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PubMed1999

Comparison of the color of fecal blood with the anatomical location of gastrointestinal bleeding lesions: potential misdiagnosis using only flexible sigmoidoscopy for bright red blood per rectum.

OBJECTIVE: Flexible sigmoidoscopy has been recommended for diagnosis of patients with bright red rectal bleeding. The purpose of this study was to determine whether lesions associated with bright red hematochezia are located in the distal 60 cm of the colorectum and, therefore, in reach of a flexible sigmoidoscope. METHODS: Three hundred-twelve consecutive patients presenting with hematochezia were shown a card containing three shades of red and asked to choose the color most representative of their fecal blood. Patients then underwent colonoscopy. The colonoscopist noted the length of the scope inserted when bleeding lesions were found. RESULTS: Of 217 patients with bright red hematochezia, 181 bled from the distal 60 cm of the colon, 20 had more proximal lesions (including eight with cancer), and 16 had no lesion found. However, 140 patients with rectosigmoid neoplasms or nonbleeding nonneoplastic lesions (e.g., hemorrhoids, diverticula, vascular anomalies, and fissures) if found by sigmoidoscopy would have subsequently required full colonoscopic surveillance. It was calculated that the average per patient medical charges employing an initial colonoscopic approach would save $12 or $116 over one beginning with sigmoidoscopy (depending on whether sigmoidoscopy is performed in an office setting or endoscopy suite, respectively), and would reduce the probability of perforation slightly. CONCLUSION: A diagnostic approach to hematochezia beginning with colonoscopy should be more effective, safer, and less costly than one beginning with flexible sigmoidoscopy, even when the blood is bright red.

Adolescent↗
PubMed2001

Effect of ecabet sodium enema on mildly to moderately active ulcerative proctosigmoiditis: an open-label study.

OBJECTIVES: Ecabet sodium (ES), a nonabsorbable antigastric ulcer agent, has been shown to adhere to the region of an ulcer. It topically enhances gastric mucosal defensive factors such as the endogenous prostaglandins, capsaicin-sensitive sensory nerves, nitric oxide, and mucin. All of these mucosal defensive factors play an important role in maintaining the mucosal integrity of the colon and rectum. Therefore, we investigated the effect of ES in patients with mildly to moderately active ulcerative proctosigmoiditis. METHODS: In an open-label study, seven patients with mildly to moderately active ulcerative colitis (UC) who had an inflamed mucosa in the rectum and/or sigmoid and were resistant to 4-wk topical and systemic standard treatment were treated with an ES enema b.i.d. for 14 days. The enema consisted of ES (1 g) and tepid water (20 or 50 ml). These patients were assessed by the Clinical Activity Index, colonoscopically, and histologically before and after the ES therapy. The ES therapy was started after obtaining informed consent from the patients. RESULTS: Six of the seven patients responded to therapy and achieved clinical, endoscopic, and histological remissions. One patient was withdrawn because of increased stool frequency. All six patients who completed the study showed a significant change in the mean Clinical Activity Index score from 5.3+/-1.4 (mean +/- SD) to 0.5+/-0.8 (p < 0.05), in the colonoscopic score from 3.0+/-0.9 to 0.8+/-0.4 (p < 0.05), and in the histological score from 2.7+/-0.5 to 0.5+/-0.6 (p < 0.05), and achieved remission at the end of the study. There were no side effects attributable to the ES therapy. Five of the six patients are still in clinical remission after a median follow-up period of 5 months. CONCLUSIONS: The ES enemas proved to be a safe and potentially useful adjuvant therapy currently available for treating patients with mildly to moderately active ulcerative proctosigmoiditis. A controlled study is necessary to confirm our results.

Abietanes↗
PubMed2001

Endoscopic therapy of acute diverticular hemorrhage.

OBJECTIVE: Diverticular hemorrhage is a common cause of lower GI bleeding and can be diagnosed acutely during colonoscopy. However, whether early diagnosis leads to effective intervention remains controversial. The aim of this study was to evaluate whether urgent colonoscopic therapy is effective as acute and long term treatment for diverticular bleeding with stigmata of hemorrhage. METHODS: We reviewed the medical records of all patients who underwent endoscopic therapy for diverticular bleeding from January, 1994 to June, 2000 at Duke University Medical Center. Patients or their families were contacted to obtain complete follow-up including data on subsequent bleeding. RESULTS: We identified 13 patients who underwent colonoscopic hemostatic management for the treatment of acute diverticular bleeding. Therapy consisted of epinephrine injection and/or multipolar electrocoagulation. Five patients (38%) experienced early rebleeding, within 30 days of the index bleed, four of whom required surgery, and three patients (23%) had late rebleeding. There were no complications of endoscopic therapy. CONCLUSIONS: Endoscopic therapy can provide early hemostasis in some cases of acute diverticular hemorrhage. However, its value in preventing subsequent diverticular bleeding is unclear.

Aged↗
PubMed2001

Magnifying colonoscopy in differentiating neoplastic from nonneoplastic colorectal lesions.

OBJECTIVE: Because the medical management of persons with adenomatous colorectal polyps differs from that of those with hyperplastic polyps, accuracy of diagnosis is essential. This study reports our experience using a magnifying colonoscope combined with indigocarmine dye to diagnose colorectal polyps, emphasizing its ability to differentiate neoplastic from nonneoplastic lesions. METHODS: The materials consisted of 175 polyps. A 0.2% indigocarmine solution was sprayed, and the colonoscope zoom apparatus performed a magnified observation after an ordinary colonoscopy identified the lesions. The pit patterns were classified into six categories: I, II, III(L), IIIs, IV, and V according to Kudo's modified classification. RESULTS: The percentages of neoplastic changes in the lesions with pit pattern I, II, III(L), IIIs, IV, and V were 0, 12.2, 69.7, 80, 84.4, and 100%, respectively. The diagnostic sensitivity of neoplastic lesions was 93.8% and specificity was 64.6% when types I and II represented the pit pattern of nonneoplastic lesions and types III(L), IIIs, IV, and V represented neoplastic lesions. The overall diagnostic accuracy in differentiating neoplastic from nonneoplastic lesions was 80.1%. The diagnostic accuracy is not influenced by the size and shape of the lesions. The six neoplastic lesions that were misjudged to be nonneoplastic were histologically adenoma with only mild atypia. CONCLUSIONS: The pit pattern analysis of colorectal lesions by magnifying colonoscopy is a useful and objective tool for differentiating neoplastic from nonneoplastic lesions of the large bowel. In its current state of development, however, this technique is not a substitute for histology.

Adult↗
PubMed2002

Method of colonoscopy in 42 consecutive patients presenting after prior incomplete colonoscopy.

OBJECTIVES: Cecal intubation is one of the goals of colonoscopy. We sought to describe the methodology used by a single experienced examiner to perform colonoscopy in a consecutive group of patients with challenging colons. METHODS: Records of 42 consecutive patients with one or more prior unsuccessful attempts at colonoscopy by a gastroenterologist or surgeon and referred for a repeat attempt at colonoscopy were reviewed. RESULTS: Colonoscopy was complete to the cecum in 40 of the 42 patients (95%). An array of methods was employed, including propofol sedation (n = 2), pediatric colonoscope (n = 8), an external straightener (n = 9), external straightener with pediatric colonoscope (n = 2), upper endoscope (n = 8), guidewire exchange (n = 3), and enteroscope with a colon straightener (n = 1) or an enteroscope straightener (n = 1). CONCLUSIONS: A variety of methods and instruments were employed to achieve a high cecal intubation rate during colonoscopy in a group of patients with prior incomplete colonoscopies. Others may find one or more of these methods useful in patients with challenging colons.

Adult↗
PubMed1994

Cyclosporin as initial treatment for Crohn's disease.

Childhood Crohn's disease may cause significant morbidity. T cell activation is considered to be central to Crohn's disease pathology, and as cyclosporin is a powerful inhibitor of T cell activation, and has been used in adult Crohn's disease with encouraging results, it may offer the prospect of remission if given early in the course of disease. Children with newly diagnosed Crohn's disease or those relapsing off treatment were therefore given cyclosporin or conventional treatment (enteral nutrition or corticosteroids) by random allocation. Evaluation was performed initially and at two months. Twenty four children were studied (10 on cyclosporin and 14 on conventional treatment; one child on cyclosporin withdrew). Significant clinical improvement occurred in the group on conventional treatment, but not in the cyclosporin group. Colonoscopic improvement was noted in 5/9 on cyclosporin and 8/14 on conventional treatment, but neither group produced a significant fall in median colonoscopic index. Histological improvement was seen in 7/8 on cyclosporin and 8/13 on conventional treatment, but cyclosporin was not significantly better. Cyclosporin produced improved clinical and histological appearance without matched improvement in blood disease indices. It was not better than conventional treatment, and simple oral administration is probably not suitable for newly diagnosed patients with Crohn's disease.

Adolescent↗
PubMed1990

Schistosomal colonic disease.

This study evaluates 216 patients with schistosomal colonic disease, diagnosed by endoscopic biopsies at the Armed Forces Hospital, Riyadh. The colonoscopic appearance was suggestive of schistosomiasis in 98 of these patients (45.37%), Schistosoma mansoni ova in stool was detected in only 24 of these 216 patients (11.11%). The most common histopathological finding in colonic biopsies of these patients was Schistosoma mansoni ova in the colonic mucosa with no or mild inflammatory cells infiltrates. These findings correlate with the endoscopic appearances in most patients. The most common symptoms were abdominal pain or distention in 84 patients (38.88%). Sixty five patients (30.09%) had hepatosplenic schistosomiasis. Eight patients had schistosomal polyps and two patients had colonic malignancy in which no association between their malignancy and Schistosoma mansoni infection was established. After antischistosomal treatment follow up, sigmoidoscopy was normal in 28 patients who previously had abnormal endoscopic appearances. Colonoscopic examination is valuable in colonic schistosomiasis as it can show characteristic colonic lesions and colonic biopsies are diagnostic and correlates with histological findings.

Adolescent↗
PubMed1991

Dysplasia and carcinoma in longstanding ulcerative colitis: an endoscopic and histological surveillance programme.

From 1976 to 1989 a total of 66 patients with longstanding ulcerative colitis were entered in a colonoscopic surveillance programme in order to detect dysplasia. Thirty patients had extensive or total ulcerative colitis and 36 left sided colitis. The median duration of the disease at the end of the follow up was 15.0 years. Altogether 182 colonoscopies (2.8 per patient), each involving approximately 20 biopsies from different sites of the colon, were performed. In the total or extensive colitis group, five patients had low grade and one patient had high grade dysplasia. In the left sided colitis group, three patients had low grade dysplasia. In three patients low grade dysplasia was detected in a macroscopic lesion or mass of colonic mucosa. Sixty per cent of the dysplasia specimens were from the right colon. The incidence of dysplasia was higher in patients with extensive colitis and increased with the duration of the disease. None of the patients have so far developed colorectal carcinoma. Our results indicate that a colonoscopic surveillance programme is a safe alternative to prophylactic colectomy in longstanding ulcerative colitis.

Adolescent↗
PubMed2003

Grading of distal colorectal adenomas as predictors for proximal colonic neoplasia and choice of endoscope in population screening: experience from the Norwegian Colorectal Cancer Prevention study (NORCCAP).

BACKGROUND AND AIMS: The purpose of this study was to evaluate the utility of easily measured clinical variables at flexible sigmoidoscopy (FS) screening that might predict a proximal advanced neoplasm (PAN). METHODS: We studied 1833 subjects with biopsy verified adenomas at FS who subsequently underwent full colonoscopy. RESULTS: A total of 387 (21%) subjects had proximal colonic neoplasms (PCN) and 85 (5%) had PAN. In univariate comparison, the risk of PAN increased more than threefold in the presence of a distal adenoma measuring either > or =10 mm in diameter or containing villous components. Multiplicity of distal adenomas, severe dysplasia, or age > or =60 years increased the risk of PAN more than twofold. In the multivariate model, the presence of a distal adenoma > or =10 mm, villousness, and multiplicity maintained their significance as predictive variables for increased risk of proximal neoplasms, whereas sex and severe dysplasia lost their significance. By recommending colonoscopy only to individuals with multiple (>1) adenomas or any high risk adenoma at FS, we would have reduced the number of colonoscopies by 1209 (66%) but would have missed 32 (38%) participants with PAN and 217 (56%) with PCN. By using a 60 cm endoscope instead of an ordinary colonoscope at FS, nine (2%) participants with advanced neoplasms, including three patients with cancer, would have been missed. CONCLUSION: The present study supports the concept of defining "any adenoma" as a positive FS, qualifying for colonoscopy. We recommend the use of an ordinary colonoscope instead of a 60 cm sigmoidoscope for FS screening examinations.

Adenoma↗
PubMed2002

How could pathologists improve the initial diagnosis of colitis? Evidence from an international workshop.

BACKGROUND: The taking of multiple colorectal biopsies is in widespread use although there is little research into their benefit for the pathological diagnosis of inflammatory bowel disease. There is also still debate about appropriate morphological criteria for interpreting these biopsies. AIMS: To determine the effect of single versus multiple biopsies on the accuracy of diagnosis and to study the accuracy and reproducibility of the different criteria used in the diagnosis of multiple biopsies by expert and non-expert pathologists. METHOD: Thirteen expert and 12 non-expert international diagnostic histopathologists attended a workshop. Sixty cases with full follow up were viewed, blinded, in two rounds. Diagnoses were made on rectal biopsies and then full colonoscopic series. RESULTS: Experts correctly identified 24% of Crohn's disease cases (non-experts, 12%) from the rectal biopsies. This improved to 64% (non-experts, 60%) with the full series. The accuracy of the diagnosis of ulcerative colitis also improved slightly with the full series from 64% to 74% overall. Experts had a similar (moderate) level of agreement and accuracy to non-experts. For Crohn's disease, the likelihood ratios (LR) for the most important individual features were 12.4 for granulomas and 3.3 for focal or patchy inflammation. Features favouring ulcerative colitis were diffuse crypt architectural irregularity (LR, 3.4), general crypt epithelial polymorphs (LR, 3.7), and reduced crypt numbers (LR, 2.9). CONCLUSIONS: A full colonoscopic series gave more accurate diagnosis than a rectal biopsy. Accurate pathologists used the same evidence based criteria for multiple biopsies as for single biopsies.

Biopsy↗
PubMed1997

A clinical study on physiological response in electroacupuncture analgesia and meperidine analgesia for colonoscopy.

Fifty-nine patients underwent consecutive colonoscopic examination with premedication of electroacupuncture analgesia (EA) were compared with conventional meperidine analgesia (MA) in pain relief and changes of neurotransmitters in serum. The results showed that analgesic efficacy of both groups were the same but with less side effects in the EA group (P < 0.01) especially in regard to dizziness. Serum concentration of beta-endorphin in both groups has a similar curve change at 4 different phases during colonoscopy. Serum concentration of epinephrine, norepinephrine, dopamine and cortisol showed no significant difference between these two groups. The analgesic effect of EA and MA during colonoscopic examination may be closely related to beta-endorphin production in serum.

Acupuncture Analgesia↗
PubMed1977

Colonic polyp detection: role of roentgenography and colonoscopy.

In order to determine the relative yields of colonoscopic and radiologic examinations of the colon, the following guidelines are suggested: (a) prospective data collection; (b) a standard, effective colon cleansing regimen; (c) colonoscopic and radiologic examiners of comparable expertise; (d) examiners should be unaware of each other's findings; (e) a suitable method for demonstrating false-negative findings and for resolving conflicting findings between the two examinations; and (f) indexing of the study findings as to lesion size, lesion location, quality of colon cleansing, and examiner's level of confidence. The two examinations should be used as complementary diagnostic procedures.

Colon↗
PubMed1998

Detection of mass lesions with MR colonography: preliminary report.

PURPOSE: To evaluate the performance of magnetic resonance (MR) colonography in the detection of colorectal mass lesions. MATERIALS AND METHODS: Twenty-three patients underwent MR colonography preceding colonoscopy. The colon was filled with a gadolinium-water mixture (1:100) with MR imaging guidance, and the patient was imaged prone and supine with a breath-hold three-dimensional spoiled gradient-recalled sequence. In addition, two-dimensional spoiled gradient-recalled images were acquired before and after intravenous administration of gadopentetate dimeglumine. Images were interactively analyzed on the basis of multiplanar reconstruction by two radiologists. For regions that were not conclusively assessable with multiplanar reconstruction, virtual intraluminal endoscopic images of the colon were reconstructed. MR findings were correlated with colonoscopic results. RESULTS: Two patients were excluded from the analysis. Findings in eight of 11 patients were correctly assessed as normal and in six of 10 as mass-positive. In the four patients with false-negative findings, one had two 8-mm polyps and the other three had polyps smaller than 5 mm. All nine mass lesions larger than 10 mm, as well as four of the 10 polyps ranging between 5 and 10 mm, were detected, but all polyps smaller than 5 mm were missed. In contrast to the polyps less than 5 mm, the four missed polyps (5-10 mm) could be identified retrospectively on virtual intraluminal endoscopic images. Contrast enhancement was documented in 13 polyps. CONCLUSION: Three-dimensional MR colonography provided virtual colonoscopic viewing and helped detection of colonic polyps.

Adult↗
PubMed2003

Simple and efficient method for isolation and cultivation of endoscopically obtained human colonocytes.

Few comparative and validated reports exist on the isolation and growth of colonoscopically obtained colonic epithelium. The aim of this study was to develop and validate a simple method for the cultivation of colonoscopically obtained colonocytes. Forty patients, who underwent routine colonoscopy and where the diagnosis of irritable bowel syndrome was later reached, were included. Seven colon biopsies were taken and incubated at varying time periods of 10-120 min and temperatures of 4-37 degrees C in a chelating buffer. The epithelium was then harvested and cultivated under three different conditions: 1) on a collagen coating, 2) embedded in a collagen gel, or 3) embedded in a gel put on a porous well insert. The effect of conditioned medium (CM), insulin, transferrin, selenium, and the oxygen content was assessed. Viability was tested by the metabolic dimethylthiazol-diphenyl-tetrazolium bromide assay, by flowcytometry, by phase contrast microscopy, and by transmission electron microscopy. Incubation at 21 degrees C for 75 min gave an optimal yield of 3 x 10(6) (2.0-3.8 x 10(6)) viable epithelial cells in intact crypts per seven biopsies. Embedding of crypts in a collagen gel put on a porous membrane was superior to the other methods applied [P < 0.003; median viability 71% (62-100%) compared with preculture values] after 24 h, which was a 160% increase in viability compared with coat-cultivated cells. CM had similar viability supporting effects to FCS. Other supplements had no effects. A simple method is presented, which makes cultivation of colonocytes obtained at endoscopy possible for up to 72 h.

Cell Culture Techniques↗
PubMed2006

Somatic BRAF-V600E mutations in familial colorectal cancer.

The BRAF gene is mutated in 4% to 12% of unselected colorectal cancers, particularly those with high microsatellite instability and in premalignant lesions, such as serrated adenomas and hyperplastic polyps. However, it has been shown that activating BRAF mutations are almost never found in tumors from hereditary nonpolyposis colorectal cancer patients. To evaluate the role of oncogenic BRAF mutations in non-hereditary nonpolyposis colorectal cancer/non-familial adenomatous polyposis familial colorectal cancer, we did a mutation screening of the most common BRAF mutation, the V600E mutation, in 194 colorectal tumors from patients with a positive family history of the disease. The BRAF-V600E mutation was identified in 100% (8 of 8) of microsatellite-unstable tumors and in 9.7% (18 of 186) of microsatellite-stable tumors. Interestingly, families with extracolonic tumors showed a much higher mutation frequency (17.5%) compared with families with colonic cancer only (3.5%; P = 0.009). In addition, we studied colonoscopic results from 448 family members who had been under colonoscopic surveillance for several years. Subjects from families where the V600E mutation was identified had less adenomas compared with those from families where no BRAF mutation had been found (odds ratio, 8.5; 95% confidence interval, 1.1-64.6). These findings indicate that adenomas might be less important in the cancer development in the group of families with BRAF-V600E mutations and indirectly support a previous hypothesis that tumors might develop through the hyperplastic polyp-serrated adenoma pathway. In conclusion, our results suggest that BRAF-V600E mutations are mainly involved in colorectal cancer families characterized by an increased risk of other common malignancies.

Adult↗
PubMedDate not supplied

Diagnostic value of fine needle aspiration biopsy of palpable colonic masses.

OBJECTIVE: To assess the role of fine needle aspiration biopsy (FNAB) in patients with palpable colonic masses. STUDY DESIGN: FNAB was performed on 32 patients with palpable colonic masses before subjecting them to colonoscopic examination. Smears prepared from the material obtained by aspiration biopsy were examined. The results of aspiration biopsy were confirmed by histopathologic examination of the tissue obtained on colonoscopy or surgery or by a salutory response to antituberculous therapy in patients with tuberculosis of the colon. RESULTS: Twenty-nine patients had carcinoma of the colon, and three had ileocecal tuberculosis. Aspiration biopsy could correctly diagnose all the cases with malignancy and two of the three cases with colonic tuberculosis. Colonoscopy could not be performed on two patients with cancer of the colon. However, a barium enema examination revealed evidence of cecal malignancy in both patients. In the two patients diagnosed as having colonic tuberculosis by FNAB, colonoscopic biopsies revealed only nonspecific changes. There were no false positive results or complications of the procedure. CONCLUSION: FNAB is a simple, rapid and accurate method of diagnosing palpable colonic masses.

Biopsy, Needle↗
PubMedDate not supplied

Brush cytology and biopsy in the diagnosis of colorectal cancer. A comparison.

OBJECTIVE: To determine the usefulness of brush cytology of colorectal lesions as compared to biopsy examination. STUDY DESIGN: One hundred brushing cytologies and biopsies were performed on patients who underwent colonoscopic examination for different symptoms. The cytologic smears were classified into five cytologic diagnostic categories. The histologic diagnoses were adenocarcinoma, adenoma and nonneoplastic lesion. RESULTS: Twenty-six cases were cytologically positive for malignant cells, and all were histologically diagnosed as adenocarcinoma. Nineteen cases were suspicious for malignancy on cytology; histologically, eight of them showed adenocarcinoma. Two other cases proved to be adenocarcinoma in subsequent biopsies. Nine cases were adenomas, with severe dysplasia in five of them. Fourteen cases that were cytologically negative with minimal glandular atypia showed seven adenomas and seven nonneoplastic lesions on biopsy. Forty cases negative for malignant cells showed 19 adenomas and 21 nonspecific changes in the biopsy examination. CONCLUSION: Colonoscopic brushing cytodiagnosis is a sensitive technique for the detection of colorectal cancer. The combination of brushing cytology and biopsy improves the accuracy of diagnosis.

Adenocarcinoma↗
PubMed2005

Colonic carcinoma resembling submucosal tumor: report of a case and review of the literature.

Submucosal tumor-like colorectal carcinoma, most of whose surface is covered with normal mucosa, is very rare. We report a case of colonic carcinoma resembling submucosal tumor. A 54-yr-old man visited our institution for an evaluation of a positive fecal occult blood test. Colonoscopic examination revealed a small, mainly red polypoid lesion with a central deep ulceration and many white spots in the sigmoid colon. Indigocarmine staining demonstrated that the white spots were faint shallow depressions. Magnifying colonoscopic examination showed that the lesion surface, except for the ulceration and the depressions, was covered with normal mucosa. Although the tumor was small, we strongly suspected its malignancy due to a deep ulceration. As we could not excise it endoscopically, we performed sigmoidectomy. The lesion was 12 mm in size. Histologic examination revealed that the lesion was a moderately differentiated adenocarcinoma that was mainly covered with normal mucosa, that carcinoma was exposed only at the ulceration and the depressions on the surface, and that it had expanded to the muscularis propria. Together with considerations from the literature, this type of colorectal carcinoma is supposed to be invasive and surgical resection should be considered, no matter how small it may be.

Adenocarcinoma↗