Cirrhosis as an independent risk factor for colonic adenomas

Liver Cirrhosis Increases the Risk of Developing Advanced Colon Polyps

GOALS

To analyze our experience with adenoma detection rates in patients with liver cirrhosis in a community setting.

BACKGROUND

Colorectal cancer (CRC) is the third most common cancer and leading cause of cancer death in men and women in the USA. The majority of CRCs arise from premalignant polyps (adenomas), which are typically detected and removed during colonoscopy. Data are limited on the risk of CRC in patients with various chronic liver diseases and the association between CRC and demographics, liver disease etiology and colonoscopy findings.

STUDY RESULTS

A total of 351 colonoscopies were performed (2006 to 2019) in patients with liver cirrhosis. Mean age was 62.3 ± 9.4 years, there were 158 females and 193 males. Adenomas were found in 159 procedures (49.07%) and were more likely found in the right colon (76.73%) vs the left colon (18.87%). Left-sided adenoma occurrence was significantly lower in women (61% lower than men, p = 0.05). Neither indication for the procedure (p = 0.08) nor advancing age (p = 0.94) affected adenoma detection rates. No significant differences were observed in the findings of adenomas between different chronic liver diseases.

CONCLUSIONS

Adenoma detection rates in patients with cirrhosis (49%) undergoing elective colonoscopy were higher than rates reported in the literature for LT candidates (22-42%) undergoing standardized screenings. Colonoscopy screenings should be expanded to all patients with cirrhosis, regardless of etiology.

COLONOSCOPY FINDINGS IN LIVER TRANSPLANTATION CANDIDATES

ABSTRACT Background Mandatory colonoscopy in liver transplantation (LT) candidates is recommended but still controversial. Objective To investigate the frequency of colonoscopy lesions in order to support colorectal cancer (CRC) screening in a real-world pre-LT cohort. Methods Retrospective study conducted at a single-center included 632 subjects who underwent pre-transplantation colonoscopy. Results Median age was 56.9 years (yr.) old (82.3% were ≥50 yr.). Primary sclerosing cholangitis (PSC) occurred in 4.6%. Colonoscopy was abnormal in 438 (69.3%) by detection of polyps (37.7%), vascular changes (29.9%), diverticulosis (18.4%), inflammatory bowel disease features (5.2%) and CRC (0.6%). Histology was available in 66.8% of polyps: hyperplastic (47.8%), low-grade dysplasia (56.6%) and high-grade dysplasia (3.8%). High-risk adenomas occurred in 8.2% of the 594 subjects evaluated. Individuals ≥50 yr. were more likely to present abnormal colonoscopy and polyps. High-grade dysplasia and CRC were only found in individuals ≥50 yr. Patients with high-risk adenomas were more likely to be ≥50 yr.: there was no association between high-risk adenomas detection and liver disease etiology or PSC diagnosis. Conclusion Most LT candidates presented abnormal colonoscopy examination, especially by polyps presence. All cases of high-grade dysplasia and CRC occurred in patients ≥50 yr., regardless of disease etiology.

Risk Factors Associated With Postendoscopic Mucosal Resection Bleeding in Patients With Cirrhosis: A Retrospective Multicenter Cohort Study

BACKGROUND AND AIM

There is limited data regarding the safety of endoscopic mucosal resection (EMR) in the cirrhotic population. Our study aimed to evaluate the safety of colonoscopic EMR in cirrhosis.

MATERIALS AND METHODS

This was a retrospective review of cirrhotics who underwent colonic EMR at 8 Cleveland Clinic Centers between January 1, 2006, and December 31, 2018. Patient data including polyp details and complications occurring within 30 days of the procedure were noted. Univariable and multivariable logistic regression analyses were conducted to find risk factors for post-EMR bleeding.

RESULTS

A total of 238 patients who underwent EMR were included. There were 145 males (60.9%) and the mean age was 61.9±8.6 years. Immediate and delayed bleeding, and postpolypectomy syndrome rates were 9.2%, 5.8%, and 1.3%, respectively. Significant risk factors for postpolypectomy bleeding were: increased age (P=0.001), procedure duration >37 minutes (P=0.001), antiplatelet use within 5 days (P=0.023), and lesion diameter >15 mm (P=0.004). Multivariable analysis revealed independent predictors of procedure-related bleeding: age above 65 years [odds ratio (OR) 2.14, P=0.044], antiplatelet use within 5 days (OR 2.42, P=0.047), right colon polyp (OR 3.51, P=0.001), and lesion diameter >15 mm (OR 3.22, P=0.003).

CONCLUSIONS

EMR in cirrhotics has an acceptable bleeding risk. Age above 65 years, right colon polyp, polyp size >15 mm, and use of antiplatelets within 5 days are independent risk factors for bleeding.

Bleeding After Elective Interventional Endoscopic Procedures in a Large Cohort of Patients With Cirrhosis

INTRODUCTION:

Elective therapeutic endoscopy is an important component of care of cirrhotic patients, but there are concerns regarding the risk of bleeding. This study examined the incidence, risk factors, and outcomes of bleeding after endoscopic variceal ligation (EVL), colonoscopic polypectomy, and endoscopic retrograde cholangiopancreatography with sphincterotomy in cirrhotic patients.

METHODS:

A cohort study of patients with cirrhosis who underwent the above procedures at a single center between 2012 and 2014 was performed. Patients with active bleeding at the time of procedure were excluded. Patients were followed for 30 days to assess for postprocedural bleeding and for 90 days for mortality.

RESULTS:

A total of 1,324 procedures were performed in 857 patients (886 upper endoscopies, 358 colonoscopies, and 80 endoscopic retrograde cholangiopancreatograpies). After EVL, bleeding occurred in 2.8%; after polypectomy, bleeding occurred in 2.0%; and after sphincterotomy, bleeding occurred in 3.8%. Independent predictors of bleeding after EVL and polypectomy included younger age and lower hemoglobin. For EVL, bleeding was also associated with infection and model for end-stage liver disease-Na. International normalized ratio was associated with bleeding in univariate analysis only, and platelet count was not associated with bleeding in any procedure. Bleeding after EVL was associated with 29% 90-day mortality, and bleeding after polypectomy was associated with 14% mortality. Of the 3 patients with postsphincterotomy bleeding, none were outliers regarding their baseline characteristics.

DISCUSSION:

In patients with cirrhosis, bleeding occurs infrequently after elective therapeutic endoscopy and is associated with younger age, lower hemoglobin, and high mortality. Consideration of these risk factors may guide appropriate timing and preprocedural management to optimize outcomes.

Chronic liver disease promotes lesions of the colorectal adenoma-carcinoma sequence, independent of liver cirrhosis

Background

Research increasingly focuses on identifying individuals at greater risk of colorectal cancer (CRC) to enhance colonoscopy screening efficacy.

Objective

The objective of this article is to determine associations between chronic liver disease and lesions along the colorectal adenoma-carcinoma sequence.

Methods

This retrospective study encompasses consecutive liver disease patients (LDPs) of all etiologies evaluated for liver transplantation at a single institution and a control group of liver-healthy patients (LHPs) undergoing colonoscopy as part of the German CRC screening program.

Rates of polyps, adenomas, high-risk situations (HRS) and CRC were analyzed in univariable and multivariable settings adjusting for age, gender, body mass index and number of colonoscopies. Differences between LHPs and LDPs and between cirrhotic and noncirrhotic hepatopathy were assessed.

Results

In total, 1046 patients (52.6% male, median age 59.6 years) were included, of whom 38.9% had liver disease. A total of 41.0% of all patients showed polyps, 23.2% adenomas, 10.0% HRS, and 0.5% CRC. LDPs were more likely to develop polyps, adenomas and HRS than LHPs, both in univariable and multivariable analysis. There were no significant differences between cirrhotic and noncirrhotic patients.

Conclusion

Chronic liver disease of any etiology is associated with colonic lesions of the colorectal adenoma-carcinoma sequence, independent of cirrhosis. LDPs should receive intensified, and earlier, colonoscopy screening.

Portal Hypertensive Polyposis in Advanced Liver Cirrhosis: The Unknown Entity?

BACKGROUND

Portal hypertension is a serious complication of liver cirrhosis.

OBJECTIVE

To identify relevant endoscopic findings in patients with advanced cirrhosis and consecutive portal hypertension.

METHODS

This was a retrospective study of liver transplant candidates who underwent upper gastrointestinal endoscopy between April 2011 and November 2015.

RESULTS

A total of 1,045 upper endoscopies were analyzed. Portal hypertensive gastric and duodenal polyps were frequently observed and were associated with thrombocytopenia (p = 0.040; OR: 2.4, 95% CI 1.04-5.50), Child-Pugh score > 6 (p = 0.033; OR: 2.3, 95% CI 1.07-4.92), Model for End Stage Liver Disease score > 16 (p = 0.030; OR: 4.1, 95% CI 1.14-15.00), and previous rubber band ligation (p < 0.001; OR = 5.2, 95% CI 2.5-10.7). These polyps often recurred after polypectomy; however, no malignant transformation occurred during the observational time until October 2017. The most common endoscopic finding was esophageal varices, observed in more than 90% of patients.

CONCLUSION

Portal hypertensive polyposis is common in patients with advanced cirrhosis. Our data suggest that these polyps have benign characteristics.

Smoking in Irritable Bowel Syndrome: A Systematic Review

OBJECTIVE

The aim of this review was to examine (1) the prevalence of smoking in subjects with irritable bowel syndrome (IBS), (2) whether smoking prevalence significantly differs between subjects with and without IBS, and (3) whether smoking significantly predicts the presence or the development of IBS.

METHODS

Articles were retrieved by systematically searching the Scopus, Web of Science, and PubMed electronic databases from inception to July 2016, using the keywords "smoking" and "tobacco" combined with "irritable bowel syndrome." Reference lists of included articles were also searched. Articles were included if they (1) reported data on smoking prevalence in subjects with IBS and/or on the association (assessed by means of multivariate analyses) between smoking and IBS, (2) identified IBS according to Manning criteria or Rome I-III criteria, (3) were English-language articles, and (4) involved only adult subjects.

RESULTS

The electronic searches yielded a total of 1,637 records, and 42 articles met inclusion criteria. Another 13 articles were retrieved through manual search, leading to a total of 55 included articles. Smoking prevalence in subjects with IBS was assessed by 48 articles and ranged from 0% in university students to 47.1% in patients with microscopic colitis. Thirty-three articles compared smoking prevalence between subjects with and without IBS. In 25 articles no significant difference was found. In seven articles smoking was significantly more frequent in subjects with IBS compared to those without IBS, while one study found a significantly higher smoking prevalence in controls. Eighteen multivariate analyses assessing the association between smoking and IBS were presented in 16 articles. Only one study employed a prospective design. In 11 analyses, smoking was not significantly associated with IBS after adjusting for covariates. In seven studies smoking independently predicted the presence of IBS.

CONCLUSIONS

According to the selected articles, a significant association between smoking and IBS cannot be confirmed. However, different shortcomings may hinder generalizability and comparability of many studies. A dimensional assessment of smoking, a prospective design, the differentiation between IBS subgroups, and the recruitment of patients in clinical settings, especially in primary care, are necessary to clarify the role of smoking in IBS.

Cirrhotic Patients Have Worse Bowel Preparation at Screening Colonoscopy than Chronic Liver Disease Patients without Cirrhosis

BACKGROUND

Cirrhosis has been shown in small studies to be a predictor of suboptimal bowel preparation at screening colonoscopy. It has yet to be established whether patients with chronic liver disease in the absence of cirrhosis experience equally poor colon cleansing. Intestinal dysmotility related to cirrhosis might impair bowel preparation in this population more than those with chronic liver disease without cirrhosis.

OBJECTIVE

This study compared the quality of bowel preparation in cirrhotic and non-cirrhotic patients with chronic liver disease and determined whether this influenced polyp detection rate.

METHODS

A retrospective study of patients with chronic liver disease, both cirrhotic and non-cirrhotic, who underwent screening colonoscopy was performed. Patient characteristics, concomitant medication use, adequacy of bowel preparation, and the total number and types of polyps found were compared between cirrhotic and non-cirrhotic groups.

RESULTS

330 patients fulfilled inclusion criteria; 36% (n = 120) were cirrhotic. Cirrhotic patients had significantly worse bowel preparation scores compared with non-cirrhotics (mean 3.4 ± 1.1 vs. 3.7 ± 0.9, P = 0.003). Worse bowel preparation scores in cirrhotics vs. non-cirrhotics persisted despite controlling for age, sex, and concomitant diabetes mellitus (DM) (P = 0.0027). Among the cirrhotics, 48% had the lowest preparation scores compared with 30% of non-cirrhotics. No difference in polyp detection rate was found between cirrhotics and non-cirrhotics. Severity of cirrhosis as assessed by the MELD score did not predict worse bowel preparation.

CONCLUSIONS

Cirrhotics have significantly worse bowel preparation scores compared to non-cirrhotics with chronic liver disease. No correlation between MELD score and bowel preparation score was observed in the cirrhotic cohort.

Incidence and risk factors of delayed postpolypectomy bleeding in patients with chronic liver disease

OBJECTIVE

Hepatologists and colonoscopists often hesitate to perform a colonoscopic polypectomy in patients with chronic liver disease (CLD), especially those with cirrhosis, because of the risk of postpolypectomy bleeding (PPB). We aimed to investigate the incidence and risk factors of delayed PPB after a colonoscopic polypectomy in patients with CLD.

MATERIALS AND METHODS

In total, 152 patients with CLD who underwent colonoscopic polypectomy from December 2005 to December 2012 were retrospectively reviewed.

RESULTS

Cirrhosis was identified in 80 (52.6%) patients. During the study period, 442 polyps were removed and delayed PPB developed in 14 (9.2%) patients. The incidence of delayed PPB was significantly higher in patients with cirrhosis than in those without the disease (13.8% [n = 11] vs. 4.2% [n = 3], p = 0.041). The polyp size (odds ratio, 1.087; 95% confidence interval, 1.009-1.172) and cirrhosis (odds ratio, 8.535; 95% confidence interval, 2.417-30.140) were independent risk factors for delayed PPB. In patients with cirrhosis, the optimal cut-off size to identify high-risk polyps for delayed PPB was 10 mm (area under the receiver operating characteristics curve, 0.737; sensitivity, 52%; specificity, 88%).

CONCLUSION

Caution is needed when colonoscopic polypectomy is planned in patients with CLD who have larger polyps and cirrhosis.

Nonalcoholic Cirrhosis Increased Risk of Digestive Tract Malignancies: A Population-Based Cohort Study

Alcoholic cirrhosis is generally accepted as a risk factor for hepatocellular carcinoma (HCC) development; however, little research has examined the relationship between nonalcoholic cirrhosis (NAC) and HCC. Thus, the aim of this study was to investigate whether NAC is associated with the risk of HCC and extrahepatic malignancies in Taiwan.We conducted a populated-based retrospective cohort study by using data from the Taiwan National Health Insurance (NHI) program. A total of 2109 patients with NAC were identified from the NHI database between 2000 and 2011. For a control group, 4 patients without NAC were frequency-matched with each NAC patient according to sex, age, and index year. We used Cox proportional hazards regression analysis to calculate adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) and determine the effects of NAC on cancer risk.The overall cancer risk was significantly higher in patients with NAC compared with those without NAC, and this association was consistent among age, sex, and comorbidity groups. The risk of developing HCC was remarkably high in the NAC group compared with in the control cohort (aHR = 122.7, 95% CI = 68.4-220.1); significantly higher risks of extrahepatic malignancies were observed in patients with digestive tract cancers and hematological malignancies. Further analyses stratified according sex, age, and follow-up duration revealed various patterns among the cancer types.The results indicate that patients with NAC in Taiwan have higher risks of HCC, digestive tract cancers, and hematological malignancies.

Standard bowel cleansing is highly ineffective in cirrhotic patients undergoing screening colonoscopy

BACKGROUND

Few data are available on tolerability and quality of standard bowel cleansing for colonoscopy in patients with chronic disease.

AIM

We seek to evaluate the tolerability and results of lavage solution for colonoscopy in cirrhotic patients in comparison with controls.

METHODS

Fifty-three cirrhotic and fifty-two normal subjects undergoing colonoscopy were prospectively enrolled in the study. Data regarding tolerability of lavage solution were harvested at the pre-procedure visit. Data on level of bowel cleansing and other endoscopic variables were recorded after the procedure.

RESULTS

Rate of failure to complete the prescribed bowel preparation and incidence of side effects during its administration were similar between cirrhotic and normal subjects. Despite this, cirrhotic patients exhibited an insufficient level of bowel preparation with approximately half exhibiting bad colon cleansing level (49% versus 5% control, p<0.001).

CONCLUSION

Alternative bowel cleansing protocols are needed for cirrhotic subjects to better match their colonoscopic screening needs.

A greater proportion of liver transplant candidates have colorectal neoplasia than in the healthy screening population

BACKGROUND & AIMS

Various types of liver disease are associated with an increased prevalence of colorectal adenomas. We investigated whether cirrhosis is a risk factor for colorectal neoplasia by analyzing colonoscopy findings from 2 cohorts of patients awaiting liver transplantation.

METHODS

We performed a retrospective analysis to compare findings from colorectal cancer screenings of 567 adult patients with cirrhosis placed on the waitlist for liver transplantation with those from controls (matched for age, sex, body mass index, smoking, and diabetes). Rates of adenoma and advanced adenoma detection were adjusted owing to differences in rates of polypectomies performed in the 2 cohorts.

RESULTS

Adenomas were detected in a significantly higher percentage of patients with cirrhosis (29.3%) than in controls (21.5%) (P = .0057; relative risk [RR], 1.36; 95% confidence interval [CI], 1.09-1.69); and patients with cirrhosis had a higher rate of advanced adenoma detection than controls (13.9% vs 7.7%; P = .0015; relative risk, 1.82; 95% CI, 1.25-2.64). A greater percentage of patients with alcoholic cirrhosis had neoplasias (34.3%) than controls (25.3%; P = .0350; RR, 1.36), and rates of advanced adenoma detection were 16.7% vs 10.2% (P = .0409; RR, 1.63). Adenomas were detected in 27.8% of patients with viral cirrhosis vs 15.9% of controls (P = .0061; RR, 1.74), with rates of advanced adenoma detection of 13.6% vs 5.0% (P = .0041; RR, 2.73). Similar proportions of patients with cirrhosis of other etiologies and controls were found to have colorectal neoplasias.

CONCLUSIONS

Based on a retrospective analysis of colonoscopy findings from patients awaiting liver transplantation, those with alcoholic or viral cirrhosis are at higher risk of developing colorectal neoplasia and should be considered for earlier colonoscopy examination.

Increased risk for malignant neoplasms among patients with cirrhosis

BACKGROUND & AIMS

It is not clear how cirrhosis affects the risks for hepatocellular carcinoma (HCC) and non-HCC cancers, which are rare among these patients. We assessed the risk for malignant neoplasms in patients with cirrhosis.

METHODS

Patients diagnosed with cirrhosis in Gothenburg, Sweden, from 1994 to 2005 were identified and linked to the National Cancer and Death registers. We studied data from 1019 patients with cirrhosis: 68% men, 48% with alcoholic liver disease (ALD), 10% with hepatitis C virus (HCV), and 12% with HCV + ALD. Standardized incidence ratios for malignant neoplasms were calculated (corrected for sex, age, and calendar year according to data from the general Swedish population). The follow-up period was 3290 person-years.

RESULTS

Overall, 114 (11%) patients developed HCC; HCC occurred more frequently among patients with HCV than other diseases (P < .05). HCC risk did not differ among patients with HCV, with or without ALD (P > .05). Compared with the general population, cirrhotic patients had increased risk for HCC (26-fold); cholangiocarcinoma (13-fold); and esophageal (8-fold), pancreatic (5-fold), and colorectal and lung cancers (each 4-fold). The risk for cholangiocarcinoma increased mainly among patients with non-ALD cirrhosis, whereas the risk for extrahepatic malignancies increased mainly among patients with ALD and cirrhosis.

CONCLUSIONS

The overall risk for non-HCC malignancies is more than 2-fold greater for patients with cirrhosis (mostly in biliary and gastrointestinal malignancies) than of the general population. The risk for non-HCC cancers differs between patients with ALD and non-ALD cirrhosis. The increased risk for HCC among patients with cirrhosis is associated with HCV; it is the same among patients with HCV, with or without ALD.

[Results of colonoscopic examination in the evaluation of cirrhotic candidates for liver transplantation]

AIM

To assess the presence of preneoplastic and neoplastic colonic lesions, as well as those related to portal hypertensive vasculopathy, and their association with liver disease in cirrhotic patients who are candidates for orthotopic liver transplantation (LT).

METHODS

Between October 2004 and December 2005, colonoscopy was performed in 92 patients who were LT candidates, aged >50 years old or aged <50 years old but with clinical indications.

RESULTS

Eighty-eight percent of the patients were > 50 years old, the mean age was 55.3 years (29-69) and 81.5% were males. The main etiology of cirrhosis was alcoholic (46.7%), and 21% were Child-Pugh class A. No abnormalities were detected in 20.7%. Polyps were discovered in 38% (35/92) of patients (adenomatous 65.2%; tubular type 86.7%). Six patients with adenomatous polyps had mild dysplasia, and one asymptomatic patient had a well-differentiated adenocarcinoma. An association was found between polyps and male sex (44% males vs 17.6% females; p=0.044) and Child-Pugh grade (63.2% Child A vs 32.9% Child B/C, p=0.016) but not with serum levels of carcinoembryonic antigen (CEA), age or etiology of liver disease. Portal hypertensive colopathy was found in 23.9%, rectal varices in 7.6% and internal or mixed hemorrhoids in 52.3%.

CONCLUSION

The prevalence of preneoplastic and neoplastic colonic lesions may support the use of colonoscopy in LT candidates aged >50 years-old or with a history suggesting lower gastrointestinal bleeding or other abnormalities.

Feasibility and findings of colonoscopy for living-donor liver transplant candidates

BACKGROUND AND AIMS

Living-donor liver transplantation (LDLT) has been widely performed in patients with end-stage liver disease and hepatocellular carcinoma in Japan. Although extrahepatic cancer survey for LDLT candidates is absolutely required, few reports have indicated the optimal surveillance method for colorectal cancer. The aim of this study is to investigate the feasibility and findings of colonoscopy before LDLT.

PATIENTS AND METHODS

From January 2004 to August 2006, we prospectively enrolled all of the scheduled LDLT candidates of our hospital for pretransplant colonoscopy examination.

RESULTS

A total of 81 patients were enrolled for colonoscopy. Of these patients, 67 (83%) could actually undergo colonoscopy. Patients who could not undergo colonoscopy exhibited more impaired liver function than those who could (median Model End-Stage Liver Disease score; 25.5 vs. 14.5, P=0.0003). Among patients who underwent colonoscopy, observation of total colon was attained in 64 (96%). Neoplasia was found in 28 (42%) patients, including 4 patients with adenomas > or =10 mm, 1 patient with adenomas with high-grade dysplasia, and 3 patients with invasive cancer. Patients who had advanced neoplasia (adenoma > or =10 mm, adenomas with high-grade dysplasia, or invasive cancer) were likely to have a lower performance status (PS) (7/8 were PS 3) than those who did not (P=0.054).

CONCLUSIONS

Clinically significant tumors were found in a considerable portion of LDLT candidates, particularly in lower PS patients. Because immunosuppressive agents after transplantation may worsen malignant tumors, colonoscopy before transplantation is recommended in patients who can tolerate the procedure.

Avoiding pitfalls: what an endoscopist should know in liver transplantation--part 1

Cirrhosis is associated with global homodynamic changes, but the majority of the complications are usually manifested through the gastrointestinal tract. Therefore, Gastrointestinal Endoscopy has become an important tool in the multidisciplinary approach in the management of these patients. With the ever growing number of cirrhotic patients requiring pre-transplant endoscopic management, it is imperative that the community endoscopists are well aware of the pathologies that can be potentially noted on Gastrointestinal Endoscopy. Their timely management is also considered to have the utmost importance in being able to stabilize the patient until their transfer to a Liver Transplant Center. The aim of this manuscript is to give a comprehensive update and review of various endoscopic findings that a non-transplant endoscopist will encounter in the pre-transplant setting.

History of cirrhosis and risk of digestive tract neoplasms

BACKGROUND

Cirrhosis is strongly related to liver cancer. Data on the possible association between cirrhosis and risk at other cancer sites are scanty.

PATIENTS AND METHODS

We analysed data from a network of case-control studies conducted in Italy between 1983 and 1997, including patients with cancers of the oral cavity and pharynx (520), oesophagus (405), stomach (731), colon (943), rectum (613), liver (425), gallbladder (63) and pancreas (395). The controls were 4297 patients admitted to hospitals for acute non-neoplastic conditions.

RESULTS

After strict allowance for alcohol drinking, tobacco smoking and history of hepatitis, the multivariate odds ratios for a history of cirrhosis were 4.7 [95% confidence interval (CI) 2.2-9.8] for neoplasms of the oral cavity and pharynx, 2.6 (95% CI 1.2-5.7) for the oesophagus, 1.0 (95% CI 0.4-2.5) for the stomach, 1.0 (95% CI 0.4-2.4) for the colon, 1.7 (95% CI 0.7-4.1) for the rectum, 20.5 (95% CI 12.3-34.2) for the liver, 2.1 (95% CI 0.3-16.8) for the gallbladder and 0.9 (95% CI 0.3-3.0) for the pancreas.

CONCLUSIONS

Our study confirms and further quantifies the increased risk of liver cancer in cirrhotic patients and is compatible with an increased risk of oral, pharyngeal and oesophageal cancers.

Use of activated recombinant human factor VII (rhFVIIa) for colonic polypectomies in patients with cirrhosis and coagulopathy

The prevalence of colonic polyps in patients with cirrhosis appears to be higher than that of the general population. The current practice for a polypectomy in a coagulopathic cirrhotic patient involves the reversal of the coagulopathy using fresh frozen plasma (FFP) prior to the polypectomy, usually at a second colonoscopy. The use of FFP is associated with many problems, particularly that of volume overload. Here we report four cases with advanced cirrhosis and severe coagulopathy that underwent polypectomies by snare cautery after an intravenous bolus infusion of recombinant human factor VIIa (rhFVIIa). The dose used was 120 microg/kg, which provided normalization of the coagulation parameters for 10-16 hr. The immediate use of rhFVIIa reduced the utilization of resources and enabled the performance of the polypectomies at the initial colonoscopy. No postpolypectomy bleeding was noted. The high cost of the drug is the only obstacle to a wider use of rhFVIIa for this purpose. The cost of the drug, however, is offset substantially by the cost of hospitalization for the administration of FFP, the cost of a second colonoscopy, and the charges associated with a second utilization of the endoscopy suite.

Excessive alcohol consumption favours high risk polyp or colorectal cancer occurrence among patients with adenomas: a case control study

BACKGROUND AND AIMS

Excessive alcohol consumption is a risk factor for developing colorectal adenomas. This study aimed to investigate the influence of excessive alcohol consumption on the occurrence of high risk polyps (adenoma > or = 10 mm, villous component, high grade dysplasia) or colorectal cancer among patients with at least one colonic adenoma.

PATIENTS AND METHODS

Three groups of patients with at least one colorectal adenoma were included in a case control study: 401 heavy drinkers (group HD, mean daily alcohol intake 117 (SD 4) g/day for a mean duration of 22 (SD 0.6) years), aged 57 (0.5) years (78% men); 152 patients suffering from irritable bowel syndrome (IBS), aged 61 (0.9) years (57% male); and 108 patients with a family history (FH) of colorectal adenoma or cancer, aged 55 (1) years (64% male). Exclusion criteria were: anaemia, haematochezia, personal history of colorectal adenoma or cancer, and for groups HD and IBS a family history of colorectal adenoma and/or cancer. Relative risks were estimated by the odds ratio (OR) using a logistic regression model and were expressed with 95% confidence interval (CI).

RESULTS

After age and sex adjustment, the likelihood of having an adenoma > or = 10 mm was higher in group HD than in the IBS group (OR 1.8, 95% CI (1.2-2.7)) and the likelihood of having high risk adenomas or cancer was higher in group HD compared with the IBS group (OR 1.6, 95% CI (1.2-2.1)) and the FH group although this was not significant (OR 1.6, 95% CI (0.97-2.6) (p=0.081); 90% CI (1.03-2.4)). After age and sex adjustment, the likelihood of having an adenoma with high grade dysplasia or cancer was higher in group HD than in the IBS group (OR 1.7, 95% CI (1.02-2.8)) or group FH, although this was not significant (OR 3.7, 95% CI (0.98-15) (p=0.076); 90% CI (1.10-12.47)).

CONCLUSION

In patients with at least one colorectal adenoma, excessive alcohol consumption increases the likelihood of developing high risk adenomas or colorectal cancer.

Definite streptococcus bovis endocarditis: characteristics in 20 patients

OBJECTIVE

To determine the specific characteristics of Streptococcus bovis infective endocarditis (IE) by reviewing our own experience of S. bovis IE.

METHODS

Twenty episodes of definite S. bovis IE were reviewed in 20 patients hospitalized from 1980 to 1996.

RESULTS

The mean age was 62 +/- 14 years, and 14 (70%) patients had no known predisposing cardiac condition. The principal antimicrobials used were penicillin G (N = 10) and amoxycillin (N = 8). Surgery was required in four (20%) patients. Neurologic complications occurred in eight (40%) patients, after initiation of therapy in six (75%) (mean time: 14 days). An unfavorable outcome was observed in four of 20 patients and tended to be more frequent in patients who had had neurologic complications (P = 0.10). Colonic tumors were present in 11 of 16 (69%) patients.

CONCLUSIONS

Advanced age, occurrence of IE on presumably normal valves, high rate of neurologic complications, associated gastrointestinal diseases and low mortality rate during initial follow-up are characteristic features of S. bovis IE observed in this study.

Risk of liver and other types of cancer in patients with cirrhosis: a nationwide cohort study in Denmark

Cancer risk in patients with cirrhosis could be modified by factors such as changes in hormonal levels, impaired metabolism of carcinogens, or alteration of immunological status. We investigated the risk of liver and various forms of cancer in patients with cirrhosis in a follow-up study. We identified 11,605 1-year survivors of cirrhosis from the files of the Danish National Registry of Patients (NRP) from 1977 to 1989. Occurrence of cancer through 1993 was determined by linkage to the Danish Cancer Registry. For comparison, the expected number of cancer cases was estimated from national age-, sex-, and site-specific incidence rates. Overall, 1,447 cancers were diagnosed among the study subjects, as compared with 708.1 expected, to yield a standardized incidence ratio (SIR) of 2.0 (95% CI: 1.9 to 2.2). In all diagnostic subgroups of cirrhosis, the risk of primary liver cancer, mainly hepatocellular carcinoma, was markedly elevated, with 245 observed cases and an overall 36-fold elevated risk (59.9-fold elevated for hepatocellular carcinoma and 10-fold for cholangiocarcinoma). Substantial and persistent excesses during follow-up were seen for all types of cancer associated with tobacco and alcohol habits (cancer of the lung, larynx, buccal cavity, pharynx, pancreas, urinary bladder, and kidney), while moderate excesses were seen for cancers of the colon and breast. The latter, however, were not complemented by any decrease in the risk of prostate cancer (SIR: 1.0; 95% CI: 0.7 to 1. 3). A slightly increased risk was seen for testis cancer, but disappeared after 10 years. We found evidence of an increased risk for liver and several extrahepatic cancers in patients with cirrhosis. Although part of this increase is likely attributable to alcohol and tobacco consumption, our study opens up the possibility that cirrhosis plays a role in the carcinogenesis of types of cancer other than liver cancer.

Colonic disease in cirrhotic patients with portal hypertension: an endoscopic and clinical evaluation

Fifty cirrhotic patients with portal hypertension but without colonic or systemic disease underwent lower gastrointestinal endoscopy in order to investigate the effects, if any, of portal hypertension on the colon. Fifty patients without liver or systemic disease, examined by colonoscopy because of irritable bowel syndrome in the same period served as controls. Rectosigmoid varices were observed in 34% of the cirrhotic patients and 2% of the controls. Hemorrhoids were observed in 70% of the cirrhotic patients and 48% of the controls. Multiple vascular-appearing lesions were found in 16% of the cirrhotic patients and 6% of the controls. Nonspecific inflammatory changes were noted in 10% of the cirrhotic patients and 4% of the controls. Simultaneous presence, in the same patient, of rectosigmoid varices, hemorrhoids, multiple vascular-appearing lesions, and nonspecific inflammatory changes, was observed in only five (10%) of the cirrhotic patients. We found polyps in 12% of the cirrhotic patients and 14% of the controls, and a malignant tumor in 4% of the cirrhotic patients. The patients with normal colonoscopic findings were 8% of the cirrhotic patients and 36% of the controls. All patients and controls were followed up for 1 year; there was no gastrointestinal hemorrhage among controls, whereas 34% of the cirrhotic patients had an upper gastrointestinal hemorrhage (88% from esophageal varices, 12% from the stomach) and 4% had a lower gastrointestinal hemorrhage (one from rectosigmoid varices and one from nonspecific inflammatory lesions). Colonic lesions were significantly more frequent in the cirrhotic patients (92%) than in the control group (64%); however, such lesions did not seem specific to the disease and were not statistically correlated with the degree of esophageal varices by Child's grading, the etiology of cirrhosis, or the bleeding risk from the lower gastrointestinal tract.

Portal hypertensive colopathy. A new entity

The aim of this paper was, first, to show in a case control study that in alcoholic cirrhotic patients colonic vascular ectasias (VE) are a complication of portal hypertension and, second, to establish in a histomorphometric study that colonic vascular ectasias and rectal varices (RV) are only endoscopic features of a new entity: portal hypertensive colopathy, the pathologic basis of which is colonic mucosal capillary ectasia. In the case control study, for each case, three age- and sex-matched controls selected from consecutive patients were used. Sixteen alcoholic cirrhotic patients, 12 men, 4 women (mean age +/- SD: 62 +/- 10 years) had colonic vascular ectasias. The prevalence of esophageal varices (88% vs 44%, P less than 0.005), esophageal varices (greater than or equal to 5 mm) (44% vs 12.5%, P less than 0.01), previous history of bleeding from esophageal varices (44% vs 8%, P less than 0.005), and rectal varices (63% vs 6%, P less than 0.001) was significantly greater in cases with colonic vascular ectasias than in controls without colonic vascular ectasias. The relative risk of colonic vascular ectasias in alcoholic cirrhotic patients with esophageal varices versus cirrhotic patients without esophageal varices was 14.4 (95% confidence interval 2.8-75.3). In the histomorphometric study, cirrhotic patients with vascular ectasias and/or rectal varices had a significantly higher mean diameter of vessels (20.3 +/- 1.5 microns vs 18.7 +/- 1.6 microns, P less than 0.05) and a higher mean cross-sectional vascular area (2143 +/- 396 microns 2 vs 1676 +/- 345 microns 2, P less than 0.05) than cirrhotic patients without vascular ectasias and/or rectal varices.(ABSTRACT TRUNCATED AT 250 WORDS)