Introduction Patients with melaena with a normal upper gastrointestinal (GI) endoscopy often undergo colonoscopy, due to concerns they may have a caecal or right-sided colonic carcinoma. We investigated yield of colonoscopy in this group of patients, and the proportion with an entirely normal upper GI endoscopy, without any clinically relevant fi ndings. Methods This was a retrospective analysis of data collected prospectively within a single centre between January 2005 and September 2010. All patients undergoing colonoscopy for melaena were identifi ed. Only data from patients who had also undergone an upper GI endoscopy, with melaena as the primary indication, in the prior 3 months were included. Gender, age, comorbidity (American Society of Anaesthesiologists (ASA) score), quality of bowel preparation, extent of colonoscopy, colonoscopic fi ndings, and histopathology (where relevant) were recorded. A normal upper GI endoscopy, without clinically relevant fi ndings, was defi ned as one where none of severe erosive oesophagitis, non-bleeding varices, non-bleeding gastric or duodenal ulcer, multiple non-bleeding gastric or duodenal erosions, gastro-oesophageal malignancy, or nonbleeding angiodysplasia were reported. Results In total, 166 patients had colonoscopy for melaena with an upper GI endoscopy for the same indication in the previous 3 months. Of these, 139 (83.7%) had complete colonoscopy, and contributed data. Mean patient age was 66.6 years (range 22-92 years), and 87 (62.6%) were male. Median ASA score was 2. Quality of bowel preparation was adequate, or better, in 107 (77.0%) patients, poor in 17 (12.2%), and unreported in the remainder. A potential lower GI cause for melaena was found in 11 (7.9%) patients. Six had angiodysplasia, 4 histologically-confi rmed infl ammatory bowel disease or ulceration, and 1 (0.7%) a caecal cancer. Three other patients had visible blood or melaena, with no defi nite lower GI cause identifi ed. Excluding these 3 from the analysis, 102 (75.0%) of 136 had an entirely normal upper GI endoscopy, without clinically relevant fi ndings. 9 of 11 (81.8%) patients with and 93/125 (74.4%) without a lower GI cause of melaena at colonoscopy had an entirely normal upper GI endoscopy (p = 0.82). There were no signifi cant differences in patient age (p = 0.39), gender (p = 0.89), or ASA status (p = 0.32) between those with and without an identifi able lower GI cause for their melaena. Conclusion Up to 25% of patients who proceeded to colonoscopy had clinically relevant fi ndings at upper GI endoscopy that may have accounted for their presentation with melaena. However, an entirely normal upper GI endoscopy did not predict fi ndings at colonoscopy. Less than 1 in 10 patients with melaena who had colonoscopy had a lower GI cause detectable, and less than 1% had colon cancer. Competing interests None.
Cholangiocarcinoma is an aggressive malignancy of the bile ducts.It has a poor prognosis because of the poor early detection rate and limited treatment options. Surgery is usually the treatment of choice; however, it is limited to patients with early-stage disease. Therefore, it is important to understand and identify the symptoms of paraneoplastic syndromes in order to detect occult malignancies early, when they are still at a highly treatable stage. Effective treatment can then be offered to improve both oncologic outcomes and quality of life, thus minimizing morbidity and mortality. 1 Paraneoplastic syndromes are a group of rare syndromes that arise from immune cross-reactivity between malignant and normal tissues and result in tissue damage distant from the location of the malignancy. Paraneoplastic syndrome is very rare in cholangiocarcinoma. However, Rahman et al concluded that cholangiocarcinoma can be associated with various paraneoplastic syndromes involving multiple organ systems, including dermatological, neurological, renal and haematological manifestations. 2 Here, we report the first case of cholangiocarcinoma with paraneoplastic syndrome consisting of acute renal failure from
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