bowel preparation kit versus customary preparation for colonoscopy

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AJG – Vol. 97, No. 9, Suppl., 2002

293). However, the precise relationship between Cox–2 and growth factor receptors remains unclear, forming the basis of this study. Methods: Human colon cancer specimens were obtained from patients undergoing surgical resection. Tissue sections were immunostained with specific antibodies against Cox–2, EGFR, ErbB2 and HGF/Met–R. Immunostaining was quantified by adding the intensity of the stain to the area of stain using videoimage analysis system. Correlation between Cox–2 and EGFR, ErbB2 and HGF/Met receptors expression was determined. Results: Immunohistochemical staining of cancer tissues demonstrated increased expression of Cox–2 (77.8% increase; p⬍0.05), EGFR (129.4% increase; p⬍0.002), ErbB2 expression (109% increase; p⬍0.0001) and HGF/Met–R (188.9% increase; p⬍0.04) vs. normal appearing colonic mucosa. Cox–2 overexpression correlated well with EGFR and ErbB2 expression (both r ⫽ 0.668), especially at the invasive front of the cancers. Conclusions: (a) Colon cancer displays increased expression of Cox–2 and distinct growth factor receptors. (b) Overexpression of Cox–2 showed correlation with increased ErbB2 and EGFR expression in colon cancer. (c) These findings indicate a spatial and temporal relationship between growth factor receptors and Cox–2 expression in colon cancer growth and invasion. 346 THE USE OF COLONOSCOPY TO DETECT NEOPLASIA: GENDER AND AGE IMPLICATIONS Tyler Stevens, M.D. and Carol A. Burke, M.D.*. The Department of Gastroenterology and Hepatology, The Cleveland Clinic Foundation, Cleveland, OH. Purpose: A recent colonoscopy study in men found 52% of subjects with advanced proximal neoplasia (APN) had no distal adenomas. The risk of APN in women and elderly subjects without distal adenomas is unknown. Our aim was to determine the effect of gender and age on prevalence of advanced adenomas and the risk of APN without distal neoplasia. Methods: All colonoscopy records between 1997–2000 were reviewed. Exams done for CRCA screening, change in bowel habit, or abdominal pain were included. Demographic information and location, size, and pathology of neoplasia was determined. “Distal” ⫽ rectum and sigmoid, “proximal” ⫽ remaining colonic segments. Advanced neoplasia (AN) ⫽ villous, tubulovillous or carcinoma in situ, sizeⱖ1cm, or invasive cancer. Results: 981 subjects (49% female) were included. The mean age was 65 (range 50 –100). 194 (20%) subjects had neoplasia. 85/194 (44%) had neoplasia distally and 109/194 (56%) had only proximal neoplasia. AN was detected in 43 (4.3%) subjects. (table 1) No difference was noted in the prevalence or location of AN between women vs men . Subjects ⬎70 yrs were more likely to have advanced neoplasia distally. Of subjects with APN 2/19 (13%) had distal neoplasia. Women with APN were more likely to have distal adenomas 20% than men 0%. Distal neoplasia was more common in subjects with APN ⬎ 70 yrs (14%) than subjects ⱕ70 (8%). Table 1. Prevalence and Location of Advanced Neoplasia Advanced Neoplasia

Total Female Male ⱕ 70 yrs ⬎ 70 yrs

Advanced Neoplasia with Distal Adenoma

Distal

Proximal

Total

24/981 (2.4%) 11/483 (2.3%) 13/498 (2.6%) 12/630 (1.9%) 12/351 (3.4%)

19/981 (1.9%) 10/483 (2.1%) 9/498 (1.8%) 12/630 (1.9%) 7/351 (2.0%)

26/43 (60%) 13/21 (62%) 13/22 (59%) 13/24 (54%) 13/19 (68%)

Proximal 2/19 (13%) 2/10 (20%) 0/9 (0%) 1/12 (8.3%) 1/7 (14%)

Conclusions: 1. More than half of subjects with proximal neoplasia and 75% with advanced proximal neoplasia have no distal neoplasia. 2. The prevalence and location of advanced neoplasia is similar in women and men. 3. Women and subjects ⬎ 70 yrs with advanced proximal neoplasia were more likely to harbor distal neoplasia than men or younger subjects.

4. The use of flexible sigmoid for colorectal neoplasia screening would miss more than 75% of subjects with advanced proximal neoplasia. 347 PREVALENCE OF COLORECTAL NEOPLASIA IN PATIENTS WITH A HISTORY OF BREAST CANCER James Smith, M.D.* and J. Scott Manton, M.D. Gastroenterology, Ochsner Clinic Foundation, New Orleans, LA. Purpose: To determine the prevalence of colorectal neoplasia in women with a history of breast cancer who underwent colonoscopy versus controls in our patient population. Methods: Breast cancer patients and sex and age matched control patients between the ages of 45– 80 years were eligible for the study. Study group patients were taken from the breast cancer registry at our institution from January 1990 to December 2000. After review of the records of 1251 breast cancer patients, we found 180 who had colonoscopy. Breast cancer was diagnosed after colonoscopy in 36 patients and they were excluded from the study, leaving a study group of 144 patients who had colonoscopy after the diagnosis of breast cancer. The average interval between the diagnosis of breast cancer and colonoscopy in the study group was 3.1 years. The control group was taken from our endoscopy databank from January 2000 to January 2001. The index colonoscopy was defined as the colonoscopy nearest to the diagnosis of breast cancer for the study group. Results: Patient characteristics in the two groups including family history, smoking history, obesity, and NSAID use were similar. The indications for colonoscopy in the study and control groups were similar: gastrointestinal bleeding (25.7% vs 16.7%), polyp on flexible sigmoidoscopy (27.1% vs 31.7%), anemia (8.33% vs 10%), family history of colonic neoplasia (29.9% vs 22.8%), and change in bowel habits (13.9% vs 13.9%) respectively. Adenomatous polyps were found in 60/144(41.7%) and 95/180(53%) patients in the study and control groups, respectively (by Fisher’s Exact p ⫽0.047). Colorectal cancer was found in 5/144 patients(3.47%) in the study group and 1/180 (0.56%) in the control group(RR⫽1.91[1.31,2.78], by Fisher Exact p⫽.06). Conclusions: Adenomatous polyps were significantly more prevalent in the control group but only a trend existed for colorectal cancer to be more prevalent in the breast cancer group. These results do not lend firm support to the hypothesis that colon cancer is more common in patients with breast cancer. Properly designed prospective studies are needed to address this issue further. 348 AN ONGOING STUDY TO ASSESS THE EFFICACY OF BOWEL PREPARATION WITH THE USE OF A PRE–PACKAGED DIET/ BOWEL PREPARATION KIT VERSUS CUSTOMARY PREPARATION FOR COLONOSCOPY Mark H. Delegge, M.D.*. Division of Gastroenterology and Hepatology Digestive Disease Center, Medical University of South Carolina, Charleston, SC. Purpose: The efficacy of standard bowel preparation for colonoscopy is often limited by patient compliance. Patient compliance is often impacted by their tolerance of the prescribed cathartic and also by the discomfort of maintaining a clear liquid diet on the day of bowel preparation. We originally reported on our results in 35 patients using a pre–packaged food kit on the day of bowel preparation coupled with a magnesium citrate, bisacodyl tablet, bisacodyl suppository colon cleansing regimen as compared to a standard clear liquid diet and Fleet Phospha–Soda colon regimen. We now report on the results of 269 patients. Methods: 269 patients were prospectively randomized to one of two bowel preparations on the day prior to colonoscopy. Active group 1 (A) received magnesium citrate, oral bisacodyl tablets, a bisacodyl suppository and a pre–packaged combination of a low residue solid and liquid food diet. The control group (C) received Fleet Phospha–Soda and a clear liquid diet, representing our standard bowel cleansing regimen. Patient tolerance of the

AJG – September, Suppl., 2002

preparations and efficacy of the preparations, often related to patient compliance, was measured by 4 endoscopists. Results: 269 patients (average age 55.2 years) completed the study. There were 151 patients in group A, and 118 patients in group C. The preparation was rated as tolerable or very tolerable by the patients in 92% of group A and 84% of group C. The preparation was rated as intolerable in 6% of group A and in 10% of group C. Overall visualization of the colon was determined to be adequate in 96% of both groups. Some retained stool was noted in 37% of both groups. 85% of group A and 80% of the control group claimed they would repeat the same preparation. Conclusions: A pre–packaged food bowel preparation kit containing low residue solids and liquids in combination with magnesium citrate, bisacodyl tablets and bisacodyl suppository was rated as more tolerable and more likely to be used by the patient as compared to a standard bowel cleansing preparation. Both preparations resulted in similar colon cleansing success. 349 RISK OF COLON POLYPS IN PATIENTS WITH EROSIVE ESOPHAGITIS Archana Verma, M.D., Bashar M. Attar, M.D., FACG* and Benjamin T. Go, M.D. Division of Gastroenterology, Cook County Hospital, Rush Medical College, Chicago, IL. Purpose: Bile acids and salts have been incriminated in the development of erosive esophagitis, Barrett’s esophagus as well as colonic polyps. GERD is a common disorder causing daily reflux in at least 5% of the general population while colon cancer; the 3rd common cancer in both men and women has a cumulative lifetime risk of 5%. Colon polyps are clinical precursors of colon cancer. The aim of this study is to look for any association between erosive esophagitis (EE) and colon polyps in these groups of presumably bile salt hypersecretors and whether they need to be more actively surveyed for colon cancer. Methods: We reviewed our endoscopy data bank for patients with chronic GERD who underwent EGD over a 3–year period (n⫽1670). We then identified the subset of these patients who underwent a colonoscopy irrespective of the indication of procedure (n⫽220) and compared the prevalence with erosive esophagitis versus non– erosive esophagitis (NERD) against the historical prevalence in the general population. Results: Out of the 220 patients, 58 patients (26%) had EE, 10 of these had colon polyps and 1 patient had colon cancer (19%). In the NERD group of 162 patients, 33 had colon polyps (20%). The mean age in the NERD group was 57.8 years that was comparable to 58.4 years in the EE group. The mean age of the patients with EE and colon polyps was 64.3 years and 59.6 years in the NERD group, which was not statistically significant. Conclusions: Patients with GERD, erosive or non– erosive have a 20% risk of developing colon polyps that is similar to the average risk population undergoing screening colonoscopies above age 50. Despite the recent implication of bile salts in increasing cellular proliferation activity, this does not translate into increased numbers of EE patients with colonic polyps. Further, any trophic effect related to the possible elevation of serum gastrin levels secondary to chronic PPI does not affect the number of patients with colonic polyps. Thus, despite theoretical risks erosive esophagitis does not appear to increase the risk of colonic polyps. 350 IS SMOKING AS PREDICTIVE AS FAMILY HISTORY FOR COLORECTAL POLYPS? RISK FACTOR ANALYSIS FOR COLORECTAL POLYPS Rajeev Attam, M.D., Patricia Hubbard, A.N.P., Zvi Alpern, M.D., Peter F. Ells, M.D. and Joseph C. Anderson, M.D.*. Gastroenterology and Hepatology, Stony Brook University, Stony Brook, NY. Purpose: To determine risk factors for colorectal polyps. Methods: We gathered data from 1566 consecutive screening colonoscopies which were performed between 12/99 and 04/02. Data collected included age, gender, family and personal history of colon cancer, smoking habits, alcohol and wine use, history of IBD and endoscopic findings on

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examination. Patients were categorized into Non smokers, current smokers if they smoked for more than 10 years, and Ex–smokers (people who quit tobacco more than 10 yrs ago and had more than 10 pack year’s history of smoking). Neoplasia was categorized as polyps (adenomatous), significant polyps (more than 2, larger than 1 cm, villous or high grade dysplasia) and adenocarcinoma. The patients were also assessed for Body mass index, fruits and vegetable intake, average weekly exercise and daily NSAID use. Multi–variate analysis was performed for various risk factors. Results: People older than 60 years, those with positive family history and smokers had a higher incidence of colorectal polyps. The incidence of polyps was higher in current smokers as compared to Ex–smokers (p⬍0.01). Relative Risk of polyps in smokers was comparable to people with positive family history. There was no statistical difference in the incidence of colonic polyps between non–smokers and ex–smokers. Pack years was not found to be a significant predictor of neoplasia on multivariate analysis. Women and people who drank wine had a lower risk for having colorectal polyps. Body Mass Index, fruits and vegetable intake, weekly exercise and daily NSAID use were not predictive of colorectal polyps. Patient Characteristics and Results

Smokers

Ex smokers

Non smokers

Gender M⫽196, F⫽158 M⫽209, F⫽155 M⫽431, F⫽417 Average Age 54.41 62.29 56.18 Family History 18.30% 20.06% 21.78% Average Tobacco 44 37 0 Pack years Average Wine Intake 1.28 1.69 1.14 Any Polyp 25.35% 18.68% 16.86% Significant Polyps 13.23% 8.24% 7.3% Adenocarcinoma 2 3 5

p Value (Smokers vs. Ex Smokers) NS ⬍.01 NS NS NS ⬍.01 ⬍.01 NS

Relative Risk for having any adenomatous polyp Risk Factor

Relative Risk

95% Confidence Interval Limits

Female Sex Age above 60 years Family History Smoking Wine Intake

0.68 2.07 1.72 1.74 0.66

0.53–0.89 1.60–2.68 1.23–2.41 1.28–2.35 0.47–0.92

Conclusions: ● ● ● ●

Smoking appears to be as predictive as family history for colorectal polyps. Wine and female sex seems to lower the risk of colorectal polyps. Quitting tobacco for more than 10 years may reduce the risk of polyps. Perhaps smokers should be screened at an earlier age.

351 A PREDICTIVE SCALE TO MEASURE PATIENT EXPERIENCE WITH COLONOSCOPY Joseph C. Anderson, M.D.*, Steven Kessler, D.O., Brian Gootzeit, M.D., Zvi Alpern, M.D., Peter F. Ells, M.D. and Catherine R. Messina, Ph.D. Gastroenterology, Stony Brook University, Stony Brook, NY and Preventive Medicine, Stony Brook University, Stony Brook, NY. Purpose: Patient experience with colonoscopy may be measured by pain, satisfaction (Group Health Association of America; GHAA–9) as well as by amount of sedation required. Our goal was to develop a scale which can assess a patient’s colonoscopic experience and identify factors predictive of a difficult colonoscopic experience. Methods: For 300 consecutive patients undergoing colonoscopy , we collected age, gender, height, weight, chronic laxative use, constipation, procedural indication and alcohol use (Audit–C scale). Patients were uni-