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CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2007;5:770 –771

BSTRACTS FROM AROUND THE WORLD

Visit CGH online at www.cghjournal.org to link to these articles and additional papers of interest.

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An Aspirin a Day?ubé C, Rostom A, Lewin G, et al. The use of aspirin forrimary prevention of colorectal cancer: a systematic reviewrepared for the U.S. preventive services task force. Ann Interned 2007;146:365–375.

Summary. Nonsteroidal anti-inflammatory drugsre now well recognized to have a protective effectgainst colorectal adenomas and colorectal cancer.his systematic review examined the effect of aspirinn the incidence of colorectal adenoma and cancer asell as cardiovascular events and gastrointestinal tox-

city. Their results suggest a reduction in incidence ofolorectal adenoma of 13%-28% in average risk indi-iduals and a 22% relative risk reduction in colorectalancer incidence. The cardiovascular outcomes wereependent upon the underlying cardiovascular riskmong the populations under study. Aspirin was asso-iated with an incidence of important ulcer complica-ions with a relative risk of 1.5 -3 with an absolute riskor GI bleeding of 0.97% per year with low dose (� 100

g/day) and 2.69% per year for a dosage (� 200 mg/ay). A dose effect was also shown with the risk foremorrhagic stroke.

Editor’s comment. These results show that in theatient at average risk for colorectal cancer who is also atverage risk for heart disease, the use of aspirin is moreikely to harm than to benefit. However, in the patient atigher risk for cardiovascular mortality, the use of aspirin

s reasonable and a secondary benefit would be the po-ential reduction in colorectal neoplasia recognizing aigher risk for gastrointestinal events as well as hemor-hagic stroke. While these beneficial effects of aspirin onolorectal cancer are encouraging, continued screeningith colonoscopy or other imaging studies should re-ain the current standard. This paper has a wealth of

nformation related to these topics.

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Surgery Is Better for Chronicancreatitisahen D, Gouma K, Nio Y, et al. Endoscopic versus surgicalrainage of the pancreatic duct in chronic pancreatitis. N EnglMed 2007;356:676 – 684.

Summary. Endoscopic therapy is commonly per-ormed for the relief of pain in patients with chronicancreatitis and a dilated pancreatic ductal system.urgery has been the standard of care for such pa-ients, but to date there has been only one comparative

rial of surgery and endoscopic treatment. In this ran- o

omized trial, 39 patients received endoscopic therapyr operative pancreaticojejunostomy. At 24-month fol-

ow-up, patients randomized to surgery had lower paincores and better quality of life as measured by SF-36urvey. Partial or complete pain relief was achieved innly 32% of patients undergoing endoscopic therapy asompared to 75% following surgical therapy.

Editor’s comment. A wealth of uncontrolled datauggests pain relief in approximately two thirds of pa-ients following endoscopic stenting. Surgical therapyas also been associated with pain relief in two thirds orore of patients, although with longer follow-up, the

ain tends to recur over time. This trial was performed byxperienced endoscopists, and the results are somewhaturprising given the wealth of data from the many un-ontrolled studies. Whether subgroups of patients basedn pancreatic ductal anatomy and cause of obstructionay be better candidates for stenting, such as stricture

lone with upstream dilatation and no stones, will re-ain for further study. This report may temper the

ong-term use of stents and perhaps form a better reli-nce on our surgical colleagues for definitive treatment.

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EUS Instead of ERCPalik S, Kaushik N, Khalid A, et al. EUS yield in evaluating

iliary dilatation in patients with normal serum liver enzymes.ig Dis Sci 2007;52:508 –512.

Summary. Evaluating patients for a dilated biliaryuctal system is a common clinical scenario. The bestpproach for such patients has been ERCP. This ret-ospective study examined the results of the findingsn EUS in patients referred for a dilated biliary ductalystem. Forty-seven patients were identified, 32 ofhom had normal liver chemistry tests. The mean

ommon bile duct diameter was 8.5 mm. In those withlevated chemistry tests, 53% of patients had a diagno-is established, but in only 2 patients (6%) with normaliver chemistry tests was an abnormality found (peri-mpullary diverticulum, common duct stone).

Editor’s comment. ERCP has been most commonlysed to evaluate patients with a dilated biliary ductalystem. This study suggests that EUS may be a moreppropriate diagnostic test after CT and/or MRCP,nd particularly in those with normal liver tests. Inhe group with normal liver tests, only one bile ducttone was found thus potentially avoiding ERCP withts attendant morbidity. Identifying important pathol-

gy in 4 of 15 patients with abnormal liver chemistry

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July 2007 ABSTRACTS FROM AROUND THE WORLD 771

ests supports a continued role for ERCP in theseatients.

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Trends in Diagnosing Celiac Spruerar P, Kwon G, Egbuna I, et al. Lack of correlation of degree ofillous atrophy with severity of clinical presentation of celiacisease. Dig Liver Dis 2007;39:26 –29.

Summary. Increasing attention has focused on ce-iac disease given the recognition that approximately% of the United States population may be affected.owever, asymptomatic cases are increasingly identi-ed. This large cohort study of 499 adults correlatedhe mode of presentation with duodenal histology andxamined their temporal trends from 1981 to 2004.he classic mode of presentation (diarrhea, malabsorp-

ion) was observed in 44% of patients and this fell overhe 20-year study period. The number of patients withotal compared to partial villous atrophy was un-hanged over this time frame.

Editor’s comment. This study highlights other ob-ervations that many patients with celiac disease are noweing identified by routine small bowel biopsy or in thevaluation for other complaints. While it is intuitive thathe histology would predict gastrointestinal symptoms,his does not seem to be the case. The entire small bowel

ay be affected in celiac disease and while a greaterength of involved intestine has been an explanation foriarrhea, the data set from which these observations wereade is limited. These results suggest that many patientsith celiac disease may be asymptomatic or present with

atypical symptoms”. Further study, perhaps with cap-ule endoscopy or double balloon enteroscopy, is appro-riate to better establish the relationship between histol-gy, length of intestine involved, and symptoms.

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Think About Hepatic Encephalopathyrasad S, Dhiman R, Duseja A, et al. Lactulose improves cog-itive functions and health-related quality of life in patientsith cirrhosis who have minimal hepatic encephalopathy.epatology 2007;45:549 –559.

Summary. Hepatic encephalopathy is a continuumnd even mild disease has clinical and prognostic im-ortance. This study was performed to determine the

nfluence of treatment on psychomotor performancend health-related quality of life of patients with mildepatic encephalopathy. Sixty-one patients with mildepatic encephalopathy were randomly assigned to ei-her lactulose for 3 months, or no treatment in aon-blinded fashion. In the treated group, the numberf abnormal neuropsychiatric tests decreased signifi-antly compared with the untreated group, whereas

he sickness impact profile score improved in the 2

reated group as compared to the untreated group.mprovement in health related quality of life was re-ated to improvement in psychometric performance.

Editor’s comment. The diagnosis of early hepaticncephalopathy can be made by a straightforward batteryf quantitative neuropsychiatric testing. These resultsuggest that a more careful evaluation of our cirrhoticatients for hepatic encephalopathy at an earlier stageay provide significant improvement in not only cogni-

ive performance but quality of life as well. Treatmentith lactulose is easy, inexpensive, and with little toxicity.

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Dose or Drug Levels With 6-MP?orales A, Salguti S, Miao C, et al. Relationship between 6-mer-

aptopurine dose and 6-thioguanine nucleotide levels in pa-ients with inflammatory bowel disease. Inflamm Bowel Dis007;13:380 –385.

Summary. Azathioprine and 6-mercaptopurine (6MP)re typically provided on a mg/kg basis, and some, butot all, studies suggest that higher concentrations of-thioguanine nucleotides (6-TGNs) may be associatedith clinical remission. In this cross-sectional study, 155atients with inflammatory bowel disease receiving eitherzathioprine or 6-MP had 6-TGN levels measured in thelood. There was a weak correlation between 6-TGN

evels and absolute dose of medication as well as doseased on mg/kg. Only 37% of patients receiving �1g/kg/day had 6-TGN levels in the therapeutic range.

Editor’s comment. 6-MP and azathioprine are in-reasingly used for the management of patients withnflammatory bowel disease. Most physicians prescribehese medications on a mg/kg basis, but this study sug-ests that we may be underdosing patients. Recent focusas been on evaluating TPMT activity prior to therapy toest avoid toxicity. Perhaps we should also be focusingn blood concentration of 6-TGN to best maximize dosend outcome.

dditional Papers of Interest

May A, Nachbar L, Pohl J, et al. Endoscopic interven-ions in the small bowel using double balloon enteros-opy: feasibility and limitations. Am J Gastroenterol007;102:527–535.

Sedjo RL, Byers T, Levin TR, et al. Change in body sizend the risk of colorectal adenomas. Cancer Epidemioliomarkers Prev 2007;16:526 –31.

Romagnuolo J, Barkun A, Enns R, et al., for theegistry for Upper GI Bleeding and Endoscopy Investi-ator Group. Simple clinical predictors may obviate ur-ent endoscopy in selected patients with nonvariceal up-er gastrointestinal tract bleeding. Arch Intern Med

007;167:265–270.