Predictive factors for the diagnosis of irritable bowel syndrome in a large cohort of 440,822 young adults.

BACKGROUND: The prevalence of irritable bowel syndrome (IBS) in the community has been reported in numerous cross-sectional surveys. However, little is known about the incidence and predictive factors for the clinical diagnosis of IBS. METHODS: We examined the association of socioeconomic, anthropometric, and occupational factors with the incidence of IBS in a cohort of 440,822 young Israeli adults aged 18 to 39 who served in active military service during the years 2005 to 2011. RESULTS: During the follow-up of 1,925,003 person-years, IBS was diagnosed de novo in 976 patients, giving an incidence rate of 221:100,000 (0.2%) person-years for the diagnosis of IBS. On multivariable Cox analysis, higher socioeconomic status [hazard ratio (HR) 1.629; 95% confidence interval (CI), 1.328-1.999; P<0.0001], Israeli birth (HR 1.362; 95% CI, 1.084-1.712; P=0.008), Jewish ethnicity (HR 2.089; 95% CI, 1.344-3.248; P=0.001), education ≥than 11 years (HR 1.674; 95% CI, 1.019-2.751; P=0.042), and a noncombat military position (HR 1.196; 95% CI, 1.024-1.397; P=0.024) were found to be risk factors for the diagnosis or for the worsening of IBS. Overweight (HR 0.744; 95% CI, 0.589-0.941; P=0.014), obesity (HR 0.698; 95% CI, 0.510-0.95; P=0.025), living in a rural settlement (HR 0.705; 95% CI, 0.561-0.886; P=0.003), and Middle Eastern (HR 0.739; 95% CI, 0.617-0.884; P=0.001,) or North African and Ethiopian origin (HR 0.702; 95% CI, 0.585-0.842; P<0.001) were found to be protective for the diagnosis or the worsening of IBS. CONCLUSIONS: This study provides novel data on the socioeconomic, anthropometric, and occupational factors predictive for IBS development. The predictive factors for IBS diagnosis may point to the fact that stress had a lower impact on IBS incidence in our study cohort.

Management of antithrombotic agents for colonoscopic polypectomies in Israeli gastroenterologists relative to published guidelines.

BACKGROUND: Endoscopic procedures are commonly performed in patients taking antithrombotic agents. OBJECTIVE: To examine the correlation between the management of antithrombotic drugs for colonoscopic polypectomies and the published guidelines. DESIGN AND SETTINGS: A structured survey delivered to gastroenterologists in 15 major Israeli hospitals and three central HMO clinics. RESULTS: We collected 100 filled out surveys. Polypectomies on aspirin were performed by 78%. Most physicians did not perform polypectomies on clopidogrel. None of the physicians performed polypectomies on warfarin. Cessation of aspirin for ≥ 3 days post-polypectomy was recommended by 60%. Renewal of LMWH or warfarin was recommended ≥ 2 days post-polepectomy in 91% and 71%, respectively. The greatest variation in recommendations was found for clopidogrel, where the majority of gastroenterologists advised renewal after 1-2 days (38%). Years in practice and increasing colonoscopy volume work had no significant association with management of antithrombotic agents. Working in a HMO clinic was associated with lower rates of polypectomies on aspirin (P=0.036). DISCUSSION: When the guidelines are clear, most gastroenterologists practice according to the existing recommendation. However, lack of prospective studies limits the ability to publish evidence-based recommendation and guidelines. We found that the practice of our cohort study varies in these situations.

Prevalence and predictive factors for gastrointestinal pathology in young men evaluated for iron deficiency anemia.

BACKGROUND: The prevalence of gastrointestinal lesions in young men with iron deficiency anemia (IDA) is unknown, and there are no evidence-based recommendations for the evaluation of the gastrointestinal tract in this population. AIMS: The purpose of this study was to assess the prevalence of significant GI lesions among young males with IDA, and to shed light on potential predictors of their presence. METHODS: Clinical, endoscopic, and histological data was retrospectively collected from medical records of 347 young males with IDA. RESULTS: Clinically significant GI lesions were diagnosed in 62 %. Upper GI lesions were found in 35 %. Peptic disease was the most common finding, diagnosed in 30 %. Celiac disease was diagnosed in 4 %. Lower GI tract lesions were diagnosed in 34 %. The most common findings were hemorrhoids (17 %) and inflammatory bowel disease (16 %). Malignant lesions were not detected. GI lesions were encountered more frequently when respective symptoms were obtained. Multivariate analysis showed that the presence of GI symptoms and the use of proton pump inhibitors were associated with an increased likelihood of significant GI lesions. CONCLUSIONS: GI lesions are common among young men with IDA. GI evaluation is mandatory in symptomatic men and in asymptomatic men when the anemia is resistant to iron therapy. Symptoms may dictate the order of evaluation.

Double balloon enteroscopy: a 2 year experience.

BACKGROUND: Double balloon enteroscopy is a new technique that enables deep intubation of the endoscope into the small bowel lumen. Through a channel in the endoscope, invasive procedures such as biopsy, polypectomy and hemostasis can be performed, avoiding the need for surgery. OBJECTIVES: To prospectively analyze our results of the first 124 DBEs performed since February 2007. METHODS: The study group comprised all patients who underwent DBE at the Sheba Medical Center between February 2007 and February 2009. Recorded were the patients' demographic data, comorbidities, indications for the examination, results of previous non-invasive small bowel imaging (computed tomography enterography, capsule endoscopy, etc), investigation time, and results of the procedure including findings, endoscopic interventions, complications and pathological report. RESULTS: A total of 124 procedures were performed in 109 patients. Of the 124 examinations, 57 (46%) were normal and 67 (54%) showed pathology. The main pathologies detected on DBE were polyps (14%), vascular lesions (17.6%) and inflammation (12%). Endoscopic biopsies and therapeutic interventions were required in 58 examinations (46%). A new diagnosis was established in 15% of patients, diagnosis was confirmed in 29% and excluded or corrected in 12%. One complication was observed: a post-polypectomy syndrome that was treated conservatively. CONCLUSIONS: DBE is a safe procedure and has a high diagnostic and therapeutic yield. Most of the examinations were performed under conscious sedation, and only a minority of patients required deeper sedation.

Interleukin-18 and its binding protein in patients with inflammatory bowel disease during remission and exacerbation.

BACKGROUND: Crohn's disease and ulcerative colitis are inflammatory bowel diseases with an unknown etiology. Interleukin-18 is a pro-inflammatory cytokine that is up-regulated in Crohn's disease. IL-18 binding protein neutralizes IL-18. The relationship of IL-18 and IL-18BP and disease activity in these diseases is not fully understood. OBJECTIVES: To investigate the correlation of IL-18 and IL-18BP with disease activity and other disease parameters in inflammatory bowel disease. METHODS: IL-18 and IL-18BP isoform a were measured in 129 patients and 10 healthy individuals. Patients' mean age was 40.5 (range 15-70 years) and 43 were women; 58 Crohn's and 28 colitis patients were in remission and 52 and 14, respectively, were in exacerbation. Twenty-three (19 and 4 respectively) were studied in both remission and exacerbation. RESULTS: The mean level of free IL-18 was significantly different between healthy individuals and Crohn patients, and between Crohn patients during exacerbation and remission (167 +/- 32 vs. 471 +/- 88 and 325 +/- 24 pg/ml, respectively, P < 0.05). Mean level of IL-18BP was significantly different between healthy individuals and Crohn patients, and between Crohn patients during exacerbation and remission (2.1 +/- 1.1, 7.5 +/- 4 and 5.23 +/- 2.8 ng/ml, respectively, P < 0.01). In the colitis patients, mean free IL-18 level and IL-18BP were significantly different between healthy individuals and patients, but not between disease remission and exacerbation (167 +/- 32, 492 +/- 247 and 451 +/- 69 pg/ml for IL-18, and 2.1 +/- 1.1, 7.69 +/- 4 and 6.8 +/- 7 ng/ml for IL-18BP, respectively, P= 0.05). CONCLUSIONS: IL-18 and IL-18BP levels are higher in patients with inflammatory bowel disease compared to healthy individuals. In Crohn's disease, but not in ulcerative colitis, IL-18 (but not free IL-18) and IL-18BP levels are significantly higher during exacerbation compared to remission. This observation highlights the importance of IL-18 in the pathogenesis of inflammatory bowel diseases, especially in Crohn's disease.

Nonsurgical management of asymptomatic incidental pancreatic cysts.

BACKGROUND & AIMS: Cystic lesions of the pancreas are detected more often nowadays. Many are considered premalignant and pancreatic resection is recommended. This study was undertaken to assess the natural course of asymptomatic pancreatic cysts and their malignant potential. METHODS: All patients referred for endoscopic ultrasound (EUS) between 1994 and 2003 because of pancreatic cystic lesions were included. RESULTS: A total of 135 patients underwent EUS because of pancreatic cysts. Twenty-three patients were excluded because they were symptomatic or had pancreatic pseudocysts. The other 112 patients were diagnosed as having true pancreatic cysts. Fourteen of the 112 patients were referred for surgery based on either unfavorable EUS morphology or fine-needle aspiration results. In 4 (29%) of 14 surgical specimens, the histology was that of malignancy. An additional 8 patients with serous cystadenoma and pseudocysts were excluded from the analysis. The remaining 90 patients were defined as having indeterminate or mucinous cysts and were managed conservatively. The follow-up period lasted between 12 and 180 months (mean, 48 +/- 33 mo). Malignancy was diagnosed in only 1 patient after 7 years of follow-up evaluation. None of the 57 patients available for clinical follow-up evaluation became symptomatic. The size of the cyst remained unchanged in 45 patients, increased in 2, and resolved in 9. Thirty-three patients were followed up through the Israel Registry: 31 were alive and 2 died from unrelated causes. CONCLUSIONS: Our data suggest that a considerable number of asymptomatic pancreatic cystic lesions can be managed conservatively, at least for a mean period of 4 years. Malignant transformation in pancreatic cystic lesions probably is less frequent than previously reported.

[ERCP for benign disease in the elderly: a good prognosis].

BACKGROUND: biliary disease in the elderly (over 80) are common and can be a diagnostic and therapeutic challenge. METHODS: medical records of patients age 80 and older who underwent endoscopic retrograde cholangiopancreatography (ERCP) for benign biliary disease from January 2000 to April 2005 were studied retrospectively. RESULTS: 100 patients of whom data was obtainable underwent 133 procedures. The indications for the procedure included suspicion of common bile duct stones (94.4%), biliary stend insertion and replacement (4%), non-malignant obstructive jaundice (0.8%) and echinococcal cyst (0.9%). Midaozolam (100%) and fentanyl (100%) were used for conscious sedation. Patient tolerance was good in 100% of procedures. Therapeutic procedures (endoscopic sphincterotomy, stent insertion or replacement) were indicated in 88% of procedures, and successful in 96.8% of cases. Short term complications (up to 30 days after procedure) occurred in 4/5% of ERCP procedures. There was no early mortality. CONCLUSIONS: ERCP is a safe procedure in the elderly with a low complication rate and good therapeutic efficacy.

Iron deficiency anemia in patients without gastrointestinal symptoms--a prospective study.

BACKGROUND AND OBJECTIVES: Chronic gastrointestinal (GI) bleeding is the leading cause of iron deficiency anaemia (IDA) in men older than 50 years and post-menopausal women. There is a scarcity of data regarding IDA patients without GI symptoms or signs. We conducted a prospective study to determine the prevalence and the locations of the GI tract lesions in patients with asymptomatic IDA. METHODS: Forty-eight patients with asymptomatic IDA (25 men older than 50 years and 23 post-menopausal women) underwent colonoscopy, gastroscopy and abdominal computed tomography (CT) with contrast agent. RESULTS: An anaemia-causing lesion was found in 14 (29%) and 16 (33%) patients in the upper and the lower GI tract, respectively. The prevalence of dual lesions (in both the upper and lower GI tract) was low (6%). In 14 (29%) patients, a malignancy, predominantly right-sided colon carcinoma, was responsible for the IDA. Only one patient had a lesion in the small bowel. In 14 (29%) patients, the work-up was negative. CONCLUSION: Our prospective study demonstrates a high rate of malignancy, predominantly right-sided colon carcinoma, in men older than 50 years and post-menopausal women with asymptomatic IDA. This finding obligates a complete and rigorous GI tract examination in this group of patients, especially of the right colon.

The education and training of gastroenterologists for the 21st century: a paradigm for the education of medical specialists in technology-intensive fields - an international and Israeli perspective.

Gastroenterology in the developed world as a paradigm for technologically intensive medical specialties has undergone dramatic changes during the last half-century with expansion, proliferation and affluence followed by serious reactions on the part of cost-conscious and demanding governments, insurers and consumers. A review of events in several regions within the developed world reveals tremendous technological progress but inadequate attention to professional, economic and ethical issues, which are crucial for the education of a model gastroenterologist who will embody the qualities that will enable him/her to function well clinically, technologically, scientifically, professionally and ethically and thus enable him/her to cope with the increasingly complex challenges that are likely to arise during the next decades. The possibility and need for defining a specific ethic for technology-intensive medical specialists is discussed.