History Of Polyps Research Articles

Full Liquid Diet Versus Clear Liquid Diet and Sodium Sulfate Solution for Colonoscopy Preparation

Introduction: Diet and the prep medication affect the quality of colonoscopy examinations. The most widely accepted clear liquid diet does not leave patients with many options, and can be especially difficult for the diabetic population. This study compares prep quality between full liquid diet (FLD) and a clear liquid diet (CLD) in the setting of a split dosing sodium sulfate solution. Methods: This was a single-blinded, prospective, randomized study in a single community setting that included 160 patients who underwent elective outpatient colonoscopy for colon cancer screening or surveillance. Patients were randomized to either the standard of care CLD or the FLD which allowed patients to consume milk, ice cream, pudding, sorbet and sherbet but avoided red or purple coloring. Both groups received sodium sulfate as the prep solution. A sample size of 80 patients per group was needed to have approximately 80% power to detect a 15% difference between the two groups. The X2 Test of Independence was used to compare differences between the groups on the categorical variables and analysis of variance was used to compare differences between continuous variables. The primary outcome was the mean difference on the Ottawa Bowel Preparation scale between the two groups. Results: Of the 160 patients enrolled, 159 were randomized. 58% of the patients were female. The most common indication for the exam was average risk screening (72.5%), followed by personal history of polyp (21.3%), family history of colon cancer (5%), and family history of colon polyp (0.6%). 81 patients were enrolled in the CLD group and 78 patients in the FLD group. There was no difference in the mean Ottawa score between the CLD and FLD, 2.68 and 2.53, respectively (P = 0.653). Overall, the prep process was well-tolerated with the exception of more headache complaints in the FLD group. The overall cecal intubation rate, adenoma detection rate and average withdraw time were 99.4%, 49.6% and 10.2 minutes, respectively. Conclusion: This non-inferior result adds to the increase in literature demonstrating a strict CLD may not be necessary for a colonoscopy exam. Endoscopists should be more confident in having greater latitude in the prep diet. This, in return, may also improve the willingness of the patients to complete such an exam.

A Rare Cause of Dysphagia to Consider: Calcific Tendinitis of the Longus Colli Muscle

Calcific tendinitis of the longus colli muscle is an acute inflammatory condition caused by the deposition of calcium hydroxyapatite crystals in the muscle's superior insertion point. It is a rare condition with a reported incidence of 1.31 per 100,000 person-years that most commonly presents during the third through sixth decades of life. Symptoms consist of acute neck pain characterized as stiffness with associated odynophagia; the condition is less frequently associated with dysphagia. A mild leukocytosis is typically present, which should prompt investigation to rule out other infectious etiologies first. Characteristic radiographic findings include calcifications in the superior fibers of the longus colli muscle tendons at the level of C1 or C2. This self-limiting condition usually resolves spontaneously with nonsteroidal anti-inflammatory agents. A 44-year old female patient with a medical history of gastroesophageal reflux disease, gastric ulcers, gastritis, gastric polyps, Schatzki ring, hiatal hernia, and benign thyroid nodules presented to the hospital with the complaint of progressive dysphagia to solid foods. This dysphagia developed after an isolated incident of food aspiration four weeks prior to her presentation. Three weeks after this event, she experienced persistent odynophagia with associated left-sided occipital headaches and neck pain radiating to the left ear and mastoid process. Physical examination was remarkable for decreased range of motion with neck flexion and extension, bilateral neck soft tissue tenderness to palpation, and thyromegaly. Laboratory data revealed a hemoglobin of 11.5, hematocrit of 34.8, and WBC of 11.88. An upper gastrointestinal series with barium swallow confirmed the presence of the patient's known Schatzki ring and hiatal hernia. A CT scan, MRI, and MRA of the brain was negative for acute abnormalities, however the CT scan of her neck was positive for calcified longus colli tendons just below the anterior ring of the C1 vertebrae. After an infectious etiology was ruled out, she underwent a trial of oral corticosteroids and NSAIDs that quickly improved her dysphagia and odynophagia. Though exceedingly rare, calcific tendinitis of the longus colli muscle must be considered in a differential diagnosis once the more common etiologies of acute dysphagia and odynophagia have been ruled out or do not correlate with the clinical presentation and/or patient's history. Since this patient's symptoms were progressive, persistent, and associated with a decreased range of motion in her neck along with soft tissue tenderness to palpation, her symptoms were not solely due to the presence of a Schatzki ring. These symptoms did indeed support the final diagnosis of calcific tendinitis of the longus colli muscle.

A genome-wide association study for colorectal cancer identifies a risk locus in 14q23.1.

Over 50 loci associated with colorectal cancer (CRC) have been uncovered by genome-wide association studies (GWAS). Identifying additional loci has the potential to help elucidate aspects of the underlying biological processes leading to better understanding of the pathogenesis of the disease. We re-evaluated a GWAS by excluding controls that have family history of CRC or personal history of colorectal polyps, as we hypothesized that their inclusion reduces power to detect associations. This is supported empirically and through simulations. Two-phase GWAS analysis was performed in a total of 16,517 cases and 14,487 controls. We identified rs17094983, a SNP associated with risk of CRC [p = 2.5 × 10(-10); odds ratio estimated by re-including all controls (OR) = 0.87, 95% confidence interval (CI) 0.83-0.91; minor allele frequency (MAF) = 13%]. Results were replicated in samples of African descent (1894 cases and 4703 controls; p = 0.01; OR = 0.86, 95% CI 0.77-0.97; MAF = 16 %). Gene expression data in 195 colon adenocarcinomas and 59 normal colon tissues from two different studies revealed that this locus has genotypes that are associated with RTN1 (Reticulon 1) expression (p = 0.001), a protein-coding gene involved in survival and proliferation of cancer cells which is highly expressed in normal colon tissues but has significantly reduced expression in tumor cells (p = 1.3 × 10(-8)).

Knowledge of Polyp History and Recommended Follow-Up Among a Predominately African American Patient Population and the Impact of Patient Navigation

Colorectal screening (CRS) rates in minority and uninsured populations have increased through patient navigation (PN) interventions. However, patient knowledge of colonoscopy results and follow-up recommendations has not been described in an African American (AA) population or following PN. Our objectives were to determine patient knowledge of colonoscopy results and follow-up recommendations within an AA patient population and to compare post-colonoscopy knowledge among patients who received either PN or usual care. This is a prospective observational study of patients who completed a screening colonoscopy in 2014. A semi-structured telephone survey was completed by 96 participants (69% AA, 78% female, and mean age 63years). The survey assessed patient recall of polyp results and follow-up recommendations. Responses were compared with the medical record. Of 96 patients surveyed (response rate, 68%), 83% accurately reported if polyps were detected and 66% accurately reported their recommended follow-up. The identification of adenomatous polyps on colonoscopy was a predictor of accurate recall of colonoscopy results and follow-up recommendations. Uninsured patients who completed PN (18 of 96) were more likely to accurately report polyp results (100 vs. 80%; P = 0.036), but the rates of accurate follow-up recall were not statistically significant (44 vs. 71%; P = 0.053) when compared to usual care patients. In an AA population, post-colonoscopy polyp recall rates were similar to those described in white populations. Uninsured patients who completed PN were more likely than insured usual care patients to accurately report the presence of polyps on colonoscopy.

The Relationship Between Colonoscopy Procedure Order and Adenoma Detection Rates: A Prospective Study.

The aim of this study was to prospectively assess the effects of the order of colonoscopic procedures and other possible factors on the adenoma detection rate (ADR). There have been conflicting studies regarding the timing or order of a colonoscopy and its ability to detect adenomas. Between March 2011 and July 2011, consecutive colonoscopies were prospectively performed by 7 board-certified staff endoscopists at the Seoul National University Hospital Healthcare System Gangnam Center. The primary outcome was the overall ADR according to the procedure order of the colonoscopies, and the secondary outcome was the identification of other possible factors influencing the ADR. A total of 1908 colonoscopies were analyzed. The detection rate was 56.5% for all polyps and 37.3% for adenomas. The ADR increased as the performance order of the colonoscopy increased and was highest for the third procedure (43.4%). However, the ADR of the remaining procedures, including later procedures, was similar throughout the workday. In the multivariable analysis, the ADR was significantly associated with older age, male sex, high body mass index, personal history of colorectal polyps, long withdrawal time, and an experienced endoscopist. However, the colonoscopy procedure order was not significantly associated with the ADR. The ADR was stable according to the procedure order for the later procedures of the workday in a setting of moderate daily procedure volumes. The withdrawal time and experience level of the endoscopist were more important than the procedure order in detecting adenomas by colonoscopy.

Factors Associated With Missed and Cancelled Colonoscopy Appointments at Veterans Health Administration Facilities

Cancelled and missed colonoscopy appointments waste resources, increase colonoscopy delays, and can adversely affect patient outcomes. We examined individual and organizational factors associated with missed and cancelled colonoscopy appointments in Veteran Health Administration facilities. From 69 facilities meeting inclusion criteria, we identified 27,994 patients with colonoscopy appointments scheduled for follow-up, on the basis of positive fecal occult blood test results, between August 16, 2009 and September 30, 2011. We identified factors associated with colonoscopy appointment status (completed, cancelled, or missed) by using hierarchical multinomial regression. Individual factors examined included age, race, sex, marital status, residence, drive time to nearest specialty care facility, limited life expectancy, comorbidities, colonoscopy in the past decade, referring facility type, referral month, and appointment lead time. Organizational factors included facility region, complexity, appointment reminders, scheduling, and prep education practices. Missed appointments were associated with limited life expectancy (odds ratio [OR], 2.74; P = .0004), no personal history of polyps (OR, 2.74; P < .0001), high facility complexity (OR, 2.69; P = .007), dual diagnosis of psychiatric disorders and substance abuse (OR, 1.82; P < .0001), and opt-out scheduling (OR, 1.57; P = .02). Cancelled appointments were associated with age (OR, 1.61; P = .0005 for 85 years or older and OR, 1.44; P < .0001 for 65-84 years old), no history of polyps (OR, 1.51; P < .0001), and opt-out scheduling (OR, 1.26; P = .04). Additional predictors of both outcomes included race, marital status, and lead time. Several factors within Veterans Health Administration clinic control can be targeted to reduce missed and cancelled colonoscopy appointments. Specifically, developing systems to minimize referrals for patients with limited life expectancy could reduce missed appointments, and use of opt-in scheduling and reductions in appointment lead time could improve both outcomes.

Abstract 3734: Modified dietary inflammatory index and increased number of colonic aberrant crypt foci

Abstract Pro-inflammatory dietary intake has been linked to the development of colorectal cancer (CRC). There is a paucity of data, however, concerning dietary behavior and prevalence of colonic aberrant crypt foci (ACF), an emerging pre-polyp intermediate endpoint thought to be on the pathway to CRC. We assessed this question in a cross-sectional study of 130 patients (mean age = 57.1 yrs) who received colonoscopy at the Colon Cancer Prevention Program at University of Connecticut Health. Typical diet intake was ascertained from the Brief Block Food Frequency Questionnaire, which provided 29 of the 45 food items in the standard Dietary Inflammatory Index (DII). Using advanced chromoendoscopy imaging, ACF were counted by an endoscopist and external reviewer for consensus. In bivariate analyses between ACF quartiles and mean number of daily servings in four food groups, using the Kruskal-Wallis Non-Parametric test, we found evidence of an inverse dose response with reduced intake of grains (3.9, 3.6, 3.1, 2.7, mean servings per ACF quartile, respectively, p = 0.06) and fruit (1.4, 1.2, 1.0, 1.1, mean servings per ACF quartile, respectively, p = 0.06). We observed little variation in vegetable or dairy intake across ACF quartiles. The association between the modified DII (mod-DII) and ACF number (continuous) was assessed using latent variable modeling controlling for continuous variables of age and waist-hip ratio, and, categorical variables of sex, regular aspirin use (≥ 1 pill per week in past 12 months), regular statin use (≥ 1 pill per week in past 12 months), cigarette smoking (ever, never), polyp history (yes, no) and education level. The final model had a good fit (CFI = 0.92, RMSEA&amp;lt;0.05), and showed statistically significant direct associations between ACF number and both increasing mod-DII score (β = 0.18) and ever having smoked cigarettes (β = 0.19). No significant effects were found between ACF number and the remaining variables in the model. In summary, these cross-sectional findings support the growing evidence base about the adverse impact of an overall pro-inflammatory diet in CRC development and potential value of ACF as intermediate endpoints in research. A limitation of this study is lack of information on physical activity, a lifestyle behavior known to reduce CRC risk presumably through anti-inflammatory effects. More research is warranted to explore possible mitigating effects of physical activity, and other factors known to have pro- or anti-inflammatory properties, in the context of inflammation-based classification of diet. Citation Format: Helen Swede, Masteneh Sharafi, Rong Wu, Valerie B. Duffy, Daniel W. Rosenberg, David A. Drew, Thomas Devers, Richard G. Stevens. Modified dietary inflammatory index and increased number of colonic aberrant crypt foci. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 3734. doi:10.1158/1538-7445.AM2015-3734

Characterizing Online Narratives About Colonoscopy Experiences: Comparing Colon Cancer “Screeners” Versus “Survivors”

Effective screening can reduce colorectal cancer mortality; however, screening uptake is suboptimal. Patients’ stories about various health topics are widely available online and in behavioral interventions and are valued by patients. Although these narratives may be promising strategies for promoting cancer screening behavior, scant research has compared the influence of different role models. This study involving content analysis of online stories aimed to (a) describe the content of online experiential narratives about colonoscopy; (b) compare narratives from individuals who had a colonoscopy and either had colon cancer (survivors) or did not have colon cancer (screeners); and (c) generate hypotheses for future studies. The authors identified 90 narratives eligible for analysis from 15 websites. More stories were about White patients, men, and routine (vs. diagnostic) colonoscopy. A higher-than-expected number of narratives reported a family history of colorectal cancer or polyps (20%) and a colorectal cancer diagnosis (47%). Colorectal cancer survivor (vs. screener) stories were longer, mentioned symptoms and diagnostic reasons for getting a colonoscopy more often, and described the colonoscopy procedure or referred to it as easy or painless less often. Future studies should examine the effects of the role model's personal characteristics and the colonoscopy test result on reader's perceptions and intentions to have a colorectal cancer screening.

PWE-323 An evaluation of surveillance colonoscopy in the elderly

<h3>Introduction</h3> The BSG guidelines on colorectal cancer (CRC) screening recommend that the minimum age to cease surveillance colonoscopy is 75 years. The decision to continue surveillance should then be based on individual patient factors. Currently, there is an increasing demand on endoscopy services due to the introduction of screening programmes and initiatives to increase accessibility. We aim to evaluate the diagnostic yield and complication rate of surveillance colonoscopy in the over 75-age group. <h3>Method</h3> A prospectively collected database of patients at GWH Swindon was interrogated and a consecutive cohort of patients undergoing surveillance colonoscopy for a history of polyps between 11/7/2011 and 6/7/2014 was identified. Patients &lt;75 years, undergoing flexible sigmoidoscopy or colonoscopy for other indications, and those with a previous history of CRC were excluded. Local databases and the electronic patient record were used to obtain further information, including surveillance period, history of CRC, the number and size of polyps seen on colonoscopy, the number of polyps biopsied/retrieved, histology results, quality of each colonoscopy (degree of pain caused, limited colonoscopy/ poor bowel preparation), complication events, and follow up arrangements after colonoscopy. The final cohort comprised 74 patients. The primary outcome was significant adenoma yield (i.e. &gt;1 cm) per annum surveillance. Secondary outcomes included complication rates, quality of colonoscopies, proportion of polyps investigated and accordance with BSG guidelines. <h3>Results</h3> 1) Polyp, adenoma and significant adenoma yield per annum surveillance was 0.37%, 0.33% and 0.17% respectively. Only 2 patients developed CRC over 225 years of polyp surveillance. 2) 13.5% experienced significant pain. 3) 52.7% of surveillance colonoscopies were incomplete or had poor bowel preparation. 4) 80.6% of polyps were biopsied or retrieved. 5) No patient was found to have post-procedure bleeding or perforation. 6) Of 44 patients analysed, 25 patients (56.8%) had inappropriate surveillance colonoscopy according to BSG guidelines. Eighteen (41%) had surveillance earlier than was appropriate. <h3>Conclusion</h3> Our service evaluation suggests that polyp surveillance in elderly patients does not result in a high adenoma/polyp yield; procedures are often suboptimal due to high rates of incomplete procedures and can cause significant pain. BSG guidelines were not followed accurately. This may expose patients to further harm and waste limited resources. It therefore may be more beneficial for endoscopy departments to reduce the number of elderly individuals to whom they offer surveillance or improve compliance with the BSG guidelines. These strategies may decrease demand without resulting in an increase in the incidence of significant neoplastic disease. <h3>Disclosure of interest</h3> None Declared.

Adenoma detection rate in high-risk patients differs from that in average-risk patients

Adenoma detection rates (ADRs) are established as quality targets in average-risk (AR) individuals undergoing colorectal cancer (CRC) screening colonoscopy. Little is known about the ADR in high-risk (HR) individuals undergoing index or surveillance colonoscopy. To determine and compare ADR in HR versus AR individuals undergoing colonoscopy. Retrospective study, tertiary care center. We reviewed records of 7357 patients who underwent colonoscopy by 66 multispecialty endoscopists at our institution during the period 2008 to 2009. Both screening and surveillance colonoscopies in AR and HR patients for CRC were studied. HR patients were further divided into 3 subgroups: those with a (1) personal history of polyps (PHP), (2) family history of polyps (FHP), and (3) family history of CRC (FHCRC). Multivariable logistic regression analysis was performed to evaluate differences in ADR between the groups after adjusting for possible confounders. ADR in HR patients. The study included 4141 patients, of whom 2170 were AR and 1971 were HR. Patients in the HR group were older (64.5 ± 9.1 years vs 59.1 ± 7.9 years, P < .001). HR patients were more likely to have adenomas (30.7% vs 25.6%, P < .001). Adenomas were detected more often in the proximal colon than in the distal colon (29.3% vs 21.0%, P < .001 and 22.8% vs 15.8%, P < .001, respectively). Patients with a PHP had the highest ADR (33.1%, P < .001). However, after adjusting for confounders, HR status was not found to be associated with ADR (odds ratio [OR] 1.2; 95% confidence interval [CI], 0.93-1.6; P = .15 for females and 0.93; 95% CI, 0.70-1.2; P = .61 for males). HR females were found to have a 40% greater likelihood of having proximal adenomas than AR females (1.4; 95% CI, 1.01-2; P = .04). Retrospective design, single tertiary center. Patients with a PHP have a significantly higher ADR compared with AR patients. Defining a minimum target ADR for individuals with a PHP undergoing surveillance colonoscopy is important.

Yield of second surveillance colonoscopy to predict adenomas with high-risk characteristics

Background and aimsThe yield of surveillance colonoscopies for patients with a history of polyps is well established for first surveillance, but limited for second surveillance. The aim of this study was to evaluate the proportion of high-risk adenomas at second surveillance colonoscopy based on findings of previous colonoscopies. MethodsThis retrospective cohort study was conducted in a tertiary hospital and patients who had undergone three colonoscopies were included. Based on the findings at index colonoscopy, patients were categorized into three groups: high-risk adenoma (n=252), low-risk adenoma (n=158) or no-adenoma (n=318). Findings of subsequent high-risk adenoma, low-risk adenoma and no adenoma at surveillance colonoscopies were documented in each group. ResultsAmong patients with high-risk adenoma at index and first surveillance colonoscopies, significantly higher rates of high-risk findings were found at second surveillance, compared with patients who had low-risk or no-adenoma at index colonoscopy and high-risk adenoma at first surveillance colonoscopy (58%, 33% and 10%, respectively, p<0.001). ConclusionsBoth index colonoscopy and first surveillance high-risk adenoma have an impact on incidence high-risk findings at second surveillance colonoscopy and these subjects need close surveillance.

Identification of a Variety of Mutations in Cancer Predisposition Genes in Patients With Suspected Lynch Syndrome

Multigene panels are commercially available tools for hereditary cancer risk assessment that allow for next-generation sequencing of numerous genes in parallel. However, it is not clear if these panels offer advantages over traditional genetic testing. We investigated the number of cancer predisposition gene mutations identified by parallel sequencing in individuals with suspected Lynch syndrome. We performed germline analysis with a 25-gene, next-generation sequencing panel using DNA from 1260 individuals who underwent clinical genetic testing for Lynch syndrome from 2012 through 2013. All patients had a history of Lynch syndrome-associated cancer and/or polyps. We classified all identified germline alterations for pathogenicity and calculated the frequencies of pathogenic mutations and variants of uncertain clinical significance (VUS). We also analyzed data on patients' personal and family history of cancer, including fulfillment of clinical guidelines for genetic testing. Of the 1260 patients, 1112 met National Comprehensive Cancer Network (NCCN) criteria for Lynch syndrome testing (88%; 95% confidence interval [CI], 86%-90%). Multigene panel testing identified 114 probands with Lynch syndrome mutations (9.0%; 95% CI, 7.6%-10.8%) and 71 with mutations in other cancer predisposition genes (5.6%; 95% CI, 4.4%-7.1%). Fifteen individuals had mutations in BRCA1 or BRCA2; 93% of these met the NCCN criteria for Lynch syndrome testing and 33% met NCCN criteria for BRCA1 and BRCA2 analysis (P = .0017). An additional 9 individuals carried mutations in other genes linked to high lifetime risks of cancer (5 had mutations in APC, 3 had bi-allelic mutations in MUTYH, and 1 had a mutation in STK11); all of these patients met NCCN criteria for Lynch syndrome testing. A total of 479 individuals had 1 or more VUS (38%; 95% CI, 35%-41%). In individuals with suspected Lynch syndrome, multigene panel testing identified high-penetrance mutations in cancer predisposition genes, many of which were unexpected based on patients' histories. Parallel sequencing also detected a high number of potentially uninformative germline findings, including VUS.

Evaluation of the clinical efficacy of colon capsule endoscopy in the detection of lesions of the colon: prospective, multicenter, open study

Colon capsule endoscopy (CCE) is a new procedure for colon imaging. Limited information is available regarding visualization of flat colon lesions and patient acceptability in Japan. The aims of this study were to evaluate the sensitivity of CCE in detecting polyps and other lesions compared with optical colonoscopy (OC) and to evaluate its safety and acceptability in a cohort of Japanese patients. A prospective, open-label, clinical study in Japan. Multicenter. Patients referred for OC because of personal history of polyps≥6mm or any other colon lesion that required endoscopic or surgical treatment. CCE followed by therapeutic colonoscopy. The primary endpoint was per-patient sensitivity of CCE in detecting significant colon lesion. The secondary endpoints were CCE safety and patient acceptability. Sixty-six of the 72 patients enrolled in the study were evaluated for efficacy. The per-patient sensitivity was 94% (95% confidence interval [CI], 88.2%-99.7%). The per-polyp sensitivity was 86.6% (95% CI, 81.3%-91.9%) when pathology-confirmed polyps were considered true positives. There were no adverse events related to CCE, and the acceptability of CCE was high. All patients had previously confirmed colon lesions, which may have falsely elevated the sensitivity of CCE. CCE had a high sensitivity for detecting significant colon lesions. CCE was safe and had a high level of patient acceptability. ( University Hospital Medical Information Network, UMIN000007258.).

Sessile serrated adenomas versus conventional adenomas. Different polyps in different populations?

The aim of this study was to determine risk factors for the development of sessile serrated adenomas (SSA/Ps) as well as to study differences between groups with SSA/Ps and conventional adenomas (tubular, tubulovillus and villus) in the general population. One hundred patients with normal colonoscopies, 27 patients with 53 SSA/Ps and 69 patients with 156 conventional adenomas were studied, epidemiological data were collected and calculations of body mass index and waist-to-hip ratio were performed prior to endoscopy. A univariate and a multivariate logistic regression analysis were performed using Stata 9.0. SSA/Ps had a positive association with increasing age (p = 0.01), heavy smoking (≥20 packet years) (p = 0.001) and past history of polyps (p = 0.004) in comparison to normal population. SSA/Ps showed an inverse association with conventional adenomas for diabetes mellitus (p < 0.001) and arterial hypertension (p = 0.001). Meanwhile, female sex was positively associated with SSA/P development in comparison to conventional adenomas (p = 0.031). Heavy smoking as a significant risk factor for developing SSA/Ps was confirmed from this study. It also seemed that patients with diabetes mellitus and/or hypertension developed conventional adenomas more frequently than SSA/Ps; on the contrary, females were at higher risk of developing SSA/Ps than conventional adenomas.

Meckel's Diverticulum: A Rare Cause of Overt Obscure Gastrointestinal Bleeding in an Adult Male

A 64-year-old male, with history of arterial hypertension and colonic polyps, recurred to the emergency department with recurrent hematochezia in the last 6 h. He denied abdominal pain, fever or other symptoms. No anemia or hemodynamic instability was present. Physical examination confirmed fresh blood and clots in the rectal ampulla. An urgent colonoscopy revealed fresh blood and clots in the terminal ileum and through the colon. Subsequently an urgent upper gastrointestinal endoscopy was performed with no relevant findings. Hence, in the same day, an urgent capsule enteroscopy was performed. In the middle ileum, a large diverticulum (Fig. 1) with erythematous mucosa in the fundus (Fig. 2) and a linear ulcer in the neck was found. Congestive mucosa and several deep ulcers with no active bleeding were apparent adjacent and downstream from the diverticulum (Fig. 3). These features highly suggested a Meckel’s diverticulum with ectopic gastric mucosa. After a multidisciplinary discussion, a laparoscopic diverticulectomy was performed. Histological evaluation confirmed a Meckel’s diverticulum with gastric and pancreatic tissues (Fig. 4). The patient was discharged 5 days later. No changes in the terminal ileum were apparent in a colonoscopy performed because of a post-polipectomy surveillance 4 months later.

Racial variation in frequency and phenotypes of APC and MUTYH mutations in 6,169 individuals undergoing genetic testing.

PurposeTo assess whether differences in frequency and phenotype of APC and MUTYH mutations exist among racially/ethnically diverse populations.Methods6169 individuals with personal and/or family history of colorectal cancer (CRC) and polyps were studied. APC testing involved full sequencing/large rearrangement analysis (FS/LRA); MUTYH involved “panel testing” (for Y165C, G382D mutations), or FS/LRA, performed by Myriad Genetics, a commercial laboratory. Subjects were identified as Caucasian, Asian, African American (AA), or Other. Statistical tests included Chi-Square, Fisher’s Exact, ANOVA and z-approximation.Results17.5% had pathogenic APC mutations. 4.8% were biallelic MUTYH carriers. 18% were non-Caucasian with >100 adenomas and younger ages of adenoma or CRC diagnosis (p<0.0001) than Caucasians. The overall APC mutation rate was higher in Asians, AAs and Others compared to Caucasians (25.2%, 30.9%, 24%, 15.5%;p<0.0001) but similar in all groups when adjusted for polyp burden. More MUTYH biallelic carriers were Caucasian or Other than Asian or AA (5%, 7%, 2.7%, 0.3%;p<0.0001). Among Caucasians, 5% were biallelic carriers identified by panel testing versus 2% by sequencing/LRA (p=0.002). Among non-Caucasians, 3% undergoing panel testing were biallelic carriers versus 10% identified by sequencing/LRA(p<0.0002).ConclusionNon-Caucasians undergo genetic testing at more advanced stages of polyposis and/or younger ages of CRC/polyp diagnosis. Restricted MUTYH analysis may miss significant numbers of biallelic carriers, particularly in non-Caucasians.

Influence of perception of colorectal cancer risk and patient bowel preparation behaviors: a study in minority populations.

BackgroundLarge disparities exist in the utilization rates of screening modalities for colorectal cancer (CRC) in different socioeconomic areas. In this study, we evaluated whether the quality of bowel preparation differed significantly among populations with a high risk of CRC compared with that among the general population after matching for potential confounding factors.MethodsHispanic and African American patients who underwent routine screening or surveillance colonoscopies in an outpatient setting between 2003 and 2013 were included in this retrospective study. Patients who underwent colonoscopies for emergent indications and repeat routine screening colonoscopies because of prior history of inadequate bowel preparation were excluded from this study. The patients were divided into three groups: patients having an average risk of being diagnosed with CRC (group 1); patients having a high risk of being diagnosed with CRC because of a personal history of adenomatous polyps (group 2); and patients having a high risk of being diagnosed with CRC because of a family history of CRC in first-degree relatives (group 3). All the patients were given preprocedural counseling and written instructions for bowel preparation. Data on demographic information, method of bowel preparation, quality of bowel preparation, comorbidities, and prescription medications were collected.ResultsIn all, 834 patients had a “high-risk for CRC” surveillance colonoscopy in view of their personal history of adenomatous polyps and were included in group 2. In total, 250 patients had a “high-risk for CRC” screening colonoscopy in view of their family history of CRC in first-degree relatives and were included in group 3. Further, 1,000 patients were selected to serve as controls (after matching for age, sex and ethnicity) and were included in group 1. Bowel preparation was graded as good, fair, or poor by the endoscopist performing the study. We observed a significantly higher number of good bowel preparations in group 2 and group 3 (P=0.0001) when compared with group 1 (controls) after adjusting for comorbidities and usage of prescription medication that could potentially cause colonic dysmotility. These differences were significant in both Hispanic and African American patients.ConclusionOur study showed that perception of CRC risk significantly influenced the bowel preparation behaviors of patients belonging to minority populations, with a significantly greater number of patients with a high risk of CRC having adequate bowel preparations.

Multiple vitello-intestinal duct anomalies in a pediatric patient: A rare case report

The omphalomesenteric duct is an embryonic structure which connects the yolk sac to the midgut. The omphalomesenteric duct attenuates between the 5 th and 9 th week of gestation. Failure of the omphalomesenteric duct involution, either partial or complete, results in various anomalies including Meckel's diverticulum, patent vitelline duct, fibrous band, sinus tract, umbilical polyp and cyst. Omphalomesenteric duct remnants are present in 2% of the population. The simultaneous presence of omphalomesenteric cyst, fibrous band and Meckel's diverticulum is extremely rare. We have an 8-year-old child with a history of umbilical polyp and discharge in his infancy now presents with persistent pain abdomen. On laparotomy we found a Meckel's diverticulum, an omphalomesenteric cyst and fibrous band. Multiple anomalies in the vitello-intestinal duct though very rare can cause clinical problem which need specific attention in terms of surgery.

Abstract B95: Barriers to completion of a free colorectal cancer screening program in a low-income population

Abstract Colorectal cancer (CRC) is the fourth most common cancer in the US. Screening is effective to prevent and detect CRC, but is underutilized in underserved populations. We assessed a free CRC screening program intended for the underserved population in central Illinois to determine what factors (demographics, medical history, risk factors, perceived barriers, rurality) prevented eligible patients from completing CRC screening. Methods: Potential participants were recruited to the Vince Demuzio Colorectal Screening Initiative via postcard mailing, media advertising and physician referral from July 2010 to June 2012. Interested participants called a toll-free number for an eligibility assessment, which required: being due for a CRC screening, age of 50-64 years, uninsured/underinsured, ≤250% of the federal poverty level, and residence in the 22 county (1 urban and 21 rural counties) catchment area. Eligible participants then completed a questionnaire via phone about their demographics, screening history, risk factors, and screening barriers, and were sent documents to sign for enrollment. Once signed documents were returned, patients chose to complete a fecal occult blood test (FOBT) or schedule a pre screening appointment and colonoscopy at 1 of 13 participating local hospitals. Analysis of 22 factors associated with screening was performed comparing residency (rural vs. urban) and screening completion (completers vs. non-completers) using Fisher's exact tests and independent t-tests. Results: There were 352 eligible participants, and they were: 86 % white, 57% female, 90% with at least a high school education, 60 % rural and 37 % current smokers. 245 participants (69.6%) completed CRC screenings (233 colonoscopies and 12 FOBTs). Ultimately, 107 (30.4%) eligible individuals did not complete screening due to the following: unreturned enrollment documents (54), loss to follow-up or withdrawal (44), did not return FOBT card (4) or were later deemed ineligible (5). Overall, rural participants were more likely than urban to be female (66.2% vs.44.4%, p&amp;lt;0.001), white (98.6% vs.68.3%, p&amp;lt;0.001), to have had a past blood stool test (25.8% vs. 9.4%, p=0.013) and to have a history of polyps (12.9% vs. 4.9%, p=0.016). Screening completion rates did not differ between urban and rural participants (65.5 % vs. 72.4%, p=0.19). The only factor significantly different between completers (C) and non-completers (NC) was report of a past blood stool test (42.4% vs. 29.9%, p=0.03), and among those reporting a past test, having a test within the past year (23.1% vs. 7.5%; p=0.04). Rural NC were more likely to note fear of discomfort as a barrier than urban NC (28.6% vs. 10.6%; p=0.03). There were no other significant differences at these stratifications. Conclusions: Despite meeting eligibility criteria, roughly a third of interested patients did not receive CRC screening. Rural NC differed from urban NC. Rural NC were more often female, white (anticipated in rural Illinois) and reported procedure discomfort as a screening barrier. However, most examined patient-related factors did not differ between groups and stratifications. Patient anecdotes indicated that more efficient processes, such as reduction in enrollment and screening steps and assistance with scheduling, may improve completion rates. Also, efforts should be made to both address gender and race differences that might impact screening in rural populations and develop better survey tools to identify screening barriers. Citation Format: Whitney Zahnd, David Steward, Wiley Jenkins, Jennifer Andoh, Georgia Mueller, Sandra Puczynski. Barriers to completion of a free colorectal cancer screening program in a low-income population. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr B95. doi:10.1158/1538-7755.DISP13-B95

Smoking Is Associated With an Increased Risk of Adenomas in Patients at High Risk for Colorectal Cancer

Introduction: Colorectal cancer (CRC) is the third leading cause of cancer mortality in the United States. Adenoma removal has been shown to reduce deaths from CRC. Although smoking has been associated with an increased risk of CRC, smoking status is not included in algorithms that guide colonoscopy for CRC screening and surveillance. This study evaluated the impact of smoking on adenoma detection in patients who are at elevated risk for CRC. Methods: Reports of consecutive colonoscopies performed at an urban university hospital during a 6-month period were reviewed and their indications and results noted. Colonoscopies performed for screening of elevated risk patients and/or surveillance indications were included. Elevated risk was defined as personal or family history of CRC or polyp, inflammatory bowel disease (IBD), or “high risk for CRC” as the stated indication. Patients’ demographics, family history, and smoking history were collected. Maintaining patient confidentiality, a database was created using Microsoft Excel. Statistical analysis was performed using Fisher’s exact test with significance set at p<0.05. The study was approved by the university IRB. Results: There were 589 screening or surveillance colonoscopies for elevated-risk patients. Among them, 373 never smoked and 216 had. Adenoma were detected in 123 elevated-risk patients who had smoked (56.9%) and 166 (44.5%) of the never smokers (p=0.0037). Family history was the sole risk factor for 79 patients deemed high risk (20 male, 59 female), and adenomas were discovered in 25 (31.6%). Colonoscopies were performed in 421 patients with history of polyp; 243 (57.7%) had adenomas. There were 56 IBD patients and 3 (5.4%) had adenomas. Among elevated CRC risk patients, smoking was associated with a higher adenoma detection rate than was IBD (p<0.001), and family history of CRC (p=0.001), but not personal history of colon polyp (p=0.8659). Conclusion: Adenoma detection and removal decreases CRC deaths. Personal and family history of CRC or adenoma and IBD are recognized risk factors and influence the recommended age of onset and interval of screening colonoscopy. In this study, there was a significantly higher adenoma detection rate in smokers at increased risk of CRC. The rate of adenoma detection was significantly higher in smokers than in those with a family history of CRC or IBD. The patient’s smoking status should be considered when individualizing recommendations for CRC screening and surveillance, particularly in patients who are at high risk.