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Objectives: Increased risk for colorectal cancer (CRC) has been associated with type 2 diabetes. Despite several studies linking insulin resistance to increased CRC risk, there are limited data on colorectal adenoma risk in diabetic women. We hypothesized that diabetic women would have increased rates of colorectal adenomas relative to a group of nondiabetic women., Methods: Colorectal adenoma rates were determined in 100 estrogen-negative women with type 2 diabetes mellitus and compared with 500 nondiabetic, estrogen-negative controls. Adenomas were defined as any adenoma or advanced adenoma (villous or tubulovillous features, size >1 cm or high-grade dysplasia). A multivariate model including age, race, diabetes, hypertension, hypercholesterolemia, body mass index, and nonsteroidal anti-inflammatory drug status was used to determine the independent effects of diabetes on colorectal adenoma incidence., Results: Diabetics as compared with nondiabetics had greater rates of any adenoma (37%vs 24%, p= 0.009) and advanced adenomas (14%vs 6%, p= 0.009). Two hundred forty-five obese subjects compared with 355 nonobese subjects had a higher rate of any adenoma (32%vs 22%, p= 0.001). Obese diabetics compared with nonobese, nondiabetics had greater rates of any adenoma (42%vs 23%, p< or = 0.001) and advanced adenomas (19%vs 7%, p< or = 0.001). Multivariate analysis showed that adenomas and advanced adenomas were independently predicted by diabetes (p < 0.05) and adenomas by age., Discussion: Women with type 2 diabetes mellitus had higher rates of colorectal adenomas as compared with lean and nondiabetic women. This finding adds to the evidence that type 2 diabetes is an important factor in the progression of the adenoma-carcinoma sequence.

Background: Various methods to drain pancreatic pseudocysts by using EUS guidance have been reported in the literature., Objective: A new drainage technique is described that uses a modified needle knife advanced over a guidewire positioned in the pseudocyst by EUS guidance., Design: Retrospective chart review., Setting: Academic medical center., Patients: Consecutive subjects from December 1, 2002, to January 10, 2005, with symptomatic pseudocysts in whom EUS-guided drainage was attempted., Interventions: By using a therapeutic linear echoendoscope, a 19-gauge aspiration needle was inserted into the pseudocyst. A guidewire was placed through the needle, and a needle knife with the cutting wire protruding and bent was advanced over the guidewire to contact the stomach mucosa. The needle knife was then advanced by using electrocautery into the pseudocyst. The cystenterostomy was dilated by using a balloon over the guidewire. One to 4 stents were placed through the tract., Main Outcome Measurements: Successful pseudocyst drainage., Results: A total of 21 of 23 patients underwent technically successful pseudocyst drainage. One patient had self-limited hypotension during the procedure. Another patient had free intraperitoneal air after the procedure but correct stent placement., Limitations: Retrospective analysis, small sample size., Conclusions: In this preliminary experience, wire-guided pseudocyst drainage with a modified needle knife appears effective and safe while allowing for a more controlled pseudocyst puncture.

Endoscopic ultrasound (EUS) is a useful imaging modality in patients with certain gastrointestinal malignancies as well as lung cancer. In many cases, EUS has been shown to have superior staging accuracy compared with other imaging techniques such as computed tomography, magnetic resonance imaging and positron emission tomography. This article will review the role of EUS in diagnosing and staging esophageal, rectal, pancreatic and lung cancers as well as subepithelial lesions. Newer therapeutic applications of EUS, namely endoscopic mucosal resection for removal of localized lesions as well as celiac plexus neurolysis for pain control, will also be discussed., ((c) 2005 S. Karger AG, Basel.)

Objectives: Selenium is a trace mineral that, as a constituent of certain selenoproteins, acts as an antioxidant. Results of studies addressing a cancer protective effect of selenium have been controversial. The present study measured selenoprotein-P, extracellular glutathione peroxidase, and plasma selenium in patients with colon cancer and adenomatous colon polyps to determine whether patients who develop colorectal adenomas or cancer are selenium deficient., Methods: Patients who presented to an endoscopy center for colonoscopy or who were referred to our institution with a newly diagnosed colorectal cancer were offered enrollment in the trial. Each patient underwent phlebotomy, usually immediately after colonoscopy. In all, 103 patients were enrolled in the study. Of these, 33 patients were found to have colorectal cancer, 35 adenomatous colon polyps, and 17 normal examinations. A total of 18 patients had other diagnoses and were not included in the study group., Results: The mean age for the colorectal cancer group was 69 yr, for the adenomatous colon polyp group 62 yr, and for the normal group was 56 yr. The adenomatous colon polyp and normal groups were predominantly female. Based on one way analysis of variance tests, there was no significant difference in selenoprotein-P or plasma selenium levels or extracellular glutathione peroxidase activity among the three groups (p = 0.28, 0.098, and 0.35 respectively)., Conclusions: The present data suggest that patients with adenomatous colon polyps and those with colorectal cancer are not selenium deficient.

Radiation therapy for thoracic malignancies is often complicated by radiation-induced esophagitis. Symptoms of radiation esophagitis are nonspecific and include dysphagia, odynophagia, and chest pain. Patients receiving radiation therapy are also at risk for infectious esophagitis, which can be indistinguished clinically from radiation-induced esophagitis. We retrospectively reviewed data on patients who had esophagitis symptoms during or after thoracic radiation therapy and were referred for upper endoscopy. We sought to determine how often infectious esophagitis or cancer was present, as compared to radiation-induced esophagitis alone. Twenty-four upper endoscopies were performed on 16 patients over a three-year period to evaluate esophagitis symptoms. Forty-four percent of the patients endoscoped had infectious esophagitis or recurrent cancer diagnosed by endoscopy. No complications occurred from the procedures. Esophagoscopy is a safe procedure that should be considered, to exclude infection or cancer, in patients who develop esophagitis symptoms during or after thoracic radiation.

Objective: The vast majority of patients undergoing colonoscopy in the United States are given sedation. There are a number of potential advantages to performing colonoscopy without sedation. We sought to determine the attitude of patients toward unsedated colonoscopy in our three practice settings (a university medical center, a cancer center, and a Veterans Affairs medical center), and to see if there were factors that predicted willingness to try it., Methods: Four-hundred thirty-four adult patients undergoing outpatient colonoscopy completed questionnaires before and after their procedures providing demographic information and assessing willingness to undergo colonoscopy without sedation. Patients were routinely given meperidine and midazolam for their procedures unless they specifically requested that they be unsedated (10 patients)., Results: Only 16.9% of our patients were willing to undergo colonoscopy on their preprocedure questionnaire. Willingness increased modestly on the postprocedure questionnaire to 22.6% (p = 0.01). Logistic regression analysis disclosed that male gender, having a college degree, low anxiety based on preprocedure anxiety scales, and lower doses of sedative drugs used during colonoscopy were the best predictors of willingness to undergo colonoscopy without sedation in the future., Conclusions: Only about a fifth of patients undergoing colonoscopy in our three practice settings expressed a willingness to try colonoscopy unsedated. Male gender, higher levels of education, and low anxiety scores on simple scales of preprocedure anxiety may help to predict willingness. Efforts to substantially increase the frequency of patients willing to undergo colonoscopy without sedation will likely require increased patient counseling and education.

Background: We sought to determine whether premedication for colonoscopy with intravenous hyoscyamine sulfate (Levsin) was helpful from the standpoint of the colonoscopist and the patient., Methods: One hundred sixteen adult patients were randomized to receive either 0.5 mg hyoscyamine sulfate intravenous (n = 57) or placebo (n = 59). After administration of study drug, patients were given meperidine and midazolam. Parameters measured included the time required to reach the cecum, total procedure time, and the endoscopist's perception of the adequacy of sedation, difficulty of insertion, and amount of colonic spasm on insertion and withdrawal. Patients were given a postprocedure questionnaire assessing their experience., Results: In patients receiving hyoscyamine, there was a shorter cecal intubation time (median 9.2 vs. 12.9 minutes; p = 0. 01), shorter total colonoscopy time (median 20.5 vs. 25.0 minutes; p = 0.01), better patient sedation (p = 0.02), easier colonic insertion (p = 0.001), and less spasm on insertion (p = 0.01). No difference was found in the amount of spasm during withdrawal or the total dosages of meperidine or midazolam used. Patients receiving hyoscyamine sulfate reported being more comfortable during their procedures ( p < 0.001) and were more willing to repeat colonoscopy in the future (p = 0.0001). The only adverse effect seen during the study was a 27% incidence of sinus tachycardia that occurred in patients receiving hyoscyamine., Conclusions: Premedication with intravenous hyoscyamine sulfate was beneficial in terms of the time required for cecal intubation, total procedure time, adequacy of sedation, and scales of patient comfort. However, the high frequency of sinus tachycardia seen with the dose used in our study, which was extremely rapid in two patients, indicates the need for further study before the drug can be recommended as a routine premedication for colonoscopy.

Background: Screening asymptomatic persons for colorectal cancer may decrease the incidence and mortality of this disease., Methods: The MEDLINE database was used to identify articles addressing the rationale for colorectal cancer screening, methods used and their effectiveness, and current recommendations., Results: Methods of screening for colorectal cancer include flexible sigmoidoscopy, fecal occult blood tests, barium enema, and colonoscopy. The method used and the frequency of screening are determined by assessing an individual's risk of having colorectal cancer., Conclusions: Colorectal cancer is a common malignancy in the United States, is curable when detected at an early stage, and is potentially preventable. The acceptance of colorectal cancer screening by patients and physicians has been suboptimal. while there remains little debate about the potential for screening to reduce mortality from colorectal cancer, debate continues about the cost-effectiveness of colorectal cancer screening when applied to the general population.

Plasma selenium concentration is decreased in patients with cirrhosis and, based on this finding, it has been suggested that patients with cirrhosis are selenium deficient. We measured plasma selenium concentration and the two plasma selenoproteins, glutathione peroxidase (GSHPx-3) and selenoprotein P, in the plasma of patients with cirrhosis of Child classes A, B, and C and in control subjects. Plasma selenium declined in proportion to the severity of the cirrhotic condition, as indicated by the Child class. Selenoprotein P, which originates largely in the liver, declined in a similar manner. Plasma glutathione peroxidase activity increased, and GSHPx-3 originates in the kidney. Selenium in the non-selenoprotein pool, shown by others to be largely selenomethionine in albumin, declined. Thus, although plasma selenium is decreased in patients with cirrhosis, the increase in plasma glutathione peroxidase activity, which occurs in them, suggests that patients with cirrhosis do not have selenium deficiency.

While methods of screening for colorectal cancer undoubtedly will be refined and new techniques developed, there is ample evidence to support use of the currently employed protocol: annual fecal occult blood testing and periodic flexible sigmoidoscopy. Aggressive attempts to educate physicians and patients on the importance of such screening are needed. Primary care physicians can play an important role in ensuring patient compliance and reducing the incidence of this serious public health problem.