Background: Most outcomes data on pancreatic extracorporeal shock wave lithotripsy (P-ESWL) for chronic calcific pancreatitis (CCP) are based on studies with < 4 years' follow-up, and U.S. long-term studies are lacking.Objective: To report long-term P-ESWL outcomes for CCP and to assess whether smoking or alcohol use influences P-ESWL outcomes.Design: Cross-sectional study, retrospective chart review.Setting: Virginia Mason Medical Center, Seattle, Washington.Patients: This study involved 120 patients who underwent P-ESWL and ERCP for CCP and completed an outcomes questionnaire.Intervention: P-ESWL and ERCP, outcomes survey.Main Outcome Measurements: Pain, quality of life, narcotics use diabetes status, pancreatic enzyme requirement, repeat P-ESWL, repeat ERCP, surgery.Results: A total of 120 patients underwent P-ESWL followed by ERCP (mean +/- standard deviation [SD] follow-up 4.3 [+/- 3.7] years) and completed a survey. The mean (+/- SD) before-P-ESWL pain score was 7.9 (+/- 2.6) compared with 2.9 (+/- 2.6) after P-ESWL (P < .001). Improved pain was reported by 102 patients (85%); 60 (50%) reported complete pain relief and no narcotic use. The mean (+/- SD) before-P-ESWL quality-of-life score was 3.7 (+/- 2.4) compared with 7.3 (+/- 2.7) after P-ESWL (P < .001). In patients with >= 4 years' follow-up, repeat procedures included P-ESWL (29%), ERCP (84%), and surgery (16%). Smokers who quit smoking after P-ESWL had improved narcotic requirements compared with those who continued smoking (95% vs 67%; P = .014), and a trend suggested a decreased need for repeat ERCPs (68% vs 84%; P = .071).Limitations: Single center, retrospective, recall bias, nonvalidated pain and quality-of-life scales.Conclusion: P-ESWL as the initial therapy for CCP may lead to more lifetime procedures; however, partial pain relief in 85%, complete pain relief with no narcotic use in 50%, and avoidance of surgery in 84% of patients may be achieved. Quitting smoking after P-ESWL may improve outcomes. (Gastrointest Endosc 2012;75:997-1004.)

Background: There are limited data on the incidence of afferent limb syndrome and other delayed GI problems in pancreatic cancer (PaC) patients, especially among long-term survivors (>2 years).Objective: To evaluate the incidence of afferent limb syndrome (chronic afferent limb obstruction resulting in pancreatobiliary obstruction) and delayed GI problems in PaC patients after pancreaticoduodenectomy (PD).Design: Retrospective case series.Setting: Tertiary referral center.Patients: PaC patients treated with PD (N = 186) over a 14-year period (January 1995-October 2009).Interventions: Endoscopic balloon dilation and stent placement, percutaneous biliary drainage.Main Outcome Measurements: Incidence of afferent limb syndrome and delayed GI complications (marginal ulcers, radiation enteropathy, anastomotic strictures).Results: Mean age was 63 +/- 10 years; 55% of patients were male. Afferent limb syndrome was noted in 24 patients (13%). Median time to diagnosis was 1.2 years (range 0.03-12.3 years); obstruction was primarily caused by recurrent PaC (8 patients, 33%) and radiation enteropathy (9 patients, 38%). Afferent limb syndrome was more likely to develop in patients with 2 years or longer of follow-up (n = 71, [38%]) compared with patients with 2 years or less of follow-up, after controlling for age, sex, surgery type, and adjuvant treatment (adjusted odds ratio, 4.5; 95% CI, 1.8-11.7). Other delayed GI problems included radiation enteropathy (6%), marginal ulcers (5%), anastomotic strictures (4%), cholangitis/liver abscesses (5%), and GI bleeding (6%).Limitations: Retrospective, single-center study.Conclusions: GI problems, including afferent limb syndrome, are relatively common in PaC patients after surgery and adjuvant therapy. Clinicians should recognize and effectively treat these delayed GI problems, especially in long-term survivors. (Gastrointest Endosc 2011;74:295-302.)

Information on afferent limb syndrome (ALS) following pancreaticoduodenectomy (PD) for pancreatic cancer (PC) is limited. We evaluated the incidence, clinical presentation, and management of afferent limb problems in PC patients who have had PD at our institution over a 14-year period (1995-2009).

Background: Although gemcitabine has been associated with both of clinical benefit and prolongation of survival in patients with advanced pancreatic carcinoma, the results can be never satisfied.Chemosensitivity test has been established method mainly using surgical resected material.However, it is hardly undergone for unresectable pancreatic carcinoma, because of difficulty of obtaining enough the material.EUS-FNA enabled to obtain the pancreatic tissue safely, however the biopsy spesiemens were extremely little.The aim of this study was to establish chemosensitivity test using the biopsy speciemen obtained by EUS-FNA and to predict of the response with gemcitabine for unresectable pancreatic carcinoma.Patients and method: Chemosensitivity testing by ATP assay was performed with fresh speciemens obtained by EUS-FNA of primary tumor from 32 patients with unresectable pancreatic carcinoma.Chemosensitivity (treated/control ratio: T/C) was calculated as the percentage of quantity of ATP of a tumor treated with gemcitabine and of control.T/C was divided into two groups at 80% according to ROC curve.Patients were treated with gemcitabine 1000 mg/m2 intravenously over 30 minutes administered on days 1, 8 and 15 every 28 days.Response was examined after 2 cycle completion according to RECIST.We evaluated the correlation between T/C ratio and progression free survival (PFS) to prove the reliability of our chemosensitivity testing.Moreover, we evaluated prognostic factors about PFS including the result of chemosensitivity testing after chemotherapy.Results: Chemosensitivity test succeeded with 27 of 32 patients (84.4%).Four patients of 27 patients were excluded because of impossible to keep the protocol, therefore, 23 patients were prospectively followed.About T/C ratio and PFS of 23 patients, there was a significant correlation between them (p= 0.033, rs=-0.445).Univariate analysis of the prognostic factors about PFS after chemotherapy showed significant factors that influenced PFS were T/C ratio (p=0.0078) and disease stage (locally advanced or metastatic) (p=0.0476).Multivariate analysis using Cox's model also showed that they were proved to be significant and independent prognostic factors after gemcitabine chemotherapy.Conclusion: Chemosensitivity test usuig biopsy speciemens obtained from EUS-FNA is feasible.From the result of this prospective study, it is possible to predict of the response of the gemcitabine.However prospective randomized control study comparing patients treated with assay guided chemotherapy to patients treated with standard chemotherapy is necessary for establish of usefulness of chemosensitivity testing.

Hepatosplenic T-cell lymphoma (HSTCL) is a rare form of peripheral T-cell lymphoma. It is associated with an aggressive clinical course, a poor response to conventional treatment, and an exceedingly high mortality rate. Recent reports suggest an excessive number of cases of HSTCL in young patients with Crohn's disease who are treated with thiopurines (azathioprine or 6-mercaptopurine [6-MP]) either in conjunction with or without agents that inhibit tumor necrosis factor-alpha (TNF-alpha). Herein, we describe the case of an 18-year-old man with Crohn's disease who developed HSTCL after 5 years of 6-MP treatment. He died 7 months after diagnosis from chemotherapy-refractory lymphoma. Through a literature review, we identified 28 cases of HSTCL in Crohn's patients. All patients were treated with azathioprine or 6-MP; 22 of 28 (79%) received concomitant treatment with infliximab, and 3 of these 22 patients later received treatment with adalimumab. The median age at diagnosis of HSTCL was 22 years (range, 12-40 years). The median survival for all patients was 8 months (range, 5 days-31 + months), with only 1 patient achieving remission. Additional research is needed to better understand the role of thiopurines and TNF-alpha inhibitors in promoting HSTCL and what can be done to prevent and treat this devastating malignancy in young patients with Crohn's disease.

expression were found between affected and unaffected parts of the colon. Conclusion: This study demonstrates for the first time that Claudin 18 is expressed in the human colon. The expression is largely increased in patients with ulcerative colitis. The observation that this appears unrelated to the severity of the inflammation might point to a primary defect in regulation in patients with ulcerative colitis and warrants further examination.

Background & Purpose: Tumors arising from the duodenal papilla can be adenomatous or non-adenomatous. Non-adenomatous lesions can be further divided into epithelial and sub-epithelial. Methods: This was a restrospective review of patients referred for papillary lesions from 9/97 to 9/07. Data collected included clinical presentation, endoscopic details, complications, histology, and follow up. Results: 193 patients were referred for endsocopic evaluation of papillary lesions. 15 juxta-ampullary lesions and 10 normal variants of the ampulla were excluded. There were 18 non-adenomatous lesions (Carcinoid 5, gangliocytic paraganglioma 2, GIST 1, Gastric foveolar metaplasia 1, pancreatic acinar cell metaplasia 1, papillitis 8) and 150 adenomatous lesions (adenomas 112, adenocarcinomas 38). Carcinoids (5): Mean age 59; Clinical presentation (pancreatitis 2, incidental 2, cholestasis 1); Mean size 2 cm; Ampullectomy in all 5; Complications (mild pancreatitis 2). Mean f/u 24 months. 0 recurrences on EUS, CT, ERCP. Of the 2 lesions larger than 2 cm, 1 refused surgery and the other was a poor surgical candidate. Gangliocytic paragangliomas (2): Mean age 54; Mean size 3.5 cm; Clinical presentation (bleeding in both); Ampullectomy in both. Complication: (mild pancreatitis 1); Mean f/u 15 months. No recurrences on EUS, CT, ERCP. GIST (1): 60 year old patient presented with bleeding, and a 3 cm ulcerated lesion at the major ampulla. On EUS it involved the muscularis propria. Biopsy only and a successful Pancreatico-duodenectomy was performed. Gastric foveolar metaplasia (1) and pancreatic acinar cell metaplasia (1): 63 year old patient with abdominal pain and a 76 year old patient presenting incidentally, respectively, had biopsies suggesting adenoma at outside institutions. At ampullectomy, they turned out to have metaplasia only. Papillitis/inflammatory polyps (8): All lesions were associated with gallstones +/− biliary stenting and at outside institutions had been diagnosed as adenomas. Of the 141 ampullectomies performed on 119 patients, complications occurred in 3/7 (43%) patients with subepithelial lesions (carcinoids, gangliocytic paragangliomas), and 21/112 (19%) patients with epithelial lesions. (p = .14) Conclusions: 1) Adenomas are the major pathology noted on ampullary lesions. 2) Sub-epithelial lesions tend to be more symptomatic and have particular clinical presentations; i.e. bleeding with gangliocytic paragangliomas, obstruction with carcinoids. 3) Such lesions are potentially endoscopically resectable, but CT, EUS are a prerequisite, and higher complication rates should be anticipated.

Background & Purpose: Tumors arising from the duodenal papilla account for about 5% of GI neoplasms, but are increasingly identified. We report a large single center experience of patients referred for endoscopic papillectomy. Methods: All patients referred for endoscopic papillary lesions between 9/97 and 9/07 were reviewed. Clinical presentation, family history, endoscopic details, complications, histology, follow up and need for surgery were analyzed. Results: Between 9/97 and 9/07, 193 patients underwent endoscopy for ampullary lesions (7 patients minor and major). 15 juxta-ampullary lesions and 10 normal variants of the ampulla were excluded. Mean f/u at VMMC was 24 months. Among 168 patients, there were 112 (67%) adenomas, 38 (23%) adenocarcinomas, 18 (10%) non-adenomatous lesions. There were 88 men, 80 women, with a mean age of 64 (28 to 94). Excluding 23 FAP patients, there was a personal history of colon polyps or cancer in 34%. Clinical presentation included: Cholestasis/cholangitis 72, abdominal pain 54, incidental 51, pancreatitis 9, bleeding 7. 58 patients were referred to surgery. 20 were sent directly after endoscopy and biopsy without ampullectomy due to high suspicion for cancer. 22 were sent due to unresectability endoscopically (intraductal extension 12, extensive lateral extension 7, other reasons 3). 16 were sent after papillectomy (invasive cancer 8, intraductal recurrence/residual 7, multiple local recurrences 1). Ampullectomies were performed in 119 patients, with 2 patients requiring minor and major ampullectomies, and 14 patients requiring more than one session (total 141 ampullectomies). Mean tumor size was 2.4 cm (0.5cm to 9cm). ERCP was performed prior to all ampullectomies with biliary and pancreatic stenting attempted in all after ampullectomy. Saline lift was only used for lateral extension and flat lesions. Overall complications from ampullectomy were 20% and included: Mild pancreatitis 13 (11%), cholestasis 1, retroperitoneal perforation 1 (adenocarcinoma), intraperitoneal perforation 1 (lateral extension), Bleeding 5 (lateral extension 2/5), delayed papillary stenosis 3. Residual adenoma was seen in 14 (12%) patients, with recurrences in 8 (7%) patients. The endoscopic success rate was 87%. Conclusions: 1) Most ampullary adenomas are endoscopically amenable. 2) There is a high risk of colonic adenomas and cancers in these patients suggesting a possible need for more frequent colorectal screening. 3) Underlying malignancy and lateral extension are risk factors for bleeding and perforation. 4) Overall complication and recurrence rates are favorable compared to surgical resection.

GOALS:The current study presents 1 tertiary endoscopy center's 20-year experience using endoscopic therapy to treat patients with symptomatic primary sclerosing cholangitis (PSC).BACKGROUND:Endoscopic therapy for patients with PSC and dominant strictures has been used for more than 20 years, but there is concern that instrumenting a sclerotic biliary tree induces risks that outweigh anticipated benefits.STUDY:In this retrospective chart review, 117 patients with PSC were identified using ICD-9 codes. Patients had a mean age of 47 years (range: 15 to 86 y). Mean duration of follow-up was 8 years (range: 2 to 20 y). Of the 117 identified patients, 106 underwent endoscopic retrograde cholangiopancreatography on one or more occasions (for a total of 317 endoscopic retrograde cholangiopancreatographies), and a subset of 84 patients received endoscopic therapy for treatment of dominant strictures and/or deteriorating clinical status. Actual survival for endoscopically treated patients was compared with predicted survival using the Mayo Clinic natural history model for PSC.RESULTS:Our chart review revealed 23 recognized complications among the 317 procedures performed (7.3%), and no procedure-related deaths. Observed patient survival at years 3 and 4 was significantly higher than that predicted by the Mayo Clinic natural history model for PSC (P=0.021).CONCLUSIONS:Patients with PSC who have a deteriorating clinical course benefited from endoscopic therapy to provide drainage of bile ducts, removal of stones, and/or temporary relief from obstructions, with acceptable procedure-related complications and higher than expected 3-year and 4-year survival.

Background: Many endoscopy units administer patient satisfaction surveys. We hypothesized that the survey collection method would affect satisfaction scores.Objective: To compare satisfaction scores obtained by using on-site (OS) surveys versus mail-back (MB) surveys.Design: Quasi-randomization based on alternating weeks.Setting: Teaching hospital.Patients: Patients undergoing elective routine outpatient colonoscopy or upper endoscopy.Interventions: Every patient was given an 11-question survey that asked about the patient's satisfaction with the nurses and the physician, wait times, the bowel-preparation process, patient education, procedural comfort, and sedation. Survey collection methods alternated weekly between an OS versus an MB method.Main Outcome Measurements: Satisfaction scores on a Likert scale ranged from 1 (worst) to 7 (best).Results: A total of 1698 subjects were included. The response rate was higher for the OS group (95%) than the MB group (62%). OS scores were significantly higher than MB scores for 5 of 11 questions, which concerned nurse satisfaction, physician satisfaction, bowel-preparation comfort, postprocedure education, and overall satisfaction (Bonferroni adjusted P <.05 for all). Younger patients gave lower scores than older patients for all questions, whereas women gave significantly lower scores than men for bowel-preparation satisfaction.Limitations: Lack of true randomization and formal validation of the satisfaction surveyConclusions: Survey collection methods may bias not only response rates but also satisfaction scores. OS survey collection methods tend to result in higher satisfaction scores than MB methods. This bias should be noted when comparing scores among studies that used different survey collection methods.

BACKGROUND:Esophageal capsule endoscopy (ECE) is an alternative to EGD for Barrett's esophagus screening. A multicenter study found ECE to be safe, well tolerated, and accurate; however, a post hoc adjudication process was used that may have biased results. OBJECTIVE:To assess the accuracy of ECE for the diagnosis of Barrett's esophagus. DESIGN:Prospective and blinded, with no adjudication. PATIENTS:Screening patients with chronic gastroesophageal reflux and surveillance patients with known Barrett's esophagus. INTERVENTIONS:ECE followed by EGD in each subject. MAIN OUTCOME MEASUREMENTS:Sensitivity, specificity, and positive and negative predictive values of ECE for Barrett's esophagus by using EGD results, with histologic confirmation as the criterion standard. RESULTS:Ninety-six subjects were enrolled, of whom 90 (94%) completed the study, including 66 screening and 24 surveillance patients. ECE was 67% sensitive and 84% specific for identifying Barrett's esophagus, diagnosing 14 of 21 cases of biopsy-confirmed Barrett's esophagus. Positive and negative predictive values were 22% and 98%, respectively (calculated for screening patients only). Sensitivity for short- and long-segment Barrett's esophagus was similar. CONCLUSIONS:Our blinded, unadjudicated study shows that ECE had only moderate sensitivity and specificity for identifying Barrett's esophagus. ECE in its present form is not suitable as a primary screening tool for Barrett's esophagus but may be used in patients unwilling to undergo EGD. Inadequate visualization of the gastroesophageal junction may be the cause of suboptimal ECE accuracy; this may be improved by advances in ingestion protocol and capsule calibration.

Ischemic colitis represents the most common form of gastrointestinal ischemia and can be classified as gangrenous or non-gangrenous. Non-gangrenous ischemic colitis is further subdivided into chronic and transient. The transient form of ischemic colitis may be seen in otherwise healthy individuals and can be attributed to a variety of factors including estrogen, severe hypovolemia and laxative use. We present several cases of bisacodyl induced ischemic colitis in previously healthy individuals undergoing bowel prep for outpatient colonoscopy.

PURPOSE:Many guidelines on colorectal cancer screening do not consider distal hyperplastic polyps to be a marker for proximal neoplasia. However, 11 of 17 published studies have shown an increased risk of proximal neoplasia in patients with distal hyperplastic polyps. Our goal is to assess the risk of proximal neoplasia in asymptomatic patients with distal hyperplastic polyps, compared to those with distal tubular adenomas or no distal polyps. METHODS:We assessed proximal (cecum, ascending, transverse colon and splenic flexure) and distal polyps in patients undergoing screening colonoscopy, classifying them into 3 groups: distal hyperplastic polyps only; distal adenomas with or without hyperplastic polyps; no distal polyps. The prevalence of proximal neoplasia and advanced neoplasia (polyps > or =1 cm, villous adenomas, or cancer) was compared among these groups. RESULTS:Of 2357 patients, 427 (18%) had neoplasia, including 103 (4%) with advanced neoplasia. Proximal neoplasia occurred in 175 (9%) of 1896 patients with no distal polyps, compared with 28 (12%) of 237 with distal hyperplastic polyps (P = 0.20) and 64 (29%) of 224 with distal adenomas (P <0.0001). Proximal advanced neoplasia occurred in 39 (2%) patients with no distal polyps, compared with 4 (2%) with distal hyperplastic polyps (P = 0.70) and 9 (4%) with distal adenomas (P = 0.13). CONCLUSIONS:Patients with distal hyperplastic polyps, unlike those with distal adenomas, do not exhibit an increased risk for proximal neoplasia or proximal advanced neoplasia compared to those with no distal polyps. The discovery of hyperplastic polyps on screening sigmoidoscopy should not prompt colonoscopy.

Pseudotumor cerebri syndrome (PTCS) is defined by the presence of elevated intracranial pressure in the setting of normal brain parenchyma and cerebrospinal fluid. PTCS can occur in the pediatric and adult populations and, if untreated, may lead to permanent visual loss. In this review, discussion will focus on PTCS in the pediatric population and will outline its distinct epidemiology and key elements of diagnosis, evaluation and management. Finally, although the precise mechanisms are unclear, the underlying pathophysiology will be considered.

Does coadministration of immunosuppressive agents alter response to infliximab in Crohn's disease?

Although PD disruption has been documented in some individuals with severe pancreatitis, to date there are no studies which have systematically reviewed ductal integrity and the consequences of treating a disruption, if found. Materials and Methods: Medical records of 100 patients (pts) with severe necrotizing pancreatitis (Balthazar CT score ≥ 6) who presented to VMMC between 6/90 and 4/99. 80 of whom were referred by other medical institutions, were reviewed. PD leak was defined as demonstrable duct disruption at ERCP, injection of the PD through a percutaneous or surgically placed drain, and/or a persistent high volume, high amylase (≥2500 IU) output from a JP drain. ERCP findings and treatment results were reviewed and placed into the perspective of overall therapy. Results: 78 pts (78%), 54 M/24 F had a documented PD leak. 56 of these pts (72%) had 62 PD leaks documented by ERCP: head 11, genu 15, body 23, tail 12, and side branches 1; whereas an additional 22 pts had no demonstrable leak. Concomitant ERCP findings included CBD stricture 28, PD stricture 20, PD stone 6, and CBD/PD fistula 6. Endoscopic treatment included placement of PD stent in 43 pts, with leak resolution in 32/40 (80%), CBD stent placement in 29, CBD and/or PD sphincterotomy 46, cystgastrostomy 11, NP drain placement 5, cystduodenostomy 3, and NB drain 2. Possible acute complications occurred in 9 pts and included post-ERCP pain exacerbation 5, bleeding 1, cholangitis 1, and positive bacterial cultures noted in JP drain sites 4 (9/89, 10%). Additional therapies in the 100 pts included CT drainage 73, and surgeries 55 (cholecystectomy 26, debridement 15, cystgastrostomy 2, Peustow 1, pancreatic resection 36, revision of pancreaticojejunostomy 4). There were a mean of 1.85 ± 0.2 hospitalizations and 79/100 pts had a mean hospital stay of 25 ± 3 days, although 2 pts had a LOS >4 months. There were 7 deaths in the series including 4 with PD leak and 3 without. Conclusions: 1) Severe pancreatic necrosis was associated with PD leak in 78% of pts in the series and may be etiologic in the severity of the disease process. 2) Although not risk-free, ERCP proved useful in both the diagnostic (72%) and successful resolution (80%) of these leaks. 3) The relatively low-mortality rate (7%) in this series may be a consequence of leak resolution and/or the multi-disciplinary approach to pancreatic necrosis practiced in our institution.

Because transpapillary stents have been successfully placed to treat the ductal disruptions associated with pseudocysts, pancreatic ascites and pleural effusions, and pancreaticoenteric fistulas, we reviewed our experience with endoscopically placed prostheses in patients who had persistent pancreaticocutaneous fistulas but an otherwise intact duct. Nine patients who underwent endoscopic transpapillary stent placement for ongoing pancreaticocutaneous fistulas at our institution were retrospectively reviewed. Fistulas were present for a mean (±SEM) of 35 ±11 days and averaged 225±55 ml of output daily. Etiology of the fistulas included percutaneous pseudocyst drainage in four patients, pancreatic necrosis in two, complications of pancreatic surgery in two, and perforation of the duct of Santorini at the time of minor aphincterotomy in one. All patients had an otherwise intact duct at the time of endoscopic retrograde cholangiopancreatography. Six patients had transpapillary stents placed that did not bridge the area of leakage and three had prostheses placed across the ductal disruption. Eight of nine fistulas were successfully closed by means of this technique including five within 48 hours. There was one instance of stent migration and one patient developed prosthesis occlusion and an infected pseudocyst, which was treated with stent exchange. Stents were retrieved 10 to 14 days after fistula closure and no patient has had a recurrence at a median follow-up of 3 years. Transpapillary stents appear to effect closure of pancreaticocutaneous fistulas that fail to respond to conventional therapy.

Objective: To define what effect seminal and controlled clinical trials have on practice patterns within a gastroenterological community. To define whether these practice patterns reproduce reported treatment methods and whether results comparable with those reported in such trials are noted within a community practice setting. Methods: Mailed surveies, with telephone follow-up, were sent to all members of the Pacific Northwest Gastroenterology Society. Respondents were queried regarding cyclosporin use in the precolectomy chronic ulcerative colitis (CUC) patient. Data collected included patient demographics, disease duration and extent, pretreatment use of steroids, method, dosage, and duration of cyclosporin therapy, side effects, and short-term and subsequent clinical results. Results: Twenty-one percent of 81 respondents had used cyclosporin for precolectomy CUC, approximately one-half using constant infusion and one-half using parenteral bolus therapy. Side effects attributed to the cyclosporin were noted in eight of 30 patients (27%), and acute colectomy was avoided in 17 patients (57%). Subsequent colectomy was required in an additional nine patients (73% total) within a 6-month follow-up period, a significantly higher colectomy rate than that reported in prospective trials. Conclusions: Potential reasons precluding cyclosporin use within the gastroenterological community may include lack of knowledge about cyclosporin therapy for CUC, lack of opportunity, skepticism, fear of medication side effects, survey sampling error, or treatment philosophy. Potential reasons for failure to duplicate the results reported in controlled trials are more complex but may include inadequate treatment duration, the learning curve associated with use of a new medication, or acceptance of colectomy as the treatment of choice in patients with acutely or chronically debilitating disease.