Adenomas and carcinomas missed in routine colonoscopy: a prospective study in resected colon segments.

Colonoscopy is the standard technique in the diagnosis and treatment of colorectal neoplasia, but small adenomas and even advanced lesions can be missed during the procedure. With large scale screening colonoscopy programs installed, information on quality of colonoscopy in primary care is essential, but scarcely available. Over a period of 45 months, we prospectively included all those patients in our study, who underwent major colonic surgery at our institution and who had undergone a colonoscopy within 42 days prior to the operation. 89 men and 100 women, median age 71 years, were included. The majority of these operations were performed for colorectal carcinoma (125), other malignant tumors (4), suspected malignancies (6) or large adenomas (14). The pathologist inspected the resected colonic segment, and we compared his findings with the colonoscopy report. Colonoscopies had been performed by 22 doctors in 13 institutions. Median length of the resected colonic segments was 20 cm (range 3 to 135 cm), total length was 41,21 metres. In 14 segments the pathologist identified 28 neoplastic lesions not described in the endoscopy report. Colonoscopy had missed 2 carcinomas, both in the right colon, and a 12 mm tubulo-villous adenoma with high-grade dysplasia. Another 25 tubular adenomas had been missed, 2 measuring 10 mm, 7 between 5 and 9 mm and 16 smaller than 5 mm. We conclude that primary care colonoscopy misses neoplastic lesions in a significant number of procedures. Most of the missed lesions in our high risk group of patients would have been of little clinical consequence. In a small, but clinically important number of cases, however, advanced adenomas and even colorectal carcinomas were missed by endoscopy.

Missed colonic adenomas in routine primary care endoscopy: a prospective tandem colonoscopy study.

Colonoscopy is the gold standard in the diagnosis of colorectal neoplasia. Several lines of independent evidence, however, suggest that a significant number of small adenomas and also some advanced lesions are missed even by experienced endoscopists. With large-scale screening colonoscopy programmes installed, information on quality of colonoscopy in primary care is essential, but not available. Between July 2006 and December 2008, a total of 40 patients (23 men and 17 women, median age: 69 years) underwent a second colonoscopy within 42 days after the first endoscopy (median: 11 days), in all cases exclusively for clinical reasons. Index colonoscopy was performed by 14 endoscopists in 6 hospitals and 4 private practices. Data on all consecutive patients were collected prospectively. A total of 98 neoplastic lesions were identified in 34 patients at the index colonoscopy, an additional 53 adenomas were removed at the second colonoscopy, 33 of them smaller than 5 mm. 25 out of 53 missed adenomas were identified between the coecum and the right colonic flexure. 12 of the additional lesions were considered significant lesions (larger than 10 mm or tubulovillous adenoma), nine of these were located between the coecum and the right colonic flexure. In 24 patients repeat colonoscopy detected adenomas not described in the original report. In eight patients a total of 12 significant lesions were removed, nine of these were located between the coecum and the right colonic flexure. About one-third of adenomas were missed in 40 routine colonoscopies, most of them only small and therefore probably of little clinical significance. However, 12 significant lesions were missed in 8 patients. Adenomas in the right colon seem to be a particular problem.

Guiding manometry probes into the human small bowel without X-ray: validation of a new technique.

BACKGROUND: In order to perform small bowel manometry studies in man, the probes have to be guided through the upper gastrointestinal tract. This is usually controlled by fluoroscopy, but a method that allows to place the tubes without X-rays is obviously desirable. METHODS: A new method that controls tube placing by sonography and pH-metry instead of X-rays is described. In a total of 19 volunteers 40 tubes were placed, either under fluoroscopic control (n = 22) or without X-rays (n = 18). RESULTS: Nose to antrum time was not significantly different between the two groups (8 +/- 2 vs. 10 +/- 2 min), but the documented transit of the tube from the antrum into the duodenum was significantly slower in the fluoroscopy group (80 +/- 20 vs. 60 +/- 12 min). Small bowel transit time was not significantly different between the groups (73 +/- 16 vs. 65 +/- 15 min). CONCLUSION: Placing motility probes in the human small bowel can be controlled by sonography and pH-metry instead of fluoroscopy. It is also easily performed, faster and more convenient for the investigator. As far as basic gastrointestinal research is concerned, in Germany less bureaucratic paperwork is involved, as these studies need not be approved by the 'Bundesamt fur Strahlenschutz' any more.

[Fat, spices and gastro-oesophageal reflux]. / Fette, Gewürze und gastroösophagealer Reflux.

In spite of poor evidence, many patients with gastro-oesophageal reflux are advised to avoid fat and spices. We therefore measured gastro-oesophageal reflux after fatty and spicy meals. During three 24-h pH monitoring sessions, eight volunteers ate two identical, low fat and mild beef stews, or a hot and fatty Indian curry for lunch. Meals for dinner were the beef stew, the hot Indian curry or a mild curry. Day-time acid exposure was significantly longer after the hot curry (7.5 % [1.4 - 27.1]) than after the beef stews (2.3 % [0.4 - 9.8] and 2.5 % [0.7 - 15.7]). Night-time acid exposure was also significantly shorter after the beef stew (1.3 % [0 - 9]) than after the mild curry (2.9 % [0 - 19.1]) or the hot curry (4.6 % [0.2 - 22.5]). Within two hours postprandially, reflux was not different between the meals. The number of episodes, however, that occurred more than two hours after lunch was significantly lower after the beef stews (4 [2 - 14] and 4.5 [2 - 10]) than after the hot curry (9 [5 - 16]). The same phenomenon was observed after beef stew (0.5 [0 - 2]), mild curry (2 [0 - 4]) and hot curry (2 [1 - 9]) for dinner. We conclude that meals high in fat can provoke reflux, possibly through delayed gastric emptying. Additional spices, however, do not further increase reflux.

Small bowel motor activity in response to physiological meals of different chemical composition in man.

Meals disrupt the interdigestive pattern of small bowel motor activity and convert it into the more irregular postprandial pattern. Previous animal studies suggest that the duration of and contractile activity within the postprandial period depend on the chemical composition of a meal. It is not clear whether this is also true for man. In 8 healthy volunteers I investigated how physiological and isocaloric meals of different chemical composition affect small bowel motor activity. Volunteers underwent two separate, ambulatory 24-hour small bowel manometry studies. Volunteers had a total of four meals on the two study days. They ingested two identical fish meals rich in protein, a pasta meal rich in carbohydrates, and a meat meal rich in fat. Records were analyzed visually for the reappearance of phase III of the migrating motor complex, and a validated computer program calculated the incidence of contractions during the postprandial period, as well as the amplitude and propagation of contractions. The durations of the postprandial periods were similar after the two protein meals (238 +/- 35 and 227 +/- 25 min), the carbohydrate (220 +/- 23 min) and the fat meal (242 +/- 43 min). The incidence of contractions was not significantly different after the protein meals (1.6 +/- 0.3 and 1.0 +/- 0.2 contractions per min), the carbohydrate meal (1.0 +/- 0.2 contractions per min) and the fat meal (1.5 +/- 0.2 contractions per min). The amplitude of contractions was similar after the protein meals (14 +/- 0.1 and 13 +/- 0.1 mmHg), the carbohydrate meal (14 +/- 0.1 mmHg) and the fat meal (14 +/- 0.1 mmHg). Propagation of contractions was similar after the protein meals (13 +/- 3 and 18 +/- 3 %), after the carbohydrate meal (15 +/- 2 %) and after the fat meal (13 +/- 2 %). Contractile activity within consecutive 30-min periods of the postprandial period was also not different between the meals. I conclude that physiological, isocaloric meals of different chemical composition elicit a similar postprandial motor response in the human small bowel.

Serial quantitative liver function tests in patients with primary biliary cirrhosis: a prospective long-term study.

Primary biliary cirrhosis (PBC) is a rare chronic cholestatic disorder of unknown origin that can now be treated effectively with ursodeoxycholic acid (UDCA). The clinical course of PBC is very variable, but a significant proportion of patients eventually die or undergo liver transplantation. In this single-center prospective long-term study, we analyzed the effect of UDCA therapy (10 mg/kg b.w./day) on conventional liver function tests and we also investigated whether serial quantitative liver function tests are useful in the clinical management of patients with PBC. Fifteen patients, most of them in an early disease stage, were followed up for either 4 (n = 7) or 5 (n = 8) years. In addition to regular conventional liver function tests, every 12 months quantitative liver function tests were performed. Thus we measured galactose elimination capacity, indocyanine green half-life and lidocaine half-life. Quantitative liver function tests were also performed once in healthy volunteers. Treatment with UDCA significantly improved conventional liver function tests, and this effect was maintained for several years (values in U/l before therapy and 4 years after therapy: AP = 1,346 +/- 317 vs. 516 +/- 93; gammaGT 378 +/- 80 vs. 144 +/- 30; LAP 122 +/- 10 vs. 71 +/- 9; AST 61 +/- 19 vs. 34 +/- 12; ALT 90 +/- 19 vs. 68 +/- 35; GLDH 14.3 +/- 1.9 vs. 8.2 +/- 1.9). Quantitative liver function tests were not significantly different between healthy volunteers and patients (GEC 6.8 +/- 0.3 vs. 7.0 +/- 0.3 mg/kg x min; ICG half-life 4.2 +/- 0.4 vs. 3.7 +/- 0.3 min; lidocaine half-life 75 +/- 8 vs. 79 +/- 6 min). In the patients, results of quantitative liver function tests (GEC, ICG and lidocaine half-lives) were not affected by UDCA therapy and remained constant over time. In the 1 patient who was transplanted, serial quantitative liver function tests did not indicate deteriorating liver function earlier than the patient's progressive symptoms or conventional liver function tests. Thus UDCA therapy markedly improved conventional liver function tests in patients with PBC, and this effect was maintained for at least 4-5 years. Possibly due to the fact that most of the patients were in an early disease stage, serial quantitative liver function tests provided little additional information that was relevant for planning therapy in the individual patient.

Comparison of the small bowel motor response to solid and liquid meals in man.

Interdigestive motor activity has been studied extensively both in the human and canine small intestine. The more irregular postprandial pattern, however, has rarely been studied. In particular, physiological studies in humans are lacking. Thus it is unknown whether the physical state of a meal affects the duration of the postprandial motor activity or contractile activity during the postprandial period. 8 healthy male volunteers, aged 19-38 years, underwent a single ambulatory 24-hour manometry study. During the study, volunteers had two physiological meals. The solid meal consisted of pasta with vegetables, and the liquid meal was a vanilla milk drink. The two meals were both palatable, isocaloric (660 kcal) and had an identical fat content (32%). Recordings were analyzed visually for phase III of the migrating motor complex and a validated computer program calculated the mean frequency and amplitude of contractions as well as the mean area under the curve (AUC). The postprandial period was significantly shorter after the liquid meal compared to the solid meal (196 +/- 43 vs. 298 +/- 23 min; p < 0.04). During the postprandial period, the mean incidence of contractions (2.0 +/- 0.5 vs. 3.7 +/- 0.4 min(-1); p < 0.02) and the mean AUC (132 +/- 32 vs. 236 +/- 27 mm Hg x s x min(-1); p < 0.02) were significantly lower after the liquid meal. The mean amplitude of contractions during the total postprandial period, however, was not significantly different between the two test meals (19.3 +/- 0.6 vs. 18.6 +/- 0.8 mm Hg). We conclude that human small bowel motor activity differs markedly between solid and liquid meals. Thus the postprandial pattern persists longer after solid meals, and this may have been due to the slower gastric emptying of solids as opposed to liquids. Furthermore the small bowel contracts far more frequently after solid meals.