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Biomedical subjects

David P Hurlstone

Publications and source records attributed to David P Hurlstone.

At least 19 recordsLinked to original sources
PubMed2006

Endoscopic mucosal resection for flat neoplasia in chronic ulcerative colitis: can we change the endoscopic management paradigm?

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.

Adenoma↗
PubMed2006

Does coeliac disease affect colorectal practice?

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.

Abdominal Pain↗
PubMed2006

Recent advances in chromoscopic colonoscopy and endomicroscopy.

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.

Colonic Polyps↗
PubMed2006

Refractory bleeding from portal hypertensive gastropathy: a further novel role for thalidomide therapy?

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.

Angiogenesis Inhibitors↗
PubMed2006

A new insight into non-specific abdominal pain.

This review aims to change clinical practice and alert clinicians to consider that unrecognised coeliac disease may present acutely with abdominal pain. Targeting patients who have non-specific abdominal pain or coeliac-associated symptoms/diseases may improve diagnosis.

Abdominal Pain↗
PubMed2005

Chefs' knowledge of coeliac disease (compared to the public): a questionnaire survey from the United Kingdom.

BACKGROUND: For patients with coeliac disease (CD), compliance with a gluten-free diet, when eating food not prepared at home may be difficult. AIMS: We assessed whether there are differences in the eating habits of coeliac patients when compared to the general public. In addition, we compared chefs' knowledge with the public's knowledge about CD. METHOD: A questionnaire survey about CD was performed on coeliac patients, chefs and the general public from the United Kingdom (UK). RESULTS: Three hundred and nineteen coeliac patients [mean age 53.8 years, 65.8% female], 513 members of the public [49.2 years, 62.6% female] and 322 chefs [37.6 years, 15.2% female] were interviewed. Chefs were less likely to have heard of CD when compared to the public (17.1% (55/322) versus 44.2% (227/513), respectively, P<0.0001). Coeliac patients ate less frequently at a friend's house than the general public (P = 0.003). Coeliac patients ate less frequently from take-away establishments (P<0.0001). However, coeliac patients' ate as frequently in restaurants (P = 0.078). CONCLUSIONS: In the UK, chefs appear to know less about CD than the general public. Patients with CD feel justifiably cautious when eating food not prepared at home. Educating chefs about a gluten-free diet may alleviate the social restrictions on coeliac patients.

Celiac Disease↗
PubMed2005

Practical uses of chromoendoscopy and magnification at colonoscopy.

New technologies in the form of high-magnification or zoom colonoscopy complemented by chromoscopic agents permits early detection of neoplastic colorectal lesions, particularly flat and depressed types. Establishing suitability for endoscopic resection or surgical excision can be enhanced using these techniques. Chromoscopic colonoscopy may play an important role in the routine endoscopic colorectal cancer surveillance programs in patients assuming a high risk of colorectal neoplasia. This article summarizes recent data regarding the prevalence and histopathologic characteristics of flat and depressed colorectal lesion in Western cohorts and describes how their detection and management can be improved by chromoscopy and magnification technology. The techniques required for chromoscopic colonoscopy and magnification imaging are outlined along with a review of the literature on these subjects.

Adenoma↗
PubMed2005

Are lower gastrointestinal investigations necessary in patients with coeliac disease?

BACKGROUND: Colonoscopy may be indicated in patients with coeliac disease who present with iron deficiency anaemia or in coeliac disease patients who have persisting diarrhoea despite being on a gluten-free diet. However, there are limited data to support this approach. METHODS: We prospectively recruited patients who were found to have coeliac disease, having been referred with newly diagnosed iron deficiency anaemia. We also recruited a second group of patients with known coeliac disease. These patients had persisting diarrhoea despite being on a gluten-free diet for 6 months. All patients had colonoscopy and were matched with controls (without coeliac disease) who had similar indications for colonoscopy. RESULTS: Ninety-eight consecutive new patients with coeliac disease and concurrent iron deficiency anaemia had colonoscopy performed. Twelve (12.2%) had pathology, three of which were carcinomas. This diagnostic yield was not significantly different from the findings in the control group 62/362 (17.1%) P=0.24. In coeliac disease patients with persisting diarrhoea (n=37), the diagnostic yield at colonoscopy was 1/37 (2.7%). This was significantly lower than our findings in the control group with chronic diarrhoea 55/390 (14%) P=0.05. CONCLUSION: Colonoscopy should be considered in patients with coeliac disease (over the age of 45 years) who present with iron deficiency anaemia. Whilst, for coeliac disease patients with persisting diarrhoea (on a gluten-free diet) in the absence of sinister symptoms, a flexible sigmoidoscopy may be the initial investigation in order to exclude microscopic colitis. However, further larger prospective studies are required to evaluate this approach.

Adolescent↗
PubMed2005

Prospective evaluation of high-frequency mini-probe ultrasound colonoscopic imaging in ulcerative colitis: a valid tool for predicting clinical severity.

BACKGROUND: High-frequency mini-probe ultrasound imaging permits trans-mural cross-sectional imaging of the colorectal wall. In ulcerative colitis, prognosis is dependent on the severity of mucosal inflammatory change where accurate assessment of disease activity is required to optimize medical therapy. Furthermore, predicting relapse of disease using conventional endoscopic, histopathological and clinical criteria has not proven reliable. AIM: To evaluate the correlation of high-frequency mini-probe imaging with standardized measures of clinical, endoscopic and histopathological severity. METHODS: High-frequency ultrasound images were obtained from the caecum to rectum in 200 patients. Tsuga colorectal ultrasound criteria were then compared to the endoscopic Baron score, Seo activity score and Matts histopathological grade. RESULTS: For rectal disease, the kappa coefficient between Tsuga criteria I/II and Matts grade 1/2 was 0.78 (95% CI, 0.67-0.89), 0.57 (95% CI, 0.46-0.68) and 0.48 (95% CI, 0.34-0.62) for Tsuga class IIIa/b, IVa/b and Matts grade 3a/b and 4, respectively. Colonic imaging showed a kappa coefficient between Tsuga class I/II and Matts grade1/2 of 0.76 (95% CI, 0.72-0.8). Tsuga class IIIa-IIIb/IVa-IVb as compared to Matts grade 3a-3b/4 yielded kappa coefficients of 0.49 (95% CI, 0.43-0.55) and 0.62 (95% CI, 0.56-0.69), respectively. In the rectum both the total wall thickness, mucosa and submucosa were significantly thicker in Matts grade 3b and 4 disease as compared to Matts grade 1/2 (P < 0.02) for all parameters. A significant increase in colonic total wall thickness was observed between Matts score 4 and Tsuga grade 1-3a disease (P < 0.001). CONCLUSIONS: High-frequency ultrasound is a valid adjunctive 'tool' for the trans-mural assessment of the colorectal wall in ulcerative colitis. This technique may aid in the initial diagnosis, and ongoing chronic management of disease.

Adult↗
PubMed2005

Do patients with unrecognized coeliac disease present as an emergency?

Screening studies of healthy volunteers have determined that coeliac disease affects 1% of the European population. Despite this the majority of cases are unrecognized. Coeliac disease may occasionally present as an acute emergency. Recent data, however, suggest that cases of undiagnosed coeliac disease may present to emergency departments with nonspecific abdominal pain. This review provides an update of the published data on coeliac disease. We discuss the relationship between coeliac disease and abdominal pain and ways in which this may change emergency physicians practice.

Abdominal Pain↗
PubMed2005

20-MHz high-frequency endoscopic ultrasound-assisted endoscopic mucosal resection for colorectal submucosal lesions: a prospective analysis.

GOALS: To prospectively assess the safety and efficacy of high-frequency ultrasound assisted mini-probe endoscopic mucosal resection for the treatment of colorectal submucosal tumors. Primary endpoints were tumor free vertical/horizontal resection margins and positive histopathologic diagnosis. Outcome data over a 24-month period were assessed. BACKGROUND: A 20-MHz high-frequency mini-probe ultrasound is an accurate modality for the diagnosis of stage T1m and T1 colorectal lesions. Few studies have addressed the safety and efficacy of this technology as applicable to submucosal lesions of the colorectum. METHODS: Thirty patients underwent high-frequency mini-probe ultrasound-guided endoscopic mucosal resection of 30 lesions (<20 mm diameter) using the inject and cut technique. Repeat endoscopy and ultrasound was performed at 3, 6, and 12 months post-"index" resection. RESULTS: A total of 27 lesions (90%) underwent complete resection with negative histologic margin status (median diameter, 8 mm; range, 3-20 mm). No statistical difference (P > 0.1) was observed between submucosal lesion position and histologic resection margin negativity. Three rectal lesions (10%) within the submucosal layer 3 failed to separate from the muscularis and underwent transanal excision of tumor. Bleeding occurred in 1 patient (3%). No recurrence was evident at the resection site in 27 cases (median follow-up, 9 months; range, 4-18 months). CONCLUSIONS: High-frequency mini-probe ultrasound-guided endoscopic mucosal resection is a safe and effective therapeutic modality for submucosal lesions of the colorectum. The technique offers a single-stage diagnostic and therapeutic technique for selected submucosal lesions and may offer an alternative to surgical resection.

Adult↗
PubMed2005

Association of adult celiac disease with surgical abdominal pain: a case-control study in patients referred to secondary care.

BACKGROUND: Acute abdominal pain is the most common indication for surgical admission. Nonspecific abdominal pain (NSAP) may account for up to 40% of cases. There has been no published prospective study in which adult patients presenting with acute abdominal pain are investigated for celiac disease. AIMS: We aimed to assess the association of celiac disease with surgical abdominal pain. PATIENTS AND METHODS: A case-control study was undertaken involving 300 consecutive new unselected patients presenting with acute abdominal pain (in a university hospital) and healthy controls (age and sex matched) without abdominal pain (n = 300). Initial investigations for celiac disease were immunoglobulins, IgA/IgG anti-gliadin (AGA), and endomysial antibodies (EMA). Any patient with a positive IgA AGA, EMA, or only IgG AGA in the presence of IgA deficiency was offered a small bowel biopsy to confirm the diagnosis. RESULTS: : There were 33 patients with abdominal pain who had positive antibodies, of whom 9 had histologically confirmed celiac disease (6 EMA positive; 3 EMA negative). One antibody positive patient (EMA in isolation) declined duodenal biopsy and the remaining 23 had normal duodenal mucosa. Within the control group, there were 2 cases of celiac disease. Compared with matched controls the association of acute abdominal pain with celiac disease gave an odds ratio 4.6. (P = 0.068, 95% confidence interval, 1.11-19.05). When only considering NSAP the prevalence of celiac disease was highly significant at 10.5% (9 of 86, P = 0.006). Patients' symptoms improved on a gluten-free diet at 12- to 18-month follow-up. CONCLUSION: Celiac disease was diagnosed in 3% of patients who presented with unselected acute abdominal pain to secondary care. Targeting patients who have NSAP or celiac associated symptoms/diseases may improve the diagnostic yield.

Abdomen, Acute↗
PubMed2005

Role of aberrant crypt foci detected using high-magnification-chromoscopic colonoscopy in human colorectal carcinogenesis.

Abstract Liaison between gastrointestinal endoscopists and histopathologists is essential to provide the highest standards of diagnostic accuracy and patient management. The histopathologist needs to be aware of the endoscopic findings when interpreting endoscopic biopsies. High-magnification-chromoscopic-colonoscopy (HMCC) is a new technology that provides the endoscopists with much greater resolution and functional staining of the gastrointestinal tract. Using HMCC, the endoscopist is now able to identify subtle changes in the colorectal luminal openings or crypts. Changes in crypt appearances now allow detection of aberrant crypt foci (ACF) in the colon, which might themselves be precancerous lesions but additionally might serve as a valid biomarker of subsequent adenoma and colorectal cancer formation. This article describes the role of the aberrant crypt focus in colorectal carcinogenesis and discusses the clinical impact of HMCC techniques as applicable to ACF.

Cell Transformation, Neoplastic↗