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Common Bowel Disorders

Common Bowel Disorders

by Samita Garg, MD | October 2nd, 2023

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Dr. Samita Garg is a board certified , fellowship trained gastroenterologist. She received her medical degree at the St. Louis University School of Medicine, and completed her residency in internal medicine at the University of Colorado Hospital. Dr. Garg’s fellowship training in gastroenterology was done at the University Hospitals Case Medical Center in Cleveland, Ohio. She then practiced as a staff gastroenterologist at Cleveland Clinic Foundation. She is currently on Staff at Porter Adventist Hospital in Denver, CO. Her philosophy of care is to provide high-quality patient focused care with an emphasis on improving patient outcomes and achieving patient satisfaction.

Up-to-Date Screening Cuts CRC Deaths by 62%

Modifiable risk factors such as inappropriate screening and poor follow-up drive mortality

  • by Diana Swift, Contributing Writer

Being up to date on screening substantially reduced the risk of death from colorectal cancer (CRC) in retrospective findings from two U.S. healthcare systems that had high rates of screening uptake.

The authors, Chyke A. Doubeni, MD, MPH, of the University of Perelman School of Medicine of the University of Pennsylvania in Philadelphia, and colleagues reported that among 1,750 CRC deaths, 75.9% occurred in people who had rectifiable failures in the screening process -- especially lack of follow-up on abnormal findings -- and these lapses significantly increased the risk of CRC death. Fewer than a quarter of deaths occurred in individuals whose screening was up to date.

The study, published in Gastroenterology, showed that CRC death was associated with higher odds of failure to screen or failure to screen at appropriate intervals, for an odds ratio (OR) of 2.40 (95% CI 2.07-2.77), while failure to follow up on abnormal results correlated with an OR of 7.26 (95% CI 5.26-10.0).

"Our study points to the importance of getting screened on time, keeping up to date on screening, and ensuring that follow-up testing occurs when the test is abnormal or incomplete," Doubeni told MedPage Today.

The most lapses in the screening process were failure to ever screen or to screen at appropriate intervals. About 8% of deaths occurred in those who did not receive follow-up after an abnormal screen.

The researchers looked at patients ages 50 to 90 in the Kaiser Permanente systems of Northern and Southern California who died of CRC during 2006 to 2012 after being enrolled for at least 5 years before diagnosis. The patients were compared with a matched cohort of cancer-free patients. Tests included colonoscopy, sigmoidoscopy, barium enema, and both fecal occult blood (FOBT) and fecal immunochemical (FIT) tests received in the 10 years before diagnosis.

The average age of patients at diagnosis was 70, and 49.5% were female, 67.0% were non-Hispanic white, 12.0% were non-Hispanic black, 9.4% were Hispanic, and 8.9% were Asian-Pacific Islander.

Significantly, more than three-quarters of those considered to be dying from CRC had an identifiable screening failure, including failure to screen (n=591, 33.8%), inappropriate screening intervals (n=574, 32.8%), no surveillance (n=22, 1.3%), or lack of follow-up (n=141, 8.1%). Screening was up to date in 24.1% (n=422) as of the diagnosis date.

Among those with follow-up after an abnormal result, 103 had a positive FOBT, and of these, 58 (57.3%) had a documented order for diagnostic colonoscopy (n=42), sigmoidoscopy (n=14), or barium enema (n=2). Of patients with follow-up, 60 received further FOBT after an initial positive, six had only barium enema, and two had only sigmoidoscopy.

The majority of the tumors in patients who were up to date with screening by any test or indication were located in the right colon (61.8%, n=261), regardless of test type: colonoscopy (58.6%, n=41/70), sigmoidoscopy (68.5%, n=100/146), or fecal tests (58.6%, n=106/181). Failures to screen were more common in those with rectal or left colon cancers than those with right colon cancers (P=<0.01).

In patients with screening or follow-up failure, right colon cancers accounted for 45.3% (n=538) of all failures to screen combined, and 58.9% (n=83) of failures of follow-up. Failure to screen was associated with fewer visits to primary care physicians, suggesting that having a regular family doctor may affect participation.

In the 3,486 cancer-free controls, 44.6% were up to date on screening and these had a reduced risk of CRC death, with an odds ratio of 0.38 (95% CI 0.33-0.44).


Failure to screen or to screen at appropriate intervals was evident in 67.8% of patients who died from CRC versus 53.2% of cancer-free patients. Failure to follow up on abnormal results occurred in 8.1% of patients who died from CRC versus 2.2% of cancer-free patients.

In a community-based study, Doubeni's group had previously reported that 84% of the screening exposures in people who died of CRC occurred within 1 year of diagnosis, compared with 3% in matched cancer-free patients, suggesting that screening occurred too late in the disease course to be protective and reinforcing the potential benefits of timely initiation of screening.

Doubeni said that the 8% of individuals dying from CRC after an abnormal screening result without appropriate follow-up and the strong seven-fold association with mortality risk underscores the need for interventions to optimize the effectiveness of screening in preventing CRC deaths. A 2017 systematic review suggested that having patient navigators and sending providers reminders or performance data may improve follow-up after positive fecal tests, but evidence on effective system-level interventions is insufficient and this area needs further research. And a recent Kaiser Permanente study reported that directly mailing FIT kits to patients' homes modestly increased participation rates.

"Our study suggests that even in settings with high screening uptake, access to and timely uptake of screening, regular re-screening, appropriate use of testing given patient characteristics, completion of timely diagnostic testing when screening is positive, and improving the effectiveness of screening tests, particularly for right colon cancer, remain important areas of focus for further decreasing CRC death," Doubeni and associates wrote.


This study was supported by the National Cancer Institute.

Doubeni is a member of the U.S. Preventive Services Task Force; one co-author is editor-in-chief of Gastroenterology, and the remaining co-authors reported having no conflicts of interest.



Peanut Gastro-Intestinal Delivery Oral Immunotherapy in Adolescents

By Jean?Luc FauquertElodie MichaudBruno PereiraLise BernardNelly Gourdon?DuboisPaul?Olivier RouzaireEmmanuelle RochetteEtienne MerlinBertrand Evrard



Oral immunotherapy to peanut is effective in desensitizing patients but has significant side effects including anaphylaxis and gastro?intestinal symptoms. In most protocols peanut is administered in a vehicle food.


In an exclusively adolescent population, we tested a new approach using sealed capsules of peanut (Gastro-Intestinal Delivery Oral Immunotherapy or GIDOIT) in order to bypass the upper gastro-intestinal tract. The primary aim was to assess the efficacy of the oral build?up phase of GIDOIT and the secondary aim to analyse its safety.


Adolescents with a history of a clinical allergic reaction after peanut ingestion were included in a two-armed, parallel-design, individually randomised, double-blind, placebo-controlled, multicentre trial after a positive double-blind placebo-controlled oral food challenge (DBPCFC1). A central randomisation centre used computer generated tables to allocate treatments. Peanut (or placebo) capsules were ingested daily over a period of 24 weeks with increments every 2 weeks from 2 to 400 mg of peanut protein. Primary outcome was tolerance of 400 mg of peanut protein at DBPCFC2.


Thirty patients were included between September 2013 and May 2014. At DBPCFC2, unresponsiveness to 400 mg of peanut protein was achieved in 17/21 peanut?group patients (2 withdrawn patients) and 1/9 in the placebo group (Intention-to-treat analysis, p < 0.001, absolute difference=0.7, 95%CI; 0.43; 0.96). Oropharyngeal symptoms were equally frequent in both groups. No dysphagia or other signs of eosinophilic oesophagitis occurred. Digestive adverse events were more frequent in the treated group (p=0.02), but mild and without compliance issues. Only one severe advent event led to withdrawal in a patient who ingested twice the investigated treatment. Peanut specific humoral immune responses were modulated.


The GIDOIT protocol demonstrated clinical and immunological efficacy and had an acceptable level of safety with weak oropharyngeal symptoms, no dysphagia, mild digestive events and few severe systemic adverse events.



ORLANDO — The use of artificial intelligence during colonoscopy appears to boost the accuracy and sensitivity of adenoma detection, even for lesions as small as 5 mm, according to recent studies.

The goal of integrating this technology into routine colonoscopy is to get the adenoma detection rate closer to the 50% reported in studies of screening-age populations, said William Karnes, MD, from the University of California, Irvine.

"Adenoma detection rates among different colonoscopists vary between 7% and 53%. The adenoma detection rate should equal prevalence," he told Medscape Medical News.

Convolutional neural network technology was able to distinguish between images with and without polyps with 96% accuracy in a study of 9000 screening colonoscopy images, he reported at the World Congress of Gastroenterology 2017.


The machine-learning system can read up to 170 images per second, making it "easily applied to live video," said Dr Karnes when he presented the research, which won the 2017 Presidential Poster Award for Colorectal Cancer Prevention.

"Artificial intelligence for polyp detection has the potential to help all colonoscopists achieve detection rates closer to true prevalence, and to further reduce the risk of interval colorectal cancers," he added.

The adenoma detection rate should equal prevalence.

Another computer-aided system, known as EndoBRAIN artificial intelligence, is easy to use and provides an automatic diagnosis at the push of a button, reported Yuichi Mori, MD, from Showa University in Shinagawa-ku, Japan.

"Recognizing a lesion as neoplastic is very useful information during a colonoscopy," Dr Mori emphasized at the recent United European Gastroenterology (UEG) Week 2017. With EndoBRAIN, lesions identified as neoplastic can be considered as such "with very high confidence."


Gut bacteria and the rise in IBD incidence in Canadian children

The overall incidence of Inflammatory Bowel Disease IBD in children in Canada is one of the highest in the world and is on the rise. It has increased from 7.9 per 100,000 children in 1999, to 10.6 per 100,000 in 2009.

As reported by Eric Benchimol, MD, and colleagues, the incidence of IBD has stabilized in children over the age of 5 years. However, the incidence is rising rapidly in children under 5-years-old. These are important findings, since these children will live longer with the disease.Data came from five provinces -- Alberta, Manitoba, Nova Scotia, Ontario, Quebec -- and comprised 79.2% of the Canadian population.

Out of the total of 5,214 new cases, 3,462 were diagnosed with Crohn's disease, 1,382 ulcerative colitis, and 279 unclassifiable.

Prevalence at the end of the study period in Canada was 38.25 per 100,000 children, with an increase of 4.56% per year over time.

The cause of the increase in IBD cases was not identified. However, one possibility is that a change in gut bacterial flora related to early life exposure to antibiotics, diet, or lower levels of vitamin D in Canadians may be responsible.

 Benchimol E, et al "Trends in epidemiology of pediatric inflammatory bowel disease in Canada: distributed network analysis of multiple population-based provincial health administrative databases" Am J Gastroenterol 2017; DOI: 10.1038/ajg.2017.97.

1 Comment

Gerond Lake-Bakaar
Posted by Gerond Lake-Bakaar
Thursday, 1st June 2017 04:09am

This is a very interesting topic. Antibiotics are indeed a possibility. However, with improving cleanliness and hygiene, there is a possibility that the gut may be less exposed to environmental antigens.

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