A solitary duodenal hamartomatous polyp is rare and it is considered to be either a variant of Peutz-Jeghers syndrome (PJS) or a separate entity. Patients do not have cutaneous manifestations and have only one hamartomatous polyp. The presentation is nonspecific and it resembles common conditions, such as a peptic ulcer disease. Most are incidentally diagnosed during endoscopy for other indications. Malignant transformation has been reported. This report describes the case of a 46-year-old man who presented with chronic intermittent abdominal pain. The initial endoscopy showed an abnormal twisting of the duodenum with a dilated duodenum. He was later diagnosed to have a solitary duodenal hamartomatous polyp with malignant transformation, which was treated by surgery. A review of the literature on the pertinent cases of this type of lesion is also presented.

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We read with interest the articles by Sylvestre [1] and Robaeys et al. [2] in the February issue on treating intravenous drug users (IDUs) with hepatitis C infection. As stated by the authors, treatment of IDUs with hepatitis C infection should now be considered as treatment compliance and sustained viral response are not different from those of non-IDUs. It is now clear that this group of patients respond as well and may also benefit from therapy. Successful eradication in this group has major implications on public health, as intravenous drug use is becoming the major cause for hepatitis C infections. Debate continues, however, as to who in this group is eligible for the costly therapy, considering that they have traditionally been regarded as a burden to society and the issue of therapy for those who are still actively using drugs is not resolved.Therapy for IDUs depends largely on who is paying for the costly treatment. In a setting in which patients are responsible for the cost, it is clear that patients should be offered therapy if they can afford the treatment. If the health services are responsible, then strict guidelines should be made available to assist physicians. Rehabilitation before therapy, however, should be strongly considered or made compulsory. In our local setting, the healthcare systems cover the cost of therapy. Intravenous drug use accounts for approximately 55.6% of the aetiologies in our patients and this is increasing. Our initial experience with a combination of standard interferon with ribavirin showed that there was no difference in the sustained viral response (64.7 vs. 63.6%, P = 0.954) in IDUs compared with non-IDUs [3]. Our IDU group is mostly male but generally younger ( < 40 years old, 59.4 vs. 31.6%, P < 0.001). No differences were observed in favourable genotypes (genotypes 2 and 3, 69.7 vs. 52.6%, P = 0.281) or viral load ( < 2 Â 10 6 copies, 52.4 vs. 46.2%, P = 0.724) in IDUs compared with non-IDUs.Initially, there was apprehension in treating IDUs owing to concerns on treatment responses, compliance and ethical issues associated with treating patients who are on drugs or have a history of substance abuse. As treatment options improved, however, particularly with combination therapy, treating IDUs became an opportunity to reduce the hepatitis C burden in our local setting. This is because all IDUs are referred to us from the rehabilitation or correctional institutions. Being in correctional facilities, we are assured that all undergoing rehabilitation and treatments are supervised. This eliminates the compliance issue. Successful eradication also eliminates the risk of spread of infection to sexual contacts. Among our hepatitis C cohort, two individuals contracted hepatitis C from their sexual partners. In our setting, treating IDUs represents an opportunity not to be missed, as most of our IDUs remain abstinent after rehabilitation. Furthermore, studies now show that even shorter duration therapy (12 or 24 weeks) might be adequate, thus alleviating the cost issue [4,5].

Inguinal hernia is a common condition that usually presents with swelling and mild groin discomfort. Complications include bowel obstruction and strangulation. We report a case of a 50 year-old man who developed lower gastrointestinal bleeding secondary to an indirect inguinal hernia. Colonoscopy showed an ileocecal valve polyp, florid inflammation of cecum and ascending colon and ulcerations of the terminal ileum. Histology showed nonspecific colitis and angiodysplasia of the polyp. Surgical correction of the hernia led to the resolution of the endoscopic changes. The trauma associated with intermittent herniation of small bowel probably led to ischemia, resulting in the observed changes.

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