Estimation of impact of American College of Radiology recommendations on CT colonography reporting for resection of high-risk adenoma findings.

OBJECTIVES: The American College of Radiology (ACR) recommends that polyps < or =5 mm in size not be reported on computed tomography (CT) colonography studies. Patients with 1 or 2 polyps 6-9 mm in size can be offered "CTC surveillance" in 3 years in lieu of polypectomy. The aim of the study was to determine the impact of ACR recommendations on resection of high-risk adenoma findings using an endoscopic polyp/histology database. METHODS: Excluding patients with inflammatory bowel disease (IBD) and polyposis, 10,034 patients underwent colonoscopy and 10,780 polyps were removed from 5,079 patients over a 5-year interval. High-risk adenoma findings were defined as an advanced adenoma (> or =1 cm in size, high-grade dysplasia (HGD), or villous elements) or 3 or more adenomas of any size, per postpolypectomy surveillance recommendations. RESULTS: A total of 5,079 patients (51%) had at least 1 polyp, 2,907 (29%) had at least 1 adenoma, and 1,001 (10%) had high-risk adenoma findings, of these, 293 (29%) had either 3 adenomas < or =5 mm in size (n=267) or an advanced adenoma < or =5 mm in size (or both) and no polyp of any histology > or =6 mm in size. There were 774 patients with 1 or 2 polyps 6-9 mm in size and no polyps of any histology > or =10 mm in size. Of these patients 184 (18% of the patients with high-risk adenomas) had either 3 or more adenomas < or =9 mm in size (n=149) or an advanced adenoma < or =9 mm in size (or both findings). There were 2,174 patients age > or =50 years with the primary indication of screening of whom 326 (15%) had high-risk adenoma findings. Of these, 108 (33%) had either > or =3 adenomas < or =5 mm in size or an advanced adenoma < or =5 mm in size and no polyps > or =6 mm in size. An additional 75 (23%) had no polyp > or =10 mm in size, 1 or 2 polyps 6-9 mm in size and > or =3 adenomas < or =9 mm in size or an advanced adenoma < or =9 mm in size. CONCLUSIONS: If computed tomographic colonography (CTC) rather than colonoscopy were used in this population, assuming 100% sensitivity of CTC for polyps > or =6 mm and ACR interpretation recommendations, then 29% of all patients and 33% of screening patients age > or =50 years with high-risk adenoma findings would be interpreted as normal, and an additional 18-23% of these groups with high-risk adenoma findings, respectively, could have polypectomy delayed at least 3 years.

Advances in endoscopic imaging: narrow band imaging.

Technological advances in endoscopic imaging are constantly being evaluated in clinical research, and encouraging results are being seen. Studies on practical applications of these new technologies are ongoing in conditions as diverse as gastroesophageal reflux disease, Barrett's esophagus, colonic polyps, and dysplasia in ulcerative colitis. This review discusses the recent advances in endoscopic imaging that appear to be on the verge of widespread and routine usage. It is evident that high-resolution and high-definition white light endoscopy should be used when available, and is considered the new "gold standard" in endoscopic imaging. There is much optimism and ongoing research surrounding the use of narrow band imaging as well.

Work and resources needed for endoscopic resection of large sessile colorectal polyps.

BACKGROUND & AIMS: Large sessile colon polyps often are referred for surgical resection, even when amenable to endoscopic resection. The aim of this study was to describe the resource use of endoscopic resection of large sessile colon polyps compared with small polyps with respect to physician time and equipment use. METHODS: Retrospectively, procedure time, medication use, and equipment use were recorded for 184 consecutive patients with sessile colorectal polyps 2 cm or larger in size and for 184 consecutive control patients with only sessile polyps less than 2 cm in size or pedunculated polyps. RESULTS: The mean duration of colonoscopy in patients with large sessile colon polyps averaged 51.4 (SD, 25.6) minutes compared with 20.0 (SD, 8.6) minutes for the control group (P < .0001). The large-polyp group required much more equipment to complete the polypectomy (eg, injection catheters and cautery probes) (P < .0001). CONCLUSIONS: Our results indicate that the costs of endoscopic large sessile adenoma resection in physician work and equipment are substantially greater than the costs of resection of small adenomas. These costs may be a deterrent to endoscopic resection of large sessile adenomas and may warrant increased reimbursement for those procedures, particularly if predictions that colonoscopic procedures will become more complex in the future are realized.

Colonoscopy technique in consecutive patients referred for prior incomplete colonoscopy.

BACKGROUND & AIMS: Cecal intubation is one of the goals of colonoscopy. In some patients cecal intubation is unsuccessful. The aim of this study was to describe the approach used by a gastroenterologist with special interest in colonoscopy to perform colonoscopy in patients with a prior incomplete colonoscopy. METHODS: The demographic features and colonoscopy methods and findings are described in 119 consecutive patients in whom a prior incomplete colonoscopy was performed by a gastroenterologist or surgeon. RESULTS: Most patients could be characterized as to the cause of previous failure, based on medical records or an initial attempt to pass the colonoscope, as redundant colon (n = 54), difficult sigmoid colon (n = 33), or difficult to sedate (n = 8). Colonoscopy was successful to the cecum (n = 116) or an ileocolonic anastomosis (n = 1) in 117 of the 119 patients. Standard adult (n = 51) and pediatric colonoscopes (n = 35) and attention to careful technique were successful in 86 cases, although these included 7 cases in which the use of propofol sedation appeared to be the critical factor allowing success. Special equipment was needed in 31 cases: external straighteners (n = 9), upper endoscopes alone (n = 9), pediatric colonoscope after guidewire exchange (n = 8), and an enteroscope with (n = 4) or without (n = 1) an external straightener. CONCLUSIONS: Most patients with a prior incomplete colonoscopy can be colonoscoped successfully if an array of tools and techniques are used. The approach varies depending on characterization of the problem as redundant colon vs difficult sigmoid colon. The approach and techniques described here may be of value to others in cases of a difficult or challenging colonoscopy.

Temporal arteritis presenting with gastrointestinal symptoms in a middle aged man.

Giant cell arteritis, also known as temporal arteritis, is a vasculitis of unknown etiology that classically involves the wall of the large to medium size. We are reporting a case of a young onset temporal arteritis presenting with gastrointestinal symptoms. The patient was a 48-year-old male who presented with a 2-week history of fever, diffuse abdominal pain, and malaise. He underwent a laparoscopic cholecystectomy after findings of elevated bilirubin and alkaline phosphatase as well as suspicion of porcelain gallbladder on ultrasound (or computed tomography scan). The patient subsequently developed painless, intermittent vision loss and unilateral headaches. A work-up included temporal artery biopsy, which showed marked lymphocytic infiltrate in the arterial wall consistent with temporal arteritis. The presentation of temporal arteritis may be atypical. We are reporting a case of temporal arteritis at a young age presenting mainly with gastrointestinal symptoms.