bluuebunny/crossref_metadata_2025 huggingface dataset:
A81 POST COLONOSCOPY COLORECTAL CANCERS IN MANITOBA: A POPULATION-BASED ANALYSIS
Authors: Singh H , Derksen S , Sirski M , McCulloch S , Lix L M
Published: February 2020

Background

Recent consensus guidelines from the World Endoscopy Organization (WEO) recommend all jurisdictions report unadjusted rates of post colonoscopy (PC) colorectal cancers (CRC). Until recently, prior reports have mostly focused on PC-CRC in the CRC screening age groups.

Aims

We evaluated the rate and predictors of PC-CRC in the adult population for the province of Manitoba from 1990 to 2016.

Methods

Individuals 18+ years at CRC diagnosis were identified from the Manitoba Cancer Registry. Colonoscopies in the 3 years preceding CRC diagnosis were identified via linkage to Manitoba Health (MH) physicians billing claims. CRCs were classified, based on WEO recommendations, as: (1) detected CRC (colonoscopy up to 6 months before CRC diagnosis) and (2) PC-CRC-3y (colonoscopy 6–36 months before CRC diagnosis). Generalized linear models with generalized estimating equations (to adjust for clustering within endoscopy physicians) were used to test for differences in rates over 3-time intervals (1990/91 – 1999/00; 2000/01 - 2009/10; 2010/11 – Dec 31 2016), provincial region of performance of colonoscopy and identify other associations from the MH data.

Results

Overall, 10.5% of the 16,639 CRCs diagnosed in the study period and with colonoscopy in the preceding 3 years were PC-CRC-3y. CRCs diagnosed between April 2000 and March 2010 were more likely to be PC-CRC-3y than those diagnosed between April 2010 and December 2016 (odds ratio [OR] 1.18; 95% confidence interval [CI]: 1.03–1.37). Female sex (OR for male: 0.86; 95% CI: 0.77–0.94), IBD diagnosis (OR 3.04; 95% CI: 2.56–4.52), prior CRC (OR 5.41; 95% CI: 4.61–6.34), prior colonoscopy (OR 2.10; 95% CI 1.88–2.36), diverticulosis (OR 2.39; 95% CI: 2.16–2.6), colonoscopy by GP (OR: 1.62; 95% CI 1.16–2.26 vs. surgeons) were associated with increased odds of PC-CRC-3y. There were no regional differences, and no effect of colonoscopy volume or age greater than 75 (or lower than 50).

Conclusions

In Manitoba, the PC-CRC-3y rate decreased slightly in recent years. The study results of large number of PC-CRC-3y along with only a slight decrease in rates over the years, support calls for root cause analysis to evaluate individual cases of PC-CRC. An initial focus could be the groups with increased risk of PC-CRC.

Funding Agencies

Manitoba Health
A87 A NEW ERA: CIRCUMFERENTIAL ENDOSCOPIC SUBMUCOSAL DISSECTION FOR EARLY ESOPHAGEAL NEOPLASM AND BARRET’S ERADICATION
Authors: Markandey B , Robert B
Published: February 2020

Background

Endoscopic submucosal dissection (ESD) has become increasingly important over the last few years as the treatment of choice for early gastrointestinal malignancies. Esophageal adenocarcinoma is among the most rapidly rising malignancies associated with a poor 5-year survival rate. ESD is emerging as a novel minimally invasive treatment for superficial esophageal neoplasms. However, with increasing circumference of dissection, the rate of stricture increases with over 90% stricture rate reported with complete circumferential ESD (cESD). Currently, for superficial Barrett’s neoplasms the dysplastic lesion is resected and subsequent eradication of remaining Barrett’s is with radiofrequency ablation over multiple sessions.

Aims

To report on a case of cESD for intramucosal carcinoma and Barrett’s eradication with one procedure with the application of prophylactic dual steroid treatment (DST) for prevention of stricture.

Methods

We present the case of a 62-year-old female with C1M5 Barrett’s esophagus with pathology confirming high grade dysplasia with a focus suspicious for intramucosal adenocarcinoma. Staging CT excluded metastatic disease. Repeat endoscopy with magnification revealed multiple areas with highly irregular vascular and surface patterns with premature loss of acetowhitening reaction consistent with multifocal at least high-grade dysplasia. Subsequently, the entire segment of Barrett’s was removed via cESD. Histopathologic analysis of the resected tissue confirmed multifocal high grade disease with margins negative for dysplasia or intestinal metaplasia. The patient was started on DST with oral prednisone and topical (swallowed) budesonide along with sucralfate as prophylactic measures to prevent luminal stricturing.

Results

During the re-epithelization period the patient required 2 prophylactic dilations. Five months post-ESD, full clinical, endoscopic and histopathologic healing had been observed. There was complete squamous re-epithelization with normal squamous mucosa without stricture. The patient remains on a yearly endoscopic surveillance protocol.

Conclusions

cESD represents a novel therapeutic strategy for the definitive histologic and endoscopic eradication of superficial esophageal neoplasms along with remaining Barrett’s. In this patient, there were no complications and significant stricturing was prevented with DST. Multiple prior studies have assessed single steroid therapy as a therapeutic option for strictures. In this report, DST represents a novel regime in preventing severe strictures post cESD. Longer term follow-up and further reports are needed to confirm these findings.

Funding Agencies

None
A100 ORAL VANCOMYCIN THERAPY FOR CLOSTRIDIOIDES DIFFICILE INFECTION AND RISK OF INFECTION WITH GRAM-NEGATIVE ORGANISMS
Authors: Someili A , Alosail A , Brooks A , Irfan N , Leto D , Hadzic A , Alajmi A , Mertz D , Bader M
Published: February 2020

Background

Vancomycin is the recommended first-line therapy for mild to severe Clostridioides difficile infection (CDI). However, oral vancomycin is associated with disruption of the indigenous microbiota, predisposing patients to overgrowth of endogenous pathogens such as vancomycin-resistant enterococci.

Aims

The primary objective of the study is to examine the effect of the treatment regimens of CDI on the risk of infection with gram-negative organisms in adult patients treated for CDI.

Methods

A retrospective cohort study of 319 adult patients treated for CDI at Hamilton Health Sciences in the year 2015. A multivariate logistic regression analysis was performed to determine if oral vancomycin-based therapy is associated with an increased risk of infection with gram-negative organisms after adjustment for other factors.

Results

Eighty-one patients were excluded because of recurrent episodes of CDI within the same year or missing information. 238 patients were included in the final analysis. 48 (20.2%) patients had positive culture for gram-negative organisms after onset of CDI. Urine was the most common source for gram-negative organisms (39/48, 81.3%) followed by blood (8/48,16.7%). The most common isolated gram-negative organisms were Escherichia coli (18/48, 37.5%) and Klebsiella pneumonia (9/48, 18.8%).

The most common CDI treatment regimens were metronidazole monotherapy (137/238, 57.6%), vancomycin monotherapy (13/238, 5.5%), and combination therapy (88/238, 37.0%). Among patients who were treated with metronidazole monotherapy, vancomycin monotherapy, and combination therapy, 30(30/137, 21.9%), 3 (3/13,23.1%), and 15 (15/88, 17.1%) had positive culture for gram-negative organisms, respectively (P= 0.6).

Ninety-seven (97/238,40.8%) patients had severe CDI, 40 (40/97, 41.2%) were treated with metronidazole monotherapy, 5(5/97, 5.2%) with vancomycin monotherapy, and 52 (52/97, 53.6%) with combination therapy. 26 (26/141,18.4%) and 22 (22/97, 22.7%) had positive culture for gram-negative organisms among patients with non-severe and severe CDI, receptively (P= 0.7). In the multivariate analysis, neither type of CDI treatment regimen (P=0.2, 95% CI 0.30–1.31) nor CDI severity (P=0.4, 95% CI 0.67–2.69) was associated an increased risk of infection with gram-negative organisms after CDI onset.

Conclusions

Contrary to the reported literature, we did not find that oral vancomycin-based CDI treatment was associated with increased risk of infection with gram-negative organisms.

Funding Agencies

None
A105 ENDOSCOPIC MUCOSAL RESECTION (EMR) OF LARGE SESSILE POLYPS: DATA FROM A MULTI-CENTER HEALTH ZONE
Authors: Meng Z , Lee A , Liu E Y , Dhillon A S , Wong C , Sultanian R , Zepeda-Gomez S , van Zanten S , Kohansal A R
Published: February 2020

Background

EMR is the standard of care for management of large non-invasive colonic polyps. Current guidelines recommend repeat colonoscopy within 6 months after EMR of large sessile polyps to assess the EMR site for residual adenoma. We reviewed the outcomes and compliance to these guidelines in patients at the University of Alberta Hospital (UAH) and surrounding 7 hospitals.

Aims

The primary outcome was the proportion of patients who received a follow up colonoscopy within 180 days.

Methods

Retrospective data was collected on consecutive patients who had a large polyp resection (size >2cm as documented per endoscopy report) from January 1st, 2014 to January 1st, 2016. Information was collected on patients from UAH as well as seven surrounding hospitals within the Edmonton geographic zone. Data was extracted from electronic health records.

Results

Of 258 patients identified patients, 250 had complete data. Of these 250 patients, 151 (60.4 %) were male and median age was 67 (IQR 60 - 72). Eighty-two cases (32.8%) were performed at UAH, with 168 cases (67.2%) at other hospitals. Polyps were removed by gastroenterologists (n=215, 86.0%), surgeons (n=26, 10.4%), and others (n=9, 3.6%).

Fifty-two patients (20.8%) had no formal follow up on electronic health records, while 198 patients (79.2%) had a repeat colonoscopy. 57 patients (29.1 %) had a repeat colonoscopy within 180 days. The median follow-up time was 224 days (IQR 172–365).

Of the 82 cases performed at UAH, 74 (90.2%) had follow up. Out of the 168 cases at the other hospitals, 124 (73.8%) had follow up (p<0.01). Sixteen (21.9%) and 41 (33.3%) cases were followed up within 180days at UAH and other hospitals, respectively (p=0.09).

Of the 74 cases with follow up at UAH, 12 (15.7%) had residual tissue confirmed by pathology. Of the 124 cases at other hospitals, 26 (21.0%) had follow up (p=0.41). Median polyp size was 2.5cm (IQR 2.0cm - 3.5cm)

Conclusions

Only 29.1% of patients with large sessile polyp removal in the Edmonton zone had a repeat colonoscopy within 180 days. Patients with large polypectomy performed at the academic hospital were more likely to be followed up compared to non-academic hospitals. Further validation studies with larger data sets are needed. These findings highlight the need for standardized pathways to appropriately manage and survey large polyps post-EMR.

Funding Agencies

None
A111 SEVERE FAT MALABSORPTION IN A PATIENT POST ILEAL POUCH ANAL ANASTAMOSIS: A RARE PRESENTATION OF MICROSCOPIC ENTERITIS
Authors: Ricci M , Ropeleski M
Published: February 2020

Background

Microscopic enteritis (ME) is a rare enteropathy characterized by malabsorptive diarrhea and lymphocytic infiltration +/- collagen deposition in the subepithelial layer of the small bowel. Its etiology is unclear.

Aims

To elucidate a rare cause of fat malabsorption and vitamin deficiency in a patient with ulcerative colitis and an ileoanal pouch.

Methods

A 74 yo male with a prior IPAA was referred to Internal Medicine in August 2018 for a 36 kg weight loss over 18 months and >16 bowel movements (BM) per day (baseline 6, no history of pouchitis). Celiac serology and infectious workup were negative. Medical management and nutritional supplements did not result in weight gain or improvement of diarrhea. He was admitted in June 2019 with ongoing weight loss, AKI, and signs of fat-soluble vitamin deficiency. A 72-hour fecal fat analysis showed an average fecal weight of 2100 g/d (ref <250 g/d), and excretion of 70% of daily fat intake (ref <7%). His fecal elastase (FE) was 147 µg/g, consistent with moderate pancreatic insufficiency (PI) with mild atrophy on CT. EGD and pouch endoscopy were macroscopically normal, with histological findings of intraepithelial lymphocytosis and mild villous blunting in the duodenum and afferent limb. CT enterography excluded small bowel abnormalities. He was started on pancreatic enzyme replacement and discharged. He returned with worsening diarrhea and AKI. He was treated with supportive care and sent home. In the ensuing 3 weeks, he had up to 24 BM per day and 4 kg of weight loss. He returned in August 2019 with AKI, lack of PO intake and worsened nutritional status. Re-examination of duodenal biopsies from June 2019 revealed an added finding of focal subepithelial collagen thickening. Budesonide was started.

Results

On budesonide, his symptoms improved within days. BMs decreased to baseline, and his ability to sustain PO intake improved. At his 4-week follow-up visit, BMs were stable with a 6 kg weight gain and no ensuing laboratory abnormalities.

Conclusions

ME is a rare enteropathy that presents with malabsorption. Fat-soluble vitamin deficiencies can develop with widespread physiological disruption of the mucosal surface. This patient was a diagnostic challenge. His steatorrhea and reduced FE levels led clinicians down a diagnostic pathway of PI. FE is the most common test used in the diagnosis of PI. Levels <200 µg/g are abnormal. Specificity is highest in chronic pancreatitis; however, this decreases in the presence of mucosal atrophy (i.e. IBD and diffuse small bowel disease). Thus, FE could not delineate the cause of steatorrhea in our patient. We can surmise that he likely has diffuse disease that was underestimated on duodenal biopsy. This is supported by his response to budesonide. This case highlights the heterogeneity of clinical presentations of ME. Awareness can reduce patient morbidity.

Funding Agencies

None
A113 COST SAVINGS OF SEROLOGIC VERSUS BIOPSY PROVEN DIAGNOSIS OF PEDIATRIC CELIAC DISEASE
Authors: Wiepjes M , Huynh H Q , Wu J , Chen M , Shirton L , Zarrabi M , Turner J
Published: February 2020

Background

Celiac disease (CD) affects approximately one percent of the population in Canada and the United States. At present, endoscopic diagnosis (ED) of CD remains the gold standard in North America, despite mounting evidence and validated European guidelines for serologic diagnosis (SD). Within publicly funded healthcare systems there is pressure to ensure optimal resource utilization and cost efficiency, including for endoscopic services. At Stollery Children’s Hospital, Edmonton, Canada, we have adopted serologic diagnosis as routine practice since 2016.

Aims

The aim of this study is to estimate cost savings, i.e. hard dollar savings and capacity improvements, to the health care system as well as impacts on families in regard to reduced work days lost and missing child school days for SD versus ED. Initial cost saving data is presented.

Methods

Micro-costing methods were used to determine health care resource use in patients undergoing ED or SD from 2017–2018. SD testing included anti-tissue glutaminase antibody (aTTG) ≥200IU/mL (on two occasions), human leukocyte antigen (HLA) DQA5/DQ2, blood sampling, transport and laboratory costs. ED diagnosis included gastroenterologist, anesthetist, OR equipment, staff, overhead and histopathology. Cost of each unit of resource was obtained from the schedule of medical benefits (Alberta) and reported average ambulatory cost for day hospital endoscopy for Stollery Children’s Hospital determined in 2016; reported in CAN$.

Results

Between March 2017-December 2018, 473 patients were referred for diagnosis of CD; 233 had ED and 127 SD. Estimated cost for ED was $1240 per patient; for SD was $85 per patient (6.8% of ED cost). Based on 127 patients not requiring endoscopy and a cost saving of $1155 per patient there was a total cost savings of $146,685 over 22 months.

Conclusions

A SD approach presents a significant cost savings to the public health care system. It also frees up valuable endoscopic resources, and limits exposure of children to the immediate and long-term risks associated with anesthesia and biopsy. SD also decreases time to diagnosis and the cost of the process to families (lost days of school/work, travel costs etc.). Our costing data can be used in combination with mounting evidence on the test performance of SD versus ED to determine cost-effectiveness of serological diagnosis for pediatric CD. Given the potential for cost saving and more efficient operating room utilization, SD for pediatric CD warrants further investigation in North America.

Funding Agencies

None
A127 THE ROLE OF ENDOGENOUS OPIOIDS IN MITIGATING OPIOID TOLERANCE IN A PRE-CLINICAL MODEL OF IBD
Authors: Lopez Lopez C D , Jaramillo Polanco J O , Yu Y , Reed D E , Lomax A E , Vanner S
Published: February 2020

Background

While opioid drugs are used to treat pain in IBD patients, escalating doses can induce tolerance and paradoxical increased pain signaling. Endogenous opioids are released by immune cells during chronic colitis and have an analgesic action but it is unknown whether they can mitigate the development of tolerance to opioid drugs in IBD.

Aims

To evaluate whether endogenous opioids released during chronic inflammation prevent the development of tolerance and/or increased pain signaling following chronic morphine treatment.

Methods

Three groups of C57BL/6 mice were studied: 1) control, 2) chronic colitis induced with 3 cycles of 2% DSS (cDSS mice) and 3) chronic DSS mice injected with escalating doses of morphine on the last 7 days of DSS (10, 20, 30 mg/kg for the first 3 days, then 40mg/kg on 4 to 7 day) (cDSS-morphine mice). Ex vivo afferent nerve recordings were obtained from flat-sheet distal colon preparations (day 31) to determine their mechanosensitivity by probing with a 1g von Frey hair before and after acute morphine (1μM, 10 min perfusion). In parallel experiments, supernatants were obtained from the proximal colon and incubated overnight with isolated dorsal root ganglia (DRG) neurons from control mice. Neuronal excitability was then examined by measuring the rheobase using perforated patch clamp.

Results

In afferent nerve recordings, acute application of 1μM morphine inhibited the colonic afferent response to probing in control mice (17.86 vs 12.31 Hz; p<0.05), whereas no effect of morphine was seen in cDSS mice. In cDSS-morphine mice acute morphine perfusion paradoxically increased the mean afferent response to probing (13.99 vs 17.28 Hz, p<0.05). Single units were analyzed to identify how many mechanosensitive responses were increased, decreased or not affected by acute morphine perfusion. Compared to control mice, cDSS mice exhibited increased numbers of unaffected units (6/18 vs 1/14) whereas cDSS-morphine mice had decreased number of inhibited units (1/17 vs 11/14) and increased number of excited units (8/17 vs. 2/14) (Figure 1). In patch clamp recordings, colonic supernatants from cDSS mice reduced the excitability of DRG neurons (rheobase increased 28%; p<0.05), however, this effect was lost in neurons incubated with cDSS-morphine supernatants.

Conclusions

Endogenous opioids released during cDSS colitis do not mitigate tolerance to chronic morphine exposure and may diminish the response to acute morphine. Moreover, the paradoxical hyperexcitable response to acute morphine induced by chronic morphine was not blocked by endogenous opioids. Our patch clamp data suggest that endogenous opioid actions are lost following chronic morphine exposure and could result from inhibition of their release from immune cells.

Funding Agencies

CCC
A138 CONCEPTUALIZING ENTRUSTMENT IN ENDOSCOPIC TRAINING
Authors: Jeyalingam T , Brydges R , Ginsburg S , McCreath G , Walsh C M
Published: February 2020

Background

Competency-based medical education (CBME), an educational paradigm that prioritizes development of measurable skills over time in training, is currently being instituted across North American residency training programs. A fundamental goal of CBME is entrustment – the process whereby supervisors come to trust trainees to perform specific tasks without supervision. How entrustment decisions are made with respect to endoscopic training has not been elucidated.

Aims

We aimed to: (1) identify the factors trainers consider in making endoscopic entrustment decisions and (2) characterize this entrustment decision-making process.

Methods

A qualitative, interview-based study was conducted using a constructivist grounded theory approach. A purposive sample of endoscopic trainers from across North America were recruited with representation from adult and pediatric gastroenterology, general surgery, and family medicine. Consenting trainers undertook audio-recorded, semi-structured interviews designed to elicit how they make endoscopic entrustment decisions and the factors they consider in making these decisions. Interview transcripts were analyzed using constant comparison, and themes were identified iteratively, working toward an explanatory framework that highlighted relationships among themes. Recruitment continued alongside analysis until theoretical saturation, determined as the point at which no new insights arose from the data.

Results

Twenty-three trainer interviews were conducted, comprising 8 (34.8%) with adult gastroenterologists, 7 (30.4%) with general surgeons, 6 (26.1%) with pediatric gastroenterologists, and 2 (8.7%) with family physicians. Of those interviewed, 10 (43.5%) practiced in Canada and 13 (56.5%) practiced in the United States. Interviewees conceptualized entrustment as a continuum rather than a binary (yes/no) decision. Entrustment decision-making was found to be a complex process, involving factors related to the: (1) trainee (insight into their own abilities, technical skills, nontechnical skills); (2) trainer (perceived self-competence, disposition, prioritization of trainee learning relative to competing demands); (3) trainer-trainee relationship (duration of exposure); (4) patient (acuity, comorbidity, comfort); (5) procedure (complexity); and (6) environment (time constraints, equipment, presence of anesthesiologist). These factors directly and indirectly contributed to the themes of trainee readiness, trainer comfort, and patient safety, which collectively predicted endoscopic entrustment decisions.

Conclusions

Entrustment in endoscopic training is a complex process incorporating multiple factors. Clarification of this process and identification of predictive factors informs the development of endoscopic assessment tools and curricula uniquely suited to CBME.

Funding Agencies

CAG
A145 A SUBMUCOSAL FLUID CUSHION PREVENTS MUSCLE LAYER DAMAGE DURING ARGON PLASMA COAGULATION
Authors: Belletrutti P J , Maselli R , Stabler T , Enderle M D , Repici A
Published: February 2020

Background

Thermal damage to the muscle layer of the gastrointestinal wall can occur during mucosal application of argon plasma coagulation (APC). This injury may be mitigated by creating a fluid cushion within the submucosal layer that physically separates the mucosa from the muscle layer and suppresses unwanted tissue temperature elevation. This in turn protects the muscle layer from thermal damage. The coagulative threshold of muscle proteins is known to be about 60°C, but there are no published systematic assessments of the minimum injection volume needed nor the ideal injectate to prevent thermal damage to the muscle layer during mucosal APC ablation.

Aims

Our aims were, firstly, to measure the final temperature inside the fluid cushion after mucosal ablation with APC and then to determine any differences in the final temperature between various injectable solutions. Secondly, we sought to determine the minimum volume of injectate required to protect the muscle layer from thermal damage.

Methods

All experiments were performed in an ex-vivo porcine gastrointestinal tract model. Five different fluids (normal saline, Glyceol, Gelafundin, Voluven and Eleview) of different volumes (range 0 - 5mL) were injected into the submucosa of the esophagus, stomach (fundus) and rectum to create a fluid cushion. APC was applied to the mucosa for a fixed duration (3s) at different power settings (ranging from 30 - 120W). Immediately after APC treatment, the final temperature was measured by placing a contact thermometer inside the fluid cushion, just on top of the muscle layer.

Results

There was no significant difference in the temperature measured at the surface of the muscle layer between elevation with normal saline, Glyceol, Gelafundin, Voluven and Eleview at all 3 tissue locations at equal injection volumes and power settings. The experiments showed that the temperature rose for each injectate with heightened power settings but also decreased with increasing volume of injected fluid. The minimum amount of fluid needed to protect the muscle layer from thermal damage was 2mL for the esophagus, stomach and rectum in the case of a power setting between 30 to 90W and 3mL in the case of 90 to 120W.

Conclusions

Normal saline and four commercially available submucosal injectates possess similar thermoregulatory effects as an insulator of the muscle layer during APC treatment. As opposed to the choice of injectate or anatomic location treated, the volume of fluid injected is the main determinant of the final temperature at the level of the muscularis propria. To reduce the likelihood of thermal damage to deeper layers of the GI tract when APC is applied, a minimum injection volume of 2mL is recommended if <90W of power is utilized.

Funding Agencies

None
A152 FOREIGN BODY INGESTIONS AT A TERTIARY CARE CENTRE - A QUALITY ASSURANCE STUDY
Authors: Mullen T , Williams G
Published: February 2020

Background

Foreign body ingestion and esophageal food bolus impaction are common emergencies encountered by gastroenterologists. If not treated in a timely fashion these can result in significant morbidity, or even mortality. The mainstay of diagnosis and therapy is endoscopy. Guidelines regarding timing of endoscopy have been published by both the American and European Societies of Gastrointestinal Endoscopy, and both suggest emergent endoscopy, meaning within 2 to 6 hours, for complete esophageal obstructions. There is relatively sparse data regarding the endoscopic techniques used in real world practice.

Aims

This is a quality assurance study looking at the endoscopic practices at an adult tertiary care hospital in Halifax, Nova Scotia with respect to foreign body and food impaction management.

Methods

The hospital records of all patients presenting with ingested foreign bodies or esophageal food bolus impactions between May 2018 and July 2019 were included. Patients were identified by searching the call-back forms used by our department which documents all on-call endoscopy cases. This was then cross-referenced by endoscopy nursing charting which documents every endoscopy performed. Information such as demographics, obstruction type, endoscopic method of removal, complications, time between consultation and endoscopy, underlying pathology, and others were analyzed.

Results

70 cases were identified. Average patient age was 51.3 years old (range 16–96). 18 (25.7%) were female and 52 (74.3%) were male. 64 cases (91.4%) were esophageal food impactions and 6 (8.57%) were foreign body ingestions. Of the food impactions, 39 cases (60.9%) were cleared by the push/slide-by technique only and 10 (16.7%) were relieved using instruments such as snares, forceps, or nets. 15 (23.4%) passed spontaneously prior to scope, of which 7 received glucagon. An overtube was used in 1 case (0.16%). Complications occurred in 5 (7.8%) cases and included 3 mucosal tears, 2 of which required therapeutic interventions, and 2 episodes of oxygen desaturation in which the procedure was aborted. Complete obstructions occurred in 42 (65.6%) cases with average time of consultation to endoscopy of 2.4 hours. However, 3 (7.1%) cases exceeded 6 hours. The most common pathology was eosinophilic esophagitis with 20 cases (31.3%).

Ingested foreign bodies included 2 long objects, 3 sharp objects, and a cylindrical battery, and all but one were in the stomach. 5 (83.3%) cases used an overtube. No complications occurred.

Conclusions

At our institution 67/70 (95.7%) cases were performed within the timelines recommended by society guidelines. No complications occurred in the cases not performed within those time limits. An overtube was used in only one case in which a food bolus was retrieved out of the esophagus. Overall this study suggests that our centre is meeting recommended targets, however there is room for improvement.

Funding Agencies

None
A156 LOW COMPLICATION RATE IN THE OUTPATIENT INTRAJEJUNAL LEVODOPA/CARBIDOPA INTESTINAL GEL CLINICAL PROGRAM
Authors: Al Yatama N , Parker C H , Tse Y , Naranian T , Fasano A , Lang A , Liu L W
Published: February 2020

Background

Levodopa/carbidopa intestinal gel (LCIG) is a formulation that is delivered continuously through a percutaneous endoscopy gastro-jejunal tube (PEG-J) for the treatment of patients with advanced Parkinson’s disease (PD). LCIG significantly reduces periods of increased motor symptoms without troublesome dyskinesia. Adverse events related to this treatment have been attributed to PEG-J insertion and the device used for LCIG delivery, rather than to the LCIG preparation itself. To date, the data evaluating long-term efficacy and safety of PEG-J insertion for LCIG administration in the outpatient setting is limited.

Aims

The aim of this study is to describe short and long-term adverse events (AEs) associated with outpatient PEG-J tube insertion for LCIG administration at our centre.

Methods

A retrospective chart review was performed of all PD patients who underwent PEG-J insertion for LCIG therapy at Toronto Western Hospital from March 2011 to October 2019. All AEs associated with PEG-J insertion were collected including procedure and tube related complications, hospital admissions, emergency room (ER) visits and deaths. Data was analyzed using descriptive statistics.

Results

A total of 58 patients were identified and included in the final analysis. 37 (64%) male, with a mean age of 74 years +/-6.17. The mean duration of PD diagnosis prior to PEG-J insertion was 16.5 years +/-2.0. Mean time from PEG-J insertion to data collection was 37.5 months +/- 19.3. 30 (51%) patients had post-procedural abdominal pain or site pain. This pain improved with over the counter analgesics. 9 (16%) had possible site infection; 6 received oral antibiotics and 3 had the tube replaced. 19 (33%) developed granulation tissue, with only 2 patients requiring tube exchange. 32 (55%) had their tube removed or exchanged secondary to PEG-J malfunction. No ER visits related to the PEG-J were recorded. During the data collection period, 12 (21%) patients died for reasons unrelated to PEG-J insertion. There were no reported serious adverse events (SAEs), including post-procedure perforation, bleeding, fistula formation, development of intra-abdominal collections or buried bumper syndrome.

Conclusions

This study demonstrates the absence of serious AEs associated with outpatient PEG-J insertion for LCIG administration in patients with advanced PD. The most common short-term AE was post-procedural pain. The most common long-term AE was related to PEG-J malfunction requiring replacement. This study supports that the current method of outpatient PEG-J insertion for the administration of LCIG is safe in patients with advanced PD.

Funding Agencies

None
A158 LACK OF DIFFERENCE OF COLONIC CURVATURE IN SUPINE VERSUS PRONE PATIENT POSITIONS, IN NORMAL AND HIGH BMI INDIVIDUALS, AS ASSESSED BY QUANTITATIVE ASSESSMENT OF COMPUTED TOMOGRAPHY COLONOGRAPHY
Authors: Tan P , Laframboise J , Barr K , Anvari H , Ungi T , Fichtinger G , Scott C , Bechara R , Hookey L
Published: February 2020

Background

Dynamic positional changes during colonoscopy are commonly used in clinical practice, in particular moving from side to side. It has been shown to improve both adenoma detection rates as well as cecal intubation times. However, perhaps due to an additional level of inconvenience, there have been few studies comparing the anatomy and changes in colonic curvature when patients are in the prone position, which may help to prevent anterior bowing of the scope, particularly in patients with high body mass index (BMI).

Aims

To compare both the number of colonic curves and degree of change in curves with patients in supine versus prone positioning during computed tomography colonography (CTC).

Methods

75 CTC studies, obtained between January and April 2017 at Hotel Dieu Hospital in Kingston, Ontario, were screened and included based on image quality and adequacy of distention. Per standardized protocol, all patients undergoing CTC are imaged both in supine and prone positioning. Using an automated computer algorithm process developed for this study, curves were identified and measured via centerline points placed digitally through the colonic lumen, and compared between supine and prone patient positioning.

Results

75 colonographies were examined. The mean age was 68 years and 37/75 were male. BMI data was available for 56 patients, with mean BMI 29.4 (SD 5.7). There were no significant differences in total mean degrees of curvature between supine and prone positions [75.3 (SD 13.5) vs. 77.3 (SD 15.3), p=0.07], nor a significantly higher total number of curves >100 degrees [4.0 (SD 2.0) vs. 4.5 (SD 2.3), p=0.14]. No significant correlation was seen between BMI and change in position (correlation factor 0.2, p=0.13).

Conclusions

No significant differences were found between the two positions during CT colonography. This certainly calls into question the strategy of starting in prone position, even in higher BMI patients. However, CT colonography doesn’t account for changes that can occur during colonoscopy, as the scope itself can dynamically affect angulations within the colon.

Funding Agencies

None
A160 THE EFFECT OF AN INSTRUCTIVE VIDEO ON THE BOWEL PREPARATION EXPERIENCE
Authors: Saraswat D K , Fung P H , Dong A , Sultanian R , Farooq O , Wong C
Published: February 2020

Background

Over 26000 new cases of colorectal cancer (CRC) are diagnosed each year in Canada. This number has been decreased significantly by the implementation of CRC screening that includes removal of any polyps found during colonoscopies. Despite this, approximately 1 in 4 colonoscopies are inadequate for the detection of early neoplasms due to insufficient bowel preparation prior to the colonoscopy. Consequently, there is a need to improve patient adherence to the bowel preparation protocol. Previous research has shown that enhanced education, including the methods and rationale for bowel preparation prior to a colonoscopy, improves the quality of the bowel preparation.

Aims

We hypothesised that patients with access to a replayable video explaining the bowel preparation protocol and its importance would have increased satisfaction and noninferior bowel preparations.

Methods

100 patients undergoing programmatic screening colonoscopy were randomly assigned into one of two groups. The control group was given the standard presentation currently given to patients. The experimental group was given the same presentation and also given access to an educational video. This video is based on Alberta provincial bowel preparations which have been tested and evaluated. Participants in both groups were sent a survey one day after their colonoscopy. Subjects completed a modified version of the Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems survey with added questions designed to assess their satisfaction with the education they received on the bowel preparation. Bowel preparation quality was assessed on a 4-point Likert scale by the endoscopist.

Results

17 participants (10 female), aged 40–72 (Mage = 60) have enrolled in the study thus far; however, most have yet to have their colonoscopy. Initial results revealed that all participants had high levels of satisfaction with the presentation they were given. Those in the control group indicated that they would have liked to have had access to a video guide to the bowel preparation before their procedure. The participant in the experimental group indicated high levels of satisfaction with this video, noting that it provided important information not available from other sources. Information on the quality of their bowel preparations is pending.

Conclusions

The use of multimedia explanations of the bowel preparation has promise in improving patient satisfaction with the bowel preparation. Further studies may guide best methods for implementing a video assisted educational model to enhance colonoscopy preparation.

Funding Agencies

The first author received an Edna Wakefield Rowe Memorial Summer Research Award from the Faculty of Medicine & Dentistry at the University of Alberta to support this work.
A161 MACROSCOPIC AND HISTOLOGY FINDINGS DURING UPPER DIGESTIVE ENDOSCOPY IN CHILDREN WITH SUSPICION OF CELIAC DISEASE AND HIGH LEVELS OF TRANSGLUTAMINASE IGA-ANTIBODY
Authors: Jantchou P , Dirks M , Grzywacz K , Marchand V , Halac U , Groleau V , Patey N , Dal Soglio D , Oligny L , Drouin E , Deslandres C
Published: February 2020

Background

The European Society of Pediatric Gastroenterology Hepatology and Nutrition suggests that the diagnosis of Celiac disease (CD) can be confirmed solely on the basis of clinical symptoms and bloodwork including a level of transglutaminase IgA-antibodies (TGA) ≥ 10 times the upper limit of normal (10XN). In Canada and the United States, this recommendation has not been endorsed. We recently demonstrated that TGA ≥ 10XN performed at our institution (INOVA Diagnostics’ Quanta Lite) was a reliable predictive test of villous atrophy in patients with suspicion of CD.

Aims

The aim of the present study was to investigate the rate of supplemental endoscopic or histological findings in a cohort of children with TGA ≥ 10XN and the association of these findings with clinical symptoms.

Methods

Consecutive children with suspected CD who had an endoscopy between 2011 and 2018 were included in this analysis. Data was extracted from our CD database. The macroscopic and histological findings were reported. We compared these diagnoses to the clinical symptoms.

Results

From 2011 to 2018, 405 new cases of CD were identified in our pediatric center. In total, 238 (58.7%) patients had baseline TGA levels ≥ 10XN (67.2% females, median (IQR) age 8.4 (4.8–12.2)). The median interval between the first visit to the gastroenterology unit and the endoscopy was 43.0 (21.0–78.0) days. In total, 58% of the endoscopies had macroscopic findings in the bulb (37.8 %) or the duodenum (41.5%) including a mosaic pattern, mucosal fissuring, or erythema. Seven cases (2.8%) of esophagitis were identified during endoscopy; histological analysis confirmed eosinophilic esophagitis in 3 cases (1.2%) and peptic esophagitis in 4 cases. Non-specific gastritis was present in 58 patients (24.4%) and 2 cases of Helicobacter pylori infection were identified. The biopsies showed subtotal/total villous atrophy of duodenum in 171 (71.8%) or partial villous atrophy in 51 patients (29.8 %). Ten patients (4,3%) had villous atrophy in the duodenal bulb alone, with normal biopsies of the second part of the duodenum. Abdominal pain did not correlate with gastritis or duodenitis. However, children with diarrhea had a greater prevalence of visible endoscopic inflammation in the duodenum than those without diarrhea: 53.5% vs 38.9% respectively; P= 0,037.

Conclusions

Apart from the classical features associated with CD, the supplementary diagnostic yield of endoscopy was low. There were only a few cases of additional diseases identified by the endoscopic procedure in a large cohort of children and adolescents with suspicion of CD. Therefore, these results support the no-biopsy approach in the settings of TGA ≥ 10XN using a reliable diagnostic kit.

Funding Agencies

None
A163 MICROCOSTING: ASSESSING HEALTH ECONOMICS IN GI
Authors: Gillies A N , Chow R , Galorport C , Telford J J , Enns R A
Published: February 2020

Background

Micro-costing is a method of collecting precise cost measurements and proves effective in determining economic requirements needed to support health interventions. At St. Paul’s GI Clinic, over 12000 procedures are performed yearly, 80% of which are colonoscopies. Specific standards in the form of appropriate documentation are recommended through Global Rating Scale (GRS) and require yearly auditing to ensure appropriate compliance with these standards. These audits require a time commitment of staff to assess charts. The cost of performing these assessments is not known.

Aims

To determine the cost of annual data collection suggested by GRS for documentation of procedures.

Methods

A retrospective chart review and data analysis of patients (≥ 19 years old) admitted to St. Paul’s GI Clinic for a colonoscopy and/or esophagogastroduodenoscopy (EGD). Data is extracted from the St. Paul’s medical database from August 1st 2018 – August 1st 2019. Since it is a ‘time-and-motion’ study, a stopwatch is used to time the collection of data from each chart. The mean time per-case is derived and used to conduct an appropriate economic analysis, such as total working hours, per-minute salary calculations and equipment costs. The purpose is to determine a yearly cost and identify what the main cost drivers were (time/labor).

Results

As per our annual review format suggested by GRS, 260 procedure reports were reviewed, 150 colonoscopies and 110 EGDs (random sampling of 10 per physician for each type of procedure). A spread sheet outlining key data assessment points for mandatory standard reporting points has been used yearly and was used for this study as well. Mean evaluation time (including recording presence or absence of each item on our standard reporting form): 1 minute and 40 seconds to review the report for a colonoscopy and 1 minute and 33 seconds to review the report for an EGD. A total of 2 hours 51 minutes 16 seconds to review all the EGD reports and 4 hours 8 minutes and 46 seconds for the colonoscopy reports.

Conclusions

It would cost $126 annually to pay a research student, who makes $18/ hour, to collect this quality assurance data required for auditing completeness of physician colonoscopy and EGD procedure documentation according to standards.

Funding Agencies

None
A170 VITAMIN D IN IBD PATIENTS – A RETROSPECTIVE REVIEW
Authors: MacMillan R A , Ponich T
Published: February 2020

Background

Vitamin D is a critical factor in bone remodelling, calcium absorption and may promote anti-inflammatory cytokines in the gut. Inflammatory bowel disease (IBD) is associated with a reduction in serum Vitamin D levels and a chronic inflammatory state, both of which are strong risk factors for bone density loss affecting IBD patients. Despite European and North American IBD maintenance guidelines for Vitamin D monitoring and bone density scans, there are limited North American investigations into factors influencing serum Vitamin D levels in the IBD patient population specifically.

Aims

We investigated whether patient demographics, disease severity indexes and/or inflammatory markers were linked to low serum Vitamin D levels in our IBD patients. We also established the extent of Vitamin D serum deficiencies and supplementation rates in our IBD patients.

Methods

A retrospective chart review of a single clinician’s practice at London Health Science Centre, Victoria Hospital, over the past 20 months, was performed to: 1) assess the frequency of low serum 25-OH Vitamin D (25-OH D) in the IBD patient population and 2) determine whether patient disease severity was linked to lower 25-OH D levels. A multivariate regression analysis was performed assessing Crohn’s Disease (CD) or Ulcerative Colitis (UC) patient factors: age, sex, disease duration, seasonality, current pharmacologic treatments, past surgeries, CD Activity Index, UC Mayo score, C-reactive protein, and fecal calprotectin (Fcal) level.

Results

175 IBD patients had at least one 25-OH D measurement with 71 patients actively on Vitamin D therapy. Of UC and CD patients who were not on Vitamin D therapy, 63% (17/27) and 79% (61/77) were 25-OH D deficient, respectively. 25-OH D levels in the CD population was associated with Vitamin D supplementation (regression coefficient [RC] 23.99, 95% confidence interval [CI] 14.54 to 33.45), summer season ([RC] 9.90, [CI] 0.56 to 19.24), and past bowel resection ([RC] -10.61, [CI] -20.48 to -0.76). 25-OH D levels in the UC population was associated with Vitamin D supplementation (regression coefficient [RC] 47.23, 95% confidence interval [CI] 27.62 to 66.83), and Mayo severity scores ([RC] -23.01, [CI] -41.82 to -4.20). Fcal (78 patients) was inversely associated with 25-OH D levels but the trend was not significant.

Conclusions

Overall, 25-OH D levels were lower in both the UC and CD patient populations relative to the already deficient Canadian population. However, IBD patients are responsive to Vitamin D supplementation. Tools with more objective evidence of disease severity such as UC Mayo score and fcal should be prioritized for identifying the IBD population requiring supplementation.

Funding Agencies

None
A172 EXPERIENCE AND PERCEPTIONS OF SIMETHICONE USE DURING COLONOSCOPY: A SURVEY OF NORTH AMERICAN ENDOSCOPISTS
Authors: Nero J D , Moffatt D C , Park J , Singh H
Published: February 2020

Background

Simethicone is an anti-foaming agent which can be used to decrease the surface tension of air bubbles and improve visualization of colonic mucosa during colonoscopy. Recent studies have found that residual simethicone persists in endoscopes despite reprocessing and disinfection and promotes persistent moisture in endoscope channels. Simethicone residues can theoretically contribute to biofilm formation by providing nutritional milieu for microbial growth, which could increase the risk of transmission of infections among patients. Endoscopists’ perceptions on simethicone use and potential benefits are unknown, and this study aims to start filling this gap.

Aims

To assess experience and perceptions of simethicone use during colonoscopy in North America.

Methods

A REDCap® survey was distributed via email to members of various national professional associations and personal contacts of the study authors. Once the survey is complete, logistic regression analysis will be performed to assess univariate and multivariate associations of simethicone use. Preliminary data are reported in this abstract.

Results

47 practicing endoscopists have responded so far, of which 31 (64%) are surgeons and 16 are gastroenterologists (34%). The participants had been in practice for a median of eight years (range 1 – 34 years) and performed a median of ten colonoscopies per week. All 47 endoscopists practiced in Canada, with representation from seven provinces. Two endoscopists (4%) ask patients to use simethicone orally as part of their bowel preparation. During outpatient colonoscopy, 22 endoscopists (47%) never use simethicone, 19 endoscopists (40%) use simethicone less than 50% of the time, and six endoscopists (13%) use simethicone more than 50% of the time. Endoscopists were divided as to whether certain bowel preparations influenced their use of simethicone (agree or strongly agree 9, 19%; neutral 29, 62%; disagree or strongly disagree 9, 19%), that simethicone use could contribute to the transmission of pathogens through endoscopes (agree or strongly agree 6, 13%; neutral 34, 72%; disagree or strongly disagree 7, 15%), or that simethicone use increases their adenoma detection rate (agree or strongly agree 18, 38%; neutral 21, 45%; disagree or strongly disagree 8, 17%).

Conclusions

Of the current respondents of this survey, just over half (53%) of endoscopists report using simethicone during outpatient colonoscopies. Most reported simethicone use was via the water pump or instrument channel; oral simethicone use maybe minimal. Current respondents were divided in their perception that type of bowel preparation influences their use of simethicone or that simethicone use could contribute to the transmission of pathogens. Many endoscopists believed simethicone use could increase their adenoma detection rate.

Funding Agencies

None