Endoscopic hemoclip treatment of gastrointestinal bleeding.

BACKGROUND: Endoscopic hemostasis of gastrointestinal (GI) bleeding is a widely accepted modality of treatment, and endoscopic hemoclipping has been reported to cause fewer complications. METHODS: Forty patients with gastrointestinal bleeding (active bleeding or non-bleeding visible vessel), 30 men and 10 women with a mean age of 59.1 +/- 14.4 (28-86) years were treated with endoscopic hemoclipping. After panendoscopy or colonoscopy, a local epinephrine injection was routinely given in the initial 20 cases, followed by hemoclipping. For the latter 20 cases, local epinephrine was given only to those with active bleeding. If there was adherent blood clot, irrigation with 3% H2O2, and removal of the blood clot with forceps or basket were done. Six cases with bleeding at technically difficult locations were managed with a new method; a transparent cap (Olympus EMRC) fitted with a 2-channel endoscope for hemoclipping. RESULTS: There were 35 patients with peptic ulcer, 2 with post endoscopic papillotomy bleeding, 1 with duodenal Dieulafoy's lesion, 1 with Mallory Weiss syndrome, and 1 with rectal ulcer. The types of bleeding were spurting in 7, oozing in 12, and non-bleeding visible vessel in 21 cases. The average number of clips used was 3.1 +/- 1.7 (1-9) and the average clip loss was 0.6 +/- 0.9 (0-4) per patient. The success rate for hemostasis using the transparent cap-fitted endoscope was 100% and the overall success rate was 85% with no complications related to the procedure. CONCLUSION: Endoscopic hemoclip treatment for GI bleeding is safe and effective. The transparent cap-fitted endoscope is a new method for hemoclipping in technically difficult lesions.

Hemoclip-assisted endoscopic polypectomy of large superior duodenal angle polyp using a needle knife.

Endoscopic polypectomy of a large polyp can be difficult due to inability to snare the polyp. The difficulty may increase when the polyp is located at turning corner of the bowel. We presented a case of a 3 cm-sized large pedunculated polyp located at the superior duodenal angle that was not amenable to conventional snare polypectomy, but was instead successfully resected by hemoclip-assisted and needle knife method. Such experience has not been reported in the English literature.

ERCP in post-Billroth II gastrectomy patients: emphasis on technique.

OBJECTIVE: Endoscopic retrograde cholangiopancreatography (ERCP) in post-Billroth II (BII) gastrectomy is more difficult due to anatomical changes. The difficulties include entrance to the afferent loop and selective cannulation. Our aim here is to report the success rate and special manipulations and techniques of this procedure. METHODS: A retrospective review of 56 ERCP procedures in post-BII gastrectomy patients was performed. There were 43 male and 13 female patients with a mean age of 63 yr (range, 32-78 yr). All cases were tried with forward-viewing endoscope first. Of the failed cases, 10 were retried by side-view duodenoscope. The entrance to the afferent loop was attempted by starting from the upper opening at the anastomosis site and, if this failed, then using the lower opening; presence of bile; and air-contrasted afferent loop under fluoroscopy. If failure of afferent loop entrance resulted, hand compression over the mid-abdomen, or polypectomy snare in the working channel of the endoscope, was tried. For failure of common bile duct cannulation with straight catheters, techniques of pushing the catheter against the duodenal wall and bending the tip of the endoscope or guidewire were used. RESULTS: The success rate of afferent loop entrance was 76.7% (43 of 56 cases). The afferent loop was identified in the upper orifice of the anastomosis in 93% (40 of 43) of the cases. Eight cases of afferent loop entrance could be facilitated by hand compression, and three by polypectomy snare in the working channel of the endoscope. The success rate of ERCP cannulation in those successful afferent loop intubation cases was 81.3% (35/43 cases). Most of the selective common bile duct (CBD) cannulation was achieved by straight (new) catheter and an additional six cases were successful using the techniques mentioned. No serious complications were encountered, except three cases of submucosal hemorrhage. CONCLUSION: The overall success rate of BII ERCP was 62.5% (35 of 56 cases). The special manipulations mentioned in BII ERCP can be helpful in certain cases.

Clinical experience of esophageal ulcers and esophagitis in AIDS patients.

In Taiwan, numbers of patients with the acquired immunodeficiency syndrome (AIDS) have been increasing in recent years. We present esophageal disease of different causes in 5(16%) heterosexual men among 31 AIDS patients over a 5-year period. Major symptoms included mild dysphagia in 4 (80%) patients and odynophagia in 3 (60%) patients. The duration of symptoms varied from 3 days to 6 months. The symptoms occurred before the diagnosis of AIDS in 3 patients. At esophagogastroduodenoscopy (endoscopy), all 5 patients had esophagitis and/or esophageal ulcers proved by histopathologic evaluation. Four had Candida esophagitis, 3 had cytomegalovirus esophagitis/ulcers and 2 had idiopathic esophageal ulcerations (IEU). Three patients had different esophagitis/ulcers at the same time or during follow-up. The median CD4 lymphocyte count at the time of diagnosis of esophageal disease was 12.2 cells/mm3 (range, 3 to 35 cells/mm3). The endoscopic pictures of the different causes of esophagitis/ ulcers lack uniformity in number, size and appearance. These observations make a conclusion that all AIDS patients with an esophageal disease should undergo endoscopy with biopsy to obtain a definitive diagnosis.

Diagnostic value of plasma aldosterone/potassium ratio in hypoaldosteronism.

The diagnosis of hypoaldosteronism usually depends upon a combination of abnormal clinical and laboratory findings. The most common abnormality in hypoaldosteronism is hyperkalemia, which may be combined with sodium depletion. In the present study, 5 of 16 patients diagnosed with isolated hypoaldosteronism (IHA) had sodium depletion due to renal salt wasting, and four patients had normokalemia. Of these 16 IHA patients, 70% had subnormal baseline and stimulated plasma renin activity (PRA). Six patients diagnosed with type I pseudohypoaldosteronism (PHA) had normal or high PRA and plasma aldosterone concentrations (PAC). In 11 control subjects, supine PAC correlated positively with serum potassium (SK), and PAC stimulated by furosemide and ambulation correlated with the 24-hour urinary potassium excretion (UK). However, these correlations were not found in IHA and PHA patients. The ratio of UK/UNa+K and UNa/UK correlated with the stimulated PAC when the IHA and control subjects were taken as a whole. However, these electrolyte excretion parameters bore no relationship to the supine PAC. The stimulated PAC/SK ratio was used to discriminate the three groups; all IHA patients had a ratio below 3. The results indicate that stimulated PAC reflects the bioactivity of aldosterone on the collecting tubule, and the stimulated PAC/SK ratio is useful for the diagnosis of hypoaldosteronism and pseudohypoaldosteronism.

Drug-induced liver disease--a review of 14 cases.

The clinical and pathological features of 14 cases of acute drug-induced liver disease (DILD) were analyzed using the French group method for drug reaction assessment. Among them, 8 were of the cytotoxic type, 4 were of the cholestatic type and 2 were of the mixed type. Serum alkaline phosphatase (ALP) levels of the cytotoxic type DILD were all < 1.8 times the normal value, while those of the cholestatic type DILD > 1.8 times (P < 0.05). The alanine aminotransaminase and aspartate aminotransaminase (ALT and AST) levels of the cholestatic type were all < 13.1 times the normal value, while those of the cytotoxic type varied from 2.2 to 118 times the normal value. We found that steatosis was the major feature in the cytotoxic type with ALT and AST < 2.5 times the normal value. Piecemeal necrosis was noted only in all the cases with ALT and AST > 20 times the normal value. In the cholestatic type, the pathological features of the oral contraceptive-related DILD showed mainly cholestasis, whereas chlorpromazine-related DILD revealed additional portal inflammation. Meticulous taking of patient history and clinical assessment are mandatory for the diagnosis of DILD. The ALP levels were helpful in distinguishing different types of DILD. There are some correlations between biochemical changes and pathological features, and both are helpful in distinguishing different etiologies of DILD when the inciting drug is in doubt.

Congestive gastropathy in cirrhotic patients: correlation between endoscopic and histological findings.

Congestive gastropathy is a common cause of gastrointestinal bleeding in cirrhotic patients. Forty-six patients with cirrhosis of the liver and 225 control subjects matched in age and sex without cirrhosis of the liver entered the study. We studied the prevalence of congestive gastropathy in cirrhotic patients, and the relationship between endoscopic and histological findings. Congestive gastropathy seen endoscopically was found to be more common in the cirrhotic group than in the control (85% vs. 5%, P < 0.05). The sensitivity, specificity and positive predictive value were 85%, 95% and 76%, respectively. The presence of endoscopic congestive gastropathy was correlated with the severity of liver disease (P < 0.05), but not to the etiology of cirrhosis and the size of esophageal varices with or without red color sign. Endoscopic congestive gastropathy showed no correlation with the histological features including gastritis, interstitial edema, vessel ectasia/congestion and hemosiderin in endoscopic biopsy specimens. In conclusion, congestive gastropathy is a common finding in cirrhotic patients. Its appearance is closely correlated with the severity of liver disease. There is no good correlation between endoscopic congestive gastropathy and mucosal histology.

Acute muscular paralysis in an adult with subclinical Bartter's syndrome associated with gentamicin administration.

We report an adult case of asymptomatic Bartter's syndrome with the first presentation of hypokalemic paralysis triggered by gentamicin injection. Marked hypokalemia and hypomagnesemia associated with excessive kaliuresis and magnesiuria were found. Plasma renin activity and aldosterone concentration were high, but blood pressure was normal. Renal biopsy revealed hypercellularity of the renin-producing cell of the juxtaglomerular apparatus. Muscular paralysis subsided after potassium chloride supplementation. Hypokalemia was corrected with potassium and magnesium supplements and the use of diclofenac. To the best of our knowledge, there have been no reports of muscular paralysis associated with gentamicin in Bartter's syndrome.

Mutation analysis of K-ras oncogenes in gastroenterologic cancers by the amplified created restriction sites method.

A rapid, simple, and nonradioactive method for diagnosing point mutations of c-K-ras oncogenes in gastroenterologic cancers is described. This method involved the selective amplification of DNA fragments from cancer tissues of surgical specimens with specific oligonucleotide primers, followed by digestion with restriction enzymes that recognized artificially created or naturally occurring restriction sites. To detect codon 12 mutations, an artificial Msp I site was created by introducing a single nucleotide mismatch into the 5' mutagenesis primer. Using a similar approach, an Hae III site was created to detect codon 13 mutations. Bal I and MBo II sites were used to detect codon 61 mutations. A total of 61 gastroenterologic cancer cases were studied. Of 35 cases of colorectal cancer, 7 showed mutations: 6 at codon 12 and 1 at codon 13. In 1 of 2 cases of cholangiocellular carcinoma, point mutation at codon 12 was found. One case of duodenal cancer showed point mutation at codon 12. No mutations were found in the cases of hepatocellular carcinoma (4), gastric cancer (12), esophageal cancer (3), or pancreatic cancer (2).

Double-blind comparison of omeprazole 20 mg OM and ranitidine 300 mg NOCTE in duodenal ulcer: a Taiwan multi-centre study.

Two hundred and twenty-six patients with endoscopically confirmed duodenal ulcers > or = 5 mm in diameter entered a double-blind randomized trial comparing 20 mg omeprazole administered once daily in the morning with 300 mg ranitidine administered once daily at night. The patients were assessed endoscopically and symptomatically after 2 weeks, and those whose ulcers had healed terminated the study. Patients with unhealed ulcers continued treatment for a total of 4 weeks. Omeprazole produced significantly higher healing rates than ranitidine at both 2 weeks (57 vs 28%, P < 0.0001) and 4 weeks (93 vs 80%, P = 0.006). Similarly, significantly higher 'effective healing rates' (defined on the criteria established by the Japanese Society of Digestive Endoscopy) were observed with omeprazole compared with ranitidine at 2 and 4 weeks. After 2 weeks, there were significantly fewer reports of both day-time and night-time epigastric pain by omeprazole-treated patients compared with ranitidine-treated patients (22 vs 44%, P < 0.0001 for day-time pain; 24 vs 35%, P = 0.025 for night-time pain). Both drugs were well-tolerated and no major adverse effects were recorded during either treatment. In conclusion, 20 mg omeprazole administered once daily was superior to 300 mg ranitidine administered once daily for duodenal ulcer healing and symptom relief.

[Imported case of malaria in Taiwan: analysis of 11 cases].

The "eradication of malaria" in Taiwan was announced by WHO in 1965. From 1966 to 1989, 919 malaria cases were detected in Taiwan. Of these cases, 803 were classified as imported malaria. During 1977 to 1989, our hospital collected 11 cases of imported malaria, 6 of Plasmodium falciparum (PF), including 1 suspicious case, 2 of Plasmodium vivax (PV), 1 of mixed infection (PF plus PV), and 2 unclassified. Most of the patients presented clinically with fever and chills. Hepatosplenomegaly was the most common abnormal finding during the physical examination. Jaundice and anemia occurred in the more severe cases. No cases had lymphadenopathy which is helpful in making a differential diagnosis. Six cases had thrombocytopenia which may be considered as an indirect sign in the diagnosis. The MCV levels were within normal limits in all of the cases. This may indirectly imply a potential protective effect against malaria infection in cases of congenital hemoglobinopathy such as thalassemia or G6PD deficiency. Initially, 10 cases were given "standard treatment", which consisted of chloroquine 450 mg qd for 2 days then 300 mg qd for 2 days and primaquine 15 mg qd for 2 weeks. Four cases of chloroquine resistance were encountered, all in cases with PF infection. Two cases were grade I delayed type resistance and were successfully treated with Fansidar, tetracycline and quinine. Two cases were grade II resistance and presented clinically as cerebral malaria. Intravenous quinine was given plus Fansidar and tetracycline. The cases were resolved without sequele or recurrence. None of the cases, except for 2, received chemoprophylaxis.(ABSTRACT TRUNCATED AT 250 WORDS)

Eosinophilic gastroenteritis with eosinophilic ascites: report of a case.

Eosinophilic gastroenteritis is a relatively uncommon disease of unknown etiology. Eosinophilic ascites resulting from significant serosal involvement is the rarest clinical subtype. The case reported here is of a 30-year-old male presenting with abdominal pain, diarrhea, and ascites. His personal history included childhood asthma, allergic rhinitis, and recurrent urticaria. The clinical picture was characterized by peripheral eosinophilia and eosinophilic infiltrates of the stomach and small bowel. Computed tomogram (CT) of the abdomen showed generalized thickening of the gastric and small bowel wall. Paracentesis revealed exudative ascites rich in eosinophils. The patient experienced an impressive response to steroid therapy.

Famotidine in the treatment of duodenal ulcers resistant to other histamine H2-receptor antagonists.

In 20% of patients with duodenal ulcers, treatment is ineffective. Ulcers are considered resistant when they fail to heal following 8-12 weeks of treatment with full dose duodenal ulcer therapy. The present study reviewed the records and endoscopic findings of 73 patients who were considered by their physicians to have resistant duodenal ulcers. From this population, 15 patients with documented, active duodenal ulcers were chosen to participate in this study. Each had failed treatment with cimetidine or ranitidine at recommended doses administered for from 56 days to more than 2 years. After up to 6 weeks' treatment with 20 mg famotidine given twice daily, eight patients showed endoscopic evidence of healing (S1 or S2) based on the criteria established by the Japanese Society of Digestive Endoscopy. Five others showed moderate to marked improvement H1-H3). No patient experienced side-effects during famotidine treatment. The greater antisecretory effect of famotidine may be useful in treating duodenal ulcer patients who fail to heal with cimetidine or ranitidine.