Rajeev Vasudeva

Colorectal cancer screening and surveillance practices by primary care physicians: results of a national survey

OBJECTIVE:Screening for colorectal cancer reduces its morbidity and mortality and is cost-effective. Screening is usually the responsibility of primary care physicians who may be unsure about its implementation. We aimed to assess primary care physicians’ knowledge and practice regarding colorectal cancer screening, and to compare their responses with those of three national experts and with published guidelines.METHODS:We mailed a postal questionnaire to 2310 primary care physicians regarding demographics, nature of practice, use of screening tests, and six hypothetical patients who may have been candidates for screening or surveillance. We used published national guidelines and the collective opinions of the three external experts as the so-called “gold standard.”RESULTS:Of all respondents, 85.1% offered colorectal cancer screening. Most used suitable tests, starting at an appropriate age; 49.8% continued screening indefinitely irrespective of patients’ age and 43.6% performed fecal occult blood testing without appropriate dietary advice to patients. Also, respondents frequently performed this test for inappropriate indications. Only 51.8% would follow a positive fecal occult blood test with colonoscopy.CONCLUSIONS:Colorectal cancer screening practices by primary care physicians vary considerably from those recommended. Many offer screening to individuals in whom it is not appropriate, and continue it into advanced age. Frequent, inappropriate use of fecal occult blood tests will produce many false positives. Primary care physicians often do not appropriately follow a positive test. Further educational efforts are needed in an attempt to improve practice and further reduce the morbidity and mortality from colorectal cancer.

Randomized, controlled study of pretreatment with magnesium citrate on the quality of colonoscopy preparation with polyethylene glycol electrolyte lavage solution.

changes in hamartomatous polyps of the small intestine (Peutz-Jeghers syndrome). Cancer 1982;49:971-83. 6. Daniel ES, Ludwig SL, Lewin KJ, Ruprecht RM, Rajacich GM, Schwabe AD. The Cronkhite-Canada syndrome. Medicine 1982;61:293-309. 7. Morson BC, Dawson IM, Day DW, Jass JR, Price AB, Williams GT. Benign epithelial tumor and polyps. In: Morson BC, Dawson IM, editors. Gastrointestinal Pathology. 3rd edition. Oxford: Blackwell Science Publishers; 1990. p. 563-96. 8. Carlson GJ, Nivatongs S, Snorer DC. Colorectal polyps in Cowdens disease (multiple hamartoma syndrome). Am J Surg Pathol 1984;8:763-70.

Simplified lansoprazole suspension--a liquid formulation of lansoprazole--effectively suppresses intragastric acidity when administered through a gastrostomy.

OBJECTIVES:Lansoprazole suppresses intragastric acidity when given as nonencapsulated intact granules. Because the administration of granules via small-bore tubes may still be problematic, we studied the effect of a liquid formulation of lansoprazole obtained by suspending the contents of a standard 30-mg capsule in 10 cc of 8.4% NaHCO3.METHODS:Six men with an established gastrostomy had a baseline 24-h intragastric pH study. Through the gastrostomy, they then received 7 days of once-daily dosing with 30 mg lansoprazole as intact granules in orange juice. After a 7-day washout period, they then received 7 days of once-daily dosing with the liquid formulation. Intragastric pH monitoring was repeated after each dosing period.RESULTS:Baseline mean intragastric pH was 1.8 ± 0.5 (SD). This increased to 4.5 ± 0.5 with lansoprazole granules in orange juice, and to 5.1 ± 1.1 after the liquid formulation. At baseline, intragastric pH was >3, 4, and 5 for 19.5%, 12.7%, and 8.1%, respectively, of the 24-h recording period. Corresponding values after lansoprazole granules in orange juice were 77.5%, 67%, and 49.6% (p < 0.01 for each comparison with baseline). After the liquid formulation, the corresponding values were 84%, 77.9%, and 65.9% respectively (p < 0.01 for each comparison with baseline; p > 0.05 for each comparison with lansoprazole granules in orange juice).CONCLUSIONS:A liquid formulation of lansoprazole suppressed intragastric acidity when given through a gastrostomy. The degree of suppression was comparable to that obtained with intact nonencapsulated granules in orange juice.

A survey of gastroenterologists’ perceptions and practices related to Helicobacter pylori infection

Abstract OBJECTIVE: The aim of this study was to assess the current practice of gastroenterologists in the United States concerning Helicobacter pylori ( H. pylori ) infection. METHODS: We mailed a structured questionnaire to 1000 gastroenterologists chosen at random from a national database. We asked about personal and practice demographics and practices relating to testing for, and treating, H. pylori infection. RESULTS: A total of 922 questionnaires were delivered, from which we received 286 responses (31%). Respondents used many different tests for H. pylori infection, but only 10% each had used either the 13 C- or 14 C-urea breath test. Testing for H. pylori infection was usually for appropriate reasons, although 21% indicated that they might not treat a patient with a positive test result. Different multiple treatment regimens were used; the most frequent were combinations of a proton pump inhibitor, clarithromycin, and either amoxicillin or metronidazole. Estimates of the prevalence of antibiotic resistance were highly variable and often inaccurate. Most respondents would not check asymptomatic individuals for the infection; however, in the absence of symptoms, 38% would personally undergo testing and treatment if positive. CONCLUSIONS: Gastroenterologists usually test for H. pylori infection in appropriate conditions, but may not always treat the infection based on a positive test result. Most use efficacious regimens to treat the infection although many have inaccurate information on resistance rates, which may adversely influence prescribing. Many would have testing and, if positive, treatment in the absence of symptoms or a specific diagnosis, but do not recommend this for their patients.

Changes in colorectal cancer over a 15-year period in a single United States City

OBJECTIVE:The aim of this study was to identify colorectal cancer trends in different patient groups in one region.METHODS:We reviewed the records of all patients with colorectal cancer who were seen at two hospitals in Columbia, SC, between 1981 and 1995. Patients were divided into three 5-yr cohorts (cohort 1, 1981–1985; cohort 2, 1986–1990; and cohort 3, 1991–1995). We recorded demographic data, histological type, tumor stage, grade, and survival.RESULTS:A total of 1395 patients were diagnosed, of whom 1252 had adenocarcinoma. Mean age of diagnosis was 64.5 yr in black and 66 in white patients (p= 0.036). Adenocarcinoma proximal to the splenic flexure was found in 62% of women and 49% of men (p < 0.001), and in 51% of black and 44% of white patients (p= 0.08). Proximal cancers accounted for 61%, 48%, and 32% of cohorts 1, 2, and 3, respectively. The proportions of patients with advanced stage (III and IV) adenocarcinoma in the three cohorts were 54%, 47%, and 40%, respectively (p= 0.001). Median survival for adenocarcinoma was 23.7, 23.5, and 23.1 months in cohorts 1, 2, and 3 (p= 0.9).CONCLUSIONS:The prevalence and demographics of colorectal cancer have been fairly stable at this center. There has been a significant decrease in proximal cancers. Although adenocarcinoma is being diagnosed at an earlier stage, this has not affected survival. Colonoscopy may be the most appropriate screening method in women and in black patients, in whom proximal cancers are more often found.

Changing trends in esophageal cancer: a 15-year experience in a single center.

Objective:Esophageal adenocarcinoma is increasing in white men. We sought to identify trends in esophageal cancer in different patient groups in our region.Methods:We reviewed the records of all patients with esophageal cancer seen at two hospitals in Columbia, SC between 1981 and 1995. Patients were divided into three cohorts (1981–1985, 1986–1990, and 1991–1995). Demographic data, histological type, tumor stage, grade, and survival were recorded.Results:Histology was available in 371 of 386 patients (cohort 1, 113 patients; cohort 2, 144; and cohort 3, 114). Adenocarcinoma accounted for 24%, 27%, and 49% of esophageal cancer in white men in cohorts 1, 2, and 3, respectively (p= 0.03). Corresponding figures for African-Americans were 10%, 7%, and 3% (p= 0.22). Women comprised 8%, 14%, and 22% of patients with squamous carcinoma in the three cohorts (p= 0.03). Median survival for esophageal cancer was 6.0, 6.8, and 10.4 mo in cohorts 1, 2, and 3 (p= 0.0002).Conclusions:Adenocarcinoma is increasing in whites. Squamous carcinoma remains the predominant type in this region, seen mainly in African-Americans. Esophageal squamous carcinoma is increasing in women. The mean age at diagnosis of squamous carcinoma has decreased in whites. There is a trend toward improved survival in patients with esophageal cancer.

The effect of stimulant laxatives and polyethylene glycol-electrolyte lavage solution for colonoscopy preparation on serum electrolytes and hemodynamics.

We have previously shown that magnesium citrate or bisacodyl before polyethylene glycol electrolyte lavage solution (PEG-ELS) improves colonoscopy preparation. Patients prefer this to preparation with full-volume PEG-ELS alone. However, such combinations might cause undesirable changes in hemodynamics or serum electrolytes. This study examined the effects of these combinations on heart rate, blood pressure, and serum electrolytes. We randomized 68 consecutive patients undergoing colonoscopy to one of three preparations. Group 1 received 4 L of PEG-ELS, group 2 received 2 L of PEG-ELS with 20 mg bisacodyl, and group 3 received 2 L of PEG-ELS preceded by 296 mL of magnesium citrate. Heart rate, blood pressure, and serum electrolytes were measured before starting the preparation and immediately before colonoscopy. Mean serum magnesium fell by 0.01 mg/dL and 0.11 mg/dL in groups 1 and 2, respectively, and rose by 0.06 mg/dL in group 3 (p = 0.044). There were no other significant changes. Statistically significant changes in serum magnesium after preparation with PEG-ELS and a stimulant laxative are minor and probably of no clinical relevance. Two liters of PEG-ELS with a stimulant laxative is safe and effective for colonoscopy.

Examination of Tissue Distribution of Helicobacter pylori Within Columnar-Lined Esophagus

H. pylori may colonize columnar-lined esophagus,although an etiologic role in esophageal adenocarcinomais unproven. H. pylori can adhere to intestinalmetaplasia in the stomach. This study was designed to examine if H. pylori adheres to specializedintestinal metaplasia in columnar-lined esophagus.Esophageal biopsies from patients with columnar-linedesophagus were reviewed. Patients with only gastric metaplasia were excluded. Sections withspecialized intestinal metaplasia in at least one thirdof at least one gland were recut, stained using theGiemsa stain, and reexamined by two independentpathologists using strict criteria for adherence by H.pylori . The 209 esophageal biopsies with adequatespecialized intestinal metaplasia from 58 patients wereexamined: H. pylori was only seen on gastric metaplasia in three patients — and never onspecialized intestinal metaplasia. Within the esophagus,H. pylori adheres only to gastric metaplasia, which isnot considered premalignant for esophagealadenocarcinoma.

Isoniazid-Related Hepatitis

Conclusive evidence of isoniazid (INH)-related hepatotoxicity ranging from asymptomatic elevation of liver enzymes to fulminant hepatic failure resulting in liver transplantation and/or death has been firmly established. Anticipation of the widespread usage of INH in the prevention and treatment of tuberculosis is expected due to the recent increasing incidence of tuberculosis. The aim of this article is to review the current concepts of pathogenesis, histopathology, risk factors and clinical features of INH-related hepatitis, emphasizing the need for vigilance.

Hepatobiliary Sarcoidosis Presenting as Sclerosing Cholangitis: Long-Term Follow-Up

Although patients with sarcoidosis present most commonly with pulmonary or constitutional symptoms, liver involvement occurs frequently. Hepatic sarcoidosis is usually characterized by a cholestatic picture, with isolated elevation of serum alkaline phosphatase and normal or minimally abnormal transaminase and bilirubin levels. The liver dysfunction is often asymptomatic, but sarcoidosis rarely can result in significant hepatobiliary disease, including cirrhosis and portal hypertension [1]. We present a patient who developed symptomatic severe cholestasis and imaging findings with the appearance of sclerosing cholangitis, shortly after presenting with biopsyconfirmed hepatic sarcoidosis. For reasons discussed, we believe that this patient did not have a distinct diagnosis of primary sclerosing cholangitis. Although several such cases have been reported previously, none have included long-term clinical follow-up to indicate the natural history and response to treatment. In contrast to those cases, we provide 6 years of follow-up.