Prevention or cure in times of crisis: the case of screening for colorectal cancer.

Colorectal cancer is a serious health problem in which screening is capable of reducing both the mortality and the incidence of the disorder. Colonoscopy, the mainstay of this type of screening, allows to establish an early diagnosis and also to eliminate malignant precursor lesions. The screening test which is performed in Spanish programs is the determination of fecal occult blood using the immunochemical method which gives around 70% of positive values for colonoscopy for any type of neoplasia. As a result, in 2009 the National Health System set as an objective that these programs cover 50% of the population by 2015. It is well known that colon screening is highly cost effective with a ratio of around 2500€ per QALY, much lower than ratios of other programs. Only the direct costs of colon and rectal cancer in Spain can be estimated at more than one thousand million euros per year. Early diagnosis and the cancers avoided thanks to screening can reduce these costs by 40%. The impact that the introduction of this screening has on health services can be lessened if the indications for colonoscopy are followed adequately. In conclusion, there is no justification for not acting to prevent CRC and this is especially so in times of crisis as there is no better social cost invested than that which saves suffering, deathsand even money.

Colon capsule endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.

PillCam colon capsule endoscopy (CCE) is an innovative noninvasive, and painless ingestible capsule technique that allows exploration of the colon without the need for sedation and gas insufflation. Although it is already available in European and other countries, the clinical indications for CCE as well as the reporting and work-up of detected findings have not yet been standardized. The aim of this evidence-based and consensus-based guideline, commissioned by the European Society of Gastrointestinal Endoscopy (ESGE) is to furnish healthcare providers with a comprehensive framework for potential implementation of this technique in a clinical setting.

Short- and long-term changes in gastric morphology and histopathology following sleeve gastrectomy in diet-induced obese rats.

BACKGROUND: Sleeve gastrectomy (SG) has been used as a multipurpose surgical procedure for the treatment of morbid obesity. The aim of the study was to analyze gastric morphology and histology at two different time points after SG in rats. METHODS: Thirty-five male Wistar rats were fed ad libitum during 3 months on a high-fat diet to induce obesity. Subsequently, 25 diet-induced obese rats underwent either SG (n = 12) or a sham operation (n = 13). The remaining ten obese animals encompassed the nonoperated control group (Co). Four weeks postoperatively, 15 rats (n = 5 rats/experimental group) were sacrificed, while the remaining 20 rats were sacrificed after 16 weeks (animals/group; Co = 5, sham = 8, SG = 7) to compare the gastric morphological and histopathological changes over time. Body weight and food intake were regularly recorded. RESULTS: For both time periods, the Co groups exhibited the highest body weight, while the rats undergoing the SG showed the lowest weight gain (P < 0.05). Initially, significant differences (P < 0.005) in food intake relative to body weight were observed between the Co rats and animals undergoing surgery, which disappeared thereafter. The actual total stomach size after both experimental periods in the SG group was similar to that of non- and sham-operated rats mainly due to a forestomach enlargement, which was more pronounced after 16 weeks. Traits of gastritis cystica profunda characterized by gastric foveolae elongation with hyperplasia and cystic dilatation of the glands were observed in the residual stomachs of the sleeve-gastrectomized rats. These findings were mostly observed after 16 weeks of performing the SG, although they were also detected occasionally following 4 weeks postoperatively. No intestinal metaplasia was observed. CONCLUSION: After SG gastric macro- and microscopic changes with functional implications in both the short and long term take place.

Recognition and management of hereditary colorectal cancer syndromes.

Over 1,900 colorectal tumors will arise in association with a hereditary colorectal cancer syndrome in Spain in 2009. The genetic defects responsible for the most common syndromes have been discovered in recent years. Genetic testing helps diagnose affected individuals and allows identification of individuals at-risk. Colonoscopy and prophylactic colectomy decrease colorectal cancer incidence and overall mortality in patients with hereditary colon cancer. Extracolonic tumors are frequent in these syndromes, so specific surveillance strategies should be offered.

[Study of colorectal metachronous neoplastic lesions]. / Estudio de las lesiones neoplásicas metacrónicas en el carcinoma colorrectal.

BACKGROUND: To analyse the frequency and characteristics of metachronous neoplastic lesions, carcinomas and adenomas, following resection of colorectal cancer. PATIENTS AND METHODS: We reviewed 382 patients subjected to RCC operations and followed up through complete colonoscopies in two hospitals in our province. We analysed the metachronous lesions registered, evaluating their localisation, time of diagnosis, histology, number and size. We studied the frequency of early adenomas (12 months), comparing their size with the rest of the lesions. RESULTS: The average follow-up was 48 months (12-112), with 2.74+/-1.47 colonoscopies/case. We diagnosed 7 metachronous cancers (1.8%), 4 of them in stage I. The average time until their diagnosis was 24 months (13-54). We registered metachronous adenomas in 162 cases (42.4%), without differences between the two hospitals: 42.1% vs. 43.8% (p=0.88). Six point three percent of the patients presented advanced adenomas. In 164 cases where the control was carried out after 12 months, the incidence of adenomas was 24%. In the majority of cases, the adenomas were sole (60.8%) and smaller than 5 mm (68.5%). In 55.5% of the cases with polyps, some had a proximal localisation. Diagnosis was made on the 1st exploration (56.2%), the 2nd (27.8%) or the 3rd (9%). Average time until diagnosis was 21 months (12-112) for simple adenoma and 35 (12-112) for advanced adenoma. CONCLUSIONS: Our follow up made it possible to apply a theoretically curative treatment in the majority of the metachronous carcinomas diagnosed. The high incidence of adenomas and the frequent proximal localisation make a follow up with complete colonoscopies necessary, which must be started one year after the operation and can become less strict following three consecutive explorations without polyps.

[Capsule endoscopy interpretation: the role of physician extenders]. / Interpretación de la cápsula endoscópica: el papel del personal no especializado.

BACKGROUND AND AIMS: capsule endoscopy (CE) allows for a new era in small-bowel examination. Nevertheless, physicians time for CE-interpretation remains longer than desirable. Alternative strategies to physicians have not been widely investigated. The aim of this study was to evaluate the accuracy of physician extenders in CE-interpretation. MATERIAL AND METHODS: one CE-experienced gastroenterologist and two physician extenders reviewed independently 20 CE-procedures. Each reader was blinded to the findings of their colleagues. A consensus formed by the readers and a second CE-experienced gastroenterologist was used as gold standard. Number, type and location of images selected, character of CE-exams and their relationship with indications were recorded. Gastric emptying time (GEt), small-bowel transit time (SBTt) and time spent by readers were also noted. RESULTS: sensitivity and specificity for "overall" lesions was 79 and 99% for the gastroenterologist; 86 and 43% for the nurse; and 80 and 57% for the resident. All 34 "major" lesions considered by consensus were found by the readers. Agreement between consensus and readers for images classification and procedures interpretation was good to excellent (? from 0.55 to 1). No significant differences were found in the GEt and SBTt obtained by consensus and readers. The gastroenterologist was faster than physician extenders (mean time spent was 51.9 +/- 13.5 minutes versus 62.2 +/- 19 and 60.9 +/- 17.1 for nurse and resident, respectively; p < 0.05). CONCLUSIONS: physician extenders could be the perfect complement to gastroenterologists for CE-interpretation but gastroenterologists should supervise their findings. Future cost-efficacy analyses are required to assess the benefits of this alternative.

[Synchronous neoplastic lesions in colorectal cancer. An analysis of possible risk factors favouring presentation]. / Lesiones neoplásicas sincrónicas en el cáncer colorectal. Análisis de posibles factores que favorezcan su presentación.

AIM: few data have been published regarding the causes of synchronous lesions in patients with colorectal cancer. The aim of our study was to identify potential factors that might be implicated in the development of multicentric lesions, since this knowledge could be useful for tailored follow-up once initial synchronous lesions have been removed. METHODS: we retrospectively reviewed 382 colorectal cancer cases diagnosed by total colonoscopy and histological study of surgical specimens. We divided our population into 2 groups, based on whether they had synchronous lesions or otherwise. Several data related to personal and family history, habits, symptoms, and tumor characteristics were assessed. Univariate and multivariate statistical analyses were performed. RESULTS: 208 (54.5%) patients had synchronous adenomas and 28 (7.3%) had synchronous cancer. A multivariate analysis showed that the following parameters were consistently related to the presence of multicentric lesions--male gender: OR = 1.97; CI = 1.13-3.45; p = 0.017; age = 59 years: OR = 2.57; CI = 1.54-4.29; p < 0.001; personal history of colonic adenomas: OR = 3.04; CI = 1.04-8.85; p = 0.042; and obstructive tumors: OR = 0.48; CI = 0.27-0.85; p = 0.012. CONCLUSION: our results show that several parameters that are easy to measure could be considered risk factors for the development of multicentric lesions. These factors need to be confirmed with follow-up studies analyzing their role in patients with and without metachronic lesions once all synchronous lesions have been removed.

[Analysis of possible influence of synchronous neoplastic lesions on prognosis of resected colorectal cancer]. / Análisis de la posible influencia de las lesiones sincrónicas en el pronóstico del cáncer colorrectal resecado.

AIM: To analyze the relationship between synchronous lesions in patients with colorectal cancer and their prognostic value. PATIENTS AND METHODS: We have retrospectively reviewed 369 patients with resected colorectal cancer. We compared the rate of apparently curative surgery, progression and tumoral relapse, development of extracolonic cancer and mortality between patients with and without synchronous cancer. Afterwards, we analyzed the same parameters in colorectal cancer with and without synchronous adenomas. Finally, we repeated the analysis after stratification of cancers in 2 groups according to pTNM staging: 0-I-II stage vs III-IV. RESULTS: We found synchronous adenomas in 54.7% of our patients and synchronous cancers in 7.6%. Follow-up period of groups with and without synchronous lesions were: 70.8 +/- 22.9 and 67.2 +/- 24.5 months (p = 0.55) respectively. Synchronous cancers showed higher mortality: 35.7 vs. 14.4%: p = 0.006; OR = 3.31 (1.33-8.13), higher tumoral progression : 39.3 vs. 19.1%: p = 0.011; OR = 2.75 (1.14-6.56) and higher relapse rate: 10.7 vs. 3.5%: p = 0.096. Stratifying according to stage, patients with stage 0-I-II and synchronous cancer showed worse prognosis: mortality = 27.7 vs. 8.1%, p = 0.019; OR = 4.45 (1.2-15.1), tumoral progression = 27.8 vs. 8.5%, p = 0.02; OR = 4.12 (1.14-14.19), and extracolonic cancer = 16.7 vs. 6.4% p = 0.095. There were no statistical differences between cases with and without synchronous adenomas. CONCLUSIONS: Synchronous cancers showed worse prognosis after resection, with higher rate of tumoral progression and mortality. This difference is focused on the cases diagnosed in stage 0-I-II, not being found in III-IV. The presence of synchronous adenomas doesn't influence prognosis.

[New applications of capsule endoscopy: PILLCAMTM ESO]. / Nuevas aplicaciones de la cápsula endoscópica: PILLCAM ESO.

Capsule endoscopy has opened a new era in small bowel examination. Its indications are now well-defined and currently, wireless capsule endoscopy is considered as the first-line imaging tool for the diagnosis of small bowel diseases. ECE has been shown to be feasible, safe and a good alternative technique in patients refusing conventional endoscopy. Although results reported in both GERD and cirrhotic patients are encouraging, great differences in terms of accuracy (particularly in GERD patients) have been found in published studies. These differences have been attributed to study designs, the lack of adequate experience and inconvenience of ingestion protocols. In summary, more large-scale studies evaluating the new 14-fps capsule, adequate ECE-experience and new modified ingestion protocols are still needed.

Use of sedation for routine diagnostic upper gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy Survey of National Endoscopy Society Members.

BACKGROUND/AIMS: Sedation rates may vary among countries, depending on patients' and endoscopists' preferences. The aim of this survey was to investigate the rate of using premedication for routine diagnostic upper gastrointestinal (UGI) endoscopy in endoscopy societies, members of the European Society of Gastrointestinal Endoscopy (ESGE). METHODS: We evaluated a multiple-choice questionnaire which was e-mailed to representatives of national endoscopy societies, which are members of the ESGE. The questionnaire had 14 items referring to endoscopy practices in each country and the representatives' endoscopy units. RESULTS: The response rate was 76% (34/45). In 47% of the countries, less than 25% of patients undergo routine diagnostic UGI endoscopy with conscious sedation. In 62% of the responders' endoscopy units, patients are not asked their preference for sedation and do not sign a consent form (59%). Common sedatives in use are midazolam (82%), diazepam (38%) or propofol (47%). Monitoring equipment is not available 'in most of the endoscopy units' in 46% (13/28) of the countries. Though they were available in 91% of the national representatives' endoscopy units, they are rarely (21%) used to monitor unsedated routine diagnostic UGI endoscopy. CONCLUSIONS: In about 50% of ESGE-related countries, less than 25% of patients are sedated for routine diagnostic UGI endoscopy. Major issues to improve include availability of monitoring equipment and the use of a consent form.

[Utility of endoscopy in digestive hemorrhage due to vasculitis]. / Utilidad de la endoscopia en la hemorragia digestiva por vasculitis.

Vasculitides constitute a heterogeneous group of diseases characterized by inflammation of blood vessels. The skin is mainly affected, although the gastrointestinal tract mucosa can also be involved. The contribution of endoscopy in these cases has not been clearly determined. We report three cases of systemic vasculitis (polyarteritis nodosa, Schonlein-Henoch purpura and Behcet's disease) presenting with acute digestive bleeding. Endoscopy was an effective technique for completing the diagnosis and in establishing an effective nonsurgical therapeutic approach in these potentially lethal cases of gastrointestinal hemorrhage.

Distribution of the long leptin receptor isoform in brush border, basolateral membrane, and cytoplasm of enterocytes.

BACKGROUND AND AIM: Leptin, a hormone mainly produced by fat cells, acts primarily on the hypothalamus regulating energy expenditure and food intake. Leptin receptors are expressed in several tissues and the possible physiological role of leptin is being extensively investigated, with the result that important peripheral actions of the hormone in the organism are being discovered. Recent studies have demonstrated leptin and leptin receptor expression in gastric epithelial cells. In the present study, we report the presence of the long leptin receptor isoform (OB-Rb) in human, rat, and mouse small intestine, supporting the hypothesis of leptin as a hormone involved in gastrointestinal function. METHODS: The presence of the leptin receptor was determined by immunocytochemical methods using antibodies against the peptide corresponding to the carboxy terminus of the long isoform of the leptin receptor. Human duodenal biopsies from normal individuals undergoing gastrointestinal endoscopy, and intestinal fragments of Wistar rats and Swiss mice were processed for the study. RESULTS: Immunoreactivity for the long leptin receptor isoform was observed in the three studied species. Staining was located throughout the cytoplasm of the enterocytes, of both villi and crypts, and in the basolateral plasma membrane. Immunolabelling for OB-Rb protein was also found in the brush border of human enterocytes of formol and paraformaldehyde fixed samples. CONCLUSION: This report demonstrates the presence of the long leptin receptor isoform in the absorptive cells of rat, mouse, and human small intestine, suggesting that leptin could have a physiological role in the regulation of nutrient absorption.

Collagenous colitis and lymphocytic colitis: clinical and endoscopic findings.

OBJECTIVE: collagenous colitis (CC) and lymphocytic colitis (LC) are two entities of unknown cause, characterized by chronic watery diarrhea, grossly normal-appearing colonic mucosa and abnormal histopathological findings in colonic biopsies. The clinical features of the disease are based mainly on case reports or small uncontrolled series. Although normal colonoscopic findings are, as a rule, part of the diagnosis of CC, several cases of macroscopic colitis associated with CC have been reported, and the spectrum of endoscopic mucosal changes has not been described in large series. METHODS: we present a retrospective study of all patients who underwent total colonoscopy and mucosal biopsy in our Endoscopy Unit between 1991 and 1997. Clinical and endoscopic findings in patients diagnosed as having CC or LC were recorded. RESULTS: of 676 patients studied, 398 suffered from chronic diarrhea. Collagenous colitis was diagnosed in 22 patients and LC in 10. Eleven per cent of the patients with CC and 20% of those with LC did not have diarrhea. Macroscopic colitis was observed in 6 out of 22 patients with CC (27%) and in 4 out of 10 with LC (40%). Macroscopic lesions included edema, erythema, abnormal vascular pattern, superficial erosions or ulcerations and hemorrhagic lacerations. In this series 7.03% of the patients with chronic diarrhea were diagnosed as having CC or LC. CONCLUSIONS: collagenous colitis and LC are two entities that should be considered in the differential diagnosis of chronic diarrhea. Total colonoscopy with multiple biopsies that include the right colon are mandatory. The presence of macroscopic lesions on endoscopy does not rule out a diagnosis of either entity. We identified patients who fulfilled the histopathological criteria for CC or LC but who did not have diarrhea.

[Colonic involvement in the Klippel-Trenaunay-Weber syndrome]. / Afectación de colon en el síndrome de Klippel Trenaunay Weber.

We report the case of a 12-year-old boy, diagnosed of Klippel Trenaunay Weber syndrome, with hemangiomas and venous varicosities in the right leg, who complaint about incidental hematochezia. In the colonoscopy some violet and plain angiodysplastic lesions like in the skin, were observed in rectum and distal sigmoid colon. We think this case is interesting, because of the unusual affectation of the gut in this disease and the importance of considering the endoscopic procedures in the evaluation of these patients.