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Lesion patchiness in endoscopic duodenal biopsies from adult celiac patients
April 1 9 9 5
A COMPARISON OF TRANSNASAL AND TRANSORAL OESOPHAGOGASTRODUODENOSCOPY.PA Bamoton. RJ Fitch, J Dent, Gastrointestinal Medicine, Royal Adelaide Hospital, Adelaide, South Australia. Transnasal oesophagogastroduodenoscopy (OGD) with a 5.3mm diameter endoscope has been shown to be feasible in unsedated volunteers The aim of this study was to compare efficacy, safety, patient tolerance and costs of unsedated transnasal OGD with standard sedated transoral OGD. Day patients presenting for OGD were randomly assigned to either procedure. They were monitored and oxygen given if the saturation fell below 90%. Time taken in the procedure room was recorded. Suitability for discharge from recovery was determined using a modified recovery room APGAR test, and the recovery time recorded. Patient tolerance was assessed by questionnaire post recovery, and by postal follow-up, using a visual anolegue scale. This scale ranged from 1 (very uncomfortable) to 5 (very comfortable). Disposables and medications used were recorded Sixty patients (M 33, F 27) were randomised, 32 to the transnasal group, 28 to the transoral. Visualisadon was unsatisfactory in one of each group. Minor epistaxis occured in 4 of the transnasal group. Desaturation below 90% occured only in 2 transoral procedures. Both groups reported the procedure as being at least 'tolerable' (3 on the analogue scale) with median patient tolerance recorded as 3.1 (range 1 to 5) in the transnasal group and 4.1 (range 3 to 5) in the transoral group (p<0.005). Mean procedure room time was 15 mins (range 7-28 mins) in the transnasal group and 20 mins (range 10 to 38mins) in the transoral (p< 0.0003). Mean recovery time was 7 mins in the transnasal group (range 1-32mins) and 37mins (range 5 -78mins) in the transoral group (p<0.0001). In this group of patients unsedated transnasal OGD was a safe, reasonably well-tolerated, procedure which provided adequate views in all but one patient. These results imply that the unsedated transnasal route is more cost-effective than the sedated transoral method, since it reduces procedure and recovery time and the usage of drugs and consumables. This cost advantage is offset by a slightly decreased, but still acceptable, level of patient comfort.
• THE INFLUENCE OF COLORECTAL PROCEDURES ON COLeRECTAL CANCER IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE: A CASE-CONTROL STUDY. Pradeep Bansal, Amnon Sennenberg. Division of Gastroenterology,VA Medical Center and The Medical College of Wisconsin, Milwaukee,WI. Background" It is presently unknown whether diagnostic procedures of the large intestine protect patients with inflammatory bowel disease (IBD) against colorectal cancer and its associated mortality. The Department of Veterans Affairs (VA) maintains a computerized Patient Treatment File (PTF) of all hospitalizations among US military veterans since 1970. Using the PTF for the present study, we took advantage of this large nationa/database, Containing one million hospital discharges per year, to assess the benefit of colorectal procedures in subjects with ulcerative colitis (UC) or Crohn's disease (CD). Methods, A casecontrol study comparedthe relative frequency of colorectalprocedures in IBD patients with and without colorectal cancer who had been discharged from a VA hospital between 1988 and 1992. Individual veterans were identified by their unique social security number and traced in the annual files from 1970 until their last discharge. All previous primary and secondary discharge diagnoses, as well as medical and surgical procedures,were listed by their 5-digit ICD-code. The influence of colorectalproceduresprecedingcolorectalcancer in preventingcancer or mortality was assessed by logistic regression analysis. Age, sex, race, presence of sclerosing cholangitis or diseases associated with aspirin consumption, number of previous hospital discharges, length of follow-up in the PTF, and length of IBD diagnosis served as modifier variables. Results: The case population comprised 86 subjects with CD and 101 with UC. The control population comprised 88 subjects with CD and 84 with UC. Colorectal procedures before the diagnosis of cancer totaled 93 in the CD and 131 in the UC group. The corresponding numbers among controls were 115 and 105, respectively. Colorectal procedures did not protect against the occurrence of cancer, the odds ratio (OR) being 1.05 (95% confidence interval: 0.89-1.25) for CD and f .00 (0.85-1.18) for UC. A similar lack of protectionwas observed, if the influences of individual procedures, such as flexible sigmoidoscopy or colonoscopy plus biopsy, were analyzed separately. A total of 43 case subjects died from their cancer, 8 controlsubjectsdied from other causes. Colorectal procedures did not affect mortality, the odds ratio being 1.02 (0.87-1.20) for CD and UC analyzed together. Of all modifier variables, only age exerted a significant influence. In UC only, sclerosing cholangitis was associated with an increased but not significant risk for the occurrence of cancer, OR=2.51 (0.59-10.72). Conclusions: In a population of hospitalized veterans with Crohn's disease and ulcerative colitis, diagnostic procedures of the large intestine did not affect the occurrence of colorectalcancer and its associatedmortality.
Clinical Pr a c tic e
A3
IRON DEFICIENCY ANEMIA IN A GENERAL HOSPITAL: ARE UPPER AND LOWER GASTROINTESTINAL INVESTIGATIONS BOTH NECESSARY? PA Bamoton. RH Holloway, Gastrointestinal Medicine, Royal Adelaide Hospital, Adelaide, South Australia. Current practice is to investigate both upper and lower gastrointestinal tracts in patients with unexplained iron deficiency anemia. The aim of this study was to investigate; a) the efficacy of this approach in a general hospital setting and b) whether symptoms or a positive immunochemical fecal human hemoglobin (FHH) influenced the findings of the investigations and could help to target the site of investigations more efficiently. We studied prospectively 56 patients ( 29 M, 27 F), aged 37-89 years (median 70 years), with iron deficiency anemia, as defined by Hb <11, microcytosis, serum ferritin <20g/dl (M) and <10g/dl (F) and a transferrin saturation of <10%. Premenopausal females and patients with overt blood loss were excluded. Patient's underwent a standardised symptom assessment and testing for FHH, upper gastrointestinal endoscopy with small bowel biopsy; and colonoscopy; a small bowel series was done if endoscopy failed to yield a diagnosis. Significant i.e. potentially causative gastrointestinal lesions were found in 30/55 (55%) patients: by upper gastrointestinal endoscopy in 21 (ulcer-5, polyp-4, cancer-l, erosions-l, reflux oesophagitis-9, portal gastropathy-1), colonoscopy in 11 (cancer-5, polyp-4, angiodysplasia-1, colitis-1).Two (4%) patients had both upper and lower lesions. Small bowel biopsy was abnormal in only i of 55 patients. Small bowel series detected 1 lesion in 18 patients. Significant lesions were found in 9/13 (70%) patients (3 upper, 2 both upper and lower, 4 lower) with positive FHH and 15/36 (42%) patients (13-upper, 2-1ower) with negative FHH (n.s.). Symptoms or the use of NSAIDs did not influence the yield of investigations or site of lesions found. We conclude that in patients with unexplained iron deficiency anaemia: l) clinically significant gastrointestinal lesions are common, and 2) neither symptoms nor the presence of fecal human hemoglobin predict the presence of endoscopically or radiologically detectable lesions or localise the site of the lesion, and 3) immunochemical testing for FHH does not alter clinical decision making. The findings support the routine performance of upper endoscopy and colonoscopy in the investigation of such patients, however, the value of routine small bowel biopsy is questionable in the absence of other indications of a small bowel lesion.
LESION PATCHINESS IN ENDOSCOPIC DUODENAL BIOPSIES FROM ADULT CELIAC PATIENTS, MT Bardella, P Velio, M__ Quatrini, M Rosa. Cattedra di Gastroenterologia, Istituto di Scienze Mediche, Universit& degli Studi di Milano, IRCCS Ospedale Maggiore, Milano, Italy We evaluated the prevalence of histological patchiness of lesions in endoscopic duodenal biopsy specimens taken from a series of Italian adult celiac patients.153 sets of duodenal biopsy specimens (three specimens each on average, range 2-10) for a total of 457 specimens taken from 117 celiac patients (at diagnosis in 65 and during gluten free diet in 52) during upper gastrointestinal tract endoscopy were evaluated. Biopsies were orientated on a filter paper, fixed in 10% formalin, routinely embedded and stained with hematoxylin-eosin. Technically unsatisfactory specimens or sets not including at least two satisfactory sampl~sWere discarded. All specimens were blindly examined and graded by~hree;of us.: A four-grade lesion classificatibri'was Used 'r&s follows: normall aspecific (normal villi and! crypts, mild inflammatory cells infiltration), moderate (partial ~il!ous atrophy with crypt hyperplasia) and severe (total villous atrophy with crypt hyperplasia and increased inflammatory cells). Of the 153 sets of endoscopic biopsies 146 were analyzed for a total of 438 specimens. Interobserver agreement in diagnosing and grading samples was complete for 428 specimens; in ten there was a difference, always of only one grade, in judging severity of lesions. Patchiness of histologic lesions was observed in five sets from patients at diagnosis and in two from patients on gluten free diet; the difference in severity was no greater than one grade. In only one case did patchiness of histologic lesions cause diagnostic problems. Conclusion In this series of adult celiac patients patchy distribution of histologic lesions was rare. Considering the high prevalence of celiac disease in Italy, the intriguing clinical pattern of the disease, and possible progression to lymphoma in untreated patients, we suggest that during upper gastrointestinal tract endoscopy, performed for whatever reason, at least one distal duodenal biopsy should always be taken.
A COMPARISON OF TRANSNASAL AND TRANSORAL OESOPHAGOGASTRODUODENOSCOPY.PA Bamoton. RJ Fitch, J Dent, Gastrointestinal Medicine, Royal Adelaide Hospital, Adelaide, South Australia. Transnasal oesophagogastroduodenoscopy (OGD) with a 5.3mm diameter endoscope has been shown to be feasible in unsedated volunteers The aim of this study was to compare efficacy, safety, patient tolerance and costs of unsedated transnasal OGD with standard sedated transoral OGD. Day patients presenting for OGD were randomly assigned to either procedure. They were monitored and oxygen given if the saturation fell below 90%. Time taken in the procedure room was recorded. Suitability for discharge from recovery was determined using a modified recovery room APGAR test, and the recovery time recorded. Patient tolerance was assessed by questionnaire post recovery, and by postal follow-up, using a visual anolegue scale. This scale ranged from 1 (very uncomfortable) to 5 (very comfortable). Disposables and medications used were recorded Sixty patients (M 33, F 27) were randomised, 32 to the transnasal group, 28 to the transoral. Visualisadon was unsatisfactory in one of each group. Minor epistaxis occured in 4 of the transnasal group. Desaturation below 90% occured only in 2 transoral procedures. Both groups reported the procedure as being at least 'tolerable' (3 on the analogue scale) with median patient tolerance recorded as 3.1 (range 1 to 5) in the transnasal group and 4.1 (range 3 to 5) in the transoral group (p<0.005). Mean procedure room time was 15 mins (range 7-28 mins) in the transnasal group and 20 mins (range 10 to 38mins) in the transoral (p< 0.0003). Mean recovery time was 7 mins in the transnasal group (range 1-32mins) and 37mins (range 5 -78mins) in the transoral group (p<0.0001). In this group of patients unsedated transnasal OGD was a safe, reasonably well-tolerated, procedure which provided adequate views in all but one patient. These results imply that the unsedated transnasal route is more cost-effective than the sedated transoral method, since it reduces procedure and recovery time and the usage of drugs and consumables. This cost advantage is offset by a slightly decreased, but still acceptable, level of patient comfort.
• THE INFLUENCE OF COLORECTAL PROCEDURES ON COLeRECTAL CANCER IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE: A CASE-CONTROL STUDY. Pradeep Bansal, Amnon Sennenberg. Division of Gastroenterology,VA Medical Center and The Medical College of Wisconsin, Milwaukee,WI. Background" It is presently unknown whether diagnostic procedures of the large intestine protect patients with inflammatory bowel disease (IBD) against colorectal cancer and its associated mortality. The Department of Veterans Affairs (VA) maintains a computerized Patient Treatment File (PTF) of all hospitalizations among US military veterans since 1970. Using the PTF for the present study, we took advantage of this large nationa/database, Containing one million hospital discharges per year, to assess the benefit of colorectal procedures in subjects with ulcerative colitis (UC) or Crohn's disease (CD). Methods, A casecontrol study comparedthe relative frequency of colorectalprocedures in IBD patients with and without colorectal cancer who had been discharged from a VA hospital between 1988 and 1992. Individual veterans were identified by their unique social security number and traced in the annual files from 1970 until their last discharge. All previous primary and secondary discharge diagnoses, as well as medical and surgical procedures,were listed by their 5-digit ICD-code. The influence of colorectalproceduresprecedingcolorectalcancer in preventingcancer or mortality was assessed by logistic regression analysis. Age, sex, race, presence of sclerosing cholangitis or diseases associated with aspirin consumption, number of previous hospital discharges, length of follow-up in the PTF, and length of IBD diagnosis served as modifier variables. Results: The case population comprised 86 subjects with CD and 101 with UC. The control population comprised 88 subjects with CD and 84 with UC. Colorectal procedures before the diagnosis of cancer totaled 93 in the CD and 131 in the UC group. The corresponding numbers among controls were 115 and 105, respectively. Colorectal procedures did not protect against the occurrence of cancer, the odds ratio (OR) being 1.05 (95% confidence interval: 0.89-1.25) for CD and f .00 (0.85-1.18) for UC. A similar lack of protectionwas observed, if the influences of individual procedures, such as flexible sigmoidoscopy or colonoscopy plus biopsy, were analyzed separately. A total of 43 case subjects died from their cancer, 8 controlsubjectsdied from other causes. Colorectal procedures did not affect mortality, the odds ratio being 1.02 (0.87-1.20) for CD and UC analyzed together. Of all modifier variables, only age exerted a significant influence. In UC only, sclerosing cholangitis was associated with an increased but not significant risk for the occurrence of cancer, OR=2.51 (0.59-10.72). Conclusions: In a population of hospitalized veterans with Crohn's disease and ulcerative colitis, diagnostic procedures of the large intestine did not affect the occurrence of colorectalcancer and its associatedmortality.
Clinical Pr a c tic e
A3
IRON DEFICIENCY ANEMIA IN A GENERAL HOSPITAL: ARE UPPER AND LOWER GASTROINTESTINAL INVESTIGATIONS BOTH NECESSARY? PA Bamoton. RH Holloway, Gastrointestinal Medicine, Royal Adelaide Hospital, Adelaide, South Australia. Current practice is to investigate both upper and lower gastrointestinal tracts in patients with unexplained iron deficiency anemia. The aim of this study was to investigate; a) the efficacy of this approach in a general hospital setting and b) whether symptoms or a positive immunochemical fecal human hemoglobin (FHH) influenced the findings of the investigations and could help to target the site of investigations more efficiently. We studied prospectively 56 patients ( 29 M, 27 F), aged 37-89 years (median 70 years), with iron deficiency anemia, as defined by Hb <11, microcytosis, serum ferritin <20g/dl (M) and <10g/dl (F) and a transferrin saturation of <10%. Premenopausal females and patients with overt blood loss were excluded. Patient's underwent a standardised symptom assessment and testing for FHH, upper gastrointestinal endoscopy with small bowel biopsy; and colonoscopy; a small bowel series was done if endoscopy failed to yield a diagnosis. Significant i.e. potentially causative gastrointestinal lesions were found in 30/55 (55%) patients: by upper gastrointestinal endoscopy in 21 (ulcer-5, polyp-4, cancer-l, erosions-l, reflux oesophagitis-9, portal gastropathy-1), colonoscopy in 11 (cancer-5, polyp-4, angiodysplasia-1, colitis-1).Two (4%) patients had both upper and lower lesions. Small bowel biopsy was abnormal in only i of 55 patients. Small bowel series detected 1 lesion in 18 patients. Significant lesions were found in 9/13 (70%) patients (3 upper, 2 both upper and lower, 4 lower) with positive FHH and 15/36 (42%) patients (13-upper, 2-1ower) with negative FHH (n.s.). Symptoms or the use of NSAIDs did not influence the yield of investigations or site of lesions found. We conclude that in patients with unexplained iron deficiency anaemia: l) clinically significant gastrointestinal lesions are common, and 2) neither symptoms nor the presence of fecal human hemoglobin predict the presence of endoscopically or radiologically detectable lesions or localise the site of the lesion, and 3) immunochemical testing for FHH does not alter clinical decision making. The findings support the routine performance of upper endoscopy and colonoscopy in the investigation of such patients, however, the value of routine small bowel biopsy is questionable in the absence of other indications of a small bowel lesion.
LESION PATCHINESS IN ENDOSCOPIC DUODENAL BIOPSIES FROM ADULT CELIAC PATIENTS, MT Bardella, P Velio, M__ Quatrini, M Rosa. Cattedra di Gastroenterologia, Istituto di Scienze Mediche, Universit& degli Studi di Milano, IRCCS Ospedale Maggiore, Milano, Italy We evaluated the prevalence of histological patchiness of lesions in endoscopic duodenal biopsy specimens taken from a series of Italian adult celiac patients.153 sets of duodenal biopsy specimens (three specimens each on average, range 2-10) for a total of 457 specimens taken from 117 celiac patients (at diagnosis in 65 and during gluten free diet in 52) during upper gastrointestinal tract endoscopy were evaluated. Biopsies were orientated on a filter paper, fixed in 10% formalin, routinely embedded and stained with hematoxylin-eosin. Technically unsatisfactory specimens or sets not including at least two satisfactory sampl~sWere discarded. All specimens were blindly examined and graded by~hree;of us.: A four-grade lesion classificatibri'was Used 'r&s follows: normall aspecific (normal villi and! crypts, mild inflammatory cells infiltration), moderate (partial ~il!ous atrophy with crypt hyperplasia) and severe (total villous atrophy with crypt hyperplasia and increased inflammatory cells). Of the 153 sets of endoscopic biopsies 146 were analyzed for a total of 438 specimens. Interobserver agreement in diagnosing and grading samples was complete for 428 specimens; in ten there was a difference, always of only one grade, in judging severity of lesions. Patchiness of histologic lesions was observed in five sets from patients at diagnosis and in two from patients on gluten free diet; the difference in severity was no greater than one grade. In only one case did patchiness of histologic lesions cause diagnostic problems. Conclusion In this series of adult celiac patients patchy distribution of histologic lesions was rare. Considering the high prevalence of celiac disease in Italy, the intriguing clinical pattern of the disease, and possible progression to lymphoma in untreated patients, we suggest that during upper gastrointestinal tract endoscopy, performed for whatever reason, at least one distal duodenal biopsy should always be taken.