High complete resection rate for pre-lift and cold biopsy of diminutive colorectal polyps.

BACKGROUND AND STUDY AIMS: The majority of polyps removed at colonoscopy are diminutive (≤ 5 mm) to small (< 10 mm) and there are few guidelines for the best way for these polyps to be removed. We aimed to assess the feasibility and effectiveness of cold biopsy forceps polypectomy with pre-lift (CBPP) for polyps ≤ 7 mm. Our aims were to assess completeness of histological resection of this technique, to identify factors contributing to this and assess secondary considerations such as timing, retrieval and complication rates. PATIENTS AND METHODS: We conducted a prospective cohort study on consecutive patients receiving a colonoscopy at Cheltenham General Hospital, as part of the National Bowel Cancer Screening Program (BCSP) in England. The study included only polyps that were judged as ≤ 7 mm by the colonoscopist. A small sub-mucosal pre-lift injection was administered prior to removal of the polyp using cold biopsy forceps. One or more biopsies were taken until the polyp was confidently assessed visually as being completely removed by the colonoscopist. The entire polypectomy site was then removed en bloc by endomucosal resection (EMR) with a margin of at least 1 to 2 mm around defect. This was sent for histopathological analysis to assess completeness of resection. Polypectomy timing, tissue retrieval, number of bites required for visual resection and complications were recorded at the time of the procedure. RESULTS: Sixty-four patients were recruited and consented. Of them, 42 patients had a total of 60 polyps resected. Three patients had inflammatory polyps and were excluded from the study, leaving 57/60 polyps for final analysis. Seventeen were hyperplastic and 40 adenomatous polyps. Retrieval was complete for all 57 polyps and there were no complications both during or post- polypectomy. The complete resection rate (CRR) was 86 %. The technique was more effective in smaller polyps with 91.7 % of diminutive polyps (≤ 5 mm) completely excised. CONCLUSIONS: CBPP is a safe and highly effective technique for polyps < 5 mm with a high complete resection and retrieval rate. The time taken for the procedure is significantly greater than cold forceps alone, or cold snare as seen in other studies.

Outbreak of hepatitis A in the injecting drug user and homeless populations in Bristol: control by a targeted vaccination programme and possible parenteral transmission.

OBJECTIVE: To study the use of hepatitis A virus (HAV) vaccination in controlling an outbreak of HAV in inner-city Bristol among injecting drug users (IDUs). To study whether hepatitis C virus (HCV) and hepatitis B virus (HBV) co-infection increases morbidity. DESIGN: Community-based cohort study. SETTING: Avon Health Authority area, UK. PARTICIPANTS: All laboratory-confirmed cases of HAV infection notified in 2000. INTERVENTION: Administration of a targeted vaccination, education and liaison programme. MAIN OUTCOME MEASURES: Number of cases of HAV before and after introduction of HAV vaccination programme. Mortality and number of patients requiring hospital admission. Association of HCV and HBV co-infection with hospital admission. RESULTS: Ninety cases of HAV were reported in the first 6 months of 2000, of whom a substantial number were IDUs and/or inner-city hostel residents. In the second 6 months of 2000, following the introduction of a vaccination programme among homeless people, hostel residents, and IDUs, the number of HAV cases fell to 33. Sixteen patients had evidence of HCV co-infection. No patient had chronic HBV infection. Two patients died as a result of HAV, and two subsequently died from drug misuse. Fifty-six per cent of HCV-co-infected patients required admission to hospital compared with 28% non-HCV-co-infected patients. CONCLUSIONS: This is the first reported successful use of vaccination to control an outbreak of HAV in a population of IDUs and to prevent transmission to the wider population. HCV co-infection appears to increase the severity of HAV illness, as demonstrated by increased incidence of hospital admission.

Patients over 45 years with iron deficiency require investigation.

BACKGROUND: Iron deficiency anaemia (IDA) that occurs in patients above the age of 45 years is often caused by gastrointestinal blood loss, and guidelines on the appropriate investigation of these patients have been published. There are few data regarding patients with iron deficiency who are not anaemic and it is not clear how these patients should be managed. OBJECTIVES: We set out to investigate the hypothesis that similar pathologies are likely to underlie iron deficiency and IDA, and to assess whether IDA was being investigated according to the guidelines published by the British Society of Gastroenterology (BSG). METHODS: The pathology computer identified 153 consecutive patients over the age of 45 years who had serum ferritin levels below 20 microg/dl (normal range 20-200 microg/dl) in a 2 month period (i.e., October and November 2000). Medical records were examined and we recorded all investigations, the diagnoses reached, and the investigating specialty. The results were compared using odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: The study shows that the causes of iron deficiency and IDA are similar, but IDA is investigated more thoroughly than iron deficiency, OR 2.07 (CI 1.08-3.97). Ten patients with iron deficiency without anaemia were found to have coeliac disease, a significant result, OR 6.71 (CI 1.38-32.6). The majority of patients with IDA are not under the care of a gastroenterologist and this group are significantly less likely to be investigated according to the BSG guidelines, OR 0.15 (0.04-0.6). CONCLUSIONS: The study shows that the yield of investigation of iron deficiency is high and, hence, it should be investigated in all patients over the age of 45 years. Despite guidelines published by the BSG, IDA is investigated sub-optimally and measures other than the issuing of guidelines are needed to change practice.