- Email: [email protected]
Easy access for colonoscopy does not assure patient compliance with colon cancer screening
S108
Abstracts
AJG – Vol. 97, No. 9, Suppl., 2002
quality than other patients (p⫽0.003).Quality of preparations using the PEG solution plus bisacodyl tablet and sodium phosphate plus bisacodyl tablet groups were similar.The number of flushes were more in the PEG solution alone group, but was not statistically significant.There were no significant differences in taste, side effects and ease of use of the preparations across the groups.Overall quality of preparation was better in female than male patients. Assessment of preparation Excellent ⫽4 Good ⫽3 Adequate ⫽2 Poor ⫽1
Age Sex(M/F)%
No formed stool, minimal fluid. Occasional stool, ⬎90 % of mucosa visiualized, large volume of clear liquid. ⬍90 % of mucosa visiualized, some semisolid stool. Formed stool that could not be washed away or suctioned. PEG nⴝ49
PEG ⴙ Bisacodyl tab. nⴝ50
Sodium Phosphate ⴙ Bisacodyl tab. nⴝ49
59⫾13 39/61
62⫾11 37/63
56⫾14 42/58
Conclusions: PEG should not be used alone for colonoscopic preparation.Patients, who are unwilling to take large amounts of fluid, can be given sodium phosphate and bisacodyl tablets with good efficacy.
328 ANAL PEMPHIGUS VULGARIS: AN AUTOIMMUNE BLISTERING DISORDER ENTERING THE CLINICAL DIFFERENTIAL DIAGNOSIS OF FISSURE IN ANO Adrian H. Ormsby, M.D.*, Anuradha V. Singhal, M.D., John C. Eggenberger, M.D., Chan Ma, M.D., Min W. Lee, M.D. and Veena Shah, M.D. Anatomic Pathology and Colon and Rectal Surgery, Henry Ford Health System, Detroit, MI. Purpose: Anal fissure formation is a common condition, which is often associated with considerable morbidity and impaired quality of life, even among otherwise healthy individuals. Causes of fissure in ano include trauma associated with childbirth or hard stool formation, internal anal sphincter hypertonia and local ischemia, however, many chronic long– standing cases of fissure in ano have an uncertain etiology with many cases failing to heal without active intervention. Although uncommon, the autoimmune blistering disorder, pemphigus vulgaris, has been reported in the anal mucosa. Methods: A 39 year old male presented with a 3 month history of pain on defecation accompanied by bright rectal bleeding which was resistant to standard medical therapy. Examination revealed a chronic anterior midline fissure inferior to the dentate line with a 2.5cm adjacent mucosal ulceration. Biopsies were taken at the time of surgery and both H&E histology and imunohistochemistry using the following commercially available primary antibodies was performed using standard ABC technique: IgG (1:40,000), IgA (1:5,000), IgM (1:5,000), C3c (1:2,000), fibrinogen (1:400). (DAKO; Carpenteria, CA). Results: Histomorphologic findings showed prominent suprabasal acantholysis with blister formation. IgG and C3c intercellular immune deposits in the region of epithelial acantholysis were identified on immunohistochemical evaluation. IgA, IgM and fibrinogen immunostaining was negative. The histologic and immunohistochemical findings were diagnostic of pemphigus vulgaris. Conclusions: This is the first report to describe classic symptoms and examination findings of chronic fissure in ano in a 39 –year– old male in which biopsies and immunohistochemistry confirmed a diagnosis of pemphigus vulgaris. Autoimmune blistering disorders such as pemphigus vulgaris, albeit rare, should be considered in the clinical differential diagnosis of fissure in ano that is resistant to conventional medical treatment.
329 EASY ACCESS FOR COLONOSCOPY DOES NOT ASSURE PATIENT COMPLIANCE WITH COLON CANCER SCREENING Gottumukkala S. Raju, M.D., FACG*, Sharon Boening, R.N., Manoop Bhutani, M.D., FACG, Karen Szauter, M.D., J. Marc Shabot, M.D., FACG, Syed Jafri, M.D., Gurinder Luthra, D.O. and Ned Snyder, M.D. Internal Medicine, University of Texas Medical Branch, Galveston, TX. Purpose: Colonoscopy has been shown to be the most cost effective tool in colon cancer prevention. Recently, Medicare has approved this method as a screening tool for prevention of colon cancer. Several factors effect the outcome of a colon cancer prevention program. These include primary care physician’s initiation of screening process, which has been shown to be unsatisfactory (JGIM 2001:16:697–700). Another factor is patient compliance– ability to undergo the preparation, & keep the appointment for colonoscopy. To facilitate the use of colonoscopy as a screening procedure, we initiated a direct access endoscopy (DAE) program & this report describes our initial experience. Methods: DAE allows primary care physicians to refer medically stable patients for colonoscopy without prior consultation. Our case manager then contacts the patient, the procedure is reviewed, and steps for bowel preparation are discussed. A database is maintained to tracks each patient from the time of referral to completion of the procedure. Results: From 9/1/02 to 4/30/02, of the 619 patients (pts) scheduled for colon cancer screening, 415 (67%) pts came for the procedure. Colonoscopy to the cecum was successful in 384 (92%) pts. Barium enema was done in 29 (6.9%) pts for incomplete examination or unsatisfactory examination. Another 29 (6.9%)pts. required a repeat colonoscopy unsatisfactory examination or inability to clear polyps during the first attempt. Of the 415 pts, colon cancer was found in 3 (0.7%) pts, tubullo–villous adenomas in 19 (4.5%) pts, tubular adenomas in 91 (21%) pts, and hyperplastic polyps in 119 (28%) pts. There were no differences in compliance between different age groups (⬍65 versus ⬎65 years) and in insured and uninsured patients. Conclusions: We believe that direct access colon cancer screening program simplifies PCP’s ability to obtain screening of pts, however additional studies are required to improve compliance since a third of patients referred for screening do not comply with the recommendation & a significant proportion (1 in 20) of pts screened have advanced pathology. Additional work is underway to enhance patient compliance with this important screening method.
330 COLORECTAL CANCER SCREENING: TRENDS IN AN URBAN PRIMARY CARE SETTING Mohamed Heikal, M.D., Faisal Saghir, M.D., Helen Margellos, M.P.H., Bharat Motwani, M.D., Steven Whitman, Ph.D. and David Ansell, M.D.*. Department of Internal Medicine, Mount Sinai Hospital/ Chicago Medical School, Chicago, IL and Sinai Urban Health Institute, Chicago, IL. Purpose: To compare the colorectal cancer (CRC) screening experience among a sample selected from an inner city hospital in Chicago with results from a national survey. Methods: 245 patients were sampled from an outpatient clinic and were asked to complete a survey about CRC screening. 196 (80%) agreed to do this of which 182 (74%) had at least one previous clinic visit and were therefore eligible for the study. For analysis purposes, subjects were divided into average (AR) (n⫽134) and high risk (HR) (n⫽48) groups. HR subjects were those with a personal or family history of CRC and/or a history of blood in their stool. Questions were consistent with those on the Behavioral Risk Factor Surveillance System (BRFSS) and were generated to elicit information consistent with screening guidelines provided by the American Cancer Society. Results: Of the 182 subjects included in this analysis, 82% were Black, and the average age was 67 years (range 51 – 94). Significantly more HR than
Abstracts
AJG – Vol. 97, No. 9, Suppl., 2002
quality than other patients (p⫽0.003).Quality of preparations using the PEG solution plus bisacodyl tablet and sodium phosphate plus bisacodyl tablet groups were similar.The number of flushes were more in the PEG solution alone group, but was not statistically significant.There were no significant differences in taste, side effects and ease of use of the preparations across the groups.Overall quality of preparation was better in female than male patients. Assessment of preparation Excellent ⫽4 Good ⫽3 Adequate ⫽2 Poor ⫽1
Age Sex(M/F)%
No formed stool, minimal fluid. Occasional stool, ⬎90 % of mucosa visiualized, large volume of clear liquid. ⬍90 % of mucosa visiualized, some semisolid stool. Formed stool that could not be washed away or suctioned. PEG nⴝ49
PEG ⴙ Bisacodyl tab. nⴝ50
Sodium Phosphate ⴙ Bisacodyl tab. nⴝ49
59⫾13 39/61
62⫾11 37/63
56⫾14 42/58
Conclusions: PEG should not be used alone for colonoscopic preparation.Patients, who are unwilling to take large amounts of fluid, can be given sodium phosphate and bisacodyl tablets with good efficacy.
328 ANAL PEMPHIGUS VULGARIS: AN AUTOIMMUNE BLISTERING DISORDER ENTERING THE CLINICAL DIFFERENTIAL DIAGNOSIS OF FISSURE IN ANO Adrian H. Ormsby, M.D.*, Anuradha V. Singhal, M.D., John C. Eggenberger, M.D., Chan Ma, M.D., Min W. Lee, M.D. and Veena Shah, M.D. Anatomic Pathology and Colon and Rectal Surgery, Henry Ford Health System, Detroit, MI. Purpose: Anal fissure formation is a common condition, which is often associated with considerable morbidity and impaired quality of life, even among otherwise healthy individuals. Causes of fissure in ano include trauma associated with childbirth or hard stool formation, internal anal sphincter hypertonia and local ischemia, however, many chronic long– standing cases of fissure in ano have an uncertain etiology with many cases failing to heal without active intervention. Although uncommon, the autoimmune blistering disorder, pemphigus vulgaris, has been reported in the anal mucosa. Methods: A 39 year old male presented with a 3 month history of pain on defecation accompanied by bright rectal bleeding which was resistant to standard medical therapy. Examination revealed a chronic anterior midline fissure inferior to the dentate line with a 2.5cm adjacent mucosal ulceration. Biopsies were taken at the time of surgery and both H&E histology and imunohistochemistry using the following commercially available primary antibodies was performed using standard ABC technique: IgG (1:40,000), IgA (1:5,000), IgM (1:5,000), C3c (1:2,000), fibrinogen (1:400). (DAKO; Carpenteria, CA). Results: Histomorphologic findings showed prominent suprabasal acantholysis with blister formation. IgG and C3c intercellular immune deposits in the region of epithelial acantholysis were identified on immunohistochemical evaluation. IgA, IgM and fibrinogen immunostaining was negative. The histologic and immunohistochemical findings were diagnostic of pemphigus vulgaris. Conclusions: This is the first report to describe classic symptoms and examination findings of chronic fissure in ano in a 39 –year– old male in which biopsies and immunohistochemistry confirmed a diagnosis of pemphigus vulgaris. Autoimmune blistering disorders such as pemphigus vulgaris, albeit rare, should be considered in the clinical differential diagnosis of fissure in ano that is resistant to conventional medical treatment.
329 EASY ACCESS FOR COLONOSCOPY DOES NOT ASSURE PATIENT COMPLIANCE WITH COLON CANCER SCREENING Gottumukkala S. Raju, M.D., FACG*, Sharon Boening, R.N., Manoop Bhutani, M.D., FACG, Karen Szauter, M.D., J. Marc Shabot, M.D., FACG, Syed Jafri, M.D., Gurinder Luthra, D.O. and Ned Snyder, M.D. Internal Medicine, University of Texas Medical Branch, Galveston, TX. Purpose: Colonoscopy has been shown to be the most cost effective tool in colon cancer prevention. Recently, Medicare has approved this method as a screening tool for prevention of colon cancer. Several factors effect the outcome of a colon cancer prevention program. These include primary care physician’s initiation of screening process, which has been shown to be unsatisfactory (JGIM 2001:16:697–700). Another factor is patient compliance– ability to undergo the preparation, & keep the appointment for colonoscopy. To facilitate the use of colonoscopy as a screening procedure, we initiated a direct access endoscopy (DAE) program & this report describes our initial experience. Methods: DAE allows primary care physicians to refer medically stable patients for colonoscopy without prior consultation. Our case manager then contacts the patient, the procedure is reviewed, and steps for bowel preparation are discussed. A database is maintained to tracks each patient from the time of referral to completion of the procedure. Results: From 9/1/02 to 4/30/02, of the 619 patients (pts) scheduled for colon cancer screening, 415 (67%) pts came for the procedure. Colonoscopy to the cecum was successful in 384 (92%) pts. Barium enema was done in 29 (6.9%) pts for incomplete examination or unsatisfactory examination. Another 29 (6.9%)pts. required a repeat colonoscopy unsatisfactory examination or inability to clear polyps during the first attempt. Of the 415 pts, colon cancer was found in 3 (0.7%) pts, tubullo–villous adenomas in 19 (4.5%) pts, tubular adenomas in 91 (21%) pts, and hyperplastic polyps in 119 (28%) pts. There were no differences in compliance between different age groups (⬍65 versus ⬎65 years) and in insured and uninsured patients. Conclusions: We believe that direct access colon cancer screening program simplifies PCP’s ability to obtain screening of pts, however additional studies are required to improve compliance since a third of patients referred for screening do not comply with the recommendation & a significant proportion (1 in 20) of pts screened have advanced pathology. Additional work is underway to enhance patient compliance with this important screening method.
330 COLORECTAL CANCER SCREENING: TRENDS IN AN URBAN PRIMARY CARE SETTING Mohamed Heikal, M.D., Faisal Saghir, M.D., Helen Margellos, M.P.H., Bharat Motwani, M.D., Steven Whitman, Ph.D. and David Ansell, M.D.*. Department of Internal Medicine, Mount Sinai Hospital/ Chicago Medical School, Chicago, IL and Sinai Urban Health Institute, Chicago, IL. Purpose: To compare the colorectal cancer (CRC) screening experience among a sample selected from an inner city hospital in Chicago with results from a national survey. Methods: 245 patients were sampled from an outpatient clinic and were asked to complete a survey about CRC screening. 196 (80%) agreed to do this of which 182 (74%) had at least one previous clinic visit and were therefore eligible for the study. For analysis purposes, subjects were divided into average (AR) (n⫽134) and high risk (HR) (n⫽48) groups. HR subjects were those with a personal or family history of CRC and/or a history of blood in their stool. Questions were consistent with those on the Behavioral Risk Factor Surveillance System (BRFSS) and were generated to elicit information consistent with screening guidelines provided by the American Cancer Society. Results: Of the 182 subjects included in this analysis, 82% were Black, and the average age was 67 years (range 51 – 94). Significantly more HR than