The completion rate of colonoscopy in normal daily practice: factors associated with failure.

BACKGROUND: Colonoscopy is an important diagnostic procedure for screening as well as for patients presenting with complaints. The completion of a colonoscopy is defined as cecal intubation. A large single center study was done in order to evaluate the completion rate of colonoscopy and identify reasons for failure. PATIENTS AND METHODS: We reviewed all consecutive endoscopies of the lower digestive tract done over a period of 15 years by 2 endoscopists. The main outcome measure was a successful cecal intubation. RESULTS: 14,139 consecutive colonoscopies were done. Overall cecal intubation was successful in 11,787 procedures (83.3%). Three hundred and sixty-one of the non-successful procedures were due to insufficient colon cleansing, and no significant abnormalities were seen in 362 procedures. In the remaining 1,629 endoscopies, significant diagnoses were made. The presence of colorectal cancer, diverticula and inflammatory bowel disease were significant findings in non-successful procedures. CONCLUSION: In normal daily practice, colonoscopy is completed in 83.3% of the procedures. Reasons for failure are obstructing tumors, diverticula and insufficient colon cleansing.

The annual yield of diagnostic endoscopy of the lower digestive tract.

BACKGROUND: Endoscopy of the colon and rectum has become a standard diagnostic procedure. No data are presented in the literature on the annual yield or on morbidity patterns. A large, cross-sectional, single-center study was done in order to detect the annual yield of endoscopy of the colon and rectum. METHODS: All consecutive endoscopies performed over an 11-year period were included. All files from a random year were taken in order to collect data on the indication for the endoscopy. A standardized endoscopy report was used. RESULTS: Over the 11-year period, 11,550 consecutive endoscopies of the lower digestive tract were performed. Seven hundred and fourteen procedures were excluded because they were done as a direct follow-up after the index procedure. The majority of endoscopies were scheduled as colonoscopy. The most common endoscopic diagnoses made each year remained constant in number. Cancer was diagnosed in 4-6% of cases, inflammation in 9-15%, polyps in 9-16%, and diverticular disease in 21-37%. The percentage of women undergoing the procedure each year ranged from 54% to 59%, that of men from 41% to 46%. CONCLUSION: From this study it can be concluded that the annual yield of endoscopy of the lower digestive tract remains rather constant. No major changes in morbidity are noted.

Helicobacter pylori and gastro-oesophageal reflux disease: a cross-sectional epidemiological study.

BACKGROUND: H. pylori infection is accompanied by a lower prevalence of reflux disease. There is still an ongoing debate as to whether H. pylori actually protects against the development of reflux oesophagitis or is merely an epiphenomenon. A cross-sectional study was performed to study the relation of H. pylori with reflux oesophagitis, hiatus hernia and Barrett's oesophagus. MATERIAL AND METHODS: Consecutive patients undergoing upper gastrointestinal endoscopy in a period of ten years were studied. Included were patients with active reflux oesophagitis and/or hiatus hernia and/or Barrett's oesophagus. As a reference group, patients without macroscopic abnormalities were included. H. pylori was detected applying routine diagnostic modalities. RESULTS: In the ten years 11,691 consecutive patients were studied. Reflux oesophagitis was seen in 1535 patients, 307 patients had Barrett's oesophagus and a hiatus hernia was present in 2116 patients. The reference group consisted of 5341 patients. H. pylori was significantly less often detected in patients with reflux oesophagitis or Barrett's oesophagus compared with the reference group, 20 vs 29% (p<0.001). Also presence of H. pylori was significantly lower in patients with hiatus hernia 20 vs 29% (p<0.0001). CONCLUSION: The present study confirms, in a very large group of patients studied in one single centre, the findings of earlier papers. Patients without H. pylori gastritis suffer more often from reflux disease. There is a relation between H. pylori and reflux disease. However, the consequence of this relation will not be the same in every patient.

Prevalence of gastroesophageal reflux disease in immigrants living in the Zaanstreek region in the Netherlands.

Racial differences in the incidence of reflux disease are reported but data on differences in ethnicity are rare. A study was undertaken to assess the prevalence of reflux disease, defined as the presence of reflux esophagitis, in immigrants and correlate the results with native inhabitants living in the same region. Consecutive patients with hiatus hernia and defective lower esophageal sphincter closure as well as reflux esophagitis were included. A large population of people of Turkish descent and a small contingent of people from northern Africa and the Middle East were studied separately. Reflux disease was diagnosed in 4165 patients. One hundred and sixty-seven (4%) were of Turkish descent, and 26 (0.6%) originated from Africa and the Middle East. Reflux disease occurred significantly less often in immigrants, 24% versus 55.5% (P < 0.0001). There was no difference relating to gender in the presence of reflux disease in native Dutch patients, while the number of men in the immigrant group with the condition was significantly higher than women; 51% versus 72%, respectively (P < 0.0001). The majority of immigrants only suffered from mild reflux esophagitis (P < 0.001). Immigrants with reflux disease are significantly younger than native Dutch patients, mean age 42 years versus 57 years, respectively (P < 0.0001). Reflux disease is less prevalent in immigrants, mostly people of Turkish descent. If the condition is present in this population, the majority of patients is male and belongs to the younger age cohorts.

Rising incidence of reflux oesophagitis in patients undergoing upper gastrointestinal endoscopy.

BACKGROUND: In the literature a lot of epidemiological data is present but little is known on the yearly incidence of oesophagitis and Barrett's oesophagus. For this reason a cross-sectional study was done to explore the yearly incidence of these conditions in patients sent for upper gastrointestinal endoscopy. METHODS: All patients diagnosed with reflux oesophagitis, Barrett's oesophagus or hiatus hernia in a 10-year period were included. RESULTS: In the period of 10 years 11,691 consecutive patients underwent endoscopic examination. Oesophagitis was diagnosed in 1,633 patients, Barrett's oesophagus in 275, and hiatus hernia without oesophagitis in 1,407 patients. The number of patients with oesophagitis almost doubled, while the number of patients with hiatus hernia or Barrett's oesophagus remained constant each year in this time period. The number of men diagnosed with oesophagitis or Barrett's oesophagus was significantly higher than the number of women. Hiatus hernia occurred significantly more often in women, and was present in 79-88% of patients with active reflux oesophagitis. CONCLUSION: This study clearly shows that the incidence of reflux oesophagitis shows a marked increase. The incidence doubled in a period of ten consecutive years. This data should be kept in mind in planning future health-care resources. It can be expected that the use of acid suppressive therapy will be rising in the years to come.

Changes in prevalence of Helicobacter pylori infection in two groups of patients undergoing endoscopy and living in the same region in the Netherlands.

BACKGROUND: There are few data on the prevalence of Helicobacter pylori in different populations and no data on changes in time. A cross-sectional study was done in a large population of patients undergoing endoscopy in order to relate the presence of H. pylori to ethnic background and to detect changes in time. METHODS: All consecutive patients over a 10-year period were included and biopsy specimens from the gastric antrum were taken for detection of H. pylori. A large population of immigrants living in the Zaanstreek region was studied separately. RESULTS: In the 10-year period, 14,909 consecutive diagnostic upper GI endoscopies were done in 11,691 consecutive patients. Only the first endoscopy done in a patient was included. Of 11,691 patients available for evaluation, there were 5669 men and 6022 women (mean age 55 years, range 4-99). Of these, 3201 (27.4%) were H. pylori-positive and 4988 (42.7%) were H. pylori-negative. No biopsy specimens were available for the remaining 3501 (29.9%) patients. In the group under study, 1309 (11%) patients were immigrants. H. pylori was present significantly more often in men and in immigrants, where prevalence was 75% versus 33% (P < 0.0001). The prevalence of H. pylori showed a marked decrease in both populations during the period of study. Extrapolating trend lines into the future indicates a prevalence of H. pylori below 10% by the year 2009. Among immigrants, this will be reached in approximately 2027. CONCLUSION: This study shows differences in prevalence of H. pylori in different populations. We found a decreasing prevalence that can be explained by the lower acquisition rate of the infection. It is important to be aware of the differences in prevalence of H. pylori in a population composed of different ethnicities.

The yield of UGIE: a study of a ten-year period in the 'Zaanstreek'.

BACKGROUND: Study of the occurrence of abnormalities in the oesophagus, stomach and duodenum, and of changes in specific diagnoses. METHODS: All consecutive upper gastrointestinal endoscopies (UGIEs) carried out in a period of ten years were included. RESULTS: In ten years 14,927 diagnostic UGIEs were performed (7335 men (49%) and 7592 women (51%)). These procedures were done at the request of the general practitioner in 4995 (33%) cases. A steady yearly increase in the number of open-access UGIEs was noted. Each year a mean of 796 abnormalities was seen in the oesophagus, a mean of 437 in the stomach, and of 162 in the duodenum. The presence of hiatal hernia and reflux oesophagitis significantly increased in the ten years (p < 0.001). The numbers of Barrett's oesophagus and oesophageal cancer remained constant. Gastritis showed a gradual increase (p < 0.001), while the number of gastric ulcers found per year decreased significantly in the ten-year period (p < 0.001). Gastric malignancy remained constant. Presence of duodenal ulcers and bulbitis significantly decreased (p = 0.01 and p = 0.06, respectively). CONCLUSIONS: The number of UGIEs carried out at the request of the general practitioner has significantly increased. Peptic ulcer disease shows a significant decrease, while reflux disease increases.

Newly developing hiatus hernia: a survey in patients undergoing upper gastrointestinal endoscopy.

BACKGROUND: Data on the incidence of hiatus hernia are lacking. A cross-sectional study was performed in a large population of consecutive patients undergoing endoscopy in order to assess the yearly incidence of hiatus hernia in this population. METHODS: Consecutive patients undergoing upper gastrointestinal endoscopy in whom no macroscopic abnormalities were seen and who, in addition, underwent a second endoscopy were included in the study. The presence of newly developed hiatus hernia was noted, as well as the time elapsed between both endoscopies. RESULTS: Over a period of 8 years, 12 122 endoscopies were performed in 9580 patients. Ninety patients developed a hiatus hernia; this was not the case in a control group of 353 patients. Patients who developed a hiatus hernia were significantly older than those who did not (P < 0.001). The number of women who developed hiatus hernia was higher than the number of men who developed hiatus hernia (P < 0.0001). The total time between both endoscopies in 443 patients was 897 patient years. Ninety patients (20.3%) developed a hiatus hernia. If these data are extrapolated to a yearly occurrence, then 35 of 176 patients will develop a hiatus hernia. It takes an average of 1.9 years for a hiatus hernia to develop. CONCLUSIONS: In the present study, it was calculated that 19.9% of the studied population would develop a hiatus hernia per year. Patients who developed a hiatus hernia were significantly older than patients who did not. The present study also shows that a hiatus hernia actually develops later in life.

Reflux esophagitis and hiatal hernia as concomitant abnormality in patients presenting with active duodenal or gastric ulcer: cross-sectional endoscopic study in consecutive patients.

BACKGROUND: Follow-up studies have shown that patients with ulcer disease are at risk of developing reflux esophagitis (RE) after successful eradication of Heliobacter pylori. It is still not clear whether this is induced by eradication of H. pylori or whether RE is already present at the time the ulcer is diagnosed. A cross-sectional study was done in consecutive patients suffering from active ulcer disease in order to assess coincidental RE. METHODS: Patients with an active duodenal or gastric ulcer were included in the study. Concomitant RE and the presence of hiatal hernia (HH) were scored. Biopsy specimens were taken for detection of H. pylori. RESULTS: In 375 patients (77%), an active duodenal ulcer was the only abnormality. In 43 patients (8.8%), duodenal ulcer and concomitant RE were present and 69 patients (14.2%) had a duodenal ulcer with concomitant HH. Patients with a duodenal ulcer were significantly younger than patients with concomitant RE or HH. From 374 patients (76.8%) with a duodenal ulcer, biopsy specimens were available for the detection of H. pylori. The majority of duodenal ulcer patients were H. pylori-positive. H. pylori was significantly more often present in patients with an active duodenal ulcer than it was in duodenal ulcer patients suffering from concomitant RE (P=0.04). In 218 patients (76%), a gastric ulcer was the only abnormality. Fifteen patients (5.2%) also had RE and 54 patients (18.8%) had a concomitant HH. There was no difference in H. pylori status in these three groups of patients. CONCLUSIONS: Given the low prevalence of concomitant RE, it is concluded that this condition is likely to occur in a large percentage of patients suffering from H. pylori-positive ulcer disease after successful eradication therapy.

Diverticular disease of the colon and concomitant abnormalities in patients undergoing endoscopic evaluation of the large bowel.

OBJECTIVE: To study the prevalence of diverticula and presence of concomitant pathology in consecutive patients undergoing endoscopic examination of the colon. METHODS: A cross-sectional analysis of the endoscopy reports of all patients sent for endoscopic evaluation of the colon in a period of 8.5 years. RESULTS: A total of 9086 endoscopies were performed. Of these 2259 (24.7%) were undertaken for follow-up. Diverticula were seen in 1849 patients (27%) (739 male, 1110 female, mean age 69 year). In 4978 patients (73%)(2162 male, 2816 female, mean age 52 year) no diverticula were seen, of these 2303 (46%) had no abnormalities in their colon. Patients with diverticula were significantly older, 69 vs 46.7 years (P < 0.001). No difference was present in gender. Colorectal cancer and inflammatory bowel disease were significantly more common in patients without diverticula, while polyps were more often seen in patient with diverticula. Patients with diverticula had a significantly lower incidence of colorectal cancer. In addition, the number of cancers located proximal to the splenic flexure was statistically higher in the group of patients presenting with diverticula (P < 0.001). CONCLUSIONS: The overall prevalence of diverticular disease in patients undergoing endoscopy is 27%, and increases with age. Patients with diverticulosis have significantly lower incidence of colorectal cancer and if cancer is detected then it is more common proximal to the splenic flexure.

The occurrence of a duodenal or gastric ulcer in two different populations living in the same region: a cross-sectional endoscopical study in consecutive patients.

BACKGROUND: Marked differences in prevalence of Helicobacter pylori have been noted between population subgroups living in the same country. A cross-sectional endoscopical study in consecutive patients presenting with active ulcer disease was done, in order to study the H. pylori prevalence in relation to ethnicity in ulcer patients. METHODS: Consecutive patients with an active duodenal or gastric ulcer were eligible for inclusion. Biopsy specimens from the gastric antrum were taken for detection of H. pylori. People originating from Turkey were studied separately. RESULTS: In an 8-year period, 375 patients with active duodenal ulcer were seen. Three hundred one patients were ethnic Dutch. Seventy-four of the patients were of Turkish origin. These were statistically significant younger than ethnic Dutchmen, 35.9 vs. 61.2 years (P<0.0001). The number of men was significantly higher, 82.4% vs. 53.8% (P<0.001). H. pylori prevalence was significantly higher in Turkish patients with duodenal ulcer, 91 vs. 74% (P<0.0001). Gastric ulcer was seen in 218 patients. Only five patients were of Turkish descent. The number of Turkish patients was too small to permit statistical analysis, but the percentage of men is higher and the mean age is lower compared with ethnic Dutchmen. CONCLUSIONS: It is concluded that if ulcer disease and H. pylori prevalence is studied in a given population, ethnicity of the population understudy has to be taken into account.

Functional dyspepsia has a good prognosis irrespective of H. pylori status. Long-term follow-up of symptoms after anti H. pylori treatment.

AIM: A prospective study with anti H. pylori therapy was done in patients with functional dyspepsia. METHODS: Inclusion criterion was the absence of any macroscopic abnormality in oesophagus, stomach, and duodenum, irrespective whether H. pylori was present or not. A questionnaire and a symptom score on a five-point Likert scale were used. Antral biopsy specimens were taken for detection of H. pylori. Treatment consisted of omeprazole 20 mg bid and amoxicilline 500 mg tid during 14 days. Patients were followed during 12 months. At follow-up the questionnaire and the symptom score were used. The main endpoint of the study was clinical remission after 1 year of follow-up. RESULTS: In 1 year 163 patients were included (85 men, 78 women, mean age 47 years, range 21-83 years). H. pylori was present in 91 patients. In the H. pylori positive group 38 patients showed a decrease in IgG antibody titre of more than 50% during follow-up of 3-12 months, 26 showed no change or increase following initial decrease. Overall there was no difference in presence or absence of specific complaints at inclusion and final follow-up. The symptom score decreased significantly in all groups (P < 0.001). CONCLUSION: The symptoms of functional dyspepsia improved to a similar extent in both H. pylori positive dyspeptics and the control group. This symptom improvement was irrespective of the change of IgG H. pylori antibodies after therapy.

Symptom clusters cannot be used in distinguishing Helicobacter pylori positive or negative patients with functional dyspepsia.

BACKGROUND: A retrospective study was done in consecutive patients in order to seek out whether dyspepsia subgroups (reflux-like, ulcer-like, and, dysmotility-like dyspepsia) can be useful in describing Helicobacter pylori positive and negative functional dyspepsia. METHODS: Consecutive patients who underwent upper gastrointestinal endoscopy were included if no macroscopic lesions in oesophagus, stomach or duodenum were seen. Antral biopsy specimens were taken for detection of H. pylori. A validated questionnaire was used. RESULTS: Six hundred patients fulfilled the inclusion criteria. Three hundred were positive for H. pylori. In the H. pylori positive (HP+) patients only 3 (1.2%) had 'pure' reflux-like dyspepsia, 17 (6.9%) had ulcer-like dyspepsia and 10 (4%) suffered from dysmotility-like dyspepsia. In the H. pylori negative (HP-) patients these figures were 6 (2.3%), 17 (6.6%) and 7 (2.7%), respectively (ns). The majority of patients had a combination of complaints belonging to the three subgroups. Reflux-like dyspepsia was present in 179 (73%) HP+ dyspeptics and 195 (76%) HP-'s (ns). Ulcer-like dyspepsia was present in 213 (88%) HP+ cases and 233 (92%) HP-'s (ns). Dysmotility-like dyspepsia was present in 197 (81%) HP+'s and 212 (82%) HP-'s (ns). CONCLUSIONS: It is concluded that it is not possible to identify patients suffering from H. pylori infection on basis of symptom clusters.

[The yield of endoscopic follow-up after removal of adenomatous polyps from the colon]. / De opbrengst van endoscopische follow-up na het verwijderen van adenomateuze poliepen uit het colon.

OBJECTIVE: To determine the results of follow-up endoscopy after resection of adenomatous polyps from the colon. DESIGN: Retrospective. SETTING: De Heel Hospital, department of Internal Medicine, Zaandam, the Netherlands. PATIENTS AND METHOD: The 124 patients, 66 males and 58 females, with a mean age of 53 years (range: 23-74), in whom a colonpolyp had been removed endoscopically, who had no colonic carcinoma and no positive family history, were registered for follow-up after one year and after 3 or 5 years. In 1997, data were collected on the polyps found and removed at follow-up. RESULTS: At the original coloscopy, 68 patients (55%) had one polyp, 46 (37%) had two to four polyps and 10 (8%) > or = five polyps. The localizations of the polyps were: rectum 17%, sigmoid 66%, descending colon 12%, transverse colon 3%, ascending colon 1% and caecum 1%. Over one-third of the polyps were larger than 1.5 cm. Ninety-eight patients underwent a first follow-up endoscopy after an average of 12 months (range: 0.4-57); one or more polyps were found and removed in 37 of them (38%). At a second follow-up endoscopy after an average of 28 months (range: 5.4-68 months), polyps were again found and removed in 26 of the 57 patients (46%). If two or more polyps had been removed at an earlier coloscopy, the risk of polyps being found again at the next coloscopy was larger (p < 0.001).

Upper gastrointestinal bleeding due to a malignant Schwannoma of the stomach.

A case history of a patient showing signs of upper gastrointestinal bleeding is described. Extensive analysis showed that the bleeding was due to a malignant Schwannoma of the stomach with several lymph node metastases. The patient was operated on and is doing well 5 years after surgery. The literature on this rare malignant tumour is reviewed.

The clinical presentation of peptic ulcer disease.

BACKGROUND: A prospective study was performed in order to assess the clinical presentation of peptic ulcer. METHODS: Consecutive patients undergoing upper GI endoscopy (n = 1527) received a questionnaire consisting 23 questions related to the upper abdomen. Eleven questions were scored on a linear scale and a symptom score was calculated. Patients with a gastric (GU) or duodenal (DU) ulcer were included. As a reference group, patients in whom endoscopy did not reveal abnormalities were included. This group was subdivided depending on whether their history was positive (PPU+) or negative (PPU- ) for previous peptic ulcer. RESULTS: GU was diagnosed in 43 patients, DU in 60; PPU+ consisted of 94 patients and PPU- of 382 patients. Patients with GU were significantly older (P < 0.0001). The symptom score was 14 (SD 8.6) in GU, 16.6 (SD 8.5) in DU, 19.5 (SD 9.8) in PPU+, and 16.7 (SD 9.6) in PPU-. PPU+ had significantly higher symptom score than the other groups. If all ulcer patients (amalgamation of DU, GU and PPU+) were compared with PPU-, a prior history of peptic ulcer, pain waning after a meal, and smoking were the only features linked to peptic ulcer. On the other hand, postprandial pain, food intolerance, nausea, and alcohol use have a negative prediction. CONCLUSIONS: It can be concluded that the symptom score in peptic ulcer disease is low (the maximum possible score was 55). It is not possible to distinguish peptic ulcer patients from other dyspeptics on basis of the clinical presentation.

Esophageal intramural pseudodiverticulosis.

A case report of a patient presenting with long-standing progressive dysphagia due to intramural esophageal pseudodiverticulosis is presented. The possible etiology, presentation, diagnostic procedure and treatment of this rare entity are discussed.