Advances in acute and chronic pancreatitis.

Acute pancreatitis (AP) and chronic pancreatitis are the third leading gastrointestinal causes for admissions and readmissions to hospitals in the United States. This review of articles published between 2019-2022 (December) from international sources identified four categories of crucial new findings: The report includes (1) New genetic pathogenic mutations (TRPV6); expected genetic outcomes in a Northern European population; (2) a new serum diagnostic marker for AP-fatty acid ethyl esters-distinguishing acute pancreatitis associated with alcohol; explanations of the impact of monocytes/macrophages on the inflammatory process that defines their future in diagnosis, staging, and treatment; (3) innovations in timing of per os low-fat, solid food intake immediately on admission; resolution of concepts of aggressive parenteral fluid intake; dramatic shifts to non-operative from operative treatment of infected pancreatic necrosis. Each modification reduced interventions, complications, and lengths-of-stay; and (4) authoritarian recommendations for medical treatment of chronic pain. These advances offer opportunities to initiate newly proven treatments to enhance outcomes, alter the natural history, and envision the future of two diseases that have no known cure.

Clinical and Genetic Characteristics of Colorectal Cancer in Persons under 50 Years of Age: A Review.

BACKGROUND: The incidence of colorectal cancer (CRC) in persons under the age of 50 years (EOCRC) is increasing even as the incidence of CRC in persons over age 50 is decreasing. This has led to recommendations to lower the age of CRC screening to age 45. It is not clear whether EOCRC is identical to CRCs in older patients or whether there are distinctive features between the two groups. AIMS AND METHODS: We reviewed the literature on the clinical and genetic aspects of EOCRC. RESULTS: We found that there is an increased likelihood of a strong genetic basis for EOCRC, but that at least 80% of cases do not come from the known high-penetrance cancer syndromes. Early-onset CRCs tend to occur in the distal colon or rectum, are more likely to be detected due to cancer-related symptoms, appear to be increasing in whites more than non-whites on a population-wide analysis, and are more likely to present in an advanced stage of disease. There are some unique genetic features of EOCRC, including an increased proportion of tumors with LINE-1 hypomethylation, and combined chromosomal and microsatellite stability. CONCLUSIONS: EOCRC deserves additional attention because of the high number of life years at risk with EOCRC, and the implications for earlier CRC screening. Additional focus is needed on determining whether some cases of EOCRC have a unique mechanistic basis.

Characterization and Identification of Colorectal Cancer in Persons Younger Than 50 Years.

The proportion of colorectal cancer (CRC) cases in persons younger than age 50, referred to as early onset CRC (EOCRC), has increased from 6% to 11% over the past 25 years, whereas the incidence of CRC has decreased in persons age 50 and older, referred to as late-onset CRC (LOCRC) in the United States.1 It is not known if EOCRC is caused by the same factors that cause LOCRC, or whether there are unique causes that alter the clinical features.2 This study was designed to analyze the clinical and genetic characteristics of EOCRC as presented at a community hospital.

Impact of a family history of colorectal cancer on the prevalence of advanced neoplasia at colonoscopy in 4,967 asymptomatic patients.

BACKGROUND AND AIMS: A family history of colorectal cancer is considered an independent risk factor for advanced neoplasia at colonoscopy. The expected outcome for screening colonoscopy in patients with a family history is not well established in all populations. METHODS: We designed a large, prospective study of an unselected population in San Diego, California to assess the impact of a family history of colorectal cancer on the prevalence of advanced neoplasia on screening colonoscopy. RESULTS: We evaluated 6,905 consecutive patients referred for colonoscopy between January 2005 and December 2006. Of the 4,967 who met the inclusion criteria, the mean age was 58.8 and consisted of 58.6% women. Overall 930 (18.7%) had neoplasia and 249 (5%) had advanced neoplasia, eight (0.16%) of which were cancer. The 4,967 patients were divided into 643 with and 4,324 without a family history of colorectal cancer. Of the 643 patients with a family history, 38 (5.9%) had advanced neoplasia, one of which was cancer. Of the 4,324 patients without a family history, 211 (4.9%) had advanced neoplasia including seven cancers. The relative risk for finding advanced neoplasia in patients with a single affected first degree relative was 1.21 (95% CI, 0.87-1.69; P = 0.31). CONCLUSIONS: A family history of one first-degree relative with colorectal cancer did not predict a significantly higher prevalence of advanced neoplasia at screening colonoscopy in this Southwestern cohort.

Colorectal cancer screening in women with endometrial cancer: are we following the guidelines?

INTRODUCTION: Colorectal cancer (CRC) is the most common gastrointestinal malignancy. There is an association between CRC and endometrial cancer (EC). Up to 10% of this linkage may be due to hereditary non-polyposis colorectal cancer but in the majority of patients a genetic disorder is not found. The National Comprehensive Cancer Network (NCCN) guidelines on CRC since 2005 have suggested that women with endometrial or ovarian cancer diagnosed at less than 60 years of age have CRC screening with colonoscopy beginning at age 40 or at time of diagnosis of the gynecologic tumor. We assessed our population of women with EC to determine if women were receiving CRC screening after a diagnosis of EC. METHODS: Electronic medical records of all women diagnosed at our institution with EC predominantly between 1997 and 2007 were reviewed. We assessed age at diagnosis, tumor type, family history of malignancy, CRC screening, and findings at CRC screening and recorded the information in a database. Patients were evaluated for the Amsterdam and Bethesda criteria. This study was approved by the Institutional Review Board. RESULTS: Two hundred sixty-seven women with EC were evaluated. The median age was 66; 39% were less than age 60 at diagnosis. Family history of CRC was present in 25 (9.4%) of EC patients. Of these women, 125 (46.8%) had CRC screening, with 12 (9.6%) being screened for CRC within 1 year of diagnosis and 33 (26.4%) screened for CRC before diagnosis of endometrial cancer. Of the women, 142 (53.2%) did not have CRC screening reported. Of the women screened, ten had adenomatous polyps with one of those polyps being greater than 1 cm, four had tubulovillous histology, and three had CRC. Colonoscopy was performed in 59.2% of women who underwent CRC screening. One woman met criteria for Amsterdam and Bethesda criteria. CONCLUSIONS: Less than half of women with EC received screening for CRC. Women who were screened had significant pathology in 13.6% of cases and 2.4% had colon cancer. The NCCN guidelines should be more aggressively followed by physicians who care for women. A prospective colonoscopy screening study on these women with EC to assess the yield and utility in screening in this population is needed.

Prevalence of advanced adenomas in small and diminutive colon polyps using direct measurement of size.

BACKGROUND AND AIMS: Most studies reporting polyp size use visual estimates. Determining the prevalence of advanced histology based on direct measurement of polyp size may help guide the management of polyps found at optical colonoscopy (OC) and CT colonography (CTC). METHODS: We designed a large, prospective study to assess the prevalence of advanced adenomas based on direct measurement of polyp size by a certified pathologists' assistant as reported in the pathology report. Patients between 40 and 89 years of age who presented for screening colonoscopy were included in our study. Advanced adenomas were defined as ≥10 mm or ≥25% villous features, high grade dysplasia or cancer. Polyps were divided by size into three groups: diminutive (≤5 mm), small (6-9 mm) and large (≥10 mm). If more than one adenoma was present, the most advanced was used for analysis. RESULTS: We evaluated 6,905 consecutive patients referred for colonoscopy between January 2005 and December 2006. Of the 4,967 who met the inclusion criteria, the mean age was 58.8 and consisted of 59% women. Overall, 930 (18.7%) had an adenoma; 248 (5%) were advanced adenomas including 8 (0.16%) cancers. Of 89 polyps≥10 mm, 76 (85%) had advanced histology; of 247 polyps 6-9 mm, 67 (27%) were advanced; of 1,025 polyps ≤5 mm, 105 (10%) were advanced. Thus, 172 of 248 (69%) patients with advanced adenomas had small or diminutive adenomas. CONCLUSIONS: Our data indicate the majority (69%) of advanced adenomas are <10 mm. Even among polyps≤5 mm, there was an appreciable prevalence of advanced adenomas (10%). These findings may help guide the management of sub-centimeter colon polyps found by OC or CTC.

Relative rates of missed diagnosis for colonoscopy, barium enema, and flexible sigmoidoscopy in 379 patients with colorectal cancer.

BACKGROUND: Failures of diagnosis of colorectal cancer by colonoscopy, barium enema, and flexible sigmoidoscopy have been demonstrated using various techniques. A relative assessment of these diagnostic tests for patients with colorectal cancer has not been reported. This study was designed to determine relative rates of failures for these tests when applied to diagnosis of colorectal cancer. METHODS: We created a database of patients with colorectal cancer diagnosed between 2000 and 2005. Records were reviewed for the results of colonoscopy, barium enema, and flexible sigmoidoscopy in the 3 years prior to diagnosis. An examination that was negative for cancer with no immediate follow-up was defined as a failure of diagnosis, either from inaccurate observation, failure to examine the entire colon, or failure of timely follow-up. The failure rates were compared. RESULTS: Three hundred seventy-nine patients, who had 421 examinations, were analyzed. The diagnosis of colorectal cancer failed in 60 of 379 patients (16%). These 60 patients had 71 examinations that failed to make the diagnosis: 25 of 282 colonoscopies (9%), 16 of 79 barium enemas (20%), and 30 of 60 flexible sigmoidoscopies (50%). These differences were statistically significant. CONCLUSIONS: Failure rates for colonoscopy, barium enema, and flexible sigmoidoscopy were 9%, 20%, and 50%.

Impact of adenoma size in distal colon on risk for advanced adenoma of the proximal colon.

Adenomas of the rectosigmoid colon are considered markers of risk for advanced adenomas of the proximal colon. However, studies report a wide variation in risk. This study was designed to determine the risk for advanced adenomas in the proximal colon in patients from a large, homogeneous population with an advanced or nonadvanced adenoma of the distal colon. We designed a prospective study of 7157 patients who were evaluated for neoplasia by flexible sigmoidoscopy and, when adenomas were found, by colonoscopy. Adenomas were considered advanced if they were > or =10 mm in size or had villous or dysplastic features. Ninety-seven patients had an advanced adenoma of the distal colon (Group A) and were compared with 183 patients who had a nonadvanced adenoma (Group B). Seven patients (7.2%) in Group A had an advanced adenoma of the proximal colon, compared with four patients (2.2%) in Group B (P < 0.05, relative risk = 3.3). When patients with adenomas of the distal colon >5 mm (Group C) were compared to patients with adenomas < or =5 mm (Group D), the prevalence of advanced adenomas of the proximal colon remained at 7% (10/143) for Group C but fell to 0.73% (1/137) for Group D (P = 0.011, relative risk = 9.6). By expanding the criteria for risk from adenomas of the distal colon to include all adenomas >5 mm, the relative risk for advanced adenoma of the proximal colon was increased threefold.

Impact of a family history of colorectal cancer on the prevalence of advanced adenomas of the rectosigmoid colon at flexible sigmoidoscopy in 3147 asymptomatic patients.

Flexible sigmoidoscopy is advised as a screening test for colorectal cancer for persons with a family history of late-onset colorectal cancer. The expected outcome for this approach is not well established. We designed a large, prospective study of an unselected population to assess the impact of a family history of one first-degree relative with colorectal cancer on the prevalence of advanced adenomas at screening flexible sigmoidoscopy. We evaluated 8121 patients referred for flexible sigmoidoscopy between 1997 and 1999 and 3147 patients met the inclusion criteria. The 3147 patients were divided into 210 with a family history of colorectal cancer and 2937 without a family history and analyzed for differences in the prevalence of advanced adenomas. Of the 210 with a family history, 3 had an advanced adenoma of the rectosigmoid colon (1.4%) Of the 2937 without a family history, 52 had an advanced adenoma of the rectosigmoid colon (1.8%), including 2 cancers. These differences were not significant. In conclusion, a family history of colorectal cancer had no impact on the prevalence of advanced adenomas in asymptomatic patients at screening flexible sigmoidoscopy. The prevalence rates for advanced adenomas and carcinomas of the rectosigmoid colon were low.

Impact of a family history of colorectal cancer on age at diagnosis, anatomic location, and clinical characteristics of colorectal cancer.

BACKGROUND: Among the risk factors for colorectal cancer (CRC) is a family history of colorectal cancer. Reliable evidence is needed regarding the clinical characteristics of cancer in patients with this history to determine if a change in the diagnostic approach is needed. AIM OF THE STUDY: This study set out to determine specific clinical outcomes in patients with CRC with a family history of one first-degree relative with sporadic colorectal cancer compared to control patients with colorectal cancer but without the family history. METHODS: We designed a case-control study of colorectal cancer registry data between 1988 and 1999. Patients with a family history of one first-degree relative with colorectal cancer were compared to those without the history with regard to four characteristics: age at cancer diagnosis, anatomic location of the cancer, presence of distal adenomas with proximal cancer, and stage of disease at diagnosis. RESULTS: Nine hundred and twenty-one patients met the inclusion criteria. Family history was positive in 124 patients. The demography of the populations was similar, except for mean age, which was 65 yr for men with a family history and proximal cancer compared to 70 yr for their counterparts without the family history (p = 0.03). The anatomic location of the cancer, presence of distal benign neoplasia when the cancer was proximal, and disease stage at diagnosis were not different between the groups. CONCLUSIONS: Men with a family history of sporadic colorectal cancer and proximal colon cancer were younger than men without the family history and proximal colon cancer. The overall results do not indicate that a change in the diagnostic approach is needed.

Incidence of advanced adenomas of the rectosigmoid colon three years and five years after negative flexible sigmoidoscopy in 4010 patients.

Flexible sigmoidoscopy is recommended for persons at average risk for colorectal cancer. A follow-up is advised in 3 to 5 years, although the outcomes are not well established. We designed a large, prospective study of an unselected population to measure the incidence of advanced adenomas at flexible sigmoidoscopy 3 and 5 years after an initial negative examination. Adenomas were considered advanced if they were villous, tubulovillous, high-grade dysplasia, adenocarcinoma, or > or = 10 mm in size. We evaluated 8121 patients referred for flexible sigmoidoscopy and 4010 met the inclusion criteria. Group 1 had flexible sigmoidoscopy between 3 and 4 years and Group 2 between 5 and 6 years after a negative examination. Group 1 included 1300 patients with an incidence rate for advanced adenomas of 0.9% (12/1300) and Group 2 included 2710 patients with an incidence rate for advanced adenomas of 1.1% (30/2710). When the two group were subdivided by the presence or absence of a family history of a first-degree relative with sporadic colorectal cancer, the incidence rates for advanced adenomas between the populations were not different. Our data indicate incidence rates of 0.9 and 1.1% for advanced adenomas at flexible sigmoidoscopy 3 and 5 years, respectively, after a negative flexible sigmoidoscopy, with no impact from a family history.