Gastroenterology Service Research Articles

Telemedicine in Pediatric Gastroenterology: An Overview of Utility.

The availability of pediatric subspecialty services is a problem evident throughout the United States. Access to pediatric gastroenterology services, especially in rural areas, can be scarce. Telemedicine has been proposed as a tool capable of decreasing healthcare costs while extending medical care. The purpose of this article is to review available literature regarding the utility of telemedicine as it applies to pediatric gastroenterology, specifically its role in eliminating healthcare disparities. Research articles were identified through a PubMed search with key words focusing on telemedicine initiatives in pediatric gastroenterology, pediatric subspecialty, rural pediatric care, and adult gastroenterology. Studies were categorized based on the following areas of application: financial, time management, communication/community, and patient health and satisfaction. We reached the conclusion that evidence-supported trends in available literature provide a framework for pediatric gastroenterology telemedicine initiatives that can provide resource-sparing, community-enriching, and physician-improving services that ultimately serve to better patient health.

Reducing Redundant Anaerobic Therapy Through Spaced Education and Antimicrobial Stewardship Interventions.

Decreasing the use of redundant anaerobic therapy is a key target for antimicrobial stewardship. Education techniques that optimize knowledge retention could be an important component of reducing these regimens. We implemented a quality improvement project that incorporated spaced education to reduce the use of redundant anaerobic therapy. The initial interventions (November through December 2015) included education in a hospital-wide newsletter and review of redundant anaerobic regimens by the antimicrobial stewardship program. A spaced education module was then developed with the gastroenterology (GI) service, which had a relatively high rate of redundant anaerobic therapy use. Ten questions with teaching points were delivered to GI physicians at spaced intervals over 2 to 4 weeks (February through March 2016). Knowledge scores were compared at initial and final question presentation using generalized estimating equations. Interrupted time-series analysis was used to compare the rates of redundant-metronidazole-days per 1000 patient-days among patients in the patients admitted to the GI service and those in the non-GI group before and after the intervention. Of 66 GI physicians, 56 (85%) participated in the spaced education activity. After the intervention, their knowledge scores on all the questions improved, and their mean knowledge score increased from 57% to 86% (P < .001). Nearly all (91%) of the participants were very or generally satisfied with the activity. In the GI group, the rate of redundant-metronidazole-days decreased from 26.2 to 13.0 per 1000 patient-days (relative risk [RR], 0.45 [95% confidence interval (CI), 0.27-0.73]; P = .001). This rate in the non-GI group also decreased from 5.47 to 2.18 per 1000 patient-days (RR, 0.47 [95% CI, 0.36-0.60]; P < .001) after our interventions. Spaced education is an effective approach for teaching antimicrobial stewardship topics. Focused provider education was associated with a sustained reduction in the use of redundant anaerobic therapy.

Translation and cultural adaptation of the Pediatric Eosinophilic Esophagitis Symptom Score (PEESS v2.0)

ObjectivesTo translate and culturally adapt the Pediatric Eosinophilic Esophagitis Symptom Score (version 2.0), a tool used to assess pediatric eosinophilic esophagitis symptoms reported by patients and/or their parents/caregivers. MethodsThe Pediatric Eosinophilic Esophagitis Symptom Score was translated through the following stages: initial translation, back-translation, and consensus of independent reviewers through the Delphi technique. The pre-final version of the Pediatric Eosinophilic Esophagitis Symptom Score was applied to five 8-to-18-year-old patients and to ten parents of two-to-18-year-old patients from an outpatient pediatric gastroenterology service (pre-test). ResultsDuring the translation process, no translations presenting with difficult consensus in the review process or grammar inconsistencies were observed. During the pre-test, difficulties in comprehension of some unconventional terms, e.g., “náusea”, were observed. Adverbs of frequency, such as “quase nunca” were also identified as being of difficult understanding by patients and parents, and the substitution by the term “raramente” was suggested. Such difficulties may be inherent to the pediatric age group. Age 8 years or above should be considered adequate for the self-reporting of symptoms. ConclusionsThe study presents the Brazilian version of the Pediatric Eosinophilic Esophagitis Symptom Score, which is adapted to the Brazilian culture. This version may be introduced as a clinical and research tool for the assessment of patients with esophagic disease symptoms. The Pediatric Eosinophilic Esophagitis Symptom Score is a breakthrough in the evaluation of symptoms of pediatric eosinophilic esophagitis, since it reinforces the importance of self-reporting by patients who experience this disease.

Prevalence of Barrett's esophagus: An observational study from a gastroenterology clinic.

Barrett's esophagus is a condition that predisposes to esophageal adenocarcinoma. Our aim was to establish the prevalence of Barrett's esophagus at our center, as well as determine its associated factors. We retrospectively assessed the endoscopic reports of 500 outpatients seen at our Gastroenterology Service from November 2014 to April 2016. We determined the prevalence of Barrett's esophagus and analyzed the demographic, clinical, and endoscopic findings associated with that pathology. The prevalence of Barrett's esophagus was 1.8%. The mean age of the patients with Barrett's esophagus was 58.7 years (range: 45-70) and there was a predominance of men (66%). In the subgroup of patients with symptoms of gastroesophageal reflux (n=125), Barrett's esophagus prevalence was 7.2%. In the multivariate analysis, the factors that were independently associated with Barrett's esophagus were gastroesophageal reflux (P=.005) and hiatal hernia (P=.006). The overall prevalence of Barrett's esophagus was 1.8% in our population, with a prevalence of 7.2% in patients that had symptoms of gastroesophageal reflux.

Microscopic Polyangiitis Masquerading as Pancreatitis

A 72-year-old female with a history of diverticulitis status post partial sigmoid colectomy, hypertension, hyperlipidemia, and osteoarthritis on chronic NSAIDs, presents with 2 months of progressive nausea, vomiting, early satiety, unintentional weight loss and abdominal pain. During an initial hospitalization she was noted to have a lipase of 1200 U/L and amylase of 130 U/L, but abdominal ultrasound did not demonstrate any gallstones or abnormality of the liver, pancreas, gallbladder or bile ducts. Laboratory findings included leukocytosis, elevated AST, ALT, alkaline phosphatase and GGT. The patient was taking acyclovir for herpes infection and was presumed to have druginduced pancreatitis, and she was discharged off acyclovir. However, her symptoms recurred along with cough and subjective fevers, and she continued to have elevated lipase and liver blood tests. CT abdomen and pelvis revealed no acute abnormalities except for a small lesion within the tail of the pancreas. Chest x-ray demonstrated diffuse bronchial wall thickening and mild bronchial opacities. The patient was admitted to the Gastroenterology service for work-up, and treated for presumed hospital-acquired pneumonia. EGD revealed no abnormalities and duodenal biopsies were negative for pathology. She was discharged, yet she again returned with similar symptoms and lab findings, except creatinine had elevated from 1.1 to 2.3 mg/dL and inflammatory markers were markedly elevated. Evaluation for vasculitis was positive for MPO and p-ANCA. Renal biopsy demonstrated pauci-immune necrotizing vasculitis. The patient was treated with steroids and rituximab, but developed alveolar hemorrhage requiring cyclophosphamide. Review of the literature reveals that abdominal pain (˜30-60%) and abnormal liver blood tests (˜85%) are common in patients with microscopic polyangiitis and other ANCA associated vasculitides. However, gastrointestinal signs and symptoms can be quite variable. There are scattered case reports of ANCA associated vasculitides mimicking inflammatory bowel disease, isolated bowel necrosis, cholecystitis and pancreatitis. Depending on the type of vasculitis, either pulmonary or renal involvement is almost always present. This case illustrates that the initial presentation of microscopic polyangiitis may be gastrointestinal, and that a broad differential should be considered in patients with vague complaints and multiorgan findings.

Clinical outcomes of a dietitian and nurse led coeliac clinic for children

Dietitian and Nurse led Coeliac Clinic (DNLCC) is a clinic model for coelic disease (CD) run in the United Kingdom (UK) by dietitians and nurses. Once patients are diagnosed with CD, they are assessed by a doctor only at diagnosis and thereafter they are exclusively followed-up under the DNLCC. Our aim was to assess the efficacy of this model in a paediatric gastroenterology service from a tertiary level Hospital in Cambridge, UK.

Frequency and Variables Associated with Fasting Orders in Inpatients with Ulcerative Colitis: The Audit of Diet Orders-Ulcerative Colitis (ADORE-UC) Study.

Current clinical practice guidelines suggest that patients with ulcerative colitis (UC) hospitalized because of a disease flare should be offered a normal diet, unless such a diet is not tolerated. Studies of hospitalized patients have demonstrated iatrogenic malnutrition from unjustified or inappropriate nil per os (NPO) or clear liquid diet (CLD) orders. In this study, we aim to characterize the burden of this problem in hospitalized patients with UC. We conducted a retrospective cohort study of all patients with UC admitted to the gastroenterology service or the general internal medicine service at a tertiary, academic hospital between January 2009 and December 2014, with a length of stay between 2 and 30 days. The frequency and duration of bowel rest and CLD orders was recorded, and the number of meals missed because of these orders was assessed. NPO or CLD diet orders were considered justified if the patient had intractable nausea or vomiting, pancreatitis, bowel obstruction, toxic megacolon or were awaiting endoscopy, or if alternative enteral nutrition was provided. Clinical and demographic factors associated with unjustified underfeeding were identified. A total of 187 admissions among 158 patients with UC were identified during the study period and included in the final analysis. Most admissions were to the gastroenterology service (148/187, 79.1%). The mean age at admission was 35.0 years (SD = 15), and 83/158 (52.5%) were female. The median length of stay was 8 days (interquartile range = 4-12). Registered dietician consultation was obtained in only 32 admissions (17.1%), and admission weight was recorded in only 68 (36.4%) admissions. A total of 252 NPO or CLD dietary orders were encountered in 142 admissions (75.9%). Of those, 112 orders were unjustified (44%). On average, patients with unjustified NPO or CLD orders spent 3 days on an NPO or CLD diet, which corresponded to a mean of 10 missed meals. Characteristics associated with unnecessary fasting included female gender, less frequent endoscopic disease staging, less frequent escalation of therapy to prednisone and/or biologics, and admission to a non-gastroenterology service. There is a high burden of unjustified underfeeding among hospitalized patients with UC, particularly in patients admitted without evidence of objective disease flare. This may lead to nutritional compromise in an at-risk population, and further studies are needed to assess the nutritional impact of unjustified bowel rest on patients with UC. Our findings also suggest that targeted quality improvement interventions are needed to decrease the frequency of inappropriate bowel rest among hospitalized patients with UC.

Criterios de cribado de enfermedad inflamatoria intestinal y espondiloartritis para derivación de pacientes entre Reumatología y Gastroenterología

ObjectiveTo define clinical screening criteria for spondyloarthritis (SpA) in patients with inflammatory bowel disease (IBD) and vice versa, which can be used as a reference for referring them to the rheumatology or gastroenterology service. MethodSystematic literature review and a two-round Delphi method. The scientific committee and the expert panel were comprised of 2 rheumatologists and 2 gastroenterologists, and 7 rheumatologists and 7 gastroenterologists, respectively. The scientific committee defined the initial version of the criteria, taking into account sensitivity, specificity, standardization and ease of application. Afterwards, members of the expert panel assessed each item in a two-round Delphi survey. Items that met agreement in the first or second round were included in the final version of the criteria. ResultsPositive screening for SpA if at least one of the following is present: onset of chronic low back pain before 45 years of age; inflammatory low back pain or alternating buttock pain; HLA-B27 positivity; sacroiliitis on imaging; arthritis; heel enthesitis; dactylitis. Positive screening for IBD in the presence of one of the major criteria or at least two minor criteria. Major: rectal bleeding; chronic diarrhea with organic characteristics; perianal disease. Minor: chronic abdominal pain; iron deficiency anemia or iron deficiency; extraintestinal manifestations; fever or low grade fever, of unknown origin and duration >1week; unexplained weight loss; family history of IBD. ConclusionScreening criteria for IBD in patients with SpA, and vice versa, have been developed. These criteria will be useful for early detection of both diseases.

Cannabinoid hyperemesis syndrome presentation to the emergency department: A two-year multicentre retrospective chart review in a major urban area.

Cannabinoid hyperemesis syndrome (CHS) is a paradoxical side effect of cannabis use. Patients with CHS often present multiple times to the emergency department (ED) with cyclical nausea, vomiting, and abdominal pain, and are discharged with various misdiagnoses. CHS studies to date are limited to case series. The objective was to examine the epidemiology of CHS cases presenting to two major urban tertiary care centre EDs and one urgent care centre over a 2-year period. Using explicit variables, trained abstractors, and standardized abstraction forms, we abstracted data for all adults (ages 18 to 55 years) with a presenting complaint of vomiting and/or a discharge diagnosis of vomiting and/or cyclical vomiting, during a 2-year period. The inter-rater agreement was measured using a kappa statistic. We identified 494 cases: mean age 31 (+/-11) years; 36% male; and 19.4% of charts specifically reported cannabis use. Among the regular cannabis users (>three times per week), 43% had repeat ED visits for similar complaints. Moreover, of these patients, 92% had bloodwork done in the ED, 92% received intravenous fluids, 89% received antiemetics, 27% received opiates, 19% underwent imaging, 8% were admitted to hospital, and 8% were referred to the gastroenterology service. The inter-rater reliability for data abstraction was kappa=1. This study suggests that CHS may be an overlooked diagnosis for nausea and vomiting, a factor that can possibly contribute to unnecessary investigations and treatment in the ED. Additionally, this indicates a lack of screening for CHS on ED history, especially in quantifying cannabis use and eliciting associated symptoms of CHS.

Endoscopy Upper

Endoscopy Upper

Prevalence of Barrett's esophagus: An observational study from a gastroenterology clinic

Introduction and aimsBarrett's esophagus is a condition that predisposes to esophageal adenocarcinoma. Our aim was to establish the prevalence of Barrett's esophagus at our center, as well as determine its associated factors. Materials and methodsWe retrospectively assessed the endoscopic reports of 500 outpatients seen at our Gastroenterology Service from November 2014 to April 2016. We determined the prevalence of Barrett's esophagus and analyzed the demographic, clinical, and endoscopic findings associated with that pathology. ResultsThe prevalence of Barrett's esophagus was 1.8%. The mean age of the patients with Barrett's esophagus was 58.7 years (range: 45-70) and there was a predominance of men (66%). In the subgroup of patients with symptoms of gastroesophageal reflux (n=125), Barrett's esophagus prevalence was 7.2%. In the multivariate analysis, the factors that were independently associated with Barrett's esophagus were gastroesophageal reflux (P=.005) and hiatal hernia (P=.006). ConclusionsThe overall prevalence of Barrett's esophagus was 1.8% in our population, with a prevalence of 7.2% in patients that had symptoms of gastroesophageal reflux.

Correlation between virulence markers of Helicobacter pylori in the oral cavity and gastric biopsies.

The clinical outcome of Helicobacter pylori infection has been associated with virulence factors. The presence of these factors is useful as molecular markers in the identification of the high risk for developing severe gastric pathologies. To correlate the presence of virulence markers cagA and bab2A of H. pylori in oral and gastric biopsy samples. An observational, prospective, descriptive, and cross-sectional study was carried out between September 2011 and September 2012. Patients suffering dyspepsia with indication for upper gastrointestinal video endoscopy who attended the Gastroenterology Service of the Hospital Dr. Julio C. Perrando were included. Epidemiological investigation was completed. To detect the bacteria and their virulence genes, samples of saliva, dental plaque and gastric biopsy were taken and processed by PCR. Sixty-one patients were selected for this study (30 women and 31 men). H. pylori was detected in 31 gastric biopsies and 31 oral samples. Significant difference between oral and gastric samples was found in cagA genotype. Agreement between oral and gastric genotypes was found in 38.7% of samples from the same patient. This study is the first in provide information about the genotypes of the Argentinean Northeast H. pylori strains. Despite the high prevalence of H. pylori infection, the most of patients had less virulent genotypes in oral cavity and gastric tissue. The cagA / babA2 combination was not frequent in the samples studied. There was not a statistical correlation between the virulence genes and gastroduodenal or oral diseases. Although in some patients the same genotype was found both in oral and gastric samples, it cannot be ensure that they corresponding to the same strain because a DNA sequencing was not performed.

Determining the worldwide epidemiology of surgical site infections after gastrointestinal resection surgery: protocol for a multicentre, international, prospective cohort study (GlobalSurg 2)

IntroductionSurgical site infection (SSI) is the most common complication following major gastrointestinal surgery, affecting between 25% and 40% of patients. The rate of SSI doubles from low-income to high-income settings,...

Interdisciplinary management of infantile colic

El cólico del lactante es uno de los principales motivos de consulta en los servicios de pediatría, gastroenterología y nutrición pediátrica. Esta patología posee múltiples características etiológicas como disfunción de la mecánica familiar, alteraciones gastrointestinales, alergias o intolerancias alimentarias, desbalance alimentario e inadecuados hábitos alimenticios. Es de carácter agudo, con inicio súbito que tiende a desaparecer entre los 3 y 6 meses de edad. Hasta el momento no existe un consenso sobre los protocolos de manejo de esta condición o sobre sus indicadores de eficacia terapéutica. Desde hace algunos años se han desarrollado fármacos, regímenes dietarios y complementos alimentarios específicos para esta patología (anticólico). Este trabajo es una revisión de la evidencia sobre los fundamentos y avances en el tratamiento del cólico del lactante en el que se recopilan las características de esta patología, las medidas terapéuticas médicas y nutricionales, el abordaje clínico y las técnicas para ayudar al paciente y su entorno familiar. El presente estudio busca brindar herramientas técnicas al profesional de la salud cuya población objeto de atención es menor de 2 años.

The 2015 upper gastrointestinal “Be Clear on Cancer” campaign: its impact on gastroenterology services and malignant and premalignant diagnoses

ObjectiveTo assess the impact of the upper gastrointestinal ‘Be Clear on Cancer’ campaign launched by Public Health England between January and February 2015 on open-access gastroscopy referrals, incidence of target...

Correlation between functional gastrointestinal disorders and gastric mucosa histopathology findings, including Helicobacter pylori infection, in Lima, Peru

Objective: This study aims to investigate the relationship between functional gastrointestinal disorders and histopathology characteristics, including H. pylori infection, of gastric mucosa, at Cayetano Heredia National Hospital, Lima-Peru, in 2013. Materials and methods: 112 patients were interviewed prospectively between June and July 2013 in the gastroenterology service. Dyspepsia, irritable bowel syndrome, and postprandial distress syndrome were characterized using the Rome III Survey. Results: Pathology results were determined by gastric biopsies obtained by endoscopy. Of the patients interviewed, biopsy results were obtained for 101. 22.8% had atrophy, 24.8% had intestinal metaplasia, 57.4% presented with H pylori. Conclusions: Using chisquare analysis, no statistically significant relationship could be identified between clinical presentation and biopsy results.

Oral Health and Quality of Life in Candidates for Liver Transplantation

BackgroundThere is a gap in the scientific literature about the association between oral health and the health-related quality of life of patients on the liver transplantation waiting list. The aim of this work was to describe aspects of oral health and quality of life of patients on a liver transplantation waiting list. MethodsThis was a cross-sectional study among 116 patients with chronic hepatic disease: 29 on a liver transplantation waiting list (Model for End-Stage Liver Disease score ≥15) and 87 under monitoring in a gastroenterology service in a Brazilian university hospital. Oral health was evaluated according to criteria recommended by the World Health Organization and by the European Association of Dental Public Health. Health-related quality of life was evaluated by means of the 36-Item Short-Form Health Survey (SF-36). ResultsPatients on the liver transplantation waiting list presented poorer health-related quality of life than those who were not on the list in the domains physical functioning, role physical, bodily pain, general health perceptions, and social functioning and in the physical component summary. Periodontitis affected 72.4% of the patients on the liver transplantation waiting list, but only 27.6% of the patients not on that list. Reduced salivary flow was associated with poorer mental health component summary in hepatitis C patients. ConclusionsPatients on the liver transplantation waiting list presented poorer health-related quality of life than those who were not on the list, mainly in the indicators concerning physical health, as well as higher frequencies of decayed teeth and periodontitis. The mental health component summary was associated with reduced salivary flow in hepatitis C patients.

Scheduling non-operating room anesthesia cases in endoscopy: Using the sandbox analogy

Study objectiveFor many hospitals, the non-operating room anesthesia (NORA) workload continues to expand. We developed a new NORA scheduling process with shared block time – a sandbox - amongst all of the gastroenterology groups and measured the efficacy of the intervention using basic operating room management metrics. DesignProspective analysis, statistical process control. SettingAcademic, rural hospital; endoscopy suite; postoperative recovery area. PatientsAdults and pediatric patients undergoing elective and/or urgent endoscopic procedures. InterventionsIn 2014, we divided the NORA block allocations on Thursdays into one afternoon block for pediatric GI, and 1.5 blocks to be shared between the two adult GI groups. We made a provision for an additional afternoon block available if necessary. No changes were made in the release policy. For scheduling, shared block time was released between the three endoscopy groups at 7days and then opened to the general pool at 48h. MeasurementsCase volumes, under-utilized time (opportunity-unused), elective time-in-block, over-utilized time. Main resultsWith the addition of a pediatric gastroenterologist, the number of cases per month increased after the change in scheduling procedure from a mean of 107 cases per month to 131, an increase of 23% (p=<0.01) (see Chart 1). Elective time-in-block increased after the intervention by 13% (p=0.09), while under-utilized time (opportunity-unused time) decreased in a reciprocal fashion (15%, p=0.03). Pre-intervention mean over-utilized time was 101min/month, while post-intervention over-utilized time decreased by 84.5% (99% CI ±3.29) to a mean of 16min/month. ConclusionsBy using a multi-disciplinary, team-based approach, we were able to increase throughput without increasing under-utilized or over-utilized time, thereby increasing efficiency. Despite the additional cases brought in by the pediatric gastroenterologist, opportunity-unused time decreased only moderately—lending support to our prediction that opening an additional NORA block was not only unnecessary to accommodate expansion of the gastroenterology service, but was also financially unviable. One of the challenges in reducing under-utilized time lies in the relatively new role played by anesthesia in the NORA environment. In our study, we showed that the open access policy applies when the block allocations have under-utilized time. As anesthesiologists continue to expand their practice into the NORA environment, good communication, interdepartmental collaboration, and flexible scheduling processes are essential to improving efficiency.

Mo1849 - The Impact of Transition to Adult Gastroenterology Services on Health-Related Quality of Life in Young Adult Patients with IBD: The UK Transit Study

Mo1849 - The Impact of Transition to Adult Gastroenterology Services on Health-Related Quality of Life in Young Adult Patients with IBD: The UK Transit Study

32-Year-Old-Woman With Abdominal Pain

32-Year-Old-Woman With Abdominal Pain