2015 · Article · Case-Control

Unexpected reduction in polyp numbers in Chronic Inflammatory conditions of the Colon

Tubular_adenoma_4_low_magI have read this article back in July, and immediately found it interesting.  One reason is that it is (albeit a poor one) an example of the use of “Big Data” type analysis where a large database of patient biopsy specimens can be searched.

Second reason – is the actual clinical finding – less polyps than expected in those with microscopic colitis – prevalence of ALL types of polyps was reduced.

Summary:  130,000 patients with symptoms of diarrhea had a colonoscopy with biopsies.  Compared with 97,000 control cases.  So, in this CASE-CONTROL study for patients with workup of diarrhea – less polyps (Odds ratios = 0.46 for hyperplastic, 0.24for serrated adenomas, and 0.35 for tubular adenomas).

Criticism: It would have been nice if the authors have age-matched the cases one for one from the beginning, even though these were adjusted for. There is no duration of disease, so the mechanism would remain elusive. Although it would be interesting to have someone do a database review of patients whose clinical history is known. It can even be compared to the current study, if the data is available, i.e. authors had 14% of colons have polyps in normals, and 8.3% in microscopic colitis,  is there an influence of disease duration or is this an all or none phenomenon?

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Right-sided colonic ischemia with and without acute mesenteric ischemia

One of the most frustrating calls that I remember getting from ED was related to general confusion between colonic ischemia and acute mesenteric ischemia. It would be a resident calling stating that the Lactate is normal, but “all signs point to mesenteric ischemia” even though there is no abdominal pain, stable vitals, and more often than not no co-morbidities, and reassuring imaging. Which drew my attention to this article, which examined patients with biopsy-proven Right-sided Colonic Ischemia alone or in combination with Acute Mesenteric Ischemia(confirmed by imaging or surgical evaluation of small bowel).


  1. IRCI + AMI = disaster. Mortality of ~90%.
  2. BUN and WBC count can be used to differentiate those with acute mesenteric ischemia to those without ( BUN would be high – above 35, and WBCs will be high as well  – above 20). Nothing new here, but nice to see this in another study. We already know that CT alone can be used as well.
  3. 15% of cases of Right-sided Colon ischemia will have Acute Mesenteric Ischemia as well – so look for it, since it is such a disaster, with almost all patients undergoing surgical resection of some sort.
  4.  COPD  may be associated with development of AMI, and poor outcomes in Colonic Ischemia in general.

The article is written by the folks from Connecticut as well as Montefiore Hospital, which bailed out my Medical School recently.

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Functional Dyspepsia Review in NEJM 2015

imgresNEJM has a great article here – a summary of latest/greatest on Functional Dyspepsia. An often frustrating diagnosis.

Key Points: 1) Watch out for alarm symptoms, such as dysphagia that is progressive, melena, fam hx of esophageal cancer, iron deficiency anemia, weight loss, etc, but keep in mind that these are of very limited value. The sensitivity of alarm symptoms varied from 0% to 83% with considerable heterogeneity between studies. The specificity also varied significantly from 40% to 98%.

2) Classification may be useful, but probably isn’t – Postprandial distress syndrome versus Epigastric Pain syndrome.  Mainly here to highlight that some of these patients will have issues with gastric emptying.  86% of patients with gastroparesis will have dyspepsia.

3) Pathophysiology – no clear answer here, mostly magical thinking and theories. Probably a link between Brain-Stress-Epithelial Permeability- Eosinophils-Duodenum Sensitivity- etc. etc. etc.

4) Rate of response to placebo is ~40%.

5) The NNT for H.pylori eradication is 15. But only 5% of functional dyspepsia cases will be positive.

6) The NNT for acid suppression/PPI therapy is 10. But most trials with acid suppression happened before Rome III criteria were out, so maybe not.

7) Prokinetic agents are either dangerous, or do not work.

8) Complementary and Alternative Therapies are bogus.

9) Natural history is chronic and fluctuating.

10) Proposed Treatment Algorythm is acceptable.

Bottom Line: Article has great references. No new stuff, but good summary of what we know. File under teaching reference.

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ROLCOL – Right or Left-sided starting position in colonoscopy

110405-N-KA543-028 SAN DIEGO (April 5, 2011) Hospitalman Urian D. Thompson, left, Lt. Cmdr. Eric A. Lavery and Registered Nurse Steven Cherry review the monitor while Lavery uses a colonoscope on a patient during a colonoscopy at Naval Medical Center San Diego. (U.S. Navy photo by Mass Communication Specialist 2nd Class Chad A. Bascom/Released) I don’t know about you, but during my fellowship thus far, I’ve only done one or two cases where the patient was positioned on the right side. Both were ICU/CCU cases, and both times we’ve reached the cecum without an issue. Positioning in those cases was difficult secondary to all the cardiac/ICU hardware the patient was hooked up to.

This study, which is amazing to see, since it actually examines a commonly held practice, something arose more from tradition/long held beliefs, rather than evidence.  There aren’t that many studies that actually go and do that.

The authors have found that right-sided positioning at the start of the colonoscopy results in a better, quicker, more comfortable procedure. N was about 80 for both arms, and about 75 cases were analyzed in post. Primary outcome was time to reach cecum.

Conclusion – 3 min and 33 seconds (30%) shorter if starter on the right side. Benefit stems largely from improved negotiation of the sigmoid.

Of note, there is a figure in the text, Figure 5, which shows how terrible fellows like me are at doing endoscopy in terms of time to cecal intubation.  Also, shows that the dramatic reduction in time to cecum happens not after 500 colonoscopies, but after 5000 colonoscopies!

We need more of these kinds of studies. The types that test “tried and true” practices, simple design, simple conclusions.

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New Approaches to Controlling Health Care Costs

A Commentary in JAMA:Internal Medicine

David Lieberman and John Allen discuss what is probably going to happen to the colonoscopy payment system: – bundling: fixed fee for the anesthesia, pathological analysis, and repeated procedures due to poor bowel preparation.

Currently Centers for Medicare and Medicaid Services waive patient costs associated with anesthesia services (i.e. propofol for all). Some think it is not a great idea from a cost perspective. The authors point out that given focus on quality and patient satisfaction, anesthesia for all cases may not be a bad idea, especially if we enter the bundled payment system.

These are good points, but from a clinical perspective, the quality and patient satisfaction are not exactly two major parameters that enter my mind when it comes to what’s best for patient. Quality is slowly becoming a nebulous term which includes anything from access, cost, etc, and the contribution of clinical indication is rapidly declining in that formula.

And bundled payments may in the end not be so bad, as long as we all share in the costs of this, from primary care to the specialist.

One more thing -“…costly, cost-effective, and well accepted. In some areas, however, charges can vary more than 10-fold for the same services, from approximately $500 to more than $8000.” $8000 for a colonoscopy?  – Where? What kind of a colonoscopy does one get for that much money?

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