Giant villous adenoma of rectum- what is the malignant potential and what is the optimal treatment? A case and review of literature.

INTRODUCTION: Villous adenomas are dubiously benign lesions, which are difficult to interpret because of their malignant potential. Distal villous adenomas present with bleeding or mucus discharge. Giant adenomas are not amenable for endoscopic or transanal resection. Only few isolated cases have been reported by laparoscopic resection. We present our case of a circumferential giant villous adenoma of the rectum managed successfully by laparoscopic ultra-low anterior resection with colo-anal anastomosis with a review of literature in regard to their malignant potential. CASE REPORT: A 62-year-old lady presented with complaints of painless bleeding per rectum and a fleshy mass protruding from the anal canal which on digital rectal examination appeared a large soft velvety flat mass with mucus discharge. Colonoscopy showed circumferential irregular, friable, edematous mucosa in rectum extending for 15 cm. Computed tomography showed a large heterogeneously enhancing polypoid mass lesion in the rectal wall involving the entire rectum. The patient underwent laparoscopic low anterior resection with colo-anal anastomosis and protecting loop ileostomy. Histopathological examination of the resected specimen revealed villous adenoma of the rectum with moderate to severe dysplasia. DISCUSSION: Villous adenomas are sessile growths lined by dysplastic glandular epithelium, whose risk of malignancy is especially high up to 50% when greater than 2 cm in size. Large size, villous content, and distal location are all associated with severe dysplasia in colorectal adenomas. Large villous rectal tumors, particularly of circumferential type pose a great challenge for endoscopic or transanal removal. Henceforth, open or laparoscopic surgery is required for these cases. CONCLUSION: Giant rectal villous polyps are usually unresectable by endoscopic methods or transanal endoscopic microsurgery and are associated with a high rate of unsuspected cancer which requires a formal radical oncologic resection. As per current data, the combined risk of dysplasia/malignancy is about 83% with 50% risk of dysplasia and frank malignancy in 33% of cases of giant rectal villous adenomas of more than 8 cm in size. Laparoscopic colorectal resection is safe and effective.

[The incidence and clinical characteristics of proximal colonic polyps when the polyps are noted on rectosigmoid colon by colonoscopy].

BACKGROUND/AIMS: Colorectal cancer is the third most common type of cancer and second leading cause of cancer death overall. Recently, there has been an emphasis on primary screening for colorectal cancer with colonoscopy. In this study, we aimed to address clinical characteristics and incidence of colonic polyps according to location. METHODS: From January 2009 to December 2010, 6,417 total colonoscopic examinations were performed at Boramae Hospital in Seoul, Korea. We reviewed these patients retrospectively. The distal colon was defined as the rectosigmoid junction. RESULTS: Overall, 1,972 patients (31.3%) had one of more colorectal polyps. Total of 4,445 patients were excluded from this study because of combined advanced colorectal cancer, inflammatory bowel disease, or familial adenomatous polyposis. Patients who had only proximal polyps were 633 (32.1%), 530 patients (26.9%) had both proximal and distal polyps, and 809 patients (41.0%) had polyps only in the rectosigmoid region. The prevalence of the proximal polyps in patients with rectosigmoid polyps was found to be significantly related to the male gender and elderly patients. However, the prevalence of the proximal colonic polyps was not related to the size and number of rectosigmoid polyps. In 530 patients with both rectosigmoid and proximal colonic polyps, the characteristics of proximal colonic polyps as size and number were similar to those of rectosigmoid polyps. Advanced proximal adenomas without distal polyps were found in 25 (29.4%) patients whom were associated with size and pathology. CONCLUSIONS: We recommend total colonoscopic examination in all patients regardless of the size and number, especially in elderly males.

The Incidence and Clinical Characteristics of Proximal Colonic Polyps When the Polyps Are Noted on Rectosigmoid Colon by Colonoscopy / 대한소화기학회지

BACKGROUND/AIMS: Colorectal cancer is the third most common type of cancer and second leading cause of cancer death overall. Recently, there has been an emphasis on primary screening for colorectal cancer with colonoscopy. In this study, we aimed to address clinical characteristics and incidence of colonic polyps according to location. METHODS: From January 2009 to December 2010, 6,417 total colonoscopic examinations were performed at Boramae Hospital in Seoul, Korea. We reviewed these patients retrospectively. The distal colon was defined as the rectosigmoid junction. RESULTS: Overall, 1,972 patients (31.3%) had one of more colorectal polyps. Total of 4,445 patients were excluded from this study because of combined advanced colorectal cancer, inflammatory bowel disease, or familial adenomatous polyposis. Patients who had only proximal polyps were 633 (32.1%), 530 patients (26.9%) had both proximal and distal polyps, and 809 patients (41.0%) had polyps only in the rectosigmoid region. The prevalence of the proximal polyps in patients with rectosigmoid polyps was found to be significantly related to the male gender and elderly patients. However, the prevalence of the proximal colonic polyps was not related to the size and number of rectosigmoid polyps. In 530 patients with both rectosigmoid and proximal colonic polyps, the characteristics of proximal colonic polyps as size and number were similar to those of rectosigmoid polyps. Advanced proximal adenomas without distal polyps were found in 25 (29.4%) patients whom were associated with size and pathology. CONCLUSIONS: We recommend total colonoscopic examination in all patients regardless of the size and number, especially in elderly males.

One-year risk for advanced colorectal neoplasia: U.S. versus U.K. risk-stratification guidelines.

BACKGROUND: Guidelines from the United Kingdom and the United States on risk stratification after polypectomy differ, as do recommended surveillance intervals. OBJECTIVE: To compare risk for advanced colorectal neoplasia at 1-year colonoscopy among patients cross-classified by U.S. and U.K. surveillance guidelines. DESIGN: Pooled analysis of 4 prospective studies between 1984 and 1998. SETTING: Academic and private clinics in the United States. PATIENTS: 3226 postpolypectomy patients with 6- to 18-month follow-up colonoscopy. MEASUREMENTS: Rates of advanced neoplasia (an adenoma ≥1 cm, high-grade dysplasia, >25% villous architecture, or invasive cancer) at 1 year, compared across U.S. and U.K. risk categories. RESULTS: Advanced neoplasia was detected 1 year after polypectomy in 3.8% (95% CI, 2.7% to 4.9%) of lower-risk patients and 11.2% (CI, 9.8% to 12.6%) of higher-risk patients by U.S. criteria. According to U.K. criteria, 4.4% (CI, 3.3% to 5.4%) of low-risk patients, 9.9% (CI, 8.3% to 11.5%) of intermediate-risk patients, and 18.7% (CI, 14.8% to 22.5%) of high-risk patients presented with advanced neoplasia; U.K. high-risk patients comprised 12.1% of all patients. All U.S. lower-risk patients were low-risk by U.K. criteria; however, more patients were classified as low-risk, because the U.K. guidelines do not consider histologic features. Higher-risk U.S. patients were distributed across the 3 U.K. categories. Among all patients with advanced neoplasia, 26.3% were reclassified by the U.K. criteria to a higher-risk category and 7.0% to a lower-risk category, with a net 19.0% benefiting from detection 2 years earlier. Overall, substitution of U.K. for U.S. guidelines resulted in an estimated 0.03 additional colonoscopy every 5 years per patient. LIMITATIONS: Patients were enrolled 15 to 20 years ago, and quality measures for colonoscopy were unavailable. Patients lacking follow-up colonoscopy or with surveillance colonoscopy after 6 to 18 months and those with cancer or insufficient baseline adenoma characteristics were excluded (2076 of 5302). CONCLUSION: Application of the U.K. guidelines in the United States could identify a subset of high-risk patients who may warrant a 1-year clearing colonoscopy without substantially increasing rates of colonoscopy. PRIMARY FUNDING SOURCE: European Union Public Health Programme.

The frequency of advanced adenoma in consulting patients: a nationwide survey in Iceland (2003-2006).

AIM: To assess the frequency of advanced colorectal adenomas in consulting patients in Iceland. METHOD: The histological configuration of colorectal adenomas (CRA) found in 3603 patients was classified into tubular (TA), villous (VA) and serrated (SA) and the degree of neoplastic severity into low-grade dysplasia (LGD), high-grade dysplasia (HGD), carcinoma in situ (CIS), intramucosal carcinoma (IMC) and submucosal carcinoma (SMC). Advanced CRA were those showing HGD, CIS, IMC and/or SMCs. In patients with two or more adenomas, the adenoma with the highest degree of epithelial neoplasia was selected to record cases. RESULTS: Between 2003 and 2006 a total of 19424 endoscopic examinations (13572 colonoscopies and 5852 sigmoidoscopies) were performed in Iceland (mean, 4856 endoscopies per year). At histology a mean of 759.3 CRA per year were found. Thus, CRA were found in 15.6% of the colorectal endoscopies performed per year. Out of the 3037 CRA studied, 67% were TA, 29% VA and the remaining 4% SA. LGD was present in 79%, HGD in 15%, CIS in 2.4%, IMC in 1.9% and SMC in 1.9%. Consequently, out of 3037 CRA investigated, 652 (21.5%) were advanced CRA; 71% of these showed HGD, 11% CIS, 9% IMC and 9% SMC. Two-thirds of the 652 advanced CRA were advanced VA, and more than three-quarters of 58 advanced CRA with SMC, were advanced VA. CONCLUSION: Advanced VA displaying intraepithelial neoplasia (HGD and CIS) showed a propensity to evolve into invasive carcinoma. Accordingly, VA displaying HGD and CIS might be regarded as biological markers for predicting colorectal cancer risk. This is the first study in which the frequency of CRA and advanced CRA detected in consulting patients is reported on a nationwide basis.

[Diseases associated with bloodstream infections caused by the new species included in the old Streptococcus bovis group]. / Cuadros clínicos asociados a bacteriemia causada por las nuevas especies incluidas en el antiguo grupo Streptococcus bovis.

OBJECTIVE: We sought to identify possible diseases associated with bloodstream infections caused by new species of S. bovis group isolated in blood cultures and by studying patient records METHODS: Forty-four consecutive blood culture isolates initially designated S. bovis were further characterised using phenotypic methods Patient records were examined. RESULTS: We identified 15 Streptococcus gallolyticus subsp. gallolyticus, 24 Streptococcus gallolyticus subsp. pasteurianus, and 5 Streptococcus infantarius isolates in 44 BSI episodes. CONCLUSIONS: The association between S. bovis bacteraemia and endocarditis and/or colon carcinoma is highly dependent on the causative species. Streptococcus gallolyticus subsp. gallolyticus is a surrogate for endocarditis and/or bowel disease, whereas Streptococcus gallolyticus subsp. pasteurianus is a surrogate for hepato-biliary disease.

Prognostic significance of high-grade dysplasia in colorectal adenomas.

AIM: Colonoscopy to detect and remove polyps has contributed to a reduction in colorectal carcinoma. Three-year follow up is recommended for patients considered to be at high risk (at least three adenomas, adenoma ≥ 1 cm, villous or high-grade features). Our study focused on patients diagnosed with high-grade dysplasia with regard to initial management and follow up. METHOD: A search of patients who had had endoscopic removal of a high-grade adenoma was carried out. Patients with the following were excluded: follow up of < 1 year, polyposis syndromes, prior colon cancer and a diagnosis of adenocarcinoma within 6 months following initial diagnosis. RESULTS: Eighty-three patients treated between 1999 and 2007 for high-grade dysplasia (HGD) in a colorectal adenoma were identified. Over a median follow-up period of 4 years, 53 (64%) developed further adenomatous polyps. Among these, 7% had an adenoma with HGD or an adenocarcinoma. In all these patients, the initial high-grade adenoma was > 1 cm in diameter. Initial follow-up colonoscopy was performed on average 7 months following the initial diagnosis. Ten per cent of patients underwent prophylactic segmental resection, and 6% received argon laser therapy. CONCLUSION: The study demonstrates that patients who have a colorectal adenoma > 1 cm with HGD may be at high risk of developing further adenomas with HGD or carcinoma. Close follow up is warranted.

Treatment strategies and outcomes for rectal villous adenoma from a single-center experience.

OBJECTIVES: To analyze a 13-year, single-surgeon experience with villous adenoma of the rectum with respect to procedure, complications, recurrence, and cancer incidence. DESIGN: Retrospective review of patient and tumor characteristics, procedure, recurrence, and complications. SETTING: University hospital. PATIENTS: Patients who underwent excision of rectal villous adenoma. MAIN OUTCOME MEASURES: Complication, recurrence, and malignancy rates. RESULTS: Thirty-six patients underwent 30 transanal and 10 transabdominal excisions. Mean age was 66 years (range, 41-86 years) and mean follow-up was 25 months (range, 0.5-132 months). Mean tumor size was 3.0 cm (range, 0.5-11 cm) and the mean distance of the tumor from the anal verge was 4.9 cm (range, 0-10 cm). Preoperatively, 18 (45%) lesions harbored low-grade dysplasia while 17 (43%) had high-grade dysplasia. Postoperative pathology was discordant in 50% of patients, including 5 of 40 lesions (13%) that were recategorized as invasive cancer. Tumor size did not correlate with malignancy. The complication rate was significantly lower in transanal compared with transabdominal excisions (3.6% vs 50%, P = .005). There were 4 (12.5%) benign recurrences, all after transanal excisions. CONCLUSIONS: Complete excision is warranted for rectal villous adenomas, as biopsies were accurate only 50% of the time, and 1 in 8 patients had unsuspected cancer found after excision. Transanal excision with negative margins is associated with low recurrence and complication rates and is the preferred approach, even with large lesions.

Is metabolic syndrome a risk factor for colorectal adenoma?

BACKGROUND AND AIMS: Epidemiologic studies provide evidence for a link between obesity or diabetes and the risk for colorectal cancer. However, there is a lack of information about the relationship between metabolic syndrome and colorectal adenoma. Therefore, we investigated whether metabolic syndrome is a risk factor for colorectal adenoma. METHODS: We did a study for consecutive subjects who underwent colonoscopy as a screening exam at the Center for Health Promotion, Samsung Medical Center, from March 2004 to December 2005. According to the modified ATP III criteria, metabolic syndrome was diagnosed. We classified a total of 2,531 subjects into the adenoma group (n = 731) and the control group (n = 1,800), including normal colonoscopic finding, nonpolyp benign lesions, or histologically confirmed hyperplastic polyp. RESULTS: The prevalence for metabolic syndrome was 17% in the adenoma group and 11% in the control group. On the multiple logistic regression analyses, metabolic syndrome was found to be associated with an increased risk of colorectal adenoma (odds ratio, 1.51; 95% confidence interval, 1.18-1.93). Also, waist circumference among the individual components of metabolic syndrome was an independent risk factor for colorectal adenoma. An increased risk for metabolic syndrome was more evident for proximal than distal colon, for multiple (>/=3), and for advanced adenoma in the adenoma group. CONCLUSION: Metabolic syndrome was associated with colorectal adenoma. Abdominal obesity of the individual components of metabolic syndrome was an important risk factor for colorectal adenoma.

Incidence of advanced adenomas at surveillance colonoscopy in patients with a personal history of colon adenomas: a meta-analysis and systematic review.

BACKGROUND: Current guidelines stratify patients with a personal history of adenomas as low risk (ie, 1-2 small [<10 mm] adenomas at index colonoscopy) or high risk (> or =3 small adenomas or advanced adenoma at index colonoscopy) for recurrent advanced adenomas. Guidelines recommend longer intervals between surveillance colonoscopies for low-risk patients, but physicians frequently perform surveillance colonoscopy at shorter intervals for these patients. OBJECTIVE: Our purpose was to perform a meta-analysis about the incidence of advanced adenomas at 3-year surveillance colonoscopy among high- and low-risk patients. METHODS: Computer searches of MEDLINE, PREMEDLINE, and EMBASE were performed to identify appropriate studies. Study selection criteria were (1) study design--prospective or registry-based study, (2) study population--patients with a personal history of adenomas, and (3) intervention--completion of surveillance colonoscopy at an interval of > or =2 years. Data were extracted on (1) incidence of advanced adenomas at surveillance colonoscopy, (2) interval between colonoscopies, and (3) risk factors associated with recurrent adenomas. After the validity of study design was assessed and independent, duplicate data extraction was performed from selected trials, summary relative risks (RR) for the incidence of advanced adenomas at 3-year colonoscopy were calculated. RESULTS: Fifteen studies met study selection criteria, but only 5 studies stratified surveillance colonoscopy results according to findings at the index colonoscopy. Patients with > or =3 adenomas at index colonoscopy were more likely to have recurrent advanced adenomas than were patients with 1 to 2 adenomas: RR 2.52, 95% CI 1.07-5.97. Patients with adenomas with high-grade dysplasia at index colonoscopy were also at increased risk for recurrent advanced adenomas: RR 1.84, 95% CI 1.06-3.19. In the individual studies, increasing size of adenomas and increasing number of adenomas at index colonoscopy were the most commonly reported risk factors associated with recurrent advanced adenomas. No studies stratified surveillance colonoscopy results according to the definitions of low risk and high risk used in current guidelines. CONCLUSION: Few published studies stratify the incidence of advanced adenomas at surveillance colonoscopy according to index colonoscopy findings. In the future, large prospective studies or studies using pooled data from existing randomized controlled trial databases or polyp registries should be used to better define which patients are at low risk for advanced adenoma recurrence.

[Results of coloscopy screening in 2005--an Internet-based documentation]. / Ergebnisse der Vorsorge-Koloskopie 2005--Internet-basierte Dokumentation.

BACKGROUND AND OBJECTIVE: In October 2002 screening coloscopy was introduced into the National Cancer Prevention Programme in Germany. The results of an online registry are presented here. METHODS: Data from consecutive screening colonoscopies in the practices of the 280 participating gastroenterologists, performed in asymptomatic subjects, were collected in an online registry. Number and histology of colorectal polyps and carcinomas, complication rates of colonoscopy and polypectomy were registered. Advanced adenoma was defined as an adenoma >10 mm in diameter, with villous or tubulovillous histology, or presence of high-grade dysplasia. RESULTS: A total of 109989 colonoscopies (43% in males) were evaluated from October 2003 to July 2005. Tubular and villous adenomas were found in 16.2% and 3.8%, respectively, whereas invasive cancers were diagnosed in 0.7%. Advanced adenomas amounted to 6.1%.The majority of carcinomas were detected in early stages (UICC stages I and II in 48 and 22 %, respectively). -In most of the polyps immediate polypectomy was carried out. The complication rate was low and no deaths were observed: cardiopulmonary complications occurred in 0.10% of the colonoscopies, bleeding in 0.79% of polypectomies most of which were managed endoscopically (surgery in 0.04% of polypectomies). Perforation occurred in 0.02% of the colonoscopies and 0.10% of polypectomies. CONCLUSIONS: Neoplasias of the colon were detected in about 20% of persons who had taken part in a colonoscopy screening programme: most of the lesions were immediately removed by polypectomy. The high rate of early stages of colorectal cancers detected by screening colonoscopy is an indirect indicator of mortality reduction. In Germany screening colonoscopy has a low risk.

Simultaneous laparoscopic treatment for diseases of the gallbladder, stomach, and colon.

We describe a successful simultaneous laparoscopic treatment of a gallstone and gastric and colonic neoplasms. The patient was a 72-year-old man with epigastric discomfort. Abdominal ultrasound revealed a gallstone 2 cm in diameter. Gastroscopy revealed a 3-cm protruding submucosal tumor in the gastric fundus and colonoscopy revealed a 2-cm sessile lesion in the sigmoid colon. He underwent simultaneous laparoscopic treatment of the 3 organs because of the high risk of perforation or bleeding after gastric or colonic resection. This required the use of 5 ports, and a 3.5-cm incision was made in the left lower quadrant to access the 3 organs. The laparoscopic procedures consisted of cholecystectomy, partial stapled resection of the gastric fundus, and partial resection of the sigmoid colon. The histopathologic diagnoses were chronic cholecystitis, leiomyoma of the stomach, and tubulovillous adenoma with severe dysplasia of the colon. The operation took 183 minutes and blood loss was minimal. The patient started oral intake from the second postoperative day and was discharged uneventfully. He had from no postoperative complications or abdominal symptoms during a 15-month follow-up period. To our knowledge, this is a first successful clinical report of simultaneous laparoscopic treatment of 3 organ disorders.

Prospective evaluation of screening colonoscopy: who is being screened?

BACKGROUND: Universal access to medical procedures is deemed an advantage of the Canadian health care system. The purposes of this prospective study were to determine the degree to which the practice of colon cancer screening by colonoscopy differed among socioeconomic classes and to assess adherence to screening guidelines. METHODS: Consecutive patients scheduled to undergo colonoscopy at a single center between August 2000 and August 2002 completed a questionnaire that determined patient characteristics and indications for the procedure. The patients were divided into two groups: screening patients, defined as individuals who indicated they were undergoing colonoscopy for screening purposes and were asymptomatic, and a control group, which comprised patients undergoing colonoscopy because of symptoms. Statistical analysis was performed to determine if patients in the screening group had different characteristics with respect to socioeconomic class, compared with the control group. RESULTS: A total of 1088 patients completed the questionnaire: 707 (65%) had colonoscopy because of symptoms, compared with 381 (35%) who underwent a screening examination. Mean age and marital status were similar in both groups. Of all colonoscopy procedures, there was a significantly greater proportion of men undergoing colonoscopy for screening purposes: 199 (52.2%) vs. 294 (41.6%) in the symptomatic group ( p = 0.001). Based on the Cochran-Armitage test, patients in the screening group had significantly higher education levels ( p = 0.004) and household incomes ( p = 0.001). CONCLUSIONS: Income and education level, two indices of socioeconomic status, are statistically significantly higher in patients undergoing screening colonoscopy compared with those having colonoscopy for any other reason.

Villous adenocarcinoma of the colon and rectum: a clinicopathologic study of 36 cases.

Some colorectal adenocarcinomas show villous architecture with morphologic similarities to tubulovillous or villous adenomas. We reviewed 420 consecutive colorectal adenocarcinoma resection specimens and found that 95 tumors (23%) showed areas of villous architecture. Thirty-six tumors (8.6%) in 35 patients showed more than 50% villous architecture and were designated villous adenocarcinomas. Only 42% of the villous adenocarcinomas showed severe atypia and only 44% of the available pre-resection biopsies of these tumors were diagnosed as adenocarcinoma. Epithelial islands in desmoplastic stroma (EIDS) may be helpful in the diagnosis of these tumors. EIDS were found in 97% of the resection specimens for villous adenocarcinomas and none of 62 resection specimens for tubulovillous or villous adenomas. The presence of EIDS showed a 67% sensitivity, 100% specificity, and 100% predictive value in the diagnosis of villous adenocarcinoma in a blinded review of villous tumors. On review of the pre-resection biopsies of villous adenocarcinoma without a final diagnosis of adenocarcinoma, 40% showed EIDS. Clinical follow-up of the 35 patients with villous adenocarcinoma showed that only one died of colorectal adenocarcinoma (median follow-up, 46 months). This sole patient dying of colorectal adenocarcinoma showed a synchronous advanced stage of nonvillous adenocarcinoma at the time of diagnosis. Villous adenocarcinoma is a diagnostically challenging subset of colorectal adenocarcinoma, which appears to be associated with a favorable prognosis. Classifying these tumors as a special type of colorectal cancer may facilitate the development of diagnostic adjuncts and optimal treatment protocols.

High frequency of colorectal adenoma in patients with duodenal adenoma but without familial adenomatous polyposis.

BACKGROUND: Duodenal adenomas are extremely common in patients with familial adenomatous polyposis. However, it is uncertain whether patients with duodenal adenomas without familial adenomatous polyposis are at greater risk for colorectal neoplasia and, therefore, should routinely undergo surveillance colonoscopy. The aim of this study was to determine whether there is a correlation between non-papillary duodenal adenoma without familial adenomatous polyposis and colorectal adenoma. METHODS: Twenty-five patients with non-papillary duodenal adenomas without familial adenomatous polyposis, seen from January 1990 to April 2003, were retrospectively evaluated. RESULTS: Non-papillary duodenal polyps were diagnosed by endoscopy in the 25 patients. Of these, 21 underwent colonoscopy and one underwent proctoscopy. The mean age of these 22 patients (12 women, 10 men) was 69 years (range 50-83 years). Sixteen of the 22 patients (72.7%) with duodenal adenomas had associated colorectal adenomas. A total of 38 adenomas and one colorectal cancer were detected. The mean size of the polyps was 6.2 mm (range 3-15 mm). The adenomas were removed by snare excision or with a biopsy forceps. CONCLUSIONS: Based on the results of this uncontrolled, retrospective study, the frequency of colorectal adenomas in patients with duodenal polyps without familial adenomatous polyposis appears to be increased compared with the general population. All patients with duodenal polyps should undergo surveillance colonoscopy for colorectal adenomas. A prospective study to definitively establish the frequency of colorectal adenomas in these patients is warranted.

Screening colonoscopy in the asymptomatic 50- to 59-year-old population.

BACKGROUND: In an effort to decrease the death rate from colorectal cancer, a multitude of medical societies and task forces recommend routine screening for colorectal cancer beginning at age 50. Yet, there is no consensus as to the best and most cost-effective screening method. Medicare now pays for screening colonoscopies for its average risk beneficiaries [3]. Many insurance companies, however, will not cover this test in younger patients. We therefore reviewed our institution's colonoscopy experience with asymptomatic 50- to 59-year-olds, with negative fecal occult blood tests and negative family histories. METHODS: Between January 1999 and January 2002, 4779 colonoscopies were performed at our institution. The charts for 619 persons 50-59 years of age were retrospectively reviewed, with 91 patients meeting the strict requirements of this study. We defined polyps with high-grade neoplasias as those with villous or tubulovillous components, and cancerous lesions included those with carcinoma in situ. The distal colon was defined as the rectum and sigmoid colon. RESULTS: There was a 58% incidence of neoplastic polyps in this younger asymptomatic population. More than 4% of our subjects had high-grade neoplasias or cancerous lesions. In the absence of any distal findings, flexible sigmoidoscopy would have missed up to 38% of these polyps. CONCLUSIONS: The findings generally support the recommendations by the American College of Gastroenterology for average-risk patients to preferentially undergo a screening colonoscopy at age 50 in lieu of other methods.

Colon neoplasia co-existing with coeliac disease in older patients: coincidental, probably; important, certainly.

BACKGROUND: Coeliac disease and colorectal neoplasia are both common, present most often in patients over 40 and cause similar symptoms. Greater awareness and early use of serological tests have improved the diagnosis of coeliac disease, but raise the concern that co-existing colorectal neoplasia may be missed. This study assessed the prevalence of colorectal neoplasia among patients with coeliac disease diagnosed after the age of 40 who presented with altered bowel habit or iron deficiency. METHODS: All patients meeting the above criteria underwent colonoscopy unless this or barium enema had been performed shortly before. RESULTS: Of 69 patients with coeliac disease undergoing colonoscopy, 7 (10%) had colon neoplasia: 5 had tubulovillous polyps, and 2 had carcinoma. The prevalence figures for coeliac patients undergoing colonoscopy with iron deficiency and altered bowel habit alone were 11% (5 of 47) and 10% (2 of 22), respectively None of a further 13 who had undergone previous colon investigation (all by barium enema) had neoplasia, although these were probably a selected population. The seven patients with colorectal neoplasia had not reported rectal bleeding. The prevalence of colorectal neoplasia was not significantly higher than in two series of non-coeliac patients undergoing colonoscopy for investigation of iron deficiency (12%) or altered bowel habit (8%). CONCLUSIONS: There is a high prevalence of colorectal neoplasia among older patients with coeliac disease who present with iron deficiency or altered bowel habit, though this is no higher than for non-coeliac patients with these presentations. The possibility of dual pathology should be considered and excluded by colon investigation.

Colorectal carcinoma in ulcerative colitis is decreasing in Scandinavian countries.

A total of 31 cases with Ulcerative Colitis (UC) and colorectal carcinoma were retrieved from the files of the Karolinska Hospital, Stockholm between 1951 and 1998. Sections from 16 colectomy specimens (operable cases) and 15 biopsies obtained at laparotomy (inoperable cases), were available for the study. Of the 31 patients reported here, 22 (71%) were 49 years of age or younger at the time of surgery for carcinoma. In comparison only 47 (5.5 %) of the 855 colorectal carcinomas without UC reported in the Stockholm area in 1990 were 49years of age oryounger. When this hospital was a referral Center (1951 through 1969) 18 cases of carcinoma in UC were operated between 1951 and 1960 (1.8 patients/year), but only 4 between 1961 and 1969 (0.44 patients/year). During the surveillance period of 29 years (1970 to March 1998) only 9 patients (0.31 cases/year) were found to have carcinoma complicating UC. Notably, 8 of the 9 patients were operated on between 1970 and December 1989 (0.42 patients/year), but only one case between January 1990 and March 1998 (0.11 patients/year). The data presented indicate that the frequency of carcinoma cases in pancolitics has decreased at this hospital, not only during the referral period, from 1.8 patients/year during the 50's to 0.40 patients/year during the 60's, but also during the surveillance period (from 0.44 patients/year/during the 70's and 80's to 0.11 patients/year between 1990 and March 1998). This, despite the incidence of UC in the Stockholm County remained stable for the past 40 years (4.2 to 5 patients/10(5) inhabitants) and that the population in the Stockholm County has steady increased since 1950. A review of the present literature indicated that the ris for colorectal carcinoma in pancolitics is presently decreasing, not only in Sweden but also in other Scandinavian countries.

Adenoma velloso de colon y recto: su relación con el cáncer, nuestra experiencia / Colon and rectal villous adenomas: relation with carcinoma, our cases

Antecedentes: Se acepta que la mayoría de los carcinomas del colon se originan de la secuencia adenoma-carcinoma. El adenoma velloso tiene una elevada incidencia de transformación maligna. Su remoción es la mejor medida de prevención del cáncer. Lugar de realización: Servicio de Coloproctología del Hospital Británico de Buenos Aires. Objetivo: Evaluar la incidencia, localización, tratamiento y relación de los adenomas vellosos con el cáncer. Material y métodos: Entre los años 1998 y 1999, se evaluaron 583 pacientes con lesiones polipoideas de colon y recto. Se detectaron 99 adenomas vellosos en 97 pacientes (41 mujeres y 56 hombres), edad media 60 años (31-81). Sésiles 53 y pediculados 46. Se localizaban en recto 47 por ciento, y 27 por ciento en sigma. Resultados: Sin malignización 79,80 por ciento tratados por endoscopía, sin ricidiva. Con algún grado de atipía 20 (carcinoma focal sin invasión de la base 65 por ciento, con invasión de la base 35 por ciento). Tamaño: > 2 cm: 60 por ciento, 1-2 cm: 25 por ciento, < 1 cm: 15 por ciento, 30 por ciento tratados por endoscopía. Recidiva 2 por ciento (> 2 cm y ubicados en recto). Conclusiones: Los adenomas vellosos son los de mayor riesgo de degeneración y es la polipectomía endoscópica o quirúrgica el mejor método de prevención del cáncer (AU)