Editorial: From eosinophils to serrated adenomas and beyond late breaking news from the dark continent

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Colonic disorders, or more accurately, disorders though to originate from the colon represent a considerable component of a gastroenterologist's work-load and a major source of discomfort and distress for the general public. Once regarded as a vestigial organ and readily removed to eliminate the ‘vile humors’ emanating from its sulfurous activities, we now recognize many important contributions of the colon and its microbial inhabitants to homeostasis and health [1▪▪,2,3]. The colon comes with some baggage, however. Colon cancer is the third most common cancer in the United States and its incidence is rising throughout the world and, most dramatically, in developing nations [4]. There is good news. Screening for colon cancer, regardless of its methodology, works and many believe that colonoscopy still maintains its position as the most effective modality [5,6▪]. It is appropriate, therefore, that this volume devotes space to two of the issues that have bedeviled our efforts to eliminate colon cancer through screening colonoscopy – inadequate preparation of the colon and our failure to visualize and remove serrated adenomas. The latter, more prevalent in the right colon and taking a different molecular pathway to carcinoma seem to plot against us to evade our gaze [7]. Indeed, our inability to identify serrated adenomas may well explain reports of different mortality rates for right-sided and left-sided cancer, lower on the left than on the right [8]. No one would argue against the importance to the patient and the colonoscopist of the importance of a well prepared colon; one interesting exception may be the value of the ‘mucus cap’ in a slightly less than perfectly cleansed right colon as a hint that a serrated adenoma may lie beneath.Eosinophilic esophagitis has emerged as a ‘new’ disease and one that all too frequently gets us out of bed at ungodly hours to remove impacted chicken or steak; investigators at the University of Newcastle (Australia) have been pioneers in expanding the ‘red state’ in to the duodenum (where it seems to be common in functional dyspepsia) and now take us all the way into the colon where eosinophils may be involved in a number of pathological processes [9▪]. As irritable bowel syndrome is increasingly recognized in older individuals, it was inevitable that the question of overlap with diverticulosis would re-emerge. Those of us who have been around for a while will remember the phrase ‘painful diverticular disease’ and the status it once enjoyed as an explanation for abdominal pain, bloating and constipation [10]. Eventually discredited as the ubiquity of diverticula was recognized, the idea that diverticula (diverticulosis) could be associated with a certain symptomatic profile (diverticular disease) has latterly re-emerged and its relationship to irritable bowel syndrome re-examined – the plot thickens but the denouement of this ‘whodunnit’ has yet to be revealed [11]. Another differential diagnosis, that of distinguishing irritable bowel syndrome from inflammatory bowel disease, frequently confronts the clinician, be they, in primary care or specialist practice [12]. At face value, this should be easy, given the vast difference in underlying pathologic findings but there are situations where diagnostic uncertainty prevails – initial presentation (not all patients with colitis have bloody diarrhea!) and when we have, by all available measures, induced clinical remission of Crohn's disease or colitis [13]. In the former, we agonize about missing an inflammatory disease (whose diagnosis is still delayed for far too long); in the latter our concern is inappropriate use of potent and expensive agents when dysfunction and not inflammation is the problem.

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