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Background The p53 tumor suppressor gene is commonly mutated in colorectal cancer. While the effect of p53 mutations on colorectal cancer prognosis has been heavily studied, less is known about how epidemiologic risk factors relate to p53 status, particularly in early colorectal neoplasia prior to clinically invasive colorectal cancer (including adenomas, carcinoma in situ (CIS), and intramucosal carcinoma). Methods We examined p53 status, as measured by protein overexpression, in 157 cases with early colorectal neoplasia selected from three New York City colonoscopy clinics. After collecting paraffin-embedded tissue blocks, immunohistochemistry was performed using an anti-p53 monoclonal mouse IgG2a [BP53-12-1] antibody. We analyzed whether p53 status was different for risk factors for colorectal neoplasia relative to a polyp-free control group (n = 508). Results p53 overexpression was found in 10.3%, 21.7%, and 34.9%, of adenomatous polyps, CIS, and intramucosal cases, respectively. Over 90% of the tumors with p53 overexpression were located in the distal colon and rectum. Heavy cigarette smoking (30+ years) was associated with cases not overexpressing p53 (OR = 1.8, 95% CI = 1.1–2.9) but not with those cases overexpressing p53 (OR = 1.0, 95% CI = 0.4–2.6). Heavy beer consumption (8+ bottles per week) was associated with cases overexpressing p53 (OR = 4.0, 95% CI = 1.3–12.0) but not with cases without p53 overexpression (OR = 1.6, 95% CI = 0.7–3.7). Conclusion Our findings that p53 overexpression in early colorectal neoplasia may be positively associated with alcohol intake and inversely associated with cigarette smoking are consistent with those of several studies of p53 expression and invasive cancer, and suggest that there may be relationships of smoking and alcohol with p53 early in the adenoma to carcinoma sequence.

This article discusses the important role endoscopy plays in the diagnosis and management of inflammatory bowel disease and how the procedure adds crucial information to the constellation of history, physical examination, radiographic findings, and laboratory values. Differentiation between Crohn's disease and ulcerative colitis has important ramifications for medical therapy, surgical options, and prognosis. This distinction can be accurately made in at least 85% of patients.

Colorectal cancer is an important cause of morbidity and mortality among Western nations, and is more common in the elderly than in younger individuals. With the general acceptance of the adenoma-carcinoma sequence, the current consideration is that colorectal cancer is preventable if all adenomas are removed before they have the chance to progress to cancer. To that end, physicians should now advocate screening for colorectal cancer and through this effort a large number of patients with adenomatous polyps will be discovered. It is important to understand the strategy in dealing with this growing population of patients with adenomas. After an initial polypectomy, patients with adenomas should be entered into a surveillance program to detect and remove recurrent adenomas. Recommended surveillance intervals are shorter for patients with a family history of colorectal cancer, those with multiple adenomas (2), large adenomas (or = 1cm), or those whose adenomas have high-grade dysplasia, villous architecture, or that are cancerous. Effective chemoprevention would be a potential method of lengthening colonoscopic surveillance intervals. Unfortunately, no treatment has been found to be effective enough to alter our current surveillance practice. The only recommendation that can be made at this time for those patients with a history of colonic adenomas is to add 3 g/day of calcium carbonate to their diet, though its effect on adenoma recurrence is modest.

Background: All colon polyps removed during colonoscopy should be recovered and submitted for histopathologic analysis. Published information is scant regarding techniques and devices for retrieval of polyps after polypectomy. The Roth Retrieval Net is a novel device that has been used to retrieve foreign bodies from the GI tract, but its use as a polyp retrieval device has not previously been described. Methods: A chart review was conducted over a 7-month period by one gastroenterologist in an office setting of all patients who had polyps retrieved after piecemeal polypectomy by using the Roth Retrieval Net. Results: All resected polyps were completely retrieved in a time-efficient manner. Histopathologic evaluation was not compromised by the use of this device. Conclusions: The Roth Retrieval Net is well suited for retrieval of multiple polyp fragments after colonoscopic polypectomy.

Although Ludlow1 in 1769 gave the first description of a pharyngo-esophageal diverticulum, it is named after Zenker who gave a precise pathologic description more than one century later2. Zenker’s diverticulum (ZD) is the commonest type of diverticulum in the upper gastro-esophageal tract. It is a herniation which usually arises in the posterior midline of the hypopharynx at a place where the muscular wall has weakened. The ZD is usually located just cranial to the upper esophageal sphincter (UES) of which the cricopharyngeal muscle is a part. However, a ZD can develop at any weak site of the muscular wall of the hypopharynx. Increased hypopharyngeal pressures during swallowing are probably important in the pathogenesis of the diverticulum3 4. The tissue bridge between the esophageal lumen and the pouch of the diverticulum is composed of mucosa, submucosa and fibrous tissue of varying thickness, and a muscular coat. In this tissue bridge the most voluminous and essential structure is the UES.

Although there is a known reciprocal association between breast and colorectal cancer in women, few studies have investigated whether a similar association exists between breast cancer and colorectal adenomatous polyps, known to be precursor lesions for colon cancer. A case-control study was conducted on patients in three colonoscopy practices in New York to determine possible risk factors for adenomatous polyps. Among women studied, there were 128 patients with incident adenomatous polyps and 284 control subjects who underwent colonoscopy and had no colorectal neoplasia. No significant association between the incidence of an adenomatous polyp in the colon or rectum and a history of breast cancer was found (odds ratio, 0.71; 95% confidence interval, 0.34 to 1.64). If shared risk factors for breast and colorectal cancer are the reasons for the concurrence of these two malignant lesions, these results suggest that these factors act at the level of promoting adenomatous polyps of the colon and rectum into colorectal cancer.

Nine consecutive patients in whom endoscopic management of delayed post-polypectomy hemorrhage was attempted are described. Each patient presented with active rectal bleeding 12 hours to 12 days after snare resection of a colon polyp. In each patient, repeat colonoscopy identified the bleeding site and various combinations of injection therapy, electrocautery, or thermal injury led to cessation of hemorrhage. No complications resulted from repeat colonoscopy and endoscopic therapy. Colonoscopy and endoscopic therapy is feasible, effective, and safe in selected patients with active delayed post-polypectomy hemorrhage.

Colonoscopic polypectomy is a major advance in the therapy of colon neoplasms. The techniques for safe and efficient polyp removal are described. The uses of a variety of ancillary devices are discussed, including clips, loops, submucosal injection of fluid, and several thermal probes, including the argon plasma coagulator. The location of a lesion may be difficult to ascertain by intracolonic landmarks, but can be more precisely determined by X-ray, magnetic imaging, or intraoperative colonoscopy. Alternatively, it is possible to permanently mark the site of polyp removal with a carbon particle submucosal injection to facilitate subsequent localization either by surgery or interval colonoscopy.

Background: Two doses of sodium phosphate are recommended for colonic cleansing before colonoscopy. Patients need information about the onset and duration of activity of the preparation. This study was designed to develop practical prescribing information to patients to reduce anxiety concerning bowel accidents. Methods: Two hundred patients were requested to take a liquid diet the day before colonoscopy, to take 45 mL sodium phosphate with water or juice the evening before and the morning of the procedure, and to complete a questionnaire. Results: Bowel activity began 1.7 hours (range 0.5 to 13) after the first dose and continued for 4.6 (1 to 14) hours. For the second dose the time to onset was 0.7 hours (0.25 to 4), and bowel activity continued for 2.9 hours (0.5 to 6.5). Bowel activity was completed 4 hours after ingestion of the second dose in 83% of patients and within 5 hours in 87%. Three of 200 patients reported the need for bowel evacuation during transit. Conclusions: The activity from the second dose of sodium phosphate starts and ends sooner than that from the first dose. When advising patients on when to take the second dose of sodium phosphate, 4 hours for most and 5 hours for those with long commutes, should provide adequate time for almost all patients to avoid bowel activity during travel. (Gastrointest Endosc 1999;50:811-3.)

In the past few years, several groups of investigators have developed colonoscopic instruments or accessories to speed up the examination and make it more tolerable for patients. The NeoGuide Endoscopy System has the computer processing ability to direct each 8-cm segment of its colonoscope to bend at the exact place where the leading segment turned around a corner. This follow-the-leader system is intended to reduce loops and ensure comfort through preventing excess pressure on the colon wall by making a turn without the usual maneuver of pushing on the wall to advance the scope.

The risk for colorectal cancer among family members of patients with colorectal cancer is well established, but the risk among family members of patients with colorectal adenomas is less well established.To examine the risk for colorectal cancer among first-degree relatives of patients with adenoma compared with that among first-degree relatives of controls without adenoma.Reconstructed cohort study.Three university-based colonoscopy practices in New York City.1554 first-degree relatives of 244 patients with newly diagnosed adenomas and 2173 first-degree relatives of 362 endoscopically normal controls.Structured interviews were used to obtain family history. Adjusted relative risks (RR) were estimated from Cox proportional hazards regression models.The risk for colorectal cancer was elevated (RR, 1.74 [95% CI, 1.24 to 2.45]) among first-degree relatives of patients with newly diagnosed adenomas compared with the risk among first-degree relatives of controls. This increased risk was the same for parents (RR, 1.58 [CI, 1.07 to 2.34]) and siblings (RR, 1.58 [CI, 0.81 to 3.08]). First-degree relatives of patients with adenomas did not have elevated risk for other cancers. The risk for colorectal cancer among family members increased with decreasing age at diagnosis of adenoma in probands. Among first-degree relatives of patients who were 50 years of age or younger when the adenoma was diagnosed, the risk was more than four times greater (RR, 4.36 [CI, 2.24 to 8.51]) than that among first-degree relatives of patients who were older than 60 years of age when the adenoma was diagnosed.First-degree relatives of patients with newly diagnosed adenomas, particularly of patients who are 50 years of age or younger at diagnosis, are at increased risk for colorectal cancer and should undergo screening similar to that recommended for relatives of patients with colorectal cancer.

Events of reproductive life, such as parity and age at menarche, have been found in some but not all studies to be associated with risk for colorectal cancer in females. Because adenomatous polyps (adenomas) are precursors of colorectal cancer, we investigated whether reproductive variables were associated with colorectal adenomas. We conducted a case-control study among patients examined in three colonoscopy practices in New York City (NY, United States) from 1986 to 1988. Adenoma cases (n = 128) were defined as women who had an adenoma detected at the index colonoscopy with no history of inflammatory bowel disease, adenomas, or cancer. Controls (n = 283) were women with a normal index colonoscopy and no history of inflammatory bowel disease, adenomas, or cancer. The adjusted odds ratio (OR) for the association of early menarche (age less than 13 years) with adenomas was 0.6 (95 percent confidence interval = 0.4-0.9). Parity, history of spontaneous or induced abortion, infertility, type of menopause, age at menopause, use of oral contraceptives, and use of menopausal hormone replacement therapy were not associated statistically significantly with adenoma risk, although some possible trends were observed. Our findings do not implicate reproductive events, nulliparity, or overexposure to estrogens or to menstrual cycles as mechanisms of increased risk for colorectal neoplasia.

PURPOSE: This study was designed to determine whether patients with coronary artery disease are at elevated risk for colorectal neoplasia. METHODS: A case-control study was conducted among consecutive patients in three colonoscopy practices in New York City from 1986 to 1988. All study participants completed an interview questionnaire covering demographics, diet, environmental and behavioral exposures, family and personal medical history, and other variables. For the present study, 298 newly diagnosed colorectal adenoma cases and 107 incident cancer cases were compared with 507 colonoscoped controls without colorectal neoplasia or other significant findings on colonoscopy. Data on history of coronary artery disease (angina and/or heart attack) were obtained solely from the study participants' questionnaire responses. RESULTS: No association was observed between angina, heart attack, or either and colorectal adenomas in males. However, prior coronary artery disease was found to be associated with colorectal cancer in males more than 60 years of age and with colorectal adenomas in females aged 50 years or younger. CONCLUSION: Men with coronary artery disease may be at elevated risk for subsequent colorectal cancer. Young women with coronary artery disease also may be at elevated risk for colorectal neoplasia.

Colonic anastomoses are frequently encountered, but their endoscopic features have never been adequately characterized. Results of 117 consecutive colonoscopies in patients with colonic anastomoses were prospectively studied during a 12-month period. Anastomoses were photographed, videotaped, and reviewed by the authors. The age range of patients was 18 to 87 years, and interval from surgery extended to 42 years. An equal number of right and left colonic resections were encountered; 9 patients had subtotal colectomies. Ninety-two anastomoses were hand-sewn, and 25 were stapled. Ileal pouch-anal anastomoses were not included. Nine common anastomotic features were identified with the following frequency of occurrence: neovascularity, 105 (89.7%); white anastomotic edge, 64 (54.7%); disruption of haustral pattern, 64 (54.7%); radial suture tracks, 35/92 (38.0%); exposed suture, 11/92 (11.9%); exposed staples, 6/25 (24%); scar tissue adjacent to anastomotic line, 8 (6.8%); nondistensibility of anastomosis, 5 (4.3%); blind colonic pouch, 10 (8.5%). No recurrent carcinomas were noted. The site of seven anastomoses (5.5%) could not be identified. Six of these patients underwent endoscopy more than 8 years postoperatively. Of the remaining 110 patients, 94 (85.5%) had between two and four of the above features identified. In three of four patients who required dilation because of strictures, neovascularity was not seen. We conclude that colonic anastomoses have characteristic endoscopic features. These features can be used as landmarks for definitive identification of anastomotic sites at colonoscopy. The lack of neovascularity at a colonic anastomosis may be an indicator of relative ischemia, predisposing to stricture formation.

Adenomatous polyps (hereinafter referred to as adenomas) are known precursors of colorectal cancer. Cigarette smoking has been associated with adenomas but not with colorectal cancer, while alcohol and fat intake have been associated with both adenomas and cancer in some studies. Approximately 30 percent of patients with resected adenomas develop another adenoma within three years. This case-control study explores the association of cigarette smoking with adenoma recurrence. Between April 1986 and March 1988, we administered a questionnaire to colonoscoped patients aged 35 to 84 years in three New York City (NY, USA) practices. We compared 186 recurrent polyp cases (130 males, 56 females) and 330 controls (187 males, 143 females) who had a history of polypectomy but normal follow-up colonoscopy, by cigarette-smoking pack-years adjusted for possible confounders. Risk for a metachronous or recurrent adenoma was significantly greater in the highest quartile of smokers than in never-smokers among both men (odds ratio [OR] = 1.8, 95 percent confidence interval [CI] = 1.0-3.4) and women (OR = 3.6, CI = 1.7-7.6). Adjustment for time since smoking cessation reduced risk only slightly, as did adjustment for dietary fat intake, which itself remained significant. No association was found between alcohol intake and risk of recurrence. Cigarette smokers appear to have an elevated risk of adenoma recurrence that is not eliminated entirely by smoking cessation. Intervention trials that use adenoma recurrence as an endpoint should take smoking into account.

India ink tattooing of the colon has been used to mark lesions for subsequent surgical identificationl -3 and to identify polypectomy sites to facilitate followUp.4 In animal studies, endoscopic injection of dyes in the colon has been shown to be an effective and welltolerated method for mucosal marking.5 Unfortunately, several side effects have been attributed to the injection of India ink. Reports include influenza infection in mice pre-treated with India ink,6 phlegmonous gastritis after injection into the stomach,7 fat necrosis,s inflammatory pseudotumor (which appeared to consist of inflammatory cells and fibroblast proliferation),S and abscess.9 Possible causes of these complications may be an inflammatory reaction to the ink (carbon particles) or diluent (either via a direct irritant effect ofthe undiluted ink or secondary to a hypersensitivity reaction), or inadequate sterilization. For example, in the case of phlegmonous gastritis7 and the cases of infection in mice,5 the ink was not sterilized. In the report of pseudotumor,s the ink (Higgins, Faber-Castell, Lewisberg, Tenn.), comprising about 7 % carbon pigment, 5% propylene glycol, and smaller concentrations of shellac, ammonium hydroxide, and surfactant, was used in a very concentrated form (approximately equal parts India ink and bacteriostatic water). Anyone ofthe multiple diluents or the carbon pigments may have caused this inflammatory response. In addition, post-autoclave contamination of the ink may have occurred. Similar reasons might account for the case offat necrosis,s in which the type of ink was unknown but was injected in concentrated form (approximately equal parts India ink and bacteriostatic water). The same possible causes could account for the abscess9 found incidentally during operative resection for tumor. The India ink used was Pelikan brand (Pelikan, Hanover, Germany), containing ethylene glycol, sodium tetraborate decahydrate, and ammonia in 1:10 dilution with sterile water. This for

Obesity has been investigated as a risk factor for various malignancies, including colon cancer. A case-control study was conducted on patients in three colonoscopy practices in New York City to determine possible risk factors for colorectal adenomatous polyps, a known precursor lesion for most cases of colorectal cancer. Among 301 case subjects with incidence adenomatous polyps (174 men and 127 women) and 506 control subjects (223 men and 283 women), an increased risk was observed with increasing body mass index in women (odds ratio 2.1, 95% confidence interval 1.1-4.0; for highest versus lowest quartile, linear trend P = .02). A nonsignificant trend was observed for men. The increased risk seen in women is consistent with prior observations regarding reproductive hormonal and dietary risk factors for colorectal cancer.

One-thousand three hundred fifty-one consecutive colonoscopies were performed in an office setting without fluoroscopy. Three different models of colonoscopies were utilized; all were manufactured by the Olympus Corporation of America, and included a videoendoscope, a CF-20L immersible OES-type instrument, and an older fiberoptic colonoscope, CFLB-3W. In all colonoscopies, the cecum was reached in 95.9%, even when an obstructing lesion or stenosis was present. Total intubation was performed in 97% of cases with the videoendoscope, 95.5% with the CF-20L, and 95.7% with the CFLB-3W. In a subgroup of 865 colonoscopies, total colonoscopy was performed in 98% of cases when obstructing lesions (carcinoma or stricture) were excluded from analysis. In this subgroup, total colonoscopy could not be performed in 16 patients because of colonic fixation, tortuosity, or for unknown anatomical reasons. Forty-five percent of this subgroup was female, but of the 16 patients in whom total colonoscopy was not possible, 15 were women, 5 of whom had a previous hysterectomy. We conclude that in the absence of any obstructing lesion, an expert can perform complete colonoscopy in 98% of examinations, and in 95% of all patients presenting for colonoscopy. Total colonoscopy may be more difficult in women than men, but a previous hysterectomy does not seem to adversely affect the ability to perform colonoscopy. The type of instrument used for colonoscopy does not impact on the ability to visualize the entire colon.