bluuebunny/crossref_metadata_2025 huggingface dataset:
405 Improving the Reconciliation and Management of Proton Pump Inhibitors: A Quality Improvement Project
Authors: Gonzalez Adalberto , Castillo Michael , Koop Hans , Cortizo Jacqueline , Chin Jodi , Beiro Zaimat , Hagar Kristen
Published: October 2019

INTRODUCTION:

Proton pump inhibitors (PPIs) are one of the most widely used classes of drugs prescribed in the ambulatory setting. This leads to significant healthcare utilization, as $7 billion was spent in 2009. We performed a quality improvement (QI) project to improve the reconciliation and management of PPIs.

METHODS:

We performed a QI project form January to May 2019. We began by providing education to our resident physicians and clinic nurses regarding guidelines on appropriate PPI management. We constructed a dot phrase in our electronic medical record meant as a decision tool for physicians (Figure 1). From February to May 2019, we performed the intervention. We included all patients on PPIs seen in the ambulatory clinic by our group of six resident physicians from February to May 2019. Nurses were instructed to point out to physicians if patients were on PPIs after rooming the patient. During the time of medication reconciliation, physicians used the decision tree to make a decision to continue, increase, wean off, or discontinue their patient’s PPI. Next, we collected data for our predetermined variables. We used descriptive statistics to analyze our data.

RESULTS:

Our group of physicians saw 558 patients in clinic during our study period. 100 patients were on PPIs. 45 patients (45%) were included in our data analysis; the remaining 55 patients did not undergo reconciliation or documentation of their PPIs. Only 8 patients (17.8%) had their PPIs reconciled in the past one year. 10 of 45 patients (22.2%) had an absolute indication for long term PPI use; 10 patients were appropriately continued on standard dose PPI. 26 (57.8%) patients had a relative indication for long term PPI; 12 of 12 symptomatic patients were appropriately continued on PPI and 14 of 14 asymptomatic patients had their PPIs discontinued. 5 (11.1%) patients had no indication for PPI; all 5 had their PPIs appropriately weaned off. 2 patients (4.4%) with a history of peptic ulcer disease were appropriately taken off PPIs since they were not taking daily aspirin or no steroidal anti-inflammatory drugs (NSAIDs). 2 patients on daily NSAIDs were appropriately continued on PPIs due to risk factors. Overall, the decision tool led to correct management in all cases.

CONCLUSION:

Despite an active effort to improve PPI reconciliation, less than half of PPIs were addressed. Our decision tree allowed for the accurate management of PPIs in all patients. Future methods should be developed to increase PPI identification and reconciliation.
407 Healthcare Resource Utilization in the 12 Months After Diagnosis in Patients With Eosinophilic Esophagitis Compared With a Matched Cohort
Authors: Goodwin Bridgett , Lu Mei , Vera-Llonch Montserrat , Williams James
Published: October 2019

INTRODUCTION:

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disease of the esophagus, characterized by esophageal dysfunction and eosinophil-predominant inflammation. Currently, no licensed therapies exist for EoE in the USA, and data on the real-world burden of EoE on healthcare systems are limited. This retrospective study aimed to investigate healthcare resource utilization (HCRU) in patients with EoE compared with matched controls without EoE in the USA.

METHODS:

The US healthcare claims databases Truven Health MarketScan Commercial Claims and Encounters and the Medicare Supplemental database were used to identify patients diagnosed with EoE from January 2008 to September 2016. HCRU was recorded from the date of diagnosis (index date) throughout the continuously enrolled 12-month study period. A cohort of individuals without EoE was matched 1:1 for age, sex, geographic region, Charlson Comorbidity Index during the 12 months before the index date, and distribution of time from eligibility start date to index date. Logistic regression models were used to compare HCRU between cohorts.

RESULTS:

Each cohort included 16 094 individuals. Mean age in each cohort was 34.3 (SD: 17.9) years; 65.0% were men. Table 1 shows the frequency of HCRU. Of patients with EoE, 73.9% underwent a diagnostic endoscopy during the study period vs 1.7% in the matched cohort. All-cause inpatient admissions occurred significantly more frequently in patients with EoE than in the matched cohort (P < 0.0001). Patients with EoE were significantly more likely to have an outpatient visit than matched controls, including visits to a gastroenterologist or a psychologist (P < 0.0001). Overall, 26.2% of patients with EoE had ≥1 ER visit in the 12-month period, compared with 12.9% of controls. In patients with EoE, these were most commonly associated with food impaction (6.7% of patients; 25.7% of ER visits in patients with EoE vs 0.34% in matched controls) and esophageal stricture (3.2% of patients; 12.1% of ER visits in patients with EoE vs 0.05% in matched controls).

CONCLUSION:

Inpatient admissions and outpatient and ER visits were more frequent in patients with EoE compared with matched controls, highlighting the ongoing burden EoE imposes on patients and healthcare systems. In particular, ER visits for food impaction and esophageal stricture comprise 38% of ER visits for patients with EoE compared with < 0.5% for those without EoE. The lack of an approved treatment for EoE in the USA may contribute to this burden.
411 Association of Eosinophilic Esophagitis With Allergic-Immunologic Conditions: A Population-Based National Study
Authors: Alaber Omar A. , Chandar Apoorva K. , Dahash Basma , Sferra Thomas J. , Chak Amitabh
Published: October 2019

INTRODUCTION:

Eosinophilic esophagitis (EoE) and asthma are two common chronic conditions that are closely related and likely mediated by similar immunopathologic mechanisms and can be treated with similar treatment modalities. We aimed to examine the association of EoE with asthma using a large nationwide hospital database. We additionally examined the association of EoE with other related allergic-immunologic conditions such as allergic urticaria, eczema, allergic conjunctivitis, allergic rhinitis, and food and environmental allergies.

METHODS:

Data were obtained from a commercial de-identified patient database (Explorys, IBM, Inc.) that integrates electronic health records from 26 major U.S. hospital systems from 1999 to June 2019. Inclusion criteria for cases was all patients with a Systematized Nomenclature of Medicine - Clinical Terms (SNOMED-CT) diagnosis of asthma whereas inclusion criteria for controls was patients without asthma. Odds ratios (OR) and confidence intervals (CI) were calculated for the association of EoE with asthma and other related allergic-immunologic conditions.

RESULTS:

A total of 3,459,740 cases had asthma. Out of these, 4,490 had a diagnosis of EoE which followed in time the diagnosis of asthma. Out of 33,336,680 controls without asthma in the database, 20,390 had a diagnosis of EoE. When compared to controls without asthma, cases with asthma had a 2 (95% CI = 2.06 - 2.19) times higher odds of receiving a diagnosis of EoE following their asthma diagnosis. Similarly, other allergic-immunologic conditions were associated with a much higher odds of having EoE (Table 1). Patients with severe asthma had a 1.75 (CI = 1.37 - 2.23) times greater odds of having EoE when compared to patients with less severe (i.e. mild or moderate) asthma.

CONCLUSION:

There is a higher tendency for EoE to be diagnosed in patients with asthma and other allergic-immunologic conditions. In addition to being a retrospective analysis, inability to fully validate SNOMED-CT codes and unavailability of histology for the diagnosis of EoE could limit generalizability of the study. Nevertheless, patients with pre-existing asthma or allergic-immunologic conditions and symptoms suggestive of EoE (dysphagia, acid reflux or feeding difficulties) may warrant endoscopic evaluation.
412 Effervescent Granules for the Treatment of Esophageal Food Bolus Obstruction
Authors: DeRosa Vincent , Corliss Judy , Li Jeanne , Cleek Cathy , Kenner Catelynn
Published: October 2019

INTRODUCTION:

Esophageal food bolus obstruction is a common GI emergency without effective medical therapy, often requiring costly emergent endoscopy (EGD) for food bolus clearance. This case-control study compared the efficacy of standard of care treatment with the use of effervescent granules (sodium bicarbonate, citric acid, simethicone) for the treatment of esophageal food bolus obstructions.

METHODS:

Adult patients were recruited from three emergency rooms in a community-based, regional hospital system. A retrospective cohort treated with the standard of care, consisting of glucagon and/or lorazepam and/or IV fluids, was compared with a prospective cohort treated with effervescent granules. The primary end point was efficacy between the two treatment groups.

RESULTS:

From January 2018 – August 2018, 21 patients met the inclusion criteria for the retrospective arm and were treated with the standard of care; from September 2018- April 2019, 33 patients met the inclusion criteria and were treated with effervescent granules for esophageal food bolus obstructions. 3 out of 21 patients from the retrospective arm and 20 out of 33 patients from the prospective arm had successful food bolus clearance without requiring an EGD (success rate = 14.3% vs. 60.6%; P = 0.002.) There was one complication of a Mallory-Weiss tear noted on endoscopy without clinical significance in a patient treated with effervescent granules. The percentage of males was slightly higher in the prospective arm (22 males, 66.7% vs. 10 males, 47.6%; P = 0.27), and patients were slightly younger in the prospective arm (mean = 55.8 years, standard deviation (SD) = 16.8 vs. mean = 64.6, SD = 20.4; P = 0.11.)

CONCLUSION:

Treatment of esophageal food bolus obstruction with effervescent granules is more efficacious than the standard of care, with no clinically significant complications. Effervescent granules should be further studied as a safe and effective medical treatment option for this common GI emergency.
416 Esophageal Body Dysfunction in Patients With Esophagogastric Junction Outflow Obstruction: A Potential Flaw in the Chicago Classification
Authors: DeVault Kenneth , Cheah Ramsah , Chirnaksorn Supphamat , Francis Dawn , Bouras Ernest , Vazquez-Roque Maria , Lacy Brian E. , Houghton Lesley
Published: October 2019

INTRODUCTION:

High-resolution manometry using the Chicago Classification is standard in the evaluation of esophageal motility. When the relaxation of the esophagogastric junction is impaired and achalasia excluded, esophagogastric junction outflow obstruction (EGJ-OO) is diagnosed and the esophageal body is essentially ignored. We sought to characterize the function of the esophageal body in consecutive patients with EGJ-OO.

METHODS:

Retrospective review of the esophageal manometry findings in consecutive patients where there was computer recognition of EGJ-OO collected over a 2-month period. In each case, the esophageal body was reviewed manually and results reported independent of the suggested computer diagnosis.

RESULTS:

116 patients underwent manometry over a 2-month period and 30 (26%) were identified as having EGJ-OO. The indications for testing included chronic cough (n = 5), GERD (n = 8), dysphagia (n = 9) and esophageal evaluation associated with severe lung disease or transplantation (n = 8). The mean IRP was 20.8 (range 16-33.6) and did not vary depending on indication (P = 0.381). Computer interpretation was EGJ-OO in all patients without mention of the esophageal body. After review, 11 (37%) had an additional esophageal diagnosis. In effective esophageal motility (IEM) was the most prevalent among them (IEM-8, achalasia-2, jackhammer esophagus-1; P = 0.020). The frequency of an additional esophageal diagnosis was significantly different between GERD (0%) and dysphagia (66%; P = 0.004), but not between other groups (i.e. 40% in cough and 37.5% in transplant group). An esophageal body diagnosis was significantly more likely in patients with IRP > 25 (80%) compared with those with IRP < 25 (28%; P = 0.028).

CONCLUSION:

1-EGJ-OO is common in patients referred for esophageal manometry. 2-An additional esophageal body diagnosis is common in those with EGJ-OO.3-Esophageal diagnoses are more common in patients with dysphagia and in those with a very high IRP. The body of the esophagus is important in cases of EGJ-OO and should be reported independent of the computer-generated interpretation of the Chicago Classification.
418 A Review of Timelines and Reporters of Adverse Events From Proton Pump Inhibitors (PPIs) That Are Conveyed to the United States Food and Drug Administration Adverse Event Reporting System (FAERS).
Authors: Kruchko David H. , Patel Ami , Ehrenpreis Eli , Villines Dana
Published: October 2019

INTRODUCTION:

Recent publications have described potential PPI-associated adverse events (AEs) including cardiovascular disease (CVD), cerebrovascular accidents (CVA) and renal disease (acute interstitial nephritis and CKD). There is public interest and potential for lawsuits for these and other PPI-related AEs. The FAERS is a database of voluntarily reported AEs used for post-marketing surveillance of medications. The aim of this study is to analyze reports of all PPI-associated-AEs to FAERS, focusing on reporter sources. This permits an understanding of the effect of published high-profile PPI-associated AEs on FDA drug surveillance.

METHODS:

A total of 9,144,290 FAERS reports from January 2013 to December 2018 were examined. Analysis of all Primary PPI-related AEs were included (C. difficile, microscopic colitis, atrophic gastritis, hypergastrinemia, hypomagnesemia, hypocalcemia, hypokalemia, hypophosphatemia, vitamin malabsorption, pneumonia, CVD, CVA, renal disease, drug-induced lupus, and dementia). AEs were defined by MedDRA terminology. All reports were categorized according to reporter source (physicians, pharmacists, other health care professionals, consumers, and lawyers).

RESULTS:

Until 2018, overall reporting of PPI-related AEs generally showed steady changes over time. In 2015 there were 7,024 reports for all PPI-related AEs, in 2016, there were 8,043, and in 2017, there were 7,682. Notably, in 2018, reports for all PPI-related AEs spiked to 14,607. For specific AEs, reports for renal disease and CVD from consumers showed marked increases. In 2015 consumers reported 427 CVD cases and 494 renal cases, while consumers reported 627 CVD cases and 1,155 renal cases in 2018 (Figure 1). Reports for lawyers and physicians for CVD and renal disease both increased between 2015 and 2018. Physicians had an increase from 368 to 503 cases of CVD (36.7% increase) and from 676 cases to 1,112 of renal disease (64.5% increase), while lawyers had an increase of 49 cases of CVD to 99 cases of CVD (102% increase) and increase of 4 cases to 974 of renal disease (24,250% increase). This resulted in a rise in percentage of total reports from lawyers (Figures 2 and 3).

CONCLUSION:

Consumers are increasing reporting of CVD and renal disease associated with PPI use. The rapid increase in reports of PPI-associated CVD and especially renal disease by lawyers suggests that lawyers are a potential source of interference on pharmacovigilance.
419 The Costly Case of Proton Pump Inhibitors: A Single Center Experience
Authors: Suresh Kumar Vishnu Charan , Patthipati Venkata Suresh , Elangovan Abbinaya , Goldstein Lawrence
Published: October 2019

INTRODUCTION:

Proton pump inhibitors (PPI) are one of the cornerstones in the management of upper gastrointestinal bleed (UGIB) with the standard practice being initiating a continuous PPI infusion (CPI). In the recent years, several studies and meta-analysis have shown that there was no significant difference in major outcomes such as re-bleeding rates when using intermittent intravenous PPI (IIP) as compared to a CPI in non-variceal UGIB (2). However, most places in the USA still largely favor using the continuous infusion. Our study aimed to show the difference in patient costs of administering a CPI vs. IIP if evidence based practice was utilized in a single community hospital.

METHODS:

We retrospectively identified 212 CPI using our Electronic Health Record (EHR) and pharmacy database that were ordered at a community hospital in Ohio from June 2018 to May 2019 for patients who were admitted with a diagnosis of non-variceal upper GI bleed. A simple cost comparison analysis was done by Excel 2016 to compare the patient cost between CPI and IIP for the similar duration of use.

RESULTS:

Out of the 212 patients that were started on CPI, 54% were ordered by gastroenterologists as compared to 46% of which were started by all other physicians including internists, intensivists and ED physicians (Figure 1). The duration of the CPI tended to be longer (3.47 days) in adults >50 years as compared to adults < /= 50 years (2.58 days). There was a major difference in the cost of administering a CPI as compared to using IIP for a similar duration (Figure 2). The cumulative cost of CPI was 326,262 USD versus 108,810 USD for IIP (Figure 3).

CONCLUSION:

Although recent studies have showed that there was no difference in major outcomes in non-variceal upper gastrointestinal bleed when using intermittent PPI as compared to a continuous PPI infusion, this has changed neither the guidelines nor our practice of using a CPI. CPI is significantly more expensive as compared to an IIP for a similar duration of administration averaging up to $310 more per day. Our study showed that 217,452 USD could have been saved in 1 year by using IIP instead of CPI. A recent quality improvement study showed a significant reduction in costs when they used IIP instead of CPI in the management of non-variceal UGIB. Further studies comparing the cost effectiveness between CPI and IIP for non-variceal UGIB along with RCTs comparing the two might help revise the guidelines regarding their usage in the future.
421 Improving Proton Pump Inhibitor Prescribing Practices in an Academic Safety Net Primary Care Clinic: Quality Improvement Project
Authors: Nallapeta Naren S. , Bakhai Smita Y.
Published: October 2019

INTRODUCTION:

Proton Pump Inhibitors (PPI) overuse in both inpatient and outpatient settings have increased drastically over the last 2 decades. Overuse of PPIs continues despite evidence based guidelines and prolonged PPI use carries serious adverse effects. The aim of this quality improvement (QI) is to reduce the percentage of patients inappropriately prescribed PPIs between the ages of 40-75 years from a baseline rate of 80% to < 60% within 1 year at ECMC internal medicine clinic (IMC).

METHODS:

We used the Plan-Do-Study-Act (PDSA) model and performed a root cause analysis to identify barriers for the reduction of inappropriate use of PPIs. The major barriers included system, provider and patient-based barriers including lack of electronic medical record (EMR) alerts, gaps in knowledge in both the provider and the patient, fear of discontinuation of the PPI. QI team included nursing and ancillary staff, residents, attending physicians, social worker. Outcome measure was to reduce the percentage of patients inappropriately prescribed PPIs from 80% to < 60% in 1 year. Process measures included measuring the percentage of patients who are appropriately referred to GI clinic for an EGD and the percentage of patients on PPI who have their GERD assessed during the clinic including assessment for alarm symptoms. Balancing measures included potential increase in patient wait times in the clinic and esophagogastroduodenoscopy (EGD) wait time. The major interventions included (1) creating a customized EMR template; (2) provider education; (3) tracking continuity of care visits and medication reconciliation; (4) patient education; (5) assessing barriers and response to discontinuation; (6) Pocket guides for physician education.

RESULTS/OUTCOME MEASURES:

Average rates of PPI discontinuation were 51.1% (n = 92/180), resulting into 30.0% inappropriate chronic PPI use from the baseline rates of 80% within 1 year. Process measures: The total percentage of patients on long term PPI use who had an EGD was recorded as 51.1% which improved from the baseline of < 30%. The EGD completion rates in eligible patients was 43.6% from baseline of < 20%.

CONCLUSION:

We exceeded the goal, achieved >50% reduction in inappropriate use of chronic PPI use within 1 year. Lack of automated medical decision support tool was identified as the biggest barrier. Optimization of EHR and education to QI team members were crucial for the success of this QI. Future directions include enhancing patient engagement and spread to other clinics.
423 Blown out Myotomy (BOM), a Complication Following Laparoscopic Heller Myotomy and Per-Oral Endoscopic Myotomy
Authors: Krause Amanda J. , Triggs Joseph R. , Carlson Dustin A. , Campagana Ryan A. , Jain Anand , Kahrilas Peter J. , Hungness Eric , Pandolfino John E.
Published: October 2019

INTRODUCTION:

Achalasia results from a failure of lower esophageal sphincter relaxation and an absence of normal peristalsis. Achalasia is diagnosed by High-Resolution Manometry (HRM) and can be treated with Laparoscopic Heller Myotomy (LHM) or Per-oral Endoscopic Myotomy (POEM). LHM and POEM are highly effective with more than 90% clinical efficacy reported in the literature. Although success rates are encouraging, patients may experience complications and recurrent symptoms. We identified patients, status post LHM or POEM, who had a BOM, a pseudodiverticulum at the prior myotomy site, on follow-up. Our aim was to assess what factors are associated with a BOM and how this affects patient reported outcomes.

METHODS:

We retrospectively identified patients from the Northwestern Esophageal Center Achalasia Natural History Study undergoing HRM between 1/2015 and 10/2017, following LHM or POEM, as therapy for achalasia. Patients must have also had a post-treatment esophagram within 1 year of HRM. A BOM was defined radiographically as a wide-mouthed outpouching (>50% increase in esophageal diameter) in the area of the prior myotomy (Image).

RESULTS:

129 consecutive patients were identified; demographics are in Table 1. A BOM was identified in 17.8% of patients. Comparing patients with a BOM to those without, initial achalasia subtypes were overall different (P = 0.004), type III achalasia specifically was more common (39.1% vs. 14.2%, P = 0.014), and LHM was more common than POEM (73.9% vs. 26.1%, P = 0.013), respectively (Table). Anterior vs. posterior approach for POEM and wrap type (Nissen, Dor, Toupet), when LHM was performed, were not predictors of BOM occurrence. Multiple treatments (prior LHM, POEM or pneumatic dilation) was not associated with an increased risk of BOM formation. The Integrated Relaxation Pressure (IRP) was significantly higher in patients with BOM compared to those without (15.0 mmHg vs. 11.0 mmHg, P = 0.025). Eckardt Scores (ES) were significantly higher, both statistically and clinically, in patients with BOM (5 vs. 2, P = 0.002).

CONCLUSION:

Our analysis suggests that an esophageal myotomy to treat spastic achalasia, treatment with LHM, and a higher post-treatment IRP are more common in patients with a BOM. These findings suggest that increased wall strain, whether it be from residual spastic contractility, continued outflow obstruction from fundoplication, or an incomplete myotomy, may be the underlying mechanism of failure.
424 POEM Training and Skills Evaluation Tool: A Pilot Study
Authors: Schlachterman Alexander , Alajlan Bader , Machicadorivero Jorge , Turkeltaub Joshua , Wagh Mihir S.
Published: October 2019

INTRODUCTION:

Hands-on training for Per-Oral Endoscopic Myotomy (POEM) in the United States is limited and without a structured curriculum and assessment tool. Training to competency in POEM is critical and POEM trainees must acquire multiple cognitive and technical skills to achieve proficiency.

METHODS/METHODS AND AIM:

The aim of this study was to develop a POEM training and skills evaluation tool. This pilot study was performed at a tertiary academic medical center in the US from 5/2018 – 11/2018. The training protocol included initial swine explant models followed by live human cases, proctored by a single endoscopist experienced in POEM who graded trainees for each task on a 5-point scale (1 = trainer had to take over, 2 = trainer provided technical assistance, 3 =trainer provided substantial verbal guidance, 4 =trainer provided minimal verbal guidance, and 5 =trainee performed completely independently). Three trainees were prospectively graded on specific cognitive (identification of GE junction, incision site selection, identification of esophageal wall layers, recognition of planes during tunneling, identifying structures at GEJ and cardia in the tunnel, and identification of circular and longitudinal muscles) and technical skills (entry into the submucosal space, submucosal tunneling, myotomy and hemostasis) essential for successful POEM completion. Competency was considered at skill level ≥ 4 for each skill.

RESULTS:

Three trainees (interventional endoscopy fellows) completed a total of 18 cases (8 cases on animal explant models and 10 human cases) and were evaluated by one expert supervisor. Cognitive skills were acquired early in training with trainee scores of ≥ 4 by the 3rd swine explant case and 3rd human case. Technical skills required more cases and direction. Level ≥ 4 in technical skills was achieved by the 8th human case. Entry of the endoscope into the submucosal space was the most difficult step. No adverse events occurred in the human cases.

CONCLUSION:

This pilot study introduces a POEM training and skills evaluation tool for training to competency. Submucosal entry, tunneling and myotomy were the most challenging to learn while cognitive skills were learned early in training. The main limitations of this study include single site study with small number of trainees and procedures, and a single instructor. Evaluation of POEM procedures performed by more trainees at multiple sites will be necessary to further validate the utility of this tool.
427 Admission Trends for Food Impaction and Foreign Body Associated With Eosinophilic Esophagitis
Authors: Senatore Frank , Bhurwal Abhishek , Brant Steven
Published: October 2019

INTRODUCTION:

The prevalence of eosinophilic esophagitis (EoE) is estimated to be 0.5-1 in 1000 and is increasing across the United States. New cases of EoE are being diagnosed, in part due to increased awareness of the disease. Recent epidemiological studies have demonstrated that the natural course of EoE is a progressive transformation from an inflammatory to a complicated fibrostenotic disease. Increased prevalence has driven sentiment for an evidence-based management algorithm for EoE. We identified trends in hospital admissions for complicated EoE demonstrated by food impactions/foreign bodies (FI/FB) and highlight gaps in the current management.

METHODS:

This is a retrospective cohort study using the 2011-2014 Nationwide Inpatient Sample (NIS) utilizing International Classification of Diseases, 9th Revision. Study included all patients above age 18 with principal or secondary discharge diagnoses of FI/FB. Primary outcomes were trends of the FI/FB cohort with associated diagnoses of EoE. Secondary outcomes included length of stay (LOS). Proportions were compared using fisher’s exact test and continuous variables using student t-test. Multivariable and Poisson regression was performed for LOS and hospitalization charges.

RESULTS:

From 2011 to 2014, the number of FI/FB admissions analyzed were 11,041, 10,730, 10,460, and 9,925, respectively. EoE was a principle diagnosis in 73.2%, 86.4%, 86.8% and 92.6% of these admissions, respectively. The average LOS for FI/FB admissions for patients without EoE (no EoE FI/FB) was 4.11 days; average LOS for FI/FB admissions for patients with EoE (EoE FI/FB) was 0.95 days (P < 0.001). Mean age of EoE FI/FB was 30.23 years vs 55.32 years in no EoE FI/FB (P < 0.001). 90.02% of EoE FI/FB were Caucasian, 3.66% African American and 4.48% Hispanic, compared to 71.78% Caucasian, 11.47% African American, and 11.08% Hispanic in no EoE FI/FB. 3.33% of EoE FI/FB underwent EGD with biopsies compared to 0.64% of no EoE FI/FB (P = 0.0002). Cost of admission for EoE FI/FB was $16,606.80 vs $38,282.34 in no EoE FI/FB (P < 0.001).

CONCLUSION:

EoE is the most common underlying etiology in cases of food impaction. This study suggests that progressive, complicated EoE is also growing in incidence. Increased admissions rates, low LOS and low numbers of patients undergoing EGD with biopsies suggests that EoE is not being appropriately surveilled nor directly addressed with patients in terms of highlighting its long-term complications and importance of implementing a management strategy.
429 High Clinical Impact of Wide Area Transepithelial Sampling (WATS) Positive - Forceps Biopsy Negative Diagnoses of Barrett Esophagus and Associated Dysplasia: A Retrospective Cohort Study of 423 Patients
Authors: Kaul Vivek , Gross Seth , Corbett F. Scott , Infantolino Anthony , Tofani Christina
Published: October 2019

INTRODUCTION:

Wide Area Transepithelial Sampling with 3-Dimensional Computer-Assisted Analysis (WATS) when used adjunctively to forceps biopsies (FB) has been demonstrated in multiple prospective studies to significantly increase detection of Barrett’s esophagus (BE) and associated neoplasia in patients undergoing either BE screening or surveillance. The clinical impact of WATS positive-FB negative diagnoses has never been evaluated. The aim of this IRB-approved clinical utility study was to determine changes in patient management when BE and/or dysplasia was detected by WATS but not by FB.

METHODS:

Between 2013-2018, we identified 423 consecutive patients from WATS clinical registries who had a WATS positive diagnosis of BE or dysplasia and a negative FB result; 317 patients were diagnosed with BE, 90 with low grade dysplasia (LGD) and 16 with high grade dysplasia (HGD) by WATS only. Physicians subsequently completed an extensive survey to determine if the positive WATS diagnosis resulted in a change in patient management such as enrolment in a surveillance program, endoscopic ablation/antireflux surgery, initiating proton pump inhibitors (PPIs) or increasing the patient’s dose of PPI.

RESULTS:

The clinical impact of WATS positive-FB negative diagnoses for patients with BE, LGD or HGD is summarized in Table 1. WATS had a direct impact on the clinical management of 97.8% of the 317 BE patients including enrolment in a surveillance program (96.2%), ablation/antireflux surgery (3.7%), or starting or increasing the dose of PPIs (60.2%). WATS impacted the management of 94.4% and 93.7% of LGD and HGD patients respectively. For instance, 30% and 50% respectively had ablation, 73.3% and 68.8% had increased frequency of or new enrollment in surveillance, and 56.7% and 62.5% had PPIs prescribed or the dose increased. Seven of 8 HGD patients not ablated were lost to follow up. One of 8 HGD patients not ablated developed invasive adenocarcinoma also identified with WATS upon follow-up endoscopy.

CONCLUSION:

The results of this study demonstrate that physicians have a high degree of confidence in WATS diagnoses even when the concurrent FB is negative. This is evidenced by the fact that physicians changed their patient management in 96.9% of all cases, often significantly with invasive treatments such as ablation, EMR, and even antireflux surgery in a small %age of patients. As an adjunct to FB, WATS has high clinical utility and adds value to the management of patients with BE and associated dysplasia.
430 Esophageal Food Bolus Impactions Are More Likely to Occur During the Weekends
Authors: Kroner Paul T. , Kesler Alex M. , Bilal Mohammad , Simons-Linares Roberto , Mönkemüller Klaus E.
Published: October 2019

INTRODUCTION:

Esophageal food impaction is a commonly encountered clinical scenario that may warrant emergent intervention, but epidemiological studies are lacking. No major studies have examined the inpatient prevalence of food impaction during the weekend. Therefore, the aim of our study is to assess the inpatient prevalence of food impaction during the weekend compared to week days.

METHODS:

Case-control study using the NIS 2016, the largest public inpatient database in the US. All patients with ICD10CM codes for food bolus impactions were included. None were excluded. The primary outcome was determining the odds of food bolus impaction during the weekend days as compared to the weekdays. Secondary outcomes included determining rates of esophageal perforation, hospital costs, charges and length of stay (LOS) when comparing admissions during a weekend to admissions during a weekday. Multivariate regression analyses were used to adjust for age, gender, Charlson Comorbidity Index, income in patient zip code, hospital region, location, size and teaching status.

RESULTS:

7,025 patients with food bolus impaction were identified. 2,475 underwent emergent EGD (within 24 hours) and 1,935 were admitted during the weekend. Mean patient age was 66.7 years (47.9% were female). Primary outcome: after adjusting for confounders, patients admitted for food impaction displayed significantly higher odds of admission during the weekend days (aOR:1.5, P < 0.01) when compared to the weekdays. No significant difference in esophageal perforation was observed between the two cohorts. Patients admitted during the weekend displayed lower hospitalization costs compared to patients admitted during the weekdays (aMean: -$1,756, P = 0.02), but no differences in hospitalization charges or length of stay were observed. All outcomes are displayed in Table 1.

CONCLUSION:

The odds of being admitted for esophageal food impaction are higher on weekends than weekdays. There are no different odds of esophageal perforation. This may be reflecting the previous studies demonstrating increased odds of food impaction during leisure times, as weekends in the US are often reserved for leisure activities rather than work. Interestingly, patients admitted during the weekend actually have lower adjusted mean hospital costs. This may suggest that these patients are likely admitted for observation or stay longer periods of time in the ED and hence do not generate the same hospital bill as an admission.
432 Post Procedural Pain Assessment in Patients Undergoing Balloon Cryotherapy Compared to Radiofrequency Ablation (RFA) for Barrett’s Esophagus: A Prospective Multi-Center Study
Authors: Khara Harshit S. , Trindade Arvind , Elias Puja S. , Smallfield George B. , Diehl David L.
Published: October 2019

INTRODUCTION:

The two most commonly used modalities for ablation of dysplastic Barrett’s Esophagus (BE) are radiofrequency ablation (RFA) and cryotherapy, wherein cryoballoon (CB) ablation has emerged as a highly effective new modality. A common side effect of ablation is pain, making it an important factor when discussing treatment options. It is speculated that CB causes less pain than RFA, as CB preserves the extracellular matrix while maintaining depth of ablation, but no head-to-head comparison trials exist to date.

METHODS:

We designed a multi-center, prospective cohort study with aims to compare pre- and post-procedural pain outcomes for CB versus RFA in ablation-naïve BE patients. IRB approval was obtained, and the study was registered on clinicaltrials.gov. Patient demographics; pre- and post-procedural pain scores and at 48 hrs, 1-week and 4 weeks using PQAS on a scale of 0-10; ablation procedure details; pain medication use; and any adverse events were collected in REDCap. Statistical analysis was performed with SAS 9.2 using the t test, chi-square test and the Fisher’s exact test.

RESULTS:

We enrolled 97 ablation-naïve dysplastic BE patients, of which 2 withdrew, leaving 95 for analysis (53 CB, 42 RFA). Baseline demographics and level of dysplasia were similar in both groups, with overall 79% males, and mean age 64.8 yrs. The number of patients using oral analgesics was similar between both groups, P = 0.459. Although there were more patients with pre-procedure pain in the CB group (8% vs 5%), the incidence of post procedure pain after RFA was significantly higher (79% vs 70%) compared to CB, and this difference persisted at 2 days (74% vs 60%), 1-week (59% vs 28%), and 4 weeks (14% vs 8%) post procedure, P = 0.0073 (Figure 1). The pattern of mean pain level was slightly different, with higher mean pain score pre- and post-procedure in the CB group (0.5 vs 0.2 and 3.6 vs 2.8) compared to RFA, but then reversed to be higher in the RFA group at 2 days (2.8 vs 2.2), 1-week (2.1 vs 0.9), and 4 weeks (0.6 vs 0.4), P = 0.0025 (Figure 2).

CONCLUSION:

Cryoballoon ablation is associated with significantly less post procedural pain when compared to RFA which appears to have a more protracted pain course and may have an impact on lifestyle resumption and follow up. Most patients have resolution of pain by 4 weeks irrespective of treatment modality. This first head-to-head study about post ablation pain between CB and RFA may help guide treatment discussions regarding post ablation expectations and recovery.
436 Peroral Endoscopic Myotomy Is a Safe and Effective Treatment Modality for Achalasia After Prior Failed Botulinum Toxin Treatment
Authors: Sanaka Madhusudhan R. , Parikh Malav P. , Tang Andrew , Chadalavada Pravallika , Khoudari George , Gupta Niyati M. , Thota Prashanthi N. , Gabbard Scott , Ray Monica , Wadhwa Neha , Murthy Sudish , Raja Siva
Published: October 2019

INTRODUCTION:

Peroral endoscopic myotomy (POEM) is shown to be effective in patients with recurrent symptoms after prior treatments such as Heller myotomy (HM) or pneumatic dilatation (PD) or Botulinum toxin (Botox) injection into lower esophageal sphincter (LES). However there is lack of a systemic study analyzing POEM in patients with prior Botox treatment alone and not confounded by other treatments. Previous Botox treatment leads to submucosal fibrosis making sub-mucosal dissection and separation of tissue planes more challenging during POEM. Hence, our study aims were to determine the safety and efficacy of POEM in achalasia patients who previously received exclusively Botox treatments.

METHODS:

Medical records of all achalasia patients who underwent POEM at our institution between April 2014 and May 2019 were reviewed. Patients who underwent timed barium esophagram (TBE) and high-resolution manometry (HREM) prior to POEM along with two-month post-POEM esophageal pH study, TBE and HREM were included. Patients were categorized into two groups as: no prior Botox (treatment naïve) and prior Botox group. Patients with prior HM or PD were excluded from both groups. Baseline patient characteristics, procedural details, TBE, HREM, pH study findings and Eckardt’s scores were compared between the two groups. Post-POEM Eckhardt’s score of ≤3 was considered as successful palliation of symptoms.

RESULTS:

From a total of 200 patients undergoing POEM, 103 patients met the study criteria (prior Botox = 35; treatment naïve = 68). Patients with no prior Botox injections were younger, had high LES integrated relaxation pressure (LES-IRP) on HREM, wider esophagus on TBE at 1 and 5 minutes. In terms of operative details and outcomes, the total myotomy length, operative time, complications, length of stay and 30-day readmission rates were similar for both groups (Table 1). POEM was successful in 96.9% and 93.8% patients in no Botox and prior Botox groups respectively. At two months post-POEM, similar improvements were noted in Eckhardt scores (Figure 1a), LES-IRP and height of barium columns at 1 and 5 minutes, however patients without prior Botox had greater improvement in TBE width at 1 and 5 minutes (Figure 1b,c). The rates of symptomatic GERD and abnormal esophageal pH study were also not significantly different between the two groups (Table 2).

CONCLUSION:

In achalasia patients with prior Botox injections, POEM is feasible and safe. Prior Botox treatment does not influence the efficacy of POEM.
437 Peroral Endoscopic Myotomy Is a Safe and Effective Treatment Modality for Geriatric Patients With Achalasia
Authors: Sanaka Madhusudhan R. , Parikh Malav P. , Tang Andrew , Chadalavada Pravallika , Khoudari George , Gupta Niyati M. , Thota Prashanthi N. , Gabbard Scott , Murthy Sudish , Raja Siva
Published: October 2019

INTRODUCTION:

Peroral endoscopic myotomy (POEM) is an emerging treatment modality for achalasia. It is a particularly appealing treatment option in older patients, as it is minimally invasive like an endoscopic procedure and highly effective as surgical myotomy. However, there is lack of a systematic study analyzing and comparing POEM outcomes in young (< 65 years) and geriatric patients (≥65 years). Hence, our study aims were to assess and compare the safety and efficacy of POEM in young versus geriatric patients.

METHODS:

Medical records of all achalasia patients who underwent POEM at our institution between April 2014 and May 2019 were reviewed. Patients who underwent timed barium esophagram (TBE) and high-resolution manometry (HREM) prior to POEM along with two-month post-POEM esophageal pH study, TBE and HREM were included. Patients were categorized into two groups as: young (<65 years) and old (≥65 years). Demographic and procedural details, TBE, HREM, pH study findings and Eckardt scores were compared between the two groups. Post-POEM Eckhardt score of ≤3 was considered as successful palliation of symptoms.

RESULTS:

148 patients met the study criteria (<65 years = 93; ≥65 years = 55). Younger patients were more likely to have higher BMI, but fewer comorbidities and lower TBE height at 1 minute but wider TBE width at 5 minutes. Rest of the TBE parameters, pre-operative Eckardt's score and lower esophageal sphincter-integrated relaxation pressure (LES-IRP) were similar between the two groups. Young patients were more likely to have undergone prior Heller myotomy, where as Botox injections were more common in older group. The operative time, total myotomy length, complications, length of stay and 30-day readmission rates were similar in the two groups (Table 1). POEM was successful in 94.5% young and 96% old patients. At two-month follow up, both groups showed significant improvements in Eckhardt scores (Figure 1a) and HREM parameters, however older patients showed greater improvement in TBE height at 1 and 5 minutes (Figure 1b,c). The rates of symptomatic GERD and abnormal esophageal pH study findings were not significantly different between the two groups (Table 2).

CONCLUSION:

POEM is a safe and effective treatment option for geriatric patients with achalasia similar to younger patients. POEM might emerge as the preferred approach for myotomy in this patient population, because of its low morbidity compared to surgical myotomy.
440 Long-Term Outcomes of POEM in Achalasia With a Minimum Follow-Up of 3, 4, and 5 Years: A Meta-Analysis
Authors: Barakat Mohamed , Aloreidi Khalil , Aamar Ali , Tsipotis Evangelos , Quintero Eduardo , Abdelfatah Mohamed Magdy
Published: October 2019

INTRODUCTION:

Per-oral endoscopic myotomy (POEM) has promising safety and efficacy outcomes in short-term studies. However, long-term follow-up data are limited. The aims of this study was to review and analyze the clinical outcomes and failure rates of of studies that reported a minimum post-POEM follow-up of 3, 4 and 5 years.

METHODS:

A systematic review of POEM performed for the treatment of achalasia was performed. We searched major medical databases (Pubmed, Medline, Ovid, Cochrane and EBSCO databases) from inception till May 2019. Major conference abstracts and presentations were searched. Statistical analysis was performed using Med Calc Software (Ostend, Belgium). Clinical success was defined as Eckardt score ≤3 and failure was defined as Eckardt score >3 on follow up.

RESULTS:

A total of 8 retrospective and prospective studies fulfilled inclusion criteria (Table 1). The studies originated from China, Czech Republic, Japan and USA. The total number of patients included in this study was 671. Eight studies (671 patients) with follow up data post-POEM of a minimum of 3 years were included in the 3 year analysis. Four studies (407 patients) with 4 year follow up data post-POEM were included in the 4 year analysis. Three studies (97 patients) with 5 year follow up data post-POEM were included in the 5 year analysis. There was no heterogeneity between studies. The overall clinical success rate at the 3, 4 and 5 year follow up was 88% (95% CI 85-91%), 87% (95% CI 83-90%), 84% (95% CI 76-90%) respectively (Figure 1). The overall failure rates at 3, 4 and 5 year follow up were 11.7% (95% CI 9-15%), 13% (95% CI 10-17%) and 16% (95% CI 10-24%) respectively. There was no significant difference in clinical success or failure rates.

CONCLUSION:

Our study demonstrates that POEM is effective and safe for treating achalasia during the long term follow up to 5 years. Randomized controlled trials are needed to validate these findings.
442 Strength of Peristalsis and Its Association With Bolus Clearance in Esophageal Motility Disorders
Authors: Al-Jashaami Layth , Alani Mustafa , Kannadath Bijun Sai , Ahmed Shifat , Mann Sarabdeep , Guha Sushovan , Mills Michael , Ratuapli Shiva
Published: October 2019

INTRODUCTION:

High resolution manometry (HRM) is a valuable tool increasingly used in clinical practice for diagnosis of esophageal disorders. Impedance measurement was recently added to the manometry catheter to assess bolus clearance. However, clinical utility of this metric and its association with esophageal motility disorders are currently unknown. The aims of this study are to a) evaluate the association between strength of peristalsis and bolus clearance and b) compare the strength of peristalsis and bolus clearance between normal patients and patients with various esophageal motility disorders.

METHODS:

A retrospective review of patients referred for HRM at our tertiary academic center from January 2016 to October 2018 was performed. All studies were interpreted by two HRM-trained GI specialists and reported in accordance with the Chicago classification of esophageal motility disorders, version 3.0. Distal Contractile Integral (DCI) was used to measure strength of peristalsis. Bolus clearance was measured by visual assessment of color topography clearance of bolus in each swallow. Greater than 50% complete bolus clearance was considered as effective peristalsis. Demographic and manometry data were analyzed using STATA 15.1.

RESULTS:

1,323 consecutive studies were included in the analysis. The mean age was 59.6± 14.5 years. Of these 898 (67.9%) were women. Women were overall older with an average of 60.1 ± 0.5 years compared to men (58.5 ± 0.8 Years, P = 0.0332). The most commonly diagnosed motility disorder was ineffective esophageal motility (IEM) (284, 21.5%). There was moderate correlation between DCI and intrabolus pressure (r = 0.29, P < 0.001). Patients with normal esophageal motility had higher DCI (1875.9 vs 551.8, P < 0.0001) and complete bolus clearance (85.8% vs 56.8%, P < 0.0001) compared to patients with IEM. In contrast, patients with spastic motility disorders (Achalasia and Esophagogastric Junction Outflow Obstruction) had lower bolus clearance (43.2% vs 85.2%, P < 0.0001) despite higher DCI than normal patients (4661 vs 1875, P < 0.0001). ROC analysis showed that a DCI of 320 mmHgcm2 had greater accuracy in predicting complete clearance of bolus in >50% of swallows (96.5% sensitivity, 24.8% specificity) compared to 450 mmHgcm2 (accuracy 83.1% vs 79.3%, P < 0.0001).

CONCLUSION:

In our large cohort of patients, HRM peristaltic metrics suggest that a DCI cut-off value of 320 mmHgcm2 had greater accuracy for predicting complete bolus clearance.