Effect of endoscopic screening at 1-year intervals on the clinicopathologic characteristics and treatment of gastric cancer in South Korea

Background and Aim: The recommended interval of endoscopic screening for gastric cancer (GC) in a general population is 2 years in Korea. However, it has not been determined whether endoscopic screening with a shorter interval is beneficial, especially for high‐risk groups. Methods: A total of 415 patients with GC were categorized according to whether they had (vigilant screening group) or not (non‐vigilant screening group) undergone endoscopic screening within 1 year before being diagnosed with GC. Clinicopathologic GC characteristics of the two groups were compared. Next, the same analyses were conducted in subgroups of patients with high risk for GC including males, current smokers, first‐degree relatives of GC; and patients with Helicobacter pylori infection, gastric atrophy, or intestinal metaplasia (IM). Results: The proportion of vigilant screening patients was 36.1%. Early gastric cancer (EGC) was more frequently observed in the vigilant screening group than the non‐vigilant screening group (62.7% vs 49.4%, P = 0.009). In the high‐risk factor analyses, EGC was more frequently detected among patients with severe IM in the vigilant screening group than the non‐vigilant screening group (66.7% vs 35.5%, P = 0.047). In addition, more patients in the vigilant screening group had undergone endoscopic submucosal dissection (ESD; 26.7% vs 0%, P = 0.008) and had stage I (84.6% vs 41.7%, P = 0.012) than in the non‐vigilant screening group. Conclusions: Endoscopic screening for GC at 1‐year intervals would be beneficial for patients with severe IM in South Korea; this method could detect EGC for which the curative modality would be ESD.     

Decreased death from gastric cancer by endoscopic screening: Association with a population-based cancer registry

Objective. To determine death rates from gastric cancer when using endoscopic screening. Material and methods. In this historical cohort study comprising 11,763 participants aged from 40 to 75 years without gastric disorders between 1990 and 1992, 2192 were examined by gastric endoscopy while 9571 were not examined by endoscopy or X-ray. The relative risk of gastric cancer death was compared between the two groups. Results. When screened with endoscopy, 41 patients were diagnosed with gastric cancer and the ratio of early cancer was 78%. On matching the population-based cancer registry (the Fukui Cancer Registry), 63 patients in the examined group were diagnosed with gastric cancer within 10 years after the initial screening including the above 41 patients. In the non-examined group, 147 patients were diagnosed with gastric cancer in the same period. In the examined and non-examined groups, 5 and 63 patients, respectively, died from gastric cancer. The relative risk for gastric cancer death in the examined group was 0.3465 (95% CI: 0.1396–0.8605) when compared with the non-examined group. For male patients, the relative risk was 0.2174 (95% CI: 0.0676–0.6992). Conclusions. The death rate from gastric cancer decreased when endoscopic screening was used. Endoscopy is recommended as a population-based screening method for gastric cancer in regions or countries where mortality from this disease is high.     

One‐hour fast for water and six‐hour fast for solids prior to endoscopy provides good endoscopic vision and results in minimum patient discomfort

Background and Aim: Current guidelines for upper gastrointestinal endoscopy (UGIE) advise at least 6–8 h fasting for solids and 4‐h fasting for liquids. We aimed to determine whether a 6‐h fast for solids and one‐hour fast for water prior to UGIE gives good endoscopic vision and less patient discomfort. Methods: 128 patients referred for UGIE were given a standard meal 6 h before endoscopy, and then randomized to either nil by mouth for 6 h (group A, n = 65) or allowed to drink water for up to one hour prior to endoscopy (group B, n = 63). Before endoscopy patients were requested to indicate discomfort due to fasting on a visual analog scale. Fluid in the gastric fundus was aspirated, when present, for volume and pH measurements, and endoscopic vision was graded. Results: 53 patients in group A and 43 patients in group B completed the study. Discomfort was significantly lower in group B than group A (P < 0.0001). Endoscopic vision was good in all 53 patients in group A and 40 in group B, and average in 3 patients in group B. Fluid in the gastric fundus was noted in 11 patients in group A and 16 in group B, but there were no significant differences in volume or pH between groups. There were no complications attributable to endoscopy in either group. Conclusions: A 6‐h fast for solids and a 1‐h fast for water prior to UGIE gives good endoscopic vision, and causes minimum patient discomfort.     

Analysis of clinicopathologic characteristics of gastric cancer in patients ≤40 and ≥40 years of age

Abstract

Objectives: Gastric cancer (GC) in young patients is a troubling clinical problem. The aim of this study was to analyze whether patients ≤40 years of age with GC differ from patients (age >40 years) in terms of clinicopathological and selected genetic factors.

Materials and methods: Between 1984 and 2011, data were collected for 840 GC patients diagnosed and treated for GC at the Department of Gastroenterology at Pomeranian Medical University. The following clinicopathological features were compared between two age groups: sex, symptom duration, family history of cancer, tumor site, stage (early vs. advanced), blood group, histology, Helicobacter pylori infection and BRCA2 C572T silent mutation status.

Results: A total of 65 (7.7%) patients were age 40 years or younger. GC was predominant in women in the younger group (p?<?.001). Patients (≤40 years) more frequently reported a positive family history of cancer (p?=?.01) and a diffuse tumor type was more common in this group (p?<?.001). The two age groups did not differ significantly regarding symptom duration, tumor location or stage, H. pylori infection, blood group, or BRCA2 C572T silent mutation status. A comparison of male and female patients aged 40 years or less did not reveal sex-based differences in any analyzed features.

Conclusion: Patients ≤40 years of age with GC differ from patient >40 years of age in having a predominance of women, diffuse tumor type, and positive family history of cancer. These results offer openings for further investigation of the relevance of these differences.     

联合内镜注射组织黏合剂与经皮肝门静脉栓塞治疗食管胃底静脉曲张出血的临床研究

目的:评价内镜下注射组织黏合剂(histoacryl)与内镜下注射组织黏合剂联合经皮肝穿胃冠状静脉栓塞(PTVE)治疗胃底食管静脉曲张二种治疗方法的疗效。方法:对57例食管胃底静脉曲张患者分别进行内镜下注射组织黏合剂(单纯组38例)与内镜下注射组织黏合剂联合经皮肝穿胃冠状静脉栓塞(联合组19例),并比较两种方法止血率、再出血发生率、曲张静脉消失率、并发症发生率等指标。结果:二组随访2～24个月;近期再出血分别为5.3%、18.4%;>6个月再发出血发生率分别10.5%、31.6%;术后3～6个月行食道钡餐检查,食道静脉曲张消失或基本消失分别为68.4%、42.1%。结论:联合治疗组比单纯内镜下治疗有效率高、重复性少、安全性好、近期复发再出血发生率低,是一种较安全、有效的方法。     

Effect of intravenous proton pump inhibitor regimens and timing of endoscopy on clinical outcomes of peptic ulcer bleeding

Background and Aim: The most effective schedule of proton pump inhibitor (PPI) administration and the optimal timing of endoscopy in acute peptic ulcer bleeding remain uncertain. The aim of this study was to determine the most efficient PPI regimen and optimal timing of endoscopy. Methods: Consecutive patients with suspected bleeding peptic ulcers were enrolled and randomized to receive either a standard regimen or a high‐dose intensive intravenous regimen. Only patients with bleeding peptic ulcers diagnosed at initial endoscopy continued the study. High‐risk patients received endoscopic hemostasis. The primary outcome measure of recurrent bleeding was compared between the two dosage regimens and between early and late endoscopy. Secondary outcome measures compared included need for endoscopic treatment, blood transfusion, hospital stay, surgery and mortality. Results: A total of 875 patients completed the study. Recurrent bleeding occurred in 11.0% in the standard regimen group, statistically higher than that in the intensive regimen group (6.4%, P = 0.02). Mean units of blood transfused and duration of hospital stay were also higher in the standard regimen group (P < 0.001 for each compared to intensive regimen group). However, no significant differences were noted between the two groups in the need for endoscopic hemostasis, need for surgery, and mortality. Recurrence of bleeding was similar between the early and late endoscopy groups. Units of blood transfused and length of hospital stay were both significantly reduced with early endoscopy. Conclusion: High‐dose PPI infusion is more efficacious in reducing rebleeding rate, blood transfusion requirements and hospital stay. Early endoscopy is safe and more effective than late endoscopy.     

Diagnostic utility of small-caliber and conventional endoscopes for gastric cancer and analysis of endoscopic false-negative gastric cancers

AIM: To analyze the diagnostic utility of a small-caliber endoscope(SC-E) and clinicopathological features of false-negative gastric cancers(FN-GCs). METHODS: A total of 21638 esophagogastroduodenoscopy(EGD) gastric cancer(GC) screening examinations were analyzed. Secondary endoscopic examinations(n = 3352) were excluded because most secondary examinations tended to be included in the conventional endoscopy(C-E) group. Detection rates of GCs and FN-GCs were compared between SC-E and C-E groups. FN-GC was defined as GC performed with EGD within the past 3 years without GC detection. Macroscopic types, histopathological characteristics and locations of FN-GCs were compared with firstly foundgastric cancers(FF-GCs) in detail. RESULTS: SC-E cases(n = 6657) and C-E cases(n = 11644), a total of 18301 cases, were analyzed. GCs were detected in 16(0.24%) SC-E cases and 40 C-E(0.34%) cases(P = 0.23) and there were 4 FN-GCs(0.06%) in SC-E and 13(0.11%) in C-E(P = 0.27), with no significant difference. FN-GCs/GCs ratio between SC-E and C-E groups was not significantly different(P = 0.75). The comparison of endoscopic macroscopic types of FN-GCs tended to be a less advanced type(P = 0.02). Histopathologically, 70.6% of FN-GCs were differentiated and 29.4% undifferentiated type. On the other hand, 43.0% of FF-GCs were differentiated and 53.8% undifferentiated type, so FN-GCs tended to be more differentiated type(P = 0.048). CONCLUSION: The diagnostic utility of SC-E for the detection of GCs and FN-GCs was not inferior to that of C-E. Careful observation for superficially depressed type lesions in the upper lesser curvature region is needed to decrease FN-GCs.     

医院就诊人群与普查人群中大肠癌患者临床资料的比较

背景:在我国有无必要开展大肠癌普查仍存在一定争议。目的:比较、分析医院就诊人群与普查人群中大肠癌患者临床资料的异同,探讨普查在大肠癌早期诊断中的作用。方法:就诊组:由协作组各成员医院按统一设计的调查表,前瞻性地登记2002年4月1日～2003年3月31日到医院就诊,并接受结肠镜检查的大肠癌患者的全部临床资料。普查组:采用“序贯粪便隐血筛检技术”,于2001年3～6月对北京地区约2万名35岁以上的自然人群进行大肠癌普查。两组大肠癌患者的诊断均经术后病理检查证实。结果:就诊组和普查组患者中,≥50岁者分别占81.9%和83.3%。就诊组DukesA、B期患者占41.1%,普查组占91.7%(P<0.001)。普查人群中存在大肠癌高危因素者的大肠癌检出率为0.28%,无高危因素者的检出率为0.05%(P<0.001)。就诊组中,内镜表现为隆起型病变者44.7%是DukesA、B期患者,溃疡型病变者仅10.0%是DukesA、B期患者(P<0.001);DukesA、B期患者的粪便隐血试验阳性率为78.5%,C、D期患者为81.9%(P>0.05),提示粪便隐血试验阳性率与大肠癌分期无关;DukesC、D期患者的血清CEA阳性率显著高于A、B期患者(P=0.019);高、中分化癌中DukesA、B期患者占51.8%,低分化癌中DukesA、B期患者仅占26.5%(P<0.001)。结论:近年北京地区的大肠癌发病率较以前明显上升     

The Munich Barrett follow up study: suspicion of Barrett's oesophagus based on either endoscopy or histology only--what is the clinical significance?

BACKGROUND: The incidence of distal oesophageal adenocarcinoma is rising, with chronic reflux and Barrett's oesophagus being considered risk factors. Reliable detection of Barrett's oesophagus during upper endoscopy is therefore mandatory but requires both endoscopy and histology for confirmation. Appropriate management of patients with endoscopic suspicion but negative on histology, or vice versa, or of patients with no endoscopic suspicion but with a biopsy diagnosis of intestinal metaplasia at the gastro-oesophageal junction, has not yet been studied prospectively. PATIENTS AND METHODS: In a prospective multicentre study, 929 patients (51% male, mean age 50 years) referred for upper gastrointestinal endoscopy were included; 59% had reflux symptoms. The endoscopic aspect of the Z line and any suspicion of Barrett's oesophagus were noted, and biopsies were taken in all patients from the Z line (n = 4), gastric cardia (n = 2), and body and antrum (n = 2 each). Biopsies positive for specialised intestinal metaplasia (SIM) were reviewed by a reference pathologist for a final Barrett's oesophagus diagnosis. All patients with endoscopic and/or histological suspicion of Barrett's oesophagus were invited for a follow up endoscopy; the remaining cases (no endoscopic or histological suspicion of Barrett's oesophagus) were followed clinically. RESULTS: Of 235 patients positive for Barrett's oesophagus on endoscopy and/or histology, 63% agreed to undergo repeat endoscopy (mean follow up period 30.5 months). 46% of patients with an endoscopic Barrett's oesophagus diagnosis but no histological confirmation (group A) showed the same distribution, a further 42% did not have Barrett's oesophagus, and 11% had confirmed Barrett's oesophagus on both endoscopy and biopsy on follow up. In the group with a histological Barrett's oesophagus diagnosis but negative on initial endoscopy (group B), follow up showed the same in 26% whereas 46% had no Barrett's oesophagus, and confirmed Barrett's oesophagus (endoscopy plus histology) was diagnosed in 17%. Of the study population, 16 patients had Barrett's oesophagus on initial endoscopy confirmed by histology which remained constant in 70% at follow up (group C). Of the remaining patients without an initial Barrett's oesophagus diagnosis on either endoscopy or histology (group D) and only clinical follow up (mean follow up period 38 months), one confirmed Barrett's oesophagus case was found among 100 patients re-endoscoped outside of the study protocol. However, no single case of dysplasia or cancer of the distal oesophagus was detected in any patient during the study period. CONCLUSIONS: Even in a specialised gastroenterology setting, reproducibility of presumptive endoscopic or histological diagnoses of Barrett's oesophagus at follow up were poor. Only 10-20% of cases with either endoscopic or histological suspicion of Barrett's oesophagus had established Barrett's oesophagus after 2.5 years of follow up. The risk of dysplasia in this population was very low and hence meticulous follow up may not be required.     

“Test,score and scope”: A selection strategy for safe reduction of upper gastrointestinal endoscopies in young dyspeptic patients referred from primary care

Objective. To test the ability of pre-endoscopic clinical evaluation to predict clinically relevant findings of upper gastrointestinal endoscopy. Material and methods. Patients (341) who had been referred to upper gastrointestinal endoscopy for further evaluation of dyspeptic symptoms were included in this prospective, single-blinded study. Prior to endoscopy, the patients underwent a standardized clinical evaluation consisting of 1) a symptom questionnaire, 2) serological testing for Helicobacter pylori antibody and 3) determination of blood hemoglobin. Based upon this evaluation, patients were assigned to one of three defined risk groups. Group A comprised patients with known risk factors for diseases that would require further therapeutic or diagnostic management. Patients in groups B and C had no such risk factors. Patients in group C had heartburn or regurgitation as a predominant symptom, whereas patients in group B did not. The prevalence of clinically relevant findings upon upper endoscopy was then compared for these three groups. Results. The prevalence of clinically relevant endoscopic findings in risk groups A, B and C were 20.1, 2.4 and 1.6%, respectively (p<0.01 for both A versus B and A versus C). Furthermore, 89% of those with clinically relevant endoscopic findings belonged to group A, which comprised a total of 45% of the patients studied. In groups B and C, the prevalence of disease was similar to the area-specific prevalence in the general population without dyspeptic symptoms. Conclusions. By using a simple standardized questionnaire, H. pylori serology and a hemoglobin reading in the evaluation of dyspeptic patients under 45 years of age, the need for endoscopy can be reduced by 55%.     

Endoscopic sphincterotomy for bile duct stones in patients 90 years of age and older

BACKGROUND: Little information is available on the outcomes of endoscopic sphincterotomy for choledocholithiasis in patients of advanced age (>/=90 years). METHODS: Endoscopic sphincterotomy was performed for choledocholithiasis in 22 patients aged 90 years or more (group A) and 381 aged 70 to 89 years (group B). Clinical features and early outcomes of endoscopic sphincterotomy were compared between the two groups. In group A, long-term results for a mean follow-up period of 33 months were assessed. RESULTS: Group A patients had a higher incidence of symptoms, acute cholangitis and concomitant diseases, as well as larger and more numerous gallstones than did group B patients. Endoscopic sphincterotomy was technically successful in 100% of group A patients and 98% of group B patients. The rate of early complications was low in both groups: 5% in group A and 7% in group B. No deaths related to endoscopic retrograde cholangiopancreatography occurred in group A patients. Complete stone clearance was achieved in 86% of group A patients and 95% of group B patients. Group A required an emergency procedure, general anesthesia, multiple sessions, mechanical lithotripsy, and permanent biliary stent placement more frequently than group B. Late complications occurred in 5% of group A patients. CONCLUSION: Endoscopic sphincterotomy is safe and effective for the treatment of choledocholithiasis in patients 90 years of age or older. Biliary stent placement is a reasonable alternative treatment when stones prove to be difficult to extract.     

"Test, score and scope": a selection strategy for safe reduction of upper gastrointestinal endoscopies in young dyspeptic patients referred from primary care

OBJECTIVE: To test the ability of pre-endoscopic clinical evaluation to predict clinically relevant findings of upper gastrointestinal endoscopy. MATERIAL AND METHODS: Patients (341) who had been referred to upper gastrointestinal endoscopy for further evaluation of dyspeptic symptoms were included in this prospective, single-blinded study. Prior to endoscopy, the patients underwent a standardized clinical evaluation consisting of 1) a symptom questionnaire, 2) serological testing for Helicobacter pylori antibody and 3) determination of blood hemoglobin. Based upon this evaluation, patients were assigned to one of three defined risk groups. Group A comprised patients with known risk factors for diseases that would require further therapeutic or diagnostic management. Patients in groups B and C had no such risk factors. Patients in group C had heartburn or regurgitation as a predominant symptom, whereas patients in group B did not. The prevalence of clinically relevant findings upon upper endoscopy was then compared for these three groups. RESULTS: The prevalence of clinically relevant endoscopic findings in risk groups A, B and C were 20.1, 2.4 and 1.6%, respectively (p<0.01 for both A versus B and A versus C). Furthermore, 89% of those with clinically relevant endoscopic findings belonged to group A, which comprised a total of 45% of the patients studied. In groups B and C, the prevalence of disease was similar to the area-specific prevalence in the general population without dyspeptic symptoms. CONCLUSIONS: By using a simple standardized questionnaire, H. pylori serology and a hemoglobin reading in the evaluation of dyspeptic patients under 45 years of age, the need for endoscopy can be reduced by 55%.     

Evaluation of iron deficiency anaemia in tertiary hospital settings: room for improvement?

Background: Iron deficiency anaemia (IDA) is a marker of occult blood loss from gastrointestinal (GI) lesions and requires thorough GI evaluation. Aim: This study aimed to determine frequency and findings of GI endoscopy in patients with IDA attending a tertiary hospital, and associations of endoscopy with patient and clinician‐related factors and results of faecal occult blood tests (FOBT). Methods: Retrospective audit of 621 subjects identified with definite and probable IDA (serum ferritin ≤15 ug/L and 16–50 µg/L respectively) between 1 January 2006 and 31 December 31 2008. Subjects were analysed as males >18 years and females ≥45 years of age with definite (group A, n= 180) or probable (group B, n= 353) IDA, and females <45 years of age with definite or probable IDA (group C, n= 88). Results: Endoscopy of any type was documented in 310 (50%) of patients with oesophagogastroduodenal endoscopy, and colonoscopy rates being significantly higher in group A patients (61% and 56% respectively) than in group B (39%, 37%) and group C (30%, 31%; P≤ 0.01 for all comparisons). Endoscopy rates ranged from 96% of patients seeing gastroenterologists to 31% of those seeing nephrologists. In patients undergoing colonoscopy, cancer and high‐risk adenomas were detected in 51 patients (20%), ranging from 27/100 (27%) of group A, 23/130 (18%) of group B and 1/27 (4%) of group C. Lesion prevalence was similar (19–24%) regardless of whether FOBT yielded positive or negative results or had not been performed. Conclusions: Almost one in two patients with IDA were not documented as undergoing GI endoscopy. More intense guideline promulgation, improved endoscopy access and ongoing practice audits are required to improve endoscopy rates.     

Efficacy and safety of therapeutic ERCP in patients 90 years of age and older

BACKGROUND: Therapeutic ERCP has an established role in the treatment of pancreatobiliary diseases, but little information is available on the outcomes of this procedure in patients 90 years of age and older. OBJECTIVE: To evaluate the efficacy and the safety of therapeutic ERCP in an extremely elderly cohort. DESIGN: Retrospective study. SETTING: Two Greek cohorts of patients > or =90 and 70 to 89 years of age who underwent therapeutic ERCPs. PATIENTS: Sixty-three patients aged 90 years and older (group A) and 350 patients 70 to 89 years of age (group B). INTERVENTIONS: A retrospective review of therapeutic ERCPs was performed between 1994 and 2000 on both groups, identified by using a database linked to the endoscopy reporting system in our department. MAIN OUTCOME MEASUREMENTS: Efficacy and safety of therapeutic ERCPs. Concomitant diseases, complications, and outcome were also evaluated. RESULTS: Group A patients had a higher incidence of concomitant diseases than group B patients (100% vs 72.8%, respectively). The rate of post-ERCP early complications was low in both groups: 6.3% in group A and 8.4% in group B. The frequency of ERCP-related mortality was 1.6% (1 patient) in group A and 0.6% (2 patients) in group B. Group A required endoscopic sessions for stone clearance and mechanical lithotripsy more frequently than group B (20.6% vs 11.4% and 17.5% vs 10.3%, respectively). No patient in either group experienced subjective deterioration in mental status, and the 3 patients who died required ventilatory support before death. Late complications occurred in 2.3% of patients in group B. CONCLUSIONS: Therapeutic ERCP is safe and effective for the treatment of pancreatobiliary diseases in extremely elderly patients, and advanced age per se should not impinge on decisions relating to its use.     

ERCP is safe and effective in patients 80 years of age and older compared with younger patients

BACKGROUND: Biliary disease frequently occurs in the elderly, but there are limited data on ERCP in the elderly population. PATIENTS: A total of 502 patients (group A, 97; group B, 405) underwent 724 ERCP procedures. MAIN OUTCOME MEASUREMENTS: All consecutive ERCPs performed between 2000 and 2002 at a single center were retrospectively reviewed for patients >/=80 years old (group A) and patients <80 years old (group B) to evaluate endoscopic findings, interventions, complications, and mortality related to complications. RESULTS: The number of important chronic concomitant diseases was significantly higher in the older group (average per patient 1.08 vs 0.57, P < .001). Successful cannulation was achieved in 88% in group A versus 86% in group B, and endoscopic sphincterotomy was performed in 63.2% versus 51.4%. Periampullary diverticulum was found significantly more often in patients of group A (39.2%) than of group B (14.1%, P < .001). Stents were used in 24.1% of ERCP procedures in group A and in 22.9% in group B. There was no significant difference in the complication rate between group A (6.8%) and group B (5.1%) and in early mortality (1.03% vs 0.25%), respectively. CONCLUSION: ERCP is a safe and effective intervention in the elderly because complication and early mortality rates are comparable to those of younger patients, although comorbidity is significantly higher.     

Causes of iron deficiency anemia in an adult inpatient population

Summary The causes of iron deficiency anemia in a population of adults admitted to two Jerusalem hospitals within a period of 7 years were examined. About one half of the 262 patients with iron deficiency anemia were over 70 years old. The ratio of males to females exclusive of young females with menorrhagia was 1:1.8. Despite the combined use of various diagnostic procedures, no definite cause of iron deficiency anemia could be established in 34% of patients. Benign gastrointestinal lesions were found in about one half of the cases in both hospitals. The prevalence of GI neoplasms in hospital B with a more intensive use of endoscopic procedures was significantly higher than in hospital A (18% vs 5%, p<0.001). The relative usefulness of barium contrast vs endoscopic studies is illustrated by the fact that 22 diagnoses established by endoscopy were missed by barium studies, whereas only 2 of those established by barium studies were not visualized by endoscopy. A particularly high risk group were anemic males aged 50 to 69 years in whom the prevalence of GI neoplasms was 30%. These data indicate that reliance on traditional contrast radioscopy may result in misdiagnosis of a high proportion of gastrointestinal neoplasms.     

Endoscopic evaluation of significant gastrointestinal lesions in patients with iron deficiency with and without anaemia: a Korean Association for the Study of Intestinal Disease Study

Background: Although endoscopy is recommended for patients with iron deficiency anaemia, there is, currently, no consensus on the role of endoscopy for iron‐deficient patients without anaemia. The goal of this study was to determine the prevalence of serious gastrointestinal (GI) lesions, identified by endoscopy in patients with iron deficiency and anaemia compared with patients with iron deficiency without anaemia. Methods: One thousand five hundred and eighteen patients with a ferritin value of ≤50 ng/mL and a total iron‐binding capacity ≥300 mg/dL were retrospectively investigated using oesophagogastroduodenoscopy and colonoscopy between January 2005 and September 2006. The lesions identified were classified as clinically important according to standard predetermined criteria. Results: Among the 1518 cases, 749 patients had anaemia and 769 had normal haemoglobin levels. Clinically important lesions were identified in 24.6% of the patients with anaemia and in 22.8% of the patients without anaemia (P > 0.05). The frequency of lower GI tract lesions (13.6 vs 11.4%, P > 0.05) and upper GI tract lesions (11.9 vs 12.5%, P > 0.05) was similar in the comparisons between the two groups. However, the frequency of malignant GI lesions was higher in the patients with anaemia (5.1 vs 0.7%, P < 0.01). In addition, the patients without anaemia were significantly more likely to have early‐stage neoplasia (adenoma, early gastric cancer and Dukes’ A and B colon cancer) than were the patients with anaemia (98.4 vs 52.5%, P < 0.01). Conclusion: The results of this study suggest that patients with iron deficiency should undergo endoscopic evaluation of the GI tract, irrespective of whether they have anaemia. The endoscopic evaluation of the GI tract in patients with iron deficiency without anaemia could provide an opportunity for the detection of early‐stage neoplasia at a curable stage.     

Synchronous and metachronous neoplasms in gastric cancer patients: A 23-year study

AIM: To determine the prevalence and characteristics of additional primary malignancies in gastric cancer (GC) patients.METHODS: GC patients (862 total; 570 men, 292 women; mean age 59.8 ± 12.8 years) diagnosed at the Department of Gastroenterology at Pomeranian Medical University over a period of 23 years were included in this retrospective analysis of a prospectively maintained database. Mean follow-up time was 31.3 ± 38.6 mo (range 1-241 mo). The following clinicopathological features of patients with synchronous tumors were compared to those with metachronous tumors: age, sex, symptom duration, family history of cancer, tumor site, stage (early vs advanced), histology, and blood group. GC patients with and without a second tumor were compared in terms of the same clinicopathological features.RESULTS: Of 862 GC patients, 58 (6.7%) developed a total of 62 multiple primary tumors, of which 39 (63%) were metachronous and 23 (37%) synchronous. Four (6.9%) of the 58 multiple GC patients developed two or more neoplasms. The predominant tumor type of the secondary neoplasms was colorectal (n = 17), followed by lung (n = 9), breast (n = 8), and prostate (n = 7). Age was the only clinicopathological feature that differed between GC patients with synchronous vs metachronous malignancies; GC patients with synchronous neoplasms were older than those with metachronous neoplasms (68.0 ± 10.3 years vs 59.9 ± 11.1 years, respectively, P = 0.008). Comparisons between patients with and without a second primary cancer revealed that the only statistically significant differences were in age and blood group. The mean age of the patients with multiple GC was higher than that of those without a second primary tumor (63.4 ± 11.4 years vs 59.5 ± 13.0 years, respectively, P = 0.026). GC patients with a second primary tumor were more commonly blood group O than those without (56.2% vs 31.6%, respectively, P = 0.002).CONCLUSION: GC patients may develop other primary cancers; appropriate preoperative and postoperative diagnostic modalities are thus required, particularly if patients are older and blood group O.     

Impact of balloon-occluded retrograde transvenous obliteration on management of isolated fundal gastric variceal bleeding

Aim: Although endoscopic injection of cyanoacrylate (CA) is the only effective method for treating isolated fundal gastric variceal bleeding, the rebleeding rate is relatively high. This study investigated the efficacy of balloon‐occluded retrograde transvenous obliteration (B‐RTO) for management of isolated fundal gastric variceal bleeding. Methods: Patients (n = 110) with acute or recent bleeding from isolated fundal gastric varices (GV) were retrospectively studied. Acute bleeding was treated by CA injection or balloon tamponade. 44 patients underwent additional endoscopic injection of CA and ethanolamine oleate (EO) weekly until obturation of GVx from 1994 to 2002 (group A). 42 patients from 2003 to 2010 underwent B‐RTO after initial hemostasis (group B). Both groups were assessed for the number of sessions required to achieve GV obturation, hospital stay, recurrent bleeding rate, morbidity and mortality. Results: Acute gastric variceal bleeding was successfully treated in all patients by CA injection or balloon tamponade. B‐RTO was successfully performed except in two patients in group B. The average number of sessions required for obturation was 3.8 for groups A and 2.2 for B (P < 0.05). Recurrent bleeding was observed in 16 and two patients in groups A and B, respectively. The cumulative non‐rebleeding rate at 5 years was 58.3% and 98.1% in groups A and B, respectively. The cumulative survival rate at 5 years was 53.8% and 87.6% in groups A and B, respectively. Conclusion: Balloon‐occluded retrograde transvenous obliteration may be superior to endoscopic injection with CA and EO for prevention of rebleeding in patients with isolated fundal GVs with a major shunt.     

Interventional radiology and endoscopic therapy for recurrent esophageal varices

BACKGROUND/AIMS: We investigated the impact long-term prognosis of combined interventional radiology and endoscopic therapy in patients with esophageal varices. METHODOLOGY: Patients with recurrent esophageal varices underwent treatment as follows: 54 were treated with endoscopic therapy alone and 32 underwent endoscopic therapy plus interventional radiologic procedures. Primary endpoints during 5-year follow-up included recurrent bleeding, second retreatment, and death. RESULTS: The bleeding rates were 11.1% in the endoscopy group, and 9.4% in the combined therapy group. Second retreatment rates at 1 year, 3 years, and 5 years in the endoscopy group and combined therapy group were 25.4% and 17.2%, 70.2% and 39.3%, and 85.0% and 69.6%, respectively. The second retreatment rates in the combined therapy group were significantly reduced compared to the endoscopy alone group (P = 0.05). Cumulative retreatment rates in Child's class C cases were significantly lower in the combined therapy group than in the endoscopy group (P = 0.01). Survival at 3 years was 97.1% in the endoscopy group and 92.0% in the combined therapy group, and 5-year survival was 79.1% and 83.6%, respectively. CONCLUSIONS: The combination of interventional radiologic and endoscopic therapy is highly effective and improves long-term prognosis in patients with recurrent esophageal varices.