The role of capsule endoscopy in the evaluation and treatment of obscure-overt gastrointestinal bleeding during daily clinical practice: a prospective multicenter study.

OBJECTIVE: Capsule endoscopy (CE) is most commonly performed to evaluate obscure gastrointestinal bleeding (GIB). However, at present the role of CE in patients with obscure-overt GIB especially during daily clinical practice is unknown. The aim of the present study was to investigate the diagnostic yield and the impact of CE on the management of patients with obscure-overt GIB. MATERIAL AND METHODS: Between January 2007 and December 2011 we prospectively included all patients with obscure-overt GIB who underwent CE after negative bidirectional endoscopy. CE findings revealing the cause of bleeding, type of therapeutic intervention and clinical variables associated with positive CE and recurrence of GIB were evaluated. RESULTS: One hundred and eighteen patients with a median age of 66 years (range 8-89 years) were enrolled in the final analysis. The overall diagnostic yield of the CE was 66.9%. The most common findings were angiodysplasias (33.1%), followed by ulcer (23.7%), and tumors (6.8%). Age (p = 0.001) and cardiovascular disease (p = 0.007) were significant clinical variables predicting the higher incidence of angiodysplasias. Specific therapeutic interventions were undertaken in 54 patients with positive CE (68.4%). Recurrence of GIB was observed in one patient with negative CE (2.6%) and 16 patients with positive CE (20.3%). Univariate and multivariate analysis showed high age and no therapeutic intervention as significant factors associated with recurrent bleeding. CONCLUSIONS: CE represents a promising diagnostic method in the investigation of obscure-overt GIB, with significant impact on its clinical management in daily clinical practice.

A prospective comparative study of blended and pure coagulation current in endoscopic mucosal resection of large sessile colorectal polyps.

BACKGROUND: The aim of this study was to compare pure coagulation and blended current in the resection of large colorectal sessile polyps (SPs). PATIENTS AND METHODS: Between January 2009 and June 2012, 84 patients (45 men, 39 women; median age 66 y; range, 42 to 88 y) with large colorectal SPs (diameter ≥2 cm) were randomized in 1:1 ratio to undergo treatment by the "lift and cut" piecemeal resection technique. A total of 43 blended current subjects (group A) were well matched to 41 pure coagulation current subjects (group B), with a median lesion size of 3.9 cm (group A, 3.7 vs. group B, 4.2 cm; P=0.316), respectively. The rate of complications, the factors that predict complications, and the recurrence of adenoma were analyzed. RESULTS: Complete macroscopic resection was achieved in 39 patients (90.7%) of group A and in 36 patients (87.6%) of group B (P=0.735). Argon plasma coagulation at resection's margins was performed in 10 patients (23.2%) of group A and in 14 patients (34.1%) of group B (P=0.269). Eight patients (9.5%) [group A, n=3 patients (7.1%) vs. group B, n=5 patients (12%); P=0.756] developed immediate (4) or delayed (4) bleeding. Four patients with bleeding were under treatment with selective serotonin reuptake inhibitors. All bleedings were successfully treated conservatively or with endoclipping and heater probe application. Perforation occurred in 1 patient of each group and was managed by clips closure and antibiotics and right hemicolectomy, respectively. Postpolypectomy syndrome was observed in 2 patients (4.6%) of group A and 3 patients (7.3%) of group B (P=0.834). In 3 patients, the histopathologic analysis of resected SPs revealed invasive carcinoma, and surgical resection was performed in 1 patient. Two patients refused operation. Among the patients who underwent follow-up surveillance colonoscopy, a total recurrence rate of 25.67% of adenomas with no difference was observed between the 2 groups [group A, n=8 patients (21.6%) vs. group B, n=11 patients (31.4%); P=0.345]. Recurrence of adenoma was observed in 12 patients (16.22%) without and in 7 patients (9.46%) with argon plasma coagulation treatment. CONCLUSIONS: No difference was found in the rate of complications between the 2 types of current used in the resection of large colorectal SPs. However, an influence of selective serotonin reuptake inhibitors on postpolypectomy bleeding was observed, which deserves further investigation.

Prophylactic clip application before endoscopic resection of large pedunculated colorectal polyps in patients receiving anticoagulation or antiplatelet medications.

BACKGROUND: The aim of the present study was to evaluate the safety of prophylactic endoclipping before resection of large pedunculated colorectal polyps in patients with uninterrupted anticoagulation or antiplatelet therapy. PATIENTS AND METHODS: In a single tertiary referral center, patients with normal coagulation parameters and those with uninterrupted anticoagulation or antiplatelet medications, who underwent prophylactic endoclipping before resection of large pedunculated colorectal polyps (polyp's head diameter >10 mm), were evaluated retrospectively. Demographic, clinical, and laboratory parameters, polyp characteristics, number of clips used for endoclipping, histology of resected polyps, the polypectomy technique, and postpolypectomy complications were recorded and compared. RESULTS: In 64 patients with large pedunculated colorectal polyps, successful endoclipping before resection was achieved. Eleven patients (17.2%) had uninterrupted anticoagulation (n = 4) or antiplatelet (n = 7) medications. Statistical analysis showed no significant differences in age, sex, indications for colonoscopy, location of polyps, size of polyp head or stalk, coexisting small polyps, histology of resected polyps, and polypectomy techniques among patients with normal coagulation parameters (group A) and patients on uninterrupted anticoagulant or antiplatelet treatment (group B). Coronary artery disease, hypertension, and atrial fibrillation were significantly more prevalent in group B. No immediate or delayed postpolypectomy hemorrhage occurred in either group. One patient (1.9%) in group A developed postpolypectomy coagulation syndrome and was successfully treated conservatively. Follow-up evaluation demonstrated no recurrence of polyps or cancer development. CONCLUSIONS: According to our experience, uncomplicated polypectomy of large pedunculated colorectal polyps can be performed by prophylactic endoclipping in patients receiving anticoagulation or antiplatelet medications.

Endoscopic mucosal resection of giant laterally spreading tumors with submucosal injection of hydroxyethyl starch: comparative study with normal saline solution.

BACKGROUND: Normal saline (NS) plus epinephrine (E) is the traditionally used solution as submucosal fluid cushion for a safe and effective endoscopic mucosal resection (EMR) of sessile colorectal polyps. It was hypothesized that hydroxyethyl starch (HES), an inexpensive and easily available solution might be an ideal solution for prolonged elevation of submucosal cushion for an easy and safe EMR of giant colorectal lateral spreading tumors (LSTs). PATIENTS AND METHODS: During a 6-year period, patients suffering from colorectal LSTs with a diameter of ≥ 30 mm were randomized to undergo EMR by using either HES+E (group A) or NS+E (group B) for submucosal fluid cushion. All patients who had undergone a colonoscopy set the diagnosis of LSTs. The LSTs were examined with standard white light and narrow-band imaging to accurately delinate their margins before resection. The initial volume of injected solution, the additional amount to maintain the submucosal cushion, the duration of submucosal elevation and post-EMR-related complications were recorded. After EMR, patients had a standard follow-up at 3, 6, and 12 months and further if it was necessary using total colonoscopy. RESULTS: Forty-nine patients suffering from giant LSTs were included in the study. No difference between the 2 groups was observed in patients' characteristics, size of LSTs, and the initial volume of injected solution. However, the additional amount of solution to maintain submucosal elevation was lower in group A (median, 4 mL; range, 2 to 25) than in group B (median, 6 mL; range, 3 to 8; P=0.001). Moreover, submucosal elevation had a statistically longer duration in group A (median, 18.5 min; range, 14.5 to 28.4) than in group B (median, 20.15 min, range, 9.6 to 13.4; P<0.001), and there was a statistical difference on total procedure time in favor of group A [group A, 20.15 min (12 to 32.5) vs. group B, 22.8 min (18 to 34.5)]. One case of macroperforation, 2 cases of postpolypectomy syndrome, and 1 case of EMR-related bleeding were observed in the HES+E group, whereas 6 cases of EMR-related bleeding were observed in the NS+E group. During a median follow-up of 32 and 34 months, for HES+E and NS+E groups, respectively, 5 and 7 recurrences were observed, which were all treated endoscopically. CONCLUSIONS: HES+E injection produces a more prolonged submucosal elevation and lowers total procedure time than NS+E; however, the safety of EMR is not influenced.

Laparoendoscopic rendezvous versus preoperative ERCP and laparoscopic cholecystectomy for the management of cholecysto-choledocholithiasis: interim analysis of a controlled randomized trial.

BACKGROUND: Although the ideal management of cholecysto-choledocholi-thiasis is controversial, the 2-stage approach [endoscopic retrograde cholangiopancreatography (ERCP), sphincterotomy, and common bile duct (CBD) clearance followed by laparoscopic cholecystectomy] remains the standard way of management worldwide. One-stage approach using the so-called laparoendoscopic rendezvous (LERV) technique offers some advantages, mainly by reducing the hospital stay and the risk of post-ERCP pancreatitis. OBJECTIVE: To compare the LERV 1-stage approach with the standard 2-stage approach consisting of preoperative ERCP followed by laparoscopic cholecystectomy for the treatment of cholecysto-choledocholithiasis. SETTING: Controlled randomized trial, University/Teaching Hospital. METHODS: : Patients with cholecysto-choledocholithiasis were randomized either to LERV or to the 2-stage approach. Both elective and emergency cases were included in the study. Primary endpoint was to detect difference in overall hospital stay, whereas secondary endpoints were (i) to detect differences in morbidity (especially post-ERCP pancreatitis) and (ii) success of CBD clearance. This is an interim analysis of the first 100 randomized patients. RESULTS: Hospital stay was significantly shorter in the LERV group; median 4 (2-19) days versus 5.5 (3-22) days, P = 0.0004. There was no difference in morbidity and success of CBD clearance between the 2 groups. Post-ERCP amylase value was found significantly lower in the LERV group: median 65 (16-1159) versus 91 (30-1846), P = 0.02. CONCLUSIONS: Interim analysis of the results suggests the superiority of the LERV technique in terms of hospital stay and post-ERCP hyperamylasemia.

Diagnostic yield and clinical impact of wireless capsule endoscopy in patients with chronic abdominal pain with or without diarrhea: a Greek multicenter study.

BACKGROUND: Wireless capsule endoscopy has become the gold standard for the examination of small bowel. However, its role in the evaluation of patients suffering from chronic abdominal pain is not yet clearly defined. We conducted an open-label prospective multi-center study to evaluate the yield and clinical outcome of capsule endoscopy in patients with chronic abdominal pain with/without diarrhea. METHODS: Seventy-two patients with chronic (>3months) abdominal pain with/without diarrhea in whom the underlying pathology could not be diagnosed by conventional modalities, underwent capsule endoscopy in either of the 6 participating centers. Patients were then followed up for clinical outcomes. RESULTS: The overall diagnostic yield of capsule endoscopy was 44.4%. More specifically, its diagnostic yield was 21.4% in patients with abdominal pain and negative inflammatory markers (C-reactive protein and erythrocyte sedimentation rate), 66.7% in patients with abdominal pain and positive inflammatory markers, 0% in patients with abdominal pain, diarrhea and negative inflammatory markers, and 90.1% in patients with abdominal pain, diarrhea and positive inflammatory markers. Both univariate and multivariate regression analyses showed that abnormal C-reactive protein and erythrocyte sedimentation rate were significant factors related with positive capsule endoscopy findings. CONCLUSIONS: Chronic abdominal pain with/without diarrhea should be accompanied by elevated inflammatory markers to be regarded as a valid indication for capsule endoscopy. The yield of capsule endoscopy in such patients is reasonably high and clinical outcomes of patients treated with capsule endoscopy findings as a guide are significant.

Endoscopic management of occluded biliary uncovered metal stents: a multicenter experience.

AIM: To compare diverse endoscopic interventions in the management of occluded uncovered self-expanding metal stents (SEMSs) that had been placed for palliative treatment of unresectable malignant biliary obstruction. METHODS: A retrospective review was undertaken in 4 tertiary endoscopic centers to determine optimal management of different types of occluded SEMSs. The technical success of performed treatment in occluded SEMSs, the patency of the stent, the need for re-intervention and the financial costs of each treatment were analyzed. RESULTS: Fifty four patients were included in the analysis; 21 received Hanaro, 19 Wallstent and 14 Flexus. For the relief of obstruction, a plastic stent was inserted in 24 patients, a second SEMS in 25 and mechanical cleaning was performed in 5 patients. The overall median second patency rates between second SEMSs and plastic stents did not differ (133 d for SEMSs vs 106 d for plastic stents; P=0.856). Similarly, no difference was found between the overall survival of SEMS and plastic stent groups, and no procedure-related complications occurred. Incremental cost analysis showed that successive plastic stenting was a cost-saving strategy at least in Greece. CONCLUSION: Insertion of uncovered SEMSs or plastic stents is a safe and effective treatment for occluded uncovered SEMSs; insertion of plastic stents appears to be the most cost-effective strategy.

Sequential or simultaneous placement of self-expandable metallic stents for palliation of malignant biliary and duodenal obstruction due to unresectable pancreatic head carcinoma.

BACKGROUND: Pancreatic cancer is generally not amenable to curative resection, and self-expanding metallic stents have been used to relieve obstruction of bile duct and duodenum in patients with unresectable pancreatic cancer. However, both relative experience with sequential or simultaneous endoscopic stents placement in biliary and duodenal stricture and long-term efficacy of these stents are limited. The aim of this study was to present our experience on the effectiveness of this form of endoscopic treatment. PATIENTS AND METHODS: We performed a retrospective review of all patients undergoing sequential or simultaneous biliary and duodenal stent placement for biliary and symptomatic duodenal obstruction due to unresectable pancreatic head carcinomas in 4 tertiary endoscopic centers. Data were collected from endoscopy and outpatient clinic reports, x-rays, and telephone calls. All patients were followed until their death. Endpoints included technical and clinical success, stent long-term patency, and survival. RESULTS: Thirty-nine patients with unresectable pancreatic head cancer were included. Biliary or duodenal stenting was unsuccessful in 7 patients (17.9%). The remaining 32 patients (median age: 77 y; range: 52 to 82 y), with locally advanced (n=21) or metastatic disease (n=11), were studied. Twenty-one patients (65.6%) received at least first-line chemotherapy. Overall median survival was 9 months (range: 2 to 22 mo), being higher in locally advanced (median survival: 11.5 mo, range: 4 to 22 mo) than metastatic disease (median survival: 3 mo, range: 2 to 5.5 mo) (P<0.001). Median duodenal and biliary patency was 3 months (range: 1 to 12 mo) and 9 months (range: 2 to 22 mo), respectively (P<0.05). Nine of 32 patients (28.1%) required reintervention for recurrent symptoms. No major complications or death occurred in relation to endoscopic treatment. CONCLUSIONS: Placement of self-expandable metal stents is a safe and efficacious palliation method for biliary and duodenal obstruction due to unresectable pancreatic head carcinoma. The majority of patients do not require reintervention and those who require can usually be managed nonoperatively.

Partially covered vs uncovered sphincterotome and post-endoscopic sphincterotomy bleeding.

AIM: To prospectively compare partially covered vs uncovered sphincterotome use on post-endoscopic biliary sphincterotomy (ES) hemorrhage and other complications. METHODS: All patients referred for therapeutic endoscopic retrograde cholangiopancreatography (ERCP) were randomly assigned to undergo ES either with a partially covered or an uncovered sphincterotome. Both patient and technical risk factors contributing to the development of post-ES bleeding were recorded and analyzed. The characteristics of bleeding was recorded during and after ES. Other complications were also compared. RESULTS: Three-hundred and eighty-seven patients were recruited in this study; 194 patients underwent ES with a partially covered sphincterotome and 193 with conventional uncovered sphincterotome. No statistical difference was noted in the baseline characteristics and risk factors for post-ES induced hemorrhage between the 2 groups. No significant difference in the incidence and pattern of visible bleeding rates was found between the 2 groups (immediate bleeding in 24 patients with the partially covered sphincterotome vs 19 patients with the uncovered sphincterotome, P = 0.418). Delayed bleeding was observed in 2 patients with a partially covered sphincterotome and in 1 patient with an uncovered sphincterotome (P = 0.62). No statistical difference was noted in the rate of other complications. CONCLUSION: The partially covered sphincterotome was not associated with a lower frequency of bleeding. Also, there was no difference in the incidence of other significant complications between the 2 types of sphincterotome.

Endoscopic hemostasis using monopolar coagulation for postendoscopic sphincterotomy bleeding refractory to injection treatment.

BACKGROUND: Endoscopic sphincterotomy (ES) is the cornerstone of therapeutic ERCP and bleeding is one of its most frequent and serious complications. Monopolar coagulation has been used effectively for many causes of gastrointestinal hemorrhages. We investigated the efficacy and safety of endoscopically delivered monopolar coagulation through a polypectomy snare in patients with ES-induced bleeding not responding to injection treatment. PATIENTS AND METHODS: The study included 672 consecutive patients who underwent ES between June 2007 and January 2009. Bleeding patterns (trickle, oozing, spurting) were recorded. Patients with bleeding not responding to spray irrigation or injection of 0.9% NaCl+epinephrine 1: 10,000 solution were treated with monopolar coagulation. Complications related to the technique were assessed. RESULTS: ES-induced bleeding occurred in 59 patients (8.78%). Visible bleeding patterns immediately after ES were: 32 trickle, 21 oozing, and 4 spurting. Delayed bleeding was observed in 2 patients. In 11 patients with intraprocedural bleeding (7 oozing and 4 spurting) not responding to spray irrigation and injection treatment with epinephrine solution, bleeding was successfully treated with monopolar coagulation. There were no procedure-related complications in this series. CONCLUSIONS: Monopolar coagulation is an effective and safe treatment modality and is recommended as an alternative method to other therapeutic modalities for post-ES bleeding not responding to injection treatment.

Laparoendoscopic rendezvous: an effective alternative to a failed preoperative ERCP in patients with cholecystocholedocholithiasis.

BACKGROUND: Although the ideal management of cholelithiasis and concomitant choledocholithiasis is controversial, the two-stage approach [endoscopic retrograde cholangiopancreatography (ERCP), sphincterotomy, and common bile duct (CBD) clearance followed by laparoscopic cholecystectomy] is the most popular treatment regimen worldwide. However, sometimes ERCP fails to solve the problem of choledocholithiasis preoperatively. The aim of this study was to evaluate the use of intraoperative ERCP using the laparoendoscopic "rendezvous" technique in patients in whom preoperative ERCP has failed or was not possible to attempt. METHODS: Twenty-two patients (13 female, nine male), in whom ERCP failed or was not possible to be performed as a separate procedure before laparoscopic cholecystectomy, were treated with the one-stage approach of intraoperative ERCP during laparoscopic cholecystectomy using the so-called laparoendoscopic "rendezvous" technique. RESULTS: The one-stage approach was completed successfully in a median time of 110 min (range = 75-160 min) in 21 cases; however, in two cases the wire introduced via the cystic duct could not be advanced through Vater's ampulla into the duodenum and the CBD was cannulated from the endoscopic route, in the usual way. There was no mortality or morbidity and most patients were discharged within 48 h after the procedure. CONCLUSION: The laparoendoscopic "rendezvous" is a valuable alternative in treating patients with cholecystocholedocholithiasis. It appears to be a reliable method when preoperative ERCP fails to clear the CBD, while it also offers a one-stage solution to the problem.

Immunophenotypic evaluation of DNA mismatch repair markers in 2 cases of synchronous histomorphologically distinct gastric adenocarcinomas with gastrointestinal stromal tumors of the proximal small bowel.

OBJECTIVES: To assess the prognostic value of combined mismatch DNA repair (MMR) phenotyping in 2 synchronous histomorphologically distinct gastric adenocarcinomas (GADCs), each accompanied by gastrointestinal stromal tumors (GISTs) of the proximal small bowel. SUMMARY BACKGROUND DATA: A 72-year-old female and a 55-year-old male patient were submitted to partial and total gastrectomy, respectively, with synchronous resection of a GIST in the proximal small bowel. The 2 patients attained contrasting survival outcomes. The female survives disease-free 20 months after surgery having received no chemotherapy. The male who received adjuvant chemotherapy developed metastases in liver and lung, and died 18 months after surgery. METHODS: We phenotype MSH2 and MLH1 protein expression in tumor relative to matched normal tissue by immunohistochemistry. RESULTS: Immunohistochemistry analysis revealed different combined MMR phenotypes for the 2 histomorhologically distinct GADCs and similar for both GISTs studied. CONCLUSIONS: Good and bad prognosis for disease-free survival of patients based on reduced and elevated combined MMR phenotypic expression of the 2 histomorphologically distinct GADCs, could be explained by disease-associated emergence of genomic MMR alterations in the tumor. The impact of synchronous GISTs with common intermediate MMR phenotypes on patient survival is rather incidental and secondary to predominating GADCs.

Wireless capsule endoscopy in detecting small-intestinal polyps in familial adenomatous polyposis.

AIM: To detect the prevalence of small bowel polyps by wireless capsule endoscopy (WCE) in patients with familial adenomatous polyposis (FAP). METHODS: We examined prospectively 14 patients with FAP to assess the location, size and number of small-intestinal polyps. Patients' age, sex, years of observation after surgery, type of surgery, duodenal polyps and colorectal cancer at surgery were analyzed. RESULTS: During WCE, polyps were detected in 9/14 (64.3%) patients. Duodenal adenomatous polyps were found in nine (64.3%) patients, and jejunal and ileal polyps in seven (50%) and eight (57.1%), respectively. The Spigelman stage of duodenal polyposis was associated with the presence of jejunal and ileal polyps. Identification of the ampulla of Vater was not achieved with WCE. Importantly, the findings of WCE had no immediate impact on the further clinical management of FAP patients. No procedure-related complications were observed in the patients. CONCLUSION: WCE is a promising noninvasive new method for the detection of small-intestinal polyps. Further investigation is required to determine which phenotype of FAP is needed for surveillance with WCE.

Migration of plastic biliary stents and endoscopic retrieval: an experience of three referral centers.

BACKGROUND: Proximal or distal migration of a plastic biliary stent is uncommon, but its management can be a technical challenge to the pancreatobiliary endoscopist. PATIENTS AND METHODS: All cases (n=51) of proximally and distally migrated plastic biliary stents over an 8-year period at 3 referral pancreaticobiliary centers were included in this retrospective study. Indications for stenting, risk factors for migration, presentation of migration, and various techniques used for stent's retrieval are herein analyzed. RESULTS: Twenty-one proximal and 30 distal bile duct-migrated stents were identified. All patients with proximally and 17 (56.7%) with distally migrated stents were symptomatic. Choledocholithiasis, dilated common bile duct, short and large size stent were the main risk factors. The retrieval of proximally migrated stents was successful in 15 patients (71.4%) and in all symptomatic patients with distal migration. The retrieval techniques included forceps, Dormia basket, snare, Soehendra stent retriever, and balloon. One patient died of sepsis due to peritonitis from duodenal perforation from a distally migrated stent. CONCLUSIONS: Retrieval of a proximally migrated stent requires experience with different endoscopic devices. Moreover, distal migration needs attention because it can cause severe complications.

Endoclipping treatment of life-threatening rectal bleeding after prostate biopsy.

Rectal bleeding is frequently seen in patients undergoing transrectal ultrasound (TRUS)-guided multiple biopsy of the prostate, but is usually mild and stops spontaneously. We report what is believed to be the first case of life-threatening rectal bleeding following this procedure, which was successfully treated by endoscopic intervention through placement of three clips on the sites of bleeding. This case emphasizes endoscopic intervention associated with endoclipping as a safe and effective method to achieve hemostasis in massive rectal bleeding after prostate biopsy. Additionally, current data on the complications of the TRUS-guided multiple biopsy of the prostate and the options for treating fulminant rectal bleeding, a consequence of this procedure, are described.

Prevalence, bowel habit subtypes and medical care-seeking behaviour of patients with irritable bowel syndrome in Northern Greece.

AIM: Although irritable bowel syndrome (IBS) prevalence ranges between 10 and 20% in the general population, it appears to be considerably undiagnosed with only 25-50% of patients with IBS seeking medical advice. The aim of this study was to determine the prevalence of IBS in Northern Greece and the prevalence by symptom subtype including diarrhoea-predominant IBS, constipation-predominant IBS (C-IBS) and mixed type IBS; to identify factors contributing to the development of this syndrome; to assess its effect on health-related quality of life and to evaluate the medical care-seeking behaviour of IBS patients. PATIENTS AND METHODS: Between January 2004 and December 2007, 3112 participants were requested to fill out a questionnaire during an interview with a primary health care clinician. Data on participants' demographics, medical history, symptoms and earlier health care-seeking behaviour were also recorded. The Rome II criteria were used to establish the diagnosis of IBS. The impact of IBS on the quality of life was examined using the EuroQol with five domains (EQ-5D) measure of health status. RESULTS: Out of 2397 participants [704 men (29.4%), mean age 46.1+/-15.0 years] included, 373 (15.7%) reported gastrointestinal symptoms compatible with IBS of whom 136 (36.5%) suffered from diarrhoea-predominant IBS, 165 (44.2%) suffered from C-IBS and 72 (19.3%) suffered from mixed type IBS. IBS patients were more likely to be female living in an urban area compared with healthy controls (P=0.03 and 0.0001, respectively). A significant decrease in health-related quality of life (impairment in two or more of measured parameters) was noted in 246 (66%) IBS patients. Female sex, older age and housekeeping were associated with C-IBS (P=0.02, 0.001, and 0.001, respectively). Female sex and IBS-M were associated with health care-seeking behaviour. CONCLUSION: The prevalence of IBS in Northern Greece is relatively high, mainly affecting female participants living in urban areas.

Long-term botulinum toxin treatment for dysphagia due to large epiphrenic diverticulum in elderly patients: a report of two cases.

Symptomatic esophageal epiphrenic diverticula are usually repaired with diverticulectomy and esophagomyotomy with substantial morbidity and mortality rates, especially in elderly patients. We describe the cases of two elderly patients who had dysphagia caused by large epiphrenic diverticula. Due to severe comorbid diseases, both patients were unable to withstand surgical intervention; botulinum toxin solution was injected endoscopically at multiple sites in the region of the lower esophageal sphincter and esophageal wall near the diverticulum. Symptoms improved immediately and the beneficial effect of botulinum toxin remained for 5-6 months. During the long-term follow-up, the patients developed symptomatic relapses treated by subsequent botulinum toxin solution reinjections resulting in longer-lasting symptom relief.