Scandinavian surveillance follow-up programmes in patients with malignant colorectal polyps

INTRODUCTION

Following endoscopic removal of malignant colorectal polyps, patients may undergo completion radical resection or surveillance. The optimal surveillance strategy remains unknown. This study included colorectal departments in Scandinavian countries with a focus on follow-up periods and examination modalities for patients with endoscopically removed malignant polyps with a resection margin > 1 mm.

METHODS

This study was conducted as an internet-based survey. A questionnaire was sent to all Scandinavian surgical departments performing > 20 colorectal procedures annually. Questions differed between follow-up on rectal and colonic malignant polyps with presence or absence of histological risk factors. The follow-up period was defined as short (one year), intermediate (three years) or long (five years).

RESULTS

The majority of the departments used a long (five years) (38-59%) or intermediate (three years) (26-38%) follow-up programme. In patients with rectal malignant polyps and presence of histological risk factors, a significant difference was observed in the use of endoscopy according to length of follow-up. No difference in the use of the different modalities was seen according to length of follow-up in patients with colonic malignant polyps.

CONCLUSIONS

The follow-up on patients with endoscopically removed malignant polyps and a surveillance strategy varies both in terms of length and performed modalities. Future studies should compare long-term patient outcomes in departments employing different follow-up strategies.

FUNDING

none.

TRIAL REGISTRATION

not relevant.

High risk of colorectal polyps in men with non-alcoholic fatty liver disease: A systematic review and meta-analysis

BACKGROUND AND AIM

This meta-analysis aims to explore the risk of colorectal polyps among non-alcoholic fatty liver disease (NAFLD) patients.

METHODS

We searched PubMed, EMBASE, and Cochrane library databases using predefined search term to identify eligible studies (published up to 7 November 2019). Data from selected studies were extracted by using a standardized information collection form, and meta-analyses were performed using random-effects model. The statistical heterogeneity among studies (I² ), subgroup analyses, meta-regression analyses, and the possibility of publication bias were assessed.

RESULTS

Twenty observational (12 cross-sectional, two case-control, and six cohort) studies met the eligibility criteria, involving 142 387 asymptomatic adults. In cross-sectional/case-control studies, NAFLD was found to be associated with an increased risk of colorectal polyps (odds ratio [OR] = 1.34; 95% confidence interval [CI] = 1.23-1.47) (including unclassified colorectal polyps, hyperplastic polyps, adenomas, and cancers) with statistically significant heterogeneity (I²  = 67.8%; P < 0.001). NAFLD was also associated with a higher risk of incident colorectal polyps (hazard ratio = 1.60; 95% CI = 1.36-1.87) with low heterogeneity (I²  = 21.8%; P = 0.263) in longitudinal studies. The severity of NAFLD was associated with a higher risk of colorectal adenomas (OR = 1.57; 95% CI = 1.30-1.88), but not colorectal cancer (OR = 1.37; 95% CI = 0.92-2.03). The subgroup analysis according to gender showed that NAFLD was significantly associated with a higher risk of colorectal polyps in the male population without significant heterogeneity (OR = 1.47; 95% CI = 1.29-1.67, I²  = 0%), but not in the female population (OR = 0.88; 95% CI = 0.60-1.29, I²  = 34.2%).

CONCLUSIONS

NAFLD was associated with an increased risk of colorectal polyps. There was a significant difference of the relationship between genders, which suggested more precise screening colonoscopy recommendation in NAFLD patients according to gender.

Associations between molecular characteristics of colorectal serrated polyps and subsequent advanced colorectal neoplasia

PURPOSE

BRAF mutation and DNA hypermethylation have linked sessile serrated adenomas/polyps (SSA/Ps) to serrated colorectal cancer (CRC) in cross-sectional studies, but they have not been evaluated in a longitudinal study. We aimed to evaluate the associations between molecular markers of serrated polyps and subsequent advanced colorectal neoplasia.

METHODS

Study subjects included Kaiser Permanente Washington members aged 20-75 years who received an index colonoscopy between 1/1/1998 and 12/31/2007 and had hyperplastic polyps (HPs) or SSA/Ps according to study pathology review. Polyps from index colonoscopies were removed and assayed for BRAF mutation, CpG island methylator phenotype (CIMP), and MLH1 methylation. Pathology reports and biopsies from the subsequent lower gastrointestinal endoscopy through 1/1/2013 were reviewed for advanced colorectal neoplasia. We identified additional incident CRC cases through linkage to the Seattle-Puget Sound Surveillance Epidemiology and End Results registry. We used generalized estimating equations to calculate adjusted odds ratios (OR) and 95% confidence intervals (CI) for subsequent advanced colorectal neoplasia, comparing index serrated polyps with different molecular markers.

RESULTS

We included 553 individuals with index serrated polyps (420 HPs and 133 SSA/Ps) and 795 subsequent endoscopies. The prevalence of BRAF-mutant, CIMP-high, and MLH1-methylated serrated polyps were 51%, 4%, and 2%, respectively. BRAF and CIMP were not associated with subsequent advanced colorectal neoplasia. MLH1-methylated SSP/As were significantly more likely to have subsequent advanced neoplasia (OR = 4.66, 95% CI 1.06-20.51).

CONCLUSION

Our results suggest that BRAF-mutant and CIMP-high serrated polyps are not associated with subsequent advanced colorectal neoplasia. Among SSA/Ps, MLH1 methylation may be an important marker to identify high-risk CRC precursors.

Clinicopathological features of colorectal polyps and risk of colorectal cancer in acromegaly

OBJECTIVE

Patients with acromegaly are at increased risk of colorectal polyps. However, their risk of colorectal cancer remains unclear. This study aimed to identify the histopathological features of colorectal polyps in patients with acromegaly and compare their risk of colorectal cancer with that in healthy controls.

METHODS

The study participants were 178 patients who underwent Hardy's operation and perioperative colonoscopy at our hospital between April 2008 and September 2016. For the control group, we randomly selected 356 age- and sex-matched patients who underwent colonoscopy at our hospital during the same period. The incidence, size, location, and histology of the colorectal polyps detected were compared between the groups.

RESULTS

Colorectal polyps were detected in 66.8% of the acromegaly group and 24.2% of the control group (P < 0.001). The average number and size of the polyps were 2.44 and 4.74 mm, respectively, in the acromegaly group and 1.77 and 3.89 mm in the control group (P = 0.001). Polyps in the acromegaly group were more likely to be in the rectosigmoid region (P = 0.006). In the acromegaly group, the frequency of polyps ≥5 mm was 34.3% and that for polyps ≥10 mm was 15.2%; the respective values were 7.6% and 2.2% in the control group (P < 0.001). We found no evidence of between-group histopathological differences in the polyp specimens resected by endoscopy.

CONCLUSIONS

Patients with acromegaly are at an increased risk of colorectal polyps, especially in the rectosigmoid region. However, there is no pathological evidence that they are at greater risk of colorectal cancer than the general population.

Colonoscopy examination requires a longer time in patients with acromegaly than in other individuals

This study aimed to determine the prevalence of colorectal neoplasms and to investigate the rate of and time required for cecal intubation in patients with acromegaly. A database search performed at our institution identified 29 patients with acromegaly who underwent colonoscopy. Data regarding the endoscopic, biological, and pathological examinations performed were retrospectively reviewed from the clinical records. Subsequently, the rate of and time required for cecal intubation were investigated in 23 patients with acromegaly and compared with the corresponding data of the control group. Control subjects were selected from a 2:1 matched historical control cohort, according to baseline characteristics. The mean age of the acromegaly group (17 female and 12 male) was 60.4 ± 12.6 years. Twelve patients had adenoma (41.4%), eight patients had hyperplastic polyps (27.6%), three patients had sessile serrated adenoma/polyps (10.3%), and three patients had colon cancer (10.3%). Successful cecal intubation was achieved in all patients in both groups. The difference in the time required for successful intubation between the acromegaly group (15.7 ± 9.8 minutes) and the control group (8.7 ± 6.0 minutes) was statistically significant. Linear regression analysis revealed that increased patient age was significantly related to longer colonoscope insertion times. In conclusion, although cecal intubation during colonoscopy was successful in all participants, it required a longer time in patients with acromegaly. Our results underscore the importance of and certain technical difficulties involved in colonoscopy procedures in patients with acromegaly, especially in older patients.

Epidemiological aspects of endoscopic resections of colorectal polyps in patients at an endoscopy training center in the Santos region, Brasil

INTRODUCTION

Colorectal polyps are structures that project from the surface of the mucosal layer of the large intestine. They are classified as neoplastic or non-neoplastic. Early detection of pre-neoplastic lesions is important for preventing colorectal cancer. These can be resected so as to decrease the morbidity and mortality rates. Colonoscopy is the gold-standard procedure for diagnosing and resecting precursor lesions.

OBJECTIVE

To evaluate the epidemiological, endoscopic and histological aspects of endoscopic resection of lesions of the colon and rectum at a training center.

MATERIALS AND METHOD

A search was conducted in the database of our institution covering the period from January 2011 to July 2014. Cases that underwent endoscopic resection of polyps and/or colorectal lesions were selection. The following variables were defined: general data on the patients (age, gender and indication from the examination) and data on the polypoid lesion (number, histological type and topographic distribution).

RESULTS

678 lesions were identified in 456 examinations. Regarding sex, 242 (53.1%) were female and 214 (46.9%) were male. The mean age was 64.54 years, with extremes of 5 and 94 years. The most frequent locations were the rectum (21%) and sigmoid (20%). Histologically, 34.7% were hyperplastic polyps and 58.9% were adenomatous polyps, of which 74.1% were tubular, 10.6% tubulovillous, 2% villous and 13% indeterminate; and 1.7% were adenocarcinomas. In 65.4% of the cases, the examination showed that only one polyps was present, while 34.6% had two or more lesions.

CONCLUSION

In our clinic, with a mean of 250 examinations/month, the parameters evaluated were compatible with the results reported in the literature.

Small Bowel Neoplasms and Polyps

The small intestine is a relatively privileged organ that only rarely develops malignant or even benign tumors. Given this rarity, the relative inaccessibility of the organ during routine endoscopic procedures, and the typical absence or nonspecific nature of clinical manifestations, these tumors often go undiagnosed. Treatment and prognosis are tailored to each histological subtype of tumor. This chapter will discuss the epidemiology, presentation, diagnostics, and management for the most common small bowel tumors, and will highlight the importance of recognizing patients at higher risk of small bowel neoplasia.

Clinical features of upper gastrointestinal serrated lesions: An endoscopy database analysis of 98746 patients

AIM

To analyse the clinical features of patients with the serrated lesions in the upper gastrointestinal tract (UPGI) tract.

METHODS

Patients who underwent routine esophagogastroduodenoscopy (EGD) at the Digestive Endoscopy Centre of General Hospital, Tianjin Medical University between January 2011 and December 2015 were consecutively recruited. Patients with UPGI serrated lesions were consecutively identified. The patients’ demographics and histopathology were recorded. The colorectal findings for patients who underwent colonoscopy simultaneously or within six months were also extracted from the colonoscopy database. In addition, we analysed differences in colorectal neoplasia detection between the study patients and randomly selected patients matched for age and gender who did not exhibit serrated lesions and who also underwent colonoscopy in the same period.

RESULTS

A total of 21 patients out of 98746 patients (0.02%) who underwent EGD were confirmed to have serrated lesions with predominantly crenated, sawtooth-like configurations. The mean age of the 21 patients was (55.3 ± 17.2) years, and 11 patients were male (52.4%). In terms of the locations of the serrated lesions, 17 were found in the stomach (including 3 in the cardia, 9 in the corpus and 5 in the antrum), 3 were found in the duodenum, and 1 was found in the esophagus. Serrated lesions were found in different mucosal lesions, with 14 lesions were detected in polyps (8 hyperplastic polyps and 6 serrated adenomas with low grade dysplasia), 3 detected in Ménétrier gastropathy, 3 detected in an area of inflammation or ulcer, and 1 detected in the intramucosal carcinoma of the duodenum. In addition, colonoscopy data were available for 18 patients, and a significantly higher colorectal adenoma detection rate was observed in the UPGI serrated lesions group than in the randomly selected age- and gender-matched group without serrated lesions who also underwent colonoscopy in the same period (38.9% vs 11.1%, OR = 5.091, 95%CI: 1.534-16.890, P = 0.010). The detection rate of advanced adenoma was also higher in the UPGI serrated lesions group (22.2% vs 4.2%, OR = 6.571, 95%CI: 1.322-32.660, P = 0.028).

CONCLUSION

Serrated lesions in the UPGI were detected in various mucosal lesions with different pathological morphologies. Moreover colonoscopy is recommended for the detection of concurrent colorectal adenoma for these patients.

[Epidemiology, treatment and follow-up of colorectal polyps]

Colorectal polyps are frequent in the general population. The diagnostic is made by endoscopy. Polyp's characteristics determine the technic to be used to remove them. Transanal endoscopic microsurgery offers an alternative to radical surgery for large rectal polyps or rectal tumors with low risk of node invasion. One peace resection is necessary to evaluate the resection margins. Lymphatic invasion, ≥ 1 mm submucosae invasion, tumor budding and poorly differentiated tumor are the four main risk factors for node invasion. In case of high risk of lymph node invasion a radical surgery is recommended. Surveillance must be adapted to the polyp type, their number, size, presence of a carcinomatous component as well as age and clinical status of the patient.

Nonampullary duodenal adenoma: Current understanding of its diagnosis, pathogenesis, and clinical management

Nonampullary duodenal adenomas are relatively common in familial adenomatous polyposis (FAP), but nonampullary sporadic duodenal adenomas (SDAs) are rare. Emerging evidence shows that duodenal adenomas, regardless of their anatomic location and whether they are sporadic or FAP-related, share morphologic and molecular features with colorectal adenomas. The available data suggest that duodenal adenomas develop to duodenal adenocarcinomas via similar mechanisms. The optimal approach for management of duodenal adenomas remains to be determined. The techniques for endoscopic resection of duodenal adenoma include snare polypectomy, endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and argon plasma coagulation ablation. EMR may facilitate removal of large duodenal polyps. Although several studies have reported cases of successful ESD for duodenal adenomas, the procedure is technically difficult to perform safely because of the anatomical properties of the duodenum. Although current clinical practice recommends endoscopic resection of all large duodenal adenomas in patients with FAP, endoscopic treatment is usually insufficient to guarantee a polyp-free duodenum. Surgery is indicated for FAP patients with severe polyposis or nonampullary SDAs or FAP-related polyps not amenable to endoscopic resection. Further studies are needed to develop newer endoscopic techniques to guide diagnostic and therapeutic decisions for future management of nonampullary duodenal adenomas.

Aspects of dietary carbohydrate intake are not related to risk of colorectal polyps in the Tennessee Colorectal Polyp Study

PURPOSE

High digestible carbohydrate intakes can induce hyperglycemia and hyperinsulinemia and collectively have been implicated in colorectal tumor development. Our aim was to explore the association between aspects of dietary carbohydrate intake and risk of colorectal adenomas and hyperplastic polyps in a large case-control study.

METHODS

Colorectal polyp cases (n = 1,315 adenomas only, n = 566 hyperplastic polyps only and n = 394 both) and controls (n = 3,184) undergoing colonoscopy were recruited between 2003 and 2010 in Nashville, Tennessee, USA. Dietary intakes were estimated by a 108-item food frequency questionnaire. Unconditional logistic regression analysis was applied to determine odds ratios (OR) and corresponding 95 % confidence intervals (CI) for colorectal polyps according to dietary carbohydrate intakes, after adjustment for potential confounders.

RESULTS

No significant associations were detected for risk of colorectal adenomas when comparing the highest versus lowest quartiles of intake for total sugars (OR 1.03; 95 % CI 0.84-1.26), starch (OR 1.01; 95 % CI 0.81-1.26), total or available carbohydrate intakes. Similar null associations were observed between dietary carbohydrate intakes and risk of hyperplastic polyps, or concurrent adenomas and hyperplastic polyps.

CONCLUSION

In this US population, digestible carbohydrate intakes were not associated with risk of colorectal polyps, suggesting that dietary carbohydrate does not have an etiological role in the early stages of colorectal carcinogenesis.

Vanek’s tumor of the small bowel in adults

Inflammatory fibroid polyps (IFPs), or Vanek’s tumor, are one of the least common benign small bowel tumors. IFP affects both sexes and all age groups, with a peak of incidence in the fifth and seventh decades. They can be found throughout the gastrointestinal tract but most commonly in the gastric antrum or ileum. The underlying cause of IFPs is still unknown. Genetic study of IFP showed mutations in platelet derived growth factor alpha in some cases. At the time of diagnosis most IFPs have a diameter of 3 to 4 cm. The lesions have always been recorded as solitary polyps. Symptoms depend on the location and the size of the lesion, including abdominal pain, vomiting, altered small bowel movements, gastrointestinal bleeding and loss of weight. IFPs arising below the Treitz ligament can present with an acute abdomen, usually due to intussusceptions. Abdominal computed tomography is currently considered the most sensitive radiological method to show the polyp or to confirm intussusceptions. Most inflammatory fibroid polyps can be removed by endoscopy. Surgery is rarely needed. Exploratory laparoscopy or laparotomy is frequently recommended as the best treatment for intussusceptions caused by IFP. The operation should be performed as early as possible in order to prevent the intussusceptions from leading to ischemia, necrosis and subsequent perforation of the invaginated bowel segment. This report aims at reviewing the diagnosis, etiology, genetics, clinical presentation, endoscopy, radiology, and best treatment of IFP.

[Long-term follow up after colonoscopy screening and polypectomy of male health care population with age ≥ 50 years]

OBJECTIVE

To analyze the trends of colorectal polyps for age ≥ 50 years male healthcare patients during a long-term colonoscopic follow-up.

METHODS

Endoscopic and pathological reports of age ≥ 50 years male healthcare patients undergoing colonoscopy from April 1983 to April 2013 were retrospectively reviewed and their general data collected. The proportion of different histological types, the distribution at different anatomic sites and the trends of size and number of colorectal polyps during different follow-up years were analyzed.

RESULTS

A total of 3 746 colonoscopy reports of 501 age ≥ 50 years healthcare cases were collected. After initial colonoscopic screening and polypectomy, 501, 371, 251 and 106 cases were followed up to the 5(th), 10(th), 15(th) and 20(th) years. Their mean age was (74 ± 9) years. And their mean age of initial colonoscopic screening and polypectomy was (66 ± 8) years. During a follow-up period of 54-348 months, each of them underwent (7 ± 5) colonoscopies. A total of 9 006 polyps were detected and 3 986 polyps confirmed pathologically. And 2 608 polyps(65.43%) belonged to adenomas. Among them, 4 638 (51.50%) polyps were located in descending colon and rectum while 1 314 (14.59%) in ascending colon and cecum.In a descending trend, the sizes of initial colonoscopy, 5(th), 10(th), 15(th) and 20(th) year were 0.44 ± 0.03, 0.07 ± 0.01, 0.07 ± 0.01, 0.12 ± 0.03 and 0.07 ± 0.01 respectively during the follow-up period (all P < 0.05). Also the numbers were in a descending trend, initial colonoscopy, 5(th), 10(th) and 20(th) year were 3.08 ± 0.19, 0.77 ± 0.09, 0.83 ± 0.10 and 1.03 ± 0.20 respectively during the follow-up period (all P < 0.05). The numbers of four different pathological types of polyps were all in a descending trend compared with initial colonoscopy. And the numbers peaked around 2(nd), 5(th), 7(th), 10(th), 11(th), 15(th), 18(th) and 19(th) year of follow-up. Statistical differences existed between tubular adenoma and tubule-villous adenoma, inflammatory polyps and hyperplastic polyps in mean number in the same follow-up year (all P < 0.05). The number of colorectal polyps in different anatomic sites was different in the same follow-up year (all P < 0.05).

CONCLUSIONS

The mean age of initial colonoscopic screening and polypectomy is 66 years. And the main histological type of colorectal polyps is adenoma.Rectum, sigmoid and descending colon are the major sites of colorectal polyps. During the follow-up, the size and number of colorectal polyps are both in a descending trend and the number changes with years. The recurrence of colorectal polyps has pathological and anatomical disparities during follow-up years.

Metabolic syndrome is associated with increased prevalence of advanced colorectal polyps

OBJECTIVES

To examine the association between metabolic syndrome (MetS) and/or its components and colorectal neoplasms in adult population undergoing screening colonoscopy.

DESIGN

Cross-sectional study.

SETTING

Institute of Gastroenterology, Kaplan Medical Center, Rehovot, Israel.

PARTICIPANTS

Two hundred ninety nine consecutive outpatients undergoing screening colonoscopy.

MEASUREMENTS

MetS was determined according to the Adult Treatment Panel III of the National Cholesterol Education Program (ATP III) criteria. Blood test results and other clinical data were retrieved from the electronic medical records.

RESULTS

In 94 patients (31.8%) polyps were detected. Thirty two (34%) of the polyps were advanced. Eighty one percent of patients with an advanced polyp met the criteria for MetS. About the same MetS prevalence (84%) was found in men, but not in women. An advanced polyp was detected in 14% of patients with MetS, compared to 5% of patients without MetS. Odds ratio for having an advanced polyp in a patient with MetS compared to a patient without MetS was 10.64.

CONCLUSION

MetS was found to be a risk factor for advanced polyps. This association is suggestive of the need that patients with MetS should be urged to have a screening colonoscopy.

[Detection of polyps, adenomas, advanced adenomas and adenocarcinomas in patients between 45 and 49 years]

BACKGROUND. Colorectal cancer (CRC) can be prevented. Colonoscopy is the first-line procedure for screening in average risk population. In 2002, Imperiale evaluated people between 40 to 49 years and reported that adenomas and advanced adenomas presented in 8.5% and 3.5% of cases, respectively. Currently, no recommendations for CRC screening in this population have been made.

OBJECTIVE

To estimate the prevalence ofpolyps, adenomas, advanced lesions and adenocarcinomas in the 45- to 49-year-old population.

METHODS

We included consecutive adults between 45 and 49 years old who performed colonoscopy because of gastrointestinal signs or symptoms. Exclusion criteria were high risk for CRC, incomplete VCC and/or previous evidence of colonic lesions. The study was conducted in a gastroenterology center from Buenos Aires, between September 2010 and October 2011. The design was prospective and cross-sectional. Polyethylene glycol (PEG) lavage solution or phosphates were usedfor cleansing. Colonoscopies were performed under sedation with Olympus equipment. The protocol was approved by the local IRB. 95% confidence intervals (95% CI) were estimated.

RESULTS

814 patients were evaluated and 764 were included, 440 (57%) were women and the average age was 47 years. The global prevalence of polyps was 20% (160 cases, 95% CI 18%-24%). The global prevalence of adenomas was 14% (107 cases, 95% CI 11%-16%). The prevalence of advanced adenomas was 5% (39 cases, 95% CI 4%-7%) and the prevalence of adenocarcinoma was 0.1% (1 case, 95% CI 0%-0.7%).

CONCLUSIONS

The prevalence of lesions in this population is lower than that in the average risk population. At the moment we do understand that there is no evidence to recommend CRC screening in 45- to 49-year-old individuals.

Statin use is associated with a reduced incidence of colorectal adenomatous polyps

BACKGROUND

Hydroxymethylglutaryl coenzyme A reductase inhibitors (statins) have been shown to have potentially useful anticancer effects against colorectal cancers in experimental studies, but clinical studies have shown inconsistent results on colorectal cancer incidence. Most colorectal cancers are believed to develop through the polyp-cancer sequence. We hypothesized that statins may protect against the development of adenomatous polyps, and this may contribute to the apparent cancer-protective effects.

OBJECTIVE

This study aims to compare previous statin use in patients with newly diagnosed adenomatous polyps against a control group without polyps.

METHOD

A case-control study involving 264 patients attending for diagnostic colonoscopy at the Norfolk and Norwich University Hospital was used. Polyp cases were age and sex matched against controls with normal colonoscopies. Structured patient interviews and clinical notes were used to ascertain drug and risk factor. Logistic regression was used to compare statin exposure and correct for confounding factors.

RESULTS

There was a significant negative association between prior statin use and a diagnosis of adenomatous polyps [odds ratio (OR) = 0.40 (0.24-0.76)]. The association was significantly stronger with higher statin doses [≥40 mg simvastatin or equivalent; OR 0.33 (0.10-0.53)] or longer duration of use [>5 years; OR 0.36 (0.10-0.67)]. Statin use was negatively associated with both high- and low-risk polyps.

CONCLUSIONS

Statins may have a protective effect against the development of adenomatous polyps. The negative association between statin use and polyp incidence showed a significant dose and duration relationship.

APC and KRAS mutations in distal colorectal polyps are related to smoking habits in men: results of a cross-sectional study

BACKGROUND

The purpose of this study was (a) to evaluate the association between cigarette smoking and the prevalence of distal colorectal polyps and adenocarcinoma and (b) to analyse genetic alterations representing different molecular pathways of the colorectal carcinogenesis.

METHODS

A total of 623 asymptomatic male (mean age: 53 years; 50-65) car factory workers were included. Information on smoking habits and other lifestyle factors were collected followed by a 60 cm colonoscopy. APC and KRAS mutations and microsatellite status were determined in colorectal lesions (colorectal carcinoma (CRC), hyperplastic (HP) and adenomatous polyps (AP)). Data were analysed using unconditional multiple logistic regression models.

RESULTS

Smokers had a higher prevalence of AP (OR 2.1; 95% CI 1.2-3.6; p<0.05) and HP (OR 5.4; 95% CI 2.6- 11.1; p<0.05). No differences in CRC were observed. There was a dose-response relationship with the number of cigarettes smoked. The risk of developing AP or HP decreased after smoking cessation, even among heavy smokers (≥20 packs/year). KRAS mutations were more prevalent among smokers AP (OR 5.6; 95% CI 1.6-20.4; p=0.007). There was a trend of positive association with APC mutations (OR 3.5; 95% CI 0.9-4.4; p=0.096). APC and KRAS mutations were found in 36% and 61% of the HP of smokers, but were absent in non-smokers (p=0.89 and 0.78, respectively). There were no differences in MSI between smokers and non-smokers.

CONCLUSIONS

Cigarette smoking is associated with a higher risk of developing both HP and AP and a higher prevalence of mutations in APC and KRAS.

[Duodenal polyps: epidemiology, clinical picture, diagnostics]

This cross-sectional comparative study included 120 patients (68 men and 52 women, mean age 58.3 +/- 14.5 yr) with duodenal polyps (DP) diagnosed by fibroesophagogastroduodenoscopy. Morphological study was conducted in 118 patients. Gastric metaplasia (GM) areas in polyp mucosa (PM) were identified by alcian blue/PAS reaction at pH 1.0 and 2.5. A total of 82859 patients were examined. Endoscopy revealed DP in 0.15% of them. The pH value below 6.5 was documented in duodenal bulb polyps in 85% of the patients having them and in 20% of those with polyps of other localization. Biliary pathology was documented in 80% of the patient with DP in major duodenal papilla and in 2.0% of those with DP of different localization. 66.7% of the patients did not complain of pain in the upper part of the gastrointestinal tract. Erosion of polyp mucosa occurred in 21.2% of the patients (92% of erosions in duodenal bulbs and 56.5% in hyperplastic DP with GM areas). H. pylori was identified in GM areas of bulb DP in 30.4% of the patients. Endoscopic study of 120 patients revealed the following localization of DP: bulbs - 83.4%, postbulbar region - 8.3%, major duodenal papilla - 8.3%. The following morphological types of DP (n = 118) were identified: hyperplastic DP - 49.2%, epithelial tumours - 16.1%, non-epithelial tumours - 1.7%, inflamed mucosal areas - 33.0%.

Gender medicine in gastroenterology

The cause for gender differences in the epidemiology, natural history and response to therapy in many diseases is unknown and has seldom been investigated in depth. Sex hormones are blamed for many of these changes, mostly without any scientific evidence. In this review I will describe some of the evidence for gender differences in gastrointestinal diseases. Gender medicine and its application for gastroenterology is a new field and one warranting research.

Frequent gastrointestinal polyps and colorectal adenocarcinomas in a prospective series of PTEN mutation carriers

BACKGROUND & AIMS

Germline phosphatase and tensin homolog (PTEN) mutations cause Cowden syndrome (CS), associated with breast and thyroid cancers. Case reports found 35%-85% of CS patients had gastrointestinal (GI) hamartomas. The association of benign and malignant GI neoplasias with CS remains debatable. Our goal is to describe the GI phenotype in a prospective series of PTEN mutation carriers.

METHODS

Patients who met relaxed International Cowden Consortium criteria (N = 2548) or with 5 or more GI polyps, 1 or more of which was hyperplastic or hamartomatous (N = 397), were prospectively recruited. Germline PTEN mutation/deletion analysis was performed. Of the 2945 patients, 127 (123 of 2548 and 4 of 397, respectively) patients having clear pathogenic PTEN mutations were eligible for this study. Esophagogastroduodenoscopy, colonoscopy, and pathology reports were reviewed. The Fisher 2-tailed exact test, unpaired t tests, and age- and sex-adjusted standardized incidence ratio were calculated.

RESULTS

Of 127 PTEN mutation carriers, 69 underwent 1 or more endoscopies with 64 (93%) having polyps. Of the 64, half had hyperplastic polyps. There were one to innumerable polyps in the colorectum, ileum, duodenum, stomach, and/or esophagus, with 24 subjects having both upper and lower GI polyps. Nine (13%) subjects had colorectal cancer, all younger than the age of 50. The adjusted standardized incidence ratio was 224.1 (95% confidence interval, 109.3-411.3; P < .0001).

CONCLUSIONS

PTEN-associated CS should be considered a mixed polyp syndrome, with hyperplastic polyps most prevalent, with a risk of early onset colorectal cancer. Routine colonoscopy should be considered in PTEN-associated CS, especially in the context of hyperplastic and/or adenomatous polyps.

Duodenal adenomas in nonpolyposis syndrome patients are not associated to colorectal neoplasia

BACKGROUND

Duodenal adenomas are extremely common in patients with familial adenomatous polyposis. In the general population, sporadic duodenal adenomas are an uncommon finding. Among individuals with duodenal adenomas, the development of concurrent colonic adenomas has been proposed, suggesting a diffuse gastrointestinal mucosa proliferative process and thus surveillance with colonoscopy.

METHODS

A total of 10,666 upper endoscopies were performed from January 1997 to July 2007. Four controls without duodenal adenomas were selected for each case. Association of duodenal polyposis with colonic adenomas was calculated using two sample proportions and chi square using SPSS.

RESULTS

In the 10-year period, 21 patients met inclusion criteria. All the patients were male with a mean age of 67 years (range: 45-86 years). Among cases, the most common indication for upper gastrointestinal endoscopy (EGD) was an abnormal imaging (47.6%). For controls, the most common indication for EGD was gastrointestinal bleeding (29.8%). Most adenomas were located in the second portion of the duodenum (63%). Mean size for duodenal adenomas was 5mm (range 1-21mm). High grade dysplasia was reported in 4 (18%) adenomas. The prevalence of sporadic duodenal adenomas was 0.2%. Nine of 21(42.8%) duodenal adenoma cases were found with concurrent colonic adenomas. In the control group, 38 of 84 (45%) patients were found with colon adenomas (p = 0.21). There was no significant statistical association between duodenal polyposis and anemia, smoking, alcohol, medical history of diabetes mellitus or BMI.

CONCLUSION

Prevalence of duodenal polyposis was low, although a high number of polyps exhibited high grade dysplasia. There was no statistically significant association between nonfamilial duodenal polyposis and colorectal adenomas. Our observations do not support early colonoscopy surveillance for patients with duodenal polyposis.

Risk factors for colorectal polyps in a Mexican population [Corrected and republished]

BACKGROUND

The prevalence of colorectal polyps and adenomas in the general population of Mexico is unknown.

AIM

To determine the prevalence and risk factors for colorectal polyps detected during flexible sigmoidoscopy (FSIG) in asymptomatic patients.

MATERIAL AND METHODS

From 1995 to 2008, FSIG was performed as part of a complete check-up in patients who had lived in northeast Mexico for over 5 years.

RESULTS

946 (794 males/152 females) were included in the study. The mean age was 48.8 years (range 21-91). A family history of colorectal cancer (FHCRC) was present in 2.2 % of the cases. The adenoma prevalence found in patients with a BMI < 25, 26-30 or > 30 was 7.3%, 6.2% and 10.2% respectively. Independent risk factor for colorectal polyps and adenomas included a positive family history of colorectal cancer (OR 12.4, 95% CI 19.1-230, and OR 12.4, 95% CI 4.1-37.3, respectively) and a body mass index > 25 (OR 4.2, 95% CI 4.2-14.2 and OR 4.2, 95% CI 1.8-9.7, respectively). Seventy two patients had polyps (7.6%) and 29 patients had adenomas (3%). The prevalence of polyps and adenomas on FSIG in patients younger than 50 years was 5.8% and 1.9% respectively, and among those older than 50 years, it was 8.9% and 4.8% respectively.

CONCLUSION

A positive family history of colorectal cancer and a body mass index > 25 are independent risk factors for colorectal polyps and adenomas. The adenoma prevalence found in our population was lower than the reported in developed countries.

Risk factors for colorrectal polyps in a Mexican population

BACKGROUND

The prevalence of colorectal polyps and adenomas in the general population of Mexico is unknown.

AIM

To determine the prevalence and risk factors for colorectal polyps detected during flexible sigmoidoscopy (FSIG) in asymptomatic patients.

MATERIAL AND METHODS

From 1995 to 2008, FSIG was performed as part of a complete check-up in patients who had lived in northeast Mexico for over 5 years.

RESULTS

946 (794 males/152 females) were included in the study. The mean age was 48.8 years (range 21-91). A family history of colorectal cancer (FHCRC) was present in 2.2 % of the cases. The adenoma prevalence found in patients with a BMI < 25, 26-30 or > 30 was 7.3%, 6.2% and 10.2% respectively. Independent risk factor for colorrectal polyps and adenomas included a positive family history of colorrectal cancer (OR 12.4, 95% CI 19.1-230, and OR 12.4, 95% CI 4.1-37.3, respectively) and a body mass index < 25 (OR 4.2, 95% CI 4.2-14.2 and OR 4.2, 95% CI 1.8-9.7, respectively). Seventy two patients had polyps (7.6%) and 29 patients had adenomas (3%). The prevalence of polyps and adenomas on FSIG in patients younger than 50 years was 5.8% and 1.9% respectively, and among those older than 50 years, it was 8.9% and 4.8% respectively.

CONCLUSION

A positive family history of colorectal cancer and a body mass index < 25 are independent risk factors for colorectal polyps and adenomas. The adenoma prevalence found in our population was lower than the reported in developed countries.

Risk and protective factors for development of colorectal polyps and cancer (Bulgarian experience)

BACKGROUND/AIMS

Colorectal cancer takes third place among all malignancies in the Varna region. The present study aims to determine the typical and distinguishing risk and protective factors for colorectal polyps and cancer formation.

METHODOLOGY

166 patients with large bowel polyps and 107 patients with colorectal cancer were questioned, examined endoscopically and histologically. Logistic regression analysis was used to find a possible correlation between alimentary habits, way of life, and risk for colorectal polyps and cancer formation. The latter have been used to define a strategy for their prevention.

RESULTS

Our results showed that fried, preserved, and grilled meat, consumption of animal fats, sugar, and being overweight are positively associated with colorectal polyps. In contrast, consumption of fruit, vegetables, rye- and brown bread, green tea, vegetable food, yoghourt, vegetarian food, fish, lamb, hare, garlic, boiled food, and mineral water, have strong protective effect against large bowel polyps. We have confirmed the role of the well-known risk factors for colorectal cancer, and discovered an association between H. pylori infection, age, villous component in the adenomatous polyps, and family history for any neoplasia and large bowel carcinoma.

CONCLUSIONS

We suggest the following protective factors for CRC: vegetarian food, plant oil, rural life, aspirin intake, legumes, fish, fruit and vegetable consumption. We observe a similarity between the risk factors for colorectal polyps and cancer formation. They act simultaneously and depend on genetic predisposition. A combination of endoscopic treatment and correction of the alimentary factors could be used as a means of cancer prevention.

[Colorectal polyps: clinical, endoscopic, and histopathologic features]

AIM

To evaluate the prevalence of colorectal polyps in a population from North- Eastern Romania, which underwent colonoscopic examination and to identify their clinical, endoscopic and histopathologic characteristics.

METHODS

A retrospective prevalence study of subjects aged 18-95 years, with no personal or familial history of familial adenomatous polyposis and inflammatory bowel disease, who underwent a colonoscopy. The number, size, gross endoscopic appearance, histopathological examination, and the anatomic location of colorectal polyps were analyzed, as well as the associated diseases.

RESULTS

Enrolled were 1001 patients (647 men, 354 women), aged 18-95 years (mean: 62.8 +/- 11.4 years) who were diagnosed with colorectal polyps. Overall, there were 1.534 colorectal polyps, and the majority of them (83.0%) were present in patients over the age of 50 years, from urban area (73.9%) and most of the patients were men (63.8%), and had solitary polyps (61.1%). Three-quarters of polyps were distal (rectum, sigmoid, and descendent colon) in location, and most of them (75.8%) had a size less than 10 mm. Over half of all polyps (54.7%) were pedunculated. Based on the histological structural configuration, 76.5% of all polyps were adenomas, and of these 62.6% were tubular adenomas; malignant polyps have been diagnosed in 82 (5.4%) patients. Associated hemorrhoids, diverticulosis, colorectal cancer, and angiodysplasia were identified in 9.6%, 10% and 1.3%, respectively.

CONCLUSION

The prevalence of colorectal polyps in our geographical area is in the range with that observed in other regions of our country. Most of polyps were identified in patients older than 50 years, predominantly men, located in distal colon, had a tubular adenoma histological structure, and frequently associated with hemorrhoids and diverticular disease.

Comparison of malignant potential between serrated adenomas and traditional adenomas

BACKGROUND

Serrated adenoma is a discrete colorectal epithelial neoplastic lesion that can evolve into colorectal cancer. However, the degree of malignant potential has not been firmly established as yet. The purpose of the present paper was to compare the malignant potential and clinicopathological features between serrated and traditional adenomas.

METHODS

A total of 124 serrated adenomas from 116 patients were assessed, and 419 traditional adenomas from 200 were randomly selected. The combination of nuclear dysplasia and serration of > or =20% of crypts was regarded as serrated adenoma. The clinicopathological features of serrated and traditional adenomas were compared, and multivariate analysis performed to confirm whether the malignant potential of serrated adenoma was similar to that of traditional adenoma.

RESULTS

The differences in age, sex, total number of adenomas, and synchronous lesions including adenoma with high-grade dysplasia and carcinoma between subjects with and without serrated adenoma were not significant. Serrated adenomas were more frequently located in the rectum and sigmoid colon (P < 0.001), and the average size of serrated adenomas was greater than that of traditional adenomas (P < 0.05). The incidence of malignant lesions including high-grade dysplasia and carcinoma in serrated adenomas was found to be lower than in traditional adenomas (3.2% vs 9.3%, P < 0.05). In the multivariate analysis, adenoma type and polyp size constituted the risk factors for the incidence of high-grade dysplasia and carcinoma.

CONCLUSIONS

Serrated adenoma is a premalignant lesion, but it has a lower potential for the development of malignancy than traditional adenomas.

Café au lait macules and juvénile polyps

Several hereditary and nonhereditary gastrointestinal tract polyposis syndromes exhibit extra-intestinal manifestations, including cutaneous findings. However, a lack of information exists regarding cutaneous features of juvenile polyposis. Our objective was to document the prevalence of cutaneous hyperpigmented lesions in children with juvenile polyposis coli or juvenile polyposis coli and their first degree relatives.Children seen in the gastroenterology practice at The Children's Hospital in Denver, Colorado with polyps (juvenile polyposis coli, sporadic juvenile polyps, and familial adenomatous polyposis coli) and their first degree relatives were invited to participate in the study. A comprehensive skin examination was performed on those who consented to participate. We found that 8 of 14 patients (eight with juvenile polyposis coli, four with juvenile polyposis, and two with familial adenomatous polyposis coli) had at least one café-au-lait macule, compared with three of 27 relatives (p=0.003).The prevalence of at least one café-au-lait macule in our patients (8/14 or 57.1%, CI: 28.9–82.3%) was significantly higher than the general population prevalence of 28.5% (p=0.023). However, if the two patients with familial adenomatous polyposis coli were excluded, the comparison with the general population prevalence did not reach statistical significance (p=0.095). The prevalence of multiple cafe´-au-lait macules in our patients (4/14 or 28.6%; CI:8.4–58.1%) was significantly higher than the general population prevalence of 5.2% (p ¼ 0.005). A notable finding was the presence of multiple café -au-lait macules in 4 of 12 juvenile polyposis coli/juvenile polyposis patients.Two patients with juvenile polyposis coli also had lentigines. In this selected case series, we observed single or multiple café-au-lait macules in a high proportion of children with the three types of polyps. Further studies are needed to assess a possible common pathway for hamartomatous polypsand café-au-lait macules.

The prevalence of suspected Barrett's esophagus in children and adolescents: a multicenter endoscopic study

BACKGROUND

The prevalence of Barrett's esophagus (BE) in young individuals is unclear.

OBJECTIVE

To estimate the prevalence of suspected BE in children and adolescent patients undergoing endoscopy.

DESIGN

A retrospective cross-sectional study.

SETTING

Prospectively collected data in the Pediatric Clinical Outcomes Research Initiative (PEDS-CORI).

PATIENTS

We identified patients younger than 20 years of age with suspected BE in the PEDS-CORI between 1999 and 2002; the corresponding histopathologic records were examined.

MAIN OUTCOME MEASUREMENTS

We analyzed the distribution of demographic and endoscopic risk factors for BE between cases and non-cases with and without suspected BE in bivariate and multivariable analyses.

RESULTS

We identified a total of 6731 patients who underwent upper endoscopy in 12 pediatric facilities. Only 17 patients had suspected BE (prevalence, 2.5 per 1000). Intestinal metaplasia was reported in only 9 of these patients (53%). Patients with suspected BE were older than patients without BE (median 14.7 vs 10.1 years; P = .011). Hiatus hernia was more commonly recorded in patients with suspected BE (11.8% vs 2.2%; P = .008). In a logistic regression model, both older age (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.02-1.35) and hiatus hernia (OR 4.62, 95% CI 1.03-20.66) were independently associated with suspected BE.

CONCLUSIONS

Endoscopically suspected BE is rare (<0.25%) in children and adolescents. Older age and the presence of hiatus hernia are possible risk factors for BE in this group.

LIMITATIONS

Lack of standardization for identifying and recording endoscopic landmarks.

Occult colorectal polyps on CT colonography: implications for surveillance

OBJECTIVE

Our purpose was to determine the prevalence of polyps that are invisible on CT colonography (CTC) in a population previously screened for colorectal neoplasms. Differences in the prevalence of occult polyps in various populations might help explain the discordant reported sensitivities for polyp detection in published reports of CTC.

SUBJECTS AND METHODS

Seventy-five consecutive patients who had been previously screened for polyps underwent same-day colonoscopy and CTC. Many of the patients had personal histories of previous polypectomies and were undergoing surveillance colonoscopy. The scans were interpreted prospectively by an experienced radiologist. Polyps missed prospectively on CTC were analyzed retrospectively by three experienced radiologists and categorized as perception errors (visible in retrospect), technical errors (e.g., obscured by feces or fluid), or occult (invisible).

RESULTS

Thirty polyps 5 mm or larger were found at colonoscopy, 18 of which were missed prospectively on CTC. Of the 18 missed polyps, 12 could not be identified in retrospect, even though they were located in clean, dry, well-distended colonic segments. These were classified as occult. Ten of the 12 occult polyps showed flat morphology on review of colonoscopy video recordings. Of the remaining six missed polyps, two were classified as perception errors, two as technical errors, and two as a combination of technical and perception error.

CONCLUSION

In this population, colonographically occult polyps were common and accounted for more detection failures than perception errors and technical errors combined. The high prevalence of occult polyps may be explained by the fact that previous screening may have led to removal of easy-to-see polyps, creating a study population with a higher percentage of hard-to-see polyps.

[Synchronous and metachronous tumours of colon cancer. A review of 5 years of experience (1999-2004)]

The authors report on 30 synchronous cancer (19%) and 9 metachronous cancer (5.7%) observed in 5 years (1999-2004) in 158 patient operated for colon cancer, defining metachronous cancer a tumor arisen at least 6 months after the first one or further then 5 cm from the anastomosis of the first colon resection. International case records report an incidence of 0.6-14% for synchronous cancer and 1-8% for metachronous cancer. The incidence of synchronous cancer is increasing for the presence of more oncogenic factors in the environment, for the improvement in radiology and endoscopy, for the raise of medium life. In accord with other authors, they show that the main risk factor for the developing of metachronous cancer is the coexistence of colon adenomas at the moment of the diagnosis of the tumor. The various incidence percentages can be explained by different way of diagnosis and classification.

Possible involvement of hyperlipidemia in increasing risk of colorectal tumor development in human familial adenomatous polyposis

BACKGROUND

Familial adenomatous polyposis (FAP) results from germline adenomatous polyposis coli (APC) gene mutations and many affected patients die from colorectal cancers which arise from colorectal polyps. We previously reported that two strains of Apc gene-deficient mice developing multiple intestinal polyps exhibit a hyperlipidemic state. The triglyceride (TG) levels were approximately 10-fold higher than the levels observed in wild-type mice.

METHODS

To examine whether a positive relationship might exist between hyperlipidemia and colorectal tumor development in FAP patients, as with Apc gene-deficient mice, a pilot experiment was performed using readily available clinical data such as ages, serum lipid levels, number of colorectal polyps and cancer development in 28 FAP patients from the National Cancer Center Hospital, Japan.

RESULTS

The overall prevalence of hyperlipidemia in FAP cases was 58%. Average TG levels in the 40-60 year age groups of FAP patients were > or =150 mg/dl (the defined threshold level of hyperlipidemia). Moreover, there was a tendency for higher serum TG levels in patients who developed colorectal cancer, as compared with those without colorectal cancer.

CONCLUSIONS

These results show that a hyperlipidemic state occurs in FAP patients. Although it is weaker than that in Apc gene-deficient mice, it may be linked to colon tumor development. These data warrant further studies for wider populations of FAP patients.

Gastrointestinal tumors in children and adolescents

Tumors of the pediatric gastrointestinal tract are extremely rare. Their infrequent presentation at treatment centers has not allowed for the development of standardized treatment protocols and prospective review. The most prevalent gastrointestinal neoplasms and malignancies are described, including gastrointestinal lymphoma, colorectal carcinoma, carcinoid tumors, gastrointestinal stromal tumors, leiomyomas, juvenile polyps, inflammatory pseudotumors, gastric tumors, and Peutz-Jeghers polyposis syndrome. Current recommendations for the medical and surgical management of these tumors are reviewed and summarized for this vast group of gastrointestinal neoplasms in children.

Frequency of Small Bowel Polyps in Patients with Duodenal Adenoma but without Familial Adenomatous Polyposis

INTRODUCTION

It is uncertain whether patients with duodenal adenomas without familial adenomatous polyposis (FAP) are at greater risk for small bowel neoplasia. We therefore conducted a study to determine the frequency of small bowel polyps in patients with non-papillary duodenal adenomas using capsule endoscopy for small bowel examination.

PATIENTS AND METHODS

14 patients (8 women, 6 men; mean age 67 +/- 10 years; range: 49 - 77 years) with non-papillary duodenal adenomas without FAP were included. All patients underwent wireless capsule endoscopy. The results were compared with an age- and sex-matched cohort of patients undergoing capsule endoscopy for suspected small bowel disease.

RESULTS

Overall, 15 polyps ranging between 1 and 8 mm in diameter were detected in eight patients of the study group, whereas no polyps could be identified in the control group. Natural excretion of the capsule within 24 hours was always reported and no complications were reported by any of the patients. Other pathological findings were multiple angiodysplasias in two patients of the study group. In the control group capsule endoscopy detected angiodysplasias in 5 patients with the indication obscure gastrointestinal bleeding, and inflammatory lesions in 2 patients with suspected Crohn's disease.

CONCLUSIONS

Based on the results of this prospective study, the frequency of small bowel polyps in patients with duodenal adenomas without familial adenomatous polyposis appears to be increased compared with a control group undergoing capsule endoscopy for other reasons. In none of the patients was the management altered. Follow-up data of these patients will be needed.

Frequency of Colorectal Polyps in Patients with Sporadic Adenomas or Adenocarcinomas of the Papilla of Vater - An Age-Matched, Controlled Study

BACKGROUND

Epithelial tumors of the papilla of Vater are rare neoplasms of the gastrointestinal tract. The carcinogenesis of these tumors seems to be fairly analogous to the genetic mechanisms which have been described for colorectal carcinoma. Patients with familial adenomatous polyposis bear a particularly increased risk for periampullary tumors. Data on whether the prevalence of colorectal tumors is increased in patients with sporadic ampullary neoplasms are scarce.

METHODS

26 consecutive patients (16 women, 10 men; median age 59 years) with sporadic adenomas (n = 19) or adenocarcinomas (n = 7) of the ampulla of Vater were retrospectively evaluated. The study patients were compared with 104 age-matched asymptomatic controls. All patients had undergone total colonoscopy.

RESULTS

Neoplastic colorectal polyps were present in a similar proportion (23%) of patients of the study group compared with 26% in the control group (p > 0.05). Overall, 16 polyps were found among patients with ampullary tumors and 40 in asymptomatic controls (p > 0.05). Colonoscopy detected rectal carcinoma in 2 patients (8%) of the study group. Patients with and without colorectal polyps differed neither significantly by age nor by ampullary histological findings. 50% of the colonic polyps in patients with ampullary neoplasms were located in the ascending colon.

CONCLUSIONS

The frequency of colorectal polyps in patients with ampullary tumors did not exceed the risk in the control group. However, the finding of 2 rectal carcinomas among patients with ampullary neoplasms supports the place of screening colonoscopy for the diagnostic work-up of ampullary tumors. Prospective multicenter studies should address this issue to provide a broad basis for future recommendations.

Distribution and prevalence of colorectal hyperplastic polyps using magnifying pan-mucosal chromoendoscopy and its relationship with synchronous colorectal cancer: prospective study

BACKGROUND AND AIM

Patients with multiple (hyperplastic polyposis) or large hyperplastic polyps (HPs) predominantly in the right-sided colon, have been reported to have an increased risk of colorectal cancer (CRC). This prospective study was conducted to clarify the distribution of various sized HPs using magnifying pan-mucosal chromoendoscopy and its relationship with synchronous CRC.

METHODS

Patients eligible for this study had an initial total colonoscopy. Indigo carmine dye was sprayed throughout the whole colon and rectum, and diagnoses were made using magnifying colonoscopy.

RESULTS

A total of 263 patients were enrolled, and a total of 3060 HPs were observed in 226 (86%) patients. The prevalence of patients with intermediate size (> or = 6 mm) HPs was 8.7% (n = 23) and that of patients with large HPs (> or = 10 mm) was 0.8% (n = 2). Of 3060 HPs, the numbers of diminutive (< 6 mm), intermediate size and large HPs were 3020, 38 and two, respectively, and 5.0%, 42.1% and 100% of these were located in the right-sided colon, respectively. Synchronous CRC was observed in 64 (24%) of 263 patients. Compared to patients without HPs, patients with intermediate size HPs showed a significant increase in odds ratio (OR) for synchronous CRC (OR = 4.9: 95% CI [1.3-18.2]), but there was no significant association between synchronous CRC and patients with diminutive or large HPs.

CONCLUSIONS

Compared to diminutive HPs, intermediate size and large HPs were predominantly located in the right-side colon. Moreover, intermediate size HPs were significantly correlated with synchronous CRC.

Risk of proximal colorectal neoplasia among asymptomatic patients with distal hyperplastic polyps

PURPOSE

Many guidelines on colorectal cancer screening do not consider distal hyperplastic polyps to be a marker for proximal neoplasia. However, 11 of 17 published studies have shown an increased risk of proximal neoplasia in patients with distal hyperplastic polyps. Our goal is to assess the risk of proximal neoplasia in asymptomatic patients with distal hyperplastic polyps, compared to those with distal tubular adenomas or no distal polyps.

METHODS

We assessed proximal (cecum, ascending, transverse colon and splenic flexure) and distal polyps in patients undergoing screening colonoscopy, classifying them into 3 groups: distal hyperplastic polyps only; distal adenomas with or without hyperplastic polyps; no distal polyps. The prevalence of proximal neoplasia and advanced neoplasia (polyps > or =1 cm, villous adenomas, or cancer) was compared among these groups.

RESULTS

Of 2357 patients, 427 (18%) had neoplasia, including 103 (4%) with advanced neoplasia. Proximal neoplasia occurred in 175 (9%) of 1896 patients with no distal polyps, compared with 28 (12%) of 237 with distal hyperplastic polyps (P = 0.20) and 64 (29%) of 224 with distal adenomas (P <0.0001). Proximal advanced neoplasia occurred in 39 (2%) patients with no distal polyps, compared with 4 (2%) with distal hyperplastic polyps (P = 0.70) and 9 (4%) with distal adenomas (P = 0.13).

CONCLUSIONS

Patients with distal hyperplastic polyps, unlike those with distal adenomas, do not exhibit an increased risk for proximal neoplasia or proximal advanced neoplasia compared to those with no distal polyps. The discovery of hyperplastic polyps on screening sigmoidoscopy should not prompt colonoscopy.

[Oral and maxillofacial manifestations of familial adenomatosis polyposis. Gardner's syndrome]

Patients suffering from familial adenomatosis polyposis develop multiple pre-malignant gastrointestinal polyps and are at high risk of developing colon cancer. In addition extra-intestinal manifestations are observed frequently. The combination of extra-intestinal manifestations and familial adenomatosis polyposis is named Gardner's syndrome. An early diagnosis of this disease is important because it could mean a better prognosis for the patient. This review describes the oral and maxillofacial symptoms of FAP, and its potential implications for dental treatment.

Adenomas at resection margins do not influence the long-term development of pouch polyps after restorative proctocolectomy for familial adenomatous polyposis

BACKGROUND

The aim of this study was to consider whether adenomas in the resection margins could represent a risk factor for pouch polyps in familial adenomatous polyposis (FAP) patients.

METHODS

We reviewed 46 patients treated by restorative proctocolectomy (RPC) for FAP: 9 hand-sewn and 37 stapled ileal pouch-anal anastomosis (IPAA). We analyzed the presence of polyps in the doughnuts from stapled anastomosis and in the resection margins from hand-sewn anastomosis. The presence of polyps in the IPAA was then assessed in 30 patients (6 hand-sewn and 24 stapled IPAA): 4 from the histology of the excised pouch and 26 by endoscopy (range 4 months to 12 years after operation, mean 6 years).

RESULTS

Surprisingly, pouch adenomas were found in only 2 of 30 (7%) of patients, 1 of 6 hand-sewn and 1 of 24 stapled anastomosis (P > 0.1), 9 and 11 years, respectively, after operation. However, there were 6 patients with inflammatory (3), fibroepithelial (2), or lymphoid (1) polyps. The risk of pouch adenomas after 8 years was 20% (P < 0.05). Pouch adenomas were found in 1 of 11 patients having adenomas in the margins or in the doughnuts (9%) and in 1 of 19 with no adenomas at the margins (5%; P > 0.1).

CONCLUSIONS

Incidence of pouch adenomas was low. There was no correlation between adenomas in the resection margins and the development of pouch adenomas.

Intestinal polyp formation in the Apcmin mouse: effects of levels of dietary calcium and altered vitamin D homeostasis

This study evaluated the effects of various levels of dietary calcium on polyp formation, vitamin D homeostasis, and fecal bile acids in the Apcmin mouse. Female Apcmin mice were randomized to three groups and fed a purified diet with either half or double the level of calcium in control AIN-93G. Serum 25-OH-D and fecal bile acids were measured at weeks 0 and 12 of treatment. Mice were killed for polyp scoring by two observers blinded to treatment after 12 weeks. Results show there was no difference in polyp number or tumor load with dietary calcium in any treatment group. Serum 25-OH-D was reduced and total fecal bile acids were increased in animals that received the high calcium diet. We have previously shown that vitamin D supplementation diminishes polyp load; the lack of effect of an altered calcium diet seen here may be due to a disturbance in vitamin D homeostasis.

A social network analysis of communication about hereditary nonpolyposis colorectal cancer genetic testing and family functioning

Hereditary cancers are relational diseases. A primary focus of research in the past has been the biological relations that exist within the families and how genes are passed along family lines. However, hereditary cancers are relational in a psychosocial sense, as well. They can impact communication relationships within a family, as well as support relationships among family members. Furthermore, the familial culture can affect an individual's participation in genetic counseling and testing endeavors. Our aims are (a) to describe the composition of familial networks, (b) to characterize the patterns of family functioning within families, (c) to analyze how these patterns relate to communications about genetic counseling and testing among family members, and (d) to identify influential family members. Specifically, we asked how the relationship between mutation status, kinship ties, and family functioning constructs, e.g., communication, cohesion, affective involvement, leadership, and conflict, was associated with discussions about genetic counseling and testing. We used social network analysis and random graph techniques to examine 783 dyadic relationships in 36 members of 5 hereditary nonpolyposis colorectal cancer (HNPCC) families interviewed from 1999-2000. Results suggest that in these five HNPCC families, two family members are more likely to discuss genetic counseling and testing if either one carries the mutation, if either one is a spouse or a first-degree relative of the other, or if the relationship is defined by positive cohesion, leadership, or lack of conflict. Furthermore, the family functioning patterns suggest that mothers tend to be the most influential persons in the family network. Results of this study suggest encouraging family members who act in the mother role to take a "team approach" with the family proband when discussing HNPCC risks and management with family members.

The clinical spectrum of duodenal polyps in pediatrics

OBJECTIVES

The aim of this retrospective study was to determine the prevalence, clinical presentation, and histologic subclassification of duodenal polyps identified on endoscopy (EGD) in pediatric patients.

METHODS

We performed an 18-year retrospective study of all pediatric patients (< 21 years) with duodenal polyps diagnosed between 1983 and 2001 at The Johns Hopkins Children's Center. Our analysis includes a formal histologic evaluation of duodenal polyps either biopsied using cold-forceps or removed by snare cautery.

RESULTS

Duodenal polyps were reported in 22 of 5766 EGDs (0.4%) performed in 16 (M:F; 1:1) patients with a mean (SD) age of 14.1 (5.1) years. Polyps were equal in both the Caucasian and African American population (adjusted ratio 1.2:1). The histologic subtypes included Adenomatous (42%), Brunner's gland hyperplastic (33%), hamartomatous (17%), and heterotopic gastric gland polyps (8%). The most frequent indication for EGD was surveillance in patients with polyposis syndromes; most of these patients were asymptomatic at the time of their EGD. In comparison, the most frequent indication for an EGD in patients without polyposis syndromes was abdominal pain and vomiting.

CONCLUSIONS

Duodenal polyps are most frequently encountered in children with polyposis syndromes, most of whom are asymptomatic. In nonsyndromic patients, the most common histologic subtype is Brunner's gland hyperplastic polyp and presenting symptoms include abdominal pain and vomiting.

The case for population-based screening for colorectal cancer

Screening for colorectal cancer is commanding increasing attention. Other cancer screening programmes have been a part of public consciousness for some time, but, until recently, colorectal cancer screening has remained in the background. Fuelled by new research, market opportunities and increased recognition of individual risk, screening for colorectal cancer is becoming a recommended procedure, but controversy about how best to implement widespread screening remains.

Prevalence of polyps and diverticulosis of the large bowel in the Cretan population. An autopsy study

While a number of studies have been performed in the United States, northern Europe, and some other countries on the epidemiology of large bowel polyps and diverticulosis, information from southern Europe and especially Greece is very limited. Our autopsy study sought to determine the prevalence of large bowel polyps and diverticulosis in the population on Crete. Specimens of colon and rectum were obtained during forensic postmortem autopsies and examined for the presence of polypoid lesions and diverticulosis. Data were collected from a total of 502 autopsies (320 men, 182 women; median age 65 years (range 16-93). Polyps were found in 106 cases (21.1%). These were adenomas in 73 cases (14.5%), hyperplastic polyps in 25 (4.9%), and mucosal tags in 8 (1.5%). Diverticulosis of the large bowel was found in 115 (22.9%). The prevalence of adenomas and diverticulosis increased with advanced age. The prevalence of colonic diverticulosis in Crete is slightly lower than that which has been reported in most other studies in economically developed countries. The prevalence of colorectal adenomas in Crete is one of the lowest rates reported in Europe and is compatible to the known low incidence of colorectal cancer in Crete.

Gender differences in colorectal polyps and tumors

OBJECTIVES

To use a national endoscopy database (CORI) to determine 1) whether gender differences are noted in the prevalence and location of polyps and tumors; 2) whether women have a higher rate of right-sided polyps or tumors; and 3) whether age influences these results.

METHODS

CORI database from April 1, 1997 to February 19, 1999, captured in a computer-generated report, was analyzed. Polyps for this study were defined as sessile or pedunculated and as >9 mm. Tumors were defined as lesions characteristic of adenocarcinoma (mass, apple-core). Pure right-sided colon (PRS) was defined as cecum, ascending, hepatic flexure; right-sided as PRS plus the transverse colon; and left-sided as the splenic flexure, descending, sigmoid and rectum.

RESULTS

Men have a greater risk of polyps [odds ratio (OR), 1.5] and tumors (OR, 1.4) than women. The risk of finding polyps and tumors at colonoscopy increases with age, with the highest risk noted in those >69 yr of age relative to patients <50 yr of age (polyps, OR = 2.7; tumors, OR = 4.0). Right-side polyps and pure right-sided polyps as defined by the study design were noted to be more frequent than left-sided polyps in patients >60 yr of age. Women have a greater risk of developing pure right-sided polyps (OR, 1.2), tumors (OR, 1.6) and right-sided tumors (OR, 1.5) than men.

CONCLUSIONS

Men have a higher prevalence of colon polyps and tumors than women. A progressive risk of polyp or tumor formation is noted with aging. Women had a greater number of pure right-sided polyps and tumor development. Colonoscopy is needed to correctly diagnose an increasing prevalence of right-sided pathology in the elderly.