Jacob Rattan

The relative value of fecal occult blood tests and flexible sigmoidoscopy in screening for large bowel neoplasia

The secondary prevention of colorectal cancer is based on the early detection of noninvasive cancer and removal of adenomatous polyps. The two commonly used screening tests are flexible sigmoidoscopy and guaiac fecal occult blood testing. Both were performed simultaneously and independently on 1176 asymptomatic volunteers followed by colonoscopic examination if either occult blood or a neoplasm was detected. Neoplasia (adenomatous polyps or cancer) were found in 48 screenees. Only ten had positive stool occult blood while 45 were detected by sigmoidoscopy. Analysis of sensitivity for neoplasia was 93.8% for sigmoidoscopy but only 20.8% for the occult blood tests, while the positive predictive values for neoplasia were 100% and 23.8% respectively. The fecal occult blood test detected only 18% of screenees with adenomas and 60% with invasive cancer. Flexible sigmoidoscopy detected 95% and 80% respectively. Analysis (kappa statistic) demonstrated little agreement between the two tests (P > 0.05), indicating that they are diagnosing different neoplasia. Evaluation of expected gain in diagnosing neoplasia, by combining both tests, gave 18% for the fecal blood test and 94% for the endoscopic test. These results confirm the complementary value of performing both tests, but especially the high sensitivity and predictive value positive of flexible sigmoidoscopy for adenomas, including those with severe dysplasia, and the converse for the fecal occult blood test. This latter test must be recommended and used within a screening program with caution and full understanding of its limitations.

A high-fiber diet does not cause mineral and nutrient deficiencies.

We evaluated the hypothesis that a healthy population taking a high-fiber diet may develop deficiencies of various minerals and nutrients in three groups of healthy subjects: 1) sixty-eight people regularly supplementing their diet with at least 2 tablespoons of bran for at least 6 months (mean 3 tablespoons for 13 months); 2) forty-three controls not consuming bran supplements; and 3) twenty vegetarians (eight of them consuming bran supplements) who had a very high fiber consumption for many years. The mean serum levels of iron, total iron binding capacity, calcium, phosphorus, alkaline phosphatase, zinc, magnesium, vitamin A, and cholesterol were within the normal range in all the three groups. In the bran eaters, vitamin A was higher, and alkaline phosphatase and magnesium lower than in the other two groups. In the vegetarians, the phosphorus level was higher and cholesterol and iron binding capacity lower than in the other two groups. There was no correlation between the amount of bran consumed and the blood level of nutrients. The fiber consumption of the vegetarians was very high, more than three times that of the controls. Our study indicates that a moderately or even extremely high consumption of fiber for a long time does not by itself cause mineral or nutrient deficiencies in a western type population.

Septic complications following endoscopic retrograde cholangiopancreatography: the experience in Tel Aviv Medical Center

At the Tel-Aviv Medical Center, five of 720 (0.69%) patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) subsequently developed septicaemia. One of these patients (0.14%) died as a direct result and three other septicaemic patients died from other complications. The most important risk factor associated with infectious complications was obstructive jaundice. Retrospective analysis of our data revealed that no cases of septicaemia developed in patients given prophylactic antibiotics, whereas 4.3% of patients who received no prophylactics developed infectious complications. Prophylactic antibiotics are therefore recommended for patients undergoing ERCP who have biliary obstruction.

Selective screening for colorectal tumors in the Tel-Aviv area: Relevance of epidemiology and family history

A selective screening program for the early detection of colorectal tumors was carried out in the Tel‐Aviv area. The criteria for inclusion were based, in part, on relevant epidemiologic data which showed that European‐ and American‐born immigrants were at the highest risk for developing this cancer, followed by Israeli‐born Jews. The Tel‐Aviv area, because of its large elderly population of European origin, has a high incidence of colorectal cancer. Families of patients with colon cancer are known to have an increased risk for developing colon tumors. These relatives were actively searched for, and were, along with the control group, examined by Hemoccult testing and flexible sigmoidoscopy. The colon tumor (cancer or adenomatous polyps) rate was 6.3% in the group with a family history of colon cancer, as contrasted to 3.8% in a similar control group without this history. This increased yield, greater than usually found in an unselected population, emphasizes the economic value of selective screening utilizing relevant epidemiologic data and the family history.

Energy intake and body weight in ovo-lacto vegetarians

Vegetarians have a lower body weight than omnivores. In this study the relationship between the weight/height ratio and food consumption was evaluated in 92 ovo-lacto vegetarians and 113 omnivores in Israel. The average weight of the vegetarians was significantly lower than that of the omnivores (60.8 kg vs. 69.1 kg), even though the vegetarian diet supplied a significantly higher amount of calories than the nonvegetarian diet (3,030.5 cal/day vs. 2,626.8 cal/day). Consumption of fat was similar in both groups. Carbohydrate consumption was higher in the vegetarians while protein consumption was lower. The prevalence of obesity was significantly lower in the vegetarian group (5.4%) as compared to 19.5% among the omnivores. The lower body weight of vegetarians despite a higher caloric intake is of considerable interest.

Rectal bleeding due to amebic colitis diagnosed by multiple endoscopic biopsies: report of two cases.

Recurrent rectal bleeding over a period of seven and 12 months, respectively, was the main and unusual manifestation of amebic colitis in two patients. The difficulty in establishing the diagnosis led to one patients receiving potentially dangerous steroid therapy. Only by taking multiple colonoscopic biopsies was the amebic colitis recognized. This and serologic tests, should be routine in all cases of inflammatory bowel disease before initiating therapy.

An audit of familial juvenile polyposis at the Tel Aviv Medical Center: demographic, genetic and clinical features.

Familial juvenile polyposis (JP) is an uncommon genetic disorder that, if untreated, can lead to gastrointestinal cancer. To evaluate familial JP prevalence, phenotypic manifestations, causative mutations, treatment and compliance for diagnosis and follow-up in our registry. Since 1993 our familial JP patients were registered, followed-up before and/or after surgery and their families encouraged to have mutation analysis, endoscopic screening and treatment. Ten pedigrees were identified, all Jewish, but only one was Ashkenazi, six were Sepharadi and three were Oriental; the only mutation found was BMPR1A in two of six pedigrees examined. Of 139 first-degree relatives at risk for JP, 62 (45%) had JP or cancer; 56 (40.3%) were available for follow-up and 35 entered the registry. Of these, 71% reported rectal bleeding, 40% had <20 colonic polyps, 31% had 20–100 polyps; 2 had >100 gastric polyps. Cancer occurred in 22.9% (6 colonic, 2 gastric) before familial JP diagnosis or during follow-up elsewhere or non-compliance for follow-up; however, 1 gastric cancer developed during our treatment. In 46% the initial clinical-pathological diagnosis was incorrect. Compliance for evaluation and follow-up of pedigree members and individual familial JP patients was inadequate in 20% and 26%, respectively. Familial JP does not occur in the Israeli Ashkenazi Jewish population at the expected proportion; it is often misdiagnosed and is inadequately recognized in Israeli non-Jews. Mutations were identified in only a minority of pedigrees despite comprehensive screening. The inadequate compliance for screening and follow-up needs to be addressed by educating the public, health care workers and health insurances.

Acute left colonic obstruction: a new nonsurgical treatment.

Acute obstruction of the left side of the colon is traditionally treated by colostomy, which entails two or three surgical procedures usually in a high-risk group of patients. We present a new nonsurgical approach by which decompression of the bowel is achieved with a tube introduced proximal to the obstruction with the aid of a flexible sigmoidoscope. This procedure was successful in six of nine patients with left-sided large-bowel obstruction, thus avoiding staged surgery and allowing one definitive operation. No complications were encountered.

Sabin-Feldman dye test in ulcerative colitis and Crohn's disease

The prevalence of Toxoplasma infection among patients with inflammatory bowel disease was studied. The Sabin-Feldman dye test was performed on 35 patients with Crohns disease, 44 patients with ulcerative colitis, and 140 control patients. A higher incidence of positive reactions was found in Crohns disease patients over the age of 40 (P<0.05). All other factors showed no significant differences among the three groups of patients. These factors include age younger than 40 years, sex, duration of disease, extent of disease, and type of treatment. It is concluded that there is no correlation between inflammatory bowel diseases and toxoplasmosis. Toxoplasma infection, however, should be considered in patients with Crohns disease who are over 40 years old, and who present with nonspecific signs of intercurrent infection.