Quantification of gastric mucosal microcirculation as a surrogate marker of portal hypertension by spatially resolved subdiffuse reflectance spectroscopy in diagnosis of cirrhosis: a proof-of-concept study.

BACKGROUND AND AIMS: Portal pressure can be used to identify patients with chronic liver disease who have progressed to cirrhosis. Portal pressure can also provide accurate prognostication for patients with cirrhosis. However, there are no practical means for assessment of portal pressure. Although it is well established that the gastric mucosal blood supply increases in patients with cirrhosis, this has been difficult to quantify reproducibly. Our group has developed a novel spectroscopic technology called spatially resolved subdiffuse reflectance spectroscopy (SRSRS), which enables quantification of mucosal microcirculation. We aim to ascertain if quantification of the gastric mucosal microcirculation with SRSRS correlates with clinical evidence of portal hypertension. METHODS: Patients undergoing EGD for clinical indications had 10 measurements taken in the endoscopically normal gastric fundus via SRSRS probe to assess the microcirculation. Cases were defined as patients with cirrhosis (n = 18), and controls were those without evidence of liver disease (n = 18); this was corroborated with transient elastography. RESULTS: The blood volume fraction (P = .06) and subdiffuse reflectance (P = .02) from a shallow depth in the gastric fundus were higher in patients with cirrhosis than those without. These markers were combined to yield an overall optical marker that can differentiate patients with cirrhosis from controls with a sensitivity of 72% and specificity of 94% (area under receiver operating curve, 0.82). CONCLUSIONS: Spectroscopic quantification of gastric fundal mucosal microcirculation is a promising surrogate of clinical correlates of portal hypertension. This approach may represent a less-intrusive surrogate biomarker for liver disease prognostication and potentially response to therapy.

Primary Intestinal Lymphangiectasia.

A high-protein, low-fat diet supplemented with medium chain triglycerides (MCT) is the simplest, most effective, and most widely prescribed treatment with the fewest side effects. Octreotide has been helpful in cases in which treatment with MCT has failed, but it is costly and requires parenteral administration. Antiplasmin therapy may have some role when evidence of increased fibrinolysis is present. Surgery is reserved for palliation of large ascites or resection of isolated lesions.

Endoscopic diagnosis and management of hereditary nonpolyposis colorectal cancer.

PURPOSE OF REVIEW: Hereditary nonpolyposis colorectal cancer (HNPCC) is an autosomal dominant condition that accounts for 2 to 7% of all colorectal malignancies diagnosed annually. Endoscopic surveillance affords a rational strategy for reducing HNPCC-associated colorectal cancer incidence and mortality. The primary objective of this review is to highlight evidence supporting the role of endoscopy, particularly colonoscopy, in the preventive management of HNPCC. Clinical features, diagnostic criteria, and use of genetic testing to identify high-risk patients who warrant surveillance will also be discussed. RECENT FINDINGS: Colonoscopic surveillance has been shown to be an effective strategy for reducing HNPCC-associated colorectal cancer incidence and mortality. Current recommendations for the appropriate use of colonoscopic surveillance are based on an understanding of the natural history of the disease and the ability to identify high-risk individuals using both clinical criteria and genetic testing. High-risk individuals should undergo surveillance every 1 to 2 years beginning at age 20 years and then annually after age 40. Endoscopic surveillance is also recommended every 1 to 2 years following surgical resection of an HNPCC-associated cancer or adenoma because of the high rate of metachronous tumors. SUMMARY: Endoscopic surveillance remains the mainstay of preventive management of HNPCC. Appropriate use of genetic testing can aid in the identification of high-risk individuals and thereby optimize cost-effectiveness of this approach.

On-site screening sigmoidoscopy promotes long-term utilization but fails as a venue for training primary care endoscopists.

BACKGROUND & AIMS: "Academic detailing" is an effective strategy for promoting the use of screening sigmoidoscopy by primary care physicians. The primary objectives of this study were to determine whether the sustained presence of an "outside" university-based gastroenterologist performing on-site screening sigmoidoscopy promoted long-term utilization and whether the provision for on-site sigmoidoscopy was an effective venue for training primary care endoscopists. METHODS: Nine urban community health centers, including 4 intervention and 5 control sites, participated in a nonrandomized controlled trial conducted over 3 years. RESULTS: By the end of year 3, overall self-reported use of screening sigmoidoscopy increased by 61% for the intervention group vs. only 25% for the comparison group (P = 0.001). Ninety-seven percent of those reporting compliance referred 1 or more asymptomatic average-risk patients for screening examinations. Only 2 of 83 (2.4%) eligible providers completed on-site training and continued performing screening examinations independently. The major barriers to participation included lack of interest, lack of time to learn or perform sigmoidoscopy, concerns about technical competence, and lack of need because of on-site availability. CONCLUSIONS: Maintenance of on-site screening sigmoidoscopy services performed by an outside gastroenterologist promotes long-term utilization but fails as venue for training primary care endoscopists. Alternative strategies for expanding capacity are needed.