bluuebunny/crossref_metadata_2025 huggingface dataset:
539 Gastroenterologists versus Gastroenterologists With Fellows versus Surgeons: A Comparison of the Detection Rates of Adenoma and Sessile Serrated Adenoma/Polyp
Authors: Hassan Seemeen , Ahmed Zaheer , Chhabra Rajiv , Sadeddin Esmat , Yousef Osama
Published: October 2019

INTRODUCTION:

Screening colonoscopies are performed by gastroenterologists & surgeons, sometimes with trainees. The aim was to compare the adenoma detection rate (ADR) & sessile serrated adenoma/polyp detection rate (SDR) between surgeons, gastroenterologists & gastroenterologists with fellows.

METHODS:

The Clinical Outcomes Research Initiative (CORI) V4 was queried for adult average risk screening colonoscopies from 2009-2014. Data on self-reported specialty of the endoscopists was collected. The number of fellows were counted by the number of procedures signed by fellows. ADR & SDR were compared between 3 groups (gastroenterologists, gastroenterologists with trainees & surgeons). Sites with ≥ 95% polyp pathology submission to CORI were included. 13 sites were included which were community-based sites and/or Veterans Affairs sites (VA). SAS was used.

RESULTS:

31467 screening average risk colonoscopies met the inclusion criteria. Most of them were performed by gastroenterologists without fellows (n=31035, 98.6%). Gastroenterologist with fellows & surgeons performed 355 & 77 procedures respectively. ADR of gastroenterologists was the highest (31.2%) & met the quality benchmark of ≥25% (Table 1). The ADR of gastroenterologists with fellows was lower (23.1%). Surgeons had a low ADR of 7.8%. The SDR of gastroenterologists, gastroenterologists with fellows & surgeons were 4.7%, 0.6% & 0% respectively. Rectal retroflexion, cecal intubation rate & total procedure time were comparable between gastroenterologists & surgeons but they all were much lower when gastroenterologists were with fellows. The complication rates were low. No deaths were reported. The rates of abdominal pain, gastrointestinal bleeding and perforation were 1.6%, 0.04% & 0.01% respectively. The adverse effects were not reported for gastroenterologists with fellows & surgeons in CORI for procedures included in this study.

CONCLUSION:

Community-based and VA gastroenterologists meet the quality benchmark of ADR ≥ 25%. Gastroenterologists had a lower ADR & SDR when they were with fellows. Gastroenterologists with fellows had longer procedure times & lower cecal intubation rates than gastroenterologists alone. There was under-reporting of colonoscopic procedural and outcome data to CORI by surgeons and those gastroenterologists who worked with fellows. University-based gastroenterology fellowship programs that participated in CORI under-reported post polypectomy pathology results to CORI nationwide & hence could not be included in this analysis.
540 Ergonomic and Procedural Metrics Associated With Musculoskeletal Pain Among Endoscopists
Authors: Miller Alexander , Herberts Michelle , Hansel Stephanie , Murray Joseph , League John , Chadrick Hinson , Van Dyke Carol
Published: October 2019

INTRODUCTION:

Rates of musculoskeletal (MSK) injury among gastroenterologists are estimated to be as high as 75%, exceeding rates of 35% among non-proceduralists. Specific ergonomic/procedural factors influencing these injuries have yet to be defined. We sought to characterize potential risk factors for MSK injury by analyzing the physical traits and technical procedural data of a cohort of endoscopists.

METHODS:

The QuickDASH (Disabilities of Arm, Shoulder, and Hand) survey was sent to all gastroenterologists across a large tertiary care system. Added questions assessed injury characteristics, glove size, and other demographic data. Endpoints defining affected vs. unaffected groups include self-reported function-limiting upper extremity or back pain, injury necessitating limiting/stopping endoscopy, and trends toward higher QuickDash, Work Impairment, or Sport/Instrument Disability scores. A procedural database capturing all endoscopic activities of each respondent from 2011 to 2018 was queried to gather procedural types, volumes, durations, and insertion times; scope types; and polyp detection rates.

RESULTS:

64 surveys were completed (28.1% female, mean age 44.4 ±10.8 yrs). The average time in practice was 18.9 (±10.8) years. 51% (n = 33) of respondents reported significant activity-limiting pain, including hand/wrist (n = 31), arm/elbow (n = 12), shoulder (n = 19), and back (n = 24) pain. Characteristics between affected and non-affected groups are detailed in Table 1 with further exploratory analyses found in Table 2. Those needing to limit/stop endoscopy due to pain more frequently used pediatric scopes (31% vs. 19%, P = 0.037), took longer to perform colonoscopy (25.3 vs. 22.1 minutes, P = 0.035) and had lower yearly procedural volumes (532 vs. 807, P = 0.009). Those with hand/wrist pain had longer colonoscopy insertion times (9.35 vs. 8.21 minutes, P = 0.03) and less colonoscopy hands-on scope hours per year (81.2 vs. 111.7 hours, P = 0.039). Females had more severe shoulder pain (P = 0.04), but there were no other associations with sex or small glove size.

CONCLUSION:

Activity-limiting MSK injuries affect over 50% of endoscopists. MSK symptoms were associated with longer procedure times and higher EGD or push enteroscopy volumes. Symptomatic subjects were more likely to use pediatric colonoscopes. Hand/wrist pain is the most common and (presumably) the most limiting type of injury. Further prospective monitoring is warranted to better elucidate which variables are causative versus compensatory responses to injury.
541 Endoscopic Evaluation of Radiological Distal Esophageal Thickening
Authors: Leung Galen , Mizrahi Joseph , Quintero Samuel , Sosa Daniel , Parkinson Deborah , Desai Deepak , Cheng Edward
Published: October 2019

INTRODUCTION:

The growth of diagnostic imaging in healthcare has led to an increase in incidental findings of “Distal Esophageal Thickening” (DET). This nonspecific finding frequently prompts a formal Esophagogastroduodenoscopy (EGD) for evaluation – many of which demonstrate benign conditions and less commonly, malignancy. There may be many unnecessary procedures being performed and a misuse of valuable resources. Thus, we aim to determine the incidence of EGDs primarily performed for DET found on imaging, and the actual endoscopic and histologic findings for these EGDs.

METHODS:

We performed a retrospective chart review of 905 EGDs performed from 2016-2018 at a single institution. Patient demographics, comorbidities, symptoms, imaging reports, procedure reports, and pathology reports were collected. Descriptive analysis was performed to determine the incidence of EGDs performed for imaging findings of DET, as well as their endoscopic and histological findings.

RESULTS:

Demographics for the EGDs are in Table 1. Out of 905 total endoscopies, 6.6% (n=60) were done specifically due to findings of DET on imaging within 6 months of the EGD. Table 2 conveys the endoscopic findings, and Table 3 shows the histologic findings for DET and non-DET EGDs. Of all the endoscopic findings for DET patients (n=76), 11 (14.5%) showed either masses or suspicion for Barrett's Esophagus. 15.8% (n=3) of histological specimens were diagnosed with cancer and 21.1% (n=4) with intestinal metaplasia. This is compared to 3.77% (n=6) of histological specimens of patients with non-DET EGDs which had cancer diagnosed, and 28.3% (n=45) with intestinal metaplasia or dysplasia.

CONCLUSION:

There is a remarkable number of upper endoscopies performed specifically for imaging findings of DET. The majority of these endoscopic histological findings are benign. However, there is indeed an increased incidence of cancer for endoscopies performed for DET, compared to endoscopies not performed for DET. Next steps include determining specific risk factors associated with metaplasia, dysplasia, or cancer in patients with DET in order to better understand who would most benefit from an upper endoscopy and who would not.
547 Increasing Endoscopy Unit Efficiency: It's Time to Take Control
Authors: Gladys-Oryhon Jordan , Umar Shifa , Cole Rita , Thakkar Payal , Syed Aslam , Midian Robin , Morrissey Suzanne , Mitre Marcia , Thakkar Shyam , Farah Katie
Published: October 2019

INTRODUCTION:

Operational flow is an important factor in relation to efficiency in an endoscopy center. There are opportunities for improvement in efficiency while keeping the standards of quality. We performed a time flow analysis in our outpatient endoscopy center to identify workflow improvement opportunities.

METHODS:

We evaluated 616 patients who underwent EGD and colonoscopy. We analyzed preop prep time, procedure time, room turnover, recovery room time, total time in unit, and physician arrival time. These times were compared to efficiency benchmarks identified in the limited literature available. A process map was documented to illustrate patient flow and to assess redundancies and non-value added steps (Figure 1). Post-intervention data was collected on 381 patients.

RESULTS:

Pre-procedure nursing time exceeded benchmark intervals for both EGD and colonoscopy (Table 1). This was due to lack of documentation if the patient could not be reached during precall assessment 5 days prior to procedure requiring the nurse to obtain the information on the day of endoscopy. 2/3 of nurses did not have EMR access to be able to chart the medical history prior to patient arrival. In addition, IV was placed prior to the restroom visit delaying procedure start time while physician was ready to proceed. Doubles were allotted only 30 min block times and progressive delay was noticed increasing pre-procedure wait time. Physician start time was delayed 26% by an average of 12 min (Figure 2). This was due to clerical tasks, staff questions, and operational tasks. Encounter forms were reformatted to be user friendly for nursing documentation. All nurses were given EMR access in the event where patient was not reached prior to procedure. Pre-call assessment changed from 5 to 7 days prior to procedure to increase probability of reaching patients. Patients were offered restroom break prior to IV placement. Block times for doubles were extended from 30 to 45 minute block times . Recovery room delays with EGDs were attributed to oversedation by a single nurse anesthetist who was educated regarding propofol usage. Physician delays remained essentially unchanged (Figure 2).

CONCLUSION:

With our interventions, we reduced pre-procedure time by 8 mins for EGDs and 7 minutes for colonoscopy. We improved recovery room time. Delays related to physician behavior remain unchanged. Our next step is to address physician arrival times will be to post results of physician start times on a weekly basis at our endocenter.
548 Five Minute Intervention for Improved Inpatient Bowel Preparation Quality at a Large, Urban Safety Net Hospital
Authors: Evans Nicole S. , Haghighat Shida , Ramprasad Chethan , Hsieh Eric
Published: October 2019

INTRODUCTION:

Achieving adequate bowel preparation can often be difficult for hospitalized patients. More than half of the colonoscopies performed at our large, urban safety net hospital are rated as suboptimal. Given the limited availability of resources in this setting, achieving adequate bowel preparation is paramount to cost effectiveness. The objective of this study is to determine the impact of patient education in the form of counseling and written instruction on the quality of bowel cleanliness at colonoscopy.

METHODS:

This was a single-blinded, randomized, prospective study. Forty-six inpatients scheduled for colonoscopy were randomized into two groups: intervention and standard of care (SOC). Patients who speak English or Spanish as their primary language were included in this study. The intervention group received a five-minute educational session as well as a pictorial and verbal brochure in their preferred language regarding the purpose of a colonoscopy and value of adequate bowel preparation. The SOC group did not receive this education session or brochure. Both groups were administered a clear liquid diet and four liters polyethylene glycol. Patient demographics, a brief medical history, and length of hospitalization were documented. Endoscopists blinded to randomization used the Boston Bowel Preparation Scale (BBPS) to grade bowel preparation quality.

RESULTS:

There were 46 colonoscopies in total, 25 in the SOC group (75% male, mean age 52.6), and 21 in the intervention group (81% male, mean age 55.7). Of these patients, 56.5% preferred Spanish as their primary language when discussing their healthcare. There were no statistically significant differences between the intervention and control group with respect to demographics, BMI, primary language, history of diabetes, family history of colorectal cancer, inpatient narcotic use, need for repeat colonoscopy, baseline educational level, or length of hospitalization. The mean BBPS score in the intervention group was greater than the mean BBPS score in the SOC group (8.6 vs. 6.8; P < 0.01). Greater than 75% of the intervention group received a perfect score of 9, compared to 0.08% in the standard of care group (P < 0.01).

CONCLUSION:

Providing both written and verbal education prior to inpatient colonoscopy is a simple and cost-effective way to optimize colonoscopy preparation. In a healthcare setting where resources are scarce, this five-minute intervention significantly improved bowel preparation quality.
555 Disaccharidase Dilemma in Adults: Utility of Routine Assays in Diagnostic Upper Endoscopies
Authors: Vasireddi Neal , Vasireddi Nikhil , Khakoo Nidah S. , Kasi Keerthana , Duggimpudi Arul Ruthwik , Minassian Haig , Vasireddi Srinivas S.
Published: October 2019

INTRODUCTION:

Disaccharidase assay for evaluating abdominal pain has been well studied in the pediatric population. Deficiency of lactase or sucrase-isomaltase can present with chronic diarrhea, flatulence, abdominal pain, and bloating in such patients. However, the prevalence of disaccharidase deficiencies in adult populations with such symptoms has not been well delineated.

METHODS:

Distal duodenal specimens from 100 patients with above symptoms, who underwent an upper endoscopy (EGD) at an outpatient facility were submitted for disaccharidase assay. Standardized laboratory cut off values were used to determine disaccharidase levels that were outside the normal range. Statistical analysis was done to determine the frequencies of abnormal disaccharidases. Analysis of the group, with normal or low lactase/sucrase and presenting clinical features, was performed.

RESULTS:

Mean age of study patients was 52 years and 46% of the patients were male. The racial distribution was as follows: 45% White, 23% Hispanic, 18% Asian, 6% Black, 8% other. Table 1 shows the frequencies of normal and low values for these patients. 84% of the cohort had low lactase, 21% had low sucrase, and 11% had all 4 values in normal range. Figure 2 shows the distribution of the remaining patients who had at least 1 abnormal disaccharide.

CONCLUSION:

The association between abdominal symptoms and carbohydrate malabsorption in adults is widely recognized, but testing is rarely performed by gastroenterologists in clinical practice. Dietary recommendations are often made empirically. We investigated the prevalence of low disaccharidase levels in the adult population with above symptoms. Besides lactase deficiency, a significant number of patients also had deficiency of sucrase, maltase and palatinase. While this study cannot establish a causal relationship between low levels noted and patient symptoms, this information can be used to recommend appropriate diets or the use of lactase and sucrase enzyme supplements offering a more selective approach in patient care.
556 A Pilot Study on the Recovery Rate in Patients Who Receive Propofol Sedation During Upper Endoscopy (EGD)
Authors: Thirumurthi Selvi , Hagan Katherine B. , Tan Jens , Cata Juan , Hernandez Mike
Published: October 2019

INTRODUCTION:

Procedural sedation for gastrointestinal endoscopy has shifted towards the use of propofol instead of moderate sedation. While medications used for moderate sedation produce delayed psychomotor recovery, patients receiving propofol often report a subjective return to baseline by the time they leave the recovery area following brief endoscopic procedures. Patients are advised to take the day off of work, abstain from major decisions and have an adult accompany them home. This comes at a societal cost as both the patient and caregiver must miss a full day of work. Willey et al. previously studied the rate of recovery for patients receiving moderate sedation with fentanyl and midazolam for upper endoscopy (EGD) finding that average psychomotor recovery was only 64.4 ± 4.4% of baseline and that the letter cancellation test (LCT) and manual dexterity test (MDT) were the most powerful predictors of recovery. We hypothesize that patients receiving propofol sedation will experience a discrete period of psychomotor depression, followed by rapid improvement.

METHODS:

IRB approval was obtained and 30 outpatients undergoing EGD (divided into three equal age groups) were enrolled (Table 1). To determine normal score variability within each age group the LCT and the MDT were given twice in the pre-procedure period to each patient. Each patient also took the tests upon awakening in recovery and a follow up 30 minutes post-procedure. A patient's recovery status was defined as a 30 minute post-procedure test score within 2 standard deviations of the average score for their age cohort.

RESULTS:

Overall and within each age group, patients experienced a decrease in performance in the immediate post-procedure period on both the LCT and the MDT. Figure 1 All groups showed improvement on the 30 minute post-procedure test, although full recovery was only achieved 40.0 to 90.0% of the time (overall average of 73.3%) with the LCT and 90.0 – 100% of the time (overall average 90%) for the MDT (Table 2).

CONCLUSION:

In comparison to previously published results of moderate sedation, propofol sedation demonstrates an improved psychomotor recovery profile. The two tests utilized for this pilot study cannot be considered to provide a full evaluation of psychomotor recovery. We hope that this prospective data may ultimately be used to develop an easily accessible, inexpensive tool to assess psychomotor recovery at the bedside.
557 Standardized Post-Endoscopy Report Card Improves Inpatient Post-Endoscopy Knowledge Translation
Authors: Taylor Stephen , Rumman Amir , Ma Ann , Saperia James , Bernstein Michael , Mosko Jeff , Al Ghamdi Sarah
Published: October 2019

INTRODUCTION:

There is limited literature reviewing the utility and validity of a post-endoscopy report card in helping to better facilitate post-endoscopy recall and patient satisfaction. Augmenting verbal instructions with written ones has been shown to improve patient comprehension and compliance. The aim of this QI initiative was to improve recall of endoscopy results post-endoscopy via the use of a written endoscopy report card (WR) for patients, augmented to the current standard of care which involves a standard verbal report (VR). We evaluated the effect of providing a WR to patients before discharge, focusing on recall of endoscopic findings, physician recommendations, follow-up and overall satisfaction. Our goal was to increase patient recall of inpatient endoscopy results and follow up plans by 50% over a 6-month period at a tertiary hospital.

METHODS:

A prospective single-center trial. Between February and May 2019, 9 patients were enrolled in the standard of care arm, consisting of VR post-procedure. 21 patients underwent the intervention receiving the standard VR followed by receipt of a WR. Patients who met inclusion criteria were given the WR prior to discharge. This included patients age3 18 years admitted to hospital for less than 2 weeks who underwent endoscopy in a non-ICU setting during admission. All patients received a standardized telephone survey containing questions about patient recall and satisfaction 5-10 days following discharge. Baseline characteristics of the two study groups were compared by using X2 tests. Results were calculated using the Pearson Chi-Square Test and the Student T-test for patient satisfaction utilizing the Likert Scale.

RESULTS:

81% of patients in intervention group (17/21) retained WR at the time of telephone survey. Receipt of a WR improved recall of findings (P < 0.001), recall of medications (P < 0.001), recall for clinic follow-up (P = 0.006) and for recall for follow-up (P = 0.008). Satisfaction was high for all patients but was significantly improved by the receipt and retention of report (P < 0.001). Study limitations include the small sample size, and exclusion of patients who did not speak English.

CONCLUSION:

A post-endoscopy report card given to patients prior to discharge may improve recall of results, prescribed medications and overall satisfaction with procedures. This inexpensive and safe intervention should be routinely adopted into the standard of care.
562 Triage Surveys Are a Safe and Efficient Method to Streamline Utilization of Direct Access Endoscopy
Authors: Hsu Angela , Haber Erin , Woo Stephanie , Lulevitch Nicole , Kruger Annie , Loughney Thomas , Jiang Tina , Moore Carmen
Published: October 2019

INTRODUCTION:

Direct Access Endoscopy (DAE) is a process by which Gastroenterology (GI) practices provide patients with access to endoscopic intervention without incurring delays in awaiting GI clinic visits. Medstar Georgetown University Hospital (MGUH) employs the DAE mechanism through a triage system called Discussed with Patient (DWP) survey which is a screening questionnaire administered by central scheduling to determine which patients are low enough risk to safely bypass a pre-procedural clinic visit. This study was designed to evaluate safety and efficacy of our DWP triage system.

METHODS:

We performed a retrospective chart review of outpatient endoscopic procedures using our department's procedure scheduling system and electronic medical record system. Inclusion criteria included colonoscopy and EGD procedures performed by MGUH GI attendings from October 1-31, 2018 (total 23 working days). To focus data analysis, other procedures (i.e.; ERCP, EUS, MRCP, Flex sig) were excluded. We then analyzed patient demographics, indication for procedure, and safety documentation recorded within triage surveys.

RESULTS:

727 total endoscopic procedures were analyzed. Sixty-five percent (479/727) of the study population was screened with a DWP prior to procedure. Of this population, a large majority (355, or 74%) did not require a pre-procedural GI clinic visit. Assuming an average of 30 minutes per pre-procedural visit, we estimated this accounted for a total of 177 hours of clinic time saved. Of the 479 cases scheduled by the direct access pathway, 120 (25%) had clear documentation of the DWP triage survey positively affecting patient care including adjustment of anticoagulation regimen (n = 29, 24%) and guidance on obtaining cardiac, renal, or pulmonary clearance (n = 23, 19%).

CONCLUSION:

The DWP triage survey utilized by our institution is an effective method to provide direct access endoscopy to a large population while eliminating unnecessary pre-procedural GI clinic visits for low-risk patients. The benefit of this intervention is evidenced by the estimated 177 hours saved per month. In addition, the DWP serves as a safety screen that allows for physicians and ancillary staff to make crucial adjustments that optimize patient safety prior to procedure. Strengths of this study include the large number of procedures analyzed and a wide distribution of MGUH endoscopists. Limitations of this study include lack of post-procedural safety outcomes.
566 Improving Bowel Preparation Quality for Inpatient Colonoscopies at a Tertiary Hospital
Authors: Mandark Gandhi , Townsend Cassandra , Almaghrabi Majed , Alotaibi Ammar , Khanna Nitin , Yan Brian , Brahmania Mayur
Published: October 2019

INTRODUCTION:

Adequate bowel preparation quality is required for appropriate mucosal visualization during colonoscopy. Several factors impede quality including patient, environmental and process factors. When colonoscopies demonstrate poor-quality preparation, it often delays further management and discharge for patients as they often need to return for a second procedure in order to get adequate visualization. This also results in increased costs to the healthcare system. Our aim was to identify the rate of poor-quality bowel preparation at our tertiary care hospital for inpatient colonoscopies and implement interventions to decrease this rate.

METHODS:

The study was conducted at University Hospital in London, Ontario from March 2018 - March 2019. In the first PDSA cycle we improved an existing order-set such that split- dose bowel preparation would more reliably be ordered and administered. Our second PDSA cycle focused on teaching junior residents how to order bowel preparation for inpatient colonoscopies. PDSA cycle three involved making bowel preparation quality assessment more objective. Lastly, PDSA cycle four wasaimed at improving patient education surrounding the importance of completing bowel preparation.

RESULTS:

Poor-quality bowel preparation in the six months prior to intervention was 14.0%. After intervention this came down to 8.0%. Similarly our process measure of patients receiving split-dose bowel preparation administration increased from 81.2% to 94.6% during this period.

CONCLUSION:

Several factors are involved with poor-quality bowel preparation for inpatient colonoscopies. Simple and sustainable interventions can be implemented to improve quality. We are continuing to identify new factors and interventions to further improve this metric.
584 Apelin Association With Hepatic Fibrosis and Esophageal Varices in Chronic HCV Patients
Authors: Soliman Lamyaa , Zayed Rania , Omran Dalia , Said Fadwa , Darweesh Samar , Ghaith Doaa , Eletreby Rasha , Barakat Mahmoud , Bendary Mahmoud , Zaky Doaa , Amer Eman , Elmahgoub Iman
Published: October 2019

INTRODUCTION:

Portal hypertension (PH) and esophageal varices complicating HCV-related chronic liver disease (CLD) are the most devastating sequelae. Angiogenesis is the hallmark of their pathogenesis. Apelin is one of the recently identified angiogenic and fibrogenic peptides. We studied apelin gene expression, apelin (rs3761581) SNP and serum apelin level in chronic HCV patients, and their association with hepatic fibrosis and esophageal varices.

METHODS:

112 patients with HCV related CLD (40 having liver cirrhosis (LC)/low grade varices, 33 with LC/high grade varices and 39 with fibrotic non-cirrhotic liver/no varices), and 80 healthy control subjects were included. Real time PCR was used for apelin gene expression assay and apelin rs3761581 SNP analysis in peripheral blood samples. Serum apelin level was measured by ELISA.

RESULTS:

Apelin gene expression was undetectable in studied samples. SNP analysis revealed higher frequency of the C-(mutant)-allele among patients compared to controls (P = 0.012, odds ratio 3.67). Serum Apelin level was significantly higher in patients with hepatic cirrhosis/ varices (median 31.6 ng/L) compared to non-cirrhotic patients/ no varices (median 2.9 ng/L) (P < 0.001). Serum apelin level at cut off value 16.55 ng/L predicted the presence of varices with AUROC 0.786. Positive correlation was found between serum apelin level and grade of liver fibrosis (r=0.346, P < 0.001) and PH (r=0.438, P < 0.001).

CONCLUSION:

Apelin rs3761581 C-allele may be associated with progression of HCV-related CLD and varices formation, and can be considered as a potential therapeutic target to control fibrosis progression. Serum apelin level provided accurate prediction of the presence of esophageal varices.
587 The Safety and Efficacy of Thalidomide for the Treatment of Gastrointestinal Bleeding Refractory to Endoscopic Intervention: A Meta-Analysis
Authors: Soin Sarthak , Ali Faisal , Saleem Nasir , Pandit Sarbagya
Published: October 2019

INTRODUCTION:

Thalidomide's role in patients with gastrointestinal bleeding (GI) secondary to angiodysplasia, cirrhosis, Crohn's disease, portal hypertensive gastropathy, hereditary hemorrhagic telangiectasia and left ventricular assist device which are refractory to endoscopic interventions has not been extensively studied. We conducted a meta-analysis to evaluate the safety and efficacy of thalidomide in the current body of literature.

METHODS:

A systematic search of Medline was performed from 2000-present. Studies enrolling adults reporting on the use of thalidomide for the treatment of refractory GI bleeding were included. The primary endpoint was the response rate, defined by reduction in frequency or resolution of GI bleed among patients treated with thalidomide. A meta-analysis of proportions was carried out to calculate pooled response rates (with calculation of 95% confidence intervals (CI)). A logistic normal random effects model was employed to account for inter-study heterogeneity and for effect sizes close to 0 and 1. Descriptive statistics were employed to outline the characteristics of included studies.

RESULTS:

Screening of 182 studies yielded 8 studies, enrolling 171 patients, of whom 99 were females. The most common cause for refractory GI bleed was angiodysplasia followed by left ventricular assist devices. [Figure 1] All patients had GI bleeds refractory to endoscopic therapy and most of the patient population was transfusion dependent. Patients underwent treatment with thalidomide for a median of 4 months, with doses ranging from 50-300 mg daily. The pooled response rate to thalidomide therapy was 77% (95% CI 70-83%). The pooled adverse event rate was 61% (95% CI 42-77%). [Figure 2] Thalidomide was discontinued in 8% (95% CI 1-35%) of the patients due to adverse events. The most common adverse event was peripheral neuropathy, accounting for 12% (95% CI 4-31%) of the adverse events, followed by fatigue, which accounted for 8% (95% CI 1-61%) of adverse events. [Figure 3] No treatment associated mortality was reported.

CONCLUSION:

Thalidomide for GI bleeding refractory to endoscopic intervention is a potentially efficacious medical therapy which can be considered before any surgical intervention is planned. Most adverse events are mild and self-limiting, though close monitoring for development of neuropathy is advised. Randomized controlled trials to validate the safety and efficacy of thalidomide for the treatment of refractory GI bleeding are warranted.
588 Skipping the Drip: Intravenous Bolus Proton Pump Inhibitor Therapy Produces Similar Outcomes to Continuous Infusions With Less Healthcare Resource Utilization
Authors: Hadi Yousaf , Khan Raja Samir , Chima Noor , Kupec Justin T.
Published: October 2019

INTRODUCTION:

Continuous proton pump inhibitor (PPI) infusions remain the most commonly employed therapeutic strategy for administration of PPIs in upper gastrointestinal (GI) bleeding. Recent data has pointed towards non-inferiority of intravenous (IV) bolus regimens, but real-world data is lacking. Cost effectiveness and resource utilization data is also unavailable and projections made by estimation have shown low potential for cost savings.

METHODS:

A retrospective cohort study to evaluate the impact of a shift in institutional practice from PPI infusions to bolus was conducted. As part of a quality improvement initiative, an electronic medical record-based order set was employed; this involved an IV PPI twice daily for 72 hours subsequently defaulting to an oral regimen. After obtaining institutional review board (IRB) approval, patients admitted with upper GI bleeding at our institution from January 2017 to December 2018 were identified with relevant ICD 10 codes. All patients with peptic ulcer disease as the cause of bleeding were included and divided into two groups on the basis of PPI administration strategy. Clinical and resource utilization outcomes were compared between the two groups. Univariate and multivariable analyses were performed to assess independent associations.

RESULTS:

Of the 368 patients included the mean age was 62.68 years (SD: 5.3 years) and 170 (46.1%) were male. On univariate analysis, age, gender, smoking status, use of anticoagulants, and PPI administration strategy were not associated with inpatient mortality, readmissions, re-bleeding at 3, 7 and 30 days, need for endoscopic hemostatic therapy and need for re-intervention or surgery (all P values > 0.05). Multivariable logistic regression revealed that smoking (OR 2.12 95% CI 1.13- 3.70), anticoagulation use (OR: 2.27 95% CI 1.17- 4.62) and age (OR: 1.03, 95% CI 1.01-1.04) were significantly associated with in-hospital packed red blood cell transfusions. Bolus PPI use was associated with less pharmacy cost of drug calculated per patient, earlier de-escalation to oral PPI, and shorter hospital stay (P < 0.05).

CONCLUSION:

Our real world, tertiary care experience ascertains non-inferiority of IV bolus PPI regimen compared to continuous infusion for acid suppression therapy in managing upper GI bleeds. The use of simpler bolus regimens can result in a decrease in healthcare resource utilization. A practice shift to such a regimen can therefore serve as a good quality improvement initiative in health care settings.
589 Diagnostic Value of FIT in Upper Gastrointestinal Malignancy
Authors: Al Yassin Altaib , Sapho Lidia , Kheder Joan , Alazzawi Yasir
Published: October 2019

INTRODUCTION:

Cancers of the esophagus and stomach are among the most lethal of all malignancies. The majority of these neoplasms are detected at an advanced stage due to their similarity in early stages to benign causes of dysphagia and dyspepsia. It has been suggested that fecal immunochemical testing (FIT) could be used for population-based screening for occult bleeding caused by colorectal cancer. However, the diagnostic sensitivity of these tests has been difficult to estimate. A positive FIT might also come from the upper gastrointestinal (GI) tract, so perhaps we should consider esophagogastroduodenoscopy (EGD), or Video capsule endoscopy (VCE) to detect upper GI cancers. We aimed to determine how many individuals are found to have upper GI cancers (esophageal, gastric, or small bowel cancer) in EGD or VCE after a positive FIT, and to see whether using FIT can predict the risk of cancer in patients.

METHODS:

A retrospective chart review of patients who were referred to a GI clinic in an academic center between 2006 and 2016, had a positive FIT, and followed by EGD or/and VCE. Patients' data including age, race, gender, in addition to the indication of EGD and VCE, and endoscopic findings were reviewed and collected.

RESULTS:

A total of 206 patients who had positive FIT. Of whom, 181 patients had EGD and 25 and had VCE. The mean age of the patients was 62 years with 94% above 50 years old. The most common indication for the EGD and VCE was gastrointestinal bleeding followed by dyspepsia and positive FIT. Abnormal endoscopic findings were found in 143 EGD and 19 VCE representing collectively 78% of the studies. Of the 172 endoscopic evaluation of the upper gastrointestinal tract, 1 patient was found to have cancer and 142 patients to have benign findings. The most common benign conditions were gastritis/duodenitis (63%) followed by esophagitis (22%) and peptic ulcers disease (12%). Positive predictive value of FIT for non-malignant lesions was found to be 79%.

CONCLUSION:

There is a high diagnostic value of positive FIT especially for patients older than 50 years. EGD and VCE evaluations after a positive FIT had a high yield of non-malignant lesions.
596 Efficacy of Self Expanding Metal Stent (SEMS) in Refractory Bleeding Esophageal Varices, Is There a Mortality Benefit? An Indirect-Comparison Meta-Analysis to Trans-Jugular Intra-Hepatic Porto-Systemic Shunt (TIPS)
Authors: Mohan Babu P. , Chandan Saurabh , Khan Shahab R. , Kotagiri Rajesh , Olaiya Babatunde , Ofosu Andrew , Adler Douglas G.
Published: October 2019

INTRODUCTION:

Acute esophageal variceal hemorrhage (eVH) is a life threatening complication of portal hypertension and current guidelines recommend endoscopy with variceal band ligation within 12 hours of presentation. Up to 20% of these episodes can be refractory to standard treatment and in these cases, a “bridge” therapy is often necessary to control hemorrhage. Self-expanding metal stents (SEMS) have been used in this setting, however their role in the treatment protocol is unknown due to paucity in data. Aim of this study was to evaluate the clinical performance of SEMS and indirectly compare it to transjugular intrahepatic portosystemic shunt (TIPS) in refractory eVH, by meta-analysis methods.

METHODS:

We searched multiple databases from inception to May2019 to identify studies that reported on the clinical outcomes of SEMS and TIPS in refractory eVH. Outcomes assessed were all-cause mortality, technical success, immediate bleeding control, rebleeding, and adverse events. I2 statistics was used to assess heterogeneity.

RESULTS:

574 patients from 21 studies were analyzed (SEMS: 12 studies, 176 patients; TIPS: 9 studies, 398 patients). The pooled rate of technical success with SEMS and TIPS were comparable (88.3%, 81.7-92.7 vs 91%, 86.2-94.2, P = 0.42). The pooled rate of immediate bleeding control with SEMS was 84.5% (74-91.2) and with TIPS was 97.9% (87.7-99.7), with statistical significance P = 0.03. The pooled rate of rebleeding with SEMS was 19.4% (11.9-30.4) and with TIPS was 8.8% (4.8-15.7), with statistical significance P = 0.04. The pooled rate of all adverse events were comparable (36.9%, 26-49.2 vs 41.4%, 26.5-58.1, P = 0.66). Pooled rate of stent migration in SEMS cohort was 31.8% (22-43.5). The pooled rate of all-cause mortality with SEMS was 43.6% (28.6-59.8) and with TIPS was 27.9% (16.3-43.6). There was no statistical significance (P = 0.16). I2 heterogeneity of 91% was observed in mortality with TIPS. All results are summarized in Table 1.

CONCLUSION:

SEMS did not demonstrate mortality benefit when compared to TIPS in the management of refractory eVH. The overall clinical outcomes with SEMS seemed to be inferior to TIPS with higher rebleeding rate and lesser immediate bleeding control rate. In addition, a stent migration rate of 32% was noted with SEMS despite the comparable overall adverse events between the modalities. Based on our analysis, an emergent TIPS should be the standard of care in refractory eVH.
597 Bidirectional Endoscopy in Asymptomatic-Iron Deficiency Anemia (A-IDA)
Authors: Schopis Michael , Gil Arcelia Guerson , Ziv Yonatan , Seu Rie , Yeat Nai Chien , Muench Samuel , Kim Mimi , Aroniadis Olga , Brandt Lawrence
Published: October 2019

INTRODUCTION:

GI investigation of pts with A-IDA typically begins with both upper (U) and lower (L) GI endoscopy. Guidelines tend to recommend bidirectional endoscopy (BDE) sequencing based on age stratification, or starting with LGI endoscopy. The aim of this study was to determine the most efficient BDE sequence among patients with A-IDA by investigating the relative frequencies of identified associated sources of bleeding by UGI or LGI endoscopy.

METHODS:

We performed a retrospective chart review of clinical characteristics of pts ≥18 yrs who had BDE performed within 6 months of A-IDA diagnosis between the yrs 2014-2019. Pts were excluded if they had GI tract surgery within 10 yrs, active pregnancy, active GI bleeding, an obvious site of non-GI blood loss or ferritin >100. McNemar's test was used to compare frequency of lesions identified across the general population and stratified for age < 50 and >50 yrs. Bivariate analyses of characteristics associated with UGI and LGI lesions were performed using t-test, Chi-squared test, or Fisher's exact test. Multivariate logistic regression estimated odds ratios.

RESULTS:

497 pts were available for analysis (65% female, mean age 63 yrs; Table 1). BDE found IDA-associated lesions in 307 (61.8%) pts comprising 196 (39.4%) exclusively UGI lesions, 66 (13.3%) exclusively LGI lesions, and 45 (9.1%) both UGI and LGI lesions. In our cohort, UGI lesions were more common than LGI lesions [241 (48.5%) vs 111 (22.3%); P < 0.001], regardless of age (P < 0.001) (Table 1). Protective variables against an LGI lesion included female sex [OR 0.51 (0.32-0.86); P = 0.01], BMI [OR 0.96 (0.93-0.99) per unit inc.; P = 0.01] and Hgb [OR 0.88 (0.78-0.98) per unit inc.; P = 0.03]. CKD was associated with LGI lesions [OR 1.99 (1.12-3.48); P = 0.02]. Hgb was higher in pts with only UGI than only LGI lesions (9.4±1.6 vs 8.5±1.5; P = 0.001). PPI use predicted absence of identifiable lesions [OR 0.66 (0.45-0.96); P = 0.03]. The most common UGI lesions were H. pylori-associated (HP-A) gastritis (24.2%) and peptic ulcer disease (17.6%) (Figure 1a). The most common LGI lesions were large polyps (37.7%) and colon CA (16.2%) (Figure 1b).

CONCLUSION:

Our results indicate 1) pts with A-IDA are more likely to have an UGI than LGI source; thus starting with UGI endoscopy may be prudent; 2) women are less likely to have a LGI source of A-IDA than men; 3) low BMI, low Hgb and CKD predict a LGI source of A-IDA. 4) HP-A UGI lesions account for a significant portion of A-IDA; 5) PPI use predicts the absence of lesions.
601 Gastrointestinal Bleeding in Patients With Co-Morbid End-Stage Renal Disease
Authors: Brindise Elizabeth , Kobeszko Matthew , Kuruvilla Aneesh , Elkhatib Imad , Silva Rogelio
Published: October 2019

INTRODUCTION:

End Stage Renal Disease (ESRD) is steadily increasing in prevalence in the United States with more than 2 million individuals affected in 2015. ESRD is believed to predispose individuals for gastrointestinal (GI) bleeding by increasing bleeding diatheses, use of heparin during dialysis and GI angiodysplastic lesions. We sought to evaluate outcomes of patients with ESRD and GI bleeding.

METHODS:

The study population was derived from the HCUP-National Inpatient Sampling (NIS) database for the years 2010 to the third quarter of 2015. ICD-9 codes were used to identify patients with GI bleeding and a history of ESRD. In-hospital all-cause mortality, total cost of hospitalization, mean length of stay and outcome rates were assessed. Propensity score matching was used to adjust for baseline confounders.

RESULTS:

Among 5,434,241 admissions with ESRD, 250,383 (4.6%) individuals developed GI bleeding during our study period. 44.2% were female. Patients with ESRD and GI bleeding were more likely to have CAD, coagulation/hemorrhagic disorders, hepatitis, liver and biliary disease and alcohol related disorder (Table 1). GI bleeding in the ESRD population was associated with significantly higher all-cause mortality (10.9% vs 4.7%, P < 0.0001), length of stay (10.5 ± 15.4 vs 6.7 ± 9.3, P < 0.0001), cost of hospitalization ($110,019 ± 207,049 vs $65,875 ± 110,995, P < 0.0001) and blood transfusion rates (16.8% vs 51.2%, P < 0.0001). Furthermore, the GI bleeding cohort required significantly more endoscopies, colonoscopies, and upper and lower GI surgical procedures (Table 2). Following propensity score matching, these statistically significant differences persisted.

CONCLUSION:

GI bleeding in patient with co-morbid ESRD is associated with significantly higher all-cause mortality, length of stay, total cost of hospitalization, blood transfusion rates as well as a number of procedures including: endoscopy, colonoscopy, and upper and lower GI surgery.
603 Incidence of Non-Variceal Upper Gastrointestinal Bleeding Worsens Outcomes With Acute Coronary Syndrome: Result of a National Cohort
Authors: Pioppo Lauren , Bhurwal Abhishek , Reja Debashis , Tawadros Augustine , Patel Anish V.
Published: October 2019

INTRODUCTION:

Upper gastrointestinal bleeding (UGIB) is a feared complication of acute coronary syndromes (ACS) and has been shown to increase morbidity and mortality. UGIB may occur due to stress-related mucosal disease as well as from standard therapy with antiplatelet and anticoagulant medications. Our aim was to assess the incidence of non-variceal UGIB in patients with ACS in a national cohort and its impact on in-hospital mortality, length of stay (LOS), and cost of hospitalization.

METHODS:

This was a retrospective cohort study using the 2016 Nationwide Inpatient Sample (NIS) utilizing ICD 10 CM codes. Principal discharge diagnoses of ACS (STEMI, NSTEMI and UA) in patients over 18 years of age were included. Non-variceal UGIB with interventions including endoscopy, angiography and embolization were also evaluated using ICD 10 CM. Primary outcome was national incidence of concomitant non-variceal UGIB in the setting of ACS. Secondary outcomes included impact on in-hospital mortality, LOS and cost of stay. Proportions were compared using Fisher's exact test and continuous variables using Student t-test. Multivariable and Poisson regression were performed.

RESULTS:

A total of 661,324 discharges with principal discharge diagnosis of ACS in 2016 were included. Patient demographics are listed in Table 1. Of this cohort, 0.65% (n = 4289) were complicated with non-variceal UGIB with increased frequency in older patients (OR 1.04, 95% CI 1.04-1.05; P = 0.001). Despite endoscopic evaluation, 17.35% (n = 744) underwent angiography whereas embolization was required in 0.5% (n = 21) of these cases. After adjustment of confounders (see Table 2), inpatient mortality was significantly higher in patients with UGIB (OR 1.49, 95% CI 1.10-2.03; P = 0.01). Non-variceal UGIB also led to significantly longer LOS (10.21 days vs 4.38 days; P = 0.001) and total cost of stay ($177,000 vs $88,592, P < 0.0001) (Table 3 and Table 4).

CONCLUSION:

We performed a retrospective cohort study which showed that the national incidence of non-variceal UGIB complicating ACS is low (less than 1%). However, as expected, its occurrence in ACS patients resulted in significantly higher inpatient mortality, LOS, and hospitalization charges. Limitations of the study include lack of information on antiplatelet or anticoagulant therapy which could affect outcomes. Further studies are needed to determine the safety and efficacy of endoscopy in patients on dual antiplatelet agents or anticoagulation.