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The article describes the case of a 46-year-old female patient with chronic renal disease and who suffered from acute pancreatitis as a complication of retrograde single-balloon enteroscopy.

Objectives: To determine the development rate of hepatocellular carcinoma and survival of patients diagnosed to have regenerative, and low-grade and high-grade dysplastic liver nodules., Design: Retrospective descriptive study., Setting: Acute public hospital, Hong Kong., Patients: Patients with non-malignant liver nodules confirmed by imaging-guided liver biopsy between January 1997 and December 2008., Main Outcome Measures: Rates of hepatocellular carcinoma development and survival., Results: A total of 147 patients with non-malignant liver nodules were followed up over a median duration of 29 months. The initial histological diagnosis included regenerative nodules (n=74), low-grade dysplastic nodules (n=34), and high-grade dysplastic nodules (n=39). The respective cumulative hepatocellular carcinoma development rate during the first, second, third, and fourth year were 3%, 5%, 9% and 12% for simple regenerative nodules, 29%, 35%, 38% and 44% for low-grade dysplastic nodules, and 38%, 41%, 51% and 51% for high-grade dysplastic nodules. The hepatocellular carcinoma development rate was highest in those with high-grade dysplastic nodules. Multivariate analysis showed that histological dysplastic changes were associated with increased alpha-fetoprotein levels and advanced age, which were both independent predictors of hepatocellular carcinoma development. Histological dysplastic changes, male sex, advanced age, prolonged prothrombin time, and ultrasound appearances were independent predictors of mortality., Conclusion: The presence of dysplastic change in liver nodules increased the risk of hepatocellular carcinoma development and death.

Objective: To describe the epidemiology, clinical features, and treatment outcome of achalasia in Chinese patients., Design: Retrospective study., Setting: Major regional hospital, Hong Kong., Patients: Clinical records of patients with the diagnosis of achalasia from July 1997 to June 2007 were reviewed., Results: Thirty-two patients were diagnosed with achalasia during the study period. The mean age at diagnosis was 50 years (standard deviation, 20 years). The female-to-male ratio was 1.3:1. The main presenting symptoms were dysphagia (78%) and vomiting (50%). Nine laparoscopic and two open Heller's operations had been performed and 16 patients had undergone endoscopic dilatations. Four patients had botulinum toxin injection and four were taking calcium channel blocker (nifedipine) medications. Botulinum toxin injection and medical therapy had poor short- and long-term responses. Laparoscopic myotomy and pneumatic dilatation had comparable good short- and long-term responses., Conclusion: Achalasia affected all age-groups but there was a peak at middle age. Pneumatic dilatation and Heller's myotomy (open or laparoscopic approach) appeared able to maintain longer symptom responses than medical therapy and botulinum toxin injection.

Objective: To evaluate survival and prognostic factors in patients with advanced hepatocellular carcinoma treated by transarterial chemoembolisation in a real-life clinical practice setting., Design: Retrospective study., Setting: Regional hospital, Hong Kong., Patients: Patients with inoperable hepatocellular carcinoma diagnosed from January 1998 to December 2003 who received transarterial chemoembolisation., Results: A total of 74 patients were identified, and had a median survival of 214 days. The cumulative survival rates at 1, 2, and 3 years were 28%, 12%, and 7%, respectively. By multivariate analysis, superselective cannulation performed in transarterial chemoembolisation (hazard ratio=0.47; 95% confidence interval, 0.23-0.95; P=0.034), embolisation with gelfoam (0.30; 0.11-0.80; P=0.017), and treatment intervals of more than 45 days (0.33; 0.15-0.72; P=0.006) were independent predictors of good survival. Child-Pugh grade B cirrhosis (hazard ratio=5.62; 95% confidence interval, 2.11-14.97; P=0.001), and high pre-treatment serum alpha-fetoprotein level (2.93; 1.50-5.73; P=0.002) were independent predictors of poor survival., Conclusions: In real-life clinical practice, survival of patients with inoperable hepatocellular carcinoma remains grave despite treatment. Patients with Child-Pugh grade A cirrhosis or with low pretreatment alpha-fetoprotein level are more suitable for this form of treatment. The procedure should be performed with superselective cannulation and embolisation with gelfoam.

Objective: To study the descriptive epidemiology and clinical profile of patients with Crohn's disease., Design: Retrospective study., Setting: Regional hospital, Hong Kong., Patients: Patients with Crohn's disease diagnosed between January 1991 and December 2006 inclusive., Results: Over the period studied, 27 Chinese patients were diagnosed with Crohn's disease in our hospital. Our hospital-based incidence and prevalence rate had increased more than 2- and 5-fold, respectively over that period. The mean age at diagnosis was 26 years and median duration of disease was 81 months. Most patients had ileocolonic disease (67%) followed by Crohn's colitis (22%) and ileal disease (11%); more patients had non-stricturing and non-penetrating disease (63%) than stricturing (15%) or penetrating disease (22%). Peri-anal disease occurred in 37% of our patients. At diagnosis, many of the patients (41%) had mild-moderate disease, but 30% each had moderate-severe and severe-fulminant disease. At the time of this study, 85% of the patients were in disease remission with medical treatment. However, 48% had undergone surgery for diagnosis or complications. No patient had developed colorectal cancer or died., Conclusions: The incidence and prevalence of Crohn's disease are increasing in the Chinese population. It usually affects young persons with a substantial proportion of patients presented with severe-fulminant disease. More epidemiological and clinical studies are needed for this emerging disease in Asian regions.

This report is of the first locally acquired case of dengue fever. The diagnosis was made even in the absence of a history of travel outside Hong Kong. The patient was a 21-year-old man, who presented with high fever, leukopenia, thrombocytopenia, and elevated liver enzymes. His haematocrit revealed mild haemoconcentration but the albumin was normal throughout the course of the illness. His blood pressure remained low with no tachycardia or overt shock syndrome. The pyrexia subsided 4 days after admission to hospital and all haematological and biochemical abnormalities eventually normalised. The pathogenesis, diagnostic criteria of dengue haemorrhagic fever and dengue shock syndrome, and control of dengue infection are discussed.

We report on three patients with lead poisoning following use of the Chinese herbal pill Bao ning dan, prepared by the same traditional Chinese medicine practitioner. The patients had varying degrees of exposure to Bao ning dan and different clinical manifestations. Blood lead concentrations did not correlate with clinical severity. Two patients received chelating therapy and blood lead concentrations subsequently rapidly decreased. One patient was managed conservatively and end-organ complications resolved gradually. With increasing use of traditional Chinese medicines, related adverse reactions are expected to become increasingly common. Practitioners of western medicine should remain alert to this possibility. A comprehensive drug review, including the use of herbal medicines, should form a routine part of medical history taking.

Chronic strongyloidiasis is a mild disease and has never been reported to be associated with nephrotic syndrome. Disseminated strongyloidiasis is known to have high mortality, but it frequently is not diagnosed until autopsy. We report a patient with nephrotic syndrome developing disseminated strongyloidiasis after steroid therapy. The findings in renal biopsy, the time course of the development, and resolution of nephrotic syndrome after thiabendazole treatment suggested a possible causal relationship between chronic strongyloidiasis and nephrotic syndrome. The case also demonstrated the importance of early diagnosis in disseminated strongyloidiasis and the good clinical outcome of early treatment before the development of organ failure.

There is an increasing prevalence of ulcerative colitis in Hong Kong and cytomegalovirus infection is an important factor in the exacerbation of the disease. We report on a 33- year-old Chinese man with ulcerative colitis in remission, who presented with bloody diarrhoea that failed to respond to an intensive regimen of oral and rectal steroid. Colonoscopy was performed and biopsy specimens showed signs of cytomegalic colitis in association with ulcerative colitis. Administration of ganciclovir and the gradual termination of steroid treatment resulted in remission of the colitis. The clinical course suggested an exacerbation of ulcerative colitis due to cytomegalovirus infection. The relationship between ulcerative colitis and cytomegalovirus is discussed.

Endoscopic sclerotherapy is a standard procedure for the treatment of oesphageal varices. It is generally regarded as a safe procedure with low morbidity and mortality. However, there are a number of rare and fatal complications associated with this procedure. We report a case of pericardial effusion developing after oesophageal sclerotherapy. The patient developed cardiac tamponade requiring pericardiocentesis. This complication is uncommon, but its true incidence may be underestimated. When pericardial effusion is diagnosed early, this potentially fatal complication can be treated without serious sequelae.