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  1. Ian Forgacs, Associate Editor

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IS THE ANAL SPHINCTER SILICONE VALLEY?

Silicone injection, not always for therapeutic purposes, has been a topic of expanding interest in recent times. A group from St Mark's has been interested in silicone as a bulking agent to augment a weak or disrupted internal anal sphincter. The study was small, uncontrolled but had data after 18 month's follow up. It's sometimes hard for readers to translate varaiables such as incontinence scores and quality of life measures into how the patients actually responded but the technique looks simple enough, seems inexpensive and apparently is also effective.

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GETTING ACTIVE IN ACUTE PANCREATITIS

Most clinicians feel frustrated about the limitations of their therapy in acute pancreatitis. Progress may have to await better understanding of the genesis of the condition. The cascade of enzyme activation is being increasingly unravelled, but its clinical use is largely restricted to diagnosis. Carboxypeptidase B is synthesised as an inactive pro-enzyme which is cleaved through the action of trypsin—in which an activation peptide is released. Müller and colleagues looked to see whether such markers might be clinically useful. Pro-enzyme leakage occurred early in acute pancreatitis but necrosis only occurred when the pro-enzyme was activated. Yet another diagnostic/prognostic marker.

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SERRATED ADENOMAS AT THE CUTTING EDGE OF MOLECULAR BIOLOGY

Serrated adenomas of the large bowel seem rather interesting. They have features that combine the architecture of hyperplastic polyps with the cytological features of classical adenomas. Sawyer and colleagues wondered whether serrated adenomas might have distinct molecular features. They screened a series of tumours for selected genetic changes. Some serrated adenomas had APC changes; few showed microsatellite instability; K-ras mutations were less common than in classical adenomas. No clear patterns emerged but what is clear is that serrated adenomas are rather heterogeneous—perhaps they are becoming even more interesting.

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FAT: NOT JUST A FEMINIST ISSUE

There is quite a lot about fat in this issue. Almost all pre-menopausal women of my acquaintance experience a decline in morale as their body mass index rises. Now (p. 191), they should also be bothered about the increased risk of colorectal cancer as they cast a larger shadow. Dietary fat (p. 164) may also influence the effectiveness of enteral diet in the treatment of Crohn's disease. Counter-intuitively (at least to the authors) a diet containing monosaturated fatty acids turned out to be less effective than a diet rich in polyunsaturates.

See pages191 and 164

HIGH CHOLESTEROL—NOT A RISK FACTOR FOR CORONARY DISEASE

All medical students know that hyperlipidaemia is associated with coronary artery disease. All good medical students know that hyperlipidaemia accompanies primary biliary cirrhosis. Yet the clinical consequence of high plasma lipids in PBC is unclear. Longo and colleagues followed 400 patients for a mean of 6 years. Marked hypercholesterolaemia in advanced cholestatic disease was not associated with cardiovascular risk. In contrast, moderately elevated cholesterol levels in patients with less advanced disease exposed patients to an enhanced cardiovascular risk. The authors are plausibly persuasive in their explanations of such intriguing findings.

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THE VIRTUES OF VIRTUAL COLONOSCOPY

For reasons upon which one can only speculate, CT colography has not been enthusiastically embraced by all clinical gastroenterologists. The technique was introduced in 1994. As helical CT, multi-slice scanners and new techniques of data acquisition and processing emerge, colonic images have progressively improved. Gluecker and colleagues have done a prospective blinded study to compare multidetector arrays CT scan with fibreoptic colonoscopy. Fifty patients underwent virtual then conventional colonoscopy. 82% of lesions >1 cm; 33% of those 6–9 mm; 3% of those <5 mm were identified by the radiologists. With normal colonoscopy specificity of CT was 90%. Not bad, but maybe its time has not yet come—though one day…

See page207

Figure1

Endoanal ultrasound showing injected silicone at three circumferential sites in a patient with idiopathic degenerations (see 225).

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