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Objective To assess the performance of a fecal immunochemical test (FIT) among participants of a population-based colorectal cancer (CRC) screening program with one or more first-degree relatives (FDR) with CRC. Methods Asymptomatic 50 to 74 years olds with a FDR diagnosed with CRC, enrolled in a colon screening program completed FIT (two samples, cut-off 20 µg Hemoglobin/gram feces) and underwent colonoscopy. FIT-interval CRCs were identified from the British Columbia cancer registry. Logistic regression analysis was used to identify variables associated with the detection of CRC and high-risk polyps (nonmalignant findings that required a 3-year surveillance colonoscopy) in those patients undergoing FIT and colonoscopy. Results Of the 1387 participants with a FDR with CRC, 1244 completed FIT with a positivity rate of 10.8%, 52 declined FIT but underwent colonoscopy and 90 declined screening. Seven CRCs were identified: six in patients with a positive FIT, one in a patient who only had colonoscopy. No CRCs were found in patients with a negative FIT. The positive and negative predictive values of FIT in the detection of CRC were 4.8% and 100%, respectively. On multivariate logistic regression, positive FIT, and not type of family history, was the only variable associated with detection of CRC or high-risk polyps. At 2-year follow-up, there was no FIT interval cancer detected in the study cohort. Conclusion FIT is more strongly associated with high-risk findings on colonoscopy than type of family history. FIT may be an alternative screening strategy to colonoscopy in individuals with a single FDR with CRC.

Background Diagnosing pancreatic cancer by EUS-FNA is a potentially appealing alternative to percutaneous biopsy. Aim To compare EUS-FNA with CT or US-guided FNA for diagnosing pancreatic cancer. Design Single center, prospective, randomized, cross-over. Setting Duke University Medical Center. Population Eighty-four patients referred with suspicious solid pancreatic mass lesions randomized to CT/US-FNA (n = 43) or EUS-FNA (n = 41). Intervention Patients underwent an imaging procedure/FNA. If cytology was nondiagnostic, cross over to the other modality was offered. Final outcome was determined by clinical follow-up every 6 months for 2 years and/or surgical pathology for patients with negative FNA. Main Outcome Measurements Sensitivity and accuracy of EUS-FNA versus CT/US-FNA for pancreatic cancer. Results There were 16 true positive (TP) by CT/US-FNA and 21 TP by EUS-FNA. Sixteen of the 20 CT/US-FNA negative patients crossed over to EUS-FNA; 12 underwent FNA, 4 had no mass at EUS. Seven of the 12 had positive EUS-FNA. Eight EUS-FNA negative crossed over to CT/US; 4 had no mass at CT/US, 3 remained true negative throughout follow-up, 1 had chronic pancreatitis at surgery. The sensitivity of CT/US-FNA and EUS-FNA for detecting malignancy was 62% and 84%, respectively. A comparison of the accuracy for CT/US-FNA and EUS-FNA was not statistically significant (P = .074, χ 2 ). Limitations Failure to meet target enrollment resulted in an inability to demonstrate a statistically significant difference between the 2 modalities. Conclusions EUS-FNA is numerically (though not quite statistically) superior to CT/US-FNA for the diagnosis of pancreatic malignancy.

Purpose The purpose of this work was to investigate the natural history of pancreatic necrosis on contrast-enhanced CT in patients managed nonoperatively. Method A computer-based radiology information search revealed 32 patients with pancreatic necrosis who had had serial contrast-enhanced CT scans and were managed nonoperatively. There were 23 men and 9 women with a mean age of 51 years. One hundred forty-five contrast-enhanced CT scans were retrospectively reviewed for the location and extent of necrosis. The medical records of all patients were reviewed. Results The 32 patients had a mean Ranson clinical grade of 5.8 (range 3-8). Eighteen of these 32 patients were managed nonoperatively, and 14 patients required a necrosectomy after initial nonoperative management. In the 32 patients, the location of necrosis was in the head (3), body (6), tail (2), head/body (2), head/body/tail (9), body/tail (9), and head/tail (1). Extent of necrosis was 0-25% (9), 26-50% (6), 51-75% (6), and 76-100% (11). The extent of necrosis remained stable during follow-up in 22 (69%) patients and increased during follow-up in 10 (31%). Necrosectomy was performed in six (60%) patients in whom there was an increase in necrosis and eight (36%) patients in whom necrosis was stable. No patient had restoration of normal enhancement in an area that was previously necrotic. There were five patients who were managed nonoperatively (mean follow-up 318 days) in whom the necrosis eventually resorbed, forming a focal parenchymal cleft reminiscent of a scar. Five of the 32 patients died. Conclusion Pancreatic necrosis as demonstrated by CT tends to remain stable in most patients treated nonoperatively. If the extent of necrosis increases, patients are more likely to require a necrosectomy. In some patients managed nonoperatively, the pancreatic necrosis will resorb, resulting in a fat-replaced cleft reminiscent of a scar.

Background: Endoscopic retrograde cholangiopancreatography (ERCP) plays an important role in the management of bile leaks after cholecystectomy. Although most leaks occur from the cystic duct stump, clinically significant leakage from accessory bile ducts is less common and has not been investigated systematically. We report our experience with endoscopic diagnosis and treatment of accessory bile duct leaks after cholecystectomy. Methods: Patients with accessory bile duct leaks were identified from a computerized database. Hospital charts and cholangiograms were reviewed to determine the outcome of diagnostic and therapeutic interventions. Results: Of 86 patients with postcholecystectomy leaks, 15 (17%) were diagnosed with accessory bile duct leaks. ERCP established the diagnosis of accessory bile duct leaks in 11 of 15 patients (73%); percutaneous fistulography (2) and percutaneous transhepatic cholangiography (2) were diagnostic in 4 patients. Endoscopic therapy led to resolution of the leak in 12 patients. One patient underwent successful percutaneous biliary drainage, and two patients required surgical repair. Conclusions: Accessory bile ducts are rare sites of significant bile leakage after cholecystectomy. ERCP identifies the leak in the majority of patients; percutaneous fistulography or percutaneous transhepatic cholangiography may help clarify the diagnosis if ERCP is nondiagnostic. Most patients can be successfully treated with endoscopic stenting. If endoscopic therapy fails, percutaneous drainage or surgical repair needs to be considered. (Gastrointest Endosc 1999;50:527-31.)

The expression of the 60-kDa heat-shock protein (HSP60) varies markedly among patients with ovarian carcinoma, and high-level expression predicts poor survival in such patients treated with cisplatin (DDP)-containing chemotherapy programs. We investigated the expression of HSP60 in human ovarian carcinoma 2008 cells and an 11-fold DDP-resistant subline 2008/C13*5.25. Heating for 2 h at 44 degrees C produced a 2.7 +/- 0.16-fold increase (mean +/- SD) that was maximal at 4 h after the start of heat exposure. Exposure to an IC50 concentration of DDP for 1 h induced a 1.8 +/- 0.03-fold increase in hsp60 expression. The opposite was true for cadmium and zinc, both of which induced increases in metallothionein IIA but not in the hsp60 message. 2008/C13*5.25 cells constitutively over-expressed hsp60 mRNA by 1.7 +/- 0.16 orders of magnitude and contained a 3.8 +/- 0.45-fold higher level of HSP60 as detected by immunocytochemical staining. 2008/C13*5.25 cells showed 1.2-fold cross-resistance to thermal killing. Expression of hsp60 was markedly reduced in 2008 xenografts as compared with 2008 cells growing in vitro; however, neither serum starvation nor refeeding altered the message level. Exposure to a variety of growth factors and drug treatments known to alter the DDP sensitivity of 2008 cells, including epidermal growth factor, 12-O-tetradecanoylphorbol-13-acetate, buthionine sulfoximine, ouabain, and forskolin, did not alter hsp60 expression. These results suggest a role for HSP60 in mediating resistance to both DDP and hyperthermia but indicate that the hsp60 mRNA levels are not regulated by the factors listed above.

Background: Percutaneous biliary drainage is an established alternative to ERCP for managing bile duct obstruction. Although generally safe and effective, percutaneous drainage has its risks and is technically more difficult in patients with nondilated bile ducts. We report the use of nasobiliary drains and subsequent nasobiliary drain cholangiography to facilitate percutaneous biliary drainage by providing a target for accessing intrahepatic bile ducts. Methods/Results: Nine patients who were identified as requiring percutaneous biliary drainage underwent nasobiliary tube placement at completion of ERCP. Five of 9 patients had generalized intrahepatic ductal dilatation; in 4 patients, dilatation was focal or absent. Following nasobiliary drain cholangiography, percutaneous needle puncture of a bile duct was successful in all patients, in most cases with only a single puncture of the liver capsule. No procedural complications were encountered. Conclusion: Nasobiliary drain placement with subsequent nasobiliary drain cholangiography facilitates percutaneous biliary drainage and may be especially helpful in patients with nondilated intrahepatic bile ducts.

Magnetic resonance cholangiopancreatography (MRCP) is a relatively new, noninvasive cholangiographic technique that is comparable with invasive endoscopic retrograde cholangiopancreatography (ERCP) in the detection and characterization of extrahepatic bile duct abnormalities. The role of MRCP in evaluation of the intrahepatic bile ducts, especially in patients with primary or secondary sclerosing cholangitis, is under investigation. The key cholangiographic features of primary sclerosing cholangitis are randomly distributed annular strictures out of proportion to upstream dilatation. As the fibrosing process worsens, strictures increase and the ducts become obliterated, and the peripheral ducts cannot be visualized to the periphery of the liver at ERCP. In addition, the acute angles formed with the central ducts become more obtuse. With further progression, strictures of the central ducts prevent peripheral ductal opacification at ERCP. Cholangiocarcinoma occurs in 10%-15% of patients with primary sclerosing cholangitis; cholangiographic features that suggest cholangiocarcinoma include irregular high-grade ductal narrowing with shouldered margins, rapid progression of strictures, marked ductal dilatation proximal to strictures, and polypoid lesions. Secondary sclerosing and nonsclerosing processes can mimic primary sclerosing cholangitis at cholangiography. These processes include ascending cholangitis, oriental cholangiohepatitis, acquired immunodeficiency syndrome-related cholangitis, chemotherapy-induced cholangitis, ischemic cholangitis after liver transplantation, eosinophilic cholangitis, and metastases.

83% of patients had heartburn ≥2 days last week. Based on GerdQ scores 29% had high impact, 49% had medium impact and 22% low probability of GERD. In the OCP arm 81% had reflux esophagitis, 3% Barrett's esophagus and 5% had abnormal pH-metry. 147 patients (87%) in the NSP and 133 patients (80%) in the OCP arm were responders to therapy. NSP was found non-inferior to OCP, but superiority was not established (p=0.14). A costminimization analysis was conducted: the average direct medical cost in the NSP arm was 71 USD per patient compared with 542 USD in the OCP arm. CONCLUSION A symptombased approach using GerdQ, after excluding patients with alarm symptoms, reduces direct medical costs without loss in efficacy. GerdQ may provide physicians with a tool for more structured care of patients.