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  1. Robin Spiller, Editor

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MICROSCOPIC COLITIS – HOW MANY ARE WE MISSING?

When first described, microscopic colitis was considered something of a rarity but as the article on page 346 shows it is no longer a rarity with an incidence which now equals that of Crohn’s disease. One in ten of those referred for colonoscopy in Sweden for non-bloody diarrhoea and one in five of those who are aged more than 70 are now diagnosed with microscopic colitis. The reported annual incidence in Sweden from 1993–1998, 4.4 cases/100 000 of the population is substantially higher than that reported in the same area from 1984–1993 when it was 1.8/100 000 population. Since many would have been diagnosed as diarrhoea-predominant IBS had they not been colonoscoped and biopsied, this increase is likely to be due to an increased ascertainment, coinciding as it did with a substantial increase in the colonoscopy rate for all indications. Furthermore, a reassessment of biopsies previously reported as “non-specific colitis” lead to a diagnosis of a further 14 cases, while 34 were described as “lymphocytic-like” but with IEL’s less than 20 per 100 epithelial cells, suggesting that microscopic colitis is being under-diagnosed. In view of the fact that there are specific treatments for microscopic colitis which are quite different form those for irritable bowel syndrome we should have a heightened awareness of this possibility, particularly in those over the age of 70.
See page 346

DOES APPENDICECTOMY BENEFIT PATIENTS WITH ULCERATIVE COLITIS?

The incidence of ulcerative colitis is less in those who have had an appendicectomy but whether appendicectomy would ameliorate the cause of ulcerative colitis once established is unknown. The current study examined the impact of appendicectomy in patients with ulcerative colitis to determine whether it influenced the rate of hospitalisation when compared with a colitis control group who did not have appendicectomy. They discerned no beneficial effect of appendicectomy on the course of established colitis which raises some questions as to whether the epidemiological observations are causally relevant or due to confounding with other environmental or genetic factors.
See page 351

BIOFEEDBACK FOR SOLIARY RECTAL ULCER SYNDROME

Solitary rectal ulcer syndrome is often a difficult and frustrating condition to treat, so the article from St Marks Hospital, London is welcomed. They report that 12/16 patients treated by a biofeedback programme combined with strict behavioural control improved and 5 out of 7 had resolution of their ulcer. The behavioural programme involved restricting visits to the toilet, reducing straining and biofeedback to prevent inappropriate pelvic muscle contractions on attempting defecation. Laser doppler flow-metre showed decreased mucosal blood flow in patients, which improved with improvement in symptoms. Whether it is the increase in blood flow that leads to healing or the behavioural changes remains to be determined but this study should encourage researchers to consider other less labour intensive ways of achieving the same effect.
See page 368

ENHANCING SENSITIVITY OF ULTRASOUND TO DETECT SMALL MALIGNANT HEPATIC LESIONS

The increasing use of screening ultrasound has led to the detection of many benign liver lesions and a quick and sensitive method of identifying those that need further evaluation is bound to be of great clinical value. The study in this issue [see page 401] used a micro-bubble contrast agent to improve the definition of lesions in which the diagnosis was inconclusive after a conventional ultrasound scan. Phase inversion ultrasound imaging (PIUS) performed two minutes after intravenous contrast, clearly distinguished a varied range of malignant tumours which all showed as a clear hypoechoic region. This hypoechoic image was not seen in 85/95 benign lesions evaluated, giving 100% sensitivity and 93% specificity when compared with the goal standard of needle biopsy. Why malignant areas fail to enhance is unknown but may reflect lack of normal structures which cause accumulation of contrast agent.
See page 401

PROGRESSION OF “MILD” HEPATITIS C

Understanding the factors which govern the progression of hepatitis C is vital for planning hepatology services over the next 20 years. While those with established fibrosis are currently offered interferon and ribavrin, whether to expose asymptomatic individuals with “mild histological lesions” to the rigours of such treatment is uncertain. The Trent Hepatitis C virus study group reports on page 451 the progress of fibrosis in 214 hepatitis C virus infected patients on serial biopsy, a median of 2.5 years apart. One in three showed a significant increase in fibrosis. Multi-variate analysis showed that age > 35 years and fibrosis on the index biopsy significantly increased the risk of progression. This implies that the complications of hepatitis C are likely to steadily increase as the infected cohort ages, and even those with an apparently benign-looking first biopsy may progress, especially in the older patients — something health service providers need to plan for.
See page 451

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