Epstein-Barr virus-associated cholangiopathy: a new disease entity?
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Adult↗
Biomedical subjects
Ian F Yusoff
Publications and source records attributed to Ian F Yusoff.
Repeat colonoscopy has a low yield even in symptomatic patients.
BACKGROUND: In many regions, the demand for colonoscopy exceeds its availability. Patients undergoing repeat examinations comprise a significant proportion of those on waiting lists. OBJECTIVE: To assess the yield of repeat colonoscopy in varied clinical settings. DESIGN: Cohort study. SETTING: Endoscopic database of an Australian tertiary referral hospital. PATIENTS: Adults who had >/=2 colonoscopies between 1992 and 2004. Patients were excluded if the repeat procedure was for completion or for high-risk surveillance. MAIN OUTCOME MEASUREMENTS: Yield for neoplasia by indication, interval to repeat examination, and appropriateness for surveillance (determined by National Australian guidelines). RESULTS: A total of 4974 colonoscopies in 2075 patients were studied. The mean age was 63.1 years (range, 19.2-92.4 years). The mean number of examinations was 2.4 (range, 2-8), with a mean interval between examinations of 2.9 years. Colorectal cancer (CRC) was significantly more prevalent at initial colonoscopy compared with subsequent colonoscopies (7.9% vs 0.6%; prevalence ratio 14.2, 95% confidence interval [CI] 8.5-23.7, P < .001), as were advanced adenomas (15.3% vs 4.8%; prevalence ratio 3.2, 95% CI 2.6-3.9, P < .001). No CRCs were detected in symptomatic patients undergoing polyp surveillance examinations performed before the recommended interval. LIMITATIONS: Retrospective design. CONCLUSIONS: Yield of repeat colonoscopy is significantly lower than for initial colonoscopy, irrespective of indication. In symptomatic patients within a polyp surveillance program, the yield is negligible when a colonoscopy is performed before the recommended surveillance interval. The need for a repeat colonoscopy should be carefully considered, and patients who have never had a colonoscopy must take priority on waiting lists over those awaiting repeat examinations.
Adult↗
Survey of consent practices for inpatient colonoscopy and endoscopic retrograde cholangiopancreatography at a tertiary referral center.
BACKGROUND: The purpose of the present paper was to determine informed consent practices for inpatient, open-access colonoscopy and endoscopic retrograde cholangiopancreatography (ERCP) at a tertiary referral center. METHODS: A two-part prospective study incorporating (i) an audit of consent practices for colonoscopy and ERCP; and (ii) a questionnaire directed at gastroenterologists and interns regarding information imparted to patients in the process of acquiring informed consent, was undertaken at Sir Charles Gairdner Hospital, Western Australia. Study subjects consisted of inpatients undergoing open-access colonoscopy and/or ERCP at the study center commencing May 2003; and gastroenterologists and interns at the study center. RESULTS: Written consent was obtained by junior medical staff in 89% of cases. Response rates for the questionnaire was 100% from interns, and 91% from gastroenterologists. Of interns surveyed, 93% had witnessed a colonoscopy, and 59% had witnessed an ERCP. For 12% of interns, colonoscopic bleeding or perforation were not always mentioned. Colonoscopy failure rate and perforation were overestimated by 51% and 63% of interns, respectively. Only 56% of interns always mentioned pancreatitis as a complication of ERCP. The rate of post-ERCP pancreatitis was overestimated by 25% of interns. Only 40% of gastroenterologists always provided additional information to patients whose consent was obtained by someone else. Written material was not routinely provided for patients. Consent was usually obtained on the day of the procedure. CONCLUSIONS: Written consent for inpatients undergoing open-access colonoscopy and ERCP is rarely obtained by the proceduralist. There is substantial variability in the information provided to patients. Guidelines are required to ensure best practice in this area.
Adolescent↗
Transesophageal echocardiography-related gastrointestinal complications in cardiac surgical patients.
OBJECTIVE: The aim of this audit was to determine the incidence of major gastrointestinal (GI) complications associated with intraoperative transesophageal echocardiography (TEE) in adult cardiac surgical patients in this institution. DESIGN: Retrospective database audit. SETTING: University-affiliated teaching hospital. PARTICIPANTS: Eight hundred fifty-nine consecutive cardiac surgical patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The records of all patients who developed a major upper GI complication within 30 days of cardiac surgery between January 2001 and May 2003 were examined. The patients were identified by cross-referencing cardiac surgery and endoscopy databases. A major GI complication was defined as a perforation of the esophagus or stomach or upper GI bleeding requiring transfusion, endoscopic, or surgical intervention. Early presentation was defined as <24 hours; late presentation was defined as >24 hours. During the audit period, 859 patients underwent cardiac surgery. Five hundred sixteen patients had cardiac surgery with TEE (group 1), and 343 patients had cardiac surgery without TEE (group 2). Six patients were identified, 1.2% (95% confidence interval [CI], CI, 0.5%-2.5%) in group 1 who had a major upper GI complication consistent with TEE injury. Two patients, 0.38% (95% CI, 0.05%-1.40%), presented early, and 4 patients, 0.76% (95% CI, 0.21%-1.98%), presented late. One patient in group 2 developed a major upper GI complication, 0.29% (95% CI, 0.01%-1.6%). CONCLUSION: The incidence of major GI complications attributed to TEE in this group of cardiac surgical patients was higher than previously reported. Late presentation was more common than early presentation. Previous studies that have not included late presentations may have underestimated the true incidence of major GI complications related to TEE.
Adult↗
Colonoscopic surveillance after curative surgery for colorectal cancer.
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Colonoscopy↗
Endoscopist administered propofol for upper-GI EUS is safe and effective: a prospective study in 500 patients.
BACKGROUND: The administration of propofol for endoscopic sedation by a qualified person, other than the endoscopist, is safe and effective. The aim of this study was to determine if propofol can be administered safely and effectively by the endoscopist performing the procedure. METHODS: All patients referred for upper-GI EUS were eligible for inclusion in the study. Exclusion criteria included the following: age less than 18 years, American Society of Anesthesiology physical status class greater than 2, a potential for difficulty in airway maintenance, and allergy to propofol constituents. The endoscopist administered propofol as an intravenous bolus followed by a constant infusion. Adverse events, drug dosage, complications, and patient/endoscopist satisfaction were recorded. RESULTS: A total of 500 patients (285 women, 215 men; mean age 53.4 [14.8 years]) were enrolled. Mean propofol dose was 301 mg (range 100-1000 mg). Mean procedure time was 19 minutes (range 3-70 minutes). The required examination was completed in all cases. There was no major adverse event. Oxygen desaturation (oxygen saturation < 95%) occurred in 16 (3%) patients. There were 4 (1%) cases of mild hypoxemia (saturation < 90%) but no case of severe hypoxemia (saturation <85%). The endoscopist rated the 92% of the procedures as "very smooth" or "smooth" and regarded administration of propofol as "easy" for 92%. All patients said they would prefer the same method of sedation if the procedure were repeated. CONCLUSIONS: Endoscopist-administered propofol is safe and effective in selected patients.
Adult↗
A prospective comparison of the yield of EUS in primary vs. recurrent idiopathic acute pancreatitis.
BACKGROUND: It is uncertain whether EUS should be performed after a single episode of idiopathic pancreatitis vs. recurrent episodes or if clinical factors can predict positive EUS findings. METHODS: Consecutive patients with a single episode of idiopathic pancreatitis or with recurrent episodes underwent EUS (with analysis of bile for bilirubinate and cholesterol crystals, when possible). The diagnostic yield was compared for patients with a single episode of idiopathic pancreatitis and recurrent episodes (stratified by cholecystectomy status). Predictors of positive EUS findings were sought. EUS was considered "positive" if it identified any possible cause of pancreatitis other than chronic pancreatitis. RESULTS: A total of 370 patients were studied (246 no-cholecystectomy group [134 single episode of idiopathic pancreatitis, 112 recurrent episodes] and 124 post-cholecystectomy group [67 single episode of idiopathic pancreatitis, 57 recurrent episodes]). Overall, EUS yielded a positive finding in 29.2%. For patients in the no-cholecystectomy group, positive EUS findings were not significantly more frequent in those with a single episode of idiopathic pancreatitis vs. those with recurrent episodes (31.3% vs. 32.1%; p = 0.89). In the post-cholecystectomy group, the yield was not significantly different for single episode of idiopathic pancreatitis (29.9%) vs. recurrent episodes (17.5%) ( p = 0.15). Chronic pancreatitis was the only abnormality identified in 30.9% of patients in the no-cholecystectomy group vs. 26.6% of those in the post-cholecystectomy group ( p = 0.24). It was the most common abnormality found in all 4 subgroups (range 16.4%-42.0%) and was approximately twice as frequent in patients with recurrent episodes vs. a single episode of idiopathic pancreatitis (no-cholecystectomy: 42.0% vs. 21.6%, p = 0.0008; post-cholecystectomy: 38.6% vs. 16.4%, p = 0.008). Analysis of bile revealed crystals in 38/80 (47.5%) patients in whom it could be performed. Patients with positive EUS findings tended to be older. CONCLUSIONS: In patients with idiopathic pancreatitis, the yield of EUS is not significantly different after an initial attack or after recurrent attacks. Therefore, it is reasonable to perform EUS after an initial attack of idiopathic acute pancreatitis, especially in older patients.
Acute Disease↗
A prospective, quantitative assessment of the effect of ethanol and other variables on the endosonographic appearance of the pancreas.
BACKGROUND & AIMS: Studies comparing endosonography with endoscopic pancreatography, histological examination, and functional assays show that the number of endosonographic abnormalities (or "criteria") increases with the severity of chronic pancreatitis. However, it is unclear to what extent such variables as demographics, body habitus, and routine exposure to such pancreatic toxins as ethanol and cigarette smoke can affect pancreatic endosonography. The aim of the study is to quantify the effects of these variables precisely. METHODS: Pancreatic endosonography was performed by a single operator in consecutive patients referred for any indication. The relationship between 8 possible endosonographic criteria and these variables was studied. RESULTS: One thousand one hundred fifty-seven patients were studied (93% of eligible patients). Number of criteria correlated most strongly with ethanol ingestion (r = 0.273; P = 0.0001) and smoking history (r = 0.201; P = 0.0001). It did not correlate with age or body mass index. The strongest independent predictors of severe pancreatic abnormalities (>/=5 criteria) were heavy ethanol ingestion (odds ratio [OR], 5.1; 95% confidence interval [CI], 3.1-8.5), male sex (OR, 1.8; 95% CI, 1.3-2.55), clinical suspicion of pancreatic disease (OR, 1.7; 95% CI, 1.2-2.3), and heavy smoking (OR, 1.7; 95% CI, 1.2-2.4). Severe endosonographic abnormalities were found in only 2 of 51 patients (3.9%) with no risk factors or symptoms of pancreatic disease. CONCLUSIONS: Several variables can affect the endosonographic appearance of the pancreas independently. Severe abnormalities may be asymptomatic. The clinical, functional, and histological significance of endosonographic abnormalities requires clarification.
Endosonography↗
Diagnosis and management of cholecystitis and cholangitis.
Cholelithiasis is a prevalent condition in Western populations. Most cases are asymptomatic but complications can occur. Acute cholangitis, cholecystitis, and gallstone pancreatitis are the most common biliary tract emergencies and are usually caused by biliary calculi. Whenever possible, acute cholecystitis should be treated with early LC. AAC is an uncommon condition usually affecting patients with significant comorbidities. Treatment is usually with percutaneous cholecystostomy, which often is also the only required therapy. Endoscopic drainage is the preferred form of biliary decompression in acute cholangitis and these patients should subsequently undergo elective LC unless unfit for surgery. Effective and optimal management of biliary tract emergencies relies on close cooperation between gastroenterologist, surgeon, and radiologist.
Acute Disease↗
Synchronous and metachronous small bowel adenocarcinomas in a patient with celiac disease.
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Adenocarcinoma↗
Staging esophageal adenocarcinoma.
The incidence of esophageal adenocarcinoma has increased dramatically in Western societies over the last 20 years. Most patients present with advanced disease. Stage-dependent treatment protocols require the most complete and accurate staging possible. With all esophageal cancers (ie, adenocarcinomas and squamous carcinomas), it is perhaps most important to identify patients who are unlikely to benefit from aggressive treatment. The performance characteristics and clinical utility of CT scanning, endoscopic ultrasound, FDG-PET, and minimally invasive surgery in staging esophageal cancer are reviewed, including issues relating specifically to staging of adenocarcinomas. These investigations are not mutually exclusive and each has its own strengths and shortcomings. Accurate staging often requires the use of multiple modalities. The optimal staging algorithm for a given practice setting (if it exists) will be determined largely by local variables that include patient population, available technology, and local expertise in applying such technology. A lack of consensus on the effectiveness of therapeutic alternatives (particularly surgical v nonsurgical methods) may also affect the perceived value of the various staging modalities and how they are used.
Adenocarcinoma↗
Colonoscopic surveillance for family history of colorectal cancer: are NHMRC guidelines being followed?
OBJECTIVES: To assess whether referrals for surveillance colonoscopy and subsequent follow-up recommendations for patients with a family history of colorectal cancer concurred with the published National Health and Medical Research Council (NHMRC) guidelines. DESIGN: A prospective audit of patients with a family history of colorectal cancer referred for surveillance colonoscopy. Follow-up recommendations were assessed retrospectively. SETTING AND SUBJECTS: All patients referred to a major teaching hospital for surveillance colonoscopy on the basis of a family history of colorectal cancer from 2 January 2000-15 April 2001. MAIN OUTCOME MEASURES: Concurrence of referrals and recommendations with NHMRC guidelines. RESULTS: Of 340 patients referred because of a family history of colorectal cancer, 202 (83 men, 119 women) were asymptomatic. Their mean age was 50 years (95% CI, 48.3-51.6 years). The family history of 95 (47%) of these patients satisfied the NHMRC criteria for colonoscopic surveillance. Another 20 patients (17%) satisfied the criteria, but were referred before the recommended age to commence surveillance. Analysis by referral source showed that the proportion of referrals meeting NHMRC guidelines was higher from specialists than from general practitioners (75% v 45%), and this difference was significant. Follow-up recommendations, when made, concurred with NHMRC guidelines in 81% of cases. CONCLUSIONS: Further education of the medical community is required to increase understanding of colorectal screening strategies and ensure appropriate resource allocation.
Algorithms↗
Liver biopsy in hepatitis C: reassessing its role in 2001.
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Adult↗
Disease recurrence after liver transplantation in Western Australia.
BACKGROUND AND AIM: Orthotopic liver transplantation (OLT) is now the accepted therapy for end-stage chronic liver disease. Long-term survival is now expected in the majority of patients and, consequently, disease recurrence has emerged as a major concern. Our aim was to document the rate of disease recurrence after liver transplantation for conditions other than hepatitis C, in patients followed up by the Western Australian Liver Transplant Service (WALTS). METHODS: The case notes of all post-OLT patients followed up by WALTS were reviewed. Patients were excluded if survival was less than 3 months post-OLT; OLT was performed for hepatitis C alone or follow up was unavailable. Detection and definition of disease recurrence depended on pretransplant diagnosis, and were based on patient interview, biochemical, immunological and serological tests. Radiological and histological confirmation were obtained where clinically indicated. RESULTS: Eighty-seven patients were identified (89 OLTs performed). The overall rate of recurrence was 10%. Recurrence rates by disease were: primary sclerosing cholangitis (17%), primary biliary cirrhosis (12%), autoimmune hepatitis (17%), hepatitis B (40%) and alcoholic liver disease (4%). Alcohol use relapse after transplantation occurred in 25%. The overall survival post-OLT was 87%, with a mean follow up of 53 months. Survival in patients with recurrent disease was 89%. CONCLUSIONS: Disease recurrence after OLT does occur, but overall, it is relatively uncommon. Recurrence rates vary significantly and depend, in part, on indication for OLT. With medium-term follow up, recurrent disease does not have an effect on mortality.
Adolescent↗
Routine colonic mucosal biopsy and ileoscopy increases diagnostic yield in patients undergoing colonoscopy for diarrhea.
BACKGROUND AND AIMS: In patients undergoing colonoscopy for diarrhea, when the examination is normal, the role of routine mucosal biopsy remains controversial, particularly in the open-access setting. It is uncertain whether routine ileoscopy adds anything to colonoscopy alone. We aimed to assess the yield of mucosal biopsy and ileoscopy in patients with diarrhea. METHODS: We retrospectively reviewed all colonoscopies performed for diarrhea over a 9-year period in a tertiary referral center with an open-access service. We then selected cases where the examination was normal and biopsies were performed. The histopathology reports of these selected cases were then reviewed. RESULTS: There were 1131 cases identified. The mucosal examination was normal in 465 cases (41%); 362 of these had colonic biopsies performed. Histology was normal in 316 cases (87%) and was non-specific in 28 cases (8%). Significant histopathology was present in 18 cases (5%) with a significantly higher prevalence of microscopic colitis in patients above 60 years old. Ileoscopy was performed in 508 cases and was abnormal in 26 cases (5%). The abnormality on ileoscopy was the sole abnormality in 13 cases (3%). CONCLUSIONS: Routine colonic mucosal biopsy and ileoscopy each identify significant additional pathology in 5% of cases when investigating patients with diarrhea, and are recommended as routine practice in this setting. We found ileal biopsy unhelpful when ileoscopy was normal.
Biopsy↗
Colonoscopic surveillance after surgery for colorectal cancer.
BACKGROUND: Intensive colonoscopic surveillance after resection of colorectal cancer (CRC) has been shown not to improve outcome. The National Health and Medical Research Council of Australia (NHMRC) has recently published guidelines recommending appropriate surveillance intervals after CRC resection. The aims of the present study were to assess current and past patterns of postoperative CRC surveillance and to determine the yield of neoplasia from such surveillance. METHODS: An audit was performed of all patients who underwent colonoscopy following surgical resection of CRC from 1989 to 2001. Two groups were assessed: (i) all patients undergoing surveillance colonoscopies; and (ii) all patients diagnosed with CRC at Sir Charles Gairdner Hospital (SCGH) who subsequently had postoperative colonoscopies. Patients who had their index colonoscopy at the study centre and who subsequently underwent surveillance colonoscopies were studied in detail. Yield for neoplasia, patterns of surveillance and concordance with NHMRC recommendations were determined. RESULTS: There were 990 surveillance examinations performed and colorectal adenomas were identified in 184. However, only one case of recurrent cancer was detected. There were a total of 161 patients who had CRC diagnosed and underwent surveillance at SCGH. Of these patients, 75% underwent colonoscopy at 12 months after resection and 48% of these cases underwent a further examination within 12 months. Only 23% of examinations concurred with NHMRC recommendations and practice has not changed with release of these guidelines. CONCLUSIONS: Resectable CRC recurrences are rarely detected at colonoscopic surveillance. Surveillance colonoscopies are -performed too frequently and release of NHMRC guidelines has failed to change practice.
Adenomatous Polyps↗