QG and SET are equivalent in their impact on many aspects of psychological function in cancer patients. However, SET leads to greater improvements in exercise capacity and helps reduce some symptoms. The reduction in beneficial effect of SET on exercise function when offered as the second intervention is a new finding that warrants further study.

Both stent placement and surgical diversion provide durable improvement in symptoms from LBO, as readily assessed by the Colon Obstruction Score. QoL is difficult to assess in terminal cancer patients, but colon stent placement is associated with improved overall QoL and QoL related to gastrointestinal symptoms.

The aim of this study was to determine the incidence and the clinical and pathological features of gastrointestinal stromal tumors within a nonselected, well-defined Canadian Health Region. A population-based cohort study of all adult patients diagnosed with gastrointestinal stromal tumors was conducted in the Calgary Health Region from April 2000 to March 2004. All charts and pathological specimens were reviewed for clinical, histological, and antigenic features. The age-adjusted and gender-adjusted annual incidence rate was 0.91/10(5) person-years. There was a trend for increased incidence with routine use of CD117. The only identified risk was advancing age (age >or=50; rate ratio = 4.6; P = .0006). All samples were positive for CD117. At presentation, 19% were at intermediate and 19% were at high risk of becoming malignant, with 14% being overtly metastatic. This is the first North American study to define the incidence and the clinical and pathologic features of gastrointestinal stromal tumors based on current diagnostic criteria.

Small intestinal permeability is increased in a proportion of healthy spouses of patients with Crohn's disease. The presence of abnormal permeability studies in patients with Crohn's disease and a proportion of their healthy close contacts suggests that this phenomenon is caused by environmental factors.

A 52-year-old previously healthy man experienced a 30-pound weight loss over 2 months. The patient was newly diagnosed with diabetes mellitus, and an abdominal ultrasound identified a pancreatic mass. Clinical history included crampy abdominal discomfort localized to the right lower quadrant, which had started 2 months earlier. No other symptoms suggestive of biliary obstruction or pancreatic insufficiency were present. Past medical history included asthma but was otherwise unremarkable, with no history of alcohol abuse or drug exposure. Findings on physical examination were normal, as were all results of initial laboratory studies, including lipase and liver enzyme levels, liver function, urinalysis results, creatinine level (66 µmol/L), levels of tumour markers (cancer antigen 19-9, carcinoembryonic antigen) and complement levels.A CT scan of the abdomen showed a bulky and heterogeneous mass in the pancreatic head, neck and uncinate (Fig. 1A), with encasement of the superior mesenteric vein (Fig. 1B). Although multiple retroperitoneal lymph nodes were identified, none was enlarged enough to fulfill the size criteria for metastasis. Three solid lesions were noted in the left kidney, with the largest measuring 1.7 cm in diameter; 3 lesions were identified in the right kidney, with the largest measuring 1.5 cm. The contrast-enhanced scans demonstrated that the lesions did not represent hyperdense cysts (Fig. 1C). A subsequent MRI confirmed the CT findings.An endoscopic ultrasound-guided fine-needle biopsy of the pancreatic mass was performed, and cytology of the aspirate revealed no malignant cells. However, we felt that the diagnosis of pancreatic cancer could not be completely ruled out, so we performed a percutaneous biopsy of the pancreatic lesion. Needle-core biopsies of the pancreas demonstrated morphology suggestive of autoimmune pancreatitis. The pancreatic tissue was almost completely replaced with fibrous tissue and an inflammatory infiltrate composed of lymphocytes and plasma cells, which were positive for IgG4 ( Fig. 2A and B). A biopsy of the duodenum revealed duodenitis with loss of mucosal villi and extensive lymphoplasmacytic and eosinophilic infiltration, which stained positive for IgG4.Laparoscopic resection was performed of one of the renal lesions, which proved to be non-neoplastic and revealed chronic tubulointerstitial nephritis with extensive interstitial fibrosis. As with the previous biopsies, there was diffuse inflammatory lymphoplasmacytic and eosinophilic infiltrate in the interstitium, which resulted in tubular obliteration ( Fig. 3A and B). No microorganisms or viral inclusions were identified. On immunochemistry there was a mixture of T and B lymphocytes; plasma cells marked uniformly for IgG and IgG4 and showed no light-chain restriction. Subsequent laboratory studies revealed elevated serum IgG and IgG4 levels. Serum electrophoresis demonstrated a slightly elevated gamma globulin level, while rheumatoid factor and antinuclear antibody levels were normal. No fresh renal tissue ...

Cardiac disease in association with inflammatory bowel disease (IBD) is uncommon. Reports include pericarditis, pericardial effusion, myocarditis, myocardial infarction, endocarditis and arrythmias. Myocardial inflammation related to IBD may be due to a drug hypersensitivity reaction or micronutrient deficiency, or may be secondary to the underlying IBD as an extraintestinal manifestation. In this setting, myocarditis usually presents as congestive heart failure and/or refractory arrhythmia. Prognosis varies among reported cases, including complete recovery, remission with recurrence and fatal disease. Treatment of myocarditis has included aminosalicylates and immunosuppressive medications. Recently, newer therapies for IBD have been developed, such as tumour necrosis factor-alpha (TNF-a) antagonists. The present report describes a case of a 46-year-old man with clinical and endoscopic evidence of moderately active colonic Crohn's disease who developed congestive heart failure due to giant cell myocarditis. Little clinical improvement occurred with immunosuppressive therapy. Only after the addition of etanercept, a TNF-a p75 receptor antagonist, did complete clinical resolution occur. These authors conclude that the use of TNF-a antagonists may be considered in the treatment of life-threatening extraintestinal manifestations of inflammatory bowel disease.

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BackgroundDemands on gastroenterology are growing, as a result of the high prevalence of digestive diseases, the impact of colon cancer screening programs and an aging population. Prioritizing referrals to gastroenterology would assist in managing wait times. Our objectives were (1) to assess whether there were consistent criteria to guide referrals from family physicians for gastroenterological outpatient consultation and (2) to determine if there were different levels of urgency or priority in referral criteria.MethodsWe conducted a scoping review, searching Medline, Embase and Cochrane databases from 1997 to 2009, using the terms referral, triage, consultation and at least one from a list of gastroenterology-specific search terms. Of 2978 initial results, 51 papers were retrieved, and 20 were retained after review by two reviewers. Additional publications were identified through hand searches of retained papers, website searches and nomination by a panel of specialists.ResultsThirty-four papers, reports or websites were retained. No referral criteria covered the spectrum of disorders that might be referred by family physicians to gastroenterologists. Criteria for referral were most commonly listed for suspected colorectal cancer, followed by suspected upper GI cancer, hepatitis, and functional disorders.ConclusionsA clinical panel comprised of gastroenterologists and primary care providers, informed by this literature review, are completing the work of formulating a Gastroenterology Priority Referral Score, and plan to test the reliability and validity of the tool for determining the relative urgency for referral from primary care to gastroenterology.