Colonoscopy conversion after flexible sigmoidoscopy screening: results from the UK Bowel Scope Screening Programme

AIM

In the UK Bowel Scope Screening Programme (BSSP), patients progress to colonoscopy based on high-risk features on flexible sigmoidoscopy (FS). We aim to assess the practice of colonoscopy conversion and predictors of detection of additional adenomas on colonoscopy.

METHOD

The Bowel Cancer Screening database was interrogated and collated with endoscopic and histological findings from patients undergoing colonoscopy following FS between August 2013 and August 2016. Multivariate analysis was performed to identify predictors of new adenomas.

RESULTS

FS was performed on 11 711 patients, with an adenoma detection rate (ADR) of 8.5% and conversion to colonoscopy in 421 (3.6%). The additional ADR at colonoscopy was 35.2%, with one additional malignant diagnosis (0.26%). The adenoma miss rate was 3.6%. On multivariate analysis, a polyp ≥ 10 mm was the only high-risk indication associated with additional ADR at colonoscopy (OR 3.68, 95% CI 1.51-3.65, P < 0.001), in addition to male gender (OR 2.36, 95% CI 1.46-3.83, P < 0.001). Predictors of detection of a new adenoma ≥ 10 mm included: villous adenoma (P = 0.002), polyp ≥ 10 mm (P = 0.007) and male gender (P = 0.039). The presence of any conversion criterion was associated with the detection of any proximal adenoma (P < 0.001) and adenoma ≥ 10 mm (P = 0.031).

CONCLUSION

Male gender, polyps ≥ 10 mm and villous-preponderant histology at FS were predictors of adenomas < 10 mm and ≥ 10 mm at colonoscopy. Further data are required to assess the role for gender-based stratification of conversion criteria.

Endoscopic full-thickness resection of colonic submucosal tumors originating from the muscularis propria: an evolving therapeutic strategy

Endoscopic resection of colonic submucosal tumors (SMTs) is challenging and carries a high risk of perforation. In this prospective pilot study we aimed to evaluate the feasibility, safety, and efficacy of endoscopic full-thickness resection of colonic SMTs. The study enrolled 19 consecutive patients with colonic SMTs 3 cm in size or smaller. In 18 of the 19 patients full-thickness resection was carried out endoscopically with the entire tumor capsule intact. In 16 of these18 patients, full-thickness resection was carried out and the colonic wall defect closed all endoscopically; in the other 2 patients, laparoscopic closure was needed. Two cases of local peritonitis were managed with conservative treatment. No deaths occurred within 30 days, and no recurrence was detected after a median of 18 months' follow-up. Endoscopic full-thickness resection is a novel method enabling resection of colonic SMTs. The colonic wall mucosal defect can be closed endoscopically in the majority of cases. It appears to be a safe and effective endoscopic technique for managing these tumors, which traditionally are managed by colonic resection.

Tolerability of aminosalicylates in inflammatory bowel disease

Since its synthesis in the 1930s and subsequent introduction, sulfasalazine has been an effective treatment for inflammatory bowel disease. However, up to one-third of patients are unable to take the drug because of severe intolerance. The finding in 1977 that the anticolitic effect of sulfasalazine lay in its 5-aminosalicylic [(5-ASA); mesalazine] moiety led to the development of new generations of 5-ASA agents. These new agents include a slow continuous release formulation, pH-dependent release formulations, formulations using alternative carrier molecules and rectally administered formulations. Newer 5-ASA formulations are more effective than placebo in maintaining remission of ulcerative colitis. They have also been used for the treatment of active Crohn's disease as well as maintenance treatment of ileocolonic Crohn's disease, although their role in isolated small bowel disease is controversial. In general terms, all of the newer 5-ASA preparations are much better tolerated than sulfasalazine. The use of standard dosages of mesalazine in pregnancy appears to be tolerated; however, continuing surveillance of pregnancy outcome is recommended. While there is evidence that mesalazine can cause nephrotoxic reactions, these reactions can occur with all 5-ASA-containing preparations, particularly in individuals with existing renal disease. Blood dyscrasias can also occur with all aminosalicylates.

Barrett’s metaplasia: clinical implications

The incidence of Barrett’s metaplasia (BM) as well as Barrett’s adenocarcinoma (BA) has been increasing in western populations. The prognosis of BA is worse because individuals present at a late stage. Attempts have been made to intervene at early stage using surveillance programmes, although proof of efficacy of endoscopic surveillance is lacking, particularly outside the specialist centres. The management of BM needs to be evidence-based as there is a lack clarity about how best to treat this condition. The role of proton pump inhibitors and antireflux surgery to control reflux symptoms is justified. Whether adequate control of gastroesophageal reflux early in the disease alters the natural history of Barrett’s change once it has developed and or prevents it in patients with gastroesophageal reflux disease but with no Barrett’s change remains unanswered. There is much to be learned about BM. Thus there is great need for carefully designed large randomised controlled trials to address these issues in order to determine how best to manage patients with BM.

Changes in serum lipids and chemistry profiles in type 2 diabetes mellitus during ramadan fasting

A prospective study of 34 Type 2 diabetic patients was carried out to determine the effect of Ramadan fasting on the lipid profiles; serum cholesterol, triglycerides, HDLcholesterol, LDL-cholesterol, Apo A-1, Apo B, Lp (a), and HbAjc. The comparison analysis of the pre-fasting with fasting and post-fasting samples did not reveal any statistically significant changes in the value of the lipid profiles. In the biochemical profile there was a slight change in the serum albumin but otherwise there was no change in the other biochemical values. The study was conducted in the Outpatient Department at Hamad Medical Corporation from November 1999 to February 2000.