A randomized trial to compare the efficacy and tolerability of sodium picosulfate-magnesium citrate solution vs. 4 L polyethylene glycol solution as a bowel preparation for colonoscopy.

PURPOSE: The purpose of this study is to compare the efficacy and acceptability of an evening-before regimens of sodium picosulfate/magnesium citrate (SPMC) and polyethylene glycol (PEG) as bowel cleansers and to explore the results of a same-day regimen of SPMC. METHODS: Multicenter, randomized, observer-blinded, parallel study carried out in subjects who were 18-80 years old and were undergoing diagnostic colonoscopy for the first time. The primary outcome was treatment success, which was a composite outcome defined by (1) the evaluation of the overall preparation quality as "excellent" or "good" by two blinded independent evaluators with the Fleet(®) Grading Scale for Bowel Cleansing and (2) a subject's acceptability rating of "easy to take" or "tolerable." The primary outcome was analyzed using a logistic regression with site, gender, and age group (age ≥65 years and <65 years) as factors. RESULTS: Four hundred ninety subjects were included in the efficacy evaluation. Although treatment success was significantly higher in subjects assigned to the evening-before regimen of SPMC vs. subjects assigned to the evening-before PEG, when evaluating the two individual components for treatment success, there were significant differences in the ease of completion but not in the quality of preparation. The same-day SPMC regimen was superior to both the evening-before regimen of SPMC and PEG in terms of the quality of preparation, especially regarding the proximal colon. CONCLUSIONS: An evening-before regimen of SPMC is superior to an evening-before regimen of PEG in terms of subject's acceptability. The same-day SPMC regimen provides better cleansing levels in the proximal colon.

Achalasia treatment in the elderly: is botulinum toxin injection the best option?

BACKGROUND: Achalasia treatment in elderly patients is a matter of controversy. Botulinum toxin injection has been proposed as the best option in this group of patients as it is a safe procedure. However, concern persists regarding its short-term effect. AIMS: To analyse the clinical and economic effectiveness of botulinum toxin injection in the treatment of achalasia patients who are elderly. METHODS: Seventeen consecutive achalasia patients older than 65 years were treated with 80 units of botulinum toxin. Clinical follow-up at 1, 6 and 12 months was performed. Control manometry when symptoms recurred was carried out. Results were compared with those of an historical control group of 16 achalasia patients also older than 65 years and who had been treated with endoscopic dilation. The costs of both procedures were compared. RESULTS: Twenty-nine botulinum toxin injections were performed in the 17 patients of the botulinum toxin group (follow-up, 12-36 months). In the dilation group only two patients had to be retreated (follow-up, 12-108 months). No major complications were observed in either group. The average duration of symptom alleviation was 48 +/- 33 months for endoscopic dilation and 13.8 +/- 9.5 months for botulinum toxin injection. Maintaining a patient free of symptoms cost E348.31 per year for botulinum toxin injection, whilst if endoscopic dilation was chosen the cost was only E117.47 per year. CONCLUSIONS: The effect of botulinum toxin injections wanes with time in elderly patients, necessitating repeated injections to keep the patients symptom-free. Due to the required repeated injections this procedure is more expensive than endoscopic dilation.

Risk factors for recurrence of acute gastrointestinal bleeding from angiodysplasia.

BACKGROUND AND AIMS: Recurrent bleeding from gastrointestinal (GI) angiodysplasia remains a therapeutic challenge. Identification of factors predicting poor outcome of haemorrhage from angiodysplasia would help us to select the patients who may likely benefit from further therapy. Thus, we analysed risk factors for recurrence of acute GI haemorrhage from angiodysplasia. PATIENTS AND METHODS: 62 patients admitted consecutively with acute GI bleeding from angiodysplasia, between June 2002 and June 2006, were included. Bivariate, multivariate and survival analysis were performed to identify risk factors for recurrence of bleeding after hospital discharge. RESULTS: Recurrence of acute haemorrhage after hospital discharge occurred in 17 of 57 (30%) patients (38 men; mean age: 74+/-6 years), after a mean follow-up (33+/-40 months). On Cox analysis, earlier history of bleeding with a high bleeding rate, over anticoagulation and the presence of multiple lesions were predictive factors of recurrence in a multivariate analysis. In contrast, endoscopic argon plasma coagulation (APC) therapy was not associated with lower rates of recurrent bleeding. CONCLUSION: In patients with acute GI haemorrhage from angiodysplasia, earlier bleeding with a high bleeding rate, over anticoagulation and multiple angiodisplasic lesions predict an increased risk of recurrent bleeding. Although there is a trend towards better management with endoscopic APC therapy for the prevention of recurrence of bleeding, endoscopic APC therapy is not predictive of a lower rate of recurrence.

Long-term efficacy of octreotide in the prevention of recurrent bleeding from gastrointestinal angiodysplasia.

OBJECTIVES: Preliminary studies suggested that octreotide may be therapeutic in bleeding angiodysplasia. Our aim was to investigate the efficacy of long-term octreotide therapy in the prevention of rebleeding from gastrointestinal angiodysplasia. METHODS: A cohort of 32 patients diagnosed with bleeding from angiodysplasia was treated with octreotide 50 mu 12 h subcutaneously for a 1-2 yr period. This cohort was compared with an external control group (38 patients who had received placebo [1 tablet/day] in a concurrent randomized clinical trial for the same period. RESULTS: Two patients of the octreotide group were lost to follow-up. Treatment failure occurred in seven of 30 (23%) patients in the octreotide group and in 17 of 35 (48%) in the placebo group (three dropouts before first visit) (P= 0.043). The actuarial probability of remaining free of rebleeding at 1 and 2 yr of follow-up was 77% and 68%, respectively, for the octreotide group and 55% and 36%, respectively, for the placebo group (log rank P= 0.030). Multivariate proportional hazards-regression analysis showed that octreotide therapy and previous bleeding episodes were positive and negative predictors of efficacy, respectively. No significant differences between the groups were observed according to number of bleeding episodes (0.4 +/- 0.7 vs 0.9 +/- 1.5, P= 0.070) and transfusion requirements (1.1 +/- 2.6 vs 0.7 +/- 1.5 units); however, iron requirements were lower in the octreotide than in the placebo group (22 +/- 62 vs 166 +/- 267 units; P < 0.001). Likewise, major adverse events (1 vs 1) and mortality (0 vs 1) were similar between groups. CONCLUSIONS: This study suggests that octreotide treatment may be beneficial in preventing rebleeding from gastrointestinal angiodysplasia.

Capsule endoscopy versus computed tomographic or standard angiography for the diagnosis of obscure gastrointestinal bleeding.

BACKGROUND AND AIMS: Capsule endoscopy (CE) is superior to push enteroscopy and small bowel barium radiography in detecting the source of obscure GI bleeding. We now compared whether CE has a superior diagnostic yield than CT angiography (CTA) or standard mesenteric angiography (ANGIO) in patients with obscure GI bleeding. METHODS: From June 2004 to October 2005, consecutive patients admitted for OGIB underwent both CTA and ANGIO, followed by CE, performed blindly by independent examiners within the next 7 days. The primary end point of the study was the diagnostic yield for each technique, defined as the frequency of detection of lesions with a high probability of bleeding. RESULTS: Twenty-eight patients (16 men and 12 women, mean age 74 +/- 2 yr) with OGIB (overt bleeding in 20 cases and chronic occult in 8) were prospectively evaluated. CTA or standard angiography could be performed in 25 of 28 patients (applicability 86%), because of contrast allergy (1 patient) and chronic renal failure (2 patients). A source of bleeding was detected by CE in a greater proportion of patients, 72% (18 of 25, 95% CI 50.6-87.9%), than CTA, 24% (6 of 25, 95% CI 9.4-45.1%, P= 0.005 vs CE), or ANGIO, 56% (14 of 25, 95% CI 34.9-75.6%, P= NS). Similarly, CE was able to diagnose 100% of patients diagnosed by CTA and 86% of patients diagnosed by ANGIO. Moreover, CE was positive in 12 of 19 (63%) negative cases on CTA and in 6 of 11 (55%) negative cases on ANGIO. As a result of the CE findings, therapeutic intervention was undertaken in 9 of 19 (47%) patients with positive results. CONCLUSION: CE detects more lesions than CTA or standard mesenteric angiography in patients with obscure GI bleeding and has a therapeutic impact in almost half of the patients with positive findings.