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Don’t Ask (Details), Don’t Tell (Details)
Vol. 96, No. 5, 2001 ISSN 0002-9270/01/$20.00
WHAT’S NEW IN GI EDITOR
Jon S. Thompson, M.D., F.A.C.S.
Coming Soon to Your Local Magnet: MR Enteroclysis
GASTROENTEROLOGY
Randall E. Brand Rene´e L. Young John K. DiBaise Hemant K. Roy Timothy M. McCashland RADIOLOGY
Aurelio Matamoros, Jr.
PATHOLOGY
James L. Wisecarver
LIVER STUDY UNIT
Carol A. Casey PEDIATRIC GASTROENTEROLOGY
David R. Mack University of Nebraska Medical Center Omaha, Nebraska
Gourtsoyiannis N, Papanikolaou N, Grammatikakis J, et al. MR imaging of the small bowel with a true-FISP sequence after enteroclysis with water solution. Invest Radiol 2000;35:707–11. The imaging modality of choice for evaluating the small bowel is enteroclysis, which has been shown to demonstrate morphological abnormalities and has a high sensitivity and specificity. This procedure involves radiation exposure and can be time consuming for the patient and the radiology staff. Magnetic resonance (MR) imaging involves no radiation, has superb soft tissue contrast, has a multiplicity of imaging planes, and can provide three dimensional imaging. However, MR imaging is susceptible to motion artifacts and can have long imaging times. This aim of Gourtsoyiannis et al.’s study was to test a new MR enteroclysis technique for evaluating the small bowel. The study group consisted of 21 patients with suspected small bowel disease or known Crohn’s disease; all patients had clinical indications to undergo conventional enteroclysis. Three to five hours before the conventional enteroclysis, these patients underwent MR enteroclysis using a true fast imaging with steady state precession (true FISP) sequence, and the bowel was distended using an iso-osmotic water solution. The average MR room time was about 15 min. Two reviewers, using 5-point scales, divided the small bowel into three anatomical segments (jejunum, ileum, and ileocecal area) and evaluated all of the images for small bowel distension, wall conspicuousness, homogeneity of opacification, and MR artifacts (chemical shift, ghost, susceptibility, and motion).
Using this technique, bowel distension and wall conspicuousness were very good to excellent in the jejunum and ileum, and there was very good distension in the ileocecal area. Homogeneity of opacification was judged to be very good in the jejunum, good to very good in the ileum, and good in the ileocecal area. Chemical shift artifacts had a low incidence, and there were no ghost artifacts. The ileum showed more prominent susceptibility artifacts, and motion artifacts were low in the three anatomic areas. High quality images were produced using this MR technique and may well be used to evaluate small bowel pathology once more clinical and radiological experience is obtained. A. Matamoros, Jr., M.D.
Don’t Ask (Details), Don’t Tell (Details) Kinney A, DeVellis B, Skrynia C, Millikan R. Genetic testing for colorectal carcinoma susceptibility. Focus group responses of individuals with colorectal carcinoma and first-degree relatives. Cancer 2001;91:57– 65. Over 100,000 patients are annually diagnosed with colorectal cancer. Recent advances in genetic testing for hereditary cancer will place a premium on discussion of appropriate information regarding genetic counseling. This interesting research used focus groups moderated by a professional focus group leader to discuss in detail the advantages and disadvantages of getting genetic testing for colorectal cancer. One hundred three eligible individuals (43 patients with colorectal cancer and 60 with firstdegree relatives with colorectal cancer) were invited to participate. Twenty-
WHAT’S NEW IN GI
THE AMERICAN JOURNAL OF GASTROENTEROLOGY © 2001 by Am. Coll. of Gastroenterology Published by Elsevier Science Inc.
1332
What’s New in GI
eight colorectal cancer patients and 33 first-degree relatives agreed. Interest in pursuing genetic testing changed considerably after the focus group discussion. Eighty-two percent of first-degree relatives wanted testing before group discussion, but only 42% wanted testing after the discussion. Colorectal patients had less change, from 96% to 89%. Both groups knew or heard little about genetic testing for colorectal cancer before the group discussions. For colorectal patients the most frequent cited advantage was to help family members make better health-related decisions. For first-degree relatives it was to assist in decisions about detection and preventive measures. However, fears outweighed the advantages, especially in the first-degree relatives, who were concerned about the value of the information, psychological distress, family stress, and discrimination by health providers and insurance companies. The conclusions that patients or relatives want their healthcare provider to be able to discuss the advantages, disadvantages, and limitations of a genetic test or minimally refer them for the services they need or request in an impartial manner are similar to those of articles about genetic counseling for other cancers. This difficult topic will involve an enormous effort to educate both physicians and patients/relatives. Newly elected American College of Gastroenterology President Rowen Zetterman recently singled this out as an educational priority. T. M. McCashland, M.D.
The Outcome TIPS in Favor of Surgical Treatment Rosemurgy AS, Francesco M, Serafini MD, et al. Transjugular intrahepatic portosystemic shunt vs. small-diameter prosthetic H-graft portacaval shunt: Extended follow-up of an expanded randomized prospective trial. Gastroint Surg 2000;6:589 –97.
AJG – Vol. 96, No. 5, 2001
The use of the transjugular intrahepatic portosystemic shunt (TIPS) is now well established and clearly of advantage as a life-saving measure in patients with end stage liver disease and significant bleeding. Perhaps its greatest advantage has been found in patients who are awaiting liver transplantation, as well as other high risk patients such as those with coagulopathy, severe ascites, hypersplenism, and hepatorenal failure. However, it has remained unclear whether or not TIPS represents a durable long term solution to bleeding varices in patients who are otherwise able to tolerate a surgical portal decompressive procedure. Dr. Rosemurgy and colleagues performed a randomized trial of 132 patients who either failed or could not undergo sclerotherapy or a banding procedure. Sixty-six patients were included in each treatment arm and were well matched for age, sex, preexisting ascites, encephalopathy, Child’s classification, and etiology of liver disease. Overall, 16% were Child’s A, 37% Child’s B, and 47% Child’s C. The patients had similar preshunt portal venous pressures and portal vein inferior vena cava pressure gradients after the two therapies. Patients undergoing an 8-mm prosthetic H-graft portacaval shunt had lower postshunt portal venous pressure as well as lower gradients. The main outcome comparisons were failure of treatment, including inability to perform the shunt, irreversible shunt occlusion, major variceal rehemorrhage, liver transplantation, and death. Significantly more patients had major variceal rehemorrhages in the TIPS group. Five patients in the TIPS group underwent transplantation, compared to none in the H-graft shunt group. Twenty-nine of the TIPS patients and twenty of the H-graft patients died during the follow-up period. The overall failure rate after a TIPS procedure was 65%, compared to 35% in the H-graft group, which was statistically significant. Although both the TIPS procedure and H-graft portacaval shunt achieved partial portal decompression, the TIPS procedure re-
quired more intervention and led to more significant failures. Rosemurgy and colleagues conclude that the Hgraft portacaval shunt would be the preferred therapy for patients with portal hypertension and variceal bleeding that has not responded to or cannot be treated by sclerotherapy or banding. These results are consistent with other recent retrospective studies that made similar comparisons. There are currently at least two prospective trials comparing TIPS to distal splenorenal shunt. Thus it would appear that the surgical portal decompression remains a viable, and perhaps the preferred, treatment for patients who are surgical candidates. J. S. Thompson, M.D.
Plasma Citrulline as a Marker of Intestinal Failure in Short Bowel Syndrome Crenn P, Coudray-Lucas C, Thuillier F, et al. Postabsorptive plasma citrulline concentration is a marker of absorptive enterocyte mass and intestinal failure in humans. Gastroenterology 2000;119:1496 –505. Intestinal failure refers to the condition in which the functioning bowel is insufficient to allow for the absorption of an adequate amount of nutrients. In adults, the main cause of intestinal failure is short bowel syndrome (SBS). Not all patients with SBS develop permanent intestinal failure requiring life-long parenteral nutrition or small bowel transplantation; however, a high probability of permanent intestinal failure is expected in SBS patients when ⬍100 cm of small bowel remains and weaning off parenteral nutrition is not completed within 2 yr of their most recent bowel surgery. There are currently no biological markers to assess the functional absorptive bowel length and, thus, support the diagnosis of either permanent or transient intestinal fail-
WHAT’S NEW IN GI EDITOR
Jon S. Thompson, M.D., F.A.C.S.
Coming Soon to Your Local Magnet: MR Enteroclysis
GASTROENTEROLOGY
Randall E. Brand Rene´e L. Young John K. DiBaise Hemant K. Roy Timothy M. McCashland RADIOLOGY
Aurelio Matamoros, Jr.
PATHOLOGY
James L. Wisecarver
LIVER STUDY UNIT
Carol A. Casey PEDIATRIC GASTROENTEROLOGY
David R. Mack University of Nebraska Medical Center Omaha, Nebraska
Gourtsoyiannis N, Papanikolaou N, Grammatikakis J, et al. MR imaging of the small bowel with a true-FISP sequence after enteroclysis with water solution. Invest Radiol 2000;35:707–11. The imaging modality of choice for evaluating the small bowel is enteroclysis, which has been shown to demonstrate morphological abnormalities and has a high sensitivity and specificity. This procedure involves radiation exposure and can be time consuming for the patient and the radiology staff. Magnetic resonance (MR) imaging involves no radiation, has superb soft tissue contrast, has a multiplicity of imaging planes, and can provide three dimensional imaging. However, MR imaging is susceptible to motion artifacts and can have long imaging times. This aim of Gourtsoyiannis et al.’s study was to test a new MR enteroclysis technique for evaluating the small bowel. The study group consisted of 21 patients with suspected small bowel disease or known Crohn’s disease; all patients had clinical indications to undergo conventional enteroclysis. Three to five hours before the conventional enteroclysis, these patients underwent MR enteroclysis using a true fast imaging with steady state precession (true FISP) sequence, and the bowel was distended using an iso-osmotic water solution. The average MR room time was about 15 min. Two reviewers, using 5-point scales, divided the small bowel into three anatomical segments (jejunum, ileum, and ileocecal area) and evaluated all of the images for small bowel distension, wall conspicuousness, homogeneity of opacification, and MR artifacts (chemical shift, ghost, susceptibility, and motion).
Using this technique, bowel distension and wall conspicuousness were very good to excellent in the jejunum and ileum, and there was very good distension in the ileocecal area. Homogeneity of opacification was judged to be very good in the jejunum, good to very good in the ileum, and good in the ileocecal area. Chemical shift artifacts had a low incidence, and there were no ghost artifacts. The ileum showed more prominent susceptibility artifacts, and motion artifacts were low in the three anatomic areas. High quality images were produced using this MR technique and may well be used to evaluate small bowel pathology once more clinical and radiological experience is obtained. A. Matamoros, Jr., M.D.
Don’t Ask (Details), Don’t Tell (Details) Kinney A, DeVellis B, Skrynia C, Millikan R. Genetic testing for colorectal carcinoma susceptibility. Focus group responses of individuals with colorectal carcinoma and first-degree relatives. Cancer 2001;91:57– 65. Over 100,000 patients are annually diagnosed with colorectal cancer. Recent advances in genetic testing for hereditary cancer will place a premium on discussion of appropriate information regarding genetic counseling. This interesting research used focus groups moderated by a professional focus group leader to discuss in detail the advantages and disadvantages of getting genetic testing for colorectal cancer. One hundred three eligible individuals (43 patients with colorectal cancer and 60 with firstdegree relatives with colorectal cancer) were invited to participate. Twenty-
WHAT’S NEW IN GI
THE AMERICAN JOURNAL OF GASTROENTEROLOGY © 2001 by Am. Coll. of Gastroenterology Published by Elsevier Science Inc.
1332
What’s New in GI
eight colorectal cancer patients and 33 first-degree relatives agreed. Interest in pursuing genetic testing changed considerably after the focus group discussion. Eighty-two percent of first-degree relatives wanted testing before group discussion, but only 42% wanted testing after the discussion. Colorectal patients had less change, from 96% to 89%. Both groups knew or heard little about genetic testing for colorectal cancer before the group discussions. For colorectal patients the most frequent cited advantage was to help family members make better health-related decisions. For first-degree relatives it was to assist in decisions about detection and preventive measures. However, fears outweighed the advantages, especially in the first-degree relatives, who were concerned about the value of the information, psychological distress, family stress, and discrimination by health providers and insurance companies. The conclusions that patients or relatives want their healthcare provider to be able to discuss the advantages, disadvantages, and limitations of a genetic test or minimally refer them for the services they need or request in an impartial manner are similar to those of articles about genetic counseling for other cancers. This difficult topic will involve an enormous effort to educate both physicians and patients/relatives. Newly elected American College of Gastroenterology President Rowen Zetterman recently singled this out as an educational priority. T. M. McCashland, M.D.
The Outcome TIPS in Favor of Surgical Treatment Rosemurgy AS, Francesco M, Serafini MD, et al. Transjugular intrahepatic portosystemic shunt vs. small-diameter prosthetic H-graft portacaval shunt: Extended follow-up of an expanded randomized prospective trial. Gastroint Surg 2000;6:589 –97.
AJG – Vol. 96, No. 5, 2001
The use of the transjugular intrahepatic portosystemic shunt (TIPS) is now well established and clearly of advantage as a life-saving measure in patients with end stage liver disease and significant bleeding. Perhaps its greatest advantage has been found in patients who are awaiting liver transplantation, as well as other high risk patients such as those with coagulopathy, severe ascites, hypersplenism, and hepatorenal failure. However, it has remained unclear whether or not TIPS represents a durable long term solution to bleeding varices in patients who are otherwise able to tolerate a surgical portal decompressive procedure. Dr. Rosemurgy and colleagues performed a randomized trial of 132 patients who either failed or could not undergo sclerotherapy or a banding procedure. Sixty-six patients were included in each treatment arm and were well matched for age, sex, preexisting ascites, encephalopathy, Child’s classification, and etiology of liver disease. Overall, 16% were Child’s A, 37% Child’s B, and 47% Child’s C. The patients had similar preshunt portal venous pressures and portal vein inferior vena cava pressure gradients after the two therapies. Patients undergoing an 8-mm prosthetic H-graft portacaval shunt had lower postshunt portal venous pressure as well as lower gradients. The main outcome comparisons were failure of treatment, including inability to perform the shunt, irreversible shunt occlusion, major variceal rehemorrhage, liver transplantation, and death. Significantly more patients had major variceal rehemorrhages in the TIPS group. Five patients in the TIPS group underwent transplantation, compared to none in the H-graft shunt group. Twenty-nine of the TIPS patients and twenty of the H-graft patients died during the follow-up period. The overall failure rate after a TIPS procedure was 65%, compared to 35% in the H-graft group, which was statistically significant. Although both the TIPS procedure and H-graft portacaval shunt achieved partial portal decompression, the TIPS procedure re-
quired more intervention and led to more significant failures. Rosemurgy and colleagues conclude that the Hgraft portacaval shunt would be the preferred therapy for patients with portal hypertension and variceal bleeding that has not responded to or cannot be treated by sclerotherapy or banding. These results are consistent with other recent retrospective studies that made similar comparisons. There are currently at least two prospective trials comparing TIPS to distal splenorenal shunt. Thus it would appear that the surgical portal decompression remains a viable, and perhaps the preferred, treatment for patients who are surgical candidates. J. S. Thompson, M.D.
Plasma Citrulline as a Marker of Intestinal Failure in Short Bowel Syndrome Crenn P, Coudray-Lucas C, Thuillier F, et al. Postabsorptive plasma citrulline concentration is a marker of absorptive enterocyte mass and intestinal failure in humans. Gastroenterology 2000;119:1496 –505. Intestinal failure refers to the condition in which the functioning bowel is insufficient to allow for the absorption of an adequate amount of nutrients. In adults, the main cause of intestinal failure is short bowel syndrome (SBS). Not all patients with SBS develop permanent intestinal failure requiring life-long parenteral nutrition or small bowel transplantation; however, a high probability of permanent intestinal failure is expected in SBS patients when ⬍100 cm of small bowel remains and weaning off parenteral nutrition is not completed within 2 yr of their most recent bowel surgery. There are currently no biological markers to assess the functional absorptive bowel length and, thus, support the diagnosis of either permanent or transient intestinal fail-