Usefulness of prognostic indices in upper gastrointestinal bleeding.

Upper gastrointestinal haemorrhage remains a significant cause of hospital admission, with mortality rates up to 14%. In order to standardise and improve care, various scoring systems (e.g. Rockall, Blatchford and Baylor) have been developed to identify those individuals at high risk of requiring treatment (transfusion, endoscopic or surgical intervention) or of re-bleeding or death. There is also increasing interest in the utilisation of scoring systems to identify individuals at low risk of complications, as these may be discharged early, possibly with outpatient endoscopy. Most scoring systems are developed to predict outcomes in non-variceal bleeding. However, several indices are used to predict the outcome of advanced liver disease, including Child-Pugh and the Model of End-Stage Liver Disease (MELD). This chapter reviews all these aspects of the various scoring systems.

Techniques for targeting screening in ulcerative colitis.

Patients with longstanding chronic ulcerative colitis are "at risk" of developing colorectal cancer. Approximately 1 in 6 patients will die as a result of colorectal malignancy, which can often be difficult to detect using conventional "white light" colonoscopy. New endoscopic techniques and technologies including the use of dye sprays, "chromoendoscopy", high magnification chromoscopic colonoscopy and recently chromoscopic assisted confocal laser scanning in vivo endomicroscopy have now been introduced to improve the diagnostic yield of intraepithelial neoplasia at screening colonoscopy. This review details the true "risk" of colorectal cancer complicating ulcerative colitis, discusses the objective evidence to support current endoscopic screening guidelines, and describes the imminent technological paradigm shift about to occur in the endoscopic management and detection of intraepithelial neoplasia.

Detection and treatment of early flat and depressed colorectal cancer using high-magnification chromoscopic colonoscopy: a change in paradigm for Western endoscopists?

Japanese researchers reported flat and depressed colorectal lesions in the 1980s. Such lesions were thought irrelevant to Western populations and described as "Phantom" or "Akitas" carcinoma. Many depressed neoplasms arise through the de novo pathogenic sequence and demonstrate early invasive characteristics. All investigators report difficulties in identifying flat and depressed lesions using conventional colonoscopy. Failure to detect and treat such lesions may be responsible for the current shortfalls in secondary colorectal cancer prevention. Given the introduction of colorectal cancer screening programs in the United Kingdom, Europe, and the United States, it is essential to re-evaluate the significance of flat lesions as applicable to Western cohorts and explore the safety and efficacy of new endoscopic technology and interventional therapeutics.