Index Esophagogastroduodenoscopy Research Articles

Esophagogastroduodenoscopy findings that do no not explain dysphagia are associated with underutilization of high-resolution manometry.

In patients with dysphagia that is not explained by upper endoscopy, high-resolution esophageal manometry (HRM) is the next logical step in diagnostic testing. This study investigated predictors of failure to refer for HRM after an upper endoscopy that was performed for but did not explain dysphagia. This was a retrospective cohort study of patients >18 years of age who underwent esophagogastroduodenoscopy (EGD) for dysphagia from 2015 to 2021. Patients with EGD findings that explained dysphagia (e.g. esophageal mass, eosinophilic esophagitis, Schatzki ring, etc.) were excluded from the main analyses. The primary outcome was failure to refer for HRM within 1 year of the index non-diagnostic EGD. We also investigated delayed referral for HRM, defined as HRM performed after the median. Multivariable logistic regression modeling was used to identify risk factors that independently predicted failure to refer for HRM, conditioned on the providing endoscopist. Among 2132 patients who underwent EGD for dysphagia, 1240 (58.2%) did not have findings to explain dysphagia on the index EGD. Of these 1240 patients, 148 (11.9%) underwent HRM within 1 year of index EGD. Endoscopic findings (e.g. hiatal hernia, tortuous esophagus, Barrett's esophagus, surgically altered anatomy not involving the gastroesophageal junction, and esophageal varices) perceived to explain dysphagia were independently associated with failure to refer for HRM (adjusted odds ratio 0.45, 95% confidence interval 0.25-0.80). Of the 148 patients who underwent HRM within 1 year of index EGD, 29.7% were diagnosed with a disorder of esophagogastric junction outflow, 17.6% with a disorder of peristalsis, and 2.0% with both disorders of esophagogastric outflow and peristalsis. The diagnosis made by HRM was similar among those who had incidental EGD findings that were non-diagnostic for dysphagia compared with those who had completely normal EGD findings. Demographic factors including race/ethnicity, insurance type, and income were not associated with failure to refer for HRM or delayed HRM. Patients with dysphagia and endoscopic findings unrelated to dysphagia have a similar prevalence of esophageal motility disorders to those with normal endoscopic examinations, yet these patients are less likely to undergo HRM. Provider education is indicated to increase HRM referral in these patients.

Gastric dysplasia in random biopsies: the influence of Helicobacter pylori infection and alcohol consumption in the presence of a lesion

Background Gastric dysplasia in the absence of an endoscopically defined lesion is rare, usually either a false positive diagnosis or a previously unidentified precancerous lesion during esophagogastroduodenoscopy (EGD). Aims Evaluate factors associated with the presence of an endoscopically visible lesion during follow-up in patients with histologic diagnosis of gastric dysplasia in random biopsies. Methods Retrospective cohort study including patients referred to our institution for gastric dysplasia in random biopsies during Index EGD. Endoscopic evaluation was performed with a high-definition endoscope using narrow band imaging (HD EGD-0). If no lesion was detected, endoscopic surveillance (HD EGD-FU) was conducted within 6 months for high grade dysplasia (HGD) or 12 months for low grade (LGD) or indefinite for dysplasia (IFD). Results From a total sample of 96 patients, 5 (5.2%) presented with an endoscopically visible lesion during HD EGD-0, while 10 lesions (10.4%) were identified during HD EGD-FU. Patients with Helicobacter pylori infection at Index EDG and with regular alcohol consumption (≥25 g/day) were 8 and 4 times more likely to have an endoscopically visible lesion on HD EGD-FU (p = 0.012 and p = 0.047). In binary logistic regression, both factors were independent predictors of the presence of gastric lesion on HD EGD-FU (OR 9.284, p = 0.009 and OR 5.025, p = 0.033). Conclusions The presence of an endoscopically visible lesion after the histologic diagnosis of gastric dysplasia in random biopsies was more frequent during HD EGD-FU. H. pylori infection at Index EGD and regular alcohol consumption were significant predictors of the presence of gastric lesion on HD EGD-FU.

Diagnosis of Eosinophilic Esophagitis at the Time of Esophageal Food Impaction.

Esophageal food impactions (EFI) often precede a diagnosis of eosinophilic esophagitis (EOE). Current guidelines suggest obtaining esophageal biopsies upon suspicion of EOE, treating with proton pump inhibitor (PPI), and repeating esophagogastroduodenoscopy (EGD). This study was conducted to determine provider practice patterns with these mentioned recommendations at the time of EFI. In this retrospective study, key outcomes were the proportion of patients who had EOE mucosal biopsies, EOE diagnosis, PPI initiation, and recommendations and completions of repeat EGD. Differences in outcomes among age, sex, race, off-hours time of procedure, and trainee involvement were examined. EOE diagnosis predictors were explored with logistic regression. Twenty-nine percent of the patients had esophageal biopsies taken at the time of index EGD (iEGD). Sixteen patients were diagnosed with EOE at the time of index EFI, while fourteen patients were diagnosed on subsequent EGDs. Among those diagnosed with EOE at iEGD, 94% were placed on PPI. Of patients with confirmed EOE on index biopsy, 63% of patients were recommended repeat EGD, of which 50% completed it within 90 days. Older age was protective of EOE diagnosis while no GERD history and endoscopist suspicion of EOE predicted diagnosis of EOE. Endoscopists uncommonly take biopsies at the time of EFI, which may delay diagnosis and treatment of EOE.

Clinical epidemiology and outcomes of patients with gastric intestinal metaplasia in the Los Angeles County System

BackgroundGastric intestinal metaplasia (GIM) is a precursor to gastric adenocarcinoma (GAC). In the United States, there is no consensus on the utility of surveillance for GIM, and minority populations most affected by GAC are understudied. Our aims were to define clinical and endoscopic features, surveillance practices, and outcomes in patients with GIM in a multicenter safety-net system.MethodsWe identified patients with biopsy-proven GIM between 2016–2020 at the three medical centers comprising Los Angeles County Department of Health Services. Demographics, findings at index esophagogastroduodenoscopy (EGD) first showing GIM, recommended interval for repeat EGD, and findings at repeat EGD were abstracted. Descriptive statistics were performed to characterize our cohort. T-tests and chi-squared (χ2) tests were used to compare patients with and without multifocal GIM.ResultsThere were 342 patients with newly-diagnosed biopsy-proven GIM, 18 (5.2%) of whom had GAC at index EGD. Hispanic patients comprised 71.8% of patients. For most patients (59%), repeat EGD was not recommended. If recommended, 2–3 years was the most common interval. During a median time to repeat EGD of 13 months and cumulative follow-up of 119 patient-years, 29.5% of patients underwent at least one repeat EGD, of whom 14% had multifocal GIM not previously detected. Progression to dysplasia or GAC was not detected in any patients.ConclusionIn a predominantly minority population with biopsy-proven GIM, there was a 5% incidence of GAC on index EGD. Though progression to neither dysplasia nor GAC was detected, there was significant variability in endoscopic sampling and surveillance practices.

Yield of Repeat Endoscopy for Barrett's Esophagus After Normal Index Endoscopy.

Guidelines suggest 1-time screening with esophagogastroduodenoscopy (EGD) for Barrett's esophagus (BE) in individuals at an increased risk of esophageal adenocarcinoma (EAC). We aimed to estimate the yield of repeat EGD performed at prolonged intervals after a normal index EGD. We conducted a national retrospective analysis within the U S Veterans Health Administration, identifying patients with a normal index EGD between 2003 and 2009 who subsequently had a repeat EGD. We tabulated the proportion with a new diagnosis of BE, EAC, or esophagogastric junction adenocarcinoma (EGJAC) and conducted manual chart review of a sample. We fitted logistic regression models for the odds of a new diagnosis of BE/EAC/EGJAC. We identified 71,216 individuals who had a repeat EGD between 1 and 16 years after an index EGD without billing or cancer registry codes for BE/EAC/EGJAC. Of them, 4,088 had a new billing or cancer registry code for BE/EAC/EGJAC after the repeat EGD. On manual review of a stratified sample, most did not truly have new BE/EAC/EGJAC. A longer duration between EGD was associated with greater odds of a new diagnosis (adjusted odds ratio [aOR] for each 5 years 1.31; 95% confidence interval [CI] 1.19-1.44), particularly among those who were younger during the index EGD (ages 19-29 years: aOR 3.92; 95% CI 1.24-12.4; ages 60-69 years: aOR 1.19; 95% CI 1.01-1.40). The yield of repeat EGD for BE/EAC/EGJAC seems to increase with time after a normal index EGD, particularly for younger individuals. Prospective studies are warranted to confirm these findings.

Interval Advanced Gastric Cancer After Negative Endoscopy

Esophagogastroduodenoscopy (EGD) is effective in reducing gastric cancer mortality through detection of early-stage cancer in areas with a high prevalence of gastric cancer. Although the risk of post-endoscopy advanced gastric cancer (AGC) is low, interval AGC remains a concern. We investigated the characteristics and predictors of interval AGC after negative EGD. We included 1257 patients with gastric cancer within 6 to 36 months of a "cancer-negative" index EGD between 2005 and 2021 at a tertiary university hospital in South Korea. Observation time on the index EGD was used as a quality indicator. We compared the clinical and endoscopic characteristics and quality indicators between interval AGC and screen-detected early gastric cancer (EGC). Within 6 to 36 months of negative EGD, 102 AGCs (8.1%) and 1155 EGCs (91.9%) were identified. The percentage of patients with shorter observation time (<3 minutes) in the index EGD was higher in the interval AGC group than in the detected EGC group (P= .002). A multivariable analysis comparing screen-detected EGD and interval AGC was adjusted for age, sex, family history of gastric cancer, H.pylori status, endoscopic findings, and endoscopy-related factors including gastric observation time and interval time. A shorter observation time (<3 minutes) (odds ratio, 2.27; 95% confidence interval, 1.20-4.30), and interval time >2 years (odds ratio, 1.84; 95% confidence interval, 1.04-3.24) were associated with an increased risk of interval AGC. A shorter observation time during index EGD is an important predictor of interval AGC. Further, withdrawal time longer than 3 minutes may be a quality indicator for screening EGD.

A136 A RARE CAUSE OF AUTOIMMUNE ATROPHIC PANGASTRITIS COMPLICATED WITH GASTRIC OUTLET OBSTRUCTION

BackgroundChronic gastritis comes in two well recognized forms: environmental, which is most commonly antral or multifocal in distribution and is typically caused by Helicobacter Pylori (HP) infection, and autoimmune gastritis(AIG), which affects the corpus and fundus. Presented here is a case of autoimmune atrophic pangastritis(AIAP).AimsTo increase awareness of a rare condition with limited data on available treatment modalities.MethodsCase ReportResultsA 68-year old female with autoimmune hypothyroidism, presented with weight loss and elevated anti-TTG serology. Index esophagogastroduodenoscopy (EGD) biopsies demonstrated chronic non-specific gastritis limited to the antrum. Strict gluten free diet adherence was initiated. Testing for HLA revealed HLADq2 and HLADq8 negativity but HLADq2.5 positivity. Subsequent EGD showed a markedly atrophic appearing gastric body. The corresponding biopsies demonstrated persistent moderately chronic active gastritis with severe atrophy now involving the body, fundus and antrum. The biopsies were negative for HP. Notably, there was a lack of ECL-cell hyperplasia and the number of antral G cells appeared decreased. Anti-parietal cell antibody serology was positive with a titre of 1:80. Despite combination therapy with budesonide and mesalamine and treatment for HP given persistent symptoms, the patient’s course was further complicated by gastric-outlet obstruction (GOO). Urgent EGD biopsies showed pyloric stenosis requiring dilation. Endoscopic Ultrasound (EUS) guided biopsies were negative for malignancy. The patient was started on corticosteroids and azathioprine(AZA). Most recently, an EGD on AZA, continued to demonstrate severe chronic active pangastritis now with intestinal metaplasia involving the body. Corticosteroid therapy was reinitiated with a plan to start mycophenolate mofetil (MMF).ConclusionsAIAP is a rarely described entity, not well documented in the literature. An eight patient case series reported a distinctive form of atrophic gastritis that was independent of HP infection with the absence of neuroendocrine hyperplasia that involved the body and antrum. Thyroid disease, specifically Hashimoto thyroiditis is present in about 40% of patients with AIG. Additionally, AIG progression to atrophic gastritis with intestinal metaplasia confers an increased risk for gastric adenocarcinoma in more than 10% of patients.Limited literature exists regarding the management of AIAP. Pediatric data suggests the use of prednisone and/or azathioprine for AIAP. Furthermore, a recent case report of AIAP demonstrated clinical and endoscopic remission with MMF. Currently, no guidelines exist for the treatment, screening and monitoring of patients with AIAP. This case report presents a rare case of AIAP refractory to AZA complicated with GOO and adds to the little literature that exists.Funding AgenciesNone

Prevalence and Predictors of Missed Dysplasia on Index Barrett’s Esophagus Diagnosing Endoscopy in a Veteran Population

Limitations of endoscopic sampling may result in missed dysplasia at the diagnosis of Barrett's esophagus (BE). However, the role of close follow-up endoscopy is unclear. The aim was to evaluate the proportion of patients diagnosed with "missed" dysplasia within 18 months of their index nondysplastic BE (NDBE) diagnosis. This was a retrospective analysis of a cohort of BE patients diagnosed during 1990-2019 at the Houston VA. Patients with BE on index esophagogastroduodenoscopy (EGD) were classified as NDBE, indefinite dysplasia, or dysplastic (low- or high-grade dysplasia) based on initial biopsies. We identified NDBE patients who had follow-up EGD within 3-18 months after index EGD. We used logistic regression models to estimate odds ratios and 95% confidence intervals for risk factors of dysplasia on follow-up EGD. We identified 614 patients who had BE on index EGD. Among those with NDBE and follow-up EGD within 3-18 months (n= 271), 4.1% had definite dysplasia on follow-up, and an additional 14.0% had indefinite dysplasia. Proportions of definite or indefinite dysplasia at follow-up within 3-18 months significantly decreased from 32.6% among patients with index EGD before 2009 to 11.7% among patients with index EGD after 2013 (P for trend= .068). Those with any indefinite or definite dysplastic BE at follow-up within 3-18 months after index EGD (n= 49) were more likely to have BE length ≥3 cm on index EGD (odds ratio, 3.39; 95% confidence interval, 1.63-7.08) than those with persistent NDBE or no BE on follow-up. The occurrence of missed dysplasia on an index EGD has decreased over time. However, those with long segment BE were more than 3 times as likely to have missed dysplasia, and this group could benefit from dysplasia surveillance within 18 months of BE diagnosis.

Diagnostic Delay in Patients with Eosinophilic Gastritis and/or Duodenitis: A Population-Based Study

Eosinophilic gastritis and/or eosinophilic duodenitis (EG/EoD) is characterized by persistent symptoms and elevated eosinophils in the gastrointestinal tract. Limited disease awareness and lack of diagnostic guidelines suggest that patients may remain undiagnosed or endure diagnostic delay. To characterize the path to diagnosis for patients with EG/EoD in a representative population. In this observational cohort study, 4108 eligible patients diagnosed with EG/EoD between 2008 and 2018 were identified in an administrative claims database in the United States. Patient medical claim history was analyzed to describe events related to diagnosis. Mean year from symptom presentation to diagnosis of EG/EoD was 3.6; factors contributing to diagnostic delay included delayed gastroenterologist referral, delayed esophagogastroduodenoscopy (EGD), and lack of biopsy collection and/or histopathologic evaluation. Missed diagnosis on index EGD occurred in 38.2% of patients, resulting in a mean increase of 1.6 years in time to diagnosis versus patients diagnosed on index EGD. Patients presented with nonspecific symptoms and 44.3% were diagnosed with another gastrointestinal condition before EG/EoD diagnosis. Independent predictors of >2-year diagnostic delay included adult age; prior diagnosis of irritable bowel syndrome, functional dyspepsia, or gastric/peptic ulcer; use of other procedures such as colonoscopy; presence of edema; and history of certain allergic diseases. This study found that patients with EG/EoD experienced an average of 3.6 years between initial symptom presentation and diagnosis and revealed several factors contributing to diagnostic delay. We hope that these findings, together with heightened awareness and standardization of diagnostic guidelines, will improve the diagnostic journey of patients with EG/EoD.

S0548 Assessment of the Quality of Upper Endoscopy Procedures Performed for Gastric Ulcers in a Tertiary Care Facility

INTRODUCTION: Although esophagogastroduodenoscopy (EGD) is a widely used modality, literature on tracking and implementation of its quality indicators remain limited. Moreover, there is some discrepancy among the societies recommendations, for example, regarding universal necessity of obtaining biopsy and repeat exam for gastric ulcer (GU). In this concise study, we assessed the adherence to selected quality metrics for endoscopic management of GU; namely documentation of ulcer description, obtaining biopsy from ulcer, helicobacter pylori (HP) testing, and recommending repeat EGD to confirm healing. METHODS: We retrospectively reviewed reports of all EGDs performed on adults between January 2015 and December 2017 at the University of Kentucky endoscopy unit and included those with GU. After collecting their clinical, demographic and endoscopic findings, the quality indicators were reported as numbers and percentages. We then performed a univariate logistic regression analysis to identify significant predictors of not meeting each quality indicator. RESULTS: A total of 118 patients met the inclusion criteria (Table 1). Documentation of ulcer size and shape was missing in 26.2% and 55.9% of patients respectively. Ulcer biopsy was not performed in 39% of patients (26% of those had ulcers with high bleeding risk). Patients with low risk ulcers had significantly higher odds of receiving an ulcer biopsy (Table 2). Repeat EGD was recommended in 17.4% of those without ulcer biopsy on the index EGD and was successfully performed in 62.5% of them. Those who did not have biopsy from ulcer and those with multiple ulcers had significantly lower odds of having a repeat EGD recommended. We also noted lower odds of successfully performing the repeat EGD in those who had the index endoscopy during hospitalization. Gastric biopsies for HP were not obtained in 75%, and only 27% of those had the recommendation for HP stool test documented in the report. Whites and those with multiple ulcers had lower odds of having HP test performed or recommended. CONCLUSION: Our results suggest that there is a room for improvement in the quality of endoscopy for GU. Additionally, we identified predictors that can be targeted through future quality improvement projects. Our methodology can be further expanded to other EGD quality indicators, ideally in studies including a larger sample size from multiple centers. *First three authors equally contributed to this study.Table 1.: Baseline and endoscopic characteristics of the included patients. EGD = esophagogastroduodenoscopy, GU = gastric ulcer, IQR = interquartile range, SD = standard deviation.Table 2.: Predictors of fulfilling the quality indicators, reported as odds ratios and 95% confidence intervals. EGD = esophagogastroduodenoscopy, HP = helicobacter pylori.

Implementation of guidelines in eosinophilic esophagitis at an academic pediatric practice.

Guidelines for eosinophilic esophagitis (EoE) require high-dose PPI (HD-PPI) trial to evaluate for PPI-responsive esophageal eosinophilia (PPI-REE) prior to EoE diagnosis and dedicated therapy. This involves a second esophagogastroduodenoscopy (EGD) to assess for PPI-REE. This study is to evaluate adherence to current guidelines in evaluation of PPI-REE and EoE. Retrospective review of new patients treated with HD-PPI after an index EGD showing>15 eos/hpf in esophageal biopsies. One hundred and eighty patients had an index EGD with esophageal eosinophilia of>15 eos/hpf. Of these, 97/180 (53.8%) received HD-PPI; remaining 83/180 were prescribed other interventions without a HD-PPI trial. Of the 180 patients, 143 (79.4%) patients returned for follow-up and of whom 96/143 (67.1%) underwent repeat EGD. Adherence to guidelines improves with time. Patients are vested in care.

Adherence to quality indicators and surveillance guidelines in the management of Barrett's esophagus: a retrospective analysis.

Background Adherence to quality indicators and surveillance guidelines in the management of Barrett’s esophagus (BE) promotes high-quality, cost-effective care. The aims of this study were (1) to evaluate adherence to standardized classification (Prague Criteria) and systematic (four-quadrant) biopsy protocol, (2) to identify predictors of practice patterns, and (3) to assess adherence to surveillance guidelines for non-dysplastic BE (NDBE). Methods This was a single-center retrospective study of esophagogastroduodenoscopy (EGD) performed for BE (June 2008 to December 2015). Patient demographics, procedure characteristics, and histology results were obtained from the procedure report-generating database and chart review. Adherence to Prague Criteria and systematic biopsies was based on operative report documentation. Multiple logistic regression analysis was performed to identify predictors of practice patterns. Guideline adherent surveillance EGD was defined as those performed within 6 months of the recommended 3- to 5-year interval. Results In total, 397 patients (66.5 % male; mean age 60.1 ± 12.5 years) had an index EGD during the study period. Adherence to Prague Criteria and systematic biopsies was 27.4 % and 24.1 %, respectively. Endoscopists who performed therapeutic interventions for BE were more likely to use the Prague Criteria (OR: 3.16; 95 %CI: 1.47 – 6.82; P < 0.01) than those who did not. Longer time in practice was positively associated with adherence to Prague Criteria (OR 1.07; 95 %CI: 1.02 – 1.12; P < 0.01) but with a lower likelihood of performing systematic biopsies (OR 0.91; 95 %CI: 0.85 – 0.97; P < 0.01). More than half (55.6 %) of patients with NDBE underwent surveillance EGD sooner (range 1 – 29 months) than the recommended interval. Conclusion Adherence to quality indicators and surveillance guidelines in BE is low. Operator characteristics, including experience with endoscopic therapy for BE and time in practice predicted practice pattern. Future efforts are needed to reduce variability in practice and promote high-value care.

Not Too Hot, Not Too Cold, but “Just Right”

When ordering diagnostic tests, physicians are faced with a problem of not too many tests, not too few, but 'just right'. However, in medical diagnostics 'just right' may be very difficult to identify. Such is the conundrum presented in study by Rubenstein and colleagues regarding appropriate use of repeat esophagogastroduodenoscopy (EGD) in Veterans Health Administration (VHA) medical facilities. The important message of this paper is that out of 235,855 patients with an index EGD, 36% underwent repeat EGD over 5 years, of which only 9% (range 3-18%a cross VHA facilities) were classified as probable overuse.

Regional Variability of Repeat Esophagogastroduodenoscopy Use in the National Veteran Population.

Esophagogastroduodenoscopy (EGD) procedures are performed frequently to evaluate gastrointestinal disease and symptoms. To determine regional practice variability of repeat EGDs in a national population. The study sample included US Veterans with an outpatient index EGD from 1/1/2008 to 12/2010. We determined risk of repeat endoscopy from 1/2008 to 10/1/2014. A logistic regression model was used to assess the association between the odds of repeated EGD and patient demographics, ICD diagnostic codes, and geographic region. Multivariable logistic regression was performed to obtain the adjusted odds ratio and predicted probabilities of repeat EGDs by region. A total of 202,086 patients had an index endoscopy from 1/2008 to 12/2010. Unique patients with an index endoscopy were predominantly male (93.2%), white (72.8%), and on average 61years. A total of 58,469 patients (28.9%) had one or more repeat EGDs, accounting for 103,253 repeat procedures through 10/2014. ICD-9-CM codes associated with increased risk of repeat procedures were Barrett's esophagus (OR 3.6, 95% CI 3.5-3.7), dysphagia (OR 1.3, 95% CI 1.2-1.3), ulcer (OR 1.3, 95% CI 2.2-2.4), stricture (OR 1.8, 95% CI 1.7-1.9), and esophageal varices (OR 2.8, 95% CI 2.7-3.0). There was a significant difference in the probability of repeat EGD by VA region, with the Midwest region having the highest probability (31.2%) and Southeast the lowest probability (27.3%). This difference would account for 400 more EGD procedures per 10,000 Veterans, after adjusting for patient demographics and diagnosis codes. Regional practice variability accounts for a substantial volume of repeat EGD procedures, regardless of patient characteristics and associated diagnoses.

Repeated Upper Endoscopy in the Medicare Population

Esophagogastroduodenoscopy (EGD) is done often for various indications. Little is known about the frequency of repeated EGD and the diagnoses that drive it. To describe the frequency of repeated EGD in the Medicare population and determine diagnoses most often associated with it. Retrospective analysis. Medicare database. Among a 5% random sample of Medicare beneficiaries, Current Procedural Terminology (CPT) codes were used to identify patients who had an index EGD between 2004 and 2006. Diagnoses from the International Classification of Diseases, Ninth Revision, Clinical Modification, reported for the index endoscopy were divided into 3 diagnostic groups on the basis of whether the index diagnosis suggested that repeated EGD was expected, uncertain, or not expected. Proportion of patients with repeated EGD within 3 years of an index EGD. Approximately 12% of Medicare beneficiaries had an EGD between 2004 and 2006 (n= 108785). Of these, 33% (n= 36331) had at least 1 repeated EGD within 3 years. Of all patients with initial EGDs, 10% (n= 11370) had an associated diagnosis suggesting a need for follow-up examination, whereas 61% (n= 66307) did not. Of all patients with repeated examinations, 54% (n= 19687) came from the group in which repeated EGD was not expected. When new clinical events were excluded, 43% of all patients with repeated EGDs (n= 15706) did not have a diagnosis at index or repeated EGD that justified a repeated examination. Whether individual procedures were clinically indicated cannot be verified. One in 3 Medicare beneficiaries who received an EGD had a repeated EGD within 3 years. Nearly one half of repeated examinations were done in patients with diagnoses at index or repeated EGD that did not suggest the need for a repeated examination. None.

Editorial: Endoscopic Missed Rates of Upper Gastrointestinal Cancers: Parallels With Colonoscopy

Recent publications assessing colonoscopy missed rates of colorectal cancer have generated efforts toward colonoscopy quality improvement. To date, esophagogastroduodenoscopy (EGD) has escaped similar scrutiny in Western populations. Raftopoulos et al. (1) report an upper gastrointestinal cancer missed rate of up to 6.7% in a cohort of 28,000 patients who underwent EGD at a hospital-based endoscopy unit in Perth, Western Australia. Of the missed esophageal and gastric cancers, approximately 80% of patients had alarm symptoms and 73% had abnormalities reported at the time of EGD. The missed cancers may not have been visualized, or were visualized and either not biopsied or biopsied inadequately, or interpreted incorrectly by pathologists. There was no difference in survival between the missed cancers and those detected at the index EGD.

Prevalence of Barrett’s esophagus in patients with moderate to severe erosive esophagitis

To investigate the proportion of patients with moderate-severe erosive esophagitis (EE) who will have Barrett's esophagus (BE) after healing of inflammation. Patients with EE of Los Angeles (LA) class B, C and D who underwent follow-up endoscopy documenting complete mucosal healing. A total of 86/169 patients were suspected of having BE (38 before healing and 48 after healing of EE) and, 46/86 eventually had the histological confirmation. At index esophago-gastro-duodenoscopy (EGD), BE was suspected in 38/169 (22%), and ultimately, histologically confirmed in 20 of these. In 11 patients where biopsies were performed in the presence of inflammation, BE was detected in 2 and missed in 5 (including 2 dysplasias). In 131/169 patients (77.5%), BE was not suspected at index EGD. After healing of EE though, 48 patients had suspicion of BE who underwent biopsies, and in 26 of these histology was positive for BE. The length of inflammation had a linear correlation with the length of BE (P = 0.01). Out of multiple variables to predict BE, only the suspicion at index endoscopy was statistically significant (P = 0.01). BE was seen in 46/169 (27%) patients with EE of LA class B, C and D. The length of EE can predict the length of underlying BE segment. Even when suspected, BE and associated dysplasia can be missed in the presence of inflammation; therefore, repeat evaluation should be considered after complete healing of esophagitis.

Yield of endoscopy in dyspepsia and concurrent treatment with proton pump inhibitors: The blind leading the blind?

Yield of endoscopy in dyspepsia and concurrent treatment with proton pump inhibitors: The blind leading the blind?

The economics of laparoscopic Nissen fundoplication

Background & Aims: A major impetus for laparoscopic Nissen fundoplication (LNF) is its purported cost savings compared with medical therapy, but few studies have examined these economic outcomes. The aim was to analyze health care costs and use among a cohort of patients undergoing LNF and compare them with patients with medically treated gastroesophageal reflux disease (GERD). Methods: Comparison of health care use and direct costs from the third-party payer perspective using 13 United HealthCare Plans. Sixty-one patients who underwent LNF from January 1994 to June 1998 and 178 matched controls were used for this study. Outcome variables included the cost of hospital and outpatient visits, hospitalizations, related endoscopic procedures, and pharmacy claims for proton pump inhibitors, H 2 receptor antagonists, and prokinetics. Cost of LNF or index esophagogastroduodenoscopy was not included. Results: Sixty-one LNF patients and 178 controls were studied. No differences were seen for the costs of office visits and hospital admissions or the number of gastrointestinal procedures. LNF patients had significantly lower gastrointestinal medication costs. Median total health care costs were significantly lower in the LNF group but mean total costs were not different. This was attributable to $201,000 in costs for managing complications in one patient that skewed total health care cost in the LNF group. Conclusions: For the 12 months after surgery, LNF reduced costs for gastrointestinal medications but not total costs for the cohort. LNF cost is impacted greatly by the cost of associated complications. Based on these data, LNF does not appear to significantly reduce the direct cost of health care for GERD patients on a population basis.