Colon interposition in the treatment of esophageal caustic strictures: 40 years of experience

The objective of this article was to analyze 40 years of experience of colon interposition in the surgical treatment of caustic esophageal strictures from the standpoints of our long-term personal experience. Colon interposition has proved to be the most suitable type of reconstruction for esophageal corrosive strictures. The choice of colon graft is based on the pattern of blood supply, while the type of anastomosis is determined by the stricture level and the part of colon used for reconstruction. In the period between 1964 and 2004, colon interposition was performed in 336 patients with a corrosively scared esophagus, using the left colon in 76.78% of the patients. In 87.5% a colon interposition was performed, while in the remaining patients an additional esophagectomy with colon interposition had to be done. Hypopharyngeal strictures were present in 24.10% of the patients. Long-term follow-up results were obtained in the period between 1 to up to 30 years. Early postoperative complications occurred in 26.48% of patients, among which anastomosic leakage was the most common. The operative mortality rate was 4.16% and late postoperative complications were present in 13.99% of the patients. A long-term follow up obtained in 84.82% of the patients found excellent functional results in 75.89% of them. We conclude that a colon graft is an excellent esophageal substitute for patients with esophageal corrosive strictures, and when used by experienced surgical teams it provides a low rate of postoperative morbidity and mortality, and long-term good and functional quality of life.     

Early relief of upper gastrointestinal dyspeptic symptoms: a survey of empirical therapy with pantoprazole in Canadian clinical practice.

BACKGROUND: Upper gastrointestinal symptoms attributable to gastroesophageal reflux disease or peptic ulcer are common, but the outcome of proton pump inhibitor therapy in clinical practice is not well documented. Aim: To assess the range of upper gastrointestinal acid-related symptoms in clinical practice and the rapidity of their response to pantoprazole (40 mg daily), after seven days of therapy. METHODS: A total of 726 Canadian physicians (65.3% family physicians) recorded a working diagnosis and alarm features in eligible patients, who then recorded the severity of eight upper gastrointestinal symptoms in a daily symptom diary during the first week of therapy. RESULTS: Complete data were obtained from 2273 (37.3% male) of 3261 patients; physicians diagnosed reflux esophagitis alone (66.9%), peptic ulcer (9.7%), other upper gastrointestinal disorders (12.3%) and reflux esophagitis with another diagnosis (11.1%). Alarm features were common (29.6%), but a history of gastrointestinal blood loss was rare (less than 1%). Mean daytime heartburn scores decreased from 2.59 to 1.40, and epigastric pain scores decreased from 2.54 to 1.56 over the first week (P<0.00001); the proportions of patients who became symptom-free were 68.1% and 55.4%, respectively. Decreased mean symptom scores were also observed for acid regurgitation (2.21 to 1.35), bloating (2.47 to 1.57), nausea (2.03 to 1.36), slow digestion (2.51 to 1.56) and burping (2.56 to 1.69). The percentage of patients with severe or very severe symptoms decreased from 53.5% to 13.8% at day 7. The physician's initial diagnosis was not predictive of outcome. CONCLUSIONS: In a predominantly primary care population with upper gastrointestinal acid-related symptoms, proton pump inhibitor therapy produces prompt symptomatic relief in most patients. Potential alarm symptoms are common, and further research is required to determine the absolute risk of alarm symptoms and their implications for empirical therapy.     

Prevention and management of complications after colon interposition for corrosive esophageal burns

SUMMARY. We present our experience in the management of complications after a colon interposition for corrosive esophageal burns. From April 1976 to December 2006, 85 patients with caustic esophageal burns were included in this study. The superior belly median incision with an anterior border incision of the left sternocleidomastoid was used. Anastomosis between the colon and the cervical esophagus was performed in 68 and between the colon and pharyngeal portion in 14 patients. An esophageal scar part resection and gastric‐esophageal anastomosis was performed in one patient who had been given an unsuccessful colon and jejunum interposition at another institute. An anastomotic modeling operation was performed in one patient with anastomotic stricture who had been managed with colon interposition at another institute. Exploratory thoracotomy and gastrostomy was performed in one patient who had an unsuccessful colon interposition at another institute. Seven of 14 patients (8.5% of 17.1%) died with serious complications such as aspirated pneumonia, interposition colon necrosis, abdominal wound dehiscence and degradation of swallowing and concordance function. However, others with such serious complications survived and were discharged for rehabilitation after corresponding treatment. The 25 patients (30.1%) with other mild complications were discharged for rehabilitation and corresponding management. Two patients from other institutes were discharged for rehabilitation and one was lost to follow‐up. The most dangerous complication of this procedure is colon necrosis, and the stomach is the best organ for re‐operation. Otherwise, aspiration in infants due to hypoplasia and degradation of swallowing co‐ordination needs attention. Peri‐operative management is very important, including the control of mediastinal and pulmonary infection and systemic nutritional support to avoid abdominal wound dehiscence. The platysma flap is an excellent method for the treatment of anastomotic stricture.     

Multicenter double-blind comparative study of terfenadine and cetirizine in hay fever.

The efficacy and safety of terfenadine in the management of hay fever were compared with those of cetirizine in a multicenter, double-blind, parallel-group study, carried out during the 1990 spring pollen season. The patients were randomly assigned to one of two groups of treatment, 70 patients being given terfenadine 120 mg, and 72 patients cetirizine 10 mg, once daily for 7 days. The severity of the main symptoms was evaluated at baseline and after treatment by a 4-point rating scale. In addition, the overall symptom severity was recorded daily by the patient on a diary card. Both terfenadine and cetirizine produced significant relief of symptoms by the end of treatment, with a decrease in symptom severity ranging from 46 to 69% for terfenadine and from 40 to 55% for cetirizine. Adverse effects experienced by terfenadine- and cetirizine-treated patients were mainly drowsiness, with minor differences between the two groups. The results of this study confirmed previous experiences, showing that both terfenadine and cetirizine once daily should be regarded as effective drugs for the management of hay fever.     

Esophageal replacement by colon interposition with microvascular surgery for patients with thoracic esophageal cancer: the utility of superdrainage

Replacing the thoracic esophagus with the colon is one mode of reconstruction after esophagectomy for esophageal cancer. There is, however, a high incidence of postoperative necrosis of the transposed colon. This study evaluated the outcomes of colon interposition with the routine use of superdrainage by microvascular surgery. Twenty‐one patients underwent colon interposition from 2004 to 2009. The strategy for colon interposition was to: (i) use the right hemicolon; (ii) reconstruct via the subcutaneous route; (iii) perform a microvascular venous anastomosis for all patients; and (iv) perform a microvascular arterial anastomosis when the arterial blood flow was insufficient. The clinicopathologic features, surgical findings, and outcomes were investigated. The colon was used because of a previous gastrectomy in 18 patients (85.7%) and synchronous gastric cancer in three patients (14.3%). Eight patients (38.1%) underwent preoperative chemoradiotherapy including three (14.3%) treated with definitive chemoradiotherapy. Seven patients (33.3%) underwent microvascular arterial anastomosis to supplement the right colon blood supply. Pneumonia occurred in four patients (19.0%). Anastomotic leakage was observed in five patients (23.8%); however, no colon necrosis was observed. The 3‐year and 5‐year overall survival rates were both 50.6%. Colon interposition with superdrainage results in successful treatment outcomes. This technique is one option for colon interposition employing the right hemicolon.     

Application of the Vienna Classification for Crohn's disease to a single clinician database of 877 patients.

An international working party at the World Congress of Gastroenterology held in Vienna, Austria from September 6 to 11, 1998 defined a classification for Crohn's disease based on patient age at diagnosis (eg, less than 40 years of age, 40 years of age or older), disease location (eg, terminal ileum, colon, ileocolon or upper gastrointestinal tract) and behaviour (eg, stricturing, penetrating). Disease location in the upper gastrointestinal tract was defined by disease being present proximal to the terminal ileum, regardless of terminal ileal or colon involvement. A 20-year, single clinician database of 877 patients from a university campus hospital was used, and comprised 492 women (56.1%) and 385 men (43.9%). Of these patients, 740 (84.4%) were diagnosed before age 40 years and 137 (15.6%) were diagnosed by 40 years of age or older. Disease was located in the terminal ileum alone in 222 patients (25.3%), colon alone in 238 patients (27.2%) and ileocolon in 304 patients (34.6%). Another 113 patients (13.1%) had disease in the upper gastrointestinal tract, usually with disease also in the terminal ileum (23 patients), colon (12 patients) or ileocolon (71 patients). Only seven of 877 patients had disease located in the upper gastrointestinal tract alone with no distal disease. Disease behaviour could be classified as nonstricturing and nonpenetrating in 256 patients (29.2%), stricturing in 294 patients (33.6%) and penetrating in 327 patients (37.2%). Of the 877 patients with Crohn's disease, 837 were white, 38 were Asian and two were black. In this tertiary care setting of a single clinician practice in a Canadian teaching hospital at the University of British Columbia, Crohn's disease predominantly affects women, and young adults with a high rate of stricturing and penetrating complications.     

Gastrointestinal disorders and symptoms: does body mass index matter?

BACKGROUND: Recent studies have shown inconsistent results about the association between body mass index (BMI) and gastrointestinal disorders. The aim of this study was to assess the association between BMI and gastrointestinal disorders in patients referred for endoscopy. METHODS: Consecutive patients received a questionnaire about gastrointestinal symptoms prior to upper gastrointestinal endoscopy. The association between BMI and gastrointestinal disease and related symptoms was determined by adjusted logistic regression analyses. RESULTS: A total of 1023 subjects were included, 303 (35%) subjects were overweight (BMI 25 to 30 kg/m2), an additional 118 (14%) subjects were obese (BMI >30 kg/m2). Overall, 42% of the patients experienced symptoms of gastro-oesophageal reflux disease (GERD ), 70% dyspepsia and 55% lower abdominal symptoms. In obese patients the prevalence of GERD was higher (52%) compared with normal weight (44%) and overweight (44%) (ns). Reflux oesophagitis was found in 13, 17 and 19% for normal weight, overweight and obese, hiatus hernia in 7, 9 and 11% and Barrett's oesophagus in 6, 7 and 8%, respectively. CONCLUSION: More than half the patients undergoing upper gastrointestinal (GI ) endoscopy were overweight or obese. In this patient population, no relation between BMI and GI disorders and symptoms was found. However, a small but statistically insignificant trend was observed toward obesity for patients with GERD-associated symptoms.     

Gastrointestinal endoscopic evaluation of premenopausal women with iron deficiency anemia

GOALS: To evaluate whether the gastrointestinal tract could be a source of chronic blood loss in premenopausal women with iron deficiency anemia. BACKGROUND: While premenopausal women with iron deficiency anemia are typically managed with simple iron replacement, the standard of care for postmenopausal women and men is to exclude a gastrointestinal source of bleeding. STUDY: We identified 111 premenopausal women who underwent endoscopy for the sole indication of iron deficiency anemia. RESULTS: The mean age was 42.5 years. Lesions potentially causative of iron deficiency anemia were detected in 22 patients (20%). Upper gastrointestinal lesions were present in 14 patients (13%) and included only erosive lesions. Lower gastrointestinal lesions were detected in 8 patients (7.2%) and included colon cancer (2.7%), inflammatory bowel disease (3.6%), and a colonic ulcer >1 cm (0.9%). Patients with upper gastrointestinal lesions were more likely to use aspirin or nonsteroidal antiinflammatory drugs (11/14, 79%) than patients with no lesions (26/89, 23%; P = 0.043). Occult blood was more common in patients with lower gastrointestinal lesions 8/8 (100%) and patients with upper gastrointestinal lesions (9/14, 64%) than in patients without lesions (28/89, 31%; P = 0.037 and 0.039). Gastrointestinal symptoms were significantly more common in patients with gastrointestinal lesions than in patients without lesions. CONCLUSIONS: A gastrointestinal source of chronic blood loss was identified in a substantial proportion of premenopausal women with iron deficiency anemia. Patients with gastrointestinal symptoms, fecal occult blood, and/or weight loss should undergo endoscopy.     

A Prospective Study of Dyspepsia in Primary Care

Dyspepsia is a common complaint, but its course and associated resource utilization have not been well described. In this study, 288 adult, primary care patients with dyspepsia treated at ambulatory clinics were followed prospectively for one year. Medical chart, utilization, and baseline and one-year follow-up survey data were collected. These patients had 13.3 medical visits (sex- and age-standardized) during the follow-up period, 55% above standardized mean visits for a comparison group of nondyspepsia patients. Standardized mean charges of $3542 for dyspeptics was 126% above nondyspepsia patient charges. Over half had gastrointestinal-related follow-up visits; 61% used gastrointestinal drugs; and 43% had gastrointestinal procedures. NSAID users had higher gastrointestinal-related utilization than did nonusers, recording an additional gastrointestinal visit (P < 0.001) and $678 more in charges (P = 0.03). Eighty-six percent of the 189 follow-up survey respondents experienced gastrointestinal symptoms at some time during the follow-up year. This study showed that most primary care dyspepsia patients remained symptomatic after one year and were intensive users of medical care.     

Late dysphagia after presternal colon interposition

Esophageal replacement by colon interposition is done for a variety of esophageal diseases. Dysphagia occasionally develops many years after successful colon interposition. Redundancy of the colon graft is usually responsible. We report a patient with onset of dysphagia 24 years after presternal colon interposition for long segment esophageal atresia. Pathophysiology, prevention, and treatment of late colon interposition dysfunction are discussed.     

Confusing untypical intestinal Behcet’s disease: Skip ulcers with severe lower gastrointestinal hemorrhage简

Behcet’s disease (BD) is a rare and life-long disorder characterized by inflammation of blood vessels throughout the body. BD was originally described in 1937 as a syndrome involving oral and genital ulceration in addition to ocular inflammation. Intestinal BD refers to colonic ulcerative lesions documented by objective measures in patients with BD. Many studies have shown that over 40% of BD patients have gastrointestinal complaints. Symptoms include abdominal pain, diarrhea, nausea, anorexia and abdominal distension. Although gastrointestinal symptoms are common, the demonstration of gastrointestinal ulcers is rare. This so-called intestinal BD accounts for approximately 1% of cases. There is no specific test for BD, and the diagnosis is based on clinical criteria. The manifestations of intestinal BD are similar to those of other colitis conditions such as Crohn’s disease or intestinal tuberculosis, thus, it is challenging for gastroenterologists to accurately diagnose intestinal BD in patients with ileo-colonic ulcers. However, giant ulcers distributed in the esophagus and ileocecal junction with gastrointestinal hemorrhage are rare in intestinal BD. Here, we present a case of untypical intestinal BD. The patient had recurrent aphthous ulceration of the oral mucosa, and esophageal and ileo-colonic ulceration, but no typical extra-intestinal symptoms. During examination, the patient had massive acute lower gastrointestinal bleeding. The patient underwent ileostomy after an emergency right hemicolectomy and partial ileectomy, and was subsequently diagnosed with incomplete-type intestinal BD by pathology. The literature on the evaluation and management of this condition is reviewed.     

Confusing untypical intestinal Behcet's disease:Skip ulcers with severe lower gastrointestinal hemorrhage

Behcet's disease(BD) is a rare and life-long disorder characterized by inflammation of blood vessels throughout the body. BD was originally described in 1937 as a syndrome involving oral and genital ulceration in addition to ocular inflammation. Intestinal BD refers to colonic ulcerative lesions documented by objective measures in patients with BD. Many studies have shown that over 40% of BD patients have gastrointestinal complaints. Symptoms include abdominal pain, diarrhea, nausea, anorexia and abdominal distension. Although gastrointestinal symptoms are common, the demonstration of gastrointestinal ulcers is rare. This so-called intestinal BD accounts for approximately 1% of cases. There is no specific test for BD, and the diagnosis is based on clinical criteria. The manifestations of intestinal BD are similar to those of other colitis conditions such as Crohn's disease or intestinal tuberculosis, thus, it is challenging for gastroenterologists to accurately diagnose intestinal BD in patients with ileocolonic ulcers. However, giant ulcers distributed in the esophagus and ileocecal junction with gastrointestinal hemorrhage are rare in intestinal BD. Here, we present a case of untypical intestinal BD. The patient had recurrent aphthous ulceration of the oral mucosa, and esophageal and ileo-colonic ulceration, but no typical extra-intestinal symptoms. During examination, the patient had massive acute lower gastrointestinal bleeding. The patient underwent ileostomy after an emergency right hemicolectomy and partial ileectomy, and was subsequently diagnosed with incomplete-type intestinal BD by pathology. The literature on the evaluation and management of this condition is reviewed.     

胃空肠Roux-en-Y吻合术后吻合口-横结肠瘘一例

胃空肠Roux-en-Y吻合术后发生吻合口-横结肠瘘非常罕见,患者早期症状不明显且容易漏诊和误诊,典型三联征包括腹泻、体重减轻、粪性呕吐或粪性嗳气,确诊方式主要依据消化道造影和胃肠镜检查,对于明确诊断的患者需在营养状况改善的前提下尽早行手术治疗。本例患者通过行上消化造影及胃镜检查确诊该疾病,经过积极的术前准备和一期手术治疗后,症状明显改善。现将本中心对该疾病的诊疗过程及治疗体会报道如下。     

Gastrointestinal symptoms in anorexia nervosa. A prospective study

Neither the natural history of gastrointestinal symptoms in patients with anorexia nervosa nor their response to refeeding have been well studied. We hypothesized that gastrointestinal symptoms in anorexia nervosa will decrease during refeeding despite high caloric intake, suggesting that delayed gastric emptying, where present, is a result rather than a cause of anorexia nervosa. Study goals were (a) to determine the type and frequency of gastrointestinal symptoms, (b) to follow symptoms during refeeding prospectively, and (c) to develop guidelines for gastrointestinal testing and intervention in hospitalized anorectic patients. Sixteen consecutive patients with anorexia nervosa were rated on 12 gastrointestinal symptoms before and after nutritional rehabilitation and followed up throughout treatment. All patients reported multiple gastrointestinal symptoms on admission; all symptoms except belching improved during treatment despite large calorie increases (p less than 0.0002); significant improvements occurred in appetite, bloating, constipation, vomiting, and diarrhea; and no patients required endoscopy, x-ray evaluation, or antipeptic regimens. We conclude that although severe gastrointestinal symptoms are common in anorexia nervosa, they improve significantly with refeeding. Specific gastrointestinal studies should be reserved for patients who do not gain weight or who have indications of independent digestive disease.     

Anterior vs. Posterior Mediastinal Routes in Colon Interposition after Esophagectomy

Background/Aims: Colon interposition is the most commonly used method of esophageal reconstruction when the stomach cannot be used; however, this method may cause surgical complications such as anastomotic leakage and sepsis due to colon necrosis. Therefore, many surgeons use a retrosternal or subcutaneous route because it is easier to manage the subcutaneous drainage when anastomotic leakage occurs. However, some researchers have reported that the posterior mediastinal route provides better long-term functional outcomes after surgery than the anterior mediastinal route. Thus, in this study, we compared these reconstruction routes used for colon interposition, with or without the supercharge technique, in patients with a history of distal gastrectomy, who have undergone colon interposition after esophagectomy. Methodology: We retrospectively studied 30 patients who underwent esophagectomy with colon interposition. These patients were divided into 2 groups based on the reconstruction route: the anterior mediastinal or subcutaneous route (A group), or the posterior mediastinal route (R group). Results: Anastomotic leakages were observed in 4 patients (26.7%) in the A group and in 1 patient (6.7%) in the R group. Conclusions: Ischemia is not always the result of arterial failure, but may also originate from venous blood flow impairment due to injury or distortion of veins.     

High-resolution ultrasonography in gastrointestinal graft-versus-host disease

Gastrointestinal graft-versus-host disease (GVHD) is one of the main causes of therapy-related death after allogeneic hemopoietic stem cell transplantation. Early diagnosis and immediate treatment are probably essential for improving clinical outcome. High-resolution sonography allows the evaluation of single bowel wall layers throughout the small and large bowel. We report the sonographic findings of seven consecutive patients with histologically confirmed GVHD grade II–IV of the gastrointestinal tract. The patients were examined sonographically within the 1st week after onset of clinical symptoms. Dilatation of the colon and striking bowel wall thickening were early and common features in these patients. Sonography may become a useful tool for diagnosis of patients with gastrointestinal GVHD. Its role for preclinical diagnosis, grading of severity of disease, and guiding therapy of patients with gastrointestinal GVHD warrants evaluation in prospective studies.     

Evaluation of toxicity and quality of life using a diary card during postoperative radiotherapy for rectal cancer

PURPOSE: Adjuvant pelvic radiotherapy after radical surgery for rectal cancer may produce several side-effects (mainly gastrointestinal) capable of affecting patient lifestyle. This prospective study evaluated by means of a diary card the toxicity and daily changes in the quality of life of patients with rectal cancer treated with postoperative pelvic radiotherapy. METHODS: We used a diary card listing ten items about lifestyle changes and side-effects compiled by patients themselves. The patients were stratified by age (< or = 65 vs. > 65 years), the presence or not of a stoma, and the administration or not of concurrent chemotherapy. RESULTS: Twenty-seven patients were evaluable. The mean number of bowel movements increased across time, without statistically significant differences. Nausea and appetite did not significantly change during the treatment period. There was a statistically significant, progressive increase in the perception of pain (P < 0.03). Although not significantly, the anxiety scores were lower during radiotherapy than at baseline. Daily activities and compliance with therapy did not significantly change during the treatment. There was a significant worsening in overall well-being (P < 0.04) and quality of life evaluation (P < 0.03). The patients who received chemoradiotherapy experienced a worsened lifestyle and greater side-effects. Older patients experienced less pain but had statistically significant higher levels of anxiety. Patients with a stoma reported a better quality of life score than those without. CONCLUSIONS: The use of a diary card may be an adequate means of detecting the extent of treatment-related changes in the lifestyle of patients with rectal cancer treated by postoperative radiotherapy.     

Clinical patterns of Crohn's disease in Greece: a follow-up study of 155 cases

The aim of this prospective study was to elucidate the clinical features and natural history of Crohn's disease in Greece. One hundred and fifty-five Greek patients with definite diagnosis of Crohn's disease were followed-up for a mean period of 9.7 years and evaluated for clinical patterns and course of illness. The male/female ratio was 1.58:1. The peak incidence of the disease was observed between 20 and 30 years of age. The majority of patients were urban dwellers and of higher socio-economic level compared to the general population of Greece. In almost 50% of the patients symptoms of the disease started below the age of 30, although in almost one in every 5 cases, symptoms appeared after the age of 50. Familial clustering of inflammatory bowel disease was observed in 1. 3%. The pattern of anatomic involvement was: ileocolic 33.3%, colon 33.3% and small bowel 33.3%. The kind of predominant symptoms at the time of diagnosis was related to the anatomic location of the disease. At least one extraintestinal manifestation appeared in 42% of patients. Perianal disease was noticed in 21.3% with fistulae and abscesses being the most common manifestation. Fifty-one percent of patients were operated upon at least once during the follow-up period because of acute abdomen, bad response to conservative treatment and fistulae and abscesses. Emergency operation was required in 17.3% of the patients. Evolution to cancer was observed in 3 patients (2%). During the follow-up period of 9.7 +/- 6.5 years, 18 patients (11.6%) died. A considerable mortality was noticed in the surgically treated group of patients, while in the nonoperated group the disease was running with milder symptoms. It is concluded that some of the clinicoepidemiological characteristics of patients with Crohn's disease in Greece are in accordance with those reported from western as well as the neighboring Mediterranean countries. However, other parameters such as the higher incidence of the disease in males, the low incidence of familial clustering, and the low incidence of perianal disease, underline the importance of environmental, genetic and other factors on the evolution and behavior of the disease in different parts of the world.     

Prospective endoscopic evaluation for gastrointestinal graft-versus-host disease: determination of the best diagnostic approach

The best endoscopic diagnostic strategy for gastrointestinal (GI) graft-versus-host disease (GVHD) is unknown. Over a 48-month period, all patients with unexplained diarrhea at risk for acute gastrointestinal GVHD were prospectively identified. Acute GVHD was defined as symptoms and histologic evidence of GVHD occurring within 100 days of transplant or donor lymphocyte infusion (DLI). Colonoscopy was performed with multiple biopsies of the ileum, right colon and rectosigmoid colon. Next, upper endoscopy with duodenal and random gastric biopsies of both antrum and body were performed. All biopsies were evaluated for GVHD by an experienced GI pathologist. Over the study period, 24 patients (mean age 37 years; 62.5% male) were evaluated. The median time from transplantation or DLI was 30.5 days. The biopsy site with the highest yield was the distal colon (82%). A combination of upper endoscopy with sigmoidoscopy and colonoscopy with ileal biopsies were equivalent ( approximately 94%). In patients with diarrhea at risk for GVHD, biopsies of the distal colon had the highest diagnostic yield suggesting the importance of sigmoidoscopy and biopsy. Colonoscopy and ileoscopy or flexible sigmoidoscopy plus upper endoscopy had the highest diagnostic yields.