Hugh Chaun

Colonic disorders in adult cystic fibrosis.

By 1996, the median survival of patients with cystic fibrosis (CF) in North America had increased to 31 years. With the markedly improved life expectancy, many CF patients are now adults. There is an associated increased risk of certain colonic disorders, and the emergence of other previously unrecognized disorders, in adult CF patients. The distal intestinal obstruction syndrome (DIOS), which is more common in older patients, is a frequent cause of abdominal pain. Intussusception may complicate DIOS; other differential diagnoses include appendiceal disease, volvolus, Crohns disease, fibrosing colonopathy and colonic carcinoma. The diagnosis of acute appendicitis, although uncommon in patients with CF, is often delayed, and appendiceal abscess is a frequent complication. The prevalence of Crohns disease in CF has been shown to be 17 times that of the general population. Right-sided microscopic colitis is a recently recognized entity in CF of uncertain clinical significance. Fibrosing colonopathy has been confined mostly to children with CF, attributed to the use of high strength pancreatic enzyme supplements, but it has been reported in three adults. Nine cases of carcinoma of the large intestine have been reported worldwide, associated with an apparent excess risk of digestive tract cancers in CF. Despite high carrier rates of Clostridium difficile in patients with CF, pseudomembranous colitis is distinctly rare, but severe cases complicated by toxic megacolon have been reported. In these patients, watery diarrhea is often absent. Adult CF patients with refractory or unexplained intestinal symptoms merit thorough investigations.

Prospective evaluation of screening colonoscopy: who is being screened?

BACKGROUND Universal access to medical procedures is deemed an advantage of the Canadian health care system. The purposes of this prospective study were to determine the degree to which the practice of colon cancer screening by colonoscopy differed among socioeconomic classes and to assess adherence to screening guidelines. METHODS Consecutive patients scheduled to undergo colonoscopy at a single center between August 2000 and August 2002 completed a questionnaire that determined patient characteristics and indications for the procedure. The patients were divided into two groups: screening patients, defined as individuals who indicated they were undergoing colonoscopy for screening purposes and were asymptomatic, and a control group, which comprised patients undergoing colonoscopy because of symptoms. Statistical analysis was performed to determine if patients in the screening group had different characteristics with respect to socioeconomic class, compared with the control group. RESULTS A total of 1088 patients completed the questionnaire: 707 (65%) had colonoscopy because of symptoms, compared with 381 (35%) who underwent a screening examination. Mean age and marital status were similar in both groups. Of all colonoscopy procedures, there was a significantly greater proportion of men undergoing colonoscopy for screening purposes: 199 (52.2%) vs. 294 (41.6%) in the symptomatic group ( p = 0.001). Based on the Cochran-Armitage test, patients in the screening group had significantly higher education levels ( p = 0.004) and household incomes ( p = 0.001). CONCLUSIONS Income and education level, two indices of socioeconomic status, are statistically significantly higher in patients undergoing screening colonoscopy compared with those having colonoscopy for any other reason.

Update on the role of H pylori infection in gastrointestinal disorders.

Infection with Helicobacter pylori is accepted as the primary cause of peptic ulcer disease, and there is evidence to suggest its role in other gastrointestinal disorders. An estimated 20% to 40% of the Canadian population is infected with H pylori; however, clinically relevant disease is present in only approximately 10% to 20% of these individuals. Therefore, it is crucial to identify the diseases for which eradication of H pylori is beneficial to ensure that patients do not receive unnecessary treatment. In patients with ulcers induced by long term treatment with nonsteroidal anti-inflammatory drugs, preliminary results suggest that eradication of H pylori may reduce the risk of peptic ulcer bleeding. Furthermore, a benefit has been observed for the eradication of H pylori before patients commence therapy with a nonsteroidal anti-inflammatory drug. An association between the presence of H pylori and specific dyspeptic symptoms has yet to be established; however, there may be a subset of patients with functional dyspepsia who benefit from the eradication of H pylori. The relationship between gastroesophageal reflux disorder and H pylori infection remains unclear. In Canada, the recommended therapy for the eradication of H pylori is seven days of twice-daily treatment with a proton pump inhibitor, clarithromycin, and amoxicillin or metronidazole. Although the proton pump inhibitors are treated as a class for use in these regimens, there is suggestion that a faster onset of action may lead to a higher rate of eradication.

Ulcerative Colitis in the Chinese Population of Vancouver, British Columbia

The clinical records of 22 Chinese patients with ulcerative colitis (UC) seen in Vancouver, British Columbia from 1975 to 1989 were reviewed. There was a predominance of males, with a male to female ratio of 1.75:1. The age range at diagnosis was 14 to 67 years (mean 38.9). Eighteen of the 22 patients were immigrants, and one was a visitor from Hong Kong. The age at diagnosis of the three Canadian-born patients (14, 26 and 26 years old) was less than the mean age at diagnosis of the immigrant group. The immigrants had resided in Canada for a mean of 9.3 years before developing symptoms of UC. Despite the rarity of UC in Hong Kong, 59% of the Chinese patients in this series were Hong Kong immigrants. This study demonstrates that UC is not as uncommon a disease in Chinese as had been previously perceived. Adequate time is apparently necessary for exposure to environmental factors in the pathogenesis of UC. The opportunity for continued study of defined ethnic immigrant populations in North America may yield useful information related to environmental factors that may be important in the etiology and pathogenesis of UC.

Sir William Osler and gastroenterology.

Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, British Columbia Correspondence and reprints: Dr Hugh Chaun, 3185 West 45th Avenue, Vancouver, British Columbia V6N 3L9. Telephone 604-261-8437, fax 604-872-7921, e-mail hchaun@mac.com Received for publication April 24, 2010. Accepted April 29, 2010 “One finger in the throat and one in the rectum makes a good diagnostician.” – William Osler

3383 Upper gastrointestinal endoscopy in hiv patients: indications and diagnostic yield in an era of highly active antiretroviral therapy (haart).

The advent of HAART has dramatically changed the progression of HIV disease. With the addition of protease inhibitors (PI) in 1997, certain disorders of the gastrointestinal (UGI) tract associated with advanced HIV disease (candida, wasting syndrome, AIDS-related diarrhea) appear to be much less common. We reviewed our experience with upper endoscopy in HIV patients since 1997 to determine: 1) the primary indications for upper GI procedures 2) the diagnostic and therapeutic yield of upper GI endoscopy 3) if patients on HAART had less HIV-related findings than those not on antiretroviral therapy. Methods: All patients, known to be HIV-positive, who had an UGI endoscopic procedure performed between 01/97 to 09/99 were identified through a computerized database. Data collected included: medications, CD4 count, comorbid diseases, indication for procedure, endoscopic and pathological diagnosis and therapy initiated. Results: 127 upper endoscopic procedures were performed. The mean CD4 count was 325 (range 0-900) cells/μl and 54% of the patients were on HAART. The most common indications for the procedures were pain (33%), dysphagia (22%), bleeding (22%) and diarrhea (17%). In endoscopies performed in patients presenting with pain, 43% were normal, 29% had esophagitis (19% candida-related) and 19% had either gastritis or gastric erosions. In those presenting with dysphagia, esophagitis was found in 66% (reflux-52%, candida-14%), 19% were normal and 7.5% had esophageal ulcers. In those with diarrhea, 57% had normal upper endoscopies and histology. An etiology of diarrhea was found in 19% (bacillary angiomatosis-2, subtotal villous atrophy-1, cryptosporidiosis-1). The highest yield of positive endoscopic results were seen in bleeding patients where 96% of patients had an etiology of bleeding discovered (esophageal or gastric varices-75%). Overall, 22% of patients had HIV-specific UGI endoscopic findings. Of these significantly more were found in patients not on antiretroviral therapy (14%) than those on HAART (7.8%). Conclusions: Since the initiation of HAART, the most common indications for upper endoscopy in HIV patients are abdominal pain, dysphagia, bleeding and diarrhea. Endoscopies performed on those patients presenting with UGI bleeding have the highest diagnostic yield and those presenting with pain the lowest. HIV-specific diagnosis are found more commonly in those HIV patients not taking HAART.

Prospective evaluation of screening colonoscopy: Evidence against universal access

and for more or less educated patients (25% vs. 23%, p =ns). Conclusions: Primary care physicians were less likely to recommend CRC screening to African-American and less educated patients in the equal access VA system. However, preliminary results indicate that adherence to screening did not vary by race or educational level. Lower CRC screening rates among minority and less educated patients may be due to lack of a physician recommendation. Physician-targeted educational efforts may be required in order to increase CRC screening rates among minority and less educated groups.