Beware the pancreatic incidentaloma in colorectal tumours: pancreatic adenocarcinoma with metastases to the colon and rectum.

Colorectal cancer (CRC) is the third most diagnosed malignancy in the Western world. Routine staging of CRC often identifies incidental lesions on cross-sectional imaging. Appropriate treatment is dependent on a correct histological diagnosis. Pancreatic Ductal Adenocarcinoma (PDAC) is a rarer and often devastating diagnosis for which the treatment pathway differs significantly to CRC. We report two rare cases: the first recorded case of PDAC with synchronous rectal metastasis and a case of an acute presentation with large bowel obstruction from synchronous colonic metastasis. Both cases presented a significant diagnostic challenge. The management of both cases would have been altered had the histological diagnosis been known prior to surgery. Clinicians treating CRC should be wary of incidental lesions on staging investigations as they rarely represent an occult extra-intestinal primary malignancy. Immunohistochemistry plays an important role in ascertaining the origin of gastrointestinal malignancy.

Outcomes from colonoscopy following referral from New Zealand general practice: a retrospective analysis.

BACKGROUND: New Zealand has high rates of colorectal cancer (CRC) but poor outcomes. Most patients with CRC are diagnosed following referral from general practice, where a general practitioner (GP) assesses symptoms according to national guidelines. All referred patients are then re-prioritised by the hospital system. The first objective of this study was to identify what proportion of patients referred by general practice to surgical/gastroenterology at Waikato District Health Board (DHB) had a colonoscopy. The second objective was to determine what proportion of these referrals have an underlying CRC and the factors associated with the likelihood of this diagnosis. METHODS: This study is a retrospective analysis of e-referral data for patients aged 30-70+ who were referred from 75 general practices to general surgery, gastroenterology or direct to colonoscopy at Waikato DHB, 01 January 2015-31 December 2017. Primary and secondary outcome measures included the proportion and characteristics of patients who were having colonoscopy, and of those, who were diagnosed with CRC. Data were analysed using chi square and logistic regression. RESULTS: 6718/20648 (32.5%) patients had a colonoscopy and 372 (5.5%) of these were diagnosed with CRC. The probability of having CRC following a colonoscopy increased with age (p value < 0.001). Females (p value < 0.001), non-Maori (p value < 0.001), and patients with a high suspicion of cancer (HSCan) label originating from their GP were more likely to have a colonoscopy, while the odds ratio of Maori having a colonoscopy was 0.66 (95% CI 0.60-0.73). The odds ratio of a CRC diagnosis following colonoscopy was 1.67 (95% CI 1.35-2.07) for men compared to women, and 2.34 (95% CI 1.70-3.22) for those with a GP HSCan label. Of the 585 patients referred with a GP HSCan, 423 (72.3%) were reprioritised by the hospital and 55 patients had their diagnosis unnecessarily delayed. CONCLUSIONS: If a GP refers a patient with an HSCan, and the patient receives a colonoscopy, then the likelihood of having CRC is almost 15.0%. This would suggest that these patients should be routinely prioritised without further triage by the hospital. Further research is needed to understand why Maori are less likely to receive a colonoscopy following referral from general practice.

Botulinum toxin versus botulinum toxin with low-dose glyceryltrinitrate for healing of chronic anal fissure: a prospective, randomised trial.

BACKGROUND: Chronic anal fissure (CAF) is perpetuated by high sphincter pressures and secondary local ischemia. Pharmacological approaches include topical nitrates and botulinum toxin (BT), which both help to decrease the sphincter pressure. AIMS & OBJECTIVES: The aims of the present study were to assess the efficacy and safety of BT injection and combined treatment with BT injection and lowered dose glyceryltrinitrate (GTN) cream for the treatment of CAF. We hypothesised that combined treatment would have a synergistic effect on healing. METHODS: Forty-one consecutive patients with CAF were randomly assigned to receive one of the following treatments: Group A, injection of BT (20 U into internal anal sphincter) and Group B, BT injection (20 units) and subsequent thrice daily topical applications of half-dose 0.2% GTN cream for 6 weeks. Patients were followed up at 6 and 12 weeks and were assessed for healing of anal fissure, by means of visual inspection using fissure grades; for faecal incontinence, using Cleveland Clinic incontinence scores; and for fissure pain and headache using a numeric pain rating scale. RESULTS: Fissure healing was similar in the two groups at both 6 (30% in BT and GTN and 33% in BT only) and 12 weeks (50% in BT and GTN vs 57% in BT-only group). Neither the change in pain score from 6 to 12 weeks, nor the overall level of pain was significantly different in the 2 groups. Moderate or severe headaches were suffered by 58% of patients using GTN. CONCLUSION: Single-agent treatment by means of BT injection alone was well tolerated compared with combination treatment with BT injection and GTN cream, with no significant differences in healing of CAF observed in this small study.

Patterns of surgery in patients belonging to amsterdam-positive families.

INTRODUCTION: The phenotype of hereditary nonpolyposis colorectal cancer includes an 80 percent lifetime risk of colorectal cancer, a predominance of lesions proximal to the splenic flexure, and a high incidence of synchronous and metachronous neoplasia. Although prophylactic colectomy is rarely advised for patients with a hereditary nonpolyposis colorectal cancer genotype and a normal colon, the presence of advanced neoplasia in the context of a qualifying family history or a hereditary nonpolyposis colorectal cancer genotype has led to such recommendations. We performed this study to document the patterns of colorectal surgery performed for cancer-bearing patients who are part of an Amsterdam criteria-positive family and to compare rates of metachronous cancers that follow index total or segmental colectomy. METHODS: Family trees fulfilling the classic Amsterdam criteria for hereditary nonpolyposis colorectal cancer were identified, and all patients for whom surgical and pathology records were available were included in the study. Type of surgery and the outcome of subsequent follow-up were abstracted. Patients were divided into those treated at the Cleveland Clinic and those treated elsewhere. RESULTS: There were 39 families with 93 affected patients. These patients had 127 colorectal cancers, 76 (60 percent) of which were right sided (proximal to the splenic flexure). Median age at diagnosis of the index cancer was 47 (range, 26-81) years. Sixteen patients (17 percent) had metachronous cancers and multiple surgeries, whereas four (4 percent) had synchronous cancers. Median follow-up for patients who underwent surgery at the Cleveland Clinic was 13 (range, 4-49) years, whereas that for those who underwent surgery elsewhere was 14 (range, 1-42) years. Sixteen (48 percent) of the 33 patients who underwent surgery at the Cleveland Clinic had a total colectomy vs. 7 (12 percent) of the 60 who had surgery elsewhere (Fisher's exact test, P < 0.001). Only one patient who had surgery at the Cleveland Clinic had a second operation for a metachronous cancer (1/17 patients having a segmental resection). Fifteen patients who underwent surgery elsewhere needed a second resection for metachronous cancer (15/53 patients having a segmental resection; Fisher's exact test, P = 0.094). CONCLUSION: We conclude that there is high risk of metachronous colorectal cancer if an index cancer in a hereditary nonpolyposis colorectal cancer patient (defined according to Amsterdam criteria) is treated by partial colectomy. However, this risk can be lowered by performing a total colectomy at the time of index surgery, or possibly by effective postoperative surveillance.