- 1 Assessment of esophageal motor function using combined multichannel intraluminal impedance and manometry in patients with achalasia
Achalasia is characterized by esophageal aperistalsis and a failure of
lower esophageal sphincter (LES) relaxation. Combined multichannel intraluminal impedance
and manometry (MII-EM) allows the simultaneous recording of esophageal peristalsis and bolus
transport patterns. The aim of this study was to evaluate the feasibility of MII-EM for the
assessment of esophageal motility and to characterize patterns of esophageal bolus transport
in patients with achalasia with or without Heller myotomy.
Materials and methods: A total of nine patients (2 men and 7 women, age range 25e46 years)
were enrolled in this study. Two of the patients had previously undergone Heller myotomy. All
patients underwent combined MII-EM with a nine-channel esophageal function testing catheter
containing four impedance measuring segments and five solid-state pressure transducers. Each
patient received 10 liquid and 10 viscous swallows in a sitting position. All tracings were recorded
and analyzed for esophageal contractions and bolus transit.
Results: None of the patients with achalasia, whether they had undergone a Heller myotomy or
not, had manometrically normal esophageal peristalsis during saline or viscous swallowing.
They had a normal LES resting pressure, incomplete LES relaxation, and lower distal esophageal
contraction. The LES relaxation percentages in the patients who had undergone Heller
myotomy (97% and 51%) were higher than those of the untreated patients (mean 47%). All patients
demonstrated a low baseline impedance level in the distal esophagus. Air trapping in the
proximal esophagus was also detected in nearly all of the patients. None of the patients in
either group had complete bolus transit with either saline or viscous swallows.
- 2 Clinical experience of large colorectal laterally spreading tumor in a regional hospital 2-year results
Nonpolypoid colorectal neoplasm has been widely recognized in the
past few years. Among nonpolypoid colorectal neoplasms, laterally spreading tumor (LST) is a
unique and distinct category in that the tumor grows horizontally with a size >1 cm. It may be
easily overlooked during colonoscopy. If the size of the colorectal LST is >2 cm, achieving definite
management is also another concerning issue. The aim of this study was to improve our
understanding of LST by reviewing its clinical manifestations.
Methods: All the large colorectal LSTs that were diagnosed and managed at our hospital in the
past 2 years were reviewed. Basic demographic data were recorded. LSTs were divided into granular
(G) and nongranular types (NG), then further subdivided into nodular mixed and homogeneous
types for the G group and flat elevated and pseudodepressed types for the NG group.
Results: A total of 28 LST in 28 patients were enrolled, with males being more predominant than
females (male/female: 18/10). Mean age of the patients and mean size of the LST were
62.6 9.75 years and 3.4 1.257 cm, respectively. Concerning morphology, 14 were diagnosed
as NG and 14 as G group. The rate of malignant change was 28.6% (8/28). Twenty-three of our
patients received endoscopic treatment (5 for endoscopic piecemeal mucosal resection 18 for
endoscopic submucosal dissection) and five for laparoscopy-assisted colectomy. The cost and
length of admission analysis between the endoscopic and operation treatment groups showed
significant cost reduction (endoscopy/operation: NTD 28172/82516, p
- 3 Empiric antibiotic choices for communityacquired biliary tract infections
The study was conducted to reveal the most appropriate empiric antibiotics
for the treatment of community-acquired biliary tract infections (CA-BTI) at a regional
hospital in Taiwan.
Methods: The study was performed between October 1, 2010 and October 31, 2012. All positive
bile culture results of presumptive community-acquired origins were collected. The associated
etiologic microorganisms and their antimicrobial susceptibilities were analyzed. The
appropriateness of empiric therapy (defined as the effectiveness of the antibiotics against
the etiologic agents) and the subsequent treatment response were examined through the review
of medical records.
Results: A total of 115 patients (cholecystitis, 83 cases, 72.2%; cholangitis, 32 cases, 27.8%)
and 189 isolates (136 Gram-negative bacilli, 37 Gram-positive cocci, and 16 anaerobes) were
analyzed. The most frequent pathogens were Escherichia coli (n Z 69, 36.5%), Klebsiella
spp. (n Z 37, 19.6%), enterococci (n Z 29, 15.3%), and Bacteroides spp. (n Z 11, 5.8%). Penicillin
resistance (5.4%) was low in Gram-positive cocci, whereas higher resistance (>20%) to cefazolin,
cefuroxime, and ampicillinesulbactam was found in Gram-negative bacilli. Anaerobes
also demonstrated high resistance to clindamycin (37.5%) but less to metronidazole (12.5%).
Appropriate empiric therapy was found in 92 (80%) cases, and among them, 83 (90.2%) were
treated successfully. The treatment success rate (69.6%) was significantly lower among the remaining
23 cases with inappropriate empiric therapy (16 of 23 vs. 83 of 92, p < 0.05). A high
treatment success rate (97.2%) was observed among cases empirically treated with ceftriaxone
plus metronidazole.
- 4 Comparison of the efficacy of esomeprazole and famotidine against stress ulcers in a neurosurgical intensive care unit
To compare the efficacy of esomeprazole and famotidine against
stress ulcers and the association of these prophylactic agents with ventilator-associated pneumonia
in patients admitted to neurosurgical intensive care unit (ICU).
Patients and Methods: Sixty patients were randomly allocated into two groups (the esomeprazole
and famotidine groups; n Z 30 each) to receive prophylaxis medication for 7 days within
24 hours of admission in a neurosurgical ICU. Patients in the esomeprazole group received
esomeprazole (40 mg) dissolved in water once a day through a nasogastric tube, whereas patients
in the famotidine group received an intravenous infusion of famotidine (20 mg) every 12
hours. We then compared the occurrence of overt upper gastrointestinal bleeding and
ventilator-associated pneumonia between these two groups.
Results: One patient in the famotidine group had overt upper gastrointestinal bleeding (3.3%),
whereas the bleeding was not observed in patients in the esomeprazole group. Ventilatorassociated
pneumonia occurred in one patient (3.3%) from each group. One patient died within
30 days (3.3%) in the esomeprazole group and three patients (10%) died in the famotidine
group. There was no difference in the occurrence of overt upper gastrointestinal bleeding
(p Z 1.000), ventilator-associated pneumonia (p Z 1.000), and 30-day mortality
(p Z 0.612) between these two groups.
Conclusion: In this small-scale study, the effect of administration of esomeprazole through a
nasogastric tube on stress ulcer was similar to that of intravenous famotidine infusion in neurosurgical
ICU patients.
- 5 Stress ulcer prophylaxis in the intensive care unit
Upper gastrointestinal tract bleeding (UGIB) is a common
sequel of critical illness. Although only 1.5e6.0% of patients
admitted to the intensive care unit (ICU) will have overt
UGIB, most of them will exhibit clinical risk factors, especially
mechanical ventilation for longer than 48 hours and
the presence of a coagulopathy [1,2]. Up to 50% of patients
will die as a result of stress-ulcer bleeding, mostly from
multi-organ failure and deterioration of the underlying
condition [3]. It is widely accepted that stress ulcer prophylaxis
(SUP) is indicated for ICU patients at high risk for
bleeding.
- 6 Thalidomide induces complete remission of advanced hepatocellular carcinoma
Hepatocellular carcinoma (HCC) is one of the most prevalent human cancers in the
world, but its prognosis is extremely poor. HCC is considered a hypervascular tumor. Thalidomide,
which has been known to inhibit growth factor-induced neovascularization, is a convenient
alternative to target therapy such as sorafenib. We report a 65-year-old male patient
with alcoholic liver cirrhosis that was diagnosed having multiple HCCs during surveillance.
The patient was assessed as inoperable and unsuited for transhepatic arterial chemoembolization
or systemic chemotherapy. After discussing the therapeutic alternatives, he decided to
receive low-dose thalidomide (100 mg daily) therapy. Fortunately, follow-up liver biochemical
tests, serum a-fetoprotein level, and dynamic computed tomography showed complete remission
of the HCCs 4.5 months after thalidomide treatment and this was documented for more
than 22 months without evidence of tumor recurrence.
- 7 Immunoglobulin G4-related disease presenting with obstructive jaundice
48-year-old male presented with diffuse abdominal fullness for 1 month and teacolored
urine for 10 days. Abdominal computed tomography/magnetic resonance cholangiopancreatography
revealed diffuse enlargement of the pancreas and unusual soft tissue density
around the left ureter. Endoscopic retrograde cholangiopancreatography demonstrated lumen
narrowing of the distal common bile duct and irregularity of the pancreatic duct. Markedly
elevated serum immunoglobulin G4 (IgG4) was also noted. Biopsy of soft tissue from the area
surrounding the left ureter identified lymphoplasmacytic infiltration with high concentrations
of IgG4-positive plasma cells accompanied by obliterative phlebitis, compatible with IgG4-
related disease. The patient was administered steroid therapy and his symptoms improved.
Clinicians should be aware of possible IgG4-related disease in a patient presenting with
obstructive jaundice and diffuse pancreatic enlargement because glucocorticoid administration
can achieve good response.
- 8 Evolution of esophageal function testing in achalasia Linking new technology to treatment outcome
Achalasia, meaning “failure to relax” in Greek, is the most
investigated primary esophageal motility disorder involving
the smooth muscle of the esophageal body and lower
esophageal sphincter (LES). Recent decades have witnessed
a great stride toward better understanding and management
of this old but rare disease. However, the exact etiology
and pathogenesis of achalasia remain elusive. Lines of
evidence show that an initial insult, such as HSV-1 infection,
to the esophagus and esophagogastric junction might
trigger an inflammatory process in the myenteric plexus,
which may be followed by autoimmune responses, resulting
in neurodegeneration with loss of inhibitory neurons. The
histopathology of achalasia further demonstrates degeneration
of ganglion cells, especially inhibitory neurons, in the
myenteric plexus of the esophageal body and LES. It has
been proposed that dysfunction of the nitrergic pathway
might cause LES hypertension and impaired relaxation in
achalasia
