Lawrence Halparin

Familial microscopic colitis

Collagenous and lymphocytic colitis are two inflammatory conditions of the colon that are often collectively referred to as microscopic colitis. The present report describes what is believed to be the third published case of familial microscopic colitis. A 55-year-old woman who suffered from chronic diarrhea was diagnosed with lymphocytic colitis on colonic biopsy. Subsequently, her 36-year-old daughter was diagnosed with collagenous colitis. The familial occurrence of these diseases may support an immunological hypothesis for their etiology. In addition, it supports the assumption that collagenous and lymphocytic colitis are two manifestations of the same disease process rather than two completely separate entities. The familial tendency of this disease may make a case for early colonoscopy and biopsy in relatives of patients diagnosed with microscopic colitis if they present with suggestive symptoms.

A randomized controlled trial assessing the effect of prescribed patient position changes during colonoscope withdrawal on adenoma detection

BACKGROUND High-quality colonoscope withdrawal technique is associated with a higher adenoma detection rate. Position change is routinely used in barium enema and CT colonography to facilitate adequate distension of the colon and promote movement of fluid from the segment of the colon being assessed. OBJECTIVE To determine whether prescribed position changes during colonoscope withdrawal affect the adenoma detection rate compared with the usual care per endoscopist. DESIGN Prospective, randomized, controlled trial. SETTING Tertiary-care, university-affiliated hospital. PATIENTS Patients referred for outpatient colonoscopy between July 2011 and July 2012 were evaluated for eligibility. Inclusion criteria were outpatient status and age ≥40 years. Exclusion criteria were (1) complete colonoscopy within 1 year before the procedure, (2) inability to provide informed consent, (3) incomplete colonoscopy to the cecum, (4) previous bowel resection, (5) inflammatory bowel disease, (6) colonic polyposis syndrome, (7) inadequate bowel preparation, and (8) musculoskeletal disorder or other mobility issues limiting effective patient position changes during colonoscopy. INTERVENTIONS Prescribed position changes during colonoscope withdrawal. MAIN OUTCOME MEASUREMENTS Polyp detection rate (PDR) and adenoma detection rate (ADR). RESULTS A total of 776 patients were enrolled, with 388 in the dynamic group. There was no difference in PDR (odds ratio [OR] 0.99; P = .93) or ADR (OR 1.17; P = .28). Colonoscope withdrawal time was longer in the dynamic group (median time 466.5 vs 422.5 seconds; P < .0001). LIMITATIONS Single-center study. Indication for procedure not controlled. Lack of standardized bowel preparation and blinding. CONCLUSION Prescribed position changes during colonoscope withdrawal do not affect polyp/adenoma detection compared with the usual practice when the baseline ADR is above the recommended standard. ( CLINICAL TRIAL REGISTRATION NUMBER NCT01395173.).

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.

Add-On Cases in the Endoscopy Unit: Factors That Affect Volume

BACKGROUND Although most procedures in the endoscopy clinic are elective, emergency add-on cases in hospital-based endoscopy clinics are common, frequently consuming a great deal of time and resources relative to elective endoscopy procedures. OBJECTIVE To determine which specific factors correlate with the high volume of add-on emergency cases in a tertiary care, hospital-based endoscopy unit. METHODS A retrospective chart review of all gastrointestinal add-on, and electively booked cases of esophagastroduodenoscopy (EGD), colonoscopy(C) and flexible sigmoidoscopy(FS)procedures from September 2006 to May 2007, was conducted. The day of the week, month, type of procedure and physician were recorded. Emergency add-on procedures performed during the weekends were not assessed. These cases were then compared with elective cases during a similar time frame to determine differences in the aspects of add-on cases versus those that were elective. RESULTS Seven hundred twenty-one add-on cases were reviewed (mean patient age 57.4 years; 46% women) and compared with 736 elective cases (mean age 56 years; 49% women; P not significant). Of the add-on cases, 377 (52%) were EGD, 216 C (30%) and 105 (15%) were FS, with 23 combined procedures (3.2%) versus 202 (27%) EGD, 442 (60%) C and 74 (10%) FS in the elective group. Add-on cases were more likely to be EGDs than elective cases (OR 2.7; 95% CI 1.8 to 4.3; P<0.0001) and less likely to be Cs (OR 0.24; 95% CI 0.15 to 0.38; P<0.0001). There were significantly more add-on cases on Mondays (OR 1.7; 95% CI 1.0 to 2.28; P>0.03). Conversely, there were significantly fewer procedures added on Fridays (OR 0.31; 95% CI 0.16 to 0.57; P=0.0001). There were statistically fewer add-on cases in September compared with the other months that were evaluated (OR 0.31; 95% CI 0.11 to 0.78; P=0.0006). CONCLUSION With the present system of performing only emergency cases on the weekend, Monday tends to have more add-on cases. Consistent with the fact that upper gastrointestinal bleeding is the most common emergency condition, EGD is more common in add-on cases than with elective cases. Although speculative, the reasons for Friday having fewer add-on cases may be the result of a change of physician on call that day; consequently, most cases may be performed earlier in the week. For unknown reasons, fewer cases tend to be added on in September than in the other months evaluated. These data demonstrate that even in the same institution with similar patients, variability in the number of add-on cases likely is a result of many additional factors governing add-on cases, which require appropriate resource planning to ensure adequate allocation of services to ensure ideal patient care.

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.

FOCUS: Future of fecal calprotectin utility study in inflammatory bowel disease

AIM To evaluate the perspective of gastroenterologists regarding the impact of fecal calprotectin (FC) on the management of patients with inflammatory bowel disease (IBD). METHODS Patients with known IBD or symptoms suggestive of IBD for whom the physician identified that FC would be clinically useful were recruited. Physicians completed an online “pre survey” outlining their rationale for the test. After receipt of the test results, the physicians completed an online “post survey” to portray their perceived impact of the test result on patient management. Clinical outcomes for a subset of patients with follow-up data available beyond the completion of the “post survey” were collected and analyzed. RESULTS Of 373 test kits distributed, 290 were returned, resulting in 279 fully completed surveys. One hundred and ninety patients were known to have IBD; 147 (77%) with Crohn’s Disease, 43 (21%) Ulcerative Colitis and 5 (2%) IBD unclassified. Indications for FC testing included: 90 (32.2%) to differentiate a new diagnosis of IBD from Irritable Bowel Syndrome (IBS), 85 (30.5%) to distinguish symptoms of IBS from IBD in those known to have IBD and 104 (37.2%) as an objective measure of inflammation. FC levels resulted in a change in management 51.3% (143/279) of the time which included a significant reduction in the number of colonoscopies (118) performed (P < 0.001). Overall, 97.5% (272/279) of the time, the physicians found the test sufficiently useful that they would order it again in similar situations. Follow-up data was available for 172 patients with further support for the clinical utility of FC provided. CONCLUSION The FC test effected a change in management 51.3% of the time and receipt of the result was associated with a reduction in the number of colonoscopies performed.

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.