Search

Introduction: Water-assisted colonoscopy increases left colon mucus production; however, the effect of saline on mucus production is unclear. We tested the hypothesis that saline infusion may reduce mucus production in a dose-related manner., Methods: In a randomized trial, patients were assigned to colonoscopy with CO 2 insufflation, water exchange (WE) with warm water, 25% saline, or 50% saline. The primary outcome was the Left Colon Mucus Scale (LCMS) score (5-point scale). Blood electrolytes were measured before and after saline infusion., Results: A total of 296 patients with similar baseline demographics were included. The mean LCMS score for WE with water was significantly higher than that for WE with saline and CO 2 (1.4 ± 0.8 [WE water] vs 0.7 ± 0.6 [WE 25% saline] vs 0.5 ± 0.5 [WE 50% saline] vs 0.2 ± 0.4 [CO 2 ]; overall P < 0.0001), with no significant difference between the 25% and 50% saline groups. The left colon adenoma detection rate (ADR) was highest in the 50% saline group, followed by the 25% saline and the water groups (25.0% vs 18.7% vs 13.3%), but the difference was not significant. Logistic regression showed water infusion as the only predictor of moderate mucus production (odds ratio 33.3, 95% confidence interval 7.2-153.2). No acute electrolyte abnormalities were documented indicating a safe modification., Discussion: The use of 25% and 50% saline significantly inhibited mucus production and numerically increased ADR in the left colon. Evaluation of the impact of mucus inhibition by saline on ADR may refine the outcomes of WE., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.)

Gastropericardial fistula is generally associated with benign gastric diseases and is an uncommon complication of gastric adenocarcinoma. Pericarditis and cardiac tamponade are the ultimate outcome, with extremely high mortality rates. We report a 47-year-old man with gastric adenocarcinoma who had completed radiotherapy and was on scheduled chemotherapy, who presented with fever and chest pain. Gastric adenocarcinoma complicated with gastropericardial fistula and Candida albicans pericarditis were diagnosed and treated successfully with conservative management. Initial chest radiography and computed tomography (CT) revealed no evident pericardial air or fluid. However, follow-up panendoscopy 2 weeks later revealed a malignant ulcer with a fistula opening over the lesser curvature of the high body of the stomach. Subsequent chest radiography and CT revealed pneumopericardium with fluid accumulation. Emergent CT-guided pericardial drainage was performed. The fluid was positive for Candida albicans. Total parenteral nutrition and antifungal therapy were administered. The patient refused surgical intervention and survived with medical management alone. This case demonstrates that first, panendoscopy may be safely performed in patients with gastropericardial fistula without significant risk of cardiac tamponade; second, although early diagnosis of gastropericardial fistula is generally important, delayed recognition may not lead to devastating outcomes even in the absence of surgical intervention.

Autoimmune hepatitis is a heterogeneous liver disease of unknown etiology. It is predominant in females and characterized by elevation of transaminase, hypergammaglobulinemia and circulating autoantibodies. Interface hepatitis and plasma cell infiltration are the main findings on liver biopsy. However, deep cholestatic jaundice is rarely seen. We present here an unusual case of type 1 autoimmune hepatitis with hyperbilirubinemia as the initial and predominant presentation. Although rare, autoimmune hepatitis should be considered in patients with cholestasis without history of drug or viral hepatitis.

Nonalcoholic fatty liver disease (NAFLD) is a fatty liver disease occurring in patients without alcohol consumption. It includes a broad spectrum of liver disease, from fatty infiltration, inflammation and fibrosis, to cirrhosis, usually having obesity, hyperlipidemia, and diabetes mellitus as its etiology. NAFLD-related cirrhosis has rarely been reported in Taiwan. We herein report a 41-year-old male patient with nonalcoholic fatty liver cirrhosis (NAFLC), with the first clinical manifestation being bleeding esophageal varices (EV). The patient was obese with diabetes mellitus, but without hyperlipidemia or any history of drinking alcohol. The laboratory tests, abdominal sonography, and computed tomography revealed a typical case of liver cirrhosis. The pan-endoscopy disclosed EV with red-color sign. EV ligation was performed successfully to stop the bleeding. When the patient was in a stabilized clinical condition, a liver biopsy showed a typical histologic finding of NAFLD. Most of the cases of NAFLC reported in the literature have silent signs and symptoms. Sudden onset of the EV as the first clinical manifestation, as in this case, is rare. This case reminds us that NAFLD may indeed induce severe liver impairment, such as liver cirrhosis. Liver biochemical tests and abdominal sonography should be considered in patients with overt obesity and diabetes.