Preferable colonic investigations for isolated abdominal pain.

OBJECTIVES: Isolated abdominal pain is seen as a poor indication for colonic investigations. The yield of serious pathology detected by optical colonoscopy (OC) has differed greatly in published series. This study aims to establish the yield of colonic investigations for isolated abdominal pain. METHODS: A retrospective analysis of the endoscopy database was undertaken on all OCs performed from 2000 to 2008. The yield of OCs for detection of pathology (polyps, cancers, and inflammatory bowel disease) was compared for the symptoms of abdominal pain, chronic diarrhea, or anemia. Data on computed tomographic colonographies (CTC), performed for isolated abdominal pain in 2008, were used to compare the yield of CTCs and OCs. RESULTS: Of the 8564 OCs and 525 CTCs performed, 5.4% and 8.2% were undertaken for isolated abdominal pain, respectively. The yield of OCs for overall pathology detection was not significantly different for abdominal pain (23.87%), compared to other indications (20.34-24.85%). The yield of pathology detection was not significantly different for CTC (20.93%) and OC. Colonic polyps were the most common pathology (OC 16.05%, CTC 18.6%). CONCLUSION: Colonic investigations undertaken for isolated abdominal pain had a high yield of incidental colonic pathology. The detection of polyps could be beneficial, but it does not explain the symptoms. CTC offers a less invasive way of detecting colonic pathology in such patients, while maintaining the same yield. If CTC is used as a first line of investigation, it could spare 75% of patients the colonoscopy procedure.

Endoscopic ultrasound: what is it and when should it be used?

Endoscopic ultrasound (EUS) is an increasingly available diagnostic and therapeutic tool used within the U.K. it has wide applications both in the gastrointestinal tract and mediastinum with its current main uses being in the staging of luminal malignancies and assessment of pancreatic and subepithelial lesions. The emergence of linear EUS has opened up new therapeutic avenues with fine needle aspiration, trucut biopsies, coeliac plexus blocks and transmural pseudocyst drainage all now possible. Future developments include localised brachytherapy/chemotherapy and alcohol ablation of unresectable pancreatic malignancies and EUS-guided endoscopic surgery.

Constitutive cyclo-oxygenase-2 does not contribute to the development of human visceral pain hypersensitivity.

BACKGROUND AND AIMS: Central sensitisation (CS), contributes to the development and maintenance of gastrointestinal pain hypersensitivity. Constitutive cyclo-oxygenase-2 (COX-2) contributes to central sensitisation in somatic pain hypersensitivity but its role in mediating visceral pain hypersensitivity is unknown. We therefore conducted a study to determine if COX-2 inhibition with Valdecoxib attenuates the development or early maintenance of CS in a validated human oesophageal pain hypersensitivity model. METHODS: Healthy volunteers were studied in two randomised, double blind, crossover studies in which pain thresholds (PT) to electrical stimulation were assessed in the proximal oesophagus, chest wall and foot, prior to and following a distal oesophageal acid infusion. Protocol 1: Valdecoxib, (40 mg) or matching placebo was given orally for 4 days prior to oesophageal acid infusion. Protocol 2: IV Parecoxib (40 mg) or saline was given 120 min after oesophageal acid infusion. RESULTS: Valdecoxib did not prevent the induction of secondary allodynia in the proximal oesophagus nor did it attenuate it following its establishment. Chest wall PT fell following oesophageal acid but foot PT remained unchanged; highlighting the development viscero-somatic convergence due to CS. Valdecoxib had no analgesic or anti-hyperalgesic effect on chest wall or foot PT. CONCLUSIONS: Neither the induction nor initial maintenance of acid induced oesophageal pain hypersensitivity is prevented by Valdecoxib, suggesting that constitutive spinal COX-2 does not contribute to the development or early maintenance of acute visceral central sensitisation.

Endoscopic balloon dilatation of Crohn's disease strictures: results from a large United kingdom series.

INTRODUCTION: Stricturing is a common complication of Crohn's disease. Endoscopic balloon dilatation (EBD) offers a valuable alternative to surgical intervention, but there are limited data on factors influencing its safety and efficacy. METHODS: A multicenter retrospective audit across 4 U.K. teaching hospitals was performed on the use of EBD for Crohn's strictures between 1998 and 2011. Demographics, smoking status, medications, C-reactive protein, endoscopic findings, and subsequent surgery at follow-up were recorded. Success of EBD was defined as symptomatic improvement without the need for surgery at follow-up. RESULTS: Seventy-nine patients (47 women; median age, 48 yr) were identified for this study. Forty-eight (61%) patients had ileocolonic anastomotic strictures, whereas the rest had de novo strictures. In total, 191 EBDs (range, 1-11; median 2) were carried out on 93 strictures (range, 1-5; median 1) over a median duration of 12 months (range, 1-84). There were no serious adverse events. Success at index EBD was 34%, with a further 43% achieving long-term benefit from additional EBDs. Eighteen (23%) patients required surgery. Time to surgery after the first EDB was 2.6 to 71.1 months (median, 12.8 mo). Longer Crohn's disease duration (P = 0.03) and high C-reactive protein (P = 0.008) were associated with an increased need for subsequent surgery. CONCLUSIONS: EBD was safe and effective in achieving long-term symptom improvement and avoidance of surgery in most patients. Prospective controlled trials are needed to evaluate the effect of other factors, including Crohn's disease phenotype, and the role of concomitant medication to identify those best suited to EBD.

Use of infliximab in the prevention and delay of colectomy in severe steroid dependant and refractory ulcerative colitis.

AIM: To determine if infliximab can prevent or delay surgery in refractory ulcerative colitis (UC). METHODS: UC patients who failed to have their disease controlled with conventional therapies and were to undergo colectomy if infliximab failed to induce a clinical improvement were reviewed. Patients were primarily treated with a single 5 mg/kg infliximab dose. The Colitis Activity Index (CAI) was used to determine response and remission. Data of 8 wk response and colectomy rates at 6 mo and 12 mo were collected. RESULTS: Fifteen patients were included, 7 with UC unresponsive or intolerant to i.v. hydrocortisone, and 8 with active disease despite oral steroids (all but one with therapeutic dosage and duration of immunomodulation). All the i.v. hydrocortisone-resistant/intolerant patients had been on azathioprine/6-MP < 8 wk. At 8 wk, infliximab induced a response in 86.7% (13/15) with 40% in remission (6/15). Within 6 mo of treatment 26.7% (4/15) had undergone colectomy and surgery was avoided in 46.6% (7/15) at 12 mo. The colectomy rate at 12 mo in those on immunomodulatory therapy < 8 wk at time of infliximab was 12.5% (1/8) compared with 100% (7/7) in patients who were on long-term maintenance immunomodulators (P < 0.02). CONCLUSION: Infliximab prevented colectomy due to active disease in immunomodulatory-naive, refractory UC patients comparable to the use of Cyclosporine. In patients, however, on effective dosage and duration of immunomodulation at time of infliximab therapy colectomy was not avoided.

Neurophysiologic assessment of esophageal sensory processing in noncardiac chest pain.

BACKGROUND & AIMS: Esophageal hypersensitivity is thought to be important in the generation and maintenance of symptoms in noncardiac chest pain (NCCP). In this study, we explored the neurophysiologic basis of esophageal hypersensitivity in a cohort of NCCP patients. METHODS: We studied 12 healthy controls (9 women; mean age, 37.1 +/- 8.7 y) and 32 NCCP patients (23 women; mean age, 47.2 +/- 10 y). All had esophageal manometry, esophageal evoked potentials to electrical stimulation, and NCCP patients had 24-hour ambulatory pH testing. RESULTS: The NCCP patients had reduced pain thresholds (PT) (72.1 +/- 19.4 vs 54.2 +/- 23.6, P = .02) and increased P1 latencies (P1 = 105.5 +/- 11.1 vs 118.1 +/- 23.4, P = .02). Subanalysis showed that the NCCP group could be divided into 3 distinct phenotypic classifications. Group 1 had reduced pain thresholds in conjunction with normal/reduced latency P1 latencies (n = 9). Group 2 had reduced pain thresholds in conjunction with increased (>2.5 SD) P1 latencies (n = 7), and group 3 had normal pain thresholds in conjunction with either normal (n = 10) or increased (>2.5 SD, n = 3) P1 latencies. CONCLUSIONS: Normal esophageal evoked potential latencies with reduced PT, as seen in group 1 patients, is indicative of enhanced afferent transmission and therefore increased esophageal afferent pathway sensitivity. Increased esophageal evoked potential latencies with reduced PT in group 2 patients implies normal afferent transmission to the cortex but heightened secondary cortical processing of this information, most likely owing to psychologic factors such as hypervigilance. This study shows that NCCP patients with esophageal hypersensitivity may be subclassified into distinct phenotypic subclasses based on sensory responsiveness and objective neurophysiologic profiles.