Screening for colorectal cancer.
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Colonoscopy↗
Biomedical subjects
E Achkar
Publications and source records attributed to E Achkar.
Surgical management of high-grade dysplasia in Barrett's esophagus.
The role of surgery in patients with Barrett's esophagus and high-grade dysplasia is controversial. The aims of this study were to determine the prevalence of unsuspected early cancer and to evaluate surgical outcome in a cohort of patients with high-grade dysplasia. Records of all 16 patients who underwent esophagectomy for high-grade dysplasia from 1986 to 1991 were reviewed. All had preoperative endoscopy with no gross evidence of carcinoma, and none had a preoperative diagnosis of intramucosal or invasive carcinoma. Intramucosal carcinoma was found in six (38%) resection specimens. There were no cases of invasive carcinoma or lymph node metastases. One patient (6%) died 3 months postoperatively. The remaining patients are alive without evidence of recurrent cancer (range of follow-up, 2-68 months). Early postoperative complications occurred in seven patients (44%). Late complications occurred in 11 patients (73%). Anastomotic strictures accounted for seven of the 11 (64%) late complications. Complications were successfully managed conservatively in all but two patients. One required laryngectomy for chronic aspiration and another required a gastrojejunostomy for gastric outlet obstruction. Intramucosal carcinoma that had been unsuspected is frequently found in patients with Barrett's esophagus and high-grade dysplasia. Mortality associated with esophagectomy is low, and perioperative complications can usually be managed conservatively. Esophageal resection is indicated in appropriately selected patients with Barrett's esophagus and high-grade dysplasia.
Adenocarcinoma↗
Interaction between patient and test administrator may influence the results of edrophonium provocative testing in patients with noncardiac chest pain.
Edrophonium is a widely used provocative agent in the evaluation of noncardiac chest pain, with reported positivity rates of 30-55%. The influence of a subjective response and psychological factors on test results have not been examined previously. A retrospective analysis was performed to compare positivity rates for three physicians in the same laboratory. This was followed by a prospective study of 62 patients with noncardiac chest pain randomized to two groups. Group 1 patients were told that intravenous medication was given to observe changes in the tracing. Group 2 patients were told that the injection was to elicit their usual pain. During the 2-yr retrospective review, 260 patients were tested. The positivity rate varied from 31.1% with physician A to 20.2% with physician B and 7.5% for physician C (p = 0.001 for A vs. C, and p = 0.04 for B vs. C). In the prospective study, chest pain was elicited in nine of 62 patients (14.5%). Two of the 29 patients in group 1 (6.9%) and seven of 33 patients in group 2 (21.2%) contributed to this result. Contraction amplitude and duration increased similarly in all groups. These data suggest that edrophonium testing may be influenced by coaching, that manometric changes are similar in positive and negative tests, and that the prevalence of positive tests is lower than previously reported.
Adult↗
Prevalence of colonic neoplasia in patients with Barrett's esophagus.
Recent reports have suggested that there might be an increased risk of colonic adenomas and cancer in patients with Barrett's esophagus. We conducted a controlled prospective study investigating the risk of colonic neoplasia in 17 patients with Barrett's esophagus. Six additional patients with previous colonoscopy were considered separately. The prevalence of colonic neoplasia in these patients was compared with that in a group of 25 asymptomatic subjects participating in a screening colonoscopy study. There were three adenomas (17.6%) in the Barrett's group and 11 (44%) in the control group. Including the six Barrett's patients with previous colonoscopy, the rate was 30.4%. No cancers were found in either group. We conclude that the rate of colonic adenomas is no higher in a group of patients with Barrett's esophagus than in a group of matched asymptomatic subjects. The presence of Barrett's esophagus does not justify a special colonoscopic surveillance program.
Barrett Esophagus↗
Hyperplastic polyps seen at sigmoidoscopy are markers for additional adenomas seen at colonoscopy.
Asymptomatic individuals undergoing screening flexible sigmoidoscopy were prospectively studied. Polyps were found in 185 subjects. The endoscopist recorded an opinion on the polyps' histology based on endoscopic appearance. No polyps were removed at sigmoidoscopy. All subjects with rectosigmoid polyps then underwent colonoscopy and polypectomy. Of them, 99 subjects (54%) had at least one rectosigmoid adenoma, 69 (37%) had only hyperplastic polyps, and 17 (9%) had other findings. The endoscopists' opinion of the histopathology of polyps at sigmoidoscopy was correct for 61% of the lesions. Of subjects with adenomatous rectosigmoid polyps, 29% had additional adenomas at more proximal sites. Proximal adenomas were found in 28% of patients with hyperplastic rectosigmoid polyps. Patients with rectosigmoid hyperplastic polyps had the same risk for additional proximal adenomas as patients with rectosigmoid adenomatous polyps.
Adult↗
Features distinguishing secondary achalasia from primary achalasia.
Eighteen patients with cancer-induced or secondary achalasia (SA) were compared to 421 patients with idiopathic or primary achalasia (PA). The aim of the study was to detect any differences in clinical presentation between the two groups. Mean age of patients with SA was 57.1 (range 15-78) and 47.1 (range 1-90) in patients with PA (p = 0.02). Three patients with SA were 15, 24, and 36 yr old, respectively. Symptom frequency was comparable in SA versus PA. Mean duration of symptoms in SA was 4.5 months, with 15 of the 18 patients experiencing symptoms for six months or less. Weight loss occurred in 88.2% of patients with SA and 57.3% of patients with PA (p less than 0.05). Cancer was at the gastroesophageal junction in 16 patients, duodenum in one, and breast in one. Endoscopy showed tumor in 12 (67%). The esophagram was suspicious for tumor in only 25%. We conclude that patients with SA are older, more likely to lose weight, and have a short duration of symptoms. However, SA may occur in younger patients, and endoscopy with biopsy is necessary in any newly diagnosed case of achalasia.
Adolescent↗
Controversies, dilemmas, and dialogues. A hyperplastic polyp is discovered on flexible sigmoidoscopy. Is a full colonoscopy indicated?
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Colonoscopy↗
Hospital readmissions: a re-evaluation of criteria.
A prospective study surveyed patients discharged from the Cardiology, Cardiovascular Surgery, and Gastroenterology services of the Cleveland Clinic Hospital during April and September 1987. The total number of hospital discharges during the study period was 5,349; the study population discharged during this period included 1,640 patients (30.7% of all hospital discharges). In the study population, 149 patients were readmitted (9.1%). The percentage of readmissions was similar for both months and similar to that reported in the literature. However, when readmissions were categorized into four subsets, significant differences were found. The four categories were: 1) complication of a previous admission (16.8% of readmissions), 2) recurrence of the disease process (11.4% of readmissions), 3) planned treatment (53% of readmissions), and 4) unrelated new diagnosis (16.1% of readmissions). The authors conclude that reviewing readmission rates without using these subdivisions can be misleading, and the results are inappropriate for evaluating the quality of medical care given in an acute care hospital. They recommend that these four subdivisions be included in future studies of readmission rates in acute care hospitals.
Delivery of Health Care↗
Small polyps found during fiberoptic sigmoidoscopy in asymptomatic patients.
STUDY OBJECTIVE: To determine the prevalence of small polyps in the rectosigmoid in an asymptomatic group and the likelihood of finding synchronous neoplastic polyps proximally at colonoscopy. DESIGN: Asymptomatic patients with polyps 9 mm or less found at screening fiberoptic sigmoidoscopy were referred for colonoscopy, at which time all polyps were removed. SETTING: Screening fiberoptic sigmoidoscopy unit. PATIENTS: Referral from Executive Health Wellness Clinic and large multispeciality clinic. RESULTS: From 3923 sigmoidoscopic examinations, 258 asymptomatic subjects (7%) were identified who had polyps 9 mm or smaller. One hundred and eighty-nine patients (73%) had colonoscopy. In 179 patients, the target lesion noted at sigmoidoscopy was identified at colonoscopy. Based on histology of the target lesion, patients were divided into three groups: Group 1 (72 patients) had only hyperplastic polyps; Group 2 (69 patients) had at least one neoplastic polyp; and Group 3 (31 patients) had polyps with normal histology. Seven patients were not classified. Neoplastic polyps were found proximally in 21 patients in Group 1 (29%; 95% CI, 19 to 39), 23 patients in Group 2 (33%; 95% CI, 22 to 44), and 4 patients in Group 3 (13%; 95% CI, 4 to 30). There was no difference in mean age between groups. The results were similar when only polyps 5 mm or smaller were analyzed. CONCLUSION: Because small polyps of any histologic type in the rectosigmoid indicate a high risk for having neoplastic polyps proximally, the guidelines of both the American College of Physicians and the American Society of Gastrointestinal Endoscopy may need to be revised. Colonoscopy seems justified in any patient in whom a small polyp is discovered at sigmoidoscopy.
Adult↗
The cost of surveillance for adenocarcinoma complicating Barrett's esophagus.
A review of endoscopic records at the Cleveland Clinic Foundation over a 7-yr period yielded 72 cases of Barrett's esophagus. Ten patients had adenocarcinoma at the time of diagnosis of Barrett's esophagus (14%). Sixty-two were followed for a mean of 31 months (range 2-154 months). During this follow-up period, cancer developed in one patient, an incidence of one cancer per 166 patient yr and an annual incidence of 0.6%. Males predominated in the group with both Barrett's esophagus (55 of 72) and adenocarcinoma (10 of 11). Symptoms were similar in those with simple Barrett's esophagus and those complicated by cancer. Our findings on incidence of cancer in Barrett's was applied to a model surveillance program. The cost of yearly endoscopic surveillance is estimated to be +62,000 and 78 lost work days to discover one cancer during the follow-up period. An endoscopic surveillance program requiring every-other-year studies appears justified and would cost only half as much, annually.
Adenocarcinoma↗
Hiatal hernia in patients with achalasia.
The occurrence of hiatal hernia and achalasia in the same patient is considered to be extremely rare. There have been very few reports regarding this association. An extensive review of achalasia cases at the Cleveland Clinic is presented, with emphasis on the frequency of concomitant hiatal hernia. Our results indicate that the presence of a hiatal hernia makes the diagnosis of achalasia unlikely in patients presenting with esophageal symptoms. However, it does not completely exclude coexistence of this esophageal motility disorder, as the present study reveals that these two entities are infrequently found together.
Esophageal Achalasia↗
Comparison of suction capsule and endoscopic biopsy of small bowel mucosa.
Small bowel mucosal biopsy specimens were studied in 52 consecutive patients. Twenty-six patients underwent biopsy by a suction capsule and 16 patients by endoscopy using an 8-mm forceps. Additionally, 10 patients were asked to undergo biopsy by both techniques in the same morning. Material was obtained in 81% of attempts by suction and 100% by endoscopy. Tissue obtained was excellent in 58%, good in 28%, and poor in 14% of suction biopsy specimens. Corresponding grades for endoscopy were 65%, 31%, and 4%. The frequency of abnormal findings was not different by either technique. In the 10 patients who had both procedures, mean time to completion was 43 min by suction and 12 min by endoscopy. Intravenous premedication was used in endoscopy, and patient comfort was judged as excellent in 60% with endoscopy, whereas 60% judged suction biopsy as very uncomfortable. The mean fluoroscopy time of 3.9 min necessary for suction biopsy was eliminated with endoscopy. Biopsy with an 8-mm forceps through the endoscope is the preferred way to obtain tissue from the proximal small bowel.
Biopsy↗
A "short pancreas".
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Cholangiopancreatography, Endoscopic Retrograde↗
Abnormal lower esophageal sphincter pressure responses in patients with orange juice-induced heartburn.
The mechanism of orange juice-induced heartburn is unclear. One previous uncontrolled study showed only a transient fall in lower esophageal sphincter pressure (LESP) after orange juice and suggested that orange juice-induced heartburn was caused by a direct effect on the esophageal mucosa. We studied the effect of orange juice on LESP by comparing symptomatic patients with asymptomatic controls. LESP was measured for 10 min before and 60 min after the ingestion of 250 ml of orange juice in eight patients with orange juice-induced heartburn and in seven asymptomatic controls. Before orange juice ingestion, LESPs were similar in the symptomatic and asymptomatic groups, 18.3 and 17.8 mm Hg, respectively (not significant). In the control group, LESP increased by at least 5 mm Hg at 20 min after orange juice ingestion and remained elevated for the duration of the observation. In the symptomatic group there was no significant change in LESP despite the onset of heartburn. This was significantly different from the control group (p less than 0.01). We conclude that LESP response to orange juice is different in those who develop heartburn from those who do not. This abnormal response may make these patients more prone to reflux, but the numerical change in LESP is small and the LESP remains within the normal range. We believe that gastroesophageal reflux is unlikely to be the mechanism of orange juice-induced heartburn.
Adult↗
The relationship between fistulas in Crohn's disease and associated carcinoma. Report of four cases and review of the literature.
Patients with carcinoma involving chronic fistulizing Crohn's disease may have developed the malignancy due to chronic epithelial irritation at either end of the fistula tract. Alternatively, the carcinoma may be the cause of the fistula. Examples of each type of relationship are presented in the reports of four patients from our institution and supported by a review of the literature. The diagnoses of such carcinomas are often delayed due to lack of specificity of symptoms and signs. A high index of suspicion and regular surveillance of high-risk patients are recommended.
Abdominal Muscles↗
Chronic active hepatitis induced by nitrofurantoin.
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Aged↗
Peptic ulcer disease: current management in the elderly.
Pain is less frequently the initial complaint in the elderly; melena is a more frequent presentation of ulcer disease. Also, in case of a complication, signs and symptoms are less severe. If one decides to treat an elderly patient symptomatically--without the benefit of any diagnostic study--the patient should be followed closely. The physician should be satisfied that at least partial relief is occurring within the first few days.
Aged↗
Return of peristalsis in achalasia after pneumatic dilatation.
Distally progressive contraction waves were demonstrated in seven of 34 (20%) patients with achalasia, successfully treated with pneumatic dilatation. There was no correlation between the appearance of such waves and clinical status, the decrease in lower esophageal sphincter resting pressure, or in the radiographically measured diameter of their esophagus. Return of these waves cannot be adequately explained by the "common cavity phenomenon."
Dilatation↗