World Journal of Gastroenterology

World Journal of Gastroenterology

World Journal of G

astroenterology ww

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jgnet.com Volum

e 16 Num

ber 10 Mar 14 2010

Volume 16 Number 10March 14, 2010

ISSN 1007-9327CN 14-1219/R

Baishideng百世登

A Weekly Journal of Gastroenterology and Hepatology

Volume 16 Number 10March 14, 2010World J Gastroenterol

2010 March 14; 16(10): 1171-1298Online Submissions

www.wjgnet.com/1007-9327offcewww.wjgnet.com

Printed on Acid-free Paper

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ISSN 1007-9327 CN 14-1219/R Local Post Offices Code No. 82-261

Published by Baishideng Room 903, Building D, Ocean International Center,

No. 62 Dongsihuan Zhonglu, Chaoyang District, Beijing 100025, ChinaTelephone: +86-10-59080039

Fax: +86-10-85381893E-mail: wjg@wjgnet.comhttp://www.wjgnet.com Indexed and Abstracted in:

Current Contents®/Clinical Medicine, Science Citation Index Expanded (also known as SciSearch®), Journal Citation Reports®, Index Medicus, MEDLINE, PubMed, PubMed Central, Digital Object Identifer, and EMBASE/Excerpta Medica. ISI, Thomson Reuters, 2008 Impact Factor: 2.081 (32/55 Gastroenterology and Hepatology).I S S N 1 0 0 7 - 9 3 2 7

9 7 7 1 0 07 9 3 2 0 45

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The World Journal of Gastroenterology Editorial Board consists of 1096 members, representing a team of worldwide experts in gastroenterology and hepatology. They are from 60 countries, including Albania (1), Argentina (7), Australia (28), Austria (13), Belgium (11), Brazil (8), Brunei Darussalam (1), Bulgaria (2), Canada (18), Chile (3), China (66), Colombia (1), Croatia (2), Cuba (1), Czech (4), Denmark (8), Ecuador (1), Egypt (2), Estonia (2), Finland (7), France (22), Germany (72), Greece (14), Hungary (10), India (25), Iran (6), Ireland (6), Israel (12), Italy (94), Japan (107), Jordan (1), Kuwait (1), Lebanon (3), Lithuania (2), Malaysia (1), Mexico (9), Moldova (1), Netherlands (27), New Zealand (2), Norway (11), Pakistan (2), Poland (10), Portugal (4), Romania (3), Russia (1), Saudi Arabia (3), Serbia (3), Singapore (9), South Africa (2), South Korea (32), Spain (36), Sweden (17), Switzerland (11), Thailand (1), Trinidad and Tobago (1), Turkey (24), United Arab Emirates (2), United Kingdom (80), United States (242), and Uruguay (1).

Editorial Board2010-2013

HONORARY EDITORS-IN-CHIEFJames L Boyer, New HavenKe-Ji Chen, BeijingMartin H Floch, New HavenEmmet B Keeffe, Palo AltoGeng-Tao Liu, BeijingLein-Ray Mo, TainanEamonn M Quigley, CorkRafiq A Sheikh, SacramentoNicholas J Talley, RochesterMing-Lung Yu, Kaohsiung

PRESIDENT AND EDITOR-IN-CHIEFLian-Sheng Ma, Beijing

ACADEMIC EDITOR-IN-CHIEFTauseef Ali, Oklahoma CityMauro Bortolotti, BolognaTarkan Karakan, AnkaraWeekitt Kittisupamongkol, BangkokAnastasios Koulaouzidis, EdinburghBo-Rong Pan, Xi’anSylvia LF Pender, SouthamptonMax S Petrov, AucklandGeorge Y Wu, Farmington

STRATEGY ASSOCIATE EDITORS-IN-CHIEFPeter Draganov, FloridaHugh J Freeman, VancouverMaria C Gutiérrez-Ruiz, MéxicoKazuhiro Hanazaki, KochiAkio Inui, KagoshimaKalpesh Jani, BarodaJavier S Martin, Punta del Este

Natalia A Osna, OmahaWei Tang, TokyoAlan BR Thomson, EdmontonHarry HX Xia, Hanover

ASSOCIATE EDITORS-IN-CHIEFYou-Yong Lu, BeijingJohn M Luk, PokfulamHiroshi Shimada, Yokohama

GUEST EDITORIAL BOARD MEMBERSChien-Jen Chen, TaipeiYang-Yuan Chen, ChanghuaJen-Hwey Chiu, TaipeiSeng-Kee Chuah, KaohsiungWan-Long Chuang, KaohsiunMing-Chih Hou, TaipeiKevin Cheng-Wen Hsiao, TaipeiPo-Shiuan Hsieh, TaipeiTsung-Hui Hu, KaohsiungWen-Hsin Huang, TaichungChao-Hung Hung, KaohsiungI-Rue Lai, TaipeiTeng-Yu Lee, TaichungChing Chung Lin, TaipeiHui-Kang Liu, TaipeiHon-Yi Shi, KaohsiungChih-Chi Wang, KaohsiungJin-Town Wang, TaipeiCheng-Shyong Wu, Chia-YiJaw-Ching Wu, TaipeiJiunn-Jong Wu, TainanMing-Shiang Wu, TaipeiTa-Sen Yeh, TaoyuanHsu-Heng Yen, Changhua

MEMBERS OF THE EDITORIAL BOARD

Albania

Bashkim Resuli, Tirana

Argentina

Julio H Carri, CórdobaEduardo de Santibañes, Buenos AiresBernardo Frider, Buenos AiresCarlos J Pirola, Buenos AiresBernabe Matias Quesada, Buenos AiresAdriana M Torres, RosarioMaria Ines Vaccaro, Buenos Aires

Australia

Leon Anton Adams, NedlandsRichard Anderson, VictoriaMinoti V Apte, New South WalesAndrew V Biankin, SydneyFilip Braet, SydneyChristopher Christophi, MelbournePhilip G Dinning, KoagarahGuy D Eslick, SydneyMichael A Fink, MelbourneJacob George, WestmeadMark D Gorrell, SydneyAlexander G Heriot, MelbourneMichael Horowitz, AdelaideJohn E Kellow, Sydney

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William Kemp, MelbourneFinlay A Macrae, VictoriaDaniel Markovich, BrisbaneVance Matthews, MelbournePhillip S Oates, PerthShan Rajendra, TasmaniaRajvinder Singh, Elizabeth ValeRoss C Smith, SydneyKevin J Spring, BrisbaneNathan Subramaniam, BrisbanePhil Sutton, MelbourneCuong D Tran, North AdelaideDebbie Trinder, FremantleDavid Ian Watson, Bedford Park

Austria

Herwig H Cerwenka, GrazAshraf Dahaba, GrazPeter Ferenci, ViennaValentin Fuhrmann, ViennaAlfred Gangl, ViennaAlexander M Hirschl, WienKurt Lenz, LinzDietmar Öfner, SalzburgMarkus Peck-Radosavljevic, ViennaMarkus Raderer, ViennaGeorg Roth, ViennaMichael Trauner, GrazThomas Wild, Kapellerfeld

Belgium

Rudi Beyaert, GentBenedicte Y De Winter, AntwerpInge I Depoortere, LeuvenOlivier Detry, LiègeMarc Peeters, De PintelaanFreddy Penninckx, LeuvenJean-Yves L Reginster, LiègeMark De Ridder, BrusselsEtienne M Sokal, BrusselsKristin Verbeke, LeuvenEddie Wisse, Keerbergen

Brazil

José LF Caboclo, São José do Rio PretoRoberto J Carvalho-Filho, São PauloJaime Natan Eisig, São PauloAndre Castro Lyra, SalvadorMarcelo Lima Ribeiro, Braganca Paulista Heitor Rosa, GoianiaDamiao C Moraes Santos, Rio de JaneiroEduardo Garcia Vilela, Belo Horizonte

Brunei Darussalam

Vui Heng Chong, Bandar Seri Begawan

Bulgaria

Zahariy Krastev, SofiaMihaela Petrova, Sofia

Canada

Alain Bitton, MontrealMichael F Byrne, VancouverKris Chadee, CalgaryRam Prakash Galwa, OttawaPhilip H Gordon, MontrealWaliul Khan, OntarioJohn K Marshall, OntarioAndrew L Mason, AlbertaKostas Pantopoulos, QuebecNathalie Perreault, SherbrookeBaljinder Singh Salh, VancouverEldon Shaffer, CalgaryMartin Storr, CalgaryPingchang Yang, HamiltonEric M Yoshida, VancouverClaudia Zwingmann, Montreal

Chile

Marcelo A Beltran, La SerenaXabier De Aretxabala, SantiagoSilvana Zanlungo, Santiago

China

Hui-Jie Bian, Xi’anSan-Jun Cai, ShanghaiGuang-Wen Cao, ShanghaiXiao-Ping Chen, WuhanChi-Hin Cho, Hong KongZong-Jie Cui, Beijing Jing-Yuan Fang, ShanghaiDe-Liang Fu, ShanghaiChun-Yi Hao, BeijingMing-Liang He, Hong KongSimon Law, Hong KongYuk-Tong Lee, Hong KongEn-Min Li, ShantouFei Li, BeijingYu-Yuan Li, GuangzhouZhao-Shen Li, ShanghaiXing-Hua Lu, BeijingYi-Min Mao, ShanghaiQin Su, BeijingPaul Kwong-Hang Tam, Hong KongYuk Him Tam, Hong KongRen-Xiang Tan, NanjingEric WC Tse, Hong KongFu-Sheng Wang, BeijingXiang-Dong Wang, ShanghaiNathalie Wong, Hong KongJustin CY Wu, Hong KongWen-Rong Xu, ZhenjiangAn-Gang Yang, Xi’an Wei-Cheng You, BeijingChun-Qing Zhang, JinanJian-Zhong Zhang, Beijing Xiao-Peng Zhang, BeijingXuan Zhang, Beijing

Colombia

Germán Campuzano-Maya, Medellín

Croatia

Tamara Cacev, ZagrebMarko Duvnjak, Zagreb

Cuba

Damian C Rodriguez, Havana

Czech

Jan Bures, Hradec KraloveMilan Jirsa, PrahaMarcela Kopacova, Hradec KralovePavel Trunečka, Prague

Denmark

Leif Percival Andersen, CopenhagenAsbjørn M Drewes, AalborgMorten Frisch, CopenhagenJan Mollenhauer, OdenseMorten Hylander Møller, HolteSøren Rafaelsen, VejleJorgen Rask-Madsen, SkodsborgPeer Wille-Jørgensen, Copenhagen

Ecuador

Fernando E Sempértegui, Quito

Egypt

Zeinab Nabil Ahmed, CairoHussein M Atta, El-Minia

Estonia

Riina Salupere, TartuTamara Vorobjova, Tartu

Finland

Saila Kauhanen, TurkuKaija-Leena Kolho, HelsinkiJukka-Pekka Mecklin, JyvaskylaMinna Nyström, HelsinkiPauli Antero Puolakkainen, TurkuJuhani Sand, TampereLea Veijola, Helsinki

France

Claire Bonithon-Kopp, DijonLionel Bueno, ToulouseSabine Colnot, ParisCatherine Daniel, Lille CedexThabut Dominique, ParisFrancoise L Fabiani, AngersJean-Luc Faucheron, GrenobleJean Paul Galmiche, Nantes cedex

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Boris Guiu, DijonPaul Hofman, NiceLaurent Huwart, ParisAbdel-Majid Khatib, ParisPhilippe Lehours, BordeauxFlavio Maina, MarseillePatrick Marcellin, ParisRene Gerolami Santandera, MarseilleAnnie Schmid-Alliana, Nice cedexAlain L Servin, Châtenay-MalabryStephane Supiot, NantesBaumert F Thomas, StrasbourgJean-Jacques Tuech, RouenFrank Zerbib, Bordeaux Cedex

Germany

Erwin Biecker, SiegburgHubert Blum, Freiburg Thomas Bock, TuebingenDean Bogoevski, HamburgElfriede Bollschweiler, KölnJürgen Borlak, HannoverChrista Buechler, RegensburgJürgen Büning, LübeckElke Cario, EssenBruno Christ, Halle/SaaleChristoph F Dietrich, Bad Mergentheim Ulrich R Fölsch, Kiel Nikolaus Gassler, AachenMarkus Gerhard, MunichDieter Glebe, GiessenRalph Graeser, FreiburgAxel M Gressner, AachenNils Habbe, MarburgThilo Hackert, HeidelbergWolfgang Hagmann, HeidelbergDirk Haller, FreisingPhilip D Hard, GiessenClaus Hellerbrand, RegensburgKlaus R Herrlinger, StuttgartEberhard Hildt, BerlinAndrea Hille, GoettingenJoerg C Hoffmann, BerlinAndrej Khandoga, MunichJorg Kleeff, MunichIngmar Königsrainer, TübingenPeter Konturek, ErlangenStefan Kubicka, HannoverJoachim Labenz, SiegenMichael Linnebacher, RostockJutta Elisabeth Lüttges, RiegelsbergPeter Malfertheiner, MagdeburgOliver Mann, HamburgPeter N Meier, HannoverSabine Mihm, GöttingenKlaus Mönkemüller, BottropJonas Mudter, ErlangenSebastian Mueller, HeidelbergRobert Obermaier, FreiburgMatthias Ocker, ErlangenStephan Johannes Ott, KielChristoph Reichel, Bad Brückenau Markus Reiser, BochumSteffen Rickes, MagdeburgElke Roeb, GiessenChristian Rust, MunichHans Scherubl, BerlinMartin K Schilling, HomburgRene Schmidt, FreiburgAndreas G Schreyer, Regensburg

Karsten Schulmann, BochumHenning Schulze-Bergkamen, MainzManfred V Singer, MannheimJens Standop, BonnJurgen M Stein, Frankfurt Ulrike S Stein, BerlinWolfgang R Stremmel, Heidelberg Harald F Teutsch, Ulm Hans L Tillmann, LeipzigChristian Trautwein, AachenJoerg Trojan, FrankfurtArndt Vogel, HannoverSiegfried Wagner, DeggendorfFrank Ulrich Weiss, GreifswaldFritz von Weizsäcker, BerlinThomas Wex, MagdeburgStefan Wirth, WuppertalMarty Zdichavsky, Tübingen

Greece

Helen Christopoulou-Aletra, ThessalonikiT Choli-Papadopoulou, ThessalonikiTsianos Epameinondas, IoanninaIoannis Kanellos, ThessalonikiElias A Kouroumalis, Heraklion Ioannis E Koutroubakis, HeraklionMichael Koutsilieris, AthensAndreas Larentzakis, AthensEmanuel K Manesis, AthensSpilios Manolakopoulos, AthensKonstantinos Mimidis, AlexandroupolisGeorge Papatheodoridis, AthensSpiros Sgouros, Athens Evangelos Tsiambas, Ag Paraskevi Attiki

Hungary

György M Buzás, BudapestLászló Czakó, SzegedGyula Farkas, SzegedPeter Hegyi, SzegedPeter L Lakatos, BudapestYvette Mándi, SzegedZoltan Rakonczay, SzegedFerenc Sipos, BudapestZsuzsa Szondy, DebrecenGabor Veres, Budapest

India

Philip Abraham, MumbaiVineet Ahuja, New DelhiDevinder Kumar Dhawan, ChandigarhRadha K Dhiman, Chandigarh Pankaj Garg, PanchkulaPramod Kumar Garg, New DelhiDebidas Ghosh, MidnporeUday C Ghoshal, LucknowBhupendra Kumar Jain, DelhiAshok Kumar, LucknowBikash Medhi, ChandigarhSri P Misra, Allahabad Gopal Nath, VaranasiSamiran Nundy, New DelhiJagannath Palepu, MumbaiVandana Panda, MumbaiBenjamin Perakath, Tamil Nadu

Ramesh Roop Rai, JaipurNageshwar D Reddy, HyderabadBarjesh Chander Sharma, New DelhiVirendra Singh, ChandigarhRupjyoti Talukdar, GuwahatiRakesh Kumar Tandon, New DelhiJai Dev Wig, Chandigarh

Iran

Mohammad Abdollahi, TehranPeyman Adibi, IsfahanSeyed-Moayed Alavian, TehranSeyed Mohsen Dehghani, ShirazReza Malekzadeh, TehranAlireza Mani, Tehran

Ireland

Billy Bourke, DublinTed Dinan, CorkCatherine Greene, DublinRoss McManus, DublinMarion Rowland, Dublin

Israel

Simon Bar-Meir, HashomerAlexander Becker, AfulaAbraham R Eliakim, Haifa Sigal Fishman, Tel AvivBoris Kirshtein, Beer ShevaEli Magen, AshdodMenachem Moshkowitz, Tel-AvivAssy Nimer, SafedShmuel Odes, Beer ShevaMark Pines, Bet DaganRon Shaoul, HaifaAmi D Sperber, Beer-Sheva

Italy

Donato F Altomare, BariPiero Amodio, PadovaPaolo Angeli, PadovaBruno Annibale, RomePaolo Aurello, RomeSalvatore Auricchio, NaplesAntonio Basoli, RomeClaudio Bassi, VeronaGabrio Bassotti, Perugia Mauro Bernardi, BolognaAlberto Biondi, RomeLuigi Bonavina, Milano Guglielmo Borgia, NaplesRoberto Berni Canani, NaplesFausto Catena, BolognaGiuseppe Chiarioni, ValeggioMichele Cicala, RomeDario Conte, Milano Francesco Costa, PisaGiuseppe Currò, MessinaMario M D’Elios, FlorenceMirko D’Onofrio, VeronaSilvio Danese, MilanoRoberto de Franchis, MilanoPaola De Nardi, MilanGiovanni D De Palma, Naples

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Giuliana Decorti, TriesteGianlorenzo Dionigi, VareseMassimo Falconi, VeronaSilvia Fargion, MilanGiammarco Fava, AnconaFrancesco Feo, SassariAlessandra Ferlini, FerraraAlessandro Ferrero, TorinoLuca Frulloni, VeronaGiovanni B Gaeta, NapoliAntonio Gasbarrini, RomeEdoardo G Giannini, Genoa Alessandro Granito, BolognaFabio Grizzi, MilanSalvatore Gruttadauria, PalermoPietro Invernizzi, MilanAchille Iolascon, NaplesAngelo A Izzo, NaplesEzio Laconi, CagliariGiovanni Latella, L’AquilaMassimo Levrero, RomeFrancesco Luzza, CatanzaroLucia Malaguarnera, CataniaFrancesco Manguso, NapoliPier Mannuccio Mannucci, MilanoGiancarlo Mansueto, VeronaGiulio Marchesini, Bologna Mara Massimi, CoppitoGiovanni Milito, RomeGiuseppe Montalto, Palermo Giovanni Monteleone, RomeLuca Morelli, TrentoGiovanni Musso, TorinoMario Nano, TorinoGerardo Nardone, NapoliRiccardo Nascimbeni, BresciaValerio Nobili, RomeFabio Pace, MilanoNadia Peparini, RomeMario Pescatori, RomeRaffaele Pezzilli, Bologna Alberto Piperno, MonzaAnna C Piscaglia, RomePiero Portincasa, Bari Michele Reni, MilanVittorio Ricci, PaviaOliviero Riggio, RomeMario Rizzetto, TorinoBallarin Roberto, ModenaFranco Roviello, SienaCesare Ruffolo, TrevisoMassimo Rugge, PadovaMarco Scarpa, PadovaC armelo Scarpignato, ParmaGiuseppe Sica, RomeMarco Silano, RomePierpaolo Sileri, RomeVincenzo Stanghellini, BolognaFiorucci Stefano, PerugiaGiovanni Tarantino, NaplesAlberto Tommasini, TriesteGuido Torzilli, Rozzano MilanoCesare Tosetti, Porretta TermeAntonello Trecca, RomeVincenzo Villanacci, BresciaLucia Ricci Vitiani, RomeMarco Vivarelli, Bologna

JapanKyoichi Adachi, Izumo

Yasushi Adachi, SapporoTakafumi Ando, Nagoya Akira Andoh, OtsuMasahiro Arai, Tokyo Hitoshi Asakura, TokyoKazuo Chijiiwa, MiyazakiYuichiro Eguchi, SagaItaru Endo, YokohamaMunechika Enjoji, FukuokaYasuhiro Fujino, AkashiMitsuhiro Fujishiro, TokyoKouhei Fukushima, SendaiMasanori Hatakeyama, TokyoKeiji Hirata, KitakyushuToru Hiyama, HigashihiroshimaMasahiro Iizuka, Akita Susumu Ikehara, OsakaKenichi Ikejima, Bunkyo-kuYutaka Inagaki, KanagawaHiromi Ishibashi, Nagasaki Shunji Ishihara, Izumo Toru Ishikawa, Niigata Toshiyuki Ishiwata, Tokyo Yoshiaki Iwasaki, OkayamaSatoru Kakizaki, GunmaTerumi Kamisawa, TokyoMototsugu Kato, Sapporo Naoya Kato, TokyoTakumi Kawaguchi, KurumeYohei Kida, KainanShogo Kikuchi, AichiTsuneo Kitamura, Chiba Takashi Kobayashi, TokyoYasuhiro Koga, IseharaTakashi Kojima, SapporoNorihiro Kokudo, TokyoMasatoshi Kudo, OsakaShin Maeda, Tokyo Satoshi Mamori, HyogoAtsushi Masamune, SendaiYasushi Matsuzaki, Tsukuba Kenji Miki, TokyoHiroto Miwa, Hyogo Kotaro Miyake, TokushimaManabu Morimoto, YokohamaYoshiharu Motoo, Kanazawa Yoshiaki Murakami, HiroshimaKunihiko Murase, Tusima Akihito Nagahara, TokyoYuji Naito, Kyoto Atsushi Nakajima, YokohamaHisato Nakajima, Tokyo Hiroki Nakamura, Yamaguchi Shotaro Nakamura, FukuokaAkimasa Nakao, NagogyaShuhei Nishiguchi, HyogoMikio Nishioka, Niihama Keiji Ogura, TokyoSusumu Ohmada, Maebashi Hirohide Ohnishi, AkitaKenji Okajima, NagoyaKazuichi Okazaki, OsakaMorikazu Onji, EhimeSatoshi Osawa, Hamamatsu Hidetsugu Saito, TokyoYutaka Saito, TokyoNaoaki Sakata, SendaiYasushi Sano, ChibaTokihiko Sawada, TochigiTomohiko Shimatan, HiroshimaYukihiro Shimizu, Kyoto

Shinji Shimoda, FukuokaYoshio Shirai, Niigata Masayuki Sho, NaraShoichiro Sumi, KyotoHidekazu Suzuki, TokyoMasahiro Tajika, NagoyaYoshihisa Takahashi, TokyoToshinari Takamura, KanazawaHiroaki Takeuchi, KochiYoshitaka Takuma, OkayamaAkihiro Tamori, OsakaAtsushi Tanaka, TokyoShinji Tanaka, Hiroshima Satoshi Tanno, HokkaidoShinji Togo, YokohamaHitoshi Tsuda, TokyoHiroyuki Uehara, OsakaMasahito Uemura, KashiharaYoshiyuki Ueno, SendaiMitsuyoshi Urashima, TokyoSatoshi Yamagiwa, NiigataTaketo Yamaguchi, ChibaMitsunori Yamakawa, YamagataTakayuki Yamamoto, Yokkaichi Yutaka Yata, MaebashiHiroshi Yoshida, Tokyo Norimasa Yoshida, Kyoto Yuichi Yoshida, OsakaKentaro Yoshika, ToyoakeKatsutoshi Yoshizato, HigashihiroshimaTomoharu Yoshizumi, Fukuoka

JordanIsmail Matalka, Irbid

KuwaitIslam Khan, Safat

LebanonBassam N Abboud, BeirutAla I Sharara, BeirutRita Slim, Beirut

LithuaniaGiedrius Barauskas, KaunasLimas Kupcinskas, Kaunas

MalaysiaAndrew Seng Boon Chua, Ipoh

MexicoRichard A Awad, MexicoAldo Torre Delgadillo, MexicoDiego Garcia-Compean, MonterreyPaulino M Hernández Magro, CelayaMiguel Angel Mercado, Distrito FederalArturo Panduro, JaliscoOmar Vergara-Fernandez, TlalpanSaúl Villa-Trevio, Mexico

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MoldovaIgor Mishin, Kishinev

NetherlandsUlrich Beuers, AmsterdamLee Bouwman, LeidenAlbert J Bredenoord, NieuwegeinLodewijk AA Brosens, UtrechtJ Bart A Crusius, AmsterdamWouter de Herder, RotterdamPieter JF de Jonge, RotterdamRobert J de Knegt, RotterdamWendy W Johanna de Leng, UtrechtAnnemarie de Vries, RotterdamJames CH Hardwick, LeidenFrank Hoentjen, HaarlemMisha Luyer, SittardGerrit A Meijer, AmsterdamServaas Morré, AmsterdamChris JJ Mulder, Amsterdam John Plukker, Groningen Albert Frederik Pull ter Gunne, TilburgPaul E Sijens, GroningenBW Marcel Spanier, ArnhemMaarten Tushuizen, AmsterdamJantine van Baal, HeidelberglaanAstrid van der Velde, The HagueKarel van Erpecum, Utrecht Loes van Keimpema, NijmegenRobert Christiaan Verdonk, GroningenErwin G Zoetendal, Wageningen

New ZealandAndrew S Day, Christchurch

Norway Olav Dalgard, OsloTrond Peder Flaten, TrondheimReidar Fossmark, TrondheimRasmus Goll, TromsoOle Høie, ArendalAsle W Medhus, OsloEspen Melum, OsloTrine Olsen, TromsoEyvind J Paulssen, TromsoJon Arne Søreide, StavangerKjetil Soreide, Stavanger

PakistanShahab Abid, KarachiSyed MW Jafri, Karachi

PolandMarek Bebenek, WroclawTomasz Brzozowski, Cracow Halina Cichoż-Lach, LublinAndrzej Dabrowski, BialystokHanna Gregorek, Warsaw

Marek Hartleb, KatowiceBeata Jolanta Jablońska, KatowiceStanislaw J Konturek, KrakowJan Kulig, KrakowJulian Swierczynski, Gdansk

PortugalRaquel Almeida, PortoAna Isabel Lopes, Lisboa CodexRicardo Marcos, PortoGuida Portela-Gomes, Estoril

RomaniaDan L Dumitrascu, ClujAdrian Saftoiu, CraiovaAndrada Seicean, Cluj-Napoca

RussiaVasiliy I Reshetnyak, Moscow

Saudi ArabiaIbrahim A Al Mofleh, RiyadhAbdul-Wahed Meshikhes, QatifFaisal Sanai, Riyadh

SerbiaTamara M Alempijevic, BelgradeDusan M Jovanovic, Sremska KamenicaZoran Krivokapic, Belgrade

SingaporeMadhav Bhatia, SingaporeKong Weng Eu, SingaporeBrian Kim Poh Goh, SingaporeKhek-Yu Ho, Singapore Kok Sun Ho, SingaporeFock Kwong Ming, SingaporeLondon Lucien Ooi, SingaporeNagarajan Perumal, SingaporeFrancis Seow-Choen, Singapore

South AfricaRosemary Joyce Burnett, PretoriaMichael Kew, Cape Town

South KoreaSang Hoon Ahn, SeoulSung-Gil Chi, SeoulMyung-Gyu Choi, SeoulHoon Jai Chun, SeoulYeun-Jun Chung, SeoulYoung-Hwa Chung, SeoulKim Donghee, SeoulKi-Baik Hahm, IncheonSun Pyo Hong, Geonggi-doSeong Gyu Hwang, Seongnam

Hong Joo Kim, SeoulJae J Kim, SeoulJin-Hong Kim, Suwon Nayoung Kim, Seongnam-siSang Geon Kim, SeoulSeon Hahn Kim, SeoulSung Kim, SeoulWon Ho Kim, SeoulJeong Min Lee, SeoulKyu Taek Lee, Seoul Sang Kil Lee, SeoulSang Yeoup Lee, Gyeongsangnam-doYong Chan Lee, SeoulEun-Yi Moon, SeoulHyoung-Chul Oh, SeoulSeung Woon Paik, SeoulJoong-Won Park, GoyangJi Kon Ryu, SeoulSi Young Song, SeoulMarie Yeo, Suwon Byung Chul Yoo, SeoulDae-Yeul Yu, Daejeon

SpainMaria-Angeles Aller, MadridRaul J Andrade, MálagaLuis Aparisi, ValenciaGloria González Aseguinolaza, NavarraMatias A Avila, PamplonaFernando Azpiroz, Barcelona Ramon Bataller, BarcelonaBelén Beltrán, ValenciaAdolfo Benages, ValenciaJosep M Bordas, Barcelona Lisardo Boscá, MadridLuis Bujanda, San SebastiánJuli Busquets, BarcelonaMatilde Bustos, PamplonaJosé Julián calvo Andrés, SalamancaAndres Cardenas, BarcelonaAntoni Castells, Barcelona Fernando J Corrales, PamplonaJ E Domínguez-Muñoz, Santiago de CompostelaJuan Carlos Laguna Egea, BarcelonaIsabel Fabregat, BarcelonaAntoni Farré, BarcelonaVicente Felipo, ValenciaLaureano Fernández-Cruz, BarcelonaLuis Grande, BarcelonaAngel Lanas, Zaragoza Juan-Ramón Larrubia, GuadalajaraMaría IT López, JaénJuan Macías, SevilleJavier Martin, GranadaJosé Manuel Martin-Villa, MadridJulio Mayol, MadridMireia Miquel, SabadellJesús M Prieto, Pamplona Pedro L Majano Rodriguez, MadridEva Vaquero, Barcelona

SwedenLars Erik Agréus, StockholmRoland Andersson, LundMauro D’Amato, HuddingeEvangelos Kalaitzakis, GothenburgGreger Lindberg, Stockholm Annika Lindblom, Stockholm

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Sara Lindén, GöteborgHanns-Ulrich Marschall, StockholmPär Erik Myrelid, LinköpingÅke Nilsson, LundHelena Nordenstedt, StockholmKjell Öberg, UppsalaLars A Pahlman, UppsalaStefan G Pierzynowski, LundSara Regnér, MalmöBobby Tingstedt, LundZongli Zheng, Stockholm

SwitzerlandPascal Bucher, GenevaMichelangelo Foti, GenevaJean L Frossard, GenevaAndreas Geier, ZürichPascal Gervaz, GenevaGerd A Kullak-Ublick, ZürichFabrizio Montecucco, GenevaPaul M Schneider, ZürichFelix Stickel, BerneBruno Stieger, ZürichInti Zlobec, Basel

Trinidad and TobagoShivananda Nayak, Mount Hope

TurkeySinan Akay, TekirdagMetin Basaranoglu, IstanbulYusuf Bayraktar, AnkaraA Mithat Bozdayi, AnkaraHayrullah Derici, BalıkesirEren Ersoy, AnkaraMukaddes Esrefoglu, MalatyaCan Goen, KutahyaSelin Kapan, IstanbulAydin Karabacakoglu, KonyaCuneyt Kayaalp, MalatyaKemal Kismet, AnkaraSeyfettin Köklü, AnkaraMehmet Refik Mas, Etlik-AnkaraOsman C Ozdogan, IstanbulBülent Salman, AnkaraSalih Sanlioglu, AntalyaOrhan Sezgin, MersinIlker Tasci, AnkaraAhmet Tekin, MersinMesut Tez, AnkaraEkmel Tezel, AnkaraÖzlem Yilmaz, Izmir

United Arab EmiratesFikri M Abu-Zidan, Al-AinSherif M Karam, Al-Ain

United KingdomSimon Afford, BirminghamNavneet K Ahluwalia, StockportMohamed H Ahmed, Southampton

Basil Ammori, SalfordLesley A Anderson, BelfastChin Wee Ang, LiverpoolYeng S Ang, WiganAnthony TR Axon, Leeds Kathleen B Bamford, LondonJim D Bell, LondonJohn Beynon, SwanseaChris Briggs, SheffieldGeoffrey Burnstock, LondonAlastair D Burt, NewcastleJeff Butterworth, ShrewsburyJeremy FL Cobbold, LondonJean E Crabtree, LeedsTatjana Crnogorac-Jurcevic, LondonWilliam Dickey, LondonderrySunil Dolwani, Cardiff Emad M El-Omar, AberdeenA M El-Tawil, BirminghamCharles B Ferguson, BelfastAndrew Fowell, SouthamptonPiers Gatenby, LondonDaniel R Gaya, EdinburghAnil George, LondonRob Glynne-Jones, NorthwoodJason CB Goh, BirminghamGianpiero Gravante, LeicesterBrian Green, BelfastWilliam Greenhalf, Liverpool Indra N Guha, NottinghamStefan G Hübscher, BirminghamRobin Hughes, LondonPali Hungin, StocktonNawfal Hussein, NottinghamClement W Imrie, GlasgowJanusz AZ Jankowski, Oxford Sharad Karandikar, BirminghamPeter Karayiannis, LondonShahid A Khan, LondonPatricia F Lalor, BirminghamJohn S Leeds, SheffieldIan Lindsey, OxfordHong-Xiang Liu, Cambridge Dileep N Lobo, NottinghamGraham MacKay, GlasgowAnne McCune, BristolDonald Campbell McMillan, GlasgowGiorgina Mieli-Vergani, London Jamie Murphy, LondonGuy Fairbairn Nash, PooleJames Neuberger, Birmingham Patrick O’Dwyer, GlasgowChristos Paraskeva, BristolRichard Parker, North StaffordshireThamara Perera, BirminghamKondragunta Rajendra Prasad, LeedsD Mark Pritchard, LiverpoolAlberto Quaglia, LondonAkhilesh B Reddy, CambridgeKevin Robertson, GlasgowJohn B Schofield, KentMarco Senzolo, PadovaVenkatesh Shanmugam, DerbyPaul Sharp, LondonChew Thean Soon, ManchesterAravind Suppiah, East YorkshireNoriko Suzuki, MiddlesexSimon D Taylor-Robinson, London Frank I Tovey, LondonA McCulloch Veitch, WolverhamptonVamsi R Velchuru, Lowestoft

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1171 Steatosisasaco-factorinchronicliverdiseases

Persico M, Iolascon A

1177 Mechanismsofresistancetoanti-EGFRmonoclonalantibodytreatmentin

metastaticcolorectalcancer

Saridaki Z, Georgoulias V, Souglakos J

1188 Influenceofinterleukinpolymorphismsondevelopmentofgastriccancerand

pepticulcer

Sugimoto M, Yamaoka Y, Furuta T

1201 MethylationofGATA-4 andGATA-5 anddevelopmentofsporadicgastric

carcinomas

Wen XZ, Akiyama Y, Pan KF, Liu ZJ, Lu ZM, Zhou J, Gu LK, Dong CX, Zhu BD, Ji JF,

You WC, Deng DJ

1209 Solidpseudopapillarytumorofthepancreas:Areviewof553casesin

Chineseliterature

Yu PF, Hu ZH, Wang XB, Guo JM, Cheng XD, Zhang YL, Xu Q

1215 Bonemarrowcellsproducenervegrowthfactorandpromoteangiogenesis

aroundtransplantedislets

Sakata N, Chan NK, Chrisler J, Obenaus A, Hathout E

1221 Managementofrupturedhepatocellularcarcinoma:Implicationsfortherapy

Bassi N, Caratozzolo E, Bonariol L, Ruffolo C, Bridda A, Padoan L, Antoniutti M,

Massani M

1226 MicroalbuminuriainhepatitisC-genotype4:Effectofpegylatedinterferon

andribavirin

Derbala M, Shebl FM, Rashid A, Amer A, Bener A

1232 Overlappinggastroesophagealrefluxdiseaseandirritablebowelsyndrome:

Increaseddysfunctionalsymptoms

Yarandi SS, Nasseri-Moghaddam S, Mostajabi P, Malekzadeh R

Contents

EDITORIAL

ORIGINAL ARTICLE

Weekly Volume 16 Number 10 March 14, 2010

百世登BaishidengTM© March 14, 2010|Volume 16|Issue 10|WJG|www.wjgnet.com I

REVIEW

BRIEF ARTICLE

ContentsWorld Journal of Gastroenterology

Volume 16 Number 10 March 14, 2010

March 14, 2010|Volume 16|Issue 10|WJG|www.wjgnet.com II百世登BaishidengTM©

1239 Managementofbleedingfrompseudoaneurysmsfollowing

pancreaticoduodenectomy

Lee HG, Heo JS, Choi SH, Choi DW

1245 Specificendoscopicfeaturesofulcerativecolitiscomplicatedby

cytomegalovirusinfection

Suzuki H, Kato J, Kuriyama M, Hiraoka S, Kuwaki K, Yamamoto K

1252 Decreasedlevelsofplasmaadiponectinassociatedwithincreasedriskof

colorectalcancer

Otake S, Takeda H, Fujishima S, Fukui T, Orii T, Sato T, Sasaki Y, Nishise S, Kawata S

1258 T300ApolymorphismofATG16L1 andsusceptibilitytoinflammatorybowel

diseases:Ameta-analysis

Cheng JF, Ning YJ, Zhang W, Lu ZH, Lin L

1267 Establishmentofanewquantitativedetectionapproachtoadefovir-resistant

HBVanditsclinicalapplication

Zhao WF, Shao YL, Chen LY, Wu JH, Zhu YL, Gan JH, Xiong H

1274 ClinicalsignificanceofFasandFasLproteinexpressioningastriccarcinoma

andlocallymphnodetissues

Li Q, Peng J, Li XH, Liu T, Liang QC, Zhang GY

1279 Influenceofeffluxpumpinhibitorsonthemultidrugresistanceof

Helicobacterpylori

Zhang Z, Liu ZQ, Zheng PY, Tang FA, Yang PC

1285 Hemeoxygenase-1protectsdonorliversfromischemia/reperfusioninjury:

TheroleofKupffercells

Zeng Z, Huang HF, Chen MQ, Song F, Zhang YJ

1293 Malignanttransformationofectopicpancreaticcellsintheduodenalwall

Bini R, Voghera P, Tapparo A, Nunziata R, Demarchi A, Capocefalo M, Leli R

1296 Concurrentamoebicandhistoplasmacolitis:Ararecauseofmassivelower

gastrointestinalbleeding

Koh PS, Roslani AC, Vimal KV, Shariman M, Umasangar R, Lewellyn R

CASE REPORT

BRIEF ARTICLE

ContentsWorld Journal of Gastroenterology

Volume 16 Number 10 March 14, 2010

FLYLEAF

APPENDIX

EDITORS FOR THIS ISSUE

Responsible Assistant Editor: Xiao-Fang Liu Responsible Science Editor: Lin TianResponsible Electronic Editor: Wen-Hua Ma Proofing Editorial Office Director: Jian-Xia ChengProofing Editor-in-Chief: Lian-Sheng Ma

NAMEOFJOURNALWorld Journal of Gastroenterology

LAUNCHDATEOctober 1, 1995

RESPONSIBLEINSTITUTIONDepartment of Science and Technology of Shanxi Province

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PUBLICATIONDATEMarch 14, 2010

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HONORARYEDITORS-IN-CHIEFJames L Boyer, New HavenKe-Ji Chen, BeijingMartin H Floch, New Haven Geng-Tao Liu, BeijingEmmet B Keeffe, Palo AltoLein-Ray Mo, TainanEamonn M Quigley, CorkRafiq A Sheikh, SacramentoNicholas J Talley, RochesterMing-Lung Yu, Kaohsiung

PRESIDENTANDEDITOR-IN-CHIEFLian-Sheng Ma, Beijing

ACADEMICEDITOR-IN-CHIEFTauseef Ali, OklahomaMauro Bortolotti, BolognaTarkan Karakan, AnkaraWeekitt Kittisupamongkol, BangkokAnastasios Koulaouzidis, EdinburghGerd A Kullak-Ublick, ZürichBo-Rong Pan, Xi’anSylvia LF Pender, Southampton Max S Petrov, AucklandGeorge Y Wu, Farmington

STRATEGYASSOCIATEEDITORS-IN-CHIEFPeter Draganov, FloridaHugh J Freeman, VancouverMaria Concepción Gutiérrez-Ruiz, México

Kazuhiro Hanazaki, KochiAkio Inui, KagoshimaKalpesh Jani, BarodaJavier S Martin, Punta del EsteNatalia A Osna, OmahaWei Tang, TokyoAlan BR Thomson, EdmontonHarry HX Xia, Hanover

ASSOCIATEEDITORS-IN-CHIEFYou-Yong Lu, BeijingJohn M Luk, PokfulamHiroshi Shimada, Yokohama

EDITORIALOFFICEJian-Xia Cheng, DirectorWorld Journal of GastroenterologyRoom 903, Building D, Ocean International Center, No. 62 Dongsihuan Zhonglu, Chaoyang District, Beijing 100025, ChinaTelephone: +86-10-5908-0039Fax: +86-10-8538-1893E-mail: wjg@wjgnet.comhttp://www.wjgnet.com

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March 14, 2010|Volume 16|Issue 10|WJG|www.wjgnet.com III百世登BaishidengTM©

AIM AND SCOPE

ACKNOWLEDGMENTS I AcknowledgmentstoreviewersofWorldJournalofGastroenterology

I Meetings

I-IV Instructionstoauthors

World Journal of Gastroenterology (World J Gastroenterol, WJG, print ISSN 1007-9327, DOI: 10.3748) is a weekly, open-access, peer-reviewed journal supported by an editorial board of 1096 experts in gastroenterology and hepatology from 60 countries.

The major task of WJG is to report rapidly the most recent results in basic and clinical research on esophageal, gastrointestinal, liver, pancreas and biliary tract diseases, Helicobacter pylori, endoscopy and gastrointestinal surgery, including: gastroesophageal reflux disease, gastrointestinal bleeding, infection and tumors; gastric and duodenal disorders; intestinal inflammation, microflora and immunity; celiac disease, dyspepsia and nutrition; viral hepatitis, portal hypertension, liver fibrosis, liver cirrhosis, liver transplantation, and metabolic liver disease; molecular and cell biology; geriatric and pediatric gastroenterology; diagnosis and screening, imaging and advanced technology.

I-VII EditorialBoard

CASE REPORT

Concurrent amoebic and histoplasma colitis: A rare cause of massive lower gastrointestinal bleeding

Peng Soon Koh, April Camilla Roslani, Kumar Vasudeavan Vimal, Mohd Shariman, Ramasamy Umasangar, Rajkumar Lewellyn

Peng Soon Koh, April Camilla Roslani, Department of Surgery, Faculty of Medicine, University Malaya, Kuala Lumpur 59100, MalaysiaKumar Vasudeavan Vimal, Ramasamy Umasangar, Rajkumar Lewellyn, Department of Surgery, Taiping Hospital, Taiping, Perak 34000, MalaysiaMohd Shariman, Department of Pathology, Raja Permaisuri Bainun Hospital, Ipoh, Perak 30990, MalaysiaAuthor contributions: Roslani AC, Koh PS and Shariman M conceived the study, analyzed and interpreted the data; Koh PS, Vimal KV, Shariman M, Umasangar R and Lewellyn R collected the data; Roslani AC and Koh PS wrote the manuscript.Correspondence to: Dr. Peng Soon Koh, MBBS, Department of Surgery, Faculty of Medicine, University Malaya, Lembah Pantai, Kuala Lumpur 59100, Malaysia. kohps2000@yahoo.comTelephone: +60-3-79492070 Fax: +60-3-79586360Received: December 1, 2009 Revised: December 28, 2009Accepted: January 4, 2010Published online: March 14, 2010

AbstractInfective colitis can be a cause of massive lower gastrointestinal bleeding requiring acute surgical intervention. Causative organisms include entamoeba and histoplasma species. However, concurrent colonic infection with both these organisms is very rare, and the in vivo consequences are not known. A 58-year-old male presented initially to the physicians with pyrexia of unknown origin and bloody diarrhea. Amoebic colitis was diagnosed based on biopsies, and he was treated with metronidazole. Five days later, the patient developed massive lower gastrointestinal bleeding with hemorrhagic shock. Emergency total colectomy with end-ileostomy was performed. However, he deteriorated and died on the second postoperative day. Histopathological examination revealed multiple deep ulcers at the hepatic flexure where fungal bodies of mycelial and yeast forms were noted. Isolated lymph nodes showed abscess formation with fungal bodies. Infective fungal

colitis with Histoplasma capsilatum was diagnosed. In vitro , amoebic parasites can increase virulence and pathogenicity of histoplasma which may account for the fulminant presentation in this patient. Although rare, this unusual dual infection should be considered in the differential diagnosis of infective colitis, as appropriate antimicrobial treatment may prevent progression to massive lower gastrointestinal bleeding, obviating the need for urgent surgical intervention.

© 2010 Baishideng. All rights reserved.

Key words: Gastrointestinal hemorrhage; Histoplasma; Amoebic colitis; Colectomy; Infective colitis

Peer reviewer: Dr. Paulino Martínez Hernández Magro, Department of Colon and Rectal Surgery, Hospital San José de Celaya, Eje Vial Norponiente No 200-509, Colonia Villas de la Hacienda, 38010 Celaya, México

Koh PS, Roslani AC, Vimal KV, Shariman M, Umasangar R, Lewellyn R. Concurrent amoebic and histoplasma colitis: A rare cause of massive lower gastrointestinal bleeding. World J Gastroenterol 2010; 16(10): 1296-1298 Available from: URL: http://www.wjgnet.com/1007-9327/full/v16/i10/1296.htm DOI: http://dx.doi.org/10.3748/wjg.v16.i10.1296

INTRODUCTIONMassive lower gastrointestinal bleeding can be fatal and emergency surgery may be required. There are various etiologies leading to such a presentation, with infective colitis being one of the causes. Causative organisms in infective colitis include entamoeba, a parasite, and histoplasma, a dimorphic fungus. Both these organisms can be virulent individually, where mortality is estimated to be 50% in fulminant amoebic colitis, and mortality rates of 20%-25% are estimated in gastrointestinal histoplasma

1296 March 14, 2010|Volume 16|Issue 10|WJG|www.wjgnet.com

World J Gastroenterol 2010 March 14; 16(10): 1296-1298 ISSN 1007-9327 (print)

© 2010 Baishideng. All rights reserved.

Online Submissions: http://www.wjgnet.com/1007-9327officewjg@wjgnet.comdoi:10.3748/wjg.v16.i10.1296

Koh PS et al . Concurrent amoebic and histoplasma colitis

in those who are immunocompromised[1,2]. However, concurrent infection with both these organisms is very rare. We present a case of amoebic and histoplasmic colitis causing fatal massive lower gastrointestinal bleeding.

Case RepORTA 58-year-old male presented initially to the physicians with pyrexia of unknown origin for a month prior to admission. There was associated bloody diarrhea with loss of appetite and weight. There was no history to suggest any respiratory or urinary tract infection and he denied any high risk behavior. There was also no alteration in bowel habit prior to these symptoms.

Blood investigations were unremarkable except for elevated white cell count, erythrocyte sedimentation rate and C-reactive protein levels. Cultures were negative and stools did not show evidence of ova and cysts.

Colonoscopy revealed mucosal inflammation along the rectum and sigmoid interspersed with normal colonic mucosa, with further inflammation and ulcers seen along the hepatic flexure (Figure 1). There was no active bleeding noted. Amoebic colitis was diagnosed based on biopsies from colonoscopy (Figure 2), and he was treated appropriately with metronidazole.

Five days later, the patient developed massive lower gastrointestinal bleeding with hemorrhagic shock. Resuscitation was commenced but he remained unstable and underwent emergency laparotomy. A total colectomy (Figure 3) with end-ileostomy was performed. Mesenteric lymphadenopathy was noted intra-operatively. His condition deteriorated postoperatively with subsequent disseminated intravascular coagulopathy. The patient died on the second postoperative day.

Histopathological examination revealed multiple deep ulcers into the muscularis propria at the hepatic flexure, where fungal bodies with mycelial and yeast formations were seen (Figure 4). Abscesses were also seen in the submucosal and serosal layers containing fungal bodies of yeast form. Isolated lymph nodes showed abscess formation with fungal bodies (yeast form). There was no evidence of malignancy or residual amoebic parasites. Infective fungal colitis with Histoplasma capsulatum was diagnosed.

DIsCUssIONInfective colitis can be severe and fatal. The spectrum of clinical presentation ranges from an asymptomatic state, a mild form with symptoms such as abdominal pain, fever or diarrhea, to a severe state which may result in gastrointestinal bleeding or colonic perforation[3-5]. When presenting with massive gastrointestinal bleeding, surgery is warranted[6].

Appropriate therapy with antimicrobials is vital in the treatment of infective colitis. Metronidazole had been shown to be effective in treatment of amoebic colitis[4]. Despite a negative stool culture and examination as seen

in our case, the endoscopic biopsy was positive, and this had been shown to be most effective in diagnosing amoebic infection[7,8]. It is also interesting to note skip colonic ulcerative lesions were present on our endoscopic findings, which may suggest an inflammatory bowel disease. One tends to associate their appearance with Crohn’s colitis but skip lesions in infective colitis does occur[9,10].

Histoplasma infection is an endemic mycosis commonly found in North and Central America, and complete recovery has been well documented with the use of antifungal therapy such as amphotericin B or itraconazole[11,12]. Isolated gastrointestinal histoplasmosis

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Figure 1 Colonoscopic appearance of an ulcer at the hepatic flexure.

Figure 2 Colonoscopic biopsy showing amoeba (× 40).

Figure 3 Gross appearance of ulcers in the colectomy specimen.

is rare as it is usually asymptomatic with clinical mani-festation occurring in less than 5% of the population, though it may be more common in those who are immuno-compromised[12-14].

In our case, concurrent histoplasmic infection was initially unsuspected, which may have caused progression to the severe end of the clinical spectrum. In vitro tests have shown that amoebic parasites may contribute to the virulence or pathogenic traits of histoplasma[15].

Concurrent colonic infection with both amoeba and histoplasma has not been documented in the literature to our knowledge, although it has been reported in lung infections[15]. The above case presents to us as a very rare form of colitis, which was eventually fatal.

In conclusion, massive lower gastrointestinal bleeding warrants urgent surgical intervention. Infective colitis,

especially with this unusual dual infection, as a cause of such a presentation is rare, but should be considered in the differential diagnosis.

ReFeReNCes1 Li E, Stanley SL Jr. Protozoa. Amebiasis. Gastroenterol Clin

North Am 1996; 25: 471-4922 Assi M, McKinsey DS, Driks MR, O’Connor MC, Bonacini M,

Graham B, Manian F. Gastrointestinal histoplasmosis in the acquired immunodeficiency syndrome: report of 18 cases and literature review. Diagn Microbiol Infect Dis 2006; 55: 195-201

3 Gironés Vila J, Roig García J, Codina Cazador A, Masvidal Calpe R, García Oria M, Codina Barreras A, Pérez Bueno F. [Low digestive hemorrhage caused by amebic colitis] Rev Esp Enferm Dig 1996; 88: 223-225

4 Wandono H. Colitis amebiasis with symptom of occasional dripped anal bleeding. Acta Med Indones 2007; 39: 183-185

5 Deshpande RB, Bharucha MA, Modhe JM, Bhalerao RA. Necrotising arteritis in amoebic colitis. J Postgrad Med 1992; 38: 151-152

6 Eggleston FC, Verghese M, Handa AK. Amebiasis causing massive gastrointestinal bleeding. Arch Surg 1978; 113: 1472

7 Jammal MA, Cox K, Ruebner B. Amebiasis presenting as rectal bleeding without diarrhea in childhood. J Pediatr Gastroenterol Nutr 1985; 4: 294-296

8 Rozen P, Baratz M, Rattan J. Rectal bleeding due to amebic colitis diagnosed by multiple endoscopic biopsies: report of two cases. Dis Colon Rectum 1981; 24: 127-129

9 Clarkston WK, Bonacini M, Peterson I. Colitis due to Histoplasma capsulatum in the acquired immune deficiency syndrome. Am J Gastroenterol 1991; 86: 913-916

10 Wong SY, Ng FH, Kwok KH, Chow KC. Skip colonic ulceration in typhoid ileo-colitis. J Gastroenterol 1999; 34: 700-701

11 Buhk T, Stellbrink HJ, Albrecht H, Sobottka I. [Severe colitis due to Histoplasma capsulatum in an AIDS patient] Z Gastroenterol 2006; 44: 603-607

12 Aubry P, Hovette P. [Digestive disorders in histoplasmosis. Report of a case of ulcerous enterocolitis caused by Histo-plasma capsulatum (author’s transl)] Med Trop (Mars) 1981; 41: 207-213

13 Jain S, Koirala J, Castro-Pavia F. Isolated gastrointestinal histoplasmosis: case report and review of the literature. South Med J 2004; 97: 172-174

14 Averbach M, Cutait R, Corrêa P, Duarte MI, Leite K, Borges JL. [Colorectal diseases in AIDS patients and endoscopic findings] Arq Gastroenterol 1998; 35: 104-109

15 Steenbergen JN, Nosanchuk JD, Malliaris SD, Casadevall A. Interaction of Blastomyces dermatitidis, Sporothrix schenckii, and Histoplasma capsulatum with Acanthamoeba castellanii. Infect Immun 2004; 72: 3478-3488

S- Editor Wang JL L- Editor Cant MR E- Editor Ma WH

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Figure 4 Histopathological examination. A: Mycelial formations (Periodic acid-Schiff, × 40); B: Yeast formations (HE, × 40).

Koh PS et al . Concurrent amoebic and histoplasma colitis

A

B