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Introduction: Water-assisted colonoscopy increases left colon mucus production; however, the effect of saline on mucus production is unclear. We tested the hypothesis that saline infusion may reduce mucus production in a dose-related manner., Methods: In a randomized trial, patients were assigned to colonoscopy with CO 2 insufflation, water exchange (WE) with warm water, 25% saline, or 50% saline. The primary outcome was the Left Colon Mucus Scale (LCMS) score (5-point scale). Blood electrolytes were measured before and after saline infusion., Results: A total of 296 patients with similar baseline demographics were included. The mean LCMS score for WE with water was significantly higher than that for WE with saline and CO 2 (1.4 ± 0.8 [WE water] vs 0.7 ± 0.6 [WE 25% saline] vs 0.5 ± 0.5 [WE 50% saline] vs 0.2 ± 0.4 [CO 2 ]; overall P < 0.0001), with no significant difference between the 25% and 50% saline groups. The left colon adenoma detection rate (ADR) was highest in the 50% saline group, followed by the 25% saline and the water groups (25.0% vs 18.7% vs 13.3%), but the difference was not significant. Logistic regression showed water infusion as the only predictor of moderate mucus production (odds ratio 33.3, 95% confidence interval 7.2-153.2). No acute electrolyte abnormalities were documented indicating a safe modification., Discussion: The use of 25% and 50% saline significantly inhibited mucus production and numerically increased ADR in the left colon. Evaluation of the impact of mucus inhibition by saline on ADR may refine the outcomes of WE., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.)

We propose an algorithmic framework of a pluripotent structure evolving from a simple compact structure into diverse complex 3D structures for designing the shape-transformable, reconfigurable, and deployable structures and robots. Our algorithmic approach suggests a way of transforming a compact structure consisting of uniform building blocks into a large, desired 3D shape. Analogous to a fertilized egg cell that can grow into a preprogrammed shape according to coded information, compactly stacked panels named the zygote structure can evolve into arbitrary 3D structures by programming their connection path. Our stacking algorithm obtains this coded sequence by inversely stacking the voxelized surface of the desired structure into a tree. Applying the connection path obtained by the stacking algorithm, the compactly stacked panels named the zygote structure can be deployed into diverse large 3D structures. We conceptually demonstrated our pluripotent evolving structure by energy-releasing commercial spring hinges and thermally actuated shape memory alloy hinges, respectively. We also show that the proposed concept enables the fabrication of large structures in a significantly smaller workspace., (© The Author(s) 2023. Published by Oxford University Press on behalf of National Academy of Sciences.)

This study starts from the counterintuitive question of how we can render conventional stiff, nonstretchable, and even brittle materials sufficiently conformable to fully wrap curved surfaces, such as spheres, without failure. Here, we extend the geometrical design method of computational origami to wrapping. Our computational wrapping approach provides a robust and reliable method for fabricating conformal devices for arbitrary curved surfaces with a computationally designed nonpolyhedral developable net. This computer-aided design transforms two-dimensional (2D)-based materials, such as Si wafers and steel sheets, into various targeted conformal structures that can fully wrap desired 3D structures without fracture or severe plastic deformation. We further demonstrate that our computational wrapping approach enables a design platform that can transform conventional nonstretchable 2D-based devices, such as electroluminescent lighting and flexible batteries, into conformal 3D curved devices., (Copyright © 2020 The Authors, some rights reserved; exclusive licensee American Association for the Advancement of Science. No claim to original U.S. Government Works. Distributed under a Creative Commons Attribution NonCommercial License 4.0 (CC BY-NC).)

Goal: The goal of this study was to estimate the risk of renal injury after the use of 3-L polyethylene glycol (PEG) before outpatient colonoscopy., Background: Population-based studies showed that the use of PEG was associated with renal injury, but this association has not been confirmed by prospective study., Study: Patients ≥40 years of age with an estimated glomerular filtration rate ≥30 mL/min were screened for enrollment. Laboratory data were collected before, during, and after the colonoscopies. Patients with a ≥30% increase in baseline serum creatinine levels were followed until a peak level was detected. Renal injury included acute renal dysfunction (ARD) and acute kidney injury (AKI), defined as a 30% to 49% increase and ≥50% increase in creatinine levels compared with the baseline, respectively., Results: A total of 1163 patients (mean age, 55.7 y) completed the study. Baseline and first postcolonoscopy laboratory data were obtained an average of 17.0 days before and 17.3 days after the colonoscopies were performed, respectively. Renal injury was identified in 32 patients; 26 patients (2.2%) had ARD, and 6 patients (0.5%) had AKI. All patients with renal injury recovered fully during follow-up. In the subgroup analysis, the use of nonsteroidal anti-inflammatory drugs (NSAIDs) before colonoscopy was statistically associated with the development of AKI (odds ratio, 6.5; 95% confidence interval, 1.2-35.5; P=0.03)., Conclusions: This prospective study showed that the use of PEG was associated with a small risk of renal injury. NSAIDs use was statistically associated with AKI in the context of colonoscopy for which PEG was used for bowel preparation.

Malnutrition is associated with adverse outcomes in patients with liver cirrhosis. Relevant data about nutrition risk in critically ill cirrhotic patients are lacking. The modified Nutrition Risk in Critically Ill (mNUTRIC) score is a novel nutrition risk assessment tool specific for intensive care unit (ICU) patients. This retrospective study was conducted to evaluate the prevalence and prognostic significance of nutrition risk in cirrhotic patients with acute gastroesophageal variceal bleeding (GEVB) using mNUTRIC scores computed on admission to the intensive care unit. The major outcome was 6-week mortality. One-hundred-and-thirty-one admissions in 120 patients were analyzed. Thirty-eight percent of cirrhotic patients with acute GEVB were categorized as being at high nutrition risk (a mNUTRIC score of ≥5). There was a significantly progressive increase in mortality associated with the mNUTRIC score (χ 2 for trend, p < 0.001). By using the area under a receiver operating characteristic (ROC) curve, the mNUTRIC demonstrated good discriminative power to predict 6-week mortality (AUROC 0.859). In multivariate analysis, the mNUTRIC score was an independent factor associated with 6-week mortality. In conclusion, the mNUTRIC score can serve as a tool to assess nutrition risk in cirrhotic patients with acute GEVB.

Purpose: This study evaluated the outcomes of hepatocellular carcinoma (HCC) patients with small normal liver volume (NLV) treated with proton beam therapy (PBT) and introduced estimated standard liver volume (eSLV) as a new constraint., Materials and Methods: HCC patients with NLV < 800 cm3 and no distant metastasis who received treatment in our proton center were included. The doses of PBT were mainly 72.6 Gray equivalents (GyE) in 22 fractions and 66 GyE in 10 fractions according to tumor locations. The Urata equation was used to calculate eSLV., Results: Twenty-two patients were treated between November 2015 and December 2016. The 1-year progression-free and overall survival rates were 40.4% and 81.8%, respectively. The 1-year in-field failure-free rate was 95.5%. NLV ranged from 483.9 to 795.8 cm3 (median = 673.8 cm3), eSLV ranged from 889.3 to 1290.0 cm3 (median = 1104.5 cm3), and the resulting NLV/eSLV ratio ranged from 44.3 to 81.2% (median = 57.7%). Non-irradiated liver volume (NILV) ranged from 232.9 to 531.6 cm3 (median = 391.2 cm3). The NILV/eSLV ratio ranged from 21.2 to 48.0% (median = 33.3%). NLV in the patients who received <30 GyE (rV30) ranged from 319.1 to 633.3 cm3 (median = 488.2 cm3), and their rV30/eSLV ratio ranged from 30.7 to 58.0%. None of our patients developed liver failure. One patient with initial abnormal liver enzyme levels developed non-classic radiation-induced liver disease (RILD)., Conclusion: From the viewpoint of minimal liver toxicity occurring in our patients with NLV < 800 cm3, conventional liver constraints involving the use of absolute volume could not accurately predict the risk of RILD. It is reasonable to start using individualized constraints with eSLV for HCC patients undergoing PBT. According to the study results, an NILV/eSLV ratio of >20% and an rV30/eSLV ratio of >30% are acceptable., Competing Interests: The authors have declared that no competing interests exist.

Background: Cirrhotic patients are susceptible to sepsis and critical illness-related corticosteroid insufficiency (CIRCI). Dehydroepiandrosterone sulfate (DHEAS) is a corticotropin-dependent adrenal androgen, which has immunostimulating and antiglucocorticoid effects. Considering the synchronized synthesis of cortisol and DHEAS and their opposing effects to each other, investigators have proposed measuring these two hormones as a ratio. Severe sepsis has been associated with low DHEAS, especially relative to high cortisol. Despite growing interest in the role of adrenal androgen replacement in critical illness, there have been no data about DHEAS and the DHEAS/cortisol ratio in patients with liver cirrhosis. We studied whether low concentrations of DHEAS and decreased DHEAS/cortisol ratio are associated with poor outcome in patients with liver cirrhosis and septic shock., Methods: We recruited 46 cirrhotic patients with septic shock, and 46 noncirrhotic counterparts matched by age and sex. We evaluated adrenal function using the short corticotropin stimulation test and analyzed the relation between DHEAS and cortisol., Results: While the nonsurvivors in the cirrhotic group had significantly lower baseline DHEAS, lower baseline DHEAS/cortisol ratio, and reduced increments of both DHEAS and cortisol upon corticotropin stimulation, the survivors had lower baseline cortisol. Cirrhotic patients with lower DHEAS/cortisol ratio (<1.50) had higher levels of interleukin-6 and tumor necrosis factor alpha, higher Sequential Organ Failure Assessment scores, and higher rates of CIRCI and hospital mortality. Using the area under the receiver operating characteristic (AUROC) curve, both DHEAS and the DHEAS/cortisol ratio demonstrated a good discriminative power for predicting hospital survival (AUROC 0.807 and 0.925 respectively). The cirrhotic group had lower DHEAS and DHEAS/cortisol ratio but higher rates of CIRCI and hospital mortality, compared to the noncirrhotic group., Conclusions: There is dissociation between cortisol (increased) and DHEAS (decreased) in those cirrhotic patients who succumb to septic shock. Low DHEAS/cortisol ratios are associated with more severe diseases, inflammation, and CIRCI and can serve as a prognostic marker. More investigations are needed to evaluate the role of adrenal androgen in this clinical setting.

Background: The greatest threat to human well-being in this century is climate change and related global issues., Purpose: We examined the effectiveness of the Modified Instrumentalism in Occupational Therapy model as a framework for facilitating occupational behaviour change to address climate change and related issues., Method: Eleven individuals participated in this mixed-methods single-subject-design study. Data were gathered using the Modified Assessment and Intervention Instrument for Instrumentalism in Occupational Therapy and Daily Occupational Inventories. Quantitative data were analyzed using two- and three-standard deviation band methods. Qualitative data were analyzed using heuristic phenomenological procedures., Findings: Occupational performance changed for five participants. Participants' feelings shifted from frustration and helplessness to empowerment and a desire for action. They felt empowered to find occupation-based solutions to the global issues., Implications: Occupation-based interventions that increase personal awareness of the connection between occupational performance and global issues could empower people to be agents for action to ameliorate the issues.

Introduction: Predicting severity of pancreatitis is an important goal. Clinicians are still searching for novel and simple biomarkers that can better predict persistent organ failure (OF). Lipoproteins, especially high-density lipoprotein (HDL), and apolipoprotein A-I (APO A-I), have been shown to have anti-inflammation effects in various clinical settings. Severe acute pancreatitis (SAP) is associated with hypo-lipoproteinemia. We studied whether the concentrations of HDL and APO A-I can predict persistent OF in patients with predicted SAP admitted to the ICU., Methods: In 66 patients with predicted SAP, we prospectively evaluated the relationship between lipid levels, inflammatory cytokines and clinical outcomes, including persistent OF and hospital mortality. Blood samples were obtained within 24 hours of admission to the ICU., Results: HDL and APO A-I levels were inversely correlated with various disease severity scores. Patients with persistent OF had lower levels of HDL and APO A-I, while those with transient OF had lower levels of interleukin-6, tumor necrosis factor-α and lower rates of hospital mortality. Meanwhile, hospital non-survivors had lower concentrations of HDL, and APO A-I compared to the survivors. By using the area under the receiver operating characteristic (AUROC) curve, both HDL and APO A-I demonstrated an excellent discriminative power for predicting persistent OF among all patients (AUROC 0.912 and 0.898 respectively) and among those with OF (AUROC 0.904 and 0.895 respectively). Pair-wise comparison of AUROC showed that both HDL and APO A-I had better discriminative power than C-reactive protein to predict persistent OF., Conclusions: Serum levels of HDL and APO A-I at admission to the ICU are inversely correlated with disease severity in patients with predicted SAP and can predict persistent OF in this clinical setting.

Objectives: Critical illness-related corticosteroid insufficiency can adversely influence the prognosis of critically ill patients. However, its impact on the outcomes of patients with cirrhosis and acute gastroesophageal variceal bleeding remains unknown. We evaluated adrenal function using short corticotropin stimulation test in patients with cirrhosis and gastroesophageal variceal bleeding. The main outcomes analyzed were 5-day treatment failure and 6-week mortality., Design: Prospective observational study., Setting: Ten-bed gastroenterology-specific medical ICU at a 3,613-bed university teaching hospital in Taiwan., Patients: Patients with liver cirrhosis and acute gastroesophageal variceal bleeding., Interventions: None., Measurements and Main Results: We evaluated adrenal function using short corticotropin stimulation test in 157 episodes of gastroesophageal variceal bleeding in 143 patients with cirrhosis. Critical illness-related corticosteroid insufficiency occurred in 29.9% of patients. The patients with critical illness-related corticosteroid insufficiency had higher rates of treatment failure and 6-week mortality (63.8% vs 10.9%, 42.6% vs 6.4%, respectively; p < 0.001). The cumulative rates of survival at 6 weeks were 57.4% and 93.6% for the critical illness-related corticosteroid insufficiency group and normal adrenal function group, respectively (p < 0.001). The cortisol response to corticotropin was inversely correlated with Model for End-Stage Liver Disease and Child-Pugh scores and positively correlated with the levels of high-density lipoprotein and total cholesterol. Hypovolemic shock, high-density lipoprotein, platelet count, and bacterial infection at inclusion are independent factors predicting critical illness-related corticosteroid insufficiency, whereas critical illness-related corticosteroid insufficiency, Model for End-Stage Liver Disease score, hypovolemic shock, hepatocellular carcinoma, and active bleeding at endoscopy are independent factors to predict treatment failure. Multivariate analysis also identified Model for End-Stage Liver Disease score, hypovolemic shock, and bacterial infection at inclusion as independent factors associated with 6-week mortality., Conclusions: Critical illness-related corticosteroid insufficiency is common in cirrhotic patients with acute gastroesophageal variceal bleeding and is an independent factor to predict 5-day treatment failure.

Background: Lipopolysaccharide binding protein (LBP) is an acute-phase protein produced by the liver. It has been shown that LBP plays an important role in the inflammatory response to sepsis. LBP has also been shown to protect animals from endotoxin challenge by facilitating the removal of endotoxin from the blood circulation. Cirrhotic patients are susceptible to bacterial infection. It is unknown whether pre-existing liver dysfunction impacts the LBP levels and thus the prognosis in severe sepsis., Methods: We evaluated the serum LBP, inflammatory cytokines, and the relationship between LBP concentrations, functional liver reserve and outcomes in 58 critically ill cirrhotic patients with severe sepsis., Results: The serum LBP levels were significantly higher in 28-day survivors, while the interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) levels were significantly higher in non-survivors. We analyzed the receiver operating characteristic (ROC) curve to determine the cut-off point for LBP to predict 28-day mortality. The cumulative rates at 28 days were 58.3% versus 16.7% for the high LBP group (>46 ng/mL) and low LBP group (<46 ng/mL) (p < 0.001). The high-LBP group had significantly lower INR, Child-Pugh, Model for End-stage Liver Disease (MELD) scores and TNF-α level. Meanwhile, the LBP levels were inversely correlated with INR, and Child-Pugh, MELD and sequential organ failure assessment (SOFA) scores., Conclusion: The concentration of LBP is associated inversely with disease severity scores and outcomes in critically ill cirrhotic patients with severe sepsis., (Copyright © 2013. Published by Elsevier B.V.)

Hypofractionated radiotherapy (RT) has been employed to treat hepatocellular carcinoma (HCC). The present study aimed to report the treatment effects, the dose-response associations and the factors that are associated with radiation-induced liver disease (RILD) in a high-dose hypofractionated RT procedure. A total of 40 patients with non-metastatic HCC who underwent RT for local control of irradiated tumors were studied. The treatment technique was that of three-dimensional conformal or intensity-modulated radiation therapy, with a fraction size of 3 Gy and a total dose of 40-66 Gy in 14-23 fractions. The biologically-effective dose (BED) was 52.0-85.8 Gy 10 (median, 74.1 Gy 10 ). Tumor regression was observed in 28 patients (70.0%) with a complete response, partial response, stable disease and progressive disease status in 11 (27.5%), 17 (42.5%), five (12.5%) and seven patients (17.5%), respectively. The one-, two- and five-year overall survival (OS) and in-field control (IFC) rates were 60, 40 and 21% and 73, 62 and 56%, respectively. A positive correlation also emerged between the radiation dose and the IFC (P=0.035). Eight of the 40 patients (20%) developed non-classic RILD. A higher Cancer of the Liver Italian Program score was associated with a higher probability of non-classic RILD (P=0.02). The tumor response and IFC rate of HCC following irradiation were significantly dose-dependent. High-dose hypofractionated X-ray RT is a feasible and effective treatment for HCC in patients with good liver function and for those who meet the criteria for a curative attempt.

Aim: To investigate the impact of esophagogastroduodenoscopy with conscious sedation on the subsequent 24-h catheter-based pH monitoring., Methods: Fifty patients with extra-esophageal symptoms of gastroesophageal reflux disease undergoing ambulatory dual-probe 24-h pH monitoring were enrolled from March 2010 to August 2011. All of the data were collected prospectively and analyzed retrospectively. Thirty-six patients (72%, group A) underwent pH monitoring shortly after esophagogastroduodenoscopy (EGD) with conscious sedation, and 14 patients (28%, group B) underwent pH monitoring without conscious sedation. The 24-h pH data from two time periods were analyzed: the first 4 h (Period I) and the remaining time of the study (Period II)., Results: The mean age of the patients was 49.6 ± 12.5 years; 20 patients (40%) were men. The baseline data, including age, sex, body mass index, reflux esophagitis, the Reflux Symptom Index, and the Reflux Findings Score, were comparable between the two groups. The percentage of total time with a pH < 4 and the frequency of acid reflux during Period I were not significantly different between the two groups, as measured using both pharyngeal (0.03% ± 0.10% vs 0.07% ± 0.16%, P = 0.32; and 0.07 ± 0.23 episodes/h vs 0.18 ± 0.47 episodes/h, P = 0.33, respectively) and esophageal probes (0.96% ± 1.89% vs 0.42% ± 0.81%, P = 0.59; and 0.74 ± 1.51 episodes/h vs 0.63 ± 0.97 episodes/h, P = 0.49, respectively). The percentage of total time with a pH < 4 and the frequency of acid reflux were also not significantly different between Periods I and II in group A patients, as measured using both pharyngeal (0.03% ± 0.10% vs 0.23% ± 0.85%, P = 0.21; and 0.07 ± 0.23 episodes/h vs 0.29 ± 0.98 episodes/h, P = 0.22, respectively) and esophageal probes (0.96% ± 1.89% vs 1.11% ± 2.57%, P = 0.55; and 0.74 ± 1.51 episodes/h vs 0.81 ± 1.76 episodes/h, P = 0.55, respectively)., Conclusion: EGD with conscious sedation does not interfere with the results of subsequent 24-h pH monitoring in patients with extra-esophageal symptoms of gastroesophageal reflux disease.

Background and Aim: Acute renal failure (ARF) is a common complication of liver cirrhosis and severe sepsis. Differentiating functional renal failure from acute tubular necrosis (ATN) has been difficult in this clinical setting. It has been shown that urinary interleukin 18 (IL-18) can serve as a sensitive marker for ARF and ATN. This study was aimed to investigate the diagnostic and prognostic values of urinary IL-18 in ARF associated with liver cirrhosis and severe sepsis., Methods: We prospectively evaluated the relationship between urinary IL-18 and clinical outcomes in 168 consecutive cirrhotic patients with severe sepsis., Results: One hundred and eight patients (64.3%) developed ARF at admission to the intensive care unit. ARF was associated with higher urinary IL-18 and impaired effective arterial volume. Renal failure was functional in 64 (59.2%), due to acute tubular necrosis (ATN) in 30 (27.7%), and mixed type in 14 (12.9%). Patients with ATN had significantly higher levels of urinary IL-18, rates of vasopressor dependency, and hospital mortality than those with functional renal failure. By using the areas under receiver operating characteristic (AUROC) curve, urinary IL-18 demonstrated an excellent discriminative power (AUROC 0.882) for diagnosing tubular injury in those with ARF. Meanwhile, hospital survivors had significantly lower urinary and serum IL-18 levels, compared to non-survivors. In multivariate analysis, urinary IL-18, international normalized ratio, and mean arterial pressure were independent factors to predict hospital mortality., Conclusions: Urinary IL-18 can serve as a diagnostic and prognostic marker in cirrhotic patients with severe sepsis., (© 2012 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd.)

Background: Gastric subepithelial tumors are usually asymptomatic and observed incidentally during endoscopic examination. Although most of these tumors are considered benign, some have a potential for malignant transformation, particularly those originating from the muscularis propria layer. For this type of tumor, surgical resection is the standard treatment of choice. With recent advent of endoscopic resection techniques and devices, endoscopic submucosal dissection (ESD) has been considered as an alternative way of treatment. The aim of this study is to demonstrate the feasibility of a modified ESD technique with enucleation for removal of gastric subepithelial tumors originating from the muscularis propria layer, and to evaluate its efficacy and safety., Methods: From November 2009 to May 2011, a total of 16 patients received a modified ESD with enucleation for their subepithelial tumors. All tumors were smaller than 5 cm and originated from the muscularis propria layer of the stomach, as shown by endoscopic ultrasonography (EUS). The procedure was conducted with an insulated-tip knife 2. Patient's demographics, tumor size and pathological diagnosis, procedure time, procedure-related complication, and treatment outcome were reviewed., Results: Fifteen of the sixteen tumors were successful complete resection. The mean tumor size measured by EUS was 26.1 mm (range: 20-42 mm). The mean procedure time was 52  minutes (range: 30-120  minutes). Endoscopic features of the 4 tumors were pedunculated and 12 were sessile. Their immunohistochemical diagnosis was c-kit (+) stromal tumor in 14 patients and leiomyoma in 2 patients. There was no procedure-related perforation or overt bleeding. During a mean follow up duration of 14.8  months (range: 6-22  months), there was no tumor recurrence or metastasis., Conclusions: Using a modified ESD with enucleation for treatment of gastric subepithelial tumors originating from the muscularis propria layer and larger than 2 cm, complete resection can be successfully performed without serious complication. It is a safe and effective alternative to surgical therapy for these tumors of 2 to 5 cm in size.

Background: To investigate the effectiveness of histological examination of ulcer margins (HEUM) in detecting Helicobacter pylori (H. pylori) infection in patients with non-bleeding gastric ulcers (GUs)., Methods: A retrospective study included 284 patients with GU undergoing concomitant HEUM and rapid urease test (RUT) to detect H. pylori infection between January 2005 and December 2006. The slides were reviewed by an experienced pathologist (revised HEUM) in the 52 patients with inconsistent results on the initial HEUM and RUT. H. pylori infection was defined as a postive RUT and/or revised HEUM. Detection rates of H. pylori infection for HEUM and RUT were calculated accordingly. In patients with H. pylori infection, several parameters including ulcer characteristics and pathological findings were compared between patients with negative and positive (revised) HEUM., Results: A total of 164 (57.7%) patients had positive results of H. pylori infection. The overall detection rates of H. pylori infection on the initial HEUM, revised HEUM and RUT were 78.0% (128/164), 89.0% (146/164), and 94.5% (155/164), respectively. For antrum ulcers, the respective detection rates were 81.0% (85/105), 92.4% (97/105), and 93.3% (98/105), for angulus ulcers, 78.6% (22/28), 85.7% (24/28), and 100% (28/28), and for proximal stomach ulcers, 61.9% (13/21), 81.0% (17/21), and 90.4% (19/21). In patients with H. pylori infection, gastric malignancy was more frequently observed in patients with false negative than true positive HEUMs., Conclusions: HEUM might be not sensitive enough for diagnosing H. pylori in patients with GU. It was especially insensitive when the ulcers were in the proximal stomach, the ulcers were malignant, or the slides were interpreted by pathologists in a rotating manner.

Background/aims: The most common mesenchymal tumors of gastrointestinal tract are gastrointestinal stromal tumors (GIST). These tumors originate from muscularis propria layer. Tissue diagnosis is usually difficult by endoscopic mucosal biopsy. The aim of this study is to evaluate the utility of endoscopic ultrasound-guided Tru-Cut biopsy (EUS-TCB) for GISTs before treatment., Methodology: A total of six patients in the period between June 2006 and May 2009 were included in this study. EUS-TCB was performed with a 19-gauge core needle to obtain sufficient specimen for pathological and immunohistochemical studies. All tumor sizes were larger than 2 cm. Specimen size and the number of needle passes were both recorded., Results: Core tissues were successfully procured by EUS-TCB in all tumors (100%). The mean tumor size was 50 mm (range 30-75 mm). The final pathological diagnosis was c-kit positive stromal tumor in five patients and leiomyoma in one patient. The mean size of specimen was 8 mm (range 3-13 mm) and the mean number of needle passes was 2 (range 1-3). No patient developed complications after the procedure., Conclusion: EUS-TCB is a safe, quicker procedure that offers sufficient tissue acquisition for pathological diagnosis and clinical decision-making in patients with GISTs.

Background: End-stage liver disease is often complicated by hyponatremia. Cirrhotic patients with hyponatremia admitted to intensive care units (ICUs) have high mortality rates. This study analyzed the outcomes of critically ill cirrhotic patients and identified the prognostic value of serum sodium concentration., Methods: One hundred twenty-six consecutive cirrhotic patients admitted to the ICU of a tertiary center during a 1.5-year period were enrolled in this study. Demographic, clinical, and laboratory variables on the first day of ICU admission were prospectively recorded for post hoc analysis., Results: Overall hospital mortality was 65.1%. Comparing with serum sodium >135 mmol/L, patients with serum sodium 135 mmol/L versus those with serum sodium

Carcinosarcoma of the esophagus is a rare neoplasm with both carcinomatous and sarcomatous components. This study aimed to investigate its clinicopathologic features and endoscopic characteristics. The data of patients diagnosed to have esophageal carcinosarcoma pathologically in the past 30 years (January 1976-December 2007) were reviewed. Of 3318 cases of esophageal malignancy, 12 were diagnosed as esophageal carcinosarcoma, with an incidence of 0.36%. All of the cases were male with a mean age of 62.3 years. Of the 12 tumors, 8 were polypoid type, and 4 were ulcerative type. In the endoscopic ultrasonography examination, the tumors show heterogeneous hypoechoic lesions with irregular outer margins and internal multicystic components. Four patients (33.3%) had previous head and neck squamous cell carcinoma that occurred metachronously. This is the first report about the characteristics of esophageal carcinosarcoma under endoscopic ultrasonography examination. The relationship between esophageal carcinosarcomas and head and neck cancer needs further investigation.

Background/aims: Severe sepsis is frequently associated with hypocholesterolemia which is also a common finding in cirrhotic patients. Lipoprotein is capable of binding endotoxin to which cirrhotic patients exhibit an excessive pro-inflammatory response., Methods: We evaluated the relationship between lipid levels, inflammatory cytokines and clinical outcomes in 103 cirrhotic patients with severe sepsis., Results: The non-survivors had significantly lower concentrations of total cholesterol, high-density lipoprotein (HDL), and apolipoprotein A-I (APO A-I). HDL and APO A-I levels were inversely correlated with interleukin-6, tumor necrosis factor-alpha, and various disease severity scores. Serum creatinine, mean arterial pressure and low level of APO A-I (<47.5mg/dl) were independent factors to predict 90-day mortality. The cumulative survival rates at 90 days were 63.8% and 8.9% for the high APO A-I and low APO A-I groups (p<0.0001). Low APO A-I was also associated with lower mean arterial pressure, higher rate of vasopressor dependency, and greater plasma renin activity., Conclusions: Serum levels of HDL and APO A-I are inversely correlated with liver reserve and disease severity in cirrhotic patients with severe sepsis. Low level of APO A-I is associated with a marked impairment of effective arterial volume, multiple organ dysfunction and a poor prognosis.

Goal: 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., Background: The sensitivity of RUT in the diagnosis of Helicobacter pylori in upper gastrointestinal bleeding has been reported with conflicting results., Study: 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., Results: 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)., Conclusions: 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.

Introduction: Gallstones are the most common cause of acute pancreatitis worldwide. Patients with severe acute biliary pancreatitis (SABP) constitute a subgroup of severe acute pancreatitis (SAP) patients in whom systemic inflammation may be triggered and perpetuated by different mechanisms. The aim of this prospective investigation was to examine the adrenal response to corticotropin and the relationship between adrenal function and outcome in patients with SABP., Methods: Thirty-two patients with SABP were enrolled in this study. A short corticotropin (250 microg) stimulation test (SST) was performed within the first 24 hours of admission to the ICU. Critical illness related corticosteroid insufficiency (CIRCI) was defined as follows: baseline value less than 10 microg/dL, or cortisol response less than 9 microg/dL., Results: CIRCI occurred in 34.4% of patients. The patients with CIRCI were more severely ill as evidenced by higher APACHE II and SOFA scores and numbers of organ system dysfunction on the day of SST. The in-hospital mortality for the entire group was 21.9%. The CIRCI group had a higher hospital mortality rate compared to those with normal adrenal function (45.5% vs. 9.5%, P = 0.032). The hospital survivors had a higher cortisol response to corticotropin (17.4 (8.3-27.1) vs. 7.2 (1.7-12) microg/dL, P = 0.019). The cortisol response to corticotropin inversely correlated with SOFA score and the number of organ dysfunction on the day of SST. The rates of pancreatic necrosis and bacteremia were significantly higher in the CIRCI group (100% vs 42.9%, P = 0.002; 81.8% vs 23.8%, P = 0.003, respectively)., Conclusions: CIRCI is common in patients with SABP. It is associated with bacteremia, multiple organ dysfunction and increased mortality.

Background: Acute liver failure is often accompanied by hyperdynamic circulation, which is also a characteristic of septic shock. Pre-existing acute liver failure may worsen the hemodynamic impairment and prognosis in sepsis., Aims: To evaluate the hemodynamic and metabolic characteristics and clinical outcomes of septic shock in patients with acute liver failure., Methods: Twenty patients with acute liver failure and 19 patients without preexisting liver disease were evaluated. Systemic hemodynamics, arterial and mixed vein blood gases, arterial lactate levels, plasma renin activity, and plasma aldosterone levels were checked during the early phase of septic shock., Results: In acute liver failure group, cardiac index (4.92 +/- 1.13 vs 3.69 +/- 1.06 L/min per square meter, P < .001) and oxygen delivery (604.7 +/- 139.7 vs 485.4 +/- 137.3 mL/min per square meter, P = .011) were significantly higher than those without preexisting liver diseases, while systemic vascular resistance index (1041.2 +/- 503.3 vs 1409 +/- 505.25 dyne.s/cm(5).m(2)), oxygen consumption (119.1 +/- 29.2 vs 162.4 +/- 49.4 mL/min per square meter) and oxygen extraction ratio (20% +/- 6% vs. 32% +/- 8%) were significantly higher in the latter group. Furthermore, the patients with acute liver failure had higher arterial lactate (P = .026), plasma renin activity (P = .03), plasma aldosterone levels (P < .001), and intensive care unit as well as hospital mortality rates (P = .005, and 0.02 respectively)., Conclusions: In patients with acute liver failure, septic shock was characterized by an accentuated hyperdynamic circulation, hyperlactatemia and an augmented renin-angiotensin-aldosterone system activity. Pre-existing liver failure has a significant impact on the disease severity of septic shock and portends a grave prognosis.

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 < 0.0001), 30-day rebleeding rate (32.6% vs 12.1%, P < 0.0001), and higher mortality rate (16.3% vs 2.0%, P < 0.0001)., Conclusion: This study emphasizes the role of non-H. pylori idiopathic ulcers and in-hospital bleeders as the determining high-risk predictors for bleeding peptic ulcers.

Background: End-stage liver disease is often complicated by renal function disturbances. Cirrhotic patients with acute renal failure admitted to intensive care units (ICUs) have high mortality rates. This work seeks to identify specific predictors of hospital mortality in critically ill cirrhotic patients with acute renal failure., Methods: A total of 111 patients with cirrhosis and acute renal failure were admitted to ICU from March 2003 to February 2005. Twenty-six demographic, clinical and laboratory variables were prospectively gathered as predictors of survival on the first day of ICU admission., Results: The overall hospital mortality rate was 81.1%. The univariate analysis identified 11 of the 32 variables as prognostically valuable. The multiple logistic regression analysis (excluding five scoring systems) indicates that the mean arterial pressure (MAP), serum bilirubin, respiratory failure and sepsis on the first day in ICU are significantly related to prognosis. The best Youden index (sensitivity + specificity - 1) yields cutoff points of 80 MAP (in mmHg) and 80 serum bilirubin (in micromol/L) (or 4.7 mg/dL) and indicates acute respiratory failure and sepsis. A simple model for mortality is developed on the basis of these four readily available parameters on Day 1 of ICU admission. The new score (MBRS score: MAP + bilirubin + respiratory failure + sepsis) displays an excellent area under the receiver operating characteristic curve (0.898 +/- 0.031, P < 0.001). The mortality rate exceeds 90% when the MBRS (MAP + bilirubin + respiratory failure + sepsis) score is 2 or higher., Conclusion: The MBRS score is a straightforward, reproducible and easily adopted evaluative tool with good prognostic abilities, which generates objective data for patient families and physicians and supplements a clinical judgment of prognosis.

Aim: For many physicians who ordinarily treat patients with colonic diseases, colonoscopy is considered a prime study interest. Developments in colonoscopic equipment and methods have led to larger numbers of endoscopic diagnoses and treatments for colorectal neoplasms. The purpose of this investigation is to evaluate the efficacy and outcomes of endoscopic treatment for colorectal neoplastic lesions and the development of colorectal cancers after colonoscopic therapy., Materials and Methods: From September 1999 to May 2005, 19,815 consecutive colonoscopic examinations in 16,318 patients were gathered, totaling 9,534 endoscopic treatments for colorectal neoplasms. Macroscopic characteristics of the neoplasms were classified into protruded (N = 7,455), sessile (N = 1,569), lateral spreading tumor (N = 201), depressed lesions (N = 21), and flat lesions (N = 288). Snare polypectomy was conducted in 7,536 lesions, hot forceps removal in 1,545 lesions, and endoscopic mucosal resection in 353 lesions., Results: Histological diagnoses were 8,333 neoplastic lesions (8,246 adenomas with low/high-grade dysplasia and 87 invasive adenocarcinomas) and 1,201 non-neoplastic lesions (1,186 hyperplastic and 15 inflammatory polyps). For the adenocarcinoma group, all had received further operations, while 73 surgical specimens discovered no residual tumors. Four perforations and 146 bleedings were found following endoscopic treatment. No procedure-related mortality was found and no recurrent malignancy was found after 6-71 months follow-up., Conclusion: To lower the incidence and mortality of advanced colorectal cancer, endoscopic treatment for colorectal neoplasms is a simple and safe procedure.

Objective: End-stage liver disease is frequently complicated by renal function disturbances. Cirrhotic patients with renal failure admitted to intensive care units (ICUs) have high mortality rates. This study analyzed the outcomes of critically ill cirrhotic patients and identified the association between prognosis and RIFLE (risk of renal failure, injury to kidney, failure of kidney function, loss of kidney function, and end-stage renal failure) classification, in comparison with other five scoring systems., Design: Prospective, clinical study., Setting: Ten-bed specialized hepatogastroenterology ICU in a university hospital in Taiwan., Patients and Participants: One hundred and thirty-four cirrhotic patients consecutively admitted to ICU during a 1.5-year period., Interventions: Thirty-two demographic, clinical and laboratory variables were analyzed as predictors of survival., Measurements and Main Results: Overall hospital mortality was 65.7%. There was a progressive and significant increase (chi2 for trend: p<0.001) in mortality based on RIFLE classification severity. Multiple logistic regression analysis indicated that RIFLE classification and Sequential Organ Failure Assessment (SOFA) score on the first day of ICU admission were independent risk factors for hospital mortality. By using the areas under the receiver operating characteristic curve (AUROC), the RIFLE category and SOFA both indicated a good discriminative power (AUROC 0.837+/-0.036 and 0.917+/-0.025; p<0.001). Cumulative survival rates at 6-month follow-up differed significantly (p<0.05) for non-ARF vs. RIFLE-R, RIFLE-I, and RIFLE-F., Conclusion: Both SOFA and RIFLE category showed high discriminative power in predicting hospital mortality in critically ill patients with cirrhosis. The RIFLE classification is a simple and easily applied evaluative tool with good prognostic abilities.

Patients with cirrhosis are susceptible to bacterial infection, which can result in circulatory dysfunction, renal failure, hepatic encephalopathy, and a decreased survival rate. Severe sepsis is frequently associated with adrenal insufficiency, which may lead to hemodynamic instability and a poor prognosis. We evaluated adrenal function using short corticotropin stimulation test (SST) in 101 critically ill patients with cirrhosis and severe sepsis. Adrenal insufficiency occurred in 51.48% of patients. The patients with adrenal insufficiency had a higher hospital mortality rate when compared with those with normal adrenal function (80.76% vs. 36.7%, P < .001). The cumulative rates of survival at 90 days were 15.3% and 63.2% for the adrenal insufficiency and normal adrenal function groups, respectively (P < .0001). The hospital survivors had a higher cortisol response to corticotropin (16.2 +/- 8.0 vs. 8.5 +/- 5.9 microg/dL, P < .001). The cortisol response to corticotropin was inversely correlated with various disease severity, Model for End-Stage Liver Disease, and Child-Pugh scores. Acute physiology, age, chronic health evaluation III score, and cortisol increment were independent factors to predict hospital mortality. Mean arterial pressure on the day of SST was lower in patients with adrenal insufficiency (60 +/- 14 vs. 74.5 +/- 13 mm Hg, P < .001), and a higher proportion of these patients required vasopressors (73% vs. 24.48%, P < .001). Mean arterial pressure, serum bilirubin, vasopressor dependency, and bacteremia were independent factors that predicted adrenal insufficiency. In conclusion, adrenal insufficiency is common in critically ill patients with cirrhosis and severe sepsis. It is related to functional liver reserve and disease severity and is associated with hemodynamic instability, renal dysfunction, and increased mortality.

Hepatitis B virus (HBV) infection is the most prevalent cause of fulminant hepatic failure (FHF) in the Far East. HBV-associated FHF is characterised by rapidly progressive end organ dysfunction/failure and a very poor prognosis. To investigate how molecular adsorbent recirculating system (MARS) treatment impacts multiple organ system function in HBV-associated FHF. Ten consecutive patients were treated with MARS in a period of 12 months. Clinical, biochemical and haemodynamic parameters were assessed before and after MARS. Various disease severity scoring systems including model for end-stage liver disease, APACHE II, APACHE III, sequential organ failure assessment and organ system failure scores were also assessed. There were significant improvements in hepatic encephalopathy grading (p < 0.001), mean arterial pressure (p < 0.001), plasma renin activity (p = 0.027), bilirubin (p < 0.001), ammonia (p = 0.001) and creatinine levels (p < 0.001). There were also significant improvements in all the scoring systems evaluated. Meanwhile, platelet count was significantly decreased (p < 0.001). One patient was successfully bridged to liver transplantation. Three patients were alive at 3 months of follow-up. MARS can improve multiple organ functions in HBV-associated FHF. On the basis of these findings, randomised controlled studies are indicated and justified.

Background: Colonic neoplastic lesions can be classified morphologically into polypoid and non-polypoid types. Non-polypoid lesions have a higher malignant potential than polypoid lesions. Removing these lesions and obtaining integral specimen for histopathology evaluation during colonoscopy examination is an important task. Endoscopic mucosal resection (EMR) is an alternative to surgery for removing of non-polypoid lesions of the GI tract. This study assessed the safety, efficacy, and clinical outcomes of EMR., Patients and Methods: From October 2000 to October 2003 during the routine colonoscopy performed at one medical center, identified 152 non-polypoid colonic neoplasms in 149 patients (92 males, 57 females) were found. The mean patient age was 57.8 +/- 15.5 yr (range 32-80 yr). EMR was performed for lesions suspected of being neoplastic tumors via magnification colonoscopy with the indigo carmine dye spray method. The lesions were removed via EMR with pure cutting current after which hemoclips were applied to the resected wounds., Results: The study identified 40 flat type lesions, 106 lateral spreading tumors, and 6 depressed lesions that were completely resected. The mean size of lesions was 19.4 +/- 10.3 mm (range 6-60 mm). Histological findings were 4 adenocarcinomas, 59 with high-grade adenoma/dysplasia, and 89 with low-grade adenoma/dysplasia. Two patients experienced bleeding immediately following EMR, while adequate hemostasis was achieved using hemoclips. Neither delayed bleeding nor perforation developed following EMR., Conclusion: EMR by using pure cutting current and hemoclip is a useful method for obtaining integral specimen for accurate pathologic assessment. This method provides a safe and minimally invasive technique managing of colonic non-polypoid lesions.

Aim: For many physicians who ordinarily treat patients with colonic diseases, colonoscopy is considered a prime study interest. Developments in colonoscopic equipment and methods have led to a large number of endoscopic diagnoses and treatment for colorectal neoplasms. The purpose of this investigation is to evaluate the efficacy and outcomes of endoscopic treatment for colorectal neoplastic lesions., Methods: From September 1999 to May 2003, 11 447 consecutive colonoscopic examinations in 9864 patients were gathered; totaling 5502 endoscopic treatments for colorectal neoplasms. Macroscopic characteristics of the neoplasms were classified into protruded (n = 3 953), sessile (n = 1402), lateral spreading tumor (n = 139) and depressed lesions (n = 8). Snare polypectomy was conducted in 3984 lesions, hot forcep removal in 1368 lesions, and endoscopic mucosal resection in 150 lesions., Results: Histological diagnoses were 4596 neoplastic lesions (4 376 adenomas and 220 adenocarcinomas) and 906 non-neoplastic lesions (891 hyperplastic and 15 inflammatory polyps). For the adenocarcinoma group, 31 instances involved submucosal invasion or resection margin, who received further operations, while 13 surgical specimens discovered no residual tumors. Three perforations and 96 bleedings were found following endoscopic treatment. No procedure-related mortality was found and no recurrent malignancy was found after 14-56 mo follow-up., Conclusion: To lower the incidence and mortality of colorectal cancer, endoscopic treatment for colorectal neoplasms is a simple and safe procedure.

Cirrhotic patients admitted to the medical intensive care unit (ICU) are associated with high mortality rates. The prognosis of critically ill cirrhotic patients is determined by the extent of hepatic and extrahepatic organ dysfunction. This study was conducted to assess and compare the accuracy of the Child-Pugh classification and APACHE II scores, obtained on the first day of ICU admission, in predicting hospital mortality in critically ill cirrhotic patients. One hundred thirty-five patients diagnosed with liver cirrhosis were admitted to the medical ICU between January 2002 and March 2003. Information considered necessary to compute the Child-Pugh and APACHE II scores on the first day of ICU admission was prospectively collected. The overall hospital mortality rate was 66.6%. Liver disease was most commonly attributed to hepatitis B viral infection. The APACHE II scores demonstrate a good fit using the Hosmer and Lemeshow goodness-of-fit test. Furthermore, by using the areas under receiver operating characteristic (AUROC) curve, the APACHE II scores demonstrated a better discriminative power (AUROC 0.833 +/- 0.039) than Child-Pugh scores (AUROC 0.75 +/- 0.05) (P=.024). This investigation confirms the grave prognosis for the cirrhotic patients admitted to the ICU. While both Child-Pugh and the APACHE II scores can satisfactorily predict the outcomes for critically ill cirrhotic patients, APACHE II is more powerful in discriminating the survivors from the nonsurvivors.

Objectives: The prognosis for critically ill cirrhotic patients depends on the extent of hepatic and extrahepatic organ dysfunction/failure. We hypothesize that a graded multiple organ dysfunction score, sequential organ failure assessment (SOFA), would provide more descriptive and discriminative power for predicting the hospital mortality for critically ill cirrhotic patients than the classical organ system failure (OSF) score, which defines organ failure as an all-or-none phenomenon., Methods: 160 patients diagnosed with liver cirrhosis were admitted to the medical intensive care unit (ICU) from January 2002 to June 2003. Information considered necessary for calculating the Child-Pugh, OSF and SOFA scores on ICU admission was collected prospectively., Results: Hepatitis B infection was the most common cause of liver cirrhosis. A significantly progressive increase in mortality rate was associated with OSF and SOFA scores (p < 0.001). Close correlation between OSF and SOFA scores (p < 0.001) suggested that both systems evaluated the same event. In patients with similar organ dysfunction, the number of failed organ system(s) was significantly higher among non-survivors. However, no correlation existed between the SOFA scores and mortality rate in patients with the same OSF number. Meanwhile, both OSF and SOFA scores displayed excellent discriminative power (areas under receiver-operating characteristic (AUROC) were 0.906 and 0.892, respectively), while Child-Pugh scores clearly performed more poorly (AUROC 0.712). Both OSF and SOFA demonstrate a good fit using the Hosmer and Lemeshow goodness-of-fit test., Conclusions: Both OSF and SOFA scores are excellent tools for predicting prognosis for cirrhotic patients admitted to ICU. Both of them are superior to Child-Pugh score. Hospital mortality for critically ill cirrhotic patients occurs owing to severe failure of a relatively few organs, rather than because of an accumulation of mild dysfunction in many organ systems. Graded organ dysfunction scales provide no further benefit for predicting hospital mortality for critically ill cirrhotic patients., (Copyright 2004 S. Karger AG, Basel)

Background: This study assessed the efficacy of endoscopic hemorrhoidal ligation for treatment of patients with symptoms caused by internal hemorrhoids., Methods: A total of 576 consecutive patients with symptoms caused by internal hemorrhoids were enrolled in the study. Symptoms were rectal bleeding (239 patients) and prolapse (337 patients). The severity of the hemorrhoids was classified by using the grading system of Goligher., Results: All patients were treated by the same operator. Mean follow-up was 17.5 months (range 8 to 24 months). The mean number of band ligations per session was 2.86. The mean number of treatment sessions was 1.24. At least one grade reduction in the severity of the hemorrhoids was achieved in most patients (93.58%). Moreover, rectal bleeding was controlled in 228 patients (95.4%), and rectal prolapse was reduced in 310 patients (91.99%). After treatment, 85 patients experienced anal pain, 37 had mild bleeding, 4 developed external hemorrhoidal thrombosis, and one had a peri-anal abscess. The latter 5 patients were treated surgically and recovered uneventfully., Conclusions: Endoscopic hemorrhoidal ligation is a simple, safe, and effective treatment for patients with symptoms caused by internal hemorrhoids.

Goals: This study was conducted to assess and compare the accuracy of Child-Pugh classification and organ system failure (OSF) scores, obtained on the first day of ICU admission, in predicting the hospital mortality in critically ill cirrhotic patients., Background: Cirrhotic patients admitted to the medical intensive care unit (ICU) are associated with high mortality rates. The prognosis of critically ill cirrhotic patients is determined by the extent of hepatic and extrahepatic organ dysfunction., Study: A total of 111 patients diagnosed with liver cirrhosis were admitted to medical ICU from July 2001 to June 2002. Information considered necessary to compute the Child-Pugh and OSF scores on the first day of ICU admission was prospectively collected., Results: The overall hospital mortality rate was 64.9%. Liver disease was most commonly attributed to hepatitis B viral infection. The OSF scores demonstrate a good fit using the Hosmer and Lemeshow goodness-of-fit test. Meanwhile, by using the areas under receiver operating characteristic (AUROC) curve, the OSF scores demonstrated an excellent discriminative power (AUROC 0.901), whereas the performance of Child-Pugh scores is clearly poorer (AUROC 0.748)., Conclusion: This investigation confirms that the prognosis for cirrhotic patients admitted to ICU is grave. The OSF score is a simple, reproducible, and easily applied tool with excellent prognostic abilities that can provide objective information for patients' families and physicians and supplement the clinical judgment of prognosis.

Background: Colonic mucosal neoplastic lesions can be classified morphologically into polypoid and nonpolypoid types. The nonpolypoid type has a greater malignancy potential than does the polypoid type. Removing these lesions and obtaining an integral specimen for histopathologic assessment during colonoscopy are very important. This study evaluates the safety and integrity of specimens obtained by endoscopic mucosal resection (EMR) using the pure cut current and hemoclip method., Methods: Fourteen nonpolypoid colonic neoplasms, which were removed by EMR using the pure cut and hemoclip method between April 2001 and April 2002, were studied. There were 9 male and 4 female patients and the mean age was 57.8 +/- 15.5 (range, 32 - 80) years. EMR was conducted in cases where the lesions were diagnosed as neoplastic tumors by magnification colonoscopy and the indigo carmine dye spray method., Results: The study revealed 11 flat type neoplasms and 3 laterally spreading tumors. The mean size of the lesions was 10.7 +/- 5.6 (range, 6 - 25) mm. All lesions were completely removed. Histopathologically, there were 1 adenocarcinoma and 13 adenomas (3 with mild dysplasia, 7 with moderate dysplasia, and 3 with severe dysplasia). The mean number of hemoclips used was 2.14 +/- 0.66 (range, 1 - 3) pieces. No bleeding or perforation was noted following EMR., Conclusion: EMR using the pure cut and hemoclip method is a useful means of obtaining an integral specimen for accurate pathologic assessment. This method provides a safe and minimally invasive technique for managing colonic non-polypoid lesions.

Background: End-stage liver disease is frequently complicated by episodes of gastrointestinal hemorrhage that are often associated with multiple organ dysfunction and require intensive care. This study aimed to identify specific predictors of hospital mortality in critically ill cirrhotic patients with gastrointestinal bleeding, and compare the prediction accuracy of the Child-Pugh score and two illness severity scoring systems frequently used for intensive care unit (ICU) patients., Methods: 76 patients with liver cirrhosis and upper gastrointestinal bleeding were admitted to the ICU from April 2001 to March 2002. In addition, 27 demographic, clinical and laboratory variables, including parameters assessing liver and renal function and systemic hemodynamics, were analyzed as survival predicators. Finally, information required, calculating the Child-Pugh, Sequential Organ Failure Assessment (SOFA), and Acute Physiology and Chronic Health Evaluation (APACHE) III score on the 1st day of ICU admission, was gathered prospectively., Results: Overall, hospital mortality was 68.4%. Liver disease was generally attributed to hepatitis B viral infection. Furthermore, multiple logistic regression analysis showed that mean arterial pressure (MAP), Child-Pugh points, and serum creatinine (Cr) were significantly related to prognosis. The SOFA and APACHE III models displayed good areas under the receiver operating characteristic (ROC) curve., Conclusion: The rise of serum Cr levels above 1.5 mg/dL is common, and indicates a poor prognosis for critically ill cirrhotic patients with gastrointestinal bleeding. SOFA is a straightforward approach with excellent prognostic abilities for this homogeneous patient subset.

Both desflurane and sevoflurane have individually been reported to induce hepatic dysfunction; however hepatic dysfunction after administration of both of them separately in a single patient has not previously been reported. As their metabolites differ in nature, we considered that it would be unlikely that their combined use would cause sensitization and induce hepatic dysfunction. We report on the first patient with reproducible liver dysfunction after sevoflurane and desflurane. This 54-year-old man sequentially received 3 anesthetics over a 1-year period. The first anesthetic was isoflurane, and the course was uneventful. The second anesthetic was sevoflurane, and this resulted in fever with chills and elevated aspartate aminotransferase (543 U/l) 17 days later. The third anesthetic was desflurane which resulted in a similar clinical picture after 17 days. The symptoms improved, and the serum transaminase level returned to normal after conservative therapy. The similar time interval between the operation date and the onset of hepatic dysfunction, after excluding other possibilities, made us highly suspicious that the hepatic dysfunction was induced by sevoflurane on 1 occasion and desflurane on the other. We suggest that inhaled anesthetics should be totally replaced by intravenous anesthetics for future operations in patients with such a diagnosis.

Portopulmonary hypertension is a rare complication of portal hypertension. Although epoprostenol infusion, nitric oxide inhalation, isosorbide-5-mononitrate, nitroglycerin, and calcium channel blockers may reduce pulmonary artery pressure in patients with portopulmonary hypertension, the prognosis remains poor. We present a case of congenital hepatic fibrosis associated with pulmonary hypertension. A 42-year-old man with congenital hepatic fibrosis visited our hospital with syncope. The man had suffered from breathlessness on exertion for 2 weeks before the episode of syncope. He also had a history of portal hypertension with documented gastric cardiac varices at the age of 28 years. Despite undergoing intensive care, the patient died 1 week after admission owing to severe right-sided heart failure. Autopsy revealed dilatation of the right atrium and right ventricle grossly and plexogenic pulmonary arteriopathy microscopically. Accurate diagnosis of portopulmonary hypertension requires awareness of the disease and a high index of suspicion when examining patients with portal hypertension and dyspnea.

Hemosuccus pancreaticus, blood entering the gastrointestinal tract through the pancreatic duct, is a rare and elusive form of gastrointestinal bleeding with diagnostic difficulties. We report a 37-year-old man who had recurrent gastrointestinal bleeding from erosion of a pseudoaneurysm of the gastroduodenal artery into the pancreatic duct. The lack of history of pancreatitis, associated symptoms, equivocal endoscopic findings, and the rarity of this entity resulted in a delay in diagnosis. Pancreatic duct stenosis detected during surgery suggested the lesion might have been caused by blunt abdominal trauma. A nearly total pancreatectomy and splenectomy were performed. The patient remained symptom-free 8 months after the operation. This obscure cause of gastrointestinal bleeding should be considered when common causes of bleeding have been ruled out, even in the absence of pancreatitis.

Hepatic angiomyolipoma is a rare benign mesenchymal tumor of the liver. Most multiple hepatic angiomyolipomas have appeared in patients with renal angiomyolipoma and tuberous sclerosis. A 38-year-old female patient without chronic hepatitis B or C was hospitalized because of epigastric fullness for 2 months. Radiologic studies showed a large solid tumor with a small daughter nodule in the right hepatic lobe. Upon intravenous bolus injection of contrast medium, both tumors showed weak heterogeneous enhancement in the delayed phase. Although hepatocellular carcinoma was suspected by the findings of computed tomography, percutaneous transhepatic ultrasound-guided biopsy was performed for the large tumor. The histopathology showed many mature fat cells intermingled with thick-walled blood vessels, and epithelioid cells with eosinophilic cytoplasm; the epithelioid cells stained positively for HMB-45 and smooth muscle actin. Angiomyolipoma of the liver was confirmed. The main tumor enlarged considerably during a follow-up period of 3 years. Surgical resection was performed due to persistent symptoms. She had an uneventful postoperative recovery and was well when followed up 10 months after surgery. We should be aware that a hepatic angiomyolipoma can change in size during its natural course, and this finding does not necessarily indicate malignancy.

The purpose of this study was to investigate the clinical manifestations and diagnosis of patients with acute jejunogastric intussusception. From May 1986 to June 1999, a total of 5 men (54-76 years old) were collected. Their initial presentations included epigastralgia (4), coffee-ground vomitus (3), frank hematemesis (1), and tarry stool (1). All patients had gastric surgeries 10-30 years previously. Radiograph of the abdomen showed a soft tissue density at the left upper quadrant in one patient. Panendoscopies were done in 4 patients. An obstructed efferent loop with a distended hyperemic small bowel protruding into the remnant of stomach was found in 3 cases, gangrenous change of the bowel wall in one of them. Stump cancer was diagnosed initially in the other patient. Barium study (3/5) showed efferent loop obstruction with "coil spring sing" and a central defect in the stomach. All 5 patients underwent segmental resection and end-to-end anastomosis between the 2nd to 6th hospital day. Operative findings were type II jejunogastric intussusception with retrograde invagination of a segment of efferent loop (30-100 cm in length) into the stomach. In conclusion, acute jejunogastric intussusception is an emergent condition. Early and accurate diagnosis is important. A high susception must be kept in mind in patients having a history of gastrojejunostomy with severe abdominal pain or upper gastrointestinal bleeding.

Repeated laparotomy with extensive small bowel resectioning and eventual short-bowel syndrome is a major problem in Peutz-Jeghers syndrome (PJS) patients. This problem is caused by gastrointestinal polyposis with intussusception. A combined surgical and endoscopic approach can assess the extent of the polyposis, and small polyps can be removed by snare polypectomy. This can avert multiple enterotomies and decrease bowel resection segments. We applied an intraoperative colonscope via the enterotomy route in an 20-year-old PJS woman, and successfully removed the other 10 polyps distributed in the whole small bowel. As part of an aggressive approach to the management of polyposis in PJS, complete polypectomy can provide a longer symptom-free interval and remove potentially premaligment polyps.

p27(Kip1) is an inhibitor of cyclin-dependent kinase. It has been reported that reduced p27(Kip1) expression is present in human hepatocellular carcinoma. To determine the role of p27(Kip1) in hepatocarcinogenesis, 46 cases with hepatocellular carcinomas were studied. p27(Kip1) mutation was first screened by single strand conformation polymorphism, and direct DNA sequencing was then performed on those cases with mobility shifts. Two polymorphism sites were found. One is a previously described polymorphism at codon 109 (GTC-->GGC) which was found in two cases. The second polymorphism was identified at codon 55 (GCG-->GCA) in six of the 46 cases. However, the polymorphism at codon 55 was also present in seven of 93 healthy controls (7.5%), indicating that it is not associated with a predisposition for development of hepatocellular carcinoma (Fisher's exact test, 0.05). These results show that p27(Kip1) mutation is not a frequent event in human hepatocellular carcinoma, and suggest that it may be inactivated predominantly by transcriptional and/or posttranscriptional regulation rather than genomic aberrations.

Objective: Our purpose was to evaluate whether inserting prostaglandin E2 gel at the time of scheduled nonstress tests in patients with postdate pregnancies can decrease rates of intervention., Study Design: A multicenter pilot study enrolled women with postdate pregnancies with Bishop score < or = 6 who were undergoing antepartum fetal heart rate testing. Patients were randomized in a double-blind fashion to receive either a prostaglandin E2 intracervical gel (Prepidil) or a placebo gel after each of their scheduled nonstress tests., Results: There were no significant differences in the number of antepartum tests, labor inductions, or cesarean sections, the maximum oxytocin dosage, or the interval from admission to delivery in the prostaglandin E2 gel and placebo gel groups (n = 90). In the subset of patients with a Bishop score between 3 and 6 (63 patients), there were fewer inductions in the prostaglandin E2 group (30% vs 55%, P < .05)., Conclusion: Application of prostaglandin E2 gel at the time of scheduled antepartum testing in patients with postdate pregnancies with unfavorable cervices decreased the induction rate only among patients with intermediate Bishop scores.

Solitary extramedullary plasmacytoma is an uncommon neoplasm and occurs most frequently in the upper respiratory tract. Herein, we reported a solitary extramedullary plasmacytoma in the retroperitoneum. A 28-year-old man presented with obstructive jaundice and a retroperitoneal tumor. Ultrasound-guided biopsy confirmed that the lesion was a plasma cell neoplasm. A detailed investigation showed that no other sites were involved. The tumor got a moderate reduction following local irradiation, and a complete remission was achieved after 12 courses of adjuvant chemotherapy. Therefore, the possibility of a solitary extramedullary plasmacytoma should be considered in the differential diagnosis of obstructive jaundice without a history of multiple myeloma.

Spontaneous liver hemorrhage with formation of subcapsular hematomas and rupture of Glissan's capsule is a rare but often lethal complication of pregnancy. This entity has usually been associated with severe preeclampsia or the HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome. A case of spontaneous subcapsular hematoma of the liver occurring in the third trimester is presented in which the patient probably had neither preeclampsia nor the HELLP syndrome. The literature on liver hematomas in pregnancy published since 1982 when the term HELLP syndrome was coined is reviewed with a focus on the association of liver hematomas with preeclampsia and the HELLP syndrome. Therapy and maternal and neonatal outcomes for this entity are reassessed.

Objectives: To assess the clinical features and susceptibility of cirrhotic patients to non-O1 Vibrio cholerae bacteremia and to provide our therapeutic experiences in this rare and high lethal infection., Methods: Twenty-eight blood culture isolates of non-O1 V. cholerae were identified by our clinical microbiology laboratory between July 1989 and June 1994. Patients with underlying cirrhosis and the aforementioned bacteremia were retrospectively reviewed., Results: Twenty-one cirrhotic patients (16 male, five female; mean age, 50.9 yr; range 28-67 yr) were identified and classified as Child B (6 cases) and Child C (15 cases). Bacteremic episodes occurred most often from March to September. Seafood ingestion (seven cases) and seawater exposure (two cases) were risk factors, but nosocomial infections were also noted in six cases. Presenting symptoms and signs included ascites (95.2%), fever (81%), abdominal pain (52.4%), diarrhea (33.3%), and cellulitis with bullae formation (19%). Concurrent spontaneous bacterial peritonitis was determined in 10 cases, seven with positive ascites cultures. Antibiotic therapy (either cephalothin with gentamicin or ceftriaxone alone) cured most of the bacteremic episodes. The overall case-fatality rate was 23.8%, but 75% of the deaths were observed in patients with skin manifestation., Conclusions: Patients with decompensated cirrhosis are susceptible to non-O1 V. cholerae bacteremia and should not ingest raw seafood or expose skin wounds to salt water. A high index of suspicion and early administration of antibiotics may lower the mortality rate.