In this population-based study, CD and UC incidences increased dramatically in adolescents across a 24-year span, suggesting that one or more strong environmental factors may predispose this population to IBD.
SUMMARYAim: To rationalize decision making around the use of different non-steroidal anti-inflammatory drug (NSAID) treatment strategies in patients with varying degrees of gastrointestinal and cardiovascular risk. Methods: The panel comprised nine physicians (three rheumatologists, two internists, two gastroenterologists and two cardiologists) from geographically diverse areas practising in community-based settings (n ¼ 4) and academic institutions (n ¼ 5). A literature review was performed by the authors on the risks, benefits and costs of NSAIDs, cyclo-oxygenase-2-specific inhibitors and proton pump inhibitor co-therapy. The RAND/UCLA Appropriateness Method was used to rate 304 clinical scenarios as 'appropriate', 'uncertain' or 'inappropriate'. Results: In patients with no previous gastrointestinal event and not concurrently on aspirin (low risk), the panel rated the use of an NSAID alone as 'appropriate' for those aged < 65 years, and the use of an NSAID + proton pump inhibitor or cyclo-oxygenase-2-specific inhibitor + proton pump inhibitor as 'inappropriate'. For patients aged > 65 years and at low risk, an NSAID or cyclo-oxygenase-2-specific inhibitor alone was rated as 'uncertain'. For patients with a previous gastrointestinal event or who concurrently received aspirin, an NSAID alone was rated as 'inappropriate', and either a cyclo-oxygenase-2-specific inhibitor or an NSAID + proton pump inhibitor was rated as 'appropriate'. Finally, for patients with a previous gastrointestinal event and on aspirin, an NSAID or cyclo-oxygenase-2-specific inhibitor in conjunction with a proton pump inhibitor was rated as 'appropriate'. Conclusions: Clinicians and managed care entities need to balance the risks, benefits and costs of NSAIDs, cyclooxygenase-2-specific inhibitors and the prophylactic use of proton pump inhibitors. The guidelines given here can assist this process.
Original article 200Introduction ! Cancer of the colon and rectum (colorectal cancer [CRC]) is one of the most common cancers diagnosed in Western countries and is a major cause of cancer-associated morbidity and mortality [1,2]. In Europe, the annual age-standardized incidence of CRC is 35 and 55 per 100 000 in women and in men respectively [1]. The age distribution of CRC shows a predominance in patients > 50 years with less than 10 % of patients being younger than 50 years [3]. The mean age at diagnosis was found to range from 65 to 71.5 years [4]. CRC is the second major cause of cancer mortality in both women and men. While the survival rate for early-stage cancers is high, the survival rate for those diagnosed with widespread cancer is low. About 75 % of all new cases of CRC occur in asymptomatic individuals with no known predisposing factor for the disease except age (≥ 50 years old; average risk) [5]. The remaining cases occur in individuals with a family history of CRC or adenomatous polyps, or with a family history of hereditary nonpolyposis colorectal cancer (HNPCC), or with familial adenomatous polyposis (FAP) or attenuated FAP. Screening, which refers to the search for colorectal lesions in asymptomatic patients with no personal history of CRC or adenomas, appears to be the best option available to reduce CRC morbidity and mortality by early detection of CRC in individuals ≥ 50 years old. However, there is debate about the best screening method and about whether colonoscopy should be recommended for CRC screening. In April 2008, a multidisciplinary European expert panel was convened in Montreux, Switzerland, to discuss and develop criteria for the appropriate use of colonoscopy. This article presents the literature review on screening for CRC in asymptomatic individuals that was provided to Background and study aims: To summarize the published literature on assessment of appropriateness of colonoscopy for screening for colorectal cancer (CRC) in asymptomatic individuals without personal history of CRC or polyps, and report appropriateness criteria developed by an expert panel, the 2008 European Panel on the Appropriateness of Gastrointestinal Endoscopy, EPAGE II. Methods: A systematic search of guidelines, systematic reviews, and primary studies regarding colonoscopy for screening for colorectal cancer was performed. The RAND/UCLA Appropriateness Method was applied to develop appropriateness criteria for colonoscopy in these circumstances. Results: Available evidence for CRC screening comes from small case-controlled studies, with heterogeneous results, and from indirect evidence from randomized controlled trials (RCTs) on fecal occult blood test (FOBT) screening and studies on flexible sigmoidoscopy screening. Most guidelines recommend screening colonos-
The balance between risks and benefits of gastrointestinal endoscopy for a given patient is essential in defining the appropriate use of endoscopic procedures. The current literature suggests that gastrointestinal endoscopy infrequently results in major procedure-related morbidity and mortality, while cardio-respiratory events occur commonly. However, true complication rates may be underestimated due to inconsistencies in the types of complications reported. No formal reporting requirements exist, and most of the published studies on complications come from centres with highly-skilled endoscopists.
Iron-deficiency anemia (IDA) is a condition where objective iron deficiency is at the origin of the anemia. The World Health Organization (WHO) defines anemia as a hemoglobin value of < 120 g/l for nonpregnant women, and < 130 g/l for men. IDA is a very common condition, particularly in women. In industrialized countries, it is estimated that 23 % of pregnant women, 10 % of all women (15 -59 years), 4 % of men (15 -59 years) and 12 % of elderly individuals ≥ 60 years are anemic [1]. IDA is commonly (62 %) caused by chronic blood loss from the gastrointestinal tract. Peptic ulcerations are the commonest lesions found in the upper gastrointestinal tract, while cancers are one of the most common abnormalities discovered in the colon. Other causes of IDA include cumulative menstrual blood loss or pregnancy in premenopausal women, decreased gastrointestinal absorption (malabsorption syndromes), and chronic intravascular hemolysis, among others. Lower gastrointestinal bleeding (LGIB) usually refers to blood loss originating from a lesion distal to the ligament of Treitz [2], even though approximately 10 % of patients with hematochezia may have an upper gastrointestinal source of bleeding [3,4]. LGIB may manifest itself as hematochezia (rectal bleeding: visible bright red or maroon blood per rectum), as opposed to melena (dark stools), which is most often a manifestation of upper gastrointestinal bleeding. Acute LGIB is of recent duration (< 3 days) and may result in hemodynamic instability, rapid hemoglobin decrease and/or the need for blood transfusion [5]. Chronic LGIB corresponds to the passage of blood per rectum over > 3 days. The patient with chronic bleeding may present with fecal occult blood (IDA and/or positive fecal occult blood test Background and study aims: To summarize the published literature on assessment of appropriateness of colonoscopy for the investigation of iron-deficiency anemia (IDA) and hematochezia, and report appropriateness criteria developed by an expert panel, the 2008 European Panel on the Appropriateness of Gastrointestinal Endoscopy, EPAGE II. Methods: A systematic search of guidelines, systematic reviews and primary studies regarding the evaluation and management of IDA and hematochezia was performed. The RAND/UCLA Appropriateness Method was applied to develop appropriateness criteria for colonoscopy for these conditions. Results: IDA occurs in 2 % -5 % of adult men and postmenopausal women. Examination of both the upper and lower gastrointestinal tract is recommended in patients with iron deficiency. Colonoscopy for IDA yields one colorectal cancer (CRC) in every 9 -13 colonoscopies. Hematoche-
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