Usefulness of performing colonoscopy one year after endoscopic polypectomy

This retrospective study defines a population with neoplastic colonic polyps who have had colonoscopic polypectomy and, in follow-up within one year, a repeat colonoscopic evaluation. The population was broken down into two groups, one group that had polyps at the second examination and one group that did not. This study determined which factor(s) were significant among this population in distinguishing whether new polyps would be found at one year follow-up. The authors found that among the many variables studied, only polyp multiplicity was significant in predicting polyp recurrence. More than one polyp found at index colonoscopy led to a significant chance of having a new polyp after only one year. Also, it was demonstrated that these "new" polyps were unlikely to have been "missed" polyps from the initial colonoscopy. Because of the shifting location, smaller size, and fewer instances of histologic atypia in these polyps compared with those at index examination, the authors believe that polyps found after one year may be assumed to have arisen de novo. Finally, the authors show that a significant number of polyps occur beyond the reach of the flexible sigmoidoscope (approximately 60 cm). The authors recommend that patients who have polyps undergo a colonoscopic examination. When patients are re-evaluated after having colonoscopic neoplastic polypectomy, they should undergo repeat colonoscopy.

Surgical management of anorectal fistulas in Crohn's disease

A retrospective review of patients with Crohn's disease treated at our institution from 1973 to 1986 revealed 35 patients operated upon for anorectal fistulas. Twenty-nine had low intermuscular fistulas (multiple in seven), and six had high intermuscular (supralevator) fistulas. Fistulotomy alone was performed in 19 patients, and eight underwent partial fistulotomy and seton insertion. Five additional patients had proximal fecal diversion before fistulotomy. Three patients with severe colonic and anorectal disease underwent proctocolectomy as the initial procedure. Of the 32 patients who had fistulotomy performed, complete healing occurred in 30. Seven patients who healed required more than one operation for fistula. One patient was left with an asymptomatic fistula, and one required proctectomy for persistent symptomatic fistula and proctitis. Success of operation correlated with absence of rectal disease and quiescent disease elsewhere in the gastrointestinal tract. Aggressive medical treatment is required to control bowel disease preoperatively. In the majority of patients, subsequent surgery is justified and healing can be anticipated.

Results of operation for rectovaginal fistula in Crohn's disease

A retrospective review of patients with Crohn's disease treated at our institution from 1973 to 1986 revealed 12 patients operated on for rectovaginal fistula. Disease involved the large intestine in 10 patients. Primary fistula repair was performed in four patients and four others had staged repair with preliminary fecal diversion. Four patients with severe colonic and anorectal disease had proctocolectomy performed as the first procedure. Of eight patients who underwent fistula repair, complete healing occurred in six. One patient has a persistent fistula, which is minimally symptomatic, and the other required proctocolectomy after three unsuccessful repairs. Success of operation correlated with quiescent intestinal disease and absence of rectal involvement. In selected patients with symptomatic fistulas, surgical repair is indicated and healing can be anticipated.

Classification of overdose/self-poisoning presentations to an accident and emergency department

A simple classification system of overdoses presenting to a hospital emergency department is described. Five major overdose categories were developed (accidental, suicidal behavior, recreational/experimentation, compulsive use, and an indeterminate category), which were divided into 10 subcategories. A prospective survey at an inner-city hospital in Sydney classified 199 consecutive self-poisoning presentations as being due to compulsive drug use in 38% of cases; suicidal gesture as a reaction to stress, 17%; adverse reactions to recreational or experimental use, 15%; suicidal gesture to influence others, 7%; genuine accident or noncompliance with medication, 6%; genuine suicide attempt, 3%; and pseudo-overdose, 3%. The reason for the overdose was uncertain in the remainder of the cases. Additional data are also presented, including the types of drugs involved in each overdose category. Categories of overdose may be useful in psychosocial assessment for follow-up interventions, assist in research, and help reduce negative attitudes toward overdoses.

Endometriosis of the bowel

One hundred sixty-three cases of endometriosis of the bowel (5.4% of 3037 laparotomies for endometriosis at the Ochsner Foundation Hospital) were reviewed to assess the management of this complication. Colon and rectal surgeons performed bowel resections of the colon in 30 cases and resections of the ileum and/or cecum in 11 cases. Gynecologic surgeons resected bowel implants, often multiple, in 153 patients, and also performed other necessary surgery, either ablative (with removal of uterus, tubes, and one or both ovaries; 58.8%) or conservative (with preservation of reproductive potential; 41.2%). The bowel mucosa was opened in 15% of implant resections. Complications included transient pulmonary febrile responses in 43%, two pelvic infections, and one hematoma. Ileus was not a problem, and there were no deaths. Resection of intestinal implants appears to be a safe procedure.

Drugs involved in self-poisoning: verification by toxicological analysis

During a two-month prospective survey in a metropolitan teaching hospital's accident and emergency department, 239 consecutive drug-related attendances (excluding admissions to hospital that were primarily alcohol related) were identified. This represented 2.6% of total attendances. Of the 199 patients who presented to hospital with self-poisoning, a biological specimen was obtained from 158 (79%) for toxicological analysis, thus providing reliable data on the drugs that were involved in the overdoses. The most common drug groups that were identified were barbiturate (51% of cases) and benzodiazepine (49%) agents, alcohol with other drugs (44%), cannabinoids (32%) and opiate analgesic drugs (25%). Quinalbarbitone and amylobarbitone (Tuinal) and oxazepam were the most common "single" preparations. The use of cannabis and alcohol and the use of several drugs concurrently were more common than in previously reported surveys of self-poisoning. Discrepancies between the purported drug consumption and the toxicological results were frequent; complete agreement occurred in only 35% of the cases. The TOXI-LAB system was an adequate method for toxicological analysis. However, for epidemiological studies an additional back-up method is recommended to verify the presence of some drugs such as barbiturate and benzodiazepine agents.

A potentially brighter prognosis for colon carcinoma in the third and fourth decades

In contrast to earlier studies that suggested that colon carcinoma is unusually lethal in the young, 69 patients, ages 20 to 39 years, had a relatively good prognosis. Fifty-nine percent lived over 5 years after diagnosis, and 51% were cured. Furthermore, 67% were cured if they did not have distant spread of the carcinoma at the time of the initial operation. Neither age, sex, tumor size, location, mere presence of lymph node metastases, depth of tumor invasion, nor predisposing disease of the colon was a strong prognostic factor. Metastases to six or more lymph nodes and distant spread of the tumor at the time of initial surgery were ominous findings. Mucinous carcinoma was relatively frequent (28%) and was also an ominous feature (only 5 of 20 patients cured as opposed to 26 of 43 with classical adenocarcinoma).

Cholelithiasis in ileostomy patients

A retrospective study of 152 ileostomates with inflammatory bowel disease (IBD) revealed that 16 patients (10.5 per cent) had diagnoses of cholelithiasis before, at the time of, or after having ileostomies. Of the remaining patients, 69 were followed for possible cholelithiasis, most of those with sonographic examination. Sixteen of this latter group of patients (23.2 per cent) were found to have cholelithiasis, usually in an asymptomatic stage. Among women over 50 years old, seven of 11 (63.6 per cent) had gallstones. Due to this high prevalence of cholelithiasis, gallbladder imaging is recommended as a part of the preoperative workup and follow-up of ileostomates. Prophylactic cholecystectomy may be carefully considered in female patients with IBD at the time of proctocolectomy.

Inflammatory bowel disease and cholelithiasis: the association in patients with an ileostomy

Sixty-nine patients were evaluated prospectively by sonography and history to determine the presence of cholelithiasis. Sixteen patients (23%) had a positive diagnosis. A control group was also prospectively evaluated. We have determined that patients above age 50 with a permanent ileostomy are at statistically significant risk of having cholelithiasis, and their risk is greater than that of a control group matched for age and sex. Radiologists should recognize this association and carefully evaluate the gallbladder of any patient with a permanent ileostomy who has abdominal pain.

High-performance liquid chromatographic analysis of diflunisal in plasma and urine: application to pharmacokinetic studies in two normal volunteers

A high-performance liquid chromatographic (HPLC) assay with fluorescence detection has been developed for the determination of diflunisal in plasma and urine. The plasma or urine, containing naproxen as the internal standard, was extracted with ether-hexane (1:1). The samples were analyzed on a microparticulate column, and the compounds were eluted using a mobile phase of 0.05 M phosphate buffer (pH 3) and methanol. Plasma samples were analyzed from two healthy male subjects who received a 250- and 750-mg oral dose of diflunisal 3 weeks apart. The data were analyzed according to a two-compartment open model. There was a disproportionate increase in the area under the plasma concentration-time curves (AUC 750 mg/AUC 250 mg was 3.84 for subject A and 4.22 for subject B) and a reduction in plasma clearance after the 750-mg dose of diflunisal. These data suggest that the kinetics of diflunisal may be dose dependent.

Guidelines for use of the flexible fiberoptic sigmoidoscope in the management of the surgical patient

Based on data from many clinical studies and programs, guidelines are presented for application of the flexible fiberoptic sigmoidoscope in the management of the surgical patient. The flexible fiberoptic sigmoidoscope has proved to be an instrument of extraordinary capability in detecting colorectal neoplasms with yields being two or three times greater than those of the rigid sigmoidoscope in the symptom-resolution, polyp and cancer surveillance patient categories. In addition, the practical advantages of the narrow diameter, flexibility, and length of the fiberoptic sigmoidoscope are readily appreciated when the surgeon finds that he can satisfactorily examine patients with rectal or sigmoid strictures, marked angulations, or contracted lumens in whom a rigid scope would be unsuitable. Data from the authors' comparative study of more than 3000 patients have permitted the development of not only guidelines for the application of the flexible fiberoptic sigmoidoscope but an appreciation of the modified role of the rigid sigmoidoscope and the proper relationship between the flexible fiberoptic sigmoidoscope and the flexible fiberoptic colonoscope. A most important consideration is based on data regarding the site distribution of 400 benign premalignant neoplasms detected in the comparative study. The even distribution of these lesions throughout the terminal 50 cm of colorectum underscores the need to examine as much of the colorectum as possible.

The pharmacokinetics and metabolism of 14C-carprofen in man

Three healthy male subjects received single 100 mg oral doses of carprofen containing 20 microCi of 14C-carprofen. Venous blood samples were drawn during the first 48 h after the dose and urine and faeces were collected for 120 h. Concentrations of carprofen and its metabolites in body fluids were determined by TLC and mass spectral analysis. After a lag time of 0.3 +/- 0.1 h (mean +/- S.D.), carprofen was absorbed rapidly and peak concentrations in the plasma were reached in 2.7 +/- 1.3 h. The 14C plasma concentrations declined in a biphasic fashion. The mean half-lives of the initial (alpha) and terminal (beta) phases were 1.1 h and 20.6 +/- 6.1 h, respectively. Biotransformation to a glucuronide metabolite appeared to be the major mechanism of carprofen clearance. In 48 h 74.0 per cent of administered radioactivity was recovered in urine and 14.1 per cent was recovered in faeces. A glucuronide of carprofen comprised 85.0 per cent of the radiolabelled compounds in urine. The remaining radioactivity was comprised of parent drug (12.0 per cent) and un unidentified acid-labile conjugate of the parent drug (3.0 per cent). This pattern of metabolism and excretion is different from that in the dog and rat and may explain species differences in drug activity and toxicity.

Colonic manifestations of collagen vascular diseases

Upper gastrointestinal manifestations of collagen vascular diseases have been well described. Recently our attention has been focused on the colonic complications: fibrosis and stricture resulting in obstruction, severe obstipation and recurrent fecal impactions secondary to pseudo-obstruction, progressive colonic dilatation resulting in gangrene of the colon, and sigmoid volvulus and diverticulitis in the presence of both wide- and narrow-mouth pseudodiverticula. Patients with these colonic manifestations of collagen vascular disease are disabled, if not severely ill. Recognition of the problem enables the surgeon to plan definitive surgical intervention ranging from segmental resection to total colectomy and ileoproctostomy to restore satisfactory large bowel function.

Comparison of transient ischemic colitis with that requiring surgical treatment

The records of 27 patients with colonic ischemia were reviewed. Twelve patients had typical reversible or transient ischemic colitis. Thirteen patients had an ischemic stricture or gangrene of the colon that required operation. Two of the patients have asymptomatic strictures of the splenic flexure and are under observation. The sigmoid colon in our series of patients was the most frequent area of symptomatic stricture formation. Any patient with ischemic colitis, especially that involving the sigmoid colon, should be observed closely for the development of a stricture. Surgical intervention is indicated only after colonoscopy and careful evaluation of symptoms and risk factors.

Vascular ectasias of the colon

Vascular ectasias are an acquired type of arteriovenous malformation distinct from neoplastic and congenital lesions. They can be the source of occult, recurrent or massive colonic bleeding usually in elderly patients but, occasionally, in younger adults. The vascular lesions are usually small but can be quite diffuse. The majority occurs in the right colon, but in our group of patients, a substantial number occurred distal to the hepatic flexure. The diagnosis can be made preoperatively, with colonoscopy but, more consistently, with arteriography. Therefore, arteriography should be performed in any patient with bleeding of the colon before surgical intervention. We recommend resection of the involved segment of the intestine as the treatment of choice.

Sigmoidoscopic examinations with rigid and flexible fiberoptic sigmoidoscopes in the surgeon's office: a comparative prospective study of effectiveness in 1,012 cases

The results obtained from 1,012 examinations in an on-going, cooperative study indicate that the overall yield provided by use of the flexible fiberoptic sigmoidoscope is 3.2 times greater than that of examinations with the rigid sigmoidoscope. More than twice (2.4 times) the number of polyps and more than three times the number of cancers were detected with the flexible fiberoptic sigmoidoscope. Experienced endoscopists can perform an examination with the flexible fiberoptic sigmoidoscope expeditiously in the office with minimal patient preparation, a high level of patient and physician acceptance, and relative safety when the usual mandatory colonoscopic precautions and guidelines are obeyed. The extraordinary advantages demonstrated by this study warrant wide clinical application of the flexible fiberoptic sigmoidoscope. We strongly recommend provision be made for appropriate training of physicians in the use of the instrument.