Abstract: BACKGROUND: Patients with Crohn disease (CD) often undergo both multislice computed tomography (MSCT) and small bowel follow-through (SBFT) for evaluation of their disease. We compared the findings on computed tomography (CT) and SBFT in patients with CD to determine whether MSCT can be the modality of choice in the evaluation of these patients. METHODS: We reviewed the CT and SBFT studies of 41 patients with CD. The findings were evaluated by three experienced abdominal imagers. RESULTS: There was no statistical difference in the detection of mural involvement of the small bowel. The CT showed additional involvement of the colon, mesenteric involvement, and extraenteric complications. CONCLUSION: Multislice CT is a reliable modality in demonstrating enteric as well as extraenteric pathological findings in patients with CD. We suggest that MSCT can replace SBFT in the evaluation of patients with CD.

Abstract: Introduction The reported rates of gastrointestinal (GI) lesions among pre-menopausal women with iron deficiency anemia (IDA) vary considerably. Aim To assess the prevalence of significant gastrointestinal lesions among symptomatic and asymptomatic pre-menopausal women with IDA, and to shed light on potential predictors of their presence. Methods Clinical, endoscopic, and histological data was collected from 116 pre-menopausal women with IDA. All women underwent upper and lower gastrointestinal tract endoscopies, duodenal biopsies, and small bowel evaluation with small bowel series or computed tomography. Results The mean age was 33 years (range: 18-45). Clinically, significant lesions were demonstrated in 30%, the majority in the upper gastrointestinal tract. Helicobacter pylori gastritis was the most common finding (16%). Celiac disease was detected in 6%. No malignant lesions were detected. The prevalence of lesions was highest among women with symptoms of heartburn and regurgitation. The presence of upper gastrointestinal symptoms (OR: 3.67, 95%CI: 2.14-5.03; P = 0.002), MCV lower than 70 pg (OR: 1.88, 95%CI: 1.27-3.91; P = 0.04), and hemoglobin levels less than 10 g/dl (OR: 1.71, 95%CI: 1.19-4.07; P = 0.05) were associated with an increased likelihood of significant gastrointestinal lesions; history of heavy menstrual blood loss was associated with negative findings (OR: 0.46, 95%CI: 0.27-0.69; P = 0.002). Conclusions Upper GI findings, mainly HP gastritis and celiac disease, were the most common pathologic findings. Initial evaluation of IDA in premenopausal women may include urea breath test and celiac serology. Further endoscopic evaluation can be reserved for those women who are found to be negative in the initial evaluation, as well as in cases of failure of IDA remission after successful HP eradication.

Abstract: INTRODUCTION: Gastric polypectomy is associated with increased risk of bleeding. The use of endoscopic ultrasound (EUS) before polypectomy to decrease the rate of bleeding in such patients has not been studied. METHODS: All gastric polyps excised by snare polypectomy were evaluated. The primary outcome was the occurrence of immediate or delayed bleeding episodes. Postpolypectomy bleeding was correlated with the presence of blood vessels at the base of the polyp on EUS examination. Characteristics of both patients and polyps were analyzed as risk factors for postpolypectomy bleeding. RESULTS: One-hundred and two snare polypectomies were performed. Fifty-seven polyps (56%) had been evaluated by prior EUS. Bleeding occurred in 7 (7%) patients. Of these, 4 had not undergone EUS evaluation, whereas in 3 patients who had had a prepolypectomy EUS evaluation, none were found to harbor a visible blood vessel. Bleeding did not occur in any of the 8 patients in whom EUS suggested the presence of blood vessel. The size, location, type, and histology did not show any significance in predicting postpolypectomy bleeding. CONCLUSIONS: The risk of bleeding after endoscopic resection of gastric polyps was 7%. EUS evaluation before gastric polypectomy does not seem to contribute to the safety of such a procedure.

Abstract: OBJECTIVE: Repeat colonoscopy is advocated for low-quality preparations. However, there are few data on how endoscopists assess the quality of bowel preparation. We aimed to investigate, in a visually reproducible manner, endoscopists' assessment of colon cleanliness, as reflected by their subsequent recommendations for follow-up. METHODS: Gastroenterologists attending the Israeli Gastroenterology Association meeting were presented with photographs depicting varying degrees of colon cleanliness at a hypothetical screening colonoscopy. Endoscopists were requested to denote their recommendation for the timing of a follow-up procedure for each of the different preparations, both when no polyps were detected and when two small adenomas were found. RESULTS: Seventy-eight gastroenterologists were included. There was considerable interobserver variability in endoscopists' assessment of preparation adequacy, and recommended follow-up timing ranged from more than 5 yr to immediate repeat colonoscopy for identical preparations. Interestingly, even when repeat colonoscopy was not considered necessary, most endoscopists recommended progressively shorter follow-up intervals in line with reduced preparation quality (mean interval dropping from 9.2+/-1.7 to 6.3+/-2.8 to 2.5+/-2 yr, P<0.001 for trend). Similar findings were observed when two adenomas were hypothetically found on the index procedure, although follow-up intervals were shorter. No correlation was found between endoscopists' clinical experience or acquaintance with clinical guidelines and their actual recommendation. CONCLUSIONS: Clinical decisions derived from colon cleanliness assessment vary considerably among endoscopists, and there is little agreement on what constitutes a disqualifying preparation. Moreover, when confronted with an intermediate-quality preparation, most gastroenterologists recommend a shorter follow-up interval, rather than repeating the procedure. Further studies are required to validate this management approach and to standardize the assessment of preparation quality.

Abstract: BACKGROUND: Endoscopic ultrasound (EUS) has been shown to be a reliable tool for staging rectal cancer. Nevertheless, the accuracy of EUS after chemoradiation remains unclear; therefore the purpose of the present paper was to compare the accuracy of EUS staging for rectal cancer before and following chemoradiation. METHODS: Patients with rectal cancer undergoing EUS staging were stratified into two groups. Group I consisted of 66 patients who underwent surgery following EUS staging without preoperative chemoradiation. Group II consisted of 25 patients who had EUS evaluation following chemoradiation. The EUS staging was compared to surgical/pathological staging. RESULTS: The accuracy of the T staging for group I was 86% (57/66). Inaccurate staging was mainly associated with overstaging EUS T2 tumors. The accuracy of the N staging for group I was 71% (47/66). The accuracy of EUS for a composite T and N staging relevant to treatment decisions in group I was 91%. In group II, the accuracy of T and N staging was 72% (18/25) and 80% (20/25), respectively. Overstaging EUS T3 tumors accounted for most inaccurate staging. The EUS staging predicted post-chemoradiation T0N0 stage correctly in only 50% of cases. CONCLUSIONS: Preoperative staging of rectal cancer by EUS is a useful modality in determining the need for preoperative chemoradiation. The EUS T staging following chemoradiation appears to be less accurate. Detection of complete response may be insufficient for selecting patients for limited surgical intervention.

Abstract: BACKGROUND/AIMS: The majority of Crohn's disease patients undergo surgery. However, the factors that predict post-operative recurrence remain controversial. The aim of the present study was to shed light on the potential predictors of such recurrence. METHODS: 86 patients who underwent operative procedures for Crohn's disease were retrospectively studied. Recurrence was defined as the need for a second operation. Life table and multivariate analysis were performed to find the predictors of recurrence. RESULTS: In 26/86 (30%) of the patients, post-operative recurrence was diagnosed within a mean of 42 months of the follow-up. Logistic regression analysis revealed that smoking (OR 3.69, 95% CI 2.06-11.52) and perforating disease (OR 4.09, 95% CI 1.31-12.65) were associated with a risk of recurrence. However, survival analysis showed that only perforating disease was associated with an early post-operative recurrence (log-rank test, p < 0.001). Neither resected surgical specimen characteristics, nor the duration and the location of the disease were found to predict the need for a second operation. CONCLUSION: The risk for Crohn's disease patients who undergo surgery is related to the presence of perforating disease and smoking, which predict the need for a second operation. The former is associated with an even earlier recurrence.

Abstract: PURPOSE: The aims of this study were to compare the performance of a mechanical radial endosonoscope and an endorectal electronic probe and to evaluate the value of hydrogen peroxide (H(2)O(2)) injection in the diagnosis of perianal fistulas. PATIENTS AND METHODS: Sixty-one patients underwent clinical and endosonographic studies for suspected perianal fistulas or abscesses. Endosonography was performed using two instruments: a mechanical radial endosonoscope (Olympus GF-UM20) and an electronic endorectal probe (Hitachi EUP-R53). The patients were re-examined during and following H(2)O(2) injection using both systems. RESULTS: Thirty-seven fistulous tracts were visualized with the electronic endorectal probe versus only 9 with the mechanical radial endosonoscope. Four patients had anal stenosis, precluding the use of the larger electronic probe. Three fistulas were detected in these patients using the mechanical radial endosonoscope. H(2)O(2) injection was not feasible in 26 patients (43%). Visualization of 11 (31%) fistulas improved after administration of H(2)O(2). Six fistulous tracts not detected before H(2)O(2) administration were clearly visualized during injection and for several minutes thereafter. CONCLUSIONS: Work-up of perianal fistula should be preferably performed using the endorectal electronic probe. However, the mechanical radial endoscope is preferred in patients with anal stricture. H(2)O(2) injection should become an integral part of every sonographic study of perianal fistulas.

Abstract: BACKGROUND AND STUDY AIMS: Percutaneous endoscopic gastrostomy (PEG) is a method used for feeding patients who are unable to eat. High early mortality rates among hospitalized patients have been reported. The aim of this study was to shed light on the risk factors for early mortality after PEG tube insertion. PATIENTS AND METHODS: Outpatients from nursing homes and hospitalized patients who underwent PEG between July 1995 and July 2001 were compared. Survival analysis was used to assess mortality after PEG. In a logistic regression analysis, mortality within 30 days among hospitalized patients was chosen as the outcome variable and the predictor variables were demographic characteristics, co-morbid conditions, and indication for PEG. RESULTS: A total of 502 PEG tubes were inserted in 419 hospitalized and 83 nursing-home patients. The prevalence of co-morbid conditions was similar in the two groups. Both the 30- and 60-day mortality rates were around six times higher in the hospitalized patient group than in the nursing-home patient group (30-day mortality rate 8 % vs. 1.2 %, P = 0.034; 60-day mortality rate 12 % vs. 2.4 %, P = 0.016). Risk factors for 30-day mortality among hospitalized patients were: serum albumin < 3 g/dl (odds ratio 2.82, 95 % CI 1.34 - 5.96), chronic obstructive pulmonary disease (odds ratio 2.79, 95 % CI 1.26 - 6.14), and diabetes mellitus (odds ratio 2.44, 95 % CI 1.20 - 4.97). CONCLUSIONS: Compared with nursing-home patients, hospitalized patients are at higher risk for early mortality after PEG. The presence of diabetes, chronic obstructive pulmonary disease, and a low serum albumin level each increase the 30-day mortality risk among hospitalized patients threefold.

Abstract: OBJECTIVE: The main objective is to study whether the month of birth is associated with the development of Crohn's disease (CD) in the Israeli Jewish population. BACKGROUND: It was suggested that perinatal exposure to infectious agents may have a role in the pathogenesis of CD. Due to the seasonal nature of some infections, a linkage between birth dates and a risk to develop CD would support such a hypothesis. Previous studies that addressed this question were conducted in Europe and differed in their findings. METHODS: Birth dates of 844 Jewish ulcerative colitis (UC) and CD patients from three medical centers representing the north, central, and the south of Israel were compared with the monthly rates of birth during the same period of time. The standard incidence ratio was used to define the risk to develop either disease according to the month of birth. The Score method was used for the evaluation of seasonality trends. RESULTS: Birth during the winter period in Israel was associated with increased risk to develop CD, whereas birth during the spring was associated with a reduced risk. The Score method for seasonality showed a significant peak during winter time in these patients (z = 2.02, p= 0.021). No such seasonal variation was noted for UC patients. CONCLUSIONS: A seasonal pattern was observed in the risk to develop CD but not UC. The findings may support the involvement of environmental factors in the pathogenesis of CD.