2015 Vol. 6, No. 2

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2015, 6(2): 81-82. doi: 10.3969/j.issn.1674-9081.2015.02.001
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2015, 6(2): 140-145. doi: 10.3969/j.issn.1674-9081.2015.02.013
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2015, 6(2): 146-149. doi: 10.3969/j.issn.1674-9081.2015.02.014
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2015, 6(2): 150-155. doi: 10.3969/j.issn.1674-9081.2015.02.015
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2015, 6(2): 156-157. doi: 10.3969/j.issn.1674-9081.2015.02.016
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2015, 6(2): 158-160. doi: 10.3969/j.issn.1674-9081.2015.02.017
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Original Contributions
Abstract:
  Objective  To evaluate the role of miniprobe endoscopic ultrasonography (EUS) in assessing the depth of tumor invasion in early gastric cancer and to analyze the factors affecting the accuracy of EUS.  Methods  This retrospective study included 59 cases of pathologically confirmed early gastric cancer diagnosed and hospitalized in Peking Union Medical College Hospital in the period of March 2010 to December 2012. They all received miniprobe EUS for predicting the depth of invasion before endoscopic or surgical resection. We assessed the diagnostic sensitivity, specificity and accuracy of EUS by comparing the pre-treatment EUS results with the postoperative histopathological findings. The endoscopic features and pathological factors possibly influencing the accuracy of EUS were also analyzed.  Results  The overall diagnostic sensitivity, specificity and accuracy of EUS in assessing the depth of early gastric cancer invasion were 79.7%, 81.4% and 79.7%, respectively. The sensitivity, specificity and accuracy for mucosal layer lesion were 66.1%, 80.0% and 79.7%, respectively; and the sensitivity, specificity and accuracy for submucosal lesion were 80.0%, 81.6% and 81.4%, respectively, showing no significant diference(P > 0.05). The overgrading rate of EUS was 16.9%, and the overgrading mainly happened in leisons located in upper third (20.0%) and middle third (27.3%) of the stomach, with a superficial appearance of elevated type (0-Ⅰ:25.0%, 0-Ⅱa:38.5%) or with ulcers (33.3%). The above mentioned lesions were also associated with a relatively lower diagnostic accuracy of EUS. The undergrading rate of EUS was 3.4%.  Conclusions  Miniprobe EUS has a fairly high diagnostic accuracy in assessing the depth of gastric cancer invasion, which helps the planning of treatment strategy. The location, macroscopic type of lesions and coexisting ulcer would affect the dignostic accuracy of EUS.
Abstract:
  Objective  To investigate the demographic features, etiology and clinical characteristics of chronic pancreatitis (CP).  Methods  We retrospectively analyzed the records of 346 CP cases hospitalized in Peking Union Medical College Hospital during the period of January 1983 to December 2008, summarizing the demographic features, clinical manifestations, causes of disease, and complications of these patients.  Results  The 346 CP cases included 267 males and 79 females (M/F ratio=3.38:1). The mean age of onset was (44.34±15.88) years. Most of the patients were Han Chinese (94.80%, 328/346), and a large proportion were cadres (32.08%, 111/346). Both the number of CP cases and its proportion in the total number of inpatients in the hospital increased rapidly. Alcohol (40.17%) and cholelithiasis (41.04%) were the most common risk factors of CP. CP of different etiologies had all increased, especially alcoholic CP, growing by an mean annual rate of 108.7%. 84.39%(292/346) of the patients presented with abdominal pain, 56.07% (194/346) had weight loss, 24.86% (86/346)had jaundice (all obstructive). Diabetes (25.14%, 87/346) was the most common complication. The median time of CP onset to occurrence of diabetes and fatty diarrhea were 1.00 year and 280.03 months, respectively. Diabetes occurred earlier in patients with autoimmune pancreatitis than those with idiopathic pancreatitis (P=0.020).  Conclusions  The incidence of CP is growing rapidly in China, with alcoholic CP increasing faster than biliary CP. The most common symptoms of CP are abdominal pain and weight loss, while the most common complication is diabetes. A patient database and regular follow-up visits could contribute to better understanding of epidemiological patterns of CP and improvement of its diagnosis and treatment.
Abstract:
  Objective  To evaluate the anorectal function and its influencing factors in patients with mid and low rectal cancer.  Methods  Patients diagnosed with mid and low rectal cancer in Peking Union Medical College Hospital from September 2012 to November 2013 were consecutively enrolled in this study. We surveyed the defecation symptoms based on a questionnaire in the face-to-face interview manner and detected the anorectal functions using three-dimensional high-resolution manometry system. The patients were divided into mid and low groups according to the distance from the distal margin of tumor to the anal margin.  Results  A total of 66 patients were enrolled in this study, including 45 males and 21 females, with a mean age of (58.86±10.99) years. There were 44 patients in the mid group and 22 patients in the low group. Hematochezia was the most commonsymptom (95.5%), frequent bowel movement occurred in 50.0% patients, abnormal bowel forms, urgency, sensation of incomplete defecation, and tenesmus occurred in 30.3%-40.9% of the patients. The occurrences of hematochezia, frequent bowel movement and sensation of incomplete defecation were positively correlated with the depth of tumor infiltration (r=0.308, P=0.012; r=0.290, P=0.018; r=0.305, P=0.013). The rectoanal inhibitory reflex was preserved in all the patients. The volume of constant desire to defecate and the maximum tolerated volume were both lower than the normal references, and both negatively correlated with the depth of tumor infiltration (r=-0.333, P=0.007; r=-0.323, P=0.009). Compared with the mid group, the low group had a higher percentage of patients with difficulties to defecate (27.2% vs. 6.8%, P=0.031), and a significantly lower mean anal resting pressure[87.20(49.80)mmHg vs. 108.25(41.80)mmHg, P=0.017].  Conclusions  Mid and low rectal cancer patients manifest with various bowel symptoms with no specificity, except for hematochezia. Patients with mid and low rectal cancer have obviously impaired rectal sensory function. Their anorectal sensory and dynamic functions are influenced by the depth of tumor infiltration and distance from the distal margin of tumor to anal margin.
Abstract:
  Objective  To summarize the clinical features of IgG4-related sclerosing cholangitis (IgG4-SC).  Methods  Clinical data of 36 cases with IgG4-SC hospitalized in Peking Union Medical College Hospital in the period of January 2004 to December 2012 were retrospectively analyzed, including symptoms, laboratory tests, imaging results, pathological results and follow-up records. All the cases were diagnosed according to 2012 Japanese clinical diagnostic criteria of IgG4-SC.  Results  The sex ratio of the 36 IgG4-SC patients was 0.24:1. The mean age of onset was (62.8±9.2) years. The most common symptoms were jaundice (77.8%, 28/36) and abdominal pain (50.0%, 18/36). Serum bilirubin level was normal in 8 cases (22.2%), among whom serum gamma-glutamyl transpeptidase (GGT) level was also normal in 3 cases. Endoscopic ultrasound found bile duct wall thickening in 34 cases (94.4%), significantly more sensitive than abdominal ultrasound (8.3%, 3/36) and CT scan (33.3%, 12/36) (P < 0.05). Seven patients underwent brush cytology or biopsy of bile duct, and the pathological results were all negative. Relapses occurred in 39.1%(9/23) of the 23 cases who were followed up for over 2 years. The patients with more extrabiliary organs or more biliary segments involved were more prone to relapse.  Conclusions  IgG4-SC is primarily found in middle-aged and elderly men, with clinical manifestations of chronic cholangitis. However, some patients might have no signs of biliary obstruction. The sensitivity of biliary biopsy is poor. The radiological uniform bile duct wall thickening in non-stricture segments is highly suggestive of IgG4-SC. Endoscopic ultrasound should be used as a routine test in suspected cases. Close follow-up is necessary for IgG4-SC patients to detect relapse or concurrent malignancy.
Abstract:
  Objective  To evaluate the efficacy of hot water drinking, isosorbide dinitrate and combination of both in achalasia.  Methods  The patients with untreated achalasia admitted to Peking Union Medical College Hospital in the period of October 2012 to May 2013 were enrolled and randomly divided into group A (hot water drinking and combined therapy) and group B (isosorbide dinitrate and combined therapy). Patients in group A received hot water drinking only during the first week, then combined with isosorbide dinitrate from the second to the fourth week. Patients in group B received isosorbide dinitrate only during the first week, then combined with hot water drinking from the second to the fourth week. Clinical symptoms were evaluated at baseline(2 weeks before treatment) as well as after 1-week and 4-week treatment. High-resolution manometry and X-ray barium esophagram were evaluated at both baseline and after 4-week treatment.  Results  A total of 41 patients were included in this study, 19 in group A and 22 in group B. There was no significant difference in gender, age and course of disease between the two groups (P>0.05). Compared with baseline, symptoms were significantly alleviated after 1-week treatment and after 4-week treatment in group A (P < 0.05), and symptoms were significantly mitigated after 4-week treatment than after 1-week treatment (P < 0.05). Compared with baseline, symptoms were significantly alleviated after 4-week treatment in group B (P < 0.05). There was no difference in scales of symptoms between the two groups (P > 0.05). Compared with baseline, there was no significant reduction in lower esophageal sphincter pressure (LESP) and integrated relaxation pressure (IRP) after 4-week treatment in both groups (P > 0.05). However, at both baseline and after 4-week treatment, LESP and IRP were significantly decreased after hot water drinking or sublingual isosorbide dinitrate compared with pre-intervention levels in both groups (P < 0.05). There was no change in the width of the esophagus after 4-week treatment in both groups(P > 0.05).  Conclusions  Hot water drinking or sublingual isosorbide dinitrate could alleviate clinical symptoms by temporarily decreasing LESP and IPR, which could be amplified by the combination of these two treatments, but the effect is not sustained. Hot water drinking combined with sublingual isosorbide dinitrate provides an option of conservative therapy for those intolerant to or relapsing after invasive treatment.
Abstract:
  Objective  To investigate the clinical and genetic characteristics of acute intermittent porphy-ria (AIP).  Methods  Thirty-six patients diagnosed with AIP and hospitalized in Peking Union Medical College Hospital from December 2006 to October 2014 were enrolled in our study. We analyzed the clinical data of the 36 patients retrospectively, summarizing the clinical manifestations, laboratory test results, treatments and outcomes. Gene mutations of some patients were analyzed.  Results  Among the 36 AIP patients, 32 (88.9%) were females. The average age was (27.2±6.3) years. Most of the patients visited Gastroenterology Department and Emergency Department. At presentation, 35 patients (97.2%) had abdominal pain varying in severity, 30 (83.3%) manifested obvious neuropsychiatric symptoms and 13 (36.1%) complained of dark-colored urine. Positive urinary porphobilinogen (PBG) in onset was of diagnostic value. In addition, the number of patients having anemia, abnormal liver function, or hyponatremia was 28 (77.8%)each. Eight patients who received genetic testing were detected with mutation at different sites in the gene coding porphobilinogen deaminase (PBGD).  Conclusions  Most of the AIP patients in our study were females of childbearing age. The main manifestations are abdominal pain, neuropsychiatric symptoms, and dark-colored urine. Urine PBG test is helpful in diagnosis. Genetic detection of patients and their families is highly important for the diagnosis and family screening of this condition. Early recognition, intervention and family screening may improve the prognosis of AIP patients.
Abstract:
  Objective  To observe the efficacy and safety of tandospirone in treating patients with functional dyspepsia(FD) co-morbid with anxiety.  Methods  Thirty-one patients diagnosed with FD co-morbid with anxiety and failed to respond to routine therapy were recruited from the outpatient clinic of gastroenterology in Peking Union Medical College Hospital during the period of March 2012 to December 2013. The patients were treated with tandospirone citrate tablets 10 mg thrice a day for 4 weeks. FD symptom scores before treatment, after 2-week treatment and after 4-week treatment were compared. The Zung anxiety and depression self-rating scales (SAS and SDS), Hamilton anxiety and depression scales (HAMA and HAMD), quality of life questionnaire (SF-36), and liquid nutrient load test results after 4-week treatments were compared with those before treatment to evaluate the efficacy of tandospirone treatment. Adverse reactions were recorded.  Results  The total symptom scores 2 weeks and 4 weeks after treatment were 8.48±5.96 and 7.39±5.463, both significantly lower than that prior to treatment (10.45±5.66; P=0.002, 0.020). Compared with before treatment, the discomfort after meal and early satiety symptom scores decreased significantly after 2-week and 4-week treatment (all P < 0.05). The SAS, HAMA and HAMD scores declined significantly after 4-week treatment compared with pre-treatment score (P=0.028, 0.002, 0.000). SF-36 indicated significantly improved physiological function, body pain and total health condition after 4-week treatment (P=0.033, 0.022, 0.041). The threshold volume and satiety volume in liquid nutrient load test showed no significant change after treatment (P=0.285, 0.532). During treatment, there were adverse reactions in 5 patients (16.1%, e.g. rash and pruritus) and one case withdrew from the therapy.  Conclusion  Tandospirone is effective and safe in treating functional dyspepsia patients with anxiety, offering an option when routine therapy fails.
Abstract:
  Objective  To explore the clinical features and key points in diagnosis of pancreatic tuberculosis.  Methods  The clinical manifestations, auxiliary tests, and diagnosis of inpatients confirmed as pancreatic tuberculosis in Peking Union Medical College Hospital in the period from January 1984 to March 2014 were retrospectively analyzed.  Results  There were 10 cases of pancreatic tuberculosis diagnosed in the study period, accounting for 0.12%(10/8689) of the total tuberculosis patients diagnosed at the same period. The 10 patients included 5 males and 5 females; aged 53.1 years on average (31-70 years), with 80% below the age of 65. The most common symptoms were abdominal pain (60%), anorexia (60%) and weight loss (60%). Fever(40%) and jaundice(10%) were less common, while night sweat was absent. CT and PET/CT failed to make the diagnosis of pancreatic tuberculosis. In one case, intestinal tuberculosis was found after positive result of purified protein derivative test. In another case with cold abscess at the neck, a clinical diagnosis of tuberculosis was made and later confirmed by response to anti-tuberculosis therapy. Tuberculosis was confirmed in one case by pretibial nodule autopsy result, another by ultrasound-guided pancreatic nodule needle autopsy. In the other 6 cases, pathological examination after laparotomy confirmed the diagnosis of tuberculosis.  Conclusions  Pancreatic tuberculosis is rare. It may present as regional cystic or solid pancreatic masses and often be misdiagnosed as pancreatic tumors, leading to surgery. History and symptoms are the first key clues in diagnosis. Imaging is helpful, while confirmed diagnosis is made based on pathological results. For young patients with signs of infection, having pancreatic masses with negative tumor markers, with or without retroperitoneal enlarged lymph nodes, pancreatic tuberculosis should be considered. Endoscope-or ultrasound-guided biopsy is needed in patients hard to identify, and laparotomy may be used when necessary.
Abstract:
  Objective  To investigate the role of ultrasound in the decision-making of surgery for thyroid nodules.  Methods  The cases receiving surgical excision of thyroid nodules in Peking Union Medical College Hospital during the period of January 2004 to December 2014 were collected. We randomly sampled 10%-15% cases from the collections in 2004, 2006, 2008, 2010, 2012 and 2014, and reviewed the outpatient and inpatient records of these sampled cases, extracting information about whether preoperative ultrasonography examination was ordered, whether the ultrasound report provided specific diagnostic suggestion, and whether that diagnosis was correct judging from pathological results. The rates of preoperative ultrasound, ultrasound diagnostic suggestion, specific diagnostic suggestion, and correct ultrasound diagnosis were calculated.  Results  The number of thyroid nodule surgery increased year by year from 2004 to 2014, with the proportion of malignant nodules rising from 15.65% in 2004 to 69.91% in 2014.The rate of preoperative ultrasound ranged from 80.65% to 96.65%. The rate of ultrasound diagnostic suggestion demonstrated a constantly ascending trend, ranging from 46.94% to 92.36%. The rate of specific diagnostic suggestion was in the range of 78.26%-93.61%, while the rate of correct ultrasound diagnosis grew year by year, from 36.73% to 81.40%.  Conclusions  The numbers of patients with thyroid nodules and thyroid cancer have been soaring in the past 11 years. With the improvement in its diagnostic capacity, ultrasonography is playing an increasingly important role in the decision-making of surgery for thyroid nodules.
Abstract:
  Objective  To evaluate the feasibility and accuracy of endorectal ultrasound (ERUS) in predicting the circumferential resection margin (CRM) of rectal cancer.  Methods  Between May 2010 and December 2013, 120 patients with rectal cancer preoperatively evaluated with ERUS in Peking Union Medical College Hospital were retrospectively analyzed. The patients underwent total mesorectal excision without neoadjuvant chemoradiotherapy. CRM was measured with preoperative ERUS, i.e. the shortest distance between the outer edge of tumor and the mesorectal fascia. With pathological results as gold standard, the diagnostic values of ERUS under different criteria for CRM were assessed. The diagnostic accuracies of ERUS in predicting CRM among different positions, distances from the anal verge, and stages were analyzed.  Results  ERUS showed mesorectal fascia in 114 cases (95%). The display rates of mesorectal fascia by ERUS with different transducer frequencies were significantly different (P=0.034). With CRM ≤ 2 mm as the standard, the sensitivity, accuracy and negative predictive value of ERUS in predicting CRM were the highest (100%, 98.2%, 100%). The diagnostic accuracies of ERUS among different positions, distances from the anal verge, and stages were not significantly different (P>0.05).  Conclusion  ERUS can accurately predict CRM, with a high negative predictive value, which can provide reliable information for assessment of prognosis and formulation of clinical treatment plan.
Abstract:
  Objective  To investigate the potential antitumor effects of cholesterol-conjugated let-7a mimics (let-7a mimics) on hepatocellular carcinoma (HCC) by down-regulating all 3 human Ras, with the aim to explore alternative therapeutic strategy for HCC.  Methods  Effects of let-7a mimics on HCC cells in vitro were detected using MTT-based cell proliferation assays in combination with propidium iodide staining and annexin-V/FITC double staining. The antitumor effects in vivo of let-7a mimics on HCC growth were analyzed in subcutaneous xenograft nude mice with intra-tumoral injections. Expressions of let-7a and its target human Ras were examined with real-time PCR and Western blot.  Results  let-7a mimics-transfected HCC cells showed increased let-7a levels and slower proliferation compared with the negative controls (both P < 0.05). let-7a mimics induced more cell-cycle arrest at the G0-G1 phase and promoted apoptosis of HCC cells (both P < 0.05). In addition, significant reductions in tumor size, local invasion and metastasis to liver were observed in let-7a mimics-treated nude mice compared to negative controls. The tumor size after let-7a treatment was 54.97% that of negative controls (P=0.039). Furthermore, the up-regulation of let-7a coincided with the reduction of K-Ras, H-Rras, and N-Ras mRNA and protein expressions in HCC cells and xenograft tumor (all P < 0.05).  Conclusions  let-7a mimics could affect cell cycle, inhibit cell proliferation and promote cell apoptosis by downregulation of mRNA and protein expressions of all the 3 human Ras. Local injections of cholesterol-conjugated let-7a mimics could effectively suppress the growth, invasion and metastasis of xenograft tumor. These findings suggest that Ras-targeting let-7 mimics could be a potential therapeutic option for HCC.