The endoscopist's guide to serrated polyposis

AIM

Serrated polyposis is a condition of the colon characterized by multiple serrated polyps. This review aims to provide a practical guide to the day-to-day management of serrated polyposis, including diagnosis, endoscopic identification of serrated polyps, surveillance, the role of endoscopic and surgical management and the screening of family members.

METHOD

The literature was searched using PubMed and MEDLINE databases for the terms "serrated polyp", "serrated polyposis" and "hyperplastic polyposis". English-language abstracts were read and the full article was retrieved if relevant to the review. Expert opinion from the authors was also sought.

RESULTS

Advances in our knowledge of the molecular pathways involved in serrated polyposis and an improved clinical picture of the disease from retrospective studies have led to better understanding of its pathogenesis and natural history. However, there are still areas not answered by the literature, and hence empirical management or expert opinion has to be followed.

CONCLUSION

Improvements in our understanding of serrated polyposis, together with improvements in endoscopic equipment and technique, have enabled the endoscopist to be at the forefront of managing this condition from diagnosis to endoscopic surveillance and control of the polyps.

Bowel preparation for colonoscopy: European Society of Gastrointestinal Endoscopy (ESGE) guideline

BACKGROUND AND AIM

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It addresses the choice amongst regimens available for cleansing the colon in preparation for colonoscopy.

METHODS

This Guideline is based on a targeted literature search to evaluate the evidence supporting the use of bowel preparation for colonoscopy. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was adopted to define the strength of recommendation and the quality of evidence.

RESULTS

The main recommendations are as follows. (1) The ESGE recommends a low-fiber diet on the day preceding colonoscopy (weak recommendation, moderate quality evidence). (2) The ESGE recommends a split regimen of 4 L of polyethylene glycol (PEG) solution (or a same-day regimen in the case of afternoon colonoscopy) for routine bowel preparation. A split regimen (or same-day regimen in the case of afternoon colonoscopy) of 2 L PEG plus ascorbate or of sodium picosulphate plus magnesium citrate may be valid alternatives, in particular for elective outpatient colonoscopy (strong recommendation, high quality evidence). In patients with renal failure, PEG is the only recommended bowel preparation. The delay between the last dose of bowel preparation and colonoscopy should be minimized and no longer than 4 hours (strong recommendation, moderate quality evidence). (3) The ESGE advises against the routine use of sodium phosphate for bowel preparation because of safety concerns (strong recommendation, low quality evidence).

Half-time and high-speed running in the second half of soccer

This study investigated if the quantity of high-speed running (movements >15 km.h(-1) completed in the first 15 min of competitive football matches differed from that completed in the corresponding 15 min of the second half. 20 semi-professional soccer players (age 21.2±3.6 years, body mass 76.4±3.8 kg, height 1.89±0.05 m) participated in the study. 50 competitive soccer matches and 192 data files were analysed (4±2 files per match) using Global Positioning Satellite technology. Data were analysed using 2-way repeated measures ANOVA and Pearson correlations. No differences were found between the first 15 min of each half for the distance completed at high-speed (>15 km.h(-1) or sprinting (>21 km.h(-1), or in the number of sprints undertaken (p>0.05). However, total distance covered was shorter (1st half vs. 2nd half: 1746±220 vs. 1644±224 m; p<0.001) and mean speed lower (1st half vs. 2nd half: 7.0±0.9 vs. 6.6±0.9 km.h(-1); p<0.001) in the first 15 min of the second half compared to the first. The correlations between the duration of the half-time interval and the difference in the high-speed running or sprinting between first and second halves (0-15 min) were very small (r=0.08 [p=0.25] and r=0.04 [p=0.61] respectively). Therefore, this study did not find any difference between the amount of high-speed running and sprinting completed by semi-professional soccer players when the first 15 min of the first and second half of competitive matches were compared The maintenance of high-speed running and sprinting, as total distance and mean speed declined, may be a function of the pacing strategies adopted by players in competitive matches.

Alcohol and drug dependence: syndrome, strong attachment or everyday behaviour?

The concept of the dependence syndrome has largely replaced that of 'alcoholism' and 'addiction' in official classifications of alcohol- and drug-related disorders. However, the utility of the concept has been widely disputed by psychologists and other social scientists. The authors of this paper, both clinical psychologists, hold opposing positions on this issue. Following a brief statement of these positions and an outline of the dependence syndrome, the authors debate a range of disputed issues.

Effects of β-alanine supplementation on exercise performance: a meta-analysis

Due to the well-defined role of β-alanine as a substrate of carnosine (a major contributor to H⁺ buffering during high-intensity exercise), β-alanine is fast becoming a popular ergogenic aid to sports performance. There have been several recent qualitative review articles published on the topic, and here we present a preliminary quantitative review of the literature through a meta-analysis. A comprehensive search of the literature was employed to identify all studies suitable for inclusion in the analysis; strict exclusion criteria were also applied. Fifteen published manuscripts were included in the analysis, which reported the results of 57 measures within 23 exercise tests, using 18 supplementation regimes and a total of 360 participants [174, β-alanine supplementation group (BA) and 186, placebo supplementation group (Pla)]. BA improved (P = 0.002) the outcome of exercise measures to a greater extent than Pla [median effect size (IQR): BA 0.374 (0.140–0.747), Pla 0.108 (−0.019 to 0.487)]. Some of that effect might be explained by the improvement (P = 0.013) in exercise capacity with BA compared to Pla; no improvement was seen for exercise performance (P = 0.204). In line with the purported mechanisms for an ergogenic effect of β-alanine supplementation, exercise lasting 60–240 s was improved (P = 0.001) in BA compared to Pla, as was exercise of >240 s (P = 0.046). In contrast, there was no benefit of β-alanine on exercise lasting <60 s (P = 0.312). The median effect of β-alanine supplementation is a 2.85% (−0.37 to 10.49%) improvement in the outcome of an exercise measure, when a median total of 179 g of β-alanine is supplemented.

Extra-articular stabilization of the cranial cruciate deficient stifle with anchor systems

Complete or partial rupture of the cranial cruciate ligament (CCL) is a common injury of the canine stifle. Most practicing veterinarians would agree that optimal outcome is best achieved with surgical intervention. A popular method of stabilization is an extra-articular suture stabilization. The objective of this manuscript is to describe suture placement in a more isometric position as compared to traditional suture placement. A second objective is to introduce the veterinary surgeon to novel anchor products used for stabilization.

Legislative and humanitarian impetus for development of alcohol and other drug policy at an Australian university

The rationale for comprehensive alcohol and other drug policy at a tertiary institution is presented here as a health promotion strategy for educating University policy makers. Particular emphasis is placed on a discussion of humanitarian issues, that is, the right to a healthy environment, and the potential for legal liability in an environment where alcohol is readily available and other drugs are present. There is little attention paid to drug use related legal issues in the University, but at the same time drawing the attention of policy makers to the organisation's vulnerability to lawsuits has been reported to be a motivating force for adoption of drug use policy. Universities do experience problems related to alcohol and other drug use by staff and students. Problem reduction, and better management of problems, are the major goals of policy in this area. Local initiatives, for example at the organisational level, make important contributions to the overall drug prevention efforts of the nation. Well-developed policy and procedures and effective implementation constitute an important structural health promotion strategy. Such policy would comply with the immediate requirements of Occupational Health, Safety and Welfare legislation and provide some protection against wrongful dismissal claims and negligence lawsuits, as well as providing long-term educative effects. Situations for which policies are needed, range widely due to the University's unique environment and complex roles.

Alcohol and other drugs: the prevention paradoxes

This paper asks what prevents the prevention of alcohol and drug use problems. Five prevention paradoxes can be identified, all of which may well be interfering with our attempts to reduce the problems associated with drug use. Drug problem preventers should be aware of these paradoxes and, thus, be able to avoid becoming ensnared by them.

Do our guardians need guarding? An examination of the Australian system of self-regulation of alcohol advertising

In this study the Australian system of self-regulation of alcoholic beverage advertising was examined. Sixteen advertisements, eight print and eight television advertisements, were subjected to public scrutiny. Respondents rated advertisements using a self-completion questionnaire based directly on the Australian Alcoholic Beverage Advertising Code. Responses were collated and where a majority of respondents had endorsed items that constituted a breach of the cose, a complaint, ostensibly from a member of the general public, was made to the Advertising Standards Council. All sixteen advertisements were regarded by the public as containing aspects which breached the code. However, the Advertising Standards Council rejected all but one of the sixteen complaints, often directly contradicting the opinions of our respondents. The social policy implications of these results are considered. It is contended that the system of self-regulation of alcohol advertising does not serve the public interest.

Alcohol and young people: minimizing the harm

In this paper the literature on patterns of use of alcohol by teenagers is reviewed. The model as proposed by Thorley is used to describe the specific nature of alcohol problems experienced by young people. A systemic approach to prevention is explored and recommendations are made about ways to minimise the harm associated with alcohol use by young people.

Motivation and addiction behaviour: a psychological perspective

In this paper traditional ideas about motivation and the addiction behaviours are critically considered. It is proposed that rather than viewing motivation as a static quality that clients either have or have not, motivation is more usefully perceived as the balance between the costs and benefits of undertaking any behaviour, juxtaposed with the costs and benefits of ceasing the behaviour. It is also proposed that confrontation approaches, rather than inducing motivation, actually increase the client's resistance. Motivational interventions therefore need to be based on a client-generated inventory of problems and concerns rather than a therapist-dictated one. A decision-making framework for motivational intervention is emphasized and the effectiveness of motivational strategies based on this paradigm is considered.

Preventing drug use problems: the university as a site for local action

While the prevention of drug use problems comes well recommended, there is limited agreement on which preventive strategies are the most effective. Furthermore there is debate as to where activity most effectively occurs-should it be at the national or local level? In this study a university community was investigated with the aim of determining whether members of that community appreciated the need for prevention of drug use problems and which preventive strategies they deemed to be of value. The difficulties inherent in taking action within a tertiary environment are also considered and an agenda for action described.

Molecular classification and genetic pathways in hyperplastic polyposis syndrome

Hyperplastic Polyposis (HPPS) is a poorly characterized syndrome that increases colorectal cancer (CRC) risk. We aimed to provide a molecular classification of HPPS. We obtained 282 tumours from 32 putative HPPS patients with >or= 10 hyperplastic polyps (HPs); some patients also had adenomas and CRCs. We found no good evidence of microsatellite instability (MSI) in our samples. The epithelium of HPs was monoclonal. Somatic BRAF mutations occurred in two-thirds of our patients' HPs, and KRAS2 mutations in 10%; both mutations were more common in younger cases. The respective mutation frequencies in a set of 'sporadic' HPs were 18% and 10%. Importantly, the putative HPPS patients generally fell into two readily defined groups, one set whose polyps had BRAF mutations, and another set whose polyps had KRAS2 mutations. The most plausible explanation for this observation is that there exist different forms of inherited predisposition to HPPS, and that these determine whether polyps follow a BRAF or KRAS2 pathway. Most adenomas and CRCs from our putative HPPS patients had 'classical' morphology and few of these lesions had BRAF or KRAS2 mutations. These findings suggest that tumourigenesis in HPPS does not necessarily follow the 'serrated' pathway. Although current definitions of HPPS are sub-optimal, we suggest that diagnosis could benefit from molecular analysis. Specifically, testing BRAF and KRAS2 mutations, and perhaps MSI, in multiple polyps could help to distinguish HPPS from sporadic HPs. We propose a specific model which would have diagnosed five more of our cases as HPPS compared with the WHO clinical criteria.

Argon plasma coagulation in chronic radiation proctitis

Chronic radiation proctitis is a relatively common late complication of pelvic irradiation. The main symptoms are diarrhea, urgency, tenesmus, and rectal bleeding. While mild cases may settle spontaneously over some months, severe hemorrhagic radiation proctitis may require repeated blood transfusions and is difficult to treat with medical therapy. Argon plasma coagulation (APC) is a noncontact thermal coagulation technique which can be applied endoscopically. A probe passed through the scope delivers a field of argon gas to the mucosal surface where it is ionized by a high voltage filament, resulting in superficial mucosal heating and coagulation of friable blood vessels. The technique reduces rectal bleeding in 80%-90% of cases, and may improve the other troublesome symptoms of diarrhea and urgency. APC is probably less effective in very severe cases of hemorrhagic radiation proctitis; in these cases topical formalin or a combination of APC and topical formalin can be useful. Overall, APC has proved to be a safe and well tolerated technique.

Video capsule endoscopy in peutz-jeghers syndrome: a blinded comparison with barium follow-through for detection of small-bowel polyps

BACKGROUND AND STUDY AIMS

Video capsule endoscopy has shown promise for the surveillance of significant small-bowel polyps in patients with Peutz-Jeghers syndrome. In this study the yield of significant small-bowel polyps by capsule endoscopy was compared to the yield of these polyps by barium follow-through in adults with Peutz-Jeghers syndrome.

PATIENTS AND METHODS

A total of 19 adults with Peutz-Jeghers syndrome who were undergoing surveillance underwent both capsule endoscopy and barium follow-through examinations, and the number of small-bowel polyps of at least 1 cm in diameter that were detected was recorded for each method. The two methods were assessed in terms of comfort and convenience for the patients and their preferred future surveillance method, using a questionnaire.

RESULTS

Capsule endoscopy detected a median of four significant small-bowel polyps while barium follow-through detected a median of one (P = 0.008). There was a trend towards more participants having at least one significant small-bowel polyp detected by capsule endoscopy than was the case with barium follow-through, though capsule endoscopy seemed to be less reliable for accurate sizing of polyps that were at the limit of clinical significance. Most participants expressed a preference for capsule endoscopy for future surveillance.

CONCLUSIONS

Capsule endoscopy should replace barium follow-through for the surveillance of small-bowel polyps in adults with Peutz-Jeghers syndrome, but the findings of this study should be interpreted with caution until a more reliable means of sizing polyps by capsule endoscopy is available.