Jean-François Bretagne

Wireless capsule endoscopy versus ileocolonoscopy for the diagnosis of postoperative recurrence of Crohn's disease: a prospective study.

Background and aims: Following ileocolonic resection for Crohn’s disease (CD), early endoscopic recurrence predicts recurrence of symptoms. The aim of the study was to compare ileocolonoscopy and wireless capsule endoscopy (WCE) for the detection of postoperative recurrence in CD. Methods: WCE and ileocolonoscopy were performed within six months following surgery in 32 prospectively enrolled patients. Two independent observers interpreted the results of WCE. Recurrence in the neoterminal ileum was defined by a Rutgeerts score ⩾1. When observers at WCE did not concur, WCE results were considered as either true negative or true positive and sensitivity and specificity were calculated according to both assumptions. Results: Recurrence occurred in 21 patients (68%) and was detected by ileocolonoscopy in 19 patients. Sensitivity was 90% and specificity 100%. Sensitivity of WCE was 62% and 76% and specificity was 100% and 90%, respectively, depending on assumptions. There was a correlation between the severity of the lesions measured by both methods (p<0.05). Lesions located outside the scope of conventional endoscopy were detected by WCE in two thirds of patients with excellent interobserver agreement (kappa >0.9) for all lesions with the exception of ulceration (kappa = 0.7). Conclusions: The sensitivity of WCE in detecting recurrence in the neoterminal ileum was inferior to that of ileocolonoscopy. In contrast, WCE detected lesions outside the scope of ileocolonoscopy in more than two thirds of patients. Additional follow up studies are needed to assess the clinical relevance of such lesions. At the present time, it seems that WCE cannot systematically replace ileocolonoscopy in the regular management of patients after surgery.

Review in depth and meta-analysis of controlled trials on colorectal cancer screening by faecal occult blood test

Background Several randomized studies have shown that colorectal cancer (CRC) screening by faecal occult blood test (FOBT) reduces CRC mortality. These trials have different designs, especially concerning FOBT frequency and duration, as well as the length of follow-up after stopping FOBT campaigns. Aims To review the effectiveness of screening for CRC with FOBT, to consider the reduction in mortality during or after screening or to identify factors associated with a significant mortality reduction. Methods A systematic review of trials of FOBT screening with a meta-analysis of four controlled trials selected for their biennial and population-based design. The main outcome measurements were mortality relative risk (RR) and 95% confidence interval (CI) of biennial FOBT during short (10 years, i.e. five or six rounds) or long-term (six or more rounds) screening periods, as well as after stopping screening and follow-up during 5–7 years. The meta-analysis used the Mantel–Haenszel method with fixed effects when the heterogeneity test was not significant, and used ‘intent to screen’ results. Results Although the quality of the four trials was high, only three were randomized, and one used rehydrated biennial FOBT associated with a high colonoscopy rate (28%). A meta-analysis of mortality results showed that subjects allocated to screening had a reduction of CRC mortality during a 10-year period (RR 0.86; CI 0.79–0.94) although CRC mortality was not decreased during the 5–7 years after the 10-year (six rounds) screening period, nor in the last phase (8–16 years after the onset of screening) of a long-term (16 years or nine rounds) biennial screening. Whatever the design of the period of ongoing FOBT, CRC incidence neither decreased nor increased, although it was reduced for 5–7 years after the 10-year screening period. Neither the design nor the clinical or demographic parameters of these trials were independently associated with CRC mortality reduction. Conclusion Biennial FOBT decreased CRC mortality by 14% when performed over 10 years, without evidence-based benefit on CRC mortality when performed over a longer period. No independent predictors of CRC mortality reduction have been identified in order to allow a CRC screening programme in any subgroups of subjects at risk.

How accurate is clinical examination in diagnosing and quantifying pelvirectal disorders? A prospective study in a group of 50 patients complaining of defecatory difficulties

We prospectively evaluated 50 patients (38 females and 12 males; mean age, 44.7±15 years) who complained of defecatory difficulties to determine the accuracy of the clinical examination in diagnosing and quantifying pelvirectal abnormalities. Each parameter was then compared with the features of anorectal manometry and evacuation proctography performed by two independent observers. Global agreement between clinical diagnosis and the reference method (radiology for rectoceles, rectal intussusceptions, and abnormal perineal descent; manometry for anismus) was observed in 80 percent of cases. In rectoceles, anismus, and rectal intussusceptions especially, excellent negative predictive values were obtained (96, 96, and 80 percent, respectively). Clinical examination always diagnosed high-grade intussusceptions. Nevertheless, abnormal perineal descent was poorly evaluated in 20 patients. When compared with anal manometry, digital assessment was able to quantify resting and squeeze pressures and length of the anal canal with excellent correlation and good global agreement as well as predicting a short or hypotonic anal canal. Clinical assessment is usually sufficient and accurate in most pelvirectal disorders encountered in patients complaining of defecatory difficulties. Both anorectal manometry and evacuation proctography retain a definite but limited place in investigating pelvirectal disorders.

Le reflux gastro-œsophagien dans la population générale française: Résultats d’une enquête sur 8 000 sujets adultes

Resume Objectifs Evaluer la prevalence dans la population generale francaise du reflux gastro-œsophagien (RGO) defini selon les recommandations de la conference de consensus de 1999, et preciser les caracteristiques de la pathologie, le taux de consultation medicale, les modalites de la prise en charge ainsi que le degre de satisfaction en resultant. Methodes Enquete epidemiologique quantitative realisee par voie postale aupres d’un echantillon de 8 000 sujets representatifs de la population francaise adulte. Le questionnaire auto-administre comprenait 46 questions portant sur la pathologie, les facteurs de risque, la prise en charge medicale et medicamenteuse, le traitement du dernier episode de RGO, et le degre de satisfaction des sujets. Le RGO a ete defini par l’existence de symptomes typiques (pyrosis, regurgitations acides) dont la frequence etait d’au moins une fois par semaine (RGO frequent). Resultats La prevalence globale (independamment de la frequence des symptomes) du RGO en France est de 31,3 %. La prevalence du RGO frequent est de 7,8 % (6 % avant 50 ans, 10 % au-dela). La plupart des sujets ayant un RGO frequent (86 %) avaient consulte, souvent apres un long delai depuis le debut des symptomes (26 % avaient attendu plus d’un an pour consulter), et 14 % n’avaient jamais consulte. Une endoscopie avait ete pratiquee chez 58 % des sujets ayant consulte. L’absence de consultation etait principalement liee a l’opinion que la pathologie n’etait pas grave et a l’automedication. La plupart des sujets (85 %) avaient traite le dernier episode de RGO frequent. Le traitement utilise avait ete principalement un medicament de prescription (68 % des cas), plus rarement un traitement d’automedication, un medicament conseille par le pharmacien, ou une association des deux (17 % des cas). Le traitement de prescription avait ete le plus souvent utilise seul (61 % des cas), rarement associe a un traitement d’automedication ou un produit de conseil (7 % des cas). Le traitement etait une monotherapie (2/3 des cas) ou une association (1/3) comprenant principalement des inhibiteurs de la pompe a protons (45 et 83 % respectivement) et des antiacides/alginates (46 et 61 % respectivement). Soixante-sept pour cent des sujets se declaraient tout a fait satisfaits de leur traitement, mais les symptomes avaient persiste chez 24 % des sujets traites. Discussion La prevalence du RGO frequent augmente avec l’âge. Le sexe, l’obesite, le tabac, l’alcoolisme ne paraissent pas influencer de facon majeure la prevalence du RGO. Une partie importante des sujets ayant un RGO frequent n’ont pas de suivi medical regulier et recourent a l’automedication. Seuls les 2/3 sont satisfaits de leur traitement. Conclusion Environ 3,5 millions de Francais adultes souffrent actuellement de RGO frequent mais une proportion encore importante ne consulte pas ou tarde a consulter malgre la frequence des symptomes. Une meilleure prise en charge du RGO frequent en France est souhaitable afin d’ameliorer le soulagement des symptomes et la surveillance des complications eventuelles.

Variations between endoscopists in rates of detection of colorectal neoplasia and their impact on a regional screening program based on colonoscopy after fecal occult blood testing

BACKGROUND There are few data about the performance variability among endoscopists participating to nationwide or regionwide colorectal cancer screening programs. OBJECTIVE To assess the variability of neoplasia detection rates among endoscopists participating in a regional colorectal cancer screening program based on colonoscopy after biennial fecal occult blood testing (FOBT). DESIGN Two rounds of colonoscopy were performed: round 1 took place in 2003 and 2004, and round 2 took place in 2005 and 2006. Secondary analysis of colonoscopy findings from the first 2 rounds was performed by using data drawn from all endoscopists who performed more than 30 colonoscopies in each round. Detection rates were adjusted for patient age and sex, and logistic regression analyses were conducted including these 2 variables and round number (1 or 2). SETTING District of Ille-et-Vilaine in Brittany (population >900,000) between 2003 and 2007. MAIN OUTCOME MEASUREMENTS The per-endoscopist adjusted rates of colonoscopies with at least 1, 2, or 3 adenomas, 1 adenoma 10 mm or larger, or a cancer. RESULTS Among the 18 endoscopists who performed 3462 colonoscopies, the adjusted detection rates were in the following ranges: at least 1 adenoma, 25.4% to 46.8%; 2 adenomas, 5.1% to 21.7%; 3 adenomas, 2.7% to 12.4%; 1 adenoma 10 mm or larger, 14.2% to 28.0%; and cancer, 6.3% to 16.4%. Multivariate analyses showed that the endoscopist was not an independent predictor of cancer detection, but was an independent predictor of detecting adenomas, regardless of category; the R(2) of the models ranged from 6% to 13% only. LIMITATIONS Other factors known to influence colorectal neoplasia occurrence and withdrawal time could not be taken into account. CONCLUSIONS In a screening program with a high compliance rate with colonoscopy after FOBT, interendoscopist variability had no effect on cancer detection, but did influence identification of adenomas. The clinical impact of such findings merits further evaluation.

A new mutation of E-cadherin gene in familial gastric linitis plastica cancer with extra-digestive dissemination

Over a 12-month period, we diagnosed poorly differentiated infiltrative independent-cell gastric adenocarcinoma in two brothers and one sister aged 41 to 47 years. Their father had died from antral cancer at the age of 34 years. These cancers had two characteristic clinical features: rapid course and distant malignant dissemination. In all three patients, polymerase chain reaction-sequencing of the E-cadherin (CDH1) gene of white blood cells identified a heterozygous nonsense mutation of exon 3, producing a stop codon at position 95 (Q95X), resulting in a truncated protein. The alteration of this protein, which plays a crucial role in epithelial cell adhesion, probably explains the clinical expression in this type of familial diffuse gastric cancer.

Fecal incontinence with normal anal canal pressures: where is the pitfall?

ObjectiveOne third of subjects who suffer from fecal incontinence are found to have values within the normal range when anal manometry is performed. For these patients, one hypothesis is that impaired rectal adaptation to distension may occur. The aim of our study was to analyze anorectal responses to rectal isobaric distension in this population.MethodsThis was a prospective study conducted in 51 consecutive incontinent patients (45 female, six male) divided into two groups according to their functional anal state: absence (19 patients aged 55 ± 6 yr) or presence of manometric anal weakness (32 patients aged 59 ± 2 yr). The subjects were submitted to two randomized modes of rectal isobaric distension (tonic, phasic) with an electronic barostat. Anal pressures, perception, and volumes of the rectum were recorded at six different preselected pressures.ResultsAs compared with those having anal weakness, patients with no anal weakness retained higher mean pressures at both upper (36.9 ± 2.2 vs 22.9 ± 1.4 mm Hg; p= 0.01) and lower parts (41.0 ± 2.0 vs 23.3 ± 1.4 mm Hg; p= 0.002) of the anal canal, similar perception scores, but much lower rectal volumes (68.5 ± 5.5 vs 121.8 ± 7.0 ml; p= 0.008) in response to rectal isobaric distension.ConclusionsA decrease in rectal adaptation could be involved in fecal leakage in patients with no anal manometric weakness.

Anal lesions: any significant prognosis in Crohn's disease?

Aim: Work‐up of anoperineal lesions usually includes indices of clinical activity as well as diagnostic criteria of Crohns disease but their prognostic implication remains unclear. This prospective study was conducted in order to evaluate the overall incidence of anoperineal lesions and their relation to the natural history of underlying intestinal Crohns disease with special reference to the steroid‐dependent state of the patients. Patients and methods: One hundred and one patients (46 males, 55 females, aged 34 ±14 years; range: 15‐79) were consecutively referred to our institution (May 1991 to May 1994) for intestinal symptoms related to Crohns disease (mean duration 66±66 months). They all underwent a proctological examination regardless of perineal symptoms. The Cardiff classification was used to describe anoperineal lesions. Patients with anal lesions (64) differed from those without (37): male predisposition (53% vs. 32%, P<0.05), more frequent rectal involvement (75% vs. 24%, P<0.001) and more acute lesions observed at proctoscopic examination (42% vs. 16%, P< 0.05). Age of onset, surgical past history of Crohns disease, colonic or ileal involvement, or Harvey‐Bradshaw score were not different between groups. Results: Patients with anal ulceration (43) as compared to patients having anal involvement without ulceration experienced pain more frequently (constant pain: 56 vs. 14%; defecatory pain: 35 vs. 19%) and a more severe evolution of intestinal (40 vs. 22%, P< 0.05) and anal (42 vs. 12%, P<0.05) involvement. In those with an aggressive ulceration (U2, 28 patients), daily stool frequency (5.1 ±3 vs. 3.6±2.5, P <0.05) and clinical score (9 ±5 vs. 7±3) were more pronounced. Steroid therapy dependency occurred more frequently in the group with anal ulceration (35 vs. 16% and 40 vs. 17%, respectively, P< 0.05). Similar associations were observed for cases of anal involvement (34 vs. 5%, P< 0.01) and azathioprine was more frequently required (39 vs. 5%, P<0.01) than in those free of anal lesions. During follow‐up, eight other patients required azathioprine (steroid dependence in six) and seven of them had anal lesions at referral. At the endpoint of the study, one out of two patients with anal lesions required azathioprine most often due to steroid dependency of the intestinal involvement (30/64 vs. 4/37, P<0.005). Conclusion: Anal ulcerations are a reliable severity index of Crohns disease in both short‐ and long‐term prognosis but their link to the steroid status of the intestinal disease remains unclear.

Nonfistulizing perianal Crohn's disease: Clinical features, epidemiology, and treatment

Nonfistulizing perianal lesions, including ulcerations, strictures, and anal carcinoma, are frequently observed in Crohns disease. Their clinical course remains poorly known. The management of these lesions is difficult because none of the treatments used is evidence-based. Ulcerations may be symptomatic in up to 85% of patients. Most ulcerations heal spontaneously but may also progress to anal stenosis or fistula/abscess. Topical treatments only improve symptoms, while complete healing can occur in patients with perianal ulcerations receiving infliximab therapy. Half of all patients with anal strictures will require permanent fecal diversion. Dilatation for symptomatic strictures should be performed on a highly selective basis in the absence of active rectal disease in order to avoid infectious complications. Anorectal strictures associated with rectal lesions should first be managed with medical therapy. Skin tags are usually painless and may hide other perianal lesions. Anal cancer is uncommon. Its treatment is similar to that recommended for anal cancer occurring in non-Crohns disease patients. After reviewing the classification, clinical features, and epidemiology of each type of nonfistulizing perianal lesion (ulceration, stricture, skin tags, and anal cancer), we discuss the efficacy of medical treatment and surgery. This review article may help physicians in decision-making when managing potentially disabling lesions.

Immunological Study in Primary Intestinal Lymphangiectasia

Primary intestinal lymphangiectasia is a rare congenital condition associated with protein-losing enteropathy. Hypogammaglobulinemia and lymphopenia secondary to this condition are frequent but infectious complications are not. So far few immunological studies have been made in these patients. We report here the results of such a study carried out in two adolescents. Both patients presented with a dramatic decrease in serum gammaglobulins, especially IgG and IgA, and in peripheral blood lymphocytes, especially CD4 T helper cells. From a functional standpoint, the proliferative response to certain mitogens was reduced. A decrease in in vitro production of immunoglobulins by B lymphocytes may be due to a faulty T/B cell cooperation. Histological examination of duodenal biopsy specimens revealed a decreased number of intraepithelial lymphocytes. Colonoscopy revealed nodular lymphoid hyperplasia in the terminal ileum, confirmed by endoscopic biopsy. The role of these abnormalities in the development of infectious complications and lymphoma is underscored.