Kaohsiung Journal of Medical Sciences

Management of Acute Esophageal Variceal Hemorrhage

Gin-Ho Lo — 2010-02-01

Acute esophageal variceal hemorrhage (AEVH) is a severe complication of portal hypertension. Its management has rapidly evolved in recent years. Traditional methods included vasoconstrictor and balloon tamponade. Vasoconstrictors were shown to control approximately 80% of the bleeding episodes and are generally used as a first-line therapy. Following the use of vasoconstrictors, endoscopic therapy is often used to arrest the bleeding varices and prevent early rebleeding. A meta-analysis showed that the combination of vasoconstrictor and endoscopic therapy is superior to endoscopic therapy alone for controlling AEVH. Balloon tamponade may be used to achieve temporary control of the hemorrhage in case of severe bleeding. A transjugular intrahepatic portosystemic stent shunt may be needed in patients with refractory acute variceal hemorrhage. Surgical intervention is now widely contraindicated during acute variceal hemorrhage, except for patients with good liver reserve. Conversely, apart from the control of acute variceal hemorrhage, prophylactic antibiotics were shown to be helpful in the prevention of bacterial infection and to prevent early variceal rebleeding. With the introduction of new treatment modalities and the measures taken to manage patients with AEVH, the mortality due to AEVH has significantly decreased in recent years.

Toona Sinensis Extracts Induced Cell Cycle Arrest and Apoptosis in the Human Lung Large Cell Carcinoma

2010-02-01

Toona sinensis extracts have been shown to exhibit anti-cancer effects in human ovarian cancer cell lines, human promyelocytic leukemia cells and human lung adenocarcinoma. Its safety has also been confirmed in animal studies. However, its anti-cancer properties in human lung large cell carcinoma have not been studied. Here, we used a powder obtained by freeze-drying the super-natant of centrifuged crude extract from Toona sinensis leaves (TSL-1) to treat the human lung carcinoma cell line H661. Cell viability was evaluated by the 3-(4-,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide assay. Flow cytometry analysis revealed that TSL-1 blocked H661 cell cycle progression. Western blot analysis showed decreased expression of cell cycle proteins that promote cell cycle progression, including cyclin-dependent kinase 4 and cyclin D1, and increased the expression of proteins that inhibit cell cycle progression, including p27. Furthermore, flow cytometry analysis showed that TSL-1 induced H661 cell apoptosis. Western blot analysis showed that TSL-1 reduced the expression of the anti-apoptotic protein B-cell lymphoma 2, and degraded the DNA repair protein, poly(ADP-ribose) polymerase. TSL-1 shows potential as a novel therapeutic agent or for use as an adjuvant for treating human lung large cell carcinoma.

Influence of Proton Pump Inhibitor Use in Gastrointestinal Polyps

2010-02-01

Proton pump inhibitors (PPIs) are the most potent anti-acid agents and are extensively used worldwide. PPI-induced hypergastrinemia is one of the very few side effects associated with these drugs. However, because hypergastrinemia is related to the occurrence of colonic adenomatous polyps, the purpose of this study was to analyze the relationship between the occurrence of gastrointestinal polyps and hypergastrinemia induced by PPIs. This study included 259 patients who underwent colonoscopy and esophagogastroduodenoscopy between January and August 2007. Chart records, including medication history and fasting plasma gastrin level, were reviewed and analyzed. Any subtle polypoid lesions in the stomach and colon were sampled by biopsy for histological examination. Helicobacter pylori infection status was examined by a rapid urea test during esophagogastroduodenoscopy. All patients underwent endoscopy examinations. A total of 122 patients were receiving PPI treatment for either peptic ulcer disease or reflux esophagitis and were included as the study group. The remaining 137 patients were not treated with PPIs and served as the non-PPI group. The mean fasting gastrin level in PPI users versus non-PPI users was 121.8 ng/L versus 56.8 ng/L, respectively (p < 0.001). Although the prevalence of gastric gland polyps was higher in the PPI group (65.6% vs. 37.2%, p < 0.001), there was no difference in the prevalence of colonic adenomatous polyps observed (22.13% vs. 22.62%, p = 0.928). In conclusion, the prevalence of gastric polyps, particularly fundic gland polyps, was higher among PPI users. However, the prevalence of colonic polyps was not affected by PPI use, regardless of past history of colonic adenomatous polyps.

Spontaneous Pneumomediastinum in Adolescents and Children

I-Chen Chen, Chien-Ming Tseng, Jong-Hau Hsu, Jiunn-Ren Wu, Zen-Kong Dai — 2010-02-01

Pneumomediastinum, the leakage of air or gas into the mediastinum, can be a primary or secondary diagnosis. Although spontaneous pneumomediastinum (SPM) is uncommon in pediatric respiratory disorders, it is potentially life-threatening. In this study, we investigated the associations between various etiologies and clinical presentations, hospital length-of-stay, and clinical outcomes of SPM. From January 2004 to December 2007, we collected medical records and chest films from 23 pediatric patients with SPM. Results showed that increased hospital length-of-stay was significantly associated with asthma (p = 0.035), dyspnea/tachypnea (p = 0.01), and emergent visit (p = 0.04). Dysphagia was associated with shorter hospital stay (p = 0.058). Besides, the disorder was misdiagnosed initially in 21% of patients. In conclusion, there may be close relationships between the predisposing factors of SPM and its clinical manifestations. The high rate of misdiagnosis highlights the importance of careful examination and history taking in pediatric patients with chest pain.

Nephrotic Syndrome Complicated by Life-Threatening Pulmonary Embolism in an Adult Patient

Szu-Chia Chen, Wan-Chun Liu, Cheng-Hsueh Lee, Jer-Ming Chang, Hung-Chun Chen — 2010-02-01

We report a 23-year-old male presenting with edema. He was originally admitted for an elective renal biopsy for diagnosis of renal pathology. Unfortunately, because of acute abdominal pain an exploratory laparotomy was done. Progressive azotemia and oliguria then developed, and he required temporary hemodialysis. However, he suffered from sudden-onset severe respiratory distress, and blood gas analysis showed profound hypoxemia with a marked arterial–alveolar oxygen difference. Assessment of a pulmonary embolism by radioisotope imaging was not possible because of his dependence on mechanical ventilation. Subcutaneous low molecular weight heparin and intravenous methylprednisolone were given to treat the presumed pulmonary embolism and the underlying nephrotic syndrome. His partial oxygen level gradually increased after continuous heparin and steroid administration. Complete obliteration of one major pulmonary artery and partial obliteration of other smaller arteries were revealed by magnetic resonance angiography. He was discharged and followed-up as an outpatient, and was given oral warfarin and prednisolone. Follow-up magnetic resonance angiography 5 months later showed a normal pulmonary tree with no residual lesions.

Female Urethral Malignant Melanoma With Vesical Invasion: A Case Report

2010-02-01

We report a 75-year-old female with a primary urethral malignant melanoma. A mass protruding from inside the urethra was detected on physical examination. Abdominopelvic magnetic resonance imaging revealed a mass extending from the urethra with dimensions of 4 × 2 cm, and periurethral heterogenous fatty planes consistent with infiltration. The histopathologic examination was consistent with HMB45(+) malignant melanoma. We performed cystourethrectomy and bilateral inguinal and pelvic lymphadenectomy in one session. The pathology report revealed primary malignant melanoma of the urethra invading the inferior bladder wall. The patient received no adjuvant therapy because of cardiopulmonary morbidities and the presence of multiple pulmonary metastases. The patient eventually died 13 months after surgery.

Tuberculous Liver Abscess in a Case Without Lung Involvement

Shou-Wu Lee, Han-Chung Lien, Chi-Sen Chang — 2010-02-01

Hepatic tuberculosis is an uncommon form of extrapulmonary tuberculosis, particularly when it presents in the form of liver abscess. Here, we report a 64-year-old man who was admitted to our hospital having experienced intermittent chills for 3 months. Aspiration of the liver abscess revealed neither bacteria nor acid-fast bacilli, but pus and granulation tissue were found. Antituberculous therapy was started empirically and cultures of the abscess confirmed the presence of Mycobacterium tuberculosis 3 weeks later. We suggest that tuberculous liver abscess should be considered in patients not showing typical features or who fail to respond to antibiotics.

Successful Conservative Treatment of Pneumatosis Intestinalis and Portomesenteric Venous Gas in A Patient With Septic Shock

Chen-Te Chou, Wei-Wen Su, Ran-Chou Chen — 2010-02-01

Pneumatosis intestinalis (PI) and portomesenteric venous gas (PMVG) are alarming radiological findings that signify bowel ischemia. The management of PI and PMVG remain a challenging task because clinicians must balance the potential morbidity associated with unnecessary surgery with inevitable mortality if the necrotic bowel is not resected. The combination of PI, portal venous gas, and acidosis typically indicates bowel ischemia and, inevitably, necrosis. We report a patient with PI and PMVG caused by septic shock who completely recovered after conservative treatment.