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Second-line Helicobacter pylori (H. pylori) eradication with fluoroquinolone-containing triple therapy is one of the recommended treatment options, but neither 7-day nor 10-day regimens provide >90% success rates. The current retrospective study aimed to clarify the effects of 10-day and 14-day levofloxacin-containing triple therapies for second-line H. pylori eradication in a Taiwanese cohort and to evaluate the potential clinical factors influencing eradication. A total of 200 patients who failed H. pylori eradication using the standard triple therapy were prescribed with either a 10-day (EAL-10) or a 14-day (EAL-14) levofloxacin-containing triple therapy group (levofloxacin 500 mg once daily, amoxicillin 1 g twice daily, and esomeprazole 40 mg twice daily). Follow-up studies to assess treatment response were carried out 8 weeks later. Eradication rates attained by EAL-10 and EAL-14 were 75.6%; 95% CI = 63.9-85.3% and 92.5%; 95% CI = 84.5-98.1%, P = 0.002 in the per protocol analysis and 68%; 95% CI = 56.6-78.5% and 86%; 95% CI = 76.8-93.4%, P = 0.002 in the intention-to-treat analysis. The duration of H. pylori therapy is the independent risk factor of H. pylori eradication (P = 0.003). In conclusion, 14-day levofloxacin-containing triple therapy can provide a >90% H. pylori eradication rate, but 10-day treatment duration may be suboptimal. The longer duration of H. pylori therapy (14 days) is the independent risk factor.

Background: Staphylococcus aureus, particularly methicillin resistant (MRSA), is a common pathogen among patients receiving hemodialysis. To evaluate nasal carriage, molecular characterization and effectiveness of decolonization of MRSA among patients receiving hemodialysis in Taiwan, we conducted this study., Methods: From January to June 2011, two nasal samplings with a 3-month interval were obtained from patients undergoing hemodialysis in a medical center (CGMH), and in a local hospital (YMH) and sent for detection of MRSA. For MRSA carriers, decolonization procedures were administered. All patients in CGMH were observed if MRSA infections occurred during the study period., Results: A total of 529 nasal specimens (265 from CGMH and 264 from YMH) were collected from 296 patients (161 from CGMH and 135 from YMH). 233 patients participated in both surveys. Average one-time point MRSA carriage rate was 3.8%, and the rate was up to 6.9% for those with two-time point surveys. No additional significant factor for MRSA carriage was identified. Seventy percent of the 20 colonizing MRSA isolates, though categorized as healthcare-associated strains epidemiologically, shared common molecular characteristics of the local community-associated strains. Only one of the 20 MRSA-colonized patients failed decolonization and had persistent colonization, while without any intervention, 17 (61%) of 28 patients with methicillin-sensitive S. aureus colonization in the first survey had persistent colonization of a genetically indistinguishable strain. Within the study period, two patients (1.24%) in CGMH, one with MRSA colonization (9.1%), developed MRSA infection., Conclusion: A substantial proportion of patients receiving hemodialysis in Taiwan had MRSA colonization, mostly genetically community strains. Decolonization procedures may effectively eliminate MRSA colonization and might reduce subsequent MRSA infection in these patients.

Background: Large meta-analyses of second-line Helicobacter pylori eradication with fluoroquinolone triple therapy have shown that neither 7-day nor 10-day therapy provides 90% or better treatment success. Reports describing second-line H. pylori eradication using 14-day fluoroquinolone-containing triple therapy are few. Current study aimed to determine the efficacy of a 14-day levofloxacin/amoxicillin/proton-pump inhibitor regimen as second-line therapy and the clinical factors influencing the outcome., Materials and Methods: One-hundred and one patients who failed H. pylori eradication using the standard triple therapy for 7 days were randomly assigned to either a levofloxacin/amoxicillin/esomeprazole group (levofloxacin 500 mg once daily, amoxicillin 1 g twice daily, and esomeprazole 40 mg twice daily for 14 days) or a esomeprazole/metronidazole/bismuth salt/tetracycline group (esomeprazole 40 mg twice daily, metronidazole 250 mg four times daily, tripotassium dicitrate bismuthate 300 mg four times daily, and tetracycline 500 mg four times daily for 14 days). Follow-up to assess treatment response consisted of either endoscopy or a urea breath test, which were carried out 8 weeks later., Results: Eradication rates attained by levofloxacin/amoxicillin/esomeprazole and esomeprazole/metronidazole/bismuth salt/tetracycline treatments in the per-protocol analysis were 44/47 (93.6%; 95% CI = 86-99.8) and 43/47 (91.8%; 95% CI = 83.2-98.5). In the intention-to-treat analysis, these were 43/47 (86.3%; 95% CI = 76.5-96.1) in the LAE group (four lost to follow-up) and 43/50 (86%; 95% CI = 76-96) in the EMBT groups. The observed adverse events were 25.5% and 38.5% among the two groups. There was 100% drug compliance among the levofloxacin/amoxicillin/esomeprazole group. Levofloxacin-resistant strains occurred at a frequency of 32.3%. H. pylori eradication rates for the levofloxacin-susceptible strains and levofloxacin-resistant strains were 92% (11/12) and 33% (1/3) in the per-protocol analysis., Conclusions: A 14-day levofloxacin/amoxicillin/esomeprazole triple therapy approach provides a >90% per-protocol report card with the caveat that this approach is markedly less effective in the presence of fluoroquinolone resistance. Levofloxacin-resistant strains are increasing in Taiwan., (© 2012 Blackwell Publishing Ltd.)

There have been some breakthroughs in the diagnosis and treatment of esophageal achalasia in the past few years. First, the introduction of high-resolution manometry with pressure topography plotting as a new diagnostic tool has made it possible to classify achalasia into three subtypes. The most favorable outcome is predicted for patients receiving treatment for type II achalasia (achalasia with compression). Patients with type I(classic achalasia) and type III achalasia (spastic achalasia) experience a less favorable outcome. Second, the first multicenter randomized controlled trial published by the European Achalasia Trial group reported 2-year follow-up results indicating that laparoscopic Heller myotomy was not superior to endoscopic pneumatic dilation (PD). Although the follow-up period was not long enough to reach a convincing conclusion, it merits the continued use of PD as a generally available technique in gastroenterology. Third, the novel endoscopic technique peroral endoscopic myotomy is a promising option for treating achalasia, but it requires increased experience and cautious evaluation. Despite all this good news, the bottom line is a real breakthrough from the basic studies to identify the actual cause of achalasia that may impede treatment success is still anticipated.

Introduction: A triple therapy consisting of proton pump inhibitor, amoxicillin and metronidazole or tetracycline has been recommended as the second-line regimen for Helicobacter pylori eradication if bismuth is not available. This study compared the efficacy of esomeprazole/amoxicillin/levofloxacin (EAL) and esomeprazole/amoxicillin/metronidazole (EAM) as second-line therapy for H pylori eradication., Methods: From April 2008 to September 2009, 90 patients who failed H pylori eradication using the standard triple therapy were randomized to receive either EAL (40 mg esomeprazole twice daily, 1 g amoxicillin twice daily and 500 mg levofloxacin once daily for 7 days) or EAM (40 mg esomeprazole twice daily, 1 g amoxicillin twice daily and 250 mg metronidazole 4 times daily for 14 days). The primary outcome variables were the rates of eradication, adverse events and compliance., Results: Our results demonstrated no differences in the eradication rates of the EAL and EAM groups in intention-to-treat analysis (68.9% versus 84.4%, respectively, P = 0.134) and per-protocol analysis (75.6% versus 88.4%, respectively, P = 0.160). Both groups exhibited similar drug compliance (EAL 95.6% versus EAM 100%, P = 0.494) and adverse events (EAL 13.3% versus EAM 8.9%, P = 0.739)., Conclusions: The 14-day EAM regimen was not inferior to the 7-day EAL regimen for second-line anti-H Pylori therapy in Taiwan. It may be an option in hospitals where bismuth salts are not available. However, regional metronidazole resistance rate and extended length of levofloxacin-base therapy should be considered.

Background: The incidence of colorectal cancer is increasing in Taiwan. Adenomatous polyps are known to be precancerous lesions and need to be removed. New techniques like chromendoscopy, magnifying endoscopy, narrow band imaging and magnifying endoscopy with flexible spectral imaging color enhancement may improve the accuracy of identifying precancerous polyps but are not widely available in the real world. This study analyzed the conventional biopsy method in diagnosing early colon cancer and the necessity for subsequent surgery after polypectomy., Methods: From January 2002 to December 2007, 1027 adenomatous polypoid specimens taken from 720 patients who received polypectomy by conventional white light colonoscopy were studied. The pathologic reports of 26 specimens of early cancer or high grade dysplasia from 25 patients were analyzed. Protruding polyps were classified as pedunculated (o-Ip), subpedunculated (o-Isp) and sessile (o-Is)., Results: Fourteen of the 26 specimens were type o-Ip, 10 were type o-Isp, and 2 were type o-Is. The pathologic reports were high grade dysplasia (n = 5), mucosal adenocarcinoma (n = 18) and submucosal adenocarcinoma (n = 3). Among these, 7 lesions from 7 patients received a randomized biopsy instead of immediate polypectomy. Adenoma was reported in 6 of them with only one malignancy detected (false negative rate: 86%). Eight patients received surgery. The mean follow-up period for these patients was 17 months, and none of them had recurrences., Conclusions: The randomized biopsy method for adenomatous polyps has a high false negative rate for early colon cancer and high grade dysplasia and is therefore not necessary in cases of protruding type polyps which can be removed by polypectomy. An adequate direct polypectomy may completely remove the protruding type of early colon cancer.

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.

Aim: To identify the predictors of rebleeding after initial hemostasis with epinephrine injection (EI) in patients with high-risk ulcers., Methods: Recent studies have revealed that endoscopic thermocoagulation, or clips alone or combined with EI are superior to EI alone to arrest ulcer bleeding. However, the reality is that EI monotherapy is still common in clinical practice. From October 2006 to April 2008, high-risk ulcer patients in whom hemorrhage was stopped after EI monotherapy were studied using clinical, laboratory and endoscopic variables. The patients were divided into 2 groups: sustained hemostasis and rebleeding., Results: A total of 175 patients (144, sustained hemostasis; 31, rebleeding) were enrolled. Univariate analysis revealed that older age (≥ 60 years), advanced American Society of Anesthesiology (ASA) status (category III, IV and V), shock, severe anemia (hemoglobin < 80 g/L), EI dose ≥ 12 mL and severe bleeding signs (SBS) including hematemesis or hematochezia were the factors which predicted rebleeding. However, only older age, severe anemia, high EI dose and SBS were independent predictors. Among 31 rebleeding patients, 10 (32.2%) underwent surgical hemostasis, 15 (48.4%) suffered from delayed hemostasis causing major complications and 13 (41.9%) died of these complications., Conclusion: Endoscopic EI monotherapy in patients with high-risk ulcers should be avoided. Initial hemostasis with thermocoagulation, clips or additional hemostasis after EI is mandatory for such patients to ensure better hemostatic status and to prevent subsequent rebleeding, surgery, morbidity and mortality.

The function of cytochrome P450 2C19 (CYP2C19) is altered in patients with end-stage liver disease (ESLD) that require liver transplantation (LT). The status of CYP2C19 is of considerable interest because the transplanted healthy donor livers are perfused with the blood of the recipient with ESLD. This study aims to clarify the changes in CYP2C19 in the peripheral blood before and after LT. Thirty pairs of living donors and recipients were enrolled in this study. The CYP2C19 genotype in peripheral blood mononuclear cells (PBMCs) was studied immediately before operation in donors, on the day preceding the operation in the unstable recipients, and one month after LT in stable recipients. Limited data suggest that the post-LT genotype in liver biopsy is the same as donor's original genotype in most cases (80.0%) and that only 2 patients in the study cohort had the same liver tissue genotype as the respective recipient PBMCs. However, expression of the CYP2C19 genotype after living donor LT (LDLT) was identical to pre-transplant expression in 100% (30/30) of recipients, i.e., CYP2C19 genotypes in recipient PBMCs did not change after LDLT, suggesting that the donor liver did not render any mutations to the CYP2C19 genotypes after LT., (© 2010 John Wiley & Sons A/S.)

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.

Background: Abdominal tuberculosis remains a serious health threat. This retrospective report aimed to analyze patients after the development of the tuberculosis control program by the Center of Disease Control (Taiwan) in January 2000. The study was conducted at the Chang Gung Memorial Hospital-Kaohsiung, Taiwan., Methods: Between January 2000 and December 2006, we evaluated 14 adult patients with abdominal tuberculosis by reviewing their clinical information, therapeutic methods and outcomes. Diagnosis of abdominal tuberculosis was made based on clinical features of abdominal infection with microbiological results from culture, acid-fast bacilli stain and polymerase chain reaction for Mycobacterium tuberculosis and/or histopathological confirmation from biopsy and ascites., Results: Tuberculous peritonitis and intestinal tuberculosis were the most common type of infections followed by hepatic tuberculosis, and intra-abdominal tuberculoma. 35.7% of these patients had the coexistence of extra-abdominal infection. The most common clinical symptoms and signs were abdominal pain, abdominal distension, ascites and body weight loss. Fever was found in 35.7% of patients and peritoneal signs were noted in 7.1%. Immunocompromised states and old age are relevant to adult abdominal tuberculosis. Overall, patients were diagnosed by bacteriology (35.7%), biopsy materials from laparotomy (42.8%), liver biopsy (14.3%), and biopsy materials from colonoscopy (7.2%). Patients were cured after taking antituberculous drugs for at least 6 months without relapse during regular follow-up for at least 2 years. However, three patients died of sepsis and decompensated liver cirrhosis during treatment., Conclusion: Extra vigilance in dealing with patients who present with unexplained abdominal conditions is the key to the diagnosis of abdominal tuberculosis. Early diagnosis, early antituberculous therapy and surgical treatment of the associated complications are essential for the survival of the patient.

Metastasis to the duodenum from a primary cancer is rare, but direct extension from pancreatic cancer is much more common. Here, we present a case of multiple duodenal metastases of pancreatic head cancer in a 77-year-old woman with upper gastrointestinal bleeding. An upper gastrointestinal endoscopic examination revealed multiple elevated reddish nodules on a normal mucosa background that extended from the superior duodenal angle to the duodenal second portion. Echo-guided fine needle aspiration biopsies of the pancreatic head tumor and endoscopic biopsies of the reddish duodenal nodules proved the diagnosis of adenocarcinoma. When such endoscopic morphology is found, especially when the locations are distant from the papillae, metastasis should be considered and multiple biopsies are mandatory.

Background and Aims: Prospective, long-term reports and predictors of outcome of endoscope-guided pneumatic dilation are lacking in the literature. The aim of this prospective 7-year follow-up study is to report the efficacy of endoscope-guided pneumatic dilation and determine the possible confounding factors related to remission., Methods: Between January 1998 and June 2004, 32 patients were enrolled. Each patient was treated with endoscope-guided pneumatic dilation and followed-up at regular intervals for a median of 4.5 years. Remission was determined with the use of a structured interview and a previously described symptom score. Cumulative remission rate was analyzed by using the Kaplan-Meier method with assessment of symptom scores between grades before and after PD at 6 weeks, 6 months, 1 year, and then every year after. Possible confounding factors related to the remissions were analyzed by Cox's proportional hazard model., Results: Complete follow-up until August 2007 was obtained in 100% of all patients. Cumulative remissions were 1 year (86.7%), 2 years (86.7%), 3 years (80.0%), 4 years (76.5%), 5 years (72.9%), 6 years (61.7%), and 7 years (61.7%), respectively. Age is a relevant confounding factor to the remissions showing a worse outcome for those under 45 (p = 0.046). One esophageal perforation occurred (3.3%)., Conclusions: Endoscope-guided PD itself is safe and modestly effective for up to 7 years investigations in current study. Older patients (>45 years) have favorable overall clinical remissions.

Background: There are only three reports using conventional sonography to detect the gastroesophageal junction through the left lobe liver window in patients with achalasia, and the results were inconsistent. This study further characterizes the sonographic features of achalasia and compares them to characteristics of subjects with gastroesophageal malignancies., Methods: Conventional sonography was performed in 21 patients with achalasia (mean age 49.0 years, 11 male and 10 female, group A); 15 patients with malignancies at the gastroesophageal junction (n=10) and cardiac of the stomach (n=5) (mean age 55.3 years, 11 male and 4 female, group B); and 30 subjects with functional dyspepsia (mean age: 38.3 years, 15 male and 15 female, control group C)., Results: The median esophageal wall thicknesses were 5.1+/-2.3 mm (group A), 19.5+/-7.8 mm (group B), and 3.3+/-1.2 mm (group C). However, there was overlap in the esophageal wall thickness in groups A and C. Sonographic features in group A were regular hypoechoic thickening of the wall at the gastroesophageal junction; in group B, we found irregular hypoechoic thickening of the wall. Control subjects had a regular hypoechoic gastroesophageal wall. Dilated lumens of the distal esophagus were seen in all achalasia patients., Conclusion: Although conventional sonography is not a diagnostic tool for achalasia, it provides interesting sonographic information. It cannot reveal each layer of the wall of the lumen as endoscopic ultrasound does, but it may tentatively differentiate achalasia from malignancies and assists clinicians when endoscopic ultrasound is not available.

Colorectal mesenchymal tumors are rare. Therefore, distinguishing between gastrointestinal stromal (GIST) and smooth muscle tumors is important. This study aimed to delineate the immunophenotype and prognostic factors of 75 colorectal mesenchymal tumors. Fifty-three GIST and 22 smooth muscle tumor specimens were included from 1986 to 2007. Forty of 53 GIST were initially diagnosed as smooth muscle tumors and re-diagnosed as CD117 (+) GIST. Immunohistochemical studies were performed with antibodies of CD117, CD34, smooth muscle actin (SMA), desmin, S-100, Ki-67 and PCNA for clinicopathologic and prognostic correlation. In comparison, colorectal GIST exhibited a larger tumor size (P<0.001), higher mitotic count (P<0.001), higher cellularity (P<0.001), less spindle cell type (P=0.004), higher nuclear pleomorphism (P=0.004), and a higher NIH risk (P<0.001) than that of smooth muscle tumors. Positive immunoreactivities of GIST to a panel of antibodies were 88.6% to CD34, 28.3% to SMA, 1.8% to S-100 and 15.1% to desmin. For 75 mesenchymal tumors, survival analyses revealed that older patients (P=0.006), with a large tumor size (P<0.001), high mitotic count (P<0.001), increased NIH risk (P<0.001), non-spindle cell type (P<0.001), high cellularity (P=0.015), high cell pleomorphism (P<0.001), positive Ki-67 (P<0.001), high PCNA (P<0.001) and GIST (P=0.001) had a shorter disease-free survival than that of comparative groups. When the analyses concentrated on 53 GIST, the cell type and cellularity were no longer viable prognostic factors. The tumor mitotic count was the only independent prognostic factor for either mesenchymal tumors or GIST. In conclusion, GIST exhibited heterogeneous characteristics and was significantly larger, more mitotic and a poorer prognostic factor than smooth muscle tumor. The mitotic count is still the most valuable prognostic factor for colorectal mesenchymal tumors after KIT.

Acute intermittent porphyria (AIP) is an inherited metabolic disease that can affect the autonomic, peripheral and central nervous systems. Pancreatic diseases assocated with AIP is rarely reported. We report here a 60-year-old non-alcoholic male who had typical manifestations of AIP, including abdominal pain, constipation, tachycardia, hypertension, mental disturbances, psychiatric manifestations, seizures, peripheral neuropathy, and excessive excretion of porphyrin precursors in urine. Increases of serum amylase and lipase, as well as mild pancreatic edema on ultrasonography, were noted during the acute attack of AIP, suggesting concomitant acute pancreatitis. In this patient, brain magnetic resonance imaging revealed reversible multifocal cerebral lesions resembling a posterior reversible encephalopathy syndrome (PRES) during the acute attack of AIP. Because the clinical manifestations of acute pancreatitis could be present with an acute attack of AIP, early confirmation of diagnosis is mandatory to effectively manage the attack and avoid inappropriate treatment.