Accuracy and interrater reliability for the diagnosis of Barrett's neoplasia among users of a novel, portable high-resolution microendoscope.

The high-resolution microendoscope (HRME) is a novel imaging modality that may be useful in the surveillance of Barrett's esophagus in low-resource or community-based settings. In order to assess accuracy and interrater reliability of microendoscopists in identifying Barrett's-associated neoplasia using HRME images, we recruited 20 gastroenterologists with no microendoscopic experience and three expert microendoscopists in a large academic hospital in New York City to interpret HRME images. They prospectively reviewed 40 HRME images from 28 consecutive patients undergoing surveillance for metaplasia and low-grade dysplasia and/or evaluation for high-grade dysplasia or cancer. Images were reviewed in a blinded fashion, after a 4-minute training with 11 representative images. All imaged sites were biopsied and interpreted by an expert pathologist. Sensitivity of all endoscopists for identification of high-grade dysplasia or cancer was 0.90 (95% confidence interval [CI]: 0.88-0.92) and specificity was 0.82 (95% CI: 0.79-0.85). Positive and negative predictive values were 0.72 (95% CI: 0.68-0.77) and 0.94 (95% CI: 0.92-0.96), respectively. No significant differences in accuracy were observed between experts and novices (0.90 vs. 0.84). The kappa statistic for all raters was 0.56 (95% CI: 0.54-0.58), and the difference between groups was not significant (0.64 vs. 0.55). These data suggest that gastroenterologists can diagnose Barrett's-related neoplasia on HRME images with high sensitivity and specificity, without the aid of prior microendoscopy experience.

Obesity and colorectal adenomatous polyps.

Obesity has been investigated as a risk factor for various malignancies, including colon cancer. A case-control study was conducted on patients in three colonoscopy practices in New York City to determine possible risk factors for colorectal adenomatous polyps, a known precursor lesion for most cases of colorectal cancer. Among 301 case subjects with incidence adenomatous polyps (174 men and 127 women) and 506 control subjects (223 men and 283 women), an increased risk was observed with increasing body mass index in women (odds ratio 2.1, 95% confidence interval 1.1-4.0; for highest versus lowest quartile, linear trend P = .02). A nonsignificant trend was observed for men. The increased risk seen in women is consistent with prior observations regarding reproductive hormonal and dietary risk factors for colorectal cancer.

Recurrent adenomatous polyps and body mass index.

Interest in risk factors for the recurrence of adenomatous polyps derives from the use of recurrent adenomas as surrogate end points in longitudinal studies of invasive colorectal cancer. In this case-control study, the effect of increased body mass index (BMI) on the risk of recurrent adenomas was investigated. Subjects consisted of patients seen at three colonoscopy practices in New York City, all of whom had a previous history of adenomas. On index colonoscopy, recurrent cases had an adenoma, whereas controls were normal. Men and women were analyzed separately, with different logistic models developed using backward elimination from a full model containing the covariates age at diagnosis, age-at-highest-weight, pack-years of smoking, activity level, energy intake, and fat and fiber intake. Men in the upper quartiles of BMI were found to be at greater risk of recurrent adenomas. In a model which controlled for age at diagnosis, age-at-highest-weight, activity level, pack-years of smoking and kilocalories, the estimated odds ratios were 2.2, 1.9 and 1.9 respectively for the second, third and fourth quartiles compared to the first quartile. Only the estimate for the second quartile was found to be statistically significant. No effect was observed for women, even in a model which controlled for age at diagnosis, age-at-highest-weight, pack-years and total fat. Obesity may play a role in adenoma recurrence. Confirmation of this finding would have important implications for possible prevention strategies in the future.

Pitfalls in polypectomy: from gene to cure.

Unsuspected problems are commonly encountered during colonoscopic polypectomy. This paper identifies the most frequent difficulties and describes solutions to them. One of the most important pitfalls is overlooking a lesion or tumour in the colon; this can only be solved by better training, experience and care, although it may happen in the best of hands with the most knowledgeable colonoscopist. Other pitfalls addressed include the stuck snare, use of a gastroscope for the difficult sigmoid polyp, and methods to aid discovery and retrieval of the polypectomy specimen.

Cigarettes, alcohol, coffee, and caffeine as risk factors for colorectal adenomatous polyps.

The possible association of colorectal adenomatous polyps, a precursor lesion for colorectal cancer, with cigarette smoking, alcohol consumption, and coffee and caffeine consumption was investigated in a case-control study. Between April 1986 and March 1988, 271 cases of patients with pathologically confirmed incident colorectal adenomatous polyps and 457 control subjects were collected from three colonoscopy practices in New York City. Information on exposure was obtained by structured interviews. After adjustment of age, statistically significant odds ratios (highest-lowest quartile) were found for cigarette smoking in males (2.2; 95% confidence interval (CI), 1.2 to 3.8) and coffee consumption in females (2.0%; 95% CI, 1.0 to 3.9). No significant associations were obtained for cigarette smoking in females, for coffee consumption in males, or for alcohol or caffeine consumption. After adjustments for alcohol, coffee, and caffeine consumption, the association of adenomas with cigarette smoking remained in males and significant associations were also observed in subcategory analysis for both left-side and right-side adenomatous polyps. Adjustment for cigarette smoking eliminated the association between colorectal adenomatous polyps and coffee consumption in females. Cigarette smoking appears to be a significant risk factor for colorectal adenomatous polyps in males.

Endoscopy in inflammatory bowel disease: indications and differential diagnosis.

Colonoscopy with multiple biopsies adds a considerable amount of information to the overall clinical approach to the patient with inflammatory bowel disease. Because colonoscopy is an invasive procedure requiring a vigorous bowel clean-out, it is not a first-line investigative procedure for patients with inflammatory bowel disease. However, in certain indicated circumstances, colonoscopy can assist greatly in the management and diagnosis of patients with inflammatory bowel disease.

Colitis, cancer, and colonoscopy.

Colonoscopy has added a new dimension to the diagnosis of colonic diseases. In the field of inflammatory bowel disease, colonscopy is indicated only when certain specific problems arise. Patients with acute colitis and those who are too sick to withstand cleansing enemas should not undergo colonoscopy. A major use of the colonoscope is in the detection of carcinoma in the colitic colon either in the form of colonic strictures or filling defects discovered by barium enema x-ray, or in the long-term surveillance of patients with universal ulcerative colitis. Criteria are listed to assist in the colonoscopic differential diagnosis between ulcerative and granulomatous colitis. By using different criteria than the radiographer, and with the help of biopsy specimens, a high degree of accuracy in proper diagnosis can be achieved.

New methods of polypectomy.

The three most prominent advances in colonoscopic polypectomy are the submucosal injection of saline to ensure safety of polypectomy, the use of the small, or mini, snare for removal of most colon polyps, and the introduction of the argon plasma coagulator for the treatment of vascular abnormalities of the colon and the fulguration of residual adenoma at the base of sessile polyps with a noncontact technique. The role of Endoloop, endoscopic clips, and rubber band ligation for polypectomy is discussed.

Endoscopic mucosal resection of colon polyps.

The term submucosal injection polypectomy (SIP) more accurately describes the technique used for removal of flat colonic polyps and is preferred, in the colon, to endoscopic mucosal resection (a procedure that usually uses a special suction-activated device). Using SIP, most polyps can be removed safely from any part of the colon. The methodology is described in detail and is within the capability of most colonoscopists.

Complications of colonoscopy and flexible sigmoidoscopy.

Complications can occur during both diagnostic and therapeutic endoscopy. Most statistics concerning complications are based on reports generated when colonoscopy was in its infancy. This article examines the diagnosis and treatment of complications that arise during the course of both colonoscopy and polypectomy. Surgery may not be required in all cases. The criteria for operative or nonoperative treatment are presented.

Colonoscopic diagnosis of inflammatory bowel disease.

The indications and limitations of colonoscopy in the diagnosis of inflammatory bowel disease are well defined. The endoscopic examination is usually easily performed and well tolerated by the patient, but, since endoscopic examination of the colon is an invasive procedure (and potentially dangerous), colonoscopy should only be performed in those patients in whom the indication is clear and the benefits identifiable. Colonoscopy may provide valuable information in the diagnosis and may help outline the course of therapy in patients with inflammatory bowel disease.

Upper gastrointestinal endoscopy.

Upper intestinal endoscopy is a well-accepted method for evaluation of the esophagus, stomach, and duodenum. The techniques are standardized and extremely safe. The therapeutic capability for control of gastrointestinal hemorrhage is a major advance in the treatment of gastrointestinal bleeding. Endoscopic ultrasound is useful in the staging of upper intestinal malignancies. Above all, the ability to directly visualize the mucosal lining, to obtain biopsies, and to remove polyps has made endoscopy a primary tool for investigation of upper gastrointestinal pathology.

The evolution of gastrointestinal endoscopy at the Mount Sinai Hospital.

Gastrointestinal endoscopy came to The Mount Sinai Hospital in the 1950s, along with the Wolf-Schindler gastroscope. In 1961, it was supplemented by the Eder-Hufford semi-flexible esophagoscope and later by the Olympus gastrocamera and then the Hirschowitz fiberoptic instruments from ACMI and Olympus. A formal training program was started by Jerome Waye in 1966 for flexible gastroscopy and esophagoscopy. In 1969, endoscopic retrograde cholangiopancreatography (ERCP) was introduced. Colonoscopy was at first performed under x-ray control, and subsequently replaced by the nonfluoroscopic method of colonoscopic topography, which was developed by Dr. Waye. A full-time nurse who was in charge of the endoscopy unit founded the Society for Gastrointestinal Nurses and Assistants while working at The Mount Sinai Hospital.

Colonoscopy 'my way': preparation, anticoagulants, antibiotics and sedation.

Colonoscopy was introduced in the 1960s. The facility with which this technique is performed has been enhanced by vast improvements in instrumentation. In spite of this, physician attitudes concerning colonoscopy have changed little over the past several decades. The diet for precolonoscopic preparation has not been altered for 30 years. Colonoscopists have a great reluctance to use a new preparation instead of the 4 L electrolyte solution, perhaps because this was such a significant advance in colonoscopic cleansing, its predecessor being castor oil and enemas. Physicians continue to be wary of the patient who is taking acetylsalicylic acid in the absence of any studies that show that this is detrimental for polypectomy. The management of the patient on warfarin anticoagulation remains a subject for debate. As for antibiotic prophylaxis, most endoscopy units do not have a standardized approach, although there are good guidelines that, if followed, should decrease the risk of infective endocarditis. Sedation for the endoscopic examination is usually administered by the colonoscopist, although anesthesiologists may, in some countries (and in some defined areas of the United States) be the primary administrators of sedation and analgesia. The present article is a personal approach to the following issues: the preparation of the colon for an examination, current thoughts about anticoagulation and acetylsalicylic acid, antibiotic prophylaxis for colonoscopy and the technique for sedation out of the hospital.

Diverticular disease.

Diverticular disease comprises a spectrum of illness beginning with the irritable bowel syndrome and progressing to the life-threatening complications of diverticulitis and hemorrhage. Step-wise progression of this disease may be seen but is not invariably present; many patients with diverticulosis do not have preceding symptoms of the irritable bowel syndrome. The typical complaints of irregularity of bowel habits and abdominal pain will usually respond to the relatively new treatment modality of a high fiber diet with added wheat bran. Barium enema x-ray examination remains the primary diagnostic modality in the investigation of diverticular disease, and colonoscopy should be used only in the presence of certain specific circumstances. Surgery, aimed at the treatment of complications of this disease, has progressed to the point where one-stage extirpation of the diseased bowel is recommended.

Dysplasia and ulcerative colitis--a colonoscopic study.

Cancer will be found on colonoscopic biopsy in 11% of patients with chronic ulcerative colitis for over eight years' duration. Sixteen percent of patients with dysplasia will subsequently be found to have carcinoma of the colon. A total of 3% of patients in the high-risk group will have cancer of the colon. Endoscopic biopsies should be separated into those performed for diagnostic or surveillance purposes, so that meaningful and reproducible results will be obtained. Annual total colonoscopy and biopsies are recommended for surveillance purposes.