The liability crisis.
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Health Care Reform↗
Biomedical subjects
Pinit Kullavanijaya
Publications and source records attributed to Pinit Kullavanijaya.
Ethics in the education system.
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Education↗
Pattern of drug resistant Helicobacter pylori in dyspeptic patients in Thailand.
Emergence of drug resistant Helicobacter pylori (H. pylori) has occurred in various countries and could compromise the efficacy of current treatment regimens. The aim of the study was to identify the pattern of antibiotic resistant H. pylori in Thailand and evaluate various factors associated with drug resistance. Between June 2001 and December 2002, a total of 560 dyspeptic patients who underwent upper gastrointestinal endoscopy at King Chulalongkorn Memorial Hospital were included in this study. Antral gastric biopsies were obtained for H. pylori cultures and susceptibility tests using Epsilometer test (E-test). The value of antibiotic resistant breakpoints were amoxicillin 0.5 microg/ml, clarithromycin 1.0 microg/ml, metronidazole 8 microg/ml, and tetracycline 4 microg/ml, respectively. H. pylori were detected in 315 patients using the rapid urease test (56.25%). Cultures for H. pylori were positive in 172 patients. E-test for all four antibiotics was successfully placed in 79 isolations. The prevalence of antibiotic resistant H. pylori were amoxicillin 13.9 per cent (11/79), clarithromycin 19.0 per cent (15/79), metronidazole 30.4 per cent (24/79), tetracycline 5.1 per cent (4/79), and multi-drugs 16.5 per cent (13/79), respectively. However, age, sex, or endoscopic findings did not differ between the patients with H. pylori resistant strains and sensitive strains. The emergence of antibiotic and multi-drug resistant H. pylori in Thailand were relatively high and these could compromise the efficacy of current treatment regimens. The factors associated with drug resistant H. pylori could not be demonstrated in the present study. Further study in a larger number of patients might be necessary to identify factors associated with resistant H. pylori.
Adult↗
Result of orthotopic liver transplantation at King Chulalongkorn Memorial Hospital: the first series from Thailand.
Liver transplantation is one of the best treatments for advanced liver disease since it can prolong the patient's survival. In Thailand, the first liver transplantation was performed in 1987 at King Chulalongkorn Memorial Hospital. Up till now the authors have transplanted the most in Thailand, having done more than 30 cases. From 1997 to 2002, there were 20 cases of liver transplantation and this is the result presented. The authors classified the patients into 2 groups, according to primary indications for transplantation. Patients with cirrhosis were included in group I and patients with hepatocellular carcinoma were included in group II. The one year survival in group I and II was 64 per cent and 29 per cent respectively. Mortality rate in the cirrhotic group was high during the first 3 months post transplant. The reason for a high mortality rate in the hepatocellular carcinoma group may be secondary to the advanced stage of cancer and the poor condition of the patients. However, the acute rejection rate in the present series of 25 per cent is relatively low compared to other series and this may need further study. The one year survival rate in patients who received a new liver from 1997 to 1999 compared to 2000-2002 was 33 per cent and 54 per cent respectively. This showed an improvement in the result of liver transplantation in Thailand. In conclusion, this report showed a satisfactory result of liver transplantation. The main problem with liver transplantation in Thailand is that potential donors do not understand the problems which leads to few donors. There is also a shortage of skilled personnel, budget, and the appropriate instruments.
Adolescent↗
Clinical indications of patients with colorectal neoplasm who underwent colonoscopy at King Chulalongkorn Memorial Hospital (presentations of colorectal neoplasm from colonoscopy database).
Even though colorectal cancer in Thailand is not the number one leading cause of death, the incidence of this malignancy is not ignorable. Unfortunately, the majority of patients are diagnosed at a very late stage because of no screening protocol for a high risk group. The authors retrospectively reviewed clinical presentations of patients with colorectal neoplasm who underwent colonoscopy at King Chulalongkorn Memorial Hospital during the two-year period from September 2000 to December 2002. There were 107 patients with colorectal polyps and 48 patients with colorectal cancer. According to frequency of indications: anemia, bowel habit change, and abnormal radiography were presented in patients with colorectal polyps and cancers. There were more right sided colorectal polyps than rectosigmoid polyps. In addition, rectosigmoid cancer was detected less often than right sided colonic cancer. Half of the patients with rectosigmoid cancer presented with hematochezia compared to right sided colonic cancer. Total colonic examination is required if a colonic neoplasm is suspected.
Adult↗
Results of emergency gastroscopy for acute upper gastrointestinal bleeding outside official hours at King Chulalongkorn Memorial Hospital.
This study was to evaluate the epidemiological characteristics, etiology and therapeutic outcome of active upper gastrointestinal bleeding in patients who underwent emergency gastroscopy outside official hours at the Gastroenterology Unit, King Chulalongkorn Memorial Hospital. From January to December 2002, 103 emergency gastroscopies were performed in 99 patients. There were 66 men and 33 women (mean age 55.4 years, range 22-98 years). Causes of bleeding were esophageal varices (29/99; 29.3%), gastric ulcer (25/99; 25.3%), duodenal ulcer (9/99; 9.1%), gastric varices (9/99; 9.1%) and miscellaneous (12/99; 12.1%). Etiology of bleeding was uncertain in 10.1 per cent of the cases. Therapeutic modalities for variceal bleeding were banding (78.6%), sclerotherapy (10.7%) and glue injection (10.7%). Endoscopic therapies for patients with non variceal bleeding were: epinephrine injection with bipolar coaptation (48.1%), epinephrine injection only (11.1%), bipolar coaptation alone (7.4%), heater probe (7.4%), epinephrine injection combined with heater probe (11.1%), epinephrine injection with bipolar coaptation and hemoclipping (7.4%), hemoclipping (3.7%), epinephrine injection with hemoclipping (3.7%). Initial hemostasis was achieved in 91.2 per cent of the patients (91/99). Recurrent bleeding within 72 hours developed in 9.1 per cent of patients (9/99). Of these, eight patients (88.9%) underwent re-endoscopy and bleeding was stopped in 62.5 per cent (5/8). And 2.0 per cent of patients (2/99) had to go for emergency surgery after failed therapeutic endoscopy. Overall mortality was 15.2 per cent (15/99). In conclusion, emergency gastroscopy can offer not only diagnostic but also therapeutic modality for patients with acute upper gastrointestinal bleeding. Endoscopic therapy is effective for both initial hemostasis and recurrent bleeding.
Adult↗
Ethics and policy.
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Clinical Competence↗
Spontaneous bacterial peritonitis caused by Streptococcus bovis: case series and review of the literature.
Streptococcus bovis is the rare cause of spontaneous bacterial peritonitis in decompensated cirrhosis. S. bovis bacteremia has long been known to be associated with colon cancer. We describe seven patients and review the seven previous reports of spontaneous bacterial peritonitis patients with S. bovis infection. Most of the patients had cirrhosis and presented with fever, abdominal pain, abdominal distention, and jaundice. Colonic adenomatous polyps with dysplastic change were found in 18.2% of the patients. The approach to this group of patients requires diagnostic paracentesis, blood cultures, ascitic fluid culture, and treatment with antimicrobial agents. Intravenous penicillin is still the antimicrobial agent of first choice (mean minimum inhibitory concentration for penicillin = 0.05 microg/ml). S. bovis is an infrequent cause of spontaneous bacterial peritonitis. The physician could make a case that colonoscopy is not needed because the patient is very sick and the possibility of GI pathology, especially colonic lesions, has been low. However, it may be that colonoscopy should be done if there are clinical suggestions to do so or the patient is well enough to withstand surgery.
Aged↗
Diagnosis method of Helicobacter pylori infection in bleeding peptic ulcer.
Peptic ulcer lesions are the most frequent cause of upper gastrointestinal bleeding and are responsible for more than 50 per cent of cases. Several etiologic factors of peptic ulcer are known, the principle one being Helicobacter pylori (H. pylori). Recent studies indicate that H. pylori eradication is associated with the marked reduction in rebleeding rate. In peptic ulcer bleeding which requires surgical intervention, knowledge H. pylori status may help to determine the choice of procedure (simple sewing in H. pylori positive patients vs full-blown ulcer surgery in H. pylori negative patients). We suggest to use the invasive combination of histology and biopsy-rapid urease test in stable bleeding peptic ulcer patients without coagulopathy for H. pylori diagnosis. Cases with positive result do not need further investigation for H. pylori diagnosis. If negative, the serology test was suggested to confirm the absence of H. pylori. However, in unstable patients, the serology test seem to effectively detect H. pylori infection.
Biopsy, Needle↗
Evaluation of inhouse rapid urease test for detection of Helicobacter pylori from gastric biopsy specimens.
Inhouse rapid urease test for detecting Helicobacter pylori was evaluated. Biopsy specimens were taken for inhouse urease test, commercial rapid urease CLO test, culture, gram stain and histology from the antrium or duodenum of patients who had peptic ulcer. The culture and/or histologic examination and CLO test were used as the gold standard. One hundred and twelve specimens were evaluated. The sensitivity and specificity of the inhouse urease test was 100 per cent and 90 per cent respectively. The inhouse urease test was suitable for detecting Helicobacter pylori from gastric antral biopsy specimens. The medium can be kept in a refrigerator for up to 6 months.
Biopsy, Needle↗
Detection of antibody in serum and secretion for the diagnosis of Helicobacter pylori infection.
Helicobacter pylori plays a major role in chronic gastritis and peptic ulcer. In addition, it has been shown to be associated with gastric carcinoma. In this study, the authors compared the detection of IgG antibodies specific to H. pylori by enzyme-immunoassay with culture, histology and a CLO test as tools for diagnosis of H. pylori infection. If the criteria that patients will be considered as H. pylori infected only when their samples are positive by culture or CLO test and histology were used, the sensitivity and specificity of detecting IgG in sera were 96.84 and 72.04 per cent respectively. The use of serological test will be useful as a screening test for H. pylori infection without the need of endoscopy. The authors also performed the assay for detecting IgA antibodies in saliva and gastric juice. The sensitivity and specificity of IgA detection in saliva were 26.79 per oent and 75.00 per cent. As for the assay in gastric juice, although the specificity was as high as 91.67 per cent, the sensitivity is very low (22.22%).
Adolescent↗
Feasibility and complications of endoscopic biliary drainage in patients with malignant biliary obstruction at King Chulalongkorn Memorial Hospital.
Currently the best curative therapy for primary malignant biliary tumor is surgery. Unfortunately, many patients present at a very late stage and only palliative biliary drainage is possible. Usually nonsurgical palliative biliary drainage means either percutaneous or endoscopic approach. In this series, the authors reported the rate of technical success and immediate complications in patients with malignant biliary obstruction who underwent endoscopic biliary drainage. From endoscopic retrograde cholangiopancreatography (ERCP) database between September 2000 and October 2001, there were 273 ERCP performed for obstructive jaundice. Of these, 50 patients with malignant tumor underwent 80 procedures for endoscopic biliary drainage. The patients were divided into three groups according to the cholangiographic findings and clinical diagnoses. Patients with carcinoma of the pancreatic head were categorized as group I (n=10). Group II (n=20) and III (n=20) were patients with extrahepatic cholangiocarcinoma and hilar cholangiocarcinoma respectively. All patients received either plastic or metallic endoprothesis placement for biliary drainage. All patients except two in group I had successful endoscopic treatment. Complications in group I, II and III were 15.4 per cent, 14.3 per cent and 53.1 per cent respectively. Only one patient in group II developed significant hypotension during the procedure. Another complication was defined as post procedure cholangitis. In conclusion endoscopic biliary drainage was technically feasible in 97.5 per cent of patients who had malignant biliary obstruction. In patients with hilar tumor the incidence of post procedure cholangitis was high (53.1%). Improvement in technique, avoiding unnecessary contrast injection, and draining the obstructed bile duct after injecting the contrast may improve the outcome and decrease the rate of post procedure cholangitis in these patients.
Aged↗
The effect of blood on rapid urease test for Helicobacter pylori detection: an in vitro study.
The sensitivity of rapid urease test (RUT) for detecting Helicobacter pylori (H. pylori) is limited in patients presented with bleeding peptic ulcers. Blood contents are potentially responsible for the lack of sensitivity of RUT in patients with upper gastrointestinal bleeding. This study was designed to determine the efficacy of RUT in detecting H. pylori when exposed to the patients' own blood at varying durations. Four gastric antral biopsy specimens were collected from dyspeptic patients who underwent gastroscopic examination. The first specimen was immediately placed into the urea broth as the control group. The second, third and fourth specimens were immersed in the patients' own blood for one, two and four hours respectively before testing for the RUT. The results of these RUT were compared to those of the control group. Gastric antral biopsy specimens tested with the RUT of twenty patients were evaluated in this study. The 1-hour RUT and 2-hour RUT was not significantly different in sensitivity (92.31% vs 100%: p>0.05, 84.62% vs 100%: p>0.05 respectively) and accuracy (95.0% vs 100%: p>0.05, 90.0% vs 100%: p>0.05 respectively) compared to the unexposed blood RUT for H. pylori diagnosis. However, the study demonstrated that the 4-hour RUT had significantly lower sensitivity (53.85% vs 100%: p<0.05) and accuracy (70.00% vs 100%: p<0.05) than that of the unexposed blood RUT for H. pylori diagnosis. It is concluded that exposure of gastric biopsy specimens to their own blood for four hours significantly decreased the sensitivity of the biopsy rapid urease test for H. pylori detection.
Biopsy, Needle↗
Gastric juice urease test and brushing urease test for Helicobacter pylori detection.
The aim of the study was to demonstrate the sensitivity, specificity and accuracy of gastric juice urease test and brushing-urease test compared to the biopsy-urease test for Helicobacter pylori (H. pylori) detection. For each patient, two milliliters of gastric juice was collected and one milliliter in the supernatant was tested for rapid urease reactions. One gastric mucus brushing and two biopsies were taken from the body and the antrum. The brushing specimens were tested for rapid urease reaction by shaking the brush into the urea broth. The gold standards for diagnosing of H. pylori are positive H. pylori upon specimen culture or positive identification of H. pylori from polymerase chain reaction (PCR) assay using primer for vac A gene. Forty patients were enrolled in the study including ten patients with gastric ulcer, six patients with duodenal ulcer and twenty four patients with non-ulcer dyspepsia. Brushing-urease test and biopsy-urease test were not different sensitivity (87.50% vs 93.20%), specificity (100% vs 100%) and accuracy (90.25% vs 95.50%). The gastric juice urease test had a sensitivity of 65.25 per cent, specificity of 100 per cent and accuracy of 75 per cent for detecting of H. pylori infection. In conclusion, gastric juice urease test had low sensitivity in the diagnosis of H. pylori infection. Brushing-urease test is as accurate as biopsy-urease test in detecting H. pylori infection. However, the brushing method had lower gastric tissue injury than the biopsy and so should be used for detecting H. pylori infection in patients with coagulopathy.
Adult↗
Inhibitory effect of Lactobacillus acidophilus on Helicobacter pylori in peptic ulcer patients: in vitro study.
Lactobacillus acidophilus (L. acidophilus) have been introduced into many fermented dairy products. The presence of L. acidophilus appears to decrease Helicobacter pylori (H. pylori) density in the human stomach and could enhance antibiotic therapy for H. pylori eradication. This study was designed to determine the optimal density of L. acidophilus that has a maximum inhibitory effect on H. pylori in peptic ulcer patients. To determine whether L. acidophilus has an inhibitory effect on H. pylori isolated from peptic ulcer patients and to determine whether the optimal density of L. acidophilus has a maximum inhibitory effect on H. pylori isolated from peptic ulcer patients. H. pylori was isolated from gastric biopsy specimens of peptic ulcer patients. The suspension of pure H. pylori colonies were inoculated into the broth and adjusted to match the density of No.3 MacFarland standard (approximately 9x10(8) cells/ml). Forty microliters of the suspension were equally spread onto each quadrant of the plate and left to dry. L. acidophilus was prepared from LC-1 (Nestle Research Center, Switzerland). They were grown on blood agar and incubated overnight at 37 degrees C. The suspension of L. acidophilus was inoculated into the broth and adjusted to match the density of No.1, No.2, No.3 and No.4 MacFarland standard (approximately 3x10(8), 6x10(8), 9x10(8) and 12x10(8) cells/ml respectively). Ten microliters of each density of L. acidophilus was dropped onto each quadrant of a previously inoculated H. pylori plate and then the plate was kept under microaerophilic conditions for 72 hours. Inhibition clear halo zone of H. pylori around the colonies of L. acidophilus was interpreted as the inhibitory effect. H. pylori were isolated from gastric biopsy specimens of fifteen peptic ulcer patients (eleven patients with gastric ulcer and four patients with duodenal ulcer). A total of sixty tests of inhibitory effect of L. acidophilus on H. pylori were evaluated in the present study. L. acidophilus had inhibitory effect on H. pylori in 13/15 patients (86.67%) and L. acidophilus in the density of No.3 MacFarland standard had a significantly higher inhibitory effect on H. pylori in the density of No.3 MacFarland than that of No.1 (60% vs 20%; p<0.05), No.2 (60% vs 20%; p<0.05) and No.4 (60% vs 20%; p<0.05) MacFarland standard. In conclusion, L. acidophilus has an inhibitory effect on H. pylori isolated from peptic ulcer patients. Approximately an equal density of L. acidophilus on H. pylori has the most favorable effect. This optimal density of L. acidophilus should have maximum effect on H. pylori clearance and could enhance antibiotic therapy for H. pylori eradication in humans.
Adult↗
A retrospective study of colorectal cancer patients in King Chulalongkorn Memorial Hospital.
To determine the basic clinical information of colorectal cancer in Thailand, the authors retrospectively reviewed the medical records and pathological reports of 293 patients with histologically proven colonic cancer but only 137 patients met the inclusion criteria in King Chulalongkorn Memorial Hospital during the three-year period from July 1997 to June 2000. There were 72 males (53%) and 65 females (47%) with an age ranging from 24 to 90 years (mean age 61.2 years). Among these, 115 patients (83.9%) were older than 50 years. Bowel-habit change, weight loss and mucous bloody diarrhea were the most common presentations respectively. Distal colorectal cancer is the most common site of colonic cancer (71.3%) and 28.7 per cent were at the proximal colon. Dukes' D (35%) was the most common colorectal cancer staging in the hospital. Considering the sites of metastases, liver was the most common site of metastases (61%). The most common cell type was moderately-differentiated adenocarcinoma. Low anterior resection was the most common surgical procedure (24.9%) since the tumor was usually located distally. In conclusion, 1) bowel habit change was the most common presentation for colorectal cancer at the hospital and the majority of patients were elderly. 2) Colorectal cancer was usually found at the late stage which was associated with poor prognosis.
Adult↗
Duodenal Helicobacter pylori associated duodenal ulcer depend on gastric Helicobacter pylori status.
Gastric Helicobacter pylori (H. pylon) plays an important role in the pathogenesis of duodenal ulcer (DU), although not all H. pylori infected persons will develop disease. Duodenal H. pylori was supposed to be one of the factors related with DU. The aim of this study was to investigate whether H. pylori in the duodenum of patients with DU plays a critical role in the pathogenesis of DU regarding the gastric H. pylori status. Furthermore, it was to determine the prevalence of duodenal H. pylori infection in Thailand. Ninety three patients were included in the study. They underwent gastroscopic evaluation for dyspeptic symptoms and none of them had previous H. pylori eradication therapy. An upper gastrointestinal endoscopy was performed and two specimens were collected each form the antrum, midcorpus and duodenal bulb in order to diagnose H. pylori infection. The gold standard for H. pylori detection is a positive specimen culture or polymerase chain reaction (PCR) assay for the vac A gene or positive urease test plus H. pylori seen in the pathology. Ninety three dyspeptic patients (43 males and 50 females; mean age 48.2 years; range 22 to 79 years) were included in the study. Duodenal H. pylori was detected in 31/93 (33.33%) patients which included 15 (48.38%) patients with duodenal ulcer, 2 (6.45%) patients with gastric ulcer and 14 (45.16%) patients with NUD. Five of thirty one (16.21%) patients with duodenal H. pylori infection had negative gastric H. pylori. These five patients included 1 with DU, 1 with DU and 3 with NUD. Duodenal H. pylori was associated with DU dependent of the presence of gastric H. pylori (p<0.05) and there was no association between duodenal H. pylori with negative gastric H. pylori and duodenal ulcer (p>0.05). Duodenal H. pylori is associated with duodenal ulcer dependent on the presence of gastric H. pylori. These results suggest that transmission of gastric H. pylori to the duodenum was prerequisited for the formation of DU.
Adult↗