Introduction

In Germany, screening colonoscopy has been offered to all adults aged 55 or older since 2002. In parallel to screening colonoscopy, fecal occult blood testing is offered (Guaiac test until 2017, fecal immunochemical test afterwards) and, in addition, there is a high use of diagnostic colonoscopies. In view of this context, we aimed to quantify the effectiveness of screening colonoscopy in reducing colorectal cancer (CRC) incidence in Germany in men and women aged 55–69 years.

Aims & Methods

Using a German claims database (GePaRD, 20% population coverage) we included persons at average CRC risk aged 55–69 years and without a colonoscopy, polypectomy or fecal occult blood test before baseline. We emulated a target trial with two arms: Colonoscopy screening vs. no colonoscopy screening at baseline. We estimated adjusted cumulative CRC incidence over 11 years of follow-up stratified by sex (at the time of the conference, 14-year follow-up data will be available).

Results

Overall, we included 99,101 men (women: 99,288) in the screening arm and 583,861 men (women: 664,052) in the control arm. In men, the adjusted 11-year CRC risk was 1.89% in the screening group and 2.85% in the control group resulting in a relative risk of 0.66 (95% CI: 0.63–0.73). In women, the adjusted 11-year CRC risk was 1.31% in the screening group and 1.96% in the control group resulting in a relative risk of 0.67 (95% CI: 0.63–0.73).

Conclusion

Our study shows that screening colonoscopy in Germany is effective in preventing CRC both in men and women. In the interpretation of the strength of the effect (~33% incidence reduction), the high background prevalence of diagnostic colonoscopy should be considered. As previously shown, screening colonoscopy accounts for less than half of the overall 10-year prevalence of colonoscopy in persons aged 55-69 years in Germany.

Introduction

Colonic diverticulosis is a prevalent gastrointestinal condition that is often diagnosed incidentally. However, its association with chronic polyps and rectal hemorrhoids remains underexplored, particularly in the northern region of Saudi Arabia.

Aims & Methods

This study aimed to assess the relationship between colonic diverticulosis and colonic conditions while considering demographic and clinical factors. This retrospective observational study was conducted at a tertiary referral center over four years. Data from 4,014 patients who underwent colonoscopy were analyzed. Statistical tests, including chi-square and independent sample t-tests, were used to determine associations between diverticulosis, polyps, hemorrhoids, and bowel preparation adequacy.

Results

Diverticulosis was observed in 14.2% of the patients, with a higher prevalence among males (16.1%) than among females (12.1%) (p < 0.001). Patients with diverticulosis were significantly older (mean age 61.35 years) than those without diverticulosis (mean age 48.25 years) (p < 0.001). Hemorrhoids were more frequent in patients with diverticulosis (18.6%) than in those without diverticulosis (11.9%) (p < 0.001). A similar association was found between diverticulosis and polyps, with the polyp prevalence being higher in patients with diverticulosis (21.4%) than in those without (11.7%) (p < 0.001). Additionally, inadequate bowel preparation was more common among patients with diverticulosis (17.1%) than among those with adequate bowel preparation (13.6%) (p = 0.023).

Conclusion

This study highlights a significant association between colonic diverticulosis and the presence of polyps and hemorrhoids. Older age and male sex were identified as the key risk factors. These findings emphasize the importance of targeted screening and optimized bowel preparation in at-risk patients. Further research is required to explore the underlying pathophysiological mechanisms and to develop preventive strategies.
Keywords: Diverticulosis; Hemorrhoids; Chronic Polyps

References

1 Nallapeta NS, Farooq U, Patel K. Diverticulosis. StatPearls. Treasure Island (FL): StatPearls Publishing 2025.
2 Tursi A, Scarpignato C, Strate LL, et al. Colonic diverticular disease. Nat Rev Dis Primers. 2020;6:20. doi: 10.1038/s41572-020-0153-5

Clinical Case Summary

Colorectal lymphomas are a rare cause of colonic neoplasia (0.2-0.6% malignant neoplasms of large bowel). Approximately 10% are primary colorectal lymphomas, while the rest correspond to colonic extension of systemic lymphoproliferative diseases.
We present the case of a 66-year-old woman with a history of rectum and pancreas adenocarcinoma (both in remission). During a follow-up CT, a thickening of the cecal pole was identified, with no adenopathy or other relevant findings (Photo1). The patient had no abdominal pain or B symptoms (night sweats, weight loss or fever).
The diagnosis was completed with a PET-CT that showed pathological uptake in the cecum (Photo2), so a colonoscopy was performed, which revealed a large polypoid lesion (30 mm) at the ileocecal level, with nodular areas with small ulcerations and no clear loss of the glandular pattern (Photo 3), from which multiple biopsies were taken.
Biopsies showed lymphoid proliferation with a ‘starry sky’ pattern, mitosis and apoptosis, and positive immunohistochemistry for CD45, CD20, CD10, BCL6, BCL2 and C-MYC, together with a high proliferation index (Ki-67 > 95%), all compatible with high-grade B-lymphoproliferative syndrome with Burkitt morphology (Photo 4).
Burkitt's lymphoma is a rare B-cell lymphoma (15% of GI lymphomas), associated with chromosomal translocation (8:14, 8:22 and 2:8) and overexpression of c-myc oncogene.
There are three clinical variants: endemic (common in Africa and associated with EBV and malaria), HIV-associated and sporadic (20%).
It is common in children and its most frequent symptoms are abdominal pain and weight loss, so diagnosis is often delayed. Although the yield of endoscopic biopsies is low (<20%), it is a key tool in its diagnosis, along with targeted biopsy of abdominal adenopathies.
Despite its aggressiveness, treatment with targeted chemotherapy achieves rates of more than 90%, and early diagnosis is essential to avoid complications and ensure adequate medical treatment.

References

- Photo 1: Thickening of the cecal pole seen in CT-Scan.
- Photo 2: Pathological uptake in the caecal area as seen on PET-CT Scan.
- Photo 3: Polypoid lesion in ileocecal area at colonoscopy
- Photo 4: Pathological anatomy of endoscopic biopsies: starry sky imaging and immunohistochemistry of Bcl-2 and C-myc

Clinical Case Summary

We present a rare case of protein losing gastropathy.A 60-year-old female presented to our clinic with 10 years history of intermittent dyspepsia with no alarm features and peripheral oedema for 6 months.Physical examination was unremarkable except mild bilateral pitting oedema.Pertinent investigations suggested normal albumin,urine analysis,renal&liver profiles and a normal echocardiogram.Subsequent testing with esophagogastroduodenoscopy(EGD) for dyspepsia showed hypertrophied mucosal folds predominantly in gastric corpus while sparing the antrum.Full thickness biopsies were taken and sent for histopathology with differentials of Lymphoma,adenocarcinoma,sarcoidosis and Menetrier’s disease.Stool antigen for Helicobacter Pylori(H.Pylori)thereafter,was positive while Contrast enhanced CT abdomen was consistent with mildly thickened gastric walls.Histological examination demostrated foveolar hyperplasia,elongated gastric pits and cystically dilated gastric glands without any features of malignancy.Hence a diagnosis of Menetrier’s disease(underlying H.Pylori) was made.
Patient then had H.Pylori eradication therapy as well as a diet rich in medium-chain fatty acids and proteins.H.Pylori eradication was confirmed.6 months follow up revealed partial resolution of her symptoms but no change in endoscopic findings.Patient could not undergo further treatment with biologics(cetuximab)due to financial constraints and octreotide for its local unavailability.She is now on a yearly endoscopic surveillance for future high risk of gastric malignancies.

References

​​Fig1A.Haematoxylin & Eosin staining shows foveolar & mucous cell hyperplasia,elongated gastric pits and lymphocytic infiltration.
Fig1B.Haematoxylin & ​Eosin staining shows cystic dilation of gastric glands
1.Pepa P, Uehara T, Wonaga A, Redondo A, Avagnina A, Mazzocchi O, Antelo P, Waldbaum C, Sorda J. Menetrier's disease. A diagnostic and therapeutic challenge. Medicina (B Aires). 2021;81(3):470-473. English. PMID: 34137712.
2.Gore M, Bansal K, Jadhav N. Menetrier Disease. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan– [updated 2023 Jun 25].

Disclosure

No conflicts

Introduction

The increasing accessibility of upper gastrointestinal endoscopy has led to a rise in its prescription. However, its overuse and inappropriate indications result in environmental and economic costs, potential iatrogenesis, and a paradoxical reduction in access. This study aims to assess the indications for elective diagnostic upper gastrointestinal endoscopy (UGE) requested in the hospital setting.

Aims & Methods

A retrospective analysis was conducted on elective diagnostic UGE requests from both outpatient and inpatient settings. The appropriateness of the requests was classified according to the recommendations of the American Society for Gastrointestinal Endoscopy and the European Society of Gastrointestinal Endoscopy.

Results

A total of 314 requests were analyzed over a three-month period: 90.8% (n=285) from outpatient consultations and 7.6% (n=24) from inpatient settings. A previous UGE had been performed in 53.8% (n=169) of patients, with an average interval of 27.13 ± 2.12 months between requests. Overall, 59.6% (n=187) of the requests were deemed appropriate, with the most frequent indications being the need for biopsies (15%, n=28), gastrointestinal bleeding or anemia (14.4%, n=27), and post-endoscopic intervention surveillance (10.7%, n=20).
Clinical information indicated the presence of alarm symptoms in 27.7% (n=87) cases, the most frequent being gastrointestinal bleeding or anemia (33.3%, n=29), age >50 years with new-onset symptoms or suspected structural disease (21.8%, n=19), and progressive dysphagia (17.2%, n=15). Conversely, 40.4% (n=127) of requests were considered inappropriate, mainly due to non-compliance with guidelines and surveillance intervals. The most common inappropriate indications included symptoms attributed to disorders of the gut-brain axis (20.5%, n=26), surveillance of atrophic gastritis, fundic gland polyps, hyperplastic polyps, and gastric intestinal metaplasia (11.8%, n=15), as well as post-gastric surgery surveillance for benign conditions in asymptomatic patients (8.7%, n=11). Additionally, 39 (28.3%) UGEs were requested for gastric cancer screening.

Conclusion

This study identified a significant proportion of UGE requests lacking appropriate and timely indications. These findings emphasize the need for well-defined criteria to ensure the rational and optimized use of this resource.

Introduction

In the United Kingdom (UK), the Royal College of Obstetricians and Gynaecology (RCOG) recommend that women who have sustained an obstetric anal sphincter injury (OASI) should undergo anorectal physiology testing (ARPT) to inform mode of delivery (MOD), where services are available [1]. ARPT is comprised of endoanal ultrasound (EAUS) which is considered the gold standard for assessing anal sphincter integrity [2,3], and high-resolution anorectal manometry (HR-ARM) for assessing motor and sensory function. However access to such services in the UK are limited, with 12.5% and 3.8% of women offered EAUS and ARM studies, respectively [2,4].

Aims & Methods

The prospective service evaluation assessed the impact of OASIs on anal sphincter anatomy and function, and reviewed the value of ARPT in MOD decision making.
Patients referred for MOD decision making underwent EAUS with the BK medical 3000 system with a 3D anorectal transducer (20R3' 6–16 MHz 360°) and HR-ARM with the Laborie water-perfused system. HR-ARM was performed in accordance with a limited version of the international anorectal physiology working group standardized testing protocol [5], and subsequently analysed in accordance with the London Classification of Anorectal Disorders [5]. Following discussion at a multi-disciplinary team meeting, patients were counselled with the ARPT results by their obstetrician in line with published guidance [6]. Postal feedback surveys were sent post-partum to assess patient experience and the impact of ARPT results on their delivery.

Results

24 pregnant patients with a previous OASI attended for ARPT during a 15 month period. Abnormalities which would encourage counselling for a C-section were identified in 12 patients. 7/12 patients had an external anal sphincter (EAS) defect >30°, 4 of which also had disruption to the internal anal sphincter (IAS). All 7 patients had normal anal contractility on HR-ARM. 1/7 patients had a hypotensive anal canal, disrupted IAS and reported faecal incontinence despite a normal stool consistency. 5/12 patients had anal hypocontractility on HR-ARM; 4 of whom had faecal urgency.
13 patients reported bowel symptoms, with the majority reporting faecal urgency (n=10) and 1 patient reporting Irritable Bowel Syndrome. Of the 13 symptomatic patients, EAUS identified significant defects in 15%, and HR-ARM identified abnormal tone or contractility in 31%. No symptomatic patients were identified to have a major or minor disorder of rectal sensation. 2 urgency patients reported loose stool.
6/18 (33%) patients completed feedback surveys after their delivery. All patients reported that counselling with ARPT results influenced their MOD decision, with 20% changing their intended MOD following ARPT. All patients were satisfied with their MOD choice.

Conclusion

HR-ARM identified 5 patients for C-section counselling, in addition to 7 patients identified by EAUS. There appeared to be poor agreement between EAUS defects and impaired manometric function. EAUS and HR-ARM identified significant anal sphincter impairment in 15% and 31% of symptomatic patients, respectively. This suggests that EAUS may lack sensitivity for identifying symptomatic cohorts, and that HR-ARM abnormality may be a more sensitive indicator of symptomology. This highlights the need to increase HR-ARM provision in perineal services.
Whilst the RCOG recommends counselling with the option of a C-section in all of the patients in this cohort [1], these findings suggest HR-ARM in addition to EAUS may offer a more individualised and collaborative approach to MOD delivery decision making.

References

1. The Management of Third-and Fourth-Degree Perineal Tears Green-top Guideline No. 29. 2015. Available from: https://www.rcog.org.uk/media/5jeb5hzu/gtg-29.pdf. Accessed 24/04/2025.
2. Badri H, et al. The role of anal manometry in the follow-up of women with obstetric anal sphincter injuries (OASI) . Int Urogynecol J. 2023;34:399–404.
3. Santoro GA, et al. State of the art: an integrated approach to pelvic floor ultrasonography. Ultrasound Obstet Gynecol. 2011;37(4):381–96.
4. Ismail SIMF. The management of obstetric anal sphincter injuries (OASIS): A national postal questionnaire survey in hospitals in the UK. J Obstet Gynaecol. 2015;35(3):229–34.
5. Carrington EV, et al. The international anorectal physiology working group (IAPWG) recommendations: Standardized testing protocol and the London classification for disorders of anorectal function. Neurogastroenterology and motility. 2020;32(1): e13679.
6. Jordan PA, et al. Effect of subsequent vaginal delivery on bowel symptoms and anorectal function in women who sustained a previous obstetric anal sphincter injury. International Urogynaecology Journal. 2018;29(11):579-1588.