Hemorrhoids detected at colonoscopy: an infrequent cause of false-positive fecal immunochemical test results.

BACKGROUND: Colorectal cancer screening by fecal immunochemical tests (FITs) is hampered by frequent false-positive (FP) results and thereby the risk of complications and strain on colonoscopy capacity. Hemorrhoids might be a plausible cause of FP results. OBJECTIVE: To determine the contribution of hemorrhoids to the frequency of FP FIT results. DESIGN: Retrospective analysis from prospective cohort study. SETTING: Five large teaching hospitals, including 1 academic hospital. PATIENTS: All subjects scheduled for elective colonoscopy. INTERVENTIONS: FIT before bowel preparation. MAIN OUTCOME MEASUREMENTS: Frequency of FP FIT results in subjects with hemorrhoids as the only relevant abnormality compared with FP FIT results in subjects with no relevant abnormalities. Logistic regression analysis to determine colonic abnormalities influencing FP results. RESULTS: In 2855 patients, 434 had positive FIT results: 213 had advanced neoplasia and 221 had FP results. In 9 individuals (4.1%; 95% CI, 1.4-6.8) with an FP FIT result, hemorrhoids were the only abnormality. In univariate unadjusted analysis, subjects with hemorrhoids as the only abnormality did not have more positive results (9/134; 6.7%) compared with subjects without any abnormalities (43/886; 4.9%; P = .396). Logistic regression identified hemorrhoids, nonadvanced polyps, and a group of miscellaneous abnormalities, all significantly influencing false positivity. Of 1000 subjects with hemorrhoids, 67 would have FP results, of whom 18 would have FP results because of hemorrhoids only. LIMITATIONS: Potential underreporting of hemorrhoids; high-risk individuals. CONCLUSIONS: Hemorrhoids in individuals participating in colorectal cancer screening will probably not lead to a substantial number of false-positive test results.

Faecal immunochemical test accuracy in patients referred for surveillance colonoscopy: a multi-centre cohort study.

BACKGROUND: Given the increasing burden on colonoscopy capacity, it has been suggested that faecal immunochemical test (FIT) results could guide surveillance colonoscopy intervals. Against this background, we have evaluated the test accuracy of single and double FIT sampling to detect colorectal cancer (CRC) and/or advanced adenomas in an asymptomatic colonoscopy-controlled high-risk population. METHODS: Cohort study of asymptomatic high-risk patients (personal history of adenomas/CRC or family history of CRC), who provided one or two FITs before elective colonoscopy. Test accuracy of FIT for detection of CRC and advanced adenomas was determined (cut-off level 50 ng/ml). RESULTS: 1,041 patients provided a FIT (516 personal history of adenomas, 172 personal history of CRC and 353 family history of CRC). Five CRCs (0.5%) and 101 advanced adenomas (9.7%) were detected by colonoscopy. Single FIT sampling resulted in a sensitivity, specificity, PPV and NPV for CRC of 80%, 89%, 3% and 99.9%, respectively, and for advanced adenoma of 28%, 91%, 24% and 92%, respectively. Double FIT sampling did not result in a significantly higher sensitivity for advanced neoplasia. Simulation of multiple screening rounds indicated that sensitivity of FIT for advanced adenoma could reach 81% after 5 screening rounds. CONCLUSIONS: In once-only FIT sampling before surveillance colonoscopy, 70% of advanced neoplasia were missed. A simulation approach indicates that multiple screening rounds may be more promising in detecting advanced neoplasia and could potentially alleviate endoscopic burden.

Use of acid suppressive therapy more than 10 years after the endoscopic diagnosis of reflux esophagitis with specific emphasis to trademark and generic proton pump inhibitors.

BACKGROUND AND AIM: Reflux esophagitis needs maintenance therapy. Data on comparison between trademark and generic medications are not available. Complaints and use of acid-suppressive therapy 10 years after diagnosis were determined. METHODS: A total of 672 patients with esophagitis between 1998 and 2000 were reviewed. Patients received a questionnaire regarding the use of acid-suppressive therapy, dosage, compliance and satisfaction. The use of trademark and generic medications was assessed. The presence of reflux complaints was assessed via a questionnaire, and a symptom score was calculated using a five-point Likert scale. RESULTS: A total of 208 patients returned the questionnaire, of whom 161 (78%) used acid-suppressive therapy. Of the patients still on therapy, 72% (n = 116, group 1) had reflux complaints, while the remaining 45 patients (28%, group 2) were in remission. There was no difference in sex, age, or severity of the initially diagnosed reflux esophagitis. Patients in group 1 were significantly less compliant and satisfied compared to patients from group 2 (73% vs 96% and 83% vs 100%, P < 0.001, respectively). An equal number of patients in both groups used trademark and generic medications (P = not significant). The presence of reflux complaints, as well as the symptom score, showed no difference between users of trademark or generic medication. CONCLUSION: More than 10 years after the diagnosis, 22% of patients stopped using acid-suppressive therapy. Only a minority (28%) were in clinical remission, associated with significantly higher satisfaction and compliance to therapy, as compared to their symptomatic counterparts. There was no difference in effect and usage of trademark versus generic medication preparations.

A survey of abnormalities in the colon and rectum in patients with haemorrhoids.

BACKGROUND: Haemorrhoids are a common problem in daily practice. However, symptoms may also be caused by other abnormalities in the rectum or colon. Data on the presence of these abnormalities in patients with haemorrhoids is sparse. To examine the prevalence of abnormalities of the colon or rectum in patients with and without haemorrhoids, stratified for age. METHODS: In a 17-year period 1910 consecutive patients with haemorrhoids and 7936 patients without haemorrhoids were analysed retrospectively. All of these patients had an endoscopic examination for different clinical reasons. All significant endoscopic co-findings (diverticuli, polyps, cancer, angiodysplasia and varices, or colitis) were recorded. RESULTS: The patients were divided in 2 groups. Group 1 (n = 861 (45.1%)) consisted of patients with only haemorrhoids, group 2 (n = 1049 (54.9%)) consisted of patients with haemorrhoids and another endoscopic diagnosis. Patients in group 1 were significantly younger, mean age 55.3 +/- 14.1 years versus 67.4 +/- 12.1 years (p < 0.001), and underwent significantly more often a sigmoidoscopy, 11% versus 2% (p < 0.0001). Furthermore, endoscopic co-findings were found with increasing age. The majority of diverticuli, polyps, cancer and vascular lesions were detected in the age group above 50 years, while only colitis was more often present in the younger group. There was no significant difference in gender when group 1 and 2 were compared with the reference group. Diverticuli and angiodysplasia/varices occurred significantly more often in group 2. The other significant diagnoses were diagnosed more often in the reference group. CONCLUSION: In patients with haemorrhoids other abnormalities can be present. Especially in older patients the clinician must be cautious to attribute complaints solely to haemorrhoids.

[An unexpected cause of nausea]. / Een onverwachte oorzaak van misselijkheid.

An 88-year old woman had a sudden onset of nausea and vomiting. She had an end colostomy following a curative resection of rectal cancer six years earlier. As we suspected a high gastrointestinal obstruction, an abdominal CT scan was made. This showed a paracolostomic herniation, including herniation of the stomach.

The value of using fludeoxyglucose positron-emission tomography scan with respect to colorectal abnormalities-a cross-sectional study.

BACKGROUND: Fludeoxyglucose positron-emission tomography (FDG-PET) shows colic uptake regularly. Complementary colonoscopy is done. Aim: study the findings of colonoscopy. METHODS: All consecutive scans in 5 years were studied. Focal FDG uptake in colon and/or rectum were scored as + or ++. Clinical files and endoscopy reports were studied for final diagnosis. RESULTS: Focal FDG uptake was noted in 173 out of 2,075 scans (8.4%). Focal FDG activity was judged ++ in 73 patients (42.2%) and + in 100 (57.8%). The majority of colorectal cancers scored ++. Patients with ++ activity underwent or had undergone significantly more often a colonoscopy compared with patients with + activity, 82% versus 65% (P=0.02). FDG PET/CT was false positive with respect to polyp(s) or cancer in 13 cases (22%) of ++ FGD activity and in 38 cases of + FDG (P<0.001). In 25 patients a total of 69 polyps were not FDG avid. CONCLUSIONS: FDG-PET scanning is a useful tool in oncology. However, false-positive and false-negative findings with respect to colonic uptake are present in a significant number of patients. If the clinical condition and the potential prognosis allows the performance of colonoscopy this procedure should be done.

Yield of endoscopy of the lower digestive tract in relation to ethnic descent.

BACKGROUND: Not much is known of the yield of endoscopy in relation to ethnic descent. The aim is to study endoscopy of the lower digestive tract in relation to the ethnicity. METHODS: A prospectively collected dataset was used. Presence four endoscopic findings (diverticuli, polyps, colorectal cancer, and signs of inflammation) was studied. The patients were divided in four groups. Group 1 patients of Western descent, group 2 patients of Turkish descent, group 3 patients originating from Morocco, Northern Africa and the Middle East, and, group 4 patients of Asian descent. RESULTS: In group 1, 35,340 procedures were done in 24,223 patients, in group 2 this was 1,776 in 1,338 patients respectively. In groups 3 and 4 this was 465 in 371 patients, and 416 in 305 patients. There was no difference in gender between the four groups, the number of women undergoing endoscopy was higher in all groups. Overall abnormalities in colon and rectum were significantly more often seen in group 1. Colorectal cancer was significantly less often diagnosed in patients of groups 3 and 4. Polyp(s) were significantly less often seen in patients of groups 2 and 3. While diverticulosis of the colon was significantly more often diagnosed in patients of group 1. Signs of inflammation in colon and/or rectum were significantly more often seen in patients of groups 2, 3, and 4. CONCLUSIONS: There are clear differences in presence of colorectal abnormalities in patients from different ethnic descent. The implication of this finding in daily practice is not obvious.

The incidence of colorectal cancer in patients with previously removed polyp(s)-a cross-sectional study.

BACKGROUND: Years ago, it was established that removal of adenomas will lead to a lower incidence of colorectal cancer. This study aims to establish the occurrence of colorectal cancer in unselected patients after index colonoscopy with polyp removal. METHODS: A prospectively collected dataset on colonoscopy covering 25 consecutive years was used. Patients in who during the index (first) procedure a polyp(s) was removed were included. Excluded were patients with colorectal cancer and patients belonging to Lynch families. In case of cancer time after the index and previous procedure, tumor stage, histology of earlier removed polyps, localization of the tumor and demographics were noted. RESULTS: In 1,617 patients polyp(s) were removed. Thirty (1.9%) patients developed colorectal cancer. In 18 cases adenomas were removed during prior endoscopies. Five patients only had hyperplastic polyp(s). Nine patients with cancer already were older than 75 years when the previous endoscopy was done. Patients with adenomas prior to the cancer were older compared with patients with hyperplastic polyps [mean (SD): 71.6 (5.8) versus 64.2 (10.5) years, P=0.046]. The majority of cancers were located in the proximal colon (75%). The time between diagnosing cancer and the previous colonoscopy was mean 70.6 months with a median of 60.0 months (range, 12.0-167.0 months). CONCLUSIONS: It is concluded that follow-up after removal of polyps in normal daily practice is associated with a low incidence of developing colorectal cancer.

Tumor stage in patients operated for rectal cancer: a comparison of the pre-operative MR and the resection specimen, with specific attention to the effect of neo-adjuvant radiotherapy.

BACKGROUND: Evaluate the preoperative TN stage with MR and the postoperative stage with histology. METHODS: Patients diagnosed with rectal cancer (2002-2015) and a pre-operative MR were included. A chart review was done. Pathology reports were evaluated for the post-operative tumor stage. Down staging was defined as a lower disease stage in the resection specimen compared with the pre-operative MR. Upgrading ("progression") was defined as a higher disease stage in the resection specimen. The study was approved by ethical committee of the Zaans Medisch Centrum. RESULTS: From 176 out of 231 operated patients a pre-operative MR was available for evaluation. 142 patients (80.7%) underwent neo-adjuvant treatment; the remainder 19.3% underwent immediate surgery. Neo-adjuvant therapy resulted in significant down staging. However, almost 14% of patients had a higher TN stage as determined by the pre-operative MR. In patients who underwent immediate surgery the percentage with "progression" was 30%. The number of patients with stage 1 and 2 were higher in the group not treated with neo-adjuvant therapy. There was no significant difference in tumor stage as determined by histological examination of the resection specimen. CONCLUSIONS: The diagnostic accuracy of the MR is not perfect. Underestimation as well as overestimation of the tumor occurred both in the patients treated with radiotherapy as well as those who underwent immediate operation. As such, MR results should be interpreted with caution when devising a treatment strategy.

Endoscopic ultrasound in patients with obstructive jaundice and inconclusive ultrasound and computer tomography findings.

The clinical work-up of patients with presumed pancreaticobiliary obstruction is usually straightforward including laboratory investigation, abdominal ultrasound and computer tomography. Ultrasound and computer tomography may, however, yield inconclusive findings regarding underlying cause. We report a case series (n = 10) demonstrating the usefulness of endoscopic ultrasound in the work-up of patients with inconclusive ultrasound and computer tomography findings, clinically suspected of pancreaticobiliary cancer.

Outcome of rectal cancer after radiotherapy with a long or short waiting period before surgery, a descriptive clinical study.

BACKGROUND: Radiotherapy and surgery have shown to improve local control and survival in rectal cancer. There are two applied schedules; radiotherapy with a long or short waiting period before surgery. The effect on survival and recurrence of both schedules was studied. METHODS: All consecutive patients with rectal cancer in the period 2002-2008 were included. Data were gathered on survival, tumour stage, co-morbidity score, and cause of death. The patients were divided in three groups: group 1 patients undergoing surgery without neo-adjuvant radiotherapy; group 2 patients undergoing radiotherapy followed by immediate surgery; and group 3 patients treated with (chemo) radiotherapy followed by a longer waiting period. RESULTS: A total of 113 patients with rectal cancer underwent surgery. Twenty two patients in group 1, 71 patients in group 2, and 20 in group 3. There was no difference in gender, time to recurrence, co-morbidity score, or causes of death. Fifty percent of patients died due to non-cancer related causes. Mean age in patients of group 3 was significantly lower than in groups 1 and 2 (P=0.02). There was a trend towards a lower tumour stage in the patients of group 3. Overall five year survival was 32% in group 1, 48% in group 2, and 35% in group 3. CONCLUSIONS: Neo-adjuvant radiotherapy seems to be of benefit in daily practice in patients with rectal cancer. A longer waiting period results in down-staging. Clinicians have to be aware that many patients will die due to other causes than those related to the rectal cancer.

Factors associated with anxiety and depressive symptoms in colorectal cancer survivors.

BACKGROUND: Up to 37% of colorectal cancer (CRC) survivors report depressive and anxiety symptoms. The identification of risk factors for depressive or anxiety symptoms might help focus supportive care resources on those patients most in need. The present study aims to explore which factors are associated with heightened anxiety or depression symptom severity. METHODS: In this cross-sectional study, individuals diagnosed with CRC 3.5 to 6 years ago completed questionnaires on sociodemographic information, medical comorbidities, anxiety symptoms (Beck Anxiety Inventory), and depressive symptoms (Inventory of Depressive Symptomatology). The general linear model analysis of covariance was used to identify factors associated with heightened anxiety or depressive symptom severity. RESULTS: The sample included 91 CRC survivors, 40.7% women, mean age 69.1 years. A minority of CRC survivors had moderate (3.4%) or severe (2.3%) anxiety symptoms, and moderate (7.7%) or severe (0%) depressive symptoms. Shorter time since diagnosis and higher number of comorbid diseases were associated with higher anxiety symptom severity. Female sex and higher number of comorbid diseases were associated with higher depressive symptom severity. CONCLUSION: From this explorative study, it follows that survivors with multiple comorbid diseases, shorter time since diagnosis, and female survivors might be at risk for higher anxiety and/or depressive symptom severity. Survivors with these characteristics might need extra monitoring.

High Risk Stage 2 and Stage 3 Colon Cancer, Predictors of Recurrence and Effect of Adjuvant Therapy in a Nonselected Population.

Patients with stage 2 and stage 3 colon cancer often are treated with adjuvant chemotherapy. However, patients seen in daily practice have more comorbidity than those enrolled in clinical trials. This study aims to evaluate prognostic factors for recurrence and to ascertain the benefit of adjuvant chemotherapy on recurrence-free survival (RFS) of patients in a nonselected population. Furthermore, the impact of relative dose intensity (RDI) of adjuvant therapy on RFS is examined. Chart review was performed for 243 consecutive patients diagnosed and treated at a single center for stage 2 and stage 3 colon cancer from 2002 to 2008. Adjuvant chemotherapy was administered to 66 patients. Median overall survival (OS) was 5.84 years and median RFS was 5.37 years. For stage 2 disease, patients treated with or without adjuvant therapy had a median RFS of 5.49 and 5.73, respectively (p = ns). For stage 3 disease, median RFS rates were 5.08 and 1.19, respectively (p = 0.084). Overall RDI of oxaliplatin based chemotherapy higher than median was associated with increased RFS (p = 0.045). In conclusion, adjuvant therapy did not significantly increase recurrence-free survival. This could be the result of comorbidity in patients. Relative dose intensity of oxaliplatin based therapy is associated with RFS.

Impact of age and comorbidity on survival in colorectal cancer.

BACKGROUND: Patients with colorectal cancer are often excluded from clinical trials based on age or a poor performance score. However, 70% of colorectal cancer is diagnosed in patients over 65. Evaluation on the influence of age and comorbidity on survival and cause of death in a non-selected population. METHODS: Included were 621 consecutive patients with colorectal cancer. An extensive chart review was performed for 392 patients with colon cancer and 143 patients with rectal cancer. Analyses were performed separately for both groups. RESULTS: Median survival of colon cancer patients was 5.13 years, 131 patients (34.3%) died from tumour progression. Age and comorbidity were significant predictors for overall survival (P<0.001). Age was also a significant predictor of cause of death (P=0.001). In rectal cancer patients median survival was 4.67 years, 51 (35.7%) of patients died from tumour progression. Neither age nor comorbidity was significant predictors of survival. Age was a significant predictor of cause of death (P<0.001). CONCLUSIONS: In colon cancer patient age and comorbidity predict survival. This represents possible bias or a reduced survival benefit of treatment, and is an indication that colon cancer is not the prognosis defining illness in the majority of patients. In rectal cancer patients neither age or comorbidity significantly impacted survival.

Thirty days post-operative mortality after surgery for colorectal cancer: a descriptive study.

BACKGROUND: The goal of surgery for colorectal cancer is cure. Unfortunately post-operative mortality occurs. This study aims to identify co-morbidity and causes of mortality in the post-operative period in relation to direct technical complications of surgery. METHODS: All consecutive patients who underwent surgery for colorectal cancer were included. Co-morbidity was determined via the Charlson co-morbidity score. The post-operative course was studied and cause of death within 30 days was determined. Patients were divided in two groups: group 1 died within 30 days after surgery and group 2 survived for longer than 30 days. RESULTS: Twenty three out of 333 patients (6.9%) with colon cancer and 6 out of 112 (5.3%) with rectal cancer died in the post-operative period. Patients in group 1 were significantly older than patients in group 2 (P<0.001). Patients in group 1 with colon cancer also significantly had more often a higher stage of cancer (P=0.03). The Charlson co-morbidity score for patients with colon cancer in group 1 was mean 5.17 (SD 1.57, range, 1-8), and for rectal cancer mean 4.83 (SD 2.32, range, 2-7). There was no difference in Charlson co-morbidity score when patients from groups 1 and 2 were compared. In group 1, 13 (44%) died as a direct consequence of technical surgical complications. Sixteen patients died due to complications because of pre-existing co-morbidity. CONCLUSIONS: Post-operative mortality very often is the direct result of pre-existing co-morbidity and not always the direct result of the surgical procedure.

The Helicobacter pylori plasticity region locus jhp0947-jhp0949 is associated with duodenal ulcer disease and interleukin-12 production in monocyte cells.

Colonization with Helicobacter pylori always results in chronic gastritis, which is controlled by infiltration of mononuclear cells and the subsequent release of cytokines like interleukin (IL)-12. To identify H. pylori factors involved in inducing cytokine production in mononuclear cells, a random H. pylori mutant library was screened for the inability to induce IL-12 production in monocyte THP-1 cells. Of the 231 random mutants screened, one mutant (M1) showed a consistent twofold decrease in the amount of IL-12 induction compared to the parental strain 1061 (P <0.01). Further characterization of mutant M1 revealed that the kanamycin resistance cassette had integrated in the jhp0945 gene, which is situated in an H. pylori strain-specific plasticity region. Three reference strains possessing this plasticity region induced significantly higher amounts of IL-12 when compared to the H. pylori 26695 reference strain, which does not possess this plasticity region. The role in disease outcome of jhp0945 as well as the neighbouring plasticity region genes jhp0947 and jhp049 was assessed in a Dutch population cohort. Firstly, the presence of jhp0947 was completely linked with that of jhp0949 and was roughly associated with jhp0945 (P=0.072), but not with the cag pathogenicity island (PAI) (P=0.464). The presence of the jhp0947 and jhp0949 genes, but not of jhp0945, was significantly associated with duodenal ulcer disease when compared to gastritis (P=0.027). Therefore, the jhp0947-jhp0949 locus may be a novel putative H. pylori marker for disease outcome independent of the cag PAI.

The localisation of cancer in the sigmoid, rectum or rectosigmoid junction using endoscopy or radiology-What is the most accurate method?

INTRODUCTION: There is a difference in approach between colon and rectal cancer. AIM: EVALUATE THE METHODS OF LOCALISATION: endoscopy and radiology. MATERIALS AND METHODS: Patients with cancer in the sigmoid or rectum diagnosed with endoscopy, were included. Patients underwent additional radiological examinations. The resection specimen served as the gold standard. A tumour surrounded by serosa was considered a sigmoid cancer, surrounded by perirectal fat, than it was rectal cancer. If the frontal edge of the tumour showed serosa and the dorsal plane perirectal fat than the tumour was located in the "rectosigmoid". RESULTS: A total of 182 cancers were diagnosed. Of the 128 cancers with gold standard, endoscopy had the correct localisation in 112 (87.5%), and radiology in 114 (90.5%) cases. Concordance between both techniques was present in 80%. In 28 cases there was discordance. Radiology located 10 sigmoidal cancers wrongly in the rectum. One rectal cancer was placed in the sigmoid. In 16 cases the endoscopic localisation wrongly was the sigmoid. Sensitivity and specificity for endoscopy in sigmoidal cancer is 100% and 77% respectively, for rectal cancer 77% and 100%. Sensitivity of radiology for cancer in the sigmoid and rectum are 80% and 98% respectively. Specificity for both cancers is 98% and 80% respectively. CONCLUSIONS: The endoscopist and the radiologist should not be too overconfident with localisation of the tumour in cases of high rectal or low sigmoidal cancer.

Detection of the Helicobacter pylori dupA gene is strongly affected by the PCR design.

The Helicobacter pylori virulence gene dupA is usually detected by PCR, but the primer binding sites used are highly variable. Our newly designed qPCR against a conserved region of dupA was positive in 64.2% of 394 clinical isolates while the positivity rate of the commonly used PCRs ranged from 29.9% to 37.8%.

[A woman with invagination of the colon]. / Een vrouw met een colocolische invaginatie.

A 78-year-old woman presented at the emergency room with abdominal pain and diarrhea. At physical examination an abdominal tumour was palpated. The CT-scan showed an invagination of the colon, whereupon an explorative laparatomy was performed. A right-hemicolectomy was conducted and pathology showed an invasive mucineus cystadenocarcinoma in the caecum.