Efficacy of different surgical treatments for management of anal fistula: a network meta-analysis.

PURPOSE: Currently, the anal fistula treatment which optimises healing and preserves bowel continence remains unclear. The aim of our study was to compare the relative efficacy of different surgical treatments for AF through a network meta-analysis. METHODS: Systematic searches of MEDLINE, EMBASE and CENTRAL databases up to October 2022 identified randomised controlled trials (RCTs) comparing surgical treatments for anal fistulae. Fistulae were classified as simple (inter-sphincteric or low trans-sphincteric fistulae crossing less than 30% of the external anal sphincter (EAS)) and complex (high trans-sphincteric fistulae involving more than 30% of the EAS). Treatments evaluated in only one trial were excluded from the primary analyses to minimise bias. The primary outcomes were rates of success in achieving AF healing and bowel incontinence. RESULTS: Fifty-two RCTs were included. Of the 14 treatments considered, there were no significant differences regarding short-term (6 months or less postoperatively) and long-term (more than 6 months postoperatively) success rates between any of the treatments in patients with both simple and complex anal fistula. Ligation of the inter-sphincteric fistula tract (LIFT) ranked best for minimising bowel incontinence in simple (99.1% of comparisons; 3 trials, n = 70 patients) and complex anal fistula (86.2% of comparisons; 3 trials, n = 102 patients). CONCLUSIONS: There is insufficient evidence in existing RCTs to recommend one treatment over another regarding their short and long-term efficacy in successfully facilitating healing of both simple and complex anal fistulae. However, LIFT appears to be associated with the least impairment of bowel continence, irrespective of AF classification.

Risk stratification of symptomatic patients suspected of colorectal cancer using faecal and urinary markers.

AIM: Faecal markers, such as the faecal immunochemical test for haemoglobin (FIT) and faecal calprotectin (FCP), have been increasingly used to exclude colorectal cancer (CRC) and colonic inflammation. However, in those with lower gastrointestinal symptoms there are considerable numbers who have cancer but have a negative FIT test (i.e. false negative), which has impeded its use in clinical practice. We undertook a study of diagnostic accuracy CRC using FIT, FCP and urinary volatile organic compounds (VOCs) in patients with lower gastrointestinal symptoms. METHOD: One thousand and sixteen symptomatic patients with suspected CRC referred by family physicians were recruited prospectively in accordance with national referring protocol. A total of 562 patients who completed colonic investigations, in addition to providing stool for FIT and FCP as well as urine samples for urinary VOC measurements, were included in the final outcome measures. RESULTS: The sensitivity and specificity for CRC using FIT was 0.80 [95% confidence interval (CI) 0.66-0.93] and 0.93 (CI 0.91-0.95), respectively. For urinary VOCs, the sensitivity and specificity for CRC was 0.63 (CI 0.46-0.79) and 0.63 (CI 0.59-0.67), respectively. However, for those who were FIT-negative CRC (i.e. false negatives), the addition of urinary VOCs resulted in a sensitivity of 0.97 (CI 0.90-1.0) and specificity of 0.72 (CI 0.68-0.76). CONCLUSIONS: When applied to the FIT-negative group, urinary VOCs improve CRC detection (sensitivity rises from 0.80 to 0.97), thus showing promise as a second-stage test to complement FIT in the detection of CRC.

Diagnostic accuracy of faecal biomarkers in detecting colorectal cancer and adenoma in symptomatic patients.

BACKGROUND: The diagnosis of colorectal cancer (CRC) can be difficult as symptoms are variable with poor specificity. Thus, there is a quest for simple, non-invasive testing that can help streamline those with significant colonic pathology. AIM: To assess using faecal immunochemical test for haemoglobin (FIT) or faecal calprotectin (FCP) to detect CRC and adenoma in symptomatic patients referred from primary care. METHODS: A total of 799 referred for urgent lower gastrointestinal investigations were prospectively recruited. Of these, 430 completed colonic investigations and returned stool samples, and were included in the final statistical analysis. Faecal immunochemical test for haemoglobin was performed on HM-JACKarc analyser (Kyowa Medex, Tokyo, Japan), and FCP by the EliA Calprotectin immunoassay (Thermo Fisher Scientific, Waltham, United States). RESULTS: The negative predictive value (NPV) using FIT alone or both markers (FIT and FCP) in combination was similar at 99% for CRC, with a sensitivity and specificity of 84% and 93%, respectively. FIT measurements were significantly higher in left-sided colonic lesions compared with the right side; 713 vs. 94; P = 0.0203). For adenoma, the NPV using FIT alone, or both markers (FIT and FCP) in combination, was similar at 94% with a sensitivity and specificity of 69% and 56%, respectively. CONCLUSIONS: Undetectable faecal immunochemical test for haemoglobin is sufficiently sensitive to exclude colorectal cancer, with higher values in left-sided lesions. FCP in combination does not appear to provide additional diagnostic information. Further studies to determine the health economic benefits of implementing faecal immunochemical test for haemoglobin in primary care are required.

Contemporary characteristics of blunt abdominal trauma in a regional series from the UK.

INTRODUCTION Blunt abdominal trauma (BAT) is a common injury in recent trauma series. The characteristics of patients with BAT have changed following the reconfiguration of UK trauma services. The aim of this study was to build a new profile for BAT patients undergoing immediate or delayed laparotomy. METHODS All 5,401 consecutive adults presenting with major trauma between April 2012 and April 2014 in the 3 major trauma centres in the West Midlands were analysed to identify all patients with BAT. A total of 2,793 patients with a mechanism of injury or symptomatology consistent with BAT were identified (52%). Outcomes were analysed using local electronic clinical results systems and notes. RESULTS Of the 2,793 patients, 179 (6.4%) had a mesenteric or hollow viscus injury, 168 (6.0%) had a hepatobiliary injury, 149 (5.4%) had a splenic injury and 46 (1.6%) had a vascular injury. Overall, 103 patients (3.7%) underwent an early (<12 hours) laparotomy while 30 (1.1%) underwent a delayed (>12 hours) laparotomy. Twenty (66.7%) of those undergoing a delayed laparotomy had a hollow viscus injury. In total, 170 deaths occurred among the BAT patients (6.1%). In the early laparotomy group, 53 patients died (51.5%) whereas in the delayed laparotomy group, 6 patients died (20.0%). CONCLUSIONS This series has attempted to provide the characteristics of patients with BAT in a large contemporary UK cohort. BAT was found to be a common type of injury. Early and delayed laparotomy occurred in 3.7% and 1.1% of these patients respectively, mostly because of hollow viscus injury in both cases. Outcomes were comparable with those in the international literature from regions with mature trauma services.

Colorectal cancer screening characteristics of patients presenting with symptoms of colorectal cancer and effect on clinical outcomes.

INTRODUCTION: National colorectal cancer screening, utilising a faecal occult blood test (FOBT), is now well established in the UK. The aim of this study was to define the screening characteristics of patients presenting to secondary care with symptoms of colorectal cancer and to assess the effect of screening outcome on subsequent symptomatic presentation. METHODS: This was a retrospective analysis of all patients of screening age presenting within one calendar year in a tertiary trust via a two-week wait (2WW) pathway owing to suspicion of colorectal cancer. Colorectal cancer related outcomes were compared between patients in the cohort who had previously accepted bowel cancer screening and patients who had previously declined bowel cancer screening. The primary endpoint was overall incidence of colorectal neoplasia. Secondary endpoints included incidence of colorectal malignancy, cancer related mortality, cancer related outcomes and polyp related outcomes. RESULTS: Overall, 2,227 patients presented via the 2WW pathway; 955 were aged 60-75 years. Among the latter, 411 (43%) had been screened previously and had a negative FOBT, and 544 (57%) had declined screening. Incidence of colorectal neoplasia did not differ between the two groups (113 [27%] vs 143 [26%], p=0.7). Of those with a negative FOBT and subsequent symptomatic presentation, 16 (3.9%) were diagnosed with a colorectal malignancy compared with 36 (6.6%) of those who declined screening and had subsequent symptomatic presentation (relative risk: 1.7, 95% confidence interval: 0.96-3.02, p=0.08). There were no differences between the two groups with regard to TNM (tumour, lymph nodes, metastasis) stage, Dukes' stage, metastases, number of polyps or cancer related mortality (median follow-up duration: 20 months). CONCLUSIONS: The incidence of colorectal neoplasia was similar among patients who previously had a negative FOBT and those who declined screening. There was a higher incidence of colorectal cancer detected among those who declined screening but it did not reach statistical significance. All other cancer and polyp outcomes were similar between the groups.

Utility of faecal calprotectin in inflammatory bowel disease (IBD): what cut-offs should we apply?

BACKGROUND: Faecal calprotectin (FC), a cytosolic protein released by neutrophils (S100 family) in response to inflammation, is a simple, non-invasive test that can be used to differentiate irritable bowel syndrome (IBS) with inflammatory bowel disease (IBD), where there can be considerable symptom overlap. AIMS AND METHODS: The aims of the study were (1) to be able to predict the ability of FC to exclude IBD and determine cut-offs when in remission, (2) to investigate the effects of time and temperature on stability of FC and (3) compare three ELISA kits to measure FC: Buhlmann, PhiCal v1 and PhiCal v2. A total of 311 patients with altered bowel habit were tested for FC; 144 with IBS, 148 with IBD and 19 with other organic causes. RESULTS: Sensitivity and specificity of FC (with PhiCal v2 kit) to distinguish between functional disorder (IBS) and IBD using cut-off 50 µg/g were 88% and 78%, respectively, with a negative predictive value of 87%. Area under the receiver operating curve was 0.84 (CI 0.78 to 0.90). For those with IBD, FC values below 250 µg/g corresponded with remission of disease with a sensitivity and specificity of 90% and 76%, respectively. Area under the receiver operating curve was 0.93 (CI 0.89 to 0.97). FC was stable once extracted and frozen for up to 2.5 months. Pearson correlation was good between Buhlmann assay and PhiCal v2 (r2 = 0.95). CONCLUSIONS: FC has up to 87% negative predictive value to exclude IBD, and cut-offs less than 250 µg/g had 90% sensitivity to determine remission in IBD. Once frozen, FC is stable and the ELISA monoclonal plates were broadly comparable.

Review article: next generation diagnostic modalities in gastroenterology--gas phase volatile compound biomarker detection.

BACKGROUND: The detection of airborne gas phase biomarkers that emanate from biological samples like urine, breath and faeces may herald a new age of non-invasive diagnostics. These biomarkers may reflect status in health and disease and can be detected by humans and other animals, to some extent, but far more consistently with instruments. The continued advancement in micro and nanotechnology has produced a range of compact and sophisticated gas analysis sensors and sensor systems, focussed primarily towards environmental and security applications. These instruments are now increasingly adapted for use in clinical testing and with the discovery of new gas volatile compound biomarkers, lead naturally to a new era of non-invasive diagnostics. AIM: To review current sensor instruments like the electronic nose (e-nose) and ion mobility spectroscopy (IMS), existing technology like gas chromatography-mass spectroscopy (GC-MS) and their application in the detection of gas phase volatile compound biomarkers in medicine - focussing on gastroenterology. METHODS: A systematic search on Medline and Pubmed databases was performed to identify articles relevant to gas and volatile organic compounds. RESULTS: E-nose and IMS instruments achieve sensitivities and specificities ranging from 75 to 92% in differentiating between inflammatory bowel disease, bile acid diarrhoea and colon cancer from controls. For pulmonary disease, the sensitivities and specificities exceed 90% in differentiating between pulmonary malignancy, pneumonia and obstructive airways disease. These sensitivity levels also hold true for diabetes (92%) and bladder cancer (90%) when GC-MS is combined with an e-nose. CONCLUSIONS: The accurate reproducible sensing of volatile organic compounds (VOCs) using portable near-patient devices is a goal within reach for today's clinicians.

Impact of the United kingdom national bowel cancer awareness campaign on colorectal services.

BACKGROUND: Poor public awareness may account for the advanced stage at diagnosis, hence, poorer survival. With the aim of reducing colorectal cancer deaths, the United Kingdom National Bowel Cancer Awareness Campaign was rolled out from January 2012. Currently, the United Kingdom government target is to have all patients suspected to have cancer seen within 2 weeks of referral from general practitioners. This has significant impact on the workload for endoscopists. OBJECTIVE: The study aimed to measure the impact on colorectal services following the National Bowel Cancer Awareness Campaign. DESIGN: The data between February and July 2012 (onset of campaign) were prospectively collected and compared with data retrospectively collected between February and July 2011 inclusive (before campaign). SETTINGS: This study was conducted at a single center, university hospital. PATIENTS: The number of 2-week wait referrals, investigations, and colorectal cancers detected were assessed. MAIN OUTCOME MEASURES: Demographics, staging, and treatment of cancers were compared between groups along with the uptake of colorectal cancer screening. RESULTS: The total number of 2-week wait referrals increased by 47% with a resultant 38% increase in colonic investigations (p = 0.034) and a 23% increase in cancers detected (p = 0.0157). There was a 6.5% increase in the uptake of screening (p = 0.001) and a 62.5% decrease in the number of patients with colorectal cancer presenting as an emergency. LIMITATIONS: This short period of study is a major limitation. Although the data were from prospectively maintained databases, some data were analyzed retrospectively. Because only a single unit was assessed, results across a wider population may be more pronounced. There was also a referral bias in the compliance of primary care in the adherence to the 2-week wait referral criteria, because these criteria can be abused to get anxious patients into secondary care quickly. CONCLUSIONS: The National Bowel Cancer Awareness Campaign significantly increased the demand for colorectal services. With a potentially more favorable oncological outcome, further evaluation of supporting this greater workload demand is warranted.

Impact of slow transit constipation on the outcome of laparoscopic ventral rectopexy for obstructed defaecation associated with high grade internal rectal prolapse.

AIM: Limited literature exists on whether slow colonic transit adversely influences the results of outlet obstruction surgery. We compared the functional results of laparoscopic ventral rectopexy (LVR) for obstructed defaecation secondary to high grade internal rectal prolapse in patients with normal and slow colonic transit. METHOD: Consecutive patients suffering from obstructed defaecation associated with an internal rectal prolapse, who underwent an LVR between 2007 and 2011, were identified from a prospective database. All patients underwent preoperative defaecating proctography, anorectal manometry and colonic transit studies. Symptoms were assessed preoperatively and at 12 months after operation using a standardized questionnaire incorporating the Patient Assessment of Constipation Symptoms (PAC-SYM) questionnaire, the Fecal Incontinence Severity Index (FISI), the Patient Assessment of Constipation Quality of Life (PAC-QOL) scale and the Gastrointestinal Quality of Life Index (GIQLI). RESULTS: In all, 151 patients underwent LVR, 109 with normal and 42 with slow colonic transit. Preoperatively there was no significant difference between the two groups in age, sex, PAC-SYM score or FISI score. The PAC-SYM and FISI scores were significantly reduced in both groups at 12 months (P < 0.001). When comparing the change from baseline of PAC-SYM between patients with and without slow transit constipation, a significant difference was observed (P = 0.030) with changes of 58% and 40%. Quality of life (GIQLI and PAC-QOL) was equally improved in both groups. Quality of life improvement was less in patients with right colonic stasis. CONCLUSION: Slow colonic transit has no adverse impact on function and quality of life after LVR for obstructed defaecation due to high grade internal rectal prolapse.

Survival outcome of patients with screening versus symptomatically detected colorectal cancers.

AIM: The national Bowel Cancer Screening Programme has been rolled out nationwide following pilot screening in two health authorities in the UK. The aim of this study was to define overall 5-year survival of screen detected cancers and to compare the overall survival outcome of screened vs symptomatic patients over a 10-year period. METHOD: All patients with colorectal cancer treated at one trust in patients of screening age (50-69 years) during the pilot screening programme (2000-2008) were analysed. Patients were defined as screen detected or symptomatically detected. Disease pathology and recurrence data were obtained from the hospital's computerized results reporting system and mortality was cross-matched with data from the West Midlands Cancer Intelligence Network. RESULTS: In all, 633 patients aged 50-69 were identified in the study period; 155 patients had a screen detected cancer and 478 did not. A log-rank test completed on survival outcomes indicated that survival was significantly worse in the symptomatic group. This difference persisted if only patients treated with curative intent were considered. CONCLUSION: Survival outcome was significantly better in the screened vs the symptomatic population in all groups and also in those treated for curative intent. There was a trend towards better survival for screen detected cancer when compared stage for stage.

Emergency presentation of retrograde intussusception as a late complication of gastric bypass.

Retrograde intussusception is a rare complication of a Roux-en-Y gastric bypass. With the rising number of gastric bypass operations being performed in the UK, the incidence of retrograde intussusception is likely to increase. We report the first case in the UK and highlight its insidious presentation and the importance of considering intussusception in any patient with a history of a Roux-en-Y gastric bypass.

Excellent response rate of anismus to botulinum toxin if rectal prolapse misdiagnosed as anismus ('pseudoanismus') is excluded.

AIM: Anismus causes obstructed defecation as a result of inappropriate contraction of the puborectalis/external sphincter. Proctographic failure to empty after 30 s is used as a simple surrogate for simultaneous electromyography/proctography. Botulinum toxin is theoretically attractive but efficacy is variable. We aimed to evaluate the efficacy of botulinum toxin to treat obstructed defecation caused by anismus. METHOD: Botulinum toxin was administered, under local anaesthetic, into the puborectalis/external sphincter of patients with proctographic anismus. Responders (resolution followed by recurrence of obstructed defecation over a 1- to 2-month period) underwent repeat injection. Nonresponders underwent rectal examination under anaesthetic (EUA). EUA-diagnosed rectal prolapse was graded using the Oxford Prolapse Grade 1-5. RESULTS: Fifty-six patients were treated with botulinum toxin. Twenty-two (39%) responded initially and 21/22 (95%) underwent repeat treatment. At a median follow up of 19.2 (range, 7.0-30.4) months, 20/21 (95%) had a sustained response and required no further treatment. Isolated obstructed defecation symptoms (OR = 7.8, P = 0.008), but not proctographic or physiological factors, predicted response on logistic regression analysis. In 33 (97%) of 34 nonresponders, significant abnormalities were demonstrated at EUA: 31 (94%) had a grade 3-5 rectal prolapse, one had internal anal sphincter myopathy and one had a fissure. Exclusion of these alternative diagnoses revised the initial response rate to 96%. CONCLUSION: Simple proctographic criteria overdiagnose anismus and underdiagnose rectal prolapse. This explains the published variable response to botulinum toxin. Failure to respond should prompt EUA seeking undiagnosed rectal prolapse. A response to an initial dose of botulinum toxin might be considered a more reliable diagnosis of anismus than proctography.

Effect of season and ambient temperature on outcome of guaiac-based faecal occult blood tests performed for colorectal cancer screening.

AIM: Guaiac-based faecal occult blood tests (gFOBTs) are used in the colorectal cancer screening programme. Recent data suggested that the immunological faecal occult blood test illustrated a variation in positivity according to season and ambient temperature. Our aim was to assess the effect of season and ambient temperature on the positivity rates of the gFOBT during pilot screening for colorectal cancer. METHOD: Data from the first year of round 1 of the pilot screening programme in Coventry and Warwickshire were analysed. Patients with positive and negative gFOBT samples were included. Patients with spoilt samples or incomplete data were excluded. Of the total of 59513 patients, 30311 were men and 29202 women. Mean age was 56 years. Daily temperature data were provided by the meteorological office. RESULTS: Median exposure of the gFOBT test card was 6 days (range 1-17). Median daily maximum temperature was 14°C. Spring and summer illustrated significantly decreased positivity rates compared with autumn and winter (Pearson's chi-squared test, P<0.001). Mean daily maximum temperature for the test card exposure showed no significant difference in positivity rates (P=0.53). Subgroup analysis revealed a significant reduction in positive samples in the >25°C subgroup (P=0.045). CONCLUSIONS: There is a seasonal variation in positivity rates of gFOBTs with increased positivity in spring and summer months. There is no difference in positivity rates in relation to ambient temperature except in subgroup analysis where there is a significant reduction in positivity rates above 25°C.

What is the nature of polyps detected by the NHS bowel cancer screening pilots?

AIM: The NHS Bowel Cancer Screening Programme is currently being introduced following three rounds of pilot screening. The study outlines the important characteristics of polyps detected by pilot screening and compares the location of polyps with those of symptomatic cancers to challenge the circumstantial evidence for the adenoma carcinoma pathway. METHOD: The first 100 patients with screen-detected polyps from University Hospitals Coventry and Warwickshire (UHCW) were identified from the colorectal cancer screening database. Important characteristics of the polyps were identified from the endoscopy reporting system and entered into a database. Polyp location was compared with the location of symptomatic cancers detected in the UHCW colorectal cancer database. RESULTS: One hundred patients were selected for investigation and 202 polyps were detected. The average age of the patients with polyps was 61 years, 35% were under the age of 60. There were 67% male subjects. The average size of the largest polyp in each of the different patients was 13.5 mm. Eighty-five per cent of polyps were excised. Histology was available for 181 polyps of which 40% were tubulovillous, 33% tubular, 14% metaplastic and 1% villous. Eighty-eight per cent showed low-grade dysplasia and 8% high-grade one. The location of screen-detected polyps was significantly different from that of symptomatic cancers in our database, with proportionally more sigmoid and proportionally less rectal and caecal polyps detected. CONCLUSION: The study outlines the important characteristics of screen-detected polyps. The significant difference in location of polyps from that of cancer suggests a variation in the malignancy potential of polyps depending on the location.

The relationship between internal rectal prolapse and internal anal sphincter function.

AIM: Faecal incontinence is commonly seen in patients with internal rectal prolapse (IRP), although the mechanism is not clear. This study assessed the relationship between IRP and anal sphincter function. METHOD: Patients both with IRP diagnosed on proctography and those with external rectal prolapse (ERP) were identified from a prospective database generated from a tertiary referral pelvic floor clinic. The results of anorectal manometry were analysed, and the relationship between sphincter pressure and grade of prolapse was assessed. RESULTS: A total of 515 patients were identified with clinical evidence of ERP or proctographic evidence of internal and external prolapse. There were 88 with grade 5 or external prolapse [mean maximal resting pressure (MRP) 28.5 (standard error 2.1) mmHg], 156 with grade 4 prolapse [44.0 (1.8) mmHg], 153 with grade 3 prolapse [49.2 (1.6) mmHg], 88 with grade 2 prolapse [56.2 (2.1) mmHg] and 29 patients with grade 1 rectal prolapse [56.8 (4.5) mmHg]. There was a significant reduction in the mean MRP with increasing grade of prolapse from grade 2 to 5. By contrast, there was no relationship between prolapse grade and mean maximal squeeze pressure, except in patients with ERP, in whom the squeeze pressure was significantly lower compared with patients with IRP. CONCLUSION: This is the first large-scale study to show the relationship between internal prolapse and MRP. The observation that squeeze pressure is unchanged suggests that the effect of internal prolapse on continence occurs mainly through a reduction in internal anal sphincter tone.

Does the location of screen-detected cancers differ from that seen in the unscreened population?

OBJECTIVE: It is important that screening detects cancers regardless of their location within the colon. The aim of this study was to see if the location of cancers detected by the pilot screening programme differs from that of unscreened cancers. METHOD: The colorectal cancer dataset of University Hospital Coventry was analysed retrospectively. A 7-year period was used to include all three rounds of the pilot screening. Two groups of patients were selected, those with colorectal cancers detected by the screening programme and those detected outside of screening. The tumour location was compared in the two groups statistically (chi-squared test). RESULTS: One thousand four hundred-ninety patients were included, 100 of whom were in the screened population and 1390 were in the unscreened population. There was no significant difference in tumour location between the two groups (P = 0.49). CONCLUSION: This study showed that screen-detected cancers do not differ in their location from unscreened cancers and suggests that faecal occult blood testscreening detects cancer irrespective of location within the colon.

Are screen detected colorectal cancers asymptomatic?

OBJECTIVE: Colorectal cancer (CRC) screening aims to detect asymptomatic disease and thus provide the opportunity for early diagnosis and treatment. This study assesses the prevalence of significant symptoms in patients found to have CRC detected through the NHS National Bowel Cancer Screening Programme (NHS NBCSP) pilots. METHOD: All patients in the NHS NBCSP pilots with a positive faecal occult blood completed a standardized symptomatology questionnaire before colonoscopy. This data was entered into the NHS BCS pilot database, data from the English arm has been analysed retrospectively. RESULTS: There were 200 patients diagnosed with colorectal cancer. Of these, 28.5% were Dukes A, 35% Dukes B, 31% Dukes C1 and 5.5% Dukes C2. Some 81.5% reported experiencing GI symptoms. Symptoms considered significant included rectal bleeding, change in bowel habit, tenesmus and peri-anal discomfort, reported in 47.7%, 24%%, 36.5% and 15.5% of patients respectively. In addition to this, 27% reported urgency, 20.5% reported abdominal pain and 29% reported upper GI symptoms. DISCUSSION: This data suggests a high prevalence of significant symptoms amongst patients with screening-detected CRC. It is possible that these patients would have presented via routine colorectal services if the awareness of symptoms of colorectal cancer were increased.

Dysgerminoma associated with hypercalcemia: A case report.

Hypercalcemia is an extremely rare paraneoplastic manifestation of malignancy in children. The authors report a case of dysgerminoma in a 14-year-old girl associated with severe hypercalcemia that only resolved after excision of the tumor. There are only 6 previously reported cases of dysgerminoma associated with hypercalcemia. Serum calcium levels should be checked in all children with solid ovarian tumors. Hypercalcemia in such circumstances may be resistant to medical management, and surgical resection of the tumor results in the normalization of calcium levels.