Robert J. Hilsden

Bleeding and Perforation After Outpatient Colonoscopy and Their Risk Factors in Usual Clinical Practice

BACKGROUND & AIMS The most widely quoted complication rates for colonoscopy are from case series performed by expert endoscopists. Our objectives were to evaluate the rates of bleeding, perforation, and death associated with outpatient colonoscopy and their risk factors in a population-based study. METHODS We identified all individuals 50 to 75 years old who underwent an outpatient colonoscopy during April 1, 2002, to March 31, 2003, in British Columbia, Alberta, Ontario, and Nova Scotia, Canada. Using administrative data, we identified all individuals who were admitted to hospital with bleeding or perforation within 30 days following the colonoscopy in each province. We calculated the pooled rates of bleeding and perforation from the 4 provinces. In Ontario, we abstracted the hospital charts of all deaths that occurred within 30 days following the procedure. We used generalized estimating equations models to evaluate factors associated with bleeding and perforation. RESULTS We identified 97,091 persons who had an outpatient colonoscopy. The pooled rates of colonoscopy-related bleeding and perforation were 1.64/1000 and 0.85/1000, respectively. The death rate was 0.074/1000 or approximately 1/14,000. Older age, male sex, having a polypectomy, and having the colonoscopy performed by a low-volume endoscopist were associated with increased odds of bleeding or perforation. CONCLUSIONS Although colonoscopy has established benefits for the detection of colorectal cancer and adenomatous polyps, the procedure is associated with risks of serious complications, including death. Older age, male sex, having a polypectomy, and having the procedure done by a low-volume endoscopist were independently associated with colonoscopy-related bleeding and perforation.

Prevalence of Adenomas and Colorectal Cancer in Average Risk Individuals: A Systematic Review and Meta-analysis

BACKGROUND & AIMS There is an extensive yet inconsistent body of literature reporting on the prevalence of adenomatous polyps (adenomas) and colorectal cancer among average risk individuals. The objectives of our study were to determine the pooled prevalence of adenomas and colorectal cancer, as well as nonadvanced and advanced adenomas, among average risk North Americans. METHODS Articles were obtained by searching electronic databases (MEDLINE: 1950 through March 2008 and EMBASE: 1980 through March 2008), bibliographies, major journals, and conference proceedings, with no language restrictions. Two reviewers independently selected cross-sectional studies reporting adenoma and colorectal cancer prevalence rates in average risk individuals and assessed studies for inclusion and quality, and extracted the data for analysis. Pooled adenoma and colorectal cancer prevalence rates were estimated using fixed and random effects models. Stratification and metaregression was used to assess heterogeneity. RESULTS Based on 18 included studies, the pooled prevalence of adenomas, colorectal cancer, nonadvanced adenomas, and advanced adenomas was 30.2%, 0.3%, 17.7%, and 5.7%, respectively. Heterogeneity was observed in the pooled prevalence rates for overall adenomas, advanced adenomas, and colorectal cancer and was explained by the mean age (> or = 65 years vs < 65 years) with older cohorts reporting higher prevalence rates. None of the study quality indicators was found to be significant predictors of heterogeneity. CONCLUSIONS The high prevalence of advanced adenomas and colorectal cancer, especially among older screen-eligible individuals, provides impetus for expanding colorectal cancer screening programs. Furthermore, the pooled prevalence estimates can be used as quality indicators for established programs.

Complementary and alternative medicine use by Canadian patients with inflammatory bowel disease: results from a national survey.

OBJECTIVES:Previous studies of complementary and alternative medicine (CAM) use by patients with inflammatory bowel disease (IBD) have relied on samples from specialty clinics. The aim of this study was to determine the prevalence of use and perceived outcomes of CAM in a large, diverse IBD populationMETHODS:A postal survey of the members of the Crohns and Colitis Foundation of Canada gathered data on demographic, disease, and conventional IBD treatment characteristics, and on the use and perceived effects of CAM. Respondents were characterized as not using CAM, as past or present users of CAM for their IBD, or as present users of CAM for other reasons. Comparisons between groups were made with the χ2 test.RESULTS:The final sample included 2847 IBD patients. Current or past use of CAM for IBD was reported by 1332 patients, of whom 666 continued their use of CAM. Use was lowest in the eastern provinces and highest in the west. Only 15% had used CAM before their IBD diagnosis. Herbal therapies were the most commonly used (41% of CAM users). Improvements in sense of well-being, IBD symptoms, and sense of control over the disease were the most commonly reported benefits. Only 16% of prior CAM users reported any adverse effect of CAM use. A complementary practitioner was consulted by 34%. During the previous year, 46% had spend more than

Colorectal Cancer Screening for Average-Risk North Americans: An Economic Evaluation

250 on CAM.CONCLUSIONS:Use of CAM by IBD patients is very common. Most of these patients attribute significant benefits to their CAM use. Few report significant adverse events.

Canadian Association of Gastroenterology position statement on screening individuals at average risk for developing colorectal cancer: 2010

An economic analysis of different screening methods for detection of colorectal cancers suggests that in US or Canadian settings, screening with fecal immunochemical testing results in lower health-care costs as compared with other screening approaches.

Epidemiology and natural history of primary biliary cirrhosis in a Canadian health region: A population‐based study

The Canadian Association of Gastroenterology and the Canadian Digestive Health Foundation published guidelines on colon cancer screening in 2004. Subsequent to the publication of these guidelines, many advances have occurred, thereby necessitating a review of the existing guidelines in the context of new technologies and clinical knowledge. The assembled guideline panel recognized three recent American sets of guidelines and identified seven issues that required comment from a Canadian perspective. These issues included, among others, the role of program-based screening, flexible sigmoidoscopy, computed tomography colonography, barium enema and quality improvement. The panel also provided context for the selection of the fecal immunochemical test as the fecal occult blood test of choice, and the relative role of colonoscopy as a primary screening tool. Recommendations were also provided for an upper age limit for colon cancer screening, whether upper endoscopy should be performed following a negative colonoscopy for a positive fecal occult blood test and when colon cancer screening should resume following negative colonoscopy.

Use of complementary and alternative medicine by patients with inflammatory bowel disease

The recent epidemiology and outcomes of primary biliary cirrhosis (PBC) in North America are incompletely described, partly due to difficulties in case ascertainment. In light of their availability, broad coverage, and limited expense, administrative databases may facilitate such investigations. We used population‐based administrative data (inpatient, ambulatory care, and physician billing databases) and a validated International Classification of Diseases coding algorithm to describe the epidemiology and natural history of PBC in the Calgary Health Region (population ≈1.1 million). Between 1996 and 2002, the overall age/sex‐adjusted annual incidence of PBC was 30.3 cases per million (48.4 per million in women, 10.4 per million in men). Although the incidence remained stable, the prevalence increased from 100 per million in 1996 to 227 per million in 2002 (P < 0.0005). Among 137 incident cases with a total follow‐up of 801 person‐years from diagnosis (median 5.8 years), 27 patients (20%) died and six (4.4%) underwent liver transplantation. The estimated 10‐year probabilities of survival, liver transplantation, and transplant‐free survival were 73% (95% confidence interval [CI] 60%–83%), 6% (95% CI 2.5%–12.6%), and 68% (95% CI 55%–78%), respectively. Survival in PBC patients was significantly lower than that of the age/sex‐matched Canadian population (standardized mortality ratio 2.87; 95% CI 1.89–4.17); male sex (hazard ratio [HR] 3.80; 95% CI 1.85–7.82) and an older age at diagnosis (HR per additional year, 1.06; 95% CI 1.03–1.10) were independent predictors of mortality. Conclusion: This population‐based study demonstrates that the burden of PBC in Canada is high and growing. Survival of PBC patients is significantly lower than that of the general population, emphasizing the importance of developing new therapies for this condition. (HEPATOLOGY 2009.)

Development and evaluation of a quality score for abstracts

&NA; In this review article we provide a broad overview of complementary and alternative medicine (CAM) use in inflammatory bowel diseases (IBDs), including prevalence of use, common therapies used, and reasons for and factors associated with CAM use. CAM is commonly used by those suffering from IBD. Multiple forms of CAM are used to treat IBD, and often patients use multiple CAM therapies and continue to use conventional medical therapies. Patients using CAM report benefits that extend beyond simply improved disease control. Using CAM allows patients to exert a greater degree of control over their disease and its management than they are afforded by conventional medicine. There is limited evidence on the efficacy of CAM therapies in IBD. It is important for physicians caring for those with IBD to be familiar with common forms of CAM and to be able to provide general counseling to their patients about CAM use. Inflamm Bowel Dis 2011

Cost-effectiveness of computerized tomographic colonography versus colonoscopy for colorectal cancer screening

BackgroundThe evaluation of abstracts for scientific meetings has been shown to suffer from poor inter observer reliability. A measure was developed to assess the formal quality of abstract submissions in a standardized way.MethodsItem selection was based on scoring systems for full reports, taking into account published guidelines for structured abstracts. Interrater agreement was examined using a random sample of submissions to the American Gastroenterological Association, stratified for research type (n = 100, 1992–1995). For construct validity, the association of formal quality with acceptance for presentation was examined. A questionnaire to expert reviewers evaluated sensibility items, such as ease of use and comprehensiveness.ResultsThe index comprised 19 items. The summary quality scores showed good interrater agreement (intra class coefficient 0.60 – 0.81). Good abstract quality was associated with abstract acceptance for presentation at the meeting. The instrument was found to be acceptable by expert reviewers.ConclusionA quality index was developed for the evaluation of scientific meeting abstracts which was shown to be reliable, valid and useful.

Intestinal permeability is increased in a proportion of spouses of patients with Crohn’s disease

Background: Computerized tomographic (CT) colonography is a potential alternative to colonoscopy for colorectal cancer screening. Its main advantage, a better safety profile, may be offset by its limitations: lower sensitivity, need for colonoscopy in cases where results are positive, and expense. Methods: We performed an economic evaluation, using decision analysis, to compare CT colonography with colonoscopy for colorectal cancer screening in patients over 50 years of age. Three-year outcomes included number of colonoscopies, perforations and adenomas removed; deaths from perforation and from colorectal cancer from missed adenomas; and direct health care costs. The expected prevalence of adenomas, test performance characteristics of CT colonography and colonoscopy, and probability of colonoscopy complications and cancer from missed adenomas were derived from the literature. Costs were determined in detail locally. Results: Using the base-case assumptions, a strategy of CT colonography for colorectal cancer screening would cost