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Background: Difficult biliary cannulation in endoscopic retrograde cholangiopancreatography (ERCP) can result in failure of common bile duct (CBD) stone removal and pancreatitis. The present study aimed to report the efficacy and safety of limited precut sphincterotomy (PS) combined with endoscopic papillary balloon dilation (EPBD) for CBD stone removal in patients with difficult biliary cannulation, and the complications associated with this combined procedure. Methods: A total of 3305 patients underwent ERCP in our hospital between October 2009 and September 2014 and 258 were diagnosed with difficult biliary cannulation. Of these 258 patients, 58 underwent limited PS combined with EPBD for CBD stone removal, and these 58 patients were included in this retrospective study. Results: The overall success rate was 94.8 % (55/58), and the success rate for single-session removal was 87.9 % (51/58). The mean procedure time was 41 ± 11.48 min (range, 20-72 min). Mechanical lithotripsy was needed in 10.3 % (6/58) of patients. Procedure-related complications included bleeding in 3.4 % (2/58), pancreatitis in 8.6 % (5/58) and biliary tract infection (BTI) in 1.7 % (1/58) of patients. Conclusions: The therapeutic outcome of limited PS combined with EPBD for CBD stone removal in patients with difficult biliary cannulation was good with an acceptable complication rate. It could be an alternative to PS and "early" limited PS should be used for prompt identification of the bile duct. Limited PS combined with EPBD is safe and effective for CBD stone removal in patients with difficult biliary cannulation. [ABSTRACT FROM AUTHOR]

Background: Infections in cirrhotic patients with upper gastrointestinal bleeding are a common event causing severe complication and mortality. This study aimed to identify risk factors that may predict rebleeding, bacterial infections, and the impact of antibiotic prophylaxis on mortality at different stages of cirrhosis following acute peptic ulcer bleeding (PUB). Methods: A hospital-based retrospective cohort study was conducted on 235 cirrhotic patients with acute peptic ulcer hemorrhage who underwent therapeutic endoscopic procedures between January 2008 and January 2014 (n = 235); of these, 88 patients received prophylactic intravenous ceftriaxone (antibiotic group) and 147 patients did not (nil-antibiotic group). The recorded outcomes were length of hospital stay, bacterial infection, rebleeding, and in-hospital mortality. Results: Forty-eight (20.4 %) patients experienced ulcer rebleeding and 46 (19.6 %) developed bacterial infections. More patients suffered from infection and recurrent bleeding in the nil-antibiotic group than the antibiotic group (25.2 % vs. 10.2 %, p = 0.005 and 30.6 % vs. 3.4 %; p < 0.001, respectively). The predictive risk factors for rebleeding were the Rockall score (p = 0.004), units of blood transfusion (p = 0.031), and no antibiotic prophylaxis (p <0.001); for bacterial infections, they were the Child-Pugh score (p = 0.003), active alcoholism (p = 0.035), and no antibiotic prophylaxis (p = 0.009). Overall, 40 (17 %) patients died during hospitalization. The Rockall score and rebleeding were predictive factors for in-hospital mortality. In subgroup analysis, survival was significantly reduced in decompensated patients (p = 0.034). Conclusions: This study suggests that antibiotic prophylaxis after endoscopic hemostasis for acute PUB prevented infections and reduced rebleeding events in cirrhotic patients. Antibiotic prophylaxis improved survival among decompensated cohort following PUB. The Rockall score and rebleeding were predictive risk factors for in-hospital mortality. [ABSTRACT FROM AUTHOR]

Background The acid-suppressive agents have been linked with an increased risk of infectious disease. The relationship between these drugs and Mycobacterium Tuberculosis (TB) was not been reported. Methods We conducted a case-control study using data from National Health Insurance research database of Taiwan. From 1996 till 2008, and 6541 cases were defined as TB infection/activation (ICD-9 coding plus prescription two of four first-line anti-TB regimen for at least one month). Control subjects who were matched to the TB cases by age and sex were selected with 10:1 ratio. Medical records including acid-suppressive agent prescription and comorbidity, and socioeconomic status were analyzed. Results TB infection/activation was more frequent to comorbidity with chronic diseases, alcohol abuse, malignancy, immune deficient/suppression status and acid-related disease (peptic ulcer, reflux esophagitis). Among the TB cases, there was higher exposure record to acidsuppressive agents within 3 months before TB index date (OR 2.43(2.06-2.88) and 1.90 (1.68-2.14) for proton pump inhibitor (PPI) and histamine 2 receptor antagonist (H2RA) respectively). After adjusting confounding factors, PPIs prescription 3 months before TB index date had an association of TB infection/activation (adjusted OR 1.63(1.61-1.63)). Similar result was found in H2RA user (adjusted OR 1.51(1.50-1.52)). The association of acid-suppressive agents in TB infection/activation was fade gradually when the drug prescription period extended Conclusions Recent prescription of acid-suppressive agent seems to associate the TB infection/activation. In the society where TB was prevalent, evaluation of pulmonary TB before prescription of PPI or H2RA is warranted. [ABSTRACT FROM AUTHOR]

Background. Recent findings suggest that patients admitted on the weekend with peptic ulcer bleeding might be at increased risk of adverse outcomes. However, other reports found that there was no "holiday effect." The purpose of this study was to determine if these findings hold true for a real-life Taiwanese medical gastroenterology practice. Materials and Methods. We reviewed the medical files of hospital admissions for patients with peptic ulcer bleeding who received initial endoscopic hemostasis between January 2009 and March 2011. A total of 744 patients were enrolled (nonholiday group, n= 615; holiday group, n = 129) after applying strict exclusion criteria. Holidays were defined as weekends and national holidays in Taiwan. Results. Our results showed that there was no significant difference in baseline characteristics between the two groups. We also observed that, compared to the nonholiday group, patients in the holiday group received earlier endoscopy treatment (12.20 hours versus 16.68 hours, p = 0.005), needed less transfused blood (4.8 units versus 6.6 units, p = 0.02), shifted from intravenous to oral proton-pump inhibitors (PPIs) more quickly (5.3 days versus 6.9 days, p = 0.05), and had shorter hospital stays (13.05 days versus 17.36 days, p = 0.005). In the holiday and nonholiday groups, the rebleeding rates were 17.8% and 23.41% (p = 0.167), the mortality rates were 11.63% versus 13.66% (p = 0.537), and surgery was required in 2.11% versus 4.66% (p = 0.093), respectively. Conclusions. Patients who presented with peptic ulcer bleeding on holidays did not experience delayed endoscopy or increased adverse outcomes. In fact, patients who received endoscopic hemostasis on the holiday had shorter waiting times, needed less transfused blood, switched to oral PPIs quicker, and experienced shorter hospital stays. [ABSTRACT FROM AUTHOR]

Background: Esophageal stricture (ES) and gastric outlet obstruction (GOO) can occurred in patients injured by the ingestion of corrosive agents. These complications may occur concurrently but has not been reported in the literature. The aims of this study are to assess the effects and complications of endoscopic-guided balloon dilations (EBD) in patients with corrosive-induced upper gastrointestinal strictures, either ES or GOO alone and simultaneous occurrences of both (ES + GOO). Methods: From July 2002 to December 2009, 36 patients with corrosive-induced upper gastrointestinal strictures in a tertiary hospital were recruited into this study. The patients were divided into three groups, ES group (n = 18), GOO (n = 7), and ES + GOO group (n = 11). All strictures were dilated under direct visualization by using throughthe- scope balloon catheters to the end point of 15 mm. The end-point of treatment was successful ingestion of a solid or semisolid diet without additional dilation for more than 12 months. Results: These 36 patients included 15 males and 21 females with average age of 47 years ranging from 25 to 79 years. The success rates for ES group is significantly better than GOO and ES + GOO group (83.3% vs. 57.1% vs. 36.4% p = 0.035). Less complications were observed in ES group than in GOO and ES + GOO group (16.7% vs. 42.9% vs. 36.4%, p = 0.041). GOO group needed more sessions of dilations in order to achieve success dilations than ES and GOO groups (13.7 ± 4.9 vs. 6.1 ± 4.7 vs. 5.5 ± 2.1, p = 0.011). Conclusions: Corrosive injuries complicated with ES can be effectively and safely treated by EBD. However, the success rates declined significantly in patients with GOO with or without ES and amore complications occurred. [ABSTRACT FROM AUTHOR]

Background: Vascular ectasias, including gastric antral vascular ectasia (GAVE) and angiodysplasia, are increasingly recognized as important sources of gastrointestinal bleeding. This study investigated and compared the efficacies and outcomes of treatment of upper gastrointestinal (UGI) angiodysplasia and GAVE hemorrhage by endoscopic argon plasma coagulation (APC). Methods: From January 2006 to December 2009, 46 patients diagnosed with upper GI bleeding caused by angiodysplasia or GAVE at a tertiary hospital were recruited into this study. They included 26 males and 20 females with an average age of 65.6 years (range, 45-90 years). All patients underwent APC for hemostasis during an endoscopic procedure. Parameters such as underlying co-morbidities, number of endoscopic treatment sessions, recurrent bleeding, and clinical outcomes during follow-up were analyzed. Results: The 46 patients with UGI vascular ectasia hemorrhage included 27 patients with angiodysplasia and 19 with GAVE. The patients with angiodysplasia were older than those with GAVE (71.6 ± 10.2 years versus 61.8 ± 11.9 years, P = 0.005). More GAVE patients than angiodysplasia patients had co-existing liver cirrhosis (63.2% versus 25.9%, P = 0.012). The patients with GAVE had a higher rate of recurrent bleeding (78.9% versus 7.4%, P<0.001) and required more treatment sessions to achieve complete hemostasis (2.4 ± 1.4 versus 1.1 ± 0.1, P<0.001) than those with angiodysplasia. Univariate analysis demonstrated that age greater than 60 years (odds ratio (OR) = 8.929, P = 0.003), GAVE (OR = 0.021, P<0.001), and previous radiation therapy (OR = 11.667, P = 0.032) were associated with higher rates of recurrent bleeding. Further multivariate analysis revealed that GAVE was the only independent risk factor for recurrent bleeding after APC treatment (OR = 0.027, P<0.001). Conclusion: Endoscopic hemostasis with APC is a safe treatment modality for both angiodysplasia and vascular ectasia bleeding. The efficacy of APC treatment is greater for angiodysplasia than for vascular ectasia bleeding. GAVE patients have a higher recurrent bleeding rate and may require multiple treatment sessions for sustained hemostasis. [ABSTRACT FROM AUTHOR]

AIM: To evaluate the effects of ginger on gastric motility and emptying, abdominal symptoms, and hormones that influence motility in dyspepsia. METHODS: Eleven patients with functional dyspepsia were studied twice in a randomized double-blind manner. After an 8-h fast, the patients ingested three capsules that contained ginger (total 1.2 g) or placebo, followed after 1 h by 500 mL low-nutrient soup. Antral area, fundus area and diameter, and the frequency of antral contractions were measured using ultrasound at frequent intervals, and the gastric half-emptying time was calculated from the change in antral area. Gastrointestinal sensations and appetite were scored using visual analog questionnaires, and blood was taken for measurement of plasma glucagon-like peptide-1 (GLP-1), motilin and ghrelin concentrations, at intervals throughout the study. RESULTS: Gastric emptying was more rapid after ginger than placebo [median (range) half-emptying time 12.3 (8.5-17.0) min after ginger, 16.1 (8.3-22.6) min after placebo, P ⩽ 0.05]. There was a trend for more antral contractions (P = 0.06), but fundus dimensions and gastrointestinal symptoms did not differ, nor did serum concentrations of GLP-1, motilin and ghrelin. CONCLUSION: Ginger stimulated gastric emptying and antral contractions in patients with functional dyspepsia, but had no impact on gastrointestinal symptoms or gut peptides. [ABSTRACT FROM AUTHOR]

Background: The American Association for the Study of Liver Diseases (AASLD) guidelines recommend that antibiotic prophylaxis should be instituted in any patient with cirrhosis and gastrointestinal hemorrhage, and that oral norfloxacin, intravenous ciprofloxacin, and ceftriaxone are preferable. However, the antimicrobial spectrum of the first generation of cephalosporins (cefazolin) covers a wide range of bacteria species, including community-acquired strains of Escherichia coli and Klebsiella pneumoniae, but their efficacy as prophylactic antibiotics in cirrhotic patients with acute hemorrhage was seldom warranted in the literature. This study aimed to explore the effects of cefazolin on the outcome of cirrhotic patients with acute variceal hemorrhage after endoscopic interventions. Methods: A cross-sectional, retrospective chart review study was conducted on cirrhotic patients with acute variceal hemorrhage who underwent endoscopic procedures in a medical center. Cirrhotic patients who did not receive antibiotics were classified as group A ( n = 63) while patients who received intravenous cefazolin 1 g q8 h for 2-7 days were classified as group B ( n = 50). The end points were the prevention of infection, length of hospital stay, time of rebleeding, and death. Results: A total of 113 patients were studied (male/female: 82/31; age: 56.8 ± 13.5 years). The incidence of infection (including proven infections) and bacteremia were significantly lower in group B patients (38.1% vs. 16.0%, P = 0.010; 17.5% vs. 4.0%, P = 0.026; 9.5% vs. 0%, P = 0.033, respectively). The no prophylactic antibiotics treatment was the independent risk factor. There was no significant difference between the two groups with respect to the source of bleeding, type of endoscopic intervention, length of hospital stay, and mortality. Actuarial probability of remaining free of early rebleeding (<7 days) was P = 0.105 by log-rank test for all cirrhosis patients and P = 0.085 for Child-Pugh class A patients. Conclusions: The use of cefazolin in cirrhotic patients after endoscopic interventions for acute variceal hemorrhage reduced infections. A trend of actuarial probability of remaining free of early rebleeding (<7 days) was observed, especially in Child-Pugh class A patients. This study may be hampered by the small sample size and more large-scale studies are mandatory. [ABSTRACT FROM AUTHOR]

Background and Aim: Hepatocellular carcinoma (HCC) tends to metastasize to extrahepatic organs. Stomach involvement has been seldom reported and has always been considered as direct invasion. This study aims to propose a possible existing pathway for the hematogenous metastasis of HCC to the stomach. Methods: Only seven cases with stomach involvement were found from 8267 HCC patients registered at our hospital between 2000 and 2007. Their laboratory data, the findings of computed tomography and upper endoscopy, therapeutic procedures, such as esophageal variceal banding ligation (EVL), and transhepatic arterial embolization (TAE) were further studied. Results: All seven patients were male. Liver cirrhosis was found in six patients (6/7 = 85.7%), HCC with portal vein thrombosis (PVT) in six patients (6/7 = 85.7%), splenomegaly in five patients (5/7 = 71.4%) and esophageal varices in five patients (5/7 = 71.4%). Six patients underwent TAE and one patient underwent EVL before the development of HCC in the stomach. Four patients had HCC at the cardia, one patient at the anterior wall of the high body and two patients at the greater curvature of the high body, far away from the original HCC. Six patients eventually developed distant metastasis. HCC with gastric metastasis developed 53–126 days after TAE in five patients and 74 days after EVL in one patient. Conclusions: When cirrhotic patients with portal hypertension have HCC with PVT, a hematogenous pathway can exist for gastric metastasis of tumor thrombi involving hepatofugal flow to the stomach after TAE or EVL apart from the major pathway of direct invasion. [ABSTRACT FROM AUTHOR]

Background and Aim: There are limited reports on esophageal motility pressures in aged patients with achalasia and these are inconclusive. The aim of the present retrospective study was to understand the changes of esophageal motility in aged achalasia patients among the Taiwan population. Methods: Manometric studies of 49 patients with achalasia had been performed through January 1998 to June 2005. The findings of lower esophageal sphincter (LES) basal and residual pressures and esophageal body contraction amplitudes were calculated and compared between the older and younger patient groups at different age cut-offs. Results: Higher basal LES pressure increased significantly from the cut-off age of 65 years (i.e. patients over 65 had significantly higher basal LES pressure than younger patients: 37.0 ± 4.19 mmHg vs 30.0 ± 1.32 mmHg, P = 0.045). With patients ≥70 years old, it was more obvious (46.0 ± 3.7 mmHg vs 29.6 ± 1.2 mmHg, P = 0.001). Beginning at the cut-off age of 55, the LES residual pressure was significantly higher in older patients than those who were younger (14.0 ± 11.06 mmHg vs 11.1 ± 0.6 mmHg, P = 0.017). LES residual pressure is more significant in the older groups. A linear correlation between age and residual LES pressures ( r = 0.383) was found. No differences were found in esophageal contraction pressure. Conclusions: Older achalasia patients in Taiwan have higher basal LES pressures, with a linear correlation between age and residual LES pressures. Age has no influence on esophageal contraction pressure. [ABSTRACT FROM AUTHOR]

Background/Aims: The cyclin kinase inhibitor p21/WAF1 is regulated by p53-dependent or independent pathways and inhibits the action of proliferating cell nuclear antigen (PCNA). The prognostic role of p21/WAF1 in hepatocellular carcinoma (HCC) is ambiguous. To further clarify this, we examined the expression of three genes in HCC. Methods: A total of 122 resected HCC specimens were collected from 1987 to 1998. Expression of p21/WAF1, p53, and PCNA in HCC was analysed by immunohistochemistry. Results: Immunoreactivity was detectable for p21/WAF1 in 37%, and for p53 in 41.8% of HCCs. Positive expression of both genes does not relate to each other, but both are associated with a high PCNA labelling index (LI) ( P<0.05) in tumour. p53 (+) is also associated with high serum α-foetoprotein (αFP) ( P<0.001), tumour dedifferentiation ( P=0.001) and advanced pathologic stages ( P=0.017). However, p21/WAF1 (+) did not show clinicopathologic significance. Survival analysis indicated that poor prognostic factors were p21/WAF1 (−) ( P=0.024), p53 (+) ( P=0.008), high PCNA ( P<0.001), tumour without capsule ( P=0.001), poor tumour differentiation ( P=0.004), advanced pathologic stage ( P<0.001), and high serum αFP( P<0.001). Independent factors were p21/WAF1 expression, pathologic stage, and PCNA. Conclusion: In HCC, increased proliferation index PCNA is significantly associated with positive p53 and p21/WAF1. But p21/WAF1 expression did not relate to p53 expression. P21/WAF1 (+) is a good event and serves as an independent survival prognostic factor for HCC, which is a novel finding apart from previous reports. [ABSTRACT FROM AUTHOR]

Objectives: Portal hypertension may develop in patients with severe acute hepatitis. Sequential changes of portal venous hemodynamics in acute hepatitis is not well understood. This study evaluated portal hemodynamic changes and prognostic values in patients with severe, acute hepatitis. Methods: Doppler studies, liver Function tests, and virology studies were done in the inclusion, the 3rd month, and the 6th month for patients with severe, acute hepatitis. An indocyanine green clearance was done in the inclusion. Doppler portal hemodynamic studies were done in the hilar area by an average of two measurements. Results: A total of 88 consecutive patients was included. Nine of them died. On initial study, fatalities were generally older patients with more delayed indocyanine green clearance, lower portal vein velocity, lower albumin values, higher bilirubin values, longer prothrombin time, and ascites. Using stepwise logistic regression, portal blood How and prothrombin time were the two independence prognostic factors. By multiple linear regression, portal blood flow was associated with ascites, and average portal blood velocity was associated with bilirubin. During the hospital days, transient, depressed portal blood velocities followed by a hyperdynamic stage were found in survivors. The portal vein velocity changes for fatalities either were kept at a lower level or had a declining pattern. Conclusions: Doppler ultrasound detects portal hemodynamic changes for patients with severe, acute hepatitis. Sequential portal hemodynamic studies will he helpful for evaluating patients with severe, acute hepatitis. [ABSTRACT FROM AUTHOR]

Objective: Laparoscopic cholecystectomy (LC) has become the choice of treatment for symptomatic gallbladder stones. The goal of this study was to predict the necessity for ERCP before LC using the noninvasive method of liver function testing (LFT) and sonography. Methods: Before LC, 115 symptomatic gallbladder stone patients, whose diagnoses were confirmed by sonography, were studied by both LFT and ERCP. Patients who were already found to have either tumors or intrahepatic biliary stones on sonogram were excluded. Patients were classified into normal and dilated biliary tree groups by sonographic findings and normal and abnormal LFT (including bilirubin, alkaline phosphatase, γ glutamyl transferase and amylase) groups. Results: In patients with both normal biliary sonogram and LFT, 97.6% of patients had a negative ERCP study. Biliary tree dilation on sonogram had an 87% positive predictability for ductal pathology on ERCP (40/46). A normal biliary tree on sonogram had a 17.4% incidence of positive ductal pathology on ERCP (12/69). A single abnormal LFT equated to a 68.8% positive predictability for ductal pathology on ERCP. Conclusion: ERCP is not necessary before LC for patients with symptomatic gallbladder stones who have both a normal biliary tree on sonogram and normal LFT. A patient with either a dilated bile duct on sonogram or an abnormal liver function test does require ERCP study. [ABSTRACT FROM AUTHOR]

Recent advances in the treatment of achalasia include the use of high-resolution manometry to predict the outcome of patients and the introduction of peroral endoscopic myotomy (POEM). The first multicenter randomized, controlled, 2-year follow-up study conducted by the European Achalasia Trial group indicated that laparoscopic Heller myotomy (LHM) was not superior to pneumatic dilations (PD). Publications on the long-term success of laparoscopic surgery continue to emerge. In addition, laparoscopic single-site surgery is applicable to advanced laparoscopic operations such as LHM and anterior fundoplication. The optimal treatment option is an ongoing matter of debate. In this review, we provide an update of the current progress in the treatment of esophageal achalasia. Unless new conclusive data prove otherwise, LHM is considered the most durable treatment for achalasia at the expense of increased reflux-associated complications. However, PD is the first choice for non-surgical treatment and is more cost-effective. Repeated PD according to an "on-demand" strategy based on symptom recurrence can achieve long-term remission. Decision making should be based on clinical evidence that identifies a subcategory of patients who would benefit from specific treatment options. POEM has shown promise but its long-term efficacy and safety need to be assessed further.