成人结肠镜在小儿出血性结直肠息肉诊治中的应用

目的：探讨成人结肠镜在小儿出血性结直肠息肉诊治中的应用价值。方法：对便血患儿进行成人肠镜检查并电切除治疗息肉,分析息肉的临床表现、镜下形态、病理特点,评估其安全性。结果：85%便血患儿发现结直肠息肉,临床症状主要为便血（35/35）,腹痛（5/35）,肛门有肿物脱出（9/35）,粪便表面可见沟槽（6/35）,直肠指检可触及肿块（8/35）。35例患儿发现息肉共38颗,单发占91.4%（32/35）,多发3例,大小多数在2cm左右。息肉主要在直肠占73.7%（28/38）,在直肠和乙状结肠共占92.1%（35/38）。息肉均在肠镜下成功微创电切治疗,术中、术后无肠出血、肠穿孔并发症,电切成功率为100%。息肉病理检查,多数为幼年性息肉占73.7%（28/38）,少数为增生性息肉占15.8%（6/38）和炎性息肉占10.5%（4/38）。术后未再便血。结论：结直肠息肉是小儿便血的最常见原因,息肉主要在直肠和乙状结肠,多为单发,病理以幼年性息肉为主,电切息肉后未再便血。成人结肠镜对小儿出血性结直肠息肉的检查和微创电切治疗是安全有效的。     

Endoscopy and surgery. A combined strategy for diagnosis and therapy of polyposis-cancer sequence in the colon

BACKGROUND: The aim of the paper is to evaluate retrospectively the series of patients affected by colon polyps and colon cancer to purpose a planned follow-up for patients who underwent colon polypectomy. METHODS: Out of 198 patients affected by colon carcinoma, the authors describe 95 cases of previous, synchronous or metachronous polyps, with a global prevalence of 47.9%, and respectively of 13.6%, 16.6%, and 17.6%. RESULTS: The evolutive sequence between colon polyp and carcinoma is shown through both clinical experience and experimental tests. The epidemiologic curve of adenoma rate precedes by five years the curve of carcinoma, and such is the average period of time for the transformation of an adenoma into invasive carcinoma. In clinical practice, it is frequent to note synchronous or metachronous polyps with respect to colon carcinoma. It is also possible to note carcinoma in patients with previous polypectomies. CONCLUSIONS: On the basis of the retrospective evaluation of the clinical cases, and reviewing international literature, the authors suggest their diagnostic-therapeutic and endoscopic follow-up protocol for patients affected by colon neoformations (Fig. 1).     

Surgical management of villous and tubulovillous adenomas of the rectum]

One hundred four cases of middle and low rectal villous and tubulovillous adenomas have been operated on with transanal polypectomy (8), transanal endoscopic microsurgery--TEM (80), anterior rectum resection with double stapled straight sigmoideorectosomy (7), and deep rectum resection, bi-directional mucosectomy and hand sutured straight sigmoideoanostomy (9). The option of the authors to remove the tumours in 5 cm to the dentate line are the transanal polypectomy or transanal mucosectomy corresponding to their size. The transanal endoscopic microsurgical technic is recommended to manage the polyps smaller than 4 to 5 cm in the middle rectum. The best radicallity in removal of the circular, extended villous adenomas could be achieved with deep rectum resection, bi-directional mucosectomy and transanal straight, hand sewn sigmoideoanostomy.     

Massive rectal blood loss after colonoscopy

A 70-year-old man presented with acute lower gastrointestinal bleeding. A colonoscopy performed one and a half months prior had revealed diverticulosis in the sigmoid colon; a small polyp located 10 cm from the anal margin had been removed at that time. The presenting patient was haemodynamically unstable and there was a significant amount of rectal blood loss. Gastroscopy revealed no abnormalities. During angiography, the patient died as a result of haemorrhagic shock. The post-mortem examination revealed a rectal perforation, which had most likely resulted from the polypectomy, and a secondary haematoma located between the common iliac artery and the rectum. The source of the gastrointestinal bleeding was the rupture of the haematoma directly into the rectal perforation. Colonoscopy is a relatively safe procedure; however, this case illustrates that potentially lethal complications from colonoscopy can be expressed, even after a few months.     

Consider colonoscopy for young patients with hematochezia

BACKGROUND: Hematochezia is a common complaint in adult patients aged <50 years. Most studies of lower endoscopy for rectal bleeding have concentrated on older patients or have failed to mention the location of lesions. OBJECTIVE: To determine the findings of complete colonoscopy in adults younger than 50 years with rectal bleeding. METHODS: Data were retrieved from medical records and included demographics, indications, endoscopic findings, and histology. Lesions were labeled according to location: proximal to the splenic flexure or distal to (and including) the splenic flexure. Excluded were those with a history of colitis, colorectal cancer, polyps, anemia, significant weight loss, severe bleeding, or strong family history of colorectal cancer. RESULTS: The study included 223 patients with rectal bleeding aged <50 years who had undergone a colonoscopy. Normal findings were recorded for 48 (21.5%). Four (1.8%) were diagnosed with cancer in the distal colon, and 22 (9.9%) were found to have colon adenomas, 6 of whom had proximal adenomas only. Hemorrhoids were present in 135 patients (60.5%). Other findings included colitis, angiodysplasia, diverticulosis, anal fissures, and rectal ulcers. CONCLUSIONS: Colon neoplasms may be present even in younger adults with nonurgent rectal bleeding. Though most findings were benign and located in the distal colon, colonoscopy should be strongly considered for this patient group.     

Piecemeal technique at the removal of large rectosigmoid polyps

INTRODUCTION: Removal of the colon polyps is a routine approach. Polyps larger than 2 cm can not be removed in one piece, the piecemeal technique is to be applied for these cases. The risk for the complications (bleeding, perforation) and the malignancy are higher, than in conventional cases. PATIENTS AND METHOD: At the 1st Surgical Department of Semmelweis University the piecemeal technique have been used at 13 patients, among others at five patients who were declared for operation because of the size of the polyps in other institutions. The average size of the polyps was 3,5 cm. Ten polyps in the rectum, three in the sigmoid colon were found. RESULTS: The executing procedure required two sections in two cases. Massive bleeding started after the procedure in one patient, which was successfully stopped by infiltration the basement of the polyps with adrenalin. The histology showed in situ carcinoma in two patients. CONCLUSION: The risk of removal of large colon polyps could be undertaken at those endoscopic units where anesthesiologic and surgical background are present, and the patient--in case of unsuccessful removal--could be treated with other minimal invasive therapy (laparoscopic colon resection).     

结肠镜治疗小儿大肠息肉70例临床分析

目的探讨小儿大肠息肉的内镜治疗方法。方法回顾2000年7月至2008年12月接受肠镜检查的小儿大肠息肉患者74例资料,对其中70例的临床症状、内镜特点、病理类型与内镜下治疗方法进行分析。结果小儿大肠息肉90．8％发生在直肠和乙状结肠．77．8％为带蒂息肉、74．29％为幼年性息肉、11．4％为P—J息肉、7．14％为炎性息肉、4．29％为增生性息肉、2．86％为腺瘤性息肉。55例患儿（78．6％）68枚息肉全部切除,其中高频电切49例、高频电凝l例、钳除5例,均无并发症,随访2年5．3％复发。结论对小儿使血,肛门指检不可忽视,有条件的应尽早行肠镜检查,结肠镜腔内治疗小儿大肠息肉简便易行和安全可靠,切除后应坚持随访。     

Focus on colorectal adenomas--therapeutic possibilities in precancerous changes and conditions of the colon and rectum in our daily practice]

The health government and also the professionals except the new screening test programme to put a stop the increasing number of colon and rectum cancer diseases, which have caused high mortality in Hungary. Believe in the success of this programme the authors give a short overview about the precancer status and alterations of the large bowel, focusing on colorectal adenoma. In particular, the pathological anatomy, symptomatology, diagnostics, therapy, treatment and prevention possibilities of adenomas are described in details. There were 3419 total colonoscopies carried out in the Laboratory of Endoscopy in Albert Schweitzer General Hospital of Hatvan between 31st January 1991 and 31st December 2001. All patients had bowel motility problems, abdominal pains, bloody stools or change of bowel movement habit. 941 large bowel polyps were diagnosed at 628 patient. 821 of them were removed with endoscopic polypectomy, 11 with mucosectomy, 43 with piecemeal polypectomy and 20 with surgical interventions. 38 carcinoma in situ and 94 serious dysplasia alteration were removed. After the endoscopical therapeutical interventions 5 complications were detected and one patient died. There were no complications after the surgical interventions. They analyse their patients in base of the polyps place, shape, number and histological structure of alterations, level of dysplasia and the type of interventions. It is confirmed that the total colonoscopy is the most adaptable method for examining the large bowel, and endoscopic polypectomy is the most efficient colorectal cancer preventing method, which could only be realized with the successful interdisciplinary cooperation of the gastroenterologist, the surgeon, the pathologist and radiologist.     

Correlation of Barrett's esophagus and colonic adenomas

INTRODUCTION: According to the case-control studies, colon adenomas are not more frequent as usual in patients with Barrett's oesophagus. AIM: Analysis of the relationship of Barrett's oesophagus with colon adenomas through a case presentation. METHOD: The 62-years old male patient has been treated with pantoprazole for reflux oesophagitis and histologically proven short-segment Barrett's oesophagus. Pantoprazole treatment was started and the patient became symptom-free. In 1997 colonoscopy was performed for rectal bleeding and 4 recto-sigmoideal polyps were removed (tubular adenomas). After 4 years of PPI treatment, laparoscopic fundoplication was performed but after one year of symptom-free period, PPI was started again because of relapse. The patient was followed-up for 5 years. The histological examinations included also Ki67 and p53 antibody staining. RESULTS: On control colonoscopies, small rectal and sigmoid polyps were found. The retrospective histologic examination of the polyps revealed the increase of Ki-67-positive cells from 2-5% to 45-55% during the 5 years of follow-up, which is higher than the values found in controls and may express the increasing proliferative activity of the epithelium. CONCLUSION: Although according to the literature, Barrett's oesophagus does not increase the risk of colon adenomas, this may occur in individual cases, warranting close follow-up.     

Colorectal cancer and polyps in patients aged 40 years and over who consult a GP with rectal bleeding

BACKGROUND: Rectal bleeding is common in the community and in general practice,but few studies have examined the causes of rectal bleedingin patients presenting to general practitioners. OBJECTIVE: To determine the frequency of neoplastic conditions in patientswith rectal bleeding presenting in general practice and to explainthe associations between presenting symptoms and final diagnoses. METHODS: We conducted two studies, the first in 1989, the second in 1991,in which we invited Danish general practitioners to register3–4 patients aged 40 and over presenting with rectal bleeding. RESULTS: In Study 1 among 208 patients aged 40 and over and presentingwith a first episode of rectal bleeding, colorectal cancer andpolyps were present in 15.4 and 7.7%, respectively. In Study2 among 209 patients aged 40 and over and presenting with overtrectal bleeding, 156 reported a first bleeding episode or achange in their usual bleeding pattern, and in this group colorectalcancer and polyps were diagnosed in 14.1 and 11.5%, respectively.In the group with unchanged bleeding the cancer polyp prevalencewas 6.7% (P < 0.05). The patients in both studies were followedthrough a yearly letter to the GP for at least 32 and 22 months,respectively. CONCLUSIONS: A joint analysis of the two study populations showed that onlyage and change in bowel habit contributed to differentiatingthe cancer from the non-cancer patients. Keywords. Colorectal cancer, polyps, rectal bleeding.     

Education, socioeconomic status and risk of cancer of the colon and rectum.

BACKGROUND: Socioeconomic correlates of cancer of the large bowel differ in various countries and calendar periods and may differ for the colon and rectum. Thus, the relationship between education and social class and risk of cancers of the colon and rectum was considered. METHODS: Combination of two hospital-based case-control studies conducted in six Italian centres between 1985 and 1996. Cases were 3533 patients aged < 79, with histologically confirmed cancer of the colon (n = 2180) or rectum (n = 1353), and controls were 7062 patients admitted to hospital for a wide spectrum of acute, non-neoplastic, non-digestive tract diseases. RESULTS: Compared to individuals with < 7 years of education the multivariate odds ratios (OR) of colon cancer for those with > or = 16 years were 2.45 (95% confidence interval [CI]: 1.87-3.23) in men and 1.29 (95% CI: 0.88-1.90) in women, with significant trends in risk. No significant association emerged between education and risk of rectal cancer, with OR of 1.18 (95% CI: 0.83-1.70) and 1.01 (95% CI: 0.61-1.67) respectively for men and women in the highest educational category compared to the lowest. Social class was also related to colon cancer risk: the OR were 2.30 (95% CI: 1.82-2.90) in men and 1.33 (95% CI: 1.03-1.73) in women in the highest versus the lowest social class. No association was found between social class and rectal cancer risk, with OR of 1.18 for either men or women in the highest as compared to the lowest social class. No significant heterogeneity was found for the association between education and colon cancer risk in either sex across strata of age at diagnosis, coffee, alcohol and vegetable intake, family history of the disease, and in anatomical subsites within the colon. CONCLUSION: This study, based on a uniquely large dataset, indicates that there are different social class correlates for colon and rectal cancer. Consequently the two sites should not be combined in studies considering lifestyle factors in the aetiology of these neoplasms.     

子宫内膜息肉的宫腔镜手术治疗及术后复发的预防效果观察

目的:探讨宫腔镜手术治疗子宫内膜息肉术后复发及术后复发的不同预防措施效果。方法:选取297例子宫内膜息肉患者,行宫腔镜电切术治疗,术后随机分为对照组、安宫黄体酮组及曼月乐组3组,每组99例,观察各组术后复发情况。结果:手术时间、术中出血量、息肉个数3组比较差异均无统计学意义(F=0.75,F=0.11,F=0.96,P>0.05),治疗费用3组比较差异存在统计学意义(F=3.75,P<0.05),各组进行两两比较,安宫黄体酮组与对照组、曼月乐与对照组、安宫黄体酮组与曼月乐组比较,差异均有统计学意义(q=3.74,q=20.35,q=14.91,P<0.05);术后随访1年,子宫内膜息肉复发率对照组为13.54%、安宫黄体酮组为2.04%、曼月乐组为1.05%,随访2年复发率对照组为25.00%、安宫黄体酮组为8.60%、曼月乐组为5.56%,复发率3组比较差异存在统计学意义(1年:χ2=17.71;2年:χ2=17.30;P<0.05),两两比较安宫黄体酮组与对照组、曼月乐组与对照组比较差异存在统计学意义(1年:χ2=8.99,χ2=10.96;2年:χ2=8.79,χ2=13.07;P<0.05)。结论:宫腔镜电切术治疗子宫内膜息肉疗效确切,术后应用激素及曼月乐能明显降低息肉复发,曼月乐效果最佳。     

内镜治疗结肠息肉的临床诊治体会

目的探讨内镜治疗结肠息肉的临床疗效。方法采用回顾性分析的方法,分析我院收治的60例结肠息肉临床资料。结果 60例结肠息肉切除手术均顺利完成,术后无大出血、穿孔等并发症发生,3例结肠息肉术中出血,生理盐水冲洗后,采用钛夹止血,1周后治愈。术后3个月随访,结肠息肉无复发。结论内镜下电凝治疗结肠息肉临床疗效良好,无出血、穿孔并发症,值得临床应用推广。     

Colon polyps.

Colonic polyps commonly occur in all age groups and are of varied significance depending on the type of polyp and the symptoms manifested. There is some debate in the medical literature regarding the appropriate clinical management of polyps and the follow-up of patients after polypectomy. This discussion addresses the significance of colon polyps, including their etiology, histology, complications, detection, and management.     

结肠癌和直肠癌危险因素的巢式病例对照研究

目的：探讨结肠癌和直肠癌的危险因素。方法：应用巢式病例对照研究方法,对一个6万余人队列随访10年队列中196例新发结、直肠癌病例作为病例组;从该队列中随机抽取980名正常人作为对照组,对有关暴露因素进行单因素分析和多因素非条件logistic回归分析,结果：年龄在病例组和对照之间差异有显著性,病例组年龄高于对照组,且结肠癌的发病年龄高于直肠癌。多因素分析表明,除年龄外,粘液血便中、肠息肉史与结肠癌关系密切,OR值分别为：2．961（95％CI：1．202－7．298）和8．941（95％CI：1．820－43．926）,饮用混合水与直肠癌的OR值为1．823（95％CI:1．024－3．247）。结论：结、直肠癌的危险因素不尽相同。除年龄是结、直肠癌发病的一个共同重要因素外,肠息肉史和粘液血便史与结肠癌有关联,而饮用混合水则与直肠癌关系密切。     

Small colon polyps: the primary physician's dilemma

This case report and literature review is presented to alert primary care physicians performing flexible sigmoidoscopy and limited colonoscopy to the malignant potential of even diminutive polyps. The term "polyp" refers to any circumscribed mass of tissue that arises from mucosa and protrudes into the lumen of the gastrointestinal tract. The significance of this lesion in the rectum and colon is its propensity for malignant change. Although small polyps in the region of the rectum tend to be hyperplastic and those more proximal tend to be adenomas with a significant malignant potential, there is no way to distinguish them visually; hence, all need to be biopsied. The following case report shows the necessity of identifying neoplastic lesions within diminutive polyps (less than 1 cm). Standard biopsy technique usually removes these lesions; nevertheless, when histology confirms the presence of adenoma or carcinoma, the patient requires additional evaluation of the entire large intestine and more frequent follow-up examinations.     

Calcium and vitamin D intakes in relation to risk of distal colorectal adenoma in women

The authors examined intakes of calcium and vitamin D, and interaction with retinol, in relation to risk of adenoma of the distal colon or rectum among 48,115 US women who were free of colorectal cancer or polyps, completed a food frequency questionnaire in 1980, and underwent endoscopy by 2002. They documented 2,747 cases of adenoma (1,064 large, 1,531 small, 2,085 distal colon, and 779 rectal). Total calcium intake was weakly associated with distal colorectal adenoma risk (multivariable relative risk (RR) for extreme quintiles = 0.88, 95% confidence interval (CI): 0.74, 1.04; p(trend) = 0.06), particularly for large adenoma (RR = 0.73, 95% CI: 0.56, 0.96; p(trend) = 0.02). Total vitamin D intake was weakly associated with reduced risk of distal colorectal adenoma (RR = 0.79, 95% CI: 0.63, 0.99; p(trend) = 0.07), but more strongly with distal colon adenoma risk (RR = 0.67, 95% CI: 0.52, 0.87; p(trend) = 0.004). The combinations of high vitamin D and low retinol intake (RR = 0.55, 95% CI: 0.28, 1.10) further decreased risk of distal colorectal adenoma when compared with the opposite extreme. Higher total calcium and vitamin D intakes were associated with reduced risk, and the actions of vitamin D may be attenuated by high retinol intake.     

Alcohol drinking, cigarette smoking, and risk of colorectal adenomatous and hyperplastic polyps

The authors evaluated alcohol drinking and cigarette smoking in relation to risk of colorectal polyps in a Nashville, Tennessee, colonoscopy-based case-control study. In 2003-2005, cases with adenomatous polyps only (n = 639), hyperplastic polyps only (n = 294), and both types of polyps (n = 235) were compared with 1,773 polyp-free controls. Unordered polytomous logistic regression was used to calculate adjusted odds ratios and 95% confidence intervals. Consumption of at least five alcoholic drinks per week was not strongly associated with development of polyps. Odds ratios for all polyp types were increased for dose, duration, and pack-years of cigarette smoking and were stronger for hyperplastic polyps than for adenoma. Compared with never smoking, dose-response relations were particularly strong for current smoking and duration; for > or =35 years of smoking, odds ratios were 1.9 (95% confidence interval (CI): 1.4, 2.5) for adenomatous polyps only, 5.0 (95% CI: 3.3, 7.3) for hyperplastic polyps only, and 6.9 (95% CI: 4.4, 11.1) for both types of polyps. Compared with current smoking, time since cessation was associated with substantially reduced odds; for > or =20 years since quitting, odds ratios were 0.4 (95% CI: 0.3, 0.6) for adenoma only, 0.2 (95% CI: 0.1, 0.3) for hyperplastic polyps only, and 0.2 (95% CI: 0.2, 0.4) for both polyp types. These findings support the adverse role of cigarette smoking in colorectal tumorigenesis and suggest that quitting smoking may substantially reduce the risk of colorectal polyps.     

Quercetin's effects on intestinal polyp multiplicity and macrophage number in the Apc(Min/+) mouse

Numerous in vitro studies argue for quercetin's chemopreventive potential in colon cancer; however, experimental studies in rodents are limited. Macrophages play a role in tumorigenesis, but the effects of quercetin on macrophage infiltration in colon cancer is unknown. We examined the effects of quercetin on intestinal polyp multiplicity and macrophage number in Apc(Min/+) mice. Apc(Min/+) mice were assigned to placebo or quercetin (n = 8/group) groups. Mice were given a placebo or quercetin (0.02%) diet from 4-20 wk of age, after which intestines were analyzed for polyp number and size in the small intestine (Sections 1-4) and colon (Section 5) and for macrophage number in the small intestine (Sections 1 and 3). Spleen weight was determined as a marker of systemic inflammation. Quercetin decreased total intestinal polyps by 67% (P < 0.05). Specifically, quercetin reduced intestinal polyps in categories >2 mm (69%) and 1-2 mm (79%; P < 0.05), and in Sections 2 (75%), 3 (80%), and 4 (79%; P < 0.05). Quercetin also decreased macrophage number in Sections 1 (57%) and 3 (81%), and spleen weight (P < 0.05). These data suggest that quercetin can reduce polyp number and size distribution in the Apc(Min/+) mouse and that these effects may be related to a reduction in macrophage infiltration.