bluuebunny/crossref_metadata_2025 huggingface dataset:
248 Analysis of Antiplatelet/Anticoagulant Agents Exposure in Patients With Positive Fecal DNA Test
Authors: Inaganti Anupama , Fahed Julien , Fahed Gracia , Huq Nadia , Affi Aboud
Published: October 2019

INTRODUCTION:

Due to the increased risk of gastrointestinal bleeding (obscure and overt), antiplatelet/anticoagulant agents may increase the chances of a positive stool DNA test, leading in an increased false positive rate. To date, there have been no published studies to evaluate if anticoagulants/anti-platelet agents can affect the results of the stool DNA test.

METHODS:

A retrospective chart review of 1413 patients who had a positive stool DNA followed by documented colonoscopy was performed. Two patients were excluded because of finding of “other carcinoma.” Attention was given to the patient's medication list at the time of the test. All patients on clopidogrel or other antiplatelet agents, warfarin, direct thrombin inhibitors were included in the analysis and patients on aspirin were excluded. Patients who met the inclusion criteria were divided in 2 groups. Group one (1) included patients who were not exposed to antiplatelet/anticoagulant therapy while group two (2) included patients who were exposed to at least 1 antiplatelet/anticoagulant therapy. Only the index lesion was recorded. Advanced adenoma was defined as an adenoma that is larger than 10 mm or had high risk features such as villous transformation or high grade dysplasia. Non-advanced adenoma was defined as an adenoma that is smaller than 10 mm and had no high-risk features. Statistical analysis with Chi- square and Fisher exact was done to compare the proportions. A P-value < 0.05 was considered to be statistically significant.

RESULTS:

Out of the 1411 patients included in the study, 1221 (86.53%) patients were not exposed to antiplatelet/anticoagulant agents while 190 (13.47%) were exposed to at least one antiplatelet/anticoagulant agent. Colonoscopy findings between group 1 and group 2 were compared. “Adenocarcinoma” was found in 1.64% vs. 2.11% respectively (P = 0.55). “Advanced adenoma” was found in 23.01% vs. 27.89% respectively (P = 0.14). “Non-advanced adenoma” was found in 28.67% vs. 34.74% respectively (P = 0.09). Finally, no adenomas were found in 39.39% vs. 28.95% respectively (P = 0.006), which was statistically significant.

CONCLUSION:

Previously published studies noted higher prevalence of colorectal neoplasms in patients with coronary artery disease. In our study, patients who are exposed to antiplatelet/anticoagulant therapy were found to have about 10% more cancerous/precancerous lesions on colonoscopy which could be due to higher cardiovascular comorbidities in patients on this therapy.
255 Yield of Non-Lynch Gene Mutations During Testing for Lynch Syndrome
Authors: Davis Christian , Harrigan Jack , Chauhan Mahak , Hejazi Reza , Buckles Daniel , Olyaee Mojtaba , Kennedy Kevin , Madan Rashna , Bansal Ajay
Published: October 2019

INTRODUCTION:

Multigene panels are commonly used for genetic testing when Lynch syndrome is suspected. However, the data about the relative yield of Lynch vs. non-Lynch mutations are sparse.

METHODS:

In this retrospective, single-center study, all patients with a diagnosis of colon or uterine cancer between January 1, 2016 and June 30th, 2018 were included. The patients were identified using search in the pathology database for SNOMED codes. Additionally, the search results of SNOMED codes were tallied with the cancer center database to capture all patients with colon cancer. A structured RedCap electronic database was created to systematically abstract data about demographics, location and stage of colon cancer, PREMM5 scores, genetic testing and a detailed 3-generation family pedigree. After being screened for Lynch syndrome using immunohistochemical assays or PCR-based detection of microsatellite instability, patients with abnormal results underwent genetic testing using well-established multi-gene commercial assays. The yields of Lynch and non-Lynch syndromes were compared. Statistical comparisons were performed using Chi-square test for categorical variables and Student's t-test for numerical variables.

RESULTS:

A total of 737 participants (whites 84.1%, mean age of 62.7) were included. A diagnosis of Lynch syndrome was made in 21 of the 737 participants (2.85%). Non-Lynch mutations were detected in 12 of the 737 participants (1.63%). When colon and uterine cancers were analyzed separately, non-Lynch mutations were detected in 2.1% and 1.5% of participants respectively (Table 1). The non-Lynch genetic mutations detected included: APC, MAP syndrome, CHEK2, BRCA1, BRCA2, MUTYH, PALB2, AXIN2, SMARC4, and NTLH1.

CONCLUSION:

Germline testing has a significant yield of non-Lynch mutations in patients suspected to have Lynch syndrome. Our data support the current practice of multigene panels to define syndromic cancer risk.
259 Open Access Colon Cancer Screening With Optical and Virtual Colonoscopy
Authors: Curtis Stephen , Tritsch Adam
Published: October 2019

INTRODUCTION:

Despite proven efficacy in improving mortality from colorectal cancer (CRC), CRC screening remains underutilized in the U.S. with nearly 1/3 of eligible patients not screened. Open access colonoscopy (OAC) allows for patients at low-risk for endoscopic complications to receive a colonoscopy without a pre-procedural visit. Although the ASGE has published guidelines on enacting an OAC program, there has been little published on the yield of such a program.

METHODS:

At Walter Reed National Military Medical Center, we enacted an OAC program in 2014. Patients due for CRC screening or surveillance can arrange a procedure by an online form. Our schedulers' review all forms, and patients reporting concerning symptoms, sedation limiting comorbidities, or who are age < 45 or > 75 have a clinic visit prior to their procedure. The remainder of patients have their forms reviewed by a gastroenterologist for suitability and are scheduled for colonoscopy or computed tomographic colonography (CTC).

RESULTS:

Prior to expanding Walter Reed's OAC program to other military hospitals in the NCR, 10,676 total screening requests were made. 48.7% were male, 53.4% were Caucasian, 18.0% were African American. The requested screening method was CTC in 19.1% of submitted forms. Of patients who fell outside the 45–75 age range, 11.4% were under the age of 45, and 1.2% were over the age of 75. Half of the patients using the OAC program had a previous screening exam, and a total of 12.7% reported a family history of CRC. Since incorporating other military hospitals in the NCR, 2,882 screening forms have been completed: 33.6% were male, 35.1% were Caucasian, 14.6% were African American, 14.9% requested a CTC, 5.1% were under the age of 45, 1.0% were over the age of 75, 33.3% had a previous screening, and 9.2% had a family history of CRC. Prior to incorporating the NCR, 20.4% of patients were referred for a clinic visit based on answers in their form, and another 6.0% were referred for a clinic visit after provider review. After the incorporation, 16.4% were referred for a clinic visit.

CONCLUSION:

By avoiding unnecessary clinic visits for patients needing a colonoscopy, OAC programs reduce wait times for colonoscopies and increase availability in gastroenterology practices to see symptomatic patients. Our program in a single payer model, analyzed across two different catchments, shows that over 80% of pre-procedural visits can be avoided by using a questionnaire.
264 The Differences in Prevalence, Distribution, and Detection Rates of Colonic Polyps Between Genders
Authors: Alomari Mohammad , Al Momani Laith , Sarmini Muhammad Talal , Khazaaleh Shrouq , Nehme Fredy , Wadhwa Vaibhav , Thota Prashanthi N. , Sanaka Madhusudhan R.
Published: October 2019

INTRODUCTION:

Gender disparities in colorectal cancer (CRC) incidence and mortality are well recognized in the literature with polyp characteristics and location being amongst some of the most important factors contributing to these disparities. Prior studies have shown an increased prevalence of proximal adenomas and CRC in women. We aimed in this study to compare the distribution and the prevalence of colonic polyps between both genders, as well as evaluating gender-specific lesion detection rates.

METHODS:

A retrospective review of all screening colonoscopies in patients ≥50 years of age performed at our center between 2012 and 2014 was done. Average risk patients who had a complete colonoscopy with excellent, good and fair bowel preparation were included. Overall, gender-specific, and segment-specific adenoma detection rates (ADR), sessile serrated polyp detection rates (SSPDR) and polypectomy rates (PR) were calculated and compared using t-tests. Proximal colon was defined as the cecum, ascending, and the transverse colon.

RESULTS:

A total of 4151 patients were included in the analysis. Average patient age was 60.0 ± 7.7 years and 53.2% were females. A total of 652 (15.7%) had excellent preparation, 2675 (64.4%) had good preparation, while 824 (19.9%) had fair preparation (Table 1). Of the 3476 polyps found, 1660 (47%) polyps were found in the proximal colon. Generally, males had more polyps and adenomas all throughout the colon (Table 2). Compared to males, females had less proximal polyps per patient (0.35 ± 0.24 vs. 0.50 ± 0.33; P < 0.001), less proximal adenomas per patient (0.22 ± 0.18 vs. 0.35 ± 0.26, P < 0.001), and less overall large adenomas (>1 cm) per patient (0.05 ± 0.07 vs. 0.09 ± 0.13, P < 0.008). In males, endoscopists had better overall ADR (32.7 ± 14.7 vs. 22.0 ± 12.7, P < 0.001), PR (51.9 ± 17.9 vs. 40.3 ± 18.8, P < 0.001), and SSPDR (22.6 ± 15.7 vs. 16.6 ± 13.7, P < 0.001) (Table 3).

CONCLUSION:

Our study demonstrates a significant difference in polyp distribution based on patient sex. This is contradictory to what has previously been reported in the literature with more proximal polyps noted in female patients. We believe the advancement in colonoscopy techniques and training in addition to the increased awareness of female sex association with right-sided tumors contributed to this topographic distribution shift of colonic polyps. Although the involved endoscopists met the recommended national ADR benchmarks, women had lower ADR reflecting the differences in the adenoma prevalence in these populations.
279 Rate of Colorectal Neoplasia in Patients With Hodgkin Lymphoma
Authors: Abu-Sbeih Hamzah , Ali Faisal , Coronel Emmanuel , Lee Hun Ju , Pande Mala , Bresalier Robert , Raju Gottumukkala , Wang Yinghong
Published: October 2019

INTRODUCTION:

Survivors of Hodgkin lymphoma (HL) are at increased risk of breast, lung, thyroid, stomach, pancreas, and colon cancer. However, information on the utility of endoscopic screening for colon cancer in this population is limited. The adenoma detection rate (ADR) reported in the literature is 25–35% in patients between 50 and 70 years of age. We aimed to describe the ADR in patients previously treated for HL to determine the appropriate timing of colonoscopy screening initiation.

METHODS:

We retrospectively studied patients with HL who underwent colonoscopy after HL diagnosis between 2000 and 2017. Patients with a history of colorectal cancer were excluded.

RESULTS:

Of the 4190 patients who were diagnosed with HL during the study period, 251 underwent colonoscopy. Eighty (32%) patients had 151 colonic polyps. About a third of the polyps (45 polyps, 30%) exhibited high-grade dysplasia, and invasive colon adenocarcinoma was found in 10 patients (Table 1). Patients with the nodular sclerosing subtype of HL had a significantly lower ADR than other subtypes (P = 0.002) (Table 2). The ADR was 5% in patients younger than 35 years (n = 64), 23% in patients between 35 and 40 years of age (n = 22), 39% in patients between 40 and 50 years of age (n = 51), and 46% in patients older than 50 years (n = 114) (Figure 1). The median time from HL diagnosis to first endoscopy was 3 years (interquartile range [IQR], 1–6 y). Thirty-seven patients (15%) underwent repeat colonoscopy. The ADR for repeat colonoscopies was 41%.

CONCLUSION:

The ADR in patients with HL is higher than the ADR of the general population reported in the literature, particularly in patients younger than 50 years of age. These data suggest that a previous diagnosis of HL should be considered as a risk factor warranting colonoscopy screening before 50 years of age.
282 Risk Factors for Colorectal Cancer in Patients Under 50: A Retrospective Study
Authors: Gellatly Matthew , Crockett Seth
Published: October 2019

INTRODUCTION:

Colorectal cancer (CRC) incidence and mortality rates are rising in patients under age 50 for uncertain reasons. This study aims to identify risk factors and tumor characteristics of younger CRC patients aged 19–49 (Y-CRC), compared to a control group of CRC patients aged 50–60 (CRC-50+).

METHODS:

From a clinical and administrative database at a single institution, we identified patients with an initial CRC diagnosis between 2010–2012. Only histologically confirmed primary colon adenocarcinomas were included. Clinical and demographic characteristics were extracted via chart review. Bivariate and multivariable analyses were performed to compare Y-CRC and CRC-50+ groups.

RESULTS:

A total of 190 patients met our criteria (100 CRC = 50+, 90 Y-CRC). Most patients were white (123 patients, 64.7%), and 49 were black (25.8%). There were 90 female patients (47.4%). The average body mass index (BMI) was 27.1 kg/m2. 64 patients (33.7%) were current smokers. Family history of CRC or polyps was noted in 54 patients (18.4%). History of inflammatory bowel disease (IBD) was present in 11 patients (5.8%). The 12 patients (6.3%) with CRC-predisposing genetic syndromes were excluded from case-control analysis. We found no differences in BMI between groups (P = 0.8). There was a substantially higher proportion of Hispanic patients in Y-CRC group versus CRC-50+ group (13.9% vs. 0%, P < 0.01). Diabetes was less common in Y-CRC than CRC-50+ (7.6% vs. 18.2%, P = 0.04). There was no statistically significant difference between groups in smoking history or family history of CRC/polyps. Although IBD was more common in Y-CRC (8.9% vs. 4.0%), the difference was not statistically significant (P = 0.2). Rectal cancers were slightly more common in Y-CRC (55.1% vs. 47.5%), but this was not statistically significant. Y-CRC patients were more likely to present at later stages and with synchronous lesions, compared to CRC-50+ cases. On multivariable analysis, Y-CRC was associated with Hispanic ethnicity and inversely associated with diabetes, after controlling for other factors (Table 2).

CONCLUSION:

Aside from a higher proportion of Hispanic ethnicity and lower proportion of diabetes among Y-CRC cases, the Y-CRC and CRC-50+ groups were comparable. We found no evidence of an association between family history, obesity or smoking with Y-CRC cases. Further work is needed to explore these and other potential risk factors for Y-CRC.
298 Positive Predictive Value of Multitarget Stool DNA Testing for Colorectal Cancer Screening
Authors: Alimirah Maryam , Naffouj Sandra , Askar Firas , Sadiq Omar , Jinjuvadia Raxitkumar , Siddiqui Yousuf
Published: October 2019

INTRODUCTION:

Colorectal cancer (CRC) remains one of the leading causes of death in the United States, however only 60% of the eligible screening population is up-to date on screening. The suboptimal rate of participation in CRC screening has paved the way for less invasive screening modalities such as the multitarget stool DNA test, which is reportedly 92.3% sensitive and 89.8% specific at identifying cancerous lesions in an adult population at average risk for CRC. Anecdotal reports have brought the specificity of this test into question. We conducted a retrospective study at our tertiary care center to assess the utility of multitarget stool DNA testing in diagnosing cancerous and pre-cancerous lesions.

METHODS:

All patients with positive Multitarget Stool DNA Testing for Colorectal-Cancer Screening between January 1st 2016 and October 30th 2018 were reviewed. A total of 589 charts were selected for analysis of demographics, anti-platelet/anticoagulation use, and endoscopic findings. All patients with subsequent surveillance colonoscopies were included. Advanced adenomas were defined as tubular or serrated adenomas with size greater than 1 cm or tubulovillous adenomas of any size. Statistical analysis was performed using R 3.6.0.

RESULTS:

A total of 589 patients had positive multitarget stool DNA testing, of which, 427 had undergone subsequent colonoscopies. Sample characteristics showed mean age of 68.6, 60% female, mean BMI 30.2. 58% smoking history and 16% diabetics (mean A1c of 7.4). In addition to 7 diagnosed adenocarcinomas, 221 patients were noted to have an advanced adenoma. Average size of advanced adenomas was 13.3 mm ± 11.4. Low risk lesions measured 6.82 mm ± 4.66. We found a positive predictive value (PPV) of 53.4% for an advanced adenoma or adenocarcinoma. In subgroup analysis, 46.4% of aspirin users had advanced adenomas on colonoscopy, compared to 65.1% of patients on factor Xa inhibitors. 62.1% of clopidogrel users had advanced adenomas.

CONCLUSION:

Our experience with Multitarget Stool DNA Testing varies from that demonstrated in literature. Initial multicenter studies demonstrate a specificity of 87% with sensitivity of 92% for adenocarcinoma and 69% for advanced adenomas. This translates to a PPV of 87.6% and 84% respectively. In comparison, our results demonstrated a PPV of 53.4%. Further studies are required to determine if these differences also extend into the sensitivity of the test and its utility as a screening test for colorectal cancer.
310 Effectiveness of Retroflexion Maneuver During Colonoscopy for Detecting Polyps
Authors: Kupferman Judah , Ziv Yonatan , Herzog Shimon , Weiss Alexander , Tokayer Aaron
Published: October 2019

INTRODUCTION:

Retroflexion during colonoscopy is a useful method used to improve visualization of certain regions of the colon and to detect hidden polyps that may otherwise have been missed. This is a study of the relative yield, effectiveness, and safety of this maneuver in the proximal colon.

METHODS:

We aim to describe the impact of right colon retroflexion in detecting polyps. We reviewed 818 colonoscopies performed by a single gastroenterologist at one site in the Bronx from November 2016 to November 2017. Polyps found on forward advance, with retroflexion in the right colon, upon withdrawal, and with retroflexion in the rectum were tallied. The location, size, and number of polyps in the colon were recorded.

RESULTS:

Of 818 patients (82.4%) who underwent colonoscopy, 674 qualified for the study. 128 patients (15.7%) did not undergo either right colonic or rectal retroflexion, most often due to anatomic hindrances or body habitus. 16 patients had missing data. The mean age was 60 (STD 9.4) and 441 subjects were female (65.4%). In 674 subjects, 48 (7.12%) had polyps found upon right colonic retroflexion maneuver, compared to 6 (0.89%) in whom polyps were found upon rectal retroflexion (P < 0.001). A total of 566 polyps were found on forward advance of the colonoscope, of which 286 were in the right colon. Another 651 polyps were found during withdrawal of the colonoscope, of which 303 were in the right colon. A total of 57 polyps were found with right colonic retroflexion (8.82% of all right colonic polyps found) (P = 0.05) (Figure 1). The majority of colonic polyps in the study were diminutive in size (≤4 mm) (Figure 2). There were no complications that occurred on retroflexion.

CONCLUSION:

We found that right colonic retroflexion yielded 8 times more polyps than rectal retroflexion. There were no complications related to retroflexion. Furthermore, rectal retroflexion is an accepted technique often performed during colonoscopy, despite its low yield. Since right colonic retroflexion has a substantially higher yield of polyps than rectal retroflexion, we suggest that right colonic retroflexion become an accepted maneuver during colonoscopy when possible.
312 Patients With Very Early Onset Colorectal Cancer Have Increased Microsatellite Instability
Authors: Dayah Rawan , Bilal Mohammad , Tun Nattpron , Abu-Shami Tewfeek , Booth Adam , Singh Shailendra , Parupudi Sreeram , Guturu Praveen
Published: October 2019

INTRODUCTION:

The incidence of colorectal cancer (CRC) in young patients has been increasing. This has led to increase interest in the molecular patterns and epigenetics of CRC in this age group. Microsatellite instability has been noted to be a positive prognostic factor in CRC. We aimed to evaluate the disease and molecular characteristics of patients with early-onset CRC (40-49 years of age) and compare them with those of very early-onset CRC (<40 years of age).

METHODS:

A retrospective cross-sectional study was performed using our electronic pathology database. All patients diagnosed with CRC between January 2012 and September 2018 were included. Data regarding patient demographics, comorbid conditions and patient presentation was noted. We also noted information regarding the location, staging and molecular features of CRC.

RESULTS:

A total of 627 patients with CRC were identified. Out of these, 117 (18.6%) were younger than 50 years of age (early-onset CRC). From patients < 50 years of age, 74 (63.2%) had early-onset CRC (40-49 years of age) and 36.8% of patients had very early-onset (<40 years of age). The mean age was 45.4 in those between 40-49 years of age and 33.5 in those < 40 years of age. The most common complaint in early-onset CRC was rectal bleeding (44.6%), while abdominal pain was the most common (39.5%) complaint in the very-early onset CRC group. There were no differences in stage of CRC among both groups. Microsatellite instability (MSI) was more common in patients with very early-onset CRC (40.7 vs 13.6%, P-value = 0.009) as compared to those with early onset CRC. Other clinical and molecular features of patients with very-early onset CRC are summarized in Table 1.

CONCLUSION:

There are unique clinical characteristics and molecular features in patients with very-early onset CRC. Our study shows that patients very early-onset CRC have increased MSI. Although our study limitations include a small sample size and an experience from a single center, our findings suggest that further understanding of molecular features in patients with very early-onset CRC is needed to improve diagnosis and management of CRC in this age group.
317 Increased Interval Between Screening and Surveillance Colonoscopy Is Associated With Decreased Withdrawal Time
Authors: Stavrakis Dimitris , Kim David , Cui Haiyan , Roe Denise , Banerjee Bhaskar
Published: October 2019

INTRODUCTION:

Colonoscopy is currently the most effective method for prevention of colon cancer in patients as seen by the declining rates of colon cancer since screening has been implemented. Adenoma detection rate is an important quality measure that is affected by many factors, including withdrawal time. Limited research has evaluated whether prior history or interval time between colonoscopies affects withdrawal time.

METHODS:

Inclusion criteria: 872 patients at a tertiary academic center who underwent screening and surveillance colonoscopies. Exclusion criteria: patients with missing procedure timestamps, incomplete or aborted procedures, history of gastrointestinal malignancy, prior colon resection, genetic syndromes, or inflammatory bowel disease. For withdrawal time, log-transformation was applied to normalize the data. For the association of withdrawal time with history of prior colonoscopy analysis of variance was used.

RESULTS:

Overall, no significant difference was found in the withdrawal time in patients with or without a prior colonoscopy (12.42 vs. 11.66 minutes, P = 0.114). Subgroup analysis in the screening group did not show any difference (10.83 vs. 11.66 minutes, P = 0.668). In patients undergoing screening with prior colonoscopies, the withdrawal time was significantly decreased with increased colonoscopy interval, which was defined as the time from the prior colonoscopy to the current colonoscopy (range 1-357 months, P = 0.033). This was also seen with patients undergoing surveillance (range 1-194 months, P = 0.005). For patients undergoing surveillance, the withdrawal time for patients with interval of ≤ 3 years was significantly longer than that for the patients with interval >3 years (14.05 vs. 11.86 minutes, P = 0.036). Similar results were seen even after adjusting for polyp removal (12.05 vs. 10.99 minutes, P = 0.021).

CONCLUSION:

Increased interval between a patient’s prior colonoscopy is associated with a shorter withdrawal time. However, bias does not appear to exist on a patient’s initial screening colonoscopy. Reassurance from prior results may affect the endoscopist’s decision to withdraw more quickly. Large-scale or prospective studies should be done to validate these findings.
327 What to Do When Fecal Immunochemical Test (FIT) Is Positive Following Normal Colonoscopy? Comparison of Adenoma Detection Rate (ADR) of Standard FIT-Colonoscopy and Relook Colonoscopy
Authors: Wei Mike , Dao Allison T. , Le Angelica , Nguyen Trina , Tran Brendan , Trinh Lindsey L. , Nguyen Huy A. , Nguyen Khanh , Levitt Brian S. , Shieh Eugenie , Goyal Treta , Cheung Ramsey , Nguyen Mindie H. , Trinh Huy
Published: October 2019

INTRODUCTION:

For average risk patients, current guidelines generally recommend either yearly FIT or colonoscopy every ten years. A positive FIT test triggers reflex colonoscopy, which can have higher ADR than screening colonoscopy. FIT tests are also frequently performed following a negative colonoscopy in routine practice for concerning symptoms or desire for “early relook.” A positive FIT test often leads to reflex “relook colonoscopy” despite negative colonoscopy within the past 10 years. It is not clear if relook colonoscopy would be necessary or lead to new findings. As such, we aimed to compare colonoscopy findings including ADR in the “relook FIT-colonoscopy” versus the “standard FIT-colonoscopy” population.

METHODS:

This is a retrospective study of 1,940 patients age ≥ 18 at a community medical center between December 1, 2002 and June 1, 2018: 51 had relook FIT-colonoscopy and 1,889 patients had standard FIT-colonoscopy. The primary outcome was ADR with secondary outcomes including other colonoscopy findings.

RESULTS:

The group receiving relook colonoscopy was on average younger than the standard FIT-colonoscopy group (61.8 v 64.5, P = 0.049). The relook colonoscopy group had lower percentage of males (37.3 v 45.6%, p< 0.001) but higher percentage of Asians (90.2 v 76.5%, p< 0.001). While the relook colonoscopy group had fewer days between FIT and colonoscopy, this was not statistically significant (61.1 v 68.9, P = 0.800). For patients receiving relook colonoscopy, 82.4% were asymptomatic at time of FIT, while 5.9% had bowel habit changes, 5.9% anemia, 3.9% abdominal pain, and 3.9% rectal bleeding. FIT occurred on average 4.9 +1.8 years following colonoscopy. Standard FIT-colonoscopy demonstrated ADR of 51.2% with cancer identified in 1.6% of patients. The relook colonoscopy strategy had ADR of 39.2% (N = 20); 49.0% of patients had no abnormal findings: 47.1% had hemorrhoids, 23.5% had diverticulosis, and none had cancer (Figure 1). Of the 20 patients with adenoma in the relook colonoscopy group, 3 patients had adenoma >1 cm and 2 had advanced neoplastic polyps (villous and serrated).

CONCLUSION:

While significant data has demonstrated that colonoscopy following positive FIT is important, data on relook colonoscopy is less clear. Given ADR of 37.7%, patients with positive FIT should receive repeat colonoscopy despite prior normal colonoscopy. Nevertheless, more data is needed to determine validity and criteria for pursuing repeat FIT following a normal colonoscopy.
334 ANNIE Text Messaging Protocol to Improve Outpatient Colonoscopy Bowel Preparation Among Veterans
Authors: Lou Susan , Sultan Shahnaz , Shaukat Aasma
Published: October 2019

INTRODUCTION:

Inadequate bowel preparation was associated with missed advanced neoplasia, lower adenoma detection rates and increased resource utilization for repeat colonoscopies. Text messaging may improve bowel preparation. ANNIE is a new VA text message service allowing for customizable educational and motivational text message reminders about clinical care. Our aim was to study the effectiveness of text messaging (via the ANNIE software) to improve the quality of colonoscopy among veterans.

METHODS:

We identified veterans scheduled to receive outpatient screening colonoscopies during the time period from 1/1/2019 through 3/31/2019 at the Minneapolis Veterans Affairs Medical Center (n = 640). We enrolled interested veterans to receive a series of text reminders through the ANNIE software platform regarding key steps for their bowel preparation (n = 187), in addition to usual care consisting of a nurse education phone call. Those not interested or not enrolled in ANNIE received usual care only (n = 484). Primary outcome was the total Boston Bowel Preparation (BBPS) score. Secondary outcome was patient satisfaction.

RESULTS:

The average age of the group was 65; 285 were diabetic, and average BMI was 31. The ANNIE group was more likely to have mental health diagnoses (If this is (Table 1). ANNIE text messaging instructions was associated with a higher BBPS score versus usual care ((8.24 versus 7.89 respectively; P = 0.002) (Figure 1). 100% of patients (n = 34) surveyed after Plan-Do-Study-Act Cycle 2 indicated that they would like to receive texts again for their next colonoscopy.

CONCLUSION:

ANNIE patients had higher bowel preparations scores compared to control patients, indicating that text message reminders were effective at helping patients follow bowel prep instructions. Data is likely an underestimation of the true impact of intervention as results do not account for patients turned away on day of procedure or aborted procedures. Future study will include measures of clinical significance (i.e. adenoma detection rate).
339 Angiotensin Converting Enzyme Inhibitor Drug Use and Risk of Finding Pre-Cancerous Colonic Polyps on Initial Colonoscopies
Authors: Shine Amal , Chaudhaury Dhruv , Liu Nanlong , Glick Connor , Furmanek Stephen , Parajuli Dipendra , McClain Craig
Published: October 2019

INTRODUCTION:

The widespread use of Angiotensin converting enzyme inhibitors (ACEi), especially lisinopril, and their association with colorectal cancer (CRC) has been studied with mixed results. Data suggest angiotensin II inhibition may decrease CRC risk. Contrasting studies suggest a role for kinins in pro-angiogenic effects with their accumulation blunting the effects of angiotensin II inhibition. Since ACEi’s affect both angiotensin II and bradykinin levels, we studied the effect of lisinopril on the risk of developing pre-cancerous (PC) colon polyps.

METHODS:

Data were collected on 3,541 patients admitted to the Louisville Veterans Affairs Medical Center, and 2,312 were excluded based on specific criteria, including pro-inflammatory states postulated to increase polyposis (e.g., IBD history and pre-existing malignancies). Of the 1,229 patients who were included, 393 (32%) used lisinopril; median age was 61; 88% of patients were male; and 24% were African American. Retrospective chart review of the patients’ active medications at the time of initial colonoscopy was done. Lisinopril use was further stratified by duration of usage. A Poisson Regression Model was employed for analysis with upper and lower bounds, and rate ratios (RR) with corresponding P-values calculated. Statistical significance was set at P < 0.05. Age, sex, race, smoking history, and NSAID use were controlled for.

RESULTS:

Our study indicates that long-term lisinopril use may be associated with increased PC colon polyp rates. Long-term (>10 years) lisinopril use was associated with a 35% increase in PC colon polyp risk (n = 46, RR = 1.35, P = 0.049). Short-term (<5 years) lisinopril use was associated with a 4%, statistically insignificant, increase in PC polyp risk (n = 273, RR = 1.04, P = 0.64). The total exposure (defined here as dose multiplied by years of use) of lisinopril did not show any difference in risk.

CONCLUSION:

The mechanisms of ACEi effects are complex and relate to their specific pharmacological properties. It needs to be determined whether or not the accumulation of kinins generated by ACEi’s attenuates their overall anti-angiogenesis effect. Our study indicates that long-term use of lisinopril, irrespective of dose, may increase PC colon polyp risk. This suggests that long-term usage changes the dynamics of the pro- and anti-neoplastic effects of ACEi’s. Larger studies are needed to determine the dose-duration relationship between ACEi and PC colon polyps, given their widespread use.
345 Caught Between a Rock and a Hard Place: EUS-Guided Drainage of a Vascular Configuration
Authors: El Douaihy Youssef , Andrawes Sherif , Landau Elliot
Published: October 2019

INTRODUCTION:

Vascular configuration in the portal confluence are rarely reported. Therefore there are currently no guidelines on how to manage bloody collection in the portal venous system.

CASE DESCRIPTION/METHODS:

A 36 yo M with a Hx of antiphospholipid syndrome & CVA on coumadin, presented for epigastric pain & vomiting. An US was negative for stones and reveled normal CBD. A CT showed edema around the portal confluence. A week later, a repeat CT showed a bloody collection at the SMV. An angiogram by IR ruled out an arterial source of bleeding, however the GDA was coiled empirically. A few days later a 3rd CT revealed an increase in size of the collection, severe SMV stenosis and the emergence of varices. The bleeding had stabilized however the emerging findings on CT raised 2 concerns: 1- A risk of bleeding from the formed varicose in a patient who is dependent on anticoagulation. 2- A risk of of thrombus formation in the portal system due to a compromise in the portal venous flowery the stenosing effect of the collection. A multidisciplinary approach was planned with with IR to drain the bloody configuration endoscopically. In the IR suite, the portal venous system was accessed percutaneously. The IMV was eventually accessed however the SMV was completely occluded. Through a collateral between the IMV and SMV, the SMV was accessed retrogradely. The catheter was then advanced to the splenic vein. With this setup, the portal vasculature was under visualization of IR who were ready to embolize in case of bleeding. EUS revealed a 4.6 cm heterogenous collection suggesting different consistencies of blood. 19 gage needle was introduced into the collection through a trans gastric access. A guide wire was then introduced and with wire guidance a 10 x 10 mm lumen apposing metallic stent was deployed between the configuration and the stomach. Blood drained spontaneously to the gastric lumen. Using a CRE balloon dilation to 12 mm was performed. Further evacuation of clots was performed to a point where the stenosis in the SMV decreased to allow anterograde access of the IR catheter. Clinically, the patient’s is doing well, is pain free and resumed his full anticoagulation.

DISCUSSION:

Our patient had complicated autoimmune disease predisposing him to clot formation. The etiology of his SMV injury is unclear. Possible etiologies include ideopathic pancreatitis or autoimmune vasculitis. Regardless of the etiology, prompt evacuation of the bleed was crucial. IR / GI coordination made this procedure safe and possible.

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375 A Look at Patient Factors Such as Body Mass Index (BMI), Age, and Gender in Achalasia
Authors: Thapa Namisha , Hum Justine , Otaki Fouad , Diamond Sarah
Published: October 2019

INTRODUCTION:

Achalasia is a disorder leading to significant difficulty eating that typically leads to weight loss. Historically, obesity in achalasia patients is uncommon; however, with the obesity epidemic, the epidemiology of achalasia may be evolving, and treatment may need to be tailored. Few studies have investigated patient characteristics such as age and gender that predict response to therapy. There is paucity of literature studying presence of obesity in achalasia and its effect on outcomes.

METHODS:

This was a retrospective cohort study of patients diagnosed with achalasia on high-resolution esophageal manometry (HREM) at a tertiary care center in 1/2008 – 12/2015. Data on patient demographics, including age at diagnosis, gender, body mass index (BMI), race, and presenting symptoms were reviewed. Interventions, including botox injection, dilation, or surgery were also reviewed. For consistency, only the interventions after HREM diagnosis at a tertiary center were assessed.

RESULTS:

131 achalasia patients were included. Median age at diagnosis was 58 years old with 15% being ≤ 40 years and 85% > 40 years. Median BMI was 27 (17–51) with 69% having BMI < 30 and 31% having BMI ≥ 30. Percent of male to female patients were 52% to 48%, respectively. Percent of patients who received botox injection, dilation, or surgery as first intervention were 10%, 11%, 53%, respectively. 26% did not receive any intervention. Heller’s myotomy accounted for 89% of all surgeries. Interventions in the lower BMI group were 14% (botox), 15% (dilation), and 71% (surgery) similar to 13.3%, 13.3%, 73.4%, respectively in the higher BMI group. 100% of patients in the younger group received surgery as the first intervention, while older group had 16% botox, 18% dilation, and 66% surgery. 19 patients failed initial treatment requiring a second intervention; majority (74%) had lower BMI < 30. More patients in > 40 years group failed first intervention. There was no significant difference between gender and treatment failure.

CONCLUSION:

Patients with achalasia underwent similar treatment(s) regardless of their BMI or gender. Younger patients underwent surgical interventions at a higher rate, primarily Heller’s myotomy. Patients with lower BMI (<30) needed a repeat intervention at a higher frequency than their higher BMI counterpart. This was true for all interventions. Factors such as BMI may play an important role in achalasia treatment outcome; however, more controlled studies are needed.
386 Delayed Esophago-Gastric Junction Relaxation in Patients With Jackhammer Esophagus Suggest That the Hypercontractile Peristalsis May Be a Compensatory Mechanism
Authors: Valdovinos-Garcia Luis R. , Horsley-Silva Jennifer L. , Crowell Michael D. , Valdovinos-Diaz Miguel A. , Vela Marcelo F.
Published: October 2019

INTRODUCTION:

Jackhammer esophagus (JE) is esophageal motility disorder characterized by hypercontractile peristalsis, diagnosed by high resolution manometry (HRM) showing increased contractile vigor distal contractile integral (DCI) >8000 mmHg/s/cm. Hypothesis: hypercontractile peristalsis in JE may be a compensatory mechanism for impaired EGJ relaxation, which even with normal integrated relaxation pressure (IRP), may be expressed as delayed onset of relaxation. We compare time to onset of EGJ relaxation in JE patients with normal IRP, control patients presenting for evaluation of esophageal symptoms with normal HRM, and asymptomatic healthy volunteers.

METHODS:

We compared time to onset of EGJ relaxation in 44 patients (24 JE, 20 with normal HRM) and 21 asymptomatic healthy volunteers who underwent HRM. Demographic characteristics and validated esophageal questionnaires (GERDQ, BEDQ, Eckardt) collected in all subjects. HRM performed by administering ten 5-ml liquid swallows, Chicago Classification v3.0 used to diagnose JE and normal esophageal motility. Time to onset of EGJ relaxation after swallow initiation was measured in seconds, from time of upper esophageal sphincter opening to EGJ opening. EGJ opening was determined at an isobaric contour of 23 mmHg, based on analysis in the healthy volunteers showing persistent EGJ effacement at this value in 100% of the volunteers. Median times to onset of relaxation for the study groups were compared by Wilcoxon rank sum test.

RESULTS:

Demographics, questionnaire scores, and HRM metrics in Table 1; patients were older and had higher scores compared to healthy volunteers; HRM metrics were different among the study groups with the exception of DL. Median times to onset of relaxation after swallow initiation shown in Figure 1. There was no difference in median time to onset of relaxation for volunteers compared to patient controls with normal HRM 0.20 s vs 0.90 s, P = 0.149. Median time to onset of relaxation was significantly longer in JE patients compared to volunteers and patient controls 3.30s vs 0.20 s vs 0.90 s, P = 0.001.

CONCLUSION:

Patients with JE and normal EGJ relaxation by IRP have significantly delayed onset of EGJ relaxation compared to healthy subjects and control patients with normal HRM. Hypercontractile peristalsis in these JE patients could be a compensatory mechanism to overcome outflow obstruction manifested as delayed EGJ relaxation. Therefore, if our findings are confirmed, therapies to address impaired EGJ relaxation could be considered.
390 Opioids Interfere With Deglutitive Inhibition Assessed by Response to Multiple Rapid Swallows During High Resolution Esophageal Manometry
Authors: Snyder Diana L. , Valdovinos-Garcia Luis R. , Horsley-Silva Jennifer L. , Crowell Michael D. , Valdovinos-Diaz Miguel A. , Vela Marcelo F.
Published: October 2019

INTRODUCTION:

We previously showed an association between chronic opioid use and esophageal motor dysfunction characterized by esophagogastric junction outflow obstruction, distal esophageal spasm, achalasia type III, and Jackhammer esophagus. Assessment of response to multiple rapid swallows (MRS) during high-resolution esophageal manometry (HRM) enables detection of impaired inhibition during MRS. Healthy subjects respond to MRS by deglutitive inhibition during MRS followed by an augmented contraction with higher vigor than single swallows. Hypothesis: during MRS, opioids may interfere with deglutitive inhibition and may enhance post MRS contraction. Aim: compare response to MRS in opioid users, non-users and healthy controls.

METHODS:

Response to MRS was evaluated in 200 patients with esophageal symptoms (100 chronic opioid users on oxycodone, hydrocodone, or tramadol for ≥3 months, 100 not on opioids), and 19 asymptomatic healthy controls that underwent HRM. Patients with prior gastroesophageal surgery, pneumatic dilation, esophageal botulinum toxin injection within 6 months of HRM, esophageal stricture, achalasia type I or II, and scleroderma were excluded. Demographic and symptom data were extracted from a prospectively maintained motility database. Response to MRS was evaluated for complete versus incomplete inhibition (contractility with DCI >100 mmHg-sec-cm during MRS), and presence of post MRS contraction augmentation (DCI post MRS greater than mean DCI for single swallows). Categorical variables were analyzed by chi square.

RESULTS:

Patients were older than controls (Table 1). HRM indications are shown in Table 2. Incomplete inhibition during MRS was significantly more frequent in chronic opioid users compared to patients not on opioids and healthy controls (26% vs 11% vs 0% P = 0.002; Figure 1). There was a significant difference in the rate of incomplete MRS inhibition for patients on oxycodone, hydrocodone, and tramadol (27% vs 34% vs 22% P = 0.002). The proportion of patients with augmentation post MRS was similar for opioid users, non-opioid users and healthy controls (P = 0.05).

CONCLUSION:

Impaired deglutitive inhibition during MRS was significantly more frequent among opioid users compared to non-opioid users and healthy controls. This was more common with stronger opioids (oxycodone and hydrocodone) compared to tramadol. These findings support our hypothesis that opioids interfere with inhibitory signals in the esophagus.
394 Esophageal Food Impaction - A Retrospective Chart Review
Authors: Gurala Dhineshreddy , Philipose Jobin , Polavarapu Abhishek , Gumaste Vivek
Published: October 2019

INTRODUCTION:

Esophageal Food Impaction (EFI) is the third most common non-biliary emergency in gastroenterology with an estimated annual incidence rate of 13 episodes per 100,000 person-year and resulting in 1500 deaths per year. Patient’s presenting with food impaction often have underlying esophageal pathology. Esophageal dysmotility is one of them which can be seen in diabetics and 60% of these patients have manometric abnormalities which may be associated with increased risk of food impaction but limited studies have been done to evaluate these correlations. The possible risk factors and association with diabetes in EFI was evaluated in our study.

METHODS:

Retrospective chart review of 455 patients who presented to the Staten Island University Hospital with symptoms of food impaction from 1999 to 2017. A retrospective analysis was undertaken on relevant clinical data such as age, risk factors, type of bolus, location, administration of glucagon, endoscopic technique, complications, and outcome.

RESULTS:

Overall, 174 patients had endoscopically confirmed FI with males 102/174 (58%). Esophageal pathology found in endoscopy includes esophagitis in 58/174 (33%), stricture in 43/174 (24%), hiatal hernia in 29/174 (17%), Schatzki ring in 15/174 (9%), normal endoscopy in 32/174 (19%) (Figure 1). Diabetes was reported in 20/174 (11%) (Figure 2). Type of food was meat in 73/174 (41%). Location of EFI mainly in the lower one-third of the esophagus in 94/174 (61%). Endoscopic push technique was used in 95/174 (55%), pull technique in 83/174 (48%). Endoscopy was successful for the first time in 165/174 (96%) patients. Complications were reported in only 5/174 (3%) including perforation and tear. Glucagon was given to 74/174 (43%) and mean door to endoscopy time (time of presentation to the emergency department to endoscopy procedure) was 10 hours in patients received glucagon, 13 hours in patients who didn’t receive glucagon (Figure 3).

CONCLUSION:

EFI is more common in males. Esophageal stricture and hiatal hernia were the most common pathologies found in endoscopy. Esophagitis is found in 33% of patients but whether it is the culprit for FI or consequence of FI is not clear. Diabetes is associated with food impaction in only 11% of patients but more studies are needed to find out the true association. Administration of glucagon resulted in the decreased door to scope time. Endoscopy is a safe and effective method for food impaction and complications reported were minimal.