Jack Leya

New occurrence and recurrence of neoplasms within 5 years of a screening colonoscopy

OBJECTIVE:The fear that colorectal adenomas were missed on initial colonoscopy or that new adenomas have developed is often a rationale for repeating a colonoscopic examination. The aim of this study was to delineate risk factors associated with recurrence of colorectal adenomas after an initial baseline screening colonoscopy.METHODS:The study population comprised 875 subjects who underwent a baseline screening colonoscopy followed by a second examination 1–5 yr later. Multiple logistic regression was used to assess the influence of potential risk factors on the occurrence or recurrence of colorectal adenomas, the strength of the influence being expressed as an OR with a 95% CI.RESULTS:Colorectal adenomas were detected in 484 of all patients (55%) at baseline colonoscopy. Within a 1- to 5-yr time interval, 181 patients (37%) had recurrent adenomas (adenomas were removed during the first colonoscopy) and 73 patients (19%) had newly developed adenomas (adenomas were absent on the first colonoscopy). The occurrence of adenomas at baseline screening colonoscopy was the only factor associated with an increased risk for the recurrence of adenomas at follow-up (OR = 2.51, 95% CI = 1.77–3.55). Recurrence was associated with multiple baseline adenomas (4.45, 2.98–6.64) and baseline adenomas larger than 1 cm (2.62, 1.99–3.11). Recurrence was not associated with histology type or family history of colorectal cancer. There was a significant trend for adenomas to recur in the same proximal or distal segment as the baseline adenomas (p = 0.02).CONCLUSIONS:Colon adenomas tend to recur with greater frequency if the adenomas removed at baseline were either large or multiple. Although patients with large adenomas or multiple adenomas at baseline screening colonoscopy are at a 2.6- to 4.5-fold risk for recurrence of adenomas, the rate of de novo adenoma formation in patients without baseline adenomas may be large enough to warrant repeat colonoscopy at some time in the future. The exact timing of the follow-up colonoscopy needs to be determined.

The long-term natural history of gastroesophageal reflux disease.

Introduction Long-term gastric acid suppression has been suggested as a means to prevent complications of reflux esophagitis. We report on the 20-year follow-up of 2,306 patients with at least two endoscopic examinations who were taking no antisecretory medication before baseline endoscopy and whose long-term treatment was determined by reflux symptoms. Methods From 1979 through 1998, endoscopy and biopsy were performed in the Hines Veterans Affairs Hospital endoscopy clinic by three endoscopists. Antireflux treatment was symptom-driven, and endoscopies were repeated mostly for symptomatic recurrence due to cessation of therapy. Results Of 4,633 patients undergoing endoscopy for reflux symptoms, 2,306 had at least one follow-up endoscopy and biopsy. Over a mean follow-up period of 7.6 years (range, 1–20 years), the esophageal mucosa of 67% of patients remained unchanged, that of 21% improved, and that of 11% worsened. Esophageal stricture requiring dilation developed from a normal baseline mucosa in one of 1,313 patients (0.08%) and from an erosive baseline mucosa in 18 of 957 patients (1.9%). The overall incidence of stricture in patients with gastroesophageal reflux (GER) disease was <1/1,000 per year. Nonsteroidal anti-inflammatory drug (NSAID) consumption was associated with less mucosal improvement (odds ration [OR]=0.67; confidence interval [CI]=0.46–0.98). Use of histamine-2 receptor antagonists (H2RAs) and proton pump inhibitors (PPIs) was associated with mucosal improvement (OR for PPIs=1.49; CI=1.14–2.17). Cohns kappa was 42%, confirming the results that demonstrate stability of esophageal mucosal disease in the majority of patients. Conclusions Symptom-driven treatment of GER disease after a thorough endoscopic examination to exclude premalignant or malignant esophageal mucosal disease is practical and safe for the vast majority of patients with uncomplicated GER symptoms.

Defining a role for endoscopic ultrasound in staging periampullary tumors

BACKGROUND The goal of the preoperative workup in patients with suspected periampullary carcinoma is to establish the diagnosis with a high degree of certainty. In this study we compared endoscopic ultrasonography (EUS) and computed tomography (CT) scans for the detection of tumor, lymph node metastasis, and vascular invasion in patients with suspected periampullary carcinoma in order to define a role for EUS in the preoperative staging of these patients. METHODS Thirty-seven consecutive patients received EUS and CT scanning followed by operation for presumed periampullary carcinoma during a 30-month period. Both imaging modalities were reviewed in a blinded fashion and the results compared with pathology and operative reports on all patients. RESULTS Sensitivity, specificity, positive predictive value, and negative predictive value for tumor detection by EUS were 97%, 33%, 94%, and 50%, respectively, compared with 82%, 66%, 97%, and 25% for CT scan. For lymph nodes the values were 21%, 80%, 57%, and 44%, respectively, for EUS compared with 42%, 73%, 67%, and 50% for CT. For vascular invasion, the values were 20%, 100%, 100%, and 89%, respectively, for EUS, compared with 80%, 87%, 44%, and 96% for CT. CONCLUSIONS CT is the initial study of choice in patients with suspected periampullary tumors. EUS is superior for detecting tumor and for predicting vascular invasion. Therefore, EUS should be used for patients in whom CT does not detect a mass and for those with an identifiable mass on CT in whom vascular invasion cannot be ruled out.

Intraluminal fungal colonization of gastrostomy tubes

Percutaneous endoscopic gastrostomy tubes are frequently colonized with fungal and bacterial organisms. This has not been previously reported. In our sample of 10 patients, nine percutaneous endoscopic gastrostomy tubes were colonized with fungi. This occurred as early as 1 week after placement. Candida tropicalis was isolated in five patients. It is hypothesized that a variety of fungi use components of the gastrostomy tube polymer, such as polymer additives, which contribute to the structural deterioration of the tube.

Oral Candida colonizes the stomach and gastrostomy feeding tubes

The lumen of gastrostomy tubes is frequently colonized with Candida. To investigate the source of this contamination, 20 consecutive malnourished patients undergoing placement of a percutaneous endoscopic gastrostomy tube and ten ambulatory controls having routine upper endoscopy performed had both their oral cavity and gastric antrum swabbed and cultured. Percutaneous endoscopic gastrostomy tube recipients who after several weeks were still under our care (9 of 20) had the lumen of their tubes cultured. Fungi were isolated from the stomach in 13 (65%) of 20 patients undergoing percutaneous endoscopic gastrostomy tube placement but in only 1 of 10 ambulatory patients (p < .01). The species isolated from the oral cavity, the stomach, and later the gastrostomy tube were identical in most cases. We conclude that gastrostomy tubes are probably colonized by oral organisms that have made their way into the stomach.

Non-Cardiac Chest Pain: The Long-Term Natural History and Comparison With Gastroesophageal Reflux Disease

OBJECTIVES:The source of most cases of non-cardiac chest pain (NCCP) is thought to be the esophagus. We reasoned that if the origin of NCCP is truly esophageal and not cardiac, the characteristics and survival of individuals with NCCP should be similar to those of individuals with benign esophageal disease, such as gastroesophageal reflux disease (GERD). The aim of this study was to compare the characteristics, natural history, and long-term survival of two well-defined groups, NCCP patients and GERD patients.METHODS:From 1984 to 1996, patients with NCCP were referred for endoscopy by the cardiology service after a coronary angiography done for chest pain was reported by the cardiologist as negative. Patients with GERD were referred for endoscopy for one of the usual symptoms of acid reflux. The baseline endoscopy and referrals occurred in the pre-proton pump inhibitor (PPI) era, before and during the availability of only the histamine receptor antagonists (HRAs). Thus, the endoscopic findings reflected the untreated natural state of the gastrointestinal mucosa. Endoscopic exams, esophageal biopsy, endoscopic anatomy mapping, and data verification were carried out in the endoscopy lab by one of three endoscopists using predefined criteria. All results were recorded both by hand and by entry into a database storage program. Patients were followed by their primary care providers in their usual outpatient general medicine clinics. The Veterans Affairs Decentralized Hospital Computer Program (VA DHCP) storage system provided access to mortality data as well as details of all prescriptions filled since 1985.RESULTS:During the 12-year enrollment period, 1,218 patients in the GERD group and 161 in the NCCP group were referred for endoscopy. The follow-up period ranged from 1–22 years (mean 9.8 years). The groups were similar in age, gender, smoking and alcohol habits, and use of aspirin and NSAIDs (non-steroidal anti-inflammatory drugs) (P=NS), but there was a greater proportion of blacks in the NCCP group (P<0.003). In every parameter, NCCP patients had a significantly lower prevalence of GERD-related findings such as endoscopic esophagitis (P<0.0001), Barretts metaplasia (P=0.02), the development of esophageal adenocarcinoma, and hiatal hernia presence (P=0.0001). In patients with hiatal hernia, the size of the hernia was similar in both groups (P=0.94). In the NCCP group compared with the GERD group, there was a significantly higher prevalence of cardiac factors, such as coronary artery disease (P=0.03), and there was a trend toward greater cardiac clinic enrollment (P=0.08) and cardiac medication usage (P=0.06). The amount and duration of anti-GERD therapy, such as HRAs and PPIs, were significantly less in the NCCP group (P=0.0001 for PPIs and P=0.0002 for HRAs). The diagnosis of NCCP disappeared from the electronic hospital record in 96% of patients within 2 years of follow-up. There was no significant difference in survival between the GERD and NCCP groups (hazard ratio=1.1; CI=0.8–1.5); however, longer duration of follow-up in those with a greater number of events may make a difference in survival.CONCLUSIONS:NCCP in most patients seems to be a short-lived event requiring extensive medical evaluation and having clinical characteristics significantly different from those associated with GERD. Patients with NCCP, confirmed by the absence of angiogram-documented coronary artery disease, who are referred for diagnostic endoscopy, have an excellent long-term benign prognosis, similar to patients with GERD.

Barrett's esophagus: prevalence–incidence and etiology–origins

Although the prevalence of Barretts esophagus (BE) is rising no data exist for racial minorities on prevalence in the general population. Minorities have a lower prevalence than Caucasians, and yet age, smoking, abdominal obesity, and Helicobacter pylori are all risk factors. Metabolic changes induced by adipocytokines and the apparently strong association between obesity, central adiposity, and BE may lead to reconsideration of some aspects of the natural history of BE. There is lack of experimental evidence on acid sensitivity and BE, which is hyposensitive compared to esophageal reflux disease. Reactive nitrogen and oxygen species lead to impaired expression of tumor suppressor genes, which can lead to cancer development; thus, antioxidants may be protective. Gastroesophageal reflux disease may be considered an immune‐mediated disease starting at the submucosal layer; the cytokine profile of the mucosal immune response may explain the different outcome of gastroesophageal reflux.

Granulomatous hepatitis, choroiditis and aortoduodenal fistula complicating intravesical Bacillus Calmette-Guérin therapy: Case report

BackgroundIntravesical instillation of Bacillus Calmette-Guérin (BCG) is the treatment of choice for superficial bladder carcinoma. Complications of BCG therapy include local infections and disseminated BCG infection with multiple endorgan complications.Case PresentationWe report a case of disseminated, post-treatment BCG infection that initially presented with granulomatous hepatitis and choroiditis. After successful anti-mycobacterial therapy and resolution of the hepatic and ocular abnormalities, the patient developed an acute upper gastrointestinal hemorrhage from an aortoduodenal fistula that required emergency surgery. The resection specimen revealed multifocal, non-caseating granulomas, indicating mycobacterial involvement.ConclusionsThis case highlights the varied end organ complications of disseminated BCG infection, and the need for vigilance even in immuno-competent patients with a history of intravesical BCG treatment.

Posttransplantation lymphoproliferative disorder

A 29-year-old woman with cystic fibrosis presented with abdominal pain, which had worsened over 3 days, together with low-grade fever and chills. The pain, which radiated from the central to the lower abdomen, increased with movement and had been present since bilateral lung transplantation 4months earlier. She had occasional nausea and nonbilious vomiting. The medical history included laparotomy for postoperative small bowel obstruction, diabetes mellitus, and osteoporosis. Medications included metoclopramide, lactulose, prednisone, tacrolimus, azathioprine, valacyclovir, itraconazole, cotrimoxazole, alendronate, lansoprazole, pancreatic enzymes, insulin, calcium, folate, and a multivitamin. Examination was normal except for mild periumbilical tenderness. Laboratory tests revealed mild anemia and a slight nonanion gap acidosis. Two small duodenal ulcers were discovered at EGD. Biopsy specimens revealed mild duodenitis with superficial ulceration. At

Colon Cancer in VA Octogenarians with Previous C-Scope But New Symptoms: Is Another C-Scope Indicated?

ESDPatients and Methods : 67 colorectal neoplasia cases performed ESD between May 2004 and September 2007. We analyzed time required for ESD, rate of en bloc resection, complete resection (defined as histologically negative at lateral and vertical margin), complication, and postoperative local persistence and recurrence. Result : The mean size of neoplasias was 28.10 12.51 mm (12-86 mm). Histologic types were tubular adenoma 14 (20.9%), tubulovillous adenoma 7(10.4%), villous adenoma 2 (3.0%), serrated adenoma 4 (6.0%), adenocarcinoma 38 (56.7%, mucoal cancer 23, submucosal cancer 14, pm cancer 1), hyperplastic polyp 1(1.5%), lymphoid hyperplasia 1(1.5%). The rate of en bloc resection and complete resection were 66/67 (98.5%) and 39/67 (58.2%), respectively. Patients whose en bloc resection was successful did not require additional therapy. The average duration of follow-up in 48 cases was 256.1 184.7 days, and no local tumor residue, metastasis or recurrence was observed. There was no delayed bleeding. 7.4% of cases of perforation (5/67) were observed in total. Surgical resection and lymphadenectomy were performed for 14 lesions, one case of local tumor residue and one case of tumor nodule in pericolic fat tissue without lymphnode metastasis and local tumor residue were observed in the corresponding specimens. Conclusion : ESD achieved a high rate of en bloc resection. Because of histopathologic diagnosis could be conducted sufficiently, and the suitability of additional surgical resection could be correctly judged; therefore ESD was useful for colorectal tumor. More outcomes research and technical advance will be needed for playing an important role in the therapeutic strategy for colorectal tumors in the near future.