Board-certified Gastroenterologists Research Articles

Digesting Digital Health: A Study of Appropriateness and Readability of ChatGPT-Generated Gastroenterological Information.

The advent of artificial intelligence-powered large language models capable of generating interactive responses to intricate queries marks a groundbreaking development in how patients access medical information. Our aim was to evaluate the appropriateness and readability of gastroenterological information generated by ChatGPT. We analyzed responses generated by ChatGPT to 16 dialogue-based queries assessing symptoms and treatments for gastrointestinal conditions and 13 definition-based queries on prevalent topics in gastroenterology. Three board-certified gastroenterologists evaluated output appropriateness with a 5-point Likert-scale proxy measurement of currency, relevance, accuracy, comprehensiveness, clarity, and urgency/next steps. Outputs with a score of 4 or 5 in all 6 categories were designated as "appropriate." Output readability was assessed with Flesch Reading Ease score, Flesch-Kinkaid Reading Level, and Simple Measure of Gobbledygook scores. ChatGTP responses to 44% of the 16 dialogue-based and 69% of the 13 definition-based questions were deemed appropriate, and the proportion of appropriate responses within the 2 groups of questions was not significantly different (P = .17). Notably, none of ChatGTP's responses to questions related to gastrointestinal emergencies were designated appropriate. The mean readability scores showed that outputs were written at a college-level reading proficiency. ChatGPT can produce generally fitting responses to gastroenterological medical queries, but responses were constrained in appropriateness and readability, which limits the current utility of this large language model. Substantial development is essential before these models can be unequivocally endorsed as reliable sources of medical information.

Closing the Gap: A Critical Examination of Adherence, Inconsistency, and Improvements in Colonoscopy Reporting Practices

Introduction: Comprehensive and standardized colonoscopy reports are crucial in colorectal cancer prevention, monitoring, and research. This study investigates adherence to national and international guidelines by analyzing reporting practices among 21 endoscopists in 7 German centers, with a focus on polyp reporting. Methods: We identified and assessed German, European, American, and World Health Organization-provided statements to identify key elements in colonoscopy reporting. Board-certified gastroenterologists rated the relevance of each element and estimated their reporting frequency. Adherence to the identified report elements was evaluated for 874 polyps from 351 colonoscopy reports ranging from March 2021 to March 2022. Results: We identified numerous recommendations for colonoscopy reporting. We categorized the reasoning behind those recommendations into clinical relevance, justification, and quality control and research. Although all elements were considered relevant by the surveyed gastroenterologists, discrepancies were observed in the evaluated reports. Particularly diminutive polyps or attributes which are rarely abnormal (e.g., surface integrity) respectively rarely performed (e.g., injection) were sparsely documented. Furthermore, the white light morphology of polyps was inconsistently documented using either the Paris classification or free text. In summary, the analysis of 874 reported polyps revealed heterogeneous adherence to the recommendations, with reporting frequencies ranging from 3% to 89%. Conclusion: The inhomogeneous report practices may result from implicit reporting practices and recommendations with varying clinical relevance. Future recommendations should clearly differentiate between clinical relevance and research and quality control or explanatory purposes. Additionally, the role of computer-assisted documentation should be further evaluated to increase report frequencies of non-pathological findings and diminutive polyps.

Evaluating the performance of ChatGPT in responding to questions about endoscopic procedures for patients

Background and aimsWe aimed to evaluate the precision, medical accuracy, superfluous content, and consistency of ChatGPT's responses to commonly asked questions about endoscopic procedures and its capability to provide emotional support, comparing its performance with the Generative Pre-trained Transformer 4 (GPT-4) model. MethodsA set of 113 questions related to esophagogastroduodenoscopy (EGD), colonoscopy, endoscopic ultrasound (EUS), and endoscopic retrograde cholangiopancreatography (ERCP) were curated from professional societies and institutional web pages. Responses from ChatGPT were generated and subsequently graded by board-certified gastroenterologists and advanced endoscopists. The emotional support efficacy of ChatGPT and GPT-4 was also assessed by a board-certified psychiatrist (LSM). ResultsChatGPT exhibited moderate precision in answering questions about EGD (57.9% comprehensive), colonoscopy (47.6% comprehensive), EUS (48.1% comprehensive), and ERCP (44.4% comprehensive). Medical accuracy was highest for EGD (52.6% fully accurate) and lowest for EUS (40.7% fully accurate). Concerning superfluous content, responses were predominantly concise for EGD and colonoscopy, with ERCP and EUS showing increased extraneous content. Reproducibility scores varied across domains, ranging from 50.34% (for EUS) to 68.6% (for EGD). GPT-4 outperformed ChatGPT in emotional support, though both models exhibited satisfactory performance. ConclusionChatGPT delivers moderately precise and medically accurate answers related to common endoscopic procedures with varying levels of extraneous content. It holds promise as a supplementary information resource for both patients and healthcare professionals.

The Awareness and Experience About Endoscopic Adverse Events Among South Korean Endoscopists.

The number of endoscopic procedures and related adverse events is increasing. We investigated South Korean endoscopists' awareness and experience of endoscopic adverse events. We used Google Forms to conduct an online questionnaire survey among South Korean endoscopists from December 11 to 29, 2020. The survey comprised 30 questions developed by members of the Quality Management Committee of the Korean Society of Gastrointestinal Endoscopy. In total, 475 endoscopists participated in the survey. Of these, 454 (95.6%) were board-certified gastroenterologists and 255 (53.7%) had >10 years of endoscopy experience. Most participants had experienced serious adverse events requiring hospitalization (80.4%, 382/475); however, only 100 (21.1%) were aware of programs for the prevention and management of adverse endoscopic events in their affiliated endoscopy centers. Most participants (98.5%, 468/475) agreed with the need for education on medical accidents for healthcare workers. Responses were inconsistent regarding the definition of adverse events formulated by the 2010 American Society for Gastrointestinal Endoscopy Workshop. Most participants were not aware of the minimal standard terminology (76.6%, 364/475) and had not used it when writing endoscopy reports (88.8%, 422/475). Responses were inconsistent regarding which events to record in endoscopy records. Further discussion on the nationwide adverse-event reporting system and education program for adverse events related to endoscopy is needed to ensure the safety of patients and endoscopists.

Detection of duodenal villous atrophy on endoscopic images using a deep learning algorithm.

Celiac disease with its endoscopic manifestation of villous atrophy is underdiagnosed worldwide. The application of artificial intelligence (AI) for the macroscopic detection of villous atrophy at routine esophagogastroduodenoscopy may improve diagnostic performance. A dataset of 858 endoscopic images of 182 patients with villous atrophy and 846 images from 323 patients with normal duodenal mucosa was collected and used to train a ResNet 18 deep learning model to detect villous atrophy. An external data set was used to test the algorithm, in addition to six fellows and four board certified gastroenterologists. Fellows could consult the AI algorithm's result during the test. From their consultation distribution, a stratification of test images into "easy" and "difficult" was performed and used for classified performance measurement. External validation of the AI algorithm yielded values of 90 %, 76 %, and 84 % for sensitivity, specificity, and accuracy, respectively. Fellows scored values of 63 %, 72 % and 67 %, while the corresponding values in experts were 72 %, 69 % and 71 %, respectively. AI consultation significantly improved all trainee performance statistics. While fellows and experts showed significantly lower performance for "difficult" images, the performance of the AI algorithm was stable. In this study, an AI algorithm outperformed endoscopy fellows and experts in the detection of villous atrophy on endoscopic still images. AI decision support significantly improved the performance of non-expert endoscopists. The stable performance on "difficult" images suggests a further positive add-on effect in challenging cases.

Cross-sectional analysis of pharmaceutical payments to Japanese board-certified gastroenterologists between 2016 and 2019

ObjectivesLimited evidence is available regarding the financial relationships between gastroenterologists and pharmaceutical companies in Japan. This study analysed the magnitude, prevalence and trends of personal payments made by major pharmaceutical...

Gastroenterology Practice Patterns Contribute to Missed Diagnoses of Eosinophilic Gastritis and Duodenitis.

Eosinophilic gastritis and eosinophilic duodenitis (EoG/EoD) are often misdiagnosed as functional gastrointestinal (GI) disorders. Consequently, patients with GI symptoms of EoG/EoD may not undergo the necessary steps for diagnosis. We studied gastroenterologists' evaluations of patients with chronic, unexplained, moderate-to-severe GI symptoms that were unresponsive to over-the-counter medications. We performed a cross-sectional online survey of 202 board-certified gastroenterologists at office-based practices, community hospitals, or academic institutions. Respondents had been in active clinical practice for 3-35 years post-residency training, spent most of their time on direct patient care, managed ≥1 patient with irritable bowel syndrome and/or functional dyspepsia, and performed ≥1 endoscopy per month. Responses were analyzed to identify barriers to EoG/EoD diagnosis and management. Respondents managed a mean of 1880 patients per year; the most common diagnoses were functional dyspepsia (36%) and gastroesophageal reflux disease (19%). Mean proportions of patients who underwent upper endoscopy ranged from 42% to 84%. Biopsies were collected from >90% of patients with visible endoscopic mucosal abnormalities vs 42%-72% of patients with normal-appearing mucosae. Approximately 20% of respondents collected only 1-2 biopsies from each site of the GI tract. Only 30% routinely requested pathologists to count eosinophils, and nearly 40% had no histologic threshold for EoG/EoD diagnosis. Gastroenterologists vary in their evaluation of patients with chronic, unexplained moderate-to-severe GI symptoms. Limited gastric and duodenal biopsy collection, particularly from normal-appearing mucosae, and failure to request tissue eosinophil counts might contribute to underdiagnosis of EoG/EoD. Availability and awareness of EoG/EoD diagnostic guidelines should improve detection in clinical practice.

Post-Colonoscopy Colorectal Cancer Etiologies in a Large Integrated US Health Care Setting

Post-Colonoscopy Colorectal Cancer Etiologies in a Large Integrated US Health Care Setting

Efficacy of combination colonoscopy using modified cap-assisted and water-exchange colonoscopy with prone position for detection of colorectal adenomas.

The efficacy of cap-assisted and water-exchange colonoscopy, individually or in combination for adenoma detection is well documented. Moreover, prone positioning colonoscopy may also improve adenoma detection by decreasing loop formation. However, the efficacy of triple-combination colonoscopy using the above methods for adenoma detection is unclear. This study aimed to compare the effectiveness of combining modified cap-assisted and water-exchange colonoscopy with prone position (CWP) and conventional colonoscopy (CC) for adenoma detection. A total of 746 patients who underwent either CWP or CC, performed by 2 board-certified gastroenterologists between December 2019 and March 2020, were investigated retrospectively. Cap-assisted colonoscopy was modified using hooking and dragging maneuver. We evaluated the polyp detection rate (PDR), adenoma detection rate (ADR), and the mean number of adenomas detected per procedure (MAP). There was no significant difference in sex, age, the indication of colonoscopy and quality of bowel preparation between the 2 groups. PDR, ADR, and proximal colon MAP were significantly higher in the CWP group than in the CC group (PDR: 84.9% vs 59.8%, P < .01; ADR: 70.1%, vs 49.2%, P < .01; proximal colon MAP: 1.24 vs 0.55, P < .01). CWP is more effective than CC for PDR, ADR, and proximal colon MAP. Although it may facilitate adenoma detection, further studies assessing the synergistic or complementary effects of combining these methods are needed.

Computer-Aided Detection Improves Adenomas per Colonoscopy for Screening and Surveillance Colonoscopy: A Randomized Trial

Background & AimsColonoscopy for colorectal cancer screening is endoscopist dependent, and colonoscopy quality improvement programs aim to improve efficacy. This study evaluated the clinical benefit and safety of using a computer-aided detection (CADe) device in colonoscopy procedures. MethodsThis randomized study prospectively evaluated the use of a CADe device at 5 academic and community centers by US board-certified gastroenterologists (n = 22). Participants aged ≥40 scheduled for screening or surveillance (≥3 years) colonoscopy were included; exclusion criteria included incomplete procedure, diagnostic indication, inflammatory bowel disease, and familial adenomatous polyposis. Patients were randomized by endoscopist to the standard or CADe colonoscopy arm using computer-generated, random-block method. The 2 primary endpoints were adenomas per colonoscopy (APC), the total number of adenomas resected divided by the total number of colonoscopies; and true histology rate (THR), the proportion of resections with clinically significant histology divided by the total number of polyp resections. The primary analysis used a modified intention-to-treat approach. ResultsBetween January and September 2021, 1440 participants were enrolled to be randomized. After exclusion of participants who did not meet the eligibility criteria, 677 in the standard arm and 682 in the CADe arm were included in a modified intention-to-treat analysis. APC increased significantly with use of the CADe device (standard vs CADe: 0.83 vs 1.05, P = .002; total number of adenomas, 562 vs 719). There was no decrease in THR with use of the CADe device (standard vs CADe: 71.7% vs 67.4%, P for noninferiority < .001; total number of non-neoplastic lesions, 284 vs 375). Adenoma detection rate was 43.9% and 47.8% in the standard and CADe arms, respectively (P = .065). ConclusionsFor experienced endoscopists performing screening and surveillance colonoscopies in the United States, the CADe device statistically improved overall adenoma detection (APC) without a concomitant increase in resection of non-neoplastic lesions (THR).ClinicalTrials.gov registration: NCT04754347.

Incomplete endoscopic resection of colorectal polyps: a prospective quality assurance study.

Endoscopic screening with polypectomy has been shown to reduce colorectal cancer incidence in randomized trials. Incomplete polyp removal and subsequent development of post-colonoscopy cancers may attenuate the effect of screening. This study aimed to quantify the extent of incomplete polyp removal. We included patients aged 50-75 years with nonpedunculated polyps ≥ 5 mm removed during colonoscopy at four hospitals in Norway. To evaluate completeness of polyp removal, biopsies from the resection margins were obtained after polypectomy. Logistic regression models were fitted to identify factors explaining incomplete resection. 246 patients with 339 polyps underwent polypectomy between January 2015 and June 2017. A total of 12 polyps were excluded due to biopsy electrocautery damage, and 327 polyps in 246 patients (mean age 67 years [range 42-83]; 52 % male) were included in the analysis. Overall, 54 polyps (15.9 %) in 54 patients were incompletely resected. Histological diagnosis of the polyp (sessile serrated lesions vs. adenoma, odds ratio [OR] 10.9, 95 % confidence interval [CI] 3.9-30.1) and polyp location (proximal vs. distal colon, OR 2.8, 95 %CI 1.0-7.7) were independent risk factors for incomplete removal of polyps 5-19 mm. Board-certified endoscopists were not associated with lower rates of incomplete resection compared with trainees (14.0 % vs. 14.2 %), OR 1.0 (95 %CI 0.5-2.1). Incomplete polyp resection was frequent after polypectomy in routine clinical practice. Serrated histology and proximal location were independent risk factors for incomplete resection. The performance of board-certified gastroenterologists was not superior to that of trainees.

Construction of a convolutional neural network classifier developed by computed tomography images for pancreatic cancer diagnosis.

BACKGROUNDEfforts should be made to develop a deep-learning diagnosis system to distinguish pancreatic cancer from benign tissue due to the high morbidity of pancreatic cancer.AIMTo identify pancreatic cancer in computed tomography (CT) images automatically by constructing a convolutional neural network (CNN) classifier.METHODSA CNN model was constructed using a dataset of 3494 CT images obtained from 222 patients with pathologically confirmed pancreatic cancer and 3751 CT images from 190 patients with normal pancreas from June 2017 to June 2018. We established three datasets from these images according to the image phases, evaluated the approach in terms of binary classification (i.e., cancer or not) and ternary classification (i.e., no cancer, cancer at tail/body, cancer at head/neck of the pancreas) using 10-fold cross validation, and measured the effectiveness of the model with regard to the accuracy, sensitivity, and specificity.RESULTSThe overall diagnostic accuracy of the trained binary classifier was 95.47%, 95.76%, 95.15% on the plain scan, arterial phase, and venous phase, respectively. The sensitivity was 91.58%, 94.08%, 92.28% on three phases, with no significant differences (χ2 = 0.914, P = 0.633). Considering that the plain phase had same sensitivity, easier access, and lower radiation compared with arterial phase and venous phase , it is more sufficient for the binary classifier. Its accuracy on plain scans was 95.47%, sensitivity was 91.58%, and specificity was 98.27%. The CNN and board-certified gastroenterologists achieved higher accuracies than trainees on plain scan diagnosis (χ2 = 21.534, P < 0.001; χ2 = 9.524, P < 0.05; respectively). However, the difference between CNN and gastroenterologists was not significant (χ2 = 0.759, P = 0.384). In the trained ternary classifier, the overall diagnostic accuracy of the ternary classifier CNN was 82.06%, 79.06%, and 78.80% on plain phase, arterial phase, and venous phase, respectively. The sensitivity scores for detecting cancers in the tail were 52.51%, 41.10% and, 36.03%, while sensitivity for cancers in the head was 46.21%, 85.24% and 72.87% on three phases, respectively. Difference in sensitivity for cancers in the head among the three phases was significant (χ2 = 16.651, P < 0.001), with arterial phase having the highest sensitivity.CONCLUSIONWe proposed a deep learning-based pancreatic cancer classifier trained on medium-sized datasets of CT images. It was suitable for screening purposes in pancreatic cancer detection.

113 Are Antibiotics Necessary for EUS-FNA of Pancreatic Cysts: A Retrospective Study

INTRODUCTION: Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) is commonly used to further characterize cystic lesions of the pancreas. Antibiotic prophylaxis has been recommended by the Americal Society for Gastrointestinal Endoscopy for EUS-FNA of cystic pancreatic lesions. The aim of this study was to compare the rate of post-procedural infection in patients who received periprocedural antibiotics for EUS-FNA of pancreatic cystic lesions versus those who did not. METHODS: A retrospective review of medical records of individuals with pancreatic cysts who underwent EUS-FNAs at a tertiary academic hospital between January 2015 and March 2018 was performed. All procedures were performed by four board-certified gastroenterologists. The data reviewed included patient demographics, cyst description, FNA needle size, cytology and use of antibiotics. Post-procedural infections were identified by the presence of leukocytosis, fever, or positive blood cultures during follow-up clinic or hospital visits for 30 days after FNA. Excluded from the study were solid neoplasms, obvious side branch intraductal papillary mucinous neoplasm without high risk features and subjects with evidence of infection or leukocytosis before the FNA. RESULTS: Two hundred and ten EUS-FNA procedures were included in this analysis. Ninety six were males and 114 were females; median age was 65 years. Cysts were 1–5 cm in diameter and evenly distributed throughout the pancreas. One hundred and fifteen of the 210 (55%) cysts were &gt;2 cm and 95 (44%) were &lt;2 cm. 27 out of 210 (13%) were pancreatitis related cysts. 22-gauge needle was used for 55% of the procedures with the remaining procedures using 19 and 25-gauge needles. Eighty nine of 210 (43%) patients received periprocedural antibiotics. Only one of the total 210 patients (0.4%) developed post-procedural gram-negative bacteremia related to EUS within 1 week of procedure. This patient had received periprocedural antibiotics. None of the patients in the “no antibiotic” group had post-procedural infections (Table 1). CONCLUSION: The evidence supporting universal use of antibiotics for all cystic lesions as recommended is lacking and overall infection risk with FNA is low, at approximately 0.3% based on small studies. Our study of 210 patients including pancreatitis related cysts demonstrate that routine use of antibiotics may not be required for FNA of pancreatic cysts. Further prospective studies may be required to support this.

P030 Patient and physician preferences for ulcerative colitis treatments in the United States

BACKGROUND: Ulcerative colitis (UC) is a chronic and debilitating inflammatory bowel disease. While there is no cure, patients and physicians can choose from a variety of treatments characterized by different attributes such as efficacy, safety, and mode and frequency of administration. Hence, it is important to understand how (and to what degree) these attributes influence treatment preferences from both patient and prescriber perspectives. Therefore, the purpose of this study was to elicit patient and physician preferences for different attributes of UC treatments via a discrete choice experiment (DCE). METHODS: The study was conducted in the United States (US) in 2 phases: (1) a qualitative phase involving in-depth individual interviews with patients and physicians to explore the UC treatment attributes that patients and physicians consider most important when making treatment decisions, and (2) a quantitative phase to estimate the relative importance of those attributes. Screening criteria for patients (self-reported clinical diagnosis of UC, disease severity of moderate to severe based on self-reported medication history) and physicians (gastroenterologists with experience treating patients with moderate to severe UC) were consistent across phases. In the quantitative phase, 2 discrete choice experiment survey instruments (one for patients, one for physicians) with an identical set of UC treatment attributes were developed and administered. The resulting data were analyzed using a random-parameters logit model to estimate preference weights and conditional relative importance of UC treatment attributes. RESULTS: Two hundred patients with moderate to severe UC and 200 board-certified (or eligible) gastroenterologists completed the survey. The average age of patients was approximately 42 years, and the majority of patients (59%) were female. In the qualitative phase, both patients and physicians indicated that the most important UC treatment attributes were time to symptom improvement, chance of long-term symptom control, risk of serious infection, risk of malignancy, mode and frequency of administration, and need for use of steroids. For patients, symptom control was 2.5 times more important than the time to symptom improvement. Patients considered a 5-year risk of malignancy almost as important as long-term symptom control (relative importance of 0.79 compared with 0.96 for long-term symptom control) and preferred all suggested pill-dosing schedules to both subcutaneous injections and intravenous infusions (relative importance of 0.47 compared with 0.11 and 0.18, respectively). For physicians, symptom control was by far the most important attribute when prescribing a treatment, and it was 5 times as important as the 5-year risk of malignancy. CONCLUSION(S): We identified patient and physician preferences for UC treatments. The differences in results between patients and physicians suggest that patients are thinking about the treatment features differently from their physicians. Both patients and physicians identified long-term symptom control as the most important attribute relative to the others; however, the 5-year risk of malignancy was almost of equal importance to patients but not for physicians. This highlights the need for improved communication about the relevant benefits and risks of different UC treatments so that patients and physicians can engage in better decision making.

Long-Term Evaluation of Outcomes for Abdominal Ultrasound Screening for Hepatocellular Carcinoma

Background: Mass screening for hepatocellular carcinoma (HCC) with abdominal ultrasound (AUS) has been demonstrated in short-term follow-up in Taiwan, but long-term effectiveness and cost-effectiveness of AUS have not been well studied particularly when the recently emerging antiviral therapy has been introduced. The aim of this study is therefore to evaluate long-term outcomes of population-based organized service screening program without control group. Methods: AUS screening based on a risk score–guided invitation has been launched since October 2008 in Changhua. A total of 85,147 subjects aged 40-74 years attended the Changhua community-based integrated screening (CHCIS) program were targeted. Those with high score based on hepatitis virus infection, ALT, AST, type 2 diabetes, platelet count were invited to receive ultrasonography screening performed by board-certified gastroenterologists in town-based health center to identify liver cirrhosis, and suspected HCC cases. We developed a pseudo-control group by building up the disease natural history for HCC embedded with the risk prediction model and the survival by detection modes. The pseudo-control model was further used to the development of health economic decision model for cost-effectiveness of various preventive strategies. Results: We observed a 61% (RR = 0.39, 95% CI: 0.32-0.46) HCC mortality reduction with AUS by risk groups together with ∼30% coverage rate of antiviral therapy in an 8-year period. The simulated results indicates the additional contribution of 30% compliance rate of antiviral therapy (empirical estimate) to HCC mortality reduction was ∼22%. The corresponding figures were raised to 30% and 35% when the compliance rate of antiviral therapy was enhanced to 50% and 70%, respectively. The results of cost-effectiveness analysis shows the incremental cost-effectiveness ratio was $22,849 for the administration of AUS, and $101,849 for the administration of AUS plus 30% compliance to antiviral therapy. The corresponding figures for 50% and 70% compliance rate to antiviral therapy were $141,805 and $181,919, respectively. Conclusion: The population-based screening program for HCC together with antiviral therapy achieved HCC mortality reduction by 60%. The computer study design with a pseudo-control group on the basis of disease natural history of HCC embedded with the predictive model, and the survival part of HCC enables us to quantify the attributable proportion from different preventive regimes, and to estimate long-term effectiveness of the overall and marginal effectiveness and cost-effectiveness of AUS and antiviral therapy under different scenarios. Such approach provides the health policy-makers a reference for resource allocation.

Polypectomy techniques among gastroenterologists in Norway - a nationwide survey.

Background and study aims Incomplete polyp removal has been estimated to cause 27 % of all colorectal cancers detected soon after colonoscopy. There is limited information regarding polypectomy techniques among endoscopists. The article is a nationwide survey of polypectomy techniques among Norwegian endoscopists. Materials and methods We invited all board-certified gastroenterologists in Norway to complete a web-based questionnaire about their polypectomy technique. Inadequate polypectomy techniques were defined as using biopsy forceps for polyps larger than 3 mm in diameter, using hot biopsy forceps for polypectomy, and using the same electrocautery output irrespective of polyp size and morphology. Results Twenty-six of 30 Norwegian gastroenterology departments participated in the study. A total of 119 endoscopists received the survey, and 70 (59 %) responded. Mean duration of endoscopy practice was 11.5 years, and 95 % had performed more than 1,000 colonoscopies during their career. Twenty-eight endoscopists (40 %) used one or more inadequate polypectomy techniques: 10 (14.3 %) used biopsy forceps for removal of polyps larger than 3 mm in diameter, five (7.1 %) used hot biopsy for polypectomy, and 17 (24 %) used the same electrocautery output for all polypectomies. Five (7 %) endoscopists reported that they did not remove polyps smaller than 4 mm. Conclusion A substantial number of Norwegian endoscopists use inadequate polypectomy techniques. Improved training and certification of endoscopists is warranted.

Improvement in Gastrointestinal Symptoms After Cognitive Behavior Therapy for Refractory Irritable Bowel Syndrome

There is an urgent need for safe treatments for irritable bowel syndrome (IBS) that relieve treatment-refractory symptoms and their societal and economic burden. Cognitive behavior therapy (CBT) is an effective treatment that has not been broadly adopted into routine clinical practice. We performed a randomized controlled trial to assess clinical responses to home-based CBT compared with clinic-based CBT and patient education. We performed a prospective study of 436 patients with IBS, based on Rome III criteria, at 2 tertiary centers from August 23, 2010, through October 21, 2016. Subjects (41.4 ± 14.8 years old; 80% women) were randomly assigned to groups that received the following: standard-CBT (S-CBT, n= 146, comprising 10 weekly, 60-minute sessions that emphasized the provision of information about brain-gut interactions; self-monitoring of symptoms, their triggers, and consequences; muscle relaxation; worry control; flexible problem solving; and relapse prevention training), or 4 sessions of primarily home-based CBT requiring minimal therapist contact (MC-CBT, n= 145), in which patients received home-study materials covering the same procedures as S-CBT), or 4 sessions of IBS education (EDU, n= 145) that provided support and information about IBS and the role of lifestyle factors such as stress, diet, and exercise. The primary outcome was global improvement of IBS symptoms, based on the IBS-version of the Clinical Global Impressions-Improvement Scale. Ratings were performed by patients and board-certified gastroenterologists blinded to treatment allocation. Efficacy data were collected 2 weeks, 3 months, and 6 months after treatment completion. A higher proportion of patients receiving MC-CBT reported moderate to substantial improvement in gastrointestinal symptoms 2 weeks after treatment (61.0% based on ratings by patients and 55.7% based on ratings by gastroenterologists) than those receiving EDU (43.5% based on ratings patients and 40.4% based on ratings by gastroenterologists) (P < .05). Gastrointestinal symptom improvement, rated by gastroenterologists, 6 months after the end of treatment also differed significantly between the MC-CBT (58.4%) and EDU groups (44.8%) (P= .05). Formal equivalence testing applied across multiple contrasts indicated that MC-CBT is at least as effective as S-CBT in improving IBS symptoms. Patients tended to be more satisfied with CBT vs EDU (P < .05) based on immediate posttreatment responses to the Client Satisfaction Questionnaire. Symptom improvement was not significantly related to concomitant use of medications. In a randomized controlled trial, we found that a primarily home-based version of CBT produced significant and sustained gastrointestinal symptom improvement for patients with IBS compared with education. Clinicaltrials.gov no.: NCT00738920.

A statewide program providing colorectal cancer screening to the uninsured of South Carolina.

Cancer screening rates are lowest in those without insurance or a regular provider. Since 2008, the Colorectal Cancer Prevention Network (CCPN) has provided open access colonoscopy to uninsured residents of South Carolina through established, statewide partnerships and patient navigation. Herein, we describe the structure, implementation, and clinical outcomes of this program. The CCPN provides access to colonoscopy screening at no cost to uninsured, asymptomatic patients aged 50-64 years (African Americans age 45-64 years are eligible) who live at or below 150% of the poverty line and seek medical care in free medical clinics, federally qualified health centers, or hospital-based indigent practices in South Carolina. Screening is performed by board-certified gastroenterologists. Descriptive statistics and regression analysis are used to describe the population screened, and to assess compliance rates and colonoscopy quality metrics. Out of >4000 patients referred to the program, 1854 were deemed eligible, 1144 attended an in-person navigation visit, and 1030 completed a colonoscopy; 909 were included in the final sample. Nearly 90% of participants exhibited good-to-excellent bowel preparation. An overall cecal intubation rate of 99% was measured. The polyp detection rate and adenoma detection rate were 63% and 36%, respectively, with male sex and urban residence positively associated with adenoma detection. Over 13% of participants had an advanced polyp, and 1% had a cancer diagnosis or surgical intervention. The CCPN program is characterized by strong collaboration with clinicians statewide, low no-show rates, and high colonoscopy quality. Future work will assess the effectiveness of the navigation approach and will explore the mechanisms driving higher adenoma detection in urban participants. Cancer 2018;124:1912-20. © 2018 American Cancer Society.

Endoscopic Stigmata: Recognition Lies in the Eye of the Beholder?

The most widely accepted classification for endoscopic stigmata is the Forrest classification, which divides endoscopically visible lesions into 3 classes (ie, I, II, and III). The classification is most useful because it is based on risk of rebleeding in the absence of endoscopic therapy. But how good are we at identifying/classifying the stigmata on endoscopy? Data from the REASON Registry from Canada, which reviewed endoscopy data retrospectively, showed that high-risk stigmata were present in 47.8% of the patients on endoscopy, but less than two-thirds of these received endoscopic therapy. On the other hand, about 9.8% patients with low-risk stigmata received endoscopic therapy. More than one-quarter of the reports did not document and classify the stigmata. Similar studies by Lau et al and Bour et al have shown poor inter-observer agreement between experts for recognition of endoscopic stigmata. An anonymous online survey was designed and separate links to the survey were e-mailed to faculty and fellows. We divided the survey into 2 parts—stigmata recognition and stigmata therapy. Under stigmata recognition, a standard image of a lesion belonging to one class of the Forrest classification was presented. The images were reproduced from records of our own endoscopies or from standard online digital libraries of endoscopic stigmata. The images were chosen to represent a very standard imagery representative of the lesion. Under stigmata therapy, we used different labeled images of endoscopic lesions and asked faculty/fellows to choose how they would treat the lesion endoscopically, including an option to not treat. Total of 17 faculty members and 11 fellows participated in the survey. Our study brings forth a few vital observations:1.Based on our data, overall low-risk stigmata was misclassified as high risk about 14% of time by board-certified gastroenterologists. This would have inadvertently led to unnecessary endoscopic therapy. In the same vein, high-risk stigmata was misclassified as low risk 6% of the time, putting patients at risk for rebleeding from them.2.Overall inter-observer agreement in recognition of stigmata was very good (κ = .85). It was poorest for an adherent clot (κ = .52) and best for spurting hemorrhage (κ = 1).3.Overall inter-observer agreement in treatment of endoscopic stigmata was good (κ = .74). It was again poorest for an adherent clot (κ = .58) and best for spurting hemorrhage/clean-based ulcer and flat pigmented spot (κ = 1).4.The κ indexes were significantly better for faculty with >3 years of experience vs junior fellows (first- and second-year fellows) (senior faculty overall κ = .85 ± .09 and junior fellows .68 ± .16; 2-tailed P = .047).

Real-life Perception and Practice Patterns of NAFLD/NASH in Romania: Results of a Survey Completed by 102 Board-certified Gastroenterologists.

Nonalcoholic fatty liver disease (NAFLD) has an increasing incidence worldwide, reflecting the epidemics of obesity and metabolic syndrome. Data on knowledge, attitude and management by the Romanian gastroenterologists with regard to NAFLD are lacking. We assessed current diagnostic and treatment patterns of the management of NAFLD among 102 Romanian board certified gastroenterologists using a survey developed to collect information regarding participants' clinical practice, diagnostic tools and usage of medication in patients with NAFLD. 71.6% of the surveyed gastroenterologists (SG) had more than 5 years of gastroenterology practice, were university affiliated and 37.3% had predominant activity in hepatology (>60%). In Romania, 60.8% of the SG would diagnose NAFLD only if all other causes of liver disease were absent. All practitioners use a noninvasive tool for staging NAFLD, 45.1% use both serum markers and transient elastography. Liver biopsy is performed by 61.8% of the SG in the presence of a discordant result in two noninvasive methods of fibrosis evaluation. The most frequently prescribed drugs are: silymarin (88.2%), vitamin E (78.4%) and ursodeoxycholic acid (77.4%). The results of this survey suggest that clinical practice patterns among Romanian gastroenterologists for the diagnosis (mainly liver biopsy) and management of NAFLD frequently diverge from published practice guidelines. Nonalcoholic steatohepatitis is probably underdiagnosed, especially in patients with normal transaminase levels and is also overtreated with drugs that are not recommended in the guidelines.