David Lieberman

Colorectal cancer prevention 2000: screening recommendations of the American College of Gastroenterology

Colorectal cancer prevention 2000: screening recommendations of the American College of Gastroenterology

Prospective determination of distal colon findings in average-risk patients with proximal colon cancer

BACKGROUND Recent guidelines indicate that colonoscopy and sigmoidoscopy are both acceptable options for screening average-risk patients for colorectal cancer. Retrospective studies have found that a majority of patients with cancer proximal to the splenic flexure have a normal screening flexible sigmoidoscopy. METHODS This was a multicenter, prospective description of colonoscopic findings and family history in consecutive patients with proximal colon cancer. RESULTS Among 116 prospectively identified average-risk patients with cancer proximal to the splenic flexure, 40 (34.5%) had neoplasia distal to the splenic flexure. The prevalence of patients with adenomas greater than or equal to 1 cm, with only one tubular adenoma less than 1 cm, and with only hyperplastic polyps were 16.4%, 8.6%, and 6.9%, respectively. CONCLUSIONS Most average-risk patients with cancer proximal to the splenic flexure will have a normal screening flexible sigmoidoscopy. These patients have an unexpectedly high prevalence of large distal adenomas, but the prevalence of both single small tubular adenomas and hyperplastic polyps alone is similar to that expected during screening of the general population. Clinicians and payers should continue to seek methods to improve the cost-effectiveness and availability of screening colonoscopy in average-risk persons.

Improved scintigraphic assessment of severe cholestasis with the hepatic extraction fraction

In previous studies, we found that biliary scintigraphy with technetium-99m-labeled iminodiacetic acid ([99mTc]IDA) provided excellent discrimination between intrahepatic and extrahepatic cholestasis, except in patients with profound cholestasis who had poor visualization of the biliary tree. In this study, we have used deconvolution analysis to determine the hepatic extraction fraction (HEF) of a hypothetical single circulatory pass of[99mTc]IDA. Our hypothesis was that extraction of radionuclide from the blood would be normal in patients with extrahepatic obstruction alone, but would be impaired in patients with intrahepatic disease (IHD). The purpose of this study was to compare the HEF in patients with profound cholestasis (bilirubin≥3.0 mg/dl) due to either IHD or common bile duct obstruction (CBDO). Normal subjects (N=13) had an HEF of 100%. Patients with CBDO (N=13) had slightly reduced HEF values (92.8±3.2%) despite profound hyperbilirubinemia (6.1±1.0 mg/dl). Patients with IHD (N=23) had a markedly reduced HEF (43.1±4.1%) which was significantly lower than patients with CBDO and normal subjects (P<0.001). We conclude that the determination of the HEF during biliary scintigraphy is helpful in distinguishing between intrahepatic and extrahepatic disease in patients with hyperbilirubinemia (bilirubin≥3.0 mg/dl).

A survey of potential adherence to capsule colonoscopy in patients who have accepted or declined conventional colonoscopy.

Background: Capsule colonoscopy might improve adherence to colorectal cancer screening. Objective: Measure attractiveness of capsule colonoscopy in patients who have declined conventional colonoscopy, using patients who have undergone colonoscopy as a control group. Design: Internet-based survey. Setting: United States. Subjects: A total of 308 geographically diverse, high school or higher educated, middle to upper income, insured internet users who had been offered colonoscopy previously. Interventions: Survey. Main Outcome Measurements: Preferences for colonoscopy, capsule colonoscopy, fecal occult blood test, or no screening. Results: After a description of capsule technology features relative to colonoscopy, including “no need for a ride,” “no time off work,” “approximately 5% less accurate,” “booster preparation needed,” and “follow-up colonoscopy needed in 20% of patients,” preference for capsule colonoscopy was shown by 24% of those who had undergone colonoscopy and 49% of those who had not. “No need for a ride” and “no time off work” were considered positive features of capsule colonoscopy. The potential to undergo capsule colonoscopy during the weekend was also considered attractive. Limitations: Restricted population. Conclusions: The availability of capsule colonoscopy could potentially increase colorectal cancer screening adherence rates among patients who decline screening colonoscopy.

What Can We Do to Optimize Colonoscopy and How Effective Can We Be

In the USA, colorectal cancer is the third most common cancer and third leading cause of cancer death among both men and women. Declining rates of colon cancer in the past decade have been attributed in part to screening and removal of precancerous polyps via colonoscopy. Recent emphasis has been placed on measures to increase the quality and effectiveness of colonoscopy. These have been divided into pre-procedure quality metrics (bowel preparation), procedural quality metrics (cecal intubation, withdrawal time, and adenoma detection rate), post-procedure metrics (surveillance interval), and other quality metrics (patient satisfaction and willingness to repeat the procedure). The purpose of this article is to review the data and controversies surrounding each of these and identify ways to optimize the performance of colonoscopy.