Endoscopy Rates Research Articles

Has National Colorectal Cancer Awareness Month increased endoscopy screening rates and public interest in colorectal cancer?

National Colorectal Cancer Awareness Month occurs each March to promote awareness and screening for colorectal cancer. The effectiveness of this public health campaign is unknown. The aim of this study was to determine the impact of National Colorectal Cancer Awareness Month on rates of screening endoscopies and on public interest in colorectal cancer. To examine the impact of National Colon Cancer Awareness Month on screening endoscopy rates, the National Endoscopy Database was retrospectively reviewed from 2002 through 2014. A time series of monthly number of colorectal cancer screening endoscopies per endoscopist in the data set was evaluated. To examine public interest in colorectal cancer, Google Trends data were collected on the monthly rates of terms related to colorectal cancer from January 2004 to July 2019. Impact of the month on screening endoscopies and public interest was assessed through an analysis of variance. Seasonality was tested for by how well a sinusoidal model fit the time series as opposed to a linear model utilizing a sum-of-squares F test. Review of National Endoscopy Database yielded 1,398,996 endoscopies, 94% were colonoscopies and 6% sigmoidoscopies, with 47% for colorectal cancer screening. Colorectal cancer screening endoscopy rates were not impacted by the month of the year, and these rates had no seasonality. However, Google searches related to colorectal cancer were significantly impacted by month of the year, specifically March, with significant seasonality observed in the data. National Colorectal Cancer Awareness Month is associated with an increased public interest in colorectal cancer based on user Google search trends. Yet, this has not translated into a demonstrable increase in the rates of screening. This presents an opportunity to capitalize on this increased public interest and harness this enthusiasm into increased screening.

Nonvariceal upper GI hemorrhage after percutaneous coronary intervention for acute myocardial infarction: a national analysis over 11 months

Nonvariceal upper GI hemorrhage (NVUGIH) is a feared adverse event after percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI). We aimed to determine the incidence of NVUGIH after PCI for AMI and its impact on mortality, morbidity, and health care resource utilization over 11 months. We used the Nationwide Readmission Database 2014. Inclusion criteria were (1) a principal diagnosis of ST or non-ST-elevation myocardial infarction, (2) in-hospital PCI, and (3) admission in January. Exclusion criteria were age less than 18 years and elective admission. The primary outcome was the 11-month incidence of NVUGIH. Secondary outcomes were 11-month mortality rate, prolonged mechanical ventilation, shock, upper endoscopy, length of stay, and total hospitalization costs and charges. Independent risk factors for NVUGIH were identified using multivariate logistic regression analysis. A total of 22,669 patients were included in the study. The mean age was 63.8 years (range, 63.4-64.1 years), and31.7% of patients were female. The 11-month incidence of NVUGIH was 1.6%. The onset of NVUGIH was associated with an increase in the 11-month mortality rate (adjusted odds ratio, 1.94; 95% confidence interval, 1.01-3.72; P=.04). The upper endoscopy, shock, and prolonged mechanical ventilation rates were 72%, 6.2%, and 1.9%, respectively. Intotal,26,532 days were associated with NVUGIH, with a total health care in-hospital economic burden of U.S.$17.6 million. Independent predictors of NVUGIH were female gender, Charlson comorbidity score, and length of stay. The 11-month incidence of NVUGIH among patients who undergo PCI for AMI is 1.6%. NVUGIH has a substantial impact on mortality, morbidity, and in-hospital health care resource utilization.

The incidence and determinants of bariatric reoperations: a population-based cohort study.

Bariatric surgery is the strongest evidence-based treatment available for obesity, but the long-term morbidity and durability of these procedures is being increasingly scrutinized. To report the incidence, timing, indications, and risk factors for bariatric reoperations. A state-wide, multicenter, retrospective study. Using the Western Australian Department of Health Data Linkage Unit, all patients undergoing an index bariatric procedure where identified across a 10-year period (2007-2016). Of 24,766 patients who underwent bariatric surgery, 5001 patients (20.2%) required at least 1 bariatric reoperation. The 5-yearly rates were 19.6% (95% confidence interval [CI], 19.0%-20.2%) for a first revision, 58.2% (95%CI, 56.6%-59.8%) for a subsequent second revision, 38.3% (95%CI, 35.4%-41.2%) for a subsequent third revision, and 45.2% (95%CI, 39.9%-50.5%) for a subsequent fourth revision. Surgical complications (67.4%) were the main indication for any bariatric reoperation ahead of weight-related causes (32.6%). In a Cox regression analysis, being younger, female, without private health insurance, and having a gastric band as the initial bariatric procedure were all significant risk factors for bariatric reoperations. Compared with bariatric patients needing only an index procedure, patients requiring bariatric reoperations also had higher postoperative incidence rate ratios of endoscopic (incidence rate ratio 2.4; 95%CI, 2.3-2.5) and body contouring (incidence rate ratio 3.8; 95%CI, 3.5-4.1) procedures. Patients undergoing bariatric surgery had a high incidence of bariatric reoperations, predominantly for surgical complications. Of those patients who required bariatric reoperations, there were additional high rates of recurrent bariatric surgery, postoperative endoscopy, and body contouring procedures.

P079 ISOLATION OF GASTROINTESTINAL PATHOGENS AFFECTS MEDICAL MANAGEMENT OF OUTPATIENTS WITH RELAPSE OF INFLAMMATORY BOWEL DISEASE

Abstract Introduction Evaluating for the presence of gastrointestinal infection is a critical component of the workup for relapse of inflammatory bowel disease (IBD). With the advent of stool multiplex gastrointestinal pathogen panels (GI PCR), infections are increasingly identified. Prior research has shown that detection of enteric infection significantly affects the management of IBD in the inpatient setting. We aimed to characterize the impact of enteric infection detection on the management of IBD therapy in outpatients with relapse of IBD. Methods In a cross-sectional study of IBD outpatients at an academic medical center presenting with acute gastrointestinal symptoms from September 2015 to April 2019 who received GI PCR testing, we recorded pathogens detected, demographic data, biomarkers of inflammation, presenting symptoms, IBD subtypes, and IBD therapy. Our primary outcome was dose escalation in IBD therapy, defined as the addition of a new therapeutic agent or an increase in the dose or frequency of an existing medication. Secondary outcomes included rates of endoscopy, abdominal imaging, and antibiotics in the 30-day period after the initial visit and rates of adverse outcomes, i.e. emergency room (ER) visits, hospitalizations, and abdominal surgeries in the 90-day period after the initial visit. Results We identified 134 IBD outpatients tested with GI PCR. A pathogen was identified in 35 (26%) patients, of whom 9 (27%) had an increase in their medication regimen; 2 (22%) were prescribed an additional mesalamine, 3 (33%) a biologic, and none glucocorticoids. In contrast, 49/99 (45%, p=0.03) patients without an infection had an increase in their medication regimen, with 3 (7%, p=0.49) prescribed mesalamines, 11 (24%, p=0.67) biologics, and 7 (16%, p=0.04) glucocorticoids (Table 1). No patient received immunomodulators. Patients with an infection received more antibiotics (49% vs. 12%, p<0.01). They were also more likely to present with vomiting (11% vs. 3%, p=0.06) and undergo less post-visit endoscopy (6% vs. 16%, p=0.13), but these differences were near significant. There were no significant differences in demographics, initial IBD medications on testing, presenting symptoms, lab markers, abdominal imaging, or adverse outcomes. The most commonly isolated organisms were Escherichia coli subtypes, with 22/35 (63%) patients having at least one species isolated on testing (Table 2). Conclusion Detection of an enteric infection in outpatients with relapse of IBD was associated with significantly fewer dose escalations in IBD therapy, including glucocorticoids, and increased exposure to antibiotics, and a marginal decrease in endoscopy. These changes in management were not associated with a difference in adverse outcomes.

Comparison of Oral versus Intravenous Proton Pump Inhibitors in Preventing Re-bleeding from Peptic Ulcer after Successful Endoscopic Therapy.

IntroductionPerforation, obstruction, and bleeding remain the most frequently encountered complications of peptic ulcer disease (PUD). Bleeding may be in the form of hematemesis or melena. The treatment of choice in patients with a bleeding peptic ulcer is endoscopic ligation to maintain the hemostatic balance followed by the administration of proton pump inhibitors (PPIs). This study focuses on the evaluation and comparison of intravenous (IV) and oral PPIs in terms of prevention of re-bleeding after successful endoscopy for peptic ulcers.MethodsA prospective, comparative study was conducted in a tertiary care hospital in Pakistan from January 1, 2018 to June 30, 2019. The trial included known cases of PUD admitted with active upper gastrointestinal bleeding (UGIB). They were randomly divided into two groups: one received oral pantoprazole and the other was administered IV pantoprazole. The outcomes for both groups were compared. Data was entered and analyzed using Statistical Package for the Social Sciences (SPSS) software version 23.0 (IBM, Armonk, NY)ResultsThere were 96 (48%) patients in the IV pantoprazole group and 104 (52%) in the oral group. From 24 hours after the medication onwards, the IV pantoprazole group showed a significant improvement in hemoglobin (Hb) levels (p: 0.01); the group also showed improvement in supine systolic BP at 48 hours (p: 0.04) and in diastolic BP at both 12 and 48 hours as compared to the oral pantoprazole group (p: 0.05). The mean duration of hospital stay, need for blood transfusion and repeat endoscopy, re-bleeding, and mortality rates were similar for both groups (p: >0.05).ConclusionWe could not find any statistically significant difference between oral and IV routes of pantoprazole administration in the prevention of rebleeding when used after successful therapeutic endoscopy in patients with bleeding PUDs.

Interventions and Operations 5 Years After Bariatric Surgery in a Cohort From the US National Patient-Centered Clinical Research Network Bariatric Study

Additional data comparing longer-term problems associated with various bariatric surgical procedures are needed for shared decision-making. To compare the risks of intervention, operation, endoscopy, hospitalization, and mortality up to 5 years after 2 bariatric surgical procedures. Adults who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) between January 1, 2005, and September 30, 2015, within the National Patient-Centered Clinical Research Network. Data from 33 560 adults at 10 centers within 4 clinical data research networks were included in this cohort study. Information was extracted from electronic health records using a common data model and linked to insurance claims and mortality indices. Analyses were conducted from January 2018 through October 2019. Bariatric surgical procedures. The primary outcome was time until operation or intervention. Secondary outcomes included endoscopy, hospitalization, and mortality rates. Of 33 560 adults, 18 056 (54%) underwent RYGB, and 15 504 (46%) underwent SG. The median (interquartile range) follow-up for operation or intervention was 3.4 (1.6-5.0) years for RYGB and 2.2 (0.9-3.6) years for SG. The overall mean (SD) patient age was 45.0 (11.5) years, and the overall mean (SD) patient body mass index was 49.1 (7.9). The cohort was composed predominantly of women (80%) and white individuals (66%), with 26% of Hispanic ethnicity. Operation or intervention was less likely for SG than for RYGB (hazard ratio, 0.72; 95% CI, 0.65-0.79; P < .001). The estimated, adjusted cumulative incidence rates of operation or intervention at 5 years were 8.94% (95% CI, 8.23%-9.65%) for SG and 12.27% (95% CI, 11.49%-13.05%) for RYGB. Hospitalization was less likely for SG than for RYGB (hazard ratio, 0.82; 95% CI, 0.78-0.87; P < .001), and the 5-year adjusted cumulative incidence rates were 32.79% (95% CI, 31.62%-33.94%) for SG and 38.33% (95% CI, 37.17%-39.46%) for RYGB. Endoscopy was less likely for SG than for RYGB (hazard ratio, 0.47; 95% CI, 0.43-0.52; P < .001), and the adjusted cumulative incidence rates at 5 years were 7.80% (95% CI, 7.15%-8.43%) for SG and 15.83% (95% CI, 14.94%-16.71%) for RYGB. There were no differences in all-cause mortality between SG and RYGB. Interventions, operations, and hospitalizations were relatively common after bariatric surgical procedures and were more often associated with RYGB than SG. ClinicalTrials.gov identifier: NCT02741674.

A Quality Improvement Initiative Results in Improved Rates of Timely Postvariceal Bleeding Surveillance Endoscopy

A Quality Improvement Initiative Results in Improved Rates of Timely Postvariceal Bleeding Surveillance Endoscopy

Revision endoscopic sinus surgery for bilateral nasal polyposis

Background Nasal polyps have an incidence of 4% in all of the population. Apart from the surgery performed, some patients will present with recurrence. Recurrence ranged from 4 to 60% in? nasal polyps (NP), with a median of 20%, across all studies reviewed over a maximum of 2 years. Objective The aim? was to review cases of recurrent bilateral nasal polyposis in terms of the incidence of local factors contributing to recurrence. Patients and methods This prospective study included 50 adult patients (males and females) experiencing recurrent BNP after previous functional endoscopic sinus surgery. The patients were recruited from the outpatient clinic, Otorhinolaryngology Department, Kobry El-Kobba Military Hospital. The mean age of primary disease was 39 years. There were significant differences between endoscopic and computed tomography (CT) findings according to the presence of different local factors contributing to recurrence of NP, in the form of lateralized middle turbinate, residual infected air cells, scarred frontal recess, middle meatal antrostomy stenosis, retained uncinate process, and retained agar nasi cells. The detection rate of endoscopy was higher than the CT scan. Results The most frequent finding was lateralized middle turbinate (74.0%) followed by residual infected air cells and scarred frontal recess (60.0% for each). Middle meatal antrostomy stenosis was found in 40.0% of cases. Retained agar nasi cells was found in 48.0% of cells, whereas retained uncinate process was found in only 36.0% of cases. Conclusion There were significant differences between endoscopic and CT findings according to the presence of different local factors contributing to recurrence of NP, in the form of lateralized middle turbinate, residual infected air cells, scarred frontal recess, middle meatal antrostomy stenosis, retained uncinate process, and retained agar nasi cells. The detection rate of endoscopy was higher than the CT scan.

Follow-Up Ileocolonoscopy Is Underused in Crohn’s Disease Patients after Ileocecal Resection despite Higher Total and Inpatient Health-Care Costs Compared to Controls

Background: Postoperative recurrence is frequently observed after ileocecal resection in Crohn’s disease (CD) patients. Since 2010, endoscopy within 1 year is considered the gold standard for its diagnosis. However, if and how frequent such endoscopies are performed in clinical practice remains unknown. Methods: We analyzed 1-year follow-up data on CD patients who underwent ileocecal resection between 2012 and 2014 and compared them with hospitalized, non-resected CD controls. Data were extracted from the Helsana database. Helsana is one of the largest Swiss health insurance companies providing coverage for 1.2 million individuals. Results: A total of 645 CD patients were identified with ≥1 hospitalization between 2012 and 2014 and a follow-up of 1 year. Of these, 79 (12.2%) underwent ileocecal resection. Although endoscopy rates increased over time and were higher in patients with resection versus controls (p = 0.029), in only 54.4% a 1-year follow-up ileocolonoscopy was performed. Postoperative prophylaxis with anti-tumor necrosis factor or azathioprine was prescribed in 63.3%. Female sex and age >60 years were independent predictors for not receiving prophylaxis (odds ratio [OR] 0.36, p = 0.048, and OR 0.2, p = 0.022). Patients with resection had significantly lower numbers of rehospitalizations (1.2 vs. 1.8, p = 0.021), with resection being an independent negative predictor for number of rehospitalizations in a Poisson regression model (incident risk ratio 0.64, p = 0.029). However, disease-related surgery was more often the cause for rehospitalization after resection versus controls (47.6 vs. 22.1%, p = 0.015). Total and inpatient health-care costs were higher in these patients. Conclusion: Endoscopies are underused after ileocecal resection. This contrasts current guidelines. Physicians should be aware of this underuse and perform follow-up examinations more often.

Investigation of Hemogram, Endoscopy, Demographic Properties of Patients Applied by Fecal Occult Blood Test Screening

Objective: Colorectal cancer (CRC) is one of the most common cancers in the world. Fecal occult blood test (FOBT) is easy and commonly used test to its screening. The aim of this study was to investigate the demographic characteristics, hemogram results and endoscopy and outcome status of the patients who underwent FOBT on history and clinical suspicion and to contribute to the literature.Methods: 400 patients who were admitted to the general surgery polyclinic between 01/12/2016 and 12/12/2017 in Ordu University Medical Faculty Training and Research Hospital were evaluated retrospectively. The data of 349 patients who underwent FOBT was reached. Age and sex, hemoglobin, hematocrit, ferritin levels, upper and lower gastrointestinal endoscopy results and pathology results of endoscopic biopsies were recorded.Results: 38 (10.9%) with FOBT (+) and 311 (89.1%) with FOBT (-) of 349 patients were detected. There was no statistically significant difference between the two groups in terms of the average age (p = 0.27) and gender (p = 0.26). There was a significant difference between the two groups in terms of the rate of upper gastrointestinal endoscopy (p = 0.03). There was a significant difference between the two groups in terms of the rate of colonoscopy (p = 0.001). Malignancy was detected in 22,2% of FOBT (+) and in 1,63% of FOBT (-) group by colonoscopy. There was a statistically significant difference between the two groups in terms of disease diagnoses (p = 0.001). There was no statistically significant difference between the two groups in terms of Helicobacter Pylori (H. pylori) (p = 0.31) and intestinal metaplasia (p = 0.44). There was a statistically significant difference between the two groups in terms of Hb and Htc value (p= 0.05). Conclusion: According to the results of FOBT, the application of endoscopy to the patients who are required, provide to detect the precancerous lesions as well as the malignancies of the upper and lower gastrointestinal tract. Good knowledge of the importance of this test will allow early detection of malignancy.

Endoscopic Algorithm for Management of Gastrointestinal Bleeding in Patients With Continuous Flow LVADs: A Prospective Validation Study

Gastrointestinal bleeding (GIB) is a common complication of left ventricular assist device (LVAD) therapy accounting for frequent hospitalizations and high resource utilization. We previously developed an endoscopic algorithm emphasizing upfront evaluation of the small bowel and minimizing low-yield procedures in LVAD recipients with GIB. We compared the diagnostic and therapeutic yield of endoscopy, health-care costs, and re-bleeding rates between conventional GIB management and our algorithm using chi-square, Fisher's exact test, Wilcoxon-Mann-Whitney, and Kaplan-Meier analysis. We identified 33 LVAD patients with GIB. Presentation was consistent with upper GIB in 20 (61%), lower GIB in 5 (15%), and occult GIB in 8 (24%) patients. Forty-one endoscopies localized a source in 23 (56%), resulting in 14 (34%) interventions. Algorithm implementation compared with our conventional cohort was associated with a 68% increase in endoscopic diagnostic yield (P< .01), a 113% increase in therapeutic yield (P= .01), a 27% reduction in the number of procedures per patient (P < .01), a 33% decrease in length of stay (P < .01), and an 18% reduction in estimated costs (P < .01). The same median number of red blood cell transfusions were used in the 2 cohorts, with no increase in re-bleeding events in the algorithm cohort (33.3%) compared with our conventional cohort (43.7%). Our endoscopic management algorithm for GIB in LVAD patients proved effective in reducing low-yield procedures, improving the diagnostic and therapeutic yield of endoscopy, and decreasing health-care resource utilization and costs, while not increasing the risk of a re-bleeding event.

Acute pediatric tracheitis: Distinguishing the disease by tracheostomy status

ObjectivesTracheitis is an upper airway infection that often presents in patients with tracheostomies and can potentially cause airway obstruction. This study aims to use a nationwide database to identify a large cohort of pediatric patients admitted with tracheitis to elucidate the management and resource utilization associated with the disease both with and without tracheostomies. MethodsThe Kids’ Inpatient Database (KID) 2012 was used to identify 2394 weighted discharges with acute tracheitis, with or without obstruction, as the primary diagnosis. Data on prior tracheostomy status, demographics, hospital characteristics, management, and resource utilization were obtained. Two groups of interest, based on presence of prior tracheostomy, were studied. Linear regression was performed to determine independent predictors of total charges. ResultsThe mean age was 5.52 years (SD: 5.54), mean length of stay (LOS) was 6.37 days (SD: 10.18), and mean total charges were $60,996.61 (SD: 107,798.41). Patients with prior tracheostomy had lower rates of endoscopy and endotracheal intubation than patients without (p < 0.0005). There was no significant difference in LOS (p = 0.076) or total charges (p = 0.210) between the groups based on prior tracheostomy status. ConclusionPediatric tracheitis should be differentiated on the basis of tracheostomy status. We propose that tracheitis diagnosis codes should be distinguished by the presence of tracheostomy as “open” and the absence of tracheostomy as “closed.”

2588 You May Spread but Can't Hide! A Rare Case of Metastatic Renal Cell Carcinoma to the Small Bowel After Nephrectomy

INTRODUCTION: Renal cell carcinoma (RCC) is a type of kidney cancer that rarely metastasizes to the small bowel. There are only a few reported cases. We present a rare case of metastatic RCC to the small bowel 13 years after nephrectomy. CASE DESCRIPTION/METHODS: A 70-year-old man with a history of RCC treated with nephrectomy 13 years prior presented to the hospital with melena and a hemoglobin of 10 g/dL. Upper endoscopy was unrevealing. Colonoscopy showed diverticulosis and scant blood in the cecum. After discharge, a capsule endoscopy showed bright red blood starting in the mid to distal small bowel. The patient later underwent a repeat capsule endoscopy which did not identify any further bleeding or a source of blood loss. The patient subsequently underwent an anterograde enteroscopy to the mid-small bowel without identifying a source GI bleeding. With oral iron supplementation, his hemoglobin normalized and the patient had no further episodes of melena. One year later, the patient presented to the hospital with abdominal pain and was found to have a distal small bowel obstruction and to be anemic with a hemoglobin level of 11 g/dL. A non-contrast CT abdomen and pelvis did not identify a cause of obstruction. After conservative management, patient was referred for MR enterography which showed a 5 cm enhancing mass in the terminal ileum (Figure 1). The mass was biopsied via ileocolonoscopy (Figure 2), which showed metastatic renal cell carcinoma, clear cell type. He subsequently underwent surgical metastasectomy (Figure 3). Surgical pathology confirmed metastatic RCC with no evidence of lymph node involvement. DISCUSSION: Metastatic RCC to the small bowel is rare and has mostly been described anecdotally thus far. Despite undergoing a presumably curative nephrectomy, this patient had a recurrence 13 years after surgery. Thus, this case adds to the growing body of literature to support late gastrointestinal metastasis from RCC as a potential cause of occult GI bleeding. Additionally, this patient's case is unique in that both capsule endoscopy and CT failed to identify the site of bleeding. Given the size of the mass, this case highlights the miss rate of capsule endoscopy. The poor distal small bowel prep likely reduced the ability to detect this distal small bowel lesion. Ultimately, the mass was identified via MR enterography. This case sheds light on an important issue regarding the utility and efficacy of capsule endoscopy compared to magnetic resonance imaging in the identification of small bowel neoplasms

617 Outcomes of Patients With Small Bowel Angiodysplasia Treated With a Small Bowel Radiofrequency Ablation Catheter: A Multicenter Case Series

INTRODUCTION: Small bowel angioectasia (SBA) are the most common cause of small bowel GI bleeding, usually treated with argon plasma coagulation (APC). Bleeding recurs in &gt;40%. The outcomes of patients with SBA treated with a dedicated radiofrequency ablation catheter was reported. METHODS: Patients were treated using a commercially available small bowel radiofrequency ablation catheter (SBRFA) during enteroscopy which is 25 mm wide, 260 cm long, and the treatment paddle is 7.5 mm wide deployed, and 10 mm long. The paddle was advanced to the lesion, and gentle pressure was applied delivering 10 J/cm2 with each application. The same area could be treated twice. Patient demographics, pre and post treatment hemoglobin, time to recurrent bleeding, and need for repeated therapy were reported. RESULTS: 20 subjects were treated from March to October 2018: 6 females (age 68; SD 11.1) and 14 males (age 73; SD 10.4). Three subjects had a left ventricular assist device (LVAD). 19 (95%) had at least one previous EGD (total at least 43, range 1 to &gt;10), and at least one previous colonoscopy (total 42, range 1 to &gt;10). 14 subjects (70%) had an abnormal video capsule endoscopy; 14 (70%) had previous APC. Median hemoglobin before treatment was 8.3 g/dL (5.1-14.4), and 13 subjects (65%) had a mean of 4 (SD 2.1) units of blood transfused. A median of 23 SBA were treated (2 to 99 total). No other treatments such as APC were used. Median follow-up was 195 days (30-240). The most recent median hemoglobin in 15 subjects (75%) was 9.4 g/dL (5 to 13) (P = 0.04). Repeat endoscopy rate was 20%; once in 2 subjects (at 45 and 210 days after SBRFA), and twice in one subject (60 days after SBRFA treatment). One subject with LVAD had a repeat upper endoscopy and no treatment, one subject with GAVE had a push enteroscopy and no treatment, and the third subject with LVAD had two assisted enteroscopies: SBA were re-treated with APC once, and no treatment was needed the last time. One patient with an LVAD had overt ileum bleeding and underwent embolization. 2 subjects (10%) required repeat blood transfusion (2 units each). Two deaths at 60 and 180 days were unrelated to GIB. CONCLUSION: In this series of SBRFA therapy of SBA up to 240 days of follow up 3/20 subjects (15%) required repeat endoscopy. Repeated endotherapy was necessary in 1 subject. All subjects with LVAD had repeat procedures. 2 subjects required more blood transfusions. The data compares favorably to historical SBA outcomes but comparative studies are needed.

594 Weekend Admissions Do Not Affect Management of Lower GI Bleeding

INTRODUCTION: Lower gastrointestinal bleeding (LGIB) is a common condition requiring GI consultation and management. Current ACG guideline recommends colonoscopy within 24 hours of LGIB. However, while colonoscopy is the most common intervention, it may not be readily available at all hospitals on the weekend when many endoscopy units are closed. Previous work has found that in non-variceal upper GI hemorrhage, patients admitted on weekends had lower total endoscopy rates and high hospitalization charges. We explored these outcomes in LGIB. METHODS: This national inpatient sample (NIS) from 2016 was queried for all cases of confirmed lower GI bleeding as the primary diagnosis code based on ICD-10. This included bleeding AVMs, diverticular hemorrhage, rectal ulcers, radiation proctitis and other anal/rectal hemorrhage. Outcomes for patients admitted on a weekend (Saturday/Sunday) were compared to weekday admissions using survey-adjusted Chi-square and correlation for comparisons and logistic/linear regression to examine mortality, length of stay, and hospitalization costs. Adjustment was made for the Elixhauser mortality score (a validated measure of comorbidities), colonoscopy, and transfusion in the regression. RESULTS: In 2016, 92,065 patients were admitted for LGIB overall. Of these, 23,070 (25%) were admitted on a weekend. See table 1 for causes of bleeding. For weekend admissions, mortality (0.8% vs 0.9%, P = 0.626), transfusion rate (28.8% vs 30.1%, P = 0.113), colonoscopy rate (58.4% vs 58.1%, P = 0.749), angiography rate (3.3% vs 3.3%, P = 0.894), mean days to colonoscopy (1.8 vs 1.8, P = 0.157), length of stay (4.1 vs 4.2 days, P = 0.068), and charges ($40,552 vs $40,604, P = 0.956) were all similar to weekday admissions. In the multivariable regression, colonoscopy (OR=2.7, P &lt; 0.001) and Elixhauser score (OR=1.09, P &lt; 0.001) but not weekday admission (OR=1.13, P = 0.535) or freedom from transfusion (OR=0.78, P = 0.140) predicted mortality. Length of stay (0.1 day difference, P = 0.053) and charges ($14 difference, P = 0.987) were also not affected by weekend admission after adjustment for the same covariates. CONCLUSION: In this estimate of all U.S. lower GI bleeding admissions from 2016, weekend admission did not affect outcomes including mortality, length of stay or total charges. Time to colonoscopy was similar. Undergoing colonoscopy was associated with a 2.7 times lower odds of mortality.

Adherence to Biopsy and Follow-Up Guidelines in a Population-Based Cohort of Children With Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated condition that is becoming more widely recognized in children. Recent EoE practice guidelines provide clear recommendations on adequate biopsy sampling at diagnostic endoscopy and necessity of close follow-up endoscopy with biopsy to ensure mucosal healing with therapy.1 Despite these recommendations, adherence to biopsy guidelines, time to first follow-up endoscopy, and overall surveillance endoscopy rates have not been robustly studied. Using a population-based cohort of children diagnosed with EoE in Utah, we assessed adherence to guidelines across multiple provider types, including academic pediatric gastroenterologists (PGIs), private practice PGIs, and adult-trained providers performing endoscopy in children.

Impact of Electronic Chromoendoscopy on Adenoma Miss Rates During Colonoscopy: A Systematic Review and Meta-analysis

The impact of virtual chromoendoscopy such as narrow-band imaging, Fujinon intelligent chromoendoscopy, blue-light imaging, linked-color imaging, and i-SCAN on adenoma detection rate has been variable. However, adenoma miss rate (another measure suggested as a quality indicator) of electronic chromoendoscopy modalities has not been systematically evaluated. This study aimed to perform a systematic review and meta-analysis to examine the adenoma miss rate of white-light endoscopy compared with electronic chromoendoscopy. Medline, Embase, Scopus, Web of Knowledge, and Cochrane were the data sources for this study. The studies selected were tandem randomized controlled trials of electronic chromoendoscopy modalities compared with white-light endoscopy. Electronic chromoendoscopy compared with white light endoscopy was used to measure the adenoma miss rate. Primary outcome was the pooled adenoma miss rate of electronic chromoendoscopy techniques compared with white-light endoscopy. Secondary outcomes were subgroup analysis, adenoma size analysis, and adenoma detection rate. A total of 3507 patients were evaluated from 7 eligible tandem randomized control trials. A total of 1423 patients had white-light endoscopy as the first of the tandem examinations. The rest of the patients had electronic chromoendoscopy as the first of the tandem examination (narrow-band imaging, 988 patients; Fujinon intelligent chromoendoscopy, 728 patients; i-SCAN, 233 patients; blue-light imaging, 64 patients; and linked-color imaging, 71 patients). The pooled adenoma miss rate for electronic chromoendoscopy was not different than white-light endoscopy (17.9% vs 21%; OR, 0.72 (0.67-1.11); I 67%; p = 0.13). When only narrow-band imaging, blue-light imaging, and linked-color imaging were considered, the pooled rate was statistically significant (OR, 0.60 (0.37-0.98); p = 0.04). The pooled adenoma detection rate was not statistically different with electronic chromoendoscopy than white-light endoscopy (OR, 1.02 (0.88-1.19); p = 0.78). The small number of studies to assess the impact of each modality limited stratified conclusions. Electronic chromoendoscopy is not associated with a significant reduction in adenoma miss rate compared with white-light colonoscopy.

Relationship between Drug-Induced Sleep Endoscopy Findings, Tonsil Size, and Polysomnographic Outcomes of Adenotonsillectomy in Children.

(1) Determine the correlation of awake tonsil scores and preadenotonsillectomy (pre-AT) sleep endoscopy findings. (2) Assess the relationship between polysomnographic AT outcomes with awake tonsil scores and sleep endoscopy ratings of tonsil and adenoid obstruction. Retrospective case series with chart review. Tertiary care children's hospital. Children aged 1 to 18 years who underwent sleep endoscopy and AT from January 1, 2013, to August 30, 2016, were included. Pre-AT sleep endoscopy findings were scored with the Sleep Endoscopy Rating Scale. Awake tonsil scores and sleep endoscopy ratings were compared with Spearman correlation. Associations between changes in pre- and post-AT polysomnography parameters and (1) awake tonsil scoring and (2) sleep endoscopy scoring were assessed with 1-way analysis of variance and linear regression. Participants included 36 children (mean ± SD age, 6.8 ± 4.3 years; 68% male, 44% obese). Awake tonsil scores and sleep endoscopy ratings were strongly correlated (R = 0.58, P = .003). Awake tonsil scores were not associated with changes in any polysomnography parameters after AT (all P > .05), while sleep endoscopy ratings of adenotonsillar obstruction were significantly associated (all P < .05, R2 = 0.16-0.35). Patients with minimal adenotonsillar obstruction during sleep endoscopy had less improvement than those with partial or complete obstruction (mean obstructive apnea-hypopnea index change: -8.2 ± 11.5 vs -15.9 ± 14.3, and -46.8 ± 31.3, respectively; P < .001). In children at risk for AT failure, assessment of dynamic collapse with sleep endoscopy may better predict the outcome of AT than awake tonsil size assessment, thus helping to inform surgical expectations.

Safety and efficacy of reduced dosage ketoprofen with or without tramadol for long-term treatment of osteoarthritis in dogs: a randomized clinical trial

BackgroundThis study aimed to evaluate the safety and efficacy of reduced-dosage ketoprofen with or without tramadol in dogs. Five healthy dogs receiving standard-dosage ketoprofen (2 mg/kg SC, then 1 mg/kg PO daily) comprised Group A. Twenty dogs with osteoarthritis were randomized to receive reduced-dosage ketoprofen (0.5 mg/kg SC once; 0.25 mg/kg PO daily) alone (Group B) or in combination with tramadol (5 mg/kg/day PO) (Group C). Treatments were administered for 28 days. Platelet aggregation time (PAT), gastrointestinal (GI) endoscopy and glomerular filtration rate (GFR) were performed up to 60 days after treatment initiation. Pain was scored using a validated clinical metrology instrument up to D120. Data were analyzed with general linear mixed model for repeated measures (α = 0.05).ResultsPAT was not different between groups but was increased with time for all groups. GI lesion scores were higher in Group A than Groups B and C (day 28; P = 0.005) and were increased with time for Group A (P = 0.005). GFR was lower in Group A than Groups B and C (day 28; P < 0.01) and were decreased with time for group A (P < 0.001). Standard-dosage ketoprofen administration resulted in clinically relevant adverse effects. Pain score decreased in both treated groups (B and C) from D0 to D28. Need of rescue analgesia from D29 to D120 was higher in Group B than in Group C (P = 0.039).ConclusionsThe long-term safety profile of reduced-dosage ketoprofen is similar whether the drug is administered alone or in combination with tramadol to dogs with osteoarthritis. Analgesic efficacy of the combination looks attractive.

Propofol sedation without endotracheal intubation is safe for endoscopic submucosal dissection in the esophagus and stomach.

BackgroundEndoscopic submucosal dissection (ESD) for early esophageal and stomach cancer is usually performed under general anesthesia. However, propofol sedation without endotracheal intubation has been suggested as a viable alternative.ObjectiveThe objective of this study was to evaluate the safety of propofol sedation without endotracheal intubation during ESD in the upper gastrointestinal tract.MethodsWe performed a retrospective cohort study of patients who underwent ESD for upper gastrointestinal tumors with propofol-remifentanil analgosedation in a tertiary referral center in the Netherlands between October 2013 and February 2018. Primary endpoints were the rates of intraprocedural endoscopy- and anesthesia-related complications. Secondary endpoints were the postprocedural complication rates within 30 days and endotracheal intubation conversion rates.ResultsOf 88 patients, intraprocedural ESD-related complications occurred in three patients (3.4%). Intraprocedural anesthesia-related complications occurred in two patients (2.3%), one of whom required conversion to endotracheal intubation. Postprocedural ESD-related complications occurred in 14 patients (15.9%), and minor postprocedural complications occurred in two patients (2.3%). Eighty-two (93.2%) patients were discharged within one day after ESD. No patient was readmitted for anesthesia-related complications.ConclusionPropofol-based sedation without endotracheal intubation is safe for ESD procedures in the esophagus and stomach with low anesthesia-related complication rates and short hospital stay.