High detection rate of adenomas in familial colorectal cancer.

BACKGROUND AND AIMS: Subjects with one first-degree relative (FDR) with colorectal cancer (CRC) <50 years old or two FDRs with CRC have an increased risk for CRC (RR 4-6). Current guidelines recommend colonoscopic surveillance of such families. However, information about the yield of surveillance is limited. The aim of the present study was to evaluate the outcome of surveillance and to identify risk factors for the development of adenomas. PATIENTS AND METHODS: Subjects were included if they fulfilled the following criteria: asymptomatic subjects aged between 45 and 65 years, with one FDR with CRC <50 years old (group A) or two FDRs with CRC diagnosed at any age (group B). Subjects with a personal history of inflammatory bowel disease or colorectal surgery were excluded. RESULTS: A total of 551 subjects (242 male) met the selection criteria. Ninety-five subjects with a previous colonoscopy were excluded. Two of 456 remaining subjects (0.4%) were found to have a colorectal tumour (one CRC and one carcinoid). Adenomas were detected in 85 (18.6%) and adenomas with advanced pathology in 37 subjects (8.1%). 30 subjects (6.6%) had multiple (>1) adenomas. Men were more often found to have an adenoma than women (24% vs 14.3%; p=0.01). Adenomas were more frequent in group B compared with group A (22.0% vs 15.6%; p=0.09). CONCLUSION: The yield of colonoscopic surveillance in familial CRC is substantially higher than the yield of screening reported for the general population.

Increased incidence of azathioprine-induced pancreatitis in Crohn's disease compared with other diseases.

BACKGROUND: Azathioprine is widely used in Crohn's disease. A major drawback is the occurrence of side-effects, especially acute pancreatitis. Acute pancreatitis is rarely seen when azathioprine is used for other diseases than Crohn's disease. AIM: To survey side-effects of azathioprine after liver or renal transplantation, for systemic lupus erythematosis, Wegener's granulomatosis, autoimmune hepatitis, rheumatoid arthritis, ulcerative colitis or Crohn's disease. METHODS: A computerized search using the term 'azathioprine' or 'imuran' was performed on the Hospital Information System of the university hospital Groningen, resulting in 1564 patients matching our criteria. RESULTS: Eleven of 224 patients with Crohn's disease experienced acute pancreatitis (4.9%) compared with two of 129 (1.5%) with autoimmune hepatitis, two of 388 (0.5%) after renal transplantation, one of 254 (0.4%) after liver transplantation. Acute pancreatitis was more prevalent in Crohn's disease compared with any other disease. Azathioprine-toxicity necessitating withdrawal occurred significantly (P < 0,05) more in rheumatoid arthritis (78 of 317), ulcerative colitis (20 of 94) and Crohn's disease (52 of 224) compared with systemic lupus erythematosis (five of 73), Wegener's granulomatosis (six of 85), autoimmune hepatitis (eight of 129), after liver transplantation (17 of 254) and after renal transplantation (22 of 388). CONCLUSIONS: Acute pancreatitis is strongly associated with Crohn's disease and rarely occurs with other underlying conditions. Overall azathioprine-induced toxicity and the necessity of withdrawal is more common in inflammatory bowel disease and rheumatoid arthritis compared with other diseases.

Late radiation injury of the rectum and sigmoid colon: barium enema findings in 92 patients.

We reviewed the findings on 169 contrast enema examinations in 92 patients with late radiation injury of the rectum and sigmoid colon, encountered over an 11-year period. The diagnosis was made by rectosigmoidoscopy in all patients. The limitations and pitfalls of both examinations were studied. The mean interval between radiotherapy and diagnosis was 1.7 years and the mean follow-up period was 3.5 years. The main radiological features varied from normal findings (15% of the initial examinations) to decreased distensibility of the bowel wall, intestinal fixation, mucosal and contour abnormalities, ulceration, stenoses and fistula formation. During follow-up, the number of all pathological findings increased. Pre-stenotic dilatation of the descending colon was always absent. The contrast enema examinations and endoscopies were found to be complementary. The barium enema showed the extent of the disease and accurately identified stenoses and fistulas, but underdiagnosed ulceration and overdiagnosed malignancy. Endoscopy allowed unequivocal detection of mucosal damage, especially ulceration, and was accurate in showing stenoses but sometimes failed to demonstrate fistulas. Moreover, in 25% of examinations it was impossible to examine the entire abnormal area.

[Severe lactic acidosis due to metformin therapy in a patient with contra-indications for metformin]. / Ernstige lactaatacidose bij metforminegebruik bij een patiënt met contra-indicaties voor metformine.

A 52-year-old woman with a medical history of diabetes mellitus type 2, chronic alcoholism and liver function disorders was hospitalized because of complaints of haematemesis, abdominal complaints and dyspnoea. This was due to a severe lactic acidosis caused by acute alcohol intoxication and the use of metformin. With bicarbonate infusion and haemofiltration, the lactic acidosis disappeared, but she developed a distributive shock with multiple organ failure and died 23 days after admission. Lactic acidosis is a rare but serious adverse effect of metformin. Almost all patients described had contraindications to the drug, like renal failure, liver disease, alcohol abuse, and intercurrent conditions causing hypoxia or ischaemia. It is important to be aware of the circumstances in which metformin should not be prescribed.

[Endovascular embolization in gastrointestinal hemorrhage]. / Endovasculaire embolisatie bij gastro-intestinale bloedingen.

The indications, the technique and the choice of materials for transcatheter embolisation in three patients are described. A 73-year-old woman with Henoch-Schönlein vasculitis was admitted with haematemesis and melaena. Angiography showed active haemorrhage in a branch of the pancreaticoduodenal artery. The common hepatic artery was catheterised up to the pancreaticoduodenal artery and superselective transcatheter embolisation was accomplished using polyvinyl alcohol (PVA) particles of 0.3-0.5 mm diameter. A 82-year-old woman with chronic cardiac decompensation developed serious haematemesis after a papillotomy. With the help of PVA particles the bleeding A. pancreaticoduodenalis inferior ramus posterior was embolised. Several days after a pancreaticoduodenectomy for a carcinoma of the papilla of Vater a 75-year-old man went into shock. The angiogram revealed haemorrhage of the right hepatic artery. With the combination of microcoils and a coaxial balloon catheter proximal of the bifurcation of the hepatic artery haemorrhage could be arrested. Haemorrhage did not recur and all patients could be discharged in good condition. When local anatomy has been changed by earlier surgery or when patients in bad general condition are concerned, transcatheter embolisation can offer the solution in active haemorrhage.

Age at diagnosis of inflammatory bowel disease influences early development of colorectal cancer in inflammatory bowel disease patients: a nationwide, long-term survey.

BACKGROUND: Data on clinical characteristics of patients with inflammatory bowel disease (IBD)-related colorectal cancer (CRC) are scarce and mainly originate from tertiary referral centres. We studied patient and disease characteristics of IBD-related CRC in a nationwide IBD cohort in general hospitals. Main outcome parameters were time to develop CRC, and factors associated with early CRC development. METHODS: All IBD patients diagnosed with CRC between 1 January 1990 and 1 July 2006 were identified using a nationwide automated pathology database (PALGA). Patient charts were assessed to confirm diagnosis and collect clinical data. Early CRC was defined as CRC diagnosed less than 8 years after IBD diagnosis. Statistical analysis was performed using descriptive statistics, independent t tests, binary logistic regression and Cox-regression analysis. RESULTS: Diagnosis of IBD-related CRC was confirmed in 251 patients (171 ulcerative colitis, 77 Crohn's disease, 3 unclassified colitis), 161 males (64 %). Median time from IBD diagnosis to CRC diagnosis was 12 years (IQR 4-20); 89 patients (35 %) developed early CRC. Type of IBD, gender, concomitant PSC, pseudopolyps, extent of inflammation, and medication use were not related to early CRC (p > 0.05). IBD diagnosis at older age (HR for 10 years older age 2.25; 95 % CI 1.92-2.63) was related to early CRC. Twenty-three patients (12 %) had been included in a surveillance programme prior to CRC diagnosis. Patients in the surveillance group had a significantly better tumor stage (p = 0.004). CONCLUSIONS: We emphasize the problem of a high proportion of IBD-associated CRCs developing before the recommended start of surveillance. Therefore, we suggest that older age at IBD onset could be an additional factor to start surveillance in IBD patients.

The endoscopic spectrum of late radiation damage of the rectosigmoid colon.

The endoscopic spectrum of late radiation damage to the rectosigmoid colon in 90 patients seen over a 10 year period (1973-1983) is presented. The main endoscopic findings were abnormalities of the mucosa with characteristic telangiectasis, luminal narrowing, superficial or deep solitary ulcers or more extensive diffuse ulceration and fistulae. A knowledge of the pathognomonic features may lead to early detection and treatment.