V. Cifalà

Post-Anaesthetic Discharge Scoring System to assess patient recovery and discharge after colonoscopy

AIM To investigate whether discharge scoring criteria are as safe as clinical criteria for discharge decision and allow for earlier discharge. METHODS About 220 consecutive outpatients undergoing colonoscopy under sedation with Meperidine plus Midazolam were enrolled and assigned to 2 groups: in Control-group (110 subjects) discharge decision was based on the clinical assessment; in PADSS-group (110 subjects) discharge decision was based on the modified Post-Anaesthetic Discharge Scoring System (PADSS). Measurements of the PADDS score were taken every 20 min after colonoscopy, and patients were discharged after two consecutive PADSS scores ≥ 9. The investigator called each patient 24-48 h after discharge to administer a standardized questionnaire, to detect any delayed complications. Patients in which cecal intubation was not performed and those who were not found at follow-up phone call were excluded from the study. RESULTS Thirteen patients (7 in Control-group and 6 in PADSS-group) were excluded from the study. Recovery from sedation was faster in PADSS-group than in Control-group (58.75 ± 18.67 min vs 95.14 ± 10.85 min, respectively; P < 0.001). Recovery time resulted shorter than 60 min in 39 patients of PADSS-group (37.5%), and in no patient of Control-group (P < 0.001). At follow-up phone call, no patient declared any hospital re-admission because of problems related to colonoscopy and/or sedation. Mild delayed post-discharge symptoms occurred in 57 patients in Control-group (55.3%) and in 32 in PADSS-group (30.7%). The most common symptoms were drowsiness, weakness, abdominal distension, and headache. Only 3 subjects needed to take some drugs because of post-discharge symptoms. CONCLUSION The Post-Anaesthetic Discharge Scoring System is as safe as the clinical assessment and allows for an earlier patient discharge after colonoscopy performed under sedation.

A comparison of different strategies used to invite subjects with a positive faecal occult blood test to a colonoscopy assessment. A randomised controlled trial in population-based screening programmes.

OBJECTIVE The purpose of this parallel randomised controlled trial was to compare compliance with different modalities used to invite patients with a positive immunochemical faecal occult blood test (FIT+) for a total colonoscopy (TC). METHOD FIT+ patients from nine Italian colorectal cancer screening programmes were randomised to be invited for a TC initially by mail or by phone and, for non-compliers, to be recalled by mail, for counselling with a general practitioner, or to meet with a specialist screening practitioner (nurse or healthcare assistant). RESULTS In all, 3777 patients were randomised to different invitation strategies. Compliance with an initial invitation by mail and by phone was similar (86.0% vs. 84.0%, relative risk - RR: 1.02; 95%CI 0.97-1.08). Among non-responders to the initial invitation, compliance with a recall by appointment with a specialist practitioner was 50.4%, significantly higher than with a mail recall (38.1%; RR:1.33; 95%CI 1.01-1.76) or with a face-to-face counselling with the GP (30.8%; RR:1.45;95%CI 1.14-1.87). CONCLUSION Compliance with an initial invitation for a TC by mail and by phone was similar. A personal meeting with a specialist screening practitioner was associated with the highest compliance among non-compliers with initial invitations, while the involvement of GPs in this particular activity seemed less effective.

Portal hypertensive enteropathy diagnosed by capsule endoscopy and demonstration of the ileal changes after transjugular intrahepatic portosystemic shunt placement: a case report

IntroductionRecent data suggest that mucosal abnormalities can occur even in the duodenum, jejunum, and distal ileum of cirrhosis patients. We present a case of portal hypertensive enteropathy in a cirrhosis patient shown by capsule endoscopy and the effect of transjugular intrahepatic portosystemic shunt on the ileal pictures.Case presentationAn 83-year-old Caucasian woman was admitted to our hospital for anemia and a positive fecal occult blood test. An upper gastrointestinal endoscopy revealed small varices without bleeding signs and hypertensive gastropathy. Colonoscopy was negative. To rule out any other cause of bleeding, capsule endoscopy was performed; capsule endoscopy revealed severe hyperemia of the jejunum-ileal mucosa with active bleeding. Because of the persistence of anemia and the frequent blood transfusions, not responding to β-blocker drugs or octreotide infusion, a transjugular intrahepatic portosystemic shunt was performed. Anemia improved quickly after the transjugular intrahepatic portosystemic shunt, and no further blood transfusion was necessary in the follow-up. The patient developed portal encephalopathy two months later and was readmitted to our department. We repeated the capsule endoscopy that showed a significant improvement of the gastric and ileal mucosa without any signs of bleeding.ConclusionHypertensive enteropathy is a rare condition, but it seems more common with the introduction of capsule endoscopy in clinical practice. This case shows that the jejunum can be a source of bleeding in cirrhosis patients, and this is the first demonstration of its resolution after transjugular intrahepatic portosystemic shunt placement.

Therapy modifies HLA‐G secretion differently in Crohn's disease and ulcerative colitis patients

To the Editor: In our previous report, we documented a different expression of soluble HLA (human leukocyte antigen)-G molecules between ulcerative colitis (UC) and Crohn’s disease (CD) patients, confirming the presence of different biological characteristics. We observed a spontaneous secretion in peripheral blood mononuclear cell (PBMC) cultures of CD patients but not in those of UC patients. Moreover, a lack of sHLA-G antigens has been reported in UC patient cultures after lipopolysaccharide (LPS) activation. HLA-G molecules are nonclassical HLA Ib antigens characterized by a lower allelic polymorphism and a restricted tissue distribution in comparison with other HLA-Ia molecules. Furthermore, the mRNA alternative splicing generates different membranebound (HLA-G1, G2, G3, and G4) and soluble isoforms (HLA-G5, G6, and G7). HLA-G molecules, in both membrane-bound (mHLA-G) and soluble (sHLA-G) isoforms, are mediators of immunosuppressive functions against innate and adaptive immune responses inducing apoptosis in CD8þ T cells, inhibiting natural killer cell activity, and allo-specific CD4þ T-cell proliferation, enhancing the production of regulatory CD4þ T cells and suppressing the differentiation of dendritic cells. Detectable levels of sHLA-G molecules have been reported in a percentage of plasma samples from healthy subjects and significant variations in the concentrations have been evidenced in different pathological conditions. In our previous study we analyzed the production of sHLA-G molecules in 20 UC (9 females, 8 males; median age 54 years) and 17 CD (11 females, 9 males; median age 51 years) patients without immunosuppressant therapy. Since different molecules are able to induce HLA-G production as cytokines (interleukin10), hormones (progesterone), and immunosuppressant drugs (methotrexate), we evaluated 27 UC (17 females, 10 males; median age 50 years) and 22 CD (12 females, 10 males; median age 55 years) patients attending the Gastroenterology and Digestive Endoscopy Unit of the Ferrara Sant’Anna Hospital for their production of sHLA-G molecules during treatment with multiple drugs (azathioprine, corticosteroids, mesalazine). We analyzed sHLA-G levels in ‘‘in vitro’’ cultures of PBMCs with or without LPS-activation and compared them with the values obtained in the previous untreated cohort. PBMCs were extracted by Ficoll centrifugation (Cederlane, Hornby, Ontario, Canada) from whole peripheral blood and activated by 10 ng/mL of LPS (Calbiochem, La Jolla, CA) for 48 hours. The culture supernatants and the plasma samples were analyzed in triplicate by enzymelinked immunosorbent assay (ELISA) for sHLA-G quantification following the Essen Workshop protocol. Informed consent for blood drawing was obtained from each subject. We compared the sHLA-G levels in PBMC cultures with or without LPS activation from untreated and treated patients. The levels of HLA-G secretion remained higher in nonactivated PBMC cultures from CD patients versus UC patients, even in the treated cohort (Fig. 1A,B) (P 1⁄4 0.011, Wilcoxon test). UC treated patients presented an increased HLA-G secretion in both nonactivated (P 1⁄4 0.057 Mann–Whitney U-test) and LPS-activated PBMC cultures (P 1⁄4 0.004 Mann–Whitney U-test) in comparison with the previous cohort of untreated UC patients (Fig. 1A,B). On the contrary, LPS-activated PBMC cultures from treated CD and UC patients released similar amounts of HLA-G (P 1⁄4 0.075; Wilcoxon test). These data suggest that therapy is able to control the hyperactivation of CD PBMCs and the unbalanced microenvironment of UC patients in the presence of an inflammatory stimulus such as LPS. Age, gender, activity, localization, or duration of the disease and previous surgery did not influence the sHLA-G levels (P 1⁄4 NS; Wilcoxon test). We also analyzed sHLA-G levels in plasma samples from treated CD and UC patients and compared the results with the HLA-G secretion by the corresponding nonactivated PBMC cultures. There was a strict correlation between in vitro and plasmatic levels of sHLAG in both CD (r 1⁄4 0.693; P 1⁄4 0.003; Spearman Correlation test) (Fig. 1C) and UC (r 1⁄4 0.911; P 1⁄4 0.0002; Spearman Correlation test) (Fig. 1D) patients, suggesting the possible use of plasma samples to screen the follow-up of immunosuppressant therapy. Our results suggest that the therapy is able to normalize the production of HLA-G molecules in both CD and UC patients but in a different way: immunosuppressant therapy decreases the hyperproduction of HLA-G in CD patients, while it starts the release of HLA-G in UC patients. These data confirm the diversity in the behavior of these two pathologies and propose the analysis of sHLA-G levels in CD and UC patients during therapeutic follow-up with the goal of distinguishing between UC and CD patients and to monitor therapy. If these results are confirmed in a prospective study, HLA-G could be considered a plasmatic biomarker to establish an individualized treatment to control inflammation, to reduce symptoms, Supported by a grant from AMICI (Associazione per le Malattie Infiammatorie Croniche dell’Intestino). Copyright VC 2011 Crohn’s & Colitis Foundation of America, Inc. DOI 10.1002/ibd.21756 Published online 20May 2011 inWiley Online Library (wileyonlinelibrary.com).

The first 2 years of colorectal cancer screening in Ferrara, Italy

We report on the first screening round in the District of Ferrara, a region of Emilia-Romagna, carried out between March 2005 and March 2007 to illustrate the effort of colorectal cancer (CRC) screening from administration and information to therapy and follow-up. After invitation of 38 344 persons aged 50–69 years (28.5%), 19 480 (50.8%) accepted the immunological faecal occult blood test, with 1 149 (6%) resulting positive. One thousand and one individuals (88.2%) who tested positive for immunological faecal occult blood test accepted examination by either colonoscopy (99.5%) or barium enema (0.5%). Out of 996 screenees having a colonoscopy, 231 had low-risk adenomas (23.2%) and 239 had high-risk adenomas (24%), and were treated endoscopically (96%) or surgically (4%). Ninety-one cancers were diagnosed in 9.1% of colonoscopies (Dukes stadia: A, 58.2%; B, 19.8%; C, 18.7%; D, 3.3%). Fourteen cancers (all in polyps) were treated endoscopically, and the remaining 77 were treated by surgery. One Dukes B patient and 13 of 17 Dukes C patients received adjuvant chemotherapy. Three Dukes D patients had chemotherapy only. During the 2-year study period, 87 screenees had a follow-up colonoscopy: no neoplasia was found in 35 patients initially diagnosed with cancer; low-risk adenomas were found in 31 of 52 patients with initial high-risk adenomas. In conclusion, the first CRC screening round in Ferrara was easy to organize, had a high acceptance, and detected 91 cancers (78% of which were in Dukes stages A and B, compared with only 40% in sporadic CRC in the same background population). Chemotherapy was necessary in 17 cases. This report may motivate other health authorities to initiate CRC screening campaigns.

Occult intestinal haemorrhage due to lipoma of the small bowel detected with the combined use of the new endoscopic techniques. A report of two cases

We report two unusual cases of occult intestinal bleeding due to lipoma of the small bowel. Both the patients underwent several inconclusive endoscopic and radiological procedures before the diagnosis of these lesions that was possible using video capsule endoscopy and double balloon enteroscopy. In the first case, the finding of capsule endoscopy was confirmed using enteroscopy, allowing us to diagnose the ileal mass. In the second and more recent case, we used double balloon enteroscopy for the further characterisation and management of the ileal lipoma. Lipoma is a very rare cause of intestinal bleeding and we describe the management and the outcome of our patients.

Unexpected finding after gastroduodenal artery embolization

An 87-year-old woman with melena and anemia was admitted to the hospital and underwent urgent GI endoscopy. During the procedure, a large clot adhering to the posterior wall of the duodenal bulb was identified. Its removal with a retrieval net revealed an underlying visible vessel with active oozing (A). After an ineffective attempt to obtain endoscopic hemostasis with epinephrine injection, argon plasma coagulation, and clips, interventional radiology was performed. Selective arteriography of the celiac trunk revealed no extravasation, so blind embolization of the gastroduodenal arterywith 3 platinumcoils (SPIRALES.01800, coilB 3 mm, coil length 5 cm; Balt Extrusion, Montmorency, France) was carried out (B, continous arrow: coil; dashed arrow: clip). Hemostasis was achieved, and the patient’s subsequent clinical course was uneventful. Three months later, the patient returned to the hospital with epigastric pain and vomiting. Upper GI endoscopy revealed a foreign body (a metallic coil) protruding from the posterior wall of the duodenal bulb. The adjacent mucosa