Flat and depressed colorectal tumours in a southern Swedish population: a prospective chromoendoscopic and histopathological study.

BACKGROUND: Flat and depressed colorectal tumours are common in Japan but are very rare or non-existent in Western countries. AIMS: To study the occurrence of flat colorectal tumours in a southern Swedish population. METHODS: In this prospective study, 371 consecutive European patients were examined by high resolution video colonoscopy combined with chromoendoscopy. The nature of the lesions was determined by histopathological examination. RESULTS: A total of 973 tumours were found; 907 (93.2%) were protruding and 66 (6.8%) were flat or depressed. Of the flat/depressed tumours, five (7.7%) were early adenocarcinomas infiltrating the submucosa. Eleven carcinomas (1.2%) were found among protruding tumours. High grade dysplasia was observed in 18% (n=11) of flat/depressed adenomas in contrast with 7.3% (n=65) of protruding adenomas, and occurred in smaller flat/depressed tumours compared with protruding ones (mean diameter 8 mm v 23 mm, respectively). Furthermore, high grade dysplasia was significantly more common in flat elevated tumours with central depression or in depressed adenomas (35.7%; 5/14) than in flat elevated adenomas (12.8%; 6/47). CONCLUSION: Flat and depressed tumours exist in a Western population. Future studies should address whether or not chromoendoscopy with video colonoscopy is necessary in the search for flat colorectal neoplasms.

Gastroduodenal tolerance of 75 mg clopidogrel versus 325 mg aspirin in healthy volunteers. A gastroscopic study.

BACKGROUND: Clopidogrel is a new antiplatelet agent that offers increased protection over aspirin in preventing vascular ischaemic events in patients with symptomatic atherosclerosis. In a large, randomized, international study of clopidogrel and aspirin (n = 19,185 patients) clopidogrel was associated with a lower incidence of gastrointestinal adverse events, including gastrointestinal haemorrhage and hospitalizations because of gastrointestinal haemorrhage. The aim of the study was to determine whether macroscopic differences in the gastric mucosa between aspirin- and clopidogrel-treated subjects could be detected by gastroscopy after short-term treatment. METHODS: Thirty-six healthy volunteers were randomized in a double-blind, double-dummy, parallel design, to 75 mg/day of clopidogrel or 325 mg/day of aspirin for 8 days. Gastroscopy was performed at base line before administration of study drug and directly after treatment completion. Gastroduodenal effects were measured in accordance with a modified Lanza scale. RESULTS: At base line no difference between the groups was detected (median Lanza score, 0.0 in both groups). At the end of treatment the aspirin group showed a median score of 7.5, and the clopidogrel group showed an unchanged median score of 0.0 (P < 0.001). In the aspirin group 13 individuals reported 19 adverse events versus 8 individuals and 13 adverse events for clopidogrel, with approximately half of the adverse events being gastrointestinal in each group. No serious adverse events were reported. CONCLUSION: In contrast to aspirin, short-term treatment with clopidogrel does not induce macroscopic changes in the gastroduodenal mucosa. The study results show that in patients without gastroduodenal disease clopidogrel, but not aspirin, does not induce any gastroscopically evident erosions during short-term treatment.

Alpha1-antitrypsin deficiency may be a risk factor for duodenal ulcer in patients with Helicobacter pylori infection.

BACKGROUND: Most individuals with Helicobacter pylori infection in Western countries have no evidence of peptic ulcer disease (PUD). We therefore assessed the PiZ deficiency variant of the major plasma protease inhibitor alpha1-antitrypsin (alpha1AT) as a risk factor for PUD in H. pylori-infected individuals. METHODS: The cohort comprised 100 patients with endoscopically or surgically proven PUD (30 patients with duodenal ulcer (DU) and 70 patients with gastric ulcer (GU)) and 162 age- and sex-matched controls with PUD-negative endoscopic findings and no history of PUD. Plasma samples were screened for alpha1AT deficiency (PiZ) with an enzyme-linked immunosorbent assay (ELISA) and phenotyped by isoelectric focusing. H. pylori infection was evaluated with an IgG ELISA technique. RESULTS: Among the 262 patients 17 (6.5%) were positive for the PiZ alpha1AT deficiency, a frequency of the same magnitude as in the Swedish general population (4.7%). Of the PiZ carriers 76% (13 of 17) had H. pylori antibodies compared with 61% (151 of 245) of the non-PiZ carriers (NS). The prevalence of DU tended to be higher in H. pylori-positive PiZ carriers than in non-PiZ carriers (15.4%, 4 of 26 versus 0 of 4). Furthermore, among patients with DU a high PiZ allele frequency (13.3%, 4 of 30) was found compared with the general population (4.7%) (odds ratio (OR), 3.2; 95% confidence interval (CI), 1.09-8.94; P = 0.02). All DU patients carrying the PiZ allele were positive for H. pylori. In addition, four of five PiZ carriers with H. pylori infection and PUD had DU. CONCLUSIONS: The PiZ allele may be a contributing factor in the development of DU in H. pylori-positive individuals.

An alternative approach to the inaccessible intradiverticular papilla.

BACKGROUND: In patients with a narrow-necked juxtapapillary diverticulum the endoscopic cannulation of the papilla of Vater and the subsequent biliary therapy is sometimes impossible. PATIENTS AND METHODS: Three patients referred for endoscopic retrograde cholangiography and stone extraction were included. Earlier attempts to cannulate failed because visual control was impeded by narrow-necked juxtapapillary diverticula with the papilla located in the fundus. Endoscopic balloon dilation of the narrow diverticular neck, using a 15-mm stone retrieval balloon, was carried out. RESULTS: In all three cases the papillary orifice was readily brought into view after balloon dilation of the diverticular opening. Subsequent endoscopic treatment to the bile duct was successful without any complications. CONCLUSION: Balloon dilation of a narrow-necked juxtapapillary diverticulum is a safe and easy procedure, which facilitates both cannulation of the papilla and subsequent biliary endoscopic treatment.

[Enteroscopy valuable in obscure small bowel disease. Chances are good to discover curable conditions]. / Enteroskopi av värde vid oklar tunntarmssjukdom. Chansen stor att hitta behandlingsbara tillstånd.

Indications for enteroscopic examination of the proximal small bowel are expanding, above all in cases of gastro-intestinal bleeding of obscure origin. Of 66 patients examined enteroscopy revealed new and unforeseen diagnoses in about half of them, such as angiodysplasia and erosions (15 per cent of cases each). Former as well as ongoing bleeding was treated with electro cautery, bicap. In four cases the need for blood transfusion ceased. Ulcers, neoplasia and varices were also diagnosed. 16 out of 36 pathologic lesions were located within reach of an ordinary gastroscope, in spite of the patients being selected through repeated normal upper and lower endoscopic examinations. This emphasises the need for better quality assurance in routine endoscopic examinations.

[Alendronate-induced severe esophagitis. A rare and severe reversible side-effect illustrated by three case reports]. / Alendronatutlöst svår esofagit. Ovanlig och allvarlig men reversibel biverkan belyses med tre fall.

The bisphosphonate, alendronate sodium (e.g. Fosamax), a bone resorption inhibitor used to treat osteoporosis, has occasionally been reported to cause severe oesophagitis. The characteristic endoscopy findings include oesophageal ulceration with discoloured exudate, a narrowed lumen and denuded, haemorrhagic mucosa. The oesophagitis heals on discontinuation of alendronate medication, and the institution of gastric acid suppression treatment. The article consists in discussion of such adverse reactions, illustrated by three case reports. As many of the patients selected for alendronate treatment are elderly and handicapped, to minimise the risk of serious side-effects it is important not only to give detailed instructions regarding medication, but also to ensure that they are properly understood. As a history of swallowing problems was a feature of all three cases reported, caution is recommended before treating such patients with alendronate sodium.

Addition of methyl cellulose enema to double-contrast barium imaging of sigmoid diverticulosis.

UNLABELLED: Double-contrast barium enema has a reduced sensitivity in patients with severe sigmoid diverticulosis. Therefore a carboxy methyl cellulose enema was employed after the conventional double-contrast examination in 15 patients with sigmoid diverticulosis. A significant increase in lumen diameter and a superior removal of barium residue from the diverticula facilitated the interpretation of the sigmoid loops. CONCLUSION: The addition of methyl cellulose enema to double-contrast barium imaging improves diagnostic imaging in diverticulosis by expanding the lumen and emptying the diverticula.

Risk of relapse in new cases of ulcerative colitis and indeterminate colitis.

PURPOSE: Changes in morbidity pattern of ulcerative colitis have created a need to update understanding of the course of the disease. METHOD: A follow-up study was done of relapse rates and progression of inflammation in 571 non-selected patients with ulcerative and indeterminate colitis. RESULTS: Relapse rate ten years after diagnosis was 70 percent in definite ulcerative colitis, 22 percent in probable ulcerative colitis, and 77 percent in indeterminate colitis. During the study period, there was no change in the relapse rate. In relapsing proctitis, 52 percent developed more extensive inflammation. Fifty-four percent of patients with only one attack of colitis had persistent signs of inflammatory bowel disease. CONCLUSIONS: Shift in morbidity pattern to a greater proportion of patients with proctitis at diagnosis and a shorter time from onset of symptoms to diagnosis had no influence on the relapse rate. Indeterminate colitis has a worse prognosis than definite ulcerative colitis. Considering the documented efficacy of sulfasalazine, the high relapse rate calls for studies of the effectiveness of such treatment in everyday practice.

Operations in unselected patients with ulcerative colitis and indeterminate colitis. A long-term follow-up study.

OBJECTIVE: To assess the need for operative treatment for ulcerative colitis and indeterminate colitis. DESIGN: Retrospective study. SETTING: University Hospital, Sweden. SUBJECT: All patients diagnosed from 1958 to 1982, in Malmö, Sweden-ulcerative colitis (n = 471) and indeterminate colitis (n = 100). MAIN OUTCOME MEASURES: Incidence of colectomy. RESULTS: The mean follow-up was 15 years. The incidence of colectomy was 7.51, 1.90 and 36.13/1000 person years for definite ulcerative colitis, probable ulcerative colitis and indeterminate colitis, respectively. The incidence of colectomy in patients with definite ulcerative colitis in the present study was low compared with other studies. In contrast to other reports, men had a threefold risk while extent of inflammation did not influence the incidence. Patients with indeterminate colitis were a high risk group with a high incidence of colectomy. The high incidence among patients with indeterminate colitis compared with that in patients with definite ulcerative colitis was also seen in subgroups such as patients with total colitis at diagnosis, in patients in remission after the first attack, and in patients with a severe attack. CONCLUSION: As patients with indeterminate colitis seem to be at increased risk of colectomy it could be important to distinguish them from those with ulcerative colitis. Today, however, it is not possible to identify all patients with indeterminate colitis early in the course of the disease.

Chronic atrophic fundic gastritis diagnosed by a modified Congo red test.

BACKGROUND AND STUDY AIMS: Chronic atrophic fundic gastritis (CAFG) is associated with several diseases, such as gastric cancer, gastric ulcer, pernicious anemia, and bacterial overgrowth. In spite of recent technical improvements, the gastroscopic diagnosis of CAFG remains uncertain. Congo red chromogastroscopy is capable of visualizing acid-producing normal fundic mucosa, but has hitherto not been suitable for routine use. The aim of our study was to establish a reliable endoscopic technique with which to diagnose CAFG. PATIENTS AND METHODS: This prospective study comprises 124 consecutive patients (71 women, 53 min) with a mean age of 65 years (range 36-92). Macroscopic evaluation of the gastric fundic mucosa in routine endoscopy using video techniques was compared with evaluation by means of a modified endoscopic Congo red test (MCRT). In routine gastroscopy, CAFG was recognized by the thin, friable mucosa, with a marked visible vascular pattern and fold atrophy. With MCRT, the diagnosis of CAFG was made within five minutes' observation when no red-to-blue color shift in the fundic mucosa could be induced by 0.2 mu g/kg intravenous pentagastrin. The results were then compared with the histological examination of biopsies from the fundic mucosa. RESULTS: CAFG was confirmed by histology in 40 of 124 cases. The diagnostic sensitivity of MCRT was 1.0 (40/40), with a positive predictive value of 0.90, whereas the values for macroscopic gastroscopic evaluation were 0.25 (10/40) and 0.50, respectively. CONCLUSIONS: We conclude that MCRT is a sensitive, fast, and cost-effective method of identifying patients with CAFG, and well suited for use in routine gastroscopy.

Endoluminal ultrasound and low-field magnetic resonance imaging are superior to clinical examination in the preoperative staging of rectal cancer.

OBJECTIVE: To compare digital examination, endoluminal ultrasound (ELU), and plain magnetic resonance imaging (MRI), with histopathological findings in the preoperative staging of rectal cancer. DESIGN: A prospective comparative study. SETTING: University hospital, Sweden. SUBJECTS: 35 patients with rectal cancer who presented during the period February 1987 to February 1991. RESULTS: The digital examination of 19 patients could be assessed and was correct in 13 (68%). ELU was done in 34 patients; the accuracy was 88%. Extension of tumour was overestimated in two and underestimated in two. MRI was done for 35 patients with an accuracy of 66%; in 12 patients extension was underestimated. The diagnostic accuracy of the assessment of lymph node involvement was 71% with ELU, and 72% with MRI. CONCLUSION: These findings indicate that MRI seems to underestimate the extension of rectal tumours, but both ELU and MRI can be helpful in selecting patients with advanced tumours for whom preoperative adjuvant treatment is being considered. ELU is superior in staging tumours confined to the rectal wall, and could be of value in the selection of patients whose tumours were suitable for local excision. None of these techniques, however, can reliably identify the extent of lymph node involvement.