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Although iron supplementation is commonly prescribed, the amount of elemental iron needed to achieve clinical efficacy, and the optimal method of supplementation, are under debate. Use of intravenous (IV) iron replacement is increasingly being advocated. We explore the physiology of iron supplementation, review clinical data suggesting that the typical oral dosing of iron may be excessive, and compare IV and oral methods of iron supplementation with a focus on inflammatory bowel disease (IBD). Both IV and oral iron can effectively raise hemoglobin levels in iron-deficiency anemia. There is no evidence that IV iron can raise hemoglobin at a faster pace. Side effects of oral iron are probably related to the relatively high doses of elemental iron that are typically prescribed. Emerging data suggest that low-dose iron has comparable efficacy, with fewer side effects. In IBD, both oral and IV iron are effective, and there is no convincing evidence that oral iron activates or exacerbates clinical symptoms. The use of a low starting dose of oral iron, such as one ferrous sulfate tablet per day, for treatment of iron deficiency is worth considering. [ABSTRACT FROM AUTHOR]

OBJECTIVES:Non-steroidal anti-inflammatory drugs (NSAIDs) have been documented in animal and human studies to reduce risk for colorectal cancer and adenomatous polyps, but risk modification for subgroups of the population and effects on hyperplastic polyps have been less studied.METHODS:Data on recent use of two frequently ingested NSAIDs, aspirin and ibuprofen, were collected at baseline from participants aged 55-74 years in the 10 centers of the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO). Participants randomized to the intervention arm of the trial received a flexible sigmoidoscopy during a baseline examination. Follow-up of detected polyps was accomplished outside the Trial setting and relevant records were sought and abstracted. Cases (n=4,017) included subjects with a biopsy-proven polyp in the left side of the colon (descending colon, sigmoid, and rectum) detected as a consequence of PLCO screening; controls (n=38,396) were subjects with no left-sided colon polyp.RESULTS:Regular use of aspirin (≥4 times/month) in the past year was inversely associated with hyperplastic polyps (odds ratios (OR)=0.8, 95% confidence interval (CI)=0.7-0.9), adenomatous polyps (OR=0.8, 95% CI=0.8-0.9), and advanced adenomas (OR=0.8, 95% CI=0.7-0.9). As frequency of aspirin use increased, the prevalence of polyps decreased significantly for each histological classification (P for trend ≤0.0004). Similar patterns were found for adenomas and ibuprofen. Overall protection was consistent in both the descending colon or sigmoid and the rectum, but more evident in males. In males, the OR for heavy use of combined aspirin and ibuprofen (≥2 times/day) was 0.6 (95% CI=0.5-0.8), as opposed to 0.9 (95% CI=0.8-1.1) in females. The protective effects of NSAIDs for females were apparent only among those with body mass index (BMI) <25 (OR=0.8, 95% CI=0.7-1.0 for regular use of NSAIDs; P interaction=0.04). We also found a slightly stronger protection of NSAIDs in the 70-74 years age group compared with those aged 55-69 years.CONCLUSIONS:This study of a large general risk population supports previous work that recent use of aspirin and ibuprofen is associated with a decreased risk of colorectal adenomas and demonstrates that this protective effect may be stronger in certain population subgroups and is also evident for aspirin and hyperplastic polyps. [ABSTRACT FROM AUTHOR]

The article discusses the issue over wide-scale implementation of computed tomographic (CT) colonography in communities. It states that two successive multicenter researches found low sensitivity of detecting polyps using CT colonography which has only 55%, despite its successful implementation. It notes that aside from detecting advanced lesions, inaccurate measure could also pose a possible problem. It adds that the implementation might lead in a much higher incidence of extracolonic pursuits.

OBJECTIVES: Colorectal cancer (CRC) is the second leading cause of cancer-related death in the United States. Endoscopic screening is now in favor and its use is increasing, but overall participation rates are poor. A substantial percentage of the population will likely continue to resist endoscopic screening. As such, a noninvasive biomarker for the early detection of CRC remains a priority. Herein, we (i) review the currently available noninvasive screening markers for the early detection of CRC, (ii) discuss newer markers that have undergone preliminary testing, and (iii) introduce and explain potentially promising markers of the future.METHODS: The published literature on markers for early detection of CRC was identified using a MEDLINE/PubMed search with secondary review of cited publications.RESULTS: Noninvasive testing for CRC is most advanced in testing for stool fecal occult blood, globin, or DNA mutations. Study of abnormal mucins has also been explored. Research for serum-based markers is just beginning and includes serum proteomics, nuclear matrix proteins, and serum DNA testing.CONCLUSIONS: Serial guaiac-based fecal occult blood testing (FOBT) is simple, inexpensive, and proven effective at reducing mortality from CRC. Immunochemical fecal occult blood tests facilitate compliance and offer improved specificity, but at increased cost in comparison to FOBT. Fecal DNA testing may provide enhanced sensitivity for detection of CRC in comparison with FOBT, but its high cost limits its use for generalized screening. Rectal mucin testing requires additional evaluation to determine its sensitivity and specificity in comparison with guaiac-based FOBT. Serum tests, such as proteomics, nuclear matrix proteins, and serum DNA, are still in their infancy, but remain a hope for the future.(Am J Gastroenterol 2005;100:1–11) [ABSTRACT FROM AUTHOR]

OBJECTIVES: Insulin is a growth factor for colorectal cancer. Visceral adipose tissue (VAT) is strongly associated with insulin levels, and insulin and visceral obesity have been associated in cohort studies with colorectal cancer. The aim of this investigation was to determine whether VAT is associated with recurrence of adenomatous polyps, the precursor to colorectal cancer.METHODS: As an ancillary study to the Polyp Prevention Trial, a randomized clinical trial that evaluated the effect of a low-fat, high-fiber, high vegetable and fruit diet on adenomatous polyp recurrence, subjects at one clinical center underwent measurement of VAT with a single-slice CT scan through the L4–L5 interspace. The scan was performed around the time of the subject's year 4 colonoscopy that determined adenoma recurrence.RESULTS: Of 119 subjects, 44 of 84 men (52%) and 16 of 35 women (46%) had a recurrent adenoma (p= 0.51). Body mass index (BMI) and weight at baseline and at year 4 colonoscopy were unrelated to adenoma recurrence. In a multivariate model including visceral fat quartile, remote history of polyps, gender, age, and randomization group, only remote history of polyps was statistically significantly associated with recurrent adenoma with a relative risk of 4.6 (95% CI 1.7, 12.4,p= 0.001). There was no consistent monotonic trend of increased or decreased risk of recurrence as one ascended quartiles of adipose tissue for visceral, subcutaneous, or total abdominal fat.CONCLUSION: In this study, no association between visceral adipose tissue and adenomatous polyp recurrence was observed. Further study and exploration of the role of VAT in adenoma progression is required. [ABSTRACT FROM AUTHOR]

As colorectal cancer screening gains acceptance by the public, the use of colonoscopy will increase. The frequency of surveillance examinations after detection of an adenoma is one of the largest contributors to the cost of colorectal cancer screening. Ten years after the publication of the landmark National Polyp Study, the issue of when to perform surveillance examinations and how often to expect advanced findings remains acute. Current guidelines for surveillance vary across specialty organizations. Individuals with advanced adenomas are at increased risk for recurrent advanced adenomas. The impact of multiple nonadvanced adenomas or a single nonadvanced adenoma on subsequent risk of an advanced adenoma or cancer is less clear. Still less is known about findings on repeat examinations after an initial negative examination, whether after colonoscopy or sigmoidoscopy. The yield after a negative examination is an important consideration in determining the recommended interval for screening colonoscopy. For example, the data supporting a 10-yr interval for screening colonoscopy is only indirect. What little we do know about the yield after negative examinations comes from selected, nonrepresentative populations. Of concern, evidence from several polyp prevention trials demonstrates higher yields for subsequent cancer than would be expected, despite a relatively high use of surveillance procedures in follow-up. Further population-based research on the frequency of use and yield of surveillance examinations is needed. Studies that examine the need and the needed timing of subsequent surveillance are essential to containing costs for screening as well as to informing the public better about what endoscopic screening can and cannot accomplish. [Copyright &y& Elsevier]

OBJECTIVE:Colorectal cancer screening is underutilized. Total colon examination (TCE), such as with colonoscopy, can have a significant effect on the measured compliance with screening, as colonoscopy may be able to be performed as infrequently as once every 10 yr. In a population-based survey we determined the prevalence and validated the self-reporting of TCE and assessed its impact on compliance with screening.METHODS:We interviewed an age- and sex-stratified random sample of 50- to 79-yr-old residents in two communities in southwestern Pennsylvania. Subjects reported ever having had and duration since last use of fecal occult blood testing (FOBT), flexible sigmoidoscopy (FS), rigid proctoscopy, barium enema, and colonoscopy. Self-reports of colorectal testing were validated via retrieval of procedure reports.RESULTS:Out of 1223 individuals sampled, 496 completed a telephone interview (40.6% overall and 58.3% of eligible contacts). In those without personal or family histories of colorectal cancer or personal histories of polyps (n = 377), 50%, 19.6%, 39.8%, and 17.5% reported ever having had FOBT, FS, barium enema, and colonoscopy, respectively. Thirty-one percent reported having FOBT within the previous year or FS within the previous 5 yr. Including TCE within the previous 5 yr increased the measured compliance to 39.7%. Compliance was significantly greater among subjects with family histories of colorectal cancer (62.9% vs 39.7%, odds ratio = 2.6, 95% CI = 1.3–5.2). Self-reports of recent colonoscopy were verified in 29 of 35 instances (83%).CONCLUSION:The prevalence of TCE in this population was significant, and including TCE substantially increased measured compliance with colorectal cancer screening. Self-reported use of colonoscopy was validated as accurate. [Copyright &y& Elsevier]

Objectives: We describe 14 patients who developed inflammatory bowel disease (IBD) after transplantation despite immunosuppression. Methods: Using an electronic medical archival retrieval system, records of 6800 liver and kidney transplant patients were searched for evidence of IBD. The pathology was reviewed, and infectious etiologies were excluded. Results: Fourteen patients developed IBD after transplantation. Twelve patients had undergone liver transplantation, and two kidney transplantation. Four had transplantation for autoimmune hepatitis; four for non-A, non-B, non-C hepatitis; two for primary sclerosing cholangitis; one for giant cell hepatitis; one for biliary artresia; one for polycystic kidney disease; and one for obstructive uropathy. Mean age at development of IBD was 38 yr. Mean time to development of IBD after transplantation was 4 yr. Endoscopically there were two cases limited to the left side, eight of pancolitis, of which one had terminal ileal disease, and four of patchy colitis. Histology was consistent with ulcerative colitis in nine patients and Crohn's disease in five. Patients with ulcerative colitis either responded and remained in remission on maintenance therapy (seven of nine) or were refractory and required a colectomy (two of nine). Patients with Crohn's disease continued to have flares despite treatment (five of five). Conclusion: 1) New onset IBD can develop after solid organ transplantation, despite use of immunosuppressive therapy. 2) A full spectrum of IBD can be seen after transplantation. 3) Study of these patients could shed light on why immunosuppression is not uniformly effective for IBD and provide clues to the inflammatory determinants of IBD. [ABSTRACT FROM AUTHOR]

Objectives: Evidence is accumulating supporting the use of screening for colorectal cancer. Patients at higher risk for colorectal career are more likely to benefit from screening. Women with breast, endometrial, or ovarian cancer are often classified as at high risk for subsequent colorectal cancer, and are urged to undergo screening, but the basis for this is uncertain. Methods: We performed a meta-analysis of published data to assess the risk of colorectal cancer after these cancers. Results: Based on 154,270 women and 779,251 person-yr of observation (PYO) after breast cancer, 37,266 women and 229,498 PYO after endometrial cancer, and 41,366 women and 126,688 PYO after ovarian cancer, the age-adjusted relative risk (95%CI) for colorectal cancer after breast cancer was 1.1 (1.07, 1.19), after endometrial cancer 1.4 (1.32, 1.55), and after ovarian cancer 1.6 (1.40, 1.80). Conclusions: 1) Women with a history of breast, endometrial, or ovarian cancer are at a statistically significant increased risk for subsequent colorectal cancer. 2) Women with a history of endometrial or ovarian cancer are at higher risk than are women with breast cancer, but ascertainment bias from heightened medical surveillance after the diagnosis of a gynecologic malignancy may contribute to this observed increase in risk. 3) The association between these cancers and colorectal cancer suggests common etiologic factors, either environmental or genetic, but the degree of increased risk is small. [ABSTRACT FROM AUTHOR]

Objectives: 1) To validate risk factors for delayed healing of duodenal ulcers identified previously in a pilot study, and 2) To evaluate whether famotidine improves the rate of duodenal ulcer healing and pain relief, compared with ranitidine. Methods: Design: prospective, multicenter, double-observer-blinded, randomized trial. Setting: 594 patients with active duodenal ulcers seen in private practice offices, university based medical practices and Veterans Affairs hospital clinics. Interventions: Patients were randomly assigned to receive famotidine 40 mg or ranitidine 300 mg qhs. Measurements: Endoscopy was performed at entry and at 2, 4, and 8 wk after therapy or until complete ulcer healing. Seventeen patient variables, including demographic, past historical, presenting historical and endoscopic characteristics, were assessed for their relationship to healing. Results: After 4 wk of treatment, by a "per protocol" analysis, three risk factors for nonhealing were statistically significant: prior ulcer history [63.0% healed, compared to 77.9% with no history, p = 0.001, odds ratio for not healing (OR) = 2.1, 95% CI = 1.4-3.1]; ulcer size (61.6% of ulcers ≥10 mm healed at 4 wk compared to 75.5% of smaller ulcers, p = 0.001, OR = 1.9, 95% CI = 1.3-2.8); and smoking (62% of smokers healed vs. 11.1% of nonsmokers, OR = 2.1, 95% CI = 1.4-3.1). The presence of multiple risk factors resulted in additive risk: for patients with no risk factors, 86.8% healed at 4 wk, with any one risk factor 76.8% healed, with two factors 63.0%, and with all three risk factors only 46.9% healed. Multiple risk factors also affected healing rates at 8 wk. Bleeding, alcohol use, and prior NSAID use did not influence ulcer healing. Although famotidine resulted in statistically significant faster ulcer healing when examined on an "intention-to-treat" basis, there were no differences between the drugs when examined on a "per protocol" basis. Patients treated with famotidine achieved more... [ABSTRACT FROM AUTHOR]

Colonic pseudo-obstruction has been associated with colonic ischemia in only 7-10% of cases. When both conditions are present, most authors recommend immediate laparotomy because of the additional weakening of the bowel wall induced by the presence of ischemia and the resultant increased risk of perforation. We report on three patients with pseudo-obstruction and right-sided colonic ischemia who were successfully managed with colonoscopic decompression with tube placement. Surgery may not be required in patients with pseudo-obstruction and associated colonic ischemia. [ABSTRACT FROM AUTHOR]

Presents information on Wilson's Disease, an inherited disorder of copper metabolism. Clinical manifestations; Information on the genetic aspects of the disease; Diagnostic tests for the disease; Details of the decoppering treatment.

The article argues that screening colonoscopy is reasonable on an 88-year-old patient with colorectal cancer (CRC). Given the patient's average life expectancy and risk of death from CRC, the author argues that the patient can still benefit from the procedure because colonoscopy can reduce the mortality to colorectal cancer due to early diagnosis. The author further states that CRC screening can decrease the incidence of cancer.

Objective: Health care reform is dramatically changing the practice and delivery of medical care. The goal of this investigation was to examine gastroenterology trainees' outlook on the impact of health care reform on training programs. Methods: A 24-question survey was mailed in February 1996 to 780 GI fellows obtained from the comprehensive American College of Gastroenterology (ACG) database. Results: A total of 362 fellows responded (46%): 85% were male, 57% Caucasian, 75% married, and 86% were university-based. Ninety-six percent of fellows believed that health care reform is adversely affecting the quality of health care and 94.1 % felt that it was adversely affecting fellowship training. Eighty-eight percent expressed concern over the impact of health care reform on practice opportunities. Only 9% of fellows reported that their training program had established a specific educational program addressing health care reform, whereas 83% of fellows felt that their program should do so. Conclusion: Gastroenterology fellows are concerned about the impact of health care reform on the quality of care and the quality of their fellowship training. Trainees believe that programs are not providing sufficient education to help them respond to the changes in health care. [ABSTRACT FROM AUTHOR]

A patient with 7 yr of severe disabling chronic epigastric abdominal pain attributed to chronic pancreatitis was seen in consultation before a 95% pancreatectomy for pain control. Previous attempts to identify and treat the pain lead to extensive radiographic, pharmacological, endoscopic, and surgical interventions, including a Roux-en-Y pancreaticojejunostomy. Pain control was poor despite implantation of a continuous intrathecal morphine infusion pump. A focused physical examination, however, raised the suspicion of thoracic disc disease, which was confirmed after myelogram with computed tomography. Disruption of the T7-T8 disc with protrusion into the vertebral canal and displacement of the spinal cord with an associated bone spur were identified. A microsurgical thoracic discectomy was performed. Immediately, the pain began resolving, and she was pain free and off her medications within several weeks. To our knowledge, this is the first description of a herniated thoracic disc presenting as the pain of chronic pancreatitis. The diagnosis of thoracic disc syndrome requires a high index of suspicion and should be considered in patients with chronic abdominal pain. [ABSTRACT FROM AUTHOR]

Reports a patient who presented with intermittent crampy pain and a benign abdominal examination who had a middle colic artery (MCA) aneurysm rupture. Features of MCA aneurysms; Treatment; Difficulty of the diagnosis of a MCA aneurysm.

A response from the author of the article "Guidelines on the diagnosis and management of iron deficiency and anemia in inflammatory bowel diseases" in 2007 issue is presented.

Comments on the study "Colonic Motility and Transit in Health and Ulcerative Colitis," by S. N. Reddy, G. Bazzocchi, S. Chan and colleagues. Overview of the study; Effect of irregular colonic transit and diminished contractility in patients with ulcerative colitis; Limitations of the study.

A response by Robert E. Schoen to a letter to the editor about his article on screening colonoscopy among elderly patient is presented.

Presents a response by Thomas R. Riley, Robert E. Schoen, Randall G. Lee and Jorge Rakela to the letter to the editor about their article "A Case Series of Transplant Recipients Who Despite Immunosuppression Developed Inflammatory Bowel Disease" in the 1997 issue.