Andrew Sanderson

Likelihood of missed and recurrent adenomas in the proximal versus the distal colon

BACKGROUND Colonoscopy may be less efficacious in reducing colorectal cancer mortality in the proximal compared with the distal colon. A greater likelihood for missed and recurrent adenomas in the proximal colon may contribute to this phenomenon. OBJECTIVE To examine whether a proximal adenoma is associated with the risk and location of missed and recurrent adenomas. DESIGN Prospective. SETTING Polyp Prevention Trial. PARTICIPANTS A total of 1864 patients with an adenoma at baseline underwent a follow-up colonoscopy 4 years later (adenoma recurrence). Of these, 1731 underwent a clearing colonoscopy 1 year after the baseline examination (missed adenoma). MAIN OUTCOME MEASUREMENTS Association of baseline adenoma location with the risk and location of adenomas found at colonoscopy performed 1 year and 4 years later. RESULTS At the year 1 colonoscopy, 598 patients (34.6%) had an adenoma (missed adenoma). Compared with those with a distal-only adenoma at baseline, patients with a proximal-only adenoma at baseline were more likely to have any missed adenomas (relative risk [RR] 1.28; 95% CI, 1.09-1.49) and a proximal-only missed adenoma (RR 2.05; 95% CI, 1.49-2.80). At the year 4 colonoscopy, 733 patients (39.3%) had adenoma recurrence. Patients with a baseline proximal-only adenoma were more likely to have any adenoma recurrence (RR 1.14; 95% CI, 1.00-1.31) and a proximal-only adenoma recurrence (RR 1.52; 95% CI, 1.15-2.02). Sensitivity analyses involving missed adenomas did not materially affect the risk or location of recurrent adenomas at year 4 colonoscopy. LIMITATION Lesions may still be missed on repeated colonoscopies. CONCLUSIONS Missed and recurrent adenomas are more likely to be in the proximal colon.

BMI and the risk of colorectal adenoma in African-Americans.

Obesity is associated with the activation of the molecular pathways that increase the risk of colorectal cancer. Increasing body mass index may accelerate the development of adenomatous polyps, the antecedent lesion of colorectal cancer. The aim of this study was to assess the BMI effect on the risk of colonic polyp and adenoma in African‐American.

Association between Diverticular Disease and Pre-Neoplastic Colorectal Lesions in an Urban African-American Population.

Background: It is unclear whether there is a shared pathway in the development of diverticular disease (DD) and potentially neoplastic colorectal lesions since both diseases are found in similar age groups and populations. Aim: To determine the association between DD and colorectal pre-neoplastic lesions in an African-American urban population. Methods: Data from 1986 patients who underwent colonoscopy at the Howard University Hospital from January 2012 through December 2012 were analyzed for this study. The presence of diverticula and polyps was recorded using colonoscopy reports. Polyps were further classified into adenoma or hyperplastic polyp based on histopathology reports. Multiple logistic regression was done to analyze the association between DD and colonic lesions. Results: Of the 1986 study subjects, 1,119 (56%) were females, 35% had DD and 56% had at least one polyp. There was a higher prevalence of polyps (70 vs. 49%; OR = 2.3; 95% CI: 1.9-2.8) and adenoma (43 vs. 25%; OR = 2.0; 95% CI: 1.7-2.5) in the diverticular vs. non-diverticula patients. Among patients who underwent screening colonoscopy, the presence of diverticulosis was associated with increased odds of associated polyps (OR = 9.9; 95% CI: 5.4-16.8) and adenoma (OR = 5.1; 95% CI: 3.4-7.8). Conclusion: Patients with DD are more likely to harbor colorectal lesions. These findings call for more vigilance on the part of endoscopists during colonoscopy in patients known to harbor colonic diverticula.

Factors associated with inadequate colorectal cancer screening with flexible sigmoidoscopy

BACKGROUND AND STUDY AIM Inadequate colorectal cancer screening wastes limited endoscopic resources. We examined patients factors associated with inadequate flexible sigmoidoscopy (FSG) screening at baseline screening and repeat screening 3-5 years later in 10 geographically-dispersed screening centers participating in the ongoing Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial. METHODS A total of 64,554 participants (aged 55-74) completed baseline questionnaires and underwent FSG at baseline. Of these, 39,385 participants returned for repeat screening. We used logistic regression models to assess factors that are associated with inadequate FSG (defined as a study in which the depth of insertion of FSG was <50 cm or visual inspection was limited to <90% of the mucosal surface but without detection of a polyp or mass). RESULTS Of 7084 (11%) participants with inadequate FSG at baseline, 6496 (91.7%) had <50 cm depth of insertion (75.3% due to patient discomfort) and 500 (7.1%) participants had adequate depth of insertion but suboptimal bowel preparation. Compared to 55-59 year age group, advancing age in 5-year increments (odds ratios (OR) from 1.08 to 1.51) and female sex (OR = 2.40; 95% confidence interval (CI): 2.27-2.54) were associated with inadequate FSG. Obesity (BMI > 30 kg/m(2)) was associated with reduced odds (OR = 0.67; 95% CI: 0.62-0.72). Inadequate FSG screening at baseline was associated with inadequate FSG at repeat screening (OR = 6.24; 95% CI: 5.78-6.75). CONCLUSIONS Sedation should be considered for patients with inadequate FSG or an alternative colorectal cancer screening method should be recommended.

Rare Manifestation of a Rare Disease, Acute Liver Failure in Adult Onset Still's Disease: Dramatic Response to Methylprednisolone Pulse Therapy—A Case Report and Review

Adult onset Stills disease (AOSD) is a rare systemic inflammatory disorder of unknown etiology. It is characterized by daily fevers, arthralgias or arthritis, typical skin rash, and leukocytosis. Hepatic involvement is frequently observed in the course of AOSD with mildly elevated transaminases and/or hepatomegaly. Fulminant hepatic failure, occasionally requiring urgent liver transplantation, is a rare manifestation of AOSD. Here, we present a case of 22-year-old woman with no significant medical history who initially came with fever, arthralgias, myalgias, generalized weakness, and sore throat. Laboratory data showed mildly elevated transaminases and markedly elevated ferritin levels. She was diagnosed with AOSD based on Yamaguchi diagnostic criteria and was started on prednisone. Three months later, while she was on tapering dose of steroid, she presented with fever, abdominal pain, jaundice, and markedly elevated transaminases. Extensive workup excluded all potential causes of liver failure. She was diagnosed with AOSD associated acute liver failure (ALF). Intravenous (IV) methylprednisolone pulse therapy was started, with dramatic improvement in liver function. Our case demonstrated that ALF can present as a complication of AOSD and IV mega dose pulse methylprednisolone therapy can be employed as a first-line treatment in AOSD associated ALF with favorable outcome.

Can optical diagnosis of small colon polyps be accurate? Comparing standard scope without narrow banding to high definition scope with narrow banding

AIM To study the accuracy of using high definition (HD) scope with narrow band imaging (NBI) vs standard white light colonoscope without NBI (ST), to predict the histology of the colon polyps, particularly those < 1 cm. METHODS A total of 147 African Americans patients who were referred to Howard University Hospital for screening or, diagnostic or follow up colonoscopy, during a 12-mo period in 2012 were prospectively recruited. Some patients had multiple polyps and total number of polyps was 179. Their colonoscopies were performed by 3 experienced endoscopists who determined the size and stated whether the polyps being removed were hyperplastic or adenomatous polyps using standard colonoscopes or high definition colonoscopes with NBI. The histopathologic diagnosis was reported by pathologists as part of routine care. RESULTS Of participants in the study, 55 (37%) were male and median (interquartile range) of age was 56 (19-80). Demographic, clinical characteristics, past medical history of patients, and the data obtained by two instruments were not significantly different and two methods detected similar number of polyps. In ST scope 89% of polyps were < 1 cm vs 87% in HD scope (P = 0.7). The ST scope had a positive predictive value (PPV) and positive likelihood ratio (PLR) of 86% and 4.0 for adenoma compared to 74% and 2.6 for HD scope. There was a trend of higher sensitivity for HD scope (68%) compare to ST scope (53%) with almost the same specificity. The ST scope had a PPV and PLR of 38% and 1.8 for hyperplastic polyp (HPP) compared to 42% and 2.2 for HD scope. The sensitivity and specificity of two instruments for HPP diagnosis were similar. CONCLUSION Our results indicated that HD scope was more sensitive in diagnosis of adenoma than ST scope. Clinical diagnosis of HPP with either scope is less accurate compared to adenoma. Colonoscopy diagnosis is not yet fully matched with pathologic diagnosis of colon polyp. However with the advancement of both imaging and training, it may be possible to increase the sensitivity and specificity of the scopes and hence save money for eliminating time and the cost of Immunohistochemistry/pathology.

Beverage intake preference and bowel preparation laxative taste preference for colonoscopy.

AIM To examine whether non-alcoholic beverage intake preferences can guide polyethylene glycol (PEG)-based bowel laxative preparation selection for patients. METHODS We conducted eight public taste test sessions using commercially procured (A) unflavored PEG, (B) citrus flavored PEG and (C) PEG with ascorbate (Moviprep). We collected characteristics of volunteers including their beverage intake preferences. The volunteers tasted the laxatives in randomly assigned orders and ranked the laxatives as 1(st), 2(nd), and 3(rd) based on their taste preferences. Our primary outcome is the number of 1(st) place rankings for each preparation. RESULTS A total of 777 volunteers completed the study. Unflavored PEG was ranked as 1(st) by 70 (9.0%), flavored PEG by 534 (68.7%) and PEG with ascorbate by 173 (22.3%) volunteers. Demographic, lifestyle characteristics and beverage intake patterns for coffee, tea, and carbonated drinks did not predict PEG-based laxative preference. CONCLUSION Beverage intake pattern was not a useful guide for PEG-based laxative preference. It is important to develop more tolerable and affordable bowel preparation laxatives for colonoscopy. Also, patients should taste their PEG solution with and without flavoring before flavoring the entire gallon as this may give them more opportunity to pick a pattern that may be more tolerable.

Diabetes Mellitus and Pancreatic Cysts in African Americans.

*Inclusion criteria for DM2: fasting blood sugar ≥ 126; 1 random blood sugar ≥ 200 with symptoms; glycosylated hemoglobin ≥ 6.5; and 5-year history of DM. IQR indicates interquartile range; HX, history. P ancreatic cysts are collections of fluid near or within the pancreas. A few studies have evaluated their risk factors in patients without a history of pancreatitis. Pseudocysts are the most common cystic lesions and may be formed in the setting of acute pancreatitis, chronic pancreatitis, or pancreatic trauma. Age, C-reactive protein, and high lactate dehydrogenase seem to be risk factors and indicators for pancreatic fluid collections and pseudocyst formation. One of the most common pancreatic-associated disorders is diabetes mellitus (DM). Whether DM is involved or not in pancreatic cysts formation is not well established.We investigated such an association in 207 African American patients with pancreatic cysts from 1988 to 2012. The rate of pancreatic cysts without a history of pancreatitis has been increasing in a stepwise fashion in the last 25 years on the basis of 5-year interval (33%–49%, Fig. 1), whereas pancreatic cysts with a history of pancreatitis have been decreasing (67%–51%, Fig. 1). At the same time, DM significantly increased from 8.3% to 52.7%. Patients with pancreatic cysts without a history of pancreatitis were older (P = 0.002) and more female (47% vs 29%, P = 0.01). Twenty-nine percent of patients without a history of pancreatitis were diabetic versus 11% of patients with a history of pancreatitis (P = 0.001, Table 1). Table 1 depicts the statistically significant parameters because it relates to pancreatic cysts in the analyzed cohort. Our data showed that in patients with pancreatic cysts, older age, DM, and female sex are associated with no history of pancreatitis. Parallel increasing trends of

Mo1068 Colorectal Cancer Disparities Between Blacks and Hispanics: Healthcare Utilization Versus Biological Differences

Background: Despite comparable rates of putative risk factors for colorectal cancer including poor access and lower screening uptake, Hispanic Americans have reduced burden of colorectal cancer when compared to Blacks. It is unknown if better healthcare utilization (when access is available) or biological differences are playing a major role in this disparity within minority groups. Aim: To compare the adherence to scheduled out-patient colonoscopy (healthcare utilization) and the findings of neoplasia (biological differences) during colonoscopy performed among compliant patients by race-ethnicity (Blacks versus Hispanics). Method: A total of 2,126 (88.2%) non-Hispanic Black and 284 Hispanic (11.8%) adult patients were scheduled for out-patient colonoscopy from September 2009 to August 2010 in our endoscopy suite at Howard University Hospital, a minority serving tertiary institution in Washington DC. We reviewed their records and abstracted the data in standard fashion. We compared Blacks to Hispanics in their rates of attendance to the scheduled colonoscopy, the quality of colonoscopy performed and the detection of neoplasia. We used logistic regression models to calculate odds ratio (OR) and 95% confidence interval (CI) and adjusted for age, sex, marital status and health insurance. Results: Blacks were slightly older (mean age 56.5 years versus 52.7 years, P<0.001) and were less likely to be married (23% versus 32%, P = 0.001), but there was no difference by sex (P = 0.64). A lower percentage of Blacks were compliant with their procedures (76.9% versus 82%, OR = 0.76; 95%CI: 0.541.06). There was no difference in cecal intubation rate (97.5% versus 97.4%, P = 0.93) and finding of good bowel preparation (73% versus 71.5%, P = 0.13). Blacks were more likely to have polyps (50.8% versus 33.2%, OR = 2.10; 95%CI: 1.54-2.88) and adenoma (26.3% versus 18.8%, OR = 1.53; 95%CI: 1.05-2.23). These differences were mainly from diagnostic procedures (Table). Nine (0.57%) Blacks and one (0.44%) Hispanic had colorectal cancer diagnosed (P = 0.8). Conclusion: Although Blacks were borderline less likely to attend their scheduled colonoscopy, they were significantly more likely to have colorectal neoplasia. This suggests that biological differences may be playing more of a role in the increased burden of CRC among Blacks as compared to Hispanics. Comparison of prevalence of adenoma among blacks and Hispanics by indication of colonoscopy

Tu1242 Characteristics of Pancreatic Cysts in African-Americans At an Urban Tertiary Medical Center

factor was alcoholic pancreatitis in 37 patients (44%), gall stones in 19 patients (22.6%), pancreatic malignancy in 4 (4.8%) patients, biliary strictures in 2 patients and trauma in 2 patients. Idiopathic pancreatic pseudocysts were seen in 20 patients (23.8%), 18 of them were incidentally found on the CT scan. Of note, in 8 cases (40%) of the idiopathic pseudocysts, were associated with non-pancreatic malignancies. In a subgroup analysis, alcohol was the commonest aetiology in male patients 29/51 (57%) while in female patients, incidental pseudocysts constituted 11/33 (33.3%) and gall stones 10/33 (30.3%). 9 patients had more than one pseudocyst. The size of the pseudocysts varied significantly in reporting from small to huge pseudocysts with extension into the left thigh in one case. The body of the pancreas was the most common site (33 pseudocysts). The majority were managed conservatively with 2 drained percutaneously and 2 drained endoscopically. Conclusion Our study showed that alcoholic pancreatitis remains the most frequent underlying aetiology for pancreatic pseudocysts although it is not as common as previously reported. Idiopathic pseudocysts constituted a substantial number of this study with a higher than expected incidental pseudocysts. The association of pancreatic pseudocysts with malignancy needs to be further evaluated