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Duodenal ulcers tend Denition to cause well-localised epigastric pain that may radiate Apepticulcer is a break in the integrity of the stomach to the back buy discount metoclopramide 10 mg on-line gastritis diet sugar. Macroscopy/microscopy Chroniculcershavesharplydenedborders order metoclopramide 10mg gastritis all fruit diet,withoutany Age heaping up of the edges (which would be suggestive of a More common with increasing age cheap 10 mg metoclopramide with visa diet untuk gastritis. There is a break in the integrity of the epithelium extending down to the muscularis mucosa generic 10 mg metoclopramide otc gastritis left shoulder pain. Sex Active inammation is seen with granulation tissue and Duodenal ulcers 4M : 1F. Patients require resuscitation and Gastric ulcer: emergency surgery to locate and close the duodenal r H. Acute bleeds re- Repeat endoscopy with biopsies is essential in all gastric quire resuscitation to stabilise the patient and may ulcers until completely healed, as there may be an un- require urgent endoscopic treatment (see page 147). If the ulcer does not heal within Early endoscopy can reduce the risk of rebleeding by 6months then surgery should be considered. In patients with rheumatoid arthritis or velopment of outow obstruction (pyloric stenosis). Fi- broticstenosisrequiressurgicalinterventionfollowing Helicobacter pylori treatment of any electrolyte imbalances resulting from copious vomiting. Older patients Aetiology and those with suspicious features should undergo en- The transmission of H. It produces an enzyme that breaks ing this treatment a further endoscopy is not neces- down the glycoproteins within the mucus. If symptoms persist or recur (or in all patients changes in the secretory patterns within the stomach initially presenting with complications) a urea breath along with toxin-mediated tissue damage. Initial infec- test should be performed at 4 weeks and further erad- tion causes an acute gastritis which rapidly proceeds to ication therapy used if positive. The excess acid causesinactivationofduodenal/jejunallipasesandhence Investigations steatorrhoea also occurs. Management Noninvasive tests can be performed if an endoscopy is Resection of the gastrinoma should be attempted but not indicated. High-dose proton pump belled urea, if the bacteria is present the urea is broken inhibitors are also used. Other treatment options in- down releasing labelled carbon dioxide which is de- clude octreotide, interferon,chemotherapy and hep- tected in the breath. In inoperable tumours 60% of patients survive 5 years r Serological testing is simple, non-invasive and widely and 40% survive 10 years. Disorders of the small bowel Management and appendix First line eradication (triple) therapy consists of a pro- ton pump inhibitor, amoxycillin or metronidazole, and clarithromycin for 1 week. Second line (quadruple) ther- Acute appendicitis apy is with a proton pump inhibitor, bismuth subcitrate, Denition metronidazole and tetracycline. Compliance with treat- Inammatory disease of the appendix, which may result mentisveryimportantforsuccessfultreatment. Incidence Commonest cause of emergency surgery of childhood ZollingerEllinson syndrome (34 per 1000). Denition Pathological secretion of gastrin resulting in hypersecre- Age tion of acid. Ultrasound is in- Aetiology/pathophysiology creasingly being used but does not exclude the diagnosis. Accumula- Conservative treatment has little place, except in patients tion of secretions result in distension, mucosal necrosis unt for surgery. Fluid resuscitation may be required and invasion of the wall by commensal bacteria. Inam- prior to surgery and intravenous antibiotics are com- mationandimpairmentofbloodsupplyleadtogangrene menced. Once perforation has occurred there is r Under general anaesthetic the abdomen is opened migration of the bacteria into the peritoneum (peritoni- by an incision along the skin crease passing through tis). Theoutcomedependsontheabilityoftheomentum McBurneys point (one third of the distance from a and surrounding organs to contain the infection. The muscle bres in each muscle layer Clinical features are then split in the line of their bres (grid iron in- This is a classic cause of an acute abdomen. The mesoappendix is divided with ligation of tially periumbilical, then migrates to the right iliac fossa. The appendix is ligated at its There is mild to moderate fever, nausea and anorexia. The wound is then ment of the disease may be over hours to days partly closed in layers. In most cases, the appendix is tally particularly if the omentum is wrapped around the removed to avoid confusion if patients ever re-present appendix, or an abscess has formed. Macroscopy Prognosis The appendix appears swollen and the surface vascula- Uncomplicated appendicitis has an overall mortality of ture is yellow. Microscopy Meckels diverticulum Initially there is acute inammation of the mucosa, which undergoes ulceration. As the condition progresses the inammation An ileal diverticulum occurring as a result of persistence spreads through the wall until it reaches the serosal sur- of part of the vitellointestinal duct. Age Investigations Congenital Presence of gastric mucosa can be detected by scintiscan- ning with 99mTc labelled sodium pertechnetate, which is Sex taken up by parietal cells (the Meckels scan). Persistence of the Malabsorption syndromes ductmayresultinaMeckelsdiverticulum(persistenceof Absorption of food occurs within the small bowel. The the ileal end of the duct), an umbilical sinus (persistence process involves breakdown of macromolecules by en- of the umbilical end of the duct) or an umbilical ileal zymes and transport across the specialised small bowel stula (see Fig. The most common causes of Pathophysiology malabsorption are pancreatic insufciency, coeliac dis- The diverticulum arises from the antimesenteric border ease, resection of the ileum, Crohns disease and liver of the ileum 2 ft from the ileocaecal valve and is on aver- disease (see Fig. Acid secreting gastric mucosa is found in 50% of cases which may result in Coeliac disease ulceration of the surrounding mucosa. Clinical features Ninety-ve per cent of cases are asymptomatic, symp- Incidence tomatic patients present most commonly with bleeding 1in2000. There is lymphocytic inltration of the lamina propria, and an increase in intra-epithelial lymphocytes (which Geography bear the eceptor). Loss of normal villous architecture Common in Europe, (1 in 300 in Ireland) rare in Black ranges from blunting (partial villous atrophy) to com- Africans. Aetiology Investigations Thought to be an autoimmune disease with genetic and r Serology: Screening by IgG gliadin and IgG anti- environmental components. Management Clinical features Aglutenfree diet leads to a restoration of normal villous Patients may present with irritability and failure to thrive structure and resolution of dermatitis herpetiformis (see in childhood, delayed puberty, short stature, or vomit- page 394). Haemoglobin and antiendomysial antibodies ing, diarrhoea, anorexia or abdominal distension at any may be checked at routine follow-up to look for inad- age. Complications Whipples disease There is an association with development of small bowel lymphomaandasmallincreasedriskinthedevelopment Denition of small bowel adenocarcinoma. Investigations and management Incidence Electron microscopy can demonstrate the organism. Tropical sprue Denition Aetiology AseveremalabsorptionsyndromeendemicinAsia,some Diverticulae are associated with high intraluminal pres- Caribbean islands and parts of South America. There is a relationship with a low bre diet and Aetiology/pathophysiology chronic constipation. The condition occurs in epidemics and improves on an- tibiotics thus it is likely that it has an infective cause. Pathophysiology They occur most commonly in the sigmoid colon and may become obstructed with a faecolith. Repeated in- Clinical features ammation and scarring may result in an ulcer difcult Patients present with diarrhoea, anorexia, abdominal to distinguish from carcinoma. The onset may be acute or by obstruction of the neck of the diverticulum resulting insidious.

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Methicillin-resistant Staphylococcus aureus prolongs intensive care unit stay in ventilator-associated pneumonia buy metoclopramide 10 mg fast delivery gastritis diet дом, despite initially appropriate antibiotic therapy purchase metoclopramide 10 mg with amex chronic gastritis mayo. Methicillin-resistant and susceptible Staphylococcus aureus bacteremia and meningitis in preterm infants metoclopramide 10mg visa gastritis treatment guidelines. Nosocomial methicillin-resistant Staphylococcus aureus bacteremia: is it any worse than nosocomial methicillin-sensitive Staphylococcus aureus bacteremia? Higher risk of failure of methicillin-resistant Staphylococcus aureus prosthetic joint infections order metoclopramide 10 mg gastritis like symptoms. Changing trends in acute osteomyelitis in children: impact of methicillin-resistant Staphylococcus aureus infections. Mortality associated with nosocomial bacteremia due to methicillin-resistant Staphylococcus aureus. Costs and outcomes among hemodialysis-dependent patients with methicillin-resistant or methicillin-susceptible Staphylococcus aureus bacteremia. High incidence of methicillin-resistant Staphylococcus aureus sepsis and death in patients with febrile neutropenia at Royal Darwin Hospital. Nosocomial Staphylococcus aureus bacteremia among nasal carriers of methicillin-resistant and methicillin-susceptible strains. Clinical and epidemiological ndings in mechanically-ventilated patients with methicillin-resistant Staphylococcus aureus pneumonia. Hematogenous vertebral osteomyelitis due to Staphylococcus aureus in the adult: clinical features and therapeutic outcomes. Epidemiology and clinical characteristics of Staphylococcus aureus bloodstream infections in a tertiary-care center in Mexico City: 2003-2007. Bactericidal activity of oxacillin and glycopeptides against Staphylococcus aureus in patients with endocarditis: looking for a relationship between tolerance and outcome. Periprosthetic joint infection: the economic impact of methicillin-resistant infections. Clinical impact of methicillin-resistant Staphylococcus aureus bacteremia based on propensity scores. Costs of nosocomial pneumonia caused by meticillin-resistant Staphylococcus aureus. Hospital mortality for patients with bacteremia due to Staphylococcus aureus or Pseudomonas aeruginosa. Community-associated methicillin-resistant Staphylococcus aureus in pediatric patients. Staphylococcus aureus bacteraemia in a tropical setting: patient outcome and impact of antibiotic resistance. Methicillin-resistant Staphylococcus aureus bloodstream infection: risk factors and clinical outcome in non-intensive-care units. Emergence of a predominant clone of community-acquired Staphylococcus aureus among children in Houston, Texas. A prospective investigation of outcomes after hospital discharge for endemic, community-acquired methicillin-resistant and -susceptible Staphylococcus aureus skin infection. Is methicillin-resistant Staphylococcus aureus more virulent than methicillin-susceptible S. A comparative cohort study of British patients with nosocomial infection and bacteremia. Poststernotomy mediastinitis due to Staphylococcus aureus: Comparison of methicillin-resistant and methicillin-susceptible cases. Risk factors and costs associated with methicillin-resistant Staphylococcus aureus bloodstream infections. Resistance to methicillin and virulence of Staphylococcus aureus strains in bacteriemic cancer patients. Clindamycin treatment of invasive infections caused by community-acquired, methicillin-resistant and methicillin-susceptible Staphylococcus aureus in children. Community- acquired, methicillin-resistant and methicillin-susceptible Staphylococcus aureus musculoskeletal infections in children. Predictive factors of meticillin resistance among patients with Staphylococcus aureus bloodstream infections at hospital admission. Clinical and economic impact of methicillin resistance in patients with Staphylococcus aureus bacteremia. Comparison of methicillin-resistant and methicillin-sensitive Staphylococcus aureus bacteremia. Clinical and molecular epidemiology of nursing home-associated Staphylococcus aureus bacteremia. Role of comorbidity in mortality related to Staphylococcus aureus bacteremia: a prospective study using the Charlson weighted index of comorbidity. Endocarditis: impact of methicillin-resistant Staphylococcus aureus in hemodialysis patients and community-acquired infection. Comparison of community- acquired methicillin-resistant Staphylococcus aureus bacteremia to other staphylococcal species in a neonatal intensive care unit. Clinical and economic analysis of methicillin-susceptible and -resistant Staphylococcus aureus infections. Outcome of Staphylococcus aureus bacteremia in patients with eradicable foci versus noneradicable foci. Persistence in Staphylococcus aureus bacteremia: incidence, characteristics of patients and outcome. Clinical impact of methicillin resistance on outcome of patients with Staphylococcus aureus infection: a stratied analysis according to underlying diseases and sites of infection in a large prospective cohort. A comparison of methicillin- resistant and methicillin-susceptible Staphylococcus aureus reveals no clinical and epidemiological but molecular dierences. Hospital-acquired Staphylococcus aureus infections at Texas Childrens Hospital, 2001-2007. Injecting drug use and community- associated methicillin-resistant Staphylococcus aureus infection. Methicillin resistance and risk factors for embolism in Staphylococcus aureus infective endocarditis. Impact of methicillin resistance on clinical features and outcomes of infective endocarditis due to Staphylococcus aureus. Risk factors and outcomes of methicillin-resistant Staphylococcus aureus bacteraemia in critically ill patients: a case control study. Methicillin-resistant versus methicillin-sensitive Staphylococcus aureus infective endocarditis. A comparison of clinical virulence of nosocomially acquired methicillin- resistant and methicillin-sensitive Staphylococcus aureus infections in a university hospital. Analysis of methicillin resistance among Staphylococcus aureus blood isolates in an emergency department. Comparative severity of pediatric osteomyelitis attributable to methicillin-resistant versus methicillin-sensitive Staphylococcus aureus. Persistent Staphylococcus aureus bacteremia: an analysis of risk factors and outcomes. Impact of methicillin resistance on the outcome of patients with bacteremia caused by Staphylococcus aureus. Derivation and validation of clinical prediction rules for reduced vancomycin susceptibility in Staphylococcus aureus bacteraemia. Long-term outcomes following infection with meticillin-resistant or meticillin-susceptible Staphylococcus aureus.

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Ciclosporin and cyclophosphamide may be effect- contact (usually a specialist nurse) who can ensure ive in severe disease refractory to other agents buy metoclopramide 10mg otc gastritis diet мультфильмы. All are given by injection and intra-articular corticosteroids) and systemic drug methotrexateshouldbecontinuedifpossible cheap 10 mg metoclopramide visa gastritis pain location. Simple analgesics: help some patients with mild titis B reactivation order 10mg metoclopramide fast delivery chronic gastritis raw food, bone marrow suppression and disease buy discount metoclopramide 10 mg gastritis flare up diet. Referral, diagnosis and investigations consider early serological and radiological screening and referral for expert review in all suspected cases. For established disease continue long-term therapy only after careful discussion with the patient regarding adverse effects, and after offering all other treatment options. Synovectomy, realignment and repair of tendons, joint prostheses and arthrodesis may be required for Corticosteroids severe pain or deformity. Glucocortocoids are effective for symptomatic relief and suppressing disease activity, although concerns Prognosis over side effects limit their use. Oral or disorder, with up to 10% of cases suffering pulsed intravenous therapy is effective for systemic severe disability. Young age at onset, severe palms and soles may be confused with the rash of disease/disability at presentation, extra-articular Reiter syndrome (keratoderma blennorrhagica). Investigation There is no single diagnostic test for psoriatic arthritis and a high index of clinical suspicion is required. Clinical presentation Prognosis Approximately 10% of patients with psoriasis develop arthritis. Thereis no correlation betweenthe presence This is dependent on the pattern of disease. The or severity of psoriatic skin changes and joint involve- symmetrical polyarthritis form follows a similar ment. Arthritis mutilans is asso- Asymmetric oligoarthritis ($3050% of cases) typi- ciated with considerable disability. Diffuse swellingofthedigits(dactylitis),inwhichoneortwo digits take on a sausage-like appearance, is a Ankylosing spondylitis distinctive feature. Inammation of the sacroiliac, facet Nail pitting and onycholysis may be the only evidence and intervertebral joints is followed by ossication of of underlying psoriasis, but a careful search for skin spinal ligaments and intervertebral discs. Bony out- changes (including the scalp, hairline and behind the growths from the vertebral margins extend vertically ears) should be performed. The infective Investigation organism is not found within the joint itself as the Diagnosis rests on the history and examination nd- inammatory process probably results from an im- ings combined with the following. Reactive arthritis is Blood tests seen most commonly in young adults of either sex. In up to half of all Management cases no prior infective episode can be identied. Sulphasalazine may be effective for peripheral joint and asymmetrical affecting large joints of the legs involvement. Anterior uveitis is a feature of chronic recurrent disease,particularlywhenassociatedwithsacroiliitis. Urethritis and circinate balanitis may persist in Autoimmune rheumatic some patients. Pustular hyperkeratotic lesions of the soles of the feet and palms of the hands (keratoderma blennor- tissue diseases) rhagica) occurs in $15% of patients. Distal interphalangeal joint swelling or dactylitis Systemic lupus erythematosus may be seen in chronic disease. There is no single diagnostic test for reactive arthritis It is exacerbated by exposure to ultraviolet radiation, and a high index of clinical suspicion is required. In following may be useful: North America and Northern Europe the prevalence per100,000isestimatedat3050forwhitewomen,100. Joint aspiration: uid is turbid, but contains no mental triggers act together with a genetic predispo- organisms or crystals. All patients should be screened for Chlamydia tra- positivity) is the key serological nding in patients chomatis infection, which can be clinically silent. Treatunderlyingsexuallytransmittedinfection(this does not inuence the course of joint disease). For 1530% it becomes a chronic disorder requiring on- Musculoskeletal system (in 90% going treatment. Migratory polyarthralgia with early morning stiff- Enteric arthropathy ness is common. Skin and mucous membranes (in 80% abnormalities on renal biopsy and 50% develop of cases) overt renal involvement. Clinical presentation Lupus may be conned to the skin as discoid or includes: subacute cutaneous lupus; typically a raised, scarring. Further investigations depending on presentation ation of clinical and laboratory features (Box 18. Five-year survival and Khamashta, Journal of Autoimmunity 2009; is > 90%, although patients with renal involvement 33: 9298. Antiphospholipid syndrome Management involves anticoagulation and anti- platelet therapy (see Box 18. Inammation is followed by pro- riage, usually in the second or third trimester); gressive brosis with narrowing of blood vessels. The cause of lipin, lupus anticoagulant) bind to plasma proteins scleroderma remains unclear and no reproducible or charged phospholipids in cell membranes. Raynauds phenomenon, oesophageal dysmotil- ity, sclerodactyly and telangiectasia). Theconditionismostcommonlyseen loss of terminal phalangeal tufts in middle-aged women (male:female $1:10). T chest X-ray/lung function testing T doppler echocardiography T gastrointestinal endoscopy contrast studies/ oesophageal manometry/malabsorption screen Clinical presentation. Penicillamine may be of value; trials of other im- mothers with SjogrensyndromewhoareRoanti- munomodulators and alkylating agents are on- body positive are at risk of congenital heart block. Schirmerstest: a small strip of lter paper is hooked Prognosis over the lower eyelid; wetting of < 5mm in 5min is considered abnormal. Biopsy of minor salivary glands shows a focal T cell Skin involvement in dermatomyositis inltrate. Antibodies to Jo-1 identify a subgroup of patients whereas in dermatomyositis it is antibody/comple- with anti-synthetase syndrome (fever, myositis, ment mediated. Clinical presentation The extent of investigation for underlying malig- The onset may be acute or chronic. In dermatomyo- nancy is determined by clinical suspicion and the sitis, skin and muscle changes occur in any order, or patients age. Patients report difculty climbing stairs and trexate or ciclosporin, are substituted as the corti- with tasks of daily living. Intravenousimmunoglobulinmayhelp,especiallyif groups may result in cardiac and/or respiratory theinitialresponsetotreatmentispoorand/orthere failure, oropharyngeal dysfunction and dysphagia. Occasionally more aggressive immunosuppressive therapy is required for pulmonary involvement. Physiotherapy is important in restoring muscle Large-vessel vasculitis strength/function. Affected in- thickening of the arterial intima may be associated dividuals exhibit high titres of autoantibodies to a with luminal thrombosis. Several tially transient, ultimately progressing to complete classications have been proposed, but currently visual loss if not recognised and treated. It has an estimated annual incidence branches and sometimes the pulmonary arteries.

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Nonsteroidal anti-inflammatory Drug Use and Colorectal Polyps in the Prostate metoclopramide 10 mg fast delivery gastritis symptoms after eating, Lung generic metoclopramide 10 mg with mastercard gastritis or gerd, Colorectal discount metoclopramide 10mg visa definition de gastritis, and Ovarian Cancer Screening Trial discount metoclopramide 10 mg online gastritis diet английский. The submucosal cushion does not improve the histologic evaluation of adenomatous colon polyps resected by snare polypectomy. Prevalence and variable detection of proximal colon serrated polyps during screening colonoscopy. Single-ballon colonoscopy versus repeat standard colonoscopy for previous incomplete colonoscopy: a randomized, controlled trial. Bowel preparation with split-dose polyethylene glycol before colonoscopy: a meta-analysis of randomized controlled trials. Association of adherence to life style recommendations and risk of colorectal cancer: A prospective Danish cohort study. Serious complications within 30 days of screeing and surveillance colonoscopy are uncommon. Hereditary nonpolyposis colorectal cancer (Lynch Syndrome): criteria for identification and management. Endoscopic trimodal imaging detects colonic neoplasia as well as standard video enscopy. Likelihood of missed and recurrent adenomas in the proximal versus the distal colon. Race and colorectal cancer disparities: health-care utilization vs different cancer susceptibilities. Interval fecal immunochemical testing in a colonoscopic surveillance program speeds detection of colorectal neoplasia. Bowel cleansing for colonoscopy: prospective randomized assessment of efficacy and of induced mucosal abnormality with three preparation agents. Randomised clinical trial: the effects of perioperative probiotic treatment on barrier function and post- operative infectious complications in colorectal cancer surgery a double-blind study. Polyp recurrence after endoscopic mucosal resection of sessile and flat colonic adenomas. Effective bowel cleansing before colonoscopy: a randomized study of split-dosage versus non-split dosage regimens of high-volume versus low-volume polyethylene glycol solutions. A pooled analysis of advanced colorectal neoplasia diagnoses after colonoscopic polypectomy. Lower albumin levels in African Americans at colon cancer diagnosis; a potential explanation for outcome disparities between groups? A randomized, double-blind trial of succinylated gelatin submucosal injection for endoscopic resection of large sessile polyp of the colon. Endoscopic mucosal resection outcomes and prediction of submucosal cancer from advanced colonic mucosal neoplasia. Colonic work-up after incomplete colonoscopy: significant new findings during follow-up. Long-term outcomes of endoscopic submucosal dissection for colorectal epithelial neoplasms. Adverse events associated with use of the three major types of osmotically acting cathartics. Racial/ethnic differences in colorectal cancer risk: the multiethnic cohort study. Molecular mechanisms for chemoprevention of colorectal cancer by natural dietary compounds. Computed tomographic virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults. Colorectal cancers detected after colonoscopy frequently result from missed lesions. Pancolonic chromoendoscopy with indigo carmine versus standard colonoscopy for detection of neoplastic lesions: a randomized two-centre trial. Warm water infusion versus air insufflation for unsedated colonoscopy: a randomized controlled trial. A back-to-back comparison of white light video endoscopy with autofluorescence endoscopy for adenoma detection in high-risk subjects. American College of Gastroenterology Action Plan for Colorectal Cancer Prevention. American College of Gastroenterology guidelines for colorectal cancer screening 2008. Guidelines for colonoscopy surveillance after cancer resection: A consensus update by the American Cancer Society and the U. Long-term effect of aspirin on colorectal cancer incidence and mortality: 20-year follow-up of five randomized trials. Colonoscopy and optical biopsy: bridging technological advances to clinical practice. A prospective, multicenter study of 1111 colorectal endoscopic submucosal dissections (with video). In vivo diagnosis and classification of colorectal neoplasia by chromoendoscopy-guided confocal laser endomicroscopy. Proximal and Large Hyperplastic and Nondysplastic Serrated Polyps Detected by Colonoscopy Are Associated With Neoplasia. American Journal of Physiology Gastrointestinal and Liver Physiology 2010;299:G807-G820. Rate and Predictors of Early/Missed Colorectal Cancers After Colonoscopy in Manitoba: A Population-Based Study. The reduction in colorectal cancer mortality after colonoscopy varies by site of the cancer. Development and validation of a novel patient educational booklet to enhance colonoscopy preparation. Effect of evidence based risk information on informed choice in colorectal cancer screening: randomized controlled trial. Genetic Testing for Hereditary Colorectal Cancer: Challenges in Identifying, Counseling, and Managing High-Risk Patients. Meta-analysisL the diagnostic yield of chromoendoscopy for detecting dysplasia in patients with colonic inflammatory bowel disease. Prospective randomized controlled trial evaluating cap-assisted colonoscopy vs standard colonoscopy. Colon neoplasms develop early in the course of inflammatory bowel disease and primary sclerosing cholangitis. Faster recovery of gastrointestinal transit after laparoscopy and fast-track care in patients undergoing colonic surgery. One to 2-year surveillance intervals reduce risk of colorectal cancer in families with Lynch syndrome. Predictive and Protective factors associated with colorectal cancer in ulcerative colitis: A Case- control study. The safety of intravenous fluorescein for confocal laser endomicroscopy in the gastrointestinal tract. A retrograde-viewing device improves detection of adenomas in the colon: a prospective efficacy evaluation. Eicosapentaenoic acid reduces rectal polyp number and size in familial adenomatous polyposis.

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