The management of Helicobacter pylori infection in Singapore remains a clinical challenge. Similar to other regions, there has been an increase in antibiotic resistance rates through the years. Nonetheless, over the past two decades, clarithromycin-based triple therapy has continued to be used as the first line treatment option, with an eradication rate exceeding 90%, although the accepted treatment duration must now be lengthened from 1 to 2 weeks to maintain efficacy. Concomitant and sequential therapies did not demonstrate superiority over standard triple therapy. Current empiric second line treatment utilizes either bismuth-based quadruple therapy or levofloxacin-based triple therapy, but outcomes remain less than ideal. Identifying options to further improve treatment success rates is challenging. Strategies being considered include the use of potent acid suppressants, such as vonoprazan, and H. pylori culture and antibiotic susceptibility testing-guided therapy.

Argon ; Gastric Antral Vascular Ectasia ; physiopathology ; therapy ; Humans ; Laser Coagulation ; methods ; Male ; Middle Aged

Neurogastroenterology and motility disorders of the gastrointestinal (GI) tract encompass a broad spectrum of diseases involving the GI tract and central nervous system. They have varied pathophysiology, clinical presentation and management, and make up a substantial proportion of outpatient clinic visits. Typically, patients experience persistent symptoms referable to the GI tract despite normal endoscopic and radiologic findings. An appropriate evaluation is thus important in the patient's care. Advances in technology and understanding of the disease pathophysiology have provided better insight into the physiological basis of disease and a more rational approach to patient management. While technological advances serve to explain patients' persistent symptoms, they should be balanced against the costs of diagnostic tests. This review highlights the GI investigative modalities employed to evaluate patients with persistent GI symptoms in the absence of a structural lesion, with particular emphasis on investigative modalities available locally and the clinical impact of such tools.
Electrophysiology ; Endoscopy ; Esophagus ; physiopathology ; Gastric Emptying ; Gastroenterology ; instrumentation ; methods ; Gastrointestinal Diseases ; diagnosis ; Gastrointestinal Tract ; physiopathology ; Humans ; Hydrogen-Ion Concentration ; Intestine, Small ; physiopathology ; Magnetic Resonance Imaging

INTRODUCTIONOvarian carcinoma usually presents at an advanced stage with diffuse intraabdominal manifestations. We report a patient who presented with a right groin swelling.

CLINICAL PICTUREThe only clinical abnormality was an enlarged right inguinal lymph node (3 x 2 cm), for which excision biopsy revealed metastatic adenocarcinoma. A computed tomography (CT) scan showed an enlarged left ovarian lesion (9.0 x 6.4 cm).

TREATMENT AND OUTCOMELaparotomy with total hysterectomy, bilateral salpingo-oophrectomy and partial omentectomy were performed. Histology confirmed left ovarian adenocarcinoma, consistent with the earlier histology of the right inguinal lymph node. There were no other sites of involvement. Postoperatively, the patient received adjuvant chemotherapy for treatment of FIGO Stage IIIc ovarian carcinoma and is clinically disease free 13 months after surgery.

CONCLUSIONSOvarian cancer presenting with inguinal lymph node metastases is uncommon. Ovarian cancer which manifests solely as a contralateral inguinal lymph node metastasis has not been previously reported. This case illustrates a rare presentation of ovarian carcinoma, and underscores the need to consider ovarian carcinoma in the differential diagnosis of women with inguinal lymphadenopathy.

Adenocarcinoma ; pathology ; surgery ; Female ; Groin ; Humans ; Lymphatic Metastasis ; Middle Aged ; Ovarian Neoplasms ; diagnostic imaging ; pathology ; surgery ; Tomography, X-Ray Computed

Percutaneous endoscopic gastrostomy (PEG) is commonly performed for feeding difficulties, in patients suffering from complications of nasopharyngeal carcinoma and its treatment, namely radiotherapy and surgery. This case report describes the challenges in hemostasis and subsequent re-establishment of enteral access for feeding, in an elderly patient with a history of NPC, treated surgically, followed by radiotherapy, who presented with massive hematemesis following reinsertion of her PEG shortly after an accidental dislodgement. Her previous nasopharyngectomy, wide field radiation therapy, and radical neck dissection precluded nasogastric tube feeding, and the presence of a large hiatus hernia made reinsertion of a new PEG technically challenging. This case highlights the methods used to overcome the above challenges.
Aged ; Enteral Nutrition ; Esophageal Stenosis ; Gastrostomy ; Hematemesis ; Hemostasis ; Hernia, Hiatal ; Humans ; Intubation, Gastrointestinal ; Neck Dissection ; Radiotherapy ; Stomach Ulcer ; Ulcer

Helicobacter pylori (H. pylori) is an infection that has a role in causing dyspepsia and complications such as peptic ulcer disease and gastric malignancies. In the primary care setting, one can adopt a stepwise approach with the 'test-and-treat' strategy to manage H. pylori-associated dyspepsia in young patients without alarm symptoms. Empiric first-line therapies should be for a two-week duration; options include clarithromycin-containing triple therapy alone or with the addition of bismuth, concomitant therapy and bismuth quadruple therapy. Post-treatment carbon urea breath test must be performed at least four weeks after the end of treatment to confirm the cure. Options for empiric second-line treatment include bismuth quadruple therapy and levofloxacin-containing triple therapy. Patients with persistent or alarm symptoms should be referred for further evaluation. Patients with persistent infection should be referred for gastroscopy so that gastric biopsies can be obtained for H. pylori culture and antibiotic susceptibility testing.

About one-third of patients with suspected gastro-oesophageal reflux disease (GERD) do not respond symptomatically to proton pump inhibitors (PPIs). Many of these patients do not suffer from GERD, but may have underlying functional heartburn or atypical chest pain. Other causes of failure to respond to PPIs include inadequate acid suppression, non-acid reflux, oesophageal hypersensitivity, oesophageal dysmotility and psychological comorbidities. Functional oesophageal tests can exclude cardiac and structural causes, as well as help to confi rm or exclude GERD. The use of PPIs should only be continued in the presence of acid reflux or oesophageal hypersensitivity for acid reflux-related events that is proven on functional oesophageal tests.
Chest Pain ; etiology ; Esophagus ; drug effects ; Gastroenterology ; methods ; Gastroesophageal Reflux ; diagnosis ; drug therapy ; Heartburn ; diagnosis ; drug therapy ; Humans ; Hydrogen-Ion Concentration ; Life Style ; Primary Health Care ; Proton Pump Inhibitors ; therapeutic use ; Surveys and Questionnaires

INTRODUCTION: We aimed to provide a practical and evidence-based guide on the indications, performance and reporting of high-resolution oesophageal manometry (HRM) and ambulatory pH monitoring (PHM) in adult patients in Singapore. METHODS: The guideline committee comprised local gastroenterologists from public and private sectors with particular expertise in aspects of HRM and PHM, and it was tasked to produce evidence-based statements on the indications, performance and reporting of these tests. Each committee member performed literature searches to retrieve relevant articles within the context of domains to which they were assigned. RESULTS: Twelve recommendation statements were created and summarised. CONCLUSION Standardising key aspects of HRM and PHM is imperative to ensure the delivery of high-quality care. We reported the development of recommendations for the performance and interpretation of HRM and ambulatory reflux monitoring in Singapore.
Adult ; Esophageal pH Monitoring ; Esophagus ; Humans ; Hydrogen-Ion Concentration ; Manometry ; Singapore

Background: Flow cytometry is an invaluable tool in the diagnostic evaluation of acute leukemia and post therapy monitoring; however, majority of Filipino population cannot afford the cost. The use of a minimal screening panel which is both cost-effective and provides an accurate diagnosis of acute lymphoblastic leukemia is seen as an alternative. Objectives: We aim to determine the cost-effectiveness and accuracy of using a minimal screening panel for the diagnosis of acute lymphoblastic leukemia (ALL). Methodology: We selected a limited panel of 9 antibodies comprising of CD45/CD19/CD20/CD10/HLA-DR/CD34/cCD3/cCD79a/cTdt and retrospectively reviewed newly diagnosed cases of B-cell and T-cell ALL from September 2016 to December 2019 using this panel. Results: Out of 719 bone marrow aspirates submitted for basic leukemia flow cytometric analysis we identified 268 ALL cases (239 B-ALL and 29 T-ALL). In all cases, a diagnosis was established using the limited panel. Compared to the current cost of our comprehensive panel (₱ 9,903.60). This limited panel cost ₱ 3,062.29, that offers a 69.08% savings per test, which translated to a ₱1.2 million savings a year (for an average of 180 annual cases). Conclusion: We underscore the utility of a limited panel for the diagnosis of ALL. Although this panel remains to be assessed with a larger validation cohort, its application in resource-limited developing countries is diagnostically useful and cost-effective. Recommendation The use of a limited panel of 9 antibodies is recommended as a screening panel for patients who are highly suspected of having ALL both clinically and initial bone marrow smear assessment.
Precursor Cell Lymphoblastic Leukemia-Lymphoma

Objective: The advent of immunotherapy has significantly changed the treatment and management of patients with advanced non-small cell lung cancer (NSCLC). Prior to initiation of immunotherapy, evaluation of programmed death ligand 1 (PD-L1) expression is required. One factor that affects PD-L1 expression in NSCLC is the presence of oncogenic driver mutations; however, little data on its association is available, especially in the Philippine setting. The study aims to determine the prevalence of PD-L1 expression and its association with driver mutations among patients with non-small cell lung cancer in a private tertiary care hospital in the Philippines. Methodology: The study was undertaken for a period of two years from July 2017-July 2019 at St. Luke’s Medical Center and included 446 NSCLC samples. PD-L1 was evaluated by immunohistochemistry using 22C3 anti-PD-L1 antibody clone, EnVision FLEX visualization system on Autostainer Link 48. Patient demographics and data on driver mutation testing were recorded. Statistical analysis was performed using logistic regression. Results: PD-L1 expression was observed in 273 (61.20%) of 446 cases, 119 (61.20%) of which demonstrated high PD-L1 expression while 154 (34.50%) had low PD-L1 expression. There was no significant association between PD-L1 expression and EGFR mutation, ALK mutation, age, and gender. For histologic type, high PD-L1 expression was significantly associated with adenocarcinoma and non- small cell carcinoma, NOS. Conclusion The overall prevalence of PD-L1 expression in non-small cell lung carcinoma is 61.20% based on the cases included. Although we did not find an association between PD-L1 expression and EGFR and ALK mutation, our study observed that ALK-mutated NSCLCs have 4.7 odds of having high PD-L1 expression, however, a higher sample size is warranted to truly determine significant association. The outcome of this study may provide help in the stratification of patients and predict those who will benefit from immunotherapy.
Carcinoma, Non-Small-Cell Lung ; B7-H1 Antigen