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Background: Currently, no clinical tools use demographic and risk factor information to predict the risk of finding an adenoma in individuals undergoing colon cancer screening. Such a tool would be valuable for identifying those who would most benefit from screening colonoscopy. Methods: We used baseline data from men and women who underwent screening colonoscopy from the randomized, multicenter National Colonoscopy Study (NCS) to develop and validate an adenoma risk model. The study, conducted at three sites in the United States (Minneapolis, MN; Seattle, WA; and Shreveport, LA) asked all participants to complete baseline questionnaires on clinical risk factors and family history. Model parameters estimated from logistic regression yielded an area under the receiver operating characteristic curve (AUROCC) used to assess prediction. Results: Five hundred forty-one subjects were included in the development model, and 1,334 in the validation of the risk score. Variables in the prediction of adenoma risk for colonoscopy screening were age (likelihood ratio test for overall contribution to model, P < 0.001), male sex (P < 0.001), body mass index (P < 0.001), family history of at least one first-degree relative with colorectal cancer (P = 0.036), and smoking history (P < 0.001). The adjusted AUROCC of 0.67 [95% confidence interval (CI), 0.61–0.74] for the derivation cohort was not statistically significantly different from that in the validation cohort. The adjusted AUROCC for the entire cohort was 0.64 (95% CI, 0.60–0.67). Conclusion: We developed and validated a simple well-calibrated risk score. Impact: This tool may be useful for estimating risk of adenomas in screening eligible men and women Cancer Epidemiol Biomarkers Prev; 24(6); 913–20. ©2015 AACR.

Is the higher reported colorectal cancer (CRC) mortality in blacks versus whites in the United States due to pathology or disparities in screening? Our study used patient navigation (PN) to assist blacks and whites adhere to screening colonoscopy and compared adenomas detected in each group.

Objective To assess the usefulness of health plan administrative data for identifying patients with irritable bowel syndrome (IBS). Study Design and Setting In this retrospective study of 442 medical records of patients in nine U.S. health plans, five sets of criteria that used administrative data were used to identify potential IBS patients. Physician reviewers provided an assessment of the likelihood of the diagnosis of IBS being present. IBS was considered to be present if the physician reviewer categorized the case as definite, probable, or possible based on medical record review. Analyses were also performed with cases categorized as possible placed in an “IBS not present” category. Results The positive predictive value (PPV) for the five sets of criteria ranged from 63% to 83% with the highest PPV found with one of the most restrictive criteria. When cases characterized as possible were included in the “IBS not present” category, the PPV for each of the five sets of criteria decreased substantially, ranging from 33% to 63%. Conclusion The PPV of different criteria used to identify patients with IBS from administrative data varies substantially based on the criteria that are used. Use of criteria with a higher PPV may come at the expense of generalizability.

BACKGROUND: Comorbid nongastrointestinal symptoms account for two-thirds of excess health-care costs in irritable bowel syndrome (IBS). OBJECTIVES: To determine whether IBS patients are at greater risk for specific comorbid disorders versus showing a general tendency to overreport symptoms; whether patients with inflammatory bowel disease (IBD) show patterns of comorbidity similar to IBS; whether comorbidity is explained by psychiatric disease; and whether excess comorbidity occurs in all IBS patients. METHODS: All 3,153 patients in a health maintenance organization with a diagnosis of IBS in 1994-1995 were compared to 3,153 age- and gender-matched controls, and to 571 IBD patients. All diagnoses in a 4-yr period beginning 1 yr before their index visit were categorized as gastrointestinal, psychiatric, or nongastrointestinal somatic. Nongastrointestinal somatic diagnoses were further divided into symptom-based versus biological marker-based diagnoses. RESULTS: Forty-eight of 51 symptom-based and 16 of 25 biomarker-based diagnoses were significantly more common in IBS versus controls. However, there were no unique associations. Bacterial, viral, and fungal infections and stroke were among diagnoses made more frequently in IBS. IBD patients were similar to controls. Greater somatic comorbidity was associated with concurrent psychiatric diagnosis. Only 16% of IBS patients had abnormally high numbers of comorbid diagnoses. CONCLUSIONS: Comorbidity in IBS is due to a general amplification of symptom reporting and physician consultation rather than a few unique associations; this suggests biased symptom perception rather than shared pathophysiology. Comorbidity is influenced by, but is not explained by, psychiatric illness. Excess comorbidity is present in only a subset of IBS patients.

Autonomic nervous system (ANS) balance was assessed in women with and without irritable bowel syndrome (IBS) using laboratory tests of function (ie, expiratory/inspiratory ratio, Valsalva, posture changes, and cold pressor) and spectral and nonspectral measures of heart rate variability (HRV). Women with (N = 103) and without IBS (N = 49) were recruited, interviewed, then completed a laboratory assessment and wore a 24-hr Holter monitor Analysis using the entire sample showed little difference between IBS and control women and between subgroups with IBS on either laboratory measures or 24-hr HRV measures. However, analysis restricted to those women with severe IBS symptoms showed quite pronounced differences between two IBS subgroups on 24-hr HRV measures. Parasympathetic tone was significantly lower and ANS balance was significantly higher in the constipation-predominant compared to the diarrhea-predominant group. Subgroups of women with IBS do differ in ANS function as measured by 24-hr HRV; however, these differences are only apparent among women with severe symptoms. These findings point out the importance of considering symptom severity when interpreting studies of IBS.

Many gastroenterology treatments would be minimally effective if patients did not adhere to prescribed therapeutic regimens. However, considerable evidence exists that patients often do not adhere. Factors associated with nonadherence include the physician's or other health care provider's behavior, the prescribed regimen, and the illness. These factors affect patient adherence such that: 1) patients do not have the skills or knowledge necessary to complete an assignment; 2) patients do not believe that they will be helped by the prevention or intervention activity, or they do not accept the activity because they do not believe that its value will outweigh its costs; and 3) patients' environments are not supportive of, or interfere with, adherence. Strategies that can increase adherence include attention to the physician/patient relationship, direct skill training, setting up a reward structure, and reminders, among others. Specific methods that gastroenterology health care providers can utilize to enhance adherence in their practice are presented.

The Rome III classification system treats functional constipation (FC) and irritable bowel syndrome with constipation (IBS-C) as distinct disorders, but this distinction appears artificial, and the same drugs are used to treat both. This study's hypothesis is that FC and IBS-C defined by Rome III are not distinct entities.In all, 1,100 adults with a primary care visit for constipation and 1,700 age- and gender-matched controls from a health maintenance organization completed surveys 12 months apart; 66.2% returned the first questionnaire. Rome III criteria identified 231 with FC and 201 with IBS-C. The second survey was completed by 195 of the FC and 141 of the IBS-C cohorts. Both surveys assessed the severity of constipation and IBS, quality of life (QOL), and psychological distress.(i) Overlap: if the Rome III requirement that patients meeting criteria for IBS cannot be diagnosed with FC is suspended, 89.5% of IBS-C cases meet criteria for FC and 43.8% of FC patients fulfill criteria for IBS-C. (ii) No qualitative differences between FC and IBS-C: 44.8% of FC patients report abdominal pain, and paradoxically IBS-C patients have more constipation symptoms than FC. (iii) Switching between diagnoses: by 12 months, 1/3 of FC transition to IBS-C and 1/3 of IBS-C change to FC.Patients identified by Rome III criteria for FC and IBS-C are not distinct groups. Revisions to the Rome III criteria, possibly including incorporation of physiological tests of transit and pelvic floor function, are needed.

Summary Aim To provide estimates of actual costs to deliver health care to patients with functional bowel disorders, and to assess the cost impact of symptom severity, recency of onset, and satisfaction with treatment. Methods We enrolled 558 irritable bowel (IBS), 203 constipation, 243 diarrhoea and 348 abdominal pain patients from primary care and gastroenterology clinics at a health maintenance organization within weeks of a visit. Costs were extracted from administrative claims. Symptom severity, satisfaction with treatment and out-of-pocket expenses were assessed by questionnaires. Results Average age was 52 years, 27% were males, and 59% participated. Eighty percent were seen in primary care clinics. Mean annual direct health care costs were $5049 for IBS, $6140 for diarrhoea, $7522 for constipation and $7646 for abdominal pain. Annual out-of-pocket expenses averaged $406 for treatment of IBS symptoms, $294 for diarrhoea, $390 for constipation and $304 for abdominal pain. Lower gastrointestinal costs comprised 9% of total costs for IBS, 9% for diarrhoea, 6.5% for constipation and 9% for abdominal pain. In-patient care accounted for 17.5% of total costs (15.2% IBS). Conclusion Costs were affected by disease severity (increased), recent exacerbation of bowel symptoms (increased), and whether the patient was consulting for the first time (decreased).

Summary Background Studies suggest that the positive predictive value of the Rome II criteria for diagnosing irritable bowel syndrome can be enhanced by excluding red flag symptoms suggestive of organic diseases. Aim We assessed the utility of red flags for detecting organic diseases in patients diagnosed irritable bowel syndrome by their physicians. Methods Systematic chart reviews were completed in 1434 patients with clinical diagnoses of irritable bowel syndrome, abdominal pain, diarrhoea or constipation, who also completed questionnaires to identify Rome II criteria for irritable bowel syndrome and red flag symptoms. Results The overall incidence of gastrointestinal cancer was 2.5% (but 1.0% in those with irritable bowel syndrome), for inflammatory bowel disease 2.0% (1.2% in irritable bowel syndrome), and for malabsorption 1.3% (0.7% in irritable bowel syndrome). Red flags were reported by 84% of the sample. The positive predictive value of individual red flags for identifying organic disease was 7–9%. Excluding any patient with a red flag improved the agreement between Rome II and clinical diagnosis by a modest 5%, but left 84% of patients who were diagnosed with irritable bowel syndrome by their physicians, without a diagnosis. Conclusions Red flags may be useful for identifying patients who require additional diagnostic evaluation, but incorporating them into the Rome criteria would not improve sensitivity and would result in too many missed irritable bowel syndrome diagnoses.

BACKGROUND: Soy isoflavones have numerous biological properties that suggest that they may protect against colorectal cancer. Colorectal epithelial cell proliferation has been used extensively as an intermediate endpoint biomarker for colorectal neoplasia. OBJECTIVE: We tested the hypothesis that supplementation with soy protein containing isoflavones decreases colorectal epithelial cell proliferation. DESIGN: A 12-mo randomized intervention was conducted in men and women aged 50-80 y with recently diagnosed adenomatous polyps. One hundred fifty participants were enrolled and randomly assigned to an active treatment group (58 g protein powder/d containing 83 mg isoflavones/d; +ISO) or a control group (ethanol-extracted soy-protein powder containing 3 mg isoflavones; -ISO). Biopsy specimens from the cecum, sigmoid colon, and rectum were collected at baseline and at the 12-mo follow-up. Ki-67 antibody immunohistostaining was used to detect cell proliferation. One hundred twenty-five participants completed the study, and proliferation was measured in the first 91 who completed the study. RESULTS: In the sigmoid colon, cell proliferation increased by 0.9 (95% CI: 0.09, 1.9) labeled nuclei per crypt more (11%) in the +ISO group than in the -ISO group over the 12-mo intervention, which was opposite the direction predicted. The number of labeled nuclei per 100 [micro]m crypt height also increased more in the +ISO than in the -ISO group. In the cecum and sigmoid colon, but not in the rectum, the proliferation count increased as the serum genistein concentration increased. Proliferation distribution and crypt height were not changed by treatment at any site. CONCLUSIONS: Supplementation with soy protein containing isoflavones does not reduce colorectal epithelial cell proliferation or the average height of proliferating cells in the cecum, sigmoid colon, and rectum and increases cell proliferation measures in the sigmoid colon.

What constitutes standard medical care for irritable bowel syndrome (IBS) in U.S. primary care and gastroenterology clinics?

Background Drossman et al. (Gastroenterology 2007) previously reported that patients frequently transition between IBS-M and C categories over the course of one year, thus indicating a close relationship between these two IBS subtypes relative to IBS-D. Aim This study utilizes ecological momentary assessment (EMA) in an effort to quantify gastrointestinal symptoms using repeated measures assessed over a two week period. Methods A total of 46 subjects diagnosed by physicians with IBS D,C or M contributed a total of 4349 ratings of abdominal pain, bloating, stool consistency (Bristol Stool Scale BSS), straining at bowel movement, urgency at bowel movement, rectal fullness, stress and well being over a two week period using a pocket pc based data collection system. Results Participants diagnosed with IBS-M and IBS-C did not differ significantly on any variable except for BSS where subjects with IBS-C reported more constipated stools, Mean BSS (IBS-C = 3.42 vs. IBS-M = 4.01, p

The ramifications of fecal incontinence and urinary incontinence extend well beyond their physical manifestations. To promote work that will reduce suffering and costs attributable to fecal and uri...

Impact of Having a Second Degree Relative with Colorectal Cancer on the Risks of Developing Adenomas Kenny Chiu, Hyung Cho, Sharon Bayuga, Tim Church, Margaret Mandelson, Andrew Feld, John Allen, Glenn Mills, Paul Jordan, Michael O’Brien, Ann Zauber, Sidney Winawer Colon cancer screening studies have concentrated on studying the risks of 1 degree relatives (FDR) with colon cancer and under current screening guidelines, having affected 2 degree relatives (SDR) place a person in the average risk category. However, there is a small increase in colon cancer risks from having an affected SDR. The aim of this study is to evaluate how an affected SDR or FDR affect the prevalence of adenomas and advanced adenomas in a multicenter colon cancer screening trial. As part of the National Colonoscopy Study (NCS), 622 subjects enrolled from 1999 to 2002 underwent a screening colonoscopy. The presence of adenomas, their number, size, and location were recorded. All histologies were confirmed by an independent pathologist. The subjects were categorized as having an affected FDR, SDR, or neither. The endoscopists determined that 99.4% had a good preparation and the cecum was reached in 98.9%. Subjects with an affected FDR and those with an affected SDR show a similar trend towards an increased risk for adenomas. Having either an affected FDR or SDR increases the risk for adenomas when compared to those with neither (p Z 0.03). There was no difference in the ratio of right vs left sided adenomas or in their multiplicity based on family history. In conclusion, subjects with an affected SDR show a trend towards an increased risk for adenomas similar to those with an affected FDR. There is a statistically significant increase in the risk for adenomas in subjects with either an affected FDR or SDR. The number of advanced adenomas is too few to show a trend. The NCS is ongoing and will accrue a larger cohort to further evaluate the role of SDR’s in the risk of advanced adenomas. The impact of family histories is still being explored and with further studies, the presence of an affected SDR may place individuals in a higher risk screening category.

We previously' (Gastro 2002,122(Suppl 1):A502) developed and validated the IBS-specific Recent Physical Symptoms Questionnaire (RPSQ) and Comorbid Medical Conditions Questionnaire (CMCQ) based on a systematic literature review We hypothesized that the excess comorhid medical cooditions and non-gastrointestinal symptoms seen in 1BS constitute somatization, that is, expresskm of psychological distress thmugb physieal symptoms (Gastro 2002;122(4):1140-56). Aims: (1) Test the hy'pothesis that comorbidity m IBS is related to anxiety and depression and (2) quantity ' the impact of excess comorbidity on IBS symptom severity, disability, quality of fite and IBScelated health care utilization. Methods: The RPSQ and CMCQ were mchided in a marl survey completed by 1603 patients with functional bowel diagnoses in a large nortfiwestem US. health maintenance organization within 2 weeks of a clinic visit. The survey also included the IBS-QOL (Dig Dis Sci 1998;43:40011), the IBS Seventy Index (Aliment Pharmacol Tber 1997;11:395-402) the Brief Symptom Inventory' -18 (NCS Pearson, Inc.) attd questions about doctor's visits and disability days. Data from the 7g\5 IBS patients who met Rome II criteria were analyzed. Results: RPSQ # of non-gastrointestinal (non-GI) symptoms and CMCQ # of comorbid medical diagnoses were moderately intercorrelated (r= 49, p 1 standard deviation above the sample mean) on either comorbidity scale bad greater quality of li|e impairment, more than 3 times the number of disability days m the past year, and greater overall IBS symptom severity (p

We conducted a case-control study at Group Health Cooperative of Puget Sound to investigate the relation between long-term cimetidine use and gastric cancer. Five of 99 cases of gastric cancer were exposed to cimetidine at least two years before diagnosis, whereas nine of 365 controls (selected from among users of the Group Health Cooperative pharmacy, matched on age, sex, and first year of pharmacy use) were similarly exposed. The odds ratio comparing users with nonusers was 2.3 (95% CI = 0.8-6.9). The odds ratio comparing users of antacids with nonusers was similar, 1.9 (95% CI = 1.0-3.7). Although a causal relation between gastric cancer and cimetidine is possible, the similarity of the findings for cimetidine and antacids lends support to other explanations.

The deleterious effects of aspirin on gastric mucosa have been well documented in experimental and clinical studies. Prostaglandins offer a potential method by which this injury may be prevented. In these studies, we developed a single-dose endoscopic assay system of aspirin-induced gastric mucosal injury in normal volunteers. With this system, 27 of 30 volunteers (90%) demonstrated severe mucosal injury after ingestion of aspirin. Subsequently, we evaluated whether pretreatment with 15-R-15 methyl prostaglandin E 2 prevented severe injury after ingestion of aspirin. Following an initial dose-response study, a double-blind crossover trial was performed using pretreatment with placebo or with 10-μg doses of 15-R-15 methyl prostaglandin E 2 for 24 h before treatment with aspirin. The results of this trial indicate that prostaglandin pretreatment significantly prevented the occurrence of endoscopically visible severe gastric mucosal injury after single-dose aspirin administration.

SUMMARY Upper gastrointestinal bleeding is a common gastrointestinal emergency associated with significant socioeconomic impact, morbidity and mortality. The aetiology of upper gastrointestinal bleeding has been reviewed, including the pathophysiological mechanisms of acid peptic and gastric mucosal disease. The initial diagnosis and therapeutic approach to the bleeding patient has been outlined.

In this follow-up study we attempted to estimate the risk of hospitalization for upper gastrointestinal bleeding (exclusive of bleeding from duodenal ulcer) caused by taking certain nonsteroidal antiinflammatory drugs (NSAIDs) in people below the age of 65 years. The final figures represent our best estimate, taking into account all of the available information, and suggest that NSAIDs (excluding aspirin) rarely cause gastrointestinal bleeding from the stomach that requires hospitalization in this age group. A formal analysis of the data according to classic techniques was not feasible since numerous important confounding factors could not be controlled. Indeed, the results indicated that such formal analysis is unnecessary. The data as they stand are of considerable value in providing a reasonable estimate of attributable risk for the drugs studied.

• The mortality from upper gastrointestinal (GI) tract bleeding has remained constant at 10% during the past 40 years. Many drugs may precipitate upper GI tract bleeding by disrupting the gastric mucosal barrier. Aspirin-induced injury to the gastric mucosa and GI tract bleeding have been documented in many studies; some of the mechanisms involved are known, but others are still being investigated. An approach to the bleeding patient is suggested; initial resuscitation, history taking, physical examination, determination of bleeding levels, and diagnostic procedures to determine the cause of bleeding are reviewed. Also described are available therapies for GI tract bleeding—gastric lavage, drug therapy, endoscopic control, electrocautery, thermal probe, tissue adhesive, and laser photocoagulation. The merits of the argon laser and the neodymium-yttrium aluminum garnet laser (both still in experimental stages) are described and compared. No pharmacologic or endoscopic therapies for upper GI tract bleeding have been proved effective. (Arch Intern Med1981;141:322-327)