Deepak V. Gopal

Risk factors for dysplasia in patients with Barrett's esophagus (BE): results from a multicenter consortium.

Studies show Barretts esophagus prevalence increases with age, while mean length of Barretts esophagus is unchanged. Few data are available about the relationship between age and length on the development of dysplasia. Our aim was to assess age and length as risk factors for dysplasia. Consecutive patients with Barretts esophagus were enrolled in a multicenter studyestablishing a tissue bank of Barretts esophagus patients 1994 and 1998. Demographics, length of Barretts esophagus (centimeters), and histology were recorded. Risk factors for dysplasia were assessed, including patient age, gender, and length of Barretts esophagus. Statistical analysis was performed comparing prevalence of dysplasia (which included the presence of any carcinoma and high- or low-grade dysplasia) to age and length. In all, 309 patients were studied [278 (90%) male and 31 (10%) female]: 5 had adenocarcinoma of the esophagus, 11 had high-grade dysplasia, and 29 had low-grade dysplasia. Patients with Barretts esophagus without dysplasia were younger than those with dysplasia [62 ± 0.8 years vs 67 ± 1.7 years (mean ± SEM, P = 0.02)]. The risk of dysplasia increased by 3.3%/yr of age. Mean length of Barretts esophagus in patients with Barretts alone vs dysplasia was 4.0 ± 0.2 cm vs 5.4 ± 0.4 cm (P = 0.003). Patients with Barretts esophagus length ≥3 cm had a significantly greater prevalence of dysplasia compared to length <3 cm (23% vs 9%, P = 0.0001). The risk of dysplasia increased by 14%/cm of increased length. Multivariate analysis showed age and length to be independent risk factors. In conclusions; prevalence of dysplasia is strongly associated with age and length of Barretts esophagus. These preliminary results can be used to develop a strategy for screening/surveillance based on age and length of Barretts epithelium.

Laryngopharyngeal Reflux Symptoms Better Predict the Presence of Esophageal Adenocarcinoma Than Typical Gastroesophageal Reflux Symptoms

Objective:To determine whether the presence of laryngopharyngeal reflux symptoms is associated with the presence of esophageal adenocarcinoma (EAC). Background:Most patients diagnosed with EAC have incurable disease at the time of detection. The majority of these patients are unaware of the presence of Barretts esophagus prior to cancer diagnosis and many do not report typical symptoms of gastroesophageal reflux disease (GERD). This suggests that the current GERD symptom-based screening paradigm may be inadequate. Data support a causal relation between complicated GERD and laryngopharyngeal reflux symptoms. We theorize that laryngopharyngeal reflux symptoms are not recognized expeditiously, resulting in chronic esophageal injury and an unrecognized progression of Barretts esophagus to EAC. Methods:This is a case-comparison (control) study. Cases were patients diagnosed with EAC (n = 63) between 1997 and 2002. Three comparison groups were selected: 1) Barretts esophagus patients without dysplasia (n = 50), 2) GERD patients without Barretts esophagus (n = 50), and 3) patients with no history of GERD symptoms or antisecretory medication use (n = 56). The risk factors evaluated included demographics, medical history, lifestyle variables, and laryngopharyngeal reflux symptoms. Typical GERD symptoms and antisecretory medication use were recorded. Multivariate analysis of demographics, comorbid risk factors, and symptoms was performed with logistic regression to provide odds ratios for the probability of EAC diagnosis. Results:The prevalence of patients with laryngopharyngeal reflux symptoms was significantly greater in the cases than comparison groups (P = 0.0005). The prevalence of laryngopharyngeal reflux symptoms increased as disease severity progressed from the non-GERD comparison group (19.6%) to GERD (26%), Barretts esophagus (40%), and EAC patients (54%). Symptoms of GERD were less prevalent in cases (43%) when compared with Barretts esophagus (66%) and GERD (86%) control groups (P < 0.001). Twenty-seven percent (17 of 63) of EAC patients never had GERD or laryngopharyngeal reflux symptoms. Fifty-seven percent of EAC patients presented without ever having typical GERD symptoms. Chronic cough, diabetes, and age emerged as independent risk factors for the development of EAC. Conclusions:Symptoms of laryngopharyngeal reflux are more prevalent in patients with EAC than typical GERD symptoms and may represent the only sign of disease. Chronic cough is an independent risk factor associated with the presence of EAC. Addition of laryngopharyngeal reflux symptoms to the current Barretts screening guidelines is warranted.

Endoscopic Appraisal of the Gastroesophageal Valve After Antireflux Surgery

OBJECTIVES:Little consensus exists regarding the endoscopic assessment of the esophagogastric junction after antireflux surgery. The purpose of this report is to characterize the gastroesophageal valve appearance unique to each type of antireflux procedure and to introduce an endoscopic lexicon by which to describe this anatomic region.METHODS:Endoscopic images were obtained from patients who had undergone any one of the following procedures: Nissen, Collis-Nissen, Toupet, and Dor fundoplications and Hill repair. Images were excluded if patients had any symptoms of heartburn, regurgitation, dysphagia, chest pain, or gas bloat or if they were using antisecretory medication. Seven photographs per operation type were evaluated by experienced surgeons and gastroenterologists tasked with describing defining characteristics of each procedure.RESULTS:Ten valve criteria were developed to uniquely identify and quantify the ideal endoscopic appearance of each procedure. Illustrations were created to clearly depict those traits.CONCLUSIONS:Using 10 gastroesophageal valve criteria, the key components of a successful functional repair of the esophagogastric junction were defined. These criteria can be employed when evaluating upper gastrointestinal complaints after antireflux surgery and may ultimately serve as a dependable outcome measure.

Abnormal findings on liver function tests. Interpreting results to narrow the diagnosis and establish a prognosis.

PREVIEW Although markers of liver disease are available, in many cases, their usefulness is limited by insufficient sensitivity or specificity. In addition, significant liver damage may already have occurred in patients who have normal findings on liver function tests. A basic understanding of abnormalities in liver enzymes is important to assist clinicians in developing a rational, cost-effective approach in patients with liver disease. In this article, Drs Gopal and Rosen discuss results of laboratory tests and how to use them in patient evaluation.

Impact of a CT Colonography Screening Program on Endoscopic Colonoscopy in Clinical Practice

OBJECTIVEThe potential effect of CT colonography (CTC) on endoscopic colonoscopy (EC) has been the topic of much speculation. The aim of this study was to evaluate the impact of a CTC screening program on colonoscopy in clinical practice.METHODSAt our institution a third-party reimbursed CTC colorectal cancer (CRC) screening program was established in 2004. The number of CTC monthly exams performed, monthly EC total and screening exams performed, EC with polypectomy performed, and the number of referrals for EC screening exams requested were prospectively examined in the first 33 months after introduction of a CTC CRC screening program.RESULTSThe mean number of overall (378.5 vs 413.1) and screening (150.7 vs 162.9) colonoscopy exams performed per month did not change significantly after screening CTC was introduced. The mean number of monthly CTC exams performed rose significantly throughout the first year of the study from 39 initially to a peak of 147.6 cases per month but decreased slightly to 114.3 monthly exams at the end of 2006. A mean 10.0 patients per month were sent for EC after a positive CTC exam. The mean number of monthly colonoscopies with polypectomy remained constant after the introduction of CTC (197.0 vs 180.2). Monthly referrals for screening EC exams initially decreased but were unchanged 3 yr after institution of a CTC screening program (255.0 vs 253.5).CONCLUSIONS(a) In our tertiary care center the initiation of a screening CTC program did not result in a decrease in the number of total colonoscopy exams, screening colonoscopy exams performed, nor requests for screening colonoscopy. (b) Only a small number of CTC exams were referred for EC with polypectomy, therefore a CTC screening program may not increase the overall number of therapeutic colonoscopies performed.

Brunner’s Gland Hamartoma: A Rare Cause of Gastrointestinal Bleeding – Case Report and Review of the Literature

An unusual cause of upper gastrointestinal bleeding is described in a previously healthy 45-year-old man who was admitted to hospital with weakness and fatigue, and had experienced an episode of melena two days before admission. His medical and surgical history was unremarkable. Upon admission to hospital, he showed evidence of iron-deficiency anemia, with a hemoglobin concentration of 61 g/L (normal range 135 to 175 g/L), a mean corpuscular volume of 73 fL (normal range 85.0 to 95.0 fL) and a ferritin concentration of 1.0 microg/L (normal range in males 15 to 400 microg/L). Upper gastrointestinal endoscopy revealed a 3.5 cm ulcerated submucosal mass in the third portion of the duodenum, for which mucosal biopsies were nondiagnostic. A subsequent endoscopic ultrasound revealed a 2.7 x 4.0 cm hyperechoic, cystic, submucosal tumour in the third portion of the duodenum. Endoscopic ultrasound-guided fine needle aspiration revealed no malignant cells. The patient eventually underwent a resection of the third portion of his duodenum. Surgical pathology revealed that this tumour was a Brunners gland hamartoma, 4.5 cm in its greatest dimension.

Findings on Optical Colonoscopy After Positive CT Colonography Exam

BACKGROUND & AIMS: The aim of this study is to evaluate the findings on optical colonoscopy (OC) after a positive CT colonography (CTC) exam and characterize the type of polyps seen on OC but not reported by CTC.METHODS:Over an 18-month period a total of 159 asymptomatic adults had polyps seen on computed tomography colonography examination and subsequently underwent planned therapeutic optical colonoscopy. The colonoscopists were aware of the findings on CT colonography prior to further evaluation of the colon. Characteristics of polyps and adenomas seen on subsequent optical colonoscopy but not seen or reported on CT colonography were examined.RESULTS:The adenoma miss rate for CT colonography overall was 18.9% (25/132) including 6.2% (4/65) for polyps >9 mm and 18.2% (8/44) for polyps 6–9 mm. Three of the adenomas >9 mm not seen on CTC were sessile, and two were found in patients with technically difficult CT colonography studies due to poor colonic distention. No adenomas with advanced pathology <6 mm were found on optical colonoscopy but not reported on CT colonography. False-positive CTC referral where no polyp was seen on colonoscopy was 5.0%.CONCLUSIONS:CT colonography has adenoma miss rates similar to miss rates historically found with optical colonoscopy, with most missed adenomas being <10 mm and sessile in shape.

Predictors of Malignancy and Recommended Follow-Up for Patients with Negative Endoscopic Ultrasound-Guided Fine-Needle Aspiration of Suspected Pancreatic Lesions

BACKGROUND Endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) can characterize and diagnose pancreatic lesions as malignant, but cannot definitively rule out the presence of malignancy. Outcome data regarding the length of follow-up in patients with negative or nondiagnostic EUS-FNA of pancreatic lesions are not well-established. OBJECTIVE To determine the long-term outcome and provide follow-up guidance for patients with negative EUS-FNA diagnosis of suspected pancreatic lesions based on imaging predictors. METHODS A retrospective review of patients undergoing EUS-FNA for suspected pancreatic lesions, but with negative or nondiagnostic FNA results was conducted at a tertiary care referral medical centre. Patient demographics, EUS imaging characteristics and follow-up data were examined. RESULTS Seventeen of 55 patients (30.9%) with negative/nondiagnostic FNA were subsequently diagnosed with pancreatic malignancy. The risk of cancer was significantly higher for patients who had associated lymph nodes on EUS (P<0.001) and vascular involvement on EUS (P=0.001). The mean time to diagnosis in the group with falsenegative EUS-FNA diagnosis was 66 days. The true-negative EUSFNA patients were followed for a mean of 403 days after negative EUS-FNA results without the development of malignancy. CONCLUSION For patients undergoing EUS-FNA for a suspected pancreatic lesion, a negative or nondiagnostic FNA does not provide conclusive evidence for the absence of cancer. Patients for whom vascular invasion and lymphadenopathy are detected on EUS are more likely to have a true malignant lesion and should be followed closely. When a patient has been monitored for six months or more with no cancer being diagnosed, there appears to be much less chance that a pancreatic malignancy is present.

A Comparison of Optical Colonoscopy and CT Colonography Screening Strategies in the Detection and Recovery of Subcentimeter Adenomas

OBJECTIVES:Evidence has shown that computerized tomographic colonography (CTC) and optical colonoscopy (OC) can detect advanced adenomas at an equal rate; however, a comparison of the subcentimeter adenoma detection has not been performed. The objective of this study is to compare CTC and OC screening programs, with a focus on the detection and recovery of subcentimeter adenomas.METHODS:In all, 1,700 screening OC examinations in average-risk patients were compared with 1,307 CTC examinations in similar patients drawn from the same referral pool completed in 2006–2008. The detection rate for adenomas ≤5 mm, 6–9 mm, and <10 mm with advanced histology were compared.RESULTS:In the OC group, 23.2% of patients had at least one adenoma removed; in the CTC screening group, 5.9% of patients had at least one adenoma detected and removed, P<0.001. There were significantly more ≤5 mm adenomas (detection rate 0.22, 378/1,700) detected by OC than by CTC (detection rate 0.04, 56/1,307), P<0.001. There were significantly more adenomas 6–9 mm (detection rate 0.12, 204/1,700) detected by OC than by CTC (detection rate 0.05, 67/1,307), with 70 patients with polyps of unknown histology in CTC surveillance, P<0.001. The number of advanced lesions <10 mm detected by OC (15/1,700) compared with CTC (4/1,307) were not significantly different, P=0.06. In the OC group, 27.1% of patients had non-adenomatous polyps removed; in the CTC group, 4.1% of patients had non-adenomatous polyps removed, P<0.001.CONCLUSIONS:(i) An OC screening program detects and recovers a significant four and a half fold greater number of non-advanced adenomas compared with a CTC screening program. (ii) The primary difference between screening with OC and CTC is the recovery and management of the subcentimeter adenoma.

Diseases of the rectum and anus: a clinical approach to common disorders.

Diseases of the rectum and anus are common, and the prevalence in the general population is probably much higher than that seen in clinical practice since most patients with symptoms referable to the anorectum do not seek medical attention. The examination and diagnosis of certain anorectal disorders can be challenging, and the physical examination of the anorectum is often inadequately performed in clinical practice. This article reviews the important features of the anorectal examination and the diagnosis and treatment of benign anorectal disorders such as hemorrhoids, fissures, fistulas, solitary rectal ulcer syndrome, fecal incontinence, and pruritus ani. Approaches to staging and managing malignant neoplasms of the anus and rectum are outlined.