Contrast-enhanced endoscopic ultrasound for swollen lymph nodes

Endoscopic ultrasound (EUS) is an important tool for the evaluation of lymphadenopathy, especially in intra-thoracic or intra-abdominal regions. EUS also provides tissue diagnosis via EUS fine-needle aspiration or biopsy. To select the target for biopsy or aspiration, conventional B-mode images are used for the evaluation, but this approach still lacks diagnostic accuracy. Contrast-enhanced EUS has been used to evaluate the vascularity of lesions. Most malignant lymphadenopathy shows heterogenous enhancement or defect of enhancement, while quantitative studies using time-intensity curves in contrast-enhanced harmonic EUS show a rapid decline in enhancement pattern. These findings are useful as an auxiliary method for tissue diagnosis or in cases in which tissue diagnosis is contraindicated.

Three-year evaluation of a novel, nonfluoroscopic, all-artificial model for EUS-guided biliary drainage training for the impact to practice: A prospective observational study (with videos)

Background and Objectives

EUS-guided biliary drainage (EUS-BD) required a dedicated training. We developed and evaluated a nonfluoroscopic, all-artificial training model known as Thai Association for Gastrointestinal Endoscopy Model 2 (TAGE-2) for the training of EUS-guided hepaticogastrostomy (EUS-HGS) and EUS-guided choledochoduodenostomy (EUS-CDS). We hypothesize that trainers and trainees would appreciate the ease of the nonfluoroscopy model and increase their confidence to start their real procedures in humans.

Materials and Methods

We prospectively evaluated the TAGE-2 launched in two international EUS hands-on workshops and have followed trainees for 3 years to see long-term outcomes. After completing the training procedure, the participants answered questionnaires to assess their immediate satisfaction of the models in and also the impact of these models on their clinical practice 3 years after the workshop.

Results

A total of 28 participants used the EUS-HGS model and 45 participants used the EUS-CDS model. The EUS-HGS model was rated as excellent by 60% of beginners and 40% by experienced and the EUS-CDS model was rated as excellent by 62.5% of beginners and 57.2% of experienced. The majority of trainees (85.7%) have started the EUS-BD procedure in humans without additional training in other models.

Conclusion

Our nonfluoroscopic, all-artificial model for EUS-BD training is convenient to be used with good-to-excellent satisfaction scored by the participants in most aspects. It can help the majority of trainees start their procedures in humans without additional training in other models.

Silymarin treatment and reduction of liver enzyme levels in non-alcoholic fatty liver disease: a case report

Non-alcoholic fatty liver disease (NAFLD) is one of the most frequent chronic liver disorders worldwide. It is closely associated with metabolic syndrome components, including type 2 diabetes, hyperlipidaemia and obesity. To date, no effective drug treatment is available for NAFLD but several clinical trials suggested that silymarin, the active milk thistle extract, has well-documented antioxidant and hepatoprotective properties. In this case report, silymarin 140 mg twice daily decreased liver enzyme activity with a good safety profile in a patient with NAFLD and overweight, supporting silymarin as a promising supportive intervention aimed at normalizing liver activity in NAFLD. This article is part of the Current clinical use of silymarin in the treatment of toxic liver diseases: a case series Special Issue: https://www.drugsincontext.com/special_issues/current-clinical-use-of-silymarin-in-the-treatment-of-toxic-liver-diseases-a-case-series.

Bowel preparation using 2-L split-dose polyethylene glycol regimen plus lubiprostone versus 4-L split-dose polyethylene glycol regimen: a randomized controlled trial

Background

Colonoscopy is a standard procedure for evaluating colon diseases and screening for colorectal cancer, and bowel cleanliness prior to colonoscopy is key. The aim of this study was to compare the bowel cleansing efficacy of low-volume (2 L) split-dose polyethylene glycol (PEG) plus single-dose (24 µg) lubiprostone (LB) and high-volume (4 L) split-dose PEG.

Methods

Patients scheduled to undergo outpatient colonoscopy between December 2019 and June 2021 at Rajavithi Hospital were enrolled and randomized into two groups: 2 L PEG + LB or 4 L PEG. Colon cleanliness was evaluated using the Boston Bowel Preparation Scale (BBPS) by reviewing images of the colon after completion of colonoscopy. Secondary outcomes comprised cecal intubation rate, procedure time, withdrawal time, polyp detection rate, adenoma detection rate, patient satisfaction, compliance (based on complete ingestion of bowel preparation regimen), willingness to repeat the preparation regimen, and associated adverse events.

Results

One hundred and forty patients were included, with 70 in each group. The mean total and segment-specific BBPS scores were not significantly different between groups. However, the rate of adequate bowel preparation was significantly higher in the 2 L PEG + LB group than the 4 L PEG group (100% [95% CI 94.6–100] versus 88.4% [95% CI 78.4–94.9], p = 0.004) in the per-protocol analysis. Colonic polyps were the most common finding. The polyp detection rate, adenoma detection rate, and all secondary outcomes were statistically similar in the two groups (p > 0.05).

Conclusions

The combination of 2 L split-dose PEG plus LB improves bowel cleanliness (based on BBPS scores) to a comparable degree to the standard 4 L split-dose PEG, without additional adverse events and with a lower PEG volume.

Coronavirus disease 2019 gastrointestinal and liver manifestations in adults: A review

Coronavirus disease 2019 (COVID-19) is an important health problem that has a serious adverse impact on the global economy and healthcare systems. The virus is not only involved in the respiratory system, but also causes other systemic effects as well as several gastrointestinal and liver issues. Evidence has shown direct viral invasion into the gastrointestinal tissue and supporting vascular network, causing various manifestations such as diarrhea, nausea, gastrointestinal bleeding, and abnormal liver function tests. The degree of gastrointestinal injury, especially in terms of liver involvement, is correlated with disease severity. There is no specific treatment for gastrointestinal involvement, and the symptoms can be managed with supportive therapy. Moreover, increased liver decompensation and mortality can be found in COVID-19-infected patients with coexisting liver disease. As the virus can be identified in gastrointestinal contents, endoscopic procedures during the pandemic should be carefully selected and proper protection strategies should be encouraged to prevent viral transmission.

Effectiveness and Safety of a Single 7-French Plastic Stent for Endoscopic Ultrasound-guided Pancreatic Pseudocyst Drainage and Long-term Follow-up Outcomes

Background

Endoscopic ultrasound (EUS)-guided cystogastrostomy with a single 7-French (Fr) double-pigtail stent (DPS) is less popular due to the concern of stent patency. We aimed to assess the effectiveness, complications, and long-term outcomes of a single 7-Fr DPS in the endoscopic drainage of uncomplicated pseudocysts, containing no or minimal (<10%) debris.

Methods

A retrospective review of patients with pancreatic pseudocysts, who underwent EUS-guided cystogastrostomy during 2010-2018, and a systematic review of the literature were conducted.

Results

Of 45 patients, 14 patients underwent endoscopic drainage of uncomplicated pseudocysts using a single 7-Fr × 5 cm DPS. The mean cyst size was 10.2 ± 3.5 cm. Stent placement had a 100% technical and clinical success, defined as complete resolution of symptoms and regression of the cyst size by more than 50% at 8 weeks after drainage. The median follow-up was 42.4 months (range, 10-103). The pseudocysts resolved without recurrence in 92.8%. Spontaneous stent dislodgment was noted in 70% at a mean follow-up of 18 months. Additional interventions were required in 14% of cases due to stent occlusion and migration. A systematic review of literature related to EUS-guided cystogastrostomy using single and multiple plastic stents included 9 of 333 studies (222 patients). The analysis showed the pooled clinical success of 89% (95% confidence interval [CI], 82.0-94.2) and complication rate of 13% (95% CI, 5.7-21.8).

Conclusion

Selected uncomplicated pseudocysts can be treated effectively with a single 7-Fr DPS as it provides comparable clinical success and long-term outcomes as using larger or multiple stents.

What You Need to Know Before Performing Endoscopic Ultrasound-guided Hepaticogastrostomy

Endoscopic retrograde cholangiopancreatography (ERCP) is the primary treatment modality for bile duct obstruction. When ERCP is unsuccessful, percutaneous transhepatic biliary drainage can be an alternative method. Endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as a treatment option for biliary obstruction, especially after ERCP failure. EUS-BD offers transluminal intrahepatic and extrahepatic drainage through a transgastric and transduodenal approach. EUS-guided hepaticogastrostomy (EUS-HGS) is an excellent choice for patients with hilar strictures or those with a surgically altered anatomy. The optimal steps in EUS-HGS are case selection, bile duct visualization, puncture-site selection, wire insertion and manipulation, tract dilation, and stent placement. Caution should be taken at each step to prevent complications. Dedicated devices for EUS-HGS have been developed to improve the technical success rate and reduce complications. This technical review focuses on the essential practical points at each step of EUS-HGS.

Diffuse Esophageal Squamous Papillomatosis: A Rare Disease Associated with Acanthosis Nigricans and Tripe Palms

Acanthosis nigricans with tripe palms is one of the skin manifestations of systemic conditions, as well as internal malignancy. There have been reports of this paraneoplastic condition's association with orocutaneous papillomatosis, but investigations into its relationship with diffuse esophageal papillomatosis are scarce. We report a case of acanthosis nigricans with tripe palms that was associated with diffuse esophageal squamous papillomatosis. A 40-year-old Thai woman with underlying systemic lupus erythematosus and secondary Sjögren's syndrome, who was recently diagnosed with acanthosis nigricans and tripe palms was investigated for occult gastrointestinal malignancy. An upper GI endoscopy revealed diffuse squamous papilloma along the entire esophagus and lower GI endoscopy revealed one pedunculated hyperplastic polyp 1 cm in size at the sigmoid colon. Long-term follow-up is needed to reassure these coexisting conditions belonging to benign systemic diseases without hidden malignancy.

Endoscopic Ultrasound-Guided Vascular Therapy for Portoduodenal Fistula

Portoenteric fistula is a rare cause of massive upper gastrointestinal bleeding. Most cases can be treated with radiointervention or surgery, but portoenteric fistula is associated with a high mortality. We reported a case of intermittent massive upper gastrointestinal bleeding in a 33-year-old man with cholangiocarcinoma who underwent surgical resection followed by chemoradiation. A portoduodenal fistula due to chronic duodenal ulceration was identified. The bleeding was successfully controlled by endoscopic ultrasound-guided coil placement through the duodenal bulb using the anchoring technique. Follow-up endoscopy and computed tomography scan showed multiple coil placements between a part of the portal vein and the duodenal bulb without any evidence of portal vein thrombosis. There were no complications, and bleeding did not recur during the 8-month follow-up period.

Successful Closure of a Benign Refractory Tracheoesophageal Fistula Using an Over-the-Scope Clip after Failed Esophageal Stent Placement and Surgical Management

Tracheoesophageal fistulas (TEFs) have traditionally been managed surgically, but the endoscopic approach is widely performed as a less invasive alternative. Different closure techniques have been proposed with inconsistent results. An over-the-scope clip (OTSC) appears to be a reasonable option, but long-term results have not been well defined. We report the long-term outcomes of a complex case of successful closure of a benign refractory TEF using an OTSC after failed surgical management and esophageal stent placement.

Comparison of early and delayed EUS-guided drainage of pancreatic fluid collection

Background and study aims  While endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collection (PFC) is recommended to be performed ≥ 4 weeks after onset of acute pancreatitis (AP), early (< 4 weeks) interventions are needed in some symptomatic cases. Despite feasibility of early percutaneous drainage, there have been few studies about early EUS-guided drainage of PFC. Patients and methods  Consecutive patients who received EUS-guided drainage (EUS-PCD) of infected or symptomatic PFC at the University of Tokyo were retrospectively studied. Contraindications for EUS-PCD are lack of encapsulation or adhesion to the gastrointestinal tract. Safety and effectiveness of early vs delayed (≥ 4 weeks) EUS-PCD were compared. Results  A total of 35 patients underwent EUS-PCD (12 early and 23 delayed) using 19 large-bore fully-covered metallic stent and 16 plastic stents. The median diameter of PFC was 110 mm (40 - 180) and 122 mm (17 - 250) in the early and delayed drainage groups, respectively. Median time from onset of AP to drainage was 23 and 85 days for early and delayed drainage, respectively. The technical success rate of EUS-guided drainage was 100 %. Endoscopic necrosectomy was performed in six early and 16 cases of delayed drainage. The adverse event rate was 25 % (3 bleeding) and 13 % (2 perforations and 1 CO ₂ retention) in the early and delayed drainage groups, respectively. Two patients died (1 early and 1 delayed) due to multiorgan failure. Conclusion  Endoscopic drainage and subsequent necrosectomy of symptomatic PFC within 4 weeks after onset of acute pancreatitis was feasible, given that the collection was encapsulated and attached to the gastrointestinal tract.

Groove Pancreatitis: Endoscopic Treatment via the Minor Papilla and Duct of Santorini Morphology

Background/Aims

Groove pancreatitis (GP) is an uncommon disease involving the pancreaticoduodenal area. Possible pathogenesis includes obstructive pancreatitis in the duct of Santorini and impaired communication with the duct of Wirsung, minor papilla stenosis, and leakage causing inflammation. Limited data regarding endoscopic treatment have been published.

Methods

Seven patients with GP receiving endoscopic treatment were reviewed. The morphology of the pancreatic duct was evaluated by a pancreatogram. Endoscopic dilation of the minor papilla and drainage of the duct of Santorini were performed.

Results

There were two pancreatic divisum cases, one ansa pancreatica case and four impaired connections between the duct of Santorini and the main pancreatic duct. Three to 31 sessions of endoscopy, with 2 to 24 sessions of transpapillary stenting and dilation, were performed. Interventions through the minor papilla were successfully performed in six of seven cases. The pancreatic stenting duration ranged from 2 to 87 months. Five patients with evidence of chronic pancreatitis (CP) tended to receive more endoscopic interventions than did the two patients without CP (2–24 vs 2, respectively) for GP and other complications associated with CP.

Conclusions

Disconnection or impairment of communication between the ducts of Santorini and Wirsung was observed in all cases of GP. No surgery was required, and endoscopic minor papilla dilation and drainage of the duct of Santorini were feasible for the treatment of GP.

Endoscopic ultrasound in diagnosis of solid pancreatic lesions: Elastography or contrast-enhanced harmonic alone versus the combination

BACKGROUND AND STUDY AIMS

Endoscopic ultrasound (EUS) elastography (EUS-E) and contrast-enhanced harmonic EUS (CH-EUS) are useful methods for the diagnosis of pancreatic lesions. This study aims to compare the accuracy of combined EUS-E and CH-EUS with that of EUS-E or CH-EUS alone in the differential diagnosis of pancreatic solid lesions.

PATIENTS AND METHODS

 One hundred thirty-six patients with solid pancreatic lesions underwent EUS with both EUS-E and CH-EUS were included. Diagnoses were classified as adenocarcinoma, neuroendocrine tumor (NET), and inflammatory pseudotumor in 95, 22, and 19 patients, respectively. EUS records in each case were rearranged into 3 groups: EUS-E, CH-EUS, and combination. Each modality was randomly reviewed by 3 reviewers with different levels of clinical experience. Sensitivity, specificity, and accuracy of each modality according to each diagnosis group were evaluated. For the combined diagnosis populations, the proportions of correct diagnoses among the 3 modalities were compared by using the multivariate logistic regression analysis.

RESULTS

The accuracies of EUS-E, CH-EUS, and the combination of them were 68.4 %, 65.4 %, and 75.7 %, respectively, for adenocarcinoma group; 83.8 %, 82.4 %, and 86.8 % for NET group; 80.1 %, 78.7 %, and 81.6 % for inflammatory pseudotumor group. The multivariate logistic regression analysis for the combined diagnosis populations showed that the proportion of correct diagnoses when EUS-E and CH-EUS were combined was slightly higher than with the other 2 modalities, although the significant differences among them were not observed.

CONCLUSION

EUS-E and CH-EUS combined may improve differential diagnosis of solid pancreatic lesions compared with use of the individual modalities.

Endoscopic ultrasound elastography for solid pancreatic lesions

Elastography is one of technologies assisting diagnosis of solid pancreatic lesions (SPL). This technology has been previously used for measuring the stiffness of various organs based on a principle of “harder the lesions, higher chance for malignancy”. Two elastography techniques; strain and shear wave elastography, are available. For endoscopic ultrasound (EUS), only the former is existing. To interpret results of EUS elastography for SPL, 3 methods are used: (1) pattern recognition; (2) strain ratio; and (3) strain histogram. Based on results of existing studies, these 3 techniques provide high sensitivity but low to moderate specificity and accuracy rate. This review will summarize all available information in order to update current situation of using elastography for an evaluation of SPLs to readers.

Feasibility of conversion of percutaneous cholecystostomy to internal transmural endoscopic ultrasound-guided gallbladder drainage

BACKGROUND/AIM

Percutaneous cholecystostomy [percutaneous transhepatic gallbladder drainage (PTGBD)] is the treatment of choice in surgically unfit patients with acute cholecystitis. However, PTGBD tube removal after symptoms resolution results in 41-46% recurrence. This study aims to demonstrate the feasibility of the conversion of PTGBD to transmural endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using plastic stents in patients unfit for cholecystectomy.

PATIENTS AND METHODS

Patients who underwent internal transmural EUS-GBD as a conversion from PTGBD were reviewed. EUS-GBD was performed after the improvement of cholecystitis due to recurrent cholecystitis and PTGBD intolerance. One or two 7-Fr double pigtail plastic stent insertion with or without temporary endoscopic naso-gallbladder drainage (ENGBD) insertion was performed.

RESULTS

Six patients (age 61-88), with three cases of acute cholecystitis after metallic biliary stenting and three cases of calculus cholecystitis, who underwent PTGBD were included. EUS-GBD was performed 10-63 days after PTGBD, using one plastic stent in five cases, two stents in one case, with temporary ENGBD in two cases. The technical success and clinical success were achieved and the PTGBD tubes were subsequently removed in all patients. All ENGBD tubes were removed within 5 days after insertion. Bile leak with peritonitis was demonstrated in one case, which was treated conservatively. No recurrent cholecystitis was seen during 3-26 months of follow-up.

CONCLUSION

The conversion of percutaneous cholecystostomy to internal transmural EUS-GBD with plastic stents is feasible for patients unfit for cholecystectomy. However, more studies are still needed to confirm the results.

Endoscopic ultrasound in the diagnosis of acinar cell carcinoma of the pancreas: contrast-enhanced endoscopic ultrasound, endoscopic ultrasound elastography, and pathological correlation

We report a case series of five patients with pancreatic acinar cell carcinoma who received surgical treatment and compared the preoperative contrast-enhanced endoscopic ultrasound (EUS) and EUS elastography patterns with the surgical specimens. The contrast-enhanced EUS indicated vascular tumors with gradual enhancement in four patients and a hypovascular tumor in one patient. The elastography indicated an elastic score of 3 (hard lesion with softer border) in two patients and a score of 5 (hard lesion, which included the surrounding area) in two patients. In tumors with an elastic score of 5, the pathology exhibited abundant hyalinizing fibrous stroma or massive tumor invasion to the surrounding tissue. We concluded that acinar cell carcinoma of the pancreas has various patterns of EUS contrast-enhancement and elastography, depending on the pathologic phenotype.

Age-related changes in pancreatic elasticity: When should we be concerned about their effect on strain elastography?

BACKGROUND

Ultrasound strain elastography is one of the useful methods for evaluating pancreatic lesions. During aging, several pancreatic parenchymal changes occur that may interfere with the interpretation of the ultrasound images. We studied age-related changes in pancreatic elasticity using transabdominal ultrasound strain elastography in subjects without known pancreatic disease.

METHODS

This study was conducted at Nagoya University Hospital, which is an academic medical center, and included 102 subjects (66 women and 39 men) aged 20-85years (mean 58.6±17.5) who underwent transabdominal ultrasonography for screening and follow-up for non-pancreatic diseases. Strain elastography of the pancreas was performed, and the results were subjected to quantitative strain histogram analysis. The correlations of age with four elastographic parameters (Mean, Standard deviation, Skewness, and Kurtosis) and other findings, including hyperechoic pancreas, hyperechoic liver, and diabetes, were evaluated.

RESULTS

There was a significant correlation between increasing age and elastographic parameters such as the Mean (P=0.004), Skewness (P=0.007), and Kurtosis (P=0.03), and these differences became significant after the age of 40. The prevalence of hyperechoic pancreas increased with age (P<0.001), and the Means were lower in those with hyperechoic pancreas (P=0.004) and a higher body mass index (BMI, P=0.008). No significant correlations with diabetes, hyperechoic liver, or elastographic parameters were demonstrated.

CONCLUSION

Strain elastography demonstrated elastographic changes in the pancreas with aging that included a decreasing Mean and increasing Skewness and Kurtosis after the age of 40. The prevalence of pancreatic hyperechogenicity increased, and the pancreatic hyperechogenicity was significantly negatively correlated with the Mean.

Combination of EUS-FNA and elastography (strain ratio) to exclude malignant solid pancreatic lesions: A prospective single-blinded study

BACKGROUND

Negative results of EUS-FNA for solid pancreatic lesions (SPL) can be false ones. Combination with strain ratio (SR) may ensure a correct benign diagnosis of SPL.

AIMS

We prospectively evaluated the sensitivity rate of EUS-FNA and EUS elastography using the strain ratio method for diagnosing SPL.

METHODS

Thirty-eight patients with SPL identified by CT or MRI between January 2013 and November 2013 were included in our prospective study. EUS diagnoses were made using SR by an endosonographer who was blinded to all clinical information. In SPL with adequate cellularity, the results of EUS-FNA were combined with strain ratio to diagnose SPL and the diagnostic value was calculated.

RESULTS

Benign SPL were diagnosed in nine patients with surgical or guided-biopsy pathology (n = 3) and benign cells from FNA with stable disease during the 12-month follow-up time (n = 6). Using the best cut-off strain ratio level at 3.17, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy rate of EUS elastography were 86.2%, 66.7%, 89.3%, 60%, and 81.6%, respectively. For the 28 patients who underwent EUS-FNA with results of adequate cellularity; EUS-FNA alone versus combination of results of cytology and SR provided sensitivity, specificity, PPV, NPV, and accuracy rate at 90% versus 95.2, 100% versus 71.4%, 100% versus 90.9%, 80% versus 83.3, and 92.9% versus 89.3%, respectively.

CONCLUSIONS

In this prospective single-blinded study, the negative results of both EUS-FNA and SR were more reliable to exclude malignant SPL. The sensitivity of EUS elastography by SR was not superior to EUS-FNA. © 2015 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd.

Uncommon complications of therapeutic endoscopic ultrasonography: What, why, and how to prevent

There is an increasing role for endoscopic ultrasound (EUS)-guided interventions in the treatment of many conditions. Although it has been shown that these types of interventions are effective and safe, they continue to be considered only as alternative treatments in some situations. This is in part due to the occurrence of complications with these techniques, which can occur even when performed by experienced endosonographers. Although common complications have been described for many procedures, it is also crucial to be aware of uncommon complications. This review describes rare complications that have been reported with several EUS-guided interventions. EUS-guided biliary drainage is accepted as an alternative treatment for malignant biliary obstruction. Most of the uncommon complications related to this procedure involve stent malfunction, such as the migration or malposition of stents. Rare complications of EUS-guided pancreatic pseudocyst drainage can result from air embolism and infection. Finally, a range of uncommon complications has been reported for EUS-guided celiac plexus neurolysis, involving neural and vascular injuries that can be fatal. The goal of this review is to identify possible complications and promote an understanding of how they occur in order to increase general awareness of these adverse events with the hope that they can be avoided in the future.

Evolution of pancreas in aging: degenerative variation or early changes of disease?

Pancreatic changes in aging have been described for many decades. They involve not only pancreatic parenchyma but also pancreatic ductal, microscopic, and exocrine functional changes. There have been many studies of these changes based on pathology and various imaging modalities, as well as functional studies. The pancreatic volume was found to decrease with advancing age, with a higher incidence of pancreatic steatosis, as demonstrated in autopsy and imaging studies. The pancreatic ductal structure has been described with wide ranges of normal variation, but many studies have shown a tendency toward enlargement with advancing age. By endoscopic ultrasound imaging, the aging pancreas may exhibit abnormal findings similar to chronic pancreatitis. Microscopically, there has been evidence of patchy lobular fibrosis and papillary hyperplasia and demonstrable k-ras mutation in both normal and dysplastic ductal mucosa. The evidence of pancreatic exocrine insufficiency has yielded conflicting results, but most studies have shown a tendency toward decreased pancreatic exocrine function in the elderly. Differentiating pancreatic change in the elderly from early chronic pancreatitis may be difficult as there are limited studies to compare these two conditions in terms of structural and functional changes.

Factors influencing clinical outcomes of Histoacryl® glue injection-treated gastric variceal hemorrhage

AIM: To determine the factors associated with clinical outcomes and complications of Histoacryl^® glue injection for acute gastric variceal hemorrhage.

METHODS: Patients who presented to the Siriraj Gastrointestinal Endoscopy Center with active gastric variceal bleeding and were admitted for treatment between April 2008 and October 2011 were selected retrospectively for study inclusion. All bleeding varices were treated by injection of Histoacryl^® tissue glue (B. Braun Melsungen AG, Germany) through a 21G or 23G catheter primed with lipiodol to prevent premature glue solidification. Data recorded for each patient included demographic and clinical characteristics, endoscopic findings, clinical outcomes in terms of early and late re-bleeding, mortality, and procedure-related complications. Data from admission (baseline) and post-treatment were comparatively analyzed using stepwise logistic regression analysis to determine the correlation between factors and clinical outcomes.

RESULTS: A total of 90 patients underwent Histoacryl^® injection to treat bleeding gastric varices. The mean age was 55.9 ± 13.9 (range: 15-88) years old, and 74.4% of the patients were male. The most common presentations were hematemesis (71.1%), melena (12.2%), and coffee ground emesis (8.9%). Initial hemostasis was experienced in 97.8% of patients, while re-bleeding within 120 h occurred in 10.0%. The presence of ascites was the only factor associated with early and late re-bleeding [odds ratio (OR) = 10.67, 95%CI: 1.27-89.52, P = 0.03 and OR = 4.15, 95%CI: 1.34-12.86, P = 0.01, respectively]. Early procedure-related complications developed in 14.4% of patients, and were primarily infections and non-fatal systemic embolization. Late re-bleeding was significantly correlated with early procedure-related complications by univariate analysis (OR = 4.01, 95%CI: 1.25-12.87, P = 0.04), but no factors were significantly correlated by multivariate analysis. The overall mortality rate was 21.1%, the majority of which were related to infections. The factors showing strong association with higher mortality risk were elevated total bilirubin (OR = 16.71, 95%CI: 3.28-85.09, P < 0.01), a large amount of transfused fresh frozen plasma (OR = 1.001, 95%CI: 1.000-1.002, P = 0.03), and late re-bleeding (OR = 10.99, 95%CI: 2.15-56.35, P = 0.02).

CONCLUSION: Histoacryl^® injection is a safe and effective hemostatic method for treating gastric variceal hemorrhage. Patients with compromised liver, including ascites, have a higher risk of re-bleeding.

Mycoplasma pneumoniae and Chlamydophila pneumoniae in children with community-acquired pneumonia in Thailand

BACKGROUND

The prevalence of community-acquired pneumonia (CAP) caused by atypical pathogens in Thai children is unknown.

OBJECTIVE

To examine the prevalence of Mycoplasma pneumoniae and Chlamydophila pneumoniae infections in paediatric patients (aged 2-15 years) with CAP in three academic hospitals using standardised laboratory techniques. The characteristics of atypical pneumonia were also compared with other causes of CAP.

METHODS

Diagnosis of current infection was based on a four-fold or more rise in antibody serum samples or persistently high antibody titres together with the presence of mycoplasmal or chlamydial DNA in secretions.

RESULTS

Of 245 patients with CAP, 17.5% of cases were caused by atypical pathogens (M. pneumoniae 14.3%, C. pneumoniae 2.8% and co-infection 0.4%). We also found atypical pathogens in young children aged 2-5 years. The clinical and laboratory findings did not distinguish atypical pneumonia from other CAPs. Segmental or lobar consolidation on chest X-rays was more common in atypical pneumonia, while dyspnoea was more prominent in other CAPs.

CONCLUSION

Our data show a high prevalence of M. pneumoniae and C. pneumoniae in Thai children with CAP, including in children aged 2-5 years.

Can parents predict the severity of childhood obstructive sleep apnoea?

OBJECTIVE

To determine whether parents' observations can be used to predict the severity of the obstructive sleep apnoea syndrome (OSAS) in children.

STUDY DESIGN

Sixty-five children with OSAS diagnosed by overnight polysomnography were consecutively recruited and classified as having severe or non-severe OSAS according to the obstructive apnoea index (OAI) and the oxygen saturation measured by pulse oximetry (SpO2) nadir. Parents were asked to complete a questionnaire about the child's breathing difficulties at night.

RESULTS

Twenty-eight patients were classified as severe OSAS and 37 as non-severe OSAS. There were no differences between the two groups with respect to age, sex or body mass index. Male to female ratio was 5:1. Parents of children with severe OSAS more frequently reported observed cyanosis (35 vs 8%; p=0.02); obstructive apnoea (60 vs 35%; p = 0.04); snoring extremely loudly (52 vs 22%; p = 0.01); shaking the child (64 vs 35%; p = 0.02); watching the child during sleep and being afraid of apnoea (85 vs 60%; p = 0.03). However, neither any single nor combinations of observations showed high values for both sensitivity and specificity.

CONCLUSIONS

Although some parents' observations are more frequently reported in children with severe OSAS, neither any single nor combinations of observations accurately predict the severity of OSAS. Polysomnography is still needed to determine the severity of obstruction.

Recombinant activated factor VII in children with acute bleeding resulting from liver failure and disseminated intravascular coagulation

Recombinant activated factor VII (rFVIIa) was given to three children with acute bleeding resulting from liver failure and disseminated intravascular coagulation. Cases I and II (girls aged 3 years and 6 years, respectively) were diagnosed with Dengue hemorrhagic fever and prolonged shock. Case III, a boy aged 9 months, underwent left lobe hepatectomy for a hepatoblastoma, during which 60% of his liver was removed. This case was complicated by myoglobinuria, liver and renal impairment and early disseminated intravascular coagulation. All three patients exhibited active bleeding. Cases I and II received rFVIIa combined with other blood component replacement, while Case III received rFVIIa as the only hemostatic agent. A bolus of 40-180 microg/kg b.w. was administered followed by 16.5-33 microg/kg b.w. per h continuous infusion. As a result, bleeding was controlled, the prothrombin time was shortened and FVII clotting activity was significantly increased. In conclusion, rFVIIa has shown some efficacy in controlling acute bleeding in children with liver failure and disseminated intravascular coagulation.

Disseminated intravascular coagulation findings in 100 patients

A retrospective study of 100 patients with disseminated intravascular coagulation from 1993 to 1997 is reported. Forty-five patients were neonates with a mean age of 12.6 days and 55 patients were infants, children and adolescents with a mean age of 6 years and 3 months. Most of them (91.5%) had complicated underlying conditions which included congenital anomalies, prematurity, malignancy, hematological and various diseases. Additionally, every patient had triggering conditions commonly identified as gram-negative septicemia. Bleeding and thromboembolic manifestations were found in 59.4 per cent and 19.8 per cent, respectively. The laboratory findings revealed red blood cell fragmentation, 89.6 per cent and thrombocytopenia, 85.8 per cent. Natural anticoagulants were studied in a few cases and revealed low levels of antithrombin III and protein C. The prompt effective management included treatment of underlying diseases, identification and relief of triggering conditions, correction of thrombocytopenia and coagulopathy, and fully supportive care. The overall case-fatality rate was 41.6 per cent which was not correlated with age, underlying diseases, triggering conditions, manifestation of bleeding, thromboembolism or shock, and exchange transfusion. However, a significant lower case-fatality rate was found in patients with positive culture (25%) as compared to those with sepsis and negative culture (51.7%) (p = 0.044). In addition, the febrile neutropenic patients, who showed good response to the administrated granulocyte-colony stimulating factor (G-CSF), survived from the DIC.

Pulmonary involvement in childhood systemic lupus erythematosus

Twenty-four children (aged 6-15 years, M:F = 1:11) with systemic lupus erythematosus (SLE), who had respiratory symptoms, were retrospectively reviewed. Chest radiographs obtained from all patients revealed pleural effusion in 13, alveolar infiltration in 9, pericardial effusion and cardiomegaly in 6, interstitial infiltration in 4, hilar adenopathy in 3, lung abscess in 2 and pneumatocele with pneumothorax in 1. Etiologic organisms were identified in 7 cases; (3 cases of nocardia isolated from pleural effusion and sputum, 2 cases of tuberculosis, 1 case with staphylococcus aureus septicemia and 1 case with salmonella septicemia). All except one patient improved with medical treatment. One patient died from pneumonitis. Although pulmonary involvement is increasingly recognized in children with SLE, neither roentgenogram nor clinical findings were specific. The differentiation of pulmonary infiltrates caused by lupus lung disease from pulmonary infection should be carefully evaluated.

Prone position in spontaneously breathing infants with pneumonia

This study was designed to evaluate further the effect of prone positioning on oxygen saturation (SpO2) and respiratory mechanics in spontaneously breathing infants with pneumonia. SpO2 and respiratory mechanics were measured in the supine and prone positions in 17 infants. Prone positioning resulted in statistically significant increases in mean (+/- SD) SpO2 (95.52+/-2.87 to 98.00+/-2.40%, p = 0.0002) and respiratory system compliance (5.99+/-2.52 to 7.93+/-4.30 ml/cm H2O, p = 0.02). This suggests that prone positioning is another beneficial supportive measure for spontaneously breathing infants with pneumonia.

Obstructive sleep apnea syndrome in Thai children diagnosed by polysomnography

Overnight polysomnography was conducted in 39 Thai children with clinically suspected obstructive sleep apnea syndrome (OSAS) during the years 1994 to 1996. Eighty-five percent of these children met the polysomnographic criteria of pediatric OSAS, 42.4% among whom had severe OSAS. Male : female ratio of children with OSAS was 4.5:1. The peak age at the time of diagnosis was 3 to 4 years. The most common predisposing factor was adenoidal and tonsillar hypertrophy. Adenoidectomy and/or tonsillectomy was the most effective therapeutic option. Recovery of symptoms was observed following surgery and nasal continuous positive airway pressure.

Incidence of Mycoplasma pneumoniae, Chlamydia trachomatis, and viral infections in pneumonia cases under six months of age, Bangkok, Thailand

The incidence of infections by Mycoplasma pneumoniae, Chlamydia trachomatis and respiratory viruses was investigated in 76 pneumonic patients aged under 6 months who attended Ramathibodi and Siriraj Hospitals in Bangkok during two study periods. M. pneumoniae infection was not found in any case from either hospital by serological diagnosis. By the isolation method, C. trachomatis infection was found in 7(16.7%) of 42 patients from Ramathibodi Hospital and 5(21.7%) of 23 patients from Siriraj Hospital with the average male:female ratio of 2.6:1; and 91.7% of the infected cases were under 3 months old. Laboratory diagnosis of respiratory virus infection was performed by indirect immunofluorescence (IIF), isolation, and by antibody detection. Data from Ramathibodi Hospital showed that 11 (24.4%), 4 (8.9%), 3 (6.7%) of the 45 patients were infected by respiratory syncytial virus (RSV), adenoviruses, parainfluenza virus type 3, and some other viruses, respectively; infection rates of 10 (32.3%), 4 (12.9%), 1 (3.2%) and 1 (3.2%) by those viruses respectively, were observed in the 31 patients from Siriraj Hospital.

Risk factors associated with morbidity and mortality of pneumonia in Thai children under 5 years

ARI is the most common cause of illness and death in children under 5 years of age. Pneumonia is the leading cause of death. This prospective study was part of an ARIC project conducted to identify risk factors associated with mortality and morbidity of community acquired pneumonia in Thai children younger than 5 years of age. Study subjects were 267 moderately severe pneumonia who were admitted to hospital. Fifteen percent required a ventilator and were categorized as severe cases. Nine patients (3.4%) died and were categorized in the fatal group. From univariate analysis only, risk factors of fatal pneumonia were lower body weight (p = 0.04), paternal age less than 35 year (OR = 6.1, p = 0.01), underlying heart disease (OR = 12.1, p = 0.0000) and protein energy malnutrition (OR = 7.9, p = 0.0087). Predictors on admission to predict fatal outcome were rapid respiratory rate > 50/minute (OR = 4.1, p = 0.03), gallop rhythm (OR = 11, p = 0.04), enlarged liver (OR = 13.2, p = 0.001), and cyanosis (OR = 12, p = 0.0006). Significant factors associated with severe pneumonia after multiple logistic regression were underlying heart disease (OR = 4.04, 95% CI 1-15.4), enlarged liver (OR = 4.31, 95% CI 1.2-15.2) and cyanosis (OR = 5, 95% CI 0.8-28.7). This information should create awareness in physicians who are responsible for young children with pneumonia. Early recognition and intervention may prevent deaths and complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Hepatopathy-thrombocytopenia vs infection-induced hemophagocytic syndrome in Wilms' tumor: a case report

A 3-year-old boy with Wilms' tumor, post operative left nephrectomy stage, had HTS on day 99 of the combined chemotherapy which lasted for more than 20 days. He had severe respiratory distress due to a moderate amount of ascites and marked pleural effusion. Because of high fever, thrombocytopenia and marked hemphagocytosis in the bone marrow, he received IVIG for 2 days. Normal platelet count and markedly decreased pleural fluid were attained within 3 days. He subsequently tolerated full doses of combined chemotherapeutic agents with an additional one (doxorubicin). In cases of HTS, IAHS should be suspected. The bone marrow should be done and treatment accordingly so that there is no need to decrease, the dosage of chemotherapeutic agents afterwards.

Protective efficacy of neonatal Bacillus Calmette-Guérin vaccination against tuberculosis

This matched case-control study was performed in two hospitals in Bangkok to evaluate the protective efficacy of neonatal Bacillus Calmette-Guérin (BCG) vaccination in Thai children and to find factors that might explain the reported variation in estimates of the protective efficacy of BCG. Cases were defined as children 3 months to 14 years of age who had tuberculosis and controls consisted of one to four children who were born in the same year and had the same district of residence as the case. A matched analysis with a variable number of controls per case was performed on 75 cases and 207 controls. Conditional logistic regression was performed to adjust for the potential confounding effects of household tuberculosis exposure and socioeconomic status. Forty-eight percent of cases had nonrespiratory tuberculosis. Laboratory-confirmed evidence for tuberculosis was found in 48% of cases. The adjusted protective efficacy of neonatal BCG vaccination was 83% (95% confidence limits, 35%, 96%). It was 96% (95% confidence limits, 66%, 100%) when only 36 matched sets of laboratory-confirmed cases were analyzed. Subgroup analyses and literature reviews indicated that the accuracy of tuberculosis diagnosis, types of tuberculosis, duration after vaccination and household tuberculosis exposure contribute to variation in the reported protective efficacy of neonatal BCG vaccination.

A study of nonbacterial agents of acute lower respiratory tract infection in Thai children

From January 1986 to December 1987, 596 children less than 5 years of age with lower respiratory tract infection (LRI)--manifested as laryngitis, croup, bronchitis, bronchiolitis, and pneumonia--were studied for evidence of infection with respiratory tract viruses Mycoplasma pneumoniae, and Chlamydia trachomatis. Of the 596 children in the study, 315 were ambulatory and 281 were hospitalized. Virologic studies included isolation and rapid diagnosis of virus from specimens of nasopharyngeal aspirate (NPA) and serologic studies of blood samples. Cultures of NPA for C. trachomatis were performed for children less than 6 months of age who had pneumonia. Of the LRI cases, 45% were associated with viral infections of the respiratory tract and 12.1% were associated with C. trachomatis. Respiratory syncytial virus (RSV) accounted for 45.2% of infections with viral agents and was associated with acute bronchitis, acute bronchiolitis, and pneumonia. Parainfluenza type 3 virus was the most common virus found in conjunction with laryngitis and croup. The incidence of infections due to RSV peaked in July and August, while that of infections due to parainfluenza viruses peaked in February and March; influenza viruses and adenoviruses were isolated throughout the year.

A hospital-based study of acute viral infections of the respiratory tract in Thai children, with emphasis on laboratory diagnosis

The hospital-based study described here examined the viruses found in 738 children less than 5 years old who presented at Ramathibodi Hospital, Bangkok, Thailand, from January 1986 to December 1987 with acute respiratory tract infections. Three methods for detection of viral infection are compared: direct examination of epithelial cells of the respiratory tract with the use of fluorescent antibody staining, isolation of virus, and measurement of antibody in acute- and convalescent-phase sera. Viral infections were found in 44.7% of the study population. Diagnosis by the examination of epithelial cells with the fluorescent antibody staining procedure was found to have several deficiencies; however, this technique was the most sensitive for diagnosis of infection due to respiratory syncytial virus. Isolation of virus was the best method for identification of adenoviruses, parainfluenza 1 and 3 viruses, and influenza B virus. Problems associated with serodiagnosis included failure to obtain specimens of convalescent-phase blood in 24.5% of cases and insensitivity of serodiagnosis for young children except for the identification of antibody to influenza A virus. The combination of all three tests yielded the best rate of detection of virus.

Blood flow during cardiopulmonary resuscitation with simultaneous compression and ventilation in infant pigs

We determined whether the simultaneous chest compression and ventilation (SCV) technique of cardiopulmonary resuscitation (CPR) enhances cerebral (CBF) and myocardial (MBF) blood flows and cerebral O2 uptake in an infant swine model of CPR as it does in most adult animal CPR models. We also tested whether SCV-CPR sustains CBF and MBF for prolonged periods of CPR when these flows ordinarily deteriorate. CPR was performed in two groups (n = 8) of pentobarbital anesthetized piglets (3.5-5.5 kg) with continuous epinephrine infusion (10 micrograms/kg/min). Conventional CPR was performed at 100 compressions/min, 60% duty cycle, 1:5 breath to compression ratio and 25-30 mm Hg peak airway pressure. SCV-CPR was performed at 60 compressions/min, 60% duty cycle and 60 mm Hg peak airway pressure applied during each chest compression. Peak right atrial and aortic pressures in excess of 80 mm Hg were generated during CPR in both groups. At 5 min of conventional and SCV-CPR, MBF was 38 +/- 7 and 46 +/- 7 mL.min-1.100 g-1 (+/- SE), respectively, and CBF was 15 +/- 3 and 13 +/- 2 mL.min1. 100 g-1, respectively. However, as CPR was prolonged to 50 min, the sternum progressively lost its recoil and the chest became more deformed. Lung inflation at high airway pressure with SCV-CPR did not prevent this chest deformation. Aortic pressure gradually declined, whereas right atrial and intracranial pressure remained constant in both groups. Consequently, MBF and CBF fell less than 10 mL.min-1.100 g-1 and cerebral O2 uptake was markedly impaired during prolonged conventional and SCV-CPR.(ABSTRACT TRUNCATED AT 250 WORDS)

Age-related changes in chest geometry during cardiopulmonary resuscitation

We studied alterations of chest geometry during conventional cardiopulmonary resuscitation in anesthetized immature swine. Pulsatile force was applied to the sternum in increments to determine the effects of increasing compression on chest geometry and intrathoracic vascular pressures. In 2-wk- and 1-mo-old piglets, permanent changes in chest shape developed due to incomplete recoil of the chest along the anteroposterior axis, and large intrathoracic vascular pressures were generated. In 3-mo-old animals, permanent chest deformity did not develop, and large intrathoracic vascular pressures were not produced. We propose a theoretical model of the chest as an elliptic cylinder. Pulsatile displacement along the minor axis of an ellipse produces a greater decrease in cross-sectional area than displacement of a circular cross section. As thoracic cross section became less circular due to deformity, greater changes in thoracic volume, and hence pressure, were produced. With extreme deformity at high force, pulsatile displacement became limited, diminishing pressure generation. We conclude that changes in chest geometry are important in producing intrathoracic intravascular pressure during conventional cardiopulmonary resuscitation in piglets.

Effect of epinephrine on cerebral and myocardial perfusion in an infant animal preparation of cardiopulmonary resuscitation

We assessed the efficacy of conventional cardiopulmonary resuscitation (CPR) in 2-week-old piglets. We determined intrathoracic vascular pressures, cerebral (CBF) and myocardial blood flows (MBF), and cerebral oxygen uptake during conventional CPR in this infant animal preparation and contrasted these results with those of previous work on adult animals. We further examined the effects of the infusion of epinephrine on these pressures and flows and on cerebral oxygen uptake, which has not been previously evaluated in adult preparations. Conventional CPR was performed on pentobarbital-anesthetized piglets with a 20% sternal displacement with the use of a pneumatic piston compressor. Chest recoil was incomplete, leading to an 18% to 27% reduction in anteroposterior diameter during the relaxation phase. Aortic and right atrial pressures in excess of 80 mm Hg were generated. These pressures are greater than those generally obtained in adult animals with similar percent pulsatile displacements. CBF and MBF were also initially greater than those reported in adult animals undergoing conventional CPR. However, when CPR was prolonged beyond 20 min, aortic pressure fell and CBF and MBF declined to the near-zero levels seen in adult preparations. At 5 min of CPR, CBF and MBF were 24 +/- 7 and 27 +/- 7 ml . min-1 x 100 g-1 (50% and 17% of the values during cardiac arrest), respectively. With the continuous infusion of epinephrine (4 micrograms/kg/min) in another group of animals, MBF was significantly greater at 20 min of CPR and CBF and cerebral O2 uptake were greater at 35 min of CPR as a result of higher perfusion pressures.(ABSTRACT TRUNCATED AT 250 WORDS)

The role of ketotifen in children with recurrent bronchitis

The efficacy and safety of ketotifen in the treatment of recurrent bronchitis were studied in twenty Thai children with an average age of 5.3 years. Symptoms studied were cough, hypersecretion and wheezing and 4-point rating scores were assigned to each of the symptoms with regard to their frequency, severity and duration. Score per dose of the symptomatic agents used was also given. The symptoms and the use of symptomatic agents were recorded during a full year prior to ketotifen treatment and during a further full year study period. PEFR measurement was performed in the children above the age of 6 years at 2-weekly intervals under the supervision of the authors at the clinic. Assessment of efficacy was done by comparing monthly symptom scores and medication scores during the study period with the mean value of the previous year. Thirteen children received ketotifen for the whole year while seven children who were almost symptom-free after 4 months ketotifen treatment, were then only observed for a further 8 months. At the end of the study period, ketotifen treatment was rated very good and good in 85% of children, satisfactory in 10% and poor in 5%. Drowsiness was the only side-effect reported in a few cases but then only initially. There were no abnormalities in any laboratory parameters studied.