Efficacy of Prophylactic Hemoclips in Prevention of Delayed Post-Polypectomy Bleeding in Patients With Large Colonic Polyps.

BACKGROUND & AIMS: The efficacy of prophylactic placement of hemoclips to prevent delayed bleeding after removal of large colonic polyps has not been established. We conducted a randomized equivalence study to determine whether prophylactic placement of hemoclips affects incidence of delayed post-polypectomy bleeding (PPB). METHODS: During elective colonoscopy performed at 4 Veterans Affairs Medical Centers, 1098 patients who had polyps ≥1 cm removed were randomly assigned to groups that received prophylactic hemoclips (n = 547) or no hemoclips (n = 551), from September 2011 through September 2018. Data on PPB (rectal bleeding resulting in hemoglobin decreases ≥2 g/dL, hemodynamic instability, colonoscopy, angiography, or surgery) within 30 days of colonoscopy (called delayed PPB) were collected during telephone interviews or hospital visits 7 and 30 days after colonoscopy. The primary outcome was the incidence of important post-polypectomy bleeding. RESULTS: Twelve patients in the hemoclip group (2.3%) and 15 patients in the no hemoclip group (2.9%) had important delayed PPB. There were no deaths, and no patients in either group required angiography or surgery. In intention-to-treat analysis, two 1-sided test's lower and upper confidence interval limits were -2.07 and 1.01, indicating that the data approached but did not meet equivalence criteria. On multiple logistic regression analysis, significant predictors of PPB included use of warfarin with bridging, thienopyridines, polyp size, and polyp location, but hemoclip placement did not associate with important delayed PPB. CONCLUSIONS: In a randomized trial, we found that prophylactic placement of hemoclips after removal of large colon polyps does not affect the proportion of important delayed PPB events, compared with no hemoclip placement. These findings call into question the widespread, expensive practice of routinely placing prophylactic hemoclips after polypectomy. ClinicalTrials.gov ID: NCT01647581.

What Can We Do to Optimize Colonoscopy and How Effective Can We Be?

In the USA, colorectal cancer is the third most common cancer and third leading cause of cancer death among both men and women. Declining rates of colon cancer in the past decade have been attributed in part to screening and removal of precancerous polyps via colonoscopy. Recent emphasis has been placed on measures to increase the quality and effectiveness of colonoscopy. These have been divided into pre-procedure quality metrics (bowel preparation), procedural quality metrics (cecal intubation, withdrawal time, and adenoma detection rate), post-procedure metrics (surveillance interval), and other quality metrics (patient satisfaction and willingness to repeat the procedure). The purpose of this article is to review the data and controversies surrounding each of these and identify ways to optimize the performance of colonoscopy.

Survival of patients with hepatocellular carcinoma in the San Joaquin Valley: a comparison with California Cancer Registry data.

BACKGROUND: Variation in the survival of patients with hepatocellular carcinoma (HCC) is related to racial differences, socioeconomic disparities and treatment options among different populations. METHODS: A retrospective review of the data from medical records of patients diagnosed with HCC were analyzed at an urban tertiary referral teaching hospital and compared to patients in the California Cancer Registry (CCR) - a participant in the Survival Epidemiology and End Results (SEER)program of the National Cancer Institute (NCI). The main outcome measure was overall survival rates. RESULTS: 160 patients with the diagnosis of HCC (M/F=127/33), mean age 59.7±10 years, 32% white, 49% Hispanic, 12% Asian and 6% African American. Multivariate analysis identified tumor size, model for end-stage liver disease (MELD) score, portal vein invasion and treatment offered as the independent predictors of survival (p <0.05). Survival rates across racial groups were not statistically significant. 5.6% received curative treatments (orthotopic liver transplantation, resection, rediofrequency ablation) (median survival 69 months), 34.4% received nonsurgical treatments (trans-arterial chemoembolization, systemic chemotherapy) (median survival 9 months), while 60% received palliative or no treatment (median survival 3 months) (p <0.001). CONCLUSION: There was decreased survival in our patient population with HCC beyond 2 years. 60% of our study population received only palliative or no treatment suggesting a possible lack of awareness of chronic liver disease as well as access to appropriate surveillance modalities. Ethnic disparities such as Hispanic predominance in this study in contrast to the CCR/SEER database may have been a contributing factor for poorer outcome.

Diagnostic performance of cyst fluid carcinoembryonic antigen and amylase in histologically confirmed pancreatic cysts.

OBJECTIVES: The objective of this study was to evaluate and validate cyst fluid carcinoembyronic antigen (CEA) and amylase in differentiating (1) nonmucinous from mucinous pancreatic cystic lesions (PCLs), (2) benign mucinous from malignant mucinous PCLs, and (3) pseudocysts from nonpseudocysts (amylase only). METHODS: A retrospective analysis of patients with histologically confirmed PCLs from February 1996 to April 2007 was performed. Cyst fluid CEA (n=124) and/or amylase (n=91) were measured and correlated to cyst type. RESULTS: Carcinoembyronic antigen levels (P=0.0001), but not amylase, were higher in mucinous versus nonmucinous cysts. The sensitivity, specificity, and diagnostic accuracy of CEA 200 ng/mL or greater for the diagnosis of mucinous PCLs were 60%, 93%, and 72%, respectively. Carcinoembyronic antigen levels did not differentiate benign from malignant mucinous cysts. Whereas amylase levels were higher in pseudocysts than nonpseudocysts (P=0.009), 54% of noninflammatory PCLs had a level greater than 250 IU/L, including mucinous cystic neoplasms (median, 6800 IU/L; interquartile range, 70-25,295 IU/L). Malignant mucinous cysts had lower amylase levels than benign mucinous cysts (P=0.0008). CONCLUSIONS: Cyst fluid CEA and amylase levels are suggestive but not diagnostic in differentiating PCLs. Unlike CEA, amylase may help differentiate benign from malignant mucinous cysts. Novel biomarkers are needed.

Use of cyst fluid CEA, CA19-9, and amylase for evaluation of pancreatic lesions.

OBJECTIVES: The study goals were development of reference intervals and an interpretive algorithm for pancreatic cyst fluid tumor markers. DESIGN AND METHODS: 442 pancreatic cyst fluids were tested for CEA, CA19-9, and amylase. RESULTS: CEA>30 ng/mL discriminates mucinous from non-mucinous cysts. After CEA analysis, amylase and CA19-9 segregate non-mucinous and mucinous subtypes, respectively. CONCLUSIONS: Pancreatic cyst fluid tumor markers supplement other diagnostic measures. This study provides estimated reference intervals and an algorithm for interpretation.

Recent advances in liver transplantation for the practicing gastroenterologist.

Liver transplantation is the definitive therapy for end-stage liver disease of various etiologies as well as acute liver failure and early-stage hepatocellular carcinoma. The Model for End-Stage Liver Disease (MELD) score is essential for organ allocation in the United States. Addition of the serum sodium level to the MELD score is a recent development that helps prognosticate cirrhotic patients with hyponatremia, a commonly seen manifestation of end-stage liver disease. The currently used Milan criteria for hepatocellular carcinoma have been expanded with some success at certain transplant centers, and tumor downstaging prior to transplant is being used more frequently. The tremendous shortage of donor organs continues to be the major limitation of this life-saving therapy. This has led to the use of extended-criteria donors, donation after cardiac death, split liver grafts, and live donor liver transplants. Renal dysfunction following liver transplant requires close monitoring and dose adjustments of immunosuppressive medications. Although most liver transplants in the United States are for chronic hepatitis C infection and its sequelae, hepatitis C virus recurrence is a common problem that is challenging to treat in the post-transplant population.

Hypovitaminosis D-induced pain.

Vitamin D deficiency is a problem of considerable magnitude that has reemerged as a major public health issue in the United States and several other developed countries. Vitamin D plays a crucial role in calcium homeostasis in the body. Hypovitaminosis D leads to osteomalacia and increased risk of fractures, especially in the elderly. Preliminary research suggests that vitamin D can prevent certain types of cancer and autoimmune diseases. A recent large study has shown the association between severe hypovitaminosis D and persistent, non-specific musculoskeletal pain, further suggesting that patients with no apparent cause of pain should be assessed and possibly treated for vitamin D deficiency.

New support for branched-chain amino acid supplementation in advanced hepatic failure.

Nutritional supplementation with branched-chain amino acids (BCAA) has been a topic of considerable debate for more than two decades. Several studies have demonstrated that supplementation with BCAA is associated with improvement of the catabolic state commonly seen in people with cirrhosis, whereas other studies have showed an improvement in portosystemic encephalopathy in patients with liver disease. Some studies have also shown there to be no benefit in BCAA supplementation in advanced cirrhosis. A recent large clinical trial showed that long-term BCAA supplementation may be useful in preventing progressive hepatic failure and improving liver function in some patients.

Tamm-Horsfall protein knockout mice are more prone to urinary tract infection: rapid communication.

BACKGROUND: Human colon contains many bacteria that commonly colonize the perineum and frequently enter the urinary tract. Uropathogenic Escherichia coli are the most common cause of urinary tract infection. Type 1 fimbriated E. coli have been associated with cystitis, and P fimbriated E. coli with pyelonephritis. Factors involved in clearing bacteria from the urinary tract are poorly understood. Tamm-Horsfall protein (THP), the most abundant protein in mammalian urine, has been postulated to play a role in defense against urinary tract infection but definitive proof for this idea has been lacking. METHODS: In this study, we generated THP gene knockout mice by the technique of homologous recombination, and examined if the THP-deficient (THP-/-) mice were more prone to urinary tract infection. Various strains of E. coli expressing type 1 or P fimbriae were introduced transurethrally into the bladders of the THP-/- and genetically similar wild-type (THP+/+) mice. Urine, bladder, and kidney tissues were obtained from the mice and cultured for bacterial growth. RESULTS: THP-/- mice inoculated with type 1 fimbriated E. coli had a longer duration of bacteriuria, and more intense colonization of the urinary bladder in comparison with THP+/+ mice. When inoculated with a P fimbriated strain of E. coli, the THP-/- mice showed no difference in kidney bacterial load when compared with the THP+/+ mice. CONCLUSION: These findings support the idea that THP serves as a soluble receptor for type 1 fimbriated E. coli and helps eliminate bacteria from the urinary tract.

Thalidomide inhibits the growth and progression of hepatic epithelioid hemangioendothelioma.

Hepatic epithelioid hemangioendothelioma (HEH) is a rare vascular tumor of the liver with an unpredictable malignant potential. Its growth can lead to hepatic failure, extrahepatic metastasis and death. Surgical resection or liver transplantation is the treatment of choice if metastasis is not identified. Several antineoplastic agents have been proposed for cases of nonresectable HEH. We report the case of a 52-year-old patient with HEH metastatic to the lungs who was successfully treated with oral thalidomide therapy.