Endoscopic mucosal resection of colorectal polyps in typical UK hospitals

AIM:To evaluate the outcomes of endoscopic mucosal resection(EMR) for colorectal polyps,with particular regard to procedural complications and recurrence rate,in typical United Kingdom(UK) hospitals that perform an average of about 25 colonic EMRs per year.METHODS:A total of 239 colorectal polyps(≥ 10 mm) resected from 199 patients referred to Rochdale Infirmary,Salford Royal Hospital and Royal Oldham Hospital for EMR between January 2003 and January 2009 were studied.RESULTS:The mean size of polyps resected was 19.6 ± 12.4 mm(range 10-80 mm).The overall major complication rate was 2.1%.Complications were less frequent with non-adenomas compared with the other groups(Pearson's χ 2 test,P < 0.0001).Resections of largersized polyps were more likely to result in complications(unpaired t-test,P = 0.021).Recurrence was associated with histology,with carcinoma-in-situ more likely to recur compared with low-grade dysplasia [hazard ratio(HR) 186.7,95% confidence interval(95% CI):8.81-3953.02,P = 0.001].Distal lesions were also more likely to recur compared with right-sided and transverse colon lesions(HR 5.93,95% CI:1.35-26.18,P = 0.019).CONCLUSION:EMR for colorectal polyps can be performed safely and effectively in typical UK hospitals.Stricter follow-up is required for histologically advanced lesions due to increased recurrence risk.

Sphincter of Oddi dysfunction:Psychosocial distress correlates with manometric dyskinesia but not stenosis

AIM:To compare postcholecystectomy patients with Sphincter of Oddi(SO)dyskinesia and those with normal SO motility to determine the psychosocial distress,gender and objective clinical correlates of dyskinesia,and contrast these findings with comparisons between SO stenosis and normal SO motility.METHODS:Within a cohort of seventy-two consecutive postcholecystectomy patients with suspected SO dysfunction,manometric assessment identified subgroups with SO dyskinesia(n=33),SO stenosis(n=18)and normal SO motility(n=21).Each patient was categorized in terms of Milwaukee Type,sociodemographic status and the severity of stress-coping experiences.RESULTS:Logistic regression revealed that in combination certain psychological,sociodemographic and clinical variables significantly differentiated SO dyskinesia,but not SO stenosis,from normal SO function.Levels of psychosocial stress and of coping with this stress(i.e.anger suppressed more frequently and the use of significantly more psychological coping strategies)were highest among patients with SO dyskinesia,especially women.Higher levels of neuroticism(the tendency to stressproneness)further increased the likelihood of SO dyskinesia.CONCLUSION:A motility disturbance related to psychosocial distress may help to explain the finding of SO dyskinesia in some postcholecystectomy patients.

Gastroenterologist perceptions of faecal microbiota transplantation

AIM: To explore gastroenterologist perceptions towards and experience with faecal microbiota transplantation(FMT).METHODS: A questionnaire survey consisting of 17 questions was created to assess gastroenterologists' attitude towards and experience with FMT. This was anonymously distributed in hard copy format amongst attendees at gastroenterology meetings in Australia between October 2013 and April 2014. Basic descriptive statistical analyses were performed.RESULTS: Fifty-two clinicians participated. Twenty one percent had previously referred patients for FMT,8% more than once. Ninety percent would refer patients with Clostridium difficile infection(CDI) for FMT if easily available,37% for ulcerative colitis,13% for Crohn's disease and 6% for irritable bowel syndrome. Six percent would not refer any indication,including recurrent CDI. Eighty-six percent would enroll patients in FMT clinical trials. Thirty-seven percent considered the optimal mode of FMT administration transcolonoscopic,17% nasoduodenal,13% enema and 8% oral capsule. The greatest concerns regarding FMT were: 42% lack of evidence,12% infection risk,10% non infectious adverse effects/lack of safety data,10% aesthetic,10% lack of efficacy,4% disease exacerbation,and 2% inappropriate use; 6% had no concerns. Seventy seven percent believed there is a lack of accessibility while 52% had an interest in learning how to provide FMT. Only 6% offered FMT at their institution.CONCLUSION: Despite general enthusiasm,most gastroenterologists have limited experience with,or access to,FMT. The greatest concerns were lack of supportive evidence and safety issues. However a significant proportion would refer indications other than CDI for FMT despite insufficient evidence. These data provide guidance on where education and training are required.

Functional gastrointestinal disorders in eating disorder patients:Altered distribution and predictors using ROME Ⅲ compared to ROME Ⅱ criteria

AIM:To compare the prevalence of Functional gastrointestinal disorders(FGIDs)using ROMEⅢand ROMEⅡand to describe predictors of FGIDs among eating disorder(ED)patients.METHODS:Two similar cohorts of female ED inpatients,aged 17-50 years,with no organic gastrointestinal or systemic disorders,completed either the ROMEⅢ(n=100)or the ROMEⅡ(n=160)questionnaire on admission for ED treatment.The two ROME cohorts were compared on continuous demographic variables(e.g.,age,BMI)using Student’s t-tests,and on categorical variables(e.g.,ED diagnosis)usingχ2-tests.The relationship between ED diagnostic subtypes and FGID categories was explored usingχ2-tests.Age,BMI,and psychological and behavioural predictors of the common(prevalence greater than 20%)ROMEⅢFGIDs were tested using logistic regression analyses.RESULTS:The criteria for at least one FGID were fulfilled by 83%of the ROMEⅢcohort,and 94%of the ROMEⅡcohort.There were no significant differences in age,BMI,lowest ever BMI,ED diagnostic subtypes or ED-related quality of life(QOL)scores between ROMEⅡand ROMEⅢcohorts.The most prevalent FGIDs using ROMEⅢwere postprandial distress syndrome(PDS)(45%)and irritable bowel syndrome(IBS)(41%),followed by unspecified functional bowel disorders(U-FBD)(24%),and functional heartburn(FH)(22%).There was a 29%or 46%increase(depending on presence or absence of cyclic vomiting)in functional gastroduodenal disorders because of the introduction of PDS in ROMEⅢcompared to ROMEⅡ.There was a 35%decrease in functional bowel disorders(FBD)in RomeⅢ(excluding U-FBD)compared to ROMEⅡ.The most significant predictor of PDS was starvation(P=0.008).The predictor of FH(P=0.021)and U-FBD(P=0.007)was somatisation,and of IBS laxative use(P=0.025).Age and BMI were not significant predictors.The addition of the 6-mo duration of symptoms requirement for a diagnosis in ROMEⅢadded precision to many FGIDs.CONCLUSION:ROMEⅢconfers higher precision in diagnosing FGIDs but self-induced vomiting should be excluded from the diagnosis of cyclic vomiting.Psychological factors appear to be more influential in ROMEⅡthan ROMEⅢ.

Daikenchuto (Da-Jian-Zhong-Tang) ameliorates intestinal fibrosis by activating myofibroblast transient receptor potential ankyrin 1 channel

AIM To investigate the anti-fibrotic effects of the traditional oriental herbal medicine Daikenchuto(DKT) associated with transient receptor potential ankyrin 1(TRPA1) channels in intestinal myofibroblasts. METHODS Inflammatory and fibrotic changes were detected in a2,4,6-trinitrobenzenesulfonic acid(TNBS) chronic colitis model of wild-type and TRPA1-knockout(TRPA1-KO) mice via pathological staining and immunoblotting analysis.Ca^(2+) imaging experiments examined the effects of DKT and its components/ingredients on intestinal myofibroblast(In Myo Fib) cell TRPA1 channel function.Profibrotic factors and transforming growth factor (TGF) -β1-associated signaling were tested in an In Myo Fib cell line by q PCR and immunoblotting experiments.Samples from non-stenotic and stenotic regions of the intestines of patients with Crohn’s disease (CD) were used for pathological analysis. RESULTS Chronic treatment with TNBS caused more severe inflammation and fibrotic changes in TRPA1-KO than in wild-type mice.A one-week enema administration of DKT reduced fibrotic lesions in wild-type but not in TRPA1-KO mice.The active ingredients of DKT,i.e.,hydroxyα-sanshool and 6-shogaol,induced Ca^(2+) influxes in In Myo Fib,and this was antagonized by co-treatment with a selective TRPA1 channel blocker,HC-030031.DKT counteracted TGF-β1-induced expression of TypeⅠcollagen andα-smooth muscle actin (α-SMA) ,which were accompanied by a reduction in the phosphorylation of Smad-2 and p38-mitogen-activated protein kinase (p38-MAPK) and the expression of myocardin.Importantly,24-h incubation with a DKT active component Japanese Pepper increased the m RNA and protein expression levels of TRPA1 in In Myo Fibs,which in turn negatively regulated collagen synthesis.In the stenotic regions of the intestines of CD patients,TRPA1 expression was significantly enhanced.CONCLUSION The effects of DKT on the expression and activation of the TRPA1 channel could be advantageous for suppressing intestinal fibrosis,and benefit inflammatory bowel disease treatment.

Endoscopic removal of a tablespoon lodged within the duodenum

Here we report the case of a 34-year-old man who underwent endoscopic removal of a tablespoon from the stomach that was lodged within the duodenum.Removal required the use of a two-channel upper endoscope and polypectomy snares.Using the doublesnare technique, the spoon was grasped at the proximal and distal parts of the handle.The doublesnare was first pulled unsuccessfully and then pulled with simultaneous manual abdominal compression of the bulbus from the body surface.Compression was gently applied towards the stomach.As a result, the head of the spoon prolapsed from the bulbus, and was easily retracted from the stomach without any complications.In cases of foreign body lodging within the duodenum, the manual abdominal compression technique may help clinicians pull out the object and avoid surgery.The usefulness of manual compression is dependent on the foreign body's sharpness and the location.

study to determine guidelines for pediatric colonoscopy

AIM To investigated characteristics, diagnosis, bowelcleansing preparation, sedation, and colonoscope length and diameter in Japanese pediatric patients receiving total colonoscopy.METHODS The present study evaluated consecutive patients aged ≤ 15 years who had undergone their first colonoscopy in Kurume University between January 2007 and February 2015. Data were retrospectively analyzed. We identified 110 pediatric patients who had undergone colonoscopy that had reached the cecum, allowing the observation of the total colon.RESULTS Hematochezia, abdominal pain, and diarrhea were the most common symptoms. For bowel-cleansing preparation, pediatric patients aged ≤ 12 years were treated with magnesium citrate, and patients aged 13-15 years were treated with polyethylene glycol 4000. For sedation, thiamylal with pentazocine, which has an analgesic effect, was used in patients aged ≤ 6 years, and midazolam with pentazocine was used in patients aged ≥ 7 years. Regarding the choice of endoscope, short and thin endoscopes were selected for younger patients, particularly patients aged ≤ 3 years. Positive diagnoses were made in 78 patients(70.9%). Inflammatory bowel disease(n = 49, 44.5%), including ulcerative colitis(n = 37, 33.6%) and Crohn's disease(n = 12, 10.9%), was the most common diagnosis. CONCLUSION Colonoscopy offers a high diagnostic capability for pediatric patients with gastrointestinal symptoms. The selection of appropriate management the performance of colonoscopy is important in pediatric patients.