A new look at anti-Helicobacter pylori therapy

With the rising prevalence of antimicrobial resistance,the treatment success of standard triple therapy has recently declined to unacceptable levels (i.e.,80% or less) in most countries.Therefore,several treatment regimens have emerged to cure Helicobacter pylori (H.pylori) infection.Novel first-line anti-H.pylori therapies in 2011 include sequential therapy,concomitant quadruple therapy,hybrid (dual-concomitant) therapy and bismuth-containing quadruple therapy.After the failure of standard triple therapy,a bismuth-containing quadruple therapy comprising a proton pump inhibitor (PPI),bismuth,tetracycline and metronidazole can be employed as rescue treatment.Recently,triple therapy combining a PPI,levofloxacin and amoxicillin has been proposed as an alternative to the standard rescue therapy.This salvage regimen can achieve a higher eradication rate than bismuth-containing quadruple therapy in some regions and has less adverse effects.The best second-line therapy for patients who fail to eradicate H.pylori with first-line therapies containing clarithromycin,amoxicillin and metronidazole is unclear.However,a levofloxacin-based triple therapy is an accepted rescue treatment.Most guidelines suggest that patients requiring third-line therapy should be referred to a medical center and treated according to the antibiotic susceptibility test.Nonetheless,an empirical therapy (such as levofloxacin-based or furazolidone-based therapies) can be employed to terminate H.pylori infection if antimicrobial sensitivity data are unavailable.

Effect of ginger Effect of ginger on gastric motility and symptoms of functional dyspepsiaon gastric motility and symptoms of functional dyspepsia

AIM:To evaluate the effects of ginger on gastric motility and emptying,abdominal symptoms,and hormones that influence motility in dyspepsia.METHODS:Eleven patients with functional dyspepsia were studied twice in a randomized double-blind manner.After an 8-h fast,the patients ingested three capsules that contained ginger(total 1.2 g) or placebo,followed after 1 h by 500 mL low-nutrient soup.Antral area,fundus area and diameter,and the frequency of antral contractions were measured using ultrasound at frequent intervals,and the gastric half-emptying time was calculated from the change in antral area.Gastrointestinal sensations and appetite were scored using visual analog questionnaires,and blood was taken for measurement of plasma glucagon-like peptide-1(GLP-1),motilin and ghrelin concentrations,at intervals throughout the study.RESULTS:Gastric emptying was more rapid after ginger than placebo [median(range) half-emptying time 12.3(8.5-17.0) min after ginger,16.1(8.3-22.6) min after placebo,P ≤ 0.05].There was a trend for more antral contractions(P = 0.06),but fundus dimensions and gastrointestinal symptoms did not differ,nor did serum concentrations of GLP-1,motilin and ghrelin.CONCLUSION:Ginger stimulated gastric emptying and antral contractions in patients with functional dyspepsia,but had no impact on gastrointestinal symptoms or gut peptides.

Current status in the treatment options for esophageal achalasia

Recent advances in the treatment of achalasia include the use of high-resolution manometry to predict the outcome of patients and the introduction of peroral endoscopic myotomy(POEM).The first multicenter randomized,controlled,2-year follow-up study conducted by the European Achalasia Trial group indicated that laparoscopic Heller myotomy(LHM)was not superior to pneumatic dilations(PD).Publications on the long-term success of laparoscopic surgery continue to emerge.In addition,laparoscopic single-site surgery is applicable to advanced laparoscopic operations such as LHM and anterior fundoplication.The optimal treatment option is an ongoing matter of debate.In this review,we provide an update of the current progress in the treatment of esophageal achalasia.Unless new conclusive data prove otherwise,LHM is considered the most durable treatment for achalasia at the expense of increased reflux-associated complications.However,PD is the first choice for non-surgical treatment and is more costeffective.Repeated PD according to an"on-demand"strategy based on symptom recurrence can achieve long-term remission.Decision making should be based on clinical evidence that identifies a subcategory of patients who would benefit from specific treatment options.POEM has shown promise but its long-term efficacy and safety need to be assessed further.

2011 update on esophageal achalasia

There have been some breakthroughs in the diagnosis and treatment of esophageal achalasia in the past few years.First,the introduction of high-resolution manometry with pressure topography plotting as a new diagnostic tool has made it possible to classify achalasia into three subtypes.The most favorable outcome is predicted for patients receiving treatment for type Ⅱ achalasia (achalasia with compression).Patients with typeⅠ(classic achalasia) and type Ⅲ achalasia (spastic achalasia) experience a less favorable outcome.Second,the first multicenter randomized controlled trial published by the European Achalasia Trial group reported 2-year follow-up results indicating that laparoscopic Heller myotomy was not superior to endoscopic pneumatic dilation (PD).Although the follow-up period was not long enough to reach a convincing conclusion,it merits the continued use of PD as a generally available technique in gastroenterology.Third,the novelendoscopic technique peroral endoscopic myotomy is a promising option for treating achalasia,but it requires increased experience and cautious evaluation.Despite all this good news,the bottom line is a real break-through from the basic studies to identify the actual cause of achalasia that may impede treatment success is still anticipated.

Predictors of rebleeding after initial hemostasis with epinephrine injection in high-risk ulcers

AIM: To identify the predictors of rebleeding after initial hemostasis with epinephrine injection (EI) in patients with high-risk ulcers. METHODS: Recent studies have revealed that endoscopic thermocoagulation, or clips alone or combined with EI are superior to EI alone to arrest ulcer bleeding. However, the reality is that EI monotherapy is still common in clinical practice. From October 2006 to April 2008, high-risk ulcer patients in whom hemorrhage was stopped after EI monotherapy were studied using clinical, laboratory and endoscopic variables. The patients were divided into 2 groups: sustained hemostasis and rebleeding. RESULTS: A total of 175 patients (144, sustainedhemostasis; 31, rebleeding) were enrolled. Univariate analysis revealed that older age (≥ 60 years), advanced American Society of Anesthesiology (ASA) status (category Ⅲ , Ⅳ and Ⅴ ), shock, severe anemia (hemoglobin < 80 g/L), EI dose ≥ 12 mL and severe bleeding signs (SBS) including hematemesis or hematochezia were the factors which predicted rebleeding. However, only older age, severe anemia, high EI dose and SBS were independent predictors. Among 31 rebleeding patients, 10 (32.2%) underwent surgical hemostasis, 15 (48.4%) suffered from delayed hemostasis causing major complications and 13 (41.9%) died of these complications. CONCLUSION: Endoscopic EI monotherapy in patients with high-risk ulcers should be avoided. Initial hemostasis with thermocoagulation, clips or additional hemostasis after EI is mandatory for such patients to ensure better hemostatic status and to prevent subsequent rebleeding, surgery, morbidity and mortality.

Clinical characteristics and prognostic factors of splenic abscess:A review of 67 cases in a single medical center of Taiwan

瞄准：在 19 年的一个时期期间在台湾的一个医学中心分析脾的脓肿的 67 个盒子。方法：从 1986 年 1 月到 2004 年 12 月，有脾的脓肿的 67 个病人的一个总数为回顾的学习被注册。临床的特征，内在的疾病，有机体系列，治疗学的方法， APACHE II 分数，和死亡率被分析。结果：与 54.1+/-14.1 年的吝啬的年龄有 41 男性和 26 女性。为 28.4% 的多重脾的脓肿(MSA ) 报道和在 71.6% 病人的独居的脾的脓肿。57 个病人(35.8%) 中的 26 个有额外的脾的脓肿，与肝(34.6%) 的领先的地点。微生物学文化在血文化在 58 个病人(86.6%) 是积极的，与 71.8% 并且 93.5% 在脓肿文化。与肺炎杆菌(22.4%) 的领先的病原体，支配的克否定杆菌(GNB ) 感染(55.2%) 由克跟随了积极球菌(GPC ) 感染(31%) 。脾切除术在 26 被执行在 21 的病人(38.8%) ，经皮的排水或渴望(31.3%) ，和在 20 个病人(29.9%) 独自一个的抗菌素治疗。最后， 67 个病人中的 12 个到期了(17.9 %) 。由统计，感染 GNB 的怒气是可能的与 GPC (P=0.036 ) 与感染相比开发多发性脓肿。有 GNB 感染(P=0.009 ) 和多发性脓肿(P=0.011 ) 的病人与 GPC 感染和独居的脓肿比病人经历了更高的死亡率。12 的吝啬的 APACHE II 分数到期了病人(16.3+/-3.2 ) 比 55 幸存(7.2+/-3.8 )(P【0.001 ) 的显著地高。结论：MSA， GNB 感染，和高 APACHE II 分数是差的预示的因素。当这些风险因素是在场的时，早外科的干预应该被鼓励。

Endosonographic surveillance of 1-3 cm gastric submucosal tumors originating from muscularis propria

AIM To observe the natural course of 1-3 cm gastric submucosal tumors originating from the muscularis propria(SMTMPs).METHODS By reviewing the computerized medical records over a period of 14 years(2000-2013), patients with 1-3 cm gastric SMTMPs who underwent at least two endoscopic ultrasound(EUS) examinations were enrolled. Tumor progression was defined as a ≥ 1.2 times enlargement in tumor diameter observed during EUS surveillance. All patients were divided into stationary and progressive subgroups and further analyzed. We also reviewed the patients in the progressive subgroup again in 2016.RESULTS A total of 88 patients were studied, including 25 in the progressive subgroup. The mean time of EUS surveillance was 24.6 mo in the stationary subgroup and 30.7 mo in the progressive subgroup. Risk factors for tumor progression included larger tumor size and irregular border. Initial tumor size > 14.0 mm may be considered a cut-off size for predicting tumor progression. Seventeen patients underwent surgery, of whom 13 had gastrointestinal stromal tumors(GISTs) and 4 had leiomyomas. Tumor progression was found only in patients with GISTs. All of the tumors exhibited benign behaviors without metastasis until 2016.CONCLUSION Most 1-3 cm gastric SMTMPs(71.6%) are indolent. Tumor progression was found only in GISTs, and it is a good predictor for differentiating GISTs from leiomyomas. Predictors of tumor progression include larger tumor size(> 14.0 mm) and irregular border.

Delayed presentation of intrathoracic esophageal perforation after pneumatic dilation for achalasia

Pneumatic dilation(PD)is considered to be a safe and effective first line therapy for achalasia.The major adverse event caused by PD is esophageal perforation but an immediate gastrografin test may not always detect a perforation.It has been reported that delayed management of perforation for more than 24 h is associated with high mortality.Surgery is the treatment of choice within 24 h,but the management of delayed perforation remains controversial.Hereby,we report a delayed presentation of intrathoracic esophageal perforation following PD in a 48-year-old woman who suffered from achalasia.She completely recovered after intensive medical care.A review of the literature is also discussed.

Gastric juice acidity in upper gastrointestinal diseases

AIM: To search the independent factors determining gastric juice acidity and to investigate the acidity of gastric juices in various benign and malignant upper gastrointestinal diseases. METHODS: Fasting gastric juice acidity of 165 healthysubjects and 346 patients with esophageal ulcer (n = 21), gastric ulcer (n = 136), duodenal ulcer (n = 100) or gastric cancer (n = 89) were measured and compared. Additionally, gastric specimens were taken from the antrum and body for rapid urease test and histological examination. RESULTS: Multivariate analysis revealed that bile stain of gastric juice, high acute inflammatory score of the corpus, and atrophy of the corpus were independent risk factors for the development of gastric hypoacidity with odds ratios of 3.1 (95% CI: 1.3-7.3), 3.1 (95% CI: 1.2-7.9) and 3.5 (95% CI: 1.3-9.2). Esophageal ulcer and duodenal ulcer patients had a lower pH level (1.9 and 2.1 vs 2.9, both P < 0.05) of gastric juices than healthy subjects. In contrast, gastric ulcer and gastric cancer patients had a higher pH level (3.4 and 6.6 vs 2.9, both P < 0.001) than healthy controls. Hypoacidity existed in 22%, 5%, 29%, 5% and 88% of healthy subjects, esophageal ulcer, gastric ulcer, duodenal ulcer and gastric cancer patients, respectively. CONCLUSION: Bile reflux, atrophy and dense neutrophil infiltrate of the corpus are three independent factors determining the acidity of gastric juice.

Endoscope-guided pneumatic dilation for treatment of esophageal achalasia

Pneumatic dilation(PD) is considered to be the first line nonsurgical therapy for achalasia.The principle of the procedure is to weaken the lower esophageal sphincter by tearing its muscle fibers by generating radial force.The endoscope-guided procedure is done without fluoroscopic control.Clinicians usually use a lowcompliance balloon such as Rigiflex dilator to perform endoscope-guided PD for the treatment of esophageal achalasia.It has the advantage of determining mucosal injury during the dilation process,so that a repeat endoscopy is not needed to assess the mucosal tearing.Previous studies have shown that endoscope-guided PD is an efficient and safe nonsurgical therapy with results that compare well with other treatment modalities.Although the results may be promising,long-term follow-up is required in the near future.

First-week clinical responses to dexlansoprazole 60 mg and esomeprazole 40 mg for the treatment of grades A and B gastroesophageal reflux disease

AIM To compare the one-week clinical effects of single doses of dexlansoprazole and esomeprazole on grades A and B erosive esophagitis.METHODS We enrolled 175 adult patients with gastroesophageal reflux disease(GERD). The patients were randomized in a 1:1 ratio into two sequence groups to define the order in which they received single doses of dexlansoprazole(n = 88) and esomeprazole(n = 87) for an intention-to-treat analysis. The primary endpoints were the complete symptom resolution(CSR) rates at days 1, 3, and 7 after drug administration.RESULTS Thirteen patients were lost to follow-up, resulting in 81 patients in each group for the per-protocol analysis. The CSRs for both groups were similar at days 1, 3 and 7. In the subgroup analysis, the female patients achieved higher CSRs in the dexlansoprazole group than in the esomeprazole group at day 3(38.3% vs 18.4%, P = 0.046). An increasing trend toward a higher CSR was observed in the dexlansoprazole group at day 7(55.3% vs 36.8%, P = 0.09). In the esomeprazole group, female sex was a negative predictive factor for CSR on post-administration day 1 [OR =-1.249 ± 0.543; 95%CI: 0.287(0.099-0.832), P = 0.022] and day 3 [OR =-1.254 ± 0.519; 95%CI: 0.285(0.103-0.789), P = 0.016]. Patients with spicy food eating habits achieved lower CSRs on day 1 [37.3% vs 21.4%, OR =-0.969 ± 0.438; 95%CI: 0.380(0.161-0.896), P = 0.027]. CONCLUSION The overall CSR for GERD patients was similar at days 1-7 for both the dexlansoprazole and esomeprazole groups, although a higher incidence of CSR was observed on day 3 in female patients who received a single dose of dexlansoprazole.

Five-year sequential changes in secondary antibiotic resistance of Helicobacter pylori in Taiwan

AIM: To determine changes in the antibiotic resistance of Helicobacter pylori(H. pylori) in southern Taiwan after failure of first-line standard triple therapy.METHODS: We analyzed 137 H. pylori-infected isolates from patients who experienced eradication failure after standard first-line triple therapy from January2010 to December 2014. The H. pylori strains were tested for susceptibility to amoxicillin, clarithromycin,levofloxacin, metronidazole and tetracycline using the E-test method. The minimal inhibitory concentration(MIC) was determined by the agar dilution test.MIC values of ≥ 0.5, ≥ 1, ≥ 1, ≥ 4 and ≥ 8 mg/L were considered to be the resistance breakpoints for amoxicillin, clarithromycin, levofloxacin, tetracycline and metronidazole, respectively.RESULTS: A high resistance rate was found for clarithromycin(65%-75%) and metronidazole(30%-40%)among patients who failed first-line standard therapy.The resistance levels to amoxicillin and tetracycline remained very low; however, levofloxacin resistance was as high as 37.5% in 2010 but did not increase any further during the past 5 years. The rates of resistance to these antibiotics did not show a statistically significant upward or downward trend.CONCLUSION: Antibiotic resistance of H. pylori remains a problem for the effective eradication of this pathogen and its associated diseases in Taiwan. High clarithromycin resistance indicated that this antibiotic should not be prescribed as a second-line H. pylori eradication therapy. Moreover, levofloxacin-based second-line therapy should be used cautiously, and the local resistance rates should be carefully monitored.

Pseudoachalasia in a patient after truncal vagotomy surgery successfully treated by subsequent pneumatic dilations

Pseudoachalasia 是一个困难的条件让临床医生甚至由测压法，放射学的研究或内视镜检查法区分开来与自发的弛缓不能。它的病原学通常与肿瘤被联系。在大多数情况中，诊断在外科的探索以后被做。疾病的建议致病被看作远侧的食管的机械阻塞或在盒子的多数影响 meyenteric 丛的禁止的神经原的恶意的渗入。外科作为 pseudoachalasia 的一个原因被报导了。我们报导受不了 pseudo-achalasia 在树干的迷走神经切断术以后引起的 deglutination 混乱的一个 70 岁的人。病人在九年的后续和从在灵魂膨胀以后的 pseudoachalasia 的食道的活动性地位的完全的恢复以后是没有症状的。我们也考察了 pseudoachalasia 的文学。

Expression and prognostic role of molecular markers in 99 KIT-positive gastric stromal tumors in Taiwan Residents

瞄准：为了阐明，象肿瘤那样的三个分子的标记的预示的角色和关系压制，增殖或基因 p53 房间原子抗原(PCNA ) 和在胃的基质肿瘤的 Ki-67。方法：108 的一个总数通过手术 resected 胃的平滑肌肿瘤标本从 1987 年 1 月被收集到 1999 年 12 月。Immunohistochemical 研究与 p53， PCNA，和 Ki-67 的抗体在 108 个 CD117 积极的肿瘤中的 99 个的石蜡节上被执行。三个分子的标记的 Immunoreactivity 被把索引标记记录(李， %) 并且为临床病理和幸存关联被分析。结果：99 个盒子，染色的免疫表明 52 个病人(52.5%) 有 p53，并且 37 个病人(37.3%) 有 Ki-67 免疫反应(定义为李的 】10%) 。所有病人(100%) 有 PCNA 免疫反应从 12% ～ 93% 李，划分了成由高或低中部。统计表明三个标记的李断然相关到对方(P【0.01 ) 并且到显微镜的肿瘤有丝分裂的计数(P【0.001 ) 。由联合，有 】=2 标记的病人(积极或高) 在肿瘤有早肿瘤复发(P【0.001 ) 和相反的结果(P【0.001 ) 。Univariate 分析显示有肿瘤尺寸 】5 厘米(P=0.003 ) 的病人，肿瘤有丝分裂 】5/50 HPF (P【0.001 ) ， p53 免疫反应(P=0.001 ) ， Ki-67 免疫反应(P=0.026 ) ，高级李普克纳(P=0.015 ) 和男性(P=0.036 ) 是为早疾病复发的六个预言者。随后多，变量分析表明有丝分裂的计数，肿瘤尺寸，和 p53 免疫反应是为免费的疾病和外套的三个独立预示的因素病人的幸存。由为组织的三个独立预示的因素的联合，我们发现更高的肿瘤再发率(P【0.001 ) 和更短的幸存(P【0.001 ) 与增加因素在组存在。结论：我们首先在大意提供三个分子的标记的预示的价值和连接。三个因素(p53，肿瘤尺寸，和肿瘤有丝分裂) 的联合比任何单个因素提供预后的更强大的预言。

Trousseau's syndrome in a patient with advanced stage gastric cancer

Patients with cancer are at high risk for thrombotic events,which are known collectively as Trousseau's syndrome. Herein,we report a 66-year-old male patient who was diagnosed with terminal stage gastric cancer and liver metastasis and who had an initial clinical presentation of upper gastrointestinal bleeding. Acute ischemia of the left lower leg that resulted in gangrenous changes occurred during admission. Subsequent angiography of the left lower limb was then performed. This procedure revealed arterial thrombosis of the left common iliac artery with extension to the external iliac artery,the left common iliac artery,the posterior tibial artery,and the peroneal artery,which were occluded by thrombi. Aspiration of the thrombi demonstrated that these were not tumor thrombi. The interesting aspect of our case was that the disease it presented as arterial thrombotic events,which may correlate with gastric adenocarcinoma. In summary,we suggested that the unexplained thrombotic events might be one of the initial presentations of occult malignancy and that thromboprophylaxis should always be considered.