Adherence to surveillance guidelines for colorectal adenomatous polyps in the elderly.

OBJECTIVE: Determining adherence to recommended surveillance intervals after polypectomy in elderly patients. DESIGN: A retrospective cohort study including 531 patients aged above 70 years undergoing polypectomy between 2009-2011 in a large Dutch teaching hospital, identified using the hospital's pathology registry. Outcomes of the index colonoscopy were reviewed. The interval until the next colonoscopy was assessed and compared both to the advised interval according to the Dutch guidelines and the gastroenterologist's recommendation. Reasons for deviating from the guideline were assessed. RESULTS: The initial recommendation of the gastroenterologist for the surveillance interval was in accordance to the guideline in 59.1% of the patients. In 21.8% the gastroenterologist's advice was not documented. In 15.8% of the patients the gastroenterologist recommended to perform surveillance endoscopy earlier than the guideline, mainly based on polyp characteristics. The gastroenterologist advised endoscopy when the guideline advised no surveillance at all in 1.0%, later than the guideline recommendation in 1.2%, or did not recommend surveillance when the guideline advised to continue in 1.0%. Actual surveillance intervals were in accordance to the guideline in 54.4% and in accordance to the initial advice of the gastroenterologist in 58.4% of the patients. CONCLUSION: Only in 41% of patients was the gastroenterologist's recommendation regarding surveillance after polypectomy either absent (21.8%) or not in accordance to the guideline (19.2%). Future research should focus on developing an evidence-based decision algorithm for elderly patients to support gastroenterologists and patients in the choices regarding cessation of surveillance at a certain level of frailty, comorbidity or remaining life-expectancy.

How the concept of biochemical response influenced the management of primary biliary cholangitis over time.

BACKGROUND: Criteria assessing biochemical response to ursodeoxycholic acid (UDCA) are established risk stratification tools in primary biliary cholangitis (PBC). We aimed to evaluate to what extent liver tests influenced patient management during a three decade period, and whether this changed over time. METHODS: 851 Dutch PBC patients diagnosed between 1988 and 2012 were reviewed to assess patient management in relation to liver test results during UDCA treatment. To do so, biochemical response at one year was analysed retrospectively according to Paris-1 criteria. RESULTS: Response was assessable for 687/851 (81%) patients; 157/687 non-responders. During a follow-up of 8.8 years (IQR 4.8-13.9), 141 died and 30 underwent liver transplantation. Transplant-free survival of non-responders (60%) was significantly worse compared with responders (87%) (p < 0.0001). Management was modified in 46/157 (29%) non-responders. The most frequent change observed, noted in 26/46 patients, was an increase in UDCA dosage. Subsequently, 9/26 (35%) non-responders became responders within the next two years. Steroid treatment was started in one patient; 19 patients were referred to a tertiary centre. No trend towards more frequent changes in management over time was observed (p = 0.10). CONCLUSION: Changes in medical management occurred in a minority of non-responders. This can largely be explained by the lack of accepted response criteria and of established second-line treatments for PBC. Nevertheless, the observation that response-guided management did not increase over time suggests that awareness of the concept of biochemical response requires further attention,particularly since new treatment options for PBC will soon become available.

Late-onset inflammatory bowel disease in the very elderly.

Elderly-onset inflammatory bowel disease (IBD) will be seen more frequently with the ageing of the population and the increasing incidence of IBD. However, knowledge regarding the best approach to IBD in this population is scarce. Furthermore, differential diagnosis in elderly patients with diarrhoea, rectal blood loss or a changed defecation pattern is comprehensive and IBD is not always considered. In this case series, we present three elderly patients with late-onset IBD, demonstrating the difficulties in diagnosing and treating IBD in this patient population; in addition an overview of IBD in the elderly is provided.

[Domperidone and the risk of sudden cardiac death]. / Domperidon en het risico op acute hartdood.

Domperidone is an antiemetic drug with relatively few side-effects. In the Netherlands, domperidone is available over the counter. Recently, discussion on the safety of domperidone has arisen because an association with sudden cardiac death has been suggested. We performed a systematic literature search to investigate whether these concerns can be justified. Three out of four case-control studies found statistically significant increased odds ratios for sudden cardiac death when using domperidone. A dose-response relationship was described in one study. Results may be influenced by several confounders. We conclude that there is a relationship between domperidone use and sudden cardiac death at doses of more than 30 mg per day. We recommend that the indication be weighed up properly, that domperidone be provided only on prescription, and dose advice be given. At a dose of 30 mg per day, domperidone can be prescribed safely.

Optimal drug therapy after aspirin-induced upper gastrointestinal bleeding.

Upper gastrointestinal bleeding is a common adverse effect of chronic aspirin treatment. Traditionally, most physicians might tend to discontinue aspirin therapy after related gastrointestinal bleeding. However, recent studies have shown that continuation of aspirin is beneficial because of a decrease of cardiovascular complications and only a relatively small increase of recurrent peptic ulcer bleeding when combined with a proton pump inhibitor. There might be individual cases where the burden of recurrent gastrointestinal complications outweighs the risk of vascular events. In these cases the physician needs to carefully consider other precipitating factors for the recurrent gastrointestinal symptoms. At the moment, alternative antiplatelet therapy does not lead to lower gastrointestinal risks. In the near future, therapies with a more favorable profile might emerge.

Optimal preparation for video capsule endoscopy: a prospective, randomized, single-blind study.

BACKGROUND AND STUDY AIM: Visualization of the small bowel by video capsule endoscopy (VCE) is frequently impaired by intestinal contents. Different bowel preparations have been studied with controversial results. The aim of this study was to determine a satisfactory and tolerable bowel preparation for VCE. METHODS: Ninety patients were randomized to three preparation regimens. Group A underwent VCE after clear liquid diet and overnight fast, while groups B and C received respectively 1 or 2 L of polyethylene glycol (PEG) solution before VCE. For each VCE five segments of 10 minutes were selected, one at the start of each quartile of the small-intestinal transit time, the fifth being the last 10 minutes of the ileum transit. Mucosal visibility was regarded as good if more than 75 % of the mucosa could be evaluated. All patients answered a questionnaire regarding procedure tolerability. RESULTS: The use of PEG solution led to a significant improvement in mucosal visualization. Mucosal visibility was good in the terminal ileum in 25 % of patients in group A, 52 % in group B, and 72 % in group C. The diagnostic yield did not change significantly. The use of 2 L of PEG solution was considered more uncomfortable than no PEG solution or 1 L of the same. CONCLUSION: One liter of PEG solution improves mucosal visualization without causing discomfort for the patient.

New endoscopic techniques for obscure gastrointestinal bleeding.

The case of a postmenopausal woman with a congenital aortic stenosis is presented. She presented with severe iron deficiency anemia. After negative extensive gastrointestinal analysis, she was treated with octreotide for six months. After cessation of octreotide, anemia rapidly recurred. A second capsule endoscopy and a double balloon enteroscopy were performed, and an intestinal vascular malformation was found. After surgical segment resection, the patient had stable, normal levels of hemoglobin and no complaints after 14 months of follow-up.

Results of videocapsule endoscopy in 250 patients with suspected small bowel pathology.

We aimed to assess technical feasibility, clinical applicability, and diagnostic yield of videocapsule endoscopy (VCE) in a large group of unselected patients. VCE was performed with the Given Imaging swallowable capsule. Findings were considered diagnostic if the observed finding could explain the symptomatology of the patient. Findings were considered suspicious if an observed finding failed to completely explain the patient's symptoms. We studied 250 patients. A definite diagnosis was made in 95 patients (38%). Suspicious findings were noted in 80 patients (32%). No diagnosis was obtained in 74 patients (30%). The yield of VCE was higher in patients with suspected Crohn's disease. Mean viewing time decreased significantly from 51 +/- 14 to 30 +/- 7 minutes after reviewing 50 procedures. VCE is an important diagnostic tool, but a definite diagnosis is established in only 38% of the patients. The highest diagnostic yield is obtained in patients with suspected Crohn's disease.

Video capsule endoscopy: procedure, indications and diagnostic yield.

Video capsule endoscopy (VCE) is a new noninvasive imaging technique for the complete small bowel. It provides good to excellent visualisation of the mucosa of the small bowel and has a high diagnostic yield in selected patients with gastrointestinal blood loss of suspected small bowel origin and in patients with Crohn's disease. In comparison with small bowel X-ray and push enteroscopy, diagnostic yield appears to be superior. Although VCE is becoming increasingly popular, good studies on its clinical implications and application are only just emerging. In this paper we review the possibilities and limitations of clinical application of VCE.

Clinical application of video capsule endoscopy.

BACKGROUND: Non-invasive imaging of the complete small bowel has become possible with the recently available video capsule endoscopy technique. The aim of this study was to review and assess the possibilities and limitations of the clinical application of video capsule endoscopy. METHODS: Literature review. RESULTS: Video capsule endoscopy is a new promising technique with good to excellent visualization of the mucosa of the small bowel. It has a high diagnostic yield in patients with occult gastrointestinal blood loss (OGIB) and Crohn disease (CD). Several other indications need further study. Compared to small-bowel X-ray and push enteroscopy, diagnostic yield appears to be superior. Video capsule endoscopy is very well tolerated by patients. Its most important limitation is the impossibility of taking biopsies and therapeutic interventions. CONCLUSION: Video capsule endoscopy is a promising new diagnostic tool for small-bowel disease.