Esophagogastroduodenoscopy In Patients Research Articles

Single-Center Review of Appropriateness and Utilization of Upper Endoscopy in Dyspepsia in the United States.

BackgroundWe compared real-world practice of dyspepsia management to the new American College of Gastroenterology (ACG)/Canadian Association of Gastroenterology (CAG) guidelines 2017.MethodsWe conducted a retrospective, observational study using administrative data to include patients undergoing esophagogastroduodenoscopy (EGD) for dyspepsia.ResultsOut of 122 EGDs, only 30 (24.5%) were deemed appropriate per guidelines. Only 13 (14.1%) patients had undergone both Helicobacter pylori (H. pylori) test and treat and adequate proton pump inhibitor (PPI) before undergoing endoscopy. Nineteen (15.5%) patients had alarm symptoms (weight loss, melena and early satiety). Positivity rate of H. pylori was 36.3%, but only half completed treatment. Twenty-six patients (21.3%) had abnormalities on endoscopy, most commonly gastritis. There were no cases of gastric/esophageal cancer.ConclusionsThe rate of inappropriate upper gastrointestinal endoscopy is higher than the existing literature, likely because of the stricter use of EGD in patients < 60 years. Only one in eight patients underwent the recommended workup before undergoing endoscopy.

A72 NON-INVASIVE PREDICTION OF ESOPHAGEAL VARICES BY TRANSIENT ELASTOGRAPHY AND PLATELET COUNT IN PATIENTS WITH HEPATITIS B AND ADVANCED CHRONIC LIVER DISEASE: VALIDATION OF BAVENO VI AND EXPANDED BAVENO VI CRITERIA

Abstract Background Patients with compensated advanced chronic liver disease (cACLD) are at higher risk of developing complications from portal hypertension, including esophageal varices (EV). Baveno VI and expanded Baveno VI criteria, based on liver stiffness measurement (LSM) by transient elastography combined with platelet count, have been proposed to avoid unnecessary esophagogastroduodenoscopy (EGD) screening for large esophageal varices needing treatment (EVNT). This approach has not been validated in patients with chronic hepatitis B virus (HBV) infection, who have etiology-specific cut-off of LSM for liver fibrosis. Aims We aimed to validate the Baveno VI and expanded Baveno VI criteria for EVNT in HBV patients with cACLD. Methods We performed a retrospective analysis of HBV patients who underwent LSM in 2014–2020. Inclusion criteria were: a) diagnosis of cACLD, defined as LSM &amp;gt;9 kPa; b) availability of EGD and platelets within 1 year of LSM. Baveno VI (LSM &amp;lt;20 kPa and platelets &amp;gt;150,000) and expanded Baveno VI criteria (LSM &amp;lt;25 kPa and platelets &amp;gt;110,000) were tested for EGD sparing. Diagnostic performance of these criteria against gold standard (EGD) was computed and compared to patients with hepatitis C virus (HCV) infection and nonalcoholic steatohepatitis (NASH) etiologies, where these criteria have been widely validated. In these patients, the threshold for cACLD definition was &amp;gt;10 kPa. Results A total of 287 patients (mean age 56, 95% Child A) were included, comprising of 43 HBV (58% on antiviral therapy), 134 HCV and 110 NASH patients. The prevalence of any grade EV and EVNT was 25% and 8% in the whole cohort, with 19% and 5% in HBV patients, respectively. Table 1 reports diagnostic performance, spared EGD and missed EVNT according to non-invasive criteria and cACLD etiology. Both Baveno VI and expanded Baveno VI criteria performed well in patients with HBV-related cACLD. There was no significant difference on diagnostic performance of these non-invasive criteria across the cACLD etiologies. Conclusions These results support use of non-invasive criteria based on LSM and platelets to spare unnecessary EGD in patients with HBV and cACLD. Baveno VI and expanded Baveno VI criteria can improve resource utilization and avoid invasive testing in context of screening EGD for patients with HBV-related cACLD. Funding Agencies None

A143 ACUTE ESOPHAGEAL NECROSIS: A COMPLICATION OF DIABETIC KETOACIDOSIS

Abstract Background Acute esophageal necrosis (AEN) is a rare entity associated with diabetic ketoacidosis (DKA). The pathogenesis is thought to be linked to low volume state, microvascular disease, impaired gastric and esophageal motility increasing acid reflex, all rendering the esophagus prone to injury. Aims We report a case of AEN as a complication of DKA in a patient without any overt gastrointestinal bleeding (GIB), along with a literature review. Methods Keywords “esophageal necrosis” and “diabetic ketoacidosis” were used in MEDLINE and BASE to retrieve English articles reporting cases of AEN in DKA. Results A 63 year old male with history of hypertension, dyslipidemia and non-insulin dependent diabetes mellitus presented to Emergency with 5 day history of severe epigastric pain, dysphagia to solids and liquids, nausea and vomiting (without any overt GIB). Most recent HbA1c was 8.4%. His diabetes was managed with metformin and semaglutide. Bloodwork revealed a hemoglobin of 165g/L and leukocytes of 17.9x109/L. Chemistries showed an anion gap of 25 with bicarbonate of 5mmol/L. Venous blood gas showed acidemia (pH=7.02). B-hydroxybutyrate level was 10.2mmol/L. Urinalysis was negative for leukocytes or nitrites. An abdominal CT ruled out bowel obstruction or intra-abdominal infection/abscess as the source of his discomfort but demonstrated circumferential wall thickening of the distal esophagus. No other triggers were found for this patient’s DKA except perhaps a recently started ketogenic diet. After resolution of DKA, he continued to experience severe epigastric pain, reflux symptoms, and dysphagia. An esophagogastroduodenoscopy (EGD) was performed, which showed AEN with circumferential black, necrotic inflammatory changes in the mid to distal esophagus. Erosions were seen in the body and antrum of the stomach, and multiple clean based ulcers were seen in the duodenum. Patient was started on an insulin regimen prior to discharge. Review of literature shows a total of 13 cases of AEN in DKA, with only one case where the patient did not present with any clinical bleeding. Risk factors for AEN include, hypertension, diabetes mellitus, malignancy, male gender, older age, chronic kidney disease, alcohol abuse and cardiovascular disease. While no medications have been linked to AEN, our patient was recently started on semiglutide, which has been implicated in impaired gastric emptying and increased GERD symptoms. This may further explain why the patient developed AEN. Conclusions AEN is a rare entity, especially in the context of DKA. Usually patients present with overt GIB; however, on occasion dysphagia, nausea, and vomiting can be the predominant symptoms. Hence, the threshold to perform EGD in patients with DKA should be low, given their low volume state and potentially impaired gastrointestinal motility due to microvascular disease or medications, putting them at higher risk for AEN. Funding Agencies None

Development and Validation of an Easy-to-Use Risk Scoring System for Screening High-Risk Varices in Patients with HBV-Related Compensated Advanced Chronic Liver Disease

BackgroundA large portion of patients with compensated advanced chronic liver disease (cACLD) do not have varices or only have low risk varices.AimsTo create and validate an easy-to-use risk scoring system to identify high-risk varices (HRV) and spare esophagogastroduodenoscopy (EGD) in patients with hepatitis B virus (HBV)-related cACLD.MethodsIn total, 334 patients with HBV-related cACLD who had undergone routine laboratory tests and ultrasound examination were enrolled. Multivariate logistic regression analysis was used to determine which variables were the independent risk factors for the presence of HRV, so as to establish the scoring system for screening HRV. The criteria were tested in a training cohort with 221 patients and validated in a validation cohort with 113 patients.ResultsIn the training cohort, the prevalence of HRV was 29.5%. Albumin (ALB) [OR 0.83; 95% confidence index (CI) 0.77–0.90; P < 0.0001], platelet count (PLT) (OR 0.96, 95% CI 0.96–0.99; P < 0.0001) and portal vein diameter (OR 1.40; 95% CI 1.15–1.71; P = 0.001) were independent risk factors for the presence of HRV. The negative predictive value was > 95%, when albumin-platelet-portal vein diameter varices scores (APP score) were < 0.24. One hundred twenty-five of 221 (56.6%) patients met an APP score < 0.24 with a 4.8% HRV miss rate. In the validation cohort, 59 of 113 (51.3%) patients met the APP score < 0.24 with a 1.7% HRV miss rate.ConclusionsAPP score is a potential model for safely screening HRV and sparing EGDs in patients with HBV-related cACLD.

Findings of Esophagogastroduodenoscopy in Patients Suspected of Upper Gastrointestinal Bleeding Referred to the Main Endoscopy Unit at King Fahad Specialist Hospital.

IntroductionUpper gastrointestinal bleeding (UGIB) is defined as any blood loss originating from the esophagus, stomach or the proximal duodenum above the ligament of Treitz. Ethnic trends regarding the causes of UGIB have been reported. The aim of this study was to identify the most common causes of UGIB among patients residing in Tabuk city, Saudi Arabia.MethodsWe have conducted a retrospective descriptive cohort study at King Fahad Specialist Hospital (KFSH), Tabuk, Saudi Arabia. All adult patients above the age of 18 years who were suspected of UGIB and referred for esophagogastroduodenoscopy (EGD) were included. The collected data included age, sex, nationality, complaint, EGD, and histopathologic findings.ResultsBetween January 1, 2017 and December 31, 2019, 73 patients were included. 83.6% were Saudi, and 64.4% were males. Hematemesis was the main complaint (65.8%). Esophagogastroduodenoscopy was normal in 6.84% of cases; however, it showed UGIB due to esophageal and gastric varices (9.57%) as well as non-variceal causes (83.56%). The most frequent non-variceal findings which represent about two-thirds of the cases were duodenal ulcer (20.53%), antral gastropathy (13.68%), gastric ulcer (12.32%), antral gastritis (10.94%), and duodenal/gastric mass (9.57%), whereas much less frequent findings representing a total of 16.39% of cases included Cameron gastropathy, gastropathy/duodenopathy, esophagitis/gastritis, gastritis/duodenitis, gastroesophageal reflux disease (GERD), and Mallory-Weiss tear.ConclusionNon-variceal causes showed higher prevalence as causes of UGIB than variceal causes in the Tabuk area. Furthermore, chronic duodenal and gastric ulcers were the most common culprits of bleeding, whereas duodenitis, gastritis, esophagitis, and Mallory-Weiss syndrome were the least common non-variceal causes.

Clinical significance of esophagogastroduodenoscopy in patients with esophageal motility disorders.

The first aim of this study was to elucidate the detection rate of esophagogastroduodenoscopy (EGD) in patients complaining of dysphagia with esophageal motility disorders; the second was to clarify the useful parameters of EGD associated with esophageal motility disorders. Participants included 380 patients who underwent EGD before high-resolution manometry (HRM) for dysphagia. EGD findings were investigated according to the following five parameters: resistance when passing through the esophagogastric junction (EGJ), residue in the esophageal lumen, esophageal dilation, and spastic and nonocclusive contractions. HRM diagnoses were based on the Chicago classification (v3.0). The percentage of abnormal EGD findings was 64.4% among patients with esophageal motility disorders, and the results differed for each esophageal motility disorder. The rate of abnormal EGD for both EGJ outflow obstruction and major disorders of peristalsis was significantly higher than that for manometrically normal subjects. On multivariate analysis, resistance when passing through EGJ, residue in the esophageal lumen, spastic and nonocclusive contraction were significantly associated with esophageal motility disorders. The sensitivity, specificity, positive predictive value, and negative predictive value of these parameters for detection of esophageal motility disorders were 75.1%, 86.6%, 84.8% and 77.8%, respectively. Esophagogastric junction outflow obstruction and major disorders of peristalsis can be screened with EGD. Among several endoscopic parameters, resistance when passing through EGJ, residue in the esophageal lumen, spastic and nonocclusive contraction are considered significantly useful indicators.

Screening Esophagogastroduodenoscopy Before Laparoscopic Sleeve Gastrectomy: Results in 819 Patients.

Aim: The routine use of esophagogastroduodenoscopy (EGD) during the preoperative evaluation of surgical weight loss candidates is controversial. The aim of this study is to evaluate the findings of preoperative EGD in patients who are scheduled for a primary laparoscopic sleeve gastrectomy (LSG). The probable effect of these findings on the medical and surgical strategy that was followed is assessed. Methods: Findings of EGD obtained from consecutive LSG candidates and all data were prospectively recorded and retrieved from the database. Results: A total of 819 patients underwent EGD successfully. Mean age and body mass index were 38 ± 11.3 and 43.17 ± 7.2 kg/m2, respectively. Fifty-eight percent were female. EGD of 263 (32.1%) patients was normal and 687 (84%) patients were asymptomatic. At least one abnormal finding was detected in 65% of the asymptomatic patients. Abnormal findings that did not change the surgical strategy were found in 550 patients (67.2%). Findings such as gastritis or duodenitis that changed the medical management before surgery were found in 309 patients (38.2%). Helicobacter pylori was positive in 218 (26.6%) patients but eradication treatment was not applied in the preoperative period. No pathology was detected that would create absolute contraindication or change the type of surgery in any patient. Only technical modifications were required in 13% due to hiatal hernia. The timing of the planned surgery has changed in only 6 patients (0.74%) (early stage neuroendocrine tumor, leiomyoma, severe ulcer). Conclusions: Routine EGD performed before LSG did not change the planned bariatric option in any patient, but led to 13% rate of technical modifications due to the presence of hiatal hernia. At least one abnormal finding was detected in 65% of asymptomatic patients. Due to endoscopic findings, the rate of patients who started medical acid-suppression treatment in the preoperative period was 38%.

Risk of Gastrointestinal Endoscopic Procedure-Related Bleeding in Patients With or Without Continued Antithrombotic Therapy.

Prospective studies on bleeding risk during/after gastrointestinal endoscopic procedures are rare. We investigated the risk of endoscopic procedure-related bleeding in patients with biopsy and/or cold snare polypectomy (CSP) in relation to antithrombotic therapy. This prospective, observational single-center cohort study (NCT02594813) enrolled consecutive patients who underwent diagnostic esophagogastroduodenoscopy (EGD) or colonoscopy. The primary outcome measure was delayed bleeding in patients with biopsy and/or CSP who required endoscopic treatment within 2weeks post-procedure. The secondary outcomes were immediate bleeding and the number of hemostatic clips used during the procedure. From November 2015 to October 2018 at our institution, 3069 (mean age, 66years) and 37,887 (57years) patients underwent EGD with and without antithrombotic therapy, respectively. In addition, 1116 (72years) and 11,901 (65years) patients had colonoscopy with and without antithrombotic therapy, respectively. In the 3069 EGD patients receiving antithrombotic therapy, no delayed bleeding occurred, whereas immediate bleeding occurred in 9 of 141 patients (6.4%) with biopsy. Of the 1116 colonoscopy patients receiving antithrombotic therapy, delayed bleeding occurred in three of 228 (1.3%) following CSP. Immediate bleeding occurred in nine of 225 (4%) following biopsy and in 32 of 228 (14%) following CSP. Multivariate analysis following univariate analysis identified chronic kidney disease and CSP as factors significantly associated with procedure-related bleeding in patients taking antithrombotic agents. The risk of delayed bleeding in diagnostic EGD with biopsy or in colonoscopy with biopsy and/or CSP was low despite continuation of antithrombotic therapy.

Requerimiento de hemostasia endoscópica en pacientes de una unidad de cuidado intensivo con hemorragia de vías digestivas altas

Introducción: los pacientes hospitalizados en la unidad de cuidados intensivos (UCI) tienen riesgo de hemorragia digestiva alta (HVDA). La endoscopia digestiva alta (EVDA) es el examen de elección en esos pacientes y es diagnóstica y terapéutica. Muchas lesiones identificadas endoscópicamente no requieren tratamiento endoscópico. En Colombia no hay estudios sobre la prevalencia de las diferentes lesiones sangrantes digestivas altas en pacientes de la UCI, ni sobre la utilización de EVDA terapéutica en esos pacientes.&#x0D; Materiales y métodos: estudio de corte transversal realizado en la Clínica Fundadores de Bogotá, Colombia, entre enero del 2003 a febrero del 2017. Se incluyeron pacientes adultos de la unidad de cuidado intensivo con EVDA indicada por HVDA.&#x0D; Resultados: en el análisis final se incluyeron 156 EVDA. Los hallazgos fueron los siguientes: gastritis crónica 76,62% (118), esofagitis erosiva (grado A-grado D) 57,79% (89), gastritis erosiva 47,4% (73), duodenitis erosiva 21,43% (33), úlcera gástrica 18,18% (28), varices esofágicas 11,69% (18), úlcera duodenal 11,04% (17) y desgarro de Mallory-Weiss 4,55% (8). Solo el 15% de los pacientes requirió manejo endoscópico, incluidos los que tenían várices esofágicas.&#x0D; Conclusión: en el presente estudio, el 15% de los pacientes con HVDA requirió tratamiento endoscópico. Se deben realizar trabajos prospectivos que permitan establecer factores de riesgo que puedan predecir la necesidad de EVDA terapéutica en pacientes con HVDA. Quien no tenga esos predictores se debe tratar empíricamente con IBP y evitar gastos innecesarios en EVDA diagnósticas.

246 Helicobacter pylori Infection Increases the Risk of Colorectal Polyps: A Large Scale Case-Control Study

INTRODUCTION: Persistent Helicobacter pylori (H. pylori) infection begins during childhood and can cause peptic ulcers and gastric cancer. It can also cause extra-gastric organ disease, including idiopathic thrombocytopenic purpura. Although some studies have indicated a correlation between H. pylori infection and the risk of colorectal neoplasms, these findings have not been consistent and are controversial. This case-control study aimed to investigate the association between H. pylori-associated endoscopic gastric mucosal atrophy (GMA) and colorectal polyp occurrence. METHODS: Records of 7394 participants who underwent colonoscopy examinations from August 2008 to July 2018 were reviewed retrospectively. Saved images of endoscopic examinations were used to evaluate the colorectal polyps and GMA. Adjusted odds ratios for predictors of colorectal polyps were computed by using the multiple logistic regression model. RESULTS: A total of 2404 subjects were registered; 1565 (65.1%) were in the GMA-positive group and 1138 (47.3%) had colorectal polyps. The multivariate analysis adjusted by age, sex, smoking habits, alcohol habits, serum lipid levels, hemoglobin A1c (HbA1c), blood pressure, and body mass index indicated that patients in the GMA-positive group more frequently had colorectal polyps compared with patients in the GMA-negative group (odds ratio [OR], 3.27; 95% confidence interval [CI], 2.68–4.01; P &lt; 0.001). An analysis of the association between GMA degree and colorectal polyp status indicated that, compared with mild GMA, severe GMA was associated with a higher risk of proximal colon polyps (OR, 1.47; 95% CI, 1.05–2.07; P = 0.024) and two or more colorectal polyps (OR, 1.80; 95% CI, 1.30–2.49; P &lt; 0.001). CONCLUSION: Colonoscopy examination is useful for discovering colorectal disease, including polyps; however, the examination is more burdensome than esophagogastroduodenoscopy for patients because of the required preparation and invasiveness. This study showed H. pylori-associated GMA found during endoscopy indicated an increased risk for colorectal polyps. Moreover, it also showed severe GMA indicated risks for proximal colon polyps and multiple polyps. These results allow physicians to recommend colonoscopy examinations for specific patients.

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.

Comparison of Diagnostic Yield of Endoscopy in Patients with Chronic Anemia with and Without Iron Deficiency: A Retrospective Study in the United States Veterans Affairs Population

Background/Aims: Iron deficiency anemia is a very common reason for referral. There are few recommendations regarding the utility of endoscopy in the mixed anemia and anemia of chronic disease groups. We evaluated the endoscopic diagnostic yield in anemic patients who do not meet criteria for iron deficiency anemia. Methods: We retrospectively reviewed electronic records of 240 patients who underwent endoscopy between January 2010 and December 2013 for anemia (hemoglobin of ≤12.5 gm/dl). We categorized patients into anemia due to iron deficiency, chronic disease and mixed based on transferrin iron saturation and serum ferritin level. Diagnostic yield of esophagogastroduodenoscopy, colonoscopy, and video capsule endoscopy were compared. We used severe anemia, requirement of blood transfusion, and use of anticoagulant/antiplatelet agents to examine differences in endoscopic diagnostic yield. Results: There were no differences in diagnostic yield among the three anemia groups, surprisingly, except for a slightly higher yield for esophagogastroduodenoscopy in patients with mixed anemia as compared to iron deficiency anemia (38% vs 23%, p=0.044). Severe anemia slightly increased endoscopic diagnostic yield for esophagogastroduodenoscopy, only in patients with iron deficiency anemia, but not in those with mixed anemia or anemia of chronic disease. Conclusion: Patients with iron deficiency anemia, anemia of chronic disease, and mixed anemia do not differ in endoscopic diagnostic yield. Funding Statement: None. Declaration of Interests: The authors of this research do not have any conflicts of interest to declare. Ethics Approval Statement: The IRB for this study was approved through the Wright State University IRB committee and Dayton Veterans Affairs Medical Center on April 4th, 2016.

Diagnostic Yield of Endoscopy in Patients with Chronic Anemia Without Classic Iron Deficiency: A Retrospective Study in the U.S. Veterans Population

Introduction: In the developed world, iron deficiency anemia (IDA) occurs in 2 to 5% of adult men and postmenopausal women and is a common reason for gastroenterology referrals. Patients undergoing investigation may instead have anemia of chronic disease (ACD) or have mixed anemia (MA). While IDA is an established indication for endoscopic investigation, there are few recommendations regarding the utility of endoscopy in the MA and ACD groups. In this retrospective study, we evaluated the endoscopic diagnostic yield (EDY) in anemic patients who do not meet criteria for IDA. Methods: We retrospectively reviewed electronic medical records of 240 patients in the Veterans Affairs population who underwent endoscopy between January 2010 and December 2013 for anemia, which was defined as hemoglobin (Hgb) of ≤12.5 gm/dl. We categorized patients into IDA, ACD and MA based on transferrin iron saturation and serum ferritin level. We then compared the EDY of esophagogastroduodenoscopy (EGD), colonoscopy (CSP), and video capsule endoscopy (VCE) among the three groups of anemia. We used severe anemia (defined as Hgb of ≤7 gm/dl), requirement of blood transfusion, and use of anticoagulant/antiplatelet agents to examine differences in EDY within each of the three groups of anemia. Results: There were no differences in EDY among the three anemia groups, except for, surprisingly, a slightly higher yield for EGD in patients with MA as compared to IDA (38% vs 23%, p=0.044). Requirement for blood transfusion and use of anticoagulant-antiplatelet agents did not lead to increased EDY within each of the three groups. Only severe anemia (Hgb ≤7gm/dl), slightly increased EDY for EGD in patients with IDA, but not in those with MA or ACD. Conclusion: In our sample of 240 patients, EGD was performed in 90% of patients, CSP in 78% and VCE in 13% of patients. While we anticipated that IDA would have a higher diagnostic yield than MA or ACD, our study did not find this to be the case for any of the three procedures. Our findings suggest that endoscopy may be beneficial even in patients without classic iron deficiency anemia. In the absence of formal guidelines, future prospective studies are suggested for the use of endoscopy in patients with chronic anemia and absence of classic iron deficiency. This should account for the limitations that were noted in our study.487_A Figure 1. Baseline Demographic, Laboratory and Clinical Characteristics.487_B Figure 2. Pairwise comparison of diagnostic yield: IDA, mixed anemia, and ACD487_C Figure 3. Comparison of endoscopic yield based on requirement of blood transfusion, use of anti-platelet or anti-thrombotic agent, and severe anemia.

PS01.013: CLINICAL SIGNIFICANCE OF ESOPHAGOGASTRODUODENOSCOPY IN PATIENTS WITH ESOPHAGEAL MOTILITY DISORDERS

Abstract Background Although dysphagia is an indication for esophagogastroduodenoscopy (EGD) its causes include organic and non-organic disorders. There has been no study to investigate the clinical significance of EGD in patients with esophageal motility disorders (EMD). The first aim was to elucidate the detection ratio for EMD with EGD. The second aim was to clarify useful EGD parameters associated with them. Methods Participants included 372 patients who underwent EGD before high resolution manometry for dysphagia. EGD findings were investigated according to the following five parameters: resistance when passing through the esophagogastric junction (EGJ), residue in the esophageal lumen, esophageal dilation, spastic and non-occlusive contraction. The EGD finding was positive when at least one EGD finding was detected. HRM diagnoses were made based on the Chicago classification (v3.0). Results Of 372 participants, pseudoachalasia were diagnosed in 6 patients (1.61%), EMD in 250, and normal in 116. The detection ratio for each EMD by EGD is shown in Table 1. There were significant differences in the detection ratio among the three groups (81.1% in major, 50.0% in minor EMD and 15.5% in normal, P &lt; 0.05). On multivariate analysis, resistance when passing through the EGJ (adjusted odds ratio (aOR): 3.99; 95% CI [1.26–12.66]), and non-occlusive contraction (aOR: 10.3; 95% CI [5.26–20.19]) were significantly associated with EMD. Conclusion The ratio of abnormal EGD findings was different in each EMD. Major EMD can be screened with EGD. Among several endoscopic parameters related with EMD, the non-occlusive contraction is most useful endoscopic parameter. Disclosure All authors have declared no conflicts of interest.

СУЧАСНІ АСПЕКТИ ДІАГНОСТИКИ ГАСТРОЕЗОФАГЕАЛЬНОЇ РЕФЛЮКСНОЇ ХВОРОБИ

Резюме: Гастроезофагеальна рефлюксна хвороба (ГЕРХ) надзвичайно поширене захворювання зумовлене порушенням моторно-евакуаторної функції органів гастроезофагеальної зони, яке характеризується спонтанним закидом шлункового або дуоденального вмісту в стравохід, що призводить до ураження його дистального відділу з розвитком у ньому запальних та ерозивно-виразкових уражень. Серед дорослого населення поширеність ГЕРХ становить до 40%.Мета роботи − проаналізувати сучасні погляди науковців і основні методи діагностики ГЕРХ.В діагностиці ГЕРХ потрібно орієнтуватися на рекомендації Монреальського консенсуса, згідно якого захворювання може бути діагностовано при наявності як мінімум одного із трьох критеріїв: а) характерних симптомів захворювання; в) інструментального підтвердження наявності патологічного гастроезофагеального рефлюксу в осіб з симптомами ГЕРХ; с) змін слизової оболонки стравоходу, гістологічного дослідження біоптату.Згідно V Маастрихтcького консенсусу рекомендовано проводити ерадикацію H-pylori незалежно від наявності чи відсутності симптомів ГЕРХ при наявності прямих показів.Діагноз ГЕРХ встановлюється на підставі клінічних критеріїв, якщо пацієнта турбує печія більше ніж двічі на тиждень впродовж трьох місяців і довше. Для діагностики ГЕРХ запропоновані тест з ІПП, альгінатний тести. Показом до проведення езофагогастродуоденоскопії (ЕГДС) у пацієнтів з ГЕРХ є наявність тривожних симптомів (дисфагія, нудота, кровотеча, зменшення маси тіла), неефективність пробного лікування (негативні альгінатний або омепразоловий тести), тривалий перебіг захворювання, вік більше 50 років. ЕГДС виконують для виявлення або виключення значних пошкоджень в окремих випадках. При типових симптомах ГЕРХ проводити ЕГДС не потрібно. При проведенні ЕГДС беруть біоптат стравоходу при ускладненнях ГЕРХ, новоутвореннях, для діагностики еозинофільного езофагіту. Для кількісного визначення впливу кислоти на стравохід та оцінки асоціації між печією та епізодами рефлюксу використовують рН-метрію в стравоході або імпеданс-метрію протягом 24 год. Стравохідний імпеданс рН застосовують у пацієнтів зі стійкими симптомами рефлюксу, які погано відповіли на стандартну терапію для оцінки як кислотної, так і некислотної рефлюксної хвороби. Для виявлення мінімальних уражень слизової оболонки стравоходу у хворих на ГЕРХ застосовують хромоскопію, ендоскопію з високою роздільністю та збільшенням, вузьку спектральну ендоскопію.Таким чином, основним методом діагностики гастроезофагеальної рефлюксної хвороби є езофагогастродуоденоскопія. Сучасні ендоскопічні технології дають можливість діагностувати ГЕРХ на ранній стадії.

The utility of routine esophagogastroduodenoscopy before laparoscopic Roux-en-Y gastric bypass

BackgroundThe routine use of esophagogastroduodenoscopy (EGD) before laparoscopic Roux-en-y gastric bypass (LRYGB) is debatable. Various studies have reported high diagnostic yield of routine EGD before LRYGB to detect pathologies that could alter surgical management. However, other studies have found that preoperative EGD did not identify significant pathologies that changed clinical management; therefore, it is not indicated in asymptomatic patients. ObjectivesWe aimed to study the utility of routine EGD in patients before LRYGB. SettingAcademic teaching hospital, (Royal Alexandra Hospital, Canada). MethodsA retrospective review of patients undergoing LRYGB with 1 surgeon at our hospital from May 2014 to March 2016 was completed. EGD findings were compared with surgical gastrojejunal specimen pathology and postoperative complications. ResultsThere were 116 patients who underwent EGD before LRYGB with 113 reported EGDs, of which 46.0% were normal, 40.7% had findings that did not result in a change of management, and 13.3% had findings resulting in a change of management. In the gastrojejunal specimen, 16 patients (14.2%) were found to have chronic gastritis. The relative risk of patients having gastrojejunal gastritis was 5.1 (P<.0005) for patients with gastritis on EGD and 5.1 (P<.0005) for patients with Helicobacter pylori infection on EGD. After surgery, 18 patients (15.9%) had complications. Preoperative EGD findings were not associated with postoperative complications. ConclusionBased on the findings from this study, we recommend using less invasive screening in the routine workup of patients awaiting LRYGB and reserving EGD for symptomatic patients.

Use of volumetric laser endomicroscopy for dysplasia detection at the gastroesophageal junction and gastric cardia.

AIMTo determine specific volumetric laser endomicroscopy (VLE) imaging features associated with neoplasia at the gastroesophageal junction (GEJ) and gastric cardia.METHODSDuring esophagogastroduodenoscopy for patients with known or suspected Barrett’s esophagus, VLE was performed before biopsies were taken at endoscopists’ discretion. The gastric cardia was examined on VLE scan from the GEJ (marked by top of gastric folds) to 1 cm distal from the GEJ. The NinePoints VLE console was used to analyze scan segments for characteristics previously found to correlate with normal or abnormal mucosa. Glands were counted individually. Imaging features identified on VLE scan were correlated with biopsy results from the GEJ and cardia region.RESULTSThis study included 34 cases. Features characteristic of the gastric cardia (gastric rugae, gastric pit architecture, poor penetration) were observed in all (100%) scans. Loss of classic gastric pit architecture was common and there was no difference between those with neoplasia and without (100% vs 74%, P = NS). The abnormal VLE feature of irregular surface was more often seen in patients with neoplasia than those without (100% vs 18%, P < 0.0001), as was heterogeneous scattering (86% vs 41%, P < 0.005) and presence of anomalous glands (100% vs 59%, P < 0.05). The number of anomalous glands did not differ between individual histologic subgroups (ANOVA, P = NS).CONCLUSIONThe transition from esophagus to gastric cardia is reliably identified on VLE. Histologically abnormal cardia mucosa produces abnormal VLE features. Optical coherence tomography algorithms can be expanded for use at the GEJ/cardia.

Oesophagogastroduodenoscopy in patients with incidental cholelithiasis, its significance and therapeutic value: an observational study

Background:Cholelithiasis along with other causes of upper abdominal pain, have a similar mode of presentation. Often the cholelithiasis is an incidental finding not causative. Aims and objectives of this study was to determine the role of oesophagogastroduodenoscopy (OGDscopy) in patients presenting with upper abdominal pain and sonographically documented cholelithiasis being considered for cholecystectomy and to eliminate the confounding causes of pain and avoiding cholecystectomy in incidental cholelithiasis.Methods: 200 patients with upper abdominal pain (typical/atypical) and sonographically documented gallstones underwent OGDscopy. Patients with normal OGDscopy underwent cholecystectomy while it was deferred in those with positive OGDs copy findings. These patients were appropriately managed and followed up with a repeat OGDscopy at 6 weeks. All patients were re-assessed for resolution of symptoms at 6 weeks and those with persistence of symptoms in spite of a normal OGDscopy on reassessment were then subjected to cholecystectomy. Pearson’s chi-square test was applied to study association between type of pain (typical/atypical) and OGDscopy findings and type of pain (typical/atypical) and requirement for cholecystectomy.Results:Of the 200 patients, 120 presented with typical and 80 with atypical pain. Among those with atypical pain (n = 80), a significant 95% (76/80) had positive findings on OGDscopy while none of those with typical pain had positive finding on OGDscopy (p&lt;0.005). Cholecystectomy to relieve pain was needed in all 120 patients with typical pain while only 17.5% (14/80) of those with atypical pain required cholecystectomy (p&lt;0.005).Conclusions:The study shows that OGDscopy in patients with cholelithiasis can suggest alternative management plan particularly in those with atypical pain.

Recalcitrant Gastroesophageal Reflux Disease in the Setting of a Gastroesophageal Junction Mass

In this case study, a sixty-three year old African American female with significant past medical history postsurgical hypothyroidism, hypertension, gastroesophageal reflux disease (GERD) presented with ongoing complaints of severe retrosternal burning associated with regurgitation. She had severe typical GERD symptoms despite twice a day PPI therapy. She had pH impedance testing on therapy which revealed abnormal esophageal acid exposure on therapy(>2.4% total esophageal acid exposure time). She underwent esophagogastroduodenoscopy (EGD) to evaluate for a source for her symptoms which revealed a freely prolapsing mass at the gastroesophageal junction. The location and dimension of the mass compromised the lower esophageal sphincter (LES) leading to her recalcitrant GERD. The patient was scheduled for laparoscopic Nissen fundoplication with transgastric resection of the gastric mass. Pathology of the intra gastric mass indicated benign sub-epithelial simple cyst. Overlying squamocolumnar junction mucosa with changes suggestive of GERD. At two weeks post op, she was significantly better. She had resolution of her previous symptoms and was no longer taking her PPI. She reported no significant dysphagia and no abdominal pain.Figure 1Discussion: Recalcitrant GERD is a common diagnostic dilemma that gastroenterologist evaluate. This case illustrates a novel cause of recalcitrant GERD secondary to benign sub-epithelial simple cyst creating lower esophageal sphincter incompetence which improved after resection. This case underscores the importance of EGD in patients who fail medical therapy.

Is gastroscopy for fecal immunochemical test positive patients worthwhile?

The use of fecal immunochemical test (FIT) in the screening for colorectal cancer is long established. However, more than 50% of patients with positive FITs have a negative colonoscopy. The role of a subsequent oesophago-gastro-duodenoscopy (OGD) is debatable. The aim of this study is to evaluate the yield of OGD in patients with positive FITs. A retrospective review of patients who underwent colonoscopy for a positive FIT between Jan. 2008 and Dec. 2012 was identified from a prospectively collected endoscopy database at the National University Hospital, Singapore. Patients who underwent concurrent or subsequent OGDs for positive FIT formed the study group. We considered any new cancer or significant upper gastrointestinal pathology such as peptic ulcer disease or gastritis requiring treatment as a positive examination. A total of 202 patients underwent both a colonoscopy and an OGD for a positive FIT and formed the study group. One hundred and six (52.5%) of them had a positive examination with gastritis and duodenitis representing the most common UGI pathology in 89 (44.1%) patients. Twenty-nine (14.4%) patients tested positive for helicobacter pylori infection and another 16 (7.9%) patients had peptic ulcer disease. There were no UGI cancers detected. One patient had an esophageal leiomyoma that was treated conservatively. Routine gastroscopy for FIT positivity has a high diagnostic yield for benign upper gastrointestinal pathology. Well-designed prospective studies to further evaluate the cost-effectiveness of routine gastroscopy in the work up of FIT positivity are warranted to make better clinical practice guidelines.