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Acariasis and disrupted sphincters
AJG – April, 2003
Letters to the Editor
litus (DM). Recent studies (4 – 6) confirmed a significantly positive association between DM and colorectal cancer risk. However, clinical features of colorectal cancer complicated by DM remain unclear. Thus, we retrospectively evaluated malignant neoplasia, especially colorectal cancer, in 845 DM patients during 12 yr in a small island of Japan. The most frequent neoplasm was colorectal cancer (11 of 845), followed by gastric cancer (eight of 845), lung cancer (eight of 845), and pancreatic cancer (seven of 845). These 11 diabetic patients with colorectal cancer (seven men, four women; mean age 69 yr) were analyzed by colonoscopic findings. Indications for colonoscopy were: positive fecal occult blood tests in three patients, abdominal pains in two, bloody stool in one, anemia in one, constipation in one, abdominal fullness in one, bowel obstruction in one, and anal pain in one. One patient had two synchronous lesions; hence, a total of 12 adenocarcinoma were found. Of the 12 adenocarcinomas, nine (75%) were detected in the rightsided colon, markedly higher than three (25%) in the leftsided colon. Endoscopic findings demonstrated three early carcinomas of sessile types and nine advanced carcinomas. Histological findings showed seven well-differentiated adenocarcinomas, four moderately differentiated adenocarcinomas, and one mucinous adenocarcinoma. In conclusion, our preliminary data suggest that the frequency of rightsided colon cancer increases with diabetic patients. Total colonoscopy should be indicated in DM patients for colorectal cancer screening. Further studies comparing DM patients with non-DM patients for this frequency are needed. Ryosaku Tomiyama, M.D. Fukunori Kinjo, M.D. Akira Hokama, M.D. Atsushi Saito, M.D. First Department of Internal Medicine Department of Endoscopy University of the Ryukyus Okinawa, Japan
REFERENCES 1. Stevens T, Burke CA. The use of colonoscopy to detect neoplasia: Gender and age implications. Am J Gastroenterol 2002; 97(suppl):S114. 2. Lieberman DA, Weiss DG, Bond JH, et al. Use of colonoscopy to screen asymptomatic adults for colorectal cancer. N Engl J Med 2000;343:162–8. 3. Okamoto M, Shiratori Y, Yamaji Y, et al. Relationship between age and site of colorectal cancer based on colonoscopy findings. Gastrointest Endosc 2002;55:548 –51. 4. Nilsen TI, Vatten LJ. Prospective study of colorectal cancer risk and physical activity, diabetes, blood glucose and BMI: Exploring the hyperinsulinemia hypothesis. Br J Cancer 2001;84:417– 22. 5. Vecchia CL, Negri E, Decarli A, et al. Diabetes mellitus and
945
colorectal cancer risk. Cancer Epidemiol Biomark Prev 1997; 6:1007–10. 6. Hu FB, Manson JE, Liu S, et al. Prospective study of adult onset diabetes mellitus (type 2) and risk of colorectal cancer in women. J Natl Cancer Inst 1999;91:542–7. Reprint requests and correspondence: Ryosaku Tomiyama, M.D., First Department of Internal Medicine, Faculty of Medicine, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa 9030215, Japan. Received Nov. 15, 2002; accepted Nov. 21, 2002.
Acariasis and Disrupted Sphincters TO THE EDITOR: As testimony to progress in public health, in the superb long-term follow-up study (median 14.5 yr) of 135 patients post-endoscopic sphincterotomy, Sugiyama and Atomi (1) did not mention the impact of Ascaris. Nor were these devils noted in Sheth and Howell’s editorial (2). Many parts of our globe are less fortunate. From Damascas (3), 300 cases of biliary/pancreatic ascariasis were collected during just a 5-yr period—232 of the 300 patients (77%) had prior endoscopic sphincterotomy! The authors (4) even developed a technique for “whirlpool” jet washing of worms resisting usual retrieval techniques! Recent photographs (5) of a retrieved worm were from a patient with a prior endoscopic sphincterotomy. Obviously, Ascaris love disrupted sphincters! David E. Langdon, M.D., F.A.C.G. University of Texas Southwestern Medical School Dallas, Texas
REFERENCES 1. Sugiyama M, Atomi Y. Risk factors of late complications after endoscopic sphincterotomy for bile duct stones: Long-term (more than 10 years) follow-up study. Am J Gastroenterol 2002;97:2762–7. 2. Sheth SG, Howell DA. What are really the true late complications of endoscopic biliary sphincterotomy? Am J Gastroenterol 2002;97:2699 –701. 3. Sandouk F, Haffar S, Zada MM, et al. Pancreatic-biliary ascariasis: Experience of 300 cases. Am J Gastroenterol 1997;92: 2264 –7. 4. Sandouk F, Anand BS, Graham DY. The whirlpool jet technique for removal of pancreatic duct ascaris. Gastrointest Endosc 1997;46:180 –2. 5. Pai CG, Alvares JFF. Roundworm in bile duct. Gastrointest Endosc 2002;55:913. Reprint requests and correspondence: David E. Langdon, M.D., F.A.C.G., University of Texas Southwestern Medical School, 1005 Findlay Drive, Arlington, TX 76012-2716. Received Nov. 18, 2002; accepted Nov. 18, 2002.
Letters to the Editor
litus (DM). Recent studies (4 – 6) confirmed a significantly positive association between DM and colorectal cancer risk. However, clinical features of colorectal cancer complicated by DM remain unclear. Thus, we retrospectively evaluated malignant neoplasia, especially colorectal cancer, in 845 DM patients during 12 yr in a small island of Japan. The most frequent neoplasm was colorectal cancer (11 of 845), followed by gastric cancer (eight of 845), lung cancer (eight of 845), and pancreatic cancer (seven of 845). These 11 diabetic patients with colorectal cancer (seven men, four women; mean age 69 yr) were analyzed by colonoscopic findings. Indications for colonoscopy were: positive fecal occult blood tests in three patients, abdominal pains in two, bloody stool in one, anemia in one, constipation in one, abdominal fullness in one, bowel obstruction in one, and anal pain in one. One patient had two synchronous lesions; hence, a total of 12 adenocarcinoma were found. Of the 12 adenocarcinomas, nine (75%) were detected in the rightsided colon, markedly higher than three (25%) in the leftsided colon. Endoscopic findings demonstrated three early carcinomas of sessile types and nine advanced carcinomas. Histological findings showed seven well-differentiated adenocarcinomas, four moderately differentiated adenocarcinomas, and one mucinous adenocarcinoma. In conclusion, our preliminary data suggest that the frequency of rightsided colon cancer increases with diabetic patients. Total colonoscopy should be indicated in DM patients for colorectal cancer screening. Further studies comparing DM patients with non-DM patients for this frequency are needed. Ryosaku Tomiyama, M.D. Fukunori Kinjo, M.D. Akira Hokama, M.D. Atsushi Saito, M.D. First Department of Internal Medicine Department of Endoscopy University of the Ryukyus Okinawa, Japan
REFERENCES 1. Stevens T, Burke CA. The use of colonoscopy to detect neoplasia: Gender and age implications. Am J Gastroenterol 2002; 97(suppl):S114. 2. Lieberman DA, Weiss DG, Bond JH, et al. Use of colonoscopy to screen asymptomatic adults for colorectal cancer. N Engl J Med 2000;343:162–8. 3. Okamoto M, Shiratori Y, Yamaji Y, et al. Relationship between age and site of colorectal cancer based on colonoscopy findings. Gastrointest Endosc 2002;55:548 –51. 4. Nilsen TI, Vatten LJ. Prospective study of colorectal cancer risk and physical activity, diabetes, blood glucose and BMI: Exploring the hyperinsulinemia hypothesis. Br J Cancer 2001;84:417– 22. 5. Vecchia CL, Negri E, Decarli A, et al. Diabetes mellitus and
945
colorectal cancer risk. Cancer Epidemiol Biomark Prev 1997; 6:1007–10. 6. Hu FB, Manson JE, Liu S, et al. Prospective study of adult onset diabetes mellitus (type 2) and risk of colorectal cancer in women. J Natl Cancer Inst 1999;91:542–7. Reprint requests and correspondence: Ryosaku Tomiyama, M.D., First Department of Internal Medicine, Faculty of Medicine, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa 9030215, Japan. Received Nov. 15, 2002; accepted Nov. 21, 2002.
Acariasis and Disrupted Sphincters TO THE EDITOR: As testimony to progress in public health, in the superb long-term follow-up study (median 14.5 yr) of 135 patients post-endoscopic sphincterotomy, Sugiyama and Atomi (1) did not mention the impact of Ascaris. Nor were these devils noted in Sheth and Howell’s editorial (2). Many parts of our globe are less fortunate. From Damascas (3), 300 cases of biliary/pancreatic ascariasis were collected during just a 5-yr period—232 of the 300 patients (77%) had prior endoscopic sphincterotomy! The authors (4) even developed a technique for “whirlpool” jet washing of worms resisting usual retrieval techniques! Recent photographs (5) of a retrieved worm were from a patient with a prior endoscopic sphincterotomy. Obviously, Ascaris love disrupted sphincters! David E. Langdon, M.D., F.A.C.G. University of Texas Southwestern Medical School Dallas, Texas
REFERENCES 1. Sugiyama M, Atomi Y. Risk factors of late complications after endoscopic sphincterotomy for bile duct stones: Long-term (more than 10 years) follow-up study. Am J Gastroenterol 2002;97:2762–7. 2. Sheth SG, Howell DA. What are really the true late complications of endoscopic biliary sphincterotomy? Am J Gastroenterol 2002;97:2699 –701. 3. Sandouk F, Haffar S, Zada MM, et al. Pancreatic-biliary ascariasis: Experience of 300 cases. Am J Gastroenterol 1997;92: 2264 –7. 4. Sandouk F, Anand BS, Graham DY. The whirlpool jet technique for removal of pancreatic duct ascaris. Gastrointest Endosc 1997;46:180 –2. 5. Pai CG, Alvares JFF. Roundworm in bile duct. Gastrointest Endosc 2002;55:913. Reprint requests and correspondence: David E. Langdon, M.D., F.A.C.G., University of Texas Southwestern Medical School, 1005 Findlay Drive, Arlington, TX 76012-2716. Received Nov. 18, 2002; accepted Nov. 18, 2002.