Position change during colonoscope withdrawal increases polyp and adenoma detection in the right but not in the left side of the colon: results of a randomized controlled trial.

BACKGROUND: It has been suggested that changing patient position during colonoscope withdrawal increases adenoma detection. The results of previous studies have been conflicting. OBJECTIVE: To evaluate whether routine position change during colonoscope withdrawal improves polyp detection. DESIGN: Randomized, 2-way, crossover study. SETTING: Teaching hospital. PATIENTS: A total of 130 patients attending for diagnostic colonoscopy. INTERVENTIONS: Patients undergoing colonoscopy had each colon segment examined twice: the right side of the colon (cecum to hepatic flexure) in the supine and left lateral position and the left side of the colon (splenic flexure and descending colon) in the supine and right lateral position. The transverse colon was examined twice in the supine position. MAIN OUTCOME MEASUREMENTS: The primary outcome measure was the polyp detection rate (≥1 polyp) per colon segment. Secondary outcome measures included the number and proportion of patients with ≥1 adenoma in each segment and adequacy of luminal distension (1 = total collapse and 5 = no collapse). RESULTS: Examination of the right side of the colon in the left lateral position significantly improved polyp detection (26.2% vs 17.7%; P = .01) and luminal distension (mean = 4.0 vs 3.5; P < .0001). Position change did not improve polyp detection in the left side of the colon (5.4% vs 4.6%; P = .99). There was no significant correlation between luminal distension and polyp detection in the right side of the colon (r = .03). LIMITATIONS: Single center and open study design. CONCLUSION: Examining the right side of the colon in the left lateral position increased polyp detection compared with examination in the supine position. Polyp detection in the left side of the colon was similar in the right lateral and supine positions. ( CLINICAL TRIAL REGISTRATION NUMBER: NCT01554098.).

Dedicated bleed units: should they be advocated?

BACKGROUND: Upper gastrointestinal haemorrhage (UGIH) is a common emergency, however, dedicated bleed units only exist in selected hospitals in the UK. OBJECTIVE: To evaluate the rebleeding and mortality rate of patients admitted with UGIH to a tertiary centre bleed unit in comparison with the current national standards and earlier unit performance in 1995-1998. METHODS: A retrospective case note review of demographics, the Rockall scores and final outcome was conducted for all patients admitted to the bleed unit over 24 months. RESULTS: Two hundred and fifty-five cases were identified with a mean age of 62 years and a median Rockall score of 3. Eighty-two percent of gastroscopies were performed within 24 h. Of these, 29% were undertaken after 5 p.m. Peptic ulcer and varices (15%) were the commonest diagnosis. The rebleeding (12%) and mortality rate (9%) were comparable with that of the units previous audit (P=0.47, 0.51, respectively) and the current national audit (P=0.58, 0.76, respectively). The number of patients requiring surgery has reduced from 6 to 0.4% in our unit over the last 8 years. Preendoscopy and postendoscopy Rockall scores were predictive of rebleeding (P=0.013, 0.045) and mortality (P=0.003, 0.01). CONCLUSION: This study has shown a consistently low rebleeding and mortality rate in patients with UGIH in a dedicated bleed unit. However there are limitations to the degree of improvements which can be demonstrated due to factors such as age and comorbidity.

Differential effects of varying concentrations of clostridium difficile toxin A on epithelial barrier function and expression of cytokines.

BACKGROUND: Presentation after Clostridium difficile infection may depend on the level of epithelial exposure to toxins. We investigated epithelial barrier function and expression of interleukin (IL)-8 and transforming growth factor (TGF)-beta in response to varying concentrations of C. difficile toxin A. METHODS: T84 cells were either preexposed or continuously exposed to C. difficile toxin A (0.01-1000 ng/mL). Barrier function was assessed by measurements of transepithelial electrical resistance. RESULTS: Preexposure to < or =10 ng/mL toxin A led to an increase in the release of TGF-beta 1, but there was no change in the expression of IL-8. In contrast, after preexposure to >10 ng/mL toxin A, there was enhanced expression of IL-8, but release of TGF-beta 1 was similar to that in control monolayers. After preexposure to >10 ng/mL toxin A, there was complete and irreversible loss of electrical resistance. At lower concentrations, loss of resistance across monolayers was followed by recovery, which was enhanced by all 3 recombinant isoforms of TGF-beta. Pretreatment with recombinant isoforms of TGF-beta or coculture with TGF-beta 3-expressing colonic subepithelial myofibroblasts was also protective. CONCLUSIONS: In C. difficile infection, the development and severity of colonic inflammation may depend on the exposure of intestinal epithelial cells to toxins and the expression of proinflammatory (IL-8) and protective (TGF-beta) factors.