Repeat colonoscopy’s value in gastrointestinal bleeding

AIM:To assess the diagnostic yield and clinical value of early repeat colonoscopies for indications other than colorectal cancer(CRC) screening/surveillance.METHODS:A retrospective review of patients who had more than one colonoscopy performed for the same indication within a three year time frame at our tertiary care referral hospital between January 1,2000 and January 1,2010 was conducted.Exclusion criteria included repeat colonoscopies performed for CRC screening/surveillance,poor bowel preparation,suspected complications from the index procedure,and incomplete initial procedure.Primary outcome was new endoscopic finding that led to an endoscopic therapeutic intervention or any change in clinical management.Clinical parameters including age,sex,race,interval between procedures,indication of the procedure,presenting symptoms,severity of symptoms,hemodynamic instability,duration between onset of symptoms and when the procedure was performed,change in endoscopist,withdrawal time,location of colonic lesions and improvement of quality of bowel preparation were analyzed using bivariate analysis and logistic regression analysis to examine correlation with this primary outcome.RESULTS:Among 19 772 colonoscopies performed during the above mentioned period,947 colonoscopies(4.79%) were repeat colonoscopies performed within 3 years from the index procedure.Out of these repeat colonoscopies,139 patient pairs met the inclusion criteria.The majority of repeat colonoscopies were for lower gastrointestinal bleeding(88.4%),change in bowel habits(6.4%) and abdominal pain(5%).Among 139 eligible patient pairs of colonoscopies,only repeat colonoscopies that were done for lower gastrointestinal bleeding and abdominal pain produced endoscopic findings that led to a change in management [25 out of 123(20.33%) and 2 out of 7(28.57%),respectively].When looking at only recurrent lower gastrointestinal bleeding cases,new endoscopic findings included 8 previously undetected hemorrhoid lesions(6.5%),7 actively bleeding lesions requiring endoscopic intervention,which included 3 bleeding arterio-venous malformations(2.43%),2 bleeding radiation colitis(1.6%),and 2 bleeding internal hemorrhoids(1.6%),5 previously undetected tubular adenomas [4 were smaller than 1 cm(4.9%) and 1 was larger than 1 cm(0.8%)],3 radiation colitis(2.43%),1 rectal ulcer(0.8%),and 1 previously undetected right sided colon cancer(0.8%).Of the 25 new endoscopic findings,18(72%) were found when repeat colonoscopy was done within the first year after the index procedure.These findings were 1 rectal ulcer,3 radiation colitis,4 new hemorrhoid lesions,3 previously undetected tubular adenomas,and 7 actively bleeding lesions requiring endoscopic intervention.Of all parameters analyzed,only the interval between procedures less than one year was associated with higher likelihood of finding a clinically significant change in repeat colonoscopy(odds ratios of interval between procedures of 1-2 year and 2-3 year compared to 0-1 year were 0.09;95%CI 0.01-0.74,P = 0.025 and 0.26;95%CI 0.09-0.72,P = 0.010 respectively).No complications were observed among all 139 colonoscopy pairs.CONCLUSION:There is clinical value of repeating a colonoscopy for recurrent lower gastrointestinal bleeding,especially within the first year after the index procedure.     

Endoscopic mucosal resection of large hyperplastic polyps in 3 patients with Barrett’s esophagus

INTRODUCTION Benign esophageal tumors are rare, representing less than 1% of all esophageal tumors[1]. They are usually asymptomatic and often discovered incidentally[2]. Many classifications have been proposed for benign esophageal tumors: by histologica…     

Characteristics of allergic colitis in breast-fed infants in the absence of cow’s milk allergy

AIM: To investigate the characteristics of mucosal le-sions and their relation to laboratory data and long-term follow up in breast-fed infants with allergic colitis. METHODS: In this study 31 breast-fed infants were prospectively evaluated (mean age, 17.4 wk) whose rectal bleeding had not ceased after a maternal elimi-nation diet for cow’s milk. Thirty-four age-matched and breast-fed infants (mean age, 16.9 wk) with no rectal bleeding were enrolled for laboratory testing as con-trols. Laboratory findings, colonoscopic and histological characteristics were prospectively evaluated in infants with rectal bleeding. Long-term follow-up with differ-ent nutritional regimes (L-amino-acid based formula or breastfeeding) was also included. RESULTS: Iron deficiency, peripheral eosinophilia andthrombocytosis were significantly higher in patients with allergic colitis in comparison to controls (8.4±3.2 μmol/L vs 13.7±4.7 μmol/L, P<0.001; 0.67±0.49 G/L vs 0.33±0.17 G/L, P<0.001; 474±123 G/L vs 376±89 G/L, P<0.001, respectively). At colonosco-py, lymphonodular hyperplasia or aphthous ulceration were present in 83% of patients. Twenty-two patients were given L-amino acid-based formula and 8 contin-ued the previous feeding. Time to cessation of rectal bleeding was shorter in the special formula feeding group (mean, 1.4 wk; range, 0.5-3 wk) when com-pared with the breast-feeding group (mean, 5.3 wk; range, 2-9 wk). Nevertheless, none of the patients ex-hibited rectal bleeding at the 3-mo visit irrespective of the type of feeding. Peripheral eosinophilia and cessa-tion of rectal bleeding after administration of elemental formula correlated with a higher density of mucosal eosinophils. CONCLUSION: Infant hematochezia, after cow’s milk allergy exclusion, is generally a benign and probably self-limiting disorder despite marked mucosal abnor-mality. Formula feeding results in shorter time to cessa-tion of rectal bleeding; however, breast-feeding should not be discouraged in long-lasting hematochezia.     

Monostotic Paget’s disease of the tibia in Korea

The incidence of Pagets disease has been estimated to be about 3%, but it is extremely rare in Asia, especially in Korea. In addition, monostotic involvement seems to be far less frequent. In this report, we describe a case of monostotic Pagets disease localized in the right tibia.Abbreviations ALP alkaline phosphatase     

Dieulafoy’s vascular malformation of the jejunum: first case report of laparoscopic treatment

A case of Dieulafoys vascular malformation of the jejunum treated by laparoscopic surgery is described. The patient was a 31-year-old-woman who had complained of melena and had severe anemia needing blood transfusion. Angiography revealed microaneurysms and hypervascularity of the jejunum in the area between the first and second jejunal arterial fields. Laparoscopic partial resection of the jejunum was performed. The resected specimen was histologically diagnosed as Dieulafoys vascular malformation. Since the operation, the patient has been free of melena and anemia. Small-intestinal Dieulafoys vascular malformation is rare, as only 41 cases have been reported during the past three decades. Almost two-thirds of the patients were under 40 years old. Most of the patients complained of melena. The lesion was preoperatively identified in 14 of the 41 patients, while angiography was useful to define the lesion. Thirty-six of 37 patients for whom treatment methods were reported were surgically treated. While there are various treatment methods for intestinal bleeding, a surgical operation is often needed. When the disease location is obvious, treatment with laparoscopic surgery can reliably produce good results, in terms of its rate of cure, minimal invasiveness, and better cosmetic effect.     

Sedation and analgesia in gastrointestinal endoscopy: What’s new?

Various types of sedation and analgesia technique have been used during gastrointestinal endoscopy procedures.The best methods for analgesia and sedation during gastrointestinal endoscopy are still debated.Providing an adequate regimen of sedation/analgesia might be considered an art,influencing several aspects of endoscopic procedures: the quality of the examination,the patient’s cooperation and the patient’s and physician’s satisfaction with the sedation.The properties of a model sedative agent for endosc...     

Role of capsule endoscopy Pillcam COLON 2 in patients with known or suspected Crohn’s disease who refused colonoscopy or underwent incomplete colonoscopic exam: a case series

Background

Almost 70–80 % of patients with Crohn’s disease and virtually all patients with ulcerative colitis have colorectal mucosa involvement. Colon capsule endoscopy is an interesting option for patients unable or unwilling to undergo colonoscopy. We report our experience with the second-generation colon capsule PillCam^® COLON 2 in the detection of significant lesions in patients with known or suspected Crohn’s disease, who refused colonoscopy or underwent incomplete colonoscopic exam.

Methods

We have retrospectively reviewed the results of capsule endoscopy in 6 patients who refused colonoscopy (n = 3) or underwent incomplete colonoscopic exam (n = 3) between March 2011 and October 2012. In all patients, a CT scan was obtained before capsule endoscopy to rule out significant stenosis.

Results

In our series of 6 patients, 4 had both small bowel and colonic involvement. The use of the PillCam^® COLON 2 capsule allowed a thorough examination and evaluation of the mucosal lesions with high acceptability, the method being perceived as noninvasive by the patients. No adverse events related to the capsule or bowel preparation were recorded.

Conclusion

In this patient population, PillCam^® COLON 2 capsule endoscopy was safe. The capsule findings had an important impact on treatment decisions and patient management.     

Roles of double-balloon endoscopy in the diagnosis and treatment of Crohn’s disease: a multicenter experience

Background

Double-balloon endoscopy (DBE) examinations are not yet widely accepted as routine procedures for examining the small bowel of patients with Crohn’s disease (CD).

Aim

To evaluate the feasibility and usefulness of DBE for CD in tertiary-care hospitals.

Methods

Between July 2004 and September 2008, 1444 DBE procedures were performed for 704 patients in 6 tertiary-care hospitals. Patient profile, indication, diagnosis and treatment of DBE were evaluated using a multicenter database.

Results

DBE examinations were most frequently performed in 75 patients with CD, corresponding to 10.5% of all the patients examined by DBE. Fifty patients were diagnosed with CD before DBE, while DBE was performed for the diagnosis of 25 new CD patients. Small bowel lesions were often detected even when the terminal ileum was not involved. In the 75 patients, 21 patients were asymptomatic at the time of DBE examinations. Active inflammatory lesions were detected in 51.2% of the CD patients, and were even detected in 33.3% of the asymptomatic CD patients. The treatment was altered in 53.3% of the CD patients after the DBE evaluation. No severe complications were experienced.

Conclusions

DBE procedures can be safely performed in patients with CD and should be considered for the precise evaluation of and to determine the treatment strategy for CD.

     

Expanding beyond endoscopy: A review of non-invasive modalities in Barrett’s esophagus screening and surveillance

Barrett’s esophagus (BE) is a condition that results from replacement of the damaged normal squamous esophageal mucosa to intestinal columnar mucosa and is the most significant predisposing factor for development of esophageal adenocarcinoma. Current guidelines recommend endoscopic evaluation for screening and surveillance based on various risk factors which has limitations such as invasiveness, availability of a trained specialist, patient logistics and cost. Trans-nasal endoscopy is a less invasive modality but still has similar limitations such as limited availability of trained specialist and costs. Non-endoscopic modalities, in comparison, require minimal intervention, can be done in an office visit and has the potential to be a more ideal choice for mass public screening and surveillance, particularly in patents at low risk for BE. These include newer generations of esophageal capsule endoscopy which provides direct visualization of BE, and tethered capsule endomicroscopy which can obtain high-resolution images of the esophagus. Various cell collection devices coupled with biomarkers have been used for BE screening. Cytosponge, in combination with TFF3, as well as EsophaCap and EsoCheck have shown promising results in various studies when used with various biomarkers. Other modalities including circulatory microRNAs and volatile organic compounds that have demonstrated favorable outcomes. Use of these cell collection methods for BE surveillance is a potential area of future research.     

Screening for Barrett’s oesophagus with oesophageal capsule endoscopy in first-degree relatives of patients affected by Barrett’s oesophagus: Results of a pilot study

Background and study aimsBarrett’s oesophagus (BE) is one of the complications of gastro-oesophageal reflux disease (GERD). Oesophageal capsule endoscopy (ECE) has been proposed as a non-invasive investigation of oesophageal pathology. The aims were to evaluate the diagnostic yield of ECE in first-degree relatives of patients with BE and reflux symptoms and to assess prospectively the prevalence of BE in these conditions.Patients and methodsInclusion criteria were familial history of at least one first-degree relative with BE and typical reflux syndrome. Patients underwent ECE followed by oesophagogastroduodenoscopy (EGD). The ECE findings were compared with those during EGD.ResultsBetween February and October 2009, 18 patients were enrolled. Oesophagitis and endoscopically suspected oesophageal metaplasia (ESEM) were present, at ECE, in 7 and 11 patients, respectively. Intestinal metaplasia was histologically confirmed in eight patients. Sensitivity and specificity of ECE were, respectively, 86% and 91%, for oesophagitis, and 100% and 70% for ESEM; positive predictive value (PPV) and negative predictive value (NPV) were 86% and 91%, respectively, for oesophagitis and 73% and 100%, respectively, for ESEM. Prevalence of BE was 44%.ConclusionECE showed an optimal NPV for BE detection. Pending confirmation of these results, ECE could be proposed as a screening test in symptomatic relatives of patients with BE.     

Safety and efficacy of infliximab therapy in active behcet’s uveitis: an open-label trial

In this open-label trial, ten male patients with active Behcet’s uveitis were enrolled. Initially, two infliximab infusions (5 mg/kg) were given at weeks 0 and 2. The patients continued to receive conventional therapy on recurrence of severe uveitis (RSU) attack. The patients with further attack were regularly given infliximab infusions every 8 weeks. In cases of further RSU attacks, the infusion interval was reduced to 6 weeks. The total follow-up period was 3 years. The patients were monitored for RSU, visual acuity and adverse effects. Reduction in the doses of prednisolone was also monitored. After receiving two infliximab infusions at weeks 0 and 2, three patients remained attack-free and seven patients had another RSU attack between 8th and 47th week. These patients were regularly given infliximab at 8-week intervals. Five out of seven patients remained attack-free. In two patients who had further attack, infusion frequency was increased to 6 weeks. There was a remarkable improvement in visual acuity with no significant adverse reaction except mild respiratory tract infection (two patients), headache (one patient) and mild infusion reaction (one patient). Infliximab is a safe and effective drug for the management of Behcet’s uveitis. Selection of optimal dose and frequency of infusion required standardization for individual patient.     

Magnifying endoscopy for the diagnosis of specialized intestinal metaplasia in short-segment Barrett’s esophagus

AIM:To determine whether magnified observation of short-segment Barrett’s esophagus(BE)is useful for the detection of specialized intestinal metaplasia(SIM).METHODS:Thirty patients with suspected short-segment BE underwent magnifying endoscopy up to×80.The magnified images were analyzed with respect to their pit-patterns,which were simultaneously classified into five epithelial types[Ⅰ(small round),Ⅱ(straight),Ⅲ(long oval),Ⅳ(tubular),Ⅴ(villous)]by Endo’s classification.Then,a 0.5%solution of methylene blue(MB)was sprayed over columnar mucosa.The patterns of the magnified image and MB staining were analyzed.Biopsies were obtained from the regions previously observed by magnifying endoscopy and MB chromoendoscopy.RESULTS:Three of five patients with a typeⅤ(villous)epithelial pattern had SIM,whereas 21 patients with a non-typeⅤepithelial patterns did not have SIM.The sensitivity,specificity,accuracy,positive predictive value,and negative predictive value of pit-patterns in detecting SIM were 100%,91.3%,92.3%,60%and100%,respectively(P=0.004).Three of the 12 patients with positive MB staining had SIM,whereas 14patients with negative MB staining did not have SIM.The sensitivity,specificity,accuracy,positive predictive value,and negative predictive value of MB staining in detecting SIM were 100%,60.9%,65.4%,25%and100%,respectively(P=0.085).The specificity and accuracy of pit-pattern evaluation were significantly superior compared with MB staining for detecting SIM by comparison with the exact McNemar’s test(P=0.0391).CONCLUSION:The magnified observation of a shortsegment BE according to the mucosal pattern and its classification can be predictive of SIM.     

The clinicopathologic characteristics of granulomatosis with polyangiitis (Wegener’s): a retrospective study of 45 patients in Korea

Objectives

The aim of this study was to determine the clinicopathologic characteristics of granulomatosis with polyangiitis (Wegener’s) (GPA) in Korean patients.

Methods

The medical records of 45 patients with GPA treated in a single tertiary referral hospital were retrospectively analyzed with respect to clinical manifestations, including histology, ANCA positivity, disease stage, and disease activity. Patients were categorized into granulomatous, vasculitic, or mixed form based on an immunopathologic scoring system of granulomatous–vasculitic activity.

Results

Thirty-one patients (68.9 %) showed ANCA positivity (C-ANCA/P-ANCA, 42.2 %/20.0 %, proteinase-3 (PR3) ANCA/myeloperoxidase (MPO) ANCA, 44.1 %/16.1 %), and these patients (female 48.4 %) were found to be associated with a higher frequency of renal involvement (51.6 vs. 7.1 %, p = 0.004), elevated serum creatinine (29.0 vs. 0 %, p = 0.018), and higher mortality (29 vs. 7.1 %, p = 0.041) than ANCA-negative patients. Thirty-three patients (73.3 %, female 60.6 %) had the granulomatous form, whereas 8.9 and 17.8 % had the vasculitic and mixed forms, respectively. Patients with the granulomatous form were diagnosed earlier in their lives (mean age 51.2 vs. 62.3, p = 0.002) and had a lower frequency of renal involvement (21.2 vs. 100 %, p = 0.005) compared with those with the vasculitic form. Initial remission (69.7 vs. 25.0 %) and relapse (60.8 vs. 0 %) rates were higher for the granulomatous than for the vasculitic form.

Conclusions

Taken together, in Korean patients with GPA, the granulomatous form was predominant and associated with a younger age at diagnosis and a lower frequency of renal involvement than the vasculitic form. ANCA positivity was found in 68.9 % and associated with renal involvement and higher mortality.     

Clinical features and outcomes of Hodgkin’s lymphoma in Korea: Consortium for Improving Survival of Lymphoma (CISL)

Ethnic and regional differences in the epidemiology and pathological aspects of Hodgkin's lymphoma (HL) between Western and Asian patients may be associated with differences in clinical features and prognosis. We retrospectively analyzed the clinical and histopathological characteristics, therapeutic outcomes, and prognostic factors of 539 HL patients treated at 16 centers in Korea. We found that the incidence of histological subtypes of HL in Korea was similar to that in Western and other Asian countries. However, the incidence peaked between 16 and 30?years of age, unlike the bimodal age distribution seen in Western countries. In patients with stage I-IIA non-bulky disease, the complete response (CR) rate was similar between combined modality therapy and chemotherapy alone (93% vs. 84%, P?=?0.44), and there was no difference in relapse-free survival (RFS) and overall survival (OS). Patients with stage I-II disease plus unfavorable factors and those with advanced-stage disease treated with combination chemotherapy regimens had an overall CR rate of 77%, with no difference between doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) and non-ABVD regimens (77.2% vs. 76.8%, P?=?0.95). Among those patients who achieved final CR, there was no significant difference in RFS or OS between those who achieved interim CR and PR. Only the presence of B symptoms was independently predictive of a shorter RFS. Age?>?45?years, Eastern Cooperative Oncology Group 2-4, and B symptoms were independent risk factors for death. Although the incidence of HL was lower in Korea than in Western countries, the distribution of morphological subtypes, treatment outcomes, and patient prognosis were similar.     

Treatment of perianal fistula and abscess: Crohn’s and non-Crohn’s

Opinion statement The management of perianal abscesses and fistulas is relatively straightforward in most cases and based on a sound knowledge of the anatomy of the anorectum and adherence to established medical and surgical principles. Asymptomatic fistulas should not be treated, whereas abscesses require surgical drainage under general anesthesia. Fistula treatment includes drainage of any associated sepsis and eradication of the fistula track to prevent recurrence while preserving sphincter integrity. A small percentage of anal abscesses and fistulas are complex and very challenging to manage, particularly in conditions such as rectovaginal fistulas and abscesses and/or fistulas complicating Crohn’s disease. Treatment strategies in these situations rely on an accurate clinical assessment of the degree of rectal inflammation and perianal pathology. Treatment should combine aggressive medical therapy (antibiotics, immunomodulators, and anti-tumor necrosis factor antibody treatment) and minimal surgical interventions. Patients with proctitis have a significantly lower healing rate and a significantly higher complication rate with aggressive surgical interventions.     

The effect of conjugated equine oestrogen on diabetes incidence: the Women’s Health Initiative randomised trial

Aims/hypothesis Recent clinical trials have found that the combination of conjugated equine oestrogen (CEO) and medroxyprogesterone has a protective effect on the incidence of type 2 diabetes. To determine the effect of CEO alone on the incidence of diabetes mellitus in postmenopausal women, we analysed the results of the Women’s Health Initiative oestrogen-alone trial. Methods The Women’s Health Initiative is a randomised, double-masked trial comparing the effect of daily 0.625 mg CEO with placebo during 7.1 years of follow-up of 10,739 postmenopausal women who were aged 50–79 years and had previously had a hysterectomy. Diabetes incidence was ascertained by self-report of treatment with insulin or oral hypoglycaemic medication. Fasting glucose, insulin and lipoproteins were measured in an 8.6% random sample of study participants, at baseline and at 1, 3 and 6 years. Results The cumulative incidence of treated diabetes was 8.3% in the oestrogen-alone group and 9.3% in the placebo group (hazard ratio 0.88, 95% CI 0.77–1.01, p=0.072). During the first year of follow-up, a significant fall in insulin resistance (homeostasis model assessment of insulin resistance) in actively treated women compared with the control subjects (Year 1 baseline between-group difference −0.53) was seen. However, there was no difference in insulin resistance at the 3- or 6-year follow-up. Conclusions/interpretation Postmenopausal therapy with oestrogen alone may reduce the incidence of treated diabetes. The effect is smaller than that seen with oestrogen plus progestin. CEO should not, however, be used with the intention of preventing diabetes, as its well-described adverse effects preclude long-term use for primary prevention. Electronic Supplementary Material Supplementary material is available for this article at     

Capsule endoscopy in diagnosis of small bowel Crohn＇s disease

AIM: To evaluate the effectiveness of wireless capsule endoscopy in patients with suspected Crohn‘s disease (CD) of the small bowel undetected by conventional modalities,and to determine the diagnostic yield of M2A Given Capsule.METHODS: From May 2002 to April 2003, we prospectively examined 20 patients with suspected CD by capsule endoscopy. The patients had the following features:abdominal pain, weight loss, positive fecal occult blood test, iron deficiency anaemia, diarrhoea and fever. All the patients had normal results in small bowel series (SBS) and in upper and lower gastrointestinal endoscopy beforethey were examined. Mean duration of symptoms before diagnosis was 6.5 years.RESULTS: Of the 20 patients, 13 (65%) were diagnosed as CD of the small bowel according to the findings of M2A Given Capsule. The findings detected by the capsule were mucosal erosions (2 patients), aphthas (5 patients),nodularity (1 patient), large ulcers (2 patients), and ulcerated stenosis (3 patients). The distribution of the lesions was mainly in the distal part of the small bowel,and the mild degree of lesions was 54%.CONCLUSION: Wireless capsule endoscopy is effective in diagnosing patients with suspected CD undetected by conventional diagnostic methods. It can be used to detect early lesions in the small bowel of patients with CD.     

Efficacy of mizoribine treatment in patients with SjÖgren’s syndrome: an open pilot trial

The aim of this study was to evaluate the efficacy and safety of mizoribine in patients with SjÖgrens syndrome. Forty patients with sicca syndrome, whose conditions were definitely diagnosed as SjÖgrens syndrome, were given mizoribine orally at a dosage of 150mg/day for 12 months. The percentage change in salivary secretion after 3, 6, and 12 months of the therapy increased to +112.2% (P 0.001), +119.9% (P 0.01), and +147.3% (P 0.001), respectively, compared with the baseline. Serum IgG levels decreased significantly throughout the study, and the level was 1969.4 ± 620.0mg/dl after treatment for 12 months compared with the pretreatment value of 2094.3 ± 746.6mg/dl (P 0.05). The patients assessment of clinical signs and symptoms on a 10-cm visual analog scale improved significantly from 7.2 ± 2.3cm at the start of the treatment to 5.0 ± 1.9cm after 12 months (P 0.001). There was a similar improvement in the physicians assessment using the 10-cm visual analog scale: 7.1 ± 1.6cm at the start of the treatment and 5.2 ± 1.9cm after 12 months (P 0.001). With regard to safety, no serious adverse reactions were observed. Although a controlled study would be required to clarify the efficacy of mizoribine, these preliminary observations indicate its efficacy for ameliorating glandular symptoms through improvements in immune abnormalities in patients with SjÖgrens syndrome.     

Long-Term Outcomes of Adalimumab Treatment in 254 Patients with Crohn’s Disease: A Hospital-Based Cohort Study from Korea

Digestive Diseases and Sciences - Large-scale studies regarding the long-term outcomes of adalimumab (ADA) treatment in Asian patients with Crohn’s disease (CD) are still scarce. We...