- Email: [email protected]
Appropriateness of general practitioner’s indications for diagnostic upper gastrointestinal endoscopy
AJG – September, Suppl., 2002
Results: 25 cases were selected for analysis. 14 were females, mean age was 52.8 years (range 25–78 years). These tubes were used for feeding a mean time of 10.8 days (range 0 –51 days). The procedure time for tube placement was a mean of 13 minutes (range 3–31 minutes) and success was 100% with no associated complications. One patient (4%) developed an occlusion secondary to kinking which was repositioned and used. Five patients (20%) were discharged to home with tubes in place and being used for nutritional support. Nasoenteric tube use was discontinued secondary to resolution of primary indication in 6 (24%), patient intolerance or accidental displacement in 6 (24%), more permanent access (PEG, PEG/J, or PEJ) in 7 (28%), death from primary disease process in 1 (4%) and unknown in 5 (20%). Conclusions: The new push technique for placement of nasojejunal feeding tubes is safe, reproducible, and effective for short–term nutritional support in those patients unable to tolerate gastric enteral nutrition.
879 HETASTARCH AS AN ALTERNATIVE TO SALINE INJECTION FOR ENDOSCOPIC MUCOSAL RESECTION Tony E. Yusuf, M.D., Ijaz Ahmed, M.B.B.S., Doug Brining, D.V.M. and Gottumukkala S. Raju, M.D., FACG*. Internal Medicine, University of Texas Medical Branch, Galveston, TX. Purpose: Submucosal saline injection is widely used to prevent perforation during endoscopic mucosal resection (EMR). However, quick dissipation of saline not only makes EMR difficult, but also increase the risk of perforation from entrapment of muscle in the snare after the loss of submucosal cushion effect. Submucosal cushion effect from a colloid may last longer as colloids tend to get reabsorped slowly compared to crystalloids (saline), allowing more time for successful completion of an EMR. Hetastarch, a colloid widely used for volume expansion, is cheap, and is free from transmission of infection (unlike another colloid – albumen). Hetastarch may be used as an alternative to saline injection for EMR. The aim of this report is to compare the duration of submucosal cushion effect of hetastarch injection with saline injection in a live animal model. Methods: Three pigs (weight 85 to 100 lbs) were used for the study. Under general anesthesia, esophageal submucosal injections were done with a 23– gauge needle using a 10 cc syringe, at 5 cm intervals, starting from the gastroesophageal junction. At each site, 2 cc submucosal injections were given using either normal saline or 6% hetastarch. Each injection was observed for 15 minutes. Resolution of submucosal cushion was recorded at 5, 10, 15 minutes following injection. A total 16 injections (n⫽8 saline; n⫽8 hetastarch) were made and studied. Results: Submucosal cushion effect lasted longer with the hetastarch compared with the saline (9.25 ⫹ 2.05 versus 5.75 ⫹ 0.88 minutes, p⫽0.0014). Conclusions: Hetastarch may be an alternative to saline injection, especially in situations where a longer lasting submucosal cushion effect is desired for endoscopic mucosal resection.
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880 LONG TERM FOLLOW–UP OF ESOPHAGEAL FOOD IMPACTIONS: THE TRUTH IS NOT THAT HARD TO SWALLOW Robert E. Sedlack, M.D. and Todd H. Baron, M.D.*. Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN. Purpose: Esophageal food impaction often occurs without an identifiable cause. There are no longitudinal data examining heath care utilization or recurrence of symptoms following a single episode of food impaction where no structural abnormalities are identified. This retrospective study sought to determine if pts. with an index episode of food impaction and endoscopically normal esophagus experienced subsequent events or symptoms over the ensuing 5 years. Methods: We reviewed records of pts. with acute food impaction at the Mayo medical center between ‘90 –’96; pts. with first impaction episode and otherwise normal esophagoscopy were identified. Subsequent 5–year rx. and sx. data were obtained by record review and questionnaires. Results: Between ‘90 –’96, 406 pts. with acute esophageal food impaction were identified. In 69 pts., this represented the index episode with no identifiable cause endoscopically. Follow– up data available on 49 (71%) of these pts. form the basis of our cohort. The mean follow– up interval after the index event was 86.4 months (range 1–137). Further testing in 39 (80%) subjects identified a potential cause for impaction in 20 (51%). 34/49 pts. (69%) had only the index event; 24 of these pts. underwent further evaluation revealing a potential source in 10 (42%). Recurrent impaction occurred in 15/49 pts. (31%) with a potential cause discovered in 10 (67%). Impaction recurrence occurred at a mean of 24 months (range 2–74) after the index episode. 28 (41%) pts. returned symptom questionnaires; 14 pts. (50%) had continued dysphagia. Conclusions: 1) 1/3 of pts. with endoscopically normal esophagus at initial food impaction will have a repeat impaction at a mean of 2 years. 2) Further testing will identify a potential cause in 42% of pts. following one episode of food impaction. This yield increases to 2/3 following recurrent impactions. 3) In pts. who present with a food impaction, a potential source may be identified with extensive testing, but the diagnostic yield increases following subsequent food impactions.
881 APPROPRIATENESS OF GENERAL PRACTITIONER’S INDICATIONS FOR DIAGNOSTIC UPPER GASTROINTESTINAL ENDOSCOPY Antonio L. Sanchez–Rio, M.D.*, Enrique Quintero, M.D., Onofre Alarcon, M.D., Salvador Baudet, M.D. and Benjamin Martin, M.D. Digestive Diseases, Hospiten Rambla, Tenerife Island, Santa Cruz de Tenerife, Spain; Digestive Diseases, University Hospital of the Canary Islands, La Laguna, Santa Cruz de Tenerife, Spain and Phamily Medicine, Hospiten Bellevue, Puerto de la Cruz, Santa Cruz de Tenerife, Spain. Purpose: This estudy was aimed at comparing the appropriateness of use of upper gastrointestinal endoscopy (UGE) referred from general practitioners (GP) with those referred from specialists in gastroenterology (SG). Methods: Procedural indications for 162 UGE referred from GP and 136 from SG were systematically and prospectively collected with special attention to disease presentation, previuos tests and treatments. To evaluate the appropriateness we used the American Society for Gastrointestinal Endoscopy criteria for the appropriate use of gastrointestinal endoscopy (ASGE97) and the criteria of the European panel of experts (EPAGE). The ASGE 97 criteria classified the indications in appropriate or inappropriate ones. With the EPAGE criteria we obtained two Results: an ordinal scale from one to nine and a qualitative classification of appropriateness based on this scale (1–3: inappropriate, 4 – 6: uncertain, 7–9: appropriate). Results: Percentage of inappropriate indications based in ASGE 97 criteria were 17.2 for GP and 17.6 for SG (p⫽ 0.29). Based on EPAGE criteria these percentages were 11.8 and 11.4 (p⫽ 0.84). There was no statistical
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difference in EPAGE ordinal score between both groups of physicians for UGE indications. Conclusions: General practitioners request UGE at the same frequency for inappropriate indications compared to gastroenterologists. 882 CLINICAL EVALUATION OF FECAL INCONTINENCE BY QUESTIONNAIRE COMPARED TO ENDOANAL ULTRASOUND–DEMONSTRATED DEFECTS Keri L. Hill, M.D. and Douglas Faigel, M.D.*. Department of Gastroenterology, Oregon Health Sciences University, Portland, Oregon. Purpose: Fecal incontinence is a debilitating condition with a negative impact on quality of life. Many patients have demonstrable anatomical defects in the anal sphincters which may be surgically correctible. Questionnaires have been used to assess the presence and degree of fecal incontinence, but the literature is mixed regarding whether the symptoms and medical history elicited from a questionnaire are predictive of sphincter defects. The purpose of this study was to determine whether fecal incontinence questionnaires are predictive of sphincter defects documented by endoanal ultrasound. Methods: 80 patients (age 32 to 84 years, mean 55) referred from various clinics at the Portland VA and Oregon Health Sciences University Hospitals underwent endoanal ultrasound (EUS). The integrity of the internal anal sphincter (IAS) and external anal sphincter (EAS) were assessed separately as intact or disrupted. A digital rectal exam (DRE) was also performed and the resting tone and voluntary squeeze were assessed. Participants were administered a validated questionnaire and responses were compared to the corresponding EUS and DRE result and analyzed for correlation using the chi–square and t–tests. Results: A history of rectal surgery or sphincter tear during childbirth significantly correlated (p⬍0.05, both IAS and EAS disruption) with EUS– demonstrated sphincter defects. Use of a vacuum extractor during vaginal delivery was more frequent in IAS disruption (p⬍0.05), while standard forceps assisted delivery had no correlation with anatomic defects. Decreased or absent voluntary rectal squeeze and a palpable sphincter defect on digital rectal examination significantly correlated with EAS defects (p⬍0.05), but not with IAS defects (p ⫽ 0.08 and 0.3). The clinical impression of sphincter disruption on DRE correlated significantly with both IAS and EAS defects (p⬍0.05). No clinically elicited symptoms commonly associated with fecal incontinence correlated significantly with EUS– documented sphincter disruption. Conclusions: Comprehensive fecal incontinence questionnaires, even when validated and reproducible, are not predictive of anatomic sphincter defects as documented objectively by EUS evaluation. Past medical history can be helpful, but is limited to prior rectal surgery or known sphincter tear, both of which have good specificity but poor sensitivity. DRE had good correlation with EUS– documented EAS defects but mixed positive predictive values. 883 MELANOSIS COLI AS A MARKER OF COLONIC NEOPLASIA Vivaik Tyagi, M.D., Gergec Abouzeidan, M.D., Fredrick Oni, M.D. and Vlado Simko, M.D.*. Medicine, Brooklyn Campus, VA NY Harbor Health Care System, Brooklyn, NY. Purpose: Melanosis coli may spare colonic polyps from pigmentation. Can it be considered as a potential tool for bioendoscopy? Methods: An 83 year old male patient with chronic constipation of many years, partly related to Parkinson’s disease,with poor response to multiple laxatives, underwent screening colonoscopy. There were three polyps (3–7 mm) starkly contrasting in whitish appearance with the very darkly pigmented mucosa of the surrounding ascending colon. Histology revealed two tubular and one villotubular adenomas with remarkable absence of the pigment in the polyps.
AJG – Vol. 97, No. 9, Suppl., 2002
Results: Despite the clinical terminology, the pigment is lipofuscin and not melanin. Stimulant laxatives of the anthraquinone type are very popular and available as non–precription remedies (incl. Senna, Ex–Lax and herbal teas). Anthranoids induce transient waves of apoptosis by releasing cytokines and altering the tight inter– epithelial junctions. This leads to the development of lipofuscin granules that are taken up by macrophages in the lamina propria. Macrophages then migrate to the regional lymph nodes. Anthranoids cause pigmentation only in the colon where colonic microorganisms transform the prodrug into an absorbable stimulant. Highest intensity of pigmentation occurs in the proximal colon. When the laxative is discontinued, the pigmentation gradually disappears. Conclusions: Our report confirms previous observation on hypopigmentation of neoplastic tissue in patients with melanosis coli. The goals of future research should be to determine why preneoplastic tissue is not affected by anthranoids. Ultimately, an anthranoid molecule should be identified which would be safe to use as a biomarker for endoscopic screening of colonic polyps.
884 DETECTION OF SMALL COLORECTAL ADENOMAS BY ROUTINE CHROMOENDOSCOPY WITH INDIGOCARMINE Jun Haeng Lee, M.D., Jung Uk Kim, M.D., Yong Kyun Cho, M.D., Chung Il Sohn, M.D., Woo Kyu Jeon, M.D. and Byung Ik Kim, M.D.*. Deparment of Medicine, Kangbuk Samsung Hospital, Seoul, Korea. Purpose: Non–polypoid adenomas, which can be important precursors of colorectal cancers, are difficult to find during routine colonoscopy. The aim of this study was to evaluate the usefulness of routine chromoendoscopy in Korea, where the incidence of colorectal cancer is low compared to the western countries. Methods: Colonoscopy with chromoendoscopy was performed in 50 consecutive patients (32 men, 18 women; mean age 52.4 years). After a careful examination of the whole colon, a defined segment of the sigmoid colon and rectum (0 –30 cm from the anal verge) was stained with 20 ml of 0.4% indigocarmine solution using a spraying catheter. Non–polypoid lesions were classified as flat or depressed types. Biopsies were taken from all lesions detected before or after staining with indigocarmine. Results: Indications for colonoscopy included routine check– up (15 patients), bowel habit change (13 patients), abdominal pain (6 patients), bleeding (4 patients) and others (12 patients). Before staining, 33 lesions were found in 18 patients (36%). Histology showed tubular adenoma in 22 lesions, hyperplastic or inflammatory changes in 8 lesions, adenocarcinoma in 2 lesions, and villous adenoma in 1 lesion. After indigocarmine staining for normal–looking distal 30 cm colorectal mucosa, 131 lesions were found in 31 patients (62%). Histologically, 114 lesions (from 23 patients) were hyperplastic or inflammatory in nature, and 17 lesions (from 10 patients) were tubular adenomas. Adenomas seen only after spraying indigocarmine were 2.6 ⫹/– 0.7 mm in diameter and classified as flat adenomas except for one small (1.5 mm) depressed adenoma. No adenoma with high– grade dysplasia or cancer was found after staining. Presence of macroscopic lesions before staining could not predict the existence of adenoma after staining. Conclusions: In a large proportion of Korean patients, flat or depressed adenomas could be found after spraying indigocarime for normal–looking colorectal mucosa. The clinical significance of these small adenomas, which could be found only after chromoscopy, needs to be further investigated.
885 UNSEDATED ENDOSCOPY: A REALITY OR STILL A DREAM Anand Madan, M.D. and Anil Minocha, M.D., FACG*. Division of Gastroenterology, Southern Illinois University School of Medicine, Springfield, IL and Division of Digestive Diseases, University of Mississippi Medical Center, Jackson, MS.
Results: 25 cases were selected for analysis. 14 were females, mean age was 52.8 years (range 25–78 years). These tubes were used for feeding a mean time of 10.8 days (range 0 –51 days). The procedure time for tube placement was a mean of 13 minutes (range 3–31 minutes) and success was 100% with no associated complications. One patient (4%) developed an occlusion secondary to kinking which was repositioned and used. Five patients (20%) were discharged to home with tubes in place and being used for nutritional support. Nasoenteric tube use was discontinued secondary to resolution of primary indication in 6 (24%), patient intolerance or accidental displacement in 6 (24%), more permanent access (PEG, PEG/J, or PEJ) in 7 (28%), death from primary disease process in 1 (4%) and unknown in 5 (20%). Conclusions: The new push technique for placement of nasojejunal feeding tubes is safe, reproducible, and effective for short–term nutritional support in those patients unable to tolerate gastric enteral nutrition.
879 HETASTARCH AS AN ALTERNATIVE TO SALINE INJECTION FOR ENDOSCOPIC MUCOSAL RESECTION Tony E. Yusuf, M.D., Ijaz Ahmed, M.B.B.S., Doug Brining, D.V.M. and Gottumukkala S. Raju, M.D., FACG*. Internal Medicine, University of Texas Medical Branch, Galveston, TX. Purpose: Submucosal saline injection is widely used to prevent perforation during endoscopic mucosal resection (EMR). However, quick dissipation of saline not only makes EMR difficult, but also increase the risk of perforation from entrapment of muscle in the snare after the loss of submucosal cushion effect. Submucosal cushion effect from a colloid may last longer as colloids tend to get reabsorped slowly compared to crystalloids (saline), allowing more time for successful completion of an EMR. Hetastarch, a colloid widely used for volume expansion, is cheap, and is free from transmission of infection (unlike another colloid – albumen). Hetastarch may be used as an alternative to saline injection for EMR. The aim of this report is to compare the duration of submucosal cushion effect of hetastarch injection with saline injection in a live animal model. Methods: Three pigs (weight 85 to 100 lbs) were used for the study. Under general anesthesia, esophageal submucosal injections were done with a 23– gauge needle using a 10 cc syringe, at 5 cm intervals, starting from the gastroesophageal junction. At each site, 2 cc submucosal injections were given using either normal saline or 6% hetastarch. Each injection was observed for 15 minutes. Resolution of submucosal cushion was recorded at 5, 10, 15 minutes following injection. A total 16 injections (n⫽8 saline; n⫽8 hetastarch) were made and studied. Results: Submucosal cushion effect lasted longer with the hetastarch compared with the saline (9.25 ⫹ 2.05 versus 5.75 ⫹ 0.88 minutes, p⫽0.0014). Conclusions: Hetastarch may be an alternative to saline injection, especially in situations where a longer lasting submucosal cushion effect is desired for endoscopic mucosal resection.
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880 LONG TERM FOLLOW–UP OF ESOPHAGEAL FOOD IMPACTIONS: THE TRUTH IS NOT THAT HARD TO SWALLOW Robert E. Sedlack, M.D. and Todd H. Baron, M.D.*. Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN. Purpose: Esophageal food impaction often occurs without an identifiable cause. There are no longitudinal data examining heath care utilization or recurrence of symptoms following a single episode of food impaction where no structural abnormalities are identified. This retrospective study sought to determine if pts. with an index episode of food impaction and endoscopically normal esophagus experienced subsequent events or symptoms over the ensuing 5 years. Methods: We reviewed records of pts. with acute food impaction at the Mayo medical center between ‘90 –’96; pts. with first impaction episode and otherwise normal esophagoscopy were identified. Subsequent 5–year rx. and sx. data were obtained by record review and questionnaires. Results: Between ‘90 –’96, 406 pts. with acute esophageal food impaction were identified. In 69 pts., this represented the index episode with no identifiable cause endoscopically. Follow– up data available on 49 (71%) of these pts. form the basis of our cohort. The mean follow– up interval after the index event was 86.4 months (range 1–137). Further testing in 39 (80%) subjects identified a potential cause for impaction in 20 (51%). 34/49 pts. (69%) had only the index event; 24 of these pts. underwent further evaluation revealing a potential source in 10 (42%). Recurrent impaction occurred in 15/49 pts. (31%) with a potential cause discovered in 10 (67%). Impaction recurrence occurred at a mean of 24 months (range 2–74) after the index episode. 28 (41%) pts. returned symptom questionnaires; 14 pts. (50%) had continued dysphagia. Conclusions: 1) 1/3 of pts. with endoscopically normal esophagus at initial food impaction will have a repeat impaction at a mean of 2 years. 2) Further testing will identify a potential cause in 42% of pts. following one episode of food impaction. This yield increases to 2/3 following recurrent impactions. 3) In pts. who present with a food impaction, a potential source may be identified with extensive testing, but the diagnostic yield increases following subsequent food impactions.
881 APPROPRIATENESS OF GENERAL PRACTITIONER’S INDICATIONS FOR DIAGNOSTIC UPPER GASTROINTESTINAL ENDOSCOPY Antonio L. Sanchez–Rio, M.D.*, Enrique Quintero, M.D., Onofre Alarcon, M.D., Salvador Baudet, M.D. and Benjamin Martin, M.D. Digestive Diseases, Hospiten Rambla, Tenerife Island, Santa Cruz de Tenerife, Spain; Digestive Diseases, University Hospital of the Canary Islands, La Laguna, Santa Cruz de Tenerife, Spain and Phamily Medicine, Hospiten Bellevue, Puerto de la Cruz, Santa Cruz de Tenerife, Spain. Purpose: This estudy was aimed at comparing the appropriateness of use of upper gastrointestinal endoscopy (UGE) referred from general practitioners (GP) with those referred from specialists in gastroenterology (SG). Methods: Procedural indications for 162 UGE referred from GP and 136 from SG were systematically and prospectively collected with special attention to disease presentation, previuos tests and treatments. To evaluate the appropriateness we used the American Society for Gastrointestinal Endoscopy criteria for the appropriate use of gastrointestinal endoscopy (ASGE97) and the criteria of the European panel of experts (EPAGE). The ASGE 97 criteria classified the indications in appropriate or inappropriate ones. With the EPAGE criteria we obtained two Results: an ordinal scale from one to nine and a qualitative classification of appropriateness based on this scale (1–3: inappropriate, 4 – 6: uncertain, 7–9: appropriate). Results: Percentage of inappropriate indications based in ASGE 97 criteria were 17.2 for GP and 17.6 for SG (p⫽ 0.29). Based on EPAGE criteria these percentages were 11.8 and 11.4 (p⫽ 0.84). There was no statistical
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difference in EPAGE ordinal score between both groups of physicians for UGE indications. Conclusions: General practitioners request UGE at the same frequency for inappropriate indications compared to gastroenterologists. 882 CLINICAL EVALUATION OF FECAL INCONTINENCE BY QUESTIONNAIRE COMPARED TO ENDOANAL ULTRASOUND–DEMONSTRATED DEFECTS Keri L. Hill, M.D. and Douglas Faigel, M.D.*. Department of Gastroenterology, Oregon Health Sciences University, Portland, Oregon. Purpose: Fecal incontinence is a debilitating condition with a negative impact on quality of life. Many patients have demonstrable anatomical defects in the anal sphincters which may be surgically correctible. Questionnaires have been used to assess the presence and degree of fecal incontinence, but the literature is mixed regarding whether the symptoms and medical history elicited from a questionnaire are predictive of sphincter defects. The purpose of this study was to determine whether fecal incontinence questionnaires are predictive of sphincter defects documented by endoanal ultrasound. Methods: 80 patients (age 32 to 84 years, mean 55) referred from various clinics at the Portland VA and Oregon Health Sciences University Hospitals underwent endoanal ultrasound (EUS). The integrity of the internal anal sphincter (IAS) and external anal sphincter (EAS) were assessed separately as intact or disrupted. A digital rectal exam (DRE) was also performed and the resting tone and voluntary squeeze were assessed. Participants were administered a validated questionnaire and responses were compared to the corresponding EUS and DRE result and analyzed for correlation using the chi–square and t–tests. Results: A history of rectal surgery or sphincter tear during childbirth significantly correlated (p⬍0.05, both IAS and EAS disruption) with EUS– demonstrated sphincter defects. Use of a vacuum extractor during vaginal delivery was more frequent in IAS disruption (p⬍0.05), while standard forceps assisted delivery had no correlation with anatomic defects. Decreased or absent voluntary rectal squeeze and a palpable sphincter defect on digital rectal examination significantly correlated with EAS defects (p⬍0.05), but not with IAS defects (p ⫽ 0.08 and 0.3). The clinical impression of sphincter disruption on DRE correlated significantly with both IAS and EAS defects (p⬍0.05). No clinically elicited symptoms commonly associated with fecal incontinence correlated significantly with EUS– documented sphincter disruption. Conclusions: Comprehensive fecal incontinence questionnaires, even when validated and reproducible, are not predictive of anatomic sphincter defects as documented objectively by EUS evaluation. Past medical history can be helpful, but is limited to prior rectal surgery or known sphincter tear, both of which have good specificity but poor sensitivity. DRE had good correlation with EUS– documented EAS defects but mixed positive predictive values. 883 MELANOSIS COLI AS A MARKER OF COLONIC NEOPLASIA Vivaik Tyagi, M.D., Gergec Abouzeidan, M.D., Fredrick Oni, M.D. and Vlado Simko, M.D.*. Medicine, Brooklyn Campus, VA NY Harbor Health Care System, Brooklyn, NY. Purpose: Melanosis coli may spare colonic polyps from pigmentation. Can it be considered as a potential tool for bioendoscopy? Methods: An 83 year old male patient with chronic constipation of many years, partly related to Parkinson’s disease,with poor response to multiple laxatives, underwent screening colonoscopy. There were three polyps (3–7 mm) starkly contrasting in whitish appearance with the very darkly pigmented mucosa of the surrounding ascending colon. Histology revealed two tubular and one villotubular adenomas with remarkable absence of the pigment in the polyps.
AJG – Vol. 97, No. 9, Suppl., 2002
Results: Despite the clinical terminology, the pigment is lipofuscin and not melanin. Stimulant laxatives of the anthraquinone type are very popular and available as non–precription remedies (incl. Senna, Ex–Lax and herbal teas). Anthranoids induce transient waves of apoptosis by releasing cytokines and altering the tight inter– epithelial junctions. This leads to the development of lipofuscin granules that are taken up by macrophages in the lamina propria. Macrophages then migrate to the regional lymph nodes. Anthranoids cause pigmentation only in the colon where colonic microorganisms transform the prodrug into an absorbable stimulant. Highest intensity of pigmentation occurs in the proximal colon. When the laxative is discontinued, the pigmentation gradually disappears. Conclusions: Our report confirms previous observation on hypopigmentation of neoplastic tissue in patients with melanosis coli. The goals of future research should be to determine why preneoplastic tissue is not affected by anthranoids. Ultimately, an anthranoid molecule should be identified which would be safe to use as a biomarker for endoscopic screening of colonic polyps.
884 DETECTION OF SMALL COLORECTAL ADENOMAS BY ROUTINE CHROMOENDOSCOPY WITH INDIGOCARMINE Jun Haeng Lee, M.D., Jung Uk Kim, M.D., Yong Kyun Cho, M.D., Chung Il Sohn, M.D., Woo Kyu Jeon, M.D. and Byung Ik Kim, M.D.*. Deparment of Medicine, Kangbuk Samsung Hospital, Seoul, Korea. Purpose: Non–polypoid adenomas, which can be important precursors of colorectal cancers, are difficult to find during routine colonoscopy. The aim of this study was to evaluate the usefulness of routine chromoendoscopy in Korea, where the incidence of colorectal cancer is low compared to the western countries. Methods: Colonoscopy with chromoendoscopy was performed in 50 consecutive patients (32 men, 18 women; mean age 52.4 years). After a careful examination of the whole colon, a defined segment of the sigmoid colon and rectum (0 –30 cm from the anal verge) was stained with 20 ml of 0.4% indigocarmine solution using a spraying catheter. Non–polypoid lesions were classified as flat or depressed types. Biopsies were taken from all lesions detected before or after staining with indigocarmine. Results: Indications for colonoscopy included routine check– up (15 patients), bowel habit change (13 patients), abdominal pain (6 patients), bleeding (4 patients) and others (12 patients). Before staining, 33 lesions were found in 18 patients (36%). Histology showed tubular adenoma in 22 lesions, hyperplastic or inflammatory changes in 8 lesions, adenocarcinoma in 2 lesions, and villous adenoma in 1 lesion. After indigocarmine staining for normal–looking distal 30 cm colorectal mucosa, 131 lesions were found in 31 patients (62%). Histologically, 114 lesions (from 23 patients) were hyperplastic or inflammatory in nature, and 17 lesions (from 10 patients) were tubular adenomas. Adenomas seen only after spraying indigocarmine were 2.6 ⫹/– 0.7 mm in diameter and classified as flat adenomas except for one small (1.5 mm) depressed adenoma. No adenoma with high– grade dysplasia or cancer was found after staining. Presence of macroscopic lesions before staining could not predict the existence of adenoma after staining. Conclusions: In a large proportion of Korean patients, flat or depressed adenomas could be found after spraying indigocarime for normal–looking colorectal mucosa. The clinical significance of these small adenomas, which could be found only after chromoscopy, needs to be further investigated.
885 UNSEDATED ENDOSCOPY: A REALITY OR STILL A DREAM Anand Madan, M.D. and Anil Minocha, M.D., FACG*. Division of Gastroenterology, Southern Illinois University School of Medicine, Springfield, IL and Division of Digestive Diseases, University of Mississippi Medical Center, Jackson, MS.