A randomized controlled trial comparing a low-residue diet versus clear liquids for colonoscopy preparation: impact on tolerance, procedure time, and adenoma detection rate.

OBJECTIVE: To achieve an excellent bowel preparation, it is routine to require a clear liquid diet on the day before the procedure. Unfortunately, this dietary modification may be poorly tolerated. We examine whether a change in precolonoscopy dietary restriction can lead to better patient tolerance without compromising examination quality. METHODS: This is a prospective, blinded, randomized controlled trial of patients undergoing screening or surveillance colonoscopy. The primary objective measures the effect of dietary modification on bowel prep quality. Secondary endpoints include polyp detection, patient tolerance, withdrawal time, and patient acceptance. A total of 200 patients were randomized to either (a) a low-residue diet for breakfast and lunch the day before the procedure or (b) clear liquids all day before the procedure. All patients underwent an identical low-volume sodium sulfate split prep. Bowel prep quality was scored using the Boston Bowel Preparation Scale (BBPS). A t test with TOST was used for noninferiority. Secondary endpoints were compared using χ analysis. RESULTS: Overall, 96.5% of patients had a good or excellent bowel prep (BBPS=6, 7, 8, or 9). LRD prep quality was noninferior to CLD prep quality (LRD 7.8 vs. CLD 8.1). Polyp detection rates were similar (68% vs. 65.4%, P=0.6899). Patient tolerance and acceptance did not differ. Withdrawal times were equivalent between both groups (16.2 vs. 16.5 min, P=NS). CONCLUSIONS: Patients allowed to have a limited low-residue diet before colonoscopy achieve a bowel prep quality that is noninferior to patients on a strict clear liquid diet limitation. Furthermore, polyp detection rates, patient tolerance, and patient acceptance were similar between the 2 groups.

High prevalence of potentially hepatotoxic herbal supplement use in patients with fulminant hepatic failure.

HYPOTHESIS: The use of potentially hepatotoxic herbal and dietary supplements is highly prevalent in the fulminant hepatic failure (FHF) patient population at our institution, and this subgroup of patients has a worse prognosis. DESIGN: Retrospective case series. Settings An adult tertiary care university hospital and a Veterans Affairs hospital in Oregon. PATIENTS: All patients referred to the liver transplantation service for FHF from January 2001 through October 2002 (N = 20). We defined FHF as onset of encephalopathy within 8 weeks of onset of jaundice in the absence of preexisting liver disease. All patients underwent investigation for potential causes of liver injury. Potentially hepatotoxic supplements were defined as those with previously published reports of hepatic injury related to their use. RESULTS: Ten patients (50%) were recent or active users of potentially hepatotoxic supplements or herbs; 10 had no history of supplement use. In the supplement group, 7 patients (35%) had no other identified cause for hepatic failure. Six patients in the supplement group and 2 patients in the nonsupplement group underwent orthotopic liver transplantation. Five patients in each group died. There were no significant differences in transplantation rate (P =.07) or survival (P>.99) between groups. Supplement use alone accounted for the most cases of FHF during this period, exceeding acetaminophen toxicity and viral hepatitis. CONCLUSIONS: Herbal and dietary supplements were potential hepatotoxins in a high proportion of patients with FHF at our institution. Enhanced public awareness of the potential hepatotoxicity of these commonly used agents and increased regulatory oversight of their use is strongly urged.

Brunner's gland hamartoma: a rare cause of gastrointestinal bleeding -- case report and review of the literature.

An unusual cause of upper gastrointestinal bleeding is described in a previously healthy 45-year-old man who was admitted to hospital with weakness and fatigue, and had experienced an episode of melena two days before admission. His medical and surgical history was unremarkable. Upon admission to hospital, he showed evidence of iron-deficiency anemia, with a hemoglobin concentration of 61 g/L (normal range 135 to 175 g/L), a mean corpuscular volume of 73 fL (normal range 85.0 to 95.0 fL) and a ferritin concentration of 1.0 microg/L (normal range in males 15 to 400 microg/L). Upper gastrointestinal endoscopy revealed a 3.5 cm ulcerated submucosal mass in the third portion of the duodenum, for which mucosal biopsies were nondiagnostic. A subsequent endoscopic ultrasound revealed a 2.7 x 4.0 cm hyperechoic, cystic, submucosal tumour in the third portion of the duodenum. Endoscopic ultrasound-guided fine needle aspiration revealed no malignant cells. The patient eventually underwent a resection of the third portion of his duodenum. Surgical pathology revealed that this tumour was a Brunner's gland hamartoma, 4.5 cm in its greatest dimension.