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Poliposis Adenomatosa del Colon/patología , Carcinoma in Situ/patología , Colitis Ulcerosa/patología , Colonoscopía/métodos , Neoplasias Colorrectales/patología , Carcinoma in Situ/etiología , Competencia Clínica , Colitis Ulcerosa/complicaciones , Neoplasias Colorrectales/etiología , Neoplasias Colorrectales/prevención & control , Colorantes , Progresión de la Enfermedad , Humanos , Microscopía Confocal , Invasividad Neoplásica , Estadificación de NeoplasiasRESUMEN
Advances in imaging technology and engineering have now permitted functional integration of a confocal endomicroscope into the distal tip of a conventional video colonoscope enabling imaging of the surface epithelium and the underlying lamina propria during ongoing video endoscopy. For the first time, the endoscopist is now able to resolve the surface and subsurface mucosa at cellular resolution in vivo and in real time. A new era in endoscopic imaging has therefore begun - histoendoscopy. In addition to providing a high-accuracy in vivo optical biopsy tool for the differentiation between benign hyperplasia, intra-epithelial neoplasia and carcinoma in sporadic cohorts, endomicroscopy with targeted biopsies has now been shown to increase the yield of intra-epithelial neoplasia complicating ulcerative colitis. Furthermore, recent data examining endomicroscopic molecular ex vivo imaging using anti-CD44v6 antibody has identified aberrant crypt foci based on their surface molecular expression. Receptor overexpression in vivo in humans may, in the near future, be exploited for the diagnosis of inflammation, neoplasia and in predicting targeted molecular therapy. Endomicroscopy will be key to this immuno-imaging interface. Within the present review, we discuss the current clinical evidence in support of confocal endomicroscopy and explore the new diagnostic possibilities for this technology.
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Endoscopía Capsular , Colon/patología , Colonoscopía/métodos , Microscopía Confocal , Recto/patología , Coloración y Etiquetado , Adenoma/etiología , Adenoma/patología , Endoscopios en Cápsulas , Endoscopía Capsular/tendencias , Carcinoma in Situ/etiología , Carcinoma in Situ/patología , Colitis/complicaciones , Colitis/patología , Colon/irrigación sanguínea , Colonoscopios , Colonoscopía/tendencias , Neoplasias Colorrectales/etiología , Neoplasias Colorrectales/patología , Diagnóstico Diferencial , Diseño de Equipo , Medicina Basada en la Evidencia , Humanos , Mucosa Intestinal/patología , Microscopía Confocal/instrumentación , Microscopía Confocal/tendencias , Valor Predictivo de las Pruebas , Recto/irrigación sanguíneaRESUMEN
BACKGROUND: Resection of an adenoma-like mass (ALM) in chronic ulcerative colitis (CUC) complicated by mucosal fibrosis has historically not been technically feasible. Endoscopic submucosal dissection techniques may now provide a therapeutic tool enabling the division of submucosal fibrotic scarring, hence enabling endoluminal resection for the first time in this select patient group. The aim was prospective evaluation of endoscopic submucosal dissection-assisted (ESD) resection of flat, sessile, and lateral spreading tumors in CUC complicated by submucosal desmoplasis. Clinical endpoints were postresection recurrence rates, R0 resection status, and complications. METHODS: ESD-assisted endoscopic mucosal resection (EMR) using the Olympus KD-630L insulation-tipped knife was performed on selected lesions. RESULTS: Sixty-nine patients met inclusion criteria, of which 2 were excluded due to follow-up default. En bloc resection was performed in 52/67 (78%) cases with 15/67 (7%) requiring a piecemeal approach. R0 resection was achieved in 49/52 (94%) of lesions undergoing en bloc resection (perforation rate 2/67 [3%]). Bleeding complications occurred in 7/67 (10%) of cases. No metachronous circumscribed intraepithelial neoplastic lesions or cancer was detected at follow-up. At a median of 18 months follow-up, overall cure rates for the ESD-assisted EMR cohort was 66/67 (98%). CONCLUSIONS: We have shown for the first time that endoscopic resection of ALM even in the presence of complicating mucosal fibrosis is technically achievable using a combined ESD-assisted EMR technique. In an appropriately selected cohort, this technique may provide a technically feasible and clinically acceptable therapy where otherwise colectomy would be required.
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Adenoma/cirugía , Colitis Ulcerosa/cirugía , Colon/cirugía , Neoplasias del Colon/cirugía , Colonoscopía/métodos , Adenoma/patología , Adulto , Anciano , Enfermedad Crónica , Estudios de Cohortes , Colitis Ulcerosa/patología , Colon/patología , Neoplasias del Colon/patología , Femenino , Estudios de Seguimiento , Humanos , Mucosa Intestinal/cirugía , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
BACKGROUND & AIMS: The optimal serologic tests for the detection of celiac disease and follow-up assessment remains controversial. Our aim was to evaluate all current immunologic assays for diagnosing celiac disease using the gold standard of duodenal biopsy. We also assessed whether tissue transglutaminase (tTG) antibody is a quantitative marker for histologic severity. METHODS: Consecutive adult patients referred for gastroscopy without a previous known diagnosis of celiac disease were recruited (group 1). Concurrently, patients with a known diagnosis of celiac disease on a gluten-free diet for more than 1 year undergoing repeat duodenal biopsy were identified (group 2). All patients had duodenal biopsies and serologic analysis performed for immunoglobulin(Ig) A and antibodies to human immunoglobulin (Ig)A-tTG, IgA-gliadin, IgG-gliadin, and IgA-endomysial antibody. RESULTS: Two thousand patients were recruited in the first group. Seventy-seven (3.9%) patients were diagnosed with new celiac disease. The sensitivity, specificity, positive predictive value, and negative predictive value for IgA tTG were 90.9%, 90.9%, 28.6%, and 99.6%. When adopting a 2-step approach using tTG first and then EMA the sensitivity, specificity, positive predictive value, and negative predictive value was 85.7%, 98.6%, 71.7%, and 99.7%, respectively. The use of nondeamidated IgA/IgG gliadin antibodies conferred no additional diagnostic benefit when considering the detection of adult celiac disease. In the second group 48 patients with celiac disease on a gluten-free diet were identified. Sixteen of 48 of these patients had persisting villous atrophy, but 7 of 16 (44%) had a normal tTG level. CONCLUSIONS: IgA tTG alone is a sensitive marker for celiac disease. A normal tTG level does not predict recovery of villous atrophy in patients with celiac disease on a gluten-free diet.
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Anticuerpos Antiidiotipos/análisis , Biopsia/economía , Enfermedad Celíaca/diagnóstico , Duodeno/patología , Inmunoglobulinas/inmunología , Pruebas Serológicas/economía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Biopsia/métodos , Enfermedad Celíaca/economía , Enfermedad Celíaca/inmunología , Costos y Análisis de Costo , Diagnóstico Diferencial , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Prospectivos , Pruebas Serológicas/métodos , Índice de Severidad de la EnfermedadRESUMEN
GOALS: To evaluate the diagnostic yield of push enteroscopy in relation to indication and compare the yield in patients who had capsule endoscopy followed by push enteroscopy against capsule endoscopy naive patients. BACKGROUND: With the advent of capsule endoscopy the role of push enteroscopy needs to be reevaluated. STUDY: Patients who underwent push enteroscopy from January 2002 to May 2006 were included. RESULTS: One hundred fifty-five patients underwent push enteroscopy: 93 females, average age 55 years. There were 74 cases where both push enteroscopy (PE) and capsule endoscopy (CE) were performed. Indications for PE were iron deficiency anemia (n=51), overt bleeding (n=31), suspected celiac disease (n=32), refractory celiac disease (n=19), assessment for Crohn's disease (n=10), and miscellaneous (n=12). In 148 patients, an average length of 70 cm of small bowel was examined (range 30 to 130 cm). PE was unsuccessful in 7 patients due to anatomic strictures or patient distress. The overall diagnostic yield was 30% with the highest yield in overt bleeding when compared with other subgroups (P<0.001). Nine percent of lesions were within the reach of a standard endoscope. Comparison of the diagnostic yield in patients who had CE followed by PE against CE naive patients was 41% versus 47%, respectively (P<1). There were no cases where push enteroscopy recognized a lesion that had not been already detected by capsule endoscopy. CONCLUSIONS: Push enteroscopy has the greatest diagnostic yield in patients with overt bleeding when compared with other referral indications. PE should be used as an adjuvant to CE for therapeutic intervention.
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Endoscopía Gastrointestinal/métodos , Hemorragia Gastrointestinal/diagnóstico , Enfermedades Intestinales/diagnóstico , Anemia Ferropénica/patología , Endoscopía Capsular/métodos , Enfermedad Celíaca/patología , Enfermedad de Crohn/patología , Diagnóstico Diferencial , Femenino , Hemorragia/patología , Humanos , Enfermedades Intestinales/patología , Intestino Delgado , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Sensibilidad y Especificidad , Reino UnidoRESUMEN
OBJECTIVE: The relationship between coeliac disease and inflammatory bowel disease (IBD) is controversial. The aim of this study was to determine the prevalence of coeliac disease in IBD and the prevalence of IBD in coeliac disease. MATERIAL AND METHODS: Patients were enrolled from specialist IBD and coeliac clinics. Antigliadins, endomysial, tissue transglutaminase antibody and total IgA levels were measured in IBD patients. Patients with positive antibodies were offered a duodenal biopsy. The notes on coeliac patients were reviewed for colonoscopic and biopsy findings. Controls were recruited from the local population. RESULTS: The study included 305 patients with coeliac disease, 354 with IBD and 601 healthy controls. The IBD group comprised 154 ulcerative colitis (UC) cases, 173 Crohn's disease, 18 indeterminate colitis and 9 cases of microscopic colitis. Forty-seven patients had positive antibodies and 3 had villous atrophy on biopsy. All three patients had positive anti-tissue transglutaminase antibodies but only two were endomysial antibody (EMA) positive. Ten coeliac patients had IBD (5 UC and 5 lymphocytic colitis). Five controls had coeliac disease and 2 had IBD (1 Crohn's disease and 1 UC). Stepwise multiple logistic regression showed only antibody positivity as being significant (p<0.0001). CONCLUSIONS: The prevalence of IBD in coeliac disease was increased 10-fold compared with that in controls (odds ratio 9.98, 95% CI 2.8-45.9, p=0.0006), while the prevalence of coeliac disease in IBD was comparable with that in controls (odds ratio 1.02, 95% CI, 0.24-4.29, p=1.0).
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Enfermedad Celíaca/complicaciones , Enfermedad Celíaca/epidemiología , Enfermedades Inflamatorias del Intestino/complicaciones , Enfermedades Inflamatorias del Intestino/epidemiología , Adulto , Enfermedad Celíaca/inmunología , Inglaterra/epidemiología , Femenino , Humanos , Inmunoglobulina A/sangre , Masculino , Persona de Mediana Edad , Prevalencia , Valores de ReferenciaRESUMEN
BACKGROUND & AIMS: The management of dysplasia-associated lesional mass (DALM) and adenoma-like mass (ALM) in chronic ulcerative colitis (CUC) differs radically, involving total pan-proctocolectomy vs endoscopic resection and surveillance. Such lesions cannot be reliably differentiated using conventional colonoscopy. Confocal laser scanning imaging enables in vivo surface and subsurface cellular resolution imaging during ongoing video endoscopy. The aim of this study was to prospectively assess the clinical applicability and predictive power of the Pentax EC3870K endomicroscope for the in vivo differentiation of ALM and DALM in CUC during ongoing videocolonoscopy. METHODS: Patients were recruited who had a diagnosis of ALM or DALM within the previous 16 weeks. Confocal laser endomicroscopic (CLE) imaging of the circumscribed lesion and 4 adjacent mucosal segments was performed. Targeted biopsy with and without tissue sampling with endoscopic mucosal resection was performed and compared with conventional histopathology as the gold standard. RESULTS: Thirty-six patients with 36 lesions fulfilled the study entry criteria. Using modified Mainz criteria for the in vivo diagnosis of ALM and DALM, the kappa coefficient of agreement between CLE and histopathologic evaluation was 0.91, and accuracy was 97% (95% confidence interval = 86%-99%). CONCLUSIONS: This is the first study addressing the novel application of the Pentax EC3870K endomicroscopy system for the in vivo differentiation of ALM and DALM during ongoing video colonoscopy in CUC. We have shown that ALM and DALM can be differentiated with a high overall accuracy, enabling the safe selection of patients suitable for endoluminal resection versus immediate referral for pan-proctocolectomy.
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Adenoma/diagnóstico , Colitis Ulcerosa/patología , Neoplasias del Colon/diagnóstico , Pólipos del Colon/diagnóstico , Colonoscopía/métodos , Mucosa Intestinal/patología , Adulto , Anciano , Biopsia , Colitis Ulcerosa/cirugía , Diagnóstico Diferencial , Femenino , Humanos , Mucosa Intestinal/cirugía , Masculino , Microscopía Confocal/métodos , Persona de Mediana Edad , Pronóstico , Grabación en VideoRESUMEN
Our objective was to evaluate the diagnostic yield and effect of capsule endoscopy on patient management in routine clinical practice. Three hundred examinations were performed (176 females; mean age, 51 years), with a median follow-up of 17 months. Indications included overt bleeding (n=55), anemia (n=104), suspected Crohn's disease (n=68), celiac disease (n=35), suspected functional symptoms (n=23), polyposis (n=5), and miscellaneous (n=10). The overall diagnostic yield was 39%, but it was notably higher in overt bleeders, 66%, compared to 46% in the anemia group (P<0.025), 32% in the suspected Crohn's group (P<0.001), and 17% in the functional group (P<0.001). As a result of capsule endoscopy, management was altered in 26% of patients. This study shows that capsule endoscopy has both a high diagnostic yield and an impact on subsequent patient management. These data further support the role of capsule endoscopy in routine clinical practice.
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Anemia/diagnóstico , Endoscopía Capsular , Enfermedad Celíaca/diagnóstico , Enfermedad de Crohn/diagnóstico , Hemorragia Gastrointestinal/diagnóstico , Neoplasias Gastrointestinales/diagnóstico , Poliposis Intestinal/diagnóstico , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Anemia/terapia , Endoscopía Capsular/efectos adversos , Enfermedad Celíaca/terapia , Niño , Enfermedad de Crohn/terapia , Femenino , Estudios de Seguimiento , Hemorragia Gastrointestinal/terapia , Neoplasias Gastrointestinales/terapia , Humanos , Poliposis Intestinal/terapia , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios ProspectivosRESUMEN
OBJECTIVE: To determine an effective diagnostic method of detecting all cases of coeliac disease in patients referred for gastroscopy without performing routine duodenal biopsy. DESIGN: An initial retrospective cohort of patients attending for gastroscopy was analysed to derive a clinical decision tool that could increase the detection of coeliac disease without performing routine duodenal biopsy. The tool incorporated serology (measuring antibodies to tissue transglutaminase) and stratifying patients according to their referral symptoms (patients were classified as having a "high risk" or "low risk" of coeliac disease). The decision tool was then tested on a second cohort of patients attending for gastroscopy. In the second cohort all patients had a routine duodenal biopsy and serology performed. SETTING: Teaching hospital in Sheffield. PARTICIPANTS: 2000 consecutive adult patients referred for gastroscopy recruited prospectively. MAIN OUTCOME MEASURE: Evaluation of a clinical decision tool using patients' referral symptoms, tissue transglutaminase antibody results, and duodenal biopsy results. RESULTS: No cases of coeliac disease were missed by the pre-endoscopy testing algorithm. The prevalence of coeliac disease in patients attending for endoscopy was 3.9% (77/2000, 95% confidence interval 3.1% to 4.8%). The prevalence in the high risk and low risk groups was 9.6% (71/739, 7.7% to 12.0%) and 0.5% (6/1261, 0.2% to 1.0%). The prevalence of coeliac disease in patients who were negative for tissue transglutaminase antibody was 0.4% (7/2000). The sensitivity, specificity, positive predictive value, and negative predictive value for a positive antibody result to diagnose coeliac disease was 90.9%, 90.9%, 28.6%, and 99.6%, respectively. Evaluation of the clinical decision tool gave a sensitivity, specificity, positive predictive value, and negative predictive value of 100%, 60.8%, 9.3%, and 100%, respectively. CONCLUSIONS: Pre-endoscopy serological testing in combination with biopsy of high risk cases detected all cases of coeliac disease. The use of this decision tool may enable the endoscopist to target patients who need a duodenal biopsy.
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Enfermedad Celíaca/diagnóstico , Técnicas de Apoyo para la Decisión , Gastroscopía/estadística & datos numéricos , Adolescente , Adulto , Anticuerpos/análisis , Femenino , Humanos , Masculino , Persona de Mediana Edad , Derivación y Consulta , Estudios Retrospectivos , Transglutaminasas/análisis , Transglutaminasas/inmunologíaRESUMEN
Capsule endoscopy is a novel technique for examining the small bowel; however, data interpretation is time consuming and requires expertise. This study aimed to compare the interpretation of capsule endoscopy between an experienced gastroenterologist and a nurse. A total of 50 consecutive videos were viewed independently by a nurse and a physician, both blinded to the referral indications. The nurse had no prior experience with capsule endoscopy. Possible pathology was graded in a pre-agreed standardized manner, with findings described as "relevant," "uncertain," or "irrelevant." Another gastroenterologist, who had knowledge of all the cases including follow-up data and clinical outcomes, independently arbitrated. Findings showed no difference in the number of relevant or uncertain pathologies identified. The nurse reader was more likely to record irrelevant findings (4.7 vs. 2.0 lesions; p < .01) and required more time to read the videos than the physician (mean = 73 vs. 58 min; p < .01). This study shows that a nurse capsule endoscopy reader is as capable as an experienced physician in identifying small bowel mucosal abnormalities on capsule endoscopy. Capsule endoscopy is an area in which nurses could develop as physician extenders.
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Endoscopía Capsular/enfermería , Gastroenterología/normas , Hemorragia Gastrointestinal/patología , Intestino Delgado/patología , Rol de la Enfermera , Evaluación en Enfermería/normas , Anemia Ferropénica/etiología , Anemia Ferropénica/patología , Endoscopía Capsular/métodos , Competencia Clínica/normas , Enfermedades Funcionales del Colon/complicaciones , Enfermedades Funcionales del Colon/patología , Enfermedad de Crohn/complicaciones , Enfermedad de Crohn/patología , Femenino , Hemorragia Gastrointestinal/etiología , Humanos , Masculino , Persona de Mediana Edad , Investigación en Evaluación de Enfermería , Variaciones Dependientes del Observador , Asistentes Médicos/normas , Autonomía Profesional , Método Simple Ciego , Factores de TiempoRESUMEN
INTRODUCTION: Flat and depressed neoplastic lesions of the colorectum [Paris type (PT) 0-II] localized to the superficial submucosal (sm) layer can be managed using endoscopic mucosal resection. Successful endoluminal management can be enhanced using endoscopic or ultrasound tools that help predict the degree of sm invasion. Previous studies addressing invasive depth estimation using high-magnification chromoscopic colonoscopy showed a low specificity for deep sm layer 3 invasion with miniprobe ultrasound demonstrating better nodal and T stage in vivo prediction. High-resolution vascular mapping of lesions can show microvascular superficial changes that may predict sm invasive disease. AIMS: Vascular mapping in combination with high-magnification chromoscopic colonoscopy (HMCC) may provide an accurate tool for the invasive depth estimation of PT type II neoplastic lesions as compared with high frequency 20/12.5 MHz miniprobe ultrasound. METHODS: Sixty-eight patients with a known diagnosis of PT II neoplasia were imaged using 3 "back to back" imaging modalities. Phase 1-vascular ectasia mapping; phase 2-HMCC with crypt analysis according to Nagata criteria; phase 3-12.5/20 MHz miniprobe ultrasound. Lesions predicted as T0/1/N0 were resected using endoscopic mucosal resection with the remaining referred for surgery. Each imaging modality was then compared with the resected histopathologic specimen used as the "gold standard." RESULTS: N=68 lesions (19 sm1/13 sm2/36 sm3). Overall accuracy of Nagata criteria, Nagata criteria combined with vascular mapping, and ultrasound staging was 65%, 78%, and 94%, respectively (P<0.001) when observing the between phase differences. Fifty-two lesions were resected surgically. The prevalence of node positive disease was 16% (8/52) with the remaining 44/52 (84%) being confirmed pN0 at histopathology. The kappa coefficient of agreement between invasive depth estimation (using histopathology as the gold standard), Nagata stage, Nagata stage plus vascular ectasia mapping and ultrasound stage was 0.47, 0.65, and 0.9, respectively. A significant improvement in between phase differences was observed (P=0.001). CONCLUSIONS: This is the first study to address the in vivo clinical utility of vascular mapping in combination with HMCC for the T and N staging of PT II neoplasia. Combination imaging may provide an adequate clinical tool for both T and N stage assessment in vivo and help stratify those patients at high risk for T2/N1 disease that may benefit from further high-frequency miniprobe ultrasound (HFUS) assessment and possible primary surgical excision. This is important in the clinical context, given the high overall costs of a second HFUS examination, limitation of HFUS resources, and safe selection of patients undergoing primary endoscopic resection versus surgical resection.
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Neoplasias Colorrectales/diagnóstico por imagen , Ectasia Vascular Antral Gástrica/diagnóstico por imagen , Adulto , Anciano , Anciano de 80 o más Años , Colonoscopía , Femenino , Humanos , Mucosa Intestinal/diagnóstico por imagen , Mucosa Intestinal/patología , Masculino , Persona de Mediana Edad , Estudios Prospectivos , UltrasonografíaRESUMEN
INTRODUCTION: Screening studies of healthy volunteers have determined that coeliac disease affects 1% of the adult European population. Despite this, the majority of cases are unrecognised. Coeliac disease often presents in adults with non-specific gastrointestinal symptoms. This may suggest that unrecognised cases are being seen in colorectal clinics with vague gastrointestinal symptoms, iron deficiency anaemia or irritable bowel syndrome. In addition, cases of coeliac disease may also be presenting as an emergency admission with non-specific abdominal pain. OBJECTIVE: This review provides an update of the published data on case finding for coeliac disease, with the aim of improving the recognition of this disease in clinical practice.
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Enfermedad Celíaca/patología , Pautas de la Práctica en Medicina , Dolor Abdominal/complicaciones , Enfermedad Celíaca/complicaciones , Humanos , Síndrome del Colon Irritable/complicaciones , Pacientes AmbulatoriosRESUMEN
BACKGROUND: The potential of endoscopic mucosal resection (EMR) for treating flat dysplastic lesions in chronic ulcerative colitis (CUC) has not been addressed so far. Historically, such lesions were referred for colectomy. Furthermore, there are only limited data to support endoscopic resection of exophytic adenoma-like mass (ALM) lesions in colitis. AIMS: To evaluate the safety and clinical outcomes of patients with colitis undergoing EMR for Paris class 0-II and class I ALM compared with sporadic controls. Secondary aims were to re-evaluate the prevalence, anatomical "mapping" and histopathological characteristics of both Paris class 0-II and class I lesions in the context of CUC. METHODS: Prospective clinical, pathological and outcome data of patients with colitis-associated Paris class 0-II and Paris class I ALM treated with EMR (primary end points being colorectal cancer development, resection efficacy, metachronous lesion rates and post-resection recurrence rates) were compared with those of sporadic controls. RESULTS: 204 lesions were diagnosed in 169 patients during the study period: 167 (82%) diagnosed at "entry" colonoscopy, and 36 (18%) diagnosed at follow-up. 170 ALMs, 18 dysplasia-associated lesion masses (DALMs) and 16 cancers were diagnosed. A total of 4316 colonoscopies were performed throughout the study period (median per patient: 6; range: 1-8). The median follow-up period for the complete cohort was 4.1 years (range: 3.6-5.21). 1675 controls were included from our prospective database of patients without CUC who had undergone EMR for sporadic Paris class 0-II and snare polypectomy of Paris type I lesions from 1998 onwards, and were considered to be at moderate to high lifetime risk of colorectal cancer. 3792 colonoscopies were performed throughout the study period in this group (median per patient: 4; range: 1-7). The median follow-up period was 4.8 years (range: 2.9-5.2). No statistically significant differences were observed between the CUC study group and controls with respect to age, sex, median number of colonoscopies per patient, median follow-up duration, post-resection complications, median lesional diameter or interval cancer rates. However, there was a significant between-group difference regarding the prevalence of Paris class 0-II lesions in the CUC group (82/155 (61%)) compared with controls (285/801 (35%); chi(2) = 31.13; p<0.001). Furthermore, recurrence rates of lateral spreading tumours were higher in the colitis cohort (1/7 (14%)) than among controls (0/10 (0%); p = 0.048 (95% CI 11.64% to 40.21%)). CONCLUSIONS: Flat DALM, similarly to Paris class I ALM, can be managed safely by EMR in CUC. A change in management paradigm to include EMR for the resection of flat dysplastic lesions in selected cases is proposed.
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Adenoma/cirugía , Colitis Ulcerosa/complicaciones , Neoplasias del Colon/cirugía , Colonoscopía/métodos , Adenoma/etiología , Adenoma/patología , Adulto , Anciano , Enfermedad Crónica , Colitis Ulcerosa/patología , Neoplasias del Colon/etiología , Neoplasias del Colon/patología , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Lesiones Precancerosas/etiología , Lesiones Precancerosas/patología , Lesiones Precancerosas/cirugía , Estudios Prospectivos , Resultado del TratamientoRESUMEN
The basic rationale for secondary prevention of colorectal carcinoma is by endoscopic polypectomy. New technologies in the form of high-magnification or "zoom" colonoscopy complemented by chromoscopic agents permit early detection of neoplastic colorectal lesions, particularly flat and depressed types. Detailed morphologic characteristics of the surface crypt or "pit pattern" can be obtained with these techniques, enabling an in vivo "optical biopsy" and staging tool. Establishing suitability for endoscopic resection or surgical excision can be enhanced using these techniques. Furthermore, chromoscopic colonoscopy may have a role in routine endoscopic colorectal cancer surveillance programs in patients at high risk for colorectal neoplasia, such as those with long-standing ulcerative colitis and familial colorectal cancer syndromes. This review summarizes recent data regarding the prevalence and histopathologic characteristics of flat and depressed colorectal lesions in Western cohorts and describes how their detection and management can be improved by chromoscopy and magnification technology. We outline these techniques from a clinical perspective and describe the basic principles of endoscopic mucosal resection.
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Colonoscopía/métodos , Neoplasias Colorrectales/diagnóstico , Neoplasias Colorrectales/patología , Pólipos del Colon/clasificación , Pólipos del Colon/patología , Neoplasias Colorrectales/clasificación , Neoplasias Colorrectales/cirugía , Colorantes , Humanos , Aumento de la Imagen , Carmin de Índigo , Microscopía Confocal , Invasividad Neoplásica , Pronóstico , Sensibilidad y EspecificidadRESUMEN
Bleeding from portal hypertensive gastropathy (PHG) can pose a therapeutic challenge. Thalidomide, which selectively inhibits tumour necrosis factor-alpha production by enhancing messenger RNA degradation, has been shown to reduce portal venous pressure in cirrhotic and non-cirrhotic portal hypertension. Thalidomide is also a potent inhibitor of angiogenesis. We describe a case of intractable bleeding from PHG secondary to extrahepatic portal vein obstruction due to malignancy, which was managed successfully by thalidomide, thus obviating the need for major surgery. Although the use of thalidomide for treatment of severe intestinal bleeding has been described previously, this is the first case report, to our knowledge, describing its efficacy in bleeding secondary to PHG. We discuss the possible therapeutic mechanisms for thalidomide in PHG.