Massive Hematochezia from Acute Hemorrhagic Rectal Ulcer in Patients with Severe Comorbid Illness: Rapid Control of Bleeding by Per Anal Suturing of Bleeder Using Anoretractor

Purpose Massive hematochezia from acute hemorrhagic rectal ulcer can arise in patients with severe comorbid illness who are bedridden for long periods. If the bleeder is not found and treated immediately, the bleeding will cause deterioration of health and even threaten life. The results of the current study show how quickly and safely per anal suturing can treat acute hemorrhagic rectal ulcer. Methods From January 2003 to December 2003, the records of 26 patients who underwent per anal suturing of acute hemorrhagic rectal ulcer were retrospectively reviewed. The identification of acute hemorrhagic rectal ulcer was confirmed by clinical and anoscopic examination. Results Most of these patients were elderly and bedridden (14 men; median age 69 years). Main comorbid illnesses existed in all patients and included liver cirrhosis (8 patients, 31 percent), sepsis (13 patients, 50 percent), cerebral vascular accident (15 patients, 58 percent), respiratory failure (13 patients, 50 percent), and malignancy (7 patients, 27 percent). Effective hemostasis was achieved in all patients by direct suture of bleeding ulcer. No complications developed relative to the per anal suturing procedure among any patients. Although 11 patients developed recurrent hematochezia, 9 patients responded to repeated therapy. The risk factors associated with recurrent bleeding were severity of disease and abnormal coagulation. Conclusions When massive hematochezia occurs in bedridden patients with severe comorbid illness, it is essential to investigate the lower rectum, which often is affected by acute hemorrhagic rectal ulcer. Recognition of this clinical presentation will result in early identification and therapy. Per anal suturing of a bleeder at the bedside provides a quick, safe, and successful management of acute hemorrhagic rectal ulcer.     

Effects of ginger on gastric emptying and motility in healthy humans

OBJECTIVE: Ginger has been reported to improve upper gastrointestinal symptoms. Little information about the effects of ginger on gastric motor function, exists, however. Our aim was to investigate the effects of ginger on gastric emptying, antral motility, proximal gastric dimensions, and postprandial symptoms. METHODS: Twenty-four healthy volunteers were studied twice in a randomized double-blind manner. After an 8 h fast, the volunteers ingested three ginger capsules (total 1200 mg) 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 over 90 min, and the gastric half-emptying time was calculated from the change in antral area. Gastrointestinal sensations and appetite were scored using visual analog questionnaires. Data are expressed in terms of mean+/-standard error. RESULTS: Antral area decreased more rapidly (P<0.001) and the gastric half-emptying time was less after ginger than placebo ingestion (13.1+/-1.1 vs. 26.7+/-3.1 min, P<0.01), whereas the frequency of antral contractions was greater (P<0.005). Fundus dimensions did not differ, and there was no significant difference in any gastrointestinal symptoms. CONCLUSION: Ginger accelerates gastric emptying and stimulates antral contractions in healthy volunteers. These effects could potentially be beneficial in symptomatic patient groups.     

Hepatitis C virus genotypes: clinical relevance and therapeutic implications

The incidence of hepatitis C virus (HCV) -related hepatocellular carcinoma (HCC) has been increasing in several countries including Taiwan. There are six main genotypes, each of which contains closely related subtypes. Molecular epidemiological studies have shown marked differences in the genotype distribution by geographical region and between patient groups. HCV genotype 1 may play a role in the development of HCC, although some studies have argued against this. A sustained virological response secondary to interferon monotherapy or interferon/ribavirin combination therapy may reduce the risk of HCC and improve survival in chronic hepatitis C patients. The HCV genotypes are associated with therapeutic response. Rapid virological response is also a predictor of therapeutic response. Although viral characteristics have consistently been shown to be important predictors of treatment response, identification of additional host immune and genetic factors involved in determining the outcome of antiviral therapy is necessary. Newly developed bio-techniques (microarray, proteomes, bioinformatics), drugs, and treatment strategies may elucidate the pathogenesis and improve the therapeutic response in HCV infection.     

Characteristics of adefovir resistance in patients with or without lamivudine‐resistant hepatitis B virus treated with adefovir: a 4‐year experience

Background/Aim: We investigated the 4‐year incidence and predictors of adefovir resistance in chronic hepatitis B patients with or without lamivudine (LAM)‐resistance treated with adefovir dipivoxil with or without short‐term LAM overlapping. Methods: One hundred and two LAM‐resistant patients and 79 without LAM resistance (36 naïve and 43 prior LAM exposure) treated with adefovir for >12 months were prospectively examined. Results: Cumulative incidences of adefovir resistance at month 12, 24, 36 and 48 were 3.9, 21.1, 31.8 and 43% respectively in LAM‐resistant patients. Cirrhosis was a significant risk factor for adefovir resistance. A similar rate of adefovir resistance was observed for LAM‐resistant patients and those with prior LAM exposure without resistance. Regarding LAM‐resistant patients, compared with those having hepatitis B virus (HBV) DNA levels <300 copies/ml, patients having HBV DNA levels >10⁴ copies/ml at week 24 of therapy had a hazard ratio (HR) of 9.8 for adefovir resistance development, while those without LAM resistance having the same HBV DNA levels at week 48 had a similar HR (9.5). Multidrug‐resistant (LAM+adefovir) variants were detected by direct sequencing in three of 35 LAM‐resistant patients treated with a switch to adefovir. Two of them had resistant mutations to both drugs on the same viral genome as determined by molecular cloning and sequencing. Conclusion: The incidence of adefovir resistance was high in LAM‐resistant patients treated with sequential adefovir. High HBV DNA levels at week 24 and 48 of therapy were the strongest predictors for adefovir resistance development in patients with and without LAM resistance respectively.     

Contrast-enhanced ultrasonographic spoke-wheel sign in hepatic focal nodular hyperplasia

BACKGROUND: To determine the utility of contrast-enhanced ultrasonography (CEUS) in assessing hepatic tumors with central feeding arteries found by color/power Doppler ultrasonograophy (CDUS/PDUS). METHODS: We prospectively studied 37 hepatic tumors (34 patients), with a mean size of 2.9cm and each having a central feeding artery, by CDUS/PDUS. The CEUS was performed with a galactose-based microbubble contrast agent. The detection of a spoke-wheel sign was interpreted as evidence of focal nodular hyperplasia (FNH). All patients underwent tumor biopsies or surgical resection. RESULTS: CEUS showed a central feeding artery with a spoke-wheel sign in 36 tumors, including 34 FNHs and 2 hepatocellular carcinomas. The remaining tumor was demonstrated to be FNH despite the absence of a spoke-wheel sign as detected by CEUS. The sensitivity of the spoke-wheel sign or central scar for FNH was 97.1% (34/35), 40% (14/35), 28.6% (10/35), 50% (8/16) and 0% (0/15) for CEUS, CDUS/PDUS, dynamic computed tomography (CT) or magnetic resonance imaging (MRI), hepatic angiography and liver scintigraphy, respectively. The two hepatocellular carcinomas showed scirrhous changes histologically. CONCLUSIONS: CEUS is more sensitive than CDUS/PDUS, dynamic CT, MRI, hepatic angiography and liver scintigraphy in the detection of the spoke-wheel sign or central scar in FNH. Scirrhous hepatocellular carcinoma should be included in the differential diagnosis for liver tumors with spoke-wheel sign detected by CEUS.     

Impact of chemotherapy-related prognostic factors on long-term survival in patients with stage III colorectal cancer after curative resection

Background

This retrospective study evaluated the prognostic factors of chemotherapy in stage III colorectal cancer after curative resection.

Methods

From 1996 to 2001, 1,054 patients with primary single colorectal cancer underwent curative resection. Seven hundred sixteen patients received various 5-fluorouracil (FU)-based adjuvant chemotherapy regimens, including oral and intravenous treatments. The chemotherapy-related parameters examined included therapeutic duration, frequency, route of administration, composition of combination therapies, and postoperative time interval from the operation to the start of chemotherapy.

Results

The therapeutic duration and postoperative time interval of starting therapy were independent prognostic factors, in addition to clinicopathological factors. The 8-year cancer-specific/overall survival rates in patients who received chemotherapy for >4 months (63.0/58.6%) were significantly higher than the rates in patients who received no chemotherapy (56.7/37.7%, P < 0.01) and those who remained on chemotherapy for 1–4 months (49.4/41.9%, P < 0.05). The 8-year cancer-specific/overall survival rates in patients who waited 1–5 weeks after surgery to receive chemotherapy (62.9/58.5%) were significantly higher versus rates in those who did not receive chemotherapy (56.7/37.7%) and those who did not receive chemotherapy until >5 weeks after surgery (52.3/45.9%) (both P < 0.05). Survival rates did not differ between patients who did not undergo chemotherapy, those for whom chemotherapy lasted 1–4 months, and patients who did not receive chemotherapy until >5 weeks after surgery.

Conclusions

The appropriate duration of therapy and early chemotherapy after surgery were 2 of the most important factors in eradicating occult cancer and effecting long-term survival benefits in patients with stage III colorectal cancer.     

Risk factors influencing the outcome of peptic ulcer bleeding in end stage renal diseases after initial endoscopic haemostasis

Background and Aims: Patients suffering from peptic ulcer (PU) bleeding who have end‐stage renal disease (ESRD) may encounter more adverse outcomes. The primary objective is to investigate the risk factors that influence the outcomes of ESRD and chronic kidney disease (CKD) patients with PU bleeding after successful initial endoscopic haemostasis. Methods: A total of 540 patients with PU bleeding after initial endoscopic haemostasis in a tertiary hospital were investigated retrospectively. They were sorted into three groups after randomised age‐matched adjustment: ESRD group (n = 90), CKD group (n = 90) and control group (n = 360). Main outcome measurements were rebleeding, requirement for blood transfusion and surgery, length of hospital stay and mortality. Results: The rebleeding rates were 43% for the ESRD group vs. 21% for the CKD group vs. 12% for the control group (overall p = < 0.001). Multivariate analysis showed the predictors of rebleeding were ESRD, time to endoscope, and non‐high‐dose proton‐pump inhibitors (PPI) users. The risk factors for bleeding‐related mortality were presence of moderate degree of CKD and ESRD group, time to endoscope, and Rockall score. All‐cause mortality was related to presence of moderate degree of CKD and ESRD group, platelet count, time to endoscope, Rockall score and length of hospital stay. Conclusions: ESRD patients who suffered from PU bleeding were at risk of excessive rebleeding and mortality with frequent occurrence of delayed rebleeding. This study suggests that early endoscopy for initial haemostasis and high‐dose intravenous PPI are associated with the reduction of rebleeding risk especially in patients with high Rockall scores.     

The efficacy of treatment schedules according to Barcelona Clinic Liver Cancer staging for hepatocellular carcinoma - Survival analysis of 3892 patients

The Barcelona Clinic Liver Cancer (BCLC) staging offers prognostic stratification and treatment allocation for hepatocellular carcinoma (HCC). We conducted this retrospective study to assess the efficacy of different treatment options for patients with initial HCC diagnosis. Survival rate and median survival times associated with different treatment options in each stage of BCLC classification were compared using the Kaplan–Meier method and log-rank test. A total of 3892 patients were enrolled. Overall survival rates were 46.2% at 1 year and 16.6% at 5 years. The median survival times decreased from 57.7 months in very early stage to 1.6 months in terminal stage. Surgical resection offered the best survival benefit for patients in very early, early and even intermediate stages. Transarterial embolisation and conformal radiotherapy offered survival benefits for selected patients in advanced and terminal stages. In conclusion, following the treatment schedules allocated by BCLC staging had survival benefits for HCC patients.