Does prophylactic stent insertion to the common bile duct during endoscopic retrograde cholangiopancreatography (ERCP) before cholecystectomy have any impact on the rate of biliary complications?

BACKGROUND: Patients with choledochocystolithiasis generally undergo endoscopic sphincterotomy (ES) followed by elective cholecystectomy. They can experience the development of recurrent biliary events while waiting for their scheduled surgery. AIM: This study investigated whether stent insertion before cholecystectomy influences the rate of complications. METHODS: The study compared retrospective and prospective groups of patients with choledochocystolithiasis who underwent ES with or without prophylactic common bile duct stent insertion before cholecystectomy. The rate of emergency cholecystectomies and biliary complications during the waiting period before the elective procedure was analyzed. RESULTS: For the study, 162 patients with choledochocystolithiasis who underwent endoscopic retrograde cholangiopancreatography (ERCP) with ES were divided to two subgroups. Group A included 52 patients with stent insertion (mean age, 58.3 ± 19.4 years), and group B included 110 patients with no stent insertion (mean age, 61.4 ± 17.7 years) (p = 0.32). Males made up 33.3% of group A and 53.7% of group B (p = 0.018). The median time to elective cholecystectomy (open or laparoscopic) was 41.5 days for the patients without bile duct stent insertion before cholecystectomy and 53.5 days for the patients who had the stent insertion before cholecystectomy (p = 0.63). Repeat emergency ERCP due to acute cholangitis was 5.6% in group A and 1.0% in group B (p = 0.43). Emergency cholecystectomy rates due to acute cholecystitis after ES were 15.4% in group A and 14.5% in group B (p = 1.00). No mortality occurred. CONCLUSIONS: According to the study findings, prophylactic stent insertion during ERCP before cholecystectomy has no impact on biliary complications.

Validation of the Capsule Endoscopy Crohn's Disease Activity Index (CECDAI or Niv score): a multicenter prospective study.

BACKGROUND AND STUDY AIMS: The Capsule Endoscopy Crohn's Disease Activity Index (CECDAI or Niv score) was devised to measure mucosal disease activity using video capsule endoscopy (VCE). The aim of the current study was to prospectively validate the use of the scoring system in daily practice. METHODS: This was a multicenter, double-blind, prospective, controlled study of VCE videos from 62 consecutive patients with isolated small-bowel Crohn's disease. The CECDAI was designed to evaluate three main parameters of Crohn's disease: inflammation (A), extent of disease (B), and stricture (C), in both the proximal and distal segments of the small bowel. The final score was calculated by adding the two segmental scores: CECDAI = ([A1 × B1] + C1) + ([A2 × B2] + C2). Each examiner in every site interpreted 6 - 10 videos and calculated the CECDAI. The de-identified CD-ROMs were then coded and sent to the principal investigator for CECDAI calculation. RESULTS: The cecum was reached in 72 % and 86 % of examinations, and proximal small-bowel involvement was found in 56 % and 62 % of the patients, according to the site investigators and principal investigator, respectively. Significant correlation was demonstrated between the calculation of the CECDAI by the individual site investigators and that performed by the principal investigator. Overall correlation between endoscopists from the different study centers was good, with r = 0.767 (range 0.717 - 0.985; Kappa 0.66; P < 0.001). There was no correlation between the CECDAI and the Crohn's Disease Activity Index or the Inflammatory Bowel Disease Quality of Life Questionnaire or any of their components. CONCLUSION: A new scoring system of mucosal injury in Crohn's disease of the small intestine, the CECDAI, was validated. Its use in controlled trials and/or regular follow-up of these patients is advocated.

Value of EUS-FNA cytological preparations compared with cell block sections in the diagnosis of pancreatic solid tumours.

OBJECTIVE: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is performed in order to achieve a definite tissue diagnosis of pancreatic lesions. This in turn is a guide to the appropriate treatment for the patient. Tissue samples collected by the same needle for cytological preparations and cell block histological sections (often referred to as FNA-cytology and FNA-biopsy, respectively) are handled differently. The specific contribution of each of these tests was evaluated. METHODS: One hundred and two consecutive patients underwent EUS-FNA while being investigated for pancreatic solid lesions. Diagnosis was made by cytology, cell block sections or both. The diagnosis was confirmed by clinical outcome. RESULTS: Male/female ratio was 61/41. Mean age was 65±12 years (range, 22-94). Mean lesion size was 3.1±1.8 cm (range, 0.6-10 cm); 68% were >2 cm and 75% were located in the pancreatic head. The average number of needle passes was two (range, 1-4 passes). Final tissue diagnosis was malignant in 66 (65%) patients. Sensitivity, specificity and accuracy were 73%, 94% and 81%, respectively, for cytology alone, and 63%, 100% and 78%, for cell blocks alone. Eighty-two patients (80%) had cytology and cell blocks, which matched in 64 (78%) patients. EUS-FNA results that relied on both techniques had 84% sensitivity, 94% specificity and 88% accuracy. Cytology revealed 13 malignancies not diagnosed on cell blocks, while cell blocks revealed five malignancies not diagnosed by cytology. Malignant lesions were more common in men; they were larger in size and located in the pancreatic head. CONCLUSION: EUS-FNA cytology was more sensitive than cell blocks but less specific for the diagnosis of solid pancreatic lesions. The two methods are complementary and implementing both improves the diagnostic value of EUS-FNA.

Prospective multicenter performance evaluation of the second-generation colon capsule compared with colonoscopy.

BACKGROUND AND STUDY AIMS: A second-generation capsule endoscopy system, using the PillCam Colon 2, was developed to increase sensitivity for colorectal polyp detection compared with the first-generation system. The performance of this new system is reported. PATIENTS AND METHODS: In a five-center feasibility study, second-generation capsule endoscopy was prospectively compared with conventional colonoscopy as gold standard for the detection of colorectal polyps and other colonic disease, in a cohort of patients scheduled for colonoscopy and having known or suspected colonic disease. Colonoscopy was independently performed within 10 hours after capsule ingestion. Capsule-positive but colonoscopy-negative cases were counted as false-positive. RESULTS: 104 patients (mean age 49.8 years) were enrolled; data from 98 were analyzed. Patient rate for polyps of any size was 44 %, 53 % of these patients having adenomas. No adverse events related to either procedure were reported. The capsule sensitivity for the detection of patients with polyps >or= 6 mm was 89 % (95 % confidence interval [CI] 70 - 97) and for those with polyps >or= 10 mm it was 88 % (95 %CI 56 - 98), with specificities of 76 % (95 %CI 72 - 78) and 89 % (95 %CI 86 - 90), respectively. Both polyps missed by colonoscopy and mismatch in polyp size by study definition lowered specificity. Overall colon cleanliness for capsule endoscopy was adequate in 78 % of patients (95 %CI 68 - 86). CONCLUSIONS: The new second-generation colon capsule endoscopy is a safe and effective method for visualizing the colon and detecting colonic lesions. Sensitivity and specificity for detecting colorectal polyps appear to be very good, suggesting a potential for improved accuracy compared with the first-generation system. Further prospective and comparative studies are needed.

The colon - the latest terrain for capsule endoscopy.

Colonoscopy is the gold standard for evaluating pathologies of the large bowel, including screening for colorectal cancer. The technological features of current colonoscopes have not progressed much in recent years except for improved image and video display. The technique requires intubation and insufflation of the colon which are operator-dependent and involve a learning curve. Colonoscopy is an invasive procedure whose overall risk of complications is approximately 0.3%, increasing to 2% when polypectomy is performed. The PillCam Colon capsule endoscope (Given Imaging Ltd., Yoqneam, Israel) was developed for use as a safe, minimally invasive, non-sedation requiring, patient-friendly modality to visualize the colon. Only the interpretation of findings requires expertise. PillCam capsule endoscopy could be an alternative approach to colonoscopy for screening large populations. We report the first clinical investigations of the safety, feasibility and performance of colon capsule endoscopy compared with standard colonoscopy.

Effect of a calcium-enriched diet on the colonic epithelial hyperproliferation induced by N-methyl-N'-nitro-N-nitrosoguanidine in rats on a low calcium and fat diet.

We examined whether hyperproliferation of colonic crypt epithelium during cancer induction by N-methyl-N-nitro-N-nitrosoguanidine (MNNG), in rats on a low fat and calcium diet could be reduced by added calcium p.o. From the age of 4 weeks, 104 male Sprague-Dawley rats received a low fat (3.5%), low calcium (0.05% calcium ion), and low vitamin D (0.4 IU/g) diet. Sixty-four also had calcium salts, derived from either calcium lactate or solubilized calcium carbonate, added to their drinking water; therefore their total calcium intake was about 1% of daily diet. At age 12 weeks the rats were divided into 4 treatment groups: 8 rats, not receiving added calcium, had rectal saline instillations weekly (saline control group) and were sacrificed after a further 28 weeks; 3 groups of 32 rats each received intrarectal MNNG (1.5 mg) weekly. One group, not receiving added calcium, was the MNNG control group; while the second group also received added calcium lactate, and the third group received calcium carbonate. Groups of 24 were sacrificed periodically until 28 weeks of treatment. Rats were sacrificed and epithelial proliferation was estimated, 1 week after the last intrarectal instillation, by in vivo labeling with tritiated thymidine and measuring the ratio of labeled to total colonic crypt epithelial cells. The mean labeling index of the MNNG treated and added calcium groups were significantly higher (8.7-9.5%) than that of the saline controls (2.8%) only at week 28; however, it was then still significantly less than that of the MNNG controls not having added calcium (17.9%). Hyperproliferation, during induction of colonic cancer by MNNG in rats on a low calcium diet, can be reduced by a calcium enriched diet even in the presence of a low fat intake.

Influence of demographic parameters on rectal epithelial proliferation.

Measurement of rectal epithelial proliferation is now being used as a biomarker for assessing risk for colorectal cancer and response within dietary intervention studies. We examined the possible confounding effects of demographic parameters on the proliferation of 52 healthy middle-aged volunteers without known risk factors for colorectal cancer. No significant effects on proliferation of age, sex or ethnic grouping were found other than marked urban-rural differences amongst men. We hypothesise that these could be explained by differences in dietary habits and their deleterious effects in the older male population. Careful matching of controls are probably needed in order to demonstrate the minor changes in mucosal proliferation that could reflect risk for neoplasia. Further human studies are needed to examine the effects of diet and extremes of age on proliferation.

Reproducibility studies and effects of bowel preparations on measurements of rectal epithelial proliferation.

Measurements of rectal epithelial proliferation (REP), using tritiated labelled thymidine, correlate with colonic epithelial proliferation, risk for cancer and response to therapies. There have been criticisms regarding its reproducibility and the possible deleterious effects of bowel preparations on this biomarker. We studied paired observations on 7 patients repeated without bowel preparation, 11 repeated after tap-water enema, and 8 repeated after PEG-electrolyte solution or extract of senna purgative and found no significant differences between paired observations. In addition, in a high-risk group for colorectal cancer, 31 persons received PEG or senna preparation and their REP was not significantly different from that of 23 examined without these preparations. Thus, REP is a reproducible biomarker and not affected by several commonly used bowel preparations.

Rectal epithelial proliferation characteristics of first degree relatives of sporadic colon cancer patients.

Hyperproliferation of rectal epithelium is characteristic of families at high genetic risk for large bowel neoplasia, but has not been well-documented in families of sporadic colorectal cancer patients. This was studied in 119 such first degree relatives and 44 comparison subjects without this family history. All screened negative for large bowel neoplasia. Within the family group proliferation was significantly higher in the men and those aged less than 45 years, also higher (insignificantly) in non-Europeans and those having greater than 1 first degree colorectal cancer relative. In comparison to the nonfamily group the labelling index (LI) of the relatives showed a significant negative correlation with age (R = -0.20, P = 0.03). Within this family group the probability of having an elevated LI (greater than 6.0%) was greatest in the young (less than 50 years old) men (odds ratio = 2.0). Measurements of rectal epithelial proliferation (REP) in these first degree relatives, at a young age, might help delineate a high risk subgroup for prospective primary and secondary intervention.

Rectal epithelial proliferation in women recovered from breast cancer.

Women recovered from breast cancer are at increased risk for colorectal neoplasia. The reasons may be genetic, dietary or endogenous hormonal risk factors. Measurements of rectal epithelial proliferation are a useful biomarker of risk for large bowel cancer. This was studied in 12 women after (mean 7.8 years) cured breast cancer, who had a mean % labelling index of 7.5 +/- 3.5 (S.D.) as compared to 5.8 +/- 1.8 (S.D.) in a disease-free comparison group of 25 women. In addition, analysis of labelled crypt compartments demonstrated a significantly higher proportion in the study group with thymidine uptake, mainly in the mid crypt zone, and an extension of crypt cell DNA synthesis towards the surface epithelium. Using proliferative activity as a biomarker of risk in a larger study group, we may learn more about common etiological factors for both malignancies and also identify a higher-risk subgroup for long-term follow-up and possible therapeutic intervention.

Rectal epithelial proliferation in persons post sporadic colorectal neoplasia.

Some studies have shown diffuse large bowel epithelial hyperproliferation in persons having colorectal neoplasia. Thus, measurements of rectal epithelial proliferation (REP) could be useful as a screening biomarker of risk for sporadic neoplasia. We examined REP, by autoradiography with tritiated thymidine, in 84 persons: 32 healthy volunteers, 37 who had had sporadic adenomas and 15 post cured sporadic colorectal cancer. Measurements of the labelling index (ratio of labelled to total number of crypt cells) showed a statistically insignificant but increasing gradient of hyperproliferation related to degree and invasiveness of neoplasia. However, this became significant when examining the proportion of labelled crypt compartments in each group and by comparing combined compartments 3 and 4 of cancer patients to non-cancer patients. Gender and age were found to be parameters that influenced the results. Using standard methods of analysis of REP, the lack of clear separation between risk groups limits the usefulness of REP measurements as a screening biomarker of risk for sporadic large bowel neoplasia.

Lethal occult pulmonary hemorrhage in drug-induced thrombocytopenia.

A patient with drug-induced thrombocytopenia who died because of massive pulmonary hemorrhage is described. The patient had a clinical picture of acute respiratory distress resembling pulmonary edema, but there was no hemoptysis. Chest x-ray films showed granular density in the pulmonary fields, and the electrocardiograms revealed a pattern of acute biatrial enlargement. The diagnosis was confirmed at autopsy.

Cyclosporine-induced optic neuropathy, ophthalmoplegia, and nystagmus in a patient with Crohn disease.

PURPOSE: To report the cyclosporine-induced complications of optic neuropathy, partial external ophthalmoplegia, and other neurologic abnormalities. METHODS: Case report. A 22-year-old man with severe active Crohn disease developed bilateral optic neuropathy, nystagmus, external ophthalmoplegia, and ataxia on the fifth day of cyclosporine A (CyA) parenteral therapy. RESULTS: Cyclosporine therapy was discontinued as soon as toxic clinical manifestations appeared. Cyclosporine blood level detected then was 1,290 ng/ml (therapeutic level: 150 to 300 ng/ml). Partial external ophthalmoplegia improved dramatically; however, the patient's optic neuropathy progressed to optic atrophy, leaving the patient visually impaired. Various possible mechanisms for cyclosporine-induced neurotoxicity are discussed. CONCLUSION: It is important to closely monitor neuro-ophthalmologic and neurologic signs of patients treated with cyclosporine.

Is gastro-oesophageal reflux a factor in exercise-induced asthma?

Exercise-induced bronchoconstriction (EIB) occurs in the majority of patients with asthma. The relationship between asthma and gastro-oesophageal reflux (GER) is well defined, and the reports of exertional gastro-oesophageal acid reflux in healthy subjects, prompted us to study the relationship between EIB and GER. Following an overnight fast and medication withholding, 15 asthmatics and 15 normal subjects were placed on continuous monitoring of oesophageal pH and ECG. After baseline monitoring of oesophageal pH, at rest, for 30 min, spirometry was performed. Thereafter, the subjects underwent rigorous treadmill exercise for 8 min followed by spirometry, 10 min after running. Twelve out of 15 asthmatics and none in the control group demonstrated significant fall in FEV1 in response to exercise. However, only six out of 15 normal subjects and three in the asthmatic group had evidence of GER during or following exercise. We concluded that there is no significant correlation between EIB and GER in patients with asthma.

The role of video capsule endoscopy in the evaluation of iron deficiency anaemia.

It is widely accepted that chronic occult blood loss from the gastrointestinal tract is a major cause of iron deficiency anaemia. Endoscopists are often asked to evaluate iron deficiency anaemia and identify the source of bleeding. This review offers an effective diagnostic strategy for this common clinical problem. After investigating the normal upper and lower parts of the gastrointestinal tract, the source of bleeding remains unidentified in about 10% of patients. The existing guidelines for evaluation of iron deficiency anaemia in patients above the age of 45, who have undergone standard upper and lower gastrointestinal examinations, are limited to a "treat and observe" phase. Small bowel X-ray series fail to detect many mucosal lesions, particularly vascular ectasias. While enteroscopy offers direct visual inspection of the small bowel mucosa beyond the reach of the standard upper endoscopes, this instrument reaches only 80-120 cm beyond the ligament of Treitz and its sensitivity in identifying the source of bleeding varies (24-75% of patients). A new and conceptually simple approach to examining the entire small intestine is video capsule endoscopy of the small bowel. This review addresses the optimal role of video capsule endoscopy in iron deficiency anaemia patients and offers guidelines for the appropriate gastrointestinal evaluation in such patients.

Prevalence of short-segment Barrett's epithelium.

BACKGROUND/AIMS: The incidence of adenocarcinoma of the oesophagus has increased. Its major risk factor is Barrett's epithelium of which the sine qua non is microscopically diagnosed intestinal metaplasia. Short segment Barrett's epithelium may often be overlooked during routine endoscopy. In routine biopsies taken from normal-appearing mucosa of the distal oesophagus, the reported rates of short segment Barrett's epithelium in the distal oesophagus reached 36%. We compared these rates with the results obtained in a community hospital in Israel. METHODS: Consecutive patients undergoing oesophagogastroduodenoscopy were enrolled. Biopsy specimens taken from cardia, oesophagogastric junction and 2 cm above the oesophagogastric junction were stained with haematoxylin & eosin and Alcian blue. RESULTS: There were 112 study patients (mean age +/- SD 48. 9+/-18.3 years, 51.8% males). Nine (8.04%) patients had intestinal metaplasia (according to specimen from 2 cm above oesophagogastric junction), and symptoms of gastro-oesophageal reflux were found in only four (44.4%) of them. Of these nine patients, six (6.66%) had normal-appearing mucosa and three (3.33%) had macroscopic Barrett's epithelium. Alcian blue staining revealed two patients with intestinal metaplasia that haematoxylin & eosin staining had missed. CONCLUSION: We found an 8% prevalence of intestinal metaplasia compared to 18-36% reported in the literature. We also determined that the added advantage of routine biopsy was 5.4%.

Malabsorption due to a ventral hernia.

A case of malabsorption due to a stagnant loop which occurred in a huge ventral hernia is presented. The clinical course was relatively indolent with symptoms of malabsorption and occasional abdominal pain. Although rare, abdominal hernia can lead to malabsorption due to bacterial overgrowth as a result of stagnant loop.

Epidemiology of ulcerative colitis in the Jewish population of central Israel 1970-1980.

The epidemiology of ulcerative colitis (UC) was studied in the Jewish population of central Israel in a densely populated urban area of more than 1,400,000 inhabitants. The mean annual incidence for the years 1970-80 was 3.86/100,000, 3.94 in males, and 3.79 in females. The incidence rose from 2.67 in 1970 to 5.09 in 1979, the rise being similar in both sexes. This rise in incidence was found in 3 separate localities in the study area inhabited by communities of different extraction and age composition. The disease started most frequently between the ages of 25 and 29. The crude prevalence of UC in 1980 was 55.2/100,000. The age-adjusted prevalence in Israel-born Jews was 45.8, in Asia-Africa-born 48.5 and in Europe-America-born 52.7/100,000. Compared with our previous study in 1960-70 in the city of Tel Aviv-Yafo, the prevalence of UC was increased and the differences between the community groups have narrowed. This suggests an effect of environmental factors in the causation of ulcerative colitis.

Helicobacter pylori: seroprevalence and colorectal cancer.

BACKGROUND: Previous studies have published controversial results regarding a connection between Helicobacter pylori infection and colorectal cancer. One possible mechanism is increased gastrin secretion in subjects infected with H. pylori, insofar as gastrin is known to be a trophic factor for the colonic mucosa. OBJECTIVES: To investigate a possible role of gastrin secretion in H. pylori infection associated with colorectal cancer, and determine whether H. pylori infection is a factor in this disease. METHODS: The serum gastrin levels and the presence of H. pylori IgG antibodies were measured in 51 colorectal cancer patients and 51 control subjects. The cancer patients were also tested for carcinoembryonic antigen and CA 19-9. RESULTS: H. pylori IgG antibodies were found in the serum of 41 (80.4%) of the cancer patients compared to 32 (62.7%) of the control subjects (P = 0.05). A significant correlation was found between CA 19-9 (r = 0.3432, n = 49, P = 0.01) and seropositive H. pylori IgG antibodies in the serum of the cancer patients (odds ratio 2.43, and 95% confidence limit 0.99-5.95), but none between CEA and H. pylori IgG antibodies nor between the serum gastrin level and the presence of colorectal cancer. CONCLUSIONS: The results of this study indicate a significant association between seropositive H. pylori IgG antibodies and elevated CA 19-9 in colorectal cancer patients, but no correlation between the serum gastrin level and the presence of this cancer. H. pylori seropositivity is more prevalent in patients with colorectal cancer.

Results of gastrointestinal evaluation in 90 hospitalized iron deficiency anemia patients.

BACKGROUND: Chronic occult blood loss from the gastrointestinal tract is widely accepted as a major cause of iron deficiency anemia. OBJECTIVES: To evaluate the diagnostic yield of gastroscopy, colonoscopy and fecal occult blood testing of hospitalized IDA patients, plus follow-up. METHODS: IDA was defined as hemoglobin < 12.5 g/dl (men) and 11 g/dl (women), and serum iron < 50 g/dl. The study group comprised 90 patients (42% male) with a mean age of 65 +/- 15 years and mean Hb 8.1 g/dl. RESULTS: Gastroscopy and colonoscopy revealed a bleeding source in 28.8% and 14.4% respectively. Gastrointestinal symptoms were found in 23% of patients with diseases of the upper gastrointestinal tract and in 15.3% of the lower. The sensitivity of fecal occult blood tests in detecting lesions in the lower and upper GI tracts was 100% and 30.7% respectively. Forty-four patients (48.9%) were discharged from the hospital with IDA of unknown origin. Over the following year, 20 of the 44 patients required further hospitalization, and of these, 13 were found to have anemia. Of the remaining 24 patients who were not hospitalized again, 15 had anemia. Four patients (9%) had significant gastrointestinal lesions and two died during the follow-up. CONCLUSIONS: Fecal occult blood is a sensitive examination for lower but not for upper GI tract lesions.