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Development of Cancer During a Colonoscopy Surveillance Program
Abstracts
T1412 Does the Degree Endoscopic Severity in Patients with Crohn’s Disease Correlate with Pathologic Findings On Mucosal Biopsy Specimens Matthew Bramlage, Robin E. Mendelsohn, Yves Makhoul, Ellen J. Scherl, Rhonda K. Yantiss, Brian P. Bosworth Background: Crohn’s Disease (CD) is a chronic inflammatory disease of the gastrointestinal tract. Endoscopy with biopsy remains the gold standard for diagnosing and following the clinical activity of CD, and there are a number of scoring systems aimed at quantifying the degree of visibly apparent inflammation. However, the relationship between the endoscopic impression of disease activity and the pathologic findings present in mucosal biopsy specimens has never been evaluated. The aim of this study was to determine whether the endoscopic impression of inflammation correlated with the pathologic assessment of injury present in mucosal biopsy specimens. Methods: We retrospectively identified 31 patients with known chronic CD who underwent serial colonoscopy and mucosal biopsy from January 2002 to July 2006. We quantified the endoscopically apparent inflammation (0 Z no inflammation, 1 Z mild erythema and/or loss of vascular pattern, 2 Z erythema with occasional erosions, 3 Z severe colitis with ulceration) and compared the endoscopic score for each area of the colon to the histologic grade of inflammation present in the biopsy specimen (0 Z no inflammation, 1 Z neutrophilic cryptitis, limited to !50% of the specimen, 2 Z cryptitis with luminal crypt abscesses present in !50% of the specimen, 3 Z diffuse neutrophilic inflammation in multiple crypts with ulceration). Results: The study patients (mean age: 49 years, male/female ratio: 13/18) underwent a total of 75 colonoscopies with 468 biopsies. The endoscopic scores for all of the biopsies were graded as follows: 0 Z 294 (62.8%),1 Z 119 (25.4%), 2 Z 34 (7.3%), 3 Z 21 (4.5%). The pathologic scores for all the biopsies were graded as follows: 0 Z 324 (67.6%), 1 Z 111 (23.22%), 2 Z 21 (4.4%), 3 Z 22 (4.6%). There was no correlation between the endoscopic score and the pathologic grade of inflammation (p O 0.05). However, the endoscopic impression of severe disease strongly correlated with the presence of severe colitis in mucosal biopsy specimens (p ! 0.001). Conclusions: Although endoscopic scoring systems that assess the severity of colitis in CD patients are helpful in monitoring the clinical course of disease, they do not correlate with the degree of inflammatory activity present in mucosal biopsies, except in the setting of severe colitis. The discrepancies between the endoscopic and pathologic assessment of disease activity likely represent sampling issues inherent in mucosal biopsy specimens. Thus, there should be a stronger reliance on endoscopic impression of disease activity than on the pathologic assessment of mucosal biopsies when evaluating the extent and severity of colitis in CD patients.
T1413 Development of Cancer During a Colonoscopy Surveillance Program Kenneth R. Devault, Andrew D. D’Alessandro, Jeffrey B. Albright, David S. Loeb, Timothy A. Woodward, Michael F. Picco, Murli Krishna Background: Colon cancer is preventable in most individuals with an appropriate screening and surveillance program, although no program is 100% effective. We sought to characterize patients in such a program who developed colon cancer within 10 years of an index colonoscopy. Method: Retrospective chart and database review of patients diagnosed with colon cancer in the years 2001-2005. The electronic medical record was then reviewed for a prior screening or surveillance colonoscopy performed within 10 years prior to the cancer diagnosis. Exclusion criteria included known high-risk patients with inflammatory bowel disease or familial polyposis. Data extracted included location and stage of tumor, number and timing of previous colonoscopy and any noted limitations of the colonoscopy (poor prep, incomplete exam or incomplete prior polypectomy). Results: 294 patients were identified with colon cancer by pathology report with 37 having had colonoscopy within 10 years of their cancer diagnosis. Mean age at time of cancer diagnosis was 77.8 years (range 61-91). Tumors were right-sided in 28 (76%) and left-sided in 9 (24%) patients. Cancer stages were Duke’s stage 1 (32%), stage 2 (24%), stage 3 (38%) and stage 4 (5%). Patients were then classified as to whether their follow-up prior to cancer diagnosis complied with ASGE surveillance guidelines. Thirteen patients were felt to deviate from the guidelines for the following reasons; poor prep on index colonoscopy (N Z 7), prior incomplete polypectomy (N Z 2) and adenoma O1 cm without early follow-up (N Z 4). The remaining 24 patients were in compliance with current guidelines. Of these patients, 7 had small adenomas within 3 years of their cancer diagnosis, 2 had only hyperplastic polyps on prior exams, and 15 had normal exams within 6 years of the cancer diagnosis. Size and stage of the cancers were not different in those who were in guideline compliance compared to those who were not. Conclusion: Colonoscopic screening and surveillance is an important tool in the prevention of colon cancer, but despite these efforts some patients will develop cancers. In our study, approximately one-third of these cancers might have been prevented with closer follow-up of patients with poor preparations or complicated lesions. Further study is needed to determine if the majority of cancers diagnosed despite appropriate screening surveillance are due to missed adenomatous lesions or if these patients have a lesion with a more aggressive course with short interval progression to cancer.
AB252 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 5 : 2007
T1414 Use of the Double-Balloon Enteroscopy System for Colonoscopy in Patients with a Previous Incomplete Examination Arved W. Schneider, Hartmut Vogell, Nadine Endres, Herrmann Meiburg, Marc Naumann, Gabriele Grebe-Schultheis Background: Colonoscopy is the gold standard for large-bowel diagnostic and therapy. But even experienced endoscopists may fail to complete colonoscopy because of fixation and angulation of the sigmoid colon. The double-balloon enteroscope is a more flexible, smaller-diameter and longer instrument than a standard colonoscope and therefore may provide advantages in fixed angulated colons. Methods: In 10 patients out of 1306 examined in our institution between January and November 2006 colonoscopy with a conventional colonoscope was incomplete because of marked angulations in the sigmoid colon preventing the visualisation of the lumen. In these 10 patients the examination was repeated with a double-balloon enteroscopy system (Fujinon EN-450 P5/20) consisting of an endoscope with a working length of 200 cm and an outer diameter of 8.5 mm and a flexible overtube with a length of 145 cm and an outer diameter of 12 mm. In difference to the configuration used for the small bowel examination no latex balloon was attached at the tip of the enteroscope. The results were evaluated retrospectively. Results: In all 10 patients the caecum could be intubated. The mean time needed to reach the caecum was 15.1 6.5 min. No complications occurred. Previously undiagnosed findings were obtained in 5 cases: 1-3 polyps were found in 3 patients; peridiverticulitis was seen in 2 patients. All polyps were removed endoscopically, histopathology showed adenomas (low-grade dysplasia). In one of the patients multiple large polyps were located in the proximal colon. In this case retrieving of the polyps after resection was performed by extraction of the enteroscope together with the polyp fixed in a snare through the obertube. The overtube remained in its position facilitating the redeployment of the enteroscope. Conclusion: The smaller diameter and the higher flexibility of the enteroscope in comparison with standard colonoscopes are substantial advantages for the passage through angulations of the colon. The drawback of the use of highly flexible endoscopes for colonoscopy is excessive looping. This disadvantage is reduced by the use of the overtube which is a regular component of the double-balloon enteroscopy system. Because this overtube is shorter than the enteroscope its stiffness prevents looping in the distal colon without impairment of the flexibility in the bending section of the enteroscope. Our results suggest that the doubleballoon enteroscopy system may enable endoscopists to perform complete colonoscopies in patients in whom the examination using a conventional colonoscope had failed previously because of marked angulations of the sigmoid colon.
T1415 Impact of the Creation of a Bleeding Unit On the Management of Lower Gastrointestinal Bleeding Francisco Rodriguez-Moranta, A.N.A. Berrozpe, Antonio Soriano-Izquierdo, Josep M. Botargues, Raquel Ballester, Sebastiano Biondo, Jordi Guardiola Introduction: The utility of the bleeding units has been well evaluated in upper gastrointestinal bleeding. The benefit of theses units are not well established on the management of lower gastrointestinal bleeding (LGB). Aims & Methods: Aim: To analyze the influence of the creation of a bleeding unit on the management of LGB. Design: cohort study. Setting: tertiary teaching hospital. Patients: all consecutive patients admitted with LGB during 2004 (before the bleeding unit creation -group 1-) and during 2005 (after the bleeding unit creation -group 2-). Analysis: Group 1 and 2 were compared with respect to diagnostic accuracy, chance of offering endoscopic therapy and length of stay by univariate and multivariate analysis (Cox regression or logistic regression as required) adjusting for age, comorbidity, and severity of the bleeding episode. Results: During the period from 2004 to 2005, two hundred eighty eight patients with LGB were admitted, 119 during 2004 (before the creation of the bleeding unit, group 1) and 169 during 2005 (after the creation of the bleeding unit, group 2). A definitive source of bleeding was found in 20.16% (24/119) of the patients in group 1 and in 50.88% (86/169) of the patients in group 2 (p ! 0.001). In addition, 7.5% of patients (9/119) received endoscopic treatment in group 1 and 15.69% of patients (27/169) in group 2 (p ! 0.05). Finally, the hospital length of stay was significantly longer in group 1 (8.7 8.0 days) than in group 2 (4.6 4.6 days) (p ! 0.001). In the multivariate analysis, management by the bleeding unit was independently associated with better chance of identifying a definitive source of bleeding (hazard ratio 3.93; 95% CI, 2.27-6.80; p ! 0.001) and receiving endoscopic therapy (hazard ratio 0.35; 95% CI, 0.15-0.80; p Z 0.03) and with shorter hospital stay (hazard ratio 2.04; 95% CI, 1.60-2.73; p ! 0.001). Concerning severity of bleeding, the benefit of the bleeding unit on hospital stay was more patent in patients with non severe LGB (8.16 8.79 days vs. 3.73 2.94; p ! 0.001) than in those with severe LGB (9.59 6.4 days vs. 7.23 6.98 days; p Z 0.81). Conclusion: The implementation of bleeding units improves the management of the LGB with regard to superior diagnostic accuracy, increase in the chance to receiving endoscopic therapy and reduction in the hospital stay. This benefit is more patent in less severe bleeding episodes.
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T1412 Does the Degree Endoscopic Severity in Patients with Crohn’s Disease Correlate with Pathologic Findings On Mucosal Biopsy Specimens Matthew Bramlage, Robin E. Mendelsohn, Yves Makhoul, Ellen J. Scherl, Rhonda K. Yantiss, Brian P. Bosworth Background: Crohn’s Disease (CD) is a chronic inflammatory disease of the gastrointestinal tract. Endoscopy with biopsy remains the gold standard for diagnosing and following the clinical activity of CD, and there are a number of scoring systems aimed at quantifying the degree of visibly apparent inflammation. However, the relationship between the endoscopic impression of disease activity and the pathologic findings present in mucosal biopsy specimens has never been evaluated. The aim of this study was to determine whether the endoscopic impression of inflammation correlated with the pathologic assessment of injury present in mucosal biopsy specimens. Methods: We retrospectively identified 31 patients with known chronic CD who underwent serial colonoscopy and mucosal biopsy from January 2002 to July 2006. We quantified the endoscopically apparent inflammation (0 Z no inflammation, 1 Z mild erythema and/or loss of vascular pattern, 2 Z erythema with occasional erosions, 3 Z severe colitis with ulceration) and compared the endoscopic score for each area of the colon to the histologic grade of inflammation present in the biopsy specimen (0 Z no inflammation, 1 Z neutrophilic cryptitis, limited to !50% of the specimen, 2 Z cryptitis with luminal crypt abscesses present in !50% of the specimen, 3 Z diffuse neutrophilic inflammation in multiple crypts with ulceration). Results: The study patients (mean age: 49 years, male/female ratio: 13/18) underwent a total of 75 colonoscopies with 468 biopsies. The endoscopic scores for all of the biopsies were graded as follows: 0 Z 294 (62.8%),1 Z 119 (25.4%), 2 Z 34 (7.3%), 3 Z 21 (4.5%). The pathologic scores for all the biopsies were graded as follows: 0 Z 324 (67.6%), 1 Z 111 (23.22%), 2 Z 21 (4.4%), 3 Z 22 (4.6%). There was no correlation between the endoscopic score and the pathologic grade of inflammation (p O 0.05). However, the endoscopic impression of severe disease strongly correlated with the presence of severe colitis in mucosal biopsy specimens (p ! 0.001). Conclusions: Although endoscopic scoring systems that assess the severity of colitis in CD patients are helpful in monitoring the clinical course of disease, they do not correlate with the degree of inflammatory activity present in mucosal biopsies, except in the setting of severe colitis. The discrepancies between the endoscopic and pathologic assessment of disease activity likely represent sampling issues inherent in mucosal biopsy specimens. Thus, there should be a stronger reliance on endoscopic impression of disease activity than on the pathologic assessment of mucosal biopsies when evaluating the extent and severity of colitis in CD patients.
T1413 Development of Cancer During a Colonoscopy Surveillance Program Kenneth R. Devault, Andrew D. D’Alessandro, Jeffrey B. Albright, David S. Loeb, Timothy A. Woodward, Michael F. Picco, Murli Krishna Background: Colon cancer is preventable in most individuals with an appropriate screening and surveillance program, although no program is 100% effective. We sought to characterize patients in such a program who developed colon cancer within 10 years of an index colonoscopy. Method: Retrospective chart and database review of patients diagnosed with colon cancer in the years 2001-2005. The electronic medical record was then reviewed for a prior screening or surveillance colonoscopy performed within 10 years prior to the cancer diagnosis. Exclusion criteria included known high-risk patients with inflammatory bowel disease or familial polyposis. Data extracted included location and stage of tumor, number and timing of previous colonoscopy and any noted limitations of the colonoscopy (poor prep, incomplete exam or incomplete prior polypectomy). Results: 294 patients were identified with colon cancer by pathology report with 37 having had colonoscopy within 10 years of their cancer diagnosis. Mean age at time of cancer diagnosis was 77.8 years (range 61-91). Tumors were right-sided in 28 (76%) and left-sided in 9 (24%) patients. Cancer stages were Duke’s stage 1 (32%), stage 2 (24%), stage 3 (38%) and stage 4 (5%). Patients were then classified as to whether their follow-up prior to cancer diagnosis complied with ASGE surveillance guidelines. Thirteen patients were felt to deviate from the guidelines for the following reasons; poor prep on index colonoscopy (N Z 7), prior incomplete polypectomy (N Z 2) and adenoma O1 cm without early follow-up (N Z 4). The remaining 24 patients were in compliance with current guidelines. Of these patients, 7 had small adenomas within 3 years of their cancer diagnosis, 2 had only hyperplastic polyps on prior exams, and 15 had normal exams within 6 years of the cancer diagnosis. Size and stage of the cancers were not different in those who were in guideline compliance compared to those who were not. Conclusion: Colonoscopic screening and surveillance is an important tool in the prevention of colon cancer, but despite these efforts some patients will develop cancers. In our study, approximately one-third of these cancers might have been prevented with closer follow-up of patients with poor preparations or complicated lesions. Further study is needed to determine if the majority of cancers diagnosed despite appropriate screening surveillance are due to missed adenomatous lesions or if these patients have a lesion with a more aggressive course with short interval progression to cancer.
AB252 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 5 : 2007
T1414 Use of the Double-Balloon Enteroscopy System for Colonoscopy in Patients with a Previous Incomplete Examination Arved W. Schneider, Hartmut Vogell, Nadine Endres, Herrmann Meiburg, Marc Naumann, Gabriele Grebe-Schultheis Background: Colonoscopy is the gold standard for large-bowel diagnostic and therapy. But even experienced endoscopists may fail to complete colonoscopy because of fixation and angulation of the sigmoid colon. The double-balloon enteroscope is a more flexible, smaller-diameter and longer instrument than a standard colonoscope and therefore may provide advantages in fixed angulated colons. Methods: In 10 patients out of 1306 examined in our institution between January and November 2006 colonoscopy with a conventional colonoscope was incomplete because of marked angulations in the sigmoid colon preventing the visualisation of the lumen. In these 10 patients the examination was repeated with a double-balloon enteroscopy system (Fujinon EN-450 P5/20) consisting of an endoscope with a working length of 200 cm and an outer diameter of 8.5 mm and a flexible overtube with a length of 145 cm and an outer diameter of 12 mm. In difference to the configuration used for the small bowel examination no latex balloon was attached at the tip of the enteroscope. The results were evaluated retrospectively. Results: In all 10 patients the caecum could be intubated. The mean time needed to reach the caecum was 15.1 6.5 min. No complications occurred. Previously undiagnosed findings were obtained in 5 cases: 1-3 polyps were found in 3 patients; peridiverticulitis was seen in 2 patients. All polyps were removed endoscopically, histopathology showed adenomas (low-grade dysplasia). In one of the patients multiple large polyps were located in the proximal colon. In this case retrieving of the polyps after resection was performed by extraction of the enteroscope together with the polyp fixed in a snare through the obertube. The overtube remained in its position facilitating the redeployment of the enteroscope. Conclusion: The smaller diameter and the higher flexibility of the enteroscope in comparison with standard colonoscopes are substantial advantages for the passage through angulations of the colon. The drawback of the use of highly flexible endoscopes for colonoscopy is excessive looping. This disadvantage is reduced by the use of the overtube which is a regular component of the double-balloon enteroscopy system. Because this overtube is shorter than the enteroscope its stiffness prevents looping in the distal colon without impairment of the flexibility in the bending section of the enteroscope. Our results suggest that the doubleballoon enteroscopy system may enable endoscopists to perform complete colonoscopies in patients in whom the examination using a conventional colonoscope had failed previously because of marked angulations of the sigmoid colon.
T1415 Impact of the Creation of a Bleeding Unit On the Management of Lower Gastrointestinal Bleeding Francisco Rodriguez-Moranta, A.N.A. Berrozpe, Antonio Soriano-Izquierdo, Josep M. Botargues, Raquel Ballester, Sebastiano Biondo, Jordi Guardiola Introduction: The utility of the bleeding units has been well evaluated in upper gastrointestinal bleeding. The benefit of theses units are not well established on the management of lower gastrointestinal bleeding (LGB). Aims & Methods: Aim: To analyze the influence of the creation of a bleeding unit on the management of LGB. Design: cohort study. Setting: tertiary teaching hospital. Patients: all consecutive patients admitted with LGB during 2004 (before the bleeding unit creation -group 1-) and during 2005 (after the bleeding unit creation -group 2-). Analysis: Group 1 and 2 were compared with respect to diagnostic accuracy, chance of offering endoscopic therapy and length of stay by univariate and multivariate analysis (Cox regression or logistic regression as required) adjusting for age, comorbidity, and severity of the bleeding episode. Results: During the period from 2004 to 2005, two hundred eighty eight patients with LGB were admitted, 119 during 2004 (before the creation of the bleeding unit, group 1) and 169 during 2005 (after the creation of the bleeding unit, group 2). A definitive source of bleeding was found in 20.16% (24/119) of the patients in group 1 and in 50.88% (86/169) of the patients in group 2 (p ! 0.001). In addition, 7.5% of patients (9/119) received endoscopic treatment in group 1 and 15.69% of patients (27/169) in group 2 (p ! 0.05). Finally, the hospital length of stay was significantly longer in group 1 (8.7 8.0 days) than in group 2 (4.6 4.6 days) (p ! 0.001). In the multivariate analysis, management by the bleeding unit was independently associated with better chance of identifying a definitive source of bleeding (hazard ratio 3.93; 95% CI, 2.27-6.80; p ! 0.001) and receiving endoscopic therapy (hazard ratio 0.35; 95% CI, 0.15-0.80; p Z 0.03) and with shorter hospital stay (hazard ratio 2.04; 95% CI, 1.60-2.73; p ! 0.001). Concerning severity of bleeding, the benefit of the bleeding unit on hospital stay was more patent in patients with non severe LGB (8.16 8.79 days vs. 3.73 2.94; p ! 0.001) than in those with severe LGB (9.59 6.4 days vs. 7.23 6.98 days; p Z 0.81). Conclusion: The implementation of bleeding units improves the management of the LGB with regard to superior diagnostic accuracy, increase in the chance to receiving endoscopic therapy and reduction in the hospital stay. This benefit is more patent in less severe bleeding episodes.
www.giejournal.org