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PubMed1979

National Cooperative Crohn's Disease Study: study design and conduct of the study.

The design and execution of the National Cooperative Crohn's Disease Study are described in this paper. The Study incorporated several noteworthy features developed to meet specific demands of the disease and its therapy. A standard clinical grading system, the Crohn's Disease Activity Index (CDAI) was developed to allow uniform decentralized clinical evaluation and decision-making throughout the 5 yr of the study. All three drugs in widespread clinical use in Crohn's disease were studied both for suppressive and prophylactic efficacy and for toxicity. The study employed a scheme for double-blind evaluation of patient progress which allowed adjustment of prednisone dose according to the degree of illness and ensured continuous monitoring for serious toxicity of any study drug. Results were analyzed primarily by ranking the clinical outcome of every patient according to a uniform and detailed scheme and applying Wilcoxon nonparametric statistics. Outcome was also analyzed by life-table methods. Eleven hundred nineteen patients were entered and 604 patients were randomized at 14 study centers during the 5-yr duration of the study. Twenty patients were eliminated from analysis as not meeting diagnostic criteria for Crohn's disease, and another 15 patients were eliminated as not meeting other preestablished criteria for analysis. Nine percent of randomized patients, equally distributed in the four treatment groups, withdrew as noncompliant. Ninety percent of patients completed all or all but one protocol-specified visits, and 95% completed the final radiologic and sigmoidoscopic evaluation.

Azathioprine↗
PubMedDate not supplied

The use of endoscopic biopsy in evaluation of polypoid lesions of the colon.

Use of flexible endoscopes affords biopsy sampling of polypoid lesions of the colon, especially within the rectum and sigmoid colon by flexible fiberoptic sigmoidoscopes. Histologic examination of colonic biopsies usually allows division of polyps into neoplastic and non-neoplastic categories. There are significant limitations to such biopsies, however, due to sampling error and inability to reach deep submucosal cores of polyps where malignant invasion may occur. When properly aware of its limitations, the endoscopist will find the endoscopic biopsy a valuable aid in planning the therapeutic approach to a polypoid lesion of the colon.

Adenoma↗
PubMed1985

Flexible sigmoidoscopy: safety and usefulness in the geriatric patient.

The flexible sigmoidoscope is clearly the best available screening tool for colorectal cancer. It is superior to rigid sigmoidoscopy in that the flexible scope can examine longer lengths of bowel and yields a larger number of pathologic findings. The majority of colon cancers lie beyond the view of the rigid scope, which detects only about 30% of all malignant lesions.

Aged↗
PubMed1974

Pseudomembranous colitis associated with antibiotic therapy - an emerging entity.

Two cases of pseudomembranous colitis are presented. The first patient had been treated with novobiocin-tetracycline and penicillin, and two weeks later developed severe fulminating diarrhea with ascites and bilateral pleural effusions which did not respond to intravenous ACTH. Subsequently she underwent subtotal colectomy and made a rapid and complete recovery. The second patient developed severe diarrhea two weeks after a 10-day course of clindamycin. She was treated with intravenous ACTH, oral Lactobacillus and a fecal enema and made a complete recovery.These cases reconfirm the importance of antibiotics as etiologic agents in this disease. They also stress the classic sigmoidoscopic and histologic findings that should facilitate prompt and rapid diagnosis.

Adolescent↗
PubMed1974

Pseudomembranous enterocolitis. Resurgence related to newer antibiotic therapy.

Six patients with pseudomembranous entercolitis were seen at one institution over a six-month period. Clindamycin therapy preceded the diagnosis in all six patients and possibly caused the disease in five cases. Common clinical features included diarrhea, abdominal pain, fever, leukocytosis, radiographic findings of large bowel dilatation with mucosal thickening and a characteristic sigmoidoscopic or gross pathologic demonstration of discrete yellow-white plaques on an otherwise normal mucosa. Complications included toxic megacolon and sigmoid colon perforation. Two of the six patients died. The literature since 1970 is tabulated to clarify the clinical and pathological features of pseudomembranous enterocolitis associated with newer antibiotic therapy. Lincomycin and clindamycin are strongly implicated in the recent resurgence of this formerly rare variety of colitis.

Adult↗
PubMed1979

Clinical usefulness of rectal biopsy in Crohn's disease.

Initial rectal biopsies from 349 patients judged on clinical, radiologic, or pathologic grounds to have Crohn's disease were studied, and findings were compared with a variety of clinical varibles. Biopsies from only 54 patients (15% of total) contained histologic changes characteristic of Crohn's disease, and all but one of these were previously known to have colonic involvement. Yield of diagnostic findings was directly associated with the presence of sigmoidoscopic or radiologic abnormality in the distal colon or rectum. Minor, nondiagnostic abnormalities were more common. It is concluded that routine single rectal biopsy in unselected cases of Crohn's disease has limited diagnostic value under usual conditions of practice, and that histologic abnormalities are most likely to be found in patients with known colonic, and especially sigmoid and rectal involvement.

Adult↗
PubMed1979

Colorectal cancer. A study of 230 patients.

Clinical presentation, risk factors, investigations, pathology and treatment were examined in a retrospective review of 230 patients with colorectal cancer. Many patients presented with symptoms not usually associated with colorectal cancer, such as pain in the upper part of the abdomen, and rectal bleeding separate from the stool. Iron deficiency anaemia was an uncommon presentation. Over all, one-third of patients had at least one risk factor for colorectal cancer. Risk factors such as adenomatous polyps and family history of colorectal cancer were more common than inflammatory bowel disease and polyposis coli. Although a delay in diagnosis was recorded in one-quarter of patients, the finding of a negative correlation between duration of symptoms and extent of spread suggests that the length of the symptomatic illness is not an important factor in prognosis. Contrary to surgical and medical teaching, only 43% of cancers were in the rectum and rectosigmoid area, and, hence, within reach of the standard sigmoidoscope. Surgical resection was performed in 76% of patients. Forty-three per cent of patients who underwent surgery developed at least one postoperative complication resulting in a longer stay in hospital.

Adenocarcinoma↗
PubMed1984

Barium enema after flexible sigmoidoscopy: is delay necessary?

There exists a traditional belief that sigmoidoscopy immediately prior to barium enema produces excessive gas and irritability, which subsequently interfere with performance and interpretation of the barium enema study. A survey was initiated to determine whether primary care physicians are generally advised not to perform barium enema examination immediately following proctosigmoidoscopy on the same day. Almost two thirds (56/89) of the physicians indicated that delaying barium enema examination was standard practice in their community. A prospective study was performed on 16 subjects who were examined by a 60-cm flexible sigmoidoscope and then sent for air-contrast barium enema. Ninety-four percent (15/16) of the subjects completed radiologic examinations with no increase in technical difficulty or patient discomfort. One subject was considered to have excessive gas on scout film and was rescheduled for barium enema examination on another day. This preliminary study supports the hypothesis that the majority of patients can sequentially receive both examinations on the same day. For appropriate patients this scheduling would represent a great savings in time, effort, and exposure to bowel preparation protocols.

Attitude of Health Personnel↗
PubMed1983

[Sphincter preservation in rectal cancer: possibilities and limits of anterior resection].

The feasibility of sphincter preservation was studied in surgery of tumours in the upper, middle and lower third of the rectum. All patients operated on for rectal cancer between January 1977 and May 1980 were included in the investigation. Preoperative localization of the tumours was performed with the rigid sigmoidoscope. Every patient was scheduled for post-operative follow up. Altogether 211 patients were operated on for rectal cancer. 111 were treated by anterior resection, 90 by abdominoperineal excision, and 10 by other sphincter-saving methods. All of the 59 tumours located in the upper third of the rectum (12 to 16 cm from the anus) were treated by anterior resection. 62 tumours were located in the middle third (8 to 12 cm). In these cases anterior resection was carried out in 60% of the men and in 82% of the women, whereas the other patients underwent abdominoperineal excision. 80 tumours were located in the lower third (4 to 8 cm). Anterior resection was possible in only 4.4% of the men and in 14% of the women. Irrespective of their localization on sigmoidoscopy, 37% of the tumours which were within reach of the finger on rectal palpation could be removed by anterior resection. Local recurrence after anterior resection occurred in 18.3%, the median follow-up time being 50 months. The cumulative probable survival for all stages was more than 5 years for 60% of the patients.

Aged↗
PubMed1984

Adenocarcinoma of the colon and rectum in patients less than 40 years of age.

Sixty-two patients less than 40 years of age were admitted with adenocarcinoma of the colon and rectum between 1967 and 1981 at the Methodist Hospitals of Memphis. These represented 3.2 per cent of a total of 1909 patients with the disease during the same time period. Eighty-one per cent presented less than 6 months after onset of symptoms; pain and bleeding being the most common complaints. Inflammatory bowel diseases and polyposis were uncommon. Fifty-eight per cent of the lesions were within reach of the sigmoidoscope. Localized disease was present in 37.9 per cent, with one-third presenting with distant metastases. Sixty-five per cent were considered curable at initial laparotomy. Only 2 per cent of the lesions were well differentiated, and mucin production was noted in 32.3 per cent of the specimens compared to 8.6 per cent in the total group. Vascular invasion was noted in 24 per cent and perineural invasion in 11 per cent. Five-year survival was only 17.6 per cent, although this increased to 33 per cent in those undergoing curative resection. Survival in the total group of 1909 patients was 35.5 per cent at 5 years. The poorer survival in the young patients does not seem to be on the basis of delay in diagnosis, premalignant states, or distribution of lesions, but rather it reflects an inherently more virulent lesion. This impression is supported by a greater incidence of mucinous tumors (a poor prognostic indicator) and higher incidence of advanced disease, especially in the second and third decades.

Adenocarcinoma↗
PubMed1983

Successful management of injuries to the extraperitoneal rectum.

We reviewed the records of 32 patients having extraperitoneal rectal trauma in the six-year period ending December 31, 1981. There were 23 penetrating injuries and nine blunt injuries. All patients were resuscitated and examined digitally by sigmoidoscope. Complete diverting colostomy and washout evacuation of the defunctionalized rectal segment were performed routinely. Dilatation of the anal sphincter and lavage with two to three liters of dilute povidone-iodine solution permitted cleansing of the rectal segment of all particulate fecal material. Retrorectal suction drains were inserted in 30 patients; the two remaining patients required abdominoperineal resection and gauze packing of the pelvis for control of hemorrhage. The mortality rate due to rectal injury was 3 per cent. Complications occurred in 5 patients (16%).

Accidents, Traffic↗
PubMed1983

Management of foreign bodies and trauma of the rectum.

A series of 101 patients with trauma of the rectum, secondary to homosexual practices, presenting at this hospital and medical center is reviewed. Two patients were injured twice. Thirty-six patients had retained foreign bodies in the rectum, 55 had lacerations of the mucosa, two had disruptions of the anal sphincter and ten had perforations of the rectosigmoid. The majority of retained foreign bodies can be removed on an outpatient basis. If removal is not immediately possible, the patient should be admitted for observation and removal of the foreign body transanally under anesthesia. Routine sigmoidoscopic examination is performed after removal. Removal seldom requires laparotomy. Simple nonbleeding lacerations of the mucosa can be managed on an outpatient basis. Patients with abdominal pain, fever, continued bleeding, large lacerations or tear of the sphincter should be admitted and observed or operated upon, or both, as needed. Serious injuries, secondary to homosexual acts, can and do occur, as evidenced by the mortality reported in this series. Perforations of the rectosigmoid above the peritoneal reflection can be treated by laparotomy, repair of the perforation, removal of gross contamination by irrigation, proximal loop colostomy and appropriate antibiotic therapy. Perforations below the peritoneal reflection are challenging instances which require individualized management.

Adolescent↗
PubMed1983

Giant pseudopolypoidal retrograde obstruction in ulcerative colitis.

A partially obstructing giant pseudopolyp of the left colon precluded examination of the proximal colon by sigmoidoscope and by retrograde barium enema. Four ounces of oral Gastrografin was used to opacify the colon at 24 h. It is suggested that the use of water soluble contrast media has a role to play in colon investigation in special situations.

Adult↗
PubMed1980

Campylobacter jejuni enterocolitis. A clinicopathologic study.

Sixteen patients with diarrhea due to Campylobacter jejuni seen within a one-year period at a general hospital were studied to review the clinical and pathological features of this illness. Campylobacter jejuni causes an acute diarrheal illness often associated with fever, delayed-onset hematochezia, and severe abdominal pain. Roentgenographically, one may see colonic and ileal ulceration. Sigmoidoscopically, the rectal appearance is similar to that from acute idiopathic ulcerative colitis, while rectal biopsy specimens show preservation of glandular architecture and a range of focal inflammatory changes. These changes are most severe in patients with a history of frank blood in stool, provided the specimens are taken within the first week of illness. No correlation between stool frequency, abdominal pain, or fever and the severity of proctitis in rectal biopsy specimens can be drawn, which suggests that the pathogenic determinants for thesse clinical manifestations may not be in the rectum, but higher in the colon or in the small intestine.

Campylobacter↗
PubMed1978

Treatment of antibiotic-associated pseudomembranous colitis with cholestyramine resin.

Pseudomembranous colitis (PMC) is an infrequent but serious complication of oral and intravenous antibiotic therapy. Twelve patients with antibiotic-associated PMC, documented by sigmoidoscopy and rectal biopsy, were treated with cholestyramine resin. The mean time from the institution of therapy to cessation of diarrhea was 2.1 days. The response interval bore no relationship to the time symptoms were present prior to therapy. Complete resolution of sigmoidoscopic and histologic evidence of PMC usually accompanied or followed cessation of diarrhea. Obstipation was reported in 5 of 12 patients as a side effect of cholestyramine treatment. Therapy should be continued for up to five days after cessation of diarrhea to prevent recurrence of active PMC. Cholestyramine resin is shown to be an effective treatment for antibiotic-associated PMC.

Adolescent↗
PubMed1980

Pseudomembranous colitis in a patient on rifampicin and ethambutol.

A fifty-seven year old male with renal tuberculosis developed pseudomembranous colitis on rifampicin and ethambutol. Diarrhoea occurred within a week, and six weeks after commencing these antituberculous agents he developed typical sigmoidoscopic and biopsy findings. Withdrawal of the drugs led to rapid recovery. Repeated challenge testing indicated that the symptoms were worse when rifampicin was given, but a test dose of ethambutol also produced temporary aggravation of the diarrhoea.

Biopsy↗
PubMed1980

Evaluation of screening tests for colorectal cancer.

The following guidelines are proposed for the asymptomatic patient representing for routine examination. Instruct the patient to eat All Bran cereal or a similar product for breakfast for three consecutive days prior to the day of appointment. At the time of appointment the stool obtained from rectal examination or from a spontaneous bowel movement is checked for occult blood using the guaiac method. If the findings are negative, no further tests are recommended. If positive, the patient is given complete dietary instructions in a non-meat, high-residue diet with avoidance of beets, horseradish, vitamins, or aspirin-containing compounds. The patient is then given six Hemoccult or Quikcult slides and is instructed to prepare two fecal slides from each stool specimen daily for three days. If these are all negative when tested, no further studies are necessary. If one or more are positive, however, sigmoidoscopic examination and colon and upper gastrointestinal radiography should be carried out in that order. Evidence that early lesions (Duke A or B) are detected and the cure rate improved with this procedure is quite convincing.

Carcinoembryonic Antigen↗
PubMed1982

Metronidazole: an alternate therapy for antibiotic-associated colitis.

The results of treatment of 13 consecutive cases of antibiotic-associated pseudomembranous colitis with oral metronidazole are described. The diagnosis was made by typical sigmoidoscopic appearance with a confirming characteristic colonic biopsy specimen and/or stools positive for Clostridium difficile cytotoxin. All patients responded with the disappearance of diarrhea between 1 and 5 days. Two patients experienced relapse when the therapy was discontinued. Our experience with metronidazole shows that it is an effective treatment for antibiotic-associated pseudomembranous colitis. The response to metronidazole treatment compares favorably with that usually obtained with vancomycin.

Adult↗