bluuebunny/crossref_metadata_2025_split huggingface dataset:
310 Effectiveness of Retroflexion Maneuver During Colonoscopy for Detecting Polyps
Authors: Kupferman Judah , Ziv Yonatan , Herzog Shimon , Weiss Alexander , Tokayer Aaron 
Published: October 2019

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

DISCUSSION:
Our patient had complicated autoimmune disease predisposing him to clot formation. The etiology of his SMV injury is unclear. Possible etiologies include ideopathic pancreatitis or autoimmune vasculitis. Regardless of the etiology, prompt evacuation of the bleed was crucial. IR / GI coordination made this procedure safe and possible.
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375 A Look at Patient Factors Such as Body Mass Index (BMI), Age, and Gender in Achalasia
Authors: Thapa Namisha , Hum Justine , Otaki Fouad , Diamond Sarah 
Published: October 2019

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

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

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

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

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

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

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

CONCLUSION:
Patients with JE and normal EGJ relaxation by IRP have significantly delayed onset of EGJ relaxation compared to healthy subjects and control patients with normal HRM. Hypercontractile peristalsis in these JE patients could be a compensatory mechanism to overcome outflow obstruction manifested as delayed EGJ relaxation. Therefore, if our findings are confirmed, therapies to address impaired EGJ relaxation could be considered.