Endoscopic mucosal resection for rectal carcinoids under micro-probe ultrasound guidance

AIM: To assess the therapeutic value of endoscopic mucosal resection (EMR) under micro-probe ultrasound guidance for rectal carcinoids less than 1 cm in diameter. METHODS: Twenty-one patients pathologically diagnosed with rectal carcinoids following colonoscopy in our hospital from January 2007 to November 2012 were included in this study. The patients consisted of 14 men and 7 women, with a mean age of 52.3 ± 12.2 years (range: 36-72 years). The patients with submucosal tumors less than 1 cm in diameter arising from the rectal and muscularis mucosa detected by micro-probe ultrasound were treated with EMR and followed up with conventional endoscopy and micro-probe ultrasound. RESULTS: All of the 21 tumors were confirmed by micro-probe ultrasound as uniform hypoechoic masses originating from the rectal and muscularis mucosa, without invasion of muscularis propria and vessels, and less than 1 cm in diameter. EMR was successfully completed without bleeding, perforation or other complications. The resected specimens were immunohistochemically confirmed to be carcinoids. Patients were followed up for one to two years, and no tumor recurrence was reported. CONCLUSION: EMR is a safe and effective treatment for rectal carcinoids less than 1 cm in diameter.     

Assessment of the validity of the clinical pathway for colon endoscopic submucosal dissection

AIM: To determine the effective hospitalization period as the clinical pathway to prepare patients for endoscopic submucosal dissection (ESD). METHODS: This is a retrospective observational study which included 189 patients consecutively treated by ESD at the National Cancer Center Hospital from May 2007 to March 2009. Patients were divided into 2 groups; patients in group A were discharged in 5 d and patients in group B included those who stayed longer than 5 d. The following data were collected for both groups: mean hospitalization period, tumor site, median tumor size, post-ESD rectal bleeding requiring urgent endoscopy, perforation during or after ESD, abdominal pain, fever above 38 ℃, and blood test results positive for inflammatory markers before and after ESD. Each parameter was compared after data collection. RESULTS: A total of 83% (156/189) of all patients could be discharged from the hospital on day 3 postESD. Complications were observed in 12.1% (23/189) of patients. Perforation occurred in 3.7% (7/189) of patients. All the perforations occurred during the ESD procedure and they were managed with endoscopic clipping. The incidence of post-operative bleeding was 2.6% (5/189); all the cases involved rectal bleeding. We divided the subjects into 2 groups: tumor diameter ≥ 4 cm and 4 cm; there was no significant difference between the 2 groups (P = 0.93, χ 2 test with Yates correction). The incidence of abdominal pain was 3.7% (7/189). All the cases occurred on the day of the procedure or the next day. The median white blood cell count was 6800 ± 2280 (cells/μL; ± SD) for group A, and 7700 ± 2775 (cells/μL; ± SD) for group B, showing a statistically significant difference (P = 0.023, t-test). The mean C-reactive protein values the day after ESD were 0.4 ± 1.3 mg/dL and 0.5 ± 1.3 mg/dL for groups A and B, respectively, with no significant difference between the 2 groups (P = 0.54, t -test). CONCLUSION: One-day admission is sufficient in the absence of complications during ESD or early postoperative bleeding.     

Low level of galacto-oligosaccharide in infant formula stimulates growth of intestinal Bifidobacteria and Lactobacilli

AIM： To investigate the effect of a new infant formula supplemented with a low level （0.24 g/100 mL） of galacto-oligosaccharide （GOS） on intestinal micro-flora （Bifidobacteria, Lactobacilli and E. coli） and fermentation characteristics in term infants, compared with human milk and a standard infant formula without GOS. METHODS： Term infants （n = 371） were approached in this study in three hospitals of China. All infants started breast-feeding. Those who changed to formula-feeding within 4 wk after birth were randomly assigned to one of the two formula groups. Growth and stool characteristics, and side effects that occurred in recruited infants were recorded in a 3-mo follow-up period. Fecal samples were collected from a subpopulation of recruited infants for analysis of intestinal bacteria （culture technique）, acetic acid （gas chromatography） and pH （indicator strip）. RESULTS： After 3 mo, the intestinal Bifidobacteria, Lactobacilli, acetic acid and stool frequency were significantly increased, and fecal pH was decreased in infants fed with the GOS-formula or human milk, compared with those fed with the formula withoutGOS. No significant differences were observed between the GOS formula and human milk groups. Supplementation with GOS did not influence the incidence of crying, regurgitation and vomiting. CONCLUSION： A low level of GOS （0.24 g/100 mL） in infant formula can improve stool frequency, decrease fecal pH, and stimulate intestinal Bifidobacteria and Lactobacilli as in those fed with human milk.     

Massive presacral bleeding during rectal surgery: From anatomy to clinical practice

AIM: To investigate control of two different types of massive presacral bleeding according to the anatomy of the presacral venous system. METHODS: A retrospective review was performed in 1628 patients with middle or low rectal carcinoma who were treated surgically in the Department of Colorectal Surgery, Changhai Hospital, Shanghai, China from January 2008 to December 2012. In four of these patients, the presacral venous plexus (n = 2) or basivertebral veins (n = 2) were injured with massive presacral bleeding during mobilization of the rectum. The first two patients with low rectal carcinoma were operated upon by a junior associate professor and the source of bleeding was the presacral venous plexus. The other two patients with recurrent rectal carcinoma were both women and the source of bleeding was the basivertebral veins.RESULTS: Two different techniques were used to con-trol the bleeding. In the first two patients with massive bleeding from the presacral venous plexus, we used suture ligation around the venous plexus in the area with intact presacral fascia that communicated with the site of bleeding (surrounding suture ligation). In the second two patients with massive bleeding from the basivertebral veins, the pelvis was packed with gauze, which resulted in recurrent bleeding as soon as it was removed. Following this, we used electrocautery applied through one epiploic appendix pressed with a long Kelly clamp over the bleeding sacral neural foramen where was felt like a pit Electrocautery adjusted to the highest setting was then applied to the clamp to "weld" closed the bleeding point. Postoperatively, the blood loss was minimal and the drain tube was removed on days 4-7. CONCLUSION: Surrounding suture ligation and epiploic appendices welding are effective techniques for controlling massive presacral bleeding from presacral venous plexus and sacral neural foramen, respectively.     

Frequency and prognostic role of mucosal healing in patients with Crohn’s disease and ulcerative colitis after one-year of biological therapy

AIM:To assess the endoscopic activity before and after a one-year period of biological therapy and to evaluate the frequency of relapses and need for retreatment after stopping the biologicals in patients with Crohn’s disease(CD)and ulcerative colitis(UC).METHODS:The data from 41 patients with CD and 22 patients with UC were assessed.Twenty-four CD patients received infliximab,and 17 received adalimumab.The endoscopic severity of CD was quantified with the simplified endoscopic activity score for Crohn’s disease in CD and with the Mayo endoscopic subscore in UC.RESULTS:Mucosal healing was achieved in 23 CD and7 UC patients.Biological therapy had to be restarted in78%of patients achieving complete mucosal healing with CD and in 100%of patients with UC.Neither clinical remission nor mucosal healing was associated with the time to restarting the biological therapy in either CD or UC.CONCLUSION:Mucosal healing did not predict sustained clinical remission in patients in whom the biological therapies had been stopped.     

Endoscopic treatment and follow-up of gastrointestinal Dieulafoy＇s lesions

AIM: To investigate retrospectively the clinical and endoscopic features of bleeding Dieulafoy's lesions and to assess the short- and long-term effectiveness of endoscopic treatment. METHODS: Twenty-three patients who had gastrointestinal bleeding from Dieulafoy's lesions underwent endoscopic therapy. Demographic data, mode of presentation, risk factors for gastrointestinal bleeding, blood transfusion requirements, endoscopic findings, details of endoscopic therapy, recurrence of bleeding, and mortality rates were collected and analyzed retrospectively. RESULTS: Hemostasis was attempted by dextrose 50% plus epinephrine in 10 patients, hemoclipping in 8 patients, heater probe in 2 patients and ethanolamine oleate in 2 patients. Comorbid conditions were present in 17 patients (74%). Overall permanent hemostasis was achieved in 18 patients (78%). Initial hemostasis was successful with no recurrent bleeding in patients treated with hemoclipping, heater probe or ethanolamine injection. In the group of patients who received dextrose 50% plus epinephrine injection treatment, four (40%) had recurrent bleeding and one (10%) had unsuccessful initial hemostasis. Of the four patients who had rebleeding, three had unsuccessful hemostasis with similar treatment. Surgical treatment was required in five patients (22%) owing to uncontrolled bleeding, recurrent bleeding with unsuccessful retreatment and inability to approach the lesion. One patient (4.3%) died of sepsis after operation during hospitalization. There were no side-effects related to endoscopic therapy. None of the patients in whom permanent hemostasis was achieved presented with rebleeding from Dieulafoy's lesion over a mean long-term follow-up of 29.8 mo. CONCLUSION: Bleeding from Dieulafoy's lesions can be managed successfully by endoscopic methods, which should be regarded as the first choice. Endoscopic hemoclipping therapy is recommended for bleeding Dieulafoy's lesions.     

Effect of infliximab on small bowel stenoses in patients with Crohn＇s disease

AIM： To assess prospectively small bowel stenoses in Crohn＇s disease （CD） patients treated with infliximab using Small Intestine Contrast Ultrasonography （SICUS）. METHODS： Twenty patients （M 12, age, 42.7 ± 11.8 years）, 15 of whom showed obstructive symptoms indicating the presence of small bowel stenosis, and 5 without stenosis, were treated with infliximab （5 mg/kg at wk 0, 2, 6 and 5 mg/kg every 8 wk thereafter） for steroid refractoriness, fistulizing disease, or to avoid high-risk surgery. SICUS was performed at the induction phase and at regular time intervals during the followup period of 34.7 ± 16.1 mo （range 7-58）. Small bowel stenoses were detected by SICUS, endoscopy and MRI. RESULTS： In no case was progression of stenoses or the appearance of new ones seen. Of the 15 patients with stenosis, 5 stopped treatment after the induction phase （2 for no response, 3 for drug intolerance, one of whom showed complete regression of one stenosis）. Among the remaining 10 patients, a complete regression of 8 stenoses （1 stenosis in 5 patients and 3 stenoses in one patient） was observed after 6-22 infliximab infusions. CONCLUSION： In patients with CD treated with infliximab we observed： （a） No progression of small bowel stenosis and no appearance of new ones, （b） Complete regression of 1/22 stenosis after the induction phase and of 8/15 （53.3%） stenosis after 6-22 infusions during maintenance therapy.     

A pilot study of single-use endoscopy in screening acute gastrointestinal bleeding

AIM:To investigate the feasibility of a single-use endoscopy as an alternative procedure to nasogastric lavage in patients with acute gastrointestinal(GI) bleeding.METHODS:Patients who presented with hematemesis,melena or hematochezia were enrolled in this study.EG scan and conventional esophagogastroduodenoscopy(EGD) were subsequently performed.Active bleeding was defined as blood in the stomach,and inactive bleeding was defined as coffee ground clots and clear fluid in the stomach.The findings were recorded and compared.RESULTS:Between January and March,2011,13 patients that presented with hematemesis(n = 4),melena(n = 6),or bleeding from a previous nasogastric feeding tube(n = 3),were enrolled in this study.In 12 patients with upper GI bleeding,the EG scan device revealed that 7 patients had active bleeding and 5 patients had inactive bleeding,whereas conventional EGD revealed that 8 patients had active bleeding and 4 patients had inactive bleeding.The sensitivity and specificity of the EG scan device was 87.5% and 100% for active bleeding,with conventional EGD serving as a reference.No complication were reported during the EG scan procedures.CONCLUSION:The EG scan is a feasible device for screening acute upper GI bleeding.It may replace nasogastric lavage for the evaluation of acute upper GI bleeding.     

Bleeding risk with clopidogrel and percutaneous endoscopic gastrostomy

AIM To compare bleeding within 48 h in patients undergoing percutaneous endoscopic gastrostomy(PEG) with or without clopidogrel.METHODS After institutional review board approval, a retrospective study involving a single center was conducted on adult patients having PEG(1/08-1/14). Patients were divided into two groups: Clopidogrel group consisting of those patients taking clopidogrel within 5 d of PEG and the non-clopidogrel group including those patients not taking clopidogrel within 5 d of the PEG.RESULTS Three hundred and nineteen PEG patients were found. One hundred and sixty-eight males and 151 females with mean body mass index 28.47 ± 9.75 kg/m2 and mean age 65.03 ± 16.11 years were identified. Thirtythree patients were on clopidogrel prior to PEG with 286 patients not on clopidogrel. No patients in either group developed hematochezia, melena, or hematemesiswithin 48 h of percutaneous endoscopic gastrostomy(PEG). No statistical differences were observed between the two groups with 48 h for hemoglobin decrease of 2 g/dL(2 vs 5 patients; P = 0.16), blood transfusions(2 vs 7 patients; P = 0.24), and repeat endoscopy for possible gastrointestinal bleeding(no patients in either group). CONCLUSION Based on the results, no significant post-procedure bleeding was observed in patients undergoing PEG with recent use of clopidogrel.     

Acute upper gastrointestinal bleeding in operated stomach： Outcome of 105 cases

AIM: To compare the causes and clinical outcome of patients with acute upper gastrointestinal bleeding (AUGB) and a history of gastric surgery to those with AUGB but without a history of gastric surgery in the past.METHODS: The causes and clinical outcome were compared between 105 patients with AUGB and a history of gastric surgery, and 608 patients with AUGB but without a history of gastric surgery.RESULTS: Patients who underwent gastric surgery in the past were older (mean age: 68.1±11.7 years vs 62.8±17.8 years, P= 0.001), and the most common cause of bleeding was marginal ulcer in 63 patients (60%). No identifiable source of bleeding could be found in 22 patients (20.9%) compared to 42/608 (6.9%) in patients without a history of gastric surgery (P = 0.003). Endoscopic hemostasis was permanently successful in 26 out of 35 patients (74.3%) with peptic ulcers and active bleeding or non-bleeding visible vessel. Nine patients (8.6%) were operated due to continuing or recurrent bleeding,compared to 23/608 (3.8%) in the group of patients without gastric surgery in the past (P= 0.028). Especially in peptic ulcer bleeding patients, emergency surgery was more common in the group of patients with gastric surgery in the past [9/73 (12.3%) vs 19/360 (5.3%), P = 0.025].Moreover surgically treated patients in the past required more blood transfusion (3.3±4.0 vs 1.5±1.7, P = 0.0001) and longer hospitalization time (8.6±4.0 vs 6.9±4.9 d,P = 0.001) than patients without a history of gastric surgery. Mortality was not different between the two groups [4/105 (3.8%) vs 19/608 (3.1%)].CONCLUSION: Upper gastrointestinal bleeding seems to be more severe in surgically treated patients than in non-operated patients.     

Severity of gastric mucosal atrophy affects the healing speed of post-endoscopic submucosal dissection ulcers

AIM To investigate factors associated with the healing of endoscopic submucosal dissection(ESD)-induced ulcers.METHODS We enrolled 132 patients with gastric tumors scheduled for ESD. Following ESD, patients were treated with daily lansoprazole 30 mg or vonoprazan 20 mg. Ulcer size was endoscopically measured on the day after ESD and at 4 and 8 wk. The gastric mucosa was endoscopically graded according to the Kyoto gastritis scoring system. We assessed the number of patients with and without a 90% reduction in ulcer area at 4 wk post-ESD and scar formation at 8 wk, and looked for risk factors for slower healing.RESULTS The mean size of gastric tumors and post-ESD ulcers was 17.4 ± 12.1 mm and 32.9 ± 13.0 mm. The meanreduction rates in ulcer area were 90.4% ± 0.8% at 4 wk and 99.8% ± 0.1% at 8 wk. The reduction rate was associated with the Kyoto grade of gastric atrophy at 4 wk(A0: 97.9% ± 0.6%, A1: 93.4% ± 4.1%, and A2: 89.7% ± 1.0%, respectively). In multivariate analysis, the factor predicting 90% reduction at 4 wk was gastric atrophy(Odds ratio: 5.678, 95%CI: 1.190-27.085, P = 0.029).CONCLUSION The healing speed of post-ESD ulcers was associated with the degree of gastric mucosal atrophy, and Helicobacter pylori eradication therapy is required to perform at younger age.     

Per rectal portal scintigraphy as a useful tool for predicting esophageal variceal bleeding in cirrhotic patients

AIM： To investigate potential roles of per rectal portal scintigraphy in diagnosis of esophageal varices and predicting the risk of bleeding. METHODS： Fifteen normal subjects and fifty cirrhotic patients with endoscopically confirmed esophageal varices were included. Patients were categorized into bleeder and non-bleeder groups according to history of variceal bleeding. All had completed per rectal portal scintigraphy using ^99mTechnetium pertechnetate. The shunt index was calculated from the ratio of ^99mTechnetium pertechnetate in the heart and the liver. Data were analyzed using Student＇s t-test and receiver operating characteristics. RESULTS： Cirrhotic patients showed a higher shunt index than normal subjects （63.80 ± 25.21 vs 13.54 ± 6.46, P 〈 0.01）. Patients with variceal bleeding showed a higher shunt index than those without bleeding （78.45 ± 9.40 vs 49.35 ± 27.72, P 〈 0.01）. A shunt index of over 20% indicated the presence of varices and that of over 60% indicated the risk of variceal bleeding. CONCLUSION： In cirrhotic patients, per rectal portal scintigraphy is a clinically useful test for identifying esophageal varices and risk of variceal bleeding.     

Treatment of rectal prolapse in children with cow milk injection sclerotherapy： 30-year experience

AIM： To evaluate the role and our experience of injection sclerotherapy with cow milk in the treatment of rectal prolapse in children.
METHODS： In the last 30 years （1976-2006） we made 100 injections of sclerotherapy with cow milk in 86 children, In this study we included children who failed to respond to conservative treatment and we perform operative treatment.
RESULTS： In our study we included 86 children and in all of the patients we perform cow milk injection sclerotherapy. In 95.3% （82 children） of patients sclerotherapy was successful. In 4 （4.7%） patients we had recurrent rectal prolapse where we performed operative treatment. Below 4 years we had 62 children （72%） and 24 older children （28%）. In children who needed operative treatment we performed Thiersch operation and without any complications.
CONCLUSION： Injection sclerotherapy with cow milk for treatment rectal prolapse in children is a simple and effective treatment for rectal prolapse with minimal complications.     

Dietary treatment of colic caused by excess gas in infants: biochemical evidence

AIM:To evaluate the impact of feeding colicky infants with an adapted formula on the hydrogen breath test and clinical symptoms.METHODS:Hydrogen expiration was measured by SC MicroLyzer gas chromatography at inclusion and 15 d after treatment with an adapted low-lactose formula in 20 colicky infants.RESULTS:All babies were symptomatic:85% with excess gas,75% with abnormal feeding pattern,and 85% with excessive crying.The hydrogen breath test at inclusion was abnormal:35 ± 3.1 ppm.After 15 d feeding with an ...     

Formalin irrigation for hemorrhagic chronic radiation proctitis

AIM: To assess the efficacy and safety of a modified topical formalin irrigation method in refractory hemorrhagic chronic radiation proctitis(CRP). METHODS: Patients with CRP who did not respond to previous medical treatments and presented with grade II-III rectal bleeding according to the Common Terminology Criteria for Adverse Events were enrolled. Patients with anorectal strictures, deep ulcerations, and fistulas were excluded. All patients underwent flexible endoscopic evaluation before treatment. Patient demographics and clinical data, including primary tumor, radiotherapy and previous treatment options, were collected. Patients received topical 4% formalin irrigation in a clasp-knife position under spinal epidural anesthesia in the operating room. Remission of rectal bleeding and related complications were recorded. Defecation, remission of bleeding, and other symptoms were investigated at follow-up. Endoscopic findings in patients with rectovaginal fistulas were analyzed.RESULTS: Twenty-four patients(19 female, 5 male) with a mean age of 61.5 ± 9.5 years were enrolled. The mean time from the end of radiotherapy to the onset of bleeding was 11.1 ± 9.0 mo(range: 2-24 mo). Six patients(25.0%) were blood transfusion dependent. The median preoperative Vienna Rectoscopy Score(VRS) was 3 points. Nineteen patients(79.2%) received only one course of topical formalin irrigation, and five(20.8%) required a second course. No side effects were observed. One month after treatment, bleeding cessation was complete in five patients and obvious in14; the effectiveness rate was 79.1%(19/24). For longterm efficacy, 5/16, 1/9 and 0/6 patients complained of persistent bleeding at 1, 2 and 5 years after treatment, respectively. Three rectovaginal fistulas were found at 1 mo, 3 mo and 2 years after treatment. Univariate analysis showed associations of higher endoscopic VRS and ulceration score with risk of developing rectovaginal fistula. CONCLUSION: Modified formalin irrigation is an effective and safe method for hemorrhagic CRP, but should be performed cautiously in patients with a high endoscopic VRS.     

Endoclipping treatment of life-threatening rectal bleeding after prostate biopsy

Rectal bleeding is frequently seen in patients undergoing transrectal ultrasound （TRUS）-guided multiple biopsy of the prostate, but is usually mild and stops spontaneously. We report what is believed to be the first case of life-threatening rectal bleeding following this procedure, which was successfully treated by endoscopic intervention through placement of three clips on the sites of bleeding. This case emphasizes endoscopic intervention associated with endoclipping as a safe and effective method to achieve hemostasis in massive rectal bleeding after prostate biopsy. Additionally, current data on the complications of the TRUS-guided multiple biopsy of the prostate and the options for treating fulminant rectal bleeding, a consequence of this procedure, are described.     

Risk factors for bleeding after endoscopic mucosal resection

AIM: To clarify the risk factors for bleeding after endoscopic mucosal resection (EMR). METHODS: A total of 297 consecutive patients who underwent EMR were enrolled. Some of the patients had multiple lesions. Bleeding requiring endoscopic treatment was defined as bleeding after EMR. Odds ratios (OR) with 95% confidence intervals (CI), calculated by logistic regression with multivariate adjustments for covariates, were the measures of association. RESULTS: Of the 297 patients, 57 (19.2%) patients with bleeding after EMR were confirmed. With multivariate adjustment, the cutting method of EMR, diameter, and endoscopic pattern of the tumor were associated with the risk of bleeding after EMR. The multivariate-adjusted OR for bleeding after EMR using endoscopic aspiration mucosectomy was 3.07 (95%CI, 1.59-5.92) compared with strip biopsy. The multiple-adjusted OR for bleeding after EMR for the highest quartile (16-50 mm) of tumor diameter was 5.63 (95%CI, 1.84-17.23) compared with that for the lowest (4-7 mm). The multiple-adjusted OR for bleeding after EMR for depressed type of tumor was 4.21 (95%CI, 1.75-10.10) compared with elevated type. CONCLUSION: It is important to take tumor characteristics (tumor size and endoscopic pattern) and cutting method of EMR into consideration in predicting bleeding after EMR.     

Copper metabolism after living related liver transplantation for Wilson＇s disease

AlM: Liver transplantation is indicated for Wilson's disease(WD) patients with the fulminant form and end-stage liverfailure. The aim of this study was to review our experiencewith living-related liver transplantation (LRLT) for WD.METHODS: A retrospective review was made for WDundergoing LRLT at our hospital from January 2001 toFebuary 2003.RESULTS: LRLT was carried out in 15 patients with WD,one of them had fulminant hepatic failure and the others had end-stage hepatic insufficiency. The mean age of the patients was 14.5±2.5 years (range 6 to 20 years). All the recipients had low serum ceruloplasmin levels with a mean value of 126.8±34t.8 mg/L before transplantation. The serum ceruloplasmin levels increased to an average of 238.6±34.4mg/L after LRLT at the latest evaluation, between 2 and 27months after transplantation. A marked reduction in urinary copper excretion was observed in all the recipients after transplantation. Among the eight recipients with preoperative Kayser-Fleischer (K-F) rings, this abnormality resolved completely after LRLT in five patients and partially in three.All the recipients are alive and remain well, and none has developed signs of recurrent WD after a mean follow-up period of 15.4±9.3 months (range 2-27 months) except one who died of severe rejection. The donors were 14t mothers and 1 father. The serum ceruloplasmin levels were within normal limits in all the donors (mean: 220±22.4 mg/L). The mean donor age was 35.0±4.0 years (range, 30 to 45 years).Two donors had biliary leakage and required reoperation.Grafts were harvested as follows: four right lobe grafts without hepatic middle vein and eleven left lobe grafts with hepatic middle vein. The grafts were blood group-compatible in all recibents. Two patients had hepatic artery thrombosis and underwent retransplantation.CONCLUSION: LRLT is a curative procedure in Wilson's disease manifested as fulminant hepatic failure and/or endstage hepatic insufficiency. After liver transplantation, the serum ceruoplasmin level can increase to its normal range while urinary copper excretion decreases. Grafts chosen from heterozygote carriers do not appear to confer any risk of recurrence in recipients.     

Clinical predictors of colorectal polyps and carcinoma in a low prevalence region： Results of a colonoscopy based study

AIM： To estimate the prevalence of colorectal cancer （CRC） in patients with long lasting colonic symptoms undergoing total colonoscopy; and to establish clinical features predicting its occurrence. METHODS： This prospective study was carried out in Imam Hospital, Tabriz University of medical sciences, Iran. Continuous patients with long lasting lower gastrointestinal tract symptoms who had the criteria of a colonoscopy were included. The endoscopist visualized the caecum documented by a photo and/or a specimen from terminal ileum. RESULTS： Four hundred and eighty consecutive symptomatic patients [mean age （SD）： 42.73 （16.21）] were included. The prevalence of colorectal neoplasia was 15.3% （34 subjects） and 37.7% （181 subjects） had a completely normal colon. Adenomatous polyps were detected in 56 （11.7%） patients, in 12.3% of men and 10.9% of women. The mean age of the patients with a polyp was significantly higher than the others （49.53 ± 14.16 vs 41.85 ± 16.26, P = 0.001）. Most of the adenomatous polyps were left sided and tubular; only 22.5% of polyps were more than 10 mm. Cancer was detected in 16 （3.6%） of our study population, which was mostly right sided （57.2%）. The mean age of patients with cancer was significantly higher than the others （60.25 ± 8.26 vs 42.13 ± 16.08, P 〈 0.005） and higher than patients with polyps [60.25 （8.26） vs 49.53 （1.91） （P 〈 0.0005）]. None of the symptoms （diarrhea, abdominal pain, rectal bleeding, constipation, altering diarrhea and constipation, history of cancer, known irritable bowel disease, history of polyp and fissure or family history of cancer） were predictors for cancer or polyps, but the age of the patient and unexplainedanemia independently predicted cancer. CONCLUSION： Less advanced patterns and smaller sizes of adenomas in Iran is compatible with other data from Asia and the Middle East, but in contrast to western countries. Prevalence of colonic neoplasia in our community seems to be lower th     

Soluble CD40 ligand in prediction of acute severe pancreatitis

AIM: To assess the early predictability of the soluble CD40L (sCD40L) in pancreatitis severity. METHODS: Between February 2000 and February 2003, 279 consecutive patients with acute pancreatitis were prospectively enrolled in our study. In this report, 40 patients with mild and 40 patients with severe pancreatitis were randomly studied. sCD40L concentrations were measured 48 hours after admission. RESULTS: sCD40L levels were significantly higher 48 hours after admission in severe pancreatitis than in mild pancreatitis. Using a cutoff of 1000 pg/L, the sensitivity and specificity of sCD40L to detect a severe course of the disease were 78% and 62% respectively compared to 72% and 81% for CRP. Logistic regression analysis found that CRP was the only statistically significant marker able to detect a severe course of the disease. CONCLUSION: These findings indicate that CRP remains a valuable marker to determine the severity and prognosis of acute pancreatitis whereas sCD40L levels should be assessed in further studies.