COLON AND RECTUM

STOMACH AND DUODENUM/COLON AND RECTUM "278 EFFECT OF PRE·IMMERSION OF BIOPSY FORCEPS IN FORMA· LIN ON HELICOBACTER PYLORI UREASE ACTIVITY DETEC· TION A. R. Wettstein,' C. T. H. Loy" A. S. Field2 , D. J. Frommer" Departments of

"280 TOTAL PERORAL INTRAOPERATIVE ENTEROSCOPY FOR OBSCURE GI BLEEDING USING A DEDICATED PUSH ENTERO· SCOPE: DIAGNOSTIC YIELD AND PATIENT OUTCOME A. Zaman, B. Sheppard, R. M. Katon, Oregon Health Sciences University,

Gastroenterology' and Anatomical Pathology2, St. Vincent's Hospital, Darlinghurst, NSW 2010, Australia Background: It is routine practice to wash biopsy forceps that have been immersed in formalin solution before taking gastric biopsies to test for urease activity, as formalin is thought to inactivate the urease enzyme. Aim: To assess the effect of pre-immersion of biopsy forceps in formalin solution on the ability to detect Helicobacter pylori (HP) urease activity in clinical practice. MaterialslMethods: 200 consecutive patients undergoing gastroscopy between 8/7/96 and 5/6/97 who had macroscopic evidence of possible HP infection had initial antral biopsy using sterile forceps for determining urease activity. The same forceps were then used to obtain an antral biopsy for H & E histological examination. The forceps were then used without washing off any adherent formalin solution, to obtain a further antral biopsy for urease testing. The interpretation of the histopathology and urease activity were performed independently by blinded observers. Result: The concordance rate of urease tests with or without formalin exposure was 100% (95% C.I.: 98.2-100%). 56/200 (28%) were found to have urease positive biopsies. Of these, 52/56 (92.9%) had identifiable HP on histopathology. 144/200 (72%) were found to have urease negative biopsies. Of these, 7/144 (4.9%) had identifiable HP on histopathology. 6/7 (85.7%) had only small number of organisms identified. Sensitivity and specificity for the urease test compared with histopathology as the reference standard was 88.1% (95% C.I.: 79.9-96.4%) and 97.2% (94.4-99.9%). Conclusion: Immersion of biopsy forceps in formalin does not reduce the ability to detect urease activity in antral biopsies taken subsequently.

Portland, Oregon Background: Intraoperative enteroscopy (IE) is an effective diagnostic and therapeutic tool in selected patients with obscure GI bleeding. Enterotomy or the use of a colonoscope orally and then rectally has been necessary to completely inspect the small bowel. However, the development of dedicated enteroscopes allows the complete inspection of the small bowel using the peroral route. Aim: Assess the diagnostic yield, patient outcome, and success in reaching the terminal ileum using a video enteroscope, Olympus SIF-100 (working length: 2175mm). Methods: 11 patients underwent IE for obscure GI bleeding, 2 patients with a known source (AVM's), underwent evaluation to determine extent. Mean transfusion for each patient was 17 units. 8 patients presented with melena, 2 with hematochezia, and 3 with brown hemoccult positive stools. Each patient on average had 3 EGD's, 2 colonoscopies, 1 tagged RBC scan, 1 small bowel enema, and 1.5 push enteroscopies as prior work up. There were 10 females and 3 males with a mean age of 66 (range 54-76 yrs). Mean duration of bleeding was 4.5 years (range 0.5·12 yrs). Range of follow up 7 to 42 months. Results: Mean endoscopy time 71 minutes (range 45-150 min) and operative time of 168 minutes (range 90-270 min). Mean hospital stay 9 days (range 7-13 days).

"279 GASTROINTESTINAL ENDOSCOPY AS A SCREENING METHOD FOR CYTOMEGALOVIRUS INFECTION FOLLOWING ALLOGE· NEIC BONE MARROW TRANSPLANTATION 4 2

*281 ACCURACY OF PATHOLOGIC INTERPRETATION OF COLON POLYPS BY GENERAL PATHOLOGISTS.

T. Yaiiwa,l) Y. Iwa0 l, T. Hisamatsu'l, S. Okamato, Y. Ikeda l, H. Sugiura, M. Mukai ,T. Kanai, H. Ogata, M. Watanabe, T. Hibi'·5l, and H. Ishii'l, I)Department of Gastroenterology, 2)Hematology and 3)Pathology, 4)Center for Diagnostic and Therapeutic Endoscopy, Sch. of Medicine, Keio University. 5)Keio Caner Center. Tokyo, Japan Background and Aim: Cytomegalovirus (CMV) infection is a serious complication following solid organ and bone marrow transplantation (BMT). CMV affects multiple organs and results in considerable morbidity and prolonged hospitalization. But the clinical feature of upper GI lesions in CMV infection after BMT remains unclear. Detection of CMV antigen in peripheral blood leukocytes with immunohistochemical technique (antigenemia) is the most reliable screening method for CMV infection. The antigenemia is, however, not sensitive enough in some cases. The aim of this study is to investigate the clinical significance of upper GI lesions in CMV infection. Patients and Methods: We performed endoscopic examination of the upper GI tract in 47 patients 20 to 70 days after allogeneic BMT from December 1992 to November 1997. Biopsy specimens, taken each from esophagus, stomach body and antrum, and duodenum, were assayed for CMV antigen with immunohistochemical technique. Results: CMV infection was revealed in the upper GI tract in 9 patients. The endoscopic findings of the affected lesions were characteristic erosions surrounded by redness in the stomach and duodenum, map-like redness in the duodenum, and ulcer in the esophagus. Stomach was involved in all cases (9/9, 100%), but duodenum (4/9, 44%) and esophagus (2/9, 22%) were less frequently infected. In 3 patients, CMV antigen was detected in the upper GI tract before antigenemia turned positive. Conclusion: The endoscopic examination of upper GI tract is a useful screening method for CMV infection following allogeneic BMT.

AB94 GASTROINTESTINAL ENDOSCOPY

Terminal ileum reached 12113 (jejunal stricture in 1 patient)

Bleeding source identified 813 (lymphoma 1, carcinoid 1, AVM's 6)

Surgical theranv 813 (resected 5, oversewn 3)

No further bleedimt 813

Complications included serosal tears 3 (one requiring resection), post-operative CHF 2, azotemia 1, and prolonged ileus 1. Conclusions: The terminal ileum was reached 92% of the time with IE. Major operative morbidity was seen in one patient, and there was no mortality. The diagnostic yield oflE was 61% with 61% of patients having no further bleeding.

M. Alikhan, D. Rex, O. Cummings, T. Ulbright, Divisions ofGI and Path IUMC, Indpls, IN. Nearly all colorectal cancer (CA) in the West develops in adenomatous polyps (AD). Correct interpretation of polyp (P) histology is important as it often guides subsequent colonoscopy and/or surgery. AIM: To study the accuracy of path interpretation of colon P in clinical practice. METHODS: We identified 20 histologic slides representing different types of P, each chosen because it demonstrated typical features of a type ofP. We submitted these slides to blinded review by 20 randomly selected general pathologists(PA) all of whom were practicing general surgical pathology in community hospitals in central Indiana. There were 5 cases of malignant P, 9 AD including 3 with severe dysplasia (Sm and 6 miscellaneous P in the sample. RESULTS: CA was correctly identified in 91% of 100 readings. Of the 91 readings of CA tumor differentiation was described in 50 (55%). 40% of PA identified poor differentiation when present. Only 10 of 20 PA made comments in any of the cases regarding whether the resection margin was free of CA. In the 3 cases where surgery was clearly indicated, resection was recommended in only 15 of60 readings (25%). In 2 cases where surgery was clearly not indicated resection was recommended in 15 of 40 readings (38%). AD were correctly identified in 169 (94%) of 180 readings. Type of AD (tubular (T), tubulo-villous (TV), villous (V) was noted in 86% (145 of 169 readings). Of TV and V AD, T was incorrectly reported in 2% (2 of 111). SD was correctly identified in 28 (47%) of 60 readings although in 25/28 it was termed "adeno CA-in-situ" or "intramucosal adeno-CA." Invasive CA was incorrectly read in 22% (13 of 60) of AD with SD and in 19 of 60 SD was not called. AD without SD were said to have SD in 12% (14 of 120) and CA in 1%. Of miscellaneous P, hamartomas were read as such by 4 of the 20 PA. The polypoid phase of solitary rectal ulcer syndrome (SRUS) was identified by 2 of 20 PA. Hamartomas and SRUS were most often read incorrectly as AD. Hyperplastic P were correctly identified in 75% (30 of 40), juvenile/retention P in 80% (16 of 20). SUMMARY: 1) Sensitivity for identifying malignant P and AD were both >90%. 2) When a malignant P was identified tumor differentiation, proximity to the resection margin and need for surgical resection were often inadequately or inaccurately reported. 3) Specificity for cancer in neoplastic polyps was high. 4) T AD were often misdiagnosed as TV or V, but TV and V were rarely called T. 5) SD was often not recognized, called CA or designated by out-of-date terminology. 6) Hamartomas and the polypoid phase of SRUS were seldom recognized. CONCLUSION: This study suggests areas to focus continuing education efforts with regard to colon P interpretation. Pathologic interpretation of polyps by community pathologists may be a major source of error in clinical management. Supported by ACG Research Award.

VOLUME 47, NO.4, 1998

COLON AND RECTUM *282 UTILITY OF A SIDE·VIEWING UPPER ECHOENDOSCOPE FOR ENDOSCOPIC ULTRASONOGRAPHY OF MALIGNANT AND BE· NIGN CONDITIONS OF THE SIGMOID COLON AND THE RECTUM

284

*283

*285 A PROSPECTIVELY VALIDATED PREDICTIVE SCORING SYS· TEM FOR PATIENTS WITH ACUTE LOWER GASTROINTESTI· NAL BLEEDING

MS Bhutani, P Nadella. Program for Endoscopic Ultrasound. Veterans Affairs Medical Center and Wright State University, Dayton, Ohio. Purpose: Majority of data on colonic EUS is limited to malignant lesions in the rectum and diseases of the anal sphincter. The side viewing upper echoendoscope has mostly been applied for staging rectal cancer as further advancement into the colon is difficult due to side viewing optics. A front viewing echocolonoscope is available but has not been widely used due to limited indications and the expense of buying another instrument. The purpose ofthis study was to evaluate the utility of a side viewing upper echoendoscope (GFUM20, Olympus) for EUS of malignant and benign lesions of the sigmoid colon and the rectum. Methods: Thirty two EUS exams were performed for a variety of indications in the rectum and the sigmoid colon. The patients were prepared for the exam in a manner similar to the performance of flexible sigmoidoscopy (e.g. two laxative enemas 1-2 hours prior to the procedure). Flexible sigmoidoscopy was performed in all cases prior to performing EUS. Surgical path data was reviewed in all cases where the patient went to surgery and pathology results were accessible. Results: Twenty six exams were done for staging of recto-sigmoid carcinoma, follow-up after chemotherapy and/or radiation, or to look for recurrence after resection of colorectal cancer. Surgical pathology results were available in 20 patients. The accuracy of EUS for T-staging was 85% and for N-staging was 80%. Six EUS exams were for benign causes including evaluation for the presence of a peri-rectal abscess in 2 (no abscess found), to rule out rectal varices in 1 (EUS confirmed rectal varices), and evaluation of submucosal compression of rectosigmoid colon in 3 (2 had leiomyomas by EUS and 1 had a lipoma). One patient subsequent to EUS imaging also underwent a linear EUS guided FNA of a submucosal mass in the rectum with the aspirate consistent with a myogenic tumor which was confirmed by surgical resection. The distance of benign and malignant lesions ranged from 1 em to 40 em from the anal verge. Conclusions: The side viewing upper echoendoscope is a versatile instrument that can be applied for malignant & benign indications not only in the rectum but the sigmoid colon as well, up to 40cm from the anal verge.

OUTCOME OF COLORECTAL CANCER SCREENING BY DIGITAL RECTAL EXAMINATION IN ASYMPTOMATIC AVERAGE·RISK INDIVIDUALS E.J. Bini, M.T. Valdes, and E.H. Weinshel. Division of Gastroenterology, New York University Medical Center, Bellevue Hospital, and VA Medical Center, New York, NY Background: In clinical practice, asymptomatic individuals with a positive fecal occult blood test (FOBT) obtained by digital rectal examination (DRE) are often referred for a colonoscopic evaluation. Although widely practiced, this screening method has been discouraged because it is thought to increase the false positive rate of FOBT. Our purpose was to compare the predictive value of a positive FOBT obtained by DRE with that obtained from spontaneously passed stools (SPS). Methods: Asymptomatic average-risk patients over the age of 50 years with a positive FOBT obtained by DRE or SPS who were referred for colonoscopy from 1/92 to 1/97 were identified. FOBT was performed using Hemoccult test kits without rehydration. Patient charts, endoscopy records, and pathology reports were reviewed. The cost of endoscopy was estimated by adding the physician fee under Medicaid reimbursement, the facility fee, and the pathology fee. Results: 672 consecutive patients (371M; 301F) were evaluated by colonoscopy. =22

50-91

enama ~ 1 em enocarcinoma onneo Ratle eSlODS

arm co onosco ost r neo 8sm

ost

r a enoma ~ 1 em ost per a enocatClDoma

N=390

50-88

47 44 125 142 1964. 0 7315.74 7,814.54

12.1% 11.3% 32.1% 36.4%

Conclusions: The predictive value of a positive FOBT performed on stool obtained by DRE is no different from that obtained by SPS in asymptomatic average-risk individuals. Furthermore, FOBT of stool obtained by DRE does not increase the rate of false positive tests or the cost per cancer detected by colonoscopy. In this patient population, all individuals with a positive FOBT obtained by either DRE or SPS should be evaluated by full colonoscopy.

VOLUME 47, NO.4, 1998

BENEFIT OF AGGRESSIVE COLONOSCOPIC DECOMPRESSION IN THE MANAGEMENT OF COLONIC PSEUDO·OBSTRUCTION

JF Buell, JA Calure, ES Cho, MJ Mastrangelo, GM Massoglia, S Graham, BJ Dunkin, A Imbembo, JL Flowers. Section of Surgical Endoscopic and Laparoscopy, Department of General Surgery, University of Maryland School of Medicine, Baltimore, Maryland. Acute colonic pseudo-obstruction (ACP) can be managed by conservative medical therapy (MT) or by colonoscopic decompression (CD). This study compares the clinical outcome and cost of these therapeutic modalities. Methods: We retrospectively reviewed 100 consecutive colonoscopic decompressions in 74 patients with ACP compared to a cohort group of 15 patients managed without colonoscopy. Both groups were similar with respect to age and underlying medical condition. Return to diet, time to discharge, complications, and treatment costs were reviewed. All data were analyzed utilizing unpaired t-tests. Results: Colonoscopic decompression in the CD group required 1 to 4 attempts (mean 1.3). One MT patient required colonoscopy. Maximal colon diameter was measured on plain x-rays and averaged 12.2 em. in the CD group compared to 12.4 em. in the MT group. Advancement to clear liquids and then regular diet averaged 4 and 5 days respectively for the CD group, compared to 8 and 11 days respectively for the MT group (p < 0.025, < 0.031). The CD group averaged 9 days to discharge following decompression while the MT group averaged 16 days (p
Floyd C. Byfield, P.D. Stevens, Jonathan Finegold, Beverly Diamond, Robert Gal, R.J. Garcia-Carrasquillo, Charles J. Lightdale. Columbia University College of Physicians and Surgeons, New York, N.Y. Introduction: The majority of patients with acute lower gastrointestinal bleeding (LGIB) will have a self-limited hemorrhage, but a significant minority will suffer from persistent or recurrent bleeding. Although there are many predictive models for stratifying risk in patients with upper gastrointestinal bleeding, there is little data on what factors predict rebleeding in patients with LGIB. We have developed a clinical scoring system to identify patients with acute LGIB who are at low risk for negative outcomes. Methods: We prospectively evaluated consecutive patients admitted with bright red blood per rectum (BRBPR). Specific clinical variables available in the first 24 hrs. were used to stratify the patients' risk for negative outcomes (increased re-bleeding, morbidity, mortality, surgery, length of stay, and/or hospital cost). The clinical variables used in the scoring system were: 0) age> 65, 1 point; (2) 20: 3 co-morbid diseases, 1 point; (3) orthostasis, 3 points; (4) requirement of > 2 units PRBC in the initial 24 hours, 3 points; and (5) prothrombin 20: 3 sec. over control, 1 point. Patients with> 3 points were stratified as high risk. The occurrence of negative outcomes were compared between the low and high risk groups. Results: We evaluated 47 patients (21 male, 26 female), mean age 68 (range = 32-100), between 7/97 and 11/97. The diagnoses at colonoscopy were diverticulosis (34%), hemorrhoids 04.9%), ischemic colitis (12.8%), cancer (6.4%), post-polypectomy (4.2%), combined (19%) or no clear diagnosis (8.5%). There were 17 patients scored as high risk and 30 as low risk. Rebleeding occurred in 5 patients in the high risk group and none in the low risk group (p=0.004) at a mean of 48 hours. The length of stay related to LGIB was 6 days for the high risk population and 3 days for the low risk population (p=o.oon Rebleeding and increased length of stay was predicted by a high risk score> 3, but not by anyone of the individual clinical variables evaluated. There were no deaths and no patients went to surgery in our population. The mean time to colonoscopy was 1.6 days and equal for both groups. Conclusions: Our score identifies patients with acute LGIB at low risk for rebleeding that could be safely discharged after 24 hrs. and undergo outpatient colonoscopy. Utilizing our score, we plan to carry out a prospective trial randomizing patients with acute LGIB to inpatient versus outpatient colon05copy.

GASTROINTESTINAL ENDOSCOPY AB95

COLON AND RECTUM *286 PATTERNS OF ENDOSCOPIC FOLLOW UP AFTER SURGERY FOR NONMETASTATIC COLORECTAL CANCER

§289 TECIDUAL P53 AND PCNA IN NEOPLASTIC AND NON· NEOPLASTIC COLORECTAL LESIONS

GS Cooper, Z Yuan, A Chak, AA Rimm, Depts. Medicine and Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, OH Because of the risk of subsequent neoplasms and local recurrence, routine endoscopic surveillance is often recommended following potentially curative therapy of colorectal cancer. However, utilization and yield of follow up testing has not been evaluated in everyday practice. Therefore, we evaluated a cohort of 6,241 patients (4965 colon, 1546 rectum) 2: 65 years with local or regional colorectal cancer who underwent resection in 1991. Patients were identified through the population-based Surveillance Epidemiology and End Results (SEER) registry. All outpatient and inpatient Medicare claims from 6 months after diagnosis through 1994 were analyzed to measure procedure use. Overall, 48% of patients underwent colonoscopy (COL), with 1, 2, 3, 4 and 2: 5 procedures performed in 9.7%, 16.9%, 5.1%, 9.3%, and 7.0% of patients, respectively. However, even with increasing numbers of procedures, the rate of polypectomy (PP) remained relatively high, ranging from 24% to 31%. Sigmoidoscopy (SIG) was performed in 16.7% of patients, with 1, 2, 3 and 2: 4 procedures in 8.8%, 4.2%, 1.7% and 2.0%, respectively. Among colon cancer patients, second primary cancers developed in 61 (1.2%) (median interval of 19 months from initial diagnosis), and 12 patients with rectal cancer (0.8%) developed second primaries (median interval of 18 months from initial diagnosis). COL, PP and SIG use during different follow up intervals is shown:

Correa P, Leite K, Borges JL, Averbach M, Cutait R. Hospital Sirio Libanes, Sao Paulo Purpose: To compare the tecidual expression of the nuclear proteins, PCNA and P53 in benign neoplastic and non-neoplastic colorectal proliferative lesions. Patients and Methods: 82 patients were submitted to 129 colonoscopic polipectomies (126 polypoids and 3 flat lesions). One lesion was found in 58.5% of them, and in 41.5% two or more were found. Rectum and sigmoid were the preferencial site of the polyps (54%). The size of the lesions ranged from 0.2 to 4.5cm (mean 0.6). Neoplastic polyps were 85.4% of them (tubular, villous and mixed adenomas) and 14.6% were hiperplastic or inflammatory. Tissue sections were incubated with PCNA (PCIO), 1:200 dilution and p53 (DO-7) 1:50 dilution were used after microwave antigen retrieval. Streptavidin-biotin-peroxidase Duet-Kit (Dako) was used as secundary antibody and amplification. At least 500 cells were counted in light microscope and the percentage of nuclear, strong staining was considered. Results: The mean number of cells expressing p53 in non-neoplastics lesions was 18.5% and with positive PCNA staining was 23%. In the neoplastic lesions 41.6% of the cells expressed p53 and 33.6% PCNA (p
Mos. 6-12 13-18 19-24 25-30 31-36 37-42

Colon Cancer

Rectal Cancer

# at RIsk C L% PY % I1SIli % # at RiSk lJuL % IYY % 11S1li %

4283 4066 3832 3605 3388 3199

22.9 23.9 16.0 16.1 12.4 11.3

7.2 8.2 4.8 5.3 4.3 3.7

6.6 4.8 3.8 3.5 3.6 2.3

1433 1368 1268 1187 1115 1052

17.3

21.~ 12.~

14. 11.8 8.8

5.0 6.9 3.3 4.1 3.4 2.8

16.5 10.3 7.8 7.8 6.6 3.8

We conclude that in routine practice, although many patients with potentially curative cancer surgery do not receive endoscopic surveillance, a distinct minority undergo intensive follow up. Although subgroups of patients at highest risk may be selected for more aggressive follow up, the yield of serial procedures remains relatively high. Further studies are needed to determine the potential impact of surveillance on patient outcomes.

287 ENDOSCOPIC TREATMENT OF LOWER INTESTINAL BLEEDING (VIDEO)

290 SEVERE HEMATOCHEZIA ASSOCIATED WITH COLONOSCOPIC DIVERTICULITIS

Correa P, Averbach M, Cutait R. Hospital Sirio Libanes - Sao Paulo - Brasil Massive lower intestinal bleeding is a very stressing situation to deal with: for the patient, for his family and for his doctor. Although in 80 to 90% of the cases the bleeding stops spontaneously, in the remaining 10 to 20% of them the patient might be submitted to an aggressive surgery, with high percentages of complications and death. Colonoscopy closer to the beginning of the hemorrhage can help to make a more certain diagnosis and also to stop it using some kind of therapeutic endoscopic maneuver. In the past 10 years, we have been performing colonoscopy within the 6 first hours from the beginning of the bleeding, right after a good proctological examination and an upper gastrointestinal endoscopy are made. The bowel preparation is usually anterograde using Mannitol 10% 750 to 1,000 ml orally. When not possible, retrograde bowel enteroclisms with 1 to 2 liters of saline are sufficient to remove the blood cloths, leaving only fluids that can be aspirated during the exam. Out of 6,000 colonoscopies executed during this period, there were 97 cases of massive bleeding. In 67% of them we were able to find the exactly site of the bleeding, and in 20 patients a successful endoscopic therapeutic procedure was achieved. In this movie we will be showing four of this situations.

AS Farivar, M Farivar, RS Farivar, Caritas Norwood Hospital, Norwood, MA Diverticular bleeding is a common cause of massive, painless hematochezia. The clinical dictum states that diverticulitis is not associated with acute, lifethreatening, lower GI bleeding. However, in our practice we have noted an association between diverticulitis and massive lower GI bleeding; therefore we retrospectively reviewed the medical records of 7 consecutive, private patients admitted to the hospital over a 10 month period with an admitting diagnosis of severe hematochezia and a discharge diagnosis of diverticulitis. Results:

Patient

Age, Sex

1

87 M 72.M R2. F 56 M 79 F ~4 F 83, F

~

3 4 5 6 7

Hct drop (low) 5 37% 14 25 3 31 9 30 11 4 9 24 -- (20)

Clinical presentation sultltestive of diverticulitis none none none none ower abd nain tender LLlcJ oain eukocV1 sis

LL\,1 pain, tenderness

Patient 1, 2, 3, and 4 on colonoscopy had a single ruptured and inflamed diverticulum. Patient 5 demonstrated mucosal edema, erythema, petechiae, and a mucopurulent discharge from a perforated diverticulum. Patient 6 had evidence of an intramural abscess secondary to diverticulitis. Patient 7 had a frozen sigmoid on a "second-look" colonoscopy due to diverticulitis and stricture formation. Patients 5, 6, and 7 required packed red blood cell transfusions (1, 2 and 4 units, respectively) for stabilization. Conclusion: A subgroup of patients with acute, life-threatening, lower GI bleeding were found on colonoscopy to have diverticulitis. We suggest that patients who present with severe diverticular bleeding that is associated with LLQ pain and tenderness, fever, leukocytosis or recurrent bleeding over several days should have a colonoscopy performed after the bleeding has stopped, and if diverticulitis is present, antibiotics should be prescribed. If the bleeding is secondary to diverticulitis this may reduce the rebleeding rate, the transfusion requirements, the need for surgery, and ultimately may shorten hospitalization.

§Abstract 288 withdrawn. AB96

GASTROINTESTINAL ENDOSCOPY

VOLUME 47, NO.4, 1998

COLON AND RECTUM *291 THE ROLE OF COLONOSCOPY IN THE DIAGNOSIS OF ACUTE DIVERTICULITIS

293 HYPERPLASTIC POLIPOSIS OF THE COLORECTUM AND ADENOCARCINOMA

AS Farivar, M Farivar, RS Farivar, Caritas Norwood Hospital, Norwood, MA and Boston University School of Medicine, Boston, MA The diagnosis of acute diverticulitis is usually made following a clinical presentation of lower abdominal pain, tenderness, and constipation. A CT scan is the diagnostic procedure of choice in severe cases when an abscess or colovesical fistula is suspected. However, in patients with less severe inflammation, CT shows segmental wall thickening andlor pericolic fat induration in up to 63% of patients. Colonoscopy allows direct visualization of the mucosal and luminal abnormalities induced by diverticular perforation and the secondary inflammatory response it produces in the submucosa. In this study we retrospectively reviewed 14 patients with a clinical and colonoscopic diagnosis of diverticulitis. Signs, symptoms, and diagnostic studies are reviewed and a comparison is made between a CT scan and colonoscopy as diagnostic tools. Colonoscopy was performed after informed consent, under conscious sedation using an Olympus video endoscope. Abnormal findings were documented by instant video photography. Results: Of the 14 patients with recent onset of lower abdominal pain and constipation, 11 had lower abdominal tenderness and less than half had leukocytosis. A CT scan was done in 13 patients and 8 of these were reported as normal, 3 showed mildly thickened wall in a short segment of the colon, and 2 had mild induration of pericolic fat. Colonoscopy revealed diverticulitis causing an intramural abscess with secondary luminal changes in 3 patients, inflamed or perforated diverticula draining a mucopurulent exudate in 6 patients, and segmental, asymmetric mucosal edema, petechiae, inflammation, granulation tissue, spasm or stricture in 10 patients. Additionally, 3 patients had incidental findings of neoplastic polyps that were removed during colonoscopy, and 1 patient had cecal angiodysplasia. Conclusion: In patients with a clinical suspicion of mild diverticulitis, colonoscopy is the diagnostic procedure of choice. In addition to providing direct evidence of diverticulitis, it rules out other etiological factors capable of producing similar clinical or CT abnormalities, and can be therapeutic if incidental pathology is found.

C. Gonzalez del Solar, R Peters, D Rosen, M Cuervo Arango, C Elizondo, M Martinez, Department of Gastroenterology and Pathology, Sanatorio Mater Dei, Buenos Aires, Argentina Hyperplastic polyps are considered the most common non-neoplastic lesions of the colon and devoid of any malignant capacity. Nevertheless, there have been reports that hyperplastic polyps can present with adenomatous areas, and in isolated cases with carcinoma. It has been suggested that large multiple hyperplastic polyposis could represent a distinct clinical entity from diminutive hyperplastic polyps. We present a 62 year old female with longstanding hyperplastic polyposis which developed an adenocarcinoma of the colon during follow up. The patient was originally investigated in 1991 due to abdominal pain. A double contrast barium enema revealed multiple polyps less than 1.4 em in size throughout the colon which were confirmed on colonoscopy. Histologic examination showed all the polyps removed to be hyperplastic without adenomatous or dysplastic tissue. Follow up colonoscopies were performed in 1993 and 1995. Once again all the polyps removed (n:17) were hyperplastic except for a small tubular adenoma in 1995. A repeat colonoscopy in 1997 showed multiple polyps throughout the colon. Hystologic examination revealed hyperplastic polyps except for samples from a sessile polyp less than 0.7 em in size with a central depression in the ascending colon which were informed as an infiltrating adenocarcinoma. The patient underwent a right sided colectomy and the resected specimen demonstrated a moderately-differentiated adenocarcinoma 0.7 x 0.7 x 0.5 em (Dukes B) with no lymph node metastasis. The long term follow up of this patient with hyperplastic polyposis of the colon revealed the development of an adenomatous polyp and eventually adenocarcinoma in a 6 year period. We suggest that all patients with hyperplastic polyposis should undergo removal of polyps and placed under periodic surveillance colonoscopy.

*292 METALLIC STENTS IN THE PALLIATIVE TREATMENT OF RECTAL CANCER AT RECTOSIGMOID JUNCTION (RSJ)

*294 ARE FIREFIGHTERS AT AN INCREASED RISK OF DEVELOPING COLORECTAL NEOPLASIA-A PROSPECTIVE STUDY

Diego Fregonese, F. Monica, and G. Di Falco. 3rd Department of General Surgery, General Regional Hospital of Treviso, 31100 Treviso, Italy Radio andlor chemotherapy treatments are useful in the palliative treatment of not operable rectal cancer. Unfortunately wide cancers do not well respond to these treatment modalities, and obstruction can occur. Laser therapy can be difficult at the RSJ, due to the curvature of the lumen, and the risk of perforation is high. Finally lasering could be ineffective and a colostomy is required. In 49 of patients (19 males and 30 females with a mean age of71.9 years/patient) with obstructive symptoms due to not treatable RSJ cancer we were able to insert a metallic stent to avoid intestinal obstruction. We used 25 times an Unistep®, 2 times a Telestep®, 20 times an UltrafleX®, 1 time a Covered UltrafleX® and in 1 case a Rectocoil®. All the attempts were successful and the stent has been correctly inserted. No complication related to manoeuvres was noted. We did not suffer any death. In 44 (89%) patients the relief of obstruction was effective. In the remaining patients a colostomy was necessary few days later. During the follow up period (a mean of 18.1 months/patients) we suffered stent clogging by cancer ingrowth in 8 cases (treated by laser), 4 stent migrations (followed by laser in 3 cases and by colostomy in an other patient). One patient required a colostomy for stool incontinence. These migrations have occurred using covered stents (2 Telestep and 1 Covered Ultraflex) and the Rectocoil within one month from insertion. 4 patients have had severe anal pain due to the stent contact with the internal anal sphincter. The overall complication rate in the follow up has been of 38.6%. In conclusion metallic stents appear to be safe and useful devices in very selected patients with intestinal obstruction due to rectal cancer at the RSJ. Moreover the complication rate during the long survival time is still too much high. At present covered stents seems to be ineffective. New models are required, increasing the diameter and shortening the length of the stents.

Andrew Grade MD, Richard Gerkin MD, Paula Stufflebeam PA-C, Richard Manch MD. Good Samaritan Regional Medical Center and The Phoenix Fire Department, Phoenix, Arizona Background: It has been reported that firefighters are at an increased risk of developing several cancers, including colorectal neoplasia, as compared to the general population. This has not been evaluated prospectively. Methods: All Phoenix firefighters are offered screening flexible sigmoidoscopy beginning at age 45 and every five years thereafter. If an adenomatous polyp is detected, then colonoscopy is performed. The study period was January 1988 through December 1995. Results: Flexible sigmoidoscopy has been performed on 195 firefighters during the study period. All firefighters were male with a mean age of 54.6 years (range 45-75).34 of 195 (17.4%) firefighters had a polyp detected. Within this group, 16 of 195 (8.2%) had a hyperplastic polyp (mean age 52 yrs, range 45-75); 2 of 195 (1%) had an inflammatory polyp; and 16 of 195 (8.2%) had an adenomatous polyp (mean age 58.4 yrs, range 49-73). All firefighters with an adenomatous polyp had colonoscopy. One of these individuals had an adenomatous polyp> 1 em, but the rest all had polyps < 1 em. No firefighters had more than three polyps detected at colonoscopy. No firefighters had a carcinoma detected. Conclusion: The risk of colorectal neoplasia is not greater in this group of firefighters than in comparison to the general population.

VOLUME 47, NO.4, 1998

GASTROINTESTINAL ENDOSCOPY AB97

COLON AND RECTUM *295 IMPROVED OUTCOME OF SYMPTOMATIC CROHN'S STRICTURES WITH BALLOON DILATION AND INTRALESIONAL STE· ROID INJECTION DA Howell, BL Hanson, PM Ku. GI Division, Maine Medical Center, Portland, ME. Background: Several authors have reported short term benefit of balloon dilation of symptomatic Crohn's strictures and one report has suggested that intralesional steroids may be of benefit in reducing recurrence. This report suggests combined therapy may be safely employed and may postpone the need for surgical intervention. Methods: Patients that had symptomatic refractory strictures ofthe small bowel and/or the colon without complete bowel obstruction were identified and their records reviewed. Patients were considered refractory when surgical therapy and medical therapy did not produce adequate remission. After careful discussion and informed consent, patients underwent upper endoscopy, enteroscopy (using the PCF-140L colonoscope [Olympus, New Hyde Park, NY]) or colonoscopy. The strictures were dilated with 45 or 48 Fr. hydrostatic balloons followed by triamcinolone (40 mg/mll or methylprednisolone (40 mg/mll intralesional injections 0.25 ml in 6-8 sites per stricture. Results: 4 patients age 36-61 were selected with recurrent Crohn's disease post resection with refractory symptomatic strictures despite azathioprine 100-150 mg and oral corticosteroid therapy. Patient characteristics included: 3-11 small bowel strictures in 3 patients, a near obstructing ascending colon stricture above a previous surgical anastomosis in one patient, and a previous failed endoscopic dilation in one patient. Two patients had an enteroscopy and all reachable strictures were treated. One patient was treated with an upper endoscope and one with a colonoscope. One patient with 3 duodenal strictures was treated using methylprednisolone and three patients were treated with triamcinolone. One patient has required repeat dilations and injections approximately once a year since initiating therapy 4/91. No patients have required surgical management. All patients have been continued on azothiaprine 100-150 mg daily and prednisone 5-10 mg as maintenance. Follow-up has been from 6 months to 80 months (mean = 40 months). There were no complications. Symptoms in all patients improved. Conclusions: Balloon dilation followed by intralesional steroid injection can effectively manage difficult symptomatic Crohn's stricture patients and postpone the need for extensive surgery. The addition of steroids to balloon dilation appears to be safe. Delaying recurrence of strictures by steroid injection therapy can only be presumed from this series and would require a randomized controlled study to prove effectiveness.

*296 A STUDY OF INVASIVE CANCER OF ELEVATED LESIONS IN COLORECTAL NEOPLASM Y. Imai, T. Komatsu, S. Kudo, N. Kusaka, H. Yamano, M. Osato. Division of Gastroenterology, Akita Red Cross Hospital, Akita, Japan We made a comparison between the histopathological finding and the endoscopic finding with pit pattern analysis on diagnosis of malignancy in elevated lesions of colorectal neoplasm. [Materials and Methods] From April 1985 to August 1997, 12,445 adenomas and early carcinomas of the colon were treated endoscopically and/or surgically. These lesions were classified into protruded (6978 cases), superficial elevated (4753 cases) and laterally spreading tumor (LST) (405 cases) and depressed type (309 cases). We examined on the first three types of lesions and also made pit pattern analysis on 7683 cases which possibly estimated. [Results] The rate of submucosal invasion and cancer in protruded tumor and LST increased when their size became larger. The rate of cancer in superficial elevated tumor also increased when their size became larger, however, the rate of submucosal invading was very low in each size. Especially, the cancer rate of the protruded tumor and the superficial elevated tumor were 1.7% and 1.0% for those less than 5mm, and submucosal invading rate for those less than 5mm was 0%. In protruded type, submucosal invading cancer with depressed area showed higher massive invading rate and vessel invading rate at smaller size than which without depressed area. Protruded type submucosal invading cancers with depressed area which remained intramucosal lesion were all non-polypoid growth. In the protruded tumor for those less than 5mm, 92.1% oflesions showed tubular pit pattern were adenoma with mild to moderate atypia, and its cancer rate was 0.9%. In the protruded and superficial elevated tumor, 20.4% oflesions which showed branch-like pit pattern were cancer, 71.5% of lesions which showed amorphus pit pattern were cancer. Especially, all lesions which showed nonstructural pit pattern were cancer, and 72.2% of lesions which showed nonstructural pit pattern were massive invading cancer. [Conclusion] The recognition of depressed area and pit pattern analyze are very important on diagnosis and therapy of elevated lesions in colorectal neoplasm.

AB98 GASTROINTESTINAL ENDOSCOPY

*297 THE CLINICOPATHOLOGICAL ADENOMA

STUDY

OF

SERRATED

M. Iwabuchi, N. Hiwatashi, T. Masuda, T. Shimada, K. Yamashita, Y. Kumagai, T. Morimoto, Y. Kinouchi, M. Noguchi, H. Watanabe, S. Takahashi, F. Nagashima, M. Chida, Y. Katsurashima, T. Oriuchi, S. Takagi, K. Negoro, T. Toyota. Third Department of Internal Medicine, Tohoku University School of Medicine, Sendai, Japan [Background & Aims] Colorectal polyps have been devided into two histological subtypes: hyperplastic polyps and adenomas. Recently mixed epithelial polyps that combine the morphological features of a hyperplastic polyp with the cytologic features of an adenoma have been reported and termed serrated adenoma. We have detected and designated those polyps as H-type adenomatous polyps since 70s. The aims of this study is to clarify the clinicopathological features and malignant potential of serrated adenomas. [Methods] Between 1974 and 1996, colonoscopic polypectomies for 8858 lesions were performed at our hospital. Of 7800 neoplastic lesions, 148 (1.9%) serrated adenomas have been detected. We devided 23 years (1974-1996) into following three periods according to the number of polypectomy per year: '74 to '83 (-100), '84 to '90 (100-500), '91 to '96 (500-). We examined the rate of serrated adenoma and differences of clinicopathologic factors of each period. [Results] Average age was 58.8 years old and male to female ratio was 2.05. Pathological characteristics were as follows: distribution (rectum 29.7%, sigmoid colon 43.8%, descending colon 6.8%, transverse colon 9.5%, ascending colon 8.8%, cecum 1.4%), the average size (8.9mm), endoscopic configurations (pedunculated 43.2%, semipedunculated 43.2%, sessile 10.2%, flat 3.4%), endoscopic findings (villous-like 25%, adenoma-like 75%), incidence of severe dysplasia (2.7%). All lesions except severe dysplasia showed no staining of p53 immunohistochemically. According to the periods; average age ('74 to '83 56.7, '84 to '90 54.7, '91 to '96 62.2), male to female ratio (1.8, 2.5, 1.9), the rate of serrated adenoma (4.7% [16/341], 2.7% [53/1998], 1.4% [79/5461]), the average size (lO.lmm, 7.6mm, 9.4mm). [Conclusions] We have already been able to detect serrated adenomas in the early 70s. Incidence of severe dysplasia and p53 positive rate were relatively low. Therefore the malignant potential of them may not be higher than reported before. Supported by grants from the Ministry of Public Welfare, Japan.

*298 SMALL DEPRESSED LESIONS OF THE COLORECTUM H. Kashida, N. Kimoto, T. Watanabe, T. Fukunaga, M. Hirasa, K. Ibuki, S. Tomita, A. Orino, A. Todo. Division of Gastroenterology, Kobe City General Hospital, Kobe, Japan It has been shown during the last decade that certain types of colorectal neoplasms; small depressed lesions with or without a slight marginal elevation, tend to progress more rapidly compared with ordinary polypoid adenomas. Depressed colorectallesions are believed, at least in Japan, to play an important role in colorectal carcinogenesis. Ten years ago they were considered extremely rare, but nowadays more and more similar cases are found not only in the Orient but also in Europe. [Objective] To clarify the characteristics of depressed colorectal lesions and to find the keys to detect them. [Materials] During the period from April 1996 to September 1997, 1712 cases of total colonoscopy were performed by 9 examiners in our institute. The examinees presented with symptoms and/or signs such as bloody stool, fecal occult blood, or polyps detected by barium enema study. Some of them underwent the colonoscopy as a regular follow-up after polypectomy or colectomy. [Results] Out of all the cases, 1116 cases were shown to have polyps or cancers amounting to 2048 lesions, which were divided into five groups; submucosal tumors such as leiomyoma (the number was 16), obvious advanced cancers (81), so-called laterally spreading tumors or large flat adenomas (49), protruded polyps or small flat adenomas (1887), and small depressed lesions (15). The frequency of the depressed lesions were higher than the general belief. The respective rates of severe dysplasia (which is considered as carcinoma in situ in Japan) in protruded polyps, laterally spreading tumors and depressed lesions were 2.6%, 20.4%, and 33.3%. The rates of invasive cancer were 0.16%,12.2%, and 46.7%, respectively. The sizes of the depressed lesions ranged from 3mm to 20mm, the number of depressed carcinomas less than lOmm in diameter being six. Thirteen of the depressed lesions were associated by large polyps (including three colon cancers) which were considered causing the symptoms and signs leading to the colonoscopic examination. Each colonoscopist's detection rate of depressed lesions was not necessarily in proportion to the number of examinations performed. Twelve cases were detected by one colonoscopist who were trained in a leading center of colonoscopy in Japan and who used a zoom colonoscope and dye spraying. [Conclusion] Depressed lesions of colorectum are more malignant than protruded polyps. They usually do not present any specific symptoms or signs but tend to be associated with large polyps or cancers. They can be detected only by the eyes of the examiners who are familiar with such lesions.

VOLUME 47, NO.4, 1998

COLON AND RECTUM *299

*301

CHARACTERISTICS OF DEPRESSED EARLY COLORECTAL CARCINOMA

COLONOSCOPY TO EVALUATE ABDOMINAL PAIN IN CLINICAL PRACTICE: HOW OFTEN IS SIGNIFICANT NEOPLASIA FOUND?

S. KUDO, H. YAMANO, Y. IMAI, H. KUSAKA, Division of Gastroenterology, Akita Red Cross Hospital, Akita, JAPAN Depressed type ealy colorectal carcinomas are important because they tend to be deeply invasive even when they are still small. Depressed cancers are increasingly found not only in Japan but also in Western countries. [Materials and Methods] From January 1985 to August 1997, 12,445 adenomas and early carcinomas of the colon were treated endoscopically or surgically. These lesions were classified into protruded (6978 cases), flat (4753), and depressed (309) types. The colonoscopes used for detecting and treating lesions were CF 200Z (Olympus, Tokyo) with zooming function. [Results] The rates of submucosal invasion (invasive early carcinoma) in protruded lesions were 0% for those less than 5mm, 1.2% for those 6-10mm, 8.9% for those 11-15mm, 17.5% for those 16-20mm and 31.5% for those more than 20mm in diameter. The respective rates in flat lesions were 0.02%, 0.2%, 0.8%, 7.9%, and 22.5%. On the other hand, invasive rates in depressed lesions were 7.9% in those not exceeding 5mm, 37.8% in those 6-10r0m, 77.8% in those 11-15mm, 84.6% in those 16-20mm, and 90% in those larger than 20mm. Histopathologically, the protruded and flat lesions were composed mainly of branched glands or crypts with budding, whereas the depressed lesions consisted of rather straight glands which showed endophytic growth and penetrated vertically into the deeper layers. Zoom colonoscopes with the aid of the spraying of dye (such as 0.4% indigocarmine) were able to demonstrate the differences of the surface structure between the protruded or flat lesions and the depressed ones; large tubular pit pattern in the former two and small tubular or round pits in the latter. When the lesions were invasive, the surface structure was irregular; in case the cancer infiltrated massively into the submucosal layer, the surface structure was destroyed and looked nonstructural. The dye-spraying also helped to clarify the depression. [Conclusion] Depressed colorectal lesions are different from flat or protruded adenomas in biological behavior, histological construction, and surface structure. Zoom colonoscopes are useful in detecting and diagnosing depressed early carcinomas of the colon.

D. A. Lieberman, D.E. Fleischer, G.M. Eisen, P. DeGarmo, M. Helfand. Depts of Medicine, Oregon Health Sciences University, Portland OR, Georgetown University, Wash. DC, Memphis VA Medical Center, Memphis, TN Colonoscopy is often performed to evaluate patients with abdominal pain, bloating, constipation or diarrhea to rule out significant neoplasia. The purpose of this study was to utilize a national physician network to determine 1) how often colonoscopy is performed to evaluate vague abdominal symptoms (abd-sx); 2) the rate of significant colon neoplasia in such patients and 3) to compare the rates of significant neoplasia to rates in patients undergoing colonoscopy because of a positive fecal occult blood test (FOBT). Methods: A computerized endoscopic report generator was used at 18 sites by 99 physicians from April, 1997 until November 1997. Endoscopy data was sent electronically to a central databank for analysis. A cohort with only vague abd-sx and no other reason for colonoscopy was compared to a cohort undergoing colonoscopy to evaluate a positive FOBT. Significant neoplasia was defined as colonic polyps or masses 2: lcm. Results: 5073 colonoscopy reports were received during the study period. 388 patients (43% male) had colonoscopy to evaluate vague abd-sx (8%). 659 patients (52% male) had colonoscopy to evaluate (+) FOBT, accounting for 13% of procedures. Rates of significant neoplasia are shown in the table:

IIndication for Colonosconv Varne Abd·sx 1 (+)FOBT

n

IMean age (±SD)

388 659 1

59 +17 65 (:'::13)'

I

Polyp >9mm Suspected TOTAL Tumor 37 12 49 12.6% 107 36 143 22%

I

*p < 0.001 Patients with vague abd-sx had a significantly lower rate of serious neoplasia compared to patients with a (+) FOBT in clinical practice settings. Patients with vague abd-sx were younger, which may contribute to the lower rate of neoplasia. Conclusion: 8% of colonoscopy procedures were performed to evaluate vague abd-sx. The yield of serious neoplasia is similar to results in asymptomatic subjects. Further study is needed to determine which patients with vague abd-sx are most likely to benefit from a complete colon evaluation. This study highlights how a national endoscopic database can be used to evaluate endoscopic outcomes.

*300

*302

GROWTH PATIERNS OF EARLY COLORECTAL CARCINOMAS

MISS RATE FOR POLYPS DURING SCREENING FLEXIBLE SIGMOIDOSCOPY AND CHARACTERISTICS OF MISSED POLYPS

S. KUDO, H. YAMANO, Y. IMAI, H. KUSAKA, Division of Gastroenterology, Akita Red Cross Hospital It has been believed that colorectal cancers evolve from polyps. Recently, however, flat adenomas and depressed carcinomas are also increasingly found not only in Japan but also in Western countries. Depressed cancers are important because they seem to invade the deeper layers rapidly. [Materials and Methods] From January 1985 to August 1997, 12,445 adenomas and early carcinomas of the colon were treated endoscopically or surgically. These lesions were classified into protruded (6978 cases), small flat (4753), large flat or laterally spreading (405) and depressed (309) types. The colonoscopes used for detecting and treating lesions were CF 200Z (Olympus, Tokyo) with zooming function. [Results and Discussion] The rates of submucosal invasion (invasive early carcinoma) in protruded lesions were 0% for those less than 5mm, 1.2% for those 6-lOmm, 8.9% for those 11-15mm, 17.5% for those 16-20mm, and 31.5% for those more than 20mm in diameter. On the other hand, the respective rates in depressed lesions were 7.9%, 37.8%, 77.8%, 84.6%, and 90%. The rates of invasive cancer in flat lesions were 0.02% for those not exceeding 5mm and 0.2% for those 6-lOmm (small flat adenomas); 0.8% for those 11-15mm, 7.9% for those 16-20r0m, and 22.5% for those larger than 20mm (large flat adenomas or laterally spreading tumors). Histopathologically, the protruded lesions were composed mainly of branched glands or crypts with budding which showed exophytic growth, whereas the depressed lesions consisted of rather straight glands which showed endophytic growth and penetrated vertically into the deeper layers. Laterally spreading tumors were characterized by the neoplastic glands with budding which extended in the upper third or half of the mucosal layer. In small flat adenomas the adenomas glands occupied only the surface part of the mucosa in about half the cases and occupied the whole depth of the mucosa in the other half cases. In other words, half of the small flat adenomas are similar to protruded polyps and half of them look like large flat polyps. Therefore we specnlate that small flat adenomas should either grow upward and become protruded polyps or continue to spread laterally and become large flat adenomas. The growth pattern of colorectal neoplasms can be grouped into exophytic or upward, lateral, and endophytic or vertically penetrating. [Conclusion] Adenomas and early cancers of the colon are classified into protruded, small flat, large flat, and depressed. Protruded lesions reflect their exophytic growth and large flat adenomas seem to reflect their tendency to spread laterally; both of them are not invasive until they are large enough. On the other hand, depressed lesions seem to grow endophytically and invade the deeper layers rapidly, Small flat adenomas are benign and seem to grow either exophyticallyor laterally.

VOLUME 47, NO.4, 1998

S Lipscomb, J Dominguez, P Schoenfeld. Division of Gastroenterology, National Naval Medical Center, Bethesda, MD INTRODUCTION: Two previous studies have evaluated the miss rate for polyps during colonoscopy using back-to-back colonoscopy. No previous studies have evaluated the miss rate for polyps during flexible sigmoidoscopy (FS) with back-to-back FS. No previous studies have identified common characteristics of missed polyps with multiple logistic regression analysis. METHODS: During informed consent, patients were asked to undergo back-toback FS, but patients were instructed that they could withdraw from the study if the first FS was too uncomfortable. Staff gastroenterolo~;sts utilized a Olympus CF140S 70 cm flexible sigmoidoscope. Endoscopists were instructed to biopsy all polyps and to record polyp size, distance from anus, and shape. Within 5 minutes of the first FS, a second staff gastroenterologist repeated the FS, and biopsied any remaining unbiopsied polyps. Depth of insertion of the sigmoidoscope and histologic diagnosis of the polyps were recorded. Multiple logistic regression analysis evaluated the association between missed polyps and their size (mm), shape (sessile or pedunculated), distance from anus (cm), and histology (hyperplastic, adenoma, or villous). RESULTS: Of 163 patients who gave informed consent, 127 (78%) completed both FS. Mean depth of insertion was 63 cm. Gastroenterologists missed 20% (24/30) of all adenomas. Two adenomas 1 em or larger were missed, and one diminutive villous adenoma was missed. Gastroenterologists missed 36% (381 106) of hyperplastic polyps. In multiple logistic regression analysis, pedunculated polyps were perfectly associated with found polyps (i.e. no missed polyps were pedunculated), and decreasing size (p = 0.01) was the only factor associated with missed polyps. CONCLUSIONS: The miss rate for adenomas during FS in this study is similar to the miss rate for adenomas during colonoscopy identified in previous studies. During post-hoc analysis, gastroenterologists stated that if a polyp "flattened out" with insuffiation, then they did not biopsy the polyp because they assumed the polyp was hyperplastic. This may partly account for the higher than expected miss rate of hyperplastic polyps.

GASTROINTESTINAL ENDOSCOPY AB99

COLON AND RECTUM *303 A RANDOMIZED, COMPARATIVE, ANIMAL SURVIVAL STUDY OF COLONIC TATTOING USING INDOCYANINE GREEN OR IN· DIAINK

305 THE DIAGNOSTIC YIELD OF TERMINAL ILEOSCOPY AND BIOPSY Madala K., Ponich T., Driman D, Gregor J, Departments of Medicine and

AH Low, JG Lee, JWC Leung. Division of Gastroenterology, UC Davis Medical Center, Sacramento, CA Purpose: To compare the efficacy, durability, and safety oflndocyanine green to India ink for endoscopic colonic tattooing. Methods: Four pigs (30-35 kg) were randomized to undergo colonic tattooing using India ink or Indocyanine green (Cardiogreen, Bectin Dickinson & Co., Chicago, IL). The animals were fasted, but given free access to water for 24 hours and prepared using tap water enemas on the morning of the procedure. After the animals were sedated, paralyzed and intubated, sigmoidoscopy was performed to 60 em (GIF2TIOO, Olympus Co., Tokyo, Japan). Submucosal injections of 0.5 ml aliquots oflndia ink or Indocyanine green were performed every 2-5 em to raise a bleb. Commercial, artist grade India ink was diluted 1:10 using normal saline and filtered through 2 tandem Millipore filters (0.2211- and 0.4511-) and the Indocyanine green was reconstituted according to the manufacturer's instructions. The animals were recovered and maintained for 2 weeks and humanely sacrificed. All visible tattoo sites were examined grossly and histologically during post mortem examination with particular attention to stain intensity, hemorrhage, perforation, inflammation, abscess and staining of associated lymph nodes. The durability of the tattooing agent was graded as: I-no change in intensity, 2-slight decrease in intensity, 3-faint staining. Results: A total of 11 sites were tattooed in 2 pigs using Indocyanine green and 28 sites using India ink in 2 pigs. The total number of tattoos were determined by the quality of the colonic lavage which was highly variable. All animals survived without obvious clinical complications. Indocyanine green was easier and faster to prepare and inject compared to the India ink. Post mortem examination easily identified 9 of 11 Indocyanine green tattoos (82%) and 26 of 28 India ink tattoos (93%) on the colonic serosa, (p>0.05). The diameter of the tattoos ranged between 5-15mm for the Indocyanine green and 10-15mm for the India ink group (p>0.05), and the mean scores for the durability of the tattoo were 2.5 and 3, (p>0.05). Histopathologic examination failed to show perforation, hemorrhage, abscess, or granuloma, but a mild inflammatory response was seen in 6 of 11 (67%) Indocyanine green tattoos and 14 or 28 (50%) India ink tattoos (p>0.05). The pharmacy costs of Indocyanine green ($17/ animal) was higher compared to the India ink plus the filters ($5/animal). Conclusions: Indocyanine green is as effective, durable, and safe as India ink when used for colonic tattooing. Although Indocyanine green is significantly easier and faster to use compared to the commercially available India ink, which must be sterilized before injection, it is more costly. Endoscopic equipment was provided by Olympus Co., Tokyo, Japan.

Pathology, The University of Western Ontario, London, Ontario, Canada Objective: Terminal ileoscopy remains a non-routine extension of colonoscopy. Intubation ofthe terminal ileum can be time consuming and may prolong patient discomfort. This however may be offset by the diagnostic information obtained from examining and/or biopsying this area. We have investigated whether terminal ileal intubation and biopsy has increased the diagnostic yield in our outpatient population of patients. Methods: From all patients who underwent colonoscopy between December 1995 and December 1996 at the Victoria Campus of the London Health Science Centre in London, Ontario Canada, we identified 178 colonoscopies, 83 terminal ileal intubations and 42 ileal biopsies. The histories and final diagnoses were reviewed. Biopsy specimens were then re-submitted to a blinded pathologist. Pathological diagnoses were limited to consistent with Crohn's ileitis, nonspecific inflammation not consistent with Crohn's ileitis, or no pathological diagnosis. Results: Twenty patients (24%) had abnormal looking terminal ileums, with 10 (12.0%) having specific changes of ulceration or stricture formation. The diagnosis of Crohn's was arrived at in 9 (90%). Six were biopsied; all were consistent with Crohn's. Ten had nodularity or erythema and 7 were biopsied; 1 (14.3%) consistent with Crohn's, and 1 with non-specific changes which later proved to be Crohn's ileitis on follow up. Sixty-three (75.9%) patients had normal looking terminal ileums endoscopically. Twenty-nine (46.0%) were biopsied. Two (6.9%) had pathology consistent with Crohn's ileitis and two (6.9%) had non-specific changes. Conclusions: Intubation of the terminal ileum at colonoscopy is useful in the diagnosis of Crohn's disease. Routine biopsy of even normal looking mucosa increases overall yield.

*304 PATIENTS WITH RECURRENT GI HEMORRHAGE AND CO· LONIC ANGIOMAS-A RANDOMIZED STUDY OF ENDOSCOPIC TREATMENT WITH BIPOLAR OR HEATER PROBE COAGULATION

*306 EVALUATION OF MOTILITY AND FORM OF ILEOCECAL VALVE (ICV) WITH ENDOSCOPIC RETROGRADE MARKERS INSER· TION (ERMI) METHOD

GA Machicado, DM Jensen, TG Kovacs, R Jutabha, G Randall, J Gornbein, ME Jensen, S Cheng, and L Fontana. CURE, West Los Angeles VA Medical Center, and UCLA, Los Angeles, CA Gastrointestinal (GI) bleeding and colon angiomas are both common in the elderly. Objectives: To compare outcomes of patients with bleeding or incidental angiomas before versus after treatment with bipolar or heater probe. Methods: A randomized, prospective clinical trial was performed and 90 patients with recurrent acute or chronic GI bleeding were randomized, 44 to bipolar (BP) and 46 to heater probe (HP) treatment. After the initial analysis, we stratified by 2 groups for further analysis. Group I - 79 patients met criteria for colon angiomas as the bleeding site and Group II - 11 patients did not meet criteria for diagnoses as the bleeding site. Pre- and post-randomization data were blood transfusions, episodes of GI hemorrhage, hospitalizations, deaths, surgeries, and complications. Results: The mean age of the patients was 71 years and co-morbid medical conditions were frequent. Group I patients had significantly fewer bleeding episodes, transfusions, and hospitalizations for GI bleeding for 2 years after colonoscopic treatments versus for 2 years before with medical therapy. See Table 1 for Group I patient results by treatment. *p < 0.05 Be ore lSi' Aft.er HP .He ore liP

After HP

N 41 41 38 38

Bleedimt/2 vrs lUU% 36.6%* 10u% 31.6%*

/I Bleedsi2 vrs

2.9 + 1.1 + 2.5 + 1.0 ±

0.4 0.3* 0.4 0.3*

URBC/2 vrs 5.5 + 1.6 2.2 + 1.1' 4.3 + 1.8 Ll ± 0.5

Group II patients had no obvious benefit, but the sample size was small. Complications occurred in 6% of patients (8.7% for heater and 4.5% for bipolar probe): 2 post-coagulation syndrome and 4 delayed GI bleeding. Conclusions: Colonoscopic treatment with bipolar or heater probe is definitely recommended for Group I patients who meet criteria for diagnosis as the bleeding site. For Group II patients with incidental angiomas and evidence of GI bleeding, a large improvement was not evident, but no complications occurred and a small treatment effect cannot be excluded. Careful follow-up, optimization of therapy for co-morbid conditions and cessation of aspirin or NSAID utilization are highly recommended for all patients. Supported in part by NIH 41301 (Human Studies CORE) and Microvasive-Boston Scientific Corporation.

T Maeda, Y Tsunemura, Y Fukui, Y Imamura, K Kato, S Fujita, H Sato, Y Tatsumi, S Mitsufuji, T Kodama, K Kashima. Third Department of Internal Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan. We have already reported the Endoscopic Retrograde Markers Insertion (ERMI) method, which enables measurement of exact transit through ileocecal valve (ICV) with simultaneous manometry in the last annual meeting of ASGE. Taking this advantage of ERMI, correlation between form and motility of ICV was examined. Subiects: 10 healthy volunteers (F-1, M-9, mean of age 34.0 yrs) were examined with ERMI under fasting condition. 5 healthy volunteers (M-5, mean of age 30.2 yrs) were subsequently investigated with manometry under postprandial condition. Methods: 1. ERMI was performed according to the previous report. Manometry was performed with the catheter which has a sleeve sensor, adapted to ICV, for 2 hours, while abdominal Xray films were taken at 30min intervals to confirm markers migration, which had been inserted by endoscopically. Motility Index (MI) was calculated from the manometric wave recorded and transit through ICV was analyzed by residual ratio of markers (RRM) in the terminal ileum. The form of the ICV was classified into three types by endoscopic findings,; 1) those remaining open (type 0), 2) those remaining closed (type C) and 3) those opening and closing (type A). 2. Manometry, performed at the ileum end, ICV and each part of the colon for 1 hour (before meal) was compared with that after definite meal injestion (after meal). Results: 1. Wave pattern of each form of ICV is showed below (Fig 1-3). MI was higher in type A than the other two types. There was no clear difference in RRM among these three groups. 2. MI was expressed as mean±SD.

a

e ore mea r mea

After eating, the wave pattern was similar to type A regardless of form of ICV. Conclusion: Although the characteristic movement of the ICV differed among the types, the wave patterns after eating were similar, and the transit was suggested to be same irrespective of the form. The catheter with a sleeve sensor was available for manometry in ICV.

ITTI Figl typeC

ABIOO GASTROINTESTINAL ENDOSCOPY

1J\Jv\.1 ~ Fig2typeO

Fig3typeA

VOLUME 47, NO.4, 1998

COLON AND RECTUM *307 MAGNIFYING ENDOSCOPY IS USEFUL FOR EARLY DETECTION OF THE RECURRENT LESIONS AFI'ER ENDOSCOPIC PIECEMEAL MUCOSAL RESECTION FOR LARGE COLON POLYPS. T. Matsumoto, N. Suzuki, S. Shiba, N. Hamasaki, I. Suwa, Y. Sawa, W. Ueda, K Watanabe, Y. Watanabe, S. Nakamura, N. Oshitani, T. Arakawa, K Kobayashi, K Kuroki. Dept. Endoscopy, Dept. Med. III, Osaka City University Medical School, Osaka, Japan. Recent advances in video-endoscopy and endoscopic ultrasonography enable us to evaluate the precise indication of endoscopic treatment for large adenomas in the colon. In large adenomas more than 20 mm in a diameter, it is often necessary to use endoscopic piecemeal mucosal resection (EPMR) technique for complete resection of the tumor. EPMR technique, however, potentially have difficulties in confirming the complete resection at the time of EPMR due to heat degeneration of the cutting edge. The aim of the present work was to determine the usefulness of magnifying endoscopy one month after the EPMR for early detection of the recurrence. [Subjects and Methods] Among 246 endoscopically resected colonic polypoid lesions in 1994-1996, 18 lesions were treated with EPMR technique. They were observed at one month after the initial resection by magnifying videocolonoscope (Olympus, CF-200Z). Residual tumorous pit was used as a indicator of recurrence. [Results] At the time of EPMR, all 18 lesions did not show tumorous pit. At one month after the initial resection, magnifying video-colonoscopy succeeded in visualizing residual or recurrent tumor type pit in 9 cases, however, usual video-colonoscopy revealed residual or recurrent tumor only in 5 cases. Eight cases with recurrent tumor have additional endoscopic mucosal resection, which resulted in safe and complete resection. Only one patient with recurrence got surgery because of his wish. [Conclusion] Magnifying video·coIonoscopy is useful in early detection of recurrence in EPMR, and provides better prognosis of the disease.

*308 MORPHOLOGICAL ANALYSIS OF COLORECTAL SUBMUCOSAL CANCERS WITH REFERENCE TO THEIR PRECURSORY LESIONS

H. Mitooka, KIrie, R.Kasiwagi, F.Tabata, T.Fujimori. Kobe Kaisei Hospital, Kobe, Tabata Icho Hospital, Akasi and 2nd Depts. of Pathology, Dokkyou University School of Medicine, Tochigi, Japan. It is controversial which kind oflesions morphologically are the main precursory lesions to advanced colorectal cancers. In the present study, the characteristics of colorectal submucosal cancers as observed from their intramucosal invasion and mode of submucosal invasion were analized to determine which lesions, polypoid or non-polypoid, are the main precursory lesions to advanced colorectal cancers in a prospective fashion. Subjects: All 54 submucosal (sm) cancer cases detected between Jan.93' and Dec.96' (among 8488 Total colonoscopic examinations). Method: The central pportion of a polyp with a long stalk and 2 to 3 mm thick sections of sessile or broad-based lesions were examined with paraffin sections by hematoxylin-eosin (H&E). Histologically, the matsrials were divided into two types: polypoid growth carcinoma (PG) from intramucosal proliferation of adenoma or carcinoma, and nonpolypoid growth carcinoma (NPG) without intramucosal protuberant growth. According to the depth of invasion, sm cancers were classified into 3 equal divisions of the submucosal layer, sml, sm2 or sm3. T-test was utilized for statistical analysis. Result: Growth nattern numhAr

size -tSllmm 'enth of invasion % sml sm2-3

All the sm cancers PH NPH 46 % 8 15% 16.9'" 7.3 11.3'" 3.1 41 59

25 75

8m cancers less than 1 em NPG PH 8 62% 5 38% 9.2'" 1.2 8.5'" 1.3 62 38

0 100

*

*: Statistically significant

Conclusion: It was suggested that PG is the main precursory lesion to advanced colorectal cancer from our morphological analysis of submucosal cancer. However, NPGs have the tendency to invade deeply in spite of their small size.

VOLUME 47, NO.4, 1998

309 DISTRIBUTION OF PRIMARY COLORECTAL CANCER IN MINORITY INNER CITY POPULATION

Arun Naik, K Digavalli, M.Siddique, KKumar, M.F.Hasan, Franklin Marsh. Interfaith Medical Center, 555 Prospect Place, Brooklyo, NY 11238. Aim: Colon cancer causes more than 60,000 cancer deaths in US every year. Flexible sigmoidoscopy and fecal occult blood testing is recommended every 3-5 years for colon cancer screening. The drawback of this is that flexible sigmoidoscopy will miss colonic lesions proximal to splenic flexure and there are doubts about sensitivity of fecal occult blood testing. Based on data that includes both symptomatic and asymptomatic patients, it is likely that up to 60% of colorectal cancers are within the reach of a flexible sigmoidoscope. Also it is apparent from several studies that in the last 40 years there is a rightsided shift in the distribution of colon cancers and polyps. We studied colorectal cancer distribution in the minority, inner city population we serve, to see what percentage of colon cancers were within the reach of a flexible sigmoidoscope. Methods: We retrospectively studied all colon cancer patients diagnosed at Interfaith Medical Center between Jan92-Nov97. Metastatic cancers to colon were excluded. These patients were symptomatic. Endoscopy and pathology reports were reviewed. We defined left sided tumor as distal to splenic flexure, right sided as proximal to splenic flexure. Prevalence of synchronous polyps and their distribution was noted. All polyps were included irrespective of size, pathology. Results: Total Number Primary Colorectal Cancer 90. Age: Mean 67, median 69, range 32 to 96. Sex: 55 Female 35 Male. Race: 95% African Americans, 3% Whites, 2% Hispanics. Distribution: 55.6% of colorectal cancers were distal to splenic flexure. 25% of right sided colon cancers were associated with syochronous polyps. 15% of right sided colon cancers had polyps distal to the cancer. 32% of left sided colorectal cancers were associated with synchronous polyps. In patients, above age 70 (Number of patients 46) 47.87% ofcolorectal cancers were distal to splenic flexure. Conclusion: The patients in this study were symptomatic. Despite this there is rightward shift noted in colon cancer distribution (44.4% Right sided). This shift is more marked in elderly patients, age more than 70 (52.13% Right sided). This is more significant as our study was done on symptomatic patients. Higher percentage of right sided colon cancers would be detected if colonoscopic screening is done on asymptomatic patients. Considering the increasing prevalence of right sided colonic pathologies, it may be important to screen the whole colon with colonoscopy or barium enema. Randomized case controlled studies are required in this patient population to see cost effectiveness of colonoscopy.

*310 LOCATION OF METACHRONOUS COLORECTAL ADENOMAS: IS A TOTAL COLONOSCOPY ALWAYS NECESSARY AT SURVEILLANCE? G. Nusko, U. Mansmann, U. Partzsch, Th. Kirchner, E.G. Hahn. Dept. of Medicine I, Dept. of Pathology, University of Erlangen, Institute of Medical Statistics, Free University of Berlin, Germany Background: After resection of colorectal adenomas patients have to be followed-up regularly. The aim of the study was to determine the suitable method of surveillance depending on the anatomical location of the initial lesions. Methods: At the Erlangen Registry of Colorectal Polyps a total of 1159 patients have been followed-up prospectively between 1978 to 1996. X2 testing was performed to determine if rectoscopy, sigmoidoscopy or total colonoscopy are adequate surveillance examinations for detecting advanced metachronous adenomas (> 10 mm or high-grade dysplasia or carcinoma). Results: At the initial examination 1271 09.0%) adenomas were located in the rectum, 3331 (49.7%) in the left colon and 2100 (31.3%) in the right colon. At the first surveillance 145 (11.1%) adenomas were found in the rectum, 580 (44.3%) in the left colon and 585 (44.7%) in the right colon. There was a significant right-sided shift at the first follow-up (p
GASTROINTESTINAL ENDOSCOPY ABIOI

COLON AND RECTUM *311 ARE MALIGNANT POTENTIAL OF COLORECTAL TUMORS DIF· FERENT ACCORDING TO ITS MACROSCOPIC APPEARANCE?ANALYSIS OF 65 SUBMUCOSAL COLORECTAL CANCER Y. Ohno, T. Terai, H. Nihei, T. Ogihara, R Miwa, N. Sato, Department of Gastroenterology, Juntendo University, School of Medicine, Tokyo, Japan Background Recently flat or depressed type of colorectal tumors has been paid attention. However, its biological feature has not been well characterized. In order to investigate the relationship between macroscopic appearance of colorectal tumor and malignant potential, we histologically analyzed various types of colorectal cancers which invaded to submucosal layer. These tumors not only express biological feature of malignant neoplasm but also remain original characteristics. Methods Sixty-five submucosal invasive colorectal cancers resected surgically or endoscopically were classified into four groups according to its macroscopic findings, which were pedunculated (P), subpedunculated (SP), sessile (S), and depressed (D) type. Tumor size, whether adenoma component is accompanied or not, and growth pattern (polypoid growth; PG, nonpolypoid growth; NPG, Shimoda et al Cancer 1989) were compared in 4 macroscopically different groups. Results & Discussion Group

size(mm)

NPGtype

313 MORE FREQUENT COLON CANCER SCREENING AMONG WOMEN IS NEEDED H.W. Olsen, W.A. Lawrence, Oakland, CA We observed a higher frequency of more advanced cancer in women than in men, in an urban community population referred for colonoscopy and polypectomy. This finding was most evident in asymptomatic patients referred because of a positive screening examination, where less than one third were women. However, among men and women who were examined because of symptoms, the number in each group, age of presentation, and incidence and severity of cancer were approximately equal. In a population of 1,421 patients, there were 342 men and 156 women referred from screening whom were asymptomatic. The men in this group, average age 66.5 years, presented approximately four years earlier than the women whose average age was 70.5 years. The incidence of invasive malignant polyps was 5% for men and 11% for women, with more advanced disease among the women. In our patient population, women were not being screened as frequently or as early as men. We believe a greater emphasis on breast and uterine cancer screening is a contributing factor. In addition, women frequently do not have family practitioners or internists as their primary doctor until later in life.

POSITIVE SCREENING EXAMINATIONS

P n=17 P n=21

14.0:!: 4.1 2 11.8% 13.3 :!: 7.5 3 14.3% n~13 12.8:!: 5.7 4 30.8% 14 (100%)** (n=14) 8.90:!: 3.3 *p<0.05, **p
312 HYPERPLASTIC POLYPS AT SCREENING SIGMOIDOSCOPY ARE NOT AN INDICATION FOR COLONOSCOPY H.W. Olsen, W.A. Lawrence, Oakland, CA Review of 1662 patients with colon polyps removed at colonoscopy identified 139 patients who had hyperplastic polyps only within the range of the flexible sigmoidoscope. These patients, who were colonoscoped for multiple reasons, had right colon findings comparable to patients with adenomatous polyps in the sigmoid. 139 PATIENTS WITH HYPERPLASTIC POLYPS PERCENTAGE RIGHT COLON POLYPS 39%

PERCENT WITH

LARGE POLYPS

PERCENT WITH ADVANCED LESIONS 5%

PERCENT WITH CANCER

14% 2.2% 1204 PATIENTS WITH ANY SIGMOID POLYPS 46%

15%

9.6%

2.7%

41 of the patients with hyperplastic polyps as the only indication for colonoscopy had no advanced lesions or cancer 41 PATIENTS WITH HYPERPLASTIC POLYPS AT SIGMOIDOSCOPY 36%

15%

o

o

The lack of serious right colon pathology by itself is of questionable significance considering the small numbers of patients. On further analysis of patients with hyperplastic polyps, two variables, a family history of colon cancer and signs of gastrointestinal bleeding are the important risk factors. Patients with either of these findings, which are themselves an indication for colonoscopy, have significant right colon pathology. Patients without these findings have no greater incidence of right colon disease than published series of screening colonoscopies. 44 PATIENTS WITH EITHER FAMILY HISTORY OR SIGNS OF

BLEEDING 48%

27%

14%

7%

95 PATIENTS WITHOUT FAMILY mSTORY OF BLEEDING 36%

AB102

7%

1%

GASTROINTESTINAL ENDOSCOPY

1%

O.B 31 66

ANEMIA 27 32

SIG 3 16

FLEX SIG 79 195

B.E. 14 24

*314 PROSPECTIVE ANALYSIS OF WORK·up OF ACUTE LOWER GASTRO·INTESTINAL BLEEDING: CAN AN OPTIMAL ALGO· RITHM BE DESIGNED? C. Prakash, G.R. Zuckerman, G. Aliperti, D.T. Walden, RD. Royal, J.R. Willis. Divisions of Gastroenterology and Nuclear Medicine, Washington University School of Medicine, St. Louis, MO. The most accurate and cost effective method of investigating the etiology of acute lower gastrointestinal bleeding (LGIB) remains elusive. To develop a clinically useful algorithm, we prospectively collected data on all patients with acute LGIB admitted to our institution. Demographics and clinical parameters were recorded without influencing clinical decision making. Over a two-month period, 38 pts presented with acute LGIB; three pts had prior bowel resections and were excluded. Of the 35 pts in this study (l7F/18M, age 68±2.6 yr), 51% had hemodynamic instability at presentation. Nasogastric aspiration performed in 21 pts (60%) excluded upper GI bleeding. Sixty percent were taking aspirin, non-steroidal anti-inflammatory drugs (NSAIDs), or anticoagulants. Using a pocket-sized stool color confirmation card test*, 77% of pts had the two brightest red card colors (color #1 & #2) at presentation. Initial investigation consisted of tagged red blood cell (TRBC) scan in 14 pts (40%) and colonoscopy in 19 (54%). Of the 9 pts who had card colors #1 or #2 at the time of TRBC scan, 67% had a positive scan; in contrast, none of the pts with maroon or brown stool had a positive scan (p=O.02). All 8 pts with card colors #1 or #2 after bowel purge had a source identified at colonoscopy, in contrast to 10 of 22 pts with maroon or clear stool (p=0.009). The source of bleeding was identified in 18 pts, and included: mass (5 pts), diverticula (5), colitis (3), fissure (2), others (2), aorto-duodenal fistula (1). Localization without etiologic diagnosis was achieved in 3 pts. Endoscopic therapy was successful in 2 pts. Stool color-> at nresentation

card colors #1 2* other card colors (#35)* D n-27 n-8 67% 0% 0.02 1~% 0.01 fina 1a 081S 70% e co on sites 53% 0% 0.01 33% 12% ns rignt co on sites+ *color confirmatIOn card, D,g D,s Sc, 40:1614, 1995 tin patients with the respective stool colors during scan tincludes all methods of investigation Conclusions: The utilization of a simple objective color test appears to optimize the predictability of diagnostic testing in acute LGIB. The passage of blood corresponding to card colors #1 and #2 during TRBe scanning and colonoscopy significantly increases diagnostic yield. These two tests appear complementary in acute LGIB. L'H.Hl scan

oSlttve

VOLUME 47, NO.4, 1998

COLON AND RECTUM *315 PALLIATION OF MALIGNANT COLORECTAL STRICTURES WITH EXPANDABLE METALLIC STENTS: EXPERIENCE WITH 20 PATIENTS I. Raijman, I. Siddique, J. Skibber, J. Ajani, S. Lahoti, P. Lynch. M.D. Anderson Cancer Center, Houston, Texas. Introduction: The application of expandable stents, commonly used for biliary and esophageal strictures is gaining acceptance in the treatment of colorectal strictures. We have previously reported our data of 13 patients with colorectal strictures palliated with expandable stents, and now update our experience with 20 patients. Methods: There were 12 men and 8 women with the average of 54 years (range 38-72). The primary diagnosis was colorectal cancer in 16, cervical/ ovarian cancer in 3 and transitional cell cancer in 1 patient. The site of obstruction was the rectum in 9, sigmoid in 10 and transverse colon in 1 patient. All patients had obstructive symptoms. Previous treatment included laser ablation in 5 and surgery in 3 patients. All patients had a prior Barium enema examination to define the length and course of the stricture. The tumor was exophytic in 10 and infiltrative in 6 patients. Extrinsic compression was seen in 4 patients. The endoscope could be advanced beyond the stricture in 8/20 patients. In the other 12 patients a standard biliary cannula was advanced through and contrast injected to define the length and course of the stricture. Dilation was needed in 9 patients (balloon 4, bougies 5). Guidewires were advanced through the strictures as far proximal as possible. Results: Stent placement was successful in 18/20 (90%) patients. All of these 18 (90%) patients had significant clinical improvement. Stents could not be placed in two patients with cervical/ovarian cancers because of the torturosity of the strictures. Dedicated enteral Wallstents (Schneider) were placed in 14, non-enteral Wallstents in 5 (esophageal 4, biliary 1) and IDtraflex (Microvasive) in 1 patient. The mean follow-up was 8 months (range 1-14). There were two complications 00%); one patient developed a recto-vesical fistula, which was successfully treated with a coated esophageal Wallstent-I. Tumor ingrowth was seen at the time of endoscopy. The second patient, who had received a biliary Wallstent, had distal migration of the stent. The average survival was 5.2 months (range 1-14). There were no procedure related morbidity or mortality. Conclusions: We conclude that expandable metallic stents are safe, effective and provide a reasonable palliative option for unresectable malignant colorectal strictures.

*317 COMPARATIVE SPECIFICITIES OF A GUAIAC & AN IMMUNO· CHEMICAL FECAL OCCULT BLOOD TEST & ELIMINATION OF DIETARY RESTRICTIONS P. Rozen, Z. Samuel, J. Knaani, Gastroenterology Dept., Tel Aviv Medical Center, Israel. Due to false positivity, in part from dietary peroxidases, guaiac fecal occult blood tests (FOBT) are faulted by their low specificity for significant colorectal neoplasia (cancers or adenomas 2:1 em). Aims: To examine if specificity can be improved by dietary restrictions or by using an immunochemical FOBT specific for human Rh. Methods: The guaiac HemoccultSENSA (HOS) & immunochemical FlexSure OBT (FS) (SmithKline Diagnostics) FOBTs were both prepared by 943 persons. These were mainly consecutive persons, at average or at high risk for neoplasia repeatedly coming to the Screening or Follow-up Service (96.7%), or to the clinic for investigation but without active rectal bleeding (3.3%). All had an endoscopic examination: a colonoscopy (52.2%) or a flexible sigmoidoscopy negative for any neoplasia (47.8%). All FOBTs were developed >3 days after the last test preparation, but :514 days of the first test preparation. Blinded development of 30 smeared FOBTs having 0, 0.2, 0.5, 1.0 or 2.0 ml added blood/100g stools, showed a reading threshold sensitivity of 0.5ml & 0.2mI added blood (0.75 & 0.3mgHb/g stool) for HOS & FS respectively. All persons stopped NSAIDS & vitamin C & the first 403 cases ate a low-peroxidase diet for 3 days before & while preparing the FOBTs (91% compliance). The last 540 had no dietary restrictions. Results: Significant neoplasia were detected in only 17 persons (1.8%), sensitivity of HOS was 58.8%, 95% confidence intervals (Cn 35,82; FS was 35.3%, CI 12,58 (P=0.17). Specificity ofHOS was 93.4%, CI 92,95; FS was 98.5%, CI 98,99 (P=O.Ol). Predictive positive value (PPVl of HS was 14.1% & FS 30.0% (P=O.I). When considering only those persons having both HOS & FS positive, PPV became 55.6%. Overall positivity ofHOS was 7.5% & FS 2.1%, while in 901 persons having an endoscopic examination negative for any neoplasia, it was 6.2% & 1.2% respectively. In 377 persons having dietary restrictions & a negative endoscopic examination HOS was positive in 7.2%, while in 524 persons without diet & a negative endoscopy HOS positivity was 5.5% (P=0.23). Conclusions: The immunochemical FOBT, FS, is easy to perform & has better specificity for significant neoplasia than the guaiac HOS. The low incidence of significant neoplasia in this population limits the evaluation of sensitivity. Delaying development of HOS by 2:3 days eliminates the need for dietary restrictions. This study was funded in part by SmithKline Diagnostics, California.

*316

*318

PROSPECTIVE DETERMINATION OF DISTAL COLON FINDINGS IN PATIENTS WITH PROXIMAL COLON CANCER D Rex, A Chak, L Sack, D Bjorkman, E Cravens, R Vasudeva, M Wiersema, D Barrido, T Gross, L Zeabart, D Lieberman, T Lemmel, S Buckley, V Portish, Indianapolis, IN and other centers. BACKGROUND: Retrospective studies showed that cancers proximal (PC) to the splenic flexure are usually not accompanied by adenomas (AD) distal to the splenic flexure indicating that flex sig would be ineffective as a screening tool for advanced proximal neoplasia. AIMS: 1. Prospectively identify distal colon findings in pts with PC to ensure that adequate clearing is performed. 2. Determine if the results apply in average-risk persons by collecting family history. Pts with positive family history often undergo colonoscopy in any case. 3. Determine the association of distal AD with PC according to size of AD. METHODS: Prospective multicenter clearing colonoscopy in consecutive pts with PC. RESULTS: 124 pts with PC 005 with negative family history) underwent prospective clearing colonoscopy. Of the 105 with negative family history of cancer or polyps, 54 were male, mean age 70.9y, range of 29-96y. 37 (35%) had either CA alone (n=2), AD only (n=30), or both (n=5). Of those with only AD distal to the splenic flexure, the 30 pts had a total of 47 AD distal to the splenic flexure. The largest distal AD was 2:1em in 17 pts, 6-9mm in 4 pts and :55mm in 9 pts. 10 pts had only a single tubular AD distal to the splenic flexure. 7 pts had AD only in the descending colon, possibly out of reach of flex sig. 8 pts had only hyperplastic polyps distal to the splenic flexure. Of 19 pts with a family history of CA or AD, 8 had AD only (6 with one or more AD 2:1em in size) and 1 had both CA and AD distal to the splenic flexure. SUMMARY: 1. Most average-risk pts with PC have no neoplasia distal to the splenic flexure when prospectively evaluated, similar to the results of retrospective studies. 2. Of those with distal AD, a high percentage have large AD. 3. A single small tubular AD in the distal colon and only hyperplastic polyps distally have similar weak associations with PC. CONCLUSION: Only screening by colonoscopy or other effective full colon evaluation can reliably identify proximal colon cancer.

FEASffiILITY OF MAGNIFIED COLONOSCOPY FOR EVALUA· TION OF ACTIVITY IN ULCERATIVE COLITIS Y. Saitoh, M. Nomura, M. Tarnishi, M. Honda, T. Fujiki, A. Sasaki, T. Ayabe, T. Ashida, T. Obara and Y. Kohgo, Third Department of Internal Medicine, Asahikawa Medical College, Asahikawa, Japan Background and Aim: The staging diagnosis of IDcerative Colitis (UC) is determined by both colonoscopic diagnosis and histological diagnosis of the biopsy specimens. Recently, magnified colonoscopy have become available and detail findings ofthe mucosa can be depicted easily. We evaluated the usefulness of the magnified colonoscopy for the accurate staging diagnosis in UC. Methods: Between July 1990 and July 1997, magnified colonoscopy ICF-200Z (Olympus corp. Tokyo Japan)} were performed in 61 case of DC 026 times) and conventional colonoscopy were in 84 cases (308 times). A total of 816 biopsy specimens were obtained during these periods; 207 specimens by magnified colonoscopy and 649 by conventional colonoscopy. Colonoscopic and histological stagings were classified according to revised Matts' gradings. We retrospectively studied the accuracy of the staging diagnosis by magnified and conventional colonoscopiy compared with that of the biopsy specimens histologically whether accurate staging diagnosis of DC will be determined by only magnified colonoscopy. Results: The biopsy specimens taken from the mucosa that diagnosed as severe active stage by conventional colonoscopy and magnified colonoscopy were histologically diagnosed as severe active stage in 63/68 (92.6%) and 39/40 (97.5%), respectively. Staging diagnosis by both conventional and magnified colonoscopy was corresponded well to that histologically in severe active stage of DC. On the other hand, the biopsy specimens taken from mild active stage by conventional colonoscopy were histologically diagnosed as active stage in 154/208 (74%) but as remission stage in 54/208 (26%). And, the biopsy specimens taken from mild active stage by magnified colonoscopy were histologically diagnosed as active stage in 67/74 (90.5%) and as remission stage in only 7/74 (9.5%). The biopsy specimens taken from quiescent stage mucosa by conventional colonoscopy were histologically diagnosed as quiescent stage in 306/353 (86.7%) but as active stage in 47/353 (13.3%). On the contrary, the biopsy specimens taken from the mucosa that diagnosed as quiescent stage in 88/93 (94.6%) and as remission in 5/93 (5.4%). Staging diagnosis by magnified colonoscopy were corresponded well with that histologically and accuracy rate was significantly higher than that by conventional colonoscopy in mild active stage (P
VOLUME 47, NO.4, 1998

GASTROINTESTINAL ENDOSCOPY ABI03

COLON AND RECTUM "319 COLONOSCOPIC BALLOON·DILATION THERAPY FOR BOWEL STRICTURES IN CROIIN'S DISEASE-OPTIMAL BALLOONING PRESSURE AND DURATION Y. Sasaki, Y. Uno, "R. Hada and A. Munakata. First Department of Internal Medicine and "Department of Medical Informatics, Hirosaki University School of Medicine, Hirosaki, Japan Background and Aim: Recent strategies for bowel strictures in Crohn's disease include endoscopic hydraulic dilation using a balloon. The purpose of this study is to determine the optimal ballooning (inflating) pressure and duration for safe and successful relief of strictures. Methods: Four symptomatic (abdominal pain) patients with a single bowel stricture narrower than 5 mm in caliber occurring in the ileum, colon, anorectum and at an ileocolic anastomosis, respectively, were studied. Under colonoscopy, a rediopaque balloon (maximal O.D. 2 em) was settled at the stricture. The balloon was rapidly inflated by infusing water to produce an initial intra-balloon pressure of 10 psi. The infusion system was abruptly closed to follow the intra-balloon pressure profile for 5 min. Then, the diameter of the balloon at the stricture (i.e., the dilated luminal caliber) was measured under fluoroscopy. The balloon was deflated for 3 min and the same procedure was repeated with the initial intra-balloon pressure of 20 and 30 psi. 30 ~

~

(poi)

10

......

2 ( a) 4

->~essure

Stncture • lleum Colon Anastomosis Anorectum

10 psi 20 psi BO(.) LC(mm) BD LC 43

17

90

20

SO 16 44 IS

166

18

ISS 42

18 20

30

IS

30 psi BD LC

210 184

20 20

Results: Irrespective of the initial pressure, the intra-balloon pressure decreased by 20% within 3 min, which indicated dilatation of the stricture. The pressure profile, thereafter, changed little (plateau), which indicated no further dilatation. In the pressure profiles, we defined the beginning of the plateau as when the pressure descent first came to 1 psi/30 s and the optimal ballooning duration (BD) as from the peak (the initial pressure) to this point. BD was 30-50 s with the initial pressure of 10 psi, 42-166 s with 20 psi, and 180-210 s with 30 psi. The dilated luminal caliber at the stricture (LC) was parallel to the initial pressure; 15-17 mm with 10 psi, 20 mm with 20 psi (for the ileal and anorectal strictures) or 20 mm with 30 psi (for the colonic and anastomotic strictures). No complication was experienced in this treatment. All patients were relieved of abdominal pain. Conclusion: When a dilation maneuver with a balloon (2 em diameter) for strictures in Crohn's disease is performed, an adequate inflation (ballooning) pressure is 30 psi. The optimal duration of ballooning (inflation) is indicated by the end of pressure fall monitored, that is no longer than 4 min.

"321 DOES PREMEDICATION WITH EITHER INTRAVENOUS OR ORAL HYOSCYAMINE FACIT..ITATE COLONOSCOPY? NJ Shaheen, DJ Robertson, M Crosby, SJ Furs, DT May, WR Harlan, IS Grimm, KL Isaacs, EM Bozymski. Division of Digestive Diseases, University of North

Carolina, Chapel Hill, North Carolina Background: Several studies have assessed the utility of hyoscyamine in facilitating colonoscopy, with conflicting results. These studies have been relatively small and none has compared intravenous (IV) to oral (PO) hyoscyamine. Aim: To determine the effects of premedication with intravenous IV or PO hyoscyamine on pertinent outcomes in elective colonoscopy. Methods: The study was a randomized, double-blinded, placebo controlled trial in which patients were assigned to one of three arms: IV hyoscyamine (0.25 mg), PO hyoscamine (0.25 mg), or placebo, administered 20-40 minutes prior to the procedure. Patients between the ages of 18-75 presenting for elective colonoscopy were included. Exclusion criteria were glaucoma, unstable cardiovascular status, pregnancy, chronic use of anticholinergic drugs, and surgical alterations of the colon. Demographic data included age, sex, prior abdominal surgeries, prior colonoscopies, and a history of diabetes or a functional bowel disorder. A pre-procedure assessment of patient anxiety levels using 1-10 visual analog scales (VAS) was performed. Primary outcome measures included: insertion time to cecum, amount of sedation used, amount and type of pathology visualized, and patient assessment of pain (1-10 VAS). Secondary outcome measures included: physician assessment of spasm (1-10 VAS), physician assessment of pain (1-10 VAS), and total procedure time. Results: One hundred and thirty-three patients were enrolled in the trial. There were no significant differences between the groups with regard to age, gender, past abdominal surgeries, or history of functional bowel disorder. Bivariate analysis showed no difference between the three groups with regard to time to cecum (14.5 min, 16.2 min, and 14.4 min, for IV, PO, and placebo, respectively, p=0.66), patient assessment of pain (3.9,3.9, and 3.7 on 1-10 VAS for IV, PO, and placebo, respectively, p=0.90), or any other primary or secondary outcome variable. A multi-variate analysis controlling for endoscopist identity, pre-procedure anxiety, and amount of sedation also failed to demonstrate any differences between the groups. High pre-procedure anxiety levels, and female gender were predictive of a longer time to cecum, higher patient assessment of pain, and higher medication needs (p < 0.05 for all). Conclusions: This randomized, double-blinded placebo-controlled trial demonstrated no efficacy of either IV or PO hyoscyamine as a pre-medication for elective colonoscopy. Investigational drug for this study was provided by Schwarz Pharma, Inc. This study was supported in part by NIH-T32 DK07634.

"320 SELF EXPANDING METALLIC STENTS IN MALIGNANT CO· LONIC OBSTRUCTION-EARLY EXPERIENCES WITH A NEW PALLIATIVE TREATMENT

"322 ENDOSCOPIC DETERMINATION OF THE ABERRANT CRYPT FOCI DENSITY BY MAGNIFICATION CHROMOSCOPY: COLO· RECTAL CANCER VS. BENIGN DISEASES OF COLON

F. Schreiber, G.C.H. Gurakuqi, M. Trauner, W. Schnedl and G.J. Krejs Department of Gastroenterology and Hepatology, University School of Medicine, Karl-Franzens-University of Graz, Austria. A major drawback of palliative endoscopic laser desobliteration therapy in colonic malignancies is the need for repeated treatments. Endoscopic implantation of self expanding metallic stents (SEMS) is a short time and single step procedure. The aim of this study was to evaluate whether SEMS are superior to laser desobliteration treatment preventing colonic obstruction. 10 patients (6 females and 4 males, mean age 76 years, 61y-88y) were treated by endoscopic laser therapy with a continuous-wave Nd:Yag laser. Mean treatment number was 2.6 (1-4), mean treatment duration was 50.5 min (25-85). The mean patency rate after laser desobliteration was estimated with 24.3 days (11-40). As a major complication perforation occured in two patients (20%). One died from peritonitis, the other patient recovered under conservative treatment. 9 patients (4 females, 5 males, mean age 74 years, 59y-89y) were treated by implantation of SEMS (coated Wallstent®, Schneider Inc, distributor Comesa Austria and Endocoil®, Euromed Inc.). A total number of 12 SEMS (7 Wallstents, 5 Endocoils) was implanted for complete desobliteration of the stenoses. Mean time consumption of the insertion procedure was 18 min (8-34 min). After marking the stent position by submucosal dye injection at the oral and distal end of the stenosis a guide wire was placed through the endoscope over the stricture. If the passage for the endoscope was impossible, only the distal end of the stricture was marked. After withdrawal of the endoscope the SEMS was positioned over the guide wire and deployed under fluoroscopic control. The success rate of implantation was 100%, in 5 patients there was need for implantation of a secondary prosthesis caused by dislocation immediately after deployment or non-optimal position. The mean patency rate was estimated with 89 days (33-161). In most cases stent occlusion occurred by tumor overgrowth at the ends of the SEMS. There was seen no complication in the stent group. Since laser desobliteration as the former procedure of choice for patients with maliguant colonic obstruction is a time consumpting procedure with a high need ofre-treatments and a remarkable complication rate there is strong evidence, that-following the early data of this study-endoscopic implantation of SEMS may be superior. The implantation is an easy to perform and safe endoscopic procedure, patency rate and life quality are superior to the laser group. More data of larger trials are necessary to confirm these early data of a small group.

D. Sorbi, L. J. Burgart, D. A. Ahlquist, W. E. Kames, L. Wang, A. R. Zinsmeister, C. J. Gostout. Mayo Clinic, Rochester, MN. Introduction: Aberrant crypt foci (ACF) are microscopic foci of enlarged and elevated crypts. Limited animal studies suggest that these lesions are precancerous. However, there is uncertainty if their density is higher in colorectal cancer in humans and if they can be evaluated and enumerated endoscopically. Aim: To determine the ACF density by magnification chromoscopy (MC) and to compare it to the value obtained by dissecting microscopy (OM) in patients with colorectal cancer and benign diseases of colon in an ex vivo model. Methods: Surgical specimens from 18 subjects (14 cancer, 4 benign) were studied. The colonic mucosa was stained with 0.2% methylene blue after washing with 10% acetylcysteine. Each specimen was then cut into 4 cm2 segments and examined with the Olympus CF-200Z magnifying colonoscope at a distance of 2-3 mm (magnification 30x-40x). The muscularis propria of the methylene blue stained tissue was subsequently discarded before examination by dissecting light microscopy by another investigator. The ACF density was calculated by dividing the number of ACF by the surface area examined. Statistical analysis was performed by the t-Test for unpaired samples. Results: The total areas examined were 626 cm 2 in the cancer and 216 cm2 in the benign group. The average ages of the patients with cancer and benign diseases were 71.9 (range 51-53, median 73; 6 male) and 64.5 (range 37-77, median 72; all male) years, respectively. The ACF density was higher in the cancer group both by magnification chromoscopy and dissecting microscopy. This difference, however, reached statistical significance only when the specimens were evaluated by maguification chromoscopy.

ABI04 GASTROINTESTINAL ENDOSCOPY

ancer n 14

Henilm n-4 va ue, one-tai

l"

ACF Densitv IX +SEM Ranl1e ML #cm DM #cm 0.19+0.04 0·0.52 0.16+0.05 0·0.75 0.05+0.01 0.04-.07 0.04+0.02 0-0.09 0.04 0.12

Summary: The ACF density can be determined by MC ex vivo. Subjects with colorectal cancer appear to have higher ACF densities compared to patients with benign diseases. Conclusion: Magnification chromoscopy can detect ACF ex vivo and may become a useful technique for estimating the ACF density in vivo. Given large variations in the ACF density values, however, large groups of subjects need to be evaluated to determine if the density is significantly higher in patients with colorectal cancer compared to those with benign diseases.

VOLUME 47, NO.4, 1998

COLON AND RECTUM *323 RISK MANAGEMENT OF POST·POLYPECTOMY LOWER GAS· TROINTESTINAL BLEEDING D. Sorbi, I. Norton, R. Balm, A. R. Zinsmeister, C. J. Gostout, GI Bleeding Team,

*325 POSSmILITY OF CURATIVE ENDOSCOPIC RESECTION FOR COLORECTAL CANCER WITH SUBMUCOSALLY MASSIVE INVASION

Mayo Clinic, Rochester, MN Introduction: Post-polypectomy bleeding (PPB) may warrant transfusions, intensive care (lCU) monitoring, and surgery. Studies have suggested that the highest risk is with large and right-sided polyps, coagulopathies, or platelet dysfunction. The role of ICU monitoring, however, has not been established. Aim: To seek factors predictive of significant PPB, and to assess the role of ICU monitoring. Methods: Patients with post-polypectomy bleeding were identified from our prospective GI Bleeding Team Database. Information collected included age, sex, comorbidity, prior PPB, medications (ASA, NSAID, coumadin, or corticosteroids within 3 days; heparin or persantine within 1 day of presentation), polyp features/location, and polypectomy technique. Bleeding severity was assessed by hemodynamic instability (normal, tachycardic, orthostatic, hypotensive), transfusion, and ICU monitoring. The outcomes measured were control of bleeding, transfusions, recurrent bleeding (> 19/dUday hemoglobin drop, new onset hematochezia), duration of stay, and death. Results: From 4/4/1989-111 2211996, 14,575 colonoscopies with polypectomy were performed. During this time, 84 patients (57 men, 27 women) were diagnosed with PPB. The median age was 72 years (range 18-88). Major comorbidity included cardiovascular (81%), hematological (8.3%), and renal (6%) diseases. Bleeding occurred up to 17 days after polypectomy (median 5.5 days). 32.1% had taken ASA, 10.7% NSAID, 11.9% coumadin, 13.1% corticosteroids, 6% IV heparin, 7.1% SC heparin, and 7.1% persantine. 56% had normal vital signs, 8.3% were tachycardic, and 35.7% orthostatic at the time of presentation. Sessile cecal polyps > 10 mm in size snared in toto or piecemeal without submucosal saline injection were more likely the bleeding source. The median hospital stay was 3 days. 43 patients were admitted to the ICU (median stay 2 days) and were more likely to require RBC transfusions (74.4%) vs. medical floor (31.7%). The median number of units transfused was 4 in both groups. 95.2% of post-polypectomy bleeds were managed endoscopically. 8 patients rebled after a median of 5 days after admission (5 medical floor, 3 ICU). Bleeding was trivial in 3 patients. Repeat endoscopic therapy was successful in 2 out of 5 cases. 3 patients continued to have significant bleeding requiring embolization 0), or hemicolectomy (2). Summary: A larger percentage of the bleeding sites corresponded to sessile cecal polyps > 10 mm in size. Medications and comorbid conditions were associated with an increased risk of bleeding. The outcomes measured were not significantly different between the patients admitted to the ICU or the medical floor. Conclusion: Post-polypectomy hemorrhage remains an uncommon but significant complication of colonoscopic polypectomy. Polyp features and location, polypectomy technique, medications, and comorbid conditions may increase the risk of bleeding. Unless indicated because of severe comorbid illness, intensive care monitoring does not appear to affect the outcome.

S. Tanaka', K. Haruma, T. Kimura, T. Shimizu, T. Oh-e, N. Koike, Kitadai, M. Yoshihara, K. Sumii, G. Kajiyama, F. Shimamot02. 'First Dept. of Internal Medicine, Hiroshima University School of Medicine, 2Dept. of Pathology, Hiroshima University Hospital, Hiroshima, Japan The deepest invasive portion of colorectal cancer (CRC) is considered to be the part which ultimately will invade, spread locally and give metastasis. We had previously reported that histologic differentiation at the deepest invasive portion of CRC closely correlated with metastatic potential and is useful in understanding the curability of endoscopic resection (ER) (Oncology 1993, Cancer 1994, Oncology 1995, Oncology 1998 in press). The AIM of this study is to clarify the possibility of curative endoscopic resection for CRC with submucosally massive invasion. METHODS: Total of 470 cases with submucosally invasive CRC (Group A; 404 surgically resected cases, Group B; 66 follow-up cases after ER) were studied. The depth of submucosal invasion was defined as the practically measured distance form muscularis mucosae. Histologic subclassification was performed at the deepest invasive tumor margin as follows: well differentiated (W), moderately differentiated (M), poorly differentiated (Por). By assessing glandular configuration and cellular arrangement, M type was further subdivided into two different groups; moderately-well differentiated (Mw) and moderately-poorly differentiated (Mp), as described previously. RESULTS: In group A lymph node (LN) metastasis was detected in 43 (11%) of 404 cases. W or Mw lesions showed LN metastasis in 5% (8/330). Mp or Por lesions showed LN metastasis in 38% (25/74) (WlMw vs MplPor; p
*324 FREQUENCY AND ENDOSCOPIC FEATURES OF DEPRESSED TYPE OF COLORECTAL SUBMUCOSAL INVADING CANCERS

*326 USEFULNESS OF ENDOSCOPIC RETROGRADE ILEOGRAPHY IN CROHN'S DISEASE-A COMBINATION OF COLONOSCOPIC AND RADIOLOGICAL EXAMINATION

S. Tamura, J. Miyazaki, T. Yano, J. Ohsaki, S. Kagiyama, H. Ueta, M. Morita, K. Nakajo, K. Miyamoto, Y. Yokoyama, A. Kaneko, K. Yamashita, Y. Yamamoto and S. Ohnishi. First Department of Internal Medicine, Kochi Medical School; Kochi Municipal Seinan Hospital; Kochi Clinic; Kochi Municipal Sukumo Hospital; Kochi Municipal Aki Hospital; Niyodo Hospital, Kochi, JAPAN [Purpose) We assess the frequency, endoscopic features and treatment of the depressed type of colorectal submucosal invading cancer. [Patients and Methods) During the period from 1985 to November 1997, 141 submucosal invading cancers were examined. Depressed type of invading cancer accounted for 39 lesions and it occupied 27.7% of all the invading cancer. We classified the submucosal extension of early cancer according to the vertical and horizontal level of invasion'. We defined laterally spreading tumor (LST) as the tumor which has a tendency oflaterally spreading growth and the tumor size is more than lOmm in a diameter. Treatment of depressed type of colorectallesions consists of either endoscopic mucosal resection (EMR) and/or surgery. EMR is the first step in the treatment of depressed type lesions. Further treatment depends on the histopathological results of resected specimens. [Result) In the examination of submucosal invading cancer, vessel invasion occurred in sm1b extension cancer and Iymphonodus metastasis occurred in sm2 and more advanced stages extension cancer. Therefore endoscopic treatment is snitable in sm1 extension without vessel invasion. Lesions were treated by endoscopically (27.6%) and surgically (45.4%). Other invading cancers (27.0%) were treated by endoscopically at first, then followed surgical treatment because of the sm2 and more advanced stages extension cancer. The rates of depressed colorectal lesion under 5mm, from 6mm to lOmm, from 11mm to 15mm, 16mm or over in diameter were 100%(1/1), 28.0%(9/32), 32.4%(12/37), 25.0%(17/68) respectively. Furthermore the rates of depressed colorectallesion in sm1a, sm1b, sm1c, sm2, sm3 extension cancer were 11.8%(2117), 7.7%(/13), 0%(0112), 27.7%(18/65), 54.5%(18/33) respectively. The endoscopic features of depressed type lesions of sm2 and more advanced stages extension cancer were sclerous change and lack of air induced deformation. [Conclusion) The frequency of depressed type invading cancer was high in sm2(27.7%) and sm3(54.5%) extension cancer. Therefore we can not deny the possibility of overlooking the small depressed type cancer in sm1 extension cancer. We should have a sure eye for the small depressed lesion with pale redness. 1) S.Kudo, S.Tamura, T.Nakajima, et 0.1.; Endoscopy 1993;25'455-461

VOLUME 47, NO.4, 1998

M. Taruishi, Y. Saitoh, M. Honda, T. Fujiki, M. Taniguchi, J. Warari, T. Ayabe, T. Ashida, T. Obara and Y. Kohgo, Third Department of Internal Medicine, Asahikawa Medical College, Asahikawa, Japan Background and Aim: The ileum is frequently affected in Crohn's disease but detailed evaluation is difficult by enteroclysis because of multiple overlapping loops crowded together. We studied the usefulness of endoscopic retrograde ileography (ERIG) that is a combination of colonoscopic and radiological ileal examination for the evaluation of the disease activity in Crohn's disease. Methods: Between April 1990 and July 1997, a total of 43 cases of established Crohn's disease patients were performed ERIG in 88 times. Four cases were colitis, 17 cases were ileocolitis and 22 cases were ileitis type. ERIG was performed as preoperative examinations in 14 cases and as evaluation of disease activity in 29 cases. Total colonoscopy was performed, followed by intubation to the ileum with chromoscopy or taking biopsy if necessary. After a guide wire (0.052 inch diameter and 3m length) was introduced through the forceps channel into the ileum, only colonoscope was removed. Silicon balloon tube 06 Fr diameter and 90 em length) was inserted over the guide wire into the terminal ileum and fixed by the expanded balloon. About 100 ml of 70% wlv barium sulfate was injected, followed by adequate amount of air into the ileum through the balloon tube. After several turning of position, double contrasted radiography was obtained. We evaluated the usefulness of ERIG as a preoperative imaging diagnosis by comparing ERIG and intraoperative findings and resected specimens and as an accurate indicator of the disease activity of Crohn's disease. Results: 1. Of total 88 examinations, 8 (9.1%) times were not succeeded because of the displacement of the balloon tube to the colon. No other complication was occurred and the complaints of patients during ERIG were slight. 2. The average length that was obtained double contrasted radiography was 149.2 em. Satisfactory double contrasted image with little overlapped loops could be obtained and early mucosal abnormalities of Crohn's disease such as aphthoid or discrete ulcers could be imaged by ERIG. 3. In 14 cases performed ERIG as a preoperative examination, the severity and the length of the stenosis were accurately evaluated in 11 cases compared with intraoperative findings and resected specimens. 4. In 29 cases as evaluation of disease activity, accurate disease activity was evaluated by only BRIG in all types ofCrohn's disease. Condusiom ERIG i. a reliable imaging diagno.tic modality that combined colono.copic and radiological examination useful for determining the choice oftherapy (strictureplasty or resection) preoperatively and for the evaluation of the accurate disease activity in all types of Grohn's disease independently.

GASTROINTESTINAL ENDOSCOPY ABI05

COLON AND RECTUM *327 MAGNIFYING COLONOSCOPY DISCRIMINATES DEGREE OF ATYPIA IN SMALL COLORECTAL NEOPLASIA CR Teixeira, NV Coelho, C Saul, RJ Torresini, EB Tonelotto Fund. Riogr. Universit. Gastroenterol., Porto Alegre, Brazil Magnifying colonoscopy (MC) allows the observation of the surface openings of colorectal crypts (pits). Endoscopic recognition of high risk small colorectal neoplasia might help in the clinical management of these lesions. AIM Determine the pit pattern of small colorectal neoplasia by (MC) and the relationship with the degree of atypia. METHODS 103 small colorectal neoplasia measuring 1-7mm in diameter (mean 4.3:': 1.3) entered the study. All lesions were examined with the 410CM Fujinon colonoscope (40x magnification). For MC evaluation of the pits each lesion was stained with 1-2ml ofpyoktanin blue 0.2% or 5-10ml of indigo-carmine 2%. Considering the normal pits as standard, neoplastic pits were classified into three types: large elongated pits (L), punctiform ring-shaped pits (S) and intermediate configuration pits (I). Macroscopically, the lesions were classified as flat (if height of the lesion did not exceed half of diameter) or polypoid. Degree of atypia was diagnosed as mild, moderate or severe according to glandular structure and cellular features. RESULTS (L) pits were observed in 45 lesions, (l) pits in 43 lesions and (S) pits in 15 lesions. Among lesions with (L) pits 41 (91%) were diagnosed as adenomas with mild atypia and 4 (9%) as moderate, whereas lesions with (l) pits 29 (67%) showed mild atypia and 14 (33%) moderate atypia. However, in lesions with (S) pits moderate atypia was diagnosed in 6 (40%) and severe atypia in 9 (60%) (p
*328 IS A MAGNIFYING COLONOSCOPY MORE USEFUL THAN ORDINARY COLONOSCOPY FOR PREDICTION OF PATHOLOGICAL DIAGNOSIS OF COLORECTAL TUMORS? T. Terai, H. Nihei, Y. Ohno, O. Kobayashi, T. Ogihara, A. Namihisa, H. Watanabe, H. Miwa, N. Sato, Department of Gastroenterology, Juntendo University, School of Medicine, Tokyo, Japan Background: Recently, a magnifying colonoscopy have been paid attention as a clinically useful diagnostic tool for diagnosis of colorectal tumors. However there were no studies available regarding whether a magnifying scope provides better ability for prediction of pathological diagnosis of the tumor than an ordinary scope. We carried out this study to validate a usefulness of a magnifying colonoscope by retrospectively comparing accuracy of its prediction of pathological diagnosis with that of an ordinary scope. Methods: 479 lesions obtained from 617 patients by endoscopic biopsy, polypectomy or mucosal resection using an ordinary endoscope CF 200-1 or CF 230-1 (Olympus Corp., Tokyo) and 872 lesions obtained from 1225 patients by the same endoscopic methods using a magnifYing endoscope CF 200-Z (Olympus Corp., Tokyo) were studied. Accuracy of prediction was compared in these 2 types of endoscopy and also in 2 tumor types: protruded and superficial. Rate of successful total colonoscopy and the mean approaching times to cecum were also studied. Results: Prediction rate of pathological diagnosis of adenoma is significantly higher by a magnifying scope than by an ordinary scope. Type of Endoscope

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329 RESULTS OF SCREENING FLEXIBLE SIGMOIDOSCOPY IN HEALTHY, NON-REFERRED, ASYMPTOMATIC SUBJECTS IN THE COMMUNITY KS Wadwa, SW Paik, PJ Thuluvath. Department of Medicine, The Johns Hopkins University, Baltimore, MD The utility of screening sigmoidoscopy in low risk, asymptomatic subjects in the community is not well established. In our institution, flexible sigmoidoscopy is offered as a part of Executive Health Program since January 1994. Aim: The aim ofour study was to determine whether the prevalence of adenomas in this non-referred, healthy, low risk population is different from average risk patients referred for screening colorectal cancer by their physicians. Method: We reviewed the results of screening flexible sigmoidoscopy in 205 asymptomatic, healthy subjects enrolled in the Executive Health Program between January 1994 to November 1997. These individuals opted voluntarily to undergo general health examination and flexible sigmoidoscopy. Results: The study population included 170 male and 35 female subjects. The median age was 54 years (range 36 to 81 years). Sigmoidoscopy revealed diminutive polyps in 66 (32%) and polyps >5mm in 4 (2%). All polyps were removed by cold biopsy. Polyps were hyperplastic in 41 subjects and tubular adenoma in 18 (9%); one had tubovillous adenoma. The rest had normal mucosa. All subjects were asked to undergo colonoscopic examination. 12 subjects underwent colonoscopic examination; the colonoscopy was normal in 9 and three had polyps in the proximal colon. None of the subjects had carcinoma. In the subject with tubovillous adenoma. Two additional polyps were detected at the hepatic flexure on follow up colonoscopy and both were hyperplastic. Conclusion: The prevalence of adenomatous polyps detected by flexible sigmoidoscopy in low risk, self-referred subjects, is similar to that of average risk, referred subjects in the community.

*330 PHOTODYNAMIC THERAPY FOR MANAGEMENT OF REFRACTORY HEMORRHAGIC RADIATION PROCTITIS.

L.M. WongKeeSong. KK Wang, A. Nourbakhsh. Department of Gastroenterology, Mayo Clinic, Rochester, MN Background: Radiation proctitis can result in transfusion-dependent bleeding refractory to topical or conventional cautery therapies. Surgical intervention carries considerable morbidity and mortality. Photodynamic therapy (PDT) is an attractive alternative modality whereby injection of a photosensitizing drug preferentially targets aberrant blood vessels. Subsequently, light activation of the drug results in thrombosis and obliteration of the neovessels. Aim: To assess the efficacy of PDT in the management of transfusion-dependent hemorrhagic radiation proctitis. Methods: PDT was applied to 3 male patients (ages 69, 76, and 82) sip radiotherapy for prostate cancer. All were chronically anemic, transfusiondependent, with radiation-induced telangiectasias and stigmata of recent bleed from radiation proctitis. All had failed traditional therapies including Nd:YAG laser, argon laser, heater probe and even experimental topical formalin therapy. Mean duration of bleeding before PDT was 13 months (range 8-22). A photosensitizing drug, hematoporphyrin derivative, was injected i.v. at a dosage of 1.75-2.0 mg/kg. Forty-eight hrs later, phototherapy was conducted on the telangiectatic areas using a cylindrical diffusing fiber passing through a flexible sigmoidoscope. A light dose of 180 J/cm2 was delivered at an output of 400 mW and wavelength of 630 nm produced from an argon-pumped tunable dye laser. Endoscopy was repeated 24 hrs post PDT to assess the degree of telangiectatic obliteration. Mean follow-up was 5 months (range 2-8). Results: Endoscopy 24 hrs post PDT demonstrated at least 50% obliteration of telangiectasias in all patients. A significant reduction in quantity and frequency of bleeding was observed. The mean hemoglobin level pre and post PDT was 8.2:':0.4 gldl and 11.1:':0.6 gldl respectively. Pre PDT, these patients required on average 1-2 units of blood monthly. Post PDT, 2 patients have been free of transfusions for a follow-up period of 5-8 months. One patient requiring blood transfusions every 2 weeks pre PDT has received a single transfusion 3 days post PDT and none since for a follow-up period of 2 months. All patients subjectively reported an improvement in quality oflife in view of minimal bleeding, reduction or elimination of blood transfusions, and enhanced stamina. Conclusions: PDT appears to be effective in controlling bleeding in patients with severe refractory radiation proctitis. In these challenging cases, PDT may be an alternative to surgical intervention. This study continues to enroll patients

to evaluate long term benefits and risks.

ABI06 GASTROINTESTINAL ENDOSCOPY

VOLUME 47, NO.4, 1998

COLON AND RECTUM/ERCP-BILIARY *331 A STUDY OF WIDELY FLAT ELEVATED LESIONS IN COLORECTAL NEOPLASM

*333 NEEDLE KNIFE SPHINCTEROTOMY. A SAFE AND EFFECTIVE PROCEDURE FOR BILIARY ACCESS

H. Yamano, S. Kudo, Y. Imai, N. Kusaka, M. Osato. Division of Gastroenterology, Akita Red Cross Hospital, Akita, JAPAN During the period from April 1985 to August 1997 we have experienced 12,448 colorectal adenomas and early cancers, and recognized that some of the lesions are very widely or circumferentially spread though they are very short in height. It is generally known that flat adenomas become sessile or pedenculated polyps in colon. We were greatly interested in the lesions, and coined a new name "laterally spreading tumors (LSTs)". The present study was carried out to clarifY the characteristics of the lesions which come under this category. [Materials and Methods] It can be speculated that flat lesions either grow upward and become protruded polyps, or extend laterally to be LSTs, but it would be difficult to predict in which way a certain small lesion may grow. Therefore we have defined for the present that LSTs should be more than 10 mm in diameter and still very short in height. During the above-mentioned period we have experienced 404 such lesions, 350 of which could be sufficiently evaluated. These LSTs were rather difficult to detect endoscopically because of its short height and its color which was almost the same as the surrounding normal mucosa. Spraying indigo carmine dye helped a lot detect and define the extent of the lesion. The orifices of colonic crypts (pits) were analyzed with magnifying colonoscopy (Olympus CF 200Z) and dissecting microscopy. [Results] LSTs were grossly classified into two groups; granular type and non-granular type (carpet-like). The former were further divided into homogeneous type and nodular-mixed type. The number of cases of homogeneous granular, nodular-mixed, and nongranular type was 113, 64 and 175, respectively. The rate of submucosally invasive cancer was 3.5% in homogeneous, 17.1% in nodular-mixed, and 6.9% in non-granular. In nodular-mixed type, 15.7% were invasive cancer for those 20-29 mm in size, and 30.4% were same for those over 30 mm. Among non-granular type LSTs, 20.0% were invasive cancer for those 20-29 mm in size, and 23.1% were same for those over 30 mm. Pit analysis with magnifying colonoscopy and/or stereomicroscope revealed that granular LSTs were composed of tubular pits and/or branched pits; while the majority of cases of non-granular type were covered only with tubular pits. In every category, almost all the invasive cancers showed non-structural pits. [Conclusion] Widely flat elevated lesions, which we named "laterally spreading tumors (LSTs)", are rather benigu in spite of their large size, but in case a nodular part exists, and/or when the diameter is over 20 mm, the tumor may be an invasive cancer. Dye-spraying helps detect the lesion and define its extent, and if non-structural pits are shown with maguifYing endoscopy, the tumor is suspected to be submucosally invasive.

D. Abi-Hanna, I. Valiozis, M. Bourke and S.J. Williams. Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia. Needle knife sphincterotomy (NKS) is a precutting technique employed to gain access to the bile duct where cannulation has not been possible with standard cannulas, sphincterotomes and wires. Its use has been controversial, with some reports claiming it adds considerable morbidity, while others claim it to be no different to standard sphincterotomy. Methods: This study evaluated 134 consecutive NKS performed over 4.5 years (Jan 1993-June 1996). The indication, immediate outcome and post procedure complications were assessed by review of the hospital and local medical officer records. Complete long term follow up was obtained by direct phone contact with the patient or their family. Out of a total of 2316 ERCPs, 610 biliary sphincterotomies and 134 NKS were performed. Results: The 134 NKS were performed for access predominantly in cases of suspected CBD stones (n=67) or pancreaticobiliary malignancy (n=58). In patients undergoing biliary sphincterotomy, 72 (8.4%) required a needle knife cut for deep access. Access to the CBD was successful in 118 of the 134 (88%) needle knifes, 100 during the first ERCP and 18 at a second ERCP. Of the 16 cases where access was not achieved, 9 had a successful combined procedure, 2 had a percutaneous cholangiogram and stent 1 had surgery and 4 had no further attempts due to a change in clinical status. Complications occurred in 7 cases (5.2%) and were classified according to standard criteria (Gastrointest endosc. 1991;37:383-93). There were 5 cases of mild pancreatitis (3.7%), all discharged on day 2 and 2 cases of retroperitoneal perforation (1.5%), both mild and discharged on day 2 following negative contrast studies. There were no episodes of significant bleeding. There was no procedure related mortality. Conclusion: In experienced hands, NKS is a safe and effective biliary access technique. It allows successful therapeutic intervention in the majority of cases where conventional cannulation techniques have failed.

*332 APPENDICEAL ORIFICE INFLAMMATION AS A SKIP LESION IN ULCERATIVE COLITIS: RELATION TO MEDICAL THERAPY AND DISEASE EXTENT

334 BILIARY OBSTRUCTION FOLLOWING ORTHOTOPIC LIVER TRANSPLANTATION (OLT) MANAGED BY COMBINED ENDOSCOPIC AND PERCUTANEOUS APPROACH

S.-K Yang, H.-Y. Jung, B.D. Cho, S.W. Nam, K.N. Shim, E.-R. Park, W.-S. Hong, Y.I. Min. Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea Several studies using colectomy specimens and a recent endoscopic study (Am J Gastroenterol 1997;92:1275) have claimed that the appendix can be involved as a skip lesion of ulcerative colitis (UC). However, as these studies were performed in patients with preexisting UC, they could not exclude the possibility of the skip lesion developed as a result of medical therapy. A prospective study was performed to determine the frequency of appendiceal orifice inflammation (AO!) as a skip lesion of UC in both the prevalent and incident cases, and to evaluate the relationship between the presence of AOI and the extent of disease. Methods: Of 149 UC patients who underwent colonoscopy between Mar. 1996 and Oct. 1997, 86 patients (prevalent 61; incident 25) were included in this study. Sixty-three patients were excluded because of 1) the failure of colonoscopy to reach the cecum (n= 18), 2) the past or present involvement of the ascending colon (n=3l) and 3) no active disease at the time of colonoscopy (n~14). Photographs and biopsy tissues were taken from each segment including appendiceal orifice, cecum and ascending colon. Positive AOI was defined as the presence of the definite macroscopic lesion supported by microscopic findings of more severe inflammation at the appendiceal orifice compared with the cecum or the ascending colon. Results: AOI was noted in 22 (26%) of 86 patients with active non-universal UC. No difference in the frequency of AOI was noted between the prevalent patients (23%) and the incident patients (32%). In the combined group of prevalent and incident patients, the frequency of AOI decreased significantly as the extent of disease increased: 35% in patients with proctitis (n=46), 19% in left-sided colitis (n=32), and 0% in extensive colitis (n~8) (p<0.05). Conclusions: AOI as a skip lesion ofUC is 1) not rare, 2) more frequent in patients with narrower extent of disease and 3) not the result of patchy improvement from the medical therapy.

VOLUME 47, NO.4, 1998

A. Ahmed, M. Sidhu, M.K. Razavi, J. Imperial, Division of Gastroenterology, Department of Medicine, Stanford University School of Medicine, Stanford, CA There are no reports that document successful treatment of patients diagnosed with non-anastomotic biliary strictures following liver transplantation (OLT) using the combined endoscopic and percutaneous approach. In fact, many such patients require re-transplantation due to repeated failure of either technique. We present a case managed successfully by combined endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTHC). A 49-year-old man who underwent OLT for chronic hepatitis B infection presented 4 months following transplantation with fever, right upper quadrant pain and cholestatic jaundice. ERCP revealed multiple biliary strictures/filling defects at the level of common, right and left hepatic ducts. Because of difficulty obtaining wire access proximal to the strictures, a PTHC was performed and a 10 French biliary drainage catheter was placed into the duodenum. A 480 em Zebra wire was introduced percutaneously and passed into the duodenum through the catheter, subsequently removed. ERCP was then repeated. The Zebra wire was pulled out through the endoscope using a polypectomy snare and a cholangiogram was obtained using a Tandem XL triple-lumen cannula .exchanged over the wire. Multiple passes with biliary stone extraction balloons were made over the wire, removing debris and black, irregularly shaped gelatinous casts. A residual filling defect was noted at the confluence. PTHC was repeated, and a 4 mm x 2 em balloon was inflated proximal to the area of bile duct narrowing and guided distally into CBD. Repeat cholangiography demonstrated improved caliber of the biliary system with adequate drainage and no further defects. The laboratory values normalized 3 days later. A percutaneous biliary catheter was left in place for 6 weeks. The patient continues to do well 2 months after the procedure. Combined percutaneous and endoscopic procedures may obviate the need for surgical intervention in some patients with post OLT biliary strictures and casts. The benefits of this approach, including avoidance ofre-transplantation, must be weighed against the increased risks associated with their performance.

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