Marcus W. Chin

Computed Tomographic Colonography: Prevalence, Nature, and Clinical Significance of Extracolonic Findings in a Community Screening Program

OBJECTIVE:Colorectal neoplasia screening by computed tomographic colonography (CTC) may lead to the detection of incidental extracolonic findings. We report the prevalence and clinical significance of extracolonic pathology found within a community-based CTC screening program and the cost of clinical follow-up and further investigation of these findings.METHODS:A total of 432 asymptomatic subjects at an average risk of colorectal neoplasia, aged 50–69, had screening by CTC using a low radiation dose protocol. Axial images were prospectively examined for extracolonic lesions and those considered clinically relevant were followed up. All clinic visits and further investigations were tallied to calculate the incremental cost to the screening CTC.RESULTS:A total of 146 extracolonic lesions were detected in 118 (27.3%) subjects. Thirty-two (7.4%) subjects had clinically relevant extracolonic abnormalities and nine (2.1%) subjects may derive a clinical benefit from the detection of these lesions. A single CTC costed

Predictive and protective factors associated with upper gastrointestinal bleeding after percutaneous coronary intervention: a case-control study.

171.12, and following up extracolonic findings resulted in an additional

Should simulator use become mandatory in endoscopy training

24.37 (14.2%) per CTC. Limiting reporting to the aorta and kidneys would have reduced the number of subjects requiring follow-up to 14 (3.2%), and decreased the cost increment to 4.7% without detriment to clinical outcome.CONCLUSIONS:Extracolonic findings of screening CTC are common, but infrequent of clinical importance. The additional burden of following up these findings was modest and could have been further reduced if clear clinical and radiological criteria and pathways for their further investigation were defined.

Vedolizumab-induced acute pancreatitis: the first reported clinical case

BACKGROUND:Hemorrhagic complications of acute coronary syndromes and percutaneous coronary intervention (PCI) are associated with increased mortality. Upper gastrointestinal (UGI) bleeding after PCI is a potential target for preventative strategies.OBJECTIVE:To evaluate the risk factors for UGI bleeding in a large cohort of contemporary PCI patients and assess the outcomes of medical and endoscopic management.METHOD:A case-control study evaluating UGI bleeding in the 30 days following PCI for stable angina and acute coronary syndromes, at one institution between 1998 and 2005. Cases were identified and outcomes assessed using linkage analysis of data from institutional PCI and endoscopy databases, statewide vital statistics and hospital discharge registries, and a detailed review of medical notes for each case and three matched controls. Analysis of the case and control groups for risk and protective factors was performed using the χ2 test with Fishers exact P value and logistic regression.RESULTS:The incidence of UGI bleeding following PCI was 1.2% (70 of 5,673 patients). The etiologies of these bleeds were diverse. Risk factors for UGI bleeding were primary PCI (OR 27.80, 95% CI 6.28–123.05, P < 0.001), cardiac arrest (OR 6.17, 95% CI 1.82–20.84, P = 0.003), inotropic requirement (OR 5.85, 95% CI 1.98–17.27, P = 0.001), thienopyridine use before PCI (OR 2.40, 95% CI 1.04–5.53, P = 0.02), and advanced age (OR 1.08, 95% CI 1.04–1.12, P < 0.001). Proton pump inhibitor use after PCI (OR 0.08, 95% CI 0.02–0.40, P = 0.002) was accompanied by a reduced risk of UGI bleeding. Endoscopy provided therapeutic intervention in 33% of patients. There were no serious complications of endoscopy. The 30-day mortality for cases was 11.9% and 0.5% for controls (P = 0.001).CONCLUSION:UGI bleeding after PCI is relatively common and associated with increased mortality. Those undergoing PCI for acute myocardial infarction or in the presence hemodynamic instability are at highest risk. Proton pump inhibition following PCI may reduce the bleeding risk, though when UGI bleeding occurs, therapeutic endoscopy is safe.

Outcomes of pre‐operative biliary drainage from a single tertiary centre: is there still a role for plastic stents?

However, it is important to note that the study may not be sufficiently powered to assess the predictive value of the other clinical features studied. Larger prospective cohort studies are required to confirm these findings. Current international data suggest that capsule endoscopy should be the preferred initial diagnostic test in OGIB in view of the diagnostic yield and outcome data, safety, and noninvasiveness. DBE should be considered as a complementary test and has a role to play mainly for therapy after capsule endoscopy is used in OGIB. Although the diagnostic yield of DBE is similar to capsule, it is invasive and time-consuming. It is often difficult to decide on the route of examination without prior imaging of the small bowel, so many patients have oral and anal examinations. Endoscopic intervention is only required in a proportion of patients in studies where DBE is used as a diagnostic test. We believe that DBE should certainly be used as a therapeutic modality when VCE detects a bleeding lesion and also to retrieve retained capsules. It may also be required in the context of ongoing bleeding with a negative VCE result. We accept that capsule endoscopy may not be universally available or affordable, and DBE therefore has a diagnostic role in this situation. We also recognize that there may be a subgroup of patients with overt obscure bleeding who may benefit from early DBE. As suggested by Byeon et al., a better understanding of the clinical features which predict endoscopic findings is important. This would help to clarify the choice and timing of DBE in OGIB.

Are proximal serrated polyps associated with clinical symptoms

Drug-induced acute pancreatitis (DIAP) is a rare, but clinically significant diagnosis. Vedolizumab, an α4β7 integrin inhibitor, which was approved in 2015 for treatment of moderate to severe inflammatory bowel disease, is a well-tolerated medication with a favourable safety profile and minimal serious adverse events in premarketing clinical trials. We present the first reported case of acute pancreatitis directly attributable to vedolizumab.

Screening for coeliac disease using anti-tissue transglutaminase antibody assays, and prevalence of the disease in an Australian community

Preoperative biliary drainage (PBD) can relieve symptoms of cholestasis, but carries risk of procedural complications. Metal stents have wider lumens and longer patency, although plastic stents (PS) remain in use. We reviewed the outcomes after PBD in patients with cholestasis.

Attitudes of Western Australian general practitioners to colorectal cancer screening.

Despite recognition of the significance of sessile serrated adenomas as precursor lesions in the serrated pathway to colorectal cancer [1,2] and the elevated risk of malignancy in serrated polyposis syndrome [3], little is known about the clinical features of colonic serrated polyps. Sessile serrated adenomas have been increasingly recognized in patients under 40 years of age [4]. The authors identified a group of five young patients with large proximal colonic serrated polyps found at colonoscopy undertaken to investigate symptoms of abdominal discomfort and loose frequent stools, within a private practice setting over a 12-month period. After failure of clinical consultation, blood and stool examination to determine a cause, all patients proceeded to endoscopy and colonoscopy under conscious sedation. As is the usual practice, routine biopsies were taken from the stomach, duodenum and right and left colon without cause for symptoms identified. At colonoscopy, all patients had at least one large, flat polyp in the proximal colon with a mucus cap identified; all visualized polyps were resected and retrieved for histopathological examination. All large flat proximal polyps were reported as serrated lesions (either hyperplastic polyp or sessile serrated adenoma). The patients were all female and aged 23 – 31 years of age without family history of colorectal cancer or of colonic polyps in first-degree relatives. All were of Caucasian background and only one was a current smoker. All patients described an improvement in diarrheal symptoms at first follow-up consultation without other interventions being instituted in the interim; however, two patients described recurrence of symptoms at subsequent review. The authors believe this small series raises the question of whether serrated colonic polyps are associated with clinical symptoms. In addition, the improvement in symptoms after polyp resection raises the possibility of a causal role. Further prospective studies which include a significant number of young patients undergoing colonoscopy for symptoms, a demographic which may be underrepresented in cohorts published to date, are required.