Haemorrhoids, rectal prolapse, anal fissure, peri-anal fistulae and sexually transmitted diseases

Anorectal disorders like haemorrhoids, rectal prolapse, anal fissures, peri-anal fistulae and sexually transmitted diseases are bothersome benign conditions that warrant special attention. They, however, can all be diagnosed by inspection or proctoscopy (sexually transmitted proctitis). Constipation can play an underlying role in haemorrhoids, rectal prolapse and anal fissures, and it is important to treat these conditions in order to avoid recurrences. Haemorrhoids and anal fissures are generally treated conservatively and surgery is seldom required. Rectal prolapse and cryptoglandular peri-anal fistulae are treated surgically. In a recurrent peri-anal fistula, the fistular tract needs to be visualised with anal ultrasound or magnetic resonance imaging (MRI). There are different techniques available for this evaluation, and care must be taken not to damage the anal sphincter. Peri-anal fistulae in Crohn's disease are treated conservatively and surgery is only required in cases with abscesses. Sexually transmitted proctitis needs to be adequately recognised and treated according to the infectious agent. (C) 2009 Elsevier Ltd. All rights reserve

IJzergebreksanemie bij 80-plussers

Iron-deficiency anaemia in very old patients is a frequent finding; this often poses a diagnostic dilemma for the physician. For example, should additional testing take place? And if so, what kind of tests? Is prescribing iron supplement therapy and adopting an expectative course sufficient? The two cases in this article illustrate different treatment strategies. If doubts about which strategy to choose arise, it is recommended that iron first be supplied and the effect of this treatment checked after three weeks. The haemoglobin level should have risen at least 0.7 mmol/l. If there has been no effect, supplemental (endoscopic) examinations may be considered, provided they meet a therapeutic goa

Duration of antibiotic therapy for cholangitis after successful endoscopic drainage of the biliary tract

BACKGROUND: Drainage of the obstructed biliary tree is the mainstay of therapy for patients with acute cholangitis; antibiotic therapy is complementary. It is unknown whether it is necessary to continue therapy with antibiotics once biliary drainage is achieved and signs of systemic inflammation have subsided. METHODS: Patients who presented with acute cholangitis and were successfully treated at ERCP were studied retrospectively. Patients were followed for 6 months after ERCP. RESULTS: Eighty patients fulfilled study criteria. In 46% of patients blood cultures grew microorganisms. All patients recovered from the episode under study. Antibiotic therapy after ERCP was given for a median duration of 3 days (range: 0-42). Forty-one patients received antibiotic therapy for 3 days or less, 19 for 4 or 5 days, and 20 patients longer than 5 days. The 3 groups were well-matched. In none of the patients did the index episode of cholangitis result in a secondary complication not present at the time of ERCP. The percentage of patients with recurrent cholangitis (24%) was not statistically different for the 3 groups (p = 0.80). CONCLUSIONS: Short-duration antibiotic therapy (3 days) appears sufficient when adequate drainage is achieved and fever is abatin

Infliximab treatment for Crohn's disease: One-year experience in a Dutch academic hospital

The aim of this study was to report the 1-year clinical experience with infliximab treatment for Crohn's disease (CD) in the Netherlands. All 73 CD patients receiving infliximab infusions were prospectively followed during I year after the drugs' registration in the Netherlands. Clinical response and adverse events were assessed for both active luminal disease as well as fistulous disease. A total of 2121 infusions were administered to 57 patients with active luminal CD and 16 patients with fistulous CD. The mean duration between infusions was 60 days. In 17% of patients, adverse events were recorded, of which one was serious. The response rate was 81% in active luminal CD and 87% in fistulous disease. Response rates were highest in patients receiving concomitant methotrexate as maintenance therapy. Steroids could successfully be tapered off in 73% of responding luminal CD patients and 100% of responding CD patients with fistulae. Eleven patients showed a loss of response to continuous infliximab readministration. Our clinical experience with infliximab for active luminal and fistulous CD showed that the administration is safe, effective, and has high steroid-sparing efficacy. Higher response rates were seen with methotrexate as concomitant medicatio

Transition of adolescents with inflammatory bowel disease from pediatric to adult care

Pediatric Inflammatory Bowel Disease (IBD) patients eventually need to transition to adult settings. Transition is of interest in many chronic illnesses with childhood onset. Pediatric providers should understand adult providers' expectations to better prepare their patients. Using a recent North American survey, we explored the insights of adult gastroenterologists in the Netherlands. The survey was sent to 288 Dutch adult gastroenterologists. Respondents indicated the importance of various transition issues, and reported which problems occurred often in their practice. They also evaluated importance and personal competence regarding uniquely adolescent medical issues. A response rate of 47% was achieved. Patients' ability to discuss IBD impact on overall daily life (60%), knowledge of their medications (53%) and impact of substance use on their health (53%) were often problematic. Patients' ability to attend the visit alone (12%) or identify health care providers (9%) were infrequently problematic. While transfer of accurate medical history by pediatricians was ranked of highest importance, it was rarely problematic (14%). Academic and younger physicians reported a higher frequency of problems. Dutch gastroenterologists reported less problems than their American colleagues. Many respondents deemed medical (94%) and developmental (89%) issues in adolescence important. However, fewer respondents reported competency regarding those issues (61% and 34%, respectively). Conclusion: Pediatric providers should focus patient education on areas recognized as important and problematic by adult providers. Adolescent medical and developmental issues should be incorporated in specialist training. Dutch providers report less problems, perhaps due the proximity of pediatric and adult health facilities

Gastroesophageal reflux - Prevalence in adults older than 28 years after correction of esophageal atresia

Objective: To study the incidence of gastroesophageal reflux (GER) related complications after correction of esophageal atresia (EA). Summary Background Data: The association of EA and GER in children is well known. However, little is known about the prevalence of GER and its potential complications in adults who have undergone correction of EA as a child. Methods: Prospective analysis of the prevalence of GER and its complications over 28 years after correction of EA by means of a questionnaire, esophagogastroscopy, and histologic evaluation of esophageal biopsies. Results: The questionnaire was returned by 38 (95%) of 40 patients. A quarter of the patients had no complaints. Swallowing solid food was a problem for 13 patients (34%), and mashed foods for 2 (5%). Heartburn was experienced by 7 patients (18%), retrosternal pain by 8 (21%). However, none of the patients were using antireflux. medication. Twenty-three patients (61%) agreed to undergo esophagogastroscopy, which showed macroscopic Barrett esophagus in 1 patient, which was confirmed by histology. One patient developed complaints of dysphagia at the end of the study. A squamous cell esophageal carcinoma was diagnosed and treated by transthoracic subtotal esophagectomy. Conclusions: This study shows a high incidence of GER-related complications after correction of EA, but it is still very disputable if all EA patients should be screened at an adult ag

CT colonography and colonoscopy: Assessment of patient preference in a 5-week follow-up study

PURPOSE: To prospectively evaluate short- and midterm patient preference of computed tomographic (CT) colonography relative to colonoscopy in patients at increased risk for colorectal cancer and to elucidate determinants of preference. MATERIALS AND METHODS: Consecutive patients at increased risk for colorectal cancer underwent CT colonography prior to scheduled colonoscopy. Patient experience and preference were assessed both directly after the examinations and 5 weeks after the examinations. Differences in pain, embarrassment, discomfort, and preference were assessed with the Wilcoxon signed rank sum test or a binomial test. Potential determinants of preference were investigated with logistic regression analyses. RESULTS: Data for 249 patients were included. Fewer patients experienced severe or extreme pain during CT colonography (seven [3%] of 245) than during colonoscopy (81 [34%] of 241) (P <.001). Directly after both examinations, 168 (71%) of 236 patients preferred CT colonography; 5 weeks later, 141 (61%) of 233 patients preferred CT colonography (P <.001). Initially, a painful colonoscopy examination (odds ratio, 0.17; 95% confidence interval [Cl]: 0.08, 0.38) was a determinant of CT colonography preference. Similarly, a painful (odds ratio, 3.70; 95% Cl: 1.54, 8.92) or an embarrassing (odds ratio, 4.46; 95% Cl: 1.18, 16.88) CT colonography examination was a determinant of colonoscopy preference. After 5 weeks, the presence of polyps emerged as a determinant of colonoscopy preference (odds ratio, 1.94; 95% Cl: 1.02, 3.70), while the role of experiences waned. CONCLUSION: Patients preferred CT colonography to colonoscopy; however, this preference decreased in time, while outcome considerations gradually replaced temporary experiences of inconvenience. (C) RSNA, 200