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PubMed1999

Natural history of colorectal cancer.

Colorectal cancer arises from a precursor lesion, the adenomatous polyp, which forms in a field of epithelial cell hyperproliferation and crypt dysplasia. Progression from this precursor lesion to colorectal cancer is a multistep process, accompanied by alterations in several suppressor genes that result in abnormalities of cell regulation, and has a natural history of 10-15 years. Environmental factors and inherited susceptibility play major roles in this sequence of events. As a result of familial and genetic studies, we now have a better understanding of various high-risk groups and the application of screening methods to these individuals and to people at average risk. In the future, further identification of genetically predisposed individuals and colonoscopic screening of the general population may provide new opportunities for control of colorectal cancer through secondary prevention, and a better understanding of lifestyle factors and their modification will lead to improved strategies for primary prevention.

Colonic Polyps↗
PubMed1989

Whole bowel irrigation during pregnancy.

Whole bowel irrigation is a routine colonoscopic preparatory procedure. It has been advocated as a method of cleansing the alimentary canal of poisons after acute overdose. Its use during pregnancy has not been described for either indication. We report a case of an iron overdose during the third trimester treated with whole bowel irrigation without complication.

Adolescent↗
PubMed2000

Controlled 15-year trial on screening for colorectal cancer in families with hereditary nonpolyposis colorectal cancer.

BACKGROUND & AIMS: Identification of the hereditary nonpolyposis colorectal cancer (HNPCC) syndrome enables prevention of colorectal cancer (CRC) by means of colonoscopy and polypectomies. We evaluated the efficacy of screening in a controlled trial over 15 years. METHODS: Incidence of CRC and survival were compared in 2 cohorts of at-risk members of 22 families with HNPCC. Colonic screening at 3-year intervals was arranged for 133 subjects; 119 control subjects had no screening. Genetic testing was offered to subjects in whose families the causative mutation was known. RESULTS: CRC developed in 8 screened subjects (6%) compared with 19 control subjects (16 %; P = 0.014). The CRC rate was reduced by 62%. In mutation-positive subjects alone, the CRC rates were 18% in screened subjects and 41% in controls (P = 0.02). The decrease resulted from the removal of adenomas in 13 mutation-positive individuals (30%) and in 6 subjects with unknown mutation status (40%). All CRCs in the study group were local, causing no deaths, compared with 9 deaths caused by CRC in the controls. The overall death rates were 10 vs. 26 subjects in the study and control groups (P = 0.003), 4 vs. 12 in mutation-positive subjects (P = 0.05). CONCLUSIONS: Colonoscopic screening at 3-year intervals more than halves the risk of CRC, prevents CRC deaths, and decreases overall mortality by about 65% in HNPCC families.

Adaptor Proteins, Signal Transducing↗
PubMed1987

Primary sclerosing cholangitis in childhood.

Thirteen children (8 female) with primary sclerosing cholangitis are described, in whom the diagnosis was confirmed by the presence of characteristic changes on endoscopic retrograde cholangiopancreatography. Nine had clinical features of chronic inflammatory bowel disease 1 mo to 5 yr before the onset of primary sclerosing cholangitis (6 patients) or appearing simultaneously with primary sclerosing cholangitis (3 patients). In 4 patients clinical evidence of chronic inflammatory bowel disease was absent but 1 of the 4 was found to have microscopic colitis in colonoscopic biopsy specimens. Biopsies were not performed in the remaining 3 patients. High immunoglobulin G concentrations and positive antinuclear or smooth muscle antibodies were present in all patients except 1 who had been given immunosuppressants. In 7 patients treated with immunosuppressants and followed up for 9 mo to 10 yr there was modest symptomatic improvement. This improvement was accompanied by a fall in transaminase levels in 6 of the patients and histologic improvement in 3 of 4 patients who had undergone biopsy. Greater use of endoscopic retrograde cholangiopancreatography in the last 6 yr led to the identification of 10 of these 13 cases, suggesting a higher incidence of primary sclerosing cholangitis in childhood than would appear from the literature.

Adolescent↗
PubMed1988

Peutz-Jeghers syndrome: a clinicopathologic survey of the "Harrisburg family" with a 49-year follow-up.

Of the original Peutz-Jeghers families reported by Jeghers, the "Harrisburg Family" has now been followed for 49 yr. Their 12 affected family members comprise the largest Peutz-Jeghers kindred reported. The course of this family illustrates that Peutz-Jeghers syndrome is not a benign disease. One family member developed a duodenal carcinoma in a hamartoma with adenomatous changes; this progression in the duodenum has not previously been reported. Ten patients underwent 75 polypectomies. One patient developed short bowel syndrome. Three patients died in young adulthood. The development of gastrointestinal malignancy in 2 of 12 affected patients suggests that Peutz-Jeghers syndrome may be a premalignant condition. Consequently, even asymptomatic gastric, duodenal, and colonic polyps should be removed endoscopically. If surgical intervention is necessary, intraoperative endoscopy with polypectomy may prevent the development of a short bowel syndrome. Colonoscopic screening of patients and their family members may be beneficial and surveillance for extraintestinal malignancy appears to be warranted.

Adolescent↗
PubMed1994

Peanut lectin stimulates proliferation in colonic explants from patients with inflammatory bowel disease and colon polyps.

BACKGROUND/AIMS: The TF antigen (galactose-beta 1,3-N-acetylgalactosamine alpha) is overexpressed in malignant and premalignant colonic epithelium. Previous studies have shown that peanut lectin (PNA), which binds TF, is mitogenic for normal human colonic epithelium. This study aimed to determine its effect on abnormal colonic epithelium. METHODS: Crypt cell proliferation rate (CCPR) was measured using vincristine arrest and mucus synthesis by incorporation of radiolabeled N-acetyl glucosamine in colonoscopic biopsy specimens cultured with and without PNA. RESULTS: Unstimulated CCPR was greater in patients with ulcerative colitis than in patients with histologically normal colon. PNA (25 micrograms/mL) produced a 25% average increase in CCPR in tissues from patients with ulcerative colitis, Crohn's disease, and colonic polyps. In ulcerative colitic biopsy specimens incubated with PNA, CCPR increased to more than double that of unstimulated normal colonic epithelium. In controls, the response to PNA was greater when adjacent specimens were positive for PNA (avidin-biotin) histochemistry than when they were negative. Mucus synthesis was increased by an average 75% over 24 hours by PNA. CONCLUSIONS: Increased TF expression by premalignant epithelia may allow stimulation of proliferation by dietary galactose N-acetylgalactosamine-binding lectins. If the hyperplasia-dysplasia cancer hypothesis is correct, this could explain the increased colon cancer risk in ulcerative colitis.

Acetylglucosamine↗
PubMed1998

Long-term treatment of ulcerative colitis with ciprofloxacin: a prospective, double-blind, placebo-controlled study.

BACKGROUND & AIMS: Although bacterial bowel flora may be one of the contributing factors in the pathogenesis of chronic mucosal inflammation, antibiotic treatment has no established role in ulcerative colitis. The aim of the study was to evaluate the role of ciprofloxacin in the induction and maintenance of remission in ulcerative colitis in patients responding poorly to conventional therapy with steroids and mesalamine. METHODS: Ciprofloxacin (n = 38; 500-750 mg twice a day) or placebo (n = 45) was administered for 6 months in a double-blind, randomized study with a high but decreasing dose of prednisone and maintenance treatment with mesalamine including follow-up for the next 6 months. Clinical assessment and colonoscopic evaluation were performed at 0, 3, 6, and 12 months. Treatment failure, the primary end point, was defined as both symptomatic and endoscopic failure to respond. RESULTS: During the first 6 months, the treatment-failure rate was 21% in the ciprofloxacin-treated group and 44% in the placebo group (P = 0.02). Endoscopic and histological findings were used as secondary end points and showed better results in the ciprofloxacin group at 3 months but not at 6 months. CONCLUSIONS: Addition of a 6-month ciprofloxacin treatment for ulcerative colitis improved the results of conventional therapy with mesalamine and prednisone.

Adult↗
PubMed2000

The impact of colorectal cancer screening on life expectancy.

METHODS: The purpose of this study was to assess the effect of screening for colorectal cancer on life expectancy and estimate the number of colonoscopies needed per life year saved. The declining exponential approximation of life expectancy was used to calculate the effect of colorectal cancer screening on expected remaining lifetime. The annual number of deaths from colorectal cancer and the size of the population were obtained from the vital statistics of the United States. Published reports were consulted to determine the decrease in mortality from colorectal cancer achieved by fecal occult blood testing, screening sigmoidoscopy or colonoscopy. A Markov chain analysis was used to determine the endoscopic resources required to screen and survey the entire population of U.S. residents age 50 years until death or age 85 years. RESULTS: Colorectal cancer decreases the life expectancy of U.S. residents aged 50 to 54 years by 292 days and those aged 70 to 74 years by 70 days. Screening with fecal occult blood tests extends expected lifetime of the 2 age groups by 51 and 12 days, respectively, whereas screening with sigmoidoscopy leads to increases of 86 and 21 days. Colonoscopic screening increases expected lifetime by 170 and 41 days, respectively. The number of colonoscopies needed to save 1 year of expected life ranges from 2.9 to 6.0, depending on the type of screening regimen used. CONCLUSIONS: The extension of life through screening colonoscopy is two or three times longer than the extension achieved through flexible sigmoidoscopy or fecal occult blood test, respectively. Although a large number of colonoscopies are required to screen the U.S. population, relatively few colonoscopies need to be invested per year of life expectancy saved.

Aged↗
PubMed2000

Hemoclipping for postpolypectomy and postbiopsy colonic bleeding.

BACKGROUND: Obtaining colonoscopic biopsies and polypectomy can result in hemorrhage. The most effective management of this complication has not been determined. The objective of this study was to evaluate the endoscopic hemoclip in postprocedural colonic bleeding. METHODS: Among 9555 consecutive colonoscopies, cases of postprocedural colonic bleeding (postpolypectomy and postbiopsy) requiring treatment were retrospectively reviewed. Endoscopic hemoclipping was initially attempted in each case; the rate of hemostasis after hemoclipping, use of additional hemostatic methods, and clinical outcome (need for transfusion/hospitalization) were analyzed. RESULTS: There were 72 cases of bleeding in which treatment was required (45 immediate postpolypectomy, 18 delayed postpolypectomy and 9 postbiopsy). Endoscopic hemostasis was achieved in all cases of immediate postpolypectomy and postbiopsy bleeding and in all but one of the cases with delayed postpolypectomy bleeding. A detachable snare was used in addition to hemoclips in 3 cases of delayed postpolypectomy bleeding. There were no episodes of recurrent bleeding, deaths or need for surgery related to bleeding. CONCLUSION: Early endoscopic management of postprocedural bleeding by hemoclipping provides hemostasis in the great majority of cases.

Biopsy↗
PubMed2000

Prolonged ambulatory colonic manometric studies using endoclips.

BACKGROUND: It is difficult to study human colonic motility under physiologic conditions. An important limitation associated with prolonged colonic recording is the failure of the sensors to resist normal expulsive forces. METHOD: In this article we describe a method of endoscopically positioning a manometric catheter by using clips in conjunction with a solid-state catheter. With the use of a rotatable clip-fixing device loaded on to a colonoscope, the manometric catheter was clipped to the colonic mucosa. RESULTS: Recordings for up to 120 hours were obtained from 6 subjects without apparent migration of the catheter assembly. No complications were noted, the catheter does not interfere with defecation, and defecation does not result in its expulsion. CONCLUSION: The current technique will allow reliable ambulatory measurements over prolonged periods of time in relatively comfortable and unrestrained subjects. This technique should increase our understanding of normal and abnormal colonic motility.

Colon↗
PubMed2000

Adenoma size and number are predictive of adenoma recurrence: implications for surveillance colonoscopy.

BACKGROUND: Three-year colonoscopic surveillance after initial polypectomy may not be required for all patients. Those with multiple baseline polyps and large adenomas, implicated as predictors of colon cancer, merit close observation. Conversely, patients with single small adenomas may be subjected to early endoscopic surveillance unnecessarily. METHODS: From our Adenoma Registry we evaluated patient and adenoma characteristics in 697 patients. All had an adenoma recurrence within 3 years of a positive baseline colonoscopy. Potential risk factors studied were age, gender, number of adenomas, size of largest adenoma and histology. We defined a significant outcome as size of 1 cm or greater, tubulovillous or villous histology, high-grade dysplasia, carcinoma in situ, invasive cancer, or 4 or more adenomas. RESULTS: Having 3 or more adenomas on initial colonoscopy with at least 1 measuring 1 cm or larger greatly increased the chance of a significant finding on the first surveillance colonoscopy. Conversely, patients with 1 or 2 adenomas all measuring less than 1 cm were at extremely low risk of an important outcome within 3 years. CONCLUSIONS: Patients with 1 or 2 adenomas all measuring less than 1 cm are an identified low risk group and their first surveillance examination may be delayed beyond the standard 3 years.

Adenomatous Polyps↗
PubMed2002

Tattoo of colonic neoplasms in 113 patients with a new sterile carbon compound.

BACKGROUND: Endoscopic marking of intestinal lesions is essential when difficulty is anticipated with subsequent localization during surgical resection or postpolypectomy surveillance. The most commonly used indelible marker has been India ink, which must be diluted and sterilized, a cumbersome process. SPOT, a prepackaged, sterile Food and Drug Administration-approved formulation of pure carbon particles in suspension, eliminates the need for preinjection preparation. METHODS: Ten patients with colonic polyps deemed endoscopically unresectable or malignant-appearing had the area surrounding the lesions injected with SPOT and subsequently underwent surgical resection. An additional 103 patients underwent colonoscopic injection with SPOT and were followed endoscopically or underwent surgery at another hospital. RESULTS: The SPOT injection sites were visible to the surgeons in all 10 cases. On histopathologic evaluation, none of the resection specimens exhibited necrosis or abscess formation. In total, there were 118 SPOT injections in 113 patients; none had fever, abdominal pain, or any other signs or symptoms of inflammation develop. In the nonoperated group, 42 patients subsequently underwent colonoscopies at our institution, and in all cases stains were readily identifiable at the injection sites. CONCLUSIONS: SPOT is a safe and effective marker for use at colonoscopy when surgical resection is anticipated. It is also useful for endoscopic follow-up of patients who have not undergone surgery.

Adult↗
PubMed2002

ERCP in patients with long-limb Roux-en-Y gastrojejunostomy and intact papilla.

BACKGROUND: ERCP by means of long-limb Roux-en-Y surgical anastomoses has been reported primarily in patients with biliary or pancreatic anastamoses, but rarely in patients with an intact papilla. METHODS: All ERCP procedures attempted over a 6-year interval in patients with Roux-en-Y gastrojejunostomies and an intact papilla were reviewed. Patients with a prior Billroth II operation or alteration of the major papilla were excluded. Cannulation and therapy were primarily performed with a duodenoscope after exploration and placement of a guidewire in the afferent limb with a forward-viewing colonoscope. In some cases the duodenoscope was pulled into the afferent limb with a wire-guided balloon passed retrograde into the afferent limb. A follow-up of 30 days was obtained for all patients as part of a prospective ERCP outcome study. RESULTS: Of 15 patients in whom ERCP was attempted, the papilla was reached in 10 patients (67%), the bile duct being accessed in all 10. Needle-knife precut papillotomy after placement of a pancreatic duct stent was performed in 3 patients. Biliary sphincterotomy with a variety of techniques was successful in all 9 patients in whom it was attempted. Other maneuvers included stone extraction, sphincter of Oddi manometry, and biliary stent placement. Final diagnoses were sphincter of Oddi dysfunction (6), malignant biliary stricture (2), choledocholithiasis plus tumor (1), and choledocholithiasis (1). Complications occurred after 3 (12%) of 25 ERCP procedures including pancreatitis (1 mild, 1 moderate) and bleeding (1 mild), all in patients with sphincter of Oddi dysfunction. CONCLUSIONS: Diagnostic and therapeutic ERCP was ultimately successful in two thirds of patients with long-limb gastrojejunostomies and an intact papilla. The success of the ERCP is determined primarily by ability to advance a duodenoscope through the afferent limb. Once the major papilla was accessed with a duodenoscope, advanced biliary and pancreatic therapeutic techniques were feasible.

Adult↗
PubMed2004

Randomized, double-blinded, placebo-controlled trial of intravenously administered hyoscine N-butyl bromide in patients undergoing colonoscopy with patient-controlled sedation.

BACKGROUND: A prospective, double-blinded, placebo-controlled randomized trial was conducted to investigate the effect of the antispasmodic hyoscine N-butyl bromide (Buscopan) during colonoscopy. METHODS: A total of 120 patients undergoing colonoscopy were randomized to receive either 40 mg of hyoscine N-butyl bromide (n=60) or normal saline solution (n=60) intravenously as premedication. Colonoscopy was performed under patient-controlled sedation. Outcome measures included cecal intubation and total procedure time, demanded and administered doses of patient-controlled sedation, spasm score, pain score, endoscopist satisfaction score, patient willingness to repeat colonoscopy, and vital signs (blood pressure, pulse rate) during colonoscopy. RESULTS: Mean cecal intubation time in the hyoscine N-butyl bromide group was significantly longer than the control group (12.20 vs. 9.74 minutes; p=0.04; but correction for multiple testing of data removed this significance). The use of hyoscine N-butyl bromide was associated with a significantly lower endoscopist mean satisfaction score (6.47 vs. 7.30; p=0.04; but correction for multiple testing of data removed this significance), higher demanded and administered mean doses of patient-controlled sedation (respectively, 34.80 and 7.25 vs. 24.20 and 5.87; p=0.045; p=0.04, respectively; but correction for multiple testing of data removed these findings of significance), fewer patients willing to repeat colonoscopy (60% vs. 83.9%; p=0.005), and more hemodynamic instability (p<0.001) when compared with the control group. No significant difference was found in the total procedure time, spasm score, or pain score. CONCLUSIONS: Premedication with intravenously administered hyoscine N-butyl bromide impedes colonoscope insertion and causes greater patient discomfort, as well as hemodynamic instability.

Adult↗
PubMed2004

Colorectal cancer screening in patients presenting with an inguinal hernia: is it necessary?

BACKGROUND: It has been suggested that patients presenting with an inguinal hernia have an increased risk for colorectal cancer. Therefore, surgeons frequently request screening for colorectal cancer before surgery. The aim of this study was to assess the frequency of premalignant and malignant colonic lesions in a group of patients with an inguinal hernia, and to compare this with a control group of subjects undergoing screening colonoscopy. METHODS: In a case-control study, 243 patients with an inguinal hernia and no history of colonic neoplasia or symptoms suggestive of colorectal cancer underwent perioperative colonoscopy. The patients were stratified into two age groups: less than 50 years old (Group I) and more than 50 years old (Group II). The colonoscopic findings were compared with findings in 534 asymptomatic control patients who underwent screening colonoscopy. RESULTS: The mean age of patients (n=64) and control subjects (n=200) in Group I was similar, at 44 (3) years. The mean age of the patients (n=179) and control subjects (n=334) in Group II was, respectively, 70 (9) years and 64 (7) years (p<0.001). In Group I, no colorectal cancer was found in patients with inguinal hernia, and only one colorectal cancer was found among control subjects (p=0.571). In Group II, a diagnosis of colorectal cancer was made in 7 patients (4%) with inguinal hernia as compared with 10 patients (3%) among the control subjects (p=0.769). In both groups, the size and the histopathologic type of the polyps were not significantly different. CONCLUSIONS: In otherwise asymptomatic patients, the presence of inguinal hernia is not associated with an increased risk for colorectal cancer. Therefore, the presence of an inguinal hernia alone does not justify screening colonoscopy before herniorrhaphy.

Adult↗
PubMed2004

Percutaneous endoscopic colostomy of the left colon: a new technique for management of intractable constipation in children.

BACKGROUND: The antegrade colonic enema is accepted as effective for management of intractable constipation in children when conventional bowel management has failed. This study describes experience with a new, minimally invasive technique, the distal antegrade colonic enema, which involves percutaneous endoscopic colostomy of the left colon. METHODS: Fifteen children with refractory constipation and soiling who had radiographic evidence of megarectum and/or distal colonic delay were selected for the procedure. The junction of the descending and the sigmoid colon was identified colonoscopically, and the percutaneous endoscopic colostomy tube, through which antegrade distal colonic enema are administered, was inserted. RESULTS: Fourteen children underwent distal percutaneous endoscopic colostomy insertion. The median time required for the procedure was 30 minutes (20-50 minutes). Excluding one child (technical difficulties with percutaneous endoscopic colostomy placement), median post-procedural hospital stay was 4 days (2-27 days). Thirteen children were no longer soiling, and improvement in quality of life was reported at 2 months' follow-up. At 6 months' follow-up, 90% of children were clean during intervals between enemas. All children evaluated at 12 months' follow-up remained clean. Median duration of follow-up was 12.5 months (2-51 months). CONCLUSIONS: The distal percutaneous endoscopic colostomy is a simple alternative to established methods for delivery of antegrade enemas. It is less invasive and on reversal leaves only minor scarring.

Child↗
PubMed2004

Bacteriologic testing of endoscopes after high-level disinfection.

BACKGROUND: There are no definitive data available concerning microbiologic safety of prolonged endoscope storage after reprocessing and disinfection. This study evaluated the durability of high-level disinfection of endoscopes stored in a dust-proof cabinet for 5 days. METHODS: Three different types of endoscopes (upper endoscopes, duodenoscopes, colonoscopes) were tested. After completion of the endoscopic procedure, endoscopes were subjected to an initial decontamination, followed by manual cleaning with the endoscope immersed in detergent. The endoscopes then were placed in an automatic reprocessor that provides high-level disinfection. They then were stored by hanging in a dust-proof cabinet. Bacteriologic samples were obtained from the surface of the endoscopes, the openings for the piston valves, and the accessory channel daily for 5 days, and by flush-through (combined with brushing) from the accessory channels after 5 days of storage. Samples were cultured for all types of aerobic and anaerobic bacteria, including bacterial spores, and for Candida species. RESULTS: For all assays, all endoscopes were bacteria-free immediately after high-level disinfection. Only 4 assays (of 135) were positive during the subsequent 5-day assessment (skin bacteria cultured from endoscope surfaces). All flush-through samples were sterile. CONCLUSIONS: When endoscope reprocessing guidelines are strictly observed and endoscopes are stored in appropriate cabinets for up to 5 days, reprocessing before use may not be necessary.

Disinfection↗
PubMed2004

EMR of large sessile colorectal polyps.

BACKGROUND: EMR optimizes histopathologic assessment of resected lesions. This study evaluated the outcome of EMR of large sessile colorectal polyps in terms of complications and recurrence. METHODS: An uncontrolled prospective study was conducted of a cohort of 136 patients with sessile colorectal polyps referred for EMR. After submucosal injection, EMR was performed piecemeal by either snare polypectomy alone or with cap aspiration. RESULTS: In 136 patients, a total of 139 sessile polyps were resected, 86 of which were in the right colon. Median polyps diameter was 20 mm in the right colon and 30 mm in the other colonic segments. Intraprocedure bleeding occurred after 15 polypectomies (10.8%) and was controlled endoscopically in all cases; there was no delayed bleeding. Post-polypectomy syndrome occurred in 5 patients (3.7%). There was no perforation. Invasive carcinoma was found in 17 sessile colorectal polyps, and surgery was performed in 10 of 17 cases. Follow-up colonoscopy in 93 patients without invasive carcinoma (96 polyps), over a median of 12.3 months, disclosed local recurrence of 21 adenomatous polyps (21.9%). Colonoscopic follow-up in 5 of the 7 patients, who had sessile colorectal polyps with invasive carcinoma and did not undergo surgery, disclosed no local recurrence. CONCLUSIONS: EMR, including EMR with cap aspiration, is effective and safe for removal of sessile colorectal polyps throughout the colon.

Adenocarcinoma↗