Roger Keith Fincher

A comparison of Bowel preparations for flexible sigmoidoscopy : Oral magnesium citrate combined with oral bisacodyl, one hypertonic phosphate enema, or two hypertonic phosphate enemas

A comparison of bowel preparations for flexible sigmoidoscopy: oral magnesium citrate combined with oral bisacodyl, one hypertonic phosphate enema, or two hypertonic phosphate enemasFig. 1

Resident participation in flexible sigmoidoscopy does not affect patient satisfaction.

OBJECTIVE:We sought to assess the effect of resident involvement in flexible sigmoidoscopy on patient satisfaction and comfort.METHODS:Adults undergoing flexible sigmoidoscopy completed a previsit questionnaire on indication for procedure, GI-related history, and functional status. Immediately after the procedure, satisfaction and procedure comfort were assessed. Additional information collected included procedure duration, depth of sigmoidoscope penetration, and visualization of diverticuli or polyps.RESULTS:Among 408 endoscopies, patient characteristics and procedure indications were similar between sigmoidoscopies done by residents (n = 111) or staff. There were no differences in patient satisfaction, procedure comfort, or willingness to undergo the procedure again in the future. Sigmoidoscopies involving residents averaged 5.6 min longer, even after adjusting for preparation quality, depth of insertion, specific endoscopist, and the presence of polyps or diverticuli.CONCLUSIONS:Patient satisfaction and comfort with flexible sigmoidoscopy was not reduced by resident involvement, though the procedure duration was slightly longer.

Ampullary Somatostatinoma in a Patient With Merkel Cell Carcinoma

A 59-yr-old white man with Merkel cell carcinoma of his right leg status post extensive skin resection and chemotherapy had dilated hepatic and common bile ducts on a routine follow-up abdominal CT scan. A 1.9-cm ampullary mass was appreciated on endoscopy. Histology showed psammoma bodies and positive immunoperoxidase staining consistent with a somatostatinoma. Merkel cell tumors and somatostatinomas are extremely rare neuroendocrine tumors derived from neural crest cells. Associations have been found between somatostatinomas and other islet cell tumors with multiple endocrine neoplasia syndromes, but no reported association has been published between islet cell tumors and Merkel cell tumors. This patient represents the first documented case of Merkel cell carcinoma and somatostatinoma in a single patient. Such an occurrence may represent a previously undescribed neuroendocrine tumor syndrome, and this possibility should be considered when either tumor is diagnosed.

4502 Colonoscopic surveillance of patients with a family history of colon cancer and past history of normal colonoscopy: is a 5-year interval between colonoscopies appropriate?

Background: Patients with a family history of colorectal cancer (ie. diagnosis in a first degree relative) have an increased risk of developing adenomas and cancer. Experts recommend that these patients should have surveillance colonoscopy every 5 years after an initial normal colonoscopy. The aims of this trial are to: 1) determine the percentage of patients with adenomas on surveillance colonoscopy; 2) determine the percentage of patients with advanced adenomas (ie. villous features, adenoma size =10mm, presence of high grade dysplasia); and 3) assess risk factors for colonic adenomas in this population. Methods:In May 1999, consecutive patients with a family history of colorectal cancer who had a normal baseline colonoscopy 5 years earlier were offered a surveillance colonoscopy. On the day of their procedure, patients completed a questionnaire about risk factors potentially associated with adenoma formation including: age(>65 yo), male gender, African-American race, NSAID use (>2 doses/week), alcohol use (>2 ounces/day), and tobacco use (>20 pack-yrs). Multiple logistic regression was used to determine which risk factors were associated with adenomas. Results: To date, 38 patients have completed the trial. Demographic data: male:female ratio(59:41); mean age 57yo±8yrs; 98% Caucasian. Eleven percent(4/38) had advanced adenomas at surveillance colonoscopy, and 34% (13/38) had any adenomas present in the colon. Since only one African-American has entered the trial so far, race was excluded from multiple logistic regression analysis. The multiple logistic regression analysis did not identify any significant association between adenomas and risk factors. Age>65yo: OR=1.34(95%CI:0.2-9.7); male gender: OR=1.40(95%CI:0.3-6.8); alcohol use: OR=1.94(95%CI:0.1-57.5); and NSAID use:OR(95%CI:0.1-1.7). Among patients with advanced adenomas, 25%(1/4) had no adenomas in the left side of the colon (ie. distal to the splenic flexure). Among patients with any adenomas, 39% (5/13) had no adenomas in the left side of the colon. Conclusions: Expert recommendations that patients with a family history of colorectal cancer should have surveillance colonoscopy 5 years after an initial normal colonoscopy are supported by these preliminary results. Over 1/3 of adenomas would be missed if surveillance was performed with flexible sigmoidoscopy.