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Colon Cancer Screening, Surveillance, Prevention, And Therapy Gastroenterology Clinics of North America. 37(1): 1-306. March 2008.

This issue of Gastroenterology Clinics of North America focuses on colon cancer screening, surveillance, prevention, and therapy. The issue includes 15 articles: pathophysiology, clinical presentation, and management of colon cancer; the classification, molecular genetics, natural history, and clinical management of sporadic and syndromic hyperplastic polyps and serrated adenomas of the colon; Lynch syndrome, a type of familial colon cancer syndrome, and familial adenomatous polyposis; the role of diet, chemoprevention, and lifestyle in the prevention of colorectal cancer; the techniques, costs, and barriers to implementation of colon cancer screening; screening for colorectal cancer; the implementation of colonoscopy for mass screening for colon cancer and colonic polyps; the use of mass screening and colonoscopic polypectomy to reduce the incidence and mortality of colon cancer; the current status and future promise of computed tomography (CT) colonography; the surveillance of patients at increased risk of colon cancer, including those with inflammatory bowel disease; the use of endoscopic ultrasound in the diagnosis, staging, and management of colorectal tumors; colonoscopic polypectomy; surgical therapy for colorectal adenocarcinoma; the role of radiation therapy for colorectal cancer; and systemic therapy for colon cancer. Each article is written by experts in the field and includes extensive references. The volume includes numerous full-color illustrations and concludes with a detailed subject index.

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Colorectal Cancer (CRC) Screening in the Geriatric Population: Factors in Risk Assessment And Outcome Benefits. Practical Gastroenterology. 32(2): 17-36. February 2008.

This article explores factors in risk assessment and outcome benefits associated with colorectal cancer screening (CRC) in the geriatric population. CRC screening is the search for polyps and cancer in individuals who have not been previously diagnosed with colonic neoplasms; surveillance refers to follow-up of patients who have already received a diagnosis of colonic neoplasms. The authors review the literature, report on the current status of CRC screening, and then analyze certain controversies in discontinuing screening colonoscopy after a certain age. Topics include the epidemiology of CRC in the United States, particularly in relation to age groups, racial factors, and ethnic groups; the prevalence of CRC in different groups; current recommendations for CRC screening, including risk stratification, recommendations for the average risk population and for those deemed at higher risk; the role of diagnostic tests, including fecal occult blood testing (FOBT), sigmoidoscopy, colonoscopy, and double contrast barium enema (DCBE); future alternatives to traditional colonoscopy, including virtual colonoscopy, stool DNA tests for colon cancer, and wireless capsule endoscopy; the effect of aging on the incidence of CRC; colonoscopy complications in older patients compared with those in younger patients; and cost factors. The authors note that many debates on screening colonoscopy in older adults are prompted by a desire to free up endoscopic resources to screen younger individuals with a longer life expectancy. The demand for screening colonoscopy continues to strain the U.S. health care system, despite overall low participation rates. The authors conclude that CRC screening should be individualized based on quality of life of the patient, comorbid situations, and a rough estimate of the individual’s life expectancy. 1 figure. 2 tables. 88 references.

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Delayed Presentation of Traumatic Diaphragmatic Hernia Due to Stab Wound: Still Missing the Diagnosis. Practical Gastroenterology. 32(1): 42-44, 46. January 2008.

This article reviews some of the difficulties in diagnosing diaphragmatic hernia (DH) due to trauma. The authors use a case report on delayed presentation of DH due to a stab wound 2 years after the initial trauma. The 20-year-old male presented with constipation for 3 days and vomiting for 1 day; his past medical history included left-sided pneumothorax due to a stab wound 2 years prior to current admission. Barium enema and colonoscopy showed a narrowing of the proximal descending colon and splenic flexure area. Laparoscopy revealed a small loop of the colon that was clearly herniating through the diaphragm into the left chest. After reducing the loop and debridement of the area, a 3-centimeter oval deficit was seen and subsequently repaired with mesh. The patient recovered uneventfully. The authors discuss the various types of blunt trauma that may result in acquired DH and why it often goes undetected at the time of original injury. They briefly suggest appropriate surgical repair techniques, mortality rates, and other complications. The authors stress that the best way to initially screen for the possibility of DH is to complete a comprehensive history with the patient, including any traumas to the area, even if minor. They recommend laparoscopy at the time of a trauma as vital in detecting DH. 4 figures. 7 references.

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Preparing for a Colonoscopy. Baltimore, MD: AGA Institute. 2007. 4 p.

This brochure from the American Gastroenterological Association (AGA) familiarizes readers with colonoscopy, a procedure in which a long flexible tube is used to check for colon cancer and to treat colon polyps. The brochure outlines the reasons for having a colonoscopy and helps readers know what to expect before, during, and after the colonoscopy. Topics include preparing the colon for the test, the equipment used, and possible complications. In addition to its role as a screening tool, colonoscopy can be used to evaluate blood loss, abdominal or rectal pain, changes in bowel habits, abnormalities that may have first been detected by other diagnostic studies, and active bleeding from the large bowel. Colonoscopy may be performed in a hospital, special outpatient surgical center, or a physician’s office. The brochure emphasizes that colorectal cancer can be cured, especially when detected early through tests such as the colonoscopy. A final section reiterates the basic information presented in the brochure. One illustration presents the organs of the digestive system labeled in a simple line drawing. Readers are referred to the AGA website at www.gastro.org/patient for more information about digestive health and to find a local AGA member physician. 4 figures.

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Suspected Asymptomatic Large Colon Lipoma: Biopsy?. Practical Gastroenterology. 32(3): 35-40. March 2008.

This article presents a case report of a suspected large colon lipoma. The authors note that lipomas are the second most common benign tumors of the colon, after adenomatous polyps. When symptomatic, colon lipomas present with abdominal pain, rectal bleeding, and changes in bowel habits. The authors report the case of a 59-year-old female with a history of hypertension and hyperlipidemia who underwent a routine colonoscopy that showed a 3.5-centimeter lipomatous-appearing polyp in the sigmoid colon. Referral to the gastroenterology clinic resulted in no further treatment until 1 year later when repeat colonoscopy showed the same sized mass. The mass was biopsied and histopathology revealed smooth muscle prominence and fibrovascular tissue. One week later, the patient presented with bright red blood per rectal and mild, crampy abdominal pain; flexible sigmoidoscopy showed a completely obstructing purplish mass in the sigmoid colon with an overlying clot. A computerized tomography (CT) scan of the abdomen showed a pendunculated soft tissue density consistent with lipoma and a 2.9-centimeter mass in the lumen of the sigmoid colon consistent with hematoma. Conservative management resulted in spontaneous resolution of the bleeding and no symptoms at 1-year follow-up. The authors conclude by reminding readers of the characteristic features of lipoma and by cautioning that biopsy can result in no additional diagnostic hints and may even cause complications such as bleeding or obstruction. 5 figures. 14 references.

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Understanding Colonoscopy. Oak Brook, IL: American Society for Gastrointestinal Endoscopy. 2008. 2 p.

This brochure from the American Society for Gastrointestinal Endoscopy (ASGE) familiarizes readers with colonoscopy, a diagnostic test that examines the lining of the colon for abnormalities. After defining the test, the brochure reviews the preparations that a person should undergo before the test, whether current medications can be continued, what to expect during the test, how long the test will last, what to expect after the test, the possible complications, and the use of biopsy in conjunction with colonoscopy. An additional section describes colonic polyps, why they need to be removed, and how they are usually removed. The brochure reminds readers of the importance of colonoscopy and the fact that most people tolerate colonoscopy without pain or complications. The brochure concludes with a brief description of the work of and contact information for the ASGE.

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American Gastroenterological Association (AGA) Institute Medical Position Statement on Obscure Gastrointestinal Bleeding. Gastroenterology. 133: 1694-1696. November 2007.

This article presents the official recommendations of the American Gastroenterological Association (AGA) Institute, approved in 2007, about the evaluation and management of occult and obscure gastrointestinal (GI) bleeding. These recommendations update the prior technical review on obscure GI bleeding, which was published in 2000. The authors define obscure GI bleeding as bleeding from the GI tract that persists or recurs without an obvious cause after esophagogastroduodenoscopy (EGD), colonoscopy, and radiologic evaluation of the small bowel. Determining the cause of some GI bleeding is difficult, particularly when it is due to bleeding lesions that are overlooked in the esophagus, stomach, and colon during initial workup or to lesions in the small intestine that are difficult to visualize with conventional endoscopy or radiologic imaging. The guidelines review etiology and definitions, along with patient evaluation and management. The authors focus on specific steps to determining the cause of occult GI bleeding, starting with a comprehensive workup, a repeat of the endoscopic examinations, and then the use of capsule endoscopy. The authors conclude that endoscopic or surgical therapy should be considered due to its ease, relatively good long-term results, and the lack of a clearly effective, well-tolerated medical therapy. They propose that the earlier use of capsule endoscopy may allow more rapid diagnosis and thus improved patient care, as well as reduce costs for managing occult bleeding. 1 reference.

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Colonic Histoplasmosis. Gastroenterology and Hepatology. 3(6): 459-463. June 2007.

This article reports the case of a renal transplant recipient who presented with chronic diarrhea and was diagnosed with colonic histoplasmosis, a fungal infection endemic to the Ohio and Mississippi River valleys in the United States. The authors note that this is the first reported case of colonic histoplasmosis in a renal transplant recipient from a nonendemic region. The patient, a 42-year-old woman, presented with 4 weeks of watery diarrhea, intermittent fevers, and weight loss. She had undergone renal transplantation 3 years prior and was on immunosuppressants––tacrolimus and mycophenolate. Colonoscopy revealed multiple scattered ulcers throughout the colon; histological examination resulted in the diagnosis of histoplasmosis. Subsequently, intravenous amphotericin B was initiated, and the symptoms resolved within 1 week. Her medication was then switched to oral itraconazole. The authors discuss the symptoms of gastrointestinal histoplasmosis, the problem of histoplasmosis in immunocompromised patients, typical diagnostic findings, and the initial treatment of severely ill patients. The authors conclude that gastroenterologists caring for transplant recipients should be aware of the varied presentations of infectious diseases in immunosuppressed individuals and should consider uncommon etiologies in this population, even from nonendemic geographic regions. Appended to the article is a commentary by Psarros and Kauffman, who review guidelines for the diagnosis and treatment of histoplasmosis. 3 figures. 32 references.

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Colonoscopy Withdrawal Times and Adenoma Detection Rates. Gastroenterology and Hepatology. 3(8): 609-610. August 2007.

This article from a series on advances in endoscopy answers common clinical questions about colonoscopy withdrawal times and adenoma detection rates. The author discusses the main quality indicators for colonoscopy, recommendations for adenoma detection rates, the relationship between withdrawal times and adenoma detection rates, the role of other factors such as bowel preparation or the presence of advanced neoplasia in this context, and areas needing additional research. Research studies have shown that adenoma detection was strongly associated with longer withdrawal times: Endoscopists whose withdrawal times were more than 6 minutes detected more than twice as many patients with adenomas that were 1 centimeter or larger in size. The author reminds readers that withdrawal time is not the only factor involved, and improved research on other aspects, such as how well endoscopists are looking behind folds, how well they clean up, and the general quality of their bowel preparations, is needed. 5 references.

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Colonoscopy. IN: Wexner, S.; Stollman, N., eds. Diseases of the Colon. . New York, NY: Informa Healthcare USA. 2007. pp 137-162.

This chapter about colonoscopy is from a comprehensive text that offers chapters about each of the major colonic disorders. Each chapter is coauthored by at least one surgeon and one gastroenterologist to reflect the in-depth collaboration between these fields that is required for managing diseases of the colon. In this chapter, the authors describe the diagnostics, imaging, and therapeutic techniques for colonic evaluation and intervention. They note that the development of a means to accurately and safely visualize the entire colon endoscopically has revolutionized the diagnosis and management of colonic diseases and the clinical practice of gastroenterologists and colorectal surgeons. The authors discuss colon embryology and endoscopic anatomy, the role of sigmoidoscopy, professional training and competence in colonoscopy, patient preparation, bowel preparation, antibiotic prophylaxis, anticoagulant and antiplatelet medication use, the equipment used for colonoscopy, the role of the colonoscopy assistant, sedation and analgesia during colonoscopy, infection control and colonoscope disinfection, contraindications and limitations of colonoscopy, and the use of air-contrast barium enema and virtual colonoscopy. The chapter includes black-and-white photographs and illustrations and concludes with an extensive list of references. 7 figures. 2 tables. 154 references.

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Diseases of the Colon. New York, NY: Informa Healthcare USA. 2007. 809 p.

This comprehensive text offers chapters about each of the major colonic disorders. Each chapter is coauthored by at least one surgeon and one gastroenterologist to reflect the in-depth collaboration between these fields that is required for managing diseases of the colon. The book is designed as a useful, definitive, and concise reference source for internists, gastroenterologists, and general and colorectal surgeons, as well as residents and fellows in these fields. The book includes 36 chapters in eight sections: colonic development; disorders of function; diagnostics, imaging, and therapeutic techniques for colonic evaluation and intervention; infectious disorders; vascular disorders; motor disorders; neoplastic disorders of the colon; inflammatory—noninfectious—bowel disorders; anorectal disorders; and miscellaneous colonic disorders. Specific topics covered include embryology, colonic and rectal obstruction, fecal incontinence, rectal prolapse, constipation, colonoscopy, radiology of the colon, laparoscopic surgery of the colon, anorectal physiology testing, ultrasound, biofeedback for pelvic floor disorders, infectious colitis, pseudomembranous colitis, colon ischemia, radiation injury, acute lower gastrointestinal (GI) tract bleeding, vascular disorders of the colon, irritable bowel syndrome, diverticular disease, megacolon, pseudo-obstruction, volvulus, adenocarcinoma, benign and malignant colonic tumors, intestinal polyposis, ulcerative colitis, Crohn’s disease, diversion colitis and pouchitis, hemorrhoids, anal fissures, anorectal neoplastic disorders, the colon and systemic disease, and medications, toxins, and the colon. Each chapter includes black-and-white photographs and illustrations and concludes with an extensive list of references. A detailed subject index concludes the volume.

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Diverticular Disease. IN: Wexner, S.; Stollman, N., eds. Diseases of the Colon. . New York, NY: Informa Healthcare USA. 2007. pp 399-434.

This chapter about diverticular disease is from a comprehensive text that offers chapters about each of the major colonic disorders. Each chapter is coauthored by at least one surgeon and one gastroenterologist to reflect the in-depth collaboration between these fields that is required for managing diseases of the colon. In this chapter, the authors cover historical aspects, epidemiology, natural history, pathologic anatomy, etiology and pathogenesis, uncomplicated diverticulosis, complicated diverticular disease, and hemorrhage associated with diverticular disease. They note that most people with diverticulosis are asymptomatic, which makes the pathogenesis and natural history of diverticular disease somewhat difficult to study. Particular emphasis is placed on the role of colonoscopy in the diagnosis and management of diverticular disease and on the emerging role of minimally invasive surgical management of diverticular complications. Dietary fiber may play a preventive role and should be recommended to those patients with asymptomatic or mild disease. Medical management of diverticulitis involves a combination of antibiotics and, when necessary, percutaneous drainage. Surgery is used electively after multiple attacks of diverticulitis and more urgently for complications such as abscess, free perforation, fistula, or obstruction. A patient care algorithm is provided. The chapter includes black-and-white photographs and illustrations and concludes with an extensive list of references. 11 figures. 3 tables. 211 references.

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Endoscopy in Pregnancy. IN: Pregnancy in Gastrointestinal Disorders. 2nd ed. Bethesda, MD: American College of Gastroenterology. 2007. pp 10-17.

This chapter about endoscopy in pregnancy is from a monograph that presents updated information about pregnancy in women with gastrointestinal disorders. The authors stress that the spectrum of gastrointestinal diseases in the pregnant patient is virtually identical to that in nonpregnant women. However, options for evaluating pregnant patients are somewhat limited because barium studies and other radiographic techniques subject the fetus to the risks of radiation. However, endoscopy can play a crucial role in the diagnosis and treatment of various disorders in the pregnant patient. The chapter focuses on bringing readers up to date on the research in the area covered, the recommended treatments, and patient management concerns, notably issues of maternal and fetal safety. Topics include the use of upper endoscopy for diagnosing nausea, vomiting, esophagitis, ulcers, and gastritis; the use of lower endoscopy to evaluate rectal bleeding and inflammatory bowel disease (IBD); sigmoidoscopy and colonoscopy; endoscopic retrograde cholangiopancreatography (ERCP) used to evaluate gallstones; percutaneous endoscopic gastrostomy (PEG) placement to assist patients who cannot sustain adequate nutritional intake; and the use of sedation for endoscopic tests in women who are pregnant. The authors conclude that endoscopy appears to be safe in pregnancy. They recommend that procedures be performed after the first trimester if possible, following guidelines to minimize radiation and excessive sedation. Endoscopists are encouraged to consult with an obstetrician in challenging, complicated cases. 1 table. 17 references.

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Gourmet Colon Prep. Practical Gastroenterology. 31(11): 41-42, 47-57. November 2007.

This article reviews the current diet regimens used during bowel preparation for colonoscopy and offers suggestions for dietary measures that may make the bowel preparation more tolerable and thus ultimately more successful. The authors summarize selected commercially available colonoscopy preparations and their accompanying manufacturer diet and liquid recommendations. The authors review clinical trials addressing some alternative regimens for bowel preparation. Specific topics include the clear liquid diet, the use of lactose-free, fiber-free nutritional supplements, low-residue diet options, sample menus, preparations for patients who have an ileostomy or jejunostomy, and tips for improving acceptability. The authors conclude that liberalizing the preprocedure diet may not only decrease hunger during the preparation period but can also decrease the patient’s dread of such a long period without food. Emphasizing the importance of adequate fluid intake to prevent dehydration is valuable, and providing a variety of options for the liquid diet may be helpful. 11 tables. 13 references.

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How to Prepare for Tests. Digestive Health Matters. 16(2): 15-17. Summer 2007.

The diagnosis of a functional gastrointestinal disorder can often be made without the assistance of laboratory testing. However, a structural disease must often be excluded by tests that probe the gastrointestinal tract. This article helps readers prepare for gastrointestinal diagnostic tests. The author stresses that correct preparation for a test helps make that test itself easier and the results more useful; in addition, patients may feel some relief at understanding what to expect before, during, and after a particular test. The author first reviews general principles, including the use of sedation, local anesthesia, and informed consent. Specific tests are then described, including sigmoidoscopy, colonoscopy, other colonic procedures such as a barium enema, upper gastrointestinal endoscopy, and other upper gut examinations. When the gut interior is to be visualized by an endoscope or barium x ray, a clean and empty interior is required for a successful examination. In some tests of gut function, as little as possible should be done to interfere with the gut’s natural performance. Sometimes fasting is necessary, but during such tests, eating and activity should be normal and drugs that might alter gut performance should be withdrawn. 5 references.

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Improvements in Ulcerative Colitis Symptoms After Use of Fish Oil Enemas. Gastroenterology and Hepatology. 3(10): 786-788. October 2007.

This article presents a case report of improvement in ulcerative colitis symptoms after use of fish oil enemas. The authors report a case of a 75-year-old woman with active colitis who experiences improvement in her symptoms after adding to her treatment omega-3 (n-3) fatty acid supplements delivered via rectal enema. The authors describe the patient’s symptoms of bloody, loose stools that had recently worsened, recommended changes in her maintenance medications of oral mesalamine and mesalamine enemas, and her colonoscopy findings. Remaining on her treatment regimen, the patient self-administered an additional enema daily of 3 grams of of fish oil. The over-the-counter preparation of fish oil she used was an oral gel-cap liquid supplement with eicosapentaenoic acid (EPA) 540 milligrams (mg), docosahexaenoic acid (DHA) 360 mg, and vitamin E 3.3 IU. The liquid portion was separated from the gel cap and administered locally by the patient. The patient’s symptoms resolved within 3 weeks of starting this supplemental therapy. Subsequent colonoscopy demonstrated vast improvements in the colonic mucosa. The authors discuss the case, as does author A. Brzezinski in an appended commentary and review. 18 references.

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New Post-Polypectomy Surveillance Guidelines. Practical Gastroenterology. 31(8): 30, 35-42. August 2007.

People found to have adenomatous polyps usually undergo polypectomy and then are placed into a surveillance program of periodic colonoscopy to remove missed synchronous and new metachronous adenomas and cancers. This article reviews new postpolypectomy surveillance guidelines issued by the United States Multi-Society Task Force on Colorectal Cancer and the American Cancer Society (USM-STF/ACS). The author outlines how this set of guidelines differs from earlier guidelines: They offer a consensus statement that strengthens the guidelines, they specifically examine predictors of advanced adenomas and incorporate them into the guidelines, and they emphasize the quality of baseline colonoscopy and its impact on detection of postpolypectomy colorectal cancer. The author maintains that risk stratification can reduce the intensity of follow-up evaluation in a substantial proportion of these patients, so limited colonoscopy resources could be shifted from surveillance to screening and diagnosis. The article includes the recommendations, addition surveillance considerations, and a discussion of their implications for clinical practice. 8 tables. 67 references.

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Post-Polypectomy Surveillance: Who and How. Practical Gastroenterology. 31(7): 19-25. July 2007.

The most common neoplastic lesions found during screening tests are colorectal adenomas; their presence indicates a possible increased risk for future colorectal neoplasia. This article considers the guidelines for postpolypectomy surveillance of these patients. The author notes that high-quality baseline colonoscopy with excellent preparation, adequate examination, and complete polypectomy will reduce miss rates and should be the basis of any program of follow-up. Findings at baseline colonoscopy can be used to predict future risk and thus recommended surveillance intervals. High-risk adenomas justify a surveillance interval of 3 years; for those with one or two tubular adenomas, an interval of 5 to 10 years is adequate. Hyperplastic polyps warrant only an average-risk screening program. The author concludes that the implementation of these guidelines could free up procedures to support screening programs. 1 figure. 1 table. 11 references.

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Pseudo-Obstruction (Ogilvie’s), Cathartic Colon-Laxative Abuse, and Melanosis IN: Wexner, S.; Stollman, N., eds. Diseases of the Colon. . New York, NY: Informa Healthcare USA. 2007. pp 449-462.

This chapter about pseudo-obstruction, cathartic colon due to laxative abuse, and melanosis is from a comprehensive text that offers chapters about each of the major colonic disorders. Each chapter is coauthored by at least one surgeon and one gastroenterologist to reflect the in-depth collaboration between these fields that is required for managing diseases of the colon. In this chapter, the authors first discuss acute colonic pseudo-obstruction (ACPO), covering presentation and etiology, pathophysiology, diagnosis, conservative management, endoscopic management, drug therapy, and surgical options. They note that drug therapy with neostigmine has become an accepted, safe means of decompression that requires fewer repeat procedures than colonoscopy and carries a lower complication and mortality rate. The second section considers laxative abuse and melanosis. The authors describe the five categories of laxatives in current use and consider whether laxative abuse syndrome could be considered a type of Munchausen syndrome. Melanosis coli is a nonspecific marker of increased apoptosis in the colon, which may result from laxative abuse or may be from numerous other etiologies. The authors caution that the treatment of laxative abuse is extremely difficult and recommend a team approach that includes psychiatric input and support from the patient’s family. The chapter includes black-and-white photographs and illustrations and concludes with an extensive list of references. 6 figures. 2 tables. 50 references.

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Recto-Sigmoid Perforation During Retroflexion: Is There a Relationship to Rectal Prolapse?. Practical Gastroenterology. 31(7): 37-38, 43. July 2007.

Although colonic perforation is a known complication of colonoscopy, the rectum is generally considered to be an area of low risk for perforation. This article presents the case of a 70-year-old man with rectosigmoid colon perforation occurring upon retroflexion in the rectum during colonoscopy. This patient had prolapse of the rectal mucosa identified on digital rectal examination (DRE) prior to insertion of the colonoscopy. The authors present the case details, including confirmation of the perforation and the laparotomy repair of the 1 to 2 centimeter colon perforation just above the peritoneal reflexion. The patient was discharged from the hospital 2 days later with no further complications. The authors conclude that rectal prolapse may increase the risk of perforation during retroflexion. Thus, endoscopists should use caution when performing this maneuver in patients with rectal prolapse. 17 references.

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Role of Fecal Occult Blood Testing in Screening for Colorectal Cancer. Practical Gastroenterology. 31(6): 20-32. June 2007.

This review article considers the role of fecal occult blood testing (FOBT) in screening for colorectal cancer (CRC). The author notes that all of the most recent guidelines for CRC screening recommend a group of screening options. However, the popular press and many gastroenterology opinion leaders focus on only one test: colonoscopy. This article discusses the various FOBTs available. The author makes the argument that FOBT screening is still relevant and important in population screening efforts. The author discusses the details of both the guaiac tests and the immunochemical tests, explaining the similarities and differences between them; reviews the practicalities of screening with colonoscopy in both the United States and the United Kingdom; and emphasizes that the best screening test is the one that actually gets performed. 5 figures. 3 tables. 52 references.

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Standards for Gastroenterologists for Performing And Interpreting Diagnostic Computed Tomographic Colonography. Gastroenterology. 133(3): 1005-1024. 2007.

This article provides standards for gastroenterologists for performing and interpreting diagnostic computed tomography (CT) colonography, a relatively new technique used to image the colon. The article provides a brief background section and an executive summary of the recommendations before presenting the full task force review and recommendations. Topics include the current status of CT colonography; current indications for CT colonography, including failed colonoscopy, evaluation of the colon proximal to an obstructing lesion, evaluation of patients with contraindications to colonoscopy, and as screening for asymptomatic normal-risk adults; qualifications and training of personnel; examination and equipment specifications, including colonic preparation, the CT acquisition technique, and CT interpretation; reading and reporting the results; quality control and safety; and regulatory issues, including the implications of the Stark laws, referrals, split interpretation and billing for services, oversight, and risk management issues. In each topic area, the authors provide specific task force recommendations. 1 figure. 2 tables. 115 references.

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Volvulus. IN: Wexner, S.; Stollman, N., eds. Diseases of the Colon. . New York, NY: Informa Healthcare USA. 2007. pp 463-476.

This chapter about volvulus is from a comprehensive text that offers chapters about each of the major colonic disorders. Volvulus refers to a torsion or twist of an organ on a stalk or stem of tissue. Each chapter is coauthored by at least one surgeon and one gastroenterologist to reflect the in-depth collaboration between these fields that is required for managing diseases of the colon. In this chapter, the authors cover definition, historical background, classification, and epidemiology of volvulus. They discuss specific types including sigmoid volvulus, cecal volvulus, transverse volvulus, and splenic flexure volvulus. The authors note that there are clinical differences in the presentation and treatment of volvulus, depending on grade of obstruction and the segment involved. The treatment of sigmoid volvulus has changed from an immediate surgical correction with a high mortality rate to a more conservative approach with immediate decompression of the volvulus followed by electric surgery. However, conservative treatment of cecal volvulus with colonoscopy is often unsuccessful, so treatment ranges from nonresectional procedures in viable bowels to resection in gangrenous bowels. The different types of volvulus are typically diagnosed with plain abdominal x rays. The chapter includes black-and-white photographs and illustrations and concludes with an extensive list of references. 2 figures. 7 tables. 100 references.

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Biomarkers for IBD-Related Colon Cancer: CCFA Researchers Seek Better Ways to Detect Risk and Prevent Disease. Take Charge. p. 32-35. Winter 2006.

One of the complications of inflammatory bowel disease (IBD, including Crohn's disease and ulcerative colitis) is an increased risk for colon cancer, a risk that rises even more after people have had colitis or Crohn's of the colon for more than 8 to 10 years. This article discusses the biomarkers used to detect IBD-related colon cancer. Gastroenterologists urge people with IBD to have a colonoscopy every one to two years after they have had IBD for more than 8 years. The author considers the increased cancer risk (which actually applies to a minority of IBD patients, approximately 10 percent) and diagnostic or screening strategies that can distinguish between inflammatory changes in the colon and precancerous ones. The author outlines the problems with colonoscopy in this patient population and makes the case for a quick, non-invasive test for colon cancer based on a biomarker, comparable to the Prostate Specific Antigen (PSA) which is used to screen for prostate cancer. The Crohn's and Colitis Foundation of America (CCFA) is currently supporting three research projects concerning the identification and testing of genetic markers for colon cancer. The author concludes that soon some of the genetic and other tests under study will be moved from the lab to clinical use, where they will complement colonoscopy in screening people with IBD for colon cancer. The article includes quotes from and photographs from three researchers in the area of biomarkers. 3 figures.

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Cancer: New Colonoscopic Techniques. IN: Jewell, D.P., et al, eds. Challenges in Inflammatory Bowel Disease: Management of Crohn's Disease. Malden, MA: Blackwell Publishing Inc. pp. 293-302.

Patients with longstanding, extensive ulcerative colitis (UC) are at increased risk of developing colorectal cancer. Colonoscopic surveillance is recommended to reduce associated mortality. This chapter on new colonoscopic techniques is from a textbook that addresses some of the challenges in the understanding of UC and Crohn’s disease (CD), collectively known as inflammatory bowel disease (IBD). In this chapter, the authors discuss detection of premalignant lesions in UC, chromoendoscopy, the efficiency of chromoendoscopy, and future trends, including confocal laser endomicroscopy. The authors conclude that the newly developed high-resolution and magnification endoscopes offer features that allow more and new mucosal details to be seen. These techniques are commonly used in conjunction with chromoendoscopy. Endoscopic prediction of neoplastic and non-neoplastic tissue is possible by analysis of the surface architecture of the mucosa, which influences the endoscopic management. 5 figures. 1 table. 19 references.

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Colonoscopic Surveillance: If and When?. IN: Jewell, D.P., et al, eds. Challenges in Inflammatory Bowel Disease: Management of Crohn's Disease. Malden, MA: Blackwell Publishing Inc. pp. 281-292.

The increased risk of intestinal cancer is one of the major problems in the long-term management of patients with inflammatory bowel disease (IBD). This chapter on colonoscopic surveillance is from a textbook that addresses some of the challenges in the understanding of ulcerative colitis (UC) and Crohn’s disease (CD), collectively known as IBD. In this chapter, the authors discuss overall cancer risk, small bowel carcinoma in CD, colorectal cancer risk in UC, colorectal cancer risk in CD, clinical risk factors, protective factors for colorectal cancer in IBD, management strategies for colorectal surveillance in patients with IBD, screening colonoscopy, and surveillance colonoscopy. The understanding that widespread dysplastic lesions in the colorectal mucosa precede the development of invasive carcinoma forms the mainstay for colonoscopic surveillance. The authors conclude that examinations with multiple biopsies, at regular intervals, can be used as an instrument to select high-risk patients for prophylactic colectomy before cancer occurs or, if cancer is detected, at a potentially curable stage. 101 references.

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Colonoscopies 101: Everything You've Always Wanted to Know But Were Afraid to Ask. Digestive Health and Nutrition. 8(1): 18-20. March- April 2006.

Colorectal cancer is the third most common cancer in both men and women in the United States. A colonoscopy is used to find and remove fleshy growths in the colon (polyps) before they become cancerous. This article answers common questions about colonoscopy, including the procedure itself, why it may be used, and alternatives. The author notes that, in order for the gastroenterologist to complete the test, the patient’s colon must be entirely empty of stool. Emptying the bowel requires fasting, laxatives, and increased drinking the day before the test. A colonoscopy is typically an outpatient procedure performed under sedation. Patients must arrange transportation after the procedure. The author walks patients through each step of the procedure. A final section describes some alternative screening methods, including virtual colonoscopy, digital rectal exam (DRE), stool blood test, flexible sigmoidoscopy, and barium enema with contrast. One sidebar outlines six steps to colorectal cancer prevention; another summarizes the guidelines for colon cancer screening using colonoscopy. 3 references.

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Irritable Bowel Syndrome (IBS): Answers to Common Questions. Digestive Health Matters. 15(1): 4-8. Spring 2006.

This article provides information on the symptoms of irritable bowel syndrome (IBS), and the factors and mechanisms that are thought to be associated with their occurrence. IBS is defined as a long-term or recurrent disorder of gastrointestinal functioning that is characterized by abdominal pain or discomfort, bloating or a sense of gaseousness, and altered bowel habits, such as diarrhea and constipation. Diagnosis is usually determined by the patient's symptoms and is also dependent on the absence of alarm signs that may suggest a condition other than IBS, such as inflammatory bowel disease or colon cancer. Some diagnostic tests may be used to help in the diagnosis, including laboratory blood and stool tests, colonoscopy, and tests for celiac sprue. The authors also discuss the causes of IBS, how serious the disease is considered to be, the difference between IBS and colitis, the causes of bloating and gas, how the menstrual cycle affects IBS symptoms, the relationship between stress and IBS, the effect of diet on IBS, and treatment options. The authors conclude that individuals who have not responded to lifestyle changes and careful use of medications should consider being evaluated by a physician who specializes in motility or stress-related gastrointestinal disorders. The article concludes with a list of seven simple guidelines to help readers cope with IBS. 1 figure.

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Preventing Colorectal Cancer. Diabetes Self-Management. 23(2): 29-36. March April 2006.

Colorectal cancer is a common type of cancer in both men and women. This article helps readers with diabetes understand the strategies they can take to help prevent the likelihood of developing colorectal cancer. Symptoms of colorectal cancer can include a change in bowel habits, blood in the stool, lower abdominal pain or cramping, fatigue, and vomiting. However, there are no symptoms in the earliest and most treatable stages of colorectal cancer, which is why screening is so important. The author outlines the risk factors for colorectal cancer, including age factors, family history, obesity, and having type 2 diabetes. There is some evidence that high levels of circulating insulin increase the risk of colon cancer. The author considers the influence of diet, noting that although there is much conflicting information, it is clear that following a nutritious diet high in fruits and vegetables and low in red and processed meats and saturated fat is likely to be beneficial. Other lifestyle changes that can have a positive impact include stopping smoking and avoiding a sedentary lifestyle. One sidebar explains the tests that are used to screen for colorectal cancer, including the fecal occult blood test, flexible sigmoidoscopy, barium enemas, and colonoscopy. Another sidebar lists resource organizations through which readers can obtain additional information.

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Preventing Colorectal Cancer. Diabetes Self-Management. 23(2): 29-36. March April 2006.

Colorectal cancer is a common type of cancer in both men and women. This article helps readers with diabetes understand the strategies they can take to help prevent the likelihood of developing colorectal cancer. Symptoms of colorectal cancer can include a change in bowel habits, blood in the stool, lower abdominal pain or cramping, fatigue, and vomiting. However, there are no symptoms in the earliest and most treatable stages of colorectal cancer, which is why screening is so important. The author outlines the risk factors for colorectal cancer, including age factors, family history, obesity, and having type 2 diabetes. There is some evidence that high levels of circulating insulin increase the risk of colon cancer. The author considers the influence of diet, noting that although there is much conflicting information, it is clear that following a nutritious diet high in fruits and vegetables and low in red and processed meats and saturated fat is likely to be beneficial. Other lifestyle changes that can have a positive impact include stopping smoking and avoiding a sedentary lifestyle. One sidebar explains the tests that are used to screen for colorectal cancer, including the fecal occult blood test, flexible sigmoidoscopy, barium enemas, and colonoscopy. Another sidebar lists resource organizations through which readers can obtain additional information.

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Role of Capsule Endoscopy in IBD. Gastroenterology and Hepatology. 2(2): 97-99. February 2006.

This article offers the answers to clinical questions about the role of capsule endoscopy in inflammatory bowel disease (IBD). Topics include the challenges in diagnosing IBD that may be addressed by capsule endoscopy, the research studies that have evaluated the use of capsule endoscopy in Crohn’s disease (CD, a type of IBD), the risks of capsule endoscopy (predominantly capsule retention, which can happen when a stricture is present), and conclusions that can be made when capsule endoscopy identifies lesions. If CD is suspected but not found on upper endoscopy or colonoscopy, a capsule endoscopy may be the next logical step. The author concludes that efforts to improve biopsy capabilities and remote control capabilities with the capsule are ongoing. It may prove possible to complement capsule endoscopy with enteroscopy, such as the double-balloon technique, enabling a larger part of the bowel to be seen. 4 references.

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Simulators for Training in Endoscopy. Gastroenterology and Hepatology. 2(1): 13-14. January 2006.

This article, written in a question-and-answer format, addresses the use of simulators for training in endoscopy. Beginning in the mid-1990s, computer simulators were able to create a realistic, visual representation of the colonoscopy, esophagogastroduodenoscopy, or other technique being performed. The simulators are designed to provide not only a visually realistic simulation of the lumen of the gastrointestinal tract, but also the feel and resistance of inserting and advancing a scope, loop formation, etc. The author describes current research studies on the effectiveness of simulation training, the goals of using this kind of training to accelerate skill acquisition, the need for achieving competence quickly, the use of simulators to assess competence, the recommended stages of training that are most appropriate for simulator program use, and advances in simulator training that would be useful. A final section considers the costs of simulator training. 5 references.

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Bringing to Light the Risk of Colorectal Cancer among Crohn's & Ulcerative Colitis Patients. New York, NY: Crohn's and Colitis Foundation of America. 2005. 2 p.

Crohn’s disease (CD) and ulcerative colitis (UC), collectively known as inflammatory bowel disease (IBD), are chronic diseases that inflame the digestive or gastrointestinal (GI) system. This brochure helps readers with IBD understand their risk factors for colorectal cancer (CRC). The two factors that are associated with increased cancer risk in this population are disease duration and the extent of the colon involved. Written in a question-and-answer format, the brochure covers the common signs and symptoms of CRC, diagnostic approaches, recommendations for screening (including with colonoscopy), the risk factors for CRC, and how to decrease the risks for developing CRC. The brochure stresses that knowledge of the connection between CRC and IBD, along with annual screenings, can lead to early treatment of CRC, which can help reduce the potential life-threatening consequences of CRC. The back cover of the brochure describes an educational campaign, sponsored by the Crohn’s and Colitis Foundation of America (CCFA), that is designed to raise awareness about the increased risk for colorectal cancer among patients with CD and UC. Readers are referred to the CCFA website for additional educational materials.

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Chronic Constipation : From Evaluation to Treatment. Digestive Health Matters. 14(4): 4-9. Winter 2005.

This article brings readers up-to-date on the evaluation and treatment of chronic constipation. The author begins by defining constipation and differentiating chronic constipation from irritable bowel syndrome (IBS), a condition that can be characterized by constipation as one of its features. The term constipation includes a complex group of symptoms related to slow, impaired, difficult, or painful defecation. The article then addresses the major identifiable causes of constipation, when to consult a doctor for evaluation, the role of colonoscopy in diagnosis, the indications for specialized testing, including anorectal manometry and defecography, and treatment strategies, which are dependent upon diagnosis. The author discusses the use of drug therapies, biofeedback therapy, dietary fiber and fluids, and surgical options. The author concludes that most people with constipation can be successfully treated when a complete evaluation is performed and a rational treatment plan is pursued in partnership with their health care provider. 2 figures. 3 tables. 3 references.

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Living with Crohn's Disease. New York, NY: Crohn's & Colitis Foundation of America. 2005. 12 p.

Crohn’s disease (CD), one of two diseases collectively known as inflammatory bowel disease (IBD), is a chronic disease that inflames the digestive or gastrointestinal (GI) system. This brochure helps readers newly diagnosed with CD to understand the basics of their disease and what to expect. Written in a question-and-answer format, the brochure covers the definition of the disease, the anatomy and physiology of the normal GI tract, risk factors for CD (including genetics), the different types of CD, the causes of CD, the signs and symptoms of the disease, extra-intestinal problems associated with CD, diagnostic tests that are used to confirm the presence of CD (including sigmoidoscopy and colonoscopy), treatment options (drug therapy and surgery), the role of nutrition, the role of stress and emotional factors, and coping strategies for living a healthy active life with CD. A final section describes the Crohn’s and Colitis Foundation of America (CCFA), a non-profit organization that funds research on IBD, provides educational resources for patients and their families, medical professionals, and the public, and offers support services for people with IBD. Readers are encouraged to join the CCFA and are referred to the CCFA website for additional educational materials; a membership application form is also included in the brochure. 1 figure.

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Living with Ulcerative Colitis. New York, NY: Crohn's and Colitis Foundation of America. 2005. 12 p.

Ulcerative colitis (UC), one of two diseases collectively known as inflammatory bowel disease (IBD), is a chronic disease that inflames the digestive or gastrointestinal (GI) system. This brochure helps readers newly diagnosed with UC to understand the basics of their disease and what to expect. Written in a question-and-answer format, the brochure covers the definition of the disease, the anatomy and physiology of the normal GI tract, risk factors for UC (including genetics), the causes of UC, the signs and symptoms of the disease, extra-intestinal problems associated with UC, diagnostic tests that are used to confirm the presence of UC (including sigmoidoscopy and colonoscopy), treatment options (drug therapy and surgery), the role of nutrition, the use of probiotics and prebiotics, the role of stress and emotional factors, and coping strategies for living a healthy active life with UC. A final section describes the Crohn’s and Colitis Foundation of America (CCFA), a non-profit organization that funds research on IBD, provides educational resources for patients and their families, medical professionals, and the public, and offers support services for people with IBD. Readers are encouraged to join the CCFA and are referred to the CCFA website for additional educational materials; a membership application form is also included in the brochure. 1 figure.

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Small and Large Intestines. IN: Digestive Disorders 2005. Palm Coast, FL: Medletter Associated. pp 24-29. 2005.

This lengthy section on the small and large intestines is from a White Paper on digestive disorders, including conditions that affect the esophagus, stomach, gallbladder, bile ducts, small intestine, and large intestine. This chapter covers normal anatomy of the small and large intestines; the examination of the colon and rectum, including barium enema, sigmoidoscopy, colonoscopy, virtual colonoscopy, and capsule endoscopy; and the causes, symptoms, diagnosis, and treatment of constipation, diverticulosis and diverticulitis, diarrhea, celiac disease (gluten intolerance), Crohn's disease, ulcerative colitis, irritable bowel syndrome, hemorrhoids, anal fissure, and colorectal cancer. Numerous sidebars cover some topics in greater detail: research on the clinical utility of virtual colonoscopy, specific foods and a suggested menu for people on a clear liquid diet, strategies for living with lactose intolerance, understanding changes in color of the feces (stool), the interrelationship between appendectomy and the risk of ulcerative colitis, the grains that are safe for people on a gluten-free diet (for celiac disease), a drug used in Crohn's disease that may reverse or delay the formation of fistulas, travel tips for people with inflammatory bowel disease (IBD), the risks associated with eating red meat and drinking alcohol for people with colitis, the impact of depression on IBD flare-ups, quality of life issues in irritable bowel syndrome (IBS), coping with pruritus ani (anal itching), the risks of colorectal cancer associated with a high-glycemic diet (one that includes a lot of simple and complex sugars), how high doses of aspirin may fight colon polyps, a new anticancer drug (Avastin, bevacizumab) used for metastatic colorectal cancer, laparoscopic surgery for colon cancer, and how colon cancer is staged. One illustration outlines the parts of the lower digestive system and the diseases or conditions that can affect each part. One chart summarizes the drugs used for IBD.

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Straight Talk on Colorectal Cancer. Digestive Health and Nutrition. 7(2): 16-18. March-April 2005.

This article discusses colorectal cancer, emphasizing the importance of early detection for best treatment results. The author cautions that because colorectal cancer does not often have symptoms in its earlier stages, screening and removal of polyps (growths on the inner wall of the large intestine) are vital. Removing a polyp eliminates the chance of it changing to a cancerous growth. The author considers some of the reasons why there are low screening rates, including people being unaware of the need for or the benefits of screening, and clinicians not recommending screening. The author also discusses the colonoscopy procedure, preparation for colonoscopy, fecal occult blood testing, recommendations for how often to have these screening tests, new testing methods that are under development (including virtual colonoscopy), risk factors for colorectal cancer, lifestyle factors that may play a role in the development of colorectal cancer, and the role of genetics in colorectal cancer. One sidebar summarizes colorectal cancer screening guidelines; another sidebar lists the different methods currently available to screen for colorectal cancer. 1 figure. 6 references.

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Adenomatous Polyps. Riviera Beach, FL: AmeriPath, Inc. 2004. 2 p.

This fact sheet helps readers understand adenomatous polyps, abnormal noncancerous (benign) growths that may be precursor lesions to colorectal cancer. The fact sheet reviews the risk factors for adenomatous polyps; the types of diagnostic tests that may be used to diagnose polyps; the treatment options, notably colonoscopy; methods to help prevent colon cancer, including monitoring one's bowel habits and including dietary fiber in one's regular plan of eating; and recommended questions to ask of one's physician. The fact sheet concludes with a list of sources of additional information, primarily the web site addresses of professional and voluntary organizations. 1 figure.

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Colorectal Carcinoma and Inflammatory Bowel Disease. Alimentary Pharmacology and Therapeutics. 20 (Suppl 4): 24-30. October 2004.

This review article considers the interplay between colorectal carcinoma and inflammatory bowel disease (IBD, which includes ulcerative colitis and Crohn's disease). The risk of colorectal cancer for any patient with ulcerative colitis is estimated to be 2 percent after 10 years, 8 percent after 20 years and 18 percent after 30 years of disease. The relative risk of colorectal cancer in Crohn's colitis is approximately 5.6 and should raise the same concerns as in ulcerative colitis. Risk factors for colorectal cancer include disease duration, early onset, extensive disease, primary sclerosing cholangitis (PSC), and a family history of sporadic colorectal cancer. The author recommends that all patients have a review colonoscopy 8 to 10 years after their diagnosis to establish the extent of their disease. Regular surveillance is recommended, with a screening interval every 3 years in the second decade of disease and annually by the fourth decade. Dysplasia (differences in cell growth and structure) is recognized as a premalignant condition, but the likelihood of progression to cancer is difficult to predict. The author concludes with a brief discussion of the socioeconomic implications of surveillance programs, notably cost-effectiveness issues. 58 references.

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Hyperplastic Polyps. Riviera Beach, FL: AmeriPath, Inc. 2004. 2 p.

This fact sheet helps readers understand hyperplastic polyps, abnormal growths rising from the lining of the large intestine (colon) and protruding into the intestinal canal (lumen). Polyps are usually classified into two types: adenomatous polyps (adenomas) and hyperplastic polyps. Adenomas are the precursor lesions for colorectal carcinoma (colon cancer). The more common hyperplastic polyps are benign and, in most cases, not considered to be premalignant. The fact sheet reviews the types of diagnostic tests that may be used to diagnose polyps; the treatment options, notably colonoscopy; methods to help prevent colon cancer, including monitoring one's bowel habits and including dietary fiber in one's regular plan of eating; and recommended questions to ask of one's physician. The fact sheet concludes with a list of sources of additional information, primarily the web site addresses of professional and voluntary organizations. 1 figure.

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Ischemic Colitis. In: Kelly, K.A.; Sarr, M.G.; Hinder, R.A., eds. Mayo Clinic Gastrointestinal Surgery. St. Louis, MO: Elsevier Science. 2004. p. 519-524.

Ischemic colitis (lack of or reduced blood flow to the colon) has a number of causes and treatments. This chapter on ischemic colitis is from a book that focuses on the major diseases treated by gastrointestinal surgeons, from the esophagus to the anal canal. The presentation has a definite clinical orientation and a major emphasis on practical applications as they are applied at the Mayo Clinic. The author of this chapter reviews colonic vascular (blood vessel) anatomy and variations, pathologic conditions, etiologic factors and patient groups, clinical presentation and diagnosis, indications for operation, conduct of operation, surgical outcomes, and long-term follow-up. The typical patient, whose diagnosis is confirmed with colonoscopy, usually responds well to treatment with intravenous fluids, antibiotics, and bowel rest. Transmural necrosis, which requires urgent surgical intervention, should be suspected in patients who have signs of peritonitis or sepsis. A surgical approach also may be indicated for complications of ischemic colitis, such as perforation, recurrence, or strictures. The chapter is illustrated with full-color photographs. 2 figures. 1 table. 30 references.

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Acute Bleeding from Diverticulosis and Ischemic Colitis. In: Chung, P. and Kim, K.E. Acute Gastrointestinal Bleeding: Diagnosis and Treatment. Totowa, NJ: Humana Press. 2003. p. 163-174.

Lower gastrointestinal (GI) bleeding is a common medical problem in the United States. Two common causes of such bleeding are diverticulosis and ischemic colitis. This chapter reviews the pathogenesis, diagnosis, and management of bleeding associated with these two conditions. The chapter is from a textbook in which leading experts in the fields of gastroenterology, surgery, and radiology comprehensively review the pathophysiology, diagnosis, management, and treatment of acute bleeding disorders of the GI tract. The authors of this chapter note that acute diverticular bleeding is the most common cause of lower GI bleeding. Most patients are otherwise asymptomatic at presentation, and bleeding ceases spontaneously 70 to 80 percent of the time. Ischemic colitis is the most common form of intestinal ischemic injury, most often occurring in the left side of the colon. Colonoscopy is the diagnostic procedure of choice since it allows direct visualization of the mucosa and tissue sampling. Management is usually merely supportive, consisting of bowel rest and intravenous fluid and antibiotics, with most patients recovering in 24 to 48 hours. 2 figures. 39 references.

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Advent of Capsule Endoscopy: A Not-So-Futuristic Approach to Obscure Gastrointestinal Bleeding. Alimentary Pharmacology and Therapeutics. 17(9): 1085-1096. May 2003.

Capsule endoscopy is a new, wireless, endoscopic examination of the small intestine; it has been shown to be superior to push enteroscopy in diagnosing the cause of blood loss. This article proposes a change in practice guidelines for obscure bleeding. The authors believe that in the future the evaluation of patients with obscure gastrointestinal bleeding will be very different from the practice of medicine today. Capsule endoscopy will become the first line method for the evaluation of patients with obscure bleeding, once upper endoscopy and colonoscopy have been shown to be negative. In patients with active bleeding, capsule endoscopy will confirm the small bowel as the site of bleeding, providing a location, or, if the study is negative for the small intestine, may indicate that the bleeding is either colonic or gastric in origin. In a patient with active bleeding within the small intestine, the capsule will guide further evaluation and therapy. A patient with a small bowel tumor detected by capsule endoscopy will proceed directly to laparoscopic surgery. If the site of bleeding is identified in the proximal small bowel and there is no mass, push enteroscopy will be used to reidentify the site and cauterize it. A distal small bowel site will require surgical intervention, coupled with intraoperative enteroscopy. A colonic site will be evaluated by colonoscopy. In patients with a more occult or intermittent type of bleeding and in those whose upper endoscopies and colonoscopies are negative, capsule endoscopy will be used similarly to identify a bleeding lesion and thereby direct subsequent testing or treatment. 1 table. 98 references.

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Cancer in Inflammatory Bowel Disease. In: Lichtenstein, G.R. The Clinician's Guide to Inflammatory Bowel Disease. Thorofare, NJ: SLACK Incorporated. 2003. p. 113-123.

Although the term inflammatory bowel disease (IBD) describes a wide range of inflammatory states, it generally refers to ulcerative colitis (UC) and Crohn's disease. This chapter on cancer in IBD is from a handbook that presents an up to date guide on selected topics in IBD, focusing on those clinically important areas that have undergone recent changes or discoveries. In this chapter, the author notes that since the risk of colorectal cancer is elevated in IBD, cancer surveillance colonoscopy has evolved over the past 30 years to become the standard of care for high risk patients, especially those with UC. Periodic colonoscopy to examine for asymptomatic cancer or the neoplastic lesion of dysplasia is routinely employed in most practices in the world, but it is costly and associated with some, albeit low, morbidity. The author stresses that gastroenterologists must understand the principles of cancer surveillance colonoscopy and make an effort to minimize cost effectiveness ratios so that this expensive form of cancer surveillance can be offered to as many patients as possible within the financial constraints of the health care system. 2 tables. 38 references.

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Colon Cancer Screening. Journal of American Medical Association. 289(10): 1334. March 2003.

Screening for colorectal cancer clearly reduces colorectal cancer mortality, yet many eligible adults remain unscreened. This patient education fact sheet describes the screening tests that are available, including fecal occult blood tests, sigmoidoscopy, colonoscopy, and double-contrast barium enema. The fact sheet includes the web site addresses of three organizations through which readers can get more information. 2 figures. 3 references.

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Colon Cancer: The Power of Prevention. Princeton, NJ: Films for the Humanities and Sciences. 2002. (videorecording).

One of the most deadly forms of cancer is also one of the most preventable. In this program, doctors from the University of Pennsylvania School of Medicine, Vanderbilt-Ingram Cancer Center, Memorial Sloan-Kettering Cancer Center, and elsewhere focus on three case studies of senior citizens with colon cancer to explore the etiology and pathology of colon cancer, risk factors, and screening options. Prevention through colonoscopic examinations is emphasized, and treatments such as surgery with adjuvant therapy and combination chemotherapy involving 5-FU, Camptosar, and oxaliplatin are described.

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Colorectal Cancer Screening: Clinical Applications. Journal of American Medical Association. 289(10): 1297-1302. March 2003.

Screening for colorectal cancer reduces mortality in individuals aged 50 years or older. A number of screening tests, including fecal occult blood tests, sigmoidoscopy, colonoscopy, and double-contrast barium enema are recommended by professional organizations for colorectal screening, yet the rates of colorectal cancer screening remain low. This article addresses questions regarding the quality of evidence for each screening test, whether screening for individuals at higher risk should be modified, the availability of tests, and cost-effectiveness. The authors note that many potential barriers to colorectal screening exist for the patient and for the physician. The authors propose strategies to increase compliance for colorectal cancer screening.

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Colorectal Cancer Screening: Scientific Review. Journal of American Medical Association. 289(10): 1288-1296. March 2003.

Screening for colorectal cancer clearly reduces colorectal cancer mortality, yet many eligible adults remain unscreened. Several screening tests are available, and various professional organizations have differing recommendations on which screening test to use. This article reports on a review that critically assessed the evidence for use of the available colorectal cancer screening tests, including fecal occult blood tests, sigmoidoscopy, colonoscopy, double-contrast barium enema, and newer tests, such as virtual colonoscopy and stool-based molecular screening. Results showed that randomized controlled trials have shown that fecal occult blood testing can reduce colorectal cancer incidence and mortality. Case-control studies have shown that sigmoidoscopy is associated with a reduction in mortality, and observational studies suggest colonoscopy is effective as well. Combining fecal occult blood testing and sigmoidoscopy may decrease mortality and can increase diagnostic yield. The authors conclude that at present, the available evidence does not currently support choosing one test over another. 1 figure. 3 tables. 105 references.

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Constipation. Bethesda, MD: National Digestive Diseases Information Clearinghouse. 2003. 8 p.

This fact sheet describes constipation, defined as small amounts of hard, dry bowel movements, usually fewer than three times a week. People who are constipated may find it difficult and painful to have a bowel movement. Other symptoms of constipation include feeling bloated, uncomfortable, and sluggish. Written in a question-and-answer format, the fact sheet covers a definition of constipation, the incidence of constipation, causes of the condition, the diagnostic tests to confirm problems of constipation, treatment options, and complications. Common causes of constipation are not enough fiber in the diet, not enough liquids, lack of exercise, medications, irritable bowel syndrome (IBS), lifestyle changes (pregnancy, older age, travel), abuse of laxatives, ignoring the urge to have a bowel movement, specific diseases such as stroke, problems with the colon and rectum, and problems with intestinal function (chronic idiopathic constipation). Diagnostic tests include colorectal transit study, anorectal function tests, barium enema x ray, and sigmoidoscopy or colonoscopy. A final section describes the goals and work of the National Digestive Diseases Information Clearinghouse. 1 figure.

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Facing Reality: The Facts About 'Virtual' Colonoscopy. Arlington, VA: American College of Gastroenterology. 2003. 2 p.

This brochure describes virtual colonoscopy, also called CT colonography, an x-ray test that looks for cancer and precancerous growths (polyps) in the colon (large bowel). Virtual colonoscopy is based on a CT scan of the abdomen and pelvis. During the examination, a tube is placed in the rectum and the colon is filled with air, followed by an abdominal-pelvic CT scan, which is then repeated with the patient lying in a different position. Because air is pumped into the colon, cramping may result. By contrast, in a conventional colonoscopy most patients receive sedative drugs that alleviate discomfort. Written in question and answer format, the brochure discusses how the test is performed, what the patient may experience, the expected results of the test, the role of conventional colonoscopy, and the guidelines of professional organizations regarding virtual colonoscopy. The brochure stresses that there has been no definitive demonstration to support either the overall effectiveness or cost-effectiveness of virtual colonoscopy. The brochure includes the contact information for the American College of Gastroenterology (www.acg.gi.org).

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Proctologic Examination. In: Stein, E. Anorectal and Colon Diseases: Textbook and Color Atlas of Proctology. New York, NY: Springer-Verlag. 2003. p. 19-67.

Positioning of the patient is of crucial importance for a comfortable and complete proctologic examination. This chapter on the proctologic examination is from a multidisciplinary reference book and atlas that covers all aspects of anorectal and colon disease (proctology). Topics in this chapter include examination positions, disinfection and sterilization, and methods of evaluation, including: history, physical examination, digital examination, speculum examination, proctoscopy and anoscopy, rigid rectosigmoidoscopy, flexible rectosigmoidoscopy, colonoscopy, imaging studies, sonography (ultrasound), anorectal manometry and electromyography, mycological and bacteriological evaluation, allergological testing methods, and cancer prevention. The chapter includes full-color and black-and-white illustrations and photographs, to support the heavily-visual aspects of proctology. Each section concludes with a list of references. 32 figures. 7 tables. 232 references.

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Rectal Malignancy. In: PDxMD. PDxMD Gastroenterology. St. Louis, MO: Elsevier Science. 2003. p. 553-589.

Rectal malignancy is colorectal cancer, the fourth most common cancer. The early clinical course is usually asymptomatic and diagnosis is possible primarily through colonoscopy with biopsy. Treatment goal is curative surgical resection, radiation therapy, and chemotherapy when indicated. The overall 5 year survival is 50 percent; prognosis depends on the staging of the cancer and how much the disease has spread. Evidence of bowel perforation or obstruction demands emergency surgical intervention. This chapter on rectal malignancy is from a book on gastroenterology that offers concise, action-oriented recommendations for primary care medicine. The chapter covers summary information and background on the condition, and comprehensive information on diagnosis, treatment, outcomes, and prevention. Specific topics covered include the ICD9 code, urgent action, synonyms, cardinal features, causes (etiology), epidemiology, differential diagnosis, signs and symptoms, associated disorders, investigation of the patient, appropriate referrals and consultations, diagnostic considerations, clinical tips, treatment options, patient management issues, drug therapies, prognosis, complications, and how to prevent recurrence. The information is provided in outline and bulleted format for ease of accessibility. The final section of the chapter offers resources, including related associations, key references, and the answers to frequently asked questions (FAQs). 23 references.

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Virtual Colonoscopy. Bethesda, MD: National Digestive Diseases Information Clearinghouse. 2003. 2 p.

Virtual colonoscopy (VC) uses x rays and computers to produce two- and three-dimensional images of the colon (large intestine). The procedure is used to diagnose colon and bowel disease, including polyps, diverticulosis, and cancer. VC can be performed with computed tomography (CT) or with magnetic resonance imaging (MRI) scans. This fact sheet describes virtual colonoscopy, including the preprocedure activities, and the advantages and disadvantages of VC. One sidebar briefly describes conventional colonoscopy. A final section describes the goals and work of the National Digestive Diseases Information Clearinghouse.

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Acute Lower Gastrointestinal Bleeding. In: Edmundowicz, S.A., ed. 20 Common Problems in Gastroenterology. New York, NY: McGraw-Hill, Inc. 2002. p. 123-136.

The typical presentation of lower gastrointestinal (GI) bleeding is the passage of blood in the stool. Approximately 80 percent of patients with GI bleeding will pass blood in some form through the rectum. The lower GI tract accounts for up to one-third of all cases of GI bleeding; the upper tract accounts for the remainder. This chapter on acute lower GI bleeding (LGIB) is from a book that focuses on the most common gastroenterological problems encountered in a primary practice setting. The chapter is organized to support rapid access to the information necessary to evaluate and treat most patients with this problems. Topics include the prevalence of LGIB; its definition and typical presentation; key points in the patient history, including the anatomic level of bleeding, the quantity of blood lost, the etiology of bleeding, and precipitating factors; the physical examination and ancillary tests, including laboratory studies, sigmoidoscopy and anoscopy, colonoscopy, a tagged red blood cell scan, angiography, esophagogastroduodenoscopy, small bowel enteroscopy, and barium studies; etiology (cause), including diverticulosis, angiodysplasia, neoplasia (including cancer), medications, and other causes; treatment options, including the initial resuscitation, specific treatment, endoscopic therapy, angiotherapy, and surgery; patient education issues; common errors in diagnosis and treatment; controversies; and emerging concepts. The chapter includes an outline for quick reference, the text itself, a diagnostic and treatment algorithm, and selected references. 2 figures. 2 tables. 27 references.

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Clinical Diagnosis of IBS. In: Camilleri, M. and Spiller, R.C., eds. Irritable Bowel Syndrome: Diagnosis and Treatment. Orlando, FL: W.B. Saunders Company. 2002. p. 1-10.

This chapter on the clinical diagnosis of irritable bowel syndrome (IBS) is from a book that provides an up-to-date overview of the care of patients with IBS. IBS is a condition characterized by abdominal pain and an erratic bowel disturbance (diarrhea, constipation, or both) that can interrupt the patient's life and persist indefinitely. The author of this chapter stresses that the high prevalence of IBS in the practices of both primary care practitioners and gastroenterologists underscores the importance of a precise diagnosis of the condition. When IBS is confidently diagnosed, a new cause of symptoms is rarely discovered during long-term followup. Practitioners can diagnose IBS in most patients by recognizing certain typical symptoms, conducting an examination, and performing individualized tests. Tests discussed include blood tests, stool tests, sigmoidoscopy or colonoscopy, barium enema, psychological tests, and other miscellaneous tests. Postprandial (after a meal) worsening of symptoms is frequent in IBS. Rectal bleeding always requires investigation. Physical examination (including rectal) is mandatory in the diagnostic process. The author cautions that psychological problems often coexist with IBS. The chapter includes full-color illustrations, highlighted sections of key points, and a list of references. 1 figure. 2 tables. 23 references.

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Colonoscopy. Ostomy Quarterly. 40(3): 58-60. Spring 2002.

This newsletter article describes colonoscopy, a common and relatively routine procedure that allows the physician to visualize the colon and rectal lining by looking through a long flexible scope or using a video monitor attached to the scope. The author covers history, indications, patient preparation, sedation, the procedure itself, and possible complications. Colonoscopy is used to diagnose and monitor many colorectal diseases and to screen for colorectal cancer (particularly in patients over age 50). Major complications can include bleeding or perforation; minor complications include the effects of bowel preparation, low blood pressure, low oxygenation, bacteria in the bloodstream, bloating, and abdominal cramping. The article concludes with a list of five web sites for additional information. 8 figures. 10 references.

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Colorectal Cancer Screening Saves Lives. Baltimore, MD: Centers for Medicare and Medicaid Services. 2002. 2 p.

This brochure offers basic information about colorectal cancer and the importance of screening for this condition. The author emphasizes that if everyone aged 50 years or older had regular screening tests, at least one-third of the deaths from this type of cancer could be avoided. The brochure discusses the risk factors for this type of cancer, which include colorectal polyps or inflammatory bowel disease (IBD); how screening for the polyps that can develop into cancer can improve diagnostic and treatment rates; symptoms that appear in some people with colon cancer; the different types of screening tests, including the fecal occult blood test or stool test, flexible sigmoidoscopy, colonoscopy, and double contrast barium enema; and concerns about health insurance of Medicare paying for screening tests. Readers are referred to the National Cancer Institute’s information service (1-800-4-CANCER or www.cdc.gov/cancer/ScreenforLife). The contact number for Medicare is also provided (1-800-633-4227). 2 figures.

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Colorectal Cancer Screening. In: Edmundowicz, S.A., ed. 20 Common Problems in Gastroenterology. New York, NY: McGraw-Hill, Inc. 2002. p. 189-202.

Colorectal cancer (CRC) is one of the most common malignancies in the developed world and the second leading cause of cancer-related death in the United States. Appropriate disease screening has the potential to prevent death from CRC. This chapter on colorectal cancer screening is from a book that focuses on the most common gastroenterological problems encountered in a primary practice setting. The chapter is organized to support rapid access to the information necessary to evaluate and treat most patients with this problems. Topics include the epidemiology of CRC; typical clinical presentations of CRC; factors that modify CRC risk; risk assessment and screening based on risk assessment; available screening tests, including fecal occult (hidden) blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema; the cost effectiveness of screening; compliance with CRC screening; interventions to encourage CRC screen; two common problems in CRC screening; and patient follow up after resected polyps and colon cancer. The chapter includes an outline for quick reference, the text itself, a diagnostic and treatment algorithm, and selected references. The authors conclude that growing public awareness of CRC and its impact, increasing evidence that CRC screening is a cost-effective method to decrease mortality, wide promulgation of screening recommendations, and greater willingness by insurers to reimburse costs of CRC screening may improve CRC screening rates. 1 figure. 5 tables. 16 references.

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Colorectal Cancer Screening: Modalities, Guidelines, and a Look at the Future. JAAPA. Journal of the American Academy of Physician Assistants. 15(6): 22-26, 28. June 2002.

Clinicians today have an array of screening guidelines and tools to choose from for early detection of colorectal cancer. This continuing education article for physician assistants brings readers up to date on the screening and diagnosis of colorectal cancer (CRC). The authors discuss the risk factors for CRC, the classification system that is used to determine prognosis, the presence and meaning of polyps, the most common presenting signs and symptoms of CRC, the advantages and disadvantages of available screening modalities, when to advise more invasive testing, and specific tests, including digital rectal examination (DRE), fecal occult (hidden) blood test, sigmoidoscopy, barium enema, and colonoscopy. One sidebar notes published guidelines and recommendations for CRC screening, with the web site address of the professional organization that published them; another sidebar offers a brief illustrative case report. 16 references.

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Colorectal Cancer: Basic Facts for Screening. Baltimore, MD: Centers for Medicare and Medicaid Services. 2002. 2 p.

This fact sheet offers basic information about colorectal cancer and the importance of screening for this condition. The author emphasizes that if everyone aged 50 years or older had regular screening tests, at least one-third of the deaths from this type of cancer could be avoided. The fact sheet discusses the epidemiology of colorectal cancer; the risk factors for this type of cancer, which include inflammatory bowel disease (IBD); how screening for the polyps that can develop into cancer can improve diagnostic and treatment rates; symptoms that appear in some people with colon cancer; the different types of screening tests, including the fecal occult blood test or stool test, flexible sigmoidoscopy, colonoscopy, and double contrast barium enema; and concerns about health insurance of Medicare paying for screening tests. Readers are referred to the National Cancer Institute’s information service (1-800-4-CANCER or www.cdc.gov/cancer/ScreenforLife). The contact number for Medicare is also provided (1-800-633-4227). 2 figures.

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Colorectal Cancer: Facts for People with Medicare. Baltimore, MD: Centers for Medicare and Medicaid Services. 2 p. 2002.

This fact sheet offers basic information about colorectal cancer and the importance of screening for this condition. Written for people on Medicare, the fact sheet emphasizes that if everyone aged 50 years or older had regular screening tests, at least one-third of the deaths from this type of cancer could be avoided. The fact sheet discusses the epidemiology of colorectal cancer; the risk factors for this type of cancer, which include inflammatory bowel disease (IBD); how screening for the polyps that can develop into cancer can improve diagnostic and treatment rates; symptoms that appear in some people with colon cancer; and the different types of screening tests that may be used, including the fecal occult blood test or stool test, flexible sigmoidoscopy, colonoscopy, and double contrast barium enema. Readers are referred to the National Cancer Institute’s information service (1-800-4-CANCER or www.cdc.gov/cancer/ScreenforLife). The contact number for Medicare is also provided (1-800-633-4227). 2 figures.

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Colorectal Cancer: Facts on Screening. Baltimore, MD: Centers for Medicare and Medicaid Services. 2002. 2 p.

This fact sheet offers basic information about colorectal cancer and the importance of screening for this condition. The author emphasizes that if everyone aged 50 years or older had regular screening tests, at least one-third of the deaths from this type of cancer could be avoided. The fact sheet discusses the epidemiology of colorectal cancer; the risk factors for this type of cancer, which include inflammatory bowel disease (IBD); how screening for the polyps that can develop into cancer can improve diagnostic and treatment rates; symptoms that appear in some people with colon cancer; the different types of screening tests, including the fecal occult blood test or stool test, flexible sigmoidoscopy, colonoscopy, and double contrast barium enema; and concerns about health insurance of Medicare paying for screening tests. The second page of the fact sheet offers a detailed chart of the screening tests, their recommended frequency, a cost estimate, the purpose, important considerations (what the patient can expect to feel during or after the exam), and whether the test is covered by insurance or Medicare. Readers are referred to the National Cancer Institute’s information service (1-800-4-CANCER or www.cdc.gov/cancer/ScreenforLife). The contact number for Medicare is also provided (1-800-633-4227). 1 figure. 1 table.

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Colorectal Cancer: Racial and Ethnic Differences. Practical Gastroenterology. 26(7): 27-28, 31-32, 34, 39-40. July 2002.

Colorectal cancer was the third most common cancer and the second most common cause of cancer related death in the United States for the year 2000. It is estimated that 138,900 new cases were diagnosed in 2001. This article reviews the racial and ethnic differences in colorectal cancer. Screening for colorectal cancer in average risk patients (asymptomatic patients over the age of 50 with no personal or high risk family history) consists of annual fecal occult blood testing combined with a flexible sigmoidoscopy every five years or total colonic examination via a colonoscopy every ten years or an air-contrast barium enema every five years. Studies have shown that there are ethnic and racial differences in the incidence, location, and mortality associated with colorectal cancer, with the highest incidence and mortality occurring in African-Americans. There have been many theories as to why this discrepancy exists, including genetic factors, diet, and access to health care. Ultimately, the key to decreasing the mortality related to colorectal cancer is to increase patient awareness of their individual risk for colon cancer and the primary preventive measures that will decrease that risk. Health care providers need to be able to categorize their patients into average or high risk groups, recommend the appropriate screening procedure, and encourage patients to follow through with the recommendations. 3 figures. 2 tables. 40 references.

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Complications of Gastrointestinal Endoscopy. In: Feldman, M.; Friedman, L.S.; Sleisenger, M.H. Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/Management. 7th ed. [2-volume set]. St. Louis, MO: Saunders. 2002. p. 539-548.

Complications of gastrointestinal (GI) endoscopy are remarkably uncommon, in spite of the striking increase in the number and diversity of procedures performed since the 1970s. This chapter on complications of GI endoscopy is from a comprehensive and authoritative textbook that covers disorders of the gastrointestinal tract, biliary tree, pancreas, and liver, as well as the related topics of nutrition and peritoneal disorders. Topics include general complications, such as adverse effects of medications, cardiopulmonary problems, infectious complications, electrosurgical hazards, and abdominal distension; complications of upper endoscopy, including perforation, bleeding, and miscellaneous complications; and complications of sigmoidoscopy and colonoscopy, including perforation, bleeding, and miscellaneous complications. The authors stress that adherence to all safety issues, particularly sedation and monitoring, and the standardization of endoscopic training and practice may lower the complication rate of endoscopy and improve the already good safety record. The chapter includes a mini-outline with page citations, full-color illustrations, and extensive references. 1 figure. 6 tables. 124 references.

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Crohn's Disease: Rational Management. Consultant. 42(2): 185-197. February 2002.

Crohn's disease can involve any part of the digestive tract: it can manifest as inflammatory (diarrhea, abdominal pain, and fever), penetrating (abscess or fistula), or structuring (recurrent bowel obstruction) disease. This article discusses the findings that govern the choice of therapy for Crohn's disease and the pros can cons of the various management options. The author notes that treatment is based on the location and activity of the disease. Mesalamine is recommended to induce and maintain remission in patients with mild to moderate, nonpenetrating, nonstricturing disease. Antibiotics may be used as an alternative or adjunct to mesalamine; ciprofloxacin and metronidazole are helpful in fistulizing Crohn's disease. For patients with moderate to severe disease, corticosteroids are recommended to induce remission; infliximab is an alternative for those with severe or refractory disease. Remission is then maintained with immunosuppressive therapy, not with corticosteroids. Fistulas (abnormal openings between two organs or leading from an internal organ to the surface of the body) are difficult to treat but may respond to antibiotics or azathioprine; however, closure rates are low. Infliximab produces higher closer rates; azathioprine or 6-mercaptopurine is used to maintain remission in this setting. Surgery is an option for patients with refractory disease, however postoperative medical therapy is needed to maintain remission. Smoking exacerbates Crohn's disease and is associated with a poor clinical course; patients should be encouraged to quit. Patients with Crohn's disease are at increased risk for gastrointestinal cancer. In those with long standing colitis or perianal disease of 10 years' duration, colonoscopy with biopsy should be performed every 1 to 2 years. 5 figures. 1 table. 40 references.

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Diagnostic Tests. Bethesda, MD: National Diabetes Information Clearinghouse (NDDIC), National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health. February 2002. [8 p.].

This packet includes seven patient education fact sheets on diagnostic tests for gastrointestinal (GI) disorders: colonoscopy, sigmoidoscopy, liver biopsy, upper endoscopy, endoscopic retrograde cholangiopancreatography (ERCP), lower GI series, and upper GI series. For each test, fact sheets note what the patient can expect during the procedure, the preparation that the patient must undergo, and the information that might be obtained from that test. Each fact sheet includes a simple line drawing of the GI tract, with the portion addressed by each test shaded in gray. Colonoscopy lets the physician look inside the entire large intestine, from the lowest part (the rectum) all the way up through the colon to the lower end of the small intestine. Sigmoidoscopy enables the physician to look at the inside of the large intestine from the rectum through the last part of the colon, called the sigmoid colon. Colonoscopy and sigmoidoscopy enable the physician to see inflamed tissue, abnormal growths, ulcers, bleeding, and muscle spasms. Upper endoscopy enables the physician to look inside the esophagus, stomach, and duodenum (first part of the small intestine). The physician can see abnormalities, like ulcers, through the endoscope that do not show up well on x rays; the physician can also insert instruments into the scope to remove samples of tissue (biopsy) for further tests. ERCP combines the use of x rays and an endoscope to enable the physician to see the inside of the stomach, duodenum, and ducts in the biliary tree and pancreas; ERCP is used to discover the reason for jaundice, upper abdominal pain, and unexplained weight loss. Upper endoscopy (for the esophagus, stomach and duodenum) might be used to diagnose swallowing difficulties, nausea, vomiting, reflux, bleeding, indigestion, abdominal pain, or chest pain. The upper and lower GI series use x rays to diagnose problems in the large intestine, colon and rectum (lower GI) and in the esophagus, stomach, and duodenum (upper GI). Liver biopsy is considered inor surgery and includes the removal of a small piece of tissue from the liver, which is then examined for signs of damage or disease. These fact sheets are designed to be photocopy masters; health care providers can make copies and distribute them to their patients. The packet also includes a brief description of the activities of the National Digestive Diseases Information Clearinghouse (NDDIC).

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Diverticular Hemorrhage: Pathogenesis, Diagnosis and Management. Practical Gastroenterology. 26(1): 13-14, 19-20, 22. January 2002.

Colonic diverticular bleeding is common cause of lower gastrointestinal tract hemorrhage. This article discusses the pathogenesis (development), diagnosis, and management of diverticular hemorrhage. Diagnostic techniques involved in determining the extent and location of diverticular bleeding include scintigraphy, angiography, and colonoscopy. Therapeutic radiographic options in controlling diverticular bleeding involve the infusion of vasopressin or selective embolization. Recently, the role of colonoscopy has expanded to allow endoscopic hemostasis of bleeding diverticuli. Current options involve electrocoagulation, injection therapy, or endoscopic hemoclipping. Surgery may be required in patients who fail attempts at hemostasis with medical, angiographic, or endoscopic therapy. 1 figure. 35 references.

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Handbook of Colon and Rectal Surgery. Philadelphia, PA: Lippincott Williams and Wilkins. 2002. 931 p.

This handbook provides a more portable version of the larger textbook with the same title: Colon and Rectal Surgery, 4th Edition. The coverage addresses the entire range of diseases affecting the colon, rectum, and anus. A stepwise approach to treatment guides physicians from evaluation to follow up with incisive coverage of symptoms, testing and diagnosis, preparation, medical and surgical management, and postoperative care. Thirty-three chapters cover anatomy and embryology of the anus, rectum, and colon; physiology of the colon; diet and drugs in colorectal surgery; evaluation and diagnostic techniques; flexible sigmoidoscopy and colonoscopy; setting up a colorectal physiology laboratory; analgesia (pain killing) in colon and rectal surgery; hemorrhoids; anal fissure; anorectal abscess; anal fistula; rectovaginal and rectourethral fistulas; anal incontinence; colorectal trauma; management of foreign bodies; disorders of defecation; rectal prolapse, solitary rectal ulcer, syndrome of the descending perineum, and rectocele; pediatric surgical problems; cutaneous conditions; colorectal manifestations of acquired immunodeficiency syndrome (HIV); polypoid diseases; carcinoma (cancer) of the colon; carcinoma of the rectum; malignant tumors of the anal canal; less common tumors and tumorlike lesions of the colon, rectum, and anus; diverticular disease; laparoscopic-assisted colon and rectal surgery; vascular diseases; ulcerative colitis; Crohn's disease and indeterminate colitis; intestinal stomas; enterostomal therapy; and miscellaneous colitides. The handbook includes the same illustrations as the larger text. A subject index concludes the volume.

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Low-Salt Bowel Cleansing Preparation (LoSo Prep) as Preparation for Colonoscopy: A Pilot Study. Alimentary Pharmacology and Therapeutics. 16(7):1327-1331. July 2002.

Currently available colon cleansing preparations are often poorly tolerated. This article reports on a study undertaken to evaluate the efficacy of a low-volume, low-salt preparation for colonoscopy. This was a pilot study in patients scheduled for colonoscopy. The preparation consisted of 34 grams of magnesium citrate and four bisacodyl tablets the day before the procedure, and one bisacodyl suppository on the morning of the procedure. The study included 20 patients (age range 49 to 81 years, all male). There were no significant side effects associated with the preparation. All rated the taste as 'tolerable or better.' The examination was considered to be adequate, with no limitations, in 17 patients (85 percent) and was scored as good to excellent (no solid stool) in 11 patients (55 percent), acceptable (small amounts of solid stool) in six patients (30 percent) and poor in three patients (15 percent). Importantly, two of the failures then received a standard polyethylene glycol preparation and again failed to show adequate colon preparation. The authors conclude that the low-salt colon cleansing preparation was an effective alternative preparation for colonoscopy. 2 tables. 34 references.

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Polypoid Diseases. In: Corman, M.L.; Allison, S.I.; Kuehne, J.P. Handbook of Colon and Rectal Surgery. Philadelphia, PA: Lippincott Williams and Wilkins. 2002. p.381-422.

This chapter on polypoid diseases is from a handbook that addresses the entire range of diseases affecting the colon, rectum, and anus. The authors discuss a number of benign polypoid conditions that are commonly observed in the practice of general and colon and rectal surgeons. A polyp is a well-circumscribed projection above the surface epithelium. Three types of polyps are discussed in this chapter: hyperplastic (metaplastic), hamartomatous, and adenomatous. For each type, the authors review clinical appearance, symptoms, histology, diagnosis and management. The chapter also covers genetics, molecular mechanisms of carcinogenesis (development of cancer), colonoscopy and polypectomy, the management of benign (non-cancerous) rectal tumors, and polyp follow-up.

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Q and A: About Crohn's Disease. New York, NY: Crohn's and Colitis Foundation of America. 2002. 11 p.

This brochure answers commonly asked questions about Crohn's disease, a serious inflammatory disease of the gastrointestinal (GI) tract. Crohn's disease usually causes diarrhea, crampy abdominal pain, often fever, and at times rectal bleeding. In Crohn's disease (compared to the other inflammatory bowel disease, ulcerative colitis), all layers of the intestine are involved, and there can be normal healthy bowel in between patches of diseased bowel. The diagnosis of Crohn's disease is suggested by the patient history (signs and symptoms); additional testing that may be used include barium x-rays of the upper and lower GI tract, flexible sigmoidoscopy, and sometimes colonoscopy. Laboratory tests are also helpful and include evaluation of the blood and stool. The goals of medical treatment are to suppress the inflammatory response to permit healing of tissue, and to relieve the symptoms of fever, diarrhea, and abdominal pain. Several groups of drugs are used: aminosalicylates, corticosteroids, immune modifiers, and antibiotics. Surgery becomes necessary in Crohn's disease when medication can no longer control the symptoms, or when there is an intestinal obstruction or other complication. Good nutrition is essential in this disease, which is characterized by reduced appetite, poor absorption, and diarrhea, all of which rob the body of fluids, nutrients, vitamins, and minerals. Most people with the illness continue to lead useful and productive lives, even though they may be hospitalized from time to time, and may need to take medications. The brochure concludes with a brief description of current research efforts and a detailed glossary of related terms. 1 figure.

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Recent Developments in Colorectal Cancer Screening and Prevention. American Family Physician. 66(2): 297-302. July 15, 2002.

Colorectal cancer is a significant contributor to morbidity (complications and related illness) and mortality (death) in the United States. Studies published in the early 1990s, showing that screening for colorectal cancer can reduce colorectal cancer-related mortality, led many organizations to recommend screening in asymptomatic, adults of average-risk older than 50 years. Since then, however, national screening rates remain low. Several important studies published over the past four years have refined the understanding of existing screening tools and explored novel means of screening and prevention. This article reviews the most important new develops. Additional trial results support the effectiveness of fecal occult (hidden) blood testing in reducing the incidence of, and mortality from, colorectal cancer. New studies document the sensitivity of fecal occult blood testing, sigmoidoscopy, and double-contrast barium enema compared with colonoscopy. Cost-effectiveness models show that screening by any of several methods is cost-effective compared to no screening. Randomized trials show that calcium is effective but fiber is not effective in preventing reoccurrence of adenomatous polyps. Preliminary data suggest that nonsteroidal antiinflammatory drugs (NSAIDs) may prevent adenomatous polyps and that DNA stool tests and virtual colonoscopy may show promise as screening tools. This new information provides further support for efforts to increase the use of colorectal cancer screening and prevention services in adults older than 50 years. 1 table. 26 references.

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Results of Screening Colonoscopy Among Persons 40 to 49 Years of Age. New England Journal of Medicine. NEJM. 346(23): 1781-1785. June 6, 2002.

The prevalence of colorectal lesions in persons 40 to 49 years of age, as identified on colonoscopy, has not been determined. This article reports on a study that reviewed the procedure and pathology reports for 906 consecutive persons 40 to 49 years of age who voluntarily participated in an employer-based screening-colonoscopy program. Among those who underwent colonoscopic screening, 78.9 percent had no detected lesions, 10.0 percent had hyperplastic polyps, 8.7 percent had tubular adenomas, and 3.5 percent had advanced neoplasms, none of which were cancerous. Eighteen of 33 advanced neoplasms (55 percent) were located distally and were potentially within reach of a sigmoidoscope. If these results are applicable to the general population, at least 250 percents, and perhaps 1000 or more, would need to be screened to detect one cancer in this age group. The authors conclude that colonoscopic detection of colorectal cancer is uncommon in asymptomatic persons 40 to 49 years of age. The noncancerous lesions are equally distributed proximally and distally. The low yield of screening colonoscopy in this age group is consistent with current recommendations about the age at which to begin screening in persons at average risk. 3 tables. 23 references.

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Virtual Colonoscopy Can it Save Lives?. Digestive Health and Nutrition. p. 24. July-August 2002.

This brief article describes a new technique called virtual colonoscopy which involves a computerized scan of the colon. Unlike conventional colonoscopy, air is instilled via a tube. The procedure is less invasive than conventional colonoscopy and requires no sedation. The patient lies on a table while a CT scanner passes over the body, a process that takes about 30 seconds. In the resulting image, the walls of the colon are color coded as to thickness so that growths stand out in a brighter color. However, there are still a number of drawbacks to this procedure that have prevented its introduction to the general public thus far. These drawbacks include the inability to detect all cancerous or precancerous growths, the high incidence of false positive tests, and the need for conventional colonoscopy for patients in whom the virtual colonoscopy demonstrates a problem. The author concludes that eventually virtual colonoscopy may prove to be a cost effective and accurate screening tool for large numbers of patients without symptoms or as a surveillance option for patients with previous adenomas. The article concludes with two web sites that readers can consult for additional information. 1 figure.

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Coexistence of Inflammatory Bowel Disease and Irritable Bowel Syndrome. In: Bayless, T.M. and Hanauer, S.B. Advanced Therapy of Inflammatory Bowel Disease. Hamilton, Ontario: B.C. Decker Inc. 2001. p. 87-90.

This chapter on the coexistence of irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD) is from the second edition of a book devoted to the details of medical, surgical, and supportive management of patients with Crohn's disease (CD) and ulcerative colitis (UC), together known as IBD. Irritable bowel syndrome (IBS) is a chronic abdominal symptom complex for which no structural underlying abnormality can be demonstrated. It is a common disorder that affects all age groups with an increased frequency in females. Few if any of the clinical features of IBS can confidently distinguish it from IBD. The multiplicity and chronicity of symptoms and their relationship to altered bowel habit can be helpful hints. A psychoneurotic disposition, evidence of anxiety or depression, and a tendency to somatize symptoms referable not only to the gut but other organ systems are pointers in favor of IBS. However, when IBS occurs in a patient with established IBD, this can be a difficult diagnosis. Since IBS is a very common disorder, it is not unexpected to find patients with both IBS and IBD. The author considers whether there is a special relationship between these two disorders. There is good scientific evidence that inflammation of the gut alters its physiologic performance, and this may persist after resolution of the inflammation. The author concludes that IBS occurs with greater frequency in certain patients in remission from IBD, and this is more easily seen in UC than in CD. Symptoms of IBS in the context of IBD are no different from those typical for that condition. An awareness of this relationship is of key importance in making a confident diagnosis, as is a good knowledge of the patients' history and the characteristic behavior of their IBD. In some complicated IBD patients, extensive investigation by colonoscopy with or without small bowel radiography may be required. For most patients, treatment of IBS should follow the usual guidelines with notable exceptions in the case of patients with histories of obstruction. 1 figure. 17 references.

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Colon Cleansing Preparation for Gastrointestinal Procedures. Alimentary Pharmacology and Therapeutics. 15(5): 605-611. May 2001.

This article reviews adequate colon cleansing, an essential procedure before reliable diagnostic and surgical colon procedures. Accuracy and safety depend on good preparation. Patient compliance to the colon cleansing procedure is enhanced by simplicity and by well tolerated methods. Several methods are available. Diet and cathartic regimens use clear liquids or diets designed to leave a minimal colonic residue. Laxatives, cathartics, and enemas are employed. Gut lavage solutions are osmotically balanced electrolyte lavage products. Oral sodium phosphate solutions and tablets are available and are attractive because of good efficacy with a small volume of administration. For colonoscopy and colon surgery preparation, these methods have been proven safe and effective. For barium enema X ray, lavage requires an adjunctive agent to enhance barium coating. Overall, all regimens are well tolerated. Efficacy is similar and adequate for most preparations, so choice is based on patient acceptance, cost, and underlying medical conditions. The authors conclude that there has been improvement over the restrictive clear liquid diet, and cathartic and enema methods, but the search for an ideal cleansing method continues. 2 tables. 82 references.

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Colonoscopy and Enteroscopy. Gastrointestinal Endoscopy Clinics of North America. 11(4): 603-639. October 2001.

Pediatric colonoscopy and enteroscopy differ significantly from their adult parallels in nearly every aspect, including patient and parent management and preparation, selection criteria for sedation and general anesthetic, bowel preparation, expected diagnoses, instrument selection, imperative for terminal ileal intubation, and requirement for biopsies from macroscopically normal mucosa. This article focuses on the technique and clinical application of ileocolonoscopy and enteroscopy in childhood. The author discusses the impact of endoscopic investigations and therapies on specific disease processes. The article illustrates the basic technique of colonoscopy in children and the author discusses advanced techniques, such as endosonography, cecostomy, and therapy of lower gastrointestinal (GI) bleeding. The advantages and disadvantages of other noninvasive investigations are compared with colonoscopy and generally are held to be second best. The article highlights those differences and provides a workable guide for those involved or training in the discipline of pediatric colonoscopy and enteroscopy. 14 figures. 3 tables. 184 references.

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Colonoscopy and Sigmoidoscopy: What to Expect. Participate. 9(1): 5-6. Spring 2000.

Colonoscopy is an examination in which a flexible tube like device with a light on the end is inserted through the anus into the intestine. An image of the entire large bowel, or colon, is relayed through the instrument onto a video screen. Sigmoidoscopy is a similar test but only the left side of the colon is visualized. This fact sheet explains what patients can expect when they undergo the diagnostic tests of colonoscopy or sigmoidoscopy (the shorter version). The colonoscopy is performed in a licensed facility with staff specially trained for these tests; sigmoidoscopy may be done in a doctor's office. Colonoscopy is commonly indicated for the diagnosis of diseases that cause acute and chronic diarrhea, intestinal bleeding, and for the detection and management of colon polyps and cancer. For a sigmoidoscopy, preparation entails taking a phosphate enema (Fleet) about 2 hours before the test. For a colonoscopy, it is necessary that the whole bowel be clean. The patient can take only fluids by mouth after noon the day before the test. The preparation includes ingestion of oral laxatives, which cause a profuse diarrhea; these laxatives may be unpleasant, but they are safe when taken with clear fluids, and necessary if the examination is to be optimal. The patient must sign a consent form prior to the procedure. For a sigmoidoscopy, sedation is seldom given; colonoscopy requires sedation, which lessens the anxiety associated with the test and when given with a pain killer, it reduces the pain. Normally, the patient will be on their left side on the examining table and can watch the examination on a video screen if they wish. The nurse will coach the patient on how to breath (regular breathing is relaxing, minimizes the pain, and maintains good oxygen saturation in the blood). If the patient has been sedated, or if the laboratory results of a biopsy are awaited, it may be necessary to speak with the doctor at a later time or schedule a visit for a full explanation of the test results. 1 figure.

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Colonoscopy: Diagnosing Problems of the Lower Digestive Tract. San Bruno, CA: StayWell Company. 2001. 15 p.

This brochure describes colonoscopy, a nonsurgical procedure that allows the health care provider to see directly inside the patient's lower digestive tract (colon and rectum). The brochure describes the use of the colonoscope, an instrument consisting of a thin, flexible tube that is moved through the colon. The tube has several openings through which instruments can be passed (for taking biopsies). The tube also has fiber optics to beam light inside the colon and a camera to pass images to the health care provider's screen. Colonoscopy is used to diagnose colon abnormalities, such as bleeding or an area of inflammation, and to prescribe the best treatment for them. Colonoscopy is also used to screen for colon cancer. Colonoscopy can detect problems in their earliest, most treatable stages. The brochure explains the preprocedure care that patients should follow, including a special diet and the use of colon preparations such as laxatives. The brochure outlines what the patient can expect during the test itself and during recovery. Within a few hours after patients return home, most of them are able to eat normally and resume most normal activities, unless otherwise directed. Results of the colonoscopy are usually given before the patient leaves for home, or within a few days. The brochure is illustrated with black and white line drawings illustrating patients and the colonoscopy procedure, and full color illustrations of the anatomy of the colon and rectum. 9 figures.

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Compliance, Adherence, and Hope (editorial). Journal of Clinical Gastroenterology. 32(1): 5. January 2001.

This brief editorial comments on patient compliance (taking medications as ordered) with medications. The author notes that an accompanying article found that patients with inflammatory bowel disease (IBD) who have emotional problems are poorly compliant in taking medications. The editorial suggests that the word compliance should be replaced by the word adherence. Compliance implies following orders or suggestions, whereas adherence gives the impression that the patient, who may be following the doctor's orders, has decided to do so out of free will. That adherence goes up the longer the patient is sick (in the accompanying study at least) could mean that patients who have not taken their medication learn to become more faithful when they feel no better or suffer recurrent flareups that respond to medication the doctor ordered. The editorial author questions some of the conclusions of the study, but encourages researchers to continue to explore these questions of patient adherence and psychosocial aspects of IBD. The author also concludes that the doctors who listen to their patients, who give them time enough to discharge any emotional conflicts, and who give them hope may help those patients more than the doctors who, behind the fortress of a desk, write out another prescription or an order for another colonoscopy.

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Current Approach to the Diagnosis of Irritable Bowel Syndrome. Participate. 10(1): 1-3. Spring 2001.

This newsletter article reviews the current approach to the diagnosis of irritable bowel syndrome (IBS). Physicians now rely less on extensive testing to exclude other disorders and instead can diagnose IBS in most patients by recognizing certain symptom details, performing a physical examination, and undertaking limited diagnostic testing. Extensive testing is usually reserved for special situations. Various symptom criteria have been proposed; the Rome II criteria are presently in use. Rome II criteria for IBS are symptoms at least 12 weeks or more in duration, which need not be consecutive, in the preceding 12 months of abdominal discomfort or pain that has two out of three features: relieved with defecation, onset associated with a change in frequency of stool, or onset associated with a change in form (appearance) of stool. Other symptoms that are not essential but that support the diagnosis of IBS include abnormal stool frequency (greater than 3 bowel movements per day or less than 3 bowel movements per week), abnormal stool form, abnormal stool passage, passage of mucus, or bloating or feeling of abdominal distension. The discomfort or pain and abnormal bowel habit of IBS typically fluctuate in severity, may be associated with stressful life events, and occur over a long time period. Diagnostic tests can include blood tests, stool tests, sigmoidoscopy or colonoscopy, barium enema, and psychological tests. Diagnosis by careful review of the patient's symptoms, a physical examination, and selected diagnostic procedures is quite secure, as followup for many years of confidently diagnosed patients seldom disclose another cause for their symptoms. With an unequivocal diagnosis, both patient and physician can work together on the most effective management.

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Diarrhea-Constipation-Pain: When is It Irritable Bowel Syndrome?. Consultant. 41(8): 1089-1091, 1095-1096. July 2001.

Central to the diagnosis of irritable bowel syndrome (IBS) are the symptoms of abdominal pain and disordered defecation of at least 3 months' duration. This article helps physicians determine when the symptoms of diarrhea, or constipation, or pain are indeed due to IBS. Either diarrhea or constipation can predominate, although the defecation pattern may vary from day to day in some patients. In the absence of evidence of more serious disease, diagnosis is based largely on the results of a thorough history and examination. For most patients, general screening tests include a complete blood cell count, erythrocyte sedimentation rate, serum chemistry panel, stool guaiac test, and stool examination for ova (eggs) and parasites. For patients older than 50 years, flexible sigmoidoscopy, colonoscopy, or barium enema may be indicated. Management of IBS consists of patient education and reassurance; dietary modification, including increased fiber intake in patients with constipation; and in some cases, judicious use of medications or psychological interventions. 2 tables. 35 references.

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Diverticulosis and Diverticulitis: Understanding and Managing Two Common Colon Problems. [Diverticulosis y Diverticulitis: Como Entender y Controlar Problemas Comunes del Colon]. San Bruno, CA: StayWell Company. 2001. 7 p.

This patient education brochure describes two common colon problems: diverticulosis and diverticulitis. Written in nontechnical language, the brochure defines diverticulosis as small pouches in the colon wall; diverticulitis is a more serious problem that occurs when these pouches become infected or inflamed. Although aging may contribute to colon problems, food choices are the primary concern for the health of one's colon. A low fiber, high fat diet can lead to an unhealthy colon. The brochure describes how pressure can cause pouches in the colon and then the conditions that can lead to diverticulitis. Symptoms often include pain, fever, chills, cramping, bloating, constipation, or diarrhea. Diet changes or medications may be enough to bring relief; in severe cases, surgery may be needed. The diagnosis will include the patient's history, a medical exam, and diagnostic tests, including barium enema, sigmoidoscopy, and colonoscopy. The two keys to controlling diverticulosis are dietary fiber (roughage) and liquid. Fiber absorbs water as it travels through the colon, helping the stool stay soft and move smoothly with less pressure. Eating more high fiber foods and drinking more liquids can often keep diverticulosis in check. If diverticulitis symptoms are mild, the treatment may begin with a temporary liquid diet and oral antibiotics. If the diverticulitis is severe, the patient may need bed rest, hospitalization, and intravenous (IV) antibiotics and nutrients. Surgery may be indicated in some cases and the brochure outlines the typical colon surgery resection that is used. The brochure concludes by reminding readers of the importance of dietary fiber and lists common foods that are high in fiber. The brochure is illustrated with full color line drawings and is available in English or Spanish. 19 figures.

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Dysplasia Surveillance in Crohn's Disease. In: Bayless, T.M. and Hanauer, S.B. Advanced Therapy of Inflammatory Bowel Disease. Hamilton, Ontario: B.C. Decker Inc. 2001. p. 263-265.

This chapter on dysplasia (abnormal tissue growth) surveillance in patients with Crohn's disease (CD) is from the second edition of a book devoted to the details of medical, surgical, and supportive management of patients with CD and ulcerative colitis (UC), together known as inflamatory bowel disease (IBD). The author notes that, contrary to traditional thinking, evidence has continued to accumulate suggesting that the risk of colorectal cancer (CRC) is elevated similarly in both UC and CD. Although imperfect, the best tool for screening and surveying these patients is colonoscopy. As has been the practice with UC, the endoscopies for patients with CD probably should commence at 8 years of disease and be repeated every 1 or 2 years. The author answers some questions about dysplasia surveillance, including what patients should have screening and surveillance colonoscopies, the significance of colonic strictures (narrowed areas), the pathologic findings that should mandate surgery, managing dysplasia found in polypoid mucosa, and choice of surgery. For lesions above the rectum, subtotal colectomy (removal of the colon) is the standard surgical procedure, and for rectal lesions, abdominoperineal resection with ileostomy or colostomy. After any of the surgical options, close follow up endoscopic surveillance of remaining colon is essential. 10 references.

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Flexible Sigmoidoscopy. American Family Physician. 63(7): 1375-1380. April 1, 2001.

Flexible sigmoidoscopy remains a common tool used for the periodic screening of colorectal cancer. This article reminds family care physicians of the recommendations for the use of flexible sigmoidoscopy. Most organizations recommend screening at three to five year intervals beginning at age 50 for persons with average risk. Extensive training in endoscopic maneuvering, colorectal anatomy, and pathologic recognition is required. Most physicians report comfort performing the procedure unsupervised after 10 to 25 supervised sessions. The procedure itself involves the insertion of the sigmoidoscope through the anus and distal rectum and advancement of the scope tip to an average depth of 48 to 55 centimeters in the sigmoid colon. Once the sigmoidoscope has been appropriately advanced, the scope is slowly withdrawn, allowing for the inspection of colon mucosa during withdrawal. Polyps less than 5 millimeters in diameter should be biopsied. Polyps 5 to 10 millimeters or greater can be assumed to be adenomatous, and follow up colonoscopy for complete polypectomy is required. Diverticulosis, hemorrhoids, nonspecific colitis and pseudomembranes may also be encountered during inspection. Use of preprocedural benzodiazepines can be helpful in reducing patient discomfort. 2 figures. 10 references.

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Flexible Sigmoidoscopy: A Pictorial Atlas. Patient Care. 35(18): 13-27. September 30, 2001.

Endoscopy continues to play an important role in colorectal screening. It is important to identify the members of those families that are at high risk for colon cancer and diligently screen them using colonoscopy. This article helps readers update their clinical skills regarding colorectal screening with direct instruction and a full color pictorial atlas. The author notes that the entire 360 degrees of the colon wall in each segment should be scrutinized as the instrument is slowly and deliberately withdrawn. In order to maximize the depth of insertion, it is important to minimize overinflation of the colon. The majority of pathologies seen in primary care are diverticulosis, hemorrhoids, and polyps. Approximately 95 percent of all colorectal cancers arise from benign polyps. Some experts recommend colonoscopy for all average risk persons older than 50. Mixed screening strategies may be employed more frequently in the future, or it may be appropriate to switch strategies as people age. Performing flexible sigmoidoscopy can be time intensive for a busy primary care physician. Experts have suggested that nurse practitioners and physician assistants be trained so that more patients can be screened (one sidebar summarizes this concept). 9 figures. 12 references.

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Gastrointestinal Bleeding in the Elderly. Gastroenterology Clinics of North America. 30(2): 377-407. June 2001.

Among patients with acute gastrointestinal (GI) bleeding, older age is associated with an increased rate of comorbidity (the presence of other diseases), greater medication use, and atypical clinical presentation (symptoms). The aging of the population makes the evaluation and management of GI bleeding in the elderly a special and increasingly common clinical challenge. This article, from a special issue on (GI) disorders in the elderly, reviews the unique features and common causes of upper and lower gastrointestinal bleeding in the elderly (defined as older than 60 years). The authors cover management issues including hemodynamic (blood system) resuscitation, anticoagulation, and medical, surgical, and endoscopic therapy. As in younger patients, elderly patients with acute upper GI bleeding usually present with hematemesis (vomiting blood, 50 percent of patients), as opposed to a combination of hematemesis and melena (black, tarry stool that contains digested blood, 20 percent of patients), or melena alone (30 percent). Dyspepsia (heartburn) is less frequent in the elderly, however, and complications are more common. Older patients with GI bleeding experience substantially more morbidity than younger patients, including cardiac, neurologic, and renal (kidney) complications; sepsis; and adverse effects from medications and transfusions. In general, the approximate site of bleeding can be predicted by the manner of presentation. After initial stabilization, endoscopy can be performed to identify the cause of bleeding. Management options include medication, endoscopy and colonoscopy, angiography, and surgery. The authors conclude that planning for care beyond the acute episode is crucial and involves an understanding of the importance of rehabilitation and community based services, as well as involvement of a caregiver. 1 figure. 10 tables. 162 references.

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Hemorrhoids and More: Common Causes of Blood in the Stool. Digestive Health and Nutrition. 3(4): 24-26. July-August 2001.

Most rectal bleeding is caused by hemorrhoids, which usually can be simply and effectively treated. This article reviews the many other conditions, including some serious disorders, that can cause blood in the stool. The author reminds readers that bleeding from any part of the nearly 40 foot long digestive tract can cause blood in the stool. Accurate and timely diagnostic tests are important to determine the cause of any bleeding. Bleeding higher up in the gut, from the esophagus or stomach, can result in stools with a black, tarry appearance. Bleeding from the lower end, such as the colon, or in large amounts, can appear as pure blood, blood clots, or as blood mixed with or streaking the stool. Another kind of blood, occult or hidden blood, may not be visible at all. A number of prescription and over the counter (OTC) medications can cause bleeding in the stomach and small intestine. The blood thinning drug warfarin also can induce bleeding in the intestine, as can some antibiotics. Other causes of bleeding can include ulcers, gastritis (inflammation of the stomach lining), ulcerative colitis, Crohn's disease, polyps (small growths inside the intestine), diverticular disease, abnormalities in the blood vessels (vascular anomalies), anal fissures (tears) and fistulas (abnormal openings between the anal canal and other organs, such as the bladder), and abscesses (pockets of infection. The author reiterates the importance of timely diagnosis, including a thorough patient history and evaluation of symptoms. Diagnostic tests can include blood tests, digital rectal examination, endoscopy, colonoscopy, sigmoidoscopy, fecal occult blood test, barium x rays, angiography (x rays of blood vessels), and nuclear scanning. Treatment depends on the source and extent of the bleeding.

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Lower GI Endoscopy: Viewing Your Colon. [Endoscopia de la Parte Baja del Tracto Gastrointestinal: Examen Visual del Colon]. San Bruno, CA: StayWell Company. 2001. [2 p.].

This brochure describes lower gastrointestinal (GI) endoscopy, a special examination that uses a long, narrow, flexible tube called an endoscope. Lower GI endoscopy can examine the entire colon and rectum (colonoscopy) or just the rectum and sigmoid colon (sigmoidoscopy). This instrument contains a strong light and a video camera, allowing the GI tract to be viewed on a video screen. The brochure provides information for patients about what to do before the exam, what to expect during the procedure itself, and what to expect after the procedure. The brochure also briefly describes lower GI anatomy and the types of problems that can be diagnosed with endoscopy, including inflammation of the colon (colitis), growths (polyps), and colon cancer. Patients may be given results of the procedure before they leave the office or hospital; additional results may take several days. The brochure cautions readers to contact their physician if they experience pain in the abdomen, fever, or rectal bleeding during their recovery time. The brochure is illustrated with full color line drawings of the colorectal anatomy and the procedure. The brochure is available in English or Spanish. 4 figures.

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Making the Best Choice for Your Endoscopic Procedure. Manchester, MA: American Society for Gastrointestinal Endoscopy. 2001. [2 p.].

This brochure educates readers about specialists in endoscopy. Physicians and surgeons who are members of the American Society for Gastrointestinal Endoscopy (ASGE) have highly specialized training in endoscopic procedures of the digestive tract, including upper GI (gastrointestinal) endoscopy, flexible sigmoidoscopy, colonoscopy, endoscopic retrograde cholangiopancreatography (ERCP), and endoscopic ultrasound (EUS). The brochure explains why ASGE members are a good choice for performing endoscopic procedures. The brochure notes that ASGE physicians usually work on referral from a primary care physician. The GI endoscopist will then communicate directly with the primary care physician about the results of the endoscopic procedure. Together, they determine what is appropriate for treatment, follow up visits, and future endoscopic exams. The brochure notes that the ASGE can help readers located an endoscopist (www.asge.org). The back page of the brochure summarizes the activities of the ASGE.

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Management of Severe Ulcerative Colitis. In: Bayless, T.M. and Hanauer, S.B. Advanced Therapy of Inflammatory Bowel Disease. Hamilton, Ontario: B.C. Decker Inc. 2001. p. 143-147.

Severe or fulminant ulcerative colitis (UC) is a potentially fatal disease that was associated with a 30 percent mortality rate prior to the introduction of corticosteroids and, in steroid-refractory cases, early surgery. During recent years, the trend has changed from saving lives to improving the quality of life of patients by saving colons or using modern surgical methods. This chapter on the management of severe UC is from the second edition of a book devoted to the details of medical, surgical, and supportive management of patients with Crohn's disease (CD) and UC, together known as inflammatory bowel disease (IBD). The author discusses the etiology, differential diagnosis, and definition of severe UC. Patients with definite or strongly suspected severe colitis must be admitted to the hospital for intensive treatment. The mainstay of the medical treatment is corticosteroids, taken orally with nothing except small sips of water, and total parenteral nutrition (TPN, outside the gastrointestinal tract). Usually, corticosteroids are administered intravenously in severe colitis, but even in acute colitis, corticosteroids given orally are absorbed completely but somewhat more slowly than those administered intravenously. Colonoscopy, rather than food challenge, is relied on to improve decision making in patients with incomplete or poor response to treatment. The author discusses the indications for using antibiotics, 5 aminosalicylic acid (5 ASA), and immunosuppressives. Beyond the drug therapy, the patient must be monitored carefully. Three or 4 days after initiating therapy, a sigmoidoscopy is of further help in monitoring the response and a biopsy helps to rule out cytomegalovirus. Assessment of response is made mainly on clinical and laboratory grounds, although repeat plain abdominal radiography during ongoing treatment can show signs of impending perforation or definite toxic dilatation that requires surgery. 1 table. 10 references.

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Rectal Bleeding. Yardley, PA: The StayWell Company: KRAMES Health and Safety Education. 2001. 2 p.

This brochure describes rectal bleeding, a common problem that needs medical care. Rectal bleeding can occur with or without a bowel movement. Rectal bleeding may be a sign of a serious problem in the rectum, colon, or upper GI (gastrointestinal) tract. The brochure lists common signs and symptoms, causes, the diagnostic approach used, specialized tests that may be used to confirm the diagnosis (endoscopy or colonoscopy), treatment options, and how the patient can participate in his or her own care. One sidebar includes an illustration of the gastrointestinal tract and a brief description of its physiology and the pathology of rectal bleeding. The brochure is illustrated with full-color drawings. 5 figures.

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Role of Endoscopy in Inflammatory Bowel Disease. Gastrointestinal Endoscopy Clinics of North America. 11(4): 641-657. October 2001.

Ever since its introduction into clinical use in the 1960s, flexible fiberoptic endoscopy has progressively become an indispensable tool to diagnose and treat gastrointestinal (GI) disorders. In addition to permitting visualization and biopsy sampling of much of the gastrointestinal tract, endoscopy can also be used therapeutically, to localize and treat bleeding, dilate strictures, and remove tumors. Ileal and colonic biopsies are critical to establish the cause of chronic diarrhea, to help distinguish between different forms of colitis, to determine the extent of disease, and to determine if neoplastic changes have arisen in the setting of chronic colitis. This article reviews the expanding use of endoscopy in inflammatory bowel disease (IBD) in the pediatric age group. The author summarizes a practical approach to endoscopic procedures in pediatric patients, including preparation for colonoscopy, sedation, choice of endoscope, and safety concerns. 1 figure. 2 tables. 85 references.

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Surveillance Issues in Inflammatory Bowel Disease: Ulcerative Colitis. Journal of Clinical Gastroenterology. 32(2): 99-105. February 2001.

This review article on the surveillance of patients with ulcerative colitis (UC) provides an overview of the criteria for evaluating screening and surveillance programs and applies the criteria to the available evidence to determine the effectiveness of the surveillance of patients with UC. The authors examine the clinical outcomes associated with surveillance, the additional clinical time required to confirm the diagnosis of dysplasia and cancer, compliance with surveillance and followup, and the effectiveness of the individual components of a surveillance program, including colonoscopy and pathologist's interpretation. The disability associated with colectomy is considered, as are the cost and acceptability of surveillance programs. Patients with longstanding UC are at risk for developing colorectal cancer, therefore recommended surveillance colonoscopy should be supported. The diagnosis of cancer at an early stage in this group is associated with a good prognosis. The authors conclude that new endoscopic and histopathologic techniques used to improve the identification of high risk patients may enhance the effectiveness and cost effectiveness of surveillance practices. 2 figures. 5 tables. 44 references.

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Ulcerative Colitis: A Diverse Disease with Diverse Questions and Diverse Solutions. In: Bayless, T.M. and Hanauer, S.B. Advanced Therapy of Inflammatory Bowel Disease. Hamilton, Ontario: B.C. Decker Inc. 2001. p. 119-121.

This chapter on ulcerative colitis is from the second edition of a book devoted to the details of medical, surgical, and supportive management of patients with Crohn's disease (CD) and ulcerative colitis (UC), together known as inflammatory bowel disease (IBD). The author notes that clinicians think of UC as one disease, but it is, in fact, a blend of several conditions whose final common denominator is diffuse inflammation of the colon associated with distortion of crypts on microscopic examination. Clinicians move from one therapy for colitis to another as if UC is a spectrum. First, 5 ASA is tried for one type of UC; if this therapy fails, corticosteroids, either local or systemic, follow for what unspokenly is another type of UC. 6-Mercaptopurine or azathioprine enters therapy for a third type of UC and, finally, surgery cures all. The author discusses the different types of therapy and also considers the cancer risk in patients with UC; surveillance of inflamed colons by means of periodic colonoscopy is the standard of care to address the latter. The author concludes that UC presents, responds to therapy, and has a natural history that suggests that it is a spectrum. The host, the luminal environment, the mucosal border, and the immune system of the lamina propria and vascular walls participate in molding this spectrum. Clinical trials that approach UC with these distinct participants in mind may yield more success than outcomes obtained in the past two decades. 10 references.

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Ulcerative Colitis: A Rational Approach to Management. Consultant. 41(4): 541-548. April 1, 2001.

Ulcerative colitis (UC), a type of inflammatory bowel disease can manifest as proctitis or proctosigmoiditis, left sided colitoss, or pancolitis. This article offers a rational approach to the management of patients with UC. Frequent low volume bowel movements, urgency, rectal bleeding, and tenesmus (ineffective spasms of the rectum) alone suggest proctitis. Prostration, fever, tachycardia (racing heartbeat), dehydration, and complications of blood loss (which may or may not be accompanied by symptoms of proctitis) suggest more severe disease or more extensive bowel involvement. For patients with mild to moderate disease, mesalamine is recommended to induce and maintain remission. Systemic corticosteroids can induce remission in patients with moderate to severe disease but are not useful for maintenance therapy. Azathioprine or 6 mercaptopurine can be used to wean patients with moderate to severe colitis from corticosteroids and to maintain remission. If severe colitis does not respond to corticosteroids, immunosuppressive therapy or colectomy may be needed. Other indications for surgery include development of acute complications related to disease activity and chronic complications, such as dysplasia, carcinoma, recurrent hemorrhage, or growth retardation in children. Annual surveillance colonoscopy with biopsy is recommended for patients with pancolitis and left sided colitis.

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Understanding Colon Cancer Screening. Manchester, MA: American Society for Gastrointestinal Endoscopy. 2001. [2 p.].

This brochure educates readers about colon cancer screening. The brochure offers six True or False statements about colorectal cancer (CRC) screening, then explains the correct answer for each. Topics include the incidence of CRC in men versus women; the indications for testing; the time involved in a colonoscopy screening examination; the mortality associated with CRC; diagnostic tests used to screen for colon cancer; and prevention of CRC. Colorectal cancer affects an equal number of men and women. Beginning at age 50, all men and women should be screened for colorectal cancer, even if they are experiencing no problems or symptoms. Colonoscopy is almost always done on an outpatient basis; the test is safe and the procedure itself typically takes less than 30 minutes. Colorectal cancer is the third leading cause of cancer deaths in women in the United States. Tests used for screening for CRC include digital rectal exam, stool blood test, barium enema, flexible sigmoidoscopy, and colonoscopy. The brochure emphasizes that colon cancer is often preventable, so screening is very important.

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What Do New Diagnostic Tools Offer the Investigation of Disease?. Jewell, D.P.; Warren, B.F.; Mortensen, N.J., eds. Challenges in Inflammatory Bowel Disease. Malden, MA: Blackwell Science, Inc. 2001. p.85-96.

The most widespread techniques for routine evaluation of a patient with inflammatory bowel disease (IBD) have not changed over the last 20 years and include clinical examination, blood samples, small and large bowel barium examinations, and colonoscopy with mucosal biopsy. This chapter on newer diagnostic tools is from a book that offers an approach to the subject of IBD that highlights current areas of controversy. The authors outline the role that each of the newer techniques may play in the assessment of IBD and how they may increase the understanding of the pathogenesis of the condition. Topics include ultrasound studies, computed tomography (CT scan), magnetic resonance imaging (MRI), technetium-labeled and indium-labeled leukocyte scans, and novel antibody scans. The authors conclude that care should be taken to determine which technique will provide the information required with the minimal radiation dose and the least discomfort to the patient. It is important to minimize duplications, as many studies may be complementary. The radiologist must form an integral part of the multidisciplinary team caring for patients with Crohn's disease and ulcerative colitis. 3 figures. 75 references.

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What's Wrong with This Picture?: Diagnostic Images, Treatment Issues. Consultant. 41(4): 569-570, 572. April 1, 2001.

This article reports a clinical case of a 29 year old teacher who experienced intermittent, colicky, right lower abdominal pain for 3 months, with 4 or 5 episodes per day of watery diarrhea without blood or mucus. In addition, the patient had a low grade fever and had lost 8 pounds (3.6 kilograms) prior to presentation. The authors report the patient's symptoms and the results of laboratory tests (including three stool specimens which were negative for ova and parasites), then note that colonoscopy and biopsy were ordered for this patient. The colonic mucosa had a cobblestoned appearance with no edema (fluid accumulation) or bleeding. The biopsy specimen of the mucosa contained numerous granulomas. Perinuclear antineutrophilic cytoplasmic antibody (P ANCA) levels were grossly increased. The authors determined that these symptoms and findings suggest Crohn disease. The patient was given prednisolone and sulfasalazine; the regimen relieved his symptoms and he was discharged after 1 week. The dosage of corticosteroids were gradually tapered and sulfasalazine was continued. At followup 1 month later, the patient had no symptoms. He had gained 10 pounds (4.5 kilograms) and had returned to teaching. The authors discuss this case and its implications for diagnosis and treatment of adults with colonic Crohn disease. The authors stress that Crohn disease is a lifelong illness characterized by exacerbation and remission; the primary goals of medical management are to provide symptomatic relief, maintain adequate nutritional status, reduce intestinal inflammation, decrease the incidence of relapses, and improve the patient's quality of life. Surgical intervention is reserved for resection of fistulas, treatment of abscesses, and relief of obstruction. 3 figures. 3 references.

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Body Invaders: Digestion. Princeton, NJ: Films for the Humanities and Sciences. The Discovery Channel. 2000. (videorecording).

In this program, host Kat Carney explores all 24 feet of the human gastrointestinal tract, stopping at each stage of digestion for a close up study of the organs involved. The program also covers foodborne illnesses, gastroesophageal reflux disease, lactose intolerance, ulcers caused by Helicobacter pylori, Crohn's disease, and traveler's diarrhea. The program includes interviews with and narration by experts from Tufts Medical School's Lahey Clinic, the City of Boston Health Department, and the New England Medical Center. The program features operating room footage of gallbladder surgery and intestinal imaging via colonoscopy. This program is one of an 11-part series called The Body Invaders that reveals the facts and fallacies of some common illnesses, disorders, and conditions.

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Clinical Evaluation and Management of Acute Severe Colitis. Inflammatory Bowel Diseases. 6(3): 214-227. August 2000.

The patient with acute severe colitis usually presents with frequent diarrheas that are more or less bloody. Fever and abdominal pain occur, but not always. This review article concentrates on the clinical evaluation, imaging, therapy, and prognostic factors in acute severe colitis of idiopathic (unknown) as well as infectious origin. The authors note that an immediate rigid rectosigmoidoscopy is essential for diagnosis and quick fecal sampling for cultivation of fecal pathogens, including Clostridium difficile toxin if there is suspicion of such an infection. The medical history and rectosigmoidoscopic appearance is usually sufficient to make a preliminary diagnosis of ulcerative colitis (UC). The next step is to evaluate the severity of the attack, extent of inflammation in the colon, and prognostic factors. Plain abdominal x-ray is often sufficient for a preliminary opinion about the extent of disease if the lumen is outlined by gas. The authors describe the superiority of colonoscopy performed at an early state, compared to other imaging modalities. Colonoscopy is the most adequate technique to evaluate both the extent and degree of inflammation, and the degree of ulceration. The introduction of early stage surgery resulted in a dramatic decrease in mortality due to severe attacks of UC. However, intensive medical treatment (rather than surgery) of a severe or moderately severe attack of UC may be followed by longstanding remission. This intensive treatment is based on corticosteroids, total parenteral nutrition (TPN), bowel rest, and antibiotics. Other treatments discussed include cyclosporine A, tacrolimus, anti tumor necrosis factor (TNF) alpha; the authors also discuss factors predicting outcome. A short section on Crohn's disease is followed by a section on acute infectious colitis, including the role of various pathogens, including Campylobacter jejuni, Yersinia enterocolitica, Escherichia coli, Salmonella, Shigella, Aeromonas, Clostridium difficile, Entamoeba histolytica, and cytomegalovirus. 188 references.

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Colonoscopy Plus Biopsy in the Inflammatory Bowel Diseases. Gastrointestinal Endoscopy Clinics of North America. 10(4): 755-774. October 2000.

Biopsy of the colon is an important diagnostic tool in the investigation of the inflammatory bowel diseases (IBD). Colon biopsies are critical in helping to diagnose diarrhea, to distinguish different forms of colitis, to determine the extent of disease, and to determine if neoplasia (including cancer) has arisen in the setting of chronic colitis. This article reviews a number of scenarios where colon biopsies are of particular importance, such as biopsies in the patient with undiagnosed diarrhea, distinguishing different forms of inflammatory bowel disease (IBD), assessing disease extent and activity, differential diagnosis of and diagnosing other disorders superimposed on inflammatory bowel disease, neoplasia in patients with IBD, and colonic biopsy as a mirror of generalized gastrointestinal or systemic disease. One table summarizes the recommended locations and numbers of biopsies for different scenarios. The author concludes that to use colon biopsies most appropriately in patient management and to get the most mileage from them usually requires frequent clinician-pathologist interaction, often repeat endoscopy with biopsies at a different time, and the assessment of the biopsies in the clinical context. 1 figure. 3 tables. 94 references.

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Colonoscopy. Gastrointestinal Endoscopy Clinics of North America. 10(1): 135-160. January 2000.

This article on colonoscopy is from a special millennium issue of Gastrointestinal Endoscopy Clinics of North America that offers an overview of the past, highlights the present, and focuses on the future of gastrointestinal endoscopy. The author notes that colonoscopy and polypectomy (removal of colonic polyps) are the most effective tools available to prevent colorectal cancer. The technical performance of colonoscopy can be improved by methods that make polyp detection easier and more reliable, facilitate cecal intubation, and reduce recurrence and complication rates after polypectomy. The author reviews the state of the art and possible future trends in patient preparation, indications, screening and surveillance intervals, sedation issues, and virtual colonoscopy. The author notes that a central goal of research in gastrointestinal disease is one whose fulfillment can already be imagined: the virtual obliteration of death from colorectal cancer. Colonoscopy already has the potential to play the central role in fulfilling this goal, but its full potential will only be reached with further improvements in acceptability, comfort, and safety for patients, with reduction of costs and improved detection of neoplasia. 1 figure. 6 tables. 198 references.

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Comparison of Colonoscopy and Double-Contrast Barium Enema for Surveillance After Polypectomy. New England Journal of Medicine. 342(24): 1766-1772. June 15, 2000.

After patients have undergone colonoscopic polypectomy, it is uncertain whether colonoscopic examination or a barium enema is the better method of surveillance. This article reports on a study undertaken as part of the National Polyp Study, in which the authors offered colonoscopic examination and double contrast barium enema for surveillance to patients with newly diagnosed adenomatous polyps. A total of 973 patients underwent one or more colonoscopic examinations for surveillance. In the case of 580 of these patients, the authors performed 862 paired colonoscopic examinations and barium enema examinations that met the requirements of the protocol. The findings on barium enema were positive in 222 (26 percent) of the paired examinations, including 94 of the 242 colonoscopic examinations in which one or more adenomas were detected (rate of detection, 39 percent). The proportion of examinations in which adenomatous polyps were detected by barium enema was significantly related to the size of the adenomas; the rate was 32 percent for colonoscopic examinations in which the largest adenomas detected were 0.5 cm or less, 53 percent for those in which the largest adenomas detected were 0.6 to 1.0 cm, and 48 percent for those in which the largest adenomas detected exceeded 1.0 cm. Among the 139 paired examinations with positive results on barium enema and negative results on colonoscopic examination in the same location, 19 additional polyps, 12 of which were adenomas, were detected on colonoscopic reexamination. The authors conclude that, in patients who have undergone colonoscopic polypectomy, colonoscopic examination is a more effective method of surveillance than double contrast barium enema. 5 tables. 23 references.

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Constipation, Colonic Inertia, and Colonic Marker Studies. Milwaukee, WI: International Foundation for Functional Gastrointestinal Disorders (IFFGD). 2000. [4 p.].

Treatment for the common condition of constipation often includes lifestyle modifications such as increasing fluid intake, consuming more fiber, and exercising regularly. At times, the symptom of constipation can represent serious illness. This fact sheet discusses constipation, colonic inertia, and the colonic marker studies used to diagnose the causes (epidemiology) of constipation. The symptoms of colonic inertia include long delays in the passage of stool accompanied by lack of urgency to move the bowels. Because there are a large number of potential causes for the symptoms of constipation, the physician may perform blood tests looking for systemic disease, as well as a colonoscopy or barium enema to look for intrinsic abnormalities of the colon. A review of medications will help determine if the patient is taking medicines that are affecting the functioning of the colon. In addition, testing of the anorectal function may be performed, including defecography (a radiographic test to identify anatomical defects during defecation) and electromyogram (EMG) to determine if a disorder of this region is present. One sidebar discusses the interplay between functional constipation (the symptoms of constipation present without a known cause) and irritable bowel syndrome (IBS). Another sidebar reviews pelvic floor dyssynergia, the failure of pelvic floor muscles to relax with defecation. The role of biofeedback therapy in the treatment of chronic constipation is emerging. Biofeedback therapy involves training the patient by using special equipment to relax pelvic floor and anal sphincter muscles. Surgical techniques have now been found to be effective in some patients who have colonic inertia. If organic disease is ruled out as the cause, then changes in diet, increased intake of fiber and liquids, and regular exercise can often help. 1 figure. 1 table.

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Controversies in the Investigation and Treatment of Lower Gastrointestinal Bleeding. Practical Gastroenterology. 24(1): 42, 52, 54, 58. January 2000.

Lower gastrointestinal (GI) bleeding may be intermittent, self limited, or produce a life threatening emergency. There are several options for diagnostic evaluation, but the location and etiology of the bleeding source may remain elusive. In this article, the authors review the diagnostic and treatment options and provide recommendations for developing an organized patient algorithm. The majority of patients with lower GI hemorrhage will stop bleeding during resuscitation. Once the bleeding has stopped, investigation of the source of the bleed usually proceeds with routine endoscopic and radiological studies, followed by elective segmental resection, if indicated. In patients where it is impossible to determine the precise location and etiology, both patient and physician must await the next bleeding episode. Patients who present with lower GI bleeding are usually adults older than 50 years. The most common etiologies of lower GI bleeding include diverticulosis, vascular ectasia, ischemic colitis, inflammatory bowel disease (IBD), and neoplasm (cancer). Diagnostic options include colonoscopy, traditional imaging techniques (CT scan or contrast studies), nuclear scintigraphy, or mesenteric angiography. Colonoscopy and mesenteric angiography both offer the means for potentially controlling the hemorrhage whereas scintigraphy does not. Colonoscopy can provide the means to treat bleeding lesions through electrocautery, epinephrine injection, or sclerotherapy. Angiography can provide access for vasopressin infusion or embolization. The unstable patient without a determined site of bleeding represents the most challenging dilemma, as blind total abdominal colectomy is associated with potential rebleeding from the small intestine and significant morbidity and mortality. 26 references.

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Crohn's Disease and Ulcerative Colitis. In: King, J.E., ed. Mayo Clinic on Digestive Health. Rochester, MN: Mayo Clinic. 2000. p. 99-114.

This chapter on Crohn's disease and ulcerative colitis (the two most common inflammatory bowel diseases, IBD) is from a comprehensive guidebook from the Mayo Clinic that focuses on a variety of digestive symptoms, including heartburn, abdominal pain, constipation, and diarrhea, and the common conditions that are often responsible for these symptoms. Written in nontechnical language, the book includes practical information on how the digestive system works, factors that can interfere with its normal functioning, and how to prevent digestive problems. This chapter first reviews the key signs and symptoms of IBD, including diarrhea, abdominal pain and cramping, blood in the stool (feces), fatigue, reduced appetite, weight loss, and fever. The authors note that although these diseases often cannot be cured, they can be treated. There are several therapies that may drastically reduce the patient's symptoms, and possibly even bring about a long term remission. The chapter outlines the differences between the two diseases (Crohn's disease can strike anywhere from the mouth to the anus; ulcerative colitis is typically limited to the colon and rectum), reviews theories about the causes of these problems, and offers classification systems to determine if the disease is mild, moderate or severe. Diagnostic tests used to confirm the presence of IBD include blood tests, X rays, and colonoscopy (which can include biopsy). Medications can effectively reduce symptoms in most people with IBD; drugs used include antiinflammatory drugs (sulfasalazine, mesalazine, olsalazine, corticosteroids), immunosuppressants (such as azathioprine, methotrexate, and cyclosporine), antibiotics (notably metronidazole and ciprofloxacin), nicotine patches, antidiarrheals, laxatives, pain relievers, iron supplements, and vitamin B12 injections. The chapter concludes with suggestions for lifestyle modifications that can help people cope with IBD and a section explaining the surgical options that may be used for IBD that is not responsive to other treatments. 1 figure.

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Crohn's Disease and Ulcerative Colitis: Taming Painful Inflammatory Bowel Disease. Mayo Clinic Women's Healthsource. 4(6): 4-5. June 2000.

This health newsletter article describes inflammatory bowel disease (IBD), an umbrella term for Crohn's disease and ulcerative colitis (UC). The author notes that the cause of IBD is unclear, but abnormalities of the immune system are associated with these diseases. IBD is an inflammatory disease, and it is this inflammation that results in pain and diarrhea. Symptoms can also include weight loss, fatigue, rectal bleeding, and anemia. The location of the inflammation within the digestive tract is one of the features that differentiates Crohn's disease from ulcerative colitis. Crohn's disease can affect any part of the digestive tract, from the mouth to the anus, although inflammation is usually in the small intestine. With UC, inflammation is usually in the large intestine and rectum, and ulcers often form. These disorders may also cause other health complications, including an increased risk for developing colon cancer. The symptoms of Crohn's disease are similar to irritable bowel syndrome (IBS), so diagnostic tests to differentiate the diseases may include blood tests, flexible sigmoidoscopy, colonoscopy, and barium enema. Treatment of IBD depends on the severity of disease and the associated complications. Treatment strategies can include diet, medications, counseling, and surgery. While there is no cure for IBD, some people have long periods of remission when their symptoms are well controlled. One sidebar describes current research efforts on Crohn's disease and ulcerative colitis. 1 figure.

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Definition and Methodological Issues. In: Manu, P. Pharmacotherapy of Common Functional Syndromes: Evidence-Based Guidelines for Primary Care Practice. Binghamton, NY: Haworth Medical Press. 2000. p. 123-124.

This chapter is from a book that evaluates drug therapies for each of the four major functional disorders: chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome (IBS), and premenstrual syndrome. In this chapter, the first of six short chapters that focus on IBS, the author provides a definition of the disorder and an introduction to the methodological issues that arise in its treatment. IBS is diagnosed by the Rome group criteria, requiring the presence of at least three months of recurrent or continuous abdominal pain or discomfort that is either relieved with defecation (bowel movement) or associated with a change in frequency or consistency of stool. In addition, the patient must have at least two of the following five symptoms: altered stool frequency (how often the patient has a bowel movement), altered stool consistency, altered stool passage, passage of mucus, and feeling of abdominal distention. Physical examination, endoscopy (colonoscopy or sigmoidoscopy), contrast radiologic studies (X rays), and stool analysis are useful only to exclude organic pathology (another disease or disorder causing the patient's symptoms). The methodological issues raised by controlled treatment trials in IBS include the difficulty of measuring effectiveness in the absence of a way to objectively measure symptom improvement. There presently exists an array of arbitrary rating scales that have attempted to quantify the effect of treatment. An overall measure carefully weighing the contribution of the changes induced by therapy in the major symptoms of the syndrome is advisable, but difficult to create and validate. The author recommends that studies undertaken to assess the impact of drug therapy on IBS be of sufficient duration (at least 8 to 12 weeks) and include a large sample size.

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Diagnosing Inflammatory Bowel Disease. In: Zonderman, J. and Vender, R.S. Understanding Crohn Disease and Ulcerative Colitis. Jackson, MS: University Press of Mississippi. 2000. p. 3-22.

Crohn's disease and ulcerative colitis, together known as inflammatory bowel disease (IBD), are chronic illnesses of unknown origin. This chapter on diagnosing IBD is from a book that provides timely information about how to obtain and maintain the highest quality of life possible while living with IBD. The authors offer a patient's perspective on coping with IBD. They caution that the diagnosis of IBD may be made quickly or may take a relatively long time, depending on the symptoms people have when they first visit a doctor because of distress. IBD is most commonly diagnosed in two age groups: young adulthood (ages 15 to 30 years), and middle age (ages 50 to 65 years). Prompt diagnosis and treatment of IBD is important; these are chronic, lifelong conditions that demand medical vigilance. In addition, those in their fifties are entering the age at which colorectal cancer becomes more prevalent; it is important that individuals be evaluated by a physician who can distinguish colitis from cancer. The chapter discusses the three classic symptoms that a doctor considers when assessing whether an individual has IBD: persistent or recurrent diarrhea (with or without rectal bleeding), pain, and fever. The authors review the laboratory tests and other diagnostic procedures that may be used, including sigmoidoscopy, colonoscopy, barium enema, and upper gastrointestinal (GI) x ray. The authors also describe the nine varieties (subtypes) of IBD: ulcerative proctitis, proctosigmoiditis, left sided colitis, pancolitis, gastroduodenal Crohn disease, jejunoileitis, ileitis, ileocolitis, and granulomatous colitis. 5 figures.

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End of Barium Enemas? (editorial). New England Journal of Medicine. 342(24): 1823-1824. June 15, 2000.

This editorial comments on an article published in the same journal describing the use of barium enema versus colonoscopy for diagnostic uses. The editorial author notes that whether or not colonoscopy is a better way to examine the colon, it has been replacing barium enemas in recent years. The appeal of endoscopic technology, the ability to detect and remove lesions during a single procedure, and the influence of the gastroenterology community have been persuasive. In the research article on the accuracy of barium enema versus colonoscopy, barium enema did not fare well, especially in the identification of small polyps. The commentary author discusses the generalization of results, the problem of translating the procedures to typical clinical practice (rather than the research procedures, which were performed by a hand picked group of top technicians), and the recent finding that some colorectal cancers may arise from flat adenomas. The author concludes that the ability of barium enema to detect clinically important polyps is not good enough to use this method for the surveillance of patients who are increased risk for polyps or for a diagnostic evaluation of the colon. Barium enema may still have a role in screening (where expectations regarding the accuracy of findings are not as high) but it is unclear exactly what this role should be. 9 references.

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Feeling Good About Your Medical Care. In: Bolen, B.B. Breaking the Bonds of Irritable Bowel Syndrome: A Psychological Approach to Regaining Control of Your Life. Oakland, CA: New Harbinger Publications, Inc. 2000. p.29-43.

Irritable bowel syndrome (IBS) consists of recurrent episodes of abdominal pain related to altered bowel habit, which may consist of predominantly constipation or diarrhea, or an alternation between the two. This chapter on feeling good about one's medical care is from a book in which the author encourages an open discussion of the symptoms and feelings that accompany irritable bowel syndrome (IBS). Charts and worksheets help readers track the relationship between unpleasant symptoms and external triggers such as foods, stressful events, emotional states, and certain thoughts. Coping skills, such as relaxation exercises and assertiveness techniques, teach readers how to manage their stress more effectively and help them break free of the restrictions placed upon them by the disruptiveness of this digestive disorder. This chapter discusses how to locate a health care provider, how to establish a good relationship between patient and doctor, reasonable expectations of one's health care provider, how to be assertive in health care matters, what to expect during the first and subsequent visits to the doctor, diagnostic tests (sigmoidoscopy, barium enema, colonoscopy), other diseases that might be considered during diagnosis (inflammatory bowel diseases, diverticular disease, and colon cancer), treatments that may be utilized (dietary changes, medication), and prognosis. Throughout the chapter, the author emphasizes the importance of educating oneself and taking an active role in one's own disease management. 1 figure.

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Gastrointestinal Bleeding in Infancy and Childhood. Gastroenterology Clinics of North America. 29(1): 37-66. March 2000.

Gastrointestinal (GI) bleeding is an alarming problem in children. Although many causes of GI bleeding are common to children and adults, the frequency of specific causes differs greatly, and some lesions, such as necrotizing enterocolitis or allergic colitis, are unique to children. This article reviews the spectrum of GI bleeding in infants and children. The author discusses the causes (etiology), diagnostic evaluation, and management, and highlights the differences with adult medicine. The more common causes of upper GI bleeding in children are ulcer and gastritis, esophagitis, and varices (enlarged veins or arteries). A detailed history and careful physical examination accompanied by limited laboratory studies may identify the underlying cause and predict the severity of gastrointestinal hemorrhage. Endoscopy is the preferred diagnostic procedure because it is sensitive and specific and, for some lesions, provides the means for immediate treatment. Medical therapy (drugs) is similar for adults and children, differing mostly in the dosage of medications. One table lists pediatric doses for medications commonly used in upper gastrointestinal bleeding. Endoscopic therapy may be used in children with an actively bleeding focal lesion or with a lesion at high risk of rebleeding. Surgery is reserved for bleeding that is uncontrollable by less invasive interventions. The latter part of the article reviews lower GI bleeding, noting that age is an important factor in diagnosis of etiology (cause). Colonoscopy is the preferred diagnostic modality for rectal bleeding. The article concludes with a brief description of small bowel hemorrhage, usually due to Meckel's diverticulum (a congenital anomaly), duplications of the bowel, or idiopathic necrotizing enteritis. 4 figures. 3 tables. 212 references.

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Gastrointestinal Endoscopy 2000. Gastrointestinal Endoscopy Clinics of North America. 10(1): 1-198. January 2000.

This special millennium issue of Gastrointestinal Endoscopy Clinics of North America offers an overview of the past, highlights the present, and focuses on the future of gastrointestinal endoscopy. Eleven chapters are on sedation and sedationless endoscopy; computers in endoscopy; light induced fluorescence endoscopy of the gastrointestinal tract; the use of light scattering spectroscopy and optical coherence tomography for enhanced gastrointestinal diagnosis; therapeutic upper endoscopy; acute gastrointestinal bleeding; enteroscopy; endoscopic retrograde cholangiopancreatography (ERCP); colonoscopy; endoscopic ultrasound; and pediatric endoscopy. The editor of the volume notes that a relatively young leadership group was invited to represent gastroenterologists likely to be directly affected by the ideas generated and to write the chapters of this special volume. The chapters are based on revisions incorporating points made in the vigorous panel discussions that were held after each of the papers was presented at a meeting in New York City in March 1999. Each chapter includes extensive references; a subject index concludes the volume.

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Investigations for IBD. St. Albans, England: National Association for Colitis and Crohn's Disease (NACC). 2000. 9 p.

This reference booklet helps people with inflammatory bowel disease (IBD) understand the diagnostic tests that they may need to undergo to confirm diagnosis and monitor progress of their disease and treatment. The booklet has four sections: blood tests, endoscopy, radiography (x rays), and scans. Specific tests discussed include full blood count (FBC), erythrocyte sedimentation rate (ESR), C reactive protein (CRP), ferritin (iron), vitamin B12 and folic acid, liver function tests (LFTs), International normalized ratio (INR), urea and electrolytes (U and E), bone chemistry, magnesium, trace elements, proctoscopy, sigmoidoscopy, flexible sigmoidoscopy, colonoscopy, gastroscopy, abdominal radiography, chest radiography, joint radiography, bone densitometry (DEXA scanning), barium meal, barium follow through, small bowel enema, barium enema, ultrasound, CT (computed tomography) scanning, MRI (magnetic resonance imaging), and nuclear medicine scans. The booklet describes the results that each test can provide and, in the case of endoscopy tests, what the patient can expect during the procedure. The booklet concludes with a list of resource organizations, all based in Britain.

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Irritable Bowel Syndrome: Clinical Issues. Participate. 9(1): 1-4. Spring 2000.

This article discusses irritable bowel syndrome (IBS), a very common condition that is characterized by abdominal pain associated with a change in a bowel pattern (constipation or diarrhea). IBS is considered a condition of the brain-gut connection and triggering factors may variously cause symptoms of diarrhea at one time and constipation at another. There is a wide range of severity of IBS, from mild or infrequent symptoms that the patient manages at home to very severe kinds of symptoms that can cause patients to seek relief with more frequent doctor visits. The article answers common questions about IBS and its treatments. IBS is in the group of conditions that are called functional gastrointestinal disorders, i.e., disorders of dysfunction, rather than pathology such as inflammation or visible tissue damage. Diagnosis include patient history, symptoms according to the Rome Criteria, and diagnostic tests such as colonoscopy or CT scan (computed tomography). Treatments are usually done in response to the specific symptoms. For example, in a patient who usually has constipation, treatment are used that increase the functioning of the bowel, the frequency, and the ease of having a bowel movement. For patients whose symptoms tend more to diarrhea, treatment includes anti diarrheal agents. Pain medications might also be indicated, particularly if the pain is meal related. Reduced dosage prescriptions of antidepressants can be effective to modulate or decrease pain. The author reviews new drugs currently under study, as well as ongoing research into the brain-gut connection. The author also discusses the impact of conceptualizing functional disorders within the traditional disease-based medical framework, which separates the mind from the body. IBS must be recognized as genuine, non trivial, and a disorder that is not fully explained as either psychiatric or organic.

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Management of Gastrointestinal Bleeding Induced by Gastrointestinal Endoscopy. Gastroenterology Clinics of North America. 29(1): 125-167. March 2000.

Therapeutic gastrointestinal (GI) endoscopy has a much higher risk of induced GI hemorrhage (bleeding) than diagnostic endoscopy. This article reviews the management of GI bleeding that is induced by endoscopy. Bleeding complications of these techniques, while uncommon, are not rare. Colonoscopic polypectomy (removal of polyps in the colon) has a risk of approximately 1.6 percent of inducing bleeding, compared to 0.02 percent for diagnostic colonoscopy. Higher risk procedures include colonoscopic polypectomy, endoscopic biliary sphincterotomy, endoscopic dilatation, endoscopic variceal therapy, percutaneous endoscopic gastrostomy (surgical creation of an opening into the stomach), and endoscopic sharp foreign body retrieval. The risk of inducing hemorrhage is decreased by meticulous endoscopic technique. Hemorrhage from endoscopy may be immediate or delayed. Immediate hemorrhage can be treated by endoscopic hemostatic therapy, including injection therapy, thermocoagulation, or electrocoagulation. Delayed hemorrhage generally requires repeat endoscopy for diagnosis and for therapy, using the same hemostatic techniques. 1 figure. 2 tables. 113 references.

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Patterns of Endoscopy Use in the United States. Gastroenterology. 118(3): 619-624. March 2000.

This article reports on a study to determine why routine endoscopy is performed in diverse practice settings. The authors used a large national endoscopic database, compiled after a computerized endoscopic report generator was developed and disseminated to gastrointestinal (GI) specialists in diverse practice settings. After reports were generated, a data file was transmitted electronically to the central databank, where data were merged from multiple sites for analysis. Between April 1997 and October 1998, 276 physicians in 31 practice sites in 21 states provided 18,444 esophagogastroduodenoscopy (EGD) reports, 20,748 colonoscopy reports, 9,767 flexible sigmoidoscopy reports to the central databank. EGD was most commonly performed to evaluate dyspepsia (heartburn) or abdominal pain (23.7 percent), dysphagia (20 percent), symptoms of gastroesophageal reflux without dysphagia (17 percent), and suspected upper GI bleeding (16.3 percent). Colonoscopy was most often performed for surveillance of prior neoplasia (24 percent) and evaluation of hematochezia (19 percent) or positive fecal occult blood test (blood in the stool, 15 percent). Flexible sigmoidoscopy was most commonly performed for routine screening (40 percent) and evaluation of hematochezia (red blood passed through the rectum, 22 percent). There were significant differences between academic and nonacademic sites. The authors conclude that this endoscopic database can be an important resource for future research in endoscopy by documenting current practice patterns and changes in practice over time. 1 appendix. 1 figure. 5 tables. 16 references.

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Pediatric Endoscopy. Gastrointestinal Endoscopy Clinics of North America. 10(1): 175-194. January 2000.

This article on pediatric endoscopy is from a special millennium issue of Gastrointestinal Endoscopy Clinics of North America that offers an overview of the past, highlights the present, and focuses on the future of gastrointestinal endoscopy. The emergence of pediatric gastroenterology as a subspecialty and the improved design and widespread distribution of small diameter endoscopes have combined to foster dramatic expansion in the practice of pediatric endoscopy over the past three decades. The author focuses on important pediatric applications, highlights differences with adult practice, and anticipates future research and development of pediatric endoscopy. Topics include informed consent, dietary restrictions, sedation, bowel preparation, pediatric endoscopy competence and training, the indications and procedure for upper gastrointestinal endoscopy (EGD), the indications and procedure for colonoscopy, and complications. Many pediatric gastroenterologists have concluded that the majority of diagnostic and therapeutic techniques developed for adult patients can be applied safely and effectively in children of all ages. Future efforts should include cost benefit analyses of diagnostic endoscopy for common indications, such as abdominal pain, bleeding, and diarrhea. 2 tables. 83 references.

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Pediatric Gastrointestinal Mucosal Biopsy: Special Considerations in Children. Gastrointestinal Endoscopy Clinics of North America. 10(4): 669-712. October 2000.

In most disorders of the gastrointestinal (GI) mucosa that occur in both children and adults, the mucosal manifestations are the same. This article focuses on those disorders and the approaches to GI procedures and mucosal biopsy that are of a particularly or peculiarly pediatric nature (i.e., are different from those in adults). The authors discuss issues pertaining to endoscopy and other techniques of mucosal biopsy in children, because some approaches and techniques are considerably different from those in adults. In children as in adults, most mucosal biopsies are taken at upper GI endoscopy or colonoscopy, with rectal suction biopsy (RSB) being performed occasionally and blind esophageal suction biopsy very rarely. The authors caution that major problems can arise in pediatric endoscopy when children are approached and instrumented like adults. The authors describe the preparation of the child and family, sedation, bowel preparation, and fasting. The authors include a section discussing disorders in which there are special features in children that may be significantly different from adults, including gastroesophageal reflux disease (GERD), idiopathic eosinophilic esophagitis, Barrett's esophagus, Helicobacter pylori infections, Crohn's disease, allergic gastritis, celiac gastritis, chronic granulomatous disease, Menetrier's disease, neonatal gastropathies, Henoch Schonlein gastritis, cow's milk protein enteritis, microvillous inclusion disease, tufting enteropathy, autoimmune enteropathy, inflammatory bowel disease, pseudomembranous colitis, necrotizing enterocolitis, glycogen storage disease, Hirschsprung's disease, intestinal neuronal dysplasia, and colorectal cancer. 217 references.

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Ulcerative Colitis. BMJ. 320(7242): 1119-1123. April 22, 2000.

This review covers ulcerative colitis, a relapsing and remitting disease characterized by acute noninfectious inflammation of the colorectal mucosa. Several of the current clinical and therapeutic issues in ulcerative colitis include: medical treatment options for relapse and for maintenance of remission; management of the minority of patients who develop a severe life threatening relapse or chronic unremitting disease; surgical treatment of ulcerative colitis; and long term complications in patients with extensive disease, namely colonic and biliary cancers and sclerosing cholangitis. Ulcerative colitis may present at any age, but the anatomical distribution of involvement at presentation is different between children and adults. All patients with bloody diarrhea need to have infection excluded. Outpatient rigid sigmoidoscopy is the best method of diagnosing the nature of inflammation. The extent of inflammation may be established by total colonoscopy (or a double contrast barium enema). The mainstays of treatment are rectal and systemic 5 ASA derivatives and corticosteroids, with azathioprine in steroid dependent or resistant cases. Restorative proctocolectomy with ileal pouch-anal anastomosis should be considered in every patient in whom colectomy is contemplated. 3 figures. 4 tables. 51 references.

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Virtual Colonoscopy: A Review. Practical Gastroenterology. 24(2): 38, 40-42, 50, 57-58. February 2000.

Virtual colonoscopy (computed tomography or CT colonoscopy) is a new imaging technique with the potential to alter current diagnostic approaches to colonic diseases, particularly colon cancer screening. This article describes the technique, clinical status, limitations and other potential indications of this new technology. Although colonoscopy remains the gold standard test, public acceptance for cancer screening remains poor. Virtual colonoscopy can detect colonic lesions greater than 1cm with an accuracy comparable to colonoscopy and is superior to barium enema for the detection of medium sized polyps. Because it offers the patient a relatively quick, minimally invasive, more comfortable and safer procedure, it may have greater patient acceptance than current recommended screening strategies. Similar to colonoscopy and barium enema, bowel cleansing prior to CT colonoscopy is essential to avoid stool or fluid artifacts. The cleansed colon is first distended throughout its length with either room air or carbon dioxide. The CT scan is then performed on a CT table. From the patients' perspective, the data acquisition phase typically takes no more than 10 minutes. However, significant limitations include the need for bowel preparation, a significant miss rate for flat or subcentimetric lesions, the inability to biopsy or remove these lesions once detected as well as cost issues. 2 figures. 4 tables. 27 references.

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