Alarm Features Research Articles

Impact of geography on Scottish cancer diagnoses in primary care: Results from a national cancer diagnosis audit

BackgroundA recent meta-analysis of global research found cancer patients living in rural locations are 5% less likely to survive than their urban counterparts, a survival disadvantage that has never been satisfactorily explained. Aims[1] To describe and compare primary-care involvement in the diagnosis of cancer between rural and urban patients in Scotland. [2] To compare the length of key diagnostic pathway intervals between rural and urban cancer patients in Scotland. MethodsParticipating GPs in the Scottish National Cancer Audit of cancer diagnosis (2017) collected data from primary-care medical records on the diagnostic pathway of patients diagnosed in 2014. Residential postcodes designated the patients as rural or urban dwellers. Key cancer diagnostic pathway intervals (primary, diagnostic, secondary, and treatment) were compared using binary logistic regression. Descriptive analysis included comparison of patient characteristics, and routes to diagnosis. Results73 Scottish general practices provided data on 1,905 cancer diagnoses. Rural patients did not have higher odds of prolonged diagnostic intervals compared to urban patients but were significantly more likely to have had a cancer alarm feature at presentation and three or more primary-care consultations prior to referral. Rural GPs were significantly more likely to perceive an avoidable delay in their patient’s diagnostic pathway. ConclusionThere was no evidence that rural patients were more likely to be subject to prolonged cancer diagnostic delays than urban patients. Rural patients may experience primary care differently in the lead-up to a cancer diagnosis. The effect on outcome is probably negligible, but further research is required to confirm this.

The diagnostic value of a change in bowel habit for colorectal cancer within different age groups.

Change in bowel habit as a sole alarm symptom for colorectal cancer is disputed. We investigated the diagnostic value of change in bowel habit for colorectal cancer, particularly as a single symptom and within different age groups. This retrospective cohort study examined colorectal cancer fast track referrals and outcomes across four Swedish hospitals (April 2016-May 2017). Entry criteria constituted one or more of three alarm features: anaemia, visible rectal bleeding, or change in bowel habit for more than 4 weeks in patients over 40 years of age. Patients were grouped as having only change in bowel habit, change in bowel habit plus anaemia/bleeding or anaemia/bleeding only. Of 628 patients, 22% were diagnosed with colorectal cancer. There were no cases of colorectal cancer in the only change in bowel habit group under 55 years, while this was 6% for 55-64 years, 8% for 65-74 years and 14% for 75 years and older. Among subjects under 55 years, 2% with anaemia/bleeding had colorectal cancer, this increased to 34% for 55 years and older (P < 0.0001). Change in bowel habit plus anaemia/bleeding gave a colorectal cancer prevalence of 16% in under 55 years and increased to 30% for 55 years and older (P = 0.07). Change in bowel habit as the only alarm feature has a low diagnostic yield for colorectal cancer in patients under 55 years.

Low-value care and endoscopy in dyspepsia: A retrospective observational study from a metropolitan Australian hospital

Recent literature suggests that young patients aged <55 years without any alarm features are at low risk of having significant endoscopic findings (SEF) including malignancy, ulceration and erosive oesophagitis. Guidelines recommend that this patient subgroup should undergo a trial of proton pump inhibitors (PPIs) and potentially Helicobacter pylori testing before being considered for endoscopy. Hence, endoscopy has been identified as a potential source of unnecessary expense and low-value care for health services. We sought to assess the yield of performing endoscopy in young patients aged <55 years with dyspepsia referred by primary care physicians; and to assess …

New Design of An Intelligent, Secure and Dependable Garage system.

This work introduces the design and development plan of a reliable, smart, secure, automation solution, applying modern design methodology, for solving real-life problems faced by many residents and related to the process of car parking inside a home garage, as well as, security and economy issues. The suggested solution is intended for achieving comfort, security and economy as a part of home automation. The solution consists of two main subsystems; security identification subsystem and the automated garage subsystem. The security identification subsystem is suggested to be placed inside the car on front tableau. The two subsystems are communicating with each other wirelessly, the whole automated garage system are activated from sleep mode and waiting for further actions, when a vehicle or a human is detected in the front of the gate by means of two sensors, or when identification signal is send from security identification subsystem. For maximum reliability and depending on customer needs, the security subsystem is designed to identify the residents, to have a permission to enter the garage by matching all of the following; face image, fingerprint, voice print, written password, specified oral password word, specially designed remote control board or radio frequency identification (RFID) card along with a alarm features. When the residents identified, the garage subsystem is activated in terms of controlling the garage gate open/close process and controlling electrical components including lighting, ventilation and surveillance camera. Each of the two subsystems, as well as overall system, was physically prototyped, tested in real situation successfully.

Use of alarm features in predicting significant endoscopic findings in Nigerian patients with dyspepsia.

IntroductionDyspepsia is prevalent in the community. Guidelines recommend early endoscopy in dyspeptic patients who are older than 55 years, or have alarm features. There is a lack of data on endoscopy in patients with alarm features in Nigeria.MethodsA retrospective study of the endoscopic findings in adults with dyspepsia and alarm features, between August 1st 2017 and July 31st 2018 in Lagos, Nigeria. Data were analysed using Statistical Package for Social Sciences, version 23.0. The sensitivity, specificity, positive predictive value, and negative predictive value of the alarm features were calculated.ResultsOne hundred and fifty-nine gastroscopies were performed during this period, mean age was 47.8 (±14.4) years, 49.1% were male. Dyspepsia was the commonest indication for endoscopy (80.5%), 60.2% of the dyspeptics had at least one alarm feature. The most frequent dyspeptic symptom was epigastric pain/burning sensation (75%), while the commonest alarm features were recent onset dyspepsia in a patient over 45 years (79%) and unexplained weight loss (28.6%). Endoscopy was normal in 26%. The most frequent significant endoscopic findings were gastritis (49%) and gastric ulcer (17%) and they were not associated with alarm features. Upper gastrointestinal bleeding, persistent vomiting and odynophagia were specific for significant endoscopic findings. The pooled sensitivity, specificity, positive predictive value, and negative predictive value of the alarm features were 65%, 49%, 71% and 41% respectively.ConclusionPatients with dyspepsia and upper gastrointestinal bleeding, persistent vomiting or odynophagia, should be referred for prompt upper GI endoscopy.

1478 Small Cell Carcinoma of the Cecum: A Rare Entity

INTRODUCTION: Small-cell carcinoma of the colon (SmCC) is a very rare disease and is difficult to achieve long-term survival due to its aggressive behavior. Distant metastases are often found at the time of diagnosis of tumor. High recurrence rates contribute to poor survival with a median survival of 10.5 months. The World Health Organisation (WHO) in 2010 classified SmCC as a subgroup of neuroendocrine carcinoma (NEC) which accounts for approximately 0.6 percent of all colorectal cancers. Peak incidence of these tumours is in the sixth and seventh decades of life. The limited information on colorectal small cell carcinoma in the literature shows that these tumors have similar demographic features to colorectal adenocarcinomas with the exception of being more common in females. Of note, cecal small cell carcinoma is even more rare. CASE DESCRIPTION/METHODS: A 51-year-old female with no significant past medical history presented with a 2 year history of iron deficiency anemia and PICA. She had experienced 3 weeks of RUQ pain, abdominal distension, and fatigue. Colonoscopy revealed a 15 cm infiltrative mass in the cecum. Pathology showed invasive poorly differentiated grade 3 small cell carcinoma of the colon (Figure 1). Immunostains + CAM, synaptophysin, MAP-2, and CDX2. CTscan showed diffuse liver metastasis. PET scan showed diffuse brain metastasis. Chemotherapy with cisplatin and etoposide was instituted. Her course was complicated by confusion, lethargy, pulmonary embolus, recurrent ascites, and sepsis. She passed away 8 months after diagnosis. DISCUSSION: The available literature consists mainly of series of case reports or small case series that provide guidance for optimal therapy to prolong survival. Prognosis is very poor and is secondary to the tumor's aggressive biology, the presence of metastatic disease at the time of diagnosis, and poor response to chemo/radiotherapy. Seventy percent of patients present with metastases at the time of diagnosis. The reported 6 months, 3 year and 5 year survival rates of 58%, 13%, and 6%, respectively, with a median survival of 10.4 months. There is no agreed standard treatment approach for colorectal SmCC at the present time. Combination of surgery, chemotherapy and radiotherapy is the standard at this time but overall prognosis is poor. It is of utmost importance to perform colonoscopic evaluation if patients have any alarm features such as iron deficiency anemia, unexplained abdominal pain, and altered bowel habits so that diagnosis can be made earlier.

373 Routine EGD Has Minimal Impact on Refractory GERD Management

INTRODUCTION: Routine diagnostic esophagogastroduodenoscopy (EGD) is recommended for refractory gastro-esophageal reflux disease (GERD) symptoms despite lack of evidence that it impacts management or outcomes. This study aims to determine if diagnostic EGD impacts management in patients with refractory GERD compared to esophageal manometry, pH testing and intra-luminal impedance. METHODS: We performed an observational study of patients with refractory GERD who underwent EGD from 2013 to 2018 at a tertiary hospital. Among 1,213 patients with GERD, we strictly excluded patients with alarm features such as dysphagia, dyspepsia; history of gastroesophageal surgery, or EGD done for other diagnostic procedures, and identified 339 patients who underwent EGD solely for persistent reflux symptoms. We then identified those who had esophageal manometry or pH-impedance studies for further evaluation of GERD, as well as if the findings of these tests resulted in a change in management (medication change or de-escalation, referral for Nissen fundoplication, etc). RESULTS: Among 339 patients with refractory GERD, 80.5% of patients were taking PPIs prior to and/or at the time of EGD. The majority of patients had completely normal (163/339, 48.1%) or solely benign or incidental findings (106/339, 31.3%) on EGD. Only 10.6% of patients had esophageal manometry or pH-impedance studies for refractory reflux symptoms, of those, 6.2% followed EGD and only 7 patients had these studies after a completely normal EGD. The majority of patients undergoing manometry had normal studies or minor abnormalities (23/32, 71.8%). All patients who had been ordered for intraluminal impedance or 24 hr pH testing alone could not tolerate the procedure. Six of 15 patients (40%) undergoing 24 hr pH-impedance testing had findings leading to a change in management. Undergoing pH-impedance testing after EGD was associated with a change in management (OR 7.33, P = 0.018). PPI use was not associated DeMeester score or with results of manometry, impedance, or pH testing. CONCLUSION: Most patients who underwent EGD for refractory GERD symptoms alone did not have pathological findings prompting a change in management. There were no demographic variables that predicted pathologic findings on EGD. Very few patients underwent subsequent or concomitant esophageal manometry, impedance or pH testing. pH-impedance after EGD was associated with a change in management, and may be a better first step in evaluating patients with refractory GERD symptoms, than EGD.

Effectiveness of Vonoprazan vs Omeprazole as Empiric Therapy for Gastroesophageal Reflux Disease (GERD) Patients Without Alarm Features

Effectiveness of Vonoprazan vs Omeprazole as Empiric Therapy for Gastroesophageal Reflux Disease (GERD) Patients Without Alarm Features

ROLE OF COLONOSCOPY IN DIAGNOSING ORGANIC DISEASES IN PATIENTS WITH COLONIC SYMPTOMS COMPATIBLE WITH ROME IV CRITERIA

Background: Irritable bowel syndrome is a symptom-based condition defined by the presence of abdominal pain or discomfort, with altered bowel habits, the diagnosis could be reached using symptom-based diagnostic criteria without the need for exhaustive investigation; however interest in the potential for a missed organic GI disease in patients diagnosed IBS has increased over the last years. Objective: This study aimed to evaluate the role of colonoscopy in diagnosing organic diseases in patients with colonic symptoms compatible with Rome IV criteria of Irritable bowel syndrome as well as studying the effect of the presence or absence of alarm features on detecting organic lesions Patients and methods: A cross sectional study was carried out on 50 patients fulfilling the Rome IV criteria for IBS. The study was conducted in in the department of Hepatogastroenterology, Al-Azhar university Hospitals from December 2018 to May 2019. Patients were selected and divided into two equal groups: Group A: fulfilled Rome IV criteria for IBS without alarm features, and Group B: included 25 patients fulfilled Rome IV criteria for IBS with alarm features. All patients underwent full colonoscopy along with biopsy from colon was taken for histopathological examination. Results: The mean age of participants was 40.12 years. Males were 27 (54%) while females were 23 (46%), Eleven of 50 patients (22%) fulfilling Rome IV criteria of IBS had organic colonic diseases. There was higher prevalence of organic GI lesions in patients who reported alarm features. Microscopic colitis was the predominant organic disease among studied patients. IBS-D has the highest contribution to the total number of organic diseases. Conclusion: Up to one in six patients meeting criteria for IBS without alarm features in routine clinical practice may have underlying organic GI lesions, and this increased to one in four patients if alarm features were present .

ROLE OF COLONOSCOPY IN DIAGNOSING ORGANIC DISEASES IN PATIENTS WITH COLONIC SYMPTOMS COMPATIBLE WITH ROME IV CRITERIA

Background: Irritable bowel syndrome is a symptom-based condition defined by the presence of abdominal pain or discomfort, with altered bowel habits, the diagnosis could be reached using symptom-based diagnostic criteria without the need for exhaustive investigation; however interest in the potential for a missed organic GI disease in patients diagnosed IBS has increased over the last years. Objective: This study aimed to evaluate the role of colonoscopy in diagnosing organic diseases in patients with colonic symptoms compatible with Rome IV criteria of Irritable bowel syndrome as well as studying the effect of the presence or absence of alarm features on detecting organic lesions Patients and methods: A cross sectional study was carried out on 50 patients fulfilling the Rome IV criteria for IBS. The study was conducted in in the department of Hepatogastroenterology, Al-Azhar university Hospitals from December 2018 to May 2019. Patients were selected and divided into two equal groups: Group A: fulfilled Rome IV criteria for IBS without alarm features, and Group B: included 25 patients fulfilled Rome IV criteria for IBS with alarm features. All patients underwent full colonoscopy along with biopsy from colon was taken for histopathological examination. Results: The mean age of participants was 40.12 years. Males were 27 (54%) while females were 23 (46%), Eleven of 50 patients (22%) fulfilling Rome IV criteria of IBS had organic colonic diseases. There was higher prevalence of organic GI lesions in patients who reported alarm features. Microscopic colitis was the predominant organic disease among studied patients. IBS-D has the highest contribution to the total number of organic diseases. Conclusion: Up to one in six patients meeting criteria for IBS without alarm features in routine clinical practice may have underlying organic GI lesions, and this increased to one in four patients if alarm features were present .

Endoscopic yield of chronic dyspepsia in outpatients: A single-center experience in Cambodia.

Background and AimThe diagnostic evaluation and management of patients with chronic dyspepsia may differ geographically according to patient age, prevalence of Helicobacter pylori or parasitic infection, and risk of gastric cancer. The characteristics and appropriate investigation of Cambodian patients with dyspepsia have not previously been studied. The aim of this study was to investigate the characteristics of Cambodian patients with chronic dyspepsia, the yield of upper endoscopy in these patients, and the value of alarm features in identifying patients with organic causes of dyspepsia.MethodsWe conducted a retrospective, single‐center study of 1231 adults with chronic dyspepsia who underwent upper endoscopy. We compared clinical characteristics, H. pylori prevalence, and endoscopic and histological findings of patients with functional or organic causes of dyspepsia. This study was approved by the National Ethics Committee for Health Research.ResultsThe majority of patients had overlapping symptoms of epigastric pain/burning and postprandial fullness/early satiety (40.6%), followed by epigastric pain/burning alone (29.7%) and postprandial fullness/early satiety alone (29.7%). Organic lesions were diagnosed in 6.9% of patients. The overall prevalence of H. pylori infection was 46% and was similar in the three clinical subgroups. The sensitivity and specificity of alarm features for organic causes of dyspepsia were 14 and 96%, respectively. The majority of patients with gastric cancer were 40 years of age or older.ConclusionsThe majority of patients with chronic dyspepsia seen at our outpatient center were diagnosed with functional or H. pylori‐associated dyspepsia. The presence of alarm features was not sensitive or specific for differentiating organic and functional dyspepsia.

Recurrent abdominal pain and upper gastrointestinal endoscopy findings in children and adolescents presenting at the Lagos University Teaching Hospital.

IntroductionRecurrent abdominal pain (RAP) is a common reason for referral to the paediatric gastroenterology unit and the attending physician needs to be able to rule out an organic cause when evaluating any child with this condition. The aim of this study was to describe the endoscopic findings in children who presented to the paediatric gastroenterology unit of the Lagos University Teaching Hospital (LUTH) with RAP.MethodsThis was a prospective descriptive study which was conducted from January 2015 to July 2018 at the Paediatric Gastroenterology unit of the department of Paediatrics and the endoscopy unit of the LUTH, Lagos, Nigeria. All children and adolescents ≤ 19 years old with recurrent abdominal pain who were referred for upper GI endoscopy during the study period, were recruited. Baseline sociodemographic data, dyspepsia and alarm symptoms if present were documented. Results of other investigations namely stool examination for ova, parasites, occult blood and faecal antigen for Helicobacter pylori and abdominal scan were also documented.ResultsA total of 113 children with recurrent abdominal pain was referred during the study period and 87 (76.7%) of them had upper GI endoscopy done. Out of the participants, 38(43.7%) were boys and 49(56.3) girls. Alarm features were present in 15(17.6%) and dyspepsia was seen in 22(25.3%) of the subjects. The main endoscopic findings were: gastritis in 39 (44.8%), gastric erosions in 14(16.2%), hiatus hernia in 7(8.1%), duodenitis in 6 (6.9%), gastric polyp in 4 (4.6%).ConclusionUpper GI endoscopy remains an invaluable tool in the tool in evaluating RAP in children as it enables accurate diagnosis of GI causes of RAP. There is a need to advocate for easier access to this procedure in the developing countries.

The Prevalence of Clinically Significant Endoscopic Findings in Outpatients with Dyspepsia

AbstractBackground: Dyspepsia is a common clinical problem. More patients with dyspepsia have no detectable lesion. Organic causes of dyspepsia only detected by endoscopy if suspected by age or alarm features.Aim of Study: To evaluate the prevalence of significant endoscopic findings and use alarm features and the age in outpatients with dyspepsia in predicting the presence of Significant Endoscopic Findings (SEFS).Patients and Methods: This is cross-sectional observational study was carried out in Tanta University Hospitals Internal Medicine Department on one hundred Egyptian outpatients with dyspepsia in the period from July 2017 to January 2018. All patients enrolled in this study were subjected to upper gastro intestinal endoscopy, and histopathological examination to suspected cases only.Results: Our study showed that the prevalence of SEFS in dyspepsia patients was 25%, mostly found in patients who were old age and or had alarm features. The most common endoscopic abnormality was non erosive gastritis (73.2% n 37), followed by small HH (70.9% n 35), class A esophagitis represent (16.8% n 8), gastric ulcer disease was found in (17% n 11), Malignancy was found in only (6.4% n 3), erosive esophagitis was found in (6.4% n 3), sever gastritis was found in (12.8% n 6) and sever doudonitis in (4.3% n 2).Conclusion: The study showed the low prevalence of SEFs, and no need for endoscopy in young patients with no alarm features and they can be managed by non-endoscopic approach. However, it is highly recommended in all patients represented with alarming symptoms.

Understanding Constipation: A Cross-sectional Study from a Developing Country Setting.

A cross-sectional study was conducted in the Gastroenterology Clinics of The Aga Khan Hospital and Jinnah Postgraduate Medical Centre in Karachi. All patients complaining of constipation were included. Patients with alarm features were excluded. Interviews were conducted by trained doctors using a structured Rome III based pre-tested questionnaire and Bristol Stool Form Scale. Out of 396 participants, 186 (47.0%) had FC and 209 (52.7%) had IBS-C. Based upon Bristol Stool Form Scale, only 214 (54%) reported to have slow transit constipation (BSS <2). A higher proportion of women reported severe form of constipation as compared to men (81.5%, n=150 vs. 65.1%, n=138 p<0.001). However, a higher percentage of men reported using medications to treat their symptoms (71.2%, n=151 vs. 57.1%, n=105 p=0.003). Proper understanding of patient's symptoms is essential for optimizing individual patient management.

MOBILISASI PENYEBARAN INFORMASI KAMPUS BERBASIS FIREBASE CLOUD MESSAGING (FCM)

Knowing information is important for students, especially information about the college. The fame of using SMS gateway as the information spread media which has much deficiency, such as the needs of credit as the sending media and cannot searching message. Nowadays some message delivery media based on Android come up with the lack in some aspects. For an instant, the user of a group can send a message in the group’s chat rooms so that the important message can jumble with the other information. &#x0D; In this research, we will offer an application that is able to give real-time information. The information used one line system so that it cannot jumble with the other information. The information contain the alarm that has benefit to remind the user and then the message searching feature to help the user to look for the previous information, the usage of website technology as the data organizing be able to be accessed by the administrator, furthermore the usage of mobile device with android based can be accessed more easily and also the usage of API from firebase to send a message in the real time. This research resulted in applications that can support needs such as providing information specifically in realtime and have an alarm feature activity.&#x0D; &#x0D; Keywords : Notifikasi, Firebase Cloud Messaging, Android, PHP, MySQL

Excluding inflammatory bowel disease in the irritable bowel syndrome patient: how far to go?

Irritable bowel syndrome (IBS) is among the most commonly encountered conditions in primary care and gastroenterology. There is ample evidence that an IBS diagnosis based on symptom-based criteria and exclusion of alarm features that would otherwise support diagnostic testing is accurate and durable. For many clinicians, however, IBS remains a diagnosis of exclusion because of concern surrounding missed diagnoses of inflammatory bowel disease (IBD) or other organic gastrointestinal diseases. Using blood and/or fecal biomarker tests to shift the precolonoscopy probability of IBD in patients with symptoms mimicking IBS is becoming an increasingly reasonable practice with improvement in 'preliminary' tests. Fecal calprotectin (FCP) testing appears to be the most sensitive preliminary test for discriminating IBD from IBS. Although both fecal lactoferrin and FCP were superior to serum C-reactive peptide (CRP) in their diagnostic accuracy, FCP is superior to fecal lactoferrin based on available literature. In patients with IBS with diarrhea who have not undergone previous extensive evaluation, the ability of screening tests to detect colonic inflammation is improving. FCP and fecal lactoferrin are reliable predictors of colonic inflammation and should be considered for standard testing in patients with IBS-D symptoms to help identify those who would benefit most from colonoscopy. Although predictive, there currently are no fecal or serum tests that can definitively identify or subtype IBD.

Retrospective Study on Upper Gastrointestinal Endoscopic Findings in Patients with Dyspepsia without Alarm Features in International Islamic University Malaysia Medical Centre

Introduction: The purpose of this study was to review the significance of oesophago-gastroduodenoscopy (OGD) findings in patients with dyspepsia but without alarm features. Materials and Methods: OGD data from January 2017 to December 2017 were collected from ipesakit. The demographic details, indications and findings were reviewed. Results: OGDs were performed. Among these 56 (49%) were performed on dyspeptic patients with no alarm features. This subgroup was further analysed. Thirty two (57%) patients in this subgroup were female and 24 (43%) were male. 33 (59%) were 50 years and younger. Twenty (36%) patients were between 51 and 70 years old, while 3 (5%) patients were above 70 years of age. The commonest finding was gastritis (70%, n=39), followed by F3 gastric ulcer (3.5%, n=2), F3 duodenal ulcer (3.5%, n=2), gastric fundic polyp (1.8%, n=1), and hiatus hernia (1.8%, n=1). 11 (20%) patients had normal finding. No malignancy or pre malignancy lesion were found in this cohort. Two patients had positive CLO test. Conclusion: OGD in patients with dyspepsia but without alarm features has low yield of significant findings. This procedure may unnecessarily expose patients to the associated potential risks and may not be cost effective. This can be addressed by introducing a hospital guideline for OGD referral. Low positivity of CLO test may also need further evaluation with regards to its sensitivity and specificity. Alternative tests for H Pylori detection such as stool antigen test or urea breath test may need to be adopted.

Review of the role of abdominal imaging in irritable bowel syndrome.

The role of radiologic imaging in the investigation of irritable bowel syndrome (IBS) remains a subject of debate and there is some evidence, from recent studies of utilization of imaging in IBS, which focused on associated costs and radiation exposure, that imaging is being used relatively widely in these patients. This review aims to assess current best evidence to accurately define the role of radiologic imaging in IBS patients. Primary and secondary literature searches were performed. Evidence suggests that the lack of “red flag” or alarm features in IBS patients should reassure the clinician that the diagnosis of IBS is correct and United States and United Kingdom guidelines recommend no radiologic imaging for IBS patients if alarm features are not present. In patients presenting with IBS symptoms and alarm features, radiologic testing may be used to exclude an alternative diagnosis and the imaging modality should be chosen based on the most likely alternative diagnosis.

A Protocol-Driven Assessment Promotes a More Accurate Diagnosis of Irritable Bowel Syndrome.

A diverse range of conditions share symptoms commonly identified with irritable bowel syndrome. The objective of this study was to examine the diagnostic process in identifying additional diagnoses in women who are attending a clinic for evaluation of symptoms suggestive of irritable bowel syndrome. A retrospective audit was conducted of anonymous data gathered on consecutive female patients presenting to a specialist nurse-led service in Christchurch, New Zealand, with a provisional diagnosis of irritable bowel syndrome. A protocol containing routine pathology investigations and physical examination was used. Alarm features were identified and pertinent investigations were implemented. Rectocele was detected on rectal examination. Final diagnosis was noted and compared with baseline symptom data. Of 231 patients, 187 initially met Rome III criteria for irritable bowel syndrome. Red flags and abnormal investigations led to an alternate diagnosis in a further 27 patients. Of the 160 patients with irritable bowel syndrome, 31% were found to have a rectocele. They were seven times more likely to report a symptom associated with pelvic floor dysfunction (p < .0001) and four times more likely to report constipation (p = .0003). The use of a protocol including routine investigations and physical examination improves diagnostic yield. Pelvic floor dysfunction should be considered in those with unique symptom patterns and rectocele in the setting of irritable bowel syndrome.

Negative payoffs of upper gastrointestinal endoscopy in patients admitted under observation status.

More than 70 million Americans (23% of the USA population) have non-cardiac chest pain at least once in their lifetime with gastroesophageal reflux disease being the leading cause (37-66%). Current guidelines support the use of a proton pump inhibitor (PPI) prior to invasive or noninvasive testing as a diagnostic, therapeutic and cost-effective method as a part of High Value Care recommendations. We performed a chart review of 126 patients admitted to the hospital under observation status who underwent upper gastrointestinal endoscopies in the hospital at 3 different urban community hospitals. This was compared with 260 patients admitted who did not have this procedure done. We calculated the healthcare burden including length of stay, reimbursement and complications from the procedures/extra stay in the hospital. The direct cost per case was almost two times in the group that underwent the procedure as compared to the group that did not. The mean length of stay was higher in the group that underwent the endoscopies. There were no complications and there was no difference in mortality. Upper gastrointestinal endoscopy in patients with atypical chest pain of gastrointestinal origin as an initial step is a significant healthcare burden and contradicts the currently recommended High Value Care recommendations. Our study delineates this large negative financial impact when performing upper endoscopies under observation status. Such patients should be started on an empirical trial of PPI, and endoscopy should be reserved for patients whose symptoms are unresponsive to PPIs or have alarm features.