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Objective: There are few data to guide the choice between colonoscopy and flexible sigmoidoscopy in patients with nonacute rectal bleeding, especially in younger age groups. Our aim was to determine the yield of colonoscopy for significant proximal large bowel disease in the absence of significant distal disease, with special reference to young patients., Methods: This was a retrospective study of data collected prospectively in 1766 patients (median age 57 yr, 711 women). The endoscopic database (GI-Trac) contained 152 discrete fields for data input. Multiple logistic regression analysis was performed to identify variables independently associated with the presence of isolated significant proximal disease., Results: Young patients had a higher percentage of normal examinations than did older patients. The incidence of diverticular disease, small polyps, large polyps, and cancer rose with increasing age. No patient aged <40 yr had an isolated proximal cancer, but 7% had other significant isolated proximal disease. There was no overall association between age and significant proximal disease in the absence of significant distal disease (p = 0.66). The only variable associated with isolated proximal disease was anemia (odds ratio = 1.81; 95% CI = 1.11-2.93; p = 0.02)., Conclusion: The yield of colonoscopy (beyond the range of sigmoidoscopy) for neoplasia is low in patients aged <40 yr, but other significant disease may be missed if age is the only criterion determining colonoscopy use.

We report the successful removal of a severed and impacted Dormia basket from an elderly patient with choledocholithiasis. One aspect of the case that increased its difficulty is that the basket had become trapped in the bile duct by attaching to an immobile stone that had formed on suture material from a prior biliary operation. Severed baskets that become entrapped in the bile duct are unusual complications of endoscopic bile duct stone removal which used to require surgical intervention. More recent reports suggest that retained baskets can be removed endoscopically in conjunction with some form of lithotripsy. The method used to remove the retained basket in our case involved advancing a Soehendra lithotripter over a looped guidewire after first shrinking the stone with extracorporeal shock wave and laser lithotripsy.

Objectives: Most colonoscopy is performed using conscious sedation to facilitate the procedure. However, little is known about which patients are dissatisfied with sedation and why. The goal of this study was to examine whether certain patient- and procedure-specific variables are associated with patient dissatisfaction., Methods: A total of 403 consecutive outpatients underwent colonoscopy during a 4-month study period. Of 342 patients who met entrance criteria, 328 completed the initial questionnaire and were enrolled. Subjects received standard conscious sedation; after colonoscopy, the primary endoscopist and nurse recorded the level of sedation as adequate or inadequate. Twenty-four to 72 hr after the procedure, an independent observer contacted the subjects by telephone and asked whether they were satisfied with the level of sedation achieved during the colonoscopy. A number of patient- (age, gender, anxiety level, and educational background) and procedure-specific variables (waiting time and procedure type, difficulty, and duration) were analyzed to determine their association with patient dissatisfaction., Results: Forty-eight patients (15%) were dissatisfied with sedation. Univariable analysis showed that females, anxiety, higher education (at least 1 yr of college), procedure duration > or = 60 min, and procedure difficulty were all associated with the dissatisfaction with sedation (p < 0.05). Multivariable analysis revealed that only higher education (p = 0.009) and longer procedure duration (p = 0.018) were associated with patient dissatisfaction., Conclusions: Highly educated patients and those who underwent longer procedures were more likely to be dissatisfied with conscious sedation used for colonoscopy. A thorough discussion of expectations and/or patient-controlled sedation might improve satisfaction with colonoscopy in educated patients. Regular supplementation of sedation, termination of a lengthy procedure with the offer of a further attempt at a later date, and referral to a more experienced endoscopist when appropriate might all improve patient satisfaction with colonoscopy.

Despite multiple invasive diagnostic procedures including exploratory laparotomy and surgical resection, our patient's diagnosis remained an enigma. However, given the clinical scenario and the documented PG, a trial of steroids was warranted. The patient has fared well since her treatment, with resolution of all her symptoms. We feel confident that her disease process is most consistent with, and is most likely, Crohn's disease. There are several lessons to be learned from this case: 1) Inflammatory bowel disease can present at any age and belongs in a clinician's differential diagnosis of fever and diarrhea. 2) Failure to consider IBD in an elderly patient may lead to significant delay in diagnosis, and may expose the patient to unnecessary and sometimes dangerous intervention. 3) IBD in the elderly generally follows the same clinical patterns seen in younger patients. 4) Appropriate therapy can lead to prompt control or even resolution of the signs and symptoms of IBD.