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Routine Terminal Ileal Intubation at Colonoscopy Increases Diagnostic Yield
*W1606 Colonoscopic Diagnosis of Mucocele of the Appendix Simon A. Zanati, Norman E. Marcon, Gregory B. Haber, Gabor Kandel, Paul Kortan Aims: Mucoceles of the appendix are an uncommon and heterogeneous group of cystic neoplasms characterized by distension of the appendiceal lumen with mucus. They may come to attention by causing pain or vague right lower quadrant symptoms or, occasionally, are an incidental finding at abdominal imaging or colonoscopy. There have been no reported series of colonoscopically-diagnosed mucoceles with clinico-pathological correlation. Methods: A retrospective review of colonoscopies performed at our institution over the past 12 years was undertaken. For those reports identifying a mucocele of the appendix, patient demographics, clinical data, surgical outcomes and histopathology were obtained from hospital records. Results: Eight patients (7 female) with mucocele of the appendix were identified at colonoscopy. Four had complained of right lower quadrant pain. Of 5 patients who have had surgical resection to date, histopathological review has demonstrated mucinous cystadenoma in all cases. No cases have revealed carcinoma and there have been no deaths related to any mucocele. One patient is awaiting surgery. Conclusions: Mucocele of the appendix has a characteristic endoscopic appearance, creating a smooth bulbous indentation of the cecum with an ‘‘eye’’ formed by the appendiceal orifice. Its recognition at colonoscopy is important as it enables accurate diagnosis and directs management. Surgery is recommended in all cases given the risk for malignancy or perforation with resultant pseudomyxoma peritonei.
*W1607 Reduced Volume Versus Standard Volume Lavage Solution for Colonoscopy Juan A. Guerrero, Charles E. Brady III, John Dalton Objective: Pt tolerance of electrolyte lavage solutions for colonoscopy is often limited by the large volume required. Some evidence suggests a lower volume gives comparable cleansing and better tolerance. We compared the efficacy and safety of a reduced volume 2L sulfate-free electrolyte lavage solution plus 20 mg p.o. bisacodyl (2L+bis) with the approved 4L sulfate-free electrolyte lavage solution (4L SF-ELS). Methods: 200 adult pts (84 F, 116 M), from two centers, were randomized in a single blinded fashion. The day prior to the exam, patients were on a clear liquid diet. The 2L+bis group took 20 mg of bisacodyl and after their first bowel movement took the 2L solution. The 4L-ELS group completed their preparation in the standard manner. Patients were provided with questionnaires to record symptoms and tolerance to the method of preparation. Lab data, including hematologic and serum chemistry measures, were taken before and after the treatment period. Colonoscopists were blinded as to the method of preparation used. Bowel cleansing was scored on a four point scale (1= poor, 2= fair, 3= good, 4= excellent) with scores of 3 and 4 considered successful and 1 or 2 considered unsuccessful. Results: 188 pts completed the study protocol. There was no statistically significant difference between the 2L+bis (n=92) and 4L SF-ELS (n=96) groups in terms of pt demographics, quality of colon cleansing, or number of successful colon preparations. Analysis of pt subjective assessment of volume related symptoms associated with their bowel preparations showed significantly less fullness (p=<0.01) and overall discomfort (p=<0.01) in the 2L+bis group. Both groups showed no significant changes in hematologic or serum chemistry parameters. Conclusions: Reduced volume colon cleansing for colonoscopy with 2L+bis is safe, with efficacy similar to 4L SF-ELS and associated with less volume related symptoms.
*W1608 Endoscopic Treatment of Anorectal Condylamata Acuminata Using Argon Plasma Coagulation Georgios Alexandrakis, Periklis Apostolopoulos, Ioannis S. Papanikolaou, Marios Christoforou, Gerasimos Markatos, Panagiotis Skordilis, Alexandra Alogari, Peter Gabriel, Nikolaos Kalantzis Background: Human papillomaviruses (HPV) comprise a large family of doublestranded DNA viruses. At least 82 different HPV types have been identified; many remain yet uncharacterized. HPV infection is among the most common sexually transmitted diseases in industrialized countries. Anogenital warts (condylomata acuminata) are a common phenotypic expression of HPV, affecting 1% of the population (15% of sexually active adults in the USA have a subclinical infection); anal and perianal condylomata are an increasing problem that the gastroenterologist might be required to treat. These warts lead to itching, discomfort and bleeding in the anal region and may also be associated with anal canal neoplasia. Treatment options include chemical caustic agents, surgical ablative methods, and immunotherapy; however, a high rate of recurrence is encountered despite best of efforts. Aim: The purpose of this study was to evaluate the efficacy of Argon Plasma Coagulation (APC) in the ablation of anorectal condylomata acuminata in a series of consecutive patients. Patients and Methods: Between September 2001 and August 2002, 5 patients were referred to our Department for endoscopic
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treatment of anorectal condylomata acuminata. Three patients were female and the other 2 male, their mean age was 32.1 (ranging between 17 and 45 years of age) and all cases demonstrated condylomata acuminata in the anal and perianal region, as well as the rectum. All patients were scheduled to undergo APC to achieve the lesions’ ablation in a maximum of three sessions; intervals between the sessions would range from 20-30 days. Local anesthesia was performed for the anal and perianal warts. We used an APC disposable probe for each patient. APC settings were: power 60 Watts and gas flow 0.8 L/min, while the application time was 0.5-1 sec (APC 300, ERBE GmbH, Germany). Results: Ablation of the lesions was obtained in 3 of the patients in 3 sessions; in 1 patient 2 sessions were adequate, whereas in 1 patient a fourth session was necessary to achieve ablation. Patients remain under endoscopic follow-up (2 months after the last APC application and afterwards every six months). The mean follow-up period in our patients has been 1 year. No hemorrhage has been noticed and in none of our patients has anal incontinence been observed; moreover the lesions have not recurred in any of the patients, once ablation was achieved. Conclusions: APC seems to be an easy-toperform and effective method of treating anorectal condylomata acuminata.
*W1609 The Effect of Prior Abdominal and Pelvic Surgery on Colonoscopy Completion and Insertion Time Sang Kil Lee, Chang Hwan Choi, Tae Il Kim, Won Ho Kim Background: It is generally presumed that performing colonoscopy in patients with history of abdominal and pelvic surgery is difficult. Though adhesion after surgery seems to make it difficult to perform a colonoscopy, severity, site and incidence of adhesion after surgery are different according to types of surgery. This prospective study attempted to analyze the effect of previous abdominal and pelvic surgery on colonoscopy. Patients and Methods: The procedural completeness and the insertion time were recorded for 4840 colonoscopies performed by a single endoscopist. Patient data collected included age, sex, height, weight, indications for colonoscopy, and findings of colonoscopy. History of abdominal and pelvic surgery was classified into gastrectomy, cholecystectomy, appendectomy, colorectal resection, hysterectomy, cesarean section and the others. We excluded patients with obstructive disease of the colon or rectum, patients who did not fill up the questionnaire, and patients who had had colon resection. Finally we analyzed 4089 patients. Results: The adjusted completion rate for colonoscopy was 96.7%. The mean time to intubate was 6.2 6 4.0 minutes. History of surgery (p=0.002), inadequate bowel cleansing (p<0.001), and old age (>60 years) (p=0.027) were independent factors associated with procedural incompleteness. Among surgical history, gastrectomy (p<0.001) and hysterectomy (p<0.001) were associated with procedural incompleteness. Inadequate bowel cleansing (p=0.003), old age (p<0.001), female sex (p=0.037), and constipation as an indication (p<0.001) were independent factors associated with prolonged insertion time (>10 minutes). Among surgical history, appendectomy was related with prolonged insertion time (p=0.040). Conclusions: The effect of previous surgery on colonoscopy was trivial on the whole. However, history of gastrectomy and hysterectomy affect colonoscopy performance, and appendectomy, delayed insertion.
*W1610 Routine Terminal Ileal Intubation at Colonoscopy Increases Diagnostic Yield Alan Coss, Abdur R. Aftab, Derek Power, Frank E. Murray, Stephen E. Patchett Colonoscopy is frequently considered complete if adequate views of the cecum are achieved, with intubation of the terminal ileum (TI) reserved for those patients with specific indications. Whether routine TI intubation results in greater recognition of significant ileal pathology is unknown. AIMS. To determine the clinical and prognostic significance of isolated TI ulceration and inflammation in patients with otherwise normal colonoscopy and small bowel imaging. METHODS. A database was compiled retrospectively using data from endoscopy, pathology, and radiology records from a single hospital covering a 3-year period. Patients included had endoscopic evidence of TI ulceration or inflammation, without colonic involvement or radiological evidence of small bowel disease. Patients with an established diagnosis of inflammatory bowel disease (IBD) were excluded. RESULTS. Seventeen patients meeting the inclusion criteria were identified (mean age 44, 11 male). Four were cigarette smokers, while 7 were on regular non-steroidal anti-inflammatory drugs, including aspirin, at the time of colonoscopy. Four patients described a family history of IBD. Diarrhea and/or abdominal pain were the presenting symptoms in 14 patients. Specific medical therapy was instituted in 6 patients, including corticosteroids in 4, and 5aminosalicylates in 3. Mean follow-up was 12 months (range 2 - 39 months), at the end of which 11 patients were asymptomatic, while 6 continued to experience symptoms. 2 patients ultimately required surgery. CONCLUSION. While isolated TI ulceration represents a benign self-limiting condition in many individuals, a significant number develop chronic symptoms requiring maintenance medications or even surgery. TI intubation should, therefore, become part of routine colonoscopic evaluation to ensure that these patients are recognised.
VOLUME 59, NO. 5, 2004
*W1607 Reduced Volume Versus Standard Volume Lavage Solution for Colonoscopy Juan A. Guerrero, Charles E. Brady III, John Dalton Objective: Pt tolerance of electrolyte lavage solutions for colonoscopy is often limited by the large volume required. Some evidence suggests a lower volume gives comparable cleansing and better tolerance. We compared the efficacy and safety of a reduced volume 2L sulfate-free electrolyte lavage solution plus 20 mg p.o. bisacodyl (2L+bis) with the approved 4L sulfate-free electrolyte lavage solution (4L SF-ELS). Methods: 200 adult pts (84 F, 116 M), from two centers, were randomized in a single blinded fashion. The day prior to the exam, patients were on a clear liquid diet. The 2L+bis group took 20 mg of bisacodyl and after their first bowel movement took the 2L solution. The 4L-ELS group completed their preparation in the standard manner. Patients were provided with questionnaires to record symptoms and tolerance to the method of preparation. Lab data, including hematologic and serum chemistry measures, were taken before and after the treatment period. Colonoscopists were blinded as to the method of preparation used. Bowel cleansing was scored on a four point scale (1= poor, 2= fair, 3= good, 4= excellent) with scores of 3 and 4 considered successful and 1 or 2 considered unsuccessful. Results: 188 pts completed the study protocol. There was no statistically significant difference between the 2L+bis (n=92) and 4L SF-ELS (n=96) groups in terms of pt demographics, quality of colon cleansing, or number of successful colon preparations. Analysis of pt subjective assessment of volume related symptoms associated with their bowel preparations showed significantly less fullness (p=<0.01) and overall discomfort (p=<0.01) in the 2L+bis group. Both groups showed no significant changes in hematologic or serum chemistry parameters. Conclusions: Reduced volume colon cleansing for colonoscopy with 2L+bis is safe, with efficacy similar to 4L SF-ELS and associated with less volume related symptoms.
*W1608 Endoscopic Treatment of Anorectal Condylamata Acuminata Using Argon Plasma Coagulation Georgios Alexandrakis, Periklis Apostolopoulos, Ioannis S. Papanikolaou, Marios Christoforou, Gerasimos Markatos, Panagiotis Skordilis, Alexandra Alogari, Peter Gabriel, Nikolaos Kalantzis Background: Human papillomaviruses (HPV) comprise a large family of doublestranded DNA viruses. At least 82 different HPV types have been identified; many remain yet uncharacterized. HPV infection is among the most common sexually transmitted diseases in industrialized countries. Anogenital warts (condylomata acuminata) are a common phenotypic expression of HPV, affecting 1% of the population (15% of sexually active adults in the USA have a subclinical infection); anal and perianal condylomata are an increasing problem that the gastroenterologist might be required to treat. These warts lead to itching, discomfort and bleeding in the anal region and may also be associated with anal canal neoplasia. Treatment options include chemical caustic agents, surgical ablative methods, and immunotherapy; however, a high rate of recurrence is encountered despite best of efforts. Aim: The purpose of this study was to evaluate the efficacy of Argon Plasma Coagulation (APC) in the ablation of anorectal condylomata acuminata in a series of consecutive patients. Patients and Methods: Between September 2001 and August 2002, 5 patients were referred to our Department for endoscopic
P268
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treatment of anorectal condylomata acuminata. Three patients were female and the other 2 male, their mean age was 32.1 (ranging between 17 and 45 years of age) and all cases demonstrated condylomata acuminata in the anal and perianal region, as well as the rectum. All patients were scheduled to undergo APC to achieve the lesions’ ablation in a maximum of three sessions; intervals between the sessions would range from 20-30 days. Local anesthesia was performed for the anal and perianal warts. We used an APC disposable probe for each patient. APC settings were: power 60 Watts and gas flow 0.8 L/min, while the application time was 0.5-1 sec (APC 300, ERBE GmbH, Germany). Results: Ablation of the lesions was obtained in 3 of the patients in 3 sessions; in 1 patient 2 sessions were adequate, whereas in 1 patient a fourth session was necessary to achieve ablation. Patients remain under endoscopic follow-up (2 months after the last APC application and afterwards every six months). The mean follow-up period in our patients has been 1 year. No hemorrhage has been noticed and in none of our patients has anal incontinence been observed; moreover the lesions have not recurred in any of the patients, once ablation was achieved. Conclusions: APC seems to be an easy-toperform and effective method of treating anorectal condylomata acuminata.
*W1609 The Effect of Prior Abdominal and Pelvic Surgery on Colonoscopy Completion and Insertion Time Sang Kil Lee, Chang Hwan Choi, Tae Il Kim, Won Ho Kim Background: It is generally presumed that performing colonoscopy in patients with history of abdominal and pelvic surgery is difficult. Though adhesion after surgery seems to make it difficult to perform a colonoscopy, severity, site and incidence of adhesion after surgery are different according to types of surgery. This prospective study attempted to analyze the effect of previous abdominal and pelvic surgery on colonoscopy. Patients and Methods: The procedural completeness and the insertion time were recorded for 4840 colonoscopies performed by a single endoscopist. Patient data collected included age, sex, height, weight, indications for colonoscopy, and findings of colonoscopy. History of abdominal and pelvic surgery was classified into gastrectomy, cholecystectomy, appendectomy, colorectal resection, hysterectomy, cesarean section and the others. We excluded patients with obstructive disease of the colon or rectum, patients who did not fill up the questionnaire, and patients who had had colon resection. Finally we analyzed 4089 patients. Results: The adjusted completion rate for colonoscopy was 96.7%. The mean time to intubate was 6.2 6 4.0 minutes. History of surgery (p=0.002), inadequate bowel cleansing (p<0.001), and old age (>60 years) (p=0.027) were independent factors associated with procedural incompleteness. Among surgical history, gastrectomy (p<0.001) and hysterectomy (p<0.001) were associated with procedural incompleteness. Inadequate bowel cleansing (p=0.003), old age (p<0.001), female sex (p=0.037), and constipation as an indication (p<0.001) were independent factors associated with prolonged insertion time (>10 minutes). Among surgical history, appendectomy was related with prolonged insertion time (p=0.040). Conclusions: The effect of previous surgery on colonoscopy was trivial on the whole. However, history of gastrectomy and hysterectomy affect colonoscopy performance, and appendectomy, delayed insertion.
*W1610 Routine Terminal Ileal Intubation at Colonoscopy Increases Diagnostic Yield Alan Coss, Abdur R. Aftab, Derek Power, Frank E. Murray, Stephen E. Patchett Colonoscopy is frequently considered complete if adequate views of the cecum are achieved, with intubation of the terminal ileum (TI) reserved for those patients with specific indications. Whether routine TI intubation results in greater recognition of significant ileal pathology is unknown. AIMS. To determine the clinical and prognostic significance of isolated TI ulceration and inflammation in patients with otherwise normal colonoscopy and small bowel imaging. METHODS. A database was compiled retrospectively using data from endoscopy, pathology, and radiology records from a single hospital covering a 3-year period. Patients included had endoscopic evidence of TI ulceration or inflammation, without colonic involvement or radiological evidence of small bowel disease. Patients with an established diagnosis of inflammatory bowel disease (IBD) were excluded. RESULTS. Seventeen patients meeting the inclusion criteria were identified (mean age 44, 11 male). Four were cigarette smokers, while 7 were on regular non-steroidal anti-inflammatory drugs, including aspirin, at the time of colonoscopy. Four patients described a family history of IBD. Diarrhea and/or abdominal pain were the presenting symptoms in 14 patients. Specific medical therapy was instituted in 6 patients, including corticosteroids in 4, and 5aminosalicylates in 3. Mean follow-up was 12 months (range 2 - 39 months), at the end of which 11 patients were asymptomatic, while 6 continued to experience symptoms. 2 patients ultimately required surgery. CONCLUSION. While isolated TI ulceration represents a benign self-limiting condition in many individuals, a significant number develop chronic symptoms requiring maintenance medications or even surgery. TI intubation should, therefore, become part of routine colonoscopic evaluation to ensure that these patients are recognised.
VOLUME 59, NO. 5, 2004