A nine-year audit of open-access upper gastrointestinal endoscopic procedures: results and experience of a single centre.

BACKGROUND: The appropriateness and safety of open-access endoscopy are very important issues as its use continues to increase. OBJECTIVE: To present a review of a nine-year experience with open-access upper gastrointestinal endoscopy with respect to indications, diagnostic efficacy, safety and diseases diagnosed. METHODS: A retrospective, observational case series of all patients who underwent open-access endoscopy between January 2000 and December 2008 was conducted. Indications were classified as appropriate or not appropriate according to American Society of Gastrointestinal Endoscopy (ASGE) guidelines. Endoscopic diagnoses were based on widely accepted criteria. Major complication rates were assessed. RESULTS: A total of 20,620 patients with a mean age of 58 years were assessed, of whom 11,589 (56.2%) were women and 9031 (43.8%) were men. Adherence to ASGE indications led to statistically significant, clinically relevant findings. The most common indications in patients older than age 45 years of age were dyspepsia (28.5%) and anemia (19.7%) in the ASGE-appropriate group, and dyspepsia in patients younger than 45 years of age without therapy trial (6.6%) in the nonappropriate group. Of the examinations, 38.57% were normal. Hiatal hernia and nonerosive gastritis were the most common findings. Important diagnoses such as malignancies and duodenal ulcers would have been missed if endoscopies were performed only according to appropriateness. There were only two major complications and no mortalities. CONCLUSIONS: Open-access upper gastrointestinal endoscopy is a safe and effective system. More relevant findings were found when adhering to the ASGE guidelines. However, using these guidelines as the sole determining factor in whether to perform an endoscopy is not advisable because many clinically relevant diagnoses may be overlooked.

Sleeve gastrectomy leads to Helicobacter pylori eradication.

BACKGROUND: The role of Helicobacter pylori (HP) in patients scheduled and undergoing laparoscopic sleeve gastrectomy (LSG) has not been previously evaluated. METHODS: Included were obese patients presenting to our institution for LSG over 24 months. All patients had presurgical HP breath test, and the symptomatic ones received triple therapy with symptom follow-up. Post surgery, all excluded stomachs were evaluated for HP, and those that were positive performed a second 13C-urea breath test (UBT) 3 months later. RESULTS: Forty patients underwent LSG. Male to female sex ratio was 1:3; mean age-42 years; mean weight-122 kg; and mean BMI of 43.4 kg/m2. Presurgical HP was positive in 15 (37.5%) patients (11 symptomatic and four asymptomatic). Only these 11 patients were given HP eradication therapy and all experienced complete subsequent symptom resolution. HP was detected in 17 out of the 40 (42.5%) cases of excluded stomachs. All performed a 13C-UBT 3 months post operation and only three (17.6%) tested positive. CONCLUSIONS: HP infection is frequent in biopsies from patients with previous LSG and the majority of follow-up 13C-UBT were negative. In our small initial sample, we treated only symptomatic patients preoperatively. Routine screening for HP for all LSG patients and/or treatment for all positive ones would subject patients to expensive and unnecessary investigations. We propose that this stomach-reducing, pylorus-preserving surgery might even lead to HP eradication. The clinical implications of HP and this gastrectomy for a non-neoplastic, non-peptic indication deserve further study.

Pruritus ani: an approach to an itching condition.

Pruritus ani is frequently encountered in children by the primary care physician and the pediatrician. It is mainly due to an infection with pinworms, but fecal soiling, poor hygiene, local irritation, and dietary agents should also be considered. Treatment should be directed at the underlying etiology. Once these have been excluded, both general and specific measures must be initiated. There is almost no experience for local treatment modalities in children, and they cannot currently be recommended.

Significant colonic neoplasia prevalence and ASGE recommendations: is it time for a change?

GOALS AND BACKGROUND: To Evaluate the indications versus diagnostic yield of significant colonic neoplasia (SCN) in the open-access era and screening colonoscopy. STUDY: During 6-year period, all procedural data were obtained from all consecutive patients who underwent colonoscopies. Indications were compared with American Society for Gastrointestinal Endoscopy guidelines. RESULTS: In all 22,341 procedures were included in the study. Indications were divided into 3 groups: Screening (21.89% of the procedures), surveillance (17.60%) and symptoms/signs (60.51%). A total of 2867 patients (12.83%) had SCNs. Of these, 278 (7.00%) SCNs were found in the group less than 50 years of age and 2589 in the group over the age of 50 years (14.10%). SCN as per indication frequency was 12.69% in the symptom/sign group (subdivided to 7.24% and 14.01% in the under 50 and over 50, age groups, respectively); screening 13.37% (5.48% and 15.09%, respectively); surveillance 12.64% (8.48% and 13.19%, respectively). The indications leading to the highest SCN rate (over 25%) were: abnormal imaging, elevated carcinoembryonic antigen, and rectal pain. CONCLUSIONS: Colonoscopy is a unique screening tool that can detect neoplastic lesions. SCN prevalence in our study was between 13% and 15% for all indications in patients above 50 years of age. This emphasizes performing a screening colonoscopy for the entire population over the age of 50 years, regardless of the indication. We feel that American Society for Gastrointestinal Endoscopy guidelines should be reassessed. The revised criteria should state that the primary indication, are all people over the age of 50 years, who should have a colonoscopy performed, unless otherwise contraindicated.

Incidental colorectal computed tomography abnormalities: would you send every patient for a colonoscopy?

BACKGROUND: The clinical significance of colorectal wall thickening (CRWT) in patients undergoing abdominal computed tomography (CT) has not yet been definitively established. OBJECTIVES: To compare alleged findings on abdominal CT with those of a follow-up colonoscopy. METHODS: Ninety-four consecutive patients found to have large-bowel abnormalities on abdominal CT were referred for colonoscopy. Of these patients, 48 were referred for a suspected colorectal tumour and 46 for CRWT. Colonoscopy was performed and findings were compared. RESULTS: Of the 48 suspected colorectal tumours, 34 were determined to be neoplastic lesions on colonoscopy. Of these, 26 were malignant and eight were benign. Colonoscopy revealed no abnormality in 30 of 46 patients with CRWT as a solitary finding, and revealed some abnormality in 16 patients (12 had diverticular disease, four had benign neoplastic lesions). CONCLUSIONS: CRWT as an incidental and solitary finding on CT should not be regarded as a pathology prompting a colonoscopy. Approximately two-thirds of the patients had a normal colonoscopy and the remaining patients had benign lesions (12 had diverticular disease and four had benign neoplastic lesions). However, many of these patients seem to warrant colonoscopy regardless of CT findings, particularly patients who have a family history of colorectal cancer, have positive fecal occult blood test results or who are older than 50 years of age.

Is traveler's diarrhea a significant risk factor for the development of irritable bowel syndrome? A prospective study.

A total of 564 travelers were enrolled in a study aimed at investigating the influence of traveler's diarrhea in the development of irritable bowel syndrome. At 6-7 months after repatriation, we found that an episode of traveler's diarrhea was associated with a quintuple risk of developing irritable bowel syndrome.

Acute pancreatitis and upper gastrointestinal bleeding as presenting symptoms of duodenal Brunner's gland hamartoma.

Brunner's gland hamartomas are rare, benign small bowel tumours. There were fewer than 150 cases reported in the English literature until the end of the last century. These hamartomas may be discovered incidentally during an upper gastrointestinal tract endoscopy. Otherwise, they may be diagnosed in patients presenting with acute upper gastrointestinal bleeding, anemia or symptoms of intestinal obstruction. The case of a young woman admitted for acute upper gastrointestinal bleeding along with acute pancreatitis is presented. The investigation revealed a giant Brunner's gland hamartoma in the second part of the duodenum. After total endoscopic resection of the tumour, the patient has remained completely asymptomatic for a follow-up period of seven months.

[Open access colonoscopy: do primary care physicians use it properly?].

BACKGROUND: Open access endoscopy facilitates the performance of colonoscopy on a physician's request, without a prior consultation with a gastroenterologist. OBJECTIVES: To investigate: (1) the rates of relevant endoscopic findings in patients referred by family physicians compared to other specialists; (2) whether there is overuse of open-access colonoscopy in our country where the examination is free of charge for the patient; (3) whether a high rate of pre-malignant and malignant incidental findings might justify a more liberal approach to the indications of colonoscopy. METHODS: Prospective study including all consecutive ambulatory patients referred for open access colonoscopy. The indication for the examination was tabulated according to the American Society for Gastrointestinal Endoscopy (ASGE) guidelines. Endoscopic findings were classified into relevant or normal; each relevant finding was correlated with the indication for which the examination was performed. RESULTS: A total of 34.2% of patients had a colonoscopy performed for an inappropriate indication; family physicians had a slightly higher rate of appropriate indications compared with the other specialists. However, a relevant endoscopic finding was diagnosed only in 14.0% of their referred cases, compared with 22.8% of the other specialists (p = 0.032). Polyps larger than 5 mm or a malignant tumor were diagnosed in 20.7% of the colonoscopies; 19 out of the 83 cases (23%) were diagnosed in examinations performed for inappropriate indications. CONCLUSION: It was found that 34% of the colonoscopies were performed for inappropriate indications. A higher proportion of relevant endoscopic findings was diagnosed among patients referred by surgeons, oncologists and internists as compared with those referred by family physicians. Considering that as much as 23% of polyps and malignant tumors were found in cases performed for inappropriate indications, we suggest that a liberal approach to the indications for colonoscopy--probably age over 50 years--may benefit the patients.

Alcohol consumption and the gastrointestinal tract.

Alcohol is one of the most commonly abused drugs, with a per capita consumption of approximately 10 L pure ethanol per year in the United States and even higher in Spain and France. In terms of mortality, the effect of alcohol on the liver and the pancreas is probably more significant than on the tubular gastrointestinal tract. However, alcohol is a very important cause of morbidity in the tubular gastrointestinal tract. Alcohol influences the motility in the esophagus, stomach and small bowel and has direct effects on the mucosa of the upper tract. While the stimulation of gastric acid secretion is inversely correlated with the alcohol concentration of the beverage, a direct pathogenetic role in peptic ulcer disease has not been demonstrated. Some alcohols, like red wine, have been shown to possess an anti-Helicobacter pylori effect. Alcohol also has a role in the development of tumors of the gastrointestinal tract.

Hydrocortisone-induced convulsions.

Glucocorticoids may indirectly cause convulsions by the induction of electrolytes abnormalities, severe hypertension, or severe hyperglycemia. These agents may rarely cause convulsions by a direct toxicity to the central nervous system (CNS). We describe a 23-yr-old patient with Crohn's disease in whom generalized convulsions developed on two occasions while receiving intravenous hydrocortisone.