Dean Keren

Diagnostic yield and safety of colonoscopy in Israeli patients in an open access referral system.

Background Open access endoscopy allows reference of patients for endoscopic procedures without prior gastrointestinal consultation, allowing the procedure to be more accessible. This practice is becoming increasingly widespread in the United States and other countries and has become commonplace in clinical practice in Israel. The objective of our study is to bring forward our experience with an open access referral system for colonoscopy and to measure the yield and safety of colonoscopy in this system. Methods Between January 2001 and September 2003, 10,866 colonoscopies were performed. Patients charts were reviewed for the following data: demographics, indication for endoscopy, endoscopic and histopathologic findings, and complications. The practice guidelines of the American Society for Gastrointestinal Endoscopy were used to assess appropriateness of colonoscopy. Results 3533 pathologic findings were found, in 2978 colonoscopies. 2336 polyps were removed, including 18% hyperplastic, 26% tubular adenomata, 13% villous adenomata, 11% tubulovillous adenomata. Advanced disease was found in 41% of pathologic findings, 11% were invasive cancer. Rate of colonoscopies “generally indicated” according to American Society for Gastrointestinal Endoscopy guidelines was 78% with a rate of colonoscopies “generally not indicated” of 22%. Colonoscopy was completed successfully to the cecum in 93% of patients. 0.08% had serious complications during or immediately after colonoscopy. Conclusions Our results suggest that open access colonoscopy is a reliable and safe method for screening average risk population. As colonoscopy is becoming the recommended screening model for colorectal cancer this attitude of performing screening in an open access system could both cut costs in the future and improve availability, in an aim to become common practice.

A nine-year audit of open-access upper gastrointestinal endoscopic procedures: results and experience of a single centre.

BACKGROUND The appropriateness and safety of open-access endoscopy are very important issues as its use continues to increase. OBJECTIVE To present a review of a nine-year experience with open-access upper gastrointestinal endoscopy with respect to indications, diagnostic efficacy, safety and diseases diagnosed. METHODS A retrospective, observational case series of all patients who underwent open-access endoscopy between January 2000 and December 2008 was conducted. Indications were classified as appropriate or not appropriate according to American Society of Gastrointestinal Endoscopy (ASGE) guidelines. Endoscopic diagnoses were based on widely accepted criteria. Major complication rates were assessed. RESULTS A total of 20,620 patients with a mean age of 58 years were assessed, of whom 11,589 (56.2%) were women and 9031 (43.8%) were men. Adherence to ASGE indications led to statistically significant, clinically relevant findings. The most common indications in patients older than age 45 years of age were dyspepsia (28.5%) and anemia (19.7%) in the ASGE-appropriate group, and dyspepsia in patients younger than 45 years of age without therapy trial (6.6%) in the nonappropriate group. Of the examinations, 38.57% were normal. Hiatal hernia and nonerosive gastritis were the most common findings. Important diagnoses such as malignancies and duodenal ulcers would have been missed if endoscopies were performed only according to appropriateness. There were only two major complications and no mortalities. CONCLUSIONS Open-access upper gastrointestinal endoscopy is a safe and effective system. More relevant findings were found when adhering to the ASGE guidelines. However, using these guidelines as the sole determining factor in whether to perform an endoscopy is not advisable because many clinically relevant diagnoses may be overlooked.

Acute Pancreatitis and Upper Gastrointestinal Bleeding as Presenting Symptoms of a Duodenal Brunner’s Gland Hamartoma

Brunners gland hamartomas are rare, benign small bowel tumours. There were fewer than 150 cases reported in the English literature until the end of the last century. These hamartomas may be discovered incidentally during an upper gastrointestinal tract endoscopy. Otherwise, they may be diagnosed in patients presenting with acute upper gastrointestinal bleeding, anemia or symptoms of intestinal obstruction. The case of a young woman admitted for acute upper gastrointestinal bleeding along with acute pancreatitis is presented. The investigation revealed a giant Brunners gland hamartoma in the second part of the duodenum. After total endoscopic resection of the tumour, the patient has remained completely asymptomatic for a follow-up period of seven months.

Incidental Colorectal Computed Tomography Abnormalities: Would You Send every Patient for a Colonoscopy?

BACKGROUND The clinical significance of colorectal wall thickening (CRWT) in patients undergoing abdominal computed tomography (CT) has not yet been definitively established. OBJECTIVES To compare alleged findings on abdominal CT with those of a follow-up colonoscopy. METHODS Ninety-four consecutive patients found to have large-bowel abnormalities on abdominal CT were referred for colonoscopy. Of these patients, 48 were referred for a suspected colorectal tumour and 46 for CRWT. Colonoscopy was performed and findings were compared. RESULTS Of the 48 suspected colorectal tumours, 34 were determined to be neoplastic lesions on colonoscopy. Of these, 26 were malignant and eight were benign. Colonoscopy revealed no abnormality in 30 of 46 patients with CRWT as a solitary finding, and revealed some abnormality in 16 patients (12 had diverticular disease, four had benign neoplastic lesions). CONCLUSIONS CRWT as an incidental and solitary finding on CT should not be regarded as a pathology prompting a colonoscopy. Approximately two-thirds of the patients had a normal colonoscopy and the remaining patients had benign lesions (12 had diverticular disease and four had benign neoplastic lesions). However, many of these patients seem to warrant colonoscopy regardless of CT findings, particularly patients who have a family history of colorectal cancer, have positive fecal occult blood test results or who are older than 50 years of age.

Correlation between incidental FDG PET/CT colorectal observations and endoscopic and histopathological results

Fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) is used in the imaging workup of various malignancies. Incidental gastrointestinal observations on FDG PET/CT may be of clinical significance. The aim of the present study was to evaluate endoscopic and histopathological observations in patients referred for colonoscopy due to incidental FDG colonic uptake on a PET/CT study. Fifty-six patients with incidental colonic findings on FDG PET/CT underwent colonoscopy. Normal colonoscopies were observed in 63% of the patients. In 37% of the colonoscopies, we identified an endoscopic observation, including 67% with benign adenomatous polyps, 3% with hyperplastic polyps, 20% with advanced histological lesions and 10% with a malignancy.

Extensive Idiopathic Colonic Varices in a Young Patient

Varices of the colon are a rare cause of lower gastroin- testinal bleeding and are usually associated with portal hypertension or portal venous obstruction (1-4). There are numerous reports of bleeding from secondary colonic varices but very few of bleeding from idiopathic (primary) colonic varices. Among those, the rarest report varices throughout the entire colon. We report such a patient with recurrent episodes of life-threatening bleeding due to id- iopathic colonic varices throughout the entire colon. This is an exceptionally rare condition in such a young patient, treated successfully with a subtotal colectomy. examination findings were normal except for slight signs of fresh blood on rectal examination. Evaluation included normal WBC, platelet count, erythrocyte sedimentation rate, blood chemistry, coagulation studies, liver function tests, and albumin. Technetium scan showed signs of bleeding at the area of hepatic flexure. Selective inferior mesenteric angiography was normal during the arterial phase, and the venous phase showed dilated and tortuous veins in the sigmoid area, with suspected blood extravasation. A Meckel technetium scan was negative. An echocardiogram showed mild LV and RV dilatation. An abdominal computed tomographic (CT) scan was normal. An additional colonoscopy supported the findings of the previous one, with varices through the whole length of the colon and signs of active bleeding in the right colon. Due to repeated episodes of life-threatening anemia and hema- tochezia secondary to extensive colonic varices, the patient underwent a subtotal colectomy with ileorectal anastomosis showing vascular malformations and, occasionally, bleeding varices from the ileocecal valve to the rectum. At follow-up 4 years after the operation, his hematocrit was stable and no recurrent episodes of rectal bleeding had occurred.

Colorectal cancer among Arab-Israeli women--possible reasons for increased incidence and mortality.

BackgroundColorectal cancer (CRC) screening is effective in reducing its incidence by discovering precancerous polyps and detecting early cancer. Evidence indicates lower participation in screening programs among minority ethnic groups. In addition, the Israel Cancer Registry published an increase in the incidence of CRC among Israeli–Arab women. It is important to attempt to understand attitudes toward screening among Israeli–Arab women, assuming it has to do to lack of knowledge and compliance.MethodsDuring the study period, a female team gave lectures in Arabic regarding CRC to women in 16 Arab villages. Prior to the lecture, the participants were asked to complete a questionnaire, obtaining information regarding CRC knowledge and screening. Following the lecture, FOBT kits were distributed. Two weeks later, a telephone survey was performed, regarding whether the FOBT was performed, the result of the test, and, if FOBT was not performed, the reasons for not completing the test.ResultsFOBT was performed by 17.8% prior to the lecture; 61% performed the FOBT following our lecture. Reasons cited for avoiding FOBT: 37% was “afraid of a positive result,” 32% avoided performing the test as they were concerned they would be further examined by a male physician; 47.8% concluded that Arab women lack knowledge regarding screening interventions; 23.9% neglect themselves from a health point of view; 11.6% advised that Arab women have no free time to perform tests.ConclusionsIsraeli–Arab women may be less knowledgeable concerning CRC. Educational efforts must be made to increase awareness and promote benefits of CRC screening, by targeting ethnic minorities and women in Israel.

Do forceps biopsies truthfully reflect the nature of endoscopically uncovered polypoid lesions of the colon

Background  Total excision of colonic polyps is not always attainable and in some patients it is clinically contraindicated. Also, a resected polyp may be lost at any step between its endoscopic removal and its embedding in paraffin. The aim of this study was to compare the histological features of colonic polyps as analysed by the study of biopsy‐forceps obtained samples with those assessed on scrutinizing the totally resected growths.

Dexamethasone-suppressed corticotropin-releasing hormone stimulation test in morbid obese adults

PURPOSE In order to differentiate between Cushings syndrome (CS) and Pseudo-Cushings syndrome, it is customary to use a test that is conducted by cortisol suppression with low-dose dexamethasone, followed by the administration of corticotropin releasing hormone (Dex-CRH test). In children with severe obesity, Dex-CRH test has shown a specificity of 55%. The aim of current study was to evaluate the specificity of Dex-CRH test in morbid obese adults. METHODS The study included a total of 19 subjects with a body mass index (BMI) equal or higher than 40kg/m(2). In all subjects Dex-CRH test was performed, and 24h urinary free cortisol was collected prior the test and during the second day of dexamethasone administration (2nd-day-UFC). RESULTS BMI was 45.1±4.6kg/m(2) and 45.7±3.3kg/m(2) in women and men, respectively. 14 subjects underwent bariatric surgery. No subject had surgical or perioperative complications and surgically treated subjects had mean body weight loss of 46.5±16.6kg. All except for 2 subjects had normal Dex-CRH test, as 15-min cortisol falling below 1.4μg/dl. During follow-up, no subject gained additional weight, neither developed signs of CS. 15-min-cortisol concentration of 1.4μg/dl revealed a specificity of 89% and 2nd-day-UFC of 16μg/24h showed a specificity of 100%. CONCLUSIONS Morbid obesity in adults seems not to comprise a significant confounder in Dex-CRH test, and 15-min-cortisol concentration of 1.4μg/dl had a higher specificity than previously reported in obese children.