Acromegaly is associated with an increased prevalence of colonic diverticula: a case-control study.

OBJECTIVE: In acromegaly, overproduction of GH and IGF-I causes abnormal extracellular matrix regulation. We hypothesized that this may predispose to the development of colonic diverticula. Because the relation between acromegaly and colonic diverticula is unknown, the study aim was to assess the prevalence of colonic diverticula in patients with cured acromegaly. DESIGN: This was a case-control study. METHODS: We screened reports of colonoscopies performed for the purpose of screening for polyps in 107 patients with cured or biochemically controlled acromegaly and in 214 age- and sex-matched controls for the presence of diverticula, dolichocolon, and polyps. In patients, the findings were related to GH/IGF-I concentrations at the time of diagnosis of acromegaly and to the duration of GH/IGF-I excess. RESULTS: In acromegaly, colonic diverticula were present in 37% of patients, dolichocolon in 34%, and adenomatous polyps in 34%, which was increased compared with controls (odds ratio 3.6, 95% confidence interval 1.4, 5.7; 12.4, 95% confidence interval 6.8, 18.0; 4.1, 95% confidence interval 1.9, 6.4, respectively). The presence of colonic diverticula was associated with both GH and IGF-I concentrations at the time of diagnosis of acromegaly, when adjusted for the duration of active disease. The presence of dolichocolon and adenomatous polyps was associated with higher IGF-I concentrations at diagnosis. CONCLUSIONS: Acromegaly is associated with an increased prevalence of colonic diverticula. In addition to the known irreversible effect of GH excess on collagen of joints and cardiac valves, this observation indicates an irreversible effect of GH and/or IGF-I on the collagen in the colon.

The exon-3 deleted growth hormone receptor polymorphism predisposes to long-term complications of acromegaly.

OBJECTIVE: The aim of the study was to evaluate the impact of the genomic deletion of exon 3 of the GH receptor (d3GHR) on long-term clinical outcome of acromegaly in a well-characterized cohort of patients with long-term remission of acromegaly. DESIGN: We conducted a cross-sectional study. METHODS: The presence of the d3GHR polymorphism was assessed in 86 acromegalic patients with long-term disease control and related to anthropometric parameters, cardiovascular risk factors, osteoarthritis, bone mineral density, colonic polyps and diverticulae, and dolichocolon. RESULTS: Fifty-one patients had two wild-type alleles (59%), whereas 29 patients (34%) had one allele and six patients (7%) had two alleles encoding for the d3GHR isoform. Carriers of the d3GHR isoform showed increased prevalence of osteoarthritis, especially of the hip [adjusted odds ratio (OR), 5.2; 95% confidence interval (CI), 3.2-7.1], of adenomatous polyps (adjusted OR, 4.1; 95% CI, 2.4-5.6), and dolichocolon (adjusted OR, 3.2; 95% CI, 1.8-4.6). Anthropometric parameters, cardiovascular risk factors, bone mineral density, and (non)vertebral fractures were not significantly different between patients with and without the d3GHR allele. CONCLUSION: In patients with long-term cured acromegaly, the d3GHR polymorphism is associated with an increased prevalence of irreversible comorbidities such as osteoarthritis, dolichocolon, and adenomatous colonic polyps, but not with other comorbidities such as cardiovascular risk factors.

Elastic band ligation of hemorrhoids: flexible gastroscope or rigid proctoscope?

AIM: To compare rigid proctoscope and flexible endoscope for elastic band ligation of internal hemorrhoids. METHODS: Patients between 18 and 80 years old, with chronic complaints (blood loss, pain, itching or prolapse) of internal hemorrhoids of grade 1-3, were randomized to elastic band ligation by rigid proctoscope or flexible endoscope (preloaded with 7 bands). Patients were re-treated every 6 wk until the cessation of complaints. Evaluation by three-dimensional anal endosonography was performed. RESULTS: Forty-one patients were included (median age 52.0, range 27-79 years, 20 men). Nineteen patients were treated with a rigid proctoscope and twenty two with a flexible endoscope. Twenty-nine patients had grade 1 hemorrhoids, 9 patients had grade 2 hemorrhoids and 3 patients had grade 3 hemorrhoids. All patients needed a minimum of 1 treatment and a maximum of 3 treatments. A median of 4.0 bands was used in the rigid proctoscope group and a median of 6.0 bands was used in the flexible endoscope group (P < 0.05). Pain after ligation tended to be more frequent in patients treated with the flexible endoscope (first treatment: 3 vs 10 patients, P < 0.05). Three-dimensional endosonography showed no sphincter defects or alterations in submucosal thickness. CONCLUSION: Both techniques are easy to perform, well tolerated and have a good and fast effect. It is easier to perform more ligations with the flexible endoscope. Additional advantages of the flexible scope are the maneuverability and photographic documentation. However, treatment with the flexible endoscope might be more painful and is more expensive.

Endosonography in anorectal disease: an overview.

Anorectal endosonography (AE), which was introduced 20 years ago, derives from the study of urology. It was first used to evaluate rectal tumours and later also to investigate benign disorders of the anal sphincters and pelvic floor. The technique is easy to perform, it has a short learning curve and causes no more discomfort than a routine digital examination. A rotating probe with a 360 degrees radius and a frequency between 5 and 16 MHz is introduced to the rectum and then slowly withdrawn so that the pelvic floor and subsequently the sphincter complex are seen. Recently, it has become possible to reconstruct three-dimensional images. AE has been used for almost every possible disorder in the anal region and has increased our insight into anal pathology. The clinical indications for AE are: 1. Faecal incontinence in patients when surgery is an option. AE can show sphincter defects with excellent precision. There is a perfect correlation with surgical findings. Studies comparing AE with endoanal magnetic resonance imaging (MRI) have shown that both methods are equally good for demonstrating defects in the external anal sphincter; the internal anal sphincter is better visualized with AE. After sphincter repair, the effect is directly related to the decrease in the sphincter defect. 2. Perianal fistulae. AE has been shown to be accurate in staging perianal cryptoglandular fistulae and fistulae in Crohn's disease. When there is an external fistula opening, H2O2 can be introduced with a plastic infusion catheter. The tract then becomes visible as a hyperechoic lesion ("white"). It has been shown that this corresponds well with surgical findings. It is equally sensitive as endoanal MRI. Since recurrent cryptoglandular fistulae are complex in 50% and Crohn's fistula in 75%, it is mandatory to perform AE preoperatively in these patients to avoid missed tracts during surgery and subsequent recurrences. 3. Rectal tumors. In low tubulovillous adenomas or malignant polyps considered removable locally, confirming the local resectability (T0 or T1) is mandatory. Although larger rectal and more advanced tumours can be evaluated with AE, MRI is more sensitive in staging nodal involvement. 4. Anal carcinoma for staging. AE has been shown to stage better than the classical TNM classification for both local extension and prognosis. In conclusion, AE images the internal and external anal sphincter with high accuracy. It is easy to perform and is of particular value in the diagnosis of anal incontinence and perianal fistulae. It is excellent in staging anal carcinoma and can also be used in staging rectal carcinoma, especially very low large malignant polyps.

Hepatic arterial 5-fluorouracil in patients with liver metastases of colorectal cancer: single-centre experience in 145 patients.

BACKGROUND: Hepatic arterial chemotherapy for liver metastases of colorectal cancer is still under discussion. Mainly because of the technical complications of this mode of treatment and the lack of a survival benefit in randomized studies. We performed an analysis of hepatic arterial 5-fluorouracil (5-FU) chemotherapy in 145 consecutive patients treated at a single institution. PATIENTS AND METHODS: One hundred forty-five patients with inoperable liver metastases from colorectal cancer were included. 5-FU, 1000 mg/m2/day continuous infusion for five days every three weeks, was delivered in the hepatic artery by percutaneous catheter or arterial access device. RESULTS: The response rate was 34% for all patients, 40% in patients with extrahepatic disease, and 15% in patients with i.v. 5-FU-based pretreatment. TTP and OS for all patients were 7.5 and 14.3 months, respectively. In patients with extrahepatic disease or i.v. 5-FU-based pretreatment, OS was significantly shorter compared to patients without extrahepatic disease or 5-FU-based pretreatment (9.7 vs. 19.3 months and 10.1 vs. 17.4 months, respectively), forty-seven percent of patients stopped treatment because of a complication. Complications most often seen in patients with arterial ports were hepatic artery thrombosis (48%) and dislocation of the catheter (22%). CONCLUSIONS: The results of our analysis are in line with previous phase III studies. Extrahepatic disease and i.v. 5-FU-based pretreatment were prognostic for reduced OS. The complication rate of hepatic arterial delivery was worrisome. although, no negative impact on survival could be established. There is a strong need for improvement of hepatic arterial delivery methods before further evaluation of hepatic arterial