Decreased Colorectal Adenoma Risk After Helicobacter pylori Eradication: A Retrospective Cohort Study.

BACKGROUND: Helicobacter pylori infection is associated with colorectal adenoma and confers a 1.3- to 2.26-fold increased risk. We evaluated the association between H. pylori and the progression of colorectal adenoma. METHODS: This retrospective cohort study included 615 adults with no history of colorectal adenoma or cancer at baseline who participated in a repeated, regular health screening examination, which included a bidirectional gastrointestinal endoscopy, between July 2006 and June 2015. A gastric biopsy specimen from each subject was tested for H. pylori. RESULTS: During follow-up, the incidence rates of colorectal adenoma progression in participants with persistent H. pylori infections (persistent group) and those whose infections had previously been successfully eradicated (eradication group) were 160.52 and 51.60 per 1000 person-years, respectively (P = .0003). After adjustment for confounding factors, the persistent group exhibited a higher risk of colorectal adenoma than the eradication group (hazard ratio = 3.04, 95% CI 1.899, 5.864). The colorectal adenoma ratio of patients uninfected with H. pylori was similar to that of the eradication group (23.93% vs 20.12%, P = .328). CONCLUSIONS: Persistent H. pylori infection was associated significantly with the independent development of colorectal adenoma. H. pylori infection may have a pathophysiological role in colorectal adenoma development and, after successful eradication of H. pylori, the colorectal adenoma ratio might decrease.

Synergistic Effect of Hyperglycemia and Helicobacterpylori Infection Status on Colorectal Adenoma Risk.

Context: Both Helicobacter pylori and type 2 diabetes mellitus are possible risk factors for colon adenoma. Objective: The purpose of this study was to assess the interaction between H. pylori and hyperglycemia status on the risk of colon adenoma. Design, Setting, and Participants: This was a cross-sectional, retrospective study conducted at the MacKay Memorial Hospital, Taiwan. The study included 3943 subjects aged >40 years undergoing bidirectional gastrointestinal endoscopy on the same day between July 2006 and June 2015. All subjects had a gastric biopsy specimen tested for H. pylori. Main Outcome Measure: Colon adenoma with and without H. pylori infection at different hemoglobin A1c (HbA1c) levels. Results: The prevalence of colorectal adenomas in patients who were H. pylori-positive and H. pylori-negative was 37.3% and 27.29%, respectively. Multivariate logistic regression analysis identified male sex, age, body mass index, H. pylori infection, and HbA1c ≥6.5% as independent risk factors for adenoma; use of hypoglycemic agents decreased this risk. The prevalence of adenoma was increased with elevated HbA1c levels regardless of H. pylori status. The odds ratio (OR) for adenoma was 1.44 (95% confidence interval [CI], 1.20 to 1.73) if H. pylori was present or 1.68 (95% CI, 1.05 to 2.70) in patients who were H. pylori-negative but had HbA1c ≥7.0%. If both conditions were present, the OR was 4.79 (95% CI, 2.92 to 7.84). A 1% increase in HbA1c was associated with an increased prevalence of adenoma by 42.4% in H. pylori-positive subjects. Conclusions: The combination of H. pylori infection and elevated HbA1c is associated with an increased risk of colon adenoma.

Hyperglycemia combined Helicobacter pylori infection increases risk of synchronous colorectal adenoma and carotid artery plaque.

BACKGROUND: Cardiovascular disease and colorectal cancer have severe consequences to human health and may occur simultaneously or sequentially. Carotid artery plaque is a predictor of cardiovascular disease, and colorectal adenoma is a premalignant lesion of colorectal cancer. We investigated the core risk factors of carotid artery plaque and colorectal adenoma. RESULTS: In total, 2361 subjects were enrolled. In multivariate analysis, age ≥ 60 years, male sex, BMI > 27, LDL > 130 mg/dL, HbA1c ≥ 6.5%, hs-CRP > 0.3 mg/L and H. pylori infection were independent risk factors for synchronous colorectal adenoma and carotid artery plaque formation. In the H. pylori-positive and -negative groups, the proportions and odds ratio (OR) for synchronous colon adenoma and carotid artery plaque increased with increasing HbA1c. OR for synchronous colon adenoma and carotid artery plaque was significantly higher in the participants with HbA1c levels of 5.7%-6.4% and HbA1c ≥ 6.5% than in those with normal HbA1c in the H. pylori-negative group. The OR was more significant increased for H. pylori-positive patients when HbA1c level ≥ 6.5% was 15.87 (95% CI 8.661-29.082, p < 0.0001). MATERIALS AND METHODS: The records of 4669 subjects aged > 40 years who underwent bidirectional gastrointestinal endoscopy and carotid artery ultrasound examination on the same day or within 12 months of endoscopy examination from January 2006 to December 2015 were reviewed. All subjects had a gastric biopsy specimen tested for Helicobacter pylori. CONCLUSIONS: Hyperglycemia combined with H. pylori infection was an increased risk factor for synchronous colorectal adenoma and carotid artery plaque formation. Diabetes control and H. pylori eradication may be warranted in higher prevalence areas.

How Does Aging Affect Presentation and Management of Biliary Stones?

Common bile duct (CBD) stones are common in elderly adults, but the effect of aging on the presentation of CBD stones remains to be evaluated. Recent studies have demonstrated that the clinical presentation of CBD stones may vary with age. Younger adults may present with classical biliary colic symptoms, whereas elderly adults may have no unapparent clinical features. Younger adults with CBD stones were significantly more likely to have abnormal liver function tests than those without. The sensitivity and accuracy of transabdominal ultrasound scans in screening for CBD stones increases with age. Antibiotic agents should be promptly administered to individuals with CBD stones complicated by cholangitis, but the effects of pharmacotherapy on renal function should be considered in elderly adults. Endoscopic retrograde cholangiopancreatography (ERCP) is considered to be first-line treatment for CBD stones, and endoscopic biliary sphincterotomy (EST) or endoscopic papillary balloon dilation (EPBD) along with ERCP is an adequate biliary drainage method in individuals with CBD stones. EPBD has a lower bleeding risk but higher post-ERCP risk of pancreatitis than EST. Longer-duration (>1 minute) EPBD may be preferred over EST because it is associated with a comparable risk of pancreatitis but a lower rate of overall complications, although recurrent cholangitis or unfavorable outcomes will increase during CBD dilation or in the presence of residual CBD stones.

Off-treatment efficacy of 3-year nucleos(t)ide analogues in chronic hepatitis B patients.

Lamivudine, telbivudine, and entecavir are the first-line drugs covered by the Taiwan National Health Insurance as 3-year treatments for patients with chronic hepatitis B virus (HBV), but the optimal treatment duration of each remains unclear. We aimed to detect HBV treatment-cessation durability, and compare the predictors in patients with and without clinical relapse. In this retrospective cohort study, 210 patients with chronic HBV who tested hepatitis B e-antigen positive or hepatitis B e-antigen negative were treated for 3 years with a nucleos(t)ide analogue. Of these, 102 patients continued therapy after 3 years, while 88 patients stopped treatment and were followed for 1 year due to financial difficulties. Efficacy was assessed in terms of alanine aminotransferase (ALT) level normalization, HBV DNA clearance, virus breakthrough, clinical relapse, and liver decompensation. The durability predictors were evaluated by host factors, HBV DNA, and drug differences. Eighty patients (14 on lamivudine, 19 on telbivudine, and 47 on entecavir) were recruited. There was no difference in clinical-relapse rate among lamivudine, telbivudine, and entecavir (35.7% vs. 36.8% vs. 31.9%, respectively; p = 0.916), and liver decompensated hepatitis was absent. In baseline clinical characteristics, there were no differences between the clinical-relapse and nonrelapse groups in age, sex, cirrhosis, prior treatment, HBV DNA, pretreatment ALT, or hepatitis B e-antigen (HBeAg). The mean 3(rd) year serum ALT level differed significantly between clinical-relapse and nonrelapse patients (37.5 U/L vs. 27.7 U/L, respectively; p = 0.044). The 3-year nucleos(t)ide analogue off-treatment in patients with chronic HBV delivered according to the Taiwan National Health Insurance guidelines had an overall 33.8% 1-year clinical-relapse rate without any decompensated hepatitis flare-ups.

Clinical presentations of patients from different age cohorts with biliary tract stone diseases.

BACKGROUND AND AIM: The role of clinical symptoms, transabdominal ultrasound scan (USS), and liver function tests (LFTs) in evaluating common bile duct (CBD) stones in patients suspected to have pancreatobiliary disease has been studied. However, it is unclear whether these predictive models are useful in different age cohorts. The aim of this study is to investigate the clinical presentations from different age cohorts with and without CBD stones. METHODS: Four hundred and forty-three patients with pancreatobiliary diseases were divided into cohorts according to decades as follows: young (Y, 18-64 years old, n = 143), young-old (YO, 65-74 years old, n = 168), old-old (OO, 75-84 years old, n = 97), and very old (VO, ≥ 85 years old, n = 35). The clinical symptoms, LFTs, and USS findings were demonstrated and compared among patients. RESULTS: Y- and YO-group patients were more likely to develop symptoms such as biliary colic in the presence of CBD stones. The proportion of abnormal serum aspartate aminotransferase and alanine aminotransferase were significantly greater in Y-, YO-, and OO-group patients with than in those without CBD stones. Sensitivity of USS for CBD stones in Y: 0.15; YO: 0.45; OO: 0.57; and VO: 0.68. Accuracy of USS for detected CBD stone in Y: 48%; YO: 62.5%; OO: 70.1%; and VO: 71.4%. CONCLUSION: Combined evaluation of clinical symptoms, biochemical and USS findings may help predict the presence of CBD stones. In Y, YO, and OO patients with CBD stones, the incidences of abnormal LFTs were higher. The sensitivity and accuracy of USS in detecting CBD stones were increased according to age.

Clinicopathological correlation and prognostic significance of protein kinase cα overexpression in human gastric carcinoma.

OBJECTIVES: This study investigated the PKCα protein expression in gastric carcinoma, and correlated it with clinicopathological parameters. The prognostic significance of PKCα protein expression in gastric carcinoma was analyzed. METHODS: Quantitative real-time PCR test was applied to compare the PKCα mRNA expression in tumorous and nontumorous tissues of gastric carcinoma in ten randomly selected cases. Then PKCα protein expression was evaluated in 215 cases of gastric carcinoma using immunohistochemical method. The immunoreactivity was scored semiquantitatively as: 0 = absent; 1 = weak; 2 = moderate; and 3 = strong. All cases were further classified into two groups, namely PKCα overexpression group with score 2 or 3, and non-overexpression group with score 0 or 1. The PKCα protein expression was correlated with clinicopathological parameters. Survival analysis was performed to determine the prognostic significance of PKCα protein expression in patients with gastric carcinoma. RESULTS: PKCα mRNA expression was upregulated in all ten cases of gastric carcinoma via quantitative real-time PCR test. In immunohistochemical study, eighty-eight out of 215 cases (41%) of gastric carcinoma revealed PKCα protein overexpression, which was statistically correlated with age (P = 0.0073), histologic type (P<0.0001), tumor differentiation (P = 0.0110), depth of invasion (P = 0.0003), angiolymphatic invasion (P = 0.0373), pathologic stage (P = 0.0047), and distant metastasis (P = 0.0048). We found no significant difference in overall and disease free survival rates between PKCα overexpression and non-overexpression groups (P = 0.0680 and 0.0587). However, PKCα protein overexpression emerged as a significant independent prognostic factor in multivariate Cox regression analysis (hazard ratio 0.632, P = 0.0415). CONCLUSIONS: PKCα protein is upregulated in gastric carcinoma. PKCα protein expression is statistically correlated with age, histologic type, tumor differentiation, depth of invasion, angiolymphatic invasion, pathologic stage, and distant metastasis. The PKCα protein overexpression in patients with gastric carcinoma is a significant independent prognostic factor in multivariate Cox regression analysis.

Recurrent cholangitis after endoscopic lithotripsy of common bile duct stones with gallstones in situ: predictive factors with and without subsequent cholecystectomy.

BACKGROUND: Common bile duct stones are a frequent complication of gallstones. Endoscopic retrograde cholangiopancreatography and sphincterotomy are often performed to evaluate the etiology of obstructive jaundice and for concomitant therapeutic removal of common bile duct stones. We aimed to evaluate the recurrence rate of cholangitis or cholecystitis after endoscopic lithotripsy with gallstones in situ and to identify associated predictive factors. PATIENTS AND METHODS: We retrospectively reviewed 183 patients who had received endoscopic lithotripsy between July 2007 and June 2010. We divided patients into two groups: One group who had received subsequent cholecystectomy (n=66) and one observational group (n=117). Patients with previous cholecystectomy or without gallstones were excluded. All included patients were followed up at our outpatient department. Our end point was the presence of symptoms of recurrent cholangitis or cholecystitis. RESULTS: Subjects included 86 males and 97 females with a mean age of 62.5±16.3 years (range, 43-81 years). Cholangitis or cholecystitis recurred in 6 patients in the cholecystectomy group and 30 patients in the observational group. Findings revealed a lower recurrence rate and longer recurrence-free period in patients who received subsequent cholecystectomy. The recurrence rate of the observational group was significantly higher than that of the cholecystectomy group (25.6% versus 9.1%, P=.007). Univariate and multivariate Cox regression analyses revealed that common bile duct dilatation was an independent predictive factor for recurrence. CONCLUSIONS: Cholecystectomy is recommended after endoscopic lithotripsy. Common bile duct dilatation is associated with the rate of recurrent cholangitis or cholecystitis.

Perforated peptic ulcer in southeastern Taiwan.

BACKGROUND: No studies focus on the population with perforated peptic ulcer in southeastern Taiwan. The present study aimed to assess the differences between the different races and the risk factors related to mortality and morbidity in postoperative patients in southeastern Taiwan. METHODS: The medical records of 237 patients were reviewed retrospectively. The following factors were analyzed: patient profiles, coexisting illnesses, diagnostic method, fever, preoperative shock, clinical data at emergency room, delay operation, site of perforation, operative method, positive ascites culture, species of microbes in ascites culture, postoperative complications, death and the length of hospital stay. RESULTS: Aborigines were significantly different from non-aborigines in the ratio of female cases and in the habits of alcohol drinking and betel nut chewing. There were also four significantly different variables between them: fever, hemoglobin value, site of perforation and operative method. Total postoperative complication rate was 41.3% and 39 patients (16.6%) died. In multivariate analysis, age > or = 65 years, lipase > upper normal limit and preoperative shock were independent predictors of mortality. Significant risk factors associated with morbidity were NSAIDs use, creatinine > 1.5 mg/dL and preoperative shock. CONCLUSION: Aborigines were different from non-aborigines in several categories. In southeastern Taiwan, NSAIDs use, creatinine > 1.5 mg/dL and preoperative shock were independent risk factors of morbidity, and age > or = 65 years, lipase > upper normal limit and preoperative shock were independent risk factors of mortality in postoperative perforated peptic ulcer. Lipase > upper normal limit is needed for further research on the influence on mortality.

Comparison of coplanar and noncoplanar intensity-modulated radiation therapy and helical tomotherapy for hepatocellular carcinoma.

BACKGROUND: To compare the differences in dose-volume data among coplanar intensity modulated radiotherapy (IMRT), noncoplanar IMRT, and helical tomotherapy (HT) among patients with hepatocellular carcinoma (HCC) and portal vein thrombosis (PVT). METHODS: Nine patients with unresectable HCC and PVT underwent step and shoot coplanar IMRT with intent to deliver 46-54 Gy to the tumor and portal vein. The volume of liver received 30Gy was set to keep less than 30% of whole normal liver (V30<30%). The mean dose to at least one side of kidney was kept below 23 Gy, and 50 Gy as for stomach. The maximum dose was kept below 47 Gy for spinal cord. Several parameters including mean hepatic dose, percent volume of normal liver with radiation dose at X Gy (Vx), uniformity index, conformal index, and doses to organs at risk were evaluated from the dose-volume histogram. RESULTS: HT provided better uniformity for the planning-target volume dose coverage than both IMRT techniques. The noncoplanar IMRT technique reduces the V10 to normal liver with a statistically significant level as compared to HT. The constraints for the liver in the V30 for coplanar IMRT vs. noncoplanar IMRT vs. HT could be reconsidered as 21% vs. 17% vs. 17%, respectively. When delivering 50 Gy and 60-66 Gy to the tumor bed, the constraints of mean dose to the normal liver could be less than 20 Gy and 25 Gy, respectively. CONCLUSION: Noncoplanar IMRT and HT are potential techniques of radiation therapy for HCC patients with PVT. Constraints for the liver in IMRT and HT could be stricter than for 3DCRT.

Findings and risk factors of early mortality of endoscopic retrograde cholangiopancreatography in different cohorts of elderly patients.

OBJECTIVES: To analyze experience of endoscopic retrograde cholangiopancreatography (ERCP) in patients with of different age cohorts and discuss the risk factors of early mortality after ERCP. DESIGN: Retrospective study. SETTING: Tertiary care medical center. PARTICIPANTS: Two hundred sixty-four patients with pancreatobiliary diseases divided into cohorts according to decades as young-old (YO, 65-74, n=143), old-old (OO, 75-84, n=88), and very-old (VO, >or=85, n=33). MEASUREMENTS: The indications, results, and complications of ERCP in these three groups were demonstrated and compared. RESULTS: Three hundred three ERCP procedures were performed. The leading indication for ERCP was common bile duct (CBD) obstruction or dilation. Diabetes mellitus was significantly more prevalent in the YO group (39.2%) than in the other two groups (OO, 15.9%; VO, 24.2%; P=.001). The most common finding of ERCP was CBD dilatation. There was no difference in incidence of malignant diseases between the three groups. Acute pancreatitis was the most frequently identified post-ERCP complication. There was no significant difference in early mortality between the three cohorts. Patients with malignancy had higher early mortality than those with benign disease (71.4% vs 11.2%; P=.001). CONCLUSION: The findings and incidences of complication of ERCP in different elderly cohorts were similar. Underlying malignancy seemed to bear some relation to early mortality after the ERCP procedure.

Predictive model for length of hospital stay of patients surviving surgery for perforated peptic ulcer.

BACKGROUND/PURPOSE: Many studies have assessed the major risk factors for mortality or morbidity in surgical patients with perforated peptic ulcer (PPU). The aim of our study was to focus on survivors and to investigate the predictive factors for length of hospital stay (LOHS) for surgical patients. METHODS: The medical records of 195 patients who survived surgery were reviewed retrospectively. The following factors were analyzed: patient profile, associated medical illnesses, diagnostic methods, fever, preoperative shock, clinical data from the emergency room, delays in surgery, sites of perforation, operative methods, positive ascites culture and species of microorganism, postoperative infection, and noninfective postoperative complications. RESULTS: Univariate analysis showed that the following factors were significantly related to longer LOHS: age > 65 years, liver cirrhosis, diabetes mellitus, history of peptic ulcer disease, number of comorbid diseases, preoperative shock, creatinine > 1.5 mg/dL, surgical delay of > 12 hours, and all postoperative factors except species of microorganisms in ascites culture. In a multivariate linear regression model, catheter infection, pneumonia, urinary tract infection, wound infection, bacteremia, non-infective abdominal complications, other infections, surgical delay of > 12 hours, and comorbidity were major factors associated with longer LOHS. CONCLUSION: A predictive model was established with nine factors that explained 71.6% of the variation in LOHS of patients who survived surgery for PPU. Several corrective methods based on the model can be devised by attending physicians to shorten LOHS.

Proposed scoring system to determine small bowel mass lesions using capsule endoscopy.

BACKGROUND/PURPOSE: Capsule endoscopy is a highly sensitive method for the detection of small bowel lesions. False-positive findings are important confounding factors. This study reports on a scoring system for evaluating the role of capsule endoscopy in small bowel tumors. METHODS: Ten men and two women (age, 23-79 years) with suspected small bowel tumors were included from 120 patients referred for capsule endoscopy between March 2004 and March 2008. The indications were gastrointestinal bleeding (n = 9), melanoma workup (n = 1), physical checkup (n = 1), and iron deficiency anemia (n = 1). The proposed tumor score was composed of five components: bleeding, mucosal disruption, an irregular surface, color, and white villi. These can be scored for probability of mass lesions seen at capsule endoscopy. Small bowel mass lesions were probably present in those with a score of >or= 4, and a score of

Partial splenic embolization: 12-month hematological effects and complications.

BACKGROUND/AIMS: To investigate the hematological effects and immediate postoperative complications of partial splenic embolization (PSE) in patients with liver cirrhosis. METHODOLOGY: Record of liver cirrhosis patients with thrombocytopenia and leukopenia in whom PSE was performed between June 1995 and June 2005 were reviewed. Peripheral blood counts were evaluated at baseline, at 1 week, and at months 1, 3, 6, and 12 months post-PSE and clinically significant complications were recorded. RESULTS: In the twenty patients who underwent PSE, significant improvements in thrombocyte and leukocyte levels were noted at all time points compared to baseline levels up to one year following PSE (P<0.01). The complication rate was 100% because all patients experienced fever and abdominal pain. Only 7 patients (35%) experienced additional, mild post-embolization complications, and only 2 (10%) experienced serious complications. The mortality rate in this study was 0%. CONCLUSIONS: PSE significantly improved thrombocytopenia and leukopenia. These results support the contention that PSE is effective and safe, and should be employed more widely in the management of thrombocytopenia in patients with liver cirrhosis, particularly higher-risk patients that may not be candidates for surgical splenectomy. Further studies evaluating risk factors, criteria for patient selection, and target embolization area are warranted.

Proboscis-like Brunner's gland hyperplasia.

Hyperplasia of Brunner's glands is a benign lesion discovered incidentally in 2% of upper gastrointestinal endoscopies. An asymptomatic 34-year-old woman had a 12-cm duodenal lesion resembling an elephant's proboscis. It was removed surgically and proved to be Brunner's gland hyperplasia.

Simultaneous Klebsiella pneumoniae and amoebic liver abscess in an immunocompetent patient.

Simultaneous Klebsiella pneumoniae and amoebic liver abscess is rarely reported in immunocompetent patients. A 47-year-old man was hospitalized with abdominal pain, fever, chills, and hypotension. Physical examination revealed right upper quadrant tenderness. Abdominal computed tomography showed an area of low attenuation with some liquefaction in the liver. Echo-guided aspiration revealed 30 mL of pus, which grew Klebsiella pneumoniae, and the same organism was isolated from the blood. Cytology examination of the pus showed scattered amoeba. The patient gradually improved over 1 month on treatment with cefmetazole and metronidazole, along with repeated drainage of the abscess. His amoebic indirect hemagglutination titer was 1:128, but no parasite ova or amoeba were found in the stool. He had no evidence of immunocompromise. Parasitic diseases may be a predisposing factor for bacterial infections, including pyogenic liver abscess. The possible coexistence of amoebae and bacteria in a liver abscess should not be discounted.