biliary tree) is rare. We recently experienced a case of obstructive jaundice as a result of paradoxical reaction of periportal tuberculous lymphadenopathy that was treated successfully with corticosteroid and biliary drainage. No similar cases have been reported previously.

[Efficacy of initial treatment with peginterferon alpha-2a versus peginterferon alpha-2b in combination with ribavirin in naive chronic hepatitis C patients living in Daejeon and Chungcheong Province in Korea: a comparative study].

BACKGROUNDS/AIMS: Peginterferon alpha-2a or -2b is the standard treatment regimen in chronic hepatitis C. However, there have been few comparative studies of the efficacies of these two types of peginterferon. We evaluated their efficacies in combination with ribavirin as a initial treatment for chronic hepatitis C. METHODS: Ninety-seven patients were treated with peginterferon alpha-2a (180 microg/week, n=48) or peginterferon alpha-2b (1.5 microg/kg/week, n=49) plus ribavirin (800 mg/day for 24 weeks in genotype non-1 or 1,000-1,200 mg/day for 48 weeks in genotype 1). Virologic responses including the early virologic response (EVR), end-of-treatment response (ETR), sustained virologic response (SVR), and adverse effects were analyzed retrospectively. RESULTS: The virologic response rates did not differ significantly between peginterferon alpha-2a and -2b: 89.6% and 89.7% for EVR, 79.2% and 79.5% for ETR, 72.9% and 73.5% for SVR, respectively. Analysis of the virologic responses according to genotype also revealed no significant differences in SVR between peginterferon alpha-2a and -2b (59.3% vs. 59.7% for genotype 1 and 90.5% vs. 83.3% for genotype non-1, respectively), or in adverse effects including flu-like symptom, rash, itching, neutropenia, and thrombocytopenia. CONCLUSIONS: We found no significant differences in therapeutic efficacies and adverse effects between the alpha-2a and -2b types of peginterferon as the initial treatment regimen in naive chronic hepatitis C patients.

[Changes in the profiles of causative agents and antibiotic resistance rate for spontaneous bacterial peritonitis: an analysis of cultured microorganisms in recent 12 years].

BACKGROUNDS/AIMS: The causative agents for spontaneous bacterial peritonitis (SBP) and antibiotic resistance rate vary according to the regions and time. This study evaluated the recent changes in the profiles of microorganisms and antibiotic resistance rate for the choice of effective antibiotics in treating SBP. METHODS: The clinical records of 1,018 episodes of SBP from November, 1994 to December, 2005, were analyzed retrospectively. The profiles of the causative agents for SBP and the rate of antibiotic resistance were compared in every 4-year-term. RESULTS: The microorganisms were isolated in 394 out of 1018 episodes (38.7%). Gram negative and positive organisms constituted 71.6% and 21.3%, respectively. The five most commonly isolated organisms were E. coli (35.8%), K. pneumoniae (15.5%), viridans Streptococci (10.4%), S. pneumoniae (4.8%) and Aeromonas group (4.6%). The rate of E. coli resistant to cefotaxime (0%, 5.4%, 7.4%) and ciprofloxacin (4.3%, 21.6%, 28.4%) were increased in recent years. In the gram positive organisms, all isolates of viridans Streptococci and Pneumococci were sensitive to cefotaxime and ciprofloxacin. Recently, methicillin-resistant Staphylococcus aureus (MRSA) (28%) and vancomycin-resistant Enterococci (VRE) (31%) have been isolated. In each period, the overall antibiotic resistance rates to cefotaxime were 12.5%, 14.0%, 14.8%, to ciprofloxacin were 3.1%, 16.7%, 18.0%, and to imipenem were 4.7%, 7.0%, 4.2%. CONCLUSIONS: Cefotaxime may still be the choice of primary empirical antibiotics for the treatment of SBP in Korea because the rate of resistance is acceptable. However, it is important to be aware of the recent increase in ciprofloxacin-resistant E. coli, extended spectrum beta-lactamase (ESBL)-producing gram negative bacilli, MRSA and VRE.