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Does Increased Adenoma Detection Reduce the Risk of Colorectal Cancer, and How Good Do We Need to Be?
Dilly, CK, Kahi, CJ
Current gastroenterology reports. 2019;(4):9
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Abstract
PURPOSE OF REVIEW Colorectal cancer (CRC) is largely preventable with colonoscopy and other screening modalities. However, the effectiveness of screening and surveillance depends on the quality of the colonoscopy exam. Adenoma detection rate (ADR) is the best-validated metric by which we measure individual physicians' performance. RECENT FINDINGS Recent evidence suggests that ADR benchmarks may be inappropriately low. There is proof that improving ADR leads to significant reductions in post-colonoscopy CRC (PCCRC). Two studies have demonstrated that when a colonoscopy is performed by physicians with higher ADRs, patients are less likely to have advanced adenomas on surveillance and less likely to develop or die from PCCRC. Finally, there is at least some evidence that higher ADRs do not lead to more cumulative surveillance exams. The ADR is a useful outcome measure that can provide individual endoscopists and their patients with information about the likelihood of developing PCCRC. To achieve the lowest possible PCCRC rate, we should be striving for higher ADRs. While strategies and innovations may help a bit in improving ADRs, our efforts should focus on ensuring a complete mucosal exam for each patient. Behavioral psychology theories may provide useful frameworks for studying motivating factors that drive a careful exam.
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Optimal Management of Malignant Polyps, From Endoscopic Assessment and Resection to Decisions About Surgery.
Rex, DK, Shaukat, A, Wallace, MB
Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 2019;(8):1428-1437
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Abstract
Colorectal cancer is defined clinically as invasion of dysplastic cells into the submucosa. Lesions with submucosal invasion but without invasion into the muscularis propria are generally called malignant polyps. A stepwise approach produces optimal management of malignant polyps (including polypoid and flat/depressed lesions). The first step is to avoid endoscopic resection of non-pedunculated lesions with endoscopic features that predict deep submucosal invasion. Lesions without such features are candidates for endoscopic resection. The second step is to assess candidates for endoscopic resection for features that predict an increased risk of superficial submucosal invasion. Such lesions should be considered for en bloc endoscopic excision if feasible. The third step is giving patients with endoscopically resected malignant polyps good advice regarding whether to undergo adjuvant therapy, usually surgery. We review the endoscopic and histologic criteria that guide clinicians through these steps.
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Is water exchange superior to water immersion for colonoscopy? A systematic review and meta-analysis.
Chen, Z, Li, Z, Yu, X, Wang, G
Saudi journal of gastroenterology : official journal of the Saudi Gastroenterology Association. 2018;(5):259-267
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BACKGROUND/AIMS: Recently, water exchange (WE) instead of water immersion (WI) for colonoscopy has been proposed to decrease pain and improve adenoma detection rate (ADR). This systematic review and meta-analysis is conducted to assess whether WE is superior to WI based on the published randomized controlled trials (RCTs). MATERIALS AND METHODS We searched studies from PubMed, Cochrane Central Register of Controlled Trials, EMBASE, and MEDLINE. Only RCTs were eligible for our study. The pooled risk ratios (RRs), pooled mean difference (MD), and pooled 95% confidence intervals (CIs) were calculated by using the fixed-effects model or random-effects model based on heterogeneity. RESULTS Five RCTs consisting of 2229 colonoscopies were included in this study. WE was associated with a significantly higher ADR than WI (RR = 1.18; CI = 1.05-1.32; P = 0.004), especially in right colon (RR = 1.31; CI = 1.07-1.61; P = 0.01). Compared with WI, WE was confirmed with lower pain score, higher Boston Bowel Preparation Scale score, but more infused water during insertion. There was no statistical difference between WE and WI in cecal intubation rate and the number of patients who had willingness to repeat the examination. Furthermore, both total procedure time and cecal intubation time in WE were significantly longer than that in WI (MD = 2.66; CI = 1.42-3.90; P < 0.0001; vs MD = 4.58; CI = 4.01-5.15; P < 0.0001). CONCLUSIONS This meta-analysis supports the hypothesis that WE is superior to WI in improving ADR, attenuating insertion pain and providing better bowel cleansing, but inferior in time and consumption of infused water consumption during insertion.
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Blood Lipid Concentrations and Colorectal Adenomas: A Systematic Review and Meta-Analysis of Colonoscopy Studies in Asia, 2000-2014.
Passarelli, MN, Newcomb, PA
American journal of epidemiology. 2016;(8):691-700
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It is unclear whether dyslipidemia is associated with risk of colorectal neoplasia. The incidence of both conditions is increasing in Asia, motivating a number of new studies from this region. We performed a systematic literature search of Asian colonoscopy-based studies that collected blood lipid concentrations at the time of endoscopy. Persons found to have colorectal adenoma were considered cases, and those found to be adenoma-free were considered controls. Seventeen studies published between 2000 and 2014 met inclusion criteria, collectively enrolling 17,387 cases and 30,427 controls. Mean differences and adjusted odds ratios were summarized with random-effects meta-analyses. Compared with controls, cases had higher total cholesterol (mean difference (MD) = 2.4 mg/dL, 95% confidence interval (CI): 0.2, 4.6), higher low-density lipoprotein cholesterol (MD = 1.3 mg/dL, 95% CI: 0.1, 2.6), higher triglyceride (MD = 16.4 mg/dL, 95% CI: 11.2, 21.5), and lower high-density lipoprotein (HDL) cholesterol (MD = -2.1 mg/dL, 95% CI: -2.7, -1.6) concentrations. Based on adjusted odds ratios, associations for 40-mg/dL-higher triglyceride levels (odds ratio = 1.13, 95% CI: 1.05, 1.21) and 10-mg/dL-higher HDL cholesterol levels (odds ratio = 0.96, 95% CI: 0.92, 1.00) achieved statistical significance. Persons with adenoma were more likely to have unfavorable cholesterol profiles at the time of colonoscopy than those without adenoma. The most convincing evidence for an association between dyslipidemia and colorectal neoplasia was observed for hypertriglyceridemia.
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Colorectal Cancer in the Arab World--Screening Practices and Future Prospects.
Arafa, MA, Farhat, K
Asian Pacific journal of cancer prevention : APJCP. 2015;(17):7425-30
Abstract
Colorectal cancer (CRC) incidence and mortality rates have dropped 30% in the US in the last 10 years among adults ages 50 and older due to the widespread uptake of colonoscopy, yet incidences in the Arab countries have been increasing in the past ten years, albeit with lower figures when compared with developed countries. Lifestyle changes, food consumption patterns and obesity have been observed during the past years where the regular consumption of traditional foods is being replaced with more Western-style and ready-made foods. Most high income countries have implemented population based colorectal cancer screening programs, which aid in decreasing the incidence and mortality of cancer, while these are lacking in most of the Arab world countries due to many cultural and religious barriers to CRC screening as well as lack of high education or familiarity. What is needed is health education to modify risky lifestyle, and to increase motives and enhance positive attitudes towards early screening especially amongst high risk groups in addition to policy designed to encourage healthier living.
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Quality bowel preparation for surveillance colonoscopy in patients with inflammatory bowel disease is a must.
Nett, A, Velayos, F, McQuaid, K
Gastrointestinal endoscopy clinics of North America. 2014;(3):379-92
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Colonoscopy is routinely performed in patients with inflammatory bowel disease (IBD) for surveillance of dysplasia. Thorough bowel preparation is necessary to facilitate lesion detection. Patients with IBD do not have poorer bowel preparation outcomes but may have decreased preparation tolerance affecting adherence to surveillance protocols. A low-fiber prepreparation diet may improve preparation tolerance without affecting preparation quality. The standard preparation regimen should consist of split-dose administration of a polyethylene glycol-based purgative. Low-volume, hyperosmolar purgatives may be considered in patients with previous preparation intolerance, heightened anxiety, stenotic disease, or dysmotility. Appropriate patient education is critical to enhance preparation quality.
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Glutaraldehyde-induced colitis: case reports and literature review.
Shih, HY, Wu, DC, Huang, WT, Chang, YY, Yu, FJ
The Kaohsiung journal of medical sciences. 2011;(12):577-80
Abstract
Glutaraldehyde-induced colitis is an uncommon colitis in clinical practice. Because the involvement of colonic segment is determined by the endoscopic part where glutaraldehyde remains, a recent history of endoscopy and a demarcated involvement of colonic segment are the most characteristic signs of glutaraldehyde-induced colitis. The typical clinical scenario is acute onset of lower abdominal pain, fever, and bloody stool. Laboratory data usually show leukocytosis and elevated C-reactive protein. The endoscopic pictures of involved segments are compatible with acute colitis, including hyperemic, edematous, with or without multiple erosions. Acute ischemic colitis and infectious colitis should be differentiated at the outset of the disease. Stool pathogen tests are usually negative. Parenteral empiric antibiotic may be considered if severe transmural edema of the involved segment is observed in computed tomography. Conservative treatment, including bowel rest and parenteral hydration, is able to stabilize the condition in a week. Herein, we present two cases of acute proctocolitis caused by glutaraldehyde after uneventful colonoscopy.
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Confocal laser endomicroscopy of the colon.
Gheonea, DI, Saftoiu, A, Ciurea, T, Popescu, C, Georgescu, CV, Malos, A
Journal of gastrointestinal and liver diseases : JGLD. 2010;(2):207-11
Abstract
Confocal laser endomicroscopy (CLE) has been recently proposed as a new technique that allows in vivo histologic assessment of mucosa during endoscopy. The most commonly used contrast agents are acriflavine hydrochloride and fluorescein sodium. For colon pathology assessment, the administration of fluorescein intravenously produces a strong staining of both surface epithelium and deeper layers of lamina propria. Confocal laser endomicroscopy is a feasible method to diagnose colon cancer in vivo. Furthermore, confirmation of neoplastic changes using CLE during colonoscopy may lead to major improvements in the clinical management of the patients with inflammatory bowel disease. Biopsies can be limited to targeted sampling of relevant lesions. Confocal laser endomicroscopy will certainly play an important diagnostic role during gastrointestinal endoscopy in the future, enabling the elimination of the diagnostic delay associated with conventional biopsy preparation and processing.
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Colon cleansing before colonoscopy: does oral sodium phosphate solution still make sense?
Rex, DK, Vanner, SJ
Canadian journal of gastroenterology = Journal canadien de gastroenterologie. 2009;(3):210-4
Abstract
Oral sodium phosphate (NaP) solution has been withdrawn from the market in the United States but remains available for over-the-counter purchase for bowel preparation for colonoscopy in Canada. The present review summarizes recent data regarding the renal toxicity of oral NaP as well as its efficacy and tolerability relative to other preparations. Given the availability of effective alternatives to NaP solution, its use for colonoscopy preparation in Canada should be limited. Candidate patients for oral NaP solution should be assessed for eligibility and preparation instructions should adhere to the current recommendations for maximizing the safety of oral NaP.
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Systematic review: adverse event reports for oral sodium phosphate and polyethylene glycol.
Belsey, J, Epstein, O, Heresbach, D
Alimentary pharmacology & therapeutics. 2009;(1):15-28
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BACKGROUND Screening colonoscopy exposes healthy patients to the risk of serious adverse events associated with bowel preparation. Randomized controlled trials are not an effective method for evaluating this risk. AIM: To search published literature in order to characterize the risk of adverse events associated with oral polyethylene glycol (PEG) or sodium phosphate (NaP). METHODS A systematic review identified case reports of any serious events associated with PEG or NaP. Reports to the Food and Drug Administration (FDA) were also examined. RESULTS Fifty-eight publications of significant events in 109 patients using NaP and 22 patients using PEG were identified. As the total number of prescriptions issued is unknown, rates for the two agents cannot be directly compared. Most commonly reported were electrolyte disturbances, renal failure and colonic ulceration for NaP and Mallory-Weiss tear, electrolyte disturbances and allergic reactions for PEG between January 2006 and December 2007; there were 171 cases of renal failure reported to the FDA following use of NaP and 10 following PEG. CONCLUSIONS Adverse events following bowel preparation are uncommon, but potentially serious. Given that many of these patients are healthy individuals undergoing screening, the benefit/risk ratio must be carefully considered when deciding which preparation to prescribe in individual patients.