American College of Gastroenterology

First-degree relatives of patients with celiac disease and patients with dermatitis herpetiformis, type 1 diabetes mellitus, and autoimmune thyroid disease are among those for whom testing is advisable.

The American College of Gastroenterology and the 80% by 2018 Colorectal Cancer Initiative: A Multifaceted Approach to Maximize Screening Rates

Colorectal cancer is one of the most common cancers in the UK after breast and lung cancer, with approximately 40 000 new cases registered each year. Occurrence of colorectal cancer is strongly related to age, with almost three-quarters of cases occurring in people aged 65 or over. Colorectal cancer is the second most common cause of cancer death in the UK. Around half of people diagnosed with colorectal cancer now survive for at least 5 years after diagnosis. The age standardized mortality rate for colorectal cancer has been decreasing for the past 25 years indicating an improvement in prognosis that may be related to improvements in disease management. These new ACPGBI guidelines reflect the updated and continued need not to be complacent with new evidence since 2007 that for example excess body weight, lack of exercise and alcohol intake are important risk factors. The first ACPGBI guideline on colorectal cancer was prompted by evidence of poorer survival rates in England relative to the United States of America and parts of Europe. Comparative data now indicate that survival in England and Wales, whilst improving, continues to be below average compared with Europe although this may be accounted for in part by variations in data quality. New developments in the treatment of patients with colorectal cancer necessitated a revision of these guidelines (last updated in 2007). The most radical changes have been in the area of non-surgical oncology but prevention, screening, family history, symptoms, investigations and surgical treatment have also been updated. Laparoscopic techniques, enhanced recovery (ERAS), deferral of surgery and complete pathological response of rectal cancer feature prominently in this update. The importance of Clinical Outcome Publication and survivorship are new additions. These new guidelines are the culmination of many national collaborations to improve the practice and treatment of patients with colorectal cancer. The involvement of stakeholders from around the UK, including members of the public and our Patient Liaison Group have contributed significantly. The processes used are systematic reviews with grading of quality of evidence and strength of recommendations. The current update aims to clarify several recent developments and provide links to relevant published material. It is hoped that these guidelines will offer a framework for clinicians and multidisciplinary teams to tailor treatments to suit individual patients. Managers, patients and commissioners of care may also find the document of interest. It is also hoped to direct future research and debate in a rapidly evolving field, aiming to drive continued improvements in the management of this condition.

Overview It is now recognized that many ulcers in the upper GI tract are the result of an infection, and that stress (as important as it may be for generating some GI symptoms) does not cause ulcers. Since the discovery of H. pylori by Marshall and Warren, we have also learned that the pathogen is linked with many other ailments, including marginal T cell lymphoma (aka MALT), gastric adenocarcinoma, functional dyspepsia, gastroesophageal reflux disease (GERD), lymphocytic gastritis, Menentrier's disease, dental caries, and iron deficiency anemia, among many others. It is noted that some of these links are proven and accepted (e.g. MALT), others are speculative or controversial (e.g. GERD, caries, iron deficiency). At the present time the prevalence of H. pylori has fallen in much of the Western world, however it remains a very important pathogen that continues to generate a large worldwide burden of illness. There is no question that there is an ongoing need to test and treat for H. pylori in our patients but in light of evolving data on diagnosis and treatment of H. pylori, this review will focus in a case-based style the following: when we should test, how we should test, and how we should treat this highly prevalent pathogen. This paper draws heavily from the American College of Gastroenterology management guidelines (see references), and focuses on salient clinical teaching points using up-to-date information on testing and treatment of H. pylori. Each vignette, below, presents a common clinical scenario, followed by a brief discussion of whether and how to test and treat H. pylori. Vignette #1: Uncomplicated GERD A 28-year-old woman is referred to you for ‘acid reflux’ symptoms for the past 3 years. She describes the pain as sharp, worse with eating, and occasionally associated with regurgitation of food, especially in the recumbent position. She received a histamine-2 receptor antagonist for these symptoms, but there was only partial improvement. She has not experienced unintended weight loss, rectal bleeding, vomiting, or dysphagia. Examination now does not reveal alarming features. Guaiac is negative and a complete blood count is normal. Which of the following should you do next? Start a 4-week trial of therapy with a proton pump inhibitor Refer for prompt esophagogastroduodenoscopy Test for H. pylori and treat if positive Lifestyle modifications and follow-up and for additional case vignettes http://www.worldendo.org/news-item-20111201.html

To increase colorectal cancer screening among urban minorities, New York Presbyterian Hospital/Columbia University, with support from the New York City Department of Health and the Citywide Colon Cancer Control Coalition (C5), instituted a patient navigation and direct endoscopic referral system. We assessed the effect of this program on the volume of colonoscopy in this institution, which caters to a socioeconomically diverse patient population. We compared colonoscopy volume during the first year of the navigator program with the volume during the year before this program. We stratified on Medicaid status to assess the secular trend of screening rates. To assess quality during this period, we measured cecal intubation rates, preparation quality, and adenoma detection rates. Of the 749 patients assessed by the patient navigators, 678 (91%) underwent colonoscopy. Colonoscopy volume among the Medicaid outpatients increased by 56% (957 to 1489). Adenoma detection was 27% and the cecal intubation rate was 97%. Comparing navigated patients with the nonnavigated Medicaid outpatients, preparation quality was superior (34% vs. 40% suboptimal, P=0.0282), although preparation quality remained inferior to that of private patients (20% suboptimal, P<0.0001). Volume of the colonoscopy increased, coinciding with the onset of the patient navigation program. This increase was nearly entirely owing to a rise in the colonoscopies among Medicaid outpatients, the principal focus of the navigator program. This increase in quantity was accomplished while maintaining an overall high level of quality as measured by cecal intubation rates and adenoma detection, although preparation quality requires further efforts at improvement.

This expert consensus document was developed by the American College of Cardiology Foundation (ACCF), the American College of Gastroenterology (ACG), and the American Heart Association (AHA). Expert consensus documents inform practitioners, payers, and other interested parties of the opinion of ACCF and document cosponsors concerning evolving areas of clinical practice or medical technologies. Expert consensus documents cover topics for which the evidence base, experience with technology, or clinical practice is not considered sufficiently well developed to be evaluated by the formal ACCF/AHA Practice Guidelines process. Often, the topic is the subject of considerable ongoing investigation. Thus, the reader should view the expert consensus document as the best attempt of the ACCF and document cosponsors to inform clinical practice in areas where rigorous evidence may not yet be available. To avoid actual, potential, or perceived conflicts of interest that may arise as a result of industry relationships or personal interests among the writing committee, all members of the writing committee, as well as peer reviewers of the document, are asked to disclose all current healthcare-related relationships and those existing 12 months before initiation of the writing effort. The ACCF Task Force on Clinical Expert Consensus Documents (CECD) reviews these disclosures to determine which companies make products (on market or in development) that pertain to the document under development. Based on this information, a writing committee is formed to include a majority of members with no relevant relationships with industry (RWI), led by a chair with no relevant RWI. Authors with relevant RWI are not permitted to draft or vote on text or recommendations pertaining to their RWI. RWI are reviewed on all conference calls and updated as changes occur. Author and peer reviewer RWI pertinent to this document are disclosed in Appendixes 1 and 2, respectively. Additionally, to ensure complete transparency, …

Irritable pouch syndrome (IPS) is a functional disease in patients with ileal pouch-anal anastomosis following colectomy for ulcerative colitis (UC). The pathophysiology of IPS is characterized by the presence of visceral hypersensitivity, similar to that seen in irritable bowel syndrome. However, the exact etiology and pathogenesis of IPS are not known. We hypothesized that serotonin-containing enteroendocrine cells or enterochromaffin (EC) cell hyperplasia and alterations in the mucosal immune cells may contribute to the patients' symptoms. The aim of the study was to assess EC cell hyperplasia and alterations in the mucosal immune cells in IPS. The Pouchitis Disease Activity Index (PDAI) was used to quantify symptoms and mucosal inflammation in 36 patients with IPS and 25 patients with normal pouches. The histology and immunohistochemistry of pouch mucosal biopsies were assessed by a blinded gastrointestinal pathologist for intraepithelial lymphocytes (IEL), CD3+ T cells, CD25- (interleukin [IL]-2 receptor), tryptase- (mast cells), and serotonin-expressing cells. The numbers of IEL and immune-stained cells were compared between the two groups. Both groups were compatible demographically in terms of age, gender, duration of UC, stage, indication, and duration of the pouch surgery. There were no differences in the number of IEL, CD3+ T cells, CD25+ cells, and mast cells between the IPS and normal control groups. However, there were a significantly larger number of EC cells in the IPS group than that in the control group (54.8 +/- 24.9 vs 36.7 +/- 17.5 per 4 200x epithelial cells, P < 0.005). The number of EC cells appeared to be correlated with the symptom score (r = 0.276, P= 0.032). There were no significant correlations between the PDAI endoscopy and histology scores and the number of EC cells or between the PDAI scores and the number of IEL or other immune-stained cells. A greater number of EC cells were found in the IPS group than the normal pouch group, and the number of EC cells appeared to be correlated with the clinical symptoms of IPS. EC cell hyperplasia may be a contributing mechanism of visceral hypersensitivity and symptoms in IPS.

Shafran Gastroenterology CenterWinter Park, Florida The data was originally presented at the American College of Gastroenterology Annual Scientific Meeting, October 12–17, 2007, Philadelphia, PA.