Patients frequently have questions about how IBD influences pregnancy. Both patients and providers should have a clear understanding of the risks of IBD and the risks and benefits of continuing IBD treatments in the pregnant patient. We sought to assess knowledge about pregnancy and IBD in trainees in specialties that might interact with these patients.

Introduction: Patients with inflammatory bowel disease are at an increased risk of colorectal cancer when compared to the general population. Chronic inflammation is thought to be the underlying cause, and medications that reduce inflammation have the potential to reduce the risk of colorectal cancer.Areas covered: After conducting a PubMed search for relevant literature, we examined several classes of medications that have been studied as potential chemopreventive agents. These include 5-aminosalicylates, thiopurines, tumor necrosis factor antagonists, ursodeoxycholic acid, NSAIDs, and statins.Expert commentary: While each class of medications has some data to support its use in chemoprevention, the majority of the evidence in each case argues against the routine use of these medications solely for a chemopreventive benefit.

Background and Aims: Definitive diagnosis of IBD requires endoscopic and pathologic confirmation.These tools are also used to classify disease activity.Our aim was to determine if the fractional exhaled nitric oxide (FeNO) could be utilized to screen for IBD and assess for disease activity. Methods:We matched weighted IBD cases and controls from the 2009-2010 NHANES dataset.All subjects underwent measurement of FeNO using standardized techniques.We assessed for potential confounders for FeNO measurement including age, height, and asthma.For IBD subjects, we used the presence of diarrhea, fatigue, and weight loss as a proxy for IBD activity.Laboratory parameters examined to estimate disease activity included anemia (≤ 10 g/dl), iron deficiency (ferritin ≤ 20 ng/ml), hypoalbuminemia (≤ 3.2 g/dl), and CRP (≥ 1.1 mg/dl). Results:The weighted sample represented 199,414,901 subjects.The weighted prevalence of IBD was 2,084,895 (1.0%).IBD subjects had nearly the same FeNO level as those without IBD (17.0 ± 16.2 vs. 16.7 ± 14.5 ppb).The odds of a FeNO > 25 ppb was half (OR=0.501;95% CI 0.497-0.504)for subjects with IBD compared to those without IBD after controlling for confounders.The AUROC curve for FeNO was 0.47 (0.35-0.59).FeNO levels were not higher in patients with laboratory values suggestive of active disease.FeNO levels were higher in IBD patients with diarrhea, rectal urgency, and fatigue but were lower in those with unintentional weight loss. Conclusion:Measurement of FeNO does not appear to be useful to screen for IBD or assess disease activity.

constitute the top two leading causes requiring a liver transplant.As this cohort of patient rises, patient education becomes essential for compliance & shared decision-making.The National Institutes of Health (NIH) recommends that the readability level of patient education materials be written at or below the 6 th grade.Imprecise, partial comprehension of text limits its efficacy in communicating the disease process to the patient.Here, we report a comparative analysis of online patient-centered text pertaining to cirrhosis & liver transplant.Methods: From April to May 2015, online patient education resources pertaining liver transplant from websites of Mayo Clinic, NIH, National Health Service (NHS), patient.info,& WebMD were downloaded & processed in Microsoft Word ® .In addition, American College of Gastroenterology (ACG), HCVadvocate.org,National Institute of Diabetes & Digestive & Kidney Diseases (NIDDK), patienteducationcenter.org (PEC) & UpToDate.comwere sourced for cirrhosis.All data were formatted & separated into various categories.Proprietary information & defined medical terms were edited out to limit inflation of readability grade level.Text was analyzed for their specific level of readability using six quantitative scales: Flesch-Kincaid level (FK), Gunning fog index (GF), SMOG, Coleman-Liau, Flesch Reading Ease & New Dale-Chall using Readability Studio software ®. Results: Modified documents had a mean grade level that was 1 less than their original counterparts.For cirrhosis, ACG had the highest mean grade level of readability of it's content (12.4±0.9), with the lowest being for WebMD (9.65±1.1).Two-way ANOVA analysis with post-hoc analysis showed that there were significant differences in the grade level for ACG & WebMD (p<0.05) when compared with FK, GF & SMOG suggestive of high syllable (>3) per word content responsible for its high grade level.There was no significant difference between subsections.For liver transplant, Patient.info had the highest mean reading grade level (13±2.8)with the lowest being for NHS (10.22±1.5).Two-way ANOVA with post-hoc analysis showed that patient.info was significantly higher (p<0.05) using all readability tests.The complications subsection was usually the most difficult section written when compared with other subsections.Conclusion: Patient material is above the recommended 6 th grade level across all websites.Greater emphasis on clear & simple language is warranted to increase quality & comprehension of online patient education resources for cirrhosis & liver transplantation in the selected prominent websites.Bar graph depicting reading grade level on X axis distributed per website (Y axis) Box and whiskers plot with 95% CI for Liver transplant sources Sa1121

Introduction: Medication non-compliance in patients with inflammatory bowel disease (IBD) is common and associated with suboptimal care and outcomes. Many IBD therapies have inherent risks including immunosuppression, lab abnormalities and malignancy. As such, following provider recommendations are important. It is not known how physicians might alter treatment strategies in non-compliant IBD patients. Methods: An email was distributed to American College of Gastroenterology members with an anonymous 16-question survey including demographic information, views on medication adherence, and questions pertaining to how a hypothetical non-compliant IBD patient with moderate to severe disease might be managed. Results: The 207 respondents were primarily male (74%) and in private practice vs academic practice (56% vs 38%). Most have practiced independently for over 20 years (34%), followed by 1-5 years of independent practice (30%), 6-20 years (28%) and fellows (8%). Many prescribers (44%) had a patient population with only 1-10% carrying a diagnosis of IBD; however, 33% had up to 25% IBD patients, 9% with 26-50% IBD patients and 13% whose majority of practice is IBD. Respondents considered adherence to medication important, however the majority (75%) never use a standardized adherence assessments. Common concerns physicians have in non-compliant patients include disease progression (94.7%) and development of antibodies to biologics (77.5%)(Table 1). In non-compliant IBD patients with moderate to severe disease, most physicians continue the current therapy regardless of whether the patient was on biologic monotherapy, immunomodulator monotherapy or combination therapy. Still, 76% of prescribers have altered treatment plans for non-compliant IBD patients. Respondents provided a variety of treatment changes that they have employed in non-compliant patients (Table 2). The most common change was using IV infusions instead of home self-injections (84.6%). Other frequently used methods were avoiding medications that require frequent monitoring (65.1%) and avoiding multiple medications (56.2%). Prescribing patterns were similar despite duration of physician practice or percentage of IBD patients.Table 1: Responses to Question: What are your concerns, if any, for a patient with moderate to severe inflammatory bowel disease who is poorly compliant with medication(s) and/or routine lab draws? Select all that apply.Table 2: Responses to Question: Which of the following strategies have you employed when choosing medications for IBD patients at risk for poor medication compliance? Select all that apply.Conclusion: Non-compliant IBD patients frequently have altered treatment plans. Often, physicians choose regimens that deviate from the standard of care and may lead to suboptimal outcomes. Further study is warranted to assess if outcomes are worse in these patients.

Background: Accurate and timely diagnosis of acute appendicitis can reduce mortality, improve clinical outcomes, and optimize resource utilization.Our aim was to compare computed tomography (CT), magnetic resonance imaging (MRI) and ultrasound (US) for the diagnosis of acute appendicitis in adults, children and pregnant women.Methods: For a hypothetical cohort of 10,000 patients, we constructed a decision analysis model to examine 3 imaging modalities for the diagnosis of acute appendicitis in adults, children and pregnant women presenting with abdominal pain.Imaging sensitivity and specificity were based on an AHRQ systematic review and meta-analysis of over 800 studies, e.g., sensitivity of CT (96%), MRI (91%) and US (83%) and specificity of CT (96%), MRI (86%) and US (89%) in adults.Prevalence and complication rates (perforation at presentation and after delayed diagnosis and mortality) were based on published estimates.Outcomes included overall surgery rate (initial+delayed), delayed surgery (false negatives), unnecessary surgery (false positives), perforated appendicitis (initial+delayed) and mortality.Results: In adults with a 25% risk of appendicitis, CT was the best strategy with 750 and 525 fewer total surgeries and unnecessary surgeries, 124 and 325 fewer delayed surgeries, 45 and 117 fewer perforations, and 9 and 22 more lives saved per 10,000 patients compared to MRI and US, respectively (Table 1).For children with a 10% risk of appendicitis, MRI performed best with 720 and 630 fewer total surgeries and unnecessary surgeries, 40 and 110 fewer delayed surgeries, 20 and 55 fewer perforations, and 1 and 1 more life saved per 10,000 patients compared to CT and US, respectively.For pregnant women with 30% risk of appendicitis, MRI was best with no fewer surgeries or unnecessary surgeries but with 40 and 110 fewer perforations, and 6 and 48 more lives saved per 10,000 patients compared to CT and US, respectively.In one-way sensitivity analysis of the 95% CI for sensitivity and specificity, the optimal strategies above remained preferred except when 1) the sensitivity of MRI increased, making it more favorable in adults, 2) the sensitivity and specificity of MRI fell in children and CT became favored and 3) the sensitivity of MRI fell and the sensitivity of CT increased in pregnant women and CT became favored.Conclusion: The results suggest that imaging should be tailored to the type of patient presenting with suspected acute appendicitis and that optimal imaging testing would reduce morbidity and mortality while reducing resource utilization.The results were sensitive to variation in test sensitivity and specificity, so patient care should consider local test performance.Future analyses should incorporate quality of life adjustments, costs and long-term effects of radiation, non-diagnostic imaging results, and serial imaging.Outcomes for 10,000 Patients with Suspected Acute Appendicitis

Inflammatory bowel disease (IBD), including Crohn’s disease (CD) and ulcerative colitis (UC), is a chronic gastrointestinal inflammatory condition. It is a fairly common diagnosis in the United States and can cause significant morbidity, resulting in hospitalization and surgery. It is associated with a significant impact on healthcare costs [1,2]. In some settings, it may be difficult to determine if a patient’s clinical symptoms are a result of active gastrointestinal inflammation. Alternative causes of symptoms include fibrostenotic sequelae of CD, infections, adhesive disease as a result of prior surgeries, and underlying irritable bowel syndrome. The best method for determining the presence of active inflammation is direct visualization and biopsy during ileocolonoscopy [3]. Although safe to perform, endoscopic procedures may not be appropriate in all situations, are invasive, require a bowel preparation, are often performed with sedation and may not be able to access the involved area. Additionally, in this era of cost-consciousness, less expensive evaluations would be preferred. Imaging modalities including computerized axial tomography scans and magnetic resonance imaging with or without enterography can be useful in evaluating mucosal inflammation, but the former involves ionizing radiation and both incur a significant cost [4]. As such, highly sensitive and specific, low-cost, non-invasive measures of inflammation would be useful tools to evaluate symptomatic patients with IBD. Alternative markers have been studied, and hopefully some will prove worthy as clinical tools.

Purpose: Inflammatory Bowel Disease (IBD) can be associated with significant stress, anxiety and depression. Psychiatric morbidity could conceivably lead to illicit drug abuse. Although small studies have been done on marijuana abuse in IBD patients, there is a paucity of evidence looking at this association at a population level. Also, abuse of other illicit drugs has not been studied carefully in IBD patients. Our aim was to determine the prevalence of illicit drug use and its association with IBD using a population-based survey sample. Methods: The entire 2009-2010 NHANES database was utilized for data analysis. After weighting using the Complex Samples module of SPSS 20.0, the age range was restricted to 18-65 years. Subjects were self-identified as having Crohn's Disease (CD) or Ulcerative Colitis (UC). All NHANES participants were asked whether they ever used marijuana/hashish (MH), or cocaine/heroin/methamphetamines (CHME). Due to missing data, prevalence values for individual drugs could not be determined. Results: Of a weighted sample size of 199,283,214 NHANES participants, there were 524,350 with CD (0.26%) and 1,628,605 with UC (0.82%). The prevalence of ever using MH was far higher in UC patients than in non-IBD subjects, and was lowest in those with CD (78.2 vs. 57.8 vs. 39.8%; P <0.001). Those with IBD started using MH at a younger age (15.7 ± 2.5 vs. 17.4 ± 4.0 years). For CHME, 12.3% of UC subjects were ever users, similar to the use of those with CD (12.1%); both were far less than non-IBD subjects (18.7%). In regression, after controlling for age and gender and using non-IBD subjects as the control, the risk of MH use was higher in those with CD (OR=2.10; 2.09 - 2.11) and lower with UC (OR = 0.37; 0.368-0.371). However, using the same controls, the risk of ever use of CHME was increased in both CD (OR=1.79; 1.77-1.81) and UC (OR = 1.54; 1.536-1.552). Conclusion: The prevalence of illicit drug use among subjects with IBD is substantial. After controlling for age and gender, the presence of underlying CD or UC was a risk for the ever use of CHME. For MH, this pattern held for CD, but not UC. In fact, the risk of MH use was significantly lower in UC patients than matched controls. Potential confounding variables, such as depression and disease activity, were not able to be included in the model. Inquiring about and counseling our IBD patients concerning the use of illicit drugs remains an important part of patient management.

Introduction: Irritable Bowel Syndrome with constipation (IBS-C) is associated with abdominal pain and infrequent spontaneous bowel movements. Patients with Chronic Idiopathic Constipation do not have abdominal pain as a predominant symptom. Linaclotide represents a new class of medication approved in the USA for both of these common conditions. Linaclotide is approved for IBS-C only in the EU. The only other medication approved at this time for IBS-C is lubiprostone.Areas covered: This review will cover the mechanism of action of linaclotide, and review the pivotal pre-clinical and clinical trials leading to its approval in 2012. The indications, common side effects, and black box warnings listed for linaclotide are reviewed.Expert opinion: Linaclotide is superior to placebo for the treatment of both IBS-C and Chronic Idiopathic Constipation. The drug has minimal systemic bioavailability and a favorable safety profile. For IBS-C, it is appropriate as a first-line prescription treatment. For Chronic Idiopathic Constipation, osmotic or stimulant laxatives should be tried prior to using linaclotide due to their considerable lower cost.

Purpose: IBD is a chronic inflammatory intestinal disorder, which has been associated with an increased prevalence of dental caries and periodontitis. Small studies have shown that patients with IBD may have poor oral health secondary to select nutritional deficiencies and immune suppression therapy, while other research suggests that treatment for IBD may actually improve the state of oral health. Our purpose was to clarify whether there is an association between IBD and the prevalence of dental and oral soft tissue disease at a population level through the use of the National Health and Nutrition Examination Survey (NHANES) database. Methods: The 2009-2010 NHANES database was utilized for data analysis. Survey data was weighted using the Complex Samples module of SPSS 20.0. Subjects are self-identified as having IBD. All survey participants 3-19 and 30 years and older were eligible for the oral health examination by trained dental hygienists. Participants aged 30 years and older were eligible for the periodontal evaluation if they had at least one tooth (excluding third molars). The periodontal examination was a full-mouth, six-site per tooth assessment. Results: Of a weighted sample size of 199,283,214 NHANES participants, there were 2,054,131 individuals (1.03%) with IBD. For all 32 teeth, the prevalence of an absent tooth at nearly all sites was higher in the group without IBD. Only for sites #16 (upper left 3rd molar-”wisdom tooth”) and #18 (lower left 2nd molar) was the absence of a tooth > 10% higher in the IBD group. The prevalence of gum/soft tissue disease was lower in the group with IBD (16.1 vs. 17.0%; P < 0.001). However, the percentage of individuals recommended to have urgent (≤ 2 weeks) dental care was slightly higher in the IBD group (4.7 vs. 3.3%; P< 0.001). Conclusion: Although slight differences existed in dental health between those with and without IBD, the overall oral condition for both groups appeared comparable. At a minimum, no alarming trends were identified. The results are limited by inability to adjust for disease activity, and medications. Despite our encouraging findings, individuals with IBD on immune modulator and TNF-α inhibitor therapy are encouraged to seek regular dental care and practice consistent high quality oral hygiene.

To the Editor:We read with interest the observations of McPherson et al.1McPherson F Maldonado M Truitt CA Mamel JJ Morgan MB. Metaplastic ossification of a benign colon polyp: case report.Gastrointest Endosc. 1999; 49: 654-656Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar regarding metaplastic ossification of benign colonic polyps and report additional information regarding this transformation. Our patient underwent snare polypectomy of a 2.5 cm sigmoid polyp. Histologically, the polyp was a tubulovillous adenoma with an area of metaplastic bone formation. Using the avidin-biotin technique, immunostains were obtained for bone morphogenetic protein (BMP) 2/4 (Genetics Institute, Boston, Mass.) at a concentration of 1:250. Positive and negative controls were appropriate. Immunohistochemistry for BMP showed no staining in the bone or surrounding cells.Bone morphogenetic proteins (BMPs) are part of the TGF-beta superfamily of peptides. The BMPs possess the ability to induce endochondral osteogenesis and fracture healing.2Wozney JM Rosen V Celeste AJ Mitsock LM Whitters MJ Kriz RW et al.Novel regulators of bone formation: molecular clones and activities.Science. 1988; 242: 1528-1534Crossref PubMed Scopus (3322) Google Scholar, 3Kingsley DM. The TGF-beta superfamily: new members, new receptors, and new genetic tests of function in different organisms.Genes Dev. 1994; 8: 133-146Crossref PubMed Scopus (1726) Google Scholar, 4Bostrom MP Lane JM Berberian WS Missri AA Tomin E Weiland A et al.Immunolocalization and expression of bone morphogenetic proteins 2 and 4 in fracture healing.J Orthop Res. 1995; 13: 357-367Crossref PubMed Scopus (318) Google Scholar They also have the unique ability to induce the complete endochondral osteogenic cascade at heterotopic sites in vivo. The antibody used in this study cross-reacts with BMPs 2 and 4 due to their 95% homology in sequence. The lesion that was stained revealed mature, lamellar bone with quiescent osteoblasts. The lack of immunostaining observed could be a result of a number of factors. As bone matures and the osteoblasts are no longer active, BMP immunostaining is no longer appreciated. Additionally, it is not known at the current time if BMP production is a continuous process at this stage of bone development. Fixation and decalcification can also play a role in immunostaining results as the half-life of the BMP message (and presumably the protein) is relatively brief. The fact that bone is indeed present in this lesion, however, is presumptive evidence that one of the BMPs was present and expressed at some point in the development of the lesion. To the Editor:We read with interest the observations of McPherson et al.1McPherson F Maldonado M Truitt CA Mamel JJ Morgan MB. Metaplastic ossification of a benign colon polyp: case report.Gastrointest Endosc. 1999; 49: 654-656Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar regarding metaplastic ossification of benign colonic polyps and report additional information regarding this transformation. Our patient underwent snare polypectomy of a 2.5 cm sigmoid polyp. Histologically, the polyp was a tubulovillous adenoma with an area of metaplastic bone formation. Using the avidin-biotin technique, immunostains were obtained for bone morphogenetic protein (BMP) 2/4 (Genetics Institute, Boston, Mass.) at a concentration of 1:250. Positive and negative controls were appropriate. Immunohistochemistry for BMP showed no staining in the bone or surrounding cells.Bone morphogenetic proteins (BMPs) are part of the TGF-beta superfamily of peptides. The BMPs possess the ability to induce endochondral osteogenesis and fracture healing.2Wozney JM Rosen V Celeste AJ Mitsock LM Whitters MJ Kriz RW et al.Novel regulators of bone formation: molecular clones and activities.Science. 1988; 242: 1528-1534Crossref PubMed Scopus (3322) Google Scholar, 3Kingsley DM. The TGF-beta superfamily: new members, new receptors, and new genetic tests of function in different organisms.Genes Dev. 1994; 8: 133-146Crossref PubMed Scopus (1726) Google Scholar, 4Bostrom MP Lane JM Berberian WS Missri AA Tomin E Weiland A et al.Immunolocalization and expression of bone morphogenetic proteins 2 and 4 in fracture healing.J Orthop Res. 1995; 13: 357-367Crossref PubMed Scopus (318) Google Scholar They also have the unique ability to induce the complete endochondral osteogenic cascade at heterotopic sites in vivo. The antibody used in this study cross-reacts with BMPs 2 and 4 due to their 95% homology in sequence. The lesion that was stained revealed mature, lamellar bone with quiescent osteoblasts. The lack of immunostaining observed could be a result of a number of factors. As bone matures and the osteoblasts are no longer active, BMP immunostaining is no longer appreciated. Additionally, it is not known at the current time if BMP production is a continuous process at this stage of bone development. Fixation and decalcification can also play a role in immunostaining results as the half-life of the BMP message (and presumably the protein) is relatively brief. The fact that bone is indeed present in this lesion, however, is presumptive evidence that one of the BMPs was present and expressed at some point in the development of the lesion. We read with interest the observations of McPherson et al.1McPherson F Maldonado M Truitt CA Mamel JJ Morgan MB. Metaplastic ossification of a benign colon polyp: case report.Gastrointest Endosc. 1999; 49: 654-656Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar regarding metaplastic ossification of benign colonic polyps and report additional information regarding this transformation. Our patient underwent snare polypectomy of a 2.5 cm sigmoid polyp. Histologically, the polyp was a tubulovillous adenoma with an area of metaplastic bone formation. Using the avidin-biotin technique, immunostains were obtained for bone morphogenetic protein (BMP) 2/4 (Genetics Institute, Boston, Mass.) at a concentration of 1:250. Positive and negative controls were appropriate. Immunohistochemistry for BMP showed no staining in the bone or surrounding cells. Bone morphogenetic proteins (BMPs) are part of the TGF-beta superfamily of peptides. The BMPs possess the ability to induce endochondral osteogenesis and fracture healing.2Wozney JM Rosen V Celeste AJ Mitsock LM Whitters MJ Kriz RW et al.Novel regulators of bone formation: molecular clones and activities.Science. 1988; 242: 1528-1534Crossref PubMed Scopus (3322) Google Scholar, 3Kingsley DM. The TGF-beta superfamily: new members, new receptors, and new genetic tests of function in different organisms.Genes Dev. 1994; 8: 133-146Crossref PubMed Scopus (1726) Google Scholar, 4Bostrom MP Lane JM Berberian WS Missri AA Tomin E Weiland A et al.Immunolocalization and expression of bone morphogenetic proteins 2 and 4 in fracture healing.J Orthop Res. 1995; 13: 357-367Crossref PubMed Scopus (318) Google Scholar They also have the unique ability to induce the complete endochondral osteogenic cascade at heterotopic sites in vivo. The antibody used in this study cross-reacts with BMPs 2 and 4 due to their 95% homology in sequence. The lesion that was stained revealed mature, lamellar bone with quiescent osteoblasts. The lack of immunostaining observed could be a result of a number of factors. As bone matures and the osteoblasts are no longer active, BMP immunostaining is no longer appreciated. Additionally, it is not known at the current time if BMP production is a continuous process at this stage of bone development. Fixation and decalcification can also play a role in immunostaining results as the half-life of the BMP message (and presumably the protein) is relatively brief. The fact that bone is indeed present in this lesion, however, is presumptive evidence that one of the BMPs was present and expressed at some point in the development of the lesion.

Patients with IBS need an integrated, individualized approach to treatment, with a foundation based on a successful patient-physician relationship. The emotional and psychologic needs of the patients need to be considered in a successful management plan. Further advances in the pathophysiology of disease are essential to develop suitable and more comprehensive treatment options.

We have previously reported impressive results in using a gonadotropin-releasing hormone analog, leuprolide acetate (Lupron), in the treatment of moderate to severe symptoms (especially abdominal pain and nausea) in patients with functional bowel disease (FBD). Pain is the hallmark of patients with FBD, and there is no consistent therapy for the treatment of these patients. The purpose of the present study was to expand the investigation to study similar patients (menstruating females) in a multicenter, double-blind, placebo-controlled, randomized study using Lupron Depot (which delivers a continuous dose of drug for one month), 3.75 mg (N = 32) or 7.5 mg (N = 33), or placebo (N = 35) given intramuscularly every four weeks for 16 weeks. Symptoms were assessed using daily diary cards to record abdominal pain, nausea, vomiting, early satiety, anorexia, bloating, and altered bowel habits. Additional assessment tools were quality of life questionnaires, psychological profile, oral-to-cecal transit using the hydrogen breath test, antroduodenal manometry, reproductive hormone levels, and global evaluations by both patient and investigator. Patients in both Lupron Depot-treated groups showed consistent improvement in symptoms; however, only the Lupron Depot 7.5 mg group showed a significant improvement for abdominal pain and nausea compared to placebo (P < 0.001). Patient quality of life assessments and global evaluations completed by both patient and investigators were highly significant compared to placebo (P < 0.001). All reproductive hormone levels significantly decreased for both Lupron Depot-treated groups by week 4 and were significantly different compared to placebo at week 16 (P < 0.001). This study shows that leuprolide acetate is effective in controlling the debilitating symptoms of abdominal pain and nausea in patients with FBD.

Villous adenomas are common neoplasms of the colon, often causing anemia or hemoccult positive stools. Less typically, these lesions may result in abdominal pain, melena, obstruction, or change in bowel habits. Intussusception may occur, but this complication is unusual in adults. Spontaneous bowel perforation attributable to colonic polyps has not been previously reported. We present here the first reported case of an adenomatous polyp with bowel perforation and bladder involvement.

Extracorporeal shock wave lithotripsy and dissolution agents are useful nonsurgical therapies for gallstones. Their effect on gallbladder emptying is unclear. We evaluated emptying by ultrasonography before and after lithotripsy in 50 patients on ursodeoxycholic acid or placebo and in nine controls. At baseline, patients had normal (68.8 +/- 3.2%) or delayed emptying (14.5 +/- 3.3%). In a subset of 24 patients, lithotripsy increased fasting volume (26.6 +/- 3. 0 to 43.8 +/- 5.0 ml, P < 0.005), postprandial volume (11.3 +/- 3.1 ml to 22.9 +/- 3.0 ml, P < 0.05), and decreased ejection fraction (70.0 +/- 4.1% to 42.7 +/- 6.0%, P < 0.0005). There was an inverse linear correlation between power and ejection fraction, r = -0.43, P < 0.005. Ursodeoxycholic acid increased fasting (23.3 +/- 2.2 ml to 36.7 +/- 4.6 ml, P < 0.005) and postprandial volume (11.1 +/- 1.8 to 17.6 +/- 2.5, P < 0.005). Treatment with ursodeoxycholic acid resulted in a greater decrease in fragment size compared to placebo after lithotripsy in patients with fragment size greater than 6 mm. In conclusion, both lithotripsy and ursodeoxycholic acid have an effect on gallbladder emptying-

Abnormalities in the gastric pacemaker potentials occur in patients with impaired gastric emptying. It is unclear if treatment effects the underlying rhythm or if normalization of dysrhythmias is important. We examined the effect of cisapride using surface electrogastrograms and radionuclide gastric emptying studies of patients with idiopathic and diabetic gastroparesis. Twelve of 14 patients had abnormal baseline electrogastrograms. After six months of cisapride, four patients had normalization of their electrical activity and six had improvement. Patients with idiopathic gastroparesis had an increase in gastric emptying at 120 min from 48.9 +/- 3.8% (baseline) to 70.9 +/- 6.0% (six months), P = 0.009. Patients with diabetes mellitus had a similar improvement. Patients who had normalization of the electrogastrogram had a greater gastric emptying rate than patients with continued dysrhythmias. Thus, dysrhythmias are important in the etiology for gastroparesis, but other factors need to be examined.