Search

Immunosuppression (IS) protocols should be individualized according to the individual recipient's immunity to minimize adverse effects. The aim of this study was to determine whether preoperative levels of CD8+ T lymphocytes could be used as a guide for the introduction of IS.Sixteen adult liver transplantations in our institute were retrospectively analyzed. The immunosuppressive agents were temporarily withheld for 8 patients with a lower (10%) preoperative percentage of CD8+ cells after transplant (classified as group A). In this group, postoperative immunosuppressive agents had never been used until acute rejection was suspected. Another 8 patients receiving classic IS were classified as group B. We collected their demographic features and analyzed the clinical courses.The postoperative IS-free period of group A was 5 to 120 days (median, 31 days). Our data showed an inverse correlation between CD8+ levels and the severity of liver disease. Although the IS-free protocol did not present a lower incidence of infection-related events, most of them were effectively treated with antibiotics. The 1-, 3-, and 5-year overall patient survival rates were not different between those with a short-term IS-free period and those with regular IS (87.5% vs 100%, 75% vs 100%, and 62.5% vs 87.5%; P = .468). No patient died of graft failure due to acute rejection.Postoperative immunosuppressive agents can be safely withheld for a period of time to preserve proper immune responses against infections in very sick recipients guided by using the CD8+ levels.

Background The liver is considered to be an immune-privileged organ. Several types of liver cells have been implicated in the induction of immunologic tolerance. Hepatic stellate cells (HSCs) seem to participate in hepatic fibrosis and to display immunological properties. Materials and results In this study, HSCs isolated from C3H mice were highly positive for GFAP (98.4%) and α-SMA (95.4%). After stimulation by interferon-γ (IFN-γ), HSCs were more active in morphology with enhanced expression of H2-K K , I-A K , CD80, and CD54, similar to mature myelogenic dendritic cells (MDCs). Through allogeneic stimulation, C3H HSCs induced proliferation of both CD8 + and CD4 + T cells in B6 mice. However, the T cells activated by allogeneic HSCs produced less INF-γ, interleukin (IL)-4, IL-10, and IL-17, but large amount of transforming growth factor-β. These T cells expressed immunoregulatory rather than effector functions. Naive T cells stimulated by allogeneic HSCs expressed Foxp3 compared with MDCs (8.67% vs 2.14%, P + T cells activated by HSCs lost their allogeneic cytotoxicity, and CD4 + T cells activated in this fashion suppressed the allogeneic cytotoxicity of CD8 + T cells activated by MDCs. Conclusion HSCs seem to act as liver-resident antigen-presenting cells instructing the generation of Foxp3 + regulatory T cells, a property suggestion of induction of immunologic tolerance.

Patients with bleeding ulcers can have recurrent bleeding and mortality after endoscopic therapy. Risk stratification is important in the management of the initial patient triage. The aim of this study is to identify the clinical and laboratory risk factors for recurrent bleeding and mortality. A prospective study was conducted in 390 consecutive patients with bleeding peptic ulcers and high-risk endoscopic stigmata, e.g., active bleeding, a non-bleeding visible vessel, adherent blood clot, and hemorrhagic dot. We tested 13 available variables for association with recurrent bleeding and 15 were tested for association with mortality. A logistic regression model was used to identify individual correlates associated with these adverse outcomes. Bleeding recurred in 46 patients (11.8%) within 3 days and 21 patients (5.4%) had in-hospital mortality. In the full-factor analysis model, the incidence of recurrent bleeding was significantly higher in five of the 13 investigated variables and mortality was significantly higher in two of the 15 variables. In the final analysis model, significant risk factors for recurrent bleeding within 3 days, with adjusted odds ratios (OR), were in-hospital bleeding (OR 3.3), initial hemoglobin level

Background and Aim: Bleeding peptic ulcers can be due to Helicobacter pylori (H. pylori) infection, use of non-steroidal anti-inflammatory drugs (NSAIDs), or idiopathic causes. The aim of this prospective study was to identify the clinical outcomes of bleeding peptic ulcers related to different causes. Methods: A total of 390 patients with bleeding ulcers were evaluated consecutively between June 2005 and August 2006. The diagnosis of H. pylori infection was made at index endoscopy, using histology and the rapid urease test. If both endoscopic diagnostic tests were not performed, a serological test was applied to detect the presence of H. pylori infection in a previously untreated patient. The prevalence and outcome of bleeding ulcers are related to H. pylori infection, NSAID use, and non-H. pylori idiopathic causes. The outcome between patients who were admitted for ulcer bleeding (outpatient bleeder) and those who bled while hospitalized (in-hospital bleeder) was also compared. Results: NSAID ulcers were noted in 223 patients, H. pylori ulcers in 102, and non-H. pylori idiopathic ulcers in 65. In total, 298 patients had outpatient bleeders, and 92 had in-hospital bleeders. The overall 3-day rebleeding rate was 11.8% and the mortality rate was 5.4%. Eighteen of the 21 mortality cases died of their underlying comorbid illness. Patients with non-H. pylori idiopathic ulcers had a significantly higher mortality rate than NSAID and H. pylori ulcers (12.3% vs 4.5% vs 2.9%, P = 0.02). Patients with H. pylori ulcers had significantly favorable outcomes than patients with NSAID ulcers (less blood transfusion and a shorter hospital stay) and non-H. pylori idiopathic ulcers (shorter hospital stay and a lower mortality). Patients with in-hospital bleeders had an adverse outcome as compared to outpatient bleeders, including a 3-day rebleeding rate (25.0% vs 7.7%, P

Some biliary neoplasms secrete copious mucin into bile ducts, yet the management of mucobilia is not well known. The objective of this study was to analyze 16 patients with copious mucin in the biliary tract stressing the diagnostic and therapeutic aspects of endoscopic retrograde cholangiography (ERC).Sixteen patients with mucobilia were found among 5635 cases of ERC from October 1999 to October 2006 in our institution. Diagnostic and therapeutic ERC as well as clinical features were retrospectively analyzed.Mucin had a greater impact than the neoplasm itself on the cholangiogram and clinical presentation. ERC failed to show the tumors but a disproportionate or aneurysmal dilatation of the segmental or lobar duct correlated with the tumor-bearing duct was evident. Endoscopic managements included clearance of intraductal mucin and/or endoscopic nasobiliary drainage (ENBD). Three patients were excluded from outcome assessment because of non-specific symptoms or spontaneously subsiding jaundice. Among the 13 patients eligible for assessment, subjective improvement in symptoms and/or a decrease in jaundice along with subsiding cholangitis following ERC was observed in 5 of the 7 patients that underwent both clearance of intraductal mucin and ENBD (ENBD function was poor in all 7 patients), in 1 patient who underwent only clearance of intraductal mucin, and in 3 of the 5 patients who underwent only ENBD. The three patients with progressive jaundice, despite endoscopic management, had advanced disease.ERC revealed the tumor-bearing duct but not the extent of the disease in most of the patients with mucobilia. When mucobilia is encountered during ERC, the management should include clearance of as much intraductal mucin as possible. ENBD is frequently obstructed by mucin and may be helpful only in selected cases.

To predict the re-bleeding after endoscopic hemostasis for delayed post-endoscopic sphincterotomy (ES) bleeding.Over a 15-year period, data from 161 patients with delayed post-ES bleeding were retrospectively collected from a single medical center. To identify risk factors for re-bleeding after initial successful endoscopic hemostasis, parameters before, during and after the procedure of endoscopic retrograde cholangiopancreatography were analyzed. These included age, gender, blood biochemistry, co-morbidities, endoscopic diagnosis, presence of peri-ampullary diverticulum, occurrence of immediate post-ES bleeding, use of needle knife precut sphincterotomy, severity of delayed bleeding, endoscopic features on delayed bleeding, and type of endoscopic therapy.A total of 35 patients (21.7%) had re-bleeding after initial successful endoscopic hemostasis for delayed post-ES bleeding. Univariate analysis revealed that malignant biliary stricture, serum bilirubin level of greater than 10 mg/dL, initial bleeding severity, and bleeding diathesis were significant predictors of re-bleeding. By multivariate analysis, serum bilirubin level of greater than 10 mg/dL and initial bleeding severity remained significant predictors. Re-bleeding was controlled by endoscopic therapy in a single (n = 23) or multiple (range, 2-7; n = 6) sessions in 29 of the 35 patients (82.9%). Four patients required transarterial embolization and one went for surgery. These five patients had severe bleeding when delayed post-ES bleeding occurred. One patient with decompensated liver cirrhosis died from re-bleeding.Re-bleeding occurs in approximately one-fifth of patients after initial successful endoscopic hemostasis for delayed post-ES bleeding. Severity of initial bleeding and serum bilirubin level of greater than 10 mg/dL are predictors of re-bleeding.

Background Patients with esophageal cancer often present with dysphagia and malnutrition. Obstructive symptoms may improve after radiotherapy and chemotherapy. Nutrition support via a nasogastric tube (NG) or gastrostomy is very important during treatment. The newly developed ultrathin endoscope (Olympus, GIF-N230, outer diameter: 6 mm) has a smaller diameter than the standard endoscope and can be introduced into the esophagus via the nasal cavity. This article reports on the use of an ultrathin endoscope for NG placement for patients with esophageal cancer who presented with dysphagia and failed traditional NG tube placement. Methods A consecutive series of 40 patients with esophageal cancer were referred to our hospital from November 2001 to October 2002 for endoscopic placement of NG tubes due to failure of traditional methods of NG placement. An ultrathin endoscope was used to advance the guidewire into the stomach via the nasal cavity. After withdrawal of the scope, the NG tube was inserted over the guidewire under fluoroscopy. Observations A total of 71 procedures were performed in 40 patients (37 males, 3 females), age 57 ± 15 years (range, 37-91 y). Seventy procedures (99%) were successful in completing NG tube placement by using an ultrathin transnasal endoscope. Only one procedure failed because the esophageal lumen was completely occluded and the guidewire was not able to be passed through the obstructed site. The average duration that the NG tube was left in place was 49 ± 35 days (range, 2-144 days). No procedure-related complications, such as bleeding or perforation, occurred. Conclusions Using ultrathin transnasal endoscopy to place an NG tube for esophageal cancer patients is effective and safe. It simplifies the procedures and increases the success rate.

This study aimed to investigate the ratios of precore stop mutant (codon 28; TGG to TAG) to total viremia in 53 HBeAg-positive patients with chronic hepatitis B by amplification-created restriction site assays along the course of HBeAg-to-anti-HBe seroconversion. At baseline, 11% had exclusive wild-type hepatitis B virus (HBV), 15% had exclusively precore mutant, and 74% had mixed viral strains. Precore mutant ratios correlated little with age, sex, or HBV DNA levels (all P > 0.1), but correlated modestly with alanine aminotransferase (ALT) levels ( P = 0.05). The intervals from presentation to anti-HBe seroconversion correlated significantly with ALT and precore mutant ratios in univariate analysis but with only precore mutant ratios in multivariate analysis ( P = 0.003). Precore mutant ratios at baseline were significantly higher ( P < 0.001) in six patients with persistent high viremia and ALT elevation after anti-HBe seroconversion (group 1) than in 47 with remission (group 2). All group 1 patients had exclusive precore mutant after anti-HBe seroconversion, as did only 14 (30%) of the group 2 patients ( P = 0.003). Among group 2 patients, precore mutant ratios at baseline or after anti-HBe seroconversion showed no significant difference between 34 patients with sustained remission and 13 with relapse. Cirrhosis developed in 50% (5 of 10) of patients with precore mutant ratios >50% at baseline but only in 12% (5 of 43) of those with precore mutant ratios of P < 0.05). In conclusion, precore mutant of variable ratios was frequently detected in HBeAg-positive patients with chronic hepatitis B. Precore mutant ratios tended to correlate with ALT levels and anti-HBe seroconversion, but high precore mutant ratios were associated with persistent hepatitis after anti-HBe seroconversion and increased risk of cirrhosis.

To determine the accuracy of Rockall and Blatchford scores for predicting outcome after endoscopic treatment in two groups of patients with bleeding peptic ulcers: those who initially presented with upper gastrointestinal (UGI) bleeding (Group A) and those who developed UGI bleeding during hospital treatment for another condition (Group B).A total of 593 patients who had had endoscopic treatment for bleeding peptic ulcers from January 2009 to July 2010 were divided into Groups A and B. Endoscopic therapy including monotherapy (thermal therapy or hemoclipping) and combination therapy was applied. The Blatchford and complete Rockall scores for the two subgroups were calculated. Predictive statistics for the use of the two scoring systems were then compared for Groups A and B.Thirty-day re-bleeding and mortality rates increased with increased Rockall and Blatchford scores. Rockall scores were more accurate than the Blatchford scores for predicting mortality. However, neither the Rockall nor the Blatchford score could accurately predict recurrence of bleeding. When the results in Group B and Group A subgroups were compared, the average Rockall score for Group A was lower than that for Group B (5.6 vs. 6.3, p0.001).In high-risk patients with peptic ulcer bleeding, the Rockall score can better predict 30-day mortality than can the Blatchford score; this was particularly true for Group B patients.

Most patients with hypopharyngeal carcinomas show advanced disease, either at the primary site or in the neck, at the time of diagnosis. Despite intensive therapy, a great number of recurrences and distant metastases can be observed. The most common metastatic sites are the lung and bone, and only in autopsy cases has peritoneum carcinomatosis been mentioned as a metastatic site. Since January 1992, two of 78 patients (2.3%) with advanced hypopharyngeal squamous cell carcinomas (SCCs) treated initially by chemotherapy in our department developed clinical peritoneal carcinomatosis during their natural courses. Both patients were man patients with advanced locoregional disease at stage T4N3. Their clinical peritoneal carcinomatosis appeared during chemotherapy, with good disease control above the clavicle. Both patients eventually died of sepsis within 1 month after diagnosis of the peritoneal carcinomatosis. The authors suggest that peritoneal carcinomatosis is not as rare as previously believed, and should be included in the differential diagnosis in patients with advanced hypopharyngeal SCC with abdominal symptoms. Peritoneal carcinomatosis appears to be refractory to chemotherapy, and carried a poor prognosis in patients in the present study.

Background Despite the technical and medical improvements in the recent years, hepatic artery thrombosis (HAT) remains a devastating complication after living donor liver transplantation (LDLT). We described our surgical techniques and monitoring protocols for hepatic artery reconstruction. We reported one of the lowest incidence rates of HAT in the literature. Methods Between 2008 and 2015, a total of 325 LDLTs performed at our institute were retrospectively analyzed. Under microscope assistance, all hepatic artery anastomosis were performed in a risk-free and back-wall first manner. We collected donors and recipients’ demographics, operative procedures and outcome. Results A total of 325 adult LDLTs were enrolled in the study. Of these, 297(91.4%) were right liver graft. The mean diameter of the hepatic arteries of the graft was 1.9±0.3mm. A single HA anastomosis was performed in 310 patients (95.4%). The 1-, 3-, and 5-year overall patient survival rates were 84.8%, 76.8% and 75.2% respectively. Only one (0.3%) episode of HAT was encountered in our series. The patient was treated successfully with non-surgical management. Conclusion Our study showed that the occurrence of HAT is evitable. Identifying risk factors associated with HAT, meticulous surgical techniques and carefully routine flow monitoring are mandatory to avoid disastrous complications. This article is protected by copyright. All rights reserved.

Virus-specific cytotoxic T lymphocytes (CTLs) have been suggested to be responsible for the liver injuries in patients with hepatitis C virus (HCV) infection. However, there has been no report of direct evidence to substantiate this hypothesis. In this study, we performed in vitro autologous hepatocytotoxicity assay in 45 patients to examine a possible role of CTLs to HCV-infected live cells. The data were correlated with histology activity index of liver biopsy specimens. Lymphocyte subsets and hepatocyte expression of human major histocompatibility complex antigens class I and class II (HLA-I and HLA-II) were also evaluated. The immunohistochemical study showed more prominent HLA-I expression than HLA-II on hepatocytes (mean score +/- SEM:2.34 +/- 0.11 vs. 0.42 +/- 0.08; P < .01). The lymphocyte subset analysis showed that CD8+ T cells were dominant in the lobular areas showing spotty necrosis, whereas CD4+ T cells were prominent in the portal and periportal areas (P < .01). Most patients had a significant T cell-mediated cytotoxicity to hepatocytes as compared with non-T cells (percentage cytotoxicity +/- SEM:46.4 +/- 2.3 vs. 13.8 +/- 2.7; P < .001). T cell-mediated hepatocytotoxicity had a linear correlation with HAI (P < .05). The T cell-mediated cytotoxicity could be blocked by anti-CD8 (43.7% vs. 18.5%, P < .05) but not by anti-CD4 or anti-HLA-II monoclonal antibodies. These findings strongly suggest that HLA-I-restricted, CD8+ T cell-mediated hepatocytotoxicity is an important pathogenetic mechanism in patients with chronic HCV infection.

Virus-specific cytotoxic T lymphocytes (CTLs) have been suggested to be responsible for the liver injuries in patients with hepatitis C virus (HCV) infection. However, there has been no report of direct evidence to substantiate this hypothesis. In this study, we performed in vitro autologous hepatocytotoxicity assay in 45 patients to examine a possible role of CTLs to HCV-infected liver cells. The data were correlated with histology activity index of liver biopsy specimens. Lymphocyte subsets and hepatocyte expression of human major histocompatibility complex antigens class I and class II (HLA-I and HLA-II) were also evaluated. The immunohistochemical study showed more prominent HLA-I expression than HLA-II on hepatocytes (mean score ± SEM: 2.34 ± 0.11 vs. 0.42 ± 0.08; P < .01). The lymphocyte subset analysis showed that CD8+ T cells were dominant in the lobular areas showing spotty necrosis, whereas CD4+ T cells were prominent in the portal and periportal areas (P < .01). Most patients had a significant T cell-mediated cytotoxicity to hepatocytes as compared with non-T cells (percentage cytotoxicity ± SEM: 46.4 ± 2.3 vs. 13.8 ± 2.7; P

We report a case of a chronic hepatitis B carrier with an episode of acute hepatitis. The patient presented with a headache, arthralgias, jaundice and fever. While the laboratory tests mimicked chronic hepatitis B with an acute exacerbation, lipogranulomatous changes seen in the liver biopsy strongly suggested the presence of Q fever. Serology testing for Coxiella burneti proved positive and the patient responded to tetracycline therapy. While previously unreported in Taiwan, Q fever is important to consider in an atypical hepatitis presentation because it is a treatable condition.

Objectives Gastric outlet obstruction (GOO) is a late complication of advanced gastric, pancreatic, and duodenal cancer. Palliative treatment of the obstruction is the main aim of therapy for these patients. Self-expandable metal stents are used for treating GOO. From our experience, the placement of the stent across the pylorus is easier and makes the curve of stent better than when the stent is placed within the duodenal area. The purposes of this study were to assess the efficacy of stents placed in either the duodenal area or across the pyloric valve in relieving GOO symptoms and to evaluate whether the location of the stent affects treatment outcomes. Materials and Methods This was a retrospective single-site study of 44 patients with malignant GOO. Expanding metal stents were placed either across the pyloric valve (n = 22; group A) or in the duodenum area (n = 22; group B). Improvement in oral intake was monitored using the Gastric Outlet Obstruction Scoring System (GOOSS). The end of the study was death of the last enrolled patient or 6 months after enrollment of the last patient, or whatever came first. Results Stent implantation similarly improved the patients’ tolerance for food intake from baseline for both groups A and B (median [interquartile range]; 2 [2–3] and 2 [2–3], respectively). Patients in group B who received adjunctive chemotherapy had greater improvement in GOOSS and survival than patients in group B who did not have chemotherapy or any group A patients ( P < 0.05). Stent patency was not affected by stent position or chemotherapy. Conclusion Palliative treatment of GOO with placement of an expandable metal stent improved the tolerability of food intake. The location of stent across the pyloric valve or within the duodenum did not affect the efficacy of the procedure or stent patency.

Gastric outlet obstruction (GOO) is frequently caused by tumor. Recently, endoscopic implantation of self-expanding metallic stents (SEMS) has been introduced as an improved palliative treatment for GOO. This study aims to study the effect of SEMS placement on nutrient intake in patients with GOO and correlate different SEMS positions with postoperative clinical outcomes.Fifty six non-operable patients with GOO were enrolled. Obstruction of the duodenum (n=23) or gastric outlet (n=33) were commonly found. Either Wallstent Enteral Stents, WallFlex Enteral Duodenal or partially covered Ultraflex esophageal stents were placed under endoscopic and fluoroscopic guidance. The Gastric Outlet Obstruction Score (GOOSS) was used as the main outcome measurement.The procedure was technically feasible in 100% of patients and gave satisfactory clinical results in 98.2% (55/56). The patients had a median survival time of 97.5 days (range 9-380). Median stent patency was 72 days with a range of 8 to 267 days. The average GOOSS, measuring oral intake, was significantly improved, regardless of obstruction site (p0.05). We also found that the site of SEMS placement did not affect the clinical outcome.Palliation with SEMS is a safe and effective method for restoring gastric intake in patients with malignant GOO.

Biliary reconstruction has been described 35 years ago by Sir Roy Calne as the technical ‘Achilles heel’ of orthotopic liver transplantation (OLT). The name “Achilles' heel” comes from Greek mythology, which is a metaphor of a single vulnerable spot. This is because the potential detrimental effects of biliary complications on graft and patient survival. Biliary complications, which “plagued” the early experience of liver transplantation occurring in nearly one of every three transplant recipients (Moser & Wall, 2001), have been reduced dramatically due to the improvements in organ selection, retrieval, preservation, and implantation techniques. However, biliary complications still remain a common source of morbidity and mortality (Greif et al., 1994). Additionally, they significantly affect the recipients’ quality of life because they entail frequent readmissions, repeated imaging, invasive procedures, and even reoperation. All of them added to the financial and emotional toll suffer the patients (Sharma et al., 2008). Biliary leaks and strictures, either anastomotic or non-anastomotic, are the most frequent complications. Cystic duct obstruction due to mucocele, stones, sludge or casts, hemobilia and sphincter of Oddi dysfunction have also been recorded (Colonna et al., 1992; Greif et al., 1994). The surgical management used to be the standard of care for these conditions in earlier practice. However, the revolutionary progress in minimally invasive armamentarium, namely endoscopy and percutaneous radiologic interventional modalities, made it the current alternative first line of management displacing surgical intervention to be a second backup option (Sharma et al., 2008; Williams & Draganov, 2009). A living donor liver transplantation (LDLT) was first reported in 1988 by Raia in Brazil, followed by Nagasue in Japan in 1989. After the leading successful experience of right lobe living related liver transplantation (RL-LDLT) that has been reported by Hong Kong team in 1996, it rapidly evolved as a well-established practice in Asian countries. World wide organ shortage and promising results were alluring to other centers to consider (RL-LDLT) as a practical option. In this review we will shed more light on biliary complications related to right lobe living donor liver transplantation and their endoscopic management.

Background Although the outcomes of caustic ingestion differ between children and adults, it is unclear whether such outcomes differ among adults as a function of their age. This retrospective study was performed to ascertain whether the clinical outcomes of caustic ingestion differ significantly between elderly and non-elderly adults. Methods Medical records of patients hospitalized for caustic ingestion between June 1999 and July 2009 were reviewed retrospectively. Three hundred eighty nine patients between the ages of 17 and 107 years were divided into two groups: non-elderly (< 65 years) and elderly (≥ 65 years). Mucosal damage was graded using esophagogastroduodenoscopy (EGD). Parameters examined in this study included gender, intent of ingestion, substance ingested, systemic and gastrointestinal complications, psychological and systemic comorbidities, severity of mucosal injury, and time to expiration. Results The incidence of psychological comorbidities was higher for the non-elderly group. By contrast, the incidence of systemic comorbidities, the grade of severity of mucosal damage, and the incidence of systemic complications were higher for the elderly group. The percentages of ICU admissions and deaths in the ICU were higher and the cumulative survival rate was lower for the elderly group. Elderly subjects, those with systemic complications had the greatest mortality risk due to caustic ingestion. Conclusions Caustic ingestion by subjects ≥65 years of age is associated with poorer clinical outcomes as compared to subjects < 65 years of age; elderly subjects with systemic complications have the poorest clinical outcomes. The severity of gastrointestinal tract injury appears to have no impact on the survival of elderly subjects.

Intrahepatic cholangiocarcinoma with sarcomatous changes is seldom reported and its clinicopathological characteristics are largely unknown.Of 466 patients treated in our institution for intrahepatic cholangiocarcinoma from 1991-2005, seven who exhibited sarcomatous features were included in this study.Most of the tumors were diagnosed in the advanced stage and abdominal pain was the most common presenting symptom. In three cases, the tumors were associated with hepatolithiasis. The tumors frequently appeared as mixed-echoic masses on ultrasonography. They were hypo-attenuated masses on plain computed tomography scans and most appeared with ring-like enhancement after contrast medium injection. Histologically, two of the three resected tumors exhibited complete sarcomatoid change. Four of the liver biopsies also showed only sarcomatous features. Immunohistochemically, tumor cells in the region with sarcomatous features stained positive for both cytokeratin and vimentin antibodies. Follow-up was available in six patients: five died of disease one week to two months after diagnosis; one who remained disease-free 4 years after diagnosis had early stage disease and complete surgical resection.Intrahepatic sarcomatoid cholangiocarcinoma is a rare but aggressive malignancy. The diagnosis needs to be confirmed by immunohistochemical study. Early detection and complete surgical resection offer the only chance for long term survival in patients with this cholangiocarcinoma variant.

To assess the efficacy of rapid urease test (RUT) in patients with bleeding ulcers, as well as the effects of visible blood in the stomach and short-term (24 h) use of standard-dose proton pump inhibitor (PPI) on RUT sensitivity.The sensitivity of RUT in the diagnosis of Helicobacter pylori in upper gastrointestinal bleeding has been reported with conflicting results.This was a prospective case-control study evaluating 324 consecutive patients with bleeding peptic ulcers (study group) and 164 with uncomplicated ulcers (control group). The presence of H. pylori infection was determined by both RUT and histology. Prevalence of H. pylori infection and the RUT sensitivity in diagnosing the bacteria between study and control groups were conducted.The prevalence of H. pylori infection in those with bleeding ulcers was significantly lower than that of controls (53.7% vs. 65.2%, P=0.015). The false-negative rate of RUT in the study group was significantly greater than that of the control group (16.7% vs. 5.6%, P=0.006), whereas the sensitivity rates in the study group with or without gastric blood were significantly lower than those of the controls (79.6% vs. 94.4%, P=0.005; 84.8% vs. 94.4%, P=0.019). There was no significant difference in RUT sensitivity between study group with or without visible gastric blood (P=0.41). The RUT sensitivity rate was also not significantly different between those treated with PPI and those without in patients with bleeding ulcers (82.7% vs. 85.7%, P=0.67).This study shows that the sensitivity of RUT in patients with bleeding ulcers is reduced. The presence of blood in the stomach and the short-term use of standard-dose PPI do not affect the RUT sensitivity in bleeding ulcers.

Dieulafoy lesion is an unusual but important cause of upper gastrointestinal bleeding. The study retrospectively reviewed 29 patients (2.1%) with Dieulafoy lesions of 1393 acute nonvariceal upper gastrointestinal bleeding episodes from October 1999 to May 2001. Nineteen patients (66%) were male and the median age was 62 years (range, 19 to 86 years). Two patients underwent emergent surgery after endoscopic diagnosis. The other patients were allocated to four therapeutic endoscopic groups: group I, epinephrine injection (11 patients); group II, epinephrine injection plus heater probe coagulation (10 patients); group III, histoacryl injection (4 patients); and group IV, hemoclipping (2 patients). Initial treatment failure ocurred in three patients (all in group I) and they received surgery, hemoclipping, or band ligation as salvage therapy, respectively. Among those who achieved initial hemostasis, recurrent bleeding developed in two patients (all in group I) and was successfully controlled by endoscopic injection plus thermal therapy. No complication was noted after endoscopic treatment. Group II had a significantly higher successful hemostasis rate than group I (100 vs 54%; P = 0.02). One patient in the therapeutic endoscopy groups died during admission, for a mortality rate of 3.7%. Patients were followed up from 6 to 36 months and no further bleeding was noted. The results suggest that epinephrine injection plus heater probe coagulation was significantly superior to epinephrine injection alone in achieving hemostasis. Histoacryl injection, hemoclipping, and endoscopic band ligation were safe and effective alternate therapies.

Emphysematous gastritis is a life-threatening disease. Although rare in incidence, it has a fulminating course with a high mortality rate. A case of a 58 year old male with emphysematous gastritis is reported. Initially, he presented with acute gastric dilatation secondary to anorexia/bulimia-like behaviour. Later, emphysematous gastritis developed. The abdominal sonographic findings, which have not been previously described in the literature, showed intramural gas and gastric wall thickening. After receiving a total gastrectomy, he had a satisfactory outcome. The present report discusses the possible aetiologic relationship between acute gastric dilatation and emphysematous gastritis, and suggests abdominal sonography to be the first choice of diagnostic measure for patients with the intramural gas in the gastric wall. This is the first case of emphysematous gastritis diagnosed by abdominal sonography.

To describe characteristics of a poorly expandable (PE) common bile duct (CBD) with stones on endoscopic retrograde cholangiography.A PE bile duct was characterized by a rigid and relatively narrowed distal CBD with retrograde dilatation of the non-PE segment. Between 2003 and 2006, endoscopic retrograde cholangiography (ERC) images and chart reviews of 1213 patients with newly diagnosed CBD stones were obtained from the computer database of Therapeutic Endoscopic Center in Chang Gung Memorial Hospital. Patients with characteristic PE bile duct on ERC were identified from the database. Data of the patients as well as the safety and technical success of therapeutic ERC were collected and analyzed retrospectively.A total of 30 patients with CBD stones and characteristic PE segments were enrolled in this study. The median patient age was 45 years (range, 20 to 92 years); 66.7% of the patients were men. The diameters of the widest non-PE CBD segment, the PE segment, and the largest stone were 14.3 ± 4.9 mm, 5.8 ± 1.6 mm, and 11.2 ± 4.7 mm, respectively. The length of the PE segment was 39.7 ± 15.4 mm (range, 12.3 mm to 70.9 mm). To remove the CBD stone(s) completely, mechanical lithotripsy was required in 25 (83.3%) patients even though the stone size was not as large as were the difficult stones that have been described in the literature. The stone size and stone/PE segment diameter ratio were associated with the need for lithotripsy. Post-ERC complications occurred in 4 cases: pancreatitis in 1, cholangitis in 2, and an impacted Dormia basket with cholangitis in 1. Two (6.7%) of the 28 patients developed recurrent CBD stones at follow-up (50 ± 14 mo) and were successfully managed with therapeutic ERC.Patients with a PE duct frequently require mechanical lithotripsy for stones extraction. To retrieve stones successfully and avoid complications, these patients should be identified during ERC.

AIM: To evaluate the effect of double balloon endoscope (DBE) on the endoscopic retrograde cholangiopancreatography (ERCP) success rate in patients with a history of Billroth II (B II) gastrectomy. METHODS: From April 2006 to March 2007, 32 patients with a B II gastrectomy underwent 34 ERCP attempts. In all cases, the ERCP procedures were started using a duodenoscope. If intubation of the afferent loop or reaching the papilla failed, we changed to DBE for the ERCP procedure (DBE-ERCP). We assessed the success rate of afferent loop intubation, reaching the major papilla, selective cannulation, possibility of therapeutic approaches, procedure-related complications, and the overall success rate. RESULTS: Among the 32 patients with a history of B II gastrectomy, the duodenoscope was successfully passed up to the papilla in 22 patients (69%), and cannulation was successfully performed in 20 patients (63%). Six patients (2 with failure in afferent loop intubation and 4 with failure in reaching the papilla) underwent DBE-ERCP. The DBE reached the papilla in all the 6 patients (100%) and selective cannulation was successful in 5 patients (83%). Four patients (67%) who had common bile duct stones were successfully treated. One patient underwent diagnostic ERCP only and the other one, in whom selective cannulation failed, was diagnosed with papilla cancer proven by biopsy. There were no complications related to the DBE. The overall ERCP success rate increased to 88% (28/32). CONCLUSION: The overall ERCP success rate increases with DBE in patients with a previous B II gastrectomy.

AIM: To compare the hemostatic efficacy between epinephrine injection alone and epinephrine injection combined with thermotherapy for delayed post-endoscopic sphincterotomy (ES) bleeding. METHODS: Cases with delayed post-ES bleeding undergoing epinephrine injection alone (epinephrine injection group, n = 26) or epinephrine combined with thermotherapy (combination therapy group, n = 33) in our institution between 1999 and 2007 were retrospectively investigated. The main outcome measurements were: initial endoscopic hemostasis, re-bleeding, complications, requirement of angiographic embolization or surgery, requirement for blood transfusion, and mortality. RESULTS: The initial hemostatic efficacy was 96.2% for epinephrine injection alone and 100% for combination therapy (P = 0.44). There were four patients with re-bleeding in each group (16.0% vs 12.1%, P = 0.72). There was only one complication of pancreatitis from the combination therapy group. Three patients (11.5%) in the epinephrine injection group and one patient (3%) in the combination therapy group required angiographic embolization or surgery (P = 0.31). The total number of blood transfusions was not significantly different between the two groups (3.5 ± 4.6 U vs 3.5 ± 4.5 U, P = 0.94). There was no bleeding-related death in either group. CONCLUSION: Epinephrine injection alone is as effective as epinephrine injection combined with thermotherapy for the management of delayed post-ES bleeding.